Household food insecurity and associations with hemoglobin A1c and acute diabetes-related complications in youth and young adults with type 1 diabetes: The SEARCH for Diabetes in Youth study.

AIMS: To examine, among youth and young adults (YYA) with type 1 diabetes (T1D), the association of household food insecurity (HFI) with: 1) HbA1c and 2) episodes of diabetic ketoacidosis (DKA) and severe hypoglycemia. METHODS: HFI was assessed using the U.S. Household Food Security Survey Module in SEARCH for Diabetes in Youth participants with T1D between 2016 and 2019. Linear and logistic regression models adjusted for age, diabetes duration, sex, race, ethnicity, clinic site, parent/participant education, household income, health insurance, and diabetes technology use. RESULTS: Of 1830 participants (mean age 20.8 ± 5.0 years, 70.0 % non-Hispanic White), HbA1c was collected for 1060 individuals (mean HbA1c 9.2 % ± 2.0 %). The prevalence of HFI was 16.4 %. In the past 12 months, 18.2 % and 9.9 % reported an episode of DKA or severe hypoglycemia, respectively. Compared to participants who were food secure, HFI was associated with a 0.33 % (95 % CI 0.003, 0.657) higher HbA1c level. Those with HFI had 1.58 (95 % CI 1.13, 2.21) times the adjusted odds of an episode of DKA and 1.53 (95 % CI 0.99, 2.37) times the adjusted odds of an episode of severe hypoglycemia as those without HFI. CONCLUSIONS: HFI is associated with higher HbA1c levels and increased odds of DKA in YYA with T1D.

Acute Diabetes Complications After Transition to a Value-Based Medication Benefit.

Importance: The association of value-based medication benefits with diabetes health outcomes is uncertain. Objective: To assess the association of a preventive drug list (PDL) value-based medication benefit with acute, preventable diabetes complications. Design, Setting, and Participants: This cohort study used a controlled interrupted time series design and analyzed data from a large, national, commercial health plan from January 1, 2004, through June 30, 2017, for patients with diabetes aged 12 to 64 years enrolled through employers that adopted PDLs (intervention group) and matched and weighted members with diabetes whose employers did not adopt PDLs (control group). All participants were continuously enrolled and analyzed for 1 year before and after the index date. Subgroup analysis assessed patients with diabetes living in lower-income and higher-income neighborhoods. Data analysis was performed between August 19, 2020, and December 1, 2023. Exposure: At the index date, intervention group members experienced employer-mandated enrollment in a PDL benefit that was added to their follow-up year health plan. This benefit reduced out-of-pocket costs for common cardiometabolic drugs, including noninsulin antidiabetic agents and insulin. Matched control group members continued to have cardiometabolic medications subject to deductibles or co-payments at follow-up. Main Outcomes and Measures: The primary outcome was acute, preventable diabetes complications (eg, bacterial infections, neurovascular events, acute coronary disease, and diabetic ketoacidosis) measured as complication days per 1000 members per year. Intermediate measures included the proportion of days covered by and higher use (mean of 1 or more 30-day fills per month) of antidiabetic agents. Results: The study 10 588 patients in the intervention group (55.2% male; mean [SD] age, 51.1 [10.1] years) and 690 075 patients in the control group (55.2% male; mean [SD] age, 51.1 [10.1] years) after matching and weighting. From baseline to follow-up, the proportion of days covered by noninsulin antidiabetic agents increased by 4.7% (95% CI, 3.2%-6.2%) in the PDL group and by 7.3% (95% CI, 5.1%-9.5%) among PDL members from lower-income areas compared with controls. Higher use of noninsulin antidiabetic agents increased by 11.3% (95% CI, 8.2%-14.5%) in the PDL group and by 15.2% (95% CI, 10.6%-19.8%) among members of the PDL group from lower-income areas compared with controls. The PDL group experienced an 8.4% relative reduction in complication days (95% CI, -13.9% to -2.8%; absolute reduction, -20.2 [95% CI, -34.3 to -6.2] per 1000 members per year) compared with controls from baseline to follow-up, while PDL members residing in lower-income areas had a 10.2% relative reduction (95% CI, -17.4% to -3.0%; absolute, -26.1 [95% CI, -45.8 to -6.5] per 1000 members per year). Conclusions and Relevance: In this cohort study, acute, preventable diabetes complication days decreased by 8.4% in the overall PDL group and by 10.2% among PDL members from lower-income areas compared with the control group. The results may support a strategy of incentivizing adoption of targeted cost-sharing reductions among commercially insured patients with diabetes and lower income to enhance health outcomes.

