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Belal MM, Khalefa BB, Rabea EM, Aly Yassin MN, Bashir MN, Abd El-Hameed MM, Elkoumi O, Saad SM, Saad LM, Elkasaby MH. Low dose insulin infusion versus the standard dose in children with diabetic ketoacidosis: a meta-analysis. Future Sci OA 2024; 10:FSO956. [PMID: 38827803 PMCID: PMC11140676 DOI: 10.2144/fsoa-2023-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 12/13/2023] [Indexed: 06/05/2024] Open
Abstract
Aim: This systematic review aims to consolidate findings from current clinical trials that compare the effectiveness of insulin infusion at 0.05 IU/kg/h versus 0.1 IU/kg/h in managing pediatric diabetic ketoacidosis. Methods: We searched several databases, including PubMed, Embase, Scopus, Cochrane Central and Web of Science. Our primary outcomes were time to reach blood glucose ≤250 mg/dl and time to resolution of acidosis. Secondary outcomes included rate of blood glucose decrease per hour, incidence of hypoglycemia, hypokalemia, treatment failure, and cerebral edema. Results & conclusion: The present study establishes that a low insulin dose exhibits comparable efficacy to the standard dosage for managing pediatric patients suffering from diabetic ketoacidosis, with a lower incidence of complications.
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Affiliation(s)
- Mohamed Mohamed Belal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Basma Badrawy Khalefa
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Ain shams University, Cairo, Egypt
| | - Eslam Mohammed Rabea
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mazen Negmeldin Aly Yassin
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Nabih Bashir
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Malak Mohamed Abd El-Hameed
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Zagazig University, Ash Sharqia, Egypt
| | - Omar Elkoumi
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Suez University, Suez, Egypt
| | - Saad Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Loubna Mohamed Saad
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
| | - Mohamed Hamouda Elkasaby
- Medical Research Group of Egypt (MRGE), Cairo, Egypt
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Insulin Infusion Dosing in Pediatric Diabetic Ketoacidosis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Explor 2023; 5:e0857. [PMID: 36844374 PMCID: PMC9943979 DOI: 10.1097/cce.0000000000000857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
In children with diabetic ketoacidosis (DKA), insulin infusions are the mainstay of treatment; however, optimal dosing remains unclear. Our objective was to compare the efficacy and safety of different insulin infusion doses for the treatment of pediatric DKA. DATA SOURCES We searched MEDLINE, EMBASE, PubMed, and Cochrane from inception to April 1, 2022. STUDY SELECTION We included randomized controlled trials (RCTs) of children with DKA comparing intravenous insulin infusion administered at 0.05 units/kg/hr (low dose) versus 0.1 units/kg/hr (standard dose). DATA EXTRACTION We extracted data independently and in duplicate and pooled using a random effects model. We assessed the overall certainty of evidence for each outcome using the Grading Recommendations Assessment, Development and Evaluation approach. DATA SYNTHESIS We included four RCTs (n = 190 participants). In children with DKA, low-dose compared with standard-dose insulin infusion probably has no effect on time to resolution of hyperglycemia (mean difference [MD], 0.22 hr fewer; 95% CI, 1.19 hr fewer to 0.75 hr more; moderate certainty), or time to resolution of acidosis (MD, 0.61 hr more; 95% CI, 1.81 hr fewer to 3.02 hr more; moderate certainty). Low-dose insulin infusion probably decreases the incidence of hypokalemia (relative risk [RR], 0.65; 95% CI, 0.47-0.89; moderate certainty) and hypoglycemia (RR, 0.37; 95% CI, 0.15-0.80; moderate certainty), but may have no effect on rate of change of blood glucose (MD, 0.42 mmol/L/hr slower; 95% CI, 1 mmol/L/hr slower to 0.18 mmol/L/hr faster; low certainty). CONCLUSIONS In children with DKA, the use of low-dose insulin infusion is probably as efficacious as standard-dose insulin, and probably reduces treatment-related adverse events. Imprecision limited the certainty in the outcomes of interest, and the generalizability of the results is limited by all studies being performed in a single country.
