Hospitalizations For Diabetic Ketoacidosis Research Articles

Diabetic Ketoacidosis and Adverse Outcomes Among Pregnant Individuals With Pregestational Diabetes in the United States, 2010-2020.

To assess the frequency of, risk factors for, and adverse outcomes associated with diabetic ketoacidosis (DKA) at delivery hospitalization among individuals with pregestational diabetes (type 1 and 2 diabetes mellitus) and secondarily to evaluate the frequency of and risk factors for antepartum and postpartum hospitalizations for DKA. We conducted a serial, cross-sectional study using the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project Nationwide Readmissions Database from 2010 to 2020 of pregnant individuals with pregestational diabetes hospitalized for delivery. The exposures were 1) sociodemographic and clinical risk factors for DKA and 2) DKA. The outcomes were DKA at delivery hospitalization, maternal morbidity (nontransfusion severe maternal morbidity (SMM), critical care procedures, cardiac complications, acute renal failure, and transfusion), and adverse pregnancy outcomes (preterm birth, hypertensive disorders of pregnancy, and cesarean delivery) and secondarily DKA at antepartum and postpartum hospitalizations. Of 392,796 deliveries in individuals with pregestational diabetes (27.2% type 1 diabetes, 72.8% type 2 diabetes), there were 4,778 cases of DKA at delivery hospitalization (89.1% type 1 diabetes, 10.9% type 2 diabetes). The frequency of DKA at delivery hospitalization was 1.2% (4.0% with type 1 diabetes, 0.2% with type 2 diabetes), and the mean annual percentage change was 10.8% (95% CI, 8.2-13.2%). Diabetic ketoacidosis at delivery hospitalization was significantly more likely among those who had type 1 diabetes compared with those with type 2 diabetes, who were younger in age, who delivered at larger and metropolitan hospitals, and who had Medicaid insurance, lower income, multiple gestations, and prior psychiatric illness. Diabetic ketoacidosis during the delivery hospitalization was associated with an increased risk of nontransfusion SMM (20.8% vs 2.4%, adjusted odds ratio [aOR] 8.18, 95% CI, 7.20-9.29), critical care procedures (7.3% vs 0.4%, aOR 15.83, 95% CI, 12.59-19.90), cardiac complications (7.8% vs 0.8%, aOR 8.87, 95% CI, 7.32-10.76), acute renal failure (12.3% vs 0.7%, aOR 9.78, 95% CI, 8.16-11.72), and transfusion (6.2% vs 2.2%, aOR 2.27, 95% CI, 1.87-2.75), as well as preterm birth (31.9% vs 13.5%, aOR 2.41, 95% CI, 2.17-2.69) and hypertensive disorders of pregnancy (37.4% vs 28.1%, aOR 1.11, 95% CI, 1.00-1.23). In secondary analyses, the overall frequency of antepartum DKA was 3.1%, and the mean annual percentage change was 4.1% (95% CI, 0.3-8.6%); the overall frequency of postpartum DKA was 0.4%, and the mean annual percentage change was 3.5% (95% CI, -1.6% to 9.6%). Of 3,092 antepartum hospitalizations among individuals with DKA, 15.7% (n=485) had a recurrent case of DKA at delivery hospitalization. Of 1,419 postpartum hospitalizations among individuals with DKA, 20.0% (n=285) previously had DKA at delivery hospitalization. The above risk factors for DKA at delivery hospitalization were similar for DKA at antepartum and postpartum hospitalizations. The frequency of DKA at delivery hospitalization and antepartum hospitalizations for DKA increased between 2010 and 2020 among deliveries in individuals with pregestational diabetes in the United States. Diabetic ketoacidosis is associated with an increased risk of maternal morbidity and adverse pregnancy outcomes. Risk factors for DKA at delivery were similar to those for DKA during the antepartum and postpartum periods.

Challenges in the management of patients with HNF1B MODY and multisystem manifestations: the cases of two adolescent boys.

Hepatocyte nuclear factor-1 beta (HNF1B) encodes a homeodomain-containing transcription factor, which is expressed early in embryogenesis and is involved in the development of multiple tissues and organs. HNF1B mutations cause complex multisystem disorders, with renal developmental disease and maturity onset diabetes of the young (HNF1B MODY), a rare cause of diabetes mellitus, being representative features. We present two adolescent boys from different socioeconomic backgrounds who were diagnosed with genetically confirmed HNF1B MODY following hospitalization for diabetic ketoacidosis in the first case and after diagnostic work-up due to impaired glucose tolerance in the second case. Multisystem manifestations, including pancreatic hypoplasia and early-onset diabetes mellitus (DM), renal cysts, hypomagnesemia, hyperuricemia, liver and biliary impairment, genital tract malformations, and primary hyperparathyroidism were also present, strongly suggesting HNF1B MODY. The first patient was treated with subcutaneous insulin but was lost to follow-up due to social reasons. Conversely, early diagnosis in the second patient allowed the management of multisystem defects by a multidisciplinary team of experts. Moreover, manifestation of HNF1B MODY in the form of diabetic ketoacidosis was prevented and a structured diabetes training program has proven successful in regulating glycemic control, postponing the necessity for insulin treatment. Early genetic work-up of patients with dysglycemia associated with a specific phenotype suggestive of HNF1B MODY is extremely important in the care of children and adolescents with diabetes since it ensures that early and optimal management is initiated, thereby preventing the onset of life-threatening diabetic ketoacidosis and other multisystem complications and/or comorbidities.

