Neurological consequences of diabetic ketoacidosis at initial presentation of type 1 diabetes in a prospective cohort study of children

Systemic Inflammatory Response Index (SIRI) as a Predictive Marker for Adverse Outcomes in Children with New-Onset Type 1 Diabetes Mellitus

(1) Background: Although most cases of new-onset type 1 diabetes mellitus (T1DM) are managed without serious events, life-threatening complications do arise in a subset of patients. Our objective was to assess the correlation between elevated SIRI values and adverse events related to the onset of T1DM. (2) Methods: This retrospective study, spanning ten years, included 187 patients with new-onset T1DM divided into three groups based on SIRI tertiles. The primary outcome was the occurrence of acute complications during hospital admission, while the secondary outcome was prolonged Intensive Care Unit (ICU) admission. (3) Results: Patients with high SIRI values were more likely to experience higher disease activity, leading to longer ICU admission times and more frequent complications. Multivariate logistic regression analysis revealed that the SIRI was independently associated with acute complications (p = 0.003) and prolonged ICU length of stay (p = 0.003). Furthermore, receiver operating characteristic analysis demonstrated the SIRI's superior predictive accuracy compared to venous pH (AUC = 0.837 and AUC = 0.811, respectively) and to the individual component cell lineages of the SIRI. (4) Conclusions: These findings emphasize the potential utility of the SIRI as a prognostic marker in identifying patients at increased risk during T1DM hospital admissions.

Identification of diagnostic biomarkers used in the diagnosis of cardiovascular diseases and diabetes mellitus: A systematic review of quantitative studies

AIMS

To perform a systematic review of studies that sought to identify diagnostic biomarkers for the diagnosis of cardiovascular diseases (CVDs) and diabetes mellitus (DM), which could be used in low- and middle-income countries (LMICs) where there is a lack of diagnostic equipment, treatments and training.

MATERIALS AND METHODS

Papers were sourced from six databases: the British Nursing Index, Google Scholar, PubMed, Sage, Science Direct and Scopus. Articles published between January 2002 and January 2023 were systematically reviewed by three reviewers and appropriate search terms and inclusion/exclusion criteria were applied.

RESULTS

A total of 18 studies were yielded, as well as 234 diagnostic biomarkers (74 for CVD and 160 for DM). Primary biomarkers for the diagnosis of CVDs included growth differentiation factor 15 and neurogenic locus notch homologue protein 1 (Notch1). For the diagnosis of DM, alpha-2-macroglobulin, C-peptides, isoleucine, glucose, tyrosine, linoleic acid and valine were frequently reported across the included studies. Advanced analytical techniques, such as liquid chromatography mass spectrometry, enzyme-linked immunosorbent assays and vibrational spectroscopy, were also repeatedly reported in the included studies and were utilized in combination with traditional and alternative matrices such as fingernails, hair and saliva.

CONCLUSIONS

While advanced analytical techniques are expensive, laboratories in LMICs should carry out a cost-benefit analysis of their use. Alternatively, laboratories may want to explore emerging techniques such as infrared, Fourier transform-infrared and near-infrared spectroscopy, which allow sensitive noninvasive analysis.

PRE1BRAZIL Protocol: A Randomized Controlled Trial to Evaluate the Effectiveness and Safety of the DPP-4 Inhibitor Alogliptin in Delaying the Progression of Stage 2 Type 1 Diabetes

Background

The incidence of Type 1 Diabetes Mellitus (T1DM) is on the rise. Since there is no curative treatment, it is urgent to look for therapies that can delay disease progression and protect pancreatic β-cells. Dipeptidyl peptidase-4 inhibitors (DPP-4i) have shown potential in modulating inflammation and preventing β-cell destruction. This protocol describes an upcoming trial to evaluate the effectiveness of the DPP-4i alogliptin in delaying the progression of stage 2 (presymptomatic) to stage 3 (symptomatic) T1DM.

Patients and Methods

We propose a two-year, two-arm, multicenter, randomized, open-label clinical trial targeting Brazilian patients aged 18 to 35 with stage 2 T1DM. The study, facilitated by the custom-developed "PRE1BRAZIL" web application, aims to enroll 130 participants. They will be randomly assigned in a 1:1 ratio to either a treatment group (alogliptin 25 mg daily plus regular clinical and laboratory assessments) or a control group (regular assessments only). The primary outcome is the rate of progression to stage 3 T1DM. Secondary outcomes include changes in A1c levels, glucose levels during a 2-hour oral glucose tolerance test (OGTT), C-peptide levels, exogenous insulin requirements, Insulin-Dose Adjusted A1c (IDAA1c), and the incidence of diabetic ketoacidosis (DKA) in those advancing to stage 3.

Discussion

This protocol outlines the first randomized clinical trial (RCT) to investigate the impact of a DPP-4i in the presymptomatic stage of T1DM. The trial is designed to provide critical insights into the role of DPP-4i in the secondary prevention of T1DM. Utilizing the "PRE1BRAZIL" web application is expected to enhance participant enrollment and reduce operational costs.

Registration

Brazilian Registry of Clinical Trials.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Associations between type 1 diabetes and educational outcomes: an Aotearoa/New Zealand nationwide birth cohort study using the Integrated Data Infrastructure

AIMS/HYPOTHESIS

Type 1 diabetes is one of the most common chronic diseases of childhood. It is hypothesised that the metabolic and psychosocial consequences of type 1 diabetes may affect educational outcomes; however, existing literature presents conflicting results. This study aimed to assess whether educational outcomes differ for young people with and without type 1 diabetes in Aotearoa/New Zealand (NZ).

METHODS

This was a nationwide 9 year birth cohort study of all people born in NZ from 1993 to 2001 using linked administrative data held within the Integrated Data Infrastructure, a national research database containing linked health and non-health data. Educational outcomes of high school attainment, high school attendance and university enrolment were measured from age 13 years until 20 years. Generalised linear regression models with log link and Gaussian distributions were used to compare educational outcomes between those with and those without type 1 diabetes, adjusting for sociodemographic and maternal characteristics.

RESULTS

Of the 442,320 children in the birth cohort, type 1 diabetes was identified in 2058 (0.47%) (mean [SD] age of type 1 diabetes diagnosis 7.7 [3.4] years). Educational outcomes were significantly lower for children with type 1 diabetes than for those without type 1 diabetes, including for any high school qualification (RR 0.97 [95% CI 0.95, 0.99]), university entrance-level high school attainment (RR 0.88 [95% CI 0.84, 0.92]), regular high school attendance (RR 0.91 [95% CI 0.85, 0.97]) and university enrolment (RR 0.93 [95% CI 0.88, 0.98]), even after adjusting for sociodemographic and maternal factors. In addition, educational outcomes were substantially lower for those with post type 1 diabetes diagnosis hospitalisations for diabetic ketoacidosis and hypoglycaemia.

CONCLUSIONS/INTERPRETATION

In this whole NZ birth cohort study, type 1 diabetes was associated with lower educational outcomes spanning secondary school and into university enrolment. Ongoing efforts to support students with type 1 diabetes are needed, particularly for those with a greater risk profile.

Predictors of the clinical severity of T1DM presentation at diagnosis in children and adolescents with type 1 diabetes mellitus (T1DM)

PURPOSE

We aimed to assess factors associated with the presence and severity of ketoacidosis (DKA) at pediatric type 1 diabetes (T1DM) diagnosis, in relation to pancreatic, associated and familial autoimmunity.

METHODS

Antibodies against pancreatic beta-cells, organ specific autoantibodies (thyroid, celiac, and parietal) and family history of autoimmunity were retrospectively evaluated in 116 T1DM patients aged 11.9 ± 4.6 (mean ± SD) years, with disease duration 7.62 ± 3.67 years (mean ± SD).

