Egyptian Pediatric Guidelines for the Management of Children with Isolated Thrombocytopenia Using the Adapted ADAPTE Methodology-A Limited-Resource Country Perspective

BACKGROUND

Thrombocytopenia is a prevalent presentation in childhood with a broad spectrum of etiologies, associated findings, and clinical outcomes. Establishing the cause of thrombocytopenia and its proper management have obvious clinical repercussions but may be challenging. This article provides an adaptation of the high-quality Clinical Practice Guidelines (CPGs) of pediatric thrombocytopenia management to suit Egypt's health care context.

METHODS

The Adapted ADAPTE methodology was used to identify the high-quality CPGs published between 2010 and 2020. An expert panel screened, assessed and reviewed the CPGs and formulated the adapted consensus recommendations based on the best available evidence.

DISCUSSION

The final CPG document provides consensus recommendations and implementation tools on the management of isolated thrombocytopenia in children and adolescents in Egypt. There is a scarcity of evidence to support recommendations for various management protocols. In general, complete clinical assessment, full blood count, and expert analysis of the peripheral blood smear are indicated at initial diagnosis to confirm a bleeding disorder, exclude secondary causes of thrombocytopenia and choose the type of work up required. The International Society of Hemostasis and thrombosis-Bleeding assessment tool (ISTH-SCC BAT) could be used for initial screening of bleeding manifestations. The diagnosis of immune thrombocytopenic purpura (ITP) is based principally on the exclusion of other causes of isolated thrombocytopenia. Future research should report the outcome of this adapted guideline and include cost-analysis evaluations.

Transfusion of blood components in pediatric age groups: an evidence-based clinical practice guideline adapted for the use in Egypt using 'Adapted ADAPTE'

Pediatric transfusion is a complex area of medicine covering a wide age range, from neonates to young adults. Compared to adult practice, there is a relative lack of high-quality research to inform evidence-based guidelines. We aimed to adapt the pre-existing high-quality practice guidelines for the transfusion of blood components in different pediatric age groups to be available for national use by general practitioners, pediatricians, and other health care professionals. The guideline panel included 17 key leaders from different Egyptian institutions. The panel used the Adapted ADAPTE methodology. The panel prioritized the health questions and recommendations according to their importance for clinicians and patients. The procedure included searching for existing guidelines, quality appraisal, and adaptation of the recommendations to the target context of use. The guideline covered all important aspects of the indications, dosing, and administration of packed red cells, platelets, and fresh frozen plasma. It also included transfusion in special situations, e.g., chronic hemolytic anemia and aplastic anemia, management of massive blood loss, malignancies, surgery, recommendations for safe transfusion practices, and recommendations for modifications of cellular blood components. The final version of the adapted clinical practice guideline (CPG) has been made after a thorough review by an external review panel and was guided by their official recommendations and modifications. A set of implementation tools included algorithms, tables, and flow charts to aid decision-making in practice. This adapted guideline serves as a tool for safe transfusion practices in different pediatric age groups.

Consensus recommendations for diagnosis and treatment of Multiple Sclerosis: 2023 revision of the MENACTRIMS guidelines

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for Multiple Sclerosis (MS), most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and time and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of MS therapies is critical to maximize patient benefit. The current guidelines review the current diagnostic criteria for MS and the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, progressive MS, pediatric cases and pregnant women. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Riverine forest as a significant habitat to harbor a wide range of bird species

Abstract Riverine forests are unique and highly significant ecosystems that are globally important for diverse and threatened avian species. Apart from being a cradle of life, it also serves as a gene pool that harbors a variety of flora and fauna species (repeated below). Despite the fact, this fragile ecosystem harbored avian assemblages; it is now disappearing daily as a result of human activity. Determining habitat productivity using bird species is critical for conservation and better management in the future. Multiple surveys were conducted over a 15-month period, from January to March 2019, using the distance sampling point count method. A total of 250 point count stations were fixed systematically at 300 m intervals. In total, 9929 bird individuals were recorded, representing 57 species and 34 families. Out of 57 bird species, two were vulnerable, one was data deficient, one was nearly threatened, and the remaining 53 species were of least concern. The Eurasian Collard Dove – Streptopelia decaocto (14.641 ± 2.532/ha), White-eared Bulbul – Pycnonotus leucotis (13.398 ± 4.342/ha) and Common Babbler – Turdoides caudata (10.244 ± 2.345/ha) were the three first plenteous species having higher densities. However, the densities of three species, i.e., Lesser Whitethroat – Sylvia curruca, Gray Heron – Ardea cinerea and Pallas Fish Eagle – Haliaeetus leucoryphus, were not analyzed due to the small sample size. The findings of diversity indices revealed that riverine forest has harbored the diverse avian species that are uniformly dispersed across the forest. Moreover, recording the ten foraging guilds indicated that riverine forest is rich in food resources. In addition, the floristic structure importance value index results indicated that riverine forest is diverse and rich in flora, i.e. trees, shrubs, weeds and grass, making it an attractive and productive habitat for bird species.

Contribution of T helper 17 cells and interleukin-17 to the pathogenesis of primary immune thrombocytopenia in Egyptian children

Though pathogenesis of primary immune thrombocytopenia (ITP) is still rendered unclear, yet there are many research efforts that have been directed to the role of T helper 17 (Th17) and interleukin 17 (IL-17) in the pathogenesis of this disease. The Th17 cell, which produces IL-17, is a subset of T helper cells. Interleukin 17 is pro-inflammatory cytokine that is recently proved to have a crucial role in the emergence of autoimmune diseases. We aimed to investigate the role of T helper17 cells and interleukin-17 in the pathogenesis of ITP in Egyptian children. This study was carried out on 100 children with ITP and 100 apparently healthy children as a control group. Patients were subjected to full medical history taking, thorough physical examination and routine investigations according to our local standards. Percentage of Th17 cells was measured by flow cytometry in study groups. Also, serum IL-17 was measured in in study groups by ELISA. Th 17 cells were significantly higher in patients compared to controls. Moreover, 3.1-fold increased serum levels of IL-17 were observed in patients with ITP compared to controls. Newly diagnosed patients had significantly higher percentage of Th-17cells as well as higher IL-17 levels than patients with either persistent or chronic ITP.   Conclusion: We concluded that Th 17 cells and IL-17 seem to play an important role in the pathogenesis of ITP in Egyptian children. What is Known -- What is New: • The pathogenesis of ITP is heterogeneous A novel subset of CD4+ T cells, distinct from Th1 and Th2, was recently identified. It is characterized by the production of IL-17 and, therefore, designated as Th17 cells. Several studies support a pivotal role for serum cytokines in the pathogenesis of ITP and provide evidence to suggest that helper Tlymphocytes polarize into Th1 and Th2 immune response. we aimed to investigate the role of T helper17 cells and interleukin-17 in the pathogenesis of ITP in Egyptian children.

