Temporal variation of diabetic ketoacidosis and hypoglycemia in adults with type 1 diabetes: A nationwide cohort study

Incidence of diabetic ketoacidosis does not differ in Ramadan compared to other months and seasons: results from a 6-year multicenter study

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA.

METHODS

We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons.

RESULTS

Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25-45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons.

CONCLUSIONS

DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar.

Development of an "all-data-on-hand" deep learning model to predict hospitalization for diabetic ketoacidosis (DKA) in youth with type 1 diabetes (T1D)

BACKGROUND

While prior research has identified multiple risk factors for diabetic ketoacidosis (DKA), clinicians continue to lack clinic-ready models to predict dangerous and costly episodes of DKA. We asked whether we could apply deep learning, specifically use of a long short-term (LSTM) model, to accurately predict 180-day risk of DKA-related hospitalization for youth with type 1 diabetes (T1D).

OBJECTIVE

To describe the development of a LSTM model to predict 180-day risk of DKA-related hospitalization for youth with T1D.

METHODS

We used 17 consecutive calendar quarters of clinical data (01/10/2016-03/18/2020) for 1745 youth 8 to 18-years with T1D from a pediatric diabetes clinic network in the Midwestern US. Input data included demographics, discrete clinical observations (lab results, vital signs, anthropometric measures, diagnosis and procedure codes), medications, visit counts by type of encounter, number of historic DKA episodes, number of days since last DKA admission, patient-reported outcomes (answers to clinic intake questions), and data features derived from diabetes- and non-diabetes-related clinical notes via natural language processing (NLP). We trained the model using input data from quarters 1-7 (n=1377), validated using input from quarters 3-9 in a partial out-of-sample cohort (OOS-P; n=1505), and further validated in a full out-of-sample cohort (OOS-F; n=354) with input from quarters 10-15.

RESULTS

DKA admissions occurred at a rate of 5% per 180-days in both OOS cohorts. For the OOS-P and OOS-F cohorts, respectively: median age was 13.7 years (IQR=11.3,15.8) and 13.1 years (10.7,15.5); and HbA1c at enrollment was 8.6% (7.6,9.8) [70 (60,84) mmol/mol] and 8.1% (6.9,9.5) [65 (52,80) mmol/mol]; 14% and 13% had prior DKA admissions (post-T1D-diagnosis); and recall was 0.33 and 0.50 for the top-ranked 5% of youth with T1D. For lists rank-ordered by probability of hospitalization, precision increased from 0.33 to 0.56 to 1.0 for positions 1-80, 1-25, and 1-10 in the OOS-P cohort and from 0.50 to 0.60 to 0.80 for positions 1-18, 1-10, and 1-5 in the OOS-F cohort.

CONCLUSIONS

The proposed LSTM model for predicting 180-day DKA-related hospitalization is valid in the present sample. Future work should evaluate model validity in multiple populations and settings to account for health inequities that may be present in different segments of the population (e.g., racially and/or socioeconomically diverse cohorts). Rank-ordering youth by probability of DKA-related hospitalization will allow clinics to identify the most at-risk youth. The clinical implication of this is that clinics may then create and evaluate novel preventive interventions based on available resources.

Associations of hyperglycemic emergency and severe hypoglycemia incidences with seasonality and ambient temperature among pregnant women with diabetes: a nested case-control study in Taiwan

Background

Associations of acute glycemic complications with season and ambient temperature have been reported in general population with diabetes. However, little is known about the risks of acute glycemic complications in relation to season and ambient temperature in pregnant women, who are likely to be even more vulnerable. This work aimed to investigate the associations of season and ambient temperature with pregnancies complicated with hyperglycemia emergency or severe hypoglycemia.

Methods

Two separate case-control studies were nested within 150,153 pregnancies by women with type 1, type 2, or gestational diabetes between 2009 and 2014 in Taiwan. Hyperglycemia emergency (mainly diabetic ketoacidosis and hyperosmolar hyperglycemic state) and severe hypoglycemia occurred in 77 and 153 diabetic pregnancies (cases), respectively. Ten control pregnancies were randomly selected for each case by matching each case pregnancy on type of diabetes (i.e., T1DM, T2DM, or GDM), maternal age on the date of acute glycemic complication occurrence (i.e., index date), and “length of gestation at risk” (i.e., period between conception and index date). Meteorological parameters were retrieved from 542 meteorological monitoring stations across Taiwan during 2008–2014. Conditional logistic regression analysis with generalized estimation equation was separately performed to estimate the covariate adjusted odds ratios (ORs) of each of the two acute glycemic complications in association with season and ambient temperature within 30 days prior to the index date.

Results

Compared to summer, winter season was associated with a significantly elevated risk of severe hypoglycemia with an OR of 1.74 (95% confidence interval (CI) 1.08–2.79). The OR of hyperglycemic emergency was also elevated in winter season at OR of 1.88, but the significance is only marginal (95% CI 0.97–3.64, p = 0.0598). Subgroup analyses further noted that such seasonal variation was also observed in pregnancies with pre-pregnancy type 1 diabetes and gestational diabetes. On the other hand, ambient temperature was not significantly associated with the two acute glycemic complications.

Conclusions

A moderately but significantly elevated risk of severe hypoglycemia was found in pregnant women with diabetes during winter season, and such increased risk was more evident in pregnancies with T1DM.

Supplementary information

The online version contains supplementary material available at https://doi.org/10.1265/ehpm.22-00003.

Seasonal variation of diabetes with hyperosmolarity hospitalizations and its characteristics in mainland Portugal

AIMS

The family physician devotes a part of his care to the surveillance of diabetic patients. Hyperosmolarity is a severe acute complication. The aim of this study was to analyse seasonal variation of type 2 diabetes with hyperosmolarity hospitalizations, regarding their occurrence, mortality, length of stay, Charlson comorbidity index and its factors.

