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

Islet autoantibody frequency in relatives of children with type 1 diabetes who have a type 2 diabetes diagnosis

AIM

This study aimed to evaluate characteristics of autoimmunity in individuals who have a type 2 diagnosis and are relatives of children with type 1 diabetes.

METHODS

Pre-diagnosis samples (median 17 months before onset) from relatives who were later diagnosed with type 2 diabetes were measured for autoantibodies to glutamate decarboxylase 65 (GADA), islet antigen-2 (IA-2A), zinc transporter 8 (ZnT8A) and insulin (IAA) as well as the type 1 diabetes genetic risk score (GRS2). Associations between islet autoantibodies, insulin treatment and GRS2 were analysed using Fisher's exact and t-tests.

RESULTS

Among 226 relatives (64% men; mean age at sampling 41 years; mean age 54 years at diagnosis), 32 (14%) were islet autoantibody-positive for at least one autoantibody more than a decade before diagnosis. Approximately half of these (n = 15) were treated with insulin. GADA-positivity was higher in insulin-treated relatives than in non-insulin-treated relatives (12/18 [67%] vs. 6/18 [33%], p < 0.001). IAA-positivity was observed in 13/32 (41%) of relatives with autoantibodies. GRS2 scores were increased in autoantibody-positive relatives (p = 0.032), but there was no clear evidence for a difference according to treatment (p = 0.072).

CONCLUSION

This study highlights the importance of measuring islet autoantibodies, including IAA, in relatives of people with type 1 diabetes to avoid misdiagnosis.

Incidence of type 1 diabetes in Sardinian children aged 0-14 years has almost doubled in the last twenty years. On top of the world

AIMS

The primary objectives were to investigate the incidence rate (IR) of type 1 diabetes (T1D) in Sardinian children aged 0-14 years in 2019-2022 and to examine the temporal trend from 1989-1999.

METHODS

Data from new-onset T1D patients aged 0-14 years who were residents of Sardinia were collected from all pediatric diabetology clinics. The overall, sex- and age specific (groups 0-4, 5-9, and 10-14 years), and calendar year IRs were calculated. The standardized IR (SIR) was also calculated using the direct method. Poisson regression was used to estimate the temporal trend in the SIRs from 1989-1999 to 2019-2022.

RESULTS

In 2019-2022, 512 patients aged 0-14 years were diagnosed with T1D in Sardinia. The overall IR was 73.9 per 100,000 person-years (95 % CI 67.6-80.0). Since 1989, the SIR has increased by 2.3 % per year (CI 1.7-2.8, p < 0.0001). The frequency of ketoacidosis at onset was 26.4 %, with no significant differences among the four years.

CONCLUSIONS

The incidence of T1D in Sardinia, unlike in other countries such as Finland, has almost doubled in the last 20 years, and currently, it appears to be the highest in the world.

Use of teplizumab in children and adolescents at risk of type 1 diabetes: perspectives of parents and caregivers from an Italian Pediatric Diabetes Center

AIMS

In view of the imminent introduction of a novel category of disease-modifying treatments for type 1 diabetes (T1D) in European countries, it becomes imperative to understand the existing awareness and viewpoints of parents and caregivers of children and adolescents predisposed to T1D. This study aims to evaluate the perspectives of a cohort of parents and caregivers regarding using teplizumab to delay the onset of T1D in predisposed children and adolescents.

METHODS

This single-center study used a survey-based approach. Parents or caregivers of children and adolescents with T1D having at least one additional child without T1D answered 15 questions assessing their awareness about teplizumab, their potential willingness to provide consent for its administration in case of eligibility, and their expectations regarding potential outcomes.

RESULTS

Approximately half of the participants (52.6%) expressed readiness to consent to teplizumab administration for their child if the prescription criteria were met in the future. Only 6.3% of parents claimed detailed knowledge about this innovative medication. Notably, parents with prior experience of diabetic ketoacidosis (DKA) demonstrated a higher inclination to consent to teplizumab treatment (p = 0.018).

CONCLUSIONS

Our findings underscore the necessity for comprehensive awareness campaigns spreading the current evidence concerning teplizumab in terms of both effectiveness and possible side effects. Additionally, our study reinforces the pivotal role of DKA prevention in successfully integrating disease-modifying treatments into clinical practice.

