El Dr. Ayu Wirastiti 25.03 Pk 18.00.docx

LONG CASE REPORT

SUSPECT TYPE 1 DIABETES MELLITUS (E10) DIFERENTIAL DIAGNOSIS TYPE 2 DIABETES MELLITUS, AKI INJURY, CLINICALLY DOWN SYNDROME, WELL NOURISHED, SHORT STATURE

By: Ni Made Ayu Wirastiti

Local Evaluation Denpasar, April 1th, 2019

POSTGRADUATE PEDIATRIC TRAINING PROGRAMME DEPARTMENT OF CHILD HEALTH FACULTY OF MEDICINE UDAYANA UNIVERSITY/ SANGLAH HOSPITAL DENPASAR 2019

I.

Identity a. Patient identity Name

: NKGC

Age on case determination : 14 years 7 months old Date of birth

: August 25th, 2004

Sex

: Female

Address

: Indonesia

Date of admission

: March 21st, 2019

Date of case determination : March 22nd, 2019 Medical record number

: 19012697

b. Parents identity

II.

Father

Mother

Name (initial)

IWS

NS

Age

54 years old

37 years old

Education

Uneducated

Junior high school

Occupation

Farmer

Farmer

History Taking (Subjective) History of illness was taken from the parents. 1. History of present illness Chief complaint: high blood glucose level Patient was referred from T State Hospital with diagnosis of post diabetic ketoacidosis. She was referred for further management of blood sugar. Patient arrived at pediatric emergency unit with chief complaint of high blood sugar initially noticed since 4 days before admission to hospital. At that time, she was taken to T Hospital due to weakness of the body and decrease of consciousness. After being treated for four days, her condition improved but the blood glucose remained high. The measurement of her blood sugar at the time of admission to T Hospital was 749 mg/dL. Weakness of her body was noticed two days before admission to T Hospital. Her parents said that at home she would most likely lie down in

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bed. She remained alert and responsive but was unable to walk even to the bathroom. There was no history of stomachache, vomiting, nor shortness of breath before nor during that period of treatment. Upon arrival to our hospital, she appeared alert and conscious, she responded adequately to her surroundings. Her parents noticed that she has been experiencing an increase of urination since 1 month before admission to hospital. In one day she would urinate up to 6-7 times. She would wake up at night frequently to just go to the bathroom. Her parents noticed decreased appetite since the fever started. Before these symptoms occur, she could eat about 1,5 portions of rice with the accompanying meals. She would regularly eat three times daily. This eating habit started since approximately 1 year ago, and due to that eating habit her parents noticed her figure appeared overweight. However, since her condition deteriorated she only managed to eat half a portion of meals. Her figure was said to appear thinner significantly since approximately 1 month ago. At that time they said her appetite had not changed. However, they noticed she appears much thinner since her appetite decreased 5 days prior to admission, but they never measure her body weight before. She started menstruating since the age of … teratur/tidak? History of snoring during sleeping is denied. 2. History of past illness Patient had never experienced similar complaints like this one previously. Her parents were aware that her development was unlike other children. She was admitted to T Hospital due to decrease of consciousness and high blood sugar level. She was treated for diabetic ketoacidosis at that hospital for 4 days, before being referred to our hospital. The treatment given to her included: cefotaxime 500 mg three times daily (iv) (given

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for 4 days), ranitidine 1 ampoule twice daily (iv), and insulin drip 2 units/hours (iv). 3. Family medical history Patient is the third child of four siblings. All her siblings are healthy. They are 22 years old, 18 years old, and 10 years old. All her siblings are able to interact appropriately with her. There are no family members who have similar complaint. No family history of diabetes mellitus or other diseases such as hypertension, pulmonary disease, kidney disease, and liver disease were reported. 4. Social history 1. Prenatal history She was born from a 22-year old mother with full term pregnancy. Her mother had antenatal care with a midwife at least 4 times throughout her pregnancy. Mother only took vitamin supplements without any other medication. Her blood pressure was always normal, so was her blood sugar level. There was no history of X-ray exposure, fever, rash, pain, edema, and other illness during pregnancy. Conclusion: no problem appeared during pregnancy. 2. Intranatal history She was born by spontaneous vaginal delivery, assisted by doctor in a hospital. She was vigorous and her birth weight was 3350 grams. No history of shortness of breath, cyanotic, and jaundice were reported. Conclusion: no problem appeared during delivery. 3. Postnatal history She was able to suck breast milk immediately after birth. No history of hospitalization due to jaundice, seizure, nor bleeding was reported. Conclusion: no problem appeared during postnatal period. 4. Nutritional history She was exclusively breastfed for six months and continued until 24 months. She started to eat soft food at the age of 6 months old, steamed rice at the age of 9 months old, and adult food at the age of 12 months old. The food combination mainly consists of white meat,

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fish, vegetables, and fruits. She was thought to be allergic to eggs due to experiencing itchiness of the skin after every time consuming eggs. Prior to admission, her appetite was said to have decreased. She usually ate one and half portion of rice but before admission she only managed to eat half portion of rice in every mealtime with half a piece of fried tempe and chicken. She ate 3 times the day prior to admission. The calorie intake for 24 hours was 1770 kcal/day. Calories fulfilled were 54% of the recommended dietary allowance (RDA). Conclusion: decreased food intake. 5. Growth and development history Her body weight was reported to increase throughout her growth. Since she was 8 years old, her parents notice her body seemed overweight compared to other children her age. However, they never measure her body weight so they cannot be precisely sure of how much weight she has lost after she became ill. Her parents notice her figure is shorter than other children her age, but they also never measure her height routinely. Her parents understand that she had a delayed development history. She started to be able to stand up at the age of 16 month, and started walking at the age of 18 months. She was only able to speak a few words at the age of 3 years old. Currently, she is able to speak simple words like mentioning her name (“Mang”), calling her parents (“Pak”, “Ibu”), or asking for food, and occasionally she can form a simple sentence. She entered school for children with special needs until 5th grade. She isn’t generally physically active. She prefers to sit down in front of the television and watch television programs in most of her hours at home. She is not fond of physical activities such as playing outside the house or being involved in outdoor games with her peers. Conclusion: weight loss was noticed, although not objectively measured. There is delayed development, which was 6. Immunization history

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History of immunization is as follows: BCG once with scar (1 month old), DPT 3 times (2, 3, 4 months old), Hepatitis B 4 times (0, 2, 3, 4 months old), Polio 4 times (0, 2, 3, 4 months old), and measles once (9 months). Her mother couldn’t recall her having a booster immunization at age 18 months. She did recalled her having one immunization at school which was MR (1 year ago), but she had not had her JE immunization. Conclusion: immunization status is not appropriate with the basic immunization requirements. 7. Basic needs history Stimulation

: she receives sufficient stimulation from her parents. She is able to get along well with her peers. She attended school for children with special needs at the age of 8 years old and stayed in school until Grade 5, after which she dropped out of school due to being unhappy because her friends were said to be mean to her. Her last day at school was over 1 year ago. Since then she was given stimulation at home by her parents.

Parenting

: she is the third child in her family and was born from a happy marriage. She is loved and supported by both parents.

Caring

: she was breastfed exclusively for six months. Immunization was received at Posyandu. Health care was received from a midwife or doctors from primary health care and hospital. She lives with her parents and siblings in a permanent house.

Conclusion

: basic needs history is sufficient.

8. Family socio-economic condition She lives with her parents and three siblings in a permanent house in a village. The building of the house was funded by a house-funding program. The size of the housing space is approximately 30 sq.

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meters, including a small kitchen. The bathroom is outside of the main building. Water source is from the well, whereas electricity is sourced from the state electricity company (PLN). Both her parents work as farmers in another person’s farm. Average family income per month is approximately 600.000 IDR. The family has good relationship with the surrounding neighbours. The patient uses government health insurance for seeking health care. Conclusion: low socioeconomic level, patient has public health insurance.

III.

History During Admission Until Determination as Case On the first and second day of hospitalization (March 21 and 22, 2019), the patient looked alert, no shortness of breath was noticed, he had good appetite, but still had excessive urination. On physical examination, he appeared moderately ill, he was alert with level of consciousness 12/12, blood pressure was 100/70 mmHg (50-90th percentile), pulse rate was 98 beats/minute, regular, good pulse quality, respiratory rate was 24 times/minute, regular, axillary temperature was 36.8°C, pain score (FLACC) was 0 (no pain), fall risk (Humpty-Dumpty) was 9 (low risk to fall), body weight (BW) was 34 kg, body height (BH) was 142 cm, ideal body weight (IBW) was 36 kg, mid upper arm circumference (MUAC) was 23,5 cm, nutritional status based on Waterlow was 94% (normal). On laboratory findings, WBC 4,42 K/µL (neutrophils 3,13 K/µL (70,94%); lymphocyte 0,66 K/µL (14,93%)), hemoglobin 7,71 g/dL (MCV 75,16 fL; MCH 22,79 pg; MCHC 30,32 g/dL), trombosit 103,90 K/µL, serum iron 34,38 µg/dL, Total iron binding capacity 196 µg/dL, ferritin 51,57 ng/mL, sodium 135, mmol/L; potassium 1,99 mmol/L; calcium 7,5 mg/dL; chloride 98,1 mmol/L, ureum 22,90 mg/dL, creatinin 1,35 mg/dL, Hb-A1c 12,6%, blood glucose 473 mg/dL. Result of blood gas analysis pH 7.42, pCO2 31,7 mmHg, pO2 190,70 mmHg, HCO3- 20,20 mmol/L, BE -4,3 mmol/L, SO2 99,3%. On urinalysis, pH was 6.50, cloudy, leucocyte (1+)25 leuco/uL, protein (1+)20 mg/dL, Glukosa (2+) 200 mg/dL, blood (1+)

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ery/Ul, no keton was found on macroscopic examination, while urine sedimentation showed white blood cell 10, red blood cell 11, epithel cell 5 per field of view. TSHs 2,15 µIU/mL, free T4 1,13 ng/Dl. Echocardiography evaluation was found normal echocardiography finding. The patient was suspect type 1 diabetes mellitus (E10) differential diagnosis type 2 diabetes mellitus (E11), clinically down syndrome (Q90) , well nourished. He was given insulin short acting (novorapid) 0,05 IU/BW/hour with rate 2ml/hour, Kalium correction 0,5 mmol/BW/hour . His maintenance fluid requirements was 1900 ml/day (fulfilled from oral intake), calorie requirements 3430 kcal/day, carbohydrate requirements 428 grams/day, protein requirements 137 grams/day, fat requirements 114 grams/day with the following calorie diet arrangement: 20% breakfast, 10% snacks, 25% lunch, 10% snacks, 25% dinner, 10% snacks. The patient was monitored for vital signs, urine production, fluid balance and evaluation of blood glucose stick before insulin injection and meals. He was planned for C-peptide examination.

