Updated guidelines for managing diabetic ketoacidosis (DKA) preferentially recommend using β-hydroxybutyrate instead of anion gap for determining DKA resolution. Although physiological reasons suggest benefits of β-hydroxybutyrate over anion gap, clinical data supporting this idea are limited. To compare time to DKA resolution (time from initial intravenous insulin to first dose of long-acting subcutaneous insulin) between patients managed with β-hydroxybutyrate and patients managed with anion gap. This retrospective study evaluated patients with DKA who were managed with the same continuous intravenous insulin protocol at 2 participating sites, one that used β-hydroxybutyrate and the other that used anion gap to assess resolution. The primary outcome was time to first dose of long-acting insulin, with secondary outcomes including incidence of DKA recurrence after transition to subcutaneous insulin. A total of 178 patients were included, with 89 in the β-hydroxybutyrate-managed arm. Baseline characteristics, including DKA severity, were similar in the 2 groups. Conversion to a long-acting insulin regimen occurred at a median (IQR) of 23.5 (17.9-31.0) hours in the β-hydroxybutyrate group and 13.3 (10.0-18.2) hours in the anion gap group (P < .01) with no difference in rates of DKA recurrence. Monitoring anion gap rather than β-hydroxybutyrate for DKA resolution led to shorter time on an insulin infusion with no increase in DKA recurrence. Prospective studies evaluating β-hydroxybutyrate thresholds or how to best use β-hydroxybutyrate in practice are warranted.

Safety of GLP-1 receptor agonists in type 1 diabetes: a systematic review and meta-analysis.

Evidence on cardiovascular/renal outcomes associated with GLP-1-based therapies in type 1 diabetes (T1D) is limited. We examined the effects of GLP-1-based therapy on major clinical outcomes and safety, including diabetic ketoacidosis (DKA) and hypoglycemia risk, in adults with T1D in a large real-world cohort. This retrospective cohort study utilised the TriNetX global health research network. Adults with T1D were classified by exposure to GLP-1-based therapies. Propensity score matching (1:1) balanced baseline characteristics for age, sex, demographic characteristics, cardiometabolic risk factors, comorbidities, medication use, and laboratory parameters including lipid profile and glycemic control. Outcomes included all-cause mortality, myocardial infarction, cerebral infarction, heart failure (HF), adapted major adverse cardiovascular events (MACE-all CV clinical outcomes), chronic kidney disease (CKD), and all-cause hospitalisation, plus safety outcomes (hypoglycemia and DKA). Event accrual began 6 months after therapy initiation. After matching, 4088 individuals per group were included. GLP-1-based therapy was associated with lower risks of all-cause mortality (HR 0.67, 95% CI 0.46-0.98), HF (HR 0.38, 95% CI 0.21-0.67), adapted-MACE (HR 0.61, 95% CI 0.40-0.94) and all-cause hospitalisation (HR 0.70, 95% CI 0.51-0.96). No significant differences were observed for myocardial infarction, ischemic stroke, or CKD. DKA incidence was not increased, while hypoglycemia risk was lower with GLP-1 therapy (HR 0.72, 95% CI 0.55-0.95). Less than 10 (0.2%) events of pancreatitis were noted in both groups. In this propensity score-matched real-world cohort of adults with T1D, GLP-1-based therapy was associated with lower risks of all-cause mortality, HF, adapted-MACE, hospitalisation, and hypoglycemia without increased DKA risk. Randomised controlled trials are needed to confirm these findings.

