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Flood K, Nour M, Holt T, Cattell V, Krochak C, Inman M. Implementation and Evaluation of a Diabetic Ketoacidosis Order Set in Pediatric Type 1 Diabetes at a Tertiary Care Hospital: A Quality-Improvement Initiative. Can J Diabetes 2019; 43:297-303. [PMID: 30777707 DOI: 10.1016/j.jcjd.2018.12.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/11/2018] [Accepted: 12/19/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Despite published clinical practice guidelines in pediatrics for the use of a standardized diabetic ketoacidosis (DKA) protocol, our centre lacked an accepted, evidence-informed protocol for pediatric DKA management. Our primary aim was to attain broad clinical uptake of a DKA order set. Secondary aims included improved standard-of-care DKA management principles regarding fluid, potassium and dextrose administration. METHODS A pediatric multidisciplinary collaborative was created to examine evidence for the development and implementation of a DKA order set. A modified plan-do-study-act cycle guided by end-user feedback and early clinical outcomes allowed progressive order-set modifications and hospitalwide implementation. RESULTS We achieved 83% uptake of the order set for patients presenting to our tertiary centre and 67% uptake for patients transferred from peripheral centres. Following the implementation of the DKA order set, we observed improvements in DKA management, which included more appropriate intravenous (IV) replacement fluid rates (30% vs. 55.1%; p=0.03); earlier administration of potassium to IV fluids (66% vs. 93.1%; p=0.006); more appropriate potassium chloride dosing to IV fluid (40% vs. 79.3%; p=0.0007) and earlier addition of IV dextrose (67.4% vs. 93.1%; p=0.009). CONCLUSIONS Implementation of a DKA order set in a tertiary hospital required identification of key stakeholders, formation of a multidisciplinary team and the development of an evaluation process. There was an observed increase in physician order-set uptake and DKA management practice improvements. Future goals involve expanding the implementation and evaluation process to provincial regional and remote centres and analyzing the impact on resource utilization.
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Affiliation(s)
- Kayla Flood
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Munier Nour
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Tanya Holt
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Vicki Cattell
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Carla Krochak
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Mark Inman
- Department of Pediatrics, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Royal University Hospital, Saskatoon, Saskatchewan, Canada.
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102
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Gauntt J, Vaidyanathan P, Basu S. Utilizing serum bicarbonate instead of venous pH to transition from intravenous to subcutaneous insulin shortens the duration of insulin infusion in pediatric diabetic ketoacidosis. J Pediatr Endocrinol Metab 2019; 32:11-17. [PMID: 30530908 DOI: 10.1515/jpem-2018-0394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 11/02/2018] [Indexed: 11/15/2022]
Abstract
Background Standard therapy of diabetic ketoacidosis (DKA) in pediatrics involves intravenous (IV) infusion of regular insulin until correction of acidosis, followed by transition to subcutaneous (SC) insulin. It is unclear what laboratory marker best indicates correction of acidosis. We hypothesized that an institutional protocol change to determine correction of acidosis based on serum bicarbonate level instead of venous pH would shorten the duration of insulin infusion and decrease the number of pediatric intensive care unit (PICU) therapies without an increase in adverse events. Methods We conducted a retrospective (pre/post) analysis of records for patients admitted with DKA to the PICU of a large tertiary care children's hospital before and after a transition-criteria protocol change. Outcomes were compared between patients in the pH transition group (transition when venous pH≥7.3) and the bicarbonate transition group (transition when serum bicarbonate ≥15 mmol/L). Results We evaluated 274 patient records (n=142 pH transition group, n=132 bicarbonate transition group). Duration of insulin infusion was shorter in the bicarbonate transition group (18.5 vs. 15.4 h, p=0.008). PICU length of stay was 3.2 h shorter in the bicarbonate transition group (26.0 vs. 22.8 h, p=0.04). There was no difference in the number of adverse events between the groups. Conclusions Transitioning patients from IV to SC insulin based on serum bicarbonate instead of venous pH led to a shorter duration of insulin infusion with a reduction in the number of PICU therapies without an increase in the number of adverse events.
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Affiliation(s)
- Jennifer Gauntt
- Division of Cardiology, Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH 43205, USA, Phone: +614-722-0596
| | - Priya Vaidyanathan
- Division of Endocrinology and Diabetes, Children's National Health System, Washington, DC, USA
| | - Sonali Basu
- Division of Critical Care Medicine, Children's National Health System, Washington, DC, USA
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103
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Lombardo F, Passanisi S, Gasbarro A, Tuccari G, Ieni A, Salzano G. Hepatomegaly and type 1 diabetes: a clinical case of Mauriac's syndrome. Ital J Pediatr 2019; 45:3. [PMID: 30616577 PMCID: PMC6322227 DOI: 10.1186/s13052-018-0598-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 12/19/2018] [Indexed: 02/08/2023] Open
Abstract
Background Hepatic glycogenosis is characterized by excessive glycogen accumulation in hepatocytes and represents a complication of poor controlled type 1 diabetes. It can be caused by excessive insulin doses or recurrent ketoacidosis episodes. Mauriac’s syndrome is a rare disease, which includes short stature, growth maturation delay, dyslipidemia, moon facies, protuberant abdomen, hepatomegaly with transaminase elevation. It has become even less common after the emergence of advances on diabetes treatment, but still exists. Recent reports described glycogenosis without the full spectrum of Mauriac’s syndrome in both adults and children with brittle diabetes. Clinical, laboratory and histological abnormalities are reversible with appropriate glycemic control. Case presentation We hereby report a case of 11-year-old male who presented with hepatic glycogenosis mimicking Mauriac’s syndrome. The patient was admitted at our Pediatric Diabetes Clinic for marked hepatomegaly, short stature and for the poor metabolic control. Blood investigations and liver tests excluded most of major causes of hepatopathy. A liver biopsy allowed us to make diagnosis of hepatic glycogenosis. To control hyperglycaemia, initially we titrated daily insulin dosage, and then intravenous insulin treatment was practiced with the consequent normalization of liver enzymes. Conclusion Mauriac’s syndrome should be considered in subjects with brittle type 1 diabetes and hepatomegaly.
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Affiliation(s)
- Fortunato Lombardo
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Stefano Passanisi
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Albino Gasbarro
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Giovanni Tuccari
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", Section of Anatomic Pathology, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Antonio Ieni
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", Section of Anatomic Pathology, University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy
| | - Giuseppina Salzano
- Department of Human Pathology in Adult and Developmental Age "Gaetano Barresi", University of Messina, Via Consolare Valeria 1, 98125, Messina, Italy.
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104
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Thalange N, Gundgaard J, Parekh W, Tutkunkardas D. Cost analysis of insulin degludec in comparison with insulin detemir in treatment of children and adolescents with type 1 diabetes in the UK. BMJ Open Diabetes Res Care 2019; 7:e000664. [PMID: 31543973 PMCID: PMC6731813 DOI: 10.1136/bmjdrc-2019-000664] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/03/2019] [Accepted: 07/25/2019] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE With healthcare systems under increasing financial pressure from costs associated with diabetes care, it is important to assess which treatments provide clinical benefits and represent best value. This study evaluated the annual costs of insulin degludec (degludec) versus insulin detemir (IDet) in children and adolescents with type 1 diabetes (T1D) in the UK. RESEARCH DESIGN AND METHODS Using data from a randomized, treat-to-target, non-inferiority trial-BEGIN YOUNG 1-annual costs with degludec versus IDet in children and adolescents aged 1-17 years with T1D were estimated, as costs of these insulins and hyperglycemia with ketosis events. Analyses by age group (1-5, 6-11 and 12-17 years) and scenario (no ketosis benefit, no dose benefit, hyperglycemia with ketones >0.6 and >3.0 mmol/L and the additional costs of twice-daily IDet in 64% of patients) were also performed. RESULTS The mean annual cost per patient was estimated as £235.16 for degludec vs £382.91 for IDet, resulting in an annual saving of £147.75 per patient. These substantial cost savings were driven by relative reductions in the frequency of hyperglycemia with ketosis and basal insulin dose with degludec versus IDet. Annual savings in favor of degludec were observed across each age group (£122.63, £140.59 and £172.50 for 1-5, 6-11 and 12-17 years age groups, respectively). Five scenario analyses further demonstrated the robustness of the results, which included no ketosis or dose benefits in favor of degludec. CONCLUSIONS Degludec provides appreciable annual cost savings compared with IDet in children and adolescents with T1D in a UK setting. While a cost-effectiveness analysis could incorporate the health impact of treatment complications better than the present cost analysis, the strong generalizability of the data from this study suggests that degludec can help healthcare providers to maximize health outcomes despite increasingly stringent budgets.
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Affiliation(s)
- Nandu Thalange
- Al Jalila Children’s Hospital, Dubai, United Arab Emirates
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105
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Everett E, Mathioudakis NN. Association of socioeconomic status and DKA readmission in adults with type 1 diabetes: analysis of the US National Readmission Database. BMJ Open Diabetes Res Care 2019; 7:e000621. [PMID: 31114699 PMCID: PMC6501850 DOI: 10.1136/bmjdrc-2018-000621] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To identify patient and hospital predictors of recurrent diabetic ketoacidosis (DKA) admissions in adults in the USA with type 1 diabetes, focusing on socioeconomic indicators. RESEARCH DESIGN AND METHODS This cross-sectional study used the National Readmission Database to identify adult patients with type 1 diabetes admitted for DKA between 2010 and 2015. The index DKA admission was defined as the first admission within the calendar year and the primary outcome was recurrent DKA admission(s) within the same calendar year. Multivariable logistic regression analysis was performed using covariates of patient and hospital factors at the index admission to determine the odds of DKA readmission(s). RESULTS Among 181 284 index DKA admissions, 39 693 (22%) had at least one readmission within the calendar year, of which 33 931 (86%) and 5762 (14%) had 1-3 and ≥4 DKA readmissions, respectively. When compared with the highest income quartile, patients in the first and second income quartiles had 46% (95% CI 30% to 64%) and 34% (95% CI 19% to 51%) higher odds of four or more DKA readmissions, respectively. Medicaid and Medicare insurance were both associated with a 3.3-fold adjusted risk (95% CI 3.0 to 3.7) for ≥4 readmissions compared with private insurance, respectively. Younger age, female sex, and discharge against medical advice were also predictive. CONCLUSIONS Lower socioeconomic status and Medicaid insurance are strong predictors of DKA readmissions in adults with type 1 diabetes in the USA. Further studies are needed to understand the mediators of this association to inform multilevel interventions for this high-risk population. SIGNIFICANCE OF THE STUDY The association of socioeconomic status (SES) and hospital admission for DKA has been studied in pediatrics with type 1 diabetes, but the data in adults are limited, and studies evaluating recurrent DKA admissions are scarcer. To our knowledge, this is the first study to describe predictors of recurrent DKA admissions in adults with type 1 diabetes on a national level in the USA. We found that those at highest risk of recurrent DKA are young women with low SES who had Medicaid or Medicare insurance. These findings should prompt further studies to explore the mediators of these disparities in patients with type 1 diabetes, as recurrent DKA results in high healthcare utilization and increased risk of long-term complications.
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Affiliation(s)
- Estelle Everett
- Endocrinology, Johns Hopkins University, Baltimore, Maryland, USA
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106
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Al-Obaidi A, Alidrisi H, Mansour A. Precipitating Factors for Diabetic Ketoacidosis among Patients with Type 1 Diabetes Mellitus: The Effect of Socioeconomic Status. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2019. [DOI: 10.1159/000499839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
<b><i>Background:</i></b> Diabetic ketoacidosis (DKA) is one of the life-threatening acute complications of diabetes mellitus that mainly occurs in type 1 diabetes mellitus (T1DM). This study aimed to determine the socioeconomic factors associated with DKA in patients with T1DM in Basrah. <b><i>Methods:</i></b> A cross-sectional study including patients with T1DM who were admitted due to DKA or any other complaint in any of the teaching hospitals in Basrah, from February to October 2017. Data collection from each patient or their parents using a questionnaire was designed to capture personal, social, and disease-related factors. <b><i>Results:</i></b> One hundred forty-seven patients were involved in this study. They were compared with different factors to assess correlations with the risk of DKA. Younger age, underweight, being without a job, low personal and/or mother educational level, travel, home glucose monitoring less than 7 times a week, uncontrolled HbA<sub>1c</sub> and insulin stoppage as a cause of DKA regardless of the reasons to stop were associated with an increased risk of DKA. On the other hand, own home, availability of a glucometer for checking glucose, basal-bolus insulin regimen, insulin supply, and education at a tertiary center, correct injection technique whoever injected the insulin and dietary adherence, all were associated with a decreased risk of DKA. Other factors like gender, marital status, smoking status, father educational level, residency, income, personal home area, the frequency of HbA<sub>1c</sub> checking, and family history of diabetes were not associated with a significant effect on the DKA risk. <b><i>Conclusions:</i></b> Multiple socioeconomic factors interact to play a vital role in the development of DKA among patients with T1DM in Basrah.