METHODS

The authors analysed all hospitalizations in Portuguese Mainland public sector hospitals between 2000 and 2015 with primary diagnosis of type 2 diabetes with hyperosmolarity (ICD-9-CM codes 250.20 or 250.22), using a national administrative database. Cases were classified into four seasons according to date of admission. The authors compared the occurrence, length of stay, in-hospital mortality and Charlson comorbidity index and its factors.

RESULTS

A total of 6596 hospitalization episodes were included. The authors found that admissions occurred more in winter, being 23% more common. No seasonal statistically significant differences were found considering the other variables.

CONCLUSIONS

There is an increased occurrence of this acute metabolic complication during the winter in patients with type 2 diabetes. These results should be taken into account by the family physician when planning surveillance to this risk group.

Children with onset-ketoacidosis are admitted to the nearest hospital available, regardless of center size

Background To investigate longitudinal trends of admissions with diabetic ketoacidosis (DKA) in new-onset type 1 diabetes (T1D) and subsequent duration of hospitalization in association with structural health care properties, such as size of treatment facility, population density and linear distance between home and treatment centers. Methods Data from 24,321 German and Austrian pediatric patients with newly-diagnosed T1D between 2008 and 2017 within the DPV registry were analyzed. Results Onset-DKA rates fluctuated at around 19% and slightly increased over the observation period (p<0.001). Compared to children without onset-DKA, children with onset-DKA were more frequently treated at centers located closer to their homes, independent of center size or urbanity. Annual median duration of hospitalization decreased from 13.1 (12.6;13.6) to 12.7 (12.3;13.2) days (p<0.001). It was highest in patients younger than 5 years, with migration background, and in severe DKA. Conclusion Patients with onset-DKA are admitted to the nearest hospital, independent of center size. Facilities close to patients' homes therefore play an important role in the acute management of T1D onset. In Germany and Austria, diabetes education at diagnosis is mainly performed in inpatient settings. This is reflected by a long duration of hospitalization, which has decreased only slightly over the past decade.

The Long-Term Incidence of Hospitalization for Ketoacidosis in Adults with Established T1D-A Prospective Cohort Study

CONTEXT

The long-term natural history of diabetic ketoacidosis (DKA) and its risk factors are poorly understood.

OBJECTIVE

To determine the long-term incidence and predictors of DKA in adults with longstanding type 1 diabetes (T1D).

DESIGN

All hospitalizations and deaths due to DKA between 1996 and 2016 were identified in 4758 adults with T1D from the Finnish Diabetic Nephropathy Study (FinnDiane), and a cohort of 16 224 adults with T1D from the Finnish general population.

RESULTS

Between 1996 and 2015, there were 1228 DKA events in the FinnDiane participants (1.4/100 person-years) and 4914 DKA events (1.8/100 person-years) in adults with T1D from the general population. The majority were hospitalized only once. There was a modest increase in the frequency of DKA in the FinnDiane over the follow-up (~2.4%/year [95% CI, 0.3-4.5%]; P = 0.03). Predictors of DKA were glucose control, CSII, smoking and alcohol consumption, and raised high-density lipoprotein cholesterol and triacylglycerides. Diabetic nephropathy and renal impairment were associated with DKA; patients with end-stage renal disease, macroalbuminuria, and microalbuminuria had 2.09-fol (95% CI, 1.40-3.12), 1.65-fold (95% CI, 1.23-2.19), and 0.87-fold (95% CI, 0.61-1.24) risk of DKA compared with patients with normal albumin excretion rate, respectively. Patients with an estimated glomerular filtration rate <60 mL/min/1.73 m2 were also more likely to be hospitalized for DKA (HR 1.71 [95% CI, 1.26-2.67]).

CONCLUSIONS

DKA remains a common cause of hospitalization in individuals with longstanding T1D. These data suggest that the goal to use SGLT2 inhibitors for their vasculo- and renoprotective actions may be problematic, as those most likely to benefit may also have the highest risk for DKA.

Seasonal variation in hospital encounters with hypoglycaemia and hyperglycaemia

AIM

To assess whether rates of hospital encounters with hypoglycaemia and hyperglycaemia display seasonal variation.

METHODS

Time series analyses of the monthly rates of hospital encounters (emergency room visits or inpatient admissions) with hypoglycaemia and hyperglycaemia from 2003 to 2012 using linked healthcare databases in Ontario, Canada.

RESULTS

Over the study period, there were 129 887 hypoglycaemia and 79 773 hyperglycaemia encounters. The characteristics of people at the time of their encounters were similar across the seasons in 2008 (median age 68 years for hypoglycaemia encounters and 53 years for hyperglycaemia encounters; 50% female; 90% with diabetes). We observed moderate seasonality in both types of encounters (R² autoregression coefficient 0.58 for hypoglycaemia; 0.59 for hyperglycaemia). The rate of hypoglycaemia encounters appeared to peak between April and June, when on average, there was an additional 49 encounters per month (0.36 encounters per 100 000 persons per month) compared with the other calendar months (5% increase). The rate of hyperglycaemia encounters appeared to peak in January, when on average, there was an additional 69 encounters per month (0.50 encounters per 100 000 persons per month) compared with the other calendar months (11% increase).

CONCLUSIONS

In our region, there is seasonal variation in the rate of hospital encounters with hypoglycaemia and hyperglycaemia. Our findings may help to highlight periods of vulnerability for people, may inform future epidemiological studies and may aid in the appropriate planning of healthcare resources.