The COVID-19 pandemic led to fundamental changes in daily routines of children. Our aim was to evaluate the incidence and characteristics of fractures among Israeli children during 2020 compared with ...2015–2019. Demographic, clinical data, and incidence rates of fractures in individuals aged < 18 years were derived from the electronic database of Meuhedet Health Services, which provides healthcare services to 1.2 million people in Israel. We further subdivided the year to five periods according to government regulations of lockdown and isolation at each period. Fracture sites were determined according to ICD9 definitions. During 2020, 10,701 fractures occurred compared with 12,574 ± 599 fractures per year during 2015–2019 (
p
-value < 0.001). Fracture rates were lower during all periods in 2020. The largest decline was observed during the first lockdown for both boys (56% decline, 95% confidence interval CI 52–60%) and girls (47% decline CI 41–53%). While the fracture rate declined for most age groups, the largest decline was recorded for the age group 11–14 years, with significant reduction rates of 66% (CI 59–71%) for boys and 65% (CI 54–73%) for girls. The most prominent declines were of fractures of the hand bones of both boys and girls (64% and 59%, respectively).
Conclusions:
Our data showed a significant decrease in fracture rate in 2020 compared to the previous 5 years, as well as differences between periods within that year.
What is New:
•The COVID-19 pandemic led to fundamental change in daily routines of children with significant decrease in school attendance and sport activities.
•Consequent to these public health measures, the incidence rate of pediatric fractures decreased significantly.
What is New:
•This study demonstrates declines in fracture rates during lockdown periods, with only partial reversing of the trends between the lockdown periods.
•The most pronounced decline was observed during the first lockdown period.
•The decline was most prominent in children aged 11-14 years; there was no significant change in fracture incidence of children aged <3 years.
To analyse the risk of fractures among children with attention-deficit/hyperactivity disorder (ADHD) compared with matched children without ADHD; and to evaluate the impact of pharmacological ...treatment. This registry-based cohort study included 31,330 children diagnosed with ADHD and a comparison group of 62,660 children matched by age, sex, population sector and socioeconomic status. Demographic and clinical information was extracted from the electronic database of Meuhedet, a health maintenance organization. Fracture events between 2–18 years of age were identified by coded diagnoses. The overall fracture incidence rate was 334 per 10,000 patient-years (PY) in the ADHD group and 284 per 10,000 PY in the comparison group (p < 0.001). Among boys, the fracture incidence rates were 388 per 10,000 PY and 327 per 10,000 PY (p < 0.001), for the respective groups. Among girls, the rates were lower in both groups compared to boys, but higher in the ADHD compared to the matched group (246 vs 203 per 10,000 PY, p < 0.001). Among the children with ADHD, the hazard ratios (HR) to have a fracture were similar in boys (1.18, 95%CI 1.15–1.22, p < 0.001) and girls (1.22, 95%CI 1.16–1.28, p < 0.001). Children with ADHD were also at increased risk for two and three fractures; the hazard ratios (HRs) were 1.32 (95%CI 1.26–1.38, p < 0.001) and 1.35 (95%CI 1.24–1.46, p < 0.001), respectively. In a multivariable model of the children with ADHD, pharmacological treatment was associated with reduced fracture risk (HR 0.90, 95%CI 0.82–0.98, p < 0.001) after adjustment for sex, resident socioeconomic status and population sector.
Conclusion
: Children with ADHD had greater fracture risk than a matched group without ADHD. Pharmacological treatment for ADHD may decrease this risk.
What is Known:
• Children with attention-deficit/hyperactivity disorder (ADHD) may be more prone to injuries and fractures than children without ADHD.
What is New:
• Children with ADHD were 1.2 times more likely to have a fracture than children with similar characteristics, without ADHD. The increased risk for fractures was even greater for two and three fractures (hazard ratios 1.32 and 1.35, respectively).
• Our study suggests a positive effect of pharmacological treatment for ADHD in reducing fracture risk.
