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Aims/hypothesisThe aim of this work was to evaluate geographical variability and trends in the prevalence of diabetic ketoacidosis (DKA), between 2006 and 2016, at the diagnosis of childhood-onset type 1 diabetes in 13 countries over three continents.MethodsAn international retrospective study on DKA at diagnosis of diabetes was conducted. Data on age, sex, date of diabetes diagnosis, ethnic minority status and presence of DKA at diabetes onset were obtained from Australia, Austria, Czechia, Denmark, Germany, Italy, Luxembourg, New Zealand, Norway, Slovenia, Sweden, USA and the UK (Wales). Mean prevalence was estimated for the entire period, both overall and by country, adjusted for sex and age group. Temporal trends in annual prevalence of DKA were estimated using logistic regression analysis for each country, before and after adjustment for sex, age group and ethnic minority status.ResultsDuring the study period, new-onset type 1 diabetes was diagnosed in 59,000 children (median age [interquartile range], 9.0 years [5.5–11.7]; male sex, 52.9%). The overall adjusted DKA prevalence was 29.9%, with the lowest prevalence in Sweden and Denmark and the highest in Luxembourg and Italy. The adjusted DKA prevalence significantly increased over time in Australia, Germany and the USA while it decreased in Italy. Preschool children, adolescents and children from ethnic minority groups were at highest risk of DKA at diabetes diagnosis in most countries. A significantly higher risk was also found for females in Denmark, Germany and Slovenia.Conclusions/interpretationDKA prevalence at type 1 diabetes diagnosis varied considerably across countries, albeit it was generally high and showed a slight increase between 2006 and 2016. Increased awareness of symptoms to prevent delay in diagnosis is warranted, especially in preschool children, adolescents and children from ethnic minority groups.

Background The Time In Range (TIR) represents the amount of time spent by a given individual in the range close to normoglycemia, i.e . 70–180 mg/dl. On the basis of studies demonstrating an association of TIR with the incidence of diabetes complications, guidelines recommend a target of at least 70% of TIR for most people with diabetes. However, no study has explored the effect of variable degrees of TIR on molecular mechanisms relevant for the development of diabetes complications. Methods We exposed endothelial cells and monocytes to increasing percentages of TIR, i.e . 50%, 70%, 85% by changing cell media twice a day as appropriate, as well as to constant normoglycemia ( i.e . fixed 100 mg/dl of glucose for endothelial cells) and hyperglycemia ( i.e . 500 mg/dl glucose), evaluating the development of senescence, of the associated pro-inflammatory response, and monocytes adhesion to endothelial cells as a functional assay. We then assessed the expression of a plethora of markers of senescence and inflammation at the mRNA level in peripheral blood mononuclear cells (PBMC)s derived from individuals with early ( i.e . 1-year post-diagnosis) type 1 diabetes (T1D, n = 37), categorized according to the TIR (< or > 70%) observed in the previous 14 days, comparing the two groups through ANCOVA adjusted for HbA1c. As a confirmatory analysis, we also compared the expression of the same markers in people with Time Above Range (TAR), considered as the whole time above 180 mg/dl, ≥ vs < 30%. Correlations between TIR values and the expression of the same markers were tested through linear regression. Results Constant hyperglycemia promoted the development of senescence in endothelial cells and induced inflammatory responses in both endothelial cells and monocytes, promoting also monocytes adhesion to endothelial cells. A TIR of 70%, but not of 50%, suppressed these effects while a TIR of 85% did not provide additional benefit. Data from people with T1D mirrored such results, as demonstrated by the higher expression of p16, a marker of senescence, and of IL-6, MCP-1, and CXCL1, three inflammatory mediators, in PBMCs from individuals with TIR < 70% and compared with those with TIR > 70%, independently of HbA1c. Similar results were obtained when comparing people with TAR ≥ vs < 30%. When considered as a continuous variable, TIR values were correlated with p16, IL-6, and CXCL1. Conclusions A TIR above 70% is associated with attenuated pro-senescence and pro-inflammatory effects of hyperglycemia. These molecular results support the TIR target currently recommended by guidelines, especially for people with T1D. Graphical Abstract

The number of young people with diabetes attending school is increasing (A), placing a significant burden on families, health care systems, and schools (E). Schools provide a unique opportunity to identify and treat psychological problems in young people with diabetes and close liaison between school personnel and health care professionals is recommended (E). The need to achieve and maintain blood glucose (BG) as near to normal as possible at all times, and for as long as possible, in order to reduce the risk of diabetes-related complications (both acute and chronic) and to optimize the learning ability of young people with diabetes is clear and unequivocal. [...]the need to educate school personnel about diabetes and to train them to support young people with this condition is important and in keeping with contemporary standards of clinical practice. Without adequate training and education, school personnel will have difficulty understanding and applying the correct principles of diabetes management and ongoing lack of knowledge and misperceptions will undermine the core objectives of achieving optimal BG control.

