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Original article
New diagnoses of type 1 diabetes mellitus in children during the COVID-19 pandemic Regional multicenter study in Spain
Nuevos diagnósticos de diabetes mellitus tipo 1 en niños durante la pandemia COVID-19. Estudio multicéntrico regional en España
María Hernández Herreroa,
Corresponding author
, Pilar Terradas Mercadera,b, Ester Latorre Martinezc, Albert Feliu Rovirac, Neus Rodríguez Zaragozad, Ester Parada Ricarta
a Servicio de Pediatría, Hospital Joan XXIII de Tarragona, Tarragona, Spain
b Servicio de Pediatría, Pius Hospital de Valls, Tarragona, Spain
c Servicio de Pediatría, Hospital Sant Joan de Reus, Reus, Tarragona, Spain
d Servicio de Pediatría, Hospital Verge de la Cinta, Tortosa, Tarragona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The year 2020 has been marked by the COVID-19 pandemic&#46; From 21 March to 26 April&#44; Spain was under strict lockdown&#46; This was followed by a progressive easing of restrictions until the state of alarm ended on 21 June&#46; From October&#44; regional lockdown restrictions of territorial confinement were reintroduced&#46; The fear of going out into the street and getting infected&#44; added to the restrictions on face-to-face care in health centres&#44; led to a drastic drop in consultations in the different paediatric emergency services&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Previous publications have not documented a significant increase in new diagnoses of type 1 diabetes mellitus &#40;DM1&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#8211;5</span></a> However&#44; a German study on a national scale reported an increase in the incidence of new cases in 2020&#46; Still&#44; it did not differ significantly from that predicted according to the trend observed between 2011 and 2019&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Regarding the severity of presentation at the onset of DM1&#44; most publications report a significant increase in diabetic ketoacidosis &#40;DKA&#41; and severe DKA&#44; predominantly at younger ages&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#8211;5&#44;7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The objectives of this study were to describe the incidence and severity of the onset of DM1 in the province of Tarragona during the first year of the COVID-19 pandemic compared to previous years&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">The study was an analytical&#44; observational&#44; retrospective&#44; multicentre study in the province of Tarragona &#40;Spain&#41; of the newly diagnosed cases of DM1 in children up to 15 years of age during the years 2018&#8211;2020&#46; The Clinical Research Ethics Committee approved the study&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There are three paediatric diabetes units in the province of Tarragona&#44; at Joan XXIII Hospital in Tarragona&#47;Pius Hospital in Valls&#44; Sant Joan Hospital in Reus and Verge de la Cinta Hospital in Tortosa&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">All patients under 15 years of age who attended a hospital in the province of Tarragona with an initial diagnosis of DM1 during the years 2018&#8211;2020 were included&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The following data were obtained from the medical records&#58; age&#44; sex&#44; origin&#44; severity at onset according to analytical parameters&#44; PCR COVID-19&#46; The same data was obtained &#40;except PCR COVID-19&#41; for the beginning of 2018 and 2019&#46; For the calculation of the incidence rates&#44; the demographic data of the general population of the Institut d&#39;Estad&#237;stica de Catalunya &#40;IDESCAT&#41; &#91;Institute of Statistics of Catalonia&#93; were accessed&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">DM1 and DKA criteria were defined according to the International Society for Pediatric and Adolescent Diabetes &#40;ISPAD&#41; criteria&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> For the comparison of quantitative variables&#44; the Kruskall&#8211;Wallis ANOVA H test was used&#59; for the comparison of qualitative variables&#44; Fischer&#39;s exact test was used&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">The level of statistical significance used was 0&#46;05&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Statistical analysis was performed with the SPSS Statistics 21 program&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> describes the general characteristics of the sample Between 1 January 2020 and 31 December 2020&#44; 37 children between 0 and 14 years old were diagnosed with DM1&#59; 60&#46;8&#37; and 27&#46;6&#37; more than in 2019 and 2018&#44; respectively &#40;p&#8239;&#61;&#8239;0&#46;190&#41;&#46; This increase mainly occurred at one of the units &#40;Hospital Joan XXIII&#47;Pius Hospital de Valls&#41; with 23 cases &#40;p&#8239;&#61;&#8239;0&#46;013&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">The incidence rate in the province of Tarragona in 2020 increased compared to previous years&#44; being 29&#46;2 cases per 100&#44;000 inhabitants in 2020&#44; 18&#46;1&#47;100&#44;000 in 2019 and 22&#46;9&#47;100&#44;000 in 2018 &#40;95&#37; CI&#58; 17&#46;1&#8211;29&#46;7&#41; &#40;p&#8239;&#61;&#8239;0&#46;189&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The incidence rate in children with families from the Maghreb area was 132&#46;1 per 100&#44;000 inhabitants in 2020&#59; 52&#46;2&#47;100&#44;000 in 2019&#44; and 74&#46;6&#47;100&#44;000 in 2018 &#40;95&#37; CI&#58; 39&#46;7&#8211;133&#41;&#46; In