Initial Diagnosis Of Type Research Articles

How to descript a clinical case correctly: For inquiry scientists and demanding doctors

The article presents step by step international CARE guidelines (CAse REport), which regulate the structure of the description of a clinical case and include a checklist of 13 points. This form of presentation of the material does not create any difficulties in understanding, does not require a long period of time to prepare a publication for the author, demonstrating a unique personalized experience and informing the medical community about interesting clinical manifestations, diagnostic or therapeutic approaches within a particular nosology, as well as describing rare or newly reported side effects of drugs or features of their prescription. Below as an example presented a clinical observation of a young man with diabetes mellitus of complex origin, which was diagnosed after the initial diagnosis of type 2 diabetes mellitus, which was later supplemented with recurrent pancreatitis, pancreatic cyst development and alcohol abuse with underlying severe hypertriglyceridemia (up to 67 mmol/l). Given the limited choice of glucose-lowering therapy, inability to prescribe metformin, glucagon-like peptide-1 agonists, infeasibility to use dipeptidyl peptidase 4 inhibitors and gliflozins (history of episodes of balanoposthitis), after a detailed discussion with the patient, a decision was made to prescribe a combination insulin drug – biphasic Lispro (RinLis Mix 25, Geropharm, Russia), which, together with fundamental lifestyle changes, strong alcohol avoidance, and regular medical follow-ups, allowed him to achieve glycemic targets and reduce plasma triglyceride levels, which once again supported the versatility of insulin as hypoglycemic agent, easiness to use and comprehensive glycemic control, if pre-mixed ultra-fast-acting insulin analogue and its protaminized analogue are prescribed. The prescription of insulin premix in this case is also justified in terms of clinical guidelines, as the man led a regular lifestyle, had low physical activity, an HbA1c level greater than 1.5% of the target value, as well as fasting and postprandial hyperglycemia.

Risk of Neurodegenerative Diseases in Elderly Koreans with an Initial Diagnosis of Type 2 Diabetes: A Nationwide Retrospective Cohort Study.

Type 2 diabetes (T2D) and neurodegenerative diseases (NDs) are common among elderly individuals. Growing evidence has indicated a strong link between T2D and NDs, such as Alzheimer's disease. However, previous studies have limitations in exploring the epidemiological relationship among these diseases as a group of NDs rather than as a specific type of ND. We aimed to investigate the risk of NDs in elderly Koreans who were first diagnosed with T2D and determine the association between T2D and NDs. We conducted a retrospective longitudinal cohort study of patients with who were initially diagnosed with T2D using the Korean National Health Information Database. The study participants were categorized into a T2D group (n = 155,459) and a control group (n = 155,459), aged 60-84 years, that were matched for age, sex, and comorbidities. We followed the participants for 10 years to investigate the incidence of NDs. The Cox proportional hazards regression model was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for NDs. The numbers of patients diagnosed with ND at the end of follow-up were as follows: 51,096/155,459 (32.9%) in the T2D group and 44,673/155,459 (28.7%) in the control group (χ2 = 622.53, p < 0.001). The incidences of NDs in the T2D and control groups were 44.68 (95% CI: 44.29, 45.07) and 36.89 (95% CI: 36.55, 37.24) cases per 1,000 person-years at risk, respectively. The overall incidence of NDs was higher in the T2D group than that in the control group (HR: 1.23, 95% CI: 1.22, 1.25, p < 0.001). This study revealed a higher incidence of NDs in elderly Koreans who were initially diagnosed with T2D. This suggests that T2D is a risk factor for NDs in elderly Koreans.

A Histology-Guided Approach to the Management of Patients with Lupus Nephritis: Are We There Yet?

Renal involvement is a frequent complication of systemic lupus erythematosus (SLE). It occurs in up to two-thirds of patients, often early during the disease course, and is the most important predictor of the morbidity and mortality of SLE patients. Despite tremendous improvements in the approach of the lupus nephritis (LN) therapy, including the recent approval of two new disease-modifying therapies, up to 50% of patients do not obtain a renal response and up to 25% will eventually progress to end-stage renal disease (ESRD) within 10 years of diagnosis. Given the lack of correlation between clinical features and histological lesions, there is an increasing need for a histology-guided approach to the management of patients with LN. Apart from the initial diagnosis of type and severity of renal injury in SLE, the concept of a repeat kidney biopsy (either in a for-cause or a per-protocol scenario) has begun to gain increasing popularity in the nephrology community. Herein, we will provide a comprehensive overview of the most important areas of utility of the kidney biopsy in patients with LN.

