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Sooy MGQ, Pyle L, Alonso GT, Broncucia HC, Rewers A, Gottlieb PA, Simmons KMW, Rewers MJ, Steck AK. Lower Prevalence of Diabetic Ketoacidosis at Diagnosis in Research Participants Monitored for Hyperglycemia. J Clin Endocrinol Metab 2024:dgae158. [PMID: 38470864 DOI: 10.1210/clinem/dgae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 03/14/2024]
Abstract
CONTEXT In Colorado children, the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) has been increasing over time. OBJECTIVE Evaluate the prevalence of and factors involved in DKA at T1D diagnosis among participants followed in monitoring research studies before diagnosis compared to patients from the community. SETTING AND PARTICIPANTS Patients < 18 years diagnosed with T1D between 2005 and 2021 at the Barbara Davis Center for Diabetes. OUTCOME Prevalence of and factors associated with DKA at diagnosis among participants in preclinical monitoring studies compared to those diagnosed in the community. RESULTS Of 5049 subjects, 164 were active study participants, 42 inactive study participants, and 4843 were community patients. Active study participants, compared to community patients, had lower HbA1c (7.3% vs 11.9%]; P < 0.001) and less frequently experienced DKA (4.9% vs 48.5%; P < 0.001), including severe DKA (1.2% vs 16.2%; P < 0.001). Inactive study participants had intermediate levels for both prevalence and severity of DKA. DKA prevalence increased in community patients, from 44.0% to 55%, with less evidence for a temporal trend in study participants. DKA prevalence was highest in children <2 years (13% in active study participants vs 83% in community patients). In community patients, younger age (P = 0.0038), public insurance (P < 0.0001), rural residence (P < 0.0076), higher HbA1c (P < 0.0001), and ethnicity minority status (P < 0.0001) were associated with DKA at diagnosis. CONCLUSIONS While DKA prevalence increases in community patients over time, it stayed <5% in active research participants, who have a 10 times lower prevalence of DKA at diagnosis, including in minorities.
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Affiliation(s)
- Morgan G Q Sooy
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - G Todd Alonso
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hali C Broncucia
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimber M W Simmons
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marian J Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
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2
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Brown KM, Glaser NS, McManemy JK, DePiero A, Nigrovic LE, Quayle KS, Stoner MJ, Schunk JE, Trainor JL, Tzimenatos L, Rewers A, Myers SR, Kwok MY, Ghetti S, Casper TC, Olsen CS, Kuppermann N. Rehydration Rates and Outcomes in Overweight Children With Diabetic Ketoacidosis. Pediatrics 2023; 152:e2023062004. [PMID: 37920947 PMCID: PMC10657773 DOI: 10.1542/peds.2023-062004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis (DKA) (FLUID) Trial found that rapid fluid infusion does not increase the risk of cerebral injury. Concern persists, however, whether fluid rates should be adjusted for overweight or obese patients. We used the FLUID Trial database to evaluate associations between fluid infusion rate and outcomes in these patients. METHODS We compared children and youth who were overweight, obese, or normal weight, in regard to protocol adherence, mental status changes, time to DKA resolution, and electrolyte abnormalities. We investigated associations between outcomes and the amount of fluid received in these groups. RESULTS Obese children and youth were more likely to receive fluids at rates slower than dictated by protocol. Overweight and obese children and youth in the fast fluid arms, who received fluids per the study protocol based on their measured weight, had similar rates of mental status changes or clinically apparent cerebral injury as those with normal weights. Risk of hypophosphatemia was increased in those receiving larger initial bolus volumes and reduced in those receiving higher rehydration rates. No other metabolic outcomes were associated with rehydration. CONCLUSIONS Protocol adherence data in the FLUID Trial suggest that physicians are uncomfortable using weight-based fluid calculations for overweight or obese children. However, higher rates of fluid infusion were not associated with increased risk of mental status changes or cerebral injury, suggesting that physicians should not limit fluid resuscitation in obese children and youth with DKA.
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Affiliation(s)
- Kathleen M. Brown
- Division of Emergency Medicine, Department of Pediatrics, Children’s National Medical Center, the George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | | | - Julie K. McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Andrew DePiero
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Kimberly S. Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children’s Hospital, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Michael J. Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University School of Medicine, Columbus, Ohio
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Leah Tzimenatos
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, the Colorado Children’s Hospital, University of Colorado-Denver School of Medicine, Aurora, Colorado
| | - Sage R. Myers
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Maria Y. Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children’s Hospital, Columbia University College of Physicians and Surgeons, New York, New York
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Kuppermann
- Departments of Pediatrics
- Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, California
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3
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Trainor JL, Glaser NS, Tzimenatos L, Stoner MJ, Brown KM, McManemy JK, Schunk JE, Quayle KS, Nigrovic LE, Rewers A, Myers SR, Bennett JE, Kwok MY, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Clinical and Laboratory Predictors of Dehydration Severity in Children With Diabetic Ketoacidosis. Ann Emerg Med 2023; 82:167-178. [PMID: 37024382 PMCID: PMC10523885 DOI: 10.1016/j.annemergmed.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 04/08/2023]
Abstract
STUDY OBJECTIVE Our primary objective was to characterize the degree of dehydration in children with diabetic ketoacidosis (DKA) and identify physical examination and biochemical factors associated with dehydration severity. Secondary objectives included describing relationships between dehydration severity and other clinical outcomes. METHODS In this cohort study, we analyzed data from 753 children with 811 episodes of DKA in the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation Study, a randomized clinical trial of fluid resuscitation protocols for children with DKA. We used multivariable regression analyses to identify physical examination and biochemical factors associated with dehydration severity, and we described associations between dehydration severity and DKA outcomes. RESULTS Mean dehydration was 5.7% (SD 3.6%). Mild (0 to <5%), moderate (5 to <10%), and severe (≥10%) dehydration were observed in 47% (N=379), 42% (N=343), and 11% (N=89) of episodes, respectively. In multivariable analyses, more severe dehydration was associated with new onset of diabetes, higher blood urea nitrogen, lower pH, higher anion gap, and diastolic hypertension. However, there was substantial overlap in these variables between dehydration groups. The mean length of hospital stay was longer for patients with moderate and severe dehydration, both in new onset and established diabetes. CONCLUSION Most children with DKA have mild-to-moderate dehydration. Although biochemical measures were more closely associated with the severity of dehydration than clinical assessments, neither were sufficiently predictive to inform rehydration practice.
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Affiliation(s)
- Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Julie K McManemy
- Division of Emergency Medicine; Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, CO
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, (UT)
| | - Simona Ghetti
- Department of Psychology, and the Center for Mind and Brain, University of California Davis, Davis, CA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA; Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento, CA
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4
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Cai LY, Tanase C, Anderson AW, Patel NJ, Lee CA, Jones RS, LeStourgeon LM, Mahon A, Taki I, Juvera J, Pruthi S, Gwal K, Ozturk A, Kang H, Rewers A, Rewers MJ, Alonso GT, Glaser N, Ghetti S, Jaser SS, Landman BA, Jordan LC. Exploratory Multisite MR Spectroscopic Imaging Shows White Matter Neuroaxonal Loss Associated with Complications of Type 1 Diabetes in Children. AJNR Am J Neuroradiol 2023; 44:820-827. [PMID: 37263786 PMCID: PMC10337627 DOI: 10.3174/ajnr.a7895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 05/03/2023] [Indexed: 06/03/2023]
Abstract
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.
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Affiliation(s)
- L Y Cai
- From the Department of Biomedical Engineering (L.Y.C., A.W.A., B.A.L.)
| | - C Tanase
- Departments of Psychiatry and Behavioral Sciences (C.T.)
| | - A W Anderson
- From the Department of Biomedical Engineering (L.Y.C., A.W.A., B.A.L.)
- Vanderbilt University Institute of Imaging Science (A.W.A., B.A.L.)
- Departments of Radiology and Radiological Sciences (A.W.A., S.P., B.A.L.)
| | - N J Patel
- Pediatrics (N.J.P., R.S.J., S.S.J., L.C.J.)
| | | | - R S Jones
- Pediatrics (N.J.P., R.S.J., S.S.J., L.C.J.)
| | | | - A Mahon
- Psychology (A.M., S.G.), University of California, Davis, Davis, California
| | - I Taki
- Department of Pediatrics (I.T., A.R., M.J.R.)
| | - J Juvera
- Department of Psychiatry (J.J.), University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - S Pruthi
- Departments of Radiology and Radiological Sciences (A.W.A., S.P., B.A.L.)
| | - K Gwal
- Departments of Radiology (K.G., A.O.)
| | - A Ozturk
- Departments of Radiology (K.G., A.O.)
| | - H Kang
- Biostatistics (H.K.), Vanderbilt University Medical Center, Nashville, Tennessee
| | - A Rewers
- Department of Pediatrics (I.T., A.R., M.J.R.)
| | - M J Rewers
- Department of Pediatrics (I.T., A.R., M.J.R.)
| | | | - N Glaser
- Pediatrics (N.G.), University of California Davis Health, University of California Davis School of Medicine, Sacramento, California
| | - S Ghetti
- Psychology (A.M., S.G.), University of California, Davis, Davis, California
| | - S S Jaser
- Pediatrics (N.J.P., R.S.J., S.S.J., L.C.J.)
| | - B A Landman
- From the Department of Biomedical Engineering (L.Y.C., A.W.A., B.A.L.)
- Vanderbilt University Institute of Imaging Science (A.W.A., B.A.L.)
- Department of Electrical and Computer Engineering (B.A.L.), Vanderbilt University, Nashville, Tennessee
- Departments of Radiology and Radiological Sciences (A.W.A., S.P., B.A.L.)
| | - L C Jordan
- Pediatrics (N.J.P., R.S.J., S.S.J., L.C.J.)
- Neurology (C.A.L., L.C.J.)
