The influence of diet therapeutic intervention on the sarcopenic index of patients with metabolic syndrome

Introduction

The published data showed the importance of metabolic control in preventing complications in metabolic syndrome (MS) and the role of nutritional medical therapy in glycemic control and in the control of dyslipidemia, hypertension, weight loss/normalization (in overweight or malnourished subjects).

Objectives

This study follows the evolution of sarcopenic index (SI) and other clinical parameters (body mass index (BMI), homeostasis evaluation index (HOMA index)) correlated with MS after diet therapy or diet therapy combined with sports, in patients with MS.

Patients and methods

Our research was conducted during 12 months, on 110 patients >18 years of age, with HOMA index>2, divided into three groups: control group (CG, N=20), diet therapy group (DTG, N=58), diet therapy and sports group (DTSG, N=32). HOMA index for insulin resistance was calculated as the product of resting plasma insulin (in microunits/milliliter) and plasma glucose (in millimoles/liter), divided by 22.5. SI was determined using BIA, as being the ratio between muscle mass and fat mass, measured in cm²/m².

Results

A significant decrease of BMI (p<0.05) in DTG (from 31.63 to 24.50) and DTSG (from 30.18 to 24.17) vs. CG was observed (Pearson coefficient r=0.281, p<0.001). Weight status changed significantly (p<0.05) in the high-risk patients. There was a significant decrease of HOMA index (p<0.05) in DTG (from 5.93 to 2.57), DTSG (from 3.93 to 2.23), and in CG an increase was observed (from 3.15 to 3.37).

Conclusion

The best results in the prevention/ treatment of sarcopenia in MS patients were obtained for DTSG, which benefited from both the positive effect of diet and physical activity.

569 Association between periodontal disease, coronary calcium score and markers of subclinical atherosclerosis in patients with unstable angina-a CT-based sub-study from the ATHERODENT clinical trial

Funding Acknowledgements

PlaqueImage financed by the National Authority of Scientific Research and Innovation and the Romanian Ministry of European Funding

Background

The relationship between periodontal disease (PD) and chronic inflammation is well established. PD leads to increased cardiovascular risk and favours development of acute coronary syndromes; however, the association between PD and markers of subclinical atherosclerosis has not been elucidated so far.

Purpose

To evaluate the interrelation between severity of PD, coronary calcium, subclinical atherosclerosis and plaque vulnerability in patients with unstable angina, who underwent coronary computed tomography angiography (CCTA).

Methods

Fifty-two patients with unstable angina were enrolled in the ATHERODENT clinical trial (NCT03395041). All patients underwent: (1) complex dental examination for assessment of periodontal status, expressed by the total periodontal index (PI) evaluating the following indices: gingival index, plaque index, tantrum index, furcation index, mobility, loss of attachment, pocket depth and papillary bleeding index, (2) CCTA for analysis of morphology, composition and vulnerability features of the culprit plaques causing myocardial schema. For each patient, coronary calcium score, body mass index, neck circumference, abdominal circumference and Intima-media thickness of the carotid artery were calculated. According to the median value of the total PI (set by 22) the study population was divided into two groups: group 1 included 26 patients with low PI (normal gum or gingivitis) and group 2 included 26 patients with high PI (periodontitis and severe PD).

Results

In patients with high PI the plaque volume (p = 0.019) and the non-calcified volume (p = 0.002) were more increased compared with patients with low PI. In patients with high risk features in the culprit coronary plaques (positive remodelling, low density atheroma, spotty calcification and napkin ring sign) the severity of PD was more expressed compared with those with low risk plaques (28.20+/-13.34 vs. 18.71+/-11.31, p = 0.001). From all PI indices, loss of gingival attachments (3.6 +/-2.91 vs. 1.66 +/- 1.8, p = 0.009) and papillary bleeding index (4.5 +/-3.06 vs. 2.04+/-1.96, p = 0.002) were significantly correlated with the plaque vulnerability. there was no significant correlation between PI and the markers of subclinical atherosclerosis expressed by the neck circumference, abdominal circumference and IMT of the carotid artery. However, total PI presented significantly correlation with the total coronary artery calcium score (r = 0.45, p = 0.0008). A higher calcium score was identified in patients with high PI compared with those with low PI (505.29 +/-478.64 vs. 93.82+/-233.0, p = 0.0001).

Conclusions

In patients with vulnerable coronary plaques, subclinical atherosclerosis is not correlated with PI. However, the severity of PD is directly associated with the total calcium score and with a more vulnerable phenotype of the atheromatous coronary plaques.

A MSFD complementary approach for the assessment of pressures, knowledge and data gaps in Southern European Seas: The PERSEUS experience

PERSEUS project aims to identify the most relevant pressures exerted on the ecosystems of the Southern European Seas (SES), highlighting knowledge and data gaps that endanger the achievement of SES Good Environmental Status (GES) as mandated by the Marine Strategy Framework Directive (MSFD). A complementary approach has been adopted, by a meta-analysis of existing literature on pressure/impact/knowledge gaps summarized in tables related to the MSFD descriptors, discriminating open waters from coastal areas. A comparative assessment of the Initial Assessments (IAs) for five SES countries has been also independently performed. The comparison between meta-analysis results and IAs shows similarities for coastal areas only. Major knowledge gaps have been detected for the biodiversity, marine food web, marine litter and underwater noise descriptors. The meta-analysis also allowed the identification of additional research themes targeting research topics that are requested to the achievement of GES.

Vascular endothelial growth factor (VEGF) levels in short, GH treated children: a distinct pattern of VEGF-C in Noonan syndrome

CONTEXT

Noonan syndrome (NS) is characterized by short stature and elevated risk of lymphedema. The mechanism underlying lymphedema may be mediated by vascular endothelial growth factors (VEGFs).

OBJECTIVE

To assess the effect of growth hormone (GH) treatment on plasma insulin-like growth factor (IGF)-1, VEGF-A and VEGF-C levels in patients with NS as compared to short GH-sufficient children.

DESIGN

Retrospective, comparative.

SETTING

Endocrinology department of a tertiary pediatric medical center.

PATIENTS AND METHODS

Plasma IGF-1, VEGF-A and VEGF-C levels were measured before and during GH treatment in 6 patients with NS and 18 age-matched short subjects (Turner, idiopathic short stature and small for gestational age).

MAIN OUTCOME MEASURES

Changes in plasma VEGF and IGF-1 levels.

RESULTS

Baseline IGF-1 SDS levels were slightly lower in NS patients compared with controls; IGF-1 response to GH therapy was markedly lower in NS patients compared with controls (p = 0.017). Mean baseline VEGF-A levels were similar in NS patients and controls whilst mean baseline VEGF-C levels were significantly lower in the NS group as compared with controls (p = 0.022). Plasma VEGF-A and VEGF-C levels did not significantly change during GH treatment in the study cohort. No correlation was found between VEGF-C levels and levels of IGF-1, VEGF-A and auxological parameters, either before or during GH administration.

CONCLUSION

Children with NS have a distinct growth factor profile including low basal VEGF-C and flattened IGF-1 response to GH. Further studies are needed to confirm our findings and to elucidate the interaction between VEGF-C levels and lymphedema.