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 364] [Impact Index Per Article: 60.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Houshyar J, Bahrami A, Aliasgarzadeh A. Effectiveness of Insulin Glargine on Recovery of Patients with Diabetic Ketoacidosis: A Randomized Controlled Trial. J Clin Diagn Res 2015; 9:OC01-5. [PMID: 26155506 DOI: 10.7860/jcdr/2015/12005.5883] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Diabetic Ketoacidosis (DKA) is a major hyperglycemic emergency in diabetes mellitus (DM). The basic treatment is injection of Regular insulin (RI). This study was aimed to investigate the effects of insulin Glargine (GI) on recovery of patients with DKA. MATERIALS AND METHODS A randomized clinical trial conducted on 40 patients (twenty patients in each group) with DKA. Both groups received standard treatment for DKA. Experimental group was given 0.4U/kg of GI within three hours of initiation of IV insulin infusion. RESULTS The mean duration of acidosis correction time and recovery from DKA was 13.77±6.10 and 16.91±6.49 h in the intervention and control groups respectively (p=0.123). The mean dosage of RI until recovery from DKA was 84.8±45.6 in the intervention and 116.5±91.6 units in control groups (p=0.17). Hypokalemia occurred in three patients in intervention and four patients in control groups. In 35% of samples in intervention group and 51% in controls blood sugar was more than 10 mmol/l for 24 h after discontinuation of the insulin infusion (p=0.046). The mean duration of hospitalization was 5.1±1.88 in intervention and 5.9±2.19 d in control group (p=0.225). CONCLUSION Adding GI to the standard treatment of DKA reduced average time of recovery from DKA, without incurring episodes of hypoglycemia and hypokalemia. This also reduced in the time of recovery from DKA, amount of required insulin and the duration of hospitalization. It seems that the non-significant difference in the time of recovery from DKA be related to the small sample size and study design. Further studies are recommended.
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Affiliation(s)
- Jalil Houshyar
- Assistant Professor, Department of Medicine, Endocrine Section, Endocrine Research Center, Tabriz University of Medical Sciences , Iran
| | - Amir Bahrami
- Professor, Department of Medicine, Endocrine Section, Endocrine Research Center, Tabriz University of Medical Sciences , Iran
| | - Akbar Aliasgarzadeh
- Associate Professor, Department of Medicine, Endocrine Section, Endocrine Research Center, Tabriz University of Medical Sciences , Iran
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Wolfsdorf JI, Allgrove J, Craig ME, Edge J, Glaser N, Jain V, Lee WWR, Mungai LNW, Rosenbloom AL, Sperling MA, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2014; 15 Suppl 20:154-79. [PMID: 25041509 DOI: 10.1111/pedi.12165] [Citation(s) in RCA: 214] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/21/2014] [Indexed: 12/16/2022] Open
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Murunga AN, Owira PMO. Diabetic ketoacidosis: an overlooked child killer in sub-Saharan Africa? Trop Med Int Health 2013; 18:1357-64. [PMID: 24112393 DOI: 10.1111/tmi.12195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The true incidence of diabetic ketoacidosis (DKA) in sub-Saharan Africa is unknown but unlike in the Western countries, DKA is also uniquely frequent among type 2 diabetes patients of African origin. Increased hyperglycaemia and hepatic ketogenesis lead to osmotic diuresis, dehydration and tissue hypoxia. Acute complications of DKA include cerebral oedema, which may be compounded by malnutrition, parasitic and microbial infections with rampant tuberculosis and HIV. Overlapping symptoms of these conditions and misdiagnosis of DKA contribute to increased morbidity and mortality. Inability of the patients to afford insulin treatment leads to poor glycemic control as some patients seek alternative treatment from traditional healers or use herbal remedies further complicating the disease process. Standard treatment guidelines for DKA currently used may not be ideal as they are adapted from those of the developed world. Children presenting with suspected DKA should be screened for comorbidities which may complicate fluid and electrolyte replacement therapy protocol. Patient rehabilitation should take into account concurrent treatment for infectious conditions to avoid possible life-threatening drug interactions. We recommend that health systems in sub-Saharan Africa leverage the Expanded Immunization Programme or TB/HIV/AIDS programmes, which are fairly well entrenched to support diabetes services.
