Why do children with diabetes die?

In vitro and functional investigation reveals the curative effect of thymoquinone from black cumin-loaded chitosan nanoparticles on streptozotocin induced paediatric diabetes

Diabetic ketoacidosis (DKA) is regarded to be a communal complication of both type 1 and type 2 diabetes mellitus in children and adolescents. Successful therapy of DKA in children requires prompt diagnosis, strict monitoring of medical indicators, and prompt action. Thymoquinone (Tq) from black cumin loaded chitosan nanoparticles (ChNPs) intend to assess an effective agent to overcome this problem. XRD, FTIR, SEM, and TEM were used in the physicochemical analysis. Enzymatic activity of α-amylase and α-glucosidase was used in in vitro tests of anti-diabetic efficacy. Protecting insulin against enzyme breakdown is a crucial part of the insulin delivery mechanism. In the STZ-induced diabetes RIN-5F cell line, the anti-apoptotic capability of Tq-ChNPs was demonstrated through the NF-κB mediated apoptotic pathway. The combination of thymoquinone and chitosan NPs demonstrated that a wide variety of incredibly effective substances to elevate their curative effects, thus contributing to the growth of clinical and pharmaceutical fields.

Outcomes of children with severe diabetic ketoacidosis managed outside of a pediatric intensive care unit

OBJECTIVES

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes. Our objective was to determine if children with severe DKA without alteration in mental status can be managed safely on a general children's medical unit.

METHODS

Single center retrospective study of 191 patient encounters among 168 children admitted to the children's medical unit (CMU) at Primary Children's Hospital between 2007 and 2017 with severe DKA (pH <7.1 and/or bicarbonate <5 mmol/L). Chart review identified complications including death, transfer to the intensive care unit (ICU), incidence of cerebral edema, and hypoglycemia. We compared patients requiring ICU transfer with those who did not with respect to demographics, laboratory findings at presentation, therapeutic interventions, length of stay, and cost.

RESULTS

Of 191 patient encounters, there were 0 deaths (0%, 95% CI 0-2.4%), 22 episodes of alteration of mental status concerning for developing cerebral edema (11.5%, 95% CI 7.7-16.9%), 19 ICU transfers (10%, 95% CI 6.4-15.1%), and 7 episodes of hypoglycemia (3.7%, 95% CI 1.6-7.5%). ICU transfer was associated lower initial pH (7.03 ± 0.06 vs. 7.07 ± 0.07, p<0.05), increased length of stay (3.0 ± 0.8 vs. 2.2 ± 0.9 days, p<0.05), and increased cost of hospitalization (mean ± SD $8,073 ± 2,042 vs. $5,217 ± 1,697, p<0.05).

CONCLUSIONS

The majority of children with severe DKA without alteration in mental status can be managed safely on a medical unit. Implementing a pH cutoff may identify high-risk patients that require ICU level of care.

Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes

PURPOSE OF REVIEW

In this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up.

RECENT FINDINGS

Though in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients' response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients' safe transition through levels of care, following hospital discharge from a DKA episode. This evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.

DKA Prevention and Insulin Pumps: Lessons Learned From a Large Pediatric Pump Practice

PURPOSE

This purpose of the study was to describe recent diabetic ketoacidosis (DKA) incidence data in youth with type 1 diabetes using insulin pumps and the impact of continuous glucose monitors (CGMs) on DKA rates.

METHODS

DKA data were obtained through a retrospective chart review of insulin pump users (ages <26 years) between December 2019 and June 2021 in an academic pediatric endocrinology practice where 68% of patients were pump users.

RESULTS

Among 591 pump patients, 28 events occurred (3.16 events per 100 patient-years). Mean age was 13.6±3.4 years; 85.7% ranged from 12 to 19 years. Mean A1C was 10.2±2.3%, diabetes duration was 6.1±4.0 years, and 57.1% used CGM. Admission pH levels ranged between 7.0 and 7.31, with 28.6% of events classified as "moderate" and 46.4% "severe." There was no significant difference in the DKA severity between those who wore a CGM and those who did not (ie, pH, serum bicarbonate, mentation alteration, length of stay, intensive care unit admission, and hospital admission). DKA events were attributed to concurrent illness (10.7%), insulin omission (14.3%), pump site failure (57.1%), or other pump malfunctions (14.3%).

CONCLUSION

DKA events in pump-treated patients were relatively uncommon; most episodes occurred in adolescents with higher A1C levels, and notably, most events could have been avoided if users followed standard troubleshooting guidelines. Thus, DKA prevention education should be reinforced at each encounter, particularly for teens with higher A1C levels. Moreover, more than 50% of those with DKA episodes wore a CGM, suggesting that pump users using CGM require frequent reinforcement of this education and that the development of such educational materials is critical.

Fatty acid-binding protein 4: a key regulator of ketoacidosis in new-onset type 1 diabetes

AIMS/HYPOTHESIS

Fatty acid-binding protein 4 (FABP4) is an adipokine with a key regulatory role in glucose and lipid metabolism. We prospectively evaluated the role of FABP4 in the pathophysiology of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes.

METHODS

Clinical and laboratory data were prospectively collected from consecutive children presenting with new-onset type 1 diabetes. In addition to blood chemistry and gases, insulin, C-peptide, serum FABP4 and NEFA were collected upon presentation and 48 h after initiation of insulin treatment. In a mouse model of type 1 diabetes, glucose, insulin, β-hydroxybutyrate and weight were compared between FABP4 knockout (Fabp4^-/-) and wild-type (WT) mice.

RESULTS

Included were 33 children (mean age 9.3 ± 3.5 years, 52% male), of whom 14 (42%) presented with DKA. FABP4 levels were higher in the DKA group compared with the non-DKA group (median [IQR] 10.1 [7.9-14.2] ng/ml vs 6.3 [3.9-7] ng/ml, respectively; p = 0.005). The FABP4 level was positively correlated with HbA_1c at presentation and inversely correlated with venous blood pH and bicarbonate levels (p < 0.05 for all). Following initiation of insulin therapy, a marked reduction in FABP4 was observed in all children. An FABP4 level of 7.22 ng/ml had a sensitivity of 86% and a specificity of 78% for the diagnosis of DKA, with an area under the receiver operating characteristic curve of 0.78 (95% CI 0.6, 0.95; p = 0.008). In a streptozotocin-induced diabetes mouse model, Fabp4^-/- mice exhibited marked hypoinsulinaemia and hyperglycaemia similar to WT mice but displayed no significant increase in β-hydroxybutyrate and were protected from ketoacidosis.

CONCLUSIONS/INTERPRETATION

FABP4 is suggested to be a necessary regulator of ketogenesis in insulin-deficient states.

Brain injury in children with diabetic ketoacidosis: Review of the literature and a proposed pathophysiologic pathway for the development of cerebral edema

Cerebral edema (CE) is a potentially devastating complication of diabetic ketoacidosis (DKA) that almost exclusively occurs in children. Since its first description in 1936, numerous risk factors have been identified; however, there continues to be uncertainty concerning the mechanisms that lead to its development. Currently, the most widely accepted hypothesis posits that CE occurs as a result of ischemia-reperfusion injury, with inflammation and impaired cerebrovascular autoregulation contributing to its pathogenesis. The role of specific aspects of DKA treatment in the development of CE continues to be controversial. This review critically examines the literature on the pathophysiology of CE and attempts to categorize the findings by types of brain injury that contribute to its development: cytotoxic, vasogenic, and osmotic. Utilizing this scheme, we propose a multifactorial pathway for the development of CE in patients with DKA.

