Search

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. [ABSTRACT FROM AUTHOR]

This column on translating research into practice is crafted to offer advanced practice registered nurses an analysis of current research topics that hold practical relevance for emergency care settings. The article titled "Using Artificial Intelligence to Predict Adverse Outcomes in Emergency Department PatientsWith Hyperglycemic Crises in Real Time," authored by C. Hsu et al. (2023), investigates through a randomized control trial, the effectiveness of artificial intelligence as a practical tool compared with the traditional predicting hyperglycemic crisis death score to clinically predict adverse outcomes in individuals presenting to the emergency department with hyperglycemic crises. The results are discussed in the context of averting adverse outcomes associated with sepsis/septic shock, intensive care unit admission, and all-cause mortality within a 1-month time frame. [ABSTRACT FROM AUTHOR]

Diabetic ketoacidosis (DKA) is a serious complication that affects millions of individuals globally and presents significant health complications. Hyperchloremia, an electrolyte imbalance characterized by high levels of chloride in the blood, may result in gastrointestinal problems, kidney damage, and even death, especially in DKA patients. Early detection and treatment of hyperchloremia are of utmost importance in the management of DKA. This study explores the potential of the bootstrap aggregating ensemble with random subspaces machine learning approach to predict the occurrence of hyperchloremia, providing a basis for early intervention and improved patient outcomes. We tested our approach with the retrospective MIMIC-III database containing 1177 DKA patients and compared it with previous studies with an area under the curve (AUC) of 100%. Our approach showed significant performance outperforming other methods. The combination of this approach may enhance the early detection and timely intervention of hyperchloremia cases, ultimately leading to improved patient outcomes and a more effective management of DKA-associated complications. Our work aims to contribute to the development of decision support tools for healthcare professionals, assisting them in making informed decisions for DKA patients, with a focus on preventing and managing hyperchloremia.

Introduction-Diabetic ketoacidosis (DKA) is one of the most serious complications of diabetes mellitus (DM). Precise early prediction of infection and its severity in diabetic patients serves an important role in improving infection control and prognosis. Procalcitonin (PCT), a marker of the inflammatory response during infections, can be elevated by diabetic ketoacidosis (DKA). Early detection and treatment of infections are key elements to improved patient outcomes, and as such, empiric antibiotics are frequently prescribed to patients who present with DKA. Aims and objectives- Study of procalcitonin as a early marker of sepsis in patients of DKA admitted in SMS Hospital. Methodology-Hospital based cross sectional study in department of Medicine SMS MEDICAL COLLEGE Jaipur on 60 cases of DKA-20 cases positive bacterial culture (Proven Bacterial Infection group -PBI) and 40 cases of negative blood culture (without Proven Bacterial Infection group – without PBI). Results- The two groups (PBI and without PBI ) were comparable on parameter of TLC, fever intensity (measured by temperature) at time of admission, however TLC and Temperature at 2nd day were significantly higher in PBI group as compared to without PBI group at 2nd day of admission. However the two groups have significant differences on quantitative measurement of serum PCT at time of admission as well at at 2nd day of admission.(PBI group have significantly higher PCT than without PBI group. Conclusion- PCT can serve as early marker of sepsis in DKA and by use of PCT as a sepsis marker, reduction of antibiotic misuse may be possible. Prospective studies will be needed to confirm the diagnostic thresholds of PCT marker. [ABSTRACT FROM AUTHOR]

The aim of the study was to determine the frequency of different DKA precipitating factors and the initial clinical feature at the time of admission. This descriptive prospective cross sectional study based on purposive sampling, was conducted in the medical ward of Nangarhar University Teaching Hospital from 28/12/2019 to 10/2/2021 including both female and male patients of any type of DM with DKA at the time of admission. After thorough history taking, physical examination and investigations such as lab, radiological and ECG, precipitating factors were found out. All 72 patients had DKA. 52 (72.2%) patients were female and 20 (27.8%) were male. 11 patients (15.3%) were type 1 and 61 (84.7%) were type 2 DM. The median age of the patients was 50; median weight was 61; median systolic blood pressure 120 mmHg and the median FBS was 272 mg/dl at the time of admission. Nausea/vomiting (49, 68.1%), tachycardia (46, 63.9%), dry tongue (42, 58.3%), and epigastric tenderness (40, 55.6%), were the most frequent clinical presentation. Infection specifically UTI (68.1%) was the most frequent precipitating factor followed by IHD (11.1%) and insulin withdrawal (5.6%) respectively. UTI distribution across gender (52.8% vs 15.2% two sided P value 0.14 CI 0.95), DM type (58.33% T2DM vs 9.72% in T1DM out of 68% two sided P value 0.7 CI 0.95) and age category was different, however not significant due to the small sample size where the same story occurred with FBS difference across gender (two sided P value 0.035, CI 95%). Infection especially UTI, ischemic heart disease and insulin withdrawal are the leading precipitating factors; and clinical presentation of gastrointestinal tract (nausea/vomiting), dehydration (dry tongue), cardiovascular system and urinary tract are the most prevalent in DKA patients at the time of admission in Nangarhar Afghanistan

