Satisfaction with continuous glucose monitoring is associated with quality of life in young people with type 1 diabetes regardless of metabolic control and treatment type

AIMS

While continuous glucose monitoring (CGM) and associated technologies have positive effects on metabolic control in young people with type 1 diabetes (T1D), less is known about their impact on quality of life (QoL). Here, we quantified CGM satisfaction and QoL in young people with T1D and their parents/caregivers to establish (i) the relationship between QoL and CGM satisfaction and (ii) the impact of the treatment regimen on QoL.

METHODS

This was a cross-sectional study of children and adolescents with T1D on different treatment regimens (multiple daily injections, sensor-augmented pumps and automated insulin delivery). QoL was assessed with the KINDL instrument, and CGM satisfaction with the CGM-SAT questionnaire was evaluated in both youths with T1D and their parents.

RESULTS

Two hundred and ten consecutively enrolled youths with T1D completed the KINDL and CGM-SAT questionnaires. The mean total KINDL score was greater than neutral in both subjects with T1D (3.99 ± 0.47) and parents (4.06 ± 0.40), and lower overall CGM-SAT scores (i.e., higher satisfaction) were significantly associated with higher QoL in all six KINDL subscales (p < 0.05). There were no differences in KINDL scores according to delivery technology or when participants were grouped according to optimal and sub-optimal glucose control.

CONCLUSIONS

Higher satisfaction with recent CGMs was associated with better QoL in all dimensions. QoL was independent of both the insulin delivery technology and glycaemic control. CGM must be further disseminated. Attention on perceived satisfaction with CGM should be incorporated with the clinical practice to improve the well-being of children and adolescents with T1D and their families.

Maintaining a gluten-free diet is associated with quality of life in youths with type 1 diabetes and celiac disease

AIM

Conflicting findings have been reported on whether in youths, the double diagnosis of type 1 diabetes (T1D) and celiac disease (CD) substantially impacts quality of life QoL, compared to subjects with T1D only.

METHODS

In this study, 86 youths with double diagnosis and their parents were compared to 167 subjects with T1D only. QoL was assessed through the KINDL questionnaire. Anti-tissue transglutaminase antibodies and dietary interviews evaluated the degree of maintaining a gluten-free diet (GFD).

RESULTS

We found that having CD in addition to T1D has little effect on overall QoL. However, analysis of the degree of maintaining GFD revealed significantly lower total QoL scores in groups with T1D + CD not strictly maintaining GFD compared to T1D only (p = 0.0014). The multivariable linear regression model confirmed the importance of maintaining GFD on QoL in subjects (p = 0.0066) and parents (p = 0.023).

CONCLUSION

The coexistence of T1D and CD and the adoption of a GFD resulted in poor QoL levels, as in youth as in their parents, when difficulties implementing the GFD are present. Psychological support should consider the importance of maintaining GFD not only to prevent potential complications in the future but also to improve actual QoL in different subdomains.

The changing landscape of neonatal diabetes mellitus in Italy between 2003-2022

CONTEXT

In the last decade Sanger method of DNA sequencing has been replaced by next generation sequencing (NGS). NGS is valuable in conditions characterized by high genetic heterogeneity such as neonatal diabetes mellitus (NDM).

OBJECTIVE

To compare results of genetic analysis of patients with NDM and congenital severe insulin resistance (c.SIR) identified in Italy in 2003-2012 (Sanger) versus 2013-2022 (NGS).

METHODS

We reviewed clinical and genetic records of 104 cases with diabetes onset before 6 months of age (NDM+c.SIR) of the Italian dataset.

RESULTS

Fiftyfive patients (50 NDM + 5 c.SIR) were identified during 2003-2012 and 49 (46 NDM + 3 c.SIR) in 2013-2022. Twenty-year incidence was 1:103,340 (NDM) and 1:1,240,082 (c.SIR) live births. Frequent NDM/c.SIR genetic defects (KCNJ11, INS, ABCC8, 6q24, INSR) were detected in 41 and 34 probands during 2003-2012 and 2013-2022, respectively. We identified a pathogenic variant in rare genes in a single proband (GATA4) (1/42 or 2.4%) during 2003-2012 and in 8 infants (RFX6, PDX1, GATA6, HNF1B, FOXP3, IL2RA, LRBA, BSCL2) during 2013-2022 (8/42 or 19%, p= 0.034 vs 2003-2012). Notably, five among rare genes were recessive. Swift and accurate genetic diagnosis led to appropriate treatment: patients with autoimmune NDM (FOXP3, IL2RA, LRBA), were subjected to bone marrow transplant; patients with pancreas agenesis/hypoplasia (RFX6, PDX1) were supplemented with pancreatic enzymes and the individual with lipodystrophy caused by BSCL2 was started on metreleptin.

CONCLUSIONS

NGS substantially improved diagnosis and precision therapy of monogenic forms of neonatal diabetes and congenital SIR in Italy.

Maintaining the gluten-free diet: The key to improve glycemic metrics in youths with type 1 diabetes and celiac disease

AIMS

Gluten-free diets (GFD) were considered as high glycemic index and/or high content of saturated fats; this could affect keeping good metabolic control in individuals with both type 1 diabetes (T1D) and celiac disease (CD). Our objective was to analyze time in range and other continuous glucose monitoring (CGM) metrics with real-time CGM systems, in youths with T1D and CD, compared to those with T1D only.

METHODS

An observational case-control study, comparing youths aged 8-18 years with T1D and CD, with people with T1D only was performed. The degree of maintaining GFD was assessed through anti-tissue transglutaminase antibodies and dietary interview, and maintaining Mediterranean diet through the KIDMED questionnaire.

RESULTS

86 youths with T1D and CD, 167 controls with T1D only, were included in the study and the two groups reported similar real-time CGM metrics. Among the first group, 29 % were not completely maintaining GFD and compared to people with T1D only they showed higher hyperglycemia rates (% time above range: 38.72 ± 20.94 vs 34.34 ± 20.94; P = 0.039).

CONCLUSIONS

Individuals with T1D and CD who maintain GFD presented similar glucose metrics compared to youths with T1D only. Individuals not strictly maintaining GFD presented higher hyperglycemia rates.

Glycemic variability and Time in range are associated with the risk of overweight and high LDL-cholesterol in children and youths with Type 1 Diabetes

INTRODUCTION

Reducing cardiovascular risk factors (CVRFs) exposure in children and youths with type 1 diabetes (T1D) is critical for cardiovascular diseases (CVD) prevention. Long-term exposure to hyperglycaemia, measured by HbA1c, had been recognized as the main factor affecting CVRFs profile. To date, the possible association between short-term glycaemic control and variability measured by continuous glucose monitoring (CGM) metrics and CVRFs has not been explored. The aim of this study was to test the hypothesis that CGM metrics independently contribute to CVRFs exposure in children and youths with T1D.