RESULTS

Most patients (67.2%) presented with DKA at diagnosis. Younger children (< 2 years) had tenfold risk of DKA, compared to older children (12.1-15 years) (OR = 10.8, 95% CI: 1.0-116.9, P = 0.05). Fasting c-peptide levels were lower in the DKA group (OR = 0.26, 95% CI = 0.07-0.89, P = 0.033). The number of anti-pancreatic antibodies at disease onset did not show any significant correlations with the presence (p = 0.889) or severity of DKA (p = 0.863). All patients with multiple autoimmunity (> 2 autoimmune diseases plus T1DM) presented with DKA. Familial autoimmunity acted protectively against DKA manifestation (OR = 0.40, 95% CI = 0.16-1.0, P = 0.051).

CONCLUSIONS

Among newly diagnosed T1DM patients, 67.2% presented with DKA. Younger age, lower c-peptide and the presence of associated autoimmunity were predictive factors of the presence and severity of DKA at diagnosis. High degree of suspicion, due to family history, may prevent DKA development and severity.

Relative Frequency of Islet Autoimmunity in Children and Adolescents with Autoimmune Thyroid Disease

Objective

The aim of the present study was to investigate islet autoimmunity and susceptibility to type 1 diabetes (T1D) in children/adolescents with autoimmune thyroid disease (AITD, and in family members of AITD patients with islet autoimmunity.

Methods

Islet-cell cytoplasmic, glutamic-acid decarboxylase, and tyrosine-phosphatase autoantibodies (AAbs) were measured in 161 AITD patients [127 with autoimmune thyroiditis (AT); 34 with Graves’ disease (GD)], 20 family members of AITD patients with islet autoimmunity, and 155 age-matched controls.

Results

Islet autoimmunity was found in 10.6% of AITD patients, significantly more frequent than in controls (1.9%; p=0.002). A higher prevalence of islet AAbs was found in females with AITD (p=0.011) but not in males (p=0.16) and in AT (p=0.013) but not in GD patients (p=0.19), compared to corresponding controls. Two or three islet AAbs were found concurrently in six AITD patients with islet autoimmunity. They all developed T1D and had significantly higher islet AAbs titers (p=0.01) than AITD patients with single islet AAbs but normal glucose metabolism. T1D was found in 3.7% of AITD patients compared to 0.2% of the age-matched, general Croatian population. Islet AAbs were found in 5/20 family members of AITD patients with islet autoimmunity, among whom two developed T1D. None of the controls was positive for more than one islet AAb or developed T1D.

Conclusion

Children/adolescents with AITD, particularly females and patients with AT, appear to represent a risk group for islet autoimmunity and T1D, as do family members of AITD patients with positive islet AAbs. However, these findings should be validated in larger studies.

Screening and Prevention of Type 1 Diabetes: Where Are We?

A diagnosis of type 1 diabetes (T1D) and the subsequent requirement for exogenous insulin treatment is associated with considerable acute and chronic morbidity and a substantial effect on patient quality of life. Importantly, a large body of work suggests that early identification of presymptomatic T1D can accurately predict clinical disease, and when paired with education and monitoring, can yield improved health outcomes. Furthermore, a growing cadre of effective disease-modifying therapies provides the potential to alter the natural history of early stages of T1D. In this mini review, we highlight prior work that has led to the current landscape of T1D screening and prevention, as well as challenges and next steps moving into the future of these rapidly evolving areas of patient care.

Central nervous system microstructural alterations in Type 1 diabetes mellitus: A systematic review of diffusion Tensor imaging studies

AIMS

Type 1 diabetes mellitus (T1DM) is a chronic childhood disease with potentially persistent CNS disruptions. In this study, we aimed to systematically review diffusion tensor imaging studies in patients with T1DM to understand the microstructural effects of this entity on individuals' brains METHODS: We performed a systematic search and reviewed the studies to include the DTI studies in individuals with T1DM. The data for the relevant studies were extracted and a qualitative synthesis was performed.

RESULTS

A total of 19 studies were included, most of which showed reduced FA widespread in optic radiation, corona radiate, and corpus callosum, as well as other frontal, parietal, and temporal regions in the adult population, while most of the studies in the juvenile patients showed non-significant differences or a non-persistent pattern of changes. Also, reduced AD and MD in individuals with T1DM compared to controls and non-significant differences in RD were noted in the majority of studies. Microstructural alterations were associated with clinical profile, including age, hyperglycemia, diabetic ketoacidosis and cognitive performance.

CONCLUSION

T1DM is associated with microstructural brain alterations including reduced FA, MD, and AD in widespread brain regions, especially in association with glycemic fluctuations and in adult age.

Understanding Providers' Readiness and Attitudes Toward Autoantibody Screening: A Mixed-Methods Study

Screening for autoantibodies associated with type 1 diabetes can identify people most at risk for progressing to clinical type 1 diabetes and provide an opportunity for early intervention. Drawbacks and barriers to screening exist, and concerns arise, as methods for disease prevention are limited and no cure exists today. The availability of novel treatment options such as teplizumab to delay progression to clinical type 1 diabetes in high-risk individuals has led to the reassessment of screening programs. This study explored awareness, readiness, and attitudes of endocrinology providers toward type 1 diabetes autoantibody screening.

Association Between COVID-19 and Severity of Illness for Children With Hyperglycemic Crisis

OBJECTIVES

Admissions to the ICU for children with hyperglycemic crisis (HGC, defined as diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, or hyperosmolar ketoacidosis) increased during the COVID-19 pandemic. We sought to identify if severity of illness for HGC also increased from prepandemic to pandemic years 1 and 2.

METHODS

Retrospective study of children aged ≤18 years hospitalized in the Pediatric Health Information System for HGC. Pre-COVID-19 years were defined as March 2017-February 2020, COVID-19 year 1 as March 2020-February 2021, and COVID-19 year 2 as March 2021-February 2022. The primary outcome was ICU admission. Secondary outcomes included mortality, length of stay, cost, and use of neurologic therapies, mechanical ventilation, or vasoactive support.

RESULTS

There were 46 425 HGC admissions to 42 hospitals, 20 045 (43.2%) of which were ICU admissions. In comparison with pre-COVID-19, children admitted in COVID-19 year 1 (odds ratio, 1.31 [95% confidence interval, 1.25-1.38], P < .0001) and year 2 (odds ratio, 1.17 [95% confidence interval, 1.11-1.22], P < .0001) had a higher odds of ICU admission in multivariable modeling after controlling for confounding variables. Severity of illness was higher during COVID-19 years when considering secondary outcomes, although these associations were not consistent across outcomes and year. There was no difference in mortality.

CONCLUSIONS

Children with HGC had a higher severity of illness during the pandemic which was sustained over 2 years. Reduction in social distancing and evolving variants of SARS-CoV-2 over the 2 years of the pandemic did not significantly alter the relationship between HGC and higher requirement for ICU care.

Children diagnosed with presymptomatic type 1 diabetes through public health screening have milder diabetes at clinical manifestation

AIMS/HYPOTHESIS

We aimed to determine whether disease severity was reduced at onset of clinical (stage 3) type 1 diabetes in children previously diagnosed with presymptomatic type 1 diabetes in a population-based screening programme for islet autoantibodies.

METHODS

Clinical data obtained at diagnosis of stage 3 type 1 diabetes were evaluated in 128 children previously diagnosed with presymptomatic early-stage type 1 diabetes between 2015 and 2022 in the Fr1da study and compared with data from 736 children diagnosed with incident type 1 diabetes between 2009 and 2018 at a similar age in the DiMelli study without prior screening.

RESULTS

At the diagnosis of stage 3 type 1 diabetes, children with a prior early-stage diagnosis had lower median HbA1c (51 mmol/mol vs 91 mmol/mol [6.8% vs 10.5%], p<0.001), lower median fasting glucose (5.3 mmol/l vs 7.2 mmol/l, p<0.05) and higher median fasting C-peptide (0.21 nmol/l vs 0.10 nmol/l, p<0.001) compared with children without previous early-stage diagnosis. Fewer participants with prior early-stage diagnosis had ketonuria (22.2% vs 78.4%, p<0.001) or required insulin treatment (72.3% vs 98.1%, p<0.05) and only 2.5% presented with diabetic ketoacidosis at diagnosis of stage 3 type 1 diabetes. Outcomes in children with a prior early-stage diagnosis were not associated with a family history of type 1 diabetes or diagnosis during the COVID-19 pandemic. A milder clinical presentation was observed in children who participated in education and monitoring after early-stage diagnosis.

