Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study
Identifieur interne : 002938 ( Pmc/Corpus ); précédent : 002937; suivant : 002939Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study
Auteurs : Helen Siyoum Atkilt ; Muluken Gizaw Turago ; Balewgizie Sileshi TegegneSource :
- PLoS ONE [ 1932-6203 ] ; 2017.
Abstract
Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type 1 diabetes (T1D) and the leading cause of morbidity and mortality in children with T1D. This study was aimed at assessing the prevalence and associated factors of DKA in children with newly diagnosed T1D in Addis Ababa.
A hospital based cross-sectional study was conducted in selected hospitals in Addis Ababa. Children below the age of 12 years with DKA who were admitted to the pediatric ward in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. DKA was defined as children below the age of 12 years who have blood glucose level ≥250mg/dl, ketonuria, and ketonemia and diagnosed being T1D patient for the first time. Descriptive statistics was performed using frequency distribution, mean, median, tables, and graphs. Logistic regression analysis was used to identify independent factors associated with the prevalence of DKA in children with newly diagnosed T1D.
Of 395 DKA patients who were hospitalized during the five-year period, 142(35.8%) presented with DKA at first diagnosis of diabetes. On the other hand 253 (64.2%) children with DKA had longstanding T1D. Independent factors associated with DKA include: Age category 2–4.49years, 7–9.49 years and ≥9.5years (Adjusted odd ratio (AOR) = 3.14[1.21,8.06]), 3.44(1.39,8.49) and 4.02(1.68,9.60), respectively); parents’ knowledge on the sign and symptoms of DKA (AOR = 0.51[0.27, 0.95]); sign and symptoms of DKA before the onset of DKA (AOR = 0.35[0.21, 0.59]) and infection prior to DKA onset (AOR = 3.45[1.97, 6.04]).
The overall proportion of children diagnosed with DKA and new onset of T1D in Addis Ababa was high. In particular, children between 9–12 years of age and children whose parents did not know the sign and symptoms of DKA had a high risk of DKA at primary diagnosis of T1D.
Url:
DOI: 10.1371/journal.pone.0169666
PubMed: 28135278
PubMed Central: 5279745
Links to Exploration step
PMC:5279745Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study</title><author><name sortKey="Atkilt, Helen Siyoum" sort="Atkilt, Helen Siyoum" uniqKey="Atkilt H" first="Helen Siyoum" last="Atkilt">Helen Siyoum Atkilt</name><affiliation><nlm:aff id="aff001"><addr-line>Bole Health Center, Addis Ababa, Ethiopia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Turago, Muluken Gizaw" sort="Turago, Muluken Gizaw" uniqKey="Turago M" first="Muluken Gizaw" last="Turago">Muluken Gizaw Turago</name><affiliation><nlm:aff id="aff002"><addr-line>Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Tegegne, Balewgizie Sileshi" sort="Tegegne, Balewgizie Sileshi" uniqKey="Tegegne B" first="Balewgizie Sileshi" last="Tegegne">Balewgizie Sileshi Tegegne</name><affiliation><nlm:aff id="aff003"><addr-line>Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">28135278</idno><idno type="pmc">5279745</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5279745</idno><idno type="RBID">PMC:5279745</idno><idno type="doi">10.1371/journal.pone.0169666</idno><date when="2017">2017</date><idno type="wicri:Area/Pmc/Corpus">002938</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">002938</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study</title><author><name sortKey="Atkilt, Helen Siyoum" sort="Atkilt, Helen Siyoum" uniqKey="Atkilt H" first="Helen Siyoum" last="Atkilt">Helen Siyoum Atkilt</name><affiliation><nlm:aff id="aff001"><addr-line>Bole Health Center, Addis Ababa, Ethiopia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Turago, Muluken Gizaw" sort="Turago, Muluken Gizaw" uniqKey="Turago M" first="Muluken Gizaw" last="Turago">Muluken Gizaw Turago</name><affiliation><nlm:aff id="aff002"><addr-line>Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Tegegne, Balewgizie Sileshi" sort="Tegegne, Balewgizie Sileshi" uniqKey="Tegegne B" first="Balewgizie Sileshi" last="Tegegne">Balewgizie Sileshi Tegegne</name><affiliation><nlm:aff id="aff003"><addr-line>Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2017">2017</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title><p>Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type 1 diabetes (T1D) and the leading cause of morbidity and mortality in children with T1D. This study was aimed at assessing the prevalence and associated factors of DKA in children with newly diagnosed T1D in Addis Ababa.</p></sec><sec id="sec002"><title>Methods</title><p>A hospital based cross-sectional study was conducted in selected hospitals in Addis Ababa. Children below the age of 12 years with DKA who were admitted to the pediatric ward in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. DKA was defined as children below the age of 12 years who have blood glucose level ≥250mg/dl, ketonuria, and ketonemia and diagnosed being T1D patient for the first time. Descriptive statistics was performed using frequency distribution, mean, median, tables, and graphs. Logistic regression analysis was used to identify independent factors associated with the prevalence of DKA in children with newly diagnosed T1D.</p></sec><sec id="sec003"><title>Results</title><p>Of 395 DKA patients who were hospitalized during the five-year period, 142(35.8%) presented with DKA at first diagnosis of diabetes. On the other hand 253 (64.2%) children with DKA had longstanding T1D. Independent factors associated with DKA include: Age category 2–4.49years, 7–9.49 years and ≥9.5years (Adjusted odd ratio (AOR) = 3.14[1.21,8.06]), 3.44(1.39,8.49) and 4.02(1.68,9.60), respectively); parents’ knowledge on the sign and symptoms of DKA (AOR = 0.51[0.27, 0.95]); sign and symptoms of DKA before the onset of DKA (AOR = 0.35[0.21, 0.59]) and infection prior to DKA onset (AOR = 3.45[1.97, 6.04]).</p></sec><sec id="sec004"><title>Conclusions</title><p>The overall proportion of children diagnosed with DKA and new onset of T1D in Addis Ababa was high. In particular, children between 9–12 years of age and children whose parents did not know the sign and symptoms of DKA had a high risk of DKA at primary diagnosis of T1D.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Wolfsdorf, J" uniqKey="Wolfsdorf J">J Wolfsdorf</name></author><author><name sortKey="Glaser, N" uniqKey="Glaser N">N Glaser</name></author><author><name sortKey="Sperling, Ma" uniqKey="Sperling M">MA Sperling</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zeitler, P" uniqKey="Zeitler P">P Zeitler</name></author><author><name sortKey="Fu, J" uniqKey="Fu J">J Fu</name></author><author><name sortKey="Tandon, N" uniqKey="Tandon N">N Tandon</name></author><author><name sortKey="Nadeau, K" uniqKey="Nadeau K">K Nadeau</name></author><author><name sortKey="Urakami, T" uniqKey="Urakami T">T Urakami</name></author><author><name sortKey="Barrett, T" uniqKey="Barrett T">T Barrett</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Wilson, Jf" uniqKey="Wilson J">JF Wilson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kitabchi, Ae" uniqKey="Kitabchi A">AE Kitabchi</name></author><author><name sortKey="Umpierrez, Ge" uniqKey="Umpierrez G">GE Umpierrez</name></author><author><name sortKey="Miles, Jm" uniqKey="Miles J">JM Miles</name></author><author><name sortKey="Fisher, Jn" uniqKey="Fisher J">JN Fisher</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Van Zyl, Dg" uniqKey="Van Zyl D">DG Van Zyl</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Usher Smith, J" uniqKey="Usher Smith J">J Usher-Smith</name></author><author><name sortKey="Thompson, M" uniqKey="Thompson M">M Thompson</name></author><author><name sortKey="Ercole, A" uniqKey="Ercole A">A Ercole</name></author><author><name sortKey="Walter, F" uniqKey="Walter F">F Walter</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Murunga, A" uniqKey="Murunga A">A Murunga</name></author><author><name sortKey="Owira, P" uniqKey="Owira P">P Owira</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Majaliwa, Es" uniqKey="Majaliwa E">ES Majaliwa</name></author><author><name sortKey="Mohn, A" uniqKey="Mohn A">A Mohn</name></author><author><name sortKey="Chiavaroli, V" uniqKey="Chiavaroli V">V Chiavaroli</name></author><author><name sortKey="Ramaiya, K" uniqKey="Ramaiya K">K Ramaiya</name></author><author><name sortKey="Swai, Ab" uniqKey="Swai A">AB Swai</name></author><author><name sortKey="Chiarelli, F" uniqKey="Chiarelli F">F