Aristides K. Maniatis

Increased incidence and severity of diabetic ketoacidosis among uninsured children with newly diagnosed type 1 diabetes mellitus

Abstract:  Objectives:  (a) To determine the incidence and severity of diabetic ketoacidosis (DKA) and (b) to stratify according to insurance status at the initial diagnosis of type 1 diabetes (T1DM).

Life with continuous subcutaneous insulin infusion (CSII) therapy: child and parental perspectives and predictors of metabolic control

Abstract: Objective:  The purpose of this study was twofold (i): to evaluate metabolic control in patients receiving CSII therapy in a routine pediatric diabetes clinic by describing reasons for initiating therapy and daily management issues, including needle fear; and (ii) to assess the change in parental involvement and anxiety once their child initiated CSII therapy.

Prediction and Prevention of Type 1 Diabetes

At present, the prediction of type 1 diabetes is not a major clinical issue outside of trials for diabetes prevention. Patients, especially children, usually present acutely with diabetes with a dramatic history of polyuria, polydipsia, and weight loss. Despite what in retrospect is almost always a clear-cut clinical history of diabetes, a significant number of children have a delay in diagnosis, which increases the risk of severe metabolic decompensation with diabetic ketoacidosis (DKA), cerebral edema, and death.

455 INCREASED INCIDENCE AND SEVERITY OF DIABETIC KETOACIDOSIS AMONG UNINSURED CHILDREN WITH NEWLY DIAGNOSED TYPE 1 DIABETES

Objective This study analyzed pediatric subjects at the time of initial diagnosis of type 1 diabetes (T1DM) with two objectives: 1) to determine the incidence and severity of diabetic ketoacidosis (DKA), and 2) to stratify these subjects according to insurance status. Methods The subject population included all children less than 18 years who presented with new onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. The insurance status was collected on all subjects, and the initial pH was collected on subjects who presented to an emergency department and/or were admitted to the hospital. Results 359 patients presented with new onset T1DM. Forty-three (12.0%) of these children had no insurance. One hundred two (28.4%) subjects presented with DKA. When stratified by insurance status, 26 (60.5%) of the 43 uninsured subjects presented with DKA compared to only 76 (24.1%) of the 316 insured subjects, p≤0.001, OR=1.5. Further stratification based on pH severity revealed that uninsured subjects tended to present with more severe DKA than subjects with insurance, p=0.09 (borderline significant chi-square test for trend). The proportions among the most life-threatening DKA (most severe pH ≤ 6.90) included 7 (26.9%) of 26 uninsured subjects compared to 7 (9.2%) of 76 insured subjects, p=0.04. Conclusion At the time of initial diagnosis, patients without insurance were more likely to present with DKA than subjects with insurance. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening, as indicated by a lower initial pH. A potential explanation is that subjects without insurance may delay seeking timely medical care and therefore present more critically ill, whereas subjects with insurance may have their T1DM diagnosed earlier.