The incidence of type 1 diabetes in children under 15 years of age is rising again-a nationwide study

International incidence rates (IRs) and trends of childhood type 1 diabetes (T1D) vary. Recent data from Ireland and other high incidence countries suggested a stabilisation in IRs of T1D in children aged under 15 years. Our primary objective was to report the IR of T1D in children in Ireland from 2019 to 2021 and evaluate if age, sex and season of diagnosis had changed. Incident cases of T1D in those aged under 15 years were identified prospectively by clinicians nationally and reported to the Irish Childhood Diabetes National Register (ICDNR). Following case verification, capture-recapture methodology was applied, and IRs calculated. Numbers of children including age, sex and season of diagnosis per year were evaluated. There were 1027 cases, 542 males (53%). The direct standardised incidence rates (SIRs) increased by 21% overall and were 31.1, 32.2 and 37.6/100,000/year, respectively, with no significant sex difference. The highest IRs were in the 10-14-year category until 2021, then changed to the 5-9-year category (40% of cases). Whilst autumn and winter remain dominant diagnostic seasons, seasonality differed in 2021 with a greater number presenting in spring.

CONCLUSION

The incidence of childhood T1D in Ireland is increasing, observed prior to the COVID-19 pandemic, and shifting to an earlier age at diagnosis for the first time. The pattern of seasonality also appears to have changed. This may reflect an increased severity of diabetes with important implications for healthcare providers.

WHAT IS KNOWN

• Ireland has a very high incidence of T1D in childhood, which had stabilised following a rapid rise, similar to other high incidence countries. • The incidence rate is consistently highest in older children (10-14 years).

WHAT IS NEW

• Irish IR is no longer stable and has increased again, with the highest incidence occurring in the younger 5-9 age category for the first time. • The seasonality of diagnosis has changed during the COVID-19 pandemic years of 2020-2021.

Differential evolution of diabetic ketoacidosis in adults with pre-existent versus newly diagnosed type 1 and type 2 diabetes mellitus

BACKGROUND

Diabetic ketoacidosis (DKA) was once known to be specific to type-1 diabetes-mellitus (T1D); however, many cases are now seen in patients with type-2 diabetes-mellitus (T2D). Little is known about how this etiology shift affects DKA's outcomes.

METHODS

We studied consecutive index DKA admissions from January 2015 to March 2021. Descriptive analyses were performed based on pre-existing T1D and T2D (PT1D and PT2D, respectively) and newly diagnosed T1D and T2D (NT1D and NT2D, respectively).

RESULTS

Of the 922 patients, 480 (52%) had T1D, of which 69% had PT1D and 31% NT1D, whereas 442 (48%) had T2D, of which 60% had PT2D and 40% NT2D. The mean age was highest in PT2D (47.6 ± 13.1 years) and lowest in PT1D (27.3 ± 0.5 years) (P < 0.001). Patients in all groups were predominantly male except in the PT1D group (55% females) (P < 0.001). Most patients were Arabic (76% in PT1D, 51.4% in NT1D, 46.6% in PT2D) except for NT2D, which mainly comprised Asians (53%) (P < 0.001). Patients with NT2D had the longest hospital length of stay (LOS) (6.8 ± 11.3 days) (P < 0.001), longest DKA duration (26.6 ± 21.1 h) (P < 0.001), and more intensive-care unit (ICU) admissions (31.2%) (P < 0.001). Patients with PT1D had the shortest LOS (2.5 ± 3.5 days) (P < 0.001), DKA duration (18.9 ± 4.2 h) (P < 0.001), and lowest ICU admissions (16.6%) (P < 0.001).

CONCLUSIONS/INTERPRETATION

We presented the largest regional data on differences in DKA based on the type and duration of diabetes- mellitus (DM), showing that T2D is becoming an increasing cause of DKA, with worse clinical outcomes (especially newly diagnosed T2D) compared to T1D.

Advances for pediatricians in 2022: allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology

The last year saw intensive efforts to advance knowledge in pediatric medicine. This review highlights important publications that have been issued in the Italian Journal of Pediatrics in 2022. We have chosen papers in the fields of allergy, anesthesiology, cardiology, dermatology, endocrinology, gastroenterology, genetics, global health, infectious diseases, metabolism, neonatology, neurology, oncology, pulmonology. Novel valuable developments in epidemiology, pathophysiology, prevention, diagnosis and treatment that can rapidly change the approach to diseases in childhood have been included and discussed.

