Long-term functional outcome between Yamane technique and retropupillary iris-claw technique in a large study cohort

PURPOSE

To evaluate which secondary intraocular lens (IOL) implantation technique was more successful in achieving the best postoperative results and refractive outcomes between retropupillary iris-claw IOL (ICIOL) and flanged intrascleral IOL (FIIOL) fixation with the Yamane technique.

SETTING

Eye Clinic of the University of Trieste, Trieste, Italy.

DESIGN

Retrospective observational study.

METHODS

116 eyes of 110 patients who underwent ICIOL or FIIOL were analyzed. Patients with follow-up shorter than 6 months or with incomplete clinical data were excluded. Collected data included demographics, ocular comorbidity, indication of surgery, intraocular pressure, early (≤1 month) and late (>1 month) postoperative complications, corrected distance visual acuity (CDVA), and manifest refraction at the last follow-up visit.

RESULTS

50% (n = 58) of eyes underwent FIIOL and 50% (n = 58) ICIOL implantation for aphakia (n = 44, 38%) and IOL dislocation (n = 72, 62%). No statistically significant differences in demographics, comorbidity, follow-up duration, postoperative complications, and surgical indications were found. The refractive prediction error (RPE) was 0.69 ± 0.94 diopter (D) in the FIIOL group and 0.21 ± 0.75 D in the ICIOL group ( P = .03), indicating residual hyperopia after both techniques. RPE, mean absolute error, and median absolute error were higher in the FIIOL group ( P = .003). ICIOL implantation was more successful in obtaining a RPE between -0.50 D and +0.50 D (52% of ICIOL, n = 30, and 31% of FIIOL, n = 18).

CONCLUSIONS

Both techniques were effective in increasing preoperative CDVA with no statistical difference between them. Although complication rates did not significantly differ, the FIIOL group exhibited less predictable refractive outcomes. Adjusting the dioptric power of the 3-piece IOL, as performed in ciliary sulcus implantation, to prevent myopic shift, is not recommended.

Functional and anatomical outcomes of brolucizumab for nAMD in a real-life setting

To report long-term outcomes of brolucizumab in neovascular age-related macular degeneration (nAMD) treatment. Records from 74 patients were retrospectively reviewed. Both naïve eyes and those previously treated with other antiVEGF agents were included. Primary outcomes included variation in best corrected visual acuity (BCVA), central subfield thickness (CST), intraretinal fluid (IRF), subretinal fluid (SRF), and pigment epithelial detachment (PED) dimensions. Outcomes were reviewed after the loading phase, at week 24, and at last follow-up. IOI occurrence represented the secondary outcome. BCVA improved significantly in both groups. In switched eyes, IRF and SRF were significantly reduced at every timepoint, with CST reduction from week 24 (p = 0.005). In naïve group, CST decreased from the loading phase (p = 0.006) and all patients showed dry macula from week 24. A significant reduction in PED maximum high was demonstrated in both groups. In seven naïve eyes, PED completely reabsorbed; a slight increase in PED horizontal maximal diameter was also observed from week 24. IOI occurred in 5.4% of cases. In conclusion, brolucizumab showed a strong drying effect, permitting functional improvement together with fluid reabsorption and an encouraging modification of PED dimension, especially on naïve patients. These results together with the extension of treatment intervals make brolucizumab an efficient therapeutic strategy for nAMD.

Capecitabine-Related Fourth Nerve Palsy: A Case Report

Introduction

Capecitabine has rarely been associated with neurotoxicity. Cerebellar ataxia, multifocal leukoencephalopathy, and sensorimotor peripheral neuropathy have been reported in the literature. A case of 6th nerve palsy associated with capecitabine has also been described. This article reports the first case of capecitabine-related 4th nerve palsy.

Case Presentation

A 72-year-old Caucasian woman was referred by the Oncology Department because she had been complaining of binocular diplopia for 6 months. The symptoms started 1 month after the introduction of capecitabine. A diagnosis of right 4th nerve palsy was made using the Parks three-step test and the Hess test. Neuroimaging analysis was negative. A slow but progressive deterioration of function was confirmed during a year of follow-up. On suspicion of a chemotherapy-related palsy, capecitabine was discontinued and switched to vinorelbine. Subsequent improvement of the clinical picture was confirmed within 2 months.

