Presence Of Diabetic Ketoacidosis Research Articles

Diabetic ketoacidosis in patients with maturity onset diabetes of the young.

Maturity onset diabetes of the young (MODY) is the most frequent monogenetic diabetes form. MODY is caused by mutations in genes important for development and function of pancreatic beta-cells, resulting in impaired insulin secretion capacity. Up to now, 14 different types have been described. The inheritance pattern is autosomal dominant, leading to a strong family history with more than three affected generations. Young age at diagnosis and lack of pancreatic autoantibodies are further characteristics of MODY. The presence of diabetic ketoacidosis (DKA) was long regarded as an exclusion criterion for MODY. However, in the recent years several case reports on MODY patients presenting with DKA have been published. The present study aims at giving an overview on the current knowledge of DKA in MODY patients, with a collection of published case studies as a prerequisite for this review.

The INNODIA Type 1 Diabetes Natural History Study: a European cohort of newly diagnosed children, adolescents and adults

Aims/hypothesisType 1 diabetes is an heterogenous condition. Characterising factors explaining differences in an individual’s clinical course and treatment response will have important clinical and research implications. Our aim was to explore type 1 diabetes heterogeneity, as assessed by clinical characteristics, autoantibodies, beta cell function and glycaemic outcomes, during the first 12 months from diagnosis, and how it relates to age at diagnosis.MethodsData were collected from the large INNODIA cohort of individuals (aged 1.0–45.0 years) newly diagnosed with type 1 diabetes, followed 3 monthly, to assess clinical characteristics, C-peptide, HbA1c and diabetes-associated antibodies, and their changes, during the first 12 months from diagnosis, across three age groups: <10 years; 10–17 years; and ≥18 years.ResultsThe study population included 649 individuals (57.3% male; age 12.1±8.3 years), 96.9% of whom were positive for one or more diabetes-related antibodies. Baseline (IQR) fasting C-peptide was 242.0 (139.0–382.0) pmol/l (AUC 749.3 [466.2–1106.1] pmol/l × min), with levels increasing with age (p<0.001). Over time, C-peptide remained lower in participants aged <10 years but it declined in all age groups. In parallel, glucose levels progressively increased. Lower baseline fasting C-peptide, BMI SD score and presence of diabetic ketoacidosis at diagnosis were associated with lower stimulated C-peptide over time. HbA1c decreased during the first 3 months (p<0.001), whereas insulin requirement increased from 3 months post diagnosis (p<0.001).Conclusions/interpretationIn this large cohort with newly diagnosed type 1 diabetes, we identified age-related differences in clinical and biochemical variables. Of note, C-peptide was lower in younger children but there were no main age differences in its rate of decline.Graphical

Diabetic Ketoacidosis at Onset of Type 1 Diabetes and Glycemic Outcomes with Closed-Loop Insulin Delivery.

The presence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) is associated with higher glycated hemoglobin levels over time. We evaluated whether hybrid-closed loop (HCL) therapy from onset of T1D could prevent the adverse impact of DKA at diagnosis on long-term glycemic outcomes. This was a posthoc analysis from 51 adolescents using HCL from diagnosis of T1D as part of the CLOuD trial (NCT02871089). We compared glycemic and insulin metrics between adolescents with (n = 17) and without (n = 34) DKA at diagnosis. Participants with and without DKA at diagnosis had similar time in target glucose range 3.9-10.0 mmol/L (70-180 mg/dL), time below range (<3.9 mmol/L, <70 mg/dL) and HbA1c at 6, 12, and 24 months. While insulin requirements at 6 months were higher in those with DKA at diagnosis, this was not statistically significant after adjusting for bodyweight. Residual C-peptide secretion was similar between groups. We conclude that HCL therapy may mitigate against the negative glycemic effects of DKA at T1D diagnosis.

Clinical Utility and Outcome Prediction of Early ZnT8-IgG Testing and Titer in Type 1 Diabetes