Comparison of the clinical characteristics and outcomes of pediatric patients with and without diabetic ketoacidosis at the time of type 1 diabetes diagnosis.

PurposeWe investigated the possible effects of diabetic ketoacidosis (DKA) at the initial diagnosis of type 1 diabetes mellitus (T1DM) on the clinical outcomes of pediatric patients.Methods Medical records of children and adolescents with newly diagnosed T1DM seen in the Ajou University Hospital from January 2008 to August 2020 were reviewed and analyzed.ResultsAmong 129 diagnosed T1DM patients, 40.3% presented with DKA. Although demographic and basic characteristics did not differ between DKA and non-DKA patients, DKA patients needed a significantly higher insulin dosage than non-DKA patients for 2 years after diagnosis. However, control of glycated hemoglobin was not different between the DKA and non-DKA groups during the observation period. In the biochemical analysis, C-peptide, insulin-like growth factor-1, and insulin-like growth factor binding protein 3, high-density lipoprotein cholesterol, free T4, and T3 values were lower, but thyroid-stimulating hormone, initial serum glucose, uric acid, total cholesterol, triglyceride, and low-density lipoprotein cholesterol values were higher in DKA patients than non-DKA patients at the diagnosis of T1DM; however, these differences were temporarily present and disappeared with insulin treatment. Other clinical outcomes, such as height, thyroid function, and urine microalbumin level, did not vary significantly between the DKA and non-DKA groups during 5 years of follow-up.ConclusionsDKA at initial presentation reflects the severity of disease progression, and the deleterious effects of DKA seem to impact insulin secretion. Although no difference in long-term prognosis was found, early detection of T1DM should help to reduce DKA-related islet damage and the socioeconomic burden of T1DM.

Prediction of diabetic kidney disease with machine learning algorithms, upon the initial diagnosis of type 2 diabetes mellitus

IntroductionDiabetic kidney disease (DKD) accounts for the majority of increased risk of mortality for patients with diabetes, and eventually manifests in approximately half of those patients diagnosed with type 2...

Incidence of Proliferative Diabetic Retinopathy and Other Neovascular Sequelae at 5 Years Following Diagnosis of Type 2 Diabetes.

To determine the incidence and risk factors for developing proliferative diabetic retinopathy (PDR), tractional retinal detachment (TRD), and neovascular glaucoma (NVG) at 5 years after the initial diagnosis of type 2 diabetes. Insured patients aged ≥18 years with newly diagnosed type 2 diabetes and 5 years of continuous enrollment were identified from a nationwide commercial claims database containing data from 2007 to 2015. The incidences of PDR, TRD, and NVG were computed at 5 years following the index diagnosis of type 2 diabetes. Associations between these outcomes and demographic, socioeconomic, and medical factors were tested with multivariable logistic regression. At 5 years following the initial diagnosis of type 2 diabetes, 1.74% (1,249 of 71,817) of patients had developed PDR, 0.25% of patients had developed TRD, and 0.14% of patients had developed NVG. Insulin use (odds ratio [OR] 3.59, 95% CI 3.16-4.08), maximum HbA1c >9% or >75 mmol/mol (OR 2.10, 95% CI 1.54-2.69), renal disease (OR 2.68, 95% CI 2.09-3.42), peripheral circulatory disorders (OR 1.88, 95% CI 1.25-2.83), neurological disease (OR 1.62, 95% CI 1.24-2.11), and older age (age 65-74 years) at diagnosis (OR 1.62, 95% CI 1.28-2.03) were identified as risk factors for development of PDR at 5 years. Young age (age 18-23 years) at diagnosis (OR 0.46, 95% CI 0.29-0.74), Medicare insurance (OR 0.60, 95% CI 0.70-0.76), morbid obesity (OR 0.72, 95% CI 0.59-0.87), and smoking (OR 0.84, 95% CI 0.70-1.00) were identified as protective factors. A subset of patients with type 2 diabetes develop PDR and other neovascular sequelae within the first 5 years following the diagnosis with type 2 diabetes. These patients may benefit from increased efforts for screening and early intervention.

