Impact of serum hepcidin and inflammatory markers on resistance to erythropoiesis-stimulating therapy in haemodialysis patients.

PURPOSE: Anaemia and resistance to erythropoiesis-stimulating agents (ESAs) are common complications in haemodialysis (HD) patients. We investigated the role of hepcidin in the development of anaemia and ESA resistance/hyporesponsiveness and its relation to the plasma levels of the inflammatory markers interleukin 6 (IL-6) and high-sensitivity C-reactive protein (hsCRP). METHODS: This study included 60 maintenance HD patients attending Ain Shams University Hospital and 30 age- and sex-matched healthy subjects as a control group. Serum hepcidin, IL-6, hsCRP and haemoglobin (Hb) levels were measured in all subjects. The erythropoietin resistance index (ERI) was calculated in the patient group only. RESULTS: There was a significant difference between the patients and controls; the patients had higher hepcidin, IL-6, and hsCRP levels and a lower Hb level. Patients were classified according to their response to ESAs into responder and non-responder groups. Those in the non-responder group had higher hepcidin, IL-6, and hsCRP levels, a higher ERI, and a lower Hb level. Hepcidin showed a positive correlation with IL-6 and hsCRP but a negative correlation with Hb. Upon performing a ROC curve analysis, a cut-off of ≥ 280 ng/ml for hepcidin and ≥ 7.5 for ERI was able to discriminate the responder and non-responder groups with a prognostic accuracy of 83% and 77.3%, respectively. In addition, upon classifying the patients into tertiles according to the ERI, hepcidin significantly increased with increasing ERI. CONCLUSION: Our findings demonstrate an association between the hepcidin level, anaemia and ESA resistance/hyporesponsiveness in HD patients, suggesting its possible role as a candidate marker for ESA resistance.

Occlusion of Epicardial Coronary Arteries by Localized Pericardial Calcification.

Localized pericardial calcification is a relatively rare finding of often unknown etiology. We present the case of a 68-year-old man who was found to have bulky pericardial calcification, resulting in external compression of epicardial coronary arteries. (Level of Difficulty: Beginner.).

Prevalence of diarrheagenic Escherichia coli in animal products in Duhok province, Iraq.

BACKGROUND: Diarrheagenic Escherichia coli (DEC) is regarded as a great public health concern all around the world causing diarrhoea which can be transmitted through food chain. AIMS: This study aimed to determine the contamination level and exact distribution rate of DEC in food products consumed by human. METHODS: Seven hundred and twenty samples of food from animal origin and fishes were analysed by conventional and molecular method for the presence of E. coli and two multiplex polymerase chain reaction (mPCR) for detection of DEC. RESULTS: Two hundred and eighty-three E. coli isolates were detected. The classification of DEC by two multiplex PCR assay yielded 84 DEC pathotypes. Enterotoxigenic E. coli (ETEC) was detected at high rates (75%) followed by shiga-toxigenic E. coli (STEC) and enterohemorrhagic E. coli (EHEC) (each of 9.5%), enteroaggregative E. coli (EAEC) (3.5%) and atypical enteropathogenic E. coli (aEPEC) (about 2.3%). The highest number of DEC (n=26; 21.6%) was observed from beef carcasses in abattoir while the lowest number (n=7; 5.8%) was noticed from burger samples (P<0.01). Enterotoxigenic E. coli was widespread in local raw ground meat and fish surface swabs (P<0.001), EAEC (P<0.01), and EHEC (P<0.001) were only in beef carcasses swabs, STEC was more prevalent in both imported and local raw burger (P<0.01), while the isolates of aEPEC were from imported chicken carcasses (P>0.05). CONCLUSION: High DEC contamination rate that was observed is attributed to the poor hygienic practices during food processing. Therefore, a superior hygienic application is required.

Activation of migration of endogenous stem cells by erythropoietin as potential rescue for neurodegenerative diseases.

