Diabetic ketoacidosis

GLP-1 mimetics and diabetic ketoacidosis: possible interactions and clinical consequences

Diabetic ketoacidosis is a serious diabetes-related consequence that occurs in type 1 diabetes and less commonly in type 2 diabetes and is a major cause of death. It results from the metabolic consequences due to a lack of insulin secretion or impaired insulin activity in diabetes leading to dysregulated pathophysiologic pathways resulting in excessive ketone body formation. While ketone bodies are physiologic molecules, their high levels reduce the physiological pH of the blood and induce ketoacidosis, leading to increasing metabolic dysfunction. Glucagon-like peptide-1 (GLP-1) mimetics are a class of recently developed diabetes therapy that do not lead to hypoglycemic, but some reports have suggested a relationship between GLP-1 mimetics and ketogenesis. To clarify the possible interactions between GLP-1 mimetics and ketogenesis in diabetes, this review was undertaken to collate and interpret the literature.

Case report: catamenial hyperglycemia: the trigger of recurrent DKA in a female patient with three-year follow-up

Background

Catamenial hyperglycemia is a rare type of spontaneous, recurring Diabetic Ketoacidosis(DKA) in females during the luteal phase, most commonly observed in type 1 diabetes mellitus. Even with controlled serum glucose levels, adherence to a diabetic diet, medications, and in the absence of other common influencing factors such as infection, glucose levels tend to increase during the premenstrual period. This uncommon issue related to the menstrual cycle phase has not been extensively researched. Therefore, this study aims to diagnose catamenial hyperglycemia promptly and initiate early treatment to prevent complications.

Case report

We presented a case of a 19-year-old girl who experienced recurrent DKA during the premenstrual period, without an apparent cause. She was admitted multiple times to various hospitals and sought consultations, undergoing numerous laboratory and imaging examinations, yet the etiology remained elusive. Ultimately, she received a diagnosis of catamenial diabetic hyperglycemia. To prevent recurrence of complications associated with catamenial hyperglycemia, we initiated a comprehensive approach which included continuous glucose monitoring, adherence to a strict diabetic diet, diabetic health education, regular exercise, timely medication administration, and increase in insulin dosage during the premenstrual period based on glucose levels.

Conclusions

Although catamenial hyperglycemia is rare, it should be considered a cause of recurrent hyperglycemia in any postpubertal female to prevent complications. The specific underlying mechanisms responsible for catamenial hyperglycemia or DKA remain unidentified.

Associations Between Postdischarge Care and Cognitive Impairment-Related Hospital Readmissions for Ketoacidosis and Severe Hypoglycemia in Adults With Diabetes

OBJECTIVE

Patients with severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) experience high hospital readmission after being discharged. Cognitive impairment (CI) may further increase the risk, especially in those experiencing an interruption of medical care after discharge. This study examined the effect modification role of postdischarge care (PDC) on CI-associated readmission risk among U.S. adults with diabetes initially admitted for DKA or SH.

RESEARCH DESIGN AND METHODS

We used the Nationwide Readmissions Database (NRD) (2016-2018) to identify individuals hospitalized with a diagnosis of DKA or SH. Multivariate Cox regression was used to compare the all-cause readmission risk at 30 days between those with and without CI identified during the initial hospitalization. We assessed the CI-associated readmission risk in the patients with and without PDC, an effect modifier with the CI status.

RESULTS

We identified 23,775 SH patients (53.3% women, mean age 65.9 ± 15.3 years) and 140,490 DKA patients (45.8% women, mean age 40.3 ± 15.4 years), and 2,675 (11.2%) and 1,261 (0.9%), respectively, had a CI diagnosis during their index hospitalization. For SH and DKA patients discharged without PDC, CI was associated with a higher readmission risk of 23% (adjusted hazard ratio [aHR] 1.23, 95% confidence interval 1.08-1.40) and 35% (aHR 1.35, 95% confidence interval 1.08-1.70), respectively. However, when patients were discharged with PDC, we found PDC was an effect modifier to mitigate CI-associated readmission risk for both SH and DKA patients (P < 0.05 for all).

CONCLUSIONS

Our results suggest that PDC can potentially mitigate the excessive readmission risk associated with CI, emphasizing the importance of postdischarge continuity of care for medically complex patients with comorbid diabetes and CI.

Acidosis induces significant changes to the murine supraspinatus enthesis organic matrix

Rotator cuff pathology is a common musculoskeletal condition that disproportionately affects older adults, as well as patients with diabetes mellitus and chronic kidney disease. It is known that increased age and kidney dysfunction have been correlated to acidotic states, which may be related to the increased incidence of rotator cuff injury. In order to investigate the potential relationship between acidosis and rotator cuff composition and mechanics, this study utilizes a 14-day murine model of metabolic acidosis and examines the effects on the supraspinatus tendon-humeral head attachment complex. The elastic matrix in the enthesis exhibited significant changes beginning at day 3 of acidosis exposure. At day 3 and day 7 timepoints, there was a decrease in collagen content seen in both mineralized and unmineralized tissue as well as a decrease in mineral:matrix ratio. There is also evidence of both mineral dissolution and reprecipitation as buffering ions continually promote pH homeostasis. Mechanical properties of the tendon-to-bone attachment were studied; however, no significant changes were elicited in this 14-day model of acidosis. These findings suggest that acidosis can result in significant changes in enthesis composition over the course of 14 days; however, enthesis mechanics may be more structurally mediated rather than affected by compositional changes.

Euglycemic diabetic ketoacidosis associated with ST segment elevation myocardial infarction following SGLT-2 inhibitor therapy

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are the latest approved class of oral antidiabetic agents that inhibit renal SGLT-2 receptors and increase urinary glucose excretion in the luminal membrane of the proximal tubule. Diabetic ketoacidosis (DKA) is a triad of hyperglycemia, ketosis, and a high anion gap with metabolic acidosis. We present the case of 61 years-old men with severe euglycemic DKA (EDKA) complicated ST-segment elevation myocardial infarction following SGLT-2 inhibitor therapy for type 2 diabetes mellitus. Atypical presentation of ketoacidosis without hyperglycemia can delay diagnosis and may result in catastrophic complications. Quick diagnosis, appropriate clinical and biochemical assessment, and effective treatment protocols ensure successful resolution of EDKA.