Health Care Utilization and Outcomes in Young Adults with Type 1 and Type 2 Diabetes

Abstract Young adulthood can be a challenging time for individuals with diabetes mellitus (DM) as they experience increasing independence and life transitions, which can make it difficult to engage in DM self care. Compared to older adults, young adults are more likely to have higher HbA1c. They also often have lower adherence to standards of care in DM, and higher utilization of emergency department (ED) visits and hospitalizations for DKA. This review describes healthcare utilization and explores factors that may contribute to high HbA1c among young adults with DM. In addition, it discusses the unique healthcare needs of young adults with DM, examines the role of technology in their DM care, and analyzes the effects of social determinants of health on their healthcare utilization.

The association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia. a scoping review

The association between heat exposure and hospitalization for diabetic ketoacidosis, hyperosmolar hyperglycemic state, and hypoglycemia. a scoping review

THU362 A Diagnostic Dilemma: Type 1 Diabetes Vs. Pancreatic Diabetes

Abstract Disclosure: U. Rafat: None. R. Alshantti: None. M. Kim: None. J.L. Gilden: None. Background: Several presentations of diabetes mellitus (DM) do not fit the classic descriptions. Type 1 DM, characterized by immune-mediated destruction of insulin-secreting cells of the pancreas, typically appears before age 40. The first antibodies described associated with development of Type 1 DM were islet cell autoantibodies, and later antibodies to insulin, glutamic acid decarboxylase, protein tyrosine phosphatase, and Zinc transporter 8. Pancreatic DM or type 3c, is characterized by functional deficiency of the pancreas to secrete insulin and maintain glucose homeostasis. It may be caused by acute or chronic pancreatitis, trauma, neoplasia, hemochromatosis, fibrocalculous pancreatopathy, genetics, or idiopathic, and is commonly misdiagnosed as type 2 DM. Case Presentation: We present a 73-year-old Caucasian male with Type 1 DM and retinopathy, neuropathy, hypertension, hyperlipidemia, benign prostatic hyperplasia, obstructive sleep apnea. He was diagnosed with Type 1 DM at age 33 with BMI=29 and hospitalization for diabetic ketoacidosis, and symptoms of polyuria, weight loss, and visual disturbances. He was started with insulin injections. Antibodies were not measured, as they were not widely available at that time. Family history: MI in father and brother and type 2 DM in grandfather. He later started using insulin pump at age 58 for wide fluctuations in blood glucose levels. At age 64, he presented to our endocrine clinic for continued management of assumed autoimmune Type 1 DM. Physical examination: BMI 36, abdominal lipodystrophy, abnormal monofilament with decreased sensations in the left foot. Laboratory: HbA1c=6.7%. c-peptide was low (0.09 ng/mL; normal range: 0.81 - 3.85) with a concomitant BG of 243 mg/dL suggestive of low insulin reserves. After several years, with the development of increased trust, the patient felt confident to reveal a hidden history of extensive alcohol abuse in his 20s, resulting in recurrent episodes of symptoms suggestive of pancreatitis, which required extensive rehabilitation for his drinking problem. He admitted that he had not divulged this history previously. This additional history proved critical to acquiring a correct diagnosis. With this in mind, we deduced that it is highly probable this patient's recurrent bouts of subacute pancreatitis due to alcohol consumption resulted in development of pancreatic DM. Conclusion: Our patient initially presented with the diagnosis of autoimmune type 1 DM. However, after many visits, he first admitted to a past history of long-standing alcohol abuse, which now suggests that he actually has pancreatic DM. Correctly classifying DM can prove crucial to formulating an individualized treatment plan. It is important to note that the classification of DM is not always clear-cut and involves a periodic review of the medical history and clinical characteristics, besides review of laboratory data. Presentation: Thursday, June 15, 2023

THU304 Diabetic Ketoacidosis In Pregnancy: A Nationwide Analysis Of Trend In Hospitalizations, Comorbidities And Outcomes

Abstract Disclosure: V. Master: None. M. Faisaluddin: None. S. Fatima: None. D. Parekh: None. S. Charatz: None. Introduction: Diabetic Ketoacidosis (DKA) is an obstetric emergency associated with high materno-fetal morbidity and mortality. Aim: To analyse the trend of DKA hospitalizations among pregnant women, and to evaluate the comorbidities and in hospital outcomes associated with DKA events in United States. Methods: A national population- based study was conducted in the US. Hospitalizations during pregnancy from 2015 - 2020 were identified using ICD- 10 codes (E101) from Healthcare Cost and Utilization Project (HCUP), National Inpatient Sample (NIS) database. Pregnant women with DKA and without DKA formed the two comparison cohorts. Demographic characteristics, baseline comorbidities, and outcomes such as maternal mortality, fetal mortality, length of stay (LOS), and cost of hospitalization were compared. A two- tailed p-value of p< 0.05 was used to determine the statistical significance. Results: 11,215 out of 14,613,248 hospitalizations during pregnancy were identified with DKA from 2015 - 2020. An increasing trend in DKA hospitalizations per 100,000 pregnancy related hospitalizations was noted, highest in 2017 and 2020. Demographic distribution was similar in both groups. Comorbidities such as pre-eclampsia, eclampsia, gestational hypertension, tobacco and alcohol use were more common in the DKA group (p<0.0001). DKA was associated with higher maternal (0.18% vs 0.01%) and fetal mortality rates (2.9% vs 0.7%) compared to non-DKA group (p<0.0001). The median length of hospital stay was higher (3 days vs 2 days), along with the median cost of hospitalization ($25,248 vs $18,306) among pregnant DKA patients. Other in hospital outcomes such as need for mechanical ventilation, cardiac arrest, cardiac arrhythmias, acute kidney injury, need for dialysis, and septic shock, were all higher in DKA patients (p<0.0001). Conclusion: DKA in pregnancy is associated with high maternal and fetal mortality, longer LOS, higher cost of hospitalizations, and other maternal morbidities, as compared to non-DKA hospitalizations during pregnancy. A high index of suspicion for DKA should be maintained in all pregnant women, along with prompt evaluation and treatment. Presentation: Thursday, June 15, 2023

