Laszlo Kovacs

Association between obesity and the severity of ambulatory hypertension in children and adolescents

The goal of our study was to analyze the association between obesity and the severity of ambulatory hypertension in obese children. A total of 109 patients with primary obesity ages 7 to 18 years (mean ± SD age 14.1 ± 3.1) were enrolled. Patients were divided into three groups according to body mass index (BMI) Z-scores: group 1 (n = 27): BMI >1.65 and < 3.28 standard deviation scores (SDS); group 2 (n = 55): BMI >3.29 and <4.91 SDS; group 3 (n = 27): BMI >4.92 SDS. Definition and staging of ambulatory hypertension was based on blood pressure (BP) levels and BP load, obtained from ambulatory BP monitoring (ABPM). Only 24% had ambulatory normotension, 25% had ambulatory prehypertension, 3% had hypertension, and 48% had severe ambulatory hypertension. The severity of hypertension increased significantly with the degree of obesity (P = .0027). Daytime systolic, diastolic, and mean arterial BPs increased significantly with increased BMI, whereas the nighttime pressure remained elevated regardless of the degree of obesity. Isolated nighttime hypertension was observed in 25% of patients and 38% were classified as nondippers. Almost 50% of children with obesity and hypertension detected on ABPM suffer from severe ambulatory hypertension. BMI is associated with the severity of ambulatory hypertension and the increase of daytime BP.

Alcohol intoxication requiring hospital admission in children and adolescents: retrospective analysis at the University Children's Hospital in the Slovak Republic

Background. Few epidemiological studies have investigated the problem of children and adolescents taken to hospital with acute alcohol intoxication. Methods. We reviewed the medical records of children and adolescents aged ≤ 18 years hospitalized with alcohol intoxication alone in the University Childrens Hospital in Bratislava, Slovak Republic, during the years 1996–2005 and compared their characteristics between the first and the second 5-year time periods. Results. 537 patients (273 boys and 264 girls) were admitted to the hospital with intentional acute alcohol intoxication (1.5% of all admissions and 34.2% of all intoxications) between 1996 and 2005. The average age of the patients with alcohol intoxication presenting to hospital was 15.1 ± 1.7 and the youngest were 9-year-old children. The proportion of children admitted with alcohol intoxication increased every year (R2 = 0.935) (p < 0.001). The average blood alcohol concentration was 1.98 ± 0.57 g/L, and it increased in 2001–2005 in relation to the previous 5 years (p < 0.001). The highest estimated alcohol concentration (4.39 g/L) was found in the blood of a 17-year-old boy. The mean poisoning severity score was 1.53 ± 0.61 and had increased in line with blood alcohol concentration for the years 2001–2005 (p < 0.001). Conclusions. The results of this analysis emphasize the severity of underage alcohol consumption by young people in the Slovak Republic. Measures are needed to decrease alcohol abuse in children and adolescents.

Successful use of tocilizumab in a patient with rheumatoid arthritis following severe pancytopenia during etanercept therapy.

Severe cytopenia, including neutropenia and anemia, may occasionally occur during anti-tumor necrosis factor &agr; (TNF-&agr;) therapy. However, its mechanism is poorly understood, and little is known concerning the rationale of the choice of biologic therapy after a severe episode of cytopenia. The authors present the case of a 68-year-old rheumatoid arthritis patient in whom severe pancytopenia developed soon after the initiation of etanercept therapy. After resolution, the interleukin 6 receptor-blocking agent tocilizumab was introduced, which resulted in long-lasting complete remission of the rheumatoid arthritis without any adverse effects. The apoptosis-inducing effects of 3 TNF-&agr; blockers and tocilizumab on peripheral blood mononuclear cells of the patient were compared by means of annexin V and propidium iodide labeling and flow cytometry. In concert with the clinical events, the anti-TNF-&agr; agents demonstrated significantly higher apoptotic activities than that of tocilizumab. Tocilizumab appeared safe after anti-TNF-&agr;-induced cytopenia possibly caused by apoptosis induction.

