Inheritance of Mildly Activating ABCC8 Mutation From a Mother With MODY Causes Permanent Neonatal Diabetes Mellitus (NDM) in Two Siblings Who Also Carry a Second Inactivating Mutation: Genetic Testing Allows for Improved Treatment With Sulfonylureas (SU)

Background: Heterozygous activating mutations in KCNJ11 or ABCC8 are the most common cause of neonatal diabetes (NDM). ABCC8 (SUR1) mutations more often cause transient NDM. Inactivating ABCC8 mutations can cause congenital hyperinsulinism (HI), but very rarely will such mutations be inherited together. Mildly activating KATP mutations can also be a cause of MODY, but even if genetic testing is considered, many commercial testing panels do not include these genes, despite the significant difference in treatment that can result due to sulfonylurea (SU) responsiveness.

Clinical Case: The proband was diagnosed with DM at 11 months old and fortuitously treated with SU for 3 years. He was switched to insulin and had poor DM control thereafter. Sister was diagnosed at 3.5 months old and had poor DM control on insulin. Mother was diagnosed with DM at 27 years old and treated with various medications including insulin. Genetic testing revealed that mother carried ABCC8 mutation R1380C previously described to cause transient NDM and/or later-onset DM consistent with her phenotype. Both children inherited this mutation from her and inherited a variant (L1148R) from their father without diabetes that has been reported in association with HI. The L1148R allele may reduce cell surface expression thereby increasing the relative expression and pathogenic effect of the R1380C allele that has not previously been described to cause permanent NDM.

We assessed SU responsiveness by measuring maximal beta-cell function through combined mixed meal and arginine testing. Mother exhibited easily detectable C-peptide levels at baseline that improved by SU treatment. In contrast, the children displayed almost undetectable baseline beta-cell function with variable response to SU: the sister who had been chronically poorly controlled on insulin therapy displayed barely improved C-peptide production, while her brother who had previously been treated with SU as an infant had markedly improved beta-cell function on SU. Within two months of continued treatment with high doses of SU only, he was able to start lowering his SU dose with improved glycemia. His sister was started on high-dose SU in addition to insulin, but continued to have difficulty adhering to her treatment regimen. Her blood sugar improved after the addition of long-acting GLP-1 agonist (liraglutide) but she later became pregnant and returned to insulin only. Her glycemic control improved when re-started on SU after pregnancy. The mother exhibited excellent DM on a lower dose of exclusive SU therapy.

Clinical Lesson: Genetic testing can dramatically alter management and must be pursued in both NDM and family members with diabetes later in life. Careful assessment of clinical characteristics along with genetic testing for segregation patterns in family members can greatly improve understanding of the causality of previous uncharacterized variants.

Investigating infant development through an interprofessional research collaboration: case report

Background/aims

From a dynamic systems perspective of infant development, several systems (eg sensorimotor, perceptual, and reasoning, among others, may self-organise and change behavioural responses over time following experience. These changes in infant behaviour are often measured through the achievement of age-adjusted developmental milestones. However, the majority of research guiding the understanding of typical infant developmental trajectories rarely depicts collaborations across more than one or two disciplines. The purpose of this case report was to describe an interprofessional research collaboration among researchers and clinicians in clinical and experimental psychology, occupational therapy, speech-language pathology, and physical therapy to establish methods and procedures that describe different developmental domains in infancy for a single participant.

Methods

One infant who was typically developing was video and audio recorded during 60 minutes of free play at ages 8, 12, and 16 months. Four research labs scored the middle 20 minutes of recorded time for infant and caregiver utterances, touch and motor behaviours, play participation and performance, co-occupation, and caregiver sensitivity to infant affect. The combined data from the four labs captured and revealed a rich description of the infant's development from 8 to 16 months of age.

Results

The data for this single infant indicated that important developmental changes occurred leading to greater independence in communication, mobility and co-occupation, while reducing some of the requirements for attention from the caregiver.