Diabetic Ketoacidosis in Northern Jordan: Seasonal Morbidity and Characteristics of Patients.

This study aimed to characterize adult patients admitted with diabetic ketoacidosis (DKA) in northern Jordan. The study examined medical records of patients diagnosed with DKA from January 2015 to April 2018. Variables analyzed included diabetes type, precipitating illness, admission month, hospital length of stay, and biochemical markers. Out of 232 admissions with DKA, 70% were diagnosed with type 2 diabetes, and 56% were females. 12% of admissions had a new diagnosis of diabetes, of which 51% had type 2 diabetes. Sepsis (48%), Non-adherence (26%), and diabetic foot infections (18%) were the most encountered precipitating factors for DKA in T1DM. As for T2DM, sepsis (52%), acute coronary syndrome (12%), and pancreatitis (8%) were the most precipitating factors for DKA. High urea levels, high creatinine levels, low phosphorous levels, low hemoglobin levels, and high platelet counts were associated with a longer hospital stay for type 1 diabetes. For type 2 diabetes, low pH on admission, old age, and high Hb A1c within 6 months of admission were factors associated with a prolonged hospital stay. The study found a significant peak of admissions for DKA in both type 1 and type 2 patients in the winter and spring months (Pearson P-value= 0.0013). The results of the present study highlight the seasonal variation in the frequency of DKA hospitalizations. It also highlights sepsis as the most frequent precipitating factor of DKA in both type 1 and type 2 DM patients.

Newly diagnosed type 1 diabetes mellitus in a human immunodeficiency virus-infected patient with antiretroviral therapy-induced immune reconstitution inflammatory syndrome: a case report

BackgroundDiabetes that develops in human immunodeficiency virus (HIV)-infected patients who receive antiretroviral therapy (ART) is usually type 2 diabetes mellitus (T2DM); however, autoimmune diabetes, such as type 1 diabetes mellitus (T1DM) can also develop in this population. After treatment with ART, patients might experience clinical deterioration following an increase in the CD4 cell count, which is termed immune reconstitution inflammatory syndrome (IRIS). Here, we describe an HIV-infected patient on ART who developed T1DMat due to IRIS, highlighting the clinical complexity in diagnosis and treatment.Case presentationA 36-year-old man infected with HIV had a nadir CD4 cell count of 15.53/μL before medication, which increased to 429.09/μL after 9 months of regular ART. The fasting serum glucose at 9 months was between 96 mg/dL and 117 mg/dL. After 11 months of ART, the patient was admitted to hospital for diabetic ketoacidosis (DKA) and Graves’ disease (GD). Noninsulin antidiabetics (NIADs) were prescribed following the resolution of DKA. However, poor glycemic control was noted despite well-titrated NIADs. Further investigation demonstrated poor pancreatic beta cell function and elevated anti-glutamic acid decarboxylase (anti-GAD) and anti-tyrosine phosphatase-like insulinoma antigen 2 (anti-IA2) titers. According to the results, he was diagnosed with T1DM and received multiple daily injections(MDI) of insulin. The regimen of MDI was insulin degludec as basal insulin and insulin aspart as prandial insulin. After MDI therapy, his glycemic control was improved.ConclusionIn this case, T1DM was ascribed to IRIS. Although this phenomenon has been demonstrated in previous case reports, further study is necessary to realize the mechanism of this association. Therefore, we emphasize that when HIV-infected patients on ART experience an unstable blood glucose level and abnormal thyroid function, physicians should consider T1DM and GD associated with ART-induced IRIS to reduce the subsequent complications and more serious endocrine dysfunction.

An "All-Data-on-Hand" Deep Learning Model to Predict Hospitalization for Diabetic Ketoacidosis in Youth With Type 1 Diabetes: Development and Validation Study.