CONCLUSIONS/INTERPRETATION

Diagnosis of presymptomatic type 1 diabetes in children followed by education and monitoring improved clinical presentation at the onset of stage 3 type 1 diabetes.

Does diabetic ketoacidosis at diagnosis of type 1 diabetes mellitus predict poorer long-term glycemic control

BACKGROUND

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus.

AIMS

This study aimed to determine (1) whether DKA at diagnosis of type 1 diabetes is associated with poorer long-term glycemic control and (2) whether there are confounding factors which may impact the mode of presentation of type 1 diabetes mellitus or subsequent glycemic control.

METHODS

This study was conducted via review of 102 patient files extracted from the Young Person's Type 1 Diabetes Clinic at Cork University Hospital. Glycemic control was measured using the average of the patient's three most recent HbA1C levels, recorded a median of 11 years post-diagnosis of type 1 diabetes mellitus.

RESULTS

Data analysis revealed a positive association between DKA at diagnosis and poorer long-term glycemic control, with HbA1c levels tracking 6.58 mmol/mol (0.6%) higher at follow up in the group with DKA compared to the group without DKA at diagnosis. Certain sociodemographic factors were found to predict worse glycemic control at follow-up: Individuals using recreational drugs and those reporting mental health difficulties were found to have higher levels of HbA1C at follow up (p = ·006,·012, respectively) compared to individuals who did not.

CONCLUSIONS

Diabetic ketoacidosis at diagnosis of type 1 diabetes mellitus was shown to be associated with poorer long-term glycemic control in this study. Furthermore, individuals who utilize recreational drugs or have mental health difficulties had significantly worse glycemic control at follow-up.

Exploratory Multisite MR Spectroscopic Imaging Shows White Matter Neuroaxonal Loss Associated with Complications of Type 1 Diabetes in Children

BACKGROUND AND PURPOSE

Type 1 diabetes affects over 200,000 children in the United States and is associated with an increased risk of cognitive dysfunction. Prior single-site, single-voxel MRS case reports and studies have identified associations between reduced NAA/Cr, a marker of neuroaxonal loss, and type 1 diabetes. However, NAA/Cr differences among children with various disease complications or across different brain tissues remain unclear. To better understand this phenomenon and the role of MRS in characterizing it, we conducted a multisite pilot study.

MATERIALS AND METHODS

In 25 children, 6-14 years of age, with type 1 diabetes across 3 sites, we acquired T1WI and axial 2D MRSI along with phantom studies to calibrate scanner effects. We quantified tissue-weighted NAA/Cr in WM and deep GM and modeled them against study covariates.

RESULTS

We found that MRSI differentiated WM and deep GM by NAA/Cr on the individual level. On the population level, we found significant negative associations of WM NAA/Cr with chronic hyperglycemia quantified by hemoglobin A1c (P < .005) and a history of diabetic ketoacidosis at disease onset (P < .05). We found a statistical interaction (P < .05) between A1c and ketoacidosis, suggesting that neuroaxonal loss from ketoacidosis may outweigh that from poor glucose control. These associations were not present in deep GM.

CONCLUSIONS

Our pilot study suggests that MRSI differentiates GM and WM by NAA/Cr in this population, disease complications may lead to neuroaxonal loss in WM in children, and deeper investigation is warranted to further untangle how diabetic ketoacidosis and chronic hyperglycemia affect brain health and cognition in type 1 diabetes.

The Evaluation and Management of Pediatric Diabetic Ketoacidosis: A Comprehensive Review

Diabetic ketoacidosis (DKA) is a common, serious acute complication in children with diabetes mellitus (DM). DKA can accompany new-onset type 1 insulin-dependent DM, or it can occur with established type 1 DM, during the increased demands of an acute illness or with decreased insulin delivery due to omitted doses or insulin pump failure. In addition, DKA episodes in children with type 2 DM are being reported with greater frequency. Although the diagnosis is usually straightforward in a known diabetes patient with expected findings, a sizable proportion of patients with new-onset DM present with DKA. The purpose of this comprehensive review is to acquaint clinicians with details regarding the pathophysiology, treatment caveats, and potential complications of DKA.

Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most alarming concerns in the management of type 1 diabetes (T1D) in pediatric age. Prevalence of DKA at the onset of diabetes ranges from 30 to 40%. In selected cases of severe DKA, admission to pediatric intensive care unit (PICU) should be considered.

METHODS

This study aims to assess the prevalence of severe DKA treated in PICU in our 5-year monocentric experience. Secondary outcome of the study was to describe the main demographical and clinical features of individuals who required admission to PICU. All clinical data were collected by retrospectively reviewing the electronic medical records of children and adolescents with diabetes hospitalized in our University Hospital from January 2017 to December 2022.

RESULTS

During the study period, 103 children and adolescents were newly diagnosed with T1D. Among these, 51.5% presented clinical criteria for DKA and almost 10% needed to be treated in PICU. A higher rate of new T1D diagnoses was observed in 2021, as well as episodes of severe DKA being more frequent than in previous years. Due to severe clinical manifestations of DKA, 10 subjects (9.7%) with T1D onset needed to be treated in PICU. Of these, four children were younger than 5. The great majority came from a low household income and some of them had also immigrant background. The most common complication of DKA was acute kidney injury presented by four children. Other complications were cerebral edema, papilledema and acute esophageal necrosis. A 15-year-old girl had deep vein thrombosis (DVT) that evolved into multiple organ failure leading to death.

CONCLUSIONS

Our findings demonstrated that severe DKA is still quite common in children and adolescents at T1D onset, especially in some areas such as Southern Italy. Public awareness campaigns should be increasingly promoted to facilitate the recognition of early symptoms of diabetes and to reduce morbidity and mortality related to DKA.

Diabetes complications and cognitive function in young adults with youth-onset type 1 or type 2 diabetes: the SEARCH for Diabetes in Youth Study

Aims/hypotheses

People with type 1 (T1D) or type 2 diabetes (T2D) who also have diabetes complications can have pronounced cognitive deficits. It remains unknown, however, whether and how multiple diabetes complications co-occur with cognitive dysfunction, particularly in youth-onset diabetes.

Methods

Using data from the SEARCH for Diabetes in Youth study cohort, a prospective longitudinal cohort, we examined clustering of complications and their underlying clinical factors with performance on cognitive tests in young adults with youth-onset T1D or T2D. Cognition was assessed via the NIH Toolbox Cognition Battery. The main cognitive variables were age-corrected scores for composite fluid cognition and associated cognitive subdomains. Diabetes complications included retinopathy, microalbuminuria, and peripheral neuropathy (PN). Lipids, systolic blood pressure (SBP), hemoglobin A1c, and other clinical factors were included in the analyses. Clustering was applied separately to each group (T1D=646; T2D=165). A three-cluster(C) solution was identified for each diabetes type. Mean values and frequencies of all factors were compared between resulting clusters.

Results

The average age-corrected score for composite fluid cognition differed significantly across clusters for each group (p<0.001). People with T1D and the lowest average fluid cognition scores had the highest frequency of self-reporting at least one episode of hypoglycemia in the year preceding cognitive testing and the highest prevalence of PN. Persons with T2D and the lowest average fluid cognition scores had the highest SBP, the highest central systolic and diastolic blood pressures, and highest prevalence of PN.

Conclusions/interpretations

These findings highlight shared (PN) and unique factors (hypoglycemia in T1D; SBP in T2D) that could be targeted to potentially mitigate cognitive issues in young people with youth-onset diabetes.