Chiarelli</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Onyiriuka, An" uniqKey="Onyiriuka A">AN Onyiriuka</name></author><author><name sortKey="Ifebi, E" uniqKey="Ifebi E">E Ifebi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fantahun, Ge" uniqKey="Fantahun G">GE Fantahun</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ibekwe, Mu" uniqKey="Ibekwe M">MU Ibekwe</name></author><author><name sortKey="Ibekwe, Rc" uniqKey="Ibekwe R">RC Ibekwe</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Marigliano, M" uniqKey="Marigliano M">M Marigliano</name></author><author><name sortKey="Morandi, A" uniqKey="Morandi A">A Morandi</name></author><author><name sortKey="Maschio, M" uniqKey="Maschio M">M Maschio</name></author><author><name sortKey="Costantini, S" uniqKey="Costantini S">S Costantini</name></author><author><name sortKey="Contreas, G" uniqKey="Contreas G">G Contreas</name></author><author><name sortKey="D Annunzio, G" uniqKey="D Annunzio G">G D'Annunzio</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Razavi, Z" uniqKey="Razavi Z">Z Razavi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Reddy, Y" uniqKey="Reddy Y">Y Reddy</name></author><author><name sortKey="Ganie, Y" uniqKey="Ganie Y">Y Ganie</name></author><author><name sortKey="Pillay, K" uniqKey="Pillay K">K Pillay</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mbugua, P" uniqKey="Mbugua P">P Mbugua</name></author><author><name sortKey="Otieno, C" uniqKey="Otieno C">C Otieno</name></author><author><name sortKey="Kayima, J" uniqKey="Kayima J">J Kayima</name></author><author><name sortKey="Amayo, A" uniqKey="Amayo A">A Amayo</name></author><author><name sortKey="Mcligeyo, S" uniqKey="Mcligeyo S">S McLigeyo</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Dabelea, D" uniqKey="Dabelea D">D Dabelea</name></author><author><name sortKey="Rewers, A" uniqKey="Rewers A">A Rewers</name></author><author><name sortKey="Stafford, Jm" uniqKey="Stafford J">JM Stafford</name></author><author><name sortKey="Standiford, Da" uniqKey="Standiford D">DA Standiford</name></author><author><name sortKey="Lawrence, Jm" uniqKey="Lawrence J">JM Lawrence</name></author><author><name sortKey="Saydah, S" uniqKey="Saydah S">S Saydah</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Usher Smith, Ja" uniqKey="Usher Smith J">JA Usher-Smith</name></author><author><name sortKey="Thompson, Mj" uniqKey="Thompson M">MJ Thompson</name></author><author><name sortKey="Sharp, Sj" uniqKey="Sharp S">SJ Sharp</name></author><author><name sortKey="Walter, Fm" uniqKey="Walter F">FM Walter</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="research-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">28135278</article-id><article-id pub-id-type="pmc">5279745</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0169666</article-id><article-id pub-id-type="publisher-id">PONE-D-16-18743</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Diagnostic Medicine</subject><subj-group><subject>Signs and Symptoms</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pathology and Laboratory Medicine</subject><subj-group><subject>Signs and Symptoms</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Endocrinology</subject><subj-group><subject>Endocrine Disorders</subject><subj-group><subject>Diabetes Mellitus</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Metabolic Disorders</subject><subj-group><subject>Diabetes Mellitus</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Social Sciences</subject><subj-group><subject>Sociology</subject><subj-group><subject>Human Families</subject></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Population Groupings</subject><subj-group><subject>Age Groups</subject><subj-group><subject>Children</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Population Groupings</subject><subj-group><subject>Families</subject><subj-group><subject>Children</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Medicine and Health Sciences</subject><subj-group><subject>Pediatrics</subject></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Research and Analysis Methods</subject><subj-group><subject>Mathematical and Statistical Techniques</subject><subj-group><subject>Statistical Methods</subject><subj-group><subject>Multivariate Analysis</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Physical Sciences</subject><subj-group><subject>Mathematics</subject><subj-group><subject>Statistics (Mathematics)</subject><subj-group><subject>Statistical Methods</subject><subj-group><subject>Multivariate Analysis</subject></subj-group></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>People and Places</subject><subj-group><subject>Geographical Locations</subject><subj-group><subject>Africa</subject><subj-group><subject>Ethiopia</subject></subj-group></subj-group></subj-group></subj-group><subj-group subj-group-type="Discipline-v3"><subject>Research and Analysis Methods</subject><subj-group><subject>Research Design</subject><subj-group><subject>Cross-Sectional Studies</subject></subj-group></subj-group></subj-group></article-categories><title-group><article-title>Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study</article-title><alt-title alt-title-type="running-head">Diabetic Ketoacidosis in Children</alt-title></title-group><contrib-group><contrib contrib-type="author"><contrib-id contrib-id-type="orcid" authenticated="false">http://orcid.org/5050-5050-5050-5050</contrib-id><name><surname>Atkilt</surname><given-names>Helen Siyoum</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="corresp" rid="cor001">*</xref></contrib><contrib contrib-type="author"><name><surname>Turago</surname><given-names>Muluken Gizaw</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref></contrib><contrib contrib-type="author"><name><surname>Tegegne</surname><given-names>Balewgizie Sileshi</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Bole Health Center, Addis Ababa, Ethiopia</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Department of Preventive Medicine, School of Public Health, College of Health Sciences Addis Ababa University, Addis Ababa, Ethiopia</addr-line></aff><aff id="aff003"><label>3</label><addr-line>Department of Public Health, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Reboldi</surname><given-names>Gianpaolo</given-names></name><role>Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Universita degli Studi di Perugia, ITALY</addr-line></aff><author-notes><fn fn-type="COI-statement" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con"><p><list list-type="simple"><list-item><p><bold>Conceptualization:</bold> HSA MGT.</p></list-item><list-item><p><bold>Formal analysis:</bold> HSA MGT.</p></list-item><list-item><p><bold>Methodology:</bold> HSA MGT.</p></list-item><list-item><p><bold>Supervision:</bold> HSA MGT BST.</p></list-item><list-item><p><bold>Writing – original draft:</bold> HSA MGT BST.</p></list-item><list-item><p><bold>Writing – review & editing:</bold> HSA MGT BST.</p></list-item></list></p></fn><corresp id="cor001">* E-mail: <email>helux24@gmail.com</email></corresp></author-notes><pub-date pub-type="epub"><day>30</day><month>1</month><year>2017</year></pub-date><pub-date pub-type="collection"><year>2017</year></pub-date><volume>12</volume><issue>1</issue><elocation-id>e0169666</elocation-id><history><date date-type="received"><day>9</day><month>5</month><year>2016</year></date><date date-type="accepted"><day>20</day><month>12</month><year>2016</year></date></history><permissions><copyright-statement>© 2017 Atkilt et al</copyright-statement><copyright-year>2017</copyright-year><copyright-holder>Atkilt et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p></license></permissions><self-uri content-type="pdf" xlink:href="pone.0169666.pdf"></self-uri><abstract><sec id="sec001"><title>Background</title><p>Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type 1 diabetes (T1D) and the leading cause of morbidity and mortality in children with T1D. This study was aimed at assessing the prevalence and associated factors of DKA in children with newly diagnosed T1D in Addis Ababa.</p></sec><sec id="sec002"><title>Methods</title><p>A hospital based cross-sectional study was conducted in selected hospitals in Addis Ababa. Children below the age of 12 years with DKA who were admitted to the pediatric ward in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. DKA was defined as children below the age of 12 years who have blood glucose level ≥250mg/dl, ketonuria, and ketonemia and diagnosed being T1D patient for the first time. Descriptive statistics was performed using frequency distribution, mean, median, tables, and graphs. Logistic regression analysis was used to identify independent factors associated with the prevalence of DKA in children with newly diagnosed T1D.