the native population&#44; it was 22&#46;7 per 100&#44;000 inhabitants in 2020&#59; 18&#47;100&#44;000 in 2019 and 29&#46;1&#47;100&#44;000 in 2018 &#40;95&#37; CI&#58; 15&#46;1&#8211;21&#46;1&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In the Maghrebi population&#44; this incidence increases and is statistically significant &#40;p&#8239;&#61;&#8239;0&#46;004&#41; in the subgroup aged 10&#8211;14 years&#58; 303&#46;8 per 100&#44;000 inhabitants in 2020&#59; 46&#46;9&#47;100&#44;000 in 2019&#59; 98&#47;100&#44;000 in 2018 &#40;95&#37; CI&#58; &#8722;4&#46;32 to 303&#46;47&#41;&#44; remaining stable in the group aged 5&#8211;9 years &#40;86&#46;9&#47;100&#44;000 in 2020&#59; 61&#47;100&#44;000 in 2019&#59; 89&#46;7&#47;100&#44;000 in 2018&#59; 95&#37; CI&#58; 61&#46;32&#8211;97&#46;08&#41; and children under 4 years of age &#40;73&#46;4&#47;100&#44;000 in 2020&#59; 48&#46;1&#47;100&#44;000 in 2019&#59; 50&#47;100&#44;000 in 2018&#59; 95&#37; CI&#58; 41&#46;21&#8211;73&#46;13&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">If we analyse the sum of onsets in the three years in Maghrebi children and compare it with the sum of onsets in autochthonous children&#44; we can observe a greater risk in the Maghrebi population of developing DM1 &#40;p&#8239;&#61;&#8239;0&#46;00&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Median age at onset was nine years in 2020 &#40;interquartile range&#58; 1&#8722;14 years&#41;&#44; nine years in 2019 &#40;interquartile range&#58; 1&#8722;14 years&#41;&#44; and eight years in 2018 &#40;interquartile range&#58; 0&#8722;14 years&#41; &#40;p&#8239;&#61;&#8239;0&#46;729&#41;&#46; If we separate the children by age groups&#44; we can see that the onsets have progressively decreased in the subgroup of 0&#8211;4 years while increasing in the range of 10&#8211;14 years&#44; which accounted for 43&#37; of new diagnoses in 2020&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In 2020&#44; 54&#46;1&#37; of onsets of DM1 were in the male sex and 45&#46;9&#37; in the female sex&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">DKA as a form of presentation was observed in 12 of 37 patients &#40;32&#46;4&#37;&#41; in 2020&#44; 13 of 23 patients &#40;56&#46;5&#37;&#41; in 2019&#44; and nine of 29 patients &#40;31&#37;&#41; in 2018&#46; If we compare the onsets with DKA with those without DKA&#44; there are no statistically significant differences &#40;p&#8239;&#61;&#8239;0&#46;111&#41;&#44; even comparing the years 2020 and 2019 with a decrease in DKA at onset from 56&#46;5&#37; to 32&#46;4&#37; &#40;p&#8239;&#61;&#8239;0&#46;066&#41;&#46; In the different age groups&#44; we can observe that the rate of onset with DKA decreases both in the group from 0 to 4 years old &#40;10&#46;8&#37;&#44;30&#46;4&#37; and 6&#46;9&#37; in the years 2020&#44; 2019 and 2018&#44; respectively&#41; and the group from 10 to 14 years old &#40;5&#46;4&#37;&#44; 21&#46;7&#37; and 13&#46;8&#37; in 2020&#44; 2019 and 2018&#44; respectively&#41;&#44; rising in the intermediate range from 5 to 9 years old &#40;16&#46;2&#37;&#44; 8&#46;7&#37; and 10&#46;3&#37; in 2020&#44; 2019 and 2018&#44; respectively&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">During 2020&#44; no patients with the onset of DM1 were diagnosed with COVID-19&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">At diagnosis&#44; anti-glutamic acid decarboxylase&#44; membrane tyrosine phosphatase&#44; anti-pancreatic islet cell and anti-insulin autoantibodies were all analysed&#46; Data were obtained from two hospitals where a decrease in positive results was observed in the last year &#40;96&#37; in 2018&#44; 100&#37; in 2019 and 84&#37; in 2020&#41;&#44; with a non-statistically significant result&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">Our study shows an increase&#44; albeit not significant&#44; in the absolute number and the incidence rate of DM1 onset in 2020 in the province of Tarragona during the first year of the COVID-19 pandemic&#44; with presentations in the form of DKA decreasing overall and more specifically in young children under four years of age&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Part of our results regarding the increase in cases coincides with the German publication by Kamrath et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and the British publication by Unsworth et al&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> However&#44; in a second publication by the same German group&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> they refer to the fact that the increase observed in 2020 was what was expected according to the trend in recent years&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the German publication by Kamrath et al&#46;&#44; data were collected from the German diabetes registry of new diagnoses of DM1 in children and adolescents between March 2020 and May 2020&#44; when most kindergartens and schools were closed to reduce social contact&#46; They compare the number of DKA cases during the 2020 lockdown period to the same time period in previous years&#46; They conclude that during the COVID-19 period of 2020&#44; the frequency of DKA cases was significantly higher than in the previous two years&#46; Severe DKA cases were also higher&#46; Children younger than six years old had a higher risk of severe DKA&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Like Kamrath&#44; Unsworth et al&#46; collected data from five paediatric hospitals in the same region in England from 23 March to 4 June 2020&#44; coinciding with the total lockdown&#46; They observed an