UNLABELLED: Neurodegenerative disorders such as Alzheimer's disease (AD) are characterized by progressive cognitive dysfunction and memory loss. There is deposition of amyloid plaques in the brain and subsequent neuronal loss. Neuroinflammation plays a key role in the pathogenesis of AD. There is still no effective curative therapy for these patients. One promising strategy involves the stimulation of endogenous stem cells. This study investigated the therapeutic effect of erythropoietin (EPO) in neurogenesis, and proved its manipulation of the endogenous mesenchymal stem cells in model of lipopolysaccharide (LPS)-induced neuroinflammation. METHODS: Forty five adult male mice were divided equally into 3 groups: Group I (control), group II (LPS untreated group): mice were injected with single dose of lipopolysaccharide (LPS) 0.8 mg/kg intraperitoneally (ip) to induce neuroinflammation, group III (EPO treated group): in addition to (LPS) mice were further injected with EPO in dose of 40 µg/kg of body weight three times weekly for 5 consecutive weeks. Groups were tested for their locomotor activity and memory using open field test and Y-maze. Cerebral specimens were subjected to histological and morphometric studies. Glial fibrillary acidic protein (GFAP) and mesenchymal stem cell marker CD44 were assessed using immunostaining. Gene expression of brain derived neurotrophic factor (BDNF) was examined in brain tissue. RESULTS: LPS decreased locomotor activity and percentage of correct choices in Y-maze test. Cerebral sections of LPS treated mice showed increased percentage area of dark nuclei and amyloid plaques. Multiple GFAP positive astrocytes were detected in affected cerebral sections. In addition, decrease BDNF gene expression was noted. On the other hand, EPO treated group, showed improvement in locomotor and cognitive function. Examination of the cerebral sections showed multiple neurons exhibiting less dark nuclei and less amyloid plaques in comparison to the untreated group. GFAP positive astrocytes were also reduced. Cerebral sections of the EPO treated group showed multiple branched and spindle CD44 positive cells inside and around blood vessels more than in LPS group. This immunostaining was negative in the control group. EPO administration increased BDNF gene expression. CONCLUSION: This study proved that EPO provides excellent neuroprotective and neurotrophic effects in vivo model of LPS induced neuroinflammation. It enhances brain tissue regeneration via stimulation of endogenous mesenchymal stem cells proliferation and their migration to the site of inflammation. EPO also up regulates cerebral BDNF expression and production, which might contributes to EPO mediated neurogenesis. It also attenuates reactive gliosis thus reduces neuroinflammation. These encouraging results obtained with the use of EPO proved that it may be a promising candidate for future clinical application and treatment of neurodegenerative diseases.

Managing perianal Crohn's fistula in the anti-TNFα era.

Perianal fistulas in Crohn's disease are common and difficult to treat. Their aetiology is poorly understood. Assessment is clinical, endoscopic and radiological, and management is undertaken by a multidisciplinary team of gastroenterologists, surgeons and radiologists. Surgical drainage of the fistula tract system with the placement of loose setons precedes combined therapy with immunosuppressant and anti-TNFα agents in most patients. Proctitis should be rigorously eliminated where possible. Definitive surgical repair is sometimes possible and diversion or proctectomy are occasionally required. Combined medical and surgical management represents a promising avenue for the future.

Systematic review: the combined surgical and medical treatment of fistulising perianal Crohn's disease.

BACKGROUND: The management of perianal Crohn's fistulas represents a significant challenge. A combination of medical and surgical therapy, guided by radiology, is often required. AIM: To review systematically the literature to assess fistula healing rates with medical treatment (anti-TNF-α therapies ± immunomodulators) or surgical treatment alone, compared with combined medical and surgical treatment in fistulising perianal Crohn's disease (CD). METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. Two independent reviewers searched the literature. RESULTS: Twenty-four articles were included. The total population was 1139 patients; 460 (40%) received single treatment with either medical or surgical therapy, and 679 (60%) received combined medical and surgical therapy. Eight studies compared single and combination therapy, with a total population of 797 patients (single therapy: n = 448, combination therapy: n = 349). In the single therapy group, 191/448 were in complete remission (43%). This was lower than the healing rate of the combination therapy group 180/349 (52%). No response to therapy was noted in 34% (153/448) of the single therapy group compared with 23% (80/349) of the combination group. CONCLUSIONS: Combined surgical and medical (anti-TNF-α ± immunomodulators) therapy may have additional beneficial effects on perianal fistula healing in patients with Crohn's disease, compared with surgery or medical therapy alone. A well-designed Crohn's perianal fistula clinical trial is required in a multidisciplinary medical and surgical setting, with clearly defined end points of clinical (and likely patient reported outcomes) and radiological healing.

