Exercise improves the ApoB/ApoA‐I ratio,a marker of the metabolic syndrome in obese children

Aim: This study was designed to examine the effect of training on components of the metabolic syndrome and ApoB/ApoA‐I ratio in obese children. Methods: We studied thirty‐two obese children (13.3 ± 0.4 years) with 16 subjects who participated to 8‐week training and 16 subjects serving as a control group. Training was individualized at the point where fat oxidation was maximal (Fat max). In each subject, pre‐ and postintervention anthropometric measures and biochemical tests on fasting blood were performed. Results: After the programme, the training group showed an increase in VO_2peak and fat oxidation during exercise. Body mass index (BMI), blood glucose and triglycerides were reduced, and high‐density lipoprotein (HDL) was increased. ApoB/ApoA‐I ratio decreased significantly (?0.43%, p < 0.01). Systolic and diastolic blood pressure also decreased (?8.4% and ?10.9%, respectively). Among the training group, 10 subjects were classified as having the metabolic syndrome before the intervention and none after. No significant changes in any other variables were measured in the control group. Conclusions: Training targeted at Fat max reduces the prevalence of metabolic syndrome and its associated factors in obese children. In particular, this intervention decreases the ApoB/ApoA‐I ratio, which may be considered as a marker for following this syndrome.     

Lipoprotein (a) and apolipoprotein A-1 and B in schoolchildren whose grandparents had coronary and cerebrovascular events: A preliminary study of 12–13 year old Japanese children

The aim of this study was to evaluate the relationship between the serum levels of lipoprotein (a) [Lp (a)] and apolipoproteins (apo A-1 and apo B) in schoolchildren with a history of coronary and cerebrovascular events in their grandparents. We measured serum concentrations of Lp (a) and apoliproteins immunochemically in 289 schoolchildren aged 12–13 years and questioned parents about coronary and cerebrovascular events in the children's grandparents. In boys and girls, mean ± s.d. levels of apo A-1, apo B and Lp (a) were 134 ± 20.3 and 136 ± 17.4 mg/dL, 61 ± 16 and 66 ± 15 mg/dL and 12.5 ± 15.3 and 12.5 ± 15.1 mg/dL, respectively. There were no significant sex differences in the levels of apo A-1, apo B, and Lp (a). The Lp (a) levels (mean ± s.d., 12.5 ± 15.2 mg/dL; median 7.5 mg/dL, n = 289) were not affected by other variables. The Lp (a) distribution was strongly positively skewed and 75% of schoolchildren had very low levels. In the total 289 schoolchildren, thirty-two grandparents who had had coronary vascular events (21 myocardial infarction, 11 angina pectoris) and twenty-three grandparents who had had cerebrovascular events were recorded. By the boxplot statistical analysis, no difference was found in Lp (a) levels in children whose grandparents had myocardial infarction compared with those whose grandparents had no such history, or compared with those whose grandparents had suffered cerebrovascular events. Analysis also showed that the values of log Lp (a) in children whose grandparents had myocardial infarction tended to be higher than the values in children whose grandparents had no such history (P = 0.09). No significant differences in the levels of apo A-1 and apo B and in the apo B/A-1 ratio could be seen between children grouped according to the presence or absence of coronary and cerebrovascular events in their grandparents. These results suggest that high levels of Lp (a) in schoolchildren aged 12–13 years may partly reflect the existence of coronary vascular disease in older family members. Lp (a) may account for the strongest index of family history to disease risk in comparison with other apolipoproteins. Further study is needed to clarify the appropriate mass measurement method for Lp (a) in schoolchildren.     