A Receptor Story: Insulin Resistance Pathophysiology and Physiologic Insulin Resensitization's Role as a Treatment Modality

Physiologic insulin secretion consists of an oscillating pattern of secretion followed by distinct trough periods that stimulate ligand and receptor activation. Apart from the large postprandial bolus release of insulin, β cells also secrete small amounts of insulin every 4-8 min independent of a meal. Insulin resistance is associated with a disruption in the normal cyclical pattern of insulin secretion. In the case of type-2 diabetes, β-cell mass is reduced due to apoptosis and β cells secrete insulin asynchronously. When ligand/receptors are constantly exposed to insulin, a negative feedback loop down regulates insulin receptor availability to insulin, creating a relative hyperinsulinemia. The relative excess of insulin leads to insulin resistance (IR) due to decreased receptor availability. Over time, progressive insulin resistance compromises carbohydrate metabolism, and may progress to type-2 diabetes (T2D). In this review, we discuss insulin resistance pathophysiology and the use of dynamic exogenous insulin administration in a manner consistent with more normal insulin secretion periodicity to reverse insulin resistance. Administration of insulin in such a physiologic manner appears to improve insulin sensitivity, lower HgbA1c, and, in some instances, has been associated with the reversal of end-organ damage that leads to complications of diabetes. This review outlines the rationale for how the physiologic secretion of insulin orchestrates glucose metabolism, and how mimicking this secretion profile may serve to improve glycemic control, reduce cellular inflammation, and potentially improve outcomes in patients with diabetes.

Effect of a four-week isocaloric ketogenic diet on physical performance at very high-altitude: a pilot study

BACKGROUND

A ketogenic diet (KD) reduces daily carbohydrates (CHOs) ingestion by replacing most calories with fat. KD is of increasing interest among athletes because it may increase their maximal oxygen uptake (VO₂max), the principal performance limitation at high-altitudes (1500-3500 m). We examined the tolerance of a 4-week isocaloric KD (ICKD) under simulated hypoxia and the possibility of evaluating ICKD performance benefits with a maximal graded exercise bike test under hypoxia and collected data on the effect of the diet on performance markers and arterial blood gases.

METHODS

In a randomised single-blind cross-over model, 6 recreational mountaineers (age 24-44 years) completed a 4-week ICKD followed or preceded by a 4-week usual mixed Western-style diet (UD). Performance parameters (VO₂max, lactate threshold [LT], peak power [P_peak]) and arterial blood gases (PaO₂, PaCO₂, pH, HCO₃^-) were measured at baseline under two conditions (normoxia and hypoxia) as well as after a 4-week UD and 4-week ICKD under the hypoxic condition.

RESULTS

We analysed data for all 6 participants (BMI 19.9-24.6 kg m^-2). Mean VO₂max in the normoxic condition was 44.6 ml kg^-1 min^-1. Hypoxia led to decreased performance in all participants. With the ICKD diet, median values for PaO₂ decreased by - 14.5% and VO₂max by + 7.3% and P_peak by + 4.7%.

CONCLUSION

All participants except one could complete the ICKD. VO₂max improved with the ICKD under the hypoxia condition. Therefore, an ICKD is an interesting alternative to CHOs dependency for endurance performance at high-altitudes, including high-altitude training and high-altitude races. Nevertheless, decreased PaO₂ with ICKD remains a significant limitation in very-high to extreme altitudes (> 3500 m). Trial registration Clinical trial registration Nr. NCT05603689 (Clinicaltrials.gov). Ethics approval CER-VD, trial Nr. 2020-00427, registered 18.08.2020-prospectively registered.

Self-Testing of Ketone Bodies, along with Glucose, Using Touch-Based Sweat Analysis

β-Hydroxybutyrate (HB) is one of the main physiological ketone bodies that play key roles in human health and wellness. Besides their important role in diabetes ketoacidosis, ketone bodies are currently receiving tremendous attention for personal nutrition in connection to the growing popularity of oral ketone supplements. Accordingly, there are urgent needs for developing a rapid, simple, and low-cost device for frequent onsite measurements of β-hydroxybutyrate (HB), one of the main physiological ketone bodies. However, real-time profiling of dynamically changing HB concentrations is challenging and still limited to laboratory settings or to painful and invasive measurements (e.g., a commercial blood ketone meter). Herein, we address the critical need for pain-free frequent HB measurements in decentralized settings and report on a reliable noninvasive, simple, and rapid touch-based sweat HB testing and on its ability to track dynamic HB changes in secreted fingertip sweat, following the intake of commercial ketone supplements. The new touch-based HB detection method relies on an instantaneous collection of the fingertip sweat at rest on a porous poly(vinyl alcohol) (PVA) hydrogel that transports the sweat to a biocatalytic layer, composed of the β-hydroxybutyrate dehydrogenase (HBD) enzyme and its nicotinamide adenine dinucleotide (NAD⁺) cofactor, covering the modified screen-printed carbon working electrode. As a result, the sweat HB can be measured rapidly by the mediated oxidation reaction of the nicotinamide adenine dinucleotide (NADH) product. A personalized HB dose-response relationship is demonstrated within a group of healthy human subjects taking commercial ketone supplements, along with a correlation between the sweat and capillary blood HB levels. Furthermore, a dual disposable biosensing device, consisting of neighboring ketone and glucose enzyme electrodes on a single-strip substrate, has been developed toward the simultaneous touch-based detection of dynamically changing sweat HB and glucose levels, following the intake of ketone and glucose drinks.

Biochemical mechanism underlying the pathogenesis of diabetic retinopathy and other diabetic complications in humans: the methanol-formaldehyde-formic acid hypothesis

Hyperglycemia in diabetic patients is associated with abnormally-elevated cellular glucose levels. It is hypothesized that increased cellular glucose will lead to increased formation of endogenous methanol and/or formaldehyde, both of which are then metabolically converted to formic acid. These one-carbon metabolites are known to be present naturally in humans, and their levels are increased under diabetic conditions. Mechanistically, while formaldehyde is a cross-linking agent capable of causing extensive cytotoxicity, formic acid is an inhibitor of mitochondrial cytochrome oxidase, capable of inducing histotoxic hypoxia, ATP deficiency and cytotoxicity. Chronic increase in the production and accumulation of these toxic one-carbon metabolites in diabetic patients can drive the pathogenesis of ocular as well as other diabetic complications. This hypothesis is supported by a large body of experimental and clinical observations scattered in the literature. For instance, methanol is known to have organ- and species-selective toxicities, including the characteristic ocular lesions commonly seen in humans and non-human primates, but not in rodents. Similarly, some of the diabetic complications (such as ocular lesions) also have a characteristic species-selective pattern, closely resembling methanol intoxication. Moreover, while alcohol consumption or combined use of folic acid plus vitamin B is beneficial for mitigating acute methanol toxicity in humans, their use also improves the outcomes of diabetic complications. In addition, there is also a large body of evidence from biochemical and cellular studies. Together, there is considerable experimental support for the proposed hypothesis that increased metabolic formation of toxic one-carbon metabolites in diabetic patients contributes importantly to the development of various clinical complications.

