Diabetes incidence in 0- to 14-year age-group in Italy: a 10-year prospective study

Continuous improvement of quality of care in pediatric diabetes: the ISPED CARD clinical registry

AIM

In Italy, the ISPED CARD initiative was launched to measure and improve quality of care in children and adolescents with type 1 diabetes.

METHODS

Process and outcome indicators and the related information derived from electronic medical records were identified. A network of pediatric diabetes centers was created on a voluntary basis.

RESULTS

Overall, 20 centers provided data on 3284 patients aged <  = 18 years. HbA1c was monitored ≥ 2/year in 81.2% of the cases. BMI was monitored ≥ 1/year in 99.0%, lipid profile in 45.3%, and blood pressure in 91.7%. Pubertal status, albuminuria, eye examination, and screening of celiac disease and thyroiditis were underreported. From 2017 to 2021, average HbA1c levels decreased from 7.8 ± 1.2 to 7.6 ± 1.3%, while patients with LDL cholesterol > 100 mg/dl increased from 18.9 to 36.7%. Prevalence of patients with elevated blood pressure and BMI/SDS values also increased. In 2021, 44.7% of patients were treated with the newest basal insulins, while use of regular human insulin had dropped to 7.7%. Use of insulin pump remained stable (37.9%).

CONCLUSIONS

This report documents the feasibility of the ISPED CARD initiative and shows lights and shadows in the care provided. Improving care, increasing number of centers, and ameliorating data recording represent future challenges.

Trends and cyclic variation in the incidence of childhood type 1 diabetes in two Italian regions over 33 years and during the COVID-19 pandemic

AIM

There is conflicting evidence about the impact of the COVID-19 pandemic on the incidence of type 1 diabetes. Here, we analysed long-term trends in the incidence of type 1 diabetes in Italian children and adolescents from 1989 to 2019 and compared the incidence observed during the COVID-19 pandemic with that estimated from long-term data.

MATERIALS AND METHODS

This was a population-based incidence study using longitudinal data from two diabetes registries in mainland Italy. Trends in the incidence of type 1 diabetes from 1 January 1989 to 31 December 2019 were estimated using Poisson and segmented regression models.

RESULTS

There was a significant increasing trend in the incidence of type 1 diabetes of 3.6% per year [95% confidence interval (CI): 2.4-4.8] between 1989 and 2003, a breakpoint in 2003, and then a constant incidence until 2019 (0.5%, 95% CI: -1.3 to 2.4). There was a significant 4-year cycle in incidence over the entire study period. The rate observed in 2021 (26.7, 95% CI: 23.0-30.9) was significantly higher than expected (19.5, 95% CI: 17.6-21.4; p = .010).

CONCLUSION

Long-term incidence analysis showed an unexpected increase in new cases of type 1 diabetes in 2021. The incidence of type 1 diabetes now needs continuous monitoring using population registries to understand better the impact of COVID-19 on new-onset type 1 diabetes in children.

Increasing trend of type 1 diabetes incidence in the pediatric population of the Calabria region in 2019-2021

BACKGROUND

Although type 1 diabetes (T1D) represents one of the most common chronic diseases in pediatric age, few studies on the epidemiology of T1D exist globally and the exact prevalence and incidence rates of the disease are unknown. In many countries, including Italy, national registries are missing.

METHODS

This study aims to assess T1D incidence in the pediatric population of the Calabria region (southern Italy) in the period 2019-2021. The secondary objective was to describe the main demographical, clinical and immunological features of incident cases. Case ascertainment and all clinical data were assessed by retrospectively reviewing the electronic medical records of children and adolescents diagnosed with diabetes at any Pediatric Diabetes Center belonging to the Rete Diabetologica Calabrese (Calabria Region Diabetes Network), from January 2019 to December 2021. The incidence of T1D was estimated for the entire region and was stratified according to age group (0-4 years, 5-9 years, and 10-14 years) and gender. Standardized incidence ratios for each province in the region were also calculated.

RESULTS

The crude incidence of T1D was 20.6/100,000 person/years. Incidence rates were higher among females and children aged 5-9 years. The crude incidence of T1D was higher in the province of Reggio Calabria (26.5/100,000 person-years). The provinces of Crotone, Catanzaro, and Vibo Valentia showed significantly lower standardized incidence ratios. The annual incidence in the region progressively increased by 43% during the study period.

CONCLUSIONS

Our study revealed a relatively high incidence in the Calabria region. The marked increasing incidence trend over the past two years could be related to the global impact of the COVID-19 pandemic, but further long-scale population-based studies are needed to confirm these findings.

The Silent Epidemic of Diabetic Ketoacidosis at Diagnosis of Type 1 Diabetes in Children and Adolescents in Italy During the COVID-19 Pandemic in 2020

AIM/HYPOTHESIS

To compare the frequency of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes in Italy during the COVID-19 pandemic in 2020 with the frequency of DKA during 2017-2019.

METHODS

Forty-seven pediatric diabetes centers caring for >90% of young people with diabetes in Italy recruited 4,237 newly diagnosed children with type 1 diabetes between 2017 and 2020 in a longitudinal study. Four subperiods in 2020 were defined based on government-imposed containment measures for COVID-19, and the frequencies of DKA and severe DKA compared with the same periods in 2017-2019.

RESULTS

Overall, the frequency of DKA increased from 35.7% (95%CI, 33.5-36.9) in 2017-2019 to 39.6% (95%CI, 36.7-42.4) in 2020 (p=0.008), while the frequency of severe DKA increased from 10.4% in 2017-2019 (95%CI, 9.4-11.5) to 14.2% in 2020 (95%CI, 12.3-16.4, p<0.001). DKA and severe DKA increased during the early pandemic period by 10.4% (p=0.004) and 8% (p=0.002), respectively, and the increase continued throughout 2020. Immigrant background increased and high household income decreased the probability of presenting with DKA (OR: 1.55; 95%CI, 1.24-1.94; p<0.001 and OR: 0.60; 95 CI, 0.41-0.88; p=0.010, respectively).

CONCLUSIONS/INTERPRETATION

There was an increase in the frequency of DKA and severe DKA in children newly diagnosed with type 1 diabetes during the COVID-19 pandemic in 2020, with no apparent association with the severity of COVID-19 infection severity or containment measures. There has been a silent outbreak of DKA in children during the pandemic, and preventive action is required to prevent this phenomenon in the event of further generalized lockdowns or future outbreaks.

Incidence of diabetes mellitus in Italy in year 2018. A nationwide population-based study of the ARNO Diabetes Observatory

BACKGROUNDS AND AIMS

To assess incidence of diabetes in Italy in 2018 by the use of administrative claims from several million residents. Differences in rates in men and women across decades of age were investigated. Incident rates of insulin or noninsulin treated subjects were also examined.

METHODS AND RESULTS

We analyzed administrative healthcare claims of 11,300,750 subjects monitored by the ARNO Diabetes Observatory. Incident cases of diabetes were identified by glucose lowering drug prescriptions, disease-specific co-payment exemptions and hospital discharge codes related to diabetes occurring in 2018 but not in 2017. We identified 697,208 subjects with ascertained diabetes. Incident cases were 65,932, with a rate of 5.83 per 1000 person-years (p-y). Incidence of drug-treated diabetes (n = 60,271) was 5.33 per 1000 p-y. Subjects receiving only insulin prescriptions were 5652 (rate 0.50 per 1000 p-y) and those receiving only prescriptions of noninsulin medications were 51,085 (rate 4.52 per 1000 p-y). Incidence rates progressively increased across decades until age 80 and then dropped by 25-30%. Overall, incident rates were generally higher in women aged 11-40 and in men aged ≥51.

