Precipitating Factors and Outcome of Diabetic Ketoacidosis among Children and Adolescents with Type-1 Diabetes Mellitus.

OBJECTIVE: To determine the precipitating factors and outcomes of diabetic ketoacidosis (DKA) among patients with type 1 diabetes mellitus. STUDY DESIGN: An analytical study. Place and Duration of the Study: Department of Paediatrics, National Institute of Child Health, Karachi, Pakistan, from July to December 2022. METHODOLOGY: Children of either gender aged up to 18 years and presenting with DKA with a known diagnosis of type-1 diabetes were enrolled. Demographic, clinical, and anthropometric characteristics of all children were noted. Laboratory investigations were sent to the institutional laboratory. Presenting features, precipitating factors, severity of DKA, and outcomes noted. RESULTS: Among 131 children, 101 (77.1%) were girls. The socio-economic status of 75 (57.3%) patients was the lower middle. Celiac disease was the commonest associated disease noted in 23 (17.6%) patients. A total of 123 (93.9%) children were using basal plus bolus types. Adherence to diabetes-related drug therapy was seen in 105 (80.2%) patients. At the time of presentation, vomiting, fever, abdominal pain, and respiratory distress were the most frequent presenting features reported in 77 (58.8%), 67 (51.1%), 42 (32.1%), and 34 (26.0%) patients, respectively. The most common precipitating factors for DKA were infection/illness (n=90, 68.7%) and missed insulin dose (n=16, 12.2%); no cause was identified in 25 (19.1%) patients. The mean duration of hospital stay was 5.25±2.4 days. Four patients could not survive. CONCLUSION: The most common precipitating factor for the current episode of DKA were infection or illness, or missed insulin dose. Vomiting, fever, abdominal pain, and respiratory distress were the most frequent presenting features. In-hospital mortality was found to be 3% in DKA patients. KEY WORDS: Diabetic ketoacidosis, Type-1 diabetes mellitus, Insulin, Vomiting, Abdominal pain.

Celiac And Autoimmune Thyroid Disease In Patients With Anti-Gad Positive Type-1 Diabetes Mellitus.

BACKGROUND: Type-1 diabetes mellitus (T1DM) and autoimmune thyroid disease can occur concomitantly and patients with TIDM have a high risk of other autoimmune conditions like thyroid disease and celiac disease. This study aimed to analyze the association of anti-GAD positive T1DM with anti-thyroid antibodies and celiac disease. METHODS: This cross-sectional study was conducted at the Department of Paediatric Endocrinology & Diabetes, National Institute of Child Health, Karachi Pakistan from July 2022 to December 2022. A total of 115 children of both genders aged between 1-18 years having known T1DM were analyzed. Children with chronic kidney disease or chronic liver disease were excluded. Those children were also not included whose parents/caregivers did not wish their children to be part of this research. The blood sample of each child was taken in a sterilized container and sent to an institutional laboratory for biochemical investigations. RESULTS: In a total of 115 patients, 67 (58.3%) were female and 48 (41.7%) males. The mean age was 8.87±3.43 (ranging between 1.5-17 years). The mean HbA1c was 11.86±7.31%. It was found that anti-GAD IgG was having signification association with celiac disease (p<0.001). Significant correlation of anti-GAD positive antibodies with Ttg-IgG antibodies (correlation coefficient=0.303, p=0.001), thyroid peroxidase antibodies (correlation coefficient=0.228, p=0.001). CONCLUSIONS: High proportions of children with anti-GAD positive T1DM patients were found to have thyroid disorders and celiac disease. A significant correlation was found between anti-GAD positive antibodies, celiac disease and anti-thyroglobulin antibodies.

Pediatric Risk of Mortality III Score in Predicting Mortality Among Diabetic Ketoacidosis Patients in a Pediatric Intensive Care Unit.

Background Diabetic ketoacidosis (DKA) is one of the most common complications of type 1 diabetes. Mortality is not uncommon in DKA, mostly in younger children with severe DKA and those complicated with cerebral edema. Early identification of high-risk patients can help in timely interventions to improve the outcome of DKA. Pediatric Risk of Mortality (PRISM III) is a standard scoring system to objectively predict the prognosis and outcome of pediatric intensive care unit (PICU) patients. Objective To predict the need for inotrope and mechanical ventilation and mortality rate using PRISM III in DKA patients admitted to PICU. Methods A prospective observational study was conducted in the PICU of the National Institute of Child Health, Karachi, from February 2020 to September 2021 involving 114 children. PRISM III scoring protocol was applied. A PRISM III score of >8 predicted higher mortality risk.  Results The mean PRISM III score was 6.56 ± 3.18 with 30 (26.3%) children having a score >8. Of the 30 (26.31%) patients with >8 PRISM III scores, 14 (46.67%) needed inotropic support, 6 (20%) needed mechanical ventilation, and there were eight (26.67%) mortalities. There was no reported mortality among patients with a PRISM III score ≤8. All differences were statistically significant (p < .05). Conclusion PRISM III is a highly sophisticated scoring system that can aid clinicians in the early prediction of adverse clinical outcomes in patients with DKA. Robust scientific evidence supporting its clinical application can help practically improve the outcome of DKA in young patients.