Yael Levy-Shraga

Eating Disorders in Adolescents with Type 2 and Type 1 Diabetes

Diabetes is associated with increased risk for eating disorders; with different types of eating disorders associating with different types of diabetes. Binge eating disorders show increased prevalence among individuals with type 2 diabetes (T2DM). Intentional omission of insulin for the purpose of inducing weight loss presents among individuals with type 1 (T1DM). Similarly, some individuals with T2DM intentionally omit oral hypoglycemic drugs, resulting in poor glycemic control, and weight loss. Common dominators for the development of eating disorders in T1DM and T2DM are female gender, increased body weight, body dissatisfaction, a history of dieting, and a history of depression. Patients tend to deny the existence of the problem. Clinical signs that should raise suspicion are: poor glycemic control, missed clinical appointments, recurrent episodes of diabetes ketoacidosis, recurrent hypoglycemia secondary to intentional overdose, poor self-esteem, and dietary manipulation. Eating disorders are associated with poorer glycemic control, and therefore increased risk of diabetes associated comorbidities.

High prevalence of vitamin D deficiency and insufficiency in adolescent inpatients diagnosed with eating disorders

OBJECTIVEnPrevious studies assessing vitamin D status in adolescents with eating disorders showed inconsistent results. The aim of the current study was to assess vitamin D status in a large cohort of adolescent inpatients with eating disorders and its relation to bone mineral density (BMD) and depression.nnnMETHODn25-Hydroxyvitamin D (25OHD), calcium, phosphorus, and alkaline phosphatase levels as well as BMD and depression were assessed on admission in 87 inpatients (aged 16 ± 2 years, females = 81) with eating disorders [anorexia nervosa (AN)u2009= 64; bulimia nervosa (BN)u2009= 5; eating disorders not otherwise specified-binge/purge type (EDNOS-B/P)u2009= 18].nnnRESULTSnMean 25OHD levels were 24.1 ± 7.5 ng/ml (25.0 ± 7.6, 25.4 ± 9.9, and 22.0 ± 9.9 ng/ml in patients with AB, BN, and EDNOS-B/P, respectively). Vitamin D deficiency (<15 ng/ml) was found in 7.8% of the patients, and insufficiency (15-20 ng/ml) in 22.2%. Only 16.7% had levels >32 ng/ml, considered optimal by some experts. No associations were found between 25OHD levels and BMD or comorbid depression. 25OHD levels during winter were significantly lower than summer levels (p < .001). Mean lumbar spine BMD z-score in patients with AN and EDNOS-B/P type was low (-1.5 ± 1.1) and correlated with body mass index standard deviation score (p = .03).nnnDISCUSSIONnAdolescents with eating disorders show a high prevalence of vitamin D deficiency and insufficiency. Given the risk of osteoporosis in this population, 25OHD levels found in this group may not offer optimal bone protection. Vitamin D levels should be routinely checked and supplementation should be administered as required.

Glycemic control and clinic attendance of emerging adults with type 1 diabetes at a transition care clinic

BackgroundEmerging adulthood is a challenging period for diabetes management. Our aim was to determine whether a dedicated transition clinic for emerging adults with type 1 diabetes can improve glycemic control and visit attendance.MethodsAn observational study of 53 emerging adults (30 males) treated during 2010–2014 in a newly established transition clinic. The clinic was operated jointly by pediatric and adult endocrinologists and included a transition coordinator. Data collected included the source of referral, HbA1c levels, frequency of visit attendance, and acute complications. For 27 patients who had attended the pediatric clinic at the same medical center, data from up to 2xa0years preceding the transition were also collected. Patients filled the Diabetes Quality of Life–Youth questionnaire at the transition and 1xa0year later.ResultsMeanxa0±xa0SD age at the transfer to the transition clinic was 22.1xa0±xa02.7xa0years; mean disease duration was 8.4xa0±xa05.0xa0years. Follow-up duration at the transition clinic was 1.2xa0±xa01.1xa0years. Mean HbA1c levels decreased from 67xa0mmol/mol (95xa0% CI 63–72) [8.3xa0% (95xa0% CI 7.9–8.7)] at transfer to 57xa0mmol/mol (95xa0% CI 52–63) [7.4xa0% (95xa0% CI 6.9–7.9)] after 1xa0year (pxa0<xa00.001). Thirty-six patients (68xa0%) attended three or more visits during their first year in the transition clinic. The impact of diabetes on quality of life, disease-related worries, and life satisfaction did not change significantly during 1-year attendance in the transition clinic.ConclusionsA dedicated transition clinic for emerging adults, with tailored support according to the developmental needs of emerging adulthood, showed improved glycemic control and visit attendance.

