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Sodium-glucose co-transporter 2 (SGLT2) inhibitors have demonstrated efficacy in slowing the progression of chronic kidney disease (CKD), managing conditions such as congestive heart failure (CHF), and reducing cardiovascular and overall mortality in patients with type 2 diabetes mellitus (T2DM). However, their use is associated with complications, including euglycemic diabetic ketoacidosis (euDKA), genital fungal infections, and urinary tract infections (UTIs). Although rare, complications like euDKA can lead to serious consequences if not promptly addressed, as illustrated by this case report of a 90-year-old man with ischemic cardiomyopathy and type 2 diabetes who developed both euDKA and a UTI while on SGLT2 inhibitor therapy. Early identification of euDKA from SGLT2 inhibitor usage prompted cessation of the SGLT2 inhibitor and administration of insulin infusion, ultimately resolving the life-threatening condition.

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OBJECTIVES: We sought to determine if the early months of the coronavirus disease 2019 (COVID-19) pandemic influenced pediatric diabetic ketoacidosis (DKA) hospitalization characteristics. METHODS: This is a cross-sectional study of youth with laboratory-confirmed DKA admitted to a large tertiary children's hospital in the USA. Data were collected from admissions in March through July 2019 and March through July 2020, respectively. We evaluated the clinical characteristics of hospitalization, including demographic data and DKA severity. We used univariable ordinal logistic regression followed by multiple ordinal logistic regression to adjust for potential confounders. RESULTS: We included 137 children with diabetes admitted for DKA in the relevant period in 2019 and 173 patients admitted for DKA in the same period in 2020. Hemoglobin A1C (HbA1c) upon admission was higher in 2020 (median=12.2 %) than in 2019 (11.5 %, p=0.018). Children who were admitted with DKA in 2020 were less likely to be autoantibody positive than those in 2019 (83 vs. 91 %, p=0.028). In the univariable model, being admitted in 2020 was significantly associated with more severe DKA (p=0.038), as was HbA1c (p=0.001). After adjusting for HbA1c upon admission, admission year was no longer significantly associated with more severe DKA. CONCLUSIONS: In this study of pediatric diabetes of any type and duration of diabetes, youth admitted for DKA at the start of the COVID-19 pandemic, compared with those admitted during the year before, were more likely to have autoantibody-negative diabetes and had significantly higher HbA1c. Additionally, higher HbA1c seemed to mediate more severe DKA during the pandemic.

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Capivasertib, a pan-AKT inhibitor, has shown promising efficacy in treating metastatic tumors harboring the AKT1 E17K mutation. However, its use is associated with notable adverse events, including hyperglycemia, which may impact treatment outcomes. This case describes a patient with estrogen receptor-positive/human epidermal growth factor receptor 2-negative (ER+/HER2-) metastatic breast cancer and no prior history of diabetes who developed diabetic ketoacidosis (DKA) following capivasertib therapy.

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Hyperketonemia is a risk factor for prurigo pigmentosa; therefore, diabetic ketosis and ketoacidosis as background diseases are more frequent in prurigo pigmentosa. However, it is underrecognized by clinicians and easily missed. Herein, we present a case of diabetic ketoacidosis in which prurigo pigmentosa was recognized as a dermadrome. A 37-year-old woman with no medical history presented with thirst, polydipsia, and polyuria approximately 1 month prior to transport. and a pruritic skin rash on both shoulders 1 week later. After no diagnosis by a local dermatologist, the patient was diagnosed with diabetic ketoacidosis, and insulin therapy was initiated at our hospital. Based on the patient's history, post-hospitalization course, and pathological findings, the pruritic skin rash was diagnosed as prurigo pigmentosa. The clinical course suggested that prurigo pigmentosa is a dermadrome of diabetic ketosis and ketoacidosis. The medical clinicians' awareness of its relevance is crucial for designing therapeutic interventions for diabetic ketosis and ketoacidosis.

