This systematic review identified 46 studies from 31 countries involving over 24,000 children with new onset type 1 diabetes. The studies compared various factors to determine which were associated with the presence of diabetic ketoacidosis (DKA) at diagnosis. Younger age, diagnostic errors, ethnic minority status, lack of health insurance, lower body mass index, preceding infections, and delayed treatment were associated with increased risk of DKA. Having a family member with diabetes, higher parental education, and living in an area with a higher background rate of type 1 diabetes were protective factors against DKA. Many children presented with DKA despite being seen by a doctor before diagnosis, suggesting potential opportunities for earlier diagnosis and treatment.
This document discusses effective and cost-effective treatment for diabetes. It summarizes the key points made in the document in 3 sentences:
Intensified glucose control alone offers limited benefits for type 2 diabetes patients, as it provides only weak protection against cardiovascular outcomes and has not been shown to improve life expectancy. Combined treatment of all cardiovascular risk factors can significantly improve outcomes. The best approach is to consider a patient's individual prognosis, risks, and preferences when determining the appropriate treatment goals and therapies.
- Irritable bowel syndrome (IBS) affects 7-21% of the general population and is the most commonly diagnosed gastrointestinal condition. It is defined by abdominal pain or discomfort with altered bowel habits in the absence of underlying disease.
- Factors that contribute to IBS include alterations in the gut microbiome, intestinal permeability, immune function, motility, sensation, brain-gut interactions, and psychosocial status. Dietary triggers and a history of infection or antibiotics can also play a role.
- IBS substantially reduces quality of life and productivity. While some patients improve over time, it is generally a chronic relapsing condition. Diagnosis involves symptom evaluation and exclusion of other diseases through selected testing. Management
Comparative Outcomes of C difficile infected patients with NAP1 v non NAP1 st...Benjamin (Ben) Cottongim
This study compared outcomes between patients infected with the NAP1 strain of Clostridium difficile vs. non-NAP1 strains. The study found:
1) Mortality was not significantly different between groups, though NAP1 patients had 3% higher mortality.
2) NAP1 patients were more likely to have severe disease according to scoring indices, especially the University of Illinois severity index.
3) NAP1 patients were older, had lower albumin, and were more likely to have feeding tubes. Disease severity increased with age but did not affect mortality.
Clinical and epidemiological characteristics of childhood vitiligo a study of...tloanphan
This study analyzed clinical and epidemiological data from 701 children with vitiligo who were seen at a dermatology clinic in Brazil between 2006-2014. The main findings were:
1) Vitiligo was more common in females (62% of cases) and the average age of onset was 5.9 years.
2) The most common subtype was generalized vitiligo (53.8% of cases) and the most common initial site was the head/neck region (44.2% of cases).
3) Associated autoimmune diseases, family history of vitiligo, and the Koebner phenomenon were present in 6.5%, 16.9%, and 38.2% of
Clinical and epidemiological characteristics of childhoodtloanphan
This study analyzed clinical and epidemiological data from 701 children with vitiligo who were seen at a dermatology clinic in Brazil between 2006-2014. The main findings were:
1) Most patients were female (62%) and the average age of onset was 5.9 years. The most common subtype was generalized vitiligo (53.8%).
2) The most affected initial site was the head/neck region (44.2%). Emotional stressors were reported as triggering factors in 67% of patients.
3) Segmental and nonsegmental vitiligo differed significantly in characteristics like age of onset, presence of the Koebner phenomenon, associations with autoimmune diseases, and family
Vitiligo is a common autoimmune disease that causes loss of skin pigmentation. It has a significant psychological impact on patients' quality of life. There are different clinical presentations of vitiligo that provide clues about disease activity and prognosis. Segmental vitiligo presents as rapidly progressive patches but often stabilizes, whereas inflammatory, trichrome, and confetti-like lesions indicate more active disease. Recognizing vitiligo as treatable and initiating early treatment can help patients physically and psychologically.
Vitiligo clinical findings in 1436 patientstloanphan
This study analyzed clinical findings from 1436 patients with vitiligo seen between 1989-1993. The key findings were:
1) Vitiligo vulgaris was the most common type (69.8% of patients), followed by focal (14.9%) and segmental (5.0%) vitiligo.
2) The most common sites of onset were the face (22.9%), trunk (22.3%), and legs (18.6%). Less than 20% body area was involved in 94.4% of patients.
3) Associated conditions included atopic/nummular eczema (1.4%), bronchial asthma (0.7%), diabetes (0.
The document provides World Gastroenterology Organisation global guidelines on celiac disease from April 2012. It was reviewed by an international team and covers definitions, epidemiology, diagnosis, and management of celiac disease. Key points include that celiac disease affects genetically predisposed individuals and is triggered by ingestion of gluten. Diagnosis requires histological changes in intestinal biopsy and positive celiac disease serology or response to gluten-free diet. Management involves strict lifelong gluten-free diet to avoid complications.
This document discusses effective and cost-effective treatment for diabetes. It summarizes the key points made in the document in 3 sentences:
Intensified glucose control alone offers limited benefits for type 2 diabetes patients, as it provides only weak protection against cardiovascular outcomes and has not been shown to improve life expectancy. Combined treatment of all cardiovascular risk factors can significantly improve outcomes. The best approach is to consider a patient's individual prognosis, risks, and preferences when determining the appropriate treatment goals and therapies.
- Irritable bowel syndrome (IBS) affects 7-21% of the general population and is the most commonly diagnosed gastrointestinal condition. It is defined by abdominal pain or discomfort with altered bowel habits in the absence of underlying disease.
- Factors that contribute to IBS include alterations in the gut microbiome, intestinal permeability, immune function, motility, sensation, brain-gut interactions, and psychosocial status. Dietary triggers and a history of infection or antibiotics can also play a role.
- IBS substantially reduces quality of life and productivity. While some patients improve over time, it is generally a chronic relapsing condition. Diagnosis involves symptom evaluation and exclusion of other diseases through selected testing. Management
Comparative Outcomes of C difficile infected patients with NAP1 v non NAP1 st...Benjamin (Ben) Cottongim
This study compared outcomes between patients infected with the NAP1 strain of Clostridium difficile vs. non-NAP1 strains. The study found:
1) Mortality was not significantly different between groups, though NAP1 patients had 3% higher mortality.
2) NAP1 patients were more likely to have severe disease according to scoring indices, especially the University of Illinois severity index.
3) NAP1 patients were older, had lower albumin, and were more likely to have feeding tubes. Disease severity increased with age but did not affect mortality.
Clinical and epidemiological characteristics of childhood vitiligo a study of...tloanphan
This study analyzed clinical and epidemiological data from 701 children with vitiligo who were seen at a dermatology clinic in Brazil between 2006-2014. The main findings were:
1) Vitiligo was more common in females (62% of cases) and the average age of onset was 5.9 years.
2) The most common subtype was generalized vitiligo (53.8% of cases) and the most common initial site was the head/neck region (44.2% of cases).
3) Associated autoimmune diseases, family history of vitiligo, and the Koebner phenomenon were present in 6.5%, 16.9%, and 38.2% of
Clinical and epidemiological characteristics of childhoodtloanphan
This study analyzed clinical and epidemiological data from 701 children with vitiligo who were seen at a dermatology clinic in Brazil between 2006-2014. The main findings were:
1) Most patients were female (62%) and the average age of onset was 5.9 years. The most common subtype was generalized vitiligo (53.8%).
2) The most affected initial site was the head/neck region (44.2%). Emotional stressors were reported as triggering factors in 67% of patients.
3) Segmental and nonsegmental vitiligo differed significantly in characteristics like age of onset, presence of the Koebner phenomenon, associations with autoimmune diseases, and family
Vitiligo is a common autoimmune disease that causes loss of skin pigmentation. It has a significant psychological impact on patients' quality of life. There are different clinical presentations of vitiligo that provide clues about disease activity and prognosis. Segmental vitiligo presents as rapidly progressive patches but often stabilizes, whereas inflammatory, trichrome, and confetti-like lesions indicate more active disease. Recognizing vitiligo as treatable and initiating early treatment can help patients physically and psychologically.
Vitiligo clinical findings in 1436 patientstloanphan
This study analyzed clinical findings from 1436 patients with vitiligo seen between 1989-1993. The key findings were:
1) Vitiligo vulgaris was the most common type (69.8% of patients), followed by focal (14.9%) and segmental (5.0%) vitiligo.
2) The most common sites of onset were the face (22.9%), trunk (22.3%), and legs (18.6%). Less than 20% body area was involved in 94.4% of patients.
3) Associated conditions included atopic/nummular eczema (1.4%), bronchial asthma (0.7%), diabetes (0.
The document provides World Gastroenterology Organisation global guidelines on celiac disease from April 2012. It was reviewed by an international team and covers definitions, epidemiology, diagnosis, and management of celiac disease. Key points include that celiac disease affects genetically predisposed individuals and is triggered by ingestion of gluten. Diagnosis requires histological changes in intestinal biopsy and positive celiac disease serology or response to gluten-free diet. Management involves strict lifelong gluten-free diet to avoid complications.
This document discusses inflammatory bowel disease (IBD) and the relationship between psychological distress and symptom severity in IBD patients. It finds that IBD patients experience significant psychological symptoms like anxiety and depression that are correlated with worse physical symptoms. Current treatments primarily focus on medication but have adverse side effects and do not address psychological issues. The document proposes developing a new intervention for IBD patients that treats psychological distress in order to decrease symptom severity and improve quality of life.
C11 nonpharmacologic therapy and exercise in diabetes preventionDiabetes for all
Randomized controlled trials have demonstrated that lifestyle interventions focusing on diet and exercise can significantly prevent or delay the onset of type 2 diabetes. These trials showed that people with impaired glucose tolerance who received lifestyle advice like diet modification and increased physical activity had approximately a 50% lower risk of developing type 2 diabetes over follow-up periods ranging from 2-20 years compared to control groups. Maintaining a healthy lifestyle through diet and exercise can protect against most cases of type 2 diabetes.
This document summarizes a study that assessed the knowledge, attitudes, and practices of 100 patients with type 2 diabetes in Pakistan. The study found:
1) Patients had low overall awareness and knowledge about diabetes, glycemic control, risk factors, and complications. The mean correct answers regarding these topics ranged from 33.5-69%.
2) While 61% checked their blood sugar regularly, few knew the target glucose values. Only 18% understood diabetic diet.
3) Awareness of risk factors like hypertension, smoking, and obesity was higher at 69-92% but target values were unknown.
4) 23% first presented with complications and awareness of eye and renal complications was low at
This study investigated risk factors for progression from dengue fever (DF) to dengue hemorrhagic fever (DHF) in Brazil between 2009-2012. The study found that arterial hypertension and skin allergies were significant risk factors for developing DHF after being diagnosed with DF, with adjusted odds ratios of 1.6 and 1.8 respectively. The study highlights the need for close monitoring of DF patients with these comorbidities during dengue outbreaks to help identify potential DHF cases early and provide appropriate clinical management.
This document provides guidelines for the diagnosis, treatment and prevention of Clostridium difficile infections (CDI). It summarizes key recommendations with evidence grading. For diagnosis, it recommends nucleic acid amplification tests over toxin enzyme immunoassays, and only testing diarrheal stool samples. It stratifies treatment based on disease severity into mild-moderate (treat with metronidazole), severe (vancomycin with/without metronidazole), and complicated (vancomycin orally and rectally with intravenous metronidazole). It also covers recurrent CDI treatment, managing CDI in patients with comorbidities, and infection control practices like contact precautions and environmental disinfection. The guidelines
This document discusses prediabetes in children. It begins by defining prediabetes according to the ADA and WHO. It then discusses the prevalence of prediabetes in children, which ranges from 13.1-16.1% according to various studies. Risk factors for prediabetes in children include obesity, family history of diabetes, puberty, male sex, younger age, and certain ethnic origins. The pathophysiology and progression from prediabetes to diabetes is also reviewed. Treatment focuses on lifestyle changes and weight management, though some studies showed metformin may help in the short term. Screening and treatment guidelines are provided.
The University of Virginia Department of Medicine is hosting its 36th Annual Recent Advances in Clinical Medicine Conference from October 28-30, 2009 at the Omni Charlottesville Hotel. The conference will feature lectures on various medical specialties from allergy/immunology to psychiatry delivered by UVA faculty. Attendees will have opportunities for interactive case discussions and workshops. The goal is for attendees to learn how to better manage and evaluate patients for various clinical issues. Charlottesville provides a beautiful fall setting for the conference near Thomas Jefferson's UVA and Monticello estates.
