Spectrum of neuro-developmental disorders in children with congenital hyperinsulinism due to activating mutations in GLUD1

Background

Hyperinsulinism/hyperammonemia (HI/HA) syndrome is the second most common type of congenital hyperinsulinism caused by an activating GLUD1 mutation.

Objective

The aim of this study was to determine the clinical profile and long-term neurological outcomes in children with HI/HA syndrome.

Method

This study is a retrospective review of patients with GLUD1 mutation, treated at two centers in the UK and Russia, over a 15-year period. Different risk factors for neuro-developmental disorders were analysed by Mann-Whitney U test and Fisher's exact P test.

Results

We identified 25 cases with GLUD1 mutations (12 males). Median age of presentation was 7 months (12 h-18 months). Hypoglycaemic seizures were the presenting feature in 24 (96%) cases. Twenty four cases responded to diazoxide and protein restriction whilst one patient underwent partial pancreatectomy. In total, 13 cases (52%) developed neurodevelopmental manifestations. Epilepsy (n = 9/25, 36%), learning difficulties (n = 8/25, 32%) and speech delay (n = 8/25, 32%) were the most common neurological manifestation. Median age of presentation for epilepsy was 12 months with generalised tonic-clonic seizures being the most common (n = 4/9, 44.4%) followed by absence seizures (n = 3/9, 33.3%). Early age of presentation (P = 0.02), diazoxide dose (P = 0.04) and a mutation in exon 11 or 12 (P = 0.01) were associated with neurological disorder.

Conclusion

HI/HA syndrome is associated with wide spectrum of neurological disorders. These neurological manifestations were more frequent in cases with mutations affecting the GTP-binding site of GLUD1 in our cohort.

Insulinoma in childhood: a retrospective review of 22 patients from one referral centre

Background

Insulinomas are very rare in childhood with sparse knowledge on the clinical aspects and the presence of Multiple Endocrine Neoplasia type 1 (MEN1).

Methods

We conducted a retrospective review of patients diagnosed with insulinoma between 1995 and 2021, presenting to one referral centre in Russia. Clinical, biochemical, genetic, imaging and histological data were collected. In addition, follow-up and family data were obtained.

Results

A total of twenty-two children aged 5 to 16 years were identified. The median (range) gap between the first hypoglycaemia symptoms and diagnosis was 10 (1-46) months. Twelve children (55%) were misdiagnosed to have epilepsy and were treated with anticonvulsants before hypoglycemia was revealed. Contrast enhanced MRI and/or CT were accurate to localize the lesion in 82% (n=18). Five patients (23%) had multiple pancreatic lesions. All children underwent surgical treatment. The median (range) diameter of removed tumors was 1.5 (0.3-6) cm. Histopathological studies confirmed the presence of insulinoma in all cases. Immunohistochemical studies revealed G2 differentiation grade in 10 out of 17 cases. Two patients were diagnosed with metastatic insulinoma. One of them had metastases at the time of insulinoma diagnosis, while the other was diagnosed with liver metastases eight years after the surgery. Eight children (36%) were found to carry MEN1 mutations, inherited n=5, de novo n=1, no data, n=2. Children with MEN1 had significantly higher number of pancreatic tumors compared to sporadic cases. All of them developed additional MEN1 symptoms during the following 2-13 years. In the five patients with inherited MEN1, seven family members had hitherto undiscovered MEN1 manifestations.

Conclusions

In this large cohort of children with rare pediatric insulinomas, MEN1 syndrome and G2 tumors were frequent, as well as hitherto undiscovered MEN1 manifestations in family members. Our data emphasize the need of genetic testing in all children with insulinoma and their relatives, even in the absence of any other features, as well as the importance of a prolonged follow-up observation.

The coincidence of two rare diseases with opposite metabolic phenotype: a child with congenital hyperinsulinism and Bloom syndrome

OBJECTIVES

Congenital hyperinsulinism (CHI) is a group of rare genetic disorders characterized by insulin overproduction. CHI causes life-threatening hypoglycemia in neonates and infants. Bloom syndrome is a rare autosomal recessive disorder caused by mutations in the BLM gene resulting in genetic instability and an elevated rate of spontaneous sister chromatid exchanges. It leads to insulin resistance, early-onset diabetes, dyslipidemia, growth delay, immune deficiency and cancer predisposition. Recent studies demonstrate that the BLM gene is highly expressed in pancreatic islet cells and its mutations can alter the expression of other genes which are associated with apoptosis control and cell proliferation.