The use of continuous glucose monitoring systems in a pediatric population with type 1 diabetes mellitus in real-life settings: the AWeSoMe Study Group experience

AimsThe aim of the study was (a) to compare annual glycemic control in pediatric patients with type 1 diabetes mellitus (T1DM) who used a healthcare-funded continuous glucose monitoring system (RT-CGMS) to that of those who performed self-monitoring blood glucose (SMBG) only, in a real-life setting, and (b) to define parameters associated with compliance and glycemic control.Methods A total of 149 youth with T1DM (52.3xa0% females), mean age 11.8xa0±xa03.6xa0years, and 83 in the CGMS group were followed prospectively for 12xa0months. Glycemic control parameters and compliance to RT-CGMS were assessed periodically.ResultsGlycemic parameters did not differ significantly between the groups during follow-up periods. The time spent with RT-CGMS decreased and only 38xa0% used it for more than 75xa0% of the time during the 12xa0months (consistent users). Mean HbA1c decreased by 0.27xa0% in consistent users and increased by 0.21xa0% among intermittent users (used RT-CGMS less than 75xa0% of time), pxa0=xa00.013. Consistent users were younger 10. 6xa0±xa04.2 vs. 12.5xa0±xa03.6, pxa0=xa00.07, and had higher frequency of SMBG at baseline, 10.6xa0±xa04.9 vs. 6.3xa0±xa02.8, pxa0=xa00.011.ConclusionsThe adoption of RT-CGMS was low, even in a healthcare system that funds its use. Caregivers should consider patient characteristics when recommending RT-CGMS use.

Sun Exposure and Protection Habits in Pediatric Patients with a History of Malignancy

Background Survivors of childhood cancer are at high risk for developing non-melanoma skin cancer and therefore are firmly advised to avoid or minimize sun exposure and adopt skin protection measures. We aimed to compare sun exposure and protection habits in a cohort of pediatric patients with a history of malignancy to those of healthy controls. Methods Case-control study of 143 pediatric patients with a history of malignancy (aged 11.2±4.6y, Male = 68, mean interval from diagnosis 4.4±3.8y) and 150 healthy controls (aged 10.4±4.8y, Male = 67). Sun exposure and protection habits were assessed using validated questionnaires. Results Patients and controls reported similar sun exposure time during weekdays (94±82minutes/day vs. 81±65minutes/day; p = 0.83), while during weekends patients spent significantly less time outside compared to controls (103±85minutes/day vs. 124±87minutes/day; p = 0.02). Time elapsed from diagnosis positively correlated with time spent outside both during weekdays (r = 0.194, p = 0.02) and weekends (r = 0.217, p = 0.01), and there was a step-up in sun exposure starting three years after diagnosis. There was no significant difference regarding composite sun protection score between patients and controls. Age was positively correlated with number of sunburns per year and sun exposure for the purpose of tanning, and was negatively correlated with the use of sun protection measures. Conclusions Although childhood cancer survivors are firmly instructed to adopt sun protection habits, the adherence to these instructions is incomplete, and more attention should be paid to improve these habits throughout their lives. Since sunlight avoidance may results in vitamin D deficiency, dietary supplementation will likely be needed.