Normal Saline Versus Low Chloride Solutions in Treatment of Diabetic Ketoacidosis: A Systematic Review of Clinical Trials

Traditionally, normal saline solution (NSS) has been the fluid of choice in diabetic ketoacidosis (DKA) patients, but the NSS is an acidic fluid and may lead to the delayed resolution of DKA. A systemic review search was conducted on PubMed, Embase, and Central Cochrane Registry to compare the efficacy of low chloride solutions with normal saline solution in DKA resolution. Randomized clinical trials with normal saline as a control arm and low chloride solutions as an intervention arm were included. Four studies were included in the analysis. The investigated outcomes, including time to resolution for DKA and duration of insulin infusion, varied depending on the endpoint were reported in the studies. Overall, balanced solutions were generally associated with faster correction of pH. The time to reach overall DKA endpoints was comparable in both groups. We concluded that crystalloid solutions may be used as an initial resuscitation fluid in the DKA population and may lead to earlier resolution of acidosis. More clinical trial data is required to reach statistical significance for the hypothesis.

Case Report: Occurrence of Thyroid Storm in a Young Patient With Recurrent Diabetic Ketoacidosis

BACKGROUND

Thyroid storm (TS) is a fatal disease that leads to multiple organ failure and requires prompt diagnosis. Diabetic ketoacidosis (DKA) is a trigger for thyroid crisis. However, TS and DKA rarely occur simultaneously. Moreover, owing to the rarity of the co-occurrence, the clinical course remains unclear. In this study, we present a case of TS that developed during the follow-up for repeated DKA in a young patient.

CASE PRESENTATION

A 25-year-old man with a history of recurrent DKA was brought to the emergency room frequently with similar symptoms. DKA treatment was initiated, but his tachycardia and disturbance of consciousness did not improve. Further examination of the patient revealed a Burch-Wartofsky Point Scale score of 80 points, consistent with the Japan Thyroid Association criteria. Therefore, DKA coexisting with TS was diagnosed. Antithyroid medication, inorganic iodine, and corticosteroids were then started as treatment for TS, and β-blockers were administered to manage tachycardia. With these treatments, the patient's health improved and he recovered.

CONCLUSIONS

In severe cases of recurrent DKA, the presence of TS should be considered, and early treatment should be initiated before the patient's condition worsens.

New strategies of diagnostic and therapeutic approach to emergencies in the evolution of patients with diabetes mellitus (Review)

Diabetes mellitus, known as the most widespread disease in the world, along with four other chronic diseases, involves major expenditures and significant human resources for care, thus representing a burden on any type of health care system especially due to its rapid evolution of acute and chronic complications. For the emergency department (ED), the requirements of patients with acute complications of diabetes, determine expenses which are three times higher than those for non-diabetic patients and their hospitalizations are four times more frequent. The acute complications for which patients with diabetes most frequently require the ED are hypoglycemic, hyperosmolar, or ketoacidosis coma as well as alterations of the general condition that is typical of hypoglycemia, diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state and new-onset hyperglycemia. Hypoglycemia and the Somogyi phenomenon are the most common complications of type 1 diabetes but they can also occur in patients with type 2 diabetes who are treated with insulin through its overdose. DKA can occur in type 1 and 2 diabetes either by administering inadequate doses of insulin or due to the existence of precipitating factors such as stress, acute myocardial infarction, infections, sepsis, and/or gastrointestinal bleeding. Hyperosmolar hyperglycemic status is the most common complication in patients with type 2 diabetes and DKA. Treating the acute complications of diabetes in the ED involves, besides taking immediate measures to assess and maintain vital functions, monitoring patients, assessing blood sugar, electrolytes, urea, creatinine, and bicarbonate, and applying appropriate immediate therapeutic measures for each type of acute diabetes complication.

Factors Influencing the Formation of Chemical-Hemoglobin Adducts

Hemoglobin (Hb) adducts have been used as biomarkers for the internal exposure to chemicals. Simultaneous exposure to chemicals that bond with the N-terminal valine of Hb to form adducts, such as glycidol, acrylamide, and glucose, may affect the formation of the individual Hb adducts. In this study, various factors influencing the formation of chemical–Hb adducts were analyzed using in vitro and in vivo systems. In the in vitro assays, the formation of glycidol– and acrylamide–Hb adducts was altered in the presence of glucose, serum albumin, and other chemicals. In contrast, in the in vivo experiments, glycidol– and acrylamide–Hb adduct formation was unchanged in mice exposed to glycidol and acrylamide. The interaction between glycidol and acrylamide with residues other than the N-terminal valine of Hb was analyzed using the protein thermal shift assay. Glycidol and acrylamide also interacted with amino acid residues other than the N-terminal valine of Hb. The presence of other blood components, such as amino acids, may affect the formation of chemical–Hb adducts. Further research is expected to elucidate the remaining unknown factors that affect the formation of chemical–Hb adducts.

Case Series: Management of Hypernatremia in DKA in a Tertiary Healthcare Setting in a Developing Country

Diabetic ketoacidosis (DKA) commonly presents with hyponatremia, but hypernatremia is a rare case. We report two cases of hypernatremia, a 54-year-old woman (case 1) admitted with altered sensorium with blood glucose unrecordably high, serum sodium 134 mmol/L and an 18-year-old girl (case 2) admitted with reduced levels of consciousness, a random blood sugar of 21.2 mmol/L and serum sodium of 121 mmol/L. Case 1 was hydrated with isotonic saline and serum sodium values then escalated to 154 mmol/L on day 2, reaching 166 mmol/L on day 4. Case 2 was hydrated with isotonic saline and also given hypertonic saline for treatment of hyponatremia, and the sodium levels for this patient rose to 153 mmol/L on day 2 reaching a maximum of 176 mmol/L on day 3. On day 2, both patients were switched to half strength Darrow’s for correction of the hypernatremia along with insulin therapy. The patients recovered fully and were discharged without any sequelae. These reports exhibit a learning point in the choice of intravenous fluids for the treatment of DKA. They also show the need to delay the correction of hyponatremia in patients with high blood glucose levels.

Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State

BACKGROUND

Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations.

OBJECTIVE

This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state.

DISCUSSION

Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit.

CONCLUSIONS

Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

The role of ketogenesis in the migratory fattening of the northern wheatear Oenanthe oenanthe

The fuelling capacity of migratory birds and their ability to avoid health conditions derived from the subsequent fat overload are exceptional among vertebrates. In this work, we screen the expression of the genes involved in the production of ketone bodies (KB) in the liver of northern wheatears (Oenanthe oenanthe) during the development and resolution of migratory fattening. Thirteen genes were found to be regulated among the migratory stages. Based on the dynamics of gene expression, we concluded that KB play a versatile role in wheatears' energy metabolism homeostasis. The ketogenic pathway can adaptively: (i) provide carbon equivalents for lipogenesis, speeding up fuelling; (ii) replace glucose during long-distance flights using lipids as the substrate; (iii) act as a floodgate to avoid steatosis; and (iv) might provide a metabolic solution to defatting in captive birds.

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

BACKGROUND

Diabetic ketoacidosis is the most frequent hyperglycemic complication in the evolution of diabetes mellitus. Common precipitating factors include newly diagnosed diabetes mellitus, noncompliance with therapy and infections. However, few studies have been conducted in Brazil and none were prospective in design.

OBJECTIVE

To describe the incidence, clinical and laboratory characteristics and precipitating factors of diabetic ketoacidosis among emergency department patients in a tertiary-level teaching hospital in Brazil. We also aimed to identify immediate and long-term mortality within two years.

DESIGN AND SETTING

Prospective prognosis cohort study conduct at a tertiary-level teaching hospital in São Paulo, Brazil.

METHODS

All patients > 12 years old presenting diabetic ketoacidosis who were admitted to the emergency department from June 2015 to May 2016 were invited to participate.

RESULTS

The incidence of diabetic ketoacidosis per 1,000 admissions was 8.7. Treatment noncompliance and infection were the most common causes of diabetic ketoacidosis. The immediate mortality rate was 5.8%, while the six-month, one-year and two-year mortality rates were 9.6%, 13.5% and 19.2%, respectively. Death occurring within two years was associated with age, type 2 diabetes, hypoalbuminemia, infection at presentation and higher sequential organ failure assessment (SOFA) score at admission.

CONCLUSIONS

Diabetic ketoacidosis among patients presenting to the emergency department was relatively frequent in our hospital. Treatment noncompliance and infection were major precipitating factors and presence of diabetic ketoacidosis was associated with immediate and long-term risk of death.

Euglycemic Ketoacidosis

PURPOSE OF REVIEW

Diabetic ketoacidosis is a life-threatening complication of diabetes characterized by hyperglycemia, acidosis, and ketosis. Ketoacidosis may occur with blood glucose level < 200 mg/dl (improperly defined as euglycemic ketoacidosis, euKA) and also in people without diabetes. The absence of marked hyperglycemia can delay diagnosis and treatment, resulting in potential serious adverse outcomes.

RECENT FINDINGS

Recently, with the wide clinical use of sodium glucose co-transporter 2 inhibitors (SGLT2i), euKA has come back into the spotlight. Use of SGLT2i use can predispose to the development of ketoacidosis with relatively low or normal levels of blood glucose. This condition, however, can occur, in the absence of diabetes, in settings such as pregnancy, restriction on caloric intake, glycogen storage diseases or defective gluconeogenesis (alcohol abuse or chronic liver disease), and cocaine abuse. euKA is a challenging diagnosis for most physicians who may be misled by the presence of normal glycemia or mild hyperglycemia. In this article, we review pathophysiology, etiologies, clinical presentation and the management of euKA.

Successful management of severe diabetic ketoacidosis in a patient with type 2 diabetes with insulin allergy: a case report

BACKGROUND

Diabetic ketoacidosis (DKA) is an acute, major, life-threatening complication of diabetes that requires immediate treatment. Allergic reaction to insulin is rare, especially when using recombinant human insulin. The clinical presentation of insulin allergy can range from minor local symptoms to a severe generalized allergic reaction such as anaphylaxis. A limited number of cases have been reported on the treatment of severe DKA in patients with type 2 diabetes with insulin allergy. Here, we describe a patient with type 2 diabetes with insulin allergy in which severe DKA resolved after the initiation of continuous intravenous (IV) recombinant human insulin infusion.

CASE PRESENTATION

A 58-year-old man with type 2 diabetes initiated subcutaneous insulin administration (SIA) after failure of oral antidiabetic treatment. Symptoms of an allergic reaction developed, including pruritic wheals appearing within 10 min of injection and lasting over 24 h. Both skin prick and intradermal tests were positive with different types of insulin. Two days before admission, he stopped SIA because of allergic symptoms and then experienced weakness and upper abdominal pain. On admission, he was in severe metabolic acidosis with a pH of 6.984 and bicarbonate of 2.5 mmol/litre. The blood glucose level was 20.79 mmol/litre, BUN 4.01 mmol/litre, creatinine 128 μmol/litre, and urinary ketone 11.44 mmol/litre. Over 24 h, metabolic acidosis was refractory to IV fluids, bicarbonate and potassium replacement, as well as haemodialysis. Ultimately, he received continuous IV recombinant human insulin infusion at a rate of 0.1 units/kg/hour, in combination with haemodiafiltration, and no further allergic reactions were observed. On day 5, ketonaemia and metabolic acidosis completely resolved. He had transitioned from IV insulin infusion to SIA on day 14. He was discharged on day 21 with SIA treatment. Three months later, he had good glycaemic control but still had allergic symptoms at the insulin injection sites.

CONCLUSIONS

In this patient, SIA caused an allergic reaction, in contrast to continuous IV insulin infusion for which allergic symptoms did not appear. Continuous IV recombinant human insulin infusion in combination with haemodiafiltration could be an option for the treatment of severe DKA in patients with diabetes with insulin allergy.

