Transient Neonatal Diabetes Mellitus with an Unknown Cause in a 1-Month-Old Infant: A Case Report.

Transient neonatal diabetes mellitus (TNDM) is a genetically heterogeneous form of neonatal diabetes characterized by hyperglycemia that remits during infancy with a tendency to recur in later life. This case report presents the history of a male infant with transient neonatal diabetes mellitus. The patient was treated with a continuous subcutaneous insulin infusion (CSII) and a continuous glucose monitoring (CGM) system until the age of 2 months, when the normoglycemia connected with a withdrawal of treatment was noted. The genetic test results excluded the majority of known mutations related to TNDM. This case report focuses on various genetic mutations and the clinical features connected with them that cause TNDM and highlights the difficulties in the diagnostic and therapeutic processes of this disease. CSII and CGM systems seem to be a safe and effective treatment option in TNDM and may be used in the therapy.

Glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system 2-year prospective, observational, two-center study.

Background and aims: MiniMed 780G is the first Advanced Hybrid Closed Loop (AHCL) system in Poland, approved in the EU in 2020. To date, observations of glycemic control up to 12 months have been published. This study aimed to analyze glycemic control and anthropometric parameters in children and adolescents with type 1 diabetes (T1D) after two years of using the AHCL system. Materials and methods: We prospectively collected anthropometric data, pump, and continuous glucose records of fifty T1D children (9.9 ± 2.4 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system. We compared the two-week AHCL records obtained after AHCL enrollment with data 6, 12, and 24 months after starting AHCL. Results: Time in range (70-180 mg/dl) and BMI z-score did not change during the 2 years of observation (p>0.05). The percentage of autocorrection in total daily insulin increased significantly (p<0.005). Conclusion: Glycemic control in the investigated group of children with T1D treated with the AHCL system for 2 years remained stable. Children in this group maintained weight and optimal metabolic control, most likely due to autocorrection boluses.

MiniMed 780GTM in children with type 1 diabetes under seven years of age: Prospective open-label, single-arm, double-center, follow-up study.

BACKGROUND: Given the steadily rising incidence of type 1 diabetes (T1D), particularly among the youngest preschool children, coupled with well-documented challenges of achieving and maintaining optimal metabolic control in this age group, there is a growing need for advanced technological devices. OBJECTIVE: To evaluate glycaemic control in children below the age of seven with type 1 diabetes (T1D) and assess the safety of the advanced hybrid closed loop (AHCL) system in comparison to the previous treatment method, a sensor-augmented pump with predictive low-glucose suspend (SAP-PLGS). METHOD: Data from 10 children (aged 2.60-6.98 years) with T1D who transitioned to the AHCL system from SAP-PLGS were analysed. SAP-PLGS records from two weeks prior to the initiation of AHCL were compared with records from the initial four weeks post-switch (excluding the training period). These data were examined at two 2-week intervals and compared with records from two weeks post six-month usage of the AHCL. RESULTS: A significant decrease in the average nighttime glucose concentration was observed compared to pre-AHCL values (p= 0.001, concordance W = 0.53). The Glucose Management Indicator (GMI) value significantly decreased from 6.88 ± 0.37% to 6.52 ± 0.32% (p= 0.018, rbc = 0.93) immediately following the device switch and stabilized at 6.50 ± 0.28% (p= 0.001, W = 0.53) and 6.55 ± 0.41% (p= 0.001, W = 0.53) at subsequent stages of the study. An improvement was also observed in mean glucose values for time spent < 54 mg/dl, while the proportion of time within this range was maintained, both during the day (p< 0.001, W = 0.58) and at night (p= 0.002, W = 0.83). CONCLUSION: The AHCL MiniMed 780GTM system improved glycaemic control in the studied group of children under seven years of age with T1D compared to previous SAP-PLGS therapy. It proved to be safe for delivering insulin in this age group.

Commercial hybrid closed-loop systems available for a patient with type 1 diabetes in 2022.

