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What Is Flatbush Diabetes?

Flatbush Diabetes - Ny Daily News

Flatbush Diabetes - Ny Daily News

Doctors used to divide diabetes cases into two neat camps: Types 1 and 2. But the disease is not quite that simple. Flatbush diabetes, one of several variations of the disease, was identified in 1994 at SUNY Downstate Medical Center in the East Flatbush section of Brooklyn.The first symptom of Flatbush diabetes is usually diabetic ketoacidosis (DKA) a potentially fatal buildup in the blood of chemicals known as ketones, which results when the body stops producing insulin and burns an excessive amount of stored fats. (Sometimes the first symptom of Flatbush diabetes is severe hyperglycemia, or high blood sugar.)It was once thought that DKA only occurred in Type 1 patients. When middle-aged African-Americans in Flatbush were diagnosed with it, doctors assumed they were Type 1 also, even though they didnt fit the age or weight criteria.But those patients actually represented a previously unidentified subtype of Type 2. Many of them are able to manage their disease through diet, exercise, pills and some insulin. Though initially they all required insulin, they werent the brittle Type 1s who have to have insulin otherwise theyre dead the next day, said Dr. Mary Ann Banerji, clinical assistant professor of medicine at Downstate. Up to three-quarters of the Flatbush patients also had family histories of Type 2, and they all lacked the auto-immune markers that distinguish Type 1 cases. Basically, these are Type 2 diabetics who look like Type 1, said Banerji. Downstate sees about 150 cases a year of Flatbush diabetes, most of them in African-Americans. The disease also occurs in Hispanics but is rare in non-Hispanic whites.Note: THE SILENT EPIDEMIC THE SPECIAL REPORT Continue reading >>

Flatbush Diabetes

Flatbush Diabetes

Most of us who have had diabetes for at least a few years are likely to be familiar with the main types of diabetes: type 1, which is autoimmune, and type 2, which involves insulin resistance. We may also be aware of some minor types like LADA (latent autoimmune diabetes of adults), a slower-onset form of autoimmune diabetes that appears in adults. Another type is MODY (maturity-onset diabetes of the young), which often, but not always, appears in children or young people. It is monogenic, meaning a mutation in only one gene causes the disease, and the affected gene is dominant, meaning that you can inherit only one copy of the gene from one parent and a normal gene from the other parent and you’ll get MODY. Type 2 diabetes is polygenic, meaning a lot of genes are usually involved. Other forms of diabetes include gestational diabetes, a usually temporary form of diabetes that occurs in late pregnancy and then goes away after the baby is born, although having gestational diabetes greatly increases your risk of getting type 2 diabetes later. And there are various rare forms of diabetes as well as diabetes induced by taking drugs, including steroids. But there’s another form of diabetes that seems to becoming more and more common, especially in Africa, and that’s Flatbush diabetes, named after the New York area where it was described some years ago. It’s also been called a lot of other things, including atypical diabetes, type 1B diabetes, idiopathic [meaning the cause is unknown) type 1 diabetes, and ketosis-prone type 2 diabetes. I’ll use the term Flatbush diabetes because I find it easier to rememember colorful nicknames, and also because it doesn’t require one to decide if this form of diabetes is really type 1 or type 2. In fact, it seems to be somewhat in Continue reading >>

Barker's Type 2 Ketosis Prone Diabetes / Atypical Diabetes T1b/ Flatbush Diabetes

Barker's Type 2 Ketosis Prone Diabetes / Atypical Diabetes T1b/ Flatbush Diabetes

Barker's Type 2 Ketosis Prone Diabetes / Atypical Diabetes T1b/ Flatbush Diabetes The accepted knowledge is that Diabetes destroys gradually over years. Ketosis Prone Type 2 diabetes is an acute form of type 2. This type 2 can reach fasting blood sugars of 300 or higher in months. This blog brings together all the documentation that I could find in the world and my speculation of what it means for KPDs in specific and diabetics in general. I ask you to leave your stories about what happened to you so that we can all gain a better understanding of what we are dealing with. If you are reading this then you probably have already recognized that you have a problem. You are probably experiencing an unslackable thirst, blurred vision, possibly chills. If you are seeing blood sugar numbers north of 300 then you really need to get medical help. If you are under medical care and have been given medications but still can't get your numbers down. You must drastically reduce your carbohydrates.The very first thing you need to know is that, unless you are extremely lucky, your medical providers will know next to nothing about KPT2 diabetes. In this case, almost everything you will be told to do will be bad for you. I know of no oral diabetes med that will successfully intervene in this situation and they may cause more harm than good. This will especially be the case if you follow the advice of a certified diabetes educator. They will tell you that you must take in at least 100 to 150 grams of carbs a day. You won't be able to do it without insulin and the amount of insulin you'll be taking will be huge and very hard to control. This is because high blood sugars will give you even more high blood sugars. You will be chasing your tail while your blood sugars go higher and higher. Th Continue reading >>

