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Hammersen J, Tittel SR, Kamrath C, Warncke K, Galler A, Menzel U, Hess M, Meißner T, Karges B, Holl RW. Clinical Outcomes in Pediatric Patients With Type 1 Diabetes With Early Versus Late Diagnosis: Analysis From the DPV Registry. Diabetes Care 2024; 47:1808-1817. [PMID: 39186468 DOI: 10.2337/dc24-0625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 07/15/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVE This study was conducted to evaluate the effects of early clinical diagnosis of type 1 diabetes by comparison of clinical parameters at diagnosis and during follow-up in patients with pediatric type 1 diabetes with early, intermediate, and late diagnosis. RESEARCH DESIGN AND METHODS In a population-based analysis, data on 14,292 pediatric patients with type 1 diabetes diagnosed between 2015 and 2019 were retrieved from the Diabetes Prospective Documentation (DPV) registry in March 2023. Patients were divided into four groups: one with diabetic ketoacidosis (DKA) at diagnosis and three with early, intermediate, or late diagnosis based on age-dependent HbA1c terciles. Laboratory-measured HbA1c values and those estimated from continuous glucose monitoring were aggregated as a combined glucose indicator (CGI). Insulin dose-adjusted CGI values <9% were defined as partial remission. RESULTS At diagnosis, patients had a median age of 9.8 years (IQR 6.8; 13.0). Three years later, patients with early diagnosis had lower CGI than patients with late diagnosis or DKA (mean [95% CI] 7.46% [7.40; 7.53] vs. 7.81% [7.75; 7.87] or 7.74% [7.68; 7.79], respectively; each P < 0.001). More patients experienced partial remission (12.6% [11.0; 14.4] vs. 9.1% [7.7; 10.7] or 8.6% [7.3; 10.0]; each P < 0.001), and 11.7% [10.2; 13.5] of patients with intermediate diagnosis were in partial remission. CONCLUSIONS Early clinical diagnosis of type 1 diabetes may be beneficial for metabolic control and remission after 3 years of follow-up. Patients diagnosed early may represent a distinct group with better resources or with a different disease biology and slower β-cell destruction, which needs further evaluation.
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Affiliation(s)
- Johanna Hammersen
- University Hospital Erlangen, Department of Pediatrics, Erlangen, Germany
- Friedrich-Alexander-Universität, Erlangen-Nürnberg, Erlangen, Germany
| | - Sascha R Tittel
- Institute of Epidemiology and Medical Biometry, CAQM, Ulm University, Ulm, Germany
- German Center for Diabetes Research, Munich Neuherberg, Germany
| | - Clemens Kamrath
- Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Warncke
- Department of Pediatrics, Kinderklinik München Schwabing, Technical University of Munich School of Medicine, Munich, Germany
- Institute of Diabetes Research, Helmholtz Munich, German Center for Environmental Health, Munich, Germany
| | - Angela Galler
- Charité-Universitätsmedizin Berlin, Sozialpädiatrisches Zentrum, Berlin, Germany
| | - Ulrike Menzel
- Department of Paediatric Endocrinology, Altonaer Kinderkrankenhaus, Hamburg
| | - Melanie Hess
- Pediatric Endocrinology and Diabetology, University Children's Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Thomas Meißner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, Medical Faculty, University Hospital, Duesseldorf, Germany
| | - Beate Karges
- Medical Faculty, Division of Endocrinology and Diabetes, RWTH Aachen University, Aachen, Germany
- Department of Pediatrics, Bethlehem Hospital Stolberg, Stolberg, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, CAQM, Ulm University, Ulm, Germany
- German Center for Diabetes Research, Munich Neuherberg, Germany
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Ziegler J, Tittel SR, Biester T, Kapellen T, Dost A, Rochow N, Barbarini DS, Böhle A, Galler A, Holl RW. Type 1 Diabetes Mellitus in the First Years of Life - Onset, Initial Treatment, and Early Disease Course. Exp Clin Endocrinol Diabetes 2024; 132:432-442. [PMID: 39142301 DOI: 10.1055/a-2316-0512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/16/2024]
Abstract
OBJECTIVE This study investigated the onset and the choice of treatment in children with very early onset of type 1 diabetes mellitus (T1D). METHODS The study included 5,763 patients from the German Diabetes Patient Follow-up registry with onset of T1D in the first 4 years of life from January 2010 - June 2022. The analysis included diabetes-specific parameters, anthropometric data, and mode of treatment at onset, within the first and second year of T1D. Three groups were compared according to age at onset (G1: 223 patients 6-<12 months, G2: 1519 patients 12-<24 months, G3: 4001 patients 24-48 months). RESULTS In 12.3% of all cases in childhood and adolescence, the incidence of diabetes in the first 4 years of life was rare. At the onset, clinical status was worse and diabetic ketoacidosis (DKA) rates were higher in G1 and G2 (52.3% and 46.5%, respectively) compared to G3 (27.3% (p<0.001)). G1 and G2 were significantly more likely to be treated with insulin pump therapy (CSII) 2 years after onset (98.1% and 94.1%, respectively)) compared to G3 (85.8%, p<0.001). Median HbA1c after 2 years did not differ between groups (G1: 7.27% (56.0 mmol/mol), G2: 7.34% (56.7 mmol/mol) and G3: 7.27% (56.0 mmol/mol)) or when comparing CSII vs MDI. The rate of severe hypoglycemia (SH) and DKA during the first 2 years of treatment did not differ among the three groups, ranging from 1.83-2.63/100 patient-years (PY) for DKA and 9.37-24.2/100 PY for SH. Children with T1D under 4 years of age are more likely to be diagnosed with celiac disease but less likely to have thyroiditis than older children with T1DM. CONCLUSIONS Young children with T1D had high rates of DKA at onset and were predominantly treated with insulin pump therapy during the first 2 years. The median HbA1c for all three groups was<7.5% (58 mmol/mol) without increased risk of SH or DKA. The use of continuous glucose monitoring (CGM) was not associated with lower HbA1c in children under 48 months.
