Understanding diabetes heterogeneity: key steps towards precision medicine in diabetes

Diabetes is a highly heterogeneous condition; yet, it is diagnosed by measuring a single blood-borne metabolite, glucose, irrespective of aetiology. Although pragmatically helpful, disease classification can become complex and limit advances in research and medical care. Here, we describe diabetes heterogeneity, highlighting recent approaches that could facilitate management by integrating three disease models across all forms of diabetes, namely, the palette model, the threshold model and the gradient model. Once diabetes has developed, further worsening of established diabetes and the subsequent emergence of diabetes complications are kept in check by multiple processes designed to prevent or circumvent metabolic dysfunction. The impact of any given disease risk factor will vary from person-to-person depending on their background, diabetes-related propensity, and environmental exposures. Defining the consequent heterogeneity within diabetes through precision medicine, both in terms of diabetes risk and risk of complications, could improve health outcomes today and shine a light on avenues for novel therapy in the future.

Excess BMI Accelerates Islet Autoimmunity in Older Children and Adolescents

OBJECTIVE

Sustained excess BMI increases the risk of type 1 diabetes (T1D) in autoantibody-positive relatives without diabetes of patients. We tested whether elevated BMI also accelerates the progression of islet autoimmunity before T1D diagnosis.

RESEARCH DESIGN AND METHODS

We studied 706 single autoantibody-positive pediatric TrialNet participants (ages 1.6-18.6 years at baseline). Cumulative excess BMI (ceBMI) was calculated for each participant based on longitudinally accumulated BMI ≥85th age- and sex-adjusted percentile. Recursive partitioning analysis and multivariable modeling defined the age cut point differentiating the risk for progression to multiple positive autoantibodies.

RESULTS

At baseline, 175 children (25%) had a BMI ≥85th percentile. ceBMI range was -9.2 to 15.6 kg/m² (median -1.91), with ceBMI ≥0 kg/m² corresponding to persistently elevated BMI ≥85th percentile. Younger age increased the progression to multiple autoantibodies, with age cutoff of 9 years defined by recursive partitioning analysis. Although ceBMI was not significantly associated with progression from single to multiple autoantibodies overall, there was an interaction with ceBMI ≥0 kg/m², age, and HLA (P = 0.009). Among children ≥9 years old without HLA DR3-DQ2 and DR4-DQ8, ceBMI ≥0 kg/m² increased the rate of progression from single to multiple positive autoantibodies (hazard ratio 7.32, P = 0.004) and conferred a risk similar to that in those with T1D-associated HLA haplotypes. In participants <9 years old, the effect of ceBMI on progression to multiple autoantibodies was not significant regardless of HLA type.

CONCLUSIONS

These data support that elevated BMI may exacerbate islet autoimmunity prior to clinical T1D, particularly in children with lower risk based on age and HLA. Interventions to maintain normal BMI may prevent or delay the progression of islet autoimmunity.

Medication-induced hyperglycemia: pediatric perspective

Medication-induced hyperglycemia is a frequently encountered clinical problem in children. The intent of this review of medications that cause hyperglycemia and their mechanisms of action is to help guide clinicians in prevention, screening and management of pediatric drug-induced hyperglycemia. We conducted a thorough literature review in PubMed and Cochrane libraries from inception to July 2019. Although many pharmacotherapies that have been associated with hyperglycemia in adults are also used in children, pediatric-specific data on medication-induced hyperglycemia are scarce. The mechanisms of hyperglycemia may involve β cell destruction, decreased insulin secretion and/or sensitivity, and excessive glucose influx. While some medications (eg, glucocorticoids, L-asparaginase, tacrolimus) are markedly associated with high risk of hyperglycemia, the association is less clear in others (eg, clonidine, hormonal contraceptives, amiodarone). In addition to the drug and its dose, patient characteristics, such as obesity or family history of diabetes, affect a child's risk of developing hyperglycemia. Identification of pediatric patients with increased risk of developing hyperglycemia, creating strategies for risk reduction, and treating hyperglycemia in a timely manner may improve patient outcomes.

Racial/Ethnic Minority Youth With Recent-Onset Type 1 Diabetes Have Poor Prognostic Factors

OBJECTIVE

To compare races/ethnicities for characteristics, at type 1 diabetes diagnosis and during the first 3 years postdiagnosis, known to influence long-term health outcomes.

RESEARCH DESIGN AND METHODS

We analyzed 927 Pediatric Diabetes Consortium (PDC) participants <19 years old (631 non-Hispanic white [NHW], 216 Hispanic, and 80 African American [AA]) diagnosed with type 1 diabetes and followed for a median of 3.0 years (interquartile range 2.2-3.6). Demographic and clinical data were collected from medical records and patient/parent interviews. Partial remission period or "honeymoon" was defined as insulin dose-adjusted hemoglobin A_1c (IDAA1c) ≤9.0%. We used logistic, linear, and multinomial regression models, as well as repeated-measures logistic and linear regression models. Models were adjusted for known confounders.

RESULTS

AA subjects, compared with NHW, at diagnosis, were in a higher age- and sex-adjusted BMI percentile (BMI%), had more advanced pubertal development, and had higher frequency of presentation in diabetic ketoacidosis, largely explained by socioeconomic factors. During the first 3 years, AA subjects were more likely to have hypertension and severe hypoglycemia events; had trajectories with higher hemoglobin A_1c, BMI%, insulin doses, and IDAA1c; and were less likely to enter the partial remission period. Hispanics, compared with NHWs, had higher BMI% at diagnosis and over the three subsequent years. During the 3 years postdiagnosis, Hispanics had higher prevalence of dyslipidemia and maintained trajectories of higher insulin doses and IDAA1c.

CONCLUSIONS

Youth of minority race/ethnicity have increased markers of poor prognosis of type 1 diabetes at diagnosis and 3 years postdiagnosis, possibly contributing to higher risk of long-term diabetes complications compared with NHWs.

Heterogeneity of Type 1 Diabetes: The Effect of Ethnicity

BACKGROUND

Most of the current understanding of type 1 diabetes (T1D) etiology and pathogenesis stemmed from studies conducted in majoritarily Non-Hispanic White (NHW) populations. However, evidence is emerging that unique mechanisms of disease may contribute to the development of T1D in individuals of Hispanic ethnicity.

OBJECTIVE

We reviewed the currently available literature on genetic, immunologic, metabolic and clinical characteristics of T1D in Hispanic as compared with NHW individuals.

