Ketosis-Prone Diabetes (Flatbush Diabetes): an Emerging Worldwide Clinically Important Entity

Envisioning Tools to Help Classify Type 1 Diabetes and Type 2 Diabetes in New-Onset Adult Diabetes

A tool is needed to distinguish type 1 diabetes (T1D) and type 2 diabetes (T2D) in adults with new-onset diabetes because correct classification is needed for correct diagnoses and treatments. Current classification methods are usually applied to biomarkers using binary or quantitative classification with a cut point and may not be adequately nuanced. Combinations of clinical features are not necessarily specific for classifying and may not always indicate a single diagnosis. A probabilistic decision tree classification tool with multiple branches per decision node is needed for adults with new-onset diabetes to avoid misdiagnosis of actual T1D as T2D, misdiagnosis of actual T2D or monogenic diabetes as T1D, and misclassified patients in future population health studies which will lead to incorrect conclusions and suboptimal patient outcomes.

Retrospective derivation of a causal pathway for diabetic ketoacidosis in adult patients with type 2 diabetes mellitus

BACKGROUND

Type 2 ketone-prone diabetes mellitus (T2KPDM) is thought to occur in men of African descent, with obesity who experienced prolonged hyperglycemia; the role of medication non-adherence as a contributing cause remains unstudied.

RESEARCH DESIGN AND METHODS

This was a retrospective study of unique adults (>18 years) who sought emergency care one of four hospitals in the greater Detroit area. Patients were identified on the basis of a laboratory order for a ß-hydroxybutyrate concentration. Two research coordinators abstracted 119 data fields. Patients were divided into four phenotypes: (1) no prior DM, (2) type 2 DM without prior ketosis, (3) type 2 with prior ketosis and (4) type 1 DM. A ß-hydroxybutyrate >20 mg/dL defined diabetic ketoacidosis (DKA). A directed acyclic graph was constructed to diagram a causal pathway.

RESULTS

Of 450 patients, 326 were non-type I and 37% of these had DKA. Concentrations of ß-hydroxybutyrate, glucose, bicarbonate were not different between non-type1 versus type 1 DM patients. Admission rates to the ICU and hospital lengths of stay were similar between the four phenotypes with DKA. We found no association with sex, race or body mass index. Unadjusted odds for DKA were significant for non-adherence (odds=1.74, 95% CI 1.08 to 2.21) arrival by Emergency Medical Services (odds=0.54, 95% CI 0.33 to 0.86) and private or Medicare insurance (odds=6.80, 95% CI 4.00 to 11.60). The median HbA1C was statistically higher in patients with DKA (median 11.3%) versus those without DKA (median 9.5%, Mann-Whitney U p<0.001) and was also higher in patients with a history of non-adherence. In multivariable analysis, non-adherence was found to be a mediator of DKA with T2KPDM.

CONCLUSIONS

in Detroit, MI, prior ketosis and private or Medicare health insurance were significantly associated with new or recurrent DKA in T2KPDM. Medication non-adherence had a mediating role.

Young-Onset Diabetes in Sri Lanka: Experience From the Developing World

Background: Young-onset diabetes (YOD) is characterised by unique diagnostic and management challenges more pronounced in resource-limited settings like Sri Lanka. Aims: We aimed to ascertain the prevalence, patterns and characteristics of YOD in Sri Lanka and describe the state of care. Methods: Retrospective review of baseline data of all patients enrolled in the prospective multicentre Database for Young-Onset Diabetes, Sri Lanka (DYOD-SL), was performed, from April 2021 to April 2023. Results: A total of 2531 patient data were included from 28 centres island-wide. Females were 57.6%. The median age was 20 years (interquartile range (IQR) 17, 23), and the age at diagnosis was 15 years (IQR 12, 18). Type 1 diabetes (T1D) was the commonest (57.6%), followed by Type 2 diabetes (T2D) at 34.3%. Younger age at disease onset (p < 0.001), lower BMI (p < 0.001), and diabetic ketoacidosis (DKA) at presentation (p < 0.001) favoured T1D. In the total cohort, the median HbA1c was 9.8% (IQR 7.8, 12.1) with younger patients having poorer control (p = 0.001). Prevalence of nephropathy was 8.1%, retinopathy was 6.6%, neuropathy was 4.1%, moderate-high-risk diabetic foot disease was 1.9%, and macrovascular complications were 0.5%. Hypertension and dyslipidaemia occurred in 2.7% and 14%, respectively. Among patients > 18 years, overweight and obese were 22.2% and 10.4%. Corresponding prevalence in the 5-18-year age group was 20% and 14.7%. Among the insulin users (76%) in the total cohort, the majority (64.7%) were on premixed-based insulin regimens delivered by syringes. Self-monitoring of blood glucose (BG) was reported in 71.3% of the total population. None were on continuous/flash glucose monitoring or insulin pumps. Conclusion: T1D was the commonest subtype of YOD in this hospital-based population. However, T2D was notably higher and is of significant concern. Overall, suboptimal glycaemic control and high rate of complications were noted along with substandard insulin regimens and BG monitoring.

Hyperglycemic Crises in Adults With Diabetes: A Consensus Report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE), and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment, and prevention of diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes health care professionals and individuals with diabetes.

Hyperglycaemic crises in adults with diabetes: a consensus report

The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), Joint British Diabetes Societies for Inpatient Care (JBDS), American Association of Clinical Endocrinology (AACE) and Diabetes Technology Society (DTS) convened a panel of internists and diabetologists to update the ADA consensus statement on hyperglycaemic crises in adults with diabetes, published in 2001 and last updated in 2009. The objective of this consensus report is to provide up-to-date knowledge about the epidemiology, pathophysiology, clinical presentation, and recommendations for the diagnosis, treatment and prevention of diabetic ketoacidosis (DKA) and hyperglycaemic hyperosmolar state (HHS) in adults. A systematic examination of publications since 2009 informed new recommendations. The target audience is the full spectrum of diabetes healthcare professionals and individuals with diabetes.

Not all ketosis is type 1 - remember Flatbush

A 35-year-old otherwise healthy gentleman from Togo, was referred as a 'walk-in' to our clinic with polyuria and polydipsia, and a glycated haemoglobin (Hba1c) of 119 mmol/mol (13.1%). The patient also noted 5kg weight loss over a short span of time. He had a significant family history of Type 2 Diabetes Mellitus (T2DM). Initial blood tests revealed a blood glucose of 22.84 mmol/L, with positive ketones (1.2 mmol/L). Urinalysis showed glycosuria (1000 mg/dL) but was negative for nitrites and white cells. Renal, liver and thyroid function tests were all within normal limits. He had mild metabolic acidosis.

Risk of chronic kidney disease in patients with a hyperglycemic crisis as the initial presentation of type 2 diabetes

Limited data exist on long-term renal outcomes in patients with hyperglycemic crisis (HC) as initial type 2 diabetes presentation. We evaluated the risk of chronic kidney disease (CKD) development in those with concurrent HC at diagnosis. Utilizing Taiwan's insurance claims from adults newly diagnosed with type 2 diabetes during 2006-2015, we created HC and matched non-HC cohorts. We assessed incident CKD/diabetic kidney disease (DKD) by 2018's end, calculating the hazard ratio (HR) with the Cox model. Each cohort comprised 13,242 patients. The combined CKD and DKD incidence was two-fold higher in the HC cohort than in the non-HC cohort (56.47 versus 28.49 per 1000 person-years) with an adjusted HR (aHR) of 2.00 (95% confidence interval [CI] 1.91-2.10]). Risk increased from diabetic ketoacidosis (DKA) (aHR:1.69 [95% CI 1.59-1.79]) to hyperglycemic hyperosmolar state (HHS) (aHR:2.47 [95% CI 2.33-2.63]) and further to combined DKA-HHS (aHR:2.60 [95% CI 2.29-2.95]). Subgroup analysis in individuals aged ≥ 40 years revealed a similar trend with slightly reduced incidences and HRs. Patients with HC as their initial type 2 diabetes presentation face a higher CKD risk than do those without HC. Enhanced medical attention and customized interventions are crucial to reduce this risk.