This study surveyed home parenteral nutrition (HPN) in approved centers in France from 1993-1995. 524 new adult patients received HPN, with an incidence of 3.75 per 100,000 adults. Indications for AIDS increased from 8% to 18% while other indications remained stable. At six months, the probability of continuing treatment was 19.5% for cancer and AIDS but 52% for other diagnoses, with death rates of 59% and 9% respectively. Short-term treatment for cancer and AIDS patients was due to poor prognosis, while other patients had a good prognosis but dependency on long-term treatment.
This study examined the demographic profiles, risk factors, health problems, reasons for admission, and knowledge of diabetes patients admitted to BPKIHS hospital in Nepal. The results showed that over half of patients were aged 40-60 years old, Hindu, and married. About 60% had hypertension, 39% had eye problems, and 25% had kidney issues. The top reasons for admission were adjusting insulin doses, investigations, and treating complications. While most patients knew they had diabetes, their knowledge of causes, treatments, and prevention was limited. The study concluded there is a need for diabetes education programs to improve patient knowledge.
The document announces the 37th Annual Recent Advances in Clinical Medicine Conference hosted by the University of Virginia Department of Medicine from October 27-29, 2010 at the Omni Charlottesville Hotel. The conference will feature lectures on current issues in both outpatient and inpatient care, including sessions on sleep disorders and pain/addiction. It is intended for generalists and specialists to stay up-to-date on advances in medical care. Attendees can earn CME credits, network with faculty, and enjoy the scenic surroundings of Charlottesville in late October.
This document provides guidelines for managing hyperglycemia in type 2 diabetes from the American Diabetes Association and European Association for the Study of Diabetes. It summarizes that glycemic management has become complex with many treatment options and uncertainties about benefits. The guidelines aim to encourage individualized patient-centered care over prescriptive algorithms. Effective management of cardiovascular risk factors is also important given risks of complications. The guidelines stress shared decision making between clinicians and patients based on evidence and patient preferences and needs.
Susan Mitchell-Care of the Patient with Advanced Dementia: What Physicians Ne...jewishhome
This document discusses care of patients with advanced dementia. It summarizes that dementia is a terminal illness and the most common complications are feeding problems and infections. Aggressive interventions are less likely when families understand the prognosis and expected complications. Tube feeding is not recommended as it does not provide benefits and antibiotics for pneumonia may prolong life but cause more discomfort. Most hospital transfers can be avoided by managing complications in the nursing home based on the goals of comfort care. The document emphasizes making ethical decisions guided by the patient's goals of care rather than feeling compelled to offer all possible interventions.
Frequency of migraine headaches in patients with fibromyalgiaPaul Coelho, MD
- The study evaluated the frequency of migraine headaches in a large cohort of patients with fibromyalgia using a brief migraine screening tool.
- Of the 1730 patients with fibromyalgia who completed the survey, 966 (55.8%) met the criteria for migraine headaches based on the screening tool.
- Several comorbid conditions such as depression, anxiety, chronic fatigue syndrome, and irritable bowel syndrome were found to be significantly more common in those fibromyalgia patients who also met the criteria for migraines.
Novel Approach Of Diabetes Disease Classification By Support Vector Machine W...IJARIIT
Early diagnosis of any disease with less cost is always preferable. Diabetes is one such disease. It has become the fourth leading cause of death in developed countries and is also reaching epidemic proportions in many developing and newly industrialized nations. Diabetes leads to increase in the risks of developing kidney disease, blindness, nerve damage, blood vessel damage and heart disease also. In this study, we investigate an automatic approach to diagnose Diabetes disease based on Bacterial Foraging Optimization and Artificial Neural Network .firstly, we applied Bacterial Foraging Optimization for features selection and then we implement artificial neural network for finding out the classification accuracy. The proposed SVM method obtains 87.23% accuracy on UCI diabetes dataset which is better than other models.
Secondly, we applied again Bacterial foraging optimization for features selection and then we applied support vector machine for finding out the classification accuracy .The proposed Correlation with SVM method obtains on UCI dataset.
Toluwalase Ajayi MD presented on palliative care for patients with dementia. Key points include:
- Dementia prevalence is increasing as the population ages and life expectancy rises.
- Palliative care aims to improve quality of life for patients and families dealing with dementia.
- Management involves a multidisciplinary team and focuses on both pharmacological and non-pharmacological approaches.
- Advance care planning is important to help families navigate challenging end-of-life decisions as the disease progresses.
The document provides information from a community needs assessment conducted to inform a presentation for a high school health class. An observation of the class found it to be quiet and unparticipatory. A survey of students found most had heard of celiac disease and a gluten-free diet but lacked detailed knowledge. It was determined a presentation on celiac disease, gluten intolerance, and gluten-free diets would be most appropriate, incorporating activities to engage the class.
The document summarizes 5 research articles related to diabetes. It discusses the purpose, background, methods, subjects, data collection and analysis, and conclusions of each study. The first study examined pregnant women's knowledge of gestational diabetes prevention. The second looked at factors influencing insulin initiation in UK adults with diabetes. The third evaluated the relationship between continuous glucose monitoring and type 1 diabetes management. The fourth assessed the link between vitamin D intake and risk of type 1 diabetes in infants. The fifth studied the association between erectile dysfunction and glycemic control in men with type 2 diabetes.
The document describes a study protocol for a randomized controlled trial evaluating a "self-selected" lifestyle intervention aimed at improving insulin sensitivity in people at risk of developing type 2 diabetes. 360 subjects at risk will be randomly assigned to a control group receiving general lifestyle/diabetes risk information or an intervention group participating in a 12-week supervised exercise program with dietary advice. The primary outcome is change in insulin sensitivity. Secondary outcomes include other measures of glucose function, fitness, body composition, and quality of life. The intervention group will choose their own exercise classes 4 times per week and receive guidance to modify dietary choices. The study will assess if this self-selected approach improves diabetes risk factors more than the control.
This document provides guidelines for treating diabetic ketoacidosis (DKA) in children and adolescents. It recommends:
1. Using capillary blood ketone measurements during treatment and reducing the degree of dehydration used to calculate fluid needs.
2. Starting intravenous fluids for at least an hour before beginning insulin at 0.1 units/kg/hour, and continuing insulin even after blood glucose falls below 14 mmol/L.
3. Providing potassium with rehydration fluids at 20 mmol/L and monitoring electrolytes frequently, using cardiac monitoring for changes.
4. Carefully monitoring patients for cerebral edema, a potentially fatal complication, and treating it urgently with hypertonic saline or
This document describes the case of an 8-year-old girl brought to the emergency department with vomiting, breathlessness, fever, and altered mental status due to diabetic ketoacidosis (DKA). Her history of type 1 diabetes and discontinuing insulin therapy for 2 days contributed to the development of DKA. On examination, she had a low blood pressure, tachycardia, and altered mental status. Laboratory findings showed high blood glucose, low bicarbonate, and ketones in the urine, consistent with DKA. She was treated according to the Milwaukee protocol for DKA, which involves slow correction of dehydration with intravenous fluids, administration of insulin, and monitoring of electrolytes and mental status. Her
this power point descripe diabetic ketoacidosis in pediatric age group .. we talk about the risk of it .. management specially (fluid management) as case study .. complications and the treatment of brain oedema .. i hope to be auseful one .. enjoy
This document discusses inflammatory bowel disease (IBD) and the relationship between psychological distress and symptom severity in IBD patients. It finds that IBD patients experience significant psychological symptoms like anxiety and depression that are correlated with worse physical symptoms. Current treatments primarily focus on medication but have adverse side effects and do not address psychological issues. The document proposes developing a new intervention for IBD patients that treats psychological distress in order to decrease symptom severity and improve quality of life.
C11 nonpharmacologic therapy and exercise in diabetes preventionDiabetes for all
Randomized controlled trials have demonstrated that lifestyle interventions focusing on diet and exercise can significantly prevent or delay the onset of type 2 diabetes. These trials showed that people with impaired glucose tolerance who received lifestyle advice like diet modification and increased physical activity had approximately a 50% lower risk of developing type 2 diabetes over follow-up periods ranging from 2-20 years compared to control groups. Maintaining a healthy lifestyle through diet and exercise can protect against most cases of type 2 diabetes.
This document summarizes a study that assessed the knowledge, attitudes, and practices of 100 patients with type 2 diabetes in Pakistan. The study found:
1) Patients had low overall awareness and knowledge about diabetes, glycemic control, risk factors, and complications. The mean correct answers regarding these topics ranged from 33.5-69%.
2) While 61% checked their blood sugar regularly, few knew the target glucose values. Only 18% understood diabetic diet.
3) Awareness of risk factors like hypertension, smoking, and obesity was higher at 69-92% but target values were unknown.
4) 23% first presented with complications and awareness of eye and renal complications was low at
This study investigated risk factors for progression from dengue fever (DF) to dengue hemorrhagic fever (DHF) in Brazil between 2009-2012. The study found that arterial hypertension and skin allergies were significant risk factors for developing DHF after being diagnosed with DF, with adjusted odds ratios of 1.6 and 1.8 respectively. The study highlights the need for close monitoring of DF patients with these comorbidities during dengue outbreaks to help identify potential DHF cases early and provide appropriate clinical management.
This document provides guidelines for the diagnosis, treatment and prevention of Clostridium difficile infections (CDI). It summarizes key recommendations with evidence grading. For diagnosis, it recommends nucleic acid amplification tests over toxin enzyme immunoassays, and only testing diarrheal stool samples. It stratifies treatment based on disease severity into mild-moderate (treat with metronidazole), severe (vancomycin with/without metronidazole), and complicated (vancomycin orally and rectally with intravenous metronidazole). It also covers recurrent CDI treatment, managing CDI in patients with comorbidities, and infection control practices like contact precautions and environmental disinfection. The guidelines
This document discusses prediabetes in children. It begins by defining prediabetes according to the ADA and WHO. It then discusses the prevalence of prediabetes in children, which ranges from 13.1-16.1% according to various studies. Risk factors for prediabetes in children include obesity, family history of diabetes, puberty, male sex, younger age, and certain ethnic origins. The pathophysiology and progression from prediabetes to diabetes is also reviewed. Treatment focuses on lifestyle changes and weight management, though some studies showed metformin may help in the short term. Screening and treatment guidelines are provided.
The University of Virginia Department of Medicine is hosting its 36th Annual Recent Advances in Clinical Medicine Conference from October 28-30, 2009 at the Omni Charlottesville Hotel. The conference will feature lectures on various medical specialties from allergy/immunology to psychiatry delivered by UVA faculty. Attendees will have opportunities for interactive case discussions and workshops. The goal is for attendees to learn how to better manage and evaluate patients for various clinical issues. Charlottesville provides a beautiful fall setting for the conference near Thomas Jefferson's UVA and Monticello estates.
This study surveyed home parenteral nutrition (HPN) in approved centers in France from 1993-1995. 524 new adult patients received HPN, with an incidence of 3.75 per 100,000 adults. Indications for AIDS increased from 8% to 18% while other indications remained stable. At six months, the probability of continuing treatment was 19.5% for cancer and AIDS but 52% for other diagnoses, with death rates of 59% and 9% respectively. Short-term treatment for cancer and AIDS patients was due to poor prognosis, while other patients had a good prognosis but dependency on long-term treatment.
This study examined the demographic profiles, risk factors, health problems, reasons for admission, and knowledge of diabetes patients admitted to BPKIHS hospital in Nepal. The results showed that over half of patients were aged 40-60 years old, Hindu, and married. About 60% had hypertension, 39% had eye problems, and 25% had kidney issues. The top reasons for admission were adjusting insulin doses, investigations, and treating complications. While most patients knew they had diabetes, their knowledge of causes, treatments, and prevention was limited. The study concluded there is a need for diabetes education programs to improve patient knowledge.
The document announces the 37th Annual Recent Advances in Clinical Medicine Conference hosted by the University of Virginia Department of Medicine from October 27-29, 2010 at the Omni Charlottesville Hotel. The conference will feature lectures on current issues in both outpatient and inpatient care, including sessions on sleep disorders and pain/addiction. It is intended for generalists and specialists to stay up-to-date on advances in medical care. Attendees can earn CME credits, network with faculty, and enjoy the scenic surroundings of Charlottesville in late October.
This document provides guidelines for managing hyperglycemia in type 2 diabetes from the American Diabetes Association and European Association for the Study of Diabetes. It summarizes that glycemic management has become complex with many treatment options and uncertainties about benefits. The guidelines aim to encourage individualized patient-centered care over prescriptive algorithms. Effective management of cardiovascular risk factors is also important given risks of complications. The guidelines stress shared decision making between clinicians and patients based on evidence and patient preferences and needs.
