The revised Atlanta criteria more accurately reflect severity of post-ERCP pancreatitis compared to the consensus criteria

Background and objective

Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) is the most prevalent complication after ERCP with an incidence of 3.5%. PEP severity is classified according to either the consensus criteria or the revised Atlanta criteria. In this international cohort study we investigated which classification is the strongest predictor of PEP-related mortality.

Methods

We reviewed 13,384 consecutive ERCPs performed between 2012 and 2017 in eight hospitals. We gathered data on all pancreatitis-related adverse events and compared the predictive capabilities of both classifications. Furthermore, we investigated the correlation between the two classifications and identified reasons underlying length of stay.

Results

The total sample consisted of 387 patients. The revised Atlanta criteria have a higher sensitivity (100 vs. 55%), specificity (98 vs. 72%) and positive predictive value (58 vs. 5%). There is a significant difference (p < 0.001) between the two classifications. In 124 patients (32%), the length of stay was influenced by concomitant diseases.

Conclusion

The revised Atlanta classification is superior in predicting mortality and better reflects PEP severity. This has important implications for researchers, clinicians and patients. For the diagnosis of PEP pancreatitis, the consensus criteria remain the golden standard. However, the revised Atlanta criteria are preferable for defining PEP severity.

Current evidence on the transmissibility of chronic wasting disease prions to humans-A systematic review

A number of prion diseases affect humans, including Creutzfeldt-Jakob disease; most of these are due to genetic mutations in the affected individual and occur sporadically, but some result from transmission of prion proteins from external sources. Of the known animal prion diseases, only bovine spongiform encephalopathy prions have been shown to be transmissible from animals to humans under non-experimental conditions. Chronic wasting disease (CWD) is a prion disease that affects cervids (e.g., deer and elk) in North America and isolated populations in Korea and Europe. Systematic review methodology was used to identify, select, critically appraise and analyse data from relevant research. Studies were evaluated for adherence to good conduct based on their study design following the Cochrane collaboration's approach to grading the quality of evidence and the strength of recommendations (GRADE). Twenty-three studies were included after screening 800 citations from the literature search and evaluating 78 full papers. Studies examined the transmissibility of CWD prions to humans using epidemiological study design, in vitro and in vivo experiments. Five epidemiological studies, two studies on macaques and seven studies on humanized transgenic mice provided no evidence to support the possibility of transmission of CWD prions to humans. Ongoing surveillance in the United States and Canada has not documented CWD transmission to humans. However, two studies on squirrel monkeys provided evidence that transmission of CWD prions resulting in prion disease is possible in these monkeys under experimental conditions and seven in vitro experiments provided evidence that CWD prions can convert human prion protein to a misfolded state. Therefore, future discovery of CWD transmission to humans cannot be entirely ruled out on the basis of current studies, particularly in the light of possible decades-long incubation periods for CWD prions in humans. It would be prudent to continue CWD research and epidemiologic surveillance, exercise caution when handling potentially contaminated material and explore CWD management opportunities.

Image plate characterization and absolute calibration to low kilo-electron-volt electrons

We report on the characterization of an image plate and its absolute calibration to electrons in the low keV energy range (1-30 keV). In our case, an Agfa MD4.0 without protection layer was used in combination with a Fuji FLA7000 scanner. The calibration data are compared to other published data and a consistent picture of the sensitivity of image plates to electrons is obtained, which suggests a validity of the obtained calibration up to 100 keV.

Probing the complex ion structure in liquid carbon at 100 GPa

We present the first direct experimental test of the complex ion structure in liquid carbon at pressures around 100 GPa, using spectrally resolved x-ray scattering from shock-compressed graphite samples. Our results confirm the structure predicted by ab initio quantum simulations and demonstrate the importance of chemical bonds at extreme conditions similar to those found in the interiors of giant planets. The evidence presented here thus provides a firmer ground for modeling the evolution and current structure of carbon-bearing icy giants like Neptune, Uranus, and a number of extrasolar planets.