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107
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Jeziorny K, Niwald A, Moll A, Piasecka K, Pyziak-Skupien A, Waszczykowska A, Baranska D, Malachowska B, Szadkowska A, Mlynarski W, Zmyslowska A. Measurement of corneal thickness, optic nerve sheath diameter and retinal nerve fiber layer as potential new non-invasive methods in assessing a risk of cerebral edema in type 1 diabetes in children. Acta Diabetol 2018; 55:1295-1301. [PMID: 30327872 PMCID: PMC6244862 DOI: 10.1007/s00592-018-1242-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/05/2018] [Indexed: 01/17/2023]
Abstract
AIMS Some patients with diabetic ketoacidosis develop cerebral edema (CE) in the course of type 1 diabetes mellitus (T1D), which may result in central nervous system disorders and high mortality. The imperfection of existing neuroimaging techniques for early recognition of CE forces us to search for the new and non-invasive methods. The aim of the study was to assess the usefulness of new methods (pachymetry, transorbital ultrasonography-USG, optical coherence tomography-OCT study) in the assessment of the risk of CE occurrence in children with newly diagnosed T1D. METHODS The study group included 50 children with newly diagnosed T1D, 54 patients with long-term T1D as a reference group and 40 children without glucose tolerance disorders as controls. In all subjects, a corneal thickness (CCT) index with pachymeter, optic nerve sheath diameter (ONSD) using transorbital USG and retinal nerve fiber layer (RNFL) during OCT study were measured and compared with selected clinical parameters of T1D. RESULTS In patients from a study group at onset of T1D, the higher CCT (p < 0.001) and ONSD (p < 0.001) values were observed as compared to the results obtained after 48 h of metabolic compensation. The ONSD correlated negatively with pH value (r = - 0.64; p < 0.001), BE (r = - 0.54, p < 0.001) and HCO3- (r = - 0.50; p < 0.001). A positive correlation between RNFL and Na+ levels (r = 0.47; p < 0.005) was also observed. CONCLUSIONS Transorbital USG and pachymetry may serve as the potential promising methods for the non-invasive assessment of the increased risk of development of CE in patients with T1D.
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Affiliation(s)
- Krzysztof Jeziorny
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Sporna Str. 36/50, 91-738, Lodz, Poland
| | - Anna Niwald
- Outpatient Clinic of Pediatric Ophthalmology, Central Clinical Hospital, Lodz, Poland
| | - Agnieszka Moll
- Outpatient Clinic of Pediatric Ophthalmology, Central Clinical Hospital, Lodz, Poland
| | - Katarzyna Piasecka
- Outpatient Clinic of Pediatric Ophthalmology, Central Clinical Hospital, Lodz, Poland
| | - Aleksandra Pyziak-Skupien
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Sporna Str. 36/50, 91-738, Lodz, Poland
| | - Arleta Waszczykowska
- Department of Ophthalmology and Vision Rehabilitation, Medical University of Lodz, Lodz, Poland
| | - Dobromiła Baranska
- Department of Diagnostic Imaging, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Beata Malachowska
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, Lodz, Poland
| | - Agnieszka Szadkowska
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Sporna Str. 36/50, 91-738, Lodz, Poland
| | - Wojciech Mlynarski
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Sporna Str. 36/50, 91-738, Lodz, Poland
| | - Agnieszka Zmyslowska
- Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Sporna Str. 36/50, 91-738, Lodz, Poland.
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108
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Muller M, Wheeler BJ, Blackwell M, Colas M, Reith DM, Medlicott NJ, Al-Sallami HS. The influence of patient variables on insulin total daily dose in paediatric inpatients with new onset type 1 diabetes mellitus. J Diabetes Metab Disord 2018; 17:159-163. [PMID: 30918850 DOI: 10.1007/s40200-018-0355-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/06/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Insulin dose requirements at new diagnosis of type 1 diabetes mellitus (T1DM) vary widely. Current guidelines recommend an initial total daily dose (TDD) ranging from 0.5 to 1.0 IU/kg/day. It often takes several days of frequent dose adjustments before an optimal insulin dose is achieved. The aim of this study was to identify the influence of patient variables on the dose-requirement of insulin in newly diagnosed children with T1DM. METHODS A retrospective chart review of children (≤ 18 years old) admitted to hospital between 2010 and 2016 due to new onset T1DM was undertaken. Demographic, clinical, insulin dosing, and laboratory data were recorded. The influence of patient characteristics on insulin TDD was analysed statistically by performing univariate and multivariate linear regression analyses. RESULTS Complete clinical records for 70 patients were available for analysis. The median insulin TDD on first day of admission was 21 (4.5 to 75 units) and that on the day before discharge was 27 (5.5 to 124 units). In the multivariate regression analysis, body size (total body weight and fat-free mass), glycated haemoglobin (HbA1C), and blood ketone concentration were found to be significant predictors of optimal insulin TDD (p < 0.05). CONCLUSION In addition to body size, HbA1c and ketone concentrations are useful in calculating initial TDD in newly diagnosed children with T1DM. This could potentially decrease the number of days needed to reach a stable dose and result in improved early glycaemic control.
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Affiliation(s)
- Marion Muller
- 1School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - Benjamin J Wheeler
- 2Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Miranda Blackwell
- 2Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Mathilde Colas
- 1School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - David M Reith
- 2Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
| | - Natalie J Medlicott
- 1School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
| | - Hesham S Al-Sallami
- 1School of Pharmacy, University of Otago, PO Box 56, Dunedin, 9054 New Zealand
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109
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Rogowicz-Frontczak A, Pilacinski S, Wyka K, Wierusz-Wysocka B, Zozulinska-Ziolkiewicz D. Zinc transporter 8 autoantibodies (ZnT8-ab) are associated with higher prevalence of multiple diabetes-related autoantibodies in adults with type 1 diabetes. Diabetes Res Clin Pract 2018; 146:313-320. [PMID: 30465779 DOI: 10.1016/j.diabres.2018.11.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 09/27/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
AIM The study aimed to assess the prevalence of zinc transporter 8 autoantibodies (ZnT8-ab), other diabetes-related autoantibodies and clinical manifestation of type 1 diabetes in adults, depending on age of the onset of disease. METHODS 119 patients with type 1 diabetes, 66 at age <35 years (T1DM < 35) and 53 T1DM at age ≥35 years (T1DM ≥ 35). We assessed clinical features, GAD-ab, IA2-ab, ICA, ZnT8-ab and thyroid peroxidase antibodies (ATPO). RESULTS In T1DM < 35 lower initial serum C-peptide concentration was observed and diabetes ketoacidosis (DKA) was more common. ATPO positivity was more prevalent in T1DM ≥ 35 (35.8 vs 21.2%, p = 0.04). The prevalence of GAD-ab, IA2-ab and ZnT8-ab was similar in both groups, the titres of IA2-ab and ICA were higher in T1DM < 35 but titre of ZnT8-ab was higher in T1DM ≥ 35. The majority of T1DM < 35 patients were positive for three autoantibodies (40.9%), while T1DM ≥ 35 subjects most often presented with only one (30.2%) antibody, most commonly GAD-ab (81.2%). 45% T1DM < 35 and 34% T1DM ≥ 35 subjects were positive for ZnT8-ab. ZnT8-ab positive patients had higher titre and more frequent occurrence of multiple diabetes-related autoantibodies than ZnT8-ab negative patients. CONCLUSIONS Adults with T1DM < 35 and T1DM ≥ 35 differ in the severity of autoimmune response at diagnosis. ZnT8-ab positivity is related to higher titre and more frequent occurrence of multiple diabetes-related autoantibodies.
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110
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Derraik JGB, Cutfield WS, Maessen SE, Hofman PL, Kenealy T, Gunn AJ, Jefferies CA. A brief campaign to prevent diabetic ketoacidosis in children newly diagnosed with type 1 diabetes mellitus: The NO-DKA Study. Pediatr Diabetes 2018; 19:1257-1262. [PMID: 30014558 DOI: 10.1111/pedi.12722] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/07/2018] [Accepted: 07/02/2018] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE New-onset diabetic ketoacidosis (NO-DKA) is entirely preventable with early recognition of the symptoms of type 1 diabetes mellitus (T1D). In this study, we aimed to assess whether a simple and easily delivered educational campaign could reduce the risk of DKA. METHODS A poster highlighting key features of new-onset T1D was delivered once a year over 2 years to mailboxes of over 460 000 individual residential households in the Auckland region (New Zealand). In the first year, the campaign poster was also delivered to all general practices in the region. Families of all newly diagnosed cases of T1D in children answered a brief questionnaire to ascertain whether the campaign reached them. RESULTS Over the 24-month period covered by this study, 132 new cases of T1D were diagnosed in children and adolescents in Auckland. There were 38 cases (28.8%) of DKA, which is similar to the average over the previous 5-year period (27.0%). The caregivers of three children reported both seeing the campaign poster and seeking medical attention as a result. None of these three children were in DKA at diagnosis; they were aged 6.3 to 9.7 years, and of New Zealand European ethnicity. CONCLUSIONS A non-targeted campaign to raise awareness of diabetes symptoms in youth led only a few caregivers to seek timely medical attention. Overall, this once-yearly untargeted campaign to raise awareness of diabetes symptoms in youth had limited impact. More effective strategies are required, possibly involving sustained targeted education of medical practitioners.
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Affiliation(s)
- José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start-National Science Challenge, University of Auckland, Auckland, New Zealand.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Wayne S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start-National Science Challenge, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Sarah E Maessen
- Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Timothy Kenealy
- Liggins Institute, University of Auckland, Auckland, New Zealand.,School of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand.,Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Craig A Jefferies
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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111
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Rabbone I, Minuto N, Toni S, Lombardo F, Iafusco D, Marigliano M, Schiaffini R, Maltoni G, Frongia AP, Scardapane M, Nicolucci A, Cherubini V, Bonfanti R, Scaramuzza AE. Insulin pump breakdown and infusion set failure in Italian children with type 1 diabetes: A 1-year prospective observational study with suggestions to minimize clinical impact. Diabetes Obes Metab 2018; 20:2551-2556. [PMID: 29893044 DOI: 10.1111/dom.13419] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/06/2018] [Accepted: 06/09/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the incidence of insulin pump and infusion set failures in a cohort of children and adolescents with type 1 diabetes during a 1-year follow-up. MATERIALS AND METHODS Insulin pump breakdown and infusion set failures were prospectively registered in a cohort of 1046 children and adolescents from 25 tertiary pediatric diabetes centres (50% male, mean age 12.2 ± 4.1 years), with type 1 diabetes from the age of 6.7 ± 3.6 years, and using an insulin pump from the age of 3.3 ± 2.2 years. RESULTS An average rate of 4.5 failures/person-year was registered; the incidences (events per person-year) for each failure were 8.4 for hyperglycaemia episodes solved with infusion set change, 7 for bubbles, 2.8 for kinking, 2.4 for bleeding, 2 for set dislodge, 2 for pump blockage, 1.9 for tunnelling, 1.8 for lipohypertrophy, and 0.3 for infection. At multivariate analysis significant association between HbA1c and lipohypertrophy (P < 0.0028) was shown. Analysis by age group (<6, 6-11, >11 years) showed a higher frequency of bubbles, hyperglycaemia episodes and lipohypertrophy in preschoolers; tunnelling and pump blockage were more frequent in adolescents. Aspart was associated with a lower risk of bubbles and hyperglycaemia whereas glulisine was associated with a higher risk of lipohypertrophy and pump blockage. The usage of oblique cannula was associated with a low risk of all failures except infections. CONCLUSIONS This prospective 1-year study on a large cohort of Italian children and adolescents with type 1 diabetes using insulin pump therapy showed a low total failure rate, highlighting the importance of continuous education to reduce failures. Lipohypertrophy was the only issue associated with a worsening of metabolic control.
