Epidemiology of haemoglobin disorders in Europe: an overview.

OBJECTIVE: As a result of global population movements, haemoglobin disorders (thalassaemias and sickle cell disorders) are increasingly common in the formerly non-indigenous countries of Northern and Western Europe and in the indigenous countries of Southern Europe. This article presents an overview of the changing picture and a method for assessing service needs. METHOD: Data on country of birth or ethnic origin of residents are adjusted to obtain the estimated proportions of residents and births in non-indigenous groups at risk for haemoglobin disorders in European countries. The results are combined with prevalence data in each country of origin to obtain country prevalence estimates. Service indicators (annual tests or other interventions required to ensure equitable delivery of treatment and prevention) are then derived by country. RESULTS: Haemoglobin disorders now occur at comparable frequency throughout Northern, Western and Southern Europe. Annually, there are more affected conceptions in Northern and Western than in Southern Europe, and sickle cell disorders are more common than thalassaemias. There is growing need for health policy-makers to support motivated professionals working to develop optimal patient care, carrier diagnosis, genetic counselling and access to prenatal diagnosis throughout the Region. CONCLUSION: There is a strong case for pan-European collaboration on haemoglobin disorders to share policies, standards and the instruments required to support them. These include methods for needs assessment, service standards, education and information strategies and materials, and methods for evaluating service delivery.

Improved metabolic control decreases platelet activation markers in patients with type-2 diabetes.

BACKGROUND: Cardiovascular disease is associated with platelet dysfunction in patients with diabetes. Hyperglycaemia is known as an independent risk factor for micro- and macrovascular complications, and improvement of metabolic control has shown beneficial effects on diabetic late complications. Our study attempts to clarify the effect of improved metabolic control on platelet activation markers in patients with type-2 diabetes. MATERIALS AND METHODS: Thirty patients were studied at baseline and 3 months after improvement of metabolic control and compared with an age-matched nondiabetic control group. Platelet activation markers (CD31, CD36, CD49b, CD62P and CD63) were assessed by flow cytometry analysis. RESULTS: Significantly more activated platelets were detected in patients with diabetes compared with controls. After 3 months' improvement of metabolic control, a significant decline of all platelet activation markers except CD36 was noted. Furthermore a significant correlation between CD62P, CD63 and HbA(1c) levels was observed. CONCLUSIONS: We conclude therefore that improvement of metabolic control has a beneficial effect on platelet activation. This may have an implication in the pathogenesis of vascular disease in patients with type-2 diabetes.

[Bone pain after long distance flight as first manifestation of HbSC disease]. / Rezidivierende Knochenschmerzen nach Langstreckenflug als Erstmanifestation einer HbSC Krankheit.

A 7-year old Ghanese boy was admitted with repeated bone pain. Multiple bone marrow alterations were seen as the causal factor. HbSC disease was diagnosed by hemoglobin electrophorics. The onset of pain attacks appears to be linked to the long distance flight from Ghana to Austria. Due to severe bone marrow affection, beside symptomatic therapy a long-term treatment with hydroxyurea was started, leading to an HbF increase from 5.1 % to 19.3 %. After a follow-up of 8 months the patient has remained free of complaints.

Severe factor XI deficiency caused by compound heterozygosity for the type III mutation and a novel insertion in exon 9 (codons 324/325 +G).

We investigated a 42-year-old Caucasian woman with severe factor XI deficiency and her family members. Restriction enzyme analysis and DNA sequencing revealed compound heterozygosity in the patient for the known type III mutation, which is a Phe283Leu amino acid substitution in the fourth apple domain causing impaired dimerization and secretion, and for a novel frameshift mutation in exon 9 (codons 324/325 +G), leading to premature termination with lack of parts of the fourth apple domain and the downstream serine protease domain.

A serine/alanine polymorphism in the nucleotide-binding fold-2 of the sulphonylurea receptor-1 (S1369A) is associated with enhanced glucose-induced insulin secretion during pregnancy.