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.
Aims
Frequent glucose testing is required for optimal management of type 1 diabetes (T1D). Limited data are available regarding real-world experience of the novel technology for monitoring by ...continuous interstitial fluid glucose (IFG), using flash glucose-sensing technology (FSL-CGM). We aimed to assess the effect of FSL-CGM in a real-life clinical setting on glycemic control parameters, compliance, and adverse events among pediatric and young adult T1D patients.
Methods
This observational multi-center study assessed FSL-CGM use (6–12 months) in T1D patients (mean ± SD age 13.4 ± 4.9 years) who purchased the device out-of-pocket. Outcome measures included HbA1c, mean IFG levels, CGM metrics time in hypoglycemia (< 5
4
mg/dL; < 3 mmol/L), in target range (70–180 mg/dL; 3.9–10 mmol/L), and in hyperglycemia > 240 mg/dL;
>
13.3 mmol/L), frequency of self-monitoring of blood glucose, acute complications, skin reactions, and reasons for initiation/discontinuation.
Results
Among patients with regular use of the FSL-CGM (
n
= 59), mean HbA1c decreased from 8.86 ± 0.23 to 8.05 ± 0.2% (73.3–64.5 mmol/mol) in 3 months (
p
= 0.0001) and plateaued thereafter. A clinically significant reduction in HbA1c (defined as a decrease of ≥ 0.5%) was associated with shorter diabetes duration. Of 71 patients who initiated use of the FSL-CGM, 12 (16.9%) discontinued during the study period. No statistically significant changes were found after FSL-CGM use, in mean and standard deviation IFG levels, and in time of glucose levels in target, hypoglycemia, and hyperglycemia ranges. One patient with hypoglycemia unawareness was found dead-in-bed while using FSL-CGM.
Conclusions
Real-life observational data in a self-selected young T1D population demonstrated a significant and sustained reduction in HbA1c with FSL-CGM in one-third of the participants. Surveillance of glucose monitoring should be individualized, especially for patients with hypoglycemia unawareness.
Abstract
Context
Growth retardation is an established complication of anorexia nervosa (AN); however, findings concerning the adult height of AN patients are inconsistent.
Objective
The objective of ...this work was to assess linear growth and adult height in female adolescents with AN.
Design and Setting
A prospective observational study was conducted in a tertiary university hospital.
Participants
Participants included all 255 female adolescent AN patients hospitalized in the pediatric psychosomatic department between January 1, 2000 and May 31, 2015.
Interventions
Height and weight were assessed at admission and during hospitalization. Patients were subsequently invited for measurement of adult height. Additional data collected included premorbid height data, menstrual history, skeletal age, pertinent laboratory studies, and parental heights.
Main Outcome Measure
The main outcome measure of this study was adult height.
Results
Mean age at admission was 15.4 ± 1.75 years, mean body mass index (BMI) was 15.7 ± 1.8 kg/m2 (BMI SDS = –2.3 ± 1.45 kg/m2). Premorbid height SD scores (SDS) were not significantly different from those expected in normal adolescents (0.005 ± 0.96). However, height SDS at admission (–0.36 ± 0.99), discharge (–0.34 ± 0.96), and at adult height (–0.29 ± 0.95), were significantly (P < .001) lower than expected. Furthermore, adult height was significantly (P = .006) shorter compared to the midparental target height. Stepwise forward linear regression analysis identified age (r = 0.32, P = .002) and bone age (r = –0.29, P = .006) on admission, linear growth during hospitalization (r = 0.47, P < .001), and change in luteinizing hormone during hospitalization (r = –0.265, P = .021) as independent predictors of improvement in height SDS from the time of admission to adult height.
Conclusions
Whereas the premorbid height of female adolescent AN patients is normal, linear growth retardation is a prominent feature of their illness. Weight restoration is associated with catch-up growth, but complete catch-up is often not achieved.