Although prior research has identified multiple risk factors for diabetic ketoacidosis (DKA), clinicians continue to lack clinic-ready models to predict dangerous and costly episodes of DKA. We asked whether we could apply deep learning, specifically the use of a long short-term memory (LSTM) model, to accurately predict the 180-day risk of DKA-related hospitalization for youth with type 1 diabetes (T1D). We aimed to describe the development of an LSTM model to predict the 180-day risk of DKA-related hospitalization for youth with T1D. We used 17 consecutive calendar quarters of clinical data (January 10, 2016, to March 18, 2020) for 1745 youths aged 8 to 18 years with T1D from a pediatric diabetes clinic network in the Midwestern United States. The input data included demographics, discrete clinical observations (laboratory results, vital signs, anthropometric measures, diagnosis, and procedure codes), medications, visit counts by type of encounter, number of historic DKA episodes, number of days since last DKA admission, patient-reported outcomes (answers to clinic intake questions), and data features derived from diabetes- and nondiabetes-related clinical notes via natural language processing. We trained the model using input data from quarters 1 to 7 (n=1377), validated it using input from quarters 3 to 9 in a partial out-of-sample (OOS-P; n=1505) cohort, and further validated it in a full out-of-sample (OOS-F; n=354) cohort with input from quarters 10 to 15. DKA admissions occurred at a rate of 5% per 180-days in both out-of-sample cohorts. In the OOS-P and OOS-F cohorts, the median age was 13.7 (IQR 11.3-15.8) years and 13.1 (IQR 10.7-15.5) years; median glycated hemoglobin levels at enrollment were 8.6% (IQR 7.6%-9.8%) and 8.1% (IQR 6.9%-9.5%); recall was 33% (26/80) and 50% (9/18) for the top-ranked 5% of youth with T1D; and 14.15% (213/1505) and 12.7% (45/354) had prior DKA admissions (after the T1D diagnosis), respectively. For lists rank ordered by the probability of hospitalization, precision increased from 33% to 56% to 100% for positions 1 to 80, 1 to 25, and 1 to 10 in the OOS-P cohort and from 50% to 60% to 80% for positions 1 to 18, 1 to 10, and 1 to 5 in the OOS-F cohort, respectively. The proposed LSTM model for predicting 180-day DKA-related hospitalization was valid in this sample. Future research should evaluate model validity in multiple populations and settings to account for health inequities that may be present in different segments of the population (eg, racially or socioeconomically diverse cohorts). Rank ordering youth by probability of DKA-related hospitalization will allow clinics to identify the most at-risk youth. The clinical implication of this is that clinics may then create and evaluate novel preventive interventions based on available resources.

Diabetic ketoacidosis diagnosis in a hospital setting.

Diabetic ketoacidosis (DKA) is an endocrine emergency that can occur in people with diabetes. Its incidence is estimated to be 220,340 hospital admissions each year. Treatment algorithms include fluid resuscitation, intravenous (IV) insulin infusion, and scheduled electrolyte and glucose monitoring. The misdiagnosis of DKA in the setting of hyperglycemic emergencies results in overtreatment and unnecessary increases in healthcare utilization and costs. The aims of this study were to determine how often DKA is overdiagnosed in the context of other acute hyperglycemic emergencies, to describe the baseline characteristics of patients, to determine the hospital treatments for DKA, and to identify the frequency of endocrinology or diabetology consultation in the hospital setting. A retrospective chart review was conducted utilizing charts from three different hospitals within a hospital system. Charts were identified utilizing ICD-10 codes for admissions to the hospital for DKA. If the patient was over 18 and had one of the diagnostic codes of interest, the chart was reviewed for further details regarding the criteria for DKA diagnosis as well as admission and treatment details. A total of 520 hospital admissions were included for review. DKA was incorrectly diagnosed in 28.4 % of the hospital admissions reviewed, based on a review of the labs and DKA diagnostic criteria. Most patients were admitted to the intensive care unit (ICU) and treated with IV insulin infusion (n=288). Consultation of endocrinology or diabetology occurred in 40.2 % (n=209) of all hospital admissions, and 128 of those consults occurred in ICU admissions. The diagnosis of DKA was incorrect in 92 of the patients admitted to the medical surgical unit (MSU) and in 49 of patients admitted to the ICU. Almost one third of hospital admissions forhyperglycemic emergencies were misdiagnosed and managed as DKA. DKA diagnostic criteria are specific; however, other diagnoses like hyperosmolar hyperglycemic syndrome (HHS), hyperglycemia, and euglycemic DKAcan make an accurate diagnosis more complicated. Education directed at improving the diagnostic accuracy of DKA among healthcare providers is needed to improve diagnostic accuracy, ensure the appropriate use of hospital resources, and potentially reduce costs to the healthcare system.

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.

Machine learning prediction models and nomogram to predict the risk of in-hospital death for severe DKA: A clinical study based on MIMIC-IV, eICU databases, and a college hospital ICU