Diabetes mellitus is associated with an increased incidence of aortic valve stenosis.

Background:The prognosis of patients with diabetes mellitus (DM) is particularly determined by vascular comorbidities. A recent theory implies that DM could also promote aortic valve stenosis (AS). The present study investigates this association in a large collective of outpatients.Methods:This retrospective cohort study compared the incidence of AS in patients with an initial diagnosis of type 2 DM and a matched non-DM cohort in 809 general and diabetologist practices in Germany between January 2005 and December 2018. Cox regression models were performed to study the association between type 2 DM and AS incidence.Results:A total of 78,805 patients with type 2 DM and 78,805 patients without diabetes were analysed. Diabetes patients were more frequently diagnosed with obesity (52% vs 21%). Four percent of patients with and three percent of without diabetes were diagnosed with AS (p < 0.001). Diabetes was significantly associated with an increased incidence of AS (HR: 1.36, p < 0.001). This association was higher in men (HR: 1.41) versus women (HR: 1.30). The strongest association was observed in young patients (18–50 years, HR: 2.35, p < 0.001).Conclusion:In our study, diabetes patients had a higher incidence of aortic stenosis during their disease course.

Source-specific social support and psychosocial stress among mothers and fathers during initial diagnosis of type 1 diabetes in young children.

Background: Given parents' elevated stress following children's diagnoses of type I diabetes (T1D), more information about protective factors is needed. The current study examined social support from various sources (e.g., partner, family, general) in relation to stress among mothers and fathers of young children shortly following T1D diagnosis. Methods: Participants included 157 children ages 1-6 recently diagnosed with T1D and their parents (152 mothers and 59 fathers) who were enrolled in a behavioral randomized controlled trial (RCT). Mothers and fathers self-reported on their demographic background, social support and stress; T1D data were parent report and/or gathered from medical records. Results: Maternal and paternal stress were examined in two separate regression models. Higher general social support predicted less stress for both mothers and fathers. For mothers, higher family support predicted less stress, while college educations status predicted more stress. For fathers, more partner support predicted less stress. Discussion: Findings contribute to the literature on gender differences in source-specific social support and psychosocial functioning in a pediatric health population. Sample characteristics limit generalizability of results, and future studies should aim to include diverse samples. Results have both scientific and clinical implications for supporting families following T1D diagnosis. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Characterization of Adults with Initial Diagnosis of Type 2 Diabetes Mellitus in Peru

Aims: To describe the characteristics of adults with an initial diagnosis of type 2 diabetes mellitus (T2D) in multiple regions of Peru. Methods: Descriptive case series study performed at 26 centers. Subjects age &gt;20 years with T2D debut were included. Exclusion criteria were pregnancy, use of drugs known to alter glucose metabolism, and having renal, hepatic, respiratory, or cardiac insufficiency. Results: 581 subjects were enrolled, 48.9% were female, mean age was 53.2 years (SD ± 12.8). Mean weight was 77.3 kg (SD +/- 16.6), 39.2% were overweight and 45.1% were obese. Mean waist circumference was 100.6 cm (SD +/- 13.1). Mean blood glucose and HbA1c were 249.4 mg/dl and 8.9%, respectively. Subjects from Lima and the northern sites had higher levels of glucose and HbA1c. Subjects from high altitude sites had higher rates of fatty liver and lower levels of LDL-c and total cholesterol. Younger patients tended to have more metabolic alterations. Conclusions: This study is among the first to describe characteristics of adults with T2D debut in Peru. People from Lima and the northern provinces as well as those diagnosed at an early age seem to be at higher risk.

Determinants of diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes using paired glycated haemoglobin measurements in a large English primary care population: cross-sectional study.