Type 1 diabetes autoantibodies are directed against multiple antigens including: glutamic acid decarboxylase, protein tyrosine phosphatase-like islet antigen 2 (IA2), insulin (IAA), and Zinc transporter 8 protein (ZnT8). The aim of our study was to determine if the presence or titer of ZnT8 antibodies (Ab) was predictive for clinical presentation at diagnosis or for the subsequent disease course. Between January, 2003 and May, 2019, 105 patients aged ≤21 years with a clinical diagnosis of type 1 diabetes mellitus had at least 1 autoantibody measured. A retrospective chart review was completed. At diagnosis, we evaluated the body mass index z-score, hemoglobin (HbA1c), and the presence of diabetic ketoacidosis (DKA). Complications analyzed post-diagnosis included episodes of DKA, the diagnosis of autoimmune disease, and the presence of vascular complications. We evaluated cumulative lifetime excess glucose as HbA1c area under the curve (AUC) >6%. Seventy-one patients were ZnT8-Ab(+) (68%), with 19 having low titer ZnT8-Ab and 52 with high titer ZnT8-Ab. Follow-up ranged from 10 days to 15.7 years (median 2.08 years). There were no differences in the characteristics at disease onset or in the subsequent follow-up between those with and those without ZnT8-Ab or those with high or low titers of ZnT8 Ab, except for a small but statistically significant difference in cumulative excess glucose (HbA1c AUC >6%) between those with low and high titers (p=0.0095). Our study adds to the limited literature on the effect of the presence and titer of ZnT8-Ab in pediatric diabetes. The small effect of ZnT8-Ab titer on glucose excess as measured by HbA1c AUC warrants further study.

Neutrophil-to-Lymphocyte Ratio Adds Valuable Information Regarding the Presence of DKA in Children with New-Onset T1DM.

Diabetic ketoacidosis (DKA) is an acute life-threatening complication occurring mainly at the onset of type 1 diabetes mellitus. The neutrophil-to-lymphocyte ratio (NLR), a marker for systemic inflammation, has recently generated increasing interest in many chronic diseases. The aim of this cross-sectional study was to determine the value of the neutrophil-to-lymphocyte ratio (NLR) in association with DKA severity across these cases. A total of 155 children with new-onset type 1 DM from one large center were included in the study. Total and differential leukocyte counts were measured upon admission and calculation of the NLR was performed. Patients were classified into four groups: without DKA, mild, moderate, and severe DKA at disease onset. Total WBCs, neutrophils, and monocytes increased with DKA severity (p-value < 0.005), while eosinophiles displayed an inverse relationship (p-value < 0.001). Median NLR scores increased from those without ketoacidosis (1.11) to mild (1.58), moderate (3.71), and severe (5.77) ketoacidosis groups. The statistical threshold value of the NLR in predicting DKA was 1.84, with a sensitivity of 80.2% and a specificity of 80%. Study findings indicate that a higher NLR score adds valuable information regarding the presence of DKA in children with new-onset T1DM.

Increased Presentation of Diabetic Ketoacidosis and Changes in Age and Month of Type 1 Diabetes at Onset during the COVID-19 Pandemic in Spain.

Objective: To assess the impact of the COVID-19 pandemic and lockdown measures on the presenting characteristics (age at diagnosis, severity, monthly distribution) of newly diagnosed type 1 diabetes in Spanish children. Research Design and Methods: An ambispective observational multicenter study was conducted in nine Spanish tertiary-level hospitals between January 2015 and March 2021. Inclusion criteria: new cases of type 1 diabetes in children (0–14 years) recording age, sex, date of diagnosis, presence of diabetic ketoacidosis (DKA) at onset, and severity of DKA. Data were compared before and during the pandemic. Results: We registered 1444 new cases of type 1 diabetes in children: 1085 in the pre-pandemic period (2015–2019) and 359 during the pandemic (2020–March 2021). There was a significant increase in the group aged ≤4 years in the pandemic period (chi-squared = 10.986, df 2, p = 0.0041). In 2020–2021, cases of DKA increased significantly by 12% (95% CI: 7.2–20.4%), with a higher percentage of moderate and severe DKA, although this increase was not significant. In 2020, there was a sharp decrease in the number of cases in March, with a progressive increase from May through November, higher than in the same months of the period 2015–2019, highlighting the increase in the number of cases in June, September, and November. The first three months of 2021 showed a different trend to that observed both in the years 2015–2019 and in 2020, with a marked increase in the number of cases. Conclusions: A change in monthly distribution was described, with an increase in DKA at onset of type 1 diabetes. No differences were found in severity, although there were differences in the age distribution, with an increase in the number of cases in children under 4 years of age.