Role of interleukin 4 (IL4) and interleukin 6 (IL6) in the pathogenesis and prognosis of childhood primary immune thrombocytopenia

Immune thrombocytopenia (ITP) is an autoimmune disease characterized by the breakdown of immune tolerance. Impairment of the cellular immunity is primarily evaluated by the levels of the cytokines which can help in predicting the course of ITP. We aimed to assess the levels of IL4 and IL6 in children with ITP and evaluate their role in the pathogenesis and prognosis of this disease. A prospective cohort study was carried on 60 children (15 patients with newly diagnosed ITP, 15 patients with persistent ITP, 15 patients with chronic ITP and 15 healthy children as a control group). Serum IL-4 and serum IL-6 were measured using Human IL-4 and IL-6 ELISA kit in patients and controls. Patients with newly diagnosed and persistent ITP had significantly higher levels of IL4 and IL6 compared to patients with chronic ITP and healthy controls (p < 0.001). The mean serum level of IL4 was 762.0, 741.0, 364.6 and 436.8 pg/ml, and the mean serum level of IL6 was 178.5, 164.4, 57.9 and 88.4 pg/ml for patients with newly diagnosed, persistent, chronic ITP and healthy controls respectively. Serum IL-4 was significantly higher in patients who achieved remission than those who did not improve on first line therapy.

CONCLUSION

Serum IL-4 and IL-6 may have a role in the pathogenesis of primary ITP. IL-4 seems to be a good predictor to treatment response.

WHAT IS KNOWN

• There is a delicate balance of specific cytokine levels in immune thrombocytopenia, which has an important role in the immune system and is known to be deregulated in autoimmune diseases. changes in IL-4 and IL-6 might be involved in the pathogenesis of newly diagnosed ITP in both paediatric and adult patients. • We conducted this research study to measure the serum level of IL-4 and IL-6, in newly diagnosed, persistent and chronic ITP patients and study their relation to disease pathogenesis as well as patient's outcome.

WHAT IS NEW

• We found that IL4 seems to be a good predictor to treatment response and it was a very interesting observation in our study, and to the best of our knowledge, there is no published data about this finding.

FcγRIIa and FcγRIIIa genes polymorphism in Egyptian children with primary immune thrombocytopenia

INTRODUCTION

Phagocytosis of autoantibody-sensitized coated platelets through Fc gamma receptors on phagocytic cells is an important mechanism of thrombocytopenia in primary immune thrombocytopenia (ITP).

OBJECTIVE

We aimed to investigate the contribution of the FcγRIIa and FcγRIIIa genes polymorphism to the risk of ITP and their association with disease characteristics in Egyptian children.

METHODS

A case control study was conducted on eighty children with primary ITP and eighty age and sex healthy matched subjects as a control group. The FcγRIIa and FcγRIIIa genes polymorphism was detected using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

We found that the FcγRIIa-131H and -131R allele frequencies were 51.3 % and 48.7%, respectively, in children with ITP, versus 75% and 25%, respectively, in controls (p = 0.002). The compound heterozygous HR genotype was significantly higher in ITP patients (p < 0.05). The FcγRIIIa-158F and -158V allele frequencies were 46.3% and 53.7%, respectively, in children with ITP, versus 70% and 30%, respectively, in controls (p = 0.002). The compound heterozygous VF genotype was significantly higher in ITP patients (p < 0.05). The combined HR/FV genotype was 47.5% in ITP patients, versus 10% in controls (p < 0.001). No significant difference was found between children with newly diagnosed ITP and those who developed chronic ITP, regarding the frequency distribution of the FcγRIIa and FcγRIIIa alleles and genotypes (p > 0.05).

CONCLUSION

There is a possible association of the FcγRIIa and FcγRIIIa genes polymorphism with the risk for, and genetic susceptibility to ITP in Egyptian children, but large-scale studies are still needed to support our findings.

Role of serum cystatin C in the prediction of acute kidney injury following pediatric cardiac surgeries: A single center experience

Intense contemporary research is directed towards validating novel biomarkers to predict acute kidney injury (AKI) in children undergoing cardiothoracic surgeries. We aimed to evaluate the role of cystatin C in early prediction of AKI following cardiac surgery in children with congenital heart disease. Prospective observational cohort study was conducted on 40 children with congenital heart disease undergoing cardiac surgery. 40 healthy children with matched age and sex were enrolled as a control group. Children were subjected to physical examination, routine blood tests, echocardiography, and measurement of plasma cystatin C level on different occasions. The median age of the patients was 3.65 years, a range from 1 to 5 years with no significant difference regarding the age and sex of cases and control groups. The mean serum cystatin C level in patients was 0.75 ± 0.15, 1.35 ± 0.34 and 1.21 ± 0.38 mg/dL (preoperative, at 6 h and at 24 h postoperative, respectively) with statistically significant difference P < .05. 30% of the patients developed postoperative AKI with significantly higher serum cystatin C at 6 hours postoperative >1.33 mg/dL compared to preoperative level p P < .05. Serum cystatin C level was positively correlated with cardiac bypass time, ischemic time and length of hospital stay at 6 hours postoperative. Serum cystatin C is a sensitive marker for early detection of AKI following cardiac surgery in children with congenital heart disease and it was positively correlated with cardiac bypass time, ischemic time and length of hospital stay.