NAIS: nuclear activation-based imaging spectroscopy

In recent years, the development of high power laser systems led to focussed intensities of more than 10(22) W/cm(2) at high pulse energies. Furthermore, both, the advanced high power lasers and the development of sophisticated laser particle acceleration mechanisms facilitate the generation of high energetic particle beams at high fluxes. The challenge of imaging detector systems is to acquire the properties of the high flux beam spatially and spectrally resolved. The limitations of most detector systems are saturation effects. These conventional detectors are based on scintillators, semiconductors, or radiation sensitive films. We present a nuclear activation-based imaging spectroscopy method, which is called NAIS, for the characterization of laser accelerated proton beams. The offline detector system is a combination of stacked metal foils and imaging plates (IP). After the irradiation of the stacked foils they become activated by nuclear reactions, emitting gamma decay radiation. In the next step, an autoradiography of the activated foils using IPs and an analysis routine lead to a spectrally and spatially resolved beam profile. In addition, we present an absolute calibration method for IPs.

Energy loss and charge transfer of argon in a laser-generated carbon plasma

This Letter reports on the measurement of the energy loss and the projectile charge states of argon ions at an energy of 4  MeV/u penetrating a fully ionized carbon plasma. The plasma of n(e)≈10(20)  cm(-3) and T(e)≈180  eV is created by two laser beams at λ(Las)=532  nm incident from opposite sides on a thin carbon foil. The resulting plasma is spatially homogenous and allows us to record precise experimental data. The data show an increase of a factor of 2 in the stopping power which is in very good agreement with a specifically developed Monte Carlo code, that allows the calculation of the heavy ion beam's charge state distribution and its energy loss in the plasma.

Ultrafast melting of carbon induced by intense proton beams

Laser-produced proton beams have been used to achieve ultrafast volumetric heating of carbon samples at solid density. The isochoric melting of carbon was probed by a scattering of x rays from a secondary laser-produced plasma. From the scattering signal, we have deduced the fraction of the material that was melted by the inhomogeneous heating. The results are compared to different theoretical approaches for the equation of state which suggests modifications from standard models.

Evolution of elastic x-ray scattering in laser-shocked warm dense lithium

We have studied the dynamics of warm dense Li with near-elastic x-ray scattering. Li foils were heated and compressed using shock waves driven by 4-ns-long laser pulses. Separate 1-ns-long laser pulses were used to generate a bright source of 2.96 keV Cl Ly- alpha photons for x-ray scattering, and the spectrum of scattered photons was recorded at a scattering angle of 120 degrees using a highly oriented pyrolytic graphite crystal operated in the von Hamos geometry. A variable delay between the heater and backlighter laser beams measured the scattering time evolution. Comparison with radiation-hydrodynamics simulations shows that the plasma is highly coupled during the first several nanoseconds, then relaxes to a moderate coupling state at later times. Near-elastic scattering amplitudes have been successfully simulated using the screened one-component plasma model. Our main finding is that the near-elastic scattering amplitudes are quite sensitive to the mean ionization state Z[over ] and by extension to the choice of ionization model in the radiation-hydrodynamics simulations used to predict plasma properties within the shocked Li.

Intravenous immunoglobulin treatment in hematological diseases

In the last decade large amounts of intravenous immunoglobulin (i.v.Ig) have been used worldwide. Doubts exist as to whether this increased use is paralleled by a comparable growth of reliable data on the therapeutic effectiveness of i.v.Ig. We performed a literature search using MEDLINE from January 1981 to January 1997 and analysed articles on the use of i.v.Ig in hematological disorders and searched for published guidelines. For most hematological disorders, evidence to use i.v.Ig as first line therapy is not very strong. For many disorders no controlled trials have been performed. In published guidelines, i.v.Ig is only recommended, with a few exceptions, when other treatments have failed or are contraindicated. Therefore the increase of consumption of i.v.Ig can not be explained by an increase in established indications in hematology.