Conclusions

The procedures used within research labs by principal investigators from four disciplines to describe development in a single infant between 8 and 16 months of age yielded a rich example of development, consistent with published milestones. Future studies with larger sample sizes using the interdisciplinary research methods applied in this case study may improve the understanding of, influences on, and relationships between, infant developmental trajectories.

A Cohort Study of Relations Among Caregiver-Infant Co-Occupation and Reciprocity

Co-occupation is the mutual engagement of two people in a shared occupation. Recent research has investigated co-occupational activities during sensitive periods to inform clinical practice. However, there remains a dearth of applied research to bridge gaps between research and practice within salient co-occupational relationships between caregivers and infants. The study applied co-occupational constructs of physicality, emotionality, and intentionality within caregiver-infant dyads across infancy. These constructs were examined in relation to caregiver-infant reciprocity in other domains (i.e., language, motor, and affective) to determine the overlapping features of reciprocal co-occupation with established aspects of reciprocity. Results suggest that as infants transitioned into toddlerhood and became more mobile and intentional in behavior, there were observable changes in caregiver-infant reciprocity. Caregiver utterances, affect, touch, and co-occupation were significantly related within and across time, highlighting the need for more studies to disentangle these relations in reference to infant development.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

The Spinal Cord, Not to Be Forgotten: the Final Common Path for Development, Training and Recovery of Motor Function

Research on learning, memory, and neural plasticity has long focused on the brain. However, the spinal cord also exhibits these phenomena to a remarkable degree. Following a spinal cord injury, the isolated spinal cord in vivo can adapt to the environment and benefit from training. The amount of plasticity or recovery of function following a spinal injury often depends on the age at which the injury occurs. In this overview, we discuss learning in the spinal cord, including associative conditioning, neural mechanisms, development, and applications to clinical populations. We take an integrated approach to the spinal cord, one that combines basic and experimental information about experience-dependent learning in animal models to clinical treatment of spinal cord injuries in humans. From such an approach, an important goal is to better inform therapeutic treatments for individuals with spinal cord injuries, as well as develop a more accurate and complete account of spinal cord and behavioral functioning.

Multivariable Artificial Pancreas for Various Exercise Types and Intensities

BACKGROUND

Exercise challenges people with type 1 diabetes in controlling their glucose concentration (GC). A multivariable adaptive artificial pancreas (MAAP) may lessen the burden.

METHODS

The MAAP operates without any user input and computes insulin based on continuous glucose monitor and physical activity signals. To analyze performance, 18 60-h closed-loop experiments with 96 exercise sessions with three different protocols were completed. Each day, the subjects completed one resistance and one treadmill exercise (moderate continuous training [MCT] or high-intensity interval training [HIIT]). The primary outcome is time spent in each glycemic range during the exercise + recovery period. Secondary measures include average GC and average change in GC during each exercise modality.

RESULTS

The GC during exercise + recovery periods were within the euglycemic range (70-180 mg/dL) for 69.9% of the time and within a safe glycemic range for exercise (70-250 mg/dL) for 93.0% of the time. The exercise sessions are defined to begin 30 min before the start of exercise and end 2 h after start of exercise. The GC were within the severe hypoglycemia (<55 mg/dL), moderate hypoglycemia (55-70 mg/dL), moderate hyperglycemia (180-250 mg/dL), and severe hyperglycemia (>250 mg/dL) for 0.9%, 1.3%, 23.1%, and 4.8% of the time, respectively. The average GC decline during exercise differed with exercise type (P = 0.0097) with a significant difference between the MCT and resistance (P = 0.0075). To prevent large GC decreases leading to hypoglycemia, MAAP recommended carbohydrates in 59% of MCT, 50% of HIIT, and 39% of resistance sessions.

CONCLUSIONS

A consistent GC decline occurred in exercise and recovery periods, which differed with exercise type. The average GC at the start of exercise was above target (185.5 ± 56.6 mg/dL for MCT, 166.9 ± 61.9 mg/dL for resistance training, and 171.7 ± 41.4 mg/dL HIIT), making a small decrease desirable. Hypoglycemic events occurred in 14.6% of exercise sessions and represented only 2.22% of the exercise and recovery period.