This paper focuses on hyperglycemic hyperosmolar syndrome (HHS), a unique hyperglycemic state requiring divergent diagnosis and treatment approaches from diabetic ketoacidosis (DKA) despite some shared characteristics. We introduce the mnemonic DI-FF-ER-EN-CE-S to encapsulate unique HHS management and complications. 'DI' emphasizes the need to delay and decrease initial insulin therapy until serum glucose decline is managed by fluid resuscitation alone. 'FF' stresses the importance of double fluid replacement compared to DKA due to severe dehydration and 'ER' electrolyte replacement due to profound losses and imbalances. 'EN' denotes the potential for encephalopathy and the requirement for a controlled serum osmolality reduction. 'CE' indicates cerebral edema, a rare complication in HHS. 'S' signifies systemic multiorgan failure. We categorize the associated risks into three mnemonic groups: the 3Rs (renal failure, respiratory distress, rhabdomyolysis), the 3Hs (heart failure, hypercoagulation, hyperthermia), and AP (arrhythmias, pancreatitis) to facilitate awareness and screening of HHS. [ABSTRACT FROM AUTHOR]

The publication is devoted to the study of the frequency of various factors provoking the development of diabetic ketoacidosis (DKA), and the initial clinical signs at the time of admission. Diabetic ketoacidosis (DKA) is known to be one of the life-threatening acute complications of diabetes mellitus (DM), resulting from a decrease in insulin levels, a decrease in glucose intake by peripheral tissues and an increase in glucose production. The annual incidence of DKA ranges from 4.6-8 episodes per thousand diabetic patients. DKA most often occurs in type 1 diabetes mellitus (DM1), but also affects patients with type 2 diabetes in the presence of provoking factors. We conducted a descriptive prospective cross-sectional study based on a targeted sample. The study was conducted in the medical department of the Nangarhar University Teaching Hospital from 12/28/2019 to 10/22/2021, including both female and male patients with any type of DM with DKA at the time of admission. [ABSTRACT FROM AUTHOR]

Hypertriglyceridemia is a complication of diabetic ketoacidosis (DKA) secondary to insulin deficiency inhibiting lipoprotein lipase and increasing lipolysis, but it is rare in children. A 7-year-old boy with history of autism spectrum disorder (ASD) presented with abdominal pain, vomiting, and "heavy breathing." Initial laboratory tests revealed pH 6.87 and glucose 385 mg/dL (21.4 mmol/L), consistent with new-onset diabetes and DKA. His blood appeared lipemic; triglycerides were 17 675 mg/dL (199.6 mmol/L) with normal lipase (10 units/L). He received intravenous insulin and DKA resolved within 24 hours. Insulin infusion continued through day 6 for management of hypertriglyceridemia; triglycerides decreased to 1290 mg/dL (14.6 mmol/L) during this period. He never developed pancreatitis (lipase peaked at 68 units/L) or required plasmapheresis. With his ASD history, he had a restrictive diet high in saturated fat, which included up to 30 breakfast sausages daily. His triglycerides normalized after discharge. Severe hypertriglyceridemia can complicate DKA in newly diagnosed type 1 diabetes (T1D). Hypertriglyceridemia can be safely managed with insulin infusion in the absence of end-organ dysfunction. This complication should be considered in patients with DKA at diagnosis of T1D. [ABSTRACT FROM AUTHOR]

We report a case of 77-year-old woman with fulminant type 1 diabetes (T1D) who developed diabetic ketoacidosis (DKA) after the second dose of SARS-CoV-2 vaccine tozinameran. The patient had been diagnosed as having T1D associated with an immune-related adverse event caused by pembrolizumab at the age of 75. After the second dose of tozinameran, she developed DKA and needed intravenous insulin infusion and mechanical ventilation. Although the direct causal relationship between the vaccination and the DKA episode could not be proven in this case, published literatures had suggested the possibility of developing DKA after SARS-CoV-2 vaccination in patients with T1D. As the magnitude of the risk of the combination of the known adverse drug reactions of SARS-CoV-2 mRNA vaccine and T1D patients' vulnerability to sick-day conditions is not yet thoroughly assessed, future studies such as a non-interventional study with adequate sample size would be required to address this issue. [ABSTRACT FROM AUTHOR]

