Vaccination and diabetes mellitus type 1 in children

Influence of vaccination on the risk of developing diabetes mellitus type 1 (DM1) has been studied by different researchers for several decades. In rodents, vaccination can prevent development of DM1. This review summarises existing literature and discusses the results of a 2016 meta-analysis, pertaining to vaccination and DM1. No vaccines appear to increase the risk of DM1. Additional investigations are needed to determine if vaccines can be considered protective against DM1. Patients with DM1 are at increased risk of morbidities from controllable infections. Children with DM1 should receive regularly-scheduled vaccinations; choice of vaccines and inoculation with non-regular vaccines should be determined on an individual basis. We present basic principles surrounding vaccination in patients with DM1 and analyse the role of the paediatric endocrinologist in increasing vaccination uptake in children with DM1

Characteristics of insulin therapy of diabetes mellitus type 1 in children and adolescents receiving glucocorticoids

BACKGROUND: In coexistence of diabetes mellitus type 1 (DM1) with severe autoimmune and inflammatory diseases some patients need simultaneous administration of insulin and glucocorticoids (GC). GC therapy in patients with DM1 can worsen glycemic control. AIM: To determine characteristics of insulin therapy of DM1 in children and adolescents receiving GC. DESCRIPTION OF CLINICAL CASES: We observed 5 patients with DM1 receiving GC for juvenile idiopathic arthritis (JIA), juvenile systemic sclerosis (JSS), juvenile dermatomyositis (JDM), ulcerative colitis (UC), and reactive arthritis (RA). Intra-articular administration of GC did not significantly influence glycemic control. In case of GC pulse therapy hyperglycemia and increased insulin requirements were recognized in 3–6 hours after GC receipt, persisted from few hours up to 3 days after each administration. While therapy with oral GC in high doses the worst glycemic control was registered in daylight hours. To overcome insulin resistance change of time of injection and 10%-increase of long-acting insulin analogue, additional injections of ultrashort-acting insulin analogues, temporal prescription of short-acting human insulin were used. While GC therapy insulin daily dose was individual and could reach 2.0 U/kg. After transition to maintaining doses of GC or discontinuation of GC therapy patients returned to standard or relatively low insulin requirements. Levels of glycosylated hemoglobin differed significantly among patients at different stages of treatment, were maximal while long-term therapy with high doses of oral GC, but mostly depended on patient’s compliance. CONCLUSION: Bettering of glycemic control while receiving GC can be reached by timely dose correction of insulin therapy, selection of individual schemes, taking into account time of receipt and pharmacokinetic characteristics of GC. Adherence of the patient and his family to treatment of DM1 plays an important role in glycemic control

Resolution on the results of the first working meeting of the scientific advisory board «Actual problems of glycemic variability as a new criterion of glycemic control and safety of diabetes therapy»

The Scientific Advisory Board, chaired by Professor G. R. Galstyan (cochair - A.V. Zilov), met in Moscow on 19 June 2018 to discuss the possibilities of improving the results of diabetes mellitus (DM) treatment by considering glycaemic variability (GV) as an additional criterion for effective glycaemic control (especially in patients receiving insulin therapy) and as one of the goals of treatment in patients with unstable glycaemia. The purpose of the working meeting was to develop a strategy for the introduction of GV as a predictor and as an additional criterion for assessing the effectiveness and safety of hypoglycaemic therapy to improve the pharmacotherapy of diabetes and reduce cardiovascular and total mortality. The aims of the working meeting were to conduct a comprehensive data analysis of the relationship between GV and hypoglycaemia; to gather and analyse published data and the experience of decrease in GV and improved outcomes of diabetes against the background of different types of insulin therapy; to compare existing methods of glycaemia monitoring and GV assessment and examine their validity and availability in real practice in the context of limited budget and to analyse the informativeness and clinical and prognostic significance of various parameters of GV assessment and to determine their reasonable ‘minimum’ for a comprehensive assessment of GV as a criterion for evaluating the effectiveness of DM treatment and the predictors of negative diabetes outcomes. The following reports were presented during the discussion: ‘Glycemic variability: clinical and prognostic value. Types of glycemic variability’ (Candidate of Medical Sciences, assistant Professor Zilov A.V.); ‘Methods of assessment of variability of glycemia in clinical trials and routine practice’ (PhD, Professor Markova T. N.); ‘Current international and national recommendations on glycemic monitoring’ (PhD, Professor Galstyan G. R.) and ‘Peculiarities of glycemic variability and its evaluation among children and adolescents’ (Candidate of Medical Sciences Vitebskaya A.V.)