New Mutations Associated with Rasopathies in a Central European Population and Genotype–Phenotype Correlations

We performed the genetic analysis of Rasopathy syndromes in patients from Central European by direct sequencing followed by next generation sequencing of genes associated with Rasopathies. All 51 patients harboured the typical features of Rasopathy syndromes. Thirty‐five mutations were identified in the examined patients (22 in PTPN11, two in SOS1, one in RIT1, one in SHOC2, two in HRAS, three in BRAF, two in MAP2K1 and two in the NF1 gene). Two of them (p.Gly392Glu in the BRAF gene and p.Gln164Lys in the MAP2K1 gene) were novel with a potentially pathogenic effect on the structure of these proteins.

Thirty-Nine Novel Neurofibromatosis 1 (NF1) Gene Mutations Identified in Slovak Patients

We performed a complex analysis of the neurofibromatosis type 1 (NF1) gene in Slovakia based on direct cDNA sequencing supplemented by multiple ligation dependent probe amplification (MLPA) analysis. All 108 patients had café‐au‐lait spots, 85% had axilary and/or inguinal freckling, 61% neurofibromas, 36% Lisch nodules of the iris and 31% optic pathway glioma, 5% suffered from typical skeletal disorders, and 51% of patients had family members with NF1.

Evaluation of lipid and glucose metabolism and cortisol and thyroid hormone levels in obese appropriate for gestational age (AGA) born and non-obese small for gestational age (SGA) born prepubertal Slovak children

Abstract Aim: Obesity is the major determinant of metabolic syndrome. Being born small for gestational age (SGA) may be co-responsible. We aimed at evaluating the association between 1. obesity and 2. being born SGA and the presence of endocrine-metabolic abnormalities in prepubertal Slovak children. Methods: The study included 98 children, aged 3–10.9 years: 36 AGA-born obese children (OB), 31 SGA-born children (SGA) and 31 appropriate for gestational age born non-obese children (AGA). Fasting serum levels of glucose, total cholesterol, LDL, HDL, triglycerides, fT4, TSH, cortisol and insulin were determined. HOMA-IR was calculated. Personal data about birth weight and length and family history were collected. Actual anthropometric measurement was done. Results: In every group, high prevalence of positive family history of metabolic disorder was found. In comparison with AGA children, OB children were taller (p<0.01) with higher body mass index (BMI) (p<0.001), and had increased insulin levels and homeostasis model assessment for insulin resistance (HOMA-IR) (p<0.001), decreased high-density lipoprotein (HDL) (p<0.001), and a trend to higher cortisol levels (p=0.069) was noted. SGA-born children were shorter (p<0.001), with BMI comparable to the AGA group. They had higher glucose levels (p<0.001), a trend to decreased HDL levels (p=0.085) and increased fT4 levels (p<0.001). A three-fold higher occurrence of metabolic abnormalities was present in obese children and twice more metabolic abnormalities were present in SGA-born children in comparison with AGA-born children. Conclusions: SGA-born children are more prone to developing endocrine-metabolic abnormalities than non-obese children born AGA, but they are at less risk than obese AGA-born children. We should provide specialized care for obese children already in prepubertal age and pay attention to SGA-born children.

Is arterial stiffness predicted by continuous metabolic syndrome score in obese children

The aim of the article was to evaluate arterial stiffness, an early marker of increased cardiovascular risk, in relation to obesity. The continuous metabolic syndrome (cMetS) score was calculated as sum of Z score of mean arterial pressure, body mass index, serum glucose, triglyceride, and high-density lipoprotein cholesterol in 144 obese patients and 66 nonobese controls. Ambulatory arterial stiffness index (AASI) was calculated as 1 minus regression slope of diastolic on systolic blood pressure from ambulatory blood pressure measurements. The mean AASI increased progressively with severity of obesity. The receiver operator curve analysis of body mass index and AASI showed area under the curve of 0.64 ± 0.06; cMetS area under the curve was 0.72 ± 0.05 suggesting a better predictive power of the cMetS for an increased AASI (>0.3). Patients with obesity have significantly higher arterial stiffness. A composite score such as cMetS seems to be better predictor of an increased stiffness than individual risk factors.

