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Le Bec E, Kam M, Aebischer Perone S, Boulle P, Cikomola JC, Gandur ME, Gehri M, Kehlenbrink S, Beran D. Using Clinical Vignettes to Understand the Complexity of Diagnosing Type 1 Diabetes in Sub-Saharan Africa. Res Rep Trop Med 2023; 14:111-120. [PMID: 38024811 PMCID: PMC10656429 DOI: 10.2147/rrtm.s397127] [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] [Received: 07/20/2023] [Accepted: 11/07/2023] [Indexed: 12/01/2023] Open
Abstract
Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician's medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software's efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.
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Affiliation(s)
- Enora Le Bec
- Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon, Switzerland
| | - Madibele Kam
- Pediatric University Hospital Charles de Gaulle, Ouagadougou, Burkina Faso
| | - Sigiriya Aebischer Perone
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Health Unit, International Committee of the Red Cross, Geneva, Switzerland
| | | | | | | | - Mario Gehri
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Sylvia Kehlenbrink
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA
| | - David Beran
- Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
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2
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Rugg-Gunn CEM, Dixon E, Jorgensen AL, Usher-Smith JA, Marcovecchio ML, Deakin M, Hawcutt DB. Factors Associated With Diabetic Ketoacidosis at Onset of Type 1 Diabetes Among Pediatric Patients: A Systematic Review. JAMA Pediatr 2022; 176:1248-1259. [PMID: 36215053 DOI: 10.1001/jamapediatrics.2022.3586] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Presenting with diabetic ketoacidosis (DKA) at onset of type 1 diabetes (T1D) remains a risk. Following a 2011 systematic review, considerable additional articles have been published, and the review required updating. OBJECTIVE To evaluate factors associated with DKA at the onset of T1D among pediatric patients. EVIDENCE REVIEW In this systematic review, PubMed, Embase, Scopus, CINAHL, Web of Science, and article reference lists were searched using the population, intervention, comparison, outcome search strategy for primary research studies on DKA and T1D onset among individuals younger than 18 years that were published from January 2011 to November 2021. These studies were combined with a 2011 systematic review on the same topic. Data were pooled using a random-effects model. FINDINGS A total of 2565 articles were identified; 149 were included, along with 46 from the previous review (total 195 articles). Thirty-eight factors were identified and examined for their association with DKA at T1D onset. Factors associated with increased risk of DKA were younger age at T1D onset (<2 years vs ≥2 years; odds ratio [OR], 3.51; 95% CI, 2.85-4.32; P < .001), belonging to an ethnic minority population (OR, 0.40; 95% CI, 0.21-0.74; P = .004), and family history of T1D (OR, 0.46; 95% CI, 0.37-0.57; P < .001), consistent with the 2011 systematic review. Some factors that were not associated with DKA in the 2011 systematic review were associated with DKA in the present review (eg, delayed diagnosis: OR, 2.27; 95% CI, 1.72-3.01; P < .001). Additional factors associated with risk of DKA among patients with new-onset T1D included participation in screening programs (OR, 0.35; 95% CI, 0.21-0.59; P < .001) and presentation during the COVID-19 pandemic (OR, 2.32; 95% CI, 1.76-3.06; P < .001). CONCLUSIONS AND RELEVANCE In this study, age younger than 2 years at T1D onset, belonging to an ethnic minority population, delayed diagnosis or misdiagnosis, and presenting during the COVID-19 pandemic were associated with increased risk of DKA. Factors associated with decreased risk of DKA included greater knowledge of key signs or symptoms of DKA, such as a family history of T1D or participation in screening programs. Future work should focus on identifying and implementing strategies related to these factors to reduce risk of DKA among new patients with T1D.