[Asystole due to complex partial epilepsy]

A 56-year-old man was seen in the Emergency Room because of sudden and transient loss of consciousness. An asystole was diagnosed with 10 S duration after which a pacemaker was implanted. The patient had experienced such collapses before, preceded by odd smell sensations. After the implantation of the pacemaker, the patient did not collapse again but still experienced attacks of the same smell sensations combined with a strange feeling in his stomach. An EEG, recorded during such an attack, showed epileptic activity predominantly over the right hemisphere while at the same moment a pacemaker rhythm was observed. After the epileptic activity had stopped, normal sinus rhythm reappeared. On anticonvulsant therapy the attacks disappeared completely.

[Thyroid gland ultrasound and urinary iodine excretion in children and adolescents with type I diabetes mellitus]

BACKGROUND

Date, studies on thyroid volume and urinary iodide excretion in patients with diabetes mellitus are not available. Sonographically determined parameters of the thyroid size are correlated to other anthropometrous data and the urinary iodide excretion is correlated to glucosuria, the HbA1c value and the diabetes duration.

METHOD

In this prospective study we evaluated sonographically the thyroid volume in 107 patients with type I diabetes mellitus and 112 healthy children. The urinary iodide excretion was measured photometrically by using a modified ceric ion arsenious acid method for spontaneous urinary specimen and if available for the 24 h collected urin.

RESULTS

The thyroid volume depended on site and age. A positive correlation of the thyroid volume and age, body weight and height, could be demonstrated. Referring to reference data a goitre prevalence of 30% in juvenile patients with diabetes mellitus type I was detected. Interestingly, juvenile type I diabetics presented with an average urinary iodide excretion of 183.0 micrograms iodide/g creatinine. Even the urinary iodide excretion of 162.5 micrograms iodide confirmed this increased level. The urinary iodide excretion in 24 hours correlated with glucosuria and the HbA1c level. The healthy children presented with an average urinary iodide excretion of 42.6 micrograms iodide/g creatinine. The mean value was clearly below the WHO recommendation of 150-300 micrograms iodide/g creatinine. Only 2.8% of the healthy children examined exceeded the lower limit of this range.

CONCLUSION

In addition to the existing distinct under supply of iodide we assume an increased urinary iodide excretion in context with the osmotic diuresis in juvenile diabetics. Contrary to current opinion, that these data are correlated to the daily intake of iodide, which was calculated from urinary excretion rate, this thesis could not be affirmed for juvenile diabetics. Therefore it seems reasonable to frequently control thyroid volume and thyroid function in children and adolescents with diabetes mellitus.

[The epizootiology and pathogenic significance of infections with Isospora suis in ten piglet production operations in Nordrhein-Westfalen]

From July 1993 to June 1994 2036 fecal samples from 196 litters from 10 pig farms were collected. Three or four piglets from each litter and the respective sows were examined 3 times at 2, 3 and 4 weeks after farrowing. I. suis was detected in all 10 farms. The rate of infection of the litters was 62.2%. 71.6% of all litters with diarrheic problems were I. suis positive. The percentage of I. suis in the feces of piglets was 17.4% at the age of 2 weeks, 41.3% at the age of 3 weeks and 39.1% at the age of 4 weeks. It was also shown that I. suis occurs on any farm with any type of management system and at any time of the year. Fecal samples of sows were always Isospora negative. It is inferred that I. suis is a more important causative agent of porcine neonatal diarrhoea than considered so far. Therefore, further studies on epizootiological and therapeutical aspects and sanitation measures are necessary.

