Shereen Abdelghaffar

BACKGROUND: Preterm neonates comprise the most heavily transfused group of patients, and about 85% of extremely low birth weight newborns receive a transfusion by the end of their hospital stay. The aim of this study was to assess the possible metabolic effects of RBC transfusion on preterm infants, especially during the first 2 weeks of life, and its relation to blood volume.

MATERIALS AND METHODS: This study was conducted on 40 preterm neonates with gestational age of less than or equal to 34 weeks. They received RBCs transfusion during first 2 weeks of life. Venous blood samples of infants were collected 2 to 4 hours before and 1 hour after the end of transfusion to evaluate hemoglobin (Hb) level, hematocrit, acid-base, electrolytes, and glucose status. Then, infants were classified into two main groups: those who received RBCs volume less than or 20 ml/kg and those who received RBCs volume more than 20 ml/kg.

RESULTS: Infants received a mean volume of 20.38 ± 3.2 ml/kg RBCs (range, 10.9 - 26.6 ml/kg) at a median age of 9.8 ± 3.6 days. After transfusion, a significant increase of mean Hb (P<0.001), mean Hct (P<0.001), pH (P<0.001), pO(2) (P<0.05), and a significant decrease of the pCO2 (41.46 ± 8.8torr vs 35.4 ± 9.34 torr; P<0.001) were observed. In addition, there was a significant increase of serum K(+) (P<0.001), and a significant decrease of Ca(+2) (P<0.001). A positive correlation was found between the K(+) intake and the changes of kalemia (r = 0.99; P = 0.00). Furthermore, we observed an inverse correlation between the patients' calcium intake and the changes of calcemia (r = -0.35; P = 0.02). On comparing the changes in clinical and biochemical variables between two groups after transfusion, we observed a significant increase in mean Hb and Hct associated with a significant decrease in mean serum Ca(+2) (P<0.001) in the group receiving the larger blood volume.

CONCLUSION: RBC transfusion was effective in improving anemia, oxygenation, increasing pH, and decreasing CO(2) and Ca(+2). However, from a more clinically relevant point of view, we demonstrated the development of hyperkalemia, especially in infants with a previously borderline hyperkalemia.

End-stage renal failure is still a leading cause of mortality among type 1 diabetes patients. Insulin resistance plays a larger role in type 1 diabetes disease process than is commonly recognized. Detection of diabetic nephropathy as early as possible currently offers the best chance of delaying or possibly preventing progression to end-stage disease. Renal resistive index (RI) and pulsatility index (PI), measured using renal Doppler ultrasonography, reflect intrarenal vascular resistance. The present work aimed at examining renal Doppler indices (RI and PI) in type 1 diabetic children and their relation to features of insulin resistance and other established parameters of early diabetic nephropathy as microalbuminuria. One hundred diabetic children with a mean age of 13.4 ± 2.9 yr and an average diabetes duration of (7.2 ± 2.5 yr) were included. Thirty healthy children served as controls. All renal Doppler indices were significantly higher in children with type 1 diabetes mellitus (p ≤ 0.01). The worst parameters were observed in children diagnosed with insulin resistance syndrome (IRS) (38%), hypertensive (12%), and obese (4%) children. Resistive index showed a significant correlation to blood pressure (r = 0.2, p = 0.04), waist-hip ratio (r = 0.5, p = 0.02), insulin dose (r = 0.2, p = 0.02) and estimated glucose disposal rate (r = -0.5, p = 0.01). No correlation was noted to microalbuminuria, HbA1c, or duration of diabetes. The present work concluded that renal Doppler indices are worse in diabetic children and particularly those with IRS. These children appear to be at graver risk for diabetic nephropathy. In these patients adding renal Doppler assessment to their work up, might diagnose diabetic nephropathy at a prealbuminuric stage.