</p></sec><sec id="sec003"><title>Results</title><p>Of 395 DKA patients who were hospitalized during the five-year period, 142(35.8%) presented with DKA at first diagnosis of diabetes. On the other hand 253 (64.2%) children with DKA had longstanding T1D. Independent factors associated with DKA include: Age category 2–4.49years, 7–9.49 years and ≥9.5years (Adjusted odd ratio (AOR) = 3.14[1.21,8.06]), 3.44(1.39,8.49) and 4.02(1.68,9.60), respectively); parents’ knowledge on the sign and symptoms of DKA (AOR = 0.51[0.27, 0.95]); sign and symptoms of DKA before the onset of DKA (AOR = 0.35[0.21, 0.59]) and infection prior to DKA onset (AOR = 3.45[1.97, 6.04]).</p></sec><sec id="sec004"><title>Conclusions</title><p>The overall proportion of children diagnosed with DKA and new onset of T1D in Addis Ababa was high. In particular, children between 9–12 years of age and children whose parents did not know the sign and symptoms of DKA had a high risk of DKA at primary diagnosis of T1D.</p></sec></abstract><funding-group><funding-statement>The authors received no specific funding for this work.</funding-statement></funding-group><counts><fig-count count="0"></fig-count><table-count count="3"></table-count><page-count count="9"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>Data are available in the dryad public repository with DOI <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.5061/dryad.n5526">10.5061/dryad.n5526</ext-link>.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>Data are available in the dryad public repository with DOI <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.5061/dryad.n5526">10.5061/dryad.n5526</ext-link>.</p></notes></front><body><sec sec-type="intro" id="sec005"><title>Introduction</title><p>Diabetic ketoacidosis (DKA) is one of the most serious acute complications of type1 diabetes mellitus (T1D)P[<xref rid="pone.0169666.ref001" ref-type="bibr">1</xref>]. The International Society for Pediatric and Adolescent Diabetes define DKA as a blood glucose level >11mmol/l (≈200 mg/dl), Venous PH <7.3 or bicarbonate< 15mmol/L, ketonemia, and ketonuria[<xref rid="pone.0169666.ref002" ref-type="bibr">2</xref>]. DKA is a medical emergency that requires treatment and monitoring for multiple metabolic abnormalities and vigilance for complications.It is the common cause of death and permanent disability in children and adolescents with new onset diabetes[<xref rid="pone.0169666.ref001" ref-type="bibr">1</xref>,<xref rid="pone.0169666.ref003" ref-type="bibr">3</xref>].</p><p>Every year, worldwide, approximately 79,100 children under 15 years of age develop T1D. Up to 80% of these young people already have DKA when they are diagnosed with diabetes. There is a wide geographic variation in the frequency of DKA at the onset of diabetes [<xref rid="pone.0169666.ref003" ref-type="bibr">3</xref>,<xref rid="pone.0169666.ref004" ref-type="bibr">4</xref>]. The mortality rate for DKA ranges from 2 to 5% in developed countries and 6 to 24% in developing countries[<xref rid="pone.0169666.ref004" ref-type="bibr">4</xref>]. The mortality rate of DKA in developing countries is higher due to the higher rates of infection, protein energy malnutrition, less developed medical services and delay in health seeking behavior[<xref rid="pone.0169666.ref005" ref-type="bibr">5</xref>,<xref rid="pone.0169666.ref006" ref-type="bibr">6</xref>].</p><p>Geographical factors like climate may influence the number of people affected with DKA. Countries nearer to the equator have a high prevalence of DKA due to hot climates which lead to more rapid dehydration and onset of hyperglycemia particularly in young children [<xref rid="pone.0169666.ref007" ref-type="bibr">7</xref>].</p><p>Many children in sub-Saharan Africa are diagnosed with diabetes only when they present with DKA, which quite often is misdiagnosed. In many sub-Saharan African countries, diabetic patients just die because health care facilities are overstretched by even more urgent healthcare needs, HIV/AIDS, malaria and other tropical diseases[<xref rid="pone.0169666.ref008" ref-type="bibr">8</xref>–<xref rid="pone.0169666.ref010" ref-type="bibr">10</xref>].</p><p>In developing countries,where medical services are less developed, the risk of dying from DKA is greater and children may die before they receive treatment[<xref rid="pone.0169666.ref011" ref-type="bibr">11</xref>].The actual incidence of DKA in Sub-Saharan Africa is unknown, but unlike the western country DKA is uniquely frequent among type 2 diabetes ([<xref rid="pone.0169666.ref008" ref-type="bibr">8</xref>]). Some observational studies in Africa suggested a high prevalence of DKA at diagnosis, which ranges 77.1% to 88% [<xref rid="pone.0169666.ref010" ref-type="bibr">10</xref>,<xref rid="pone.0169666.ref012" ref-type="bibr">12</xref>].</p><p>In Ethiopia like other African countries, the prevalence and risk factors of DKA in children with newly diagnosed T1D is not well studied. Without the knowledge of the magnitude and associated risk factors of DKA in children the preventable associated risk factors will not be handled and this leads to increase the magnitude of DKA in children. Hence, the aim of this study was to assess the prevalence and associated risk factors of DKA in children with newly diagnosed T1D in Addis Ababa, Ethiopia.</p></sec><sec sec-type="materials|methods" id="sec006"><title>Materials and Methods</title><sec id="sec007"><title>Study design</title><p>A hospital-based cross-sectional study was conducted using routine hospital data and interview in three different hospitals (Black Lion, Yekatit and Zewditu hospital) in Addis Ababa.</p></sec><sec id="sec008"><title>Study setting and participants</title><p>This study was conducted in Addis Ababa from January 1 to March 30, 2015. Addis Ababa is the capital and largest city of Ethiopia. Based on the 2007 Census projection conducted by the <ext-link ext-link-type="uri" xlink:href="http://en.wikipedia.org/wiki/Central_Statistical_Agency_%28Ethiopia%29">Central Statistical Agency</ext-link> of Ethiopia (CSA), in 2015 Addis Ababa has a total population of 3,273,001, of whom 1,551,000 are male, and 1,722,001 female; all of the population is urban inhabitants [<xref rid="pone.0169666.ref013" ref-type="bibr">13</xref>]. Children below the age of 12 years with DKA who were admitted to pediatric wards in the selected hospitals between January 2009 and December 2014 and the residence of Addis Ababa were included. Black Lion, Yekatit and Zewditu hospital were selected purposely because they had higher pediatric patient flow. During the five years study period, a total of 715 children were admittedto the selected hospitals with DKA (300 in Black Lion, 210 in Yekatit and 205 in Zewditu). To calculate the adequate minimum sample size we took the magnitude of DKA from a study conducted in Tikur Anbesa specialized hospital which was 80% [<xref rid="pone.0169666.ref011" ref-type="bibr">11</xref>]. We have considered 95% confidence level, 4% margin of error (d) and 10% non-response rate. Based on the calculated sample, we included 421 children for analysis in this study.</p></sec><sec id="sec009"><title>Data collection procedures</title><p>The dependent variable for this study was DKA in newly diagnosed children, and it was defined as children between 0–12 years who have blood glucose level ≥ 250mg/dl, ketonuria and ketonemia and diagnosed being T1D patient for the first time. The independent variables were socio-demographic characteristics and clinical factors like family history of DM, knowledge of the sign and symptoms of DM/DKA and others.</p><p>A checklist that measures the socio-demographic characteristics and clinical information of DKA was used to collect the data. Data which are not included in the patient card were obtained from the parents/guardians when they came with the child in the selected hospital for follow up. The patients were followed up with the frequency of visit of 1–3 months. Data was collected using systematic random sampling with ak value of two which was calculated by dividing the number of DKA patient in each hospital divided by the number of sample size allocated to each hospital. The first chart was selected randomly.