Hyponatremia and decreased bone density in adolescent inpatients diagnosed with anorexia nervosa

OBJECTIVEnRecent studies demonstrated an association between low serum sodium levels and reduced bone density. Patients with anorexia nervosa (AN) are at greater risk for osteoporosis as well as for hyponatremia. The aim of the present study was to assess the association between hyponatremia and bone mineral density (BMD) in a large cohort of adolescent inpatients with AN.nnnMETHODSnA historic cohort study of 174 adolescent females (mean age 15.7xa0±xa01.8xa0y) hospitalized because of AN between 2003 and 2013. Demographic and clinical data, including age, psychiatric comorbidity, anthropometric measurements, laboratory tests, and BMD scores were obtained from the patients medical charts.nnnRESULTSnMean lumbar spine BMD z-score of the patients was lower than expected in the normal population (mean -1.5xa0±xa01.2) and positively correlated with body mass index standard deviation score (rxa0=xa00.42, Pxa0<xa00.0001). Sixty-four participants (36.8%) had at least one episode of hyponatremia during the year preceding the BMD measurement. These participants had a significantly lower lumbar spine BMD z-score (-1.8xa0±xa01.2 versus -1.3xa0±xa01.2, Pxa0=xa00.01) compared with participants with no hyponatremia. Lumbar spine BMD z-score was also positively correlated with the levels of free triiodothyronine (rxa0=xa00.16, Pxa0=xa00.038), 17 b-estradiol (rxa0=xa00.23, Pxa0=xa00.005), and luteinizing hormone (rxa0=xa00.25, Pxa0=xa00.001), and negatively correlated with cortisol levels (rxa0=xa00.33, Pxa0<xa00.0001). Having at least one episode of hyponatremia, BMI z-score and cortisol levels were identified as independent predictors of BMD z-score (Pxa0<xa00.001, Pxa0<xa00.001, and Pxa0=xa00.034, respectively).nnnCONCLUSIONSnHyponatremia may be associated with decreased bone density in adolescent females with AN. Additional studies are required to evaluate whether the correction of hyponatremia will improve BMD.

Pituitary function in children following infectious diseases of the central nervous system.

Recent studies in adults suggest that pituitary deficiencies develop in a considerable proportion of patients who recover from infectious meningitis. The aim of this study was to evaluate pituitary function of children with a history of meningitis. Seventy-nine children were admitted to the Safra Children’s Hospital due to meningitis between 2007 and 2010. Twenty-four families were lost for follow-up, 55 were interviewed by phone and 14 (9 males) participated in the study. Evaluation included medical history, physical examination, auxological measurements and basal levels of TSH, fT4, cortisol and IGF1. Children with abnormal results were followed for a year and dynamic testing was performed when indicated. Mean age at time of infectious meningitis was 3.8xa0±xa05.4xa0years (range 0.03–15.8), and at clinical evaluation 6.4xa0±xa06.4 (range 1.2–20). The interval between the acute event and evaluation was 2.7xa0±xa01.2xa0years. Thyroid function tests and basal cortisol levels were normal for all children. Three children had low IGF1 levels; however over a year of follow-up two of them had normal height and growth velocity, making growth hormone deficiency unlikely. One child had low height SDS, but exhibited a normal response to a growth hormone stimulation test. Pituitary dysfunction with overt clinical symptoms is not a frequent consequence of acute meningitis in children. Follow-up of growth and puberty of children post-meningitis by the primary care physician is probably sufficient. Invasive assessments should be reserved for selected cases where there is slow growth or other clinical suspicion of hypopituitarism.