Prevalence, Cost, and Burden of Diabetic Ketoacidosis.

Diabetic ketoacidosis (DKA) is a life-threatening complication, which is most common in individuals with type 1 diabetes (T1D) and is a significant risk for morbidity and mortality, and it is an economic burden on individuals, health care systems, and payers. Younger children, minority ethnic groups, and those with limited insurance are at the greatest risk for presentation of DKA at T1D diagnosis. Although monitoring ketone levels is an essential part of acute illness management and for both early detection and prevention of a DKA episode, studies have reported poor adherence to ketone monitoring. Ketone monitoring is particularly important for patients treated with sodium glucose cotransporter 2 inhibitor (SGLT2i) medications, in which DKA can present with only moderately elevated glucose levels, referred to as euglycemic DKA (euDKA). A majority of people with T1D and many with type 2 diabetes (T2D), particularly those using insulin therapy, are using continuous glucose monitoring (CGM) as their preferred method for measurement and management of glycemia. These devices provide a continuous stream of glucose data that enables users to take immediate action to mitigate and/or prevent severe hyperglycemic or hypoglycemic events. An international consensus of leading diabetes experts has recommended the development of continuous ketone monitoring systems, ideally a system that combines CGM technology with measurement of 3-ß-OHB into a single sensor. In this narrative review of current literature, we report on the prevalence and burden of DKA, examine challenges to detecting and diagnosing this condition, and discuss a new monitoring option for DKA prevention.

Patient Demographics and Clinical Outcomes Among Type 1 Diabetes Patients Using Continuous Glucose Monitors: Data From T1D Exchange Real-World Observational Study.

BACKGROUND: The benefits of Continuous Glucose Monitoring (CGM) on glycemic management have been demonstrated in numerous studies; however, widespread uptake remians limited. The aim of this study was to provide real-world evidence of patient attributes and clinical outcomes associated with CGM use across clinics in the U.S. based T1D Exchange Quality Improvement (T1DX-QI) Collaborative. METHOD: We examined electronic Health Record data from eight endocrinology clinics participating in the T1DX-QI Collaborative during the years 2017-2019. RESULTS: Among 11,469 type 1 diabetes patients, 48% were CGM users. CGM use varied by race/ethnicity with Non-Hispanic Whites having higher rates of CGM use (50%) compared to Non-Hispanic Blacks (18%) or Hispanics (38%). Patients with private insurance were more likely to use CGM (57.2%) than those with public insurance (33.3%) including Medicaid or Medicare. CGM users had lower median HbA1c (7.7%) compared to nonusers (8.4%). Rates of diabetic ketoacidosis (DKA) and severe hypoglycemia were significantly higher in nonusers compared to CGM users. CONCLUSION: In this real-world study of patients in the T1DX-QI Collaborative, CGM users had better glycemic control and lower rates of DKA and severe hypoglycemia (SH) events, compared to nonusers; however, there were significant sociodemographic disparities in CGM use. Quality improvement and advocacy measures to promote widespread and equitable CGM uptake have the potential to improve clinical outcomes.

SGLT-2 inhibitors and euglycemic diabetic ketoacidosis/diabetic ketoacidosis in FAERS: a pharmacovigilance assessment.

