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Was there a change in the incidence of diabetes in children and adolescents after the onset of the COVID-19 pandemic?

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In a recent study published in JAMA Network Open, researchers performed a meta-analysis to compare the incidence rates of pediatric diabetes of types 1 (T1D) and 2 (T2D) during and before the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.Study: Incidence of Diabetes in Children and Adolescents During the COVID-19 Pandemic. Image Credit: AfricaStudio/Shutterstock

Background

Diabetes is a chronic illness among children, and coronavirus disease 2019 (COVID-19) has reportedly increased T1D and T2D incidence among pediatric individuals.

A few studies have indicated that COVID-19 may be associated with incident diabetes; however, the validity of the study findings is uncertain. Diabetes pathophysiology and the biological pathways of the association between COVID-19 and diabetes are distinct, making it crucial to assess T1D and T2D incidence.

COVID-19 has also contributed to a previously observed increase in yearly T1D incidence in the European Union, periodicity, and variation in estimated incidence between the initial and subsequent months.

It is critical to evaluate if the observed elevated incidence of recently diagnosed diabetes among children is greater and more persistent or if it is a consequence of an ongoing catch-up impact following a lower incidence rate earlier in the SARS-CoV-2 pandemic.

The rise in sedentary habits during COVID-19 may be linked to increased pediatric obesity, an established T2D risk factor. Furthermore, persistent observations regarding an elevated diabetic ketoacidosis (DKA) risk during diabetes development in children during COVID-19 underscore the necessity for more studies on diabetes incidence and its impact on youth.

About the study

In the present meta-analysis, researchers evaluated the impact of COVID-19 on diabetes incidence among pediatric individuals.

The team searched studies published in English between 1 January 2020 and 28 March 2023 on databases such as Cochrane Library, Embase, Medline, Web of Science, and Scopus; additionally, the references of all included studies were reviewed, and gray literature was searched for relevant studies published on government websites.

Studies analyzing T2D and T2D cases in individuals under 19.0 years one year before and one year into the pandemic were included. Two researchers independently screened the data, and disagreements were resolved by consensus or by a third researcher when required.

Bias risks in the included studies were assessed using the Risk of Bias in Non-randomized Studies of Exposure (ROBINS-E) tool. Studies that did not report diabetes incidence for at least 12 months before and 12 months during COVID-19 were excluded from the quantitative evaluation (meta-analysis).

Random effects modeling was performed for the quantitative assessment (meta-analysis), and the incidence rate ratios (IRR) were determined. The primary study outcome was an alteration in the diabetes incidence among pediatric individuals during COVID-19 compared to the pre-pandemic period. The secondary study outcome was an alteration in diabetes ketoacidosis (DKA) incidence among the youth with diabetes during COVID-19.

Results

In total, 10,757 studies were initially identified, from which 4,353 duplicates were eliminated, and after reviewing the abstracts, the entire text of 81 studies was screened for eligibility. As a result, 42 studies, consisting of 102,984 pediatric diabetes patients, satisfied the inclusion criteria and were considered for the qualitative review, whereas 17 studies, including 38,149 patients, were considered for the quantitative assessment.

The references of the included studies did not yield additional relevant records. The meta-analysis findings indicated a higher pediatric diabetes incidence during the initial COVID-19 wave than during pre-pandemic times (IRR, 1.1). Diabetes incidence increased between months 13 and 24 of COVID-19 compared to pre-COVID-19 times (IRR. 1.3).

In total, 10 studies (24%) documented new-onset T2D cases before and during COVID-19; however, the incidence rate of diabetes was not documented in the study’s-incidence, and therefore, the findings were not considered to derive the pooled estimates.

A total of 15 studies (36%) reported diabetes ketoacidosis incidence, which was higher during COVID-19 than in the pre-pandemic period (IRR, 1.3). There was considerable heterogeneity in the meta-analysis of diabetes incidence but not in that of DKA.

Diabetes is linked to the SARS-CoV-2 pandemic, with changes in glucose metabolism and insulin-producing beta cells being affected. Previous studies have reported that the angiotensin-converting enzyme 2 (ACE2) receptor, essential for SARS-CoV-2 entry into the host, is expressed in insulin-producing beta cells.

COVID-19 contributes to the dysregulation of glucose metabolism, making individuals with increased susceptibility vulnerable.