Key Words: diabetes, glycemic variability, chronic complications, mortality, time in range, continuous glucose monitoring, HbA1c, fasting blood glucose

Heterozygous variants in the NPR2 gene, which encodes the B-type natriuretic peptide receptor (NPR-B), a regulator of skeletal growth, were reported in 2–6% cases of idiopathic short stature (ISS). Using next-generation sequencing (NGS), we aimed to assess the frequency of NPR2 variants in our study cohort consisting of 150 children and adolescents with ISS, describe the NPR2 phenotypic spectrum with a growth pattern including birth data, and study the response to growth hormone (GH) treatment. A total of ten heterozygous pathogenic/likely pathogenic NPR2 variants and two heterozygous NPR2 variants of uncertain significance were detected in twelve participants (frequency of causal variants: 10/150, 6.7%). During follow-up, the NPR2 individuals presented with a growth pattern varying from low–normal to significant short stature. A clinically relevant increase in BMI (a mean gain in the BMI SDS of +1.41), a characteristic previously not reported in NPR2 individuals, was observed. In total, 8.8% participants born small for their gestational age (SGA) carried the NPR2 causal variant. The response to GH treatment was variable (SDS height gain ranging from −0.01 to +0.74). According to the results, NPR2 variants present a frequent cause of ISS and familial short stature. Phenotyping variability in growth patterns and variable responses to GH treatment should be considered.

Diet is an essential element of treating and managing type 1 diabetes (T1D). However, limited research has examined food behaviour in children and adolescents with T1D and their relationship to glycaemic control. This study evaluated food behaviour, metabolic characteristics and their impact on the glycaemic control of children and adolescents with T1D. Two hundred and fifty-eight participants with T1D (6–15 years, duration of diabetes >1 year) were recruited. Demographic, anthropometric and clinical data were collected. Questionnaires on food neophobia and food preferences were administered. The Child Food Questionnaire (CFQ) also assessed parental feeding practices. An analysis of food behaviour showed that food neophobia was inversely associated with the liking of vegetables, fruits, fish, sweets and carbohydrates. Moreover, by analysing parental feeding practices, an inverse association of “Pressure to eat”, “Monitoring” and “Restriction” with liking for vegetables and carbohydrates emerged. Considering glycaemic control, increased food neophobia and the parent practices “Restriction”, “Pressure to eat” and “Concern about weight” were found in participants with glycated haemoglobin (HbA1c) values >8.5%. Finally, higher body mass index (BMI) and total cholesterol values were observed in subjects with HbA1c values >8.5%. These findings contribute to a better understanding of eating behaviour, metabolic status and their complex relationship with glycaemic control.

The HNF1A transcription factor, implicated in the regulation of pancreatic beta cells, as well as in glucose and lipid metabolism, is responsible for type 3 maturity-onset diabetes of the young (MODY3). HNF1A is also involved in increased susceptibility to polygenic forms of diabetes, such as type 2 diabetes (T2D) and gestational diabetes (GD), while its possible role in type 1 diabetes (T1D) is not known. In this study, 277 children and adolescents with T1D and 140 healthy controls were recruited. The following SNPs in HNF1A gene were selected: rs1169286, rs1169288, rs7979478, and rs2259816. Through linear or logistic regression analysis, we analyzed their association with T1D susceptibility and related clinical traits, such as insulin dose-adjusted glycated hemoglobin A1c (IDAA1c) and glycated hemoglobin (HbA1c). We found that rs1169286 was associated with IDAA1c and HbA1c values (p-value = 0.0027 and p-value = 0.0075, respectively), while rs1169288 was associated with IDAA1c (p-value = 0.0081). No association between HNF1A SNPs and T1D development emerged. In conclusion, our findings suggest for the first time that HNF1A variants may be a risk factor for beta cell function and glycaemic control in T1D individuals.

Regular self-monitoring of blood glucose is crucial for proper insulin dosing and gives a reliable foundation for reasonable glycaemic control. According to recent data, recommended values for glycated haemoglobin A1c as set by the professional associations remain out of the reach for a large proportion of the paediatric population. In the last decades, the treatment of type 1 diabetes has changed significantly as new devices gain a role in routine clinical care. Real-time glucose levels can be monitored with continuous glucose monitoring (CGM), which provides a broad spectrum of information on glucose trends on a moment-to-moment basis. This information can be useful for patients' decision making and clinicians' understanding of patients' conduct. However, several barriers, including the current price, impede a broader use of CGM in most regions of the world. This review summarizes data from randomized, controlled trials that included a paediatric population, and it provides some evidence-based visions for the possible broader utilization of CGM, also for incorporation into insulin delivery devices that enable a closed-loop insulin delivery.