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Affiliation(s)
| | - Eleanor Dixon
- Usher Institute, University of Edinburgh, Edinburgh, Scotland
| | - Andrea L Jorgensen
- Department of Biostatistics, University of Liverpool, Liverpool, England
| | - Juliet A Usher-Smith
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, England
| | | | - Mark Deakin
- Alder Hey Children's Hospital, Liverpool, England
| | - Daniel B Hawcutt
- NIHR Alder Hey Clinical Research Facility, Liverpool, England.,Department of Women's and Children's Health, University of Liverpool, Liverpool, England
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3
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Virmani A, Brink SJ, Middlehurst A, Mohsin F, Giraudo F, Sarda A, Ajmal S, von Oettingen JE, Pillay K, Likitmaskul S, Calliari LE, Craig ME. ISPAD Clinical Practice Consensus Guidelines 2022: Management of the child, adolescent, and young adult with diabetes in limited resource settings. Pediatr Diabetes 2022; 23:1529-1551. [PMID: 36537524 DOI: 10.1111/pedi.13456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Anju Virmani
- Department of Pediatrics, Max Super Specialty Hospital, New Delhi, India.,Department of Endocrinology, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Stuart J Brink
- New England Diabetes and Endocrinology Center, Boston, Massachusetts, USA.,New England Diabetes and Endocrinology Center, Newton, Massachusetts, USA.,Harvard School of Medicine, Tufts School of Medicine, Boston, Massachusetts, USA
| | - Angela Middlehurst
- ISPAD & International Volunteer Pediatric Diabetes Educator, Sydney, Australia
| | - Fauzia Mohsin
- Pediatric Endocrinology and Metabolism Unit, Dept of Pediatrics, BIRDEM General Hospital, Dhaka, Bangladesh
| | - Franco Giraudo
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile.,San Borja Arriarán Clinical Hospital, Santiago, Chile
| | - Archana Sarda
- UDAAN, NGO for Persons with Diabetes, Aurangabad, India
| | - Sana Ajmal
- Meethi Zindagi, Not-for-Profit Community Organisation for Persons with Diabetes, Rawalpindi, Pakistan
| | - Julia E von Oettingen
- Dept of Pediatrics, Division of Endocrinology, Montreal Children's Hospital, Quebec, Canada
| | | | - Supawadee Likitmaskul
- Siriraj Diabetes Center, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | | | - Maria E Craig
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia.,The University of Sydney Children's Hospital, Westmead Clinical School, Sydney, New South Wales, Australia.,School of Women's and Children's Health, University of NSW, Sydney, New South Wales, Australia
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4
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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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Maurice L, Julliand S, Polak M, Bismuth E, Storey C, Renolleau S, Dauger S, Le Bourgeois F. Management of severe inaugural diabetic ketoacidosis in paediatric intensive care: retrospective comparison of two protocols. Eur J Pediatr 2022; 181:1497-1506. [PMID: 34993625 DOI: 10.1007/s00431-021-04332-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/24/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
UNLABELLED The best protocol for severe inaugural diabetic ketoacidosis (DKA) in children remains unclear. We compared two protocols by assessing effects during the first 24 h on osmolality, serum sodium, and glucose variations, which are associated with the risk of cerebral oedema, the most dreaded complication of DKA. We also recorded complications. We retrospectively included children aged 28 days to 18 years and admitted for severe DKA to either of two paediatric intensive care units (PICUs) in Paris (France). The two protocols differed regarding hydration volume, glucose intake, and sodium intake. From 17 June 2010 to 17 June 2015, 93 patients were included, 29 at one PICU, and 64 at the other. We compared severe glycaemic drops (> 5.5 mmol/L/h), mean glycaemia variations, serum sodium, serum osmolality, and the occurrence of cerebral oedema (CE) during the first 24 h after PICU admission. Severe glycaemic drops occurred in 70% of patients, with no between-group difference. Blood glucose, serum sodium, and serum osmolality variations were comparable. Seven (7.5%) patients were treated for suspected CE, (4 [10.3%)] and 3 [6.3%]) in each PICU; none had major residual impairments. CONCLUSION The two paediatric DKA-management protocols differing in terms of fluid-volume, glucose, and sodium intakes had comparable effects on clinical and laboratory-test changes within 24 h. Major drops in glycaemia and osmolality were common with both protocols. No patients had residual neurological impairments. WHAT IS KNOWN • Cerebral oedema is the most severe complication of diabteic ketoacidosis in children.The risk of cerebral oedema is dependant on both patient related and treatment-related factors. • The optimal protocol for managing severe inaugural diabetic ketoacidosis in children remains unclear, and few studies have targeted this specific population. WHAT IS NEW • Two management protocols that complied with ISPAD guidelines but differed regarding the amounts of fluids, glucose, and sodium administered produced similar outcomes in children with severe inaugural diabetic ketoacidosis. • Cerebral oedema was rare with both protocols and caused no lasting impairments.