Susan Mitchell-Care of the Patient with Advanced Dementia: What Physicians Ne...jewishhome
This document discusses care of patients with advanced dementia. It summarizes that dementia is a terminal illness and the most common complications are feeding problems and infections. Aggressive interventions are less likely when families understand the prognosis and expected complications. Tube feeding is not recommended as it does not provide benefits and antibiotics for pneumonia may prolong life but cause more discomfort. Most hospital transfers can be avoided by managing complications in the nursing home based on the goals of comfort care. The document emphasizes making ethical decisions guided by the patient's goals of care rather than feeling compelled to offer all possible interventions.
Frequency of migraine headaches in patients with fibromyalgiaPaul Coelho, MD
- The study evaluated the frequency of migraine headaches in a large cohort of patients with fibromyalgia using a brief migraine screening tool.
- Of the 1730 patients with fibromyalgia who completed the survey, 966 (55.8%) met the criteria for migraine headaches based on the screening tool.
- Several comorbid conditions such as depression, anxiety, chronic fatigue syndrome, and irritable bowel syndrome were found to be significantly more common in those fibromyalgia patients who also met the criteria for migraines.
Novel Approach Of Diabetes Disease Classification By Support Vector Machine W...IJARIIT
Early diagnosis of any disease with less cost is always preferable. Diabetes is one such disease. It has become the fourth leading cause of death in developed countries and is also reaching epidemic proportions in many developing and newly industrialized nations. Diabetes leads to increase in the risks of developing kidney disease, blindness, nerve damage, blood vessel damage and heart disease also. In this study, we investigate an automatic approach to diagnose Diabetes disease based on Bacterial Foraging Optimization and Artificial Neural Network .firstly, we applied Bacterial Foraging Optimization for features selection and then we implement artificial neural network for finding out the classification accuracy. The proposed SVM method obtains 87.23% accuracy on UCI diabetes dataset which is better than other models.
Secondly, we applied again Bacterial foraging optimization for features selection and then we applied support vector machine for finding out the classification accuracy .The proposed Correlation with SVM method obtains on UCI dataset.
Toluwalase Ajayi MD presented on palliative care for patients with dementia. Key points include:
- Dementia prevalence is increasing as the population ages and life expectancy rises.
- Palliative care aims to improve quality of life for patients and families dealing with dementia.
- Management involves a multidisciplinary team and focuses on both pharmacological and non-pharmacological approaches.
- Advance care planning is important to help families navigate challenging end-of-life decisions as the disease progresses.
The document provides information from a community needs assessment conducted to inform a presentation for a high school health class. An observation of the class found it to be quiet and unparticipatory. A survey of students found most had heard of celiac disease and a gluten-free diet but lacked detailed knowledge. It was determined a presentation on celiac disease, gluten intolerance, and gluten-free diets would be most appropriate, incorporating activities to engage the class.
The document summarizes 5 research articles related to diabetes. It discusses the purpose, background, methods, subjects, data collection and analysis, and conclusions of each study. The first study examined pregnant women's knowledge of gestational diabetes prevention. The second looked at factors influencing insulin initiation in UK adults with diabetes. The third evaluated the relationship between continuous glucose monitoring and type 1 diabetes management. The fourth assessed the link between vitamin D intake and risk of type 1 diabetes in infants. The fifth studied the association between erectile dysfunction and glycemic control in men with type 2 diabetes.
The document describes a study protocol for a randomized controlled trial evaluating a "self-selected" lifestyle intervention aimed at improving insulin sensitivity in people at risk of developing type 2 diabetes. 360 subjects at risk will be randomly assigned to a control group receiving general lifestyle/diabetes risk information or an intervention group participating in a 12-week supervised exercise program with dietary advice. The primary outcome is change in insulin sensitivity. Secondary outcomes include other measures of glucose function, fitness, body composition, and quality of life. The intervention group will choose their own exercise classes 4 times per week and receive guidance to modify dietary choices. The study will assess if this self-selected approach improves diabetes risk factors more than the control.
This document provides guidelines for treating diabetic ketoacidosis (DKA) in children and adolescents. It recommends:
1. Using capillary blood ketone measurements during treatment and reducing the degree of dehydration used to calculate fluid needs.
2. Starting intravenous fluids for at least an hour before beginning insulin at 0.1 units/kg/hour, and continuing insulin even after blood glucose falls below 14 mmol/L.
3. Providing potassium with rehydration fluids at 20 mmol/L and monitoring electrolytes frequently, using cardiac monitoring for changes.
4. Carefully monitoring patients for cerebral edema, a potentially fatal complication, and treating it urgently with hypertonic saline or
This document describes the case of an 8-year-old girl brought to the emergency department with vomiting, breathlessness, fever, and altered mental status due to diabetic ketoacidosis (DKA). Her history of type 1 diabetes and discontinuing insulin therapy for 2 days contributed to the development of DKA. On examination, she had a low blood pressure, tachycardia, and altered mental status. Laboratory findings showed high blood glucose, low bicarbonate, and ketones in the urine, consistent with DKA. She was treated according to the Milwaukee protocol for DKA, which involves slow correction of dehydration with intravenous fluids, administration of insulin, and monitoring of electrolytes and mental status. Her
this power point descripe diabetic ketoacidosis in pediatric age group .. we talk about the risk of it .. management specially (fluid management) as case study .. complications and the treatment of brain oedema .. i hope to be auseful one .. enjoy
DIABETES MELLITUS TYPE 1 & MANAGEMENT OF DIABETIC KETOACIDOSIS Rakesh Verma
1) Type 1 diabetes is characterized by low or absent insulin production and is caused by autoimmune destruction of pancreatic beta cells.
2) It requires lifelong insulin replacement therapy via injections or pumps to control blood glucose levels and prevent complications.
3) Intensive insulin regimens aim to mimic normal physiology using rapid, short, intermediate and long-acting insulin preparations in combination with diet, exercise and glucose monitoring.
CASE PRESENTATION ON DIABETIC KETOACIDOSIS (DKA)Aaromal Satheesh
This patient, an 11-year-old female, presented with diabetic ketoacidosis symptoms including fever, excessive urination and thirst. Laboratory tests found elevated blood sugar, urine ketones and dehydration. She was treated with IV fluids, insulin and monitoring of blood sugar and electrolytes. Her symptoms improved over time and she was discharged with a prescription for long-acting insulin and diet and lifestyle counseling.
The document discusses diabetic ketoacidosis (DKA), providing information on its pathophysiology, classification, epidemiology, clinical manifestations, diagnosis, and treatment in individuals with type 1 diabetes mellitus. DKA results from a lack of insulin leading to hyperglycemia and ketone production. Its presentation includes vomiting, Kussmaul breathing, and if severe, cerebral edema. Treatment involves fluid resuscitation, electrolyte replacement, low-dose insulin infusion to resolve acidosis without rapidly lowering blood glucose, and careful monitoring to prevent cerebral edema.
Celiac disease is a lifelong autoimmune disorder triggered by ingesting gluten, which damages the small intestine. Several studies examined factors that influence the risk and development of celiac disease. Introducing gluten at 12 months rather than 6 months had no long-term effect on risk. Gradually introducing gluten between 4-6 months while breastfeeding may reduce risk. A randomized controlled trial found introducing small amounts of gluten at 16-24 weeks did not reduce risk by age 3. Genetics play a role, as the HLA-DQ2 and HLA-DQ8 genes increase susceptibility. Ongoing education is important for managing the lifelong gluten-free diet required to treat celiac disease.
This document discusses childhood diabetes mellitus. It is authored by Prof. Dr. Saad S Al- Ani, a pediatric consultant and head of the pediatric department at Khorfakkan Hospital in Sharjah, UAE. The document discusses that rates of both type 1 and type 2 diabetes are rising in children. It outlines symptoms of childhood diabetes like thirst, tiredness, weight loss, frequent urination, and behavioral issues. It also discusses treatment which primarily involves insulin therapy. Good glucose control and lifestyle changes are important for managing the condition. The prevalence of both type 1 and type 2 diabetes increased significantly in children over the last 5 years.
nejm obesidad en adolescente. 2102062.pdfmedineumo
obesidad en adolescente: suscríbase a nuestro canal de YouTube _MediNeumo_
La obesidad durante la adolescencia (10 a 19 años de edad) está asociada con consecuencias para la salud que incluyen prediabetes y diabetes tipo 2, enfermedad del hígado graso no alcohólico, dislipidemia, síndrome de ovario poliquístico (SOP), apnea obstructiva del sueño, y salud mental trastornos y estigma social. demás, la obesidad durante la adolescencia es un factor de riesgo de complicaciones y muerte por enfermedad coronaria , así como de muerte por cualquier causa en la edad adulta, incluida la edad adulta temprana.
Community Based Pilot Study of Diagnostic Paths to the Gluten Free DietChristopher Barrett
This community-based pilot study examined the diagnostic paths that 59 individuals (mostly female, average age 54.6) took to adopting a gluten-free diet. Most participants consulted multiple medical professionals over an average of 7 years due to atypical or overlapping symptoms. While 55% presented with classic celiac symptoms, negative biopsy or blood tests and overlapping conditions delayed diagnosis for others. The study found 43 participants were diagnosed with celiac disease and 16 with non-celiac gluten sensitivity, with little difference in their reported symptom levels. Self-diagnosis and consultation with naturopaths accounted for some adopting a gluten-free diet beyond predicted prevalence rates of 1-2%.
Background: Incidence of diabetes mellitus continues to rise, common focus areas for diabetes control are blood glucose levels, diet, and exercise. Controlling these factors are essential for a better quality of life in diabetes patients. Patients with diabetes have an increased risk of asymptomatic bacteriuria and pyuria, cystitis, and, more important, serious upper urinary tract infection.
Materials and Methods: This was a hospital based descriptive and cross-sectional study which included 250 Study subjects who were admitted in CSI Kalyani General hospital during the period from July 2017 to July 2018 and who has Diabetic as a comorbidity were interviewed using structured protocol based proforma. Patient underwent routine clinical, pathological and biochemical investigations.
Results: In this study, 250 in-patients were included and analyzed. The prevalence of Infection in Diabetes mellitus was 65.6%. There is no significant association between Age, Education, Occupation, HbA1C, Duration and type of treatment and biochemical values. The commonest organism in Urine sample among the study group was E.coli followed by Klebsiella. UTI is more common in females, Respiratory infection is more common in males and it is statistically significant (p<0.009) and it is statistically significant (p<0.007).
Conclusion: From this study, we have concluded that patient with diabetes mellitus is at increased risk for common infections due to poor glycemic control and Obesity. Poor glycemic control suppresses the immunity and more prone for infection. Therefore, the challenges will be to attain good glycemic control, change in lifestyle to maintain normal BMI. This will prevent the morbimortality, reduce the long-term complication and maintenance to prolong the life without any sequele. More prospective case control studies on the management of infections in DM patients are needed.
Keywords: type 2 diabetes mellitus, infections, clinical profile, hba1c, glycemic control
Diabetic is a well known public health problem of today. There are many risk factors of it, which can be identified in pre-diabetic state. So the present study was conducted with the aim to know the status of anthropometric and haematological parameters in pre-diabetic states. For this hospital based study pre-diabetic subjects were identified from first degree relatives of type 2 DM Patients, enrolled in diabetic research centre P.B.M. hospital Bikaner. Relevant investigations were done. Data thus collected on semi-structured questionnaire and analysed using content analysis. Data analysis revealed that although mean Body Mass Index (BMI) was within normal range but Waist circumference (WC), West Hip (W/H) Ratio, Systolic blood pressure were higher than the normal range accepted for that parameter. But mean value of all the studied haematological parameter were within the normal range accepted for that parameter. So it can be conclude that anthropology of an individual may be associated with the pre-diabetic state. Hypertension was found in 25.35% of pre-diabetics. Further researches are necessary to find out this possible association of anthropologic parameter and pre-diabetic state.
Diabetes Type 1 Sara MartinezChamberlain College of Nursing.docxlynettearnold46882
Diabetes Type 1
Sara Martinez
Chamberlain College of Nursing
NR 507 Advanced Pathophysiology
2018
1
1
What is Diabetes
Body Does not make or properly use insulin: (ADA,2005)
No insulin production
Insufficient insulin production
Resistance to insulin’s effects
No insulin to move glucose from blood into cells
High blood glucose means:
Fuel loss, cells starve
Short and long term complications
2
Diabetes is a chronic disease in which the body does not make or properly
use insulin, a hormone that is needed to convert sugar, starches, and other
food into energy by moving glucose from blood into the cells ( American Diabetes Association, 2005).
People with diabetes have increased blood glucose (sugar) levels for one or
more of the following three reasons: Either
No insulin is being produced,
Insulin production is insufficient, and/or
The body is resistant to the effects of insulin.