The lung adenocarcinoma is one subtype of non-small cell lung cancer (NSCLC), its incidence keeps increasing in China, accounting for 40%-55% of the total number of lung cancers. The emergence of immune checkpoint inhibitors (ICIs) has changed the treatment prospects for patients with NSCLC. Studies have shown that monotherapy or combination therapy with ICIs resulted in a significantly higher 5-year survival rates for patients with advanced NSCLC. With the increased use of ICIs, immunerelated adverse events are frequent. Diabetic ketoacidosis caused by ICIs was rarely reported, which should arouse the attention of physicians and pharmacists. Here we report a male patient with lung adenocarcinoma who developed multiple vomiting and fatigue after 4 cycles of treatments of chemotherapy combined with immunotherapy (pemetrexed disodium+nedaplatin+bevacizumab+camrelizumab). Blood test on admission： the fasting blood glucose> 60 mmol/L, ketone body 1.96 mmol/L, fasting insulin 92.7 μU/mL, fasting Cpeptide 0.28 ng/mL,β -hydroxybutyric acid 1.20 mmol/L, amylase 148 U/L, blood gas analysis (no oxygen) pH=7.17. The patient was diagnosed as diabetes ketoacidosis. The ketone body turned negative after treating with fluid infusion and insulin, and correction of electrolyte disorder and acidosis. After discontinuation of camrelizumab and continued insulin therapy, the blood glucose was controlled three weeks later. [ABSTRACT FROM AUTHOR]

This paper focuses on hyperglycemic hyperosmolar syndrome (HHS), a unique hyperglycemic state requiring divergent diagnosis and treatment approaches from diabetic ketoacidosis (DKA) despite some shared characteristics. We introduce the mnemonic DI-FF-ER-EN-CE-S to encapsulate unique HHS management and complications. ‘DI’ emphasizes the need to delay and decrease initial insulin therapy until serum glucose decline is managed by fluid resuscitation alone. ‘FF’ stresses the importance of double fluid replacement compared to DKA due to severe dehydration and ‘ER’ electrolyte replacement due to profound losses and imbalances. ‘EN’ denotes the potential for encephalopathy and the requirement for a controlled serum osmolality reduction. ‘CE’ indicates cerebral edema, a rare complication in HHS. ‘S’ signifies systemic multiorgan failure. We categorize the associated risks into three mnemonic groups: the 3Rs (renal failure, respiratory distress, rhabdomyolysis), the 3Hs (heart failure, hypercoagulation, hyperthermia), and AP (arrhythmias, pancreatitis) to facilitate awareness and screening of HHS.

Background: Considering the roles of 25-hydroxyvitamin D (25OHD) in glucose homeostasis and immune modulation, vitamin D deficiency may be related to the development of type 1 diabetes (T1DM) and diabetic ketoacidosis (DKA). We evaluated the total, free, bioavailable 25OHD levels and vitamin D binding protein (VDBP) levels and genotypes between T1DM patients and controls. Methods: This retrospective, cross-sectional study included 84 children with T1DM (38 boys and 46 girls, 8.0 ± 3.6 years) and 1:1 age- and sex-matched healthy controls. A multiplex liquid chromatography-tandem mass spectrometry-based assay was used to simultaneously measure vitamin D metabolites. Results: Patients with T1DM had lower levels of total 25OHD (16.3 ± 5.1 vs. 19.9 ± 6.5 ng/mL, P< 0.001) and VDBP (146.0 ± 27.8 vs. 224.9 ± 36.1 µg/mL, P = 0.001), but higher free 25OHD (8.0 ± 2.5 vs. 6.5 ± 2.3 pg/mL, P< 0.001) than controls. Patients who presented with DKA had lower levels of 25OHD in the total (15.0 ± 4.6 vs. 17.6 ± 5.2 ng/mL, P = 0.020), free (7.5 ± 2.6 vs. 8.4 ± 2.4 pg/mL, P = 0.059), and bioavailable (2.3 ± 0.9 vs. 2.8 ± 0.8 ng/mL, P = 0.014) forms than those without DKA at the T1DM diagnosis. The lower the total, free, and bioavailable 25OHD levels at diagnosis, the lower the pH and HCO3-. The proportions of the VDBP genotypes did not differ between the patients and controls. Conclusion: Patients with T1DM had higher levels of free 25OHD than healthy children, despite lower levels of total 25OHD. However, patients with DKA exhibited lower levels of bioavailable 25OHD than those without DKA at the T1DM diagnosis. The lower the concentrations of free and bioavailable 25OHD, the more severe the acidosis at the initial T1DM presentation. [ABSTRACT FROM AUTHOR]

