Treatment intensification without improved HbA1c levels in children and adolescents with Type 1 diabetes mellitus.

AIMS: To examine trends in diabetes treatment in Danish children and adolescents with Type 1 diabetes mellitus, comparing treatment intensity with metabolic outcomes in the population, and to describe the challenges of population-based registries in a clinical setting with rapidly changing treatment methods. METHODS: This observational study is based on the Danish national population registry of childhood diabetes, which includes 99% of children diagnosed with Type 1 diabetes before the age of 15 years. We included 4527 people diagnosed between 2000 and 2012. Self-monitored blood glucose measurements, insulin injections/boluses, treatment method and metabolic control quantifications were analysed and adjusted for the effects of gender and ethnicity, the combined effect of age, visit year and duration, and for the random effects of individual and hospital settings. RESULTS: Treatment was intensified via an increasing number of self-monitored blood glucose measurements and injections/boluses. More than six injections/boluses and an increased number of self-monitored blood glucose measurements were significantly associated with lower metabolic control. No reduction, however, in the overall mean HbA1c concentration was observed between 2005 [66 mmol/mol (8.2%)] and 2012 [65 mmol/mol (8.1%)]. Changed registration practices in 2009 introduced artificial jumps in data. CONCLUSIONS: Intensifying treatment alone does not lead to improved metabolic control in the overall population despite the appearance of lower HbA1c in individuals with a greater number of self-monitored blood glucose measurements and injections/boluses. The contradictory results reflect difficulties in using observational studies to predict results of intervention in the individual. Data collected from population-based registries need to be adjusted continuously to reflect changes in care.

Prevalence and predictors of severe hypoglycemia in Danish children and adolescents with diabetes.

OBJECTIVE: To investigate the prevalence of severe hypoglycemia in Danish children and adolescents with type 1 diabetes and to pinpoint predictors of this acute complication in children on modern treatment modalities. RESEARCH DESIGN AND METHODS: The study is based on data from DanDiabKids, a national diabetes register for children and adolescents. The register contains data on patients with type 1 diabetes with an ascertainment rate of 99%. Data from 3320 patients aged 0-18 yr was included in the study period from 1998 to 2009 and analyzed using a negative binomial model. RESULTS: One thousand nine hundred and ninety-nine episodes of severe hypoglycemia in 867 patients were registered conferring an overall incidence of severe hypoglycemia of 15.1 [95% confident interval (CI): 13.8; 16.4] per 100 patient years. This remained unchanged during the study period. Duration of diabetes, age and treatment in centers managing less than 100 patients significantly increased the risk of severe hypoglycemia (p < 0.001). Patients on insulin pump therapy had a 42% reduced risk of severe hypoglycemia compared with pen treated patients (p = 0.01). Patients treated with five or more daily insulin injections had a 31% (95% CI: 17; 49) reduced risk of severe hypoglycemia compared to patients on fewer daily injections (p = 0.015). CONCLUSIONS: Despite improvements in metabolic control over a decade the prevalence of severe hypoglycemic events remained unchanged. More intensive treatments such as insulin pump therapy and multiple daily injections on a national level seems to be a protective factor for developing severe hypoglycemia up to 2009.

Diabetic ketoacidosis at the onset of type 1 diabetes is associated with future HbA1c levels.

AIMS/HYPOTHESIS: We investigated the long-term impact of diabetic ketoacidosis (DKA) at onset on metabolic regulation and residual beta cell function in a Danish population with type 1 diabetes. METHODS: The study is based on data from DanDiabKids, a Danish national diabetes register for children. The register provides clinical and biochemical data on patients with type 1 diabetes diagnosed in 1996-2009 and then followed-up until 1 January 2012. Repeated-measurement models were used as statistical methods. RESULTS: The study population comprised 2,964 children <18 years. The prevalence of DKA at diagnosis was 17.9%. Of the total subjects, 8.3% had mild, 7.9% had moderate and 1.7% had severe DKA. DKA (moderate and severe) was associated with increased HbA1c (%) levels (0.24; 95% CI 0.11, 0.36; p = 0.0003) and increased insulin dose-adjusted HbA1c (IDAA1c, 0.51; 95% CI 0.31, 0.70; p < 0.0001) during follow-up, after adjustment for covariates. Children without a family history of diabetes were more likely to present with DKA (19.2% vs 8.8%, p < 0.0001); however, these children had a lower HbA1c (%) level over time (-0.35; 95% CI -0.46, -0.24; p < 0.0001). Continuous subcutaneous insulin infusion (CSII) was associated with a long-term reduction in HbA1c, changing the effect of DKA, after adjustment for covariates (p < 0.0001). CONCLUSIONS/INTERPRETATION: DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta cell function, changing the effect of DKA at onset in our population.

