Kongre Özetleri

Avrupa Çocuk Endokrinolojisi Birliği ( ESPE ) yıllık toplantısı Brüksel'de yapıldı....

Çocuk endokrinolojisi alanındaki bilimsel toplantılardan en önemlisi olan Avrupa Çocuk Endokrinolojisi Birliği yıllık toplantılarının 39'uncusu 800 kişinin katılımı ile 17-19 Eylül tarihleri arasında Brüksel'de yapıldı. Kongredeki ana konulardan birisini diyabet oluşturuyordu. Aşağıda kongrede sunulan diyabet posterlerinin özetlerini topluca sunuyoruz.

Not: ESPE hakkında daha fazla bilgi için http://espe.shef.ac.uk/ adresine başvurulabilir

European Society for Paediatric Endocrinology(ESPE)
39th Annual Meeting
Brussels, 17. - 19. September 2000
Diyabetle ilgili poster özetleri

OR8-55 - Aetiology and Implications of Transient Neonatal Diabetes

J. Shield 1; R. Gardner 2; D. Mackay 2; D. Robinson 2; I.K. Temple 2; Introduced by E.C. Crowne

1 Institute of Child Health, Bristol, United Kingdom; 2 Wessex Regional Genetics Service and Laboratory, Salisbury, United Kingdom

Introduction: Transient neonatal diabetes (TNDM) is a rare (1:400,000 births) but well recognised form of diabetes beginning in growth retarded infants during the first six port-natal weeks. It resolves within the first year after birth but is associated with the development of type II diabetes in later life. Patients and Methods: 30 cases of TNDM analysed for natural history and genetic basis of disease.

Results: TNDM phenotype: Equal sex distribution. Mean birth weight 2.1 kg at term (83% <2nd percentile). Most patients not dysmorphic (7 children had macroglossia, 2 had umbilical herniae). All children analysed at birth (n = 13), islet cell antibody negative. Classical autoimmune HLA haplotypes not associated with condition. Median age at presentation 3 days (maximum 31 days). Median requirement for exogenous insulin therapy 12 weeks. In those children now over the age of 4 years (n = 18) recurrence of diabetes occurred in 11 (>60%). The mean age of recurrence was 14 years (range 4-25 years). TNDM genotype: 11 cases have been identified with uniparental isodisomy of chromosome 6. 11 cases have been identified with either large or sub-microscopic paternal unbalanced duplications of chromosome 6 - critical region of interest 300-400 kb within 6q24. A further 2 cases with no rearrangement of chromosome 6 have now been identified with a methylation pattern identical to those patients with UPD6 implying a loss of methylation in the maternal. Conclusions: We have now identified a genetic cause for TNDM in 80% of our cases. The novel finding of loss of methylation in 2 cases appears to confirm our previous hypothesis that there is an imprinted region within 6q24 that is involved in normal pancreatic function and develop-ment. In the normal individual, solely the paternal allele is functional but three mechanisms have now been identified leading to over-expression of the region either through additional paternal copies or loss of maternal methylation. Given the significant association between TNDM, intrauterine growth retardation and the predisposition to non-autoimmune diabetes in later life, we suggest that this imprinted locus may well be relevant to our understanding of the association between low birth weight and Type II diabetes in the general population.

OR8-58 - Cytokine Profile in Newly-Diagnosed, Long-Standing Type 1
Diabetes Patients and
First Degree Relatives

G. d'Annunzio 1; M.A. Avanzini 2; L. Ciardelli 2; A. A librandi 2; E. Lenta 2; M. Cotellessa 2; A. Pistorio 1; R. Lorini 3

1 IRCCS Policlinico San Matteo, Pavia, Italy; 2 Pavia, Italy; 3 G. Gaslini Institute, Genova, Italy

Objective: Type 1 diabetes is an autoimmune disease in which an imbalance between Th1 and Th2 subsets has been reported. The aim of our study was to detect intracellular cytokines, IL-2 and IFN-gamma or IL-4 as expression of Th1 or Th2 activity, by flow cytometry after mitogen (Phorbol Myristate Acetate, PMA) stimulation in cryopreserved peripheral blood mononuclear cells (PBMC) from type 1 diabetic patients and subjects at risk (first-degree relatives, FDR).

Subjects: We evaluated 17 newly-diagnosed type 1 diabetic patients (10 m and 7 f, aged 6.5-20.3 yrs), 12 first degree relatives (6 m and 6 f, aged 5.9-14.6 years) and 13 age- and sex-matched healthy controls. Ten patients were re-evaluated after 15 months and 7 patients after 8 years. In all patients and FDR, GADA and IA-2A were detected by RIA, and HLA typing and DQ molecular analysis were performed.

Results: A) Patients. At diagnosis the percentage of CD4+ cells (Th) producing IFN-gamma was lower in the 17 patients than in controls (p = 0.008), while the percentage of Th producing IL-2 or IL-4 was not statistically different. After 15 months the percentage of Th producing IL-2 was higher in the 10 patients than at diagnosis (p = 0.046), while the percentage of Th producing IFN-gamma or IL-4 was not statistically different. After 8 years the percentage of Th producing IL-2 or IFN-gamma was higher in the 7 patients than at diagnosis (p = 0.042 respectively), while the percent-age of Th producing IL-4 was not statistically different. B) First-Degree Relatives. In FDR the percentage of Th producing IFN-gamma was lower than in controls (p = 0.0002), but similar to patients at diagnosis. The percentage of Th producing IL-2 or IL-4 was similar to that observed both in patients at clinicalonset of diabetes and controls. Moreover a lower (p = 0.042) percentage of Th producing IL-2 was observed in FDR compared to patients at 8 years follow-up, while no difference was observed between FDR and patients at 15 month follow-up. In patients and FDR no significant correlation was found between intracellular cytokine profile and age, GADA and IA-2A, blood glucose levels, degree of metabolic control (HbA1c mean levels). No significant association was observed between cytokine profile and HLA typing or DQ heterodimers.

Conclusions: Our results do not suggest a prevalence of Th1 activity in overt type 1 diabetes. Moreover the cytokine profile in the FDR is similar to that observed in patients at the clinical onset of diabetes, suggesting the importance of follow-up study.

OR8-59 - No Effect of Oral Insulin on Residual b-Cell Function in Recent
Onset Type 1
Diabetes (The IMDIAB VII)

A. Crino 1; P. Ciampalini 1; S. Spera 1; S. Corbi 1; M.L. Manca Bitti 1; G. Marietti 1; G. Multari 1; C. Bizzarri 1; M.G. Cavallo 1; M. Cervoni 1; G. Coppolino 1; F. Ferrazzoli 1; M.C. Matteoli 1; N. Visalli 1; E. Sarugeri 2; P. Pozzilli 1; IMDIAB Study Group 3

1 Hospital Bambino Gesu, Roma, Italy; 2 S. Raffaele Hospital, Milano, Italy; 3 Roma, Italy

Introduction: Type 1 diabetes is characterized by progressive and irreversible destruction of pancreatic beta cells. Oral insulin may be administered with the aim to induce tolerance to the hormone and its peptides, which are known to be important targets of the autoimmune response leading to beta cell destruction.

Aim: To investigate if the addition of oral insulin to regular subcutaneous insulin therapy may influence the natural history of type 1 diabetes in the first year after diagnosis.

Patients: 80 with recent onset type 1 diabetes (h 4 weeks duration), 40 males, 40 females, mean age ± SD: 14 ± 8 yrs (range 4 to 36 yrs).

Methods: A double blind trial was carried out in these patients in whom oral insulin (5 mg daily) (n. 45) or placebo (n. 35) were administered for 12 months in addition to intensive subcutaneous insulin therapy. Basal C-peptide, glycated haemoglobin and insulin requirement were monitored every 3 months up to 1 year. Insulin antibodies were also measured in 27 patients treated with oral insulin and in 18 patients receiving placebo at the beginning of the trial and after 3, 6 and 12 months of treatment.

Results: Overall and without distinction between age at diagnosis, baseline mean C-peptide secretion in oral insulin treated patients at 3, 6, 9 and 12 months did not differ from placebo treated patients. In patients below the age of 15 years a tendency for lower C-peptide values at 9 and 12 months was observed in the oral insulin group. Insulin requirement at 1 year was similar between the two groups as well as glycated haemoglobin levels. Finally, IgG insulin antibody levels were similar in the two groups at each time point.

Conclusions: Results of this trial indicate that the addition of 5 mg of oral insulin does not modify the course of the disease in the first year after diagnosis, and probably does not significantly affect the humoral immune response against insulin.

P2-450 - Early Onset of Type 2 Diabetes in an Obese Paediatric Population

A. Drake 1; L. Greenhalgh 1; R. Newbury-Ecob 1; I.S. Farooqi 2; J.P.H. Shield 1; E.C. Crowne 1

1 The Royal Hospital for Sick Children, Bristol, United Kingdom; 2 University of Cambridge, Cambridge, United Kingdom

The rapidly increasing prevalence of obesity in adults is now being reflected in the childhood population. Initial published studies report on children from minority populations with an established increased incidence of non-insulin dependent diabetes mellitus (NIDDM). There are few data in children from non-minority populations concerning the increasing prevalence of obesity, and the potential increased risk of insulin resistance and NIDDM. A regional multidisciplinary paediatric obesity clinic has been established and we present a cross sectional study of the results of patients referred with pathological obesity (BMI > 2SD) during the first year. All patients had height, weight and blood pressure measurements and were seen and assessed by clinicians with interests in clinical genetics, metabolism and endocrinology. Fasting blood was sent for insulin, proinsulin, split proinsulin and leptin.

Results: 36 patients with prepubertal onset of pathological obesity were assessed, (17 males; 19 females; age range 3.6-17.9 years; 17 prepubertal). The median (range) of BMI standard deviation score was 3.47 kg/m2 (2.04-6.36). 13/36 children had both systolic and diastolic blood pressures above the 90th centile for age and sex. Dysmorphic features were noted in eight individuals, five of whom had a recognisable syndrome or cytogenetic abnormality. Learning difficulties were present in 14 children. 4/17 of the prepubertal children had an elevated fasting insulin level (60 < pmol/l) and 7/17 had elevated proinsulin levels (> 5 pmol/l). Of the pubertal children, 7/19 had fasting insulin levels > 120 pmol/l and 14/19 had elevated proinsulin levels. One had already developed frank glucose intolerance.

