Evaluating Sex and Age Differences in ADI-R and ADOS Scores in a Large European Multi-site Sample of Individuals with Autism Spectrum Disorder

Research on sex-related differences in Autism Spectrum Disorder (ASD) has been impeded by small samples. We pooled 28 datasets from 18 sites across nine European countries to examine sex differences in the ASD phenotype on the ADI-R (376 females, 1763 males) and ADOS (233 females, 1187 males). On the ADI-R, early childhood restricted and repetitive behaviours were lower in females than males, alongside comparable levels of social interaction and communication difficulties in females and males. Current ADI-R and ADOS scores showed no sex differences for ASD severity. There were lower socio-communicative symptoms in older compared to younger individuals. This large European ASD sample adds to the literature on sex and age variations of ASD symptomatology.

High incidence of pandrug-resistant Acinetobacter baumannii isolates collected from patients with ventilator-associated pneumonia in Greece, Italy and Spain as part of the MagicBullet clinical trial

OBJECTIVES

To investigate the molecular epidemiology, antimicrobial susceptibility and carbapenem resistance determinants of Acinetobacter baumannii isolates from respiratory tract samples of patients diagnosed with ventilator-associated pneumonia (VAP) who were enrolled in the MagicBullet clinical trial.

METHODS

A. baumannii isolates were prospectively cultured from respiratory tract samples from 65 patients from 15 hospitals in Greece, Italy and Spain. Susceptibility testing was performed by broth microdilution. Carbapenem resistance determinants were identified by PCR and sequencing. Molecular epidemiology was investigated using rep-PCR (DiversiLab) and international clones (IC) were identified using our in-house database.

RESULTS

Of 65 isolates, all but two isolates (97%) were resistant to imipenem and these were always associated with an acquired carbapenemase, OXA-23 (80%), OXA-40 (4.6%), OXA-58 (1.5%) or OXA-23/58 (1.5%). Resistance to colistin was 47.7%. Twenty-two isolates were XDR, and 20 isolates were pandrug-resistant (PDR). The majority of isolates clustered with IC2 (n = 54) with one major subtype comprising isolates from 12 hospitals in the three countries, which included 19 XDR and 16 PDR isolates.

CONCLUSIONS

Carbapenem resistance rates were very high in A. baumannii recovered from patients with VAP. Almost half of the isolates were colistin resistant, and 42 (64.6%) isolates were XDR or PDR. Rep-PCR confirmed IC2 is the predominant clonal lineage in Europe and suggests the presence of an epidemic XDR/PDR A. baumannii clone that has spread in Greece, Italy and Spain. These data highlight the difficulty in empirical treatment of patients with A. baumannii VAP in centres with a high prevalence of carbapenem-resistant A. baumannii.

Increased prevalence of proliferative retinopathy and cardiovascular autonomic dysfunction in IDDM patients with proteinuria

The purpose of the present cross-sectional clinical study was to evaluate the prevalence of retinopathy in Type 1 diabetic patients without nephropathy and with different degrees of nephropathy. In addition we investigated the association between retinopathy, nephropathy, and other variables, and studied the importance of cardiovascular autonomic dysfunction to these conditions. 76 Type 1 diabetic patients were investigated. All patients were initially selected on the basis of body weight, and 47 proteinuric patients were further selected for age, diabetes duration and the duration of insulin treatment (see Table 1). Proteinuric diabetic patients were categorized by degree of nephropathy, i.e. for incipient nephropathy (proteinuria of less than 0.5 g/day), for overt nephropathy (proteinuria of more than 0.5 g/day), and for renal failure (serum creatinine of more than 103 mumol/l). Retinopathy was assessed by ophthalmoscopy. Cardiovascular autonomic dysfunction (CAD) was assessed by heart rate variations, 30:15 ratios, the Valsalva maneuver, and systolic blood pressure fall upon standing. Our findings revealed increased prevalence of retinopathy in patients with more advanced stages of nephropathy. CAD abnormalities exhibited increased prevalence among proteinuric patients. Our data clearly revealed differences between proteinuric and non-proteinuric patients. In both proteinuric and non-proteinuric patients there were found correlations of retinopathy with diabetes duration, and only in proteinurics was retinopathy correlated with kidney function, systolic blood pressure and CAD findings. In patients in identical stages of nephropathy, increased prevalence of CAD abnormalities was shown in patients suffering from proliferative retinopathy. Thus our data suggest that CAD abnormalities might be related in some way to both the proliferative retinopathy and to diabetic nephropathy.

Relationships between glucose variability and conventional measures of glycemic control in continuously monitored patients with type 2 diabetes

Given the importance of glucose variability in the development of diabetic complications, the present study used continuous glucose monitoring (CGM) to determine various indices of glucose variability and to investigate their relationships with conventional measures of chronic sustained hyperglycemia. We examined 53 women and 61 men, aged 36-79 years afflicted with type 2 diabetes for 1-24 years. The following indices of glycemic variability were computed from CGM data sets: mean amplitude of glycemic excursions (MAGE), CGM glucose range, interquartile range (IQR), SD-score, and average daily risk range (ADRR). CGM measurements and self-monitored blood glucose (SMBG) records were used to calculate mean CGM sensor glucose and mean SMBG, respectively. In simple correlation analysis, the indices of glucose variability showed weak correlations with HbA1c: MAGE (r=0.27, p <0.01), CGM glucose range (r=0.21, p <0.05), IQR (r=0.31, p <0.01), SD-score (r=0.34, p<0.001), and ADRR (r=0.24, p<0.05). These indices were found to differ at identical HbA1c among several patients, as reflected by diurnal excursions of different frequency and magnitude. With the exception of ADRR, stronger correlations were found between mean SMBG and the other variability indices (r=0.51-0.63, p<0.01 for all). CGM provides various indices of glycemic variability not captured by conventional measures of glycemic control. Detection of the location and the magnitude of glucose fluctuations by CGM should aid in optimal treatment of glycemic disorders in type 2 diabetes.