364-OR: Apolipoprotein A-I and Clinical Remission in Adults with Type 1 Diabetes-InLipoDiab1 Study

Introduction: Apolipoprotein A-I (Apo A-I) , the main protein in high-density lipoproteins, improves beta-cell function and insulin sensitivity in experimental models and in people with type 2 diabetes. In those with type 1 diabetes (DM1) , clinical remission (CR) is a key factor for improved prognosis. However, predictors of CR in DM1 are not well described. Whether Apo A-I predicts CR in patients with DM1 remains unknown. Aim To assess the relationship between baseline Apo A-I at the time of diagnosis of DM1 with the presence of CR after 12 months of the disease. Methods: The participants of Insulin Therapy and Lipoproteins' Profile in Type 1 Diabetes Study (InLipoDiab1; NCT02306005) were prospectively observed from the onset of the disease (the blood collection was performed before exogenous insulin administration) through 12 months. The final observation included 53 adults (62% men, age at onset 27±6 years) . DM1 was confirmed with guideline-based criteria on the presence of specific autoantibodies. The endpoint was the presence of pCR at the end of observation, which was defined as IDAA1C ≤ 9, according to the definition by Mortensen et al.: A1C (%) + [4 × insulin dose (U/kg/day) ]. Apo A-I was measured in serum with an ELISA kit. The group was divided into two according to the presence and absence of pCR. Results: At 12 months, pCR was present in 43 participants (81%) . Baseline serum Apo A-I was significantly lower in participants without pCR versus those with the presence of pCR [0.79 (0.39-1.58) vs. 4.51 (0.95-5.93) mg/dl, p=0.002, respectively]. In multiple logistic regression, higher baseline Apo A-I was associated with the presence of pCR after 12 months, adjusted for sex, age, weight and the presence of diabetic ketoacidosis at onset (OR 1.74 (CI 95% 1.02-2.96) , p=0.03) . Conclusion: The higher Apo A-I serum concentration at onset of DM1 the higher chance is for pCR in adults with DM1, after 12 months of observation. Higher serum Apo A-I levels seem to be a good prognostic factor for pCR of DM1. Disclosure A.Uruska: Other Relationship; Lilly, Novo Nordisk. A.Rohatgi: Speaker's Bureau; CSL Behring. A.Cieluch: None. A.Grzelka-wozniak: Other Relationship; Novo Nordisk, Roche Diabetes Care. J.Flotynska: None. A.Pypec: None. D.Zozulinska-ziolkiewicz: Advisory Panel; Dexcom, Inc., Medtronic, Speaker's Bureau; Abbott Diabetes, Ascensia Diabetes Care, AstraZeneca, BIOTON S.A., Boehringer Ingelheim International GmbH, Eli Lilly and Company, Merck &amp; Co., Inc., Novo Nordisk, Sanofi. Funding Kosciuszko Foundation and Poznan University of Medical Sciences

Epidemiology, clinical presentation and management of COVID-19 associated mucormycosis: A single centre experience from Pune, Western India.

BackgroundThe second COVID‐19 wave in India has been associated with an unprecedented increase in cases of COVID‐19 associated mucormycosis (CAM), mainly Rhino‐orbito‐cerebral mucormycosis (ROCM).MethodsThis retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India, between 1 April, 2020, and 1 August, 2021, to identify CAM patients and assess their management outcomes. The primary endpoint was incidence of all‐cause mortality due to CAM.Results59 patients were diagnosed with CAM. Median duration from the first positive COVID‐19 RT PCR test to diagnosis of CAM was 17 (IQR: 12,22) days. 90% patients were diabetic with 89% having uncontrolled sugar level (HbA1c >7%). All patients were prescribed steroids during treatment for COVID‐19. 56% patients were prescribed steroids for non‐hypoxemic, mild COVID‐19 (irrational steroid therapy), while in 9%, steroids were prescribed in inappropriately high dose. Patients were treated with a combination of surgical debridement (94%), intravenous liposomal Amphotericin B (91%) and concomitant oral Posaconazole (95.4%). 74.6% patients were discharged after clinical and radiologic recovery while 25.4% died. On relative risk analysis, COVID‐19 CT severity index ≥18 (p = .017), presence of orbital symptoms (p = .002), presence of diabetic ketoacidosis (p = .011) and cerebral involvement (p = .0004) were associated with increased risk of death.ConclusionsCAM is a rapidly progressive, angio‐invasive, opportunistic fungal infection, which is fatal if left untreated. Combination of surgical debridement and antifungal therapy leads to clinical and radiologic improvement in majority of cases.

Epidemiology and phenotypes of diabetes in children and adolescents in non-European-origin populations in or from Western Pacific region.