Technological advances offer the opportunity to improve glycemic control and reduce the risk of complications and burden of type 1 diabetes while improving patient quality of life. Closed-loop insulin delivery systems take the technology to a larger scale by integrating CGM systems with an insulin pump and an algorithm that automates insulin delivery (HCL systems). Several systems using hybrid closed loop technology are currently offered in the global marketplace: the MiniMed™ 670G and MiniMed™ 780G (SmartGuard™) system from Medtronic; the T slim x2 Control IQ from Tandem; the Omnipod5 automated mode (HypoProtect™)5 from Insulet; and the CamAPS FX DanaRS or Ypso pump. Insulet's Omnipod5 automated mode (HypoProtect™) is currently in clinical trials. As technology moves forward, advanced systems are being developed that include an elaborate algorithm with individualization of major target points, automated correction bolus functionality, and increased stability of the automated mode (Advanced Hybrid Closed-Loop - AHCL systems). The AHCL systems include: MiniMed™ 780G (SmartGuard™); Tandem's T slim x2 Control IQ; Insulet's Omnipod5-Automated mode (HypoProtect™); and CamAPS FX. The purpose of this paper is to present commercial devices using HCL and AHCL in 2022, also from a scientific point of view. It is an undeniable fact that "auto-mode" systems represent a new stage that can be confidently called a revolution in diabetology.

The Use of a Hybrid Closed-Loop System for Glycemic Control in Two Pediatric Patients with Type 1 Diabetes Undergoing Minor Surgery.

Technological progress in the treatment of type 1 diabetes requires doctors to use modern methods of insulin therapy in all areas of medicine that patients may come into contact with, including surgical interventions. The current guidelines indicate the possibility of using continuous subcutaneous insulin infusion in minor surgical procedures, but there are few reported cases of using a hybrid closed-loop system in perioperative insulin therapy. This case presentation focuses on two children with type 1 diabetes who were treated with an advanced hybrid closed-loop (AHCL) system during a minor surgical procedure. In the periprocedural period, the recommended mean glycemia and the time in range were maintained.

Body mass index, basal insulin and glycemic control in children with type 1 diabetes treated with the advanced hybrid closed loop system remain stable - 1-year prospective, observational, two-center study.

Background: Information on the influence of insulin treatment using advanced hybrid closed loop systems (AHCL) on body weight of young patients with type 1 diabetes (T1D) is scarce. The aim of this study was to observe whether there were any changes in body mass index (BMI) of children and adolescents with T1D treated using the Medtronic Minimed 780G AHCL after 1 year of follow up and to analyze potential associations between these changes and the insulin doses. Materials and methods: For 50 children and adolescents (age 5.4-16.8 years, 24 (48%) boys, T1D for 3.9 ± 2.56 years) using an AHCL system anthropometric and AHCL data were collected prospectively. BMI Z-scores and two-week AHCL records obtained after AHCL enrollment were compared with data after 6 months and also 1 year after starting AHCL. Results: The BMI Z-score of the patients at 1 year follow-up did not change from time of AHCL initiation (0.51 ± 2.79 vs 0.57 ± 2.85, p>0.05). There was a slight increase in total daily insulin per kg of body weight (0.67 ± 0.21 U/kg vs 0.80 ± 0.21 U/kg, p <0.001), but the percent of basal insulin was unchanged (34.88 ± 6.91% vs 35.08 ± 6.30%, p>0.05). We observed also no change (AHCL start vs after 1 year) in glycemic control parameters: average sensor glucose (131.36± 11.04 mg/dL vs 132.45 ± 13.42 mg/dL, p>0.05), coefficient of variation (34.99± 5.17% vs 34.06 ± 5.38%, p>0.05), glucose management indicator (6.45 ± 0.26% vs 6.48 ± 0.32%, p>0.05), and time spent in the range of 70-180 mg/dL (79.28 ± 8.12% vs 80.40 ± 8.25%, p>0.05). Conclusion: During the 1 year of follow-up the BMI of children and adolescents with T1D treated with an AHCL system remained stable. Although there was a slight increase in the total daily insulin dose, the percent of basal insulin was unchanged. The patients maintained recommended glycemic control.

Increased prevalence of cardiovascular risk factors in children and adolescents with type 1 diabetes and hypertension: The SWEET international database.