CONCLUSIONS

Recent cases represented ~10% of the population of diabetic subjects. Incidence of noninsulin-treated diabetes was almost 10-fold higher than incidence of insulin-treated diabetes. Substantial differences in incidence rates were observed in men and women of several decades of age: women more affected in adolescence and young adult age, men more affected in mature and advanced age. These data provide further understanding on the epidemiological burden of the disease in Italy.

Socioeconomic Inequalities Increase the Probability of Ketoacidosis at Diagnosis of Type 1 Diabetes: A 2014-2016 Nationwide Study of 2,679 Italian Children

This study aims to compare the frequency of Diabetic Ketoacidosis (DKA) at diagnosis in 2014-2016 with the one previously reported in 2004-2013; and to assess the association between family socioeconomic status and DKA at type 1 diabetes (T1D) diagnosis in children <15 years of age from 2014 to 2016. Methods: This nationwide, population-based, observational study included 2,679 children diagnosed with T1D from 54 Italian centers for pediatric diabetes during 2014-2016. The ISPAD criteria for DKA were used as a standard reference. The overall and by age frequency of DKA between the two time periods were compared. The association between family socioeconomic status and DKA was assessed using multiple logistic regression analysis. Results: Nine hundred and eighty nine children had DKA (36.9, 95% CI: 35.1-38.8). The frequency of DKA was significantly lower in 2014-2016 in comparison to 2004-2013 (40.3, 95% CI: 39.3-41.4, p = 0.002). The probability of having DKA at diagnosis was lower in mothers with a high level of education (OR = 0.69, 95% CI: 0.51-0.93) or a high level of occupation (OR = 0.76, 95% CI: 0.58 0.99), and in fathers with a high level of occupation (OR = 0.72, 95% CI: 0.55-0.94). Children living in Southern Italy had a higher probability of diagnosis with severe DKA than children living in Central Italy. Conclusion: There was a decrease in the frequency of DKA in children diagnosed with T1D under 15 years of age during 2014-2016. However, DKA frequency remains unacceptably high. This study demonstrated that socioeconomic inequalities, measured as low education and occupational levels, were associated with an increased probability of DKA at T1D diagnosis.

Global and regional estimates of the morbidity due to type I diabetes among children aged 0-4 years: a systematic review and analysis

Background

Epidemiology of type 1 diabetes mellitus (T1DM) among children aged 0-4 years globally is not well understood. We aim to assess the incidence of T1DM in low- and middle-income countries (LMIC) by conducting a systematic review of previous reports. We also aim to address possible contribution to child mortality and to identify any temporal trends.

Methods

A systematic review was performed using a carefully designed search strategy to explore MEDLINE, EMBASE and Global Health databases. Data was extracted from all studies that satisfied the inclusion criteria –a total of 83 records extracted from 26 830 sources that were analysed. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process to assess quality of evidence and applied meta-analysis approaches to assess global and regional incidence and time trends.

Results

The overall pooled incidence of T1DM in children aged 0-4 years globally is 11.2 (95% CI = 10.0-12.3) per 100 000 child years. The regional incidence were the highest for European Region A (EUR A) at 15.5 (95% CI = 13.5-17.5) per 100 000 child years. EUR C had the incidence of 10.0 (95% CI = 6.5-13.6) and EUR B 5.8 (95% CI = 4.7-7.0), Region of the Americas A (AMR A) 11.4 (95% CI = 7.8-14.9), AMR B of 2.5 (95% CI = 0.2-4.8), Eastern Mediterranean Region (EMR B) 7.1 (95% CI = 4.2-10.0) and Western Pacific Region (WPR A) 7.0 (95% CI = 2.9-11.0) per 100 000 child years, while other regions had very low rates or no data. When data points were categorised in the study periods and re-analysed, an increasing trend of the T1DM incidence was observed, with the incidence of 20.9 (95% CI = 7.8-34.1) per 100 000 child years in the years 2010-2015, preceded by 13.2 (95% CI = 11.0-15.5) in 2000-2009 study period, 10.0 (95% CI = 8.4-11.7) in 1990-1999 and 8.3 (95% CI = 5.1-11.6) in 1980-1989, respectively. Although the data are scarce, and variation and uncertainty are large, we estimated that the number of new cases of T1DM among children aged 0-4 years in the world each year is between 100 000 and 150 000.

Conclusions

The identified large variation in incidence estimates for different parts of the world, along with scarcity of information and the identified strong temporal increase in T1DM incidence suggest a clear need for further research into this subject.

Disordered eating behaviors in adolescents with type 1 diabetes: A cross-sectional population-based study in Italy

OBJECTIVE

To evaluate the association of clinical, metabolic and socioeconomic factors with disordered eating behaviors (DEB) among adolescents with type 1 diabetes screened using the Diabetes Eating Problem Survey-Revised (DEPS-R).

METHODS

A cross-sectional, population-based study involved 163 adolescents with type 1 diabetes, aged 11-20 years, recruited from the registry for type 1 diabetes of Marche Region, Italy, who completed the DEPS-R (response rate 74.4%). Clinical characteristics, lipid profile, HbA_1c , family profile of education and occupation were evaluated. The Italian version of DEPS-R was validated, and the prevalence of DEB estimated. The association of demographic, socioeconomic, and clinical factors with DEB was evaluated by multiple correspondence analysis and multiple logistic regression.

RESULTS

The prevalence of DEPS-R-positive (score ≥20) was 27% (95% CI 17-38) in boys and 42% (95% CI 31-53) in girls. A clinical profile of DEPS-R-positive was identified: overweight, little time spent in physical activity, low socioeconomic status, poor metabolic control, skipping insulin injections. Furthermore, the probability of DEPS-R-positive increased 63% for every added unit of HbA_1c , 36% for every added number of insulin injections skipped in a week and decreased about 20% for every added hour/week spent in physical activity. Overweight youth were six times more likely to be DEPS-R-positive.

DISCUSSION

A specific clinical profile of DEPS-R-positive was identified. A multidisciplinary clinical approach aimed to normalize eating behaviors and enhance self-esteem should be used to prevent the onset of these behaviors, and continuous educational programs are needed to promote healthy behaviors and lifestyles.

Epidemiology of type 1 diabetes in Polish children: A multicentre cohort study

BACKGROUND

The incidence of childhood type 1 diabetes (T1D) varies greatly between populations, and the estimates and/or predictions of the rates would aid in adequate planning of health care resources. The study's aim was to assess the incidence of T1D in the paediatric population of eastern and central Poland.

METHODS

In this cohort study covering the period from January 2010 to December 2014, data were collected for children and adolescents below 18 years of age with newly diagnosed T1D living in eastern and central Poland. A total of 2174 children were included in the analysis. The population estimates were from the Central Statistical Office of Poland.

RESULTS

Overall, the annual incidence of T1D increased from 12.84/100,000 in 2010 to 18.46/100,000 in 2014 with the incidence rate (IR) ratio of 1.5 (an increase in the IR by 12.7% per year over 5 years). The lowest increase in the IR by 7.1% per year was seen in 15 to 17-year-olds. In the urban population (age 0-17 years), the overall incidence rate was significantly higher than in subjects from rural communities (P < .02). The incidence of T1D in rural areas was significantly higher (p = .004) in voivodeships of higher population density. Such dependence was not observed in urban areas.