Dermatological Complications of Insulin Therapy in Children with Type 1 Diabetes: Cross-Sectional Study

Background. Dermatological complications of insulin therapy in children with type 1 diabetes (T1D) cause low patient retention to treatment, reduce insulin therapy (with injection pens and pumps) efficiency, limit the use of modern high-tech methods of glycemia monitoring. Objective. Our aim was to study the structure and risk factors of dermatological complications of insulin therapy in children with T1D. Methods. Children aged from 1 to 17 with T1D and their parents were interviewed using the questionnaire containing 28 questions about skin changes associated with insulin therapy or glycemia monitoring in the past and about injection techniques. Skin (local allergic and/or inflammation reactions) and subcutaneous fat (hypotrophy and hypertrophy) changes at injection, infusion set, catheter and sensor sites were estimated via patient examination. The structure of dermatological complications of insulin therapy and their correlation with injection technique, infusion pump sets installation and glycemia monitoring were analyzed. Results. The study has included 50 patients with median age of 12 years (10; 14), T1D duration of 4 years (3; 7). 32 patients have performed insulin injections via injection pens, others have used insulin pump therapy. Continuous glycemia monitoring via sensor-augmented pump was performed in 5 patients, flash glycemia monitoring — in 17 patients. Allergic reactions (urticarial-type) to insulin were reported in 4 (8%) cases. Signs of allergic contact dermatitis at the catheter/sensor site were revealed in 5/18 (28%) patients on insulin pump therapy (no rotation of infusion systems installation sites) and 10/22 (45%) patients on glycemia monitoring (3 with continuous glycemia monitoring, 7 with flash glycemia monitoring). Lipoatrophy was revealed in 1 patient (on insulin pump therapy), lipohypertrophy was revealed in 22 patients: 20/32 (63%) were using injection pens and 2/18 (11%) — insulin pump therapy. Lipohypertrophy was revealed more often on self-administration via injection pens (in all cases patients did not change the insulin injection site, the needle was replaced less than 1 time per day). Conclusion. Risk of dermatological complications in children with T1D is higher when the injection technique or infusion set installation is inappropriate

Lifestyle in children and adolescents with obesity: results of the survey of patients and their parents

Introduction. Growth of obesity prevalence in children and adolescents is a serious problem of modern medicine. To learn characteristics of patient’s behaviour, their dietary preference, feeding time and physical loads one can use specialized questionnaires.Aim. Evaluation of lifestyle, physical activity, dietary regimen and consumption of some meals according to results of questioning childrenand adolescents with obesity and their parents.Materials and methods. Hundreds of children and adolescents with obesity 10–17 years and their parents answered the questionnaire onage of obesity onset, its causes, physical activity and nutrition.Results and conclusion. Obesity develops more often at the age of 7–10 years. The most commonly insufficient physical activity and heredity. Specific characteristics of sedentary lifestyle and impared dietary regimen were identified. Comparison of patients’ and parents’ answers allowed to demonsrate the differense in attitude to the problem of obesity and to diminish the influence of not transparant answers on the results of investigation

The Genetic Basis of the First Patient with Wiedemann–Rautenstrauch Syndrome in the Russian Federation