In a cohort of 2303 children with type 1 diabetes (T1D), we found that non-English speaking status (HR 2.82, 95% CI 1.54-5.18) and public insurance (HR 1.48, 95% CI 1.07-2.05) were associated with an increased risk of incident albuminuria, after adjusting for T1D-related variables (age, hemoglobin A1c, diabetic ketoacidosis episodes with acute kidney injury)., Competing Interests: Declaration of competing interest The authors have no relevant conflict of interests to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This review discusses the challenges and controversies in the treatment of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). Key areas include the selection of intravenous (IV) fluids, insulin therapy, strategies for preventing and monitoring cerebral edema (CE) by managing hyperglycemia overcorrection, electrolyte replacement, timing of nutrition, use of IV sodium bicarbonate, and airway management in critically ill DKA patients. Isotonic normal saline remains the standard for initial fluid resuscitation, though balanced solutions have been shown to have faster DKA resolution. Current guidelines recommend using continuous IV insulin for DKA management after fluid status has been restored potassium levels have been achieved and subcutaneous (SQ) insulin is started only after the resolution of metabolic acidosis. In comparison, the British guidelines recommend using SQ insulin glargine along with continuous regular IV insulin, which has shown faster DKA resolution and shorter hospital stays compared to continuous IV insulin alone. Although rare, rapid overcorrection of hyperglycemia with fluids and insulin can lead to CE, seizures, and death. Clinicians should be aware of risk factors and preventive strategies for CE. DKA frequently involves multiple electrolyte abnormalities, such as hypokalemia, hypophosphatemia, and hypomagnesemia and regular monitoring is essential for DKA management. Early initiation of oral nutrition has been shown to reduce intensive care unit and overall hospital length of stay. For impending respiratory failure, Bilevel positive airway pressure is not recommended due to aspiration risks. Instead, intubation and mechanical ventilation, with monitoring and management of acid-base and fluid status, are recommended. The use of sodium bicarbonate is discouraged due to the potential for worsening ketosis, hypokalemia, and risk of CE. However, IV sodium bicarbonate can be considered if the serum pH falls below 6.9, or when serum pH is less than 7.2 and/or serum bicarbonate levels are below 10 mEq/L, pre-and post-intubation, to prevent metabolic acidosis and hemodynamic collapse that occurs from apnea during intubation. Managing DKA and HHS in critically ill patients includes using balanced IV fluid solutions to restore volume status, followed by continuous IV insulin, early use of SQ glargine insulin, electrolyte replacement, and monitoring, CE preventive strategies by avoiding hyperglycemia overcorrection, early nutritional support, and appropriate airway management., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Dunn et al.)

Aim: Cerebrovascular insult (CVI) is a known and significant morbidity of diabetic ketoacidosis (DKA); yet, its prevalence is underestimated. Untreated cerebral hypoperfusion in DKA may lead to cerebral injury, arterial ischemic stroke, cerebral venous thrombosis, and hemorrhagic stroke. This study assesses the cerebral perfusion status among children and adolescents with DKA during and after the resolution of DKA. Methodology: Forty children and adolescents with type 1 diabetes mellitus (T1DM) presenting with DKA were assessed for severity of DKA, diabetes-duration, insulin therapy, Rappaport coma/ Near coma scale, Rancho los amigos levels of cognitive functioning scale, glycated-hemoglobin (HbA1c), D-dimer, INR and brain magnetic resonance imaging (MRI) during DKA and repeated neuro cognitive scoring, laboratory and MRI after resolution of the DKA. Results: The mean age of the children and adolescents with T1DM presenting with DKA was 11.40 ± 2.82 years; their median diabetes-duration was 3 year; their mean HbA1c was 13.54 ± 2%. There was significant increase in platelet (P = 0.005), D- dimer (P < 0.001), Creatinine (P < 0.001) and Pulse wave velocity (P = 0.004) during attack of DKA while there was significance decrease in Apparent diffusion coefficient (P < 0.001). There was 30% of children and adolescents with T1DM had ischemic MRI changes during DKA. In children and adolescent with ischemic changes there was significant increase in severity of DKA (P = 0.003), HbA1c (P = 0.016), INR (P = 0.002), D-dimer (P < 0.001), Creatinine (P = 0.003). Conclusion: Significant cerebral hypoperfusion occur during the DKA which is correlated with the DKA severity and D-dimer levels. [ABSTRACT FROM AUTHOR]