Ketosis-prone Diabetes

Ketosis-prone Diabetes

Does presenting with diabetic ketoacidosis (DKA) mandate indefinite insulin treatment? Not always. Since the mid-1990s, weve increasingly observed and recognized patients that dont neatly fit into either type 1 diabetes (T1DM) or T2DM. Ketosis-prone type 2 diabetes mellitus (KPDM) is underrecognized and distinctive. First described by Winter and colleagues in 1987, 12 African-American patients initially presented with DKA, but their disease course unfolded more like that of an individual with T2DM.1 KPDM was initially thought to be a variant of maturity onset diabetes of the young (MODY). Other names include Flatbush diabetes (named for the part of Brooklyn, NY where young African-Americans were described to have these clinical features of KPDM), type 1.5 diabetes, and atypical diabetes. 1. A large number of KPDM patients present without a previous diagnosis of DM and without a known precipitating cause for the DKA. >75% of KPDM patients fit this description. Most patients are African-American or Hispanic, overweight or obese, male (theres a two- to three-fold greater prevalence in men compared with women), in their 40s or 50s at the time of diagnosis. 2. If the patients insulin requirements rapidly decline in the first several weeks after presenting, think of possible KPDM. i. Patients test pre-meal glucose at least 2 times/day, and check in with their health care professional team every 2 weeks for the first 2 months after being discharged from the hospital to titrate insulin, and subsequently every 2 or 3 months, as extent of control warrants. ii.Clinicians begin tapering insulin by 25% at each visit, once fasting glucose declines below 130 mg/dL for 2 weeks, or if the patient develops hypoglycemia. 3. Many patients with KPDM will spontaneously remit. Most patients Continue reading >>

Ketosis-prone Diabetesa New Subgroup Of Patients With Atypical Type 1 And Type 2 Diabetes?

Ketosis-prone Diabetesa New Subgroup Of Patients With Atypical Type 1 And Type 2 Diabetes?

Ketosis-Prone DiabetesA New Subgroup of Patients with Atypical Type 1 and Type 2 Diabetes? Division of Endocrinology, Diabetes and Metabolism, Department of Medicine University of Tennessee College of Medicine Memphis, Tennessee 38163 Address all correspondence and requests for reprints to: Abbas E. Kitabchi, Ph.D., M.D., Division of Endocrinology, University of Tennessee College of Medicine, 951 Court Avenue, Room 335M, Memphis, Tennessee 38163. Search for other works by this author on: The Journal of Clinical Endocrinology & Metabolism, Volume 88, Issue 11, 1 November 2003, Pages 50875089, Abbas E. Kitabchi; Ketosis-Prone DiabetesA New Subgroup of Patients with Atypical Type 1 and Type 2 Diabetes?, The Journal of Clinical Endocrinology & Metabolism, Volume 88, Issue 11, 1 November 2003, Pages 50875089, One objective for classification of a disease is the opportunity to study its epidemiology, etiology, and pathogenesis to provide various effective interventions for its prevention and treatment. The paper of Maldonado et al. ( 1 ) in this issue of JCEM reports on the classification of four groups of diabetic patients who presented with diabetic ketoacidosis (DKA). Of the two most common types of hyperglycemic crises, DKA most often occurs in type 1 diabetes (DM-1), and hyperglycemic hyperosmolar state most frequently arises in type 2 diabetes (DM-2). However, the occurrence of these acute metabolic emergencies is not specific to one type of diabetes or the other ( 2 ). Maldonado et al. ( 1 ) have carefully and meticulously studied a well-defined multiethnic group of patients with diabetes who presented with DKA. The study cohort was divided into four groups based on positive or negative -cell insulin function (B+ or B, respectively), as well as positive or negative au Continue reading >>