Trabecular bone score (TBS) is an emerging technology that provides information regarding bone microarchitecture. A recent study showed that in healthy girls normal TBS (≥1.35) was achieved within ...the first year post-menarche. The aims of our study was to assess TBS in adolescents with anorexia nervosa (AN) and to evaluate correlations with clinical, laboratory and densitometric variables.
A cohort study of 208 adolescent females (mean age 15.6 ± 1.8 y) hospitalized because of AN between 2003 and 2017 was retrospectively assessed. Demographic and clinical data, including age, weight, height, body mass index (BMI), laboratory parameters and bone mineral density (BMD) measurements by dual-energy X-ray absorptiometry (DXA) were retrieved from the medical charts. Bone mineral apparent density (BMAD) was calculated for each participant. TBS was assessed by reanalyzing DXA spinal images.
Mean TBS was 1.308 ± 0.083, lower than the values previously described in healthy adolescents (p < 0.001). Compromised microarchitecture was found in 17 participants (8.2%) and partially compromised in 123 (59.1%). TBS was significantly correlated with age, weight standard deviation score (SDS), BMI SDS, BMD measurements of the lumbar spine and total body, BMAD, BMAD Z-score, luteinizing hormone (LH) and 17b-estradiol (E2) level, and was negatively correlated with cortisol (p = 0.017). Participants with regular menstruation or secondary amenorrhea had higher TBS than participants who were pre-menarche or with primary amenorrhea (p < 0.001). A stepwise linear regression analysis identified BMD L1-4 Z-score and log E2 as independent predictors of TBS.
TBS of adolescent females with AN was found to be lower than TBS of healthy adolescents. Prospective longitudinal studies should be undertaken to investigate whether recovery may result in correction of bone microarchitecture.
Pseudohypoparathyroidism type IA (PHPIA) is a rare genetic disorder characterized by hormone resistance and a typical phenotype named Albright hereditary osteodystrophy. Unawareness of this rare ...disease leads to delays in diagnosis.
The aims of this study were to describe the clinical and molecular characteristics of patients with genetically confirmed GNAS mutations and to evaluate their long-term outcomes.
A retrospective search for all patients diagnosed with PHPIA in 2 referral centers in Israel was conducted.
Nine children (8 females) belonging to 6 families were included in the study. Five patients had GNAS missense mutations, 2 had deletions, and 2 had frameshift mutations. Four mutations were novel. Patients were referred at a mean age of 2.4 years due to congenital hypothyroidism (5 patients), short stature (2 patients), or obesity (2 patients), with a follow-up duration of up to 20 years. Early obesity was observed in the majority of patients. Elevated parathyroid hormone was documented at a mean age of 3 years; however, hypocalcemia became evident at a mean age of 5.9 years, about 3 years later. All subjects were diagnosed with mild to moderate mental retardation. Female adult height was very short (mean -2.5 SD) and 5 females had primary or secondary amenorrhea.
Long-term follow-up of newborns with a combination of congenital hypothyroidism, early-onset obesity, and minor dysmorphic features associated with PHPIA is warranted and molecular analysis is recommended since the complete clinical phenotype may develop a long time after initial presentation.