Objectives: To asses the seasonal variability in the hospital admissions of Diabetic Ketoacidosis (DKA) patients. Methods: This two year retrospective analysis was carried out from first November 2018 to 31st OCTOBER 2020, which involved medical chart reviewing of all those patients admitted to the Department of Diabetes, Endocrinology and Metabolic diseases, Hayatabad Medical complex, Peshawar, Pakistan with confirmed DKA. Data related to patient demography, past history, biochemical profile and treatment was collected and analysed using SPSS version 25. Results: During the above mentioned 24 months, 104 diabetic patients with confirmed DKA were admitted. Fifty-nine (57%) patients were male. Most of the patients had moderate DKA that is 42(40%). Seasonality was observed with majority of the patient admitted in winter season overall 62(60%). In both the years encounter with DKA patient peaked in January. DKA was found to be more severe in female and in age group 10-15 years. DKA severity was found to be significantly associated with age, gender, previous episodes of DKA, length of hospital stay and non compliance plus infection (p<0.05). Conclusion: We found seasonal variation and peaked cases of DKA in the winter season presenting at a tertiary care hospital in Pakistan. Noncompliance was found to be major contributory factor. [ABSTRACT FROM AUTHOR]

The article focuses on a pediatric case of an intravesical fungus ball following delayed diagnosis and treatment of severe diabetic ketoacidosis (DKA) in a girl with type 1 diabetes mellitus (T1DM). Topics discussed include the high incidence of organ damage in children with DKA, the challenges in early detection of T1DM, and the rare occurrence of fungus balls in pediatric patients, emphasizing the importance of awareness and timely diagnosis to prevent lethal complications.

Introduction: diabetic Ketoacidosis is the leading cause of mortality in children and adolescents with T1DM and accounts for about 50% of all deaths in patients younger than 24 years with diabetes. It affects 8 out of 1000 people with diabetes annually, with a worldwide mortality rate of 2-10%. The purpose of this study is to assess the knowledge and practice towards DKA among patients with diabetes attending three diabetes clinics in Khartoum. Methods: we conducted a cross-sectional institution-based study. It included all patients with diabetes attending three diabetes clinics in Khartoum state over the period July - September 2016. A self-administered questionnaire was used to assess and score knowledge and practice towards DKA among patients with diabetes. Data were analyzed using SPSS 23.0. Results: one hundred and ten patients participated in the study, of whom 86 had heard of DKA and were questioned further. Fifty-six point nine percent of participants had poor knowledge (0-8 out of 24) and low practice scores (0-2 out of 6). There was a strong association between knowledge scores and attended clinics. Conclusion: there was an evident lack of knowledge and poor practice towards DKA among patients with diabetes attending diabetes clinics in Khartoum, Sudan. [ABSTRACT FROM AUTHOR]

Objectives: To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis. Design: Retrospective review of medical records. Patients: Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years. Materials and methods: Retrospective analysis of medical records was done, and data including patients' age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22. Measurements and main results: Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1-17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema. Conclusions: Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney. [ABSTRACT FROM AUTHOR]

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., Competing Interests: Conflicts of interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Vu et al.)

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., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Rodriguez et al.)

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., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Alsubaie et al.)

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., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Rangoonwala et al.)

BACKGROUND: Diabetic ketoacidosis (DKA) is a medical emergency with a high mortality rate and is associated with severe metabolic acidosis and dehydration. DKA patients have an increased risk of arterial and venous thromboembolism, however little is known about this metabolic derangement in the first 24 hours of admission and to assess its effect on coagulation. We therefore utilised a novel functional marker of clot microstructure (fractal dimension - df) to assess these changes within the first 24 hours. METHODS: Prospective single centre observational study to demonstrate whether the tendency of blood clot formation differs in DKA patients. RESULTS: 15 DKA patients and 15 healthy matched controls were recruited. Mean df in the healthy control group was 1.74±0.03. An elevated df of 1.78±0.07 was observed in patients with DKA on admission. The mean pH on admission was 7.14±0.13 and the lactate was 3.6±2.0. df changed significantly in response to standard treatment and was significantly reduced to 1.68±0.09 (2–6& h) and to 1.66±0.08 at 24& h (p < 0.01 One-way ANOVA). df also correlated significantly with lactate and pH (Pearson correlation coefficient 0.479 and –0.675 respectively, p < 0.05). CONCLUSIONS: DKA patients at presentation have a densely organising less permeable thrombogenic clot microstructure as evidenced by high df. These structural changes are due to a combination of dehydration and a profound metabolic acidosis, which was reversed with treatment. These changes were not mirrored in standard clinical markers of thromboge-nicity. [ABSTRACT FROM AUTHOR]

Hamman's syndrome or Macklin phenomenon - spontaneous pneumomediastinum - is an uncommon condition that often gets missed due to the lack of awareness. It may rarely be associated with diabetic ketoacidosis (DKA) due to repeated vomiting or Kussmaul breathing associated with it. This condition is self-resolving, and improvement in symptoms is usually observed with appropriate management of DKA. Secondary pneumomediastinum is relatively more common, but spontaneous pneumomediastinum, which is rare, is often diagnosed incidentally. Here, we describe a case of a 24-year-old gentleman where this condition was found incidentally during the examination and was confirmed through imaging (X-ray and CT scans) and resolved with successful management of DKA., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Usman et al.)

