Adequate versus deep response to ursodeoxycholic acid in primary biliary cholangitis: To what extent and under what conditions is normal alkaline phosphatase level associated with complication-free survival gain?

BACKGROUND AND AIMS

Normal alkaline phosphatase (ALP) levels in ursodeoxycholic acid (UDCA)-treated patients with primary biliary cholangitis (PBC) are associated with better long-term outcome. However, second-line therapies are currently recommended only when ALP levels remain above 1.5 times the upper limit of normal (×ULN) after 12-month UDCA. We assessed whether, in patients considered good responders to UDCA, normal ALP levels were associated with significant survival gains.

APPROACH AND RESULTS

We performed a retrospective cohort study of 1047 patients with PBC who attained an adequate response to UDCA according to Paris-2 criteria. Time to liver-related complications, liver transplantation, or death was assessed using adjusted restricted mean survival time (RMST) analysis. The overall incidence rate of events was 17.0 (95% CI: 13.7-21.1) per 1000 out of 4763.2 patient-years. On the whole population, normal serum ALP values (but not normal gamma-glutamyl transpeptidase (GGT), alanine aminotransferase (ALT), or aspartate aminotransferase (AST); or total bilirubin < 0.6 ×ULN) were associated with a significant absolute complication-free survival gain at 10 years (mean 7.6 months, 95% CI: 2.7 - 12.6 mo.; p = 0.003). In subgroup analysis, this association was significant in patients with a liver stiffness measurement ≥ 10 kPa and/or age ≤ 62 years, with a 10-year absolute complication-free survival gain of 52.8 months (95% CI: 45.7-59.9, p < 0.001) when these 2 conditions were met.

CONCLUSIONS

PBC patients with an adequate response to UDCA and persistent ALP elevation between 1.1 and 1.5 ×ULN, particularly those with advanced fibrosis and/or who are sufficiently young, remain at risk of poor outcome. Further therapeutic efforts should be considered for these patients.

Liver stiffness measurement by vibration-controlled transient elastography improves outcome prediction in primary biliary cholangitis

BACKGROUND & AIMS

Liver stiffness measurement (LSM) by vibration-controlled transient elastography (VCTE) has been shown to predict outcomes of patients with primary biliary cholangitis (PBC) in small-size studies. We aimed to validate the prognostic value of LSM in a large cohort study.

METHODS

We performed an international, multicentre, retrospective follow-up study of 3,985 patients with PBC seen at 23 centres in 12 countries. Eligibility criteria included at least 1 reliable LSM by VCTE and a follow-up ≥ 1 year. Independent derivation (n = 2,740) and validation (n = 568) cohorts were built. The primary endpoint was time to poor clinical outcomes defined as liver-related complications, liver transplantation, or death. Hazard ratios (HRs) with CIs were determined using a time-dependent multivariable Cox regression analysis.

RESULTS

LSM was independently associated with poor clinical outcomes in the derivation (5,324 LSMs, mean follow-up 5.0 ± 3.1 years) and validation (1,470 LSMs, mean follow-up 5.0 ± 2.8 years) cohorts: adjusted HRs (95% CI) per additional kPa were 1.040 (1.026-1.054) and 1.042 (1.029-1.056), respectively (p <0.0001 for both). Adjusted C-statistics (95% CI) at baseline were 0.83 (0.79-0.87) and 0.92 (0.89-0.95), respectively. Between 5 and 30 kPa, the log-HR increased as a monotonic function of LSM. The predictive value of LSM was stable in time. LSM improved the prognostic ability of biochemical response criteria, fibrosis scores, and prognostic scores. The 8 kPa and 15 kPa cut-offs optimally separated low-, medium-, and high-risk groups. Forty percent of patients were at medium to high risk according to LSM.

CONCLUSIONS

LSM by VCTE is a major, independent, validated predictor of PBC outcome. Its value as a surrogate endpoint for clinical benefit in PBC should be considered.

LAY SUMMARY

Primary biliary cholangitis (PBC) is a chronic autoimmune disease, wherein the body's immune system mistakenly attacks the bile ducts. PBC progresses gradually, so surrogate markers (markers that predict clinically relevant outcomes like the need for a transplant or death long before the event occurs) are often needed to expedite the drug development and approval process. Herein, we show that liver stiffness measurement is a strong predictor of clinical outcomes and could be a useful surrogate endpoint in PBC trials.

Clinical efficacy, drug sustainability and serum drug levels in Crohn's disease patients treated with ustekinumab - A prospective, multicenter cohort from Hungary

INTRODUCTION

Although efficacy of ustekinumab (UST) has been demonstrated through randomized trials, data from real-life prospective cohorts are still limited. Our aim was to evaluate clinical efficacy, drug sustainability, dose intensification and results from therapeutic drug monitoring in UST treated patients with Crohn's disease (CD) using a prospective, nationwide, multicenter cohort.

