Rate Of Diabetic Ketoacidosis Research Articles

A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes.

AimTo estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition.MethodsA national population‐based case–control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case–control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls).ResultsIn all, 82 women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI: 5.0–7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with 11 stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3rd trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case–control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy.ConclusionDKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio‐economic deprivation, mental health problems and long‐term difficulties with glycaemic control.

Higher rates of diabetic ketoacidosis and admission to the paediatric intensive care unit among newly diagnosed children with type 1 diabetes in Kuwait during the COVID-19 pandemic.

IntroductionThe COVID‐19 pandemic might have a multifaceted effect on children with type 1 diabetes (T1D), either directly through infection itself or indirectly due to measures implemented by health authorities to control the pandemic.ObjectiveTo compare data on children newly diagnosed with T1D in Kuwait during the COVID‐19 pandemic to the pre‐pandemic period.Research Design and MethodsWe analysed data on children aged 12 years or less registered in the Childhood‐Onset Diabetes electronic Registry (CODeR) in Kuwait. Data were incidence rate (IR), diabetic ketoacidosis (DKA), and its severity and admission to the paediatric intensive care unit (PICU).ResultsThe IR of T1D was 40.2 per 100,000 (95% CI; 36.0–44.8) during the COVID‐19 pandemic period and was not statistically different from pre‐pandemic. A higher proportion of incident T1D cases presented with DKA and were admitted to the PICU during the pandemic (52.2% vs. 37.8%: p ˂ 0.001, 19.8% vs. 10.9%; p = 0.002, respectively). The COVID‐19 pandemic was positively associated with presentation of DKA and admission to PICU (AOR = 1.73; 95% CI, 1.13–2.65; p = 0.012, AOR = 2.04; 95% CI, 1.13–3.67; p = 0.018, respectively). Children of families with a positive history for diabetes were less likely to present with DKA and get admitted to the PICU during the COVID‐19 pandemic (AOR = 0.38; 95% CI, 0.20–0.74; p = 0.004, AOR = 0.22; 95% CI, 0.08–0.61; p = 0.004, respectively).ConclusionHigh rates of DKA at presentation and admission to PICU in incident T1D cases during the COVID‐19 pandemic warrant further studies and effective mitigation efforts through increasing awareness, early detection, and timely intervention.

Flash monitor initiation is associated with improvements in HbA1c levels and DKA rates among people with type 1 diabetes in Scotland: a retrospective nationwide observational study

Aims/hypothesisWe assessed the real-world effect of flash monitor (FM) usage on HbA1c levels and diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH) rates among people with type 1 diabetes in Scotland and across sociodemographic strata within this population.MethodsThis study was retrospective, observational and registry based. Using the national diabetes registry, 14,682 individuals using an FM at any point between 2014 and mid-2020 were identified. Within-person change from baseline in HbA1c following FM initiation was modelled using linear mixed models accounting for within-person pre-exposure trajectory. DKA and SHH events were captured through linkage to hospital admission and mortality data. The difference in DKA and SHH rates between FM-exposed and -unexposed person-time was assessed among users, using generalised linear mixed models with a Poisson likelihood. In a sensitivity analysis, we tested whether changes in these outcomes were seen in an age-, sex- and baseline HbA1c-matched sample of non-users over the same time period.ResultsPrevalence of ever-FM use was 45.9% by mid-2020, with large variations by age and socioeconomic status: 64.3% among children aged <13 years vs 32.7% among those aged ≥65 years; and 54.4% vs 36.2% in the least-deprived vs most-deprived quintile. Overall, the median (IQR) within-person change in HbA1c in the year following FM initiation was −2.5 (−9.0, 2.5) mmol/mol (−0.2 [−0.8, 0.2]%). The change varied widely by pre-usage HbA1c: −15.5 (−31.0, −4.0) mmol/mol (−1.4 [−2.8, −0.4]%) in those with HbA1c > 84 mmol/mol [9.8%] and 1.0 (−2.0, 5.5) mmol/mol (0.1 [−0.2, 0.5]%) in those with HbA1c < 54 mmol/mol (7.1%); the corresponding estimated fold change (95% CI) was 0.77 (0.76, 0.78) and 1.08 (1.07, 1.09). Significant reductions in HbA1c were found in all age bands, sexes and socioeconomic strata, and regardless of prior/current pump use, completion of a diabetes education programme or early FM adoption. Variation between the strata of these factors beyond that driven by differing HbA1c at baseline was slight. No change in HbA1c in matched non-users was observed in the same time period (median [IQR] within-person change = 0.5 [−5.0, 5.5] mmol/mol [0.0 (−0.5, 0.5)%]). DKA rates decreased after FM initiation overall and in all strata apart from the adolescents. Estimated overall reduction in DKA event rates (rate ratio) was 0.59 [95% credible interval (CrI) 0.53, 0.64]) after FM vs before FM initiation, accounting for pre-exposure trend. Finally, among those at higher risk for SHH, estimated reduction in event rates was rate ratio 0.25 (95%CrI 0.20, 0.32) after FM vs before FM initiation.Conclusions/interpretationFM initiation is associated with clinically important reductions in HbA1c and striking reduction in DKA rate. Increasing uptake among the socioeconomically disadvantaged offers considerable potential for tightening the current socioeconomic disparities in glycaemia-related outcomes.Graphical abstract