BACKGROUNDType 1 diabetes (T1D) incidence varies substantially between countries/ territories, with most studies indicating increasing incidence. In Western Pacific region (WPR), reported rates are much lower than European-origin populations. In contrast, there are reports of substantial numbers of young people with type 2 diabetes (T2D). A deeper understanding of T1D and T2D in the WPR may illuminate factors important in pathogenesis of these conditions. Furthermore, with varying resources and funding for diabetes treatment in this region, there is a need to more clearly determine the current burden of disease and also any gaps in knowledge.AIMTo compile and summarise published epidemiologic and phenotypic data on childhood diabetes in non-European populations in and from WPR.METHODSResearch articles were systematically searched from PubMed (MEDLINE), Embase, Cochrane library, and gray literature. Primary outcome measures were incidence and prevalence, with secondary measures including phenotypic descriptions of diabetes, including diabetes type categorization, presence of diabetic ketoacidosis (DKA) at onset, autoantibody positivity, C-peptide levels, and human leucocyte antigen phenotype. Extracted data were collected using a customized template. Three hundred and thirty relevant records were identified from 16 countries/territories, with analysis conducted on 265 (80.3%) records published from the year 2000.RESULTST1D incidence ranged from < 1-7.3/100000 individuals/year, rates were highest in emigrant/ mixed populations and lowest in South-East Asia, with most countries/territories (71.4%) having no data since 1999. Incidence was increasing in all six countries/territories with data (annual increases 0.5%-14.2%, highest in China). Peak age-of-onset was 10-14 years, with a female case excess. Rate of DKA at onset varied from 19.3%-70%. Pancreatic autoantibodies at diagnosis were similar to European-origin populations, with glutamic acid decarboxylase-65 autoantibody frequency of 44.1%-64.5%, insulinoma-associated 2 autoantibody 43.5%-70.7%, and zinc transporter-8 autoantibody frequency 54.3% (one study). Fulminant T1D also occurs. T2D was not uncommon, with incidence in Japan and one Chinese study exceeding T1D rates. Monogenic forms also occurred in a number of countries.CONCLUSIONT1D is less common, but generally has a classic phenotype. Some countries/ territories have rapidly increasing incidence. T2D is relatively common. Registries and studies are needed to fill many information gaps.

Familial autoimmunity in pediatric patients with type 1 diabetes (T1D) and its associations with the severity of clinical presentation at diabetes diagnosis and with coexisting autoimmunity.

PurposeThe aim was to evaluate the impact of familial autoimmunity on the age and severity of type 1 diabetes (T1D) presentation and on the coexistence of other autoimmune diseases.MethodsWe retrospectively evaluated the medical records of 121 children/adolescents (male: 63) followed in our Diabetic Clinic from 2002 to 2016.ResultsSeventy-six patients (62.8%) had at least one relative with an autoimmune disease, Hashimoto’s thyroiditis (49.5%) and T1D (22.3%) being the commonest. Children with familial autoimmunity were younger at T1D diagnosis (mean age ± SD) (6.766 ± 3.75). Median fasting c-peptide levels at presentation were not related to familial autoimmunity. Patients with familial autoimmunity more often exhibited GADA autoantibody positivity at diagnosis. The larger the number of the patient’s relatives diagnosed with an autoimmune disease, the higher were the patient’s GADA levels (Spearman’s rho test = 0.19, p = 0.049). Children with a first-degree relative with autoimmunity had a coexisting autoimmune disorder at a significantly higher percentage (p = 0.016). Family history of autoimmunity was negatively associated with the presence of diabetic ketoacidosis (DKA) (p = 0.024). Patients with a relative with T1D less frequently exhibited DKA at diagnosis (12.8 vs. 87.2%, p = 0.003). The presence of DKA was associated with younger age (p = 0.05) and lower c-peptide levels (p = 0.033).ConclusionsFamilial autoimmunity was present in 62.8% of children with T1D, autoimmune thyroiditis and T1D being the two most frequent familial autoimmune diseases. Familial autoimmunity reduced the risk of DKA at diagnosis, but these patients were younger and had higher levels of pancreatic autoantibodies and a greater risk of developing additional autoimmune diseases.

Heterogeneity of DKA Incidence and Age-Specific Clinical Characteristics in Children Diagnosed With Type 1 Diabetes in the TEDDY Study.