Concurrent presentation of thyroid storm and diabetic ketoacidosis: a systematic review of previously reported cases

BACKGROUND

Simultaneous development of thyroid storm and diabetic ketoacidosis (DKA) is a rare condition. The review aims to summarise its clinical presentation, investigation findings and treatment options.

METHODS

Databases and reference lists of the selected articles were searched for case reports in English which describe concurrent presentation of thyroid storm and diabetic ketoacidosis. CARE guidelines were used for the quality assessment of the selected articles.

RESULTS

Twenty-six cases from twenty-one articles were selected out of 198 search results. Western Pacific, and American regions contributed to 77% of the cases. Females were most affected (88%). Features of Graves' disease like hyperthermia and tachycardia, gastrointestinal and neuro-psychiatric disturbances were the common clinical presentations. In most of the cases, previous diagnosis of diabetes mellitus preceded that of Graves' disease (46%). Among patients having their drug compliance reported, all had poor compliance to their routine anti-thyroid (9/9) and anti-diabetic (2/2) agents. Moreover, in all cases where HbA_1C (7/7) and T4 (16/16) were measured, the results were elevated and where TSH (17/17) was measured, the results were low. The recommended treatment for DKA and thyroid storm was used in most cases and methimazole was the thionamide of choice in the latest four cases reported. All cases survived except four (15%).

CONCLUSIONS

Concurrent presentation of thyroid storm and diabetic ketoacidosis is rare but life-threatening. Therefore, efforts should be made to maximise patient compliance to anti-thyroid and anti-diabetic agents in treating such patients.

A Rare and Lethal Complication: Cerebral Edema in the Adult Patient with Diabetic Ketoacidosis

Commonly seen in the emergency department, diabetic ketoacidosis is a potentially lethal sequela of uncontrolled diabetes mellitus. In the adult population, a rare complication of diabetic ketoacidosis is cerebral edema. This case report discusses a 26-year-old male with new onset diabetes mellitus who developed cerebral edema leading to death.

β-Hydroxybutyrate suppresses inflammasome formation by ameliorating endoplasmic reticulum stress via AMPK activation

β-Hydroxybutyrate, a ketone body that is used as an energy source in organs such as the brain, muscle, and heart when blood glucose is low, is produced by fatty acid oxidation in the liver under the fasting state. Endoplasmic reticulum (ER) stress is linked with the generation of intracellular reactive oxygen species and the accumulation of misfolded protein in the ER. ER stress is known to induce the NOD-like receptor protein 3 inflammasome, which mediates activation of the proinflammatory cytokine interleukin-1β, whose maturation is caspase-1-dependent. We investigated whether β-hydroxybutyrate modulates ER stress, inflammasome formation, and insulin signaling. Sprague Dawley rats (6 and 24 months of age) that were starved for 3 d and rats treated with β-hydroxybutyrate (200 mg·kg⁻¹·d⁻¹ i.p., for 5 d) were used for in vivo investigations, whereas human hepatoma HepG2 cells were used for in vitro studies. Overexpression of AMPK in cultured cells was performed to elucidate the molecular mechanism. The starvation resulted in increased serum β-hydroxybutyrate levels with decreased ER stress (PERK, IRE1, and ATF6α) and inflammasome (ASC, caspase-1, and NLRP3) formation compared with non-fasted 24-month-old rats. In addition, β-hydroxybutyrate suppressed the increase of ER stress- and inflammasome-related marker proteins. Furthermore, β-hydroxybutyrate treatment increased the expression of manganese superoxide dismutase and catalase via the AMP-activated protein kinase-forkhead box protein O3α transcription factor pathway both in vivo and in vitro. The significance of the current study was the discovery of the potential therapeutic role of β-hydroxybutyrate in suppressing ER-stress-induced inflammasome formation.

Hyperglycemic Hyperosmolar State: A Pragmatic Approach to Properly Manage Sodium Derangements

INTRODUCTION

Although hypovolemia remains the most relevant problem during acute decompensated diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance usually complicate the clinical picture at presentation and may be worsened by the treatment itself.

AIM

This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar state with the aim of providing clinicians a useful tool to early identify the sodium derangement in order to address properly its treatment.

DISCUSSION

The plasma sodium concentration is modified by most of the therapeutic measures commonly required in such patients and the physician needs to consider these interactions when treating HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality during treatment has been associated with two rare potentially life-threatening complications (cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids that need to be infused to restore volume losses is crucial to prevent complications.

CONCLUSION

A quantitative approach based on the comparison between the measured PNa+ (PNa+ M) and the PNa+ expected in the presence of an exclusive water shift (PNa+ G) may provide more thorough information about the true hydroelectrolytic status of the patient and may therefore, guide the physician in the initial management of HHS. On the basis of data derived from our previous studies, we propose a 7-step algorithm to compute an accurate estimate of PNa+ G.

Hyperglycemic Hyperosmolar State During Induction Chemotherapy for Acute Lymphoblastic Leukemia

We present the case of a 16-year-old boy who presented with fatigue, polyuria, and polydipsia while on chemotherapy for his relapsed acute lymphoblastic leukemia (ALL). Blood gas examination confirmed the diagnosis of hyperosmolar hyperglycemic state. The etiology for his hyperglycemia was most likely a result of oral glucocorticoid therapy combined with asparaginase therapy-both are a cornerstone of induction chemotherapy for ALL. The patient was aggressively rehydrated with saline, and medications were administered to correct his hyperkalemia. He was then slowly brought to euglycemia with a continuous infusion of insulin. Although hyperosmolar hyperglycemic state is rare during the treatment of ALL, frontline providers should be aware of this diagnosis because of the significant risk of hypovolemic shock and death if correction of hyperglycemia occurs prior to complete fluid resuscitation.

The role of point-of-care 3-hydroxybutyrate testing in patients with type 2 diabetes undergoing coronary angiography

PURPOSE

Ketone bodies, 3-hydroxybutyrate (3BOHB), and acetoacetate derive from increased free fatty acid beta-oxidation, thus reflecting marked insulin deprivation with or without decompensated diabetes. Objectives of this study were (1) to determine circulating levels of 3BOHB in patients with and without type 2 diabetes (T2DM), before and after an elective coronary angiography; (2) to detect 3BOHB modification during the procedure; (3) to study possible associations between 3BOHB and clinical parameters/outcomes.