Lipid profiles in Polish adolescents from high- and low-risk families: tracking unfavourable lipid levels over a one-year period

In a country with a high cardiovascular mortality rate, lipid profiles were studied in 929 adolescents (440 from affected and 489 from non-affected families for cardiovascular disease and hypercholesterolaemia). In 334 children with elevated or borderline total cholesterol level, lipid profiles were re-measured after a 1-y period. In boys from affected families, in contrast to boys from non-affected families, significantly higher total cholesterol levels (4.36 +/- 0.81 vs 4.19 +/- 0.78 mmol/L, p < 0.05) and LDL-C level (2.1 +/- 0.72 vs 1.89 +/- 0.79 mmol/L, p < 0.05) and significantly lower HDL-cholesterol levels (1.81 +/- 0.34 vs 1.93 +/- 0.38 mmol/L, p < 0.05) were found. The odds ratio for being in the most unfavourable decile for LDL-cholesterol was significantly higher for girls from affected families (2.17, p = 0.02). A relatively high HDL-C level as well as a favourable TC/HDL-C ratio was demonstrated in all groups, being lowest in boys from affected families. A significant correlation was found between baseline lipids and their values re-measured after 1 y. It is concluded that (1) adolescents with a positive family history are at increased risk for unfavourable lipid profile, (2) adolescents with elevated total cholesterol and LDL-cholesterol levels remain hypercholesterolaemic after a 1-y period and are therefore candidates for further biochemical and clinical monitoring, and (3) children with elevated total cholesterol may not be at high risk for cardiovascular disease owing to the favourable TC/HDL-C ratio. The study results do not indicate that general cholesterol screening in Polish adolescents is necessary, as the proportion of children with elevated LDL-cholesterol is relatively low.     

Bone infarction in children with sickle cell disease: early diagnosis and differentiation from osteomyelitis

An early differential diagnosis between bone infarction and osteomyelitis in sickle cell patients is practically impossible using routine laboratory methods. Twenty radioisotope studies in sickle cell patients during vaso-occlusive crises, were analyzed. A three stage process can be described. In the first stage a decreased uptake can be demonstrated by Tc 99 m methylene diphosphanate (MDP) bone scanning. In osteomyelitis, an increased uptake area is usually seen at this early stage, corresponding to increased uptake in Ga-67 citrate scanning. At the second stage, approximately a week later, normal uptake can be seen. Two to four weeks later an area of increased uptake is recorded that corresponds to the healing process, stage three. We recommend therefore Tc 99m MDP bone scanning in the early stages if clinical signs and symptoms suggest a vaso occlusive crisis or osteomyelitis in a sickle cell patient. This study can be followed by a Ga-67 citrate scintigraphy in doubtful cases. Later studies should be used for the assessment of the healing process. Two illustrative case reports are included.     

Early predictors of myocardial disease in children and adolescents with type 1 diabetes mellitus

Background: The spectrum of diabetic heart disease involves a progression from normal heart to preclinical left ventricular diastolic and systolic dysfunction followed by overt echocardiographic evidence of left ventricular (LV) dysfunction and finally symptomatic heart failure. Objective: To compare the value of tissue Doppler imaging (TDI) over the conventional echocardiography in the assessment of early myocardial dysfunction in type 1 diabetics in correlation with serum N‐terminal pro‐brain natriuretic peptide (NT‐pro‐BNP), state of metabolic control, and diabetes duration. Methods: Sixty subjects were included; 40 type 1 diabetics (aged 12–18 years). Twenty matched subjects served as controls. They were subjected to clinical examination with assessment of cardiovascular reflexes for autonomic neuropathy. Laboratory investigations included mean random blood sugar (MRBS), hemoglobin A1c (HbA1c), urinary microalbumin, and serum determination of NT‐pro‐BNP. Echocardiography for chamber dimensions, systolic and diastolic function, Tie index, and longitudinal myocardial global biventricular function by pulsed TDI of 6 LV walls and right ventricle (RV) free wall. Results: All diabetics and controls had normal LV dimensions, LV mass index and systolic functions except for higher left ventricular posterior wall (LVPW) in diabetics (P < 0.05). LV and RV diastolic dysfunction diagnosed in 25% of diabetics by conventional Doppler with higher peak A (P < 0.05, P < 0.05) and lower E/A (P < 0.05, P < 0.05) compared to controls. Diabetics had larger Tie index (P < 0.05). TDI showed delayed myocardial relaxation in 52.5% of diabetics with lower LV and RV peak Em (P < 0.05, P < 0.01) and Em/Am (P < 0.01, P < 0.001) compared to controls. NT‐pro‐BNP was elevated in diabetics (P < 0.01) with best cut‐off value = 62.5 Fmol/mL, sensitivity (82%), and specificity (95%) for detection of isolated diastolic dysfunction in diabetics. It was correlated negatively with LV Em (P < 0.05), Em/Am (P < 0.01) and positively with Am (P < 0.01), impaired diastolic velocities were associated with higher HbA1c. Conclusion: Asymptomatic diabetics had evidence of subtle right and LV dysfunction with delayed myocardial relaxation which was related to metabolic control. Tissue Doppler (TD) has an additional value in evaluating ventricular filling. NT‐pro‐BNP is considered a sensitive, specific, and predictive marker for diastolic dysfunction.     