Conclusion

The recognition of chemotherapy-related neurotoxicity is of paramount importance in the management of oncology patients. Once secondary invasion of the brain or the orbit by the tumor itself is ruled out, it must be suspected to prevent further deterioration.

How Could Medical and Surgical Treatment Affect the Quality of Life in Glaucoma Patients? A Cross-Sectional Study

BACKGROUND

To evaluate and compare the visual function and the quality of life (QoL) in glaucomatous patients treated with topical medical therapy (TMT) alone, canaloplasty (CP), or trabeculectomy (TB).

METHODS

A total of 291 eyes of 167 patients with primary open-angle glaucoma or secondary pseudoexfoliative glaucoma in TMT or surgically treated with CP or TB were included. Eligibility criteria for surgical patients included not needing TMT after surgery. Each patient underwent a visual field assessment and peripapillary retinal nerve fiber layer (pRNFL) optical coherence tomography and filled out the Glaucoma Symptoms Scale (GSS) questionnaire and the 25-Item National Eye Institute Visual Functioning Questionnaire (25-NEI-VFQ). Comparison between the QoL level of the three groups and its correlation with optic nerve's anatomical and functional status was the primary outcome.

RESULTS

CP patients reported the best general vision (p = 0.01), a lower incidence of eye burning (p = 0.03), and the lowest annoyance level of non-visual symptoms (p = 0.006). QoL positively correlated with pRNFL thickness, whereas no correlation was found with visual field damage.

CONCLUSION

CP provides a better QoL when compared both to TB and TMT, regardless of glaucoma stage. pRNFL seems to provide additional information for predicting change in QoL.

Early DMO: a predictor of poor outcomes following cataract surgery in diabetic patients. The DICAT-II study

BACKGROUND

The prospective DIabetes and CATaract Study II (DICAT II) was performed to characterise the risks of cataract surgery to the retinae of patients with early diabetic macular oedema (E-DMO).

METHODS

DICAT II was a prospective, comparative, multicentre, observational study involving six Italian clinics. Patients were aged ≥55 years, had type 1 or 2 diabetes with spectral-domain optical coherence tomography evidence of ESASO classification Early DMO. Group 1 eyes (78 eyes, 78 patients) underwent phacoemulsification-based cataract surgery. Group 2 eyes (65 eyes, 65 patients) had E-DMO and either clear media or had undergone uncomplicated cataract surgery ≥1 year previously. Central subfield thickness (CST) and best-corrected visual acuity (BCVA) were assessed in both groups.

RESULTS

The negative impact of surgery on CST was evident after the first postoperative week; CST peaked during the first month, then rapidly decreased. CST worsening ≥10 µm was observed in 63/78 eyes (80.7%) and 29/65 eyes (44.6%) in Groups 1 and 2, respectively (p < 0.0001). CST worsening of ≥50 µm was observed in 51 eyes (65.4%) and 10 eyes (15.4%) in Groups 1 and 2, respectively (p < 0.0001). Mean CST worsening was lower in Group 2 than in Group 1 (38.6 ± 30.4 µm vs 85.5 ± 55.3 µm, p < 0.0001) with a lower BCVA loss (-2.6 ± 3.5 letters vs -8.2 ± 6.2 letters, p < 0.0001). Higher glycaemic levels and HBA1c levels were significantly associated with the risk of >50 μm CST worsening in eyes from both groups.

CONCLUSION

Early DMO is associated with poorer outcomes after cataract surgery and requires close pre- and postoperative monitoring.

Worse impact of second wave COVID-19 pandemic in adults but not in children with inflammatory bowel disease: an Italian single tertiary center experience

OBJECTIVE

From September 2020, a second wave of COVID-19 pandemic started. We aimed at exploring the impact of SARS-CoV-2 infection in IBD patients during the two waves.

PATIENTS AND METHODS

All IBD patients with a confirmed diagnosis of SARS-CoV-2 infection were enrolled. They were sorted into two groups (those infected before September 2020, and those from September 2020 to January 2021) and compared by demographic and clinical data.

