Variation and trends in incidence of childhood diabetes in Europe. EURODIAB ACE Study Group

Relation of circulating concentrations of chemokine receptor CCR5 ligands to C-peptide, proinsulin and HbA1c and disease progression in type 1 diabetes

Th1 related chemokines CCL3 and CCL5 and Th2 related CCL4 as ligands of the receptor CCR5 contribute to disease development in animal models of type 1 diabetes. In humans, no data are available addressing the role of these chemokines regarding disease progression and remission. We investigated longitudinally circulating concentrations of CCR5 ligands of 256 newly diagnosed patients with type 1 diabetes. CCR5 ligands were differentially associated with beta-cell function and clinical remission. CCL5 was decreased in remitters and positively associated with HbA1c suggestive of a Th1 associated progression of the disease. Likewise, CCL3 was negatively related to C-peptide and positively associated with the beta-cell stress marker proinsulin but increased in remitters. CCL4 associated with decreased beta-cell stress shown by negative association with proinsulin. Blockage of chemokines or antagonism of CCR5 by therapeutic agents such as maraviroc may provide a new therapeutic target to ameliorate disease progression in type 1 diabetes.

Joint effects of HLA, INS, PTPN22 and CTLA4 genes on the risk of type 1 diabetes

BACKGROUND/HYPOTHESIS

HLA, INS, PTPN22 and CTLA4 are considered to be confirmed type 1 diabetes susceptibility genes. HLA, PTPN22 and CTLA4 are known to be involved in immune regulation. Few studies have systematically investigated the joint effect of multiple genetic variants. We evaluated joint effects of the four established genes on the risk of childhood-onset type 1 diabetes.

METHODS

We genotyped 421 nuclear families, 1,331 patients and 1,625 controls for polymorphisms of HLA-DRB1, -DQA1 and -DQB1, the insulin gene (INS, -23 HphI), CTLA4 (JO27_1) and PTPN22 (Arg620Trp).

RESULTS

The joint effect of HLA and PTPN22 on type 1 diabetes risk was significantly less than multiplicative in the case-control data, but a multiplicative model could not be rejected in the trio data. All other two-way gene-gene interactions fitted multiplicative models. The high-risk HLA genotype conferred a very high risk of type 1 diabetes (OR 20.6, using the neutral-risk HLA genotype as reference). When including also intermediate-risk HLA genotypes together with risk genotypes at the three non-HLA loci, the joint odds ratio was 61 (using non-risk genotypes at all loci as reference).

CONCLUSION

Most established susceptibility genes seem to act approximately multiplicatively with other loci on the risk of disease except for the joint effect of HLA and PTPN22. The joint effect of multiple susceptibility loci conferred a very high risk of type 1 diabetes, but applies to a very small proportion of the general population. Using multiple susceptibility genotypes compared with HLA genotype alone seemed to influence the prediction of disease only marginally.

Interrelationship among asthma, atopy, and helminth infections

To describe the principal evidence in the literature regarding the interrelationship among helminth infections, atopy, and asthma, a nonsystematic review of the literature was conducted. Among the publications on the subject, we found a number in which there was controversy regarding the capacity of geohelminth infections to inhibit responsiveness to skin allergy tests and to minimize the symptoms of allergic diseases. However, although small in number, studies of patients infected with Schistosoma spp. suggest that these helminths can inhibit the responsiveness to skin allergy testing and minimize asthma symptoms. Evidence provided by in vitro studies suggests that helminthiases inhibit T helper 1- and T helper 2-type immune responses. This opens new therapeutic possibilities for the treatment of immune system diseases.

Steep increase of incidence of childhood diabetes since 1999 in Austria. Time trend analysis 1979-2005. A nationwide study

In a prospective population-based incidence study all newly diagnosed type 1 diabetic patients 0-<15 years of age were registered by the Austrian Diabetes Incidence Study Group. The nationwide incidence of type 1 diabetes between 2000-2005 was compared with the previously published incidence rates. Long-term trends as well as seasonal trends were estimated by Poisson regression models. A total of 3,599 incident cases (1,908 boys; 1,691 girls) were identified. Case ascertainment was >92%. The overall incidence rate doubled from 7.3 (95% CI; 6.8-7.9)/100,000 in the period 1979-84 to 14.6 (95% CI, 13.7-15.4)/100,000 in the time period 2000-2005. A significant increase during the observation period of 26 years could be demonstrated in all age groups and both sexes (p<0.01), with the steepest increment during the last 5 years. Until 1994 the incidence rate in children 0-<5 years was rather stable, but afterwards increased dramatically with 9.2% (95% CI, 5.2-13.4) annually. Despite this steep increase in time trend, we did not observe a seasonal variation in this age group (0-<5) in contrast to significant seasonal variations in the groups 5-<10 and 10-<15 years of age. Over the past 26 years incidence of type 1 diabetes in childhood increased clearly in Austria. The steepest rise was observed in the last 5 years and in the younger age groups.

Intensive insulin therapy in preschool-aged diabetic children: from multiple daily injections to continuous subcutaneous insulin infusion through indwelling catheters

In this study, glycemic control, diabetes care indices and quality of life (QoL) were assessed in 2 groups of newly diagnosed Type 1 diabetic subjects <6 yr old who were randomized to multiple daily injections with (Group A) or without (Group B) an indwelling catheter. Group A [12 males (M)/8 females (F), mean age 3.2+/-1.4 yr] and Group B (9M/11F, mean age 3.9+/-1.8 yr) were evaluated at baseline and after 6 and 12 months of treatment. No significant difference was observed in metabolic control (glycosylated hemoglobin) or in the number of hypoglycemic events between the groups. Patients in Group A had a greater number of daily insulin injections, monitored blood glucose more frequently and had a lower total daily insulin dose per kg (p<0.05). QoL was better in group A. At the end of the study 30% of group A patients progressed to continuous sc insulin infusion (CSII), while no child in Group B switched to a different insulin regimen. Based on these findings, indwelling catheter therapy may be helpful for selected CSII candidates.

[Management of diabetes mellitus in young children]

The occurrence of type 1 diabetes mellitus in children under 5-years-old is rare, but its incidence has been growing all over the world. The diagnosis is usually delayed and the patient presents advanced states of ketoacidosis. After the diagnosis, it is extremely crucial the involvement of the family in the treatment from the beginning, due to the dependency of the young children. The attention focused on the patient must be intense, since there are no evident hypoglycemic symptoms, the food intake and physical activities are irregular and there is higher insulin sensitivity. Insulin administration has to be individualized, and glucose monitoring is essential to obtain a good control.

A unifying hypothesis on the development of type 1 diabetes and celiac disease: gluten consumption may be a shared causative factor

This paper presents a hypothesis of the aetiology of the increasing incidence of type 1 diabetes (T1D). This together with the global increased incidence of celiac disease (CD) and that these increases cannot be explained by genetic factors suggest a common environmental factor for these two diseases. Even though enterovirus (EV) infections are believed to trigger T1D and gluten is the trigger of CD, the increasing intake of gluten containing products all over the world could be the trigger for both diseases directly and indirectly. It has been shown that the duration of exposure to gluten is related to the prevalence of T1D. It has also been shown that T1D patients at onset have an inflammatory reaction in the gut. Hence, early diagnose of CD followed by elimination of dietary gluten will lead to a decreased incidence of T1D.

Parental country of birth is a major determinant of childhood type 1 diabetes in Sweden

OBJECTIVE

To test the hypothesis that the risk of childhood diabetes type 1 increases with migration from a low to a high incidence region.