Erratum. Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic. Diabetes Care 2021;44:1451-1453.

Erratum. Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic. Diabetes Care 2021;44:1451-1453.

Short Time Effect of COVID 19 Pandemic on HbA1c and Acute Metabolic Complications in Children with Type 1 Diabetes

Background: COVID19 pandemic is currently affecting every aspect of daily life of communitiesy throughout the world. We aimed to check how this situation affects the metabolic control of children with type 1 diabetes. Methods: We analyzed all patients with type 1 diabetes a HbA1c test after at least two months ensuing the start of the epidemic in Turkey. We compared the results with the most recent HbA1c test in the hospital’s automation system before the epidemic. In addition, diabetic ketoacidosis (DKA) and severe hypoglycemia rates were compared. Results: Among the eligible 219 cases 77.6% had decreased HbA1c levels according to their former result. Mean drop was about 9.71% compared to the former test in the whole group. Age, sex and time interval between two tests were not found to affect this tendency. Diabetic ketoacidosis rate was the same as before the pandemic, whereas severe hypoglycemia rates increased. Conclusions: Despite the potential of the pandemic to affect routine care of chronic diseases in a negative way the short term metabolic control of type 1 children with type 1 diabetes improved. Telemedicine support by the diabetes team and increased care in the family environment might be possible explanations.

Changes in the presentation of newly diagnosed type 1 diabetes in children during the COVID-19 pandemic in a tertiary center in Southern Turkey

Abstract Objectives The COVID-19 pandemic is a global health problem with high morbidity and mortality. This study aimed to investigate patients who were diagnosed with type 1 diabetes during the pandemic and evaluate the effect of the pandemic on the clinical findings of these patients by comparing them with findings from a year prior. Methods Patients diagnosed with type 1 diabetes mellitus between 2019 and 2021 were separated into two groups: Patients diagnosed prepandemic and those diagnosed during the pandemic. Results The number of newly diagnosed diabetes cases increased from 46 in the prepandemic period to 74 in the pandemic period. The number of cases diagnosed with diabetic ketoacidosis (DKA) in the clinic increased from 58.7 to 91.9%. We found that moderate and severe DKA rates from 18.5 and 14.8% to 23.5 and 22.1%, respectively. Besides, the average HbA1c was higher, while the average bicarbonate was lower in cases diagnosed during the pandemic period compared to the prepandemic period (p=0.048 and p&lt;0.001, respectively). We found that celiac autoantibody positivity antibodies to glutamic acid decarboxylase (anti GAD) positivity, and islet cell antibodies (ICA), ICA and anti GAD positivity coexistence were higher (p=0.045, p=0.008, and p=0.007, respectively) among the patients diagnosed during the pandemic. Conclusions We observed an increase in the number of patients newly diagnosed with type 1 diabetes mellitus, an increase in autoantibody positivity, and higher rates and severity of DKA during the COVID-19 pandemic period compared to the prepandemic period.

