[Ketoacidosis at time of diagnosis of type 1 diabetes in children and adolescents: effect of a national prevention campaign]. / Effet à un an de la campagne nationale de prévention de l'acidocétose au moment du diagnostic de diabète de type 1 chez l'enfant et l'adolescent.

The aim of the study was to evaluate, after the first year of a national information campaign, the effect on the frequency and severity of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) in children and adolescents in France. The following data were collected during a 2-year period in people younger than 15 years of age at diagnosis of T1D, in 146 pediatric centers: age, sex, duration of symptoms, patient's previous care, clinical and biological signs, and family history of T1D. DKA was defined as pH<7.30 or bicarbonate<15mmol/L, severe DKA as pH<7.10 or bicarbonate <5mmol/L. During the 2nd year, an information campaign targeting health professionals and families was launched with the objective of reducing the time to diagnosis. Data were compared between the year before the campaign (year 0) and the first year of the campaign (year 1). The number of new cases of T1D was 1299 for year 0 and 1247 for year 1. Between year 0 and year 1, the rate of DKA decreased from 43.9% to 40.5% (P=0.08), exclusively due to the decrease of severe DKA from 14.8 to 11.4% (P=0.01). In the 0- to 5-year-old and 5- to 10-year-old age groups, the relative decrease in the rate of DKA was 13% and 15%, and 23% and 41% for severe DKA, respectively. In patients referred to the hospital by a pediatrician or who came at the family's initiative, the decrease was 34% and 7%, and 39% and 32% for severe DKA, respectively. No change was observed in the 10- to 15-year-old group or in those children who were referred by a general practitioner. In multivariate analyses, a higher DKA rate was associated with the young age of the child (<5 years), being hospitalized at the parents' initiative rather than being referred by a doctor, and the absence of a family history of T1D. A higher rate of severe DKA was associated with these last two factors but not with the child's age. The frequency of DKA at diagnosis of type 1 diabetes remains high in children and adolescents, but the first year of an information campaign decreased it. The results have also helped better define the strategy and targets of the continuing prevention campaign, to more efficiently reduce the morbidity and mortality of T1D at diagnosis in children and adolescents in France.

Ketoacidosis at diagnosis of type 1 diabetes in French children and adolescents.

OBJECTIVES: This study aimed to evaluate the frequency of diabetic ketoacidosis (DKA) and its associated factors at the diagnosis of type 1 diabetes (T1D) in French children and adolescents prior to launching a public-health campaign of information to prevent DKA. PATIENTS AND METHODS: Over a 1-year period, 1299 youngsters (aged < 15 years) were diagnosed with T1D at 146 paediatric centres in all regions of France. Age, gender, duration of symptoms, patient's pathway to diagnosis, clinical and biological signs, and family history of T1D were collected for each newly diagnosed patient. DKA was defined as pH < 7.30 or bicarbonate < 15 mmol/L, and severe DKA as pH < 7.10 or bicarbonate < 5 mmol/L. RESULTS: At the time of diagnosis, 26% of the children were aged 0-5 years, 34% were 5-10 years and 40% were 10-15 years. The overall prevalence of DKA was 43.9% (0-5 years: 54.2%; 5-10 years: 43.4%; and 10-15 years: 37.1%) and 14.8% for severe DKA (0-5 years: 16.6%; 5-10 years: 14.4%; and 10-15 years: 13.9%; < 2 years: 25.3%). Severe DKA was more frequent when the child was hospitalized at the family's behest (26.6%) than when referred by a general practitioner (7.6%) or paediatrician (5.1%; 30.6%, 53.7% and 9.2%, respectively, by patients' age group). The frequency of DKA decreased to 20.1% (severe DKA: 4.4%) in families with a history of T1D. Multivariate analysis showed that age, pathway to diagnosis, duration of polyuria/polydipsia (< 1 week) and family history of T1D were associated with the presence of DKA, while pathway to diagnosis and family history of T1D were associated with severe DKA. CONCLUSION: DKA at the time of T1D diagnosis in children and adolescents is frequent and often severe. Patients' age, pathway to hospitalization and family history of diabetes were the main factors associated with DKA. These data suggest that a public-health campaign to prevent DKA at diagnosis can help reduce the frequency of DKA and also provide baseline data for evaluating the efficacy of such a campaign.