METHOD

BMI, blood pressure (BP), lipid profile, and CGM data of 895 children and youths with T1D were analysed. Binary multivariable logistic regression analyses were performed to test independent associations between CVRFs (BMI percentile>85th, LDL-c>100 mg/dL, BP>90th percentile) and CGM metrics according to sex and adjusting for confounding factors.

RESULTS

In both sexes, metrics of hypoglycaemia and glycaemic variability (coefficient of variation [%CV]) positively correlated with BMI percentile. LDL-c positively correlated with mean glucose and metrics of hyperglycaemia. A negative correlation was found between LDL-c and time in range (TIR). No significant correlations were found between CGM metrics and BP percentiles. In both sexes, TIR<70% was significantly associated with LDL-c>100 mg/dL (OR 3.2 in males, 2.1 in females). In females, CV>36% was significantly associated with overweight (OR 2.1).

CONCLUSIONS

CGM metrics of glycaemic control and variability were significantly associated with the risk of overweight in females and high LDL-c in both sexes.

Can obesity exacerbate hyperinsulinaemia in the presence of the mutation of an insulin receptor gene?

Insulin receptor gene (INSR) mutations are a relatively rare and diverse cause of insulin resistance (IR), typically associated with a lean phenotype. However, we present a unique case of severe obesity and Type A severe IR syndrome in a patient with a heterozygous mutation of the INSR gene. Next Generation Sequencing (NGS) analysis was conducted to identify the genetic variant. A 16-year-old girl with severe obesity (BMI-SDS +2.79) exhibited markedly elevated basal insulin levels (>800 mcU/L). Despite obesity being a known cause of hyperinsulinism, further investigation was pursued due to the severity of hyperinsulinaemia. A heterozygous nucleotide variant at the donor splicing site of intron 13 (c.2682 + 1G > A) of the INSR gene was identified. This mutation was also present in the proband's normal-weight mother and her two younger brothers with obesity. Metformin treatment provided limited benefits, but subsequent liraglutide therapy resulted in weight loss and decreased IR 3 months after initiation. Our findings suggest that obesity can exacerbate hyperinsulinaemia in individuals with an INSR gene mutation. Although INSR signalling defects play a minor role in the aetiology of IR, they should still be considered in the diagnostic pathway, particularly in severe phenotypes. Clinicians should not overlook the possibility of genetic causes in patients with obesity and IR, as they may require personalized management approaches.

Satisfaction with continuous glucose monitoring is positively correlated with time in range in children with type 1 diabetes

AIMS

Continuous glucose monitoring (CGM) can improve glucometrics in children with type 1 diabetes (T1D), and its efficacy is positively related to glucose sensor use for at least 60% of the time. We therefore investigated the relationship between CGM satisfaction as assessed by a robust questionnaire and glucose control in pediatric T1D patients.

METHODS

This was a cross-sectional study of children and adolescents with T1D using CGM. The CGM Satisfaction (CGM-SAT) questionnaire was administered to patients and demographic, clinical, and glucometrics data were recorded.

RESULTS

Two hundred and ten consecutively enrolled patients attending 14 Italian pediatric diabetes clinics completed the CGM-SAT questionnaire. CGM-SAT scores were not associated with age, gender, annual HbA1c, % of time with an active sensor, time above range (TAR), time below range (TBR), and coefficient of variation (CV). However, CGM satisfaction was positively correlated with time in range (TIR, p < 0.05) and negatively correlated with glycemia risk index (GRI, p < 0.05).

CONCLUSIONS

CGM seems to have a positive effect on glucose control in patients with T1D. CGM satisfaction is therefore an important patient-reported outcome to assess and it is associated with increased TIR and reduced GRI.

Prevalence and Multidimensional Model of Disordered Eating in Youths With Type 1 Diabetes: Results From a Nationwide Population-Based Study

OBJECTIVE

The aim of this study was to report nationwide data of the prevalence of disordered eating behaviors (DEBs) in adolescents with type 1 diabetes (T1D) and to evaluate a multidimensional model of eating problems, analyzing how psychopathological problems are associated with DEBs and with metabolic control.

METHODS

This study was carried out using a cross-sectional design with a sample of 1,562 patients with T1D (812 male), aged 11-19 years. Participants were recruited from multiple pediatric diabetes centers (N = 30) located in northern, central, and southern Italy, and they individually completed the Diabetes Eating Problem Survey-Revised (DEPS-r) and the Youth Self-Report (YSR). Sociodemographic and clinical data were also gathered. Multiple-group structural equation modeling was used to investigate the relationships between internalizing/externalizing symptoms, DEBs, and glycosylated hemoglobin (HbA1c) values.

RESULTS

A total of 29.7% of the participants reported DEBs (DEPS-r scores ≥20), 42.4% reported insulin manipulation (IM). The prevalence of DEBs was higher for female participants (p ≤ .001). The model explains 37% of the variance in disordered eating, 12% in IM, and 21% in HbA1c values. Body mass index, externalizing symptoms, and internalizing symptoms were significantly and positively associated with DEBs, which in turn were significantly and positively associated with HbA1c values (all p ≤ .001). Externalizing (p ≤ .001) and internalizing (p ≤ .01) symptoms were also directly associated with HbA1c values.

CONCLUSION

Given the relevant prevalence of DEBs, their significant positive association with psychopathological symptoms, and their relationship with worse diabetes outcomes, regular psychological screening and support is needed to ensure the best care of adolescents with T1D.

The treatment of obesity in children and adolescents: consensus position statement of the Italian society of pediatric endocrinology and diabetology, Italian Society of Pediatrics and Italian Society of Pediatric Surgery

This Position Statement updates the different components of the therapy of obesity (lifestyle intervention, drugs, and surgery) in children and adolescents, previously reported in the consensus position statement on pediatric obesity of the Italian Society of Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics. Lifestyle intervention is the first step of treatment. In children older than 12 years, pharmacotherapy is the second step, and bariatric surgery is the third one, in selected cases. Novelties are available in the field of the medical treatment of obesity. In particular, new drugs demonstrated their efficacy and safety and have been approved in adolescents. Moreover, several randomized control trials with other drugs are in process and it is likely that some of them will become available in the future. The increase of the portfolio of treatment options for obesity in children and adolescents is promising for a more effective treatment of this disorder.

Glycemia Risk Index as a novel metric to evaluate the safety of glycemic control in children and adolescents with Type 1 Diabetes: an observational, multicenter, real-life cohort study

Glycemia Risk Index (GRI) is a novel composite metric for the evaluation of the safety of glycemic management and control. The aim of this study was to evaluate GRI and its correlations with continuous glucose monitoring (CGM) metrics by analysing real-life CGM data in 1067 children/adolescents with type 1 Diabetes (T1D) using four different treatment strategies (intermittently scanned CGM [isCGM]-Multiple daily injections [MDI]; real time CGM [rtCGM]-MDI; rt-CGM-insulin pump [IP]; Hybrid Closed-Loop [HCL] therapy). GRI was positively correlated with High Blood Glucose Index (HBGI), Low Blood Glucose Index (LBGI), mean glycemia, its standard deviation, coefficient of variation and HbA1c. The four treatment strategies groups showed significantly different GRI with the lowest value in the HCL group (30.8) and the highest in the isCGM-MDI group (68.4). These findings support the use of GRI for the assessment of the glycemic risk and the safety of specific treatment in paediatric subjects with T1D.