CONCLUSIONS

The incidence of T1D in children living in eastern and central Poland increased 1.5-fold over the 5-year observation period with the highest rise in 10 to 14-year-olds and significantly higher rates in urban children compared with their peers living in rural areas.

Incidence and prevalence of childhood-onset Type 1 diabetes in Japan: the T1D study

AIMS

A majority of children with Type 1 diabetes in Japan are registered with the government-subsidized Specified Pediatric Chronic Disease Treatment Research Projects (SPCDTRP). In this study, the incidence and prevalence of childhood-onset (< 15 years) Type 1 diabetes in Japan were estimated by drawing on SPCDTRP data.

METHODS

Data available for 2005-2012 from the SPCDTRP and Statistics Bureau, Ministry of Internal Affairs and Communications were used to estimate the incidence of Type 1 diabetes for 2005-2010, adjusted to cover those registered within 3 years of disease onset and stratified by sex, age at onset and period of onset.

RESULTS

The incidence of Type 1 diabetes for 2005-2010 was 2.25/100,000 persons [95% confidence intervals (95% CI), 2.14-2.36] (boys: 1.91, 95% CI, 1.83-1.98; girls: 2.52, 95% CI, 2.34-2.69), with that for the age brackets 0-4, 5-9 and 10-14 years being 1.48 (95% CI, 1.29-1.66), 2.27 (95% CI, 2.08-2.47) and 3.00 (95% CI, 2.74-3.25), respectively. The onset of disease was shown to peak at age 13 among boys (3.28, 95% CI, 3.02-3.55) and at age 10 among girls (3.28, 95% CI, 3.02-3.55). The peak periods of disease onset were April/May and December. The number of children aged < 15 years with Type 1 diabetes for 2005-2012 was estimated to be 2326 (95% CI, 2202-2450) with the prevalence estimated as 13.53/100,000 persons (95% CI, 12.63-14.43).

CONCLUSIONS

Study findings demonstrated no increase in the incidence of Type 1 diabetes, although suggesting, in agreement with earlier reports, that the onset of disease peaks in adolescence with a female predominance. In addition, the incidence of childhood-onset diabetes exhibited an annual bimodal pattern in this study.

High frequency of diabetic ketoacidosis at diagnosis of type 1 diabetes in Italian children: a nationwide longitudinal study, 2004-2013

This longitudinal population-based study analyses the frequency of diabetic ketoacidosis (DKA) at type 1 diabetes diagnosis in Italian children under 15 years of age, during 2004-2013. DKA was defined as absent (pH ≥ 7.30), mild/moderate (7.1 ≤ pH < 7.30) and severe (pH < 7.1). Two multiple logistic regression models were used to evaluate the time trend of DKA frequency considered as present versus absent and severe versus absent, adjusted for gender, age group and geographical area of residence at diagnosis. Overall, 9,040 cases were ascertained. DKA frequency was 40.3% (95%CI: 39.3-41.4%), with 29.1% and 11.2% for mild/moderate and severe DKA, respectively. Severe DKA increased significantly during the period (OR = 1.03, 95%CI: 1.003-1.05). Younger-age children and children living in Southern Italy compared to Central Italy were at significantly higher risk of DKA and severe DKA. Family history of type 1 diabetes and residence in Sardinia compared to Central Italy were significantly associated with a lower probability of DKA and severe DKA. The high frequency of ketoacidosis in Italy over time and high variability among age groups and geographical area of residence, strongly suggests a continuing need for nationwide healthcare strategies to increase awareness of early detection of diabetes.

Incidence, prevalence, costs and quality of care of type 1 diabetes in Italy, age 0-29 years: The population-based CINECA-SID ARNO Observatory, 2002-2012

BACKGROUND AND AIMS

To assess temporal trend in incidence (2003-12) and prevalence (2002-12) of type 1 diabetes in children and young adults, direct costs and selected indicators of quality of care under the coverage of the universalistic Italian National Health System (NHS).

METHODS AND RESULTS

The ARNO Observatory, a healthcare monitoring system based on administrative data, identified a population-based multiregional cohort of subjects aged 0-29 years. Type 1 diabetes was defined by at least two prescriptions of insulin over 12 months and continuous insulin-treatment in the following year. Indicators of quality of care and directs costs were assessed in persons with diabetes and in people without diabetes, individually matched for age, gender and health unit (1:4 ratio). We identified 2357 incident cases of type 1 diabetes aged 0-29 years (completeness of ascertainment, 99%). Incidence rates were similar in ages 0-14 (15.8, 95% CI 14.9-16.8) and 15-29 years (16.3, 15.4-17.2), with no significant trend. Prevalence increased from 137 to 166.9/100,000, particularly in the age 15-29 years. Direct costs accounted for € 2117 in persons with diabetes and € 292 in control individuals. A statistically significant decreasing trend in hospitalization for acute complications was evident (p < 0.001), which was almost completely due to ketoacidosis. People with at least one HbA1c measurement over the year were 48.5%.

CONCLUSION

We showed high incidence and increasing prevalence of type 1 diabetes in young adults in Italy, which impact on direct costs under the universalistic coverage of the NHS.

Registry of Youth Onset Diabetes in India (YDR): Rationale, Recruitment, and Current Status

BACKGROUND

With the aim of addressing the relative scarcity of information on youth-onset diabetes in India, the Indian Council of Medical Research (ICMR) decided to establish the Registry of People with Diabetes with Young Age at Onset (YDR) in 2006. The major objectives of YDR are to generate information on disease pattern or types of youth-onset diabetes including their geographical variations within India and to estimate the burden of diabetes complications.

METHODS

YDR is an observational multicenter clinic based registry enlisting physician diagnosed diabetes in individuals below 25 years of age. Diabetes was classified using symptom based clinical criteria. YDR data collection is coordinated through regional collaborating centers and their interacting reporting centers across India. A baseline and an annual follow-up proformas are used to obtain information on sociodemographic details, clinical profile, and anthropometric and laboratory measurements of the patients.

RESULTS

In phase 1, the registry has enrolled 5546 patients, in which type 1 diabetes mellitus (T1DM) was the most prevalent (63.9%), followed by youth-onset type 2 diabetes mellitus (T2DM) (25.3%).

CONCLUSION

This registry provides a unique opportunity to study the natural history of youth-onset diabetes in India.

Incidence of Type 1 Diabetes among Children and Adolescents in Italy between 2009 and 2013: The Role of a Regional Childhood Diabetes Registry

BACKGROUND

Surveillance represents a key strategy to control type 1 diabetes mellitus (T1DM). In Italy, national data are missing. This study aimed at evaluating the incidence of T1DM in subjects <18 year olds in Apulia (a large southeastern region, about 4,000,000 inhabitants) and assessing the sensitivity of the regional Registry of Childhood-Onset Diabetes (RCOD) in the 2009-2013 period.

METHODS

We performed a retrospective study matching records from regional Hospital Discharge Registry (HDR), User Fee Exempt Registry (UFER), and Drugs Prescription Registry (DPR) and calculated T1DM incidence; completeness of each data source was also estimated. In order to assess the RCOD sensitivity we compared cases from the registry to those extracted from HDR-UFER-DPR matching.