The Environmental Determinants of Diabetes in the Young (TEDDY) study is uniquely capable of investigating age-specific differences associated with type 1 diabetes. Because age is a primary driver of heterogeneity in type 1 diabetes, we sought to characterize by age metabolic derangements prior to diagnosis and clinical features associated with diabetic ketoacidosis (DKA). The 379 TEDDY children who developed type 1 diabetes were grouped by age at onset (0-4, 5-9, and 10-14 years; n = 142, 151, and 86, respectively) with comparisons of autoantibody profiles, HLAs, family history of diabetes, presence of DKA, symptomatology at onset, and adherence to TEDDY protocol. Time-varying analysis compared those with oral glucose tolerance test data with TEDDY children who did not progress to diabetes. Increasing fasting glucose (hazard ratio [HR] 1.09 [95% CI 1.04-1.14]; P = 0.0003), stimulated glucose (HR 1.50 [1.42-1.59]; P < 0.0001), fasting insulin (HR 0.89 [0.83-0.95]; P = 0.0009), and glucose-to-insulin ratio (HR 1.29 [1.16-1.43]; P < 0.0001) were associated with risk of progression to type 1 diabetes. Younger children had fewer autoantibodies with more symptoms at diagnosis. Twenty-three children (6.1%) had DKA at onset, only 1 (0.97%) of 103 with and 22 (8.0%) of 276 children without a first-degree relative (FDR) with type 1 diabetes (P = 0.008). Children with DKA were more likely to be nonadherent to study protocol (P = 0.047), with longer duration between their last TEDDY evaluation and diagnosis (median 10.2 vs. 2.0 months without DKA; P < 0.001). DKA at onset in TEDDY is uncommon, especially for FDRs. For those without familial risk, metabolic monitoring continues to provide a primary benefit of reduced DKA but requires regular follow-up. Clinical and laboratory features vary by age at onset, adding to the heterogeneity of type 1 diabetes.

Predictors of associated and multiple autoimmunity in children and adolescents with type 1 diabetes mellitus.

PurposeType 1 diabetes mellitus (T1DM) is an autoimmune condition characterised by the presence of antipancreatic antibodies. The autoimmune process is also directed against other organs, most frequently against the thyroid gland, intestinal mucosa, and gastric parietal cells.MethodsOur investigation included 121 children with T1DM with a mean age±standard deviation of 11.99±4.63 years (range, 2.0–20.0 years). We explored the frequency of associated autoimmunity; the presence of predictive factors such as current age, sex, and severity at diabetes diagnosis; T1DM duration; and family history of autoimmunity.ResultsAssociated autoimmunity was present in 28.9% of T1DM patients. Children with associated autoimmunity were older at diabetes diagnosis (P=0.009) and had a longer diabetes duration compared to children without associated autoimmunity (P=0.044). Adolescents aged 12–20 years had a statistically significant higher chance of developing thyroid autoimmunity compared to children aged 1–5 years (P=0.019). Multiple autoimmunity (MA), T1DM, and 2 or more autoimmune diseases were present in 5.8% of the study population. All children with MA presented with ketoacidosis at diabetes diagnosis and had a higher percentage of familial autoimmunity (P=0.042). The familial autoimmunity of these patients most frequently affected ≥3 relatives (P=0.026) and was more frequently diagnosed before 5 years of age (P=not significant).ConclusionsAssociated autoimmunity was present in almost one-third of T1DM patients. Significant associations with associated autoimmunity were longer diabetes duration, female sex, older age at diabetes diagnosis, and glutamic acid decarboxylase positivity. Predictors of MA were age <5 years at T1DM diagnosis, the presence of diabetic ketoacidosis at diagnosis, and a significant family history of autoimmunity.

Demographic and diagnostic markers in new onset pediatric type 1 and type 2 diabetes: differences and overlaps.

PurposeType 1 diabetes (T1D) is the most common type of diabetes in children, but the frequency of type 2 diabetes (T2D) is increasing rapidly. Classification of diabetes is based on a constellation of features that vary by type. We aimed to compare demographic, clinical, and laboratory characteristics at diagnosis of pediatric T1D and T2D.MethodsWe studied children who visited a large academic hospital in Houston, Texas (USA) with a new diagnosis of T2D (n=753) or T1D (n=758). We compared age, sex, race/ethnicity, presence of obesity, glucose, hemoglobin A1c, islet autoantibody positivity, C-peptide, and presence of diabetic ketoacidosis (DKA) at diabetes diagnosis.ResultsAt diagnosis, children with T2D, compared with those with T1D, were older (13.6 years vs. 9.7 years), more likely female (63.2% vs. 47.8%), of racial/ethnic minority (91.1% vs. 42.3%), and obese (90.9% vs. 19.4%) and were less likely to have DKA (7.8% vs. 35.0%) and diabetes autoantibodies (5.5% vs. 95.4%). Children with T2D also had significantly lower glucose, lower hemoglobin A1c and lower C-peptide level (all comparisons, P<0.0001). In multiple logistic regression analysis, older age, racial/ethnic minority, obesity, higher C-peptide, and negative islet autoantibodies were independently associated with T2D (all, P<0.05), while sex, glucose, hemoglobin A1c, and DKA were not (model P<0.0001).Conclusions There are important demographic, clinical, and laboratory differences between T1D and T2D in children. However, none of the characteristics were unique to either diabetes type, which poses challenges to diabetes classification at diagnosis.