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Affiliation(s)
- Ivana Rabbone
- Department of Paediatrics, University of Turin, Turin, Italy
| | - Nicola Minuto
- Department of Paediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Sonia Toni
- Juvenile Diabetes Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Fortunato Lombardo
- Department of Paediatric Sciences, University of Messina, Messina, Italy
| | - Dario Iafusco
- Regional Center for Paediatric Diabetes "G. Stoppoloni," Department of Paediatrics, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Marigliano
- Regional Center for Paediatric Diabetes, Paediatric Diabetes and Metabolic Disorders Unit, University of Verona, Verona, Italy
| | - Riccardo Schiaffini
- Diabetes Unit, University Department of Paediatric Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giulio Maltoni
- Department of Paediatrics, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Anna P Frongia
- Unit of Paediatric Diabetes, Brotzu Hospital, Cagliari, Italy
| | - Marco Scardapane
- CORESEARCH, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Antonio Nicolucci
- CORESEARCH, Center for Outcomes Research and Clinical Epidemiology, Pescara, Italy
| | - Valentino Cherubini
- Division of Pediatric Diabetology, Department of Woman's and Children's Health, AOU G. Salesi Hospital, Ancona, Italy
| | - Riccardo Bonfanti
- Pediatric Diabetes and Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
| | - Andrea E Scaramuzza
- Pediatric Diabetes and Endocrinology & Nutrition ASST Cremona, Cremona, Italy
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112
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Sildorf SM, Breinegaard N, Lindkvist EB, Tolstrup JS, Boisen KA, Teilmann GK, Skovgaard AM, Svensson J. Poor Metabolic Control in Children and Adolescents With Type 1 Diabetes and Psychiatric Comorbidity. Diabetes Care 2018; 41:2289-2296. [PMID: 30270201 DOI: 10.2337/dc18-0609] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 07/26/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Type 1 diabetes is associated with an increased risk of psychiatric morbidities. We investigated predictors and diabetes outcomes in a pediatric population with and without psychiatric comorbidities. RESEARCH DESIGN AND METHODS Data from the Danish Registry of Childhood and Adolescent Diabetes (DanDiabKids) and National Patient Register were collected (1996-2015) for this population-based study. We used Kaplan-Meier plots to investigate whether age at type 1 diabetes onset and average glycated hemoglobin (HbA1c) levels during the first 2 years after onset of type 1 diabetes (excluding HbA1c at debut) were associated with the risk of being diagnosed with a psychiatric disorder. Mixed-effects linear and logistic regression models were used to analyze HbA1c, BMI, severe hypoglycemia (SH), or ketoacidosis as outcomes, with psychiatric comorbidities as explanatory factor. RESULTS Among 4,725 children and adolescents with type 1 diabetes identified in both registers, 1,035 were diagnosed with at least one psychiatric disorder. High average HbA1c levels during the first 2 years predicted higher risk of psychiatric diagnoses. Patients with psychiatric comorbidity had higher HbA1c levels (0.22% [95% CI 0.15; 0.29]; 2.40 mmol/mol [1.62; 3.18]; P < 0.001) and an increased risk of hospitalization with diabetic ketoacidosis (1.80 [1.18; 2.76]; P = 0.006). We found no associations with BMI or SH. CONCLUSIONS High average HbA1c levels during the first 2 years after onset of type 1 diabetes might indicate later psychiatric comorbidities. Psychiatric comorbidity in children and adolescents with type 1 diabetes increases the risk of poor metabolic outcomes. Early focus on the disease burden might improve outcomes.
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Affiliation(s)
- Stine M Sildorf
- Department of Pediatrics and Adolescent Medicine, Herlev Hospital, Herlev, Denmark
| | - Nina Breinegaard
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Emilie B Lindkvist
- Department of Pediatrics and Adolescent Medicine, Herlev Hospital, Herlev, Denmark
| | - Janne S Tolstrup
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | - Kirsten A Boisen
- Center of Adolescent Medicine, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Grete K Teilmann
- Department of Pediatrics and Adolescent Medicine, Nordsjællands Hospital, Hillerød, Denmark.,Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Mette Skovgaard
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.,Institute of Public Health, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jannet Svensson
- Department of Pediatrics and Adolescent Medicine, Herlev Hospital, Herlev, Denmark .,Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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113
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Martins KAKF, Mascarenhas LPG, Morandini M, Cat MNL, Pereira RM, Carvalho JRD, Lacerda Filho LD, França SN. Health-related quality of life in a cohort of youths with type 1 diabetes. Rev Assoc Med Bras (1992) 2018; 64:1038-1044. [DOI: 10.1590/1806-9282.64.11.1038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 03/24/2018] [Indexed: 12/17/2022] Open
Abstract
SUMMARY Health-related quality of life (HRQOL) in type 1 diabetes mellitus (T1DM) has been widely studied. The objectives of this study were to evaluate and identify the factors influencing the HRQOL of children and adolescents with T1DM. MATERIAL AND METHODS: In total, 59 patients (9–16 years, T1DM for ≥1 year) responded to a version of the Diabetes Quality of Life Instrument for Youth (DQOLY) adapted to adapted to Brazilian patients, the Instrumento de Qualidade de Vida para Jovens com Diabetes (IQVJD). This instrument comprises 50 items (domains satisfaction, impact, and concerns, with the lowest scores corresponding to better HRQOL) and a questionnaire gathering social, demographic, and clinical parameters. RESULTS: The mean age of the patients was 13.6 years, and 57.6% were girls. The median age at diagnosis was 7.16 years, 63% presented diabetic ketoacidosis (DKA) at diagnosis and 29% during follow-up. Mean glycated hemoglobin (HbA1c) in the previous year was 10%. All patients administered multiple insulin doses (mean 4.2 applications/day), 74.5% used rapid-acting and intermediate-acting insulin analogs, and 67.8% used pens for insulin application. The results of the DQOLY were within the cutoff limit for better HRQOL. An isolated analysis of each domain and the questionnaire results showed that the following factors were associated with better HRQOL: height Z-score, lower HbA1c, practice of physical activity, use of pen, fewer hospitalizations, and residence in a rural area. There was a high DKA rate at diagnosis, and the metabolic control was inappropriate in most patients. Despite coming from low-income households, most patients had access to the recommended treatment. CONCLUSION: Among T1DM patients, 71% had IQVJD scores compatible with better HRQOL.
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114
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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115
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Chen T, Zhang D, Bai Z, Wu S, Wu H, Xie R, Li Y, Wang F, Chen X, Sun H, Wang X, Chen L. Successful Treatment of Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar Status in an Infant with KCNJ11-Related Neonatal Diabetes Mellitus via Continuous Renal Replacement Therapy. Diabetes Ther 2018; 9:2179-2184. [PMID: 30094785 PMCID: PMC6167281 DOI: 10.1007/s13300-018-0484-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Indexed: 12/20/2022] Open
Abstract
Neonatal diabetes mellitus (NDM) is a rare monogenic disorder presenting as uncontrolled hyperglycemia during the first 6 months of life. Hyperglycemic hyperosmolar state (HHS) is quite rare in NDM patients, and reported experience with this condition is limited. Continuous renal replacement therapy (CRRT) is frequently used as a mode of dialytic treatment in critically ill patients with acute renal failure, but has seldom been used in patients with diabetic ketoacidosis (DKA) and HHS. We report the case of a 2-month-old infant admitted to our hospital presenting with dyspnea and lethargy. Blood gas showed severe hyperosmotic DKA. After 21 h of fluid and insulin therapy, the baby presented with increased drowsiness and irregular respiration, which suggested cerebral edema. Moreover, the DKA and HHS were exacerbated. After 18 h of CRRT, the patient gradually recovered from DKA and HHS. The gene analysis revealed a de novo mutation (c.602G > A (p.R201H)) of the KCNJ11 gene, and oral glibenclamide successfully replaced insulin treatment in the patient.
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Affiliation(s)
- Ting Chen
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Dandan Zhang
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Zhenjiang Bai
- Department of Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shuiyan Wu
- Department of Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Haiying Wu
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Rongrong Xie
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ying Li
- Department of Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fengyun Wang
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiuli Chen
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Hui Sun
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiaoyan Wang
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Linqi Chen
- Department of Endocrinology, Metabolism and Genetic Disorders, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
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116
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Yesilbas O, Cem E, Cimbek EA. Successful treatment of life-threatening severe metabolic acidosis by continuous veno-venous hemodialysis in a child with diabetic ketoacidosis. J Pediatr Endocrinol Metab 2018; 31:1043-1045. [PMID: 30130252 DOI: 10.1515/jpem-2018-0232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 07/13/2018] [Indexed: 11/15/2022]
Affiliation(s)
- Osman Yesilbas
- Pediatric İntensive Care Specialist, University of Health Sciences, Van Training and Research Hospital, Pediatric Intensive Care Unit, Van, Turkey, Phone: +90 533 541 97 22
| | - Ela Cem
- University of Health Sciences, Van Training and Research Hospital, Pediatrics, Van, Turkey
| | - Emine Ayca Cimbek
- University of Health Sciences, Van Training and Research Hospital, Pediatric Endocrinology, Van, Turkey
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117
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Kuppermann N, Glaser NS. Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018; 379:1183. [PMID: 30231223 DOI: 10.1056/nejmc1810064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Nicole S Glaser
- University of California Davis School of Medicine, Sacramento, CA
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118
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Chiang JL, Maahs DM, Garvey KC, Hood KK, Laffel LM, Weinzimer SA, Wolfsdorf JI, Schatz D. Type 1 Diabetes in Children and Adolescents: A Position Statement by the American Diabetes Association. Diabetes Care 2018; 41:2026-2044. [PMID: 30093549 PMCID: PMC6105320 DOI: 10.2337/dci18-0023] [Citation(s) in RCA: 246] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Jane L Chiang
- McKinsey & Company and Diasome Pharmaceuticals, Inc., Palo Alto, CA
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Katharine C Garvey
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Korey K Hood
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA
| | - Stuart A Weinzimer
- Pediatric Endocrinology & Diabetes, Yale School of Medicine, New Haven, CT
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Desmond Schatz
- Division of Endocrinology, Department of Pediatrics, University of Florida, Gainesville, FL
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119
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Pavić I, Tješić Drinković D, Galić S, Tješić Drinković D, Rojnić Putarek N. ACUTE RESPIRATORY DISTRESS SYNDROME IN A FOUR-YEAR-OLD BOY WITH DIABETIC KETOACIDOSIS - CASE REPORT. Acta Clin Croat 2018; 57:588-592. [PMID: 31168194 PMCID: PMC6536282 DOI: 10.20471/acc.2018.57.03.24] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
SUMMARY – Among many disease states as known initiators of acute respiratory distress syndrome (ARDS), diabetic ketoacidosis (DKA) is the rarest one. We present a 4-year-old boy with DKA as the first manifestation of insulin-dependent diabetes mellitus who developed ARDS, required tracheal intubation and mechanical ventilation, and survived without significant sequels. To improve survival of patients with ARDS as a complication of DKA, physicians should be aware of this rare pulmonary complication and its appropriate management.
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Affiliation(s)
| | - Dorian Tješić Drinković
- 1Zagreb Children's Hospital, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 2Zagreb University Hospital Centre, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 3Zagreb University Hospital Centre, Pediatric Intensive Care Unit, Zagreb, Croatia; 4Zagreb University Hospital Centre, Department of Pediatric Gastroenterology and Nutrition, Zagreb, Croatia; 5Zagreb University Hospital Centre, Department of Pediatric Endocrinology and Diabetes, Zagreb, Croatia
| | - Slobodan Galić
- 1Zagreb Children's Hospital, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 2Zagreb University Hospital Centre, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 3Zagreb University Hospital Centre, Pediatric Intensive Care Unit, Zagreb, Croatia; 4Zagreb University Hospital Centre, Department of Pediatric Gastroenterology and Nutrition, Zagreb, Croatia; 5Zagreb University Hospital Centre, Department of Pediatric Endocrinology and Diabetes, Zagreb, Croatia
| | - Duška Tješić Drinković
- 1Zagreb Children's Hospital, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 2Zagreb University Hospital Centre, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 3Zagreb University Hospital Centre, Pediatric Intensive Care Unit, Zagreb, Croatia; 4Zagreb University Hospital Centre, Department of Pediatric Gastroenterology and Nutrition, Zagreb, Croatia; 5Zagreb University Hospital Centre, Department of Pediatric Endocrinology and Diabetes, Zagreb, Croatia
| | - Nataša Rojnić Putarek
- 1Zagreb Children's Hospital, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 2Zagreb University Hospital Centre, Department of Pulmonology, Allergology, Rheumatology and Clinical Immunology, Zagreb, Croatia; 3Zagreb University Hospital Centre, Pediatric Intensive Care Unit, Zagreb, Croatia; 4Zagreb University Hospital Centre, Department of Pediatric Gastroenterology and Nutrition, Zagreb, Croatia; 5Zagreb University Hospital Centre, Department of Pediatric Endocrinology and Diabetes, Zagreb, Croatia
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120
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Çatlı G, Anık A, Acar S, Küme T, Karabulut M, Çalan ÖG, Dündar BN, Abacı A. Brain injury markers: S100 calcium-binding protein B, neuron-specific enolase and glial fibrillary acidic protein in children with diabetic ketoacidosis. Pediatr Diabetes 2018; 19:1000-1006. [PMID: 29484801 DOI: 10.1111/pedi.12667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/15/2018] [Accepted: 02/19/2018] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND To investigate serum levels of brain injury markers in diabetic ketoacidosis (DKA) and the relation of these markers with clinical and radiological findings of brain injury and laboratory results. METHODS Twenty-nine patients with DKA, 30 with type 1 diabetes mellitus (T1DM), and 35 healthy children were included. Clinical and laboratory findings, and the Glasgow Coma Scale (GCS) were recorded. In the DKA group, neuron-specific enolase (NSE), S100 calcium-binding protein B (S100B) and glial fibrillary acidic protein (GFAP) levels were measured at baseline and 6 and 12 hours after treatment. Magnetic resonance imaging was performed in the DKA group to demonstrate any brain injury. RESULTS No clinical or radiological findings of brain injury were found in any of the patients with DKA. In the DKA group, S100B was significantly higher than the healthy control and T1DM groups, while GFAP and NSE levels were not different from controls and T1DM patients. No significant differences were found in GFAP, NSE and S100B levels according to severity of DKA, diabetes duration and GCS. CONCLUSION NSE and GFAP levels do not increase in DKA patients without overt brain injury. Elevated levels of S100B, which is also synthesized from non-neuronal tissues, might arise from peripheral sources. A lack of concurrent increase in serum levels of these brain injury markers might result from the yet intact blood brain barrier or a true absence of neuronal damage. In order to reveal subclinical brain injury related to DKA, there is a need for studies concurrently assessing neurocognitive functions.