BACKGROUND: In adolescents with type 1 diabetes, insulin resistance likely plays a role in the deterioration of metabolic control. In type 1 diabetes, addition of metformin to insulin therapy, to improve insulin sensitivity, has been assessed in a few trials involving few patients or in uncontrolled studies of short duration. No systematic reviews are available up to date to summarize the evidence about metformin addition to insulin therapy in adolescents with type 1 diabetes.

OBJECTIVES: To assess the effects of metformin added to insulin therapy for type 1 diabetes mellitus in adolescents.

SEARCH STRATEGY: We searched The Cochrane Library, MEDLINE and EMBASE. We also searched databases of ongoing trials, reference lists of relevant reviews, and we contacted experts, authors and manufacturers.

SELECTION CRITERIA: Any randomised controlled trial (RCT) of at least three months duration of treatment comparing metformin added to insulin therapy versus insulin therapy alone in adolescents with type 1 diabetes was included. Cross-over and quasi-randomised controlled trials were excluded.

DATA COLLECTION AND ANALYSIS: Two reviewers read all abstracts, assessed quality and extracted data independently. Authors were contacted for missing data.

MAIN RESULTS: Only two trials (60 participants) investigating the effect of metformin added to insulin therapy for three months in adolescents with poorly controlled type 1 diabetes could be included. Meta-analysis was not possible due to the clinical and methodological heterogeneity of data. Both studies suggested that metformin treatment lowered glycosylated haemoglobin A1c (HbA1c) in adolescents with type 1 diabetes and poor metabolic control. Improvements in insulin sensitivity, body composition or serum lipids were not documented in either study, however, one study showed a decrease in insulin dosage by 10%. Adverse effects were mainly gastrointestinal in both studies and hypoglycaemia in one study. No data on health-related quality of life, all-cause mortality or morbidity are currently available.

AUTHORS' CONCLUSIONS: There is some evidence suggesting improvement of metabolic control in poorly controlled adolescents with type 1 diabetes, on addition of metformin to insulin therapy. Stronger evidence is required from larger studies, carried out over longer time periods to document the long-term effects on metabolic control, health-related quality of life as well as morbidity and mortality in those patients.

To establish the optimal age of sexual maturation in Egyptian children, Tanner's maturity stages were determined for a sample of children and adolescents (1550 girls, 1563 boys) ranging from 6.5 to 18.5 years. The mean age for attainment of pubic hair (stage PH2) was 10.46 (SD 1.36) years for girls and 11.86 (SD 1.45) years for boys. For axillary hair (stage A2), mean age was 11.65 (SD 1.62) years for girls and 13.55 (SD 1.52) years for boys. The mean age at menarche in girls was 12.44 years and for breast development (stage B2) was 10.71 (SD 1.30) years. Testicular volume by palpation showed that the mean age of genital stage G2 for boys was 10.56 (SD 1.40) years. The study results can aid in the assessment of sexual maturation and pubertal disorders in Egyptian adolescents.

Cardiovascular disease and the development of coronary artery atherosclerosis play a pivotal role in increasing mortality in patients with diabetes. The aim of the present study was to determine the presence of subclinical atherosclerosis (measured as carotid intima-media thickness [cIMT] and to study possible associated risk factors in adolescents with type 1 diabetes. Forty type 1 diabetic subjects, aged 11-30 years, with duration of diabetes 3-25 years and 40 normal healthy controls, were included. Blood pressure (BP) measurement, as well as screening for diabetic complications, was performed. Lipid profile, albumin/creatinine ratio, renal functions and glycosylated hemoglobin (HB A(1)c) were assayed. Carotid intima-media thickness (cIMT) was measured using ultrasound. The mean aggregate cIMT was higher in diabetics than controls (0.6 mm 00 +/- 0.1 vs. 0.4 mm +/- 0.1, p = 0.000). Moreover, it was higher in patients with positive family history of type 2 diabetes than in those with negative family history (mean 0.7 mm +/- 0.1 vs. 0.6 mm +/- 0.1, p = 0.018). cIMT was found to positively correlate with: age in both diabetics and controls (r = 0.76, p = 0.000, r = 0.74, p = 0.000 respectively), body mass index (BMI) in diabetics but not controls (r = 0.82, p = 0.000, r = 0.30, p = 0.06 respectively). In diabetics, mean aggregate cIMT positively correlated with duration of diabetes (r = 0.66, p = 0.000), systolic blood pressure (r = 0.82, p = 0.000), diastolic BP (r = 0.83, p = 0.000), as well as HB A1c (r = 0.40, p = 0.004) and correlated negatively with high density lipoprotein -cholesterol (HDL-C) (r = -0.88, p = 0.000). As cardiovascular morbidity is high in diabetes, non-invasive methods for monitoring vascular changes as cIMT might be useful in clinical practice for early diagnosis of subclinical atherosclerosis, which can allow for strategies designed to reduce the cardiovascular event rate in those patients.