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Affiliation(s)
- J Ziegler
- University Hospital Tübingen, Department of Pediatric and Adolescent Medicine, Tübingen, Germany
| | - S R Tittel
- University of Ulm, Institute for Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany
- German Center for Diabetes Research e.V., Munich-Neuherberg, Germany
| | - T Biester
- Children's Hospital Auf der Bult, Hanover, Germany
| | - T Kapellen
- University Hospital Leipzig, Department of Pediatric and Adolescent Medicine, Leipzig, Germany
| | - A Dost
- University Hospital Jena, Department of Pediatric and Adolescent Medicine, Jena, Germany
| | - N Rochow
- University Hospital of Paracelsus Medical Private University, Department for Newborns, Children and Adolescents, Nuremberg, Germany
| | - D Seick Barbarini
- Landeskrankenhaus Feldkirch, Academic Teaching Hospital, Department of Pediatrics, Feldkirch, Austria
| | - A Böhle
- Wilhelmstift Children's Hospital, Hamburg, Germany
| | - A Galler
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Sozialpädiatrisches Zentrum, Paediatric Endocrinology and Diabetology, Berlin, Germany
| | - R W Holl
- University of Ulm, Institute for Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany
- German Center for Diabetes Research e.V., Munich-Neuherberg, Germany
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Shaheen MF, Bukhari R, Almutairi TM, Altheaby A, Altamimi A, Bin Saad K. Enhancing Transplant Awareness and Acceptance Through Targeting Knowledge Gaps and Common Misconceptions. Cureus 2024; 16:e52303. [PMID: 38226316 PMCID: PMC10789223 DOI: 10.7759/cureus.52303] [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] [Accepted: 01/15/2024] [Indexed: 01/17/2024] Open
Abstract
Introduction Organ transplantation is a critical intervention for patients with end-stage organ failure, but misconceptions and knowledge gaps often hinder organ donation. This study evaluates the acceptability and effectiveness of an organ donation campaign focusing on addressing knowledge gaps and misconceptions in Riyadh, Saudi Arabia. Methods A two-day awareness campaign was conducted in a shopping mall, featuring four stations providing information on various aspects of organ donation. Participants completed a self-administered, researcher-developed, questionnaire before and after the tour. Results Of the 201 participants, 167 completed the questionnaire (83% response rate). The majority (92.9%) reported learning new information and indicated that the knowledge improved their perspective on organ donation. A high percentage (93.5%) felt the campaign answered their questions, with 90.9% deciding to register as organ donors. Conclusion A knowledge-enhancing campaign can effectively improve public perception and promote awareness of organ donation and transplantation. However, the study is limited by its short timeframe, location, and subjective data. Future research should explore the impact of such campaigns on donor registrations and evaluate their effectiveness in different cultural contexts.
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Affiliation(s)
- Mohammed F Shaheen
- Organ Transplant Center and Hepatobiliary Sciences Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Rawan Bukhari
- College of Nursing, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Taif M Almutairi
- King Abdullah International Medical Research Center, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulrahman Altheaby
- Organ Transplant Center and Hepatobiliary Sciences Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Abdulrahman Altamimi
- Organ Transplant Center and Hepatobiliary Sciences Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | - Khalid Bin Saad
- Organ Transplant Center and Hepatobiliary Sciences Department, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
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Kommentar: Die diabetische Ketoazidose ist vermeidbar. DIABETOL STOFFWECHS 2023. [DOI: 10.1055/a-1987-4427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Göldel JM, Kamrath C, Minden K, Wiegand S, Lanzinger S, Sengler C, Weihrauch-Blüher S, Holl RW, Tittel SR, Warschburger P. Access to Healthcare for Children and Adolescents with a Chronic Health Condition during the COVID-19 Pandemic: First Results from the KICK-COVID Study in Germany. CHILDREN (BASEL, SWITZERLAND) 2022; 10:10. [PMID: 36670561 PMCID: PMC9856628 DOI: 10.3390/children10010010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/12/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
This study examines the access to healthcare for children and adolescents with three common chronic diseases (type-1 diabetes (T1D), obesity, or juvenile idiopathic arthritis (JIA)) within the 4th (Delta), 5th (Omicron), and beginning of the 6th (Omicron) wave (June 2021 until July 2022) of the COVID-19 pandemic in Germany in a cross-sectional study using three national patient registries. A paper-and-pencil questionnaire was given to parents of pediatric patients (<21 years) during the routine check-ups. The questionnaire contains self-constructed items assessing the frequency of healthcare appointments and cancellations, remote healthcare, and satisfaction with healthcare. In total, 905 parents participated in the T1D-sample, 175 in the obesity-sample, and 786 in the JIA-sample. In general, satisfaction with healthcare (scale: 0−10; 10 reflecting the highest satisfaction) was quite high (median values: T1D 10, JIA 10, obesity 8.5). The proportion of children and adolescents with canceled appointments was relatively small (T1D 14.1%, JIA 11.1%, obesity 20%), with a median of 1 missed appointment, respectively. Only a few parents (T1D 8.6%; obesity 13.1%; JIA 5%) reported obstacles regarding health services during the pandemic. To conclude, it seems that access to healthcare was largely preserved for children and adolescents with chronic health conditions during the COVID-19 pandemic in Germany.
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Affiliation(s)
- Julia M. Göldel
- Department of Psychology, Counseling Psychology, University of Potsdam, 14476 Potsdam, Germany
| | - Clemens Kamrath
- Center of Child and Adolescent Medicine, Division of Pediatric Endocrinology and Diabetology, Justus-Liebig-University, 35392 Giessen, Germany
| | - Kirsten Minden
- Program Area Epidemiology, Deutsches Rheuma-Forschungszentrum (DRFZ), 10117 Berlin, Germany
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Susanna Wiegand
- SPZ-Pädiatrische Endokrinologie und Diabetologie, Charité-Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Stefanie Lanzinger
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, 89081 Ulm, Germany
- Germany and German Center for Diabetes Research (DZD), 85764 Neuherberg, Germany
| | - Claudia Sengler
- Program Area Epidemiology, Deutsches Rheuma-Forschungszentrum (DRFZ), 10117 Berlin, Germany
| | - Susann Weihrauch-Blüher
- Department of Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), 06120 Halle (Saale), Germany
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, 89081 Ulm, Germany
- Germany and German Center for Diabetes Research (DZD), 85764 Neuherberg, Germany
| | - Sascha R. Tittel
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, 89081 Ulm, Germany
- Germany and German Center for Diabetes Research (DZD), 85764 Neuherberg, Germany
| | - Petra Warschburger
- Department of Psychology, Counseling Psychology, University of Potsdam, 14476 Potsdam, Germany
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Hofelich A, Marcus BA, Achenbach P. Früherkennung und Prävention des Typ-1-Diabetes. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-0894-1860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Akter F, Rashid SMM, Alam N, Lipi N, Qayum MO, Nurunnahar M, Mannan A. Knowledge, attitude and practice of diabetes among secondary school-going children in Bangladesh. Front Public Health 2022; 10:1047617. [PMID: 36466517 PMCID: PMC9713846 DOI: 10.3389/fpubh.2022.1047617] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 10/31/2022] [Indexed: 11/18/2022] Open
Abstract
Diabetes Mellitus (DM) is a global public health concern. DM has been increasing alarmingly among the young people and childhood-onset has now become an emerging issue worldwide. Unlike other chronic diseases, DM requires constant and active attention of the patients, sometimes of their family members for successful management of this disease. Knowledge, attitude, and practices make significant differences at the population level, which largely depend on socioeconomic status, area of residence, level of education, and other socio-demographic attributes. A descriptive cross-sectional study was carried out among secondary school students in grades 6 through 10 attending schools in 18 districts of Bangladesh. A total of 2009 students were enrolled for the study from the selected schools and madrasas from Bengali, English, and Arabic medium. The majority of responders (79.34%) reported that they had heard of diabetes, however, only 45% knew that diabetes can cause blood glucose levels to rise. Among different therapeutic options, only 15% of students had heard the name of metformin, while 56.2% were familiar with insulin. English medium students were significantly more likely to have good knowledge than the Bangla medium students (19.31%, OR: 1. 44; 95% CI: 1.07, 1.95). Respondents of semi-urban (19.66%, OR: 1.7; 95% CI: 1.21, 2.36) and urban (18.47%, OR: 1.48; 95% CI: 1.17, 1.86) areas were more likely to have good knowledge than rural areas. Of the respondents, 20.61% did not know of any diabetic treatment options. Only a small percentage of students (11%) attended any diabetes education classes and 10.7% of students followed any recommended diabetes prevention methods. Knowledge, attitude, and practice related to diabetes were found to have been influenced by socioeconomic factors, societal practices, and behavioral patterns. This is the first nationwide research study in Bangladesh among secondary school students to study knowledge, attitudes, and practices related to diabetes. With a focus on Bangladesh's youthful population, this study sought to provide an informational framework that can be supportive for effective intervention to increase knowledge of diabetes and its implications.