The hematopoietic growth factor "erythropoietin" enhances the therapeutic effect of mesenchymal stem cells in Alzheimer's disease.

Alzheimer's disease is a neurodegenerative disorder clinically characterized by cognitive dysfunction and by deposition of amyloid plaques, neurofibrillary tangles in the brain. The study investigated the therapeutic effect of combined mesenchymal stem cells and erythropoietin on Alzheimer's disease. Five groups of mice were used: control group, Alzheimer's disease was induced in four groups by a single intraperitoneal injection of 0.8 mg kg(-1) lipopolysaccharide and divided as follows: Alzheimer's disease group, mesenchymal stem cells treated group by injecting mesenchymal stem cells into the tail vein (2 x 10(6) cells), erythropoietin treated group (40 microg kg(-1) b.wt.) injected intraperitoneally 3 times/week for 5 weeks and mesenchymal stem cells and erythropoietin treated group. Locomotor activity and memory were tested using open field and Y-maze. Histological, histochemical, immunohistochemical studies, morphometric measurements were examined in brain sections of all groups. Choline transferase activity, brain derived neurotrophic factor expression and mitochondrial swellings were assessed in cerebral specimens. Lipopolysaccharide decreased locomotor activity, memory, choline transferase activity and brain derived neurotrophic factor. It increased mitochondrial swelling, apoptotic index and amyloid deposition. Combined mesenchymal stem cells and erythropoietin markedly improved all these parameters. This study proved the effective role of mesenchymal stem cells in relieving Alzheimer's disease symptoms and manifestations; it highlighted the important role of erythropoietin in the treatment of Alzheimer's disease.

Clinical outcomes of colo-anal pull-through procedure for complex rectal conditions.

AIM: Pull-through with colo-anal sleeve anastomosis may be used as a last resort to avoid permanent diversion in patients with complex rectal conditions. This procedure allows the preservation of intestinal continuity by minimizing the hazards of deep dissection in an inflamed and fibrosed pelvis. METHOD: A retrospective study was performed of colo-anal pull-through procedures carried out between January 1998 and December 2012 at St Mark's Hospital by one surgeon. Patients were identified from operative logbooks and their case notes were reviewed. Thirty-four patients (21 women) with a median age of 54 (21-75) years underwent the pull-through operation for complex rectal conditions involving fistulae and/or a hostile pelvis as a final attempt to restore intestinal continuity. RESULTS: The median length of hospital stay was 7.5 (5-45) days. Median follow-up was 23 (3-71) months. There was no peri-operative mortality. There were two (6%) outright failures. Early complications occurred in 14 (41%) patients and late complications in 10 (29%). Fistulae recurred in seven (25%) of 28 patients but with further treatment four healed, giving an overall healing rate of 89%. Normal continence was achieved in 19 (79%) of 24 patients who were evaluated. CONCLUSION: In clinically difficult rectal situations the colo-anal pull-through procedure is a suitable salvage procedure to restore intestinal continuity before considering a permanent stoma.

Seven-year experience of enterocutaneous fistula with univariate and multivariate analysis of factors associated with healing: development of a validated scoring system.

