BACKGROUND: Prognosis of DKA has improved over time with the availability of evidence-based protocols and resources. However, in Kenya, there are limited resources for the appropriate diagnosis and management of DKA, mostly limited to tertiary-level referral facilities. This study aimed to review the clinical presentation, management, and outcomes of adult patients admitted with DKA and assess differences in these parameters before and during the COVID-19 pandemic.
METHODS: This was a retrospective study of DKA admissions from January 2017 to December 2021. Patient data were retrieved from the medical records department using ICD-10 codes, and individual details were abstracted on clinical presentation, management, and outcomes of DKA. Comparisons were made between pre-COVID-19 and during COVID-19 durations.
RESULTS: 150 patients admitted with DKA were included (n = 48 pre- COVID-19, n = 102 during COVID-19 (n = 23 COVID-19 positive, n = 79 COVID-19 negative)). Median age was 47 years (IQR 33.0, 59.0), median HbA1C was 12.4% [IQR 10.8, 14.6]), and most patients had severe DKA (46%). Most common DKA precipitants were infections (40.7%), newly diagnosed diabetes (33.3%) and missed medication (25.3%). There was a significant difference in pulmonary infections as a DKA precipitant, between the pre- COVID and during COVID-19 pandemic (21.6% during COVID-19 versus 6.3% pre- COVID-19; p = 0.012). Median total insulin dose used was 110.0 units [IQR 76.0, 173.0], and a 100% of patients received basal insulin. Median length of hospital stay was 4.0 days [IQR 3.0, 6.0] and time to DKA resolution was 30.0 h [IQR 24.0, 48.0]. There were 2 deaths (1.3%), none directly attributable to DKA. Severity of DKA significantly differed between pre- COVID-19, COVID-19 positive and COVID-19 negative DKA (52.2% of COVID-19 positive had moderate DKA compared to 26.6% of COVID-19 negative and 22.9% of Pre-COVID-19 (p = 0.006)).
CONCLUSIONS: Even in developing regions, good outcomes can be achieved with the appropriate facilities for DKA management. Clinician and patient education is necessary to ensure early detection and prompt referral to avoid patients presenting with severe DKA. Exploratory studies are needed to assess reasons for prolonged time to DKA resolution found in this study.

The incidence, prevalence, mortality, and health expenditure associated with diabetes continue to grow, despite efforts. The use of multianalyte sensors, which detect glucose as well as key analytes such as ketones, lactate, insulin, uric acid, and electrolytes, may provide additional information to guide earlier identification and management of diabetes and its complications. We undertook a narrative review using a systematic approach in May 2023, with a bridge search undertaken in April 2024. Four biomedical databases were searched: MEDLINE (Ovid), Embase, Emcare, and Cochrane Library. Searches for gray literature were conducted on ClinicalTrials.gov, Google Scholar, and websites of relevant organizations. Included studies incorporated articles on multianalyte sensors in diabetes and single-analyte sensors proposing integration into multianalyte diabetes management, with no limits placed on publication date and study design. Data were screened and extracted using CovidenceTM software. Overall, 11 articles were included, of which 7 involved multianalyte sensors (involving glucose and other analytes) and 4 single-analyte sensors (measuring non-glucose substances for proposed future integration into multianalyte systems). Analytes examined were ketones (n = 3), lactate (n = 4), uric acid (n = 3), insulin (n = 1), and potassium (n = 1). Results demonstrated that in vitro and in vivo measurements of multi- and single-analyte sensors accurately and reliably corresponded with human capillary and serum samples. While the literature on this topic is sparse, our review demonstrated that measurement of glucose and other analytes can be feasibly undertaken using multi- and single-analyte sensors. More studies in humans are needed to establish clinical utility in diabetes self-management and assist with technological improvements.

OBJECTIVE: This study aimed to develop and validate a nomogram to predict prolonged diabetes ketoacidosis (DKA) resolution time (DRT).
METHODS: We retrospectively extracted sociodemographic, clinical, and laboratory data from the electronic medical records of 394 adult patients with DKA admitted to Tawam Hospital between January 2017 and October 2022. Logistic regression stepwise model was developed to predict DRT ≥ 24 h. Model discrimination was evaluated using C-index and calibration was determined using calibration plot and Brier score.
RESULTS: The patients\' average age was 34 years; 54 % were female. Using the stepwise model, the final variables including sex, diabetes mellitus type, loss of consciousness at presentation, presence of infection at presentation, body mass index, heart rate, and venous blood gas pH at presentation were used to generate a nomogram to predict DRT ≥ 24 h. The C-index was 0.76 in the stepwise model, indicating good discrimination. Despite the calibration curve of the stepwise model showing a slight overestimation of risk at higher predicted risk levels, the Brier score for the model was 0.17, indicating both good calibration and predictive accuracy.
CONCLUSIONS: An effective nomogram was established for estimating the likelihood of DRT ≥ 24 h, facilitating better resource allocation and personalized treatment strategy.