Peripheral arterial disease in diabetes mellitus type 1 and type 2: are there different risk factors?

BACKGROUND

Diabetic patients have increased prevalence of peripheral arterial disease (PAD). It is not clearly shown whether the prognostic factors are identical in relation to the type of diabetes. This study was done to compare the associations of PAD with risk factors and with micro- and macrovascular complications of inpatients with type 1 and type 2 diabetes.

METHODS

In a retrospective cross-sectional study 1087 patients with type 1 diabetes and 1060 patients with type 2 diabetes were examined. PAD was diagnosed when ankle-brachial-pressure-index (ABI) was < 1.0. In cases with incompressible arteries (mediasclerosis) pulse wave forms were analyzed. Multivariate logistic regression analysis was applied to evaluate the impact of different variables on PAD risk, after adjusting for different variables separately.

RESULTS

In both types of diabetes (type 1 vs. type 2) PAD risk (odds ratio; OR) was increased in the presence of coronary heart disease (OR 9.3 vs. 3.5), diabetic nephropathy (OR 3.0 vs. 2.8), neuropathy (OR 7.9 vs. 1.8), foot ulceration (OR 8.9 vs. 5.5), increased daily insulin requirement > 0.6 mu/kg b.w. (OR 5.2 vs. 2.9), diabetes duration of 20-29 years (OR 28.9) and > 30 years (OR 51.1) in type 1 diabetes, and diabetes duration of 10-19 years (OR 3.8) and > 20 years (OR 4.3) in type 2 diabetes. In type 2 diabetes, PAD risk was associated with microalbuminuria (OR 2.1), macroalbuminuria (OR 3.3), background retinopathy (OR 1.9), proliferative retinopathy (OR 2.8), increased triglycerides (TG) (OR 1.7) and decreased HDL-cholesterol (HDL-C > 0.90 mmol/l: OR 0.49).

CONCLUSIONS

PAD risk factors and micro- and macrovascular comorbidity are very similar in type 1 and type 2 diabetes.

Maculopathy in patients with diabetes mellitus type 1 and type 2: associations with risk factors

AIM

To examine possible relation between diabetic maculopathy and various risk factors for diabetic complications in patients with diabetes mellitus type 1 and type 2.

METHODS

Cross sectional study of two cohorts of diabetic patients, comprising 1796 patients with type 1 diabetes (mean age 47 years, mean duration of diabetes 24 years) and 1563 patients with type 2 diabetes (mean age 62 years, mean duration of diabetes 16 years). Retinopathy levels (R0-RV) and maculopathy were assessed by fluorescence angiography and fundus photography and binocular biomicroscopy. Diabetic neuropathy was assessed by means of computer assisted electrocardiography and by thermal and vibratory sensory examination. Patients were classified as normoalbuminuric (<20 microg/min) or microalbuminuric (20-200 microg/min) according to their albumin excretion rates measured in urine collected overnight. Using univariate analyses, the effects of selected patient characteristics on the presence of maculopathy were evaluated. Multiple logistic regression analyses were performed to determine independent effects of risk variables on diabetic maculopathy.

RESULTS

Background retinopathy (RII) was found to be present in 28% of type 1 diabetic patients and in 38% of type 2 diabetic patients. The prevalence of maculopathy in these patients was remarkably high (42% in type 1 and 53% in type 2 diabetic patients). Patients with maculopathy had significantly impaired visual acuity. Multiple logistic correlation analysis revealed that in both types of diabetes maculopathy exhibited independent associations with duration of diabetes and with neuropathy (p <0. 01); in type 1 diabetic patients there were significant associations with age at diabetes onset, serum triglyceride and total cholesterol levels (p <0.05); in type 2 diabetes with serum creatinine levels and with hypertension (p <0.05).

CONCLUSIONS

Irrespective of the type of diabetes, diabetic patients with long standing diabetes have a high risk for the development of diabetic maculopathy. Diabetic maculopathy is closely associated with diabetic nephropathy and neuropathy and with several atherosclerotic risk factors which suggests that these factors might have an important role in the pathogenesis of maculopathy. However, prospective trials are necessary to evaluate the predictive value of such factors. The findings of the present cross sectional study reinforce the arguments of previous studies by others for tight control of hypertension and hyperglycaemia.