As a result, high levels of glucose build up in the blood, and spill into the
urine and out of the body. The body loses its main source of fuel and cells
are deprived of glucose, a needed source of energy. High blood glucose
levels may result in short and long term complications over time ( Centers for Disease Control and Prevention, 2017).
2
Understanding Diabetes Type 1
Auto immune disorder
Insulin – producing cells destroyed
Daily insulin replacement necessary
Age of onset: usually childhood, young adults
Most prevalent type of diabetes in children and adolescent’s
(CDC,2017)
3
Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both (CDC,2017).
The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.
The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.
Diabetes is a condition where the body fails to utilize the ingested glucose properly. This could be due to lack of the hormone insulin or because the insulin that is available is not working effectively. Diabetes is the fastest growing long term disease that affects millions of people worldwide (CDC,2017). According to the charity Diabetes UK, more than two million people in the UK have the condition and up to 750,000 more are unaware of having the condition. In the United States 25.8 million people or 8.3% of the population have diabetes. Of these, 7.0 million have undiagnosed diabetes. In 2010, about 1.9 million new cases of diabetes were diagnosed in population over 20 years. It is said that if this trend continues, 1 in 3 Americans would be diabetic by 2050 (Mayo Clinic, 2017).
Type 1 diabetes is a disease of the immune system, which is the body’s system for fighting infection.
In people with type 1 diabetes, the .
RunningHead: PICOT Question 1
RunningHead: PICOT Question 7
PICOT Question
Avery Bryan
NRS-433V
Professor Christine Vannelli
May 19, 2019
Clinical Problem
A report from the Center for Disease Control and Prevention in 2015 revealed that (9.4%) 30.3 million Americans are diabetic and 84.1 million have prediabetes. This is a total population of over 100 million is at risk of developing type 2 diabetes which is a growing health problem being the seventh leading cause of death in the U.S. An estimated 1.5 million new cases were among 18-year old bracket and the rates of diagnosed diabetes increased proportionally to age. Below 44 years accounted for 4%, below 64 years at 17 % and 25% for those above 65 years across both genders. One-third of adults in America has prediabetes but sadly, they are unaware despite reports released by The National Diabetes Statistics Report every year. These reports elaborate on prevalence and incidence, prediabetes, long-term complications, risk factors, mortality, and cost. Diabetes poses the risk of serious complications like death, blindness, stroke, kidney disorders, cardiac diseases and health problems that lead to amputation of legs. However, the risks can be mitigated through physical body activities, proper dieting and prescribed use of insulin and other related measures to control the blood sugar levels. Diabetes Prevention Program was funded by NIH to research a yearly evidence-based program to improve healthy weight loss through diet and physical activities. There also efforts to determine the effectiveness of public service campaigns in improving the real-life experience in the diagnosis and treatment of diabetes.
PICOT Question.
The population affected by diabetes cuts across all ages, gender, race, and ethnicity. The prevalence is significantly high from 18 years and it increases with age to about 25% above 65 years. In terms of gender, men are at higher risk accounting for 37% while women are at 30% across races and educational levels. On races, the rates were higher among Indians/Alaska natives at 15%, non-Hispanic blacks at 12.7% and Hispanics at 12%. Among Asians, the rates were lower at 8% and 7.4% for non-Hispanic whites.
Intervention indicator for diabetes shows that individuals who do not observe a healthy diet are more exposed to the disease. Some risk behaviors include lack of exercise and excessive intake of junk foods that lead to obesity and increased blood sugar levels. Diabetes prevalence varied according to education levels were those with less than high school education at 12.6% and 7.2% for those higher than high school education.
Comparison and use of a control group from the popularity of Complementary and Alternative Medicine and Traditional Chinese Medicine showed distinct knowledge of diabetes, blood sugar control, and self-care. The experimental group received education through interactive multimedia for three months while the control group received.
1. The study examined whether genetic and childhood clinical risk factors can predict adult dyslipidemia using data from the Cardiovascular Risk in Young Finns Study, a long-term study of Finnish children and adults.
2. The results showed that childhood lipid levels and genetic risk scores based on 157 lipid-associated SNPs were independently associated with dyslipidemia in adulthood 31 years later.
3. Including genetic risk scores in childhood lipid screening programs could modestly improve identification of individuals at highest risk of adult dyslipidemia.
Epidemiological study of diabetes mellitus dm among different ethnic segments...pharmaindexing
This study conducted an epidemiological survey of diabetes mellitus among different ethnic groups in Pakistan. The survey found:
1) The prevalence of diabetes in adults over 25 was 0.74 with a relative risk of 1.49, while prevalence in geriatrics was lower at 0.22.
2) Type 2 diabetes had a prevalence of 0.72 while type 1 was lower at 0.21.
3) The ethnic group with the highest prevalence was Sindhi of Urdu speaking origin at 28%, followed by Punjabi at 27% and Sindhi of Sindhi speakers at 20%.
The Journal of NutritionSymposium Nutritional Experiences.docxarnoldmeredith47041
1. Poor growth in utero is associated with increased risk of diseases like type 2 diabetes later in life. Studies in humans and animals provide evidence that early nutrition plays an important role in this relationship.
2. A study of twins found that the twin with lower birth weight was more likely to develop type 2 diabetes, indicating the importance of prenatal environmental factors over genetics. Studies of people born during the Dutch famine linked maternal malnutrition to impaired glucose tolerance in offspring.
3. In animal models, maternal protein restriction in rats leads to low birth weight offspring that develop insulin resistance and type 2 diabetes. This is associated with changes in the expression of genes related to insulin signaling and may represent an early risk factor for metabolic
impact of covid19 pandemic on long term trends in the prevalence of DKA at di...AncutaCaliment2
The study analyzed data from 104,290 children diagnosed with type 1 diabetes between 2006-2021 across 13 countries. It found an increasing trend in the prevalence of diabetic ketoacidosis (DKA) at diagnosis, which rose further during the COVID-19 pandemic in 2020-2021. Stricter pandemic containment policies were modestly associated with higher DKA rates. The increases suggest delays in diagnosis rather than pandemic severity or Sars-Cov-2 infection directly causing more DKA cases. Improving public awareness of type 1 diabetes symptoms and screening programs could help address the concerning global rise in pediatric DKA.
This document discusses global and national trends in diabetes prevalence. It finds that the number of people with diabetes worldwide is projected to increase from 171 million in 2000 to 366 million by 2030, with more than 80% of people with diabetes living in low- and middle-income countries. In the US, diabetes prevalence is projected to increase over 50% and certain ethnic groups like Native Americans have disproportionately high rates. Childhood obesity is rising sharply in the US, which will profoundly impact obstetrics and pediatrics in coming decades by increasing rates of childhood and adolescent diabetes. Meticulous prenatal care can help reduce excessive fetal and neonatal risks for women with diabetes during pregnancy, though risks are still higher than for non-di
This document discusses hyperglycemic crises in adult patients with diabetes, specifically diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). It outlines:
1) DKA and HHS are metabolic complications of diabetes caused by insulin deficiency and counterregulatory hormone excess, leading to hyperglycemia, ketosis, and metabolic acidosis in DKA or severe hyperglycemia and dehydration in HHS.
2) Common precipitating factors are infection, discontinuation of insulin therapy, and acute illnesses. Symptoms can range from mild to life-threatening coma.
3) Diagnosis is based on clinical history and lab criteria including blood
Diabetes is a rapidly and serious health problem in Pakistan. This chronic condition is associated with serious long-term complications, including higher risk of heart disease and stroke. Aggressive treatment of hypertension and hyperlipideamia can result in a substantial reduction in cardiovascular events in patients with diabetes 1. Consequently pharmacist-led diabetes cardiovascular risk (DCVR) clinics have been established in both primary and secondary care sites in NHS Lothian during the past five years. An audit of the pharmaceutical care delivery at the clinics was conducted in order to evaluate practice and to standardize the pharmacists’ documentation of outcomes. Pharmaceutical care issues (PCI) and patient details were collected both prospectively and retrospectively from three DCVR clinics. The PCI`s were categorized according to a triangularised system consisting of multiple categories. These were ‘checks’, ‘changes’ (‘change in drug therapy process’ and ‘change in drug therapy’), ‘drug therapy problems’ and ‘quality assurance descriptors’ (‘timer perspective’ and ‘degree of change’). A verified medication assessment tool (MAT) for patients with chronic cardiovascular disease was applied to the patients from one of the clinics. The tool was used to quantify PCI`s and pharmacist actions that were centered on implementing or enforcing clinical guideline standards. A database was developed to be used as an assessment tool and to standardize the documentation of achievement of outcomes. Feedback on the audit of the pharmaceutical care delivery and the database was received from the DCVR clinic pharmacist at a focus group meeting.
THE PREVALENCE AND IMPACT OF DIABETIC RETINOPATHY AMONG TYPE 2 DIABETES POPUL...indexPub
Objective: This study aimed to evaluate the prevalence and visual impact of Diabetic Retinopathy (DR) among individuals with Type 2 Diabetes (T2D) in Hazara, Pakistan. Methods: A cross-sectional study was conducted from May to August 2023. The sample consisted of 1332 patients who attended the Outpatient Department for eye examination, with 133 (10%) identified as diabetics. Parameters such as glycemic control, HbA1C levels, comorbidities, family history, medication, lifestyle factors, and ocular manifestations were analyzed. Results: The study indicated that 73.01% of diabetic patients had uncontrolled glycemic levels. The prevalence of refractive errors was high (84.12%), and the incidence of DR was significant, with 6.34% having proliferative DR. The findings also emphasized lifestyle factors, including screen usage and spectacle usage patterns. In addition, weight-height proportions and a family history of diabetes were associated with the incidence of DR. Conclusion: The high prevalence of uncontrolled diabetes and significant incidence of DR underscores the urgent need for improved diabetes management and regular screenings for early detection of DR. The results advocate for prioritizing regular health checkups, enhancing public health strategies, and improving accessibility to healthcare facilities, particularly in rural regions.
This document summarizes a study that aimed to identify subtypes of type 2 diabetes (T2D) based on clinical characteristics before diagnosis and determine if genetic risk factors differ between the subtypes. The study used clustering analysis to group 832 T2D cases into two clusters based on metabolic and anthropometric measurements. Cox proportional hazards models were then used to test if T2D genetic risk factors differed between the clusters. The clustering resulted in two clusters with cluster one having a higher percentage of women and higher values for waist-to-hip ratio, HDL, and fasting insulin. No statistically significant differences were found in genetic risk factors between the clusters, though adiposity genes were most associated with T2D risk, suggesting an interaction
Diabetes mellitus is a metabolic disorder characterized by high blood glucose levels due to either lack of insulin production or resistance to insulin. It ranges from asymptomatic to causing severe health issues like cardiovascular disease if uncontrolled. Risk factors include genetics, obesity, physical inactivity, and diet. Prevention strategies involve education, screening high risk groups, early treatment, and ongoing management of the condition and related health factors.
Similar to Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults a systematic review (20)
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kol...rightmanforbloodline
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Versio
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
TEST BANK For An Introduction to Brain and Behavior, 7th Edition by Bryan Kolb, Ian Q. Whishaw, Verified Chapters 1 - 16, Complete Newest Version
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Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
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Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults a systematic review
1. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 1 of 16
Research
RESEARCH
Factors associated with the presence of diabetic
ketoacidosis at diagnosis of diabetes in children and
young adults: a systematic review
Juliet A Usher-Smith academic clinical fellow 1, Matthew J Thompson senior clinical scientist 2,
Stephen J Sharp senior statistician 3, Fiona M Walter clinical lecturer in general practice 1
1
General Practice and Primary Care Research Unit, University of Cambridge, Cambridge CB2 0SR, UK; 2Department of Primary Health Care,
University of Oxford, Oxford OX3 7LF, UK; 3MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge CB2 0QQ
Abstract symptom onset and development of diabetic ketoacidosis for both parents
Objective To identify the factors associated with diabetic ketoacidosis and clinicians.
at diagnosis of type 1 diabetes in children and young adults.
Introduction
Design Systematic review.