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5
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Glaser NS, Stoner MJ, Kwok MY, Quayle KS, Brown KM, Schunk JE, Trainor JL, McManemy JK, Tzimenatos L, Rewers A, Nigrovic LE, Bennett JE, Myers SR, Smith M, Casper TC, Kuppermann N. Relationships among biochemical measures in children with diabetic ketoacidosis. J Pediatr Endocrinol Metab 2023; 36:313-318. [PMID: 36637392 PMCID: PMC9986464 DOI: 10.1515/jpem-2022-0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/14/2022] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Investigating empirical relationships among laboratory measures in children with diabetic ketoacidosis (DKA) can provide insights into physiological alterations occurring during DKA. We determined whether alterations in laboratory measures during DKA conform to theoretical predictions. METHODS We used Pearson correlation statistics and linear regression to investigate correlations between blood glucose, electrolytes, pH and PCO2 at emergency department presentation in 1,681 pediatric DKA episodes. Among children with repeat DKA episodes, we also assessed correlations between laboratory measures at the first vs. second episode. RESULTS pH and bicarbonate levels were strongly correlated (r=0.64), however, pH and PCO2 were only loosely correlated (r=0.17). Glucose levels were correlated with indicators of dehydration and kidney function (blood urea nitrogen (BUN), r=0.44; creatinine, r=0.42; glucose-corrected sodium, r=0.32). Among children with repeat DKA episodes, PCO2 levels tended to be similar at the first vs. second episode (r=0.34), although pH levels were only loosely correlated (r=0.19). CONCLUSIONS Elevated glucose levels at DKA presentation largely reflect alterations in glomerular filtration rate. pH and PCO2 are weakly correlated suggesting that respiratory responses to acidosis vary among individuals and may be influenced by pulmonary and central nervous system effects of DKA.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, USA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, USA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, Saint Louis, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington DC, USA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Denver, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, USA
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, USA
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - McKenna Smith
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, USA
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis Health, University of California Davis, School of Medicine, Sacramento, USA.,Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Sacramento, USA
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6
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Ghetti S, Kuppermann N, Rewers A, Myers SR, Schunk JE, Stoner MJ, Garro A, Quayle KS, Brown KM, Trainor JL, Tzimenatos L, DePiero AD, McManemy JK, Nigrovic LE, Kwok MY, Olsen CS, Casper TC, Glaser NS. Cognitive function following diabetic ketoacidosis in young children with type 1 diabetes. Endocrinol Diabetes Metab 2023; 6:e412. [PMID: 36788736 PMCID: PMC10164422 DOI: 10.1002/edm2.412] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/14/2023] [Accepted: 01/28/2023] [Indexed: 02/16/2023] Open
Abstract
INTRODUCTION Young children with type 1 diabetes (T1D) may be at particularly high risk of cognitive decline following diabetic ketoacidosis (DKA). However, studies of cognitive functioning in T1D typically examine school-age children. The goal of this study was to examine whether a single experience of DKA is associated with lower cognitive functioning in young children. We found that recently diagnosed 3- to 5-year-olds who experienced one DKA episode, regardless of its severity, exhibited lower IQ scores than those with no DKA exposure. METHODS We prospectively enrolled 46 3- to 5-year-old children, who presented with DKA at the onset of T1D, in a randomized multi-site clinical trial evaluating intravenous fluid protocols for DKA treatment. DKA was moderate/severe in 22 children and mild in 24 children. Neurocognitive function was assessed once 2-6 months after the DKA episode. A comparison group of 27 children with T1D, but no DKA exposure, was also assessed. Patient groups were matched for age and T1D duration at the time of neurocognitive testing. RESULTS Children who experienced DKA, regardless of its severity, exhibited significantly lower IQ scores than children who did not experience DKA, F(2, 70) = 6.26, p = .003, partial η2 = .15. This effect persisted after accounting for socioeconomic status and ethnicity. CONCLUSIONS A single DKA episode is associated with lower IQ scores soon after exposure to DKA in young children.
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Affiliation(s)
- Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California, USA.,Center for Mind and Brain, University of California, Davis, Davis, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA.,Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, Colorado, USA
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, Ohio, USA
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
| | - Andrew D DePiero
- Division of Emergency Medicine, Nemours/A.I. DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York City, New York, USA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis, School of Medicine, Davis, California, USA
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7
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Birkebaek NH, Kamrath C, Grimsmann JM, Aakesson K, Cherubini V, Dovc K, de Beaufort C, Alonso GT, Gregory JW, White M, Skrivarhaug T, Sumnik Z, Jefferies C, Hörtenhuber T, Haynes A, De Bock M, Svensson J, Warner JT, Gani O, Gesuita R, Schiaffini R, Hanas R, Rewers A, Eckert AJ, Holl RW, Cinek O. Impact of the COVID-19 pandemic on long-term trends in the prevalence of diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes: an international multicentre study based on data from 13 national diabetes registries. Lancet Diabetes Endocrinol 2022; 10:786-794. [PMID: 36202118 PMCID: PMC9597608 DOI: 10.1016/s2213-8587(22)00246-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/10/2022] [Accepted: 08/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND An increased prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes in children was observed in various diabetes centres worldwide during the COVID-19 pandemic. We aimed to evaluate trends in the prevalence of diabetic ketoacidosis at diagnosis of paediatric type 1 diabetes before and during the COVID-19 pandemic, and to identify potential predictors of changes in diabetic ketoacidosis prevalence during the pandemic. METHODS For this international multicentre study, we used data from 13 national diabetes registries (Australia, Austria, Czechia, Denmark, Germany, Italy, Luxembourg, New Zealand, Norway, Slovenia, Sweden, USA [Colorado], and Wales). The study population comprised 104 290 children and adolescents aged 6 months to younger than 18 years, who were diagnosed with type 1 diabetes between Jan 1, 2006, and Dec 31, 2021. The observed diabetic ketoacidosis prevalence in 2020 and 2021 was compared to predictions based on trends over the pre-pandemic years 2006-19. Associations between changes in diabetic ketoacidosis prevalence and the severity of the COVID-19 pandemic and containment measures were examined with excess all-cause mortality in the whole population and the Stringency Index from the Oxford COVID-19 Government Response Tracker. FINDINGS 87 228 children and adolescents were diagnosed with type 1 diabetes between 2006 and 2019, 8209 were diagnosed in 2020, and 8853 were diagnosed in 2021. From 2006 to 2019, diabetic ketoacidosis at diagnosis of type 1 diabetes was present in 23 775 (27·3%) of 87 228 individuals and the mean annual increase in the prevalence of diabetic ketoacidosis in the total cohort from 2006 to 2019 was 1·6% (95% CI 1·3 to 1·9). The adjusted observed prevalence of diabetic ketoacidosis at diagnosis of type 1 diabetes was 39·4% (95% CI 34·0 to 45·6) in 2020 and 38·9% (33·6 to 45·0) in 2021, significantly higher than the predicted prevalence of 32·5% (27·8 to 37·9) for 2020 and 33·0% (28·3 to 38·5) for 2021 (p<0·0001 for both years). The prevalence of diabetic ketoacidosis was associated with the pandemic containment measures, with an estimated risk ratio of 1·037 (95% CI 1·024 to 1·051; p<0·0001) per ten-unit increase in the Stringency Index for 2020 and 1·028 (1·009 to 1·047; p=0·0033) for 2021, but was not significantly associated with excess all-cause mortality. INTERPRETATION During the COVID-19 pandemic, there was a marked exacerbation of the pre-existing increase in diabetic ketoacidosis prevalence at diagnosis of type 1 diabetes in children. This finding highlights the need for early and timely diagnosis of type 1 diabetes in children and adolescents. FUNDING German Federal Ministry for Education and Research, German Robert Koch Institute, German Diabetes Association, German Diabetes Foundation, Slovenian Research Agency, Welsh Government, Central Denmark Region, and Swedish Association of Local Authorities and Regions.
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Affiliation(s)
- Niels H Birkebaek
- Department of Pediatrics and Adolescent Medicine and Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark.
| | - Clemens Kamrath
- Division of Pediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University, Giessen, Germany
| | - Julia M Grimsmann
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany; German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Karin Aakesson
- Department of Paediatrics, County Hospital Ryhov, Jönköping, Sweden; Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | | | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC Ljubljana, University Children's Hospital, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Carine de Beaufort
- Department of Pediatric Diabetes and Endocrinology, Centre Hospitalier Luxembourg, Luxembourg
| | - Guy T Alonso
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - John W Gregory
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, UK
| | - Mary White
- Department of Endocrinology and Diabetes, and Health Services Research Unit, The Royal Children's Hospital, Parkville, Melbourne, VIC, Australia; Diabetes Research, Murdoch Children's Research Institute, Parkville, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Torild Skrivarhaug
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Zdenek Sumnik
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague, Prague, Czechia; University Hospital Motol, Prague, Czechia
| | - Craig Jefferies
- Starship Children's Health and University of Auckland, Auckland, New Zealand
| | - Thomas Hörtenhuber
- Department of Pediatrics and Adolescent Medicine, Kepler University Clinic, Linz, Austria
| | - Aveni Haynes
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Martin De Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Jannet Svensson
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Justin T Warner
- Department of Paediatric Endocrinology and Diabetes, Children's Hospital for Wales, Cardiff, UK
| | - Osman Gani
- Division of Paediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Rosaria Gesuita
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | | | - Ragnar Hanas
- NU Hospital Group, Uddevalla, Trollhättan, Sweden; Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Arleta Rewers
- Denver Scool of Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Alexander J Eckert
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany; German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany; German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Ondrej Cinek
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague, Prague, Czechia; University Hospital Motol, Prague, Czechia
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Glaser N, Fritsch M, Priyambada L, Rewers A, Cherubini V, Estrada S, Wolfsdorf JI, Codner E. ISPAD clinical practice consensus guidelines 2022: Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes 2022; 23:835-856. [PMID: 36250645 DOI: 10.1111/pedi.13406] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/01/2023] Open
Affiliation(s)
- Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California, USA
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Division of General Pediatrics, Medical University of Graz, Austria Medical University of Graz, Graz, Austria
| | - Leena Priyambada
- Division of Pediatric Endocrinology, Rainbow Children's Hospital, Hyderabad, India
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado, USA
| | - Valentino Cherubini
- Department of Women's and Children's Health, G. Salesi Hospital, Ancona, Italy
| | - Sylvia Estrada
- Department of Pediatrics, Division of Endocrinology and Metabolism, University of the Philippines, College of Medicine, Manila, Philippines
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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9
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Glaser NS, Quayle KS, McManemy JK, Nigrovic LE, Tzimenatos L, Stoner MJ, Bennett JE, Trainor JL, Rewers A, Schunk JE, Myers SR, Kwok MY, Brown KM, Ghetti S, Casper TC, Olsen CS, Kuppermann N. Clinical Characteristics of Children with Cerebral Injury preceding Treatment of Diabetic Ketoacidosis. J Pediatr 2022; 250:100-104. [PMID: 35944716 DOI: 10.1016/j.jpeds.2022.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/12/2022] [Accepted: 07/28/2022] [Indexed: 11/15/2022]
Abstract
Previous studies have identified more severe acidosis and higher blood urea nitrogen (BUN) as risk factors for cerebral injury during treatment of diabetic ketoacidosis (DKA) in children; however, cerebral injury also can occur before DKA treatment. We found that lower pH and higher BUN levels also were associated with cerebral injury at presentation.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California Davis School of Medicine, CA.
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine in St. Louis, St Louis, MO
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California Davis School of Medicine, Sacramento, CA
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University School of Medicine, Columbus, OH
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/AI DuPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, The Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora, CO
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - Simona Ghetti
- Department of Psychology, University of California Davis, Sacramento, CA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Nathan Kuppermann
- Department of Pediatrics, University of California Davis Health, University of California Davis School of Medicine, CA; Department of Emergency Medicine, University of California Davis Health, University of California Davis School of Medicine, Sacramento, CA
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10
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Melena I, Piani F, Tommerdahl KL, Severn C, Chung LT, MacDonald A, Vinovskis C, Cherney D, Pyle L, Roncal-Jimenez CA, Lanaspa MA, Rewers A, van Raalte DH, Cara-Fuentes G, Parikh CR, Nelson RG, Pavkov ME, Nadeau KJ, Johnson RJ, Bjornstad P. Aminoaciduria and metabolic dysregulation during diabetic ketoacidosis: Results from the diabetic kidney alarm (DKA) study. J Diabetes Complications 2022; 36:108203. [PMID: 35523653 PMCID: PMC9119939 DOI: 10.1016/j.jdiacomp.2022.108203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 04/17/2022] [Accepted: 04/17/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVE We examined changes in the excretion of various amino acids and in glycolysis and ketogenesis-related metabolites, during and after diabetic ketoacidosis (DKA) diagnosis, in youth with known or new onset type 1 diabetes (T1D). METHODS Urine samples were collected from 40 youth with DKA (52% boys, mean age 11 ± 4 years, venous pH 7.2 ± 0.1, blood glucose 451 ± 163 mg/dL) at 3 time points: 0-8 h and 12-24 h after starting an insulin infusion, and 3 months after hospital discharge. Mixed-effects models evaluated the changes in amino acids and other metabolites in the urine. RESULTS Concentrations of urine histidine, threonine, tryptophan, and leucine per creatinine were highest at 0-8 h (148.8 ± 23.5, 59.5 ± 12.3, 15.4 ± 1.4, and 24.5 ± 2.4% of urine creatinine, respectively), and significantly decreased over 3 months (p = 0.028, p = 0.027, p = 0.019, and p < 0.0001, respectively). Urine histidine, threonine, tryptophan, and leucine per urine creatinine decreased by 10.6 ± 19.2, 0.7 ± 0.9, 1.3 ± 0.9, and 0.5 ± 0.3-fold, respectively, between 0 and 8 h and 3 months. CONCLUSIONS In our study, DKA was associated with profound aminoaciduria, suggestive of proximal tubular dysfunction analogous to Fanconi syndrome.