Endocrinological Involvement in Children and Adolescents Affected by COVID-19: A Narrative Review

Since the advent of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, an increased incidence of several endocrinological anomalies in acute-phase and/or long-term complications has been described. The aim of this review is to provide a broad overview of the available literature regarding changes in the worldwide epidemiology of endocrinological involvement in children since December 2019 and to report the evidence supporting its association with coronavirus disease 2019 (COVID-19). Although little is known regarding the involvement of endocrine organs during COVID-19 in children, the current evidence in adults and epidemiological studies on the pediatric population suggest the presence of a causal association between the virus and endocrinopathies. Untreated transient thyroid dysfunction, sick euthyroid syndrome, nonthyroidal illness syndrome, and hypothalamic-pituitary-adrenal (HPA) axis and central precocious puberty have been observed in children in acute infection and/or during multisystem inflammatory syndrome development. Furthermore, a higher frequency of ketoacidosis at onset in children with a new diagnosis of type 1 diabetes is reported in the literature. Although the direct association between COVID-19 and endocrinological involvement has not been confirmed yet, data on the development of different endocrinopathies in children, both during acute infection and as a result of its long-term complications, have been reported. This information is of primary importance to guide the management of patients with previous or current COVID-19.

Severe multiple organ failure as a consequence of diabetic ketoacidosis in an adolescent with new-onset type 1 diabetes: A case report

The initial presentation of pediatric diabetes is variable, making prompt diagnosis and treatment challenging. The overlap between type 1 and type 2 diabetes and presence of developmental delays can complicate diagnosis, resulting in delays and severe illness at presentation. Here we describe a case of a 13-year-old male with autism and attention deficit hyperactivity disorder who presented with severe diabetic ketoacidosis, multiple organ failure, and shock. Within 2 weeks of this initial presentation, he had further clinical decompensation due to an intestinal perforation. Cultures from resected gastrointestinal tissue grew mucormycosis, protracting his hospital stay and recovery. He was able to go home several months later with remarkable improvement. This case highlights the necessity of careful history taking and early testing, and how investigation for rare complications of diabetes is vital when patients do not improve as expected.

Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

Importance

There are reports of increasing incidence of pediatric diabetes since the onset of the COVID-19 pandemic. Given the limitations of individual studies that examine this association, it is important to synthesize estimates of changes in incidence rates.

Objective

To compare the incidence rates of pediatric diabetes during and before the COVID-19 pandemic.

Data Sources

In this systematic review and meta-analysis, electronic databases, including Medline, Embase, the Cochrane database, Scopus, and Web of Science, and the gray literature were searched between January 1, 2020, and March 28, 2023, using subject headings and text word terms related to COVID-19, diabetes, and diabetic ketoacidosis (DKA).

Study Selection

Studies were independently assessed by 2 reviewers and included if they reported differences in incident diabetes cases during vs before the pandemic in youths younger than 19 years, had a minimum observation period of 12 months during and 12 months before the pandemic, and were published in English.

Data Extraction and Synthesis

From records that underwent full-text review, 2 reviewers independently abstracted data and assessed the risk of bias. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline was followed. Eligible studies were included in the meta-analysis and analyzed with a common and random-effects analysis. Studies not included in the meta-analysis were summarized descriptively.

Main Outcomes and Measures

The primary outcome was change in the incidence rate of pediatric diabetes during vs before the COVID-19 pandemic. The secondary outcome was change in the incidence rate of DKA among youths with new-onset diabetes during the pandemic.

Results

Forty-two studies including 102 984 incident diabetes cases were included in the systematic review. The meta-analysis of type 1 diabetes incidence rates included 17 studies of 38 149 youths and showed a higher incidence rate during the first year of the pandemic compared with the prepandemic period (incidence rate ratio [IRR], 1.14; 95% CI, 1.08-1.21). There was an increased incidence of diabetes during months 13 to 24 of the pandemic compared with the prepandemic period (IRR, 1.27; 95% CI, 1.18-1.37). Ten studies (23.8%) reported incident type 2 diabetes cases in both periods. These studies did not report incidence rates, so results were not pooled. Fifteen studies (35.7%) reported DKA incidence and found a higher rate during the pandemic compared with before the pandemic (IRR, 1.26; 95% CI, 1.17-1.36).

Conclusions and Relevance

This study found that incidence rates of type 1 diabetes and DKA at diabetes onset in children and adolescents were higher after the start of the COVID-19 pandemic than before the pandemic. Increased resources and support may be needed for the growing number of children and adolescents with diabetes. Future studies are needed to assess whether this trend persists and may help elucidate possible underlying mechanisms to explain temporal changes.

Prevalence and clinical features of severe diabetic ketoacidosis treated in pediatric intensive care unit: a 5-year monocentric experience

BACKGROUND

Diabetic ketoacidosis (DKA) is one of the most alarming concerns in the management of type 1 diabetes (T1D) in pediatric age. Prevalence of DKA at the onset of diabetes ranges from 30 to 40%. In selected cases of severe DKA, admission to pediatric intensive care unit (PICU) should be considered.

