Hospital Admissions For Diabetic Ketoacidosis Research Articles

Management of diabetic ketoacidosis in internal medicine: insulin protocols, electrolyte balance, and clinical outcomes

Diabetic ketoacidosis (DKA) is a critical complication of diabetes mellitus (DM), characterized by hyper-glycemia, acidosis, and ketosis. It poses a substantial risk of morbidity and mortality, especially in type 1 DM patients. DKA can be triggered by various factors, including insulin deficiency, infections, alcohol abuse, and other medical conditions. Hospital admissions for DKA are increasing, with mortality rates of up to 5-9%, often linked to severe underlying illnesses and complications such as myocardial infarction and stroke. Effective DKA management involves rehydration, correction of electrolyte imbalances, insulin administration, and addressing precipitating factors. Fluid resuscitation with isotonic saline is vital to restore hydration, and continuous intravenous insulin infusion is the preferred method to control blood glucose and suppress ketone production. Electrolyte imbalances, particularly potassium, sodium, phosphate, and magnesium, require careful monitoring and correction. Clinical outcomes in DKA management include resolving acidosis, normalizing blood glucose, and restoring electrolyte balance, all while achieving and maintaining clinical stability. Complications like cerebral edema and acute respiratory distress syndrome can significantly impact the prognosis. Long-term considerations encompass diabetes management, patient education, and follow-up care.

1060-P: After-Hours Nurse Line Utilization Decreased Call Burden in an Academic Pediatric Endocrinology Practice

Background: Optimal management of childhood diabetes benefits from access to a 24-hour support line. If staffed by on-call physicians, repeated interruptions to sleep can lead to physician burn out. Utilization, and outcomes of an after-hours nurse call service in a pediatric endocrinology practice have not been previously reported. Methods: Barton Schmitt guidelines, which are widely accepted as the standard for telephone triage care, were modified to include our institution specific diabetes management protocols. We analyzed demographics, reasons for call, clinical presentation to the emergency room, and clinical disposition of the callers. Results: After we instituted our after-hours nurse triage service (September 2019), the call burden to the on-call physicians decreased by 70%. Patients who called the after-hours line before coming to the emergency room were less sick (higher pH and lower glucose) and were more likely to be discharged home. We cannot infer causality from our data. Nevertheless, given that <10% of patients called first, encouraging earlier and more consistent utilization of the nurse line seems like a low-cost intervention that might reduce hospital admissions for diabetic ketoacidosis. After-hours service was utilized well by our patients of all races and insurance statuses. We noted that language was a barrier in utilization which is an opportunity for improvement. Disclosure A.Choudhary: None.

National Trends in Hyperglycemia and Diabetic Ketoacidosis in Children, Adolescents, and Young Adults With Type 1 Diabetes: A Challenge Due to Age or Stage of Development, or Is New Thinking About Service Provision Needed?

Adolescence is associated with high-risk hyperglycemia. This study examines the phenomenon in a life course context. A total of 93,125 people with type 1 diabetes aged 5 to 30 years were identified from the National Diabetes Audit and/or the National Paediatric Diabetes Audit for England and Wales for 2017/2018-2019/2020. For each audit year, the latest HbA1c and hospital admissions for diabetic ketoacidosis (DKA) were identified. Data were analyzed in sequential cohorts by year of age. In childhood, unreported HbA1c measurement is uncommon; however, for 19-year-olds, it increases to 22.3% for men and 17.3% for women, and then reduces to 17.9% and 13.1%, respectively, for 30-year-olds. Median HbA1c for 9-year-olds is 7.6% (60 mmol/mol) (interquartile range 7.1-8.4%, 54-68 mmol/mol) in boys and 7.7% (61 mmol/mol) (8.0-8.4%, 64-68 mmol/mol) in girls, increasing to 8.7% (72 mmol/mol) (7.5-10.3%, 59-89 mmol/mol) and 8.9% (74 mmol/mol) (7.7-10.6%, 61-92 mmol/mol), respectively, for 19-year-olds before falling to 8.4% (68 mmol/mol) (7.4-9.7%, 57-83 mmol/mol) and 8.2% (66 mmol/mol) (7.3-9.7%, 56-82 mmol/mol), respectively, for 30-year-olds. Annual hospitalization for DKA rose steadily in age from 6 years (2.0% for boys, 1.4% for girls) and peaked at 19 years for men (7.9%) and 18 years for women (12.7%), reducing to 4.3% for men and 5.4% for women at age 30 years. For all ages over 9 years, the prevalence of DKA was higher in female individuals. HbA1c and the prevalence of DKA increase through adolescence and then decline. Measurement of HbA1c, a marker of clinical review, falls abruptly in the late teenage years. Age-appropriate services are needed to overcome these issues.