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Affiliation(s)
- Isabella Melena
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Federica Piani
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Kalie L Tommerdahl
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO, USA
| | - Cameron Severn
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Biostatistics and Informatics, Colorado School of Public Health, CO, USA
| | - Linh T Chung
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alexis MacDonald
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Carissa Vinovskis
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - David Cherney
- Department of Medicine, Division of Nephrology, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Laura Pyle
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Biostatistics and Informatics, Colorado School of Public Health, CO, USA
| | - Carlos A Roncal-Jimenez
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA
| | - Miguel A Lanaspa
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA
| | - Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Daniël H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Gabriel Cara-Fuentes
- Department of Pediatrics, Section of Nephrology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Chirag R Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, MD, USA
| | - Robert G Nelson
- Chronic Kidney Disease Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, Phoenix, AZ, USA
| | - Meda E Pavkov
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kristen J Nadeau
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Richard J Johnson
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA
| | - Petter Bjornstad
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, CO, USA; Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, CO, USA.
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11
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Piani F, Melena I, Severn C, Chung LT, Vinovskis C, Cherney D, Pyle L, Roncal-Jimenez CA, Lanaspa MA, Rewers A, van Raalte DH, Obeid W, Parikh C, Nelson RG, Pavkov ME, Nadeau KJ, Johnson RJ, Bjornstad P. Tubular injury in diabetic ketoacidosis: Results from the diabetic kidney alarm study. Pediatr Diabetes 2021; 22:1031-1039. [PMID: 34435718 PMCID: PMC8957478 DOI: 10.1111/pedi.13259] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 08/07/2021] [Accepted: 08/16/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Glomerular injury is a recognized complication of diabetic ketoacidosis (DKA), yet the tubular lesions are poorly understood. The aim of this prospective study was to evaluate the presence and reversibility of tubular injury during DKA in children with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS Blood and urine samples were collected from 40 children with DKA (52% boys, mean age 11 ± 4 years, venous pH 7.2 ± 0.1, glucose 451 ± 163 mg/dL) at three timepoints: 0-8 and 12-24 h after starting insulin, and 3 months after discharge. Mixed-effects models evaluated the changes in tubular injury markers over time (neutrophil gelatinase-associated lipocalin [NGAL], kidney injury molecule 1 [KIM-1], and interleukin 18 [IL-18]). We also evaluated the relationships among the tubular injury biomarkers, copeptin, a vasopressin surrogate, and serum uric acid (SUA). RESULTS Serum NGAL, KIM-1, and IL-18 were highest at 0-8 h (306.5 ± 45.9 ng/mL, 128.9 ± 10.1 pg/mL, and 564.3 ± 39.2 pg/mL, respectively) and significantly decreased over 3 months (p = 0.03, p = 0.01, and p < 0.001, respectively). There were strong relationships among increases in copeptin and SUA and rises in tubular injury biomarkers. At 0-8 h, participants with acute kidney injury (AKI) [17%] showed significantly higher concentrations of tubular injury markers, copeptin, and SUA. CONCLUSIONS DKA was characterized by tubular injury, and the degree of injury associated with elevated copeptin and SUA. Tubular injury biomarkers, copeptin and SUA may be able to predict AKI in DKA.
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Affiliation(s)
- Federica Piani
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Isabella Melena
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cameron Severn
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Linh T. Chung
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carissa Vinovskis
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - David Cherney
- Department of Medicine, Division of Nephrology, University of Toronto School of Medicine, Toronto, Ontario, Canada
| | - Laura Pyle
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Colorado, USA
| | - Carlos A. Roncal-Jimenez
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Miguel A. Lanaspa
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Daniël H. van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, the Netherlands
| | - Wassim Obeid
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Chirag Parikh
- Department of Medicine, Division of Nephrology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert G. Nelson
- Chronic Kidney Disease Section, Phoenix Epidemiology and Clinical Research Branch, NIDDK, Phoenix, Arizona, USA
| | - Meda E. Pavkov
- Division of Diabetes Translation, Center for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Kristen J. Nadeau
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Richard J. Johnson
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Petter Bjornstad
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Pediatrics, Section of Endocrinology, University of Colorado School of Medicine, Aurora, Colorado, USA
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12
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Alonso GT, Murphy C, Pyle L, Thomas S, Ohman-Hanson R, Rewers A. Increased Prevalence of Diabetic Ketoacidosis Among Colorado Children at Diagnosis of Type 1 Diabetes During the COVID-19 Pandemic Lockdown Resolves After Reopening. Diabetes Technol Ther 2021; 23:663-664. [PMID: 33835859 DOI: 10.1089/dia.2021.0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Guy Todd Alonso
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Chelsea Murphy
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz medical Campus, Aurora, CO, USA
| | - Laura Pyle
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Sarah Thomas
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Rebecca Ohman-Hanson
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz medical Campus, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz medical Campus, Aurora, CO, USA
- Children's Hospital Colorado, Aurora, CO, USA
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13
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Glaser NS, Stoner MJ, Garro A, Baird S, Myers SR, Rewers A, Brown KM, Trainor JL, Quayle KS, McManemy JK, DePiero AD, Nigrovic LE, Tzimenatos L, Schunk JE, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics 2021; 148:peds.2021-050243. [PMID: 34373322 DOI: 10.1542/peds.2021-050243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is typically characterized by low or low-normal serum sodium concentrations, which rise as hyperglycemia resolves. In retrospective studies, researchers found associations between declines in sodium concentrations during DKA and cerebral injury. We prospectively investigated determinants of sodium concentration changes and associations with mental status alterations during DKA. METHODS Using data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in Diabetic Ketoacidosis Trial, we compared children who had declines in glucose-corrected sodium concentrations with those who had rising or stable concentrations. Children were randomly assigned to 1 of 4 intravenous fluid protocols that differed in infusion rate and sodium content. Data from the first 4, 8, and 12 hours of treatment were analyzed for 1251, 1086, and 877 episodes, respectively. RESULTS In multivariable analyses, declines in glucose-corrected sodium concentrations were associated with higher sodium and chloride concentrations at presentation and with previously diagnosed diabetes. Treatment with 0.45% (vs 0.9%) sodium chloride fluids was also associated with declines in sodium concentration; however, higher rates of fluid infusion were associated with declines in sodium concentration only at 12 hours. Frequencies of abnormal Glasgow Coma Scale scores and clinical diagnoses of cerebral injury were similar in patients with and without declines in glucose-corrected sodium concentrations. CONCLUSIONS Changes in glucose-corrected sodium concentrations during DKA treatment are influenced by the balance of free-water loss versus sodium loss at presentation and the sodium content of intravenous fluids. Declines in glucose-corrected sodium concentrations are not associated with mental status changes during treatment.
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Affiliation(s)
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital and School of Medicine, The Ohio State University, Columbus, Ohio
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital and The Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Scott Baird
- Division of Critical Care Medicine, Department of Pediatrics, NewYork-Presbyterian Morgan Stanley Children's Hospital and College of Physicians and Surgeons, Columbia University, New York City, New York
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center and School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St Louis Children's Hospital and School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Andrew D DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware.,Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Leah Tzimenatos
- Emergency Medicine, School of Medicine, University of California, Davis Health, University of California, Davis, Sacramento, California
| | - Jeff E Schunk
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Cody S Olsen
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - T Charles Casper
- Department of Pediatrics, School of Medicine, The University of Utah, Salt Lake City, Utah
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, California
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14
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Rewers A, Kuppermann N, Stoner MJ, Garro A, Bennett JE, Quayle KS, Schunk JE, Myers SR, McManemy JK, Nigrovic LE, Trainor JL, Tzimenatos L, Kwok MY, Brown KM, Olsen CS, Casper TC, Ghetti S, Glaser NS. Effects of Fluid Rehydration Strategy on Correction of Acidosis and Electrolyte Abnormalities in Children With Diabetic Ketoacidosis. Diabetes Care 2021; 44:2061-2068. [PMID: 34187840 PMCID: PMC8740930 DOI: 10.2337/dc20-3113] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 05/20/2021] [Indexed: 02/03/2023]
Abstract
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.
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Affiliation(s)
- Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento.,Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Michael J Stoner
- Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, OH
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York, NY
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Simona Ghetti
- Department of Psychology and the Center for Mind and Brain, University of California, Davis, Davis, CA
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis Health, University of California, Davis, School of Medicine, Sacramento
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15
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Jensen ET, Stafford JM, Saydah S, D'Agostino RB, Dolan LM, Lawrence JM, Marcovina S, Mayer-Davis EJ, Pihoker C, Rewers A, Dabelea D. Increase in Prevalence of Diabetic Ketoacidosis at Diagnosis Among Youth With Type 1 Diabetes: The SEARCH for Diabetes in Youth Study. Diabetes Care 2021; 44:1573-1578. [PMID: 34099516 PMCID: PMC8323183 DOI: 10.2337/dc20-0389] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We previously reported a high (˜30%) but stable prevalence of diabetic ketoacidosis (DKA) at youth-onset diagnosis of type 1 diabetes (2002 and 2010). Given the changing demographics of youth-onset type 1 diabetes, we sought to evaluate temporal trends in the prevalence of DKA at diagnosis of type 1 diabetes from 2010 to 2016 among youth <20 years of age and evaluate whether any change observed was associated with changes in sociodemographic distribution of those recently diagnosed. RESEARCH DESIGN AND METHODS We calculated prevalence of DKA within 1 month of type 1 diabetes diagnosis by year and evaluated trends over time (2010-2016) (n = 7,612 incident diabetes cases; mean [SD] age 10.1 [4.5] at diagnosis). To assess whether trends observed were attributable to the changing distribution of sociodemographic factors among youth with incident type 1 diabetes, we estimated an adjusted relative risk (RR) of DKA in relation to calendar year, adjusting for age, sex, race/ethnicity, income, education, health insurance status, language, season of diagnosis, and SEARCH for Diabetes in Youth Study site. RESULTS DKA prevalence increased from 35.3% (95% CI 32.2, 38.4) in 2010 to 40.6% (95% CI 37.8, 43.4) in 2016 (P trend = 0.01). Adjustment for sociodemographic factors did not substantively change the observed trends. We observed a 2% annual increase in prevalence of DKA at or near diagnosis of type 1 diabetes (crude RR 1.02 [95% CI 1.01, 1.04] and adjusted RR 1.02 [95% CI 1.01, 1.04]; P = 0.01 for both). CONCLUSIONS Prevalence of DKA at or near type 1 diabetes diagnosis has increased from 2010 to 2016, following the high but stable prevalence observed from 2002 to 2010. This increase does not seem to be attributable to the changes in distribution of sociodemographic factors over time.