Data sources PubMed, EMBASE, Web of Science, Scopus, and Cinahl
Type 1 diabetes is one of the most common endocrine diseases
and article reference lists.
in children. Worldwide, an estimated 65 000 children under 15
years old develop the disease each year, and the global incidence
Study selection Cohort studies including unselected groups of children
in children continues to increase at a rate of 3% a year.1 2 The
and young adults presenting with new onset type 1 diabetes that
current incidence in the UK is around 26/100 000 per year.3
distinguished between those who presented in diabetic ketoacidosis and
those who did not and included a measurement of either pH or
Between 10% and 70% of these diagnosed children present in
bicarbonate in the definition of diabetic ketoacidosis. There were no
diabetic ketoacidosis, a metabolic derangement characterised
restrictions on language of publication.
by the triad of hyperglycaemia, acidosis, and ketonuria. The
current criteria for diagnosis published by the International
Results 46 studies involving more than 24 000 children in 31 countries
Society for Paediatric and Adolescent Diabetes is blood glucose
were included. Together they compared 23 different factors. Factors
>11 mmol/L, venous pH <7.3 or bicarbonate <15 mmol/L, and
associated with increased risk were younger age (for <2 years old v
ketonaemia and ketonuria.4 It carries a substantial risk of life
older, odds ratio 3.41 (95% confidence interval 2.54 to 4.59), for <5 years
threatening complications such as cerebral oedema and is the
v older, odds ratio 1.59 (1.38 to 1.84)), diagnostic error (odds ratio 3.35
commonest cause of diabetes related death in children.5 The
(2.35 to 4.79)), ethnic minority, lack of health insurance in the US (odds
longer term clinical course of type 1 diabetes also seems to be
ratio 3.20 (2.03 to 5.04)), lower body mass index, preceding infection
influenced by it: children with diabetic ketoacidosis at diagnosis
(odds ratio 3.14 (0.94 to 10.47)), and delayed treatment (odds ratio 1.74
have poorer glycaemic control,6 less residual β cell function up
(1.10 to 2.77)). Protective factors were having a first degree relative with
to two years after diagnosis,7 and a lower frequency of
type 1 diabetes at the time of diagnosis (odds ratio 0.33 (0.08 to 1.26)),
remission.8 9
higher parental education (odds ratios 0.4 (0.20 to 0.79) and 0.64 (0.43
to 0.94) in two studies), and higher background incidence of type 1
It is unclear why some children present in diabetic ketoacidosis
diabetes (correlation coefficient –0.715). The mean duration of symptoms
whereas others do not and whether the development of diabetic
was similar between children presenting with or without diabetic
ketoacidosis is a consequence of delayed diagnosis and treatment
ketoacidosis (16.5 days (standard error 6.2) and 17.1 days (6.0)
or whether it reflects a particularly aggressive form of diabetes.10
respectively), and up to 38.8% (285/735) of children who presented with
Understanding which factors are associated with diabetic
diabetic ketoacidosis had been seen at least once by a doctor before
ketoacidosis at diagnosis and the relative importance of delayed
diagnosis.
diagnosis and treatment is, therefore, important. This potentially
informs both our understanding of the disease as well as the
Conclusions Multiple factors affect the risk of developing diabetic
development of patient, professional, and population based
ketoacidosis at the onset of type 1 diabetes in children and young adults,
interventions to reduce the proportion of children presenting in
and there is potential time, scope, and opportunity to intervene between
diabetic ketoacidosis. Several individual factors from individual
Correspondence to: J Usher-Smith jau20@cam.ac.uk
Search terms used in electronic literature search (as supplied by the author) (see http://www.bmj.com/content/343/bmj.d4092/suppl/DC1)
Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe
2. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 2 of 16
RESEARCH
studies have been quoted in guidelines and consensus standardised form to minimise bias, at least two researchers
statements.11-13 To our knowledge, this is the first systematic (JAUS and FMW or MJT) independently extracted data on all
review of all factors associated with diabetic ketoacidosis at the factors for which there were data available for children
diagnosis of type 1 diabetes in children and young adults. presenting both with and without diabetic ketoacidosis. The
factors were grouped into individual, family, physician, disease
Methods related, and others. Studies reported the effects of risk factors
in a variety of ways, and hence various approaches to synthesis
Search strategy were needed. We expressed the effect of a risk factor as an odds
An electronic literature search of PubMed, EMBASE, Web of ratio with 95% confidence interval where possible, but where
Science, Scopus, and Cinahl up to March 2011 was performed the data did not allow this we compared the mean and standard
using a combination of subject headings and free text deviation of the risk factor between those individuals with and
incorporating “diabetic ketoacidosis” , “diabetes and without diabetic ketoacidosis and expressed this as mean and
ketoacidosis” , and “diagnosis” limited to infants, children, or standard error. When studies recruited children over more than
adolescents (see appendix on bmj.com for complete search one time period and it was possible to separate all the data into
strategy). The search was then extended by manually screening different time periods, we used only the most recent period. In
the reference lists of all included papers. all other cases we combined the data from all time periods.
Study selection Statistical methods
Included studies fulfilled all of the following criteria: published Where possible, we combined odds ratios using random effects
as a primary research paper in a peer reviewed journal; included meta-analysis: data were analysed with Stata (version 11.1),
cohorts of children and young adults presenting with new onset and we assessed heterogeneity between studies using Cochran’s
(that is, previously undiagnosed) type 1 diabetes who had not Q test and the I2 statistic.16 17 Where the mean and standard
been selected based on other characteristics; distinguished deviation of the risk factor were compared between those
between those children who presented in diabetic ketoacidosis individuals with and without diabetic ketoacidosis, we used a
and those who did not; and included a measurement of either two sample t test. Significance was set at P<0.05, and 95%
pH or bicarbonate in the definition of diabetic ketoacidosis. confidence intervals are quoted throughout.
Studies including only highly selected groups—such as neonates
or children being treated with high dose corticosteroids or Results
receiving chemotherapy—as well as drug trials and conference
proceedings were excluded. We chose to include all studies After duplicates were removed, the search identified 1441
which defined diabetic ketoacidosis based on measurement of papers. One author (JAUS) excluded 1333 of these as clearly
either pH or bicarbonate as this was an exploratory review not irrelevant on the basis of title and abstract. A second author
limited by time or language of publication, and we expected a (FMW) independently reviewed a random selection of these
range of different definitions. and was in complete agreement. A further 71 papers were
excluded after full text assessment by at least two authors (JAUS
One reviewer (JAUS) performed the search and screened the and FMW or MJT). The most common reasons for exclusion
titles and abstracts to exclude papers that were clearly not were that the papers included only a measure of the frequency
relevant. A second reviewer (FMW) independently assessed a of diabetic ketoacidosis and no further clinical details or it was
random selection of papers excluded at that stage. For papers not possible to separate the data for children with new onset
where a definite decision to reject could not be made based on diabetes (fig 1). We excluded three papers after contacting the
title and abstract alone, the full text was examined. At least two authors as it was not possible to establish the definition of
reviewers (JAUS and FMW or MJT) independently assessed diabetic ketoacidosis used. A further eight papers were identified
all full text papers, and those not meeting the inclusion criteria through citation searching. One paper compared the severity of
by both researchers were excluded. Papers in which it was type 1 diabetes at presentation in south east Sweden and
unclear whether the inclusion criteria were met were assessed Lithuania and so is reported as two studies.18 The analysis is
by a third researcher (MJT or FMW), and where either the therefore based on 46 studies.
definition of diabetic ketoacidosis was not given or we were
unable to interpret the data presented adequately we contacted
Study characteristics
the authors for clarification.
The 46 eligible studies included more than 24 000 children in
Quality assessment 31 different countries. Included studies showed considerable
heterogeneity in terms of size, setting, length of study, and the
Quality assessment was conducted independently by at least proportion of children presenting in diabetic ketoacidosis (tables
two reviewers (JAUS and FMW or MJT). We used the Critical 1 and 2). Nearly three quarters of children (70%) were recruited
Appraisal Skills Programme guidelines for case control and from Canada (n=3947), Austria (n=3471), Finland (n=3002),
cohort studies14 as an initial framework and classified each as Germany (n=2533), Sweden (n=2304), and the US (n=2181).
key paper, satisfactory, unsure, fatally flawed, or irrelevant as Most studies included children from birth to 18 years old, but
in the approach of Dixon-Woods et al.15 We excluded papers two included young adults up to the ages of 20 and 21 years.19 20
classified as fatally flawed or irrelevant and discussed those
classified as unsure at consensus meetings. Studies used a wide range of definitions of diabetic ketoacidosis,
but all included either pH values of ≤7.2 to <7.36 or bicarbonate
values of <15 to ≤21 mmol/L. One study, which used two
Data extraction and synthesis
different definitions of diabetic ketoacidosis on the same cohort
Characteristics of included studies were extracted; these included of children (pH <7.3 alone or combined with bicarbonate <15
period of study, number and type of study centres, study design, mmol/L),21 found an increased frequency of diabetic ketoacidosis
methods of recruitment, sample size, age and number of when the definition based on pH alone was used (22.4%
participants, and definition of diabetic ketoacidosis. Using a
Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe
3. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 3 of 16
RESEARCH
compared with 18.1%) but found no differences in the other studies compared the frequency of diabetic ketoacidosis between
conclusions based on definition used. two different ethnic groups. All showed a significant difference
in the frequency of diabetic ketoacidosis, and in each case the
Study quality ethnic minority group experienced an increased risk of diabetic
ketoacidosis—in the US, non-Hispanic white people v others
All included studies were cohort studies and most recruited
(odds ratio 0.55 (0.32 to 0.96)),36 white people v Hispanic (odds
children retrospectively from hospital or clinic records. Study
ratio 0.33 (0.14 to 0.76)),55 and non-Hispanic white v Hispanic
quality was variable, and formal assessment of ascertainment
(odds ratio 0.58 (0.37 to 0.89))56; and in the UK, white v others
was performed in only 16 studies. We classified 12 studies as
(odds ratio 0.39 (0.15 to 0.98))57 and non-Asian v Asian (odds
key papers (identified in table 1) and 28 as satisfactory. Only
ratio 0.35 (0.18 to 0.66)).22 A French study also reported that
one study was excluded based on quality alone (see fig 1) as
parental birth in France had no significant effect on the
we were unable to adequately interpret the numerical data after
frequency of diabetic ketoacidosis,43 and a Kuwaiti study showed
contacting the author.
no difference between Kuwaiti nationals, Arabs, Asians, and
those with no identified citizenship.47
Analysis of identified factors
Together, the 46 studies compared 23 factors in children Family history of diabetes
presenting with and without diabetic ketoacidosis. Table 3 shows
Six studies reported the effect of family history of diabetes on
these factors along with the number of studies and children
presentation with diabetic ketoacidosis, of which five examined
included for each, and fig 2summarises the effect of these factors
the influence of having a relative with diabetes at the time of
on the risk of presenting with diabetic ketoacidosis.
diagnosis. Although having a first degree relative with type 1
diabetes decreased the frequency of diabetic ketoacidosis in
Individual factors three studies (odds ratios 0.60 (0.44 to 0.82)58 and 0.15 (0.05 to
Age 0.41)47 (not combined as I2=84.7%) and P<0.0120), it did not
Age was the most common factor described: 32 studies reported predict a diagnosis of new onset diabetes before progression to
the effect of age on presentation, and 24 included data on the diabetic ketoacidosis in a US study after adjustment for age,
frequency of diabetic ketoacidosis in children grouped into sex, whether children were diagnosed in primary or secondary
different age ranges (fig 3).8 19-41 Together, they showed that care, and duration of symptoms.44 A German study which
children <2 years old had three times the risk of presenting in adjusted for age, sex, having a single parent, and social status
diabetic ketoacidosis as children aged ≥2 years (odds ratio 3.41 also failed to show a significant association with a family history
(95% confidence interval 2.54 to 4.59), P<0.001, I2=21.1%), of either type 1 or type 2 diabetes in siblings, parents, or
and this association continued up to age 5 (odds ratio 1.59 (1.38 grandparents (odds ratio for positive family history v no family
to 1.84), P<0.001, I2=23.5%). history 0.58 (0.20 to 1.66), P=0.312).27
Four studies reported instead the mean age at diagnosis.37 38 42 43 Two studies examined the effect of being the first or second
Combining these showed that children who presented with affected member of a family, thereby separating the effect of
diabetic ketoacidosis tended to be younger than those without, having an increased genetic risk of developing diabetes from
but the difference was negligible (8.6 (SE 4.0) years v 8.7 (3.5) the environmental effects of having a family member with
years, P=0.007). Data from the remaining six studies were diabetes at the time of diagnosis. Among Finnish children
insufficient for meta-analysis; four showed that younger children followed for a median of 7.7 years after initial diagnosis, those
were more likely to present in diabetic ketoacidosis44-47 while with a first degree relative with diabetes at the time of diagnosis
two reported no difference in mean48 or median49 age at had a significantly lower frequency of diabetic ketoacidosis
diagnosis. than those in whom a family member was subsequently
diagnosed with diabetes during the follow-up period (4.9%
Sex (4/90) v 21.4% (7/30), P<0.05; odds ratio 0.16 (0.04 to 0.59)).