Dijabetesna ketoacidoza kod bolesnika sa cerebrovaskularnim insultom - uzroci, mehanizmi, dijagnostika i naše smernice za terapiju

Although cerebrovascular disease may be a well recognised trigger for diabetic ketoacidosis (DKA), literature data on the precise mechanisms, characteristics, or treatment guidelines are rare. The risk of developing an ischemic stroke is doubled in adults with diabetes compared to people with normal glucose metabolism. It is important to point out that even children with DKA have a significantly increased risk of cerebrovascular insult and that they can have a stroke with a frequency of about 10%. Given the significant overlap of symptoms between these two diseases, it can be assumed that attributing DKA symptoms as a manifestation of stroke is not uncommon, especially in elderly and less communicative patients. In addition, pH, bicarbonate concentration, and anion gap are not routinely measured in all diabetics suffering from stroke, at least not in secondary health institutions.Children who develop cerebrovascular stroke during DKA often at the beginning have a preserved consciousness or only mild confusion or lethargy. After a few hours, with the institution of therapy, however, loss of consciousness may occur accompanied by signs of increased intracranial pressure. It was previously thought that the cause was too fast fluid replacement. Recent data suggest that reperfusion injury may be a more likely mechanism. Although most of these studies relate to younger individuals with ketoacidosis, it is clear that at least some of them may be operative in adult DKA. Literature therapeutic guidelines for adult diabetics with stroke-related diabetic ketoacidosis are almost lacking, although it is clear that they could not be the same as those utilised in population with normal glucose metabolism. In this paper, we have tried to define our treatment guidelines for these particular patients.

Young adult patients with type 1 diabetes have a higher risk of mortality than those of similar age with type 2 diabetes: A nationwide analysis in Hungary

BACKGROUND

There are few papers comparing complications of type 1 diabetes with those of a similarly young age with type 2 diabetes. The aim of our nationwide study was to compare the risks of mortality and morbidities between the two types of diabetes (age ≤ 40).

METHODS

We identified all young adult patients with type 1 diabetes who were recorded in the database of the Hungarian National Health Insurance Fund between 2001 and 2014 (n = 11 863) and compared them with a population of similar age with young adult type 2 diabetes (n = 47 931). The incidence of all-cause mortality, myocardial infarction, stroke, any type of cancer, diabetic ketoacidosis, and hypoglycemia was followed from the onset of diabetes to the date of death or end of study period.

RESULTS

The risks of all-cause mortality were significantly higher in patients with type 1 compared with patients with type 2 diabetes (hazard ratio, 95%CI; 2.17, 1.95-2.41; P < .0001). The risks of myocardial infarction (0.90, 0.71-1.13; P = 0.36) and stroke (1.06, 0.87-1.29; P = .582) were not significantly different in type 1 compared with type 2. In contrast, the risk of cancer (1.35, 1.15-1.59; P = .0003), dialysis (2.20, 1.76-2.75; P < .0001), hypoglycemia (7.70, 6.45-9.18; P < .0001), and ketoacidosis (22.12, 19.60-25.00; P < .0001) was higher among patients with type 1 compared with those with type 2 diabetes.

CONCLUSIONS

A comparatively higher incidence of diabetic ketoacidosis and hypoglycemia and higher risk of cancer and dialysis in patients with type 1 diabetes than in those with type 2 may play a role in the higher risk of mortality.

Diabetic Ketoacidosis at Onset of Type 1 Diabetes: Rates and Risk Factors Today to 15 Years Ago

Diabetic ketoacidosis (DKA) is a serious, potentially lethal complication of type 1 diabetes mellitus that may be present at diagnosis. The aim of this study was to determine factors associated with presentation in DKA in new-onset youth and compare the rate of DKA and risk factors to a similar study 15 years prior. This study was a retrospective chart review of newly diagnosed patients with type 1 diabetes mellitus from 2010 to 2013. Of the 276 patients, 29% presented in DKA, compared with 38% 15 years prior (P < .002). Those with Medicaid, those misdiagnosed at initial encounter, and those not evaluated by a pediatrician initially were more likely to present in DKA (P = .002, P = .002, P < .001, respectively). The diagnosis of diabetes was not elicited in one third of patients who ultimately presented in DKA. Pediatricians should be reeducated to ask about polyuria and polydipsia in routine encounters. Furthermore, public awareness initiatives are needed to reduce late presentation in DKA.

Presentation to primary care during the prodrome of type 1 diabetes in childhood: A case-control study using record data linkage

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.

Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis

BACKGROUND

Diabetic ketoacidosis in children may cause brain injuries ranging from mild to severe. Whether intravenous fluids contribute to these injuries has been debated for decades.

METHODS

We conducted a 13-center, randomized, controlled trial that examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis. Children were randomly assigned to one of four treatment groups in a 2-by-2 factorial design (0.9% or 0.45% sodium chloride content and rapid or slow rate of administration). The primary outcome was a decline in mental status (two consecutive Glasgow Coma Scale scores of <14, on a scale ranging from 3 to 15, with lower scores indicating worse mental status) during treatment for diabetic ketoacidosis. Secondary outcomes included clinically apparent brain injury during treatment for diabetic ketoacidosis, short-term memory during treatment for diabetic ketoacidosis, and memory and IQ 2 to 6 months after recovery from diabetic ketoacidosis.

RESULTS

A total of 1389 episodes of diabetic ketoacidosis were reported in 1255 children. The Glasgow Coma Scale score declined to less than 14 in 48 episodes (3.5%), and clinically apparent brain injury occurred in 12 episodes (0.9%). No significant differences among the treatment groups were observed with respect to the percentage of episodes in which the Glasgow Coma Scale score declined to below 14, the magnitude of decline in the Glasgow Coma Scale score, or the duration of time in which the Glasgow Coma Scale score was less than 14; with respect to the results of the tests of short-term memory; or with respect to the incidence of clinically apparent brain injury during treatment for diabetic ketoacidosis. Memory and IQ scores obtained after the children's recovery from diabetic ketoacidosis also did not differ significantly among the groups. Serious adverse events other than altered mental status were rare and occurred with similar frequency in all treatment groups.

CONCLUSIONS

Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Health Resources and Services Administration; PECARN DKA FLUID ClinicalTrials.gov number, NCT00629707 .).

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

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.

"Keeping it on your radar"-assessing the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood: A qualitative study from the early detection of type 1 diabetes in youth study

AIMS

The aim of this study was to explore from the perspectives of key stakeholders involved in the pathway to diagnosis, the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood.

METHODS

Qualitative interviews and free-text analyses were undertaken in 21 parents with a child diagnosed with type 1 diabetes, 60 parents without a child diagnosed with type 1 diabetes, 9 primary healthcare professionals, 9 teachers and 3 community diabetes liaison nurses. Data were analysed thematically and 30% double coded.

