Incidence of insulin-dependent diabetes mellitus in age groups over 30 years in Denmark.

The incidence of IDDM in the age group over 30 years was estimated in a historical prospective study, using clinical and biochemical measurements at onset as criteria for classification. The study population, nearly one million, represents 20% of the Danish population. The degree of ascertainment was > 99%. One thousand two hundred and forty patients were treated with insulin during the study period (1973-77). Based on the clinical and biochemical variables, the patients were classified into three groups: insulin-dependent diabetes mellitus (IDDM) accounted for 16.2%, insulin-treated diabetes mellitus for 54.1% and short-term treated diabetes mellitus for 29.6% of the total insulin-treated group. The incidence of IDDM in the age group over 30 years at onset was 8.2 100,000(-1) year-1. The cumulative incidence rate (0-90 years) was 1.5-1.6 per cent. The present study indicates that IDDM may develop at any age. Thus the life-time risk of developing IDDM is higher than hitherto expected.

A comparison between nebulized terbutaline, nebulized corticosteroid and systemic corticosteroid for acute wheezing in children up to 18 months of age.

One hundred and twenty-three children, aged 1.5-18 months, participated in a randomized, double-blind, placebo-controlled multicentre study comparing different treatments for acute wheezing. The children were admitted to one of five participating paediatric departments. They were randomized into one of four treatment groups: (1) soluble prednisolone+placebo inhalation+terbutaline inhalation; (2) soluble placebo+budesonide inhalation+terbutaline inhalation; (3) soluble placebo+placebo inhalation+terbutaline inhalation; and (4) soluble placebo+placebo inhalation+normal saline inhalation. On admission, measurements of temperatures, respiratory rate and heart rate were made and once-a-day thereafter. Wheezing, accessory respiratory muscle use, prolonged expiration and general condition were scored on a scale ranging from 0 to 3. Significantly more treatment failures were recorded in the placebo group. Children from both steroid groups were discharged earlier than children from the terbutaline group. Compared with children from the placebo group, children from all three treatment groups had a greater improvement in symptom score, but this was significant for the budesonide group only.

Islet cell cytoplasmic antibodies (ICA) in diabetes and disorders of glucose tolerance.

Islet cell cytoplasmic antibodies were determined in 85 individuals 60 to 74 years old with fasting hyperglycaemia, in 65 patients with cystic fibrosis, in 113 patients with pancreatitis, in 21 patients with Turner's phenotype, and in 135 first-degree relatives of patients with Type 1 (insulin-dependent) diabetes. Islet cell antibodies were absent in all 60 to 74-year-old subjects with fasting hyperglycaemia detected by screening, and who did not require insulin treatment within 3 years. Islet cell antibodies were also absent in all patients with pancreatitis, cystic fibrosis, or Turner's phenotype. Islet cell antibodies were detected in 2 out of 135 (1.5%) first-degree relatives of new Type 1 diabetic patients, and in 1 out of 371 (0.3%) non-diabetic control subjects. During 12 years of follow-up 1 of the 2 first-degree relatives with islet cell antibodies and the only positive control developed Type 1 diabetes. It is suggested that islet cell antibodies are primarily associated with Type 1 diabetes and not with other disorders of glucose tolerance.

Insulin-dependent diabetes mellitus secondary to chronic pancreatitis is not associated with HLA or the occurrence of islet-cell antibodies.

We assessed HLA-DR types and investigated serum samples for islet-cell cytoplasmic antibodies (ICA) in 31 Danish patients with chronic pancreatitis. The antigen frequencies were compared with those in 1177 unrelated healthy Danish controls. Twenty patients had insulin-dependent diabetes and 11 had normal intravenous glucose tolerance. No significant differences in the frequencies of DR3, DR4, or DR2 were found between patients with insulin-dependent diabetes and patients with normal glucose tolerance or between any of these groups and controls. ICA were negative in all patients with chronic pancreatitis. It is concluded that the beta-cell dysfunction in insulin-dependent diabetes in chronic pancreatitis differs from that of classical insulin-dependent diabetes.

Nonislet pancreatic autoantibodies in sibship with permanent neonatal insulin-dependent diabetes mellitus.

Neonatal insulin-dependent diabetes mellitus (IDDM) occurs rarely. A sibship of two HLA-Dw3/4-positive boys who developed IDDM within the 1st wk of life is described. Although the HLA-D region genotype would be consistent with IDDM associated with islet autoimmunity, islet cell antibodies were negative, but both boys exhibited the presence of a novel autoantibody that reacted specifically with a conspicuous, yet unidentified, determinant in the interstitial tissue among the acinar cells. The possible relationship between this acinar nonislet autoantibody and permanent neonatal diabetes remains to be established.

