Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study

Continuous glucose monitor metrics from five studies identify participants at risk for type 1 diabetes development

AIMS/HYPOTHESIS

We aimed to assess whether continuous glucose monitor (CGM) metrics can accurately predict stage 3 type 1 diabetes diagnosis in those with islet autoantibodies (AAb).

METHODS

Baseline CGM data were collected from participants with ≥1 positive AAb type from five studies: ASK (n=79), BDR (n=22), DAISY (n=18), DIPP (n=8) and TrialNet Pathway to Prevention (n=91). Median follow-up time was 2.6 years (quartiles: 1.5 to 3.6 years). A participant characteristics-only model, a CGM metrics-only model and a full model combining characteristics and CGM metrics were compared.

RESULTS

The full model achieved a numerically higher performance predictor estimate (C statistic=0.74; 95% CI 0.66, 0.81) for predicting stage 3 type 1 diabetes diagnosis compared with the characteristics-only model (C statistic=0.69; 95% CI 0.60, 0.77) and the CGM-only model (C statistic=0.68; 95% CI 0.61, 0.75). Greater percentage of time >7.8 mmol/l (p<0.001), HbA1c (p=0.02), having a first-degree relative with type 1 diabetes (p=0.02) and testing positive for IA-2 AAb (p<0.001) were associated with greater risk of type 1 diabetes diagnosis. Additionally, being male (p=0.06) and having a negative GAD AAb (p=0.09) were selected but not found to be significant. Participants classified as having low (n=79), medium (n=98) or high (n=41) risk of stage 3 type 1 diabetes diagnosis using the full model had a probability of developing symptomatic disease by 2 years of 5%, 13% and 48%, respectively.

CONCLUSIONS/INTERPRETATION

CGM metrics can help predict disease progression and classify an individual's risk of type 1 diabetes diagnosis in conjunction with other factors. CGM can also be used to better assess the risk of type 1 diabetes progression and define eligibility for potential prevention trials.

The impact of the COVID-19 pandemic on DKA severity in Black and White pediatric patients

OBJECTIVES

Diabetic ketoacidosis (DKA) is a complication of uncontrolled diabetes mellitus, with a known increase in severity and incidence during the COVID-19 pandemic. Our institution also observed a rise in pediatric DKA cases in our largely underserved patient population. We hypothesized that the impact would be more pronounced in Black patients due to prepandemic healthcare inequities.

METHODS

To investigate this, we confirmed the increased number of severe DKA cases in our pediatric patients during the pandemic and then stratified data to compare laboratory values between Black and White patients. We analyzed patients with a DKA diagnosis admitted to our institution's pediatric intensive care unit (PICU) prior to the pandemic (March 2016 to December 2017) and during its peak (March 2020 to December 2021).

RESULTS AND CONCLUSIONS

Our data demonstrated more cases of severe DKA overall during 2020-2021 and when compared to prepandemic years, a statistically significant increase in severity for Black, but not White patients.

The incidence of cerebral edema in pediatric patients with diabetic ketoacidosis: a retrospective study

OBJECTIVE

Cerebral edema is a severe and potentially fatal complication of diabetic ketoacidosis (DKA), particularly in pediatric patients. Despite its clinical significance, limited data exist on its incidence and associated risk factors in resource-limited settings. This study aimed to determine the incidence of cerebral edema in pediatric patients with DKA and investigate potential contributing factors. This retrospective study analyzed data from 270 pediatric DKA patients admitted to the Children's Medical Center Hospital, Tehran, between March 2018 and March 2020. Patients aged 1 day to 18 years were included based on standard DKA diagnostic criteria (blood glucose > 250 mg/dL, pH < 7.3, bicarbonate < 18 mEq/L, and ketonemia/ketonuria). Patients with incomplete records or pre-existing neurological conditions were excluded. The statistical analyses included independent t-tests and Fisher's exact tests.

RESULTS

The incidence of cerebral edema was 6.67%. Elevated blood glucose levels at admission were significantly associated with cerebral edema (P = 0.01), suggesting a potential role in its pathophysiology. Additionally, a strong correlation was observed between cerebral edema and ICU admission (P < 0.001), indicating a more severe disease course. The results suggest that early glucose control and neurological monitoring are critical for preventing adverse outcomes such as cerebral edema in pediatric DKA patients.

Early parameter to detect the resolution of pediatric diabetic ketoacidosis

Objective

The present study aimed to analyze the incidence of hyperchloremia and compare the time to reach DKA resolution with different parameters.

Methods

A chart review of patients diagnosed with DKA and aged <18 years was conducted. DKA was defined as serum glucose ≧200 mg/dl, venous pH (vpH) <7.30, serum bicarbonate <15 mmol/L, and presence of ketonemia, or ketonuria. Electrolytes and blood gases were recorded at 6-h intervals after treatment initiation.

Results

Overall, 84 patients were admitted because of DKA. The initial biomedical parameters in the emergency department were as follows: median glucose, 497 mg/dl; vpH, 7.1; serum HCO3, 6.6 mmol/L; anion gap (AG), 24.7 mmol/L; and ketone, 5.7 mmol/L. After treatment, the incidence of hyperchloremia increased progressively from 15.4% at treatment initiation to 80% at 18 h. The median time to resolution defined by AG ≦12 mmol/L was 12 h, which was significantly faster than the recovery of vpH ≧7.3 (median time, 17 h) and HCO3 >15 mmol/L (median time, 18 h). Approximately 63 (75%) patients reached the endpoints of AG ≦12 mmol/L prior, 14 (16.6%) patients reached the endpoints of vpH ≧7.3 prior, 7 (8.4%) patients reached the endpoints of HCO3 >15 mmol/L prior.

Conclusions

Hyperchloremic metabolic acidosis (HMA) was a common entity in pediatric DKA following treatment. The median time of AG ≦ 12 mmol/L was approximately 12 h and was the parameter that can identify DKA resolution at a faster rate, i.e., approximately 5, and 6 h faster than the normalization of vpH and HCO3, respectively. Future studies were warranted to use AG ≦12 mmol/L as the endpoint of DKA treatment and check if the treatment course and incidence of HMA could be reduced.

Assessment of the use of long-acting insulin in management of diabetic ketoacidosis in pediatric patients: a randomized controlled trial

PURPOSE

We evaluated the effectiveness of early start of long-acting insulin during management of diabetic ketoacidosis (DKA) in pediatric patients.

METHODS

Patients with DKA were randomly assigned to receive either a traditional DKA management protocol or concurrent administration of subcutaneous (SC) long-acting insulin alongside intravenous insulin during DKA treatment. The primary outcomes were duration of insulin infusion and adverse effects of the intervention, mainly hypoglycemia and hypokalemia.

RESULTS

For this study, 100 pediatric patients with DKA were enrolled, 50 in each group (group I received the conventional DKA management and group II received conventional DKA management plus SC long-acting insulin once daily). Patients in group II showed a significant reduction in both duration and dose of insulin infusion compared to group I, with a median (interquartile range) of 68.5 hours (45.00-88.25 hours) versus 72 hours (70.25-95.5 hours) (P=0.0001) and an insulin dose of 3.48±1.00 units/kg versus 4.04±1.17 units/kg (P=0.016), respectively. Concurrent administration of SC long-acting insulin with intravenous insulin during DKA treatment was associated with a decreased risk of hypoglycemia (number of hypoglycemia events: group I, 22 events; group II, 12 events, P=0.029), with no increased risk of hypokalemia compared to the control group (number of hypokalemia events: group I, 12 events; group II, 19 events, P=0.147).