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Affiliation(s)
- Farhana Akter
- Department of Endocrinology, Chittagong Medical College, Chattogram, Bangladesh
- Disease Biology & Molecular Epidemiology Research Group, Chattogram, Bangladesh
| | - S. M. Mahbubur Rashid
- Department of Genetic Engineering & Biotechnology, University of Dhaka, Dhaka, Bangladesh
| | - Nazmul Alam
- Department of Public Health, Asian University for Women, Chittagong, Bangladesh
| | - Nasrin Lipi
- Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh
| | - Md. Omar Qayum
- Department of Epidemiology, Institute of Epidemiology, Disease Control & Research (IEDCR), Dhaka, Bangladesh
| | - Mehejabin Nurunnahar
- Department of Epidemiology, Institute of Epidemiology, Disease Control & Research (IEDCR), Dhaka, Bangladesh
| | - Adnan Mannan
- Disease Biology & Molecular Epidemiology Research Group, Chattogram, Bangladesh
- Department of Genetic Engineering & Biotechnology, University of Chittagong, Chattogram, Bangladesh
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Chambers C. Diabetic ketoacidosis awareness and prevention for new onset Type 1 diabetes. J Pediatr Nurs 2022; 67:170-171. [PMID: 36470660 DOI: 10.1016/j.pedn.2022.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Colleen Chambers
- Pediatric Endocrinology, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA.
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Li GH, Huang K, Dong GP, Zhang JW, Gong CX, Luo FH, Luo XP, Wang CL, Zhu M, Li P, Wang L, Fu JF. Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers. Front Pediatr 2022; 10:888370. [PMID: 35783304 PMCID: PMC9242427 DOI: 10.3389/fped.2022.888370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China. Methods Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria. Results The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy. Conclusion The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.
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Affiliation(s)
- Guo-Hua Li
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guan-Ping Dong
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jian-Wei Zhang
- Department of Pediatrics, Shaoxing Maternal and Child Health Care Hospital, Hangzhou, China
| | - Chun-Xiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Ping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Lin Wang
- Department of Pediatric, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhu
- Department of Endocrinology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Laboratory for Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Jun-Fen Fu
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Koripalli M, Giruparajah M, Laur C, Shulman R. Selecting an intervention to prevent ketoacidosis at diabetes diagnosis in children using a behavior change framework. Pediatr Diabetes 2022; 23:406-410. [PMID: 35001490 DOI: 10.1111/pedi.13314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE The rate of diabetic ketoacidosis (DKA), a preventable, life-threatening complication of diabetes, at the time of diagnosis in children remains unacceptably high worldwide. We describe our initial approach to selecting a national DKA prevention strategy, to be implemented by the Canadian Pediatric Endocrine Group DKA Prevention Working Group, informed by a framework for behavior change interventions. METHODS Existing interventions were identified from a systematic review and our own gray literature search. We then characterized interventions using the Behavior Change Wheel, a framework to inform and drive behavior change, and matched interventions to behavioral targets, audiences, and identified barriers and facilitators. Feedback from the CPEG DKA prevention working group was incorporated into the intervention plan. RESULTS We identified 27 interventions. Our proposed target behaviors are: (1) prompt recognition of symptoms of diabetes in children; (2) urgent attendance to medical care with a request for an office-based test for diabetes; and (3) rapid confirmation of diagnosis and urgent consultation with pediatric diabetes experts. We initially identified four possible intervention functions including education, training, environment restructuring, and enablement. Feedback from the working group favored education intervention functions including symptom recognition messages targeting parents, caregivers, teachers, and providers and messages about how to make a rapid diagnosis and need for urgent referral targeting providers. CONCLUSIONS The Behavior Change Wheel has been used successfully in selecting interventions in other clinical areas. We describe how we used this framework to provide a foundation for developing an intervention to prevent DKA at diabetes diagnosis in children.
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Affiliation(s)
- Maanasa Koripalli
- Child Health Evaluative Services, Sickkids Research Institute, Toronto, Ontario, Canada
| | - Mohana Giruparajah
- Child Health Evaluative Services, Sickkids Research Institute, Toronto, Ontario, Canada
| | - Celia Laur
- Women's College Hospital, Institute for Health System Solutions and Virtual Care (WIHV), Toronto, Ontario, Canada
| | - Rayzel Shulman
- Child Health Evaluative Services, Sickkids Research Institute, Toronto, Ontario, Canada.,Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada.,Division of Endocrinology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Goldman S, Pinhas-Hamiel O, Weinberg A, Auerbach A, German A, Haim A, Zung A, Brener A, Strich D, Azoulay E, Levy-Khademi F, Ludar H, Koren I, Rachmiel M, Yackobovitch-Gavan M, Zuckerman-Levin N, David O, Halloun R, Cahn R, Ben-Ari T, Yeshayahu Y, Landau Z, Phillip M, Lebenthal Y. Alarming increase in ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the first wave of the COVID-19 pandemic in Israel. Pediatr Diabetes 2022; 23:10-18. [PMID: 34865288 DOI: 10.1111/pedi.13296] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 11/02/2021] [Accepted: 11/26/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To evaluate the incidence and severity of ketoacidosis (DKA) at type 1 diabetes diagnosis during the first wave of the coronavirus disease 2019 (COVID-19) pandemic in Israel. RESEARCH DESIGN AND METHODS A population-based study the product of a national collaboration of Israeli pediatric diabetes centers investigated the presentation of childhood-onset type 1 diabetes. The frequencies of DKA and severe DKA observed during the COVID-19 period from March 15, 2020 (commencement of the first nationwide lockdown) until June 30, 2020 were compared with the same periods in 2019, 2018, and 2017 using multivariable logistic regression, adjusting for age, sex, and socioeconomic position. RESULTS During the COVID-19 period, DKA incidence was 58.2%, significantly higher than in 2019 (adjusted OR [aOR] 2.18 [95% CI, 1.31-3.60], P = 0.003); 2018 (aOR 2.05 [95% CI, 1.26-3.34], P = 0.004); and 2017 (aOR, 1.79 [95% CI, 1.09-2.93], P = 0.022). The incidence of severe DKA was 19.9%, significantly higher than in 2018 (aOR, 2.49 [95% CI, 1.20-5.19], P = 0.015) and 2017 (aOR, 2.73 [95% CI, 1.28-5.82], P = 0.009). In 2020, admissions and duration of stay in the intensive care unit were higher than in previous years (P = 0.001). During the COVID-19 pandemic, children aged 6-11 years had higher incidences of DKA (61.3% vs. 34.0%, 40.6%, and 45.1%, respectively, P = 0.012), and severe DKA (29.3% vs. 15.1%, 10.9%, and 5.9%, respectively, P = 0.002). CONCLUSIONS The dramatic increase in DKA at presentation of childhood-onset type 1 diabetes during the COVID-19 pandemic mandates targeted measures to raise public and physician awareness.