</p></sec><sec id="sec010"><title>Statistical analysis</title><p>Data was entered into EpiInfo version7 statistical software and exported to SPSS (statistical package for the social sciences) version 21. The data were examined for outliers and checked accordingly. Descriptive analysis was performed using frequency distribution, mean, median, tables and graph. A bivariate analysis was carried out using crude odds ratio (COR) to assess the relationship between dependent and independent variables. The significance of the relationship between dependent and independent variables was checked using p-value and p< 0.05 was determined as a significance relationship. Moreover, multivariate analysis was used to identify the associated risk factors by controlling possible confounding factors using logistic regression. All variables in the bivariate analysis were included in the multivariate analysis and variables were entered hierarchically to fit the logistic regression model.</p></sec><sec id="sec011"><title>Ethical considerations</title><p>Ethical clearance for this study was obtained from the Review Ethics Committee of School of Public Health at Addis Ababa University. As the study was conducted through review of medical records and interview, the study participants were informed about the purpose of the study and the importance of their participation in the study. And also they were informed as they could not participate; stop at any time in between; skip or decline to answer questions if they felt uncomfortable without losing the benefit thatwould get in the institution. Their participation was purely on voluntary. Moreover, no personal identifiers were used on the data collection form. The recorded data were not accessed by a third person and were kept confidentially. The mother/caregiver of the children had signed the informed consent sheet.</p></sec></sec><sec sec-type="results" id="sec012"><title>Results</title><p>A total of 421 charts from children below the age of 12 years who were diagnosed with DKA between January 2009 and December 2014 were reviewed. Of 421 charts, we found 395 under 12 children who came for the refill (follow-up) and answered the socioeconomic and clinical risk factors that are not included in the chart, making the response rate of 93.8%. Among a total of 395 patients with DKA, who were hospitalized during the five year period under review, 142(35.8%, 95% CI [31.6%, 40.8%]) were newly diagnosed. Of 142 newly diagnosed DM children at the primary diagnosis of DKA, more than half, 77(55.9%) were males. The mean age at presentation was 7.08±3.8 years (7.4 ± 3.74 years for boys and 6.66 ± 3.85 years for girls). Of 395 children the marital status of the mother/father/guardian with whom the child live; 330(83.5%) were married, 36(9.1%) were separated, 15(3.8%) were widowed, and the rest were single. The mean and standard deviation of family income were 2569±1216. The majority, 182(46.1%) of children were from Orthodox Christian religion family followed by, 113 (28.5%) Muslims and 60(15.2%) Protestants. Of the total respondents; majority completed at least high school grades and above (100(25.3%) were above grade 12, 93(23.5%) were 9–12). Of 395 children’s mother/caregiver; more than half were a housewife, 137(34.7%) and civil servant, 92(23.3%) by occupation (<xref ref-type="table" rid="pone.0169666.t001">Table 1</xref>).</p><table-wrap id="pone.0169666.t001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0169666.t001</object-id><label>Table 1</label><caption><title>Socio-demographic characteristics of the subjects.</title></caption><alternatives><graphic id="pone.0169666.t001g" xlink:href="pone.0169666.t001"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Variables</th><th align="left" rowspan="1" colspan="1">Category</th><th align="left" rowspan="1" colspan="1">Frequency N = 395</th><th align="left" rowspan="1" colspan="1">Percent</th></tr></thead><tbody><tr><td align="left" rowspan="2" colspan="1">Sex</td><td align="left" rowspan="1" colspan="1">Male</td><td align="left" rowspan="1" colspan="1">221</td><td align="left" rowspan="1" colspan="1">55.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Female</td><td align="left" rowspan="1" colspan="1">174</td><td align="left" rowspan="1" colspan="1">44.1</td></tr><tr><td align="left" rowspan="5" colspan="1">Age category</td><td align="left" rowspan="1" colspan="1"><2</td><td align="left" rowspan="1" colspan="1">39</td><td align="left" rowspan="1" colspan="1">9.9</td></tr><tr><td align="left" rowspan="1" colspan="1">2.0–4.49</td><td align="left" rowspan="1" colspan="1">75</td><td align="left" rowspan="1" colspan="1">19</td></tr><tr><td align="left" rowspan="1" colspan="1">4.5–6.99</td><td align="left" rowspan="1" colspan="1">46</td><td align="left" rowspan="1" colspan="1">11.6</td></tr><tr><td align="left" rowspan="1" colspan="1">7.0–9.49</td><td align="left" rowspan="1" colspan="1">105</td><td align="left" rowspan="1" colspan="1">26.6</td></tr><tr><td align="left" rowspan="1" colspan="1">> = 9.5</td><td align="left" rowspan="1" colspan="1">130</td><td align="left" rowspan="1" colspan="1">32.9</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Religion</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Orthodox</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">182</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">46.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Muslim</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">113</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">28.5</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Protestant</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">60</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">15.2</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Catholic</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">20</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">5.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Others</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">20</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">5.1</td></tr><tr><td align="left" rowspan="5" colspan="1">Ethnicity</td><td align="left" rowspan="1" colspan="1">Amhara</td><td align="left" rowspan="1" colspan="1">125</td><td align="left" rowspan="1" colspan="1">31.6</td></tr><tr><td align="left" rowspan="1" colspan="1">Tigre</td><td align="left" rowspan="1" colspan="1">62</td><td align="left" rowspan="1" colspan="1">15.7</td></tr><tr><td align="left" rowspan="1" colspan="1">Oromo</td><td align="left" rowspan="1" colspan="1">126</td><td align="left" rowspan="1" colspan="1">31.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Gurage</td><td align="left" rowspan="1" colspan="1">50</td><td align="left" rowspan="1" colspan="1">12.7</td></tr><tr><td align="left" rowspan="1" colspan="1">Others</td><td align="left" rowspan="1" colspan="1">32</td><td align="left" rowspan="1" colspan="1">8.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Mother/caregiver education</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Unable to read & write</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">35</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">8.9</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Read and Write</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">74</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">18.8</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Grade 1–8</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">93</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">23.5</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Grade 9–12</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">93</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">23.5</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Above 12</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">100</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">25.3</td></tr><tr><td align="left" rowspan="4" style="background-color:#FFFFFF" colspan="1">Marital status of the mother/caregiver</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Single</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">14</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.6</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Married</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">330</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">83.5</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Separated</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">36</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">9.