Detection of islet cell autoantibodies in newly diagnosed diabetic patients using insulin-producing Syrian hamster cells.

An insulin-producing cell line, Clone-16, of hamster origin, was characterized for islet hormone production and for reactivity with islet cell surface (ICSA) and islet cell cytoplasmic (ICA) antibodies in sera from children with newly diagnosed insulin-dependent (Type 1) diabetes mellitus (IDDM). The Clone-16 cells have a doubling time of about 50-60 hr. The cells produced 63 +/- 3 ng (mean +/- SD) immunoreactive insulin and 9.4 +/- 0.3 ng immunoreactive glucagon per day per 10(6) cells, while somatostatin (SRIF) and pancreatic polypeptide (PP) were undetectable. The reactivity with autoantibodies in IDDM sera was assessed by indirect immunofluorescence or 125I-protein A binding assay on intact cells to detect islet cell surface antibodies (ICSA) or on frozen sections of cell pellets to detect islet cell cytoplasmic antibodies (ICCA) by indirect immunofluorescence. Although the proportion of the ICSA-positive Clone-16 cells compared favorably with rat islet cells (r = 0.81; p less than 0.01), we found 5/10 IDDM sera to be positive on rat islet cells but 8/10 on the Clone-16 cells. There was also a good correlation in the 125I-protein A binding assay between mouse islet cells and Clone-16 cells (r = 0.91; p less than 0.01). Frozen sections of Clone-16 cells showed a cytoplasmic immunofluorescence in 8/10 of the IDDM sera and this reaction parallelled the results obtained in the standard indirect immunofluorescence assay with a frozen section of human blood group O pancreas. We conclude that the insulin- and glucagon-producing Clone-16 cells are a useful cell line for detecting islet cell autoantibodies.

Islet cell and other organ-specific autoantibodies in healthy first-degree relatives to insulin-dependent.

The presence of organ-specific autoantibodies including islet cell surface, cytoplasmic and cytotoxic as well as thyroid-gastric antibodies were determined in healthy, non-diabetic, first-degree relatives to 30 insulin-dependent diabetic (IDDM) children. Thirty healthy families without family-history of diabetes mellitus served as controls. The prevalence of organ-specific autoantibodies among the healthy members in the diabetic families was increased compared to the control families (p less than 0.005). Islet cell cytoplasmic antibodies were only detected in diabetes families, since 23% (7/30) of the probands and 7% (2/31) of the siblings were positive and all others negative. Organ-specific autoantibodies were associated with HLA DR3 only in the diabetes families (p less than 0.025) while autoantibody positive members in the control families were associated with HLA B7 (p less than 0.01). This study suggests that childhood IDDM occurs in families with an increased prevalence of organ-specific autoantibodies.

Increased reduction in fasting C-peptide is associated with islet cell antibodies in type 1 (insulin-dependent) diabetic patients.

A cohort of 82 patients with Type 1 (insulin-dependent) diabetes was followed prospectively for 24 months, and 54 of them for 30 months, to study the relationship between fasting levels of immunoreactive C-peptide and titres of islet cell antibodies. After diagnosis, fasting C-peptide rose temporarily for 1-6 months of insulin therapy and declined continuously thereafter. While islet cell antibodies were present among 55% of the newly diagnosed patients, only 31% remained positive at 30 months. Their antibody titres decreased from 1:81 at diagnosis to 1:3. Only 3 patients (4%) who were islet cell antibody negative at diagnosis became positive later. The median C-peptide values among the persistently islet cell antibody positive patients decreased from 0.11 pmol/ml at 18 months, to 0.09 pmol/ml at 24 months, to 0.06 pmol/ml at 30 months compared to 0.18 (p = 0.04), 0.15 (p = 0.05) and 0.16 (p less than 0.003) pmol/ml, respectively, for the islet cell antibody negative patients. The median slope for the latter was -0.09 compared to -0.19 for the islet cell antibody positive patients (p = 0.01). These differences were reflected in increasing dosages of insulin, since patients remaining antibody-positive for 30 months were given 1.3-1.4 times more insulin (p = 0.01-0.004) than the antibody negative patients. This study demonstrates that islet cell antibodies may be a useful marker for predicting an increased rate by which endogenous B cell function is lost in Type 1 diabetes.

Autoantibodies in chronic pancreatitis.