CONCLUSION

The current study showed that coadministration of SC long-acting insulin in addition to the usual insulin infusion during DKA management in the pediatric population can lead to a shorter duration of insulin infusion. In addition, this approach is not associated with increased risk of hypoglycemia or hypokalemia. Moreover, coadministration of long-acting insulin may be associated with a decreased incidence of hypoglycemia.

Management of Immunotherapy-Induced Type 1 Diabetes

One of the life-threatening adverse effects associated with the use of immune checkpoint inhibitors is β cells destruction resulting in type 1 diabetes. Immune checkpoint inhibitor-induced type 1 diabetes (ICI-T1D) usually has a rapid onset requiring admission to the intensive care unit for the management of diabetic ketoacidosis using an insulin drip protocol. Once stabilized patients with ICI-T1D are started on insulin therapy to mimic usual pancreatic function. Insulin administration may be through multiple daily injections or continuous subcutaneous insulin infusions using an insulin pump. People who develop ICI-T1D will require insulin therapy for life.

Diabetic Ketoacidosis in Pediatric Emergency Medicine: Risk Factors, Myths, and Evidence-Based Management of Complications

Purpose

Diabetic ketoacidosis (DKA) is a common condition among type 1 diabetics, commonly affecting those below the age of 20.

Methods

A comprehensive literature search was conducted in databases like PubMed to identify primary studies conducted in children with DKA. Finally, 79 studies were included for qualitative synthesis.

Results

The disease is characterized by acute-onset metabolic and pathological derangements, necessitating immediate intervention. With the rising incidence, concerns have been emerging regarding the disparities in the presentation and treatment of DKA among different countries with inequitable resources. Within its management lies the common misconceptions, both among patients and primary physicians, prohibiting an optimistic approach to the disease. Pediatric children in particular need specialized treatment and care during an episode of DKA due to its long-term cognitive and neurological sequelae. Hence, efforts have been undertaken to ensure minimization of neurological damage when treating DKA. While guidelines are in place for treatment of DKA, there are considerable differences in their protocols across different regions.

Conclusion

It is imperative to analyze recent evidence and continually update treatment guidelines for DKA. Additionally, maximal efforts need to be taken to bridge the gap between different nations, allowing accessibility to equitable resources to all.

Magnitude, risk factors and economic impacts of diabetic emergencies in developing countries: A systematic review

BACKGROUND

Diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar syndrome (HHS) and severe hypoglycemia are considered as the life-threatening diabetic emergencies of diabetic patients worldwide. As the prevalence of diabetes grows in developing countries, so too does the impact of these costly human and economic complications. Noticeable scarcity of data concerning the magnitude, the cost expenditures as well as well unidentified predictors of these complications made the management more difficult in the resource limited health care settings. Thus, this systematic review aimed to assess the magnitude, risk factors and economic impacts of diabetes emergencies among diabetic patients in the developing countries.

METHODS

Following PRISMA (2020) guidelines, databases of PubMed, EMBASE, Cochrane and Scopus were searched for studies reporting on prevalence, risk factors, and direct costs of diabetes emergencies published in English from 2000 to 2023. Forty eligible studies were extracted and retrieved using manual data extraction form and automation tools. Studies were analyzed and combined in a narrative synthesis. The estimations of direct cost expenditure were standardized to 2023 USD.

RESULT

A comprehensive examination was conducted on the 40 eligible studies, with the majority originating from African sources. The review shows the prevalence of diabetic emergencies; DKA episodes in the range of (3.8%-73.4%), HHS (0.9%-58%) and Severe hypoglycemia (3.3%-64.7%) per year in the developing countries. Infection, new onset of the diabetes, and non-compliance to medications and diets were reported as the most common risk factors of theses diabetic emergencies. Besides, the costs of hospitalization taken from the patients' perspective, that were associated per one diabetic emergency event per patient was reported in the range of 105-230 USD in the developing countries.

CONCLUSION

The rising prevalence of diabetic emergencies in poor nations, where infections, non-compliance, and new onset of diabetes are major causes, highlighted the urgent need for preventative interventions. Identifying high-risk individuals is crucial for implementing tailored strategies to reduce emergency visits and hospital admissions. The significant economic burden of these emergencies exacerbates the strain on already limited healthcare resources. In order to enhance health outcomes and lessen the financial strain on healthcare systems in these areas, preventive strategies must be incorporated into diabetes management programs.

Lymphocyte-C-reactive protein ratio upon admission to predict disease progression and ICU admission in adult patients with diabetic ketoacidosis

This study aimed to investigate whether lymphocyte-C-reactive protein ratio (LCR) upon admission can predict disease progression and intensive care unit (ICU) admission in adult patients with diabetic ketoacidosis (DKA). A single-center retrospective study was conducted, including adult DKA patients admitted to the First Affiliated Hospital of Harbin Medical University between March 2018 and March 2023. Multiple demographic and clinical data were collected from the medical records upon admission and during hospitalization. Subsequently, sequential organ failure assessment (SOFA) score and LCR were calculated based on relevant clinical parameters within 24 h of admission. These indicators were compared among different disease severity groups, and factors related to severe DKA, concurrent acute kidney injury (AKI), and ICU admission were further analyzed. Receiver operating characteristic (ROC) curve analysis was performed to determine the sensitivity, specificity, area under the ROC curve (AUC), and cut-off value of LCR. A total of 271 adult DKA patients were enrolled and categorized into three groups: mild group (n = 42), moderate group (n = 64), and severe group (n = 165). Significant differences in demographic and clinical data were observed among these groups. Glasgow coma scale (GCS) score, LCR, pH, and bicarbonate (HCO3-) were identified as protective factors for severe DKA. Conversely, SOFA score, neutrophil count (NEUT), serum creatinine (SCr), and glucose (GLU) were risk factors for concurrent AKI. Concurrent AKI and SOFA score were risk factors for ICU admission, while pH was a protective factor. The areas under the ROC curve (AUC) of LCR to classify adult DKA patients into mild group, severe group, and ICU admission were 0.679, 0.718, and 0.621, respectively, with cut-off value of 212.80, 96.16, and 63.35, sensitivity of 54.8%, 76.4%, and 78.9%, and specificity of 76.0%, 62.4%, and 46.3%. LCR upon admission provides great potential to predict disease progression and ICU admission in adult patients with DKA.

2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Lower Prevalence of Diabetic Ketoacidosis at Diagnosis in Research Participants Monitored for Hyperglycemia

CONTEXT

In Colorado children, the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes has been increasing over time.

OBJECTIVE

To evaluate the prevalence of and factors involved in DKA at type 1 diabetes diagnosis among participants followed in monitoring research studies before diagnosis compared to patients from the community.

METHODS

We studied patients < 18 years diagnosed with type 1 diabetes between 2005 and 2021 at the Barbara Davis Center for Diabetes and compared the prevalence of and factors associated with DKA at diagnosis among participants in preclinical monitoring studies vs those diagnosed in the community.

RESULTS

Of 5049 subjects, 164 were active study participants, 42 inactive study participants, and 4843 were community patients. Active study participants, compared to community patients, had lower HbA1c (7.3% vs 11.9%; P < .001) and less frequently experienced DKA (4.9% vs 48.5%; P < .001), including severe DKA (1.2% vs 16.2%; P < .001). Inactive study participants had intermediate levels for both prevalence and severity of DKA. DKA prevalence increased in community patients, from 44.0% to 55%, with less evidence for a temporal trend in study participants. DKA prevalence was highest in children < 2 years (13% in active study participants vs 83% in community patients). In community patients, younger age (P = .0038), public insurance (P < .0001), rural residence (P < .0076), higher HbA1c (P < .0001), and ethnicity minority status (P < .0001) were associated with DKA at diagnosis.

