Dysregulation of immune system in diabetic child

Diabetes is a chronic disease associated with selective destruction of the pancreatic B-cells. The exact etiology of the disease is unclear; however, insulin deficiency results from autoimmune destruction of B-cells. The appearance of auto antibodies to beta cell antigen, such as those against the 65-KDA isoform of glutamic acid decarboxylase GAD65 and the protein tyrosine phosphates in the peripheral circulation is a predictive sign of clinical disease in non diabetic individuals. Although GAD65 and IA-2 [insulin auto antibodies] may not be directly involved in the pathogenic processes in beta-cell destruction. They are good markers in assessing the risk of disease manifestation. This study aimed to evaluate GAD65 [glutamic acid decarboxylase] and ICA [islet cell auto antibodies] and IA-2 [insulin auto antibodies] auto antibodies as a disease markers and their relationship to certain residual beta cell function and glycemic control in type I diabetes and risk group, and assess the relation between CD4 [+] CD25 [+] [T-regulatory cells] and immune mediated diabetes. This study was conducted on 50 subjects randomly selected from those attending pediatrics outpatients clinics in the period of 2008. The subjects were classified into 3 groups: 1-Group A [patient group]: This group included 20 patients diagnosed as type I DM according to WHO classifications. Their ages ranging from 3-16 years with a mean age of 10.6 +/- 4.0. They were 11 males and 9 females. 2-Group B: [Risk group]: included 20 sibling of diabetic [type I DM] father, mother or both. They were 9 females and 11 males their ages ranging from 18 years to 25 years with a mean of age 21 +/- 2.5. 3-Group C: Control group, included 10 healthy children; they were 5 females and 5 males, their ages ranging from 5-16 years with a mean age of 10.8 +/- 2.8, with no family history of diabetes mellitus. All subjects are subjected to: Complete history taking, Full clinical examination, Complete blood picture, Glycosylated Hb using ion-exchane chromatography, C-peptide of insulin by-ELISA, determination of GAD 65, ICA and IA-2 auto antibodies by ELISA technique, Flowcytometric measurement of the expression of the CD4 [+] /CD25 [+] of T-regulatory cell. The most frequently encountered antibody in children group was GAD65 in 60% of cases, followed by ICA, 40%. When taken together, both GAD65 and ICA were detected in 30%. IA-2 was detectable only in 30% of cases. When both GAD65 and IA-2 were taken together, they were detected in 25% of cases also ICA and IA-2 were detected in 15% of cases. When GAD, ICA and IA-2 were taken together, they were detectable in 5% of cases. The most frequently encountered antibody in risk group was ICA in 15% of cases, followed by GAD, in 10%. When taken together, both GAD65 and ICA were detected in 10%. IA-2 was detectable only in 10% of cases. When both GAD65 and IA-2 were taken together. they were detected in 5% of cases also ICA and IA-2 were detected in 15% of cases. When GAD, ICA and IA-2 were taken together, they were detectable in 5% of cases. There was highly significant difference between 3 groups for prevalence of GAD65 autoantibody [p<0.001] and significant difference between 3 groups for prevalence of ICA autoantibody [p<0.005] and significant difference between 3 groups for prevalence of IA-2 autoantibody [p<0.003]. There were highly significant differences in the level of fasting C-peptide of insulin between patient and control groups. [p value<0.001]. There were significant difference between level of fasting Cpeptide and single and multiple autoantibody positivity [p<0.05]. In the children group the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells were 0.96, 0.46 respectively. In the control group the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells were 2.85, 0.92 respectively. The difference between control and study group according to the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells was statistically highly significant [p<0.001]. In the Risk group the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells were 0.99, 0.7 respectively. In the control group the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells were 2.96, 0.62 respectively. The difference between control and risk group according to the mean and SD of the percentage of CD4 [+] CD25 [+] from CD4 cells was statistically non significant. There was highly sig relation [p<0.001] between percent of CD4 [+] CD25 [+] out of CD4 cells and the presence and absence of auto antibodies in the children group. There was no sig relation between percent of CD4 [+] CD25 [+] out of CD4 cells and the presence and absence of auto antibodies in the in risk group. At the time of diagnosis almost all patients with type I diabetes have auto antibodies that are reactive to islet antigens and auto antibodies GAD, ICA, lA-2 are of' value for predicting IDDM in sibling of diabetic parents type I also CD4[+] CD25[+]T-regulatory cells actively suppress activation of the immune system and prevent pathological self-reactivity

Ropivacaine 0.2% versus lidocaine 0.5% for intravenous regional anesthesia

Purpose: This study was designed to compare the anesthetic efficacy, post block analgesia, local and systemic related side effects between ropivacaine 0.2% and lidocaine 0.5% when used for forearm intravenous regional anesthesia I.V.R.A.

Patients and Methods: The study comprised 50 patients, allocated randomly into two groups: lidocaine group [gp I] and ropivacaine group [gpII]. Before distal tourniquet deflation, visual analogue pain score [VAS] and verbal rating score [VRS] were recorded at the operative site and at the tourniquet site every [5] minutes until deflation of the distal tourniquet. Tourniquet tolerance was recorded for each patient in both groups, intravenous boluses of fentanyl [25] microgm were given to relieve tourniquet pain with maximum of [3] microgm/ kg through the cannula of the healthy arm and the total dose of fentanyl was recorded for each patient in both groups. Routine monitoring were applied continuously, during surgical procedure [ECG, pulse oximetry, non-invasive blood pressure]. After distal tourniquet deflation [VAS] and [VRS] were recorded every 10 minutes for 90 minutes, sedation score was recorded every 10 minutes for 60 minutes and hemodynamic changes [mean arterial blood pressure] were also recorded every 15 minutes for 45 minutes after distal tourniquet deflation, and any adverse effects of the added drugs were recorded in both groups

Results: The results of this study showed that [VAS] and [VRS] at site of surgery and the tourniquet before distal tourniquet deflation were significantly lower in group II compared with group I, tourniquet tolerance was significantly longer in group II compared with group I, the total dose of fentanyl given to relieve tourniquet pain was significantly lower in group II compared with group I as no patient in group II required fentanyl to relieve tourniquet pain. After distal tourniquet deflation [VAS] and [VRS] were significantly lower in group II compared with group I, sedation score was significantly higher in group I compared with group II as regarding mean arterial blood pressure it did not change significantly in group II compared with group I

Summary and Conclusion: We conclude that ropvicane provides anesthesia and, superior post operative analgesia compared with lidocaine in intravenous regional anesthesia