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Affiliation(s)
- Laure Maurice
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Sébastien Julliand
- Paediatric Mobile Emergency Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Michel Polak
- Department of Paediatric Endocrinology, Gynaecology, and Diabetology, IMAGINE Affiliate, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Elise Bismuth
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Storey
- Department of Paediatric Endocrinology and Diabetology, Robert Debré Teaching Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Sylvain Renolleau
- Paediatric Intensive Care Unit, Necker Enfants-Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Stéphane Dauger
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université de Paris, Paris, France
| | - Fleur Le Bourgeois
- Paediatric Intensive Care Unit, Robert Debré University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
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Al-Abdulrazzaq D, Othman F, Qabazard S, Al-Tararwa A, Ahmad D, Al-Sanae H, Al-Kandari H. Epidemiological trends in the presentation of diabetic ketoacidosis in children newly diagnosed with type 1 diabetes from 2011 to 2017 in Kuwait. Front Endocrinol (Lausanne) 2022; 13:908458. [PMID: 36568099 PMCID: PMC9780369 DOI: 10.3389/fendo.2022.908458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Monitoring the trends in the presentation of T1D over decades cannot be underestimated as it provides a rich source of information on diabetes-related complications like DKA. DKA represents a medical emergency, with potentially fatal outcome, and thus the prevention of DKA is a priority in diabetes care. The aim of this study is to report on trends in the presentation of DKA in children newly diagnosed with T1D in Kuwait. MATERIAL AND METHODS This study is based on a retrospective review of children newly diagnosed with T1D aged 14 years or less at three Governmental Hospitals representing three health sectors out of the total six health sectors in the country during the period 2011-2017. RESULTS A total of 799 children (376 males and 423 females) were newly diagnosed with T1D. 287 children presented with DKA (35.9%) with only 73 children (9.1%) classified as severe. During the years 2011 to 2017, we note that the percentage of children older than 6 years of age presenting with severe DKA has decreased significantly (p=0.022). Unfortunately, this has not been replicated in children younger than 6 years. CONCLUSION This study highlights the importance of continued monitoring of clinical characteristics of children at diagnosis of T1D specifically presenting with DKA to enable diabetes care professionals to appreciate the multifaceted aspects of T1D, in particular the importance of raising awareness of the early signs of the onset of T1D with special attention to DKA and its severe consequences.
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Affiliation(s)
- Dalia Al-Abdulrazzaq
- Department of Pediatrics, Faculty of Medicine, Kuwait University, Kuwai City, Kuwait
- Department of Population Health, Dasman Diabetes Institute, Kuwai City, Kuwait
- *Correspondence: Dalia Al-Abdulrazzaq,
| | - Fouzeyah Othman
- Department of Population Health, Dasman Diabetes Institute, Kuwai City, Kuwait
| | - Sarah Qabazard
- Department of Population Health, Dasman Diabetes Institute, Kuwai City, Kuwait
| | - Abeer Al-Tararwa
- Department of Pediatrics, Al-Farwaniyah Hospital, Ministry of Health, Kuwai City, Kuwait
| | - Dina Ahmad
- Department of Pediatrics, Al-Farwaniyah Hospital, Ministry of Health, Kuwai City, Kuwait
| | - Hala Al-Sanae
- Department of Pediatrics, Al-Amiri Hospital, Ministry of Health, Kuwai City, Kuwait
| | - Hessa Al-Kandari
- Department of Population Health, Dasman Diabetes Institute, Kuwai City, Kuwait
- Department of Pediatrics, Al-Farwaniyah Hospital, Ministry of Health, Kuwai City, Kuwait
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7
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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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Darmonkow G, Chafe R, Aslanova R, Hagerty D, Twells L, Barter OJ, Allwood Newhook LA. A Multi-Intervention Campaign Lowers Pediatric and Young Adult Diabetic Ketoacidosis Hospitalizations in a Canadian Province. Can J Diabetes 2021; 45:792-797. [PMID: 34016537 DOI: 10.1016/j.jcjd.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The Newfoundland and Labrador diabetic ketoacidosis Project (NLdkaP) is a multi-intervention, province-wide project aimed at lowering rates of diabetic ketoacidosis (DKA) within the pediatric and young adult populations. METHODS The NLdkaP interventions were first selected, developed and implemented. We then conducted a retrospective study of hospitalization data over three 2-year periods: pre-, during and post-NLdkaP. Data included demographic factors, DKA hospitalizations and length of hospital stay. RESULTS There were 412 DKA hospitalizations over the study period. Before the NLdkaP, the provincial hospitalization rate of DKA for patients <25 years of age was 55.61 per 100,000. During the NLdkaP, the rate dropped to 38.48 per 100,000 (p<0.001). After the NLdkaP, the rate rose to 54.53 per 100,000 (p<0.001). Hospitalization rates were highest for females (p<0.001) and for those in the 19- to 24-year age group (p<0.001). CONCLUSIONS The NLdkaP was associated with decreased rates of DKA hospitalizations, but the rates remained relatively stable in both the pre- and postintervention periods. Although the approach and resources developed in the NLdkaP appear effective, continuous preventive efforts are needed to sustain reductions in DKA hospitalizations.