Association between ATP binding cassette gene member 1 polymorphism and glucocorticoid response in children with immune thrombocytopenia

ATP binding Cassette gene member 1 (ABCB1) polymorphism has been incriminated in susceptibility to many malignant, infectious and autoimmune diseases. Recently, it was reported that ABCB1 polymorphisms might have a link to disease progression as well as response to therapy. We aimed to study the association between ABCB1 gene polymorphism and glucocorticoid response in children with newly diagnosed immune thrombocytopenia (ITP). A case control study was conducted on 90 newly diagnosed children with ITP and 90 healthy controls over a period of 1 year. ABCB1 (C3435T) polymorphism was determined by restriction fragment length polymorphism-polymerase chain reaction (RFLP-PCR) in patients and controls. There was no significant difference between patients and controls as regards to frequency of different ABCB1 genotypes (CC, CT, and TT genotypes were 44.4%, 36.7%, and 18.9% respectively in patients and 48.9%, 38.9%, and 12.2% respectively in controls, P value = 0.18). 80% of patients who received steroids alone or steroids in combination with intravenous immunoglobulin showed complete recovery. There was highly significant relationship between ABCB1 genotypes and response to steroids where 55 % of responders had CC (wild) genotype while 40 % of nonresponders had TT (mutant) genotype. We concluded that ABCB1 gene polymorphism may contribute to the response to steroids in Egyptian children with ITP where patients with homozygous CC genotype responded better to steroids than patients with homozygous TT genotype. These results may help us choose the appropriate initial treatment in these children.

Contribution of interleukin 27 serum level to pathogenesis and prognosis in children with immune thrombocytopenia

Concepts surrounding the mechanisms of thrombocytopenia in ITP have shifted from the traditional view of autoantibody mediated platelet destruction to more complex mechanisms in which impaired platelet production, T-cell-mediated effects, and disturbed cytokine profiles play a role. Interleukin 27 (IL-27) plays pleiotropic roles in immunomodulation and autoimmune diseases.We aimed to determine the level of IL-27 in patients with ITP and its relationship to patient and disease characteristics as well as disease chronicity and response to treatment.Sixty childrens with primary immune thrombocytopenia were consequetively enrolled in this study as well as 20 age and sex matched healthy controls.ITP patients had significantly higher levels of IL-27 than controls (770.6 and 373.8 pg/ml, respectively). Patients with acute ITP had the highest levels of IL-27 among patient groups, while patients in remission had the lowest IL-27 levels (860.1and 622.9 pg/ml, respectively). Patients who received IVIG and combined steroids plus IVIG had significantly higher IL-27 levels than others. Patients who received Eltrombopag had significantly lower IL-27 levels than others.IL-27 seems to play a role in pathogenesis of childhood ITP. IL-27 can be used as a predictor for disease occurrence as well as responsiveness to treatment.

Cerebral sinuses thrombosis prior to the diagnosis of acute lymphoblastic leukemia in a child: A case report

Acute lymphoblastic leukemia is the most common malignancy in children. In children, venous thromboembolism is relatively common. In most cases, venous thromboembolism manifests in patients who are diagnosed with acute lymphoblastic leukemia. Several risk factors associated with acute lymphoblastic leukemia predispose patients to the development of venous thromboembolism. Unlike most reported cases of venous thromboembolism, herein we report a child who developed cerebral venous sinus thrombosis prior to the diagnosis of acute lymphoblastic leukemia. The patient recovered from an attack of acute gastroenteritis with sepsis, pancytopenia, and disseminated intravascular coagulation 2 weeks before the development of thrombosis. Her laboratory workup for coagulopathy and disseminated intravascular coagulation was normal at the time of diagnosis of cerebral sinus thrombosis. The genetic workup for thrombophilia risk identified several genetic thrombophilia mutations: the homozygous factor XIII V34L and MTHFR A1298C mutations and heterozygous factor V Leiden mutation. Three weeks later, the patient was diagnosed with acute lymphoblastic leukemia. However, it remains questionable whether the thrombotic event was caused by the previous infection of gastroenteritis, sepsis, and disseminated intravascular coagulation picture (which was augmented by her genetic thrombophilia risk), or was it caused by acute lymphoblastic leukemia (that was not detected at early stages with its associated hypercoagulable state), or was it caused by a type of paraneoplastic syndrome. A multifactorial etiology is proposed.

Genetic polymorphism of vitamin D receptors and plasminogen activator inhibitor-1 and osteonecrosis risk in childhood acute lymphoblastic leukemia

BACKGROUND

Osteonecrosis (ON) is one of the major therapy-related complications in childhood acute lymphoblastic leukemia (ALL). The purpose of the current study is to assess the frequency of ON in children with ALL and to detect whether polymorphisms in vitamin D receptor gene (VDR) and plasminogen activator inhibitor-1 (PAI-1) gene can affect the risk of ON.

PATIENTS AND METHODS

Nighty-six ALL children were enrolled. Serum 25-hydroxyvitamin D 25(OH)D levels were performed in addition to the detection of polymorphisms in PAI-1and VDR genes by polymerase chain reaction.

RESULTS

Ten out of 96 patients had ON (four males and six females aged above 10 years) and had an insufficient level of 25(OH)D. Fifty-two percent of patients had PAI-1 GG genotype while 48% had PAI-1 GA genotype. PAI-1 polymorphism was detected in 60% of all ON cases. The frequencies of VDR genotypes were CT (56.3%), CC (39.6%), and TT (4.2%). Osteonecrosis was found in eight patients with CC genotype and in two patients with CT genotype.

CONCLUSION

Osteonecrosis can develop early during the therapy of ALL. Older age and insufficient level of 25(OH)D were considered important risk factor for the development of osteonecrosis. PAT-1 and VDR gene polymorphism may be a genetic risk factor in its pathogenesis.

Serum endocan and endothelial dysfunction in childhood acute lymphoblastic leukemia survivors: a tertiary center experience

Background:

An increased risk of cardiovascular complications is reported in survivors of childhood acute lymphoblastic leukemia (ALL). Early identification of impaired vascular health may allow for early interventions to improve outcomes.

Aim:

The study was conducted to assess the endothelial dysfunction in ALL survivors using a new marker, serum endocan, and measurement of the mean common carotid arteries intima media thickness (cIMT).

Methods:

A case-control study was conducted on 100 childhood ALL survivors (aged 6–18 years), with 80 healthy age and sex-matched children as a control group. Lipid profile, hepatitis markers, and serum ferritin where measured, in addition to the measurement of serum endocan. and cIMT by B-mode high-resolution ultrasonography for all study participants.

