A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Left congenital diaphragmatic hernia -- case report

Congenital diaphragmatic hernia (CDH) occurs when the abdominal contents protrude into the thoracic cavity through an anatomical defect in the diaphragm. The incidence of CDH is 1 in 2500 births, with left congenital diaphragmatic hernias(LCDH) being more common than right-side hernias (85% to 12%). While many cases are discovered prenatally or during the immediate postnatal period, 5 to 25% of CDH can be late presenting events which are detected by routine examinations,during medical check-ups, because of respiratory or gastrointestinal problems or complications such as gastric volvulus,occlusion, perforation, peritonitis or necrosis. Trans-abdominal or trans-thoracic approach is mandatory in those cases where complications have been identified. The prognosis for late presenting patients with LCDH is usually favorable. We report he case of a 7-year-old girl with recent history of trauma,who was admitted to a local hospital with respiratory distress. In our clinic, LCDH was diagnosed and closure of the defect was performed through an open trans-abdominal approach with favorable outcome.

Difficulties in the diagnostics and treatment of near-total congenital megacolon

Near total colonic aganglionosis is one of the rarest forms of Hirschsprung's disease and until recent years it has been considered deadly. Establishing a correct diagnosis has proven to be challenging, because while the clinical and radiological features can be useful, they are not pathognomonic. Chronic intestinal obstruction and long-term parenteral nutrition dependency are associated with a high mortality risk for these patients. While there is no current consensus with regards to a superior operative method, the patients benefit from surgical techniques aimed at lengthening the intestine, as well as from intestine transplant. We report the case of a newborn baby girl who was admitted to our clinic for abdominal distension,biliary and fecaloid vomiting. With an initial suspicion of digestive tract malformation, the diagnosis of near total congenital megacolon was established with great difficulty and the infant underwent serial surgeries, ending up with an extended myotomy-myectomy (Ziegler's procedure) as a curative approach, with favorable immediate postoperative evolution.However, the patient developed sepsis and although the infection was treated accordingly, the baby's general condition kept deteriorating and exitus was recorded 77 days after admission.

Complex malformation of the inferior vena cava

Malformations of the inferior vena cava (IVC) are rare presentations, exceptional in children, and are usually asymptomatic.They are caused by disturbances in the embryological formation of the venous system or can develop as a result of perinatal venous thrombosis with secondary impairment of the venous development. We report the case of a 14 year old boy,admitted for pediatric evaluation before undergoing plastic surgery in order to remove superficial varicose veins of the lower abdomen. The patient presents with inequality in circumference and length of the legs. Laboratory investigations are normal and the abdominal ultrasound describes hypoplasia of the retrohepatic segment of the inferior vena cava. The diagnosis of complex malformation of the abdominal deep venous system (retrohepatic vena cava atresia, cavo-caval anastomosis through azygos veins, abnormal formation of the inferior vena cava with the absence of the left iliac vein) was established through a CT angiography. The presence of abdominal varicose dilations should indicate the necessity to closely look for malformations of the portal and/or caval venous systems.

Associated type IIIB and type IV multiple intestinal atresia in a pediatric patient

Multiple intestinal atresia (MIA) is a complex congenital defect which represents a challenge for the pediatric surgeon,especially in the rare event of encountering type IIIb or apple peel atresia, which has a high mortality rate. The surgeon’s aim is to preserve as much bowel length as possible, to avoid postoperative sepsis and to prevent long-term complications such as short bowel syndrome. Access to a good neonatal intensive care unit and to parenteral nutritional support is crucial in the survival of these children. We report a rare case of multiple intestinal atresia associated with an apple peel atresia, which was managed by multiple intestinal resections and anastomosis without the placement of transanastomotic tubes or stomas.

Ileocolic intussusception due to Burkitt lymphoma: a case report

Burkitt lymphoma has many forms of clinical presentations and, in children, it is usually discovered due to the presence of an abdominal mass. This rapidly growing tumor is highly malignant, aggressive, and may cause either indirect symptoms, due to pressure phenomena or direct involvement of the bowel lumen, leading to either intestinal obstruction or intussusception. We describe the case of a 4-year-old girl who exhibited an unusual presentation of ileocolic intussusception on a Burkitt lymphoma lesion of the ileum.