METHODS

Patients from 10 Inflammatory Bowel Disease centers were enrolled between 2019 January and 2020 May. Patient demographics, disease phenotype, treatment history, clinical disease activity (Crohn's Disease Activity Index(CDAI), Harvey Bradshaw Index(HBI)), biomarkers, and serum drug levels were obtained. Evaluations were performed at week8 (post-induction), w16-20, w32-36, and w52-56 follow-up visits.

RESULTS

A total of 142 patients were included [57.4% female; complex disease behavior (B2/B3):48%, previous anti-TNF exposition:97%]. Clinical response and remission rates after induction(w8) were 78.1% and 57.7% using CDAI, and 82.5% and 51.8% based on HBI scores. The one-year clinical remission rate was 58%/57.3%(CDAI/HBI). Composite clinical and biomarker remission (CDAI<150 and C-reactive protein<10 mg/L) rates were 35.4%; 33.3%; 38.6% and 36.6% at w8/w16-20/w32-36 and w52-56. Drug sustainability was 81.9%(standard deviation(SD): 3.4) at 1 year(1y). Probability of dose intensification was high and introduced early, 42.2%(SD:4.2) at ~w32 and 51.9%(SD:4.4%) at 1y.

CONCLUSION

Ustekinumab showed favorable drug sustainability and clinical efficacy in a patient population with severe disease phenotype and previous anti-tumor necrosis factor (anti-TNF) failure, however frequent dose intensification was required.

Cardiometabolic risk factors and insulin resistance in obese children and adolescents: relation to puberty

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

The prevalence of obesity with concomitant increasing risk for having cardiometabolic diseases is rising in the childhood population. Insulin resistance has a key role in metabolic changes in these children. Insulin levels elevate as puberty commences in every individual.

WHAT THIS STUDY ADDS

Children with increased risk for cardiometabolic diseases show significant differences in insulin levels even before the onset of puberty compared with those without risks. The pattern of appearance of dyslipidaemia also varies in children with risk factors even in the pre-pubertal group from those without risk. Children with metabolic syndrome display considerably pronounced changes in their metabolic parameters before the onset of puberty, which become more pronounced as puberty passes.

BACKGROUND

Insulin resistance (IR) has a key role in the metabolic changes in obese children. In commencing puberty, the insulin levels elevate. It is not clear, however, how insulin levels develop if the metabolic syndrome appears.

OBJECTIVES

Metabolic changes were assessed in obese children before, during and after puberty to analyse the relationship between IR and puberty in subjects with and without metabolic syndrome.

METHODS

Three hundred thirty-four obese children (5-19 years) attended the study. The criteria of the International Diabetes Federation were used to assess the presence of cardiometabolic risks (CMRs). Subjects with increased CMR were compared with those without risk (nCMR). Pubertal staging, lipid levels, plasma glucose and insulin levels during oral glucose tolerance test were determined in each participant. IR was expressed by homeostasis model assessment (HOMA-IR) and the ratio of glucose and insulin areas under the curve (AUC-IR).

RESULTS

Significantly higher AUC-IR were found in pre-pubertal CMR children compared with nCMR subjects (11.84 ± 1.03 vs. 8.00 ± 0.69; P < 0.01), but no difference was discovered during and after puberty. HOMA-IR differs between CMR and nCMR only in post-puberty (6.03 ± 1.26 vs. 2.54 ± 0.23; P < 0.01). CMR children have dyslipidaemia before the onset of puberty.

CONCLUSIONS

CMR is associated with increased postprandial IR in pre-pubertal and increased fasting IR in post-pubertal obese children. Dyslipidaemia appeared already in pre-puberty in CMR children.

Brain glucose sensing and counterregulatory response to hypoglycaemia

An important obstacle to achieve optimal glycaemic control in diabetics on intensive insulin therapy is the frequent occurrence of insulin induced hypoglycaemic events. In healthy subjects and in diabetics without autonomic neuropathy hypoglycaemia activates the sympathetic nervous system, resulting in epinephrine and glucagon release. Both hormones increase hepatic glucose production and this counterregulatory response is of key importance of glucose homeostasis. Recent research shed light on the fact that antecedent hypoglycaemic episodes play pivotal role in hypoglycaemia associated autonomic failure (HAAF). In this condition the sympatho-adrenal response to decreased blood glucose level is blunted. The existence of HAAF clearly indicates that the nervous system contributes to glucose homeostasis in a substantial manner. This review outlines the mechanisms of both peripheral and central neuronal glucose sensing and of neural pathways involved in the counterregulatory response.

Urinary flow disturbance as an early sign of autonomic neuropathy in diabetic children and adolescents

AIMS

Urinary bladder dysfunction is a frequent complication of diabetes mellitus in adults. The aim of this study is to determine the early disturbances of the detrusor contractility in children, and adolescents with type 1 diabetes.

MATERIALS AND METHODS

The bladder urine flow parameters were investigated in 37 children with type 1 diabetes, 10/37 with cardiovascular autonomic dysfunction (CAD) voided 482 +/- 128 mils (Group A), 27/37 without CAD voided 258 +/- 52 mils (Group B). From an earlier uroflow screening study 20 healthy children formed group control A, who had voided 488 +/- 94 mils, and another 30 healthy children formed group control B, who had voided 260 +/- 50 mils. The compared groups were matched for voided volume, age, weight, and height. There was no evidence of urinary tract abnormalities in any of the children.