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Affiliation(s)
- Elizabeth T Jensen
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jeanette M Stafford
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sharon Saydah
- Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | | | - Lawrence M Dolan
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jean M Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Santica Marcovina
- Northwest Lipid Research Laboratories, University of Washington, Seattle, WA
| | | | | | - Arleta Rewers
- Department of Pediatrics, University of Colorado Denver, Aurora, CO
| | - Dana Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Denver, Aurora, CO
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16
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Myers SR, Glaser NS, Trainor JL, Nigrovic LE, Garro A, Tzimenatos L, Quayle KS, Kwok MY, Rewers A, Stoner MJ, Schunk JE, McManemy JK, Brown KM, DePiero AD, Olsen CS, Casper TC, Ghetti S, Kuppermann N. Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes. JAMA Netw Open 2020; 3:e2025481. [PMID: 33275152 PMCID: PMC7718599 DOI: 10.1001/jamanetworkopen.2020.25481] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Acute kidney injury (AKI) occurs commonly during diabetic ketoacidosis (DKA) in children, but the underlying mechanisms and associations are unclear. OBJECTIVE To investigate risk factors for AKI and its association with neurocognitive outcomes in pediatric DKA. DESIGN, SETTING, AND PARTICIPANTS This cohort study was a secondary analysis of data from the Pediatric Emergency Care Applied Research Network Fluid Therapies Under Investigation in DKA Study, a prospective, multicenter, randomized clinical trial comparing fluid protocols for pediatric DKA in 13 US hospitals. Included DKA episodes occurred among children age younger than 18 years with blood glucose 300 mg/dL or greater and venous pH less than 7.25 or serum bicarbonate level less than 15 mEq/L. EXPOSURES DKA requiring intravenous insulin therapy. MAIN OUTCOMES AND MEASURES AKI occurrence and stage were assessed using serum creatinine measurements using Kidney Disease: Improving Global Outcomes criteria. DKA episodes with and without AKI were compared using univariable and multivariable methods, exploring associated factors. RESULTS Among 1359 DKA episodes (mean [SD] patient age, 11.6 [4.1] years; 727 [53.5%] girls; 651 patients [47.9%] with new-onset diabetes), AKI occurred in 584 episodes (43%; 95% CI, 40%-46%). A total of 252 AKI events (43%; 95% CI, 39%-47%) were stage 2 or 3. Multivariable analyses identified older age (adjusted odds ratio [AOR] per 1 year, 1.05; 95% CI, 1.00-1.09; P = .03), higher initial serum urea nitrogen (AOR per 1 mg/dL increase, 1.14; 95% CI, 1.11-1.18; P < .001), higher heart rate (AOR for 1-SD increase in z-score, 1.20; 95% CI, 1.09-1.32; P < .001), higher glucose-corrected sodium (AOR per 1 mEq/L increase, 1.03; 95% CI, 1.00-1.06; P = .001) and glucose concentrations (AOR per 100 mg/dL increase, 1.19; 95% CI, 1.07-1.32; P = .001), and lower pH (AOR per 0.1 increase, 0.63; 95% CI, 0.51-0.78; P < .001) as variables associated with AKI. Children with AKI, compared with those without, had lower scores on tests of short-term memory during DKA (mean [SD] digit span recall: 6.8 [2.4] vs 7.6 [2.2]; P = .02) and lower mean (SD) IQ scores 3 to 6 months after recovery from DKA (100.0 [12.2] vs 103.5 [13.2]; P = .005). Differences persisted after adjusting for DKA severity and demographic factors, including socioeconomic status. CONCLUSIONS AND RELEVANCE These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.
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Affiliation(s)
- Sage R. Myers
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nicole S. Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
| | - Jennifer L. Trainor
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Aris Garro
- Department of Emergency Medicine, Rhode Island Hospital, Providence
- Department of Pediatrics, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Leah Tzimenatos
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Kimberly S. Quayle
- Division of Emergency Medicine, St Louis Children’s Hospital, St Louis, Missouri
- Department of Pediatrics, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Maria Y. Kwok
- Division of Emergency Medicine, NewYork-Presbyterian Morgan Stanley Children’s Hospital, New York
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York
| | - Arleta Rewers
- Division of Emergency Medicine, Colorado Children’s Hospital, Denver
- Department of Pediatrics, University of Colorado–Denver School of Medicine, Aurora
| | - Michael J. Stoner
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Jeff E. Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Julie K. McManemy
- Division of Emergency Medicine, Texas Children’s Hospital, Houston
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Kathleen M. Brown
- Division of Emergency Medicine, Children’s National Medical Center, Washington, District of Columbia
- Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Andrew D. DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Simona Ghetti
- Department of Psychology, UC Davis Health, University of California School of Medicine, Sacramento
| | - Nathan Kuppermann
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
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17
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Ghetti S, Kuppermann N, Rewers A, Myers SR, Schunk JE, Stoner MJ, Garro A, Quayle KS, Brown KM, Trainor JL, Tzimenatos L, DePiero AD, McManemy JK, Nigrovic LE, Kwok MY, Perry CS, Olsen CS, Casper TC, Glaser NS. Cognitive Function Following Diabetic Ketoacidosis in Children With New-Onset or Previously Diagnosed Type 1 Diabetes. Diabetes Care 2020; 43:2768-2775. [PMID: 32962981 PMCID: PMC7576431 DOI: 10.2337/dc20-0187] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 08/18/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study assessed whether a single diabetic ketoacidosis (DKA) episode is associated with cognitive declines in children with newly diagnosed type 1 diabetes and whether the same is true in children who had previously been diagnosed after accounting for variations in glycemic control and other relevant factors. RESEARCH DESIGN AND METHODS We prospectively enrolled 758 children, 6-18 years old, who presented with DKA in a randomized multisite clinical trial evaluating intravenous fluid protocols for DKA treatment. DKA was moderate/severe in 430 children and mild in 328 children. A total of 392 children with DKA had new onset of type 1 diabetes, and the rest were previously diagnosed. Neurocognitive assessment occurred 2-6 months after the DKA episode. A comparison group of 376 children with type 1 diabetes, but no DKA exposure, was also enrolled. RESULTS Among all patients, moderate/severe DKA was associated with lower intelligence quotient (IQ) (β = -0.12, P < 0.001), item-color recall (β = -0.08, P = 0.010), and forward digit span (β = -0.06, P = 0.04). Among newly diagnosed patients, moderate/severe DKA was associated with lower item-color recall (β = -0.08, P = 0.04). Among previously diagnosed patients, repeated DKA exposure and higher HbA1c were independently associated with lower IQ (β = -0.10 and β = -0.09, respectively, P < 0.01) and higher HbA1c was associated with lower item-color recall (β = -0.10, P = 0.007) after hypoglycemia, diabetes duration, and socioeconomic status were accounted for. CONCLUSIONS A single DKA episode is associated with subtle memory declines soon after type 1 diabetes diagnosis. Sizable IQ declines are detectable in children with known diabetes, suggesting that DKA effects may be exacerbated in children with chronic exposure to hyperglycemia.
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Affiliation(s)
- Simona Ghetti
- Department of Psychology, University of California, Davis, Davis, CA .,Center for Mind and Brain, University of California, Davis, Davis, CA
| | - Nathan Kuppermann
- Department of Emergency Medicine, UC Davis Health, UC Davis School of Medicine, Sacramento, CA.,Department of Pediatrics, UC Davis Health, UC Davis School of Medicine, Sacramento, CA
| | - Arleta Rewers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, University of Colorado Denver, Aurora, CO
| | - Sage R Myers
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeff E Schunk
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - Michael J Stoner
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Aris Garro
- Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, The Warren Alpert Medical School, Brown University, Providence, RI
| | - Kimberly S Quayle
- Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Kathleen M Brown
- Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, The School of Medicine & Health Sciences, The George Washington University, Washington, DC
| | - Jennifer L Trainor
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Leah Tzimenatos
- Department of Emergency Medicine, UC Davis Health, UC Davis School of Medicine, Sacramento, CA
| | - Andrew D DePiero
- Division of Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Julie K McManemy
- Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Maria Y Kwok
- Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
| | - Clinton S Perry
- Center for Mind and Brain, University of California, Davis, Davis, CA.,Department of Psychology, Tufts University, Medford, MA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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18
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Alonso GT, Coakley A, Pyle L, Manseau K, Thomas S, Rewers A. Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Colorado Children, 2010-2017. Diabetes Care 2020; 43:117-121. [PMID: 31601639 PMCID: PMC6925579 DOI: 10.2337/dc19-0428] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 09/24/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We examined trends in diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes at a large pediatric diabetes center between 2010 and 2017, overlapping with the Affordable Care Act's overhaul of U.S. health care. RESEARCH DESIGN AND METHODS Colorado residents <18 years old who were diagnosed with type 1 diabetes from 2010 to 2017 and subsequently followed at the Barbara Davis Center for Diabetes were included. Logistic regression models were used to test associations among age, sex, race/ethnicity, insurance, language, year of diagnosis, and rural/nonrural residence and DKA at diagnosis. Linear regression models were used to test the association of each predictor with HbA1c at diagnosis. RESULTS There were 2,429 subjects who met the inclusion criteria. From 2010 to 2017, the rate of DKA increased from 41 to 58%. It increased from 35.3 to 59.6% among patients with private insurance (odds ratio 1.10 [95% CI 1.05-1.15]; P < 0.0001) but remained unchanged (52.2-58.8%) among children with public insurance (1.03 [0.97-1.09]; P = 0.36). In the multivariable model, public insurance (1.33 [1.08-1.64]; P = 0.007), rural address (1.42 [1.08-1.86]; P = 0.013), and HbA1c (1.32 [1.26-1.38]; P < 0.0001) were positively associated with DKA, whereas age, race/ethnicity, sex, and primary language were not. CONCLUSIONS The increase in the rate of DKA in patients with newly diagnosed type 1 diabetes was driven by patients with private insurance. This paradoxically occurred during a time of increasing health insurance coverage. More study is needed to understand the factors driving these changes.
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Affiliation(s)
- G Todd Alonso
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Alex Coakley
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | | | - Sarah Thomas
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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19
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Duca LM, Reboussin BA, Pihoker C, Imperatore G, Saydah S, Mayer-Davis E, Rewers A, Dabelea D. Diabetic ketoacidosis at diagnosis of type 1 diabetes and glycemic control over time: The SEARCH for diabetes in youth study. Pediatr Diabetes 2019; 20:172-179. [PMID: 30556249 PMCID: PMC6361710 DOI: 10.1111/pedi.12809] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The diagnosis of type 1 diabetes (T1D) in youth is often associated with diabetic ketoacidosis (DKA). We aimed to evaluate if the presence of DKA at diagnosis of T1D is associated with less favorable hemoglobin A1c (HbA1c) trajectories over time. METHODS The SEARCH for Diabetes in Youth study of 1396 youth aged <20 years with newly diagnosed T1D were followed for up to 13 (median 8 [interquartile range or IQR 6-9]) years after diagnosis. Of these, 397 (28%) had DKA (bicarbonate level < 15 mmol/L and/or pH < 7.25 (venous) or < 7.30 (arterial or capillary) or mention of DKA in medical records) at diabetes onset. Longitudinal HbA1c levels were measured at each follow-up visit (average number of HbA1c measures 3.4). A linear piecewise mixed effects model was used to analyze the effect of DKA status at diagnosis of T1D on long-term glycemic control, adjusting for age at diagnosis, diabetes duration at baseline, sex, race/ethnicity, household income, health insurance status, time-varying insulin regimen and glucose self-monitoring, study site, and baseline fasting C-peptide level. RESULTS At baseline, HbA1c levels were significantly higher in youth with T1D diagnosed in DKA vs those who were not (9.9% ± 1.5% vs 8.5% ± 1.4%, respectively). After the first year with diabetes, there was a significant difference in the rate of change in HbA1c levels by DKA status: HbA1c was 0.16% higher each year in youth with DKA compared to those without (interaction P-value<0.0001), after adjusting for aforementioned covariates. CONCLUSIONS DKA at T1D diagnosis is associated with worsening glycemic control over time, independent of demographic, socioeconomic, and treatment-related factors and baseline fasting C-peptide.