AIMS: To investigate the main feature and the association between euglycemic diabetic ketoacidosis (euDKA) /diabetic ketoacidosis (DKA) and sodium-dependent glucose transporters 2 inhibitors (SGLT-2i) from the FDA adverse event reporting system (FAERS). METHODS: Cases of SGLT-2i-associated with euDKA/DKA were extracted from the FAERS database and compared with the reports for other hypoglycemia agents (ATC10 class). Disproportionality analyses used the reporting odds ratio (ROR) and information components (IC). The lower limit of the IC 95% credibility interval for IC > 0 is considered a reported signal, with at least 3 cases. RESULTS: A total of 10,195 cases of euDKA (n = 1680) and DKA (n = 8515) associated with SGLT-2i were identified from the FAERS. The SGLT-2i was associated with higher reporting of euDKA and DKA compared to other hypoglycemia agents (ROR = 16.69 [95% CI 14.89-18.70], IC = 3.27 [95% CI 2.91-3.66] for euDKA; ROR = 16.44 [95% CI 15.72-17.20], IC = 3.19 [95% CI 3.05-3.34] for DKA). In available data, the median onset time of euDKA/DKA was 31 days, and canagliflozin had the longest onset time (96.5 days for euDKA and 75 days for DKA) compared with dapagliflozin and empagliflozin (p < 0.05). Male patients predominate in euDKA (51.9%), and female patients predominate in DKA (53.7%). Most patients discontinue the treatment (95.5% for euDKA, 93.9% for DKA), and approximately 49.0% (n = 3658) of patients had symptomatic remission after discontinuation of SGLT-2i, and 2.3% (n = 173) of patients had no remission. About 75.6% (n = 6126) of patients need hospitalization after euDKA/DKA. CONCLUSIONS: Post-marketing data showed that SGLT-2i was significantly associated with higher reporting of euDKA/DKA. Although euDKA/DKA is rare, clinicians should be aware of SGLT-2i-associated euDKA/DKA events.

Psicologia e diabetes no Brasil: um mapeamento de profissionais e de suas ações / Psychology and diabetes in Brazil: the mapping of professionals and their practices / Psicología y diabetes en Brasil: un mapeo de los profesionales y sus acciones

Pouco se sabe sobre a atuação do psicólogo no Brasil junto a pessoas com Diabetes Mellitus. O objetivo desta pesquisa foi identificar os psicólogos brasileiros que trabalham com essa população e suas ações. Foram convidados a responder a um questionário online psicólogos que atuam ou atuaram junto a pessoas com diabetes. Participaram 79 psicólogos, principalmente da região Sudeste (59,5%). Todos declararam que haviam cursado pósgraduação. Na amostra, predominou o gênero feminino (89,9%), com idade entre 26 e 40 anos (46,8%). A maioria dos que atuam com diabetes declarou-se autônoma ou voluntária, e quase metade trabalhava menos do que 10 horas semanais. Entre aqueles que deixaram de trabalhar com diabetes, apenas uma minoria tinha vínculo empregatício. Além do trabalho com pessoas com diabetes, a maior parte declarou exercer outras atividades profissionais, como atendimentos clínicos em consultórios particulares, sugerindo que esta não é a atividade principal. Majoritariamente, os respondentes declararam não ter conhecimentos suficientes para o atendimento específico às pessoas com diabetes. Discute-se a qualidade da formação profissional dos psicólogos no Brasil, a necessidade de aprimoramento em relação à atuação com pessoas com diabetes e as condições de trabalho.(AU)

Little is known about the practice of psychologists in Brazil caring for people with Diabetes Mellitus. The aim of this research was to identify the Brazilian psychologists who work with this population and describe their actions. Psychologists who work or have worked with people diagnosed with diabetes were invited to answer an online questionnaire. The 79 participants lived mainly in the Southeast Region (59.5%). All of them declared to have a graduate degree, most were female (89.9%), aged 26 to 40 years (46.8%). Most of those working with diabetes declared to be autonomous or voluntary, and almost half had a workload of less than 10 hours a week. Among those who stopped working with diabetes, only a minority had a formal employment contract. In addition, most of them stated that they had other professional activities related to clinical care in private offices, suggesting that working with diabetes is not their main activity. Mostly, respondents stated that they did not have enough knowledge to care for people with diabetes. The quality of professional education of psychologists in Brazil, the need for specific improvement in labor relations and conditions were discussed.(AU)

