INTRODUCTION Type 1 diabetes mellitus (T1DM) is an autoimmune disorder leading to the destruction of insulin producing pancreatic beta cells, resulting in elevated blood sugar levels 1. Polyuria, polydipsia and weight loss are the key presenting symptoms 2. A systematic review and meta-analysis reported the global T1DM prevalence of 9.5%, with an incidence of 15 per 100,000 people3. Diabetic ketoacidosis (DKA) is a grievous complication of diabetes mellitus caused by insufficient insulin, resulting in elevated blood glucose, ketonemia and acidosis. The overall DKA prevalence across 13 countries over 13 years was 29.9%, with a 3.5% prevalence in Nepal. 4,5.The most common risk factors leading to DKA include missed insulin doses and infections, while other factors like stress-inducing events or the initial onset of diabetes can also trigger DKA. The clinical manifestations of DKA encompass a range of symptoms, including nausea, severe vomiting, dehydration, polyuria, polydipsia, abdominal pain or discomfort, presence of acetone breath odor, Kussmaul breathing, overall profound fatigue with altered consciousness, disorientation, confusion or occasionally coma when the condition is severe 6. Typical diagnosing criteria for DKA include blood glucose greater than 250 mg/dl, arterial pH less than 7.3, serum bicarbonate less than 15 mEq/l, and the presence of ketonemia or ketonuria 7.Immediate intervention is crucial that includes restoring the circulatory volume, correcting electrolyte abnormalities, insulin therapy and addressing the underlying cause 8. Failure to promptly treat DKA can result in the breakdown of compensatory mechanisms and cause electrolyte abnormalities like hyponatremia, hyperkalemia and ultimately lead to life threatening complications including cerebral edema, acute respiratory distress syndrome, and sepsis. Nursing management for a patient with Diabetic Ketoacidosis (DKA) involves a comprehensive approach that involves monitoring vital signs, blood sugar levels, and electrolytes, administering fluids, assessing renal function and mental status, monitoring intake output, checking for signs of infection, assessing lung sound; educating the patient on insulin injection techniques, medication compliance, promoting lifestyle changes like smoking cessation and diabetic diet9.In DKA, dilutional hyponatremia is common due to rising glucose level that creates osmolar gradient causing water to shift from cells into the intravascular space. However, on rare occasion, hypernatremia is found that happens when there’s a deficit of water intake and excessive loss of free water, which outweighs electrolyte loss through various factors10. This report emphasizes the significance of a fluid management strategy for DKA patients, even when encountering the unusual occurrence of hypernatremia. 

Hypernatremia in diabetic ketoacidosis: a rare metabolic derangement requiring a cautionary approach in fluid resuscitation

AIM
This study was designed to investigate the association between Charlson Comorbidity Index (CCI) and in-hospital mortality and other clinical outcomes among patients with hyperglycemic crises.


METHOD
This retrospective cohort study was conducted using data from electric medical records. A total of 1668 diabetic patients with hyperglycemic crises from six tertiary hospitals met the inclusion criteria. CCI < 4 was defined as low CCI and CCI ≥ 4 was defined as high CCI. Propensity score matching (PSM) with the 1:1 nearest neighbour matching method and the caliper value of 0.02 was used to match the baseline characteristics of patients with high CCI and low CCI to reduce the confounding bias. In-hospital mortality, ICU admission, hypoglycemia, hypokalemia, acute kidney injury, length of stay (LOS), and hospitalisation expense between low CCI and high CCI were compared and assessed. Univariate and multivariate regression were applied to estimate the impact of CCI on in-hospital and other clinical outcomes.


OUTCOME
One hundred twenty-one hyperglycemic crisis (HC) patients died with a mortality rate of 7.3%. After PSM, compared with low CCI, patients with high CCI suffered higher in-hospital mortality, ICU admission, LOS, and hospitalisation expenses. After multivariate regression, age (aOR: 1.12, 95% confidence interval [CI]: 1.06-1.18, p < 0.001), CCI(aOR: 4.42, 95% CI: 1.56-12.53, p = 0.005), uninsured (aOR: 22.32, 95% CI: 4.26-116.94, p < 0.001), shock (aOR: 10.57, 95% CI: 1.41-79.09, p = 0.022), mechanical ventilation (aOR: 75.29, 95% CI: 12.37-458.28, p < 0.001), and hypertension (aOR: 4.34, 95% CI: 1.37-13.82, p = 0.013) were independent risk factors of in-hospital mortality of HC patients. Besides, high CCI was an independent risk factor for higher ICU Admission (aOR: 5.91, 95% CI: 2.31-15.08, p < 0.001), hypoglycemia (aOR: 2.19, 95% CI:1.01-4.08, p = 0.049), longer LOS (aOR: 1.23, 95% CI: 1.19-2.27, p = 0.021), and higher hospitalisation expense (aOR: 2089.97, 95% CI: 193.33-3988.61, p = 0.031) of HC patients.


CONCLUSION
CCI is associated with in-hospital mortality, ICU admission, hypoglycemia, LOS, and hospitalisation expense of HC patients. CCI could be an ideal indicator to identify, monitor, and manage chronic comorbidities among HC patients.