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Affiliation(s)
- A N Murunga
- School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Abstract
Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado Denver, School of Medicine, Aurora, CO 80045, USA.
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Glossop AJ, Stanworth RD, Whiteside AM. Controversies and pitfalls in the management of hyperglycaemic crises in critically ill diabetic patients. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2011.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Devi R, Selvakumar G, Clark L, Downer C, Braithwaite SS. A dose-defining insulin algorithm for attainment and maintenance of glycemic targets during therapy of hyperglycemic crises. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/dmt.11.18] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus (DM), occurs more commonly in children with type 1 DM than type 2 DM. Hyperglycemia, metabolic acidosis, ketonemia, dehydration and various electrolyte abnormalities result from a relative or absolute deficiency of insulin with or without an excess of counter-regulatory hormones. Management requires careful replacement of fluid and electrolyte deficits, intravenous administration of insulin, and close monitoring of clinical and biochemical parameters directed towards timely detection of complications, including hypokalemia, hypoglycemia and cerebral edema. Cerebral edema may be life threatening and is managed with fluid restriction, administration of mannitol and ventilatory support as required. Factors precipitating the episode of DKA should be identified and rectified. Following resolution of ketoacidosis, intravenous insulin is transitioned to subcutaneous route, titrating dose to achieve normoglycemia.
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Insulin infused at 0.05 versus 0.1 units/kg/hr in children admitted to intensive care with diabetic ketoacidosis. Pediatr Crit Care Med 2011; 12:137-40. [PMID: 20473242 DOI: 10.1097/pcc.0b013e3181e2a21b] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the effects of infusing insulin at 0.05 units/kg/hr rather than 0.1 units/kg/hr in children admitted to the intensive care unit with diabetic ketoacidosis. DESIGN A retrospective observational study. SETTING A tertiary pediatric intensive care unit. PATIENTS All children with diabetic ketoacidosis admitted during the 6-yr period from 2000 to 2005. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The effective plasma osmolality (plasma glucose concentration in mmol/L + twice the plasma sodium concentration in mmol/L), plasma glucose, plasma sodium, fluid intake, and acid-base status 12 hrs after the commencement of the insulin infusion. Compared to the 34 children who received 0.1 units/kg/hr of insulin, the 33 children who received 0.05 units/kg/hr of insulin were younger (median age, 25 mos vs. 62 mos, p = .024) and had a more gradual reduction in the effective plasma osmolality over the first 12 hrs (p < .0005); this was because plasma glucose decreased more slowly (p = .004) and plasma sodium increased faster (p < .0005). Both groups had a satisfactory improvement in acidosis and ketosis, and they had a similar length of stay in the intensive care unit. CONCLUSIONS Further studies are needed to evaluate the role of using 0.05 units/kg/hr of insulin to treat children with diabetic ketoacidosis. The smaller dose of insulin may make it easier to lower the effective plasma osmolality gradually and might, therefore, reduce the risk of cerebral edema.