METHODS

Sixteen T2DM (72 ± 11 years) and 22 matched controls (71 ± 12 years) undergoing elective coronary angiography were enrolled. In all subjects, biohumoral parameters were determined at hospital admission. Point-of-care determinations of 3BOHB, glucose, and creatinine were performed, at 7 a.m, immediately before and after the procedure. The duration of the fasting period and of the procedure was recorded.

RESULTS

T2DM had significantly higher fasting (0.538 ± 0.320 vs 0.255 ± 0.197 mM/l;   p = 0.005) and pre-procedural (0.725 ± 0.429 vs 0.314 ± 0.205; p = 0.002) 3BOHB concentrations than controls. Similarly, absolute increment of 3BOHB from the morning value was significantly greater in T2DM (0.369 ± 0.252 vs 0.127 ± 0.135 in controls; p = 0.002). Significant correlations were observed between pre-procedure 3BOHB and glucose levels (r = 0.586; p < 0.0001) and between pre-procedure 3BOHB and fasting creatinine concentrations (r = 0.364; p = 0.029).

CONCLUSIONS

An overnight fasting period and a concomitantly stressful condition induce inappropriate 3BOHB increase in T2DM. Point-of-care capillary 3BOHB may be useful before any procedural/surgical intervention in these patients.

Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department

BACKGROUND

Diabetic Ketoacidosis (DKA) is a potentially life-threatening emergency that requires prompt diagnosis and treatment. In paediatric populations an end tidal capnography value greater than 36 mmHg was found to be 100 % sensitive in ruling out DKA.

METHODS

A cross sectional observational study of adults ≥ 17 years of age presenting to the emergency department between January 2014 and May 2014 with glucose > 550 mg/dL. In all patients, nasal capnography and venous blood gas analysis were performed prior to any insulin or intravenous fluid administration. The diagnosis of DKA was based on the presence of anion gap metabolic acidosis, hyperglycaemia and ketonemia. The overall diagnostic performance (area under the curve [AUC]), sensitivity, specificity and likelihood ratios at different end tidal CO2 (ETCO2) cut-offs were determined.

RESULTS

71 patients were enrolled in the study of which 21 (30 %) met the diagnosis of DKA. The area under the curve for ETCO2 was 0.95 with a 95 % CI of 0.91 to 0.99. Test sensitivity for DKA at ETCO2 level ≥35 mmHg was 100 % (95 % CI, 83.9-100). An ETCO2 level ≤ 21 mmHg was 100 % specific (95 % CI, 92.9-100.0) for DKA.

CONCLUSION

Nasal capnography exhibits favourable diagnostic performance in detecting patients with or without DKA among those who present to the emergency department with a glucometer reading > 550 mg/dL.

Pycnogenol® and its fractions influence the function of isolated heart in rats with experimental diabetes mellitus

The aim of this study was to test the effect of Pycnogenol(®) (PYC) mixture and its three fractions (buthanolic, water, ethyl acetate) on heart function in rats with experimental diabetes mellitus (DM) and compare their effects to the diabetic group. Their antioxidant activity "in vitro" was also determined. DM rats (streptozotocin over 3 consecutive days at a dose of 25 mg/kg of body weight) had increased systolic blood pressure, thicker left ventriculi wall (LV) and weaker myocardial contraction, prolonged QT interval in comparison to controls rats. In comparison to the diabetic group, PYC (20 mg/kg b.w./day) suppressed the influence of DM on the LV, improved contraction, increased coronary flow and displayed negative effect on electrical activity of hearts. The most effective of PYC's fractions was the water fraction. It improved biometric parameters and hemodynamic function of the DM hearts, enhanced shortening the QT interval, reduced the amount of dysrhythmias of the DM hearts and had the strongest antioxidant activity. In conclusion, DM damaged isolated rat heart function. Only the water fraction improved the function of the diabetic heart. The different results of three fractions and PYC on myocardial function may be caused by a various lipo- and hydro-philic action of the PYC components.

Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment

The hyperosmolar hyperglycemic state (HHS) is the most serious acute hyperglycemic emergency in patients with type 2 diabetes. von Frerichs and Dreschfeld described the first cases of HHS in the 1880s in patients with an "unusual diabetic coma" characterized by severe hyperglycemia and glycosuria in the absence of Kussmaul breathing, with a fruity breath odor or positive acetone test in the urine. Current diagnostic HHS criteria include a plasma glucose level >600 mg/dL and increased effective plasma osmolality >320 mOsm/kg in the absence of ketoacidosis. The incidence of HHS is estimated to be <1% of hospital admissions of patients with diabetes. The reported mortality is between 10 and 20%, which is about 10 times higher than the mortality rate in patients with diabetic ketoacidosis (DKA). Despite the severity of this condition, no prospective, randomized studies have determined best treatment strategies in patients with HHS, and its management has largely been extrapolated from studies of patients with DKA. There are many unresolved questions that need to be addressed in prospective clinical trials regarding the pathogenesis and treatment of pediatric and adult patients with HHS.

Leptin reverses diabetes by suppression of the hypothalamic-pituitary-adrenal axis

Leptin treatment reverses hyperglycemia in animal models of poorly controlled type 1 diabetes (T1D), spurring great interest in the possibility of treating patients with this hormone. The antidiabetic effect of leptin has been postulated to occur through suppression of glucagon production, suppression of glucagon responsiveness or both; however, there does not appear to be a direct effect of leptin on the pancreatic alpha cell. Thus, the mechanisms responsible for the antidiabetic effect of leptin remain poorly understood. We quantified liver-specific rates of hepatic gluconeogenesis and substrate oxidation in conjunction with rates of whole-body acetate, glycerol and fatty acid turnover in three rat models of poorly controlled diabetes, including a model of diabetic ketoacidosis. We show that the higher rates of hepatic gluconeogenesis in all these models could be attributed to hypoleptinemia-induced activity of the hypothalamic-pituitary-adrenal (HPA) axis, resulting in higher rates of adipocyte lipolysis, hepatic conversion of glycerol to glucose through a substrate push mechanism and conversion of pyruvate to glucose through greater hepatic acetyl-CoA allosteric activation of pyruvate carboxylase flux. Notably, these effects could be dissociated from changes in plasma insulin and glucagon concentrations and hepatic gluconeogenic protein expression. All the altered systemic and hepatic metabolic fluxes could be mimicked by infusing rats with Intralipid or corticosterone and were corrected by leptin replacement. These data demonstrate a critical role for lipolysis and substrate delivery to the liver, secondary to hypoleptinemia and HPA axis activity, in promoting higher hepatic gluconeogenesis and hyperglycemia in poorly controlled diabetes.