RESULTS

Two key themes were identified, namely the importance of widespread awareness and knowledge and seeking healthcare professional help. Parents with a child diagnosed with type 1 diabetes described seeking opinions from a number of individuals prior to seeking health professional help. Healthcare professionals recognized the rarity of the condition and the need for it to be kept on their "radar", to ensure they considered it when examining an unwell child. The process of obtaining a primary healthcare appointment was identified as potentially playing a crucial role in the diagnostic process. However, most parents with a child diagnosed with type 1 diabetes described receiving an appointment on the day they sought it.

CONCLUSIONS

Knowledge and awareness of type 1 diabetes in childhood remain limited in the general population and misconceptions persist relating to how children present with this serious condition. An effective community-based intervention to raise awareness amongst key stakeholders is required to ensure children receive a timely diagnosis once symptomatic.

Plasma Levels of Cell-Free Apoptotic DNA Ladders and Gamma-Glutamyltranspeptidase (GGT) in Diabetic Children

The plasma levels of apoptotic DNA ladders (i.e., apoptosemia) and γ-glutamyltranspeptidase (GGT) in diabetic outpatients and rats were investigated. Apoptotic DNA ladders were detected in plasma from 26.8% of type 1 (T1) and 18.5% of type 2 (T2) diabetic children 1–20 years of age, 25.7% of hospitalized children and 35.7% of adult RA outpatients, but in only 3.5% of adult pre-op patients. Plasma from 7.7% of young streptozotocin-induced diabetic but not control rats contained apoptotic DNA ladders. Apoptosemia was detected more often in male T1 (31%) and T2 (30.8%) diabetic outpatients than in female T1 (20.8%) and T2 (15.4%) diabetic outpatients. GGT in apoptosemic plasma was significantly higher than in nonapoptosemic plasma from T1 ( P = 0.001) but not T2 diabetic children. The highest amounts of apoptotic DNA were detected most often in diabetic children ≥14 years of age. In vitro study results suggest that cell-free apoptotic DNA ladders appear prior to an increase in GGT activity in serum from human blood incubated at 37°C. The results suggest that 24.7% of plasma samples from diabetic children contained apoptotic DNA ladders, the incidence and amounts of apoptotic DNA ladders were higher in the older diabetic children, and GGT was elevated in apoptosemic T1 diabetic children ( P = 0.01). The results indicate that “silent” apoptosemia occurs in T1 and T2 diabetic children and suggest elevated GGT in diabetic children could be due to release from apoptotic cells.

Increased risk of severe diabetic ketoacidosis among Jewish ultra-orthodox children

AIMS

Diabetic ketoacidosis (DKA) at diabetes diagnosis is a dangerous yet potentially preventable condition. Young age, low socioeconomic status, and low parental education have been found to be associated with increased risk of DKA. We aimed to evaluate the impact of religious affiliation on presentation with DKA at type 1 diabetes mellitus (T1DM) diagnosis in Jewish children.

METHODS

The study comprised an analysis of medical records of all consecutive patients with new-onset T1DM who were admitted to one tertiary medical center from January 2007 to January 2014. DKA was defined as venous pH <7.3 or HCO3(-) < 15 mmol/l, and severe DKA as pH <7.1 or HCO3(-) < 5 mmol/l.

RESULTS

Of 81 patients with new-onset T1DM (38 females, mean ± SD age at diagnosis 9.9 ± 4.2 years), 34 (42 %) presented with DKA: 21 of 60 (35 %) of patients from secular families and 13 of 21 (62 %) from ultra-orthodox families. Children from ultra-orthodox families had a 3.5-fold increased risk of presenting with DKA than children from secular families (95 % CI 1.2-10.1, p = 0.02) and a 3.8-fold risk to be admitted with severe DKA (95 % CI 1.1-12.6, p = 0.02). Other factors that were found to be associated with an increased risk of DKA were younger age, an absence of maternal academic education, and residence in an area of low socioeconomic status.

CONCLUSIONS

DKA and severe DKA at diabetes diagnosis were more common among religious ultra-orthodox than among secular Jewish children. Awareness of the symptoms and dangers of DKA in new-onset T1DM should be directed to particularly high-risk population groups.

Stroke and diabetic ketoacidosis--some diagnostic and therapeutic considerations

Cerebrovascular insult (CVI) is a known and important risk factor for the development of diabetic ketoacidosis (DKA); still, it seems that the prevalence of DKA among the patients suffering CVI and its influence on stroke outcome might be underestimated. Diabetic ketoacidosis itself has been reported to be a risk factor for the occurrence of stroke in children and youth. A cerebral hypoperfusion in untreated DKA may lead to cerebral injury, arterial ischemic stroke, cerebral venous thrombosis, and hemorrhagic stroke. All these were noted following DKA episodes in children. At least some of these mechanisms may be operative in adults and complicate the course and outcome of CVI. There is a considerable overlap of symptoms, signs, and laboratory findings in the two conditions, making their interpretation difficult, particularly in the elderly and less communicative patients. Serum pH and bicarbonate, blood gases, and anion gap levels should be routinely measured in all type 1 and type 2 diabetics, regardless of symptomatology, for the early detection of existing or pending ketoacidosis. The capacity for rehydration in patients with stroke is limited, and the treatment of the cerebrovascular disease requires intensive use of osmotic and loop diuretics. Fluid repletion may be difficult, and the precise management algorithms are required. Intravenous insulin is the backbone of treatment, although its effect may be diminished due to delayed fluid replenishment. Therefore, the clinical course of diabetic ketoacidosis in patients with CVI may be prolonged and complicated.

Factors associated with diabetic ketoacidosis at onset of Type 1 diabetes in children and adolescents

AIMS

To identify risk factors for diabetic ketoacidosis at diagnosis of Type 1 diabetes in children and adolescents.

METHODS

In three time periods (1986-1987, 1996-1997 and 2006-2007) 75, 86 and 245 patients, respectively, aged < 20 years were newly diagnosed with Type 1 diabetes in one tertiary care centre. In this retrospective comparative study, data of clinical characteristics, laboratory evaluation at diagnosis, as well as demographic data were retrieved from the patients' files. Comparative analyses were performed between patients presenting with or without diabetic ketoacidosis and between the three time periods.

RESULTS

Patients presenting with diabetic ketoacidosis were younger (9.2 ± 4.7 vs. 10.4 ± 4.7 years; P < 0.02), thinner (weight standard deviation score -0.59 ± 1.2 vs. -0.25 ± 1.1; P = 0.002) and less frequently had a first- and/or second-degree relative with Type 1 diabetes compared with those without diabetic ketoacidosis at presentation (16.0 vs. 31.2%, respectively; P = 0.001). Children with diabetic ketoacidosis were less likely to have had relevant testing before diagnosis than children without diabetic ketoacidosis. Children aged < 2 years presented more often with diabetic ketoacidosis than the older children (85 vs. 32%; P < 0.001). Children of Ethiopian origin had a higher rate of diabetic ketoacidosis at diagnosis than the rest of the cohort (57.8 vs. 33%; P = 0.04).

CONCLUSIONS

Factors affecting the risk of developing diabetic ketoacidosis at diagnosis of Type 1 diabetes may be related to the degree of awareness of symptoms of diabetes among parents and primary care physicians. Prevention programmes should aim at increasing awareness and consider the application of special measures to avoid diabetic ketoacidosis in children aged < 2 years and high-risk ethnic groups.