RESULTS

Twenty-five patients (out of about 600 with a follow-up visit) were infected with SARS-CoV-2 (4.1%). Sixteen were male and the mean age was 46.5 ± 14.3 years (range 24-74). Six were smokers and 11 had comorbidities; 2 were on steroids and 17 on immunosuppressants or biologics. Three patients (12%) needed hospitalization and other three patients were treated with azithromycin, steroids and LMWH, all of them during the second wave. No patient died or developed any sequelae. Two subjects were infected during the first wave (0.3 vs. 3.83, p<0.0001). Non-significant differences were found between the two groups.

CONCLUSIONS

A higher number of IBD patients were infected during the second wave. No patient developed a severe form of pneumonia, even those treated with immunosuppressants or biologics. No risk factor for hospitalization was found.

Correction of low corneal astigmatism in cataract surgery

AIM

To evaluate and compare aspheric toric intraocular lens (IOL) implantation and aspheric monofocal IOL implantation with limbal relaxing incisions (LRI) to manage low corneal astigmatism (1.0-2.0 D) in cataract surgery.

METHODS

A prospective randomized comparative clinical study was performed. There were randomly recruited 102 eyes (102 patients) with cataracts associated with corneal astigmatism and divided into two groups. The first group received toric IOL implantation and the second one monofocal IOL implantation with peripheral corneal relaxing incisions. Outcomes considered were: visual acuity, postoperative residual astigmatism, endothelial cell count, the need for spectacles, and patient satisfaction. To determine the postoperative toric axis, all patients who underwent the toric IOL implantation were further evaluated using an OPD Scan III (Nidek Co, Japan). Follow-up lasted 6mo.

RESULTS

The mean uncorrected distance visual acuity (UCVA) and the best corrected visual acuity (BCVA) demonstrated statistically significant improvement after surgery in both groups. At the end of the follow-up the UCVA was statistically better in the patients with toric IOL implants compared to those patients who underwent implantation of monofocal IOL plus LRI. The mean residual refractive astigmatism was of 0.4 D for the toric IOL group and 1.1 D for the LRI group (P<0.01). No difference was observed in the postoperative endothelial cell count between the two groups.

CONCLUSION

The two surgical procedures demonstrated a significant decrease in refractive astigmatism. Toric IOL implantation was more effective and predictable compared to the limbal relaxing incision.

Susceptibility of black bullhead Ameiurus melas to a panel of ranavirus isolates

Ranaviruses are considered a serious threat to lower vertebrates, including fish, amphibians and reptiles. However, epidemiological data on these agents are lacking, and further investigations are needed to understand the role of carriers and to update the list of susceptible hosts. We carried out various experimental infections under controlled conditions to contribute to the current knowledge on the susceptibility of black bullhead Ameiurus melas to European catfish virus (ECV) and other ranaviruses. A panel of 7 ranavirus isolates was used to challenge duplicate groups of A. melas juveniles maintained in aquaria supplied with running dechlorinated tap water. The experiments were performed at 15 and 25 degrees C. The results confirmed the high susceptibility of A. melas to ECV infection. Furthermore, a significant mortality associated with the typical signs of systemic viral infections was observed in groups challenged with Epizootic haematopoietic necrosis virus (EHNV) at 25 degrees C, and to a lesser extent, at 15 degrees C. No significant mortality was recorded in fish challenged with European sheatfish virus (ESV), Frog virus 3 (FV3), Rana esculenta virus-like (REV-like), Bohle iridovirus (BIV) or short-finned eel virus (SERV).

Increased intestinal permeability precedes clinical onset of type 1 diabetes

AIMS/HYPOTHESIS

Recent observations have shown subclinical intestinal abnormalities in human type 1 diabetes. Whether these are related to the pathogenetic process or secondary to the diabetes remains to be clarified. The aim of this study was to investigate this issue by examining intestinal permeability to sugars in subjects at different stages of type 1 diabetes: preclinical, new-onset and long-term established disease.

METHODS

Eighty-one subjects with islet autoimmunity (18 preclinical, 28 new-onset and 35 long-term type 1 diabetes) and 40 healthy control subjects were investigated by a lactulose-mannitol test, consisting of oral administration of the two sugars and measurement of their urinary excretion.

RESULTS

All groups of subjects with islet autoimmunity showed an increase in intestinal permeability (p < or = 0.009 vs controls) to the disaccharide lactulose, indicative of a damaged barrier, but a similar permeability to the monosaccharide mannitol (NS vs controls), indicative of an integral surface mucosa; consequently there was an increase in the lactulose:mannitol excretion ratio (p < or = 0.025 vs controls).