To evaluate the efficacy and safety of automated insulin delivery (AID) systems in very young children with type 1 diabetes (T1D). PubMed, Embase, Scopus, and Web of Science were searched until 10 October 2025. Inclusion criteria were randomized controlled trials (RCTs); T1D populations under 7 years old; comparing AID systems with standard care (SC). Primary efficacy endpoint was the percentage of time-in-range of 70-180 mg/dL (TIR) derived from continuous glucose monitoring (CGM), secondary outcomes included glycated haemoglobin (HbA1c), other CGM metrics, and insulin dose. Safety endpoints included severe hypoglycaemia (SH) and diabetic ketoacidosis (DKA). Four RCTs involving 292 participants were included. The mean age was 4.70 years, with a mean T1D duration of 1.96 years. The study duration ranged from 8 to 16 weeks. Compared with SC, AID significantly improved TIR by mean difference (MD) +9.29% (95% confidence interval [CI]: 7.27-11.30, I2 = 70%, p < 0.001) accompanied by a favourable effect on HbA1c by MD -4 mmol/mol (-0.39%) (95% CI [-6 to -2] (-0.57 to -0.21), I2 = 82%, p < 0.001). A favourable decrease in time-above-range (TAR, >180 mg/dL; >250 mg/dL) and mean blood glucose were also observed in AID over SC (all p < 0.05). No significant differences were observed between AID and SC groups in time in hypoglycaemia, insulin dose, and risk of SH and DKA (all p > 0.05). AID systems may outperform SC in improving short-term glycaemic control (TIR, HbA1c, TAR) in very young children with T1D, without increasing time in hypoglycaemia, insulin dose, or risk of SH and DKA. These preliminary findings support the clinical potential of AID systems and highlight the need for longer term studies.

Adult-onset type 1 diabetes is not well characterized, especially after 40 years of age, and is commonly misdiagnosed as type 2 diabetes. We evaluated the differences in clinical presentation, islet autoantibodies, and HLA genetics between pediatric- and adult-onset type 1 diabetes. Individuals who were newly diagnosed with type 1 diabetes were tested for islet autoantibodies within 1 year of diagnosis in this retrospective study. Islet autoantibodies against GAD, insulin, islet antigen 2, and zinc transporter 8 were measured using fluid-phase radiobinding assays. High-resolution HLA class I (n = 655) and II (n = 1,196) typing was performed in a subset of participants. In total, 414 adults (aged ≥20 years) and 2,000 children were included. Adults were aged 20-76 years and had a mean BMI of 23.5 ± 4.7 kg/m2 at onset. Compared with children, adults presented with diabetic ketoacidosis (DKA) less frequently (32.6% vs. 56.0%; P < 0.001) and with slightly lower HbA1c values (11.3% ± 2.6% vs. 12.0% ± 2.4%; P < 0.001). Notably, adults older than 40 years (n = 84) presented with DKA only 13.1% of the time. Adults more often presented with zero or one islet autoantibodies compared with children (43.0% vs. 20.2%; P < 0.001). There were no differences in high-risk HLA haplotypes between adults and children (DR4-DQ8: 57.1% vs. 63.7%; P = 0.060; DR3-DQ2: 43.6% vs. 46.1%; P = 0.482). Adult-onset type 1 diabetes is characterized by a reduced frequency of DKA and by fewer total islet autoantibodies. Our findings can help in the accurate diagnosis of type 1 diabetes in adults.

Type 1 diabetes intervention clusters in resource-limited settings: a systematic review and economic evaluation.

Type 1 diabetes (T1D) is a chronic autoimmune disease that disproportionately affects children and adolescents and is associated with substantial medical and psychosocial burden. Despite advances in insulin delivery systems and continuous glucose monitoring, most patients do not achieve optimal glycemic control and remain at risk for diabetic ketoacidosis, long-term microvascular and macrovascular complications, and premature mortality. Increasing evidence demonstrates that T1D is a progressive disease characterized by years of asymptomatic autoimmunity and gradual pancreatic beta-cell loss, creating an opportunity for early disease-modifying intervention. This review summarizes the genetic and immunologic foundations of T1D, the disease classification system, and emerging strategies aimed at preserving endogenous insulin production. Particular focus is given to teplizumab (Tzield), an anti-CD3 monoclonal antibody that is the first FDA-approved therapy shown to delay progression from stage 2 to stage 3 T1D in individuals ages 8 years and older. Disease-modifying immunotherapies such as teplizumab represent a paradigm shift in T1D management, with the potential to delay disease onset and reduce long-term complications.

