Pandemic influenza vaccination coverage in children with type 1 diabetes: analysis from seven Italian centers

The pandemic influenza vaccination coverage in children with type 1 diabetes has been analysed. 1461 charts have been reviewed (788 M and 673 F, ages 13.0±4.1 yrs, disease duration 6.0±4.8 yrs, HbA1c 7.9±1.2%). Among them, 428 patients (29.3%) underwent A/H1N1 vaccination. A special effort is required to implement an increased immunization rate.

Mother and daughter carrying the same KCNJ11 mutation but with a different response to switching from insulin to sulfonylurea

KCNJ11 gene mutations are related to permanent neonatal diabetes mellitus (PNDM). Glycemic stability minimizes the risk of complications. Sulfonylureas (SU) are the proven best therapeutic option. We report a 18-month follow-up of switching from insulin to SU in a mother and her daughter with PNDM due to KCNJ11 mutation.

Acute juvenile cataract in newly diagnosed type 1 diabetic patients: a description of six cases

Cataract represents one of the most frequent eye complications in type 1 and type 2 patients; contrarily, acute cataract in young diabetic patients occurs very rarely. The aim of this study was to describe six cases of acute cataract in adolescents at the onset of type 1 diabetes. Eight hundred and twenty-six patients with type 1 diabetes were retrospectively studied. A multivariate analysis was applied to verify the weight of the following laboratory findings taken on admission (independent variables): glycemia, glycated hemoglobin (HbA1c), pH, base excess (BE),and on the occurrence of cataract (dependent variable). Six patients (0.7%) presented with acute lens opacities. Cataract development was significantly correlated with HbA1c and glycemia. The relative risk increases about twice for each percentage point from 12.8 to 14.1% of HbA1c; glycemic blood levels represent a moderate risk factor for cataractogenesis. Ketoacidosis and BE were not significantly correlated.

Physical activity and sedentary lifestyle in children with type 1 diabetes: a multicentre Italian study

BACKGROUND

Regular Physical Activity (RPA) is one of the cornerstones of Type 1 Diabetes (T1D) therapy, but conflicting results are reported in the literature.

AIM

To compare (RPA) and Sedentary Lifestyle (SL) among children with type 1 diabetes (T1D) and healthy peers.

SUBJECTS AND METHODS

Seven Italian paediatric diabetes centres enrolled 129 children with T1D and 214 healthy peers who were interviewed by a telephone questionnaire on physical activity level, sedentary lifestyle and clinical data.

RESULTS

Compared to healthy peers, children with T1D: performed the same amount of RPA, were more frequently engaged in team sports (p = 0.018), described RPA as an enjoyable activity (p = 0.033), not boring (p = 0.035), a chance to spend time with peers (p = 0.033) and to meet new friends (p = 0.016). Children with T1D were finally used to consume less snacks during watching TV (p < 0.001) or after physical activity (p < 0.001 ). HbA1c values were not related with time spent in physical activity, in watching TV or in playing video-games.

CONCLUSIONS

Most interviewed children with T1D are physically active and perform the same amount of exercise as their healthy peers. They demonstrate to consider RPA a source of enjoyment and sociality and not a therapeutic imposition. (www.actabiomedica.it)

Permanent diabetes during the first year of life: multiple gene screening in 54 patients

AIMS/HYPOTHESIS

The aim of this study was to investigate the genetic aetiology of permanent diabetes mellitus with onset in the first 12 months of age.

METHODS

We studied 46 probands with permanent, insulin-requiring diabetes with onset within the first 6 months of life (permanent neonatal diabetes mellitus [PNDM]/monogenic diabetes of infancy [MDI]) (group 1) and eight participants with diabetes diagnosed between 7 and 12 months of age (group 2). KCNJ11, INS and ABCC8 genes were sequentially sequenced in all patients. For those who were negative in the initial screening, we examined ERN1, CHGA, CHGB and NKX6-1 genes and, in selected probands, CACNA1C, GCK, FOXP3, NEUROG3 and CDK4. The incidence rate for PNDM/MDI was calculated using a database of Italian patients collected from 1995 to 2009.

RESULTS

In group 1 we found mutations in KCNJ11, INS and ABCC8 genes in 23 (50%), 9 (19.5%) and 4 (8.6%) patients respectively, and a single homozygous mutation in GCK (2.1%). In group 2, we identified one incidence of a KCNJ11 mutation. No genetic defects were detected in other loci. The incidence rate of PNDM/MDI in Italy is estimated to be 1:210,287.