High day-to-day glucose variability: a frequent phenomenon in children and adolescents with type 1 diabetes attending summer camp.

BACKGROUND: Day-to-day glucose variability may cause difficulty for patients trying to adjust their insulin dosages and for healthcare providers when they have to make recommendations. The aim of this research was to evaluate the frequency of high variability in a population of diabetic children and adolescents attending summer camp. METHODS AND RESULTS: The mean of the daily differences (MODD) in glucose concentrations was calculated from continuous glucose monitoring (CGM) over five consecutive days in 6 diabetic patients. This index was correlated to the MODD calculated from pre-meal and bedtime blood glucose (BG) measurements (r=0.87). We used the MODD calculated on these four BG measurements for five consecutive days to evaluate day-to-day glucose variability in 100 young diabetic patients treated with glargine and ultrarapid analogue insulin. Only one child had a MODD value lower than 36mg/dl, considered a threshold for high day-to-day variability, and 94 children had a MODD value higher than 45mg/dl. The median value was 78mg/dl. The expected positive correlation between the MODD and its standard deviation (r=0.32, P<0.01) suggested that the greater the day-to-day variability, the more variable the variability across five consecutive days. CONCLUSIONS: The estimation of MODD from four pre-meal BG values correlated to that from CGM, and may represent a simple index of day-to-day glycaemic variability. High day-to-day glucose variability in glucose profile is frequently observed in diabetic children attending summer camp.

Prevalence of diabetic retinopathy in children and adolescents with type-1 diabetes attending summer camps in France.

OBJECTIVE: To evaluate, using fundus photography, the prevalence of diabetic retinopathy (DR) in young diabetic subjects attending summer camps run by the Aide aux Jeunes Diabétiques Association (Aid to Young Diabetics). RESEARCH DESIGN AND METHODS: Five hundred and four children and adolescents (250 boys and 254 girls), with type 1 diabetes mellitus, aged 10-18 years (mean:13+/-2), were screened for DR using non mydriatic photography, during their stay in a holiday camp. Demographic and clinical data recorded on subjects' arrival in the camp included date of birth, height, weight, treatment, blood pressure, and duration of diabetes. HbA(1c) was determined with a DCA 2000 kit. RESULTS: Mean diabetes duration was 4.8+/-3.4 years and mean HbA(1c) was 8.5+/-1.3%. Mild non proliferative DR was diagnosed in 23 children (4.6%). Compared to subjects without DR, those with DR were significantly older (P<10(-3)), had a longer duration of diabetes (P=0.001), higher systolic blood pressure (P=0.04), and had higher (but not significantly so) HbA(1c) (P=0.15). After adjustment for age, only longer duration remained significantly associated with DR (P=0.01). CONCLUSION: The prevalence of DR in these young patients was low compared to that reported in previous studies. The decrease may be due to modern diabetes care with multiple insulin injections. However, early detection of DR in adolescents, especially in their late teens, remains important, because it allows the identification of patients at high risk of progression towards severe stages of DR.

[Therapeutic penetrating keratoplasty for microbial keratitis].