IV.

Physical Examination (Objective) on March 22nd, 2019 a. Present status General condition

: moderatelly ill

Level of consciousness

: E4V5M6 15/15 (compos mentis)

Blood pressure

: 100/70 mmHg (50-90th percentile)

50th percentile

: 106/63mmHg

90th percentile

: 119/77 mmHg

95th percentile

: 123/81 mmHg

99th percentile

: 130/88 mmHg

Pulse rate

: 98 beats/minute, regular, good pulse quality

Respiratory rate

: 24 times/minute, regular

Axillary temperature

: 36.8°C

Oxygen saturation

: 98% in room air

Pain scale (FLACC)

: 0 (no pain)

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Fall risk (Humpty-Dumpty) : 9 (low risk to fall) b. General status Head

: normocephaly, black hair, not easily plucked.

Face

: no abnormality, no edema, dysmorphic face, no hirsutisme, no acne

Eye

: no sunken eyes, no palpebral edema, symmetrical eyelids, no pale conjunctiva, no icteric sclera, round pupils with both diameter 3 mm and good light reflexes, no deviation conjugae, strabismus in both eyes, no exopthalmos.

Ear

: normal shape, no discharge.

Nose

: no nasal flare, no discharge, no bleeding, no septal deviation.

Throat

: no pharynx hyperemia, tonsil T1/T1.

Mouth

: no cyanosis on surrounding mouth, tongue and gum, symmetrical corners of the mouth, no drooling, no tongue enlargement, no white plaque on tongue and mouth, no caries dentis.

Neck

: no neck stiffness or enlargement of lymph nodes, no acanthosis nigricans at posterior of the neck

Chest Heart

:

Inspection

: precordial bulging not visible, ictus cordis not visible.

Palpation

: ictus cordis was palpable in the intersection of left midclavicular line and fourth intercostals space, no thrill, LV lift and RV heave not palpable.

Auscultation : first and second heart sound was normal, M1>T1 and A2>P2 regular, no murmur. Lung

:

Inspection

: normal chest shaped, no pectus excavatum, no pectus carinatum, symmetrical on static and dynamic state, without subcostal retraction.

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Palpation

: symmetrical chest movement.

Auscultation : vesicular breath sound, without crackles and wheezing on both lungs. Abdomen

:

Inspection

: no distention, superficial vein was not visible.

Auscultation : normal peristaltic sound. Palpation

: liver and spleen was not palpable.

Percussion

: tympanic, shifting dullness not found.

Limbs

: no edema, no cyanosis on fingers, palms were not pale, warm on palpation, capillary refill time 2 second, simian crease on both hands.

Inguinal

: no enlargement of inguinal lymph nodes.

Buttocks

: no rash.

Skin

: no cutis marmorata, no makulopapular rash

Genital

: labia mayora cover labia minora, pubic hair becomes more coarse and curly, and begins to extend laterally, no candidiasis vulvovaginalis

Neurological examination of four limbs: Upper limbs

Lower limbs

Power

555

555

Tone

Normal

Normal

Trophy

Normal

Normal

Physiological reflex

Normal

Normal

Pathological reflex

Negative

Negative

c. Pubertal status Mammae

: breast begins to become more elevated, and extends

beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast. Pubic hair

: hair becomes more coarse and curly, and begins to

extend laterally. Appropriate with M3P3 (Tanner stage 3)

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d. Anthropometric status (based on WHO growth chart) Body weight, weight for age

: 34 kg, P<3 (underweight)

Body height, height for age

: 142 cm, P<3 (underweight)

Weight for height

: P25-50

Ideal body weight

: 36 kg

MUAC

: 23,5 cm

Nutritional status (Waterlow)

: 94% (normal)

Father height

: 165 cm

Mother height

: 150 cm

Genetic height potential

: 142,5-159,5 cm (the patient’s height is

within

his

genetic

height

potential) e. Developmental status The result of PedsQL evaluation score on both the patient and the parents is 98.37. This indicates that there is never a problem in the child’s quality of life. In addition, the score of Pediatric Symptom Checklist-17 questionnaire is 1. Conclusion: there is no developmental disturbances in the patient.

V.

Resume A 14 year 7 months old boy was referred from T State Hospital with diagnosis of post diabetic ketoacidosis. She was referred for further management of blood sugar. Patient with chief complaint of high blood sugar initially noticed since 4 days before admission to hospital. At that time, she was taken to T Hospital due to weakness of the body and decrease of consciousness. After being treated for three days, her condition improved but the blood glucose remained high. The measurement of her blood sugar at the time of admission to T Hospital was 749 mg/dL. Weakness of her body was noticed two days before admission to T Hospital. Her parents noticed that she has been experiencing an increase of urination since 1 month before admission to hospital. In one day she would urinate up to 6-7 times. Her parents noticed decreased appetite since

10

the fever started. Before these symptoms occur, she could eat about 1,5 portions of rice with the accompanying meals. She would regularly eat three times daily. This eating habit started since approximately 1 year ago, and due to that eating habit her parents noticed her figure appeared overweight. On physical examination, he appeared in moderately ill, level of consciousness was 15/15, blood pressure was 100/70 mmHg (50-90th percentile), pulse rate was 98 beats/minute, regular, good pulse quality, respiratory rate was 24 times/minute, regular, axillary temperature was 36.8°C, and he’s well nourished based on Waterlow’s nutritional status. A significant laboratory finding revealed Hb-A1c level 12,6%.

VI.

Workup Diagnosis Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11), Clinically down syndrome (Q90), Acute kidney injury stage injury (N17), well nourished.

VII.

Problems a. At this moment 1. Diagnosis To establish the definitive diagnosis of diabetes mellitus and Clinically down syndrome in this patient. 2. Management a. Management of insulin regiment. b. Nutrition management. c. Self-monitoring of blood glucose. d. Clinically down syndrome management. 3. Complications a. Patient could suffered retinopathy. b. Patient could suffered neuropathy. c. Patient could suffered nephropathy.

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4. Prognosis a. Routine monitoring of the HbA1C. b. The possibility of experiencing growth and developmental problem. 5. Prevention Prevention of ketoacidosis diabetic and hypoglicemia b. Long term 1. Management of diabetes mellitus in long term, treatment compliance, drug adverse event, complication, risk of growth and development impairment. 2. Intervention and stimulation focused on language sector to reach normal milestone of development. 3. Psychological impact and quality of life of children and their parents. Some of these issues will be solved by journal searching using evidence based medicine (EBM) method.

VIII. Planning 1. Medical treatment plan with insulin i.

Management of type 2 diabetes uses basal bolus insulin administration. Provision of insulin with an initial dose of 0.05 IU/kg/hour. Preferred insulin is Humalog insulin which is a rapid acting insulin. Currently the dose of insulin is still being adjusted.

ii.

sodium replacement based on laboratory monitoring. Potassium replacement in patients is carried out carefully according to serum potassium levels and urine production. KCL drip is given at a dose of 0,5 mmol / kg body weight / hour.

2. Nutrition management and dietary regulation in type I diabetes mellitus Provision of nutrition with calculation of caloric needs based on RDA according to ideal body weight based on height on WHO Growth Chart.

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Calorie distribution in 24 hours given 3 times the main meal and 3 times snack as follows: 20% of breakfast, 10% in the form of snacks, 25% in the form of lunch, 10% of snacks, 25% of dinner, 10% of snacks. Dietary composition of carbohydrate 50%, 35% fat, and 15% protein. Recommended diet is high in fiber and contains a low glycemic index. 3. Planning monitoring a. Monitoring of short-term complications that can occur in people with type 2 DM include DKA, hypoglycemia and hyperglycemia. The occurrence of short-term complications above is associated with a monitor of glucose levels that must be done continously. There are two ways to monitor daily glucose levels, namely Self monitoring Blood Glucose (SMBG) and Continuous Glucose Monitoring System (CGMS). Monitoring Blood Glucose is with intermittent blood glucose monitor generally 2 - 6 times per day. b. Monitoring and treatment of long-term complications of type 2 diabetes melitus - HbA1c examination every 3 months for monitoring of metabolic conditions. - Monitoring the risk of comorbidities including macrovascular and microvascular complications. - Monitoring of macrovascular complications such as hypertension and lipid profile. Screening of hypertension by measuring the blood pressure since diagnosed and monitored every time of follow up. If the hypertension diagnosed, ACE inhibitor is the drug of choice. Screening of lipid profile is proceed as soon as 2 years after diagnosis confirmed, if the result normal, it can be repeated every 5 year. - Monitoring of microvascular complications such as retinopathy (eyes evaluation screening every year or more often if any risk of blindness), nephropathy (evaluate 2 years after the diagnosis confirmed, monitoring every year, with urine examination for

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microalbuminuria) and diabetic neuropathy (as soon as 2 years after diagnosis confirmed, monitoring the clinical sign every year, with clinical evaluation) and other complications including growth disorders, puberty disorders, osteopenia and cataracts. c.