RESULTS

During 2009-2013, a total of 917 cases (about 184/year) in at least one of the three sources and an annual incidence of 25.2 per 100,000 were recorded, lower in infant, increasing with age and peaked in 5- to 9-year-olds. The completeness of DPR was 78.7%, higher than that of UFER (64.3%) and of HDR (59.6%). The RCOD's sensitivity was 39.05% (360/922; 95% CI: 34.01%-44.09%).

CONCLUSIONS

Apulia appeared as a high-incidence region. A full, active involvement of physicians working in paediatric diabetes clinics would be desirable to improve the RCOD performance.

Epidemiology of type 1 diabetes mellitus in the pediatric population in Veneto Region, Italy

We assessed the prevalence and incidence of type 1 diabetes mellitus (T1DM) in Veneto Region in Italy. The average prevalence and incidence rates were 1.26/1000 subjects and 16.5/100,000 person-years, respectively. This study shows that the Veneto Region is an area with intermediate-high risk of T1DM.

An easy, fast, effective tool to monitor the incidence of type 1 diabetes among children aged 0-4 years in Italy: the Italian Hospital Discharge Registry (IHDR)

National data of type 1 diabetes incidence are currently missing in Italy. To fill this gap, we estimated the national rate of first hospitalizations for type 1 diabetes among children aged 0-4 years and resident in Italy, as well as rates for each of the twenty-one Italian regions. We extracted the first episode of hospitalization in years 2005-2010 from the Italian Hospital Discharge Registry (IHDR). Record-linkage procedure and cleansing data method were applied to exclude prevalent cases and potentially miscoded patients. At the end, 2,250 incident hospitalizations for type 1 diabetes were extracted. In the years 2005-2010, the mean nation-wide first hospitalization rate for type 1 diabetes in children aged 0-4 years was 13.4 (95% CI 12.8-14.0), 14.1 (95% CI 13.3-14.9) in males and 12.7 (95% CI 11.9-13.4) in females. A geographically heterogeneous pattern of incidence was found: even excluding Sardinia, incidence for this age range and calendar period tended to be slightly higher in Southern than in Northern Italy. Our incidence of first hospitalizations corresponds to the estimates of disease incidence obtained with different data sources by other authors in selected Italian regions. We provide, for the first time ever, the estimate of type 1 diabetes incidence for the overall population aged 0-4 years resident in Italy. When methodological cautions are adopted, IHDR emerges as a reasonable proxy of type 1 diabetes incidence and as a cost-effective tool for public health purposes.

Economic evaluation of continuous subcutaneous insulin infusion for children with diabetes - a pilot study: CSII application for children - economic evaluation

Background

The objective of this study is to assess the cost of using continuous subcutaneous insulin infusion to treat children with type-1diabetes in Bulgaria, considering changes in body mass index (BMI) and the glycated hemoglobin. The study was performed from the perspective of the Bulgarian National Health Insurance Fund (NHIF) and patients.

Methods

A total of 34 pediatric type-1-diabetes patients were observed for 7 months, divided into 2 groups – on pumps and on insulin analogue therapy. Patient demographic data, BMI and glycated hemoglobin level were obtained and recorded. The cost of insulin, pumps, and consumables were calculated and compared with changes in glycated hemoglobin level. The incremental cost-effectiveness ratio was below the threshold value of gross domestic product per capita.

Results

The results were sensitive to changes in glycated hemoglobin level. Improvements associated with glycemic control led to a reduced glycated hemoglobin level that could ensure good diabetes management, but its influence on BMI in growing children remains unclear.

Conclusion

Continuous subcutaneous insulin infusion appears to be more cost-effective for the Bulgarian pediatric population and health care system.

Rising incidence of type 1 diabetes in Belgrade children aged 0-14 years in the period from 1982 to 2005

BACKGROUND

Type 1 diabetes (T1DM) is an autoimmune disease in which both genetic and environmental factors play a role in the etiology.

AIM

The aim of this study was to analyze the incidence of T1DM.

METHODS

A retrospective technique was used to register all newly diagnosed cases of T1DM in Belgrade (Serbia) children at the age of 0- 14 yr between 1982 and 2005. The incidence was adjusted directly by age using the Segi's world population as the standard. A total of 702 cases was identified from the two sources: patients' records from two pediatric hospitals in Belgrade referent for the disease, and from the population based register.

RESULTS

The average annual age adjusted incidence rate of T1DM for Belgrade was 10.4/100,000 [95% confidence interval (95% CI)=3.8-15.4]. It was slightly higher in boys than in girls. The age-specific annual incidence rates (per 100,000) for the age groups 0-4, 5-9, and 10-14 were 5.5 (95% CI=4.5-6.7), 11.9 (95% CI=10.5-13.5), and 15.4 (95% CI=13.8-17.1), respectively. Over the 24 yr incidence rates significantly increased by 8.5% for boys and 3.0% for girls. The highest increase of incidence rate was in the 5-9 age group.

DISCUSSION

The results obtained are in line with data from other studies showing that the incidence of T1DM has been increasing in almost all populations worldwide.

Bayesian analysis of the geographical variation of type 1 diabetes mellitus in under 15 yr olds in northeast Spain, 1991-2009

OBJECTIVE

High variability has been observed in type 1 diabetes mellitus (DM1) incidence rates (IRs) in childhood. The aim of this study was to characterize DM1 in Aragón and to identify variations in the geographical pattern by gender.

METHODS

A descriptive and ecological study was conducted to determine geographical variations in the DM1 incidence for the period 1991-2009. The source of information was the registry of DM1. To determine data completeness, a capture-recapture analysis was performed. Cases were georeferenced according to the Basic Healthcare Area (BHA) of residence. IRs for both genders, age group, 5 yr of diagnosis, and 95% confidence intervals (95% CIs) were calculated. Geographical pattern was studied applying Bayesian statistical model. The standardized incidence ratios (SIRs), smoothed SIR, and the posteriori risk probability (PRP) were represented cartographically for BHA stratified by gender.

RESULTS

The completeness was 93.5%. The global IR was 19.2 cases/10(5) person-years (95% CI: 17.6-20.8), boys 21.4 (95% CI: 19.0-23.8) and girls 16.8 (95% CI: 14.7-19.1). The age-specific rates were significantly lower in the 0-4 year age group with respect to the groups of 5-9 and 10-14 years. For boys, areas with a statistically significant excess of risk were found in the north [smoothed SIR: 118-167.9 and PRP of what the smoothed SIR would be greater than 100 (PRP) above 0.8] and below average risk in the south (smoothed SIR: 65.9-79.1 and PRP less than 0.2).

CONCLUSIONS

DM1 IR presented a north-south geographical pattern in boys. This pattern was not observed in girls or when both genders were considered together. Later studies should include gender as an essential variable.

Incidence of type 1 diabetes mellitus in Turkish children from the southeastern region of the country: a regional report

OBJECTIVE

Variability in the incidence of type 1 diabetes mellitus (T1DM) related to geographical region, ethnic background, gender, and age indicates a need for further epidemiological studies. To date, there are no reported studies on the incidence of T1DM in the pediatric age group from the Southeastern region of Turkey. To define the incidence, demographic and clinical characteristics of T1DM in children 0-14 years of age in Diyarbakir, one of the largest cities in the Southeast region of Turkey.