Type 1 diabetes mellitus (T1DM) is a metabolic disorder characterized by an absolute deficiency of insulin due to pancreatic failure. Diabetes ketoacidosis (DKA) has emerged as one of the most common complications of T1DM. Although exceedingly rare, the onset of T1DM with DKA may result in lipemia secondary to severe hypertriglyceridemia (HTG), accounting for several cases in the pediatric population. Along this line, plasma exchange treatment in children with DKA and severe hyperlipidemia has only been reported in some cases. In this case report, the diagnosis of an 11-year-old girl with diabetes ketoacidosis accompanied by severe HTG, along with subsequent plasma exchange treatment, is presented. Initially, the patient received initial management with crystalloid fluid bolus and intravenous insulin therapy. Despite rapid correction of acidosis, persistent HTG subsequently prompted the plasma exchange treatment. A total of three sessions were administered over 2 days, leading to a significant reduction in the triglyceride levels and corneal opacity resolution, indicating a successful therapeutic intervention.

UNASSIGNED: Every July, new residents begin training across the United States, but it is unclear whether this affects the mortality rate of critically ill patients such as those with diabetes ketoacidosis (DKA).
UNASSIGNED: This national retrospective cohort study included patients aged 18 years or older admitted to acute care with DKA between 2016 and 2020. Data were obtained from the National Inpatient Sample Database. We compared patients admitted in July and August with those admitted during the remaining months and assessed the primary endpoint of all-cause inpatient mortality. We also obtained an odds ratio adjusted for confounders using multivariate logistic regression analysis. Secondary endpoints included length of hospital stay, total hospital charges, the crude rate of mechanical ventilation, acute kidney injury requiring hemodialysis, and vasopressor requirement. Hypothesis testing was conducted using the chi-square test for categorical variables and Student\'s t test for continuous variables. A two-tailed P value of < 0.05 was considered statistically significant.
UNASSIGNED: Of the 269,095 hospitalizations identified over 5 years with a discharge diagnosis of DKA, 250,990 met the inclusion criteria. During July and August, 42,668 (17%) hospitalizations occurred, and 208,322 (83%) occurred during the remaining months. The mean age of the patients was 47 years, and there was no significant difference among the cohorts (P = 0.41). Female patients represented 54% of the total patients, and there was no difference between the cohorts (P = 0.68). Of the admitted patients, 61% were White, 21% were Black, and 11% were Hispanic, with no differences between the cohorts (P = 0.38). Medicare (35%) and Medicaid (30%) were the primary payers for most patients, and approximately 25% had private insurance. There were no differences between the cohorts in terms of primary payers (P = 0.49). The mean length of stay was 7 days, and the total hospitalization cost was $85,509. Admission in July or August did not increase the odds of inpatient mortality (adjusted odds ratio 0.96, P = 0.58).
UNASSIGNED: In this retrospective cohort study of patients admitted with DKA, inpatient care during July and August did not increase the odds of inpatient mortality.

There are very few therapeutic options to treat patients with locally advanced or metastatic Urothelial Cancer (UC). Enfortumab vedotin (EV) was recently approved by the FDA and has become a new therapeutic option for patients previously managed with conventional treatments. Despite its efficacy, EV carries the potential for infrequent yet severe adverse effects. In this report, we present a case of a patient undergoing EV treatment for urothelial carcinoma who developed refractory diabetic ketoacidosis (DKA) unresponsive to escalating insulin doses and necessitating continuous renal replacement therapy. While DKA was resolved, the patient eventually succumbed to progressive maculopapular skin rash, liver failure, and respiratory failure. Additionally, the study delves into a review of cases of EV-induced refractory DKA in the literature, shedding light on the similarities in patient profiles, timelines of adverse effects and the treatment strategies employed to manage the ensuing complications.

UNASSIGNED: Trace elements play an important role in reflecting physical metabolic status, but have been rarely evaluated in diabetes ketoacidosis (DKA). Since clinical biochemical parameters are the first-line diagnostic data mastered by clinical doctors and DKA has a rapid progression, it is crucial to fully utilize clinical data and combine innovative parameters to assist in assessing disease progression. The aim of this study was to evaluate the levels of trace elements in DKA patients, followed by construction of predictive models combined with the laboratory parameters.
UNASSIGNED: A total of 96 T1D individuals (48 DKA patients) were collected from the First Hospital of Jilin University. Serum calcium (Ca), magnesium (Mg), zinc (Zn), copper (Cu), iron (Fe) and selenium (Se) were measured by Inductively Coupled Plasma Mass Spectrometry, and the data of biochemical parameters were collected from the laboratory information system. Training and validation sets were used to construct the model and examine the efficiency of the model. The lambda-mu-sigma method was used to evaluate the changes in the model prediction efficiency as the severity of the patient\'s condition increases.
UNASSIGNED: Lower levels of serum Mg, Ca and Zn, but higher levels of serum Fe, Cu and Se were found in DKA patients. Low levels of total protein (TP), Zn and high levels of lipase would be an efficient combination for the prediction of DKA (Area under curves for training set and validation set were 0.867 and 0.961, respectively). The examination test confirmed the clinical applicability of the constructed models. The increasing predictive efficiency of the model was found with NACP.
UNASSIGNED: More severe oxidative stress in DKA led to further imbalance of trace elements. The combination of TP, lipase and Zn could predict DKA efficiently, which would benefit the early identification and prevention of DKA to improve prognosis.