Changes in weight and BMI following the diagnosis of type 1 diabetes in children and adolescents

The aim of this study was to study weight and body mass index (BMI) before, at, and after diagnosis of type 1 diabetes (T1D) and to identify factors associated with weight gain. Studied retrospectively were 209 children <18 years with T1D followed for 6 years. Data collected included clinical and laboratory data before diagnosis, at diagnosis, and during 6 years of follow-up. Anthropometric parameters of patients were compared along follow-up and with those of their parents and siblings. Mean BMI-standard deviation score (SDS) was below average at diagnosis (-0.66 ± 1.27), had increased to 0.37 ± 0.93 at 3 months, and decreased to a nadir at 6 months in females and 12 months in males; between 1 and 3 years, there was a slight increase and between 3 and 6 years a further increase only in the females. BMI-SDS at 6 years was significantly higher than pre-diabetes BMI-SDS (0.35 ± 0.83 vs. -0.04 ± 1.23, p < 0.001). Patients' BMI-SDS at 6 years was similar to that of their parents and siblings, was higher in the females (0.53 ± 0.74 vs. 0.27 ± 0.82, p = 0.02) and in those keeping diabetes a secret (0.66 ± 0.82 vs. 0.33 ± 0.78, p = 0.027), and was not associated with age or pubertal stage at diagnosis, ethnicity, or metabolic control. A longer duration of insulin pump therapy was associated with a lower BMI-SDS (r = -0.2375, p < 0.025). BMI-SDS increased during the 6 years following diagnosis of T1D in pediatric patients, especially in the females, but remained in the normal range and was similar to that of other family members.

Factors associated with diabetic ketoacidosis at onset of Type 1 diabetes in children and adolescents

AIMS

To identify risk factors for diabetic ketoacidosis at diagnosis of Type 1 diabetes in children and adolescents.

METHODS

In three time periods (1986-1987, 1996-1997 and 2006-2007) 75, 86 and 245 patients, respectively, aged < 20 years were newly diagnosed with Type 1 diabetes in one tertiary care centre. In this retrospective comparative study, data of clinical characteristics, laboratory evaluation at diagnosis, as well as demographic data were retrieved from the patients' files. Comparative analyses were performed between patients presenting with or without diabetic ketoacidosis and between the three time periods.

RESULTS

Patients presenting with diabetic ketoacidosis were younger (9.2 ± 4.7 vs. 10.4 ± 4.7 years; P < 0.02), thinner (weight standard deviation score -0.59 ± 1.2 vs. -0.25 ± 1.1; P = 0.002) and less frequently had a first- and/or second-degree relative with Type 1 diabetes compared with those without diabetic ketoacidosis at presentation (16.0 vs. 31.2%, respectively; P = 0.001). Children with diabetic ketoacidosis were less likely to have had relevant testing before diagnosis than children without diabetic ketoacidosis. Children aged < 2 years presented more often with diabetic ketoacidosis than the older children (85 vs. 32%; P < 0.001). Children of Ethiopian origin had a higher rate of diabetic ketoacidosis at diagnosis than the rest of the cohort (57.8 vs. 33%; P = 0.04).

CONCLUSIONS

Factors affecting the risk of developing diabetic ketoacidosis at diagnosis of Type 1 diabetes may be related to the degree of awareness of symptoms of diabetes among parents and primary care physicians. Prevention programmes should aim at increasing awareness and consider the application of special measures to avoid diabetic ketoacidosis in children aged < 2 years and high-risk ethnic groups.

Decrease in frequency of ketoacidosis at diabetes onset over the past two decades - perspectives of a paediatric tertiary care centre

AIMS

To determine whether the frequency and severity of diabetic ketoacidosis and the clinical characteristics of children at diagnosis of Type 1 diabetes mellitus have changed over the past decades among patients under surveillance of a tertiary paediatric centre.

METHODS

In three time-periods, 75 (1986-1987), 86 (1996-1997) and 245 (2006-2007) patients at mean age 10.1 ± 4.7 years (0.6-20.0) were diagnosed with new-onset Type 1 diabetes. Data on clinical characteristics and laboratory evaluation at diagnosis retrieved from the patients' files . Comparative analysis was performed between the three time periods.

RESULTS

The frequency of diabetic ketoacidosis at diagnosis was 40% in 1986-1987, 41.8% in 1996-1997 and 29.4% in 2006-2007; the last rate was significantly lower (P=0.04). No significant differences in the proportions of patients with severe or moderate diabetic ketoacidosis were found over time. Mean weight standard deviation score significantly increased from -0.72 ± 1.8 in 1986-1987 to -0.27 ± 1.2 in 2006-2007 (P<0.05), while percentage weight loss (∼6.5%) before diagnosis remained unchanged. In 2006-2007 a higher proportion of children had glucose testing at the community clinic before diagnosis, than in the earlier years (73.1 vs. 59.6%, P=0.003).

CONCLUSIONS

The overall frequency of diabetic ketoacidosis in children with newly diagnosed Type 1 diabetes has decreased in the past decade, although the degree of metabolic decompensation has remained unchanged.

PP004. Study of the methylenetetrahydrofolate reductase and the reduced-folate carrier-1 gene polymorphism in healthy and severe pre-eclamptic patients

INTRODUCTION

One-carbon cycle is involved in two essential physiological processes: The synthesis of purins and pyrimidines required for DNA synthesis and repair. The other is the methylation with the methionine cycle. These one-carbon groups are served by the tetrahydrofolate and the S-adenosylmethionine. Deficiencies of the folate, or other abnormalities within the methionine pathway lead to elevated homocysteine levels. These disorders have been implicated in placental diseases. Earlier studies have shown that homocysteine levels are elevated by patients with severe pre-eclampsia than by healthy pregnant normotensive women. Methylenetetrahydrofolate reductase (MTHFR) gene C677T missense mutation has a high frequency by patients with HELLP syndrome and connected with elevated serum homocysteine levels. The reduced-folate carrier (RFC-1) facilitates the internalization of 5-methyltetrahydrofolate from the blood into peripheral cells. The mutation G80A this gene leads to higher plasma folate.

OBJECTIVES

Our aim was to identify the polymorphism of these two genes in samples of severe pre-eclamptic patients and healthy controls.

METHODS

Blood samples were collected from healthy pregnant normotensive women (n=82) and women with pre-eclampsia (n=75). DNA was isolated and quantitative real-time PCR method combined with melting curve analysis was performed for the detection of the two polymorphisms. Statistical analysis was performed with the STATISTICA software package.

RESULTS

The frequency of the A allele in the RFC-1 gene was 46.57% by healthy pregnant and 41% by severe pre-eclamptic patients. The overall distribution of genotypes was not significantly different between the control and pre-eclamptic groups (p=0.58). In the study groups by the MTHFR gene the frequency of the T was 32% in pre-eclamptics, and 35.92% in controls. Similarly the overall distribution of genotypes was not significantly different between the two study groups (p=0.15).

CONCLUSION

In hypertensive disorders of the pregnancy the one-carbon cycle is disturbed. We studied single nucleotide mutations in the genes of two enzymes involved in the cycle. We determined the allele and genotype frequencies in healthy control and pre-eclamptic patients and found no significant differences. Further examinations of other genetical compounds can help to understand the elevated homocysteine levels in pre-eclampsia.

Relative value of clinical, laboratory and imaging tools in diagnosing pediatric acute appendicitis

OBJECTIVE

Aim of the study was to evaluate the relative value of the tools used to diagnose suspected acute appendicitis (AA) in children.