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Post-transplant diabetes mellitus (PTDM) is a well-known solid organ transplant complication, which can be related to immunosuppressants, particularly tacrolimus. We report an unusual presentation of PTDM with diabetic ketoacidosis (DKA). This is unique as PTDM typically resembles Type 2 DM, whereas DKA is associated with Type 1 DM and has rarely been reported as a complication of tacrolimus. A 38-year-old African American male on LCP-tacrolimus presented four months post kidney transplant with vomiting, weakness, poor appetite, and polyuria. Labs demonstrated hyperglycemia, ketonuria, and high anion gap metabolic acidosis. He was nonobese and had no personal or family history of Type 2 DM. DKA was suspected to be secondary to tacrolimus-induced pancreatic beta cell damage worsened by supratherapeutic tacrolimus levels. Latent autoimmune diabetes in adults (LADA) was diagnosed when further testing showed insulinopenia, low C-peptide, and anti-glutamic acid decarboxylase (GAD) autoantibodies. He required 120-units of subcutaneous insulin daily. Our literature review revealed only 16 other tacrolimus-induced DKA cases. No cases reported anti-GAD positivity and most showed beta cell toxicity reversibility with tacrolimus tapering or substitution. Our patient was early post-transplant with leukocytopenia, so tacrolimus was not exchanged. This unusual PTDM case may have resulted from both autoimmune and tacrolimus-induced beta cell destruction. Physicians should be aware of new onset LADA post-transplantation and tacrolimus toxicity leading to DKA, even in patients without traditional risk factors. Anti-GAD antibody screening in patients on tacrolimus who develop PTDM may identify patients less likely to recover beta cell function with immunosuppression augmentation which requires careful monitoring.

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BACKGROUND: Information on the incidence and risk factors for diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) caused by tacrolimus has rarely been reported. This study aims to assess the spectrum of DKA/HHNS associated with tacrolimus. METHODS: We conducted an observational, retrospective pharmacovigilance study using the Food and Drug Administration adverse event reporting system (FAERS) database. We employed the information component (IC) and reporting odds ratio (ROR) to evaluate the association between tacrolimus and DKA/HHNS. RESULTS: A total of 232 events were identified as tacrolimus-related DKA/HHNS, 186 cases from DKA and 54 cases from HHNS. The frequency of tacrolimus-associated DKA and HHNS was found to be significantly higher compared to all other drugs. Specifically, HHNS was significantly associated with tacrolimus based on its ROR and IC. There were no significant differences in death and non-death cases in gender, age group, year of reporting and region of reporting. CONCLUSION: Our study showed that DKA and HHNS were associated with tacrolimus use. Healthcare professionals should be aware of the possibility of DKA/HHNS following tacrolimus administration, as they were associated with an increased risk of mortality in transplant recipients.

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Goal: An insulin pump's failure to deliver insulin in the right amount at the right time is a preventable cause of hospitalization. We evaluated key performance metrics of a novel insulin pump that prevents "silent insulin non-delivery" caused by blockage, delivery of air and site leakage. This is accomplished via an acoustic sensor that measures the volume of insulin delivered with each pulse in real-time. Methods: We tested long and short-term flow accuracy, occlusion-detection time and pressure, and air management of the new device (ND) versus 3 U.S. commercial insulin pumps (CIPs) using standardized methods. Results: The ND outperformed CIPs on long-term basal flow rate error. Occlusion detection was 5 to 22.5 times faster depending on the basal rate and resulted in significantly lower (2 to 5x) pressures at time of occlusion. With air included in the drug reservoir, the tested CIPs can infuse air without detection, while the ND prevented air delivery without interruption. Conclusions: Bench tests of the ND versus 3 commercially available pumps showed improved occlusion detection and air management without flow performance tradeoffs. Additionally, the lower delivery pressure measured at time of occlusion suggests a substantially lower potential for site leakage at both basal and bolus rates. These enhancements combine to decrease the likelihood of silent insulin non-delivery.

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This case report details the diagnostic challenges and management of a middle-aged man who presented with complaints of fever and breathlessness. He was initially suspected of lower respiratory tract infection and diabetic ketoacidosis on clinical examination and treated with intravenous fluids, antibiotics, and insulin infusion. The point of care ultrasound (POCUS), as part of the primary survey, showed right atrium (RA)-right ventricle (RV) dilation and a D-shaped left ventricle, which was highly suspicious of pulmonary embolism and was later confirmed with computed tomography pulmonary angiogram (CTPA). The patient was successfully managed for pulmonary embolism, diabetic ketoacidosis, and lower respiratory tract infection.