Diabetic ketoacidosis in an adult with beta-ketothiolase deficiency (BKD) involving a novel ACAT1 variant : first report of established diabetes in BKD and a review of the literature

BACKGROUND

Diabetes presenting in young adults is often challenging to classify. Diabetic ketoacidosis is typically seen in autoimmune type 1 diabetes mellitus and more rarely in young onset type 2 diabetes mellitus. Beta-ketothiolase deficiency (BKD) is a rare autosomal recessive condition affecting isoleucine catabolism and ketone body metabolism. BKD typically manifests in childhood as recurrent episodes of ketoacidosis, the frequency of which tends to reduce with age. There is a paucity of data with respect to the co-existence of persistent dysglycemia with BKD.

CASE PRESENTATION AND LITERATURE REVIEW

We present a novel case of diabetes presenting as diabetic ketoacidosis in a 34-year-old man with BKD, with genetically confirmed compound heterozygosity for variants in ACAT1, including a novel ACAT1 c.481T>C, p.(Tyr161His) variant. Diabetes in people with BKD presents unique diagnostic and management challenges. To further contextualize our findings, we conducted a comprehensive narrative review of the existing literature with respect to dysglycemia in those with BKD, especially in adulthood. There are no existing reports describing diabetes in adults with BKD. Stress hyperglycemia is not uncommon when children with BKD are acutely unwell, with several pediatric case reports describing short-lived hyperglycemia but normal HbA1c measurements during metabolic crises (indicating the absence of persistent hyperglycemia).

CONCLUSIONS

This is the first report of diabetic ketoacidosis in an adult with BKD, with an elevated HbA1c consistent with persistent hyperglycemia. This case highlights the importance of checking HbA1c in people with BKD and hyperglycemia in order to uncover potential coexisting diabetes, facilitating timely management and preventing complications. Increased reporting on the longitudinal outcomes of those with rare metabolic disorders is essential for identifying potential associations with conditions like diabetes.

Enhancing outcome prediction by applying the 2019 WHO DM classification to adults with hyperglycemic crises: A single-center cohort in Thailand

BACKGROUND AND AIMS

Hyperglycemic crisis is a metabolic catastrophe which can occur in any type of diabetes. In 2019, the World Health Organization (WHO) revised the classification of diabetes mellitus (DM) and established two new hybrid forms, latent autoimmune diabetes in adults (LADA) and ketosis-prone type 2 diabetes (T2D). This study aimed to determine clinical outcomes after a hyperglycemic crisis event in people with diabetes classified subtypes by 2019 WHO DM classification.

METHODS

A five-year (2015-2019) retrospective study of adult patients admitted with hyperglycemic crises was conducted. Types of diabetes were recategorized based on the 2019 WHO DM classification. Clinical characteristics, in-admission treatment and complications, long-term follow-up outcomes, and mortality were collected, analyzed, and compared.

RESULTS

A total of 185 admissions occurred in 136 patients. The mean age was 50.6 ± 18.4 years (49.3 % men). The annual average incidence of hyperglycemic crises was 5.2 events/1000 persons. The proportion of type 1 diabetes, T2D, LADA, ketosis-prone T2D, and pancreatic DM were 15.4 %, 69.1 %, 2.2 %, 11 %, and 2.2 %, respectively. In-hospital mortality was 3.7 % while cumulative mortality totaled 19.1 %. During the 24-month follow-up, ketosis-prone T2D had the highest success of insulin discontinuation (HR 6.59; 95 % CI 6.69-319.4; p < 0.001), while T2D demonstrated the highest mortality compared to others (HR, 2.89; 95%CI 1.15-6.27; p = 0.02).

CONCLUSION

The reclassification of diabetes based on 2019 WHO DM classification helped elucidate differences in long-term outcomes and mortality among DM types. The new classification, which separates ketosis-prone T2D from standard T2D, should be encouraged in clinical practice for precise and individualized management.

Phenotype and predictors of insulin independence in adults presenting with diabetic ketoacidosis: a prospective cohort study

AIMS/HYPOTHESIS

The aim of this work was to describe the phenotype of adults presenting with a first episode of diabetic ketoacidosis (DKA) in Cape Town, South Africa, and identify predictors of insulin independence at 12 and 60 months after presentation.

METHODS

A prospective, descriptive cohort study of all individuals, 18 years or older, presenting for the first time with DKA to four public-sector hospitals of the Groote Schuur Academic Health Complex was performed. Clinical, biochemical and laboratory data including GAD antibody and C-peptide status were collected at baseline. Insulin was systematically weaned and stopped in individuals who achieved normoglycaemia within the months after DKA. Individuals were followed for 12 months and then annually until 5 years after initial presentation with ketoacidosis.

RESULTS

Eighty-eight individuals newly diagnosed with diabetes when presenting with DKA were included and followed for 5 years. The mean ± SD age was 35±10 years and the median (IQR) BMI at diagnosis was 28.5 (23.3-33.4) kg/m2. Overall, 46% were insulin independent 12 months after diagnosis and 26% remained insulin independent 5 years after presentation. Forty-one participants (47%) tested negative for anti-GAD and anti-IA-2 antibodies and had C-peptide levels >0.3 nmol/l; in this group, 68% were insulin independent at 12 months and 37% at 5 years after diagnosis. The presence of acanthosis nigricans was strongly associated with insulin independence (OR 27.1 [95% CI 7.2, 102.2]; p<0.001); a positive antibody status was associated with a lower likelihood of insulin independence at 12 months (OR 0.10 [95% CI 0.03, 0.36]; p<0.001). On multivariable analysis only acanthosis (OR 11.5 [95% CI 2.5, 53.2]; p=0.004) was predictive of insulin independence 5 years after diagnosis.

CONCLUSIONS/INTERPRETATION

The predominant phenotype of adults presenting with a first episode of DKA in Cape Town, South Africa, was that of ketosis-prone type 2 diabetes. These individuals presented with obesity, acanthosis nigricans, negative antibodies and normal C-peptide and could potentially be weaned off insulin at follow-up. Classic type 1 diabetes (lower weight, antibody positivity, low or unrecordable C-peptide levels and long-term insulin dependence) was less common. The simple clinical sign of acanthosis nigricans is a strong predictor of insulin independence at 12 months and 5 years after initial presentation.

Honeymoon phase in type 1 diabetes mellitus: A window of opportunity for diabetes reversal?