METHODS

Hospital files of patients with the diagnosis of T1DM were reviewed. Data of all patients diagnosed between 1 June 2010 and 31 May 2011 were evaluated. Population data on the 0-14 age group were obtained from the Turkish Statistical Institute (TSI) reports.

RESULTS

From a total of 41 T1DM patients, 24 (58.5%) were female (male: 41.5%) with a male/female ratio of 1.4. The overall annual incidence of T1DM was 7.2/10(5), being 8.7/10(5) in females and 5.7/10(5) in males. The peak incidence was found to occur at age 5-9 years in the girls and 10-14 years in the boys. Mean age at diagnosis was 8.1±3.8 years. Rate of presentation with diabetic ketoacidosis was 65.9%. Patients applied most frequently in spring and winter months.

CONCLUSIONS

In this first T1DM incidence study on the pediatric age group in Diyarbakir, Turkey, T1DM incidence was found to be similar to that in countries with low-middle incidence.

How robust is the evidence of an emerging or increasing female excess in physical morbidity between childhood and adolescence? Results of a systematic literature review and meta-analyses

For asthma and psychological morbidity, it is well established that higher prevalence among males in childhood is replaced by higher prevalence among females by adolescence. This review investigates whether there is evidence for a similar emerging female ‘excess’ in relation to a broad range of physical morbidity measures. Establishing whether this pattern is generalised or health outcome-specific will further understandings of the aetiology of gender differences in health. Databases (Medline; Embase; CINAHL; PsycINFO; ERIC) were searched for English language studies (published 1992–2010) presenting physical morbidity prevalence data for males and females, for at least two age-bands within the age-range 4–17 years. A three-stage screening process (initial sifting; detailed inspection; extraction of full papers), was followed by study quality appraisals. Of 11 245 identified studies, 41 met the inclusion criteria. Most (n = 31) presented self-report survey data (five longitudinal, 26 cross-sectional); 10 presented routinely collected data (GP/hospital statistics). Extracted data, supplemented by additional data obtained from authors of the included studies, were used to calculate odds ratios of a female excess, or female:male incident rate ratios as appropriate. To test whether these changed with age, the values were logged and regressed on age in random effects meta-regressions. These showed strongest evidence of an emerging/increasing female excess for self-reported measures of headache, abdominal pain, tiredness, migraine and self-assessed health. Type 1 diabetes and epilepsy, based on routinely collected data, did not show a significant emerging/increasing female excess. For most physical morbidity measures reviewed, the evidence broadly points towards an emerging/increasing female excess during the transition to adolescence, although results varied by morbidity measure and study design, and suggest that this may occur at a younger age than previously thought.

Regional differences in incidence and clinical presentation of type 1 diabetes in children aged under 15 years in Croatia

AIM

To determine regional differences in the incidence, incidence trends, and clinical presentation of type 1 diabetes in children under the age of 15 years in Croatia in a 9-year period (1995-2003).

METHODS

We included the patients who had been diagnosed with the disease and had started the insulin treatment before they were 15 years old. Regional differences between eastern, central, and southern Croatia were observed. The gross incidence was expressed by the number of newly diagnosed type 1 diabetes patients in 100000 children of the same age and sex per year, ie, for the 0-14 age group, and for the 0-4, 5-9, and 10-14 subgroups.

RESULTS

The highest incidence was observed in southern Croatia (10.91 per 100000/y) and the lowest in central Croatia (8.64 per 100000/y), and in eastern Croatia the incidence was 8.93 per 100000/y. All three regions showed a growing incidence trend, which was significant only in eastern and southern Croatia. There was 35.9% of patients with diabetic ketoacidosis in eastern Croatia, 41.7% in central Croatia, and 31.28% in southern Croatia.

CONCLUSION

Croatian regions show differences in the incidence, incidence trends, and disease presentation of type 1 diabetes. A further follow-up is needed to establish whether the regional differences are a consequence of the population dynamics in the observed period or they will continue to exist, pointing to differences in environmental risk factors.

Type 1 diabetes and measles, mumps and rubella childhood infections within the Italian Insulin-dependent Diabetes Registry

AIMS

Several studies confirmed the growing rate of Type 1 diabetes mellitus in childhood coinciding with increasing diagnosis of viral infections. A study investigating the incidence of Type 1 diabetes during 1996-1997 showed a higher notification of viral infections in the Pavia District. The aim was to confirm these results.

METHODS

This study evaluated the relationship between new cases of Type 1 diabetes and those of measles, mumps and rubella in 1996-2001, analysing data of newly-diagnosed Type 1 diabetes children, aged 0-14 years and enrolled into the RIDI (Italian Insulin-dependent Diabetes Registry) during the same years. Measles, rubella and mumps rates were calculated using as denominator the estimated 'population at risk', represented by the number of 0- to 14 year-old subjects who did not undergo the MMR (measles, mumps and rubella) vaccination. In order to investigate the association between Type 1 diabetes incidence and measles, rubella and mumps respectively, Spearman's rank correlation was used.

RESULTS

The analysis of the whole Registries data did not at first show any statistical significance between age-standardized Type 1 diabetes incidence density and estimated rates of measles, mumps and rubella notifications. Excluding data from Sardinia Registry, a significant association was observed between Type 1 diabetes incidence and mumps (P = 0.034) and rubella (P = 0.014), respectively, while there was no statistical significance between the incidence of measles cases and diabetes rates (P = 0.269).

CONCLUSIONS

According to our findings, mumps and rubella viral infections are associated with the onset of Type 1 diabetes. The statistical significance observed after exclusion of the Sardinian data suggests that other environmental factors may operate over populations with different genetic susceptibility.

The ALBA project: an evaluation of needs, management, fears of Italian young patients with type 1 diabetes in a school setting and an evaluation of parents' and teachers' perceptions

OBJECTIVE

To determine how Italian parents and school personnel of 6-13-year-old children with type 1 diabetes (T1D) manage during school hours, including insulin administration, management of hypoglycemia, and glucagon use. A further aim was an investigation into the responsibilities and training of school personnel regarding diabetes.

RESEARCH DESIGN AND METHODS

After an initial qualitative phase, semi-structured questionnaires were completed by a sample of parents and teachers.

RESULTS

220 parent and 52 teacher questionnaires were completed. 43.6% of parents said diabetes had negatively influenced school activities. Children either self-administer insulin, or have help from a parent, since there is very rarely a nurse present (3.6%) or a teacher who will take responsibility for the treatment (2.9%). Most parents (55.9%) stated either that the school had no refrigerator to store glucagon or that they did not know if the school was so equipped. A small percentage of teachers considered their schools to be equipped to manage an emergency (23%) and said they would use glucagon directly in an emergency (14.9%). Only 40.4% of teachers said that they had received any specific training.

CONCLUSIONS

The study shows that people who are not directly involved have superficial knowledge of the different aspects of diabetes, even though no parents reported episodes of neglect/incorrect management. There is no legislation which clearly defines the role of the school in the care of children with T1D, and teachers are not trained to help them. Training sessions for school personnel and greater legislative clarity about the 'insulin and glucagon question' are key factors that may improve the full integration of the child with diabetes.