The sulphonylurea receptor-1 (SUR-1) regulates glucose-induced insulin secretion by controlling K+-ATP channel activity of the pancreatic beta-cell membrane. In this study, we investigated the putative role of a T/G-polymorphism (exon 33, codon 1369; S1369A) in the adenosine diphosphate-sensing nucleotide-binding fold-2 (NBF-2) of the SUR-1 on glucose-induced insulin secretion during an oral glucose tolerance test in pregnant women (PW; n=182). Compared to PW with the T/T genotype, statistically significant elevated C-peptide concentrations were found 60 min after glucose intake in PW with the T/G and G/G genotype (T/T 9.0+/-0.4 ng/ml vs T/G 10.8+/-0.4 ng/ml or G/G 10.8+/-0.7 ng/ml, p=0.01). Furthermore, compared to PW with T/T genotype the deltaC-peptide (60/0 min) was significantly enhanced in PW with T/G or G/G genotype (T/T 6.7+/-0.3 vs T/G 8.9+/-0.4 or G/G 8.9+/-0.7, p=0.0009). A significant correlation of C-peptide concentrations with blood glucose (BG) 60 min after glucose intake was only found in PW with the T/T genotype (r=0.6, p<0.0004). Similarly, a significant correlation of insulin concentrations with BG 60 min after glucose intake was observed in PW with T/T genotype (r=0.5, p<0.0001) and T/G genotype (r=0.24, p<0.03) but not in PW with G/G genotype (r=0.01, p=0.9). From our data we conclude that in PW with the alanine substitution in the NBF-2 region, the insulin response of the pancreatic beta-cell after glucose intake is enhanced and does not correlate with actual BG levels.

Relative hypoleptinaemia in women with mild gestational diabetes mellitus.

AIMS: There is increasing evidence suggesting that leptin plays a major role in the regulation of energy homeostasis, as well as in the neuroendocrine and reproductive systems. Leptin is synthesized in the human placenta. The aim of this study was to relate serum leptin levels during pregnancy to glucose tolerance, body mass index (BMI) and specific metabolic variables, such as specific insulin and proinsulin. METHODS: A 2-h 75 g oral glucose tolerance test was performed in 221 pregnant women at 22-29 weeks of gestation (median 25th week). Serum leptin was measured using a radioimmunoassay. In 49 women, sequential leptin measurements were performed (during pregnancy and post partum (median 5 months)). RESULTS: During pregnancy serum leptin was significantly related to body weight (r = 0.49), BMI (r = 0.51), fasting immunoreactive insulin (r = 0.46), specific insulin (r = 0.43) and proinsulin (r = 0.29) (all P-values <0.0001). In women with mild gestational diabetes (GDM, n = 55), leptin levels were lower compared to women with normal glucose tolerance (n = 166) after adjusting for BMI and fasting insulin (26.9 vs. 19.4 ng/ml, P = 0.0001). Leptin was significantly higher during pregnancy compared to post partum (mean +/- SE: 24.3+/-1.5 vs. 19.6+/-1.6 ng/ml, P = 0.0003), even after adjustment for changes in BMI and changes in fasting insulin (P = 0.013). CONCLUSIONS: Leptin levels are elevated in pregnancy. Women with mild GDM presented with relative hypoleptinaemia compared to women with normal glucose tolerance.

Trp64Arg polymorphism of the beta3-adrenergic receptor gene in pregnancy: association with mild gestational diabetes mellitus.

A missense mutation of the beta3-adrenergic receptor gene (Trp64Arg) has been associated with obesity and increased capacity to gain weight in nonpregnant populations. Furthermore, the mutation is a potential modifying factor in the etiology of impaired glucose tolerance and type 2 diabetes. We studied the relation of the beta3-adrenergic receptor genotype to glucose tolerance during pregnancy, a state of physiological insulin resistance. In 179 pregnant women (mean age, 28.5 +/- 0.4 yr), a 2-h oral glucose tolerance test was performed between gestational weeks 20 and 31. The beta3-adrenergic receptor genotype was assessed using restriction fragment length polymorphism. The frequency of the Arg64 allele was 9.15%. In women with mild gestational diabetes (n = 70), as defined by 60 min postload glucose values, the Trp64Arg genotype was more frequent than in women with normal glucose tolerance (n = 109; 26% vs. 11%; P = 0.01). Furthermore, the Trp64Arg polymorphism was associated with increased weight gain during pregnancy (baseline to gestational weeks 20-31) and increased postload glucose, insulin, and C peptide values during the oral glucose tolerance test. The results of the present study extend current knowledge about the association of the Trp64Arg beta3-adrenergic receptor polymorphism with glucose tolerance to a pregnant population. The association with mild gestational diabetes suggests that the impact of the polymorphism may be clinically important during pregnancy, a state of physiological insulin resistance.