METHODS

A retrospective review of data from 1 848 children admitted to the Pediatric Surgery Department between 2004 and 2008 in our university-affiliated medical center was conducted. A total of 780 children underwent appendectomy at first presentation. Of these patients, 75 children required removal of their appendix during laparotomy for other reasons and 19 had appendectomy following peri-appendicular abscess and were excluded from the study. The study included 686 children (2-16 years of age) with presumed AA managed by appendectomy. Clinical, laboratory, and imaging data were collected and compared to pathology results.

RESULTS

Of the 686 children who underwent surgery for suspected AA, 34 (5%) had a normal appendix (negative appendectomy rate). No statistical differences were found between normal and AA groups with regard to vomiting, diarrhea, pain duration, and peritoneal signs on admission. Children in the AA group were younger (10.9±3.2 vs. 12.1±2.3 years, p=0.004), had higher fever (36.9±0.7°C vs. 37.4±0.8°C, p=0.004), WBC (14.8±4.8 vs. 10.5±4.6×103/mL, p<0.0005), and neutrophil counts (77.2±11.1% vs. 64.0±15.9%, p<0.0005) on admission, and larger appendicular diameters on ultrasound (US) examination (0.9±0.2 cm vs. 0.7±0.08 cm, p<0.0005). The parameters with the highest positive predictive values for AA were WBC (>10×10 (3)/mL), neutrophil (>66%) count on admission (positive predictive value [PPV]=0.971 and 0.975, respectively), and appendicular diameter on US (>6 mm; PPV=0.968). These 3 parameters combined had a PPV of 0.991.

CONCLUSIONS

The results of laboratory tests (WBC, neutrophils) and imaging (US) contributed far more than clinical signs and symptoms (pain duration, vomiting, diarrhea, fever, and peritoneal signs at first physical examination) to the correct diagnosis of AA in children. When these 3 parameters were positive, the probability of a false positive (normal appendix) was only 1%. The contribution of US was particularly high as it was used primarily in patients in whom the diagnosis was in doubt and its results matched the final diagnosis better than diagnoses based on clinical signs and symptoms alone. It provides the additional benefit of no radiation exposure.

Is sex hormone priming in peripubertal children prior to growth hormone stimulation tests still appropriate?

Low growth hormone (GH) secretion during puberty may stem from either a permanent GH axis abnormality or from transient GH deficiency secondary to lack of sex hormones. Although well known to enhance stimulated GH secretion in pre- or early puberty, sex hormone priming for the evaluation of the function of the GH-IGF-I axis remains controversial. Many pediatric endocrinologists consider that omission of such priming during the preadolescent period decreases the specificity of GH stimulation tests and increases the percentage of false-positive diagnosis results. Others believe that it leads only to a temporary augmentation of GH secretion followed by a decrease in spontaneous secretion to levels which may be insufficient for normal pubertal growth; thus priming with sex hormones may lead to underdiagnosis of peripubertal children that could have benefited from GH treatment. The increased availability of biosynthetic GH has enabled expanding the indications for GH therapy and judging and renewing the criteria for the diagnosis of GH deficiency, including the practice of sex hormone priming which was and still is executed in clinical use in many centers in the world. We would like to recommend that priming should not be routinely performed in every peripubertal child undergoing GH evaluation but may be considered in adolescents with pubertal delay--girls aged >11.5-12 years and boys aged >13-13.5 years exhibiting no evidence of puberty or only initial signs.

Synthesis of carbon nanotubes by plasma-enhanced chemical vapor deposition in an atmospheric-pressure microwave torch

There are many different techniques for the synthesis of carbon nanotubes (CNTs), and plasma technologies experience a significant competitor in thermal chemical vapor deposition (CVD) processes. A particular process is, therefore, selected according to the specific requirements of an application, which clearly differ for the development of composites as compared to nanoelectronics, field emission, displays, sensors, and the like. This paper discusses the method for the synthesis of CNTs using an atmospheric-pressure microwave (MW) torch. It was successfully applied in the fast deposition of multiwalled nanotubes (MWNTs) on a substrate without the necessity of any vacuum or heating equipment. Dense straight-standing nanotubes were prepared on Si substrates with and also without barrier SiOx layer. Therefore, it was possible to produce CNTs directly on conductive Si and to use them as an electron-emitting electrode of the gas pressure sensor. The CNTs grown in MW torch were also used to create a gas sensor based on the changes of electrical resistance measured between two planar electrodes connected by the CNTs.

Growth without growth hormone and similar dysmorphic features in three patients with sporadic combined pituitary hormone deficiencies

BACKGROUND/AIMS

Mutations in the HESX1 gene are associated with a broad spectrum of phenotypes: septo-optic dysplasia, midline defects, pituitary abnormalities with consequent hypopituitarism, isolated growth hormone (GH) deficiency or combined pituitary hormone deficiencies (CPHD). This study examined the prevalence of mutations in the HESX1 gene in patients with CPHD.

PATIENTS/METHODS

Sixty patients with sporadic CPHD without septo-optic dysplasia were screened for mutations in HESX1.

RESULTS

Three patients were found to be heterozygous for the same Asn125Ser variant in the HESX1 gene. In all 3, panhypopituitarism was presented in the neonatal period, manifested by severe hypoglycemia and neonatal jaundice in 2 patients and respiratory distress in 1. Remarkable findings from physical examination included coarse face; prominent, large, low-set ears; and skeletal abnormalities. Magnetic resonance imaging, performed in 2 patients, revealed a hypoplastic anterior and ectopic posterior pituitary without other midline anomalies. Despite persistent GH deficiency and undetectable levels of insulin-like growth factor 1, all patients had normal linear growth along the 10-25th percentile without GH therapy.

CONCLUSION

The present study expands the clinical picture of HESX1 mutations by demonstrating that patients heterozygous for Asn125Ser may have a severe endocrinologic and neuroradiologic phenotype and similar dysmorphic features appearing very early in life.

Analysis of perioperative morbidity according to whether the uterine cavity is opened or remains closed during abdominal myomectomy--results of 423 abdominal myomectomy cases

For women who desire pregnancy or who wish to retain their uterus, myomectomy is the standard approach for the treatment of fibroids. Abdominal myomectomy seems to be the best choice when there are large subserosal or intramural fibroids (> 5-7 cm), or submucosal fibroids > 3 cm or when multiple fibroids (> 3) are to be removed. When submucosal myomas are present or multiple fibroids are to be removed, opening the uterine cavity during the surgical procedure is more likely to happen. There is lack of published evidence about whether there is any difference in perioperative morbidity and management of those cases where the uterine cavity is opened during the surgical procedure compared with those where the uterine cavity remains closed.

METHODS

We undertook a retrospective review of 423 abdominal myomectomies via either an opened or closed uterine cavity. As a primary outcome we assessed the overall perioperative morbidity rate and as a secondary outcome we compared the necessity of pre and postoperative transfusions, intraoperative bleeding, febrile morbidity, unintended surgical interventions, life-threatening events, need for relaparotomies and duration of hospital stay between the opened and non opened uterine cavity groups.

RESULTS

The overall perioperative morbidity rate was significantly higher in those cases where the uterine cavity was opened during surgery; however the difference was caused only by the increased risk of intraoperative bleeding. All the other variables, such as febrile morbidity, number of relaparotomies, unintended surgical procedures and life-threatening events did not differ between the two groups.

CONCLUSION

Although there is an increased risk of intraoperative bleeding it seems that entering the uterine cavity during abdominal myomectomy can be considered as safe a procedure as in those cases where the uterine cavity remains closed.