Relations between diabetic retinopathy and cardiovascular neuropathy--a cross-sectional study in IDDM and NIDDM patients

The pathogenetic process of diabetic retinopathy and the role of different systemic risk factors in IDDM and NIDDM is not completely understood. The aim of the present cross-sectional clinical study was (1) to compare the prevalence of systemic risk factors for diabetic retinopathy in IDDM and NIDDM patients, (2) to determine relations between these risk factors and the degree of retinopathy and (3) to evaluate the relationship between retinopathy and neuropathy. The study included 1,218 IDDM and 784 NIDDM patients attending our hospital during 1994. The mean diabetes duration was 15.4 and 13.2 years, respectively. IDDM patients with proliferative retinopathy were characterized by higher mean age of 46.4 +/- 1.08 vs. 21.8 +/- 0.42 years and longer diabetes duration of 30.0 +/- 0.79 vs. 7.7 +/- 0.26 years. Among the NIDDM patients, those ones with proliferative retinopathy had the lowest mean age of 40.5 +/- 1.42 vs. 49.7 +/- 0.61 years (p < 0.01) at diabetes manifestation. There was no statistical difference between mean HbA1c concentrations in relation to retinopathy stages. Albumin excretion was increased in both IDDM and NIDDM patients with proliferative retinopathy (p < 0.01) along with increased BMI of IDDM and increased insulin requirement of NIDDM patients (p < 0.01). Multiple regression analysis showed that proliferative retinopathy with the inclusion of non-proliferative retinopathy of IDDM and NIDDM patients was significantly correlated with diabetes duration, albumin excretion, somatic and autonomic neuropathy (p < 0.01). In NIDDM patients proliferative retinopathy with the inclusion of non-proliferative retinopathy was correlated with the age at diabetes manifestation and with cholesterol levels (p < 0.05). In IDDM and NIDDM patients proliferative retinopathy was found to be correlated with somatic and autonomic neuropathy, albumin excretion (p < 0.01) and hypertension (p < 0.05). The importance of the significant correlation of autonomic neuropathy both with background and proliferative retinopathy in IDDM and NIDDM patients needs to be prospectively investigated.

How the brain processes complex words: an event-related potential study of German verb inflections

Event-related brain potentials (ERPs) were recorded as German-speaking subjects read verbs in correct and incorrect participle forms. The critical words were presented in three different versions to three different groups of subjects, as part of a simple sentence, in a word list, and embedded in a story; for each version separate ERPs were recorded. Three types of verbs were investigated, regulars, irregulars and nonce verbs. We compared correct regular and irregular participles with incorrect ones; the latter had -(e)n on verbs that actually take -t participles (* getanz-en), or -(e)t on verbs that require -(e)n (* gelad-et). For the nonce verbs, we compared participles with the unexpected -(e)n ending with the expected -t participle forms. The ERP responses were very consistent across the three versions of the experiment: (i) incorrect irregular participles (* gelad-et) elicited a left frontotemporal negativity; (ii) incorrect regulars (* getanz-en) produced no differences to the correct ones; (iii) nonce verbs were associated with an N400 component but did not show a difference between expected and unexpected endings. We will interpret these findings with respect to psycholinguistic models of morphological processing and argue that the brain processes regularly inflected words differently from irregularly inflected ones, the latter by accessing full-form entries stored in memory and the former by a computational process that decomposes complex words into stems and affixes.

Increased prevalence of elevated urinary albumin excretion rate in type 2 diabetic patients suffering from ischemic foot lesions

Present cross-sectional clinical study was aimed at the evaluation the prevalence of cardiovascular risk factors in Type 2-diabetics suffering from different clinical manifestations of diabetic foot lesions due to peripheral vascular disease and/or diabetic neuropathy. 1025 non-insulin-dependent (Type 2) diabetics (NIDDM) of both sexes were investigated. Patients were classified in Type II diabetes without peripheral vascular disease and foot lesions (group 0, controls), with macroangiopathic related foot lesions (group 2), with neuropathic foot lesions (group 3), and with mixed neuropathic-ischemic foot lesions (group 4). Apart from urinary albumin excretion rate (UAE), the following micro- and macroangiopathic risk factors and diseases were taken into account: Hypertension, degree of metabolic control (HbA1c), lipid concentrations, duration of diabetes, retinopathy, clinical nephropathy.

RESULTS

In the total population the UAE was significantly (p < 0.01) correlated with duration of diabetes, serum creatinine, hypertension, age, lipid concentrations, HbA1c and insulin requirement. In comparison to Type II diabetic patients without peripheral vascular disease (group 0) and with neuropathic foot lesions (group 3), subjects with ischemic (group 2) and mixed neuropathic-ischemic foot lesions demonstrated an increased prevalence of pathological UAE, which was associated with a higher frequency of clinical nephropathy, retinopathy, an older age and longer duration of diabetes. It is concluded that microalbuminuria in Type 2 diabetes reflects both the existence of diabetic nephropathy and peripheral vascular disease which is often associated with the insulin resistance syndrome.

Innervation of the skin of the forearm in diabetic patients: relation to nerve function

Complications of diabetes include sensory and autonomic neuropathy. The aim of the present paper was to study the degree of sensory and autonomic neuropathy and correlate these findings with the distribution and density of neuropeptidergic nerve fibers in the skin of the forearm of diabetic patients and healthy controls. We investigated 30 diabetics (24 type 1 and 6 type 2) and compared them with 13 healthy controls. There were no differences between the groups with respect to density and distribution of nerve fibers displaying immunoreactivity to the pan-neuronal marker PGP 9.5 and sensory and parasympathetic neuropeptides (substance P, calcitonin gene-related peptide and vasoactive intestinal peptide). By contrast, nerve fibers containing neuropeptide Y, a marker of sympathetic neurons, were reduced in number in the diabetic patients. C-fiber function (measured as the axon-reflex-evoked flare response) became impaired with increasing age in all subjects. The diabetic patients, however, showed a reduced flare compared to age-matched healthy controls. The reduction was particularly prominent in the younger patients (20-50 years). There was a greater reduction of the flare in neuropathic patients than in non-neuropathic patients, but there was no correlation between the degree of functional impairment and the duration of the disease.