However, there was no difference between children in whom a
Twenty one studies reported the effect of sex on the frequency family member was subsequently diagnosed with diabetes during
of diabetic ketoacidosis, of which 20 showed no effect and one the follow-up period and those without a family history at the
(n=2121) reported a small but statistically significant increase end of the follow-up period (odds ratio 0.93 (0.39 to 2.20)).58
in the frequency in girls (odds ratio 1.30 (1.07 to 1.58), A small UK study also showed that children who were the
P=0.0079).25 Twelve studies compared the proportion of each second affected child in a family were less likely to present in
gender presenting with and without diabetic ketoacidosis, and diabetic ketoacidosis than first affected children (odds ratio for
together gave a pooled odds ratio for boys of 0.93 (0.76 to 1.14, second v first affected 0.07 (0.003 to 1.51), n=79).48
P=0.472, I2=51.8%).18 (fig 4).21 25 26 35 36 40 50-53 Of the remaining
nine studies, eight lacked sufficient data for Body mass index
meta-analysis20 24 41 42 46-48 54 and one was a multivariate analysis
of 262 children—which showed that, although female sex was Two studies reported on the association between body mass
significantly associated with increased risk of delayed diagnosis index and a diagnosis of diabetic ketoacidosis and both showed
(symptomatic period ≥4 weeks) (odds ratio 2.78 (1.09 to 7.14), a higher frequency of diabetic ketoacidosis in those children
P=0.033), it was not associated with an increased risk of severe with a lower body mass index.41 53
diabetic ketoacidosis (odds ratio 0.68 (0.26 to 1.83), P=0.450).27
Parental consanguinity
Ethnicity Two small studies from Saudi Arabia with parental
Seven studies explored the effects of ethnicity. Because of the consanguinity rates of >40% (19/40 and 47/110) failed to show
heterogeneity of the populations, it was not possible to establish a significant difference in the rate of diabetic ketoacidosis in
whether the frequency of diabetic ketoacidosis was significantly children of consanguineous parents (combined odds ratio 1.19
different in any particular race or ethnic group. However, five (0.59 to 2.37), P=0.63, I2=0).28 29
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RESEARCH
Family factors Two studies examined the effect of parental employment on the
Parental education frequency of diabetic ketoacidosis: in Sweden having a mother
who did not work significantly increased the risk of presenting
Three studies reported on the influence of parental education. in diabetic ketoacidosis (odds ratio 4.8 (1.8 to 13.1)), whilst in
Having a mother with higher than secondary education was Lithuania the father’s employment status had no effect on the
protective against developing diabetic ketoacidosis in Lithuania rate of diabetic ketoacidosis (odds ratio 1.17 (0.53 to 2.57)).18
(odds ratio 0.4 (0.20 to 0.79)),18 and in Finland children from Only one study from the UK assessed the influence of social
families in which at least one parent had an academic degree status. It did not provide numerical data, but reported that
had a lower incidence of diabetic ketoacidosis at presentation children with parents in social classes 3–5 were more likely to
than those without (16.9% (43/254) v 24.4% (105/431), P<0.05, present in diabetic ketoacidosis than those in social classes 1
odds ratio 0.64 (0.43 to 0.94)).34 The third study, set in Germany, and 2 (P<0.05).20
did not report the effect of parental education on the presence
or absence of diabetic ketoacidosis at presentation, but Physician factors
multivariate analysis showed that children from families in
which parents had ≤9 years of education had a significantly Delayed diagnosis
increased risk of severe diabetic ketoacidosis (pH≤7.2) (odds Four studies explored the impact of delayed diagnosis (delay
ratio 3.54 (1.10 to 11.35), P for trend=0.034) compared with >24 hours for any reason) on the development of diabetic
children whose parents had ≥12 years of education, even after ketoacidosis. All reported that a significant proportion (16–51%)
adjustment for rates of delayed diagnosis.27 of children experienced a delay, but it was not possible to
combine data because of different definitions of end points used.
Family structure Delay of more than 24 hours between initial presentation to a
Three studies explored the effects of family structure and found primary or secondary care provider and referral to a
that neither living in a single parent family48 27 nor the number multidisciplinary diabetes team in the UK was associated with
of children in the family43 were significantly associated with an increased risk of presenting with diabetic ketoacidosis (52.3%
diabetic ketoacidosis at diagnosis (odds ratio 1.85 (0.43 to 7.82), v 20.5%, P<0.05, odds ratio 4.26 (1.54 to 11.79)).57 A similar
P=0.41127). increase in risk occurred in children who were not diagnosed
on the day of admission to a US children’s hospital (59% (17/29)
v 33% (35/105), P=0.0178, odds ratio 2.83 (1.22 to 6.58)).37 In
Health insurance status
contrast, two European studies found no effect when there was
Three studies examined the influence of insurance status. Two a delay between the first medical consultation and hospitalisation
US studies reported that lack of private insurance was a risk (odds ratio 0.79 (0.31 to 2.00))43 or delay of more than 24 hours
factor for presenting in diabetic ketoacidosis, with significantly between the first visit and diagnosis (odds ratio 0.98 (0.73 to
more patients with either Medicaid or no insurance presenting 1.31)).42
in diabetic ketoacidosis (62% (13/21) and 48% (40/83) compared
with 34% (40/118) and 22.5% (62/276) respectively, combined Diagnostic error
odds ratio 3.20 (2.03 to 5.04), P<0.001, I2=0).36 37 Children with
no insurance also had a greater risk of presenting in diabetic Four studies in the US, France, and Poland looked specifically
ketoacidosis compared with those receiving Medicaid (odds at the outcome of children in whom the diagnosis of type 1
ratio 2.84 (1.16 to 6.93)), but there was no difference between diabetes was not made at the first medical consultation because
those with private insurance and those receiving Medicaid (odds of diagnostic error, judged to have occurred when children were
ratio 0.54 (0.26 to 1.10)).36 In contrast, a French study showed not diagnosed on their first visit, either because they were given
that the presence or absence of free medical assistance (aide a misdiagnosis or signs and symptoms were missed or not
medicale gratuite) was not significantly associated with diabetic recognised. Such children had a threefold increased risk of
ketoacidosis at diagnosis of diabetes.43 presenting in diabetic ketoacidosis (combined odds ratio 3.35
(2.35 to 4.79), P<0.001, I2=0%) (fig 5).37 43 59 60 This risk was
independent of the presence or absence of infection preceding
Rural or urban residence
diagnosis,59 but diagnostic error was significantly more likely
Three studies found that living in rural or urban areas had no to occur in younger children: the mean age of children who
significant effect on rates of diabetic ketoacidosis at diagnosis. presented with diabetic ketoacidosis was 5.4 (standard error
In Finland there was no difference in frequency of diabetic 4.4) years when the diagnosis was missed compared with 8.8
ketoacidosis between families living in a city, town, or suburb (4.0) years when the diagnosis was not missed (P<0.001).37
compared with those living in a village or rural areas,34 while
in Sweden and Lithuania the rates of diabetic ketoacidosis were Number of medical consultations before diagnosis
not significantly different in those living in cities or small towns
compared with those in villages (odds ratios 2.06 (0.80 to 5.30) Two studies reported the number of medical consultations that
and 0.63 (0.32 to 1.27) respectively).18 occurred before the diagnosis of diabetes. A Canadian study
found that 84% (207/247) of children had been seen in primary
care before referral to secondary care: 66% (163/247) on the
Family income, parental employment, and social
day of diagnosis, 14% (35/247) once, and 4% (10/247) at least
status
twice before the date of diagnosis.44 However, the number of
Three studies examined the effect of family income. Two visits did not differ between children with and without diabetic
European studies found that family income had no significant ketoacidosis (P=0.30).44 A US study found that significantly
effect on risk of presenting in diabetic ketoacidosis.34 43 In more children who presented with diabetic ketoacidosis had one
contrast, a Canadian study, which adjusted for age and sex, or more medical consultations in the week before diagnosis
showed that being from a family in the two lowest quintiles of (38.8% (285/735) v 34.4% (1104/3212), P=0.026).46
family income was associated with an increased risk of diabetic
ketoacidosis (odds ratio 1.38 (1.17 to 1.63)).46
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RESEARCH
Delayed treatment and presence of structured the proportion of diabetic ketoacidosis cases remained stable
diabetes team (combined odds ratio 1.07 (0.89 to 1.28), P=0.49).
One multicentre study across Europe showed that a delay of
more than 24 hours between diagnosis and treatment was Background incidence of type 1 diabetes
associated with a small increased risk of children developing Only one multicentre study reported specifically on the influence
diabetic ketoacidosis (odds ratio 1.74 (1.10 to 2.77)).42 One of the background incidence of type 1 diabetes on the frequency
Kuwaiti study compared the frequency of diabetic ketoacidosis of diabetic ketoacidosis. Using data from 11 centres across
in children diagnosed in hospitals with and without a structured Europe, it showed a significant inverse correlation between the
diabetes team, and found that diabetic ketoacidosis was proportion presenting with diabetic ketoacidosis and the
significantly more common in hospitals lacking a structured background incidence of type 1 diabetes for these centres
diabetes team (P<0.002).47 (rs=–0.715, P=0.012).42
Disease factors Discussion
Duration of symptoms Principal findings
Four studies compared the duration of symptoms in children
This systematic review provides a comprehensive synthesis of
presenting with and without diabetic ketoacidosis.25 35 38 61
the factors associated with diabetic ketoacidosis in children and
Although the mean duration of symptoms was similar in both
young adults presenting with new onset of type 1 diabetes. We
groups, it was slightly shorter in those with diabetic ketoacidosis
found that younger children, those from ethnic minority groups,
(16.5 (SE 6.2) days and 17.1 (6.0) days respectively, P<0.001).
without medical insurance (in the US), and with a lower body
Two other studies found that children with diabetic ketoacidosis
mass index were at highest risk. Having a preceding infection
had a shorter duration of symptoms (P<0.005),47 but the
and being exposed to diagnostic error or delayed treatment were
percentage of children with symptoms for less than two weeks
also associated with an increased risk of developing diabetic
did not differ between the groups (24.8% (108/436) and 24.2%
ketoacidosis. In contrast, we found that children with a first
(145/601) for those with and without diabetic ketoacidosis
degree relative with type 1 diabetes, with parents with higher
respectively, P=0.80).42 After adjustment for age, sex, family
levels of education, or who lived in an area with a higher
history of type 1 diabetes, and whether children were diagnosed
background incidence of type 1 diabetes seemed less likely to
in primary or secondary care, the duration of classic symptoms
present in diabetic ketoacidosis (see fig 2).
(enuresis or nocturia, polyuria, polydipsia, change in appetite,
weight loss, candidiasis, and fatigue) also did not predict a
diagnosis of new onset diabetes before progression to diabetic
Strengths and limitations
ketoacidosis.44 Our rigorous and systematic search encompassed multiple
databases and languages, and identified data on more than 24
Pattern and frequency of symptoms 000 children from 31 countries. Although this strengthens the
generalisability of our findings, it also contributed to
The six studies which compared symptom pattern and frequency
considerable heterogeneity in terms of design, setting, and
between children with and without diabetic ketoacidosis showed
predictors included. Despite using appropriate meta-analytic
inconsistent findings. One found no difference in the frequency
techniques with random effect models, we were unable to control
of any of the typical symptoms of diabetes (enuresis or nocturia,
fully for these differences. The studies also varied in quality,
polyuria, or polydipsia),44 whereas children with diabetic
and only 18 formally assessed case ascertainment. Many were
ketoacidosis presented more often with vomiting,43 35 40
also retrospective and may have been subject to recording and
abdominal pain,43 35 dyspnoea,40 weakness,35 anorexia,35 and
recall bias. Most of the studies did not provide quantitative data
changes in mental status.35 Two studies also showed that children
for negative findings, but merely stated that no differences were
with diabetic ketoacidosis had significantly greater weight loss
observed, implying some degree of reporting bias. Although
than those without (4.84% (SD 3.87%) of body weight v 3.32%
we cannot exclude publication bias, we expect this to be minimal
(3.53%), P<0.0001; and 3.35 (SD 2.07) kg v 1.45 (1.85) kg,
because of the exploratory nature of the question.
P<0.005),42 61 while a third study showed no difference
(P=0.296).40 Included studies also used a wide range of definitions of diabetic
ketoacidosis, reflecting different international settings and
Preceding infection or febrile illness periods of study. Only one47 used the current diagnostic criteria
for diabetic ketoacidosis published by the International Society
Three studies included data on the effect of a preceding infection for Paediatric and Adolescent Diabetes.4 However, our inclusion
or febrile illness. In two, a history of infection or febrile illness criteria incorporated a measurement of pH (pH ≤7.2 to <7.36)
was associated with an increased risk of diabetic ketoacidosis or bicarbonate (<15 to ≤21 mmol/L) and so consistently
(odds ratios 6.50 (2.06 to 20.53) and 1.87 (1.05 to 3.33), not identified those with worse metabolic derangements. Although
combined because I2=72.2%).33 40 In the third study febrile illness the absolute frequency of diabetic ketoacidosis may vary with
before the start of symptoms was more common in the groups different definitions, it is unlikely that this would substantially
with shorter duration of symptoms (<1 month), but it did not alter our overall conclusions.21 Finally, because of the format
change the percentage with severe ketoacidosis.62 of the data, it was not possible to assess the independent
contribution of each of the predictors we identified, but we
Other factors include results of multivariate analyses where reported.