Rising Rates and Widening Socioeconomic Disparities in Diabetic Ketoacidosis in Type 1 Diabetes in Scotland: A Nationwide Retrospective Cohort Observational Study.

Whether advances in the management of type 1 diabetes are reducing rates of diabetic ketoacidosis (DKA) is unclear. We investigated time trends in DKA rates in a national cohort of individuals with type 1 diabetes monitored for 14 years, overall and by socioeconomic characteristics. All individuals in Scotland with type 1 diabetes who were alive and at least 1 year old between 1 January 2004 and 31 December 2018 were identified using the national register (N = 37,939). DKA deaths and hospital admissions were obtained through linkage to Scottish national death and morbidity records. Bayesian regression was used to test for DKA time trends and association with risk markers, including socioeconomic deprivation. There were 30,427 DKA admissions and 472 DKA deaths observed over 393,223 person-years at risk. DKA event rates increased over the study period (incidence rate ratio [IRR] per year 1.058 [95% credibility interval 1.054-1.061]). Males had lower rates than females (IRR male-to-female 0.814 [0.776-0.855]). DKA incidence rose in all age-groups other than 10- to 19-year-olds, in whom rates were the highest, but fell over the study. There was a large socioeconomic differential (IRR least-to-most deprived quintile 0.446 [0.406-0.490]), which increased during follow-up. Insulin pump use or completion of structured education were associated with lower DKA rates, and antidepressant and methadone prescription were associated with higher DKA rates. DKA incidence has risen since 2004, except in 10- to 19-year-olds. Of particular concern are the strong and widening socioeconomic disparities in DKA outcomes. Efforts to prevent DKA, especially in vulnerable groups, require strengthening.

Inequities in Health Outcomes in Children and Adults With Type 1 Diabetes: Data From the T1D Exchange Quality Improvement Collaborative.

Health care inequities among racial and ethnic groups remain prevalent. For people with type 1 diabetes who require increased medical access and care, disparities are seen in access to care and health outcomes. This article reports on a study by the T1D Exchange Quality Improvement Collaborative evaluating differences in A1C, diabetic ketoacidosis (DKA), severe hypoglycemia, and technology use among racial and ethnic groups. In a diverse cohort of nearly 20,000 children and adults with type 1 diabetes, A1C was found to differ significantly among racial and ethnic groups. Non-Hispanic Blacks had higher rates of DKA and severe hypoglycemia and the lowest rate of technology use. These results underscore the crucial need to study and overcome the barriers that lead to inequities in the care and outcomes of people with type 1 diabetes.

Diabetic Ketoacidosis at Manifestation of Type 1 Diabetes in Childhood and Adolescence—Incidence and Risk Factors.

Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic disorder that can occur with manifestation of type 1 diabetes mellitus (T1D). The aim of this study was to analyze the incidence of DKA at the time of the diagnosis of T1D in childhood and adolescence, the risk factors, and regional approaches to reduce the incidence of ketoacidosis. We investigated the proportion of patients under 18 years of age with DKA (defined as pH <7.3, severe DKA pH <7.1) at the manifestation of T1D in Germany in the period 2000-2019, based on data from the German-Austrian registry of diabetes (Diabetes-Patienten-Verlaufsdokumentation, DPV). The influence of the following factors was evaluated: year of manifestation, age, sex, family history of migration (MiH), and distance from the hospital. Moreover, data from the region with and the region without a pilot screening project from 2015 onwards were compared. Of the 41 189 patients with manifestation of T1D, 19.8% presented with DKA (n = 8154, slight increase [p <0.001] over the study period) and 6.1% (n = 2513) had severe DKA. Children under 6 years of age had DKA more often than adolescents (12-17 years) (21.7% versus 18.6%, OR 1.22 {95% CI: [1.14; 1.30]}). Girls had a higher rate of DKA than boys (20.5% versus 19.2%, OR 1.10 [1.03; 1.14]), and patients with MiH were more likely to have DKA than those without MiH (21.4% versus 18.2%, OR 1.40 [1.32; 1.48]). In the region with a pilot screening project, the DKA rate stayed the same, at 20.6%, while in the control region the rate was 22.7% with a decreasing tendency. The frequency of DKA at the time of diagnosis of T1D did not decrease between 2000 and 2019 and increased towards the end of the observation period. Children with MiH, children under 6, and girls were at a higher risk of DKA.

Spike in Diabetic Ketoacidosis Rates in Pediatric Type 2 Diabetes During the COVID-19 Pandemic.

OBJECTIVEThe impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) on the incidence of new-onset type 2 diabetes and diabetic ketoacidosis (DKA) is unclear. It is unknown whether the coincidence of DKA noted in adult patients with type 2 diabetes is an issue for youth during the coronavirus disease 2019 pandemic.RESEARCH DESIGN AND METHODSA retrospective single-center medical record review was conducted in a large, urban children’s hospital of pediatric subjects presenting with new-onset type 2 diabetes between March and August of 2018 to 2020.RESULTSThe proportion of subjects presenting with new-onset type 2 diabetes in DKA dramatically increased in 2020 (9% in 2018, 3% in 2019, and 20% in 2020, P = 0.029).CONCLUSIONSIn 2020, youth with new-onset type 2 diabetes had a greater incidence of DKA at presentation than previously observed. Future studies should examine the impact of SARS-CoV2 exposure on the presentation of type 2 diabetes in all age-groups to inform better patient care.

69-LB: Nonadjunctive Continuous Glucose Monitoring to Control Hypoglycemia (COACH)

Previous studies have been insufficiently powered to assess whether CGM can reduce severe hypoglycemia. The Continuous Monitoring and Control of Hypoglycemia study evaluated nonadjunctive use of the Dexcom CGM system for diabetes management decisions in adults new to CGM. This post-approval 12-month observational study enrolled adults with insulin-requiring diabetes who based diabetes management and insulin dosing decisions on self-monitored blood glucose (SMBG) values for 6 months and then on CGM for 6 months. Per protocol, diabetes management was per usual care. Subjects were queried monthly about hypoglycemic and diabetic ketoacidosis (DKA) events. The primary outcome was change in moderate (requiring third party assistance) and severe (seizure or loss of consciousness) hypoglycemic event frequency between SMBG and CGM phases; secondary outcomes included DKA events. The per-protocol population included all 519 adult subjects who completed the 12-month visit with mean±SD age 50.3±16.1 y, A1C 8.0±1.4%, 32.8% with impaired hypoglycemia awareness, 54.1% male, 66.5% and 33.5% with T1D/T2D, and 29.7% using pumps. Compared to the SMBG phase, the frequency of moderate and severe hypoglycemic events was significantly (p=0.0051) lower during the CGM phase; DKA frequency was also lower (Table). Compared to SMBG, nonadjunctive CGM use reduces rates of severe hypoglycemia and DKA. Disclosure S. Beck: Employee; Self; Dexcom, Inc. C. Kelly: Consultant; Self; Ajinomoto Co., Inc., Dexcom, Inc., Hitachi, Ltd., Vascular Dynamics Inc. N. Njeru: None. J. J. Gorelick: Employee; Self; Dexcom, Inc., Edwards Lifesciences. J. C. Bowers: Employee; Self; Dexcom, Inc. D. A. Price: Employee; Self; Dexcom, Inc.

Outcomes of diabetic ketoacidosis in a tertiary centre with restricted intensive care unit bed capacity.