AIMS: To investigate the prevalence of modifiable cardiovascular risk factors (CVRFs), including dyslipidaemia, obesity and high glycated haemoglobin (HbA1c) concentration, in patients with type 1 diabetes (T1D), and to evaluate their association with blood pressure (BP) categories. METHODS: We analysed 21 634 children and adolescents with T1D from the SWEET international database with office BP values assessed at a three or more visits within a year from 2010 to 2021. Participants were classified into a normotensive group, a group with elevated BP (90 to 94th percentile) or a hypertensive group (≥95th percentile), based on the median BP for the visits within the last treatment year. The prevalences of dyslipidaemia [cholesterol ≥ 5.18 mmol/L (200 mg/dL)  and/or HDL cholesterol ≤ 1.036 mmol/L (40 mg/dL)  and/or LDL cholesterol ≥ 2.59 mmol/L (100 mg/dL)], obesity (body mass index ≥2 standard deviation score) and elevated HbA1c [≥ 75 mmol/mol (9%)] were evaluated in patients within each BP group. RESULTS: Patients with hypertension/elevated BP had less favourable lipid profiles, and a higher prevalence of obesity and HbA1c ≥ 75 mmol/mol than normotensive patients. A total of 38.4% of hypertensive patients and 36.0% of those with elevated BP had one CVRF, 15.1% and 10.1%, respectively, had two CVRFs, and 2.3% and 0.8%, respectively, had three CVRFs. Patients with hypertension/elevated BP had a higher prevalence of one or more CVRFs versus normotensive patients (P < 0.001). Obesity was the CVRF most strongly related to hypertension. Girls had a higher prevalence of one or more CVRFs than boys. Similar results were found in patients aged ≥13 years with hypertension compared to those aged <13 years. CONCLUSIONS: The prevalence of modifiable CVRFs is higher in children and adolescents with T1D who have elevated BP/hypertension than in those with normotension, suggesting that they are more vulnerable to future morbidity and mortality requiring early detection and intervention.

Prospective Open-Label, Single-Arm, Single-Center Follow-Up Study of the Application of the Advanced Hybrid Closed Loop System in Well-Controlled Children and Adolescents with Type 1 Diabetes.

Background: The aim of this prospective open-label single-arm single-center follow-up study was to analyze glycemic control in children and adolescents with type 1 diabetes treated with the advanced hybrid closed loop (AHCL) system in relation to a sensor-augmented pump with low-glucose suspend (SAP-LGS) or predictive low-glucose suspend (SAP-PLGS). Materials and Methods: The data for 50 children and adolescents (age 5.5-19.6 years) with type 1 diabetes, receiving insulin through an AHCL system after being switched from SAP-LGS/PLGS systems, were included in the analysis. The SAP-LGS/PLGS records from 2 weeks preceding the AHCL connection were compared with the records from the first 4 weeks of AHCL use, represented as two separate 2-week intervals. Results: Significant improvements in most of the parameters, namely time spent in the range of 70-140 mg/dL (from 53.80% ± 12.35% to 61.70% ± 8.42%, P < 0.001) and 70-180 mg/dL (from 76.17% ± 10.28% to 81.32% ± 7.71%, P < 0.001), average sensor glucose (from 138.61 ± 16.66 to 130.02 ± 10.91 mg/dL, P < 0.001), and glucose management indicator (from 6.54% ± 0.45% to 6.27% ± 0.29%, P = 0.001), were observed within 2 weeks of switching to the AHCL. More evident improvements were observed for the parameters monitored at night than during the day. The potential limitations of this study were the short observation time, lack of glycated hemoglobin measurements, and no control arm. Conclusion: The AHCL system can significantly improve glycemic control even in well-controlled children and adolescents with type 1 diabetes by increasing the proportion of time spent in the narrower range of 70-140 mg/dL and decreasing the mean glucose concentration, especially during the night.

Diabetic ketoacidosis incidence among children with new-onset type 1 diabetes in Poland and its association with COVID-19 outbreak-Two-year cross-sectional national observation by PolPeDiab Study Group.