Concentrations of circulating P-selectin are increased in patients with newly diagnosed insulin-dependent diabetes mellitus.

Endothelial cell activations and/or dysregulations of the coagulation system are crucial parameters for the prognosis of disease in patients with IDDM. Recent data suggest that expression of the adhesion molecules E-selectin and P-selectin are markers of endothelial cell activation and/or platelet activation and might modify immunologic responses after shedding from cell membranes. In patients with newly diagnosed IDDM only limited data on circulating selectins are available. This has prompted us to measure levels of soluble (s) forms of P-selectin and E-selectin in 18 patients with newly diagnosed IDDM and two years after the onset of insulin substitution therapy in comparison to 18 age-matched healthy control subjects. HbA1c and blood glucose levels were significantly higher in patients with new onset diabetes, compared to the same patients after two years of insulin therapy (HbA1c: 12 +/- 3% vs. 7.8 +/- 2%; p < 0.01; blood-glucose: 409 +/- 163 mg/dl vs. 131 +/- 23 mg/dl; p < 0.01), but no correlation between these metabolic parameters and soluble forms of E- and P-selectins were noted. Levels of sP-selectin decreased from 210 +/- 120 ng/ml in newly diagnosed IDDM patients to 127 +/- 75 ng/ml after two years of therapy (p < 0.01) and were similar to those of the control subjects (110 +/- 31 ng/ml). Serum concentrations of circulating E-selectin showed no differences in the three groups (newly diagnosed IDDM: 42 +/- 17 ng/ml; two years later: 43 +/- 19 ng/ml; control subjects: 41 +/- 14 ng/ml; n.s.). Increased levels of sP-selectin together with normal levels of sE-selectin at the onset of IDDM suggest enhanced platelet activation during the initial phase of the autoimmune process and return to baseline levels within two years of the disease.

Haemoglobin O Padova and falsely low haemoglobin A1c in a patient with type I diabetes.

Glycated haemoglobin (HbA1c) measured by high performance liquid chromatography (HPLC) in a 20 year old female with insulin dependent diabetes mellitus was consistently within the normal range although her daily blood glucose values were > 11.1 mmol/l. HbA1c measured by immunoagglutination and fructosamine was elevated and correlated with the patient's blood glucose values. The HPLC chromatogram showed an additional peak at HbA0. Electrophoresis of haemoglobin on citrate agar gel revealed an abnormal haemoglobin anodal of HbS. Cellulose acetate electrophoresis and isoelectric focusing demonstrated an additional haemoglobin migrating close to HbA2. Amino acid analysis and DNA sequencing revealed an alpha 30 (B11) Glu-->Lys replacement, that is, haemoglobin O Padova. Investigations of two family members without diabetes revealed the same rare haemoglobin variant. This case showed that this silent haemoglobin mutation caused an additional peak and falsely low HbA1c values when measured by HPLC, the gold standard for this evaluation.

Renal and metabolic effects of 1-year treatment with ramipril or atenolol in NIDDM patients with microalbuminuria.