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Puttha R, Cooke D, Subbarayan A, Odeka E, Ariyawansa I, Bone M, Doughty I, Patel L, Amin R. Low dose (0.05 units/kg/h) is comparable with standard dose (0.1 units/kg/h) intravenous insulin infusion for the initial treatment of diabetic ketoacidosis in children with type 1 diabetes-an observational study. Pediatr Diabetes 2010; 11:12-7. [PMID: 19602154 DOI: 10.1111/j.1399-5448.2009.00536.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To compare low dose (0.05 units/kg/h) with standard dose (0.1 units/kg/h) intravenous insulin infusion for the treatment of diabetic ketoacidosis (DKA) in children with type 1 diabetes. STUDY DESIGN Data from five paediatric centres were compared in children who received 0.05 (41 episodes) or 0.1 units/kg/h (52 episodes). RESULTS In the low vs. standard dose group, at 6 h following admission, the fall in blood glucose levels [11.3 (95% confidence interval 8.6 to 13.9) vs. 11.8 (8.4 to 15.2) mmol/L, p = 0.86] and rise in pH [0.13 (0.09 to 0.18) vs. 0.11 (0.07 to 0.15), p = 0.78] were similar. These changes were comparable between doses in relation to: severity of initial acidosis, children newly diagnosed with diabetes or aged less than 5 years. After adjustment for other clinical and biochemical covariates, insulin dose was unrelated to the change in pH and blood glucose levels at 6 h following admission. Comparisons of safety data, particularly in relation to abnormal Glasgow Coma Score, were inconclusive. CONCLUSION In this observational study, low dose was as effective as standard dose intravenous insulin infusion in the initial treatment (less than 6 h) of DKA in children with type 1 diabetes. A randomised controlled trial is required to show true equivalence between doses and to evaluate potential safety benefits.
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Affiliation(s)
- R Puttha
- Department of Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee W, Rosenbloom A, Sperling M, Hanas R. Diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:118-33. [PMID: 19754623 DOI: 10.1111/j.1399-5448.2009.00569.x] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, MA 02115, USA.
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Kitabchi AE, Murphy MB, Spencer J, Matteri R, Karas J. Is a priming dose of insulin necessary in a low-dose insulin protocol for the treatment of diabetic ketoacidosis? Diabetes Care 2008; 31:2081-5. [PMID: 18694978 PMCID: PMC2571050 DOI: 10.2337/dc08-0509] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The purpose of this study was to assess the efficacy of an insulin priming dose with a continuous insulin infusion versus two continuous infusions without a priming dose. RESEARCH DESIGN AND METHODS This prospective randomized protocol used three insulin therapy methods: 1) load group using a priming dose of 0.07 units of regular insulin per kg body weight followed by a dose of 0.07 unit x kg(-1) x h(-1) i.v. in 12 patients with diabetic ketoacidosis (DKA); 2) no load group using an infusion of regular insulin of 0.07 unit . kg body weight(-1) x h(-1) without a loading dose in 12 patients with DKA, and 3) twice no load group using an infusion of regular insulin of 0.14 x kg(-1) x h(-1) without a loading dose in 13 patients with DKA. Outcome was based on the effects of insulin therapy on biochemical and hormonal changes during treatment and recovery of DKA. RESULTS The load group reached a peak in free insulin value (460 microU/ml) within 5 min and plateaued at 88 microU/ml in 60 min. The twice no load group reached a peak (200 microU/ml) at 45 min. The no load group reached a peak (60 microU/ml) in 60-120 min. Five patients in the no load group required supplemental insulin doses to decrease initial glucose levels by 10%; patients in the twice no load and load groups did not. Except for these differences, times to reach glucose <or=250 mg/dl, pH >or=7.3, and HCO(3)(-) >or=15 mEq/l did not differ significantly among the three groups. CONCLUSIONS A priming dose in low-dose insulin therapy in patients with DKA is unnecessary if an adequate dose of regular insulin of 0.14 unit x kg body weight(-1) x h(-1) (about 10 units/h in a 70-kg patient) is given.