Italian translation and validation of the CGM satisfaction scale questionnaire

AIMS

Patient-reported outcomes (PROs) are increasingly important for assessing patient satisfaction with diabetes technologies. PROs must be assessed with validated questionnaires in clinical practice and research studies. Our aim was to translate and validate the Italian version of the continuous glucose monitoring (CGM) Satisfaction (CGM-SAT) scale questionnaire.

METHODS

Questionnaire validation followed MAPI Research Trust guidelines and included forward translation, reconciliation, backward translation, and cognitive debriefing.

RESULTS

The final version of the questionnaire was administered to 210 patients with type 1 diabetes (T1D) and 232 parents. The completion rate was excellent, with almost 100% of items answered. The overall Cronbach's coefficient was 0.71 and 0.85 for young people (patients) and parents indicating moderate and good internal consistency, respectively. Parent-young people agreement was 0.404 (95% confidence interval: 0.391-0.417), indicating moderate agreement between the two assessments. Factor analysis identified that factors assessing the "benefits" and "hassles" of CGM accounted for 33.9% and 12.9% of score variance in young people and 29.6% and 19.8% in parents, respectively.

DISCUSSION

We present the successful Italian translation and validation of the CGM-SAT scale questionnaire, which will be useful for assessing satisfaction with Italian T1D patients using CGM systems.

Psychological consequences of the COVID-19 pandemic in people with type 1 diabetes: A systematic literature review

OBJECTIVE

A comprehensive picture of the data on the impact of COVID-19 on the mental health of individuals with type 1 diabetes (T1D) is currently lacking. The purpose of this systematic review was to synthesize extant literature reporting on the effects of COVID-19 on psychological outcomes in individuals with T1D and to identify associated factors.

METHODS

A systematic search was conducted with PubMed, Scopus, PychInfo, PsycArticles, ProQuest, and WoS using a selection procedure according to the PRISMA methodology. Study quality was assessed using a modified Newcastle-Ottawa Scale. In all, 44 studies fulfilling the eligibility criteria were included.

RESULTS

Findings suggest that during the COVID-19 pandemic, people with T1D had impaired mental health, with relatively high rates of symptoms of depression (11.5-60.7%, n = 13 studies), anxiety (7-27.5%, n = 16 studies), and distress (14-86.6%, n = 21 studies). Factors associated with psychological problems include female gender, lower income, poorer diabetes control, difficulties in diabetes self-care behaviors, and complications. Of the 44 studies, 22 were of low methodological quality.

CONCLUSIONS

Taking appropriate measures to improve medical and psychological services is needed to support individuals with T1D in appropriately coping with the burden and difficulties caused by the COVID-19 pandemic and to prevent mental health problems from enduring, worsening, or having a long-term impact on physical health outcomes. Heterogeneity in measurement methods, lack of longitudinal data, the fact that most included studies did not aim to make a specific diagnosis of mental disorders limit the generalizability of the findings and have implications for practice.

Adolescents with type 1 diabetes vs. hybrid closed loop systems: a case series of patients' behaviour that challenges the algorithm

OBJECTIVES

Hybrid closed loop systems (HCL) improve the management of type 1 diabetes (T1DM). T1DM adolescent patients represent a risk category also if they are in an automated insulin infusion delivery therapy.

CASE PRESENTATION

We describe a series of four cases in which adolescent patients have adopted incorrect behaviours in the managing of HCL systems, challenging the algorithm skills. Two patients performed fabricated sensor calibrations. The other two did not perform pre-prandial insulin boluses correctly. Despite these behaviours, the algorithm corrected the glucose values in three out of four patients. Only in one case, where fabricated calibrations were too frequent, the automatic system failed to restore the glycemic balance.

CONCLUSIONS

Fabricated calibrations seem to be more important than uncorrected insulin boluses to challenge the HCL systems.

Euthyroid sick syndrome and its association with complications of type 1 diabetes mellitus onset

OBJECTIVE

To evaluate (i) the prevalence and association of euthyroid sick syndrome (ESS) [decreased FT3 and/or FT4 and normal/decreased TSH] with severity indexes of type 1 diabetes mellitus (T1DM) onset such as diabetic ketoacidosis (DKA) and kidney damage [acute kidney injury (AKI) based on KDIGO criteria, acute tubular necrosis (ATN), renal tubular damage (RTD)], (ii) relationship between clinical/metabolic parameters at T1DM onset and thyroid hormones, and (iii) ESS as a prognostic indicator of delayed recovery from kidney damage.

METHODS

A total of 161 children with T1DM onset were included. RTD was defined by abnormal urinary beta-2-microglobulin and/or neutrophil gelatinase-associated lipocalin (NGAL) and/or tubular reabsorption of phosphate <85% and/or fractional excretion of Na>2%. ATN was defined by RTD+AKI.

RESULTS

Of 161 participants, 60 (37.3%) presented ESS. It was more prevalent in case of more severe T1DM presentation both in terms of metabolic derangement (DKA) and kidney function impairment (AKI, RTD and ATN). Only ATN, however, was associated with ESS at adjusted analysis. FT3 inversely correlated with serum triglycerides and creatinine, and urinary calcium/creatinine ratio and NGAL. Participants with euthyroidism showed earlier recovery from AKI than those with ESS. ESS spontaneously disappeared.

CONCLUSIONS

ESS is associated with T1DM onset severity and spontaneously disappears. ESS delayed the recovery from AKI.

IMPACT

This is the first longitudinal study describing in detail the relationship between clinical/metabolic factors at type 1 diabetes mellitus (T1DM) onset and thyroid hormones, with particular attention to the relationship between diabetic ketoacidosis (DKA)-related kidney function impairment and euthyroid sick syndrome (ESS). Participants with more severe T1DM onset presentation both in terms of metabolic derangement and kidney function impairment had an increased prevalence of ESS. Children with ESS had a slower recovery from acute kidney injury compared with those without ESS. ESS spontaneously disappeared in all participants.

Prevalence of disordered eating behaviors in adolescents with type 1 diabetes: Results of multicenter Italian nationwide study

OBJECTIVE

To assess the prevalence of disordered eating behaviors (DEBs) in a large sample of Italian adolescents with type 1 diabetes and to explore potential demographic, clinical, and psychological differences (understood as emotional and behavioral problems) among adolescents with and without DEBs.

METHOD

Adolescents (11-19 years) with type 1 diabetes completed the Diabetes Eating Problems Survey-revised (DEPS-r) and the Youth Self Report (YSR). Demographic and clinical data were also collected.