Individuals living with type 1 diabetes (T1D) are at increased risk for cardiovascular (CV) and renal complications, yet therapeutic strategies specifically targeting cardiorenal risk reduction in this population remain limited. The role of glucagon-like peptide-1 (GLP-1)-based therapies in T1D remains unclear. We conducted a review of published studies examining the CV, clinical, and renal effects of GLP-1-based therapies in people with T1D, while also evaluating safety outcomes and future research priorities. Three observational real-world studies evaluating GLP-1-based therapies in adults with T1D were identified. Overall, these studies demonstrated clinically meaningful reductions in all-cause mortality, hospitalisation, heart failure, and composite CV outcomes. Renal benefits were also observed, including lower risks of early estimated glomerular filtration rate decline and end-stage kidney disease. Importantly, no consistent increase in diabetic ketoacidosis or severe hypoglycemia was identified, supporting a generally reassuring safety profile. These findings challenge the traditional view of GLP-1 receptor agonists as therapies of predominantly glycemic relevance in T1D and support their potential role in cardiorenal risk reduction. Nevertheless, the currently available evidence is entirely observational and warrants confirmation through prospective randomised studies specifically designed for T1D populations. Current real-world evidence suggests that GLP-1-based therapies in T1D may provide clinically meaningful CV and renal benefits with a reassuring safety profile; however, adequately powered randomised trials are needed to confirm these findings.

Managing diabetes during exercise remains challenging, particularly in settings of sustained physical activity such as diabetes-camps. This study aimed to evaluate the efficacy and safety of a diabetes-camp protocol including an adaptive algorithm for prandial bolus reduction and the use of automated insulin delivery (AID) exercise modes in children with type 1 diabetes (CwD). Data from two 7-day camps for 77 CwD aged 8-14 years using 780G, Control-IQ, or CamAPS were evaluated. Exercise modes were active throughout each camp, and meal boluses were adjusted by an adaptive algorithm. Continuous glucose monitoring metrics were evaluated and compared among AID systems and the 14-day pre-camp period. Hypoglycemia episodes and carbohydrates were recorded. Median time in range (TIR) was 80% during the camps, with time below range 3% (level 1; TBR1) and 1% (level 2; TBR2). Participants experienced a median of 2 hypoglycemia episodes/day. No severe hypoglycemia or diabetic ketoacidosis occurred. Median prandial bolus reduction in comparison with the calculated bolus was 45% (range 10-110%). Outcomes were similar across AID systems. TIR increased (80% vs. 78%, p = 0.015) and TBR rose modestly (TBR1 3% vs. 2%, p < 0.001; TBR2 1% vs. 0%, p = 0.002) compared to the pre-camp period. The protocol provided a safe and effective option to achieve glycemic targets across assessed AID systems during sustained physical activity at diabetes camps.

Sodium-glucose cotransporter-2 inhibitors (SGLT2i) may have favorable hepatic effects, but long-term outcomes in cirrhosis are uncertain. We investigated the relationship between SGLT2i exposure and 5-year outcomes among adults with cirrhosis. We performed a retrospective cohort study in the TriNetX US Collaborative Network (March 2013- January 2025). Adults (≥18 years) with cirrhosis were classified as SGLT2i users (first exposure on/after cirrhosis diagnosis) or non-users (no SGLT2i exposure) and propensity score matched 1:1. Outcomes were assessed over 5 years beginning 1 day after index. Primary outcomes were all-cause mortality and hospitalization burden (inpatient encounters per patient). Secondary outcomes included hepatic decompensation complications and prespecified adverse events; tertiary outcomes were the most recent liver- and kidney-related laboratory values during follow-up. After matching, 24,559 patients were included per cohort. SGLT2i use was associated with lower all-cause mortality (11.8% vs 26.0%; OR=0.381, 95%CI: 0.363-0.399; p<0.001) and fewer hospitalizations (mean 3.6±10.7 vs 5.4±13.4; p<0.001). Composite hepatic decompensation was less frequent (OR=0.617, 95%CI: 0.580-0.656; p<0.001), including lower odds of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome; hepatic encephalopathy did not differ. Acute kidney failure and urinary tract infection were less frequent, while diabetic ketoacidosis did not differ. Laboratory profiles favored SGLT2i use (lower aspartate aminotransferase and bilirubin, higher albumin, lower international normalized ratio, and improved renal indices). In this matched real-world cohort, SGLT2i exposure after cirrhosis diagnosis was associated with an improved 5-year survival, fewer hospitalizations, and fewer decompensation events.

