Publications by authors named "Jarosz-Chobot Przemysława"

93 Publications

Oral microbiota in children with type 1 diabetes mellitus.

Pediatr Endocrinol Diabetes Metab 2021 Apr 21. Epub 2021 Apr 21.

Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland.

Introduction: The oral cavity is a unique ecosystem in which the microbiome is formed by the colonization of billions of bacteria, viruses, and fungi. Aim of the study was to assess the quality and quantity of bacterial microbiota of the oral cavity in children with type 1 diabetes in comparison to healthy children.

Material And Methods: The study group consisted of 50 randomly selected type 1 diabetic children aged 10-18 years divided into 2 groups (25 people each) according to the level of diabetes control: well-controlled group (WC) - HbA1c ≤ 7.5%) and poorly-controlled group (PC) - HbA1c > 7.5%. The control group (GC) consisted of 25 randomly selected children with no systemic diseases. The material for microbiological tests was collected as two swabs: one from the bottom of the oral cavity and the other one from the posterior part of the dorsum of the tongue).

Results: The statistical analysis revealed statistically significant differences in the total number of isolated microorganisms between PC and GC (post hoc test p = 0.003) and WC and GC (post hoc test p < 0.001). There were no statistically significant differences in the number of isolated microorganisms between PC and WC (p = 0.195).

Conclusions: Oral microbiome in type 1 diabetic children is significantly quantitatively different in comparison to healthy children. There are also visible qualitative differences in the profile of oral microbiota in type 1 diabetic children and healthy children.
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http://dx.doi.org/10.5114/pedm.2021.104343DOI Listing
April 2021

Thyroid diseases - ally or enemy of type 1 diabetes in children and adolescents?

Pediatr Endocrinol Diabetes Metab 2021 Apr 15. Epub 2021 Apr 15.

Department of Pediatrics and Children's Diabetology, Medical University of Silesia, Katowice, Poland.

Introduction: Autoimmune thyroid diseases (AIT) are one of the most common disorders associated with type 1 diabetes (T1D) and they are capable of influencing its course. For Hashimoto's lymphocytic thyroiditis, the incidence is 14-28%, while for Graves-Basedow hyperthyroidism it is 0.5-7%. Aim of the study: Assessment of type 1 diabetes in the pediatric population with coexisting autoimmune thyroid diseases: Hashimoto's lymphocytic thyroiditis and Graves-Basedow's disease.

Material And Methods: Analyzing publications from the PubMed scientific database from 1990 to May 2020.

Results: Among pediatric patients with T1D and coexisting thyroid autoimmunity insufficient glycemic control is usually observed. Reported average increase in glycated hemoglobin concentration ranges from 7.9 to 9.2%. In children with T1D and subclinical hypothyroidism, an increased number of episodes of hypoglycemia was noted - 5 vs. 2 episodes per year among children with euthyroidism. In hyperthyroidism patients the number of episodes of hypoglycemia was 34.4 vs. 17.2 per 100 incidents in euthyroidism patients. An increased occurrence of diabetic ketoacidosis events may also be observed - 18.1 vs. 7.7 per 100 patients with euthyroidism per year. The risk of developing chronic complications in the form of cardiovascular diseases is also higher. However, basing on the available literature, this subject is still debatable.

Conclusions: Autoimmune thyroid diseases often accompany and interfere with type 1 diabetes in children and adolescents. Paying special attention to the different course of diabetes in the presence of thyroid disorders is an important and essential element of diabetes care.
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http://dx.doi.org/10.5114/pedm.2020.101809DOI Listing
April 2021

Clinical heterogeneity among pediatric patients with autoimmune type 1 diabetes stratified by immunoglobulin deficiency.

Pediatr Diabetes 2021 Apr 10. Epub 2021 Apr 10.

Department of Pediatrics, Oncology, and Hematology, Medical University of Łódź, Łódź, Poland.

Background: Type 1 diabetes (T1D) may coexist with primary immunodeficiencies, indicating a shared genetic background.

Objective: To evaluate the prevalence and clinical characteristics of immunoglobulin deficiency (IgD) among children with T1D.

Methods: Serum samples and medical history questionnaires were obtained during routine visits from T1D patients aged 4-18 years. IgG, IgA, IgM, and IgE were measured by nephelometry and enzyme-linked immunosorbent assay (ELISA). IgG and IgM deficiency (IgGD, IgMD) were defined as IgG/IgM >2 standard deviations (SD) below age-adjusted mean. IgE deficiency was defined as IgE <2 kIU/L. IgA deficiency (IgAD) was defined as IgA >2 SD below age-adjusted mean irrespective of other immunoglobulin classes (absolute if <0.07 g/L, partial otherwise) and as selective IgAD when IgA >2 SD below age-adjusted mean with normal IgG and IgM (absolute if <0.07 g/L, partial otherwise).

Results: Among 395 patients (53.4% boys) with the median age of 11.2 (8.4-13.7) and diabetes duration 3.6 (1.1-6.0) years, 90 (22.8%) were found to have hypogammaglobulinemia. The IgGD and IgAD were the most common each in 40/395 (10.1%). Complex IgD was found in seven patients. Increased odds of infection-related hospitalization (compared to children without any IgD) was related to having any kind of IgD and IgAD; OR (95%CI) = 2.1 (1.2-3.7) and 3.7 (1.8-7.5), respectively. Furthermore, IgAD was associated with having a first-degree relative with T1D OR (95%CI) = 3.3 (1.4-7.6) and suffering from non-autoimmune comorbidities 3.3 (1.4-7.6), especially neurological disorders 3.5 (1.2-10.5).

Conclusions: IgDs frequently coexist with T1D and may be associated with several autoimmune and nonimmune related disorders suggesting their common genetic background.
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http://dx.doi.org/10.1111/pedi.13208DOI Listing
April 2021

Impact of diabetes mellitus on in-hospital mortality in adult patients with COVID-19: a systematic review and meta-analysis.

Acta Diabetol 2021 Mar 20. Epub 2021 Mar 20.