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Affiliation(s)
- Abbas E Kitabchi
- Department of Medicine and Molecular Sciences, Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Kitabchi AE, Umpierrez GE, Fisher JN, Murphy MB, Stentz FB. Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. J Clin Endocrinol Metab 2008; 93:1541-52. [PMID: 18270259 PMCID: PMC2386681 DOI: 10.1210/jc.2007-2577] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
CONTEXT Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) cause major morbidity and significant mortality in patients with diabetes mellitus. For more than 30 yr, our group, in a series of prospective, randomized clinical studies, has investigated the pathogenesis and evolving strategies of the treatment of hyperglycemic crises. This paper summarizes the results of these prospective studies on the management and pathophysiology of DKA. SETTING Our earliest studies evaluated the comparative efficacy of low-dose vs. pharmacological amounts of insulin and the use of low-dose therapy by various routes in adults and later in children. Subsequent studies evaluated phosphate and bicarbonate therapy, lipid metabolism, ketosis-prone type 2 patients, and use of rapid-acting insulin analogs as well as leptin status, cardiac risk factors, proinflammatory cytokines, and the mechanism of activation of T lymphocytes in hyperglycemic crises. MAIN OUTCOME The information garnered from these studies resulted in the creation of the 2001 American Diabetes Association (ADA) technical review on DKA and HHS as well as the ADA Position and Consensus Paper on the therapy for hyperglycemic crises. CONCLUSIONS Areas of future research include prospective randomized studies to do the following: 1) establish the efficacy of bicarbonate therapy in DKA for a pH less than 6.9; 2) establish the need for a bolus insulin dose in the initial therapy of DKA; 3) determine the pathophysiological mechanisms for the absence of ketosis in HHS; 4) investigate the reasons for elevated proinflammatory cytokines and cardiovascular risk factors; and 5) evaluate the efficacy and cost benefit of using sc regular insulin vs. more expensive insulin analogs on the general ward for the treatment of DKA.
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, 920 Madison Avenue #909, Memphis, TN 38163, USA.
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Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WRW, Rosenbloom A, Sperling MA, Hanas R. Diabetic ketoacidosis. Pediatr Diabetes 2007; 8:28-43. [PMID: 17341289 DOI: 10.1111/j.1399-5448.2007.00224.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, MA, USA
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18
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Kitabchi AE, Nyenwe EA. Hyperglycemic crises in diabetes mellitus: diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am 2006; 35:725-51, viii. [PMID: 17127143 DOI: 10.1016/j.ecl.2006.09.006] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) potentially are fatal but largely preventable acute metabolic conditions of uncontrolled diabetes, the incidence of which continues to increase. Mortality from DKA has declined remarkably over the years because of better understanding of its pathophysiology and treatment. The mortality rate of HHS remains alarmingly high, however, owing to older age and mode of presentation of patients and associated comorbid conditions. DKA and HHS also are economically burdensome; therefore, any resources invested in their prevention would be rewarding.
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN 38163, USA.
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Kitabchi AE, Umpierrez GE, Murphy MB, Kreisberg RA. Hyperglycemic crises in adult patients with diabetes: a consensus statement from the American Diabetes Association. Diabetes Care 2006; 29:2739-48. [PMID: 17130218 DOI: 10.2337/dc06-9916] [Citation(s) in RCA: 266] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 956 Court Ave., Suite D334, Memphis, Tennessee 38163, USA.
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Wang J, Williams DE, Narayan KMV, Geiss LS. Declining death rates from hyperglycemic crisis among adults with diabetes, U.S., 1985-2002. Diabetes Care 2006; 29:2018-22. [PMID: 16936146 DOI: 10.2337/dc06-0311] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine trends in death rates for hyperglycemic crisis (diabetic ketoacidosis or hyperglycemic hyperosmolar state) among adults with diabetes in the U.S. from 1985 to 2002. RESEARCH DESIGN AND METHODS Deaths with hyperglycemic crisis as the underlying cause were identified from national mortality data. Death rates were calculated using estimates of adults with diabetes from the National Health Interview Survey as the denominator and age adjusted to the 2000 U.S. population. The trends from 1985 to 2002 were tested using joinpoint regression analysis. RESULTS Deaths due to hyperglycemic crisis dropped from 2,989 in 1985 to 2,459 in 2002. During the time period, age-adjusted death rates decreased from 42.4 to 23.8 per 100,000 adults with diabetes (4.4% decrease per year, P for trend <0.01). Death rates declined in all age-groups, with the greatest decrease occurring among individuals aged > or =65 years. Age-adjusted death rates fell for all race-sex subgroups, with black men experiencing the smallest decline. About one-fifth of deaths occurred at home or on arrival at the hospital, and the death rates for hyperglycemic crisis occurring at these places declined only modestly over time (2.1% decrease per year, P for trend = 0.049). CONCLUSIONS Overall death rates due to hyperglycemic crisis among adults with diabetes have declined in the U.S. However, scope for further improvement remains, especially to further reduce death rates among black men and to prevent deaths occurring at home.