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Affiliation(s)
- Shira Goldman
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Orit Pinhas-Hamiel
- Pediatric Endocrine and Diabetes Unit, Edmond and Lily Safra Children's Hospital, Sheba Medical Center, Ramat Gan, Israel.,Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Adi Weinberg
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Adi Auerbach
- Pediatric Endocrinology and Diabetes Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,The School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alina German
- Pediatric Department, Bnai Zion Medical Center, Haifa, Israel.,The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Alon Haim
- Pediatric Endocrinology and Metabolic Unit, Soroka University Medical Center, Beer Sheva, Israel.,The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Amnon Zung
- The School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Endocrinology Unit, Kaplan Medical Center, Rehovot, Israel
| | - Avivit Brener
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - David Strich
- Pediatric Endocrinology and Diabetes Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,The School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.,Pediatric Specialist Clinic, Clalit Health Services, Jerusalem, Israel
| | - Erez Azoulay
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Floris Levy-Khademi
- Pediatric Endocrinology and Diabetes Unit, Shaare Zedek Medical Center, Jerusalem, Israel.,The School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hanna Ludar
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Endocrine Unit, Ha'Emek Medical Center, Afula, Israel
| | - Ilana Koren
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Endocrinology and Diabetes Unit, Carmel Medical Center, Clalit Health Services, Haifa, Israel
| | - Marianna Rachmiel
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Harofeh) Medical Center, Zerifin, Israel
| | - Michal Yackobovitch-Gavan
- The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.,Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nehama Zuckerman-Levin
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Pediatric Diabetes Clinic, Diabetes, Endocrinology, and Metabolism Institute, Rambam Health Care Campus, Haifa, Israel
| | - Odeya David
- Pediatric Endocrinology and Metabolic Unit, Soroka University Medical Center, Beer Sheva, Israel.,The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Rana Halloun
- Pediatric Diabetes Clinic, Diabetes, Endocrinology, and Metabolism Institute, Rambam Health Care Campus, Haifa, Israel.,Pediatric Endocrinology Unit, Ruth Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Ranit Cahn
- The School of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel.,Division of Pediatric Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tal Ben-Ari
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology Unit, Edith Wolfson Medical Center, Holon, Israel
| | - Yonatan Yeshayahu
- Pediatric Endocrinology and Diabetes Unit, Assuta Ashdod Hospital, Ashdod, Israel.,Goldman School of Medicine, Ben-Gurion University, Beer-Sheva, Israel
| | - Zohar Landau
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.,Pediatrics Department, Barzilai Medical Center, Ashkelon, Israel
| | - Moshe Phillip
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,The Jesse Z. and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Yael Lebenthal
- Sackler School of Medicine, Tel-Aviv University, Tel Aviv, Israel.,Pediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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12
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Nagl K, Waldhör T, Hofer SE, Fritsch M, Meraner D, Prchla C, Rami-Merhar B, Fröhlich-Reiterer E. Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry. Front Pediatr 2022; 10:820156. [PMID: 35237540 PMCID: PMC8882618 DOI: 10.3389/fped.2022.820156] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE We analyzed the annual prevalence of onset-DKA (diabetic ketoacidosis) from 2012 to 2020 with a sub-analysis for lockdown-periods during the COVID-19 pandemic in 2020. DESIGN All newly diagnosed children with type 1 diabetes (T1D) aged <15 years are prospectively registered in the population-based Austrian Diabetes Incidence Study in Austria. MAIN OUTCOME MEASURES The annual DKA prevalence was analyzed using Joinpoint regression. Definition of DKA: pH <7.3, mild DKA: pH 7.3 to ≤ 7.1, severe DKA: pH <7.1. DKA prevalence during the lockdown periods in 2020 and the corresponding periods in 2015-2019 were examined using Fisher's exact test. RESULTS In the years 2012-2020 the mean prevalence for onset-DKA in Austria was 43.6% [95%CI (confidence interval): 41.6, 45.7] and thus above the mean prevalence of previous decades (1989-2011) of 37,1 % (95%CI: 35.6, 38.6). A particularly high prevalence was found among children <2 years of age (72.0% DKA, 32.8% severe DKA). No significant gender difference was found. Prevalence of severe DKA at T1D-onset increased significantly since 2015 (p = 0.023). During the lockdown in 2020, 59.3% of children were diagnosed with DKA at T1D-onset, compared to 42.1% during the previous 5 years (p = 0.022). Moreover, 20% of children had severe DKA at T1D diagnosis, compared to 14% during the comparison period. CONCLUSIONS The previously already high prevalence of DKA at T1D-onset has further increased over time. The COVID-19 pandemic has exacerbated the problem of a late or delayed diagnosis of diabetes in children resulting in onset-DKA. The alarmingly increased prevalence of DKA in Austrian children with T1D calls for urgent action.
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Affiliation(s)
- Katrin Nagl
- Department for Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Waldhör
- Department for Epidemiology, Center of Public Health, Medical University of Vienna, Vienna, Austria
| | - Sabine E Hofer
- Department for Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Fritsch
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Dagmar Meraner
- Department for Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Birgit Rami-Merhar
- Department for Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Elke Fröhlich-Reiterer
- Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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13
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Sittipreechachan P, Pichayapinyo P, Lagampan S, Chongsuwat R. A Community Health Volunteer Involvement Program for Glycated Hemoglobin Reduction Among Thai Patients With Uncontrolled Type 2 Diabetes: A Mixed-Method Study. J Prim Care Community Health 2022; 13:21501319221077960. [PMID: 35184585 PMCID: PMC8864256 DOI: 10.1177/21501319221077960] [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: 11/23/2022] Open
Abstract
Background: Diabetes mellitus is increasing and a shortage exists of nurses to care for
patients. Community health volunteers (CHVs) pose potential supportive
networks in assisting patients to perform healthy behaviors. Aim: The study aimed to develop and investigate the effects of a CHV involvement
program on reducing glycated hemoglobin (HbA1c) levels among Thai
patients with uncontrolled type 2 diabetes. Methods: This sequential mixed-method study was conducted from January to June 2019.