Diabetic ketoacidosis (DKA) stands as the most common acute hyperglycaemic complication in children with type 1 diabetes (T1D) and remains associated with considerable morbidity and mortality. Although gut dysbiosis has been reported in newly diagnosed T1D, the gut microbiota and microbial metabolites during DKA onset remain poorly characterized. Shotgun metagenomic sequencing was performed on fecal samples from 96 newly diagnosed T1D children, including 32 presenting with DKA upon admission. Short-chain fatty acids (SCFAs) were quantified using gas chromatography/mass spectrometry (GC/MS). Comparative and correlation analyses were conducted to explore differences in gut microbial composition, SCFA levels, and their association with clinical indicators of DKA severity. Children with DKA exhibited distinct gut microbial compositions, with marked β-diversity separation from non-DKA individuals. The DKA group was characterized by an enrichment of potential pathogens and a significant depletion of SCFA-producing genera, including Anaerobutyricum, Dialister, Ruminococcus, Roseburia, Dorea, and Butyricicoccus. Correspondingly, fecal SCFA levels were significantly reduced in the DKA group. Moreover, SCFAs and their producing bacteria were strongly correlated with clinical indices of DKA severity. Mediation analysis suggested that reductions in SCFAs, particularly propionic acid and butyric acid, were associated with metabolic alterations linking SCFA-producing bacteria to DKA. This study provides a comprehensive characterization of gut microbiota and SCFA alterations in T1D children at DKA onset. The depletion of SCFA-producing bacteria and their metabolites reflects metabolic disturbances associated with DKA, and highlights SCFAs and their producers as candidate metabolic features warranting further validation as biomarkers and therapeutic targets.

Hybrid closed-loop insulin delivery systems are increasingly regarded as the preferred therapy for type 1 diabetes, although evidence in older adults remains limited. The aim of this randomised study was to evaluate the effectiveness and safety of the MiniMed 780G system in individuals with type 1 diabetes aged ≥65 years, with HbA1c<86 mmol/mol (10%), who were naive to this technology, with the primary endpoint based on glycaemic management (time in range). Vascular status and other glycaemic metrics were assessed as secondary outcomes. This single-centre, open labelled (outcome assessors were not masked), randomised, controlled, parallel-group trial enrolled 34 participants who were randomly assigned in a 1:1 ratio using a computer-generated randomisation schedule to either advanced hybrid closed-loop (AHCL) therapy or control therapy (multiple daily injections or continuous subcutaneous insulin infusion) and followed for 12 months. Twenty-nine participants completed the study. Baseline characteristics, including glycaemic metrics, were comparable across groups (p>0.05). The AHCL group demonstrated a rapid and sustained improvement in glycaemic management, with time in range increasing from 57.4% at baseline to 79.7% at 12 months (p<0.001), accompanied by reductions in hyperglycaemia as reflected by time above range and time above range 2 (nominal p<0.001; p<0.001), and with no increase in hypoglycaemia across time below range and time below range 2 (nominal p=0.463; p=1). Adjusted between-group differences favoured AHCL for time in range (15.7% [95% CI 8.6, 22.6]) and HbA1c (-5 mmol/mol; [95% CI -9.7, -0.4 mmol/mol] [-0.46%; -0.89%, -0.04%]). No serious adverse events or episodes of diabetic ketoacidosis or severe hypoglycaemia occurred. Post-occlusive reactive hyperaemia showed a shortening of time to maximal flow in the AHCL group, indicating a favourable numerical trend towards improved microvascular function (nominal p>0.05). Retinal vascular status assessed using artificial intelligence remained stable throughout follow-up in both eyes (nominal p=0.710 and p=0.563, respectively). The MiniMed 780G system appears effective for glycaemic management and safe for use in older adults with long-standing type 1 diabetes and a high burden of comorbidities. A non-statistically significant numerical tendency (p>0.05) in the improvement of vascular function that requires further confirmation was also observed. ClinicalTrials.gov NCT06207838.