Heat-shock protein peptide DiaPep277 treatment in children with newly diagnosed type 1 diabetes: a randomised, double-blind phase II study

BACKGROUND

Type 1 diabetes mellitus (T1DM) is a T-cell-mediated autoimmune disease that leads to the destruction of insulin-producing beta cells. Treatment with DiaPep277, a peptide derived from heat-shock protein 60 (hsp60), has been found to slow the deterioration of beta-cell function after clinical onset of diabetes in NOD mice and human adults. Our aim was to evaluate the efficacy and safety of DiaPep277 treatment in attenuating beta-cell destruction in children with recent-onset T1DM.

METHODS

A prospective, randomized, double-blind, phase II design was used. The sample included 30 children (19 males) aged 7-14 years who had been diagnosed with T1DM from 53 to 116 days previously, and had basal C-peptide concentrations above 0.1 nmol/L. The children were randomized to receive subcutaneous injections of 1 mg DiaPep277 (15 patients) or 40 mg mannitol (placebo) at entry and at 1, 6, and 12 months. The duration of follow-up was 18 months. The groups were compared for stimulated C-peptide level, exogenous insulin dose, and HbA1c concentration.

RESULTS

C-peptide levels similarly decreased over time in the DiaPep277- and placebo-treated patients. There was no significant difference in insulin dose or HbA1c concentration between the groups at any time point. No serious drug-related adverse effects were recorded throughout the study period.

CONCLUSIONS

One-year treatment with DiaPep277 at a dosage of 1 mg is safe for use and well tolerated in children with recent-onset T1DM. However, it appears to have no beneficial effect in preserving beta-cell function or improving metabolic control.

A new mutation in the growth hormone-releasing hormone receptor gene in two Israeli Arab families

BACKGROUND

Mutations in the GHRH receptor gene (GHRH-R) are emerging as a common cause of familial isolated GH deficiency (IGHD).

DESIGN

We searched for GHRH-R mutations in 10 patients with IGHD of Israeli-Arab origin, belonging to two highly consanguineous families.

METHODS

Analysis of the 13 coding exons, the intron-exon boundaries, and the proximal promoter of the GHRH-R was performed by denaturing gradient gel electrophoresis. Abnormally migrating bands were sequenced. The newly found mutation was inserted into GHRH-R cDNA. Wild type and mutant receptor were expressed in Chinese hamster ovary (CHO) cells, and the cAMP response to GHRH was measured.

RESULTS

All patients were homozygous for a novel GHRH-R missense mutation in exon 11 that replaces arginine with cysteine (R357C). Functional assay demonstrated complete inactivity of the mutant receptor in vitro. The prevalence of the mutant allele in the Israeli-Arab population was found to be 2%. All the patients had low but detectable GH reserve, proportionate short stature, and growth retardation since early childhood, with good growth response to GH treatment. Magnetic resonance imaging, performed in 3 patients, revealed a normal sized anterior pituitary in one patient evaluated at early childhood, and a borderline hypoplastic gland in the 2 patients evaluated at puberty.

CONCLUSIONS

We describe a novel missense mutation in the GHRH-R. The high incidence of the mutant allele in Israeli Arabs suggests that the mutation may be a common cause of familial IGHD in this population.

Effect of sex hormone administration on circulating ghrelin levels in peripubertal children

BACKGROUND

Ghrelin levels gradually decrease throughout childhood and with advancing pubertal stage. The change during puberty is more pronounced in boys than girls.

OBJECTIVE

The objective of the study was to investigate whether the pubertal drop in ghrelin secretion is modified by the increase in sex hormones.

PATIENTS AND METHODS

Ghrelin levels were measured in 34 short peripubertal children (17 boys and 17 girls) aged 8-12.5 yr before and after sex hormone priming for GH stimulation testing.

RESULTS

In boys, priming with testosterone increased testosterone to pubertal levels (23.7 +/- 7.1 nmol/liter), which in turn induced a marked decrease in ghrelin (from 1615.8 +/- 418.6 to 1390.0 +/- 352.0 pg/ml) and leptin (from 8.0 +/- 4.5 to 5.8 +/- 3.2 ng/ml) and an increase in IGF-I (from 162.7 +/- 52.8 to 291.1 +/- 101.6 ng/ml) (P < 0.001 for all parameters). In girls, priming with estrogen led to a supraphysiological increase in estradiol levels (1313.8 +/- 438.0 pmol/liter), which had no effect on ghrelin, leptin, or IGF-I. There was no correlation between ghrelin levels and levels of sex hormones, leptin, or body mass index in either boys or girls.

CONCLUSIONS

A pharmacological increase in sex hormones is associated with a marked decline in circulating levels of ghrelin in boys but not girls. Additional longitudinal studies through puberty are needed to elucidate the physiological interaction between sex hormones and ghrelin.

Three novel mutations in POU1F1 in Israeli patients with combined pituitary hormone deficiency

BACKGROUND

POU1F1, a pituitary-specific transcription factor of the class 1 POU family, is crucial for the development and differentiation of the anterior pituitary gland. Mutations in the POU1F1 gene have been shown to be responsible for a syndrome of combined pituitary hormone deficiency (CPHD), including prolactin, growth hormone and thyroid-stimulating hormone deficiencies.

METHODS

Five patients with CPHD from three families were evaluated. The clinical and biochemical data were taken from the medical records. DNA was analyzed by polymerase chain reaction (PCR), denaturing gradient gel electrophoresis (DGGE), and sequencing.

RESULTS

Molecular analysis yielded three novel mutations in POU1F1: W193X, Q242R (-2 bp), and F262L.

CONCLUSIONS

Three novel POU1F1 mutations were detected in Israeli patients with CPHD. Two of them, a W193X missense mutation and a deletion of two adenine bases at position 242Q, may lead to the production of a truncated protein that lacks the entire POU homeodomain or part of it, respectively. The third mutation, F262L, resides in the POU homeodomain and hence might change the activity of the protein.

Prepubertal gynaecomastia: aetiology, course and outcome

BACKGROUND

Palpable and measurable glandular breast tissue is a rare finding in prepubertal boys and warrants thorough evaluation to rule out an underlying pathology.

OBJECTIVE

To characterize the course and outcome of prepubertal gynaecomastia, examine its effect on puberty, and try to identify its underlying cause.

PATIENTS AND METHODS

Twenty-nine out of 581 (5%) boys referred to our clinic for evaluation of gynaecomastia between 1980 and 2000 were prepubertal at diagnosis. Data on age at appearance of gynaecomastia, general and endocrine evaluation, course of growth and puberty, and treatment were collected from the medical files.

RESULTS

Prepubertal gynaecomastia was diagnosed at mean age of 8.9 +/- 2.2 years. In 27 of the 29 boys (93.2%) no underlying cause was identified. The remaining two boys (6.8%) had hyperaromatase syndrome. Nine boys (31%) were obese. Spontaneous resolution was recorded in six boys (20.5%), no change in 15 (52%), and further breast enlargement in eight (including the two with hyperaromatase syndrome) (27.5%). Accelerated growth and bone maturation rates were noted only in the two boys with hyperaromatase syndrome. Pubertal onset was documented in 13 boys at 11.8 +/- 1.1 years.