Insulin pump therapy is associated with higher rates of mild diabetic ketoacidosis compared to injection therapy: A 2-year Swedish national survey of children and adolescents with type 1 diabetes.

Diabetic ketoacidosis (DKA) in type 1 diabetes (T1D) can occur during both insulin pump therapy (continuous subcutaneous insulin infusion, CSII) and insulin injection therapy (multiple daily injections, MDI). The primary aim of this study was to compare CSII and MDI regarding DKA frequency. A secondary aim was to compare metabolic derangement between CSII and MDI at hospital admission for DKA. RESEARCH DESIGNAND METHODS: Children 0-17.99 years with established T1D admitted for DKA in Sweden from February 1, 2015 to January 31, 2017 were invited to participate. Data regarding demographics, laboratory data, CSII or MDI, and access to ketone meters and CGM were provided through questionnaires and medical records. The Swedish National Diabetes Registry (SWEDIABKIDS) was used to compare the distribution of CSII and MDI in the national population with the population admitted for DKA, using the chi-square goodness-of-fit test. Distribution of CSII and MDI was then categorized in clinical severity grades for mild (pH7.20-7.29), moderate (pH7.10-7.29) and severe DKA (pH <7.10). The distribution of CSII at DKA admission was significantly larger than in the national pediatric population with T1D (74.7% vs. 59.7%, p=0.002). CSII was overrepresented in mild DKA (85.2% vs. with CSII, p < 0.001), but not in moderate/severe DKA (57.9% with CSII, p=0.82). Mean HbA1c at hospital admission was 73.9 mmol/mol with CSII and 102.7 mmol/mol with MDI. CSII was associated with higher risk of mild DKA than MDI. MDI was associated with markedly higher HbA1c levels than CSII at hospital admission for DKA.

Disparities in Utilization and Outcomes With Continuous Subcutaneous Insulin Infusion in Young Adults With Type 1 Diabetes

ObjectiveTo evaluate which factors determine utilization patterns and outcomes of continuous subcutaneous insulin infusion (CSII) in young adults with type 1 diabetes. MethodsUtilizing the Optum deidentified electronic health record data set between 2008 to 2018 to perform a retrospective cohort study, we identified 2104 subjects with type 1 diabetes aged 18 to 30 years. We evaluated the effect of race on determining CSII utilization, HbA1c (%), and hospital admission for diabetic ketoacidosis (DKA). Crude and adjusted estimates were computed using logistic regression and linear mixed models. ResultsThere was low CSII utilization among individuals who were Black, Hispanic, male, and those with governmental insurance. These groups also demonstrated higher HbA1c levels. Subjects who were Black, Hispanic, and those with governmental insurance had higher odds of DKA. Even when commercially insured, Black and Hispanic subjects demonstrated higher HbA1c levels, and Black individuals had higher odds of DKA. ConclusionIn a large electronic health record database in the U.S., there was low CSII utilization overall, particularly in Black and Hispanic minorities, despite CSII showing superior HbA1c control without an increase in DKA events.

Clinical Impact of Residual C-Peptide Secretion in Type 1 Diabetes on Glycemia and Microvascular Complications.

