The Coronavirus Disease 2019 Pandemic is Associated with a Substantial Rise in Frequency and Severity of Presentation of Youth-Onset Type 2 Diabetes.

OBJECTIVES: To evaluate the frequency and severity of new cases of youth-onset type 2 diabetes in the US during the first year of the pandemic compared with the mean of the previous 2 years. STUDY DESIGN: Multicenter (n = 24 centers), hospital-based, retrospective chart review. Youth aged ≤21 years with newly diagnosed type 2 diabetes between March 2018 and February 2021, body mass index ≥85th percentile, and negative pancreatic autoantibodies were included. Demographic and clinical data, including case numbers and frequency of metabolic decompensation, were compared between groups. RESULTS: A total of 3113 youth (mean [SD] 14.4 [2.4] years, 50.5% female, 40.4% Hispanic, 32.7% Black, 14.5% non-Hispanic White) were assessed. New cases of type 2 diabetes increased by 77.2% in the year during the pandemic (n = 1463) compared with the mean of the previous 2 years, 2019 (n = 886) and 2018 (n = 765). The likelihood of presenting with metabolic decompensation and severe diabetic ketoacidosis also increased significantly during the pandemic. CONCLUSIONS: The burden of newly diagnosed youth-onset type 2 diabetes increased significantly during the coronavirus disease 2019 pandemic, resulting in enormous strain on pediatric diabetes health care providers, patients, and families. Whether the increase was caused by coronavirus disease 2019 infection, or just associated with environmental changes and stressors during the pandemic is unclear. Further studies are needed to determine whether this rise is limited to the US and whether it will persist over time.

A centennial review of discoveries and advances in diabetes: Children and youth.

Diabetes is an increasingly common chronic metabolic disorder in children worldwide. The discovery of insulin in 1921 resulted in unprecedented advancements that improved the lives of children and youth with diabetes. The purpose of this article is to review the history of diabetes in children and youth over the last century and its implications for future developments in the field. We identified 68 relevant events between 1921 and 2021 through literature review and survey of pediatric endocrinologists. Basic research milestones led to the discovery of insulin and other regulatory hormones, established the normal physiology of carbohydrate metabolism and pathophysiology of diabetes, and provided insight into strategies for diabetes prevention. While landmark clinical studies were initially focused on adult diabetes populations, later studies assessed etiologic factors in birth cohort studies, evaluated technology use among children with diabetes, and investigated pharmacologic management of youth type 2 diabetes. Technological innovations culminated in the introduction of continuous glucose monitoring that enabled semi-automated insulin delivery systems. Finally, professional organizations collaborated with patient groups to advocate for the needs of children with diabetes and their families. Together, these advances transformed type 1 diabetes from a terminal illness to a manageable disease with near-normal life expectancy and increased our knowledge of type 2 diabetes and other forms of diabetes in the pediatric population. However, disparities in access to insulin, diabetes technology, education, and care support remain and disproportionately impact minority youth and communities with less resources. The overarching goal of diabetes management remains promoting a high quality of life and improving glycemic management without undermining the psychological health of children and youth living with diabetes.

Uncertain, Not Unimportant: Callosal Dysgenesis and Variants of Uncertain Significance in ROBO1.

Congenital anomalies affect 3% to 5% of births and remain the leading cause of infant death in the United States. As whole exome and genome sequencing are increasingly used to diagnose underlying genetic disease, the patient's clinical presentation remains the most important context for interpreting sequencing results, including frequently reported variants of uncertain significance (VUS). Classification of a variant as VUS acknowledges limits on evidence to establish whether a variant can be classified as pathogenic or benign according to the American College of Medical Genetics guidelines. Importantly, the VUS designation reflects limits on the breadth of evidence linking the genetic variant to a disease. However, available evidence, although limited, may be surprisingly relevant in an individual patient's case. Accordingly, a VUS result should be approached neither as nondiagnostic genetic result nor as automatically "uncertain" in its potential to guide clinical decision-making. In this article, we discuss a case of an infant born at 29 weeks 4 days without a corpus callosum, whose whole genome sequencing yielded compound heterozygous variants both classified as VUS in ROBO1, a gene encoding for a receptor involved in a canonical signaling mechanism that guides axons across midline. Approaching the VUS result as potentially pathogenic, we found the infant ultimately had pituitary dysfunction and renal anomalies consistent with other reported ROBO1 variants and basic science literature. Accordingly, we highlight resources for variant interpretation available to clinicians to evaluate VUS results, particularly as they inform the diagnosis of individually rare but collectively common rare diseases.