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Affiliation(s)
- Georgia Darmonkow
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Roger Chafe
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Rana Aslanova
- Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Donna Hagerty
- Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Laurie Twells
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; School of Pharmacy, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Ola Jill Barter
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Division of Children and Women's Health, Eastern Health, St. John's, Newfoundland and Labrador, Canada
| | - Leigh Anne Allwood Newhook
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Janeway Pediatric Research Unit, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada; Division of Children and Women's Health, Eastern Health, St. John's, Newfoundland and Labrador, Canada.
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9
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Kakleas K, Basatemur E, Karavanaki K. Association Between Severity of Diabetic Ketoacidosis at Diagnosis and Multiple Autoimmunity in Children With Type 1 Diabetes Mellitus: A Study From a Greek Tertiary Centre. Can J Diabetes 2020; 45:33-38.e2. [PMID: 32800761 DOI: 10.1016/j.jcjd.2020.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 05/05/2020] [Accepted: 05/06/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Type 1 diabetes mellitus is a chronic disorder associated with development of autoimmunity. In this work, we studied the relationship between severity of acidosis at diagnosis and future risk for autoimmunity development in children with type 1 diabetes. METHODS We investigated the presence of associated autoimmunity in 144 children with type 1 diabetes (mean ± standard deviation: age, 12.44±4.76 years; diabetes duration, 4.41±3.70 years). We identified the presence of thyroid disease, celiac disease, autoimmune gastritis and adrenal autoimmunity, and retrospectively reviewed the files for presence of diabetic ketoacidosis at diagnosis. RESULTS Autoimmunity prevalence was 16.7% for thyroid autoimmunity, 9.5% for celiac disease, 5% for gastric autoimmunity and 8.0% for multiple autoimmunities. There were strong associations between severe acidosis at diabetes diagnosis (pH<7.10) and development of thyroid autoimmunity (odds ratio [OR], 5.34; 95% confidence interval [CI], 1.90‒15.1; p<0.001), celiac disease (OR, 5.83; 95% CI, 1.19‒28.6; p=0.013), gastric autoimmunity (OR, 13.1; 95% CI, 1.22‒140; p=0.006) and multiple autoimmunity (OR, 26.7; 95% CI, 2.36‒301; p<0.01). The associations persisted after adjustment for sex, age at diabetes diagnosis, age at assessment, time since diabetes diagnosis and antiglutamic acid decarboxylase autoantibody status. CONCLUSIONS The severity of acidosis at diagnosis is strongly associated with the development of associated autoimmune diseases in children with type 1 diabetes and could act as a predictive factor for multiple autoimmunity development. This association can be either due to effect of acidosis on immune system or to the presence of a more aggressive diabetes endotype.