Time of year
Two studies25 26 looked at the effect of time of year on the
Factors associated with increased risk of
frequency of diabetic ketoacidosis. Although the total number
diabetic ketoacidosis
of cases was higher in winter than in summer, both found that Younger age was consistently associated with an increased risk
of diabetic ketoacidosis at diagnosis. This increased risk was
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6. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 6 of 16
RESEARCH
most noticeable in children less than 2 years old and was still experience of diabetes rather than an increased genetic risk for
present at 5 years, but by age 10 there was no significant type 1 diabetes predisposing to a milder onset of disease, as
difference. The reasons for this are probably multifactorial. suggested previously.70 This interpretation is consistent with
Clinicians may have a lower index of suspicion for diabetes other observations that initial differences in metabolic indices
among younger children, and the classic symptoms of diabetes observed at diagnosis between those with and without a family
may be subtle and difficult to distinguish from other acute history of diabetes disappear by one year after diagnosis.71
illnesses at this age. Decompensation due to dehydration and It is also possible that some of this protective effect could be
acidosis also develop more quickly in young children as the due to a family history of diabetes alerting clinicians to an
mechanisms of metabolic compensation are less developed.29 38 increased possibility of type 1 diabetes. Better disease
Moreover, β cell destruction may be more aggressive in young recognition because of improved awareness of diabetes is further
children: serum levels of proinsulin C peptide are lower in supported by the finding that children from families with higher
children under 2 years old at diagnosis of diabetes, and they parental education were less likely to present in diabetic
continue to lose their endogenous insulin secretory capacity ketoacidosis, and that the risk of diabetic ketoacidosis was
faster than older children after diagnosis.24 63 Some of these inversely proportional to background incidence of type 1
factors may also explain why children with a lower body mass diabetes. These differences may also reflect variations in, for
index seemed to be at greater risk. example, access to healthcare, child supervision, or schooling.
Children from ethnic minority groups seem to have an increased
risk of developing diabetic ketoacidosis, but it is difficult to Implications for practising clinicians
draw strong conclusions as the studies compared different ethnic
This study has implications for clinicians in both primary and
groups, and we do not know the independent effect of ethnicity
secondary care, as the vast majority of children who develop
(rather than sociodemographic differences). Possible
type 1 diabetes will have a consultation before diagnosis.
explanations include difficulties in recognising the symptoms
Although type 1 diabetes can be diagnosed in primary care, a
because of language and cultural barriers, lack of awareness of
diagnosis of diabetic ketoacidosis requires measurement of
type 1 diabetes in ethnic minorities, and cultural or practical
serum pH or bicarbonate and so typically requires referral to
difficulties in accessing healthcare.64 65 These factors are also
secondary care. Furthermore, many children present directly to
likely to contribute to the threefold increase in diabetic
hospital emergency or paediatric departments. As with other
ketoacidosis seen in children without private health insurance
serious illnesses in children, differentiating the occasional child
in the US.
with a serious illness from the large number with minor
Several physician level factors were also associated with an undifferentiated illness is challenging. The relatively easy access
increased risk of diabetic ketoacidosis. Children who were not to point of care tests for hyperglycaemia, ketonaemia, and
diagnosed at their first visit to a doctor had a threefold increased glycosuria, however, means that diagnosis does not require
risk of presenting in diabetic ketoacidosis, and delays in starting access to specialist diagnostic services (such as imaging for
treatment were associated with a small increased risk. However, suspected malignancy) but, instead, a high index of suspicion.
the contribution of delayed recognition itself was not consistent Our findings suggest that clinicians should be particularly alert
as some studies found delays contributed to diabetic ketoacidosis for diabetic ketoacidosis in children under 5 years old, those
while others did not. The duration of symptoms was also similar from ethnic minority groups, and those from families with low
in children with and without diabetic ketoacidosis, although this education level or socioeconomic status.
effect may be confounded by the age of children—as diabetic
We found clear evidence that at least some children with diabetic
ketoacidosis is more common in younger children, who tend to
ketoacidosis experienced diagnostic or treatment delays.
have a shorter duration of symptoms.10
Children presenting with diabetic ketoacidosis had symptoms
A history of prior infection was the only disease related factor for a mean of two weeks, up to a third had at least one medical
associated with an increased risk of diabetic ketoacidosis. consultation in the week before diagnosis, and misdiagnosis
Infection is known to cause inflammation, pro-inflammatory was associated with a threefold increase in diabetic ketoacidosis.
cytokine release, and a counter regulatory response that However, the influence of delays at the physician level on risk
collectively lead to insulin resistance and metabolic of diabetic ketoacidosis was not consistent across studies, and
decompensation.66 The infection itself may also trigger more we did not identify reasons for the diagnostic errors. High rates
rapid autoimmune destruction of β cells. Infections are of misdiagnosis have also been found in children presenting
associated with a transient increase in risk of type 1 diabetes,67 with type 1 diabetes without diabetic ketoacidosis, with up to
and there is increasing evidence for the role of enteroviruses in 86% of children not diagnosed at first encounter.37 43 59 72 73 In
the early phase of type 1 diabetes through infection of β cells these studies, common diagnostic errors included misinterpreting
and activation of innate immunity and inflammation.68 69 symptoms (such as polyuria misdiagnosed as urinary tract
Alternatively, the presence of infection may mask the early infection), exclusively focusing on one or more symptoms (such
symptoms of diabetes and make the diagnosis more difficult. as oral candidiasis), and not performing appropriate
investigations (such as blood glucose or urine tests). Clinicians
Factors associated with a decreased risk of should therefore be aware of these difficulties in diagnosis and
diabetic ketoacidosis be particularly alert for diabetic ketoacidosis in those children
Having a first degree relative with diabetes was associated with at higher risk. Improving awareness among parents and
an up to sixfold decreased risk of diabetic ketoacidosis at clinicians about the early symptoms of diabetes through diabetes
diagnosis. The absence of any significant difference between education programmes—such as the community intervention
children in whom a member of the family was subsequently in Italy, which reduced the prevalence of diabetic ketoacidosis
diagnosed with diabetes and those without such a family history at diagnosis from 78% to 12.5%74—could also decrease the
at the end of the follow-up period suggests that the protective frequency of diabetic ketoacidosis.
effect of a first degree relative with diabetes at diagnosis was
probably due to increased awareness among families with
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7. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 7 of 16
RESEARCH
Implications for future research 14 Public Health Resource Unit. Critical Appraisal Skills Programme. www.phru.nhs.uk/casp/
casp.htm
While it seems intuitive that an earlier diagnosis of diabetes 15 Dixon-Woods M, Sutton A, Shaw R, Miller T, Smith J, Young B, et al. Appraising qualitative
research for inclusion in systematic reviews: a quantitative and qualitative comparison of
should lead to a decreased risk of diabetic ketoacidosis, our three methods. J Health Serv Res Policy 2007:42-7.
review still leaves unanswered the major question of whether 16 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med
2002;21:1539-58.
diabetic ketoacidosis is a consequence of delayed diagnosis and 17 Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in
treatment or whether it reflects a more aggressive form of meta-analyses. BMJ 2003;327:557-60.
diabetes.10 Additionally, no studies addressed the reasons for 18 Sadauskaite-Kuehne V, Samuelsson U, Jasinskiene E, Padaiga Z, Urbonaite B, Edenvall
H, et al. Severity at onset of childhood type 1 diabetes in countries with high and low
delays in diagnosis or the relative contribution of individual, incidence of the condition. Diabetes Res Clin Pract 2002;55:247-54.
parental or physician factors. Further studies should explore the 19 Mayer-Davis EJ, Beyer J, Bell RA, Dabelea D, D’Agostino R, Imperatore G, et al. Diabetes
in African American youth. Diabetes Care 2009;32(suppl 2):S112-22.
factors that influence help seeking behaviour among parents, 20 Pinkney JH, Bingley PJ, Sawtell PA, Dunger DB, Gale EAM. Presentation and progress
and delineate the time course of clinical presentation of this of childhood diabetes mellitus: a prospective population-based study. Diabetologia
1994;37:70-4.
disease. A better understanding of the patient pathway from 21 Hekkala A, Knip M, Veijola R. Ketoacidosis at diagnosis of type 1 diabetes in children in
symptom onset to diagnosis is needed to appropriately target northern Finland—temporal changes over 20 years. Diabetes Care 2007;30:861-6.
22 Alvi NS, Davies P, Kirk JM, Shaw NJ. Diabetic ketoacidosis in Asian children. Arch Dis
interventions to decrease the frequency of diabetic ketoacidosis Child 2001;85:60-1.
at diagnosis of type 1 diabetes in children and young adults. 23 Charemska D, Przybyszewski B, Klonowska B. Estimation of the severity of metabolic
disorders in children with newly diagnosed insulin dependent diabetes mellitus (IDDM).
Med Wieku Rozwoj 2003;7:261-70.
We thank Isla Kuhn, Reader Services Librarian, University of Cambridge 24 Komulainen J, Kulmala P, Savola K, Lounamaa R, Ilonen J, Reijonen H, et al. Clinical,
autoimmune, and genetic characteristics of very young children with type 1 diabetes.
Medical Library, for her help developing the search strategy and
Childhood Diabetes in Finland (DiMe) Study Group. Diabetes Care 1999;22:1950-5.
Professor David Dunger for helpful advice throughout the study and for 25 Neu A, Willasch A, Ehehalt S, Hub R, Ranke MB, Becker SA, et al. Ketoacidosis at onset
proofreading the manuscript. of type 1 diabetes mellitus in children—frequency and clinical presentation. Pediatr
Diabetes 2003;4:77-81.
Contributors: JAUS performed the literature search, selected articles 26 Olak-Białoń B, Deja G, Jarosz-Chobot P, Buczkowska EO. The occurrence and analysis
of chosen risk factors of DKA among children with new onset of DMT1. Pediatr Endocrinol
for inclusion, extracted the data, performed the analysis, and wrote the
Diabetes Metab 2007;13:85-90.
first draft of the manuscript. FMW and MJT selected articles for inclusion, 27 Rosenbauer J, Icks A, Giani G. Clinical characteristics and predictors of severe
extracted the data, and reviewed and edited the manuscript. SJS ketoacidosis at onset of type 1 diabetes mellitus in children in a North Rhine-Westphalian
region, Germany. J Pediatr Endocrinol Metab 2002;15:1137-45.
assisted with the statistical analysis and reviewed and edited the 28 Salman H, Abanamy A, Ghassan B, Khalil M. Childhood diabetes in Saudi Arabia. Diabet
manuscript. Med 1991;8:176-8.
29 Salman H, Abanamy A, Ghassan B, Khalil M. Insulin-dependent diabetes mellitus in
Funding: JAUS is supported by an NIHR academic clinical fellowship children: familial and clinical patterns in Riyadh. Ann Saudi Med 1991;11:302-6.
and FW by an NIHR clinical lectureship. MJT is funded by NIHR 30 Al Khawari M, Shaltout A, Qabazard M, Abdella N, al Moemen J, al-Mazidi Z, et al.
Incidence and severity of ketoacidosis in childhood-onset diabetes in Kuwait. Kuwait
programme grant “Development and implementation of new diagnostic Diabetes Study Group. Diabetes Res Clin Pract 1997;35:123-8.
processes and technologies in primary care,” and SJS is employed by 31 Sebastiani Annicchiarico L, Guglielmi A. The EURODIAB experience in Lazio. Ann Ig
1992;4:173-8.
the MRC. 32 Soliman A, al Salmi I, Asfour M. Mode of presentation and progress of childhood diabetes
Competing interests: All authors have completed the Unified Competing mellitus in the Sultanate of Oman. J Trop Pediatr 1997;43:128-32.
33 Bober E, Dundar B, Buyukgebiz A. Partial remission phase and metabolic control in type
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request from the corresponding author) and declare: no support from 2001;14:435-41.