Prediction and prevention of Type 1 diabetes mellitus

Type 1A diabetes mellitus (T1DM) is caused by autoimmune islet β-cell destruction with consequent severe insulin deficiency. We can now predict the development of T1DM by determining four biochemically characterized islet autoantibodies, namely those antibodies against insulin, glutamic acid decarboxylase 65, insulinoma antigen (IA)-2 (ICA512) and the zinc transporter ZnT8. We can also prevent T1DM in animal models, but the final goal is the prevention of T1DM in humans. Multiple clinical trials are underway investigating methods to prevent β-cell destruction.

Increasing incidence of childhood type 1 diabetes in Montenegro from 1997 to 2006

OBJECTIVE

To determine and analyze the incidence of type 1 diabetes mellitus (T1DM) in 0- to 14-yr-old children in Montenegro from 1997 to 2006.

RESEARCH DESIGN AND METHODS

This was a prospective study. Primary case ascertainment came from a diabetes register and secondary independent data source was from prescription data. Age and sex-standardized incidence rates were calculated using direct method, assuming an equal distribution in each age/sex group. The 95% confidence interval (CI) were estimated assuming the Poisson distribution. The independent effects of calendar year, two 5-yr time periods, sex and age groups were estimated with Poisson regression modeling.

RESULTS

During the 10-yr period, 184 new cases of type 1 diabetes were identified. Case ascertainment was 100% complete using the capture-recapture method. The mean annual standardized incidence rate over the 10-yr period was 13.4/100 000/yr (95% CI: 11.5-15.5). It increased on average by 4.6% per year (95% CI: -0.4 to -9.6%, p = 0.07). The time-period specific incidence rate from year 1997 to 2001 was significantly lower (10.8; 8.5-13.5) compared with the second period from 2002 to 2006 (16.3; 13.3-19.7), (p < 0.0001). The age-specific incidence for the 0-4-yr age group was significantly lower (8.9; 6.3-12.3) than in 5- to 9-yr age group (14.1; 10.8-18.1); and in the 10-14 yr group (17.2; 13.7-21.3) per 100,000 children.

CONCLUSIONS

The incidence rate in last 5 yr places Montenegro in the group of countries with moderate risk for development of type 1 diabetes in children. The average annual increase in incidence is 4.6%.

Age-period-cohort analysis of 1990-2003 incidence time trends of childhood diabetes in Italy: the RIDI study

OBJECTIVE

To investigate age-period-cohort effects on the temporal trend of type 1 diabetes in children age 0-14 years in Italian registries.

RESEARCH DESIGN AND METHODS

This report is based on 5,180 incident cases in the period 1990-2003 from the Registry for Type 1 Diabetes Mellitus in Italy (RIDI). Multilevel (random intercept) Poisson regression models were used to model the effects of sex, age, calendar time, and birth cohorts on temporal trends, taking into account the registry-level variance component.

RESULTS

The incidence rate was 12.26 per 100,000 person-years and significantly higher in boys (13.13 [95% CI 12.66-13.62]) than in girls (11.35 [10.90-11.82]). Large geographical variations in incidence within Italy were evident; incidence was highest in Sardinia, intermediate in Central-Southern Italy, and high in Northern Italy, particularly in the Trento Province, where the incidence rate was 18.67 per 100,000 person-years. An increasing temporal trend was evident (2.94% per year [95% CI 2.22-3.67]). With respect to the calendar period 1990-1992, the incidence rates increased linearly by 15, 27, 35, and 40% in the following time periods (P for trend < 0.001). With respect to the 1987-1993 birth cohort, the incidence rate ratio increased approximately linearly from 0.63 (95% CI 0.54-0.73) in the 1975-1981 cohort to 1.38 (1.06-1.80) in the 1999-2003 cohort. The best model, however, included sex, age, and a linear time trend (drift).

CONCLUSIONS

Large geographical variations and an increasing temporal trend in diabetes incidence are evident among type 1 diabetic children in Italy. Age-period-cohort analysis shows that the variation over time has a linear component that cannot be ascribed to either the calendar period or the birth cohort.

Incidence of diabetes mellitus among children of Italian migrants substantiates the role of genetic factors in the pathogenesis of type 1 diabetes

To investigate the role of genetic and environmental factors in the pathogenesis of type 1 diabetes mellitus (T1D), we carried out a study in Germany aimed at comparing the prevalence and incidence of T1D among children of migrant Italians from high-risk (Sardinia) and low-risk (continental Italy) regions versus German children. Children from Italy were identified by the "Baden-Wuerttemberg (BW) Diabetes Incidence Registry", which registered 4017 newly diagnosed T1D patients, aged 0-14 years, between 1987 and 2003. Data relating to T1D children from Sardinia were elicited from more than 2000 questionnaires. Our findings were: (1) T1D is more frequent among German children than among children of Italian migrants [incidence rate (IR) 14.8/100,000/year, 95% confidence interval (CI) 14.4-15.4 vs. IR 10.8/100,000/year, 95% CI 8.2-13.6); (2) the incidence of T1D among Italian children residing in Germany is similar to that of Italian children in the home country (IR 10.8/100,000/year, 95% CI 8.2-13.6 vs. 8.4/100,000/year, 95% CI 7.9-8.9); (3) the prevalence of T1D among Sardinian children is higher than that among German children (0.11%, 95% CI 0.11-0.12) independent of the place where the Sardinian children are living (Sardinian children in Germany 2.3%, 95% CI 0.5-6.5 vs. Sardinian children in Sardinia 0.30%, 95% CI 0.27-0.32).

CONCLUSION

Children from high- and low-risk areas of Italy have incidence rates of T1D that are closer to those of their native regions than to those of German children, indicating that genetic factors play a predominant role in the pathogenesis of T1D.

Association of alleles at polymorphic sites in the Osteopontin encoding gene in young type 1 diabetic patients

The Osteopontin (OPN) encoding gene, SPP1, can be considered as a candidate for genetic susceptibility to type 1 diabetes (T1D) because of its known function in immune response and inflammation. This work aimed to evaluate the role of SPP1 gene in susceptibility to T1D. Patients (238: 130 male, 108 female) and unaffected adult control individuals (137: 68 males and 69 females) have been genotyped for three variants in the SPP1 gene: -156 (G/GG) and -66 (T/G) in the promoter and a biallelic ins/del variant (TG/TGTG) at +245 in the first intron. The G allele at the -66 SNP had significantly higher frequency in controls than T1D patients. Interestingly, case-control comparison in males showed no significant association, whereas the association was confirmed in females. These results suggest that SPP1 can play a role as susceptibility gene, possibly by a sex-specific mechanism acting in the autoimmune process.

Variant late infantile ceroid lipofuscinoses associated with novel mutations in CLN6

The neuronal ceroid lipofuscinoses (NCL) are heterogeneous neurodegenerative disorders with typical autofluorescence material stored in tissues. Ten clinical NCL forms and eight causative genes are known. Mutations in CLN6 have been reported in roughly 30 patients, mostly in association with the variant late-infantile NCL (v-LINCL) phenotype. We screened CLN6 in 30 children from a cohort of 53 v-LINCL cases and revised their clinical and ultrastructural features. We detected 11 mutations, eight of which are novel, all predicting a direct impairing of the putative gene function. No clear-cut genotype-phenotype correlations were observed, with inter- and intra-familial variability evident for few recurrent mutations. Ultrastructural findings were suggestive of an impaired regulation of the autophagic vacuoles turnover. While expanding the array of CLN6 mutations, we showed that more than half of our v-LINCL cases lack a DNA confirmation and further molecular etiologies are to be searched.