METHODS

We searched PubMed, Google Scholar, and authors' bibliographies to collect information from relevant articles on the influence of ethnicity on T1D etiology and pathogenesis.

RESULTS

There are significant epidemiological variation based on ethnicity, with consistently higher T1D incidence and prevalence rate in NHWs than Hispanics. The frequencies of T1D high-risk HLA haplotypes and genotypes, as well as their susceptibility or protective effects show considerable ethnic differences. There are conflicting data on immunologic factors (e.g. islet autoantibody positivity) and markers of beta-cell function (e.g., C-peptide levels), as well as in some clinical characteristics (e.g. frequencies of diabetic ketoacidosis and severe hypoglycemia), while age of onset is consistently similar between both groups. Higher prevalence of obesity, less intensive diabetes management, and poorer glycemic control were reported in Hispanics. Accordingly, ethnic disparities in clinical outcomes have been demonstrated as well.

CONCLUSION

There are considerable differences in T1D characteristics between NHWs and Hispanics. Better insight into these ethnic differences would not only affect patient care of patients with T1D, but may also inform the design of future prediction and prevention trials.

Racial and ethnic differences among children with new-onset autoimmune Type 1 diabetes

AIM

To compare demographic and clinical characteristics among children from ethnic minorities and non-Hispanic white children with new-onset autoimmune Type 1 diabetes.

METHODS

We analysed a single-centre series of 712 children with new-onset autoimmune Type 1 diabetes between January 2008 and March 2011. The median (range) age was 9.7 (0.3-18.1) years, the mean (sd) BMI percentile was 69.7 (25.4) and 48.3% of the cohort were girls. The cohort comprised 57.3% non-Hispanic white, 20.5% Hispanic and 14.8% African-American children, and 7.4% were of other, mixed or unknown race.

RESULTS

The Hispanic subgroup, compared with non-Hispanic white subgroup, had a higher mean (sd) C-peptide level [0.82 (1.62) vs 0.55 (0.47) ng/ml; P=0.004), and a greater proportion of children with elevated BMI (overweight or obesity; 49.6% vs 32.5%; P<0.001) and diabetic ketoacidosis (51.8% vs 38.2%; P=0.006). The African-American group had a higher mean (sd) glucose level [24.4 (12.8) vs 21.4 (10.7) mmol/l; P=0.017], a greater proportion of children with ketoacidosis (56.7% vs 38.2%; P=0.001), a greater proportion with elevated BMI (52.9% vs 32.5%; P<0.001), and a lower proportion of children at pre-pubertal stage (49.0% vs 61.6%; P=0.01), and tended to have higher C-peptide levels [0.65 (0.59) vs 0.55 [0.47] ng/ml; P=0.079) compared with the non-Hispanic white children. The differences in C-peptide levels compared with non-Hispanic white children persisted for Hispanic (P=0.01) but not African-American children (P=0.29) after adjustment for age, sex, BMI, ketoacidosis, glucose, Tanner stage and autoantibody number.

CONCLUSION

At the onset of paediatric autoimmune Type 1 diabetes, Hispanic, but not African-American children had higher C-peptide levels, after adjustment for potential confounders, compared with non-Hispanic white children. These findings suggest that ethnicity may contribute to the heterogeneity of Type 1 diabetes pathogenesis, with possible implications for intervention.

Dissecting heterogeneity in paediatric Type 1 diabetes: association of TCF7L2 rs7903146 TT and low-risk human leukocyte antigen (HLA) genotypes

AIMS

To test the hypothesis that non-obese individuals with childhood-onset Type 1 diabetes and the rs7903146 TT genotype would be less likely to have high-risk human leukocyte antigen (HLA) genotypes and alleles.

METHODS

We studied a cohort of 105 non-obese participants in the T1D Exchange Biobank Residual Insulin Study who had childhood-onset Type 1 diabetes [mean (sd) age at onset and recruitment, respectively, 9.9 (4.15) and 14.4 (4.13) years; 84.8% non-Hispanic white]. We analysed islet autoantibodies (glutamic acid decarboxylase 65, islet cell autoantigen 512/islet antigen-2 and zinc transporter 8), non-fasting random C-peptide levels, HLA type and TCF7L2 single nucleotide polymorphism rs7903146 in this cohort.

RESULTS

None of the 13 individuals with the rs7903146 TT genotype carried the highest Type 1 diabetes risk HLA genotype, i.e. DRB1*03:01/DR4 (DRB1*0401, *04:05 or *04:02), compared with 29.4% (27/92) of those without it (P=0.023). The DRB1*03:01 allele was present in 15.4% (2/13) of individuals with the single nucleotide polymorphism, compared with 59.8% (55/92) of those without it (P=0.003). Analyses restricted to autoantibody-positive individuals (n=80) yielded similar results. The HLA DRB1*15:01 allele, which affords dominant protection against Type 1 diabetes, was found in one participant, who had multiple islet autoantibodies and carried the rs7903146 TT genotype.

CONCLUSIONS

These findings further support the hypothesis that TCF7L2 gene variation contributes to diabetogenesis in a subset of young people with Type 1 diabetes, opening possible new pathways for therapy and prevention.

Serum adiposity-induced biomarkers in obese and lean children with recently diagnosed autoimmune type 1 diabetes

BACKGROUND/OBJECTIVE

Obesity increases the risk of cardiovascular disease and diabetic complications in type 1 diabetes. Adipokines, which regulate obesity-induced inflammation, may contribute to this association. We compared serum adipokines and inflammatory cytokines in obese and lean children with new-onset autoimmune type 1 diabetes.

SUBJECTS AND METHODS

We prospectively studied 32 lean and 18 obese children (age range: 2-18 yr) with new-onset autoimmune type 1 diabetes and followed them for up to 2 yr. Serum adipokines [leptin, total and high molecular weight (HMW) adiponectin, omentin, resistin, chemerin, visfatin], cytokines [interferon (IFN)-gamma, interleukin (IL)-10, IL-12, IL-6, IL-8, and tumor necrosis factor (TNF)-alpha] and C-reactive protein (CRP) were measured at a median of 7 wk after diagnosis (range: 3-16 wk).