Diagnosis of clinically down syndrome -

Intervention with chromosome examination

-

Monitoring patient with developmental evaluation tool to determine outcome of the therapy

4. Communication, information and education plan

a. Education about basic knowledge of type 1 or type 2 DM, management

of

type

(administration, type,

2 diabetes mellitus side effect,

includes

insulin

adjustment dose), eating

arrangements, exercise, emergency treatment of type 2 DM complication (hypoglicemia, insulin administration during sickness) and independent monitoring (home monitoring).

b. Exercise will help the patient to achieve ideal weight, increase heart capacity, reduce the occurrence of long-term complications, help the body's metabolism work that can reduce insulin demand. Monitoring for the possibility of hypoglycemia or hyperglycemia during or after activities is required.

c. Self monitoring is necessary because diabetes mellitus is a chronic disease and requires lifelong treatment. Monitoring blood glucose levels using home made tools is important to adjust daily insulin requirements.

d. The parents should be educate about how to keep maintaining the stimulation and routinely take the patient to do milestone evaluation to detect further problem and determine the treatment outcome.

5. Long-term prognosis Type 2 diabetes mellitus is a chronic disease with a good prognosis if the patient in good metabolic control.

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6. Growth and development of the patient Long-term problems of type 2 diabetes mellitus are not only about the disease, but also the impact of patient’s growth and development. Developmental screening tools showed communication disorder and needed some intervention. Parents role to intervening patients should be optimized by education. The outcome is patient able to cath up the normal development milestone.

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IX. Day (Date) Day 1 (March 23rd, 2019)

Follow Up Subjective

Objective

Assesment

Planning

alert, no shortness of breath, slightly decreased appetite, frequent urination

Physical examination Present status General condition : moderately ill Conciousness : compos mentis Blood pressure : 100/60 mmHg (50-90th percentile) Pulse rate : 98 beats/minute, regular Respiratory rate : 26 times/minute, regular Temperature : 36.5oC O2 saturation : 98% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 9 (low risk to fall)

Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11), Clinically down syndrome (Q90), Acute kidney injury stage risk (N17), moderate anemia hypochromic microcytic et causa chronic infection well nourished.

Therapy - Fluid requirements 1900 ml/day (intake oral 500 ml/day, NaCL 0,9% infusion 58 ml/hour) - Potassium chloride 0,5 mmol/kgBW/hour in 500 ml maintenance fluid ~ 17 mmol/hour - Calorie requirements 2520 kcal/day, protein requirements 100,4 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks night 25% dinner, 10% snacks - Insulin Novorapid 10 IU-10 IU10 IU subcutaneously (before meal) - Insulin Levemir 10 IU at bedtime

General status Eyes : pale conjunctiva (-), sclera icteric (-), strabismus in both eyes Thorax : symmetrical, retraction (-) Heart : S1S2 normal, regular, murmur (-) Lung : vesicular +/+, rales (-), wheezing (-) Abdomen : distention (-), normal abdominal sound Extremities: warm, CRT <2 seconds, simian crease on both hands Anthropometric status BW 34 kg, BH 142 cm, IBW 36 kg, nutritional status based on Waterlow 94% (well nourished)

Diagnostic - C-peptide examination - HbA1c examination every 3 months - Profil lipid examination

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Laboratory findings Blood glucose level morning 124 mg/dL, day 235 mg/dL, night 235 mg/dL, basal 212 mg/dL.

Monitoring - vital signs, urine production, fluid balance, blood glucose level

Complete blood count Hb: 7,71g/dL, hematocrit: 22,44%, WBC: 5,24

10µ/µL, Platelet : 128,5 10µ/µL, Reticulocyte: 2,5% Electrolyte Kalium : 3,15 mmol/L, Natrium 143 mmol/L, Chlorida 103 mmol/L, Calsium : 7,6 mg/dL Ureum : 18 mg/dL, creatinin: 1,06 mg/dL

Day 2 (March 24th, 2019)

alert, no shortness of breath, able to eat and drink, frequent urination

24 hours fluid balance : -474 ml Urine production : 1,3 ml/kg/hour Physical examination Present status General condition : moderately ill Conciousness : compos mentis Blood pressure : 100/60 mmHg (50-90th percentile) Pulse rate : 98 beats/minute, regular Respiratory rate : 26 times/minute, regular Temperature : 36.5oC O2 saturation : 98% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 9 (low risk to fall) General status Eyes : pale conjunctiva (-), sclera icteric (-), strabismus in both eyes Thorax : symmetrical, retraction (-)

Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11), Clinically down syndrome (Q90), Acute kidney injury stage risk (N17), moderate anemia hypochromic microcytic et causa chronic infection well nourished.

Therapy - Fluid requirements 1900 ml/day (intake oral 500 ml/day, NaCL 0,9% infusion 58 ml/hour) - Potassium chloride 0,5 mmol/kgBW/hour in 500 ml maintenance fluid ~ 17 mmol/hour - Calorie requirements 2520 kcal/day, protein requirements 100,4 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks

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Heart : Lung : Abdomen : Extremities:

S1S2 normal, regular, murmur (-) vesicular +/+, rales (-), wheezing (-) distention (-), normal abdominal sound warm, CRT <2 seconds, simian crease on both hands

night 25% dinner, 10% snacks - Insulin Novorapid 10 IU-10 IU-10 IU subcutaneously (before meal) - Insulin Levemir 10 IU at bedtime

Anthropometric status BW 34 kg, BH 142 cm, IBW 36 kg, nutritional status based on Waterlow 94% (well nourished)

Diagnostic - HbA1c examination every 3 months - Waiting for the result of Cpeptide examination - Homeostasis model assessmentestimated insulin resistance (HOMA IR) examination

Laboratory findings Blood glucose level morning 185 mg/dL, day mg/dL, night mg/dL, basal mg/dL Profil Lipid Total Cholesterol: 100 mg/dL, HDL: 47 mg/dL, LDL: 43 mg/dL, Trigliserida 75 mg/dL

Day 5 alert, (December 4, able to eat 2017) and drink well

24 hours fluid balance : -474 ml Urine production : 1,3 ml/kg/hour Physical examination Present status General condition : well Conciousness : compos mentis Blood pressure : 100/60 mmHg (90-95th percentile) Pulse rate : 100 beats/minute, regular Respiratory rate : 26 times/minute, regular Temperature : 36.8oC O2 saturation : 98% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 14 (high risk to fall)

Monitoring - vital signs, urine production, fluid balance, blood glucose level Suspect type 1 diabetes mellitus (E10) differential diagnosis type 2 diabetes mellitus (E11), expressive language disorder (F80.1), well nourished

Therapy - Fluid requirements 1125 ml/day (fulfilled from oral intake) - Calorie requirements 1150 kcal/day, protein requirements 43 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks

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night 25% dinner, 10% snacks - Insulin Humalog 3 IU-3 IU-3 IU subcutaneously (before meal) - Insulin Lantus 0-0-5 IU subcutaneously - Speech therapy (outpatient)

General status Eyes : pale conjunctiva (-), ikterik sclera (-) Thorax : symmetrical, retraction (-) Heart : S1S2 normal, regular, murmur (-) Lung : vesicular +/+, rales (-), wheezing (-) Abdomen : distention (-), normal abdominal sound Extremities: warm, CRT <2 seconds

Diagnostic - Waiting for the result of Cpeptide examination - HbA1c examination every 3 months

Anthropometric status BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional status based on Waterlow 108% (well nourished) Laboratory findings Blood glucose level morning 223 mg/dL, day 277 mg/dL, night 65 mg/dL, basal 65 mg/dL

Day 6 alert, (December 5, able to eat 2017) and drink well

24 hours fluid balance : +137.5 ml Urine production : 2.8 ml/kg/hour Physical examination Present status General condition : well Conciousness : compos mentis Blood pressure : 90/60 mmHg (90-95th percentile) Pulse rate : 95 beats/minute, regular Respiratory rate : 26 times/minute, regular Temperature : 36.6oC O2 saturation : 98% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 14 (high risk to fall) General status

Monitoring - vital signs, urine production, fluid balance, blood glucose level

Suspect type 1 diabetes mellitus (E10) differential diagnosis type 2 diabetes mellitus (E11), expressive language disorder (F80.1), well nourished

Therapy - Fluid requirements 1125 ml/day (fulfilled from oral intake) - Calorie requirements 1150 kcal/day, protein requirements 43 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks night 25% dinner, 10% snacks

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Eyes : Thorax : Heart : Lung : Abdomen : Extremities:

- Insulin Humalog 3 IU-3 IU-3 IU subcutaneously (before meal) - Insulin Lantus 0-0-5 IU subcutaneously - Speech therapy (outpatient)

pale conjunctiva (-), ikterik sclera (-) symmetrical, retraction (-) S1S2 normal, regular, murmur (-) vesicular +/+, rales (-), wheezing (-) distention (-), normal abdominal sound warm, CRT <2 seconds

Diagnostic - Waiting for the result of Cpeptide examination - HbA1c examination every 3 months

Anthropometric status BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional status based on Waterlow 108% (well nourished) Laboratory findings Blood glucose level morning 215 mg/dL, day 107 mg/dL, night 229 mg/dL, basal 52 mg/dL

Day 7 alert, (December 6, able to eat 2017) and drink well

24 hours fluid balance : +37.5 ml Urine production : 2.8 ml/kg/hour Physical examination Present status General condition : well Conciousness : compos mentis Blood pressure : 90/60 mmHg (90-95th percentile) Pulse rate : 98 beats/minute, regular Respiratory rate : 24 times/minute, regular Temperature : 36.3oC O2 saturation : 98% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 14 (high risk to fall) General status Eyes : pale conjunctiva (-), ikterik sclera (-) Thorax : symmetrical, retraction (-)

Monitoring - vital signs, urine production, fluid balance, blood glucose level

Type 1 diabetes mellitus (E10), expressive language disorder (F80.1), well nourished

Therapy - Fluid requirements 1125 ml/day (fulfilled from oral intake) - Calorie requirements 1150 kcal/day, protein requirements 43 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks night 25% dinner, 10% snacks - Insulin Humalog 3 IU-3 IU-3 IU subcutaneously (before meal)