A 10-year (1996-2005) prospective study of the incidence of Type 1 diabetes in Moscow in the age group 0-14 years

AIMS

To provide data on the incidence of Type 1 diabetes (T1D) in Moscow, determined prospectively from 1996 to 2005 for a total of > 10 million subjects aged < 15 years.

METHODS

Data on T1D incidence in patients with newly discovered T1D resident in Moscow diagnosed between 1 January 1996 and 31 December 2005 were analysed. Primary ascertainment was based in endocrinology departments of children's hospitals in Moscow. A secondary source were the archives of Moscow Region where patients are registered to obtain exemption from paying for medication.

RESULTS

We identified 2031 new cases of T1D patients with a degree of ascertainment through primary and secondary sources of 94%. Overall the incidence rate of the disease was 12.9 per 100,000 per year (95% confidence interval 12.3- 13.4). The cumulative risk of the disease was 0.28 per 1000 in the age group 0-4 years, 0.84 in the age group 5-9 years and 1.8 in the age group 10-14 years. The incidence rate in girls increased by a mean of 6% per year in all age groups (P < 0.05 for all comparisons), whereas in boys it increased by a mean of 7% in the age group 10-14 years. Thirty percent of cases presented with diabetic ketoacidosis and coma at diagnosis, whereas hyperglycaemia without ketonuria was present in 20% of patients.

CONCLUSIONS

This is the first study to report on validated incidence data for T1D in Moscow. We conclude that the incidence of T1D in Moscow is comparable to that of those European countries having intermediate incidence rates, and that the incidence is increasing.

Incidence and trends of childhood Type 1 diabetes in Croatia from 1995 to 2003

AIMS/HYPOTHESIS

The aim of this study was to examine incidence and trends of Type 1 diabetes in children aged 0-14 years in Croatia from 1995 to 2003.

METHODS

The incidence data were obtained from two sources. The incidence was calculated as the number of newly diagnosed Type 1 diabetes patients per 100,000 person-years for the age group 0-14 years, and subgroups 0-4, 5-9, and 10-14 years. Standardized incidence was calculated using the method of direct standardization to the world standard population for the age group 0-14 years. The ascertainment was estimated with capture-recapture method. Trends in the incidence of Type 1 diabetes for period from 1995 to 2003 in Croatia were analyzed using Poisson regression model.

RESULTS

The standardized incidence of Type 1 diabetes for the whole age group was 8.87 per 100,000 person-years (95% CI: 5.07-12.68), for girls 8.47 (95% CI: 7.54-9.41) and for boys 9.26 (95% CI: 8.30-10.21). During the studied period, the trend in incidence raised significantly for the whole age group (chi(2)=32.6, p<0.001). The average annual increase in incidence was 9% (95% CI: 5.8-12.2).

CONCLUSIONS/INTERPRETATION

This rate of incidence places Croatia in a group of countries with moderate risk for development of Type 1 diabetes. The average annual increase in incidence of 9% is markedly higher than in most European countries, and probably reflects lifestyle changes upon economic recovery of the country.

Double or hybrid diabetes associated with an increase in type 1 and type 2 diabetes in children and youths

The increase in the incidence of type 1 diabetes (T1D), especially in children <5 yr of age, reported over the past decade can be attributed to changes in environmental factors (either quantitative or qualitative) rather than to an effect of genetic factors operating in such a short period of time. The notable increase in the incidence of type 2 diabetes (T2D) in children and adolescents is very likely the consequence of an increasing sedentary lifestyle and an increase in obesity, which has been occurring in developed countries. An increase in the number of children and adolescents with a mixture of the two types of diabetes has recently come to light (i.e., subjects who are obese and/or with signs of insulin resistance as well as positive for markers of autoimmunity to beta cells), although the epidemiological data supporting such a conclusion are sparse. Under the current classification, it is difficult to define the type of diabetes affecting these young subjects, who might be classified as T2D because they are obese and insulin resistant but also as T1D because of the presence of autoantibodies to beta cells. These subjects show an overlapping diabetes phenotype typical of both T1D and T2D, suggesting that the current classification of diabetes should be revised to take into account this new form of diabetes, which has been called 'double diabetes' or 'hybrid diabetes'. In this review, we report recent findings on the increasing rates of all forms of diabetes in the young population, including unpublished data collected in Russia.

Metabolic syndrome: from global epidemiology to individualized medicine

The metabolic syndrome (MetS) encompasses a constellation of metabolic abnormalities that are thought to place patients at higher risk for the development of diabetes and cardiovascular (CV) disease. The underlying pathophysiology is still a point of contention among various professional organizations leading to inconsistencies in the manner in which MetS is defined. Each definition has its advantages and disadvantages. Nonetheless, there is an agreement that insulin resistance and obesity are likely the central contributing factors. Because the prevalence of obesity has been increasing at a frightening rate in the past few decades, MetS represents a major public health problem that should be identified clinically in individual patients. This review describes the changing epidemiology of obesity and of MetS and discusses its importance in CV disease. We outline the existing controversies that surround MetS and discuss the role of lifestyle, pharmacological, surgical, and novel approaches in its management.

Type I diabetic bone phenotype is location but not gender dependent

Bone is highly dynamic and responsive. Bone location, bone type and gender can influence bone responses (positive, negative or none) and magnitude. Type I diabetes induces bone loss and increased marrow adiposity in the tibia. We tested if this response exhibits gender and location dependency by examining femur, vertebrae and calvaria of male and female, control and diabetic BALB/c mice. Non-diabetic male mice exhibited larger body, muscle, and fat mass, and increased femur BMD compared to female mice, while vertebrae and calvarial bone parameters did not exhibit gender differences. Streptozotocin-induced diabetes caused a reduction in BMD at all sites examined irrespective of gender. Increased marrow adiposity was evident in diabetic femurs and calvaria (endochondrial and intramembranous formed bones, respectively), but not in vertebrae. Leptin-deficient mice also exhibit location dependent bone responses and we found that serum leptin levels were significantly lower in diabetic compared to control mice. However, in contrast to leptin-deficient mice, the vertebrae of T1-diabetic mice exhibit bone loss, not gain. Taken together, our findings indicate that TI-diabetic bone loss in mice is not gender, bone location or bone type dependent, while increased marrow adiposity is location dependent.

Bone loss and increased bone adiposity in spontaneous and pharmacologically induced diabetic mice

Insulin-dependent diabetes mellitus (IDDM) is associated with increased risk of osteopenia/osteoporosis in humans. The mechanisms accounting for diabetic bone loss remain unclear. Pharmacologic inducers of IDDM, such as streptozotocin, mimic key aspects of diabetes in rodents, allow analysis at the onset of diabetes, and induce diabetes in genetically modified mice. However, side effects of streptozotocin, unrelated to diabetes, can complicate data interpretation. The nonobese diabetic (NOD) mouse model develops diabetes spontaneously without external influences, negating side effects of inducing agents. Unfortunately, in this model the onset of diabetes is unpredictable, occurs in a minority of male mice, and can only be studied in a single mouse strain. To validate the relevance of the more flexible streptozotocin-induced diabetes model for studying diabetes-associated bone loss, we compared its phenotype to the spontaneously diabetic NOD model. Both models exhibited hyperglycemia and loss of body, fat pad, and muscle weight. Furthermore, these genetically different and distinct models of diabetes induction demonstrated similar bone phenotypes marked by significant trabecular bone loss and increased bone marrow adiposity. Correspondingly, both diabetic models exhibited decreased osteocalcin mRNA and increased adipocyte fatty acid-binding protein 2 mRNA levels in isolated tibias and calvaria. Taken together, multiple streptozotocin injection-induced diabetes is a valid model for understanding the acute and chronic pathophysiologic responses to diabetes and their mechanisms in bone.