METHODS

Register study of a national cohort of 783 547 children born between 1987 and 1993 who remained in Sweden in 2002, including 3225 children with childhood type 1 diabetes identified in hospital discharge data. Logistic regression analysis was used to test the hypotheses.

RESULTS

Offspring of two parents born in very low (Asia excluding Middle East and Latin America) and low (southern and eastern Europe and the Middle East) incidence regions had the lowest adjusted odds ratios (ORs) of childhood type 1 diabetes; 0.21 (0.11-0.41) and 0.37 (0.29-0.48), respectively, compared with the Swedish majority population. When one parent was born in a low incidence country and one parent was Swedish born, the adjusted ORs increased but remained lower than the Swedish majority population.

CONCLUSIONS

Parental country of birth is an important determinant of childhood type 1 in Sweden. Heritable factors seem most likely to explain this pattern.

Glycohemoglobin screening in adolescents attending to the Department of Paediatrics at a tertiary hospital in Turkey

OBJECTIVE

To investigate glycohemoglobin (HbAIc) levels in adolescents without diabetes, attending to our Adolescent Day Care Clinic.

SUBJECTS AND METHODS

We studied on randomly selected 186 subjects aged between 9 and 18 years. HbA1c levels were measured in all subjects and those whose HbA1c levels >95th percentile were invited for oral glucose tolerance test (OGTT). Homeostasis of model assessment (HOMA-IR) value was used to define insulin resistance in subjects who underwent OGTT.

RESULTS

The median age of all subjects was 11 (min 9-max 18) years and 50.5% were boys. The median HbA1c level was higher in boys (5.2%; min 4.4-max 6.2) than girls (5.0%; min 4.0-max 6.4) (p=0.001). Fasting glucose was positively correlated to HbA1c (r=0.26, p=0.001). HOMA-IR values were >2.5 in six subjects and four of them were obese while two had impaired glucose tolerance. In multivariate analysis, it was observed that gender (boy) and high-fasting glucose levels were associated with high-HbA1c levels (OR 1.9, CI 95%: 1.0-3.4, p=0.02 and OR 1.1, CI 95%: 1.0-1.1, p=0.001, respectively).

CONCLUSIONS

We believe that routine HbA1c screening is not necessary for adolescents without diabetes. However screening may become desirable in the future at least for obese adolescents.

Changing geographical distribution of diabetes mellitus type 1 incidence in Austrian children 1989--2005

OBJECTIVES

We investigated whether the significant spatial West/East trend of incidence of Diabetes mellitus Type 1 in Austrian children changed between 1989 and 2005. Additionally we tested, whether population density and mean body mass index of newborns is associated with incidence.

STUDY DESIGN AND SETTING

All newly diagnosed cases aged 0-14 years in Austria (n = 2644), prospectively registered from 1989 to 2005 were allocated to 99 districts. Ecological regression and analysis was done by Bayesian hierarchical models including spatially correlated risks.

RESULTS

In Austria, the incidence rose from 9.1/100.000 in 1989--1994 to 14.9/100.000 in 2001--2005. The spatial trend in the period 1989--1995, showing high incidence in the Eastern parts of Austria, disappeared. In the period 2001--2005 a significant inverse negative association of population density with incidence was found. Mean body mass index of newborns in the Austrian population is significantly positively associated with incidence.

CONCLUSION

The observation of higher incidence in rural areas in Austria during recent years may reflect a lower exposure to protective environmental factors, e.g. infections early in life. The observed association with the BMI in newborns indicates that neonatal or prenatal metabolic aspects may modulate the risk for childhood diabetes. We cannot explain the change in the spatial distribution of incidence.

Extent of beta cell destruction is important but insufficient to predict the onset of type 1 diabetes mellitus

Background

Type 1 diabetes mellitus is characterized by an inability to produce insulin endogenously. Based on a series of histopathology studies of patients with recent onset of the disease, it is commonly stated that the onset of clinical symptoms corresponds to an 80-95% reduction in beta cell mass. Motivated by the clinical importance of the degree of beta cell destruction at onset, a meta-analysis was used to determine the validity of this common wisdom.

Methods and Findings

The histopathology results identifying insulin containing islets in patients younger than 20 years of age were extracted from three different studies. The results for 105 patients were stratified by duration of diabetic symptoms and age at onset. Linear regression and a non-parametric bootstrap approach were used to determine the dependence of residual beta cell mass to age at onset. The percentage reduction in beta cell mass was highly correlated (p<0.001) with the age of onset with the greatest reduction in beta cell mass in the youngest patients. As this trend had not been previously observed, an alternative physiology-based model is proposed that captures this age-dependence.

Conclusions

The severity in beta cell reduction at onset decreased with age where, on average, a 40% reduction in beta cell mass was sufficient to precipitate clinical symptoms at 20 years of age. The observed trend was consistent with a physiology-based model where the threshold for onset is based upon a dynamic balance between insulin-production capacity, which is proportional to beta cell mass, and insulin demand, which is proportional to body weight.

Epidemiology and genetic risk of type 1 diabetes among children in Aragon community, Spain

The incidence of type 1 diabetes in children from Aragon (a population of the North of Spain) is reported determining the relations between the onset of type 1 diabetes and gender, age at diagnosis, genetic risk (HLA class II genes) or climatology factors. The population at risk was all 0-14 year-old inhabitants. Patients were identified from five sources: hospitals, primary assistance, endocrinologists, diabetic associations and diabetes camps. The degree of ascertainment was 98.93%. HLA genetic study was performed. Annual incidence was 16.4 per 100,000 per year (95% CI: 14.7-18.2). This incidence was significantly higher in males than in females, 18.7 versus 14.2 (p<0.02), and increased with age. The haplotypes (DR3)-DQB1*0201/(DR4)-DQB1*0302 and (DR3)-DQB1*0201/(DR7)-DQB1*0202 conferred the highest risk of type 1 diabetes. A relative high incidence of type 1 diabetes mellitus has been demonstrated in the Northeast of Spain, and it does not support south-to-north incidence gradient in Europe. Haplotypes that conferred a higher risk of disease agree with those founded in other Caucasic populations.

Incidence and prevalence of type 1 diabetes in children aged <15 yr in Castilla-Leon (Spain)

OBJECTIVES

To determine the incidence and prevalence of type 1 diabetes in children younger than 15 yr in the Autonomous Community of Castilla-Leon (Spain).

RESEARCH DESIGN AND METHODS

All type 1 diabetic cases with onset at <15 yr of age were recorded during 2003-2004. Identified case subjects were ascertained from several sources and the capture-recapture method was used to estimate the completeness of ascertainment. For prevalence, all patients younger than 15 yr with type 1 diabetes at the beginning and at the end of the study were identified.

RESULTS

Over the study period, 130 children aged 0-14 yr were diagnosed with type 1 diabetes. The average observed incidence of type 1 diabetes in this population was 22.22/100 000/yr (95% CI 14.57-29.81). Age-standardized incidence was 22.01/100 000/yr (95% CI 18.18-25.83). The highest incidence was observed in the 5-9 yr age-group (32.45/100 000/yr, 95% CI 24.31-40.59). The prevalence at the beginning and at the end of the study was 1.01/1000 and 1.18/1000, respectively.

CONCLUSION

Castilla-Leon appears to have one of the highest incidences of childhood type 1 diabetes in Spain, with recent incidence approaching those of some northern European countries.