The knowledge of the pathogenesis of type 1 diabetes mellitus (T1DM) continues to rapidly evolve. The natural course of the disease can be described in four clinical stages based on the autoimmune markers and glycemic status. Not all individuals of T1DM progress in that specific sequence. We hereby present a case of T1DM with a classical third phase (honeymoon phase) and discuss the intricacies of this interesting phase along with a possible future promise of "cure" with the use of immunotherapies. We now know that the course of T1DM may not be in only one direction towards further progression; rather the disease may have a waxing and waning course with even reversal of type 1 diabetes concept being discussed. The third phase popularly called the "honeymoon phase", is of special interest as this phase is complex in its pathogenesis. The honeymoon phase of T1DM seems to provide the best window of opportunity for using targeted therapies using various immunomodulatory agents leading to the possibility of achieving the elusive "diabetes reversal" in T1DM. Identifying this phase is therefore the key, with a lot of varying criteria having been proposed.

The clinical value of glycosylated hemoglobin level in newly diagnosed ketosis-prone type 2 diabetes

Objective

To evaluate the clinical value of glycosylated hemoglobin (HbA1c) in newly diagnosed ketosis-prone type 2 diabetes (KPD).

Methods

A total of 330 patients with newly diagnosed type 2 diabetes (T2DM) hospitalized in our department with an average age of 48.72 ± 13.07 years old were selected and divided into T2DM group (193 cases) and KPD group (137 cases) according to whether they were combined with ketosis. According to the quartile level of HbA1c, they were divided into group A (HbA1c < 8.90%, 84 cases), group B (8.90%≤HbA1c < 10.70%, 86 cases), group C (10.70%≤HbA1c ≤ 12.40%, 85 cases) and group D (HbA1c > 12.40%, 75 cases). The general clinical features, laboratory indicators and islet function of each group were compared. Spearman correlation analysis was used to explore the correlation between HbA1c and β- Hydroxybutyric acid (β- HB) and islet function. ROC curve was used to analyze the sensitivity and specificity of HbA1c in diagnosing KPD, and the optimal tangent point was obtained.

Results

HbA1c, β-HB, FFA, RBG, insulin dosage, GSP, OGTT (0, 0.5, 1, 2, 3h) in KPD group were significantly higher than those in T2DM group (P< 0.001). HDL-C, IRT (0, 0.5, 1, 2, 3h), HOMA-β, HOMA-IR, HOMA-IS, ΔC30/ΔG30, AUC insulin were significantly lower than those in T2DM group (P< 0.001). With the increase of HbA1c level, the incidence of ketosis, β-HB, FFA and insulin dosage increased, while IRT (0, 0.5, 1, 2, 3h), ΔC30/ΔG30, AUC insulin, HOMA-β and HOMA-IS decreased accordingly (P< 0.001). In all newly diagnosed T2DM patients, Spearman correlation analysis showed that HbA1c was positively correlated with β-HB (r=0.539, P < 0.001), and was negatively correlated with HOMA-β (r=-0.564, P < 0.001), HOMA-IS (r=-0.517, P < 0.01, P < 0.001), HOMA-IR (r=-0.177, P < 0.001), ΔC30/ΔG30 (r=-0.427, P < 0.01) and AUC insulin (r=-0.581, P < 0.001). In ROC curve analysis, the optimal threshold for the diagnosis of KPD was 10.15%, Youden index was 0.616, area under the curve (AUC) was 0.882, sensitivity = 92.70%, specificity = 70.50%.

Conclusion

In newly diagnosed T2DM patients, if HbA1c > 10.15%, it is more likely to develop KPD. Monitoring HbA1c level is conducive to timely detection of high-risk individuals with KPD and taking appropriate measures to prevent the occurrence and development of the disease.

Comprehensive analysis of factors associated with significant blood loss during percutaneous nephrolithotomy

INTRODUCTION

The objective of this study is to conduct a thorough investigation of the risk factors associated with blood loss during PCNL, within the setting of a US urban tertiary care center.

MATERIALS AND METHODS

We conducted a retrospective analysis of our endourology database to identify adult patients who underwent PCNL for stone extraction at our tertiary stone center between October 2014 and December 2022. Patients were categorized into two groups based on the extent of blood loss: significant blood loss (SBL) and no significant blood loss (NSBL). The cut-off value for SBL was determined as the median change in hematocrit levels from preoperative to postoperative among patients who required postoperative transfusions. Several factors were evaluated, including stone dimensions, operative details, the presence of preoperative drains, patient position, type of access, access site, number of accesses, tract size, tract length, stone location, number of stones, operative time, and the S.T.O.N.E. Nephrolithometry Scoring System.

RESULTS

Our analysis included a total of 695 procedures performed on 674 distinct patients who met our inclusion criteria. Of these, 102 patients (14.7%) were included in the SBL group. Patients in the SBL group had a higher mean number of accesses (1.57 vs. 1.29, P<0.001), were positioned prone more often (96.0% vs. 88.6%, P = 0.025), and underwent fluoroscopic-guided access more frequently (89.9% vs. 64.8%, P<0.001). Additionally, significant differences were observed in stone morphology, with the SBL group having higher rates of complete staghorn stones (42.2% vs. 27.0%, P = 0.019) and lower rates of partial staghorn stones (27.7% vs. 36.8%, P = 0.019). A larger proportion of patients in the SBL group required a 16 French nephrostomy tube for postoperative drainage (13.3% vs. 10.4%, P = 0.041). Lastly, the SBL group had a longer mean operative time compared to the NSBL group (P<0.001). Multiple logistic regression analysis identified stone volume (P = 0.039), number of accesses (P = 0.047), and operative time (P = 0.006) as independent risk factors associated with SBL status.

CONCLUSION

Surgical complexity factors such as stone volume, number of accesses, and operative time are linked to a higher risk of SBL during PCNL. Stone volume and the requirement for multiple accesses can usually be estimated with reasonable accuracy before surgery.

Development and validation of a novel nomogram for prediction of ketosis-prone type 2 diabetes

Background

Ketosis-prone type 2 diabetes (KPD), as a unique emerging clinical entity, often has no clear inducement or obvious clinical symptoms at the onset of the disease. Failure to determine ketosis in time may lead to more serious consequences and even death. Therefore, our study aimed to develop and validate a novel nomogram to predict KPD.

Methods

In this retrospective study, clinical data of a total of 398 newly diagnosed type 2 diabetes in our hospital who met our research standards with an average age of 48.75 ± 13.86 years years old from January 2019 to December 2022 were collected. According to the occurrence of ketosis, there were divided into T2DM groups(228 cases)with an average age of 52.19 ± 12.97 years, of whom 69.74% were male and KPD groups (170cases)with an average age of 44.13 ± 13.72 years, of whom males account for 80.59%. Univariate and multivariate logistic regression analysis was performed to identify the independent influencing factors of KPD and then a novel prediction nomogram model was established based on these independent predictors visually by using R4.3. Verification and evaluation of predictive model performance comprised receiver-operating characteristic (ROC) curve, corrected calibration curve, and clinical decision curve (DCA).

Results

4 primary independent predict factors of KPD were identified by univariate and multivariate logistic regression analysis and entered into the nomogram including age, family history, HbA1c and FFA. The model incorporating these 4 predict factors displayed good discrimination to predict KPD with the area under the ROC curve (AUC) of 0.945. The corrected calibration curve of the nomogram showed good fitting ability with an average absolute error =0.006 < 0.05, indicating a good accuracy. The decision analysis curve (DCA) demonstrated that when the risk threshold was between 5% and 99%, the nomogram model was more practical and accurate.