To quantify the relationship of residual C-peptide secretion to glycemic outcomes and microvascular complications in type 1 diabetes. C-peptide was measured in an untimed blood sample in the Scottish Diabetes Research Network Type 1 Bioresource (SDRNT1BIO) cohort of 6,076 people with type 1 diabetes monitored for an average of 5.2 years. In regression models adjusted for age at onset and duration, effect sizes for C-peptide ≥200 vs. <5 pmol/L were as follows: insulin dose at baseline, 27% lower (P = 2 × 10-39); HbA1c during follow-up, 4.9 mmol/mol lower (P = 3 × 10-13); hazard ratio for hospital admission for diabetic ketoacidosis during follow-up, 0.44 (P = 0.0001); odds ratio for incident retinopathy, 0.51 (P = 0.0003). Effects on the risk of serious hypoglycemic episodes were detectable at lower levels of C-peptide, and the form of the relationship was continuous down to the limit of detection (3 pmol/L). In regression models contrasting C-peptide 30 to <200 pmol/L with <5 pmol/L, the odds ratio for self-report of at least one serious hypoglycemic episode in the last year was 0.56 (P = 6 × 10-8), and the hazard ratio for hospital admission for hypoglycemia during follow-up was 0.52 (P = 0.03). These results in a large representative cohort suggest that even minimal residual C-peptide secretion could have clinical benefit in type 1 diabetes, in contrast to a follow-up study of the Diabetes Control and Complications Trial (DCCT) intensively treated cohort where an effect on hypoglycemia was seen only at C-peptide levels ≥130 pmol/L. This has obvious implications for the design and evaluation of trials of interventions to preserve or restore pancreatic islet function in type 1 diabetes.

1303-P: Comparative Performance of a Recurrent Neural Network (RNN) and Logistic Regression (LR) Model to Predict Diabetic Ketoacidosis (DKA) among Youth Postdiagnosis with Type 1 Diabetes (T1D)

Preventing dangerous and costly episodes of DKA is a goal of diabetes care, but clinicians lack tools to predict DKA events. We sought to compare performance characteristics of an RNN model with that of a LR model to predict hospital admission for DKA in the next 180 days. We developed an RNN model using training (n=1453) and testing (n=1530) datasets restricted to youth &amp;lt;18 yo with T1D &amp;gt;30 days. In this sample, 6% (90/1530) of youth were admitted for DKA over 180 days. The model considered &amp;gt;500 features per quarter from discrete medical record data and free-text clinical documents. For comparative purposes, we developed an LR model using a testing dataset derived from the same sample (n=1388). The LR model included 10 evidence-based variables derived from critical review of the literature: number of previous DKAs (p&amp;lt;0.001), most recent A1c (p&amp;lt;0.001), age, gender, race, ethnicity, duration of T1D, days since most recent A1c, multiple daily injections vs. pump therapy, and public vs. private insurance. We used model output parameters to produce probability of DKA admission. RNN yielded an AUC=0.77 [95% CI: 0.71,0.83] while LR produced an AUC=0.79 [95% CI: 0.74,0.85]. We generated rank-ordered lists of the 90 youth with highest probability of DKA admission for both models and measured performance at different thresholds in rank-ordered lists. For ranks 1-5, RNN yielded precision (Pr)=100% (all 5 members on the list experienced a DKA admission) and LR yielded Pr=80%. For ranks 1-10, RNN yielded Pr=100% and LR yielded Pr=70%. For ranks 1-25, RNN yielded Pr=48% and LR yielded Pr=44%. An RNN model, in terms of precision, performs favorably relative to LR in predicting future DKA for a rank-ordered list of youth. Patient lists rank-ordered by DKA risk can be used by clinicians to identify youth with T1D for intensive intervention. Disclosure D.D. Williams: None. S. Dass: None. J. Bass: Employee; Self; Cyft, Inc. S.R. Patton: None. S.N. Mehta: None. R. McDonough: None. C. Mullaney: Employee; Self; Cyft. L. Davolio: Employee; Self; Cyft Inc. M.A. Clements: Consultant; Self; Glooko, Inc. Other Relationship; Self; Glooko, Inc. Funding The Leona M. and Harry B. Helmsley Charitable Trust (G-2017PG-T1D019)

Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database

ObjectiveTo identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators.Research design and methodsThis cross-sectional study...