Results:

Triglycerides, total cholesterol, post prandial glucose, and serum ferritin were significantly higher in ALL survivors than controls (p < 0.05). Dyslipidemia was detected in 6% of ALL survivors. ALL survivors showed statistically higher serum endocan levels (470.41 ± 556.1 ng/l, versus, 225.94 ± 185.2 ng/l, respectively) and increased cIMT levels compared with the control group (0.650 ± 0.129 mm versus 0.320 ± 0.095 mm, respectively) p < 0.05. Serum endocan was positively correlated with cIMT and blood cholesterol.

Conclusions:

The survivors of childhood ALL demonstrated an elevated level of serum endocan and increased cIMT. These can be used as predictors of endothelial dysfunction, and, as a consequence, the risk of developing premature atherosclerosis.

Assessment of serum aflatoxin B1 levels in neonatal jaundice with glucose-6-phosphate dehydrogenase deficiency: a preliminary study

Aflatoxin (AF) contamination of food products is still a major health issue globally. Prior studies suggest that exposure to AFs during pregnancy has harmful fetal outcomes. This preliminary study was designed to assess serum AFB₁ levels in neonatal jaundice (NNJ) secondary to glucose-6-phosphate dehydrogenase (G6PD) deficiency. Twenty-four full-term neonates with hemolytic jaundice secondary to G6PD deficiency were enrolled in the study. Erythrocyte G6PD status was assessed colorimetrically, and serum aflatoxin B₁ (AFB₁) concentrations were measured by high-performance liquid chromatography. The results revealed that AFB₁ was detected in 58% (14/24) of the studied newborns while detected in 75% (18/24) of their mothers. AFB₁ positive cases had a highly significantly lower birthweight and G6PD activity (P = 0.001, each). Birthweight (r = - 0.574, P = 0.032) and G6PD activity (r = - 0.585, P = 0.028) negatively correlated with serum AFB₁ levels while serum alanine aminotransferase activity positively correlated with serum AFB₁ levels (r = 0.536, P = 0.048). Maternal AFB₁ exposure is associated with adverse birth outcomes as verified by the low birthweight and the evident decline in the activity of G6PD enzyme with the resultant hemolytic NNJ.

PTPN22 gene polymorphism as a genetic risk factor for primary immune thrombocytopenia in Egyptian children

OBJECTIVES

Several genetic and non-genetic risk factors are implicated in the etiology and pathogenesis of primary immune thrombocytopenia (ITP). Protein tyrosine phosphatase non-receptor 22 gene (PTPN22) plays an important role in regulation of signal transduction through the T-cell receptors. PTPN22 1858 C > T single nucleotide polymorphism was reported to be associated with increased risk of autoimmune diseases. There are very few studies investigating the role of PTPN22(SNP) 1858 C > T in childhood ITP.

METHODS

This case-control study was designed for assessing the contribution of PTPN22 1858 C > T polymorphism to the risk of ITP in Egyptian children. Eighty children with newly diagnosed ITP were recruited from pediatric hematology out-patient clinic. Also, eighty age and sex-matched healthy children were enrolled as a control group. PTPN22 1858 C/T SNP gene polymorphism was performed using polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP).

RESULTS

Frequency of PTPN22 1858 C/T genotypes CT, CC, and TT were 32.5,55, and 12.5% in patients versus 10, 90, and 0% in controls (p < 0.05).TT genotype was significantly associated with higher risk of ITP (OR = 17.8(0.94-333.35), 95% CI, and P = 0.02).

CONCLUSION

PTPN22 gene polymorphism may play a pivotal role in genetic predisposition to ITP and disease progress in Egyptian children.

Tissue factor expression predicts outcome in children with neuroblastoma: A retrospective study

Previous studies have revealed that the processes of tumor angiogenesis, metastasis and invasiveness are highly dependent on components of the blood coagulation cascade. Tissue factor (TF) is one of the key proteins in coagulation. Cumulative evidence suggested that in addition to its role in coagulation, TF regulates intracellular signaling pathways that serve an important role in angiogenesis, tumor development and metastasis. In the present study, TF expression in neuroblastoma as well as its association with tumor stage, pathology and outcome were assessed. A total of 40 formalin-fixed paraffin-embedded tissues were evaluated for TF expression by immunohistochemical analysis. Results revealed that TF expression was positive in 75% of the analyzed tumor tissues. No significant association between TF expression and sex, age, tumor stage or disease pathology was observed. MYCN proto-oncogene bHLH transcription factor (MYCN) was upregulated in 45% (n=18) of the study cases. Positive TF expression was observed in 94.4% of patients (n=17) with upregulated MYCN, while 59% of patients (n=13) with normal MYCN showed positive TF expression (P<0.05). TF expression was a significant outcome predictor for patients; 18/30 patients (60%) with positive TF expression succumbed to the disease during the study period. In conclusion, TF may be a promising prognosis indicator for neuroblastoma. Future studies to determine how TF affects the progression and outcome of neuroblastoma, as well as to investigate its potential role as a therapeutic target, are required.

Consensus recommendations for the diagnosis and treatment of multiple sclerosis: 2019 revisions to the MENACTRIMS guidelines

With evolving diagnostic criteria and the advent of new oral and parenteral therapies for MS, most current diagnostic and treatment algorithms need revision and updating. The diagnosis of MS relies on incorporating clinical and paraclinical findings to prove dissemination in space and in time, and exclude alternative diseases that can explain the findings at hand. The differential diagnostic workup should be guided by clinical and laboratory red flags to avoid unnecessary tests. Appropriate selection of multiple sclerosis (MS) therapies is critical to maximize patient benefit. The current guidelines review the scientific evidence supporting treatment of acute relapses, radiologically isolated syndrome, clinically isolated syndrome, relapsing remitting MS, and progressive MS. The purpose of these guidelines is to provide practical recommendations and algorithms for the diagnosis and treatment of MS based on current scientific evidence and clinical experience.