CONCLUSIONS/INTERPRETATION

Genetic mutations were identified in ~75% of non-consanguineous probands with PNDM/MDI, using sequential screening of KCNJ11, INS and ABCC8 genes in infants diagnosed within the first 6 months of age. This percentage decreased to 12% in those with diabetes diagnosed between 7 and 12 months. Patients belonging to the latter group may either carry mutations in genes different from those commonly found in PNDM/MDI or have developed an early-onset form of autoimmune diabetes.

Chat line for adolescents with type 1 diabetes: a useful tool to improve coping with diabetes: a 2-year follow-up study

BACKGROUND

We evaluated the impact of a 2-year chat line involving adolescents with type 1 diabetes regarding quality of life and metabolic control.

METHODS

We enrolled 193 children, 10-18 years of age (mean ± SD, 13.6 ± 2.7 years), with type 1 diabetes for 1.2-6 years (3.6 ± 2.4 years), body mass index of 23.2 ± 4.1 kg/m(2), insulin requirement of 0.7 ± 0.3 U/kg/day, and glycated hemoglobin (HbA1c) of 7.8 ± 1.1%, who participated in a weekly physician-moderated chat line for a 2-year follow-up period. Each patient completed the Diabetes Quality of Life for Youth Inventory (DQOLY) at baseline and after 1 and 2 years. A measure of glycemic control (HbA1c) was also collected. Data from 17 patients who discontinued using the chat line were not included in the analysis. As controls, 203 patients with type 1 diabetes, age- and sex-matched, with similar HbA1c at baseline and socioeconomic status, were randomly selected among 834 patients who refused to participate in the chat sessions.

RESULTS

DQOLY responses from youth with type 1 diabetes showed a significant improvement (P = 0.0001) only in patients who participated in chat sessions. We observed a decrease of 0.4% in HbA1c in patients who participated in chat session (7.8 ± 1.1% vs. 7.4 ± 0.5%, P < 0.0001) compared with the 0.1% of the controls (7.9 ± 1.9% vs. 7.8 ± 1.8%, P = 0.668). No difference was observed in HbA1c between the two groups (P = 0.056).

CONCLUSIONS

A chat line is also a cheap and effective tool that helps improve diabetes compliance. The chat line could help the diabetes team understand and treat their patients more comprehensively; moreover, it could help patients cope better with their daily life.

Potential celiac disease in type 1 diabetes: a multicenter study

AIMS

To describe the prevalence of potential celiac disease (pot-CD) in young patients with type 1 diabetes mellitus (T1DM) and characterize their clinical features.

METHODS

This cross-sectional multicenter study involved 8717 T1DM patients from 31 Italian centers. Information was collected on the total number of T1DM patients, CD patients and pot-CD patients. The following data were collected on pot-CD patients: gender, age at T1DM diagnosis, age at the first CD serological positivity, presence of CD-related symptoms, presence of other autoimmune disorders and treatment with gluten free diet (GFD). One thousand-three-hundred-sixty-one patients who were positive for CD serology were the control group.

RESULTS

CD serological positivity was found in 7.2% T1DM patients. Prevalence of pot-CD was 12.2% (n=77) among CD positive patients: symptoms were present in 12/77; a third autoimmune disorder was found in 15 patients. Prevalence of pot-CD in the control population was 8.4% (n=114; p=0.005). No difference was found with regard to clinical features. Only few symptomatic patients were on GFD both in T1DM and control patients.

CONCLUSIONS

A higher prevalence of pot-CD was found in T1DM patients, that may be ascribed to the routine screening, although the influence of genetic factors cannot be excluded.

Lowering postprandial glycemia in children with type 1 diabetes after Italian pizza "margherita" (TyBoDi2 Study)

BACKGROUND

Continuous subcutaneous insulin infusion is considered a safe and effective way to administer insulin in pediatric patients with type 1 diabetes, but achieving satisfactory and stable glycemic control is difficult. Several factors contribute to control, including fine-tuning the basal infusion rate and bolus type and timing. We evaluated the most effective type and timing of a pump-delivered, preprandial bolus in children with type 1 diabetes for a pizza "margherita" meal.

SUBJECTS AND METHODS

We assessed the response of 38 children with type 1 diabetes to a meal based on pizza "margherita" (with mozzarella cheese and tomato sauce) after different types and timings of a bolus dose.