CASE PRESENTATION

A 5-month-old female patient from consanguineous parents presented with drug-resistant CHI and dysmorphic features. Genetic testing revealed a homozygous mutation in the KCNJ11 gene and an additional homozygous mutation in the BLM gene. While ¹⁸F-DOPA PET scan images were consistent with a focal CHI form and intraoperative frozen-section histopathology was consistent with diffuse CHI form, postoperative histopathological examination revealed features of an atypical form.

CONCLUSIONS

In our case, the patient carries two distinct diseases with opposite metabolic phenotypes.

Clinical and genetic heterogeneity of HNF4A/HNF1A mutations in a multicentre paediatric cohort with hyperinsulinaemic hypoglycaemia

OBJECTIVE

The phenotype mediated by HNF4A/HNF1A mutations is variable and includes diazoxide-responsive hyperinsulinaemic hypoglycaemia (HH) and maturity-onset diabetes of the young (MODY).

DESIGN

We characterised an international multicentre paediatric cohort of patients with HNF4Aor HNF1Amutations presenting with HH over a 25-year period (1995-2020).

METHODS

Clinical and genetic analysis data from five centres were obtained. Diazoxide responsiveness was defined as the ability to maintain normoglycaemia without intravenous glucose. Macrosomia was defined as a birth weight ≥90th centile. SPSS v.27.1 was used for data analysis.

RESULTS

A total of 34 patients (70.6% female, n = 24) with a mean age of 7.1 years (s.d. 6.4) were included. A total of 21 different heterozygous HNF4Amutations were identified in 29 patients (four novels). Four different previously described heterozygous HNF1A mutations were detected in five patients. Most (97.1%, n = 33) developed hypoglycaemia by day 2 of life. The mean birth weight was 3.8 kg (s.d. 0.8), with most infants macrosomic (n = 21, 61.8%). Diazoxide was commenced in 28 patients (82.3%); all responded. HH resolved in 20 patients (58.8%) following a median of 0.9 years (interquartile range (IQR): 0.2-6.8). Nine patients (n = 9, 26.5%) had developmental delay. Two patients developed Fanconi syndrome (p.Arg63Trp, HNF4A) and four had other renal or hepatic findings. Five (14.7%) developed MODY at a median of 11.0 years (IQR: 9.0-13.9). Of patients with inherited mutations (n = 25, 73.5%), a family history of diabetes was present in 22 (88.0%).

CONCLUSIONS

We build on the knowledge of the natural history and pancreatic and extra-pancreatic phenotypes of HNF4A/HNF1Amutations and illustrate the heterogeneity of this condition.

Dispensing antibiotics without prescription at pharmacies: barriers and strategies for improvement

Background

Antimicrobial resistance (AMR) is a worldwide public health challenge, and non-prudent use of antibiotics is one of key drivers of AMR. In some countries antibiotics are often sold without a prescription at pharmacies. In Armenia this problem is also observed despite national regulation. The objective of this work was to identify perception of pharmacy staff on main barriers for dispensing antibiotics with a prescription at community pharmacies and perceived strategies for improving the situation in Armenia.

Methods

Survey was conducted at community pharmacies in different regions of Armenia. Pharmacists and pharmacy technicians were asked to complete pretested questionnaire. Data were analysed with SPSS statistical software.

Results

Despite most of professionals reported that they are aware about regulation, 78.4% of 241 participants indicated that patients can buy antibiotics at their pharmacy without a prescription from doctor. Most of participants reported that the percentage of patients whom antibiotics were sold without a prescription is high. More than a half of responders indicated the following barriers for dispensing antibiotics with a prescription at community pharmacies: lack of patients' awareness about effectiveness and safety of antibiotics (61.0%), difficulties for doctors to prescribe using approved forms (60.6%), poor prescribing practice (56.4%). More than a half of professionals consider that it is necessary to introduce the following strategies: organizing public awareness campaigns (68.0%), organizing special training courses for physicians and pharmacists (63.9%), introducing Medicines and therapeutic committees at health facilities (54.8%).

Conclusions

Patients can buy antibiotics without a prescription at community pharmacies in Armenia. There are certain barriers for dispensing antibiotics with a prescription at community pharmacies. Educational and organizational strategies can be helpful for improving the situation.