CONCLUSION

While DKA prevalence increases in community patients over time, it stayed < 5% in active research participants, who have a 10 times lower prevalence of DKA at diagnosis, including among minorities.

Comparison of pediatric diabetic ketoacidosis in newly diagnosed versus known patients with type 1 diabetes mellitus: A single-center study

OBJECTIVES

To compare the demographic, clinical, and biochemical characteristics of newly diagnosed versus known patients with type 1 diabetes mellitus (T1DM) presenting with diabetic ketoacidosis (DKA) in a tertiary care center in the Western region of Saudi Arabia.

METHODS

We retrospectively reviewed 147 children and adolescents diagnosed with T1DM who presented with DKAs between January 2019 and December 2023. Data on age, gender, nationality, economic status, episode severity, presenting symptoms, and biochemical markers were collected and analyzed.

RESULTS

The mean patient age was 7.24 years, with known patients being older (mean age: 8.24 years) than newly diagnosed patients (mean age: 6.34 years). Most patients (55.8%) belonged to the middle-childhood age group (6 to 11 years). Among known patients, the most prevalent symptoms included vomiting, reported by 62 (88.6%) individuals, and abdominal pain, which affected 55 (78.6%). In contrast, new patients exhibited a strikingly high incidence of polyuria, with 68 (88.3%) cases, and polydipsia, affecting 65 (84.4%) individuals.

CONCLUSION

The DKA incidence was higher in newly diagnosed patients, particularly in the middle-childhood age group. Economic factors may contribute to disease manifestations, and newly diagnosed patients had longer DKA symptom durations. The higher DKA incidence and severity in newly diagnosed patients, particularly in certain age groups, underscores the importance of increased disease awareness and early diagnosis.

An Epidemiological Perspective on New Pediatric Cases of Type 1 Diabetes and Vitamin D Deficiency in South-East Romania: A Retrospective Study

OBJECTIVES

The aim of this study is to analyze the epidemiological characteristics and the biological profile of children from the southeast of Romania who have been newly diagnosed with type 1 diabetes (T1DM) and to investigate the potential relationships between vitamin D deficiency and the onset of this disease, especially in the context of the COVID-19 pandemic.

METHODS

This is a retrospective study that included 79 children under the age of 18 who were diagnosed with T1DM at the St. Ioan Galati Children's Emergency Clinical Hospital between 2018 and 2023. Their demographic data (age, sex, and home environment), medical history (family medical history, birth weight, Apgar score, and type of nutrition), and biological parameters, including glycemia, HbA1C, and vitamin D level, were collected. We used advanced statistical methods to compare the levels of vitamin D in the children with T1DM with a control group of nondiabetic children.

RESULTS

The demographic characteristics of new T1DM are a median age of 9 and female/male sex ratio of 1:3, with 50.6% living in urban areas, 59.5% with a normal body mass index, and 74.6% presenting with ketoacidosis. Vitamin D deficiency was found in 52% of diabetic cases compared to 2.53% in the nondiabetic controls.

CONCLUSIONS

There is an increasing incidence of pediatric T1DM. Diabetic ketoacidosis was frequently diagnosed as an initial manifestation and has frequently accompanied lower levels of vitamin D. Children with T1DM showed significant vitamin D deficiencies compared to the control group, highlighting the need for the monitoring and supplementation of this vitamin.

Use of Degludec in Youth With Type 1 Diabetes and Recurrent Diabetic Ketoacidosis

This article describes a pediatric diabetes center quality improvement initiative to switch youth with type 1 diabetes and diabetic ketoacidosis (DKA) from insulin glargine to longer-duration insulin degludec to determine whether this change would reduce DKA recurrence. Overall, the change in DKA recurrence with degludec was not statistically significant. However, subgroup analysis showed that race/ethnicity and insurance status were significantly associated with change in DKA rates. The association of degludec and decreased rates of repeat DKA in Hispanics and privately insured individuals requires further exploration.

Management of diabetic ketoacidosis in children: Does early insulin glargine help improve outcomes?

BACKGROUND

Rebound hyperglycemia following the resolution of diabetic ketoacidosis (DKA) is common in pediatric patients with type 1 diabetes, increasing the risk of recurrent DKA and complicating the transition to subcutaneous insulin. Multiple studies suggest that early administration of long-acting insulin analogs during DKA management safely improves this transition.

OBJECTIVE

This study aimed to determine whether early insulin glargine administration in children with DKA prevents rebound hyperglycemia and recurrent ketosis without increasing the rate of hypoglycemia or hypokalemia.

METHODS

Patients aged <21 years presenting with DKA to Children's Mercy Kansas City between October 2012 and October 2016 were reviewed. They were categorized as Early (>4 h of overlap with intravenous [IV] insulin) and Late (<2 h of overlap) cohorts.

RESULTS

We reviewed 546 DKA admissions (365 Early and 181 Late). Rebound hyperglycemia (>180 mg/dL) was lower in the Early group (66% vs. 85%, p ≤ 0.0001). Hypoglycemia (<70 mg/dL) during IV insulin administration was higher in the Early group than in the Late group (27% vs. 19%, p = 0.042). Hypoglycemia within 12 h of IV insulin discontinuation was lower in the Early group (16% vs. 26%, p = 0.012). Recurrent ketosis, hypokalemia, and cerebral edema were not different between the groups.

CONCLUSIONS

Early glargine administration in pediatric DKA management is safe, decreases the rate of rebound hyperglycemia, and improves the transition to subcutaneous insulin. Hypoglycemia is less frequent following IV insulin discontinuation with early glargine, but the IV insulin rate may need to be reduced to minimize hypoglycemia during IV insulin infusion.

Trends in diabetic ketoacidosis in Victoria, Australia 2002-2016

BACKGROUND

International longitudinal studies have indicated an increasing incidence of diabetic ketoacidosis (DKA). We aim to examine the incident trends, demographic differences, length of stay and mortality for DKA in adults with type 1 diabetes (T1D) and type 2 diabetes (T2D) in Victoria, Australia from 2002 to 2016.

METHODS

Age and sex adjusted incident trends, length of stay and mortality for DKA was retrospectively obtained using the Victorian Admitted Episode Dataset between 2002 and 2016. Data for adults with T1D and T2D was obtained from the National Diabetes Services Scheme (NDSS). Joinpoint regression analysis was used to identify changes in linear trends that were described as average annual percentage change (AAPC).

RESULTS

There were 23,628 DKA presentations in Victoria between 2002 and 2016. For T1D there was an increase in DKA presentations (AAPC + 6.8%) from 2003 to 2016 and for T2D there was a decline from 2003 to 2011 (APC - 3.5%), increase from 2011 to 2014 (APC + 38.5%), and a decrease from 2014 to 2016 (APC - 20.9%). Length of stay was longer for people with T2D than T1D (P < 0.001) and the mortality rate was 0.51% for the study period.

CONCLUSIONS

DKA rates increased for T2D from 2011 to 2014 which correlates with the introduction of sodium glucose-linked transport protein 2 inhibitors. However, the aetiology for the observed increase in T1D from 2002 to 2016 remains unknown.