UNASSIGNED: The purpose of this systematic review and meta-analysis was to evaluate the common clinical adverse events associated with sodium/glucose cotransporter-2 inhibitor (SGLT2i) use compared to placebo in patients with chronic kidney disease (CKD) with or without type 2 diabetes.
UNASSIGNED: Twelve articles were chosen via a systematic search of the PubMed, Embase, and Cochrane Library databases. We screened for randomised placebo-controlled trials. The main clinical adverse events included diabetes ketoacidosis (DKA), amputation, and volume depletion. We performed heterogeneity testing and assessment of publication bias.
UNASSIGNED: In all, 65 600 patients were included in the analysis. Compared to placebo, SGLT2i may increase the risk of DKA and volume depletion in patients with CKD with or without type 2 diabetes. For DKA, compared with placebo, the combined effect of SGLT2i was OR 2.03 (95% CI: 1.28 to 3.23 I2: 2.3%, P: 0.420). For volume depletion, compared with placebo, the combined effect of SGLT2i was OR 1.24 (95% CI: 1.13 to 1.37 I2: 0.0%, P: 0.484). For the risk of amputation, despite low heterogeneity for amputation, the forest plot indicated no statistical significance, and thus it cannot be concluded that SGLT2i increases the risk of amputation. Compared with placebo, the combined effect of SGLT2i was OR 1.10 (95% CI: 0.94 to 1.29 I2: 0.0%, P: 0.642).
UNASSIGNED: The use of SGLT2i may increase the risk of DKA and volume depletion in patients with chronic renal insufficiency with or without type 2 diabetes.

The first-line treatment of diabetes ketoacidosis (DKA) involves fluid resuscitation with normal saline infusion to correct hypovolemia. Hyperchloremic metabolic acidosis from aggressive normal saline administration was associated with worse clinical outcomes in managing DKA. Other choices for normal saline include balanced electrolyte solutions (BESs). This study aimed to compare the clinical effects between BESs and normal saline in managing DKA. This study was a systematic review of probing articles published from inception to October 2021 in Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online, Google Scholar, and Scopus. Eight randomized controlled trials with a total of 595 individuals were included. The data were analyzed at 95% confidence level using random-effects models. For the primary outcomes, there was no difference in the duration of DKA resolution. (Mean difference [MD] -4.73, 95% confidence interval [CI] -2.72-4.92; I2 = 92%; P = 0.180). However, there was a significantly lower postresuscitation chloride concentration in the BES (MD 2.96 95% CI - 4.86 to - 1.06; I2 = 59%; P = 0.002). For the secondary outcomes, there was a significant reduction in duration for normalization of bicarbonate in the BES group (MD 3.11 95% CI - 3.98-2.23; I2 = 5%; P = 0.0004). There were no significant differences between groups in duration for recovery of pH, intensive unit admission, and adverse events (mortality and acute renal failure). Resuscitation with BES was associated with decreased chloride and increased bicarbonate values in DKA patients. It suggests that BES prevents DKA patients from hyperchloremic metabolic acidosis.

OBJECTIVE: This study aimed to provide a global insight into initiatives in type 1 diabetes care driven by the COVID-19 pandemic and associations with glycemic outcomes.
METHODS: An online questionnaire regarding diabetes care before and during the pandemic was sent to all centers (n = 97, 66,985 youth with type 1 diabetes) active in the SWEET registry. Eighty-two responded, and 70 (42,798 youth with type 1 diabetes) had available data (from individuals with type 1 diabetes duration >3 months, aged ≤21 years) for all 4 years from 2018 to 2021. Statistical models were adjusted, among others, for technology use.
RESULTS: Sixty-five centers provided telemedicine during COVID-19. Among those centers naive to telemedicine before the pandemic (n = 22), four continued only face-to-face visits. Centers that transitioned partially to telemedicine (n = 32) showed a steady increase in HbA1c between 2018 and 2021 (p < 0.001). Those that transitioned mainly to telemedicine (n = 33 %) improved HbA1c in 2021 compared to 2018 (p < 0.001).
CONCLUSIONS: Changes to models of care delivery driven by the pandemic showed significant associations with HbA1c shortly after the pandemic outbreak and 2 years of follow-up. The association appeared independent of the concomitant increase in technology use among youth with type 1 diabetes.