Acute pancreatitis secondary to hyperlipidemia in an 11-year-old girl: a case report and review of literature

We report the case of an 11-year-old female with acute pancreatitis, and review the literature highlighting the presenting symptoms and signs, laboratory tests, and investigational tools that helped in the establishment of a correct diagnosis. First, the patient presented to a regional hospital reporting abdominal pain, vomiting and liquid stool. She was admitted with the diagnosis of acute surgical abdomen and underwent surgery. Upon admission in our department, laboratory findings showed high values for total lipids = 2600 mg/dL and triglycerides 1200 mg/dL. Abdominal ultrasound revealed a pancreas with a small enlargement of the head (19 mm), and with a heterogeneous structure of the parenchyma. Abdominal computed tomography showed small left pleural collection and a high-dimensioned pancreas, particularly at the head, with heterogeneous structure, and peripancreatic collections. The patient was treated by fasting, gastric decompression by nasogastric tube, and intravenous antibiotherapy followed by antialgic and antispasticity treatment. Time of the patient's first feeding was after the 7th day of hospitalization. The patient was discharged in a very good condition after 22 days of hospitalization.

Clinical and surgical aspects in necrotizing enterocolitis

BACKGROUND

The purpose of the paper is to establish whether clinical and radiological parameters can predict the progression of the pathology, the necessity of performing laparotomy for patients with peritoneal drain and the mortality in surgically treated neonatal necrotizing enterocolitis patients.

MATERIAL AND METHODS

A number of 51 cases with necrotizing enterocolitis from our institution were reviewed (from 2005 to 2011) and information on patient demographics and data about the clinical and radiological parameters was collected.

RESULTS

Of the 51 patients, 29 were (56.8%) males and 22 (43.2%) females. Age at presentation ranges between 1 and 87 days, with a mean 18.71 days. Birth weight varies between 400- 4700g (mean 1979.6 g ± 1012.5). The mortality rate in our study was 45% (23 patients out of 51).

CONCLUSIONS

The mortality rate in our series was 45%. Even though Bell stage III patients have clear indications for surgery, the procedure involves high fatality. Patients who undergo surgery are more likely to die than the ones who do not. We found that a later debut of symptoms should be an alarm sign for both the severity of the condition and for its outcome.

Neurovascular abnormalities in Gartland III supracondylar fractures in children

The most common elbow injuries in pediatric trauma practice are supracondylar fractures of the humerus. Posteriorly displaced fractures may be angulated or displaced medially or laterally with associated internal or external rotation. We compared two groups of patients, each with grade III supracondylar fractures after Gartland. The goal of this study was to see if reduction and pinning maneuvers create neurovascular abnormalities and if there are any differences in terms of neurovascular consequences for reducing grade III Gartland supracondylar fractures of the humerus using reduction in supination or pronation of the forearm. We formed two study groups based on the reduction method used. Concretely: patients who needed reduction in pronation were included in the first group and patients who needed reduction in supination were included in the second group. Patients were added to each group until every group reached 40, to have equal and comparable groups. No statistically significant differences on clinical outcome and neurovascular complications appeared between the two methods of closed reduction. We can say that both methods used are correct.

Use of minimally invasive (percutaneous) Fassier-Duval telescopic rod on an 8 year old patient with Lobstein disease

Lobstein disease is a severe disease characterized primarily by bone fragility which causes numerous fractures, especially in long bones. Multiple fracture of a bone will cause in time a deformity with consecutive functional impotence. The treatment for Lobstein disease in children must take into account both increasing bone strength and fracture prevention and treatment of possible fractures. Regarding the choice of synthesis material, in children, there are many constraints related to the small size of the bones, presence of growth plate and the risk of periosteal blood supply infringement. Currently, for the long-term fixation of long bone fractures in children, telescopic Fassier Duval rods are used, allowing reinforcement throughout growth. In this article we present an 8 years old patient, with a femoral fracture and Lobstein disease, who underwent initial intramedullar fixation with a Kirschner pin which was subsequently replaced by a Fassier Duval telescopic rod. Mounting the telescopic rod was performed minimally invasively through a technique improved in our service. We believe that this method can be applied in all cases where other types of fracture stabilization was used, and to ensure straightness of the medullar canal.

Anomalies associated with anorectal malformations

BACKGROUND

The purpose of the paper is to review the incidence of associated congenital anomalies that are encountered in patients presenting anorectal malformations and compare these results with those previously published.

MATERIAL AND METHODS

A number of 50 cases with ARM from our institution were reviewed (from 2005 to 2012) and information was collected on patient demographics, type of ARM and associated congenital anomalies, the latter being then categorized according to organ systems.

RESULTS

Out of 50 newborns, 28 were males and 22 females (1.27:1). 34 (68%) had at least one associated abnormality. The majority of patients (40%) had imperforated anus without fistula. The most frequent seen anomalies were gastrointestinal (36%), urogenital (24%) and cardiovascular (16%).