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.

Dissipative solitons with extreme spikes in the normal and anomalous dispersion regimes

Prigogine's ideas of systems far from equilibrium and self-organization (Prigogine & Lefever. 1968 J. Chem. Phys.48, 1695-1700 (doi:10.1063/1.1668896); Glansdorff & Prigogine. 1971 Thermodynamic theory of structures, stability and fluctuations New York, NY/London, UK: Wiley) deeply influenced physics, and soliton science in particular. These ideas allowed the notion of solitons to be extended from purely integrable cases to the concept of dissipative solitons. The latter are qualitatively different from the solitons in integrable and Hamiltonian systems. The variety in their forms is huge. In this paper, one recent example is considered-dissipative solitons with extreme spikes (DSESs). It was found that DSESs exist in large regions of the parameter space of the complex cubic-quintic Ginzburg-Landau equation. A continuous variation in any of its parameters results in a rich structure of bifurcations.This article is part of the theme issue 'Dissipative structures in matter out of equilibrium: from chemistry, photonics and biology (part 1)'.

Infant and Maternal Reciprocity as Expressed Through Play Performance and Participation

Date Presented 3/30/2017

Infant–maternal reciprocity may be captured and represented through play. Play construction, purpose, object choice, and type were observed and coded using a retrospective analysis, demonstrating an increase in frequency and duration in most categories.

Primary Author and Speaker: Bryan Gee

Additional Authors and Speakers: Susan Kunkel

Contributing Authors: Hillary Swann, Nancy Devine, Nicholas Burgett, Nicki Aubuchon-Endsley, Michele R. Brumley, Heather Ramsdell-Hudock

The Reciprocity Team: Development of an Interprofessional Research Collaboration

The purpose of this article is to articulate and provide detail about an interprofessional research collaboration at a public university in a rural area of western United States. This interprofessional research collaboration was organized to explore infant and maternal reciprocity. As a part of the organization and process portion of the collaborative effort, the authors identify the unique attributes of their collaboration. Additionally, barriers to collaborative research are presented, with opportunities and recommendations made to support existing and future interprofessional collaborative efforts for basic science scholars, clinicians, and educators in health-related professions.

Breather turbulence versus soliton turbulence: Rogue waves, probability density functions, and spectral features

Turbulence in integrable systems exhibits a noticeable scientific advantage: it can be expressed in terms of the nonlinear modes of these systems. Whether the majority of the excitations in the system are breathers or solitons defines the properties of the turbulent state. In the two extreme cases we can call such states "breather turbulence" or "soliton turbulence." The number of rogue waves, the probability density functions of the chaotic wave fields, and their physical spectra are all specific for each of these two situations. Understanding these extreme cases also helps in studies of mixed turbulent states when the wave field contains both solitons and breathers, thus revealing intermediate characteristics.

Infant and Maternal Reciprocity as Expressed Through Movement, Play Participation, and Co-Occupation

Date Presented 4/8/2016

A retrospective study exploring the bidirectionality of reciprocity in infants and mothers revealed changes occurring over 6 mo in several domains. The retrospective analysis creates a novel process of assessing development through the lens of reciprocity.

Primary Author and Speaker: Bryan Gee

Additional Authors and Speakers: Susan Kunkle, Lauren Troy

Contributing Authors: Hillary Swann, Nancy Devine, Nicholas Burgett, Nicki Aubuchon-Endsley, Michele R. Brumley, Heather Ramsdell-Hudock

Integrable Turbulence and Rogue Waves: Breathers or Solitons?

Turbulence in dynamical systems is one of the most intriguing phenomena of modern science. Integrable systems offer the possibility to understand, to some extent, turbulence. Recent numerical and experimental data suggest that the probability of the appearance of rogue waves in a chaotic wave state in such systems increases when the initial state is a random function of sufficiently high amplitude. We provide explanations for this effect.