Subclinical nephrotoxicity in patients with beta-thalassemia: role of urinary kidney injury molecule

We aimed to investigate the role of urinary kidney injury molecule-1 (KIM-1) in detection of subclinical nephrotoxicity in patients with Beta-thalassemia (β-TM) in relation to chelation therapy and to correlate the urinary KIM-1 level with other clinical and laboratory findings. We conducted a cross-sectional study on 66 thalassemic patients. Their ages range from 7 to 22 years. Routine kidney indices and novel urinary KIM/creatinine ratio (U_KIM-1/Cr) were measured. Estimated glomerular filtration rate (eGFR) was calculated. Results indicate that the level of serum creatinine was significantly higher in patients on deferasirox therapy than patients on deferoxamine and deferiprone therapy [median(IQR), 0.85(0.63-0.99), 0.50(0.34-0.58) and 0.44(0.36-0.45)] mg/dL, respectively, p < 0.001]. The median(IQR) level of eGFR was significantly lower in patients on deferasirox therapy than patients on deferoxamine and deferiprone therapy [63.3(56.5-92.1), 117.3(91.9-162) and 136.7(109.4-157.6)] ml/min/1.73 m², respectively, p < 0.001]. The mean level of U_KIM-1/Cr was significantly higher in patients on deferasirox therapy than patients on deferoxamine and deferiprone therapy (7.0 ± 1.9, 4.1 ± 1.7 and 4.2 ± 1.5) ng/mg creatinine, respectively, p < 0.001). We concluded that urinary KIM-1 is an early predictive biomarker for decline in eGFR in patients with β-TM on deferasirox therapy. The appropriate chelation therapy and good monitoring of those patients are intensely needed for early detection of renal dysfunction and timely intervention.

Association between genotype and disease complications in Egyptian patients with beta thalassemia: A Cross-sectional study

In beta thalassemia, the degree of globin chain imbalance is determined by the nature of the mutation of the β-gene. β° refers to the complete absence of production of β-globin on the affected allele. β⁺ refers to alleles with some residual production of β-globin. The homozygous state results in severe anemia that necessitates regular blood transfusion. On the other hand, frequent blood transfusion can lead to iron overload resulting in progressive dysfunction of the heart, Liver as well as multiple endocrinopathies. We studied the impact of genotype on the development of disease complications in patients with β thalassemia. A Cross sectional study was carried on 73 patients with beta thalassemia. Genotyping was determined by DNA sequencing technique. Routine investigations as well as MRI liver and heart were performed to assess iron overload. We found that β⁺β⁺ was the most common genotype in our patients followed by β°β° and β°β⁺. Mean Liver iron content (LIC) was significantly higher in β°β° compared to β°β⁺ and β⁺β⁺ genotypes and mean cardiac T2* was significantly lower in β°β° compared to β°β⁺ and β⁺β⁺ genotypes. Hepatic complications, hepatitis C, cardiac complications and some endocrinopathies were significantly higher in patients with β°β° genotype compared to other genotypes which explain the role of the underlying genetic defect in thalassemia patients in development of disease complications.

Impact of Genotype of Beta Globin Gene on Hepatic and Myocardial Iron Content in Egyptian Patients with Beta Thalassemia

Iron overload causes most of the mortality and morbidity associated with thalassemia. Excess iron deposits primarily in the liver, but once a threshold level is reached, iron loading may occur in other tissues such as the heart. Magnetic resonance imaging is a well established technique to noninvasively quantify myocardial and liver iron content. More than 300 disease-causing mutations have been identified. We aimed to determine the impact of genotype on liver iron content in patients with beta thalassemia. Cross sectional study was carried on 73 patients with beta thalassemia. MRI liver and heart was performed to determine hepatic and myocardial iron overload. Genotyping was determined by DNA sequencing technique. The mean liver iron content was 17.4 mg/g dw and mean cardiac T2* was 25.5 ms in our patients. Patients with β⁰β⁰ were associated with significantly higher liver and myocardial iron content compared to those with β⁰β⁺ and β⁺β⁺ genotypes. There was a clear association between genotype and both hepatic and myocardial iron overload. Patients with β⁰β⁰ had significantly higher liver and heart iron content compared to those with β⁰β⁺ and β⁺β⁺ genotypes. Liver iron content was strongly correlated to serum ferritin levels and myocardial iron overload.

Study of dijet events with a large rapidity gap between the two leading jets in pp collisions at s = 7 TeV

Events with no charged particles produced between the two leading jets are studied in proton-proton collisions ats = 7 TeV . The jets were required to have transverse momentump T jet > 40 GeV and pseudorapidity1.5 < | η jet | < 4.7 , and to have values of η jet with opposite signs. The data used for this study were collected with the CMS detector during low-luminosity running at the LHC, and correspond to an integrated luminosity of 8pb - 1 . Events with no charged particles withp T > 0.2 GeV in the interval - 1 < η < 1 between the jets are observed in excess of calculations that assume no color-singlet exchange. The fraction of events with such a rapidity gap, amounting to 0.5-1% of the selected dijet sample, is measured as a function of the p T of the second-leading jet and of the rapidity separation between the jets. The data are compared to previous measurements at the Tevatron, and to perturbative quantum chromodynamics calculations based on the Balitsky-Fadin-Kuraev-Lipatov evolution equations, including different models of the non-perturbative gap survival probability.

Measurements of the associated production of a Z boson and b jets in pp collisions at s = 8 TeV

Measurements of the associated production of a Z boson with at least one jet originating from a b quark in proton-proton collisions ats = 8 TeV are presented. Differential cross sections are measured with data collected by the CMS experiment corresponding to an integrated luminosity of 19.8fb - 1 . Z bosons are reconstructed through their decays to electrons and muons. Cross sections are measured as a function of observables characterizing the kinematics of the b jet and the Z boson. Ratios of differential cross sections for the associated production with at least one b jet to the associated production with any jet are also presented. The production of a Z boson with at least two b jets is investigated, and differential cross sections are measured for the dijet system. Results are compared to theoretical predictions, testing two different flavour schemes for the choice of initial-state partons.

Search for new phenomena with the M T 2 variable in the all-hadronic final state produced in proton-proton collisions at s = 13 TeV

A search for new phenomena is performed using events with jets and significant transverse momentum imbalance, as inferred through the M T 2 variable. The results are based on a sample of proton-proton collisions collected in 2016 at a center-of-mass energy of 13TeV with the CMS detector and corresponding to an integrated luminosity of 35.9fb -1 . No excess event yield is observed above the predicted standard model background, and the results are interpreted as exclusion limits at 95% confidence level on the masses of predicted particles in a variety of simplified models of R-parity conserving supersymmetry. Depending on the details of the model, 95% confidence level lower limits on the gluino (light-flavor squark) masses are placed up to 2025 (1550)GeV . Mass limits as high as 1070 (1175)GeV are set on the masses of top (bottom) squarks. Information is provided to enable re-interpretation of these results, including model-independent limits on the number of non-standard model events for a set of simplified, inclusive search regions.

