A new distensibility technique to measure sphincter of Oddi function

BACKGROUND

Evaluation of the biliary tract is important in physiological, pathophysiological, and clinical studies. Although the sphincter of Oddi (SO) can be evaluated with manometry, this technique has several limitations. This may explain the difficulties in identifying pathophysiological mechanisms for dysfunction of the SO and in identifying patients who may benefit from certain therapies. To encompass problems with manometry, methods such as the functional lumen imaging probe (FLIP) technique have been developed to study GI sphincters. This study set about miniaturising the FLIP probe and validating it for measurements in the SO. In order to get a better physiological understanding of the SO the aims were to show the sphincter profile in vivo and motility patterns of SO in pilot studies using volunteers that were experiencing biliary type pain but had normal SO manometry.

METHODS

The SO probe was constructed to measure eight cross-sectional areas (CSA) along a length of 25 mm inside a saline-filled bag. To validate the technique for profiling the SO, six perspex cylinders with different CSAs were measured nine times to assess reproducibility and accuracy.

KEY RESULTS

Reproducibility and accuracy for these measurements were good. The probe performed well in bench tests and was therefore tested in four humans. The data indicated that it was possible to make distensions in the human SO and that a geometric sphincter profile could be obtained.

CONCLUSIONS & INFERENCES

The probe will in future studies be tested for diagnostic purposes related to sphincter of Oddi diseases.

Gallstone Ileus, Bouveret's Syndrome and Choledocholithiasis in a Patient with Billroth II Gastrectomy - A Case Report of Combined Endoscopic and Surgical Therapy

Intestinal obstruction due to gallstone is a rare, but quite severe gastrointestinal disorder, which always requires a rapid and correct diagnosis to achieve optimal therapy. Digestive endoscopy is an important method to determine the level of the bowel obstruction and to plan an optimal therapeutic strategy. Our present case demonstrates that in a high-risk patient, a combined endoscopic and surgical therapy is the best choice to solve the obstruction of the colon, of the stomach and of the common bile duct caused by multiple gallstones.

The interferon-induced helicase IFIH1 Ala946Thr polymorphism is associated with type 1 diabetes in both the high-incidence Finnish and the medium-incidence Hungarian populations

AIMS/HYPOTHESIS

The rs1990760 polymorphism (Ala946Thr) of interferon induced with helicase C domain 1 (IFIH1) has been proposed to associate with type 1 diabetes. In this study, association between IFIH1 Ala946Thr and type 1 diabetes was investigated in two distinct white populations, the Hungarians and Finns.

METHODS

The rs1990760 polymorphism was genotyped in 757/509 Hungarian/Finnish childhood-onset cases, 499/250 Hungarian/Finnish control individuals and in 529/924 Hungarian/Finnish nuclear family trios. Disease association was tested using case-control and family-based approaches. A meta-analysis of data from 9,546 cases and 11,000 controls was also performed.

RESULTS

In the Hungarian dataset, the A allele was significantly more frequent among cases than among controls (OR 1.29, 95% CI 1.10-1.52; p = 0.002). Combined analysis of Hungarian and Finnish datasets revealed a strong disease association (OR 1.235, 95% CI 1.083-1.408; p = 0.002). Furthermore, the A allele was significantly overtransmitted in both family trio datasets (p = 0.017 in Hungarians; p = 0.007 in Finns). The A allele was increased in Hungarian vs Finnish cases (64.9% vs 60.8% in Finns; p = 0.003). The meta-analysis yielded a significant effect for IFIH1 rs1990760 A allele on type 1 diabetes risk (OR 1.176, 95% CI 1.130-1.225; p = 5.3 x 10(-15)) with significant heterogeneity between effect sizes across the studied populations (p = 0.023).

CONCLUSIONS/INTERPRETATION

This study represents the first independent confirmation of the association between type 1 diabetes and the IFIH1 gene in Hungarian and Finnish populations. Summarising the data published so far, a clear association between the Ala946Thr polymorphism and type 1 diabetes was detected, with an apparent difference in the contribution to disease susceptibility in different populations of European ancestry.