To investigate factors influencing diagnostic discordance for non-diabetic hyperglycaemia and Type 2 diabetes. Some 10000 adults at increased risk of diabetes were screened with HbA1c and fasting plasma glucose (FPG). The 2208 participants with initial HbA1c ≥42mmol/mol (≥6.0%) or FPG ≥6.1mmol/l were retested after a median 40 days. We compared the first and second HbA1c results, and consequent diagnoses of non-diabetic hyperglycaemia and Type 2 diabetes, and investigated predictors of discordant diagnoses. Of 1463 participants with non-diabetic hyperglycaemia and 394 with Type 2 diabetes on first testing, 28.4% and 21.1% respectively had discordant diagnoses on repeated testing. Initial diagnosis of non-diabetic hyperglycaemia and/or impaired fasting glucose according to both HbA1c and FPG criteria, or to FPG only, made reclassification as Type 2 diabetes more likely than initial classification according to HbA1c alone. Initial diagnosis of Type 2 diabetes according to both HbA1c and FPG criteria made reclassification much less likely than initial classification according to HbA1c alone. Age, and anthropometric and biological measurements independently but inconsistently predicted discordant diagnoses and changes in HbA1c . Diagnosis of non-diabetic hyperglycaemia or Type 2 diabetes with a single measurement of HbA1c in a screening programme for entry to diabetes prevention trials is unreliable. Diagnosis of non-diabetic hyperglycaemia and Type 2 diabetes should be confirmed by repeat testing. FPG results could help prioritise retesting. These findings do not apply to people classified as normal on a single test, who were not retested.

Predictive factors of ketoacidosis in type 1 diabetes mellitus

Background Diabetic ketoacidosis (DKA) is an acute complication in type 1 diabetes mellitus (DM) and a significant cause of morbidity and mortality in developing countries. Diabetic ketoacidosis can be prevented by good management of the disease. Risk factors from previous studies that increase the DKA incidence were peripubertal age, female gender, low socio-economic status, low parental education status, DKA at the first diagnosis of type 1 DM, infection, psychological problems, poor metabolic control, and non-compliance with insulin treatment.&#x0D; Objective To determine whether sex, age, socio-economic status, parental education level, DKA at the initial diagnosis of type 1 DM, infection, psychological problems, poor metabolic control, and failing to take insulin as needed were predictive of DKA in type 1 DM patients.&#x0D; Methods We conducted a retrospective cohort study using medical records from type 1 DM patients aged 0-20 years, at the Department of Child Health, Dr. Sardjito Hospital, Yogyakarta, from January 2011 to May 2017. We assessed for the incidence and predictors of DKA. Logistic regression analysis was done to determine which factors increased DKA incidence.&#x0D; Results A total of 57 type 1 DM patients were recruited, with DKA incidence of 37 (65%). Five (8.8%) DKA patients died. Multivariate analysis revealed that infection (OR 5.23; 95%CI 1.47 to 19.68; P=0.014) and DKA at the first diagnosis of type 1 DM (OR 5.37; 95%CI 1.40 to 19.52; P=0.011) were significant risk factors for DKA. &#x0D; Conclusion Infection and DKA at the first diagnosis of type 1 DM are significant predictors of increased DKA incidence.

Diabetic Kidney Disease: A Determinant of Cardiovascular Risk in Type 1 Diabetes.

Diabetes, regardless of type, has well-accepted vascular consequences. In fact, atherosclerotic cardiovascular disease (CVD) is the most important cause of death attributable to diabetes (1). Acute complications of diabetes such as hypoglycemia, hyperglycemia, and diabetic ketoacidosis are important causes of morbidity and mortality beginning early in its course. However, microvascular and macrovascular complications drive excess mortality over the long term (2–4). Diabetic kidney disease (DKD) is strongly associated with CVD (5). DKD may be a marker of cumulative vascular damage due to diabetes or may causally promote CVD through several mechanisms, such as blood pressure dysregulation, retention of uremic toxins, anemia, and altered mineral metabolism. Provocative studies suggest that the preponderance of excess CVD risk in both types 1 and 2 diabetes is restricted to people with DKD (6–8). The question posed by Groop et al. (9) in this issue of Diabetes Care was whether patients with type 1 diabetes have heightened CVD mortality risk in the absence of DKD compared with people without diabetes. To examine this question, they looked at two different databases. The first was a registry of 10,737 Finnish children followed for 10 years after the initial diagnosis of type 1 diabetes, a period considered generally too early for DKD development. The mortality rate of children in the Finnish registry was compared with that of the general population as a standardized mortality ratio (SMR) that adjusts for demographic characteristics. Children with diabetes had a mortality rate of 8 per 10,000 person-years, yielding an SMR of 2.6. (An SMR …

Assessment of Newly Proposed Clinical Criteria to Identify HNF1A MODY in Patients with an Initial Diagnosis of Type 1 or Type 2 Diabetes Mellitus.