In 60 consecutive patients clinically suspected of having chronic pancreatitis the serum concentration of the immunoglobulins (IgA, IgG, IgM), the IgG- and IgA-type non-organ-specific autoantibodies against nuclear material (ANA), smooth and striated muscle, mitochondria, basal membrane, and reticulin, and the IgG- and IgA-type pancreas-specific antibodies against islet cells, acinus cells, and ductal cells (DA) were estimated blindly. In 23 of the patients chronic pancreatitis was verified, whereas chronic pancreatitis was rejected in 37 patients (control group). IgG and IgA were found in significantly higher concentrations in the patients with chronic pancreatitis than in the control group but within the normal range. ANA and DA occurred very frequently in both groups but with no statistical difference. Other autoantibodies only occurred sporadically. The findings of this study do not support the view of an immunological pathogenesis in chronic pancreatitis.

Islet cell antibodies in insulin-dependent (type 1) diabetic children treated with plasmapheresis.

Plasma levels of islet cell cytoplasmic and cytotoxic antibodies were determined in 10 children with insulin-dependent diabetes mellitus (IDDM) treated with plasmapheresis shortly after diagnosis, and in 9 children with IDDM treated by conventional means alone. Islet cell cytoplasmic antibody (ICA) titers were determined by indirect immunofluorescence using unfixed sections of human pancreas, and islet cell cytotoxic antibody levels were determined in a complement-dependent antibody-mediated cytotoxicity (C'AMC) assay using a human fetal cloned insulin-producing cell line (JHPI-1) as target. Before plasmapheresis, ICA was present in 7 out of 10 children and C'AMC was positive in 4. Four successive treatments with plasmapheresis did not consistently decrease plasma levels of ICA or C'AMC. ICA was present in 15 out of the total 19 children at diagnosis, and titers of ICA decreased in 12 out of 15 subjects by at least 1 degree of dilution (1:3) at 18-30 months follow-up, whether or not they had been treated with plasmapheresis; C'AMC was positive in 6 out of the 18 children at diagnosis and decreased in 2 out of 6. Plasma levels of C-peptide did not differ at diagnosis but remained higher in the plasmapheresis treated diabetic children at 3 and 18-30 months follow-up. Neither ICA titers nor C'AMC levels correlated with plasma C-peptide responses at 18-30 months. It is concluded that plasmapheresis decreases ICA and C'AMC but is followed rapidly by a rebound effect, and does not affect the rates at which these islet cell antibodies decrease with increasing duration of IDDM.

Disappearance and reappearance of islet cell cytoplasmic antibodies in cyclosporin-treated insulin-dependent diabetics.

In 68 newly diagnosed patients with insulin-dependent diabetes mellitus (IDDM) whose treatment included cyclosporin (CyA) the prevalence and mean titre of islet cell cytoplasmic antibodies (ICA) fell faster than they did in the 56 who received only insulin. However, in the CyA-treated patients the prevalence or titre of ICA at diagnosis did not correlate with beta-cell function as measured by glucagon-stimulated C-peptide levels; improvement and recovery of beta-cell function after 30 days of CyA therapy occurred despite the continued presence of ICA; and CyA-induced remission of IDDM (ie, glucagon stimulated plasma C-peptide levels greater than 0.6 pmol/ml) was not predicted by nor coincident with disappearance of ICA. Therefore, although CyA therapy was associated with a higher than expected frequency of remission and faster disappearance of ICA, the two observations were not temporally and may not be causally related. ICA should not be used to identify the target population for or to predict response to immunosuppressive therapy. The contribution of ICA to the pathogenesis of beta-cell destruction in IDDM needs serious re-examination.

Spontaneous in vitro immunoglobulin secretion at the diagnosis of insulin-dependent diabetes.

Blood mononuclear cells obtained from 17 newly diagnosed insulin-dependent diabetic (IDDM) patients treated with insulin for 5-7 days were assessed for the number of spontaneous and pokeweed mitogen (PWM)-stimulated immunoglobulin-secreting cells in a reverse haemolytic plaque assay. The spontaneous in vitro immunoglobulin secretion was evanescent and decreased in individual patients within 1-4 months of insulin treatment. Compared to matched controls, 53% (9/17) of the IDDM patients had an elevated spontaneous secretion of immunoglobulin, 41% (7/17) for IgG, 35% (6/17) for IgM, and 35% (6/17) for IgA. The quantities of PWM-stimulated IgG, IgM, or IgA secreting cells in IDDM were comparable to the controls. The IDDM patients with spontaneous immunoglobulin secreting cells had higher fasting C-peptide levels compared to the patients with immunoglobulin-producing cells within the normal range (P less than 0.05). The average titre of islet cell cytoplasmic antibodies was 1:26 in (9 out of 9 were positive) patients with, compared to 1:1 in patients (4 out of 8 were positive) without spontaneous secretion (P = 0.025). These results suggest that the clinical onset of IDDM is associated with a polyclonal B lymphocyte activation and that higher levels of fasting C-peptide islet cell antibodies are associated with this immunoregulatory abnormality.