In addition, the pandemic has indirect effects, such as lifestyle changes, pediatric non-COVID-19 infections, increased stress, and social isolation. Hesitancy to seek care may also contribute to the increased risk of DKA during the pandemic.

Conclusions

Overall, the study findings showed that T1D incidence increased by 1.1-fold during the initial COVID-19 wave and 1.3-fold during the subsequent wave compared to the pre-pandemic period among children and adolescents.

The increase was higher than the expected 3.0% to 4.0% yearly increase based on pre-pandemic temporal alterations in Europe.

Increased health resources and facilities may be required to cater to the increasing pediatric diabetes count globally. Further research is needed to investigate the trend and elucidate the mechanisms underlying the temporal alterations.

The increased prevalence of DKA at the time of diabetes diagnosis highlights the need to identify gaps in the pathway from diabetes development to diagnosis.

 

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Older patients, non-English speakers more likely to be harmed in hospital: report

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Patients who are older, don’t speak English, and don’t have a high school education are more likely to experience harm during a hospital stay in Canada, according to new research.

The Canadian Institute for Health Information measured preventableharmful events from 2023 to 2024, such as bed sores and medication errors,experienced by patients who received acute care in hospital.

The research published Thursday shows patients who don’t speak English or French are 30 per cent more likely to experience harm. Patients without a high school education are 20 per cent more likely to endure harm compared to those with higher education levels.

The report also found that patients 85 and older are five times more likely to experience harm during a hospital stay compared to those under 20.

“The goal of this report is to get folks thinking about equity as being a key dimension of the patient safety effort within a hospital,” says Dana Riley, an author of the report and a program lead on CIHI’s population health team.

When a health-care provider and a patient don’t speak the same language, that can result in the administration of a wrong test or procedure, research shows. Similarly, Riley says a lower level of education is associated with a lower level of health literacy, which can result in increased vulnerability to communication errors.

“It’s fairly costly to the patient and it’s costly to the system,” says Riley, noting the average hospital stay for a patient who experiences harm is four times more expensive than the cost of a hospital stay without a harmful event – $42,558 compared to $9,072.

“I think there are a variety of different reasons why we might start to think about patient safety, think about equity, as key interconnected dimensions of health-care quality,” says Riley.

The analysis doesn’t include data on racialized patients because Riley says pan-Canadian data was not available for their research. Data from Quebec and some mental health patients was also excluded due to differences in data collection.

Efforts to reduce patient injuries at one Ontario hospital network appears to have resulted in less harm. Patient falls at Mackenzie Health causing injury are down 40 per cent, pressure injuries have decreased 51 per cent, and central line-associated bloodstream infections, such as IV therapy, have been reduced 34 per cent.

The hospital created a “zero harm” plan in 2019 to reduce errors after a hospital survey revealed low safety scores. They integrated principles used in aviation and nuclear industries, which prioritize safety in complex high-risk environments.

“The premise is first driven by a cultural shift where people feel comfortable actually calling out these events,” says Mackenzie Health President and Chief Executive Officer Altaf Stationwala.

They introduced harm reduction training and daily meetings to discuss risks in the hospital. Mackenzie partnered with virtual interpreters that speak 240 languages and understand medical jargon. Geriatric care nurses serve the nearly 70 per cent of patients over the age of 75, and staff are encouraged to communicate as frequently as possible, and in plain language, says Stationwala.

“What we do in health care is we take control away from patients and families, and what we know is we need to empower patients and families and that ultimately results in better health care.”

This report by The Canadian Press was first published Oct. 17, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

The Canadian Press. All rights reserved.

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Alberta to launch new primary care agency by next month in health overhaul

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CALGARY – Alberta’s health minister says a new agency responsible for primary health care should be up and running by next month.

Adriana LaGrange says Primary Care Alberta will work to improve Albertans’ access to primary care providers like family doctors or nurse practitioners, create new models of primary care and increase access to after-hours care through virtual means.

Her announcement comes as the provincial government continues to divide Alberta Health Services into four new agencies.

LaGrange says Alberta Health Services hasn’t been able to focus on primary health care, and has been missing system oversight.

The Alberta government’s dismantling of the health agency is expected to include two more organizations responsible for hospital care and continuing care.

Another new agency, Recovery Alberta, recently took over the mental health and addictions portfolio of Alberta Health Services.