RESULTS

Of 690 adolescents with type 1 diabetes (mean age 14.97 ± 1.81, n = 337 girls) assessed in this study, 28.1% (21% boys, 35% girls) were DEPS-r positive (score ≥ 20). Girls had higher DEPS-r total scores (p < .0001, d = .42) than boys, although no age differences were found in mean DEPS-r total scores (p = .961). In both genders, adolescents with DEBs had significantly higher zBMI (p < .0001, d = .52) and HbA1c values (p < .0001, d = .54) and showed more emotional and behavioral problems (both as internalizing and externalizing problems) than those without DEBs (all p < .0001). These differences were largely confirmed in all age groups. Adolescents reporting insulin misuse had higher HbA1c values (p = .001, d = .26), higher DEPS-r mean scores (p < .0001, d = 1.07), and greater psychological problems (all p < .001) than those who did not.

DISCUSSION

DEBs are prevalent among adolescents with type 1 diabetes, and those with eating problems showed adverse clinical and psychological conditions. Routine screening for DEBs and of general psychological condition should be a fundamental part of diabetes care, especially during adolescence.

PUBLIC SIGNIFICANCE STATEMENT

This nationwide study indicated that DEBs are common in adolescents with T1D, and those suffering from them show poorer clinical conditions and higher emotional and behavioral problems. As such, it offers important contributions for those working with EDs and in the T1D field, as it provides a deeper understanding of the co-occurring DEBs-emotional/behavioral problems in youths with T1D and highlights the importance of continuous monitoring of their psychological condition by a multidisciplinary team.

Uric acid and cardiometabolic risk by gender in youth with type 1 diabetes

The aim of this study was to investigate the association between uric acid (UA) and cardiometabolic risk factors (CMRFs) by sex in youth with type 1 diabetes (T1D). Retrospective data collected from 1323 children and adolescents (5–18 years; 716 boys) with T1D recruited in 9 Italian Pediatric Diabetes Centers were analyzed. CMRFs included UA, HbA_1c, blood pressure (BP), cholesterol (TC), HDL, triglycerides (TG), neutrophils (N) and lymphocytes (L) count, glomerular filtration rate (eGFR) (calculated using Schwartz-Lyon equation). In boys, we found a higher age, daily insulin dose, TG, TG/HDL ratio, TC/HDL ratio, systolic BP, N/L ratio and lower HDL, and eGFR across UA tertiles (p = 0.01–0.0001). Similar results were found in girls but not for TG and systolic BP. In boys, the odds ratio (OR) of high levels of TG/HDL ratio, TC/HDL ratio, BP and mildly reduced eGFR (MRGFR) increased for 0.5 mg/dL of UA. Instead, in girls an increased levels of 0.5 mg/dL of UA were associated with high OR of TC/HDL ratio, N/L ratio and MRGFR. Uric acid may represent a useful marker for identifying youth with T1D at high cardiometabolic risk, and this association appears to vary by sex.

Very low birth weight newborn with diabetes mellitus due to pancreas agenesis managed with insulin pump reservoir filled with undiluted insulin: 16-month follow-up

BACKGROUND

When very low doses of insulin are used insulin dilution, a procedure prone to errors, is recommended.

CASE PRESENTATION

We managed a neonate with pancreas agenesis with insulin pump therapy from the first days of life to 16 months of age without insulin dilution. Predictive low glucose suspend mode first and then closed loop control were used. No episodes of severe hypoglycemia were observed.

CONCLUSIONS

Though limited to a single patient with pancreas agenesis we believe that the use of pump should be warranted in patients with permanent neonatal diabetes mellitus and intestinal malabsorption, even with undiluted insulin.

Eating Problems in Youths with Type 1 Diabetes During and After Lockdown in Italy: An 8-Month Follow-Up Study

Eighty-five youths with T1D and 176 controls aged 8–19 years were asked to complete online questionnaires (ChEAT and EAT-26) measuring disordered eating behaviors (DEBs) during (baseline) and after (8-month follow-up) the lockdown. DEB symptoms in all participants (especially younger than 13 years), glycemic control, and zBMI were found unchanged from baseline to follow-up (all p > .05). After 8 months, the ChEAT/EAT-26 critical score frequency decreased significantly in controls (p = .004), as was the score for the ChEAT/EAT-26’s Oral Control subscale in both groups (T1D: p = .005; controls: p = .01). Participants with T1D, especially those older than 13 years, had higher ChEAT/EAT-26 Dieting scores (p = .037) and lower ChEAT/EAT-26 Oral Control scores (p = .046) than controls. Unchanged DEB symptoms suggest that the COVID-19 restrictions did not significantly affect participants’ eating behaviors and that a general adaptation to the challenges of lockdown and other pandemic containment measures occurred in both T1D and control participants.

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.

High Glycemic Variability Is Associated with Worse Continuous Glucose Monitoring Metrics in Children and Adolescents with Type 1 Diabetes

OBJECTIVE

The primary aim of this study was to quantify the prevalence of children and adolescents with type 1 diabetes (T1D) who achieve the recommended target for coefficient of variation (CV) identifying the determining factors to reach this target. The secondary aim was to examine the relationship between CV, the other metrics derived from continuous glucose monitoring (CGM) data and clinical parameters.

METHOD

CGM data were collected from 805 children/adolescents with T1D. Several CGM metrics and patients' characteristics were evaluated. Participants were stratified by CV ≤36% and CV >36%. Binary logistic regression analysis was run to identify the determining factors of high CV.

RESULTS

CV was positively correlated with %TBR <70 mg/dL, %TBR <54 mg/dL, %TAR >250 mg/dL, low blood glucose index, and high blood glucose index and negatively with %TIR. CV ≤36% was found in 31.4% of the subjects. The CV >36% group spent less time in %TIR, more time in hypoglycemia and hyperglycemia with lower proportion of subjects using real-time CGM and continuous subcutaneous insulin infusion. Percentage of TBR <70 mg/dL and TAR >250 mg/dL were significant predictors of CV >36%, whereas age, gender, BMI, duration of diabetes, type of CGM device, type of insulin therapy administration and %TIR were not significant predictors (p < 0.001, R2 Nagelkerke = 0.48).

CONCLUSIONS

CV identifies children and adolescents with worse glycemic control at higher risk of both hypoglycemia and hyperglycemia.

Evaluation of HbA1c and glucose management indicator discordance in a population of children and adolescents with type 1 diabetes

BACKGROUND

Glucose management indicator (GMI) is a useful metric for the clinical management of diabetic patients using continuous glucose monitoring (CGM). In adults, a marked discordance between HbA1c and GMI has been reported. To date, no studies have evaluated this discordance in children/adolescents with type 1 diabetes (T1D).

METHODS

HbA1c and real-life CGM data of the 12 weeks preceding HbA1c measurement were collected from 805 children/adolescents. The absolute difference between HbA1c and GMI was calculated for both the 12-week and 4-week periods preceding HbA1c measurement and the proportion of discordant patients was defined according to specific thresholds in the entire study population and in subjects stratified by type of CGM, insulin therapy, gender, age and puberty. Regression analyses were performed with HbA1c-GMI discordance as dependent variable and patients' characteristics as independent ones. A new GMI equation for children and adolescent was derived from the linear regression analysis between mean glucose and HbA1c.