Impact of Charlson Comorbidity Index on in-hospital mortality of patients with hyperglycemic crises: A propensity score matching analysis.

Supplementary Material 1: The missing rates for all excluded variables 

Additional file 1 of Clinical nomogram prediction model to assess the risk of prolonged ICU length of stay in patients with diabetic ketoacidosis: a retrospective analysis based on the MIMIC-IV database

Diabetic ketoacidosis (DKA) is a life-threatening adverse complication of patients with diabetes mellitus (DM). It is postulated that fasting during Ramadan can increase the risk of DKA; however, there are contradicting data in this regard. Furthermore, studies from Western countries have suggested a seasonal variation in the incidence of DKA. This study examines the differences in the number of DKA episodes during Ramadan compared to the rest of the year in patients with type 1 DM (T1D) and type 2 DM (T2D). Besides, we aim to examine the seasonal difference in the incidence of DKA.We included consecutive index-DKA admissions from 2015 to 2021 and used descriptive statistics to compare the episodes of DKA in Ramadan vs other months and seasons.Of 922 patients, 480 (52%) had T1D, whereas 442 (48%) had T2D. The median age (IQR) was 35 (25-45) years, with the majority being Arab (N = 502, 54.4%). There were 94 DKA admissions in six collective Ramadan months, whereas the DKA admissions ranged from 61 to 88 episodes in other months (p = .3). The highest DKA admissions were observed in Autumn (N = 236) and the lowest in Spring (N = 226) with no statistically significant difference (p = .4). There were no differences in DKA severity or new-onset diabetes rates when analyzed based on Hiji months, Roman months, or seasons.DKA occurrence is not increased during Ramadan. We found no evidence of seasonal variations in the rates of DKA in the State of Qatar. 

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

Purpose This study aimed to characterize adult patients admitted with diabetic ketoacidosis (DKA) in northern Jordan. Methods The study examined medical records of patients diagnosed with DKA from January 2015 to April 2018. Variables analyzed included diabetes type, precipitating illness, admission month, hospital length of stay, and biochemical markers. Results Out of 232 admissions with DKA, 70% were diagnosed with type 2 diabetes, and 56% were females. 12% of admissions had a new diagnosis of diabetes, of which 51% had type 2 diabetes. Sepsis (48%), Non-adherence (26%), and diabetic foot infections (18%) were the most encountered precipitating factors for DKA in T1DM. As for T2DM, sepsis (52%), acute coronary syndrome (12%), and pancreatitis (8%) were the most precipitating factors for DKA. High urea levels, high creatinine levels, low phosphorous levels, low hemoglobin levels, and high platelet counts were associated with a longer hospital stay for type 1 diabetes. For type 2 diabetes, low pH on admission, old age, and high Hb A1c within 6 months of admission were factors associated with a prolonged hospital stay. The study found a significant peak of admissions for DKA in both type 1 and type 2 patients in the winter and spring months (Pearson P-value= 0.0013). Conclusion The results of the present study highlight the seasonal variation in the frequency of DKA hospitalizations. It also highlights sepsis as the most frequent precipitating factor of DKA in both type 1 and type 2 DM patients.

Diabetic Ketoacidosis in Northern Jordan: Seasonal Morbidity and Characteristics of Patients

Abstract Background The increasing prevalence of diabetic ketoacidosis (DKA) related admissions poses a significant burden on the healthcare systems globally. However, data regarding the predictors of healthcare resource utilization in DKA is limited and inconsistent. This study aimed to identify key predictors of hospital length of stay (LOS), readmission and recurrent DKA episodes. Methods We undertook a retrospective cross-sectional analysis of all DKA admissions from 2015 to 2021 across four hospitals in Qatar. The primary outcomes were the length of stay (LOS), 90-day readmission and 6-month and 1-year DKA recurrence. Results We included 922 patients with a median age of 35 years (25–45). 62% were males with type-1 diabetes-mellitus (T1DM) and type-2 DM (T2DM), present in 52% and 48% of patients. The median LOS was 2.6 days (IQR 1.1–4.8), and the median DKA resolution time was 18 h (10.5–29). Male-gender, new-onset DM, higher Charlson Comorbidity Index (CCI), lower haemoglobin, sodium and potassium, higher urea, longer DKA duration and MICU admission predicted a longer LOS in a multivariate regression analysis. None of the factors were significantly associated with 90-day readmission. Patients with pre-existing T1DM were more likely to have a six-month DKA recurrence than pre-existing T2DM. Patients with a 6-month DKA recurrence, female gender and T1DM had higher odds of 12-month recurrence, whereas a consult with a diabetes educator at the index admission was associated with decreased odds of recurrence. Conclusions/interpretation This is the most extensive study from the Middle-East region reporting on LOS, readmissions and the recurrence of DKA. Results from this study with a diverse population may be valuable for physicians and healthcare systems to decrease the diabetes-related healthcare burden in DKA patients.

Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis

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Clinical and biochemical determinants of length of stay, readmission and recurrence in patients admitted with diabetic ketoacidosis