Diabetic ketoacidosis (DKA) is an acute metabolic condition, sometimes requiring admission to an intensive care unit (ICU). To investigate the outcomes of DKA patients admitted to a hospital with restricted ICU capacity. We included all DKA patients above age 18 who were admitted to a tertiary hospital during 2004-2017. We conducted multivariate logistic regression analysis adjusted for ICU bed availability to analyse parameters associated with ICU admission, and a composite outcome of mortality, DKA recurrence and mechanical ventilation. Among 382 DKA patients in our cohort, 94 (24.6%) were admitted to the ICU. The in-hospital mortality was 4.7%. Low bicarbonate (<10 mmoL/L) and pH (<7) levels at presentation were associated with ICU admission (P < 0.001 for both). In multivariate models availability of beds in the ICU was not associated with ICU admission, mortality or DKA recurrence of any type. In a setting of limited ICU capacity, DKA treatment does not necessarily require admission to the ICU. When the rising rates of diabetes mellitus and the associated elevated rates of DKA are taken into account, our results highlight the importance of including step-down units when devising local protocols for care of these patients.

Impact of Covid-19 on the Rate of Diabetic Ketoacidosis in Pediatric New-Onset Type 1 Diabetes

Introduction: Several demographic and clinical characteristics, including age, low socioeconomic status, and misdiagnosis at initial clinical presentation were previously associated with increased risk of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in the pediatric population. However, it is unclear whether the coronavirus (COVID-19) pandemic and subsequent lockdown influenced the rate of DKA in children newly diagnosed with T1D. We undertook this study to identify the impact of the COVID-19 pandemic on the rate of DKA in children newly diagnosed with T1D in a single tertiary care referral center in central Pennsylvania. Methods: We performed an extension of a retrospective analysis of all pediatric patients (age ≤18) newly diagnosed with T1D within a tertiary care referral center between 01/01/2017-09/14/2020. Demographics, insurance coverage, and all clinical documents 30 days before their T1D diagnosis were abstracted to assess for symptoms at diagnosis (polyuria, polydipsia, nocturia, weight loss, nausea, vomiting, altered mental status, infection, vision changes, and autism spectrum disorder), lab values (blood glucose, HbA1c, venous pH, and bicarbonate), and any healthcare encounters within 30 days of their diagnosis of T1D. We performed descriptive statistics and univariate analyses [evaluating children diagnosed with T1D during the pre-COVID-19 era (diagnosed between 1/1/2017-2/28/2020) and post-COVID-19 era (diagnosed between 03/01/2020-09/14/2020) associated with the incidence of DKA], followed by logistic regression analysis (incorporating key clinical factors previously associated with DKA and the pre- or post- COVID-19 era classification). Results: 412 pediatric patients with T1D [171 F:241 M; 370 pre-COVID-19 era:42 post-COVID-19 era] were included. The percentages of DKA diagnoses at admission were very similar between the pre-COVID-19 and post-COVID-19 groups (47% vs. 48%), as were the severity (13% vs. 14% mild DKA; 33% vs. 31% moderate or severe DKA). There were no temporal associations with the rate of DKA in respect to COVID-19, however, age (0-3 and 9-13 years), misdiagnosis during a preceding healthcare encounter, presenting to the emergency department directly, elevated HbA1c (>10.0%/13.4mmol/L), and altered mental status were associated with increased risk of DKA on multivariable analysis. Conclusion: There were no fluctuations in the rate of DKA among pediatric patients newly diagnosed with T1D throughout the COVID-19 pandemic in central Pennsylvania. Interestingly, some geographic locations observed an increased frequency of DKA in children newly diagnosed with T1D, while others noted a decreased rate. Regardless, our findings suggest previously described predictors of DKA in the pediatric population persist, even in the setting of the COVID-19 pandemic.