Treatment of acne vulgaris with salicylic acid pads

Most cases of acne vulgaris are either mild or moderate in severity and well-suited for treatment with nonprescription agents that are safe, effective, and convenient to use. A review of four clinical studies and a comedolytic assay attests to the efficacy and safety of 0.5% and 2% solutions of salicylic acid for the treatment of acne vulgaris. In three placebo-controlled studies and a comedolytic assay, salicylic acid pads reduced the number of primary lesions and thereby the number and severity of all lesions associated with acne. Comparative studies of salicylic acid have shown it to be superior to benzoyl peroxide in reducing the total number of acne lesions. Adverse reactions to salicylic acid are generally limited to mild, local irritation occurring in a minority of patients.

Autoimmune reactions in a patient with malignant insulinoma treated by multiple low dose streptozotocin

A 66-year-old female patient with a malignant insulinoma was treated with streptozotocin (STZ; Zanosar) in 5 cycles every 4 weeks as 5 day courses with an intravenous dosage of 850 mg per day. Under this treatment hypoglycemic episodes decreased continuously in number as well as severity and - after a delay of 12 months after the last treatment - an overt diabetes mellitus appeared. Plasma insulin concentrations dropped immediately after starting of STZ therapy. On the other hand, islet cell surface antibodies and their complement-dependent cytotoxicity increased continuously, being at their highest 6 months after termination of STZ treatment. Thus, STZ is able to induce a specific immune response against islet cells with a progressive damage of malignant insulin producing cells.

The effect of antihypertensive treatment on kidney function in insulin-dependent (type I) diabetics with renal failure

Diabetic nephropathy is the dominant cause of hypertension in insulin-dependent diabetics, and long-term rigid antihypertensive treatment inhibits the progression of nephropathy, probably even when there is renal insufficiency. In our clinical study 14 insulin-dependent diabetics with diabetic nephropathy and renal failure (glomerular filtration rate [GFR] 0.39 +/- 0.12 ml/sec) underwent rigid blood pressure treatment. Antihypertensive therapy included furosemide, propranolol, dihydralazine and nifedipine. The whole group showed a lowering in mean blood pressures from 150.1 +/- 2.3/91.3 +/- 1.4 mm Hg to 139.8 +/- 3.1/86.5 +/- 2.0 mm Hg (p less than 0.01). During the observation period the mean decline in glomerular filtration rate decreased from -0.022 +/- 0.003 ml/sec per month to -0.010 +/- 0.007 ml/sec per month. In 10 out of 14 patients with very advanced nephropathy the further decline of GFR halted markedly. Thus, vigorous blood pressure control is able to postpone endstage renal disease even in advanced diabetic nephropathy.

Causes of death in insulin-dependent diabetic patients treated with hemodialysis

Causes of death were analyzed for 63 diabetic patients treated with hemodialysis. In all cases, autopsy-based death certificates were evaluated. The causes of death were compared during the periods 1969 through 1979 versus 1980 through 1987, and the causes of death in patients who died after less than 18 months versus those who died greater than 18 months after starting hemodialysis treatment. Our population of decreased diabetics had a mean age of 41.8 years, with a mean of 23.4 years of diabetes duration. The mean age at manifestation of diabetes was 18.2 years. Cardiac failure has been shown to be the most prevalent cause of death (55.6%), while sepsis accounted for 20.6% of the deaths. In both the period from 1969 through 1979 and that from 1980 through 1987, cardiac failure was identified as the commonest cause of death, with an equal proportion of septic causes (i.e., 20% versus 21.05%). When comparing causes of death among diabetics on hemodialysis for less than 18 months versus those receiving greater than 18 months of treatment, cardiac failure was responsible for 54% versus 61.5% of deaths. Septic causes were found to be more prevalent after a longer duration of treatment (i.e., 30.8%). Therefore, it is concluded that to prevent cardiac deaths, blood pressure control has to be as tight as possible in patients with diabetic kidney disease. To prevent late-occurring septic deaths, good nutritional status in patients undergoing hemodialysis seems to be of importance. The prevention of macroangiopathy in diabetes represents a major medical problem that needs to be solved.

Frequency and therapy of end-stage renal disease due to diabetic nephropathy in the German Democratic Republic

The prevalence of diabetic nephropathy among the German Democratic Republic (GDR) population is substantial, as is true of many other countries. An epidemiologic survey performed in the county of Neubrandenburg revealed increased creatinine values in 44.9% of diabetics with diabetes duration greater than 15 years, and in 24.9% of those with the disease less than 15 years. Given these data, the prevalence of renal insufficiency due to diabetic nephropathy is estimated as 27/100,000 in diabetics with greater than 15 years, and 9/100,000 in diabetics with less than 15 years of diabetes, including only patients up to the age of 49 years; this must be substantially greater when considering all age groups. Only 13% of all patients on chronic hemodialysis are diabetics. Although we offer each of our nephropathic diabetics such kidney replacement therapies as dialysis and transplantation, a substantial number of diabetics are not treated, presumably due to advanced macrovascular complications.