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Affiliation(s)
- Kostas Kakleas
- Paediatric Department, Leicester Royal Infirmary, Leicester, United Kingdom.
| | - Emre Basatemur
- Population, Policy and Practice Programme, Institute of Child Health, University College of London, London, United Kingdom
| | - Kyriaki Karavanaki
- Diabetic Clinic, Second Department of Pediatrics, University of Athens, "P&A Kyriakou" Children's Hospital, Athens, Greece
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10
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Alonso GT, Coakley A, Pyle L, Manseau K, Thomas S, Rewers A. Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Colorado Children, 2010-2017. Diabetes Care 2020; 43:117-121. [PMID: 31601639 PMCID: PMC6925579 DOI: 10.2337/dc19-0428] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/24/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined trends in diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes at a large pediatric diabetes center between 2010 and 2017, overlapping with the Affordable Care Act's overhaul of U.S. health care. RESEARCH DESIGN AND METHODS Colorado residents <18 years old who were diagnosed with type 1 diabetes from 2010 to 2017 and subsequently followed at the Barbara Davis Center for Diabetes were included. Logistic regression models were used to test associations among age, sex, race/ethnicity, insurance, language, year of diagnosis, and rural/nonrural residence and DKA at diagnosis. Linear regression models were used to test the association of each predictor with HbA1c at diagnosis. RESULTS There were 2,429 subjects who met the inclusion criteria. From 2010 to 2017, the rate of DKA increased from 41 to 58%. It increased from 35.3 to 59.6% among patients with private insurance (odds ratio 1.10 [95% CI 1.05-1.15]; P < 0.0001) but remained unchanged (52.2-58.8%) among children with public insurance (1.03 [0.97-1.09]; P = 0.36). In the multivariable model, public insurance (1.33 [1.08-1.64]; P = 0.007), rural address (1.42 [1.08-1.86]; P = 0.013), and HbA1c (1.32 [1.26-1.38]; P < 0.0001) were positively associated with DKA, whereas age, race/ethnicity, sex, and primary language were not. CONCLUSIONS The increase in the rate of DKA in patients with newly diagnosed type 1 diabetes was driven by patients with private insurance. This paradoxically occurred during a time of increasing health insurance coverage. More study is needed to understand the factors driving these changes.
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Affiliation(s)
- G Todd Alonso
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Alex Coakley
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | | | - Sarah Thomas
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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Townson J, Cannings-John R, Francis N, Thayer D, Gregory JW. Presentation to primary care during the prodrome of type 1 diabetes in childhood: A case-control study using record data linkage. Pediatr Diabetes 2019; 20:330-338. [PMID: 30737875 DOI: 10.1111/pedi.12829] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 12/21/2018] [Accepted: 01/28/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To evaluate primary care presentations during the prodrome (12 months prior to onset type-1 diabetes (T1D), with or without diabetic ketoacidosis [DKA]), to identify opportunities for earlier diagnosis. METHODS This was a case-control study, linking 16 years of data from children (≤15 years) registered at diagnosis of T1D, and routinely collected primary care records in Wales (United Kingdom). Controls (without T1D) were matched on a 3:1 ratio. Conditional logistic regression modeling was used to compare characteristics occurring in cases (children with T1D) and controls; and cases that presented with/without DKA. RESULTS A total of 1345 children with T1D (19% DKA) and 4035 controls were identified. During the 12 months prior to diagnosis, cases were 6.5 times more likely to have at least one primary care contact (P < 0.001). One to 30 days prior to diagnosis, contacts relating to blood tests, fungal conditions, respiratory tract infections (RTIs), urinary conditions, vomiting, and weight were independently associated with T1D, as were contacts relating to blood tests, between 91 and 180 days prior to diagnosis. Children with a contact up to a month prior to diagnosis, relating to RTIs, antibiotic prescriptions, and vomiting, were more likely to present in DKA, as were boys (P = 0.047). CONCLUSION There are opportunities in primary care for an earlier diagnosis of T1D in childhood. These data could be used to create a predictive diagnostic tool, as a potential aid for primary care health professionals, to prevent presentation in DKA.