AIM: The management of enterocutaneous fistulae (ECF) is complex and challenging. We examined factors associated with fistula healing at a National Intestinal Failure Centre and devised the first scoring system to predict spontaneous fistula healing prior to surgery. METHOD: A retrospective audit of 177 patients (mean age 48.7 years) treated over 7 years was undertaken. Results were compared with a previously reported series from this unit. Univariate and multivariate analyses wete performed on variables to assess relationship with ECF healing. A scoring system was devised and validated on a prospective cohort. RESULTS: One-hundred and fifty patients underwent surgery between January 2003 and December 2009. The overall healing rate following surgery in the current series was 94.6% (82% in the previous series). Mean delay from previous surgery to the current operation was 1 year (compared with 8 months previously). Thirty-day postfistula resection mortality was 0% (compared with 3.5% previously). Twenty-seven patients underwent medical management alone with overall healing rate of 46.4% (vs 19.9%). Multivariate analysis revealed that comorbidity (P = 0.02), source of referral (P = 0.01) and aetiology (P = 0.006) had associations with healing. Almost all patients with scores of 0 and 1 healed, whereas the highest scores healed least frequently. CONCLUSION: Surgical management of ECF is safe and improving. Fistula healing is affected by aetiology, comorbidity and source of referral. The scoring system has the potential to predict ECF healing and can be a useful clinical decision-making tool.

Ligation of the intersphincteric fistula tract in the management of anal fistula. A systematic review.

AIM: Over the last 5 years, the ligation of the intersphincteric fistula tract (LIFT) procedure has become increasingly popular as a sphincter-preserving technique for the treatment of anal fistula. The aim of this article was to review the published literature on the LIFT procedure. METHOD: The Cochrane database and EMBASE were searched from January 1980 to November 2012, and PubMed from January 1966 to November 2012. All peer-reviewed studies that investigated the LIFT procedure for the treatment of anal fistula were eligible for inclusion. Technical notes, commentaries, letters and meeting abstracts were excluded. The primary outcome measured was the overall fistula closure rate in relation to the length of follow-up. RESULTS: Twenty-nine articles were originally identified using the search criteria. Thirteen were finally included for analysis. Sample sizes ranged from 18 to 93 patients, with a pooled total of 498. Most fistulae, 494 (99%), were of cryptoglandular aetiology, of which 470 (94%) were transsphincteric. Overall success rates ranged from 40 to 95%, with a pooled success of 71% (352 of 495 patients; 3 of 498 were lost to follow-up). Follow-up ranged from 1 to 55 months, with a reported mean or median of 4 to 19.5 months. One hundred and eighty-three patients were formally assessed for continence, out of whom 11 (6%) had a minor disturbance. CONCLUSION: Overall the systematic review shows that the LIFT procedure appears to be an effective sphincter-conserving approach for the treatment of transsphincteric anal fistula with a pooled healing rate of 71% over a mean or median follow-up period ranging from 4 to 19.5 months.

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey.

PURPOSE: Evidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent. METHODS: Surgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined. RESULTS: The study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons' personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these. CONCLUSION: In the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Mechanisms of vincristine-induced neurotoxicity: Possible reversal by erythropoietin.

Vincristine (VCR) is a potent anticancer drug, but neurotoxicity is one of its most important dose-limiting toxicities. In this study, we investigated the neurotoxic effect of VCR, the possible mechanisms and the role of erythropoietin (EPO) in the protection against VCR-induced neurotoxicity in a rat model. The neurotoxicity of VCR and protective effect of EPO were examined using the tail flick test and by recording electrophysiological characteristics in isolated sciatic nerve. To elucidate the underlying mechanisms, mRNA expression of N-methyl-D-aspartate (NMDA) receptor, an index of glutamate excitotoxicity, and calcitonin gene-related peptide (CGRP), an important regulator of vascular tone, were measured in both spinal cord and sciatic nerves using an RT-PCR method. After intraperitoneal injection at a dose of 150 µg/kg three times weekly for five consecutive weeks, VCR significantly decreased the latency of tail withdrawal reflex, the amplitude of maximum compound action potential (MCAP) and chronaxie, and prolonged the duration of action potential (AP) and relative refractory period (RRP), but it had no effect on conduction velocity. VCR increased NMDA receptor expression and decreased CGRP expression. Forty µg/kg of EPO improved all VCR-induced changes, except chronaxie, while a higher dose of 80 µg/kg reversed all parameters and its effect was more prominent on tail flick test latency and NMDA receptor expression. These results suggested that VCR might cause increased nerve excitability and induce a state of glutamate excitotoxicity through enhancing NMDA receptor expression and diminishing CGRP expression, thus resulting in axonal degeneration. EPO had an obvious neuroprotective effect probably through decreasing NMDA receptor expression and increasing CGRP expression both centrally and peripherally.