Novel (Rp)-cAMPS analogs as tools for inhibition of cAMP-kinase in cell culture. Basal cAMP-kinase activity modulates interleukin-1 beta action

Novel (Rp)-cAMPS analogs differed widely in ability to antagonize cAMP activation of pure cAMP-dependent protein kinase I and II and to antagonize actions of cAMP on gene expression, shape change, apoptosis, DNA replication, and protein phosphorylation in intact cells. These differences were related to different abilities of the analogs to stabilize the holoenzyme form relative to the dissociated form of cAMP kinase type I and II. (Rp)-8-Br-cAMPS and (Rp)-8-Cl-cAMPS were the most potent cAMP antagonists for isolated type I kinase and for cells expressing mostly type I kinase, like IPC-81 leukemia cells, fibroblasts transfected with type I regulatory subunit (RI), and primary hepatocytes. It is proposed that (Rp)-8-Br-cAMPS or (Rp)-8-Cl-cAMPS should replace (Rp)-cAMPS as the first line cAMP antagonist, particularly for studies in cells expressing predominantly type I kinase. The phosphorylation of endogenous hepatocyte proteins was affected oppositely by (Rp)-8-Br-cAMPS and increased cAMP, indicating that (Rp)-8-Br-cAMPS inhibited basal cAMP-kinase activity. The inhibition of basal kinase activity was accompanied by enhanced DNA replication, an effect which could be reproduced by microinjected mutant cAMP-subresponsive RI. It is concluded that the basal cAMP-kinase activity exerts a tonic inhibition of hepatocyte replication. (Rp)-8-Br-cAMPS and microinjected RI also desensitized hepatocytes toward inhibition of DNA synthesis by interleukin-1 beta. This indicates that basal cAMP-kinase activity can have a permissive role for the action of another (interleukin-1 beta) signaling pathway.

Interleukin-1 (IL-1)-induced resistance to bacterial infection: role of the type I IL-1 receptor

Pretreatment with a low dose of recombinant human interleukin-1 beta (IL-1) (3 to 30 micrograms/kg) 24 h before a lethal Pseudomonas aeruginosa infection prolongs survival in neutropenic mice. We investigated the role of the type I IL-1 receptor (IL-1RI) and IL-1RII in this IL-1-induced protection by using a specific IL-1 receptor antagonist (IL-1-Ra), which blocks effects mainly via IL-1RI. Pretreatment with IL-1Ra before IL-1 partially blocked the IL-1-induced enhanced survival, whereas pretreatment with a specific neutralizing monoclonal antibody to IL-1RI (35F5) eliminated the IL-1 induced protection. The nonapeptide fragment 163-171 of recombinant human IL-1 beta, which possesses the immunoadjuvant but not the inflammatory effect of the entire molecule via a non-receptor-mediated signal transduction process, did not reproduce the IL-1-induced protection. IL-1-induced protection was associated with reduced serum aspartate aminotransferase and alanine aminotransferase concentrations in conjunction with ameliorated histopathology of the liver. These findings may be due to reduced cytokine production and cytokine sensitivity of target cells after infection. We conclude that the IL-1-induced nonspecific resistance to infection is mediated by cells bearing IL-1RI and is associated with a reduction of liver damage.

Clinical and biochemical consequences of copper-histidine therapy in Menkes disease

Menkes disease (MD) is an X-linked recessively inherited neurodegenerative disorder of copper (Cu) metabolism leading to death in early childhood. Symptoms are attributed to deficient activity of Cu-dependent enzymes. Limited experience has been reported concerning clinical and biochemical consequences of parenteral treatment with copper-(histidine)2-complex (Cu-His) in MD. Cu-His was administered in a 13-week-old boy with MD by daily intramuscular injections. After 6 weeks of therapy, Cu and caeruloplasmin in serum and Cu in CSF were normalized. The excessive dopamine level in CSF was corrected after 3 months of treatment. After 6 weeks of Cu supplementation, complete reduction of epileptic discharges, improved muscular tone and increased motor activities were observed. Developmental regression stopped and was replaced by a slight progression. Death at the age of 19 months was caused by septicaemia due to a fulminant urinary tract infection; there was no evidence of chronic Cu toxicity. These findings suggest that Cu-His supplementation may be a promising palliative treatment in MD.