Department of Pediatrics and Children's Diabetology, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Silesia, Poland.

Background: The novel coronavirus disease 2019 (COVID-19) has spread worldwide since the beginning of 2020, placing the heavy burden on the health systems all over the world. The population that particularly has been affected by the pandemic is the group of patients suffering from diabetes mellitus. Having taken the public health in considerations, we have decided to perform a systematic review and meta-analysis of diabetes mellitus on in-hospital mortality in patients with COVID-19.

Methods: A systematic literature review (MEDLINE, EMBASE, Web of Science, Scopus, Cochrane) including all published clinical trials or observational studies published till December 10, 2020, was performed using following terms "diabetes mellitus" OR "diabetes" OR "DM" AND "survival" OR "mortality" AND "SARS-CoV-2" OR "COVID-19".

Results: Nineteen studies were included out of the 7327 initially identified studies. Mortality of DM patients vs non-DM patients was 21.3 versus 6.1%, respectively (OR = 2.39; 95%CI: 1.65, 3.64; P < 0.001), while severe disease in DM and non-DM group varied and amounted to 34.8% versus 22.8% (OR = 1.43; 95%CI: 0.82, 2.50; P = 0.20). In the DM group, the complications were observed far more often when compared with non-DM group, both in acute respiratory distress (31.4 vs. 17.2%; OR = 2.38; 95%CI:1.80, 3.13; P < 0.001), acute cardiac injury (22.0% vs. 12.8%; OR = 2.59; 95%CI: 1.81, 3.73; P < 0.001), and acute kidney injury (19.1 vs. 10.2%; OR = 1.97; 95%CI: 1.36, 2.85; P < 0.001).

Conclusions: Based on the findings, we shall conclude that diabetes is an independent risk factor of the severity of COVID-19 in-hospital settings; therefore, patients with diabetes shall aim to reduce the exposure to the potential infection of COVID-19.
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http://dx.doi.org/10.1007/s00592-021-01701-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005367PMC
March 2021

Variation in nutrition education practices in SWEET pediatric diabetes centers-an international comparison.

Pediatr Diabetes 2021 Mar 3;22(2):215-220. Epub 2020 Dec 3.

Department of Endocrinology, John Hunter Children's Hospital, Newcastle, New South Wales, Australia.

Background: Nutrition education is central to pediatric type 1 diabetes management. Dietary management guidelines for type 1 diabetes are evidence based, but implementation may be challenging and inconsistent. We describe variation in the practice of nutrition education across pediatric diabetes centers globally and explore associations with A1c and BMI.

Methods: In 2018, 77 pediatric diabetes clinics in the SWEET network received a survey about nutrition education. Using data submitted to the registry, regression analysis corrected for age, diabetes duration, BMI, and sex was used to compare survey parameters with A1c and BMI.

Results: Fifty-three centers who collectively cared for 22,085 patients aged 0 to 18 with type 1 diabetes responded. Median A1c was 7.68% [IQR 7.37-8.03], age 13.13 y [12.60-13.54], insulin pump use 39.1%, and continuous glucose monitor use 37.3%. 34% reported screening for disordered eating, but only 15.1% used validated screening tools. Recommending insulin boluses for snacks in patients taking insulin via injection varied, with 23% of the clinics giving this recommendation to half or fewer patients. In regression analysis, instructing patients to take insulin for snacks was the only survey parameter associated with the percent of clinic percent of patients attaining A1c <7.5% (<58 mmol/mol, P = 0.018) and < 7.0% (<53 mmol/mol, P = 0.026).

Conclusions: There is considerable variation in nutrition education for pediatric patients with type 1 diabetes across this international registry. Consistently recommending independent of treatment modality (insulin pump or injections) that patients take insulin for snacks and more uniformity in screening for disordered eating are improvement opportunities.
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http://dx.doi.org/10.1111/pedi.13161DOI Listing
March 2021

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

Acta Diabetol 2021 Feb 17;58(2):191-195. Epub 2020 Sep 17.

Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland.

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/m (16.28-18.62 kg/m) versus 15.98 kg/m (15.14-17.96 kg/m) 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.
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http://dx.doi.org/10.1007/s00592-020-01601-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889531PMC
February 2021

Dental caries and periodontal status in children with type 1 diabetes mellitus.

Pediatr Endocrinol Diabetes Metab 2020 ;26(1):39-44

Department of Conservative Dentistry with Endodontics, Medical University of Silesia, Katowice, Poland.

Introduction: Type 1 diabetes mellitus (T1DM) is a chronic metabolic disease that strongly affects the health of individuals. Some studies have sug-gested that it affects oral health, thus indicating a higher-than-average predisposition of patients with diabetes to caries and periodontal diseases.

Aim Of The Study: We aimed at investigating the association between caries, periodontal diseases, and diabetes among children using dental indices.

Material And Methods: The study included 50 children (aged 10-18 years) who had type 1 diabetes for at least years. The participants were divided into well controlled (WC), (HBA1c < 7.5%) and poorly controlled (PC) (HBA1c ≥ 7.5%) groups (25 diabetic children each). The control group (GC) included non-diabetic children. The following clinical parameters were measured: DMFT index, plaque index (PI), approximal plaque index (API), gingival index (GI), and modified sulcus bleeding index (mSBI).

Results: The WC group had the lowest average value - 3.44 of the DMFT index with values of 5.80 and 3.88 in the PC and GC groups, respec-tively. A statistically significant difference was found in the DMFT value between PC and WC groups (p = 0.04). No statistically signif-icant differences in the values of other indices were found between the groups.

Conclusions: Children with poorly controlled type 1 diabetes were characterised by a significantly higher intensity of caries. In contrast, no statistical-ly significant differences were observed in the periodontal status between the study groups.
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http://dx.doi.org/10.5114/pedm.2020.93249DOI Listing
March 2021

The Usefulness of Genotyping of Celiac Disease-Specific HLA among Children with Type 1 Diabetes in Various Clinical Situations.