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Affiliation(s)
- Jing Wang
- Division of Diabetes Translation, Centers for Disease Control and Prevention, 4770 Buford Highway N.E., Mailstop K-10, Atlanta, GA 30341, USA.
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Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association. Diabetes Care 2006. [PMID: 16644656 DOI: 10.2337/dc06-9909] [Citation(s) in RCA: 204] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Joseph Wolfsdorf
- Division of Endocrinology, Children's Hospital Boston, Boston, Massachusetts, USA
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Della Manna T, Steinmetz L, Campos PR, Farhat SCL, Schvartsman C, Kuperman H, Setian N, Damiani D. Subcutaneous use of a fast-acting insulin analog: an alternative treatment for pediatric patients with diabetic ketoacidosis. Diabetes Care 2005; 28:1856-61. [PMID: 16043723 DOI: 10.2337/diacare.28.8.1856] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To look for technical simplification and economic efficiency in the treatment of pediatric diabetic ketoacidosis (DKA) with subcutaneous use of the fast-acting insulin analog (lispro) and compare its use with regular intravenous insulin treatment. RESEARCH DESIGN AND METHODS In this controlled clinical trial from June 2001 to June 2003, we randomized 60 episodes of DKA with a blood glucose level > or = 16.6 mmol/l (300 mg/dl), venous pH <7.3 and/or bicarbonate <15 mmol/l, or ketonuria greater than + +. Of the 60 episodes, 30 were treated with subcutaneous lispro (0.15 units/kg) given every 2 h (lispro group) and the other 30 cases received continuous intravenous regular insulin (0.1 unit x kg(-1) x h(-1); CIRI group). Volume deficit was repaired with 10-ml/kg aliquots of 0.9% sodium chloride. Laboratory monitoring included hourly bedside capillary glucose, venous blood gas, beta-hydroxybutyrate, and electrolytes. Plasma blood glucose levels were measured on admission, 2 h after admission, when capillary blood glucose reached < or = 13.8 mmol/l (250 mg/dl), and 6, 12, and 24 h thereafter. RESULTS Capillary glucose levels decreased by 2.9 and 2.6 mmol x l(-1) x h(-1) in the lispro and CIRI groups, respectively, but blood glucose fluctuated at different time intervals. In the CIRI group, metabolic acidosis and ketosis resolved in the first 6-h period after capillary glucose reached 13.8 mmol/l, whereas in the lispro group, they resolved in the next 6-h interval; however, both groups met DKA recovery criteria without complications. CONCLUSIONS DKA treatment with a subcutaneous fast-acting insulin analog represents a cost-effective and technically simplified procedure that precludes intensive care unit admission.