RESULTS

The glucose levels for 6 h after the meal were lower (i.e., closer to the therapeutic target of <140 mg/dL) when the bolus doses were administered as a simple bolus 15 min before the meal (area under the curve [AUC] 0-6 h, 6.9 ± 14.9 mg/dL/min) versus a simple bolus administered immediately before the meal (AUC 0-6 h, 4.2 ± 25.9 mg/dL/min) (P = not significant) versus a double-wave bolus 30/70 extended over a 6-h period administered 15 min before the meal (AUC 0-6 h, 1.9 ± 21.3 mg/dL/min) (P = not significant) versus a double-wave bolus 30/70 extended over a 6-h period administered immediately before the meal (AUC 0-6 h, 13.3 ± 15.6 mg/dL/min) (P = 0.01).

CONCLUSIONS

In the case of a pizza "margherita," our data support the injection of the simple bolus 15 min before a meal, rather than immediately before or delivered as a double-wave bolus, to control the glycemic rise usually observed.

Use of integrated real-time continuous glucose monitoring/insulin pump system in children and adolescents with type 1 diabetes: a 3-year follow-up study

BACKGROUND

Insulin pumps and real-time continuous glucose monitoring devices have recently been combined into the sensor-augmented pump (SAP) system. The objective of this study was the evaluation of the clinical use of SAP in a large series of children with type 1 diabetes using insulin pump therapy.

METHODS

A questionnaire was administered in all pediatric diabetologic centers in Italy; data were analyzed only regarding patients 18 years old or younger and using SAP for 6 months or more.

RESULTS

Among all patients using an insulin pump, 129 (13.5 ± 3.8 years old, with a disease duration of 6.3 ± 3.4 years) have been using SAP for 1.4 ± 0.7 years. Four hundred ninety-three patients (12.9 ± 3.4 years old, with a disease duration of 6.2 ± 3.3 years) using conventional insulin pump therapy for 1.7 ± 0.5 years have been evaluated as the control group. After 0.5-3 years of using SAP or conventional insulin pump therapy, glycosylated hemoglobin significantly improved (8.0 ± 1.5% vs. 7.4 ± 0.8% [P = 0.002] and 8.0 ± 1.6% vs. 7.7 ± 1.1% [P = 0.006], respectively); the improvement was higher with SAP (P = 0.005). Insulin requirement showed a significant decrease only in SAP patients (0.88 ± 0.25 vs. 0.7 ± 0.23 U/kg/day, P = 0.003). Body mass index did not change during the observation period. No diabetic ketoacidosis episodes were observed during the follow-up, and severe hypoglycemia significantly decreased in SAP patients (P = 0.04).

CONCLUSIONS

The increased availability of continuous glucose sensors is likely to have a significant impact on pediatric diabetes therapy and education in the near future. In daily settings, patients using SAP can achieve a better control than patients using conventional insulin pump.

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.

Recommendations for the implementation of international standardization of glycated hemoglobin in Italy

This document is issued by the Italian Society of Clinical Biochemistry and Clinical Molecular Biology (SIBioC) and a number of other National Scientific Societies and Associations in order to promote a coordinated plan for implementing the standardization of glycated hemoglobin (HbA(1c)) measurement in Italy according to the recommendations by the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC). Changes in reporting HbA(1c) results, new units, how to relate old and new units, a timeline for changes and definition of the analytical goals are the main issues discussed.

Timing of bolus in children with type 1 diabetes using continuous subcutaneous insulin infusion (TiBoDi Study)

BACKGROUND

Continuous subcutaneous insulin infusion is considered a safe and effective way to administer insulin in pediatric patients with type 1 diabetes, but achieving satisfactory and stable glycemic control is difficult. Several factors contribute to control, including fine-tuning the basal infusion rate and bolus timing. We evaluated the most effective timing of a pump-delivered, preprandial bolus in children with type 1 diabetes.

METHODS

We assessed the response of 30 children with type 1 diabetes to a standard meal after different timing of a bolus dose.