J Diabetes Res 2020 20;2020:7869350. Epub 2020 Feb 20.

Department of Children's Diabetology, Medical University of Silesia in Katowice, Poland.

Aim: The aim of the study was to determine the usefulness of HLA DQ2/DQ8 genotyping in children with T1D in various clinical situations: as a screening test at the diabetes onset, as a verification of the diagnosis in doubtful situations, and as a test estimating the risk of CD in the future. . Three groups of patients with T1D were included: newly diagnosed ( = 92), with CD and villous atrophy ( = 92), with CD and villous atrophy ( = 92), with CD and villous atrophy ( = 30), and with potential CD ( = 23). Genetic tests were performed (commercial test, PCR, and REX), and clinical data were collected.

Results: The results of genetic tests confirmed the presence of DQ2/DQ8 in 94% of children with diabetes (group I) and in 100% of children with diabetes and CD (groups II and III, respectively). Comparative analysis of the HLA DQ2/DQ8 distribution did not show any differences. Allele DRB104 (linked with HLA DQ8) was significantly less common in children with diabetes and CD (group I versus groups II and III, 56.5% vs. 24.5%; = 0.001). The probability of developing CD in DRB104-positive patients was 4 times lower (OR 0.25; 95% CI 0.118-0.529; = 0.001). The probability of developing CD in DRB104-positive patients was 4 times lower (OR 0.25; 95% CI 0.118-0.529; = 0.001). The probability of developing CD in DRB104-positive patients was 4 times lower (OR 0.25; 95% CI 0.118-0.529.

Conclusions: Genotyping HLA DQ2/DQ8 as a negative screening has limited use in assessing the risk of CD at the diabetes onset and does not allow to verify the diagnosis of CD in doubtful situations. The presence of the DRB104 allele modulates the risk of CD and significantly reduces it and can predict a potential form.
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http://dx.doi.org/10.1155/2020/7869350DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7057025PMC
December 2020

Proinsulin-specific T regulatory cells may control immune responses in type 1 diabetes: implications for adoptive therapy.

BMJ Open Diabetes Res Care 2020 02;8(1)

Department of Medical Immunology, Medical University of Gdańsk, Gdańsk, Poland

Objective: Here we looked for possible mechanisms regulating the progression of type 1 diabetes mellitus (T1DM). In this disease, autoaggressive T cells (T conventional cells, Tconvs) not properly controlled by T regulatory cells (Tregs) destroy pancreatic islets.

Research Design And Methods: We compared the T-cell compartment of patients with newly diagnosed T1DM (NDT1DM) with long-duration T1DM (LDT1DM) ones. The third group consisted of patients with LDT1DM treated previously with polyclonal Tregs (LDT1DM with Tregs). We have also looked if the differences might be dependent on the antigen specificity of Tregs expanded for clinical use and autologous sentinel Tconvs.

Results: Patients with LDT1DM were characterized by T-cell immunosenescence-like changes and expansion of similar vβ/T-cell receptor (TCR) clones in Tconvs and Tregs. The treatment with Tregs was associated with some inhibition of these effects. Patients with LDT1DM possessed an increased percentage of various proinsulin-specific T cells but not GAD65-specific ones. The percentages of all antigen-specific subsets were higher in the expansion cultures than in the peripheral blood. The proliferation was more intense in proinsulin-specific Tconvs than in specific Tregs but the levels of some proinsulin-specific Tregs were exceptionally high at baseline and remained higher in the expanded clinical product than the levels of respective Tconvs in sentinel cultures.

Conclusions: T1DM is associated with immunosenescence-like changes and reduced diversity of T-cell clones. Preferential expansion of the same TCR families in both Tconvs and Tregs suggests a common trigger/autoantigen responsible. Interestingly, the therapy with polyclonal Tregs was associated with some inhibition of these effects. Proinsulin-specific Tregs appeared to be dominant in the immune responses in patients with T1DM and probably associated with better control over respective autoimmune Tconvs.

Trial Registration Number: EudraCT 2014-004319-35.
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http://dx.doi.org/10.1136/bmjdrc-2019-000873DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7206972PMC
February 2020

How does a predictive low glucose suspend (PLGS) system tackle pediatric lifespan challenges in diabetes treatment? Real world data analysis.

Pediatr Diabetes 2020 03 24;21(2):280-287. Epub 2019 Nov 24.

Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland.

Objectives: The aim of the study was to assess the benefits of a predictive low glucose suspend (PLGS) system in real-life in children and adolescents with type 1 diabetes of different age and age-related clinical challenges.

Methods: Real life retrospective and descriptive analysis included 44 children (26 girls) with type 1 diabetes who were introduced to PLGS system. We divided them in three age groups: I (3-6 years old, n = 12), II (7-10 y/o, n = 16), III (11-19 y/o, n = 16). All children and their caregivers received unified training in self-management during PLGS therapy. Patients' data included: age, HbA1C levels, sex. While from the CGM metric, we obtained: time of sensor use (SENSuse), time in range (TiR): in, below and over target range and average blood glycemia (AVG), insulin suspension time (INSsusp).

Results: SENSuse was 93% in total, with 92%, 94%, and 87% in age groups I, II, III, respectively. In total the reduction of mean HbA1C from 7.61% to 6.88% (P < .05), while for the I, II, and III it was 7.46% to 6.72%, 6.91% to 6.41%, and 8.46 to 7.44%, respectively (P < .05). Although we observed a significant reduction of HbA1C, the time below target range was minimal. Specific findings included: group I-longest INSsusp (17%), group II-lowest glycemic variability (CV) (36%), and group III-highest AVG (169 mg/dL). There was a reverse correlation between suspend before low and age (-0.32, P < .05). In group I CV reduced TiR in target range (TiRin) (-0.82, P < .05), in group II use of complex boluses increased TiRin (0.52, P < .05). In group III higher CV increased HbA1C (0.64, P < .05) while reducing TiRin (-0.72, P < .05).