Evidence-based review of enhancing postoperative recovery after breast surgery.

BACKGROUND: The introduction of enhanced recovery after surgery (ERAS) protocols has revolutionized preoperative and postoperative care. To date, however, the principles of enhanced recovery have not been applied specifically to patients undergoing breast surgery. METHODS: Based on the core features of ERAS, individual aspects of postoperative care in breast surgery were defined. A comprehensive search of MEDLINE, PubMed, Embase and the Cochrane Library database was performed from 1980 to 2010 to determine the best evidence for perioperative care in oncological breast surgery. A graded recommendation based on the best level of evidence was then proposed for each feature of ERAS. RESULTS: Twelve core features of enhanced recovery after breast surgery were identified. Use of the thoracic block, from both analgesic and anaesthetic viewpoints, is well supported by evidence and should be encouraged. Trials specific to breast surgery regarding aspects such as perioperative fasting, preanaesthetic medication, prevention of hypothermia and postdischarge support are scarce, and evidence was extrapolated from non-breast trials. Trials on postoperative analgesia and prevention of postoperative nausea and vomiting in breast surgery are generally of small numbers. In addition, there is heterogeneity between studies. CONCLUSION: This review suggests that the principles of enhanced recovery can be adopted in breast surgery. A 12-point protocol is proposed for prospective evaluation.

Comparative studies on hypocholesterolemic effect of different fractions of Hyphaene thebaica (Doum) in experimental animals.

A comparison of different fractions of the fruit of Hyphaene thebaica (Doum) was performed in order to investigate their effects on serum cholesterol, triglycerides and lipoproteins: HDL (high density lipoprotein) cholesterol and Non-HDL cholesterol in normal rats. Female Sprague-Dawely rats were treated orally with different fractions of the Doum plant. We used atorvastatin and a natural extract of Monascus purpureus as references. The total cholesterol, HDL cholesterol, Non-HDL cholesterol and triglycerides were estimated. Three fractions of the Doum plant exhibited a highly significant decrease in serum cholesterol and Non-HDL cholesterol. One fraction exhibited a highly significant decrease in cholesterol level but with only a moderately significant effect in decreasing the Non-HDL level. Decreasing Non-HDL, especially LDL, cholesterol, can reduce the risk of atherosclerosis and subsequent cardiovascular diseases. The natural, safe and non-toxic Doum plant could be of great merit for use as a hypocholesterolemic drug.

Association between antibodies to the MR 67,000 isoform of glutamate decarboxylase (GAD) and type 1 (insulin-dependent) diabetes mellitus with coexisting autoimmune polyendocrine syndrome type II.

By using an immunoprecipitation assay, we analysed reactivity of autoantibodies to human recombinant GAD65 and GAD67 in sera from patients with autoimmune polyendocrine syndrome Type II (APS II) with and without Type 1 (insulin-dependent) diabetes mellitus (IDDM) compared to patients with organ-specific autoimmunity. Overall antibodies to GAD65 were correlated with IDDM in all study groups, whereas GAD67 antibodies were associated with IDDM when APS II coexists. Antibodies to GAD65 and GAD67 were detected in 13 (44.8%) and 7 (24.1%) out of 29 APS II patients with IDDM, but in only 4 (13.8%) and 2 (6.9%) out of 29 APS II patients without IDDM, respectively (p < 0.05). In short-standing IDDM (< 1 year), antibodies to GAD67 were significantly more frequent in patients with APS II (5 of 9 [55.6%] subjects) compared to matched diabetic patients without coexisting polyendocrinopathy (1 of 18 [5.6%] subjects) (p < 0.02). The levels of GAD65 (142 +/- 90 AU) and GAD67 antibodies (178 +/- 95 AU) were significantly higher in patients with polyglandular disease than in patients with isolated IDDM (91 +/- 85 AU and 93 +/- 57 AU) (p < 0.02). Interestingly, all 11 GAD67 antibody positive subjects also had GAD65 antibodies (p < 0.0001), and in 10 of 11 anti-GAD67 positive sera the GAD67 antibodies could be blocked by either GAD67 or GAD65, suggesting the presence of cross-reactive autoantibodies. No correlation was observed between GAD antibodies and age, sex or any particular associated autoimmune disease, besides IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)

A multiplicity of protein antigens in subcellular fractions of rat insulinoma tissue are able to stimulate T cells obtained from non-obese diabetic mice.