The most common form of maturity-onset diabetes of the young (MODY) is caused by mutations in the hepatocyte nuclear factor 1A (HNF1A) gene. However, most HNF1A mutation-carriers are initially misdiagnosed with type 1 (T1DM) or type 2 (T2DM) diabetes mellitus; hence, they often receive nonoptimal treatment. The aim of our study was to test newly proposed clinical criteria for the identification of HNF1A MODY in patients with a diagnosis of T1DM or T2DM. To achieve this, the following criteria to preselect patients for screening were used: for T1DM: TDIR (total daily insulin requirement) > 0.3 IU of insulin/kg and the percentage of basal insulin > 30% of TDIR; for T2DM: sulphonylurea- (SU-) based oral treatment (monotherapy or combined with Metformin) > 15 years and BMI < 30 kg/m2. We reviewed the clinical data of 140 patients with T1DM and 524 clinically diagnosed with T2DM. On the basis of these criteria, we found a HNF1A mutation in 1 out of 2 individuals with a diagnosis of T1DM and 1 out of 11 selected individuals with a diagnosis of T2DM. We believe that the simplicity of the proposed criteria might prove useful in clinical practice, as an alternative to more time-consuming classical diagnostic techniques.

Characteristics of children presenting with newly diagnosed type 1 diabetes

Background. The clinical presentation of type 1 diabetes in children can be acute or insidious, and symptoms may be subtle and frequently misinterpreted. Presentation with diabetic keto-acidosis (DKA) may be associated with significant morbidity and mortality in the paediatric population. This study set out to determine the characteristics of children presenting to the paediatric endocrine service at Inkosi Albert Luthuli Central Hospital (IALCH) with DKA at the time of diagnosis, and to determine the frequency of missed diagnoses in the previous month. Methods. A retrospective study was done at IALCH, the paediatric tertiary referral centre for KwaZulu-Natal, South Africa. The study sample included all children with an initial diagnosis of type 1 diabetes between January 2008 and June 2010. Children presenting with DKA were compared with those who presented without DKA. Results. During the period under review, 63 children presented with type 1 diabetes. Of these, 44 (69.8%) had DKA at the time of diagnosis. The median duration of symptoms preceding diagnosis in the DKA group was 2 weeks, versus 4 weeks in the non-DKA group ( p =0.002). There was no significant difference between the groups when ethnicity, gender and age at presentation were compared. Of 42 patients who presented to healthcare facilities in the month preceding diagnosis, 27 (64.3%) were misdiagnosed. Conclusion. Patients who presented with DKA had a shorter duration of symptoms than the non-DKA group. Ethnicity had no effect on characteristics at presentation. There was an unacceptable rate of missed diagnoses of type 1 diabetes in both the private and public sectors.

A diabetes awareness campaign prevents diabetic ketoacidosis in children at their initial presentation with type 1 diabetes

To evaluate the effect of a diabetes awareness campaign on the incidence of diabetic ketoacidosis (DKA) at the first presentation of type 1 diabetes in children (0-18 yr). This study was a controlled population intervention study with a 2-yr baseline period and a 2-yr intervention period. Data were collected on all children presenting with their initial diagnosis of type 1 diabetes [pH, bicarbonate, base excess, blood glucose level (BGL), urea, and creatinine] at Gosford, Newcastle, and Sydney (Sydney Children's Hospital and Royal North Shore Hospital). During the intervention period, diabetes education occurred in the intervention region (Gosford). Child care centers, schools, and doctor's offices were offered education and posters about the symptoms of type 1 diabetes. Doctor's offices were given glucose and ketone testing equipment. The control regions (Newcastle and Sydney) did not receive any educational intervention or test equipment. DKA was defined as pH < 7.3 or bicarbonate < 15 mmol/L. In Gosford, the proportion of children presenting in DKA decreased from 37.5% (15/40) during the 2-yr baseline period to 13.8% (4/29) during the 2-yr intervention (p < 0.03). There was no significant change in the control regions during the same time periods, 37.4% (46/123) and 38.6% (49/127), respectively. In Gosford, the average BGL at presentation was 27.5 mmol/L during the baseline and 21.2 mmol/L during the intervention (p < 0.01). During the diabetes awareness campaign, the rate of DKA at initial diagnosis of type 1 diabetes in children decreased by 64%.