Ketosis-proned Diabetes

Ketosis-proned Diabetes

Patient Case discussion: Ketosis-proned Diabetes A SERMO Endocrinologist presented a patient case for discussion focusing on Ketosis-proned Diabetes, that started an interesting dialogue about treating patients with diabetes. Today, were offering a look into SERMO by sharing the original case presentation (with some clinical pearls!) and subsequent insights from another Endocrinologist about 1) how they advise residents and fellows to discard the Type 1 & 2 labels and 2) it would relate to the case. Join the discussion now on SERMO ! A 31-year-old African-American male patient is found to have a blood glucose of 267 on a chem panel done as an outpatient. There is an anion gap of 17. Noting this, the PCP calls the patient. He advises the patient to go to the ER for further evaluation. The patient presents to the ER in diabetic ketoacidosis (DKA). He is started on insulin, and while its too early to tell for this particular individual, many patients like him can usually come off insulin rapidly, and be well-controlled on PO agents only. Does presenting with diabetic ketoacidosis (DKA) mandate indefinite insulin treatment? Not necessarily. Weve increasingly recognized since the mid-1990s that some patients defy classification into either type 1 diabetes (T1DM) or T2DM. Ketosis-prone type 2 diabetes mellitus (KPDM) is at once underrecognized and distinctive. Winter and colleagues first described this condition in 1987. Twelve African-American patients initially presented with DKA, but their disease course unfolded similarly to an individual with T2DM.1 KPDM was initially thought to be a variant of maturity onset diabetes of the young (MODY). Other names you may have seen or heard for this include Flatbush diabetes (named for the part of Brooklyn, NY where young African-Ame Continue reading >>

Syndromes Of Ketosis-prone Diabetes Mellitus

Syndromes Of Ketosis-prone Diabetes Mellitus

INTRODUCTION Since the mid-1990s, increasing attention has been focused on a heterogeneous condition characterized by presentation with diabetic ketoacidosis (DKA) in patients who do not necessarily fit the typical characteristics of autoimmune type 1 diabetes. Earlier reports used the terms "atypical diabetes," "Flatbush diabetes," "diabetes type 1B," and "ketosis-prone type 2 diabetes mellitus" to describe subsets of this condition, and it was noted that in some instances patients presented with DKA as the first manifestation of diabetes and evolved to insulin independence [1]. While initially these reports suggested that the condition, now termed ketosis-prone diabetes (KPD), might be limited to persons of non-Caucasian ethnicity, its prevalence appears to be increasing in a wide range of ethnic groups worldwide [2-5]. The classification, pathophysiology, natural history, and management of KPD will be reviewed here. Patients with islet autoantibodies who do not present with ketosis, including those termed "latent autoimmune diabetes in adults" (LADA), "type 1.5 diabetes" [6,7], and "slowly progressing type 1 diabetes" [8] are discussed elsewhere. (See "Classification of diabetes mellitus and genetic diabetic syndromes".) CLASSIFICATION OF KPD The goal of new classification schemes is to enable clinicians to predict which patients with diabetic ketoacidosis (DKA) require temporary insulin treatment versus life-long insulin therapy. They also highlight subgroups for genetic and pathogenetic studies. Ketosis-prone diabetes (KPD) comprises a group of diabetes syndromes characterized by severe beta cell dysfunction (manifested by presentation with DKA or unprovoked ketosis) and a variable clinical course. These syndromes do not fit the traditional categories of diabetes d Continue reading >>