Clinical time-course and characteristics of islet cell cytoplasmatic antibodies in childhood diabetes.

Circulating islet cell antibodies (ICA) were present in high frequency (80%) early after diagnosis and decreased in the time course of childhood diabetes mellitus. The complement fixing ability of islet cell antibodies (CF-ICA) in the course of the disease appeared to depend on the titre of ICA: the coefficient of correlation between ICA and CF-ICA titres was 0.79 and all ICA's with a titre over 16 were complement-fixing. Incubating fresh frozen human pancreatic sections thrice rather than once with the children's sera, increased the detectability of complement fixation by a factor 1.4 in all ICA-positive sera. Thus tested, the detection of complement fixation per se did not appear to have a separate pathogenic significance, as the fraction of complement fixing ICA's was almost constant throughout the clinical course. The presence of ICA-IgG subclasses also was dependent on the ICA titre: above a titre of 16 mostly all four subclasses could be detected. Incubating the pancreatic tissue thrice rather than once with ICA-positive sera resulted in enhanced detectability of ICA-IgG1. Early in the course of childhood diabetes, including two prediabetic children, most of the IgG subclasses could be detected in ICA, but after a duration of one year IgG1 alone was mainly seen. In two other children, having a family history of insulin-dependency, restriction to the IgG2 subclass was found.

Analysis of islet cell antibodies on frozen sections of human pancreas.

The sensitivity and specificity of the assay for islet cell cytoplasmic antibodies in human serum were examined using cryostat sections from fresh frozen pancreas. The specificity of the assay was close to 100% while the sensitivity was 40%-98% depending on the pancreas used. Inter-observer variation was 12-27%. End-point titres of islet cell antibodies varied with the sensitivity of each pancreas. End-point titration of the antibodies in two different laboratories using the same pancreas was significantly correlated (Spearman test p less than 0.001). We conclude that a reliable determination of islet cell antibody titres in human serum requires careful characterization of the sensitivity and specificity of each pancreas used as a source of frozen sections, in the indirect immunofluorescence assay.

Plasmapheresis in the initial treatment of insulin-dependent diabetes mellitus in children.

Several factors indicate that autoimmune mechanisms may play a part in the aetiology of insulin-dependent diabetes mellitus. At the onset of the disease in 10 children (aged 11-16 years) plasmapheresis was performed four times over one to two weeks. Seventeen age-matched children with the same clinical features served as controls. The C-peptide concentrations at onset were the same in the two groups, but after one month the children treated with plasmapheresis had significantly higher values. This difference became even more pronounced after three, nine, and 18 months, both during fasting and at the maximum response to a standardised meal. The study group also had a significantly more stable metabolism, longer partial remission, and no higher insulin requirement. Of the 10 treated children islet-cell cytoplasmic antibodies were present in seven before plasmapheresis and in nine during treatment. The antibodies remained detectable in five and six out of nine patients at one and six months respectively after plasmapheresis. Although the mechanisms are obscure, plasmapheresis performed at the onset of insulin-dependent diabetes mellitus may help to preserve beta-cell function.

Disodium cromoglycate in the treatment of ulcerative colitis and Crohn's disease.

A controlled clinical study on disodium cromoglycate (DSCG) at a dose of 800 mg per day versus placebo was carried out in 141 patients with ulcerative colitis and 25 patients with Crohn's disease. Those of the ulcerative colitis patients who had been on sulphasalazine treatment continued that treatment during the trial (101 patients). Forty patients were intolerant of sulphasalazine. No patient received steroids during the last month before the study. Patients with Crohn's disease had their possible sulphasalazine treatment stopped before the trial. No beneficial effect of DSCG as compared with placebo was found, as the DSCG and the placebo group showed the same number of relapses in patients with a clinically inactive ulcerative colitis at the start of the trial and the same number of patients improving, deteriorating, and maintaining steady state in patients with clinically active ulcerative colitis at the start of the trial. There was no difference between relapse rate in DSCG and placebo groups in patients with Crohn's disease. No correlation between the eosinophil count in rectal mucosa and the outcome of the attack of ulcerative colitis could be demonstrated.