The age at diagnosis of type 1 diabetes continues to decrease in Belgian boys but not in girls: a 15-year survey

BACKGROUND

The age at clinical onset of type 1 diabetes is decreasing. Preliminary Belgian data suggested that this anticipation occurred preferentially in boys. We investigated whether this gender-specific anticipation could be confirmed over a 15-year observation period.

METHODS

In Antwerp, we studied incidence trends between 1989 and 2003 in 746 type 1 diabetic patients under age 40. For 2928 antibody-positive patients diagnosed nationwide during the same period, age at diagnosis was analysed according to gender and calendar year.

RESULTS

In Antwerp, the incidence of type 1 diabetes under age 15 increased significantly with time from 10.9/100 000/year in 1989-1993 to 15.8/100 000/year in 1999-2003 (p = 0.008). The rising incidence in children was largely restricted to boys under age 10 where the incidence more than doubled during the 15-year period (6.8/100 000/year in 1989-1993 vs 17.2/100 000/year in 1999-2003; p < 0.001). Such an increase was not found in girls under age 10 (p = 0.54). This selective trend toward younger age at diagnosis in boys was confirmed in the larger group of Belgian patients where the median age at diagnosis decreased in boys-but not in girls-from 20 years in 1989-1993 to 15 years in 1999-2003 (p < 0.001).

CONCLUSIONS

Over a 15-year observation period, a selective anticipation of clinical onset of type 1 diabetes was found in boys but not in girls. This suggests that an environmental factor may preferentially accelerate the sub-clinical disease process in young boys.

Type 1 diabetes risk analysis on dried blood spot samples from population-based newborns: design and feasibility of an unselected case-control study

Development of type 1 diabetes mellitus (T1D) may be triggered pre- or perinatally by multiple factors. Identifying new predisposing T1D markers or combinations of markers in a large, well-characterised case-control collection may be important for future T1D prevention. The present work describes the design and feasibility of a large and unselected case-control study, which will define and evaluate prediction criteria for T1D at the time of birth. Danish registries (Biological Specimen Bank for Neonatal Screening, and the National Discharge Registry) made it possible to identify and collect dried blood spots (DBS) from newborns who later developed T1D (cases) born 1981-2002. DBS samples from 2086 cases and two matching control subjects per case were analysed for genetic and immune factors that are associated with T1D: (a) candidate genes (HLA, INS and CTLA4), (b) cytokines and inflammatory markers, (c) islet auto-antibodies (GAD65A, IA-2A). The objective of the study was to define reliable prediction tools for T1D using samples available at the time of birth. In a unique approach, the study linked a large unselected and population-based sample resource to well-ascertained clinical databases and advanced technology. It combined genetic, immunological and demographic data to develop prediction algorithms. It also provided a resource for future studies in which new genetic markers can be included as they are identified.

Prevalence and clinical features of celiac disease in 950 children with type 1 diabetes in France

The prevalence of celiac disease is higher in children with type 1 diabetes mellitus (DM) than in the general pediatric population, but may vary widely across countries. Sensitive and specific antibody tests are available for detecting celiac disease.

AIMS

To evaluate the prevalence in France of histologically documented celiac disease in a vast cohort of children with type 1 DM, and to describe the features of celiac disease and treatment response.

METHODS

Retrospective cohort study of 950 children with type 1 diabetes seen between 1994 and 2001. Antibodies to gliadin, reticulin, endomysium and transglutaminase were looked for one to seven times in each patient.

RESULTS

Fifteen patients (1.6%) had biopsy-confirmed celiac disease. Symptoms led to the diagnosis in six patients (mean age, 7 years) and screening tests in nine patients (mean age, 11 years). Anti-endomysium antibodies were consistently positive. Tests for HLA-DQB1 0201 and/or 0302 were positive. Anti-endomysium antibody seroconversion was seen in two patients, 2 and 6 years, respectively, after the diagnosis of diabetes. In another patient, the biopsy became abnormal 6 years after the first positive anti-endomysium antibody test (latent form). After a mean of 3 years on a gluten-free diet, significant increases were noted in body weight (P=0.04) and insulin dose (P=0.05); clinical symptoms completely resolved in five of the six symptomatic patients.

CONCLUSIONS

The prevalence of celiac disease is higher in children with type 1 DM than in the general pediatric population. Serological screening is useful for diagnosing asymptomatic celiac disease, detecting seroconversion and monitoring latent forms of disease.

Higher prevalence of elevated albumin excretion in youth with type 2 than type 1 diabetes: the SEARCH for Diabetes in Youth study

OBJECTIVE

To estimate the prevalence of an elevated albumin-to-creatinine ratio (ACR) (> or = 30 microg/mg) among youth with type 1 or type 2 diabetes and to identify factors associated with elevated ACR and their effect on the relationship between elevated ACR and type of diabetes.

RESEARCH DESIGN AND METHODS

Cross-sectional data were analyzed from 3,259 participants with onset of diabetes at < 20 years of age in the SEARCH for Diabetes in Youth, a multicenter observational study of diabetes in youth. Multiple logistic regression was used to explore determinants of elevated ACR and factors accounting for differences in this prevalence between type 2 and type 1 diabetes.

RESULTS

The prevalence of elevated ACR was 9.2% in type 1 and 22.2% in type 2 diabetes (prevalence ratio 2.4 [95% CI 1.9-3.0]; P < 0.0001). In multiple logistic regression analysis, female sex, A1C and triglyceride values, hypertension, and type of diabetes (type 2 versus type 1) were significantly associated with elevated ACR. Adjustment for variables related to insulin resistance (obesity, hypertension, dyslipidemia, and inflammation) attenuated, but did not completely explain, the association of diabetes type with elevated ACR.

CONCLUSIONS

Youth with type 2 diabetes have a higher prevalence of elevated ACR than youth with type 1 diabetes, in an association that apparently does not completely depend on age, duration of diabetes, race/ethnicity, sex, level of glycemic control, or features of insulin resistance.

Identifying the special needs of children with Type 1 diabetes in the school setting. An overview of parents' perceptions

AIMS

The aims of this observational study were to identify the special needs of children with Type 1 diabetes in schools from the parents' point of view and the difficulties experienced with full integration, and to define a series of interventions which may improve the situation.

METHODS

Parents of children aged 3-18 years with Type 1 diabetes were eligible. Those who agreed to participate completed a self-reporting questionnaire which determined the effects of the disease on children, parents and school personnel, and addressed aspects including children's integration, glycaemic control, insulin administration, meals, sports, trips and attitudes of teachers and school colleagues to their disease.

RESULTS

A total of 499 questionnaires were completed and validated. Median age of children was 11.5 years (95% CI 7.8-15.2). Only 34% of parents believed that teachers could recognize the symptoms of a mild hypoglycaemic episode. Seventeen per cent of parents experienced problems at their schools when they informed staff about their children's disease, 5% were finally not accepted and 8% were forced to change school. In some cases, they had to modify glucose monitoring (9%) and treatment administration (16%) because of a lack of cooperation from the school.

CONCLUSIONS

Training sessions on Type 1 diabetes, an increase in the number of nurses, better availability of resources from diabetic associations to schools and improved communication between school personnel and parents were identified as key factors that may improve the full integration of the diabetic child in this setting.

Worldwide childhood type 1 diabetes incidence--what can we learn from epidemiology?