RESULTS

Lean children were 71.9% non-Hispanic White, 21.9% Hispanic, and 6.3% African-American, compared with 27.8, 55.6, and 16.7%, respectively, for obese children (p = 0.01). Compared with lean children, obese children had significantly higher serum leptin, visfatin, chemerin, TNF-alpha and CRP, and lower total adiponectin and omentin after adjustment for race/ethnicity and Tanner stage. African-American race was independently associated with higher leptin among youth ≥10 yr (p = 0.007). Leptin levels at onset positively correlated with hemoglobin A1c after 1-2 yr (p = 0.0001) independently of body mass index, race/ethnicity, and diabetes duration. Higher TNF-alpha was associated with obesity and female gender, after adjustment for race/ethnicity (p = 0.0003).

CONCLUSION

Obese children with new-onset autoimmune type 1 diabetes have a proinflammatory profile of circulating adipokines and cytokines that may contribute to the development of cardiovascular disease and diabetic complications.

Immunohistochemical characterization of polyclonal antibodies against Enteromyxum leei and Enteromyxum scophthalmi (Myxozoa: Myxosporea), intestinal parasites of fish

The enteric myxozoan parasites Enteromyxum leei (Diamant, Lom et Dyková) and Enteromyxum scophthalmi Palenzuela, Redondo et Álvarez-Pellitero are responsible for high weight loss in infected fish, which leads to subchronic disease and low mortality rates in gilthead sea bream (GSB), Sparus aurata L., and to high mortality rates in turbot, Psetta maxima (L.). The detection of initial parasite stages in histological sections is particularly difficult, but can be simplified by means of specific antibodies. Rabbit polyclonal antibodies (pAbs) were raised against E. scophthalmi and E. leei, and direct enzyme-linked immunosorbent assay (ELISA) and immunohistochemistry were used to characterize their sensitivity and specificity. Both pAbs were adsorbed (apAb) with non-infected intestines to avoid non-specific labelling of fish tissues and to improve their specificity. The highest titre obtained in ELISA was 1: 32 000 for apAb-Eleei and 1:16 000 for apAb-Escoph. Working dilutions in immunohistochemistry were 1:1000 for apAb-Eleei and 1:8000 for apAb-Escoph. Both apAbs labelled proliferative and sporogonic stages with high specificity. apAb-Escoph was very specific, whereas apAb-Eleei cross-reacted with Sphaerospora dicentrarchi Sitjà-Bobadilla et Álvarez-Pellitero and Sphaerospora testicularis Sitjà-Bobadilla et Álvarez-Pellitero, suggesting the presence of shared antigens. These pAbs stand as new tools for antigenic characterization and the diagnosis of both Enteromyxum species.

Therapeutics in pediatric diabetes: insulin and non-insulin approaches. Part of a series on Pediatric Pharmacology, guest edited by Gianvincenzo Zuccotti, Emilio Clementi, and Massimo Molteni

Treatment of pediatric diabetes can be challenging. Strict glucose control can be accompanied by hypoglycemia and weight gain. Recently, there have been many developments in insulin preparations and delivery methods which make insulin levels more close to a physiologic pattern. Newly developed rapid/long acting analogues and delivery devices such as continuous subcutaneous insulin infusion (CSII, insulin pump) may reduce hypoglycemia and improve glycemic control. CSII combined with continuous glucose monitoring can achieve even better glycemic control. The closed-loop system is rapidly evolving and an artificial pancreas will be available in the near future. It is now recognized that several hormones other than insulin such as glucagon, amylin, and incretins contribute to glucose homeostasis. The role of co-adjuncts such as metformin, amylin analogues, and incretin based therapy is now emerging. Immunotherapy in a high risk population or patients in the early phase of type 1 diabetes may prevent further destruction of pancreatic β cells.

Light and electron microscopic studies on turbot Psetta maxima infected with Enteromyxum scophthalmi: histopathology of turbot enteromyxosis

In the last decade, a new parasite that causes severe losses has been detected in farmed turbot Psetta maxima (L.), in north-western Spain. The parasite was classified as a myxosporean and named Enteromyxum scophthalmi. The aim of this study was to characterize the main histological changes that occur in E. scophthalmi-infected turbot. The parasite provoked catarrhal enteritis, and the intensity of the lesions was correlated with the progression of the infection and with the development of the parasite. Infected fish were classified into 3 groups, according to the lesional degree they showed (slight, moderate and severe infections). In fish with slight infections, early parasitic stages were observed populating the epithelial lining of the digestive tract, without eliciting an evident host response. As the disease progressed, catarrhal enteritis was observed, the digestive epithelium showed a typical scalloped shape and the number of both goblet and rodlet cells was increased. Fish with severe infections suffered desquamation of the epithelium, with the subsequent release of parasitic forms to the lumen. The dislodged enterocytes underwent anoikis, a mode of apoptosis triggered by the loss of anchorage, which might facilitate spreading of the parasite. Lymphohaematopoietic depletion was also observed, mainly in head kidney and spleen, which could contribute to the high virulence of this parasite.

An unidentified epi-epithelial myxosporean in the intestine of gilthead sea bream Sparus aurata L

In the course of experimental infections of gilthead sea bream Sparus aurata with the myxozoan Enteromyxum leei, stages of an unidentified myxozoan were observed attached to the intestinal brush border of some fish. Infection levels of the parasite, which was named "epi-epithelial myxosporean" (EEM) were recorded, and its structure was studied by light microscopy (LM) and electron microscopy (EM). In situ hybridisation (ISH) probes specific for E. leei were developed and used to differentiate between the two parasites. The EEM parasite was observed only in epi-epithelial position on the intestine mucosa and never in any of the other tissues studied (kidney and gall bladder). Prevalence was variable, with values reaching 40.2%. With transmission EM, trophozoites displayed pseudopodia-like projections inserted in between the enterocyte microvilli, producing an intimate interface. No mucosal histopathology that could be attributed to the myxozoan was found. EEM stages did not stain with the E. leei-specific ISH probes. From the results of the LM, EM and ISH studies, we conclude that the EEM parasite found in gilthead sea bream intestine in both Mediterranean and Red Sea sites is a coelozoic myxosporean, distinct from E. leei.