The COVID-19 pandemic with the outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus has been one of the largest topics of discussion in the medical world over the last few years. Most of the research has focused on the risks and correlation of chronic diseases and immunosuppression with the severity and mortality of the viral infection. Less research has occurred in the setting of post-infectious sequelae and the long-term effects of COVID-19 with the development of chronic conditions and diseases, such as new-onset type 1 diabetes mellitus. The incidence of diabetic ketoacidosis (DKA) has increased during the COVID-19 pandemic, but the relationship between the two conditions remains to be fully understood. We report the case of a 24-year-old male who presents with malaise, polyuria, polydipsia, headache, and fatigue and was eventually found to be in diabetic ketoacidosis (DKA). He had a history of COVID-19 infection 12 weeks prior to this presentation. He also had a family history of DKA and type 1 diabetes mellitus. This case highlights the need to perform an in-depth workup for each patient with DKA and new-onset diabetes mellitus in order to find a potential cause of the autoimmune condition., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Kellogg et al.)

Background Diabetic ketoacidosis (DKA) is a life-threatening metabolic emergency due to insulin deficiency in patients with diabetes mellitus. The United Kingdom national survey and local audits of the management of DKA have revealed several areas of suboptimal care, and room for improvement, necessitating the need for intensified education, updating local guidelines, and increased recruitment of seven-day working inpatient diabetes specialist nurses. Therefore, this project aimed to re-audit our adherence to the DKA treatment guidelines. Methodology A retrospective re-audit examining patient admissions with DKA between October 2022 and September 2023. A list of 18 standards/criteria, adopted from the Joint British Diabetes Society (JBDS) DKA treatment guidelines was used for this re-audit. Results were compared with that of the previous audit. Results We had 126 patients admitted with DKA between October 2022 and September 2023. There were 62 males and 64 females with an average (range) age of 46.5 (19-92) years. Eighty percent had type 1 diabetes, and common precipitating factors for admission included infection and poor adherence to insulin treatment. The median (IQR) length of hospital stay was 2.1 (1.0-5.1) days. Compared to the previous audit, improvements occurred in 11 of 18 standards/criteria. This included timely commencement of intravenous fluids and fixed-rate insulin, commencing glucose infusion to prevent hypoglycemia, potassium replacement, continuation of long-acting insulin during treatment, timely conversion to variable-rate insulin infusion, and conversion to the usual subcutaneous insulin regimen. Additionally, 124 patients (98.4%) were reviewed at least once by the inpatient diabetes specialist nurses (DSN) during their admission. Complications of treatment, namely, iatrogenic hypoglycemia and transient hypokalemia occurred in 13 (10.3%) and 40 (31.7%) patient admissions, respectively. Conclusions This re-audit demonstrated improved adherence to the guidelines during several steps in the management of DKA. It also demonstrated room for improvement regarding other aspects of care. The importance of continued education, accurate documentation, and the presence of seven-day working inpatient DSN cover cannot be overemphasized., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Periyasami et al.)

Background and objective Diabetes mellitus (DM) is a chronic debilitating metabolic disease caused by insulin deficiency. Diabetic ketoacidosis (DKA) is a potentially fatal complication characterized by acute hyperglycemia and metabolic acidosis. In light of the high prevalence of DM in Saudi Arabia, we sought to investigate the knowledge, attitudes, and practices of the Saudi general population about DKA. Methods An online self-administered questionnaire was distributed through popular social media platforms among diabetics in the Saudi population. The survey questions involved demographic data; diabetes status including the time of diagnosis, current medications, and the latest HbA1c level; and an assessment of the knowledge about DKA through queries related to diagnostic criteria, definition, risk factors, symptoms, and preventive measures. Results Our study involved 400 participants, and 42.5% of them were able to correctly identify DKA as an emergency requiring immediate medical attention. Regarding the awareness of DKA's symptoms among the participants, 33.8% correctly identified excessive thirst as a key indicator, followed closely by frequent urination (31.8%), and the characteristic fruity breath odor (31.3%). As for the awareness of the participants of the causes of DKA, 33.8% correctly linked forgetting insulin injections to DKA development. Encouragingly, 39.8% of participants identified regular blood sugar monitoring as the most effective way to prevent DKA. Conclusions Most patients in our study demonstrated limited knowledge of DKA. However, a significant portion of them was able to identify it as an emergency. To prevent such events, raising awareness about DM and its complications may serve as the first step toward better outcomes in diabetic patients. We believe our findings can be used to devise quality-improving interventions in this field., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Hassan et al.)