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Affiliation(s)
- Julia Townson
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Rebecca Cannings-John
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, Cardiff, UK
| | - Nick Francis
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Dan Thayer
- SAIL Databank, School of Medicine, Swansea University, Swansea, UK
| | - John W Gregory
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
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12
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Deylami R, Townson J, Mann M, Gregory JW. Systematic review of publicity interventions to increase awareness amongst healthcare professionals and the public to promote earlier diagnosis of type 1 diabetes in children and young people. Pediatr Diabetes 2018; 19:566-573. [PMID: 28782293 DOI: 10.1111/pedi.12565] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/10/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Children with new onset type 1 diabetes (T1D) are at risk of developing the life-threatening condition ketoacidosis if they have a delayed diagnosis. The rate of children presenting in ketoacidosis remains high in a number of countries worldwide. To ensure interventions to raise awareness of symptoms are effective a systematic review was conducted to evaluate previous publicity campaigns. METHODS A range of databases was searched using search terms relating to T1D, publicity campaigns, and symptom awareness. Identified articles were checked against the inclusion criteria, ensuring interventions were designed to target individuals prior to diagnosis of T1D. Papers were independently assessed under the criteria specified within the Critical Appraisal Skills Programme checklist. RESULTS The initial search retrieved 1537 papers and following screening 20 were identified for full consideration. Thirteen did not meet the inclusion criteria, leaving 7 to be assessed. Of these 7, 2 observational case-control studies reported a reduction in the rate of ketoacidosis following a publicity campaign using posters and providing glucose testing equipment to primary healthcare professionals. Four observational cohort studies, utilized posters, and media campaigns; 2 reported a reduction in the rate of ketoacidosis and 2 reported no difference following their interventions. A feasibility study, not designed to evaluate effectiveness, reported some anecdotal evidence of a more timely diagnosis. CONCLUSION Due to the methodological limitations of the studies identified, it is not possible to make a definitive conclusion on the effectiveness of the interventions reported.
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Affiliation(s)
- R Deylami
- School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - J Townson
- Centre for Trial Research (CTR), Cardiff University, Cardiff, Wales, UK
| | - M Mann
- Specialist Unit for Review Evidence (SURE), Cardiff University, Cardiff, Wales, UK
| | - J W Gregory
- Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
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13
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Gunn ER, Albert BB, Hofman PL, Cutfield WS, Gunn AJ, Jefferies CA. Pathways to reduce diabetic ketoacidosis with new onset type 1 diabetes: Evidence from a regional pediatric diabetes center: Auckland, New Zealand, 2010 to 2014. Pediatr Diabetes 2017; 18:553-558. [PMID: 27726271 DOI: 10.1111/pedi.12456] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/03/2016] [Accepted: 09/09/2016] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND There has been little change in the incidence of diabetic ketoacidosis (DKA) in newly diagnosed type 1 diabetes mellitus (T1DM) in children and adolescents in most developed countries. OBJECTIVES To assess potentially modifiable antecedents of DKA in children <15 years of age with new onset T1DM. METHODS Retrospective review of prospectively collected data from a complete regional cohort of children with T1DM in Auckland (New Zealand) from 2010 to 2014. DKA and severity were defined according to the ISPAD 2014 guidelines. RESULTS A total of 263 children presented with new onset T1DM during the 5-year study period at 9.0 years of age (range 1.0-14.7), of whom 61% were NZ-European, 14% Maori, 13% Pacifica, and 11% other. A total of 71 patients (27%) were in DKA, including 31 mild, 20 moderate, and 20 severe DKA. DKA was associated with no family history of T1DM, higher glycated hemoglobin (HbA1c) values at presentation, self-presenting to secondary care, health care professional contacts in the 4 weeks before final presentation, and greater deprivation. Although a delay in referral from primary care for laboratory testing was common (81/216), only delay for more than 48 hours was associated with increased risk of DKA (11/22 > 48 h vs 12/59 referred at <48 h, P = .013). CONCLUSIONS These data suggest that in addition to lack of family awareness potentially modifiable risk factors for new onset DKA include prolonged delay for laboratory testing and a low index of medical suspicion for T1DM leading to delayed diagnosis.