Innate and adaptive immune responses of turbot, Scophthalmus maximus (L.), following experimental infection with Enteromyxum scophthalmi (Myxosporea: Myxozoa)

The innate and adaptive immune responses against Enteromyxum scophthalmi was studied in turbot (Scopthalmus maximus (L.)) experimentally exposed to the parasite by cohabitation. Haematological, histopathological, cellular and humoral factors were determined in samples taken from control (CTRL) and recipient (RCPT, naïve fish cohabited with donor infected fish) animals at 0, 20, 29, 40 and 43 days post exposure (p.e). Infection was first detected at day 20 p.e. and prevalence reached 100% at 40 days p.e, when first mortalities occurred. A significant reduction in weight and condition factor was found in RCPT, though no significant differences in haematocrit or serum protein levels were detected between CTRL and RCPT. Some immune effectors were clearly activated in RCPT: the percentage of circulating granulocytes was significantly increased, as well as the number of blood cells positive in the respiratory burst assay; leucocyte infiltration in intestine was found mainly on days 20 and 29 p.e.; total serum antiproteases and alpha-2-macroglobulin levels were higher in most of the samplings, with significant differences on the last sampling. Other effectors were clearly down regulated in RCPT: haematopoietic depletion appeared in head kidney from day 29 p.e. onwards, and the number of apoptotic cells and MMC increased in head kidney and spleen; the percentage of lymphocytes decreased progressively and significantly; a clear, but not statistically significant, drop in serum complement was registered at 40 days p.e.; also, a significant decrease occurred in serum lysozyme at 29 days p.e. No specific antibodies against the parasite were detected in any sampling.

Risk factors associated with Enteromyxum scophthalmi (Myxozoa) infection in cultured turbot, Scophthalmus maximus (L.)

An epidemiological cohort study of Enteromyxum scophthalmi in cultured turbot was performed on a farm in North Western Spain. Four different ongrowing stocks (A, B, C, D) were monitored monthly until market size. Fish from stocks C and D were divided into 2 subgroups, receiving filtered (CF and DF) or unfiltered (CUF and DUF) water. The lack of water filtration was positively associated with infection prevalence, as all fish kept in filtered water remained uninfected. Parasite abundance varied seasonally (P<0.05) in stock B and subgroup CUF. Infection was also associated (P<0.05) with host weight, and the highest prevalences and intensities were detected in 101-200 g and 201-300 g fish. Distribution pattern of E. scophthalmi in subgroups CUF and DUF had a variance higher than the mean, indicating overdispersion. The minimum period necessary for the first detection of the parasite and for the appearance of disease symptoms and mortality, varied depending on the stock and introduction date, although a long pre-patent period was always observed. Several factors, such as host density, parasite recruitment and parasite-induced fish mortality can contribute to the observed distribution pattern. Risk factors found to be associated with E. scophthalmi infection, including water quality and accumulation of infective stages in the culture tanks, should be considered when designing control strategies to prevent the introduction and spread of infective stages in the facilities.

Seasonality of month of birth of children and adolescents with type 1 diabetes mellitus in homogenous and heterogeneous populations

BACKGROUND

Type 1 childhood-onset diabetes mellitus has a multifactorial origin involving an interplay between genetic and environmental factors. We have previously shown that many children who subsequently develop T1DM have a different seasonality of birth than the total live births of the same population, supporting the hypothesis that perinatal viral infection is a trigger for the autoimmune process of T1DM.

OBJECTIVES

To compare the seasonality of children with T1DM in different populations around the world for which data were available.

METHODS

We analyzed large cohorts of T1DM patients with a clinical disease onset before age 14 or 18 years.

RESULTS

We found a seasonality pattern only in ethnically homogenous populations (such as Ashkenazi Jews, Israeli Arabs, individuals in Sardinia and Canterbury, New Zealand, and Afro-Americans) but not in heterogeneous populations (such as in Sydney, Pittsburgh and Denver).

CONCLUSIONS

Our findings attempt to explain the controversial data in the literature by showing that ethnically heterogeneous populations comprising a mixture of patients with various genetic backgrounds and environmental exposures mask the different seasonality pattern of month of birth that many children with diabetes present when compared to the general population.

Cryptosporidium scophthalmi n. sp. (Apicomplexa: Cryptosporidiidae) from cultured turbot Scophthalmus maximus. Light and electron microscope description and histopathological study

Cryptosporidium scophthalmi n. sp. is described from the turbot Scophthalmus maximus L., sampled from different farms on the coast of NW Spain. The parasite was found mainly in the intestinal epithelium and very seldom in the stomach. Oocysts were almost spherical, with 4 naked sporozoites and a residuum, and measured 3.7-5.03 x 3.03-4.69 microm (mean 4.44 x 3.91) (shape index 1.05-1.34, mean 1.14). Sporulation was endogenous, as fully sporulated oocysts were found within the intestinal epithelium, lumen and faeces. Merogonial and gamogonial stages were in the typical extracytoplasmic position, whereas sporogonial stages were deep within the epithelium. Oocysts and other stages of C. scophthalmi comply with most of the diagnostic features of the genus Cryptosporidium, but differ from all hitherto described species. Ultrastructural features, including the characteristic feeding organelle, were mainly comparable with those of other Cryptosporidium species. Mitochondria were frequently observed in sporozoites. Infection prevalence was very variable, and juvenile fish were most frequently and intensively parasitised. External clinical signs were not detected, although some fish showed intestinal distension at necropsy. The marked histopathological damage occurring in severe infection includes distension of epithelial cells by large vacuoles, containing clusters of oocysts, and can lead to sloughing of epithelial cell remnants and oocysts or even detachment of intestinal mucosa. An inflammatory reaction involving leucocyte infiltration was sometimes observed.

Development of immunohistochemistry and enzyme-linked immunosorbent assays for the detection of circulating antibodies against Enteromyxum scophthalmi (Myxozoa) in turbot (Scophthalmus maximus L.)

Immunohistochemistry and enzyme-linked immunosorbent assays were developed for the detection of specific antibodies against the myxosporean parasite Enteromyxum scophthalmi in turbot (Scophthalmus maximus L.). Fish which had survived a previous epizootic were exposed to the parasite by cohabitation with infected animals, and 83 days later the plasma was tested for the presence of antibodies. Plasma of non-exposed fish was used as negative control. Immunohistochemistry (IHC) using rabbit anti-turbot IgM antibody was first used to detect these antibodies, and to study to which parasite structures they were directed against. Also, an antibody-ELISA using whole cell lysates of the parasite as antigen, and a monoclonal antibody anti-turbot IgM, was developed. All the exposed fish were found to have specific antibodies against the parasite, and none of them developed signs of disease or died during the experiment. Primary cells were the main parasite stage immunolabelled, and the staining was distinctly located on the cytoplasm and the cytoplasmic membrane. IHC was more sensitive than ELISA, as the endpoint was two to four fold higher with the former technique. Although there was great individual variation, the antibody titres found can be considered high, reaching up to 1:32,000 with ELISA and 1:64,000 with IHC. The results suggest that turbot showing acquired immunity against E. scophthalmi, could develop resistance against new infections.