CONCLUSIONS/INTERPRETATION

These findings indicate the presence of a subclinical enteropathy associated with type 1 diabetes that is already detectable before clinical onset of the disease, and suggest that the small intestine is an organ participating in the pathogenetic process of type 1 diabetes.

13C-octanoic acid breath test for measuring gastric emptying of solids

Non invasive evaluation of gastric emptying is generally performed by scintigraphy which is, however, difficult to perform and not suitable to children and childbearing women. A new method based on stable isotope breath testing analysis has been introduced in clinical practice: the 13C-octanoic acid breath test. In this paper, an overview of the current knowledge on this technique is given with special emphasis on the principle of the test, the mathematics used to analyse the results, and the physiological, pathological, and pharmacological aspects of gastric emptying studied with this new method.

T cell responses to type 1 diabetes related peptides sharing homologous regions

Glutamic acid decarboxylase (GAD) 65 is a major autoantigen in type 1 diabetes. Regions of homology exist between GAD65 (residues 250-273) and the Coxsackie P2-C protein (residues 28-50) and between GAD65 (residues 506-518) and proinsulin (residues 24-36), and each of these has been reported to be a diabetes-associated T cell target. The aim of this study was to determine whether the homologous regions are shared targets of T lymphocyte reactivity in individual patients with type 1 diabetes. T cell proliferation against the corresponding peptide pairs, GAD254-276 and Coxsackie P2-C32-54 and GAD506-518 and proinsulin24-36, were measured in peripheral blood mononuclear cells from 26 patients with newly diagnosed type 1 diabetes and 24 control subjects. Responses with stimulation indices higher than 3 were found against each of the antigens tested in both patients and control subjects, and no differences were observed between groups. A strong positive correlation was found between responses to the corresponding peptide pairs GAD254-276 and Coxsackie P2-C32-54 (r=0.77, P<0.0001), and between responses to the corresponding peptide pairs GAD506-518 and proinsulin24-36 (r=0.66, P<0.0001). However, a similar correlation was also observed between responses to the noncorresponding pairs Coxsackie P2-C32-54 and proinsulin24-36 (r=0.82, P<0.0001), Coxsackie P2-C32-54 and GAD506-518 (r=0.82, P<0.0001), and GAD254-276 and proinsulin24-36 (r=0.83, P<0.0001). Strikingly, increased responses to peptides were found almost exclusively in subjects with high stimulation indices against the recall antigen tetanus toxoid, further suggesting that peripheral blood T cell responses are related to a general subject hyperreactivity. These data suggest that proliferative T cell responses to peptides containing putative autoreactive epitopes of GAD65 and proinsulin are not specific for type 1 diabetes, that correlation between T cell reactivity to peptides is not restricted to those containing homologous regions, and that non-antigen-specific factors are important determinants of in vitro measurements of T cell reactivity.

Postabsorptive muscle protein metabolism in type 1 diabetic patients after pancreas transplantation

Insulin was shown to induce protein anabolism in vivo mainly by inhibiting proteolysis. Heterotopic pancreas transplantation in type 1 diabetes mellitus is characterized by peripheral hyperinsulinemia due to systemic rather than portal insulin delivery. Therefore, we studied the postabsorptive muscle protein metabolism in type 1 diabetic patients with or without pancreas transplantation. The forearm balance technique was performed in 9 type 1 diabetic patients on exogenous insulin treatment, in 4 type 1 diabetic patients following successful pancreas transplantation and in 6 healthy volunteers. Labelled leucine and phenylalanine were infused to quantify whole-body and muscle protein synthesis, respectively. In the postabsorptive state, whole-body protein synthesis (leucine kinetics) was similar in pancreas-transplanted patients and controls. In contrast, muscle protein synthesis tended to be less negative in pancreas-transplanted patients with respect to type 1 diabetic patients and healthy volunteers. The present data suggest that recipients with peripheral insulin delivery and chronic hyperinsulinemia are characterized by a preferential stimulation of protein synthesis in muscle rather than in the splanchnic district. When insulin was infused acutely, while maintaining euglycemia, the whole-body and muscle protein synthesis rates were approximately halved in type 1 diabetic patients with and without pancreas transplantation. We conclude that pancreas transplantation is able to normalize basal and insulin-stimulated protein metabolism. Chronic hyperinsulinemia counteract steroid-induced protein degradation by means of a mild, but persistent stimulation of muscle protein synthesis.