Importance of cardiovascular autonomic dysfunction in IDDM subjects with diabetic nephropathy

Diabetic nephropathy (DNP) is associated with increased cardiovascular mortality. This may be contributed to by associated cardiovascular autonomic dysfunction (CAD). The aim of this study was to investigate the prevalence of CAD in patients with insulin-dependent diabetes mellitus (IDDM) at different stages of DNP. We studied patients with incipient DNP (group 1, n = 10), overt DNP (group 2, n = 20), renal insufficiency (group 3, n = 27), and end-stage renal failure (group 4, n = 12) and compared them with 30 IDDM patients without clinical signs of DNP (group 5) and with 17 nondiabetic controls (group 6). All groups were matched for age and diabetic groups were matched for duration of diabetes. Assessments of CAD included beat-to-beat variation during forced respiration, heart-rate response to standing, heart-rate response to Valsalva maneuver, basal heart rate, and blood pressure response to standing. Clinical evaluation included assessment of the history and an examination for peripheral polyneuropathy. We found mean impairment of heart-rate variation during respiration, in response to Valsalva maneuver, and in heart-rate response to standing in all diabetic groups compared with nondiabetic controls (P less than .01). Heart-rate responses differed significantly between patients with renal insufficiency (groups 3 and 4) and with other patient groups (group 5; P less than .01). CAD was shown to be more prevalent in patients with DNP, more so as DNP progresses. To some extent, it is already present in the early stages of DNP. CAD may be a contributory factor for increased cardiovascular mortality in patients with DNP.(ABSTRACT TRUNCATED AT 250 WORDS)

The progression of diabetic nephropathy in type I diabetics: relationship to metabolic control and blood pressure

This study was designed to investigate the importance of risk factors such as hyperglycemia and elevated systolic and diastolic blood pressures on the progression of renal insufficiency in diabetics suffering from diabetic nephropathy. Seventeen patients with Type I, insulin-dependent diabetes mellitus (IDDM) (8 women and 9 men) undergoing chronic hemodialysis were investigated by retrospective follow-up and compared with 17 age and sex matched IDDM patients without diabetic nephropathy (controls). According to the time interval of creatinine increase from 200 to 600 mumol/l, the patients were divided arbitrarily into two groups with rapidly (group I less than 20 months) or slowly progressive (group II greater than or equal to 20 months) renal insufficiency. This period was 13.4 +/- 2.05 months in group I (age 36.67 +/- 2.47 years, diabetes duration 23.55 +/- 2.37 years) and 32.75 +/- 4.34 months in group II (age 40.62 +/- 2.63 years, diabetes duration 26.62 +/- 2.63 years, P.n.s.), respectively. The IDDM patients studied exhibited individually differing progressions of renal insufficiency at different times after manifestation of diabetes. After 15 years of diabetes duration, both risk factors, that is blood pressure and blood glucose concentrations, were elevated in nephropathic diabetics when compared with controls (p less than 0.01). During the phase of declining kidney function, mean blood pressures were found to be higher in IDDM patients with rapid progression of renal insufficiency when compared with slowly progressing diabetics. Although both risk factors were related to diabetic nephropathy, during the phase of renal insufficiency hypertension appeared to be more closely related to the further deterioration of kidney function.

[Preparation and implementation of kidney transplantation in patients with terminal renal failure and type I diabetes]

The newest results of transplantation in diabetic nephropathy (diabetics type I) of the world were described according to the data of the EDTA and after the symposium in The Hague. Own experience in the field of transplantation carried out in diabetics needing insulin with terminal renal failure were critically evaluated. The investigations in several centres of the GDR concerning the decompensation of diabetic nephropathy show that it is necessary to perform a three- to six-month creatinine control in long-term diabetics from the 15th year of the disease and from a serum value of 200 mumol/l to carry out in good time a common diabetological and nephrological control with test concerning the fitness for a kidney transplantation. Only by this means the conditions for an improvement of the consequence of transplantation may be achieved.

Muscular exercise in type I-diabetics. II. Hormonal and metabolic responses to moderate exercise

In Type I-diabetics metabolic response to exercise is largely determined by the availability of exogenous insulin. The aim of the present study was to assess the metabolic response to moderate exercise of 24 insulin-dependent (Type I-) diabetics treated by multiple subcutaneous injections of short acting insulin. Differences in insulin availability (hypo- [trial A] or hyperinsulinemia [trial B]) resulted from the different periods of time that had elapsed since the previous insulin injection, i.e., after 3 hours (trial A), and 1 hour (trial B). Bicycle ergometer tests at intensities up to 75% VO2max, were carried out with patients and controls. Plasma glucose, FFA, glycerol, alanine, growth hormone and glucagon levels were measured during a period of 85 min. In both trials, physical exertion did not have a significant statistical effect on the glucose concentration in the blood of hypo- and hyperinsulinemics. Surprisingly, despite the different insulin availabilities FFA, glycerol, alanine and glucagon concentrations were not statistically different in either trial and appear similar to those of healthy controls. A normal metabolic response to exercise can thus also be expected in Type I-diabetics, provided adequate insulin is available. When compared to controls, growth hormone concentrations were found to have increased during exercise. These experimental data strongly suggest the great necessity of adequate insulin availability in order to obtain normal metabolic responses to exercise in insulin-dependent diabetics. Despite certain degrees of hypo- or hyperinsulinemia, moderate exercise did not cause any marked metabolic derangements. This type of moderate exercise is therefore recommended for improving metabolic control in such patients.