Conclusion

In our novel prediction nomogram model, we found that age, family history, HbA1c and FFA were the independent predict factors of KPD. The proposed nomogram built by these 4 predictors was well developed and exhibited powerful predictive performance for KPD with high discrimination, good accuracy, and potential clinical applicability, which may be a useful tool for early screening and identification of high-risk population of KPD and therefore help clinicians in making customized treatment strategy.

Prevalence, clinical characteristics and HLA genotypes of idiopathic type 1 diabetes: A cross-sectional study

AIMS

Idiopathic type 1 diabetes (T1D) is a neglected subtype of T1D. Our aim was to investigate the frequency, clinical characteristics, and human leucocyte antigen (HLA) genotypes of idiopathic T1D.

METHODS

We enrolled 1205 newly diagnosed T1D patients in our analysis. To exclude monogenic diabetes in autoantibody-negative patients, we utilised a custom monogenic diabetes gene panel. Individuals negative for autoantibodies and subsequently excluded for monogenic diabetes were diagnosed with idiopathic T1D. We collected clinical characteristics, measured islet autoantibodies by radioligand assay and obtained HLA data.

RESULTS

After excluding 11 patients with monogenic diabetes, 284 cases were diagnosed with idiopathic T1D, accounting for 23.8% (284/1194) of all newly diagnosed T1D cases. When compared with autoimmune T1D, idiopathic T1D patients showed an older onset age, higher body mass index among adults, lower haemoglobin A1c, higher levels of fasting C-peptide and 2-h postprandial C-peptide, and were likely to have type 2 diabetes (T2D) family history and carry 0 susceptible HLA haplotype (all p < 0.01). A lower proportion of individuals carrying 2 susceptible HLA haplotypes in idiopathic T1D was observed in the adult-onset subgroup (15.7% vs. 38.0% in child-onset subgroup, p < 0.001) and in subgroup with preserved beta-cell function (11.0% vs. 30.1% in subgroup with poor beta-cell function, p < 0.001). Multivariable correlation analyses indicated that being overweight, having T2D family history and lacking susceptible HLA haplotypes were associated with negative autoantibodies.

CONCLUSIONS

Idiopathic T1D represents about 1/4 of newly diagnosed T1D, with adult-onset and preserved beta-cell function patients showing lower HLA susceptibility and more insulin resistance.

A Devastating Floating Aortic Thrombus and Ketosis-Prone Diabetes

This article reports a case study of a middle-aged patient diagnosed with Ketosis-Prone Diabetes (KPD) and diabetic ketoacidosis who had a mobile thrombus in the distal aortic arch with catastrophic complications from thrombus embolization. The pathogenesis of the mobile aortic thrombus is currently under investigation, with many risk factors having been found. Based on the patient's limited manifestation of atherosclerosis and the absence of any indications of thrombophilia, KPD and inflammation from uncontrolled hyperglycemia likely played a significant role in the formation of the thrombus. KPD is a subtype of diabetes characterized by the abrupt onset of severe hyperglycemia and ketoacidosis. The inflammation caused by uncontrolled hyperglycemia in KPD patients can lead to endothelial dysfunction and the activation of prothrombotic pathways. There is a lack of consensus regarding the optimal approach for managing a mobile aortic thrombus. The main strategies under consideration are conservative care, including anticoagulation alone, invasive removal of the thrombus, or endovascular intervention.

Development and validation of a multivariable risk prediction model for identifying ketosis-prone type 2 diabetes

BACKGROUND

To develop and validate a multivariable risk prediction model for ketosis-prone type 2 diabetes mellitus (T2DM) based on clinical characteristics.

METHODS

A total of 964 participants newly diagnosed with T2DM were enrolled in the modeling and validation cohort. Baseline clinical data were collected and analyzed. Multivariable logistic regression analysis was performed to select independent risk factors, develop the prediction model, and construct the nomogram. The model's reliability and validity were checked using the receiver operating characteristic curve and the calibration curve.

RESULTS

A high morbidity of ketosis-prone T2DM was observed (20.2%), who presented as lower age and fasting C-peptide, and higher free fatty acids, glycated hemoglobin A1c and urinary protein. Based on these five independent influence factors, we developed a risk prediction model for ketosis-prone T2DM and constructed the nomogram. Areas under the curve of the modeling and validation cohorts were 0.806 (95% confidence interval [CI]: 0.760-0.851) and 0.856 (95% CI: 0.803-0.908). The calibration curves that were both internally and externally checked indicated that the projected results were reasonably close to the actual values.

CONCLUSIONS

Our study provided an effective clinical risk prediction model for ketosis-prone T2DM, which could help for precise classification and management.

Association Between Intestinal Prevotella copri Abundance and Glycemic Fluctuation in Patients with Brittle Diabetes

Objective

Previous studies have demonstrated an association between gut microbiota composition and non-brittle type 2 diabetes (NBT2DM) pathogenesis. However, little is known about the correlation between the abundance of intestinal Prevotella copri and glycemic fluctuations in patients with brittle diabetes mellitus (BDM). In this context, we conducted a case-control study of BDM patients and patients with NBT2DM, aiming to determine and analyze the relationship between the abundance of intestinal Prevotella copri and glycemic fluctuations in patients with BDM.

Research Design and methods

We performed a metagenomic analysis of the gut microbiome obtained from fecal samples of 10 BDM patients, and compared their microbial composition and function to NBT2DM patients (1:1 ratio). Then further collected data including age, sex, BMI, glycated hemoglobin (HbA1c), blood lipids, and alpha diversity of the gut microbiota, which were comparable between the BDM and NBT2DM patients by t-test.

Results

A significant difference existed in the beta diversity of the gut microbiota between the two groups (PCoA, R² = 0.254, P = 0.0001). The phylum-level abundance of Bacteroidetes in the gut microbiota of the BDM patients was significantly lower, by 24.9% (P = 0.001), than that of the NBT2DM patients. At the gene level, the abundance of Prevotella copri was obviously reduced, Correlation analysis showed that the Prevotella copri abundance was inversely correlated to the standard deviation of blood glucose (SDBG) (r = -0.477, P = 0.034). Quantitative PCR confirmed that the abundance of Prevotella copri in the BDM patients in the validation cohort was significantly lower than that in NBT2DM patients, and was negatively correlated with SDBG (r = -0.318, P = 0.043). Glycemic variability in BDM was inversely correlated with the abundance of intestinal Prevotella copri.

Conclusion

The decreased abundance of Prevotella copri in patients with BDM may be associated with glycemic fluctuation.

Polygenic Scores Help Reduce Racial Disparities in Predictive Accuracy of Automated Type 1 Diabetes Classification Algorithms

OBJECTIVE

Automated algorithms to identify individuals with type 1 diabetes using electronic health records are increasingly used in biomedical research. It is not known whether the accuracy of these algorithms differs by self-reported race. We investigated whether polygenic scores improve identification of individuals with type 1 diabetes.

RESEARCH DESIGN AND METHODS

We investigated two large hospital-based biobanks (Mass General Brigham [MGB] and BioMe) and identified individuals with type 1 diabetes using an established automated algorithm. We performed medical record reviews to validate the diagnosis of type 1 diabetes. We implemented two published polygenic scores for type 1 diabetes (developed in individuals of European or African ancestry). We assessed the classification algorithm before and after incorporating polygenic scores.