Type 1 diabetes is the most common form of diabetes in most part of the world, although reliable data are still unavailable in several countries. Wide variations exist between the incidence rates of different populations, incidence is lowest in China and Venezuela (0.1 per 100,000 per year) and highest in Finland and Sardinia (37 per 100,000 per year). In most populations girls and boys are equally affected. In general, the incidence increases with age, the incidence peak is at puberty. After the pubertal years, the incidence rate significantly drops in young women, but remains relatively high in young adult males up to the age 29-35 years. Prospective national and large international registries (DIAMOND and EURODIAB) demonstrated an increasing trend in incidence in most regions of the world over the last few decades and increases seem to be the highest in the youngest age group. Analytical epidemiological studies have identified environmental risk factors operating early in life which might have contributed to the increasing trend in incidence. These include enteroviral infections in pregnant women, older maternal age (39-42 years), preeclampsia, cesarean section delivery, increased birthweight, early introduction of cow's milk proteins and an increased rate of postnatal growth (weight and height). Optimal vitamin D supplementation during early life has been shown to be protective. Some of these environmental risk factors such as viruses may initiate autoimmunity toward the beta cell, other exposures may put on overload on the already affected beta cell and thus accelerate the disease process.

Presentation of childhood CNS tumours: a systematic review and meta-analysis

BACKGROUND

Suspicion of a CNS tumour is classically raised by symptoms of raised intracranial pressure, focal deficits (including seizures), or papilloedema. Development of guidelines is needed for the identification and referral of children who might have a CNS tumour. We did a systematic literature review and meta-analysis to identify the clinical presentation of childhood CNS tumours to provide evidence to support the development of guidelines to assist with the identification and referral for imaging of children who might have a central nervous system tumour.

METHODS

Medline, Embase, and PubMed were searched for cohort studies and case series in children, published between January, 1991, and August, 2005, detailing the symptoms and signs at diagnosis of a CNS tumour.

FINDINGS

74 papers (n=4171) met the inclusion criteria. 56 symptoms and signs at diagnosis were identified, ranked by frequency, and clustered according to age, anatomical criteria, and genetic criteria. The most frequent symptoms and signs at diagnosis were: headache (33%), nausea and vomiting (32%), abnormalities of gait and coordination (27%), and papilloedema (13%) for intracranial tumours; macrocephaly (41%), nausea and vomiting (30%), irritability (24%), and lethargy (21%) for children aged under 4 years with intracranial tumours; reduced visual acuity (41%), exophthalmia (16%), and optic atrophy (15%) for children with an intracranial tumour and neurofibromatosis; nausea and vomiting (75%), headache (67%), abnormal gait and coordination (60%), and papilloedema (34%) for posterior fossa tumours; unspecified symptoms and signs of raised intracranial pressure (47%), seizures (38%), and papilloedema (21%) for supratentorial tumours; headache (49%), abnormal eye movements (21%), squint (21%), and nausea and vomiting (19%) for central brain tumours; abnormal gait and coordination (78%), cranial nerve palsies (52%), pyramidal signs (33%), headache (23%), and squint (19%) for brainstem tumours; and back pain (67%), abnormalities of gait and coordination (42%), spinal deformity (39%), focal weakness (21%), and sphincter disturbance (20%) for spinal-cord tumours. Other features noted were weight loss, growth failure, and precocious puberty. Symptoms of raised intracranial pressure were absent in more than half of children with brain tumours. Other neurological features were heterogeneous and related to tumour location.

INTERPRETATION

Apart from raised intracranial pressure, motor and visual system abnormalities, weight loss, macrocephaly, growth failure, and precocious puberty also suggest presence of an intracranial tumour. Children with signs and symptoms that could result from a CNS tumour need a thorough visual and motor system examination and an assessment of growth and pubertal status. Occurrence of multiple symptoms and signs should alert clinicians to possible CNS tumours.

Current aspects on the clinical immunology and genetics of autoimmune diabetes in Japan

Japan is one of the countries with lowest incidence rate of childhood type 1 diabetes in the world, averaging 2.4 cases/100,000/year. However, it appears that the prevalence of type 1 diabetes in adulthood is more than twice compared to childhood patients. There are at least three clinical subtypes of type 1 diabetes in Japan, i.e. acute-onset, slow-onset, and fulminant type 1 diabetes. Fulminant type 1 diabetes is a unique subtype of type 1 diabetes that accounts for about 20% of acute-onset type 1 diabetes, and is rare in childhood in Japan. Furthermore, the slow-onset form of type 1 diabetes might be a major subtype of disease in adulthood. In patients with acute-onset type 1 diabetes, about 90% of patients express at least one of GADAbs, IAA, and IA-2Abs at disease onset. Slow-onset form of type 1 diabetes is diagnosed as having type 2 diabetes at disease onset, which is referred as "latent autoimmune diabetes in adults (LADA)", "GADAb(+) type 2 diabetes", or "slowly progressive type 1 diabetes". The prevalence of GADAbs in adulthood patients with type 2 diabetes without insulin therapy is 3-4%, and is higher in the patients with shorter duration of diabetes. Although high levels of GADAbs are one of the predictive markers for future insulin requirement, there are a certain number of patients with high titer of GADAbs who do not progress to insulin dependency for many years, and the predictive value of GADAbs positivity for future insulin requirement is estimated about 67% by Baye's theory. Thus, accurate predictive strategies of future insulin deficiency in LADA patients using autoantibody epitope analysis, genetic determination, or T cell assay are needed for the effective immune intervention.

Polymorphisms in the cathepsin L2 (CTSL2) gene show association with type 1 diabetes and early-onset myasthenia gravis

Type 1 diabetes (T1D) is an autoimmune disease characterized by loss of beta cells in the pancreas. The CTSL2 gene encodes the cysteine protease cathepsin V involved in antigen presentation in human cortical thymic epithelial cells, and involvement of the protease in autoimmunity has been suggested. This study aimed to evaluate CTSL2 as a candidate gene for T1D, and test whether the gene predisposes more generally to autoimmune diseases. Four polymorphisms aiming at tagging the CTSL2 locus were genotyped in 421 T1D families, and subsequently in 861 rheumatoid arthritis patients, 530 juvenile idiopathic arthritis patients, and 559 controls of Norwegian origin. Additionally, DNA from 83 German myasthenia gravis (MG) patients and 244 controls were investigated. A polymorphism, rs16919034, situated downstream of CTSL2 was associated with T1D (60.8%T, p = 0.008; p(c) = 0.03). An association with early-onset MG (45% in cases vs 36.6% in controls; p = 0.03) was observed for another polymorphism (rs4361859) situated upstream of the gene, but within the same linkage disequilibrium block. No association was observed in rheumatoid arthritis or juvenile idiopathic arthritis. Our findings suggest that the CTSL2 gene is associated with T1D and with early-onset MG.

Maternal psychological reaction to newborn genetic screening for type 1 diabetes

OBJECTIVE

The purpose of this work was to describe levels of maternal anxiety, depressive symptoms, and perceptions of infant vulnerability associated with newborn genetic screening for susceptibility to type 1 diabetes.

PATIENTS AND METHODS

Mothers of infants tested at birth for genetic susceptibility to type 1 diabetes as part of a prospective study investigating potential environmental triggers of autoimmunity were recruited to this study. Three mother-infant cohorts were studied: 38 infants at increased genetic risk, 73 at low risk, and 76 who had not undergone testing. The Vulnerable Baby Scale, Edinburgh Postnatal Depression Scale, and state subscale of the State Trait Anxiety Inventory were administered at the 9-week, 4-month, and 1-year postnatal ages. Genetic-risk notification occurred at the 10-week postnatal age. Mothers whose infants had undergone genetic testing were also asked to subjectively rate how much they thought and worried about their child's genetic test result. Statistical analyses were conducted to test for differences in questionnaire scores among the 3 groups.