Cellular and humoral immunity against cow's milk proteins in type 1 diabetes

Cow's milk beta-casein has been proposed as a candidate trigger of autoimmunity associated with type 1 diabetes. In this study, cellular and humoral immunity against beta-casein was compared to that against other major cow's milk proteins in patients with recent onset type 1 diabetes and control subjects. T cell responses were found against alpha-casein, beta-casein, beta-lactoglobulin and bovine serum albumin in both patients with type 1 diabetes (stimulation index: 0.2-22.8, n=23) and control subjects (stimulation index: 0.1-18.2, n=22), with no significant differences between groups. Twelve (52%) patients and nine (41%) control subjects had stimulation indices >3 to at least one protein, including 9 (39%) patients and 4 (18%) control subjects against beta-casein, all but one of these also having elevated responses to alpha-casein. The highest responses (stimulation index >9) were against alpha- and beta-casein in some patients and control subjects who had the HLA DR3 allele. Antibody levels against alpha-casein, beta-casein and beta-lactoglobulin were low in both patients (n=59) and control subjects (n=52). Nevertheless, significantly higher IgG binding to both alpha-casein in ELISA (P=0.02) and beta-casein using ELISA (P=0.02) and RIA (P=0.04) was observed in patients aged <15 years compared to control subjects of similar age. No relationship was found between cellular and humoral immunity against individual antigens. These data show that immune responses to cow's milk are not limited to patients with diabetes and not solely against beta-casein.

Autoimmune responses to the beta cell autoantigen, insulin, and the INS VNTR-IDDM2 locus

Type 1 diabetes is associated with autoimmunity to insulin. Genetic susceptibility to type 1 diabetes is polygenic and includes the INS VNTR-IDDM2 locus which may regulate the expression of insulin in pancreas and thymus. In order to determine whether insulin autoimmunity could be attributed to a genetic susceptibility conferred by the INS VNTR-IDDM2 locus, peripheral blood T cell proliferation to human insulin and insulin autoantibodies (IAA) was measured in patients with new onset type 1 diabetes and control subjects. IAA were detected in 21 of 53 patients and in none of 25 control subjects, while T cell responses were low (stimulation index range 0.4-7.2) and similar in both groups. Both antibody and T cell responses were higher in younger subjects and IAA were more prevalent in patients with the HLA-DR4 allele. No relationship was observed between humoral and cellular responses to insulin. No association was found between the INS VNTR-IDDM2-susceptible allele and insulin autoimmunity. Increased T cell responses and IAA were found in patients with either the diabetes-susceptible or the diabetes-protective INS VNTR-IDDM2 locus genotypes, and increased T cell responses were also found in control subjects with either susceptible or protective INS VNTR-IDDM2 locus genotypes. This study confirms that primary T cell proliferative responses to insulin are low and detectable also in control subjects. The detection of T cell proliferation and autoantibodies to insulin in subjects with and without the protective INS VNTR-IDDM2 locus genotypes does not support the hypothesis of an allele-specific capacity for tolerance induction which could determine a susceptibility to develop autoimmunity against the insulin protein and subsequently diabetes.

Two-step islet autoantibody screening for risk assessment of type 1 diabetes in relatives

OBJECTIVE

To examine the performance of islet cell antibodies (ICAs) and antibodies to glutamate decarboxylase (GADA), IA-2 (IA-2 antibody [IA-2A]), and insulin (insulin autoantibody [IAA]), alone and in combination, in assessing type 1 diabetes risk within type 1 diabetic families to identify a practical and effective screening strategy for predicting type 1 diabetes in relatives.

RESEARCH DESIGN AND METHODS

ICA, GADA, IA-2A, and IAA were determined in 806 first-degree relatives participating in a prospective type 1 diabetes family study (median follow-up 6.17 years, range 0.6-8.3). The conferred risk of developing type 1 diabetes within 6 years was evaluated by Kaplan-Meier for each antibody marker, used alone or in combination.