Clinical course in insulin-dependent diabetics undergoing hemodialysis

Nephropathy continues to be the most serious complication in type I-diabetics. When we started chronic hemodialysis in these patients 15 years ago survival figures were poor. Later on the survival rate for diabetics undergoing hemodialysis has improved progressively. The aim of this report was to present our own experience in hemodialysis treatment of insulin-dependent diabetics. The cumulative survival rate of 46 insulin-dependent diabetics undergoing hemodialysis has increased progressively and now amounts to 70% after one year, and 50% after two years of treatment. At the same time we could attain a certain improvement of metabolic control. Nutrition has also been improved, as indicated by increased transferrin (p less than 0.05) and stable serum protein levels. Systolic blood pressure control became better (p less than 0.05) but, a fluid overload was still present. Here, further improvements are necessary to increase the survival rate. Therefore, the survival of diabetic patients with hemodialysis may be approaching that of non-diabetics. In some patients retinopathy was improved after one year of treatment. Despite a better prognosis for survival in diabetics treated by chronic hemodialysis we suggest that the successful renal transplantation should be the treatment of choice in patients suffering from diabetic nephropathy. In general, hemodialysis and renal transplantation should be started earlier than hitherto, i.e. already at creatinine levels of about 600 mumol/l, and at urea levels of 30 mmol/l. Strict metabolic and blood pressure control, as well as early laser coagulation therapy of retinopathy should be instituted for patients with creatine levels above 200 mumol/l, in close cooperation of a diabetologist, nephrologist, and ophthalmologist. This will be our future therapeutic strategy for these patients.

Relationship between insulin secretion and pancreas morphology in subjects with chronic pancreatitis

In order to investigate whether a relationship exists between in vivo insulin secretion and islet mass, 8 patients suffering from severe chronic relapsing pancreatitis were studied before and after pancreatectomy by glucose-glucagon-test (per os 1.75 g glucose; i.v. glucagon 0.01 mg/kg b.w.) and by intravenous glucose-tolerance-test (iGTT) (i.v. glucose 0.33 g/kg b.w.). Postoperative in vitro assessments of pancreatic insulin and alpha-amylase content were performed, and morphometric studies were carried out. Patients were characterized by reduced c-peptide secretion when compared with healthy subjects. The c-peptide response to the glucose-glucagon-test correlated well with the morphometrically estimated exocrine and islet tissue mass (P less than 0.05) and with the content of insulin and amylase in the tissue. The findings suggest that in subjects suffering from severe chronic relapsing pancreatitis the maximal insulin response might represent a parameter for the patient's islet mass.

[Problems of monitoring metabolism of type I diabetics undergoing hemodialysis treatment]

The metabolic control of nephropathic type I diabetics dependent on dialysis is especially difficult and can be rendered more difficult by the procedure of haemodialysis, mainly due to the use of glucose-free dialysis fluid. The blood glucose level is reduced, resulting in hypoglycaemia. The purpose of this study was to compare the effects of various methods of compensating for the glucose loss on blood glucose homoeostasis. 5 dialysis-dependent type I diabetics on equal supplies of carbohydrates and insulin received extra glucose in the dialysis fluid and as infusions before and after dialysis. All 3 experimental regimens prevented reduction of the blood glucose level due to dialysis, without any significant differences between them. The choice of method can be made according to the dialysis equipment used.

[Cause and treatment of hydrocephalus in newborns and infants]

The history and classification of the various types of hydrocephalus are outlined and the mechanisms as well as causes of infantile hydorcephalus are discussed. Acoording to aetiology the possible operative treatments are described and special mention is made of ventriculocardiac shunting with its indications, advantages and complications. Finally, the results that may be expected from operative treatment of infantile hydrocephalus are studied and the neuropsychological aspect is emphasized.

Ergometric heart rate, blood pressure and work capacity (PWC170) in type I diabetics with diabetes-specific microangiopathy

118 male and 68 female type I diabetics and 25 male and 23 female nondiabetic healthy controls were compared during submaximal bicycle ergometer tests using four work stages (duration: 6 min each) of 50 W, 75 W, 100 W and a submaximal stage producing a heart rate of 170 min-1. We found that male type I diabetics with and without retinopathy who had significantly higher than normal heart rates both at the start and during the ergometer test also had above normal ergometric blood pressures. Female type I diabetics, in contrast, did not differ significantly from the controls in terms of heart rate before and during the ergometer tests. The PWC170 of all male type I diabetics was, in contrast to that of the female patients, lower than that of the controls. In diabetics with diabetic nephropathy there was no correlation between exercised acceleration of the heart rate and the degree of nephropathy despite their higher heart rates at the beginning and during the ergometer test, but a correlation was found between the ergometrically increased blood pressure and the severity of the diabetic nephropathy. In male type I diabetics cardiocirculatory adaptation to muscular work was reduced, and this reduction became more marked as the degree of diabetic microangiopathy increased. Compared with the controls, the increase in systolic blood pressure evoked by activity on the ergometer in male and female type I diabetics was disproportionate to the actual load and correlated with the degree of diabetic microangiopathy.