The effect of posture on gastroesophageal reflux event frequency and composition during fasting.

OBJECTIVE: To examine the influence of three postures (upright and left and right recumbent) on gastroesophageal reflux event (RE) frequency and composition and a possible mechanism for the observations. METHODS: A) Forty fasting patients with (E+, n = 20) and without (E-, n =20) esophagitis were studied. Simultaneous manometry and pH monitoring were conducted in the left and right recumbent (10 min each) as well as the upright posture (20 min). RE were classified by the pH probe and/or the manometry catheter as acid or gas RE. B) In 23 patients referred for UGI series, radiographs were taken in the left and right recumbent and upright postures after barium and Fizzies. RESULTS: A) Upright RE were similar in frequency in E+ and E- patients (2.6 +/- 0.5 vs 3.05 +/- 0.6). However, E+ patients had more recumbent RE (16.3 +/- 3 vs 0.65 +/- 0.2, p = 0.0001) than E- patients; moreover, the left recumbent posture had more recumbent RE than the right (10.9 +/- 2 vs 5.3 +/- 1, p < 0.02). Moving from recumbent to the upright posture had an opposite effect on RE in the two groups; RE decreased sixfold in E+ patients (16.3 +/- 3 vs 2.6 +/- 0.5, p = 0.0001) but increased fourfold in E- patients (0.65 +/- 0.2 vs 3.05 +/- 0.6, p = 0.0001). In examining RE composition in the E+ patients, RE were twofold more likely to be gas in the left recumbent posture (7.6 +/- 2 vs 3.3 +/- 1, p < 0.1); in direct contrast, RE were eightfold more likely to be acid in the right recumbent posture (4.7 +/- 1 vs 0.6 +/- 0.5, p = 0.0001). As expected from this observation, acid exposure was greater in the right than left posture (52 +/- 8 vs 15 +/- 6%, p < 0.0001). Although RE were too infrequent in E- patients to reach statistical significance, the effect of posture on the composition of the few RE that did occur mirrored that of the E+ patients. B) In 17/23 (74%) radiographs in the right recumbent posture, the EG junction was submerged in a barium pool below the air-barium interface in the stomach. In contrast, this occurred in 0/23 patients in the left recumbent and 1/23 patients in the upright postures because the EG junction was in the air above the barium pool. CONCLUSION: Posture has an influence on RE frequency and composition while fasting, and the latter is likely due to whether the EG junction is submerged below liquid gastric contents or in the air above the liquid gastric contents.

[Molybdenum cofactor deficiency. Clinical symptoms and diagnostic strategy]. / Molybdaen-kofaktormangel. Kliniske symptomer og diagnostisk strategi.

The clinical, neuroradiological and biochemical findings in two siblings with molybdenum cofactor deficiency are presented. A search for this deficiency is advocated in each case of unexplained refractory neonatal convulsions. Early diagnosis is prompted by the often rapid fatal outcome and the availability of methods for prenatal diagnosis. Diagnosis may be missed or delayed on standard metabolic screening for several reasons discussed. Magnetic resonance imaging in this condition seems to be rather characteristic.

[Prognosis of children with very low birth weight in the county of Viborg. A follow-up of an unselected patient group]. / Prognosen for børn med meget lav fødselsvaegt i Viborg amt. Efterundersøgelse af en uselekteret patientgruppe.