Analysis of the motor function of the human sphincter of Oddi by endoscopic retrograde cinecholangiography gated by manometry--a report of a case

Although the motor function of the sphincter of Oddi (SO) has been clearly identified by endoscopic SO manometry (ESOM), the physiologic role of the phasic contractions of the SO remains unsettled in humans. The aim of this study was to correlate SO motor activity measured by ESOM with bile flow characteristics determined by simultaneously recorded endoscopic retrograde cinecholangiography. We investigated a 55-year-old female patient by means of ESOM. During the station pull-through recording, the ESOM catheter was withdrawn into the SO zone and retained there for 15 min. The pressures transmitted by the external transducers and the enlarged video picture of the choledochoduodenal junction from the X-ray fluoroscopic monitor (25 digital pictures/sec) were recorded simultaneously on the computer system with a time-correlated basis. During the analysis without taking note of the cinefluoroscopic events, we selected different manometric periods manually, such as the pressure wave of the SO phasic contraction, no SO phasic activity and the first second of the beginning of the next phasic contraction. Cumulative cinecholangiographic pictures were then constructed by the computer for each period, at a frequency of one frame/sec to create representative sum-of-pictures for each manometric period. By means of the application of manometrically gated cinecholangiography, we succeeded in demonstrating an exact time correlation between the SO systolic and diastolic movements on cinecholangiography and the pressure recording detected by ESOM in humans.

Altered Distribution of the Debrisoquine Oxidative Phenotypes in Children with Type 1 Diabetes mellitus

OBJECTIVE

The recently observed increase in the incidence of type 1 diabetes mellitus (Type 1 DM) suggests a major role of environmental factors in the etiopathogenesis of the disease. The individual variation in cytochrome P(450)IID6 may influence the individual susceptibility to environmentally linked diseases. We aimed to evaluate the prevalence of cytochrome P(450)IID6 phenotypes in Hungarian children with Type 1 DM (n = 69) compared to healthy controls (n = 100).

METHODS

Debrisoquine was administered orally and debrisoquine hydroxylation phenotype was determined as a metabolic ratio of urinary recovered debrisoquine and 4-hydroxydebrisoquine.

RESULTS

Eight of the 100 healthy subjects (8%) and 15 of the 69 diabetic children (22%) (p < 0.05) had cytochrome P(450)IID6 poor metabolizer phenotype (metabolic ratio > or =12.6).

CONCLUSION

Cytochrome P(450)IID6's activity may play a role in the development of Type 1 DM.

HbA1c levels and erythrocyte transport functions in complication-free type 1 diabetic children and adolescents

Higher erythrocyte sodium-lithium countertransport activity (SLC) is implicated in the development of diabetic nephropathy. Altered glucose homeostasis and genetic susceptibility are claimed to play a role in the elevation of SLC. We aimed to test whether metabolic control or the genetic variants of G protein beta 3 (Gb3) subunits determine SLC and other erythrocyte transport activities in complication-free stage of type 1 diabetes. A total of 96 complication-free type 1 diabetic children and adolescents were enrolled. SLC, Na(+)/K(+)-ATPase (NAK) and Ca(2+)-ATPase (CA) were measured by functional assays in erythrocytes. Gb3-C825T polymorphism was determined by PCR-RFLP. Results were related to HbA(1c) and were compared to those of 97 healthy controls. SLC activity was higher in diabetics (387+/-146 vs. 280+/-65 mmol/RBC. hour) and correlated with HbA(1c) levels (y=0.004x+6.42, r=0.33, n=96, p<0.01). NAK and CA activities were unaltered. The prevalence of (825)T allele was similar in the patient and control groups (0.34 vs 0.37) and no differences in enzyme activities were observed between the (825)T allele-positive and negative subjects. Although metabolic control correlated with SLC, other membrane functions were not affected. Therefore we hypothesize that the relationship between advanced glycation and SLC elevation is not causative. Rather, a genetic susceptibility for the coexistence of poor metabolic control and higher SLC is more likely. However, the presence of Gb3-C825T variant is not likely to be a risk factor for SLC-elevation and altered metabolic control diabetes.

Recurrent nonvariceal upper gastrointestinal bleeding in a patient with gastroduodenal schistosomiasis

In this case report, we describe the rare situation of a patient with nonvariceal upper gastrointestinal bleeding induced by gastric and duodenal involvement of Schistosoma mansoni infection. In this unique case severe, recurrent upper gastrointestinal bleeding was induced by central ulcerations of gastric pseudopolypoid and duodenal polypoid lesions. However, very atypically, there were no signs of portal hypertension, coagulopathy, or variceal bleeding, and no macroscopic evidence of lower gastrointestinal tract involvement. Neither anti-ulcer therapy nor endoscopic hemostasis methods were effective in preventing recurrent bleeding episodes. Finally, typical histological and serological tests (positive for S. mansoni hemagglutination) led to the correct diagnosis, and the patient was completely cured by specific antischistosomal therapy.