Congenital hyperinsulinism as the presenting feature of Kabuki syndrome: clinical and molecular characterization of 9 affected individuals.

PURPOSE: Describe the clinical and molecular findings of patients with Kabuki syndrome (KS) who present with hypoglycemia due to congenital hyperinsulinism (HI), and assess the incidence of KS in patients with HI. METHODS: We documented the clinical features and molecular diagnoses of 9 infants with persistent HI and KS via a combination of sequencing and copy-number profiling methodologies. Subsequently, we retrospectively evaluated 100 infants with HI lacking a genetic diagnosis, for causative variants in KS genes. RESULTS: Molecular diagnoses of KS were established by identification of pathogenic variants in KMT2D (n = 5) and KDM6A (n = 4). Among the 100 infants with HI of unknown genetic etiology, a KS diagnosis was uncovered in one patient. CONCLUSIONS: The incidence of HI among patients with KS may be higher than previously reported, and KS may account for as much as 1% of patients diagnosed with HI. As the recognition of dysmorphic features associated with KS is challenging in the neonatal period, we propose KS should be considered in the differential diagnosis of HI. Since HI in patients with KS is well managed medically, a timely recognition of hyperinsulinemic episodes will improve outcomes, and prevent aggravation of the preexisting mild to moderate intellectual disability in KS.

Correction: "Congenital hyperinsulinism as the presenting feature of Kabuki syndrome: clinical and molecular characterization of 10 affected individuals".

The author Diva D. De Leon was incorrectly listed as instead of Diva D. De Leó-Critchlow in the original version of this paper.

Effectiveness of a spanish language clinic for Hispanic youth with type 1 diabetes.

OBJECTIVE: A pilot study was undertaken to determine whether establishment of a Spanish Language Diabetes Clinic (SLDC) for Spanish-speaking families conducted by a team of Spanish-speaking, Hispanic and nonHispanic clinicians provides a means to improve control of type 1 diabetes (T1D). METHODS: The first 21 Hispanic pediatric patients with T1D who enrolled in the SLDC were matched to 21 Hispanic patients treated in the English Language Diabetes Clinic (ELDC) based on age and duration of diabetes. The two groups did not differ significantly with respect to gender, body mass index (BMI), or glycated hemoglobin (HbA1c). Patients in both groups were followed for 12 months. RESULTS: The mean (± standard deviation) baseline glycated hemoglobin (HbA1c) level in the SLDC group (8.4 ± 1.0%) was similar to that in the ELDC group (8.6 ± 1.4%, P = .83). HbA1c levels fell by 0.5 ± 1.0% (P = .01) during the year following enrollment in the SLDC but did not change significantly from baseline during the year of follow-up in the ELDC group (decrease of 0.2 ± 0.9%, P = .1). At the start of the study, only 5 patients (23%) in the SLDC group and 7 patients (33%) in the ELDC group met the ≤7.5% target HbA1c level. After 1 year, 10 of the SLDC patients (48%) and 4 of ELDC patients (19%) had HbA1c levels ≤7.5% (P = .01). CONCLUSIONS: Our preliminary findings support the hypothesis that overcoming language barriers by the establishment of a SLDC can be an effective means of improving metabolic control in youth with T1D in Hispanic families with limited English language skills.

Propylthiouracil is teratogenic in murine embryos.

