Comparing Disease Severity: Diabetic Ketoacidosis in Local and Tourist Children With New-Onset Diabetes Mellitus
Authors: Hinds Autumn , Carakushansky Mauri , Maul Timothy , Alexander Kenneth , Gurnurkar Shilpa 
Published: May 2021

Abstract
Introduction: Approximately 30% of youth present with diabetic ketoacidosis (DKA) at the time of diagnosis of type 1 diabetes mellitus (DM). DKA severity can be mild to severe, impacting hospitalization duration as severity worsens, or even result in death. A delay in care from onset of symptoms results in greater illness severity. Travel has been a proposed risk factor for illness severity in general; one study identified ruptured appendicitis as a more frequent complication in children vacationing from their hometown. Identifying travel as a potential risk factor for severe DKA is necessary. There is no research highlighting the association between vacation and severity of DKA in new onset diabetics. Central Florida is one of the major vacation destinations and is home to a diverse population, so offers a unique study population. The goal of this novel study was to investigate the association between travel and severity of DKA in new onset diabetics. Methods: A retrospective chart review of children admitted to a children’s hospital in Central Florida with both new onset diabetes and DKA from October 2012-March 2020 was conducted. Patients that did not meet criteria for DKA based on venous pH (pH) &lt; 7.3 or bicarbonate (HCO3) &lt; 15 mmol/l were excluded. Patients were divided into two groups by primary residence: locals versus tourists. The severity of DKA was determined as either mild (pH &lt; 7.3 or HCO3 10 to &lt; 15), moderate (pH &lt; 7.2 or HCO3 5–9), or severe (pH &lt; 7.1 or HCO3 &lt; 5), and compared between local versus tourist children with Chi-squared testing. Results: There was no significant difference in DKA severity between locals and tourists. 33% of local children presented in severe DKA compared to 29% of tourist children (p=0.809). The percentage of children overall presenting with moderate or severe DKA was about 70%. Gender and admission status had a statistically significant correlation to DKA severity. More females presented in severe DKA than males (56 % versus 44%, p=0.029), and patients transferred from an outside facility versus directly admitted from the emergency department had a higher percentage of severe DKA (76% versus 24%, p=0.002). Conclusion: This study is the first in the literature to report that travel does not seem to be a contributing risk factor to the severity of DKA. We did find that more than half of all new onset diabetics presented in moderate or severe DKA, indicating that there is currently a frequent delay in diagnosis of children with new onset diabetes. A higher rate of severe DKA was noted in patients transferred from an outside facility versus children admitted directly to the ICU from our emergency department, which may likely be due to challenging access to a specialty pediatric hospital among patients living in remote areas. We propose that future studies investigate this relationship further to guide interventions that can significantly reduce the rate of severe DKA on presentation.