RESULTS

Time to maximum flow was longer in both diabetic groups as compared with controls (P < 0.01), and the acceleration (the ratio of maximum flow and the time to maximum flow) of diabetics was significantly lower (P < 0.01). Bladder emptying was complete in each subject. Bladder wall disturbances were not seen by ultrasound.

CONCLUSIONS

The decreased acceleration of detrusor muscle contraction may be interpreted as an early sign of autonomic neuropathy in children and adolescent with type 1 diabetes, even in patients without CAD. Clinicians may be able to determine autonomic neuropathy by using uroflowmetry that is easy to perform, sensitive, reproducible, and needs only a child's minimal cooperation.

Association of angiotensin-converting enzyme DD genotype with 24-h blood pressure abnormalities in normoalbuminuric children and adolescents with Type 1 diabetes

AIMS

To assess the distribution of the insertion/deletion (I/D) polymorphism of the angiotensin-converting enzyme (ACE) gene in children and adolescents with Type 1 diabetes and to evaluate the association between ACE genotype and blood pressure (BP).

METHODS

ACE genotypes were assessed in 124 normoalbuminuric, clinically normotensive Type 1 diabetic children and adolescents and 120 non-diabetic controls using polymerase chain reaction. Twenty-four-hour ambulatory BP monitoring was undertaken in all patients.

RESULTS

ACE genotypes distributed in patients as follows: 34 (27%) DD, 57 (46%) ID, 33 (27%) II. The distribution was similar in the control group: DD in 28% (33), ID in 45% (54), and II in 27% (33). Patients with DD genotype had higher mean 24-h diastolic BP (73.8 +/- 6.2 vs. 70.2 +/- 5.0 and 69.7 +/- 6.3 mmHg; P = 0.005) and lower diurnal variation in BP (11.8 +/- 4.6 vs. 14.2 +/- 4.2 and 14.8 +/- 4.3%; P = 0.011) compared with ID and II groups. Four patients in the DD group proved to be non-dipper compared with one in the ID and none in the II group (P = 0.026). Twenty-four-hour diastolic blood pressure was independently predictive for AER as dependent variable in the DD genotype patient group (r(2) = 0.12, P = 0.03).

CONCLUSIONS

Children and adolescents with Type 1 diabetes do not differ from the non-diabetic population regarding the I/D polymorphism of the ACE gene. ACE gene polymorphism is associated with BP abnormalities in normotensive and normoalbuminuric children and adolescents with Type 1 diabetes.

Altered Distribution of the Debrisoquine Oxidative Phenotypes in Children with Type 1 Diabetes mellitus

OBJECTIVE

The recently observed increase in the incidence of type 1 diabetes mellitus (Type 1 DM) suggests a major role of environmental factors in the etiopathogenesis of the disease. The individual variation in cytochrome P(450)IID6 may influence the individual susceptibility to environmentally linked diseases. We aimed to evaluate the prevalence of cytochrome P(450)IID6 phenotypes in Hungarian children with Type 1 DM (n = 69) compared to healthy controls (n = 100).

METHODS

Debrisoquine was administered orally and debrisoquine hydroxylation phenotype was determined as a metabolic ratio of urinary recovered debrisoquine and 4-hydroxydebrisoquine.

RESULTS

Eight of the 100 healthy subjects (8%) and 15 of the 69 diabetic children (22%) (p < 0.05) had cytochrome P(450)IID6 poor metabolizer phenotype (metabolic ratio > or =12.6).

CONCLUSION

Cytochrome P(450)IID6's activity may play a role in the development of Type 1 DM.

Corticosteroids administered by nebulization to children with bronchial asthma

Inhaled corticosteroids are recommended for long-term control of asthma in children, and nebulization simplifies administration to patients who lack hand-to-lung coordination. Information on the efficacy and safety of nebulized corticosteroids in children with mild to moderate asthma is limited, however, and comparison between corticosteroids is lacking. One hundred thirty-three patients 6 to 14 years of age with bronchial asthma were randomly assigned to receive flunisolide 500 microg or budesonide 500 microg, both administered twice daily by nebulizer for 4 weeks. Morning peak expiratory flow rate (primary efficacy endpoint) increased significantly from baseline (P<.001) with both medications (P = NS between treatments). Use of salbutamol as rescue medication decreased by 82.6% with flunisolide and by 82.7% with budesonide; respective decreases in asthma score were 78.8% and 82.3% (P<.001 vs baseline, P = NS between treatments). Only flunisolide reduced the number of nocturnal awakenings (P<.001). Ten patients in the flunisolide group and 12 in the budesonide group reported adverse events, none of which required discontinuation of treatment. In children with asthma, nebulized corticosteroids are effective and have good safety and tolerability profiles. Flunisolide and budesonide seem to produce equivalent clinical responses.

