I like the idea of putting this new information but it seems like too much of a long card to be done efficiently and for people to learn from it. Most people should read diabetic in dka and connect it with low insulin automatically as there is another card that covers that topic. Beta oxidation is a nice addition to connect things together but it could be placed in extra.
@kevinpanini @Brian_BH curious if you have any additional thoughts. I still feel like the current card feeds into a pretty common misconception that DKA is caused by or necessitates hyperglycemia. High blood glucose is a common feature of DKA because of impaired glucose uptake and increased gluconeogenesis, but it is not the cause of the acidosis itself (See Euglycemic DKA - DKA without having hyperglycemia). It is specifically the low insulin and consequent low intracellular glucose that produce the observed metabolic alterations. Therefore, the card is incorrect and does not contribute to a good mechanistic understanding of DKA. I feel like the suggested edit makes the correct links between 1. low insulin causing low intracellular glucose 2. compensatory B-oxidation and 3. downstream build up of ketone bodies. All of which is currently supported by the currently linked Youtube Video as well.
I unfortunately donât think Kaplan offers any help:
Kaplan: Diabetes mellitus is caused by a disruption of the insulin/GLUT 4 mechanism. In type 1 diabetes, insulin is absent and cannot stimulate the insulin receptor. In type 2 diabetes, the receptor becomes insensitive to insulin and fails to bring GLUT 4 transporters to the cell surface. In both cases, blood glucose rises, leading to immediate symptoms (increased urination, increased thirst, ketoacidosis) and long-term symptoms (blindness, heart attacks, strokes, nerve damage).
This is included in a quick âReal Worldâ connection passage and I think ultimately does a disservice to the reader by providing too high level of a summary and as a result seemingly directly attributing the rise in blood glucose directly to ketoacidosis. I wonder if something like
{{c1::Diabetic ketoacidosis (DKA)}} occurs when low intracellular glucose caused by insulin deficiency causes increased compensatory {{c2::B-oxidation}} and a dangerous downstream build-up of {{c2::acidic ketone bodies}}
is better?
So quick takeaway: the existing card is not great, objectively. The phrasing is informal, and loose, and it needs improvement.
That being said, we run into an issue here where, again, âliving document.â
If a user has seen âvery highâ behind cloze2 for 5,000 repetitions and is on week 10 of 12 in their MCAT prep, we canât suddenly change cloze2 from âvery highâ to âB-oxidationâ without causing a lot of (rightfully) pissed off users.
So the card falls into that realm where, for better or worse, we canât really re-write an existing card from scratch; we have to work within the confines of the existing architecture (at least for an existing card).
Thatâs not to say that the task is easy, or fun, and maybe the solution is that the card gets minimally cleaned up here and, separately, we need to submit a suggestion for another card to adequately tackle the nuance (Iâm not saying that that is, necessarily, the solution just that itâs a conceivable option).
So the question becomes: for this card in particular, how do we improve the phrasing (and, ideally, maybe even the content treatment) without reinventing the wheel and upsetting the apple cart for the 10,000+ active users who are studying with the deck?
Iâm open to suggestions for sure. My instinct is that this will be a tough one to find a happy medium on (without simply adding an additional card). But, Iâm happy to hash it out and maybe Iâm wrong and we can land on something
Second from that, I think the Extra field, while adding some good info, would benefit from some conciseness and parsimony in phrasing. Expanding from a single sentence to three paragraphs is a very big jump and needs to be weighed against the cost benefit/utility to that much text expansion for the user-base. But that is, arguably, a secondary issue; the cloze-content/s is definitively the larger issue at hand
Makes sense to me. I agree and personally have no idea how you could fix this to fit the new info within the existing architecture. At the very least though I think it might benefit from something like
{{c1::Diabetic ketoacidosis (DKA)}} is often accompanied by {{c2::very high}} blood sugar and is caused by a dangerous build up of {{c3::acidic}} substances called {{c3::ketones}}.
This 1. Accomplishes making it clear that hyperglycemia itself is not the cause of DKA nor is DKA necessarily always accompanied by hyperglycemia which was my primary concern. âOccurs when your blood sugar is very highâ is what I took particular issue with because it makes DKA appear secondary to/the result of hyperglycemia 2) doesnât change the cloze answers/unlikely to really throw off users as much.