Exploring ketoacidosis frequency and risk factors in childhood-onset type 1 diabetes: an 8-year retrospective study (2011-2018) at a tertiary paediatric hospital in Tripoli, Libya

OBJECTIVES

Diabetic ketoacidosis (DKA) stands as a critical, acute complication of type 1 diabetes. Despite its severity, there exists a dearth of data concerning the frequency and prevalence of DKA at the onset of type 1 diabetes in Libyan children. This study aimed to ascertain the frequency of DKA during the initial presentation of type 1 diabetes among children aged 0.5-14 years admitted to Tripoli Children's Hospital between 2011 and 2018.

METHODS

Employing a retrospective approach, the study examined the proportion of children with newly diagnosed type 1 diabetes who presented with DKA. Data analysis included estimating DKA frequency concerning age at presentation, sex, and age groups. The comparative analysis involved assessing DKA frequency between 0.5 and <2 and 2-14 years age groups. Logistic regression analysis evaluated the impact of age group, sex, and family history of type 1 diabetes on DKA and severe DKA occurrence.

RESULTS

Among 497 children with newly diagnosed type 1 diabetes, 39.2 % presented with DKA, of these 44.5 % had severe DKA. Females exhibited a higher DKA rate than males (OR 1.63, 95 % CI 1.13-2.34, p=0.009). Very young children (0.5 to <2 years) presented with DKA more frequently than those aged 2-14 years (OR 4.73, 95 % CI 2.65-8.47, p<0.001), and they were more likely to present in severe DKA (63.9 vs. 39.1 %, [OR 7.26, 95 % CI 3.65-14.41, p<0.001]).

CONCLUSIONS

The frequency of DKA at type 1 diabetes onset among children admitted to Tripoli Children's Hospital is notably high, with nearly half of the DKA episodes categorized as severe. Very young children notably demonstrated a fivefold increase in the likelihood of presenting with DKA.

Multicentre, retrospective cohort study protocol to identify racial and ethnic differences in acute kidney injuries in children and adolescents with diabetic ketoacidosis

INTRODUCTION

Approximately 40% of children with diabetic ketoacidosis (DKA) develop acute kidney injury (AKI), which increases the risk of chronic kidney damage. At present, there is limited knowledge of racial or ethnic differences in diabetes-related kidney injury in children with diabetes. Understanding whether such differences exist will provide a foundation for addressing disparities in diabetes care that may continue into adulthood. Further, it is currently unclear which children are at risk to develop worsening or sustained DKA-related AKI. The primary aim is to determine whether race and ethnicity are associated with DKA-related AKI. The secondary aim is to determine factors associated with sustained AKI in children with DKA.

METHODS AND ANALYSIS

This retrospective, multicentre, cross-sectional study of children with type 1 or type 2 diabetes with DKA will be conducted through the Paediatric Emergency Medicine Collaborative Research Committee. Children aged 2-18 years who were treated in a participating emergency department between 1 January 2020 and 31 December 2023 will be included. Children with non-ketotic hyperglycaemic-hyperosmolar state or who were transferred from an outside facility will be excluded. The relevant predictor is race and ethnicity. The primary outcome is the presence of AKI, defined by Kidney Disease: Improving Global Outcomes criteria. The secondary outcome is 'sustained' AKI, defined as having AKI ≥48 hours, unresolved AKI at last creatinine measurement or need for renal replacement therapy. Statistical inference of the associations between predictors (ie, race and ethnicity) and outcomes (ie, AKI and sustained AKI) will use random effects regression models, accounting for hospital variation and clustering.

ETHICS AND DISSEMINATION

The Institutional Review Board of Children's Minnesota approved this study. 12 additional sites have obtained institutional review board approval, and all sites will obtain local approval prior to participation. Results will be presented at local or national conferences and for publication in peer-reviewed journals.

Candida albicans skin infection in diabetic patients: An updated review of pathogenesis and management

Candida species, commensal residents of human skin, are recognized as the cause of cutaneous candidiasis across various body surfaces. Individuals with weakened immune systems, particularly those with immunosuppressive conditions, are significantly more susceptible to this infection. Diabetes mellitus, a major metabolic disorder, has emerged as a critical factor inducing immunosuppression, thereby facilitating Candida colonization and subsequent skin infections. This comprehensive review examines the prevalence of different types of Candida albicans-induced cutaneous candidiasis in diabetic patients. It explores the underlying mechanisms of pathogenicity and offers insights into recommended preventive measures and treatment strategies. Diabetes notably increases vulnerability to oral and oesophageal candidiasis. Additionally, it can precipitate vulvovaginal candidiasis in females, Candida balanitis in males, and diaper candidiasis in young children with diabetes. Diabetic individuals may also experience candidal infections on their nails, hands and feet. Notably, diabetes appears to be a risk factor for intertrigo syndrome in obese individuals and periodontal disorders in denture wearers. In conclusion, the intricate relationship between diabetes and cutaneous candidiasis necessitates a comprehensive understanding to strategize effective management planning. Further investigation and interdisciplinary collaborative efforts are crucial to address this multifaceted challenge and uncover novel approaches for the treatment, management and prevention of both health conditions, including the development of safer and more effective antifungal agents.

Blood Urea Nitrogen to Serum Albumin Ratio as A New Prognostic Indicator in Critically Ill Patients with Diabetic Ketoacidosis: A Retrospective Cohort Study

OBJECTIVE

To investigate the predictive value of the blood urea nitrogen to serum albumin ratio for in-hospital and out-of-hospital mortality in critically ill patients with diabetic ketoacidosis.

METHODS

Data were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) database, and all eligible participants were categorized into two groups based on the BAR cutoff value. Multiple logistic regression analysis was conducted to determine the association between BAR and in-hospital mortality. The Kaplan-Meier (K-M) analysis was performed to evaluate the predictive performance of BAR. Propensity score matching (PSM) was applied to control confounding factors between the low and high BAR groups.

RESULTS

A total of 589 critically ill patients with diabetic ketoacidosis were enrolled. Patients with diabetic ketoacidosis with a higher BAR level were associated with higher in- and out-hospital mortality (all p<0.001). A significant 4-year survival difference was observed between the low and high BAR groups (p<0.0001). After PSM analysis, two PSM groups (202 pairs, n=404) were generated, and similar results were observed in the K-M curve (p<0.0001).

DISCUSSION

Elevated BAR levels were associated with an increased risk of in-hospital mortality in critically ill patients with diabetic ketoacidosis, and BAR could serve as an independent prognostic factor in in-hospital and out-of-hospital mortality for patients diagnosed with diabetic ketoacidosis.

2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Screening and Prevention of Type 1 Diabetes: Where Are We?

A diagnosis of type 1 diabetes (T1D) and the subsequent requirement for exogenous insulin treatment is associated with considerable acute and chronic morbidity and a substantial effect on patient quality of life. Importantly, a large body of work suggests that early identification of presymptomatic T1D can accurately predict clinical disease, and when paired with education and monitoring, can yield improved health outcomes. Furthermore, a growing cadre of effective disease-modifying therapies provides the potential to alter the natural history of early stages of T1D. In this mini review, we highlight prior work that has led to the current landscape of T1D screening and prevention, as well as challenges and next steps moving into the future of these rapidly evolving areas of patient care.

[Cetoacidosis diabética al diagnóstico de diabetes mellitus tipo 1 en Asturias entre 2011 y 2020: influencia de la duración de los síntomas en la prevalencia de cetoacidosis y en la pérdida de peso.]