Diabetic ketoacidosis and hyperglycemic hyperosmolar state

Diabetic ketoacidosis (DKA) and the hyperglycemic hyperosmolar state (HHS) are potentially fatal hyperglycemic crises that occur as acute complications of uncontrolled diabetes mellitus. The authors provide a review of the current epidemiology, precipitating factors, pathogenesis, clinical presentation, evaluation, and treatment of DKA and HHS. The discovery of insulin in 1921 changed the life expectancy of patients with diabetes mellitus dramatically. Today, almost a century later, DKA and HHS remain significant causes of morbidity and mortality across different countries, ages, races, and socioeconomic groups and a significant economic burden for society.

Gender-related differences in clinical characteristics and outcomes in patients with diabetic ketoacidosis

BACKGROUND

Diabetic ketoacidosis (DKA) is 1 of the most common and serious complications of diabetes, and is a significant cause of morbidity and mortality. There is a paucity of data regarding gender-related differences in clinical characteristics and outcomes of patients hospitalized for DKA.

OBJECTIVE

The purpose of this study was to assess whether gender plays a role in clinical characteristics and outcome of DKA.

METHODS

We performed a retrospective cohort study of patients hospitalized with DKA between January 1, 2003 and January 1, 2010. The outcomes of male and female patients were compared. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality and rate of complications: sepsis, respiratory failure, multiple organ failure, stroke, and myocardial infarction.

RESULTS

Eighty-nine men and 131 women with DKA were included in the study. Male patients had higher rates of chronic renal failure compared with women (16.9% vs 3.1%; P = 0.001), whereas more women than men received oral hypoglycemic therapy (19.8% vs 9.0%; P = 0.046); women also had higher glycosated hemoglobin levels before admission (11.9% [1.7%] vs 9.9% [2.2%]; P = 0.025). The in-hospital mortality rate was not significantly different for both genders (4.5% in the male group vs 3.8% in the female group; P = 1.0). We did not find significant differences between the 2 groups in the 30-day mortality rate (4.5% vs 6.1%; P = 0.7) or the rate of complications (5.6% vs 6.9%; P = 0.9). Advanced age, mechanical ventilation, and bedridden state were independent predictors of 30-day mortality.

CONCLUSIONS

In our study we did not find statistically significant differences in the in-hospital mortality, 30-day all-cause mortality, or rate of complications between men and women hospitalized with DKA. However, women with poorly controlled type 2 diabetes mellitus receiving oral hypoglycemic therapy required particular attention and might benefit from earlier introduction and intensification of insulin therapy to avoid DKA.

Is salt, vitamin, or endocrinopathy causing this encephalopathy? A review of endocrine and metabolic causes of altered level of consciousness

Altered level of consciousness describes the reason for 3% of critical emergency department (ED) visits. Approximately 85% will be found to have a metabolic or systemic cause. Early laboratory studies such as a bedside glucose test, serum electrolytes, or a urine dipstick test often direct the ED provider toward endocrine or metabolic causes. This article examines common endocrine and metabolic causes of altered mentation in the ED via sections dedicated to endocrine-, electrolyte-, metabolic acidosis-, and metabolism-related causes.

Neurologic presentations of acid-base imbalance, electrolyte abnormalities, and endocrine emergencies

Accurate identification of nervous system dysfunction is vital in the assessment of any multisystem disorder. The neurologic manifestations of acid-base disturbances, abnormal electrolyte concentrations, and acute endocrinopathies are protean and typically determined by the acuity of the underlying derangement. Detailed history and physical examination may guide appropriate laboratory testing and lead to prompt and accurate diagnosis. Neurologic manifestations of primary and secondary systemic disorders are frequently encountered in all subspecialties of medicine. This article focuses on key neurologic presentations of respiratory and metabolic acid-base derangements and potentially life-threatening endocrinopathies.

Vital sign triage to rule out diabetic ketoacidosis and non-ketotic hyperosmolar syndrome in hyperglycemic patients

AIMS

To develop a prediction algorithm to rule out diabetic ketoacidosis (DKA) and non-ketotic hyperosmolar syndrome (NKHS) based on vital signs for early triage of patients with diabetes.

METHODS

The subjects were consecutive adult diabetic patients with hyperglycemia (blood glucose >or=250mg/dl) who presented at an emergency department. Based on a derivation sample (n=392, 70% of 544 patients at a hospital in Okinawa), recursive partitioning analysis was used to develop a tree-based algorithm. Validation was conducted using the other 30% of the patients in Okinawa (n=152, internal validation) and patients at a hospital in Tokyo (n=95, external validation).

RESULTS

Three risk groups for DKA/NKHS were identified: a high-risk group of patients with glucose >400mg/dl or systolic blood pressure <100mmHg; a low risk group of patients with glucose <or=400mg/dl and normal vital signs (systolic blood pressure >or=100mmHg, pulse <or=90/min, and respiratory rate <or=20/min); and an intermediate risk group. The prevalences of DKA/NKHS were 2% (derivation set), 0% (internal validation set), and 0% (external validation set) in the low risk group, respectively.

CONCLUSIONS

Our algorithm may help DKA/NKHS triage and patients with normal vital signs can be initially triaged as low risk for DKA/NKHS.