BACKGROUND: Microbial keratitis is a potentially sight threatening disease. Most cases respond well to antimicrobial therapy. However, in cases that progress despite intensive medical therapy, an urgent therapeutic penetrating keratoplasty (TPKP) is required. AIM: To evaluate the indications and results of TPKP in Israel. METHODS: A retrospective study reviewed the TPKP performed at the Goldschleger Eye Institute, Sheba Medical Center, between 1990-2003. The study included 18 cases of at least one-year follow-up. RESULTS: The indications for TPKP included severe infectious keratitis unresponsive to medical treatment in 33% of the patients and severe corneal destruction in 66% of them. The infectious keratitis was diagnosed as bacterial keratitis in 44% of the patients, unidentified pathogen in 39%, mycotic in 11% and acanthamoeba in 6% of the patients. Risk factors in the patients with microbial keratitis requiring TPKP included: previous ocular disease in 39%, previous ocular surgery in 66%, systemic disorders in 28% and ocular risk factors in 28% patients. TPKP was successful in bacterial and acanthamoeba keratitis as far as the transparency of the graft and elimination of the infection and improvement of visual acuity. However, TPKP failed in mycotic and unidentified keratitis. The risk factors for failure included: previous ocular disease or surgeries, systemic disorders or large corneal grafts. CONCLUSIONS: Therapeutic penetrating keratoplasty is an important and effective therapeutic tool for intractable bacterial and acanthamoeba keratitis. Prognostic factors for graft success include lack of ocular disease or previous surgeries, lack of systemic disorders or small corneal graft size.

Human corneal stromal tissue concentration after consecutive doses of topically applied 3.3% vancomycin.

AIMS: To evaluate vancomycin penetration into human corneal stromal tissue in patients treated with topical vancomycin eyedrops before penetrating keratoplasty (PKP). METHODS: Twenty four patients who underwent PKP, seven patients with keratoconus (group 1) and 17 patients with corneal scar or corneal decompensation (group 2). All patients received topical application of vancomycin eyedrops (concentration: 33 mg/ml) 10, 3, 2, 1 hour, and 15 minutes before the operation. Corneal cumulative vancomycin levels were assessed by bioassay. RESULTS: Mean vancomycin corneal stromal tissue concentration was 46.7 (SE 4.11) microg/g tissue. This value was four to 20-fold in excess of the MIC90 of vancomycin in Staphylococcus aureus (2-10 microg/ml). CONCLUSIONS: Vancomycin reached high corneal tissue concentrations that significantly exceeded the MIC90 (2-10 microg/ml) for most key Gram positive corneal pathogens. The ratio of vancomycin stromal concentration to protein concentration was statistically higher in group 2 (non-keratoconus).

Risk factors for microalbuminuria in children and adolescents with type 1 diabetes.

OBJECTIVES: The aim of this study was to investigate the influence of sex, age, diabetes duration, puberty, blood pressure, glycemic control and parental blood pressure on microalbuminuria in children with type 1 diabetes. STUDY DESIGN: The study was a multicenter cross-sectional survey including 702 children and adolescents (age = 14.3+/-2.9 yr) with type 1 diabetes duration of 7.6+/-3.1 yr. One third of the population had not undergone pubertal development. Blood pressure was measured in children and their parents using a Dinamap instrument. Microalbuminuria was defined as a urinary albumin excretion rate > or = 15 microg/min measured on at least two out of three urine collections. HbA1c centrally measured by HPLC, was 8.7+/-1.5%. RESULTS: The proportion of permanent microalbuminuria was 5.1+/-1.6%. The prevalence was significantly enhanced after 10 yr of diabetes duration (11.6+/-5.2%) and complete puberty (8.2+/-3.1%). Independent risk factors for microalbuminuria tested in a logistic regression model were diabetes duration (OR/1 yr = 1.04-1.32), complete puberty (OR = 5.02-8.0), and maternal hypertension (OR = 1.94-4.28). HbA1c had a borderline independent and significant effect (OR/1% = 0.96-1.62; p = 0.07). CONCLUSIONS: Our results indicate that pubertal adolescents with a long duration of the disease and maternal history of hypertension are candidates for targeted interventions with the objective of reducing the rate of developing nephropathy in these individuals.

Artificial cornea and the future of eye banking.

A report on the construction of functional human corneal equivalent reflects a step towards creation of an artificial cornea. We discuss the current status of supply and demand for corneas for transplanation, and wonder if the creation of an artificial cornea will have an effect on corneal transplantation in the near future

The incidence of hepatitis C virus positive serological test results among cornea donors.

