Effect of COVID-19 on the clinical course of diabetic ketoacidosis (DKA) in people with type 1 and type 2 diabetes

Objective COVID-19 in people with diabetes is associated with a disproportionately worse prognosis. DKA is an acute complication of diabetes with a mortality rate of approximately 0.67%. Little is known about the natural history of DKA in the presence of COVID-19. This study aimed to explore the effects of COVID-19 on presentation, clinical course and outcome in patients presenting with DKA. Design Retrospective cohort study. Methods All patients treated for DKA between 1 March 2020 and 30 May 2020 were included. Patients were categorised as COVID-positive or COVID-negative based on the swab test. A pre-COVID group was established using data from 01 March 2019 to 30 May 2019 as external control. Data regarding demographics, diabetes type, pH, bicarbonate, lactate, glucose, DKA duration, complications and outcome were collected. Results A total of 88 DKA episodes were included in this study. There was no significant difference in the severity or duration of DKA between the three groups. COVID-positive T1DM were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was an over representation of T2DM in COVID-positive patients with DKA than in pre-COVID or COVID-negative groups. Conclusion COVID-19 appears to influence the natural history of DKA differently in T1DM and T2DM. Patients with T1DM and COVID-19 presented with more hyperglycaemia (60 mmol/L (35.9–60.0) vs 31.4 mmol/L (28.0–39.1) vs 24 mmol/L (20.2–33.75), respectively). Patients with T2DM were unusually presenting in DKA when infected with COVID-19 with greater ICU need and higher mortality rates. A collaborative, multi-centre study is needed to provide more definitive results

Clinical and biochemical profile of 786 sequential episodes of diabetic ketoacidosis in adults with type 1 and type 2 diabetes mellitus.

INTRODUCTION We explored the clinical and biochemical differences in demographics, presentation and management of diabetic ketoacidosis (DKA) in adults with type 1 and type 2 diabetes. RESEARCH DESIGN AND METHODS \ud This observational study included all episodes of DKA from April 2014 to September 2020 in a UK tertiary care hospital. Data were collected on diabetes type, demographics, biochemical and clinical features at presentation, and DKA management. RESULTS From 786 consecutive DKA, 583 (75.9%) type 1 diabetes and 185 (24.1%) type 2 diabetes episodes were included in the final analysis. Those with type 2 diabetes were older and had more ethnic minority representation than those with type 1 diabetes. Intercurrent illness (39.8%) and suboptimal compliance (26.8%) were the two most common precipitating causes of DKA in both cohorts. Severity of DKA as assessed by pH, glucose and lactate at presentation was similar in both groups. Total insulin requirements and total DKA duration were the same (type 1 diabetes 13.9 units (9.1-21.9); type 2 diabetes 13.9 units (7.7-21.1); p=0.4638). However, people with type 2 diabetes had significantly longer hospital stay (type 1 diabetes: 3.0 days (1.7-6.1); type 2 diabetes: 11.0 days (5.0-23.1); p<0.0001). CONCLUSIONS In this population, a quarter of DKA episodes occurred in people with type 2 diabetes. DKA in type 2 diabetes presents at an older age and with greater representation from ethnic minorities. However, severity of presentation and DKA duration are similar in both type 1 and type 2 diabetes, suggesting that the same clinical management protocol is equally effective. People with type 2 diabetes have longer hospital admission

Differences in presentation, severity and management of DKA in type 1 and type 2 diabetes during the COVID-19 pandemic