RESULTS

ICAs were detected in 3%, GADA in 5.1%, IA-2A in 2.5%, and IAA in 3.7% of relatives; > or =1 antibody markers were detected in 10.7% of relatives and > or =2 were detected in 1.9% of relatives. The risk of type 1 diabetes at 6 years was 1.5% in relatives with only 1 marker and 24.8% in relatives with > or =2 markers. As a practical and effective strategy for type 1 diabetes risk assessment in relatives, this study indicates a first-step screening based on GADA and IA-2A measurement--which identified 6.5% of relatives, including all who developed the disease, with a 6-year type 1 diabetes risk of 9.0%--followed by a second step based on ICA and IAA measurement in relatives with either GADA or IA-2A, which identified a total of 1.9% of all relatives as having > or =2 markers, and a 6-year risk of 24.8%, including 6 of 7 who developed type 1 diabetes.

CONCLUSIONS

A two-step antibody screening, based first on GADA and IA-2A and then on ICA and IAA measurements in identified individuals, is likely to be a practical, sensitive, and effective strategy for predicting type 1 diabetes in first-degree relatives.

Residual beta-cell function and spontaneous clinical remission in type 1 diabetes mellitus: the role of puberty

To investigate the role of puberty on spontaneous clinical remission and on secretion of residual C-peptide during the first year of type 1 diabetes mellitus, we studied 77 pre-pubertal, 39 pubertal and 41 post-pubertal type 1 diabetic patients. Spontaneous partial clinical remission (HbA1c within the normal range and insulin dose less than 0.3 U x kg(-1) body weight x day(-1) lasting for at least 10 days) decreased with duration of diabetes: months 3 vs 6 vs 12, respectively 13 vs 7 vs 4% (P<0.025). Remission was higher in post-pubertal than pubertal and prepubertal patients: month 6 respectively 20 vs 5 vs 1% (P<0.001). Secretion of C-peptide was significantly lower in pre-pubertal than the other two groups of patients. Basal and stimulated C-peptide secretion were higher in patients in clinical remission than in those who were not: basal value 0.4 (0.26-0.53) vs 0.28 (0.14-0.4) nmol/l (P<0.05); stimulated value 0.63 (0.5-0.95) vs 0.56 (0.31-0.74) nmol/l (P<0.05). Spontaneous remission is less frequent in children and adolescent patients than in adult post-pubertal patients, but different mechanisms may be involved. Low residual insulin secretion seems implicated in children meanwhile low insulin sensitivity could be more important in pubertal patients.

Personality traits and metabolic control: a study in insulin-dependent diabetes mellitus patients

BACKGROUND

In the present study the authors evaluated the relationship between personality traits (according to DSM-III-R) and poor metabolic control in an adult onset insulin-dependent diabetes mellitus sample (n = 77).

METHODS

Personality traits were assessed with the Personality Diagnostic Questionnaire--Revised. Metabolic control was evaluated through glycosilated hemoglobin (HbA1c): poor metabolic control was defined as HbA1c > or = 9% (normal values < 6.0%).

RESULTS

Principal Component Analysis revealed three personality profiles: 'Cluster A/C Mixed', 'Cluster B Dependent' and 'Cluster B Aggressive'. Oneway ANCOVA, using sex as covariate, revealed a significant association (p = 0.01) only between poor metabolic control and Cluster B Dependent profile. No correlation was found between HbA1c and the other profiles.

CONCLUSION

These data suggest that a specific personality profile is associated with poor metabolic control.

HLA-DQ screening for risk assessment of insulin dependent diabetes in northern Italy

Genetic markers may be used to improve the prediction of insulin-dependent diabetes mellitus (type 1) in individuals with islet autoantibodies. In order to develop a risk assessment strategy for the Lombardy region of northern Italy based on genetic and immunological markers, we analyzed HLA DQA1 and DQB1 alleles in 60 type 1 probands and their first-degree relatives and 65 unrelated control subjects from the same area using polymerase chain reaction (PCR) and oligonucleotide probes. The major risk haplotypes were DQA1 *0501-DQB1*0201 (39.1% of diabetic vs. 8.9% of non-diabetic haplotypes) and DQA1 *0301-DQB1*0302(20% of diabetic vs 7.1% of non-diabetic haplotypes). Stratified analysis showed DQA1*0102-DQB1*0502 also to be associated with type 1 susceptibility when found together with DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302. One type 1 patient had the type 1-protective DQA1*0102-DQB1*0602 haplotype. Overall, 88% of patients and 20% of unrelated control subjects had either DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302 in the absence of DQA1*0102-DQB1*0602. These data suggest that typing for markers identifying these three haplotypes in the Lombardy population will achieve a sensitivity of almost 90% and exclude 80% of children from subsequent islet autoantibody testing.