RESULTS

The glucose levels for 3 h after the meal were lower (i.e., closer to the therapeutic target of <140 mg/dL) when the bolus doses were administered 15 min or immediately before the meal, rather than after the meal. However, these differences were not statistically significant, except at the 1-h postprandial time point: bolus just after meal, 177 +/- 71 mg/dL (9.83 +/- 3.94 mmol/L); 15 min before meal, 136 +/- 52 mg/dL (7.55 +/- 2.89 mmol/L) (P = 0.044); and just before meal, 130 +/- 54 mg/dL (7.22 +/- 3.00 mmol/L) (P = 0.024). The area under the curve (AUC) (in mg/min) did not differ significantly with different bolus times, but the SD of the AUC was the lowest with the bolus given 15 min before the meal.

CONCLUSIONS

These data support injection of the bolus before, rather than after, eating, even if the patient is hypoglycemic before meals.

Bone involvement in clusters of autoimmune diseases: just a complication?

Bone loss, described in individual groups of patients with Type 1 diabetes (T1D), autoimmune thyroid disease (ATD) or celiac disease (CD) is usually viewed as a complication of these diseases. There is increasing evidence that alterations in the immune system may directly affect bone mass. Clustering of autoimmune diseases in the same individual might predispose to higher risk of osteopenia due to imbalance in immune regulation. The aim of this study was to evaluate bone involvement in clusters of the most common autoimmune diseases (T1D, ATD and CD) in children. The study was performed at a tertiary care center for the care of pediatric diabetes. One-hundred-two patients with T1D alone or associated with ATD and/or CD were studied; 13 patients had cluster of three autoimmune diseases. Amplitude-dependent speed of sound (AD-SoS) was measured by phalangeal quantitative ultrasound and expressed as standard deviation score (SDS). AD-SoS SDS < -2 was considered indicative of osteopenia. Osteopenia was equally distributed among children with T1D alone (8.1%), T1D associated with ATD (7.7%) or CD (10.3%), while it was 53.8% in patients presenting with three autoimmune diseases. Poor compliance to gluten-free diet increased osteopenia to 18.8% in patients with T1D and CD and 80% in patients with three autoimmune disorders. No difference among groups was found with regard to gluco-metabolic control, calcium metabolism, thyroid function. In conclusion bone impairment in multiple autoimmune diseases might be considered not only a complication due to endocrine or nutritional mechanisms, but also a consequence of an immunoregulatory imbalance. Alterations of homeostatic mechanisms might explain an imbalance of osteoclast activity leading to osteopenia.

Insulin pump therapy management in very young children with type 1 diabetes using continuous subcutaneous insulin infusion

BACKGROUND

Compared to older children and adolescents very young patients with type 1 diabetes represent a unique population. We analyzed the age-dependent characteristics and parameters of continuous subcutaneous insulin infusion (CSII) in children under 6 years of age with type 1 diabetes.

METHODS

We evaluated metabolic control and pump-dependent characteristics in 46 children with type 1 diabetes after 0.89 +/- 0.62 years of CSII.

RESULTS

Metabolic control significantly improved after CSII initiation (glycosylated hemoglobin, 8.12 +/- 1.24% vs. 7.30 +/- 0.67%; P < 0.05), without increased risk for diabetic ketoacidosis or hypoglycemia. Interestingly, very young patients required bigger boluses than expected, especially in the morning and at the afternoon snack.

CONCLUSIONS

These data support the need to personalize pump-dependent characteristics, especially in very young children with type 1 diabetes, in order to optimize CSII therapy in this unique age group of patients.

Maturity-onset diabetes of the young in children with incidental hyperglycemia: a multicenter Italian study of 172 families

OBJECTIVE

To investigate the prevalence of maturity-onset diabetes of the young (MODY) in Italian children with incidental hyperglycemia.

RESEARCH DESIGN AND METHODS

Among 748 subjects age 1-18 years with incidental hyperglycemia, minimal diagnostic criteria for MODY were met by 172 families. Mutational analyses of the glucokinase (GCK) and hepatocyte nuclear factor 1alpha (HNF1A) genes were performed.

RESULTS

We identified 85 GCK gene mutations in 109 probands and 10 HNF1A mutations in 12 probands. In GCK patients, the median neonatal weight and age at the first evaluation were lower than those found in patients with HNF1A mutations. Median fasting plasma glucose and impaired fasting glucose/impaired glucose tolerance frequency after oral glucose tolerance testing were higher in GCK patients, who also showed a lower frequency of diabetes than HNF1A patients.

CONCLUSIONS

GCK mutations are the prevailing cause of MODY (63.4%) when the index case is recruited in Italian children with incidental hyperglycemia.