Conclusions: This pilot study demonstrates that a significant number of severely obese children have evidence of fasting hyperinsulinaemia, pancreatic dysfunction and hypertension. They are at risk for the early development of NIDDM and its complications and clearly need assessment and management. A number of children seen had syndromic obesity. Longitudinal studies are required to assess the long-term risk factors in these children and the effectiveness of any active intervention.

P2-472 - Increased Circulating Nitric Oxide in Young Patients with Type 1Diabetes mellitus and Persistent Microalbuminuria: Relation with Glomerular Hyperfiltration

F.Chiarelli 1 ; S. Tumini 1; L. di-Ricco 1; M. Pomilio 1; A. Mohn 1

1 University of Chieti, Chieti, Italy

NO is candidate for mediating hyperfiltration and increased vascular pemeability induced by diabetes.

Objective: Firstly, to evaluate whether serum NO levels and GFR values are increased in type 1 diabetic adolescents with and without persistent microalbuminuria; secondly, to assess if NO concentrations are influenced by chronic hyperglycaemia in these subjects. Finally, to study whether NO plays a role in the development of glomerular hyperfiltration and persistent microalbuminuria in type 1 diabetic patients with early nephropathy.

Patients and Methods: Serum nitrite and nitrate (NO-/2 +NO-/3) concentrations were assessed as index of NO production in 30 type 1 diabetic adolescents and young adults, 15 with and 15 without microalbuminuria (AER between 20 and 200 µg/min) compared to a matched group of healthy controls. In all subjects glomerular filtration rate (GFR) was detemlined by radionuclide imaging (DTPA TCm99).

Results: NO serum concentrations and GFR values were significantly higher in microalbuminuric diabetic patients than in the other two groups. GFR resulted significantly and positively related to AER levels (r2 = 0.75, p < 0.0001), whereas NO-/2 + NO-/3 serum content was independently associated with both AER and GFR values (b = 2.086, p = 0.05, b = 1.273, p = 0.0085, respectively). Mean HbA1c serum concentrations was significantly higher in microalbuminuric than in normoalbuminuric diabetic subjects (p < 0.05) and was independently associated with AER values. HbAlc serum concentrations resulted significantly and positively related to NO2 + NO3 serum content (r2 = 0.45, p = 0.0063) and GFR values (r2 = 0.57, p = 0.0011). Conclusions: In young type 1 diabetic patients with early nephropathy chronic hyperglycaemia is associated with an increased NO biosynthesis and action that contributes to glomerular hyperfiltration and persistent micro albuminuria.

P2-473 - Endothelial Perturbation in Children and Adolescents with Type 1 Diabetes: Role of the Immune-Inflammatory Reaction

M. Pomilio 1; M. Romano 4; S. Vigneri 5; A. Falco 2; P. Lelli Chiesa 3; F. Chiarelli 1; G. Dav 2

Department of Medicine, Division of 1 Pediatrics, 2 Hematology, and 3 Pediatric Surgery, University of Chieti, 4 Department of Human Pathology, University of Messina; 5 Department of Medicine, University of Palermo, Italy

Vascular endothelin is a primary target of the unbalanced glycaemic metabolism in type 1 diabetes mellitus.

Objective: To investigate on early events that could influence the development of diabetic angiopathy.

Patients and methods: We examined endothelial perturbation (both vWF:Ag and t-PA:Ag higher than 2SD above control values) in 40 young type 1 diabetic patients without retinopathy and/or nephropathy, subdivided according to the duration of diabetes in two groups. Group A (patients with diabetes duration no longer than1 year) and group B (patients with diabetes duration longer than 1 year) were compared to a matched control group. Sixteen out of the 20 children belonging to group A were re-examined after 12 months. We also detennined F1+2, ICA and TNF-a levels, as index of prothrombotic state, immune and inflammatory response, respectively.

Results: Group A children had a significant increase in vWF and tPA levels compared to either healthy subjects or group B patients. 70% of group A but only 20% of group B patients showed endothelial perturbation. Group A patients also showed increased levels of F1+2, ICA and TNF-a . Significant direct correlations between TNF-a . and either vWF (Rho = 0.685, p= 0.0001), tPA (Rho = 0.469, p = 0.0034) or F1+2 levels (Rho = 0.61, p = 0.0001) were observed. No statistically significant correlation was found between HbA1c and either vWF, tPA or F1+2. After 1 year, 16 of the 20 group A patients had a significant reduction in vWF, tPA, F1+2 and TNF-a levels and 5 of these subjects the reversal of endothelial perturbation.

Conclusions: Endothelial perturbation represents an early, and in some cases reversible, event in the chronology of type 1 diabetes in children. A correlation might exist between the initial immune-inflammatory reaction and the appearance of endothelial perturbation.

P2-475 - Insulin Improves Clinical Status of Patients with Cystic Fibrosis Related Diabetes mellitus

A. Galli-Tsinopoulou 1; S. Nousia-Arvanitakis *1; M. Karamouzis *1

Departments of 1 Pediatrics and 2 Biochemistry, Aristotle University Thessaloniki, Greece

Cystic fibrosis (CF) related diabetes mellitus (DM) is frequently underdiagnosed and associated with deterioration of the overall clinical status in CF.

Objective: The purpose of this study is to investigate the influence of insulin on nutrition, lung function and clinical status of CF patients.

Patients and Methods: For a period of five years and at 6 monthly intervals body mass index (BMI), spirometry (FEV1: %), Schwachman score (SS), first phase insulin response (FPIR: IU/l) and K rate (%/min) were determined in 30 CF patients (age range: 13 to 31 years) having exocrine pancreatic insufficiency.

Results: During the study period six patients (age range: 15-22 years, 3 males and 3 females) developed CF-DM (FPIR, mean ± standard error: 23.9 ± 1.97, K rate 0.51 ± 0.02) and required insulin therapy. During the prediabetic phase, there was marked deterioration of their nutritional and clinical status [BMI 16.36 ± 1.34, FEV1 50.66 ± 6.68, SS 66.33 ± 3.84] which improved significantly shortly after the institution of insulin [BMI 19.07 ± 1.06 (t = 5.1694, p = 0.0018), FEV1 70.83 ± 5.4 (t = 3.8183, p = 0.0062), SS 84.50 ± 4.41 (t = 6.6958, p = 0.0006) (paired t student's test)]. Positive correlation (Pearson) between FPIR and BMI (r = 0.759) was detected.

Conclusions: A clear association of clinical status deterioration with insulin hyposecretion is demonstrated in CF. Insulin has a significant anabolic effect resulting in weight gain and improved pulmonary function. It is important to identify CF individuals at risk to develop DM by strict monitoring of glucose metabolism so that early insulin therapy is instituted.

P2-476 - Analysis of the Factors Influencing Partial Remission in Children with Insulin Dependent Diabetes mellitus (IDDM)

F. Lombardo *1; M. Valenzise *1; T. Arrigo 1; F. De-Luca 1

1 Institute of Pediatrics, University of Messina, Messina, Italy

After diagnosis and insulin therapy onset a large proportion of IDDM children is known to pass into a phase of partial remission (PR), which has significant implications in terms of potential pharmacological and immune intervention.

Aim of the present retrospective study was to evaluate the frequency of PR in 67 children aged between 1.4 and 17.3 years (7.9 ± 4.0) at the time of IDDM diagnosis and to analyze the factors influencing its duration. We abstracted insulin requirement data for the first 2 years after diagnosis (at 3, 6, 12 and 24 months) and defined PR as insulin requirement <0.5 U/kg/day. PR duration was related to: a) patients' socioeconomic status; b) their clinical and metabolic status at the time of IDDM diagnosis (age, BMI, length of history of symptoms, blood pH and base excess, Hba1c concentrations, C-peptide levels 6 min after glucagon stimulation test); c) insulin requirements 3 months after diagnosis. In the entire cohort only 13 patients (4 aged less than 3 years at diagnosis) did not experience a PR. At 6 months 52 of cohort (77.6%) were still in remission. By 12 and 24 months these figures had fallen to 41 (61.2%) and 23 (34.3%) respectively. The duration of PR correlated positively with: a) age at diagnosis (r = 2.7, p < 0.05); b) BMI at diagnosis (r = 3.1, p < 0.05); c) 6-min C-peptide levels (r = 2.9, p < 0.05). A strong negative relationship was found between PR duration and insulin requirements at 3 months after diagnosis (r = -0.77, p < 0.0001). No other variables significantly influenced PR duration.

Conclusions: 1) more than 60% of our IDDM children experienced a prolonged (>12 months) PR; 2) PR duration increased with age and BMI at diagnosis; 3) PR duration was positively influenced by the entity of residual B-cell function at diagnosis; 4) the greater is the reduction of insulin requirements soon after IDDM diagnosis, more prolonged is metabolic remission.

P2-478 - Type 2 Diabetes in U.K. Children - An Emerging Problem

S. Ehtisham *1; T. Barrett *1; N. Shaw 1

1 Birmingham Children's Hospital, Birmingham, United Kingdom

Introduction: The prevalence of obesity in childhood is increasing and is a recognised risk factor for the development of diabetes. Children from ethnic minorities are now presenting with obesity and Type II diabetes.

Aims: The aim of this study was to identify and characterise children with Type II diabetes in the Midlands.

Methods: Children were identified by contacting paediatricians responsible for diabetes in five hospitals. Details were collected on demographics, mode of presentation, investigations and treatment on a standard proforma.

Results: We identified eight girls aged 9-16 years who were of Pakistani, Indian or Arab origin. They were all overweight (percentage weight for height 140-206%) and had a family history of diabetes in at least two generations. They presented insidiously with hyperglycaemia and glycosuria without ketosis and five were asymptomatic. Islet cell antibodies measured in six patients were negative. Four had acanthosis nigricans which is a cutaneous marker of insulin resistance and the other four had high plasma levels of insulin and/or C-peptide. These patients are distinct from those with maturity onset diabetes of youth (MODY) who do not show insulin resistance. All were managed with dietary measures. Seven were treated with a biguanide, three with sulphonylureas, one with an alpha-glucosidase inhibitor and two require insulin.

Conclusions: We present the first UK case reports of Type II diabetes in children. Paediatricians need to be aware of the risk of Type II diabetes developing in childhood in high risk ethnic groups, particularly in association with obesity and a positive family history.