BACKGROUND: There are several observations that the onset of coronavirus 19 (COVID-19) pandemic was associated with an increase in the incidence of diabetic ketoacidosis (DKA). However, due to heterogeneity in study designs and country-specific healthcare policies, more national-level evidence is needed to provide generalizable conclusions. OBJECTIVE: To compare the rate of DKA in Polish children diagnosed with type 1 diabetes (T1D) between the first year of COVID-19 pandemic (15 March 2020 to 15 March 2021) and the preceding year (15 March 2019 to 15 March 2020). METHODS: Reference centers in 13 regions (covering ~88% of Polish children) retrospectively reported all new-onset T1D cases in children from assessed periods, including DKA status at admission, administered procedures and outcomes. Secondly, we collected regions' demographic characteristics and the daily-reported number of COVID-19-related deaths in each region. RESULTS: We recorded 3062 cases of new-onset T1D (53.3% boys, mean age 9.5 ± 4.3 years old) of which 1347 (44%) had DKA. Comparing pre- and post-COVID-19 period, we observed a significant increase in the rate of DKA (37.5%-49.4%, p < .0001). The fraction of moderate (+5.4%) and severe (+3.4%) DKA cases increased significantly (p = .0089), and more episodes required assisted ventilation (+2.1%, p = .0337). Two episodes of DKA during 2020/2021 period were fatal. By region, change in DKA frequency correlated with initial COVID-19 death toll (March/April 2020) (R = .6, p = .0287) and change in T1D incidence (R = .7, p = .0080). CONCLUSIONS: The clinical picture of new-onset children T1D in Poland deteriorated over a 2-year period. The observed increase in the frequency of DKA and its severity were significantly associated with the overlapping timing of the COVID-19 epidemic.

The Importance of Office Blood Pressure Measurement Frequency and Methodology in Evaluating the Prevalence of Hypertension in Children and Adolescents With Type 1 Diabetes: The SWEET International Database.

OBJECTIVE: The prevalence of hypertension is higher in children and adolescents with type 1 diabetes (T1D) compared with those without. This retrospective analysis of a large cohort of children and adolescents with T1D from the SWEET (Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference) international consortium of pediatric diabetes centers aimed to 1) estimate the prevalence of elevated office blood pressure (BP) and hypertension and 2) investigate the influence of BP measurement methodology on the prevalence of hypertension. RESEARCH DESIGN AND METHODS: A total of 27,120 individuals with T1D, aged 5-18 years, were analyzed. Participants were grouped into those with BP measurements at three or more visits (n = 10,440) and fewer than 3 visits (n = 16,680) per year and stratified by age and sex. A subgroup analysis was performed on 15,742 individuals from centers providing a score indicating BP measurement accuracy. RESULTS: Among participants with BP measurement at three or more visits, the prevalence of hypertension was lower compared with those with fewer than three visits (10.8% vs. 17.5% P < 0.001), whereas elevated BP and normotension were higher (17.5% and 71.7% vs. 15.3% and 67.1%, respectively; both P < 0.001). The prevalence of hypertension and elevated BP was higher in individuals aged ≥13 years than in younger ones (P < 0.001) and in male than female participants (P < 0.001). In linear regression models, systolic and diastolic BP was independently determined by the BP measurement methodology. CONCLUSIONS: The estimated prevalence of elevated BP and hypertension in children and adolescents with T1D is ∼30% and depends on the BP measurement methodology. Less frequent BP evaluation may overestimate the prevalence of hypertension.

Has the COVID-19 Pandemic Affected the Prevalence of Diabetic Ketoacidosis in Polish Children with Newly Diagnosed Type 1 Diabetes? An Example of the Largest Polish Pediatric Diabetes Center (Upper Silesia-Katowice, Poland).

PURPOSE: The aim of this study was to analyze the prevalence of diabetic ketoacidosis (DKA) in children with newly disclosed type 1 diabetes (T1D) during the COVID-19 pandemic in 2020 compared to 2019. METHODS: A retrospective analysis of the history database of all hospitalized children in our department. The International Society for Pediatric and Adolescent Diabetes (ISPAD) guidelines were used for the diagnosis of DKA. RESULTS: The database of children with newly disclosed T1D included 196 patients (89 girls and 107 boys) from 2019, and 223 patients (113 girls and 110 boys) from 2020 (a total of 419 patients-202 girls and 217 boys) aged 0 to 18 years. A significantly higher percentage of DKA was observed in 2020 compared to the previous year (47.53% vs. 35.2% [p = 0.005]). The percentage of severe DKA increased in 2020 compared to 2019 (18.39% vs. 14.07% [p = 0.118]). Compared to 2019, the average HbA1c level was higher in 2020 (12.57 ± 2.75% vs. 11.95 ± 2.89% [p < 0.025]), and the average pH level (7.26 vs. 7.31 [p = 0.002], and average HCO3 level (16.40 vs. 18.66 [p = 0.001]) were lower, respectively. CONCLUSIONS: During the COVID-19 (2020) pandemic, the incidence of DKA increased in Polish children with newly diagnosed T1D. The conclusions from the analysis of the functioning of health systems during the pandemic should be used in the future to prevent, in similar periods, an increase in severe complications of delayed diagnosis of T1D.