Association between G-308A polymorphism of the tumor necrosis factor-alpha gene and 24-hour ambulatory blood pressure values in type 1 diabetic adolescents

Tumor necrosis factor-alpha (TNF-alpha) is an inflammatory cytokine, which also influences blood pressure (BP). The G-308A polymorphism of the TNF-alpha gene is associated with altered TNF-alpha production. The prevalence of the TNF-alpha-308A allele is reportedly higher among patients with type 1 diabetes mellitus (T1DM) than in the healthy population. In this study we investigated whether this genetic polymorphism might correlate with BP values in diabetic adolescents. Ambulatory BP monitoring (ABPM) was performed in 126 adolescents with T1DM (mean age: 14 +/- 2.4 years). The TNF-alpha G-308A genotype was determined by using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) methodologies. ABPM results were related to healthy reference values and are given as standard deviation score (SDS). The prevalence of the -308A allele was higher in diabetic adolescents than the Hungarian reference population (0.26 vs 0.14, p < 0.01). TNF-alpha genotype was associated both with systolic and diastolic BP values (p < 0.01 and p < 0.01, respectively). In patients with TNF-alpha-308GG and -308GA/AA genotypes, the 24-h systolic BP average values were 0.37 +/- 1.33 and -0.38 +/- 1.28 SDS, while 24-h diastolic BP average values were 0.09 +/- 1.30 and -0.67 +/- 1.31 SDS. Hence, the TNF-alpha-308A allele carrier state appears to be associated with lower systolic and diastolic BP values.

Antibodies against different epitopes of heat-shock protein 60 in children with type 1 diabetes mellitus

The aim of this study was to investigate the amounts and epitope specificity of antibodies against heat shock protein 60 (hsp60) in the sera of type 1 diabetic and healthy children. Antibodies specific for peptide p277 of human hsp60 and of M. bovis as well as for human hsp60, M. bovis hsp65 proteins were measured by ELISA. Other autoantibodies (islet cell antibodies, glutamate decarboxylase antibodies and IA-2 antibodies) were also determined. A total number of 83 serum samples from children with type 1 diabetes mellitus and 81 samples of control children were investigated. Epitope scanning of the hsp60 for linear antibody epitopes was carried out using synthetic peptides attached to pins. The antibody levels specific for peptide p277 of human- and of M. bovis origin were significantly (human: P=0.0002, M. bovis: P=0.0044) higher in the diabetic children group than in the healthy children. We could not find significant difference in the antibody levels to whole, recombinant hsp proteins among the examined groups of children. Antibodies to two epitope regions on hsp60 (AA394-413 and AA435-454) were detected in high titres in sera of children with diabetes mellitus. The first region similar to the sequence found in glutamate decarboxylase, whereas the second one overlaps with p277 epitope to a large extent. Presence of antibodies to certain epitopes of hsp60 (AA394-413-glutamic acid decarboxylase-like epitope; AA435-454-p277-like epitope) in diabetic children may reflect their possible role in the autoimmune diabetogenic process of the early diabetes.

Gallbladder hypomotility in diabetic polyneuropathy

This study was performed to evaluate the gallbladder motility in long-standing diabetes mellitus. The gallbladder function of diabetic patients was measured by means of quantitative hepatobiliary scintigraphy, and the severity of the associated autonomic and sensory polyneuropathy was determined. The presence of a marked gallbladder hypomotility was established, and a positive correlation was observed between the severity of the autonomic disturbance and the contractile disorder. This study underlines the important role of the neuropathy in the development of gallbladder hypomotility accompanying long-term diabetes mellitus.

[Latent autoimmune diabetes in adults(LADA): part of the clinical spectrum of type-1 diabetes mellitus of autoimmune origin]