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Widowed</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">15</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.8</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Mother/caregiver occupation</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Unemployed</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">28</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">7.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Civil servant</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">92</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">23.3</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Student</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">11</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.8</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Housewife</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">137</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">34.7</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Daily labor</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">57</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">14.4</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Merchant</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">58</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">14.7</td></tr></tbody></table></alternatives></table-wrap><p>From this study one-third of the children 131(33.2%) had first-degree relatives with diabetes. Less than half (43.0%) of the parents of children knew about the sign and symptoms of DM/DKA. The result of this study also showed the majority of mothers/caregiver’s had knowledge on polydipsia and polyuria as sign and symptoms of DM/DKA (41.1% and 36.2% respectively). In this study the frequently reported presenting symptoms of DKA were vomiting (31.9%) abdominal pain (19.8%) dry mucous membrane (16.3%) and polydipsia (11.9%).</p><p>The study showed 108(27.3%) children had an infection before the onset of DKA. Of these, 8.2% of children had dysuria, fever 7.7% and 1.4% of children had skin lesion before DKA (<xref ref-type="table" rid="pone.0169666.t002">Table 2</xref>).</p><table-wrap id="pone.0169666.t002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0169666.t002</object-id><label>Table 2</label><caption><title>Clinical characteristics of the subjects.</title></caption><alternatives><graphic id="pone.0169666.t002g" xlink:href="pone.0169666.t002"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Variable</th><th align="left" rowspan="1" colspan="1">Category</th><th align="left" rowspan="1" colspan="1">Frequency N = 395</th><th align="left" rowspan="1" colspan="1">Percent</th></tr></thead><tbody><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Child first-degree relatives with DM</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">131</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">33.2</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">264</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">66.8</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Parent’s knowledge about the sign and symptoms of DM/DKA</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">170</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">43</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">225</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">57</td></tr><tr><td align="left" rowspan="2" style="background-color:#FFFFFF" colspan="1">Sign and symptoms of DKA before the onset of DKA</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">253</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">64.1</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">142</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">35.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Which sign and symptoms of DKA</td><td align="left" rowspan="1" colspan="1">Polyuria</td><td align="left" rowspan="1" colspan="1">12</td><td align="left" rowspan="1" colspan="1">4.8</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Polydipsia</td><td align="left" rowspan="1" colspan="1">38</td><td align="left" rowspan="1" colspan="1">15</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Weight loss</td><td align="left" rowspan="1" colspan="1">36</td><td align="left" rowspan="1" colspan="1">14.2</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Polyuria & Polydipsia</td><td align="left" rowspan="1" colspan="1">117</td><td align="left" rowspan="1" colspan="1">46.2</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Polyuria & Weight loss</td><td align="left" rowspan="1" colspan="1">38</td><td align="left" rowspan="1" colspan="1">15</td></tr><tr><td align="left" rowspan="1" colspan="1"></td><td align="left" rowspan="1" colspan="1">Polydipsia & weight loss</td><td align="left" rowspan="1" colspan="1">12</td><td align="left" rowspan="1" colspan="1">4.8</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Infection before the onset of DKA</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">108</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">27.3</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"></td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">287</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">72.7</td></tr></tbody></table></alternatives></table-wrap><p>Bivariate logistic regression analysis was done to identify the relation between DKA and the associated risk factors. In this analysis age of the child, family history of DM, preceding sign and symptoms DKA/DM, mothers’ knowledge on sign and symptoms of DM/DKA and preceding infection found to have a significant association with DKA at primary diagnosis of T1D.</p><p>In multivariate analysis, the independent variables that were not significant in the bivariate analysis like sex, marital status, and family income were not significant in the multivariate analysis too. Accordingly, knowledge of the sign and symptoms of DM/DKA, preceding sign and symptoms of DM/DKA, prior history of infection and age found to be statistically significant factors for developing DKA at the first onset of T1D. Compared to under-2- year old children; the age group 2–4.49 years and 5–9.49 years had three times and 2.6 times higher odds of developing DKA in newly diagnosed children (AOR = 3.13[1.22, 8.06]), 2.61[1.40, 8.50] respectively). Similarly, older children (≥9.5 years) also had four times higher chance of developing (AOR = 4.02[1.69, 9.60]) as compared to children less than two years (<xref ref-type="table" rid="pone.0169666.t003">Table 3</xref>).</p><table-wrap id="pone.0169666.t003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0169666.t003</object-id><label>Table 3</label><caption><title>Factors associated with diabetic ketoacidosis.</title></caption><alternatives><graphic id="pone.0169666.t003g" xlink:href="pone.0169666.t003"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Variables</th><th align="left" rowspan="1" colspan="1"></th><th align="left" rowspan="1" colspan="1">DKA</th><th align="left" rowspan="1" colspan="1"></th><th align="left" rowspan="1" colspan="1">COR (95%CI</th><th align="left" rowspan="1" colspan="1">AOR (95%CI)</th></tr><tr><th align="left" colspan="2" style="background-color:#FFFFFF" rowspan="1"> </th><th align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</th><th align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</th><th align="left" colspan="2" style="background-color:#FFFFFF" rowspan="1"> </th></tr></thead><tbody><tr><td align="left" rowspan="5" style="background-color:#FFFFFF" colspan="1">Age category</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">< = 2 year</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">22</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">17</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2–4.49</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">24</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">51</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.75(1.27,6.10)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.13(1.21,8.06)<xref ref-type="table-fn" rid="t003fn002">*</xref></td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">4.5–6.99</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">20</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">26</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.68(0.71,3.98)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.61(0.93,7.29)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">7–9.49</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">41</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">64</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.02(0.25,0.96)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.44(1.39,8.49)<xref