Beclomethasone dipropionate versus budesonide inhalation suspension in children with mild to moderate persistent asthma

Inhaled steroids are the most effective long-term treatment of persistent asthma but many children are unable to use correctly the available inhalers. Administration of nebulized corticosteroids has some advantages over the administration with pressurised metered-dose inhalers (pMDls). The objective of this multicenter randomised study was to compare the efficacy and tolerability of nebulized corticosteroids in paediatric patients with asthma. 127 patients aged > or = 6 and < or = 14 years with a diagnosis of mild to moderate persistent asthma (PEFR % predicted > 50% and < 85%) and positive response to the reversibility test were randomized. The patients were assigned by randomisation to one of the two treatment groups (4 weeks): beclomethasone dipropionate (BDP) 800 microg/daily b.i.d. (n = 66) or budesonide (BUD) 1000 microg/daily b.i.d. (n = 61) both administered by nebulizer. The primary efficacy end point was the final mean of PEFR measured at clinical visit (clinic PEFR). In the BDP group clinic PEFR increased from 177.5 +/- 80 L/min to 246.6 +/- 84.2 L/min (p < 0.001 vs baseline), while in the BUD group the increase was from 180.4 +/- 77.8/min to 260.9 +/- 84.1 L/min (p < 0.001 vs baseline) (NS between treatments). FEV1 (% predicted) increased from 77.8% to 92.7% (p < 0.001 vs baseline) and from 74.1% to 95.9% (p < 0.001 vs baseline) in BDP and BUD group respectively (NS between treatments). Patients reduced the use of salbutamol rescue medication by 76% and 81% in BDP and BUD group respectively (p < 0.001 vs baseline, NS between treatments). 4 patients in the BDP group and 2 in the BUD group reported adverse events (AEs). AEs were mild to moderate and never there was the need to discontinue the treatments. In conclusion the results of this study demonstrate that both BDP (800 microg/daily) and BUD (1000 microg/daily) administered by nebulization are effective and with a acceptable safety and tolerability profile.

[Glucose metabolism and insulin sensitivity in patients with Turner syndrome treated with growth hormone]

The authors investigated the effect of growth hormone treatment on 20 Turner syndrome patients. The aim was to assess glucose and insulin responses to oral glucose loading in 9 prepubertal and 11 pubertal patients with Turner syndrome. Thirty eight healthy subjects matched for chronological age and BMI were selected as controls. Similar glucose responses were observed in the prepubertal and postpubertal patients groups and no difference was found between patients and controls. No correlation was observed between glycaemic control of insulin sensitivity and growth hormone treatment. Although the supraphysiological doses of growth hormone did not result in substantial impairement in glucose tolerance, it is concluded that hyperinsulinaemia could be a consequence of the treatment and regular check up for glycaemic control is needed in these patients.

Prospective assessment of severe hypoglycaemia in diabetic children and adolescents with impaired and normal awareness of hypoglycaemia

To establish whether impaired hypoglycaemic awareness is associated with increased rate of severe hypoglycaemia and to assess clinical predictors of severe episodes without warning symptoms a prospective study of 130 insulin-dependent diabetic children and adolescents was undertaken for 1 year. Using a structured questionnaire, 48 patients reported impaired awareness and 82 reported normal awareness of hypoglycaemia at baseline of the study. The two groups did not differ regarding clinical and metabolic characteristics. Episodes of severe hypoglycaemia were recorded for 1 year. The rate of severe hypoglycaemia was higher in the group with impaired awareness than in the group with normal awareness (p < 0.0001). Of the severe hypoglycaemic episodes, 34.0% developed without warning symptoms. Patients with impaired awareness experienced more severe episodes without warning symptoms than those with normal awareness (p = 0.0054). Severe hypoglycaemia occurred more frequently in patients with impaired awareness aged 6 years and less (p = 0.0041) than in older counterparts. Impaired awareness reported at baseline [adjusted odds ratio (OR): 5.8; p =0.0021], age 6 years or less (3.4; p = 0.0121), previous severe episode (4.8; p = 0.0043) and more than 5 % of home blood glucose readings 3.3 mmol/l or less in the preceding month (4.2; p = 0.0211) proved to be independently predictive of severe hypoglycaemic events without warning symptoms. In conclusion, impaired hypoglycaemic awareness is associated with an increased rate of severe hypoglycaemia in diabetic children and adolescents. One third of severe episodes developed without warning symptoms. Impaired awareness, young age and recent biochemical or severe hypoglycaemias are independent risk factors for such episodes. Avoidance of hypoglycaemia should be a priority in preschool children with diabetes.

Enhanced progression of urinary albumin excretion in IDDM during puberty

OBJECTIVE

To determine whether the progression of urinary albumin excretion rate (AER) is higher during puberty than before or after this period.

RESEARCH DESIGN AND METHODS

A prospective study was conducted in which normoalbuminuric prepubertal (n = 20), pubertal (n = 28), and postpubertal (n = 26) IDDM groups matched for diabetes duration and long-term metabolic control were followed for 3 years. At 6-month intervals, 24-h urine collection was used to determine AER.