Can the AHCL System Be Used in T1D Patients with Borderline TDDI? A Case Report.

(1) Background: Intensive insulin therapy using continuous subcutaneous insulin infusion (CSII) with continuous real-time glucose monitoring (rt CGM) is the best option for patients with T1D. The recent introduction of a technology called Advanced Hybrid Closed Loop (AHCL) represents a new era in the treatment of type 1 diabetes, the next step towards better care, as well as improving the effectiveness and safety of therapy. The aim is to present the case of a T1D patient with a borderline total daily dose of insulin being treated with the Medtronic AHCL system in automatic mode. (2) Materials and Methods: A 9-year-old boy, from October 2020, with type 1 diabetes in remission was connected to the Minimed™ 780G (AHCL) system in accordance with the manufacturer's recommendations (daily insulin dose > 8 units, age > 7). Records of the patient's history were collected from visits to The Department of Children's Diabetology, as well as from the Medtronic CareLink™ software and the DPV SWEET program from October 2020 to April 2021. (3) Results: The patient's total daily insulin requirement decreased in the first 6 weeks after the AHCL was connected, which may reflect the remission phase (tight glycemic control with a healthy lifestyle). The lowest daily insulin requirement of 5.7 units was also recorded. In a three-month follow-up of the patient treated with AHCL, it was found that for almost 38% of the days the insulin dose was less than 8 IU. (4) Conclusions: The AHCL system allows safe and effective insulin therapy in automatic mode, as well as in patients with a lower daily insulin requirement. The AHCL system should be considered a good therapeutic option for patients from the onset of T1D, as well in the remission phase.

Type 1 diabetes in an adolescent with social problems and mental disorders - case report.

Discontinuation of type 1 diabetes (T1DM) treatment (interruption of insulin therapy) rapidly leads to diabetic ketoacidosis (DKA) which is a life-threatening condition. Our case report is intended to draw attention to persons with T1DM and significant social/psychological problems. They typically, due to the lack of legal regulations, "fall out of the system", which should provide in such cases additional assistance in care conditioning proper treatment. Psychological an psychiatric disorders and/or social problems may interfere with self-control and diabetes treatment, making it difficult or even impossible. These patients represent a significant challenge for the diabetes team and require individualized management from the social care system. Patient safety-focused support from consulting physicians of other specialties is also essential. The case of our patient highlights the need for relevant legal and administrative regulations that would allow for quick, safe and adequate care.

The Quality of Life and Satisfaction with Continuous Glucose Monitoring Therapy in Children under 7 Years of Age with T1D Using the rtCGM System Integrated with Insulin Pump-A Caregivers Point of View.

Quality of life (QoL) is an important parameter that affects the choice of therapy. Assessment of QoL and satisfaction with therapy using the rtCGM in children with T1D aged < 7 years was conducted. The study group consisted of 38 children with T1D aged < 7 years (34% aged 2-4, 66% aged 5-7 years), HbA1c: 6.53 ± 0.63%, duration of diabetes: 2.6 ± 1.6 years, treated with an rtCGM-augmented insulin pump for 1.92 ± 1.15 years. Two anonymous surveys were conducted: a. PedsQL3.0 diabetes standardized questionnaire-QoL assessment among age groups: 2-4/5-7 years. b. An original survey assessing the CGM use satisfaction. The mean scores in PedsQL3.0: communication 75%, worries 30%, treatment 70%, and problems associated with diabetes 65%. The QoL scale is: 0-19% very low, 20-39% low, 40-59% moderate, 60-79% high, 80-100% very high. The most frequently reported concerns were long-term diabetes complications and prick pain. Satisfaction with CGM use was high (68% in group aged 5-7 and 92% 2-4 years). Twenty-seven (71%) caregivers confirmed the positive effect of CGM on sleep. During the use of rtCGM a high quality of life was reported, and the quality of sleep in their caregivers was increased.