P2-482 - Cystic Fibrosis (CF) Related Diabetes (CFRD):Clinical Consequences before Insulin Treatment and Management of the Insulin Therapy

M.A. Rolon *1; K. Benali *1; A. Munck *2; J. Navarro *2; A. Clement *3; N. Tubiana-Rufi *1; P. Czernichow 1; M. Polak 1

Departments of 1 Pediatric Diabetology and 2 Pediatric Gastroenterology, Hôpital Robert Debré and 3 Department of Pediatric Pneumology, Hôpital Trousseau, Paris, France

The prevalence of diabetes increases with increasing age of the CF patients. Diabetes may have in its preclinical phase a deleterious effect on the clinical status of the CF patients.

Aim: To evaluate the repercussions of glucose intolerance on the nutritional state and respiratory function in a group of CF patients treated by insulin, in the period before this therapy was started. We also aim at describing the management of the insulin therapy and its effects in a french cohort of insulin treated CF patients (IT-CFRD).

Patients and methods: In a retrospective study, two groups were compared: group I, CF patients (n = 14) with diabetes, studied in the 5 years preceeding insulin therapy, and group II, matched CF patients (n = l4) with normal glucose tolerance (OGTT). The following parameters: body mass index (BMI), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) were collected during the same period in both groups. In the IT-CFRD group, parameters of insulin treatment (mean annual doses in units/kg/day), glycaemic control (mean annual HbAlc in %) and frequence of hypoglycemia were collected during the five years following the onset of insulin therapy.

Results: Before onset of insulin therapy, BMI, FVC and FEV1 values in the IT-CFRD deviated increasingly from those in the control patients. This decline in the clinical parameters of the IT-CFRD group reaches statistical significance in the 6- (for FVC and FEV1) or 3- (for BMI) month period preceeding the onset of insulin therapy. Insulin dosage increasedfrom 0.62 (first year) to 1.25 after five years, in favor of a progressive decline of endogenous insulin production. Good metabolic control was achieved with HbA1c values varying from 6.6% to 7.8% (first and fifth year of treatment, respectively). BMI of the IT-CFRD returned to normal value after a year of treatment, demonstrating the impressive anabolic effect of insulin. Episodes of severe hypoglycemia were extremely rare: 2 over 42 years/patient observation time. The insulin regimen more often used was two daily injections of a mixture of short and intermediate acting insulin (n = 10) given with the insulin pen. Conclusion: The clinical status of the CF patients who will need insulin therapy deteriorates before the onset of the treatment. In the diabetic CF patients, insulin therapy allows an excellent anabolic effect and a good metabolic control with few hypoglycemia. Prospective randomized trial with small dosage of insulin during the prediabetic period in glucose intolerant CF patients is needed to study the benefit of early treament in the course of the disease.

P2-484 - Neonatal Diabetes Mellitus: Clinical Description of a Large Cohort of Permanent and Transient Cases

C. Metz *1; B. Gueguen-Giroux *1; M. Polak 2; on behalf of the NDM French study group

1 Department of Pediatrics, Hôpital Morvan, Brest; 2 Pediatric Endocrine Unit, Hôpital Robert Debré Paris, France

Neonatal diabetes (NDM) is a rare but potentially devastating condition in a newborn. NDM has been essentially divided in two groups: the transient (TNDM) and the permanent (PNDM) form according to insulin dependence during the early course of the disease. Through a multicenter study by questionnaire in France, patients were included according to the following criteria: insulin treatment before three months of age, insulin therapy for more than 7 days and more than 18 months of survey. We identified a case as TNDM if insulin could be stopped within 18 months of its beginning. 32 cases were recruited according to these criteria: 15 TNDM and 17 PNDM. Intrauterine growth retardation (IUGR) was present in 24 (75%) (TNDM, 14 and PNDM, 7). TNDM cases had significantly lower birth weight than PNDM cases (1820 ± 451 versus 2444 ± 636 g; p < 0.05) for identical mean gestational ages (38.5 versus 39.2 weeks; p = 0.36). Mean age at diagnosis was 9.2 days in TNDM versus 27.6 in PNDM (p < 0.001). Mean blood glucose at diagnosis, was 5.07 ± 3.15 g/l, ketonuria was present in 1/3 of the cases and insulin levels were low (mean 7.6 ± 6.16 mU/l) in comparison with the glucose levels (no difference in glucose and insulin levels between both groups). No evidence of type I diabetes mellitus markers were found: anti-islets antibodies were negative (tested in 28) and HLA typing did not show type 1 DM related haplotypes (tested in 16). Pancreatic ultrasonography was normal in 15 subjects and detected a profound pancreatic hypoplasia in 1 case of PNDM. Initial treatment consisted in rehydration and insulin therapy. Mean initial insulin dose was 0.9 units/kg/day (0.16-2) and not different in TNDM and PNDM. Insulin therapy was then delivered either by continuous subcutaneous infusion (pump n = 13) or by discontinuous insulin injections (n = 21). Insulin therapy could be stopped in TNDM at a mean age of 5 months (0.5-15.3 months). Permanent hyperglycemia and insulin dependence occured in two cases of TNDM at 10 and 14 years of age (out of three cases of more than 8 years at the time of the survey). The mean observation time in TNDM is 31 months.

Conclusion: even though in PNDM, IUGR is less often present and age at diagnosis is greater than in TNDM, it is impossible for the clinican to distinguish PNDM from TNDM in the neonatal period on a pure clinical basis. Recurrence is present after 'TNDM' and long term follow-up of these children is necessary. Advances in the genetic understanding of the disease may help to distinguish the two groups of patients in the neonatal period.

P3-406 - Longitudinal Study of Type 1 Diabetes (T1D) Risk Markers in PTS with Autoimmune Thyroid Disease (ATD)

D. Larizza 1; M. Locatelli 2; C. Calcaterra 1; M. Martinetti 3; E. Lenta 1; G. d'Annunzio 1; R. Lorini 4

1 Dip. di Scienze Pediatriche, Univ. di Pavia; 2 Direzione Scientifica, Ospedale Pediatrico Bambino Gesù, Roma; 3 Servizio di Immunoematologia e Trasfusione IRCCS Policlinico S. Matteo, Pavia; 4 Dip. di Pediatria, Univ. di Genova, IRCCS G. Gaslini, Genova, Italy

Patients with ATD are at risk of developing other autoimmune diseases, such as T1D. This study is aimed to evaluate prospectively the risk for T1D conferred by immunological and genetic markers, in a cohort of 90 patients with ADT (77 females and 13 males, median age 13.8 yrs, range 4.3-25.5). Among these patients, 68 are affected by autoimmune thyroiditis (AT) and 22 by Graves' disease (GD). At the time of recruitment, first phase insulin response (FPIR) to an intravenous glucose tolerance test, protein tyrosine phosphatase (IA2A), glutamic acid decarboxylase (GADA) and islet cell antibodies (ICA) were determined. HLA-DQa and DQb typing was also performed in 87 of them. All patients were followed up for2.8 ± 1.2 yrs, and a second evaluation of FPIR, GADA and IA2A has been repeated in 54 patients. None of the patients of this cohort developed TID. On the basis of HLA-DQa and DQb genotypes, the patients were divided in: reduced (R), low (L), moderate (M) and high (H) risk for T1D. A summary of the results is reported in the following table.

The prevalence of islet-related autoantibodies in ATD patients is similar to that found in general population. Moreover the frequency of protective genes was higher in our patients than in general population, while the frequency of susceptible ones was similar. On the basis of our data, patients with ATD seem to have low risk of developing T1D.

P3-488 - Does Humoral Immunity against Insulin (Insulin Autoantibodies, IAA)Promote Lipodystrophy in Children and Adolescents with Type 1 Diabetes?

K. Raile *1; V. Noelle *2; R. Landgraf *3; H.P. Schwarz 2

1 University Children's Hospital, Munich; 2 Munich; 3 University of Munich, Germany

Introduction: In children and adolescents with type 1 diabetes the development of lipodystrophy, i.e. lipohypertrophy and lipoatrophy, are common problems at frequently used injection sites. Especially lipohypertrophic areas cause irregular and prolonged absorption of injected insulin and therefore lead to high fluctuations of blood glucose. So far, the underlying mechanism for the formation of lipodystrophy is not clear. Lipohypertrophy consists of both fibrous and fat tissue and growth is explained by local trophic effects of injected insulin. Lipoatrophy is rarely seen in children, and its formation is explained by local immunological reactions against fat and fibrous tissue. Patients and methods: In 81 randomly surveyed children and adolescents with type 1 diabetes on regular injections of insulin antibodies, specific for type 1 diabetes (IAA, IA-2, GAD65) and clinical parameters were recorded. To classify lipodystrophy, a clinical score was used as follows: grade 0 = no hypertrophy of the injection site; grade 1 = moderate hypertrophy of fat and no increased density of tissue; grade 2 = increased density of tissue; grade 3 = lipoatrophy.

Results: Out of 81 examined children, 2 had lipoatrophy (grade 3), 10 severe lipohypertrophy (grade 2), 17 moderate (grade 1) lipohypertrophy and 52 no alteration (grade 0) of at least one injection site. Markedly elevated IAA levels were present in patients with grades 2 and 3 compared with patients with grades 0 and 1 lipodystrophy (p = 0.017, t-test). No significant difference between both groups was found regarding age, duration of diabetes, insulin dose and episodes of severe or moderate hypoglycaemia. Linear regression analysis displayed a significant correlation between the levels of IAAs and the degree of lipodystrophy (p = 0.005). IA-2 levels correlated negatively with duration of diabetes (p = 0.005) and GAD antibodies showed no correlation at all.

Conclusions: The correlation of lipodystrophy and IAA levels suggests involvement of humoral immunity against injected insulin in the development of lipodystrophy. This process is independent from autoimmune beta cell inflammation, reflected by levels of IA-2 and GAD antibodies. Nevertheless, the causal link between IAA levels and lipodystrophy remains unproven and stipulates further longitudinal studies.