Frequency, Clinical Characteristics and Predictors of Ketoacidosis at Diagnosis of Type One Diabetes Mellitus in Children and Adolescents from Jordan

OBJECTIVE

Data regarding diabetic ketoacidosis (DKA) at diagnosis of type one diabetes (T1D) in developing countries are scarce. The aim of this study was to describe the frequency of DKA at the onset of T1D in children and adolescents in Jordan and to compare the clinical and biochemical characteristics between the group that presented with DKA and the group that did not.

METHODS

The records of 341 children and adolescents, less than sixteen years of age, who were diagnosed with T1D between 2015 and 2019 were evaluated retrospectively.

RESULTS

Of all the children diagnosed with T1D, 108 (31.7%) presented with DKA. The majority had mild or moderate DKA (38% and 33.3% respectively). Higher paternal education levels were associated with a lower probability of presenting with DKA (p=0.043). A family history of T1D had a protective effect on the occurrence of DKA (Odds ratio=2.138; 95% confidence interval=1.167-3.917, p=0.014). Patients with celiac disease and higher HbA1c levels were more likely to experience recurrent episodes of DKA, (p=0.004 and 0.011, respectively).

CONCLUSION

In Jordan, the rate of DKA at presentation of T1D remains high. Prevention campaigns are needed to increase diabetes awareness among the public and healthcare providers.

Increased Use of Hyperosmolar Therapy for Suspected Clinically Apparent Brain Injury in Pediatric Patients with Diabetic Ketoacidosis during the Peak of the COVID-19 Pandemic

The incidence of pediatric diabetic ketoacidosis (DKA) increased during the peak of the COVID-19 pandemic. The objective of this study was to investigate whether rates of hyperosmolar therapy administration for suspected clinically apparent brain injury (CABI) complicating DKA also increased during this period as compared to the three years immediately preceding the pandemic and to compare the characteristics of patients with suspected CABI before the pandemic, patients with suspected CABI during the peak of the pandemic, and those with DKA but without suspected CABI during the pandemic. Patients aged ≤18 years presenting with DKA before (March 11, 2017-March 10, 2020) and during the peak of the pandemic (March 11, 2020-March 10, 2021) were identified through a rigorous search of two databases. Predefined criteria were used to diagnose suspected CABI. Biochemical, clinical, and sociodemographic data were collected from a comprehensive review of the electronic medical record. The proportion of patients with DKA who received hyperosmolar therapy was significantly higher (P = 0.014) during the pandemic compared to the prepandemic period; however, this was only significant among patients with newly diagnosed diabetes. Both groups with suspected CABI had more severe acidosis, lower Glasgow Coma Scale scores, and longer hospital admissions (P< 0.001 for all) than cases without suspected CABI. During the pandemic, the blood urea nitrogen concentration was significantly higher in patients with suspected CABI than those without suspected CABI, suggesting they were more severely dehydrated. The clinical, biochemical, and sociodemographic characteristics of patients with suspected CABI were indistinguishable before and during the pandemic. In conclusion, administration of hyperosmolar therapy for suspected CABI was more common during the peak of the COVID-19 pandemic, possibly a result of delayed presentation, highlighting the need for increased awareness and early recognition of the signs and symptoms of diabetes and DKA, especially during future surges of highly transmissible infections.

Nonketotic hyperglycemic hemichorea-hemiballismus in a pediatric patient: A case report

Nonketotic hyperglycemic hemichorea-hemiballismus (NHHH) is an infrequent complication of diabetes mellitus, and rarely occurs in children. We present an adolescent boy with recent diagnosis of type 1 diabetes who presented with hemichorea and brain imaging findings consistent with NHHH. His symptoms resolved with euglycemia and valproic acid after few weeks.

COGNITIVE FUNCTIONS IN CHILDREN WITH TYPE I DIABETES

OBJECTIVE

The aim: To assess the patterns and severity of cognitive impairment in children with type 1 diabetes as well as its association with disease onset and poor glycemic control.

PATIENTS AND METHODS

Materials and methods: We assessed higher mental function and screened for psychosocial functioning in 60 children with type 1 DM and 60 age-matched control using the Modified Mini-Mental State examination and Pediatric Symptoms Checklist and its relation with age, gender, socioeconomic status, age at the onset of disease, duration of disease, HbA1c level, frequency of diabetic ketoacidosis and hypoglycemic attacks and type of treatment.

RESULTS

Results: Diabetic patients demonstrated a lower Modified Mini-Mental State examination score than controls (25.12±4.58 versus 30.08±2.95) with a highly significant difference. Furthermore, the mean Pediatric symptoms checklist score in patients was 39.08±8.18 which was much lower than that of controls 54.42±6.0 with a highly significant difference.

CONCLUSION

Conclusions: There is neurocognitive impairment in diabetic children compared to non-diabetics, and poor glycemic control whether hyper or hypoglycemia could affect their cognition and mental health.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Epilepsia Partialis continua secondary to diabetic ketoacidosis

Epilepsia partialis continua is a rare epileptic syndrome presenting with simple, partial, repetitive motor seizures. It can be a result of structural central nervous system lesion or due to metabolic causes. We report a case of a 65-year-old male patient diagnosed with EPC secondary to diabetic ketoacidosis.

Diabetic Ketoacidosis at Onset of Type 1 Diabetes and Long-term HbA1c in 7,961 Children and Young Adults in the Australasian Diabetes Data Network

OBJECTIVE

The relationship between diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes and long-term glycemic control varies between studies. We aimed, firstly, to characterize the association of DKA and its severity with long-term HbA1c in a large contemporary cohort, and secondly, to identify other independent determinants of long-term HbA1c.

RESEARCH DESIGN AND METHODS

Participants were 7,961 children and young adults diagnosed with type 1 diabetes by age 30 years from 2000 to 2019 and followed prospectively in the Australasian Diabetes Data Network (ADDN) until 31 December 2020. Linear mixed-effect models related variables to HbA1c.

RESULTS

DKA at diagnosis was present in 2,647 participants (33.2%). Over a median 5.6 (interquartile range 3.2, 9.4) years of follow-up, participants with severe, but not moderate or mild, DKA at diagnosis had a higher mean HbA1c (+0.23%, 95% CI 0.11,0.28; [+2.5 mmol/mol, 95% CI 1.4,3.6]; P < 0.001) compared with those without DKA. Use of continuous subcutaneous insulin infusion (CSII) was independently associated with a lower HbA1c (-0.28%, 95% CI -0.31, -0.25; [-3.1 mmol/mol, 95% CI -3.4, -2.8]; P < 0.001) than multiple daily injections, and CSII use interacted with severe DKA to lower predicted HbA1c. Indigenous status was associated with higher HbA1c (+1.37%, 95% CI 1.15, 1.59; [+15.0 mmol/mol, 95% CI 12.6, 17.4]; P < 0.001), as was residing in postcodes of lower socioeconomic status (most vs. least disadvantaged quintile +0.43%, 95% CI 0.34, 0.52; [+4.7 mmol/mol, 95% CI 3.4, 5.6]; P < 0.001).

CONCLUSIONS

Severe, but not mild or moderate, DKA at diagnosis was associated with a marginally higher HbA1c over time, an effect that was modified by use of CSII. Indigenous status and lower socioeconomic status were independently associated with higher long-term HbA1c.