RESULTS

HbA1c-GMI discordance calculated on the 12-week period was <0.1, ≥0.5 and ≥1.0 in 24.8, 33.9 and 9.2% of the subjects, respectively. No significant differences in the proportion of discordant patients were found comparing patients stratified by type of CGM, insulin therapy, gender, age and puberty. GMI-HbA1c discordance was not significantly explained by age, gender, BMI, type of CGM, insulin therapy, hemoglobin, anemia and autoimmune diseases (R²  = 0.012, p = 0.409). HbA1c-GMI discordance calculated on the 4-week period was comparable. GMI (%) equation derived for this cohort was: 3.74 + 0.022x (mean glucose in mg/dl).

CONCLUSIONS

GMI could be meaningfully discordant respect to HbA1c in more than a third of children/adolescents with T1D. This discrepancy should be taken into careful consideration when the two indices are directly compared in daily clinical practice.

Corrigendum: 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

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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.

Comparison of emotional approaches of medical doctors against COVID-19 pandemic: Eastern and Western Mediterranean countries

BACKGROUND

Pandemics are states of disease that occur worldwide and sharply increase in populations. It causes life events which trigger anxiety, depression, anger, sleep deprivation, emotional distress and stress. World Health Organization (WHO) declared coronavirus disease 2019 (COVID-19) a pandemic on March 11, pointing to the over 118,000 cases in over 110 countries. Many healthcare workers became ill during the pandemic and some among them died. In this study, we aimed to evaluate and compare level of stress against COVID-19 pandemic among doctors from Turkey and Italy.

METHODS

This research is a cross-sectional study in which Perceived Stress Scale (PSS-10) and Secondary Traumatic Stress Scale (STSS) are administered online via social networks. All data collection tools were delivered to individuals between 1 and 15 June 2020 and filled in online with Google Forms application. In total, 618 individuals were included in this study and all of them were medical doctors.

RESULTS

Higher PS and STS levels were found related to female gender, being married, working in pandemic hospital and older ages. Stress levels were found statistically higher in Turkish doctors when compared to Italian doctors for both stress scales (Turkish/Italian PSS:20.18 ± 7.90/ 19.35 ± 6.71, STSS: 44.19 ± 13.29/ 38.83 ± 13.74).

CONCLUSION

The number of doctors per 1000 of population is lower and per capita visits to a physician are higher in Turkey when compared to Italy. Besides pandemic, these heavier working conditions, increased weekly working hours can cause stress for Turkish doctors. Reporting information such this study is important and international collaborations are essential to plan future prevention strategies. We need to strengthen international ties and build more international collaborations rather than staying within our national silos. Additionally, interventions to promote mental well-being in health care professionals exposed to COVID-19 need to be immediately implemented.

Effectiveness of a closed-loop control system and a virtual educational camp for children and adolescents with type 1 diabetes: A prospective, multicentre, real-life study

AIM

To evaluate the impact of a virtual educational camp (vEC) on glucose control in children and adolescents with type 1 diabetes using a closed-loop control (CLC) system.

MATERIALS AND METHODS

This was a prospective multicentre study of children and adolescents with type 1 diabetes using the Tandem Basal-IQ system. Insulin pumps were upgraded to Control-IQ, and children and their parents participated in a 3-day multidisciplinary vEC. Clinical data, glucose metrics and HbA1c were evaluated over the 12 weeks prior to the Control-IQ update and over the 12 weeks after the vEC.

RESULTS

Forty-three children and adolescents (aged 7-16 years) with type 1 diabetes and their families participated in the vEC. The median percentage of time in target range (70-180 mg/dL; TIR) increased from 64% (interquartile range [IQR] 56%-73%) with Basal-IQ to 76% (IQR 71%-81%) with Control-IQ (P < .001). After the vEC, more than 75% of participants achieved a TIR of more than 70%. The percentage of time between 180 and 250 mg/dL and above 250 mg/dL decreased by 5% (P < .01) and 6% (P < .01), respectively, while the time between 70 and 54 mg/dL and below 54 mg/dL remained low and unaltered. HbA1c decreased by 0.5% (P < .01). There were no episodes of diabetic ketoacidosis or severe hypoglycaemia.

CONCLUSIONS

In this study of children managing their diabetes in a real-world setting, more than 75% of children who participated in a vEC after starting a CLC system could obtain and maintain a TIR of more than 70%. The vEC was feasible and resulted in a significant and persistent improvement in TIR in children and adolescents with type 1 diabetes.

Rethinking Carbohydrate Intake and Time in Range in Children and Adolescents with Type 1 Diabetes

The aim of this study was to evaluate the association between macronutrient intake and time in range (TIR) of 70–180 mg/dL in children and adolescents with type 1 diabetes (T1D). A multi-center study recruited patients with T1D using continuous glucose monitoring (CGM) between January 2019 and January 2020 from centers across Italy. Diet intake was recorded using three-day weighed food diaries. Nutrients were evaluated as percentages of total intake. TIR was considered at target if the percentage of readings was higher than 70%. Clinical and nutritional factors associated with TIR at target were analyzed using multiple correspondence analysis and multiple logistic regression. Data from 197 participants (53% male, median age 11.6 years, median HbA1c 55.2 mmol/mol, median TIR 60%) were analyzed. Macronutrient intake was 45.9% carbohydrates, 16.9% protein, 37.3% fat, and 13.1 g/day fiber (median values). TIR > 70% was observed in 28% of participants; their diet contained more protein (17.6%, p = 0.015) and fiber (14.4 g/day, p = 0.031) than those not at target. The probability of having a TIR > 70% was significantly higher with 40–44% consumption of carbohydrates compared with 45–50% consumption of carbohydrates and with the use of a carbohydrate counting system. Based on these results, a five percent reduction in the percentage of carbohydrate intake can help children and adolescents with T1D achieve the goal of a TIR > 70%. Both a lower and higher percentage of carbohydrate intake appears to reduce the probability of reaching the target TIR > 70%. These results require validation in other populations before being used in clinical practice.

Renal Involvement in Children with Type 2 Diabetes Mellitus Onset: A Pilot Study

Type 2 Diabetes Mellitus (T2DM) is a main cause of chronic kidney disease (CKD) in adulthood. No studies have examined the occurrence of acute kidney injury (AKI)-that enhances the risk of later CKD-and renal tubular damage (RTD)-that can evolve to AKI-in children with onset of T2DM. We aimed to evaluate the prevalence and possible features of AKI and RTD in a prospectively enrolled population of children with onset of T2DM. We consecutively enrolled 10 children aged 12.9 ± 2.3 years with newly diagnosed T2DM. AKI was defined according to the KDIGO criteria. RTD was defined by abnormal urinary beta-2-microglobulin and/or tubular reabsorption of phosphate (TRP) <85% and/or fractional excretion of Na >2%. None of the patients developed AKI, whereas 3/10 developed RTD with high beta-2-microglobulin levels (range: 0.6-1.06 mg/L). One of these three patients also presented with reduced TRP levels (TRP = 70%). Proteinuria was observed in two out of three patients with RTD, while none of patients without RTD had proteinuria. Patients with RTD presented higher beta-2-microglobulin, acute creatinine/estimated basal creatinine ratio, and serum ketones levels compared with patients without RTD. In conclusion, in our pilot observation, we found that none of the 10 children with T2DM onset developed AKI, whereas three of them developed RTD.