Genetic control of autoimmunity in Type I diabetes and associated disorders

Type I (insulin-dependent) diabetes mellitus is a heterogeneous disease with major subdivisions termed Type 1A (immune-mediated) and Type 1B. Immune-mediated diabetes is also heterogeneous with "monogenic", oligogenic, and polygenic forms present in humans and in animal models. Single-gene mutations of two transcription factors have been recently identified in rare syndromes of autoimmunity with type 1A diabetes: autoimmune polyendocrine syndrome type 1 (APS-1) and X-linked polyendocrinopathy, immune dysfunction and diarrhoea (XPID). For more common forms of diabetes, susceptibility loci within the major histocompatibility complex and at the insulin locus have been identified. Both DQ(*) and DR* alleles provide susceptibility and certain alleles dominant protection. In the Diabetes Autoimmunity Study of the Young approximately 50 % of the siblings studied with the highest-risk HLA genotype develop anti-islet autoantibodies by age 3. Insulin could be a crucial autoantigen related to genetic susceptibility. The crystal structure of the high-risk allele, HLA-DQ8, complexed with an insulin peptide has just been reported. Insulin production by macrophage-dendritic cells within the thymus and lymphoid organs could underlie insulin gene polymorphisms influencing the risk of diabetes. Genome-wide scans for linkage in animal models and in humans have not conclusively identified other susceptibility genes though many loci have been implicated. We favour the hypothesis that HLA is a major determinant of susceptibility in animal models and in most families, and that the search for diabetogenes should concentrate on unique families to decrease heterogeneity and favour the eventual discovery of genes influencing risk.

Description of Enteromyxum scophthalmi gen. nov., sp. nov. (Myxozoa), an intestinal parasite of turbot (Scophthalmus maximus L.) using morphological and ribosomal RNA sequence data

A new Myxozoa species causing enteritis and death in cultured turbot, Scophthalmus maximus, is described at light and electron microscope levels. In addition, small subunit ribosomal RNA gene sequences (SSU rDNA) from the new species and from similar myxozoans were obtained and used for phylogenetic inference, as complementary criteria to resolve its taxonomic classification. The new parasite is closely related to Myxidium leei, another enteric histozoic species from marine fish. However, the ascription of M. leei to the genus Myxidium was based on weak morphological evidence and is not supported by our rDNA data analysis. A close relationship with Zschokkella, the other morphologically related myxozoan genus is also not supported. The combined morphological and molecular study results in the establishment of the new genus Enteromyxum to accommodate the new species E. scophthalmi, and the former M. leei, which is transferred to the new genus as Enteromyxum leei (Diamant, Lom & Dyková 1994) n. comb. This genus of marine, histozoic and enteric myxozoans includes significant parasite species for marine finfish culture.

Comparison of various liquid chromatographic methods for the analysis of avermectin residues in citrus fruits

Various liquid chromatographic (LC) techniques for analyzing avermectin (Abamectin) were compared after extraction of residues from citrus fruit samples by matrix solid-phase dispersion (MSPD). LC with UV and fluorescence detection were used as also was LC coupled to the mass spectrometer by an electrospray interface. The results obtained by the three methods were compared in terms of sensitivity and selectivity. The combination of MSPD extraction and LC with fluorescence detection have made it possible to quantify 0.5 microg kg(-1) of Abamectin in 0.5 g of orange sample, with an overall average recovery of 94%. The procedure provides a simple and sensitive method for monitoring Abamectin residues in citrus fruit at the levels required by legislation.

Genetics of type 1A diabetes

Type 1A diabetes is an autoimmune disease with genetic and environmental factors contributing to its etiology. Twin studies, family studies, and animal models have helped to elucidate the genetics of autoimmune diabetes. Most of the genetic susceptibility is accounted for by human leukocyte antigen (HLA) alleles. The most-common susceptibility haplotypes are DQA1*0301-DQB1*0302 and DQA1*0501-DQB1*0201. Less-common haplotypes such as DQA1*0401-DQB1*0402 and DQA1*0101-DQB1*0501 are associated with high risk for diabetes; however, large study populations are needed to analyze their effect. The DQA1*0102-DQB1*0602 haplotype is associated with diabetes resistance. DR molecules, such as DRB1*1401, confer protection from diabetes. Monozygotic twins of patients with type 1A diabetes have a diabetes risk higher than that for HLA-identical ordinary siblings, suggesting that non-HLA genes contribute to diabetes risk. Polymorphisms in the regulatory region of the insulin gene (designated IDDM2), polymorphisms in cytotoxic T lymphocyte antigen-4 (CTLA-4) gene (IDDM12), and other genes are likely to contribute to diabetes risk and susceptibility in some individuals. In selected families, major diabetogenes (e.g., IDDM17, autoimmune regulator gene (AIRE)) are likely to be of importance. Other factors--either noninherited genes (i.e., somatic mutations and T-cell receptor or immunoglobulin rearrangements) or environment--may have a role in progression to diabetes. This is suggested by the finding that the risk for monozygotic twins of patients with type 1A diabetes is not 100 percent. Studying the genetics of type 1A diabetes will allow us to better define this disease, to improve our ability to identify individuals at risk, and to predict the risk of associated disorders.

Self-antigen-presenting cells expressing diabetes-associated autoantigens exist in both thymus and peripheral lymphoid organs

Recent reports indicate that genes with tissue-restricted expression, including those encoding the type 1 diabetes autoantigens insulin, glutamic acid decarboxylase (GAD), and the tyrosine-phosphatase-like protein IA-2 (or ICA512), are transcribed in the thymus. The reported modulation of diabetes susceptibility by genetically determined differences in thymic insulin levels and studies in transgenic mice provide correlative and functional evidence that thymic expression of peripheral proteins is crucial for immunological self-tolerance. However, there are no specific data about the existence, tissue distribution, phenotype, and function of those cells that express insulin and other self-antigens in the human thymus. We find that the human thymus harbors specialized cells synthesizing (pro)insulin, GAD, and IA-2, mainly localized in the medulla, and we demonstrate such cells also in peripheral lymphoid organs (spleen and lymph nodes). Phenotypic analysis qualifies these cells as antigen-presenting cells (APCs), including both dendritic cells and macrophages. These cells often appear surrounded by apoptotic lymphocytes, both in thymus and spleen, and may therefore be involved in the deletion of autoreactive lymphocytes. Our findings demonstrate the existence of, and define the tissue distribution and phenotype of, a novel subset of APCs expressing self-antigens in human lymphoid organs that appear to be involved in the regulation of self-tolerance throughout life.