RESULTS

AER increased significantly over a period of 3 years in the pubertal (P = 0.001) and postpubertal (P = 0.003) subjects but not in prepubertal subjects. The annual progression of AER was significantly higher in the pubertal group than in the prepubertal (P = 0.001) or postpubertal (P = 0.001) groups. Six pubertal, two postpubertal, and none of the prepubertal subjects developed microalbuminuria (AER > or = 20 micrograms/min on two consecutive occasions) over a 3-year period (P = 0.047). Multiple logistic regression analysis showed that the risk of development of microalbuminuria was increased in pubertal subjects compared with the prepubertal and postpubertal subjects (adjusted relative risk [95% CI]: 4.3 [1.5-9.3], P = 0.012, and 2.1 [1.1-5.0], P = 0.023, respectively).

CONCLUSIONS

Puberty represents an independent risk of the development of microalbuminuria in diabetes. This findings suggests that the endocrine changes of puberty lead to an accelerated process of early kidney damage in diabetes. In pediatric diabetes care, screening for microalbuminuria is needed soon after the onset of puberty.

Peripheral sensory nerve dysfunction in children and adolescents with type 1 diabetes mellitus

The aim of the present study was to investigate peripheral sensory nerve function in diabetic children and adolescents without neurological symptoms. Ninety-two children and adolescents with Type 1 (insulin-dependent) diabetes mellitus (mean +/- SD age: 14.2 +/- 2.1 years, diabetes duration: 5.8 +/- 3.0 years) and 80 healthy control subjects (age: 13.8 +/- 2.2 years) matched for age, sex, body mass index, and height standard deviation score were involved in the study. Using a sine-wave transcutaneous stimulator, current perception threshold (CPT) testing at 2000, 250 and 5 Hz was performed on the left median and peroneal nerves. Diabetic children had increased CPT at 2000 Hz on both nerves as compared to the control group (median (interquartile range), median nerve: 2.43 (2.20-3.43) vs 1.80 (1.51-2.60) mA, p = 0.02; peroneal nerve: 3.51 (2.81-4.82) vs 2.70 (2.04-3.70) mA, p = 0.01). Twenty-one (23%) of patients had CPT values higher than that of any healthy individual. Of these, elevated CPT was observed in 9 (9.8%) patients on the median nerve, in 8 (8.7%) patients on the peroneal nerve, and in 4 (4.3%) patients on both median and peroneal nerves. Using multiple logistic regression analysis, worse long-term metabolic control and advanced puberty were independently predictive of peripheral sensory nerve dysfunction as the dependent variable (adjusted OR (95% CI): 3.4 (1.2-6.2), p = 0.01, and 2.8 (1.1-5.6), p = 0.03, respectively). In conclusion, evidence of peripheral sensory nerve dysfunction is not rare in children and adolescents with diabetes and can be demonstrated by CPT testing in asymptomatic patients. Poor metabolic control is a risk factor for such subclinical neuropathy, and pubertal development may be involved in the pathogenesis of diabetic peripheral neuropathy.

[The effect of captopril therapy on the degree of microalbuminuria in diabetic children and adolescents with incipient nephropathy]

In the present study the effect of angiotensin converting enzyme inhibitor captopril was studied in normotensive diabetic children and adolescents with persistent microalbuminuria (repeated albumin excretion rate higher than 30 mg/24 h). In 1993/1994, 15 microalbuminuric patients (age: 10-17 yrs, diabetes duration: 6.5 +/- 3.0 yrs) had been treated with captopril (0.9 mg/kg/day for a period of 13.1 +/- 4.4 months). In 1992/1993, 13 patients (age: 11-17 yrs, diabetes duration: 5.8 +/- 2.7 yrs, study period: 12.3 +/- 4.0 months) had not received captopril. Same restriction of the dietary protein intake was recommended in both groups (less than 10% of the total calorie intake). Timed 24-h urine samples were used to determine albumin excretion by an immunonephelometric method. Significant increase in microalbuminuria was observed in patients who had not received captopril during the study period (56.2 +/- 16.0 mg/24 h vs. 77.8 +/- 20.1 mg/24 h, p = 0.045). There was no change in microalbuminuria in the captopril treated group during the study period (60.6 +/- 19.5 mg/24 h vs. 60.4 +/- 25 mg/24 h, n. s.). No change in metabolic control and blood pressure was observed in the two groups during the study period. These results support that captopril treatment may prevent or delay the progression of incipient nephropathy in normotensive children and adolescents in diabetes.