Epidemiological pattern of newly diagnosed children with type 1 diabetes mellitus, Taif, Saudi Arabia

Introduction and Aim. Type-1-diabetes mellitus (T1DM) is the most commonly diagnosed type of DM in children and adolescents. We aim to identify the epidemiological profile, risk factors, clinical features, and factors related to delayed diagnosis or mismanagement in children with newly diagnosed T1DM in Taif, Saudi Arabia. Patients and Methods. Ninety-nine newly diagnosed patients were included in the study along with 110 healthy controls. Patients were classified into 3 groups (I: >2 years, II: 2–>6 years, and III: 6–12 years). Both patients and controls were tested for C-peptide, TSH, and autoantibodies associated with DM and those attacking the thyroid gland. Results. Diabetic ketoacidosis was present in 79.8%. Delayed and missed diagnoses were recorded in 45.5%, with significant correlation to age and district of origin. Severity at presentation showed significant correlation with age and cow's milk feeding. Group I, those with misdiagnosis or positive DM related autoantibodies, had more severe presentations. The correlation of C-peptide and TSH levels in patients and controls was significant for C-peptide and nonsignificant for TSH. Conclusion. Misdiagnosis and mismanagement are common and account for more severe presentation, especially in young children >2 years. Early introduction of cow's milk appears to be a risk factor for the development of T1DM.

Cardiovascular risk in type 1 diabetes mellitus

Commonly cardiovascular risk (CVR) is linked to type 2 diabetes mellitus as this type is known to be part of the metabolic syndrome, which includes other cardiovascular factors such as hypertension, dyslipidemia. Inversely, CVR of type 1 diabetes mellitus (T1DM) is currently being debated apart from the occurrence of diabetic nephropathy (DN). For this, we did a review of CVR in patients with T1DM complicated or not with DN. The place of novel non-invasive techniques in screening of subclinical vascular damage is also discussed in this review.

Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial

Treatment protocols for pediatric diabetic ketoacidosis (DKA) vary considerably among centers in the USA and worldwide. The optimal protocol for intravenous (IV) fluid administration is an area of particular controversy, mainly in regard to possible associations between rates of IV fluid infusion and the development of cerebral edema (CE), the most common and the most feared complication of DKA in children. Theoretical concerns about associations between osmotic fluid shifts and CE have prompted recommendations for conservative fluid infusion during DKA. However, recent data suggest that cerebral hypoperfusion may play a role in cerebral injury associated with DKA. Currently, there are no existing data from prospective clinical trials to determine the optimal fluid treatment protocol for pediatric DKA. The Pediatric Emergency Care Applied Research Network FLUID (FLuid therapies Under Investigation in DKA) study is the first prospective randomized trial to evaluate fluid regimens for pediatric DKA. This 13-center nationwide factorial design study will evaluate the effects of rehydration rate and fluid sodium content on neurological status during DKA treatment, the frequency of clinically overt CE and long-term neurocognitive outcomes following DKA.

Standardised mortality is increased three-fold in a population-based sample of children and adolescents with type 1 diabetes

There are no type 1 diabetes (T1DM) mortality data on Australian children and limited contemporary data on their international counterparts. Fatalities in children and adolescents (1-17 yr) with T1DM were identified from the Western Australia Children's Diabetes Database between 1987-2011. Seventeen thousand four hundred and fifty-three patient-years of diabetes data were analysed and 13 deaths were confirmed (six male). The overall standardised mortality ratio was 3.1 [95% confidence interval (CI), 1.7-5.3] and was highest in the 10-14 yr age group, at 4.6 (95% CI, 1.5-10.8). Median age at death was 16.4 yr (range 5 to 17.8 yr), and median haemoglobin A1c at death was 10.5% (range 6.7 to >14). Cause of death was attributed to diabetes in 10 (77%) cases. Two patients were found 'dead-in-bed'. All diabetes-related deaths in subjects with known T1DM occurred outside the hospital setting.

Assessment of psychosocial variables by parents of youth with type 1 diabetes mellitus

PURPOSE

To evaluate the impact of type 1 diabetes (T1D) on family functioning and child-rearing practices from parents' point of view, to assess parents' health-related quality of life and to explore the relations between psychosocial variables and diabetes care outcomes in youth with diabetes.

METHODS

This research was part of the cross-sectional multicenter Brazilian Type 1 Diabetes Study, conducted between December 2008 and December 2010 in 28 public clinics of 20 cities across four Brazilian geographical regions. Psychosocial questions were addressed to 1,079 parents of patients with T1D through an interview (89.3% mothers, 52.5% Caucasians, 38.6 ± 7.6 years old). Overall, 72.5% of the families were from low or very low socioeconomic levels. Parents were also submitted to health-related quality of life instruments (EQ-5D+EQ-VAS). Clinical data from the last medical appointment were collected by a physician using standardized chart review forms. The demographic, educational and socioeconomic profiles were also obtained and HbA1c levels registered.

RESULTS

Discomfort and anxiety/depression were the main complaints in EQ-5D, and were significantly more frequent in mothers (37.3% and 53.4%, respectively) than in fathers (25.7% and 32.7%, respectively). The mother was the only parent involved in diabetes care in 50.5% of the cases. The majority of parents (78.5%) mentioned changes in family functioning after the diagnosis, although they neither treated their diabetic children differently from the others (76.3%), nor set prohibitions (69.1%) due to diabetes. The majority was worried about diabetes complications (96.4%) and felt overwhelmed by diabetes care (62.8%). Parents report of overwhelming was significantly associated with anxiety/depression, as measured by the EQ-5D questionnaire. Less than half of the patients had already slept over, and the permission to do it increased as a function of children's age. Nearly half of the parents (52%) admitted to experiencing difficulties in setting limits for their children/adolescents. HbA1c levels in patients from this group (9.7 ± 2.5%) were significantly higher than those of children/adolescents whose parents reported no difficulties towards limit-setting (8.8 ± 2.1%). Parents whose children/adolescents reported the occurrence of hypoglycemic episodes in the last month complained significantly more about anxiety/depression (55.1%) than parents from patients who did not report it (45.7%). Also a significantly greater proportion of parents whose children/adolescents had been hospitalized due to hyperglycemia reported anxiety /depression (58.7%) than those whose children/adolescents had not been hospitalized (49.8%).

CONCLUSIONS

After the diagnosis of T1D, the lifestyle of all family members changes, what interferes with their quality of life. Mothers are still the primary caregivers for children/adolescents with diabetes. Difficulty to set limits for children/adolescents may be a risk for poor metabolic control. The study demonstrates the importance of family context in the adjustment of young patients to T1D. The specific needs of T1D patients and their impact on a family routine must be considered for future improvement on therapy elements and strategies.