RESULTS

The automated algorithm was more likely to incorrectly assign a diagnosis of type 1 diabetes in self-reported non-White individuals than in self-reported White individuals (odds ratio 3.45; 95% CI 1.54-7.69; P = 0.0026). After incorporating polygenic scores into the MGB Biobank, the positive predictive value of the type 1 diabetes algorithm increased from 70 to 97% for self-reported White individuals (meaning that 97% of those predicted to have type 1 diabetes indeed had type 1 diabetes) and from 53 to 100% for self-reported non-White individuals. Similar results were found in BioMe.

CONCLUSIONS

Automated phenotyping algorithms may exacerbate health disparities because of an increased risk of misclassification of individuals from underrepresented populations. Polygenic scores may be used to improve the performance of phenotyping algorithms and potentially reduce this disparity.

The impact of family history of type 2 diabetes on clinical heterogeneity in idiopathic type 1 diabetes

AIM

To investigate the impact of family history of type 2 diabetes (T2D) on the clinical phenotypes of patients with idiopathic type 1 diabetes (T1D).

METHODS

In clinically diagnosed T1D cases, a total of 335 idopathic T1D patients were included in the study, after excluding autoimmune T1D using islet autoantibody testing and monogenic diabetes using a custom monogenic diabetes gene panel obtained from clinically diagnosed T1D cases. A semi-structured questionnaire was used to collect information on the presence of T2D in first-degree relatives. The demographic and metabolic markers of idiopathic T1D patients were analysed. Subgroup analysis was performed to investigate potential interactions between T2D family history and human leukocyte antigen (HLA) genotypes.

RESULTS

A total of 18.2% of individuals with idiopathic T1D had a T2D family history, and these individuals were more likely to have features associated with T2D, such as older age of onset, higher body mass index at diagnosis, lower insulin dosage and better beta-cell function, as indicated by higher levels of fasting C-peptide and 2-hour postprandial C-peptide (all P < 0.05). Additionally, regardless of HLA susceptible genotypes, the impact of family history of T2D was consistently observed in idiopathic T1D patients. Multivariable analyses showed that T2D family history was negatively correlated with the risk of beta-cell function failure in idiopathic T1D patients (P < 0.05).

CONCLUSIONS

Family history of T2D may be implicated in the heterogeneity of idiopathic T1D patients.

The phenotype of type 1 diabetes in sub-Saharan Africa

The phenotype of type 1 diabetes in Africa, especially sub-Saharan Africa, is poorly understood. Most previously conducted studies have suggested that type 1 diabetes may have a different phenotype from the classical form of the disease described in western literature. Making an accurate diagnosis of type 1 diabetes in Africa is challenging, given the predominance of atypical diabetes forms and limited resources. The peak age of onset of type 1 diabetes in sub-Saharan Africa seems to occur after 18-20 years. Multiple studies have reported lower rates of islet autoantibodies ranging from 20 to 60% amongst people with type 1 diabetes in African populations, lower than that reported in other populations. Some studies have reported much higher levels of retained endogenous insulin secretion than in type 1 diabetes elsewhere, with lower rates of type 1 diabetes genetic susceptibility and HLA haplotypes. The HLA DR3 appears to be the most predominant HLA haplotype amongst people with type 1 diabetes in sub-Saharan Africa than the HLA DR4 haplotype. Some type 1 diabetes studies in sub-Saharan Africa have been limited by small sample sizes and diverse methods employed. Robust studies close to diabetes onset are sparse. Large prospective studies with well-standardized methodologies in people at or close to diabetes diagnosis in different population groups will be paramount to provide further insight into the phenotype of type 1 diabetes in sub-Saharan Africa.

Type 2 diabetes

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.

Acquired Glucose-6-Phosphate Dehydrogenase Deficiency

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a hereditary condition caused by mutations on chromosome X and is transmitted by a sex-linked inheritance. However, impairment of G6PD activity may result from biochemical mechanisms that are able to inhibit the enzyme in specific clinical conditions in the absence of a structural gene-level defect. In this narrative review, a number of clinical settings associated with an "acquired" G6PD deficiency, phenotypically undistinguishable from the primary deficiency, as well as the mechanisms involved, were examined. Hyperaldosteronism and diabetes are the most common culprits of acquired G6PD deficiency. Additional endocrine and metabolic conditions may cause G6PD deficiency in both hospitalized and outpatients. Contrary to the inherited defect, acquired G6PD deficiency is a condition that is potentially curable by removing the factor responsible for enzyme inhibition. Awareness regarding acquired G6PD deficiency by physicians might result in improved recognition and treatment.

Ketosis-prone diabetes mellitus: A phenotype that hospitalists need to understand

Diabetes has been classified mainly into types 1 and 2. Some type 2 diabetes patients, when developing ketosis, have been labeled as having atypical diabetes. Lately, syndromes of ketosis-prone diabetes, primarily in patients who we previously classified as type 2 diabetics, have emerged, and calls are being made to even reclassify diabetes. This mini-review will extensively deal with the historical, molecular, phenotypical, and clinical basis of why ketosis-prone diabetes is different than the traditional principles of type 1 and 2 diabetes and should be classified as such. Clinicians, especially those who are not diabetologists or endocrinologists, as well as hospitalists, intensivists, and primary care providers, will greatly benefit from this review.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Ketosis-Prone Type 2 Diabetes (Flatbush Diabetes) in Remission: A Report of Two Cases

Diabetic ketoacidosis (DKA) is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration. It is a well-known manifestation of type 1 diabetes mellitus (T1DM). However, it can also be the first presentation of type 2 diabetes mellitus (T2DM). This subtype of diabetes shares the characteristics of both T1DM and T2DM and is called 'Flatbush diabetes,' also known as 'ketosis-prone T2DM.' This article highlights the importance of early identification of ketosis-prone T2DM (KPD). We describe two cases of African American men with no past medical histories who presented with unproved DKA as the first presentation of T2DM requiring initial intensive insulin therapy, which was gradually withdrawn with the addition of metformin. Both patients are currently insulin independent for more than 15 months. It is an essential clinical entity to recognize as insulin independence positively impacts the quality of life and decreases the economic burden on the health care system. 

Knockdown of IFNAR2 reduces the inflammatory response in mouse model of type 1 diabetes

BACKGROUND

and Purpose: To investigate the biological role of interferon α/β receptor 2 (IFNAR2) in type 1 diabetes (T1D).

METHODS

First, IFNAR2 mRNA and protein expression levels in serum of T1D patients and healthy controls were detected by RT-qPCR and Western blot. For experimental studies, 80 male C57BL/6 mice were randomly divided into 4 groups with 20 mice in each group: the control group, the T1D group, the T1D + ad-con group and the T1D + ad-si-IFNAR2 group. The T1D mouse model was generated by multiple intraperitoneal injections of small doses of streptozotocin (STZ). Body weight and blood glucose levels were measured weekly until 6 weeks. After 6 weeks, all mice were sacrificed and the levels of insulin (Ins), tumor necrosis factor α (TNF-α), interleukin 4 (IL-4), IL-6, and type I interferon γ (IFN-γ), IFNAR2 protein expression, the number of dendritic cells (DCs), and changes in islet β cells were assessed.

RESULTS

IFNAR2 mRNA and protein expression levels in serum of T1D patients were significantly higher than those in healthy controls (P < 0.05). Furthermore, IFNAR2 protein expression, number of DCs, and IFNAR2 mRNA, blood glucose, TNF-α, and IFN-γ levels were significantly upregulated in T1D mice compared with the control group (P < 0.05), while weight, and Ins, IL-6, and IL-4 levels were decreased (P < 0.05). However, knockdown of IFNAR2 reversed these trends. There was no significant difference in markers between the T1D + ad-con group and the T1D group (P > 0.05).