Conclusions: PLGS is a suitable and safe therapeutic option for children with diabetes of all age and it is effective in addressing age-specific challenges. PLGS improves glycemic control in children of all age, positively affecting its different parameters.
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http://dx.doi.org/10.1111/pedi.12944DOI Listing
March 2020

Proportion of Basal to Total Insulin Dose Is Associated with Metabolic Control, Body Mass Index, and Treatment Modality in Children with Type 1 Diabetes-A Cross-Sectional Study with Data from the International SWEET Registry.

J Pediatr 2019 12 22;215:216-222.e1. Epub 2019 Jul 22.

Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark.

Objectives: To investigate in a large population the proportion of daily basal insulin dose (BD) to daily total insulin dose (TD) (BD/TD) and its association with glycated hemoglobin A1c (HbA1c), body mass index (BMI)- SDS, and treatment modality in children with type 1 diabetes.

Study Design: Cross-sectional study in subjects with type 1 diabetes, age ≤18 years, and ≥2 years of diabetes duration, registered in the international multicenter Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference registry in March 2018. Variables included region, sex, age, diabetes duration, treatment modality (multiple daily injections [MDI] or continuous subcutaneous insulin infusion [CSII]), self-monitoring blood glucose, HbA1c, BD/TD, and BMI-SDS. BMI was converted to BMI-SDS using World Health Organization charts as reference. Hierarchic linear regression models were applied with adjustment for age, sex, and diabetes duration.

Results: A total of 19 687 children with type 1 diabetes (49% female, 49% CSII users) with median age 14.8 (11.5; 17.2) years and diabetes duration 6.0 (3.9; 9.0) years were included. HbA1c was 63 (55; 74) mmol/mol (7.9 [7.2; 8.9]%), and BMI-SDS 0.55 (-0.13; 1.21). Unadjusted, a lower BD/TD was associated with lower HbA1c, male sex, younger age, shorter diabetes duration, lower BMI-SDS, higher numbers of self-monitoring blood glucose and CSII (all P < .01). After adjustment for confounders, lower BD/TD was associated with lower HbA1c (P < .01) and lower BMI-SDS (P < .01) in children on CSII, but not on MDI.

Conclusions: Lower BD/TD is positively associated with lower HbA1c and lower BMI-SDS in children with type 1 diabetes on CSII. It remains to be investigated in a prospective study whether reducing BD/TD insulin will improve metabolic control and normalize body weight in children with type 1 diabetes.
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http://dx.doi.org/10.1016/j.jpeds.2019.06.002DOI Listing
December 2019

[What was discussed during the 44th ISPAD - International Society for Pediatric and Adolescent Diabetes?]

Pediatr Endocrinol Diabetes Metab 2019 ;25(2):99-102

Katedra Pediatrii, Klinika Diabetologii Dziecięcej, Śląski Uniwersytet Medyczny w Katowicach Specjalistyczne Centrum Medyczne, Specjalistyczne Centrum Medyczne, Polska.

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http://dx.doi.org/10.5114/pedm.2019.85823DOI Listing
February 2020

Nutrition of children and adolescents with type 1 diabetes in the recommendations of the Mediterranean diet.

Pediatr Endocrinol Diabetes Metab 2019 ;25(2):74-80

Paediatric Diabetology Clinic, Medical Faculty in Katowice, Medical University of Silesia in Katowice, Poland.

Introduction: The nutrition of children and adolescents significantly affects the physical and mental development of those suffering from type 1 diabetes and their healthy peers. Nutrition rules for children and adolescents with type 1 diabetes do not differ from the principles of feeding their healthy peers. Hence, the demand for individual nutrients in type 1 diabetes and healthy people is the same. The nutrition of children and adolescents should meet the recommendations of the Institute of Food and Nutrition and the Polish Diabetes Association.

Aim Of The Study: Aim of the study is to present a pattern of nutrition for children and adolescents with type 1 diabetes, treated with intensive insulin therapy using the Mediterranean diet, which was recognised by the World Health Organization as a model of a healthy diet for both children and adults. Through the participation of a large number of natural products, it has antioxidant, chemopreventive, and anti-inflammatory effects, it reduces the level of triglycerides and cholesterol, as well as postprandial glycaemia.

Conclusions: Żywienie dzieci i młodzieży istotnie wpływa na rozwój fizyczny i psychiczny dziecka - zarówno chorego na cukrzycę typu 1, jak i zdrowego. Zasady odżywiania dzieci i młodzieży z cukrzycą typu 1 nie różnią się od zasad żywienia ich zdrowych rówieśników. Dlatego też zapotrzebowanie na poszczególne składniki pokarmowe u dzieci chorych na cukrzycę typu 1 oraz dla zdrowych jest takie samo. Sposób odżywiania dzieci i młodzieży powinien spełniać zalecenia Instytutu Żywności i Żywienia oraz Polskiego Towarzystwa Diabetologicznego.
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http://dx.doi.org/10.5114/pedm.2019.85817DOI Listing
February 2020

The Empowerment of Adolescents with Type 1 Diabetes Is Associated with Their Executive Functions.

Biomed Res Int 2019 30;2019:5184682. Epub 2019 Apr 30.

Department of Pediatrics, Endocrinology, Diabetology with Cardiology Division, Medical University of Białystok, Białystok 15-274 Waszyngtona 24, Poland.

Background: Adolescence is a difficult period for young people with type 1 diabetes mellitus (T1DM), both in psychological and clinical terms. Empowerment therapy may support these patients, provided they are ready to change and have adequate executive functions to facilitate this change. Therefore, we hypothesise that the readiness of adolescents with T1DM to change is related to clinical features and/or their executive functions.

Methods: Using the Diabetes Empowerment Scale and the Behavioural Rating Inventory of Executive Function, we evaluated patients with T1DM duration of more than one year from three Polish diabetes centres of the PolPeDiab study group (N = 146). We related the data to features associated with disease and treatment and compared the results to those of adolescents without diabetes (N = 110).