AimTo establish a prediction model and assess the risk factors for severe diabetic ketoacidosis (DKA) in adult patients during the ICU. IntroductionWith DKA hospitalization rates consistently increasing, in-hospital mortality has become a growing concern. MethodsDKA patients aged >18 years old in the US-based critical care database (Medical Information Mart for Intensive Care (MIMIC-IV)) were considered. Independent risk factors for in-hospital mortality were screened using extreme gradient boosting (XGBoost) and the Bayesian information criterion (BIC) optimal subset regression. One predictive model was developed using machine learning extreme gradient boosting (XGBoost), and the other one was a nomogram based on logistic regression to estimate risks of in-hospital mortality with severe DKA. Established models were assessed by using internal validation and external validation. The MIMIC-IV was split into training and testing samples in a 7:3 ratio. The eICU Collaborative Research Database and admissions data from the department of critical care medicine of the first affiliated hospital of Harbin medical university were used for independent validation. The discriminatory ability of the model was determined by illustrating a receiver operating curve (ROC) and calculating the C-index. Meanwhile, the calibration plot and Hosmer-Lemeshow goodness-of-fit test (HL test) was conducted to evaluate the performance of our new build model. Decision curve analysis (DCA) was performed to assess the clinical net benefit. Net Reclassification Improvement (NRI) was used to compare the predictive power of the two models. ResultsA multivariable model that included acute physiology score III (APS III), the highest levels of blood plasma osmolality (osmolarity_max), minimum osmolarity (osmolarity_min)/osmolarity _max, vasopressor, and the highest levels of blood lactate was represented as the nomogram. The C- index of the nomogram model was 0.915 (95% CI: 0.966–0.864) in the training dataset and 0.971 (95% CI: 0.992–0.950) in the internal validation. The nomogram’s sensitivity was well according to all data's HL test (P > 0.05). DCA showed that our model was clinically valuable. The XGB (extreme gradient boosting) model achieved an AUC (area under the curve) of 0.950 (95% CI, 0.920–0.980); however, the nomogram model made was more effective than XGB based on NRI. ConclusionThe predictive XGB and nomogram models for predicting in-hospital patient deaths with DKA were effective. The forecast models can help clinical physicians promptly identify patients at high risk of DKA, prevent in-hospital deaths, and promptly intervene.

Reduced acute diabetes events after FreeStyle Libre® system initiation in people 65 years or older with type 2 diabetes on intensive insulin therapy in France.

Background and aims Older people with type 2 diabetes (T2DM) on insulin are at increased risk of hypoglycemia and associated morbidity. Management of T2DM in older people must optimize glycemic control while minimizing risks for hypoglycemia and diabetic ketoacidosis (DKA). In France, the FreeStyle Libre® system (FSL) has been reimbursed since June 2017 for T2DM on intensive insulin therapy. We assessed the impact of starting FSL on hospitalizations for acute diabetes events (ADEs) in people ≥65 years old, with T2DM on intensive insulin therapy. Materials and methods A retrospective study on the French SNDS claims database was conducted on people ≥65 years old with T2DM, treated with MDI or insulin pump and starting FSL between 01/08/2017 to 31/12/2018. The analysis covered claims data for 12 months before, and up to 24 months after FSL initiation. Hospitalizations for severe hypoglycemia (SH), DKA, comas and hyperglycemia were identified using ICD-10 codes. Results We identified 38,312 people with T2DM ≥65 years old on intensive insulin therapy initiating FSL during the selection period. Hospitalizations for ADEs were observed in 1.6% of subjects in the 12 months before FSL initiation, compared to 1.05% after 12 months and 0.96% after 24 months, a 34% and 40% reduction, driven by fewer DKA admissions after 12 months and by fewer SH admissions at 24 months. Conclusions These results indicate that FSL can reduce hospitalization for ADEs in this vulnerable older population of adults aged 65 years and older with T2DM on intensive insulin therapy, in whom optimal glycemic control must be achieved while minimizing risk of hypoglycemia and other ADEs.

Evaluating the Efficacy and Safety of Long-Acting GLP-1 Receptor Agonists in T1DM Patients

(1) Background: Glucagon-like peptide 1 receptor agonists (GLP-1 RA) are a class of therapeutic agents that mimic the endogenous incretin hormone GLP-1. While this class of agents is not approved for Type 1 Diabetes (T1DM) due to concern of increased diabetic ketoacidosis (DKA) risk, long-acting GLP-1 medications are being commonly prescribed off label for T1DM in clinical practice. Several studies addressed the efficacy and safety of short-acting GLP-1 agonists therapy in patients with T1DM, but the data on long-acting agents are lacking. In our study, we aim to fill in this gap and help healthcare providers in their clinical decision making on the use of these agents for T1DM patients. (2) Methods: We conducted a retrospective chart review of T1DM patients on a long-acting GLP-1 for at least six months. Our retrospective chart review included information starting two years prior to starting GLP-1, and six or more months after starting GLP-1. Parameters collected included HbA1c, 14-day Continuous Glucose Monitor (CGM) and blood glucose (BG) data, and metabolic data (weight, systolic and diastolic blood pressure, and cholesterol levels). Statistical analysis was conducted using paired t-tests on R and Excel with α of 0.05. (3) Results: Our cohort consisted of 54 participants with T1DM on a long-acting GLP-1 (semaglutide, dulaglutide, exenatide extended-release [ER], albiglutide). Mean GLP-1 treatment duration was 23.85 ± 15.46 months. HbA1c values decreased significantly by an average of 0.71% percentage points (%-points, p = 0.002) comparing pre-therapy vs. on GLP-1 treatment. Similarly, for pre-therapy vs. on GLP-1 treatment values, CGM results were significant for increased time in range by 12.15%-points (p = 0.0009) showing a decreased average time in hyperglycemia (BG > 180 mg/dL) by a mean difference of 11.97%-points (p = 0.006), decreased 14-day mean BG by 19 mg/dl (p = 0.01), decreased 14-day BG standard deviation by 8.45 mg/dl (p = 0.01), decreased incidence of DKA hospitalization, and a decrease in weight by 3.16 kg (p = 0.007). (4) Conclusions: As more data emerges on cardiovascular and renal benefits of long acting GLP-1 in type 2 diabetes, there have been no reported outcomes in T1DM. Our study is the first to demonstrate glycemic and metabolic benefits of this class of medication as an adjunct therapy to insulin in T1DM, and safety of its use over an average of 1.5–2 years’ time. This study represents real life experience and the data warrants confirmation by additional prospective studies.