Islet autoantibody markers in IDDM: risk assessment strategies yielding high sensitivity

Identification of islet autoantigens offers the possibility that antibody tests other than islet cell antibodies may be used for assessing risk of insulin-dependent diabetes mellitus (IDDM). The aim of this study was to determine the combination of islet autoantibody markers that could identify most future cases of IDDM. Islet cell antibodies, antibodies to glutamic acid decarboxylase (GAD)65, 37,000/40,000 M(r) islet tryptic fragments, carboxypeptidase-H, and islet cell autoantigen (ICA)69 were measured in sera from 100 newly-diagnosed IDDM patients, 27 individuals prior to onset of IDDM, and 83 control subjects. Islet cell antibodies were detected in 88% of IDDM patients and 81% with pre-IDDM, GAD65 antibodies in 70% of IDDM patients and 89% with pre-IDDM, and antibodies to 37,000/40,000 M(r) islet tryptic fragments in 54% of IDDM patients and in 48% with pre-IDDM. The latter were found only in conjunction with islet cell antibodies and were more frequent in young onset cases. All 20 IDDM patients and the 3 pre-IDDM subjects who had islet cell antibodies without GAD65 antibodies had antibodies to 37,000/40,000 M(r) islet tryptic fragments, and all but one had disease onset before age 15 years. No sera strongly immunoprecipitated in vitro translated ICA69 or carboxypeptidase-H; 4% of patients had anti-ICA69 and 11% anti-carboxypeptidase-H levels above those of the control subjects. The findings suggest that none of the single antibody specificities are as sensitive as islet cell antibodies, but that a combination of GAD65 antibodies and antibodies to 37,000/40,000 M(r) islet tryptic fragments has the potential to identify more than 90% of future cases of IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of personality on metabolic control in IDDM patients

OBJECTIVE

The aim of this study was to evaluate the relationship between poor metabolic control and maladaptive personality traits (according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised) in an adult-onset insulin-dependent diabetes mellitus sample group (n = 77).

RESEARCH DESIGN AND METHODS

Metabolic control was evaluated through glycosylated hemoglobin (HbA1c). Personality traits were assessed with the Personality Diagnostic Questionnaire-Revised, a self-administered questionnaire. Residual pancreatic secretion (fasting serum C-peptide) was also evaluated.

RESULTS

Principal components analysis revealed three personality profiles: "withdrawn-suspicious" (P1), "dramatic-dependent" (P2), and "aggressive-irresponsible" (P3). Multiple linear regression analysis showed that C-peptide levels and P2 personality profiles were significant and independent predictors of HbA1c plasma levels: P2 predicted high HbA1c values and C-peptide predicted low HbA1c levels.

CONCLUSIONS

These data suggest that a P2 personality profile is a significant predictor of poor metabolic control.

Sera from patients with IDDM and healthy individuals have antibodies to ICA69 on western blots but do not immunoprecipitate liquid phase antigen

ICA69 is a recently cloned pancreatic islet protein proposed as a potential target of autoimmunity in insulin dependent diabetes mellitus (IDDM). The aim of our study was to verify the relevance of ICA69 antibodies as markers of the disease. We measured antibodies to ICA69 in sera from newly-diagnosed IDDM patients, in age- and sex-matched normal controls, and in sera prior to the onset of IDDM (pre-IDDM). Human islet ICA69 was cloned and inserted into a bacterial expression vector and an in vitro transcription vector. Binding to affinity purified recombinant ICA69 on Western blots was found in 33/48 (68%) sera from newly-diagnosed IDDM patients and in 36/56 (64%) controls. No differences in band intensity were found between IDDM and controls. Using immunoprecipitation of 35S methionine labelled in vitro translated ICA69, none of 53 sera from newly diagnosed IDDM patients, 0 of 57 control sera and 1 of 24 pre-IDDM sera had detectable antibodies. We conclude that solid-phase assays are inappropriate for measurement of ICA69 antibodies as specific markers of IDDM and that antibodies to ICA69 are not detected by a liquid-phase immunoprecipitation assay. These data support neither a role for ICA69 as a relevant autoantigen in IDDM, nor a role for the measurement of antibodies to ICA69 in the prediction of IDDM.

