title: Variation between countries in the frequency of diabetic ketoacidosis at first presentation of type 1 diabetes in children: a systematic review.
abstract: OBJECTIVE
  Type 1 diabetes is the most frequent endocrine disease in children, with 65,000 children diagnosed worldwide every year. Up to 80% of these children present with diabetic ketoacidosis (DKA), which is associated with both short-term risks and long-term consequences. This study aimed to characterise the worldwide variation in presentation of type 1 diabetes to inform future interventions to reduce this excess morbidity and mortality.
  
  
  METHODS
  This was a systematic review of studies indexed on PubMed, EMBASE, Web of Science, Scopus or CINAHL before March 2011 that included unselected groups of children presenting with new-onset type 1 diabetes, reported the proportion presenting with DKA and used a definition of DKA based on measurement of pH or bicarbonate.
  
  
  RESULTS
  Sixty-five studies of cohorts comprising over 29,000 children in 31 countries were included. The frequency of DKA at diagnosis ranged from 12.8% to 80%, with highest frequencies in the United Arab Emirates, Saudi Arabia and Romania, and the lowest in Sweden, the Slovak Republic and Canada. Multivariable modelling showed the frequency of DKA was inversely associated with gross domestic product, latitude and background incidence of type 1 diabetes.
  
  
  CONCLUSIONS
  This is the first description of the variation in frequency of DKA at presentation of type 1 diabetes in children across countries. It demonstrates large variations that may, at least in part, be explained by different levels of disease awareness and healthcare provision and suggests ways to decrease the excess morbidity and mortality associated with DKA at diagnosis.
authors.affiliation: The Primary Care Unit, Department of Public Health and Primary Care, Strangeways Research Laboratory, University of Cambridge, Worts Causeway, Cambridge CB1 8RN, UK. Juliet.usher-smith@cantab.net
authors.forename: J A
authors.initials: JA
authors.lastname: Usher-Smith
authors.forename: M
authors.initials: M
authors.lastname: Thompson
authors.forename: A
authors.initials: A
authors.lastname: Ercole
authors.forename: F M
authors.initials: FM
authors.lastname: Walter
mesh_terms: D002648:Child; D003922:Diabetes Mellitus, Type 1 / Q000453:epidemiology*; D016883:Diabetic Ketoacidosis / Q000453:epidemiology*; D014943:Global Health; D006801:Humans; D015994:Incidence; D009017:Morbidity