[Neonatal diabetes mellitus and microcephaly. Indications for autosomal recessive inheritance]

Still, there are a lot of questions about the pathogenesis of neonatal diabetes mellitus. In the author's opinion neonatal diabetes mellitus is a distinct entity which differs from the well-known types of diabetes in children (type 1 diabetes, MODY-diabetes) and transient neonatal hyperglycemia regarding pathogenesis, pathophysiology and prognosis. Casuistics of three children two of whom were sibs are reported in detail to demonstrate the characteristics of neonatal diabetes mellitus. Regarding the reported sibs we suppose genetic origin of the disease. Autosomal-recessive mode of inheritance must be assumed.

[Characteristics of thyroid sonography in infants and children]

In a prospective study the thyroid glands of 598 healthy boys and girls (newborn to 17 years old) were examined by ultrasound. The volume of the normal gland was 1.1 cm3 in neonates, 2 cm3 in 4 year-old-children, and 8.7 cm3 in schoolchildren. The gland of a normal newborn, a girl with congenital hypothyroidism, a girl with inflammation of a median cervical cyst, a girl with insulin-dependent diabetes mellitus and autoimmune thyroiditis, and a girl with an adenoma all showed typical differences in ultrasonic structure from the normal adult gland. Sonography of the thyroid gland discloses valuable information, especially in childhood.

[Ultrasonographically determined thyroid gland volume in children]

The size of the thyroid was evaluated by sonography in 199 boys and 237 girls age one month to 17 years. The volume is 1.2/1.06 ml in boys/girls during the first month, 1.2/1.6 ml at the end of the first year of life, 1.7/2.4 ml at age four, 3.2/3.4 ml with eight years and up to the age of 12 years 5.7/5.7 ml. In juveniles older than 12 years the average volume is 8 ml, sex independently. However, the range appears to be rather wide (1.5-14.5 ml). The right lobe is usually larger than the left one. The rates of the length of the right lobe and the body length, of the total volume and the body weight, and of the total volume and the body surface area are almost independent of age for schoolchildren. There is no significant difference of the thyroid volume between the sexes.

[Macrocephaly as the initial manifestation of glutaryl-CoA-dehydrogenase deficiency (glutaric aciduria type I)]

Glutaric aciduria type I is due to an impaired glutaryl-CoA-dehydrogenase with an increased urinary excretion of glutaric and 3-OH glutaric acid. Typically, the clinical course until the sixth month or even 3rd year of life is symptom free, and only later an encephalopathic crisis develops. The only symptom of our 4 patients was macrocephaly (head circumference greater than 97. percentile) in early infancy. 3 of them suffered from an encephalopathic crisis at 8 months to 3 years of age; during that time they lost already established abilities as sitting, walking and speaking, and developed choereoathetotic movements. One child aged 15 months was normal beside it's macrocephalus. All children were treated with a diet low in lysine (80 mg/kg BW/day), tryptophane (21 mg/kg BW/day), and by supplementation of L-carnitine (200 mg/kg BW/day) and riboflavine (200 mg/day) and the motorically disturbed children received Lioresal 1 mg/kg BW/day. The effect of this treatment cannot be evaluated so far, but there is evidence that the dietetic therapy together with carnitine supplementation may prevent further deterioration in affected, or an encephalopathic crisis in unaffected patients. Therefore we suggest to investigate organic acids in urine in every child or infant with macrocephalus to exclude glutaric aciduria type I.

Glyceryl trinitrate increases platelet cyclic GMP after metabolism in fibroblasts

Glyceryl trinitrate had no direct effect on cyclic GMP levels in platelets. However, in the presence of fibroblasts (RFL-6 cells), glyceryl trinitrate increased platelet cyclic GMP up to 7.8 fold (11.5 fold in the presence of superoxide dismutase). Fibroblasts alone had no effect. Endothelial cells alone increased platelet cyclic GMP up to 4.1 fold (9.6 fold in the presence of superoxide dismutase), but glyceryl trinitrate had no additional effect. Thus fibroblasts, but not endothelial cells, metabolize glyceryl trinitrate to a nitric oxide-like material that stimulates platelet soluble guanylyl cyclase.