Muscular exercise in type I-diabetics. I. Different metabolic reactions during heavy muscular work in dependence on actual insulin availability

The present study focussed on the impact of heavy muscular work upon metabolic homeostasis in insulin dependent (type I) diabetics in situations involving a certain degree of hyper- and hypoinsulinemia. 20 juvenile type I-diabetics were compared with 6 nondiabetic healthy subjects. The diabetics were studied in states of hypo-(trial A) and hyperinsulinemia (trial B) at the start of the exercise. Differences in insulin availability resulted from the different times that had elapsed from the last insulin injection (3 hours in trial A and 1 hour in trial B) before the ergometer test started at 7 a.m. Six diabetics out of 20 patients were studied in both trials A and B to establish the reproducibility of metabolic reactions to the exercise. Bicycle ergometer tests were carried out in the upright position at 5 graded steps of 50 W, 75 W, 100 W, 125 W and a load near to exhaustion. Rest periods of five minutes were allowed between these work periods for taking blood samples before and after each work load. Plasma glucose, FFA, glycerol, lactate, alanine, IRI and HCP concentrations were investigated. The blood pressure at rest and during exercise was measured, and the physical working capacity (PWC170) was calculated according to Wahlund on the basis of the heart rate response to exercise. The results of the exercise tests reflect clearly the different metabolic reactions to heavy muscular work despite the relatively slight differences in insulin availability at the start: --Exhausting muscular work during the hypoinsulinemic state resulted in hyperglycemia and exaggerated lipolysis. --Heavy muscular work in a hyperinsulinemic state resulted in a reduced blood glucose level and antilipolytic reactions in comparison to nondiabetics. These findings suggest the great necessity of an adequate insulin availability during heavy muscular work in juvenile type I-diabetics.

[Effect of a combined diet-training program on the insulin sensitivity of obese persons with normal or disordered glucose tolerance]

The majority of the obese persons is characterized by a disturbed glucose tolerance and an increased insulin secretion. The cause of this apparent contradiction lies in the existence of an insulin resistance. In 23 obese persons (relative weight greater than 120% according to Möhr and Johnson) with normal or disturbed glucose tolerance the effect of a diet restriction lasting 4 weeks (700 kcal/die) or of a combined diet training programme on the body weight, serum lipids, state of conditioning (PWC170) and insulin sensitivity in vivo was investigated. The insulin sensitivity was characterized by means of 1 h insulin infusion test. At comparable peripheral steady state insulin levels the relative decrease of the plasma glucose and free fatty acid concentration is a measure of the insulin sensitivity in vivo. In 9 obese persons with disturbed glucose tolerance observations of the course over 1 year are existing. The finding demonstrate that only a combined diet training programme leads to a significant improvement of the insulin sensitivity and prevails a unique dietary treatment. The measure of the improved insulin effectivity directly correlates with the effect of conditioning. The reduction of the body weight obtained is about double as large in a combined diet conditioning treatment as after a unique restriction of the diet (18% or 10% of the relative weight). Triglyceride and cholesterol levels significantly decrease, the HDL-cholesterol increases in tendency. On the other hand, the results are unsatisfactory after one year. The therapy regime is a promising strategy for the reduction of the insulin resistance in adiposity as a preventive medical measure, provided a good cooperation and motivation on the side of the patient is present.

Use of the artificial B-cell (Biostator) in improving insulin therapy in unstable insulin-dependent diabetes

The present study was designed to improve the conventional subcutaneous insulin treatment of labile insulin-dependent diabetic patients by means of the artificial B-cell (Biostator) during a combination of conventional treatment and a glucose-controlled insulin infusion. Eleven patients with no residual B-cell function and poor metabolic control were studied. All patients were treated as effectively as possible by conventional methods using a combination of regular and intermediate insulin under clinical conditions. In order to determine the inadequacy of previous insulin treatment, all patients were connected to the Biostator, and the profile of daily physical activity was simulated using a bicycle ergometer. Metabolic control was compared during a 6-day period before and after a 30-50-h connection to the artificial B-cell. Using a preselected blood glucose level of 80 mg/dl (4.44 mmol/L), the additional insulin requirement amounted to 45.5 +/- 11.1 U/24 h (N = 6). The day after connection to the artificial B-cell, the patients received a new insulin regimen according to the additional insulin delivery determined by the Biostator. No better metabolic control was achieved and frequent hypoglycemic episodes occurred in this group. Another group (N = 5) was therefore studied at a preselected blood glucose level of 130 mg/dl (7.22 mmol/L). The mean additional insulin delivery by the Biostator was lower (17.2 +/- 2.1 U/24 h; P less than 0.05) and all patients were significantly better equilibrated after the new insulin regimen derived from data given by the Biostator. The ratio of short-acting to intermediate-acting insulin was 3:1; 40% of the total dosage was given in the morning. This study demonstrates that using the Biostator in addition to subcutaneous insulin allows determination of the amount of additional regular insulin that should be administered to improve glycemic control in labile diabetes.