Effect of hematocrit, galactose and ascorbic acid on the blood glucose readings of three point-of-care glucometers

Glucometers are commonly used in a variety of healthcare settings and use in critically ill patients should not be assumed without appropriate tool validation. The study objective was to evaluate the accuracy of three point-of-care glucometers (POCGs) to assess glucose concentration in human blood sample. The POCGs tested included three different instruments and utilized three factors (hematocrit [Hct], galactose and ascorbic acid) in glucose measurements to determine the glucometers' accuracy and compared to the reference laboratory biochemical analyzer (Cobs 8000, Roche, Basal, Switzerland). In this study, the Nova StatStrip glucometer showed no significant variation compared to the laboratory method at high glucose level with various Hct%. ACCU-Chek Inform II overestimated the glucose results at Hct 22% and underestimated at Hct 62%. The Freestyle glucometer showed lower glucose levels compared to the Cobas 8000 at Hct 62%. The ACCU-Check showed significant increase of blood glucose with low Hct% levels when compared to the laboratory method. The Freestyle showed a decreased level of glucose with high Hct 62% interference compared to the Cobas 8000. Galactose interference 100 and 200 mg/dL dramatically affected the accuracy of ACCU-Chek Inform II. Nevertheless, among all three POCGs in this study, the Nova StatStrip showed the most reliable and stable results for glucose level in the presence of interference. Especially, those in critical care units, whereas the Freestyle Precision Pro and ACCU-Chek Inform II were insufficiently accurate for critically ill patients.

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.

Multi-Timepoint Metabolic Fingerprinting of a Post-Episode Period of Hypoglycemia and Ketoacidosis Among Children With Type 1 Diabetes

Background: Acute complications of type 1 diabetes mellitus such as diabetes ketoacidosis (DKA) and hypoglycemia (HG) are detrimental in a short- and long-term perspective. Restoration of normoglycemia and correction of pH do not mean that all metabolic disturbances caused by HG or DKA are immediately reversed.

Aim: This study aimed to identify serum metabolic changes caused by an episode of DKA and HG that may indicate the mechanisms contributing to long-term consequences of DKA/HG.

Materials and methods: Four groups of children with type 1 diabetes were recruited. The first two study groups included patients after an episode of DKA or HG, respectively. Additionally, two comparative groups were recruited—children with established type 1 diabetes (EDM) and patients with newly diagnosed diabetes without diabetes ketoacidosis (NDM). Serum samples were collected in three group-specific time points (since the hospital admission): HG 0h-12h–48h; DKA or NDM 0h-24h–72 h; and one random fasting sample from patients with EDM. Two batches of 100 samples each were created: for DKA batch 20 × 3 DKA patients, 10 × 3 NDM and 10 EDM; for HG batch: 10 × 3 HG patients, 25 EDM and 15 × 3 NDM. All patients within the batches were age and sex matched. Metabolic fingerprinting was performed with LC-QTOF-MS.

Results: Four metabolites were associated with a DKA episode occurring in the preceding 72 h: three were found higher after the DKA episode versus comparative groups: lysophosphatidylcholine (LPC) (18:1), sphingomyelins (SM) (34:0 and d18:0/15:0), and one was found lower: LPC (18:0). Similarly, four metabolites were identified for the HG episode in the last 48 h: three were found higher after the HG episode versus comparative groups: two lysophosphatidylethanolamines (LPE) (18:2 and 20:3) and one LPC (18:2); and one was found lower after the HG episode: oxy-phosphatidylocholine (PC O-34:4).

Conclusions: We found eight metabolites whose levels may be traced in the serum, indicating the DKA or HG episode for up to 72 h and 48 h, respectively. Acute complications of diabetes may cause persistent metabolic disturbances long after pH and glucose level normalization.

Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers

Objective

To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China.

Methods

Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria.

Results

The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy.

Conclusion

The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.

Comparison of the clinical characteristics and outcomes of pediatric patients with and without diabetic ketoacidosis at the time of type 1 diabetes diagnosis

PURPOSE

We investigated the possible effects of diabetic ketoacidosis (DKA) at the initial diagnosis of type 1 diabetes mellitus (T1DM) on the clinical outcomes of pediatric patients.

METHODS

Medical records of children and adolescents with newly diagnosed T1DM seen in the Ajou University Hospital from January 2008 to August 2020 were reviewed and analyzed.

RESULTS

Among 129 diagnosed T1DM patients, 40.3% presented with DKA. Although demographic and basic characteristics did not differ between DKA and non-DKA patients, DKA patients needed a significantly higher insulin dosage than non-DKA patients for 2 years after diagnosis. However, control of glycated hemoglobin was not different between the DKA and non-DKA groups during the observation period. In the biochemical analysis, C-peptide, insulin-like growth factor-1, and insulin-like growth factor binding protein 3, high-density lipoprotein cholesterol, free T4, and T3 values were lower, but thyroid-stimulating hormone, initial serum glucose, uric acid, total cholesterol, triglyceride, and low-density lipoprotein cholesterol values were higher in DKA patients than non-DKA patients at the diagnosis of T1DM; however, these differences were temporarily present and disappeared with insulin treatment. Other clinical outcomes, such as height, thyroid function, and urine microalbumin level, did not vary significantly between the DKA and non-DKA groups during 5 years of follow-up.

CONCLUSION

DKA at initial presentation reflects the severity of disease progression, and the deleterious effects of DKA seem to impact insulin secretion. Although no difference in long-term prognosis was found, early detection of T1DM should help to reduce DKA-related islet damage and the socioeconomic burden of T1DM.

The impact of type 1 diabetes mellitus in childhood on academic performance: A matched population-based cohort study

BACKGROUND AND OBJECTIVE

The impact of type 1 diabetes mellitus (T1D) on academic performance is inconclusive. This study aims to compare scholastic performance and high-school completion in young people hospitalized with T1D compared to matched peers not hospitalized with diabetes.

RESEARCH DESIGN

Retrospective case-comparison cohort study.

METHOD

A population-level matched case-comparison study of people aged ≤18 hospitalized with T1D during 2005-2018 in New South Wales, Australia using linked health-related and education records. The comparison cohort was matched on age, gender, and residential postcode. Generalized linear mixed modeling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with T1D compared to peers. Adjusted relative risks (ARR) were calculated.

RESULTS

Young females and males hospitalized with T1D did not have a higher risk of not achieving the NMS compared to peers for numeracy (ARR: 1.19; 95%CI 0.77-1.84 and ARR: 0.74; 95%CI 0.46-1.19) or reading (ARR: 0.98; 95%CI 0.63-1.50 and ARR: 0.85; 95%CI 0.58-1.24), respectively. Young T1D hospitalized females had a higher risk of not completing year 11 (ARR: 1.73; 95%CI 1.19-2.53) or 12 (ARR: 1.65; 95%CI 1.17-2.33) compared to peers, while hospitalized T1D males did not.

CONCLUSIONS

There was no difference in academic performance in youth hospitalized with T1D compared to peers. Improved glucose control and T1D management may explain the absence of school performance decrements in students with T1D. However, females hospitalized with T1D had a higher risk of not completing high school. Potential associations of this increased risk, with attention to T1D and psycho-social management, should be investigated.

Effects of TRAM-34 and minocycline on neuroinflammation caused by diabetic ketoacidosis in a rat model

INTRODUCTION

Diabetic ketoacidosis (DKA) causes acute and chronic neuroinflammation that may contribute to cognitive decline in patients with type 1 diabetes. We evaluated the effects of agents that reduce neuroinflammation (triarylmethane-34 (TRAM-34) and minocycline) during and after DKA in a rat model.

RESEARCH DESIGN AND METHODS

Juvenile rats with DKA were treated with insulin and saline, either alone or in combination with TRAM-34 (40 mg/kg intraperitoneally twice daily for 3 days, then daily for 4 days) or minocycline (45 mg/kg intraperitoneally daily for 7 days). We compared cytokine and chemokine concentrations in brain tissue lysates during DKA among the three treatment groups and in normal controls and diabetic controls (n=9-15/group). We also compared brain inflammatory mediator levels in these same groups in adult diabetic rats that were treated for DKA as juveniles.

RESULTS

Brain tissue concentrations of chemokine (C-C) motif ligand (CCL)3, CCL5 and interferon (IFNγ) were increased during acute DKA, as were brain cytokine composite scores. Both treatments reduced brain inflammatory mediator levels during acute DKA. TRAM-34 predominantly reduced chemokine concentrations (chemokine (C-X-C) motif ligand (CXCL-1), CCL5) whereas minocycline had broader effects, (reducing CXCL-1, tumor necrosis factor (TNFα), IFNγ, interleukin (IL) 2, IL-10 and IL-17A). Brain inflammatory mediator levels were elevated in adult rats that had DKA as juveniles, compared with adult diabetic rats without previous DKA, however, neither TRAM-34 nor minocycline treatment reduced these levels.