HYPERGLYCEMIC CRISIS AND COVID-19 AT CROSSROADS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Diabetic Ketoacidosis (DKA) & Hyperosmolar Hyperglycemic State (HHS) are known complications of Diabetes Mellitus and a common cause of hospitalization. In patients admitted to the hospital for DKA, routine practice is to screen for source of infection as a trigger of the hyperglycaemic state. Although workup and medical management of patients presenting with DKA/HHS has been standardized, the COVID-19 pandemic has brought on new challenges to consider. This case will highlight these considerations and dissect the dichotomy in treatment of patients with DKA/HHS and co-existing COVID-19 pneumonia. CASE PRESENTATION: An 83 y/o female with Insulin-dependent Diabetes Mellitus presents with lethargy and fatigue. On admission, she was normotensive with elevated HR/RR, saturating 90% on RA and T-max of 99.9. Lab-work showed glucose of 726, High Anion-Gap Metabolic Acidosis, PH of 7.3 on ABGs, leukocytosis and high serum ketones. Although SIRS criteria were present on admission, it was thought to be confounded by presence of DKA. Per protocol, cardiovascular emergencies and non-compliance were ruled out prior to infectious workup. U/A was unremarkable while CXR showed B/L ground-glass opacities. Due to presentation during the SARS-CoV-2 pandemic, patient underwent viral PCR screening and tested positive. She was admitted to ICU and started on IV Insulin & IV fluid hydration for DKA. BMP was done Q4-6hrs to address metabolic disturbances while reducing exposure for medical staff. She was successfully transitioned to Sub-Q Insulin. corticosteroids were avoided to prevent worsening hyperglycemia. IV fluids were discontinued upon initiation of po intake. Patient was discharged in stable condition, without worsening respiratory status. DISCUSSION: Infection is one of the most common culprits of hyperglycemic crisis in diabetic patients. During the COVID-19 pandemic, screening for this viral infection is imperative to guide clinical decision making. As clinical studies have emerged, some guidelines now suggest Sub-Q insulin therapy in place of IV Insulin in order to reduce the need for monitoring and exposure of health-care workers. Treatments of these diseases are contradictory. In hyperglycemic state, IVF plays a crucial role in reducing mortality while in COVID-19 pneumonia, it has the potential to worsen respiratory status. On the other hand, use of corticosteroids in COVID-19 infection is fundamental to reduce the burden of systemic inflammation, while it may cause worsening glycemic status in uncontrolled diabetes mellitus. CONCLUSIONS: Routine infectious screening during a pandemic must include testing for COVID-19. Decision regarding IV fluid hydration, initiation of corticosteroids, and type of insulin therapy should be done on case-to-case basis. Further studies, scoring criteria, and consideration of other co-morbidities may help guide clinical management of these two pathologies side by side. REFERENCE #1: Francisco J. Pasquel, MD. "Diabetic Ketoacidosis Among Patients Hospitalized With or Without COVID-19." JAMA Network Open, JAMA Network, 10 Mar. 2021, jamanetwork.com/journals/jamanetworkopen/fullarticle/2777312. REFERENCE #2: Rao, Sanjana et al. "Diabetic ketoacidosis in patients with COVID-19." The American Journal of the Medical Sciences, 25 Nov. 2020, doi:10.1016/j.amjms.2020.11.027 REFERENCE #3: "Inpatient Insulin Protocols - COVID-19." Inpatient Insulin Protocols - COVID-19 | American Diabetes Association, professional.diabetes.org/content-page/inpatient-insulin-protocols-covid-19. DISCLOSURES: No relevant relationships by Padmini Giri, source=Web Response No relevant relationships by Victoria Gonzalez, source=Web Response No relevant relationships by Sourabh Sourabh, source=Web Response No relevant relationships by DANYAL TAHERI ABKOUH, source=Web Response

Intensive Care Unit Admission, Mechanical Ventilation, and Mortality Among Patients With Type 1 Diabetes Hospitalized for COVID-19 in the U.S.