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Affiliation(s)
- Thais Della Manna
- Pediatric Endocrine Unit, São Paulo University Medical School, São Paulo, SP, Brazil
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23
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Umpierrez GE, Cuervo R, Karabell A, Latif K, Freire AX, Kitabchi AE. Treatment of diabetic ketoacidosis with subcutaneous insulin aspart. Diabetes Care 2004; 27:1873-8. [PMID: 15277410 DOI: 10.2337/diacare.27.8.1873] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE In this prospective, randomized, open trial, we compared the efficacy and safety of aspart insulin given subcutaneously at different time intervals to a standard low-dose intravenous (IV) infusion protocol of regular insulin in patients with uncomplicated diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS A total of 45 consecutive patients admitted with DKA were randomly assigned to receive subcutaneous (SC) aspart insulin every hour (SC-1h, n = 15) or every 2 h (SC-2h, n = 15) or to receive IV infusion of regular insulin (n = 15). Response to medical therapy was evaluated by assessing the duration of treatment until resolution of hyperglycemia and ketoacidosis. Additional end points included total length of hospitalization, amount of insulin administration until resolution of hyperglycemia and ketoacidosis, and number of hypoglycemic events. RESULTS Admission biochemical parameters in patients treated with SC-1h (glucose: 44 +/- 21 mmol/l [means +/- SD], bicarbonate: 7.1 +/- 3 mmol/l, pH: 7.14 +/- 0.09) were similar to those treated with SC-2h (glucose: 42 +/- 21 mmol/l, bicarbonate: 7.6 +/- 4 mmol/l, pH: 7.15 +/- 0.12) and IV regular insulin (glucose: 40 +/- 13 mmol/l, bicarbonate 7.1 +/- 4 mmol/l, pH: 7.11 +/- 0.17). There were no statistical differences in the mean duration of treatment until correction of hyperglycemia (6.9 +/- 4, 6.1 +/- 4, and 7.1 +/- 5 h) or until resolution of ketoacidosis (10 +/- 3, 10.7 +/- 3, and 11 +/- 3 h) among patients treated with SC-1h and SC-2h or with IV insulin, respectively (NS). There was no mortality and no differences in the length of hospital stay, total amount of insulin administration until resolution of hyperglycemia or ketoacidosis, or the number of hypoglycemic events among treatment groups. CONCLUSIONS Our results indicate that the use of subcutaneous insulin aspart every 1 or 2 h represents a safe and effective alternative to the use of intravenous regular insulin in the management of patients with uncomplicated DKA.
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Affiliation(s)
- Guillermo E Umpierrez
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia 30303, USA.
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24
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. ESPE/LWPES consensus statement on diabetic ketoacidosis in children and adolescents. Arch Dis Child 2004; 89:188-94. [PMID: 14736641 PMCID: PMC1719805 DOI: 10.1136/adc.2003.044875] [Citation(s) in RCA: 215] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). Mortality is predominantly related to the occurrence of cerebral oedema; only a minority of deaths in DKA are attributed to other causes. Cerebral oedema occurs in about 0.3-1% of all episodes of DKA, and its aetiology, pathophysiology, and ideal method of treatment are poorly understood. There is debate as to whether physicians treating DKA can prevent or predict the occurrence of cerebral oedema, and the appropriate site(s) for children with DKA to be managed. There is agreement that prevention of DKA and reduction of its incidence should be a goal in managing children with diabetes.
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Affiliation(s)
- D B Dunger
- University of Cambridge, Department of Paediatrics, Addenbrooke's Hospital, Level 8, Box 116, Cambridge CB2 2QQ, UK.
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25
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Dunger DB, Sperling MA, Acerini CL, Bohn DJ, Daneman D, Danne TPA, Glaser NS, Hanas R, Hintz RL, Levitsky LL, Savage MO, Tasker RC, Wolfsdorf JI. European Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society consensus statement on diabetic ketoacidosis in children and adolescents. Pediatrics 2004; 113:e133-40. [PMID: 14754983 DOI: 10.1542/peds.113.2.e133] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- David B Dunger
- European Society for Paediatric Endocrinology, West Smithfield, London, United Kingdom.
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26
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27
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Hensen J. [Diabetic coma. Management of diabetic ketoacidosis and nonketotic hyperosmolar coma]. Internist (Berl) 2003; 44:1260-74. [PMID: 14689088 DOI: 10.1007/s00108-003-1058-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This review describes the current guidelines of German diabetes association for the management of diabetic coma, both of diabetic ketoacidosis and hyperosmolal coma. The outline focuses on emergency treatment and the management on the intensive care unit, in particular, volume and insulin therapy, and potassium replacement. The delineation of the concept of low insulin therapy is emphasized to avoid the incidence of disequilibrium syndrome. Also, the indications for bicarbonate therapy in diabetic ketoacidosis are critically discussed, as well as phosphate and magnesium replacement. With today's therapeutic possibilities the therapeutic goal, i.e. a low mortality, may be achieved, dependent on the underlying illness.