The Impact of Anti-TNF Therapy on CD4+ and CD8+ Cell Subsets in Ankylosing Spondylitis

Objectives: Ankylosing spondylitis (AS) is a chronic, progressive immune-mediated inflammatory disease, driven primarily by Th1 and Th17 cells. Anti-TNF therapies are successfully used in AS to achieve and maintain remission. However, their influence on the composition of T-cell subsets is not clear. We aimed to characterize the changes in the T-cell repertoire after a long-term anti-TNF treatment in AS patients. Methods: Twenty-two AS patients under long-term anti-TNF therapy were evaluated (15 anti-TNF responders and 7 nonresponders). A wide range of cell subtypes was analyzed with flow cytometry and compared with therapy-naïve and short-term data too. Results: Key findings include decreased proportions of naïve CD4 and CD8 cells, increased frequencies of Th1 and Th17 cells and higher Th1/Th2 ratios in the long-term anti-TNF-treated patients (responders, nonresponders and total), which was found to be significant not only when compared with healthy controls, but also with therapy-naïve and short-term anti-TNF-treated AS patients. We noted several alterations within the various activated T-cell subsets – increase in CD4HLADR cells in responders, in CD8HLADR cells in the whole AS group and in responders, and in CD4CD25 cells in responders, and decrease in CD4CD69 cell percentages in long-term treated patients – becoming evident only after long-term anti-TNF therapy. Conclusions: This study provides a comprehensive assessment of the impact of anti-TNF therapy on the T-cell repertoire in AS. Changes in T-cell phenotype seem to develop progressively during therapy, even in inactive disease, and reflect an ongoing effector T-cell differentiation and activation, along with the parallel compensatory increase in regulatory T cells.

A Novel MTHFR Isoform-based Biomarker for RA and SLE

Objective: Disease- and drug-related biomarkers are the basis of personalized medicine by guiding patient-specific clinical decisions. The methylene-tetrahydrofolate reductase (MTHFR) gene-associated C677T polymorphism has garnered particular attention because it can lead to an amino acid change resulting in a catalytically compromised enzyme. Here, we provide an alternative interpretation of C677T-associated MTHFR phenotypes that does not exclude the original hypothesis but rather places it in a different context. Our duon-based theory has practical implications as it facilitates the development of a new predictive biomarker for Rheumatoid Arthritis (RA) and Systemic Lupus Erythematosus (SLE).Methods: The new MTHFR promoter was identified using the 5’RACE method and functionally characterized in transient expression studies. Western blotting and confocal microscopy were used to investigate the subcellular localization of MTHFR isoforms. Expression of MTHFR transcript variants was monitored by qRT-PCR and a gene expression index (Li/Si score) was calculated from the Ct values.Results: A new MTHFR isoform was identified, driven by a novel promoter region that overlaps with the site of the C677T polymorphism. Quantitative monitoring of the catalytically active and the catalytically inactive isoforms’ expression revealed that the proportion of MTHFR isoforms could be altered in PBMCs in a disease-specific manner. The calculated Li/Si scores were found to be characteristic for specific subgroups of RA and SLE patients.Conclusion: Differential expression of MTHFR isoforms provides a foundation on which a predictive biomarker (Li/Si score) could be developed for RA and SLE reflecting disease susceptibility and drug response.

The prevalence of melanocortin-4 receptor gene mutations in Slovak obese children and adolescents

Abstract Melanocortin-4 receptor (MC4R) deficiency is the most frequent monogenic form of obesity. The contribution of MC4R mutations to the Slovak population has not been investigated as yet. We screened the coding sequence of the MC4R gene in a cohort of 210 Slovak obese children and adolescents. We identified four different mutations in four patients, giving a mutation detection rate of 0.95%. Of these, three were missense mutations previously identified and characterized by other research groups (p.R7C, p.S127L and p. R305W, respectively). One was a novel nonsense mutation p.W174* detected in a severely obese 7-year-old boy. This mutation was further analyzed in family segregation analysis and exhibited variable penetrance. Two known amino acid polymorphisms (p.V103I and p.I251L) were also identified in seven subjects of our cohort group. We also performed multifactorial statistical analysis to determine the influence of genotypes on standard biochemical blood markers. No significant influence was observed in carriers of DNA variants on tested parameters. We conclude that rare heterozygous MC4R mutations contribute to the onset of obesity only in a few cases in the Slovak population.