Study of Jet Quenching with Z+jet Correlations in Pb-Pb and pp Collisions at sqrt[s]_{NN}=5.02 TeV

The production of jets in association with Z bosons, reconstructed via the μ^{+}μ^{-} and e^{+}e^{-} decay channels, is studied in pp and, for the first time, in Pb-Pb collisions. Both data samples were collected by the CMS experiment at the LHC, at a nucleon-nucleon center-of-mass energy of 5.02 TeV. The Pb-Pb collisions were analyzed in the 0%-30% centrality range. The back-to-back azimuthal alignment was studied in both pp and Pb-Pb collisions for Z bosons with transverse momentum p_{T}^{Z}>60  GeV/c and a recoiling jet with p_{T}^{jet}>30  GeV/c. The p_{T} imbalance x_{jZ}=p_{T}^{jet}/p_{T}^{Z}, as well as the average number of jet partners per Z, R_{jZ}, was studied in intervals of p_{T}^{Z}. The R_{jZ} is found to be smaller in Pb-Pb than in pp collisions, which suggests that in Pb-Pb collisions a larger fraction of partons associated with the Z bosons fall below the 30  GeV/c p_{T}^{jet} threshold because they lose energy.

Measurement of the jet mass in highly boosted [Formula: see text] events from pp collisions at [Formula: see text][Formula: see text]

The first measurement of the jet mass [Formula: see text] of top quark jets produced in [Formula: see text] events from pp collisions at [Formula: see text] [Formula: see text] is reported for the jet with the largest transverse momentum [Formula: see text] in highly boosted hadronic top quark decays. The data sample, collected with the CMS detector, corresponds to an integrated luminosity of 19.7[Formula: see text]. The measurement is performed in the lepton+jets channel in which the products of the semileptonic decay [Formula: see text] with [Formula: see text] where [Formula: see text] is an electron or muon, are used to select [Formula: see text] events with large Lorentz boosts. The products of the fully hadronic decay [Formula: see text] with [Formula: see text] are reconstructed using a single Cambridge-Aachen jet with distance parameter [Formula: see text], and [Formula: see text] [Formula: see text]. The [Formula: see text] cross section as a function of [Formula: see text] is unfolded at the particle level and is used to test the modelling of highly boosted top quark production. The peak position of the [Formula: see text] distribution is sensitive to the top quark mass [Formula: see text], and the data are used to extract a value of [Formula: see text] to assess this sensitivity.

Measurement of the top quark mass using single top quark events in proton-proton collisions at [Formula: see text] TeV

A measurement of the top quark mass is reported in events containing a single top quark produced via the electroweak t channel. The analysis is performed using data from proton-proton collisions collected with the CMS detector at the LHC at a centre-of-mass energy of 8 TeV, corresponding to an integrated luminosity of 19.7 fb[Formula: see text]. Top quark candidates are reconstructed from their decay to a [Formula: see text] boson and a b quark, with the [Formula: see text] boson decaying leptonically to a muon and a neutrino. The final state signature and kinematic properties of single top quark events in the t channel are used to enhance the purity of the sample, suppressing the contribution from top quark pair production. A fit to the invariant mass distribution of reconstructed top quark candidates yields a value of the top quark mass of [Formula: see text]. This result is in agreement with the current world average, and represents the first measurement of the top quark mass in event topologies not dominated by top quark pair production, therefore contributing to future averages with partially uncorrelated systematic uncertainties and a largely uncorrelated statistical uncertainty.

Searches for pair production of third-generation squarks in [Formula: see text][Formula: see text] pp collisions

Searches are presented for direct production of top or bottom squark pairs in proton-proton collisions at the CERN LHC. Two searches, based on complementary techniques, are performed in all-jet final states that are characterized by a significant imbalance in transverse momentum. An additional search requires the presence of a charged lepton isolated from other activity in the event. The data were collected in 2015 at a centre-of-mass energy of 13[Formula: see text] with the CMS detector and correspond to an integrated luminosity of 2.3[Formula: see text]. No statistically significant excess of events is found beyond the expected contribution from standard model processes. Exclusion limits are set in the context of simplified models of top or bottom squark pair production. Models with top and bottom squark masses up to 830 and 890[Formula: see text], respectively, are probed for light neutralinos. For models with top squark masses of 675[Formula: see text], neutralino masses up to 260[Formula: see text] are excluded at 95% confidence level.

A search for new phenomena in pp collisions at [Formula: see text] in final states with missing transverse momentum and at least one jet using the [Formula: see text] variable

A search for new phenomena is performed in final states containing one or more jets and an imbalance in transverse momentum in pp collisions at a centre-of-mass energy of 13[Formula: see text]. The analysed data sample, recorded with the CMS detector at the CERN LHC, corresponds to an integrated luminosity of 2.3[Formula: see text]. Several kinematic variables are employed to suppress the dominant background, multijet production, as well as to discriminate between other standard model and new physics processes. The search provides sensitivity to a broad range of new-physics models that yield a stable weakly interacting massive particle. The number of observed candidate events is found to agree with the expected contributions from standard model processes, and the result is interpreted in the mass parameter space of fourteen simplified supersymmetric models that assume the pair production of gluinos or squarks and a range of decay modes. For models that assume gluino pair production, masses up to 1575 and 975[Formula: see text] are excluded for gluinos and neutralinos, respectively. For models involving the pair production of top squarks and compressed mass spectra, top squark masses up to 400[Formula: see text] are excluded.