Time to treatment initiation with oral antihyperglycaemic therapy in US patients with newly diagnosed type 2 diabetes

To compare the time from initial diagnosis to initiation with oral antihyperglycaemic treatment in younger versus older patients with type 2 diabetes, and to evaluate factors associated with initiating treatment. This was a retrospective US cohort study with a 2-year follow-up period after diagnosis of type 2 diabetes. Using the General Electric Healthcare's Clinical Data Services electronic medical record database, eligible patients included those aged ≥30 years at initial diagnosis of type 2 diabetes between January 2003 and December 2005. In the 2-year period following diagnosis, the time to the first prescription of an oral antihyperglycaemic agent was compared between younger (30-64 years) and older (≥65 years) patients. Factors associated with time to treatment with an oral antihyperglycaemic agent were examined using Cox proportional hazards regression. Of the 10 743 patients with newly diagnosed type 2 diabetes, 43% were ≥65 years old. The mean age at diagnosis was 73 years for older patients and 52 years for younger patients. Compared to younger patients, a greater proportion of older patients had a baseline haemoglobin A1c (HbA1c) value <7% (38 vs. 32%; p < 0.001). In the 2-year follow-up period, a significantly greater proportion of younger patients (59%) received oral antihyperglycaemic treatment compared to older patients (44%; p < 0.001). The median time between diagnosis and initiating treatment with an oral antihyperglycaemic agent was 350 days for younger patients and >2 years for older patients. After adjusting for covariates, older patients had a greater risk of not receiving treatment with oral antihyperglycaemic therapy than younger patients [adjusted hazard ratio = 0.82 (95% confidence interval: 0.75, 0.90)]. In patients with newly diagnosed type 2 diabetes, the time to initiation of oral antihyperglycaemic therapy was significantly longer in older patients (≥65 years old) than younger patients (<65 years).

Progression of Type 2 to Type 1 Retinopathy of Prematurity in the Early Treatment for Retinopathy of Prematurity Study

To examine the frequency and timing of progression from type 2 to type 1 retinopathy of prematurity (ROP) in the Early Treatment for Retinopathy of Prematurity Study. Infants with prethreshold ROP that was no worse than low risk in 1 or both eyes, based on the RM-ROP2 model, were examined every 2 to 4 days for at least 2 weeks. Using the Early Treatment for Retinopathy of Prematurity Study-defined classification of eyes as having type 1 or type 2 prethreshold ROP, we analyzed the time to conversion from type 2 to type 1. Data were analyzed for 1 randomly selected eye for each child. Of 294 eyes at first diagnosis of type 2 ROP, 65 (22.1%) progressed to type 1 (mean [SD] interval, 9.0 [6.6] days; median, 7.0 days). Of 217 eyes with type 2 ROP that had an examination in less than 7 days, 25 (11.5%) were diagnosed with type 1 ROP in less than 7 days. Of 200 eyes that continued to have type 2 disease at the first follow-up examination and underwent a subsequent examination, 24 (15.7% of the 153 eyes that had an examination in <7 days) developed type 1 ROP in less than 7 days. The risk of progression from type 2 to type 1 in less than 7 days was greatest between 33 and 36 weeks' postmenstrual age, regardless of zone of retinopathy. Type 1 ROP can be identified with weekly examinations in most eyes with initial diagnosis of type 2 ROP; a small subset progresses to type 1 in less than 7 days. clinicaltrials.gov Identifier: NCT00027222.