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Affiliation(s)
- Eleanor R Gunn
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand
| | - Benjamin B Albert
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand.,The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Paul L Hofman
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand.,The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Wayne S Cutfield
- The Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Alistair J Gunn
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand.,Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Craig A Jefferies
- Starship Children's Hospital, Auckland District Health Board, Auckland, New Zealand.,The Liggins Institute, University of Auckland, Auckland, New Zealand
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Affiliation(s)
- Drew Bunker
- 1 Tulane University School of Medicine, New Orleans, LA, USA
| | - Edwin Frieberg
- 2 Tulane University Medical Center, New Orleans, LA, USA
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Ziegler AG, Bonifacio E, Powers AC, Todd JA, Harrison LC, Atkinson MA. Type 1 Diabetes Prevention: A Goal Dependent on Accepting a Diagnosis of an Asymptomatic Disease. Diabetes 2016; 65:3233-3239. [PMID: 27959859 PMCID: PMC5860440 DOI: 10.2337/db16-0687] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/14/2016] [Indexed: 12/13/2022]
Abstract
Type 1 diabetes, a disease defined by absolute insulin deficiency, is considered a chronic autoimmune disorder resulting from the destruction of insulin-producing pancreatic β-cells. The incidence of childhood-onset type 1 diabetes has been increasing at a rate of 3%-5% per year globally. Despite the introduction of an impressive array of therapies aimed at improving disease management, no means for a practical "cure" exist. This said, hope remains high that any of a number of emerging technologies (e.g., continuous glucose monitoring, insulin pumps, smart algorithms), alongside advances in stem cell biology, cell encapsulation methodologies, and immunotherapy, will eventually impact the lives of those with recently diagnosed or established type 1 diabetes. However, efforts aimed at reversing insulin dependence do not address the obvious benefits of disease prevention. Hence, key "stretch goals" for type 1 diabetes research include identifying improved and increasingly practical means for diagnosing the disease at earlier stages in its natural history (i.e., early, presymptomatic diagnosis), undertaking such efforts in the population at large to optimally identify those with presymptomatic type 1 diabetes, and introducing safe and effective therapeutic options for prevention.
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Affiliation(s)
- Anette-G Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, Neuherberg, Germany
- Forschergruppe Diabetes, Klinikum rechts der Isar, Technische Universität München, München, Germany
| | - Ezio Bonifacio
- DFG-Center for Regenerative Therapies Dresden, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Paul Langerhans Institute Dresden, German Center for Diabetes Research (DZD), Technische Universität Dresden, Dresden, Germany
- Forschergruppe Diabetes e.V., Neuherberg, Germany
| | - Alvin C Powers
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- VA Tennessee Valley Healthcare System, Nashville, TN
| | - John A Todd
- JDRF/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, U.K
| | - Leonard C Harrison
- Walter and Eliza Hall Institute of Medical Research, Department of Medical Biology, University of Melbourne, Parkville, Victoria, Australia
| | - Mark A Atkinson
- Departments of Pathology and Pediatrics, UF Diabetes Institute, University of Florida, Gainesville, FL
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16
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[Epidemiology of type 1 diabetes in children]. SOINS. PÉDIATRIE, PUÉRICULTURE 2016:10-2. [PMID: 26776685 DOI: 10.1016/j.spp.2015.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Type 1 diabetes is by far the most common in children. In 2004, its incidence was 13 to 14 new cases per 100 000 children each year and is progressing every year by more than 3%. This increase in incidence is affecting younger children. More than one quarter of children diagnosed in France are under the age of 5. The disease is still, in more than 40% of cases, first diagnosed as a result of an episode of ketoacidosis.
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Gómez Rivera N, García Zárate MG, Fonseca Chon I, Gómez Figueroa CO, Gómez Jiménez IA, Villalobos García L. [Diabetic ketoacidosis in children: hospital experience. A 15-year retrospective study]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2015; 72:313-317. [PMID: 29421529 DOI: 10.1016/j.bmhimx.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Revised: 09/11/2015] [Accepted: 09/13/2015] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the major complications of diabetes mellitus (DM). The objective of this report was to highlight the clinical and laboratory importance in the treatment of patients with DKA during a 15-year period treated at the Hospital Infantil del Estado de Sonora (HIES). METHODS We retrospectively reviewed 140 patients with episodes of DKA to report clinical and laboratory features, mortality, and treatment with HIES protocol. RESULTS Mortality was 0%. Using descriptive statistics we observed minimal complications without neurologic sequelae in three patients with cerebral edema. CONCLUSIONS The HIES protocol is a practical and effective electrolyte and acid-base treatment for DKA.
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