Improvements in the life expectancy of type 1 diabetes: the Pittsburgh Epidemiology of Diabetes Complications study cohort

Survival in type 1 diabetes has improved, but the impact on life expectancy in the U.S. type 1 diabetes population is not well established. Our objective was to estimate the life expectancy of the Pittsburgh Epidemiology of Diabetes Complications (EDC) study cohort and quantify improvements by comparing two subcohorts based on year of diabetes diagnosis (1950-1964 [n = 390] vs. 1965-1980 [n = 543]). The EDC study is a prospective cohort study of 933 participants with childhood-onset (aged <17 years) type 1 diabetes diagnosed at Children's Hospital of Pittsburgh from 1950 to 1980. Mortality ascertainment was censored 31 December 2009. Abridged cohort life tables were constructed to calculate life expectancy. Death occurred in 237 (60.8%) of the 1950-1964 subcohort compared with 88 (16.2%) of the 1965-1980 subcohort. The life expectancy at birth for those diagnosed 1965-1980 was ~15 years greater than participants diagnosed 1950-1964 (68.8 [95% CI 64.7-72.8] vs. 53.4 [50.8-56.0] years, respectively) (P < 0.0001); this difference persisted regardless of sex or pubertal status at diagnosis. This improvement in life expectancy emphasizes the need for insurance companies to update analysis of the life expectancy of those with childhood-onset type 1 diabetes because weighting of insurance premiums is based on outdated estimates.

Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review

AIMS/HYPOTHESIS

Type 1 diabetes is the most frequent endocrine disease in children, with 65,000 children diagnosed worldwide every year. Up to 80% of these children present with diabetic ketoacidosis (DKA), which is associated with both short-term risks and long-term consequences. This study aimed to characterise the worldwide variation in presentation of type 1 diabetes to inform future interventions to reduce this excess morbidity and mortality.

METHODS

This was a systematic review of studies indexed on PubMed, EMBASE, Web of Science, Scopus or CINAHL before March 2011 that included unselected groups of children presenting with new-onset type 1 diabetes, reported the proportion presenting with DKA and used a definition of DKA based on measurement of pH or bicarbonate.

RESULTS

Sixty-five studies of cohorts comprising over 29,000 children in 31 countries were included. The frequency of DKA at diagnosis ranged from 12.8% to 80%, with highest frequencies in the United Arab Emirates, Saudi Arabia and Romania, and the lowest in Sweden, the Slovak Republic and Canada. Multivariable modelling showed the frequency of DKA was inversely associated with gross domestic product, latitude and background incidence of type 1 diabetes.

CONCLUSIONS/INTERPRETATION

This is the first description of the variation in frequency of DKA at presentation of type 1 diabetes in children across countries. It demonstrates large variations that may, at least in part, be explained by different levels of disease awareness and healthcare provision and suggests ways to decrease the excess morbidity and mortality associated with DKA at diagnosis.

The Armanni-Ebstein Lesion and the Postmortem Diagnosis of Ketoacidosis

The diagnoses of ketoacidosis and disturbances of glucose metabolism are difficult at autopsy because of changes in glucose concentrations postmortem. The Armanni-Ebstein lesion is a histological change in the kidney that has been reported as a marker of diabetic ketoacidosis. This paper examines the specificity of the Armanni-Ebstein lesion and the diagnosis of alterations in glucose metabolism and ketoacidosis at autopsy. The Armanni-Ebstein lesion consists of subnuclear vacuolation of the proximal tubules. The vacuoles contain fat and can be demonstrated on fresh and formalin fixed tissue using standard fat stains. Recently it has been reported in other conditions associated with non-diabetic ketoacidosis. The lesion has the same appearance whatever the cause of the ketoacidosis. This review, with illustrative cases shows the Armanni-Ebstein lesion is a marker of ketoacidosis and not specific for diabetic ketoacidosis. It may be seen in cases of diabetic and alcoholic ketoacidosis and in starvation and hypothermia, in which ketoacidosis occurs. It has also been reported in isopropanol poisoning.

Diabetic ketoacidosis-associated stroke in children and youth

Diabetic ketoacidosis (DKA) is a state of severe insulin deficiency, either absolute or relative, resulting in hyperglycemia and ketonemia. Although possibly underappreciated, up to 10% of cases of intracerebral complications associated with an episode of DKA, and/or its treatment, in children and youth are due to hemorrhage or ischemic brain infarction. Systemic inflammation is present in DKA, with resultant vascular endothelial perturbation that may result in coagulopathy and increased hemorrhagic risk. Thrombotic risk during DKA is elevated by abnormalities in coagulation factors, platelet activation, blood volume and flow, and vascular reactivity. DKA-associated cerebral edema may also predispose to ischemic injury and hemorrhage, though cases of stroke without concomitant cerebral edema have been identified. We review the current literature regarding the pathogenesis of stroke during an episode of DKA in children and youth.

Cause-specific mortality trends in a large population-based cohort with long-standing childhood-onset type 1 diabetes

OBJECTIVE

Little is known concerning the primary cause(s) of mortality in type 1 diabetes responsible for the excess mortality seen in this population.

RESEARCH DESIGN AND METHODS

The Allegheny County (Pennsylvania) childhood-onset (age < 18 years) type 1 diabetes registry (n = 1,075) with diagnosis from 1965 to 1979 was used to explore patterns in cause-specific mortality. Cause of death was determined by a mortality classification committee of at least three physician epidemiologists, based on the death certificate and additional records surrounding the death.

RESULTS

Vital status for 1,043 (97%) participants was ascertained as of 1 January 2008, revealing 279 (26.0%) deaths overall (141 females and 138 males). Within the first 10 years after diagnosis, the leading cause of death was acute diabetes complications (73.6%), while during the next 10 years, deaths were nearly evenly attributed to acute (15%), cardiovascular (22%), renal (20%), or infectious (18%) causes. After 20 years' duration, chronic diabetes complications (cardiovascular, renal, or infectious) accounted for >70% of all deaths, with cardiovascular disease as the leading cause of death (40%). Women (P < 0.05) and African Americans (P < 0.001) have significantly higher diabetes-related mortality rates than men and Caucasians, respectively. Standardized mortality ratios (SMRs) for non-diabetes-related causes do not significantly differ from the general population (violent deaths: SMR 1.2, 95% CI 0.6-1.8; cancer: SMR 1.2, 0.5-2.0).

CONCLUSIONS

The excess mortality seen in type 1 diabetes is almost entirely related to diabetes and its comorbidities but varies by duration of diabetes and particularly affects women and African Americans.

Is diabetic ketoacidosis at disease onset a result of missed diagnosis?

OBJECTIVE

To determine the frequency of medical encounters before diagnosis of diabetes in children in Ontario, Canada; to determine risk factors for diabetic ketoacidosis (DKA).

RESEARCH DESIGN

All medical encounters within 4 weeks before date of diagnosis for all new cases of diabetes in children <18 years were identified from April 1994 to March 2000 by use of administrative databases. The main outcome measure was the frequency of medical encounters before diagnosis in children presenting with and without DKA.

RESULTS

A total of 3947 new cases of diabetes were identified, 735 (18.6%) with DKA. DKA rates were 39.7% for children < or =3 years and 16.3% for children >3 years (P < .001). During the week before diagnosis, 285 children with DKA (38.8%) and 1104 children with diabetes without DKA (34.4%; P = .026) had at least 1 medical visit. Children with diabetes overall had more medical encounters before diagnosis than control subjects. Children with DKA were less likely to have had relevant laboratory testing before diagnosis than children with diabetes without DKA.

CONCLUSIONS

Children with diabetes presenting with DKA more frequently had a medical encounter before diagnosis compared with children with diabetes without DKA. These data have important implications for enhancing public and physician awareness of diabetes in children.

Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging

OBJECTIVE

To determine clinical and biochemical factors influencing cerebral edema formation during diabetic ketoacidosis (DKA) in children.

STUDY DESIGN

We used magnetic resonance diffusion-weighted imaging to quantify edema formation. We measured the apparent diffusion coefficient (ADC) of brain water during and after DKA treatment in 26 children and correlated ADC changes with clinical and biochemical variables.

RESULTS

Mean ADC values were elevated during DKA treatment compared with baseline (8.13 +/- 0.47 vs 7.74 +/- 0.49 x 10(-4) mm(2)/sec, difference in means 0.40, 95% CI: 0.25 to 0.55, P < .001). Children with altered mental status during DKA had greater elevation in ADC. ADC elevation during DKA was positively correlated with initial serum urea nitrogen concentration (correlation coefficient 0.41, P = .03) and initial respiratory rate (correlation coefficient 0.61, P < .001). ADC elevation was not significantly correlated with initial serum glucose, sodium or effective osmolality, nor with changes in glucose, sodium or osmolality during treatment. Multivariable analyses identified the initial urea nitrogen concentration and respiratory rate as independently associated with ADC elevation.

CONCLUSIONS

The degree of edema formation during DKA in children is correlated with the degree of dehydration and hyperventilation at presentation, but not with factors related to initial osmolality or osmotic changes during treatment. These data support the hypothesis that CE is related to cerebral hypoperfusion during DKA, and that osmotic fluctuations during DKA treatment do not play a primary causal role.

Cerebral blood flow and cerebral edema in rats with diabetic ketoacidosis

OBJECTIVE

Cerebral edema (CE) is a potentially life-threatening complication of diabetic ketoacidosis (DKA) in children. Osmotic fluctuations during DKA treatment have been considered responsible, but recent data instead suggest that cerebral hypoperfusion may be involved and that activation of cerebral ion transporters may occur. Diminished cerebral blood flow (CBF) during DKA, however, has not been previously demonstrated. We investigated CBF and edema formation in a rat model of DKA and determined the effects of bumetanide, an inhibitor of Na-K-Cl cotransport.

RESEARCH DESIGN AND METHODS

Juvenile rats with streptozotocin-induced DKA were treated with intravenous saline and insulin, similar to human treatment protocols. CBF was determined by magnetic resonance (MR) perfusion-weighted imaging before and during treatment, and CE was assessed by determining apparent diffusion coefficients (ADCs) using MR diffusion-weighted imaging.

RESULTS

CBF was significantly reduced in DKA and was responsive to alterations in pCO(2). ADC values were reduced, consistent with cell swelling. The reduction in ADCs correlated with dehydration, as reflected in blood urea nitrogen concentrations. Bumetanide caused a rapid rise in ADCs of DKA rats without significantly changing CBF, while saline/insulin caused a rapid rise in CBF and a gradual rise in ADCs. DKA rats treated with bumetanide plus saline/insulin showed a trend toward more rapid rise in cortical ADCs and a larger rise in striatal CBF than those observed with saline/insulin alone.

CONCLUSIONS

These data demonstrate that CE in DKA is accompanied by cerebral hypoperfusion before treatment and suggest that blocking Na-K-Cl cotransport may reduce cerebral cell swelling.

A teenage girl with cystic fibrosis-related diabetes, diabetic ketoacidosis, and cerebral edema

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes, most commonly associated with type 1 diabetes. Here, we report the case of a 17-yr-old girl with cystic fibrosis and a prior diagnosis of cystic fibrosis-related diabetes (CFRD) who presented with DKA in the setting of insulin omission and glucocorticoid use. During the course of treatment for DKA, her neurologic status declined and head computerized tomography confirmed cerebral edema. Recognition of DKA and cerebral edema allowed for timely treatment, and the patient recovered without sequelae. This is the first report of DKA complicated by cerebral edema that is attributable to CFRD.

Cerebral edema in diabetic ketoacidosis

OBJECTIVE

To review the causes of cerebral edema in diabetic ketoacidosis (CEDKA), including pathophysiology, risk factors, and proposed mechanisms, to review the diagnosis, treatment, and prognosis of CEDKA and the treatment of diabetic ketoacidosis as it pertains to prevention of cerebral edema.

DATA SOURCE

A MEDLINE search using OVID was done through 2006 using the search terms cerebral edema and diabetic ketoacidosis. RESULTS OF SEARCH: There were 191 citations identified, of which 150 were used. An additional 42 references listed in publications thus identified were also reviewed, and two book chapters were used.

STUDY SELECTION

The citations were reviewed by the author. All citations identified were used except 25 in foreign languages and 16 that were duplicates or had inappropriate titles and/or subject matter. Of the 194 references, there were 21 preclinical and 40 clinical studies, 35 reviews, 15 editorials, 43 case reports, 29 letters, three abstracts, six commentaries, and two book chapters.

DATA SYNTHESIS

The data are summarized in discussion.

CONCLUSIONS

The causes and mechanisms of CEDKA are unknown. CEDKA may be due as much to individual biological variance as to severity of underlying metabolic derangement of the child's state and/or treatment risk factors. Treatment recommendations for CEDKA and diabetic ketoacidosis are made taking into consideration possible mechanisms and risk factors but are intended as general guidelines only in view of the absence of conclusive evidence.

Extent of beta cell destruction is important but insufficient to predict the onset of type 1 diabetes mellitus

Background

Type 1 diabetes mellitus is characterized by an inability to produce insulin endogenously. Based on a series of histopathology studies of patients with recent onset of the disease, it is commonly stated that the onset of clinical symptoms corresponds to an 80-95% reduction in beta cell mass. Motivated by the clinical importance of the degree of beta cell destruction at onset, a meta-analysis was used to determine the validity of this common wisdom.

Methods and Findings

The histopathology results identifying insulin containing islets in patients younger than 20 years of age were extracted from three different studies. The results for 105 patients were stratified by duration of diabetic symptoms and age at onset. Linear regression and a non-parametric bootstrap approach were used to determine the dependence of residual beta cell mass to age at onset. The percentage reduction in beta cell mass was highly correlated (p<0.001) with the age of onset with the greatest reduction in beta cell mass in the youngest patients. As this trend had not been previously observed, an alternative physiology-based model is proposed that captures this age-dependence.

Conclusions

The severity in beta cell reduction at onset decreased with age where, on average, a 40% reduction in beta cell mass was sufficient to precipitate clinical symptoms at 20 years of age. The observed trend was consistent with a physiology-based model where the threshold for onset is based upon a dynamic balance between insulin-production capacity, which is proportional to beta cell mass, and insulin demand, which is proportional to body weight.

Can we prevent diabetic ketoacidosis in children?

Diabetic ketoacidosis (DKA) is an acute potentially life-threatening complication of diabetes affecting more than 100,000 persons annually in the United States. Although major advances have improved diabetes care, DKA remains the leading cause of hospitalization, morbidity, and death in youth with type 1 diabetes (T1D). As the majority of patients presenting with DKA have established diabetes, it is important to address outpatient educational approaches directed at sick-day management and early identification and treatment of impending DKA. Teaching and reinforcement of sick-day rules involves improved self-care with consistent self-monitoring of blood glucose and ketones, and timely administration of supplemental insulin and fluids. DKA as an initial manifestation of T1D may be less amendable to prevention except with an increased awareness by the lay and medical communities of the symptoms of diabetes and surveillance in high-risk populations potentially identified by family history or genetic susceptibility. New technologies that can detect the blood ketone 3beta-hydroxybutyrate (3beta-OHB) instead of traditional urine ketones appears to provide opportunity for early identification and treatment of impending DKA leading to reduced need for hospitalization and potential cost-savings.