Son escasas las informaciones del trabajo de los psicólogos en Brasil con las personas con Diabetes Mellitus. El objetivo de este estudio fue identificar los psicólogos brasileños que trabajan con esta población y describir sus acciones. Se invitó a psicólogos que trabajan o hayan trabajado con personas con diabetes a responder un cuestionario en línea. Participaron 79 psicólogos, principalmente de la región Sureste de Brasil (59,5%). Todos declararon tener posgrado. En la muestra hubo una mayor prevalencia del género femenino (89,9%), de edades de entre 26 y 40 años (46,8%). La mayoría de los que trabajan con personas con diabetes se declararon autónomos o voluntarios, y casi la mitad trabajaba menos de 10 horas a la semana. Entre los que dejaron de trabajar con las personas con diabetes, solo una minoría tenía una relación laboral. Además de trabajar con personas con diabetes, la mayoría afirmó tener otras actividades profesionales, como la atención clínica en consultorios privados, lo que sugiere que esta no es su actividad principal. La mayoría de los encuestados afirmaron que no tenían los conocimientos suficientes para atender específicamente a las personas con diabetes. Se discuten la calidad de la formación profesional de los psicólogos en Brasil, la necesidad de mejora en relación con el trabajo con personas con diabetes y las condiciones laborales.(AU)

Assessment of Awareness and Practice toward Diabetic Ketoacidosis among Diabetic Patients and Their Caregivers in Hail Region.

Introduction: Diabetic ketoacidosis (DKA) is one of the most serious consequences of diabetes. This serious issue occurs when the body cannot use the glucose as a source of energy because of a lack in the level of insulin which as consequence will lead to an increased level of glucose resulting in DKA. Aim: The goal of this study was to increase diabetic patients' and caregivers' awareness and practice of DKA at the community level in Hail City, Saudi Arabia, in 2022. The assessment of people's awareness and knowledge on DKA is importance to support any subsequent actions. Subjects and Methods. This is a cross-sectional study conducted in Hail City, Saudi Arabia, among diabetic patients and carers. A self-administered questionnaire in Arabic was given to the target demographic via an internet survey. The questionnaire includes basic demographic data (i.e., age, gender, and marital status), clinical characteristics of the diabetic patients, and a set of questionnaires to assess the awareness and practice of the subjects regarding DKA. Results: 348 surveys were received (51.1% males vs. 48.9% females). A total of 29.9% of patients have been diagnosed with DKA. Out of a possible 14 points, the average awareness score was 5.22 (SD 3.39). Poor awareness levels had been found in nearly 70% of the subjects, 23.6% were moderate, and only 8.6% were considered good. Factors associated with increased awareness were being younger, female gender, unmarried, students, type 1 DM, DKA diagnosis, and having good information about DKA. Conclusion: The awareness of diabetic patients and their caregivers toward DKA was unsatisfactory. Younger female patients who were single and who had been diagnosed with DKA tend to be more aware of DKA as compared to other subjects. There is a compelling reason to bridge the gaps in the awareness of DKA among the diabetic population and their caregivers in our region.

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 (ß = -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.

Development and Validation of the Transition Readiness Assessment Instrument in Type 1 Diabetes "On TRAck".

OBJECTIVES: Transition to adult care is challenging for youth with type 1 diabetes (T1D) and their caregivers. We have developed the diabetes-specific "On TRAck" transition readiness scale, and in this study we assess its reliability and validity compared with TRANSITION-Q, a generic transition readiness questionnaire. METHODS: We systematically created 3 versions of On TRAck: adolescent, parent and health-care provider (HCP) versions (for case managers and physicians). Among adolescents 13 to 18 years of age with T1D at a single academic centre, we conducted an exploratory factor analysis and assessed interrater agreement, internal consistency and relationship with age; recent glycated hemoglobin (A1C); and recent diabetic ketoacidosis (DKA) with On TRAck and TRANSITION-Q. RESULTS: One hundred fifteen adolescents (aged 15.8±1.6 years and diabetes duration 6.7±4.1 years), their caregivers and diabetes HCPs participated. The final 24-item adolescent and parent scales (with 3 subscales: "Self-efficacy," "Autonomy" and "Support & maturity") and the 3-item HCP version had a Cronbach's alpha of 0.86 to 0.93. Adolescent scores correlated with parents (r=0.64), case managers (r=0.39) and physicians (r=0.28). Mean adolescent score was 190.3±27.1 points out of 240. Adolescent scores were 3.4 points higher per year of age (p=0.03) and 4.4 points higher for every 1% lower A1C (p=0.01), but were not associated with DKA. TRANSITION-Q was associated with age. On TRAck HCP scores were associated with adolescent's age, A1C and DKA. CONCLUSIONS: On TRAck represents a new psychometrically comprehensive diabetes-specific scale that can be used in adolescent diabetes clinics for measuring transition readiness. It is a multidimensional instrument with ease of use and high reliability scores.