Key messages

Lack of patients’ awareness about antibiotics is a very important barrier for dispensing antibiotics with a prescription at community pharmacies. Most of pharmacy professionals are interested in improving the situation and indicate necessity of appropriate measures.

Role of community pharmacists in pharmacovigilance: pharmacists’ and patients’ perceptions

Background

Pharmacists are involved in pharmacovigilance in many countries, their role varies. Some studies show that they are not active enough in reporting adverse drug reactions (ADR). Pharmacists' and patients' awareness about engagement of pharmacists in reporting ADR and other medicines use problems, as well as in counseling on medication safety is essential for improving patient safety. The objective of this work was to study attitude of pharmacy professionals and patients to role of community pharmacy staff in providing patient medication safety in Armenia.

Methods

297 pharmacists and technicians, as well as 2066 patients were interviewed in Yerevan (capital of Armenia) according to designed and pretested questionnaire.

Results

201 (68.0%) pharmacists and technicians consider that community pharmacists in Armenia are engaged in ADR reporting and 198 (66.6%) professionals indicated that they wish to be involved in this activity. 215 (72.4%) professionals supposed that community pharmacists are engaged in providing advices related to medicines safety and indicated that they are interested to be involved. Slightly more than a half of patients reported that they wish that community pharmacy staff would be involved in ADR reporting and would provide advices related to medicines safety: 1171 (56.7%) and 1115 (54.0%), correspondingly. The number of participated patients who think that pharmacists are already engaged in these activities was much less: 726 (35.1%) and 876 (42.4%), correspondingly (p < 0.001).

Conclusions

Most of pharmacy professionals and patients are interested that community pharmacy staff would be involved in ADR reporting and advising on medicines safety. Some pharmacy professionals and most of patients are not aware about this role of pharmacy staff. Special strategies for educating pharmacists and patients should be developed. Lecture on Pharmacovigilance was included in continuing education course curricula for pharmacy professionals.

Key messages

Pharmacy professionals and patients are interested in engaging pharmacists in activity in the area of pharmacovigilance. It is important to improve education of pharmacists and increase awareness of patients about role of pharmacists in this area.

Patients’ perception of role of pharmacists in health promotion

Background

Perceptions of patients is very important for accepting new role pharmacists play. The objective of this work was to study opinion of patients about role of community pharmacists in health promotion in Armenia.

Methods

Visitors (N = 2066) of community pharmacies in Yerevan were interviewed according to previously designed questionnaire.

Results

Some respondents suppose that pharmacists already provide advices on diet and physical activity for preventing obesity (32.1%), advices on healthy lifestyle for preventing cardiovascular diseases and cancer (30.9%), in promoting healthy lifestyle for preventing chronic diseases (27.5%). The number of patients who thinks that pharmacists are involved in providing advices on smoking cessation (38.1%) is significantly higher than the number of those who believe that pharmacists participate in campaigns on smoking cessation (27.1%) (p < 0,001). Part of respondents wish that community pharmacists would be involved in providing advices on smoking cessation (55.9%), advices for preventing obesity (57.7%), cardiovascular diseases and cancer (57.2%), promoting healthy lifestyle for preventing chronic diseases (51.5%).

Conclusions

Most of patients are interested that community pharmacists would be involved in implementing activity in the area of health promotion. The number of patients who wish pharmacist would be involved in health promotion is higher than the number of those who suppose that pharmacists already have such functions.

Key messages

Patients are interested in receiving advices related to health from community pharmacists. It is important to improve education of pharmacists in the area of health promotion.

Community pharmacists’ involvement in ensuring patient safety

Burden of injuries to patients from adverse events is one of the top 10 causes of death and disability in the world; medication errors are a leading cause of injury. Most adverse events can be avoided. The objective of this work was to study involvement of community pharmacy professionals in ensuring patient safety in Armenia.

Community pharmacists and technicians from all the regions of Armenia were asked to complete previously designed questionnaire. 353 professionals completed self-administered questionnaire. Data were analysed with SPSS statistical software, version 22.0.

87.8% of respondents reported that they observe prescribing errors when evaluating prescription at pharmacy. 69.4% of them indicate that the main error is wrong dose; 32.3% pointed medicines interactions; 32.0% - contraindications. Number of professionals from Yerevan, who indicated wrong dose, is higher than number of those from other regions (p < 0.001). Only 5.1% of participants register errors at pharmacy. 83.0% of pharmacy staff reported they always or often evaluate therapeutic aspects of prescriptions. 42.2% of respondents noted that, when patient is pressing, they never dispense a medicine without being sure that it is safe for patient; 27.5% do it very rarely. 76.8% of responders are sure their services ensure safe use of medicines by patients. 26.1% of pharmacy staff reported having SOPs at their pharmacy; 80.3% are interesting in introducing this strategy.