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Affiliation(s)
- Lindsey M Duca
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Beth A Reboussin
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sharon Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Elizabeth Mayer-Davis
- Departments of Nutrition and Medicine, Gillings School of Global Public Health and School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Dana Dabelea
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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20
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Wolfsdorf JI, Glaser N, Agus M, Fritsch M, Hanas R, Rewers A, Sperling MA, Codner E. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19 Suppl 27:155-177. [PMID: 29900641 DOI: 10.1111/pedi.12701] [Citation(s) in RCA: 344] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/31/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Joseph I Wolfsdorf
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Nicole Glaser
- Department of Pediatrics, Section of Endocrinology, University of California, Davis School of Medicine, Sacramento, California
| | - Michael Agus
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts.,Division of Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Fritsch
- Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Ragnar Hanas
- Department of Pediatrics, NU Hospital Group, Uddevalla and Sahlgrenska Academy, Gothenburg University, Uddevalla, Sweden
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Mark A Sperling
- Division of Endocrinology, Diabetes and Metabolism, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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21
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Kuppermann N, Ghetti S, Schunk JE, Stoner MJ, Rewers A, McManemy JK, Myers SR, Nigrovic LE, Garro A, Brown KM, Quayle KS, Trainor JL, Tzimenatos L, Bennett JE, DePiero AD, Kwok MY, Perry CS, Olsen CS, Casper TC, Dean JM, Glaser NS. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis. N Engl J Med 2018; 378:2275-2287. [PMID: 29897851 PMCID: PMC6051773 DOI: 10.1056/nejmoa1716816] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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 .).
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Affiliation(s)
- Nathan Kuppermann
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Simona Ghetti
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Jeff E Schunk
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Michael J Stoner
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Arleta Rewers
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Julie K McManemy
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Sage R Myers
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Lise E Nigrovic
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Aris Garro
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Kathleen M Brown
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Kimberly S Quayle
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Jennifer L Trainor
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Leah Tzimenatos
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Jonathan E Bennett
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Andrew D DePiero
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Maria Y Kwok
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Clinton S Perry
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Cody S Olsen
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - T Charles Casper
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - J Michael Dean
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
| | - Nicole S Glaser
- From the Departments of Emergency Medicine (N.K., L.T.), Pediatrics (N.K., N.S.G.), and Psychology (S.G., C.S.P.), University of California Davis Health, University of California, Davis, School of Medicine, Sacramento; the Department of Pediatrics, University of Utah School of Medicine, Salt Lake City (J.E.S., C.S.O., T.C.C., J.M.D.); the Division of Emergency Medicine, Department of Pediatrics, Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus (M.J.S.); the Division of Emergency Medicine, Department of Pediatrics, Colorado Children's Hospital, University of Colorado-Denver School of Medicine, Aurora (A.R.); the Division of Emergency Medicine, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston (J.K.M.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania (S.R.M.), and the Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Sidney Kimmel Medical College at Thomas Jefferson University (J.E.B., A.D.D.) - both in Philadelphia; the Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston (L.E.N.); the Departments of Emergency Medicine and Pediatrics, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence (A.G.); the Division of Emergency Medicine, Department of Pediatrics, Children's National Medical Center, George Washington School of Medicine and Health Sciences, Washington, DC (K.M.B.); the Division of Emergency Medicine, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine in St. Louis, St. Louis (K.S.Q.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago (J.L.T.); and the Division of Emergency Medicine, Department of Pediatrics, New York Presbyterian Morgan Stanley Children's Hospital, Columbia University College of Physicians and Surgeons, New York (M.Y.K.); and the Department of Psychology, Tufts University, Medford, MA (C.S.P.)
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Fularz M, Adamiak P, Czepczynski R, Jarzabek-Bielecka G, Rewers A, Kędzia W, Ruchała M. Utility of PET/CT in the diagnosis of recurrent ovarian cancer depending on CA 125 serum level. Nuklearmedizin 2017; 54:158-62. [DOI: 10.3413/nukmed-0709-14-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 05/26/2015] [Indexed: 11/20/2022]
Abstract
SummaryThe aim of this study was to estimate the diagnostic value of common application of CA 125 level measurement and 18F-FDG PET/CT examination in patients with a suspicion of recurrent ovarian cancer. Patients, methods: A retrospective analysis was performed on a group of 68 patients aged 31–77 (average 57.7) with a suspicion of relapsing ovarian cancer who had CA 125 serum level measurement and PET/CT examination done with a maximum interval of 60 days. Results: PET/CT examination result was positive in 33 patients (48.5%) and negative in 35 (51.5%). Level of CA 125 was significantly higher in women with a positive PET/ CT result than in patients with a negative one (average 199.9 U/ml and 15.7 U/ml, respectively, p < 0.001). Nevertheless, comparison of CA 125 level in groups defined according to the localization of the relapse showed no significant differences. Moreover, the ROC analysis revealed that the optimal cut-off point of CA 125 concentration to predict positive PET/CT result was 17.6 U/ml. Area under the curve was 0.91. Sensitivity, specificity and accuracy in prognosticating positive PET/CT result for the selected cut-off point of 17.6 U/ml were 90.9%, 80.0% and 85.3%, respectively. Conclusion: CA 125 level does not depend on the localization of the recurrence. PET/CT is particularly useful in patients with a suspicion of relapsing ovarian cancer with CA 125 value of at least 17.6 U/ml.
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Duca LM, Wang B, Rewers M, Rewers A. Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes Predicts Poor Long-term Glycemic Control. Diabetes Care 2017; 40:1249-1255. [PMID: 28667128 DOI: 10.2337/dc17-0558] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/05/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study tested the hypothesis that diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes in children predicts poor long-term glycemic control independently of established risk factors. RESEARCH DESIGN AND METHODS This was a prospective cohort study of 3,364 Colorado residents diagnosed with type 1 diabetes before 18 years of age, in 1998-2012, and monitored for up to 15 years. Of those, 1,297 (39%) had DKA at diagnosis (blood glucose >250 mg/dL, and venous pH <7.3 or bicarbonate <15 mEq/L). Severity of DKA was further classified as mild/moderate (pH 7.10-7.29 or bicarbonate 5-14 mEq/L) or severe (pH <7.10 or bicarbonate <5 mEq/L). HbA1c levels were measured an average of 2.8 times/year (median 20 HbA1c values/patient). A linear mixed model was used to examine the effect of DKA on long-term HbA1c levels, adjusting for age, race/ethnicity, sex, family history of diabetes, health insurance, and insulin pump use. RESULTS DKA at diagnosis predicted persistently elevated HbA1c levels. Compared with children without DKA, HbA1c tracked 1.4% (15.3 mmol/mol) higher in those with severe DKA (P < 0.0001) and 0.9% (9.8 mmol/mol) higher in those with mild/moderate DKA at diagnosis (P < 0.0001). These effects were independent of ethnic minority status or lack of health insurance at diagnosis that predicted higher HbA1c by 0.5% (5.5 mmol/mol; P < 0.0001) and 0.2% (2.2 mmol/mol; P < 0.0001), respectively. Insulin pump use or having a parent or sibling with type 1 diabetes predicted lower long-term HbA1c by, respectively, 0.4% (4.4 mmol/mol; P < 0.0001) and 0.2% (2.2 mmol/mol; P = 0.01). CONCLUSIONS DKA at diagnosis of type 1 diabetes in children predicts poor long-term glycemic control, independent of demographic and socioeconomic factors.
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Affiliation(s)
- Lindsey M Duca
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO.,Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Bing Wang
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
| | - Arleta Rewers
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, CO
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Garro A, Chodobski A, Szmydynger-Chodobska J, Shan R, Bialo SR, Bennett J, Quayle K, Rewers A, Schunk JE, Casper TC, Kuppermann N, Glaser N. Circulating matrix metalloproteinases in children with diabetic ketoacidosis. Pediatr Diabetes 2017; 18:95-102. [PMID: 26843101 PMCID: PMC4974171 DOI: 10.1111/pedi.12359] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 12/16/2015] [Accepted: 12/17/2015] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Matrix metalloproteinases (MMPs) mediate blood-brain barrier dysfunction in inflammatory disease states. Our objective was to compare circulating MMPs in children with diabetic ketoacidosis (DKA) to children with type 1 diabetes mellitus without DKA. RESEARCH DESIGN AND METHODS This was a prospective study performed at five tertiary-care pediatric hospitals. We measured plasma MMP-2, MMP-3, and MMP-9 early during DKA (time 1; within 2 h of beginning intravenous fluids) and during therapy (time 2; median 8 h; range: 4-16 h). The primary outcome was MMP levels in 34 children with DKA vs. 23 children with type 1 diabetes without DKA. Secondary outcomes included correlations between MMPs and measures of DKA severity. RESULTS In children with DKA compared with diabetes controls, circulating MMP-2 levels were lower (mean 77 vs. 244 ng/mL, p < 0.001), MMP-3 levels were similar (mean 5 vs. 4 ng/mL, p = 0.57), and MMP-9 levels were higher (mean 67 vs. 25 ng/mL, p = 0.002) early in DKA treatment. MMP-2 levels were correlated with pH at time 1 (r = 0.45, p = 0.018) and time 2 (r = 0.47, p = 0.015) and with initial serum bicarbonate at time 2 (r = 0.5, p = 0.008). MMP-9 levels correlated with hemoglobin A1c in DKA and diabetes controls, but remained significantly elevated in DKA after controlling for hemoglobin A1c (β = -31.3, p = 0.04). CONCLUSIONS Circulating MMP-2 levels are lower and MMP-9 levels are higher in children during DKA compared with levels in children with diabetes without DKA. Alterations in MMP expression could mediate BBB dysfunction occurring during DKA.
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Affiliation(s)
- Aris Garro
- Departments of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, RI, USA,Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Adam Chodobski
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | | | - Rongzi Shan
- Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Shara R Bialo
- Departments of Pediatrics and Emergency Medicine, Rhode Island Hospital, Providence, RI, USA,Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Jonathan Bennett
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE, USA
| | - Kimberly Quayle
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado, School of Medicine, Denver, CO, USA
| | - Jeffrey E Schunk
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah, School of Medicine, Salt Lake City, UT, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis, Davis, CA, USA
| | - Nicole Glaser
- Department of Pediatrics, University of California Davis, Davis, CA, USA
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Poppy A, Retamal-Munoz C, Cree-Green M, Wood C, Davis S, Clements SA, Majidi S, Steck AK, Alonso GT, Chambers C, Rewers A. Reduction of Insulin Related Preventable Severe Hypoglycemic Events in Hospitalized Children. Pediatrics 2016; 138:peds.2015-1404. [PMID: 27317577 PMCID: PMC5901907 DOI: 10.1542/peds.2015-1404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Insulin is a commonly used, high-risk medication in the inpatient setting. Incorrect insulin administration can lead to preventable hypoglycemic events, which are a significant morbidity in inpatient diabetes care. The goal of this intervention was to decrease preventable insulin-related hypoglycemic events in an inpatient setting in a tertiary care pediatric hospital. METHODS Methods included the institution of several interventions such as nursing and physician education, electronic medical record order sets, electronic communication note templates, and the development of new care guidelines. RESULTS After the institution of multiple interventions, the rate of preventable hypoglycemic events decreased from 1.4 preventable events per 100 insulin days to 0.4 preventable events per 100 insulin days. CONCLUSIONS Through the use of a multi-interventional approach with oversight of a multidisciplinary insulin safety committee, a sustained decreased rate of severe preventable hypoglycemic events in hospitalized pediatric patients receiving insulin was achieved.