CONCLUSIONS

According to our large single tertiary care centre experience, 5% of boys referred for evaluation of gynaecomastia were prepubertal. The development of gynaecomastia was the only abnormality and was not associated with other pubertal signs or accelerated growth rate. In most cases, the gynaecomastia was idiopathic. Further prospective studies are needed to evaluate the pathophysiological mechanisms responsible for this phenomenon.

PROP-1 Gene Mutation (R120C) Causing Combined Pituitary Hormone Deficiencies with Variable Clinical Course in Eight Siblings of One Jewish Moroccan Family

BACKGROUND

PROP-1 gene mutations have been described in patients with combined pituitary hormone deficiencies (CPHD).

METHODS

Clinical follow-up and molecular analysis of the PROP-1 gene were performed in 4 affected sisters of one consanguineous family, in whom 8 members had CPHD.

RESULTS

The 4 sisters were homozygous for the same R120C mutation. Growth hormone and thyroid-stimulating hormone deficiencies were diagnosed concomitantly in all subjects, but at different ages (5.5-10.8 years). All 8 subjects exhibited complete gonadotropin deficiency with failure of spontaneous sexual maturation. Adrenocorticotropic hormone deficiency developed in only 2 sisters in the 3rd and 4th decades of life.

CONCLUSIONS

The CPHD in this family, caused by an R120C mutation, was characterized by clinical phenotypic variability in terms of the severity of hormonal deficiencies and the time of their development. Identifying the mutation does not predict the clinical course. Therefore, continuous follow-up with repeated endocrine evaluations is mandatory to provide proper hormone substitution therapy.

Craniopharyngioma: presentation and endocrine sequelae in 36 children

We studied the clinical presentation by age of 36 children with craniopharyngioma, and outcome by height and body mass index (BMI). Presenting symptoms included headache (51.4%), vomiting (31%), visual disturbances (22.9%), polyuria and/or polydipsia (17.1%), delayed puberty (19.4%), short stature (13.8%), and precocious puberty (2.7%). Growth deceleration was overlooked, as was diabetes insipidus (actual rate, 52% for both). Delayed puberty was observed in all patients of appropriate age. Mean height standard deviation score (SDS) at admission was significantly lower than mean target height SDS (p = 0.004), while mean final height SDS was similar (p = 0.14). BMI SDS at last follow-up was similar to mean parental BMI SDS. We conclude that although endocrinopathies are present in most patients with craniopharyngioma, they are rarely the reason for referral. While affected prepubertal children have non-endocrine complaints, most adolescents are referred because of delayed puberty. Diabetes insipidus may be more prevalent in craniopharyngioma than previously reported. When patients with hypothalamic obesity are excluded, mean BMI SDS remains within normal range and is influenced mostly by parental BMI SDS.

Gonadotropin-suppressive therapy in girls with early and fast puberty affects the pace of puberty but not total pubertal growth or final height

Early and fast puberty (EFP) in girls, defined as pubertal onset at age 8-9 yr, with an accelerated course, may cause compromised final height (FHt) and psychosocial distress. Treatment with a gonadotropin-suppressive agent is controversial, because the improvement in FHt is equivocal and there may be risk of obesity. We analyzed the data of 126 girls with EFP: 63 treated with GnRH analog (GnRHA) since Tanner stage 3, for 2-4 yr; and 63 untreated. Age at onset of puberty; accelerated time of transition from Tanner stage 2 to 3 (<1.3 yr); and clinical, hormonal and sonographic findings were similar in the 2 groups. The girls given GnRHA treatment had a significantly prolonged pubertal course, compared with the accelerated course in the untreated girls (4.7 +/- 0.4 vs. 2.45 +/- 0.4 yr, P < 0.001). After therapy, they reached Tanner stages 4 and 5 and FHt at a significantly older age than the untreated group (P < 0.001), and their menarche was delayed (12.8 +/- 0.6 vs. 10.8 +/- 0.5 yr, P < 0.001). However, the different pace of puberty in the 2 groups did not change the total pubertal growth and the bone maturation rate. The Ht gain from Tanner stage 3 to 4 (10.4 +/- 2.7 vs. 11.2 +/- 3.1 cm) and from Tanner stage 4 to FHt (8.2 +/- 2.7 vs. 8.8 +/- 3.6 cm) was similar in the treated and untreated girls, as were absolute Ht and bone age at each pubertal stage. The weight gain of the treated girls was more pronounced during treatment (P = 0.0016), but it was arrested after discontinuation of therapy; and by the time FHt was reached, the body mass index was similar in the 2 groups. The treated and untreated girls achieved a similar mean FHt, which was not significantly different from their respective mean target Ht (THt). Individual analysis revealed that 70% of the treated girls and 67% of the untreated girls attained their THt range (THt +/- 0.5 SD) or surpassed it. In conclusion, treatment with GnRHA affected only the pace of EFP. The similar Ht gain and bone maturation rate at each pubertal stage in the treated and untreated girls may suggest that the total pubertal growth is not dependent on pubertal duration and pace and is probably determined already at the onset of the normal pubertal development. The treatment did not compromise the FHt and did not cause long-lasting obesity. Therefore, GnRHA therapy may be suggested for use in girls who have psychosocial difficulties in coping with EFP.

A novel mutation in PIT-1: phenotypic variability in familial combined pituitary hormone deficiencies

Mutations in PIT-1 have been described in several cases of familial combined pituitary hormone deficiencies. This study describes a novel PIT-1 mutation that was found in two siblings of a highly consanguineous family of Israeli-Arab origin. The missense mutation (G688A) causes a lysine (K) to glutamic acid (E) substitution at codon 230. This codon resides in the first helix of the POU-homeodomain, which is directly involved in DNA binding. This amino acid is conserved in most homeodomain proteins, suggesting that the substitution disrupts the DNA-binding activity of the mutant protein. Two main observations are described: 1. The clinical presentation of the mutation involves intrauterine growth retardation. 2. One sibling had full deficency of growth hormone and thyroid stimulating hormone, whereas the other had only growth hormone deficiency. This is, to the best of our knowledge, a unique expression of a novel PIT-1 mutation.

Quadriceps paresis in pediatric groin surgery

A total of 2,624 groin operations were performed in 2,202 infants and children aged 6 months-14 years during the last 4.5 years. Preventive analgesia was used in all operations, and included ilioinguinal and iliohypogastric nerve block combined with inguinal canal infiltration. In 6 patients transient postoperative quadriceps muscle paresis (QMP) was noted. They required bed rest and monitoring for a few hours, and complete spontaneous recovery was noted in all cases. The aim of this study was to examine the incidence of transient QMP following regional nerve block and to discuss models of possible prevention.

The distal pouch in esophageal atresia -- to dissect or not to dissect, that is the question

Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon and reconstruction using the native esophagus is considered to be superior to any interposition procedure. Because of esophageal segmental blood supply and vascular vulnerability of the distal esophageal pouch in the short term and its motility disorder in the long term, surgeons are reluctant to perform extensive esophageal dissection. However, ascending and descending branches of esophageal vessels converge along the anterolateral and posterolateral aspects of the esophagus. This arrangement allows for dissection and mobilization of the distal pouch without necessarily causing vascular impairment. Extensive dissection of the distal pouch was advocated by Robert Gross over fifty years ago. More recently, circular myotomy of the distal pouch has been performed. However, manometric studies showed that prior to surgical repair, peristalsis of the upper and lower esophageal pouch was synchronized, while after surgery this coordination was clearly defective. Furthermore, in the adriamycin-induced rat model, inherent abnormalities in the course and branching pattern of the vagus nerves in the lower esophagus have been demonstrated. Significant abnormalities of the intramural nervous components involving both the excitatory and inhibitory nerves, and elevated levels of S100 and galanin in the lower esophageal pouch could explain an inborn motility disorder. The selective injury of minor vagal branches in experimental animals also alters esophageal peristalsis. In conclusion, given that the native esophagus is still considered the best alternative for reconstruction of esophageal atresia, when indicated, gentle but extensive dissection of the lower esophageal pouch seems to be preferable, keeping in mind the possibility of vascular compromise and the inevitability of motility disfunction.

