DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic

ABSTRACT We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic.

We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.

MECHANISMS IN ENDOCRINOLOGY: A sense of time of the glucocorticoid circadian clock: from the ontogeny to the diagnosis of Cushing's syndrome.

The circadian rhythm of glucocorticoids has long been recognised within the last 75 years. Since the beginning, researchers have sought to identify basic mechanisms underlying the origin and emergence of the corticosteroid circadian rhythmicity among mammals. Accordingly, Young, Hall and Rosbash, laureates of the 2017 Nobel Prize in Physiology or Medicine, as well as Takahashi's group among others, have characterised the molecular cogwheels of the circadian system, describing interlocking transcription/translation feedback loops essential for normal circadian rhythms. Plasma glucocorticoid circadian variation depends on the expression of intrinsic clock genes within the anatomic components of the hypothalamic-pituitary-adrenal axis, which are organised in a hierarchical manner. This review presents a general overview of the glucocorticoid circadian clock mechanisms, highlighting the ontogeny of the pituitary-adrenal axis diurnal rhythmicity as well as the involvement of circadian rhythm abnormalities in the physiopathology and diagnosis of Cushing's disease.

Impact of the Canonical Wnt Pathway Activation on the Pathogenesis and Prognosis of Adamantinomatous Craniopharyngiomas.

CTNNB1 mutations and abnormal ß-catenin distribution are associated with the pathogenesis of adamantinomatous craniopharyngioma (aCP). We evaluated the expression of the canonical Wnt pathway components in aCPs and its association with CTNNB1 mutations and tumor progression. Tumor samples from 14 aCP patients and normal anterior pituitary samples from eight individuals without pituitary disease were studied. Gene expression of Wnt pathway activator (WNT4), inhibitors (SFRP1, DKK3, AXIN1, and APC), transcriptional activator (TCF7), target genes (MYC, WISP2, and, CDH1), and Wnt modulator (TP53) was evaluated by qPCR. ß-Catenin, MYC, and WISP2 expression was determined by immunohistochemistry (IHC). The transcription levels of all genes studied, except APC, were higher in aCPs as compared to controls and TCF7 mRNA levels correlated with CTNNB1 mutation. CDH1 mRNA was overexpressed in tumor samples of patients with disease progression in comparison to those with stable disease. ß-Catenin was positive and aberrantly distributed in 11 out of 14 tumor samples. Stronger ß-catenin immunostaining associated positively with tumor progression. MYC positive staining was found in 10 out of 14 cases, whereas all aCPs were negative for WISP2. Wnt pathway genes were overexpressed in aCPs harboring CTNNB1 mutations and in patients with progressive disease. Recurrence was associated with stronger staining for ß-catenin. These data suggest that Wnt pathway activation contributes to the pathogenesis and prognosis of aCPs.

Postnatal Ontogeny of the Circadian Expression of the Adrenal Clock Genes and Corticosterone Rhythm in Male Rats.

The postnatal synchronization of the circadian variation of the adrenal clock genes in mammals remains unknown. We evaluated the postnatal ontogeny of daily variation of clock genes (Clock/Bmal1/Per1/Per2/Per3/Cry1/Cry2/Rorα/Rev-Erbα) and steroidogenesis-related genes (Star and Mc2r) in rat adrenals and its relationship with the emergence of plasma corticosterone rhythm using cosinor analysis. Plasma corticosterone circadian rhythm was detected from postnatal day (P)1, with morning acrophase, between zeitgeber time (ZT)0 and ZT2. From P14, there was a nocturnal acrophase of corticosterone at ZT20, which was associated with pups' eye opening. From P3 there was a circadian variation of the mRNA expression of Bmal1, Per2, Per3, and Cry1 genes with morning acrophase, whereas Rev-Erbα had nocturnal acrophase. From P14, Bmal1, Per2, Per3, and Cry1 acrophases advanced by approximately 10 hours, as compared with early neonatal days, becoming vespertine-nocturnal. In all postnatal ages, Per2 and Cry1 circadian profiles were synchronized in phase with the circadian rhythm of plasma corticosterone, whereas Bmal1 was in antiphase. An adult-like Star circadian rhythm profile was observed only from P21. In conclusion, our original data demonstrated a progressive postnatal maturation of the circadian variation of the adrenal clock genes in synchrony with the development of the corticosterone circadian rhythm in rats.

Postnatal growth and cardiometabolic profile in young adults born large for gestational age.

CONTEXT: The association between large for gestational age (LGA) phenotype, postnatal growth and cardiometabolic risk (CMR) in adult life remains unclear. The role of IGF1 genotype on LGA-related outcomes in adult life is unknown. AIM: To assess the postnatal growth, IGF-I levels, CMR and the influence of the 737.738 IGF1 in adults born LGA. SUBJECTS: Case-control study (n = 515) nested in a population-based prospective cohort (n = 2063); 117 LGA and 398 gender-matched controls appropriate for gestational age (AGA) subjects. METHODS: Anthropometry was evaluated at birth, at 9-10 and at 23-25 years old. At the age of 23-25 years, blood pressure (BP), glycaemia, insulinaemia, homeostasis model assessment - insulin resistance, lipids, fibrinogen, and plasma IGF-I and 737.738 IGF1 polymorphism were assessed. RESULTS: Large for gestational age subjects remained heavier and taller than AGA at 9-10 and 23-25 years (P < 0·05); at 23-25 years, LGA had greater waist circumference (WC; P < 0·05) and higher BP (P < 0·05) than controls. Body proportionality at birth did not predict metabolic outcome. LGA subjects presenting catch-down of weight in childhood had lower body mass index (BMI; P = 0·001), lower WC (P < 0·05) and lower BP (P < 0·05) at 23-25 years. 737.738 IGF-I genotype differed between groups (P < 0·001). Homozygosis for polymorphic alleles was associated with increased odds of LGA (OR: 3·2; 95% CI: 1·5-6·9), higher IGF-I (56·9 ± 16·4 vs 37·7 ± 16·0 nm; P < 0·01) and lower BP (114/68 vs 121/73 mmHg; P < 0·05). CONCLUSIONS: Young adults born LGA presented higher BMI, WC and BP and appear to be at higher CMR risk than AGA subjects. The 737.738 IGF1 polymorphism appears to play a role on birth size and LGA-related metabolic outcomes.