RESULTS

No difference among the groups was detected in Vulnerable Baby Scale or Edinburgh Postnatal Depression Scale scores using linear mixed-effects model analysis. Maternal anxiety was paradoxically slightly lower in the increased-risk group shortly after notification of results, but there were no significant differences among the groups by 1 year. Mothers of infants in the high-risk group reported thinking and worrying about their child's test result significantly more than mothers of low-risk infants at both time points after notification of results.

CONCLUSIONS

Newborn genetic screening to identify infants at risk for type 1 diabetes is not associated with elevated levels of maternal anxiety, depressive symptoms, or heightened perceptions of infant vulnerability. However, responses to subjective assessment questions suggest that it is possible that more subtle effects on mothers do occur, and this requires further investigation.

Major increase in Type 1 diabetes: no support for the Accelerator Hypothesis

BACKGROUND

The Accelerator Hypothesis postulates that the apparent increase in incidence of Type 1 diabetes mellitus (T1DM) is related to an acceleration of disease onset by weight-related insulin resistance. Our diabetes clinic has experienced a major recent increase in newly diagnosed diabetes. The Accelerator Hypothesis predicts that this increase should be associated with younger age and increased body mass at diagnosis, with youngest children having the highest body mass index (BMI).

AIM

To test the Accelerator Hypothesis in the context of the major increase in T1DM at our centre.

METHODS

Data from all young people diagnosed with T1DM between 1992 and 2003 were reviewed. Height and weight measurements from initial outpatient review were used to calculate BMI.

RESULTS

The mean increase in BMI standard deviation score (SDS) is 0.03 per year (P = 0.01). Age at diagnosis has also increased by a mean of 0.11 years annually (P = 0.003). There was no association between BMI SDS and age at diagnosis (P = 0.7). A significant difference in BMI SDS between age-banded subgroups was evident (P = 0.04); however, youngest children had the lowest SDS.

CONCLUSION

Our results do not support increased body mass as an accelerator of diabetes presentation.

IA-2 autoantibodies in incident type I diabetes patients are associated with a polyadenylation signal polymorphism in GIMAP5

In a large case-control study of Swedish incident type I diabetes patients and controls, 0-34 years of age, we tested the hypothesis that the GIMAP5 gene, a key genetic factor for lymphopenia in spontaneous BioBreeding rat diabetes, is associated with type I diabetes; with islet autoantibodies in incident type I diabetes patients or with age at clinical onset in incident type I diabetes patients. Initial scans of allelic association were followed by more detailed logistic regression modeling that adjusted for known type I diabetes risk factors and potential confounding variables. The single nucleotide polymorphism (SNP) rs6598, located in a polyadenylation signal of GIMAP5, was associated with the presence of significant levels of IA-2 autoantibodies in the type I diabetes patients. Patients with the minor allele A of rs6598 had an increased prevalence of IA-2 autoantibody levels compared to patients without the minor allele (OR=2.2; Bonferroni-corrected P=0.003), after adjusting for age at clinical onset (P=8.0 x 10(-13)) and the numbers of HLA-DQ A1*0501-B1*0201 haplotypes (P=2.4 x 10(-5)) and DQ A1*0301-B1*0302 haplotypes (P=0.002). GIMAP5 polymorphism was not associated with type I diabetes or with GAD65 or insulin autoantibodies, ICA, or age at clinical onset in patients. These data suggest that the GIMAP5 gene is associated with islet autoimmunity in type I diabetes and add to recent findings implicating the same SNP in another autoimmune disease.

Is neonatal phototherapy associated with an increased risk for hospitalized childhood bronchial asthma?

This population-based register study examined if factors during the fetal and neonatal period influence the risk for the child to develop bronchial asthma (asthma). From the Swedish Hospital Discharge Register we identified children, born between 1987 and 1999, who had been hospitalized for asthma up to 2001. Thus, the outcome measure contains only hospitalized cases, not all children with asthma. Children younger than 2 yr at admission were excluded because of the uncertainty about the diagnosis of asthma in younger children. The remaining 14,803 children were compared with all children born the same years, recorded in the Swedish Medical Birth Registry, for information on pre- and perinatal characteristics. Odds ratios (ORs) were calculated with Mantel-Haenszel technique and 95% confidence intervals (CIs) with Miettinen's test-based method. The presence of various maternal and neonatal confounders were identified and adjusted for in the analyses. The association between some known factors and childhood asthma were confirmed: young maternal age, maternal smoking, period of unwanted childlessness, low maternal level of education, maternal diabetes, preterm birth, low birth weight, small-for-gestational age, caesarean section, and instrumental vaginal delivery. A number of neonatal characteristics were shown to be independent risk factors: sepsis or pneumonia, neonatal respiratory problems and treatments, neonatal icterus, and/or neonatal phototherapy. The association with icterus and phototherapy remained after exclusion of cases showing other neonatal risk factors and after adjustment for maternal factors (OR 1.27, 95% CI: 1.08-1.50), and increased to 1.5 if the children had been hospitalized for asthma more than once. In conclusion, our results suggest an association between neonatal icterus and/or treatment with neonatal phototherapy and hospitalized childhood asthma. This association needs further exploration.

Rising incidence of type 2 diabetes in children in the U.K

OBJECTIVE

To estimate the incidence of type 2 diabetes in children <17 years of age and to investigate the relationship of diabetes with increasing childhood obesity in the U.K. and the Republic of Ireland (ROI).

RESEARCH DESIGN AND METHODS

Active monthly reporting of cases by consultant pediatricians occurred through the framework of the British Pediatric Surveillance Unit, with additional reports from specialist diabetes nurses. All children <17 years of age and diagnosed by their clinician as having non-type 1 diabetes from 1 October 2004 to 31 October 2005 were included.

RESULTS

A total of 168 confirmed cases of non-type 1 diabetes were reported, resulting in a national incidence (excluding the ROI) of 1.3 x 100,000(-1) x year(-1). Of these, 40% were diagnosed with type 2 diabetes giving a minimum incidence of 0.53 x 100,000(-1) x year(-1). Children of ethnic minorities were greatly overrepresented, with those of black and South-Asian origin (England data only) having an incidence of 3.9 and 1.25 x 100,000(-1) x year(-1), respectively, compared with 0.35 x 100,000(-1) x year(-1) in those defined as white. Of those diagnosed with type 2 diabetes, 95% were overweight and 83% obese according to International Obesity Task Force guidelines. Eighty-four percent had a family history of type 2 diabetes.

CONCLUSIONS

Type 2 diabetes is still less common than type 1 diabetes in U.K. children. However, compared with previous prevalence data, the frequency of type 2 diabetes appears to be increasing. Incidence among ethnic minorities is far higher than in whites, as previously described in the U.S. Increased adiposity and family history of type 2 diabetes were strongly associated with the diagnosis of type 2 diabetes in U.K. children.

Perinatal risk factors for childhood Type 1 diabetes in Western Australia--a population-based study (1980-2002)

AIMS

To investigate perinatal risk factors for childhood Type 1 diabetes in Western Australia, using a complete population-based cohort.