Inpatient physical therapy rehabilitation provided for a patient with complete vision loss following a traumatic brain injury

BACKGROUND

Data from the World Health Organization estimates the global incidence of traumatic brain injury resulting in hospitalization or mortality to be close to 10 million people each year. People who sustain a blast-related TBI are more likely to sustain visual impairment than people injured by other means. There is a lack of published literature regarding the most effective means to assist a patient's recovery from TBI with new vision loss. The aim of this report is to describe the physical therapy management of a person regaining functional mobility when newly blind following a blast-related TBI.

METHOD

This case report describes the inpatient rehabilitation physical therapy (PT) services provided for a single subject who experienced a blast-related TBI with complete vision loss.

OUTCOMES

The subject spent 3.5 weeks in IPR and participated in 21 PT sessions before being discharged home. Improvements in cognition, transfers and functional mobility with adaptations for vision loss were achieved, as well as caregiver training, to provide 24-hour supervision in the home.

DISCUSSION

Collaborating with a blind specialist teacher assisted the rehabilitation of this subject. Further research is needed regarding the effective interventions for those with TBI and vision loss.

A Call for Action: Advocating for Increased Funding for the Allied Health Professions: ASAHP Leadership Development Program

Allied health professionals are a diverse group of health care workers who provide necessary services to patients in addition to, or in place of, services provided by physicians, nurses, and medical paraprofessionals. Two forces generating increased demand for allied health professionals are the aging of the US population and health care reform associated with the implementation of the Patient Protection and Affordable Care Act. Although the allied health professions comprise nearly 60% of the health care workforce, the funding to support workforce training, faculty development, and research in the allied health fields lags substantially behind funding for the physician and nursing professions. Increased advocacy efforts are needed to increase the awareness of what the allied health professions contribute to health care and to expand funding across all health care professions.

Advocacy Priorities and Strategies for ASAHP: A Survey of the ASAHP Membership

The Association of Schools of Allied Health Professions (ASAHP) recently established a strategic goal to increase advocacy efforts. The purpose of this study was to identify advocacy priorities and preferred advocacy strategies among the ASAHP membership. A brief Advocacy Priorities and Strategies Survey was sent to 234 ASAHP members included in the ASAHP email list using an online survey software. Forty-eight members (20%) completed the survey. Data were analyzed using the online survey software and response frequency counts. ASAHP members identified the following federal advocacy priorities: 1) support for students entering allied health professions, 2) support for faculty seeking higher degrees to enhance quality of education in allied health programs, 3) support for higher education institutions to increase capacity of professional programs to address projected allied health workforce needs identified by the Bureau of Labor Statistics, and 4) support for research funding from federal agencies for allied health. The need for education regarding allied health professions to enhance advocacy efforts was also reported. Preferred advocacy strategies included scheduling ASAHP conferences in Washington, DC, to facilitate trips to Capitol Hill and visiting legislators in home states. Members also indicated a need to participate in advocacy training to enhance their advocacy skills.

Rogue waves of the Sasa-Satsuma equation in a chaotic wave field

We study the properties of the chaotic wave fields generated in the frame of the Sasa-Satsuma equation (SSE). Modulation instability results in a chaotic pattern of small-scale filaments with a free parameter-the propagation constant k. The average velocity of the filaments is approximately given by the group velocity calculated from the dispersion relation for the plane-wave solution. Remarkably, our results reveal the reason for the skewed profile of the exact SSE rogue-wave solutions, which was one of their distinctive unexplained features. We have also calculated the probability density functions for various values of the propagation constant k, showing that probability of appearance of rogue waves depends on k.

Home health physical therapy intervention for an adolescent after intramedullary skeletal kinetic distractor limb-lengthening surgery: a case report

This case report describes the physical therapy episode of care for an adolescent following surgical placement of an intramedullary skeletal kinetic distractor (ISKD) to minimize a leg-length discrepancy (LLD).

METHODS

A 14-year-old female was referred to home health physical therapy 2 weeks after ISKD placement in her right femur. The initial evaluation revealed the need to instruct in ISKD limb-lengthening exercises, strength, flexibility, and endurance exercises and provide functional mobility training.