Endothelial cyclic GMP and cyclic AMP do not regulate the release of endothelium-derived relaxing factor/nitric oxide from bovine aortic endothelial cells

The present study was designed to investigate whether cyclic GMP or cyclic AMP modulates the release of endothelium-derived relaxing factor/nitric oxide (EDRF/NO) in cultured bovine aortic endothelial cells (BAE cells). BAE cell-conditioned medium was transferred onto rat fetal lung fibroblasts (RFL-6 cells) and the increase in cyclic GMP in these cells was used as a sensitive bioassay of EDRF/NO activity. BAE cells released a material that markedly enhanced cyclic GMP in RFL-6 cells. The synthesis of this substance could be stimulated with bradykinin (10 nM) or Ca++ ionophore A23187 (1 microM) and was completely prevented by treatment of the BAE cells with the EDRF/NO synthesis inhibitors NG-nitro-L-arginine (100 microM) or NG-methyl-L-arginine (1 mM). Addition of hemoglobin (10 microM) or incubation of the RFL-6 detector cells with methylene blue (10 microM) also abolished the cyclic GMP increase in the RFL-6 cells. The release of EDRF/NO by bradykinin and A23187 was accompanied by an approximately 2-fold increase in the cyclic GMP content in the producing BAE cells (in the presence of the cyclic GMP phosphodiesterase inhibitor M&B 22,948, 0.1 mM). Incubation of BAE cells with atrial natriuretic peptide (0.1 microM) or sodium nitroprusside (10 microM) enhanced cyclic GMP content of BAE cells 6.5-fold and 4.1-fold, respectively (in the presence of M&B 22,948, 0.1 mM). These increases in the cyclic GMP levels in BAE cells had no effect on basal or bradykinin- and A23187-stimulated release of EDRF/NO. Bradykinin (10 nM) and A23187 (1 microM) also stimulated prostacyclin production in BAE cells 2.4-fold and 5.6-fold, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgical treatment of nesidioblastosis in childhood

A review of the literature on the surgical treatment of nesidioblastosis in childhood was made to answer the following questions: age at operation, surgical procedure, pathohistological findings, incidence of recurrence and its treatment, as well as mortality. Primary subtotal pancreatectomy appears to be the method of choice. It should be performed as early as possible following exact diagnosis. Total pancreatectomy is reserved for treatment of a recurrence.

[Efficacy and side effects of differential calcium and phosphate administration in prevention of osteopenia in premature infants]

The prevention of osteopenia and frequency of renal and intestinal side effects of mineral supplementation was studied in 24 preterm infants with birth weight under 1,500 g, prospectively (gestational age 26-34 weeks). Calcium intake varied from 2.5 vs. 3.75 vs. 5 mmol/kg/day, phosphate was offered in dose of 2.5 mmol/kg/day. At the expected birth date 40% of infants with low calcium dose showed an activity of serum alkaline phosphatase greater than five times the maximum adult normal value which is defined as a reliable marker; for osteopenia no infant with medium or high calcium intake reached this critical value (p = 0.03). Medium and high calcium doses resulted in an increased risk for hypercalcuria (25 vs. 50%) (p = 0.03). Half of these infants developed typical signs of nephrocalcinosis on ultrasound examination. No significant difference of fecal fat content was observed with increased calcium intake; but more episodes of abdominal distension occurred during the first days of high calcium supplementation (p = 0.03). We conclude, that a calcium intake of 3.75 mmol/kg/day in combination with phosphate 2.5 mmol/kg/day is sufficient for adequate bone mineralization on a low level of side effects. Calcium excretion in urine has to be observed for early diagnosis of nephrocalcinosis.

[Differences in free amino acid serum levels in premature neonates fed Feminar supplemented with whey proteins]

Free amino acids were examined in plasma of premature infants fed adapted dried milk (15 and 22 infants resp.) and breastfed infants (20). The dried milk was Feminar (casein: whey protein 40:60) where the whey (serum) proteins were prepared either by thermal denaturation (F-TD) or by ultrafiltration (F-U). The concentration of different amino acids in infants fed F-TD were closer to those recorded in breastfed infants, as compared with F-U where greater differences (higher values) were recorded.