METHODS

Children born between 1980 and 2002 and diagnosed with Type 1 diabetes aged < 15 years (n = 940) up to 31 December 2003 were identified using a prospective population-based diabetes register with a case ascertainment rate of 99.8%. Perinatal data were obtained for all live births in Western Australia from 1980 to 2002 (n = 558 633) and record linkage performed to identify the records of cases.

RESULTS

The incidence of Type 1 diabetes increased by 13% for each 5-year increase in maternal age [adjusted incidence rate ratio (IRR) 1.13, 95% confidence interval (CI) 1.05, 1.21], by 13% for every 500-g increase in birth weight (adjusted IRR 1.13, 95% CI 1.04, 1.23). The incidence decreased with increasing birth order (adjusted IRR 0.89, 95% CI 0.82, 0.96) and increasing gestational age (adjusted IRR 0.84, 95% CI 0.77, 0.93). A higher incidence of Type 1 diabetes was associated with an urban vs. non-urban maternal address at the time of birth (adjusted IRR 1.38, 95% CI 1.18, 1.63), but no association was found with socio-economic status of the area.

CONCLUSIONS

A higher incidence of Type 1 diabetes was associated with increasing maternal age, higher birth weight, lower gestational age, lower birth order and urban place of residence at the time of birth.

Ketoacidosis at diagnosis of type 1 diabetes in children in northern Finland: temporal changes over 20 years

OBJECTIVE

To study the frequency of diabetic ketoacidosis (DKA) over a 20-year period among children diagnosed with type 1 diabetes in northern Finland.

RESEARCH DESIGN AND METHODS

The study population comprised 585 patients (328 boys) diagnosed with type 1 diabetes aged <15 years in the Department of Pediatrics, Oulu University Hospital, between 1 January 1982 and 31 December 2001. The data for clinical characteristics were collected retrospectively from the patients' case records. The earlier 10-year period (1982-1991) was compared with the later 10-year period (1992-2001). Two definitions for DKA were used: DKA(i) pH <7.30 or DKA(ii) pH <7.30 and/or bicarbonate <15 mmol/l.

RESULTS

During the later 10-year period, children less often had DKA at diagnosis [DKA(i) 15.2 vs. 22.4%, P = 0.028, and DKA(ii) 18.9 vs. 29.5%, P = 0.003]. The proportion of young children aged <5 years at diagnosis increased over time, but the frequency of DKA also was lower in this age-group during 1992-2001 compared with the earlier 10-year period [DKA(i) 17.7 vs. 32.1%, P = 0.052, and DKA(ii) 20.3 vs. 42.6%, P = 0.005]. In children aged <2 years at diagnosis, the frequency of DKA remained high during 1992-2001 [DKA(i) 39.1% and DKA(ii) 47.8%].

CONCLUSIONS

The overall frequency of DKA in children with newly diagnosed type 1 diabetes decreased over a 20-year period in northern Finland. However, children aged <2 years are still at high risk for DKA at diagnosis.

Seasonal variation in the diagnosis of type 1 diabetes in south-east Sweden

With the aim to survey the seasonal pattern of diagnosis of type 1 diabetes we included all 1903 children <16 years of age and who had been diagnosed with type 1 diabetes between 1977 and 2001 in the south-east of Sweden. To investigate the seasonal pattern a mixture of two cosine functions was included in a logistic regression model. There was a clear seasonal variation over the years (p<0.001). Children in the oldest age group (11-15 years) showed the most obvious seasonal variation (p<0.001). Children with a short duration of symptoms had about the same seasonal variation as children with a long duration. Both children with and without an infection 3 months prior to diagnosis showed significant seasonal variation (p<0.001) although the seasonal pattern differed between the two groups (p<0.001). As the incidence of diabetes increased during the 25 years the study period was divided into periods of 5 years and it was only during the two last periods that significant seasonal variation occurred. There is a clear seasonal variation in diagnosis of type 1 diagnosis in children and the results suggest that children with a less aggressive disease process at diagnosis were most responsible for this variation. Children with and without prior infection showed a different seasonal pattern.

Marked increase in type 1 diabetes mellitus incidence in children aged 0-14 yr in Victoria, Australia, from 1999 to 2002

OBJECTIVES

The objectives of the study were to (i) determine the incidence of type 1 diabetes mellitus (T1DM) in children aged <15 yr in Victoria, Australia, from 1999 to 2002 and (ii) to analyze trends in incidence over this period.

METHODS

Prospective population-based incidence study. The primary source of case ascertainment was from the Australasian Paediatric Endocrine Group (APEG) Victorian diabetes register. The secondary source was the National Diabetes Register (NDR), which ascertains cases from the National Diabetes Service Scheme (NDSS), a Commonwealth government initiative, where patients register to receive diabetes supplies at a subsidized price.

MAIN OUTCOME MEASURES

Age-standardized incidence, trends in incidence by age, sex and year, and variation in incidence by region, season, and socioeconomic status.

RESULTS

Case ascertainment was 99.1% complete using the capture-recapture method. The mean annual age-standardized incidence was 19.3 per 100 000 person years from 1999 to 2002. On average, incidence increased by 9.3% per year, with a greater relative increase in the 0-4 yr age-group (p = 0.037). No gender bias in incidence was found, but the increase in females was statistically significant (13.6% per year, 95% confidence interval 3.7-24.3). Variation in geographical distribution and seasonal onset of incidence was not statistically significant.

CONCLUSIONS

The marked increase in the incidence of T1DM in Victoria is greater than that recently described in other Australia states and developed nations. The etiology of this rise is unclear, while the increased caseload has major implications for diabetes health care providers for current and future resource allocation.

Estimating infectious diseases incidence: validity of capture-recapture analysis and truncated models for incomplete count data

Capture-recapture analysis has been used to evaluate infectious disease surveillance. Violation of the underlying assumptions can jeopardize the validity of the capture-recapture estimates and a tool is needed for cross-validation. We re-examined 19 datasets of log-linear model capture-recapture studies on infectious disease incidence using three truncated models for incomplete count data as alternative population estimators. The truncated models yield comparable estimates to independent log-linear capture-recapture models and to parsimonious log-linear models when the number of patients is limited, or the ratio between patients registered once and twice is between 0.5 and 1.5. Compared to saturated log-linear models the truncated models produce considerably lower and often more plausible estimates. We conclude that for estimating infectious disease incidence independent and parsimonious three-source log-linear capture-recapture models are preferable but truncated models can be used as a heuristic tool to identify possible failure in log-linear models, especially when saturated log-linear models are selected.

Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study

OBJECTIVE

The objective of this study was to describe the incidence, prevalence, risk factors, and prognosis of fatigue, chronic fatigue, and chronic fatigue syndrome in 11- to 15-year-olds.

METHODS

A random general population sample (n = 842) of British adolescents and their parents were assessed at baseline and 4 to 6 months later. The main outcomes were fatigue, chronic fatigue, and chronic fatigue syndrome, operationally defined.

RESULTS

The incidence over 4 to 6 months was 30.3% for fatigue, 1.1% for chronic fatigue, and 0.5% for chronic fatigue syndrome. The point prevalence was 34.1% and 38.1% for fatigue, 0.4% and 1.1% for chronic fatigue, and 0.1% and 0.5% for chronic fatigue syndrome at time 1 and time 2, respectively. Of participants who were fatigued at time 1, 53% remained fatigued at time 2. The 3 cases of chronic fatigue and 1 case of chronic fatigue syndrome at time 1 had recovered by time 2. Higher risk for development of chronic fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and maternal distress; in multivariate analysis, baseline anxiety or depression remained a significant predictor of chronic fatigue. Increased risk for development of fatigue at time 2 was associated with time 1 anxiety or depression, conduct disorder, and older age; in multivariate analyses, these factors and female gender all were significant predictors of fatigue.