Thyroid diseases and diabetes mellitus are the two most common endocrine disorders encountered in clinical practice. Diabetes and thyroid disorders have been shown to mutually influence each other and associations between both conditions have long been reported [1, 2]. On one hand, thyroid hormones contribute to the regulation of carbohydrate metabolism and pancreatic function, and on the other hand, diabetes affects thyroid function tests to variable extents. We reported a case of 40 years old woman with a history of type 2 diabetes mellitus and hyperthyroidism who presented to the emergency with complaints of fever, nausea, vomiting, abdominal pain. Patient was drowsy with dry skin and mucous membranes. Kussmaul breathing was present. Blood glucose levels were 658 mg/dl, urine was positive for ketone bodies and metabolic acidosis with an anion gap of 56. An arterial blood gas showed Ph 7.1, PaO2 105.3, PaCO2 22, and HCO3 6.1 meq/l. ECG showed tachycardia. T3 = 181.5 ng/dl, T4 = 12.5 micro g/dl, TSH= 0.013 micro u/l. Further examination revealed Hashimoto's Thyroiditis with Thyrotoxic Goiter. This is a rare case of Diabetic Ketoacidosos in Hashimoto's Thyroiditis with Thyrotoxic Goiter in adult female patient with thyrotoxicosis. [ABSTRACT FROM AUTHOR]

This research investigated prelicensure nursing and physician assistant students' psychological well-being in an interprofessional, diabetic ketoacidosis (DKA) simulation. A mixed-between within-subjects analysis of variance was performed to examine the impact of an interdisciplinary simulation, addressing the needs of a DKA patient, on health care students' perceived psychological well-being across three time periods (before simulation, immediate after the simulation, and after debriefing). Statistically significant changes in psychological well-being were observed throughout the different time periods during the DKA simulation experience, Wilks' Lambda = 0.85, F (2, 66) = 5.732, p =.005, partial eta squared = 0.148. Health care students experience greater levels of psychological well-being when given the opportunity to participate in debriefing. As a result, health care simulation educators must ensure that appropriate debriefing time is allotted. • Simulation can serve as a place for interprofessional education relating to chronic disease patient care. • Psychological well-being is an important component to assess when establishing interprofessional simulation curriculum. • Debriefing appears to enhance psychological well-being in nursing and physician assistant students when tending to a simulated diabetic ketoacidosis patient. [ABSTRACT FROM AUTHOR]

Abstract Background Advances in cancer immunotherapy have generated encouraging results in multiple malignancies refractory to standard chemotherapies. As the use of immune checkpoint inhibitors (ICI) proliferates, the incidence of autoimmune side effects associated with these agents, termed immune related adverse events (irAE), is expected to increase. The frequency of significant irAE in ICI treated patients is about 10–20% and early recognition is critical to prevent serious morbidity and even mortality. New onset autoimmune diabetes mellitus (DM) associated with immune checkpoint inhibitor treatment is extremely rare, occurring in less than 1% of patients. Autoimmune DM often presents as diabetic ketoacidosis, a medical emergency requiring immediate treatment. We describe the first reported case of a patient with lung cancer who developed autoimmune diabetes after nivolumab treatment and was found to have three diabetes related (islet) autoantibodies present before ICI treatment and seroconversion of another after ICI treatment and onset of autoimmune DM. Case Presentation A 34 year old African American woman with metastatic non-small cell lung cancer (NSCLC) was treated with nivolumab in the second line setting after disease progression following standard chemoradiation therapy. After receiving two doses of nivolumab, the patient developed abrupt onset of hyperglycemia and diabetic ketoacidosis. Autoimmune diabetes was diagnosed on the basis of undetectable C-peptide levels, seropositivity of three diabetes related (islet) autoantibodies and absolute insulin dependence. The patient eventually required use of continuous subcutaneous insulin infusion (insulin pump) due to erratic glycemic excursions and multiple readmissions for DKA. Human leucocyte antigen (HLA) genoyping revealed none of the high risk haplotypes associated with the development of type 1 diabetes. Interestingly, a frozen blood sample obtained prior to treatment with nivolumab tested positive for three of the four diabetes related (islet) autoantibodies despite no prior history of diabetes and no family history of diabetes. Notably, at the time of manuscript preparation, the patient is without evidence of NSCLC recurrence with no further treatment since the nivolumab therapy. Conclusion New onset autoimmune diabetes mellitus associated with nivolumab has been described only in case reports and occurs at rates of