According to the most recent classification of diabetes mellitus the latent autoimmune diabetes in adults belongs to the group of type 1 autoimmune diabetes mellitus, as a slowly progressive form. It is not clear whether LADA is a distinct clinical entity or it is a part of the clinical spectrum of type 1 diabetes mellitus. The authors compare the antropologic (body mass index, waist to hip ratio), immunologic (occurrence of islet cell cytoplasmic autoantibodies and autoantibodies against glutamic acid decarboxylase and tyrosin phosphatase), genetic (HLA DR and DQ alleles known to be associated to type 1 diabetes mellitus) characteristics and occurrence of the features of the metabolic syndrome in the groups of type 1 and type 2 diabetes and LADA. 81 type 1 and 190 type 2 diabetics and 38 LADA patients were involved into the study. Freshly diagnosed type 1 diabetics served for controls of the autoantibody study: 48 patients manifested < or = 16 years of age and 89 type 1 diabetics manifested above 16 years of age. The three main diabetic groups differed in age: the average age in the type 1, type 2 and LADA groups were 37, 63 and 58 years respectively. There was no difference among the three groups in gender. The duration of the disease differed significantly between the type 2 and LADA groups (4.0 and 8.0 years respectively). In spite of the shorter duration of the disease in the LADA group, compared to the type 2 diabetics the frequency of insulin dependency was significantly higher in the LADA (81.6%) than in the type 2 group (46.7%). The BMI and WHR were comparable between the type 1 and LADA patients (average values were 23 and 0.83 in type 1 patients and 23.25 and 0.89 in LADA). The type 2 group differed significantly from type 1 and LADA (average values were 29.1 and 0.5). The concentration of glycated hemoglobin was comparable in the three groups. But there was a significant difference in HbA1c concentration between the freshly diagnosed subgroups of type 1 and LADA patients: 10.85% and 8% respectively. The fasting C-peptid levels were significantly higher in the sera of type 2 diabetics (0.75 pmol/l) compared to type 1 (0.2 pmol/l) and LADA patients (0.29 pmol/l). There was a significant difference in C-peptid concentrations between the type 1 and LADA groups, too. The insulin deficiency in LADA seemed to be not as severe as in type 1 diabetes. The serum total cholesterol and triglyceride levels were significantly higher and the HDL cholesterol concentration significantly lower in type 2 diabetics comparing to type 1 and LADA patients and there was no significant difference in this respect between the type 1 and LADA groups. The frequency of occurrence of hypertension differed no significantly between type 2 and LADA, but that of in type 1 diabetes was significantly lower than both type 2 and LADA. The occurrence of multiple autoantibodies (ICA + GADA + anti-IA2) was much more frequent in type 1 diabetes compared to LADA. In the sera of LADA patients the occurrence of ICA and GADA alone or ICA + GADA was characteristic (31.5% - 21.1% - 15.8% respectively). There was no difference between type 1 diabetes and LADA in the occurrence of the alleles of the MHC kown to be associated with type 1 diabetes. The occurrence of the haplotypes HLA DQ2/DR3 and/or DQ8/DR4 was observed in two thirds of type 1 diabetic and LADA patients. Chronic diabetic complications were observed in all of the groups and there was only a secondary connection of the complications with the type of the diabetes. Based on the results the authors suggest that LADA is a part of the clinical spectrum of type 1 diabetes of autoimmune origin.

[High prevalence of islet cell and glutamate decarboxylase antibodies in healthy young adults born with low birth weight]

Low birth weight is an independent risk factor for several chronic adult diseases. The authors determined the prevalence of islet cell cytoplasmatic antibody (ICA), glutamic acid decarboxylase antibody (GADA) and tyrosine phosphatase antibody (IA2) in 41 women and 34 men born with a birth weight under 2500 grams. ICA and/or GADA positivity was detected in 32% of the subjects tested. Both antibodies were present in 11% of the subjects. IA2 positivity was not found in any of the enrolled subjects. The cause of the high prevalence of autoantibodies is still unclear. Further studies are needed to elucidate whether this phenomenon might have a role in the development of metabolic disturbances in late adulthood.

[Prognostic significance of retinal microaneurysm number and localization in type-1 diabetes mellitus]

The authors studied whether central retinal microaneurysm count predicts further progression of background retinopathy in juvenile onset type-1 diabetes mellitus. 94 patients (49 females and 45 males) were followed up longitudinally (8-17.5, mean 10 years) by evaluating fluorescein angiograms. Age at last examination was 17-32 years (mean age 22.4 years) and duration of diabetes was 8-22 years (mean duration 13.7 years). Microaneurysm counts and location were determined with the help of a grid consisting of three concentring circles and four radial lines (nine subfields) centered for the macula. 82% of the all microaneurysms were found inside the circle with 1500 micron radius. Participants were divided into three groups: those with no microaneurysms (1st group, n = 28) and those with 1-4 (2nd group, n = 35) and those with 5 or more microaneurysms (3rd group, n = 31) in the central circle with 600 micron radius at least one time during the whole follow up. Background retinopathy was found in 3 of 28 cases (approximately 10%) in the first group, 8 of 35 (approximately 23%) in the second group and in all the 31 patients (100%) in the third group. Proliferative retinopathy was found in the third group only. The authors suggest that the appearance of 5 or more microaneurysms in the macular area in type-1 diabetes mellitus may be sensitive indicator of the development of severe background and proliferative retinopathy. Study describes the importance of central microaneurysm count predicting further progression of background retinopathy could not be found in the available literature.

Quantitative hepatobiliary scintigraphy and endoscopic sphincter of Oddi manometry in patients with suspected sphincter of Oddi dysfunction: assessment of flow-pressure relationship in the biliary tract

OBJECTIVE

In the present study, the diagnostic efficacy of quantitative hepatobiliary scintigraphy (QHBS) was compared with that of endoscopic sphincter of Oddi (SO) manometry (ESOM) in patients with a suspected SO dysfunction (SOD) of biliary type II or III.