P3-491 - Metabolic Control and Insulin Regimens in Young Danish Patients with Diabetes

B.S. Olsen *1; H.B. Mortensen 1; P. Hougaard *2

1 Glostrup University Hospital, Glostrup, Denmark; 2 Novo Nordisk, Bagsværd, Denmark

A Danish nationwide cohort of children and adolescents was followed up for 6 years (1989-1995) to evaluate the change in metabolic control and insulin regimen over time. In total 353 patients (50.1% of the inception cohort) were included in both study years. In 1995 mean age was 20.7 years and mean diabetes duration was 13.2 years. Mean HbA1c was 9.5% in 1989 (normal range 4.3-5.8) and 9.7% in 1995. HbA1c increased to 10% between the ages of 12 to 20 years followed by a gradual decrease to 8.6% after 25 years of age. In 1989 55.2% of the patients were treated with 3 or more daily insulin injections compared to 87.5% in 1995. Among the patients treated with 1 or 2 injections in 1989, 79% increased the number of daily insulin injections in 1995, while 21% remained on the same regimen. Among the patients treated with 3 or more injections in 1989, 10% received more daily injections, 76% remained on the same regimen while 14% received fewer injections in 1995. Mean daily insulin dose was 1 IU/kg/24 h at the age of 15 years and subsequently decreased to 0.75 IU/kg/24 hours at the age of 25 years. Between 15 and 20 years girls received more insulin than boys while males tended to receive more insulin from the age of 20 years. Females had significantly higher BMI than males and even at the age of 25 years the BMI values of both sexes continued to increase. Up to the age of 16 years about half of the young patients were treated with premixed insulin (all types), the other half with a mixture of intermediate and short-acting insulin. After the age of 16 years more than 90% of the patients had a mixture of short and intermediate-acting insulin. Among the patients on twice insulin daily, 89% were treated with premixed insulin, either alone or in combination with intermediate-acting insulin, while 53% of the patients on 3 daily injections were treated with premixed insulin in combination with short- and intermediate-acting insulin. Of the patients on 3 or 4 injections 98.5% received a mixture of short- and intermediate-acting insulin. Metabolic control is still unsatisfactory in young Danish patients with diabetes. Interestingly, the poor metabolic control seem to continue into young adulthood. In the treatment centres intensified insulin regimens are used particularly in the older adolescents. Nevertheless the goal of near normoglycaemia is achieved in only a few. This suggest that factors such as patient-education and self-care behaviour may be of greater importance for improved metabolic regulation than insulin regimens.

P3-492 - Leptin in Children and Adolescents with Type 1 Diabetes: A 1
Year Longitudinal
Study

R. Bonfanti *1; P. Brambilla 2; S. de-Poli 2; S. Mora 2; E. Calzi 2; E. Bognetti 2; F. Meschi 2; L. Barbieri 2; G. Chiumello 2

1 Universit à degli studi di Milano, Milan, Italy; 2 Clinica Pediatrica III, Milan, Italy

Type 1 diabetic patients show an important variation in body weight, during the first year of insulin treatment. Insulin is directly and undirectly involved in the regulation of leptin secretion. However, discordant results have been described in patients at onset and during the first year of diabetes. Aim of this study was to evaluate the correlations between auxologic and metabolic parameters and leptin variations in a cohort of patients with type 1 diabetes mellitus at onset and during the first year of treatment. From a cohort of 300 diabetic patients followed regularly during the first year of disease, we investigate 26 patients (14 M/12 F), with a mean age 12 ± 2.5 yrs (range 6-15.8). 10 patients presented at onset a weight loss (rbw <85%) and 16 patients a normal weight (rbw 85-115%). We evaluated metabolic parameters (HbA1c, pH, C-peptide, insulin dose), auxologic parameters (weight, height, relative body weight, height sds, bmi) at the onset and at 6 and 12 months of insulin treatment. Leptin was measured by radioimmunoassay at onset of diabetes within 6 days from first insulin administration and after correction of DKA if present at each time points of follow up.

Results: At onset, log transformed leptin levels, normalized by bmi, sex, age, were in the lower part of normal reference range (3-50° centile), mean 0.54 ± 0.29 ng/ml. Leptin levels showed a decrease at 6 months and increased thereafter (at 6 months 0.49 ± 0.3, at 12 months 0.56 ± 0.34, p = 0.01, Anova). Leptin levels showed a significant correlation between each others at each time point. Leptin levels were not different between patients who did and did not gain weight during follow up (respectively 0.6 vs. 0.45, 0.54 vs. 0.41, 0.6 vs. 0.42 ng/ml). There were no correlations between variation in leptin levels and variation in bmi. Leptin values were correlated significantly to bmi, insulin dose and sex at onset and not to degree of acidosis, and at 12 months of disease. However, at 6 months leptin levels were related to bmi but also to residual beta-cell function (C-peptide) and degree of metabolic control (HbA1c).

Conclusion: We confirm that in IDDM patients at onset of disease leptin levels are in the normal range, and then showed a decrease at 6 months followed by an increase thereafter. Leptin levels are mainly explained by BMI and sex variation as in normal subjects, but at 6 months exists a negative relation to residual insulin secretion, which can explain the decrease in leptin levels. These data suggest a role of C-peptide in the regulation of leptin secretion, and this new issue needs to be confirmed by larger studies.

P3-493 - Relationship between Early Feeding Habits and Childhood Type 1
Diabetes mellitus during 1995-1999 in Sweden and Lithuania

V. Sadauskaite *1; E. Jasinskiene *1; Z. Padaiga *1; U. Samuelsson *2; J. Ludvigsson *2

1 Kaunas University of Medicine, Kaunas, Lithuania; 2Linköping University Hospital, Linköping, Sweden

Background: A relationship between type 1 diabetes mellitus (DM) and other immune diseases has been described. Early introduction of flour, containing gluten, in relation to coeliac disease and early introduction of egg, a cause for atopic status, are interesting as potential risk factors in causal relationship with type 1 DM in children. Early introduction of meat as a source of nitrites that increase risk for type 1 DM could also influence development of type 1 DM later in life. Aim: To compare differences in feeding habits between children with diabetes and healthy controls in Sweden and Lithuania, where incidence of childhood type 1 DM is quite different (1997: 31.9 and 10.3/100 000, respectively).

Methods: A case-control study involved all newly diagnosed children, 0-15 years, with type 1 DM (as cases) in South-East of Sweden during 1995-1999 (n = 403) and in Lithuania during 1996-1999 (n = 234). Three age and sex matched randomly selected population based healthy children were invited as controls. Control response rates were 74.8% in Sweden and 84.6% in Lithuania. Information on risk factors important for the development of type 1 DM was collected using a structured questionnaire at the time of diagnosis in both countries.

Results: There were no differences in the time of introduction of flour and egg between children with diabetes and controls in both countries, except for meat, which was introduced significantly later among healthy children in both countries altogether and in the 5-9 years age group in Sweden and in the 5-9 years and 10-15 years age groups in Lithuania.

Table. Month of introduction of food items in age groups

Conclusions: Early introduction of meat products might contribute to a risk for development of type 1 DM later in life both in Sweden and Lithuania.

P3-494 - Antibodies to Tissue Transglutaminase C in Newly-Diagnosed and Long-Standing Type 1 Diabetes

R. Lorini 1; M.A. Avanzini *2; E. Lenta *2; M. Cotellessa *1; C. De Giacomo *2; P. Barbieri *1; G. d'Annunzio *2

1 Department of Pediatrics, University of Genoa, Gaslini Institute, Genoa; 2 Department of Pediatrics, IRCCS Policlinico San Matteo, Pavia, Italy

Tissue transglutaminase C (tTG) has been identified as an autoantigen target of antiendomysium antibodies (EMA), the serological marker of coeliac disease (CD). We detected tTG-IgA by immunoenzymatic method, IgA antiendomysium (EMA) by immunofluorescence, and serological markers of type 1 diabetes (IA-2A and GADA) by RIA in 68 type 1 diabetes patients (36 M and 32 F, aged 1-25.7 yrs, 31 newly-diagnosed and 37 with disease duration 1.1-16 years). TTG values >14 U/ml (mean + 3 SD of 56 controls) were defined as positive. In 18/68 patients (6/31 newly-diagnosed, ND and 12/37 long-standing, LS) high levels of tTG were observed, with a frequency higher than controls (0/56) (p = 0.0000). In 2/6 ND patients positive for tTG EMA were also found, and jejunal biopsy revealed CD. In 10/12 LS patients positive for tTG EMA were also found, and jejunal biopsy showed CD in 9 and partial villous atrophy ('latent' CD) in 1. Results of immunological markers of diabetes are reported in the table. TTG have been suggested as a sensitive test replacing EMA detection for diagnosis and screening of CD. Since multiple immunological abnormalities have been reported at clinical diagnosis of diabetes, the detection of tTG in newly-diagnosed patients could reflect an abnormal immunological response in the early stage of diabetes, with increased production of antibodies by specific clones of B-lymphocytes, instead of markers of coeliac disease.

* Only EMA positive patients were biopsied.

P3-498 - Exercise Stress Test and Left Ventricular Function in Adolescents and Young Adults with Insulin Dependent Diabetes mellitus (IDDM)

H. Tsoka-Gennata 1; V. Pailopoulos *1; A. Kafourou *1; G. Papadopoulos *1; K. Kassiou *1

1 Aghia Sophia Children's Hospital, Athens, Greece

Diabetic patients are at increased risk of cardiovascular disease. Since there is today a possibility of patient directed intervention it is important to know the age of the disease onset before the development of clinical symptoms and signs.

Objective: To evaluate the response to the exercise stress as well as the cardiac function of our older patients and their relation to known risk factors for cardiovascular disease.

Patients and methods: Thirty IDDM patients, 17 boys and 13 girls, with a mean age of 16.7 years (range 10-25) have been studied. A symptom-limited exercise test has been performed and exercise time, work performed, maximum heart rate, maximum systolic and diastolic blood pressure and ST segment on electrocardiogram have been recorded. A Doppler echocardiography has also been done and left ventricular systolic and diastolic function has been assessed. All these parameters have been correlated with common risk factors for cardiovascular disease in diabetes: age, disease duration, smoking, BMI, HbA1c, dyslipidemia and microalbuminuria. Thirty normal subjects have served as controls for the heart tests.