Effects of hyperglycaemia on visual evoked potentials in insulin-dependent diabetic patients

Multimodality evoked potentials frequently reveal subclinical involvement of the central nervous system in patients with insulin-dependent diabetes mellitus. We devised this study to evaluate the possible effects of acute hyperglycaemia on visual evoked potential (VEP) parameters in type 1 diabetic patients. A hyperglycaemic clamp (250 mg/dl for 180 min) was performed in ten patients. Monocular pattern reversal VEPs (check size 15', contrast 50%) were recorded before, and every 30 min after the start of the clamp. Basal VEP latencies and amplitudes were normal bilaterally in nine patients. No significant changes in pattern reversal and flash VEP parameters were observed after the induction or during the clamp period. None of the neurophysiological parameters evaluated during the test was related to the duration of the disease, the basal VEP latency or amplitude or the presence of retinopathy. Our data suggest that the neurophysiological abnormalities detected in insulin-dependent diabetic patients are due to structural involvement of the central nervous pathways and not to functional damage induced by acute short-term hyperglycaemia.

HLA-antigens in Italian type 1 diabetic patients: role of DR3/DR4 antigens and breast feeding in the onset of the disease

HLA-A, B, C, DR and DQ typing was performed in 381 Italian insulin-dependent diabetic patients and in 905 normal Italian subjects. The diabetic patients had significantly higher frequencies of HLA-Cw7, B8, B18, DR3, DR4, DQw2 and DQw3 and significantly lower frequencies of HLA-B17, Bw51, DR2, DR7 and DRw11. The frequency of heterozygosity for HLA-DR3/DR4 was significantly higher in patients who developed the disease in the first 2 years of life and DR3+/DR4-, DQw2 and DQw3 alleles were higher in those aged less than 14 years at onset. The HLA-DR4 allele was associated with onset of diabetes in autumn and HLA-B18 with onset in Autumn-winter. Diabetic children who were breast fed had a later onset of insulin-dependent diabetes mellitus than those who were bottle fed but these differences were independent of HLA typing (11.8 +/- 0.72 years vs 9.23 +/- 0.42 years; mean +/- SEM). We conclude that: (1) in general, HLA distribution in Italian insulin-dependent diabetic patients reflects previous data reported in other European and North American populations; (2) HLA-DR3 and DR4 are strongly associated with insulin-dependent diabetes in Italy as well, and these alleles seem to predispose to an earlier onset of the disease; and (3) breast feeding may delay the onset of the disease.

Prednisone administration in recent onset type I diabetes

The aim of our study was to investigate the efficacy of prednisone to preserve pancreatic beta-cell function in patients with recent-onset Type I diabetes mellitus (IDDM). Twenty-five patients with IDDM, aged 24 +/- 6 years, entered the trial within 8 weeks of the onset of diabetes. They were allocated, according to a single blind randomized protocol, to one of the following treatments: (A) prednisone (15 mg/day), (B) indomethacin (100 mg/day), (C) placebo. All treatments lasted 8 months and all patients achieved satisfactory metabolic control with a multi-injection regimen (three injections/day) within a few weeks, and maintained it throughout the entire period of observation. Only minor side effects were observed in the prednisone-treated patients. A lower insulin requirement was observed in the prednisone group than in other patients at 12 months (0.33 +/- 0.11 vs 0.57 +/- 0.06 U/kg/day, P less than 0.05), 18 months (0.34 +/- 0.11 vs 0.64 +/- 0.06, P less than 0.05) and 24 months (0.38 +/- 0.10 vs 0.63 +/- 0.05, P less than 0.05). Endogenous insulin release, evaluated as urinary C-peptide, was higher in the prednisone group than in other patients at 3, 6, 9, 12, 18 and 24 months (P less than 0.05). ANOVA confirmed differences among the three groups. Our study indicates that prednisone administration, at low doses and for a long period of time, effectively restored endogenous insulin release in IDDM patients.