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

(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). Subjects included children <18 yr who presented with new-onset T1DM from January 2002 to December 2003 and were subsequently followed at the Barbara Davis Center. Insurance status and initial venous pH were obtained. Overall, 383 subjects presented with new-onset T1DM and 359 (93.7%) were enrolled. Forty-three (12.0%) of these children were uninsured and 40 (11.1%) had Medicaid. One hundred and two (28.4%) subjects presented with DKA. When compared to the insured subjects, uninsured subjects had a significantly increased risk of presenting with DKA [odds ratios (OR): 6.19, 95% CI 3.04-12.60, p < 0.0001], as well as presenting with severe DKA, defined as venous pH <7.10 (OR: 6.09, 95% CI 3.21-11.56, p < 0.0001). There were no differences, however, between the insured and Medicaid subjects in their probability of presenting with DKA or severe DKA. The risk of presenting with DKA (as well as with severe DKA) was the highest among patients <4 yr old. At the time of initial diagnosis, uninsured patients were more likely to present with DKA than insured patients. Furthermore, when the uninsured subjects presented with DKA, the condition tended to be more severe and life-threatening. A potential explanation is that uninsured subjects may delay seeking timely medical care, thereby presenting more critically ill, whereas insured subjects may have their T1DM diagnosed earlier.

Thyroid function in children with newly diagnosed type 1 diabetes mellitus.

Evaluation of thyroid hormone indices was performed in 138 children with newly diagnosed type 1 diabetes, with their siblings serving as controls. The DKA group consisted of 76 children who had diabetic ketoacidosis (DKA) at initial diagnosis. The non-DKA group consisted of 62 children and the control group of 35. The thyroid function tests of the patients were measured within 3 days of the initial diagnosis of diabetes and at least one follow-up test one month to two years after adequate treatment of diabetes. The DKA group had significantly lower levels of T3, T4, free T4 and FTI than did the other two groups (p < 0.0001, p < 0.0001, p < 0.0001, and p < 0.0001, respectively). T3 concentration was lower in non-DKA subjects than in controls (p = 0.0003), but the two groups did not significantly differ in terms of T4, free T4, and FTI. The TSH level did not differ among the three groups. We conclude that DKA changes thyroid function measurements. In the absence of true thyroid disease, abnormal thyroid function tests are reversible after institution of good diabetic control. We suggest that thyroid function tests should be restricted to those patients suspected of having thyroid disorders at the initial diagnosis of type 1 diabetes.

One-Hour Meal Tolerance Test to Assess Withdrawal of Insulin Therapy in Overweight Patients With Type 2 Diabetes

To evaluate the clinical usefulness of a 1-hour meal tolerance test to determine the feasibility and safety of discontinuation of insulin therapy in overweight, insulin-treated patients with type 2 diabetes mellitus. Overweight patients who presented with metabolic decompensation at initial diagnosis of type 2 diabetes were hospitalized and treated with insulin. A 1-hour meal tolerance test was performed in an outpatient setting when patients had maintained a stable metabolic status with decreasing daily insulin requirement and the possibility of withdrawal of insulin therapy was considered. After an overnight fast, venous blood samples were collected before and 1 hour after consumption of an oral liquid meal (240 mL, 240 kcal, approximately 30 g of sucrose) to measure glucose and C-peptide levels. If the postmeal glucose level was < or = 10 mmol/L, the insulin therapy was discontinued. Patients underwent follow-up to validate the clinical decision. Twenty-four overweight adult Mexican American patients (8 of whom had ketoacidosis) were treated with insulin at initial diagnosis of type 2 diabetes. The mean insulin dosages were reduced progressively from 71 +/- 8 U/day to 31 +/- 3 U/day during a period of 4 +/- 0.5 months. At that stage, the mean fasting and 1-hour postmeal blood glucose levels were 5.0 +/- 0.2 mmol/L and 8.4 +/- 0.4 mmol/L, respectively. Meal-induced plasma C-peptide levels showed 1.9- to 4-fold increases, confirming substantial endogenous insulin secretion. The C-peptide responses were similar in the two subgroups of patients with or without initial ketoacidosis. On the basis of postmeal blood glucose levels, the insulin therapy was discontinued in all cases. After 3 months of follow-up, all patients were in good metabolic control. Fourteen patients underwent follow-up for >12 months; 10 of them were maintained without antidiabetic medications for 21.4 +/- 2.8 months. Two patients were treated with sulfonylurea drugs after 4 months, and another two required insulin therapy by the 4th and 18th months, respectively. A 1-hour postmeal blood glucose level is helpful for deciding the withdrawal of insulin therapy in overweight, insulin-treated patients with type 2 diabetes.