OBJECTIVE

Diabetic ketoacidosis (DKA) is a serious complication that usually occurs at diagnosis of type 1 diabetes mellitus (T1D). However, the prevalence of DKA at diagnosis of T1D is heterogeneous in different regions of the world. The aim of this study was to determine the prevalence of DKA at diagnosis of T1D in Asturias.

METHODS

This study included all patients under nineteen years of age diagnosed with T1D in Asturias between 2011 and 2020. Retrospective review of medical records was performed to analyse DKA and other characteristics at diagnosis. A log binary regression model was constructed to obtain an estimate of the prevalence ratio of DKA to diagnosis in the years studied.

RESULTS

A total of 267 people were diagnosed with a mean age of 9.85±4.46 years. The prevalence of DKA at diagnosis during this period was 38.63%. There was an increasing trend, with a prevalence ratio over the years studied of 1.015 (95%CI: 0.96-1.07; p=0.61). Duration of symptoms before diagnosis was 4.57±7.64 weeks. Weight loss was 7.56±7.26%, being more than 10% of previous weight in almost half of the patients who loosed weight. There was a positive relationship between symptoms duration and prevalence of DKA and between time to diagnosis and weight loss.

CONCLUSIONS

Asturias has a high prevalence of DKA at diagnosis of T1D, slightly higher than observed in other studies at national level and higher than in other similar countries, with a tendency to increase. Delayed diagnosis is a key factor in the prevalence of DKA and weight loss. Thus, health actions are needed for the early detection of T1D to avoid DKA at diagnosis.

Uncovering the alarming rise of diabetic ketoacidosis during COVID-19 pandemic: a pioneer African study and review of literature

Introduction

Reports around the world indicate that COVID-19 pandemic may be contributing to an increase in the incidence of new onset diabetic ketoacidosis (DKA). This has yet to be studied in Africa. We aimed to compare the incidence trend of new onset DKA before and during the COVID-19 pandemic, with a focus on the type of diabetes mellitus (DM).Materials and methodsThis was a cross sectional analytical study, over a 4-year period, between March 2018 until February 2022 conducted in the referral center: diabetology department of university hospital Farhat Hached Sousse, Tunisia. The study population included patients hospitalized for new onset DKA divided in two groups: G1: before COVID-19 pandemic and G2: during COVID-19 pandemic. Patients younger than 14, new onset DM not presenting with DKA, other types of diabetes (monogenic, secondary or pancreatic diabetes) were not included. A statistical analysis of the monthly incidence trend was conducted using the Jointpoint software providing the average monthly percentage of change (AMPC).

Results

a total of 340 patients were included:137 registered before the pandemic and 203 during the pandemic, representing a 48.17% increase. The mean monthly incidence of new onset DKA during COVID-19 pandemic was statistically higher than that before COVID-19 pandemic (8.42 ± 4.87 vs 5.75 ± 4.29 DKA per month) (p=0.049). The temporal trend of DKA during the 4-year study showed a significant upward trend with a change in AMPC of +0.2% (p=0.037). The incidence of type 1 diabetes (T1D) and type 2 diabetes (T2D) increased by 50% and 44% respectively during COVID-19 pandemic. Anti-glutamic acid decarboxylase (anti-GAD) antibodies' titers significantly increased in G2 compared with G1 (median of 330[Q1-Q3]=[58.5-1795]vs 92.5[Q1-Q3]=[22.5-1074] respectively)(p=0.021).

Discussion

The incidence trend of DKA showed an increase during the COVID-19 pandemic along with an increase of T1D and T2D implying that the pandemic may have been the underlying factor of this upward trend.

The Computational Acid-Base Chemistry of Hepatic Ketoacidosis

Opposing evidence exists for the source of the hydrogen ions (H⁺) during ketoacidosis. Organic and computational chemistry using dissociation constants and alpha equations for all pertinent ionizable metabolites were used to (1) document the atomic changes in the chemical reactions of ketogenesis and ketolysis and (2) identify the sources and quantify added fractional (~) H⁺ exchange (~H⁺e). All computations were performed for pH conditions spanning from 6.0 to 7.6. Summation of the ~H⁺e for given pH conditions for all substrates and products of each reaction of ketogenesis and ketolysis resulted in net reaction and pathway ~H⁺e coefficients, where negative revealed ~H⁺ release and positive revealed ~H⁺ uptake. Results revealed that for the liver (pH = 7.0), the net ~H⁺e for the reactions of ketogenesis ending in each of acetoacetate (AcAc), β-hydroxybutyrate (β-HB), and acetone were -0.9990, 0.0026, and 0.0000, respectively. During ketogenesis, ~H⁺ release was only evident for HMG CoA production, which is caused by hydrolysis and not ~H⁺ dissociation. Nevertheless, there is a net ~H⁺ release during ketogenesis, though this diminishes with greater proportionality of acetone production. For reactions of ketolysis in muscle (pH = 7.1) and brain (pH = 7.2), net ~H⁺ coefficients for β-HB and AcAc oxidation were -0.9649 and 0.0363 (muscle), and -0.9719 and 0.0291 (brain), respectively. The larger ~H⁺ release values for β-HB oxidation result from covalent ~H⁺ release during the oxidation-reduction. For combined ketogenesis and ketolysis, which would be the metabolic condition in vivo, the net ~H⁺ coefficient depends once again on the proportionality of the final ketone body product. For ketone body production in the liver, transference to blood, and oxidation in the brain and muscle for a ratio of 0.6:0.2:0.2 for β-HB:AcAc:acetone, the net ~H⁺e coefficients for liver ketogenesis, blood transfer, brain ketolysis, and net total (ketosis) equate to -0.1983, -0.0003, -0.2872, and -0.4858, respectively. The traditional theory of ketone bodies being metabolic acids causing systemic acidosis is incorrect. Summation of ketogenesis and ketolysis yield H⁺ coefficients that differ depending on the proportionality of ketone body production, though, in general, there is a small net H⁺ release during ketosis. Products formed during ketogenesis (HMG-CoA, acetoacetate, β-hydroxybutyrate) are created as negatively charged bases, not acids, and the final ketone body, acetone, does not have pH-dependent ionizable groups. Proton release or uptake during ketogenesis and ketolysis are predominantly caused by covalent modification, not acid dissociation/association. Ketosis (ketogenesis and ketolysis) results in a net fractional H⁺ release. The extent of this release is dependent on the final proportionality between acetoacetate, β-hydroxybutyrate, and acetone.

Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement

Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.

G Protein-Coupled Receptors and the Rise of Type 2 Diabetes in Children

The human genome counts hundreds of GPCRs specialized to sense thousands of different extracellular cues, including light, odorants and nutrients in addition to hormones. Primordial GPCRs were likely glucose transporters that became sensors to monitor the abundance of nutrients and direct the cell to switch from aerobic metabolism to fermentation. Human β cells express multiple GPCRs that contribute to regulate glucose homeostasis, cooperating with many others expressed by a variety of cell types and tissues. These GPCRs are intensely studied as pharmacological targets to treat type 2 diabetes in adults. The dramatic rise of type 2 diabetes incidence in pediatric age is likely correlated to the rapidly evolving lifestyle of children and adolescents of the new century. Current pharmacological treatments are based on therapies designed for adults, while youth and puberty are characterized by a different hormonal balance related to glucose metabolism. This review focuses on GPCRs functional traits that are relevant for β cells function, with an emphasis on aspects that could help to differentiate new treatments specifically addressed to young type 2 diabetes patients.

Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most alarming concerns in the management of type 1 diabetes (T1D) in pediatric age. Prevalence of DKA at the onset of diabetes ranges from 30 to 40%. In selected cases of severe DKA, admission to pediatric intensive care unit (PICU) should be considered.

METHODS

This study aims to assess the prevalence of severe DKA treated in PICU in our 5-year monocentric experience. Secondary outcome of the study was to describe the main demographical and clinical features of individuals who required admission to PICU. All clinical data were collected by retrospectively reviewing the electronic medical records of children and adolescents with diabetes hospitalized in our University Hospital from January 2017 to December 2022.

RESULTS

During the study period, 103 children and adolescents were newly diagnosed with T1D. Among these, 51.5% presented clinical criteria for DKA and almost 10% needed to be treated in PICU. A higher rate of new T1D diagnoses was observed in 2021, as well as episodes of severe DKA being more frequent than in previous years. Due to severe clinical manifestations of DKA, 10 subjects (9.7%) with T1D onset needed to be treated in PICU. Of these, four children were younger than 5. The great majority came from a low household income and some of them had also immigrant background. The most common complication of DKA was acute kidney injury presented by four children. Other complications were cerebral edema, papilledema and acute esophageal necrosis. A 15-year-old girl had deep vein thrombosis (DVT) that evolved into multiple organ failure leading to death.

CONCLUSIONS

Our findings demonstrated that severe DKA is still quite common in children and adolescents at T1D onset, especially in some areas such as Southern Italy. Public awareness campaigns should be increasingly promoted to facilitate the recognition of early symptoms of diabetes and to reduce morbidity and mortality related to DKA.

Intraoperative diagnosis of type 1 diabetes and diabetic ketoacidosis during scoliosis surgery

Diabetic ketoacidosis is the leading cause of morbidity and mortality in children with type 1 diabetes. Management of diabetic ketoacidosis requires meticulous monitoring and treatment of severe dehydration and metabolic derangement. We present an adolescent patient who was diagnosed with diabetic ketoacidosis during spinal fusion for idiopathic scoliosis and discuss the management of this unexpected intraoperative emergency.

Incidence of type 1 diabetes in Navarra, 2009-2020. Evidence of a stabilization

INTRODUCTION

The evolution of the incidence of type 1 diabetes (T1D) in all groups is controversial. Our objective is to study the incidence from 2009 to 2020, based on the Type 1 Diabetes Registry of Navarra, and to analyze the clinical presentation as diabetic ketoacidosis (DKA), and HbA1c at onset.

MATERIALS AND METHODS

Descriptive study of all cases diagnosed as T1D and included in the Population Registry of T1D of Navarra in the period 1/1/2009 to 12/31/2020. Data are obtained from primary and secondary sources with an ascertainment rate of 96%. Incidence rates are expressed per 100,000 person-years of risk, by age group and sex. Likewise, a descriptive analysis of the HbA1c and DKA at diagnosis of each patient is performed.

RESULTS

627 new cases are registered, which represents an incidence of 8.1 (10 in men, 6.3 in women), without differences throughout the analyzed period. The group with the highest incidence is the 10-14 years old children (27.8), followed by that of 5-9 years old (20.6). The incidence in people older than 15 years is 5.8. Twenty six percent of patients present DKA at onset. The global mean of HbA1c is 11.6%, without changes throughout the studied period.

CONCLUSIONS

The population registry of T1D of Navarra shows a stabilization in the incidence of T1D at all ages in the 2009-2020 period. The percentage of presentation as severe forms is high, even in adulthood.

Effective assay technologies fit for large-scale population screening of type 1 diabetes

While worldwide prevention efforts for type 1 diabetes (T1D) are underway to abrogate or slow progression to diabetes, mass screening of islet autoantibodies (IAbs) in the general population is urgently needed. IAbs, the most reliable biomarkers, play an essential role in prediction and clinical diagnosis of T1D. Through laboratory proficiency programs and harmonization efforts, a radio-binding assay (RBA) has been well established as the current 'gold' standard assay for all four IAbs. However, in view of the need for large-scale screening in the non-diabetic population, RBA consistently faces two fundamental challenges, cost-efficiency and disease specificity. While all four IAbs are important for disease prediction, the RBA platform, with a separate IAb test format is laborious, inefficient and expensive. Furthermore, the majority of IAb positivity in screening, especially from individuals with single IAb were found to be low risk with low affinity. It is well documented from multiple clinical studies that IAbs with low affinity are low risk with less or no disease relevance. At present, two non-radioactive multiplex assays, a 3-assay ELISA combining three IAbs and a multiplex ECL assay combining all four IAbs, have been successfully used as the primary methods for general population screenings in Germany and the US, respectively. Recently, the TrialNet Pathway to Prevention study has been organizing an IAb workshop which aims to analyze the 5-year T1D predictive values of IAbs. A T1D-specific assay with high efficiency, low cost and requiring low volume of sample will definitely be necessary to benefit general population screening.

2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Decreased occurrence of ketoacidosis and preservation of beta cell function in relatives screened and monitored for type 1 diabetes in Australia and New Zealand

AIMS

Islet autoantibody screening of infants and young children in the Northern Hemisphere, together with semi-annual metabolic monitoring, is associated with a lower risk of ketoacidosis (DKA) and improved glucose control after diagnosis of clinical (stage 3) type 1 diabetes (T1D). We aimed to determine if similar benefits applied to older Australians and New Zealanders monitored less rigorously.

METHODS

DKA occurrence and metabolic control were compared between T1D relatives screened and monitored for T1D and unscreened individuals diagnosed in the general population, ascertained from the Australasian Diabetes Data Network.

RESULTS

Between 2005 and 2019, 17,105 relatives (mean (SD) age 15.7 (10.8) years; 52% female) were screened for autoantibodies against insulin, glutamic acid decarboxylase, and insulinoma-associated protein 2. Of these, 652 screened positive to a single and 306 to multiple autoantibody specificities, of whom 201 and 215, respectively, underwent metabolic monitoring. Of 178 relatives diagnosed with stage 3 T1D, 9 (5%) had DKA, 7 of whom had not undertaken metabolic monitoring. The frequency of DKA in the general population was 31%. After correction for age, sex and T1D family history, the frequency of DKA in screened relatives was >80% lower than in the general population. HbA1c and insulin requirements following diagnosis were also lower in screened relatives, consistent with greater beta cell reserve.

CONCLUSIONS

T1D autoantibody screening and metabolic monitoring of older children and young adults in Australia and New Zealand, by enabling pre-clinical diagnosis when beta cell reserve is greater, confers protection from DKA. These clinical benefits support ongoing efforts to increase screening activity in the region and should facilitate the application of emerging immunotherapies.

First STEPS: Primary Outcomes of a Randomized, Stepped-Care Behavioral Clinical Trial for Parents of Young Children With New-Onset Type 1 Diabetes

OBJECTIVE

Despite the emotional challenges of parental adjustment to a child's type 1 diabetes diagnosis and the unique complexities of early childhood, there are few programs designed to meet the needs of parents of young children at new onset. This study evaluated First STEPS (Study of Type 1 in Early childhood and Parenting Support), a stepped-care behavioral intervention designed to support parents' psychosocial functioning and promote children's glycemic outcomes.