increase in cases at two of the hospitals&#46; In all of them&#44; there was a greater number of cases of DKA&#44; and more cases of severe DKA&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Contrary to our results are those of the diabetes group of the Italian Society of Paediatric Endocrinology and Diabetology&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> which published the results obtained by survey in 68 hospitals with cases of childhood diabetes in Italy&#46; They compared new diagnoses of DM1 in children under 15 between 20 February 2020 and 14 April 2020 and in the same period in 2019&#46; They observed a lower overall incidence in the absolute number of cases and a lower amount of DKA cases&#44; but these were more severe than in the previous year&#46; In this study&#44; they looked at acute complications in patients already diagnosed and did not find a greater increase than in the previous year&#46; They diagnosed eight COVID-19 patients by PCR&#44; of which one was a new diagnosis&#44; and the others were already known patients&#46; All of them had mild or asymptomatic symptoms&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Finally&#44; Lawrence et al&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> reviewed the incidence at the John Hunter Children&#39;s Hospital in Australia&#46; They compared the number of onsets of DM1 in patients under 18 between 1 March 2020 and 31 May 2020 and the same period in the previous five years&#46; Contrary to our data&#44; they did not detect a higher incidence or changes in terms of predominance of sex or age&#46; But they did observe&#44; like the Kamrath and Unsworth groups&#44; a higher frequency of DKA and severe DKA&#46; They had no diagnosed cases of COVID-19&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">In the last nine years in Catalonia&#44; we observed a non-statistically significant increase &#40;p&#8239;&#61;&#8239;0&#46;07&#41; in the incidence rate of DM1 in children under 15 years of age&#44; which went from 14&#46;6 per 100&#44;000 inhabitants in 2011&#44; to 16&#46;3 in 2018 and 18&#46;4 in 2019&#44; before the pandemic &#40;source&#58; IDESCAT&#41;&#46; The data for 2020 has not yet been published&#46; In our region&#44; we have collected the data for these last three years and have observed this increase&#44; but with a very striking increase during 2020&#46; We cannot relate this increase to COVID-19 infection since none of the cases in which a PCR test was performed for COVID-19 was positive&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Some authors&#44; such as Unsworth&#44; hypothesise that SARS could act as a trigger due to its involvement at the level of the pancreatic beta cell&#44; especially after finding some publications on small localised outbreaks of diagnoses&#46; Marchand<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> reaches this same conclusion&#44; pointing to COVID-19 infection as a possible trigger for the onset of DM 1&#44; as well as other viral infections&#44; such as enteroviruses and other coronaviruses&#44; which have already been described in the literature as environmental agents that trigger the development of DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Other authors&#44; such as Tittel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> state that psychological stress is known as a potential risk factor for DM1 and that COVID-19 and its social-distancing consequences have affected biological&#44; psychological&#44; economic and social aspects of people&#39;s lives&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">On the contrary&#44; the Italian group that reported a lower incidence of cases during the 2020 lockdown justifies this finding by claiming that social distancing would have reduced exposure to seasonal viruses that could trigger DM1&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The possible causes of the decrease in the number of diagnoses of DKA could be explained since&#44; during the year 2020&#44; due to lockdowns and social distancing&#44; families have spent more time together&#44; thus being able to detect the initial symptoms of diabetes in their children earlier&#46; In addition&#44; although health centres drastically reduced face-to-face visits for several months and switched to mostly telephone consultations&#44; the cases diagnosed in our areas were quickly identified and treated&#46; Other authors who have accumulated more DKA cases attribute it to the restriction in medical services and&#47;or people not going to health centres due to fear of COVID-19 infection&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Our study shows a very marked increase in the incidence of new DM1 onsets in the Maghrebi population&#44; as well as the increased risk from being of Maghrebi origin to begin with&#46; These results coincide with the data published by Torrab&#237;as-Rodas et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> who reviewed the incidence of DM1 onset in two regions of Catalonia between 2000 and 2012&#46; Their results show an incidence of 37&#46;1 cases per 100&#44;000 inhabitants in Maghrebis&#44; compared to 12&#46;2&#47;100&#44;000 in the autochthonous population&#46; Contrary to our results&#44; they found a higher incidence in the population under five years of age&#46; These data indicate that there is possibly a greater genetic predisposition that interacts with environmental factors and thus makes Maghrebis more susceptible to developing DM1 than the native population&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The limitations of