High prevalence and fast rising incidence of multiple sclerosis in Caltanissetta, Sicily, southern Italy

BACKGROUND

Epidemiological studies conducted in Sicily and Sardinia, the two major Mediterranean islands, showed elevated incidence and prevalence of multiple sclerosis (MS)and a recent increase in disease frequency.

OBJECTIVE

To confirm the central highlands of Sicily as areas of increasing MS prevalence and elevated incidence, we performed a follow-up study based on the town of Caltanissetta (Sicily), southern Italy.

METHODS

We made a formal diagnostic reappraisal of all living patients found in the previous study performed in 1981. All possible information sources were used to search for patients affected by MS diagnosed according to the Poser criteria. We calculated prevalence ratios, for patients affected by MS who were living and resident in the study area on December 31, 2002. Crude and age- and sex-specific incidence ratios were computed for the period from January 1, 1993, to December 31, 2002.

RESULTS

The prevalence of definite MS rose in 20 years from 69.2 (retrospective prevalence rate) to 165.8/100,000 population. We calculated the incidence of definite MS for the period 1970-2000. These rates calculated for 5-year periods increased from 2.3 to 9.2/100,000/year.

CONCLUSION

This survey shows the highest prevalence and incidence figures of MS in the Mediterranean area and confirms central Sicily as a very-high-risk area for MS.

Incidence and trends of childhood Type 1 diabetes worldwide 1990-1999

AIM

To examine incidence and trends of Type 1 diabetes worldwide for the period 1990-1999.

METHODS

The incidence of Type 1 diabetes (per 100 000/year) was analysed in children aged <or= 14 years from 114 populations in 112 centres in 57 countries. Trends in the incidence of Type 1 diabetes were analysed by fitting Poisson regression models to the dataset.

RESULTS

A total of 43,013 cases were diagnosed in the study populations of 84 million children. The age-adjusted incidence of Type 1 diabetes among 112 centres (114 populations) varied from 0.1 per 100,000/year in China and Venezuela to 40.9 per 100,000/year in Finland. The average annual increase in incidence calculated from 103 centres was 2.8% (95% CI 2.4-3.2%). During the years 1990-1994, this increase was 2.4% (95% CI 1.3-3.4%) and during the second study period of 1995-1999 it was slightly higher at 3.4% (95% CI 2.7-4.3%). The trends estimated for continents showed statistically significant increases all over the world (4.0% in Asia, 3.2% in Europe and 5.3% in North America), except in Central America and the West Indies where the trend was a decrease of 3.6%. Only among the European populations did the trend in incidence diminish with age.

CONCLUSIONS

The rising incidence of Type 1 diabetes globally suggests the need for continuous monitoring of incidence by using standardized methods in order to plan or assess prevention strategies.

Clinical phenotype and beta-cell autoimmunity in Italian patients with adult-onset diabetes

OBJECTIVE

To characterize the phenotype of a large population of Italian patients with adult onset (> or =40 years) diabetes who were attending outpatient clinics and who were screened for glutamic acid decarboxylase 65 autoantibodies (GADA), protein tyrosine phosphatase IA-2 (IA-2A) and IA-2beta/phogrin (IA-2betaA).

DESIGN AND METHODS

This was a cross-sectional study comprising a total of 881 patients, aged < or = 70 years, diagnosed with type 2 diabetes after the age of 40 years, and consecutively recruited in five clinics located in different geographic areas of Italy (Milan, Florence, Rome, Naples and Catania). Their mean disease duration was 8.1 (6.9; s.d.) years. GADA, IA-2A and IA-2betaA were measured with radiobinding assays with in vitro translated S-methionine-labelled glutamic acid decarboxylase 65 (GAD65) or IA-2 or IA-2beta. Anthropometric and clinical data were collected and compared amongst patients with or without autoantibodies.

RESULTS

Sixty-three (7.1%) patients had one or more autoantibodies, 58 (6.6%) had GADA, 22 (2.5%) had IA-2A, six (0.7%) had IA-2betaA and 19 (2.15%) had two or more autoantibodies. IA-2A or IA-2betaA, in the absence of GADA, were found in only five patients. Autoantibody-positive patients were more often female (63.5 vs 36.5%; P < 0.009), had higher glycated haemoglobin (Hb A1c) (P < 0.001), lower body mass index (BMI; P < 0.0005) and waist/hip ratio (WHR; P < 0.01); female gender being the main contributor to BMI and WHR. We did not observe any differences in age at diagnosis or duration of disease with respect to the presence or absence of islet autoantibodies. The proportion of patients on insulin therapy was higher in patients with two or more antibodies, compared with those with one antibody only, and no antibodies (P for trend < 0.001), and among patients with GADA, in those with higher antibody titre (73.9% in those with > 10 units vs 42.0% in those with < or = 10 units; P < 0.007).

CONCLUSIONS

Patients with adult onset diabetes characterized by autoimmunity to beta-cells showed a clinical phenotype with anthropometric features that differed from those classically observed in patients with type 2 diabetes. The number and titre of autoantibodies, which reflect the severity of autoimmunity and beta-cell impairment, amplified this difference. The usefulness of autoantibody screening in adult-onset diabetes is further emphasized by these findings.

Incidence of type 1 and type 2 diabetes in adults aged 30-49 years: the population-based registry in the province of Turin, Italy

OBJECTIVE

Incidence of type 1 diabetes is considered to be low in adults, but no study has been performed in Mediterranean countries.

RESEARCH DESIGN AND METHODS

We extended the study base of the registry of the province of Turin, Italy, to subjects aged 30-49 years in the period 1999-2001 to estimate the incidences of type 1 and type 2 diabetes. Diagnosis of type 1 diabetes was based on permanent insulin treatment or a fasting C-peptide level < or =0.20 nmol/l or islet cell (ICA) or GAD (GADA) antibody positivities.

RESULTS

We identified 1,135 case subjects with high completeness of ascertainment (99%), giving an incidence rate of 58.0 per 100,000 person-years (95% CI 54.7-61.5). The incidence of type 1 diabetes was 7.3 per 100,000 person-years (6.2-8.6), comparable with the rates in subjects aged 0-14 and 15-29 years (10.3 [9.5-11.2] and 6.8 [6.3-7.4]). Male subjects had a higher risk than female subjects for both type 1 (rate ratio [RR] 1.70 [95% CI 1.21-2.38]) and type 2 (2.10 [1.84-2.40]) diabetes. ICA and/or GADA positivities were found in 16% of the cohort. In logistic regression, variables independently associated with autoimmune diabetes were age 30-39 years (odds ratio [OR] 2.39 [95% CI 1.40-4.07]), fasting C-peptide <0.60 nmol/l (3.09 [1.74-5.5]), and BMI <26 kg/m2 (2.17 [1.22-3.85]).

CONCLUSIONS

Risk of type 1 diabetes between age 30 and 49 years is similar to that found in the same area between age 15 and 29 years. Further studies are required to allow geographical comparisons of risks of both childhood and adulthood autoimmune diabetes, the latter being probably higher than previously believed.