Type 1 (insulin-dependent) diabetes mellitus is a T-cell mediated autoimmune disease with a number of different proteins being implicated as target autoantigens. A 38 kDa protein residing in the insulin secretory granule of insulinoma tissue is recognized by T-cell clones from a newly-diagnosed Type 1 diabetic patient. We have investigated the capacity of normal rat pancreatic beta-cell extracts and various subcellular fractions of transplantable RIN tissue to induce proliferation of T cells from non-obese diabetic (NOD) mice and H-2 identical NON.NOD-H-2g7 control mice. Normal rat islet beta-cell protein fractions induced intense, dose-dependent proliferation of NOD splenic T cells, but only marginal proliferative responses of NON.NOD-H-2g7 splenic T cells. To further localize the target antigens, four different subcellular fractions from RIN tissue were used as a source of antigen; here in particular the cytosolic proteins showed dose-dependent activation capacity with splenic T cells in NOD animals. These activities were absent in control mice. There was no proliferation after incubation with microsome preparations from other rat endocrine tissues. Purified carboxypeptidase H did not have any stimulatory activity on NOD T cells. Fractionation of the RIN cytosolic proteins showed a large number of different fractions eliciting proliferative activity. These results demonstrate that NOD T cells respond to a large number of potential islet beta-cell target antigens and it will be necessary to utilize NOD T-cell clones to identify the number and nature of these antigens.

Antineutrophil cytoplasmic autoantibodies (ANCA) in acute pancreatitis.

Antineutrophil cytoplasmic autoantibodies, which are now considered reliable serological markers of acute necrotizing vasculitic diseases, were measured in 11 patients with acute necrotizing pancreatitis and 12 patients with acute interstitial pancreatitis. When tested by indirect immunofluorescence, none of the sera was positive for diffuse cytoplasmic staining, and none was positive for perinuclear staining of antineutrophil cytoplasmic antibodies. Also by the sensitive enzyme-linked immunosorbent assay, none of the sera was positive when purified alpha-granule fraction of granulocytes was used as an antigen. We can therefore conclude that neither the diffuse cytoplasm-reacting, nor the perinuclear form of antineutrophil cytoplasmic antibodies, is involved in cases of acute pancreatitis.

Antibodies to the M(r) 64,000 (64K) protein in islet cell antibody positive non-diabetic individuals indicate high risk for impaired beta-cell function.

A prospective study of a normal childhood population identified 44 islet cell antibody positive individuals. These subjects were typed for HLA DR and DQ alleles and investigated for the presence of antibodies to the M(r) 64,000 (64K) islet cell antigen, complement-fixing islet cell antibodies and radiobinding insulin autoantibodies to determine their potency in detecting subjects with impaired Beta-cell function. At initial testing 64K antibodies were found in six of 44 islet cell antibody positive subjects (13.6%). The same sera were also positive for complement-fixing islet cell antibodies and five of them had insulin autoantibodies. During the follow-up at 18 months, islet cell antibodies remained detectable in 50% of the subjects studied. In all six cases who were originally positive, 64K antibodies were persistently detectable, whereas complement-fixing islet cell antibodies became negative in two of six and insulin autoantibodies in one of five individuals. HLA DR4 (p less than 0.005) and absence of asparic acid (Asp) at position 57 of the HLA DQ beta chain (p less than 0.05) were significantly increased in subjects with 64K antibodies compared with control subjects. Of 40 individuals tested in the intravenous glucose tolerance test, three had a first phase insulin response below the first percentile of normal control subjects. Two children developed Type 1 (insulin-dependent) diabetes mellitus after 18 and 26 months, respectively. Each of these subjects was non-Asp homozygous and had persistent islet cell and 64K antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)