METHODS

Twenty cholecystectomized patients with SOD biliary types II and III were investigated by QHBS and by ESOM. Twenty asymptomatic cholecystectomized patients served as controls for scintigraphy. ESOM was performed by applying the station pull-through method. Then SO basal pressure and phasic contraction characteristics were determined. During QHBS, time-activity curves were generated, and the time-to-peak (Tmax), the half-time of excretion (T(1/2)), the duodenal appearance time (DAT) and the hilum-to-duodenum transit time (HDTT) were then calculated. At the 60th minute of QHBS, 5 ng/kg body weight/min caerulein was administered.

RESULTS

In patients with SOD and elevated SO basal pressure (> 40 mmHg), QHBS parameters, such as Tmax and T(1/2) calculated from regions of interest over the hepatic hilum and common bile duct, HDTT and DAT proved to be significantly increased compared to controls: 28.7 +/- 4.3 versus 21.1 +/- 4.6 min, 39.7 +/- 15.4 versus 18.8 +/- 2.6 min, 9.0 +/- 3.6 versus 2.3 +/- 1.3 min and 27.1 +/- 4.9 versus 16.6 +/- 3.0 min, respectively. In contrast, in patients with SOD and normal SO basal pressure, QHBS parameters did not differ significantly from the controls. For the pooled data on the symptomatic patients with SOD, a statistically significant linear correlation was found between the SO basal pressure and the QHBS parameters. Although HDTT was the most sensitive scintigraphic parameter (89%), the combined sensitivity and specificity of Tmax and T(1/2) of the common bile duct reached 100%. No scintigraphic sign of a paradoxical response to cholecystokinin was detected.

CONCLUSIONS

QHBS is a useful non-invasive diagnostic method for the selection of SOD patients with an elevated SO basal pressure. A significant correlation has been established between the trans-papillary bile flow measured by QHBS and the SO basal pressure determined by ESOM.

[Diabetic ketoacidosis in childhood]

Diabetic ketoacidosis is the most serious acute complication of insulin-dependent diabetes mellitus and the most frequent reason for hospital admission of diabetic children. The most frequent cause of death of these patients is also the diabetic ketoacidosis. The mortality rate of the disease has not changed since the seventies (1-2%). In this work, the data of 89 patients with diabetic ketoacidosis were analyzed. These patients were admitted to the 1. Department of Pediatrics of the Semmelweis University of Medicine between 1992-1997. The data (metabolic parameters, the causes of ketoacidosis and the length of hospital stay) of previously known diabetic children was compared with the data of previously unknown diabetic children. Our patients were divided in 2 groups: serious (n = 11), and mild-to-moderate (n = 48) acidosis. Their laboratory findings, their intravenous infusion-, and insulin demand and the length of their hospital stay were compared. The state of consciousness at their hospitalisation and the concomitant complications were also examined. Significant difference was found only in the duration of intravenous insulin administration (with the exception of pH and BE, of course). There was no relationship between the seriousness of the disease and the duration of hospital treatment. It is noteworthy that even the previously known diabetic children with the shortest hospitalization spent more than 7 days at the department.

Video manometry of the sphincter of Oddi: a new aid for interpreting manometric tracings and excluding manometric artefacts

BACKGROUND AND STUDY AIMS

Endoscopic sphincter of Oddi manometry (ESOM) allows direct assessment of motor function in the sphincter of Oddi. However, variations in examination conditions and duodenal motility may have a critical effect on the results of ESOM. The aim of the present study was to develop a new method sphincter of Oddi video manometry-based on simultaneous ESOM and real-time endoscopic image analysis, and to investigate the usefulness of video manometry for detecting manometric artefacts during ESOM.

PATIENTS AND METHODS

Seven consecutive patients who had undergone cholecystectomy and were referred with a suspicion of sphincter of Oddi dysfunction were investigated. Sphincter of Oddi pressure and endoscopic images (20 frames/s) were recorded simultaneously on a Synectics PC Polygraf computer system with a time-correlated basis, and then compared.

RESULTS

On ESOM, 69 sphincter of Oddi phasic contractions were identified, with an average amplitude of 153.9+/-85.0 mm Hg and a duration of 7.9+/-1.2 seconds. Visual analysis of the real-time endoscopic images, replayed in cine loop by the computer, revealed 236 separate duodenal contractions, with an average frequency of 3.5+/-2.4/min (range: 1-12/min). On the ESOM tracing, 78% of the duodenal contractions had a corresponding pressure wave with an average duration of 2.8+/-0.4 seconds and an amplitude of 71.9+/-16.7 mm Hg. Other artefacts on the ESOM tracings, such as catheter movements, pseudocontractions, hyperventilation, or retching, were also easily recognized using simultaneous ESOM and real-time endoscopic image analysis.