Various prescription errors are observed by community pharmacists; however they are mainly not registered (there is no such requirement). In some cases prescriptions are not evaluated at community pharmacies. Approval of new standards for pharmacy practice seems to be beneficial. Recommendations are drafted for submitting to Ministry of Health.

Key messages

Involvement of pharmacy professionals in ensuring patient safety have to be increased. There is need for changes in pharmacy practice regulation leading to safer use of medicines by patients.

Practice of dispensing antimicrobial medicines from community pharmacies

Background

Inappropriate use of antimicrobial medicines is one of the main causes of antimicrobial resistance (AMR). The objective of this work was to study the situation on dispensing antimicrobials from pharmacy outlets in Armenia.

Methods

The study was implemented in 30 community pharmacies from different regions of Yerevan. Medicines dispensed to 900 patients/caregivers (30 visitors in each pharmacy outlet) were analyzed. The following indicators were calculated: the percentage of antimicrobials prescribed by physicians, the percentage of visitors, who got antimicrobials without providing a prescription and so on.

Results

Antimicribials (n = 171) consisted 11.3% of all the dispensed medicines (N = 1513). Only 25 (14.6%) antimicrobials were dispensed to visitors who had prescriptions. Only 19 (12.6%) of 151 medicines provided without prescription were OTC-medicines, other 132 (87.4%) were prescription only medicines. According to information received from visitors, 58.5% of all dispensed antimicrobials were selected by physicians, 10.5% of antimicrobials were advised by pharmacists and almost one third was selected by patients, family members, etc. More than 90% of the total number of visitors, whom antimicrobials were dispensed, got them without providing a prescription. 13 patients received 2 and more antimicrobials.

Conclusions

Many prescription only antimicrobials are dispensed from community pharmacies without prescription and some medicines are not prescribed by physicians. That means many antimicrobials are used inappropriately. There is need in strategy that could prevent dispensing antimicrobials without prescription.

Key messages

Dispensing prescription only antimicrobials without prescription can compromise rational use of medicines. Professional knowledge and public awareness about AMR should be improved.

18F-DOPA PET/CT and 68Ga-DOTANOC PET/CT scans as diagnostic tools in focal congenital hyperinsulinism: a blinded evaluation

Purpose

Focal congenital hyperinsulinism (CHI) is curable by surgery, which is why identification of the focal lesion is crucial. We aimed to determine the use of 18F–fluoro-dihydroxyphenylalanine (18F-DOPA) PET/CT vs. 68Ga-1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic-acid-1-Nal3-octreotide (68Ga-DOTANOC) PET/CT as diagnostic tools in focal CHI.

Methods

PET/CT scans of children with CHI admitted to Odense University Hospital between August 2005 and June 2016 were retrospectively evaluated visually and by their maximal standardized uptake values (SUV_max) by two independent examiners, blinded for clinical, surgical and pathological data. Pancreatic histology was used as the gold standard. For patients without surgery, the genetic profile served as the gold standard.

Results

Fifty-five CHI patients were examined by PET/CT (18F-DOPA n = 53, 68Ga-DOTANOC n = 18). Surgery was performed in 34 patients, no surgery in 21 patients. Fifty-one patients had a classifiable outcome, either by histology (n = 33, 22 focal lesions, 11 non-focal) or by genetics (n = 18, all non-focal). The predictive performance of 18F-DOPA PET/CT to identify focal CHI was identical by visual- and cut-off-based evaluation: sensitivity (95% CI) of 1 (0.85–1); specificity of 0.96 (0.82–0.99). The optimal 18F-DOPA PET SUV_max ratio cut-off was 1.44 and the optimal 68Ga-DOTANOC PET SUV_max cut-off was 6.77 g/ml. The area under the receiver operating curve was 0.98 (0.93–1) for 18F-DOPA PET vs. 0.71 (0.43–0.95) for 68Ga-DOTANOC PET (p < 0.03). In patients subjected to surgery, localization of the focal lesion was correct in 91%, and 100%, by 18F-DOPA PET/CT and 68Ga-DOTANOC PET/CT, respectively.