Childhood type 1 diabetes mellitus in Newfoundland and Labrador, Canada

The aim of this study was to calculate incidence and hospitalization rates of childhood type 1 diabetes mellitus (T1DM) in Newfoundland and Labrador, and to assess hospitalization trends and associated factors. Data for all patients aged 0-19 years with a diagnosis of T1DM was obtained from the clinical database management system (CDMS) for a 7-year period between April 1, 1995 and March 31, 2002. Incidence was calculated for the 0-7 years age group. A total of 894 T1DM hospital separations among children aged 0-19 years were identified, representing a hospitalization rate of 88.6 per 100,000 person-years (P-Y). The CDMS identified 518 incidences of hospitalization (51.2 per 100,000 P-Y). The overall hospitalization rate increased over the study period (P((2))=0.065). Hospitalization rates for males and females were 77.3 and 100.2 per 100,000 P-Y, respectively (P((2))=0.00011). Of the 894 hospitalization separations, 216 hospitalizations were for diabetic ketoacidosis (DKA) (21.4 per 100,000 P-Y). Female gender and older age were found to be predictive factors of DKA. The incidence rate of T1DM among children aged 0-7 years was 19.0 per 100,000 P-Y. Newfoundland and Labrador has one of the highest incidence rates of T1DM in the world. Hospitalization rates for DKA and non-DKA increased slightly over the study period. Age and sex patterns suggest that DKA is a particular challenge among adolescent girls. Preventive strategies are needed, particularly in areas of the province with the highest rates.

Sick day management using blood 3-hydroxybutyrate (3-OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial

AIMS

Diabetic ketoacidosis (DKA), a life-threatening acute complication of Type 1 diabetes, may be preventable with frequent monitoring of glycaemia and ketosis along with timely supplemental insulin. This prospective, two-centre study assessed sick day management using blood 3-hydroxybutyrate (3-OHB) monitoring compared with traditional urine ketone testing, aimed at averting emergency assessment and hospitalization.

METHODS

One hundred and twenty-three children, adolescents and young adults, aged 3-22 years, and their families received sick day education. Participants were randomized to receive either a blood glucose monitor that also measures blood 3-OHB (blood ketone group, n = 62) or a monitor plus urine ketone strips (urine ketone group, n = 61). All were encouraged to check glucose levels > or = 3 times daily and to check ketones during acute illness or stress, when glucose levels were consistently elevated (> or = 13.9 mmol/l on two consecutive readings), or when symptoms of DKA were present. Frequency of sick days, hyperglycaemia, ketosis, and hospitalization/emergency assessment were ascertained prospectively for 6 months.

RESULTS

There were 578 sick days during 21,548 days of follow-up. Participants in the blood ketone group checked ketones significantly more during sick days (276 of 304 episodes, 90.8%) than participants in the urine ketone group (168 of 274 episodes, 61.3%) (P < 0.001). The incidence of hospitalization/emergency assessment was significantly lower in the blood ketone group (38/100 patient-years) compared with the urine ketone group (75/100 patient-years) (P = 0.05).

CONCLUSIONS

Blood ketone monitoring during sick days appears acceptable to and preferred by young people with Type 1 diabetes. Routine implementation of blood 3-OHB monitoring for the management of sick days and impending DKA can potentially reduce hospitalization/emergency assessment compared with urine ketone testing and offers potential cost savings.

Pediatric diabetic ketoacidosis and hyperglycemic hyperosmolar state

Diabetic ketoacidosis is an important complication of diabetes in children and is the most frequent diabetes-related cause of death in childhood. The pathophysiology of this condition can be viewed as an exaggeration of the normal physiologic mechanisms responsible for maintaining an adequate fuel supply to the brain and other tissues during periods of fasting and physiologic stress. The optimal therapy has been a subject of controversy, particularly because the most frequent serious complication of diabetic ketoacidosis-cerebral edema-and the relationship of this complication to treatment are incompletely understood. In this article, the author reviews the pathophysiology of diabetic ketoacidosis and its complications and presents an evidence-based approach to the management of this condition.

Excess mortality in Black compared with White patients with Type 1 diabetes: an examination of underlying causes

AIMS

Excess mortality in Type 1 diabetes has previously been found among Black individuals. The aim of the present study was therefore to determine underlying causes.

METHODS

A longitudinal study of 1261 [1184 White (93.9%) and 76 Black (6.0%)] individuals diagnosed with Type 1 diabetes between 1965 and 1979, at age<17 years from the Allegheny County, Pennsylvania and Children's Hospital of Pittsburgh registries. Subjects were contacted in 1999 to determine living status and, where appropriate, cause of death. Living status was determined in 1183 participants (93.8%).

RESULTS

Of the 200 deaths overall, cause of death was determined in 157 subjects (79%); 31 dying from acute and 101 from chronic complications, and 25 from non-diabetes related causes. Seven deaths were investigated but no cause determined. Black participants had a significantly higher mortality rate compared with White participants for acute complications (hazard ratio=4.9, 95% confidence interval: 2.0, 11.6), but not for any other cause. There was a temporal decline in the 20-year mortality rates in both racial groups across the three cohorts diagnosed in 1965-69, 1970-74 and 1975-79.

CONCLUSIONS

These results show that the excess mortality in Black people was attributed to acute complications which therefore should be a focus for prevention.

Diabetic ketoacidosis: risk factors and management strategies

Diabetic ketoacidosis (DKA) is the most common hyperglycemic emergency in patients with diabetes mellitus. DKA most often occurs in patients with type 1 diabetes, but patients with type 2 diabetes are susceptible to DKA under stressful conditions, such as trauma, surgery, or infections. DKA is reported to be responsible for more than 100 000 hospital admissions per year in the US, and accounts for 4-9% of all hospital discharge summaries among patients with diabetes. Treatment of patients with DKA uses significant healthcare resources and accounts for 1 out of every 4 healthcare dollars spent on direct medical care for adult patients with type 1 diabetes in the US. Recent studies using standardized written guidelines for therapy have demonstrated a mortality rate of less than 5%, with higher mortality rates observed in elderly patients and those with concomitant life-threatening illnesses. Worldwide, infection is the most common precipitating cause for DKA, occurring in 30-50% of cases. Urinary tract infection and pneumonia account for the majority of infections. Other precipitating causes are intercurrent illnesses (i.e., surgery, trauma, myocardial ischemia, pancreatitis), psychological stress, and non-compliance with insulin therapy. The triad of uncontrolled hyperglycemia, metabolic acidosis and increased total body ketone concentration characterizes DKA. These metabolic derangements result from the combination of absolute or relative insulin deficiency and increased levels of counter-regulatory hormones (glucagon, catecholamines, cortisol, and growth hormone). Successful treatment of DKA requires frequent monitoring of patients, correction of hypovolemia and hyperglycemia, replacement of electrolyte losses, and careful search for the precipitating cause. Since the majority of DKA cases occur in patients with a known history of diabetes, this acute metabolic complication should be largely preventable through early detection, and by the education of patients, healthcare professionals, and the general public. The frequency of hospitalizations for DKA has been reduced following diabetes education programs, improved follow-up care, and access to medical advice. Novel approaches to patient education incorporating a variety of healthcare beliefs and socioeconomic issues are critical to an effective prevention program.