Diabetic Ketoacidosis (DKA) at Diabetes Diagnosis in Children (0-18 years) in Ontario, Canada: A Population-Based Retrospective Cohort Study of Health Administrative Data

IntroductionDiabetic ketoacidosis (DKA), a life-threatening complication of diabetes, is the leading cause of mortality and disability in children. The high cost of care for DKA and negative consequences of DKA on child’s health are known; however, the pediatric DKA trends in Ontario were not studied in the last fifteen years.&#x0D; Objectives and ApproachTo examine time trends of the prevalence of pediatric DKA at diabetes diagnosis and socio-demographic characteristics associated with the DKA risk (child’s sex; age; geographic region; rural residence; material deprivation and ethnic concentration) in Ontario, Canada. Person-level de-identified data from the provincial registry for all Ontario children (0-18 years) newly diagnosed with diabetes (type 1 and 2) in 2004-2012 was linked with records in the national discharge abstract database (CIHI DAD) at the Institute for Clinical and Evaluative Sciences (ICES). SAS software (v.9.3) was used for Poisson and logistic regressions.&#x0D; ResultsOf 10,617 children diagnosed with diabetes, 15.5% were diagnosed during a hospital admission for DKA. Prevalence of DKA at diagnosis did not change over the nine-year period (ptrend =0.99). There were statistically significant within-province regional differences in DKA prevalence at diabetes diagnosis, with the highest prevalence in South-Western Ontario (17.2%). Younger children (0-6 years and 7-12 years) were at higher DKA risk than 13-18 years old children (adjusted odds ratio (OR) 2.5 95% CI 2.2-2.8 and 2.1 95% CI 1.9-2.4). DKA at diabetes diagnosis was associated with material deprivation in young children (0-6 years)(OR 1.9 95% CI 1.4-2.5 for “most deprived” versus “least deprived”). In the older group (13-18 years), boys were at higher DKA risk than girls (OR 1.4 95% CI 1.1-1.7).&#x0D; Conclusion/ImplicationsPrevalence of pediatric DKA at diabetes diagnosis in Ontario is among the lowest in the world; however, higher DKA prevalence among children residing in some geographic regions or most deprived neighbourhoods of the province despite the universal access to government-funded health care warrants further research.

Identifying all persons in Wales with type 1 diabetes mellitus using routinely collected linked data

IntroductionType 1 diabetes mellitus (T1DM) is an autoimmune condition characterised by hyperglycaemia, caused by the destruction of insulin producing β-cells in the pancreas. Previous epidemiological population level studies of T1DM and its complications have typically used recorded T1DM diagnoses to determine diabetes status and define cohorts.&#x0D; Objectives and ApproachThe objective was to identify all persons with T1DM in Wales from Primary (~70\% population coverage) and Secondary Care (100% coverage) data held in the Secure Anonymised Information Linkage (SAIL) databank. People with a coded T1DM diagnosis (using Read codes in Primary Care data and International Classification of Disease (ICD10) codes in Secondary Care data), plus either insulin prescribed shortly after diagnosis or a hospital admission for diabetic ketoacidosis were identified as having T1DM. A sub-group of this SAIL e-cohort were validated using a register of persons diagnosed with T1DM in Wales under 15 years old (Brecon cohort).&#x0D; Results18,285 people had a T1DM diagnosis and 10,539 had more T1DM than type 2 diabetes mellitus (T2DM) diagnoses. 6,375 persons were identified with T1DM in Primary Care data using our criteria, with a median diagnosis age of 19.2 years (interquartile range 11.0, 35.5). 47.5\% were diagnosed under 18 years of age. 39.6% of people with a T1DM diagnosis did not have T1DM using our criteria. False positive and negative rates of 4.8% and 4.5% respectively were achieved by comparing persons in the SAIL e-cohort against the Brecon cohort. Clinician estimated false positive and negative rates were 1.4% and 3.9% respectively. The prevalence of T1DM in Wales in 2016 was 0.37% or 11,049 people.&#x0D; Conclusion/ImplicationsOur criteria for identifying people with T1DM was more reliable than using diagnosis codes alone, allowing for a more accurate, efficient and reproducible means of identifying individuals with T1DM for researchers utilising the SAIL databank, and other national health repositories.