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Heart : Lung : Abdomen : Extremities:

- Insulin Lantus 0-0-5 IU subcutaneously - Speech therapy (outpatient)

S1S2 normal, regular, murmur (-) vesicular +/+, rales (-), wheezing (-) distention (-), normal abdominal sound warm, CRT <2 seconds

Diagnostic - HbA1c examination every 3 months

Anthropometric status BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional status based on Waterlow 108% (well nourished)

Monitoring - vital signs, urine production, fluid balance, blood glucose level

Laboratory findings Blood glucose level morning 95 mg/dL, day 143 mg/dL, night 104 mg/dL, basal 94 mg/dL C-peptide <0.1 (0.9-7.1)

Day 8 alert, (December 7, able to eat 2017) and drink well

24 hours fluid balance : +87.5 ml Urine production : 2.6 ml/kg/hour Physical examination Present status General condition : well Conciousness : compos mentis Blood pressure : 100/60 mmHg (90-95th percentile) Pulse rate : 95 beats/minute, regular Respiratory rate : 24 times/minute, regular Temperature : 36.5oC O2 saturation : 99% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 14 (high risk to fall) General status Eyes : pale conjunctiva (-), ikterik sclera (-) Thorax : symmetrical, retraction (-)

Type 1 diabetes mellitus (E10), expressive language disorder (F80.1), well nourished

Therapy - Fluid requirements 1125 ml/day (fulfilled from oral intake) - Calorie requirements 1150 kcal/day, protein requirements 43 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks night 25% dinner, 10% snacks - Insulin Humalog 3 IU-3 IU-3 IU subcutaneously (before meal)

21

Heart : Lung : Abdomen : Extremities:

- Insulin Lantus 0-0-5 IU subcutaneously - Speech therapy (outpatient)

S1S2 normal, regular, murmur (-) vesicular +/+, rales (-), wheezing (-) distention (-), normal abdominal sound warm, CRT <2 seconds

Diagnostic - HbA1c examination every 3 months

Anthropometric status BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional status based on Waterlow 108% (well nourished)

Day 9 alert, (December 8, able to eat 2017) and drink well

Laboratory findings Blood glucose level morning 241 mg/dL, day 44 mg/dL, night 176 mg/dL, basal 107 mg/dL 24 hours fluid balance : +187.5 ml Urine production : 2.6 ml/kg/hour Physical examination Present status General condition : well Conciousness : compos mentis Blood pressure : 100/60 mmHg (90-95th percentile) Pulse rate : 100 beats/minute, regular Respiratory rate : 24 times/minute, regular Temperature : 36.8oC O2 saturation : 99% in room air Pain scale (FLACC) :0 Fall risk (Humpty-Dumpty) : 14 (high risk to fall) General status Eyes : pale conjunctiva (-), ikterik sclera (-) Thorax : symmetrical, retraction (-) Heart : S1S2 normal, regular, murmur (-) Lung : vesicular +/+, rales (-), wheezing (-) Abdomen : distention (-), normal abdominal sound

Monitoring - vital signs, urine production, fluid balance, blood glucose level

Type 1 diabetes mellitus (E10), expressive language disorder (F80.1), well nourished

Therapy - Fluid requirements 1125 ml/day (fulfilled from oral intake) - Calorie requirements 1150 kcal/day, protein requirements 43 grams/day with the following programme: morning 20% breakfast, 10% snacks afternoon 25% lunch, 10% snacks night 25% dinner, 10% snacks - Insulin Humalog 3 IU-3 IU-3 IU subcutaneously (before meal) - Insulin Lantus 0-0-5 IU subcutaneously - Speech therapy (outpatient)

22

Extremities: warm, CRT <2 seconds Anthropometric status BW 12.5 kg, BH 85 cm, IBW 11.5 kg, nutritional status based on Waterlow 108% (well nourished) Laboratory findings Blood glucose level morning 318 mg/dL,

Diagnostic - HbA1c examination every 3 months Monitoring - vital signs, urine production, fluid balance, blood glucose level

24 hours fluid balance : +187.5 ml Urine production : 2.6 ml/kg/hour

23

X.

Prognosis Ad vitam

: dubius ad bonam. The patient currently has a good clinical condition

Ad functionam

: dubius ad bonam. Patient has no morbidity of the eyes, neurological and kidney due to complication of diabetes mellitus.

Ad sanactionam : dubius ad bonam The patient will have a longterm experience of insulin deficiency that requires therapy and tight monitoring of

the

blood

glucose,

and

risk

of

disease

complications.

24

XI.

Scheme of Ilness History

March 18th-22nd, 2017

March 23rd-24th, 2019 (Day 1-2)

March 25th-28th, 2019 (Day 3-6)

Weakness of the body and decrease of consciousness

Anamnesis History of high blood glucose level, frequent urination, Weakness of the body and decrease of consciousness

Anamnesis

Anamnesis

alert, decreased appetite, no weight loss.

alert, able to eat and drink well.

Physical examination Blood pressure 100/60 mmHg (50-90th percentile), pulse rate 98 beats/minute, respiratory rate 24 times/minute, regular, axillary temperature 36.5°C

Physical examination Blood pressure 100/60 mmHg (90-95th percentile), pulse rate 112 beats/minute, respiratory rate 28 times/minute, regular, axillary temperature 37°C

Physical examination Blood pressure 100/60 mmHg (90-95th percentile), pulse rate 110 beats/minute, respiratory rate 26 times/minute, regular, axillary temperature 36.8°C

Laboratory findings Hb: 7,71 gr/dL, hematocrit: 22,44%, WBC: 5,24 10µ/µL, Platelet : 128,5 10µ/µL, Reticulocyte: 2,5%, kalium : 3,15 mmol/L, natrium 143 mmol/L, chlorida 103 mmol/L, calsium : 7,6 mg/dL ureum : 18 mg/dL, creatinin: 1,06 mg/dL, choleterol total : 100 mg/dL, HDL: 47 mg/dL, LDL: 43 mg/dL, trigliserida 75 mg/dL

Blood glucose level morning 95 mg/dL, day 143 mg/dL, night 104 mg/dL, basal 94 mg/dL C-peptide <0.1 (0.9-7.1)

Admitted to a private hospital, diagnosed diabetic ketoacidosis

Insulin therapy 2 unit/hour

Symptoms improved but blood glucose level remained high

Referred to Sanglah Hospital

Diagnosis Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11), Clinically down syndrome (Q90), AKI risk (N17), moderate anemia hypochromic microcytic et causa chronic infection well nourished. Treatment Insulin Novorapid 10 IU-10 IU-10 IU subcutaneously (before meal), Insulin Levemir 10 IU at bedtime, calorie diet settings: 20% breakfast, 10% snacks, 25% lunch, 10% snacks, 25% dinner, 10% snacks

November 8, 2017 (Day 7)

Laboratory findings

Diagnosis Suspect type 1 diabetes mellitus (E10) dd type 2 diabetes mellitus (E11), Clinically down syndrome (Q90), AKI risk (N17), moderate anemia hypochromic microcytic et causa chronic infection well nourished. Treatment Insulin Novorapid 10 IU-10 IU-10 IU subcutaneously (before meal), Insulin Levemir 10 IU at bedtime, calorie diet settings: 20% breakfast, 10% snacks, 25% lunch, 10% snacks, 25% dinner, 10% snacks

Laboratory findings

Blood glucose level morning 241 mg/dL, day 44 mg/dL, night 176 mg/dL, basal 107 mg/dL Diagnosis Type 1 diabetes mellitus, expressive language disorder, well nourished Treatment Insulin humalog 3 x 3 IU, insulin lantus 0 - 0 - 5 IU, calorie diet settings: 20% breakfast, 10% snacks, 25% lunch, 10% snacks, 25% dinner, 10% snacks .

25

Male, 1 years 11 months old 2nd Journal. Level of evidence 3B, grade of recommendation C Clinical symptoms: thirsty, frequent urination and weight loss

Risk Factors: maternal age at delivery > 35 years old, infection in early life

Can only say one specific word

Diagnosis

Laboratory finding: random blood glucose, HbA1c ↑ Clinical symptoms: thirsty, frequent urination and weight loss Laboratory finding: random blood glucose, HbA1c, and C-peptide Definitive therapy

Prognosis

Risk Factors: lack of verbal stimulation

Diabetes mellitus

Therapy

Problem

Risk Factors

XII. Scheme of Case Analysis

1st Journal. Level of evidence 1b, grade of recommendation A Quality of life th 4 Journal. level of evidence 3b, grade of recommendation C

Type 1 Diabetes Mellitus

Monitoring therapy

Denver, KPSK, CatClams test

Treatment of long-term complication

Expressive language disorder

Stimulation

Metabolic control 3rd Journal. level of evidence 2b, grade of recommendation B Ad vitam: dubius ad bonam Ad functionam: dubius ad bonam Ad sanactionam: dubius ad bonam

Optimal growth Stimulation, parenting, caring,

and 26 development

XIII. Case Analysis Diabetes mellitus (DM) is a disorder of the metabolic homeostasis controlled by insulin resulting in abnormalities of carbohydrate and lipid metabolism. There are two main types of diabetes mellitus: Type 1 diabetes ( also called juvenile-onset diabetes melitus and insulin-dependent diabets melitus), is caused by an absolute insulin deficiency, the result of a loss of the insulin insulin-producing beta cells of the pancreas. Type 2 diabetes, also called non-insulin dependent diabetes mellitus (NIDDM), is caused by decreased sensitivity of target tissues to insulin. The effect of lack insulin or insulin resistance on glucose metabolism is to prevent the efficient uptake and utilization of glucose by most cells of the body, except those of the brain. As a result, blood glucose concentration will increase, cell utilization of glucose falls increasingly lower and utilization of fats and proteins increases.1,2 According to the American Diabetes Association criteria for diabetes melitus is confirmed if fulfilled one of the criteria: 1.Clinical manifestation of polyuria, polydipsi, ployfagia, nocturia, enuresis, weight loss, random boold glucose ≥ 200mg/dL (11.1 mmol/L), or 2. Fasting blood glucose ≥126 mg/dL(7 mmol/L), or 3. Plasma blood glucose ≥ 200mg/dL (11.1 mmol/L) on oral glucose tolerance test, or 4. The level of HbA1c > 6.5%. Asymptomatic patient with increase random blood glucose level ≥ 200mg/dL need to be confirmed with fasting blood glucose or with oral glucose tolerance test.3 The distinction between T1DM and T2DM may not be apparent until insulin requirements have declined significantly. Distinguishing children with type 1 diabetes mellitus (T1DM) from those with T2DM may be difficult.