Results: We observed that adolescents with T1DM had a higher rate of abnormal results in executive function tests than their peers without diabetes (p > 0.05). Diabetes empowerment in this group of patients decreased with disease duration (r = -0.25, p = 0.006) and increased with deteriorating metabolic control (HbA1c; r = 0.25, p = 0.006). The greater the deficiencies in executive functions among adolescents with T1DM, the greater their readiness to change. The relationship between executive functions and diabetes empowerment is partially gender-differentiated.

Conclusions: To conclude, we propose individualized diabetes education in this group of patients based on the assessment of readiness to change and executive functions.
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http://dx.doi.org/10.1155/2019/5184682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6515027PMC
December 2019

Assessment of Safety and Glycemic Control During Football Tournament in Children and Adolescents With Type 1 Diabetes-Results of GoalDiab Study.

Pediatr Exerc Sci 2019 11 27;31(4):401-407. Epub 2019 Jun 27.

Poznan University of Medical Sciences.

Purpose: To assess glycemic control and safety of children and adolescents with type 1 diabetes participating in a 2-day football tournament.

Methods: In total, 189 children with type 1 diabetes from 11 diabetes care centers, in Poland, participated in a football tournament in 3 age categories: 7-9 (21.2%), 10-13 (42.9%), and 14-17 (36%) years. Participants were qualified and organized in 23 football teams, played 4 to 6 matches of 30 minutes, and were supervised by a medical team. Data on insulin dose and glycemia were downloaded from personal pumps, glucose meters, continuous glucose monitoring, and flash glucose monitoring systems.

Results: The median level of blood glucose before the matches was 6.78 (4.89-9.39) mmol/L, and after the matches, it was 7.39 (5.5-9.87) mmol/L (P = .001). There were no episodes of severe hypoglycemia or ketoacidosis. The number of episodes of low glucose value (blood glucose ≤3.9 mmol/L) was higher during the tournament versus 30 days before: 1.2 (0-1.5) versus 0.7 (0.3-1.1) event/person/day, P < .001. Lactate levels increased during the matches (2.2 [1.6-4.0] mmol/L to 4.4 [2.6-8.5] mmol/L after the matches, P < .001).

Conclusions: Large football tournaments can be organized safely for children with type 1 diabetes. For the majority of children, moderate mixed aerobic-anaerobic effort did not adversely affect glycemic results and metabolic safety.
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http://dx.doi.org/10.1123/pes.2018-0264DOI Listing
November 2019

How modern technologies improve daily diabetic control.

Pediatr Endocrinol Diabetes Metab 2018 ;2018(3):140-144

Introduction: Diabetic children who live surrounded by modern technologies such as Facebook, Google, and GPS want their treatment to stand up to the times, especially if it accompanies them for their whole life.

Aim Of The Study: In this review we aim to analyse which technologies help diabetics in their everyday struggle to keep up with diabetes as well as whether those inventions catch up to the reality of 21st century.

Material And Methods: We decided to discuss the most outstanding inventions in the field of diabetology. We chose insulin pumps, constant glucose monitoring (CGM) systems, mobile apps, and, last but not least, social media and the Internet as the most promising and fastest developing areas. Thanks to all of these technologies and devices we are now able to monitor patients all time. We have to take into account that the limitations of technology, the possibility of technical malfunction, and human error might prove to be fatal.

Conclusions: To sum up, technology simplifies treatment and aids patients in daily diabetic control.
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http://dx.doi.org/10.5114/pedm.2018.80996DOI Listing
May 2019

[Hypoglycaemia unawareness in patients with type 1 diabetes].

Pediatr Endocrinol Diabetes Metab 2018 ;2018(3):126-134

Chair and Department of Pediatrics, Diabetology and Endocrinology, Medical University of Gdansk, Poland.

Hypoglycaemia unawareness, defined at the onset of neuroglycopenia before the appearance of autonomic warning symptoms, is an serious problem in type 1 diabetes mellitus. It is often caused by recurrent or severe hypoglycaemia, which leads to the failure of the autonomic nervous system (hypoglycaemia-associated autonomic failure - HAAF). The hypoglycaemia awareness can be restored by avoiding episodes of hypoglycaemia. Management of hypoglycaemia unawareness is complex, and can only be achieved by a multifactorial intervention of clinical care and structured patient education. In patients in whom functional intensive insulin therapy with insulin analogue, continuous subcutaneous insulin infusion using insulin pumps are ineffective in the prevention of hypoglycaemia the implementation of continuous glucose monitoring (CGM) is advisable. CGM systems equipped with low glucose alarms and prediction alarms not only significantly reduce the risk of severe hypoglycaemia, but also significantly reduce the fear of hypoglycaemia and improve the quality of life of patients and their families. The insulin pumps integrated with CGM automatically suspending insulin infusion when glucose is predicted to soon be low (PLGS) should be preferred in patient with hypoglycaemia unawareness. Hypoglycaemia management is complex and should also include structural education. Particular attention should be paid to the management of hypoglycaemia and appropriate use of modern therapy. The hypoglycaemia unawareness is very common among children under the age of 6 years who are unable to observe the early symptoms of hypoglycemia by themselves. This induces a high risk of frequent and severe hypoglycaemia, which can lead to structural changes in the brain, cognitive dysfunctions, poor mental abilities and behavioral disorders later in life.
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http://dx.doi.org/10.5114/pedm.2018.80994DOI Listing
May 2019

Assessment of optimal insulin administration timing for standard carbohydrates-rich meals using continuous glucose monitoring in children with type 1 diabetes: A cross-over randomized study.

J Diabetes Investig 2019 Sep 18;10(5):1237-1245. Epub 2019 May 18.

Department of Children's Diabetology, Medical University of Silesia, Katowice, Poland.

Aims/introduction: The present study was an assessment of postprandial glucose concentration after carbohydrates-rich meals using continuous glucose monitoring in 30 children with type 1 diabetes treated using continuous subcutaneous insulin infusion with a rapid-acting insulin analog.

