Nancy Samir Elbarbary

Is exercise a therapeutic tool for improvement of cardiovascular risk factors in adolescents with type 1 diabetes mellitus? A randomised controlled trial

BackgroundType 1 diabetes mellitus (T1DM) is associated with a high risk for early atherosclerotic complications especially risk of coronary heart disease.ObjectiveTo evaluate the impact of six months exercise prgram on glycemic control, plasma lipids values, blood pressure, severity and frequency of hypoglycemia, anthropometric measurements and insulin dose in a sample of adolescents with T1DM.Research design and methodsA total of 196 type 1 diabetic patients participated in the study. They were classified into three groups: Group (A) did not join the exercise program(n = 48), group (B) attended the exercise sessions once/week (n = 75), group (C) attended the exercise sessions three times/week (n = 73). Studied parameters were evaluated before and six months after exercise programe.ResultsExercise improved glycemic control by reducing HbA1c values in exercise groups (P = 0.03, P = 0.01 respectively) and no change in those who were not physically active (P = 0.2). Higher levels of HbA1c were associated with higher levels of cholesterol, LDL-c, and triglycerides (P = 0.000 each). In both groups, B and C, frequent exercise improved dyslipidemia and reduced insulin requirements significantly (P = 0.00 both), as well as a reduction in BMI (P = 0.05, P = 0.00 respectively) and waist circumference(P = 0.02, P = 0.00 respectively). The frequency of hypoglycemic attacks were not statistically different between the control group and both intervention groups (4.7 ± 3.56 and 4.82 ± 4.23, P = 0.888 respectively). Reduction of blood pressure was statistically insignificant apart from the diastolic blood presure in group C (P = 0.04).ConclusionExercise is an indispensable component in the medical treatment of patients with T1DM as it improves glycemic control and decreases cardiovascular risk factors among them.

Honey and a Mixture of Honey, Beeswax, and Olive Oil–Propolis Extract in Treatment of Chemotherapy-Induced Oral Mucositis: A Randomized Controlled Pilot Study

In spite of being one of the most investigated subjects among supportive care in cancer, no therapy has been found effective in treatment of chemotherapy-induced oral mucositis. Based on the observations that honey bees products have anti-inflammatory and wound healing effects, the present study tried to evaluate the effect of topical application of honey and a mixture of honey, olive oil–propolis extract, and beeswax (HOPE) in treatment of oral mucositis. This was a randomized controlled clinical trial conducted on 90 patients with acute lymphoblastic leukemia and oral mucositis grades 2 and 3. The mean age of enrolled patients was 6.9 years. The patients were assigned into 3 equal treatment groups: Honey, HOPE, and control groups. Topical treatment for each patient consists of honey, HOPE, and benzocaine gel for honey, HOPE, and control groups, respectively. Recovery time in grade 2 mucositis was significantly reduced in the honey group as compared with either HOPE or controls (P < .05). In grade 3 mucositis, recovery time did not differ significantly between honey and HOPE (P = 0.61) but compared with controls, healing was faster with either honey or HOPE (P < .01). Generally, in both grades of mucositis, honey produced faster healing than either HOPE or controls (P < .05). Based on our results that showed that honey produced faster healing in patients with grade 2/3 chemotherapy-induced mucositis, we recommend using honey and possibly other bee products and olive oil in future therapeutic trials targeting chemotherapy-induced mucositis

Insulin-like growth factor-1 cytokines cross-talk in type 1 diabetes mellitus: relationship to microvascular complications and bone mineral density.