The syringo-hydromyelia and its surgical treatment

In this communication, we present a homogeneous series of 12 cases out of 25 patients having undergone a surgical operation on the posterior fossa for troubles of the cranio-rachidian junction, between 1967 and 1973. Each of these 12 cases presented an Arnold Chiari's malformation and either a "syringo-hydromyelia" (6 times), or "bulbie" (6 times) communicating with the IVth cerebral ventricle. Two cases with hydrocephaly and HIC were drained before the operation on the posterior fossa. Two cases had a ventriculo-atrial drainage 4 and 11 years after the operation for a hydrocephaly revealed by cerebral scanning done in 8 out of 12 of our cases, while the axial transversal tomography of the cervical column and the base of the skull showed a large medulla on the 7 examined cases. Two exitus have to be mentioned 3 and 9 years after the operation, respectively after a cardiac infarction and a pulmonary embolism. With a recoil of 6 to 12 years, we can speak of an improvement and a stabilisation of our cases with the technique chosen.

Investigation of insulin sensitivity in early diabetes III. The effect of a combined physical training and diet programme on body weight, serum lipids and insulin sensitivity in obese asymptomatic diabetics

The effect of a physical training and low caloric diet (700 calories/day) for 4 weeks on insulin sensitivity in vivo, body weight and serum lipids was investigated in 10 obese asymptomatic diabetics (normal fasting plasma glucose and pathological glucose tolerance). Glucose tolerance and insulin secretion pattern were characterized by means of a 2h-glucose infusion test (12 mg/kg/min) primed by an initial injection of 0.33 g/kg glucose. Insulin responsiveness in vivo was estimated by means of a 1h-insulin infusion test (two 30-min. periods of 8 and 16 mU/kg insulin MC-Actrapid, primed by initial injection of 1 and 2 mU/kg, respectively). Under comparable steady-state insulin levels the decrease in plasma glucose and free fatty acids (FFA) was considered as estimate of insulin sensitivity in vivo. Physical working capacity (PWC170) was determined by means of a bicycle ergometer test in stepwise working loads. The training programme consisted of daily 15 min. bicycle ergometer training periods (75% of the maximal working capacity) in the morning and a 1 h mild physical training on a bicycle in the afternoon. After the combined training and diet programme the mean decrease in absolute and relative body weight amounted to 11.9 +/- 1.07 kg and 16.7 +/- 1.2%, respectively. There was a significant decrease of plasma triglycerides whereas the decrease in cholesterol was modest. Physical fitness increased by delta PWC170 of 31.1 +/- 11.6 W. In addition, the combined training and diet programme for 4 weeks resulted in a significant improvement of insulin sensitivity in vivo as indicated by an augmented insulin-induced decrease in plasma glucose and FFA (17.60 +/- 3.91%, vs 36.40 +/- 5.54%; p less than 0.05 and 35.90 +/- 6.95% vs 56.50 +/- 3.63%; p less than 0.05; respectively). Our findings provide direct evidence that physical training and low caloric diet enhance insulin sensitivity in vivo. From the practical point of view our results suggest the potential benefits of physical training in the treatment of obese asymptomatic diabetics.

Immune complexes associated with brain tumors: correlation with prognosis

The presence of circulating immune complexes in the sera of 208 patients with intracranial space occupying lesions was assayed using the C1 q binding test. Twenty-eight percent of 96 high grade glioma patients had immune complexes as compared to 14% of 28 low grade glioma patients. The incidence of immune complexes was found to decrease in the first post-operative month. The presence of immune complexes correlated with shorter survival in a group of malignant glioma patients tested preoperatively. Nineteen patients without immune complexes had a mean survival of 8.6 months as compared to 13 patients with immune complexes who had a mean survival of 4.7 months. These results confirm similar observations in other types of malignancies.

Familial gliomas

The authors report two pairs of siblings who had intracranial malignant gliomas. Genetic influences in the occurence of gliomas are discussed.

Brain abscess after transnasal intracranial penetration of a paint-brush

The case of a brain abscess caused by intracranial, transnasal penetration of a paint-brush is presented. The danger that such foreign bodies may remain unnoticed, especially in children, is stressed. Cure was achieved by total resection of the abscess capsule.

[Anti-tumor antibodies in the blood of patients with gliomas]

Anti-tumor antibodies have been searched for with an antibody-dependent cell-mediated cytotoxicity assay in the sera of patients with glioma. Sera from 60 patients and from 25 normal individuals have been tested against cells from 8 human glioblastoma lines. 10 patients (17%) and 5 controls (20%) were found to have antibodies against one or more tumor lines. There were extensive cross-reaction between the positive sera against the different glioma cells, but the reactivity of each serum was different. The specificity of the antibodies thus detected has been investigated. The positive patients' sera were found to have a similar cytotoxic activity against unrelated tumor and normal cells. Moreover, their activity was absorbed by cells from unrelated tumors and normal platelets. These results do not support the concept of a specific humoral response of glioma patients to a possible common tumor-associated antigen.

Intracranial sarcoidosis presenting angiographically as a sub-dural hematoma

Intracranial sarcoidosis is rare. Usually it involves the cranial nerves and presents with symptoms of meningeal irritation, convulsive seizures, hydrocephalus, hemiparesis, mental changes and hypothalamic dysfunction. A case in which the condition simulated a subdural hematoma is reported.

Combined chemotherapy with VM 26 and BCNU for recurrent malignant gliomas after operation and irradiation

The preliminary results of a combined chemotherapy trial with VM 26 and BCNU for recurrent malignant gliomas are presented. Four patients out of seven responded favourably to this treatment. Toxicity was mild and reversible.