BACKGROUND: Hyperthyroidism during pregnancy is treated with the antithyroid drugs (ATD) propylthiouracil (PTU) and methimazole (MMI). PTU currently is recommended as the drug of choice during early pregnancy. Yet, despite widespread ATD use in pregnancy, formal studies of ATD teratogenic effects have not been performed. METHODS: We examined the teratogenic effects of PTU and MMI during embryogenesis in mice. To span different periods of embryogenesis, dams were treated with compounds or vehicle daily from embryonic day (E) 7.5 to 9.5 or from E3.5 to E7.5. Embryos were examined for gross malformations at E10.5 or E18.5 followed by histological and micro-CT analysis. Influences of PTU on gene expression levels were examined by RNA microarray analysis. RESULTS: When dams were treated from E7.5 to E9.5 with PTU, neural tube and cardiac abnormalities were observed at E10.5. Cranial neural tube defects were significantly more common among the PTU-exposed embryos than those exposed to MMI or vehicle. Blood in the pericardial sac, which is a feature indicative of abnormal cardiac function and/or abnormal vasculature, was observed more frequently in PTU-treated than MMI-treated or vehicle-treated embryos. Following PTU treatment, a total of 134 differentially expressed genes were identified. Disrupted genetic pathways were those associated with cytoskeleton remodeling and keratin filaments. At E 18.5, no gross malformations were evident in either ATD group, but the number of viable PTU embryos per dam at E18.5 was significantly lower from those at E10.5, indicating loss of malformed embryos. These data show that PTU exposure during embryogenesis is associated with delayed neural tube closure and cardiac abnormalities. In contrast, we did not observe structural or cardiac defects associated with MMI exposure except at the higher dose. We find that PTU exposure during embryogenesis is associated with fetal loss. These observations suggest that PTU has teratogenic potential.

Myopathy Associated with Acute Hypothyroidism following Radioiodine Therapy for Graves Disease in an Adolescent.

We describe acute myopathy following I-131 treatment for hyperthyroidism due to Graves Disease (GD) in an adolescent. A 15 year-old diagnosed with GD required treatment with radioactive iodine (I-131) therapy. Six weeks post I-131, he developed generalized muscle cramps. The CK was 19.800 U/L, the total thyroxine was 2.3 mcg/dL (29.6 nmol/L SI) and the estimated free thyroxine (EFT) was 0.5 ng/dL (6.4 pmol/L SI). The ALT was 112 U/L and AST was 364 U/L (normal <35 U/L). The muscle cramps and CK elevation normalized five months after initiation of thyroid replacement therapy. This observation shows that acute myopathy can rarely occur in pediatric patients with GD following treatment with I-131.

Travel health care for immigrant children visiting friends and relatives abroad: retrospective analysis of a hospital-based travel health service in a US urban underserved area.

BACKGROUND: There is a lack of studies evaluating pre-travel health care for children who travel to visit friends and relatives (VFR). We evaluated travel health services provided to children VFR travelers (CVFRs) as compared with adult VFR travelers (AVFRs). CVFRs and AVFRs were also compared with children and with adults traveling as tourists (CTs and ATs, respectively), to explore relevant differences within each age group between VFRs and tourist travelers. METHODS: Retrospective chart review of all pre-travel consultations from March 2005 to July 2006 at the Bronx-Lebanon Hospital Center travel health clinic, Bronx, New York. RESULTS: Of 204 pre-travel consultations, 51% comprised CVFRs, 20% AVFRs, 7% CTs, and 23% ATs. About 54, 44, 57, and 30% of CVFRs, AVFRs, CTs, and ATs, respectively, presented within 14 days of departure. CVFRs were more likely than AVFRs and CTs to plan long-term travel (> 6 months). CVFRs and AVFRs traveled mostly to West Africa (75 and 73%) in contrast to CTs and ATs (7 and 35%). Mefloquine was the most frequently prescribed antimalarial medication overall (70%) and among CVFRs (94%). Yellow fever vaccine was most frequently administered overall and to CVFRs and AVFRs followed by hepatitis A, typhoid fever, and meningococcal vaccine. CTs were more likely than CVFRs to receive rabies vaccine. Delayed yellow fever administration (< 10 d before departure) was noted for 48% of CVFRs and 33% of AVFRs. CONCLUSIONS: CVFRs frequently plan to travel for long-term trips to West Africa and present late for pre-travel care. Routine screen for high-risk travel activities and coordination of pre-travel care within the routine preventive health care may improve the effectiveness of the travel health services.