OBJECTIVE This study was designed to investigate the association between inflammatory cytokines (IL-8, IL-6) and IGF-1 levels in relation to metabolic control, microvascular complications and bone mineral density (BMD) in a cohort of Egyptian adolescents with T1DM. RESEARCH DESIGN AND METHODS Sixty patients with T1DM (mean age was 14.67±1.53 years, mean disease duration was 6.87±1.25 years) and 40 controls participated in the study. Thirty-six patients (60%) had poor glycemic control (HbA1C measurements ≥8%) while the rest (n=24%, 40%) had good glycemic control (HbA1C measurements <8%). Serum IL-6, IL-8, and IGF-1 levels were measured. Whole body DXA scan were assessed. Total body and lumbar spine (L2-L4) bone mineral content (BMC, g) and bone area (BA, cm(2)) were measured by DXA scan, bone mineral density (BMD, g/cm(2)) was calculated by BMC/BA. RESULTS Patients with T1DM had higher IL-6 and IL-8 levels with lower IGF-1 than healthy controls (P<0.001). Within the T1DM patients those with poor glycemic control had higher IL-6 and IL-8 as well as lower IGF-1 and total BMD than those with good glycemic control (P<0.001 for all). IL-6 and IL-8 were negatively correlated with IGF-1 (P=0.005 and 0.021, respectively). The peripheral neuropathy rate was also greater in T1DM patients with poor glycemic control (P=0.02). Presence of nephropathy or retinopathy was not different (P=0.69 and 0.50, respectively). CONCLUSION High IL-6, IL-8 with low IGF-1 levels are found in adolescents with T1DM. It seems that poor glycemic control exacerbates inflammatory cytokines, increases peripheral neuropathy, and decreases bone mineral density.

Plasminogen activator inhibitor-1 (PAI-1) in children and adolescents With Type 1 Diabetes Mellitus: relation to diabetic micro-vascular complications and carotid intima media thickness

BACKGROUND Plasminogen activator inhibitor-1 (PAI-1) is a fast-acting inhibitor of fibrinolysis that has been linked to increase risk of thrombosis. We determined PAI-1 levels in 80 children and adolescents with type 1 diabetes (T1DM) compared with 40 healthy controls as a potential marker for micro-vascular complications and assessed the relation to carotid intima media thickness (CIMT) as a synergistic risk factor for development of atherosclerosis. METHODS Patients were divided into 2 groups according to micro-vascular complications. Hemoglobin A1c (HbA1c), urinary albumin excretion, fasting serum lipid profile and PAI-1 levels were measured. CIMT of the common carotid artery was assessed using high resolution ultrasonography. RESULTS PAI-1 levels were significantly elevated in the group with diabetes compared with control group (p<0.001). PAI-1 levels were also increased in patients with micro-vascular complications compared with those without (p<0.001). CIMT was significantly higher in patients, particularly those with micro-vascular complications than patients without complications or controls (p<0.001). Positive correlations were found between PAI-1 levels and random blood glucose, HbA1c, triglycerides, total cholesterol and CIMT (p<0.05). CONCLUSIONS Increased plasma PAI-1 may be involved in the state of hypofibrinolysis in patients with T1DM leading to the occurrence of micro-vascular complications and increased risk of atherosclerosis.

A trial to assess the efficacy of glutamic acid in prevention of vincristine-induced neurotoxicity in pediatric malignancies: a pilot study.

Vincristine is considered as a backbone of therapy in the induction and consolidation phases of pediatric malignancies. Neurotoxicity is a principal side effect of its use. This study is a randomized single-blinded placebo-controlled clinical trial to evaluate the role of glutamic acid in ameliorating neurotoxicity in pediatric patients with hematologic and solid tumors receiving vincristine during induction course. Fifty-four patients in the glutamic acid group received glutamic acid 1.5 grams daily orally in 3 divided doses during the 4-week induction with vincristine in a dose of 1.5 mg/m2 IV weekly. Placebo group (40 patients) received oral placebo 3 times daily in the same way as the glutamic acid group. The onset of neurotoxicity was significantly earlier in placebo group than in glutamic acid group regarding tendon Achilles reflex, Patellar reflex, parasthesia, and increased frequency of constipation. This was statistically significant mostly in third and fourth visits, no severe cases of strength and mental alteration side effects in both groups. Glutamic acid was well tolerated with no gastrointestinal side effects in patients. This study suggests that the coadministration of oral glutamic acid with repetitive intravenous bolus injections of vincristine resulted in a reduction of its neurotoxicity.