Increased frequency of IgM antibodies to cow's milk proteins in Hungarian children with newly diagnosed insulin-dependent diabetes mellitus

We investigated the association between serum antibodies to cow's milk proteins and insulin-dependent diabetes mellitus (IDDM) in Hungarian children. Forty-eight children 1.0-17.1 years of age with newly diagnosed IDDM and 74 control children 1.0-16.0 years of age were studied for serum IgG, IgA and IgM antibodies to cow's milk, beta-lactoglobulin, bovine serum albumin and ovalbumin by enzyme-linked immunosorbent assays. The specificity of IgM antibodies to beta-lactoglobulin and bovine serum albumin was controlled by Western blot. The levels of IgG and IgA antibodies to cow's milk proteins were similar in children with and without IDDM, with the exception of slightly increased levels of IgA antibodies to beta-lactoglobulin in diabetic children (P = 0.05). The levels of IgM antibodies to cow's milk were significantly higher in IDDM patients than in control children (P = 0.0002). Children with IDDM more often had IgM antibodies to beta-lactoglobulin (46.3% vs 18.8%; P = 0.002) and bovine serum albumin (87.8% vs 49.3%, P < 0.0001) than control children. Neither the levels of IgG or IgA antibodies to ovalbumin nor the frequency of IgM antibodies to ovalbumin differed between diabetic and control children.

CONCLUSION

In Hungarian children, clinical manifestation of IDDM is often associated with IgM antibody response to cow's milk protein and its fractions, beta-lactoglobulin and bovine serum albumin, indicating a loss of immunological tolerance to these proteins. IgG and IgA antibodies to cow's milk proteins, associated with an early introduction of cow's milk in diet, seem to play a minor role in the development of childhood IDDM in Hungary.

Physical work capacity in diabetic children and adolescents with and without cardiovascular autonomic dysfunction

The aim of the present study was to evaluate the influence of autonomic nervous system dysfunction on work capacity in children and adolescents with Type 1 (insulin-dependent) diabetes. Fifteen patients with autonomic dysfunction (abnormal autonomic tests, age: 14.9 +/- 2.3 years), 35 patients without autonomic dysfunction (normal autonomic tests, age: 15.2 +/- 2.5 years), and 25 non-diabetic subjects (age:15.0 +/- 2.3 years) were investigated. Resting heart rate, deep breathing heart rate variation, standing/lying heart rate ratio, decrease in blood pressure during orthostasis, and increase in blood pressure during sustained handgrip were used to assess cardiovascular autonomic dysfunction. Physical work capacity at heart rate of 170 min-1 was determined by bicycle ergometry. Glycated haemoglobin level was higher in patients with than without autonomic dysfunction (12.3 +/- 3.1 vs 9.4 +/- 2.9%, p = 0.04). Patients with autonomic dysfunction had significantly lower physical work capacity at heart rate of 170 min-1 than those with normal autonomic function or non-diabetic subjects (0.81 +/- 0.12 vs 1.49 +/- 0.16 and 1.54 +/- 0.20 W kg-1 p = 0.01). Physical work capacity at heart rate of 170 min-1 was related to glycated haemoglobin level (r = -0.55, p = 0.01), to resting heart rate (r = 0.57, p = 0.01), and to deep breathing heart rate variation (r = 0.51, p = 0.02). In conclusion, impaired work capacity is associated with poor blood glucose control and cardiovascular autonomic dysfunction. Autonomic tests can help to identify those patients who may need special consideration during exercise.

Cardiovascular autonomic dysfunction in diabetes mellitus

The aim was to assess cardiovascular autonomic dysfunction in children and adolescents with diabetes mellitus. A total of 110 children and adolescents with type 1 (insulin dependent) diabetes (aged 6 to 18 years) and 130 non-diabetic controls were studied. Resting heart rate, heart rate variation to deep breathing, heart rate response to standing from a lying position, fall in systolic blood pressure on standing, and rise in diastolic blood pressure during sustained handgrip were measured. A reference range of results was obtained in the controls. Diabetic children had significantly increased resting heart rate [92.4 (SEM 2.5) v 84.2 (2.2) beats/min], decreased deep breathing heart rate variation [25.3 (0.9) v 32.8 (0.6) beats/min], and lower standing/lying heart rate ratio [1.23 (0.04) v 1.31 (0.03)] compared with controls. 46 diabetic children (42%) had at least one abnormal autonomic test result. Of these, 20 (15%) had only one abnormal test and 26 (24%) had two or more abnormal tests. Using multiple logistic regression analysis, longer diabetes duration and worse long term metabolic control were independently predictive of cardiovascular autonomic dysfunction as the dependent variable [adjusted OR (95% CI): 2.9 (1.1-5.9) and 3.3 (1.2-6.4), respectively]. Cardiovascular autonomic dysfunction is not rare in children with diabetes. Efforts should be made to maintain the best metabolic control to prevent or delay these complications.