CONCLUSIONS

These data demonstrate that both TRAM-34 and minocycline reduce acute neuroinflammation during DKA, however, treatment with these agents for 1 week after DKA does not reduce long-term neuroinflammation.

Effects of the timing of the initiation of dietary intake on pediatric type 1 diabetes for diabetic ketoacidosis

Background

Precision treatment of pediatric diabetic ketoacidosis (DKA) has been the focus of research for decades. Whether the timing of the initiation of dietary intake contributes to DKA correction is ignored.

Methods

We conducted a retrospective study to investigate the effects of the timing of the initiation of dietary intake on DKA correction in Children’s Hospital of Nanjing Medical University, a tertiary children’s hospital, from June 2017 to December 2020. Individual basic characteristic and clinical information of all DKA cases (n = 183) were collected. Multiple linear regression, logistic regression model and random forest (RF) model were used to assess the effect of the timing of the initiation of dietary intake on DKA correction.

Results

The mean age of the children diagnosed with DKA was 6.95 (SD 3.82) years. The median DKA correction time and the timing of the initiation of dietary intake was 41.72 h and 3.13 h, respectively. There were 62.3% (n = 114) patients corrected DKA at the end of the 48-h rehydration therapy. For each hour delay in starting dietary intake, child’s DKA correction was prolonged by 0.5 (95% CI 1.05, 1.11, P < 0.001) hours and the adjusted odds of DKA over 48 h was increased by 8% (OR = 1.08, 95% CI: 1.05, 1.11, P < 0.001) after adjustment for potential confounders. The RF model based on the timing of the initiation of dietary intake and child’s weight and systolic pressure achieved the highest AUC of 0.789.

Conclusion

Pediatricians should pay attention to the effect of the timing of the initiation of dietary intake, a controllable factor, on DKA correction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03243-z.

Sodium-glucose cotransporter 2 inhibitors and neurological disorders: a scoping review

Background

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are a group of antidiabetic medications with a favourable cardiovascular, renal and overall safety profile. Given the limited treatment options available for neurological disorders, it is important to determine whether the pleiotropic effects of SGLT2i can be utilised in their prevention and management.

Methods

All articles published before 20 March 2021 were systematically searched in MEDLINE, EMBASE, Scopus, Web of Science, APA PsycINFO and ClinicalTrials.gov. Overall, 1395 titles were screened, ultimately resulting in 160 articles being included in the qualitative analysis. Screening and data extraction were conducted by two independent authors and studies were excluded if they were not an original research study.

Findings

Of the 160 studies, 134 addressed stroke, 19 cognitive impairment, 4 epilepsy and 4 movement disorders, encompassing a range from systematic reviews and randomised controlled trials to bioinformatic and animal studies. Most animal studies demonstrated significant improvements in behavioural and neurological deficits, which were reflected in beneficial changes in neurovascular units, synaptogenesis, neurotransmitter levels and target receptors' docking energies. The evidence from the minority clinical literature was conflicting and many studies did not reach statistical significance.

Interpretation

SGLT2i may exert neurological benefits through three mechanisms: reduction in cardiovascular risk factors, augmentation of ketogenesis and anti-inflammatory pathways. Most clinical studies were observational, meaning that a causal relationship could not be established, while randomised controlled trials were heterogeneous and powered to detect cardiovascular or renal outcomes. We suggest that a longitudinal study should be conducted and specifically powered to detect neurological outcomes.

Costs of Public Health Screening of Children for Presymptomatic Type 1 Diabetes in Bavaria, Germany

OBJECTIVE

We sought to evaluate costs associated with public health screening for presymptomatic type 1 diabetes in 90,632 children as part of the Fr1da study in Bavaria and in forecasts for standard care.

RESEARCH DESIGN AND METHODS

We report on resource use and direct costs for screening-related procedures in the Fr1da study coordination center and laboratory and in participating pediatric practices and local diabetes clinics. Data were obtained from Fr1da study documents, an online survey among pediatricians, and interviews and records of Fr1da staff members. Data were analyzed with tree models that mimic procedures during the screening process. Cost estimates are presented as they were observed in the Fr1da study and as they can be expected in standard care for various scenarios.

RESULTS

The costs per child screened in the Fr1da study were €28.17 (95% CI 19.96; 39.63) and the costs per child diagnosed with presymptomatic type 1 diabetes were €9,117 (6,460; 12,827). Assuming a prevalence of presymptomatic type 1 diabetes of 0.31%, as in the Fr1da study, the estimated costs in standard care in Germany would be €21.73 (16.76; 28.19) per screened child and €7,035 (5,426; 9,124) per diagnosed child. Of the projected screening costs, €12.25 would be the costs in the medical practice, €9.34 for coordination and laboratory, and €0.14 for local diabetes clinics.

CONCLUSIONS

This study provides information for the planning and implementation of screening tests for presymptomatic type 1 diabetes in the general public and for the analysis of the cost-effectiveness of targeted prevention strategies.

Diabetes ketoacidosis recovery in youth with newly diagnosed and established type 1 diabetes

BACKGROUND

The objective of this study was to describe the differences in metabolic parameters and in time to recovery from diabetes ketoacidosis (DKA), between children and adolescents with newly diagnosed diabetes compared with established type 1 diabetes (T1DM).

METHODS

This was a single-center, retrospective study. The cohort consists of 356 children and adolescents with T1DM who had DKA during 2008-2018. Data were obtained from the patients' medical files. Recovery of DKA was defined as the resolution of acidosis (pH >7.3 and bicarbonate >15 meq/L).

RESULTS

The mean time to recovery from DKA was significantly longer in patients with newly diagnosed diabetes than in those with established diabetes (13± versus 8.5± h) (p < 0.001). This difference was maintained in an analysis according to DKA severity: mild, moderate, and severe. pH at presentation did not differ between the groups, but bicarbonate at presentation was significantly lower in patients with newly diagnosed diabetes than in those with established diabetes, 9.9± versus 12± mmol/L (p < 0.001). Potassium and phosphorus levels were lower, and sodium and chloride levels were higher in patients with newly diagnosed diabetes than in those with established diabetes (p < 0.001).

CONCLUSIONS

DKA is associated with a shorter recovery time in patients with established diabetes compared to newly diagnosed diabetes. This may have implications on the treatment of people with established diabetes.

IMPACT

DKA is associated with a shorter recovery time in patients with established diabetes compared with newly diagnosed diabetes. Shorter recovery time in a patient with established diabetes compared with newly diagnosed diabetes was observed in any DKA severity. The time to recovery from DKA did not differ significantly between patients treated with an insulin pump and those treated with multiple daily injections. Triggers for DKA among patients with established diabetes were poor compliance with treatment, infection, pump dysfunction, and dehydration.

Cystic Encephalomalacia in a Young Woman After Cardiac Arrest Due to Diabetic Ketoacidosis and Thyroid Storm

Cystic encephalomalacia is commonly reported in neonates with prenatal or perinatal hypoxic events. It is rarely observed in adults. A 25-year-old woman with a history of type 1 diabetes mellitus and hyperthyroidism presented to the emergency department with diabetic ketoacidosis (DKA) and a thyroid storm. She sustained cardiac arrest due to ventricular fibrillation and subsequently developed hypoxic encephalopathy. Initial brain computed tomography showed no significant findings; however, follow-up magnetic resonance imaging three months later revealed cystic encephalomalacia in the bilateral parieto-occipital lobes. A Tc-99m ethyl cysteinate dimer (ECD) brain perfusion scan revealed extensive hypoperfusion in the bilateral frontal and parieto-occipital lobes. She showed severe cognitive impairment and marked spasticity in all her limbs. Although cystic encephalomalacia is mostly reported in neonates with hypoxic injury, it can be seen in adults with hypoxic encephalopathy, leading to a significant neurological deficit.