CONCLUSIONS

Video manometry of the sphincter of Oddi is a promising new method for improving the analysis and documentation of ESOM tracings. It has several advantages over the conventional technique, allowing visual detection of duodenal activity and enabling enhanced recognition of other manometric artefacts.

[Detection of antibodies against pancreatic islet cells in clinical practice]

Development of diabetes mellitus caused by pancreatic beta-cell destruction of autoimmune origin is the result of a long lasting process. The most easily examinable feature of this stage is the occurrence of the islet cell antibodies. The sera which are positive for islet cell cytoplasmic antibodies (ICA), examined by indirect immunofluorescence, contain a mixture of antibodies. The glutamic acid decarbocylase (GAD), the tyrosin phosphatase (IA2), the insulin, and the GM2-1 glycolipid can be the targets of these antibodies. One can routinely examine the ICA, the GADA, the IA2 antibodies. The detection of antibodies against insulin (IAA) and GM-2-1 glycolipid is not invented in the routine laboratory work. The aim of the authors was the evaluation of clinical significance of occurrence of islet cell antibodies: one hundred and eighteen nondiabetic children an adult human being without known diabetic first degree relatives and 366 type 1 diabetic children and adult patients served as controls. The authors evaluated the predictive value of the different islet cell antibodies to the development of type 1 diabetes mellitus in 596 nondiabetic children with type 1 diabetic first degree relatives. The authors looked for markers of beta-cell destruction among sera of 320 diabetics manifested after 30 years of age with at least half a year of non-insulin-dependency and in the sera of 68 females suffered from gestational diabetes after 0-14 years of the index pregnancy. Finally the authors report 7 cases in which the examination of islet cell antibodies helped the diagnosis and classification of diabetes mellitus. Indirect immunofluorescence method was used for the detection of ICA, radioimmunoassay for that of GADA and IA2 antibodies. There was no positive reaction for ICA and GADA in the nondiabetic population without diabetic first degree relatives. Among the freshly diagnosed type 1 diabetic children 39% were positive for only ICA, 44% for only GADA and 80% for any antibodies. Among the freshly manifested type 1 diabetic adults ICA positivity only was observed in 21%, GADA positivity only in 7.1% and 93% for any antibodies. From the 595 nondiabetic children with type 1 diabetic first degree relatives 23 were positive for ICA, from whom 5 became diabetic during a two years observation period. These diabetic children had multiplex autoantibodies besides ICA. One child from this group, who was negative for ICA became diabetic, too. Among type 2 diabetic patients 13% were positive for ICA alone, 17% were positive for GADA alone and 27% were positive for any antibodies. The insulin dependency manifested in a short time was associated with antibody positivity. Among the gestational diabetics 10 were found positive for ICA. From them, 7 were type 1 diabetics, and 3 were type 2 diabetics at the time of the detection of antibodies. The authors suggest the need of determination of islet cell antibodies in the group of nondiabetic first degree relatives of type 1 diabetic patients (ICA, GADA, IA2 and IAA), in the group of non-insulin-dependent diabetics (ICA and GADA) as a screening for later insulin dependency, and in gestational diabetes after delivery (ICA) as screening for type 1 diabetes mellitus.

N-acetyltransferase-2 polymorphism, smoking and type 1 diabetic nephropathy

The N-acetyltransferase (NAT2) polymorphism has been suggested to be related to diabetic microvascular complications. To study the distribution of NAT2 genotypes in Caucasian type 1 diabetic patients with and without diabetic nephropathy, 214 adult type 1 diabetic patients and 53 healthy individuals were genotyped by polymerase chain reaction-restriction fragment length polymorphism. In addition, 75 young type 1 diabetic patients were genotyped, and 70 of them also phenotyped by caffeine. Of the adult patients, 83 had normal albumin excretion, 58 had microalbuminuria, and 73 had overt diabetic nephropathy. NAT2 allele frequencies were similarly distributed between the diabetic patients and healthy individuals: 0.29/0.2 5 (NAT2*4), 0.03/0.04 (NAT2*7B), 0.25/0.27 (NAT2*6A), and 0.43/0.44 (NAT2*5B), and within the diabetic subgroups. Because smoking is a known risk factor for diabetic nephropathy, nonsmoking and smoking patients were analysed separately. NAT2 allele frequencies differed significantly between the nonsmoking normoalbuminuric, microalbuminuric and nephropathic patients: 0.18/0.41/0.30 (NAT2*4), 0.04/0.00/0.02 (NAT2*7B), 0.35/0.18/0.17 (NAT2*6A), 0.43/0.41/0.50 (NAT2*5B), P = 0.013. In nonsmoking fast acetylators odds ratio for microalbuminuria and nephropathy was 3.1 (95% confidence interval 1.36-7.05), P = 0.007 by logistic regression. In smokers, a nonsignificant odds ratio was found [0.31 (95% confidence interval 0.08-1.2), P = 0.09]. Smoking is a strong confounding factor in relation to NAT2 analyses and diabetic nephropathy. According to our data, in nonsmoking type 1 diabetic patients fast NAT2 genotype implies an increased risk for diabetic nephropathy.