CONCLUSIONS

The incidence rates for chronic fatigue and chronic fatigue syndrome in this adolescent sample were relatively high, but the prognosis for these conditions was good. This prospective study provides evidence for an association between emotional/behavioral problems and subsequent onset of fatigue/chronic fatigue.

A new expression of diabetes: double diabetes

Diabetes is on the increase worldwide. The incidence of both type 1 and type 2 diabetes has shown a rise, in parallel with a notable increase in the incidence of a new expression of the disease in children and adolescents, with the characteristics of a mixture of the two types of diabetes, and referred to as 'double diabetes'. Insulin resistance and obesity, together with the presence of markers of pancreatic autoimmunity - namely, autoantibodies to islet cell antigens - typically define this condition. However, recognition of double diabetes can pose problems. In most cases, a reduction in the 'autoimmune load' and an increase in the 'metabolic load' are helpful for attaining a correct diagnosis in a diabetic child.

Tyrosine kinase receptors are crucial for normal β-cell development and function

Signaling pathways play critical roles in most physiological and pathological processes and convert an extracellular stimulus into a change of function in the recipient cell. Intracellular messages originate from the activation of membrane receptors by a variety of ligands, such as hormones, nutrients or growth factors. The receptors subsequently interact with specific intracellular cascades, triggering the phosphorylation of cell effectors. In the pancreas, these processes control the organogenesis, maintenance and function of endocrine cells within the islets. Growth factors acting through tyrosine kinase receptors play a prominent role among the multitude of signaling pathways active in pancreatic β cells. Deregulation of these processes leads to the development of disorders such as hypoglycemia or diabetes. This review will describe recent advances made on the understanding of the roles of major tyrosine kinase receptors in pancreatic β-cell physiology.

Increasing incidence of type 1 diabetes in 0- to 17-year-old Colorado youth

OBJECTIVE

We sought to assess the long-term trends in the incidence of type 1 diabetes among non-Hispanic white and Hispanic youth aged 0-17 years from Colorado using data from the Colorado IDDM Study Registry (1978-1988) and SEARCH for Diabetes in Youth (2002-2004).

RESEARCH DESIGN AND METHODS

Cases of diabetes were ascertained through physician reporting and hospital databases. Type 1 diabetes was defined as use of insulin within 2 weeks from diagnosis. Completeness of ascertainment was estimated as 97%. Annual average incidence rates (per 100,000/year) and 95% CIs for the time periods were computed. Trends in incidence were assessed by Poisson regression.

RESULTS

The incidence of type 1 diabetes was 14.8 (95% CI 14.0-15.6) in 1978-1988 and 23.9 (22.2-25.6) in 2002-2004 for the state of Colorado (P < 0.0001). From 1978 to 2004, the incidence of type 1 diabetes increased by 2.3% (1.6-3.1) per year (P < 0.0001). The increase in incidence was significant for both non-Hispanic white (2.7% [95% CI 1.9-3.6] per year, P < 0.0001) and Hispanic youth (1.6% [0.2-3.1] per year, P = 0.013).

CONCLUSIONS

The incidence of type 1 diabetes has increased 1.6-fold among Colorado youth from 1978-1988 to 2002-2004, and both non-Hispanic white and Hispanic youth are affected by this trend.

Association between parasite infection and immune responses in multiple sclerosis

OBJECTIVE

To assess whether parasite infection is correlated with a reduced number of exacerbations and altered immune reactivity in multiple sclerosis (MS).

METHODS

A prospective, double-cohort study was performed to assess the clinical course and radiological findings in 12 MS patients presenting associated eosinophilia. All patients presented parasitic infections with positive stool specimens. In all parasite-infected MS patients, the eosinophilia was not present during the 2 previous years. Eosinophil counts were monitored at 3- to 6-month intervals. When counts became elevated, patients were enrolled in the study. Interleukin (IL)-4, IL-10, IL-12, transforming growth factor (TGF)-beta, and interferon-gamma production by myelin basic protein-specific peripheral blood mononuclear cells were studied using enzyme-linked immunospot (ELISPOT). FoxP3 and Smad7 expression were studied by reverse-transcriptase polymerase chain reaction.

RESULTS

During a 4.6-year follow-up period, parasite-infected MS patients showed a significantly lower number of exacerbations, minimal variation in disability scores, as well as fewer magnetic resonance imaging changes when compared with uninfected MS patients. Furthermore, myelin basic protein-specific responses in peripheral blood showed a significant increase in IL-10 and TGF-beta and a decrease in IL-12 and interferon-gamma-secreting cells in infected MS patients compared with noninfected patients. Myelin basic protein-specific T cells cloned from infected subjects were characterized by the absence of IL-2 and IL-4 production, but high IL-10 and/or TGF-beta secretion, showing a cytokine profile similar to the T-cell subsets Tr1 and Th3. Moreover, cloning frequency of CD4+CD25+ FoxP3+ T cells was substantially increased in infected patients compared with uninfected MS subjects. Finally, Smad7 messenger RNA was not detected in T cells from infected MS patients secreting TGF-beta.

INTERPRETATION

Increased production of IL-10 and TGF-beta, together with induction of CD25+CD4+ FoxP3+ T cells, suggests that regulatory T cells induced during parasite infections can alter the course of MS.

Children diagnosed with diabetes during infancy have unique clinical characteristics

OBJECTIVE

Characterizing clinical and biochemical features of children diagnosed with diabetes mellitus between the ages of 6-24 months.

DESIGN AND METHODS

Medical records of 42 children diagnosed with diabetes mellitus at age of 6-24 months were reviewed for gender, ethnic origin, family medical history, clinical and biochemical features at onset of diabetes compared with 60 diabetic patients diagnosed at age 5-16 years.

RESULTS

Children diagnosed at 6-24 months had at onset more symptoms of apathy, restlessness, hyperglycemia during acute illness and a lower rate of remission than those diagnosed at older age (p < 0.001), significantly more episodes of diabetic ketoacidosis (83% vs. 40%, p < 0.001), lower HbA1c levels (mean 11.6 +/- 3.4 vs. 13.75 +/- 3.4%, p < 0.05) and a higher rate of celiac disease (12% vs. 3%, p = 0.046). There were no significant differences as to other autoimmune diseases.

CONCLUSIONS

Patients with diabetes presenting at 6-24 months might be associated with a different clinical pattern and higher rate of celiac disease than diabetes presenting later in life. Understanding the nature and course of diabetes in this age group is crucial for planning interventional and preventive programs.

Swedish families' lived experience when a child is first diagnosed as having insulin-dependent diabetes mellitus: An ongoing learning process

Sweden has the second highest nationwide incidence of childhood diabetes in Europe, and it is rapidly increasing. The diagnosis of Type 1 insulin-dependent diabetes mellitus has been indicated as a crisis in the life of the individual and family. The purpose of this study was to elucidate the whole family's lived experience when a child in the family is diagnosed as having diabetes. It was designed as a longitudinal, descriptive, inductive study including qualitative interviews. Family members in 12 families were recruited from a children's university hospital in Sweden to participate in a series of three interviews: when first diagnosed, and 1 and 3 years after diagnosis. This article derives from the first interview. All invited families agreed to participate and were interviewed 1 to 3 months after diagnosis using a hermeneutic phenomenological approach. The family's lived experience was identified as an ongoing learning process including learning about the inevitable and learning about the extent. The learning process was experienced as a recurrent phenomenon when the family was exposed to new situations or contexts. Therefore, individualized treatment may reduce the difficulties experienced in coping with the diabetic management regimen after discharge, thus making the transition smoother.