Autonomic function in Kawasaki disease with myocardial infarction: Usefulness of monitoring heart rate variability

BACKGROUND: Despite anticoagulant therapy, many patients with Kawasaki disease and giant coronary artery aneurysm develop myocardial infarction. These patients have a high risk of sudden death, but the etiology is not clear. We studied autonomic function and the possibility of malignant ventricular arrhythmia through heart rate variability. METHODS: We studied six Kawasaki disease patients with myocardial infarction and 16 normal controls. Heart rate variability was investigated using a 24 h electrocardiogram. We assessed the standard deviation from the mean of the normal R-R intervals (SDNN), the proportion of adjacent R-R intervals with a difference greater than 50 msec (pNN50) and the root-mean square of successive R-R differences as time-domain analysis (rMSSD). We assessed very low-frequency power, low-frequency power (LF), high-frequency power (HF) and the LF/HF ratio in frequency-domain analysis. RESULTS: There was no significant difference in SDNN, but there was a significant difference in pNN50 and rMSSD. Patients with Kawasaki disease showed lower HF and higher LF/HF than normal controls. CONCLUSION: Our findings suggest that patients with Kawasaki disease and myocardial infarction show decreased vagal activity, which could cause malignant arrhythmia.     

Increased ApoB/ApoA1 ratio is associated with excess weight,body adiposity,and altered lipid profile in children

Objective

To investigate ApoB/ApoA1 ratio and its association with cardiovascular risk factors in children.

Basal insulin switch from NPH to glargine in children and adolescents with type 1 diabetes

Background:  Insulin glargine is a long-acting insulin analogue increasingly used instead of neutral protamine Hagedorn (NPH) insulin in young subjects with type 1 diabetes.
Objective:  We evaluated the clinical course of diabetes in children and adolescents who were switched from NPH to insulin glargine.
Methods:  Between August 2003 and November 2004, a total of 76 subjects were switched to glargine in our clinic, treating 340 children with type 1 diabetes. All the subjects had been receiving insulin NPH, and their serum C-peptide levels had been non-detectable for at least 1 yr. Data were collected retrospectively, and 12–18 months after the change, experiences with glargine were inquired using a questionnaire. Seven subjects (9.2%) discontinued glargine before 12 months, and seven refused to participate.
Results:  Data for 62 subjects were analyzed. At the switch (0 months), their mean age was 12.7 yr (range 5.1–17.5), mean duration of diabetes was 6.7 yr (range 1.8–14.3), and mean hemoglobin A1c was (HbA1c) 9.2%. Twelve months later (+12 months), the mean HbA1c remained similar (9.2%), the proportion of long-acting insulin was smaller (47.7 vs. 58.1%; p < 0.001), and the daily insulin dose was lower (0.97 vs. 1.05 IU/kg; p < 0.001). The number of injections was lower at +12 months (17.7% with more than five injections vs. 64.5%; p < 0.001). No differences were seen in weight for height or the number of severe hypoglycemias. Most subjects who continued with glargine for ≥12 months considered glargine better than NPH.
Conclusions:  A switch to insulin glargine retains a similar glycemic control and does not change the number of severe hypoglycemias.     