Sixty patients with HbA1c exceeding 7% were recruited from 2
communities assigned as the intervention and comparison groups. Using King’s
General Systems Framework as a basis to develop the program, the study
initially explored the perceptions of diabetes and its management among
patients, family members, and CHVs. Then, a quasi-experimental study with 2
groups pretest-posttest design was conducted and compared with usual care.
The intervention included educational sessions, home visits, and activities
created by CHVs including a campaign, broadcasting, and health food shops.
Quantitative data were collected at baseline and 20-week follow-up and
analyzed by descriptive statistics, Independent t-test, and
paired t-test. Results: The intervention group exhibited a lower mean HbA1c
(p < .001) and reported significant, improvement
concerning diabetes knowledge, self-efficacy, perceived support, and
behavior compared with the comparison group at the end of the study (Cohen’s
d > 1.0, effect size large). Conclusion: Applying this framework to develop the program could benefit glycemic control
among patients with uncontrolled diabetes residing in communities. Further
studies should be conducted on a large sample to demonstrate the efficacy of
the program.
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14
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Alfayez OM, Aldmasi KS, Alruwais NH, Bin Awad NM, Al Yami MS, Almohammed OA, Almutairi AR. Incidence of Diabetic Ketoacidosis Among Pediatrics With Type 1 Diabetes Prior to and During COVID-19 Pandemic: A Meta-Analysis of Observational Studies. Front Endocrinol (Lausanne) 2022; 13:856958. [PMID: 35355556 PMCID: PMC8959619 DOI: 10.3389/fendo.2022.856958] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/08/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Previous reports suggest that the Coronavirus Disease-2019 (COVID-19) pandemic might have affected incidences of diabetic ketoacidosis (DKA) and new diagnoses of type 1 diabetes. This systematic review and meta-analysis aimed to estimate the risk of DKA, including severe DKA, during the COVID-19 pandemic versus the prior-to-COVID-19 period among pediatric patients with type 1 diabetes. METHODS PubMed and EMBASE were searched for observational studies investigating the risk of DKA among pediatric patients with type 1 diabetes during the COVID-19 pandemic and the prior-to-COVID-19 period. A random meta-analysis model was performed to estimate the relative risk of DKA during the COVID-19 pandemic compared to before the pandemic. Subgroup analyses were conducted based on the type 1 diabetes status, established or newly diagnosed. In addition, sensitivity analysis was conducted for studies that reported results from adjusted analysis for potential confounders using fixed effect model. RESULTS A total of 20 observational studies reported the risk of DKA, of which 18 reported the risk of severe DKA. The risks of DKA and severe DKA were 35% (RR 1.35, 95%CI 1.2-1.53, I2 = 71%) and 76% (RR 1.76, 95%CI 1.33-2.33, I2 = 44%) higher in the during-COVID-19 group compared to the prior-to-COVID-19 group, respectively. Among patients with newly diagnosed type 1 diabetes, the risk of DKA was 44% higher for the during-COVID-19 group compared to the prior-to-COVID-19 group (RR 1.44, 95%CI 1.26-1.65; I2 = 64%). Only two studies reported the risk of DKA among patients with established type 1 diabetes and the cumulative risk was not statistically significant. In the sensitivity analysis, four studies reported an adjusted odds ratio (aOR) of the risk of DKA during COVID-19 compared to the prior-to-COVID-19 period. The fixed estimate from the meta-analysis found an increase in the risk of DKA in the during-COVID-19 group compared to the prior-to-COVID-19 group (aOR 2.04, 95%CI 1.66-2.50). CONCLUSIONS This study showed that DKA risk, especially the risk of severe DKA, has increased significantly during the pandemic. Healthcare systems must be aware and prepared for such an increase in DKA cases and take all necessary measures to prevent future spikes during the pandemic. SYSTEMATIC REVIEW REGISTRATION https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=272775, identifier PROSPERO [CRD42021272775].
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Affiliation(s)
- Osamah M. Alfayez
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia
- *Correspondence: Osamah M. Alfayez,
| | | | - Nada H. Alruwais
- College of Pharmacy, University of Shaqra, Al Dawadmi, Saudi Arabia
| | - Nouf M. Bin Awad
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Majed S. Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Omar A. Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Pharmacoeconomics Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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15
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Loh C, Weihe P, Kuplin N, Placzek K, Weihrauch-Blüher S. Diabetic ketoacidosis in pediatric patients with type 1- and type 2 diabetes during the COVID-19 pandemic. Metabolism 2021; 122:154842. [PMID: 34332999 PMCID: PMC9188025 DOI: 10.1016/j.metabol.2021.154842] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/23/2021] [Accepted: 07/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND COVID-19 pandemic caused families to stay home and cancel everyday activities. Hospital admissions decreased, affecting changes in diagnoses and management of chronic disease in children. AIMS We analyzed how the first lockdown influenced clinical presentation and manifestation of children with diabetes mellitus (DM) in a German University Hospital. METHODS During March 15th and October 11th 2020, data on general patient information, clinical symptoms and on lab results related to diabetic ketoacidosis (DKA) were analyzed in children (0-18 years) who presented with new onset of DM or poor metabolic control of known DM. All data including frequency and severity of DKA were compared to data from patients who presented in 2019. RESULTS Data from 125 participants with DM were evaluated (2020: n = 52; 2019: n = 73). In 2020, twelve patients (23.1%) were diagnosed with new onset DM, two of them with type2 diabetes, and 66.7% presented with DKA including both patients T2DM. In 2019, 24.5% of patients had new onset DM, and 50% of them presented with DKA. In 2020, patients with new onset DM were younger, presented with more severe symptoms of DKA and had to stay longer in hospital compared to 2019. In 2020, six children (50%) with new onset DM were <6 years, whereas in 2019 most children with new onset DM were adolescents (n = 7, 38.9%). CONCLUSION COVID-19 lockdown aggravated complications of diabetes onset and therapy management, including severity and frequency of DKA. It underlines the need of health education for early DKA diagnosis to early identify children at risk.
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Affiliation(s)
- Charlotte Loh
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Paul Weihe
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Nicole Kuplin
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Kerstin Placzek
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany
| | - Susann Weihrauch-Blüher
- Clinic for Pediatrics I, Pediatric Endocrinology, University Hospital Halle (Saale), Germany.