Heterogeneity of type I diabetes: analysis of monozygotic twins in Great Britain and the United States

AIMS

To determine the risk, hazard rate and factors affecting progression to diabetes in monozygotic twins of patients with Type I (insulin-dependent) diabetes mellitus.

METHODS

Prospective analysis was done of two cohorts of non-diabetic monozygotic twins of patients with Type I diabetes from Great Britain (n = 134) and the United States (n = 53).

RESULTS

The diabetes-free survival analysis was similar between both cohorts (p = 0.6). The combined survival analysis (n = 187, median follow-up = 17.7 years, range = 0.01-57) at 40 years of discordance estimated a 39% probability of diabetes for the initially discordant twin. Survival analysis with left truncation of data estimated that probability to be 50%. For twins who became concordant (n = 47), the median discordance time was 4.2 years (range 0.4 to 39), exceeding 15 years in 23.4%. Twins of probands diagnosed at 24 years of age or younger had a 38% probability of diabetes by 30 years of discordance, compared with 6% for twins of probands diagnosed after 24 years of age (p = 0.004). The twins of probands diagnosed before 15 years of age had the highest diabetes hazard rate in the first discordance year, decreasing thereafter. By survival analysis, diabetes risk was higher in twins who were heterozygous for DR3-DQ2 and DR4-DQ8 than in twins with neither DR3-DQ2 nor DR4-DQ8 (p < 0.05).

CONCLUSION/INTERPRETATION

Monozygotic twins of patients with Type I diabetes from two different countries had similar rates of progression to diabetes. Whereas most twins did not develop diabetes, 25% of the twins who progressed did so after more than 14 years of discordance. An age-related heterogeneity was observed, with higher progression to diabetes for twins of patients diagnosed at a younger age.

DR- and DQ-associated protection from type 1A diabetes: comparison of DRB1*1401 and DQA1*0102-DQB1*0602*

The transmission disequilibrium test was used to analyze haplotypes for association and linkage to diabetes within families from the Human Biological Data Interchange type 1 diabetes repository (n = 1371 subjects) and from the Norwegian Type 1 Diabetes Simplex Families study (n = 2441 subjects). DQA1*0102-DQB1*0602 was transmitted to 2 of 313 (0.6%) affected offspring (P < 0.001, vs. the expected 50% transmission). Protection was associated with the DQ alleles rather than DRB1*1501 in linkage disequilibrium with DQA1*0102-DQB1*0602: rare DRB1*1501 haplotypes without DQA1*0102-DQB1*0602 were transmitted to 5 of 11 affected offspring, whereas DQA1*0102-DQB1*0602 was transmitted to 2 of 313 affected offspring (P < 0.0001). Rare DQA1*0102-DQB1*0602 haplotypes without DRB1*1501 were never transmitted to affected offspring (n = 6). The DQA1*0101-DQB1*0503 haplotype was transmitted to 2 of 42 (4.8%) affected offspring (P < 0.001, vs. 50% expected transmission). Although DRB1*1401 is in linkage disequilibrium with DQB1*0503, neither of the two affected children who carried DQA1*0101-DQB1*0503 had DRB1*1401. However, all 13 nonaffected children who inherited DQA1*0101-DQB1*0503 had DRB1*1401. In a case-control comparison of patients from the Barbara Davis Center, DQA1*0101-DQB1*0503 was found in 5 of 110 (4.5%) controls compared with 3 of 728 (0.4%) patients (P < 0.005). Of the three patients with DQB1*0503, only one had DRB1*1401. Our data suggest that both DR and DQ molecules (the DRB1*1401 and DQA1*0102-DQB1*0602 alleles) can provide protection from type 1A diabetes.

Determination of abamectin in citrus fruits by liquid chromatography-electrospray ionization mass spectrometry

Liquid chromatography coupled to electrospray mass spectrometry (LC-ES-MS) with positive ion detection was used to determine abamectin in oranges. MS conditions were optimized to achieve maximum sensitivity. The main ion for abamectin was [M+Na]+ at a fragmentor voltage of 180 V. Abundant structural information can be obtained at different fragmentor voltages. The detection limit for the standard solution was 12 pg injected, and good linearity and reproducibility were observed. Abamectin residues were extracted using matrix solid-phase dispersion. Orange samples were homogenized with C18 bonded silica placed onto a glass column and eluted with dichloromethane. Recoveries of the abamectin from oranges fortified with approximately 0.01-10 mg/kg ranged from 94 to 99% with an overall average recovery of 96%. The quantification limit is 0.0025 mg/kg, which means detection limit for this analyte could be set at a few hundred picograms per gram of fruit. The presence in the electrosprayed solution of numerous citrus constituents did not interfere significantly with the ionization process of abamectin. The assay procedure provides a simple, rapid, and sensitive method for monitoring residues in oranges. The method was applied to field treatment orange samples.

Heterophile anti-mouse immunoglobulin antibodies may interfere with cytokine measurements in patients with HLA alleles protective for type 1A diabetes

Wilson and coworkers (Wilson SB, Kent SC, Patton KT, Orban T, Jackson RA, Exley M, Porcelli S, Schatz DA, Atkinson MA, Balk SP, Strominger JL, Hafler DA: Extreme Th1 bias of invariant V alpha24J alpha Q T-cells in type 1 diabetes. Nature 391:177-181, 1998) have recently reported raised serum levels of interleukin-4 (IL-4) in anti-islet autoantibody-positive first-degree relatives of patients with type 1A diabetes who did not progress to diabetes. Protection from diabetes has been noted for several human lymphocyte antigen (HLA) alleles, such as HLA DR2-DQA1*0102-DQB1*0602. We, therefore, wanted to determine whether this cytokine phenotype was associated with HLA genes protective for type 1A diabetes. We used a two-site fluoroimmunoassay with the same monoclonal antibodies as those reported by Wilson et al. Using this assay, we have found evidence for human heterophile antibodies mimicking serum IL-4: all serum IL-4 reactivity was lost if mouse serum or mouse immunoglobulin were added to the assay; serum IL-4 activity was bound and then eluted by protein A/G chromatography; and levels of anti-mouse antibodies correlated with apparent serum IL-4. This pseudo-IL-4 activity was found in a subset of control subjects, patients with type 1A diabetes, and their relatives and was primarily associated with specific HLA alleles protective for type 1A diabetes (e.g., DQB1*0602). After adjustment for HLA, positive levels of heterophile antibodies were not associated with protection from diabetes. The confounding effect of protective HLA alleles associated with heterophile antibodies could explain the previously reported association between raised serum IL-4 and protection from type 1A diabetes. The mechanism by which specific DQ alleles protect from diabetes and are associated with increased heterophile antibodies is currently unknown.