Comparing Disease Severity: Diabetic Ketoacidosis in Local and Tourist Children With New-Onset Diabetes Mellitus

Introduction: Approximately 30% of youth present with diabetic ketoacidosis (DKA) at the time of diagnosis of type 1 diabetes mellitus (DM). DKA severity can be mild to severe, impacting hospitalization duration as severity worsens, or even result in death. A delay in care from onset of symptoms results in greater illness severity. Travel has been a proposed risk factor for illness severity in general; one study identified ruptured appendicitis as a more frequent complication in children vacationing from their hometown. Identifying travel as a potential risk factor for severe DKA is necessary. There is no research highlighting the association between vacation and severity of DKA in new onset diabetics. Central Florida is one of the major vacation destinations and is home to a diverse population, so offers a unique study population. The goal of this novel study was to investigate the association between travel and severity of DKA in new onset diabetics. Methods: A retrospective chart review of children admitted to a children’s hospital in Central Florida with both new onset diabetes and DKA from October 2012-March 2020 was conducted. Patients that did not meet criteria for DKA based on venous pH (pH) < 7.3 or bicarbonate (HCO3) < 15 mmol/l were excluded. Patients were divided into two groups by primary residence: locals versus tourists. The severity of DKA was determined as either mild (pH < 7.3 or HCO3 10 to < 15), moderate (pH < 7.2 or HCO3 5–9), or severe (pH < 7.1 or HCO3 < 5), and compared between local versus tourist children with Chi-squared testing. Results: There was no significant difference in DKA severity between locals and tourists. 33% of local children presented in severe DKA compared to 29% of tourist children (p=0.809). The percentage of children overall presenting with moderate or severe DKA was about 70%. Gender and admission status had a statistically significant correlation to DKA severity. More females presented in severe DKA than males (56 % versus 44%, p=0.029), and patients transferred from an outside facility versus directly admitted from the emergency department had a higher percentage of severe DKA (76% versus 24%, p=0.002). Conclusion: This study is the first in the literature to report that travel does not seem to be a contributing risk factor to the severity of DKA. We did find that more than half of all new onset diabetics presented in moderate or severe DKA, indicating that there is currently a frequent delay in diagnosis of children with new onset diabetes. A higher rate of severe DKA was noted in patients transferred from an outside facility versus children admitted directly to the ICU from our emergency department, which may likely be due to challenging access to a specialty pediatric hospital among patients living in remote areas. We propose that future studies investigate this relationship further to guide interventions that can significantly reduce the rate of severe DKA on presentation.

Incidence of Diabetic Ketoacidosis in Hospitalized COVID19 Patients With Type 2 Diabetes

Introduction: Diabetes is a disease of persistent hyperglycemia with a devastating complication and even death if left untreated. Morbidity and mortality often increased for any condition among patients with diabetes. Diabetic ketoacidosis (DKA) is an acute and life-threatening complication of diabetes. It can occur to type 2 diabetes (T2DM) under severe stress. Since the pandemic of Coronavirus disease 2019 (COVID19), that caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in Wuhan, Hubei China, in December 2019, more than 47 million infected cases reported leading to more than 1.2 million deaths reported worldwide. The presence of diabetes in COVID19 patients had a higher odd of severity and mortality of the COVID19 compared to patients without diabetes. Our study aims to identify the incidence rate of DKA in T2DM admitted with COVID19 in a tertiary care center. Evidence showed those populations at considerable risk for morbidity and mortality and no available data in Saudi Arabia. Method: A retrospective cohort of adult patients admitted for COVID19, with a diagnosis of T2DM or clinical evidence of DKA in a tertiary care center named King Fahad Medical City located in Riyadh in Saudi Arabia. The study involved a chart review. Data collected from the beginning of March 2020 till the end of June 2020. Results: Of 244 patients with T2DM admitted for COVID19, 190 patients were male, and 55 patients were female. The mean age was 59-year-old. out of 244 patients collected, 20 had developed DKA. The incidence rate of DKA was 8%. Number and percentage of male was 15 (71.4%) and female 6 (28.6%). Out of 20 patients admitted with DKA and COVID-19, two patients were not known to have diabetes prior to the presentation. Mortality resulted in 5 out of 20 during admission stay, represent 25% of all patients with DKA. Discussion: Here we report the first study in S.A. about DKA incidence in T2DM with COVID19 pneumonia. In the present study, an alarming observation of a higher incidence of DKA in a patient with type 2 diabetes and COVID19 infection as incidence reaches 8% over a short period of time while incidence worldwide area range was less than 2 per 1000 person-year for DKA in type 2 diabetes without COVID19. A study reported 20 % of patients who have diabetes and COVID19 presented ketosis developed DKA. We report the incidence of DKA in selected group. The mortality rate was not far from different evidence in the world. The mortality rate was 25% in the present study. In the USA, it reaches 30% of inpatient with hyperglycemia at presentation. Conclusion: DKA is a life-threatening complication, and it became worse when it is related to COVID19. The incidence of DKA and mortality related to COVID19 increased when DKA occurs for T2DM subjects. A more prospective study is warranted and a longer duration of the study to establish the accurate incidence and mortality rate.

