Review of Leipzig protocol for intravenous insulin infusion in pediatric patients with type 1 diabetes during intercurrent illness and surgery.

OBJECTIVE: Continuous intravenous (IV) insulin infusion therapy minimizes blood glucose (BG) fluctuations and prevents metabolic deterioration in pediatric patients with type 1 diabetes (T1D) during intercurrent illness and surgery. However, data on the adequate fluid and insulin substitution in this situation is rare. We evaluated the effectiveness and safety of IV insulin therapy according to our local protocol. METHODS: Retrospective study of 124 cases of hospitalization with IV insulin therapy because of intercurrent illness (n = 78) or minor surgery (n = 46) in 62 patients with T1D (mean age: 9.6 ± 5.4 years). The patients received a glucose-electrolyte infusion and short-acting insulin (normal insulin). Infusion rate was adapted according to the BG measured hourly. Glycemic control was analyzed in subgroups subdivided by age, glycated hemoglobin (HbA1c) and reason for hospitalization. RESULTS: Mean infusion time was 22 hours (range 1.5-147 hours). In 65% of the infusion time, patients' BG was within the target range (4-8 mmol/L). Critical events (BG <3 or > 15 mmol/L) were found in 6% of the infusion time. Comparison of glycemic control in subgroups for HbA1c and the reason for hospitalization revealed no significant differences. However, patients aged <12 years exhibited significant more critical events, primarily hypoglycemia compared to adolescents (hypoglycemia/case 2.4 ± 2.7 vs 0.9 ± 2.0; P < 0.001). CONCLUSIONS: Our protocol for IV insulin therapy proved to be appropriate for adequate glycemic control in pediatric patients with T1D during intercurrent illness and surgery. However, the regime seems to be more suitable in adolescents. We adapted our protocol in younger patients with reduction of the insulin dose.

Cystic-fibrosis related-diabetes (CFRD) is preceded by and associated with growth failure and deteriorating lung function.

BACKGROUND: Impaired glucose metabolism and cystic fibrosis (CF)-related diabetes (CFRD) are associated with insufficient weight gain and impaired lung function in children and adolescents with CF. We have asked whether imminent CFRD may be a cause of poor growth in children and adolescents. METHODS: A retrospective case control study including 32 patients with CF with or without diabetes was conducted. Sixteen pairs, matched according to age, gender and exocrine pancreatic insufficiency, were analysed. Standard deviation scores (SDS) of height, growth, weight, body mass index (BMI), forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and forced expiratory flow at 75% of expired FVC (FEF75) were recorded during a mean observation period of 13 years per patient. RESULTS: SDS of height and weight were reduced in CF patients with diabetes compared to those without, not only at the point of diagnosis (both p<0.05) but years before the evidence of diabetes. Afterwards there was a significant decline in height (p<0.001) and weight (p<0.01) SDS in CFRD patients and an increasing difference between the height and weight of CF patients with or without diabetes. In contrast, no significant reduction of BMI-SDS was observed in CFRD patients. All analysed lung function parameters showed a marked decline in CFRD patients starting 1 year prior to the diagnosis of diabetes. CONCLUSIONS: Deteriorating growth, reduced weight and impaired lung function are related to the development of CFRD and are obvious several years before the actual diagnosis of diabetes.

Association between IgE-mediated allergies and diabetes mellitus type 1 in children and adolescents.

BACKGROUND: Type 1 diabetes mellitus (T1DM) is characterized by an immunological reaction that is dominated by type-1 T helper (Th1) cells, whereas immunoglobulin E (IgE)-mediated allergies are associated with Th2 cell. According to the Th1/Th2-hypothesis, the immune system is said to either develop into the direction of Th1 or Th2 cells. This would mean that a child developing T1DM is unlikely to develop an IgE-mediated allergy and vice versa. OBJECTIVE: The aim of the study was to investigate the association between the prevalence of T1DM and IgE-mediated allergies. METHODS: We designed a prospective case control study with 94 children and adolescents with T1DM and 188 age- and sex-matched control children. The basis of our investigations was a questionnaire concerning the family and children's history as to the presence of IgE-mediated allergies. Moreover, the following blood investigations were done: total serum IgE, specific IgE antibodies to major inhalant allergens, and a multiplex cytokine analysis measuring levels of specific cytokines representing either Th1- or Th2- cytokines. RESULTS: Children with T1DM reported the presence of IgE-mediated allergies significantly more often than children of the control group. Children with T1DM had significantly higher tumor necrosis factor alpha (TNFα) levels than healthy controls. Levels of interleukin-2 (IL-2) and IL-6 were higher in the groups of children with the presence of a personal history of allergies, regardless of the presence of T1DM. CONCLUSIONS: Our results suggest that T1DM is associated with a higher risk of a self-reported presence of IgE-mediated allergies and that the Th1/Th2-hypothesis may be an oversimplification.

Complication and mortality rate after percutaneous endoscopic gastrostomy are low and indication-dependent.

OBJECTIVE: Percutaneous endoscopic gastrostomy (PEG) is often used for the feeding of patients with malnutrition due to dysphagia, and despite more than 30 years experience, numerous questions on its benefit remain. This was a prospective observational study to assess the safety of PEG. MATERIAL AND METHODS: One hundred and nineteen patients mean age 63 years (21-91 years) who were admitted to the Hannover Medical School between November 2010 and March 2012 and had an indication for PEG according to the German guidelines were included. Primary endpoints were the following: reason for indication, date of in-hospital mortality after PEG insertion, death within 3 months after PEG placement, and complications. RESULTS: Most patients (54.6%) received PEG for dysphagia caused by tumors and second (29.4%) for neurologic diseases with a minor proportion of dementia (3%). About 73% of our patients had no complications at all and only 10% suffered severe effects. We saw only 1 case of aspiration, which did not lead to pneumonia. The 30-day mortality was 10%, and no patient died as a result of the PEG procedure. Significantly more patients with neurologic disorders died within 24 weeks of PEG placement than tumor patients (60% versus 27.7%, respectively, p = 0.002, n = 100). CONCLUSION: It is important to select patients receiving PEG very carefully. The patients' indications, their primary disease, and their capability for mental cooperation are essential. If these aspects are taken into account, PEG is a safe method with few mainly mild complications.