Neonatal mortality and follow-up examination among children with birthweight < or = 1500 g born in the period 1983-1987 inclusive has been recorded in an unselected material from a Danish county (Viborg County). There were 100 with birthweight < or = 1500 g and the low-birthweight rate was 7/1000. The neonatal survival was 72% dispersed with 32% for children with birthweight < or = 1000 g and 90% for children with birthweight 1001-1500 g. Four children died before follow-up examination. Of the surviving 68 children 66 were examined between the ages 21 months to six and a half years, the average age being about three years. The test-results were based on a questionnaire to the parents, an objective examination including neuropaediatric assessment and a Denver developmental screening test. Seven children were found to have moderate to severe handicaps, equal to 10% of surviving children. Of these seven children, three (4.5%) have cerebral paresis. Five other children were found to have small "handicaps". In conclusion 12 children or 18% had varying degrees of disability while 54 children were without demonstrable disability at follow up examination.

[Exercise-induced asthma in children and oral terbutaline. A dose-response relationship study]. / Anstrengelsesudløst astma hos børn og oral terbutalin. Et dosis-respons-studie.

We wanted to assess the protective effects on exercise-induced asthma as well as the clinical efficacy and safety of increasing doses of a new sustained-release formulation of terbutaline sulphate in 17 asthmatic children aged 6-12 years (mean 9 years). Placebo, 2, 4, and 6 mg terbutaline were given b.i.d. for 14 days in a randomized, double-blind, cross-over design. At the end of each two week period, an exercise test was performed and plasma terbutaline was measured. Compared with placebo, no significant effect was seen on asthma symptoms monitored at home, or on exercise-induced asthma. The percentage falls in FEV1 after the exercise test were 36, 35, 27 and 28%, after placebo, 4, 8 and 12 mg terbutaline/day, respectively. A small but statistically significant dose-related increase was seen in morning and evening peak expiratory flow (PEF) recordings. It is concluded that continuous treatment, even with high doses or oral terbutaline, does not offer clinically useful protection against exercise-induced asthma.

Application of molecular and cytogenetic techniques to the detection of a de novo unbalanced t(11q;21q) in a patient previously diagnosed as having monosomy 21.

The occurrence of complete autosomal monosomy in man is extremely rare and generally considered to be incompatible with life. Since the introduction of banding techniques in human cytogenetics, several cases of presumptive monosomy for chromosome 21 have nevertheless been reported. However, it has been suggested that most, if not all, of these cases may represent unbalanced translocations or other structural aberrations resulting in only partial monosomy 21. Here we described a patient in whom full monosomy 21 was initially diagnosed by routine karyotyping. Re-examination with a combination of high resolution banding technique, chromosome painting and DNA polymorphism analysis demonstrated the presence of an unbalanced translocation between the long arms of chromosome 11 and 21, respectively. Consequently, the case was re-classified as a partial monosomy for the proximal long arm of chromosome 21.

No protection by oral terbutaline against exercise-induced asthma in children: a dose-response study.

We wanted to assess the protective effects on exercise-induced asthma as well as the clinical efficacy and safety of increasing doses of a new sustained-release formulation of terbutaline sulphate, in 17 asthmatic children aged 6-12 yrs (mean 9 yrs). Placebo, 2, 4 and 6 mg terbutaline were given b.i.d. for 14 days, in a randomized, double-blind, cross-over design. At the end of each two week period, an exercise test was performed and plasma terbutaline was measured. Compared with placebo, no significant effect was seen on asthma symptoms monitored at home, or on exercise-induced asthma. The percentage falls in FEV1 after the exercise test were 36, 35, 27 and 28%, after placebo, 4, 8 and 12 mg terbutaline.day-1, respectively. There was no correlation between plasma terbutaline and dose of terbutaline. A small but statistically significant dose-related increase in morning and evening peak expiratory flow (PEF) recordings occurred, but the incidence of side-effects also increased with the dose given. There was a trend towards more side-effects when the high doses were used, and two patients withdrew from the study because of side-effects at this dose. It is concluded that continuous treatment, even with high doses of oral terbutaline, does not offer clinically useful protection against exercise-induced asthma.