Background: The COVID-19 pandemic caused by SARS-CoV-2 is a respiratory disease which created havoc worldwide, was accompanied by another peculiar, otherwise rare, secondary fungal infection Mucormycosis which was observed at exceptionally high incidence in India during the second wave of COVID-19. The article explores possible links between the two infectious diseases to understand a higher-than-normal occurrence of Mucormycosis in COVID-19 patients. Coronavirus enters the patients through ACE-2 and many other receptors like- NRP-1, TfR, CD-126, and CD-26. Virus bind to cells possessing these receptors and affect their proper functioning, disturbing homeostatic metabolism and resulting in conditions like hyperglycemia, Diabetic Ketoacidosis (DKA), low serum pH, iron overload, anemia, hypoxia, and immunosuppression as explained in the article. All these outcomes provide a very supportive environment for the attack and spread of Mucormycosis fungi. The major receptor for Mucormycosis in humans is the GRP-78. Its expression is upregulated by coronavirus entry and by hyperferritinemia, hyperglycemia, and acidic conditions prevalent in COVID patients, thus providing an easy entry for the fungal species. Upregulation of GRP-78 furthermore damages pancreatic β-cells and intensifies hyperglycemia, showing quite a synergic relationship. Inordinate rise of Mucormycosis cases in India might be explained by facts like- India possessing a large proportion of diabetic patients, emergence of a very deadly strain of coronavirus- Delta strain, higher doses of steroids and antibodies used to treat patients against this strain, overburdened health care services, sudden much higher need of oxygen supply and use of industrial oxygen could explain the Mucormycosis outbreak observed in India during the second wave of COVID-19., Objective: The present review discusses the functional interdependence between COVID-19 and Mucormycosis and summarizes the possible synergic links between COVID and Mucormycosis., Conclusion: The receptors and metabolic pathways affected by COVID-19 result in severe physiological conditions- hyperglycemia, DKA, anemia, iron overload, immunosuppression, and hypoxia. All these conditions not only increase the expression of GRP-78, the major receptor for entry of fungi but also play a crucial role in providing quality media for Mucormycosis fungus to establish and grow. Hence explains the fungal epidemic observed in India during the second wave of COVID-19 in India., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Pancreatitis is an inflammatory disease of the pancreas where as a result of a primary event, activation of pancreatic enzymes occurs which leads to destruction of the gland. Pancreatitis can be categorized as follows: 1. Acute pancreatitis, with histological resolution after full clinical recovery 2. Acute recurrent pancreatitis 3. Chronic pancreatitis, leading to irreversible inflammatory fibrosis. The acute pancreatitis in children is defined by 2 of the following: abdominal pain, elevated amylase or lipase 3 times the upper limit of normal, or imaging findings of acute pancreatitis.. In children the etiology of acute pancreatitis is more diverse compared to adults. Metabolic conditions are only 2-7% of causes. The most common was diabetic ketoacidosis, followed by hypertriglyceridemia and hypercalcemia. Overall, patients with metabolic disorders were more likely to have recurrence of pancreatitis. We present two cases of hypertriglyceridemia induced pancreatitis in patients with known Type 1 Diabetes. The first patient has had poor glycemic control for years and long lasting dyslipidemia and hypertriglyceridemia. The second one is presented with ketoacidosis (DKA) and severe hypertriglyceridemia. The triad of acute pancreatitis, hypertriglyceridemia and diabetes is a rare occurrence. Diagnosis of acute pancreatitis in the course of ketoacidosis is challenging. Although acute pancreatitis can initiate DKA as in our first case report, DKA itself may mask a coexisting acute pancreatitis that occurs due to ambiguous clinical presentations. Even worse, nonspecific elevations of amylase and/or lipase without clinical evidence of pancreatitis have been reported in some cases. Timely diagnosis of acute pancreatitis in DKA is critical as it would change the course of treatment. Therefore, in patients complaining of abdominal pain despite their improving state of DKA, further investigation to rule out acute pancreatitis is crucial. [ABSTRACT FROM AUTHOR]

We report a 66-year-old male who developed diabetic ketoacidosis (DKA) and necrosis of the small intestine due to non-occlusive mesenteric ischemia (NOMI), 3 months after starting quetiapine treatment. He was transferred to our hospital and diagnosed as diabetic for the first time, associated with DKA. Despite improvement in DKA, abdominal pain worsened gradually 10 h after hospitalization. Computed tomography (CT) revealed bowel emphysema, and gas out of the gut wall, in the mesenteric veins and the intrahepatic portal vein, suggesting intestinal necrosis. He survived because of resection of necrotic small-intestinal tissue and he finally required no diabetes treatment. Mesenteric arteries were patent with good palpitation without occlusion or thrombosis, and pathological findings showed ischemic enteritis, which is consistent with NOMI. DKA is a rare but serious side effect of second-generation antipsychotic medications (SGAMs) such as quetiapine, which can result in NOMI: a life-threatening complication. We must keep in mind that the plasma glucose concentration may increase in patients taking SGAMs, or that NOMI may occur concurrently if DKA develops. [ABSTRACT FROM AUTHOR]