Trends in Hospital Admission for Diabetic Ketoacidosis in Adults With Type 1 and Type 2 Diabetes in England, 1998-2013: A Retrospective Cohort Study.

This study determined trends in hospital admission for diabetic ketoacidosis (DKA) in adults with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) from 1998 to 2013 in England. The study population included 23,246 adults with T1DM and 241,441 adults with T2DM from the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES). All hospital admissions for DKA as the primary diagnosis from 1998 to 2013 were identified. Trends in hospital admission for DKA in incidence, length of hospital stay, 30-day all-cause readmission rate, and 30-day and 1-year all-cause mortality rates were determined using joinpoint regression, negative binomial regression, and logistic regression models. For T1DM, the incidence of hospital admission for DKA increased between 1998 and 2007 and remained static until 2013. The incidence in 2013 was higher than that in 1998 (incidence rate ratio 1.53 [95% CI 1.09-2.16]). For T2DM, the incidence increased 4.24% (2.82-5.69) annually between 1998 and 2013. The length of hospital stay decreased over time for both diabetes types (P ≤ 0.0004). Adults with T1DM were more likely to be discharged within 2 days compared with adults with T2DM (odds ratio [OR] 1.28 [1.07-1.53]). The 30-day readmission rate was higher in T1DM than in T2DM (OR 1.61 [1.04-2.50]) but remained unchanged for both diabetes types over time. Trends in 30-day and 1-year all-cause mortality rates were also stable, with no difference by diabetes type. In the previous two decades in England, hospitalization for DKA increased in adults with T1DM and in those with T2DM, and associated health care performance did not improve except decreased length of hospital stay.

Antibody-Mediated Extreme Insulin Resistance: A Report of Three Cases

BackgroundType 2 diabetes mellitus is characterized by relative insulin deficiency and insulin resistance. Features suggesting severe insulin resistance include acanthosis nigricans, hyperandrogenism, weight loss, and recurrent hospital admissions for diabetic ketoacidosis. In rare circumstances, hyperglycemia persists despite administration of massive doses of insulin. In these cases, it is important to consider autoimmune etiologies for insulin resistance, such as type B insulin resistance and insulin antibody-mediated extreme insulin resistance, which carry high morbidity and mortality if untreated. Encouragingly, immunomodulatory regimens have recently been published that induce remission at high rates. Methods/ResultsWe describe 3 cases of extreme insulin resistance mediated by anti-insulin receptor autoantibodies or insulin autoantibodies. All cases were effectively treated with an immunomodulatory regimen. ConclusionAlthough cases of extreme insulin resistance are rare, it is important to be aware of autoimmune causes, recognize suggestive signs and symptoms, and pursue appropriate diagnostic evaluation. Prompt treatment with immunomodulators is key to restoring euglycemia in patients with autoimmune etiologies of insulin resistance.

Mauriac Syndrome: Rare Complication in Type-1 Diabetic Children

Mauriac syndrome is rarely noted complication of type-1 diabetic children, which is typically associated with growth failure and delayed pubertal maturation. We have presented a case report of 13 years male adolescent who had multiple hospital admissions for diabetic ketoacidosis.

Risk of death following admission to a UK hospital with diabetic ketoacidosis.