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16
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Segerer H, Wurm M, Grimsmann JM, Karges B, Neu A, Sindichakis M, Warncke K, Dost A, Holl RW. Diabetic Ketoacidosis at Manifestation of Type 1 Diabetes in Childhood and Adolescence. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:367-372. [PMID: 34250891 DOI: 10.3238/arztebl.m2021.0133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/05/2020] [Accepted: 01/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a potentially life-threatening metabolic disorder that can occur with manifestation of type 1 diabetes mellitus (T1D). The aim of this study was to analyze the incidence of DKA at the time of the diagnosis of T1D in childhood and adolescence, the risk factors, and regional approaches to reduce the incidence of ketoacidosis. METHODS We investigated the proportion of patients under 18 years of age with DKA (defined as pH <7.3, severe DKA pH <7.1) at the manifestation of T1D in Germany in the period 2000-2019, based on data from the German-Austrian registry of diabetes (Diabetes-Patienten-Verlaufsdokumentation, DPV). The influence of the following factors was evaluated: year of manifestation, age, sex, family history of migration (MiH), and distance from the hospital. Moreover, data from the region with and the region without a pilot screening project from 2015 onwards were compared. RESULTS Of the 41 189 patients with manifestation of T1D, 19.8% presented with DKA (n = 8154, slight increase [p <0.001] over the study period) and 6.1% (n = 2513) had severe DKA. Children under 6 years of age had DKA more often than adolescents (12-17 years) (21.7% versus 18.6%, OR 1.22 {95% CI: [1.14; 1.30]}). Girls had a higher rate of DKA than boys (20.5% versus 19.2%, OR 1.10 [1.03; 1.14]), and patients with MiH were more likely to have DKA than those without MiH (21.4% versus 18.2%, OR 1.40 [1.32; 1.48]). In the region with a pilot screening project, the DKA rate stayed the same, at 20.6%, while in the control region the rate was 22.7% with a decreasing tendency. CONCLUSION The frequency of DKA at the time of diagnosis of T1D did not decrease between 2000 and 2019 and increased towards the end of the observation period. Children with MiH, children under 6, and girls were at a higher risk of DKA.
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Affiliation(s)
- Hugo Segerer
- Chair of Pediatric and Adolescent Medicine, University of Regensburg, Clinic St. Hedwig, Barmherzige Brüder Hospital, Regensburg, Germany; Institute of Epidemiology and Medical Biometry, ZIBMT, Medical Faculty of the University Ulm, Ulm, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany; Division of Endocrinology and Diabetes, Medical Faculty of the RWTH Aachen University, Aachen, Germany; Department of Pediatric and Adolescent Medicine, Bethlehem Health Center, Stolberg, Germany; Children's Hospital, Tübingen University Hospital, Tübingen, Germany; Department of Pediatric and Adolescent Medicine, Kliniken Südostbayern, Traunstein, Germany; Department of Pediatric and Adolescent Medicine, Children's Hospital Munich Schwabing, Technical University of Munich, Faculty of Medicine, Munich, Germany; Institute of Diabetes Research, Helmholtz Center Munich,German Research Center for Environmental Health, Munich, Germany; Department of Pediatric and Adolescent Medicine, Jena University Hospital, Jena, Germany
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17
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[Individualization of diabetes treatment by automated insulin delivery]. Monatsschr Kinderheilkd 2021; 169:902-911. [PMID: 34276070 PMCID: PMC8276231 DOI: 10.1007/s00112-021-01239-0] [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] [Accepted: 06/09/2021] [Indexed: 12/02/2022]
Abstract
Insulinpumpen und Glucosesensoren haben sich in Registerdaten als effektiv in der Verbesserung der Diabetestherapie und Reduktion akuter Komplikationen gezeigt. In der pädiatrischen Diabetologie ist die Nutzung mindestens eines technischen Geräts Standard. Durch die Kombination beider Systeme ergibt sich Möglichkeit der automatischen Insulinabgabe („automated insulin delivery“, AID). Viele AID-Systeme sind in klinischen Studien getestet und haben sich als sicher und effektiv erwiesen. Die Versorgungsituation in Deutschland erlaubt es derzeit nur, Mitgliedern der gesetzlichen Krankenversicherungen ein bestimmtes System zu verordnen; dieses ist für Kinder, die jünger als 7 Jahre sind, nicht geeignet. Gründe liegen in gesetzlichen Hürden und mangelnder Zertifizierung durch die Hersteller. Die CE-Zertifikate können Probleme bei der Insulinverordnung mit sich bringen. „Open-source“-Systeme sind Varianten, mit denen bestehende Regularien umgangen werden können. Daraus ergeben sich sowohl für Nutzer wie auch für Verordner Risiken. Die dauerhafte Nutzung setzt sowohl auf Anwender- als auch auf Behandlerseite die fundierte Kenntnis der Eigenschaften der einzelnen AID-Systeme voraus. Eine vollständige Automatisierung funktioniert noch nicht. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glucosesensoren, die „Zeit im Zielbereich“ und der „Glucose Management Indicator“ anerkannte und geeignete Parameter, da sie eine Beratung auf Basis der reellen Daten aus dem Alltag der Menschen mit Diabetes zulassen. Da alle Glucosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten automatisch aus einem telefonverbundenen Empfangsgerät beziehen, ist die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.
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18
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Hou L, Li X, Liu L, Wei H, Xiong F, Du H, Yang Y, Zhang H, Zhang Q, Yao H, Fu J, Yan X, Cui L, Liu G, Li T, Chen S, Li P, Xin Y, Liang X, Yu B, Dong Z, Chen R, Ma H, Cheng X, Luo F, Gong C, Song W, Chen X, Zhang Z, Peng X, Li G, Liang L, Maimaiti M, Cheung PT, Luo X. A Multicenter Survey of Type I Diabetes Mellitus in Chinese Children. Front Endocrinol (Lausanne) 2021; 12:583114. [PMID: 34211433 PMCID: PMC8239384 DOI: 10.3389/fendo.2021.583114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 05/17/2021] [Indexed: 01/17/2023] Open
Abstract
Purpose To investigate the features and treatment status of children with type 1 diabetes mellitus (T1DM) in China. Methods We recruited patients <14 years of age with T1DM from 33 medical centers in 25 major cities of China between January 2012 and March 2015. All patients completed a questionnaire that was conducted by their pediatric endocrinologists at all centers. Results A total of 1,603 children (755 males and 848 females) with T1DM participated in this survey. Of these, 834 (52.03%) of the patients exhibited diabetic ketoacidosis (DKA) at onset, while 769 patients (47.97%) did not exhibit DKA (non-DKA) at onset. There was a higher proportion of females (55.71%) in the cohort of patients exhibiting DKA at onset than in the non-DKA cohort (49.33%). The mean age of patients exhibiting DKA at presentation was 7.12 ± 0.14 years; this was significantly younger than that in non-DKA group (7.79 ± 0.15 years; P < 0.005). The frequency of DKA in 3 years old, 3-7 years old, and 7 years old or more was 77.21%, 26.17%, and 37.62%, respectively. Upon initial diagnosis, 29.4%, 15.2% and 11.8% of patients showed positivity for glutamic acid decarboxylase antibody (GADA), Insulin autoantibodies (IAA), or islet cell antibody (ICA), respectively. During six months follow-up, 244 patients (15.21%) reported receiving insulin pump therapy, and more than 60% of patients monitored their blood glucose levels less than 35 times per week. Although the majority of patients had no problems with obtaining insulin, 4.74% of the children surveyed were not able to receive insulin due to financial reasons, a shortage of insulin preparations, or the failure of the parents or guardians to acquire the appropriate medicine. Conclusion DKA is more common in very young children. Treatment and follow-up of T1DM in China still face very serious challenges.