CONCLUSIONS

Knockdown of IFNAR2 reduced the inflammatory response and improved islet function of T1D mice.

Partial Remission of Diabetes in a Young Adult While Testing Positive for Several Islet Cell Autoantibodies: A Case Report, Literature Review, and Patient Perspective

Type 1 diabetes is a chronic disease characterized by abnormal metabolism and hyperglycemia due to insulin deficiency. There is a rapid decline in insulin production due to autoimmune destruction of the pancreatic beta cells. Partial remission (honeymoon phase) of type 1 diabetes is common in children and young adults with newly diagnosed type 1 diabetes. There is temporary restoration of beta cell function such that little or no exogenous insulin is required. Stopping insulin therapy soon after an emergency admission requiring intravenous insulin and subsequent subcutaneous insulin therapy can be frightening for both patient and healthcare provider. Affected patients require education and support during this period. This report describes a case of a 28-year-old man who presented to the emergency department with features of type 1 diabetes and diabetic ketoacidosis. He was treated with intravenous fluids and intravenous insulin and discharged on a subcutaneous insulin regimen. Despite testing positive for several types of islet cell autoantibodies, the patient was able to stop insulin therapy within three months of diagnosis. The patient maintained a self-initiated low-carbohydrate diet, regular weight-reducing exercise, and normal glucose levels without the need for insulin therapy. The honeymoon phase of type 1 diabetes, latent autoimmune diabetes, and ketosis-prone type 2 diabetes are discussed as important differential diagnoses.

Was It a Case of “Flatbush Diabetes” with Severe Hypertriglyceridemia?

We present a case of a morbidly obese 27 years male patient who was admitted with sudden onset abdominal pain and crashed into diabetic ketoacidosis as new-onset diabetes and discuss the possible etiology of this combined picture of acute pancreatitis and severe hypertriglyceridemia. Flatbush diabetes was, meanwhile, thought of due to his morbid obesity that in turn raised our suspicion of acute insulin-requiring type 2 diabetes mellitus versus T1 diabetes mellitus. Ketosis-prone diabetes or Flatbush diabetes is a syndrome in which diabetes commences with ketoacidosis in patients who are glutamic acid decarboxylase and antiislet cell antibody negative and have no known precipitating causes. They are usually middle-aged, overweight, or mildly obese, and in many reports, they are likely to be male with a family history of type 2 diabetes mellitus; they present with new-onset severe hyperglycemia and ketosis or frank diabetic ketoacidosis. After intensive initial insulin therapy, many patients become insulin-independent and can be well controlled on diet plus oral medications or, more rarely, diet alone.

Steroid-Induced Diabetic Ketoacidosis: A Case Report and Review of the Literature

It has been well documented that corticosteroid treatment can precipitate hyperglycemia and may lead to new diagnoses of type 2 diabetes mellitus. However, steroid-induced diabetic ketoacidosis (DKA) has rarely been reported in the literature. We report the case of an obese 73-year-old man with no known history of diabetes mellitus who presented with DKA after two months of treatment with high-dose steroids. Our patient’s presentation and clinical course were consistent with ketosis-prone type 2 diabetes (KPDM-2). A literature review revealed three other reports of patients with steroid-induced DKA, two of whom also had clinical and biochemical features that were consistent with KPDM-2. We postulate that high-dose steroid treatment can trigger DKA in a subgroup of obese, middle-aged patients with risk factors for KPDM-2. Physicians should suspect steroid-induced KPDM-2 in obese patients who present with new-onset DKA after initiation of steroid treatment.

Characterizing progressive beta-cell recovery after new-onset DKA in COVID-19 provoked A-β+ KPD (ketosis-prone diabetes): A prospective study from Eastern India

BACKGROUND

Recent literature suggests a bi-directional relationship between COVID-19 infection and diabetes mellitus, with an increasing number of previously normoglycemic adults with COVID-19 being admitted with new-onset diabetic ketoacidosis (DKA). However, the possibility of COVID-19 being a potential trigger for A-β + ketosis-prone diabetes (KPD) in these patients needs elucidation. Our study aimed at analyzing such a cohort of patients and determining their natural course of β-cell recovery on serial follow-up.

METHODS

After initial screening, n = 42 previously non-diabetic patients with new-onset DKA and RT-PCR positive COVID-19, were included in our ten-month follow-up study. Of these, n = 22 were negative (suspected A-β + KPD) and n = 20 were positive (Type 1A DM) for autoantibodies (GAD/IA-2/ZnT8). Subsequently, n = 19 suspected KPD and n = 18 Type 1A DM patients were followed-up over ten months with serial assessments of clinical, biochemical and β-cell secretion. Amongst the former, n = 15 (79%) patients achieved insulin independence, while n = 4 (21%) continued to require insulin at ten-months follow-up.

RESULTS

On comparison, the suspected KPD patients showed significantly greater BMI, age, Hba1c, IL-6 and worse DKA parameters at presentation. Serial C-peptide estimations demonstrated significant β-cell recovery in KPD group, with complete recovery seen in the 15 patients who became insulin independent on follow-up. Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were associated with poorer recovery of β-cell secretion at ten-month follow-up amongst the KPD patients, CONCLUSIONS: This is the first prospective study to demonstrate progressive recovery of β-cell secretion in new-onset A-β + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM. Given their significant potential for β-cell recovery, meticulous follow-up involving C-peptide estimations can help guide treatment and avoid injudicious use of insulin.

An Insight Into Flatbush Diabetes: A Rare Form of Diabetes

Ketone-prone diabetes or Flatbush diabetes is being increasingly recognized worldwide. It is typically seen in obese middle-aged men with a family history of Type 2 DM. Atypicality in the onset of age and gender variation is increasingly observed worldwide. Predisposition to glucose desensitization is one of many unclear pathophysiologic mechanisms which is why extensive studies are obligatory. After intensive insulin therapy, many patients eventually become insulin-independent and attain euglycemia with oral hypoglycemic agents or with diet alone due to the recovered functionality of pancreatic beta cells. Our report sheds light on the atypicality of presentation and summarizes the main diagnostic features of this rare form of diabetes. Increased awareness of this entity can facilitate early diagnosis and management.

A Potential Synbiotic Strategy for the Prevention of Type 2 Diabetes: Lactobacillus paracasei JY062 and Exopolysaccharide Isolated from Lactobacillus plantarum JY039

The disturbance of intestinal microorganisms and the exacerbation of type 2 diabetes (T2D) are mutually influenced. In this study, the effect of exopolysaccharides (EPS) from Lactobacillus plantarum JY039 on the adhesion of Lactobacillus paracasei JY062 was investigated, as well as their preventive efficacy against T2D. The results showed that the EPS isolated from L. plantarum JY039 effectively improved the adhesion rate of L. paracasei JY062 to Caco-2 cells (1.8 times) and promoted the proliferation of L. paracasei JY062. In the mice experiment, EPS, L. paracasei JY062 and their complex altered the structure of the intestinal microbiota, which elevated the proportion of Bifidobacterium, Faecalibaculum, while inversely decreasing the proportion of Firmicutes, Muribaculaceae, Lachnospiraceae and other bacteria involved in energy metabolism (p < 0.01; p < 0.05); enhanced the intestinal barrier function; promoted secretion of the gut hormone peptide YY (PYY) and glucagon-like peptide-1 (GLP-1); and reduced inflammation by balancing pro-inflammatory factors IL-6, TNF-α and anti-inflammatory factor IL-10 (p < 0.01; p < 0.05). These results illustrate that EPS and L. paracasei JY062 have the synbiotic potential to prevent and alleviate T2D.