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Affiliation(s)
- Gönül Çatlı
- Department of Pediatric Endocrinology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Ahmet Anık
- Department of Pediatric Endocrinology, Faculty of Medicine, Adnan Menderes University, Aydın, Turkey
| | - Sezer Acar
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Tuncay Küme
- Department of Biochemistry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Melike Karabulut
- Department of Pediatrics, Tepecik Training and Research Hospital, Health Sciences University, İzmir, Turkey
| | - Özlem Gürsoy Çalan
- Department of Biochemistry, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
| | - Bumin Nuri Dündar
- Department of Pediatric Endocrinology, Faculty of Medicine, Izmir Katip Celebi University, Izmir, Turkey
| | - Ayhan Abacı
- Department of Pediatric Endocrinology, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey
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121
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Razavi Z, Maher S, Fredmal J. Comparison of subcutaneous insulin aspart and intravenous regular insulin for the treatment of mild and moderate diabetic ketoacidosis in pediatric patients. Endocrine 2018; 61:267-274. [PMID: 29797212 DOI: 10.1007/s12020-018-1635-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 05/14/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE To compare the safety/efficacy of intermittent subcutaneous rapid-acting insulin aspart with the standard low-dose intravenous infusion protocol of regular insulin for treatment of pediatric diabetic-ketoacidosis. METHODS For a prospective randomized-controlled clinical trial on 50 children/adolescents with mild/moderate diabetic-ketoacidosis, the diagnostic criteria for ketoacidosis included: blood glucose level >250 mg/dl, ketonuria>++, venous pH <7.3 and/or bicarbonate <15 mEq/l. DATA COLLECTED age, sex, clinical/laboratory parameters including blood sugar, arterial blood gases, urine ketones, severity of diabetic-ketoacidosis, amount of insulin administered to correct acidosis, time to recover from diabetic-ketoacidosis, number of days of hospitalization, and complications. Patients were randomly assigned to intervention (subcutaneous) and control (intravenous) groups. Controls received 0.05-0.1 unit/kg/hour intravenous regular insulin infusion until resolution of diabetic-ketoacidosis and stayed in the intensive care unit. Interventions received 0.15 unit/kg subcutaneous insulin aspart every two hours and stayed in regular medical ward. RESULTS From 50 children (age 2-17 years), 56% (28) were females, and 48% (24) had established-type I diabetes. Intervention and control groups had similar baseline clinical/laboratory findings. Average age (years) was 8.6 ± 0.8 for intervention and 8.86 ± 0.7 for control group (p = 0.4) with 64% having moderate diabetic-ketoacidosis. The mean total-dose of insulin units needed for treatment of diabetic-ketoacidosis in intervention (subcutaneous insulin aspart) was lower than controls (intravenous regular insulin) (p < 0.001). No mortality/serious events happened. Three diabetic-ketoacidosis recurrences among interventions and one among controls occurred. CONCLUSIONS To manage mild/moderate diabetic-ketoacidosis in children/adolescents, subcutaneous rapid-acting insulin aspart is an alternative to intravenous infusion of regular insulin. Subcutaneous insulin treated moderate DKA with faster recovery/shorter hospital stay.
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Affiliation(s)
- Zahra Razavi
- Associate Professor, Pediatric Endocrinologist, Pediatrics Department, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran.
| | - Saba Maher
- Pediatric Senior Resident, Department of Pediatrics, School of Medicine, Hamedan University of Medical Sciences, Hamedan, Iran
| | - Javad Fredmal
- Associate Professor of Biostatistics, Hamedan University of Medical Sciences, Hamedan, Iran
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122
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Vukovic R, Jesic MD, Vorgucin I, Stankovic S, Folic N, Milenkovic T, Sajic S, Katanic D, Zivic S, Markovic S, Soldatovic I. First report on the nationwide incidence of type 1 diabetes and ketoacidosis at onset in children in Serbia: a multicenter study. Eur J Pediatr 2018; 177:1155-1162. [PMID: 29774417 DOI: 10.1007/s00431-018-3172-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/05/2018] [Accepted: 05/08/2018] [Indexed: 10/16/2022]
Abstract
UNLABELLED Data regarding incidence of type 1 diabetes (T1DM), as well as data on frequency and severity of diabetic ketoacidosis (DKA) at the time of T1DM diagnosis is of paramount importance for national and regional healthcare planning. The aim of present multicenter study was to provide the first report regarding nationwide annual incidence rates for T1DM in youth in Serbia, as well as prevalence of DKA at the time of diagnosis. Data on all pediatric patients with newly diagnosed T1DM was retrospectively collected from all 15 regional centers for pediatric diabetes in Serbia during the period 2007-2017. During the study period, average-standardized incidence of T1DM in youth < 19 years was 11.82/100,000, and 14.28/100,000 in 0-14 years age group, with an average yearly increase in incidence of 5.9%. High prevalence of DKA (35.1%) at the time of diagnosis was observed, with highest frequency in children aged < 5 years (47.2%). CONCLUSION This is the first study reporting the nationwide incidence of T1DM and alarmingly high prevalence of DKA at diagnosis in youth in Serbia. The focus of public health preventive measures should be directed towards the preschoolers, considering the highest frequency and severity of DKA observed in this age group. What is Known: • Knowing regional T1DM incidence is of paramount importance for resource allocation and healthcare services provision. • DKA is the leading cause of acute mortality in youth with T1DM, and public health preventive educational measures could improve early diagnosis and reduce the frequency and severity of DKA at presentation. What is New: • Incidence of pediatric T1DM in Serbia is on the rise, with an average yearly increase of 5.9%. • Worryingly high prevalence of DKA (35.1%) at the time of T1DM diagnosis was observed, with the highest frequency of DKA in children aged < 5 years (47.2%).
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Affiliation(s)
- Rade Vukovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, Belgrade, 11070, Serbia.
| | - Maja D Jesic
- University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia.,School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
| | - Ivana Vorgucin
- Institute for Children and Youth Health Care of Vojvodina, Hajduk Veljkova 10, Novi Sad, 21000, Serbia.,Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Sandra Stankovic
- Children Clinic, Clinical Center Nis, Dr Zorana Djindjica Blvd. 48a, Nis, 18000, Serbia
| | - Nevena Folic
- Pediatric Clinic, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac, 34000, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Tatjana Milenkovic
- Mother and Child Health Care Institute of Serbia "Dr Vukan Cupic", Radoja Dakica 8, Belgrade, 11070, Serbia
| | - Silvija Sajic
- University Children's Hospital, Tirsova 10, Belgrade, 11000, Serbia.,School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
| | - Dragan Katanic
- Institute for Children and Youth Health Care of Vojvodina, Hajduk Veljkova 10, Novi Sad, 21000, Serbia.,Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, Novi Sad, 21000, Serbia
| | - Sasa Zivic
- Children Clinic, Clinical Center Nis, Dr Zorana Djindjica Blvd. 48a, Nis, 18000, Serbia.,Faculty of Medicine, University of Nis, Dr Zorana Djindjica Blvd. 81, Nis, 18000, Serbia
| | - Slavica Markovic
- Pediatric Clinic, Clinical Centre Kragujevac, Zmaj Jovina 30, Kragujevac, 34000, Serbia.,Faculty of Medical Sciences, University of Kragujevac, Svetozara Markovića 69, Kragujevac, 34000, Serbia
| | - Ivan Soldatovic
- Institute for Medical Statistics and Informatics, School of Medicine, University of Belgrade, Dr Subotica 15, Belgrade, 11000, Serbia
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123
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Patwardhan R, Gorton S, Vangaveti VN, Yates J. Diabetic ketoacidosis incidence in children at first presentation of type 1 diabetes at an Australian regional hospital: The effect of health professional education. Pediatr Diabetes 2018; 19:993-999. [PMID: 29484782 DOI: 10.1111/pedi.12666] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 02/11/2018] [Accepted: 02/12/2018] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute life threatening, resource intensive preventable complication of type 1 diabetes which has major biopsychosocial effects on patients and families. Incidence of pediatric DKA has been studied nationally and internationally in metropolitan centers. This study analyzed the DKA incidence at first presentation of type 1 diabetes at Townsville Hospital, before and after an educational intervention. This is the first study of its kind in a regional center in Queensland, Australia. METHOD The inclusion criteria consisted of children (0-18 years) diagnosed with type 1 diabetes from January, 2006 to December, 2016. Medical and laboratory patient data was retrospectively collected. Quantitative analysis was conducted using SPSS. Education sessions were delivered to health professionals by a pediatric endocrinologist during 2015 and 2016. DKA and its severity were defined by the International Society of Pediatric Diabetes 2014 Guidelines. RESULTS In total, 106 patients met inclusion criteria. Average incidence of DKA at first presentation of type 1 diabetes was 48.10%. Pre- and post-intervention incidences were 54.90% and 25%, respectively (P = 0.01). DKA severity pre- and post-intervention were severe (48.88%, 33.33%), moderate (26.67%, 16.67%), and mild (24.44%, 50%), respectively (P = 0.53). CONCLUSIONS DKA incidence at first presentation of type 1 diabetes prior to intervention, is higher than that reported by other studies in Australia: Brisbane (31.8%) and Sydney (37.7%). DKA incidence at first presentation of type 1 diabetes decreased significantly during the period of health professional education.
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Affiliation(s)
- Radhika Patwardhan
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Susan Gorton
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Venkat N Vangaveti
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Jason Yates
- Paediatric Unit, The Townsville Hospital, Townsville, Queensland, Australia
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124
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Horvat CM, Ismail HM, Au AK, Garibaldi L, Siripong N, Kantawala S, Aneja RK, Hupp DS, Kochanek PM, Clark RSB. Presenting predictors and temporal trends of treatment-related outcomes in diabetic ketoacidosis. Pediatr Diabetes 2018; 19:985-992. [PMID: 29573523 PMCID: PMC6863166 DOI: 10.1111/pedi.12663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/06/2018] [Accepted: 02/07/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE This study examines temporal trends in treatment-related outcomes surrounding a diabetic ketoacidosis (DKA) performance improvement intervention consisting of mandated intensive care unit admission and implementation of a standardized management pathway, and identifies physical and biochemical characteristics associated with outcomes in this population. METHODS A retrospective cohort of 1225 children with DKA were identified in the electronic health record by international classification of diseases codes and a minimum pH less than 7.3 during hospitalization at a quaternary children's hospital between April, 2009 and May, 2016. Multivariable regression examined predictors and trends of hypoglycemia, central venous line placement, severe hyperchloremia, head computed tomography (CT) utilization, treated cerebral edema and hospital length of stay (LOS). RESULTS The incidence of severe hyperchloremia and head CT utilization decreased during the study period. Among patients with severe DKA (presenting pH < 7.1), the intervention was associated with decreasing LOS and less variability in LOS. Lower pH at presentation was independently associated with increased risk for all outcomes except hypoglycemia, which was associated with higher pH. Patients treated for cerebral edema had a lower presenting mean systolic blood pressure z score (0.58 [95% confidence interval (CI) -0.02-1.17] vs 1.23 [1.13-1.33]) and a higher maximum mean systolic blood pressure (SBP) z score during hospitalization (3.75 [3.19-4.31] vs 2.48 [2.38-2.58]) compared to patients not receiving cerebral edema treatment. Blood pressure and cerebral edema remained significantly associated after covariate adjustment. CONCLUSION Treatment-related outcomes improved over the entire study period and following a performance improvement intervention. The association of SBP with cerebral edema warrants further study.