Urinary bladder dysfunction in diabetic children with and without subclinical cardiovascular autonomic neuropathy

The aim of this study was to assess the relationship between bladder dysfunction and impaired cardiovascular reflexes in diabetic children with no clinical symptoms of autonomic neuropathy. After 15 ml/kg of water intake, the time to first sensation to void, the voiding volume, the voiding time, the average and maximum urinary flows, and the time to maximum urinary flow were estimated by sonography and uroflowmetry in diabetic children with and without cardiovascular autonomic dysfunction (CAD), and in a healthy control group. The three groups of children were matched for age, weight and height. CAD was considered to be present if the results of cardiovascular tests were more than 2SD from the mean of healthy controls. Diabetic children with and without CAD had increased time to first sensation to void, voiding volume, and average urinary flow when compared with healthy children. Voiding volume and average and maximum urinary flows were higher in diabetic children with CAD than in those without CAD. Diabetic children with CAD had also a higher maximum urinary flow than diabetic children without CAD and healthy children. Diabetic children with CAD had a longer diabetes duration and a higher mean fructosamine level during the preceding 3 years than those without CAD. These findings suggest that diabetic children may have diminished sensation of bladder filling independent of impaired cardiovascular reflexes, however, the degree of bladder dysfunction parallels with CAD, both depending on diabetes duration and long-term glycaemic control.

Trace elements in the human blood, cerebrospinal and amniotic fluid

Human biological samples using the atomic emission method. The concentration of 27 micro- and macro elements was specified in a total number of 1221. Some of the patients tested were under hospital treatment because of chronic disease (727 persons), others were blood donors (71 persons) or pregnant women and newborn infants (107-107 persons, respectively). In the serum samples of the tested persons the concentration of barium, mercury, nickel and gallium showed characteristic differences. Concentrations of many micro elements in the serum and cerebrospinal fluid changed with age and sex. The tendency becomes characteristic after the age of 45 and 60, respectively. The concentration of elements in the blood serum of mothers and their newborn infants seems to be nearly identical with a considerable deviation observed only in case of aluminum, barium and iron (significant difference). The detected elements can pass through the placenta. This particularly applies to lead because the average lead concentration in the serum of newborn infants is 159 micrograms/litre even at birth.

[Retinal microangiopathies in diabetic children and adolescents, occurring in cases of pubertal and prepubertal onset of diabetes]

The prevalence and development of retinal microvascular complications in pre-puberty and puberty onset insulin-dependent diabetes mellitus were studied in 109 young patients with an average follow-up of 6 years. The data suggest that the earlier childhood the diabetes began, the later the microvascular abnormalities could be found by fluorescein angiography. First signs of background retinopathy were seen in average 20--22 years of age, almost independently the age at onset of diabetes. Rapid progression of retinal vascular damage occurred mainly in postpubertal but not pubertal subjects. Diabetes with puberty onset meant worse prognosis in the respect of retinal vascular complications than pre-puberty onset. Good glycemic control would be achieved more difficult in subjects with puberty onset diabetes added to a changing hormonal balance. The authors suggest that psychological factors (altered behavior during and after puberty) and other problems of adolescents (changes in social, familial and working conditions) may also contribute to poor glycemic control. Though the effect of prepubertal duration on the risk of retinal complications appears to be smaller than later years, the attendant work in prepubertal years is as important as later.

[Connection between microalbuminuria and subclinical cardiovascular autonomic neuropathy in diabetic children]

Cardiovascular tests were investigated in 16 microalbuminuric, in 20 normoalbuminuric diabetic children and a control group of 20 healthy children. Comparing to the control group, in both of two diabetic groups a similar increase in resting heart rate (74.5 +/- 2.5/min vs. 87.8 +/- 3.5/min, p less than 0.01, and 83.6 +/- 3.2/min, p less than 0.05) and a decrease in hyperventilatory arrhythmia (32.3 +/- 1.2/min vs. 20.1 +/- 0.8/min, p less than 0.01, and 17.2 +/- 0.8/min, p less than 0.01) was observed. In the diabetic group with microalbuminuria in comparison with both the control group and the normoalbuminuric group there was a lower standing/lying heart rate ratio (1.02 +/- 0.03 vs. 1.30 +/- 0.05, p less than 0.01, and 1.22 +/- 0.05, p less than 0.05), a pronounced orthostatic decrease in blood pressure (15.1 +/- 0.3 mmHg vs. 2.0 +/- 0.1 mmHg, p less than 0.001, and 5.0 +/- 0.2 mmHg, p less than 0.01) and a diminished increase in blood pressure during sustained handgrip (6.3 +/- 0.2 mmHg vs. 14.0 +/- 0.3 mmHg, p less than 0.01, and 12.2 +/- 0.3 mmHg, p less than 0.05). The occurrence of cases with distinct autonomic dysfunction (3 or more abnormal cardiovascular tests) proved to be more frequent in the group with microalbuminuria than in the diabetic group with normal albumin excretion (6/16 vs. 1/20, p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Autonomic dysfunction and severe hypoglycaemia in insulin dependent diabetes mellitus

The aims of the present study were to investigate the relationship between severe hypoglycaemia and autonomic dysfunction in diabetic children, and to assess the glycaemic response to an insulin infusion test. In a one year period, 12 of 69 diabetic patients (17%) experienced at least one severe episode of hypoglycaemia, defined as an event which required outside assistance. All patients underwent five cardiovascular autonomic tests. Seven of the hypoglycaemic patients showed three or more abnormal autonomic tests. Among the 57 non-hypoglycaemic diabetics, there was no patient with three or more abnormal tests. In hypoglycaemic diabetics with and without autonomic dysfunction, and in eight healthy age matched subjects an insulin infusion test was performed. A pronounced blood glucose decline and a subnormal increase in heart rate during insulin infusion were obtained in patients with autonomic dysfunction. Thus, severe hypoglycaemia may be due to impaired defence mechanisms against blood glucose decline in diabetic children with autonomic dysfunction.