Sodium-Glucose Cotransporter-2 Inhibitors and Risk of Diabetic Ketoacidosis Among Adults With Type 2 Diabetes: A Systematic Review and Meta-Analysis

ObjectivesThe magnitude and precision regarding the risk of diabetic ketoacidosis (DKA) with sodium-glucose cotransporter-2 (SGLT2) inhibitors is unclear. Thus, we examined the risk of DKA with SGLT2 inhibitors in both observational studies and large clinical trials. MethodsSearches were performed in PubMed, Embase, CENTRAL and Google Scholar (from inception to April 15, 2019) without language restrictions, including conference proceedings and reference lists. Study selection consisted of randomized controlled trials and observational studies that quantified the rate of DKA with an SGLT2 inhibitor in comparison to other diabetes medications or placebo. Two independent investigators abstracted the study data and assessed the quality of evidence. Data were pooled using random effects models with the Hartung–Knapp–Sidik–Jonkman method. Absolute event rates and hazard ratios for DKA were extracted from each study. ResultsSeven randomized trials encompassing 42,375 participants and 5 cohort studies encompassing 318,636 participants were selected. Among the 7 randomized controlled trials, the absolute rate of DKA among patients randomized to an SGLT2 inhibitor ranged from 0.6 to 2.2 events per 1,000 person years. Four randomized trials were included in the meta-analysis and, compared with placebo or comparator medication, SGLT2 inhibitors had a 2.5-fold higher risk of DKA (relative risk [RR], 2.46; 95% confidence interval [CI], 1.16 to 5.21]; I2=0%; p=0.54). Among the 5 observational studies, the absolute rate of DKA associated with SGLT2 inhibitor use ranged from 0.6 to 4.9 per 1,000 person years and a 1.7-fold higher rate of DKA compared with another diabetes medication (RR, 1.74; 95% CI, 1.07 to 2.83; I2=45%; p=0.12). ConclusionsIn adults with type 2 diabetes, SGLT2 inhibitors were found to increase the risk of DKA in both observational studies and large randomized clinical trials.

A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province

ObjectivesThe Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations. MethodsThe NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay. ResultsThere were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001). ConclusionsThe NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.

Clinical features, biochemistry, and HLA-DRB1 status in youth-onset type 1 diabetes in Sudan.

