Dr Nicole Glaser discussed diabetic ketoacidosis (DKA) in children. Clinically-severe cerebral injury occurs in approximately 1% of children with DKA. However, mild cerebral swelling and cerebral injury occur in a far greater proportion of children with DKA. In one study, just over half (54%) of children with DKA had ventricular narrowing, and of those patients, just over half had abnormal mental status. N-acetyl aspartate/creatine (NAA/CR) is an indicator of neuronal health that has been shown to decrease in stroke and other cerebral injury. NAA/Cr ratios were lower during DKA treatment than after recovery.
Studies using diffusion weighted imaging in children with DKA can be used to measure random motion of water molecules in cerebral tissues. This method allows you to quantify diffusion as the Apparent Diffusion Coefficient (ADC). Vasogenic edema is associated with high ADC, whereas cytotoxic edema is associated with low ADC. In a rodent model, ADC values were lower during DKA, suggesting cytoxic edema. ADC values rose to values slightly during DKA treatment, suggesting vasogenic edema. During DKA, rats have reduced cerebral blood flow compared with controls, but cerebral blood flow increased as rats are rehydrated and treated. In human studies, after several hours of treatment, ADC values were higher, suggesting vasogentic edema. Initial BUN positively correlated with ADC change, as did higher initial respiratory rate. However, not much correlation was observed between ADC change and osmolality variables.
In summary, ADC and cerebral blood flow are low in untreated DKA, suggesting cerebral hypoperfusion and cytoxic edema. CBF and ADC values increase during treatment, suggesting vasogenic edema. Patterns of change in ADC and CBF are similar to those observed in hypoxic/ischemic brain injury. Decreased cerebral blood flow occurs as a result of dehydration and hypocapnia, creating a risk of cerebral injury and cytoxic edema. Severe cerebral edema occurs rarely, mild cerebral edema occurs frequently. Although edema is a component of DKA-related cerebral injury, it may be more of a consequence than a cause.
Henk-Jan Aanstoot, MD, PhD next discussed the UN World Diabetes Day November 14, 2007. More children world wide are developing diabetes, both type 1 and type 2. Increases in prevalence may be blunted with the right message. Additionally, diabetes is different for children. The family is the patient. Diabetes may interfere with normal growth, psychosocial factors play an important role, as do socioeconomic factors. All children have the right to the best care their countries can provide. This goal requires education of the family, a multidisciplinary team approach, support for school personnel, and many other factors. There are many barriers to achieving this goal, including lack of resources and medications, as well as a lack of knowledge and understanding.
The International Diabetes Federation (IDF) in partnership with Novo Nordisk A/S are developing a charter to serve as an agent of change, present a comprehensive portrait of diabetes, and motivate global healthcare recommendations. There are 4 chapters: epidemiology, organization and delivery of care, socioeconomic aspects, and psychosocial aspects. The goals of this initiative are to create an effective lobbying tool, stimulate motivation, and act as an agent for change.
Robert G Nelson, MD, PhD next discussed type 2 diabetes in youth and adolescents with a focus on Pima Indians. The first paper on type 2 diabetes in youth was published in 1979. In the 1990s, approximately 2% of new-onset diabetes was type 2, but in 2000, from 8-45% of new onset diabetes in youth was type 2. Type 2 diabetes in youth is also prevalent in Japan, where type 2 diabetes in youth represents 80% of newly diagnosed cases. The frequency of type 2 diabetes in youth has been steadily increasing, and it is a world wide problem and has been paralleling the obesity epidemic.
Dr Nelson next presented data from the Gila River Indian Community longitudinal health study that has been going on since 1965 and has collected data on health status, bodgy size, blood pressure, glucose toleranace, A1C, complications, family data, pregnancy and health of children, and mortality and cause of death. Susceptibility to type 2 diabetes is associated with family history. When neither parent has diabetes, risk is very low. When both parents have it, type 2 diabetes is very prevalent. Environmental factors also affect diabetes risk. The interuterine environment affects risk of type 2 diabetes in children. Prevalence of the disease is much higher when the mother of the child also had diabetes. Additionally, offspring of diabetic moms are more obese at birth and remain so during life, and it is well known that incidence of diabetes increases with increasing BMI.
There has also been a shift in diabetes development over the last several decades. Over the last 40 years, there has been a 6-fold increase in 5-14 yr olds, but a decline in the 25-34 age range. This shift reflects the trend of earlier development of type 2 diabetes. Instead of developing diabetes in 20s and 30s, people are simply developing the disease at a younger age.
In terms of complications, there is no difference in risk of nephropathy based on age and diabetes duration. Much like the onset of diabetes, the onset of complications is simply occurring at an earlier age, increasing risk for morbidity and mortality. The same is true for end-stage renal disease, but does not hold true for retinopathy, where youth confers some benefit. People with youth onset type 2 diabetes have a 3-fold increase in death rate compared with healthy controls.
A number of community efforts are being undertaken in this group, including provision of comprehensive clinical care. Behavior change programs to encourage breast feeding (and reduce diabetes risk), modify school lunch programs, add physical act to the school curriculum, develop obesity prevention programs targeting children, remove sugar-containing soft drinks from vending machines in schools, and implementing lifestyle interventions in the community. |