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Affiliation(s)
- Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Heba M. Ismail
- Division of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Luigi Garibaldi
- Division of Pediatric Endocrinology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Nalyn Siripong
- The Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA
| | - Sajel Kantawala
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Rajesh K. Aneja
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Diane S. Hupp
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Robert S. B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Brain Care Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA,Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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125
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Adu MD, Malabu UH, Callander EJ, Malau-Aduli AE, Malau-Aduli BS. Considerations for the Development of Mobile Phone Apps to Support Diabetes Self-Management: Systematic Review. JMIR Mhealth Uhealth 2018; 6:e10115. [PMID: 29929949 PMCID: PMC6035345 DOI: 10.2196/10115] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/30/2018] [Accepted: 04/25/2018] [Indexed: 12/16/2022] Open
Abstract
Background There is increased research interest in the use of mobile phone apps to support diabetes management. However, there are divergent views on what constitute the minimum standards for inclusion in the development of mobile phone apps. Mobile phone apps require an evidence-based approach to development which will consequently impact on their effectiveness. Therefore, comprehensive information on developmental considerations could help designers and researchers to develop innovative and effective patient-centered self-management mobile phone apps for diabetes patients. Objective This systematic review examined the developmental considerations adopted in trials that engaged mobile phone applications for diabetes self-management. Methods A comprehensive search strategy was implemented across 5 electronic databases; Medline, Scopus, Social Science Citation Index, the Cochrane Central Register of Controlled Trials and Cumulative Index of Nursing and Allied Health Literature (CINALHL) and supplemented by reference list from identified studies. Study quality was evaluated using the Joanna Briggs Critical appraisal checklist for trials. Information on developmental factors (health behavioral theory, functionality, pilot testing, user and clinical expert involvements, data privacy and app security) were assessed across experimental studies using a template developed for the review. Results A total of 11 studies (10 randomized controlled trials and 1 quasi-experimental trial) that fitted the inclusion criteria were identified. All the included studies had the functionality of self-monitoring of blood glucose. However, only some of them included functions for data analytics (7/11, 63.6%), education (6/11, 54.5%) and reminder (6/11, 54.5%). There were 5/11(45.5%) studies with significantly improved glycosylated hemoglobin in the intervention groups where educational functionality was present in the apps used in the 5 trials. Only 1 (1/11, 9.1%) study considered health behavioral theory and user involvement, while 2 (2/11, 18.1%) other studies reported the involvement of clinical experts in the development of their apps. There were 4 (4/11, 36.4%) studies which referred to data security and privacy considerations during their app development while 7 (7/12, 63.6%) studies provided information on pilot testing of apps before use in the full trial. Overall, none of the studies provided information on all developmental factors assessed in the review. Conclusions There is a lack of elaborate and detailed information in the literature regarding the factors considered in the development of apps used as interventions for diabetes self-management. Documentation and inclusion of such vital information will foster a transparent and shared decision-making process that will ultimately lead to the development of practical and user-friendly self-management apps that can enhance the quality of life for diabetes patients.
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Affiliation(s)
- Mary D Adu
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Usman H Malabu
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
| | - Emily J Callander
- Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Australia
| | - Aduli Eo Malau-Aduli
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Townsville, Australia
| | - Bunmi S Malau-Aduli
- College of Medicine and Dentistry, James Cook University, Townsville, Australia
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Mohd Nor NS, Fong CY, Rahmat K, Vanessa Lee WM, Zaini AA, Jalaludin MY. Ischaemic Haemorrhagic Stroke in a Child with New Onset Type 1 Diabetes Mellitus. EUROPEAN ENDOCRINOLOGY 2018; 14:59-61. [PMID: 29922355 PMCID: PMC5954598 DOI: 10.17925/ee.2018.14.1.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 03/26/2018] [Indexed: 12/02/2022]
Abstract
Cerebral oedema is the most common neurological complication of diabetic ketoacidosis (DKA). However, ischaemic and haemorrhagic brain injury has been reported infrequently. A 10-year old girl who was previously well presented with severe DKA. She was tachycardic with poor peripheral perfusion but normotensive. However, two fast boluses totalling 40 ml/kg normal saline were given. She was transferred to another hospital where she was intubated due to drowsiness. Rehydration fluid (maintenance and 48-hour correction for 7.5% dehydration) was started followed by insulin infusion. She was extubated within 24 hours of admission. Her ketosis resolved soon after and subcutaneous insulin was started. However, about 48 hours after admission, her Glasgow Coma Scale score dropped to 11/15 (E4M5V2) with expressive aphasia and upper motor neuron signs. One dose of mannitol was given. Her symptoms improved gradually and at 26-month follow-up she had a near-complete recovery with only minimal left lower limb weakness. Serial magnetic resonance imaging brain scans showed vascular ischaemic injury at the frontal-parietal watershed regions with haemorrhagic transformation. This case reiterates the importance of monitoring the neurological status of patient’s with DKA closely for possible neurological complications including an ischaemic and haemorrhagic stroke.
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Affiliation(s)
- Noor Shafina Mohd Nor
- Faculty of Medicine, Universiti Teknologi MARA (UiTM), Sungai Buloh, Selangor, Malaysia
| | - Choong Yi Fong
- Division of Pediatric Neurology, Department of Pediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia.,University Malaya Pediatric and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia
| | - Kartini Rahmat
- Department of Biomedical Imaging, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Wan Mun Vanessa Lee
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Azriyanti Anuar Zaini
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
| | - Muhammad Yazid Jalaludin
- University Malaya Pediatric and Child Health Research Group, University Malaya, Kuala Lumpur, Malaysia.,Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, University Malaya, Kuala Lumpur, Malaysia
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127
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Central Pontine Myelinolysis in Pediatric Diabetic Ketoacidosis. Case Rep Crit Care 2018; 2018:4273971. [PMID: 29973999 PMCID: PMC6008881 DOI: 10.1155/2018/4273971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/18/2018] [Indexed: 01/24/2023] Open
Abstract
Central pontine myelinolysis (CPM) is rarely reported in pediatric patients with diabetic ketoacidosis (DKA). We report this case of a 16-year-old female with new onset diabetes presenting with DKA, who received aggressive fluid resuscitation and sodium bicarbonate in the emergency department. Later she developed altered mental status concerning for cerebral edema and received hyperosmolar therapy with only transient improvement. Soon she became apneic requiring emergent endotracheal intubation. MRI brain showed cerebral edema, CPM, and subdural hemorrhage. She was extubated on day seven and exhibited mild dysmetria, ataxia, unilateral weakness, and neglect. Upon discharge she was able to ambulate with a walker and speak and eat without difficulty. Although less common than cerebral edema, CPM should be considered in DKA patients with acute neurologic deterioration. Fluid and bicarbonate therapy should be individualized, but larger studies would help guide the management. Although poor outcomes are reported in CPM, favorable outcomes are possible.
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128
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Choi HS, Kwon A, Chae HW, Suh J, Kim DH, Kim HS. Respiratory failure in a diabetic ketoacidosis patient with severe hypophosphatemia. Ann Pediatr Endocrinol Metab 2018; 23:103-106. [PMID: 29969883 PMCID: PMC6057019 DOI: 10.6065/apem.2018.23.2.103] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 11/06/2010] [Indexed: 12/19/2022] Open
Abstract
Phosphate is essential in regulating human metabolic processes, and severe hypophosphatemia can induce neurologic and hematological complications and result in respiratory failure and cardiac dysfunction. Therefore, correction of severe hypophosphatemia can be pivotal in the management of diabetic ketoacidosis (DKA). We report the case of a 14-year-old female who was diagnosed with type 1 diabetes and referred to our institute for treatment of DKA. Although the patient received fluid and continuous insulin administration according to the current DKA treatment protocol, generalized tonic seizures and cardiac arrest developed. After cardiopulmonary resuscitation, the patient recovered and was stable. Within 16 hours after DKA treatment, the patient developed respiratory failure with severe hypophosphatemia that required mechanical ventilation. Concurrent neurologic evaluation revealed no specific abnormalities. The patient recovered without any complications after correcting the hypophosphatemia. We suggest vigilant monitoring of the phosphate level in DKA patients and active replacement when required.
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Affiliation(s)
- Han Saem Choi
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Ahreum Kwon
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Wook Chae
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Junghwan Suh
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | | | - Ho-Seong Kim
- Department of Pediatrics, Severance Children’s Hospital, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea,Address for correspondence: Ho-Seong Kim, MD, PhD Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-2069 Fax: +82-2-393-9118 E-mail:
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129
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Odeh R, Alassaf A, Ajlouni K. Clinical and biochemical features at diagnosis of type 1 diabetes in patients between 0 and 18 years of age from Jordan. Pediatr Diabetes 2018; 19:707-712. [PMID: 29280234 DOI: 10.1111/pedi.12625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Data regarding type 1 diabetes mellitus (T1D) in Jordan are extremely scarce. We aim to evaluate the clinical and laboratory characteristics at diagnosis of T1D in a group of children from Jordan. METHODS The records of 437 (boys/girls: 224/213) children with type 1 diabetes followed in the years 2012 to 2016 were evaluated retrospectively. The data were assessed by sex and age subgroups (<5, 6-10, and 11-18 years). RESULTS Mean age of children at diagnosis was 7.3 ± 3.6 years. The first peak in the number of T1D cases in terms of age at diagnosis was observed in the age group between 6 and 8 years (n = 116 [26.5%], 95% confidence interval [CI]: 22.3%-30.6%). This was followed by the age group of 3 to 5 years (n = 108 [24.7%], 95% CI: 20.6%-28.7%). Although the patients mostly presented in winter (30.0%, 95% CI: 25.6%-34.3%), no season-related significant differences were found. The frequency of ketoacidosis at diagnosis was 40.7% (95% CI: 36%-45.3%). At presentation, 22.8% (95% CI: 18.9%-26.7) of our patients had a positive history of T1D in their extended families. In addition, 61.1% (95% CI: 56.5%-65.7%) of the patients were started on premixed insulin at diagnosis. CONCLUSION The findings possibly indicate a decreasing age of T1D onset in Jordanian patients. The high frequency of ketoacidosis at presentation is noteworthy. In addition, the initial insulin protocols are not in accordance with the recommended insulin therapy for children and adolescents with T1D.
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Affiliation(s)
- Rasha Odeh
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Abeer Alassaf
- Department of Pediatrics, School of Medicine, University of Jordan, Amman, Jordan
| | - Kamel Ajlouni
- The National Center (Institute) for Diabetes, Endocrinology and Genetics (NCDEG), University of Jordan, Amman, Jordan
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130
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Biester T, Kordonouri O, Danne T. Pharmacotherapy of type1 diabetes in children and adolescents: more than insulin? Ther Adv Endocrinol Metab 2018; 9:157-166. [PMID: 29796246 PMCID: PMC5958426 DOI: 10.1177/2042018818763247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 02/13/2018] [Indexed: 01/24/2023] Open
Abstract
For paediatric patients with type 1 diabetes, intensified insulin therapy with either multiple daily injection or insulin pump therapy is currently the only method of treatment. To optimize this therapy, insulin analogues are fixed parts of all therapy regimens. New ultra-rapid insulins seem to be beneficial not only in adults but also in this age group. New developments in long-acting analogues have demonstrated safety and will be regular in paediatrics, we hope, soon. Furthermore, the psychosocial approach for consideration of real-life aspects becomes more the focus of therapeutic regimens and is implemented into international guidelines. Technical improvements, such as continuous glucose monitoring, particularly in combination with pump therapy, support the great success of rapid-acting analogues by reducing hypoglycaemias. Non-insulin agents such as SGLT2-inhibitors show beneficial aspects in people with type 1 diabetes. For outpatient care with these currently off-label-used drugs, special training for measurement of ketones should be imperative.
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Affiliation(s)
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Hannover, Germany
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Hannover, Germany
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131
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Wherrett DK, Ho J, Huot C, Legault L, Nakhla M, Rosolowsky E. Type 1 Diabetes in Children and Adolescents. Can J Diabetes 2018; 42 Suppl 1:S234-S246. [DOI: 10.1016/j.jcjd.2017.10.036] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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132
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Finn BP, Fraser B, O'Connell SM. Supraventricular tachycardia as a complication of severe diabetic ketoacidosis in an adolescent with new-onset type 1 diabetes. BMJ Case Rep 2018; 2018:bcr-2017-222861. [PMID: 29545427 DOI: 10.1136/bcr-2017-222861] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is one of the most common causes of morbidity and mortality in new-onset type 1 diabetes (T1D). Supraventricular tachycardia (SVT), however, is a very rare complication of DKA. We present the case of a patient with new-onset T1D who presented with DKA. He received intravenous fluid resuscitation, insulin and potassium supplementation and subsequently developed SVT, confirmed on a 12-lead electrocardiograph despite a structurally normal heart. Vagal manoeuvres and adenosine failed to restore sinus rhythm, but flecainide was successful. We conclude that SVT can occur as a complication of DKA, including in new-onset T1D. Our case is the first of this phenomenon occurring in new-onset childhood diabetes, as the few prior documented cases had established diabetes. Furthermore, a combination of potassium derangement, hypophosphataemia and falling magnesium levels may have precipitated the event.