Initiation of insulin glargine in children and adolescents with type 1 diabetes

BACKGROUND: Glargine (Lantus) is a recently approved, long-acting insulin analog that is increasingly being used in children with diabetes. The aim of this retrospective chart review was to summarize our experience in starting glargine in children and adolescents with diabetes. SUBJECTS AND STUDY METHODS: We reviewed the medical records of 71 children with type 1 diabetes (29 boys and 42 girls) who initiated glargine therapy to improve glycemic control between 1 June 2001 and 30 June 2002. Data were collected for 6 months before and 6 months after adding glargine. RESULTS: Subjects' mean age [+/-standard deviation (SD)] at diagnosis of diabetes was 7.5 +/- 4.1 yr. Mean age at initiation of glargine therapy was 11.5 +/- 4.9 yr. The total daily long-acting insulin dose decreased by about 20% after initiating glargine therapy. There were no significant differences in hemoglobin A1c (HbA1c) and blood glucose control prior to and after initiating glargine therapy (HbA1c at baseline 8.9 +/- 1.6% and HbA1c after 6 months of glargine therapy was 8.9 +/- 1.5%). Overall, blood glucose concentrations did not differ significantly throughout the study. Patients who switched to glargine because of nocturnal hypoglycemia had a 65% decrease in nocturnal blood glucose reading less than 50 mg/dL. There were three seizures in the first week after initiating glargine therapy. CONCLUSION: This retrospective study suggests that glargine is at least as effective as other long-acting insulins but that care must be taken during the conversion process to avoid hypoglycemia.     

Monitoring for retinopathy in children and adolescents with type 1 diabetes

In children with an average diabetes onset at 11 y of age, the first retinal changes can be expected after a median diabetes duration of 9y, while the median time until clinically relevant background retinopathy is 14 y. Periodic examinations of the retinal status become necessary with the onset of puberty or after 5y of diabetes duration. Only sensitive methods should be used for retinopathy screening; the minimum recommended standard is a stereoscopic slit-lamp biomicroscopic examination in mydriasis. The degree of glycaemic control, both before and after puberty, appears to be of outstanding importance for the development of retinopathy, but the contribution of other factors (arterial blood pressure, lipid abnormalities, sex steroids, smoking and genetic factors) may be of varying relevance in the individual patient. Thus, to improve the long-term prognosis for children with diabetes appropriate screening for retinopathy and associated risk factors is mandatory.     

Complementary and alternative medicine use in children and adolescents with type 1 diabetes

BACKGROUND:

The use of complementary and alternative medicine (CAM) in paediatric patients varies between 11% and 68%. There are limited reports of its use in children with type 1 diabetes mellitus (T1DM).

OBJECTIVE:

To describe the use of CAM in children with T1DM, and the perceptions of both users and nonusers regarding the effect of CAM on diabetes management.

DESIGN/METHODS:

A cross-sectional, anonymous questionnaire survey was mailed to a randomly selected subgroup of patients with T1DM. Each patient’s main caregiver was asked to complete the questionnaire.

RESULTS:

Of 403 questionnaires mailed, 195 (48%) were completed. The mean (± SD) age of the children was 12.2±4.0 years (56% boys). Use of CAM was reported in 110 children (56%) (vitamins/minerals [n=99], herbal medicine [n=22], dietary supplement [n=13]). When excluding the use of vitamins/minerals, the CAM number dropped to 47 children (24%). Only the current age of the child was significantly different between users and nonusers of CAM. In users, reasons cited for using CAM were to minimize symptoms, improve control, prevent complications and add benefits to insulin. Only 30% of CAM users stated that CAM improved diabetes control. Nonusers cited satisfaction with current diabetes treatment and lack of knowledge as reasons for not using CAM.

CONCLUSIONS:

CAM use in children with T1DM was frequent, and appeared to be an attempt to improve control or prevent diabetes complications. However, improved control was not reported as a benefit. Diabetes care teams should assess the use of CAM in children with T1DM, and monitor for any potential positive or negative effects.     

Psychological issues in the care of children and adolescents with type 1 diabetes

The present article highlights some of the psychological issues in children and adolescents with type 1 diabetes and provides health professionals with some strategies for addressing them.