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Affiliation(s)
- Amy Poppy
- Quality and Patient Safety, Children's Hospital Colorado, Aurora, Colorado;
| | | | - Melanie Cree-Green
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Colleen Wood
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Shanlee Davis
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Scott A. Clements
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and,Division of Endocrinology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Shideh Majidi
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Andrea K. Steck
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - G. Todd Alonso
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Christina Chambers
- Division of Endocrinology,,Barbara Davis Center for Childhood Diabetes, and
| | - Arleta Rewers
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado Anschutz, Aurora, Colorado; and
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Bakes K, Haukoos JS, Deakyne SJ, Hopkins E, Easter J, McFann K, Brent A, Rewers A. Effect of Volume of Fluid Resuscitation on Metabolic Normalization in Children Presenting in Diabetic Ketoacidosis: A Randomized Controlled Trial. J Emerg Med 2016; 50:551-9. [PMID: 26823137 DOI: 10.1016/j.jemermed.2015.12.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 11/19/2015] [Accepted: 12/13/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND The optimal rate of fluid administration in pediatric diabetic ketoacidosis (DKA) is unknown. OBJECTIVE Our aim was to determine whether the volume of fluid administration in children with DKA influences the rate of metabolic normalization. METHODS We performed a randomized controlled trial conducted in a tertiary pediatric emergency department from December 2007 until June 2010. The primary outcome was time to metabolic normalization; secondary outcomes were time to bicarbonate normalization, pH normalization, overall length of hospital treatment, and adverse outcomes. Children between 0 and 18 years of age were eligible if they had type 1 diabetes mellitus and DKA. Patients were randomized to receive intravenous (IV) fluid at low volume (10 mL/kg bolus + 1.25 × maintenance rate) or high volume (20 mL/kg bolus + 1.5 × maintenance rate) (n = 25 in each). RESULTS After adjusting for initial differences in bicarbonate levels, time to metabolic normalization was significantly faster in the higher-volume infusion group compared to the low-volume infusion group (hazard ratio [HR] = 2.0; 95% confidence interval [CI] 1.0-3.9; p = 0.04). Higher-volume IV fluid infusion appeared to hasten, to a greater extent, normalization of pH (HR = 2.5; 95% CI 1.2-5.0; p = 0.01) than normalization of serum bicarbonate (HR = 1.2; 95% CI 0.6-2.3; p = 0.6). The length of hospital treatment HR (0.8; 95% CI 0.4-1.5; p = 0.5) and time to discharge HR (0.8; 95% CI 0.4-1.5; p = 0.5) did not differ between treatment groups. CONCLUSIONS Higher-volume fluid infusion in the treatment of pediatric DKA patients significantly shortened metabolic normalization time, but did not change overall length of hospital treatment. ClinicalTrials.gov ID NCT01701557.
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Affiliation(s)
- Katherine Bakes
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado; Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Sara J Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Research Institute, Aurora, Colorado
| | - Emily Hopkins
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado
| | - Josh Easter
- Department of Emergency Medicine, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, Colorado
| | - Kim McFann
- Colorado School of Public Health, University of Colorado, Aurora, Colorado
| | - Alison Brent
- Section Emergency Medicine, Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
| | - Arleta Rewers
- Section Emergency Medicine, Department of Pediatrics, University of Colorado, School of Medicine, Aurora, Colorado
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DuBose SN, Hermann JM, Tamborlane WV, Beck RW, Dost A, DiMeglio LA, Schwab KO, Holl RW, Hofer SE, Maahs DM, Lipman T, Calvano T, Kucheruk O, Minnock P, Nguyen C, Klingensmith G, Banion C, Barker J, Cain C, Chase P, Hoops S, Kelsy M, Klingensmith G, Maahs D, Mowry C, Nadeau K, Raymond J, Rewers M, Rewers A, Slover R, Steck A, Wadwa P, Walravens P, Zeitler P, Haro H, Manseau K, Weinstock R, Izquierdo R, Sheikh U, Conboy P, Bulger J, Bzdick S, Goland R, Gandica R, Weiner L, Cook S, Greenberg E, Kohm K, Pollack S, Lee J, Gregg B, Tan M, Burgh K, Eason A, Garg S, Michels A, Myers L, DiMeglio L, Hannon T, Orr D, Cruz C, Woerner S, Wolfsdorf J, Quinn M, Tawa O, Ahmann A, Castle J, Joarder F, Bogan C, Cady N, Cox J, Pitts A, Fitch R, White B, Wollam B, Bode B, Lindmark K, Hosey R, Bethin K, Quattrin T, Ecker M, Wood J, Chao L, Cheung C, Fisher L, Jeandron D, Kaufman F, Kim M, Miyazaki B, Monzavi R, Patel P, Pitukcheewanont P, Sandstrom A, Cohen M, Ichihara B, Lipton M, Cemeroglu A, Appiagyei-Dankah Y, Daniel M, Postellon D, Racine M, Wood M, Kleis L, Hirsch I, DeSantis A, Dugdale D, Failor RA, Gilliam L, Greenbaum C, Janci M, Odegard P, Trence D, Wisse B, Batts E, Dove A, Hefty D, Khakpour D, Klein J, Kuhns K, McCulloch-Olson M, Peterson C, Ramey M, Marie MS, Thomson P, Webber C, Liljenquist D, Sulik M, Vance C, Coughenour T, Brown C, Halford J, Prudent A, Rigby S, Robison B, Starkman H, Berry T, Cerame B, Chin D, Ebner-Lyon L, Guevarra F, Sabanosh K, Silverman L, Wagner C, Fox M, Buckingham B, Shah A, Caswell K, Harris B, Bergenstal R, Criego A, Damberg G, Matfin G, Powers M, Tridgell D, Burt C, Olson B, Thomas L, Mehta S, Katz M, Laffel L, Hathway J, Phillips R, Cengiz E, Tamborlane W, Cappiello D, Steffen A, Zgorski M, Peters A, Ruelas V, Benjamin R, Adkins D, Cuffee J, Spruill A, Bergenstal R, Criego A, Damberg G, Matfin G, Powers M, Tridgell D, Burt C, Olson B, Thomas L, Aleppo-Kacmarek G, Derby T, Massaro E, Webb K, Burt Solorzano C, DeBoer M, Madison H, McGill J, Buechler L, Clifton MJ, Hurst S, Kissel S, Recklein C, Tsalikian E, Tansey M, Cabbage J, Coffey J, Salamati S, Clements M, Raman S, Turpin A, Bedard J, Cohoon C, Elrod A, Fridlington A, Hester L, Kruger D, Schatz D, Clare-Salzler M, Cusi K, Digman C, Fudge B, Haller M, Meehan C, Rohrs H, Silverstein J, Wagh S, Cintron M, Sheehan E, Thomas J, Daniels M, Clark S, Flannery T, Forghani N, Naidu A, Reh C, Scoggin P, Trinh L, Ayala N, Quintana R, Speer H, Zipf W, Seiple D, Kittelsrud J, Gupta A, Peterson V, Stoker A, Gottschalk M, Hashiguchi M, Smith K, Rodriguez H, Bobik C, Henson D, Simmons J, Potter A, Black M, Brendle F, Gubitosi-Klug R, Kaminski B, Bergant S, Campbell W, Tasi C, Copeland K, Beck J, Less J, Schanuel J, Tolbert J, Adi S, Gerard-Gonzalez A, Gitelman S, Chettout N, Torok C, Pihoker C, Yi-Frazier J, Kearns S, Libman I, Bills V, Diaz A, Duke J, Nathan B, Moran A, Bellin M, Beasley S, Kogler A, Leschyshyn J, Schmid K, Street A, Nelson B, Frost C, Reifeis E, Haymond M, Bacha F, Caldas-Vasquez M, Klinepeter S, Redondo M, Berlanga R, Falk T, Garnes E, Gonzalez J, Martinez C, Pontifes M, Yulatic R, Arnold K, Evans T, Sellers S, Raman V, Foster C, Murray M, Raman V, Brown T, Slater H, Wheeler K, Harlan D, Lee M, Lock JP, Hartigan C, Hubacz L, Buse J, Calikoglu A, Largay J, Young L, Brown H, Duncan V, Duclos M, Tricome J, Brandenburg V, Blehm J, Hallanger-Johnson J, Hanson D, Miller C, Weiss J, Hoffman R, Chaudhari M, Repaske D, Gilson E, Haines J, Rudolph J, McClave C, Biersdorf D, Tello A, Blehm J, Amundson D, Ward R, Rickels M, Dalton-Bakes C, Markman E, Peleckis A, Rosenfeld N, Dolan L, Corathers S, Kichler J, Baugh H, Standiford D, Hassing J, Jones J, Willis S, Willis S, Wysham C, Davis L, Blackman S, Abel KL, Clark L, Jonas A, Kagan E, Sosenko J, Blashke C, Matheson D, Edelen R, Repas T, Baldwin D, Borgwardt T, Conroy C, DeGrote K, Marchiando R, Wasson M, Fox L, Mauras N, Damaso L, Englert K, Hamaty M, Kennedy L, Schweiger M, Konstantinopoulos P, Mawhorter C, Orasko A, Rose D, Deeb L, Rohrbacher K, Schroeder L, Roark A, Ali O, Kramer J, Whitson-Jones D, Potter A, Black M, Brendle F, Gassner H, Kollipara S, Bills V, Duke J, Harwood K, Prasad V, Brault J. Obesity in Youth with Type 1 Diabetes in Germany, Austria, and the United States. J Pediatr 2015; 167:627-32.e1-4. [PMID: 26164381 DOI: 10.1016/j.jpeds.2015.05.046] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2014] [Revised: 04/28/2015] [Accepted: 05/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To examine the current extent of the obesity problem in 2 large pediatric clinical registries in the US and Europe and to examine the hypotheses that increased body mass index (BMI) z-scores (BMIz) are associated with greater hemoglobin A1c (HbA1c) and increased frequency of severe hypoglycemia in youth with type 1 diabetes (T1D). STUDY DESIGN International (World Health Organization) and national (Centers for Disease Control and Prevention/German Health Interview and Examination Survey for Children and Adolescents) BMI references were used to calculate BMIz in participants (age 2-<18 years and ≥ 1 year duration of T1D) enrolled in the T1D Exchange (n = 11,435) and the Diabetes Prospective Follow-up (n = 21,501). Associations between BMIz and HbA1c and severe hypoglycemia were assessed. RESULTS Participants in both registries had median BMI values that were greater than international and their respective national reference values. BMIz was significantly greater in the T1D Exchange vs the Diabetes Prospective Follow-up (P < .001). After stratification by age-group, no differences in BMI between registries existed for children 2-5 years, but differences were confirmed for 6- to 9-, 10- to 13-, and 14- to 17-year age groups (all P < .001). Greater BMIz were significantly related to greater HbA1c levels and more frequent occurrence of severe hypoglycemia across the registries, although these associations may not be clinically relevant. CONCLUSIONS Excessive weight is a common problem in children with T1D in Germany and Austria and, especially, in the US. Our data suggest that obesity contributes to the challenges in achieving optimal glycemic control in children and adolescents with T1D.