Introduction: COVID-19 infection in people with diabetes is associated with a disproportionately increased risk of complications and mortality.1 Diabetic ketoacidosis (DKA) is an acute complication of diabetes.2,3 Little is known about DKA in the presence of COVID-19 infection. This study aimed to explore the effects of COVID-19 infection on presentation, clinical course and outcome in patients presenting with DKA. Methods: This retrospective cohort study included all patients treated for DKA between 1 March and 30 May 2020 at University Hospitals Birmingham. Patients were categorised as COVID-positive or negative based on PCR swab test. A pre-COVID group was established as external control. Data regarding demographics, diabetes type, admission pH, bicarbonate, lactate, glucose, serum electrolytes, urea, creatinine, time to resolution of acidosis and ketosis, complications and outcome were collected. DKA onset was defined as the presence of hyperglycaemia (serum glucose >11 mmol/L), ketosis (serum ketones >3 mmol/L or urine ketone >+++) and metabolic acidosis (pH 7.3 or bicarbonate >15 mmol/L) as per national guidelines in the UK.4 Results: A total of 88 episodes were included in the final analysis (20 COVID-positive, 31 COVID-negative, 37 pre-COVID). These were further sub-classified into type 1 (five COVID-positive, two COVID-negative, 29 pre-COVID) and type 2 diabetes (15 COVID-positive, two COVID-negative, eight pre-COVID). There was no significant difference in the severity of DKA at presentation (median for COVID positive, COVID negative and pre-COVID groups): pH (7.15 vs 7.2 vs 7.2), bicarbonate (11.4 mmol/L vs 11 mmol/L vs 13.3 mmol/L), glucose (25.85 mmol/L vs 30.9 mmol/L vs 29.1 mmol/L), lactate (2.7 mmol/L vs 3.2 mmol/L vs 2.8 mmol/L), serum osmolality (314.6 mmol/L vs 323.1 mmol/L vs 316.2 mmol/L). There was also no significant difference between the groups for the duration of DKA (from the time of admission to resolution of DKA: 12.5 hours vs 14.9 hours vs 17.9 hours for COVID-positive, COVID-negative and pre-COVID groups, respectively; Fig 1). COVID-positive patients with type 1 diabetes were more hyperglycaemic on admission compared to COVID-negative and pre-COVID patients. There was a significantly higher incidence of type 2 diabetes in COVID-positive patients than in pre-COVID or COVID-negative groups. COVID-negative patients had more episodes of hypokalaemia and hyperkalaemia during DKA compared to other two groups. There was no significant difference between the number of episodes of hypokalaemia in the COVID-positive compared to the pre-COVID group. In patients with type 2 diabetes, hypokalaemia was more common in COVID-negative patients. Conclusion: COVID infection appears to influence the natural history of DKA differently in type 1 and type 2 diabetes. Infection was associated with increased hyperglycaemia in type I diabetes and greater acidosis on presentation with DKA. People with type 2 diabetes were presenting unusually in DKA when infected with COVID. These patients also had higher mortality rates. There is need for a multi-centre approach to conduct larger cohort studies in this area

Developing a simulation-based learning model for acute medical education during COVID-19 pandemic with Simulation via Instant Messaging - Birmingham Advance (SIMBA).

Simulation-based learning (SBL) is well-established in medical education and has gained popularity, particularly during the COVID-19 pandemic when in-person teaching is infeasible. SBL replicates real-life scenarios and provides a fully immersive yet safe learning environment to develop clinical competency. Simulation via Instant Messaging - Birmingham Advance (SIMBA) is an exemplar of SBL, which we previously showed to be effective in endocrinology and diabetes. Previous studies reported the efficacy of SBL in acute medicine. We studied SIMBA as a learning intervention for healthcare professionals interested in acute medicine and defined our aims using the Kirkpatrick model: (i) develop an SBL tool to improve case management; (ii) evaluate experiences and confidence before and after; and (iii) compare efficacy across training levels.Three sessions were conducted, each representing a PDSA cycle (Plan-Do-Study-Act), consisting of four cases and advertised to healthcare professionals at our hospital and social media. Moderators facilitated progression through 25 min simulations and adopted patient and clinical roles as appropriate. Consultants chaired discussion sessions using relevant guidelines. Presimulation and postsimulation questionnaires evaluated self-reported confidence, feedback and intended changes to clinical practice.Improvements were observed in self-reported confidence managing simulated cases across all sessions. Of participants, 93.3% found SIMBA applicable to clinical practice, while 89.3% and 88.0% felt SIMBA aided personal and professional development, respectively. Interestingly, 68.0% preferred SIMBA to traditional teaching methods. Following participant feedback, more challenging cases were included, and we extended the time for simulation and discussion. The transcripts were amended to facilitate more participant-moderator interaction representing clinical practice. In addition, we refined participant recruitment over the three sessions. In cycle 1, we advertised incentives: participation counted towards teaching requirements, certificates and feedback. To rectify the reduction in participants in cycle 2, we implemented new advertisement methods in cycle 3, including on-site posters, reminder emails and recruitment of the defence deanery cohort