RESEARCH DESIGN AND METHODS

Using a two-site randomized clinical trial design, parents (n = 157) of children aged 1-6 years completed baseline data within 2 months of diabetes diagnosis and were randomly assigned to intervention (n = 115) or usual care (n = 42) for 9 months. Intervention steps included: 1) peer parent coaching, with step-ups to 2) structured behavioral counseling and 3) professional consultations with a diabetes educator and psychologist, based on parent mood and child HbA1c. Participants completed follow-ups at 9 and 15 months postrandomization. Primary outcomes were parent depressive symptoms and child HbA1c.

RESULTS

Depressive symptoms improved in both groups, and intervention parents had significantly lower depressive symptoms at the 9- and 15-month follow-ups compared with usual care. HbA1c decreased in both groups, but there were no between-group differences at 9 or 15 months.

CONCLUSIONS

First STEPS improved parents' mood following young children's type 1 diabetes diagnosis. Results indicate likely benefits of parent coach support, supplemented by intervention intensifications, including behavioral intervention and diabetes education. This model has high potential for patient engagement. The absence of a medical intervention component may explain null findings for HbA1c; incorporating targeted behavioral support for intensive diabetes treatment may maximize intervention impact.

Estimated Cost-effectiveness of Subcutaneous Insulin Aspart in the Management of Mild Diabetic Ketoacidosis Among Children

IMPORTANCE

Intravenous (IV) insulin infusion is the standard of care for treating diabetic ketoacidosis (DKA) worldwide. Subcutaneous (SC) insulin aspart could decrease the use of health care resources.

OBJECTIVE

To compare the cost-effectiveness of mild uncomplicated DKA management with SC insulin aspart vs IV insulin infusion among pediatric patients from the perspective of a public health care payer using clinical data.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation included children aged 2 to 14 years presenting to the emergency department of a single academic medical center with mild DKA between January 1, 2015, and March 15, 2020. The medical records for DKA treatment course and its associated hospitalization costs were reviewed. Data were analyzed from January 1, 2015, to March 15, 2020.

EXPOSURES

Subcutaneous insulin aspart vs IV regular insulin infusion.

MAIN OUTCOMES AND MEASURES

The incremental cost-effectiveness ratio (US dollars per hour), duration of DKA treatment, and length of hospital stay.

RESULTS

A total of 129 children with mild DKA episodes (mean [SD] age, 9.9 [3.1] years; 72 girls [55.8%]) were enrolled in the study. Seventy children received SC insulin aspart and 59 received IV regular insulin. Overall, the length of hospital stay in the SC insulin group was reduced (mean, 16.9 [95% CI, -31.0 to -2.9] hours) compared with the IV insulin group (P = .005). The mean (SD) cost of hospitalization in the SC insulin group (US $1071.99 [US $523.89]) was less than that in the IV insulin group (US $1648.90 [US $788.03]; P = .001). The incremental cost-effectiveness ratio was -34.08 (95% CI, -25.97 to -129.82) USD/h. The use of SC insulin aspart was associated with a lower likelihood of prolonged hospital stay (β = -17.22 [95% CI, -32.41 to -2.04]; P = .03) than IV regular insulin when controlling for age and sex.

CONCLUSION AND RELEVANCE

Findings of this economic evaluation suggest that SC insulin aspart is dominant vs IV regular insulin in the management of mild uncomplicated DKA in children.

Frequency of Ketoacidosis at Diagnosis of Pediatric Type 1 Diabetes Associated With Socioeconomic Deprivation and Urbanization: Results From the German Multicenter DPV Registry

OBJECTIVE

To investigate whether socioeconomic deprivation and urbanization are associated with the frequency of diabetic ketoacidosis (DKA) at diagnosis of pediatric type 1 diabetes.

RESEARCH DESIGN AND METHODS

Children and adolescents aged ≤18 years, living in Germany, with newly diagnosed type 1 diabetes documented between 2016 and 2019 in the Diabetes Prospective Follow-up Registry (DPV; Diabetes-Patienten-Verlaufsdokumentation), were assigned to a quintile of regional socioeconomic deprivation (German Index of Socioeconomic Deprivation) and to a degree of urbanization (Eurostat) by using their residence postal code. With multiple logistic regression models, we investigated whether the frequency of DKA at diagnosis was associated with socioeconomic deprivation or urbanization and whether associations differed by age-group, sex, or migration status.

RESULTS

In 10,598 children and adolescents with newly diagnosed type 1 diabetes, the frequency of DKA was lowest in the least deprived regions (Q1: 20.6% [95% CI 19.0-22.4], and increased with growing socioeconomic deprivation to 26.9% [25.0-28.8] in the most deprived regions [Q5]; P for trend <0.001). In rural areas, the frequency of DKA at diagnosis was significantly higher than in towns and suburbs (intermediate areas) or in cities (27.6% [95% CI 26.0-29.3] vs. 22.7% [21.4-24.0], P < 0.001, or vs. 24.3% [22.9-25.7], P = 0.007, respectively). The results did not significantly differ by age-group, sex, or migration background or after additional adjustment for socioeconomic deprivation or urbanization.

CONCLUSIONS

This study provides evidence that prevention of DKA at diagnosis by means of awareness campaigns and screening for presymptomatic type 1 diabetes should particularly target socioeconomically disadvantaged regions and rural areas.

Moderate and severe diabetic ketoacidosis at type 1 diabetes onset in children over two decades: A population-based study of prevalence and long-term glycemic outcomes

OBJECTIVE

To investigate in a population-based pediatric cohort: prevalence of moderate-severe diabetic ketoacidosis (DKA) at type 1 diabetes (T1D) diagnosis over two decades and its association with long-term glycemic control.

RESEARCH DESIGN AND METHODS

Children <16 years diagnosed with T1D in Western Australia 2000-2019 were included and followed up for ≤14 years. Moderate-severe DKA at diagnosis was defined as serum pH < 7.2 or bicarbonate<10 mmol/L with hyperglycemia and ketosis. HbA1c was measured ~3-monthly. Trend in prevalence of moderate-severe DKA at diagnosis was investigated using a logistic regression model adjusting for sex, age, socioeconomic status, and area of residence. Long-term glycemic control associated with DKA at diagnosis was investigated using linear mixed models adjusting for the same variables and also for visit frequency, CGM and pump use.

RESULTS

Moderate-severe DKA occurred in 534 of 2111 (25.3%) participants. Odds of presenting with moderate-severe DKA increased by 4.1% (95% CI: 2.3, 5.9; p < 0.001) per year. Patients with moderate-severe DKA at diagnosis had higher HbA1c levels than other patients initially; the groups were similar between 2 and 6 years duration; from 7 years HbA1c levels tracked higher in the group with moderate-severe DKA at diagnosis with significant differences at 8 and 12 years (p < 0.05).

CONCLUSION

The increasing prevalence of DKA at diagnosis of pediatric T1D is concerning and highlights the need for early detection programs. Unlike a similar US study, this study did not find a consistent, clinically significant relationship between DKA at diagnosis and long-term HbA1c, raising important questions about the influence of other factors on long-term glycemic outcomes.

Increase in newly diagnosed type 1 diabetes in youth during the COVID-19 pandemic in the United States: A multi-center analysis

BACKGROUND

An increase in newly diagnosed type 1 diabetes (T1D) has been posited during the COVID-19 pandemic, but data are conflicting. We aimed to determine trends in newly diagnosed T1D and severity of presentation at diagnosis for pediatric and adolescent patients during COVID-19 (2020) as compared to the previous year (2019) in a multi-center analysis across the United States.

METHODS

This retrospective study from seven centers in the T1D Exchange Quality Improvement Collaborative (T1DX-QI) included data on new onset T1D diagnosis and proportion in DKA at diagnosis from January 1 to December 31, 2020, compared to the prior year. Chi-square tests were used to compare differences in patient characteristics during the pandemic period compared to the prior year.