ref-type="table-fn" rid="t003fn002">*</xref></td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">>9.5</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">35</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">95</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.51(1.67,7.38)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">4.02(1.68,9.60)<xref ref-type="table-fn" rid="t003fn002">*</xref></td></tr><tr><td align="left" rowspan="5" style="background-color:#FFFFFF" colspan="1">Mother/caregiver education status</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Unable to read & write</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">20</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">15</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Read and Write</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">30</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">44</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.96(0.86,4.42)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.71(0.62,4.70)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Grade 1–8</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">35</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">58</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.21(1.0,4.87)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.61(0.53,4.90)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Grade 9–12</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">32</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">61</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2.54(1.2,5.60) 4.0(1.78,8.97)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.80(0.58,5.50)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Above 12</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">25</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">75</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3.03(0.92,10.0)</td></tr><tr><td align="left" rowspan="5" style="background-color:#FFFFFF" colspan="1">Family income</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">< = 1000 birr</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">6</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">13</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">10001–2200</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">67</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">90</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.62(0.22,1.72)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.36(0.10,1.30)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">2201–3400</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">33</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">85</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.19(0.42,3.34)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.69(0.18,2.60)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">3401–3600</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">30</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">50</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.77(0.26,2.24)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.31(0.07,1.23)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">>3600</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">60</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">15</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">1.15(0.29,4.46)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.4(0.07,2.20)</td></tr><tr><td align="left" rowspan="3" style="background-color:#FFFFFF" colspan="1">Having first degree relatives with DM</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">38</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">93</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.63(0.40,0.90)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.77(0.40,1.52)</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">104</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">160</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Parent’s knowledge about the sign &</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">46</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">124</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.49(0.32,0.76)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.51(0.27,0.95)<xref ref-type="table-fn" rid="t003fn002">*</xref></td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Symptom</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">96</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">129</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">of DM/DKA</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1"> </td></tr><tr><td align="left" rowspan="2" style="background-color:#FFFFFF" colspan="1">Symptoms and sign of DKA before the onset of DKA</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Yes</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">181</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">72</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">Ref.</td></tr><tr><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">No</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">72</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">70</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.41(0.27,0.63)</td><td align="left" style="background-color:#FFFFFF" rowspan="1" colspan="1">0.35(0.21,0.59)<xref ref-type="table-fn" rid="t003fn002">*</xref></td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t003fn001"><p>N.B. Ref. is designated for reference</p></fn><fn id="t003fn002"><p>*statistically significant at α = 0.05.</p></fn></table-wrap-foot></table-wrap><p>The final model included the following variables: Age category, mothers’ or caregivers’ educational status, family income, having first degree relative with DM, parents’ knowledge of sign and symptom of DM/DKA, infection before the onset of DKA and sign and symptoms of DKA before onset of DKA.</p><p>Children who their parents knew the sign and symptoms of DM/DKA had 49% times less likely chance to develop DKA at primary diagnosis of DM than children who their parents did not have knowledge about the sign and symptoms of DM controlling for the rest of the independent variables. Children who had first-degree relatives with DM had a significant association with new-onset DM/DKA in bivariate analysis, but it was not significantly associated in multivariate analysis adjusting for the other independent variables. The odds of developing new onset DM with DKA was 3.45 (AOR = 3.455[1.97–6.04]) times higher in children who had an infection before 1–2 week of DKA than who did not have the sign and symptoms of infection adjusting for the rest of independent variables (<xref ref-type="table" rid="pone.0169666.t003">Table 3</xref>).</p></sec><sec sec-type="conclusions" id="sec013"><title>Discussion</title><p>This study revealed over one-third of children in the present study manifested with DKA at first diagnosis of diabetes. It is not surprising as a similar prevalence has been reported in a previous study in Italy [<xref rid="pone.0169666.ref014" ref-type="bibr">14</xref>] and Iran (24%) [<xref rid="pone.0169666.ref015" ref-type="bibr">15</xref>]. Another systematic review also reported consistent findings in Finland (22%) and Hungary (23%) [<xref rid="pone.0169666.ref007" ref-type="bibr">7</xref>]. However, some studies have reported higher prevalence, UAE(80%), Romania(67%),Taiwan(65%)[<xref rid="pone.0169666.ref007" ref-type="bibr">7</xref>], South Africa[<xref rid="pone.0169666.ref016" ref-type="bibr">16</xref>] all reflecting the well-known wide geographic variation in frequency of DKA at the onset of pediatric diabetes mellitus. Differences in study population might explain the differing in magnitude, the background prevalence of diabetes in the given population, presence or absence of family history ofT1D, socioeconomic status, delayed diagnosis and treatment as well as the definition of DKA used in the particular study[<xref rid="pone.0169666.ref017" ref-type="bibr">17</xref>].</p><p>Another study conducted in black lion hospital, Ethiopia [<xref rid="pone.0169666.ref011" ref-type="bibr">11</xref>] found the prevalence of DKA to be 80%, which was higher than our study. The magnitude might be overestimated due to severe cases are referred to black lion hospital. Another retrospective cross-sectional study carried out in Benin teaching hospital found the frequency of DKA in newly diagnosed children to be 77.1%[<xref rid="pone.0169666.ref010" ref-type="bibr">10</xref>], and this percentage is higher compared to our study which might be this study included under 15 years children for extended study periods.