2. Harrower AD, Murray A, Campbell IW, Murray A, Neilson JM, Clarke BF.
fect and that some residual correlation between heart rate
The value of continuous ECG monitoring during treatment of diabetic keto-
acidosis: a computer study. Acta Diabetol Lat. 1978;15(1-2):88-94.
3. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, chil-
dren, and adolescents: a consensus statement from the American Diabetes
Association. Diabetes Care. 2006;29(5):1150-1159.
4. Andrássy G. The Effect of Different Stressors on the QT Interval and the T Wave
[doctoral dissertation]. Budapest, Hungary: Semmelweis University, School
of Medicine; 2007:115. http://phd.sote.hu/mwp/phd_live/vedes/export
/andrassygabor.d.pdf. Accessed July 21, 2008.
5. Davey P. A new physiological method for heart rate correction of the QT interval.
Heart. 1999;82(2):183-186.
In reply
The letter by Drs Szabo and Andrássy highlights 2 points:
(1) mental stress rather than ketosis could account for QTc
prolongation during DKA and (2) the Bazett formula can
be inaccurate, particularly at elevated heart rates. The ref-
erence that Szabo and Andrássy cite regarding the effect of
mental stress on QTc appears to be a non–peer-reviewed doc-
toral thesis.1 Furthermore, in our article,2 we acknowledge
the controversy regarding how to best adjust the QT inter-
val for heart rate. We selected the Bazett method, as it is
the one most commonly used in practice, despite known in-
tersubject variability in the QT/RR relation.3
Szabo and Andrássy also reference an article published
30 years ago (not 20, as stated) documenting 2 (ie, not “rare”)
minor arrhythmias in 14 patients (mainly adults) with DKA
who underwent continuous ECG monitoring4; QT intervals
were not reported in that study. Furthermore, Szabo and An-
drássy reference the American Diabetes Association con-
sensus statement on pediatric DKA and suggest that the state-
ment indicates that ECG changes during DKA result only
from abnormalities in serum potassium.5 As the senior au-
thor of our article (N.G.) is one of the authors of the Ameri-
can Diabetes Association statement, we can say that its aim
was not to implicate potassium abnormalities as the sole fac-
tors that cause ECG abnormalities during DKA. The con-
nection between ketosis and prolonged QTc was not men-
tioned in that statement because our work was not yet
published. Abnormalities in electrolytes could not have ac-
counted for the prolonged QTc observed in our study.
Szabo and Andrássy’s suggestion that psychological stress
may have played a more prominent role than ketosis in our
ECG findings is interesting. Our patients, however, were chil-
dren with severe acidosis and dehydration. The work cited
by Szabo and Andrássy, in contrast, assessed mostly healthy
adult volunteers. We documented a strong correlation of ke-
tosis (anion gap) with QTc prolongation. Ketosis was in-
dependently associated with QTc prolongation after fur-
ther adjusting for age and heart rate (beyond the Bazett
formula). The plausibility of variations in mental stress dur-
ing DKA resulting in alterations of QTc is unclear, particu-
larly because most children with DKA are lethargic and som-
nolent during much of the initial therapy. Furthermore, most
stress hormones (ie, “adrenaline levels,” as suggested by
Szabo and Andrássy) are typically elevated during DKA ow-
ing to acidosis and dehydration, regardless of mental stress.
Finally, Szabo and Andrássy suggest that the Bazett for-
mula is imprecise for measuring the QTc. In our article,1
we acknowledge the controversy surrounding measures of
QTc and state that “currently available formulas for cor-
recting QT interval measurements for heart rate are imper-
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93
©2009 American Medical Association. All rights reserved.
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and QT interval may persist, despite the application of for-
mulas for correction.” Finally, we state in our article and
reemphasize that, “It is highly unlikely, however, that tachy-
cardia during DKA is the sole or even a main factor respon-
sible for QTc prolongation during DKA because subanaly-
ses did not demonstrate a significant correlation between heart
rate and QTc and because multivariable analyses demon-
strated a persistent significant association between the an-
ion gap and QTc prolongation, after adjusting for age and
heart rate.”
Nathan Kuppermann, MD, MPH
Jeanny Park, MD
Nicole Glaser, MD
Correspondence: Dr Kuppermann, Departments of Pe-
diatrics and Emergency Medicine, University of Califor-
nia–Davis Medical Center, 2315 Stockton Blvd, PSSB Bldg,
Ste 2100, Sacramento, CA 95817 (nkuppermann@ucdavis
.edu).
Author Contributions: Study concept and design: Kup-
permann, Park, and Glaser. Acquisition of data: Kupper-
mann and Glaser. Analysis and interpretation of data: Kup-
permann, Park, and Glaser. Drafting of the manuscript:
Kuppermann. Critical revision of the manuscript for im-
portant intellectual content: Park and Glaser. Statistical
analysis: Kuppermann and Glaser. Obtained funding: Gla-
ser. Administrative, technical, and material support: Park.
Study supervision: Kuppermann and Glaser.
Financial Disclosure: None reported.
1. Andrássy G. The Effect of Different Stressors on the QT Interval and the T Wave
[doctoral dissertation]. Budapest, Hungary: Semmelweis University, School
of Medicine; 2007:115. http://phd.sote.hu/mwp/phd_live/vedes/export
/andrassygabor.d.pdf. Accessed July 21, 2008.
2. Kuppermann N, Park J, Glatter K, Marcin JP, Glaser NS. Prolonged QT in-
terval corrected for heart rate during diabetic ketoacidosis in children. Arch
Pediatr Adolesc Med. 2008;162(6):544-549.
3. Malik M, Farbom P, Batchvarov V, Hnatkova K, Camm A. Relation between