Increasing obesity in the general population further blurs the

distinction between T1DM and T2DM in children. C-peptide is a useful and widely used method of assessing pancreatic beta cell function. C-peptide has been shown to denote endogenous insulin production and correlates with type of disease, duration of diabetes, as well as age of diagnosis. In insulintreated individuals, fCP less than 0.2 nmol/L and GST of less than 0.32

nmol/l have been found to correlate significantly with T1DM.3 In this case, the patient is a 14 years 7 month old female came to hospital with chief complain high with glucose, patient also complained always feel thirsty and hungry with random plasma glucose was 473 mg/dL. From other laboratory examination found with HbA1c 12,6 %, and C-peptide level 1.8 ng/mL. Patient diagnosed by type 2 diabetes mellitus. T2DM results from an interaction between genetic and environmental factors. Genes and the environment together are important determinants of insulin resistance and β-cell dysfunction. Changes in the gene pool cannot account for the rapid increase in prevalence of T2DM in recent decades, environmental changes are essential to the understanding of the epidemic. Risk factors of diabetes melitus are obesity, family with diabetes, low birth weight, sedentary lifestyles etc.3 Based on this problems we was conducted searches for the journal to determine risk factors of diabets melitus type 2. We found a journal entitled “Risk factors for type 2 diabetes mellitus: An exposure-wide umbrella review of metaanalyses ” Vanesa B, Lazaros B , Ioanna T, Evangelos E. Plosone. 13 (3): e0194127. This journal was valid, important and applicable (level of evidence 1A and grade of recommendation A). Based on this journal, Adiposity, low hip circumference,

serum

biomarkers

(increased

level

of

alanine

aminotransferase, gamma-glutamyl transferase, uric acid and C-reactive protein, and decreased level of adiponectin and vitamin D), an unhealthy dietary pattern, low level of education and conscientiousness, decreased physical activity, high sedentary time and duration of television watching, low alcohol drinking, smoking, air pollution, and some medical conditions (high systolic blood pressure, late menarche age, gestational diabetes, metabolic syndrome, preterm birth) presented robust evidence for increased risk of T2DM. In the case, the patient had history of obesity, her father suffered from diabetes, unhealthy dietary pattern and sedentary lifestyles. Management of type 2 diabetes in youth, consist of acute and long term management. The treatment approach to alleviate insulin resistance and β-cell failure, achieve glycemic control, and prevent further

complications.5,6,7,8 Management of newly diagnosed type 2 diabetes mellitus (T2DM) from the American Academy of Pediatrics in children and adolescents consist of six recommendations.5 The first recommendation, insulin therapy is initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in whom the distinction between types 1 and 2 diabetes mellitus is unclear and, in usual cases, should initiate insulin therapy for patients (a) who have random venous or plasma BG concentrations ≥250 mg/dL, or (b) whose HbA1c is >9%.5 In this case, The patient had random BG concentrations ≥250 mg/dL (473 mg/dL) and HbA1c 12,6 %, patient got metformin 500 mg every 12 hours and insulin lantus 10 unit at night. We performed journal searching to find out the medical treatment for children with diabetes melitus type 2 and found evidence-based journal entitled “Treatment of pediatric type 2 diabetes” by Smith et al. 2016. This journal was valid, important, and applicable (level of evidence 1a, grade of recommendation A). Based on this journal, we concluded that metformin and insulin are the main treatment in children with diabetes melitus. The second recommendation, in all other instances, clinicians should initiate a lifestyle modification program, including nutrition and physical activity, and start metformin as first-line therapy for children and adolescents at the time of diagnosis of Type 2 Diabetes Mellitus. In this case, diagnosis of type 2 diabetes is made, with history signs of ketotic or diabetic ketoacidosis, with blood plasma glucose 473 mg/dL and HbA1c 12,6 %. The patient were treated with metformin previously a year ago with metformin and on current admission the patient treated with metformin and insulin. Patient was ancouraged to do lifestyle modification (especially diet modification and exercise). The third recommendation, the committee suggests that clinicians monitor HbA1c concentrations every 3 months and intensify treatment if treatment goals for finger-stick BG and HbA1c concentrations are not being met.1 The fourth recommendation, the committee suggests that clinicians advise patients to monitor finger-stick BG concentrations in patients who (a)

are taking insulin or other medications with a risk of hypoglycemia,or (b) are initiating or changing their diabetes treatment regimen, or (c) have not met treatment goals, or (d) have intercurrent illnesses. Self monitoring of blood glucose (SMBG) should be performed regularly. The frequency of self monitoring depends on the target fasting blood glucose and target of HbA1C. Patient with basal bolus regiment need to monitor blood glucose>3 times a day. During acute illness or when symptoms of hyper- or hypoglycemia occur, patients should perform more frequent testing and be in contact with their diabetes care team for advice. Patients on insulin or sulfonylureas need to monitor for asymptomatic hypoglycemia.6 In this case, since it was first established with type 2 diabetes, parents are taught to perform self monitoring of blood glucose by using finger-stick blood glucose test. At this time we initiating the diabetes treatment regimen so self monitoring of blood glucose is performed by parents and patient. The fifth recommendation, the committee suggests that clinicians incorporate the Academy of Nutrition and Dietetics Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines in their dietary or nutrition counseling of patients with T2DM at the time of diagnosis and as part of ongoing management.5 Nutritional management is one most important of diabetes care and education. Dietary recommendations for children with diabetes are based on healthy eating recommendations suitable for all children and adults and therefore the whole family. Nutritional advice must be adapted to cultural, ethnic and family traditions, and the psychosocial needs of the individual child.Energy requirement for the patient is based on Recommended Dietary Allowances (RDA). Allocation of the calories per 24 hours divided into thrice main food, and thrice snack as follows 20% for breakfast, 10% snack, 25% for lunch, 10% snack, 25% for dinner and 10% snack. Recommended calories composition are 50-55% from carbohydrate, 15-20% from protein, 25-35% from fat.9 Dietary management should include, (i) initial focus on eliminating sugar-containing soft drinks and juices in large quantities, (ii) increase fruits and vegetables food, (iii) recommending that meals should

be taken on schedule, in one place, with no other activity (television, studying, reading, playing), preferably as a family unit, (iv) portion control. Food and snacks should be served in a plate or bowl and not eaten directly from a box or can, (v) limiting availability of high-fat, high caloric density food and drink in the home, the reading of labels and control of purchasing, (vi) encouraging positive reinforcement of minor achievement (e.g. no or minimal weight gain, reduction in high caloric drinks) and avoiding blame for failure.3,6,7.10,11 The sixth recommendation, the committee suggests that clinicians encourage children and adolescents with T2DM to engage in moderate-tovigorous exercise for at least 60 minutes daily and to limit nonacademic “screen time” to less than 2 hours a day.5 In this case, she was taught to do more physical activity both at home and outside home. If there is free time at home, she was asked to help clean the house, more playing in the yard, and reduce watching TV or playing a computer which is not related to education. On weekends (Saturday and Sunday) children are invited to swim or exercise in the field so she can increase her physical activity. The longterm vascular complications of diabetes include retinopathy, nephropathy, neuropathy and macrovascular disease. The outcomes are: visual impairment and blindness due to diabetic retinopathy, renal failure and hypertension due to diabetic nephropathy, pain, paraesthesiae, muscle weakness and autonomic dysfunction due to diabetic neuropathy, cardiac disease, peripheral vascular disease and stroke due to macrovascular disease.6,7,8,12 Complication testing specific to type 2 diabetes mellitus in young people: Testing for either micro or macro-albuminuria, should be performed at the time of diagnosis and annually thereafter, blood pressure should be monitored at every visit according to standardized techniques specific for children, testing for dyslipidemia should be performed soon after diagnosis when BG control has been achieved and annually thereafter, hyperlipidemia should also be managed with a goal of LDL 100 mg/dL, triglycerides 150 mg/dL, and HDL 35 mg/dL, evaluation for non-alcoholic fatty liver disease

(NAFLD) should be done at diagnosis and annually thereafter, inquiries about puberty, menstrual irregularities and obstructive sleep apnea should be made at diagnosis and regularly thereafter, Female patient with diabetes melitus has higher possibility to have vaginal candidiasis. Examination for retinopathy should be performed at diagnosis and annually thereafter.6,7,12 In this case, Based on anamnesis, history of blurred vision, snoring during sleep, sleepy during the morning or at school, of pain, paraesthesiae, muscle weakness and autonomic dysfunction were denied. On physical examination, we did not found the presence of hypertension. In the urine examination there were no presence of protein in the urine, the renal function tests are also still in the normal range. On examination of the lipid profile was also obtained in the normal range. In this case, the patient had candidiasis vulvovaginitis but has not found signs and symptoms of microvascular complications (retinopathy, nephropathy, neuropathy) or macrovascular complications (cardiac disease, peripheral vascular disease, and stroke). Monitoring of these complications be done regularly to prevent the complications. Complications due to macrovascular disease is associated with hypertension, high blood sugar levels which are not controlled and the duration of diabetes, based on this problems we was conducted searches for the journal to determine the parameters/ indicators in adolescents with type 2 diabetes which are associated with cardiovascular complications. We found a journal entitled “Clinical and Biochemical Predictors of Increased Carotid Intima-Media Thickness in Overweight and Obese Adolescents with Type 2 Diabetes ” Nesreen A Kotb, Rania Gaber, Mai Salama, Hala M Nagy and Abdou Elhendy Diabetes & Vascular Disease Research 9(1) 35–41.This journal was valid, important and applicable (level of evidence 3b and grade of recommendation C). Based on this journal, carotid intima-media thickness (CIMT) is increased in adolescents with type 2 diabetes. Poor glycemic control, HOMA, increased C-reactive protein, body mass index, duration of diabetes, and elevated blood pressure are associated with early atherosclerosis in these patients

Diabetes could bring psychosocial problems to the patient and family. Education about the disease that diabetes mellitus is a life time disease, the important of long term and routine follow up, takes time, patience and cost. Patients with diabetes required long-term treatment and collaboration of various modalities. The smaller age of occurrence of DM will have a higher likelihood of complications if the patient has no treatment adherence. Where a child will be difficult to adjust the diet so that the complication of the disease more quickly arise due to uncontrolled blood glucose. Based on these issues we conducted evidence-based journal searches and found a journal entitled “Health-related Quality of life of Children and Adolescents with Type 1 or type 2 Diabetes Melitus” by Michelle JN et al. Arch Pediatr Adolesc Med. 2008. This journal was valid, important and applicable (level of evidence 3b and grade of recommendation C). Based on this journal, we concluded that among with youths with type 2 DM, HRQOl was lower compared with those with type 1 diabetes.

a.