Clinical characteristics of diabetic ketoacidosis in Korea over the past two decades

AIMS

The aim of this study was to investigate changes in the clinical characteristics of diabetic ketoacidosis (DKA) in Korea over the last two decades.

METHODS

A retrospective medical record review of all episodes of DKA from 1982 to 2002 in four University-affiliated urban hospitals in Korea was performed. A total of 255 episodes of DKA (217 patients) were identified and divided into three consecutive 7-year periods to compare trends over time. Clinical characteristics including precipitating factors and hospital mortality were analyzed.

RESULTS

A dramatic increase in DKA admissions has occurred over the last two decades, accompanied by a marked increase in admissions of diabetic patients. The clinical characteristics of DKA remained constant over the observation period. Non-compliance to treatment was the most common precipitating factor of DKA. A total of 30 patients died in hospital (11.8% of all episodes). Older age and infection appeared to influence mortality.

CONCLUSIONS

Our results suggest that rapidly increasing episodes of DKA in Korea, in parallel with increases in the numbers of diabetic patients, continue to be associated with significant mortality.

Cerebral oedema in childhood diabetic ketoacidosis: is treatment a factor?

Cerebral oedema (CO) is the most dreaded complication of diabetic ketoacidosis (DKA) in children. Despite advances in many areas of the management of DKA, the mortality from CO has remained constant for decades. This rare disorder, complicating about 1% of cases of DKA in children, is lethal in 20% to 50% of victims. Since it was first described in 1936, much effort has gone into the search for a cause for this condition, but CO in childhood DKA remains a mysterious illness. Researchers have suggested that the treatment for DKA may be causally related to the development of CO. Others have disputed this claim, and both camps cite evidence to support their point of view. This article reviews the literature pertinent to the question: Is the treatment of DKA in children responsible for the development of CO?

Bumetanide reduces cerebral edema formation in rats with diabetic ketoacidosis

The mechanisms responsible for cerebral edema formation in diabetic ketoacidosis (DKA) are not well understood, although evidence suggests ischemia as a contributing factor. Previous studies have shown that the Na-K-Cl cotransporter of cerebral microvascular endothelial cells and astrocytes is a major participant in ischemia-induced cerebral edema in stroke. The present study was conducted to test the hypothesis that the Na-K-Cl cotransporter also contributes to cerebral edema in DKA. Sprague-Dawley rats were administered streptozotocin to induce DKA, and then cerebral edema was assessed by determination of apparent diffusion coefficients (ADC) with magnetic resonance diffusion-weighted imaging. Cerebral ADC values in DKA rats were significantly reduced in both cortex and striatum compared with non-DKA control rats, indicating the presence of cerebral edema. Intravenous administration of bumetanide to DKA rats abolished the drop in cortical ADC values, while having no significant effect in the striatum. Insulin and saline treatment had no effect when given after bumetanide but increased both cortical and striatal ADC values when given before bumetanide. Evidence is also presented here that acetoacetate and beta-hydroxybutyrate stimulate brain microvascular Na-K-Cl cotransporter activity. These findings suggest that the Na-K-Cl cotransporter contributes to brain edema in DKA.

Cell column chromatography: a new research tool to quantify cerebral cell volume changes following chemically-induced anoxia/re-oxygenation

OBJECTIVE

The roles of individual types of cerebral cells in contributing to brain edema are undefined. The objective of this study was to determine the role of cerebral cell-column chromatography in quantifying cell volumes of individual cerebral cell lines, under chemically-induced anoxia/re-oxygenation (A/R).

METHODS

Cerebral endothelial cells (4 experiments) or type II astrocytes (4 experiments) were cultured to confluence on microcarrier beads. A chromatographic cell-column of 1.5 cm height was filled with non-treated cell-covered beads. The column was perfused at 1 ml/min with a balanced perfusate for one hour (Baseline). The perfusate was then switched to that containing 5 mM thioglycolic acid for one hour (Anoxia). Then the column was perfused with the normal perfusate for another two hours (Re-oxygenation). The total free space in the column, reversely reflecting cell volumes, was determined by averaged transit time (TTa) of a non-permeable flow tracer blue dextran. Decreased TTa means that cells swell, and vice versa.

RESULTS

TTa in endothelial cell columns increased with a peak at 60 minutes of re-oxygenation. TTa in astrocyte columns decreased with a nadir at 30 minutes of re-oxygenation.

CONCLUSION

Cell column chromatography can be used to determine the cerebral cell volume changes following chemically-induced anoxia/re-oxygenation.

Fatal cerebral infarctions in diabetic ketoacidosis in a child with previously unknown heterozygosity for factor V Leiden deficiency

An 11-year-old boy with poorly controlled diabetes had sudden collapse after the development of lower extremity deep venous thrombosis, with fatal cerebral infarctions. He was heterozygous for factor V Leiden deficiency. This case emphasizes the value of cranial imaging after initial resuscitative treatment of neurologic collapse in diabetic ketoacidosis.

Cerebral edema in childhood diabetic ketoacidosis: natural history, radiographic findings, and early identification

OBJECTIVE

Children who develop cerebral edema (CE) during diabetic ketoacidosis (DKA) exhibit definable signs and symptoms of neurological collapse early enough to allow intervention to prevent brain damage. Our objective was to develop a model for early detection of CE in children with DKA.

RESEARCH DESIGN AND METHODS

A training sample of 26 occurrences of DKA complicated by severe CE and 69 episodes of uncomplicated DKA was reviewed. Signs of neurological disease were incorporated into a bedside evaluation protocol that was applied to an independent test sample of 17 patients previously reported to have developed symptomatic CE during treatment for DKA. Head computed tomograms and their reports were reviewed.

RESULTS

The protocol allowed 92% sensitivity and 96% specificity for the recognition of CE sufficiently early for intervention. The diagnostic criteria were fulfilled in two temporal patterns, defining early- and late-onset CE. Although initial computed tomograms were often normal, the findings also included diffuse CE and focal brain injury, the latter only in patients with an early onset of abnormal neurological signs.

CONCLUSIONS

CE may occur in the absence of acute changes on head computed tomograms. Early detection of CE at the bedside using an evidence-based protocol permits intervention in time to prevent permanent brain damage.

[Diabetic coma. Management of diabetic ketoacidosis and nonketotic hyperosmolar coma]

This review describes the current guidelines of German diabetes association for the management of diabetic coma, both of diabetic ketoacidosis and hyperosmolal coma. The outline focuses on emergency treatment and the management on the intensive care unit, in particular, volume and insulin therapy, and potassium replacement. The delineation of the concept of low insulin therapy is emphasized to avoid the incidence of disequilibrium syndrome. Also, the indications for bicarbonate therapy in diabetic ketoacidosis are critically discussed, as well as phosphate and magnesium replacement. With today's therapeutic possibilities the therapeutic goal, i.e. a low mortality, may be achieved, dependent on the underlying illness.