Incidence of new-onset type 1 diabetes during Covid-19 pandemic: A French nationwide population-based study

AimThe association between infection with SARS-CoV-2 and the development of new-onset type 1 diabetes mellitus (T1DM) is unclear. The aim of this study was to examine the impact of the Covid-19 pandemic on the hospitalization rates for new-onset T1DM and diabetic ketoacidosis at diagnosis, in metropolitan France. MethodsThis nationwide retrospective cohort study included hospital data on all patients aged 1 to 35 years old, hospitalized in France due to onset of T1DM, in 2020 and 2021 compared to 2019. ResultsApart from a decrease during the lockdown in 2020, the number of hospitalizations due to new-onset T1DM was not significantly different in 2020 and 2021 than it was in 2019. In the regions most affected by Covid-19 and covering 7,995,449 inhabitants aged from 1 to 35 years old, standardized hospitalization rates were not significantly different in 2020 and in 2021 compared with 2019. The number of hospitalizations for diabetic ketoacidosis at diagnosis was not significantly different after week 14 in 2020 and in 2021 compared with 2019. ConclusionIn this nationwide study, the incidence of hospitalizations for new-onset T1DM and the incidence of diabetic ketoacidosis at diagnosis was not increased during the Covid-19 pandemic in 2020 and 2021. Our results support the fact that infection with SARS-CoV-2 does not promote the development of T1DM.

Abstract 10436: Spontaneous Hemopericardium After Rivaroxaban

Direct oral anticoagulants (DOACs) such as rivaroxaban have become the drugs of choice when treating a variety of conditions requiring anticoagulation. We describe a case of a patient found to have hemopericardium with tamponade physiology on a routine echo ordered for evaluation of tachycardia. A 49-year-old man with systemic hypertension was found to have a right lower lobe pulmonary embolus (PE) during a hospitalization for diabetic ketoacidosis complicated by pneumoperitoneum s/p small bowel resection. Rivaroxaban 15 mg twice daily was initiated for treatment of PE. On day 2 rivaroxaban, patient became tachycardic. Chest CT showed a small to moderate pericardial effusion with pericardial enhancement. On day 7, a echo showed trivial pericardial effusion without hemodynamic compromise. Tachycardia persisted after hospital discharge, but patient was otherwise asymptomatic. Patient transitioned to rivaroxaban 20 daily after 3 weeks. Outpatient echo done 2 months after discharge showed a large pericardial effusion with tamponade physiology. Patient was instructed to go to hospital for admission. Labs were significant for Hgb 7.8, and elevated PT 52.50, INR 4.5 and PTT 33.80. Rivaroxaban was held, and patient was given 2 units FFP, Vitamin K 10 mg oral, Kcentra 4208 units and 2 units pRBCs. Patient underwent a pericardiocentesis with removal of 600 cc of sanguineous fluid. Fluid analysis was consistent with hemorrhagic effusion. Repeat echo showed a small residual, anterior pericardial effusion with constrictive physiology. Patient was discharged on reduced dose of rivaroxaban 10 daily and Vitamin K 5 mg daily until outpatient follow up. Our case of hemopericardium occurring in a middle-aged man without confounding issues is unusual. Although hemopericardium with DOACs have been reported, the majority of cases have occurred in patients with pre-disposing risk factors. A systemic review of 26 cases by Asad, et al. described risks associated with cardiac tamponade with DOACs. The incidence of hemopericardium and tamponade appeared highest in elderly men with renal and coagulation abnormalities. Our case highlights the importance of vigilance in patients on DOACs who present with subtle symptoms suggestive of hemodynamic compromise or instability.

An Audit of Factors Impacting the Time to Resolution of the Metabolic Parameters in Diabetic Ketoacidosis Patients.

Diabetic ketoacidosis (DKA) is a major complication affecting patients with diabetes. It is often the first presentation of type I diabetes and can also occur due to a lack of compliance with insulin therapy or infection, among other causes. Hospitalizations for DKA have increased globally among patients with type I and type II diabetes, which poses a strain on health systems. To determine the factors impacting the time to resolution of metabolic parameters in DKA patients. This retrospective study was performed by reviewing the clinical records of hospitalized DKA patients at King Fahad Specialist Hospital, a tertiary-level healthcare center in Buraidah, Al Qassim region, Saudi Arabia. The study included all DKA admissions that met the inclusion criteria between September 2019 and April 2022. A total of 129 patients with a diagnosis of DKA from January 2019 to April 2022 were identified. Of these, 67 patients met the inclusion criteria. More females experienced DKA (56.7%), and the study population had an improvement rate of 97%. The mean length of stay (LOS) for patients with DKA was 73.19 hours, and the median time for DKA resolution was 15 hours (mean time 21.38 hours). The omission of insulin was the leading precipitating factor for DKA (43%) followed by infection (12%). A high serum bicarbonate (HCO3) level was identified as an independent predictor for a longer time to resolution. Patients with DKA who have high glucose levels on admission, higher body mass index (BMI), older age, and higher weight stayed in the hospital for extended periods. Conversely, patients with a higher serum potential of Hydrogen (pH) had a shorter LOS. Age was the only clinically independent predictor for a minimum LOS for DKA. Patients with comorbidities had a longer hospital LOS than patients without comorbidities; no such relationship has been reported in other studies. Patients in our study population had a longer time of resolution than observed in other studies, although no clear cause was identified. This study contributes to our understanding of DKA in hospitalized patients in Saudi Arabia. This is the first study to link patients with DKA who have comorbidities to a longer hospitalstay in the kingdom of Saudi Arabia. This study also identified multiple clinical and biochemical parameters related to the variability in LOS and time to resolution of DKA in hospitalized patients.