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Affiliation(s)
| | - Brian Fraser
- Department of Paediatrics and Child Health, Cork University Hospital Group, Cork, Ireland
| | - Susan M O'Connell
- Department of Paediatrics and Child Health, Cork University Hospital Group, Cork, Ireland
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133
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Ziegler R, Neu A. Diabetes in Childhood and Adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:146-156. [PMID: 29563012 PMCID: PMC5876549 DOI: 10.3238/arztebl.2018.0146] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/01/2017] [Accepted: 01/30/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND The incidence of type 1 diabetes mellitus in childhood and adolescence is steadily rising and now stands at 22.9 new cases per year per 100 000 persons up to age 15. METHODS This review is based on pertinent publications retrieved by a selective literature search, with special attention to the current German S3 guideline on diabetes in childhood and adolescence. RESULTS Polydipsia, polyuria, and weight loss are the characteristic presenting symptoms of diabetes mellitus. The acutely presenting patient needs immediate stabilization because of the danger of rapid metabolic decompensation (risk of keto - acidosis, 21.1%). Long-term insulin therapy can be delivered either by subcutaneous injection or by an insulin pump. The goals of treatment are the near-normalization of glucose metabolism (HbA1c <7.5%), the avoidance of acute complications (hypoglycemia and ketoacidosis), the reduction of diabetes-specific sequelae (retinopathy, nephropathy, neuropathy, hypertension, and hyperlipidemia), unrestricted participation in age-appropriate everyday activities, and normal physical and psychosocial development. Children and adolescents with diabetes need individualized treatment with frequent adjustments and holistic overall care so that these goals can be effectively met. CONCLUSION Every physician must be able to diagnose the initial presentation of diabetes and to initiate the first steps in its management. The patient should be referred as soon as possible to a diabetes team that has experience in the treatment of children and adolescents.
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134
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Agrawal S, Kremsdorf R, Uysal S, Fredette ME, Topor LS. Nephrolithiasis: A complication of pediatric diabetic ketoacidosis. Pediatr Diabetes 2018; 19:329-332. [PMID: 28737266 DOI: 10.1111/pedi.12559] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Revised: 05/19/2017] [Accepted: 06/20/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To determine the frequency of nephrolithiasis as a complication of diabetic ketoacidosis (DKA) in pediatrics. METHODS We performed a retrospective chart review of patients with DKA admitted to a pediatric hospital between January 2009 and July 2016. We identified patients with nephrolithiasis during admission for DKA. RESULTS We identified 395 episodes of DKA over 7.5 years. Nephrolithiasis developed as a complication of DKA in 3 of those admissions (0.8%). All three patients with nephrolithiasis were males with new onset type 1 diabetes, aged 11 to 16.5 years. They all developed symptoms of nephrolithiasis after transition to subcutaneous insulin. One patient had subsequent worsening acidosis that required an additional 24 hours of IV insulin administration. CONCLUSIONS Nephrolithiasis is a rare complication of pediatric DKA, and should be considered in children with DKA who develop hematuria, flank pain, or suprapubic pain. Nephrolithiasis can increase insulin resistance due to increased pain and inflammation, so these patients should be monitored closely for recurrence of DKA. As patients with diabetes have increased risk of chronic kidney disease and nephrolithiasis can cause kidney injury, risk factors for nephrolithiasis should be identified and addressed to avoid subsequent kidney damage.
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Affiliation(s)
- Sungeeta Agrawal
- Division of Pediatric Endocrinology, Floating Hospital for Children at Tufts Medical Center/ Tufts University School of Medicine, Boston, Massachusetts
| | - Robin Kremsdorf
- Division of Pediatric Nephrology, Rhode Island Hospital, Providence, Rhode Island.,The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Serife Uysal
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Pediatric Endocrinology, Hasbro Children's Hospital/Rhode Island Hospital, Providence, Rhode Island
| | - Meghan E Fredette
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Pediatric Endocrinology, Hasbro Children's Hospital/Rhode Island Hospital, Providence, Rhode Island
| | - Lisa Swartz Topor
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Division of Pediatric Endocrinology, Hasbro Children's Hospital/Rhode Island Hospital, Providence, Rhode Island
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Niechciał E, Rogowicz-Frontczak A, Piłaciński S, Fichna M, Skowrońska B, Fichna P, Zozulińska-Ziółkiewicz D. Autoantibodies against zinc transporter 8 are related to age and metabolic state in patients with newly diagnosed autoimmune diabetes. Acta Diabetol 2018; 55:287-294. [PMID: 29327148 PMCID: PMC5829102 DOI: 10.1007/s00592-017-1091-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 12/19/2017] [Indexed: 01/02/2023]
Abstract
AIMS To assess the prevalence of ZnT8-ab and its correlation to other autoimmune markers and diabetic ketoacidosis occurrence in children and adults with T1DM onset. METHODS The study included 367 patients (218 children; 149 adults) at the T1DM onset. Selected diabetes-related autoantibodies such as GAD-ab, IA2-ab, ZnT8-ab were tested before the initiation of insulin therapy. Diabetic ketoacidosis was defined as glucose concentration > 13.9 mmol/l, pH < 7.30, concentration of HCO3 < 15 mmol/l, presence of ketone bodies in the blood and urine. RESULTS The autoantibodies pattern differs in both study groups. Children were mostly positive for two (37.8%) and three (49.5%) autoantibodies, whereas adults for one (32.2%) and two (30.7%). The most frequently detected autoantibodies in youth were ZnT8-ab (81.1%) and IA2-ab (80.7%), while in adults GAD-ab (74.8%). ZnT8-ab (p < 0.0001) titers were significantly higher in children, but adults had higher titer of GAD-ab (p < 0.0001) and IA2-ab (p < 0.0001). Children developed more frequently diabetic ketoacidosis (28.4 vs. 10.7%, p = 0.0002). ZnT8-ab (p = 0.002) and IA2-ab (p = 0.008) were reported mostly in individuals with ketoacidosis. A correlation between the number of positive antibodies and the severity of ketoacidosis was observed (Rs - 0.129 p = 0.014). ZnT8-ab were associated with a greater risk of ketoacidosis independent of gender, age group and the autoantibodies number [OR = 2.44 (95% CI 1.0-5.94), p = 0.04]. CONCLUSIONS Children are at greater risk of ketoacidosis at the diagnosis of diabetes. ZnT8-ab and IA2-ab are commonly detected in children, while adults have frequently higher titer of GAD-ab. ZnT8-ab are associated with more acute diabetes onset.
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Affiliation(s)
- Elżbieta Niechciał
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572, Poznan, Poland.
| | - Anita Rogowicz-Frontczak
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Mickiewicza Street 2, 60-101, Poznan, Poland
| | - Stanisław Piłaciński
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Mickiewicza Street 2, 60-101, Poznan, Poland
| | - Marta Fichna
- Department of Endocrinology, Metabolism and Internal Medicine, Poznan University of Medical Sciences, Przybyszewskiego Street 49, 60-101, Poznan, Poland
- Institute of Human Genetics, Polish Academy of Sciences, Strzeszyńska Street 32, 60-479, Poznan, Poland
| | - Bogda Skowrońska
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572, Poznan, Poland
| | - Piotr Fichna
- Department of Pediatric Diabetes and Obesity, Poznan University of Medical Sciences, Szpitalna Street 27/33, 60-572, Poznan, Poland
| | - Dorota Zozulińska-Ziółkiewicz
- Department of Internal Medicine and Diabetology, Poznan University of Medical Sciences, Mickiewicza Street 2, 60-101, Poznan, Poland
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Guo C, Wang Q, Yang L, Wang H, Wang D, Tang X. Selective naked eye and turn-on fluorescence for detection of D-3-HB based on an erbium complex. J Photochem Photobiol A Chem 2018. [DOI: 10.1016/j.jphotochem.2017.07.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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137
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Ronsley R, Islam N, Ronsley C, Metzger DL, Panagiotopoulos C. Adherence to a pediatric diabetic ketoacidosis protocol in children presenting to a tertiary care hospital. Pediatr Diabetes 2018; 19:333-338. [PMID: 28664545 DOI: 10.1111/pedi.12556] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/24/2017] [Accepted: 06/06/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To review adherence to a provincial diabetic ketoacidosis (DKA) protocol and to assess factors associated with intravenous fluid administration and the length time on an insulin infusion. METHODS A retrospective chart review was conducted of all DKA admissions to British Columbia Children's Hospital (BCCH) during September 2008 to December 2013. Data collection included diabetes history, estimation of dehydration, insulin and fluid infusion rates, and frequency of laboratory investigations. Markers of adherence included appropriate use of a fluid bolus, normal saline and insulin infusion time, fluid intake and outputs, and the frequency of blood work during the insulin infusion. A log-linear regression model was fitted to assess the factors associated with insulin infusion duration. RESULTS Of 157 children (median [interquartile range] age: 10.6 years [5.0, 13.8]) hospitalized for DKA, 45% (n = 70) were male, 55% (n = 86) were transferred from other hospitals, and 26% (n = 40) were admitted to intensive care unit. Thirty-five percent of subjects estimated to have mild or moderate dehydration received fluid boluses. In the adjusted analysis, the average duration on DKA protocol was 39% (95% confidence interval [CI]: 12%, 67%) longer for children admitted with severe dehydration (compared to those with mild dehydration). CONCLUSIONS Health care providers' adherence to the BCCH DKA protocol is poor. More severe dehydration at presentation is associated with longer duration of insulin infusion. Further knowledge translation initiatives focused on accurate estimation of volume depletion to ensure appropriate initial fluid resuscitation-as well as careful monitoring during DKA hospitalization-are important, especially in community centers.
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Affiliation(s)
- Rebecca Ronsley
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Nazrul Islam
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.,Harvard T. H. Chan School of Public Health, Harvard University, Boston, USA
| | - Claire Ronsley
- Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
| | - Daniel L Metzger
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
| | - Constadina Panagiotopoulos
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Endocrinology and Diabetes Unit, BC Children's Hospital, Vancouver, Canada
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Ushijima K, Fukami M, Ayabe T, Narumi S, Okuno M, Nakamura A, Takahashi T, Ihara K, Ohkubo K, Tachikawa E, Nakayama S, Arai J, Kikuchi N, Kikuchi T, Kawamura T, Urakami T, Hata K, Nakabayashi K, Matsubara Y, Amemiya S, Ogata T, Yokota I, Sugihara S. Comprehensive screening for monogenic diabetes in 89 Japanese children with insulin-requiring antibody-negative type 1 diabetes. Pediatr Diabetes 2018; 19:243-250. [PMID: 28597946 DOI: 10.1111/pedi.12544] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 04/03/2017] [Accepted: 05/02/2017] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Mutations in causative genes for neonatal diabetes or maturity-onset diabetes of the young have been identified in multiple patients with autoantibody-negative type 1 diabetes (T1D). OBJECTIVES We aimed to clarify the prevalence and phenotypic characteristics of monogenic abnormalities among 89 children with autoantibody-negative insulin-requiring T1D. METHODS Mutations in 30 genes were screened using next-generation sequencing, and copy-number alterations of 4 major causative genes were examined using multiplex-ligation-dependent probe amplification. We compared the clinical characteristics between mutation carriers and non-carriers. RESULTS We identified 11 probable pathogenic substitutions (6 in INS , 2 in HNF1A , 2 in HNF4A , and 1 in HNF1B ) in 11 cases, but no copy-number abnormalities. Only 2 mutation carriers had affected parents. De novo occurrence was confirmed for 3 mutations. The non-carrier group, but not the carrier group, was enriched with susceptible HLA alleles. Mutation carriers exhibited comparable phenotypes to those of non-carriers, except for a relatively normal body mass index (BMI) at diagnosis. CONCLUSIONS This study demonstrated significant genetic overlap between autoantibody-negative T1D and monogenic diabetes. Mutations in INS and HNF genes, but not those in GCK and other monogenic diabetes genes, likely play critical roles in children with insulin-requiring T1D. This study also suggests the relatively high de novo rates of INS and HNF mutations, and the etiological link between autoimmune abnormalities and T1D in the non-carrier group. Carriers of monogenic mutations show non-specific phenotypes among all T1D cases, although they are more likely to have a normal BMI at diagnosis than non-carriers.