UNLABELLED: The clinical importance of selection of different antihypertensive drugs for the treatment of diabetic patients is still unclear. Thus we performed a randomised, controlled study in 105 hypertensive non-insulin-dependent diabetic (NIDDM) patients with microalbuminuria over 1 year. Patients received either the angiotensin converting enzyme (ACE) inhibitor ramipril (2.5-5.0 mg/day; in addition 24% of patients also received felodipine) or the beta blocking agent atenolol (50-100 mg/day; in addition 24% of patients also received hydrochlorothiazide). Blood pressure, metabolic control, lipid levels and albumin excretion rate were studied during the follow-up. After 1 year an almost identical fall (p < 0.001) in blood pressure was observed with ramipril (170/100 vs 150/ 85 mmHg, median) and atenolol (180/100 vs 150/ 80 mmHg, median). With ramipril a reduction of total cholesterol (6.3 vs 5.9 mmol/l), of LDL cholesterol (3.8 vs 3.6 mmol/l) and HDL cholesterol (1.3 vs 1.2 mmol/l) was found, whereas triglycerides slightly increased (1.8 vs 2.0 mmol/l). With atenolol a similar reduction of total cholesterol (6.3 vs 5.9 mmol/l), LDL cholesterol (3.8 vs 3.7 mmol/l) and HDL cholesterol (1.4 vs 1.2 mmol/l) and an increase of triglycerides (1.4 vs 1.7 mmol/l) was noted. Metabolic control of the patients was maintained with both ramipril and atenolol treatment. With ramipril treatment urinary albumin creatinine ratio (14.4 vs 13.8 mg/mmol) and creatinine clearance (82 vs 84 ml/min) were constant, but with atenolol an increase of albumin creatinine ratio (13.9 vs 19 mg/mmol, p < 0.001) and a slight decrease of creatinine clearance (80 vs 66 ml/min, p < 0.05, not significant after Bonferroni correction) was observed. IN CONCLUSION: 1-year treatment of NIDDM patients with ramipril or atenolol does not influence metabolic control, the changes in serum lipids were similar. Despite almost identical blood pressure reduction in both groups the albumin creatinine ratio was constant under ramipril, but increased under atenolol treatment.

[Activated protein C resistance--an evaluation of current status]. / Aktivierte Protein C-Resistenz--eine Standortbestimmung.

The discovery of APC resistance and of the factor V Leiden mutation brought a break-through in thrombosis research and has greatly improved our understanding of the pathogenesis of venous thrombosis. In particular, it became obvious that thrombotic disease is the result of multiple factors. However, many clinically relevant questions still remain unanswered: for instance, the individual risk of thrombosis for a gene carrier is difficult to assess, since only some of the factors which may finally lead to thrombosis are presently recognized as such. The functional tests which are in common use today have a number of drawbacks and will soon be replaced by improved methods.

[Evaluation of a new method for determining glycated hemoglobin with monoclonal antibodies (DCA 2000)]. / Evaluation einer neuen Methode zur Bestimmung von glykiertem Hämoglobin mittels monoklonaler Antikörper (DCA 2000).

HPLC (High Performance Liquid Chromatography) is commonly regarded as the reference method for HbAlc measurements. However, HPLC requires a relatively large technical staff, expensive laboratory equipment and is rather time consuming. The mobile DCA 2000 instrument determines HbAlc in only 9 minutes, using only one microliter of capillary blood. It uses an immunoassay based on the inhibition of latex agglutination and a monoclonal antibody specific for the glycated N-terminal end of the beta-chain of haemoglobin. In order to determine the reliability of this new method for clinical practice we compared HbAlc measurements on DCA 2000 with HPLC values. A correlation analysis in 283 diabetic patients showed a highly significant correlation between the two methods (r = 0.96; p < 0.0001). In 215 samples (75.7%) the value measured by means of DCA 2000 was lower than the reference value (mean deviation: 0.6% HbAlc), in 58 samples (20.8%) it was higher (mean deviation: 0.39%). In 10 samples the values were identical. The maximum deviations were plus 1.6% and minus 1.3% HbAlc. DCA 2000 is easy to handle and gives rapid and reliable information on long-term metabolic control. Hence, it could be very useful for clinical practice and outpatient departments.

Hemoglobin variants recently detected in Austria.

Measurement of glycated hemoglobin (HbAtc) is used for routine management of diabetic patients. Glucose linkage to HbAtc reflects mean blood glucose levels during the last 3 months before examination. Various methods for HbA1c determination show abnormal values with hemoglobin variants. In some diabetic patients excessively high HbA1c values with high-performance liquid chromatography (HPLC) led to the detection of Hb Graz. In addition to Hb Graz, other silent hemoglobin variants have been found in Austria. Here we review Hb Graz, Hb Sherwood Forest, and Hb Okayama detected while using HPLC for the measurement of HbA1c in diabetic patients.