Materials And Methods: Over a period of 3 days, participants administered simple boluses with different delay times between insulin administration and the beginning of carbohydrates-rich meal consumption (meal no. 1 containing 197 kcal, no. 2 containing 247 kcal and meal no. 3 containing 323 kcal; containing practically no protein and fat). In the present cross-over randomized study, we analyzed the average glucose concentration profiles in 5-min intervals, mean glucose at insulin administration, mean glucose after 120 and 180 min, mean and peak glucose, glucose peak time, areas under the glucose and glucose increase curves, and time period lengths with glucose <50, 70 mg/dL, and >140 and 200 mg/dL.

Results: For test meals at 20-min versus 0-min delay time, the study exposed a longer median time period to reach peak glucose (95 vs 65 min, P = 0.01) after meals. A tendency to the lowest peak and mean glucose, and the longest time with glucose within a normal range was observed in patients who administered bolus insulin 20 min before a meal.

Conclusions: For carbohydrates-rich meals, administration of a proper dose of a rapid-acting insulin analog is crucial. The influence of rapid-acting insulin analog administration timing seems to be of minor importance in comparison with correct insulin dose adjustment; however, a tendency to achieve more balanced glucose profiles was found in a group who administered insulin 20 min before a meal.
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http://dx.doi.org/10.1111/jdi.13027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717813PMC
September 2019

Remission phase in children diagnosed with type 1 diabetes in years 2012 to 2013 in Silesia, Poland: An observational study.

Pediatr Diabetes 2019 05 20;20(3):286-292. Epub 2019 Feb 20.

Department of Children's Diabetology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.

Background/objective: The study aimed to analyze the frequency of partial remission (PR) and its association with chosen clinical and laboratory factors among pediatric patients with newly diagnosed type 1 diabetes (T1D). The long-term effect of PR on chosen parameters was also investigated.

Methods: In 194 patients (95 girls) aged 8.1 ± 4.3 years, we analyzed data at T1D onset: glycemia, pH, C-peptide, antibodies, weight, and concomitant autoimmune diseases. Anthropometric parameters, daily insulin requirement (DIR), and HbA1c 2 and 4 years after T1D diagnosis were also analyzed. We determined PR based on HbA1c and DIR measurements at least every 3 months.

Results: PR occurred in 59% of patients. Remitters had significantly higher pH (7.33 vs 7.28, P = 0.03), weight SD score (SDS) (0.25 vs -0.24, P = 0.002), and body mass index SDS (0.19 vs -0.66, P = 0.02) compared with non-remitters. Concomitant diseases correlated negatively with PR. Multivariate analysis indicated only pH at onset was an independent predictor of PR. pH was the most important factor associated with the beginning of PR. There was a positive correlation between the start and duration of PR. Four years after T1D onset remitters had lower HbA1c (7.24% vs 8.05%, 53 vs 63.9 mmol/mol, P < 0.001) and DIR (0.81 vs 1.08, P = 0.005).

Conclusions: PR occurred quite often and developed more frequently in children with higher: weight and BMI SDS, but the main factor influencing PR presence and duration was higher pH at T1D onset. There was a beneficial impact of PR on HbA1c and DIR after 4 years of treatment.
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http://dx.doi.org/10.1111/pedi.12824DOI Listing
May 2019

Trends and cyclical variation in the incidence of childhood type 1 diabetes in 26 European centres in the 25 year period 1989-2013: a multicentre prospective registration study.

Diabetologia 2019 03 28;62(3):408-417. Epub 2018 Nov 28.

Odense Patient data Exploratory Network (OPEN), Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.

Aims/hypothesis: Against a background of a near-universally increasing incidence of childhood type 1 diabetes, recent reports from some countries suggest a slowing in this increase. Occasional reports also describe cyclical variations in incidence, with periodicities of between 4 and 6 years.

Methods: Age/sex-standardised incidence rates for the 0- to 14-year-old age group are reported for 26 European centres (representing 22 countries) that have registered newly diagnosed individuals in geographically defined regions for up to 25 years during the period 1989-2013. Poisson regression was used to estimate rates of increase and test for cyclical patterns. Joinpoint regression software was used to fit segmented log-linear relationships to incidence trends.

Results: Significant increases in incidence were noted in all but two small centres, with a maximum rate of increase of 6.6% per annum in a Polish centre. Several centres in high-incidence countries showed reducing rates of increase in more recent years. Despite this, a pooled analysis across all centres revealed a 3.4% (95% CI 2.8%, 3.9%) per annum increase in incidence rate, although there was some suggestion of a reduced rate of increase in the 2004-2008 period. Rates of increase were similar in boys and girls in the 0- to 4-year-old age group (3.7% and 3.7% per annum, respectively) and in the 5- to 9-year-old age group (3.4% and 3.7% per annum, respectively), but were higher in boys than girls in the 10- to 14-year-old age group (3.3% and 2.6% per annum, respectively). Significant 4 year periodicity was detected in four centres, with three centres showing that the most recent peak in fitted rates occurred in 2012.

Conclusions/interpretation: Despite reductions in the rate of increase in some high-risk countries, the pooled estimate across centres continues to show a 3.4% increase per annum in incidence rate, suggesting a doubling in incidence rate within approximately 20 years in Europe. Although four centres showed support for a cyclical pattern of incidence with a 4 year periodicity, no plausible explanation for this can be given.
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http://dx.doi.org/10.1007/s00125-018-4763-3DOI Listing
March 2019

The usefulness of the FlashStyle Libre system in glycemic control in children with type 1 diabetes during summer camp.

Pediatr Endocrinol Diabetes Metab 2018 ;24(1):11-19

Department of Children's Diabetology, School of Medicine in Katowice, Medical University of Silesia in Katowice.

The Aim Of The Study: was to evaluate the usefulness of Flash FreeStyle Libre in glycemic control in children during summer camp on the basis of the participants' completed questionnaire and on the basis of the assessment o the suitability of the system performed by medical staff based on a comparative analysis: glycemia by sensor and glucometer.