QT and RR intervals is highly individual among healthy subjects: implica-
tions for heart rate correction of the QT interval. Heart. 2002;87(3):220-228.
4. Harrower AD, Campbell IW, Ewing DJ, Murray A, Neilson JM, Clarke BF.
The value of continuous ECG monitoring during treatment of diabetic keto-
acidosis: a computer study. Acta Diabetol Lat. 1978;15(1-2):88-94.
5. Wolfsdorf J, Glaser N, Sperling MA. Diabetic ketoacidosis in infants, chil-
dren, and adolescents: a consensus statement from the American Diabetes
Association. Diabetes Care. 2006;29(5):1150-1159.
Language Matters: Unintentional
Strangulation, Strangulation Activity, and
the “Choking Game”
A recent study reported that 82 American youths
aged 6 to 19 years had died of unintentional
strangling while “playing the choking game”
from 1995 to 2007.1 To that article’s recommendations,
we propose an additional recommendation to further cur-
tail unintentional strangulation mortality. We propose
referring to behaviors that might lead to death from un-
intentional strangulation as strangulation activity rather
than playing the choking game.
As defined in that article,1 the choking game is “self-
strangulation or strangulation by another person with the
hands or a noose to achieve a brief euphoric state caused
WWW.ARCHPEDIATRICS.COM
 by cerebral hypoxia.” Other articles in the scientific lit-
erature and news and entertainment media have re-
ferred to those same behaviors as the choking game or by
such terms as space monkey or pass-out game,2,3 because
these are terms that youths who engage in these behav-
iors use to describe them.
For public health practitioners, health care provid-
ers, parents, and the media to copy that playful lan-
guage, however, downplays the lethal risk associated with
these behaviors. Games are fun; people play games an-
ticipating pleasure, not death. In describing this or any
other potentially risky behavior, straightforward lan-
guage that reinforces the message that intentional chok-
ing and other risky behaviors might lead to death is war-
ranted.
The importance of language in the prevention and con-
trol of other injuries has been recognized. For example,
using the term accident to describe a motor vehicle crash
obfuscates that crashes and resulting injuries are often
predictable and preventable.4 People might be more in-
clined to take measures to avoid a crash rather than an
accident.4 Similarly, to avoid the connotation that death
is a favorable outcome of a suicide attempt, the media
has been urged to refer to completed suicides as suicide
deaths rather than successful suicide attempts.5 Likewise,
youths might be more careful about engaging in a be-
havior called strangulation activity than they would be
in playing a game.
Kenneth A. Katz, MD, MSc, MSCE
Robin L. Toblin, PhD, MPH
Correspondence: Dr Toblin, Centers for Disease Con-
trol and Prevention, National Center for Injury Preven-
tion and Control, Division of Unintentional Injury Pre-
vention, 4770 Buford Hwy, MS F-62, Atlanta, GA 30341
(rtoblin@cdc.gov).
Author Contributions: Study concept and design: Katz
and Toblin. Analysis and interpretation of data: Katz and
Toblin. Drafting of the manuscript: Katz and Toblin. Criti-
cal revision of the manuscript for important intellectual con-
tent: Katz and Toblin.
Financial Disclosure: None reported.
Disclaimer: The findings and conclusions in this article
are the authors’ and do not necessarily represent the views
of the Centers for Disease Control and Prevention or the
San Francisco Department of Public Health.
1. Centers for Disease Control and Prevention. Unintentional strangulation deaths
from the “choking game” among youths aged 6-19 years: United States,
1995–2007. MMWR Morb Mortal Wkly Rep. 2008;57(6):141-144.
2. Centre for Addiction and Mental Health. The 2007 OSDUHS Mental Health
and Well-Being Report Executive Summary. Toronto, ON: Centre for Addic-
tion and Mental Health; 2008. http://www.camh.net/News_events/News
_releases_and_media_advisories_and_backgrounders/ExecSummaryMH2007
_English_Final.pdf. Accessed May 30, 2008.
3. Johnson K. Teenager casts light on a shadowy game. The New York Times. March
28, 2007. http://www.nytimes.com/2007/03/28/us/28risk.html?_r=2&scp=5&sq=
%22choking+game%22&st=nyt&oref= slogin&oref=slogin. Accessed May 30,
2008.
4. Davis RM, Pless B. BMJ bans “accidents.” BMJ. 2001;322(7298):1320-1321.
5. Centers for Disease Control and Prevention, National Institute of Mental Health,
Office of the Surgeon General, Substance Abuse and Mental Health Services Ad-
ministration, American Foundation for Suicide Prevention, American Associa-
tion of Suicidology, Annenberg Public Policy Center. Reporting on Suicide: Rec-
ommendations for the Media. Philadelphia, PA: Annenberg Public Policy Center;
2001. http://www.sprc.org/library/sreporting.pdf. Accessed August 10, 2008.

Announcement

Submissions. The Editors welcome contributions to

Picture of the Month. Submissions should describe
common problems presenting uncommonly, rather than
total zebras. Cases should be of interest to practicing
pediatricians, highlighting problems that they are likely
to at least occasionally encounter in the office or hospi-
tal setting. High-quality clinical images (in either 35-mm
slide or electronic format) along with parent or patient
permission to use these images must accompany the sub-
mission. The entire discussion should comprise no more
than 750 words. Articles and photographs accepted for
publication will bear the contributor’s name. There is no
charge for reproduction and printing of color illustra-
tions. For details regarding electronic submission, please
see: http://archpedi.ama-assn.org.

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