</p><p>A study conducted in Germany did not find a significant association between parental education and development of DKA [<xref rid="pone.0169666.ref018" ref-type="bibr">18</xref>], similar to this study our research did not find a significant association.</p><p>In a systematic review, three studies examined the effect of family income, and two European studies found that household income had no a significant effect on risk of presenting in DKA, and this result is consistent with our results [<xref rid="pone.0169666.ref019" ref-type="bibr">19</xref>]. This might be due to the reason that even though parents who get higher income and having a higher level of education they might not be aware of DM/DKA and seek medical advice earlier.</p><p>Marital status of the child mother had no significant association in developing DKA in newly diagnosed T1D children both in bivariate and multivariate analysis. Marital status of the child parent’s is an indirect predictor of DKA. In single, divorced and widowed mother the family income is supposed to be lesser than in married, but family income had no significant association with DKA so do the child parent’s marital status.</p><p>In agreement with our study a German study which adjusted for age, sex, having a single parent, and social status also failed to show a significant association with a family history of either type1or type2 diabetes in siblings, parents, or grandparent [<xref rid="pone.0169666.ref019" ref-type="bibr">19</xref>]. Although having a first degree relative with T1D decreased the frequency of DKA in three studies; it did not predict a diagnosis of new onset diabetes before progression toDKA. This might be because it is very difficult to find the classical symptoms of DKA in young children which are polyuria, polydipsia, and weight loss so the parents of the child might not consider the other sign and symptoms of DKA as the sign of DKA.</p><p>In this cross-sectional study, the odds of developing DKA in newly diagnosed T1D children was 49% lower for children whose parents’ knew the sign and symptoms of DM/DKA than parents’ who didn’t know the sign and symptoms of DM. This is because parents’ who know the sign and symptoms of DM might seek health care before their children develop DKA.</p><p>Three studies in the systematic review by Usher Smith JA et al.[<xref rid="pone.0169666.ref019" ref-type="bibr">19</xref>]included data on the effect of a previous infection or febrile illness. In two of the included studies, a history of infection or febrile illness was associated with an increased risk of DKA. Similar to this our study found the odds of children who had infection 1–2 weeks before DKA at the first onset of DM was 3.45 times higher than children who did not have an infection before DKA at thefirst onset of DM.Infection is known to cause inflammation, pro-inflammatory cytokine release, and a counter-regulatory response that collectively lead to insulin resistance and metabolic decompensation[<xref rid="pone.0169666.ref019" ref-type="bibr">19</xref>].</p><p>This study has significant limitations. First, we could not be able to calculate the prevalence of DKA among children with T1D due to lack of data on the total number of T1D. Second, the definition used for DKA in this study was not consistent with ISPAD. Hence, due to methodological differences the comparison with other studies was challenge full. Third, because of cross-sectional nature of the study, it was not possible to determine the temporal relationship of independent variables on the development of DKA. Finally, the inclusion of only the three government hospitals might hinder the actual estimation of DKA.</p></sec><sec sec-type="conclusions" id="sec014"><title>Conclusions</title><p>The overall proportion of children diagnosed with DKA and new onset ofT1Dwas high. In particular, children between 9–12 years of age had a high risk of DKA at onset. Children’s age, knowledge of sign and symptoms of DKA, sign, and symptoms of DKA before the onset of DKA and infection before DKA were found to be the significant explanatory variable of DKA in children with newly diagnosed T1D.</p></sec></body><back><ack><p>We gratefully acknowledge the subjects who participated in this study for their invaluable cooperation.</p></ack><ref-list><title>References</title><ref id="pone.0169666.ref001"><label>1</label><mixed-citation publication-type="journal"><name><surname>Wolfsdorf</surname><given-names>J</given-names></name>, <name><surname>Glaser</surname><given-names>N</given-names></name>, <name><surname>Sperling</surname><given-names>MA</given-names></name>, <collab>American Diabetes Association</collab>. <article-title>Diabetic ketoacidosis in infants, children, and adolescents: A consensus statement from the American Diabetes Association</article-title>. <source>Diabetes Care</source><year>2006</year><month>5</month>;<volume>29</volume>(<issue>5</issue>):<fpage>1150</fpage>–<lpage>1159</lpage>. <pub-id pub-id-type="pmid">16644656</pub-id></mixed-citation></ref><ref id="pone.0169666.ref002"><label>2</label><mixed-citation publication-type="journal"><name><surname>Zeitler</surname><given-names>P</given-names></name>, <name><surname>Fu</surname><given-names>J</given-names></name>, <name><surname>Tandon</surname><given-names>N</given-names></name>, <name><surname>Nadeau</surname><given-names>K</given-names></name>, <name><surname>Urakami</surname><given-names>T</given-names></name>, <name><surname>Barrett</surname><given-names>T</given-names></name>, <etal>et al</etal><article-title>ISPAD Clinical Practice Consensus Guidelines 2014 Compendium</article-title>. <source>Pediatr Diabetes</source><year>2015</year>;<volume>16</volume>(<issue>5</issue>):<fpage>392</fpage>–<lpage>392</lpage>.<pub-id pub-id-type="pmid">26153026</pub-id></mixed-citation></ref><ref id="pone.0169666.ref003"><label>3</label><mixed-citation publication-type="other">Federation ID. IDF diabetes atlas. Brussels: International Diabetes Federation 2013.</mixed-citation></ref><ref id="pone.0169666.ref004"><label>4</label><mixed-citation publication-type="journal"><name><surname>Wilson</surname><given-names>JF</given-names></name>. <article-title>Diabetic ketoacidosis</article-title>. <source>Ann Intern Med</source><year>2010</year>;<volume>152</volume>(<issue>1</issue>):<fpage>ITC1</fpage>–<lpage>1</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.7326/0003-4819-152-1-201001050-01001">10.7326/0003-4819-152-1-201001050-01001</ext-link></comment><pub-id pub-id-type="pmid">20048266</pub-id></mixed-citation></ref><ref id="pone.0169666.ref005"><label>5</label><mixed-citation publication-type="journal"><name><surname>Kitabchi</surname><given-names>AE</given-names></name>, <name><surname>Umpierrez</surname><given-names>GE</given-names></name>, <name><surname>Miles</surname><given-names>JM</given-names></name>, <name><surname>Fisher</surname><given-names>JN</given-names></name>. <article-title>Hyperglycemic crises in adult patients with diabetes</article-title>. <source>Diabetes Care</source><year>2009</year><month>7</month>;<volume>32</volume>(<issue>7</issue>):<fpage>1335</fpage>–<lpage>1343</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.2337/dc09-9032">10.2337/dc09-9032</ext-link></comment><pub-id pub-id-type="pmid">19564476</pub-id></mixed-citation></ref><ref id="pone.0169666.ref006"><label>6</label><mixed-citation publication-type="journal"><name><surname>Van Zyl</surname><given-names>DG</given-names></name>. <article-title>Diagnosis and treatment of diabetic ketoacidosis</article-title>. <source>South African Family Practice</source><year>2008</year>;<volume>50</volume>(<issue>1</issue>):<fpage>35</fpage>–<lpage>39</lpage>.</mixed-citation></ref><ref id="pone.0169666.ref007"><label>7</label><mixed-citation publication-type="journal"><name><surname>Usher-Smith</surname><given-names>J</given-names></name>, <name><surname>Thompson</surname><given-names>M</given-names></name>, <name><surname>Ercole</surname><given-names>A</given-names></name>, <name><surname>Walter</surname><given-names>F</given-names></name>. <article-title>Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review</article-title>. <source>Diabetologia</source><year>2012</year>;<volume>55</volume>(<issue>11</issue>):<fpage>2878</fpage>–<lpage>2894</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1007/s00125-012-2690-2">10.1007/s00125-012-2690-2</ext-link></comment><pub-id pub-id-type="pmid">22933123</pub-id></mixed-citation></ref><ref id="pone.0169666.ref008"><label>8</label><mixed-citation publication-type="journal"><name><surname>Murunga</surname><given-names>A</given-names></name>, <name><surname>Owira</surname><given-names>P</given-names></name>. <article-title>Diabetic ketoacidosis: an overlooked child killer in sub‐Saharan Africa?