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Affiliation(s)
| | - Julia M Hermann
- Institute for Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | - Axel Dost
- Department of Pediatrics, University Children's Hospital Jena, Jena, Germany
| | | | | | - Reinhard W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, Aurora, CO
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Fran Dong
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Denver
| | - Robert H Slover
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Denver
| | | | - Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Denver
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Ly TT, Maahs DM, Rewers A, Dunger D, Oduwole A, Jones TW. ISPAD Clinical Practice Consensus Guidelines 2014. Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2014; 15 Suppl 20:180-92. [PMID: 25040141 DOI: 10.1111/pedi.12174] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/10/2014] [Indexed: 12/23/2022] Open
Affiliation(s)
- Trang T Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA; School of Paediatrics and Child Health, The University of Western Australia, Perth, WA, Australia
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Dabelea D, Rewers A, Stafford JM, Standiford DA, Lawrence JM, Saydah S, Imperatore G, D’Agostino RB, Mayer-Davis EJ, Pihoker C. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics 2014; 133:e938-45. [PMID: 24685959 PMCID: PMC4074618 DOI: 10.1542/peds.2013-2795] [Citation(s) in RCA: 241] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To estimate temporal changes in the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 or type 2 diabetes in youth and to explore factors associated with its occurrence. METHODS Five centers identified incident cases of diabetes among youth aged 0 to 19 years starting in 2002. DKA presence was defined as a bicarbonate level <15 mmol/L and/or a pH <7.25 (venous) or <7.30 (arterial or capillary) or mention of DKA in the medical records. We assessed trends in the prevalence of DKA over 3 time periods (2002-2003, 2004-2005, and 2008-2010). Logistic regression was used to determine factors associated with DKA. RESULTS In youth with type 1 diabetes (n = 5615), the prevalence of DKA was high and stable over time (30.2% in 2002-2003, 29.1% in 2004-2005, and 31.1% in 2008-2010; P for trend = .42). Higher prevalence was associated with younger age at diagnosis (P < .0001), minority race/ethnicity (P = .019), income (P = .019), and lack of private health insurance (P = 008). Among youth with type 2 diabetes (n = 1425), DKA prevalence decreased from 11.7% in 2002-2003 to 5.7% in 2008-2010 (P for trend = .005). Higher prevalence was associated with younger age at diagnosis (P = .001), minority race/ethnicity (P = .013), and male gender (P = .001). CONCLUSIONS The frequency of DKA in youth with type 1 diabetes, although stable, remains high, indicating a persistent need for increased awareness of signs and symptoms of diabetes and better access to health care. In youth with type 2 diabetes, DKA at onset is less common and is decreasing over time.
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Affiliation(s)
- Dana Dabelea
- Department of Epidemiology, Colorado School of Public Health, Aurora, Colorado
| | - Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeanette M. Stafford
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Debra A. Standiford
- Department of Endocrinology, Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jean M. Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
| | - Sharon Saydah
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Giuseppina Imperatore
- Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ralph B. D’Agostino
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | | | - Catherine Pihoker
- Department of Pediatrics, University of Washington, Seattle, Washington
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Cengiz E, Xing D, Wong JC, Wolfsdorf JI, Haymond MW, Rewers A, Shanmugham S, Tamborlane WV, Willi SM, Seiple DL, Miller KM, DuBose SN, Beck RW. Severe hypoglycemia and diabetic ketoacidosis among youth with type 1 diabetes in the T1D Exchange clinic registry. Pediatr Diabetes 2013; 14:447-54. [PMID: 23469984 PMCID: PMC4100244 DOI: 10.1111/pedi.12030] [Citation(s) in RCA: 172] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Severe hypoglycemia (SH) and diabetic ketoacidosis (DKA) are common serious acute complications of type 1 diabetes (T1D). The aim of this study was to determine the frequency of SH and DKA and identify factors related to their occurrence in the T1D Exchange pediatric and young adult cohort. RESEARCH DESIGN AND METHODS The analysis included 13 487 participants in the T1D Exchange clinic registry aged 2 to <26 yr with T1D ≥2 yr. Separate logistic regression models were used to evaluate the association of baseline demographic and clinical factors with the occurrence of SH or DKA in the prior 12 months. RESULTS Non-White race, no private health insurance, and lower household income were associated with higher frequencies of both SH and DKA (p < 0.001). SH frequency was highest in children <6 yr old (p = 0.005), but across the age range, SH was not associated with hemoglobin A1c (HbA1c) levels after controlling for other factors (p = 0.72). DKA frequency was highest in adolescents (p < 0.001) and associated with higher HbA1c (p < 0.001). CONCLUSIONS Our data show that poor glycemic control increases the risk of DKA but does not protect against SH in youth and young adults with type 1 diabetes. The high frequencies of SH and DKA observed in disadvantaged minorities with T1D highlight the need for targeted interventions and new treatment paradigms for patients in these high risk groups.
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Affiliation(s)
- Eda Cengiz
- Yale University 15 York St New Haven, CT
| | - Dongyuan Xing
- Jaeb Center for Health Research 15310 Amberly Dr, Suite 350 Tampa, FL 33647
| | - Jenise C. Wong
- Univesity of California San Francisco 513 Parnassus Ave, Room S679, Box 0434 San Francisco, CA 94143
| | | | | | - Arleta Rewers
- University of Colorado Denver 1775 Aurora Ct. Aurora, CO 80045
| | - Satya Shanmugham
- Stanford University Medical Center 300 Pasteur Dr. Stanford, CA 94305
| | | | - Steven M. Willi
- Children's Hospital of Philadelphia 3400 Civic Center Blvd. Suite 11NW30 Philadelphia, PA 19104
| | - Diane L. Seiple
- Central Ohio Pediatrics Endocrinology and Diabetes Services 55 Dillmont Dr. Columbus, OH 43235
| | - Kellee M. Miller
- Jaeb Center for Health Research 15310 Amberly Dr, Suite 350 Tampa, FL 33647
| | | | - Roy W. Beck
- Jaeb Center for Health Research 15310 Amberly Dr, Suite 350 Tampa, FL 33647
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Bagdure D, Rewers A, Campagna E, Sills MR. Epidemiology of hyperglycemic hyperosmolar syndrome in children hospitalized in USA. Pediatr Diabetes 2013; 14:18-24. [PMID: 22925225 DOI: 10.1111/j.1399-5448.2012.00897.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 05/17/2012] [Accepted: 06/01/2012] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Previous studies of hyperglycemic hyperosmolar syndrome (HHS) in children are limited to case series or single-institution reviews, which describe HHS primarily in children with type 2 diabetes mellitus. OBJECTIVE To estimate the incidence and describe the epidemiologic characteristics of HHS among children in USA. SUBJECTS All discharges in the Kids' Inpatient Database - a triennial, nationwide, stratified probability sample of hospital discharges for years 1997-2009 - with age 0-18 yr and a diagnosis of HHS. METHODS Using sample weights, we calculated the incidence and population rate of hospitalization with a diagnosis of HHS. RESULTS Our sample included 1074 HHS hospitalizations; of these, 42.9% were 16-18 yr, 70.6% had type 1 diabetes (T1D), and 53.0% had major or extreme severity of illness. The median length of stay was 2.6 d, 2.7% of hospitalizations ended in death, and median hospital charge was $10 882. When comparing HHS hospitalizations by diabetes type, the proportion with T1D fell steadily with age, from 89.1% among children 0-9 yr, to 65.1% in 16-18 yr olds. Patients with T1D had a shorter length of stay by 0.9 d, and had a lower median charge by $5311. There was no difference in mortality by diabetes type. Population rates for HHS hospitalization rose 52.4% from 2.1 to 3.2 per 1 000 000 children from 1997 to 2009. CONCLUSION Hospitalizations for a diagnosis of HHS have high morbidity and are increasing in incidence since 1997. In contrast to prior reports, we found a substantial percentage of HHS hospitalizations occurred among children with T1D.
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Affiliation(s)
- Dayanand Bagdure
- Department of Pediatrics, University of Maryland School of Medicine, Division of Pediatric Critical Care Medicine, Baltimore, MD 21201, USA.
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Abstract
Diabetic ketoacidosis (DKA) is caused by absolute or relative lack of insulin. Lack of insulin leads to hyperglycemia, ketonemia, and acidosis. Prevalence of DKA at diagnosis of type 1 diabetes (T1D) varies around the world from 18 % to 84 %. Incidence of recurrent DKA is higher among females, insulin pump users, those with a history of psychiatric or eating disorder, and suboptimal socioeconomic circumstances. DKA is the most common cause of death in children with T1D. Children with DKA should be treated in experienced centers. Initial bolus of 10-20 mL/kg 0.9 % saline is followed by 0.45 %-0.9 % saline infusion. Fluid infusion should precede insulin administration (0.1 U/kg/h) by 1-2 hours. The prevention of DKA at diagnosis of diabetes can be achieved by an intensive community intervention and education of health care providers to raise awareness. Prevention of recurrent DKA requires continuous patient education and access to diabetes programs and telephone services.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado Denver, School of Medicine, Aurora, CO 80045, USA.
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Affiliation(s)
- Arleta Rewers
- Emergency Medicine, Department of Pediatrics, School of Medicine, University of Colorado Denver, 13123 East 16th Avenue, B251, Aurora, CO 80045, USA.
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Clarke W, Jones T, Rewers A, Dunger D, Klingensmith GJ. Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2009; 10 Suppl 12:134-45. [PMID: 19754624 DOI: 10.1111/j.1399-5448.2009.00583.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- William Clarke
- Department of Pediatrics, University of Virginia, Charlottesville, VA 22908, USA.
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Glaser NS, Marcin JP, Wootton-Gorges SL, Buonocore MH, Rewers A, Strain J, DiCarlo J, Neely EK, Barnes P, Kuppermann N. Correlation of clinical and biochemical findings with diabetic ketoacidosis-related cerebral edema in children using magnetic resonance diffusion-weighted imaging. J Pediatr 2008; 153:541-6. [PMID: 18589447 DOI: 10.1016/j.jpeds.2008.04.048] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 03/18/2008] [Accepted: 04/14/2008] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA 95817, USA.
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Rewers A, Klingensmith G, Davis C, Petitti DB, Pihoker C, Rodriguez B, Schwartz ID, Imperatore G, Williams D, Dolan LM, Dabelea D. Presence of diabetic ketoacidosis at diagnosis of diabetes mellitus in youth: the Search for Diabetes in Youth Study. Pediatrics 2008; 121:e1258-66. [PMID: 18450868 DOI: 10.1542/peds.2007-1105] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The purpose of this work was to determine the prevalence and predictors of diabetic ketoacidosis at the diagnosis of diabetes in a large sample of youth from the US population. PATIENTS AND METHODS The Search for Diabetes in Youth Study, a multicenter, population-based registry of diabetes with diagnosis before 20 years of age, identified 3666 patients with new onset of diabetes in the study areas in 2002-2004. Medical charts were reviewed in 2824 (77%) of the patients in a standard manner to abstract the results of laboratory tests and to ascertain diabetic ketoacidosis at the time of diagnosis. Diabetic ketoacidosis was defined by blood bicarbonate <15 mmol/L and/or venous pH < 7.25 (arterial/capillary pH < 7.30), International Classification of Diseases, Ninth Revision, code 250.1, or listing of diabetic ketoacidosis in the medical chart. RESULTS More than half (54%) of the patients were hospitalized at diagnosis, including 93% of those with diabetic ketoacidosis and 41% without diabetic ketoacidosis. The prevalence of diabetic ketoacidosis at the diagnosis was 25.5%. The prevalence decreased with age from 37.3% in children aged 0 to 4 years to 14.7% in those aged 15 to 19 years. Diabetic ketoacidosis prevalence was significantly higher in patients with type 1 (29.4%) rather than in those with type 2 diabetes (9.7%). After adjusting for the effects of center, age, gender, race or ethnicity, diabetes type, and family history of diabetes, diabetic ketoacidosis at diagnosis was associated with lower family income, less desirable health insurance coverage, and lower parental education. CONCLUSION At the time of diagnosis, 1 in 4 youth presents with diabetic ketoacidosis. Those with diabetic ketoacidosis were more likely to be hospitalized. Diabetic ketoacidosis was a presenting feature of <10% of youth with type 2. Young and poor children are disproportionately affected.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, Denver, Colorado, USA.
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Affiliation(s)
- William Clarke
- Department of Pediatrics, University of Virginia, Charlottesville, VA 22908, USA.