Matrix solid-phase dispersion microextraction and determination by high-performance liquid chromatography with UV detection of pesticide residues in citrus fruit

A multiresidue method based on matrix solid-phase dispersion (MSPD) microextraction was studied to determine the carbamate, benfuracarb, and urea insecticides, diflubenzuron, flufenoxuron hexaflumuron and hexythiazox, used in control of citrus pests. Optimisation of different parameters, such as the type of solid support for matrix dispersion, elution solvents and the clean-up step were carried out. The method used 0.5 g of orange sample, C8 bonded silica as MSPD sorbent and dichloromethane as eluting solvent. Recoveries, at spiked concentrations below the maximum residue levels established by Spanish Government, were between 74 and 84% with relative standard deviations ranging from 2 to 4%. The limits of quantification were from 0.15 to 0.25 microgram/g using high-performance liquid chromatography with UV detection at 200 nm. The method may be useful as a screening protocol for the determination of these newly developed pesticides in citrus samples.

Genetic determination of islet cell autoimmunity in monozygotic twin, dizygotic twin, and non-twin siblings of patients with type 1 diabetes: prospective twin study

OBJECTIVE

To test the hypothesis that non-diabetic dizygotic and monozygotic twin siblings of patients with type 1 diabetes have a similar high prevalence of islet cell autoantibodies, thus suggesting that islet cell autoimmunity is mainly environmentally determined.

DESIGN

Prospective twin study.

SETTING

Two specialist centres for diabetes in the United States.

PARTICIPANTS

Non-diabetic monozygotic twin (n=53), dizygotic twin (n=30), and non-twin (n=149) siblings of patients with type 1 diabetes; 101 controls.

MAIN OUTCOME MEASURES

Analysis of progression to diabetes and expression of anti-islet autoantibodies.

RESULTS

Monozygotic twin siblings had a higher risk of progression to diabetes (12/53) than dizygotic twin siblings (0/30; P<0.005). At the last follow up 22 (41.5%) monozygotic twin siblings expressed autoantibodies compared with 6 (20%) dizygotic twin siblings (P<0.05), 16 (10.7%) non-twin siblings (P<0.0001), and 6 (5.9%) controls (P<0.0001). Monozygotic twin siblings expressed multiple (>/=2) antibodies more often than dizygotic twin siblings (10/38 v 1/23; P<0.05). By life table analysis the probability of developing positive autoantibodies was higher among the monozygotic twin siblings bearing the diabetes associated HLA DQ8/DQ2 genotype than in those without this genotype (64.2% (95% confidence interval 32.5% to 96%) v 23.5% (7% to 40%) at 10 years of discordance; P<0.05).

CONCLUSION

Monozygotic and dizygotic twins differ in progression to diabetes and expression of islet cell autoantibodies. Dizygotic twin siblings are similar to non-twin siblings. These two observations suggest that genetic factors play an important part in determination of islet cell autoimmunity, thus rejecting the hypothesis. In addition, there is a high penetrance of islet cell autoimmunity in DQ8/DQ2 monozygotic twin siblings.

Comparison of different sorbents for on-line liquid-solid extraction followed by high-performance liquid chromatographic determination of nitrogen-containing pesticides

LiChrolut EN [poly(styrene-divinylbenzene), PSDVB], Carbograph (graphitized carbon black, GCB), Isolute CN (cyanopropylsilica), Isolute C2 (ethylsilica), and LiChrospher RP18 (octadecylsilica) were studied for on-line solid-phase extraction of twelve nitrogen containing pesticides from water. Determination (UV 210 nm) was performed with a Spherisorb C8 analytical column and an acetonitrile-water gradient. The mean recoveries from 50 ml ranged from 83% for RP18 to 44% for GCB, and decreased in the following order: RP18, CN, LiChrolut EN, C2, and GCB. GCB showed poor recoveries due to incomplete desorption with the acetonitrile-water gradient used, and memory effects were detected. Backflush was needed to elute selected pesticides from GCB and from LiChrolut EN. Breakthrough volumes were 50-100 ml for most selected pesticides with silica-based phases, whereas LiChrolut EN allowed larger sample volumes without observable losses.

[Parenteral nutrition of patients under intensive chemotherapy: comparative study of two lipid emulsions]

Neoplastic patients receiving intensive chemotherapy often need total parenteral nutrition (TPN), with lipid emulsions based on long-chain triglycerides (LCT) or medium-chain triglycerides (MCT). Potential benefits of MCT include easier metabolism and limited storage. Our present investigation was performed to define if there is any real clinical advantage of any of these lipid emulsions in this group of patients. Fifty-one patients receiving the LCT emulsion and sixty of them receiving the MCT-LCT one were evaluated retrospectively. TPN with 40% of non-protein kilocalories as fat was administered during a mean time of 11.5 days. No differences in total cholesterol, albumin, prealbumin, transferrin, bilirubin, alkaline phosphatase, gamma-glutamyl transpeptidase and transaminases were found between both groups, neither in nitrogen balances. In conclusion, in a group of neoplastic patients receiving intensive chemotherapy, we did not found any advantage of TPN with LCT or MCT-LCT either in nutritional laboratory parameters or in liver function.