Measurement of prompt and nonprompt [Formula: see text] production in [Formula: see text] and [Formula: see text] collisions at [Formula: see text]

This paper reports the measurement of [Formula: see text] meson production in proton-proton ([Formula: see text]) and proton-lead ([Formula: see text]) collisions at a center-of-mass energy per nucleon pair of [Formula: see text] by the CMS experiment at the LHC. The data samples used in the analysis correspond to integrated luminosities of 28[Formula: see text] and 35[Formula: see text] for [Formula: see text] and [Formula: see text] collisions, respectively. Prompt and nonprompt [Formula: see text] mesons, the latter produced in the decay of [Formula: see text] hadrons, are measured in their dimuon decay channels. Differential cross sections are measured in the transverse momentum range of [Formula: see text], and center-of-mass rapidity ranges of [Formula: see text] ([Formula: see text]) and [Formula: see text] ([Formula: see text]). The nuclear modification factor, [Formula: see text], is measured as a function of both [Formula: see text] and [Formula: see text]. Small modifications to the [Formula: see text] cross sections are observed in [Formula: see text] relative to [Formula: see text] collisions. The ratio of [Formula: see text] production cross sections in [Formula: see text]-going and Pb-going directions, [Formula: see text], studied as functions of [Formula: see text] and [Formula: see text], shows a significant decrease for increasing transverse energy deposited at large pseudorapidities. These results, which cover a wide kinematic range, provide new insight on the role of cold nuclear matter effects on prompt and nonprompt [Formula: see text] production.

Effect of breastfeeding versus infant formula on iron status of infants with beta thalassemia major

BACKGROUND

Thalassemia major or Cooley's anemia is the most severe form of beta thalassemia in which the complete lack of beta protein in the hemoglobin causes a life-threatening anemia requiring regular blood transfusions and extensive ongoing medical care. These extensive, lifelong blood transfusions lead to iron-overload that must be treated with chelation therapy to prevent early death from organ failure. We compared serum iron and ferritin levels amongst infants aged up to one year with beta thalassemia major according to their feeding types, including exclusively breastfed, exclusively formula fed and combined (both breast and formula) fed types.

METHODS

Sixty out of 176 screened infants with transfusion dependant beta thalassemia major were recruited from the outpatient clinic of thalassemia at Zagazig University Hospital in Egypt, between 2007 and 2014. Patients were classified into three groups (20 patients per group) according to type of feeding. Group 1: exclusive breastfeeding, around 6-8 feeds per day; group 2: exclusive infant formula feeding, 120-150 ml of formula per kilogram of body weight per day divided into 6-8 feeds and group 3: combined breastfeeding and formula per day.

RESULTS

Serum iron and ferritin levels were lower in group 1 compared to groups 2 and 3. The mean serum iron for group 1 was 73, 87 and 96 ug/dl at 6, 9 and 12 months respectively, while that for group 2 was 85, 99 and 112 ug/dl at 6, 9 and 12 months respectively and for group 3 was 78, 92 and 99 ug/dl at 6, 9 and 12 months respectively. The mean serum ferritin for group 1 was 283, 327 and 497 ng/ml at 6, 9 and 12 months respectively, while that for group 2 was 310, 389 and 591 ng/ml at 6, 9 and 12 months respectively and for group 3 was 291, 345 and 515 ng/ml at 6, 9 and 12 months respectively. The differences were not statistically significant.

CONCLUSIONS

Breastfed infants with beta thalassemia major may accumulate less iron than infants fed iron fortified formula anticipating later onset of iron overload in the breastfed infants. Larger studies are needed to support these findings.

Relative Modification of Prompt ψ(2S) and J/ψ Yields from pp to PbPb Collisions at sqrt[s_{NN}]=5.02 TeV

The relative modification of the prompt ψ(2S) and J/ψ yields from pp to PbPb collisions, at the center-of-mass energy of 5.02 TeV per nucleon pair, is presented. The analysis is based on pp and PbPb data samples collected by the CMS experiment at the LHC in 2015, corresponding to integrated luminosities of 28.0  pb^{-1} and 464  μb^{-1}, respectively. The double ratio of measured yields of prompt charmonia reconstructed through their decays into muon pairs, (N_{ψ(2S)}/N_{J/ψ})_{PbPb}/(N_{ψ(2S)}/N_{J/ψ})_{pp}, is determined as a function of PbPb collision centrality and charmonium transverse momentum p_{T}, in two kinematic intervals: |y|<1.6 covering 6.5<p_{T}<30  GeV/c and 1.6<|y|<2.4 covering 3<p_{T}<30  GeV/c. The centrality-integrated double ratios are 0.36±0.08(stat)±0.05(syst) in the first interval and 0.24±0.22(stat)±0.09(syst) in the second. The double ratio is lower than unity in all the measured bins, suggesting that the ψ(2S) yield is more suppressed than the J/ψ yield in the explored phase space.

Suppression and azimuthal anisotropy of prompt and nonprompt [Formula: see text] production in PbPb collisions at [Formula: see text][Formula: see text]

The nuclear modification factor [Formula: see text] and the azimuthal anisotropy coefficient [Formula: see text] of prompt and nonprompt (i.e. those from decays of b hadrons) [Formula: see text] mesons, measured from PbPb and pp collisions at [Formula: see text] [Formula: see text] at the LHC, are reported. The results are presented in several event centrality intervals and several kinematic regions, for transverse momenta [Formula: see text] [Formula: see text] and rapidity [Formula: see text], extending down to [Formula: see text] [Formula: see text] in the [Formula: see text] range. The [Formula: see text] of prompt [Formula: see text] is found to be nonzero, but with no strong dependence on centrality, rapidity, or [Formula: see text] over the full kinematic range studied. The measured [Formula: see text] of nonprompt [Formula: see text] is consistent with zero. The [Formula: see text] of prompt [Formula: see text] exhibits a suppression that increases from peripheral to central collisions but does not vary strongly as a function of either y or [Formula: see text] in the fiducial range. The nonprompt [Formula: see text] [Formula: see text] shows a suppression which becomes stronger as rapidity or [Formula: see text] increases. The [Formula: see text] and [Formula: see text] of open and hidden charm, and of open charm and beauty, are compared.

Measurement of the WZ production cross section in pp collisions at [Formula: see text] and 8[Formula: see text] and search for anomalous triple gauge couplings at [Formula: see text]

The WZ production cross section is measured by the CMS experiment at the CERN LHC in proton-proton collision data samples corresponding to integrated luminosities of 4.9[Formula: see text] collected at [Formula: see text], and 19.6[Formula: see text] at [Formula: see text]. The measurements are performed using the fully-leptonic WZ decay modes with electrons and muons in the final state. The measured cross sections for [Formula: see text] are [Formula: see text] [Formula: see text] and [Formula: see text] [Formula: see text]. Differential cross sections with respect to the [Formula: see text] boson [Formula: see text], the leading jet [Formula: see text], and the number of jets are obtained using the [Formula: see text] data. The results are consistent with standard model predictions and constraints on anomalous triple gauge couplings are obtained.