Assessment of Insulin Infusion Requirements in COVID-19-Infected Patients With Diabetic Ketoacidosis.

BACKGROUND/OBJECTIVE: Coronavirus disease 2019 (COVID-19) is thought to contribute to diabetic ketoacidosis (DKA) and worse outcomes in patients with diabetes. This study compared the cumulative insulin dose required to achieve DKA resolution in the intensive care unit among patients with type 2 diabetes and COVID-19 infection versus without COVID-19 infection. METHODS: This retrospective cohort study evaluated 100 patients-50 patients with COVID-19 in cohort 1 and 50 patients without COVID-19 in cohort 2-treated with insulin infusions for DKA at a tertiary care teaching hospital. The primary outcome was to compare the cumulative insulin dose required to achieve DKA resolution in each cohort. The secondary outcomes included time to DKA resolution, mean insulin infusion rate, and mean weight-based cumulative insulin infusion dose required to achieve DKA resolution. All endpoints were adjusted for confounders. RESULTS: The mean cumulative insulin dose was 190.3 units in cohort 1 versus 116.4 units in cohort 2 (P = .0038). Patients receiving steroids had a mean time to DKA resolution of 35.9 hours in cohort 1 versus 15.6 hours in cohort 2 (P = .0014). In cohort 1 versus cohort 2, the mean insulin infusion rate was 7.1 units/hour versus 5.3 units/hour (P = .0025), whereas the mean weight-based cumulative insulin infusion dose was 2.1 units/kg versus 1.5 units/kg (P = .0437), respectively. CONCLUSION: COVID-19-infected patients required a significantly larger cumulative insulin dose, longer time to DKA resolution, higher insulin infusion rate, and higher weight-based insulin infusion dose to achieve DKA resolution versus non-COVID-19-infected patients with type 2 diabetes.

Friedreich's Ataxia related Diabetes: Epidemiology and management practices.

AIMS: Friedreich's Ataxia (FRDA) is a progressive neuromuscular disorder typically caused by GAA triplet repeat expansions in both frataxin gene alleles. FRDA can be complicated by diabetes mellitus (DM). The objective of this study was to describe the prevalence of, risk factors for, and management practices of FRDA-related DM. METHODS: FACOMS, a prospective, multi-site natural history study, includes 1,104 individuals. Extracted data included the presence of DM and other co-morbidities, genetic diagnosis, and markers of disease severity. We performed detailed medical record review and a survey for the subset of individuals with FRDA-related DM followed at one FACOMS site, Children's Hospital of Philadelphia. RESULTS: FRDA-related DM was reported by 8.7% of individuals. Age, severe disease, and FRDA cardiac complications were positively associated with DM risk. FRDA-related DM was generally well-controlled, as reflected by HbA1c, though diabetic ketoacidosis did occur. Insulin is the mainstay of treatment (64-74% overall); in adults, metformin use was common and newer glucose-lowering agents were used rarely. CONCLUSIONS: Clinical factors identify individuals at increased risk for FRDA-related DM. Future studies should test strategies for FRDA-related DM screening and management, in particular the potential role for novel glucose-lowering therapies in preventing or delaying FRDA-related cardiac disease.

Impact of Payer Status on Hospitalization Outcomes in Pediatric Diabetic Ketoacidosis.

BACKGROUND: Diabetic ketoacidosis (DKA) is a life-threatening complication seen in patients suffering from type I diabetes (T1D) with a cost burden of over $5 billion in the U.S. annually. Often, children are first diagnosed with T1D when they present with DKA. Our study examines the impact of payer type on pediatric DKA. We hypothesize that Medicaid payer type negatively impacts costs and care outcomes in pediatric patients with DKA as compared to private payers. METHODS: We utilized the Agency for Healthcare Research and Quality (AHRQ) 2012 Kids' Inpatient Database (KID) for analysis. Our inclusion criterion included All Patient Refined Diagnosis Related Groups (APR-DRG) coding for T1D DKA admissions with a uniform severity and an identifiable payer of Medicaid or private insurance. RESULTS: 27,241 weighted and severity-adjusted discharges met criterion (51.6 percent Medicaid payers, 48.4 percent private). Comparing Medicaid vs. private payer status, we found: length of stay (2.24 days vs. 2.09), number of procedures received (0.13 vs. 0.12), and total charges ($16,449 vs. $16,107). Limiting analysis to a crude measure of bottom quartile income showed: length of stay (2.26 days vs. 2.14), number of procedures received (0.12 vs. 0.12), and total charges ($15,393 vs. $14,063). CONCLUSIONS: Children admitted in DKA and covered by Medicaid had longer hospitalizations, more procedures performed, and higher total costs of care. Even after controlling for socioeconomic status, similar effects persisted. Further evaluations are warranted to reveal the causative factors behind these correlative findings which suggest DKA patients receive different care depending on their payer status.