A Cross-Sectional Study of Atherosclerosis in Newly Diagnosed Patients with Ketosis-Prone Type 2 Diabetes

PURPOSE

To investigate the prevalence, clinical and metabolic characteristics of atherosclerosis (AS) in newly diagnosed patients with ketosis-prone type 2 diabetes (KPT2D) or non-ketotic type 2 diabetes (NKPT2D).

PATIENTS AND METHODS

About 1072 subjects with non-autoimmune new-onset diabetes were included in the cross-sectional study. Patients were classified as non-ketotic type 2 diabetes (NKPT2D, n = 662) or ketosis-prone type 2 diabetes (KPT2D, n = 410). Blood samples were collected to determine the levels of glucose, HbA1c, insulin and C-peptide. Routine liver and kidney function tests were also performed. AS was determined by vascular ultrasonography.

RESULTS

The levels of fasting blood glucose and HbA1c were significant higher in the KPT2D group when compared to the NKPT2D group (P<0.001). The levels of fasting C-peptide, 2 h C-peptide and HOMA-β were lower in the KPT2D group than those in NKPT2D group (P<0.001). However, no significant difference was observed for HOMA-IR between the two groups. The onset age of the patients with KPT2D was significantly lower compared to NKPT2D patients (38±13 vs 49±14, P<0.001). After adjusting age of the two groups, the KPT2D patients had a higher prevalence of AS compared to the NKPT2D patients (31.4% vs 21.1%, P=0.005). In both groups, age and gender were independent risk factors for AS, whereas estimated glomerular filtration rate (eGFR) was an independent risk factor in the NKPT2D patients and 2-h postprandial plasma glucose (2h-PPG) was an independent risk factor in the KPT2D patients.

CONCLUSION

AS was more prevalent in KPT2D patients compared to the NKPT2D cohort, which was independent of age and gender. These data suggest that KPT2D patients may have a higher risk of macrovascular complications compared to NKPT2D of the same age.

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus

INTRODUCTION

We explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

This observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management.

RESULTS

From 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1-21.9); type 2 diabetes 13.9 units (7.7-21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7-6.1); type 2 diabetes: 11.0 days (5.0-23.1); p<0.0001).

CONCLUSIONS

In this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission.

Masqueraders: how to identify atypical diabetes in primary care

Diabetes mellitus is a complex set of conditions that impacts 34 million Americans. While type 1 diabetes, type 2 diabetes, and gestational diabetes are most frequently encountered, there are many other types of diabetes with which healthcare providers are less familiar. These atypical forms of diabetes make up nearly 10% of diabetes cases and can masquerade as type 1 or 2 diabetes mellitus (T1DM or T2DM), and the treatment may not be optimized if the diagnosis is not accurate. Atypical forms include monogenic diabetes (formally known as maturity-onset diabetes of the young [MODY]), latent autoimmune diabetes of the adult (LADA), ketosis-prone diabetes, and secondary diabetes. This paper will detail the defining characteristics of each atypical form and demonstrate how they can masquerade as type 1 or 2 diabetes mellitus. Gestational diabetes mellitus will not be discussed in this article.

The β Cell in Diabetes: Integrating Biomarkers With Functional Measures

The pathogenesis of hyperglycemia observed in most forms of diabetes is intimately tied to the islet β cell. Impairments in propeptide processing and secretory function, along with the loss of these vital cells, is demonstrable not only in those in whom the diagnosis is established but typically also in individuals who are at increased risk of developing the disease. Biomarkers are used to inform on the state of a biological process, pathological condition, or response to an intervention and are increasingly being used for predicting, diagnosing, and prognosticating disease. They are also proving to be of use in the different forms of diabetes in both research and clinical settings. This review focuses on the β cell, addressing the potential utility of genetic markers, circulating molecules, immune cell phenotyping, and imaging approaches as biomarkers of cellular function and loss of this critical cell. Further, we consider how these biomarkers complement the more long-established, dynamic, and often complex measurements of β-cell secretory function that themselves could be considered biomarkers.

Therapeutic effects of Chinese herbal medicines and their extracts on diabetes

With the improvement of people's living standards and changes in the environment, the incidence of diabetes has increased rapidly. It has gradually become one of the main diseases threatening the health and life of modern people, bringing a great burden to the society. Although the existing treatment methods can effectively control the symptoms of diabetes and delay its progression, they have not brought satisfactory improvement in the quality of life and treatment of patients. Traditional Chinese herbal medicines and their extracts combine thousands of years of experience and the scientific basis provided by modern experimental research, which is expected to bring a qualitative leap in the clinical management of diabetes. Therefore, this article systematically reviews studies on the effects of Chinese herbal medicine and its extracts on diabetes and its complications, and aims to bring new ideas and options for the clinical treatment of diabetes.

Diabetic ketoacidosis and mortality in COVID-19 infection

Aim

- Patients with diabetes have increased morbidity and mortality from COVID-19. Case reports describe patients with simultaneous COVID-19 and diabetic acidosis (DKA), however there is limited data on the prevalence, predictors and outcomes of DKA in these patients.

Methods

- Patients with COVID-19 were identified from the electronic medical record. DKA was defined by standardized criteria. Proportional hazard regression models were used to determine risk factors for, and mortality from DKA in COVID-19.

Results

- Of 2366 patients admitted for COVID-19, 157 (6.6%) patients developed DKA, 94% of whom had antecedent type 2 diabetes, 0.6% had antecedent type 1 diabetes, and 5.7% patients had no prior diagnosis of diabetes. Patients with DKA had increased hospital length of stay and in-patient mortality. Higher HbA1c predicted increased risk of incident DKA (HR 1.47 per 1% increase, 95% CI 1.40–1.54). Risk factors for mortality included older age (HR 1.07 per 5 years, 95% CI 1.06–1.08) and need for pressors (HR 2.33, 95% CI 1.82–2.98). Glucocorticoid use was protective in patients with and without DKA.

Conclusion

- The combination of DKA and COVID-19 is associated with greater mortality, driven by older age and COVID-19 severity.

The first series of cases of ketosis-prone type 2 diabetes (flatbush diabetes) in Brazilian adults

Ketosis-prone type 2 diabetes (KPD) is an emerging form of diabetes mellitus characterized by unprovoked ketoacidosis, absence of autoimmunity and beta-cell dysfunction. The KPD may improve after initial glycemic compensation and evolve to exogenous insulin independence, most cases were observed in populations with African or Hispanic backgrounds. We reviewed the literature on KPD and, to date, only one case of KPD has been described in Brazil's multi-ethnic population. A group of adult Brazilian KPD patients without autoimmunity and insulinopenia was identified for this study. We report a retrospective study of four KPD cases (3 males) evaluated in southeast Brazil, the patients were overweight or obese, age between the third and fifth decades of life, had a family history of type 2 diabetes, hyperglycemia (809.5 ± 344.2 mg/dL), acidosis (pH 7.21 ± 0.07; normal range (nr): 7.35-7.45 and bicarbonate 9.1 ± 6.2; nr: 22-26 mEq/mL), ketonuria (142.5 ± 114.4 mg/dL; nr: absence), absence of glutamic acid decarboxylase antibodies (GAD-65), and beta-cell function reserve (C-peptide 1.19 ± 0.53 ng/mL - nr: 1.1-4.4 ng/mL) on diagnosis. After glycemic compensation, there was increase of C-peptide (2.21 ± 0.41) indicating the recovery of beta-cell function and the time to insulin independence was 7.7 ± 3.5 months. They evolved after the period of glucotoxicity with insulin withdrawal and could be treated with oral antidiabetic therapy. This is the first case series of KPD described in Brazil being characterized by ketoacidosis at diagnosis, absence of autoimmunity, recovery of beta-cell function and insulin independence.