Comparison of the dynamics of bile emptying by quantitative hepatobiliary scintigraphy before and after cholecystectomy in patients with uncomplicated gallstone disease

PURPOSE

Quantitative hepatobiliary scintigraphy, a noninvasive method frequently used to diagnose several biliary tract disorders, shows abnormalities in bile secretion and outflow. It is well known that there are wide variations in the normal pattern of bile emptying, but the effect of cholecystectomy on the bile flow has not yet been investigated. The goal of the current study was to examine the dynamics and normal variations of bile flow by quantitative hepatobiliary scintigraphy before and after cholecystectomy in a group of patients with uncomplicated gallstone disease.

METHODS

Twenty patients were evaluated before and after cholecystectomy through cholecystokinin octapeptide-augmented quantitative hepatobiliary scintigraphy, and quantitative parameters of bile emptying (Tmax: time to peak activity, T1/2: half-emptying time before and after cholecystokinin octapeptide and duodenum appearance time) were determined and then compared.

RESULTS

Before operation, the bile outflow displayed wide variations, with a moderately delayed common bile duct emptying time in some patients. After cholecystectomy, the T1/2 of the common bile duct decreased significantly when compared with the preoperative status, with only minor patient-to-patient variation, indicating uniformly faster bile emptying (common bile duct T1/2 before and after operation: 30.5 +/- 14.8 and 18.8 +/- 2.6 min, respectively). Cholecystokinin octapeptide administration caused rapid bile outflow from the common bile duct, with a significant decrease in the T1/2 parameters before and after cholecystectomy.

CONCLUSIONS

In patients with their gallbladders in situ, the bile emptying rate showed wide variations and may be moderately slow without distal common bile duct obstruction. After cholecystectomy, the rate of bile emptying accelerated and showed only minor variations, thereby increasing the sensitivity of quantitative hepatobiliary scintigraphy for showing partial biliary obstruction.

The effects of somatostatin and octreotide on the human sphincter of Oddi

OBJECTIVE

Somatostatin acts at different sites in the human gastrointestinal tract and generally inhibits the release and effects of many gastrointestinal hormones and neuropeptides. Together with its long-acting analogue octreotide, somatostatin is widely used in the treatment of hormone-producing tumours, variceal bleeding, etc., but multi-centre trials have failed to prove a beneficial effect in the treatment of acute pancreatitis or in the prevention of post-ERCP pancreatitis (pancreatitis following endoscopic retrograde cholangiopancreatography). The aim of the present work was to study the effects of somatostatin and octreotide on the human sphincter of Oddi by means of quantitative hepatobiliary scintigraphy (QHBS).

METHOD

Fifteen cholecystectomized patients were enrolled in the study, six in the somatostatin group and nine in the octreotide group. QHBS was performed initially with a standard protocol (baseline data), then repeated after 0.1 mg octreotide or a 250 microg bolus + 250 microg/h somatostatin administration. In the 60th min of QHBS, 0.5 mg glyceryl trinitrate (GTN) was administered sublingually.

RESULTS

QHBS demonstrated that both somatostatin and octreotide caused a marked impairment in the bile flow: the half-time of excretion (T1/2) over the common bile duct was significantly prolonged compared with baseline data (somatostatin group: common bile duct T1/2 180 min versus 59.7+/-31 min; octreotide group: common bile duct T1/2 140.9+/-60.5 min versus 30.7+/-11.7 min). Glyceryl trinitrate administration accelerated the transpapillary bile flow, with significant decreases in the elevated T1/2 in both groups.

CONCLUSION

Increased transpapillary flow induced by glyceryl trinitrate may be beneficial in the treatment of acute or post-ERCP pancreatitis.