Material And Methods: A study using the new Flash FreeStyle Libre glycemic control system was conducted at a seaside summer camp for children with diabetes at the seaside. The study included 75 children (32 boys and 43 girls), in mean 13.4 (SD 4.6) years old, with an average duration of diabetes of 6.5 (SD 4.5) years and mean HbA1c of 7.81% (SD 2.05). All camp participants were provided with Libre sensors, however, routine glucose control measurements with therapeutic decisions was made using traditional glucose meters. On the last day of the camp, after the removal of the sensors, a satisfaction survey was conducted to assess with a new self-monitoring method and a comparative analysis of the glucose results from the sensor with the personal glucose meters - MARD, MAD, and clinical errors on the Clarke Error Grid were calculated.

Results: In the Libre user's survey, wearing comfort and ease of installation were described as very good / good by 86% and 94% of the respondends, respectively. Ease of reading blood glucose by scan was positively evaluated by 92% of the respondents, 95% of the subjects did not report any side effects. The sensor remained intact for 14 days in 46 children (62%), which value was the basis for the statistical calculations. Comparative analysis of glucose results obtained from Libre measurements performed with glucose meters (3143 measurements) showed a relatively good MARD index - 18.22% on average, with a large individual variation (6.36-29.51%). Clarke Error Grid showed that 75.2% (2309) of the results were in Zone A (Acceptable Errors) and 95.81% (3012) in Zone A and B (Non-Negative Errors).

Conclusion: Libre user's satisfaction survey revealed that most of the respondents rated the cooperation with Flash FreeStyle Libre positively. The relatively good results of Libre in comparison with glucose meters have confirmed the usefulness of this method of monitoring glucose in summer camps for children with diabetes.
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http://dx.doi.org/10.18544/PEDM-24.01.0098DOI Listing
December 2018

ISPAD Clinical Practice Consensus Guidelines 2018: Insulin treatment in children and adolescents with diabetes.

Pediatr Diabetes 2018 10;19 Suppl 27:115-135

Institute of Maternal and Child Research (IDMI), School of Medicine, University de Chile, Santiago, Chile.

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http://dx.doi.org/10.1111/pedi.12718DOI Listing
October 2018

Obesity and diabetes-Not only a simple link between two epidemics.

Diabetes Metab Res Rev 2018 10 17;34(7):e3042. Epub 2018 Jul 17.

Department of Children's Diabetology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.

Diabetes (DM) as well as obesity, due to their increasing incidence, were recognized as epidemic by the World Health Organization. Obesity is involved not only in the aetiopathogenesis of the most common worldwide type of DM-type 2 diabetes-but also in the development of its complications. There is also increasing scientific evidence regarding the role of obesity and overweight in type 1 diabetes. Weight gain may be considered as a complication of insulin treatment but also reveals significant pathophysiological impact on various stages of the disease. Another very important aspect related to DM as well as obesity is the microbiome, which is highly variable. The function of the gut microflora, its interaction with the whole organism, and its role in the development of obesity and type 1 diabetes as well as type 2 diabetes are still not fully understood and subject of ongoing investigations. This review presents a summary of recently published results concerning the relation of obesity/overweight and DM as well as their associations with the microbiome.
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http://dx.doi.org/10.1002/dmrr.3042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6220876PMC
October 2018

Dimethyl fumarate in a patient with multiple sclerosis and type 1 diabetes mellitus: The importance of ketonuria.

Mult Scler Relat Disord 2018 Apr 7;21:42-45. Epub 2018 Feb 7.

Department of Children's Diabetology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland.

Background: Dimethyl fumarate (DMF) is approved for use in patients with relapsing-remitting multiple sclerosis (MS). Its mechanism of action is still not well understood, but besides the immunological pathways in MS, it may also affect the metabolism of normally functioning internal organs, tissues and cells.

Case Presentation: We report on the case of 29-year-old woman with satisfactorily-controlled type 1 diabetes (T1D), who was diagnosed as having MS. After administration of DMF she experienced intense, adverse gastro-intestinal reactions together with ketonuria up to 160 mg/dL. The highest ketone concentrations in the urine were observed approximately 2 h after each DMF dose and always with co-existing adverse reactions. Dose reduction did not improve symptoms and treatment had to be stopped. Twelve hours after the last dose of DMF all laboratory results returned to normal ranges and all gastro-intestinal adverse reactions were resolved within the following 24 h.

Conclusion: This is a first report of ketonuria in a MS-patient with T1D treated with DMF. Patients with MS and co-existing metabolic diseases, which are not contraindicated for DMF treatment, represent a unique opportunity to address questions regarding the possible mechanisms of action of DMF on the cellular metabolism. The use of DMF in patients with metabolic diseases needs closer attention.
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http://dx.doi.org/10.1016/j.msard.2018.02.007DOI Listing
April 2018

Neonatal outcome and diabetes course in children with GCK-MODY born from women with GCK-MODY.

Pediatr Endocrinol Diabetes Metab 2018 ;24(4):167-173

Department of Obstetrics, Medical University of Gdansk, Poland.

Introduction: Gestational diabetes is one of the most common medical disorders and may cause numerous of maternal and foetal complications, such as: preterm births, congenital defects, hypertrophic cardiomyopathy, metabolic changes, and macrosomia in neonates. One of the types of diabetes that may clinically manifest in pregnancy is GCK-MODY, caused by mutations in the glucokinase (GCK) gene.

Aim Of The Study: The aim of the study was to assess the impact of diabetes during pregnancy in women with GCK-MODY on their children's health outcome and to determine the clinical and biochemical characteristics of children delivered by patients with GCK-MODY.

Material And Methods: Study was multicentre, involving 50 children from paediatric diabetology departments in Gdansk, Katowice, Bialystok, and Lodz. The risk of GCK-MODY was evaluated on the basis of the medical history of the patient, the clinical course of the disease, and laboratory tests performed during diagnostic procedures. Data concerning family history, mothers' health status, course of pregnancy, and perinatal period was collected.