ω-3 fatty acids as an adjuvant therapy ameliorates methotrexate-induced hepatotoxicity in children and adolescents with acute lymphoblastic leukemia: A randomized placebo-controlled study

OBJECTIVES Methotrexate (MTX)-induced hepatotoxicity is a significant clinical problem that may affect overall prognosis and disease outcome. Oxidative stress is a key player in its pathogenesis. The aim of this study was to investigate the role of ω-3 fatty acids as an adjuvant therapy in children and adolescents with acute lymphoblastic leukemia (ALL) during the maintenance phase of chemotherapy and the effect of ω-3 on MTX-induced hepatotoxicity. METHODS This randomized, double-blind, placebo-controlled trial included 70 patients with ALL who were in the maintenance phase. The participants were divided into two groups: group A received oral MTX and ω-3 fatty acids (1000 mg/d) and group B (received MTX and placebo). Both groups were followed-up for 6 mo with assessment of liver enzymes, total antioxidant capacity (TAC), uric acid, malondialdhyde, superoxide dismutase (SOD), and glutathione peroxidase. The trial was registered at ClinicalTrials.gov (NCT02373579). RESULTS Baseline clinical and laboratory parameters were consistent between the two groups (P > 0.05). After 6 mo, liver enzymes and malondialdhyde increased, whereas TAC, uric acid, SOD, and glutathione peroxidase decreased in group B (MTX and placebo) compared with baseline levels or with group A ALL patients receiving ω-3 fatty acids (P < 0.001). The addition of ω-3 to MTX maintained normal liver function and oxidant-antioxidant levels among group A patients at the end of treatment compared with pretherapy levels (P > 0.05). No adverse reactions due to ω-3 supplementation were reported. ALT was inversely correlated to TAC and SOD in the MTX group. CONCLUSIONS The study determined that ω-3 fatty acids ameliorated MTX-induced hepatotoxicity and could be safely used during the maintenance phase of ALL.

Intracranial Hemorrhage in Acute and Chronic Childhood Immune Thrombocytopenic Purpura over a Ten-Year Period: An Egyptian Multicenter Study

Intracranial hemorrhage (ICH) is a rare but major cause of death in immune thrombocytopenic purpura (ITP). The authors reviewed data of 1,840 patient with ITP, from 5 pediatric hematology centers in Egypt from 1997 to 2007, to study the incidence and risk factors of ICH. Ten cases of ICH were identified with a median age at presentation of 7.5 years; 4 patients had acute ITP, 2 persistent and 4 chronic. The platelet count was <10 × 109/l in 7 cases, and only 1 patient had a history of head trauma. Seven children were on treatment prior to or at the time of occurrence of ICH and all were treated by pharmacotherapy. Two children died shortly afterwards due to late referral to a specialized center. Our results suggest that treatment does not prevent ICH and that it can occur at any time during the course of the disease. Delayed referral can be considered a risk factor for unfavorable outcome of ICH, highlighting the importance of teaching sessions for patients and their parents to minimize subsequent morbidity and mortality of ICH in children with ITP.

Pulmonary Complications in Survivors of Childhood Hematological Malignancies: Single-Center Experience

Children treated for cancer face the risk of complications later in life, including pulmonary dysfunction. The objective of this study was to evaluate frequency and severity of pulmonary complications in survivors of childhood leukemia and lymphoma treated with chemotherapy alone or combined with radiotherapy. Seventy cancer survivors of hematological malignancies were evaluated for pulmonary complications through history taking, chest examination, high-resolution computed tomography (HRCT) chest, and pulmonary function testing (PFTs). Although most survivors were not clinically compromised, the spectrum of impaired PFTs included obstructive pattern (14.3%), restrictive pattern (5.7%), and mixed pattern (20%). Significant pulmonary dysfunction was seen in children older than 10 years of age (P = .003), and in patients treated with combined chemotherapy and radiotherapy (72.7%) compared with those treated with chemotherapy alone (25%) (P = .001). Cumulative dose of bleomycin was significantly associated with abnormal PFTs (P = .04). Multivariate analysis revealed methotrexate therapy as significant predictor of abnormal PFTs (P = .002). Male patients who received combined therapy showed higher frequency of restrictive, obstructive lung disease, abnormal respiratory reactance, and peripheral airway disease (P = .007, P = .04, P = .002, P = .003, P = .05, respectively). Those with abnormal CT findings (n = 14) had lower forced vital capacity (FVC%), forced expiratory volume in 1 second (FEV1%), and peak expiratory flow (PEF%) when compared to cases with normal CT (P = .001, P <0.001, P = .001, respectively). Subclinical pulmonary function abnormalities are found in survivors of childhood hematological malignancies previously treated and off therapy. Pulmonary dysfunction is more evident with combined chemotherapy and radiotherapy, bleomycin, and methotrexate are the most incriminated chemotherapeutic agents, and males are at higher risk than females; therefore a specific and extended follow-up is warranted.