Type 2 diabetes in pediatrics

Type 2 diabetes (T2D) in adolescents has become an increasing health concern throughout the world and its prevention and screening should be implemented in pediatric care. As clinical features at presentation, in some cases can be similar to type 1 diabetes and family history can be in favour of a monogenic form of diabetes, it is pivotal for physicians to be aware of youth-onset T2D specificities to ensure an accurate diagnosis. The global increase of overweight and obesity can complicate the diagnostic process and makes it essential to apply a systematic approach to each new diagnosis. Microvascular complications may be present at the time of diagnosis and chronic complications are frequent and need to be screened regularly. Regular screening of comorbidities should also be performed. Childhood T2D should be followed up by pediatric diabetes units to avoid diagnostic errors and delay in care. A multidisciplinary approach, by an experienced team, is pivotal to provide treatment options targeting the unique needs of pediatric patients. Treatment programs must include the whole family and address all the aspects of the care (lifestyle, pharmacological therapy, psychological aspects, complications and comorbidities). An organized process of transition to adult care is essential.

"CoVidentary": An online exercise training program to reduce sedentary behaviours in children with type 1 diabetes during the COVID-19 pandemic

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Covid-19 restrictions disrupted physical activities in children with type 1 diabetes.

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Diabetes management worsened in glycemia values and insulin delivery.

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Active breaks rather than structured training may interrupt sedentary in children with type 1 diabetes.

Aim

We explored the physical activity (PA) level and the variation in glycaemic control in children with type 1 diabetes (T1D) before and during the lockdown. Then, we proposed an online training program supported by sport-science specialists.

Methods

Parents of children with T1D (<18 years) filled out an online survey. Anthropometric characteristics, PA, play, sport and sedentary time and the medical related outcomes were recorded. An adapted online program “Covidentary” was proposed through full-training (FT) and active breaks (AB) modality.

Results

280 youth (11.8 ± 3.3 years) were included in the analysis. We reported a decline in sport (-2.1 ± 2.1 h/week) and outdoor-plays (-73.9 ± 93.6 min/day). Moreover, we found an increase in sedentary time (+144.7 ± 147.8 min/day), in mean glycaemic values (+25.4 ± 33.4 mg/dL) and insulin delivery (71.8% of patients). 37% of invited patients attended the training program, 46% took part in AB and 54% in FT. The AB was carried out for 90% of the total duration, while the FT for 31%. Both types of training were perceived as moderate intensity effort.

Conclusion

A decline of participation in sport activities and a subsequent increase of sedentary time influence the management of T1D of children, increasing the risk of acute/long-term complications. Online exercise program may contrast the pandemic's sedentary lifestyle.

Relationships between HbA1c and continuous glucose monitoring metrics of glycaemic control and glucose variability in a large cohort of children and adolescents with type 1 diabetes

AIMS

To evaluate the relationships between HbA1c and Continuous Glucose Monitoring (CGM) metrics in children/adolescents with Type 1 Diabetes (T1D).

METHODS

HbA1c and real-life CGM data of the 12 weeks preceding its measurement were retrospectively collected from 654 children/adolescents with T1D. The relationships between HbA1c and CGM metrics were assessed by Spearman correlation coefficient. Participants were categorized into groups based on HbA1c and CGM metrics values. ANOVA was run across HbA1c and CGM metrics groups in the entire study population and in subjects stratified by CGM type, insulin therapy, age and puberty.

RESULTS

HbA1c was positively correlated with mean glucose, SD, %TAR > 180 mg/dL, %TAR > 250 mg/dL, HBGI and negatively with %TIR, %TBR and %time < 54 mg/dL. HbA1c-based groups were significantly associated with these metrics, but for each group their value widely ranged with a substantial overlap between them. HbA1c and HbA1c-based groups were not associated with %CV and LBGI, as well as %CV and LBGI-based groups had not significantly different HbA1c. Comparable results were found analysing subjects according to age, type of CGM, insulin therapy and puberty.

CONCLUSIONS

The relationships between HbA1c and CGM metrics described in this cohort of paediatric subjects with T1D support the importance of the evaluation of these metrics, in particular %CV and LBGI, independently of HbA1c value.

Albuminuric and non-albuminuric reduced eGFR phenotypes in youth with type 1 diabetes: Factors associated with cardiometabolic risk

BACKGROUND AND AIM

Albuminuria and reduced eGFR are hallmarks of Diabetic Kidney Disease in adults. Our aim was to analyze factors associated with albuminuric and non-albuminuric mildly reduced eGFR phenotypes in youths with type 1 diabetes.

METHODS AND RESULTS

This multicenter cross-sectional study included 1549 youths (age 5-17 years) with type 1 diabetes enrolled at 14 Italian Pediatric Diabetes Centers. Albuminuria, creatinine, glycosylated hemoglobin (HbA1c), lipids, blood pressure (BP), neutrophils (N) and lymphocytes (L) count were analyzed. Uric acid (UA) was available in 848 individuals. Estimated GFR (eGFR) was calculated using bedside Schwartz's equation. The sample was divided in three phenotypes: 1) normoalbuminuria and eGFR ≥90 mL/min/1.73 m² (reference category, n = 1204), 2) albuminuric and normal GFR phenotype (n = 106), 3) non-albuminuric mildly reduced GFR (MRGFR) phenotype (eGFR 60-89 mL/min/1.73 m², n = 239). Albuminuric and non-albuminuric reduced eGFR phenotypes were significantly associated with autoimmune thyroiditis (P =0.028 and P=0.044, respectively). Albuminuric phenotype showed high risk of high HbA1c (P=0.029), high BP (P < 0.001), and low HDL-C (P =0.045) vs reference category. Non-albuminuric MRGFR phenotype showed high risk of high BP (P < 0.0001), low HDL-C (P =0.042), high Triglycerides/HDL-C ratio (P =0.019), and high UA (P < 0.0001) vs reference category.

CONCLUSION

Non albuminuric MRGFR phenotype is more prevalent than albuminuric phenotype and shows a worst cardiometabolic risk (CMR) profile). Both phenotypes are associated with autoimmune thyroiditis. Our data suggest to evaluate both albuminuria and eGFR earlier in type 1 diabetes to timely identify young people with altered CMR profile.