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Acute pancreatitis results from any insult that leads to inflammation of the organ. Hypertriglyceridemia is one of the risk factors associated with acute pancreatitis. The typical presentation is abdominal pain, nausea, and vomiting. We present a unique case in which the patient's condition was further complicated by diabetic ketoacidosis. Consequently, he presented somnolent to the emergency room, providing a limited history only pertaining to generalized weakness and a skin rash. The patient was found to have hypertriglyceridemia-induced pancreatitis, which was appropriately managed in the intensive care unit. The skin lesions were diagnosed as xanthomas, which are associated with hypertriglyceridemia and acute pancreatitis secondary to hypertriglyceridemia. The patient was discharged on fibrate therapy, dietary counseling, and strict monitoring by his primary care physician. This unique case highlights the importance of recognizing dermatological conditions and their associated diseases to allow for prompt diagnosis and treatment in the face of limited history.

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Acute esophageal necrosis (AEN), also known as Gurvits syndrome, is a rare and potentially life-threatening condition characterized by necrosis of the esophageal mucosa. Acute esophageal necrosis is often associated with critical conditions, such as myocardial infarction, diabetic ketoacidosis (DKA), coronavirus disease 2019 (COVID-19) infection, or post-surgical complications. Patients typically present with nausea, hematemesis, acute dysphagia, and melena. Given its high mortality rate, prompt detection with upper endoscopy and early initiation of treatment are crucial. Most cases of Gurvits syndrome are managed conservatively using intravenous fluids, proton pump inhibitors, and antibiotics. Herein, we present a case series of AEN in the setting of DKA. Both patients received supportive care and were discharged in a stable condition.

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BACKGROUND: Hospitalization of patients with DKA creates a significant burden on the US healthcare system. While previous studies have identified multiple potential contributors, a comprehensive review of the factors leading to DKA readmissions within the US healthcare system has not been done. This scoping review aims to identify how access to care, treatment adherence, socioeconomic status, race, and ethnicity impact DKA readmission-related patient morbidity and mortality and contribute to the socioeconomic burden on the US healthcare system. Additionally, this study aims to integrate current recommendations to address this multifactorial issue, ultimately reducing the burden at both individual and organizational levels. METHODS: The PRISMA-SCR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) was used as a reference checklist throughout this study. The Arksey and O'Malley methodology was used as a framework to guide this review. The framework methodology consisted of five steps: (1) Identify research questions; (2) Search for relevant studies; (3) Selection of studies relevant to the research questions; (4) Chart the data; (5) Collate, summarize, and report the results. RESULTS: A total of 15 articles were retained for analysis. Among the various social factors identified, those related to sex/gender (n = 9) and age (n = 9) exhibited the highest frequency. Moreover, race and ethnicity (n = 8) was another recurrent factor that appeared in half of the studies. Economic factors were also identified in this study, with patient insurance type having the highest frequency (n = 11). Patient income had the second highest frequency (n = 6). Multiple studies identified a link between patients of a specific race/ethnicity and decreased access to treatment. Insufficient patient education around DKA treatment was noted to impact treatment accessibility. Certain recommendations for future directions were highlighted as recurrent themes across included studies and encompassed patient education, early identification of DKA risk factors, and the need for a multidisciplinary approach using community partners such as social workers and dieticians to decrease DKA readmission rates in diabetic patients. CONCLUSION: This study can inform future policy decisions to improve the accessibility, affordability, and quality of healthcare through evidence-based interventions for patients with DM following an episode of DKA.

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Acute pancreatitis is a common and potentially life-threatening condition. It is characterized by inflammation of the pancreas, most often leading to elevated levels of pancreatic enzymes in the blood. In a subset of patients, however, conventional biomarker levels may remain within the reference range. Such instances have the potential to create a diagnostic challenge for healthcare professionals and can lead to misdiagnosis or delayed treatment. This article presents the intriguing clinical scenario of acute pancreatitis with normal amylase and lipase, discusses factors that may lead to normoenzymatic presentation, and reminds clinicians of the diagnostic criteria for acute pancreatitis, which does not necessarily require elevated pancreatic enzymes.