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Affiliation(s)
- Ling Hou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiuzhen Li
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Li Liu
- Department of Genetics and Endocrinology, Guangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Hanyang Wei
- Department of Endocrinology and Genetic, Henan Provincial Children’s Hospital, Zhengzhou, China
| | - Feng Xiong
- Department of Endocrine and Genetic Metabolism Disease, Children’s Hospital of Chongqing Medical University, Chongqing, China
| | - Hongwei Du
- Department of Pediatrics, The First Affiliated Hospital, Jilin University, Changchun, China
| | - Yu Yang
- Department of Endocrinology, Metabolism, and Genetics, Children’s Hospital of Nanchang University & Jiangxi Provincial Children’s Hospital, Nanchang, China
| | - Huifeng Zhang
- Department of Pediatrics, The Second Affiliated Hospital of Hebei Medical University, Shijiazhuang, China
| | - Qin Zhang
- Department of Endocrinology, Shenzhen Children’s Hospital, Shenzhen, China
| | - Hui Yao
- Department of Endocrinology, Wuhan Children’s Hospital, Wuhan, China
| | - Junfen Fu
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoli Yan
- Department of Pediatrics Endocrinology, Xi’an Children’s Hospital, Xi’an, China
| | - Lanwei Cui
- Department of Pediatrics, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Geli Liu
- Department of Pediatrics, General Hospital of Tianjin Medical University, Tianjin, China
| | - Tang Li
- Department of Pediatrics, Qingdao Women and Children’s Hospital, Qingdao University, Qingdao, China
| | - Shaoke Chen
- Department of Pediatrics, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children’s Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ying Xin
- Department of Pediatrics Endocrinology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiangrong Liang
- Department of Endocrinology, Qilu Children’s Hospital, Shandong University, Jinan, China
| | - Baosheng Yu
- Department of Pediatrics, The Second Affiliated Hospital, Nanjing Medical University, Nanjing, China
| | - Zhiya Dong
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ruimin Chen
- Department of Endocrinology, Fuzhou Children’s Hospital, Fuzhou, China
| | - Huamei Ma
- Department of Pediatrics, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xinran Cheng
- Department of Endocrinology and Metabolism, Chengdu Women’s and Children’s Central Hospital, Chengdu, China
| | - Feihong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children’s Hospital of Fudan University, Shanghai, China
| | - Chunxiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children’s Hospital, Beijing, China
| | - Wenhui Song
- Department of Pediatric Endocrinology, Shanxi Provincial Children’s Hospital, Taiyuan, China
| | - Xiaobo Chen
- Department of Endocrinology, Children’s Hospital of Capital Institute of Pediatrics, Beijing, China
| | - Zhixin Zhang
- Department of Pediatrics, China-Japan Friendship Hospital, Beijing, China
| | - Xiangyun Peng
- Department of Endocrinology, Hunan Provincial Children’s Hospital, Changsha, China
| | - Guimei Li
- Department of Pediatrics, Shandong Provincial Hospital, Jinan, China
| | - Liyang Liang
- Department of Pediatrics, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Mireguli Maimaiti
- Department of Pediatrics, The First Affiliated Hospital, Xinjiang Medical University, Urumqi, China
| | - Pik To Cheung
- Paediatric Endocrinology, Genetics, and Metabolism, Virtus Medical Group and The University of Hong Kong, Hong Kong SAR, China
| | - Xiaoping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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19
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Abstract
Insulinpumpen und Glukosesensoren können laut Registerdaten die Diabetestherapie verbessern sowie die Rate akuter Komplikationen reduzieren. In der pädiatrischen Diabetologie ist daher die Nutzung mindestens eines dieser technischen Geräte Standard. Deren Kombination macht Systeme zur automatischen Insulinabgabe („automated insulin delivery“ [AID]) möglich. Viele AID-Systeme wurden in klinischen Studien getestet und erwiesen sich als sicher und effektiv. Die Versorgungsituation in Deutschland jedoch lässt derzeit nur ein System als Verordnung bei Versicherten der gesetzlichen Krankenversicherungen zu, und Kinder unter 7 Jahren können damit derzeit nicht versorgt werden. Gründe hierfür sind gesetzliche Hürden und die mangelnde Zertifizierung durch die Hersteller. Die CE-Zertifikate können zudem zu Problemen bei der Insulinverordnung führen. Open-Source-Systeme sind nicht geprüfte Varianten, um bestehende regulatorische Verhältnisse zu umgehen. Deren Anwendung geht mit Risiken sowohl für Nutzer als auch Verordner einher. Für ihren dauerhaften Einsatz müssen sowohl Anwender als auch Behandler über fundierte Kenntnisse der Eigenschaften der einzelnen AID-Systeme verfügen. Zur Evaluation der AID-Therapie sind die metrischen Daten der Glukosesensoren, die „time in range“ und der Glukosemanagementindex die anerkannten und geeigneten Parameter, da sie eine Beratung auf Basis der reellen Werte aus dem Alltag der Menschen mit Diabetes zulassen. Da alle Glukosesensoren über Cloud-basierte Software ausgelesen werden oder die Daten direkt automatisch übermitteln, ist hiermit die ideale technische Grundlage für eine telemedizinische Betreuung geschaffen, die noch der Ausgestaltung bedarf.
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Cherubini V, Marino M, Carle F, Zagaroli L, Bowers R, Gesuita R. Effectiveness of ketoacidosis prevention campaigns at diagnosis of type 1 diabetes in children: A systematic review and meta-analysis. Diabetes Res Clin Pract 2021; 175:108838. [PMID: 33901625 DOI: 10.1016/j.diabres.2021.108838] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/30/2021] [Accepted: 04/21/2021] [Indexed: 11/17/2022]
Abstract
AIM To determine if diabetes awareness campaigns are an effective intervention to reduce diabetes ketoacidosis at diagnosis of type 1 diabetes in children and youth. METHODS Search strategies included PubMed, Scopus, CINAHL and WOS electronic databases, hand search of select journals and a grey literature search "Google" search to include all relevant information. Studies included community-based interventions focused on children younger than 18 years old. The difference in the frequency of DKA was measured in two separate comparisons; before and after perform awareness campaigns in the same area, and between areas with and without intervention campaigns. RESULTS Of 1136 records identified, 14 studies were eligible for the analysis. The first group of 12 studies measured DKA at diagnosis, before (n = 6548 individuals) and after (n = 4931 individuals) the awareness campaigns. The pooled difference was a reduction of 7.20% (95%CI: 0.99-13.41). The second group of four studies measured the difference in an area with no intervention (n = 338 individuals) and in an area with an awareness campaign (n = 187 individuals). The pooled difference in DKA was 35.71% (95%CI: 5.81-65.61). CONCLUSIONS This review demonstrated that DKA awareness campaigns are effective to reduce DKA among children and adolescents with type 1 diabetes and the core components that explain why these campaigns are effective. Back to top.