References

Case analysis 1.

Ozougwu JC, Obimba KC, Belonwu CD, Unakalamba CB. The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. Academic journals. 2013; 4(4):46-57. 2. David W, Cooke MD, Leslie P.Type 1 Diabetes Melitus in Pediatrics.Pediatrics in review.2008;29(11):374-84 3. Julia M, Utari A, Moelyo AG, Rochmah N. Konsensus Ikatan Dokter Anak Indonesia: Konsensus nasional pengelolaan diabetes melitus tipe 2 pada anak dan remaja. Jakarta: Badan Penerbit IDAI; 2015. p. 5-21. 4. American Diabetes Association. Classification and Diagnosis of Diabetes. Diabetes Care 2017;40(Suppl. 1):S11–S24.\ 5. Copeland KC, Silverstein J, Moore KR, Prazar GE, Raymer T, Shiffman RN, et al. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics. 2013;131:364-82. 6. Hanas R, Donaghue K,Klingensmith G, Swift P, Colagiuri S. Global IDF/ISPAD Guideline for Diabetes in Childhood and Adolescence. International Diabetes Federation. 2011: 1-128. 7. Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler P, Klingensmith GJ. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Type 2 Diabetes in The Child and Adolescent. Pediatric Diabetes. 2009;10 (supplement 12): 17–32. 8. Flint A, Arslanian S. Treatment of Type 2 Diabetes in Youth. Diabetes Care. 2011; 34 (supplement 2):177-83 9. Shenoy, Greening. Pediatric management of diabetic ketoacidosis Guideline. Children’s Service Medical Guideline NHS. 2004;13:1-12. 10. Court JM, Cameron FJ, Berg-Kelly K, Swift PGF. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Diabetes in Adolescence. Pediatric Diabetes 2009; 10 (Supplement 12): 185–194. 11. Robertson K, Adolfsson P, Riddell M, Scheiner G, Hanas R. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Exercise in Children and Adolescents with Diabetes. Pediatric Diabetes 2009; 10 (Supplement 12): 154–168. 12. Donaghue KC, Chiarelli F, Trotta D, Allgrove J, Dahl-Jorgensen K. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium. Microvascular and macrovascular complications associated with diabetes in children and adolescents. Pediatric Diabetes 2009; 10 (supplement 12): 195–203.

2. Journal (evidence based practice) 1.

Bellou V, Belbasis L, Tzoulaki L, Evangelou E. Risk factors for type 2 diabetes mellitus: An exposure-wide umbrella review of metaanalyses. PloS ONE. 2017.13(3):1-27

2.

Jennifer D, Elizabeth M, Sara EC. Treatment of pediatric type 2 diabetes.Annals of Pharmacotherapy.2016.1(10):1-10

3.

Nesreen AK, Rania G, Mai S, Hala MN, Abdou E. Clinical and biochemical predictors of increased carotid intima-media thickness in overweight and obese adolescents with type 2 diabetes. 2011.9(1):35-41

4.

Michelle JN, Andrea MG, Jean ML, Giuseppina I, Debra AS et al. Health-related quality of life of children and adolescents with type 1 or type 2 diabetes melitus.Arch Pediatr adolesc med. 2008;162 (7):649-657

XV. ABBREVIATION ACE

: Angiotensin-Converting Enzyme

ALT

: Alanine Aminotransferase

AST

: Aspartate Aminotransferase

BCG

: Bacille Calmette Guerrine

BH

: Body Height

BW

: Body Weight

CBC

: Complete Blood Count

CGMS

: Continuous Glucose Monitoring

CIMT

: Carotid Intima-Media Thickness

DKA

: Diabetic Ketoacidosis

DM

: Diabetes Mellitus

EBM

: Evidence Based Medicine

FLACC

: Face, Legs, Activity, Cry, Consolability

GST

: Glutathione-S-Transferase

HbA1C

: Hemoglobin A1C

HDL

: High-Density Lipoprotein

HOMA

: Homeostasis model assessment

IBW

: Ideal Body Weight

IU

: International Unit

IV

: Intra Venous

JE

: Japanese Encephalitis

LDL

: Low Density Lipoprotein

LV

: Left Ventricular

MCH

: Mean Corpuscular Volume

MCHC

: Mean Corpuscular Hemoglobin Concentration

MCV

: Mean Corpuscular Volume

MR

: Measles & Rubella

MUAC

: Mid Upper Arm Circumference

NAFLD

: Non-Alcoholic Fatty Liver Disease

NIDDM

: Non Insulin Dependent Diabetes Mellitus

PedsQL

: Pediatric Quality of Life Inventory

pH

: Potential of Hydrogen

PLN

: Perusahaan Listrik Nasional

RDA

: Recommended Dietary Allowance

RV

: Right Ventricular

SMBG

: Self Monitoring Blood Glucose

T1DM

: Type 1 Diabetes Mellitus

T2DM

: Type 2 Diabetes Mellitus

WBC

: White Blood Count

WHO

: World Health Organization

XVI. ATTACHMENTS Attachment 1. Growth Charts for Children with Down Syndrome Name Record 2 to 20 years: Girls Weight-for-age percentiles

: NNGC : 19012697

2 to 20 years: Girls Height-for-age percentiles

2 to 20 years: BMI-for-age percentiles

Attachment 2. Pediatric Quality of Life Inventory. ID# __________________________ NNGC Date: 22/03/2019 _________________________

™

PedsQL

Pediatric Quality of Life Inventory Version 4.0 English (Canada)

PARENT REPORT for TEENS (ages 13-18)

DIRECTIONS On the following page is a list of things that might be a problem for your teen. Please tell us how much of a problem each one has been for your teen during the past ONE month by circling: 0 if it is never a problem 1 if it is almost never a problem 2 if it is sometimes a problem 3 if it is often a problem 4 if it is almost always a problem There are no right or wrong answers. If you do not understand a question, please ask for help.

In the past ONE month, how much of a problem has your teen had with … Never

Almost Never

Sometimes

Often

Almost Always

0

1

2

3

4

0

1

2

3

4

3. Participating in sports activity or exercise 4. Lifting something heavy 5. Taking a bath or shower by him or herself 6. Doing chores around the house 7. Having hurts or aches

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

8. Low energy level

0

1

2

3

4

Never

Almost Never

Sometimes

Often

Almost Always

(problems with…) 1. Feeling afraid or scared 2. Feeling sad or blue

0

1

2

3

4

0

1

2

3

4

3. Feeling angry

0

1

2

3

4

4. Trouble sleeping

0

1

2

3

4

5. Worrying about what will happen to him or her

0

1

2

3

4

SOCIAL FUNCTIONING

Never

Almost Never

Sometimes

Often

Almost Always

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

PHYSICAL FUNCTIONING (problems with…) 1. Walking more than one block 2. Running

EMOTIONAL FUNCTIONING

(problems with…) 1. Getting along with other teens 2. Other teens not wanting to be his or her friend 3. Getting teased by other teens 4. Not able to do things that other teens his or her age can do

5. Keeping up with other teens

0

1

2

3

4

SCHOOL FUNCTIONING

Never

Almost Never

Sometimes

Often

Almost Always

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

0

1

2

3

4

(problems with…) 1. Paying attention in class 2. Forgetting things 3. Keeping up with schoolwork 4. Missing school because of not feeling well 5. Missing school to go to the doctor or hospital

Result:

Attachment 3. Pediatric Symptom Checklist-17 (PSC-17) Caregiver Completing this Form: Date: 22/03/2019 WS _______________________ _____________________ Name of Child: _______________________ NNGC Please mark under the heading that

For Office Use

best fits your child NEVER

SOMETIMES

1. Fidgety, unable to sit still



2. Feels sad, unhappy



3. Daydreams too much



4. Refuses to share



Does not understand

1 1 1 2 0

Has trouble

2



Fights with other

1



8. children 9. herself



10 Blames others for his or . her troubles



0 0

11 Seems to be having less . fun



12 . Does not listen to rules



13 Acts as if driven by a . motor



14 . Teases others



15 . Worries a lot



16 Takes things that do not . belong to him or her



17 . Distracted easily

1 1 0 0 0 0



1 2

Total: 12 (normal behavior)

E

1



7. concentrating

Is down on him or

A



5. other people’s feelings 6. Feels hopeless

I

OFTEN

5

5

EVIDENCE-BASED CRITICAL APPRAISAL

CASE A 1 year 11 months old boy was referred from private hospital in rural area with suspected Diabetes Mellitus type 1. The patient’s family had complained about high blood glucose level since 10 days before admitted to the hospital about weight loss since a month before admitted to the hospital. High blood glucose level was first determined at the private hospital when he was admitted due to decreased of consciousness. He also had frequent urination since three weeks before admitted to the hospital. Frequent urination occured especially at night, the frequency increased twice than before. He frequently felt thirsty and drank plenty amount of water. His mother had complained of delayed speech. The patient can only speak one specific word (“ma-em”) which his mother recognized it as a delay compared to other children at his age. On physical examination, he appeared in moderatelly ill, level of consciousness was 12/12, blood pressure was 100/60 mmHg (90-95th percentile), pulse rate was 110 beats/minute, regular, good pulse quality, respiratory rate was 24 times/minute, regular, axillary temperature was 36,8°C, and he’s well nourished based on Waterlow’s nutritional status. A significant laboratory finding revealed Hb-A1c level 10,8%. C-peptide <0,1 %.