Congenital short-bowel and malrotation: clinical presentation and outcome of six affected offspring in three related families

Newborns with congenital short small bowel associated with malrotation and intestinal dysmotility have a uniformly bad prognosis. However, few long-term survivors have been reported, suggesting that the disorder is not invariably fatal. The majority of cases previously reported were familial. We report on six affected siblings in three related families. The aim of this report is to assess the mode of inheritance, the expression of this disorder, and to point to the correlation between the onset of gastrointestinal symptoms and the outcome.

Volvulus of the stomach in childhood: the spectrum of the disease

INTRODUCTION

During a 5-year time frame, five cases of symptomatic gastric volvulus were diagnosed and treated in our department. Four presented with the acute form of gastric volvulus and underwent emergency surgery. The fifth suffered the chronic variant of the syndrome and was benefited by nonoperative management. The cases serve to remind emergency physicians of the spectrum of gastric volvulus. The report supplements the sparse clinical description in the emergency literature.

RESULTS

In the operated patients, there were no postoperative complications. The outcome, to the time of publication, has been good in every instance. The history, etiology, presentation, and treatment of the disease are discussed in detail.

CONCLUSIONS

Not infrequently, gastric volvulus in children fails to exhibit the full gamut of signs and symptoms such as abdominal distension, vomiting, pain, and retching. For this, as well as for other stated reasons, symptomatic gastric volvulus in infancy and childhood may not be as rare as is commonly assumed.

Ultrasound features of spermatic cord hydrocele in children

The aim was to evaluate the value of ultrasound diagnosis of spermatic cord hydrocele as a cause of inguinal swelling or mass in children. Clinical and ultrasound (US) findings and surgical procedures of 27 children with spermatic cord hydrocele were reviewed. All children, except one, were referred for US because of suspected inguinal hernia, hydrocele or inguinal mass. In one child, the US examination was performed to confirm the diagnosis of a spermatic cord hydrocele. An encysted hydrocele was diagnosed in 24 out of 27 cases, whereas a funicular type of spermatic cord hydrocele was found in the remaining 3 cases. Internal septa were seen within the fluid mass in four patients. 23 children underwent surgical exploration that confirmed the US diagnosis. Three children with encysted-type hydrocele were only followed clinically and by US, and one was lost from follow-up. US examination is a very sensitive and accurate method for diagnosis of this entity and for exclusion of other lesions in this region.

Sexual precocity in boys: accelerated versus slowly progressive puberty gonadotropin-suppressive therapy and final height

The indication for GnRH analog treatment in boys with central sexual precocity is based mainly on the age of onset of puberty. Our aim was to determine whether the rate of pubertal progression should also be taken into consideration. Included in the study were 81 boys with central sexual precocity: 27 with true precocious puberty (onset at <9 yr) and 54 with early puberty (onset at 9-10.5 yr). At the time of analysis, all had completed puberty, and 66 (22 central precocious puberty, 44 early puberty) had achieved final height. Progression of puberty (Tanner stage 2 to 3) was accelerated (0.5-1.32 yr) in 42 boys (16 central precocious puberty, 26 early puberty) and slow (1.7-2.9 yr) in 39 (11 central precocious puberty, 28 early puberty). The boys with accelerated puberty had significantly elevated T levels (central precocious puberty and early puberty, P < 0.001), faster growth rate (change in height SD score/duration: central precocious puberty, P < 0.05; early puberty, P < 0.01), and faster bone maturation rate (change in bone age/duration: central precocious puberty, P < 0.05; early puberty, P < 0.001). All 42 boys with accelerated puberty were treated with GnRH analog for 2.3-4.2 yr; the duration to completion of puberty and the height gain after therapy was discontinued were similar for the boys with central precocious puberty and early puberty. The 39 boys with slow puberty received no treatment and had a prolonged course of puberty (central precocious puberty, 5.05 +/- 0.3 yr; early puberty, 4.72 +/- 0.77 yr; average normal, 3.5 yr). The final height achieved in the 35 (11 central precocious puberty, 24 early puberty) untreated boys was within the range of their respective target height. The 31 (11 central precocious puberty, 20 early puberty) treated boys also achieved their genetic target height. Predictions based on the Bayley-Pinneau method at Tanner stage 3 for all boys and at discontinuation of therapy for treated boys overestimated the achieved final height (P < 0.001). In conclusion, boys with sexual precocity, whether central precocious puberty or early puberty, may have either accelerated or slow pubertal development. The decision to institute suppressive therapy should be based also on the rate of pubertal progression. Treatment should be offered only to those (either central precocious puberty or early puberty) with accelerated growth and bone maturation rates and rapid increase in T levels. Suppression therapy apparently converts accelerated puberty into nonsustained slow puberty and probably prevents compromised final height.

Abdominal injuries caused by bicycle handlebars

OBJECTIVE

To find out whether the increase in the number of children admitted with injuries from mountain bicycle handlebars is attributed to recent changes in the design of children's bicycles.

DESIGN

Retrospective study.

SETTING

Teaching general hospital, Israel.

SUBJECTS

76 children who presented with abdominal injuries caused by bicycle handlebars.

RESULTS

In 12 of the 76 children, there was an imprint of the handlebar edge on the hypochondrium. The most common injuries were isolated ruptures of spleen or liver, (14 and 11 patients, respectively). Five of the 25 patients were operated on and the rest treated conservatively.

CONCLUSIONS

Children with an imprint or bruise made by the handlebar edge on the abdominal wall, or who give a clear history of injuries by a bicycle handlebar should be treated with great care. BMX handlebars are relatively high (for young riders) and wide; they also turn freely and are therefore in direct line with the upper abdomen. Prohibiting the use of bicycles with unpadded handlebars may prevent some of these intra-abdominal injuries.

Thyrotoxicosis in prepubertal children compared with pubertal and postpubertal patients

The course of Graves' thyrotoxicosis in 7 prepubertal children (6.4+/-2.4 yr) was compared with that in 21 pubertal (12.5+/-1.1 yr) and 12 postpubertal (16.2+/-0.84 yr) patients. In the prepubertal group the main complaints were weight loss and frequent bowel movements (86%), whereas typical symptoms (irritability, palpitations, heat intolerance, and neck lump) occurred significantly less often (P < 0.01). The most prominent manifestation at diagnosis was accelerated growth and bone maturation: their height SD score was significantly greater than that of the pubertal and postpubertal patients (2.6+/-0.7 us. 0.15+/-0.65 and 0.15+/-0.9, respectively, P < 0.001), and their bone age to chronological age ratio was 1.39+/-0.35 compared with 0.98+/-0.06 in the pubertal children (P = 0.02). T3 levels were also significantly higher than in the other two groups (9.9+/-2.9 nmol/L vs. 6.32+/-1.9 nmol/L and 6.02+/-2.0 nmol/L, P = 0.01). All patients were initially prescribed antithyroid drugs (ATDs). Overall, adverse reactions to ATDs occurred in 35%, with a higher rate among the prepubertal children (71%) than the pubertal (28%) and postpubertal (25%) patients (P = 0.08). Major adverse reactions were noted in two children, both prepubertal. Remission was achieved in 10 patients (28%). Although the rate of remission did not differ among the three groups, time to remission tended to be longer in the prepubertal children (P = 0.09). In conclusion, thyrotoxicosis has an atypical presentation and more severe course in prepubertal children. Considering their adverse reactions to ATD, overall low remission rate, and long period to remission, definitive treatment should be considered earlier in this age group.