To assess the long-term efficacy of burosumab for pediatric patients with X-linked hypophosphatemia, focusing on linear growth. This multi-center retrospective study included 35 pediatric patients ...who began treatment with burosumab between January 2018 and January 2021. We collected clinical data, anthropometric measurements, laboratory results, and Rickets Severity Score (RSS), from 2 years prior to treatment initiation and up to 4 years after. Burosumab was initiated at a mean age of 7.5 ± 4.4 years (range 0.6–15.9), with a mean initial dose of 0.8 ± 0.3 mg/kg, which was subsequently increased to 1.1 ± 0.4 mg/kg. The patients were followed for 2.9 ± 1.4 years (range 1–4) after initiating burosumab. Serum phosphorus levels increased from 2.7 ± 0.8 mg/dl at burosumab initiation to 3.4 ± 0.6 mg/dl after 3 months and remained stable (
p
< 0.001). Total reabsorption of phosphorus increased from 82.0 ± 6.8 to 90.1 ± 5.3% after 12 months of treatment (
p
= 0.041). The RSS improved from 1.7 ± 1.0 at burosumab initiation to 0.5 ± 0.6 and 0.3 ± 0.6 after 12 and 24 months, respectively (
p
< 0.001). Both height
z
-score and weight
z
-score improved from burosumab initiation to the end of the study: from − 2.07 ± 1.05 to − 1.72 ± 1.04 (
p
< 0.001) and from − 0.51 ± 1.12 to − 0.11 ± 1.29 (
p
< 0.001), respectively. Eight children received growth hormone combined with burosumab treatment. Height
z
-score improved among those who received growth hormone (from − 2.33 ± 1.12 to − 1.94 ± 1.24,
p
= 0.042) and among those who did not (from − 2.01 ± 1.01 to − 1.66 ± 1.01,
p
= 0.001).
Conclusion
: Burosumab treatment in a real-life setting improved phosphate homeostasis and rickets severity and enhanced linear growth.
What is Known:
• Compared to conventional therapy, burosumab treatment has been shown to increase serum phosphate levels and reduce the severity of rickets.
• The effect of burosumab on growth is still being study.
What is New:
• Height z-score improved between the start of burosumab treatment and the end of the study (-2.07 ± 1.05 vs. -1.72 ± 1.04, p < 0.001).
• Eight children received burosumab combined with growth hormone treatment without side effects during the concomitant treatments.
Trabecular bone score (TBS) reflects vertebrae microarchitecture and assists in fracture risk assessment. The International Society of Clinical Densitometry postulates that the role of TBS in ...monitoring antiresorptive therapy is unclear. Whether changes in TBS correlate with bone resorption measured by bone turnover markers is not known.
To determine whether longitudinal changes in TBS correlate with C-terminal telopeptide (CTX) of type I collagen.
Examinees with two bone mineral density (BMD) measurements were detected via the institutional database. Over 5.8% change in TBS was considered least significant and patients were grouped accordingly (increment, decrement, or unchanged). CTX, BMD, co-morbidities, incident fractures, and medication exposure were compared between the groups by Kruskal-Wallis. The correlation between TBS and BMD change and CTX in a continuous model was analyzed by Pearson's correlation coefficient.
In total, 110 patients had detailed medical records. In 74.5%, TBS change was below least significant change. Two other TBS categories, fracture incidence or medication exposure, did not differ by CTX. In the continuous model, BMD and TBS change was positively correlated (r = 0.225, P = 0.018). A negative correlation was observed between BMD change and CTX. The decrease in BMD level was associated with higher CTX (r = -0.335, P = 0.004). No correlation was observed between CTX and TBS.
No correlation between TBS dynamics and bone resorption marker was found. Clinical interpretation and implication of longitudinal TBS changes should be further explored.
Adequate adrenocortical function is essential for survival in critical illness. Most critically ill patients display elevated plasma cortisol concentrations, which reflects activation of the ...hypothalamic-pituitary-adrenal axis and is considered to be a homeostatic adaptation. However, many critically ill patients have 'relative' or 'functional' adrenal insufficiency, which is characterized by an inadequate production of cortisol in relation to an increased demand during periods of severe stress. Recently, the term 'critical illness-related corticosteroid insufficiency' (CIRCI) was coined. CIRCI occurs as a result of a decrease in adrenal steroid production or tissue resistance to glucocorticoids. An international task force of the American College of Critical Care Medicine issued recommendations for the diagnosis and management of this condition in adult patients. We review the prevalence, diagnosis, and therapeutic approach to adrenal insufficiency in critically ill children. We found a lack of consensus within the pediatric field as to the optimal approach to CIRCI, and call for an international task force to establish unified guidelines.
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