</article-title><source>Tropical Medicine & International Health</source><year>2013</year>;<volume>18</volume>(<issue>11</issue>):<fpage>1357</fpage>–<lpage>1364</lpage>.<pub-id pub-id-type="pmid">24112393</pub-id></mixed-citation></ref><ref id="pone.0169666.ref009"><label>9</label><mixed-citation publication-type="journal"><name><surname>Majaliwa</surname><given-names>ES</given-names></name>, <name><surname>Mohn</surname><given-names>A</given-names></name>, <name><surname>Chiavaroli</surname><given-names>V</given-names></name>, <name><surname>Ramaiya</surname><given-names>K</given-names></name>, <name><surname>Swai</surname><given-names>AB</given-names></name>, <name><surname>Chiarelli</surname><given-names>F</given-names></name>. <article-title>Management of diabetic ketoacidosis in children and adolescents in sub Saharan Africa: a review</article-title>. <source>East Afr Med J</source><year>2010</year>;<volume>87</volume>(<issue>4</issue>):<fpage>167</fpage>–<lpage>173</lpage>. <pub-id pub-id-type="pmid">23057293</pub-id></mixed-citation></ref><ref id="pone.0169666.ref010"><label>10</label><mixed-citation publication-type="journal"><name><surname>Onyiriuka</surname><given-names>AN</given-names></name>, <name><surname>Ifebi</surname><given-names>E</given-names></name>. <article-title>Ketoacidosis at diagnosis of type 1 diabetes in children and adolescents: frequency and clinical characteristics</article-title>. <source>Journal of Diabetes & Metabolic Disorders</source><year>2013</year>;<volume>12</volume>(<issue>1</issue>):<fpage>1</fpage>.<pub-id pub-id-type="pmid">23497470</pub-id></mixed-citation></ref><ref id="pone.0169666.ref011"><label>11</label><mixed-citation publication-type="journal"><name><surname>Fantahun</surname><given-names>GE</given-names></name>. <article-title>A prevalence of diabetic ketoacidosis in newly diagnosed diabetes mellitus pediatric patients in Tikur Anbesa specialized hospital</article-title>. <source>Ethiopian Journal of Pediatrics and Child Health</source><year>2008</year>;<volume>4</volume>(<issue>1</issue>).</mixed-citation></ref><ref id="pone.0169666.ref012"><label>12</label><mixed-citation publication-type="journal"><name><surname>Ibekwe</surname><given-names>MU</given-names></name>, <name><surname>Ibekwe</surname><given-names>RC</given-names></name>. <article-title>Pattern of type 1 diabetes mellitus in Abakaliki, Southeastern Nigeria</article-title>. <source>Pediatric Oncall</source><year>2011</year>;<volume>8</volume>(<issue>7</issue>):<fpage>99</fpage>.</mixed-citation></ref><ref id="pone.0169666.ref013"><label>13</label><mixed-citation publication-type="other">Federal Democratic Republic of Ethiopia, Central Statistical Agency. Population Projection of Ethiopia for All Regions at Wereda Level from 2014–2017. Addis Ababa, Ethiopia. 2013.</mixed-citation></ref><ref id="pone.0169666.ref014"><label>14</label><mixed-citation publication-type="journal"><name><surname>Marigliano</surname><given-names>M</given-names></name>, <name><surname>Morandi</surname><given-names>A</given-names></name>, <name><surname>Maschio</surname><given-names>M</given-names></name>, <name><surname>Costantini</surname><given-names>S</given-names></name>, <name><surname>Contreas</surname><given-names>G</given-names></name>, <name><surname>D'Annunzio</surname><given-names>G</given-names></name>, <etal>et al</etal><article-title>Diabetic ketoacidosis at diagnosis: role of family history and class II HLA genotypes</article-title>. <source>Eur J Endocrinol</source><year>2012</year><month>12</month><day>10</day>;<volume>168</volume>(<issue>1</issue>):<fpage>107</fpage>–<lpage>111</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1530/EJE-12-0541">10.1530/EJE-12-0541</ext-link></comment><pub-id pub-id-type="pmid">23065995</pub-id></mixed-citation></ref><ref id="pone.0169666.ref015"><label>15</label><mixed-citation publication-type="journal"><name><surname>Razavi</surname><given-names>Z</given-names></name>. <article-title>Frequency of ketoacidosis in newly diagnosed type 1 diabetic children</article-title>. <source>Oman Med J</source><year>2010</year>;<volume>25</volume>(<issue>2</issue>):<fpage>114</fpage>–<lpage>117</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.5001/omj.2010.31">10.5001/omj.2010.31</ext-link></comment><pub-id pub-id-type="pmid">22125712</pub-id></mixed-citation></ref><ref id="pone.0169666.ref016"><label>16</label><mixed-citation publication-type="journal"><name><surname>Reddy</surname><given-names>Y</given-names></name>, <name><surname>Ganie</surname><given-names>Y</given-names></name>, <name><surname>Pillay</surname><given-names>K</given-names></name>. <article-title>Characteristics of children presenting with newly diagnosed type 1 diabetes</article-title>.<source>South African Journal of Child Health</source><year>2013</year>;<volume>7</volume>(<issue>2</issue>):<fpage>46</fpage>–<lpage>48</lpage>.</mixed-citation></ref><ref id="pone.0169666.ref017"><label>17</label><mixed-citation publication-type="journal"><name><surname>Mbugua</surname><given-names>P</given-names></name>, <name><surname>Otieno</surname><given-names>C</given-names></name>, <name><surname>Kayima</surname><given-names>J</given-names></name>, <name><surname>Amayo</surname><given-names>A</given-names></name>, <name><surname>McLigeyo</surname><given-names>S</given-names></name>. <article-title>Diabetic ketoacidosis: clinical presentation and precipitating factors at Kenyatta National Hospital, Nairobi</article-title>. <source>East Afr Med J</source><year>2005</year>;<volume>82</volume>(<issue>12</issue>).</mixed-citation></ref><ref id="pone.0169666.ref018"><label>18</label><mixed-citation publication-type="journal"><name><surname>Dabelea</surname><given-names>D</given-names></name>, <name><surname>Rewers</surname><given-names>A</given-names></name>, <name><surname>Stafford</surname><given-names>JM</given-names></name>, <name><surname>Standiford</surname><given-names>DA</given-names></name>, <name><surname>Lawrence</surname><given-names>JM</given-names></name>, <name><surname>Saydah</surname><given-names>S</given-names></name>, <etal>et al</etal><article-title>Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study</article-title>. <source>Pediatrics</source><year>2014</year><month>4</month>;<volume>133</volume>(<issue>4</issue>):<fpage>e938</fpage>–<lpage>45</lpage>. <comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1542/peds.2013-2795">10.1542/peds.2013-2795</ext-link></comment><pub-id pub-id-type="pmid">24685959</pub-id></mixed-citation></ref><ref id="pone.0169666.ref019"><label>19</label><mixed-citation publication-type="journal"><name><surname>Usher-Smith</surname><given-names>JA</given-names></name>, <name><surname>Thompson</surname><given-names>MJ</given-names></name>, <name><surname>Sharp</surname><given-names>SJ</given-names></name>, <name><surname>Walter</surname><given-names>FM</given-names></name>. <article-title>Factors associated with the presence of diabetic ketoacidosis at diagnosis of diabetes in children and young adults: a systematic review</article-title>. <source>BMJ</source><year>2011</year><month>7</month><day>7</day>;<volume>343</volume>:<fpage>d4092</fpage><comment>doi: <ext-link ext-link-type="uri" xlink:href="http://dx.doi.org/10.1136/bmj.d4092">10.1136/bmj.d4092</ext-link></comment><pub-id pub-id-type="pmid">21737470</pub-id></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/SidaSubSaharaV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 002938 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 002938 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Sante
|area= SidaSubSaharaV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé= PMC:5279745
|texte= Clinical Characteristics of Diabetic Ketoacidosis in Children with Newly Diagnosed Type 1 Diabetes in Addis Ababa, Ethiopia: A Cross-Sectional Study
}}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/RBID.i -Sk "pubmed:28135278" \
| HfdSelect -Kh $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd \
| NlmPubMed2Wicri -a SidaSubSaharaV1
| This area was generated with Dilib version V0.6.32. |  |