METHODS

This study aims to assess the prevalence of severe DKA treated in PICU in our 5-year monocentric experience. Secondary outcome of the study was to describe the main demographical and clinical features of individuals who required admission to PICU. All clinical data were collected by retrospectively reviewing the electronic medical records of children and adolescents with diabetes hospitalized in our University Hospital from January 2017 to December 2022.

RESULTS

During the study period, 103 children and adolescents were newly diagnosed with T1D. Among these, 51.5% presented clinical criteria for DKA and almost 10% needed to be treated in PICU. A higher rate of new T1D diagnoses was observed in 2021, as well as episodes of severe DKA being more frequent than in previous years. Due to severe clinical manifestations of DKA, 10 subjects (9.7%) with T1D onset needed to be treated in PICU. Of these, four children were younger than 5. The great majority came from a low household income and some of them had also immigrant background. The most common complication of DKA was acute kidney injury presented by four children. Other complications were cerebral edema, papilledema and acute esophageal necrosis. A 15-year-old girl had deep vein thrombosis (DVT) that evolved into multiple organ failure leading to death.

CONCLUSIONS

Our findings demonstrated that severe DKA is still quite common in children and adolescents at T1D onset, especially in some areas such as Southern Italy. Public awareness campaigns should be increasingly promoted to facilitate the recognition of early symptoms of diabetes and to reduce morbidity and mortality related to DKA.

Secondary Prevention of Diabetes Type 1 with Oral Calcitriol and Analogs, the PRECAL Study

Screening for Type 1 Diabetes (T1D, incidence 1:300) with T1D autoantibodies (T1Ab) at ages 2 and 6, while sensitive, lacks a preventive strategy. Cholecalciferol 2000 IU daily since birth reduced T1D by 80% at 1 year. T1D-associated T1Ab negativized within 0.6 years with oral calcitriol in 12 children. To further investigate secondary prevention of T1D with calcitriol and its less calcemic analog, paricalcitol, we initiated a prospective interventional non-randomized clinical trial, the PRECAL study (ISRCTN17354692). In total, 50 high-risk children were included: 44 were positive for T1Ab, and 6 had predisposing for T1D HLA genotypes. Nine T1Ab+ patients had variable impaired glucose tolerance (IGT), four had pre-T1D (3 T1Ab+, 1 HLA+), nine had T1Ab+ new-onset T1D not requiring insulin at diagnosis. T1Ab, thyroid/anti-transglutaminase Abs, glucose/calcium metabolism were determined prior and q3-6 months on calcitriol, 0.05 mcg/Kg/day, or paricalcitol 1-4 mcg × 1-3 times/day p.o. while on cholecalciferol repletion. Available data on 42 (7 dropouts, 1 follow-up < 3 months) patients included: all 26 without pre-T1D/T1D followed for 3.06 (0.5-10) years negativized T1Ab (15 +IAA, 3 IA2, 4 ICA, 2 +GAD, 1 +IAA/+GAD, 1 +ICA/+GAD) within 0.57 (0.32-1.3) years or did not develop to T1D (5 +HLA, follow-up 3 (1-4) years). From four pre-T1D cases, one negativized T1Ab (follow-up 1 year), one +HLA did not progress to T1D (follow-up 3.3 years) and two +T1Ab patients developed T1D in 6 months/3 years. Three out of nine T1D cases progressed immediately to overt disease, six underwent complete remission for 1 year (1 month-2 years). Five +T1Ab patients relapsed and negativized again after resuming therapy. Four (aged <3 years) negativized anti-TPO/TG, and two anti-transglutaminase-IgA. Eight presented mild hypercalciuria/hypercalcemia, resolving with dose titration/discontinuation. Secondary prevention of T1D with calcitriol and paricalcitol seems possible and reasonably safe, if started soon enough after seroconversion.

Impact of COVID-19 pandemic on incidence of long-term conditions in Wales: a population data linkage study using primary and secondary care health records

BACKGROUND

The COVID-19 pandemic has directly and indirectly had an impact on health service provision owing to surges and sustained pressures on the system. The effects of these pressures on the management of long-term or chronic conditions are not fully understood.

AIM

To explore the effects of COVID-19 on the recorded incidence of 17 long-term conditions.

DESIGN AND SETTING

This was an observational retrospective population data linkage study on the population of Wales using primary and secondary care data within the Secure Anonymised Information Linkage (SAIL) Databank.

METHOD

Monthly rates of new diagnosis between 2000 and 2021 are presented for each long-term condition. Incidence rates post-2020 were compared with expected rates predicted using time series modelling of pre-2020 trends. The proportion of annual incidence is presented by sociodemographic factors: age, sex, social deprivation, ethnicity, frailty, and learning disability.