DIAGNOSIS Type 1 diabetes mellitus (E10), expressive language disorder (F80.1), well nourished

PROBLEMS 1. How does the management of insulin administered in type 1 diabetes mellitus, what insulin regimen should be administered? 2. What are the risk factors for diabetes mellitus? 3. What factors play a role in the metabolic control of people with type 1 diabetes mellitus? 4.

How is the quality of life of children with type 1 diabetes mellitus?

PROBLEM 1 PICO According to the problems, PICO can be described as follows: P (Patient/Problem)

: Children with type 1 diabetes mellitus

I (Intervention)

: Insulin detemir

C (Comparation/Control)

: NPH (Neutral protamine Hagedorn)

O (Outcome)

: Glycaemic control

CLINICAL QUESTION In children with type 1 diabetes mellitus, is insulin detemir compared to NPH (Neutral protamine Hagedorn) improving glycaemic control? JOURNAL SEARCHING STRATEGY Keywords: type 1 diabetes mellitus AND detemir AND NPH AND glycaemic control. RESULT “Insulin analogues in children with type 1 diabetes:a 52-week randomized clincal trial” N. Thalange, A. Bereket, J. Larsen, C. Hiort and V. Peterkova. Diabetic Medicine. 2013;30:216–25.

ABSTRACT Background: The challenge of achieving good glycaemic control is more difficult in children and adolescents compared with adults because of the characteristics of the paediatric population. Consequently, an ideal insulin regimen would be flexible and predictable, whilst protecting against hypoglycaemia and inappropriate weight. The aim of the current study was to establish the efficacy and safety of insulin detemir in children aged 2–16 years with Type 1 diabetes over 52 weeks of treatment. Methods:

A randomized, multinational, open-label, parallel-group, non-

inferiority trial investigated the efficacy and safety of basal–bolus treatment with insulin detemir vs. NPH (neutral protamine Hagedorn) insulin, in combination with insulin aspart. Children with Type 1 diabetes for at least 12 months (n = 347), aged 2–16 years was randomized, 177 received insulin detemir and 170

NPH insulin, both administered once or twice daily in combination with mealtime insulin aspart. Glycaemic measurements and weight were followed over 52 weeks. Results After 52 weeks, insulin detemir was shown to be non-inferior to NPH insulin with regard to HbA1c [mean difference insulin detemir–NPH: 1.30 mmol/mol, 95% CI –1.32 to 3.92 (0.12%, 95% CI –0.12 to 0.36) in the full analysis set and 1.41 mmol/mol, 95% CI –1.26 to 4.08 (0.13%, 95% CI –0.12 to 0.37) in the per protocol analysis set]. Hypoglycaemic events per subject-year of exposure of 24-h and nocturnal hypoglycaemia were significantly lower with insulin detemir than with NPH insulin (rate ratio 0.76, 95% CI 0.60–0.97, P = 0.028 and 0.62, 95% CI 0.47–0.84, P = 0.002, respectively). Weight standard deviation (SD) scores (body weight standardized by age and gender) decreased with insulin detemir, but increased slightly with NPH insulin (change: –0.12 vs. 0.04, P < 0.001). At end of the trial, median insulin doses were similar in both treatment groups. Conclusions Insulin detemir was non-inferior to NPH insulin after 52 weeks treatment of children and adolescents aged 2–16 years, and was associated with a significantly lower risk of hypoglycaemia, together with significantly lower weight SD score when compared with NPH insulin.

Evidence-based Critical Appraisal: Clinical Trial Are the results of the trial valid? (Internal Validity) 1. Was the assignment of patients to Yes, this study was a randomized, treatments randomised?

multinational, open-label, parallel-group, non-inferiority trial

2. Were the groups similar at the start of Yes, The treatment groups were similar the trial?

with respect to withdrawal and baseline characteristics (Table 2)

3. Aside from the allocated treatment, Yes. Both groups received insulin aspart were groups treated equally?

4 times daily, with main meals.

4. Were all patients who entered the trial Yes, they used intention to treat analysis accounted for? – and were they and preprotocol analysis. analysed in the groups to which they were randomised?? 5

Were measures objective or were the No, this study was open label study, patients and clinicians kept “blind” to because of Insulin detemir which treatment was being received?

and NPH are visually distinguishable

This study is valid What were the results? 

1

How large was the treatment effect?

2

How precise was the estimate of the

1.30 mmol/mol, 95% CI (–1.32 to 3.92) 

treatment effect?

Mean difference insulin detemir–NPH:

Hypoglycaemic events per subject-year of exposure of 24-h and nocturnal hypoglycaemia were significantly lower with insulin detemir (rate ratio 0.76, 95% CI 0.60–0.97, P = 0.028 and 0.62, 95%

CI

0.47–0.84,

P

=

0.002,

respectively). 

Weight standard deviation (SD) scores decreased with insulin detemir, but increased slightly with NPH insulin (change: – 0.12 vs. 0.04, P < 0.001)

This study is important Will

the

results

help

me

in

caring

(ExternalValidity/Applicability) 1. Is my patient so different to those in the No. study that the results cannot apply? 2. Is the treatment feasible in my setting? 3

Yes.

Will the potential benefits of treatment Yes. outweigh

the

potential

treatment for my patient?

harms

of

for

my

patient?

This study is applicable Conclusion: Valid, Important, and Applicable. Level of evidence 1B with grade of recommendation A. PROBLEMS 2 PICO According to the problems, PICO can be described as follows: P (Patient/Problem)

: Children with type 1 diabetes mellitus

I (Intervention)

:-

C (Comparation/Control)

:-

O (Outcome)

: maternal age, pre-eclampsia, taking medications during pregnancy, infection in early life, low birth weight children, consumption of cow's milk, and vitamin D supplementation.

CLINICAL QUESTION In Children with type 1 diabetes mellitus, are maternal age, pre-eclampsia, taking medications during pregnancy, viral infection in early life, low birth weight children, consumption of cow's milk, and vitamin D supplementation as a risk factor of type 1 diabetes mellitus? JOURNAL SEARCHING STRATEGY Keywords: diabetes mellitus type 1 AND child AND risk factors. RESULT “Environmental Factors and the Risk of Type 1 Diabetes Mellitus-A CaseControl Study.” Basma Abdelmoez Ali, Mostafa Ahmed Elfoly, Eman Ramadan Ghazawy and Rania Rashad Bersom. J Diabetes Metab.2017;8:379-84.

ABSTRACT: Background: An interaction between genetic susceptibility and environmental factors is assumed to be elaborate in the etiology of type 1 diabetes mellitus (T1DM). Autoimmunity may be induced in first years of life, suggesting that

environmental agents encountered early in life could be triggers of the disease process. The aim of the study was therefore to investigate the associations of T1DM with several environmental factors. Methods: A case-control study was conducted in Minia University Maternity and Children Hospital, Minia governorate, Egypt. One hundred and ten children aged from 2-16 years old who were diagnosed with T1DM and 110 age and sexmatched controls were included. Data regarding environmental factors during gestation, neonatal period, and early years of life were collected by a structured questionnaire. Results: On multivariable logistic regression analysis, maternal age >35 years at delivery, the presence of gestational diabetes, pre-eclampsia and taking medications during pregnancy were significantly associated with the occurrence of T1DM. Also, viral infection in early life, low birth weight children (<2500 grams) and those who suffered from neonatal diseases (respiratory distress, jaundice, and infection) were 4.71 and 2.17 folds increased the risk of T1DM. Consumption of cow's milk during the 1st year of life was a significant predictor for developing T1DM with OR 3.83 (1.64-8.96), However, vitamin D supplement and increased duration of breast feeding were significant protective factors. Conclusions: n the present study, certain environmental risk factors were associated with the development of T1DM.

Evidence-based Critical Appraisal: Causation Is the study design valid? 1. Were there clearly defined groups of

Yes, this study was case control study

patients, similar in all important ways

and has been matched by age and sex

other than exposure to the treatment or

between two groups

other causes? 2. Were treatments/exposures and clinical Yes, exposures were measured in the outcomes measured in the same way same way for both groups. for both groups? Was the assessment of outcomes either objective or blinded to exposure?

3. Was the follow-up of study patients

No, this study using case control method

sufficiently long for the outcome to occur? 4. Is it clear that the exposure preceded the onset of the outcome? 5. Is there a dose-response gradient?

Yes, it is clear that the exposure preceded the onset of the outcome No, this study was not associated with dose response gradient

6

Is the association consistent from study Yes, Similar results were reported by to study?

7

Stene et al.

Does the association make biological Possible that the introduction of foreign sense?

proteins in early infancy, when the maturation of the gut immune system is not complete, is someway harmful and predisposes to β-cell autoimmunity

This study is valid

Are the results important? 1. How strong is the association between

potential risk factors during pregnancy of

exposure and outcome, i.e. the estimate the index child; mother age, presence of of risk?

gestational diabetes, pre-eclampsia and taking medications during pregnancy

2. How precise is the estimate of risk?

were

significantly

associated

with

occurrence of T1DM, OR (95% CI) were (1.93 (1.37-2.73), 4.16 (1.53-11.28), 3.97 (1.19-13.24)

and

3.15

(1.72-5.77)).