Conclusion

18F-DOPA PET/CT was excellent in predicting focal CHI and superior compared to 68Ga-DOTANOC PET/CT. Further use of 68GA-DOTANOC PET/CT in predicting focal CHI is discouraged.

Electronic supplementary material

The online version of this article (10.1007/s00259-017-3867-1) contains supplementary material, which is available to authorized users.

Both Low Blood Glucose and Insufficient Treatment Confer Risk of Neurodevelopmental Impairment in Congenital Hyperinsulinism: A Multinational Cohort Study

BACKGROUND/AIMS

Congenital hyperinsulinism (CHI) is a heterogeneous disease most frequently caused by KATP-channel (ABCC8 and KCNJ11) mutations, with neonatal or later onset, variable severity, and with focal or diffuse pancreatic involvement as the two major histological types. CHI confers a high risk of neurological impairment; however, sparsely studied in larger patient series. We assessed the neurodevelopmental outcome in children with CHI at follow-up in a mixed international cohort.

METHODS

In two hyperinsulinism expert centers, 75 CHI patients were included (Russian, n = 33, referred non-Scandinavian, treated in Denmark n = 27, Scandinavian, n = 15). Hospital files were reviewed. At follow-up, neurodevelopmental impairment and neurodevelopmental, cognitive and motor function scores were assessed.

RESULTS

Median (range) age at follow-up was 3.7 years (3.3 months-18.2 years). Neurodevelopmental impairment was seen in 35 (47%). Impairment was associated with abnormal brain magnetic resonance imaging (MRI); odds ratio (OR) (95% CI) 15.0 (3.0-74.3), p = 0.001; lowest recorded blood glucose ≤1 mmol/L; OR 3.8 (1.3-11.3), p = 0.015, being non-Scandinavian patient, OR 3.8 (1.2-11.9), p = 0.023; and treatment delay from first symptom to expert center >5 days; OR 4.0 (1.0-16.6), trend p = 0.05. In multivariate analysis (n = 31) for early predictors with exclusion of brain MRI, treatment delay from first symptom to expert center >5 days conferred a significantly increased risk of neurodevelopment impairment, adjusted OR (aOR) 15.6 (1.6-146.7), p = 0.016, while lowest blood glucose ≤1 mmol/L had a trend toward increased risk, aOR 3.5 (1.1-14.3), p = 0.058. No associations for early vs. late disease onset, K_ATP-channel mutations, disease severity, focal vs. diffuse disease, or age at follow-up were seen in uni- or multivariate analysis.

CONCLUSION

Not only very low blood glucose, but also insufficient treatment as expressed by delay until expert center hospitalization, increased the risk of neurodevelopmental impairment. This novel finding calls for improvements in spread of knowledge about CHI among health-care personnel and rapid contact with an expert CHI center on suspicion of CHI.

Idiopathic postprandial hyperinsulinaemic hypoglycaemia

BACKGROUND

Idiopathic postprandial hyperinsulinaemic hypoglycaemia (PPHH) has rarely been reported in the paediatric age. The objective of this study was to describe the clinical characteristics, diagnosis and management in a group of children with PPHH.

METHODS

Six children (three females) with a mean follow-up of 3.5±3.0 years at a single tertiary paediatric hospital. All had 24-h blood glucose monitoring, diagnostic fast and prolonged oral glucose tolerance test (OGTT). Follow-up included: 24-h blood glucose monitoring or continuous glucose monitoring system, prolonged OGTT and/or mixed meal (MM) test.

RESULTS

Age at diagnosis ranged from 5.4 to 15.7 years and auxology parameters were within normal range in all subjects. All the children had a normal fasting tolerance for age. Prolonged OGTT demonstrated symptomatic hypoglycaemia after 120 min in all the patients with simultaneous detectable serum insulin concentration. Acarbose was tried in three patients, having a positive effect on glycaemic and symptom control, but due to side effects, only two patients continued acarbose in the long run. Diazoxide proved to be beneficial in one patient. The rest of the patients were managed with frequent feeds but despite this, prolonged OGTT/MM demonstrated on-going PPHH.

CONCLUSIONS

Prolonged OGTT is necessary to diagnose PPHH in children. Acarbose is beneficial in children with PPHH, although not well tolerated. Patients managed exclusively on frequent feeds demonstrated persistent hypoglycaemia on OGTT. The underlying cause of the PPHH in these patients remains unknown.