Insulin resistance and secretion indexes in healthy Italian children and adolescents: a multicentre study

BACKGROUND AND AIM

To establish normal values of insulin resistance, secretion and sensitivity using respectively HOMA-IR, HOMA-beta% and QUICKI indexes in healthy Italian children and adolescents, based on fasting samples.

METHODS

We determined HOMA-IR, HOMA-beta% and QUICKI at baseline in 142 healthy subjects from Pediatric Centres, aged 2.7 to 19 years (10.6 +/- 3.8, Mean +/- SD), with different Tanner's pubertal Stages (TS). None had hypo/hyperglycemia (fasting plasma glucose ranging from 3.6 to 5.6 mmol/l), obesity (BMI (kg/m2) 17.9 +/- 2.4, M +/- SD), or family history for diabetes mellitus.

RESULTS

The HOMA-IR index slightly increases with Tanner's stage. As regards HOMA-beta% and QUICKI, a weak variation throughout puberty was observed. No significant correlation was observed between HOMA-IR, HOM A-beta%, QUICKI and BMI-SDS or chronologic age.

CONCLUSIONS

Normal values of HOMA-IR, HOMA-beta% and QUICKI are useful tools in the clinical and epidemiological practice for baseline screening and follow-up of subjects at risk for type 2 diabetes mellitus.

Insulin gene mutations as cause of diabetes in children negative for five type 1 diabetes autoantibodies

OBJECTIVE

Heterozygous, gain-of-function mutations of the insulin gene can cause permanent diabetes with onset ranging from the neonatal period through adulthood. The aim of our study was to screen for the insulin gene in patients who had been clinically classified as type 1 diabetic but who tested negative for type 1 diabetes autoantibodies.

RESEARCH DESIGN AND METHODS

We reviewed the clinical records of 326 patients with the diagnosis of type 1 diabetes and identified seven probands who had diabetes in isolation and were negative for five type 1 diabetes autoantibodies. We sequenced the INS gene in these seven patients.

RESULTS

In two patients whose diabetes onset had been at 2 years 10 months of age and at 6 years 8 months of age, respectively, we identified the mutation G(B8)S and a novel mutation in the preproinsulin signal peptide (A(Signal23)S).

CONCLUSIONS

Insulin gene mutations are rare in absolute terms in patients classified as type 1 diabetic (0.6%) but can be identified after a thorough screening of type 1 diabetes autoantibodies.

The influence of gluten free diet on quantitative ultrasound of proximal phalanxes in children and adolescents with type 1 diabetes mellitus and celiac disease

A reduced bone mineral density has been reported in patients with untreated celiac disease (CD) as well as in patients with poorly controlled type 1 diabetes mellitus (T1DM). The aim of this study was to evaluate the bone mineral status by phalangeal quantitative ultrasound in 52 children and adolescents with both diseases (mean age 13.3+/-4.9 years). As a control group 50 patients with T1DM and no CD (age 12.2+/-4.0 years) were studied. The following bone parameters, amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT) were considered and expressed as z score. Compliance to gluten free diet and long term glycemic control (mean of four determinations of HbA1c in the last year) were also assessed. The lowest mean AD-SoS z score values were found in patients with T1DM and CD, who reported transgressions to gluten free diet and exhibited positivity for serum anti-tissue transglutaminase antibodies (tTG) and/or endomysial antibodies (EmA), compared with patients with occasional transgressions but negative for anti-tTG and/or -EmA, patients strictly adherent to the diet, and patients who suffered only from diabetes (ANOVA p=0.021). No difference was found between patients with diabetes alone and patients with both diseases strictly adherent to gluten free diet. Prevalence of osteopenia (z AD-SoS values <-2 SD) was higher in patients with T1DM and CD and poor compliance to the diet (45.5%) compared with patients with T1DM (8%) or patients with both diseases strictly compliant to diet (12.9%) (p=0.015). A negative correlation between Ad-SoS z score and HbA1c (r -0.236, p=0.036) was found when patients with T1DM and patients with T1DM and CD, who strictly adhere to the diet, were pooled. In conclusion the quality of bone as assessed by phalangeal ultrasound in patients with T1DM and CD, who strictly adhere to gluten free diet, is similar to that found in T1DM patients. A higher prevalence of osteopenia is present in patients with both diseases who reported habitual transgressions to gluten free diet. The gluten free diet, as well as the optimization of glycemic control, plays an important role in preventing the osteopenic status caused by the clustering of these two chronic diseases.