34 Komulainen J, Lounamaa R, Knip M, Kaprio EA, Akerblom HK. Ketoacidosis at the
any organisation for the submitted work; no financial relationships with diagnosis of type 1 (insulin dependent) diabetes mellitus is related to poor residual beta
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35 Ting WH, Huang CY, Lo FS, Hung CM, Chan CJ, Li HJ, et al. Clinical and laboratory
the previous three years, no other relationships or activities that could characteristics of type 1 diabetes in children and adolescents: experience from a medical
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36 Maniatis AK, Goehrig SH, Gao D, Rewers A, Walravens P, Klingensmith GJ. Increased
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in Europe. EURODIAB ACE Study Group. Lancet 2000;355:873-6. 38 Samuelsson U, Stenhammar L. Clinical characteristics at onset of type 1 diabetes in
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Society for Paediatric Endocrinology/Lawson Wilkins Pediatric Endocrine Society 49 Mlynarski W, Zmyslowska A, Kubryn I, Perenc M, Bodalski J. Factors involved in
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13 Wolfsdorf J, Craig ME, Daneman D, Dunger D, Edge J, Lee WR, et al. Diabetic 50 Hodgson MI, Ossa JC, Velasco N, Urrejola P, Arteaga A. Clinical picture at the onset of
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8. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 8 of 16
RESEARCH
What is already known on this topic
A sizeable proportion of children and young adults with newly diagnosed type 1 diabetes present in diabetic ketoacidosis,
which carries a substantial risk of life threatening complications
It is unclear why some children present in diabetic ketoacidosis whereas others do not and whether the development
of diabetic ketoacidosis is a consequence of delayed diagnosis and treatment
What this study adds
This systematic review of 46 studies including more than 24 000 children in 31 different countries provides the first
synthesis of the factors associated with diabetic ketoacidosis at the onset of type 1 diabetes in children and young
adults
Younger age, diagnostic error, ethnic minority status, lack of health insurance in the US, lower body mass index,
preceding infection, and delayed treatment were all associated with an increased risk of diabetic ketoacidosis, while
having a first degree relative with type 1 diabetes at the time of diagnosis, higher parental education, and higher
background incidence of type 1 diabetes appear to be protective
The mean duration between onset of symptoms and development of diabetic ketoacidosis is over 14 days, and up to
a third of children have at least one medical consultation during that period, suggesting a possible window of opportunity
to improve recognition
51 Prisco F, Picardi A, Iafusco D, Lorini R, Minicucci L, Martinucci ME, et al. Blood ketone 63 Sochett E, Daneman D, Clarson C, Ehrlich R. Factors affecting and patterns of residual
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2006;7:223-8. children. Diabetologia 1987;30:453-9.
52 Mylnarski W, Zmyslowska A, Kubryn I, Perenc M, Bodalski J. Factors involved in 64 Weech-Maldonado R, Morales LS, Spritzer K, Elliott M, Hays RD. Racial and ethnic
ketoacidosis at the onset of type 1 diabetes in childhood. Endokrynol Diabetol Chor differences in parents’ assessments of pediatric care in Medicaid managed care. Health
Przemiany Materii Wieku Rozw 2003;9:23-8. Serv Res 2001;36:575-94.
53 Hekkala A, Reunanen A, Koski M, Knip M, Veijola R. Age-related differences in the 65 Brousseau DC, Hoffmann RG, Yauck J, Nattinger AB, Flores G. Disparities for Latino
frequency of ketoacidosis at diagnosis of type 1 diabetes in children and adolescents. children in the timely receipt of medical care. Ambul Pediatr 2005;5:319-25.
Diabetes Care 2010;33:1500-2. 66 Rayfield EJ, Ault MJ, Keusch GT, Brothers MJ, Nechemias C, Smith H. Infection and
54 Tahirovic H, Toromanovic A, Bacaj D, Hasanovic E. Ketoacidosis at onset of type 1 diabetes: the case for glucose control. Am J Med 1982;72:439-50.
diabetes mellitus in children in Bosnia and Herzegovina: frequency and clinical 67 Yang Z, Zhou F, Dorman J, Wang H, Zu X, Mazumdar S, et al. Association between
presentation. J Pediatr Endocrinol Metab 2007;20:1137-40. infectious diseases and type 1 diabetes: a case-crossover study. Pediatr Diabetes
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diagnosis of type 1 diabetes: is there room for concern? Pediatr Diabetes 2009;10:310-5. 68 Tanaka S, Nishida Y, Aida K, Maruyama T, Shimada A, Suzuki M, et al. Enterovirus
56 Vehik K, Hamman RF, Lezotte D, Norris JM, Klingensmith GJ, Dabelea D. Childhood infection, CXC chemokine ligand 10 (CXCL10), and CXCR3 circuit: a mechanism of
growth and age at diagnosis with type 1 diabetes in Colorado young people. Diabet Med accelerated beta-cell failure in fulminant type 1 diabetes. Diabetes 2009;58:2285-91.
2009;26:961-7. 69 Hober D, Sauter P. Pathogenesis of type 1 diabetes mellitus: interplay between enterovirus
57 Sundaram PCB, Day E, Kirk JMW. Delayed diagnosis in type 1 diabetes mellitus. Arch and host. Nat Rev Endocrinol 2010;6:279-89.
Dis Childhood 2009;94:151-2. 70 Komulainen J, Knip M, Sabbah E, Vahasalo P, Lounamaa R, Akerblom HK, et al.
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HLA-DQB1-defined genetic susceptibility, beta cell autoimmunity, and metabolic risk loads defined by HLA-DQB1 alleles. Childhood Diabetes in Finland Study Group. Clin
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1996;98:2489-95. 71 O’Leary LA, Dorman JS, LaPorte RE, Orchard TJ, Becker DJ, Kuller LH, et al. Familial
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type 1 diabetes mellitus in children? The consequences of delayed diagnosis. Endokrynol Res Clin Pract 1991;14:183-90.
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62 Savova R, Popova G, Koprivarova K, Konstantinova M, Angelova B, Atanasova M, et al.
Clinical and laboratory characteristics of type I (insulin dependent) diabetes mellitus at Accepted: 13 May 2011
presentation among Bulgarian children. Diabetes Res Clin Pract 1996;34:S159-63.
Cite this as: BMJ 2011;343:d4092
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9. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 9 of 16
RESEARCH
Tables
Table 1| Characteristics of 46 studies included in systematic review to identify factors associated with diabetic ketoacidosis at diagnosis
of type 1 diabetes in children and young adults
Study Country Period of study No of study centres Design* Recruitment method
Abdul-Rasoul et al, 2010 † 47
Kuwait 2000–6 Nationwide R Hospital records
Al Khawari et al, 199730 Kuwait 1992–5 Nationwide P Kuwait IDDM register; Hospital records;
Diabetic clinic mandatory registry
Alvi et al, 200122 UK 1987–96 Regional R Local paediatricians; General practitioners
and diabetes nurse specialists
Blanc et al, 200343† France Not given 1 Endocrinology and diabetes P Hospital records
department
Bober et al, 200133 Turkey 1991–8 1 Paediatric endocrinology R Hospital records
department
Bowden et al, 20088 USA 2004 1 Children’s hospital R Hospital records
Bui et al, 201046† Canada 1994–2000 Regional R Health insurance plan; Database of health
and long term care; Discharge abstract
database
Charemska et al, 200323 Poland 1998–2002 1 Children’s hospital R Clinic records
Hekkala et al, 2007 21
Finland 1982–2001 1 Paediatric department R Hospital and clinic register
Hekkala et al, 201053 Finland 2002–5 27 Centres R Paediatric diabetes register; Hospital
records
Hodgson et al, 200650 Chile 1988–2003 1 Hospital R Hospital records
Kapellen et al, 2001 † 61
Germany 1995–9 1 Children’s hospital R Hospital records
Komulainen et al, 199634‡ Finland 1986–9 Nationwide P Diabetes nurses; National Central Drug
Registry
Komulainen et al, 199924†‡ Finland 1986–9 Nationwide P Diabetes nurses; National Central Drug
Registry
Levy-Marchal et al, 200142† Europe 1989–94 24 EURODIAB centres R Incidence surveillance cohort
Mallare et al, 2003 † 37
USA 1995–8 1 Children’s hospital R Hospital records
Maniatis et al, 200536 USA 2002–3 1 Diabetes centre R Diabetes centre records
Mayer-Davies et al, 200919 USA 2002–5 6 Clinical centres P Reporting network of clinics and
healthcare providers; Hospital discharge,
billing, and paediatric endocrinology case
lists; Mailed survey to providers likely to
see children not included in above
Mlynarski et al, 200349 Poland 1997–2001 1 Diabetes centre P Hospital records
Neu et al, 2003 †25
Germany 1987–97 31 Paediatric departments, 1 R Hospital records; Questionnaire to
diabetes centre members of Diabetic Patients Association
Newfield et al, 200955 USA 1998–2001 1 Children’s hospital R Hospital database
Olak-Bialori et al, 2007 26
Poland 2004–5 1 Children’s endocrinology and R Clinic records
diabetes centre
Pawlowicz et al, 200859§ Poland 1999–2004 1 Paediatric endocrinology R Hospital records; Regional diabetic
department polyclinic records
Pawlowicz et al, 200960†§ Poland 1999–2005 1 Paediatric endocrinology R Hospital records; Regional diabetic
department outpatient clinics
Pinkney et al, 199420 UK 1990 1985–6 Regional P Prospective registration; Hospital
discharge records and death certificates;
General practitioners
Pocecco et al 199339 Italy 1987–90 14 Paediatric departments, 14 R Departmental records; Central register for
diabetes services all patients receiving drug reimbursement
Prisco et al, 200651 Italy 2003 7 Territorial reference P Hospital records
hospitals
Quinn et al, 200644† USA 1990–9 1 Children’s hospital R Hospital records
Roche et al, 2005 45
Ireland 1997–8 Nationwide P Irish paediatric surveillance unit; National
survey of adult physicians and
endocrinologists
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10. BMJ 2011;343:d4092 doi: 10.1136/bmj.d4092 Page 10 of 16
RESEARCH
Table 1 (continued)
Study Country Period of study No of study centres Design* Recruitment method
Rosenbauer et al, 200227 Germany 1993–5 41 Paediatric and diabetes R Active clinic based surveillance system;
departments Yearly surveillance among paediatric,
general, and internal medicine practices
Salman et al, 199128§ Saudi Arabia 1985–9 1 Children’s hospital R Hospital records
Salman et al, 199129§ Saudi Arabia 1985–9 1 Children’s hospital R Hospital records
Samuelsson et al, 200538 Sweden 1977–2001 7 Paediatric clinics R Medical records; Swedish Diabetes
Register
Saudaskaite-Kuehne et al, Sweden 1995–9 12 Hospitals P Existing case-control study
200215†
Saudaskaite-Kuehne et al, Lithuania 1996–2000 Nationwide P Existing case-control study
200218†
Savova et al, 199662 Bulgaria 1974–96 1 Children’s hospital R Hospital records; National centralised
system of insulin delivery
†Schober et al, 201041 Austria 1989–2008 Nationwide P Network covering all paediatric hospitals,
wards, and diabetologists
Sebastiani et al, 199231¶ Italy 1989–90 51 Local health units, 71 P Basic incidence surveillance cohort
hospitals
Smith et al, 199848 UK 1990–6 1 Children’s hospital R Clinic records
Soliman et al, 199732 Oman 1990–3 Regional (10 hospitals) P Diabetologists and pediatricians in regions
Sundaram et al, 200957† UK 2004–7 1 Children’s hospital R Hospital database
Tahirovic et al, 2007 54
Boznia and 1990–2005 1 Children’s hospital R Prospective local diabetes register;
Herzegovina Hospital records
Ting et al, 200735 Taiwan 1979–2006 1 Paediatric department R Hospital records
Vehik et al, 200956† USA 2002–4 Regional R Search for Diabetes in Youth Study (rapid
reporting network of clinics and healthcare
providers)
Veijola et al, 199658‡ Finland 1986–9 Nationwide P Diabetes nurses; National Central Drug
Registry
Xin et al, 201040 China 2004–8 1 Hospital R Hospital records
*R=Retrospective; P=Prospective.
†Papers assessed as key papers through quality assessment.
24
‡Papers probably based on the same cohort of children, but not possible to combine the results as the later study (Komulainen et al,1999 ) included only those
34 58
children with blood pH, c peptide, and HbA1c measurements, whereas earlier papers (Komulainen et al, 1996 and Veijola et al, 1996 ) report on different data.
The three papers are therefore reported as separate studies, but the children included only once in the total number of children studied.
§Probably overlap in the subjects reported in these papers as the children were recruited from the same hospitals over the same time, but, because the numbers
differed in the two papers, it was not possible to combine the data.
¶This paper reports on the EURODIAB experience in Lazio. Although Lazio is also included in the combined report of the EURODIAB study (Levy-Marchal et al,
42
2001 ), the numbers of subjects and focus of analysis are different and so this report is treated as a separate study.
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