Bacterial strains colonizing the sensor electrodes of a continuous glucose monitoring system in children with diabetes.

INTRODUCTION: The higher frequency of infections in diabetic patients is caused by a hyperglycemic environment, which promotes immune dysfunction. People with diabetes are more prone to skin infections. A continuous glucose monitoring (CGM) system provides information on changes in blood glucose (BG) levels throughout the day. Its use facilitates optimal therapeutic decisions for a diabetic patient. One of the factors limiting the use of CGM is inflammation at the insertion site. AIM OF THE STUDY: The aim of the study was the microbiological identification of the bacterial strains which are found on CGM sensor electrodes. MATERIAL AND METHODS: We performed microbiological tests on patients' CGM Enlite Medtronic electrodes, which were removed after 6 days of usage according to the manufacturer's instructions. 31 sensors were examined from 31 children (14 girls) aged from 0.5 to 14.6 years. The microbiological analysis was routinely performed at the Department of Children's Diabetology Medical University of Silesia in Katowice, Poland. RESULTS: 12 (39%) of the electrodes were colonized. In 11 (92%) cases the electrodes were colonized by one bacteria strain. 7 times methicillin-sensitive coagulase negative staphylococcus (MSCNS) was detected. We also found one case of Klebsiella pneumoniae, Ochrobactrum tritici, Bacillus sonorensis and methicillin-resistant coagulase-negative Staphylococci (MRCNS) colonization. One electrode was colonized by the mixed flora Enterococcus faecalis, methicillin-susceptible coagulase-negative Staphylococci (MSCNS), Pseudomonas stutzeri, methicillin-susceptible Staphylococcus aureus (MSSA). The median HbA1c in the group with colonization of electrodes was 6, 85% (6, 3-7, 6%) versus 6, 3% (5, 8-7, 5%) in the group without colonization. The median BMI in the group with colonization of the electrodes was 17.10 kg/m2 (16.28-18.62 kg/m2) versus 15.98 kg/m2 (15.14-17.96 kg/m2) in the group without colonization. Statistically, significantly more frequently electrodes are colonized in older children (median age in the group with colonization of electrodes 11.43 years (6.52-12.27 years), without colonization 8.42 years. (3.098-9.375 years); (p = 0.033). CONCLUSIONS: It seems that older children are more likely to have their sensor electrode colonized by bacterial strains.

Nighttime Hypoglycemia in Children with Type 1 Diabetes after one Day of Football Tournament.

The aim of the study was to investigate factors related to the occurrence of nighttime hypoglycemia after a football tournament in children with type 1 diabetes mellitus. The multicenter study (GoalDiab study) included 189 children and adolescents with type 1 diabetes mellitus, from 11 diabetes care centers in Poland. Hypoglycemia was defined according to the International Hypoglycemia Study Group Statement. We analyzed the data of 95 participants with completed protocols with regards to nighttime hypoglycemia (82% male), aged 11.6 (9.8-14.2) years, diabetes duration 5.0 (2.0-8.0) years. There were 47 episodes of nighttime Level 1 hypoglycemia (≤3.9 mmol/L). Occurrence of clinically important Level 2 hypoglycemia (<3.0 mmol/L) during a game period was positively associated with nighttime hypoglycemia (≤3.9 mmol/L) incident (Odds Ratio=10.7; 95% Confidence Interval: 1.1-100.2; p=0.04). Using Continuous Glucose Monitoring was negatively associated with the occurrence of nighttime hypoglycemia (≤3.9 mmol/L) compared with using glucose meters or Flash Glucose Monitoring (Odds Ratio=0.31; 95% Confidence Interval: 0.12-0.83; p=0.02). The occurrence of clinically important hypoglycemia related to physical activity is associated with the occurrence of hypoglycemia during the night. Continuous Glucose Monitoring is negatively associated with nighttime hypoglycemia after a day of competition.