To assess whether risk of severe outcomes among patients with type 1 diabetes mellitus (T1DM) hospitalized for coronavirus disease 2019 (COVID-19) differs from that of patients without diabetes or with type 2 diabetes mellitus (T2DM). Using the Premier Healthcare Database Special COVID-19 Release records of patients discharged after COVID-19 hospitalization from U.S. hospitals from March to November 2020 (N = 269,674 after exclusion), we estimated risk differences (RD) and risk ratios (RR) of intensive care unit admission or invasive mechanical ventilation (ICU/MV) and of death among patients with T1DM compared with patients without diabetes or with T2DM. Logistic models were adjusted for age, sex, and race or ethnicity. Models adjusted for additional demographic and clinical characteristics were used to examine whether other factors account for the associations between T1DM and severe COVID-19 outcomes. Compared with patients without diabetes, T1DM was associated with a 21% higher absolute risk of ICU/MV (RD 0.21, 95% CI 0.19-0.24; RR 1.49, 95% CI 1.43-1.56) and a 5% higher absolute risk of mortality (RD 0.05, 95% CI 0.03-0.07; RR 1.40, 95% CI 1.24-1.57), with adjustment for age, sex, and race or ethnicity. Compared with T2DM, T1DM was associated with a 9% higher absolute risk of ICU/MV (RD 0.09, 95% CI 0.07-0.12; RR 1.17, 95% CI 1.12-1.22), but no difference in mortality (RD 0.00, 95% CI -0.02 to 0.02; RR 1.00, 95% CI 0.89-1.13). After adjustment for diabetic ketoacidosis (DKA) occurring before or at COVID-19 diagnosis, patients with T1DM no longer had increased risk of ICU/MV (RD 0.01, 95% CI -0.01 to 0.03) and had lower mortality (RD -0.03, 95% CI -0.05 to -0.01) in comparisons with patients with T2DM. Patients with T1DM hospitalized for COVID-19 are at higher risk for severe outcomes than those without diabetes. Higher risk of ICU/MV in patients with T1DM than in patients with T2DM was largely accounted for by the presence of DKA. These findings might further guide recommendations related to diabetes management and the prevention of COVID-19.

175-LB: Stress Hyperglycemia Predicts Mechanical Ventilation and Death in COVID-19 Infected Adults

People with diabetes (DM) hospitalized with COVID-19 infection have a 2-3 fold higher risk of death compared with those without DM, and mechanical ventilation (MV) has been identified as a major risk factor for death. While stress hyperglycemia (StH) has been established as a risk factor for death in some critically ill cohorts, it is not a well-established risk factor for MV in COVID-19. The COVIDEastDM consortium pooled data from 5 academic hospitals on the East Coast of the US to study the relationship between hyperglycemia and COVID-19 outcomes. Data were obtained retrospectively from electronic records of adults with COVID-19 and either DM or StH (defined in this cohort as day-1 admission blood glucose &amp;gt;180 mg/dl and A1c &amp;lt;6.5%). This analysis included 3,435 individuals, of which 1,001 (29.1%) required MV and 748 (21.8%) died. The mean age was 67 ± 15 yrs., BMI 30.4 ± 7.7 kg/m2, A1c 7.98 ± 2.21 % and glucose 184 ± 104 mg/dl. Additionally, 57% were male, 4 % Asian,19% Black, 52% White, and 28% Hispanic. In a univariate analysis, risk factors for MV included younger age (OR 0.98 [95% CI 0.97, 0.99] per year older), male sex (OR 1.4 [1.2, 1.7]), BMI (OR 1.013 [1.003, 1.023] per kg/m2), Hispanic ethnicity (OR 1.16 [1.07, 1.28]) and the presence of diabetic ketoacidosis (n=38) at admission (OR 3.9 [2.0, 7.5]). Patients with StH were more likely to require MV (OR 1.93, [1.10, 3.39]). In a multivariate analysis, this relationship was continuous, with both lower A1c and higher glucose increasing risk of MV (p&amp;lt; 0.01 for higher glucose, p&amp;lt;0.001 for lower A1c). Patients who required MV were more likely to die than those who did not require MV (OR 5.1, [4.3, 6.1]) and StH predicted mortality in the multivariate analysis. Thus, in patients hospitalized with COVID19 infection, StH is a strong predictor of both MV and death in COVID-19 infected adults. While it is unclear if StH is a cause or effect of severe COVID-19, its presence early in the hospital course identifies higher risk patients and could potentially impact management. Disclosure M. E. Mcdonnell: Stock/Shareholder; Spouse/Partner; Abbott Diabetes. N. E. Palermo: None. R. Radhakrishnan: None. G. P. Westcott: None. R. S. Weinstock: Research Support; Self; Boehringer Ingelheim International GmbH, Diasome Pharmaceuticals, Inc., Eli Lilly and Company, Insulet Corporation, Kowa Research Institute, Inc., Medtronic, Tolerion, Inc. R. Garg: None. D. C. Simonson: Stock/Shareholder; Spouse/Partner; Phase V Technologies, Inc. G. Cromwell: None. G. Gopalakrishnan: None. M. Greenfield: None. M. Johnson: None. S. R. Katta: None. J. Lebastchi: None. J. Mitri: Consultant; Self; L-Nutra. Funding TechFoundation; Brigham Education Institute

Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report

BackgroundPatients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis.Case presentationA 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient’s postoperative recovery was remarkable.ConclusionsLong-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.