The post-mortem relationship between beta-hydroxybutyrate (BHB), acetone and ethanol in ketoacidosis

A reduced blood pH (ketoacidosis) from the production of beta-oxidative ketone bodies as a result of alcoholism (alcoholic ketoacidosis, AKA) or diabetes (diabetic ketoacidosis, DKA) can feature in many fatalities and analytical evidence can be used to support a pathological diagnosis, or provide a possible cause of death in the absence of other pathologically significant findings. Existing beliefs concerning the relationship of BHB concentrations, acetone and ethanol have been re-examined by analysis of BHB, acetone and ethanol in over 350 fatalities grouped into alcoholics, diabetics, alcoholic diabetics, coupled with speculative cases and those with an alternative cause of death. Uniquely, the concentrations of BHB were measured in post-mortem blood, urine and vitreous humour using selective GC-MS. The results showed that existing beliefs need to be re-evaluated. Ethanol is not always low (<10mg/dL) or absent in cases of AKA. Also, the absence of acetone precludes [corrected] a high BHB (>250mg/L), therefore acetone can be used as an initial marker pathologically significant ketoacidosis. For blood and urine BHB concentrations the following interpretative ranges can be used (in mg/L); normal (<50mg/L), raised (51-249mg/L), high and pathologically significant (>250mg/L). Initial data suggest vitreous humour BHB could be a useful alternative in the absence of blood (same interpretative ranges may also apply). Analytical recommendation for investigation of post-mortem ketoacidosis is also presented.

A 2-yr national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use

The aim was to investigate triggering factors and insulin pump usage (continuous subcutaneous insulin infusion, CSII) at diabetic ketoacidosis (DKA). Data from 1999 and 2000 were collected retrospectively from Sweden. In 1999 and 2000, 7.4 and 11.0%, respectively, of children with diabetes used CSII. One hundred and forty-two episodes of DKA (pH < 7.30) were identified in 115 children (DKA at onset not included). Their hemoglobin A1c (HbA1c) was 10.1 +/- 2.0%, age 14.6 +/- 3.1 yr (range 1.5-19.9 yr), and diabetes duration 6.6 +/- 3.5 yr (range 0.4-17.7 yr). Fourteen persons (seven girls) had more than one episode of DKA. Reported causes of DKA were missed insulin doses (48.6%), gastroenteritis (14.1%), technical pump problems (12.7%), infection (13.4%), social problems (1.4%), unknown (5.6%), and not stated (4.2%). Alcohol was involved in eight episodes and drugs in one. Thirty of 115 patients (19 girls) used insulin pumps. The overall DKA incidence was 1.4/100 patient years in 1999 and 1.7/100 patient years in 2000. For insulin pump users, the DKA incidence was 3.2/100 patient years in 1999 and 3.6/100 patient years in 2000. HbA1c at DKA admission was lower for CSII users than patients who used injections (9.1 +/- 1.5 vs. 10.8 +/- 2.2%, p < 0.01), but pH and age did not differ. CSII had been used for 6 months (median) before the DKA episode. In conclusion, the DKA frequency in CSII users was approximately twice that of patients who used injections. Seventy-seven percent of the episodes occurred within 1 yr after CSII start. The high number of events reported to be caused by gastroenteritis is alarming because this may reflect a misinterpretation of DKA symptoms.

[Diabetic ketoacidosis in adults--update of an old complication]

Diabetic ketoacidosis is an acute complication of Diabetes Mellitus characterized by hyperglycemia, metabolic acidosis, dehydration, and ketosis, in patients with profound insulin deficiency. It occurs predominantly in patients with type 1 diabetes and is frequently precipitated by infections, insulin withdrawal or undiagnosed type 1 diabetes. The authors review its pathophysiology, diagnostic criteria and treatment options in adults, as well as its complications.

Is this the worst outcome of metabolic syndrome? Hypophosphatemia and resulting cardiac arrest during the treatment of diabetic ketoacidosis with hypertriglyceridemia

We report a case of diabetic ketoacidosis (DKA) and severe hypertriglyceridemia who developed cardiac arrest due to hypophosphatemia. He was diagnosed with diabetes and hyperlipidemia, indicating metabolic syndrome. Hypophosphatemia was caused by large insulin doses received while treating DKA, which were required because of insulin resistance owing to hypertriglyceridemia. Metabolic syndrome may have accelerated serum phosphate depletion. We suggest frequent monitoring of serum phosphate and phosphate replacement for patients with DKA and severe hypertriglyceridemia. Although such a critical condition has not been reported, it may occur during treatment of patients with poorly controlled type 2 diabetes with DKA.

Diabetic ketoacidosis in pregnancy tends to occur at lower blood glucose levels: case-control study and a case report of euglycemic diabetic ketoacidosis in pregnancy

BACKGROUND AND OBJECTIVE

The occurrence of diabetic ketoacidosis (DKA) during pregnancy is considered a medical emergency. The aims of the present study were to evaluate the incidence of DKA in pregnant and non-pregnant women with diabetes; to compare the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women; and to show a case of euglycemic DKA in pregnancy.

METHODS

The subjects consisted of 90 cases of DKA in pregnant women with diabetes and 286 cases of non-pregnant female inpatients receiving treatment for diabetes during 2001 to 2005 in our hospital. The incidence of DKA in pregnant and non-pregnant women with diabetes and the blood glucose levels at the diagnosis of DKA in pregnant and non-pregnant women were compared.

RESULTS

DKA had a higher incidence in pregnant women with diabetes (8/90, 8.9%) than in non-pregnant women with diabetes (9/286, 3.1%) (P < 0.05). The blood glucose levels (mmol/L) in pregnant women with DKA were significantly lower than those in non-pregnant women with DKA (16.3 +/- 4.6 vs 27.5 +/- 4.8, P < 0.001). A case of euglycemic DKA in pregnancy was described whose serum glucose level was only 6.9 mmol/L.

CONCLUSIONS

DKA in pregnant women with diabetes may occur more frequently, and at lower blood glucose levels than DKA in non-pregnant women with diabetes.

Impact of a multidisciplinary approach to guideline implementation in diabetic ketoacidosis

Background. Faculty members developed diabetic ketoacidosis (DKA) guidelines based on the current American Diabetes Association guidelines. Objectives. To evaluate the impact of a multidisciplinary approach to implementing DKA guidelines on residents' knowledge, guideline compliance, and patient outcomes. Design. Longitudinal case-control study with 2 arms. Setting. University-affiliated teaching hospital in Fresno, California. Methods. A Web-based testing software (TestWare) was used for educational/ assessment testing before and after DKA guidelines implementation. Patients' charts were reviewed to determine the degree of guideline compliance, patient care charges, and length of stay before and after DKA guidelines introduction. Results. Testing scores improved from 48% to 54% correct answers after implementation of the guidelines (P = .06). Overall, guidelines compliance improved from 67% to 88% (P < .05). Conclusion. A multidisciplinary intervention including knowledge assessment, individualized education, and formal didactic teaching was effective at improving knowledge and guideline compliance in DKA for internal medicine residents.