[Pancreatic pseudocysts in children]

Pancreas pseudocysts in childhood. On the basis of experience obtained with 9 patients treated over 31 years the authors publish the first comprehensive study in Hungary on the pancreas pseudocyst in childhood. Having reviewed their series and the medical literature main features and the possible prevention and management of this disease is outlined. Review of these patients with ultrasonography and chemistry tests is advised in order to follow-up the recovery and to screen the error in the glucose metabolism.

[Obstetric analgesia using nitralgin inhalation and lumbal peridural anesthesia (a model for obstetric analgesia)]

Authors report the systems of anesthesia used at their ward for delivery in the last eight years. Nitralgin inhalation is used since 1981, lumbar peridural anesthesia is used since 1983. Of 13,458 deliveries in case of 3893 parturiants Nitralgin analgesia was used, while LEDA was used for 2300 parturients. By means of Nitralgin inhalation system it could be assured in the delivery room to apply the pain relief gas mixture (Nitralgin) simultaneously for several parturients. With direction of anesthesiologists employed for the ward the LEDA was attained by gynecologists knowing the use and application of general anesthesia. Thus the continuous application of both procedures can be ensured in 24 hours a day. In our study the frequency of vacuum extraction (0.26 p. c.) and that of Cesarean section (12.81 p. c.) did not increase. With application of these methods it could be achieved that 60 p. c. of vaginal deliveries are performed with anesthesia. Authors propose their system for wider application since in the same ward more and more parturients can be applied anesthesia for pain relief at vaginal delivery.

Investigation of subclinical signs of autonomic neuropathy in the early stage of childhood diabetes

It has been suggested that subclinical signs of neuropathy appear earlier than microvascular complications of diabetes. To evaluate the occurrence of autonomic nervous system dysfunction in the early stage of childhood diabetes, subclinical signs of autonomic neuropathy (resting heart rate, hyperventilatory arrhythmia, standing/lying heart rate ratio, orthostatic decrease in blood pressure, and increase in blood pressure during sustained handgrip) were investigated in 54 children with type 1 diabetes divided into three groups: 14 recent-onset diabetics (3 weeks after the diagnosis), 20 diabetics in the remission phase, and 20 patients after the remission phase. 30 healthy age-matched children were used as control group. The mean resting heart rates of the diabetic groups in the remission phase and after the remission phase were significantly higher than those in the healthy control group (81.7 +/- 5/min and 88.5 +/- 6/min vs. 72.2 +/- 8/min; p less than 0.01). The hyperventilatory arrhythmia in the group of diabetic children after the remission phase in comparison with the control group was significantly decreased (29.1 +/- 4/min vs. 22.7 +/- 3/min; p less than 0.01). In a few cases of the recent-onset diabetic group, the increase in resting heart rate, the decrease in hyperventilatory arrhythmia, and the standing/lying heart rate ratio proved to be significant. In the remission phase, the same parameters showed abnormal values in one third to one fifth of the children.(ABSTRACT TRUNCATED AT 250 WORDS)

[Correlation of autonomic neuropathy and retinal microangiopathy in diabetic children]

The authors investigated the preclinical signs of autonomic neuropathy (resting heart rate, hyperventilatory arrhythmia, heart rate on standing/lying, orthostatic blood-pressure decrease) in 15 type I diabetic children with negative FLAG as well as a control group of 10 healthy children. In the diabetic group with negative FLAG as compared to control children the mean resting heart rate was significantly higher, the mean values of cardiovascular reflexes did not show significant differences, however in a third of these patients the narrowing of hyperventilatory arrhythmia was demonstrable. The differences of mean values of all the four investigated parameters in the group with positive FLAG comparing with the control group proved to be significant. According to their results the initial disturbances of the autonomic nervous system in childhood diabetes may appear relatively early--before the preclinical stage of retinal microangiopathy--showing the untimely dysfunction of the parasympathetic nervous system, on the other hand the signs relating to disturbance of the sympathetic nervous system (heart rate ratio on standing/lying, orthostatic blood-pressure decrease) become only in preclinical retinopathic children positive.

[Microelements in the placenta, in maternal blood and in umbilical cord blood]

The content of copper, zinc, plumbum and cadmium was determined in maternal blood, umbilical blood and placental tissue using atomic absorption method. In umbilical blood the concentration of copper and zinc was significantly lower, independent from sex and birth weight of the newborns and from age and residence of the mothers. Cadmium and plumbum did not show such differences. Placenta is permeable to cadmium.