Different Prognostic Patterns in Epilepsies and Considerations About the Denotations of Atypical Patterns

Epilepsy is a dynamic and heterogeneous neurological disease, and in long-term studies on prognosis, classically 5 basic patterns (early remission, late remission, relapsing-remitting, worsening, and non-remitting) have been identified. The most frequent pattern was relapsing-remitting course, and factors such as the presence of genetic etiology, rare seizures at the beginning of epilepsy and the absence of psychiatric comorbid diseases were found to be related with this pattern as well as reaching 5 years of remission in the follow-ups. Anti-seizure drug resistance (ASD-R) and factors affecting the presence of this resistance (such as symptomatic etiology, abnormal electroencephalographic findings, having multiple seizure types together, status epilepticus and febrile seizure history) decrease the chance of remission, while idiopathic/genetic etiology, generalized epilepsy, and absence of comorbid diseases seem to be associated with achieving long-term remission. Apart from these basic course patterns, there are some patients with an "atypical prognosis" such as drug-resistant juvenile myoclonic epilepsy (JME), benign hippocampal sclerosis-related mesial temporal lobe epilepsy (HS-MTLE), and severe childhood epilepsy with centro-temporal spikes (CESTS), in which the pathophysiological mechanisms underlying these patterns have not been clarified despite the suggestions of various hypotheses. The presence of comorbid diseases such as hormonal factors (as in catamenial epilepsy), autoimmune processes, thyroid disorders and metabolic and psychiatric diseases may also cause an atypical prognostic pattern by affecting the course of the disease. In this review, our aim is to provide the clinician with an up-to-date and questioning perspective on the prognostic markers of epilepsy, by examining in detail some specific epilepsy syndromes that may show atypical prognosis as well as the general prognostic features of epilepsy.

Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis

Objectives

To study the clinical profile and risk factors of cerebral edema and acute kidney injury in children with diabetic ketoacidosis.

Design

Retrospective review of medical records.

Patients

Fifty consecutive patients (age <18 years) admitted to our pediatric intensive care unit with a diagnosis of diabetic ketoacidosis over 5 years.

Materials and methods

Retrospective analysis of medical records was done, and data including patients’ age, sex, presenting features, biochemical profile including blood glucose, osmolality, urea, creatinine, and venous blood gas, electrolytes were recorded at admission, at 12 and 24 hours. Treatment details including fluid administration, rate of fall of glucose, time to resolution of diabetic ketoacidosis were noted. Complications such as cerebral edema and acute kidney injury were recorded. Patients with and without cerebral edema and acute kidney injury were compared. Variables that were significant on univariate analysis were entered in a multiple logistic regression analysis to determine the independent predictors for cerebral edema and acute kidney injury. Odds ratio and 95% confidence interval were calculated using SPSS version 22.

Measurements and main results

Between November 2015 and 2020, 48 patients were admitted for a total of 50 episodes of diabetic ketoacidosis. Two patients had recurrent diabetic ketoacidosis. Median age was 9.5 years (range 1–17). Thirty-one patients (62%) had new-onset type I diabetes mellitus. Twenty-two patients (44%) presented with severe diabetic ketoacidosis. Cerebral edema and acute kidney injury were seen in 11 (22%) and 15 (30%) patients, respectively. On multiple logistic regression analysis, higher blood urea level, lower serum bicarbonate level, and higher corrected sodium levels at admission were identified to be variables independently associated with risk of cerebral edema.

Conclusions

Higher corrected sodium, higher urea level, and lower serum bicarbonate levels at admission are predictive of cerebral edema in patients presenting with diabetic ketoacidosis. The severity of dehydration and acidosis in DKA appears to be a common factor responsible for the development of dysfunction of both brain and kidney.

How to cite this article

Raghunathan V, Jevalikar G, Dhaliwal M, Singh D, Sethi SK, Kaur P, et al. Risk Factors for Cerebral Edema and Acute Kidney Injury in Children with Diabetic Ketoacidosis. Indian J Crit Care Med 2021;25(12):1446–1451.

Impact of glucose metabolism on the developing brain

Glucose is the most important substrate for proper brain functioning and development, with an increased glucose consumption in relation to the need of creating new brain structures and connections. Therefore, alterations in glucose homeostasis will inevitably be associated with changes in the development of the Nervous System. Several studies demonstrated how the alteration of glucose homeostasis - both hyper and hypoglycemia- may interfere with the development of brain structures and cognitivity, including deficits in intelligence quotient, anomalies in learning and memory, as well as differences in the executive functions. Importantly, differences in brain structure and functionality were found after a single episode of diabetic ketoacidosis suggesting the importance of glycemic control and stressing the need of screening programs for type 1 diabetes to protect children from this dramatic condition. The exciting progresses of the neuroimaging techniques such as diffusion tensor imaging, has helped to improve the understanding of the effects, outcomes and mechanisms underlying brain changes following dysglycemia, and will lead to more insights on the physio-pathological mechanisms and related neurological consequences about hyper and hypoglycemia.

Alarming Increase of Ketoacidosis Prevalence at Type 1 Diabetes-Onset in Austria-Results From a Nationwide Registry

OBJECTIVE

We analyzed the annual prevalence of onset-DKA (diabetic ketoacidosis) from 2012 to 2020 with a sub-analysis for lockdown-periods during the COVID-19 pandemic in 2020.

DESIGN

All newly diagnosed children with type 1 diabetes (T1D) aged <15 years are prospectively registered in the population-based Austrian Diabetes Incidence Study in Austria.

MAIN OUTCOME MEASURES

The annual DKA prevalence was analyzed using Joinpoint regression. Definition of DKA: pH <7.3, mild DKA: pH 7.3 to ≤ 7.1, severe DKA: pH <7.1. DKA prevalence during the lockdown periods in 2020 and the corresponding periods in 2015-2019 were examined using Fisher's exact test.

RESULTS

In the years 2012-2020 the mean prevalence for onset-DKA in Austria was 43.6% [95%CI (confidence interval): 41.6, 45.7] and thus above the mean prevalence of previous decades (1989-2011) of 37,1 % (95%CI: 35.6, 38.6). A particularly high prevalence was found among children <2 years of age (72.0% DKA, 32.8% severe DKA). No significant gender difference was found. Prevalence of severe DKA at T1D-onset increased significantly since 2015 (p = 0.023). During the lockdown in 2020, 59.3% of children were diagnosed with DKA at T1D-onset, compared to 42.1% during the previous 5 years (p = 0.022). Moreover, 20% of children had severe DKA at T1D diagnosis, compared to 14% during the comparison period.

CONCLUSIONS

The previously already high prevalence of DKA at T1D-onset has further increased over time. The COVID-19 pandemic has exacerbated the problem of a late or delayed diagnosis of diabetes in children resulting in onset-DKA. The alarmingly increased prevalence of DKA in Austrian children with T1D calls for urgent action.

Multimodal neuroimaging in pediatric type 1 diabetes: a pilot multisite feasibility study of acquisition quality, motion, and variability

Type 1 diabetes (T1D) affects over 200,000 children and is associated with an increased risk of cognitive dysfunction. Prior imaging studies suggest the neurological changes underlying this risk are multifactorial, including macrostructural, microstructural, and inflammatory changes. However, these studies have yet to be integrated, limiting investigation into how these phenomena interact. To better understand these complex mechanisms of brain injury, a well-powered, prospective, multisite, and multimodal neuroimaging study is needed. We take the first step in accomplishing this with a preliminary characterization of multisite, multimodal MRI quality, motion, and variability in pediatric T1D. We acquire structural T1 weighted (T1w) MRI, diffusion tensor MRI (DTI), functional MRI (fMRI), and magnetic resonance spectroscopy (MRS) of 5-7 participants from each of two sites. First, we assess the contrast-to-noise ratio of the T1w MRI and find no differences between sites. Second, we characterize intervolume motion in DTI and fMRI and find it to be on the subvoxel level. Third, we investigate variability in regional gray matter volumes and local gyrification indices, bundle-wise DTI microstructural measures, and N-acetylaspartate to creatine ratios. We find the T1-based measures to be comparable between sites before harmonization and the DTI and MRS-based measures to be comparable after. We find a 5-15% coefficient of variation for most measures, suggesting ~150-200 participants per group on average are needed to detect a 5% difference across these modalities at 0.9 power. We conclude that multisite, multimodal neuroimaging of pediatric T1D is feasible with low motion artifact after harmonization of DTI and MRS.