Effect of mental retardation and motor disability on testing with visual acuity cards.

The visual acuity of 77 children (aged between 1 1/2 and eight years) with cerebral palsy and mental retardation was tested using acuity cards. Results varied by no more than one octave in 79 per cent of the cases. The median acuity of children with severe motor disabilities was lower and the variability from test to test was greater than for those with mild motor disabilities. Grouping the children roughly according to degree of mental retardation, the more retarded group tended to be more visually disabled and vary more from test to test. In general, day-to-day variability was greater than within-day inter-observer variability. The use of acuity cards to evaluate visual acuity in severely disabled and mentally retarded children, whose acuity is difficult to evaluate with conventional acuity tests, is a useful alternative method.

Surface polymers of the nematode-trapping fungus Arthrobotrys oligospora.

The nematophagous fungus Arthrobotrys oligospora captures nematodes using adhesive polymers present on special hyphae (traps) which form a three-dimensional network. To understand further the adhesion mechanisms, A. oligospora surface polymers were visualized by transmission electron microscopy and characterized by chemical methods. Both traps and hyphae were surrounded by a fibrillar layer of extracellular polymers which stained with ruthenium red. The polymer layer was resistant to most of the chemicals and enzymes tested. However, part of the layer was removed by sonication in a Tris-buffer or by extraction in a chaotropic salt solution (LiCl), and the structure of the polymers was modified by treatment with Pronase E. Chemical analysis showed that the crude extracts of surface polymers removed by sonication or LiCl solution contained neutral sugars, uronic acids and proteins. Gel chromatography of the extracts revealed that the major carbohydrate-containing polymer(s) had a molecular mass of at least 100 kDa, containing neutral sugars (75% by weight, including glucose, mannose and galactose), uronic acids (6%) and proteins (19%). There was more polymer in mycelium containing trap-bearing cells than in vegetative hyphae. SDS-PAGE of the extracted polymers showed that the trap-forming cells contained at least one protein, with a molecular mass of approx. 32 kDa, not present on vegetative hyphae. Examining the capture of nematodes by traps of A. oligospora in which the layer of surface polymers was modified, or removed by chemical or enzymic treatments, showed that both proteins and carbohydrate surface polymers were involved in the adhesion process.

Absolute bioavailability of terbutaline from a CR-granulate in asthmatic children.

The study aimed at finding the absolute bioavailability of terbutaline of a newly developed CR-granulate. Eight asthmatic children, aged 8-13 years, were given 3 mg of terbutaline as the CR-granulate, concomitant with the intravenous administration of 0.100 mg of deuterium-labelled terbutaline. The labelling of the intravenous dose made possible a separation, in the analytical step, of terbutaline originating from the intravenous and oral administration. Maximal plasma concentration, 8.7 (range: 4.9-15.2) nmol l-1, was reached after 4.7 (2.2-6.0) h. Absolute bioavailability was 10.8 (7.63-16.4) per cent. The parameter values were similar to those found after administration of terbutaline CR-tablets to adults. The CR-formulation is easily swallowed and can be dosed twice daily. Thus it should be a good alternative to elixir or plain tablets, dosed three times a day.

Occurrence and metabolic significance of microbodies in trophic hyphae of the nematophagous fungus Arthrobotrys oligospora.

This paper describes the results of an ultrastructural study on the subcellular events occurring in nematode-infecting (trophic) hyphae of the nematophagous fungus Arthrobotrys oligospora. In early stages of the infection process (30 min-4 h), the infection bulb and developing trophic hyphae are characterized by a highly proliferated endoplasmic reticulum (ER). Its membranes often appeared vesiculated and occur in close association with the cell membrane of the cells. Upon further invasion of the nematode, lipid droplets developed in the trophic hyphae; these droplets were first observed 4-5 h after the infection but were abundantly present after 24-36 h. Along with the formation of lipid droplets proliferation of microbodies was observed. These organeles were characterized by the presence of catalase and thiolase and were frequently observed in close association with the lipid droplets. Later on the lipid droplets disappeared. During this period new vegetative mycelium developed from the trap that had originally captured the nematode. Our results suggest that part of the nutrients released from the nematode are first converted into lipids by the fungus which in turn are degraded via the beta-oxidation pathway and further metabolized to support growth of new vegetative hyphae.