Results: Mean age at diagnosis of IDDM was 9.6 years (2.7-15.3) and mean disease duration 7 years (2.7-15.3). Mean BMI was 22.7 (16.8-12.9) and mean HbA1c of the past two years 8.86% (6.0-12.7). Seven patients had dyslipidemia. Four patients had elevated urinary microalbumin excretion and one had diabetic retinopathy. All patients had a normal exercise test but in four cases a slightly elevated systolic and diastolic pressure has been recorded and in another two cases a significantly high heart rate has been noted. One patient had a reduced diastolic function (E/A 1) on Doppler echocardiography. The above results did not differ from the results of the control group. In the study group there was a statistically significant correlation between DMI and shorting fraction (p = 0.050), work performed (p = 0.009) and maximum diastolic pressure (p = 0.017).

Conclusions: In this group of patients our study did not reveal any significant cardiovascular abnormality. Further studies are required in order to clarify the relation between risk factors and the age of onset of cardiovascular disease in IDDM patients.

P3-505 - Type 1 Diabetes and Celiac Disease in a Pediatric Catalan Population
C. Farre *1; M. Torres *1; C. Pavia 1; M. Hernandez *1; V. Varea *1; P. Vilar *1
1 Hospital Sant Joan de D?u, Barcelona, Spain

Type 1 diabetes (DM1) and celiac disease (CD) are both immunologic disorders that could be present in genetically susceptible individuals. Their association is relatively frequent and different serological markers are used with the aim to detect silent CD in DM1 patients.

Objective: 1) To study the frequency of silent CD in our paediatric DM1 population using serological markers previous intestinal biopsy. 2) To compare the reference qualitative and manual serological method against two differents quantitative and automated Elisa methods.

Patients and methods: In a cohort of 233 DM1 patients aged ranged from 0.9 to 18 years, we measured IgA (or IgG class in patients with IgA deficiency) antiendomysium antibodies (AEA) using monkey oesophagus as substrate of indirect immunofluorescence, that serves as reference method. Besides, we analyze IgA (or IgG) antigliadin antibodies (AGA, Pharmacia Co) in 121 of the 233 patients, and IgA (or IgG) tissue transglutaminase antibodies (Quanta LiteÔ t-TG, Inova Diagnostics Inc) in the remaining 112 cases. Antigliadin and tissue transglutaminase antibodies were analysed using a quantitative and automated Elisa method.

Results: We found positive IgA (or IgG) AEA in 15 of the 233 DM1 patients (6.4%, 15/233). Ten of them (4.3%, 10/233) were diagnosed by CD using intestinal biopsy. In two AEA positive patients, biopsy is not already performed. In the last three AEA positive patients, intestinal biopsy showed minimal abnormalities of the intestinal villous, these patients have to be controlled in order to detect CD activation. Whether we compare AGA and t-TG concentration with AEA results, we can see that AGA concentration is normal in five AEA positive DM1 patients and elevated in ten AEA negative. Moreover, t-TG ab is normal in two AEA positive DM1 patients and elevated in nine AEA negative. Six DM1 patients had IgA deficiency (2.6%, 6/233) and one of them was diagnosed by celiac disease.

Conclusions: The frequency of celiac disease in our diabetic population ranges 4.3% to 6.4%. From our results it seems that t-TG not improve the accuracy and specificity of AGA, and non automated AEA is the best serological marker to detect silent or latent CD in DM1 patients.

P3-506 - Day/Night Variations in the Ambulatory Blood Pressure Monitoring in Children and Adolescent with Type 1 Diabetes

R. Cardani *1; A. Salvatoni *1; R. Rovelli *1; E. Piantanida *1; C. Orsatti *1; L. Nespoli *1; Introduced by P. Brambilla

1 Insubria University, Varese, Italy

A reduction in the day-night variations of blood pressure has been reported in IDDM patients as a sign of incipient hypertension.

Objective: To compare the day-night variation of blood pressure in children and adolescents with different IDDM duration with that of healthy controls and to find correlations, if any, between blood pressure and insulin requirement, metabolic control, AER and cotecholamines in plasma and urines. Patients and methods: We studied 28 subjects with IDDM and 16 healthy controls (12 boys and 4 girls) aged. The duration of IDDM was less than 5 years (Group 1) (2.0 ± 1.5 years) in 14 subjects (9 boys and 5 girls aged 11.1 ± 4.4) and more than 5 years (Group 2) (9.4 ± 3.2) in 14 subjects (9 boys and 5 girls aged 17.5 ± 5.7). All patients were in treatment with 2-4 daily subcutaneous injections of short- and intermediate-acting human insulin. The metabolic control was assessed by daily monitoring of blood glucose and by measurement of HbA1c (DCA2000, Bayer) every two months. 24 hrs ambulatory blood pressure monitoring (ABPM) was measured by oscillometric and auscultatory technique using a TM2421 equipment (AND & D Company Ldt, Tokio, Japan). Urinary and plasmatic noradrenaline, adrenaline and dopamine were measured by HPLC. Student's t test, ANOVA, simple, multiple and stepwise regression were used for statistical analysis.

Results: Mean systolic and diastolic ABPM, adjusted for age, height and weight were similar in Group 1, Group 2 and Controls; however Group 2showed a lower drop of diastolic BP during night-time compared to controls(10 ± 12% vs. 18 ± 7%; p < 0.05). Direct significant correlations were found between HbA1c and mean nocturnal diastolic blood pressure (p > 0.05), insulin requirement and plasmatic adrenaline, noradrenaline and dopamine (p < 0.5) and mean nocturnal/diurnal diastolic blood pressure ratio and urinary dopamine.

Conclusion: Our results confirm the observation that patients with IDDM for more than 5 years have a reduction in the day-night variation of blood pressure and suggest that an increase in dopaminergic system activity may be responsible for this condition.

P3-508 - HLA-DQ2 in Catalan Type 1 Diabetes Population

C. Farre *1; T. Marques *1; M. Hernandez *1; C. Pavia 1; M. Torres *1; P. Vilar *1; V. Varea *1

1 Hospital Sant Joan De Déu, Barcelona, Spain

The likely explanation for the frequent simultaneous occurrence of celiac disease (CD) in Type I diabetes (DM-I) is that both of them have a similar genetic background. Class-II HLA genes encode cell-surface molecules which bind and present antigenic peptides to T cells and have a major role in the pathogenesis of many autoimmune disorders. It is known that DQA1*0501 and DQB1*0201 alleles (HLA-DQ2 haplotype) are primarily related to CD.

Objective: To study the frequency of DQ2 haplotype in a sample of Catalan Type 1 diabetes population.

Patients and methods: We studied eight DM1 patients with positive antiendomysium antibodies (AEA). CD was confirmed by intestinal biopsy. Thirty-five DM1 patients with negative AEA, sixty CD patients and sixty-four ethnically matched controls from the general population. DQ2 haplotype was determined by SSCP-PCR. Whole genomic DNA was isolated by phenol extraction and ethanol precipitation, Gene Amp PCR2400 system (Perkin Elmer) was used for amplification and PCR products were electrophoresed on a 1.5% agarose gel. Examination under UV light confirmed amplification efficiency. This method detects the presence or absence of at least one copy of DQA1*0501 and DQB1*0201.

Results: Five of the eight AEA positive diabetic patients were diagnosed of celiac disease by intestinal biopsy. The three remaining, DQ2 positive, showed minimal non-specific abnormalities of the intestinal villous.

DM1/AEA+

DM1

CD

Conclusions: We suggest that the three diabetic patients with positive antiendomysium antibodies, positive DQ2 and minimal abnormalities in the jejunal biopsy, have latent CD. The frequency of DQ2 haplotype obtained in our DM1 population confirms the higher genetic susceptibility to CD in these patients.

P3-509 - Occurrence of Coeliac Disease after the Onset of Insulin-Dependent Diabetes mellitus: A Six Years Follow-Up

R. Bonfanti *1; G. Barera 2; M. Viscardi 2; E. Bognetti 2; F. Meschi 2; C. Bianchi 2; G. Chiumello 2; Introduced by C. Giuseppe

1 Istituto Scientifico H San Raffele, Milano, Italy; 2 Italy

The prevalence of coeliac disease (CD) as determined by screening programs among children and adolescents with insulin-dependent diabetes (IDDM) is higher than in general population, with rates of 1.1-7.8%. These figures are probably underestimated, since many patients with positive antibody tests don't agree to small-bowel biopsy. Only occasionally CD precedes the onset of IDDM; more often it is diagnosed at IDDM onset or shortly after. Few studies focused on the occurrence of CD at the onset of IDDM and after the clinical onset by long-term longitudinal study. The aim of this study was to evaluate the occurrence of CD at the clinical onset of IDDN and the development of new cases of CD during a six years follow-up. We studied 275 patients (116 F,159 M; mean age 8.4 yrs; range 0.3-26.7 yrs) at the onset of IDDM. One patient was on gluten free diet because a previous diagnosis of CD. A longitudinal prospective evaluation was performed in 223 pts at 1 yr, 170 pts at 2 yrs, 117 pts at 3, 73 pts at 4, 44 pts at 5, 22 pts at 6 yrs from onset of disease.

IgA-antiendomysium antibodies (AEA) test on monkey's oesophagus was performed at onset and at each year of follow-up. Serum IgA vere also determined, IgG AEA and IgG antigliadine antibodies were tested in patients with IgA deficiency (<0.05 g/l).

Results: At onset were found 14 AEA positives with 7 biopsies all athrophy; At 1 year 4 AEA+, 2 biopsied, at 2 yrs 6 AEA+ with 4 biopsies, at 3 yrs 7 AEA+ with 4 biopsies, at 4 yrs 4 AEA+ with 3 biopsies, no more positives at 5 and 6 yrs follow-up. Two patients were IgA deficient but IgG test negative. Two patients with CD diagnosis at follow-up were already positive at onset. Conclusion: Our data confirm an increased prevalence of CD in IDDM population (6.2%) with an annual incidence of 1.38% (respectively 0.9%, 1.2%, 2.56%, 2.74%, 0% and 0%). A small group of patients (11/274) had a variable week AEA positivity that changed during time. Our study suggests the opportunity to screen IDDM patients for CD with AEA, at the onset and also during years near onset. Same patients show fluctuation of AEA levels as expression of CD latency.