Bi-allelic pathogenic variations within POLR3A have been associated with a spectrum of hereditary disorders. Among these, a less frequently observed condition is Wiedemann–Rautenstrauch syndrome (WRS), also known as neonatal progeroid syndrome. This syndrome typically manifests neonatally and is characterized by growth retardation, evident generalized lipodystrophy with distinctively localized fat accumulations, sparse scalp hair, and atypical facial features. Our objective was to elucidate the underlying molecular mechanisms of Wiedemann–Rautenstrauch syndrome (WRS). In this study, we present a clinical case of a 7-year-old female patient diagnosed with WRS. Utilizing whole-exome sequencing (WES), we identified a novel missense variant c.3677T>C (p.Leu1226Pro) in the POLR3A gene (NM_007055.4) alongside two cis intronic variants c.1909+22G>A and c.3337-11T>C. Via the analysis of mRNA derived from fibroblasts, we reconfirmed the splicing-affecting nature of the c.3337-11T>C variant. Furthermore, our investigation led to the reclassification of the c.3677T>C (p.Leu1226Pro) variant as a likely pathogenic variant. Therefore, this is the first case demonstrating the molecular genetics of a patient with Wiedemann–Rautenstrauch syndrome from the Russian Federation. A limited number of clinical cases have been documented until this moment; therefore, broadening the linkage between phenotype and molecular changes in the POLR3A gene will significantly contribute to the comprehensive understanding of the molecular basis of POLR3A-related disorders

Current Approaches in Management of Patients with Hypophosphatasia

he authors present the latest data on the hypophosphatasia (HPP) management in children. Hypophosphatasia is a rare genetic disease caused by deficiency of tissue-specific alkaline phosphatase due to mutation in the ALPL gene. The article covers all the features of epidemiology, etiology and pathogenesis, detailed stages of differential diagnostics. Treatment guidelines for pediatric patients are provided, they are based on the principles of evidence-based medicine. Special attention was given to the only effective method of hypophosphatasia management —enzyme replacement therapy (ERT). This material is the clinical guideline draft for the management of patients with hypophosphatasia prepared by the Union of Pediatricians of Russia and the Association of Medical Geneticists

Clinical and Genetic Characteristics of Pediatric Patients with Hypophosphatasia in the Russian Population

(1) Hypophosphatasia (HPP) is a rare inherited disease caused by mutations (pathogenic variants) in the ALPL gene which encodes tissue-nonspecific alkaline phosphatase (TNSALP). HPP is characterized by impaired bone mineral metabolism due to the low enzymatic activity of TNSALP. Knowledge about the structure of the gene and the features and functions of various ALPL gene variants, taking into account population specificity, gives an understanding of the hereditary nature of the disease, and contributes to the diagnosis, prevention, and treatment of the disease. The purpose of the study was to describe the spectrum and analyze the functional features of the ALPL gene variants, considering various HPP subtypes and clinical symptoms in Russian children. (2) From 2014–2021, the study included the blood samples obtained from 1612 patients with reduced alkaline phosphatase activity. The patients underwent an examination with an assessment of their clinical symptoms and biochemical levels of TNSALP. DNA was isolated from dried blood spots (DBSs) or blood from the patients to search for mutations in the exons of the ALPL gene using Sanger sequencing. The PCR products were sequenced using a reagent BigDye Terminator 3.1 kit (Applied Biosystems). Statistical analysis was performed using the GraphPad Prism 8.01 software. (3) The most common clinical symptoms in Russian patients with HPP and two of its variants (n = 22) were bone disorders (75%), hypomyotonia (50%), and respiratory failure (50%). The heterozygous carriage of the causal variants of the ALPL gene was detected in 225 patients. A total of 2 variants were found in 27 patients. In this group (n = 27), we identified 28 unique variants of the ALPL gene, of which 75.0% were missense, 17.9% were frameshift, 3.6% were splicing variants, and 3.6% were duplications. A total of 39.3% (11/28) of the variants were pathogenic, with two variants being probably pathogenic, and 15 variants had unknown clinical significance (VUS). Among the VUS group, 28.6% of the variants (7/28) were discovered by us for the first time. The most common variants were c.571G > A (p.Glu191Lys) and c.1171del (Arg391Valfs*12), with frequencies of 48.2% (13/28) and 11% (3/28), respectively. It was found that the frequency of nonsense variants of the ALPL gene was higher (p < 0.0001) in patients with the perinatal form compared to the infantile and childhood forms of HPP. Additionally, the number of homozygotes in patients with the perinatal form exceeded (p < 0.01) the frequencies of these genotypes in children with infantile and childhood forms of HPP. On the contrary, the frequencies of the compound-heterozygous and heterozygous genotypes were higher (p < 0.01) in patients with infantile childhood HPP than in perinatal HPP. In the perinatal form, residual TNSALP activity was lower (p < 0.0005) in comparison to the infantile and childhood (p < 0.05) forms of HPP. At the same time, patients with the heterozygous and compound-heterozygous genotypes (mainly missense variants) of the ALPL gene had greater residual activity (of the TNSALP protein) regarding those homozygous patients who were carriers of the nonsense variants (deletions and duplications) of the ALPL gene. Residual TNSALP activity was lower (p < 0.0001) in patients with pathogenic variants encoding the amino acids from the active site and the calcium and crown domains in comparison with the nonspecific region of the protein