RESULTS

Across seven sites, there were 1399 newly diagnosed T1D patients in 2020, compared to 1277 in 2019 (p = 0.007). A greater proportion of newly diagnosed patients presented in DKA in 2020 compared to 2019 (599/1399(42.8%) vs. 493/1277(38.6%), p = 0.02), with a higher proportion presenting with severe DKA (p = 0.01) as characterized by a pH <7.1 and/or bicarbonate of <5 mmol/L. Monthly data trends demonstrated a higher number of new T1D diagnoses over the spring and summer months (March to September) of 2020 compared to 2019 (p < 0.001).

CONCLUSIONS

We found an increase in newly diagnosed T1D and a greater proportion presenting in DKA at diagnosis during the COVID-19 pandemic compared to the prior year. Future longitudinal studies are needed to confirm these findings with population level data and determine the long-term impact of COVID-19 on diabetes trends.

Association of Neighborhood Resources and Race and Ethnicity With Readmissions for Diabetic Ketoacidosis at US Children's Hospitals

Importance

The Child Opportunity Index 2.0 (COI) assesses neighborhood resources and conditions that influence health. It is unclear whether the COI scores are associated with health outcomes by race and ethnicity among children with type 1 diabetes (T1D).

Objective

To determine whether COI categories are associated with diabetes-related outcomes by race and ethnicity, including readmissions for diabetic ketoacidosis (DKA) and co-occurring acute kidney injury (AKI) or cerebral edema (CE).

Design, Setting, and Participants

This cross-sectional study included children discharged with a primary diagnosis of T1D with DKA between January 1, 2009, and December 31, 2018. Merged data were obtained from the Pediatric Health Information System and COI. Participants included children and adolescents younger than 21 years with an encounter for DKA. Data were analyzed from April 29, 2021, to January 5, 2022.

Exposures

Neighborhood opportunity, measured with the COI as an ordered, categorical score (where a higher score indicates more opportunity), and race and ethnicity.

Main Outcomes and Measures

The primary outcome was readmission for DKA within 30 and 365 days from an index visit. Secondary outcomes included the proportion of encounters with AKI or CE. Mixed-effects logistic regression was used to generate probabilities of readmission, AKI, and CE for each quintile of COI category by race and ethnicity.

Results

A total of 72 726 patient encounters were identified, including 38 924 (53.5%) for girls; the median patient age was 13 (IQR, 9-15) years. In terms of race and ethnicity, 600 (0.8%) of the encounters occurred in Asian patients, 9969 (13.7%) occurred in Hispanic patients, 16 876 (23.2%) occurred in non-Hispanic Black (hereinafter Black) patients, 40 129 (55.2%) occurred in non-Hispanic White (hereinafter White) patients, and 5152 (7.1%) occurred in patients of other race or ethnicity. The probability of readmission within 365 days was significantly higher among Black children with a very low COI category compared with Hispanic children (risk difference, 7.8 [95% CI, 6.0-9.6] percentage points) and White children (risk difference, 7.5 [95% CI, 5.9-9.1] percentage points) at the same COI category. Similar differences were seen for children with very high COI scores and across racial groups. The COI category was not associated with AKI or CE. However, race and ethnicity constituted a significant factor associated with AKI across all COI categories. The probability of AKI was 6.8% among Black children compared with 4.2% among Hispanic children (risk difference, 2.5 [95% CI, 1.7-3.3] percentage points) and 4.8% among White children (risk difference, 2.0 [95% CI, 1.3-2.6] percentage points).

Conclusions and Relevance

These results suggest that Black children with T1D experience disparities in health outcomes compared with other racial and ethnic groups with similar COI categories. Measures to prevent readmissions for DKA should include interventions that target racial disparities and community factors.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is a form of a hyperglycemic emergency mainly characterized by the triad of hyperglycemia, ketosis, and anion gap metabolic acidosis. DKA may be the initial presentation in approximately 25-40 % of patients with type 1 diabetes. It may also occur in at least 34% of patients with type 2 diabetes. DKA has economic as well as medical implications. This review aims to explore and discuss diabetic ketoacidosis, its pathophysiology, clinical presentation, diagnosis, and management, including nuances in special populations such as pediatrics, obstetrics, and patients with chronic kidney disease.

Epidemiological trends in the presentation of diabetic ketoacidosis in children newly diagnosed with type 1 diabetes from 2011 to 2017 in Kuwait

BACKGROUND

Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait.

MATERIAL AND METHODS

This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017.

RESULTS

A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years.

CONCLUSION

This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.

2. Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Incidence of Type 1 Diabetes May Be Underestimated in the Chinese Population: Evidence From 21.7 Million People Between 2007 and 2017

OBJECTIVE

Previous reports of the annual incidence of type 1 diabetes (T1D) in China were conducted using retrospective hospital cases, which may not reflect the reality. This longitudinal study estimated T1D incidence in a Chinese population of 21.7 million from 2007 to 2017.

RESEARCH DESIGN AND METHODS

A population-based registry of T1D was performed by the Beijing Municipal Health Commission Information Center. Annual incidence and 95% CIs were calculated by age group and sex. The association of sex with T1D incidence and predicted new cases of T1D were assessed using Poisson regression models. Annual percentage change and average annual percentage of change were assessed using Joinpoint regression.

RESULTS

Overall, there were 6,875 individuals who developed T1D from 2007 to 2017 in this population. T1D incidence (/100,000 persons) (95% CI) significantly increased from 2.72 (2.51, 2.93) in 2007 to 3.60 (3.38, 3.78) in 2017 (P < 0.001). The T1D onset peak was in the 10-14-year-old age group. While no significant trend was found in the 0-14- and 15-29-year-old age groups, T1D incidence markedly increased from 1.87 to 3.52 in the ≥30-year-old age group (P < 0.05). The prevalence of diabetic ketoacidosis at diagnosis was highest in the 0-4-year-old age group. We predicted new cases of T1D will increase 1.57-fold over the next decade.

CONCLUSIONS

T1D incidence in this large Chinese population is higher than has been reported previously. From 2007 to 2017, although the incidence peak was in the 10-14-year age group, the T1D incidence increased sharply in adults but not in youth.

Diabetes: Concepts of β-Cell Organ Dysfunction and Failure Would Lead to Earlier Diagnoses and Prevention

As the world endures a viral pandemic superimposed on a diabetes pandemic, the latter incorporates most of the comorbidities associated with the former, thereby exacerbating risk of death in both. An essential approach to both pandemics is prevention and unrealized earlier treatment. Thus, in this Perspective relating to diabetes, we emphasize a paradigm of, first, reversible β-cell organ dysfunction and then irreversible β-cell organ failure, which directly indicate the potential for earlier prevention, also unrealized in current guidelines. Four pillars support this paradigm: epidemiology, pathophysiology, molecular pathology, and genetics. A substantial worldwide knowledge base defines each pillar and informs a more aggressive preventive approach to most forms of the disorder. This analysis seeks to clarify the temporal and therapeutic relationships between lost β-cell function and content, illuminating the potential for earlier diagnoses and, thus, prevention. We also propose that myriad pathways leading to most forms of diabetes converge at the endoplasmic reticulum, where stress can result in β-cell death and content loss. Finally, genetic and nongenetic origins common to major types of diabetes can inform earlier diagnosis and, potentially, prevention, with the aim of preserving β-cell mass.