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OBJECTIVE: Summarize the studies evaluating the use of subcutaneous (SQ) insulin in the management of diabetic ketoacidosis (DKA) in adults and pediatrics. DATA SOURCES: A PubMed literature search was conducted for articles published between 2000 and the end of May 2024 which contained the following terms in their title: (1) subcutaneous, glargine, or basal and (2) ketoa*. STUDY SELECTION AND DATA EXTRACTION: Review articles, guidelines, meta-analysis, commentaries, studies not related to the acute management of DKA, studies evaluating continuous SQ insulin, animal studies, if the time to DKA resolution was not clearly defined, and studies where basal insulin was administered greater than 6 hours after the insulin infusion was started were excluded. DATA SYNTHESIS: The electronic search identified 58 articles. Following the initial screening 38 articles were excluded and 3 were added after bibliography review. Of the 23 articles assessed for eligibility, 7 were excluded. Sixteen articles were included. Five studies compared SQ rapid/short-acting insulin and intravenous (IV) insulin infusions in adults, 4 compared SQ rapid/short-acting insulin and IV insulin infusions in pediatrics, 4 evaluated IV insulin infusions with or without SQ basal insulin in adults, and 3 evaluated IV insulin infusions with or without SQ basal insulin in pediatrics. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE: In comparison with IV insulin infusions, rapid/short-acting SQ insulin regimens were associated with reduced ICU admission rates, hospital length of stay, and hospitalization costs. IV insulin infusion regimens that included a single SQ basal insulin dose upon therapy initiation were associated with reduced concurrent IV insulin infusion durations. CONCLUSION: Studies reviewed suggest that SQ insulin regimens may be as effective and safe as IV insulin infusions in the management of DKA and are associated with the conservation of resources. Providers may refer to this review when establishing or modifying their DKA management protocols.

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

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

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One of the most widespread enzymopathies affecting human beings is glucose-6-phosphate dehydrogenase (G6PD) deficiency, which is brought on by inherited mutations in the X-linked gene. Red blood cells (RBCs) with a G6PD deficiency are more sensitive to oxidative assault and consequently to hemolysis. There are more than 200 known G6PD mutations, of which around half are polymorphic and thus prevalent in a variety of populations. We present a case of diabetic ketoacidosis (DKA), with severe hemolytic anemia and methemoglobinemia. The patient was admitted to the intensive care unit, treated for DKA, and received a blood transfusion. In addition, the patient presented with high methemoglobin levels and features of severe hemolytic anemia from the onset, which made the diagnostic consideration of G6PD highly likely. Accordingly, the patient was treated with several doses of ascorbic acid instead of methylene blue. In a nutshell, a patient with DKA who has hemolytic anemia has to have it properly evaluated and controlled. The link between methemoglobinemia, G6PD deficiency, and DKA should be recognized by medical professionals, particularly when oxygen saturation gaps are found.

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Diabetic ketoacidosis (DKA) is an extreme complication of diabetes mellitus characterized by hyperglycemia, metabolic acidosis, and ketonemia. Thyroid storm, a potentially life-threatening manifestation of thyrotoxicosis, presents with a multitude of symptoms, including hyperthermia, tachycardia, and altered mental status. Periodic paralysis can be precipitated by different metabolic disturbances, including thyrotoxicosis, and may lead to extreme episodes of muscle weakness and paralysis. We present a case of a 41-year-old female with a history of type 1 diabetes mellitus and hyperthyroidism, who presented with DKA complicated by an impending thyroid storm and likely periodic paralysis exacerbated due to hypokalemia. Prompt recognition and aggressive management of each component of this triad were essential for a positive patient outcome. This case highlights the importance of a broad and comprehensive approach to managing complex metabolic emergencies, particularly in patients with multiple comorbidities. Our patient presented to the emergency department with symptoms of severe vomiting, shortness of breath, and altered mental status. Laboratory investigations revealed metabolic derangements consistent with DKA, alongside impending thyrotoxicosis and hypokalemia-induced periodic paralysis. Management involved aggressive fluid resuscitation, insulin therapy, anti-thyroid medications, and potassium supplementation, with a multidisciplinary approach to stabilize the patient's condition.