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Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) affects many children with type 1 diabetes. Insulin treatment of DKA is traditionally guided by changes in the blood glucose levels and blood gases, whereas beta-hydroxybutyrate (beta-OHB)--the main ketoacid causing acidosis--is rarely measured. The purpose of this study was to evaluate if bedside monitoring of blood beta-OHB levels can simplify management of DKA through elimination of superfluous laboratory monitoring. METHODS Our emergency department treated 68 children with DKA using a standard protocol with monitoring of venous pH, partial pressure of CO(2) (pCO(2)), bicarbonate, glucose, blood urea nitrogen, and electrolytes (two to 10 time points per patient). Venous beta-OHB levels were measured using the Precision Xtra meter (MediSense/Abbott Diabetes Care, Abbott Park, IL) and, on duplicate batched serum samples, using a reference laboratory method (Cobas Mira Plus; Roche Diagnostics, Indianapolis, IN). Correlations between bedside meter beta-OHB and other parameters were evaluated in a series of general linear models with a time series covariance structure fit using spatial power law. RESULTS The bedside meter beta-OHB levels were significantly correlated with pH (r = -0.63; P <0.0001), bicarbonate (r = -0.74; P <0.0001), and pCO(2) (r = -0.55; P <0.0001) at all points of measurement during the treatment (unadjusted Pearson correlations). The pH, bicarbonate, and pCO(2) were entered into separate time series analysis models with treatment duration as a measure of time. The results confirmed that bedside levels of beta-OHB correlated very closely with time-dependent levels of venous pH, bicarbonate, and pCO(2). Good agreement between the two methods of beta-OHB measurement (r = 0.92; P <0.0001) was confirmed using the Bland-Altman plot analysis. CONCLUSIONS The Precision Xtra accurately measures blood beta-OHB levels, particularly at lower levels. While the initial measurement of pH and/or bicarbonates is warranted, real-time beta-OHB levels may replace repeat laboratory measurement of these parameters in the management of DKA. Future studies should evaluate safety and cost-effectiveness of such simplified DKA treatment protocol.
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Affiliation(s)
- Arleta Rewers
- Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, Denver, Colorado 80218, USA.
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Glaser NS, Wootton-Gorges SL, Buonocore MH, Marcin JP, Rewers A, Strain J, DiCarlo J, Neely EK, Barnes P, Kuppermann N. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes 2006; 7:75-80. [PMID: 16629712 DOI: 10.1111/j.1399-543x.2006.00156.x] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Symptomatic cerebral edema occurs in approximately 1% of children with diabetic ketoacidosis (DKA). However, asymptomatic or subclinical cerebral edema is thought to occur more frequently. Some small studies have found narrowing of the cerebral ventricles indicating cerebral edema in most or all children with DKA, but other studies have not detected narrowing in ventricle size. In this study, we measured the intercaudate width of the frontal horns of the lateral ventricles using magnetic resonance imaging (MRI) in children with DKA during treatment and after recovery from the DKA episode. We determined the frequency of ventricular narrowing and compared clinical and biochemical data for children with and without ventricular narrowing. Forty-one children completed the study protocol. The lateral ventricles were significantly smaller during DKA treatment (mean width, 9.3 +/- 0.3 vs. 10.2 +/- 0.3 mm after recovery from DKA, p < 0.001). Children with ventricular narrowing during DKA treatment (22 children, 54%) were more likely to have mental status abnormalities than those without narrowing [12/22 vs. 4/19 with Glasgow Coma Scale (GCS) scores below 15 during therapy, p = 0.03]. Multiple logistic regression analysis revealed that a lower initial PCO2 level was significantly associated with ventricular narrowing [odds ratio (OR) = 0.88, 95% confidence interval (95% CI) = 0.78-0.99, p = 0.047). No other variables analyzed were associated with ventricular narrowing in the multivariate analysis. We conclude that narrowing of the lateral ventricles is evident in just over half of children being treated for DKA. Although children with ventricular narrowing did not exhibit neurological abnormalities sufficient for a diagnosis of 'symptomatic cerebral edema', mild mental status abnormalities occurred frequently, suggesting that clinical evidence of cerebral edema in children with DKA may be more common than previously reported.
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Affiliation(s)
- Nicole S Glaser
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento 95817, USA.
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Maniatis AK, Goehrig SH, Gao D, Rewers A, Walravens P, Klingensmith GJ. Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus. Pediatr Diabetes 2005; 6:79-83. [PMID: 15963034 DOI: 10.1111/j.1399-543x.2005.00096.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES (a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM). RESEARCH DESIGN AND METHODS Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained. RESULTS Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old. CONCLUSIONS At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.
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Affiliation(s)
- Aristides K Maniatis
- The Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Denver, CO 80262, USA.
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Rewers A, Hedegaard H, Lezotte D, Meng K, Battan FK, Emery K, Hamman RF. Childhood femur fractures, associated injuries, and sociodemographic risk factors: a population-based study. Pediatrics 2005; 115:e543-52. [PMID: 15867019 DOI: 10.1542/peds.2004-1064] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The objectives of this study were to determine the incidence of femur fractures in Colorado children, to assess underlying causes, to determine the prevalence and predictors of associated injuries, and to identify potentially modifiable risk factors. METHODS The study population included all Colorado residents who were aged 0 to 17 years at the time of injury between January 1, 1998, and December 31, 2001. Cases of femur fracture were ascertained using the population-based Colorado Trauma Registry and International Classification of Diseases, Ninth Revision, Clinical Modification codes 820.0 to 821.39. Associated injuries with an Abbreviated Injury Scale of 2 or higher were classified into 5 categories. Poisson regression, small area analysis, and multivariate logistic regression were used to identify predictors of femur fractures and associated injuries, respectively. RESULTS During the study period, 1139 Colorado children (795 boys, 344 girls) sustained femur fractures, resulting in the incidence of 26.0 per 100000 person-years. Rates were higher in boys than in girls in all age groups (overall risk ratio: 2.19; 95% confidence interval: 1.92-2.47) but did not differ by race/ethnicity. Femur fractures that were caused by nonaccidental trauma showed more distal and combined shaft + distal pattern; their incidence did not differ by gender or race but was higher in census tracts with more single mothers and less crowded households. Associated injuries were present in 28.6% of the cases, more often in older children. Fatalities occurred only among children with associated injuries. Children who were involved in nonaccidental trauma, motor vehicle crashes, or auto-pedestrian accidents were 16 to 20 times more likely to have associated injuries than those with femur fractures as a result of a fall. In small-area analysis, the incidence of femur fractures in infants and toddlers was higher in census tracts characterized by higher proportion of Hispanics, single mothers, and more crowded households. Among children 4 to 12 years of age, the incidence was higher in census tracts with fewer single-family houses and more crowded households. Finally, the incidence of femur fractures among teenagers was higher in rural tracts and those with a higher proportion of Hispanics. CONCLUSIONS Femur fractures and associated injuries remain a major cause of morbidity in children. Predictors of femur fractures change with age; however, the risk is generally higher among children who live in the areas with lower socioeconomic indicators.
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Affiliation(s)
- Arleta Rewers
- Department of Pediatrics, University of Colorado School of Medicine, 1056 E 19th Ave, B251, Denver, CO 80218, USA.
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Maniatis AK, Goehrig SH, Rewers A, Walravens P, Klingensmith GJ. 455 INCREASED INCIDENCE AND SEVERITY OF DIABETIC KETOACIDOSIS AMONG UNINSURED CHILDREN WITH NEWLY DIAGNOSED TYPE 1 DIABETES. J Investig Med 2005. [DOI: 10.2310/6650.2005.00005.454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
CONTEXT Diabetic ketoacidosis and severe hypoglycemia are acute complications of type 1 diabetes that are related, respectively, to insufficient or excessive insulin treatment. However, little is known about additional modifiable risk factors. OBJECTIVE To examine the incidence of ketoacidosis and severe hypoglycemia in children with diabetes and to determine the factors that predict these complications. DESIGN, SETTING, AND PARTICIPANTS A cohort of 1243 children from infancy to age 19 years with type 1 diabetes who resided in the Denver, Colo, metropolitan area were followed up prospectively for 3994 person-years from January 1, 1996, through December 31, 2000. MAIN OUTCOME MEASURES Incidence of ketoacidosis leading to hospital admission or emergency department visit and severe hypoglycemia (loss of consciousness, seizure, or hospital admission or emergency department visit). RESULTS The incidence of ketoacidosis was 8 per 100 person-years and increased with age in girls (4 per 100 person-years in < 7; 8 in 7-12; and 12 in > or =13 years; P<.001 for trend). In multivariate analyses, sex-adjusted and stratified by age (<13 vs > or =13 years), the risk of ketoacidosis in younger children increased with higher hemoglobin A(1c) (HbA(1c)) (relative risk [RR], 1.68 per 1% increase; 95% confidence interval [CI], 1.45-1.94) and higher reported insulin dose (RR, 1.40 per 0.2 U/kg per day; 95% CI, 1.20-1.64). In older children, the risk of ketoacidosis increased with higher HbA(1c) (RR, 1.43; 95% CI, 1.30-1.58), higher reported insulin dose (RR, 1.13; 95% CI, 1.02-1.25), underinsurance (RR, 2.18; 95% CI, 1.65-2.95), and presence of psychiatric disorders (for boys, RR, 1.59; 95% CI, 0.96-2.65; for girls, RR, 3.22; 95% CI, 2.25-4.61). The incidence of severe hypoglycemia was 19 per 100 person-years (P<.001 for trend) and decreased with age in girls (24 per 100 patient-years in < 7, 19 in 7-12, and 14 in > or =13 years). In younger children, the risk of severe hypoglycemia increased with diabetes duration (RR, 1.39 per 5 years; 95% CI, 1.16-1.69) and underinsurance (RR, 1.33; 95% CI, 1.08-1.65). In older children, the risk of severe hypoglycemia increased with duration (RR, 1.34; 95% CI, 1.25-1.51), underinsurance (RR, 1.42; 95% CI, 1.11-1.81), lower HbA(1c) (RR, 1.22; 95% CI, 1.12-1.32), and presence of psychiatric disorders (RR, 1.56; 95% CI, 1.23-1.98). Eighty percent of episodes occurred among the 20% of children who had recurrent events. CONCLUSIONS Some children with diabetes remain at high risk for ketoacidosis and severe hypoglycemia. Age- and sex-specific incidence patterns suggest that ketoacidosis is a challenge in adolescent girls while severe hypoglycemia continues to affect disproportionally the youngest patients and boys of all ages. The pattern of modifiable risk factors indicates that underinsured children and those with psychiatric disorders or at the extremes of the HbA(1c) distribution should be targeted for specific interventions.
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Affiliation(s)
- Arleta Rewers
- Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado, School of Medicine, The Children's Hospital, Denver, CO 80218, USA.
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Zeromski J, Szmeja Z, Rewers A, Kruk-Zagajewska A. Immunofluorescent assessment of tumour infiltrating cells in laryngeal carcinoma. Application of monoclonal antibodies. Acta Otolaryngol 1986; 102:325-32. [PMID: 2946139 DOI: 10.3109/00016488609108683] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In order to gain some insight into host cell accumulations within primary tumour, frozen sections from surgical specimens of laryngeal carcinoma were subjected to indirect immunofluorescence using a panel of monoclonal antibodies against various human lymphocyte subsets as well as macrophages. In addition, polyclonal antibodies against Ig were used in order to trace B cells. Numerous host cell infiltrates seen at the tumour periphery were composed of T4 (helper) lymphocytes and macrophages. Lymphocytes of OKT8 (suppressor/cytotoxic) and Leu-7 (NK cells) series were intermingled with tumour cells in the case of scanty infiltrates. Infiltrating cells were also linked to the presence of metastases in regional lymph nodes. OKT4-positive abundant infiltrates were usually accompanied by uninvolved nodes, while scanty ones with OKT8 specificity were relatively frequently seen in the patients with evidence of nodal metastases. These differences were not statistically significant, however, B cells as well as plasma cells were infrequently observed and were encountered both in tumour samples with intensive cellular infiltrates as well as in those with scanty ones.
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