Aims/hypothesisThe aim of this study was to assess the risk of death during hospital admission for diabetic ketoacidosis (DKA) and, subsequently, following discharge. In addition, we aimed to characterise the risk factors for multiple presentations with DKA.MethodsWe conducted a retrospective cohort study of all DKA admissions between 2007 and 2012 at a university teaching hospital. All patients with type 1 diabetes who were admitted with DKA (628 admissions of 298 individuals) were identified by discharge coding. Clinical, biochemical and mortality data were obtained from electronic patient records and national databases. Follow-up continued until the end of 2014.ResultsCompared with patients with a single DKA admission, those with recurrent DKA (more than five episodes) were diagnosed with diabetes at an earlier age (median 14 [interquartile range 9–23] vs 24 [16–34] years, p < 0.001), had higher levels of social deprivation (p = 0.005) and higher HbA1c values (103 [89–108] vs 79 [66–96] mmol/mol; 11.6% [10.3–12.0%] vs 9.4% [8.2–10.9%], p < 0.001), and tended to be younger (25 [22–36] vs 31 [23–42] years, p = 0.079). Antidepressant use was greater in those with recurrent DKA compared with those with a single episode (47.5% vs 12.6%, p = 0.001). The inpatient DKA mortality rate was no greater than 0.16%. A single episode of DKA was associated with a 5.2% risk of death (4.1 [2.8–6.0] years of follow-up) compared with 23.4% in those with recurrent DKA admissions (2.4 [2.0–3.8] years of follow-up) (HR 6.18, p = 0.001).Conclusions/interpretationRecurrent DKA is associated with substantial mortality, particularly among young, socially disadvantaged adults with very high HbA1c levels.Electronic supplementary materialThe online version of this article (doi:10.1007/s00125-016-4034-0) contains peer-reviewed but unedited supplementary material, which is available to authorised users.

Glycogenosis: A Rare Etiology of Transaminitis

Hepatic glycogenosis is a rare etiology of elevated hepatic transaminases reported in the literature. Glycogenosis is associated with uncontrolled diabetes and can be confused with other forms of acute liver injury. This disease can be diagnosed via liver biopsy and reversed by ensuring tight glycemic control. Given this diagnosis is unrecognized but curable, we highlight a case of hepatic glycogenosis in a patient treated at our institution. Patient is a 24 year-old female with past medical history of depression and uncontrolled Diabetes Mellitus Type 1 with recurrent hospital admissions for Diabetic Ketoacidosis (DKA). She presented to the hospital with one day of nausea and vomiting; she was subsequently diagnosed with DKA, and admitted to the intensive care unit for further clinical care. The patient was initiated on fluids and insulin drip for DKA treatment and continued on her home regimen of duloxetine for depression management. Several days into her admission, the patient developed increases in aspartate transaminase (AST) and alanine transaminase (ALT), with initially normal then elevated alkaline phosphatase. Bilirubin and INR remained with normal limits. Over 10 days, lab values peaked with AST of 535, AST of 465, and alkaline phosphatase of 194. Initial serology including HBs Ag, HBc Ab, HCV Ab, CMV, EBV, HIV, ANA, AMA, antiSMA, and ferritin were negative. Given that there was no history of herbal intake or new hepatotoxic medications initiated, suspicion for drug induced liver injury was low, albeit remained on the differential. There were no episodes of hypotension or active infection throughout the admission. A right-upperquadrant ultrasound was performed with unremarkable findings. During previous admissions for DKA, there were similar acute instances of elevated liver-associated enzymes (Figure 1). Given concern of this recurrent transaminitis, a liver biopsy was pursued. Hematoxylin & eosin (H&E) staining revealed glycogen deposits with no hepatitis or fibrosis, convincing for a diagnosis of hepatic glycogenosis (Figure 2).Figure 1Figure 2Hepatic glycogenosis should be suspected in the appropriate clinical situation after other etiologies are ruled out. It is easily treatable with strict glycemic control. Given the reversibility of liver injury in these patients, raising awareness about an underreported and unrecognized disease is undoubtedly clinically significant in medical practice.

Hospital admission for diabetic ketoacidosis or severe hypoglycemia in 31,330 young patients with type 1 diabetes.