P3-512 - Early Signs of Polyneuropathy in Adolescents with Type 1 Diabetes

P. Riihimaa *1; K. Suominen 2; U Tolonen *2; M Knip 3; P Tapanainen 4

1 University of Oulu, Oulu, Finland; 2 Department of Neurophysiology, University of Oulu, Oulu, Finland; 3 Department of Pediatrics, University of Tampere, Tampere, Finland; 4 Department of Pediatrics, University of Oulu, Oulu, Finland

Impact of peripheral nerve conduction velocity (NCV) and autonomic nerve system (ANS) in adolescent patients with type 1 diabetes was studied. Objective: To evaluate the peripheral neurological function in adolescents with type 1 diabetes (age 9-19 yr, diabetes duration over 2 yr). Patients and Methods: One hundred adolescent patients (21 in pubertal stage T I; 60 in T II-IV; 19 in T V) and 100 healthy age and sex matched controls (15 in T I; 56 in T II-III; 29 in T V) participated in the study. The motor and sensory NCV in right median nerve and peroneal and sural nerves was measured bilaterally and adjusted for the mean height and skin temperature. ANS was evaluated with heart rate variability in rest, deep breath and during active standing. Distal polyneuropathy was defined as NCV 5th percentile of the healthy controls in three or more nerves. The mean duration of diabetes was 7.0 yr and the mean HbA1c was 8.5%.

Results: Eleven patients (5F/6M) had distal polyneuropathy. Three of these 11 patients were prepubertal, three in T II-IV and five in T V. NCV in the median, peroneal and sural nerves were significantly lower in the whole study group of the patients than in the healthy controls. There were no significant differencies in heart rate in rest, in DB or during active standing between the patients and the controls. The patients with HbA1c over 8.5% had significantly slower peroneal NCV bilaterally than the patients with HbA1c 8.5% or below. No such difference was observed between the patients with disease duration over 7.0 yr and below 7.0 yr. Conclusion: Adolescent patients with type 1 diabetes had obvious signs of mixed sensorimotor polyneuropathy. No cleardifference in ANS function tests were observed between the patients and the controls. This implies that ANS may be more resistant to diabetic neuropathy or factors other than those involved in the development of sensorimotor neuropathy may contribute to autonomic neuropathy.

P3-515 - Defective Function of Fas in Patients with Type I (Insulin-Dependent) Diabetes mellitus Associated with Other Autoimmune Diseases

S. De Franco *1; S. Bonissoni *1; A. Petri *1; M. Bragardo *1; F. Cadario *1; A. Aguzzi *1; F. Sacco *1; F. Cerutti *2; A. Corrias *2; U. Dianzani*1; G. Bona 1; Introduced by G. Bona

1 University of Eastern Piedmont, Novara, Italy; 2 Regina Margherita Hospital, Turin, Italy

Aims: Fas (CD 95) triggers programmed cell death. It is also involved in cell-mediated cytotoxicity and in shutting off the immune response. Inherited loss-of-function mutations of its gene or downstream alterations of its signaling pathway cause the immune/lymphoproliferative syndrome (ALPS). This study evalutes Fas function in patients with diabetes associated with other autoimmune diseases (autoimmune polyreactive patients).

Patients and Methods: Cell death induced by anti-Fas monoclonal antibody was investigated in T cells from three group of patients with Type I diabetes mellitus (IDDM T-1): IDDM T-1 only (n = 13), IDDM T-1 plus thyroiditis (n = 13) and IDDM T-1 plus other autoimmune diseases (n = 6), and 19 patients with thyroiditis alone. The study was extended to parents of four patients with IDDM T1 plus thyroiditis.

Results: Frequency of resistence to Fas-induced cell death was significantly higher in patients with IDDM T-1 plus thyroiditis (77%) and plus other autoimmune diseases (67%) than in normal controls (3%); and in patients with IDDM T-1 plus thyroiditis than in thyroiditis alone (16%) and IDDM T-1 alone (23%). Fas was always expressed at normal levels and no mutations were detected in one IDDM T-1 plus thyroiditis and in one IDDM T-1 plus autoimmunitis Fas-resistant patient. The defect was likely to due to genetic component since parents were Fas- resistant even if healthy. Conclusion: These data suggest that Fas defects may be a genetic factor involved in the development of other autoimmune diseases in patients with IDDM T-1.

P3-516 - Uncommon Early-Onset Acute Painful Neuropathy in a Boy with Type 1 Diabetes mellitus

M.V.B. Pescador *1; L.C. Fortes *1; I.V. Brandi *2; M.C. Geiger *3; L. De-Lacerda *3; W.O. Arruda *2; M.C.S. Boguszewski 3; Introduced by M.C.S. Boguszewski

1 Curitiba, Brazil; 2 Neuromuscular Diseases Unit, Curitiba, Brazil; 3 Pediatric Endocrinology Unit, Curitiba, Brazil

An acute neuropathy rarely occurs early in the course of insulin-dependent diabetes mellitus (IDDM). A 14-year-old boy was admitted at the Intensive Care Unit with diabetic ketoacidosis (DKA) when the diagnosis of IDDM was made. He reported a profound weight loss (approximately 10 kg) during the months preceding onset. He developed an acute painful symmetrical distal neuropathy some days after his admission. He presented distal muscle weakness and he could not walk. Reflexes were diminished or absent in ankle and knee. Nerve conduction study showed absence of motor and sensory action potentials in both legs. Needle electromyography evaluation showed signs of denervation in distal muscles of the lower limbs. The patient was treated according to the routine for DKA and received carbamazepine to alleviate the painful paresthesis. A good glycemic control and weight gain occurred after beginning treatment with insulin. Six months after the diagnosis, the patient was pain free and paresthesia in feet remained as the only symptom.

Comments: Acute painful neuropathy is a rare condition that may affect young diabetic patients at the start or shortly after development of the disease. Although a nerve biopsy was not performed, we can suggest that acute disequilibrium of the metabolic state and/or the autoimmune process may facilitate the occurrence of neuropathy in these patients.

P3-517 - IPF-1 Gene Mutations as a New Possible Cause of Neonatal Diabetes mellitus: A Case Report

A. Maret 1; V. Schwitzgebel *2; B. Ritz-Laser *2; D. Balmer *3; J. Philippe *2; G. Theintz 1

1 University Hospital of Lausanne, Lausanne, Switzerland; 2 University of Geneva, Geneva, Switzerland; 3 University of Zürich, Zürich, Switzerland

Introduction: Neonatal diabetes mellitus (NDM) is a very rare condition of variable outcome (transient vs permanent forms). Whereas the origin of most cases is still obscure, some are part of complex syndromes (Pearson, Wolcott-Rallison) or associated with paternal uniparental disomy of chromosome 6, particularly the transient form. We describe a case with permanent NDM and pancreatic exocrine insufficiency with preliminary results suggesting a novel mutation in the IPF-1 gene.

Case report: This term female baby was born with intra-uterine growth retardation (2,140 g/44 cm) after a pregnancy marked by slight gestational diabetes. She was admitted at 12 days of age for poor weight gain despite marked appetite, followed by steatorrhea. Investigations: glycaemia: 43.7 mmol/l; pH: 7.46; BE: +0.8 mmol/l; amylase: 4 U/l; lipase:15 U/l; stool elastase: 13 µg/l (normal: >200); ICA (baby + parents): negative; CT-scan: marked isolated pancreatic hypoplasia; genetic studies: suggest two point mutations in the IPF-1 gene (compound heterozygocity). Chromosome 6: normal biparental inheritance. Outcome: continuous subcutaneous insulin infusion and enzyme replacement therapy are required at 21 months of age; normal developmental milestones.

Discussion: Endocrine and exocrine pancreatic failure suggest abnormal pancreatic development as confirmed by CT-scan imaging. The homeodomain protein IPF-1 is critical for pancreas development: in transgenic mice, knock-out studies resulted in pancreatic agenesis. A point deletion of the IPF-1 gene in a patient with pancreatic agenesis has been identified recently (Stoffers et al, Nat Genet 1997;15:106). In the absence of clinical markers to differentiate transient from permanent NDM forms, genetic investigations represent a useful tool: there is a strong association between the transient NDM and paternal uniparental disomy for chromosome 6. On the other hand, IPF-1 gene anomalies point to permanent NDM with pancreatic hypoplasia/aplasia.

P3-518 - Occurence of Microangiopathy after Long-Term Follow-Up (12-18 Years) in 40 Patients with Type 1 Diabetes of Childhood Onset

S. Rouleau *1; B. Bouhanick *1; H. Raguin *1; R. Coutant *1; V. Rohmer *1; J.M. Limal 1

1 University Hospital, Angers, France

Objectives: To estimate the outcome of patients with type 1 (immune mediated) diabetes followed in one university hospital during at least 12 years.

Methods: Retrospective study of medical records of 40 patients (24 F, 16 M) with type 1 diabetes from 1979 to 1997.

Results: Mean age at diabetes onset was 8 ± 4 years (1-16 years), and follow-up lasted 16 ± 4 years. Ketoacidosis revealed diabetes in 42% of the children. Mean HbA1c was 8.5 ± 1.3% during the whole study time. Mean HbA1c was less than 7.5% in 17% of the patients, 7.5-8.5% in 38%, and over 8.5% in 45%. After 5, 10, and 15 years, 15%, 50%, and 81% of the patients received multiple daily injections (2/day), respectively. The mean age at onset of puberty (Tanner stage II) was 12 ± 1 years in girls and 13 ± 1 years in boys. Mean HbA1c was 7.9 ± 1.2% during the year before puberty onset, and 8.7 ± 1.1% in the following 3 years, corresponding to a 10% pubertal increase of HbA1c. Mild nonproliferative retinopathy was seen in 57.5% of the patients, at a mean age of 21 ± 4 years, after 13 ± 5 years diabetes duration. Proliferative retinopathy was seen in 10% of the patients, at a mean age of 25 ± 2 years, after 20 ± 6 years diabetes duration. No retinopathy appeared before the age of 15 years. Mean HbA1c was 9.6 ± 1.8% in patients with proliferative retinopathy, 8.4 ± 1.2% in patients with nonproliferative retinopathy, and 8.2 ± 1.5% in those with no retinopathy (p < 0.05 proliferative vs. no retinopathy, p > 0.05 non proliferative vs no retinopathy). Persistent microalbuminuria (Albumin excretion rate 20 mg/l on 3 different urine collections) was diagnosed in 30% of the patients, at a mean age of 21 ± 3 years, after 11 ± 4 years diabetes duration. Mean HbA1c was 9.2 ± 1.2% in patients with persistent microalbuminuria versus 8.2 ± 1.3% in those with normal AER (p = 0.002). No patient with persistent microalbuminuria had mean HbA1c below 7.5%. Twenty-five percent of the patients had both retinopathy and nephropathy. Conclusions: Glycemic control was similar in patients with non proliferative retinopathy and those with no retinopathy. Whereas proliferative retinopathy and nephropathy were both related to the level of glycemic control, we observed a trend for nephropathy to be more prevalent, occur earlier for lower HbA1c than proliferative retinopathy.