Observation of Charge-Dependent Azimuthal Correlations in p-Pb Collisions and Its Implication for the Search for the Chiral Magnetic Effect

Charge-dependent azimuthal particle correlations with respect to the second-order event plane in p-Pb and PbPb collisions at a nucleon-nucleon center-of-mass energy of 5.02 TeV have been studied with the CMS experiment at the LHC. The measurement is performed with a three-particle correlation technique, using two particles with the same or opposite charge within the pseudorapidity range |η|<2.4, and a third particle measured in the hadron forward calorimeters (4.4<|η|<5). The observed differences between the same and opposite sign correlations, as functions of multiplicity and η gap between the two charged particles, are of similar magnitude in p-Pb and PbPb collisions at the same multiplicities. These results pose a challenge for the interpretation of charge-dependent azimuthal correlations in heavy ion collisions in terms of the chiral magnetic effect.

Measurement of the [Formula: see text] production cross section using events in the [Formula: see text] final state in pp collisions at [Formula: see text]

The cross section of top quark-antiquark pair production in proton-proton collisions at [Formula: see text] is measured by the CMS experiment at the LHC, using data corresponding to an integrated luminosity of 2.2[Formula: see text]. The measurement is performed by analyzing events in which the final state includes one electron, one muon, and two or more jets, at least one of which is identified as originating from hadronization of a b quark. The measured cross section is [Formula: see text], in agreement with the expectation from the standard model.

Measurement of the production cross section of a W boson in association with two b jets in pp collisions at [Formula: see text]

The production cross section of a W boson in association with two b jets is measured using a sample of proton-proton collisions at [Formula: see text] collected by the CMS experiment at the CERN LHC. The data sample corresponds to an integrated luminosity of 19.8[Formula: see text]. The W bosons are reconstructed via their leptonic decays, [Formula: see text], where [Formula: see text] or [Formula: see text]. The fiducial region studied contains exactly one lepton with transverse momentum [Formula: see text] and pseudorapidity [Formula: see text], with exactly two b jets with [Formula: see text] and [Formula: see text] and no other jets with [Formula: see text] and [Formula: see text]. The cross section is measured to be [Formula: see text]+[Formula: see text], in agreement with standard model predictions.

Search for Dark Matter and Supersymmetry with a Compressed Mass Spectrum in the Vector Boson Fusion Topology in Proton-Proton Collisions at sqrt[s]=8 TeV

A first search for pair production of dark matter candidates through vector boson fusion in proton-proton collisions at sqrt[s]=8  TeV is performed with the CMS detector. The vector boson fusion topology enhances missing transverse momentum, providing a way to probe supersymmetry, even in the case of a compressed mass spectrum. The data sample corresponds to an integrated luminosity of 18.5  fb^{-1}, recorded by the CMS experiment. The observed dijet mass spectrum is consistent with the standard model expectation. In an effective field theory, dark matter masses are explored as a function of contact interaction strength. The most stringent limit on bottom squark production with mass below 315 GeV is also reported, assuming a 5 GeV mass difference with respect to the lightest neutralino.

Measurements of the [Formula: see text] production cross section in lepton+jets final states in pp collisions at 8 [Formula: see text] and ratio of 8 to 7 [Formula: see text] cross sections

A measurement of the top quark pair production ([Formula: see text]) cross section in proton-proton collisions at the centre-of-mass energy of 8[Formula: see text] is presented using data collected with the CMS detector at the LHC, corresponding to an integrated luminosity of 19.6[Formula: see text]. This analysis is performed in the [Formula: see text] decay channels with one isolated, high transverse momentum electron or muon and at least four jets, at least one of which is required to be identified as originating from hadronization of a b quark. The calibration of the jet energy scale and the efficiency of b jet identification are determined from data. The measured [Formula: see text] cross section is [Formula: see text]. This measurement is compared with an analysis of 7[Formula: see text] data, corresponding to an integrated luminosity of 5.0[Formula: see text], to determine the ratio of 8[Formula: see text] to 7[Formula: see text] cross sections, which is found to be [Formula: see text]. The measurements are in agreement with QCD predictions up to next-to-next-to-leading order.

Status of serum magnesium in Egyptian children with type 1 diabetes and its correlation to glycemic control and lipid profile

Diabetes mellitus has been suggested to be the most common metabolic disorder associated with magnesium deficiency, having 25% to 39% prevalence. This deficit could be associated with the development of late diabetic complications, especially macroangiopathy.We aimed to evaluate the status of serum Mg in children with type 1 diabetes and assess its relation to glycemic control and lipid profile.We included 71 Egyptian children with type 1diabetes having their follow-up at Pediatric Endocrinology outpatient clinic, Zagazig University Hospital and 71 age- and sex-matched control. We measured Serum magnesium, HbA1c, and lipid profile in all study subjects.Diabetic children had significantly lower serum magnesium level compared to control children (1.83 ± .27 mg/dL in diabetic children versus 2.00 ± .16 mg/dL in control children). Taking cut-off level of serum magnesium <1.7 mg/dL for definition of hypomagnesemia, hypomagnesemia was detected in 28.2% of diabetic children compared to 9.9% of control children. In diabetic patients, there was statistically significant difference in HbA1c between hypomagnesemic and normomagnesemic group being higher in the low magnesium group, as it is mean ± SD was 11.93 ± 3.17 mg/dL in group I versus 8.92 ± 0.93 mg/dL in the normomagnesemic group. Serum magnesium was found to be positively correlated with HDL (P < 0.001), and negatively correlated with age, HbA1c, triglycerides, total cholesterol, LDL, and duration of diabetes (P < 0.001).We concluded that total serum magnesium was frequently low in Egyptian children with type 1 diabetes and it is correlated with HbA1c and with lipid profile. Hypomagnesemia was more evident in patients with poor diabetic control and those with higher atherogenic lipid parameters. We suggest that low serum magnesium may be included in pathogenesis of poor glycemic control and abnormal lipid profile in children with type 1 diabetes. We need to perform further studies on giving magnesium supplements in diabetic children with hypomagnesemia to observe the effect of correction of serum magnesium on glycemic control, lipid profile, and the risk of diabetic complications.