To investigate rates and risk factors of hospital admission for diabetic ketoacidosis (DKA) or severe hypoglycemia in young patients with established type 1 diabetes. In total, 31,330 patients with type 1 diabetes (median age 12.7 years) from the Diabetes Patienten Verlaufsdokumentation (DPV) Prospective Diabetes Registry treated between 2011 and 2013 in Germany were included. Admission rates for DKA (pH < 7.3 or bicarbonate <15 mmol/l) and severe hypoglycemia (requiring assistance from another person) were calculated by negative binomial regression analysis. Associations of DKA or hypoglycemia with patient and treatment characteristics were assessed by multivariable regression analysis. The mean admission rate for DKA was 4.81/100 patient-years (95% CI, 4.51-5.14). The highest DKA rates were observed in patients with HbA1c ≥ 9.0% (15.83 (14.44-17.36)), age 15-20 years (6.21 (5.61-6.88)) and diabetes duration of 2-4.9 years (5.60 (5.00-6.27)). DKA rate was higher in girls than in boys (5.35 (4.88-5.86) vs 4.34 (3.95-4.77), P = 0.002), and more frequent in migrants than in non-migrants (5.65 (4.92-6.49) vs 4.57 (4.23-4.93), P = 0.008). The mean admission rate for severe hypoglycemia was 1.45/100 patient-years (1.30-1.61). Rates were higher in migrants compared to non-migrants (2.13 (1.72-2.65) vs 1.28 (1.12-1.47), P < 0.001), and highest in individuals with severe hypoglycemia within the preceding year (17.69 (15.63-20.03) vs patients without preceding hypoglycemia 0.42 (0.35-0.52), P < 0.001). Differences remained significant after multivariable adjustment. The identification of at-risk individuals for DKA (patients with high HbA1c, longer diabetes duration, adolescents, girls) and for severe hypoglycemia (patients with preceding severe hypoglycemia, migrants) may facilitate targeted diabetes counselling in order to prevent these complications.

The effect of deprivation and HbA1c on admission to hospital for diabetic ketoacidosis in type 1 diabetes

Diabetic ketoacidosis is a potentially life-threatening complication of diabetes and has a strong relationship with HbA(1c). We examined how socioeconomic group affects the likelihood of admission to hospital for diabetic ketoacidosis. The Scottish Care Information - Diabetes Collaboration (SCI-DC), a dynamic national register of all cases of diagnosed diabetes in Scotland, was linked to national data on hospital admissions. We identified 24,750 people with type 1 diabetes between January 2005 and December 2007. We assessed the relationship between HbA(1c) and quintiles of deprivation with hospital admissions for diabetic ketoacidosis in people with type 1 diabetes adjusting for patient characteristics. We identified 23,479 people with type 1 diabetes who had complete recording of covariates. Deprivation had a substantial effect on odds of admission to hospital for diabetic ketoacidosis (OR 4.51, 95% CI 3.73, 5.46 in the most deprived quintile compared with the least deprived). This effect persisted after the inclusion of HbA(1c) and other risk factors (OR 2.81, 95% CI 2.32, 3.39). Men had a reduced risk of admission to hospital for diabetic ketoacidosis (OR 0.71, 95% CI 0.63, 0.79) and those with a history of smoking had increased odds of admission to hospital for diabetic ketoacidosis by a factor of 1.55 (95% CI 1.36, 1.78). Women, smokers, those with high HbA(1c) and those living in more deprived areas have an increased risk of admission to hospital for diabetic ketoacidosis. The effect of deprivation was present even after inclusion of other risk factors. This work highlights that those in poorer areas of the community with high HbA(1c) represent a group who might be usefully supported to try to reduce hospital admissions.

Multisystemic Therapy for Adolescents With Poorly Controlled Type 1 Diabetes

OBJECTIVE—The study aim was to determine if multisystemic therapy (MST), an intensive home-based psychotherapy, could reduce hospital admissions for diabetic ketoacidosis (DKA) in youth with poorly controlled type 1 diabetes over 24 months. Potential cost savings from reductions in admissions were also evaluated.RESEARCH DESIGN AND METHODS—A total of 127 youth were randomly assigned to MST or control groups and also received standard medical care.RESULTS—Youth who received MST had significantly fewer hospital admissions than control subjects (χ2 = 11.77, 4 d.f., n = 127; P = 0.019). MST-treated youth had significantly fewer admissions versus their baseline rate at 6-month (P = 0.004), 12-month (P = 0.021), 18-month (P = 0.046), and 24-month follow-up (P = 0.034). Cost to provide MST was 6,934 USD per youth; however, substantial cost offsets occurred from reductions in DKA admissions.CONCLUSIONS—The study demonstrates the value of intensive behavioral interventions for high-risk youth with diabetes for reducing one of the most serious consequences of medication noncompliance.