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Affiliation(s)
- Kikumi Ushijima
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Maki Fukami
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Tadayuki Ayabe
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Sanaikai General Hospital, Misato, Japan
| | - Satoshi Narumi
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Misako Okuno
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan.,Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Akie Nakamura
- Department of Molecular Endocrinology, National Research Institute for Child Health and Development, Tokyo, Japan
| | | | - Kenji Ihara
- Department of Pediatrics, Oita University School of Medicine, Oita, Japan
| | - Kazuhiro Ohkubo
- Department of Pediatrics, Kyushu University School of Medicine, Fukuoka, Japan
| | - Emiko Tachikawa
- Department of Pediatrics, Tokyo Women's Medical University Hospital, Tokyo, Japan
| | - Shoji Nakayama
- Department of Pediatrics, Mominoki Hospital, Kochi, Japan
| | - Junichi Arai
- Department of Pediatrics, Hosogi Hospital, Kochi, Japan
| | - Nobuyuki Kikuchi
- Department of Pediatrics, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Toru Kikuchi
- Department of Pediatrics, Saitama Medical University Faculty of Medicine, Saitama, Japan
| | - Tomoyuki Kawamura
- Department of Pediatrics, Osaka City University School of Medicine, Osaka, Japan
| | - Tatsuhiko Urakami
- Department of Pediatrics and Child Health, Nihon University School of Medicine, Tokyo, Japan
| | - Kenichiro Hata
- Department of Maternal-Fetal Biology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kazuhiko Nakabayashi
- Department of Maternal-Fetal Biology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yoichi Matsubara
- Institute Director, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Shin Amemiya
- Department of Pediatrics, Saitama Medical University Faculty of Medicine, Saitama, Japan
| | - Tsutomu Ogata
- Department of Pediatrics, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Ichiro Yokota
- Department of Pediatrics, Division of Pediatric Endocrinology and Metabolism, Shikoku Medical Center for Children and Adults, Kagawa, Japan
| | - Shigetaka Sugihara
- Department of Pediatrics, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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Abulebda K, Lutfi R, Whitfill T, Abu-Sultaneh S, Leeper KJ, Weinstein E, Auerbach MA. A Collaborative In Situ Simulation-based Pediatric Readiness Improvement Program for Community Emergency Departments. Acad Emerg Med 2018; 25:177-185. [PMID: 28977717 DOI: 10.1111/acem.13329] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 09/20/2017] [Accepted: 09/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND More than 30 million children are cared for across 5,000 U.S. emergency departments (EDs) each year. Most of these EDs are not facilities designed and operated solely for children. A Web-based survey provided a national and state-by-state assessment of pediatric readiness and noted a national average score was 69 on a 100-point scale. This survey noted wide variations in ED readiness with scores ranging from 61 in low-pediatric-volume EDs to 90 in the high-pediatric-volume EDs. Additionally, the mean score at the state level ranged from 57 (Wyoming) to 83 (Florida) and for individual EDs ranged from 22 to 100. The majority of prior efforts made to improve pediatric readiness have involved providing Web-based resources and online toolkits. This article reports on the first year of a program that aimed to improve pediatric readiness across community hospitals in our state through in situ simulation-based assessment facilitated by our academic medical center. The primary aim was to improve the pediatric readiness scores in the 10 participating hospitals. The secondary aim was to explore the correlation of simulation-based performance of hospital teams with pediatric readiness scores. METHODS This interventional study measured the Pediatric Readiness Survey (PRS) prior to and after implementation of an improvement program. This program consisted of three components: 1) in situ simulations, 2) report-outs, and 3) access to online pediatric readiness resources and content experts. The simulations were conducted in situ (in the ED resuscitation bay) by multiprofessional teams of doctors, nurses, respiratory therapists, and technicians. Simulations and debriefings were facilitated by an expert team from a pediatric academic medical center. Three scenarios were conducted for all teams and include: a 6-month-old with respiratory failure, an 8-year-old with diabetic ketoacidosis (DKA), and a 6-month-old with supraventricular tachycardia (SVT). A performance score was calculated for each scenario. The improvement of PRS was compared before and after the simulation program. The correlation of the simulation performance of each hospital and the PRS was calculated. RESULTS Forty-one multiprofessional teams from 10 EDs in Indiana participated in the study, five were of medium pediatric volume and five were medium- to high-volume EDs. The PRS significantly improved from the first to the second on-site verification assessment (58.4 ± 4.8 to 74.7 ± 2.9, p = 0.009). Total adherence scores to scenario guidelines were 54.7, 56.4, and 62.4% in the respiratory failure, DKA, and SVT scenarios, respectively. We found no correlation between simulation performance and PRS scores. Medium ED pediatric volume significantly predicted higher PRS scores compared to medium-high pediatric ED volume (β = 8.7; confidence interval = 0.72-16.8, p = 0.034). CONCLUSIONS Our collaborative improvement program that involved simulation was associated with improvement in pediatric readiness scores in 10 EDs participating statewide. Future work will focus on further expanding of the network and establishing a national model for pediatric readiness improvement.
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Affiliation(s)
- Kamal Abulebda
- Department of Pediatrics; Riley Hospital for Children at Indiana University Health; Indianapolis IN
| | - Riad Lutfi
- Department of Pediatrics; Riley Hospital for Children at Indiana University Health; Indianapolis IN
| | - Travis Whitfill
- Department of Pediatrics; Yale University School of Medicine; New Haven CT
| | - Samer Abu-Sultaneh
- Department of Pediatrics; Riley Hospital for Children at Indiana University Health; Indianapolis IN
| | - Kellie J. Leeper
- LifeLine Critical Care Transport; Indiana University Health; Indianapolis IN
| | - Elizabeth Weinstein
- Division of Emergency Medicine; Indiana University School of Medicine; Indianapolis IN
| | - Marc A. Auerbach
- Division of Pediatric Emergency Medicine; Yale University School of Medicine; New Haven CT
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CLINICAL PROFILE OF CHILDREN WITH DIABETIC KETOACIDOSIS AND RELATED CEREBRAL EDEMA IN A TERTIARY CARE HOSPITAL FROM SOUTHERN KERALA. ACTA ACUST UNITED AC 2018. [DOI: 10.32677/ijch.2018.v05.i02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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141
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Abbas Q, Arbab S, Haque AU, Humayun KN. Spectrum of complications of severe DKA in children in pediatric Intensive Care Unit. Pak J Med Sci 2018; 34:106-109. [PMID: 29643888 PMCID: PMC5856992 DOI: 10.12669/pjms.341.13875] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objectives: To describe the spectrum of complications of Diabetic Ketoacidosis (DKA) observed in children admitted with severe DKA. Methods: Retrospective review of the medical records of all children admitted with the diagnosis of severe DKA in Pediatric Intensive Care Unit (PICU) of the Aga Khan University Hospital, from January 2010 to December 2015 was done. Data was collected on a structured proforma and descriptive statistics were applied. Results: Total 37 children were admitted with complicated DKA (1.9% of total PICU admission with 1.8% in 2010 and 3.4% in 2015). Mean age of study population was 8.1±4.6 years and 70% were females (26/37). Mean Prism III score was 9.4±6, mean GCS on presentation was 11±3.8 and mean lowest pH was 7.00±0.15. Complications observed included hyperchloremia (35.94%), hypokalemia (30.81%), hyponatremia (26.70%), cerebral edema (16.43%), shock (13.35%), acute kidney injury (10.27%), arrhythmias (3.8%), and thrombotic thrombocytopenic purpura (5.4%), while one patient had myocarditis and ARDS each. 13/37 children (35%) needed inotropic support, 11/37 (30%) required mechanical ventilation while only one patient required renal replacement therapy. Two patients (5.4%) died during their PICU stay. Conclusion: Hyperchloremia and other electrolyte abnormalities, cerebral edema and AKI are the most common complications of severe DKA.
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Affiliation(s)
- Qalab Abbas
- Dr. Qalab Abbas, FCPS. Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Saba Arbab
- Dr. Saba Arbab, FCPS. Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Anwar Ul Haque
- Dr. Anwar ul Haque, MD. Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Khadija Nuzhat Humayun
- Dr. Khadija Nuzhat Humayun, FCPS. Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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Iovane B, Cangelosi AM, Bonaccini I, Di Mauro D, Scarabello C, Panigari A, Tiri A, Mastrorilli C, Fainardi V, Dodi I, Vanelli M. Diabetic ketoacidosis at the onset of Type 1 diabetes in young children Is it time to launch a tailored campaign for DKA prevention in children <5 years? ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:67-71. [PMID: 29633745 PMCID: PMC6357617 DOI: 10.23750/abm.v89i1.6936] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 11/27/2017] [Indexed: 12/17/2022]
Abstract
AIM To analyze clinical characteristics associated with the occurrence of diabetic ketoacidosis (DKA) at the onset of type 1 diabetes (T1D) in children aged <5 years in order to identify early signs or symptoms useful to prevent DKA appearance. METHODS Data of patients with newly diagnosed TID aged <5 years (Group 1) and 6-10 years old (Group 2) coming from the province of Parma were collected in the period 2012-2016. RESULTS Mild/moderate ketoacidosis at diabetes diagnosis occurred more frequently in Group 1 than in Group 2 patients (p<0.0015). Severe DKA incidence was higher in children below 5 (21.8%) than in those over 5 years of age (3.75%; p=0.021). Latent period before overt T1D diagnosis was longer in Group 1 than in Group 2 patients (p=0.0081). During this latent period similar indicators were recorded among parents of children <3 years old: frequent use of disposable baby diapers (87%), wet baby diapers because of a large amount of urine (86%), body weight loss (79%). In children aged 3-4 years reported symptoms consisted of polyuria (89%), polydipsia (79%), fatigue (72%). In Group 2 patients predominant signs concern unusual episodes of enuresis. CONCLUSIONS We believe that it is time to launch a DKA prevention campaign tailored for children under 5 years old and focused just on the above-mentioned three warning signs. Information program must involves pediatricians, pediatric nurses, new moms and nursery school teachers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Icilio Dodi
- Department of General Pediatrics and Emergency.
| | - Maurizio Vanelli
- Center on health systems organization, quality and sustainability. Children Hospital and University of Parma, Parma, Italy.
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Weng J, Zhou Z, Guo L, Zhu D, Ji L, Luo X, Mu Y, Jia W. Incidence of type 1 diabetes in China, 2010-13: population based study. BMJ 2018; 360:j5295. [PMID: 29298776 PMCID: PMC5750780 DOI: 10.1136/bmj.j5295] [Citation(s) in RCA: 171] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To estimate the incidence of type 1 diabetes in all age groups in China during 2010-13. DESIGN Population based, registry study using data from multiple independent sources. SETTING National registration system in all 505 hospitals providing diabetes care, and communities of patients with diabetes in 13 areas across China, covering more than 133 million person years at risk, approximately 10% of the whole population. PARTICIPANTS 5018 people of all ages with newly diagnosed type 1 diabetes and resident in the study areas from 1 January 2010 to 31 December 2013. MAIN OUTCOME MEASURES Incidence of type 1 diabetes per 100 000 person years by age, sex, and study area. Type 1 diabetes was doctor diagnosed and further validated by onsite follow-up. Completeness of case ascertainment was assessed using the capture mark recapture method. RESULTS 5018 cases of newly diagnosed type 1 diabetes were ascertained: 1239 participants were aged <15 years, 1799 were aged 15-29 years, and 1980 were aged ≥30 years. The proportion of new onset cases in participants aged ≥20 years was 65.3%. The estimated incidence of type 1 diabetes per 100 000 persons years for all ages in China was 1.01 (95% confidence interval 0.18 to 1.84). Incidence per 100 000 persons years by age group was 1.93 (0.83 to 3.03) for 0-14 years, 1.28 (0.45 to 2.11) for 15-29 years, and 0.69 (0.00 to 1.51) for ≥30 years, with a peak in age group 10-14 years. The incidence in under 15s was positively correlated with latitude (r=0.88, P<0.001), although this association was not observed in age groups 15-29 years or ≥30 years. CONCLUSION Most cases of new onset type 1 diabetes in China occurred among adults. The incidence of type 1 diabetes in Chinese children was among the lowest reported in the study.