P3-521 - Celiac Disease, Type 1 Diabetes and Autoimmune Thyroid Disease: A New Polyglandular Syndrome

M.C. Matteoli *1; C. Bizzarri *1; I.P. Patera *1; O. Porzio *1; G. Giannone *1; M. Cappa 1; L. Lucentini *1

Dipartimento di Pediatria e Diabetologia, Ospedale Bambino Gesu, Palidoro, Italy

An association between celiac disease (CD) and disorders of immunological aetiology has been reported in several studies. It has been demonstrated that CD patients are frequently affected by insulin dependent diabetes mellitus (IDDM) and autoimmune thyroid disease (ATD). We screened for CD and ATD all our IDDM population. Serum autoantibodies directed against thyroid peroxidase (TPO), thyroglobulin (HTG), gliadin (AGA), endomysium (EMA) and reticulin (ARA) were detected every six months. ATD was diagnosed in patients having persistently positive antithyroid antibodies (AAT) associated with clinical goiter or morphological abnormalities found at thyroid sonography. The diagnosis of CD was based on the ESPGAN criteria. The mean duration of follow up was 5 ± 2 years. Four hundred and twenty six IDDM patients were examined (221 males and 205 females, mean age 21 ± 8 years, mean age at diabetes onset 9.1 ± 5 years). AAT were persistently positive in 70/426 IDDM patients (16.4%); 36/426 developed ATD (8.4%). Four IDDM patient presented thyroid nodules without AAT. Forty three IDDM patients were affected by CD, 9/43 (20.9%) presented persistent AAT, 8/43 (18.6%) developed ATD. Two CD patients were affected by non autoimmune thyroid disease. AAT prevalence in IDDM-CD patients is higher (but not statistically different) than in IDDM patients. On the contrary ATD is significantly more frequent in IDDM-CD patients than in IDDM patients (18.6% versus 8.4%, p < 0.005). Thirty six subjects between AAT positive. IDDM patients (51%) developed ATD whereas in the group of AAT positive-IDDM-CD patients 89% developed ATD. In conlusion AAT positive predictive value is higher in IDDM-CD patients. EMA persisted at significant titres in 50% of IDDM-CD-ATD patients, after gluten withdrawal. Since the prevalence of ATD is higher in IDDM-CD patients, we can suppose that poor compliance with the gluten free diet act as a likely determinant on the onset of ATD in this group of subjects.

P3-522 - From Incidental Hyperglycaemia to Maturity Onset Diabetes of the Young (MODY): 2 Case Reports

G. d'Annunzio *1; A. Alibrandi *1; M.A. Avanzini *1; F. Barbetti *3; M. Martinetti *2; B. Salati *1; R. Lorini 4

1 Department of Paediatrics and 2 Immunohaematology and Transfusion Center, IRCCS Policlinico S. Matteo, Pavia, Italy; 3 Unit of Molecular Pathology of Diabetes, IRCCS San Raffaele Hospital, Milan, Italy; 4 Department of Paediatrics, G. Gaslini Institute, Genoa, Italy

Differential diagnosis of incidental hyperglycaemia (>100 mg/dl) (IH) includes MODY, an heterogeneous disease characterised by autosomal dominant inheritance, juvenile onset (<25 years of age), non-insulin dependence, absence of ketosis. Among the 58 subjects with IH followed at our Department (40 M and 18 F), 20 showed persistent fasting hyperglycaemia, family history of type 2 diabetes, and absence of autoantibodies. Based on these data MODY was suspected, up to now confirmed by genetic analysis in II cases (8 MODY-2, 1 MODY-3, 2 MODY-not2/not3). Case n.1. R., with a maternal axis positive for type 2 diabetes, showed hyperglycaemia (130 mg/dl) at 3.2 years of age, then confirmed in absence of polyuria, polydypsia, weight loss and autoantibodies against b -cell (GADA, IA-2A). Regular growth and BMI were observed. Oral glucose tolerance test (OGTT) and intravenous glucose tolerance test (IVGTT) were normal. Genetic analysis showed mutation of the glucokinase gene (MODY-2). During follow-up, all clinical examinations were unremarkable, the child actually follows a normocaloric diet without simple sugars. Degree of metabolic control is good (HbA1c mean levels 5.8%; n.v. 3.5-5.8%). Case n.2. J, an 11.3 year old girl, suffering from coeliac disease and following a gluten-free diet, showed IH during an admission to the hospital because of orthopedic surgery. Growth was higher than 97th percentile according to Tanner and BMI was 21.8. Familial history reported type 2 diabetes mellitus in both parents'relatives. Hyperglycaemia was confirmed, in absence of both GADA and IA-2A. IVGTT showed first phase insulin response below the 1st percentile and OGTT was compatible with diabetes mellitus. HLA typing was A33,2; CW7,X; B49(W4),45(W6); DR11(5),4; DQ3,3. The girl was prescribed a simple sugar- and gluten-free diet, and blood glucose levels returned to normal levels. Genetic analysis showed mutation in HNF-1a gene, compatible with MODY-3. During follow-up, overnight albumin excretion rate and eye fundus examination were normal. The girl was taught about self-management of diabetes, regularly performed, and the degree of metabolic control is good (HbAlc mean levels 5.6%). An IH with a familial history for type 2 diabetes mellitus could be a MODY. Since each form of MODY has different prognosis and outcome, a firm genetic diagnosis is mandatory for correct therapy as well as follow-up of vascular complications.

P3-523 - Diabetes Type 1 in Children under Five: Multicentre Study

M. Chueca *1; M. Oyarzabal 1; A. Sola *1; M. Aliaga *1; M.J. Lopez *2; C. Luzuriaga *3; I. Rica *4; M. Rodriguez *5

Pediatric Endocrinology Units, 1 Pamplona, 2 Valencia, 3 Santander, 4 Bilbao, Spain; 5 Zaragoza Hospital, Zaragoza, Spain

Onset of diabetes type 1 occurs in early infancy in a significant number of patients. Recent epidemiologic studies show a peak incidence in this age group in which difficulties in management of the disease increase.

Objectives: To compare the characteristics of children in this age group at disease onset between 1995 and 1999, and analyse metabolic control, acute complications and treatment regimen in both groups.

Material and Methods: From January 1, 1995 to December 31, 1999, 312 children at the different centres suffered the onset of diabetes: n = 60 <5 years and n = 252 between 5 and 15 years. Data analysed at onset are: clinical (Ketoacidosis [KAD]) and metabolic (basal and post-glucagon C-peptide) aspects; and during evolution: insulin treatment (number of injections and insulin doses [IU/kg/d], use of Lyspro), metabolic control (HbAlc) and acute complications (severe hypoglycaemias [HS] and KAD).

Results: Nineteen percent of diabetes onsets correspond to the <5 years group; the Hospital of Valencia presented the most patients in this group (56%) and the Hospital of Santander the least (12%) [c 2: 13.9, p < 0.01]. No significant increase was observed over these years in this age group, with C peptide being lower (p < 0.01) and onset more often in KAD n = 30, 52% (c 2: 6.23; p < 0.05). HS were more frequent during evolution in younger patients (11 with 13 HS vs. 5 with 5 HS, [c 2: 9.71; p < 0.01], with similar metabolic control), but not KAD; no differences were found in the remaining variables studied, except in the dose of insulin/kg/day which was lower in those <5 years/t = 2.33; p < 0.05); the latter follows a regimen of 3 injections in 51% of cases and 2 in 42%, compared with 61% with 3 injections and 27% with 2 in those over 5 years of age.

Conclusions: 1) Children under 5 with diabetes constitute an important group, with greater severity and more ketoacidosis at onset. 2) Severe hypoglycaemias in this age group must be particularly warned against and forseen because of possible repercussions in cognitive development.

P3-560 - Two New Mutations in the Vasopressin-Neurophysin-II Gene Associated with Familial Neurohypophyseal Diabetes insipidus

S. Rittig 1; C. Siggaard *1; V. Hána *2; L. Kovacs *3; Introduced by O. Wolthers

1 Skejby University Hospital, Aarhus, Denmark; 2 University Hospital of Prague, Prague, Czech Republic; 3 Comenius University Medical School, Comenius, Slovakia

Familial neurohypophyseal diabetes insipidus (FNDI) is a rare autosomal dominant disorder due to a deficient pituitary secretion of arginine vasopressin (AVP) and characterized by chronic polyuria and polydipsia. The deficiency of AVP secretion develops during early childhood and there is evidence that the deficiency is caused by degeneration of magnocellular neurons in the supraoptic nuclei. Since 1991 the disease has been linked to more than 30 different mutations in the gene encoding the vasopressin-neurophysin II protein. The exact mechanism by which the mutations cause the disease is still unclear.

Purpose: To investigate the molecular genetic background in two kindreds (Ho and Co) with clinical evidence of FNDI.

Methods: A sequencing method was used for sequenase dye-terminator sequencing directly on single-stranded PCR-amplified genomic DNA obtained from a blood sample. The sequencing results were confirmed by restriction enzyme digestion analysis.

Material: In family Ho, 3 affected individuals from three generations were analyzed and in family Co, 4 affected from four generations were studied. All affected subjects had severe polyuria and polydipsia since childhood.

Results: The results showed that the affected subjects in each of the 2 families had a new and so far unreported single base mutation in the coding region of the AVP-NPII gene. In the Co family, the 4 studied affected members all had a mutation in exon 2 (T1907-->G, predicting Cys73-->Gly) located in the highly preserved part of NPII. This mutation, which eliminates an important disulphide bridge in the carboxyterminal end of the hormone precursor protein, co-segregated perfectly with the disease phenotype in this family. The Ho kindred had a missense mutation in exon 1 (G227-->A, predicting a deletion of 4 amino terminal residues of the signal peptide, SP-19-16). This mutation is likely to severely interfere with proper targeting and cleavage of the signal peptide moiety. Conclusion: In summary, we have identified 2 new gene mutations that are likely to induce conformational changes of the three-dimensional NPII structure that could impair the normal intracellular processing of the pro-hormone. This is consistent with the hypothesis that FNDI is caused by a toxic effect of abnormally folded precursor protein.