Results: The study showed that among children with glucokinase mutation, born by mothers affected with GCK-MODY, 62% received 10 points in Apgar score in the first minute of life, whereas 92% (n = 46) obtained 10 points in Apgar score in the fifth minute of life. The average age of diagnosis of GCK-MODY in children was 8.25 ±4.76 years, and the average HbA1c during diagnosis was 6.43 ±0.71%. Statis-tically significant difference between the absence of macrosomia (birth weight > 91st percentile) in children with GCK-MODY diabetes in comparison to the general paediatric population (p = 0.0229) was observed.

Conclusion: According to the presented study, possible consequences of GCK-MODY during pregnancy on foetal development are generally less severe and may differ from those characteristic for other types of diabetes. Children born by mothers with diabetes should be followed up regarding glucose disorders. Further investigation of particular phenotypes of GCK-MODY, depending on the type of inherited mu-tation in mothers and their children, is required.
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http://dx.doi.org/10.5114/pedm.2018.83362DOI Listing
May 2019

[Difficulties of the therapy in a boy with coexisting type 1 diabetes mellitus and idiopathic thrombocytopenic purpura].

Pediatr Endocrinol Diabetes Metab 2017 ;23(3):165-168

Klinika Diabetologii Dziecięcej Śląskiego Uniwersytetu Medycznego.

Idiopathic thrombocytopenic purpura (ITP) is an acquired autoimmune disease, caused by antibodies against platelet glycoproteins, which provoke platelet destruction and inhibit platelet production in bone marrow. Type 1 Diabetes Mellitus (T1DM) is an acquired autoimmune disease in witch beta cells are destroyed by autoantibodies. Patient with T1DM since the age of 6, was treated by intensive functional insulin therapy by insulin pump. At the age of 14,5 he was also diagnosed with ITP. Due to the short effect of immunoglobulin therapy, glucocorticoids were introduced. After 3 months of glucocorticotherapy the platelet count was 46 G/l. Patient developed various adverse effects of glucocorticoids, among others stretch marks covering all surface of his abdomen, buttocks, arms and thighs and raise in the daily requirement of insulin by 200%. Adverse effects of glucocorticotherapy made impossible the therapy by insulin pump and imposed urgent revision of the ITP therapy. Side effects of the glucocorticotherapy can make impossible the treatment by insulin pump of T1DM in children.
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http://dx.doi.org/10.18544/PEDM-23.03.0089DOI Listing
July 2018

[Myasthenia gravis, Graves-Basedow disease and other autoimmune diseases in patient with diabetes type 1 - APS-3 case report, therapeutic complications].

Pediatr Endocrinol Diabetes Metab 2017 ;23(3):159-164

Department of Children's Diabetology , School of Medicine in Katowice, Medical University of Silesia in Katowice.

Diabetes type 1(T1D) is the most frequent form of diabetes in children and young people, which essence is autoimmune destruction of pancreatic B cells islet. Co-occurrence of other autoimmune diseases is observed in children with T1D, the most often are: Hashimoto disease or coeliac disease. We report the case of the patient, who presents coincidence of T1D with other rare autoimmune diseases such as: Graves - Basedow disease, myasthenia gravis, vitiligo and IgA deficiency. All mentioned diseases significantly complicated both endocrine and diabetic treatment of our patient and they negatively contributed her quality of life. The clinical picture of the case allows to recognize one of the autoimmune polyendocrine syndromes: APS-3 and is associated with still high risk of developing another autoimmune disease.
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http://dx.doi.org/10.18544/PEDM-23.03.0088DOI Listing
July 2018

Monogenic diabetes prevalence among Polish children-Summary of 11 years-long nationwide genetic screening program.

Pediatr Diabetes 2018 02 24;19(1):53-58. Epub 2017 Apr 24.

Department of Pediatrics, Oncology, Hematology and Diabetology, Medical University of Lodz, Lodz, Poland.

Background: Estimated monogenic diabetes (MD) prevalence increases as screening programs proceeds.

Objective: To estimate prevalence of MD among Polish children.

Subjects: Patients and their family members suspected of suffering from MD (defined as causative mutation in one of the Maturity Onset Diabetes of the Young or permanent neonatal diabetes mellitus genes) were recruited between January 2005 and December 2015.

Methods: Nationwide prevalence was estimated based on data from 6 administrative provinces (out of 16 in Poland) with high referral rates of patients (>10 per 100 000 children).

Results: During the analysis, probands from 322 of 788 screened families tested positive yielding a total of 409 children and 299 family members with MD. An average of 70 probands/year were referred. Screening success rate reached 40% over the study period. We estimated the prevalence of MD in 2015 to 7.52/100 000 children (1 in 13 000). The most frequent MODY in this group was GCK- MODY (6.88/100 000). The prevalence estimates increased nearly 2-fold since our report in 2011 (4.4/100 000). However, the figure reached a plateau because of screening saturation in 2014 what was also proven by lowering of the median age of diagnosis lowered in time (R = -0.73, P = .0172) along with shortening of the delay between clinical and genetic diagnosis (R = -0.65, P = .0417).

Conclusions: The screening for childhood MD in Poland reached a plateau phase after 10 years showing a stable prevalence estimate. The true frequency of MD in the overall population may be higher given later onset of reportedly more frequent types of MD than GCK -MODY.
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http://dx.doi.org/10.1111/pedi.12532DOI Listing
February 2018

Dysglycemia in critically ill children.

Pediatr Endocrinol Diabetes Metab 2016 ;22(1):21-25

Department of Children's Diabetology, School of Medicine in Katowice, Medical University of Silesia in Katowice, Poland.

Stress hyperglycemia remains a significant and unsolved medical condition in critically ill children. Treatment for hyperglycemia is controversial and, to date, no recommendations exist from pediatric professional society regarding the management of hyperglycemia in critically ill children. This review summarizes recent work investigating the pathogenesis of stress hyperglycemia, the importance of hypoglycemic episodes and glycemic variability among critically ill patients.
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http://dx.doi.org/10.18544/PEDM-22.01.0046DOI Listing
October 2017