Current status of diabetes management, glycemic control and complications in children and adolescents with diabetes in Egypt. Where do we stand now? And where do we go from here?

THE AIM of this study was to use the Diabetes Registry of the Pediatric Diabetes Clinic, Ain Shams University Hospital to examine risk factors related to poor glycemic control and to provide data to health professionals for planning, evaluation and optimizing diabetes care. SUBJECTS AND METHODS Data from 600 children and adolescents with diabetes with information in the registry provide information on current clinical status, metabolic control, acute and long-term complications, presence of concomitant autoimmune diseases, and psychiatric aspects of patients. RESULTS Mean age of patients was 13.3±5.1 years, mean duration of diabetes was 6.4±3.6 years, mean HbA1c was 8.8±4.6% [73±27 mmol/mol], and 71% had poor glycemic control. Acute complications included ketoacidosis in 19.7% and severe hypoglycemia in 2.8%. Chronic complications including peripheral neuropathy, retinopathy, and persistent microalbuminuria were present in 6.3%, 1.8%, and 6.8%, respectively. The majority (97.2%) were on intensive insulin therapy. Patients with poor glycemic control had higher disease duration, DKA frequency and diabetic microvascular complications. However, regular education lecture attendance and regular SMBG were associated with better glycemic control. CONCLUSIONS These registry data indicate that although the majority of the patients were on intensive insulin therapy, poor glycemic control was common and diabetic microvascular complications were observed. These findings will provide potential avenues to improve quality of care and could be the first step in the development of a national registry for diabetes in Egypt.

An Egyptian family with H syndrome due to a novel mutation in SLC29A3 illustrating overlapping features with pigmented hypertrichotic dermatosis with insulin-dependent diabetes and Faisalabad histiocytosis.

The SLC29A3 gene, encoding hENT3, a member of the equilibrative nucleoside transporter family, has recently been found mutated in Faisalabad histiocytosis, pigmented hypertrichotic dermatosis with insulin‐dependent diabetes, familial sinus histiocytosis with massive lymphadenopathy (SHML), and H syndromes. We here report clinical and genetic findings of an Egyptian family with H syndrome. We describe two siblings, a 19‐yr old girl and a 15‐yr old boy, of consanguineous parents. From 5 yr of age, the girl developed bilateral flexion deformity of interphalengeal joints and insulin‐dependent diabetes mellitus. At age 7 yr, prominent hyperpigmented patches appeared on the skin at lower limbs, genitalia, and trunk. On clinical examination, she had hepatosplenomegaly, generalized lymphadenopathy, left ventricular hypertrophy, sensorineural hearing loss, hypogonadism, short stature, and characteristic dysmorphic features. Her brother had fixed flexion contractures of the feet, profound sensorineural hearing loss, characteristic dysmorphic features, but no diabetes. DNA sequence analysis revealed a homozygous mutation (c.300+1G>C) in SLC29A3 in both siblings. The phenotype and genotype of the siblings were compatible with that of the H syndrome, although the features were overlapping with those found in pigmented hypertrichotic dermatosis with insulin‐dependent diabetes, familial SHML, and Faisalabad histiocytosis, indicating that these four syndromes may be regarded as one disease with varying phenotypic features. A new, common name for these conditions is warranted.