A study of diabetic ketoacidosis in the pregnant population in the United Kingdom: Investigating the incidence, aetiology, management and outcomes.

AIM: To estimate the incidence of diabetic ketoacidosis (DKA) among pregnant women, describe its clinical features, management and outcomes and identify the risk factors for the condition. METHODS: A national population-based case-control study was conducted in the UK using the UK Obstetric Surveillance System between April 2019 and September 2020 including all pregnant women with DKA irrespective of the level of blood glucose. The incidence rate of DKA in pregnancy was estimated. A case-control analysis limited to women with type 1 diabetes was performed comparing characteristics of women with DKA (cases) to those of women whose pregnancies were not complicated by DKA (controls). RESULTS: In all, 82 women were identified with DKA in pregnancy; 6.3 per 100,000 maternities (95% CI: 5.0-7.9). No maternal deaths occurred, but perinatal mortality was 12/73 (16%) with 11 stillbirths and one neonatal death. DKA episodes mostly occurred in women with type 1 diabetes (85%) and in the 3rd trimester of pregnancy (71%). Episodes were mainly precipitated by infection (21%), vomiting (21%), steroid therapy (13%) and medication errors (10%). Fifteen percent of women had more than one episode of DKA during their pregnancy. Risk factors associated with DKA among women with type 1 diabetes identified through the case-control analysis were the woman and/or partner not being in a paid employment and having at least one microvascular complication of diabetes before pregnancy. CONCLUSION: DKA in pregnancy was associated with high perinatal mortality and was linked with factors related to socio-economic deprivation, mental health problems and long-term difficulties with glycaemic control.

Diabetic ketoacidosis presentations in a low socio-economic area: are services suitable?

BACKGROUND: Diabetic ketoacidosis causes a significant number of hospitalisations worldwide, with rates tending to increase with remoteness and socioeconomic disadvantage. Our study aimed to explore healthcare professionals' perceptions of factors affecting presentation of people with type 1 diabetes in a low socioeconomic area of Queensland, Australia. METHODS: This was a qualitative study. Individual semi-structured face-to-face or telephone interviews were completed with patients with type 1 diabetes who had presented in diabetic ketoacidosis, and healthcare professionals who have experience in related care. Data were analysed using Gibbs's framework of thematic analysis. RESULTS: Four patients with type 1 diabetes and 18 healthcare professionals were interviewed. Restricted access was identified as a factor contributing to diabetic ketoacidosis and delayed presentation, with ketone testing supplies, continuous glucose monitoring technology and transport considered barriers. Many of these factors were arguably preventable. Opportunities to improve the care available to patients with type 1 diabetes were detailed, with particularly strong support for dedicated out of hours telephone help lines for adults with type 1 diabetes. CONCLUSIONS: Gaps in support for patient self-care to avoid diabetic ketoacidosis presentations and prevent late presentation of diabetic ketoacidosis revealed by this study require service reconfiguration to support care delivery. Until change is made, people with type 1 diabetes will continue to make both avoidable and delayed, acutely unwell, presentations to Emergency Departments.

Comparing patient characteristics and outcomes in type 1 versus type 2 diabetes with diabetic ketoacidosis: a review and a propensity-matched nationwide analysis.