Columbia Journalism Reporter Writing On Flatbush Diabetes

Columbia Journalism Reporter Writing On Flatbush Diabetes

Columbia Journalism reporter writing on Flatbush Diabetes Columbia Journalism reporter writing on Flatbush Diabetes I'm Hillary Ojeda, a NY City Lens Reporter, and I'm writing a story about Flatbush Diabetes. It's a subtype of diabetes that was identified by Dr. Mary Banerji at Downstate in Brooklyn in 1994. She named it after the Brooklyn neighborhood and today it is also known as "atypical diabetes," "ketosis prone diabetes," "idiopathic type 1," among others. I have spoken with doctors, including Dr. Banerji, and got their perspective on the disease, but what I need now is the viewpoint of a patient living with Flatbush Diabetes. If there is anyone with Flatbush Diabetes that would like to tell me their story, send me a personal message. D.D. Family type 2 since January 27th, 2016 Moderator T2 insulin resistant Using Basal/Bolus Therapy I can see members Googling "Flatbush Diabetes" to find out what she is talking about. I personally have no clue either! D.D. Family type 2 since January 27th, 2016 I can see members Googling "Flatbush Diabetes" to find out what she is talking about. I personally have no clue either! I did just that. I do remember a new member posting about her son having symptoms like what I googled. Except I would guess, based on what she posted, it was triggered by vaccinations. Cannot remember the poster or the thread though. This article could help explain the disease a little bit. D.D. Family T1 since 1985, MM Pump 2013, CGM 2015 Continue reading >>

Flatbush Diabetes - General Practice Notebook

Flatbush Diabetes - General Practice Notebook

Ketosis prone type 2 diabetes/atypical diabetes/flatbush diabetes is a widespread, emerging, heterogeneous syndrome characterised by patients who present with diabetic ketoacidosis (DKA) or unprovoked ketosis with hyperglycaemia but do not necessarily have the typical phenotype of autoimmune type 1 diabetes is an uncommon form of diabetes characterized by severe reversible insulin deficiency atypical diabetes was originally described by Banerji et al as a unique form of diabetes among African-American patients who presented with DKA as their initial manifestation of diabetes (1) ketosis prone type 2 diabetes, though first described and mostly observed in males of African-American descent, has been identified in Asian populations, including Japanese and Chinese there is an increased male preponderance in this condition in a South African study, half the presentations of DKA were due to type 2 diabetes (2) at initial presentation, the patients with type 2 diabetes and DKA cannot be reliably separated from those with type 1 diabetes; however, they tend to be middle-aged, obese, hypertensive and may have markers of insulin resistance such as acanthosis nigricans (2) often a positive family history of type 2 diabetes mechanism underlying their presentation seems to be the combination of insensitivity to insulin and transient loss of ability to release adequate amounts of insulin in contrast to type 1 diabetes, patients with atypical diabetes undergo spontaneous remission and maintain long-term insulin independence (1,3) during admission the patients with type 2 diabetes gradually lose their insulin resistance patients with ketosis prone type 2 diabetes do not have the autoantibodies associated with type 1 diabetes and they have recovery of insulin secretion as evidenced by Continue reading >>

Flatbush Diabetes: A Report Of Two Cases And A Review Of The Literature - Review

Flatbush Diabetes: A Report Of Two Cases And A Review Of The Literature - Review

Flatbush Diabetes: A Report of Two Cases and a Review of the Literature - Review Type 2 diabetes is an endocrine and metabolic disorder appearing with insulin resistance and impaired beta cell secretory function. Type 1 diabetes is characterized by the autoimmune destruction of pancreatic beta cells, which leads to absolute insulin deficiency. Diabetic ketoacidosis is considered a cardinal feature of type 1 diabetes. A number of studies have demonstrated that diabetic ketoacidosis also occurs in subjects with type 2 diabetes. Such patients are classified as idiopathic type 1 diabetes, type 1B diabetes, Flatbush diabetes or ketosis-prone type 2 diabetes. The aim of our study was to present two patients, who were diagnosed with ketosis-prone type 2 DM, as well as to discuss the subject in the light of the extant literature and to be able to make general recommendations. Turk Jem 2009; 13: 56-9 Key words: Flatbush diabetes, prone to ketosis, classification of diabetes mellitus Tip 2 diyabet, inslin rezistans ve beta hcre sekresyon bozukluunun birlikte grld endokrin ve metabolik bir hastalktr. Tip 1 diyabet ise pankreatik beta hcrelerinin otoimmun dekstrksiyonu sonucu inslin eksiklii ile karakterizedir. Diyabetik ketoasidoz tip 1 diyabeti belirleyici en nemli zelliklerden birisidir. Baz almalarda diyabetik ketoasidozun tip 2 diyabetik hastalarda da grld saptanmtr. Ketoz veya ketoasidoz tablosu ile bavuran baz hastalarda hem tip 1 hem de tip 2 diyabete zg klinik zelliklerin bir arada bulunduu ve bu hastalarda tan karmaas yaanabilecei bildirilmektedir. Bu hastalar idiyopatik tip 1 diyabet veya tip 1B diyabet veya Flatbush diyabet veya ketozis eilimli tip 2 diyabet olarak snflandrlmtr. Biz de bu almamzda ketozis eilimli tip 2 diyabet olduunu belirlediimiz 2 olgumuzu sunmay, k Continue reading >>

