OBJECTIVE: To investigate whether serum bicarbonate (HCO3) levels can be used to accurately diagnose diabetic ketoacidosis (DKA) and classify its severity in children with new-onset diabetes mellitus (NODM). METHODS:Retrospective study of all patients with NODM presenting to Boston Children's Hospital from October 1, 2007, to July 1, 2013. DKA was defined as blood glucose $200 mg/dL, venous pH (vpH) ,7.3, and urine ketones $2+, and severe DKA as vpH ,7.1. Linear regression was used to assess serum HCO3 as a predictor of vpH, and logistic regression to evaluate serum HCO3 as a predictor of DKA and severe DKA.RESULTS: Of 690 study cohort subjects (47% girls, age 10.8 6 4.3 years, 76.7% white), 19.4% presented with DKA. The relationship between serum HCO3 and vpH was log-linear (r = 0.87, 95% CI 0.85-0.89, P , .001). HCO3 predicted vpH (R 2 0.75, P , .001) using the formula Diabetes mellitus in youth is common, with an estimated worldwide annual incidence of 80 000 children younger than 15 years 1 and the incidence is rising. 2 Diabetic ketoacidosis (DKA) at presentation of new-onset diabetes mellitus (NODM) occurs in approximately 15% to 70% of patients in Europe and North America. 3 The incidence of DKA at presentation is higher in younger children, ethnic minorities, families of lower socioeconomic status, and regions with a lower prevalence of diabetes, 3-7 which includes many resource-limited countries.In many pediatric academic medical centers in the United States, the standard initial diagnostic evaluation for children with NODM and especially those suspected to have DKA includes a panel of laboratory tests to measure venous blood gas (VBG) and the concentrations of plasma glucose, serum electrolytes, serum bicarbonate (HCO3), serum urea nitrogen (SUN), creatinine, hemoglobin A1c (HbA1c), and serum or urinary ketones. Acidemia is defined as arterial pH ,7.35 or venous pH (vpH) ,7.3, and traditionally, a vpH ,7.3 or a serum HCO3 ,15 mmol/L is used to confirm the diagnosis of DKA, with lower values of both indicating greater severity of the condition. Venous pH ,7.1 or serum HCO3 ,5 mmol/L has been used to define severe DKA. 3,8 These definitions are incorporated into hospital practice guidelines, and emergency department physicians and pediatricians often base management decisions, for example, admission to hospital and use of intravenous versus subcutaneous insulin therapy, on the vpH value. However, in remote or limited resource settings, VBG is not readily available.A recent study of pediatric patients seen in an emergency department suggested that the venous HCO3 concentration accurately predicts abnormal vpH in children with DKA. 9 Similarly, in adults, venous HCO3 concentrations predicted arterial pH with a high degree of sensitivity and specificity. 10 The objective of our study was to evaluate the ability of serum HCO3, measured at presentation, as part of a routine basic metabolic panel, to accurately predict DKA and classify its severity in a large population of youth with NODM. METHODS Stu...

The impact of chikungunya virus (CHIKV) infection on diabetic patients (DPs) has not been described. We aimed to compare clinical features of CHIKV infection in DPs and nondiabetic patients (NDPs), and to evaluate its effects on glycemic control among DPs. We recorded clinical information and, in DPs, glycemic control. Forty-six DPs and 53 NDPs aged ≥ 20 years living in Haiti, with acute CHIKV infection, were studied. Diabetes duration was 7.1 ± 6.1 years. The most common acute CHIKV clinical manifestations were arthralgia (100.0% DPs and 98.1% NDPs, P = 1.000) and fever (86.9% DPs and 90.5% NDPs, P = 0.750). In DPs as compared with NDPs, arthralgia was more intense (mean pain score of 6.0/10 ± 2.2 versus 5.1/10 ± 2.0, P = 0.04) and took longer to improve (8.2 ± 3.0 versus 3.5 ± 2.5 days, P < 0.0001). Severe arthralgia was more prevalent (58.7% versus 20.8%, P = 0.0002), as was myalgia (80.4% versus 50.9%, P = 0.003), and fever lasted longer (5.1 ± 1.8 versus 3.7 ± 1.7 days, P = 0.0002). Among DPs, median fasting capillary glucose before versus after disease onset was 132.5 and 167.5 mg/dL (P < 0.001), corresponding to a median increase of 26.8% (interquartile range: 14.4–50.1%). Antidiabetic medication was titrated up in 41.3%. In summary, among DPs, CHIKV infection has a significant negative impact on glycemic control and, compared with NDPs, results in greater morbidity. Close clinical and glycemic observation is recommended in DPs with CHIKV infection.

Objective: Few studies have reported blood lead levels (BLLs) in Haitian children, despite the known presence of lead from environmental factors such as soil, water, leaded paint and gasoline, improperly discarded batteries, and earthquakes. We sought to determine the prevalence of elevated blood lead levels (EBLLs) among healthy Haitian children. Methods: We enrolled children aged 9 months to 6 years from 3 geographic areas in Haiti (coastal, urban, and mountain) from March 1 through June 30, 2015. We obtained anthropometric measurements, household income, potential sources of lead exposure, and fingerstick BLLs from 273 children at 6 churches in Haiti. We considered a BLL 5 mg/dL to be elevated. Results: Of 273 children enrolled in the study, 95 were from the coastal area, 78 from the urban area, and 100 from the mountain area. The median BLL was 5.8 mg/dL, with higher levels in the mountain area than in the other areas (P < .001). BLLs were elevated in 180 (65.9%) children. The prevalence of EBLL was significantly higher in the mountain area (82 of 100, 82.0%; P < .001) than in the urban area (42 of 78, 53.8%) and the coastal area (56 of 95, 58.9%; P < .001). Twenty-eight (10.3%) children had EBLLs 10 mg/dL and 3 (1.1%) children had EBLLs 20 mg/dL. Exposure to improperly discarded batteries (P ¼ .006) and living in the mountain area (P < .001) were significant risk factors for EBLLs. Conclusions: More than half of Haitian children in our study had EBLLs. Public health interventions are warranted to protect children in Haiti against lead poisoning.

In this cohort of Haitian youth, DR and cataracts occur prematurely. Low-insulin requirements years after diagnosis, possibly allowing for prolonged undetected hyperglycemia prediagnosis, may explain complication risk. The phenotypes of diabetes in pediatric populations of African ancestry may be distinct. Ophthalmologic evaluation should possibly start at diagnosis, and screening guidelines may need to be adapted.