Dual-parameter model for prediction of type I diabetes mellitus

The recent cloning and recombinant expression of novel islet autoantigens [glutamic acid decarboxylase (GAD) 65 and islet-cell autoantibody 512 (ICA512)] has made possible the determination of whether the quantitative expression of autoantibodies to these molecules is correlated with age of diabetes onset and rate of progression to diabetes, similar to insulin autoantibodies (IAAs). We measured autoantibodies reacting with GAD65 (GAD65AA), ICA512 (ICA512AA), and insulin in patients who recently had received a diagnosis of diabetes and in first-degree relatives prospectively identified and then followed because of the expression of high titers of ICA. Levels of IAAs (but not GAD65AA or ICA512AA) correlated inversely with age at diagnosis of diabetes and directly with time to diabetes onset among the ICA-positive relatives. In multiple linear regression models, the level of IAAs remained a significant predictor of the time to diabetes after allowing for first-phase insulin secretion. The unique and dramatic association of IAAs with progression to diabetes suggests that IAAs contribute directly to disease pathogenesis or that levels of IAAs are influenced uniquely by the process, leading--at different rates in different prediabetic individuals--to type I diabetes. In addition, the linear regression model described (involving two variables, first-phase insulin secretion and levels of IAAs) aids in the prediction of time to diabetes among ICA-positive relatives.

Primary intrasellar germinoma with synchronous pineal tumor

Germinomas arising within the sella turcica are extremely rare. The association of intrasellar and a pineal region tumours is even more unusual. We report a 30-year-old man with germinomas in the sellar and pineal region.

Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.

Dissipation and distribution of atrazine, simazine, chlorpyrifos, and tetradifon residues in citrus orchard soil

An environmental fate study was conducted in a citrus orchard plot in València (Spain) in the fall of 1993. Dissipation and distribution of atrazine, simazine, chlorpyrifos and tetradifon residues following their controlled addition for agricultural purposes in a mediterranean red soil (Luvic Calcisol, Rhodoxeralf) were evaluated. During a two-month period, the amounts of applied pesticides in different soil layers (0-0.05, 0.05-0.22, 0.22-0.42, and 0.42-0.52 m) were monitored. In addition, information on soils, weather and agricultural practice were collected. Degradation half-lives were calculated, assuming zero-order kinetics: 11 days for atrazine, 12 days for simazine, 10 days for chlorpyrifos, and 18 for tetradifon. The distribution through the soil profile shows that the pesticide concentrations were always highest in the upper layer (0-0.05 m) of soil, and that atrazine was the most mobile of all the four pesticides investigated.

Matrix solid-phase dispersion extraction procedure for multiresidue pesticide analysis in oranges

A multiresidue extraction method based on matrix solid-phase dispersion (MSPD) is optimized for the extraction and gas chromatographic screening of eighteen insecticides (aldrin, carbophenothion, captafol, chlorpyriphos, chlorfenvinphos, diazinon, dicofol, alpha-endosulfan, beta-endosulfan, ethion, fenitrothion, folpet, methidathion, malathion, methyl-azinphos, methyl-parathion, phosmet, and tetradifon) from oranges. After optimization of different parameters, such as type of solid phase used and the amount of solid phase or eluent, recoveries ranged from 67 to 102% with relative standard deviations ranging from 2 to 10%. The limits of detection, calculated as 3 times the baseline noise ranged from 2 to 171 micrograms/kg. These limits of detection were about 10 times lower than the maximum residue levels established by the European Community. Compared with classical methods, the described procedure is simple, less labour intensive and does not require preparation and maintenance of equipment. Troublesome emulsions, such as those frequently observed in liquid-liquid partitioning did not occur.

An unknown risk group of lead poisoning: the gypsy children

The differences in average blood lead levels (PbB) between iron-deficient children of both gypsy and Caucasian origin were determined. PbB were assayed in 89 iron-deficient children (Group ID): 25 gypsies and 64 Caucasians. Two sub-groups were established: sub-group ID1, 57 iron-deficient children without anaemia (11 gypsies, 46 Caucasians), and sub-group ID2, 32 children with iron deficiency anaemia (14 gypsies; 18 Caucasians). Group IS composed of 41 iron-sufficient children (11 gypsies and 30 Caucasians) served as controls. Blood counts, red-cell indices, serum iron concentrations, serum ferritin, and PbB were determined for the entire study population. The average PbB for gypsy and Caucasian iron-deficient children, were 14.25 and 7.25 micrograms/dl (P < 0.01) respectively. The prevalence of iron-deficient children with toxic PbB (> 20 micrograms/dl) was higher in gypsies (24%) than in Caucasians (1.5%) (P < 0.01). A difference in average PbB between the two ethnic groups was also seen in children with normal iron metabolism (average PbB, 10.23 vs 5.65 micrograms/dl for gypsies and Caucasians, respectively, P < 0.001). CONCLUSION Gypsy children should be considered as a population group at risk of lead poisoning in our environment.

Solid-phase extraction on C18 in the trace determination of selected polychlorinated biphenyls in milk

The utility of solid-phase extraction with octadecylsilica for determining fifteen polychlorinated biphenyl (PCB) congeners from milk samples was examined. Recoveries higher than 80% and relative standard deviations better than 10% were obtained for PCBs from different kinds of milk (whole, skimmed, 2%, powdered, breast and evaporated). A comparison with other procedures was made. The described method provides better detection limits than those attainable with the liquid-liquid extractions currently used as standard methods, when capillary gas-liquid chromatography is used for the final determination. A study of the separation was also performed using six different fused-silica capillary columns and an electron-capture detector.

[A retrospective study of 469 cases of acute appendicitis. Importance of primary care]

In the present study 469 cases of acute appendicitis, who were referred from the community and operated in the Surgery Service from the Soria Hospital, were retrospectively evaluated. The results showed an incidence of appendectomies lower than in other series (79.76 cases/100,000/year), with a higher frequency in males and in the age group between 10-30 years. No significant relation was found between symptoms and the correct diagnosis of appendicitis; however, the time of evolution influenced the number of hospital days and the degree of inflammation in the appendix. We emphasize the relevance of early diagnosis and the referral of the patient from primary care to the hospital stay and cost.

[Familial Parkinson disease]

We report the clinical findings and the pedigree of 10 patients of a family from Blacos, a small village in the Soria province, who had Parkinson's disease and in whom secondary causes and other diseases such as essential tremor or OPCA, to be considered in the differential diagnosis, had been ruled out. There were 6 males and 4 females with a mean age of 72.1 years; the mean age at the onset of symptoms was 67 years. All had the akinetic-rigid type of disease, and associated tremor was present in two cases. 90% were in functional classes I-II of the UPRS (United Parkinson's disease Rating Scale). 50% are presently receiving levodopa therapy, and only one has complications due to it. Emphasis is made on the etiological and pathogenetical heterogeneity of Parkinson's disease, where exogenous factors are probably superimposed to a genetic susceptibility.