ODP259 Evaluating the Efficacy and Safety of Long-Acting GLP-1 Receptor Agonist in T1DM Patients

Abstract Introduction GLP-1 receptor agonist is a medication class that mimics the endogenous incretin hormone GLP-1. Short-acting GLP-1 agents were studied as adjunct therapies in type 1 diabetes (T1DM) but not approved due to concern of increased diabetic ketoacidosis (DKA) risk. Long-acting GLP-1 medications are still commonly prescribed for T1DM patients. One study has assessed the impact of a long-acting GLP-1 in 11 T1DM patients. No hospitalizations were observed, and time in range was not reported. [1] Our study aims to evaluate the efficacy and safety of long-acting GLP-1 medications in a larger cohort of T1DM patients. Methodology We conducted a retrospective chart review of T1DM patients taking a long-acting GLP-1 for at least three months. ICD-10 code E10. Type 1 diabetes mellitus was used to search our institution's Electronic Health Record system (EPIC). Primary parameters collected included A1C and glycemic trends. Data analysis was done by averaging values over a two-year period before and after starting the medication. Results We identified 27 participants with T1DM (mean age 42yrs, mean T1DM duration 18.1yrs) on a long-acting GLP-1 (semaglutide 70.4%, dulaglutide 33.3%, long-acting exenatide 3.7%, albiglutide 3.7%). Mean therapy duration was 24.28±19. 01mo. A1C values decreased significantly from7.61±1. 08% to 7.16±0.73% (p=0. 015, N=25). Per CGM data, average time in range (TIR) increased significantly from48.82±22.35% to64.70±16.58% (p=0. 0002, N=15), average time in hyperglycemia decreased from42.39±23.32% to 31.58±16.65% (p=0. 019, N=14) and 14-day blood mean glucose decreased from 190.40±38.42 mg/dl to 167. 06±25.86 mg/dl (p=0. 001, N=17). There were no statistically significant differences in time in hypoglycemia and incidence of DKA. Hyperglycemic and hypoglycemic episodes were defined per patients’ individualized CGM settings (most commonly Blood Glucose levels>180 and <70 respectively). Patients’ weight decreased non-significantly from182. 00±50.92 lbs to 170.88±51.37 lbs (p=0.128, N=8). There were no ER visits or hospitalizations for DKA while on GLP-1 therapy. Conclusion There is an urgent need for strategies to improve glycemic control and reduce morbidity and mortality in T1DM. Long-acting GLP-1s are a promising adjunct to insulin. Our study is the first to demonstrate significant A1C reduction and TIR increase without increased hypoglycemia and DKA risk in 27 T1DM patients on long-acting GLP-1s. Longer prospective studies are warranted. Presentation: No date and time listed

ODP159 A Rare Case of Pembrolizumab Induced Diabetic Ketoacidosis

Abstract Introduction Immune checkpoint inhibitors (ICI), such as Pembrolizumab, have demonstrated excellent clinical outcomes in numerous solid organ malignancies. However, this new drug comes with unpredictable adverse reactions which are still under review in the medical literature. We are showcasing a cancer patient treated with an ICI and presenting to the hospital in diabetic ketoacidosis (DKA), despite no significant history of a formal diagnosis of Diabetes Mellitus. Case description The patient is a 69 year old male who presented to the hospital with generalized weakness. His past medical history was significant but not limited to, Hypothyroidism, Tobacco use disorder, Stage IV Siewert type 2 gastroesophageal junction adenocarcinoma (cT4N2M1, HER2/FGFR negative, PD-L1 positive) after completion of one year of chemotherapy. He was now undergoing immunotherapy with Pembrolizumab, with his first dose three weeks ago. Reviews of systems including fever, abdominal pain, nausea, vomiting, polyuria, polydipsia were negative. Vital signs were grossly normal. He gave no personal or family history of diabetes. On admission venous blood gas demonstrated a high anion gap metabolic acidosis (pH 7. 096, Blood glucose 762 mg/dL, Anion Gap 29 mmol/L, bicarbonate 9 mmol/L, Plasma osmolality 337 mOsm/kg). Serum Lipase was 23 U/L. HbA1c was found to be 5.9%. Urinalysis was significant for glucose >500 mg/dl and >80 mg/dl of ketones. The physical exam was only remarkable for dry mucous membranes. Given the presentation and lab findings, he was subsequently diagnosed with DKA. The patient was treated with standard guideline therapy for DKA including bolus fluids, maintenance fluids and intravenous (IV) Insulin. The Anion gap closed and glucose decreased to under 200. He was transitioned to a subcutaneous insulin regimen, and discharged on the same. Discussion Based on diagnostic workup and exclusion of probable aetiologies, the patient was diagnosed with pembrolizumab-induced DKA. In the acute care setting, an autoimmune workup was not done in our patient. A meta analysis review of 71 such cases from 56 publications showed the average HbA1c concentration was 7.84% + 1. 0% at presentation. The A1c finding of 5.9%, defined at pre-diabetes, in represents an outlier. Another meta-analysis of such patients demonstrated DKA as the first sign of diabetes in 30 out of 35. The pathophysiology of this side effect of ICI's remains unknown, however several mouse studies have shown PD-1/PD L1 blockade precipitating diabetes in prediabetic non-obese mice. Anti -PD-1 drugs might have the same effect, and the reduction of PD-1 might activate autoreactive T cells, resulting in an autoimmune response against pancreatic islet cells. As the use of immunotherapy is expected to increase, it is essential that clinicians become aware of DKA as a rare and life threatening side effects of immunotherapy and that blood glucose monitoring is strongly considered as a method of prevention. Presentation: No date and time listed