The vitrification of in vitro fertilized cow blastocysts by the open pulled straw method

In 6 replicates, a total of 450 immature oocytes recovered from 144 slaughterhouse-derived bovine ovaries were matured and fertilized in vitro, then cultured for 7 to 9 d on a granulosa cell monolayer in tissue culture medium 199 (TCM-199) supplemented with fetal calf serum. Of 126 blastocysts (28% of oocytes cultured), 117 (26% of oocytes cultured) were vitrified in Hepes/bicarbonate-buffered TCM-199 medium and 20% fetal calf serum, with ethylene glycol and dimethylsulfoxid as the cryoprotectants. After thawing in 1.2 mL holding medium with 0.25-M sucrose and after 1 min in holding medium with 0.15-M sucrose, blastocysts were cultivated in vitro for 24 h. The re-expansion rate of blastocysts was 69.2% (81 blastocysts), and 39.5% (32 blastocysts) were hatched. Re-expansion and hatching rates differed between the blastocysts vitrified on 7 and 8+9 days (74.6% and 46% vs. 62% and 29%, respectively). After transfer to recipient cows, 3 out of 6 were diagnosed by ultrasonography as pregnant. Three calves were born from 18 transferred embryos (16.7%). The open pulled straw (OPS) method seems to be a convenient, simple and effective method for cryopreservation of 7 to 9 d bovine embryos.

Unique aspects of caring for dying children and their families

Pediatric hospice has become an important service for children and their families in the past decade. In this article we present unique aspects of StarShine, the hospice of Children's Hospital Medical Center in Cincinnati, Ohio. Length-of-service data demonstrate the need to find innovative ways of encouraging earlier referral to hospice. Several specialized aspects of care, such as long-term bereavement, pet visitation and social services for the family are presented. The initiation of a novel in-home pain management program is described. StarShine has not followed an adult hospice model, and as such, we discuss those unique aspects of dying pediatric patients and suggest specific solutions and interventions designed for children.

Delayed growth and puberty in patients with Gaucher disease type 1: natural history and effect of splenectomy and/or enzyme replacement therapy

BACKGROUND

Growth retardation in childhood was only recently recognized as a prominent feature of Gaucher disease type 1, but there are few data on both the pubertal development and the final outcome of growth and sexual maturation.

OBJECTIVE

To investigate the natural pattern of growth and puberty in patients with Gaucher disease type 1 and the effect of splenectomy and enzyme replacement therapy.

METHODS

We retrospectively analyzed growth and puberty in 57 patients with Gaucher disease type 1; 52 were followed since childhood and/or prepuberty and 42 have reached sexual maturity and final height. In the analysis we considered severity of disease, time of splenectomy, and start of enzyme replacement therapy.

RESULTS

Deceleration of growth at age 3-5 years was observed in 30 of 57 patients followed since early childhood while untreated: height-SDS decreased from -0.34 +/- 0.42 at age 0-3 years to -1.93 +/- 0.95 (P < 0.01) at age 7-10 years and was more pronounced with severe disease. A high prevalence (59.6%) of delayed puberty, which was more frequent with severe disease, was observed in 47 patients followed before and throughout puberty. No primary endocrine pathology was found. All patients, untreated as well as treated, with growth and pubertal delay had a spontaneous catch-up, achieved full sexual maturation, and most (83.3%) reached a final height within the range of parental height-standard deviation score. Splenectomy (partial and/or total) performed in 20 patients while still growing had a beneficial effect on growth, which was temporary in some and did not affect puberty. ERT improved growth in 11 patients who started therapy before puberty, as evidenced by a progressive increase in the height-SDS, and seemed to normalize the onset of puberty.

CONCLUSIONS

Growth retardation in childhood and delay of puberty are characteristic of Gaucher disease type 1 and are more frequent with severe disease. There is a spontaneous catch-up later in life and most patients reach a final height within their genetic growth potential. Enzyme replacement therapy apparently normalizes growth and possibly also the onset of puberty.

Successful implementation of a guideline by peer comparisons, education, and positive physician feedback

The objective of this study was to determine if peer comparisons, an educational intervention, and positive physician feedback would decrease ordering of knee X-ray studies. We prospectively studied the ordering of knee X-ray studies for patients presenting with knee injuries before and after an educational program to encourage use of the Ottawa decision rule for knee radiography. Physicians were able to privately compare their individual baseline X-ray utilization data with that of their colleagues. Although acceptance of the rule was voluntary, both oral and written feedback encouraged consideration of the rule in clinical decision-making. The percentage of knee injury patients who received X-ray studies, as well as the Percentage Abnormal Results (PAR, defined as the percentage of X-ray studies demonstrating a fracture or effusion), were calculated before and after the educational meeting. Results of the study showed that the percentage of patients presenting with knee injuries who received X-ray studies decreased 23%. In addition, the PAR increased 58.4% between the two study periods. In conclusion, physician behavior can be altered positively with reinforcement. Peer comparisons, education, and positive physician feedback decreased test ordering by physicians even without mandating use of a protocol. PAR is a useful outcome measure to track physician utilization.

Subtotal gastrectomy in a teenager with gastroparesis

Disorders of gastric emptying are rare in healthy infants and children. Delayed gastric emptying is encountered in adults after operations on the stomach, such as vagotomy and partial gastrectomy, and is extremely rare in young patients. The authors report on a 15-year-old patient with gastroparesis after three attempts to repair a congenital diaphragmatic hernia. Medical therapeutic trials consisting of all combinations of diet regimes with various gastrokinetic drugs failed to alleviate the intractable vomiting. All the patient's symptoms resolved after subtotal gastrectomy with gastroduodenostomy (Billroth I).

A conservative treatment for ingrown toenails in children

Ingrowing nails are not uncommon in children, and even so receive little attention in the pediatric surgery literature. The purpose of the present study was to demonstrate our modification of the conservative treatment of ingrowing nails. Our technique of local treatment combined with patient education for better foot and toe care was successfully used and well tolerated by 19 out of 20 young patients with ingrown toenails.

[Bowel-lengthening in a newborn with short bowel syndrome]

Advances in parenteral nutrition and supportive therapy have led to improvement in survival of babies with short-bowel syndrome. Those whose intestinal mass is very unlikely to be adequate should have surgical therapy as soon as possible, before they develop the complications of long-term parenteral nutrition or significant enteritis. We present a newborn with short-bowel syndrome due to prenatal midgut volvulus. At operation the remaining viable jejunum, 15 cm long, was anastomosed to the cecum. All feeding attempts failed, and the infant suffered from malabsorption. Calories and proteins had to be supplied by intravenous total parenteral nutrition. At 3 months of age there was significant widening of the remaining bowel and Bianchi's bowel-lengthening procedure was performed. The postoperative course was uneventful and there was gradual improvement in intestinal absorptive capacity. The patient was weaned from parenteral nutrition at 3 years of age. Now, 2 years later, she eats a normal diet.