Purpose. We have noticed that the incidence of positive serological tests of hepatitis C virus (HCV) among cornea donors in our eye bank is higher than expected. The purpose of this study was to determine the incidence of these positive findings and identify the contributory risk factors.Methods. All corneas procured between June 1993 and June 1997 were included in this retrospective study. In all cases a routine work-up, including serological testing of donors' sera and evaluation of the procured corneas, was performed prior to corneal transplantation. Donors found to be positive for HCV antibodies were compared to our general population of corneal donors, with respect to the demographic, serological and ophthalmological data obtained during the transplantation work-up.Results. All 851 corneas procured from 438 donors were included. Antibodies to HCV were found in 29 donors (6.6%). Following positive test results, 57 corneas (6.7%) were discarded. The time from donors' death to cornea procurement was significantly longer among HCV-positive patients than in the general donor population (12.3 vs. 9.3 h, p<0.0003). No other differences were detected between the two groups.Conclusion. Delay in harvesting of donated corneas may give rise to false positive HCV-antibodies test results, which may be partially responsible for the high rate of positive findings among cornea donors, with consequent tissue wastage.

Insulin dose and cardiovascular risk factors in type 1 diabetic children and adolescents.

Associations between a high daily insulin dose and cardiovascular risk factors, including those of the insulin-resistance syndrome, were studied in 479 Type 1 diabetic children 6 to 18 years of age. Insulin dose increased over the first two years after diagnosis of diabetes (p = 0.0001) and was significantly higher in girls (p = 0.01). For those children with diabetes duration of more than 2 years, the insulin requirement increased up to 13-14 years of age (p < 0.05) and was higher in pubertal than pre-pubertal children (p < 0.05). For girls, the requirement was higher in puberty than in post-puberty (p < 0.05) and increased with diabetes duration (p < 0.05). Triglyceride concentrations were associated positively and significantly with the insulin dose of both boys and girls, after adjustment for age, pubertal stage, diabetes duration, and metabolic control (fructosamine levels). No other consistent associations were found between insulin dose and other cardiovascular risk factors: body mass index, central adiposity, arterial blood pressures, serum total cholesterol, apoA1, apoB, Lp(a), uric acid, or urinary albumin excretion. Parental obesity, hypertension and diabetes were not related to the insulin dose of children. The results did not differ when the population was limited to the 375 children with diabetes duration of more than 2 years. It is concluded that in these Type 1 diabetic children the insulin dose for a given level of metabolic control (our surrogate measure of insulin resistance) was related to a single cardiovascular risk factor: triglyceride concentrations.

Persistent chlorpromazine deposits in donor corneal tissue after corneal transplantation.

PURPOSE: To present unusual cases with corneal graft deposits and discuss eye bank criteria concerning donors treated with phenothiazines. METHODS: We examined two patients with unusual corneal graft deposits after uneventful corneal transplantation. Donors' files and eye bank procedures were reviewed. RESULTS: Fine corneal endothelial punctate deposits were detected in both corneal grafts and did not resolve in the following 18 months. CONCLUSION: To our knowledge, this is the first case report documenting transplantation of corneas with chlorpromazine deposits. Delicate corneal findings can be missed before transplantation.

Performing peripheral iridectomy via a scleral tunnel incision: a new approach.

A peripheral iridectomy (PI) is sometimes difficult to perform through a sclero-corneal tunnel. This study evaluated the effectiveness and safety of a newly proposed technique for performing a PI. The results showed that a PI can be easily performed through a sclero-corneal tunnel, employing this technique.

Effect of capsulorhexis diameter on glare disability.