CONCLUSIONS

More than half of the children included in our series have other associated abnormalities. We found gastrointestinal anomalies to be the most common associated congenital defects in our patients. A higher incidence of this type of anomalies was encountered in newborns with persistent cloacal anomaly. The rectovestibular fistula group was most likely to present cardiac abnormalities. The incidence of genitourinary anomalies in the perineal fistula group is higher than the one described in other studies.

The modern treatment of the simple bone cysts

This study was performed between 2007-2012 and encompasses 94 patients. The patients were divided in two groups. The first group included the patients who have benefited from surgical treatment (42 cases) and the second one included patients who benefited from conservative treatment. Out of the total number of cases, 63 cases showed an intact simple bone cyst that was most of the time an accidental discovery. 31 patients presented with fracture sustained on a simple bone cyst. There were 63 boys and 31 girls. Their mean age was 9.9 +/- 2.34 years. Single injection was performed for 49 patients; the rest had double or triple injections. The mean follow-up was 34.5 +/- 6.6 months. The procedure succeeded in obtaining healing in 77 cysts (82%). Cyst index of more than five and cortical index of less than 1 mm were significantly prone to pathological fractures and had significant poor results after treatment. Our results suggested that an autogenous bone marrow injection is a safe and effective treatment method for simple bone cysts, when compared with the surgical management, but sometimes-repeated injections are necessary. Cyst index and cortical width are good indicators for treatment outcome.

Intestinal occlusion through extrinsec stenosis of transverse colon associated with internal right mesocolic hernia

RATIONALE

The incidence of malrotation has been estimated at 1 in 600 live births. An increased incidence of 0,2% has been found in barium swallow studies, whereas autopsy studies estimate that the true incidence may be high as 1% of the total population. The clinical manifestations are elusive; therefore, the diagnosis must be based on the presence or absence of the acute obstruction. Radiologic investigations, especially those using contrast substances, are the ones used most often in the diagnosis of malrotation. Laparoscopy may give the clinician a valuable tool that will help him diagnose the rotational anomalies and correct the potentially obstructing lesions with minimal surgical trauma to the patient. The role of the surgical treatment is to prevent volvulus and to treat any kind of obstruction. Ladd's procedure provides all the elements for reaching this goal.

OBJECTIVE

The following report describes a particular case of one female patient, 8 years old, admitted in our clinic with signs of intestinal obstruction. She had similar episodes in the last three months, but the symptoms had resolved spontaneously.

METHODS AND RESULTS

Upper gastrointestinal series showed an anomaly of rotation and barium enema discovered a tight stenosis on the transverse colon. Emergency surgery using laparotomy enabled diagnosis. Intraoperatively, a right mesocolic hernia and a transverse colon extrinsic stenosis due to abnormal peritoneal attachments were noted.

DISCUSSION

Colon obstruction due to peritoneal bands is extremely rare. The clinical manifestations are not specific and we need radiologic procedures to help diagnose the disease. The cause of the obstruction is not always evident despite the availability of modern imaging techniques. Since preoperative diagnosis is difficult, morbidity and mortality can be decreased by an early surgical intervention.

A new case of lower extremity glomus tumor up-to date review and case report

Glomus tumor (glomus cell tumor) is a rare, hamartomatous, usually benign neoplasm, whose cells resemble the modified smooth muscle cells of the normal glomus body. The diagnosis of a lower extremity is often delayed, due to the lack of awareness and low level of suspicion, by the treating physician. The glomus tumor (GT) often involves the nail beds. The unusual location of the lower extremity often leads to missed or delayed diagnosis and management. There is a paucy of information about GT in general, especially among orthopedic surgeons. The aim of this article is to make the surgical community more aware of this disease.

Negative Pressure-Temperature Slopes for Reactions Formign MgSiO 3 Perovskite from Calorimetry

A new and sensitive differential drop solution calorimetric technique was developed for very small samples. A single experiment using one 5.18-milligram sample of perovskite, synthesized at 25 gigapascals and 1873 Kelvin, gave 110.1 +/- 4.1 kilojoules per mole for the enthalpy of the ilmenite-pervoskite transition in MgSiO(3). The thermodynamics of the reaction of MgSiO(3) (ilmenite) to MgSiO(3) (perovskite) and of Mg(2)SiO(4) (spinel) to MgSiO(3) (pervoskite) and MgO (periclase) were assessed. Despite uncertainties in heat capacity and molar volume at high pressure and temperature, both reactions clearly have negative pressure-temperature slopes, -0.005 +/- 0.002 and -0.004 +/- 0.002 gigapascals per Kelvin, respectively. The latter may be insufficiently negative to preclude whole-mantle convection.