RESULTS

A total of 5 476 012 diagnoses from 2 257 992 individuals are included. Incidence rates from 2020 to 2021 were lower than mean expected rates across all conditions. The largest relative deficit in incidence was in chronic obstructive pulmonary disease corresponding to 343 (95% confidence interval = 230 to 456) undiagnosed patients per 100 000 population, followed by depression, type 2 diabetes, hypertension, anxiety disorders, and asthma. A GP practice of 10 000 patients might have over 400 undiagnosed long-term conditions. No notable differences between sociodemographic profiles of post- and pre-2020 incidences were observed.

CONCLUSION

There is a potential backlog of undiagnosed patients with multiple long-term conditions. Resources are required to tackle anticipated workload as part of COVID-19 recovery, particularly in primary care.

Long-term trends of pediatric type 1 diabetes incidence in Japan before and after the COVID-19 pandemic

Type 1 diabetes incidence has increased worldwide, although the long-term trends on pediatric type 1 diabetes in Japan remain elusive. To investigate the incidence and secular trend of pediatric type 1 diabetes from 1999 to 2021, including the coronavirus disease 2019 (COVID-19) pandemic years, in Oita Prefecture, Japan. We investigated the number of newly diagnosed patients with type 1 diabetes aged < 15 years from 1999 to 2021. We surveyed hospital databases in Oita Prefecture in Japan. The type 1 diabetes incidence in children aged < 15 years increased annually by 5.3% among all children, especially in boys aged 10-14 years by 8.1%, over the past 23 years. The average incidence rate of 3.9/100,000/year was nearly consistent with the previous reports on Asian countries. No significant change was found in the increasing incidence trend of type 1 diabetes before and during the COVID-19 pandemic. The incidence of pediatric type 1 diabetes has significantly increased over the past 23 years in Oita Prefecture, Japan, which is consistent with the worldwide trend.

Examining the associations between COVID-19 infection and pediatric type 1 diabetes

INTRODUCTION

The COVID-19 pandemic represents an unprecedented challenge for public health worldwide, not only for the very high number of cases and deaths but also due to a wide variety of indirect consequences. Among these, the possible relationship between SARS-CoV-2 infection and type 1 diabetes (T1D) in pediatric age has aroused notable interest in the scientific community.

AREAS COVERED

This perspective article aims to focus on the epidemiological trend of T1D during the pandemic, the diabetogenic role of SARS-CoV-2, and the influence of preexisting T1D on COVID-19 outcomes.

EXPERT OPINION

The incidence of T1D has considerably changed during the COVID-19 pandemic, but any direct role of SARS-CoV-2 is uncertain. It is more likely that SARS-CoV-2 infection acts as an accelerator of pancreatic β-cell immunological destruction, which is activated by known viral triggers whose spread has been abnormal during these pandemic years. Another interesting aspect to consider is the role of immunization as a potential protective factor both for T1D development and the risk of severe outcomes in already diagnosed patients. Future studies are still required to address unmet needs, including the early use of antiviral drugs to reduce the risk of metabolic decompensation in children with T1D.

Trends in nationwide incidence of pediatric type 1 diabetes in Montenegro during the last 30 years

Significant and unexplained variations in type 1 diabetes (T1D) incidence through the years were observed all around the world. The update on this disorder's incidence is crucial for adequate healthcare resource planning and monitoring of the disease. The aim of this study was to give an update on the current incidence of pediatric T1D in Montenegro and to analyze incidence changes over time and how the exposure to different factors might have affected it. This retrospective cohort study included a total of 582 patients younger than 15 years who were newly diagnosed with T1D during the past 30 years. The average age at diagnosis was 8.4 ± 3.91 years. The mean annual incidence of T1D in the Montenegro population during the whole study period of 30 years was 15.2/100,000 person-years. Slightly higher incidence rates were observed in male compared to female individuals, and the incidence increased with age, with the highest incidence in the 10-14 age group. If the model is observed as one without jointpoints, the annual percentage change (APC) for the total population is 3.1 (1.8-4.4); for male individuals, 3.8 (2.1-5.5); and for female individuals, 2.1 (0.6-3.5). In 2020, the first year of the coronavirus disease of 2019 (COVID-19) pandemic, in comparison to 2019, the incidence rate increased from 19.7/100,000 to 21.5/100,000, with the highest increase in the age group of 5-9 years. This is the first nationwide report on a 30-year period of T1D incidence trend in Montenegro. It suggests that T1D incidence among Montenegrin children is rising again and that there is a short-term influence of COVID-19 on new-onset T1D.