This report by The Canadian Press was first published Oct. 15, 2024.

The Canadian Press. All rights reserved.

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Experts urge streamlined, more compassionate miscarriage care in Canada

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Rana Van Tuyl was about 12 weeks pregnant when she got devastating news at her ultrasound appointment in December 2020.

Her fetus’s heartbeat had stopped.

“We were both shattered,” says Van Tuyl, who lives in Nanaimo, B.C., with her partner. Her doctor said she could surgically or medically pass the pregnancy and she chose the medical option, a combination of two drugs taken at home.

“That was the last I heard from our maternity physician, with no further followup,” she says.

But complications followed. She bled for a month and required a surgical procedure to remove pregnancy tissue her body had retained.

Looking back, Van Tuyl says she wishes she had followup care and mental health support as the couple grieved.

Her story is not an anomaly. Miscarriages affect one in five pregnancies in Canada, yet there is often a disconnect between the medical view of early pregnancy loss as something that is easily managed and the reality of the patients’ own traumatizing experiences, according to a paper published Tuesday in the Canadian Medical Association Journal.

An accompanying editorial says it’s time to invest in early pregnancy assessment clinics that can provide proper care during and after a miscarriage, which can have devastating effects.

The editorial and a review of medical literature on early pregnancy loss say patients seeking help in emergency departments often receive “suboptimal” care. Non-critical miscarriage cases drop to the bottom of the triage list, resulting in longer wait times that make patients feel like they are “wasting” health-care providers’ time. Many of those patients are discharged without a followup plan, the editorial says.

But not all miscarriages need to be treated in the emergency room, says Dr. Modupe Tunde-Byass, one of the authors of the literature review and an obstetrician/gynecologist at Toronto’s North York General Hospital.

She says patients should be referred to early pregnancy assessment clinics, which provide compassionate care that accounts for the psychological impact of pregnancy loss – including grief, guilt, anxiety and post-traumatic stress.

But while North York General Hospital and a patchwork of other health-care providers in the country have clinics dedicated to miscarriage care, Tunde-Byass says that’s not widely adopted – and it should be.

She’s been thinking about this gap in the Canadian health-care system for a long time, ever since her medical training almost four decades ago in the United Kingdom, where she says early pregnancy assessment centres are common.

“One of the things that we did at North York was to have a clinic to provide care for our patients, and also to try to bridge that gap,” says Tunde-Byass.

Provincial agency Health Quality Ontario acknowledged in 2019 the need for these services in a list of ways to better manage early pregnancy complications and loss.

“Five years on, little if any progress has been made toward achieving this goal,” Dr. Catherine Varner, an emergency physician, wrote in the CMAJ editorial. “Early pregnancy assessment services remain a pipe dream for many, especially in rural Canada.”

The quality standard released in Ontario did, however, prompt a registered nurse to apply for funding to open an early pregnancy assessment clinic at St. Joseph’s Healthcare Hamilton in 2021.

Jessica Desjardins says that after taking patient referrals from the hospital’s emergency room, the team quickly realized that they would need a bigger space and more people to provide care. The clinic now operates five days a week.

“We’ve been often hearing from our patients that early pregnancy loss and experiencing early pregnancy complications is a really confusing, overwhelming, isolating time for them, and (it) often felt really difficult to know where to go for care and where to get comprehensive, well-rounded care,” she says.

At the Hamilton clinic, Desjardins says patients are brought into a quiet area to talk and make decisions with providers – “not only (from) a physical perspective, but also keeping in mind the psychosocial piece that comes along with loss and the grief that’s a piece of that.”

Ashley Hilliard says attending an early pregnancy assessment clinic at The Ottawa Hospital was the “best case scenario” after the worst case scenario.

In 2020, she was about eight weeks pregnant when her fetus died and she hemorrhaged after taking medication to pass the pregnancy at home.

Shortly after Hilliard was rushed to the emergency room, she was assigned an OB-GYN at an early pregnancy assessment clinic who directed and monitored her care, calling her with blood test results and sending her for ultrasounds when bleeding and cramping persisted.

“That was super helpful to have somebody to go through just that, somebody who does this all the time,” says Hilliard.

“It was really validating.”

This report by The Canadian Press was first published Oct. 15, 2024.

Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content.

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