Acute Metabolic Emergencies in Diabetes: DKA, HHS and EDKA

Emergency admissions due to acute metabolic crisis in patients with diabetes remain some of the most common and challenging conditions. DKA (Diabetic Ketoacidosis), HHS (Hyperglycaemic Hyperosmolar State) and recently focused EDKA (Euglycaemic Diabetic Ketoacidosis) are life-threatening different entities. DKA and HHS have distinctly different pathophysiology but basic management protocols are the same. EDKA is just like DKA but without hyperglycaemia. T1D, particularly children are vulnerable to DKA and T2D, particularly elderly with comorbidities are vulnerable to HHS. But these are not always the rule, these acute conditions are often occur in different age groups with diabetes. It is essential to have a coordinated care from the multidisciplinary team to ensure the timely delivery of right treatment. DKA and HHS, in many instances can present as a mixed entity as well. Mortality rate is higher for HHS than DKA but incidences of DKA are much higher than HHS. The prevalence of HHS in children and young adults are increasing due to exponential growth of obesity and increasing T2D cases in this age group. Following introduction of SGLT2i (Sodium-GLucose co-Transporter-2 inhibitor) for T2D and off-label use in T1D, some incidences of EDKA has been reported. Healthcare professionals should be more vigilant during acute illness in diabetes patients on SGLT2i without hyperglycaemia to rule out EDKA. Middle aged, mildly obese and antibody negative patients who apparently resemble as T2D without any precipitating causes sometime end up with DKA which is classified as KPD (Ketosis-prone diabetes). Many cases can be prevented by following 'Sick day rules'. Better access to medical care, structured diabetes education to patients and caregivers are key measures to prevent acute metabolic crisis.

A Review of Statistical and Machine Learning Techniques for Microvascular Complications in Type 2 Diabetes

Background and Introduction: Diabetes mellitus is a metabolic disorder that has emerged as a serious public health issue worldwide. According to the World Health Organization (WHO), without interventions, the number of diabetic incidences is expected to be at least 629 million by 2045. Uncontrolled diabetes gradually leads to progressive damage to eyes, heart, kidneys, blood vessels, and nerves.

METHODS

The paper presents a critical review of existing statistical and Artificial Intelligence (AI) based machine learning techniques with respect to DM complications, mainly retinopathy, neuropathy, and nephropathy. The statistical and machine learning analytic techniques are used to structure the subsequent content review.

RESULTS

It has been observed that statistical analysis can help only in inferential and descriptive analysis whereas, AI-based machine learning models can even provide actionable prediction models for faster and accurate diagnosis of complications associated with DM.

CONCLUSION

The integration of AI-based analytics techniques, like machine learning and deep learning in clinical medicine, will result in improved disease management through faster disease detection and cost reduction for the treatment.

Acute glycaemic management before, during and after exercise for cardiac rehabilitation participants with diabetes mellitus: a joint statement of the British and Canadian Associations of Cardiovascular Prevention and Rehabilitation, the International Council for Cardiovascular Prevention and Rehabilitation and the British Association of Sport and Exercise Sciences

Type 1 (T1) and type 2 (T2) diabetes mellitus (DM) are significant precursors and comorbidities to cardiovascular disease and prevalence of both types is still rising globally. Currently,~25% of participants (and rising) attending cardiac rehabilitation in Europe, North America and Australia have been reported to have DM (>90% have T2DM). While there is some debate over whether improving glycaemic control in those with heart disease can independently improve future cardiovascular health-related outcomes, for the individual patient whose blood glucose is well controlled, it can aid the exercise programme in being more efficacious. Good glycaemic management not only helps to mitigate the risk of acute glycaemic events during exercising, it also aids in achieving the requisite physiological and psycho-social aims of the exercise component of cardiac rehabilitation (CR). These benefits are strongly associated with effective behaviour change, including increased enjoyment, adherence and self-efficacy. It is known that CR participants with DM have lower uptake and adherence rates compared with those without DM. This expert statement provides CR practitioners with nine recommendations aimed to aid in the participant's improved blood glucose control before, during and after exercise so as to prevent the risk of glycaemic events that could mitigate their beneficial participation.

Sodium-glucose cotransporter 2 inhibitors and type 2 diabetes: clinical pearls for in-hospital initiation, in-hospital management, and postdischarge

PURPOSE OF REVIEW

The aim of this article is to provide practical recommendations on safe initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors to in-patients as well as management of those who are already on SGLT2 inhibitors.

RECENT FINDINGS

Robust data from stable outpatient cohorts indicate that the SGLT2 inhibitors are associated with clinically meaningful reductions in major adverse cardiovascular events, lower rates of hospitalization for heart failure, and a reduction in major kidney outcomes There is however a lack of information on how to initiate and manage SGLT2 inhibitors in an acute in-patient setting.

SUMMARY

SGLT2 inhibitors may be cautiously appropriate for in-patients if all the criteria for safe use are met but good clinical judgment must prevail. Temporary withholding of SGLT2 inhibitors is appropriate in hospitalized patients during a period of stress and/or insulinopenia.

Trends in Emergency Department Visits and Inpatient Admissions for Hyperglycemic Crises in Adults With Diabetes in the U.S., 2006-2015

OBJECTIVE

To report U.S. national population-based rates and trends in diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) among adults, in both the emergency department (ED) and inpatient settings.

RESEARCH DESIGN AND METHODS

We analyzed data from 1 January 2006 through 30 September 2015 from the Nationwide Emergency Department Sample and National Inpatient Sample to characterize ED visits and inpatient admissions with DKA and HHS. We used corresponding year cross-sectional survey data from the National Health Interview Survey to estimate the number of adults ≥18 years with diagnosed diabetes to calculate population-based rates for DKA and HHS in both ED and inpatient settings. Linear trends from 2009 to 2015 were assessed using Joinpoint software.

RESULTS

In 2014, there were a total of 184,255 and 27,532 events for DKA and HHS, respectively. The majority of DKA events occurred in young adults aged 18-44 years (61.7%) and in adults with type 1 diabetes (70.6%), while HHS events were more prominent in middle-aged adults 45-64 years (47.5%) and in adults with type 2 diabetes (88.1%). Approximately 40% of the hyperglycemic events were in lower-income populations. Overall, event rates for DKA significantly increased from 2009 to 2015 in both ED (annual percentage change [APC] 13.5%) and inpatient settings (APC 8.3%). A similar trend was seen for HHS (APC 16.5% in ED and 6.3% in inpatient). The increase was in all age-groups and in both men and women.

CONCLUSIONS

Causes of increased rates of hyperglycemic events are unknown. More detailed data are needed to investigate the etiology and determine prevention strategies.