Expression and storage of breast milk is way to maintain breastfeeding when mother and infant are separated, if the nutritional value can be conserved. Three expressed breast milk samples were collected from 61 healthy lactating mothers in Cairo, Egypt, for determination of total protein, fat, lactose and zinc content, as well as vitamins C, A and E concentrations. One sample was analysed immediately without storage, 1 after storage for 24 hours in a refrigerator (4 degrees C) and 1 after storage for 1 week in a home freezer (-4 degrees C to -8 degrees C). Refrigeration and freezing of breast milk caused a statistically significant decline in levels of vitamins C, A and E. Nevertheless, the values of all nutrients were still within the international reference ranges for mature breast milk.

Sufficient data relating urinary iodine excretion in children to other iodine deficiency indicators are lacking in Egypt. We assayed urinary iodine concentration and serum levels of thyroid stimulating hormone (TSH), thyroglobulin, free triiodothyronine (T3) and free tetraiodothyronine in 99 school-aged Egyptian children. Goitre was found in 25 children. Median urinary iodine concentration was 70 microg/L. We found mild iodine deficiency (50-99 microg/L) in 60.6 % of the children and moderate to severe deficiency (< 50 microg/L) in 31.3%. The latter showed a high frequency of goitre and elevated mean serum free T3, TSH and thyroglobulin levels. Individual urinary iodine excretion rates vary, therefore these other indicators could help in screening for iodine deficiency at an individual level, especially in moderate to severe deficiency.

The X-linked androgen insensitivity syndrome (AIS) encompasses a heterogeneous group of defects in the androgen receptor (AR) that result in varying degrees of undermasculinization. In the current study, we characterize the R840S mutation on exon 7 of the AR ligand-binding domain. The Egyptian patient, who had been reared as female, presented ambiguous genitalia at 6.5 yr. Diagnosis of partial AIS (PAIS) was based on clinical phenotype and laboratory evidence of good testosterone response and normal testosterone/dihydrotestosterone (T/DHT) ratio. The therapeutic response to testosterone depot injections justified reassignment to male sex. To our knowledge, this mutation has been reported only once in two Brazilian brothers with PAIS. Three other mutations of this residue (R840C; R840G, nonconservative; and R840H, conservative) have been reported in patients with PAIS and, when expressed in vitro, they led to subnormal transactivation of a reporter gene. Each of these mutations was associated with a very diverse spectrum of phenotypes. These data highlight the role of the AR ligand-binding pocket (LBP) in the expression of transcriptional activity during prenatal sex differentiation.

The role of homocysteine as an independent risk factor for vascular endothelial damage, and the possible link between homocysteine and tumour necrosis factor-alpha (TNF-alpha) as two synergistic risk factors for beta-cell apoptosis in type 1 diabetes mellitus was studied. Plasma homocysteine levels were significantly elevated in all diabetic patients compared with controls and diabetic patients with vascular complications showed higher elevations. Furthermore, homocysteine levels showed significant positive correlation with the degree of microalbuminuria. TNF-alpha levels were elevated in all diabetic patients compared with controls. These results may have therapeutic implications.