Chemokine receptor CCR2 and CCR5 polymorphisms in children with insulin-dependent diabetes mellitus

Studies have shown the important roles of several regulatory and proinflammatory cytokines in insulin-dependent diabetes mellitus (IDDM). CC-chemokine receptors CCR2 and CCR5 bind chemokines that are involved in the trafficking of leukocytes in both basal and inflammatory states. A common 32-bp deletion mutation in the CCR5 gene (CCR5delta32) and a G-to-A nucleotide substitution in the CCR2 at position 190 (CCR2-64I) have recently been described. In the present study, we have determined the frequency of the CCR5delta32 and CCR2-64I alleles in children with IDDM [n = 115; age 1-14 (9.3+/-4.3) y] and in nondiabetic subjects [n = 280; age 1-14 (8.5+/-4.5) y]. The CCR5delta32 allele frequencies were 0.117 in children with IDDM and 0.111 in nondiabetic subjects, indicating that the deletion allele has no association with IDDM. The CCR2-64I allele frequency in children with IDDM was 0.226, which differed significantly from the allele frequency in controls (0.114, p = 0.001). The role of this mutation in IDDM cannot be explained yet, but, because CCR2 mediates the chemotaxis of CD4+ and CD8+ T cells to areas of inflammation and because these cells play important roles in insulitis, a mutation in the CCR2 gene may contribute to the susceptibility to the disease. Alternatively, the 64I allele could be a marker of a linked mutation through linkage disequilibrium. According to these results, the CCR2 gene may be a new candidate for the susceptibility locus of IDDM. However, because no IDDM locus has been identified near 3p21 until now, further investigations are needed to confirm this statement.

Humoral mechanisms and clinical aspects of biliary tract motility

This review is intended to summarize current information on neurohumoral regulation of the gallbladder and sphincter of Oddi motility under both physiological and pathological circumstances with emphasis on Hungarian contributions to today's knowledge. The mechanism of action of neurohumoral agents that interact on these segments of the biliary tract, and the explored details of the stimulation-contraction/relaxation coupling process of these substances, will be discussed. A modified classification of biliary tract motility disorders with new diagnostic and therapeutic approaches will also be provided. This information will aid understanding of the pathogenesis of motor disorders of the gallbladder and sphincter of Oddi, and will indicate possibilities for pharmacological exploitation in the treatment of diseases resulting from biliary tract motility abnormalities.

[Endoscopic therapy of pancreas divisum]

Pancreas divisum is the most frequent congenital ductal anomaly of the pancreas: it occurs in 5-10% of the population. In the majority of patients, this congenital anomaly is of no clinical importance. In a certain subset of patients, however, pancreas divisum is clinically important as a cause of abdominal pain, acute recurrent pancreatitis or chronic obstructive pancreatitis. The authors, experience on endoscopic drainage of the minor papilla is reported. In the history of patient 1., three episodes of recurrent pancreatitis and permanent upper abdominal pain were explored. ERP revealed a pancreas divisum and a mild irregularity and dilation of the dorsal pancreatic duct. A 7 F stent (length: 6 cm) was implanted in the dorsal pancreatic duct following a papillotomy on the stenotic minor papilla. A repeated Lundh test revealed a 58% improvement in the exocrine pancreatic function. No recurrence of pancreatitis has been observed in spite of the moderate continuous abdominal pain. In patient 2., ERP demonstrated a pancreas divisum and a severely dilated dorsal pancreatic duct as causes of the previous permanent abdominal pain. An 8 F stent (length: 5 cm) was inserted through the minor papilla without endoscopic sphincterotomy. A significant improvement in exocrine pancreatic function (70%) ensued. No abdominal pain has since been observed. In conclusion, dorsal pancreatic duct stenting (mainly in cases involving a dilated pancreatic duct) seems to have a beneficial effect in patients with both recurrent acute pancreatitis or chronic obstructive pancreatitis evoked by pancreas divisum.

Reproducibility of erythrocyte sodium-lithium countertransport activity and ambulatory blood pressure measurements in type 1 diabetes mellitus

We aimed to study the reproducibility of sodium-lithium countertransport [SLCT] activity and ambulatory blood pressure monitoring [ABPM] in type 1 diabetes. We did this by performing repeated measurements of SLCT activity and ABPM in 11 recent-onset diabetic children and in 11 patients with longer duration of diabetes. Both parameters were related to microalbuminuria. In the older group of diabetic children a significant correlation [r = 0.78; P<0.005] in SLCT activity between the first and second study was observed [514.3+/-186.4 vs 491.0+/-148.0 micromol/l erythrocytes/h]. Diurnal systolic and diastolic blood pressure were comparable at both time points within the same group of diabetic children [in group 1: 102.6+/-6.1 vs 108.6+/-7.6 mmHg N.S.; in group 2: 113.4+/-10.6 vs 114.0+/-7.8 mmHg N.S. Diastolic blood pressure in group 1: 57.4+/-4.8 vs 65.7+/-6.9 mmHg N.S., in group 2: 70.6+/-9.1 vs 68.5+/-5.3 mmHg N.S.]. Moreover, there was a significant correlation in both diurnal and nocturnal systolic blood pressure between the first and second study in the whole diabetic population. Both SLCT activity and blood pressure values obtained by ABPM were found to be reproducible individual characteristic markers in type 1 diabetic children.