부산대학교 도서관

Enora Le Bec,1 Madibele Kam,2 Sigiriya Aebischer Perone,3,4 Philippa Boulle,5 Justin Cirhuza Cikomola,6 Maria Eugenia Gandur,5 Mario Gehri,7 Sylvia Kehlenbrink,8 David Beran3,9 1Internal Medicine, Etablissements Hospitaliers du Nord Vaudois, Yverdon, Switzerland; 2Pediatric University Hospital Charles de Gaulle, Ouagadougou, Burkina Faso; 3Division of Tropical and Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland; 4Health Unit, International Committee of the Red Cross, Geneva, Switzerland; 5Médecins sans Frontières, Geneva, Switzerland; 6Faculty of Medicine, Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo; 7Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland; 8Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, USA; 9Faculty of Medicine, University of Geneva, Geneva, SwitzerlandCorrespondence: Enora Le Bec, Hôpital d’Yverdon-les-Bains, Rue d’Entremonts 11, Yverdon-les-Bains, 1400, Switzerland, Tel +41 24 424 44 44, Fax +41 24 424 43 60, Email enora.lebec@gmail.comAbstract: Lack of awareness, access to insulin and diabetes care can result in high levels of morbidity and mortality for children with type 1 diabetes (T1DM) in sub-Saharan Africa (SSA). Improvements in access to insulin and diabetes management have improved outcomes in some settings. However, many people still present in diabetic ketoacidosis (DKA) in parallel to misdiagnosis of children with T1DM in contexts with high rates of communicable diseases. The aim of this study was to highlight the complexity of diagnosing pediatric T1DM in a healthcare environment dominated by infectious diseases and lack of adequate health system resources. This was done by developing clinical vignettes and recreating the hypothetico-deductive process of a clinician confronted with DKA in the absence of identification of pathognomonic elements of diabetes and with limited diagnostic tools. A non-systematic literature search for T1DM and DKA in SSA was conducted and used to construct clinical vignettes for children presenting in DKA. A broad differential diagnosis of the main conditions present in SSA was made, then used to construct a clinician’s medical reasoning, and anticipate the results of different actions on the diagnostic process. An examination of the use of the digital based Integrated Management of Childhood Illness diagnostic algorithm was done, and an analysis of the software’s efficiency in adequately diagnosing DKA was assessed. The main obstacles to diagnosis were low specificity of non-pathognomonic DKA symptoms and lack of tools to measure blood or urine glucose. Avenues for improvement include awareness of T1DM symptomatology in communities and health systems, and greater availability of diagnostic tests. Through this work clinical vignettes are shown to be a useful tool in analyzing the obstacles to underdiagnosis of diabetes, a technique that could be used for other pathologies in limited settings, for clinical teaching, research, and advocacy.Keywords: type 1 diabetes, underdiagnosis, sub-Saharan Africa, clinical vignette