Health Risks of Young Adult Travelers With Type 1 Diabetes

AIMnInternational travel has become popular among young adults. This study evaluated the rate and characteristics of travel-associated health risks among young adults with type 1 diabetes mellitus (T1DM) compared with healthy same-aged individuals.nnnMETHODSnA retrospective study was conducted of 47 young adults with T1DM and 48 without (controls). Structured questionnaires accessed information regarding 154 international trips during the preceding 5u2009years and lasted 7u2009days and longer.nnnRESULTSnMeanu2009±u2009SD ages of the diabetic and control groups were 26.6u2009±u20095.0 and 26.9u2009±u20092.6u2009years, respectively. Mean trip durations were 80.0 (range 7.0-390.0) and 87.6u2009days (range 7.0-395.0), respectively. The number of trips per person was 1.5u2009±u20090.6 and 1.7u2009±u20090.8, and the proportion of trips to developing countries 64 and 61%, respectively. There were no differences between the groups in rates of travel-related diseases that required medical consultation (11% vs 15% for all trips). No patient sought medical attention for acute problems related to diabetes management. Prior to 71% of their trips to developing countries, respondents with diabetes consulted their diabetes physician; prior to 26% of their trips they switched from an insulin pump to injections; during 41% of the trips they increased glucose monitoring; and for the period of 11% of the trips they defined their metabolic control as poor. Self-reported mean hemoglobin A1c (HbA1c) levels before and after trips were 7.65u2009±u20091.45 and 7.81u2009±u20091.23%, respectively (pu2009=u20090.42, paired t-test).nnnCONCLUSIONSnYoung adults with type 1 diabetes did not report more travel-related diseases than did healthy individuals. Most reported reasonable to good glycemic control during the trip without severe consequences.

Growth characteristics and endocrine abnormalities in 22q11.2 deletion syndrome

22q11.2 deletion syndrome (22q11.2DS) has a wide range of clinical features including endocrine abnormalities. We aimed to characterize growth patterns, hypoparathyroidism, and thyroid dysfunction of individuals with 22q11.2DS. Anthropometric and laboratory measurements were obtained from the charts of 48 individuals (males=28, 8.0±6.8 visits/participant) followed at a national 22q11.2DS clinic between 2009 and 2016. Age at diagnosis was 4.3±4.9 years and age at last evaluation 11.2±7.2 years. Median height‐SDS was negative at all ages. Height‐SDS at last visit was correlated to the midparental height‐SDS (r=0.52 P=0.002). Yet, participants did not reach their target height, with a difference of 1.06±1.07 SD (Pu2009<0.0001). Height‐SDS at last visit of participants with a heart defect was lower compared to participants with a normal heart (−1.5±1.4 vs. −0.6±0.8, P=0.036), with lower height‐SDS in the subgroup of participants with severe heart defects (−2.1±1.6, P=0.009). Mean IGF1‐SDS was low (−0.99±1.68) but was not correlated with height‐SDS. Thirteen patients (27%) had hypoparathyroidism: 10 presented during infancy and 3 during adolescence. Five patients (10.4%, female=4) had thyroid abnormalities. In conclusions, individuals with 22q11.2 DS have a distinct growth pattern consisting of growth restriction at all ages, resulting in final adult height in the low‐normal range. Hypoparathyroidism is common and may present during the neonatal period as well as later in life. Thyroid abnormalities may present during childhood, adolescence, or adulthood.

High 17-hydroxyprogesterone level in newborn screening test for congenital adrenal hyperplasia

We report a case of a female infant with an elevated 17-hydroxyprogesterone level detected in the newborn screening for 21-hydroxylase deficiency, the most common cause of congenital adrenal hyperplasia. The physical examination was unremarkable including no dysmorphism and no signs of virilisation. In the absence of clinical evidence of androgen excess, as would be expected in a female infant with 21-hydroxylase deficiency, further evaluation was performed and led to the diagnosis of the extremely rare disorder, 3β-hydroxysteroid dehydrogenase deficiency. This case highlights the differential diagnosis of elevated 17-hydroxyprogesterone levels in newborn screening and the importance of correct diagnosis for improving patient care.