Commentary on the T1D exchange quality improvement collaborative learning session November 2022 abstracts.

The T1D Exchange Quality Improvement Collaborative (T1DX-QI) continues to be a leader in driving innovation advancements in type 1 diabetes (T1D) care.1 With over 50 diabetes centers in its consortium across the United States, including 32 pediatric and 18 adult centers, T1DX-QI has been able to capture T1D electronic medical record data on over 55 000 people with T1D. Through patient and parent partners, an engaged group of multidisciplinary healthcare providers, and an advisory board specifically focused on racial-ethnic equity, T1DX-QI has been able to glean vital insights about real-world diabetes care and outcomes, especially among those underserved and traditionally excluded from research.2 This year′s quality improvement conference covers some of the most pressing issues in diabetes care, with a focus on using technology to improve outcomes in high-risk underserved populations. Several abstracts, contributed by Noland, Lockee, Kaplin, and Izquierdo, describe use of big data and artificial intelligence algorithms to identify patients at high risk for a variety of complications, including poor glycemic outcomes, hospitalizations for diabetic ketoacidosis, and long-term complications.3-6 One abstract by Vandervelden details how the development of a T1D dashboard enabled better population health management through identification and systematic tracking of high-risk patients.7 A new QI portal dedicated to improving healthcare clinic self-monitoring and facilitating sharing of ideas has been described. This may be a model for other learning health networks to build cross-collaboration.8 These ways of harnessing real-world data have the potential to identify new at-risk populations and drive change in clinical care using QI methodologies.9, 10 Another theme of the abstracts has been a hot topic in much of the literature: continuous glucose monitoring and insulin pump equity in T1D were explored by Adams, Gandhi, Wong, and Mathias.11-14 Inequity in diabetes technology has been demonstrated in numerous studies from the T1D Exchange network based on the US population15 and in comparison to a population from the German/Austrian Diabetes-Patienten-Verlaufsdokumentation registry.16 These and other papers underscore how critical and pervasive the inequity remains. Although acknowledgement of these issues continues to be vitally important, what is exciting about the abstracts this year is that many diabetes centers have started to develop and test solutions to improve technology use among underserved populations.11-14 Interventions ranging from better outreach and tracking of patients who are eligible but may not be using technology16 to race-targeted approaches that change workflows or lower barriers for technology eligibility17, 18 and modification of clinical pathways to prescribe, authorize, and support underserved patients while using technology are all explored by Wong, Virani, and Byer-Mendoza.13, 19, 20 Future work will continue to enable cross-pollination of interventions such that a suite of possible solutions to form a change package may eventually be developed to be employed by clinics outside of the network. The last major focus of abstracts is the important topic of screening for social determinants of health in diabetes care. Multiple clinics have explored how to incorporate social determinants of health screening into current workflows,10, 11, 19, 21, 22, some using manual processes, others using electronic medical record systems and leveraging institution-wide initiatives in primary care or pediatrics to achieve specialty-care level reach.10 Overall, these abstracts show that screening for social determinants of health is feasible; valued by providers, patients, and institutions; and has potential for significant impact on addressing the unmet needs of vulnerable populations who are often at highest risk for short- and long-term complications. This year has been an exciting time of major strides for the T1D Exchange Collaborative, keeping current issues at the forefront of clinical real-world care. T1DX will continue to search for new ways to drive change for patients and their families, using novel QI methodology, stakeholder engagement, and data-driven approaches. Future directions may include diabetes technology data integration in the electronic medical record, new psychosocial care models that address highly prevalent psychological issues in people with T1D, and shared decision aids that promote patient-centered care in diabetes. OE conceptualized the manuscript. SA wrote the manuscript. SM, NR, and RR reviewed/edited and approved final versions of the manuscript. OE, NR are the guarantors of this work. All members of the T1DX-QI Collaborative, patients, and partners. The Helmsley Charitable Trust funds the T1DX-QI Collaborative. SA is a healthcare disparities advisor for Beta Bionics and Medtronic. NR has no disclosures. SM has no disclosures. OE is a member of the Medtronic Diabetes Health Equity Advisory Board; He is the Principal Investigator for research projects funded by Eli Lilly &Co, Medtronic Diabetes, Abbott Laboratories, and Dexcom Inc. All the funds for these industry-funded projects and board roles are paid directly through his organization, T1D Exchange. RR is Associate Editor for Journal of Diabetes.