This retrospective study compared the clinical and metabolic effectiveness of empagliflozin (EMPA) versus dapagliflozin (DAPA) and dipeptidyl peptidase-4 inhibitors (DPP-4i) using real-world data from the Korean National Health Insurance Service (2013-2024). Adults with type 2 diabetes who initiated treatment and maintained it for > 365 days were evaluated. Clinical and metabolic outcomes were analyzed using Cox models and linear mixed models, respectively, following 1:1 propensity score matching (n = 17,050 per group for EMPA vs. DAPA and EMPA vs. DPP-4i). Compared with DAPA, EMPA was associated with lower risks of hypoglycemia (adjusted hazard ratio [aHR] 0.60, 95% CI 0.44-0.82) and all-cause hospitalization (aHR 0.96, 95% CI 0.92-0.99). Compared with DPP-4i, EMPA was associated with lower risks of all-cause hospitalization (aHR 0.83, 95% CI 0.80-0.87) and kidney events (aHR 0.76, 95% CI 0.66-0.88). Acute safety outcomes, including hypoglycemia and diabetic ketoacidosis, were evaluated exploratorily because the sustained-exposure design may underrepresent early events. In conclusion, EMPA and DAPA showed broadly similar outcomes consistent with a class effect; however, EMPA was associated with lower risks of all-cause hospitalization and kidney events compared with DPP-4i. These associations should be interpreted cautiously given the observational study design.

Pathophysiology of Ketoacidosis: Core Curriculum 2026.

Early identification of children with type 1 diabetes at heightened risk for diabetic ketoacidosis (DKA) is necessary for preventive intervention. The present study aimed to examine whether an automated electronic medical record-based tool (the Risk Index for Diabetic Ketoacidosis [RI-DKA]) can reliably predict risk for future DKA using data obtained from only the first 6 months post diagnosis. Data were extracted for 3946 children who met the inclusion criteria. The RI-DKA showed an acceptable ability to discriminate between children who did and did not go on to experience a subsequent DKA event (area under the curve = 0.75), only slightly below the predictive ability in the RI-DKA validation sample. These findings indicate that the RI-DKA is a valuable tool for identifying at-risk children very early in the course of type 1 diabetes.

Telehealth initiatives offer valuable alternatives for enhancing diabetes management and clinician-patient engagement. This study compared two diabetes education approaches for glycemic outcomes: standard method includes regular physical visits at outpatient clinic versus telemonitoring. We conducted an interventional trial involving 140 pediatric patients with Type 1 diabetes (T1D), who were equally randomized into a telecounseling group (Intervention group, n = 70) and a standard care group (Control group, n = 70). Participants in Intervention group received weekly telephone consultations from diabetes educators, during which glucose records, dietary patterns, and insulin dose adjustments were reviewed. Control group received diabetes education during routine outpatient clinic visits. Both groups were followed up initially at the start of the study and at 6 months. Socioeconomic status and quality of life (QoL) were assessed in all participants. Glycemic control differed significantly between groups. Mean HbA1c values were 8.21 ± 1.82 SDS (Intervention group) versus 9.25 ± 2.22 SDS (Control group). Diabetic ketoacidosis (DKA) episodes were higher in Control group (18%) vs. (1.7%) in Intervention group, p = 0.001. Complication rates (lipodystrophy, proteinuria, dyslipidemia) were elevated in Control group (37.7%) vs. (15.5%) in Intervention group, p = 0.01. Intervention group demonstrated significantly improved QoL scores (p = 0.002). The telemedicine strategy helped to achieve significantly greater HbA1c reductions and fewer diabetes-related complications versus conventional care.

Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency characterized by hyperglycemia, ketosis, and acidosis due to insulin deficiency and counterregulatory hormone imbalances. Its prevalence is notably higher in the Arab world than in Western regions. Understanding biochemical differences between type 1 and type 2 diabetes patients with DKA is essential for individualized treatment strategies. This study examines the biochemical profiles and precipitating factors of DKA in Syrian patients, assessing differences between initial and recurrent episodes amid local healthcare challenges. This retrospective study has ethical approval from Damascus University and Damascus Hospital, allowing access to patient charts. The study included individuals diagnosed with diabetic ketoacidosis (DKA) and admitted to Damascus Hospital. Of 997 patients, 464 charts were excluded due to missing data or uncertain diagnoses. Patients were classified into first-time and recurrent DKA, with only initial episodes considered for analysis. Diagnosis criteria varied by age group, ensuring standardized classification. Laboratory tests were performed exclusively in the hospital's central lab. Extracted variables included demographic details, hospitalization duration, diabetes type, precipitating factors, and biochemical markers. The study analyzed 533 hospital admissions for diabetic ketoacidosis (DKA), with 263 (49.3%) being first episodes. Among these, 126 patients (47.9%) had type 1 diabetes, and 71 (26.9%) were diagnosed with diabetes after their first DKA episode. Type 2 diabetes patients exhibited higher in-hospital mortality (16.0% vs. 4.3%, p < 0.001) and longer hospital stays. Significant biochemical differences were observed between types, particularly in pH, bicarbonate, and creatinine levels. Insulin omission and unknown precipitating factors were common, especially in recurrent DKA cases. In conclusion, DKA as the first presentation of diabetes is prevalent among Syrian patients. Type 1 patients were more acidotic, but their admission was shorter, probably due to comorbidities among type 2 patients. Unknown factors and insulin omission are the most prevalent triggers of DKA, especially among patients with recurrent episodes. Not applicable.

ImportanceKlebsiella pneumoniae invasive liver abscess syndrome (ILAS) is an emerging disease characterized by liver abscess without biliary disease, often with multiorgan metastatic infection. It can cause severe critical illness with significant morbidity and disability. There remains limited literature and understanding of this syndrome in the United States.ObjectivesThis article aims to describe the clinical characteristics of hospitalized and critically ill patients with ILAS and providing management considerations for critical care clinicians.Main Outcomes and MeasuresAdult patients admitted to Scripps Health from Janurary 1, 2018 to April 1, 2024 were reviewed. Inclusion criteria required radiographic evidence of a liver abscess and cultures (blood or abscess) positive for K.pneumoniae. Data collected included demographics, symptoms and signs, laboratory and radiologic data, metastatic infection characteristics, treatment, mortality, and morbidity. Patient cases were described, and a narrative review describing clinical, therapeutic, and prognostic characteristics was conducted.ResultsSix patients had ILAS. Mean age was 54.8 years, no immunosuppression (defined as underlying malignancy, drug‐induced, or chronic infection), 83% had diabetes, 50% were male, and 50% were of Asian ethnicity. Liver abscesses were multilocular (50%), and all had percutaneous catheter drainage. Fifty percent of patients developed distant metastatic infections: emphysematous cystitis, pulmonary septic emboli, complicated parapneumonic pleural effusions, meningitis, ventriculitis, cerebral septic emboli, and endophthalmitis. These patients were younger, male, and had a higher rate of intensive care unit (ICU) admission and mechanical ventilation. Two patients required ICU admission with septic shock, diabetic ketoacidosis, respiratory failure, severe thrombocytopenia, and altered mental status. K. pneumoniae isolates were pansensitive except to ampicillin. There was no in‐hospital mortality. The patient with meningitis and ventriculitis had full neurological recovery, and the patient with endophthalmitis had very poor residual visual acuity.Conclusions and RelevanceILAS is an emerging disease that can cause severe critical illness with multiorgan involvement. Early identification of the disease and metastatic infection is essential to provide appropriate treatment. Additionally, ILAS patients require screening for endophthalmitis.