Diabetic ketoacidosis (DKA) is a known complication of patients with type 1 diabetes mellitus (T1DM), but less common in type 2 diabetes mellitus (T2DM). The aim of this study was to compare the outcomes of patients admitted to the hospital with DKA in T1DM versus T2DM. This was a population-based, retrospective, cohort study using data from the Nationwide Inpatient Sample. The group of patients hospitalized for DKA was divided based on a secondary diagnosis of either T1DM or T2DM. The primary outcome was inpatient mortality, and the secondary outcomes were rate of complications, length of hospital stay (LOS) and total hospital charge (THC). The inpatient mortality for DKA was 0.27% (650 patients). In T2DM, the adjusted OR (aOR) for mortality was 2.13 (95% CI 1.38 to 3.28, p=0.001) with adjusted increase in mean THC of $6035 (95% CI 4420 to 7652, p<0.001) and mean LOS of 0.5 day (95% CI 0.3 to 0.6, p<0.001) compared with T1DM. Patients with T2DM had significantly higher odds of having septic shock (aOR 2.02, 95% CI 1.160 to 3.524, p=0.013) compared with T1DM. T2DM was associated with higher inpatient mortality, septic shock and increase in healthcare utilization costs compared with T1DM.

Mapping the role of pH-adjusted potassium in diabetic ketoacidosis: Hypokalemia and the patient outcomes.

BACKGROUND: Incidence of hypokalemia during the management of diabetic ketoacidosis (DKA) is high despite detailed potassium replacement guidelines in its treatment. AIM: We aimed to find the role of pH-adjusted potassium (pHK ) in the development of hypokalemia, and their mutual impact on patient outcomes during DKA management. METHODOLOGY: Adult DKA patient's admission data of preceding 3 years (2015-2017) were retrospectively clerked. Outcomes of interest were time to develop hypokalemia and to terminate emergency department (ED) care (hours), severity of hypokalemia and hospitalisation length (days). Linear regression was used to determine significant associations/predictors. RESULTS: The study was concluded on 85 patients. Hypokalemia was observed in nearly 3/4th of all admissions and occurred by the time of ED care termination. Each 1 mmol/L increase in pHK significantly (a) reduced the degree of hypokalemia by 0.07 mmol/L, (b) delayed time to develop hypokalemia by 4.58 hours, (c) and reduced the ED care time by 1.28 hours. Arterial pH was the other factor significantly delaying time to develop hypokalemia (36.25 hours) and facilitating early discharge from ED (13.86 hours). Moreover, each 1 mmol/L reduction in the degree of hypokalemia increased hospitalisation length by 1.86 days. Though significant, acute kidney injury negligibly increased hospitalisation length by 0.01 days. CONCLUSION: pH-adjusted potassium shall be used as a marker for hypokalemia and to initiate potassium replacement instead of measured serum potassium in DKA. Utilising pHK will help to avoid hypokalemia, reduce its severity and shorten ED care which will subsequently reduce hospitalisation length. We expect pHK to improve pharmacoeconomics in the future.

Prevention of diabetic ketoacidosis at diagnosis of type 1 diabetes: Are certified athletic trainers an untapped resource?

Aims: To assess the knowledge of certified athletic trainers (ATs) on the presenting signs and symptoms of type 1 diabetes (T1D). Methods: We conducted a 31-question survey of secondary school ATs recruited from the National Athletic Training Association that established demographic information, knowledge of presenting signs and symptoms of T1D, and previous personal or professional exposure to individuals with T1D. We report descriptive statistics and univariate analyses evaluating the characteristics associated with T1D knowledge. We then report a multivariable model incorporating age, gender, years of experience and education level with T1D knowledge as the dependent variable. Results: 128 participants (92f:34m) met inclusion criteria and were included in this study. The majority of participants correctly identified frequent thirst (96.1%, n = 123) and frequent urination (85.9%, n = 110) as common presenting signs and symptoms of T1D, while fewer participants identified weight gain (58.6%, n = 75) or joint pain (39.1%, n = 50) as incorrect presenting signs and symptoms of T1D. Participants with over ten years of experience or previous exposure to individuals with T1D had increased T1D knowledge. Participants with advanced education (Master's degree or Doctorate) had no statistically significant difference in T1D knowledge compared to those with a Bachelor's degree. The only factor that demonstrated a significant association with T1D knowledge on multivariable analysis was the female gender. Conclusions: Educational awareness campaigns of T1D symptoms to reduce the rate of DKA at diagnosis of T1D have never included ATs. This study illustrates the importance of targeting future educational interventions on newly trained ATs.