this study include the small sample size and the fact that our data is only compared with the previous two years&#44; which is why we cannot rule out variations in the results in the following months and years&#46; Another limitation would be the methodology used for the diagnosis of COVID-19 infection&#46; A PCR test for SARS-CoV was performed on patients at admission&#44; which cannot assess whether the patient had contact with the virus prior to the DM1 onset or not&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0170" class="elsevierStylePara elsevierViewall">In this study&#44; we wanted to determine if&#44; during 2020&#44; coinciding with the COVID-19 pandemic&#44; there was an increase in the incidence of diabetes mellitus in childhood compared to the previous two years in our area&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">In 2020&#44; we had 60&#46;8&#37; more new cases compared to 2019&#46; A single unit was responsible for the increase&#46; We observed an increase in cases in the Maghrebi population compared to the autochthonous population&#44; primarily in the group aged 10&#8211;14 years&#44; and a slight increase in the mean age at diagnosis&#46; Contrary to what we would have expected due to mobility restrictions&#44; there was a decrease in cases of DKA at diagnosis&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">A longer observation time is required to see if the upward trend in the number of new diagnoses is maintained over time or if some triggering factor&#44; such as a sedentary lifestyle&#44; diet or psychological stress&#44; could have influenced and explained the increase in cases&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Funding</span><p id="par0185" class="elsevierStylePara elsevierViewall">No funding was received for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The aim of this study is to determine whether during the year 2020&#44; coinciding with the COVID-19 pandemic&#44; there has been an increase in the incidence of diabetes mellitus in children compared to the previous 2 years&#46; It is also to find out if lockdowns and the difficulty providing face-to-face care in the health system have led to children showing more severe symptoms at the time of diagnosis&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Retrospective observational multicenter study of the province of Tarragona where data is collected from new diagnoses of type 1 diabetes mellitus in patients under the age of 15 during the year 2020 and compared with years 2018 and 2019&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">The number of new diagnoses of type 1 diabetes during 2020 was 37 cases compared to 2019 and 2018 which was 23 and 29 respectively&#46; The median age at onset was 9 years&#44; 54&#37; males&#46; There was an increase in new diagnoses in the range of 10 to14-year-olds&#44; with a decrease in the range of 0&#8211;4 year-olds&#46; In 2020&#44; the incidence in the group of patients with families from the Maghreb area rose from 52&#46;2 cases per 100&#44;000 population&#47;year &#40;c&#47;10<span class="elsevierStyleSup">5</span> p-y&#41; in 2019 to 135&#46;8 in 2020&#46; Compared to the previous year&#44; 2020 showed a significant decrease of ketoacidosis at the onset&#46; None of the patients was diagnosed with COVID-19 during admission&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">During the year 2020 concurring with the COVID-19 pandemic&#44; there was an increase in the number of new diagnoses of type 1 diabetes mellitus in pediatrics&#46; Contrary to expectations&#44; the presentation did not worsen by decreasing the proportions of ketoacidosis at onset&#46; This data would suggest that&#44; although attendance in the different health facilities dropped drastically during the year 2020 at the expense of virtual consultations&#44; health systems and families were able to detect the symptoms of the disease early&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">El objetivo de este estudio es determinar si durante el a&#241;o 2020 coincidiendo con la pandemia COVID-19&#8239;ha habido un incremento en la incidencia de diabetes mellitus en la infancia respecto a los &#250;ltimos 2 a&#241;os&#46; Debido al confinamiento domiciliario y la dificultad en la asistencia presencial en los centros de salud se analiza si han debutado con s&#237;ntomas m&#225;s graves&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo observacional multic&#233;ntrico de la provincia de Tarragona donde se recogen los datos de los nuevos diagn&#243;sticos de diabetes mellitus tipo 1 en pacientes menores de 15 a&#241;os durante el a&#241;o 2020 y se comparan con los a&#241;os 2018 y 2019&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">El n&#250;mero de nuevos diagn&#243;sticos de diabetes mellitus tipo 1 durante el a&#241;o 2020 fue de 37 casos en comparaci&#243;n con los a&#241;os 2019 y 2018 que fueron de 23 y 29 respectivamente&#46; La mediana de edad al debut fue de 9 a&#241;os&#44; 54&#37; varones&#46; Hubo un incremento de debuts en la franja de 10 a 14 a&#241;os con una disminuci&#243;n en el rango de 0 a 4 a&#241;os&#46; En el a&#241;o 2020 hubo un aumento de la incidencia en el grupo de pacientes con familias procedentes de la zona del Magreb&#44; desde 52&#44;2 en 2019 a 135&#44;8 casos&#47;100&#44;000 habitantes y a&#241;o &#40;c&#47;10<span class="elsevierStyleSup">5</span> h-a&#41; en 2020&#44; especialmente en el subgrupo de 10 a 14 a&#241;os&#46; Respecto al a&#241;o anterior&#44; en 2020 se evidenci&#243; una disminuci&#243;n importante de ni&#241;os al debut con cetoacidosis&#46; Ninguno de los pacientes fue diagnosticado de COVID-19 durante el ingreso&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Durante el a&#241;o 2020 coincidiendo con la pandemia COVID-19 hubo un incremento en el n&#250;mero de nuevos diagn&#243;sticos de diabetes mellitus tipo 1 en pediatr&#237;a&#46; Al contrario de lo esperado&#44; la forma de presentaci&#243;n no empeor&#243;&#44; disminuyendo las presentaciones en forma de cetoacidosis&#46; Este dato sugerir&#237;a que&#44; aunque la presencialidad en los diferentes centros de salud baj&#243; de manera dr&#225;stica durante el a&#241;o 2020 a expensas de las consultas virtuales&#44; los sistemas de salud y las familias supieron detectar de manera precoz los s&#237;ntomas de la enfermedad&#46;</p></span>"