Significance of electron dense microbodies in trap cells of the nematophagous fungus Arthrobotrys oligospora.

We have studied the fate of electron dense microbodies in nematode-trapping organs (traps) of the fungus A. oligospora during the initial hours following nematode capture. The interaction studies were performed with isolated traps which had captured a nematode under conditions where the fungal cells had no access to external energy sources. Video enhanced contrast microscopy showed that under these conditions the number of dense bodies present in the trap cell that formed the penetration tube, rapidly decreased. During subsequent penetration and development of the infection bulb this decrease continued while at this time common cell organelles such as mitochondria and vacuoles were formed. This was confirmed by electron microscopy which also revealed that the dense bodies were degraded by means of an autophagic process. The organelles were degraded individually and finally turned into compartments which, based on ultrastructural criteria, were considered vacuoles. Fusion of such vacuoles into larger organelles frequently occurred. The degradation process was initiated early in the interaction since initial stages were already evident within 15 min after capture. Generally it took 1-2 h before the infection bulb had fully developed and trophic hyphae formation started. During this time the original trap cell, characterized by numerous dense bodies, was transformed into an active vegetative hyphal cell containing typical cell organelles such as nuclei, mitochondria, a strongly proliferated endoplasmic reticulum, vacuoles and "normal" microbodies but lacked dense bodies. This disappearance of dense bodies was confined to the cell that penetrated the nematode and--less frequently--its two neighbouring cells in the hyphal loop. In the other cells, constituting the trap, the dense bodies remained unaffected. As will be discussed, the present results support our current view that traps of A. oligospora contribute to the survival of the organism in its natural environment.

An improved method for light- and electron microscopial studies of nematode/fungal interactions.

A method is presented that enables studies to be made of single nematode-fungal interactions under conditions where fungal growth at the expense of external nutrients is prevented. The nematophagous fungus Arthrobotrys oligospora was used as a model organism in these studies. The method is based on removal of the traps from the vegetative mycelium, immediately after a nematode was captured and transfer of the trap with the captured nematode into a droplet of sterile distilled water placed in a moisture chamber. In the absence of external nutrients, such isolated traps of A. oligospora were fully effective in penetrating and subsequently digesting the captured nematode. Solely vegetative mycelium was formed at the expense of the digested nematode; this developed from the trap that originally had captured the nematode. One advantage of the present method is that studies on various stages of the nematode-fungal interaction can now be performed under conditions that exclude major influences of external nutrients which otherwise could be communicated to the trap cells by way of the vegetative mycelium.

Hyphal fusion during initial stages of trap formation in Arthrobotrys oligospora.

Hyphal fusion during initial stages of trap formation by Arthrobotrys oligospora was studied by video-enhanced contrast and electron microscopy. Trap initials grew perpendicularly to the parent hypha, then curved around and anastomosed with a peg that developed on the hypha. Trap initials usually developed 40-140 microns apart while the anastomosis occurred 20-25 microns from the initial. Vigorous cytoplasmic movements in trap initials and developed traps corresponded to intense staining with fluorescein diacetate (FDA) of these cells. In addition, bundles of microfilaments were seen in developing loops of traps. On fusion organelle migration took place from the tip cell of the trap into the peg. Later on a septum was formed at the site of fusion.

Acuity card testing of patients with cerebral visual impairment.

Acuity card tests of 11 patients with cerebral visual impairment, unexplained by clinical and electrophysiological ophthalmic examinations, confirmed the suspicion of severe visual impairment in all but one patient, but resulted in acuity estimates higher than previous evaluations for all nine of the patients for whom an estimate could be made. Relatively good inter-test agreement supports the use of acuity cards for the quantitative evaluation of the vision of these patients.