Incidence, characteristics and long-term outcomes of patients with diabetic ketoacidosis: a prospective prognosis cohort study in an emergency department.

Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design. To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years. Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil. All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate. The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission. Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Factors associated with the presence of diabetic ketoacidosis: A retrospective analysis of patients with type 1 diabetes in Saudi Arabia

Background and aimsTo Investigate the factors associated with Diabetic Ketoacidosis (DKA) among patients with type 1 diabetes (T1D). MethodsThis was a descriptive, retrospective study conducted among 1118 patients with T1D, at the Prince Sultan Military Medical City, Riyadh, Saudi Arabia. After, exclusion process, 336 patients were selected for analysis. Among these, 105 patients with T1D were hospitalized for DKA, whereas 231 patients without DKA were outpatients who visited the hospital for T1D follow-up treatment. ResultsBivariate analysis between patients with DKA and those without DKA revealed significant relationships in terms of gender (p = 0.014), age (p = 0.0001), body mass index (BMI) (p = 0.017), hemoglobin A1c (HbA1c) (p = 0.0001), duration of diabetes (p = 0.001) and clinic appointments (p = 0.001). From the logistic regression analysis, it was clear that females (OR 1.88; p = 0.038) had a higher risk for DKA. As compared to the age group of ≥30 years, those in the age category of 20–29 years (OR 1.35; p = 0.001) and teenagers (OR 3.64; p = 0.001) faced a higher risk of having DKA episodes. Compared with patients having HbA1c levels <8%, those showing HbA1c levels 8–9.9% (OR 1.77; p = 0.224) and ≥10% (OR 4.06; p = 0.003) revealed higher risk for DKA. Likewise, in comparison with the patients who were compliant to clinic appointments, those who were non-compliant to clinic appointments exhibited higher than six times the risk (OR 6.38; p = 0.0001) of being more prone to experiencing the DKA episodes. ConclusionPatients with higher risk for DKA comprise, those having high HbA1c levels, longer period of diabetes duration, teenagers, female gender and non-compliant to clinic appointments.

S0091 Admission Outcomes and Risk Factors for Patients Presenting With Acute Pancreatitis and Concomitant Diabetic Ketoacidosis

INTRODUCTION: Admissions for acute pancreatitis and diabetic ketoacidosis (DKA) often overlap. Presenting features such as abdominal pain, elevated lipase levels, and anion gap acidosis may make differentiation and management challenging. To date, studies on admission and follow up outcomes in patients presenting with concomitant DKA and acute pancreatitis has been incompletely characterized. METHODS: The clinical course of consecutive patients admitted to Los Angeles County + University of Southern California Hospital for acute pancreatitis between March 2015 and February 2020 was reviewed through April 2020. Patients with diabetes were identified and stratified by presence of DKA on admission. The outcomes of interest included the diagnosis of diabetes mellitus following index hospitalization in our hospital for acute pancreatitis, as well as general admission outcomes such as length of stay (LOS), intensive care unit admission (ICU), ICU LOS, organ failure, and pancreatitis severity as based on the Revised Atlanta Criterion. RESULTS: Among a total cohort of 1081 patients with acute pancreatitis, 252 had diabetes mellitus (DM), and 37 of the patients with DM presented in DKA. Those presenting in DKA were more likely to develop moderately severe pancreatitis by the Revised Atlanta Classification (40.5% vs. 13.5%, P < 0.0001) and new onset renal failure (21.6% vs. 7.9%, P = 0.01). Hypertriglyceridemia was more commonly identified as the etiology of acute pancreatitis in the DKA cohort (32.4% vs. 9.3%, P < 0.0001). Though rates of ICU admission were higher among DKA patients, this was largely due to the requirement for ICU monitoring for continuous insulin infusions at our center. Concomitant recurrent pancreatitis (37.8% vs. 14.4%, P = 0.001) and chronic pancreatitis (13.5% vs. 3.3%, P = 0.003) were significantly more common among patients presenting in DKA. CONCLUSION: Acute pancreatitis with concomitant DKA is associated with greater pancreatitis severity as scored by the Revised Atlanta Criterion. These patients are also much more likely to have recurrent acute and chronic pancreatitis.Table 1.: Comparison of admission outcomes for acute pancreatitis between diabetics and diabetics presenting in DKATable 2.: Recurrent pancreatitis and chronic pancreatitis among diabetics vs. diabetics presenting with DKATable 3.: Comparison of imaging features among diabetics vs. diabetics presenting in DKA