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        "etiqueta" => "Figure 2"
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          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evolution of the incidence rate of DM1 in the province of Tarragona in the Maghrebi population by age group&#46;</p>"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Data are expressed in n &#40;&#37;&#41;&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Statistically significant data &#40;p&#8239;&#60;&#8239;0&#46;05&#41; are in bold&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">DKA&#58; diabetic ketoacidosis&#59; IQR&#58; interquartile range&#46;</p>"
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                  \t\t\t\t">29&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases at Joan XXIII&#47;Pius de Valls hospitals&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">21&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases at Sant Joan de Reus Hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;289&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cases at Verge de la Cinta de Tortosa Hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;956&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Overall incidence rate</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">22&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Total population</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">127&#44;293&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">127&#44;636&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Incidence rate in the Maghrebi population</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">132&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">52&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">74&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">0&#46;125&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Maghrebi population</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#44;842&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9&#44;570&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9&#44;386&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;1&#8722;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">9 &#40;1&#8722;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">8 &#40;0&#8722;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;729&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Age groups</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t">7 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;37&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;416&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">8 &#40;34&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Maghrebi</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">5 &#40;21&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;125&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#8722;4 yrs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;866&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#8722;14 yrs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;18&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1 &#40;4&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;6&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Gender</span></td><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Male&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">20 &#40;54&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;39&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">18 &#40;62&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">17 &#40;45&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">14 &#40;60&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">11 &#40;37&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " colspan="5" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">DKA</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">12 &#40;32&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">13 &#40;56&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">9 &#40;31&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;111&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0&#8722;4 yrs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">4 &#40;10&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">7 &#40;30&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>5&#8722;9 yrs&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">6 &#40;16&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2 &#40;8&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3 &#40;10&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;864&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>10&#8722;14 yrs&nbsp;\t\t\t\t\t\t\n
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es en pt

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