[Ultrasonic evaluation of multicystic ovaries in childhood]

High resolution real-time ultrasound showed multicystic pattern of the ovaries in 30 prepubertal infants. In three neonates the cystic abdominal tumour was known since the 33/34 gestational week; the sonographic diagnosis of ovarian cyst was confirmed by the pathologist. The ultrasound study was carried out in 10 patients with suspected idiopathic precocious puberty, whereas in 17 patients, almost 2/3 of the remaining 27 girls, the multicystic ovaries were a fortuitous finding. The maximal diameter of the cysts was 8 mm in multicystic ovaries, one solitary cyst was 13 mm. The follow-up study of 13 patients demonstrated a change in the sonographic pattern. The multicystic structure of the prepubertal ovary is a common finding and must be interpreted as normal.

[Sonography of the thyroid gland in children]

The total volume of the thyroid gland is 1.2/1.0 ccm in male/female newborns; it increases with age up to 7.4 ccm in boys and 7.5 ccm in girls (13-16 years). The relation of total thyroid volume and body surface area is without a significant sex difference 4.5/4.8 ccm/sqm in newborn and about 4.8 ccm/sqm in children aged more than 9 years. Thyroid disorders to be discussed are a cyst, a nodule with an echo-free centre, connatal athyreosis and goitre.

[How sensitive and specific is the determination of gliadin antibodies in the serum of patients with severe damage of small intestine mucosa?]

Serum antigliadin antibodies of the IgG- and IgA-class were investigated by an ELISA-test in healthy children, children suffering from coeliac disease and children with recurrent diarrheas. The sensitivity and specificity of positive antibody-titres for the diagnosis of coeliac disease were evaluated. The investigation of antigliadin antibodies proved to be a useful instrument for the diagnosis of acute coeliac disease as well as for the follow-up of such patients. The limitations of this method are pointed out.

Islet cell antibodies and viral infections

The sera of 127 non-diabetic children after mumps-infection were investigated for the presence of islet cell antibodies and islet cell surface antibodies. The study also included 4 children who developed diabetes mellitus shortly after an active mumps vaccination. 21 of the non-diabetic children and four of the vaccinated children exhibited islet cell cytoplasmic antibodies. Islet cell surface antibodies were observed more frequently, namely in 43 out of 68 patients studied after mumps infection and in 32 out of 44 patients studied after different viral diseases. With one exception, none of the mumps-infected children and none of the other viral infected patients developed diabetes mellitus.

Islet cell antibodies, circulating immune complexes and antinuclear antibodies in diabetes mellitus

Serum samples of patients suffering from diabetes mellitus were tested for complement-fixing and non complement-fixing islet cell antibodies, antinuclear antibodies and circulating immune complexes. There was no correlation between circulating immune complexes or antinuclear antibodies and secondary diabetic complications. A close relationship was found between the ICA titer and complement fixation of ICA. The incidence of ICA at the onset of the disease was higher in the patients under the age of 10 (85%) and decreased with increasing age up to 45% in patients with onset above age 20. In five patients being positive and four patients being negative for ICA at onset of disease, changes and fluctuations in antibody titers were observed over 38 months. Since manifestation of diabetes mellitus is believed to be an endpoint of a long lasting autoimmune process, our observations indicate that the autoimmune phenomena are merely indicators of ongoing autoimmune reactions not necessarily reflecting the state of autoaggression or islet cell destruction.