Diagnostic value of islet autoantibody assays practised in Russia. 1. Classic immunofluorescence islet cell antibody assay, immunoradiometric glutamic acid decarboxylase antibody assay, and ELISA tyrosine phosphatase antibody and insulin antibody assays

Objective. To estimate performance characteristics and diagnostic value of immunofluorescent islet cell antibody (ICA) assay, immunoradiometric glutamic acid decarboxylase antibody (GADA) assay, and ELISA tyrosine phosphatase IA-2 antibody (IA-2A) and insulin antibody (IA) assays. Research Design and Methods. Antibodies were tested in 438 children and adolescents with newly diagnosed diabetes mellitus (DM) type 1, and in 891 subjects without DM type 1. ICA were determined by the classic indirect immunofluorescent method recommended by the Juvenile Diabetes Foundation International, GADA were determined with the Immunotech IRMA Anti-GAD kit, and IA-2A and IA were determined with Medizym Anti-IA2 and Orgentec Anti-Insulin ELISA kits, respectively. Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of the tests were estimated with contingency tables. Diagnostic accuracy was estimated from areas under receiver operating curves (AUC). Results. ICA test was of the greatest diagnostic value (Se=88%, Sp=96%, PPV=96%, NPV=94%, AUC=0,94), followed by IA-2A (Se=66%, Sp=98%, PPV=98%, NPV=59%, AUC=0,82) and GADA (Se=73%, Sp=84%, PPV=75%, NPV=83%, AUC=0,79). IA test exhibited a very low Se (4,3%) and lacked diagnostic accuracy (AUC=0,5). Conclusions. We recommend to use ICA, IA-2A and GADA tests surveyed in our study for diagnosis of DM type 1 and differential diagnosis of DM. We don’t recommend IA testing with an Orgentec Anti-Insulin ELISA kit for usage in clinical practice

Современные подходы к ведению детей с гипофосфатазией

Hypophosphatasia is rare genetic disease caused by tissue-nonspecific alkaline phosphatase deficiency due to the mutation in the ALPL gene. Disease can manifest in utero, in childhood or in adults depending on its form and severity. This article presents modern data on the epidemiology, etiology, and clinical signs of hypophosphatasia in children, covers in details differential diagnostic search, and gives guidelines for its evidence-based treatment. Without timely treatment the prognosis of the disease is unfavorable in most cases. Such patients require follow-up by multidisciplinary team of physicians. The only effective method of treatment is enzyme replacement therapy with asfotase alfa. Symptomatic therapy is also crucial as well as physiotherapeutic procedures and therapeutic exercise programs (at rehabilitation stage).Гипофосфатазия — редкое генетическое заболевание, обусловленное дефицитом тканенеспецифической щелочной фосфатазы в результате мутации в гене ALPL. В зависимости от формы и тяжести болезнь может дебютировать внутриутробно, в детском возрасте или у взрослых. В статье представлены современные сведения об эпидемиологии, этиологии и клинических проявлениях гипофосфатазии у детей, подробно освещаются этапы дифференциально-диагностического поиска, приведены рекомендации по лечению, основанные на принципах доказательной медицины. При отсутствии своевременного лечения прогноз болезни в большинстве случаев неблагоприятный для жизни. Пациенты нуждаются в наблюдении мультидисциплинарной командой врачей. Единственным эффективным методом лечения является ферментозаместительная терапия асфотазой альфа; необходимо также проводить симптоматическую терапию, а при реабилитации пациентов использовать физиотерапевтические процедуры и лечебные физкультурные комплексы упражнений