If a new card canât be added soon the extra section for this card may then benefit with the inclusion of the new material suggested in the text section for now. Maybe:
Extra:
Lack of insulin associated with diabetes prevents glucose uptake from the bloodstream causing increased compensatory B-oxidation and build up of acidic ketone bodies as described.
What do you think?
Thatâs definitely the core conundrum here; once a card exists and is in live rotation for thousands of users there is a natural amount of constraint that has to be a functional boundary to what we can do. Itâs not feasible, or advisable, to âclean-slateâ a given card when thousands of people rely on it. Itâs not always fun, of course, and no question itâs rained on my edit parades more than a few times, but itâs a natural compromise thatâs presented when editing a live deck for many thousands of active users.
This sounds solid to me. It also gets rid of the possessive âyourâ which I find overly informal and irksome (weâre not writing a textbook, exactly, but neither are we writing a commercial or a pamphlet; second person possessives sound out of place, imo).
We can definitely suggest a new card if you have an idea you think is warranted. Right now suggestions to existing cards have high priority, and new and/or deletion suggestions are in a holding stasis until we can get fully astride of all the other needs of the deck.
Adding cards will also necessitate a longer conversation about what can, and should, be added (and what that approval process looks like). For example, the Step Deck has something like 40-ish maintainers and of those 40 maintainers only one person is allowed to give the okay for addition of new cards. Such steps are taken very, very seriously (arguably for good reason) and once you start meditating on what could be included you quickly realize that the potential for runaway bloat is immense (I have some thoughts on this as well).
I like it. I think itâs a great additional level of detail, honestly. 
Iâd like to chop it up a little bit; brevity and conciseness (like a ninja):
Lack of insulin production, due to diabetes, prevents glucose uptake. Compensatory B-oxidation then leads to the build up of ketone bodies in the blood.
I go either way on the commas in the first sentence, and unsure if we need to specify âin the bloodâ since that may (or may not) be obvious. Lemme know your thoughts
Also, maybe itâs the OCD in me but Iâd love to make that the Greek beta symbol, rather than just the Latin âBâ. Iâm open if others disagree, but I canât stop staring at it as being out of place, lol
Sounds great. Made the changes. I think the commas make sense and specifying in the blood isnât a bad thing to include. LMK what you think.
Looking sharp.
@kevinpanini you wanna weigh in; share any perceptions, thoughts, opinions, such as you might have?
Much better changes then the first time I looked at this card. Its no longer a whe paragraph in the front or extra section and seems to make sense. What I understand from reading it is that DKa is caused by both of those things. If that is what is meant then I think the correct message is displayed here.
Hi @kevinpanini. When you say âwhat I understand from reading it is that DKA is caused by both of those thingsâ do you mean the original suggests to you that DKA is caused by high blood glucose and a build up of ketone bodies and that the new edit correctly avoids attributing hyperglycemia as a cause of DKA or do you mean that the new edit I made suggests this relationship.
sorry i was confused, currently the wording that DKA is accompanied by blood sugar and ketones makes it sound like all 3 occur together or at the same time, either through other mechanisms or interactions. the previous version that sattes that blood sugar and ketones cause DKA is no longer correct if I understood correctly.
No problem! DKA is caused by low intracellular glucose due to a lack of insulin required to uptake glucose from the bloodstream. As a result, there is compensatory B-oxidation to produce energy in the absence of intracellular glucose. Acetyl-coA produced by B-oxidation is increasingly shunted toward ketone body production because oxaloacetate (carbohydrate derivative - production largely dependent on ability to intake glucose) cannot be quickly replenished to keep up with acetyl-coA metabolism via the TCA. High blood glucose is a common feature of DKA because of impaired glucose uptake and increased gluconeogenesis (No insulin negative feedback), but it is not the cause of the acidosis itself (See Euglycemic DKA - DKA without having hyperglycemia). Therefore, the goal of the new edit is to suggest that ketoacidosis is caused by a build up of acidic ketones and that hyperglycemia is a common finding with diabetic ketoacidosis but it is not the cause. If you agree that the new edit accomplishes this I think we are good!