R-39 - Diabetic Nephropathy in a Prepubertal Child with Insulin Dependent Diabetes mellitus

B. Yüksel 1; N. Ö. Mungan 1; A. Beyazit 1; G. Özer 1; Introduced by P. Cinas

1 Cukurova University Medical Faculty, Adana, Turkey

Diabetic nephropathy is a rare complication in children with IDDM in prepubertal age group. An 11-year-old girl who was Tanner stage I was diagnosed as diabetic nephropathy by renal biopsy findings. She had history of six years duration of poor metabolic control of diabetes with inadequate dietary and medical compliance. She had significant growth retardation, hypertension, hyperlipidemia and overt proteinuria. A percutaneus renal biopsy was performed. On light microscopic examination increased mesangial matrix and glomerular basement membrane thickening were seen in all glomeruli. Also mesangial matrix formation was noticed in a few glomeruli. Immunofluourescence microscopy showed linear staining for IgG in glomeruli basement membranes. She was in Stage IV diabetic nephropathy with the presence of overt proteinuria and hypertension. After beginning the angiotensin converting enzyme inhibitor to our patient, her proteinuria gradually decreased and her hypertension normalized with the metabolic control of hyperglycemia.

R-42 - Subclinical Neuropathy in Children with Type 1 Diabetes mellitus

A. Bideci 1; P. Cinaz 1; A. Serdaroglu 2; L. Tümer 1; Ö. Turan 2

Departments of 1Pediatric Endocrinology and 2 Neurology, Gazy University, Ankara, Turkey

Objective: Neuropathy is one of the chronic complications of Diabetes mellitus. Peripheral and autonomy neuropathy are mostly seen in adulthood. However it is reported that nerve conduction velocity (NCV) might be decreased in 20% of diabetic children in the first 5 years of their illness. The aim of this study was to investigate NCV in diabetic children in the early period.

Patients and Methods: 16 diabetic children with age range of 5-16 years (13.6 ± 3.13) were studied. Mean duration of their illness was 6.66 ± 3.43 years (1-12.6). Mean dose of insulin was 0.72 ± 0.16 U/kg/day (0.33-1.1) and mean HbA1c level was 10.6 ± 1.9% (6.7-13.8%). NCV was measured from medial, ulnar, sural, peroneal and tibial nerves.

Results: There was no relationship between NCV, age and HbA1c levels. A negative correlation was found between nerws tibialis and peronealis motor conduction velocities and duration of the illness (r = -0.67, p = 0.004; r = -0.64, p = 0.008 respectively). There was no reduction in the upper extremity motor nerve conduction velocities.

Conclusions: As a result these data indicate that although clinical neuropathy is rare in diabetic children, subclinical neuropathy may develop and periodic NCV measurements are recommended to follow the neurologic complications.

R-43 - Estimation of Risk of Type 1 Diabetes by in vitro GAD Response

M. Zafranskaya 1; J. Boiko 2; A. Milyutin 1; A. Solnzeva 3; Introduced by Y. Boiko

1 International Sakharov Environmental University, Minsk, Belarus; 2 Belarusian State Institute for Medical Studies, Minsk, Belarus; 3 City Endocrinology Dispensary, Minsk, Belarus

According to one of the hypotheses type 1 diabetes is due to a self antigen in islet beta cells, such as glutamic acid decarboxylase (GAD), activating the autoimmune process. The second hypothesis suggests that the immune response, directed against a non-self antigen, containing a peptide sequence homologous with a self-antigen, could activate the autoimmune process against self antigen.

Objective: To study the cellular immune response to GAD in order to estimate its potential role in the pathogenesis and prediction of type 1 diabetes.

Material and Methods: Peripheral blood was obtained from 18 diabetic patients (median age: 13.8, range 6-19 yrs; median diabetes age: 4.5, 1.5-8 yrs), from 21 of their siblings (median age: 14.4, 5-20 yrs) and 15 healthy controls of similar age. Cultural method with GAD (final concentration: 5 mkg/ml) as a mitogen was used. Proliferative activity was estimated after 72 h culture followed by an overnight pulse with tritiated thymidine ([3H]TdR).

Results: Significant reduction of initial proliferative activity was established in children with type 1 diabetes (p < 0.05). The similar tendency in changes of investigated parameters was found in their non-diabetic siblings. PBMC from diabetic patients being reacted with GAD through the magnitude of the response was low in contrast to the control group (p < 0.01). The tendency to the decreased proliferative response to specific autoantigen also was fixed in siblings.

Conclusion: Cellular immune response to GAD could be taken as a criterion for revealing groups of children with high risk of type 1 diabetes development. Identification of the autoimmune response to specific autoantigens in the pre-diabetic period could rise the prospect of prediction and prevention of type 1 diabetes.

R-44 - Severe Diabetic Cardiomyopathy as a First Early Complication in a 14-Year-Old Girl with Insulin Dependent Diabetes mellitus

A. Buyukgebiz 1; G.S. Saylam 1; N. Unal 1; B. Dundar 1; E. Bober 1; A. Akcoral 1

1 Dokuz Eylül School of Medicine, Izmir, Turkey

Diabetic cardiomyopathy has been reported in type 2 diabetics with short duration of known disease. Impaired left ventricular function has been reported in the young patients with insulin dependent diabetes mellitus (IDDM) but the severe cardiomyopathy due to IDDM as first early major complication without other diabetic complications is very rare. We report a 14-year-old girl who was diagnosed as IDDM 5 years ago and referred to our clinic because of congestive heart failure. High HbA1c values due to poor glycemic control were determined. Dilated cardiomyopathy was diagnosed in M mode 2-dimensial Doppler echocardiography. There was no evidence of infective or metabolic disorder to cause cardiomyopathy except IDDM. Diabetic cardiomyopathy was the first and unique complication of IDDM and major complications of IDDM such as retinopathy, nephropathy and neuropathy were not determined in the patient.

S2-10 - Epidemiological and Clinical Aspects of Type 2 Diabetes in Children

D.E. Hale *1

1 Division of Pediatric Endocrinology and Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA

The prevalence, incidence and clinical characteristics of type 2 diabetes (DM2) in children are unknown and DM risk factors have not been systematically surveyed.

Objective: The 3 objectives are: (1) to estimate the prevalence and incidence of DM2 in Mexican American (MA) children; (2) to examine the clinical features of DM2 and compare them with DM1; (3) to examine DM risk factors in school age children.

Patients and Methods: Epidemiology: Our group provides pediatric diabetes care for a large portion of south Texas (~475,000 <18 years old, ~56% MA). Records on youth newly diagnosed between 01/01/90 and 12/31/98 were reviewed. Crude incidence was estimated based on new diagnoses and census data. The classification of diabetes type was based on clinical presentation, family history, physical examination, clinical course and response to therapy. Risk factors: A cross-sectional project investigating the prevalence of DM risk factors in urban, poor MA adolescents (6th- 8th grade) was undertaken. Youth/family answered a risk factor questionnaire and had height, weight, blood pressure, and nuchal acanthosis nigricans assessed. A fasting blood specimen was drawn for glucose, insulin and HgbA1c levels on a subset.

Results: Epidemiology: The incidence of DM2 rose sharply in MA youth between 1990 and 1998: in 1998 the apparent incidence was about 10/100,000/year, and exceeded that of DM1 in this population. During the same period, there has been no change in the incidence of DM1. Clinical features: Of children with DM2, 82% were MA. Of all MA youth with diabetes, 31% had DM2. At diagnosis, 87% with DM2 were ³ 10 years old and pubertal. The great majority (82%) had BMI >25 kg/m2 (mean BMI at diagnosis 28.5 ± 10.2 kg/m2. Acanthosis nigricans was common (93%). The parents often had diabetes (70%). In most children, insulin (72%) and/or C-peptide (58%) levels were obtained. The insulin (mean = 58 µU/ml) and C-peptide (mean = 4.2 ng/ml) were elevated. Anti-islet cell and antiGADab were obtained in some youth and were negative. Risk factors: Of 474 poor MA 6th-8th graders, 60.3% had at lease 1 DM risk factor (past history of DM, 1st or 2nd degree relative with DM, BMI >85%, evidence of insulin resistance). Fasting blood was obtained on 97: 27 had a fasting insulin >20 µU/ml, 7 had fasting glucose ³ 110 and <126 mg/dl, and 1 ³ 126 mg/dl (all subsequently confirmed). Total cholesterol was >170 mg/dl in 48% and LDL cholesterol was >110 mg/dl in 8%.

Conclusions: DM2 is increasingly common in MA children and youth. Clinical features that distinguish them from DM1 are high BMI, strong family history and acanthosis nigricans (and other evidence on insulin resistance). The risk factors for DM2 and related co-morbidities are readily demonstrable in school age children.

S2-9 - Heterogenety of Type 2 Diabetes: Lessons from Mody

A.T. Hattersley 1

1 School of Postgraduate Medicine, University of Exeter, Exeter, UK

Paediatric diabetes is not traditionally considered a diagnostic speciality, however there is considerable heterogeneity in the aetiology of the diabetes seen in children and adolescents. The recognition of the discreet subgroups is very important for determining the prognosis and appropriate treatment. The subgroups that result in the non-insulin dependent diabetes in the paediatric age group are: Type 1 diabetes in the honeymoon phase, Type 2 diabetes, genetic syndromes including diabetes, and maturity onset diabetes of the young (MODY). The relative prevalence of these different subgroups depends on the population being studied. In the UK, predominantly white European Caucasian clinic, MODY is more than 10 times more prevalent than Type 2 diabetes. In this lecture it is emphasised that maturity-onset diabetes of the young should be considered as two discreet clinical syndromes: glucokinase diabetes and transcription factor diabetes (which result from mutations in Hepatocyte Nuclear Factor (HNF) 1a , HNF1b , HNF4a , and Insulin Promoter factor (IPF) 1). The making of a molecular genetic diagnosis is important as these discrete genetic subgroups have specific clinical patterns and responses to therapy.