Delhi Docs Find Us-origin Flatbush Diabetes In India

Delhi Docs Find Us-origin Flatbush Diabetes In India

Delhi docs find US-origin Flatbush diabetes in India Delhi docs find US-origin Flatbush diabetes in India You may have heard about Type-I and Type-II diabetes. But new findings suggest that a number of patients in India may be suffering from a third type - Flatbush diabetes - which has the characteristics of both. NEW DELHI: You may have heard about Type-I and Type-II diabetes. But new findings suggest that a number of patients in India may be suffering from a third type - Flatbush diabetes - which has the characteristics of both. This possibility has been highlighted by Delhi doctors in a research article published in the medical journal 'Diabetes Care'. They claim to have identified the first case of Flatbush diabetes in a patient of Indian origin. The patient, a 39-year-old driver, visited Max Super-specialty in Saket, for the first time in 2011. His blood sugar was above 500 mg/dl which is very high but it came down within few days on insulin therapy. "The symptoms reappeared twice again, in 2012 and 2013, and it was treated with insulin therapy for a few weeks, which is not possible in Type-I or Type-II diabetes. While the former requires lifelong insulin therapy, the latter requires drastic modification, for example weight reduction, for recovery," said Dr Sujeet Jha, director, department of endocrinology at the hospital. Jha said further testing and antibody analysis confirmed Flatbush diabetes, which has so far been described in patients of African-American, Chinese, Japanese and Hispanic descent, but never in the Indian population. "During diagnosis, patients with Flatbush diabetes present very high blood sugars and ketones (a substance produced when the body starts to break down fat for energy in the setting of high blood glucose levels). Initially, they need Continue reading >>

Male Predominance In Ketosisprone Diabetes Mellitus (review)

Male Predominance In Ketosisprone Diabetes Mellitus (review)

Male predominance in ketosisprone diabetes mellitus (Review) Affiliations: Department of Endocrinology and Metabolism, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, P.R. China Published online on: May 8, 2015 Metrics: HTML 0 views | PDF 0 views Cited By (CrossRef): 0 citations The incidence of ketosisprone diabetes mellitus (KPDM) shows a higher prevalence in men. The clear male predominance of this syndrome and its underlying pathogenesis mechanisms are unclear. KPDM, once described as atypical diabetes mellitus, idiopathetic type1 diabetes (type1B diabetes) and flatbush diabetes, is an uncommon form of diabetes characterized by severe reversible insulin deficiency. KPDM was first described and mostly observed in males of AfricanAmerican descent and recently in Asian populations, including Japanese and Chinese. Patients with KPDM often present acutely with diabetic ketoacidosis without any immunological autoantibody to islet antigens of classic type1 diabetes but demonstrate clinical and metabolic features of type2 diabetes. Accumulating data indicated that genderrelated body fat distribution, hormonal and genetic factors are associated with the diabetic process and the human glucose homeostasis and metabolism. A controversial question is whether and to what degree those factors contribute to the phenomenon of male predominance in KPDM. The present review focuses on the role of gender hormones and other potential precipitating factors in explaining the male predominance in KPDM patients. Recent evidence indicates that ketosis-pronediabetes mellitus (KPDM), which was once described as atypicaldiabetes mellitus, idiopathetic type 1 diabetes (type 1B diabetes)or flatbush diabetes, shows a 2- or 3-fold higher prevalence in mencompared to women ( 1 5 Continue reading >>

Suny Downstate Medical Center, N.y.

Suny Downstate Medical Center, N.y.