Management of type 1 diabetes is challenging. We compared outcomes using a commercially available hybrid closed-loop system versus a new investigational system with features potentially useful for adolescents and young adults with type 1 diabetes. In this multinational, randomised, crossover trial (Fuzzy Logic Automated Insulin Regulation [FLAIR]), individuals aged 14–29 years old, with a clinical diagnosis of type 1 diabetes with a duration of at least 1 year, using either an insulin pump or multiple daily insulin injections, and glycated haemoglobin (HbA1c) levels of 7·0–11·0% (53–97 mmol/mol) were recruited from seven academic-based endocrinology practices, four in the USA, and one each in Germany, Israel, and Slovenia. After a run-in period to teach participants how to use the study pump and continuous glucose monitor, participants were randomly assigned (1:1) using a computer-generated sequence, with a permuted block design (block sizes of two and four), stratified by baseline HbA1c and use of a personal MiniMed 670G system (Medtronic) at enrolment, to either use of a MiniMed 670G hybrid closed-loop system (670G) or the investigational advanced hybrid closed-loop system (Medtronic) for the first 12-week period, and then participants were crossed over with no washout period, to the other group for use for another 12 weeks. Masking was not possible due to the nature of the systems used. The coprimary outcomes, measured with continuous glucose monitoring, were proportion of time that glucose levels were above 180 mg/dL (>10·0 mmol/L) during 0600 h to 2359 h (ie, daytime), tested for superiority, and proportion of time that glucose levels were below 54 mg/dL (<3·0 mmol/L) calculated over a full 24-h period, tested for non-inferiority (non-inferiority margin 2%). Analysis was by intention to treat. Safety was assessed in all participants randomly assigned to treatment. This trial is registered with ClinicalTrials.gov, NCT03040414, and is now complete. Between June 3 and Aug 22, 2019, 113 individuals were enrolled into the trial. Mean age was 19 years (SD 4) and 70 (62%) of 113 participants were female. Mean proportion of time with daytime glucose levels above 180 mg/dL (>10·0 mmol/L) was 42% (SD 13) at baseline, 37% (9) during use of the 670G system, and 34% (9) during use of the advanced hybrid closed-loop system (mean difference [advanced hybrid closed-loop system minus 670G system] −3·00% [95% CI −3·97 to −2·04]; p<0·0001). Mean 24-h proportion of time with glucose levels below 54 mg/dL (<3·0 mmol/L) was 0·46% (SD 0·42) at baseline, 0·50% (0·35) during use of the 670G system, and 0·46% (0·33) during use of the advanced hybrid closed-loop system (mean difference [advanced hybrid closed-loop system minus 670G system] −0·06% [95% CI −0·11 to −0·02]; p<0·0001 for non-inferiority). One severe hypoglycaemic event occurred in the advanced hybrid closed-loop system group, determined to be unrelated to study treatment, and none occurred in the 670G group. Hyperglycaemia was reduced without increasing hypoglycaemia in adolescents and young adults with type 1 diabetes using the investigational advanced hybrid closed-loop system compared with the commercially available MiniMed 670G system. Testing an advanced hybrid closed-loop system in populations that are underserved due to socioeconomic factors and testing during pregnancy and in individuals with impaired awareness of hypoglycaemia would advance the effective use of this technology National Institute of Diabetes and Digestive and Kidney Diseases.

Aims/hypothesis Hypoglycaemia during and after exercise remains a challenge. The present study evaluated the safety and efficacy of closed-loop insulin delivery during unannounced (to the closed-loop algorithm) afternoon physical activity and during the following night in young people with type 1 diabetes. Methods A randomised, two-arm, open-label, in-hospital, crossover clinical trial was performed at a single site in Slovenia. The order was randomly determined using an automated web-based programme with randomly permuted blocks of four. Allocation assignment was not masked. Children and adolescents with type 1 diabetes who were experienced insulin pump users were eligible for the trial. During four separate in-hospital visits, the participants performed two unannounced exercise protocols: moderate intensity (55% of V ⋅ O 2 max ) and moderate intensity with integrated high-intensity sprints (55/80% of V ⋅ O 2 max ), using the same study device either for closed-loop or open-loop insulin delivery. We investigated glycaemic control during the exercise period and the following night. The closed-loop insulin delivery was applied from 15:00 h on the day of the exercise to 13:00 h on the following day. Results Between 20 January and 16 June 2016, 20 eligible participants (9 female, mean age 14.2 ± 2.0 years, HbA 1c 7.7 ± 0.6% [60.0 ± 6.6 mmol/mol]) were included in the trial and performed all trial-mandated activities. The median proportion of time spent in hypoglycaemia below 3.3 mmol/l was 0.00% for both treatment modalities ( p  = 0.7910). Use of the closed-loop insulin delivery system increased the proportion of time spent within the target glucose range of 3.9–10 mmol/l when compared with open-loop delivery: 84.1% (interquartile range 70.0–85.5) vs 68.7% (59.0–77.7), respectively ( p  = 0.0057), over the entire study period. This was achieved with significantly less insulin delivered via the closed-loop ( p  = 0.0123). Conclusions/interpretation Closed-loop insulin delivery was safe both during and after unannounced exercise protocols in the in-hospital environment, maintaining glucose values mostly within the target range without an increased risk of hypoglycaemia. Trial registration Clinicaltrials.gov NCT02657083 Funding University Medical Centre Ljubljana, Slovenian National Research Agency, and ISPAD Research Fellowship