Acute Kidney Injury and Renal Tubular Damage in Children With Type 1 Diabetes Mellitus Onset

CONTEXT

Acute kidney injury (AKI) and renal tubular damage (RTD), especially if complicated by acute tubular necrosis (ATN), could increase the risk of later chronic kidney disease. No prospective studies on AKI and RTD in children with type1diabetes mellitus (T1DM) onset are available.

OBJECTIVES

To evaluate the AKI and RTD prevalence and their rate and timing of recovery in children with T1DM onset.

DESIGN

Prospective study.

SETTINGS AND PATIENTS

185 children were followed up after 14 days from T1DM onset. The patients who did not recover from AKI/RTD were followed-up 30 and 60 days later.

MAIN OUTCOME MEASURES

AKI was defined according to the KDIGO criteria. RTD was defined by abnormal urinary beta-2-microglobulin and/or neutrophil gelatinase-associated lipocalin and/or tubular reabsorption of phosphate < 85% and/or fractional excretion of Na (FENa) > 2%. ATN was defined by RTD+AKI, prerenal (P)-AKI by AKI+FENa < 1%, and acute tubular damage (ATD) by RTD without AKI.

RESULTS

Prevalence of diabetic ketoacidosis (DKA) and AKI were 51.4% and 43.8%, respectively. Prevalence of AKI in T1DM patients with and without DKA was 65.2% and 21.1%, respectively; 33.3% reached AKI stage 2, and 66.7% of patients reached AKI stage 1. RTD was evident in 136/185 (73.5%) patients (32.4% showed ATN; 11.4%, P-AKI; 29.7%, ATD). All patients with DKA or AKI presented with RTD. The physiological and biochemical parameters of AKI and RTD were normal again in all patients. The former within 14 days and the latter within 2months.

CONCLUSIONS

Most patients with T1DM onset may develop AKI and/or RTD, especially if presenting with DKA. Over time the physiological and biochemical parameters of AKI/RTD normalize in all patients.

A case report of a boy suffering from type 1 diabetes mellitus and familial Mediterranean fever

BACKGROUND

Type 1 diabetes mellitus could be associated with other autoimmune diseases, such as autoimmune thyroid disease, celiac disease, but the association with Familial Mediterranean Fever is rare, we describe a case of a boy with type 1 Diabetes Mellitus associated with Familial Mediterranean Fever (FMF).

CASE PRESENTATION

A 13 year old boy already suffering from Diabetes Mellitus type 1 since the age of 4 years, came to our attention because of periodic fever associated with abdominal pain, chest pain and arthralgia. The fever appeared every 15-30 days with peaks that reached 40 °C and lasted 24-48 h. Laboratory investigation, were normal between febrile episodes, but during the attacks revealed an increase in inflammatory markers. Suspecting Familial Mediterranean Fever molecular analysis of MEFV gene, was performed. The genetic analysis showed homozygous E148Q mutation. So Familial Mediterranean Fever was diagnosed and colchicine treatment was started with good response.

CONCLUSION

Familial Mediterranean Fever could be associated with other autoimmune diseases such as Ankylosing Spondylitis, Rheumatoid Arthritis, Polyarteritis Nodosa, Behcet disease, Systemic Lupus, Henoch-Schönlein Purpura, and Hashimoto's Thyroiditis. Association of type 1 Diabetes Mellitus and Familial Mediterranean Fever has been newly reported in the medical literature, this is the third association of these two diseases described in the medical literature so far.

Differences between transient neonatal diabetes mellitus subtypes can guide diagnosis and therapy

OBJECTIVE

Transient neonatal diabetes mellitus (TNDM) is caused by activating mutations in ABCC8 and KCNJ11 genes (KATP/TNDM) or by chromosome 6q24 abnormalities (6q24/TNDM). We wanted to assess whether these different genetic aetiologies result in distinct clinical features.

DESIGN

Retrospective analysis of the Italian data set of patients with TNDM.

METHODS

Clinical features and treatment of 22 KATP/TNDM patients and 12 6q24/TNDM patients were compared.

RESULTS

Fourteen KATP/TNDM probands had a carrier parent with abnormal glucose values, four patients with 6q24 showed macroglossia and/or umbilical hernia. Median age at diabetes onset and birth weight were lower in patients with 6q24 (1 week; -2.27 SD) than those with KATP mutations (4.0 weeks; -1.04 SD) (P = 0.009 and P = 0.007, respectively). Median time to remission was longer in KATP/TNDM than 6q24/TNDM (21.5 weeks vs 12 weeks) (P = 0.002). Two KATP/TNDM patients entered diabetes remission without pharmacological therapy. A proband with the ABCC8/L225P variant previously associated with permanent neonatal diabetes entered 7-year long remission after 1 year of sulfonylurea therapy. Seven diabetic individuals with KATP mutations were successfully treated with sulfonylurea monotherapy; four cases with relapsing 6q24/TNDM were treated with insulin, metformin or combination therapy.

CONCLUSIONS

If TNDM is suspected, KATP genes should be analyzed first with the exception of patients with macroglossia and/or umbilical hernia. Remission of diabetes without pharmacological therapy should not preclude genetic analysis. Early treatment with sulfonylurea may induce long-lasting remission of diabetes in patients with KATP mutations associated with PNDM. Adult patients carrying KATP/TNDM mutations respond favourably to sulfonylurea monotherapy.

Children and youth with diabetes are not at increased risk for hospitalization due to COVID-19

The severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), responsible for the coronavirus disease COVID-19, was first identified in Wuhan, China in December 2019. Diabetes, as well as other cardiovascular comorbidities, has been recognized as a major risk factor for outcomes and mortality in adults with COVID-19, particularly in the elderly with type 2 diabetes. Based on these conclusions, COVID-19 data on adults have been generalized to youth with diabetes. Nevertheless, experience from pediatric diabetes practices in China (Wuhan), Italy, Spain (Catalonia), and the United States (San Francisco Bay Area) consistently report only a single severe case of COVID-19 in a 20-year-old female youth with type 1 diabetes (T1D) that was hospitalized for bilateral pneumonia and was subsequently discharged without complications. In Italy, information on COVID-19 in all children with diabetes is collected on a weekly basis and those with positive swab test or infection-related symptoms reported to a dedicated national registry. Of a total of 15 500 children tested, 11 subjects with T1D (age 8-17y) tested positive for COVID-19; 6/11 were asymptomatic and the rest presented with mild symptoms. In the rest of locations, youths with T1D diagnosed with COVID-19 were based on clinical suspicion and a confirmatory PCR test (Wuhan:0; Catalonia-HSJD:3; California-Stanford:2). All of them were asymptomatic or had a mild course. We suggest that COVID-19 data from adults should not be generalized to children, adolescents, and youth with diabetes as their outcomes and prognosis seem to be similar to their non-diabetic-peers and consistently milder than adults with diabetes.