MR findings in growth hormone deficiency: correlation with severity of hypopituitarism

BACKGROUND AND PURPOSE

Growth hormone deficiency may present as an isolated deficit (IGHD) or in association with multiple deficiencies (MPHD). Previous studies have not compared the MR imaging findings with the severity of hypopituitarism. Our purpose was to determine whether MR imaging can distinguish between IGHD and MPHD.

METHODS

Forty-four patients with growth hormone deficiency who were examined by MR imaging were included in this retrospective study. On the basis of the endocrinologic findings, 21 were determined to have IGHD and 23 to have MPHD. The presence, size, location, and morphologic characteristics of the stalk, the neurohypophysis, and the adenohypophysis were recorded in each case. Findings in the two groups were compared. Statistical significance was determined by t-test.

RESULTS

The stalk was normal in one patient with IGHD and in none of those with MPHD; it was truncated or thin in 19 patients with IGHD (90%) and in only one with MPHD (4%); it was absent in 22 patients with MPHD (96%) and in only one patient with IGHD (5%). These differences between the two groups were highly significant. In 81% of the IGHD patients and in 91% of the MPHD patients the location of the neurohypophysis was ectopic. This difference between the two groups was not significant. Among IGHD patients, the adenohypophysis was of normal size in 13 patients (62%), small in six (29%), and absent in two (9%); the corresponding findings in MPHD patients were seven (30%), six (26%), and 10 (44%).

CONCLUSION

The majority of IGHD patients had a truncated or thin stalk and a normal or small adenohypophysis. An absent stalk and adenohypophysis are characteristic of MPHD. MR imaging can contribute to the prediction of the pattern and severity of hypopituitarism in patients with growth hormone deficiency.

Diagnosis of deep venous thrombosis by use of soluble necrosis factor receptor

The purpose of this clinical study was to find a relationship between soluble tumor necrosis factor (TNF) receptor, deep venous thrombosis (DVT), and pulmonary emboli (PE). Clinical diagnosis of deep venous thrombosis and pulmonary emboli is a major dilemma for the clinician. Most existing tests are technician dependent, are expensive, or require sophisticated equipment. Advances in molecular biology will permit investigation of the value of TNF receptor as a test for screening, diagnosis, and evolution of DVT and PE. Forty patients with diagnosis of DVT, documented by real-time ultrasound imaging, were the subject of this clinical study. Five cc of plasma from each patient was studied by enzyme-linked immunosorbent assay (Elisa) for measurement of soluble TNF receptor. Significantly increased concentration of plasma-soluble TNF receptor was present in patients with DVT as opposed to normal individuals. There was a close relationship between plasma concentration of soluble TNF receptor and evaluation of the disease. In this preliminary clinical study, it appears that plasma measurement of soluble TNF receptor could be used as a clinical test for diagnosis of DVT and PE.

MR findings in hereditary isolated growth hormone deficiency

PURPOSE

To describe the MR characteristics by which patients with hereditary isolated growth hormone deficiency (GHD) can be distinguished from patients with other types of GHD.

METHODS

A total of 51 patients with GHD were examined prospectively with MR imaging. On the basis of familial occurrence of GHD and genetic analysis, 10 patients met the criteria for hereditary deficiency. In each case, the height of the pituitary gland, the presence and location of the posterior neurohypophysis, and the completeness of the stalk were recorded. The findings in the hereditary group were compared with those in the rest of the patients.

RESULTS

In all 10 patients with hereditary GHD, the adenohypophysis, the neurohypophysis, and the stalk were normal. Of the other 41 patients, the height of the gland was normal in three (7%), the neurohypophysis was abnormal in all, and the stalk was truncated in all but two patients (95%).

CONCLUSIONS

The subgroup of patients with hereditary GHD exhibited an anatomically normal pituitary-hypothalamic region. This is in contrast to the majority of patients with idiopathic GHD. MR imaging can contribute to the classification of patients with GHD.

Pernicious anemia and adenocarcinoma of the stomach in an adolescent: clinical presentation and histopathology

Primary gastric-carcinoma accounts for only 0.05% of pediatric gastrointestinal malignancies. Although elderly patients who have pernicious anemia are at greater risk of the development of atrophic gastritis and gastric carcinoma, pernicious anemia caused by vitamin B12 deficiency is extremely rare in otherwise healthy adolescents. The authors present a 14.5-year-old boy who had dimorphic anemia caused by vitamin B12 and iron deficiencies in whom atrophic gastritis and gastric carcinoma developed. To the best of our knowledge, this association has not been previously reported in children or adolescents.

Incidence of colorectal adenocarcinoma by anatomic subsite. An epidemiologic study of time trends and racial differences in the Detroit, Michigan area

BACKGROUND

Colorectal adenocarcinoma may represent more than one disease process. Numerous epidemiologic studies suggest that rates of occurrence of colorectal adenocarcinoma at particular anatomic subsites (e.g., right colon, left colon, and rectum) may be associated with distinctive geographic, demographic, and risk factor profiles. This study explored time trends over a 22-year period of the incidence of adenocarcinoma of the colon and rectum at various subsites among patients of different race, gender, and stage of disease.

METHODS

Data on the incidence of colorectal adenocarcinoma were obtained from a population-based cancer registry in the Detroit, Michigan area funded by the National Cancer Institute. Age-adjusted incidence rates were analyzed by year of diagnosis. Relative survival rates were also obtained for different race and gender categories, along with disease stage at diagnosis.

RESULTS

A major rise was revealed in the incidence of adenocarcinoma in the right colon among African American men and women between the mid-1970s and the early 1980s. The rise was greatest among African American men and accounts for increases in late stage disease among them. Corresponding decreases in survival among African American men were noted.

CONCLUSIONS

These findings indicated widely differing disease patterns based on anatomic subsite and patient demography and also indicated a need for targeted efforts at early detection of adenocarcinoma of the right colon among African Americans.

Incidence of colorectal adenocarcinoma by anatomic subsite. An epidemiologic study of time trends and racial differences in the Detroit, Michigan area

BACKGROUND

Colorectal adenocarcinoma may represent more than one disease process. Numerous epidemiologic studies suggest that rates of occurrence of colorectal adenocarcinoma at particular anatomic subsites (e.g., right colon, left colon, and rectum) may be associated with distinctive geographic, demographic, and risk factor profiles. This study explored time trends over a 22-year period of the incidence of adenocarcinoma of the colon and rectum at various subsites among patients of different race, gender, and stage of disease.

METHODS

Data on the incidence of colorectal adenocarcinoma were obtained from a population-based cancer registry in the Detroit, Michigan area funded by the National Cancer Institute. Age-adjusted incidence rates were analyzed by year of diagnosis. Relative survival rates were also obtained for different race and gender categories, along with disease stage at diagnosis.

RESULTS

A major rise was revealed in the incidence of adenocarcinoma in the right colon among African American men and women between the mid-1970s and the early 1980s. The rise was greatest among African American men and accounts for increases in late stage disease among them. Corresponding decreases in survival among African American men were noted.

CONCLUSIONS

These findings indicated widely differing disease patterns based on anatomic subsite and patient demography and also indicated a need for targeted efforts at early detection of adenocarcinoma of the right colon among African Americans.