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AIM: The effect of COVID-19 on the occurrence of type 1 diabetes and ketoacidosis in children and adolescent. METHODS: In this descriptive-analytical cross-sectional study, the records of all children and adolescents hospitalized due to type1 diabetes for two years ago and during the COVID-19 pandemic and its peaks were investigated (January 2018-2022). Also, the desired variables including the frequency of hospitalized patients (known and new cases), the frequency of DKA, the severity of DKA, the duration of discharge from DKA, age, body mass index, duration of hospitalization, clinical symptoms including cerebral edema, laboratory data and the total daily dose insulin required at the time of discharge were compared and statistically analyzed. RESULTS: Out of the 334 hospitalized T1DM patients, the rate of new T1DM patients was significantly higher (P = 0.006) during the pandemic. Clearly, there were more cases of DKA during the pandemic (P = 0.007). The higher severity of DKA (0.026) and the need for higher doses of insulin (P = 0.005) were also observed. The hospitalization rate was higher during the corona peaks, particularly peaks 1 and 4, compared to the non-peak days of COVID-19. CONCLUSION: The increase in the incidence of diabetes (new cases) in the pandemic can suggest the role of the COVID-19 virus as an igniter. Also, as a trigger for the higher incidence of DKA with higher severities, which is probably caused by more damage to the pancreatic beta cells and requires higher doses of insulin.

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Aim: This retrospective study aimed to use mixed (qualitative and quantitative) methods to evaluate the role of FSL in reducing hospital admissions due to all causes, HbA1c, and reported hypoglycaemic episodes in people with diabetes living in a socially deprived region of Northwest England. Methods: Data were collected retrospectively from previous consultations, which coincided with the 6th -week, 6th -month and annual review including blood tests, hospital admissions due to any cause and reported hypoglycaemia. Also, FSL assessment and satisfaction semi-structured questionnaire was done to assess the impact of FSL on diabetes management and quality of life. Mixed-effects models were used to assess glycaemic control and reductions in hospital admissions and reported hypoglycaemic episodes. Results: Just 127 patients met the inclusion criteria. A multivariate linear mixed model method that analyses HbA1c data longitudinally revealed mean differences (mmol/mol) between baseline and post-FSL measurements, estimated by restricted maximum likelihood method (REML) of 9.64 (six weeks), 7.68 (six months) and 7.58 (annual review); all with a corresponding p-value of < 0.0001. For DKA patients, the bootstrap method revealed a significant reduction in mean HbA1c of 25.5, 95% confidence interval (CI) [8.8, 42.6] mmol/mol. It is demonstrated that FSL use for one year resulted in 59% reduction in hospital admissions and 46% reduction in reported hypoglycaemic episodes. Conclusion: The use of FSL resulted in statistically significant reductions in hospital admissions, HbA1c and reported hypoglycaemic episodes among diabetics in a socially deprived Northwest region of England. These outcomes show a direct association with a higher questionnaire score. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-024-01424-4.

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INTRODUCTION: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). It occurs due to a decrease in the level of insulin and an increase in the level of glucose in the blood, which makes cells unable to use glucose as an energy source and begin to break fat into ketones; an overload of ketones levels in the blood can lead to DKA. The aim of the study is to assess awareness of DKA among diabetic patients and their caregivers in Makkah City, Saudi Arabia. METHODS: This study is a cross-sectional study collected through an online questionnaire of diabetic patients and their caregivers in Makkah City. A self-reported questionnaire designed in Arabic and English through the use of Google Forms, it distributed electronically via social media to the target population with the objectives of the survey. RESULTS: A total of 400 participants were included, 73% of them were males, while 27% were females. A 9% of the participants have been diagnosed with DKA. A high awareness level about DKA was found in 32.5% of participants, while 67.5% had a poor awareness level. Factors associated with a high level of awareness towards DKA are young age, being single, students and having a previous DKA diagnosis. CONCLUSION: Regarding our participants who have poor awareness of DKA, further education for diabetic patients and their caregivers about DKA is crucial to prevent life-threatening complications, and improve quality of life for these patients.