14. Children and Adolescents: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The underlying mechanisms for severe COVID-19 progression in people with diabetes mellitus: a critical review

Diabetes mellitus (DM) has a high incidence of comorbidities among patients with severe coronavirus disease 2019 (COVID-19). The elevated prevalence of DM in the world population makes it a significant risk factor because diabetic individuals appear to be prone to clinical complications and have increased mortality rates. Here, we review the possible underlying mechanisms involved in DM that led to worse outcomes in COVID-19. The impacts of hyperglycemia side effects, secondary comorbidities, weakened innate and adaptive immunity, chronic inflammation, and poor nutritional status, commonly present in DM, are discussed. The role of the SARS-CoV-2 receptor and its polymorphic variations on higher binding affinity to facilitate viral uptake in people with DM were also considered. Clinical differences between individuals with type 1 DM and type 2 DM affected by COVID-19 and the potential diabetogenic effect of SARS-CoV-2 infection were addressed.

Is diabetic ketoacidosis a good predictor of 5-year metabolic control in children with newly diagnosed type 1 diabetes?

BACKGROUND

The study aimed to evaluate whether the presence of DKA at diabetes diagnosis was associated with poorer metabolic control during a 5-year follow-up.

METHODS

The study included children treated due to newly diagnosed T1D complicated with DKA between 2010 and 2014 with a complete 5-year follow-up. In every case we performed individual matching for age, gender and BMI with a person without DKA (nDKA) on recognition. We collected data regarding treatment modality, HbA_1C, total daily insulin dose, basal insulin and BMI-SDS.

RESULTS

85 children at the median age of 7.93 years had DKA at diabetes diagnosis. The median pH was 7.19.Continuous subcutaneous insulin infusion (CSII) was used in 87% of participants in each group. No differences in HbA_1C level (7,3%vs7,2%;p = .413) were noted after 5 years of disease duration. The severity of ketoacidosis exerted no significant effect on HbA_1C. The method of insulin delivery at baseline was significantly associated with HbA_1C levels after 5 years of observation, β_CSII = - 1.46,95%CI[- 2.01 to - 0.92],p < .001.

CONCLUSIONS

The presence of DKA at diabetes diagnosis is not associated with deteriorated long-term metabolic control in children using modern technologies. The early implementation of CSII into diabetes treatment may change the effect of DKA and lead to a long-term HbA_1C improvement.

Delayed referral is common even when new-onset diabetes is suspected in children. A Swedish prospective observational study of diabetic ketoacidosis at onset of Type 1 diabetes

OBJECTIVE

Delayed treatment for new-onset diabetes Type 1 (T1D) can lead to diabetic ketoacidosis (DKA) with potentially devastating consequences. This prospective observational study aimed to characterize pediatric patients with DKA at hospital admission, regarding parental awareness of diabetes-related symptoms and delayed referrals from primary health care providers to pediatric emergency wards.

RESEARCH DESIGN AND METHODS

Patients 0-18 years admitted to hospital with new-onset T1D and DKA between 2015 and 2017 were invited to participate. Questionnaires were filled out separately by the caregivers and by the attending hospital staff. Data from the Swedish National Diabetes Registry (SWEDIABKIDS) were used for comparison. Delayed referral was defined as a primary healthcare contact due to diabetes-related symptoms 0-4 weeks before hospital admission without immediate referral, or registered elevated glucose levels at primary healthcare centers without immediate referral.

RESULTS

The study included 237 patients, among which parental suspicion of new-onset diabetes before healthcare contacts was reported in 39%. Parental suspicion of diabetes was associated with higher pH values at diagnosis. Patients in contact with primary health care providers before hospital admission had a delayed referral in 43% of the cases. Delayed referral was associated with lower pH values at hospital admission. Symptoms leading to primary healthcare contacts were similar regardless of whether delay occurred or not.

CONCLUSIONS

Parental suspicion of diabetes was associated with milder DKA at hospital admission. Delayed referral was seen in a considerable proportion of children with primary healthcare contacts for symptoms associated with diabetes. Increased awareness of diabetes symptoms is of paramount importance.

Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis

OBJECTIVE

Fluid replacement to correct dehydration, acidosis, and electrolyte abnormalities is the cornerstone of treatment for diabetic ketoacidosis (DKA), but little is known about optimal fluid infusion rates and electrolyte content. The objective of this study was to evaluate whether different fluid protocols affect the rate of normalization of biochemical derangements during DKA treatment.

RESEARCH DESIGN AND METHODS

The current analysis involved moderate or severe DKA episodes (n = 714) in children age <18 years enrolled in the Fluid Therapies Under Investigation in DKA (FLUID) Trial. Children were assigned to one of four treatment groups using a 2 × 2 factorial design (0.90% or 0.45% saline and fast or slow rate of administration).

RESULTS

The rate of change of pH did not differ by treatment arm, but Pco₂ increased more rapidly in the fast versus slow fluid infusion arms during the initial 4 h of treatment. The anion gap also decreased more rapidly in the fast versus slow infusion arms during the initial 4 and 8 h. Glucose-corrected sodium levels remained stable in patients assigned to 0.90% saline but decreased in those assigned to 0.45% saline at 4 and 8 h. Potassium levels decreased, while chloride levels increased more rapidly with 0.90% versus 0.45% saline. Hyperchloremic acidosis occurred more frequently in patients in the fast arms (46.1%) versus the slow arms (35.2%).

CONCLUSIONS

In children treated for DKA, faster fluid administration rates led to a more rapid normalization of anion gap and Pco₂ than slower fluid infusion rates but were associated with an increased frequency of hyperchloremic acidosis.

Association of Type 1 Diabetes and Hypoglycemic and Hyperglycemic Events and Risk of Dementia

OBJECTIVE

To determine whether severe hypoglycemic and hyperglycemic events are associated with longitudinal dementia risk in older adults with type 1 diabetes.

METHODS

A longitudinal cohort study followed up 2,821 members of an integrated health care delivery system with type 1 diabetes from 1997 to 2015. Hypoglycemic and hyperglycemic events requiring emergency room or hospitalization were abstracted from medical records beginning January 1, 1996, through cohort entry. Participants were followed up for dementia diagnosis through September 30, 2015. Dementia risk was examined with Cox proportional hazard models adjusted for age (as time scale), sex, race/ethnicity, hemoglobin A1c, depression, stroke, and nephropathy.

RESULTS

Among 2,821 older adults (mean age 56 years) with type 1 diabetes, 398 (14%) had a history of severe hypoglycemia, 335 (12%) had severe hyperglycemia, and 87 (3%) had both. Over a mean 6.9 years of follow-up, 153 individuals (5.4%) developed dementia. In fully adjusted models, individuals with hypoglycemic events had 66% greater risk of dementia than those without a hypoglycemic event (hazard ratio [HR] 1.66, 95% confidence interval [CI] 1.09, 2.53), while those with hyperglycemic events had >2 times the risk (HR 2.11, 95% CI 1.24, 3.59) than those without a hyperglycemic event. There was a 6-fold greater risk of dementia in individuals with both severe hypoglycemia and hyperglycemia vs those with neither (HR 6.20, 95% CI 3.02, 12.70).

CONCLUSIONS

For older individuals with type 1 diabetes, severe hypoglycemic and hyperglycemic events are associated with increased future risk of dementia.