Adherence to insulin treatment, glycaemic control, and ketoacidosis in insulin-dependent diabetes mellitus

Intensive insulin treatment effectively delays the onset and slows the progression of microvascular complications in insulin-dependent diabetes mellitus (IDDM). Variable adherence to insulin treatment is thought to contribute to poor glycaemic control, diabetic ketoacidosis, and brittle diabetes in adolescents and young adults with IDDM. We assessed the association between the prescribed insulin dose and the amount dispensed from all community pharmacies with the Diabetes Audit and Research in Tayside Scotland (DARTS) database. We studied 89 patients, mean age 16 (SD 7) years, diabetes duration 8 (4) years, and glycosylated haemoglobin (HbA1c) 8.4 (1.9)%, who attended a teaching hospital paediatric or young-adult diabetes clinic in 1993 and 1994. The medically recommended insulin dose and cumulative volume of insulin prescriptions supplied were used to calculate the days of maximum possible insulin coverage per annum, expressed as the adherence index. Associations between glycaemic control (HbA1c), episodes of diabetic ketoacidosis, and all hospital admissions for acute complications and the adherence index were modelled. Insulin was prescribed at 48 (19) IU/day and mean insulin collected from pharmacies was 58 (25) IU/day, 25 (28%) of the 89 patients obtained less insulin than their prescribed dose (mean deficit 115 (68; range 9-246] insulin days/annum). There was a significant inverse association between HbA1c and the adherence index (R2 = 0.39; p < 0.001). In the top quartile (HbA1c > 10%), 14 (64%) of individuals had an adherence index suggestive of a missed dose of insulin (mean deficit 55 insulin days/annum). There were 36 admissions for complications related to diabetes. The adherence index was inversely related to hospital admissions for diabetic ketoacidosis (p < 0.001) and all hospital admissions related to acute diabetes complications (p = 0.008). The deterioration in glycaemic control observed in patients aged 10-20 years was associated with a significant reduction (p = 0.01) in the adherence index. We found direct evidence of poor compliance with insulin therapy in young patients with IDDM. We suggest that poor adherence to insulin treatment is the major factor that contributes to long-term poor glycaemic control and diabetic ketoacidosis in this age group.

Diabetic Ketoacidosis in Prisoners Without Access to Insulin

To assess the cause and clinical severity of diabetic ketoacidosis in male prisoners hospitalized in New York City. Retrospective chart review. A municipal hospital in New York City. Forty-nine adult male prisoners with a total of 54 hospital admissions for diabetic ketoacidosis between January 1, 1989, and June 30, 1991. Charts were reviewed for diabetic and medical history, time from arrest until hospitalization, cause of diabetic ketoacidosis, admission laboratory data, and hospital course. Thirty-eight (70%) of the 54 admissions for diabetic ketoacidosis among prisoners occurred because prisoners had not received insulin during the period immediately following arrest (mean number of days from arrest until hospitalization was 2.5). All of these individuals had a history of insulin-dependent diabetes and were reportedly compliant with their insulin regimen at the time of arrest. Admission laboratory data for this group of prisoners included a mean serum glucose level of 27.4 mmol/L (495 mg/dL) and a mean serum bicarbonate level of 14.4 mmol/L. Mean number of days in the hospital was 3.4 including a mean of 1 day in an intensive care unit. Inadequate access to medication results in serious sequelae for recently arrested prisoners in New York City with insulin-dependent diabetes. Access to health care for recently arrested prisoners needs to be improved.