Gastrointestinal Henoch-Schönlein purpura successfully treated with Mycophenolate Mofetil: Description of 2 case reports

RATIONALE

Henoch-Schönlein Purpura (HSP) is an acute small vessel vasculitis. It is the most common vasculitis in children. In majority of the cases, the disease is self-limited. Relapses can occur, in particular during the first year of the disease. There is no consensus on a specific treatment. The efficacy and safety of steroidal treatment in treating HSP is still controversial. Immunosuppressive treatment of HSP nephritis is used in patients with severe renal involvement (nephrotic range proteinuria and/or progressive renal impairment). The literature on immunosuppressive treatment of severe HSP without kidney involvement is scanty.

PATIENTS CONCERNS

We report 2 case reports of 2 adolescents affected from Henoch-Schönlein Purpura and severe gastrointestinal involvement. Both patients presented a poor response to steroids treatment.

DIAGNOSES

The diagnosis of HSP was made according to the diagnostic criteria published by European League against Rheumatism and Pediatric Rheumatology European Society in 2006.

INTERVENTIONS

In consideration of the recurrence of the Henoch Schönlein Purpura and the gastrointestinal involvement, we decided to start Mycophenolate Mofetil treatment.

OUTCOMES

In both patients all clinical manifestations resolved in few days.

LESSONS

In our cases of HSP with gastrointestinal involvement Mycophenolate Mofetil treatment has been very effective. This experience teaches us that immunosuppressive agents may be very useful to induce and maintain remission not only in renal involvement, but in all cases of persistent, recurrent, or complicated Henoch Schönlein Purpura in children.

Psychological Outcomes in Children and Early Adolescents With Type 1 Diabetes Following Pediatric Diabetes Summer Camp: A 3-Month Follow-Up Study

Objective: The aim of this study was to assess general psychosocial adjustment to diabetes and perceived disease management among patients with type 1 diabetes (T1D) and their parents before and after patients' participation in a diabetes summer camp. Methods: In this follow-up study, 20 children and adolescents with T1D (eight boys; mean age = 11.01 ± 0.94 years; mean diabetes duration = 3.02 ± 2.27) attending a southern Italian diabetic center, along with their parents, were assessed prior to and 3 months after the youths participated in a 1 week camp-based intervention involving didactic and interactive child-centered education and recreational activities. Patients and their parents completed measures assessing patients' quality of life and strategies employed by patients to cope with pain. Patients also completed measures evaluating their diabetes psychosocial adjustment, diabetes self-efficacy management, and illness perception; also, their parents completed measures of caregivers' perceived diabetes burden and treatment satisfaction. Youths' glycated hemoglobin (HbA1c) and standardized body mass index (z-BMI) values were also assessed. Within-subjects repeated-measures analyses of variance evaluated pre- and post-camp changes. Results: Camp attendance showed no beneficial effects on glycemic control, as indicated by HbA1c values both before (7.02%) and after (7.28%) camp being lower than 7.5%. HbA1c values were found to have increased after camp (pre-camp = 7.02%, post-camp = 7.28%; p = 0.010), but since they still fell within an acceptable range, they did not reveal clinically relevant changes in glycemic control. No substantial significant improvement in psychosocial measures was observed in children or parents (all p > 0.05). According to the parents' evaluation, social support-seeking as a patient pain-coping strategy was slightly increased (p = 0.044) after attending the camp. Conclusions: This study does not provide empirical evidence of benefits of participating in a diabetes camp for either patients or their parents. These findings suggest that healthcare providers rethink such camps as an experience for youths with T1D that actively involves parents and that includes both youth- and parent-focused psychological interventions.

Disordered eating behaviors in youths with type 1 diabetes during COVID-19 lockdown: an exploratory study

BACKGROUND

Recent research indicates that patients with type 1 diabetes (T1D) are at higher risk for disordered eating behaviors (DEBs) than their peers without diabetes. The present study aimed to explore the prevalence of DEBs in a sample of Italian children and adolescents with T1D and in matched-pair healthy controls during the COVID-19 lockdown.

METHODS

In a cross-sectional study, 138 children and adolescents with T1D (aged 8.01-19.11 years, 65 boys) attending a Southern Italian diabetic service and 276 age- and gender-matched healthy peers voluntarily completed an online survey about eating behaviors (ChEAT and EAT-26), anthropometric characteristics, and clinical characteristics.

RESULTS

8.69% (N = 12) of participants with T1D and 13.4% (N = 37) of controls had ChEAT/EAT-26 scores indicating presence of DEBs, with no differences between patients-whether children (total ChEAT score F(1, 157) = .104, p = .748) or adolescents (total EAT-26 score F(1, 255) = .135, p = .731)-and healthy peers. zBMI values were lower than those measured in the latest diabetes visit (p < .0001), while HbA1c values remained unchanged (p = .110). In both groups, adolescents had lower Oral Control scores than children (T1D: F(1, 138) = 20.411, p < .0001, η2 = .132, controls: F(1, 276) = 18.271, p < .0001, η2 = .063); additionally, gender (female) and age were found to be significant predictors of several ChEAT/EAT-26 scores.

CONCLUSIONS

This exploratory study suggested that children and adolescents with T1D did not experience more DEB symptoms during the COVID-19 lockdown compared to healthy controls. Results revealed DEBs as more of a female adolescent developmental issue rather than a result of the challenges of living with a chronic illness under quarantine measures. Possible effects of parental pressure on their children's eating behaviors in the context of home confinement and of using a non-diabetes-specific measure to assess DEBs are discussed.

Long-term glycemic control and glucose variability assessed with continuous glucose monitoring in a pediatric population with type 1 diabetes: Determination of optimal sampling duration

BACKGROUND

No studies have assessed if 2-week of continuous glucose monitoring (CGM) data provide good estimation of long-term glycemic control and glucose variability (GV) in pediatric patients with type 1 diabetes (T1D) as in adults.

METHODS

Six hundred fifty-four T1D pediatric patients were enrolled and 12-weeks of CGM data, before HbA1c measurement, were collected. Metrics of glycemic control and GV in incremental sampling periods were calculated. The agreement between metrics calculated in the sampling periods and the full 12-week period was assessed with correlation analysis (R² ), median relative absolute difference (RAD) or absolute difference in the entire study populations and subjects stratified by age, pubertal status, insulin therapy (MDI,CSII), type of CGM (intermittently scanned [isCGM], real-time [rtCGM]), and HbA1c level.

RESULTS

Correlations with metrics of the full 12-week period improved by extending the sampling periods. R² values close to 0.90 using 4-week period were significantly higher than 2-week period, particularly for coefficient of variation, mean glucose SD, percentage of time below the range <70 mg/dL. A significant difference was found comparing the median RAD of 2- and 4-week, especially for mean glucose and coefficient of variation. Similar results were obtained analyzing subjects according to age and pubertal status, whereas in patients with HbA1c ≤7%, using rtCGM and CSII significant correlations were found for 2-week period.

CONCLUSIONS

In T1D pediatric subjects, 4-week CGM data better reflects long-term glycemic control and GV in MDI and isCGM users. The 2-week period may be acceptably accurate in CSII and rtCGM users, especially in those with good glycometabolic control.