Is affluence a risk factor for bronchial asthma and type 1 diabetes?

In the last decades, an increase in bronchial asthma and type 1 diabetes occurrence has been observed in affluent countries, and a positive association between the two disorders has been demonstrated at the population level. This association could be explained by common risk factors predisposing to both disorders. Altered environmental and lifestyle conditions, possibly related to socio-economic status, might account for the rising trend of the two disorders. To test this hypothesis, we calculated the correlation between the occurrence of type 1 diabetes and asthma, the gross national product (GNP) and the infant mortality rate, in several European and extra-European countries. GNP was positively correlated with the incidence of type 1 diabetes and with symptoms of asthma in European (r(sp): 0.53 and 0.69; p = 0.001 and p < 0.0001, respectively) and extra-European countries (r(sp): 0.44 and 0.46; p = 0.04 for both diseases). Infant mortality rate was inversely correlated with GNP and with the occurrences of the two diseases in Europe (r(sp): -0.66, p < 0.0001 for type 1 diabetes; r(sp):- 0.51, p = 0.01 for asthma). In extra-European countries, a significant relationship was found between infant mortality and asthma (r(sp): -0.46; p = 0.03); a trend towards a negative correlation between infant mortality and type 1 diabetes was also found, although no statistical significance was reached (r(sp): -0.21; p = 0.31). This analysis indicates that type 1 diabetes and asthma are positively associated with the GNP at the population level. Similarly, countries with low infant mortality rates tend to have a higher incidence of these immune-mediated diseases. Although GNP reflects many societal and lifestyle differences, it is notable that a high socio-economic status implies a reduced or delayed exposure to infectious agents. The reduced pressure of infectious agents on the immune system throughout life might contribute to increase the susceptibility to bronchial asthma and type 1 diabetes.

Parasitic worms and inflammatory diseases

The debate on whether infection precipitates or prevents autoimmunity remains a contentious one. Recently the suggestion that some unknown microbe can be at the origin of some chronic inflammatory diseases has been countered by accumulating evidence that decreasing infection rates might have an important role to play in the rising prevalence of autoimmune disorders. The 'Hygiene Hypothesis' was initially postulated to explain the inverse correlation between the incidence of infections and the rise of allergic diseases, particularly in the developed world. Latterly, the Hygiene Hypothesis has been extended to also incorporate autoimmune diseases in general. Amongst the various infectious agents, a particular emphasis has been put on the interaction between parasitic worms and humans. Worm parasites have co-evolved with the mammalian immune system for many millions of years and during this time, they have developed extremely effective strategies to modulate and evade host defences and so maintain their evolutionary fitness. It is therefore reasonable to conclude that the human immune system has been shaped by its relationship with parasitic worms and this may be a necessary requirement for maintaining our immunological health. Fully understanding this relationship may lead to novel and effective treatments for a host of deleterious inflammatory reactions.

FOXP3 polymorphisms in type 1 diabetes and coeliac disease

The FOXP3 gene encodes a transcription factor thought to be essential for the development and function of T regulatory cells. Two previous studies have tested common polymorphisms in FOXP3 for association with type 1 diabetes (T1D) with conflicting results. The aim of our study was to see whether there is any evidence of association between the FOXP3 polymorphisms previously reported to be associated with T1D, in a Caucasian population regarding T1D and coeliac disease (CD). We further looked for evidence of interaction between FOXP3 polymorphisms and HLA-DR3 in conferring susceptibility to T1D. Initially, we analysed two microsatellites in the FOXP3 gene in 363 T1D nuclear families. Our results indicated an association between FOXP3 and T1D (global p=0.004) and a possible interaction between FOXP3 and the HLA-DR3-DQ2 susceptibility haplotype. We then genotyped an additional independent set of 826 T1D patients and 1459 controls as well as one CD dataset consisting of 325 families. A similar tendency was revealed in the CD family material (pnc=0.055 for the associated allele). On the other hand, we were unable to reproduce our initial findings in the T1D case-control dataset (global p=0.6). Our results suggest that the tested FOXP3 markers do not have any major impact on susceptibility for these diseases.

Prevention strategies for type 1 diabetes

Type 1 diabetes (T1D) is a common chronic disease of childhood. Patients with T1D are at significant risk for developing serious health complications. Understanding of the genetics, environmental factors, and natural history of diabetes has lead to greater understanding of the etiology and epidemiology of T1D. Furthermore, technology has greatly improved glycemic control and reduction of complications. However, prevention of the development of diabetes remains elusive. This review article describes the past, current and upcoming strategies for diabetes prevention for patients at risk for developing autoimmunity, after antibody production, and patients with new onset diabetes.

Clinical characteristics and diabetes associated autoantibodies in patients with both type 1 diabetes mellitus and asthma

OBJECTIVE

Type 1 diabetes mellitus (DM1) and asthma are mediated by opposite arms of the cellular immune system, namely T helper (Th)1 and Th2 CD4+ cells, respectively. It is not known whether their coexistence affects their clinical manifestations.

METHODS

The number of asthma exacerbations, frequency of hypoglycemic events, HbA1c levels, diabetes associated autoantibody status and diabetes associated late complications were determined in three paired groups of patients (n = 11) matched by gender and age: DM1 and asthma, asthma only, and DM1 only.

RESULTS

Patients with both diseases had a higher prevalence of hypoglycemic events per month compared to patients with DM1 only: 5.67 +/- 4.27 vs 1.45 +/- 2.06, respectively (p = 0.008). The co-existence of the two diseases did not modify the remaining clinical and laboratory parameters.

CONCLUSION

Patients with both DM1 and asthma have similar clinical characteristics to patients with only one of these diseases apart from a higher rate of hypoglycemic events compared to patients with DM1 without asthma.

Fetal and perinatal risk factors for inflammatory bowel disease

AIM

To study the influence of specific factors and events during pregnancy and the perinatal period on the risk of children developing inflammatory bowel disease.

METHODS

Population-based national register study. Linkage between the Swedish Medical Birth Register and the Swedish Hospital Discharge Register during the period 1987 to 2000 identified 455 singleton infants who later developed inflammatory bowel disease. Data for these children were compared with data for all children born in Sweden during the same period.

RESULTS

Smoking during early pregnancy reduced the risk of inflammatory bowel disease (odds ratio (OR) 0.71, 95% CI 0.55-0.91). For ulcerative colitis the odds ratio was 0.70 (95% CI 0.56-0.86), and for Crohn's disease 0.73 (95% CI 0.58-0.94). Infections during the neonatal period seemed to increase the risk of inflammatory bowel disease (OR 17.6, 95% CI 3.6-51.6), but the number of observed events was small. The other factors examined did not influence the risk of inflammatory bowel disease.

CONCLUSION

Maternal smoking during early pregnancy reduces the risk for the child to be hospitalized with a diagnosis of inflammatory bowel disease. Severe neonatal infections may increase the risk. Thus, some exposures during the fetal and neonatal period seem to affect the risk of inflammatory bowel disease later in life.