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von Oettingen JE, Rhodes ET, Wolfsdorf JI. Resolution of ketoacidosis in children with new onset diabetes: Evaluation of various definitions. Diabetes Res Clin Pract 2018; 135:76-84. [PMID: 29111277 PMCID: PMC6013285 DOI: 10.1016/j.diabres.2017.09.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 08/22/2017] [Accepted: 09/18/2017] [Indexed: 01/21/2023]
Abstract
AIMS Data are sparse concerning use of serum electrolyte parameters as compared to venous blood gas (VBG) measurements to monitor acid-base status during treatment of diabetic ketoacidosis (DKA). We explored the utility of various parameters to define DKA resolution by investigating the relationship of venous pH (vpH), anion gap (AG), serum bicarbonate (HCO3), and glucose concentration during management of DKA in children with new onset diabetes mellitus (NODM). METHODS We included all patients with NODM presenting with DKA to Boston Children's Hospital from 10/1/07-7/1/13. DKA was defined as serum glucose ≥ 200 mg/dL (11.1 mmol/L) and vpH<7.30; severity as mild <7.30, moderate<7.20, severe<7.10; resolution of DKA as vpH≥7.30 and AG≤18 mmol/L. We used Cox regression to determine time to DKA resolution, and logistic regression to evaluate different serum HCO3 cut-off values as predictors of DKA resolution. RESULTS 263 patients (133F, mean age 9.9±4.4 years, 74% White) were included. DKA was mild in 134 (51%), moderate in 75 (28%) and severe in 54 (20%). In mild DKA, AG closed after normalization of vpH; in moderate and severe DKA, AG closed before normalization of vpH. HCO3>15mmol/L correlated with vpH≥7.30, and had 76% sensitivity and 85% specificity to predict DKA resolution. Median times to DKA resolution were similar using two different definitions: vpH and AG (8.4h [IQR 6.3-11.9]) vs. HCO3>15 mmol/L (7.9 h [IQR 5.0-11.8]), p=.42. CONCLUSIONS During management of pediatric DKA, HCO3 > 15 mmol/L reliably predicts resolution of DKA. In low-resource settings where VBG is unavailable, electrolyte parameters alone may be used to determine DKA resolution.
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Affiliation(s)
- Julia E von Oettingen
- Division of Endocrinology, Montreal Children's Hospital, McGill University Health Center, Montreal, QC H4A3J1, Canada; Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA.
| | - Erinn T Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, MA 02115, USA; Harvard Medical School, Boston, MA 02115, USA
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T Lymphocytes and Autoimmunity. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2018; 341:125-168. [DOI: 10.1016/bs.ircmb.2018.05.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Diabetic Ketoacidosis Severity at Diagnosis and Glycaemic Control in the First Year of Childhood Onset Type 1 Diabetes-A Longitudinal Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2017; 15:ijerph15010026. [PMID: 29295580 PMCID: PMC5800126 DOI: 10.3390/ijerph15010026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 11/17/2022]
Abstract
It is unclear whether diabetic ketoacidosis (DKA) severity at diagnosis affects the natural history of type 1 diabetes (T1D). We analysed associations between DKA severity at diagnosis and glycaemic control during the first year post-diagnosis. We followed 341 children with T1D, <19 years (64% non-white) attending paediatric diabetes clinics in East London. Data were extracted from routine medical registers. Subjects were categorized with normal, mild, moderate, or severe DKA. Linear mixed-effects modelling was used to assess differences in longitudinal HbA1c trajectories (glycaemic control) during 12 months post-diagnosis (1288 HbA1c data-points) based on DKA, adjusting for sex, age, ethnicity, SES (Socioeconomic Status) and treatment type. Females (OR 1.6, 95% CI 1.1–2.4) and younger age, 0–6 vs. 13–18 years (OR 2.9, 95% CI 1.5–5.6) had increased risk for DKA at diagnosis. Moderate or severe DKA was associated with higher HbA1c at diagnosis (adjusted estimates 8 mmol/mol, 2–14, and 10 mmol/mol, 4–15, respectively, compared to normal DKA). Differences in HbA1c trajectories by DKA were no longer apparent at six months post-diagnosis. All subjects experienced a steep decrease in HbA1c during the first three months followed by a gradual increase. While, DKA severity was not associated with glycaemic control at 12 months post-diagnosis, age at diagnosis, ethnicity, gender, and treatment type were significantly associated. For example, Black and mixed ethnicity children had increased risk for poor glycaemic control compared to White children (adjusted RRR 5.4, 95% CI 1.7–17.3 and RRR 2.5, 95% CI 1.2–6.0, respectively). DKA severity at diagnosis is associated with higher initial HbA1c but not glycaemic control from six months post-diagnosis. Age at diagnosis, ethnicity, gender, and insulin pump are associated with glycaemic control at one year post-diagnosis.
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147
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Siller AF, Lugar H, Rutlin J, Koller JM, Semenkovich K, White NH, Arbelaez AM, Shimony J, Hershey T. Severity of clinical presentation in youth with type 1 diabetes is associated with differences in brain structure. Pediatr Diabetes 2017; 18:686-695. [PMID: 27488913 PMCID: PMC5290262 DOI: 10.1111/pedi.12420] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 06/30/2016] [Accepted: 07/01/2016] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Differences in cognition and brain structure have been found in youth with type 1 diabetes compared with controls, even after relatively short disease duration. To determine whether severity of clinical presentation contributes to these differences, we obtained structural magnetic resonance imaging (MRI) scans in youth ages 7-17 who were either newly diagnosed with type 1 diabetes (<3.5 months from diagnosis, n = 46) or a sibling without diabetes (n = 28). RESEARCH DESIGN AND METHODS Severity of presentation was measured by the presence of diabetic ketoacidosis (DKA) and degree of hyperglycemia exposure [hemoglobin A1c (HbA1c)] at diagnosis. MRI were obtained using T1-weighted, T2-weighted, and diffusion-weighted sequences. RESULTS Within the group with type 1 diabetes, 12 subjects presented in DKA and 34 did not. After controlling for age, sex, and multiple comparisons, the type 1 diabetes group had lower volume in the left temporal-parietal-occipital cortex compared with controls. Within the type 1 diabetes group, DKA at presentation was associated with lower radial, axial, and mean diffusivity (MD) throughout major white matter tracts and higher HbA1c was associated with lower hippocampal, thalamic, and cerebellar white matter volumes, lower right posterior parietal cortical thickness, and greater right occipital cortical thickness. CONCLUSION These data suggest that severity of clinical presentation is an important factor in predicting brain structural differences in youth with type 1 diabetes approximately 3 months after diagnosis.
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Affiliation(s)
| | | | | | | | | | - Neil H. White
- Department of Pediatrics,Department of Medicine,St. Louis Children’s Hospital
| | | | | | - Tamara Hershey
- Department of Psychiatry,Department of Radiology,Department of Neurology
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148
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Falcão MA, Francisco R. Diabetes, eating disorders and body image in young adults: an exploratory study about "diabulimia". Eat Weight Disord 2017; 22:675-682. [PMID: 28597360 DOI: 10.1007/s40519-017-0406-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 05/27/2017] [Indexed: 10/19/2022] Open
Abstract
PURPOSE The purpose of this study was to compare disordered eating (DE) and body image dissatisfaction (BID) among young adults with type 1 diabetes and their peers without diabetes, to investigate the consequences of diabetes for food, body image and weight in individuals with diabetes and to identify the behavior of insulin omission as a weight loss strategy. METHODS Fifty-five young adults with diabetes and 73 without diabetes (ages 18-30) completed self-report questionnaires to evaluate their behaviors, attitudes and feelings related to eating disorders and their perceptions about body image. The participants with diabetes were asked to answer a questionnaire with open and closed questions developed specifically for this study. RESULTS No significant differences between participants with and without diabetes in relation to BID and DE were found. The results demonstrated several changes resulting from diabetes in terms of food, body image and weight that interfere with the day-to-day life of individuals with diabetes; 7.3% of these participants reported insulin omission as a weight loss strategy. CONCLUSIONS This study emphasizes the importance of research on DE in the population with diabetes and their prevention, screening and treatment. In particular, it is essential to give more attention to insulin omission as a compensatory behavior that is inappropriate and harmful to health. LEVEL OF EVIDENCE Level III, case-control analytic study.
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Affiliation(s)
- Maria Ana Falcão
- Faculdade de Psicologia, Universidade de Lisboa, Lisbon, Portugal
| | - Rita Francisco
- Faculdade de Psicologia, Universidade de Lisboa, Lisbon, Portugal. .,Faculdade de Ciências Humanas, Universidade Católica Portuguesa, Palma de Cima, 1649-023, Lisbon, Portugal.
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149
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Harrison VS, Rustico S, Palladino AA, Ferrara C, Hawkes CP. Glargine co-administration with intravenous insulin in pediatric diabetic ketoacidosis is safe and facilitates transition to a subcutaneous regimen. Pediatr Diabetes 2017; 18:742-748. [PMID: 27807910 PMCID: PMC5415439 DOI: 10.1111/pedi.12462] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 09/16/2016] [Accepted: 09/22/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Diabetes ketoacidosis (DKA) is a common presentation and complication of type 1 diabetes (T1D). While intravenous insulin is typically used to treat acute metabolic abnormalities, the transition from intravenous to subcutaneous treatment can present a challenge. We hypothesize that co-administration of glargine, a subcutaneous long-acting insulin analog, during insulin infusion may facilitate a flexible and safe transition from intravenous to subcutaneous therapy. OBJECTIVE To determine if the practice of administering subcutaneous glargine during intravenous insulin is associated with an increased risk of hypoglycemia, hypokalemia, or other complications in children with DKA. METHODS Retrospective chart review of patients aged 2 to 21 years, presenting to our center with DKA between April 2012 and June 2014. Patients were divided into two groups: those co-administered subcutaneous glargine with intravenous insulin for over 4 hours (G+); and patients with less than 2 hours of overlap (G-). RESULTS We reviewed 149 DKA admissions (55 G+, 94 G-) from 129 unique patients. There was a similar incidence of hypoglycemia between groups (25% G+ vs 20% G-, P = 0.46). Hypokalemia (<3.5 mmol/L) occurred more frequently in the G+ group (OR = 3.4, 95% CI 1.7-7.0, P = 0.001). Cerebral edema occurred in 2/55 (3.6%) of the G- group and none of the G+ subjects. CONCLUSION Co-administration of glargine early in the course of DKA treatment is well tolerated and convenient for discharge planning; however, this approach is associated with an increased risk of hypokalemia.
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Affiliation(s)
- V Sanoe Harrison
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Stacy Rustico
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Andrew A Palladino
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Christine Ferrara
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA
| | - Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, USA,The National Children's Research Centre, Dublin, Ireland
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150
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Baldelli L, Flitter B, Pyle L, Maahs DM, Klingensmith G, Slover R, Alonso GT. A survey of youth with new onset type 1 diabetes: Opportunities to reduce diabetic ketoacidosis. Pediatr Diabetes 2017; 18:547-552. [PMID: 27726268 PMCID: PMC5388598 DOI: 10.1111/pedi.12455] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 09/07/2016] [Accepted: 09/09/2016] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE Pediatric patients in Colorado with new onset type 1 diabetes (T1D) presenting with diabetic ketoacidosis (DKA) increased from 29.9% to 46.2% from 1998 to 2012. The purpose of this study was to compare differences between patients with newly diagnosed T1D who presented in DKA with those who did not across three domains: sociodemographic factors, access to medical care, and medical provider factors, aiming to identify potential targets for intervention. METHODS Sixty-one patients <17 years of age with T1D duration <6 months completed the questionnaire. Groups were compared using Fisher's exact test or the Kruskal-Wallis test. RESULTS Parents of 28% of patients researched their child's symptoms on the Internet prior to diagnosis. At the first healthcare visit for symptoms of T1D, 23% were not diagnosed. There were no significant differences between groups (DKA vs non-DKA) in demographics, first healthcare setting for T1D symptoms, provider type at first visit or at diagnosis, insurance status, or specific barriers to care. DKA patients had a longer interval between previous well visit to diagnosis (median 172 vs 263 days, P = 0.01). Non-DKA patients were more likely to have blood glucose measured at P = 0.02, and had fewer symptoms prior to (P = 0.01) the first visit for diabetes symptoms. Parents of non-DKA patients were more likely to be familiar with symptoms of diabetes (P < 0.001) and to suspect diabetes (P = 0.01). CONCLUSION Targets for campaigns to prevent DKA include increasing provider glucose and ketone testing, increasing public knowledge about diabetes, and understanding how socio-demographic factors may delay T1D diagnosis.
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Affiliation(s)
- Luke Baldelli
- University of Colorado School of Medicine, Aurora, CO 80045
| | - Ben Flitter
- University of Colorado School of Medicine, Aurora, CO 80045
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045
,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO 80045
| | - David M Maahs
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045
,The Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045
| | - Georgeanna Klingensmith
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045
,The Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045
| | - Robert Slover
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045
,The Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045
| | - G. Todd. Alonso
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO 80045
,The Barbara Davis Center for Childhood Diabetes, Aurora, CO 80045
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