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Affiliation(s)
- J Hensen
- Medizinische Klinik, Klinikum Hannover Nordstadt.
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28
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Je HD, Shin CY, Park HS, Huh IH, Sohn UD. The comparison of vitamin C and vitamin E on the protein oxidation of diabetic rats. JOURNAL OF AUTONOMIC PHARMACOLOGY 2001; 21:231-6. [PMID: 12123467 DOI: 10.1046/j.1365-2680.2001.00226.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
1 We measured the plasma glucose and the glycosylated haemoglobin at the time of sacrifice in streptozotocin-induced diabetic mellitus (DM) rats. 2 In diabetic rats, plasma glucose and glycosylated haemoglobin was increased as compared with normal rats, and vitamin E inhibited the increase of glycosylated haemoglobin level but vitamin C had no effect. 3 The peroxidized proteins and lipids from the diabetic organs such as liver or kidney were measured to assess the oxidative damage. The 2,4-dinitrophenyl-hydrazine (DNPH) incorporation method was used to measure the peroxidized protein. In diabetic rats, DNPH incorporation was increased as compared with normal rats and vitamin E also inhibited the increase of DNPH incorporation but vitamin C had no effect. It suggests that the protein oxidation occurred on the liver in diabetic rats and the oxidative stress is general in the diabetic condition. 4 We measured the systolic arterial pressure and mean arterial pressure in normal rats, nephrectomy (NEPH)-rats, diabetic rats (DM), and NEPH-diabetic rats (NEPH-DM). Blood pressure was significantly increased in DM and NEPH-DM as compared with normal rats. 5 In conclusion, plasma glucose, glycosylated haemoglobin, and the oxidation of proteins or lipid were increased in diabetic rats. Vitamin E decreased the plasma glucose, glycosylated haemoglobin and the oxidation of proteins and lipid, but vitamin C had no effects.
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Affiliation(s)
- H D Je
- Department of Pharmacology, College of Pharmacy, Chung Ang University, Seoul 156-756, Republic of Korea
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Delaney MF, Zisman A, Kettyle WM. Diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic syndrome. Endocrinol Metab Clin North Am 2000; 29:683-705, V. [PMID: 11149157 DOI: 10.1016/s0889-8529(05)70159-6] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic syndrome (HHNS) are life-threatening acute metabolic complications of diabetes mellitus. Although there are some important differences, the pathophysiology, the presenting clinical challenge, and the treatment of these metabolic derangements are similar. Each of these complications can be seen in type 1 or type 2 diabetes, although DKA is usually seen in patients with type 1 diabetes and HHNS in patients with type 2 disease. The clinical management of these syndromes involves careful evaluation and correction of the metabolic and volume status of the patient, identification and treatment of precipitating and comorbid conditions, a smooth transition to a long-term treatment regimen, and a plan to prevent recurrence.
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Affiliation(s)
- M F Delaney
- Endocrinology-Hypertension Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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30
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Usala AL, Madigan T, Burguera B, Sinha MK, Caro JF, Cunningham P, Powell JG, Butler PC. Brief report: treatment of insulin-resistant diabetic ketoacidosis with insulin-like growth factor I in an adolescent with insulin-dependent diabetes. N Engl J Med 1992; 327:853-7. [PMID: 1508245 DOI: 10.1056/nejm199209173271205] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- A L Usala
- Department of Pediatrics, East Carolina University School of Medicine, Greenville, N.C. 27858-4354
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Walker M, Marshall SM, Alberti KG. Clinical aspects of diabetic ketoacidosis. DIABETES/METABOLISM REVIEWS 1989; 5:651-63. [PMID: 2515049 DOI: 10.1002/dmr.5610050803] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- M Walker
- Department of Medicine, Medical School, Newcastle Upon Tyne, England
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