The aim of the present study was to conduct bidirectional two-sample Mendelian randomization (MR) to explore causality between systemic diseases and periodontitis amid confounding factors. Genome-wide association study (GWAS) summary statistics were obtained from the IEU OpenGWAS project, FinnGen consortium, and GLIDE consortium. The exposures included a range of systemic diseases, such as diabetic ketoacidosis, coronary heart disease, myocardial infarction, stroke, coronary atherosclerosis, diabetic nephropathy, diabetic neuropathy, diabetic retinopathy, cataracts, nonalcoholic fatty liver disease, osteoporosis, and cardiac arrhythmia, and the outcomes were periodontitis and chronic periodontitis. The primary analytical method was inverse-variance weighted (IVW) MR, complemented by MR-Egger, weighted median, and weighted mode methods. Sensitivity analyses, including MR-PRESSO, MR-Egger intercept test, and Cochran's Q test, were performed to assess the robustness of the findings. In the forward MR analysis, no significant evidence was found to support a causal effect of genetic liability to the selected systemic diseases on the risk of periodontitis or chronic periodontitis (all P > .05). In the reverse MR analysis, a genetically predicted causal relationship was identified, suggesting that periodontitis is a risk factor for osteoporosis (IVW, OR 1.16, 95% CI 1.01-1.33, P = .031). No other significant causal effects of periodontitis on the other studied diseases were found. Sensitivity analyses did not detect significant horizontal pleiotropy for the positive finding. Novel evidence is provided suggesting that periodontitis may causally increase the risk of osteoporosis. These findings highlight the systemic impact of oral health and suggest that preventing and treating periodontitis could be a potential strategy in osteoporosis management. Clinically, integrating periodontal screening into the risk assessment protocols for patients susceptible to osteoporosis may optimize early intervention and multidisciplinary patient management.

Fulminant type 1 diabetes (FT1D) is a rare immune-related adverse event associated with nivolumab, and its clinical characteristics remain unclear. This study aims to characterize the clinical features of nivolumab-associated FT1D and to generate evidence to inform its diagnosis and prevention. A systematic search of databases was conducted to identify clinical cases of nivolumab-associated FT1D reported through March 31, 2026. Clinical data for the patients were extracted and subjected to statistical analysis. A total of 59 patients were included, with a median age of 59years (range 22, 87). The median time to onset of FT1D was 90days (range 9, 1988) after the initial administration of nivolumab, with a median treatment cycle of 6 cycles (range 1, 136). Polyuria (45.1%), polydipsia (31.4%), weight loss (29.4%), thirst (23.5%), nausea (23.5%), vomiting (21.6%), and fatigue (19.6%) were the main symptoms. The median plasma glucose level at the diagnosis of FT1D was 594mg/dL (range 208.8, 1652.4), and the median HbA1c was 7.2% (range 5.4, 8.9). Glutamic acid decarboxylase antibody positivity was detected in 23.6% of patients. Following nivolumab discontinuation and initiation of intensive insulin therapy, glycemic control was satisfactorily achieved. FT1D is a rare immune-related adverse event associated with nivolumab. Close plasma glucose monitoring should be maintained both during nivolumab therapy and after drug discontinuation. The possibility of FT1D should be considered in patients presenting with hyperglycemic symptoms and diabetic ketoacidosis. Nivolumab-associated FT1D requires long-term maintenance insulin therapy.