PURPOSE: To determine whether the diameter of the anterior capsulorhexis has an effect on postoperative glare. SETTING: Sapir Medical Center, Meir Hospital, Kfar Saba, Israel. METHODS: Forty patients had extracapsular cataract extraction (manual or phacoemulsification) through an intact continuous curvilinear capsulorhexis (CCC) of various sizes. The CCC diameter was measured and the opacity of the anterior and posterior capsules was evaluated before and after dilation of the pupils. Glare test (Miller-Nadler glare tester) was performed with the eyelid in a normal position and after lid elevation. RESULTS: The diameter of the CCC ranged from 3.50 to 7.00 mm (mean 4.87 mm). The anterior capsule was always opaque in the area of contact with the IOL material. None was graded clear; 60% were graded as +3. Mean glare disability prior to pupil dilation was 12.1 +/- 8.8 (SD) and after dilation, 17.3 +/- 9.7. There was no correlation between glare disability and the diameter of the capsulorhexis, the width of the exposed opacified capsular ring, or the grading of capsule opacification (anterior and posterior). Dilation of the pupil significantly increased glare disability (P = .016), unrelated to CCC diameter. CONCLUSION: A CCC larger than 3.5 mm does not induce significant glare.

Dislocation of a scleral-fixated, posterior chamber intraocular lens after fixation suture removal.

A 58-year-old man's posterior chamber intraocular lens dislocated after a transscleral fixation suture was removed during a routine eye examination. The lens had to be repositioned. A scleral flap over the fixation sutures and a better understanding by general ophthalmologists of transscleral fixation suturing would have prevented this complication.

Proximity-sensor dimmer device as an aid in the reduction of operating microscope-induced retinal phototoxicity.

The length of exposure to the light source of the operating microscope is a major factor determining retinal phototoxicity. In our experience, for about 20% of the time during cataract surgery, the surgeon is not looking through the oculars. To take advantage of these times, we designed a device, a proximity switch consisting of an infrared sensor mounted between the oculars in the operating microscope. When the surgeon's forehead approaches the microscope to look through the oculars, the sensor increases the illumination; when the surgeon moves away, it is automatically reduced. The resulting decreased overall exposure to light may reduce retinal phototoxicity.

[Investment of the associations: Aide aux Jeunes Diabétiques as a model]. / Investissement des associations: le modèle de l'Aide aux Jeunes Diabétiques.

This paper describes the action of an association known as l'Aide aux Jeunes Diabétiques, in terms of education, by the organization of summer camps and of regional and national meetings, of information, through these meetings and the diffusion of a quarterly journal, and or research.

[Acanthamoebic keratitis].

Acanthamoebic keratitis is still a rare infection. It occurs in contact lens-wearers, especially when saline is prepared at home from contaminated tap water. There are periods of remission, and occasionally misleading findings resembling those of herpetic keratitis, which make the diagnosis difficult. The isolation of the acanthamoeba is not easy and special culture media are required. Early recognition and aggressive therapy with antiamebic medication and epithelial debridement, often in conjunction with penetrating keratoplasty, are needed. We describe the clinical course, laboratory diagnosis and treatment of 3 patients with acanthamoebic keratitis, 2 men aged 20 and 25, respectively and a women aged 42.

HbA1c in children attending summer camps organized by l'Aide aux Jeunes Diabétiques. Evidence for a harmful effect of lipohypertrophies in the early years of diabetes.

Glycated haemoglobin was determined by using the spot test method for blood sampling in all the children and teenagers attending the summer camps organized by l'Aide aux Jeunes Diabétiques in July 1989. A questionnaire was completed for each subject, relating age, the duration of the disease, the insulin regimen, the level of knowledge, the intensivity of urine and blood glucose self monitoring, and the presence of lipohypertrophies. The statistical analysis of the data suggests that the two only parameters which were found to have an influence on the level of glycated haemoglobin were the duration of the disease and the presence of lipohypertrophies: in the early years of diabetes (up to 4 years), HbA1c was significantly lower in patients without lipohypertrophies (7.90 +/- 0.18%, n = 78), than in those with lipohypertrophies (8.60 +/- 0.22%, n = 46, m +/- SEM, p < 0.02). This study should focus the attention of clinicians on the deleterious effect of lipohypertrophies, which can be observed very early on in the course of the disease.