Yahoo!-ABC News Network | 2018 ABC News Internet Ventures. All rights reserved. SUNY Downstate SUNY Downstate is the only academic medical center in Brooklyn, where we are at the epicenter of an increasing diabetes epidemic. The population here is extremely diverse, and around the medical center, rates of diabetes are as high as 15-20 percent. Working with the CDC and New York state, we are actively involved with community education to prevent and control diabetes complications. My colleagues and I described a novel type of diabetes among African-Americans with a type 1 diabetes look-alike, in which they might need insulin treatment for life. In fact, they had type 2 diabetes and did not need long-term insulin. We called this Flatbush diabetes, after our neighborhood. Since then it has been recognized as a worldwide phenomenon. We also pioneered the concept of early, intensive control of blood sugar to induce long-term remissions of diabetes. This approach promotes the preservation of the pancreas' own beta cells. Such a period of normal blood sugars could lead to decreased complications of diabetes. People with diabetes live shorter lives by six to eight years. To prevent this and other complications, I am involved with the ACCORD trial. This is a large, multi-center, NIH-sponsored clinical trial for preventing death and complications of diabetes through the control of blood sugar, blood pressure, and lipids. Continue reading >>

Ketoacidosis In A Patient With Type 2 Diabetes – Flatbush Diabetes

Ketoacidosis In A Patient With Type 2 Diabetes – Flatbush Diabetes

There is increasing recognition of a group of patients with type 2 diabetes who can present with ketoacidosis. Most reports have been of patients of African descent; however, the condition has been reported in other groups. This is a case of a Caucasian patient who has had three presentations with ketoacidosis and whose diabetes is not usually insulin-dependent. A patient, aged 48 years, presented with diabetic ketoacidosis (DKA) in a semi-comatose condition. She had a 3-day history of vomiting and loss of appetite. In the previous weeks she had undergone radiotherapy for metastatic squamous cell carcinoma (skin primary). The patient had two similar episodes of DKA, one 20 months and another 3 months earlier. Two of the patient’s brothers had type 2 diabetes. The patient was not abusing alcohol and did not have a history of pancreatitis. Three years prior to this admission the patient had been diagnosed elsewhere with type 2 diabetes, for which she had been on metformin and a small dose of insulin glargine. Two months after stopping her insulin glargine she developed her first episode of DKA while visiting our town. DKA, was diagnosed on the basis of arterial pH 7.03, blood glucose level 25.9 mmol/L, bicarbonate level of 5 mmol/L and positive urinary ketones. It was felt that infected skin lesions may have precipitated the DKA. Eleven days later, she was discharged on metformin 250 mg twice daily and a falling dose of insulin glargine (26 units a day). She was then lost to follow-up in our centre, but apparently soon after did not require insulin and maintained adequate gylcaemic control for 18 months until just prior to her next admission solely on metformin 1 g twice daily. The next admission for DKA occurred while living in a city. She was discharged on insulin but Continue reading >>

Diabetic Ketoacidosis: Not Always Due To Type 1 Diabetes

Diabetic Ketoacidosis: Not Always Due To Type 1 Diabetes

Diabetic ketoacidosis: not always due to type 1 diabetes Diabetic ketoacidosis: not always due to type 1 diabetes BMJ 2013; 346 doi: (Published 10 June 2013) Cite this as: BMJ 2013;346:f3501 S Misra, specialty registrar metabolic medicine 1 , 1Department of Metabolic Medicine and Clinical Biochemistry, Imperial Healthcare NHS Trust, Charing Cross Hospital, London W6 8RF, UK 2Department of Diabetes and Endocrinology, Charing Cross Hospital, Imperial Healthcare NHS Trust, London, UK Correspondence to: S Misra smisra{at}imperial.ac.uk This article discusses how to diagnose and manage patients with ketosis prone type 2 diabetes Patients presenting with diabetic ketoacidosis may have type 1 or type 2 diabetes Diabetic ketoacidosis should be treated with insulin in accordance with nationally agreed guidance After treatment of diabetic ketoacidosis, patients found to have type 2 diabetes may not require lifelong insulin treatment Consider ketosis prone type 2 diabetes in older, overweight, non-white patients who present with diabetic ketoacidosis at their first presentation of diabetes; this diagnosis is also a possibility in patients with any features that are atypical for type 1 diabetes Discharge all patients on insulin and arrange for specialist follow-up Under specialist supervision consider whether insulin can be down-titrated on the basis of clinical progress and, where possible, C peptide and antibody measurements Diabetic ketoacidosis (DKA) is not just the hallmark of absolute insulin deficiency in type 1 diabetesit is increasingly being seen in people presenting with type 2 diabetes. 1 2 This is at odds with traditional physiological teachingthat clinically significant ketosis does not occur in the presence of insulin concentrations associated with type 2 diabetes b Continue reading >>

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