Consumption of cow's milk during the 1st year of life was a significant predictor for developing T1DM with OR 3.83 (1.64-8.96),

However,

vitamin

D

supplement and increased duration of breast feeding were significant protective

factors This study is important

Are the results important for my patient? 1. Is my patient so different from those No, characteristic type of subjects in included in the study that its results this study similar with our patients don’t apply? 2. What is my patient’s risk of the adverse Yes, this evidence is worth for our event? What is my patient’s potential clinical practices. benefit from therapy? 3

What are my patient’s preferences, By knowing these risk factors, we can concerns and expectations from this explain to the patient the possibility of treatment?

the next outcome.

This study is applicable Conclusion: Valid, Important, and Applicable. Level of evidence 3B with grade of recommendation C.

PROBLEM 3

PICO According to the problems, PICO can be described as follows: P (Patient/Problem)

: Children with type 1 diabetes mellitus

I (Intervention)

: risk factor

C (Comparation/Control)

:-

O (Outcome)

: glycemic control

CLINICAL QUESTION In children with type 1 diabetes mellitus, what are the factors associated with glycaemic control? JOURNAL SEARCHING STRATEGY Keywords children AND type 1 diabetes AND glycaemic control RESULT Glycaemic Control in Type 1 Diabetes Mellitus Among Children and Adolescents in a Resource Limited Setting in Dar es Salaam - Tanzania” Noorani M, Ramaiya K, Manji K. BMC Endocrine Disorders. 2016;16(29):1-8.

ABSTRACT Background: Type 1 Diabetes Mellitus is a rapidly growing problem in Tanzania. Children and adolescents with type 1 diabetes have previously been found to have poor glycaemic control and high prevalence of complications. Strict glycaemic control reduces the incidence and progression of chronic complications. The aim of this study was to identify the factors associated with glycaemic control among children and adolescents. Methods: A cross sectional study was done at the diabetes clinic for children and adolescents. Data on socioeconomic, demographic and diabetes specific variables

including adherence, diabetes knowledge, caregivers knowledge and their involvement in the care of the child was obtained. Glycaemic control was assessed by measuring glycosylated hemoglobin. (HbA1C). Linear regression analysis was done to determine factors associated with glycaemic control Results: Seventy-five participants were recruited into the study (51 % males). The mean HbA1c was 11.1 ± 2.1 %. Children aged <10 years were found to have a significantly better glycaemic control (9.8 %) as compared to 10–14 year olds (11.5 %) and >14 year olds (11.4 %) (P value = 0.022). Sixty-eight percent of patients had good adherence to insulin while adherence to blood glucose monitoring regimen was 48 % and to diet control was 28 %. Younger age, having the mother as the primary caregiver, better caregiver knowledge of diabetes, better adherence to blood glucose monitoring regimen and diabetes duration of less than 1 year were associated with better glycaemic control. In multivariate analysis, age, adherence to blood glucose monitoring regimen and the mother as the primary caregiver were found to independently predict glycaemic control (R2 = 0.332, p value = 0.00). Conclusions: Children and adolescents with type 1 diabetes in Dar es Salaam have poor glycaemic control. In order to improve metabolic control, adherence to blood glucose monitoring should be encouraged and caregivers encouraged to participate in care of their children especially the adolescents

Evidence-based Critical Appraisal: Prognostic Aspect Are the results of this prognosis study valid? 1. Was a defined, representative sample Yes. Patients were recruited after of patients assembled at a common diagnosis of type 1 diabetes mellitus and (usually early) point in the course of receiving insulin therapy their disease? 2. Was patient follow-up sufficiently long Yes. Observations were made over a 6 and complete? 3. Are clinical outcomes and clinical

month period Yes. The risk factors were obedience,

outcomes measured in the same way in

diabetes knowledge, caregiver

both groups?

knowledge. The outcome of this is

HbA1C 4. If subgroups with different prognoses Not explained in the study. are identified, was there adjustment for important prognostic factors? 5. Was there validation in an independent Not explained in the study group (“test set”) of patients? This study is valid

Are the valid results of this prognosis study important? 1. How likely are the outcomes over time? 2. How

The mean HbA1c was 11.1 ± 2.1 %. Children aged <10 years were found to

precise

are

the

prognostic have a significantly better glycaemic

estimates?

control (9.8 %) as compared to 10–14 year olds (11.5 %) and >14 year olds (11.4

%)

(P

value

=

0.022).

In

multivariate analysis, age, adherence to blood glucose monitoring regimen and the mother as the primary caregiver were found

to

independently

predict

glycaemic control (R2 = 0.332, p value = 0.00) This study is important

Can we apply this valid, important evidence about prognosis in caring for our patient? 1. Were the study patients similar to our Yes, characteristic type of subjects in own?

this study similar with our patients

2. Will this evidence make a clinically Yes, this evidence is worth for our important impact on our conclusions clinical practices. about what to offer or tell our patient? This study is applicable Conclusion: Valid, Important, and Applicable.

Level of evidence 2B with grade of recommendation B.

PROBLEM 4 PICO According to the problems, PICO can be described as follows: P (Patient/Problem)

: Children with type 1 diabetes mellitus

I (Intervention)

:-

C (Comparation/Control)

:-

O (Outcome)

: Quality of life

CLINICAL QUESTION In children with type 1 diabetes mellitus, how is their quality of life? JOURNAL SEARCHING STRATEGY Keywords: Children AND Type 1 diabetes mellitus AND quality of life RESULT “Quality of life in children with type 1 diabetes in Kuwait” M Abdul-Rasoul, F AlOtaibi, M AlMahdi, H AlKandari Med Princ Pract 2013;22:379-384. ABSTRACT Background: The development and use of pediatric HRQoL measures are important for identifying at-risk children and applying early intervention programs. the main aim of modern diabetes care in children and adolescents has changed from a purely medical approach to one aiming toward optimal glycemic control, normal psychological development and maximum QoL. To evaluate the health-related quality of life (HRQoL) of children and adolescents with type 1 diabetes (T1DM) in Kuwait using the Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scale and PedsQL 3.0 Diabetes Module, and to identify the risk factors associated with unsatisfactory QoL and their effects on metabolic control.

Methods: A total of 436 patients (2–18 years) with T1DM (>6 months) and 389 healthy controls, with the parents of both groups, completed the Arabic Generic Core Scale. Those with T1DM also completed the Arabic Diabetes Module. Results: The mean total score of the PedsQL Diabetes Module was 70.2 ± 9.8 reported by children and 59.9 ± 11.1 reported by parents (higher scores indicate better QoL). Young age and long duration of diabetes were associated with poor QoL (p < 0.001). Boys had better total scores than girls in most age groups (70.3 ± 9.3 vs. 52.3 ± 7.2, p < 0.001); however, girls did better than boys regarding treatment barriers and adherence (71.3 ± 7.8 vs. 68.1 ± 6.2, p < 0.005). High er HbA1c values were associated with lower QoL scores (31.1 ± 5.1 at HbA1c of 15% vs. 82.5 ± 6.1 at HbA1c of 6%, p < 0.0001). Conclusions: HRQoL of children and adolescents with T1DM was consistently poorer than controls. Parents consistently reported poorer QoL scores than their children. We recommend that more support should be provided for the care of children with diabetes in Kuwait.

Evidence-based Critical Appraisal: Causation Is the study design valid? 1. Were there clearly defined groups of

Yes, this study was case control study

patients, similar in all important ways

and has been matched by age, sex,

other than exposure to the treatment or

socioeconomic

other causes?

between two groups

status

and

residence

2. Were treatments/exposures and clinical Yes, exposures were measured in the outcomes measured in the same way same way for both groups using the for both groups? Was the assessment of Pediatric Quality of Life Inventory outcomes either objective or blinded to (PedsQL TM ) 3.0 Diabetes Module, a exposure?

multi-dimensional,

diabetes-specific

instrument that assesses children and adolescents (2–18 years), with both child and parent reports, was used to assess HRQoL. 3. Was the follow-up of study patients

No, this study using case control method

sufficiently long for the outcome to occur? 4. Is it clear that the exposure preceded the onset of the outcome? 5. Is there a dose-response gradient?

Yes, it is clear that the exposure preceded the onset of the outcome No, this study was not associated with dose response gradient

6

Is the association consistent from study Yes, this study has shown that children to study?

with T1DM had lower total generic QoL than controls, which isconsistent with previous findings of other researchers

7

Does the association make biological Yes, it does, patient with chronic sense?

complications may account for the low emotional QoL because of lack of autonomy and preoccupation.

This study is valid Are the results important? 1. How strong is the association between

The mean total score of the PedsQL

exposure and outcome, i.e. the estimate Diabetes Module was 70.2 ± 9.8 reported of risk?

by children and 59.9 ± 11.1 reported by parents (higher scores indicate better

2. How precise is the estimate of risk?

QoL). Young age and long duration of diabetes were associated with poor QoL (p < 0.001). Boys had better total scores than girls in most age groups (70.3 ± 9.3 vs. 52.3 ± 7.2, p < 0.001); however, girls did better than boys regarding treatment barriers and adherence (71.3 ± 7.8 vs. 68.1 ± 6.2, p < 0.005). Higher HbA1c values were associated with lower QoL scores (31.1 ± 5.1 at HbA1c of 15% vs. 82.5 ± 6.1 at HbA1c of 6%, p < 0.0001).

This study is important

Are the results important for my patient? 1. Is my patient so different from those No, characteristic type of subjects in included in the study that its results this study similar with our patients don’t apply? 2. What is my patient’s risk of the adverse Yes, this evidence is worth for our event? What is my patient’s potential clinical practices. benefit from therapy? 3

What are my patient’s preferences, By knowing this association,

We

concerns and expectations from this recommend that assessment of QoL treatment?

after diagnosis of T1DM should be a routine

practice

in

patients

with

diabetes to facilitate communication, identify early problems and implement early intervention. This study is applicable Conclusion: Valid, Important, and Applicable. Level of evidence 3B with grade of recommendation C.