To further understand clinical and biochemical features, and HLA-DRB1 genotypes, in new cases of diabetes in Sudanese children and adolescents. Demographic characteristics, clinical information, and biochemical parameters (blood glucose, HbA1c, C-peptide, autoantibodies against glutamic acid decarboxylase 65 [GADA] and insulinoma-associated protein-2 [IA-2A], and HLA-DRB1) were assessed in 99 individuals <18 years, recently (<18 months) clinically diagnosed with T1D. HLA-DRB1 genotypes for 56 of these Arab individuals with T1D were compared to a mixed control group of 198 healthy Arab (75%) and African (25%) individuals without T1D. Mean ± SD age at diagnosis was 10.1 ± 4.3 years (range 0.7-17.6 years) with mode at 9-12 years. A female preponderance was observed. Fifty-two individuals (55.3%) presented in diabetic ketoacidosis (DKA). Mean ± SD serum fasting C-peptide values were 0.22 ± 0.25 nmol/L (0.66±0.74 ng/ml). 31.3% were autoantibody negative, 53.4% were GADA positive, 27.2% were IA-2A positive, with 12.1% positive for both autoantibodies. Association analysis compared to 198 controls of similar ethnic origin revealed strong locus association with HLA-DRB1 (p < 2.4 × 10-14 ). Five HLA-DRB1 alleles exhibited significant T1D association: three alleles (DRB1*03:01, DRB1*04:02, and DRB1*04:05) were positively associated, while three (DRB1*10:01, DRB1*15:02, and DRB1*15:03) were protective. DRB1*03:01 had the strongest association (odds ratio=5.04, p=1.7 × 10-10 ). Young Sudanese individuals with T1D generally have similar characteristics to reported European-origin T1D populations. However, they have higher rates of DKA and slightly lower autoantibody rates than reported European-origin populations, and a particularly strong association with HLA-DRB1*03:01.

A point-of-care test increases same-day referral and reduces DKA in children with new-onset type 1 diabetes

Same-day referral for tertiary management of suspected childhood type 1 diabetes (T1D) is recommended as best practice. The aim of this study was to review recent primary care practice in managing suspected paediatric T1D and its impact on clinical outcomes. This was a retrospective cross-sectional study of referral patterns and clinical outcomes of youth aged <18 years withnew-onset T1D at two tertiary metropolitan paediatric diabetes centres. Almost half (73 out of 155) of children and adolescents later diagnosed with T1D had delayed referral; 56% (41 out of 73) had additional pre-referral investigations. Point-of-care (POC) blood/urine glucose testing was associated with increased same-day referral (odds ratio [OR] 14.6; 95% confidence interval [CI]: 5.9, 36.3, P<0.001), reduced pre-referral investigations (OR 0.4; 95% CI: 0.2, 0.9,P=0.02) and reduced diabetic ketoacidosis (DKA) rates (60.3%, compared with 27.8%, P <0.001). POC testing facilitated early tertiary referral and reduced DKA rates and unnecessary investigations in children and adolescents with new presentation of T1D.

Diabetic ketoacidosis at type 1 diabetes diagnosis in children during the COVID-19 pandemic.

ObjectiveThe COVID‐19 pandemic has led to significant public health measures that have resulted in decreased acute pediatric care utilization. We evaluated whether the rate of severe presentations of new onset type 1 diabetes (DM1), such as, diabetic ketoacidosis (DKA) has changed since the COVID‐19 public health measures were enacted.Research Design and MethodsA retrospective chart review of children less than 18 years of age presenting with new onset DM1 during the pandemic period of March 17, 2020 to August 31, 2020 was conducted at two tertiary care pediatric hospitals in Alberta, Canada. Rates of DKA and severe DKA were compared to the same time period in the year 2019 (pre‐pandemic control).ResultsThe number of children presenting with newly diagnosed DM1 was similar during the pandemic year of 2020 compared with 2019 (107 children in 2020 vs. 114 in 2019). The frequency of DKA at DM1 onset was significantly higher in the pandemic period (68.2% vs 45.6%; p < 0.001) and incidence of severe DKA was also higher (27.1% in 2020 vs 13.2% in 2019; p = 0.01).ConclusionsThere was a significant increase in DKA and severe DKA in children presenting with new onset DM1 during the COVID‐19 pandemic period. This emphasizes the need for educating health care professionals and families to be aware of the symptoms of hyperglycemia and the importance of early diagnosis and treatment even during public health measures for COVID‐19.