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Affiliation(s)
- Valentino Cherubini
- Salesi Hospital, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I G M Lancisi G Salesi, Department of Women's and Children's Health, via Corridoni, 11, 60123 Ancona, Italy.
| | - Monica Marino
- Salesi Hospital, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I G M Lancisi G Salesi, Department of Women's and Children's Health, via Corridoni, 11, 60123 Ancona, Italy
| | - Flavia Carle
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Via Tronto, 10/a, 60020 Torrette di Ancona, Italy.
| | - Luca Zagaroli
- Salesi Hospital, Azienda Ospedaliero Universitaria Ospedali Riuniti di Ancona Umberto I G M Lancisi G Salesi, Department of Women's and Children's Health, via Corridoni, 11, 60123 Ancona, Italy
| | - Renee Bowers
- Population Health, Faculty of Health Sciences, University of Ottawa, 64 Sherbrooke Avenue, Ottawa, Ontario K1Y 1R7 613-618-8284, Canada
| | - Rosaria Gesuita
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Via Tronto, 10/a, 60020 Torrette di Ancona, Italy.
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21
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[Is it possible to prevent diabetic ketoacidosis at diagnosis of pediatric type 1 diabetes? Lessons from the COVID-19 pandemic]. Monatsschr Kinderheilkd 2021; 169:451-460. [PMID: 33437098 PMCID: PMC7791536 DOI: 10.1007/s00112-020-01108-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 12/08/2020] [Indexed: 11/11/2022]
Abstract
Hintergrund Die diabetische Ketoacidose (DKA) ist ein lebensbedrohlicher Notfall bei Manifestation eines Diabetes mellitus Typ 1 (DM1) bei Kindern und Jugendlichen, häufig bei verspäteter Diagnosestellung oder vorheriger Fehldiagnose. Während der Zeit des „Coronavirus-disease-2019(COVID-19)-Lockdowns“ in Deutschland stellten sich weniger Patienten in Notfallambulanzen und Arztpraxen vor. Fragestellung Hat sich der Anteil der DKA bei Manifestation eines DM1 in der pädiatrischen Population in diesem Zeitraum verändert, und welche Gruppen sind besonders gefährdet, eine DKA zu erleiden? Material und Methoden Die DKA-Häufigkeit in der Zeit vom 13.03.2020 bis 13.05.2020 wurde bei Patienten <18 Jahren mit DM1-Manifestation in pädiatrischen Diabeteszentren untersucht. Die Diabeteszentren dokumentierten ihre Einschätzung, ob durch COVID-19 die Vorstellung verzögert war. Um den Einfluss von Risikofaktoren auf die DKA-Häufigkeit zu analysieren, erfolgte ein Vergleich der Daten aus dem Jahr 2020 mit denselben Zeiträumen der Jahre 2018 und 2019 mit linearen und logistischen Regressionsmodellen. Ergebnisse Die Daten von 532 Patienten aus 216 Diabeteszentren zeigten, dass das Risiko für eine DKA im Vergleich zu den Jahren 2018/2019 um 84,7 % und für eine schwere DKA um 45,3 % erhöht war. Kinder <6 Jahren waren mit einer Steigerung einer DKA um 141,6 % bzw. einer schweren DKA um 97,0 % besonders betroffen. Migrationshintergrund war ein COVID-19-unabhängiger Risikofaktor. Insgesamt wurden 31 % der Patienten verspätet vorgestellt, oder ihre Diagnose wurde zuvor verkannt. Diskussion In der Zeit des „COVID-19-Lockdowns“ war die Häufigkeit der DKA bei DM1-Manifestation für Kinder und Jugendliche signifikant erhöht. Alter <6 Jahre, Migrationshintergrund und verzögerte Vorstellung waren die Hauptrisikofaktoren.
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22
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Peng W, Yuan J, Chiavaroli V, Dong G, Huang K, Wu W, Ullah R, Jin B, Lin H, Derraik JGB, Fu J. 10-Year Incidence of Diabetic Ketoacidosis at Type 1 Diabetes Diagnosis in Children Aged Less Than 16 Years From a Large Regional Center (Hangzhou, China). Front Endocrinol (Lausanne) 2021; 12:653519. [PMID: 33986725 PMCID: PMC8112199 DOI: 10.3389/fendo.2021.653519] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of type 1 diabetes (T1D), and a leading cause of death in children aged <15 years with new-onset T1D. AIMS i) to assess the incidence of DKA in children and adolescents newly diagnosed with T1D over a 10-year period at a large regional center in China; and ii) to examine the clinical symptoms and demographic factors associated with DKA and its severity at diagnosis. METHODS We carried out a retrospective audit of a regional center, encompassing all youth aged <16 years diagnosed with T1D in 2009-2018 at the Children's Hospital, Zhejiang University School of Medicine (Hangzhou, China). DKA and its severity were classified according to ISPAD 2018 guidelines. RESULTS 681 children were diagnosed with T1D, 50.1% having DKA at presentation (36.0% mild, 30.0% moderate, and 33.9% severe DKA). The number of patients diagnosed with T1D progressively rose from approximately 39 cases/year in 2009-2010 to 95 cases/year in 2017-2018 (≈2.5-fold increase), rising primarily among children aged 5-9 years. DKA incidence was unchanged but variable (44.8% to 56.8%). At T1D diagnosis, 89% of patients reported polyuria and 91% polydipsia. Children presenting with DKA were more likely to report vomiting, abdominal pain, and particularly fatigue. DKA was most common among the youngest children, affecting 4 in 5 children aged <2 years (81.4%), in comparison to 53.3%, 42.7%, and 49.3% of patients aged 2-4, 5-9, and ≥10 years, respectively. Children with severe DKA were more likely to report vomiting, fatigue, and abdominal pain, but less likely to report polyuria, polydipsia, and polyphagia than those with mild/moderate DKA. Rates of severe DKA were highest in children aged <2 years (51.1%). CONCLUSIONS The number of children diagnosed with T1D at our regional center increased over the study period, but DKA rates were unchanged. With 9 of 10 children reporting polyuria and polydipsia prior to T1D diagnosis, increasing awareness of this condition in the community and among primary care physicians could lead to earlier diagnosis, and thus potentially reduce rates of DKA at presentation.
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Affiliation(s)
- Wei Peng
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jinna Yuan
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Valentina Chiavaroli
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
| | - Guanping Dong
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Wei Wu
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Rahim Ullah
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Binghan Jin
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Hu Lin
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - José G. B. Derraik
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- Liggins Institute, University of Auckland, Auckland, New Zealand
- Department of Women’s and Children’s Health, Uppsala University, Uppsala, Sweden
- NCD Centre of Excellence, Research Institute for Health Sciences, Chiang Mai University, Chiang Mai, Thailand
- *Correspondence: Junfen Fu, ; ; José G. B. Derraik,
| | - Junfen Fu
- Department of Endocrinology, Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- *Correspondence: Junfen Fu, ; ; José G. B. Derraik,
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