[Diagnosis and therapy of candidiasis in the premature infant]

Extension of intensive care seems to have increased the risk of systemic candida infection. We report the incidence of systemic candida infection in 8 low-birth-weight infants (gestational age 27-32 weeks, birth weight 710-1,550 g). All infants required respiratory treatment. Various silastic catheters were inserted. Antibiotic therapy was started on the first day of life, usually a combination of ampicillin and gentamycin. Candida septicaemia was diagnosed at the age of 8-69 days of life based on blood and urine cultures, in two children at autopsy. There were no specific clinical symptoms in regard to candida infection. Sonographic technique revealed hydronephrosis in 3 infants due to candida mycelium. Antimycotic therapy included amphotericin B (dosage 0.44-1.0 mg/kg X day) and 5-fluorocytosine (80-100 mg/kg X day) as well as a monotherapy of 5-fluorocytosine (100-200 mg/kg X day). Four children were treated successfully. We like to advice a regular search for candida in urine, blood, tracheal secretion, stool and skin in low-birth-weight infants under intensive care conditions. If antimycotic therapy is started in time, therapy can be successful.

[Carnitine in the treatment of methylmalonic aciduria (MMA)]

Carnitine metabolism was studied and a therapeutic trial with L-carnitine was undertaken in 3 patients with methylmalonic aciduria. Prior to carnitine therapy, the concentration of free carnitine was diminished and the contribution of acylated carnitine to total carnitine was increased in both plasma and urine. During a metabolic crisis, in a patient the intravenous administration of L-carnitine greatly increased, the urinary excretion of acylcarnitine and the plasma concentration of methylmalonic acid fell. In all 3 patients, the chronic oral administration of L-carnitine resulted in the normalisation of the plasma free carnitine concentrations and an increased urinary excretion of carnitine esters. One patient clearly showed clinical improvement under carnitine therapy. The administration of L-carnitine to patients with methylmalonic aciduria results in an increased elimination of toxic propionyl groups and thus to a regeneration of intramitochondrial CoA. In conjunction with appropriate dietary measures, this may improve the metabolic situation of these patients.

[Autoimmunity and viral infections in type-I diabetes mellitus]

Cytoplasmic islet-cell antibodies, insulin antibodies, islet-cell surface antibodies and islet-cell specific cytotoxicity were determined in serum of the following groups: 131 patients with type I diabetes, 19 with type II diabetes, 29 with mumps, 29 with enterovirus infections, 18 with measles and 28 healthy controls. Cytoplasmic islet-cell antibodies were found predominantly in type I diabetics. Islet-cell surface antibodies, on the other hand, were relatively frequently (60-80%) present in sera of both diabetics and patients with various virus infections. Islet-cell specific cytotoxicity in vitro was found not only in sera of diabetics, but also of patients with mumps or enterovirus infections. Sera of five patients with measles, however, had cytotoxic reactions comparable to those of the controls. These results suggest that cytotoxic antibody reactions against islet cells in vitro occur also in sera of non-diabetic patients. Under certain circumstances, infections which induce such immune reactions may be of significance in the pathogenesis of diabetes.

Islet cell antibodies and the development of diabetes mellitus in relation to mumps infection and mumps vaccination

Islet cell antibodies were investigated in 127 non-diabetic children after mumps infection and in four out of seven children who developed diabetes mellitus shortly after active mumps vaccination. Twenty-one of the children who had mumps and all four vaccinated children who were tested had islet cell cytoplasmic antibodies. In contrast, islet cell surface antibodies were detected in 43 out of 68 patients with mumps infection and in 32 out of 44 patients with other viral diseases. All but one mumps-infected child and all the other viral infected patients investigated did not develop diabetes mellitus. The mumps-infected ICA positive children did not show those HLA-frequencies associated with Type 1 diabetes.

Complications of mumps infection, islet-cell antibodies, and HLA

To investigate whether the development of islet-cell antibodies (ICA) in the course of mumps infection is associated with a "diabetes-like" immunogenetic condition, 45 children with mumps complications as well as 56 children with insulin-dependent diabetes mellitus (IDDM) were typed for HLA ABC and DR antigens. ICA were detected in 14 out of 35 mumps patients. In the IDDM group, significant deviations from antigen frequencies of normal controls were observed for HLA Bw39, DR2, DR3, and DR4. In contrast, in ICA positive mumps patients, the frequency of these antigens was normal, but Aw24 was significantly increased. Thus, no immunogenetic similarities of both groups of patients could be detected.