RESULTS

The patient received nine treatments over 8 weeks. Her right femur length increased by 4 cm. Improvements occurred with functional mobility, the Bruinincks-Oseretsky Test of Motor Proficiency, and the Pediatric Evaluation of Disability Inventory.

DISCUSSION

Home health physical therapy assisted this patient with reducing her LLD and improving her functional mobility. Further research is needed to identify the effectiveness of physical therapy interventions on functional mobility for adolescents after ISKD placements.

Impact of Patient and Caregiver Transfer Training Provided by a Physical Therapist in the Hospice Setting

Background:

As patients in hospice become increasingly dependent upon caregivers, physical therapy interventions can minimize the risk of injury to the patient or caregiver that may occur during transfers between surfaces.

Case Description:

A 68-year-old male hospice patient was referred to physical therapy for strengthening and transfer training after a fall that resulted in the patient remaining in bed for 5 weeks due to an increased fear of falling. Treatments focused on caregiver training for correct transfer techniques.

Outcome:

During 10 treatment sessions, the patient and caregiver became independent and safe with all transfers. Although the patient’s health declined, his risk for and fear of falling decreased. Confidence with transfers improved for the patient and caregiver.

Discussion:

Physical therapy “benefits were immeasurable” for the patient and caregiver by teaching them how to safely perform patient transfers with reduced risk of injury.

Dissipative ring solitons with vorticity

We study dissipative ring solitons with vorticity in the frame of the (2+1)-dimensional cubic-quintic complex Ginzburg-Landau equation. In dissipative media, radially symmetric ring structures with any vorticity m can be stable in a finite range of parameters. Beyond the region of stability, the solitons lose the radial symmetry but may remain stable, keeping the same value of the topological charge. We have found bifurcations into solitons with n-fold bending symmetry, with n independent on m. Solitons without circular symmetry can also display (m + 1)-fold modulation behaviour. A sequence of bifurcations can transform the ring soliton into a pulsating or chaotic state which keeps the same value of the topological charge as the original ring.

Transformations of continuously self-focusing and continuously self-defocusing dissipative solitons

Dissipative media admit the existence of two types of stationary self-organized beams: continuously self-focused and continuously self- defocused. Each beam is stable inside of a certain region of its existence. Beyond these two regions, beams loose their stability, and new dynamical behaviors appear. We present several types of instabilities related to each beam configuration and give examples of beam dynamics in the areas adjacent to the two regions. We observed that, in one case beams loose the radial symmetry while in the other one the radial symmetry is conserved during complicated beam transformations.

Soliton complexes in dissipative systems: vibrating, shaking, and mixed soliton pairs

We show, numerically, that coupled soliton pairs in nonlinear dissipative systems modeled by the cubic-quintic complex Ginzburg-Landau equation can exist in various forms. They can be stationary, or they can pulsate periodically, quasiperiodically, or chaotically, as is the case for single solitons. In particular, we have found various types of vibrating and shaking soliton pairs. Each type is stable in the sense that a given bound state exists in the same form indefinitely. New solutions appear at special values of the equation parameters, thus bifurcating from stationary pairs. We also report the finding of mixed soliton pairs, formed by two different types of single solitons. We present regions of existence of the pair solutions and corresponding bifurcation diagrams.

Salutary effects of combining early very low-dose systemic estradiol with growth hormone therapy in girls with Turner syndrome

CONTEXT

Optimizing pubertal estrogen replacement in girls with Turner syndrome is important.

OBJECTIVE

The study objective was to test the hypotheses that physiological estradiol replacement administered early with GH will preserve height potential as much as if administered late and that it will bring about a greater height gain than standard oral estrogen therapy combined with GH.

DESIGN

The study was randomized to early or late estrogen treatment; follow-up was at 3.5 yr or later.

SETTING

This was a multicenter outpatient study.

PATIENTS

Turner syndrome girls 12.0-12.9 yr (n = 7) or 14.0-14.9 yr (n = 7) of age who began GH before age 12.0 yr were the patients. The girls were matched to National Cooperative Growth Study registry patients who began GH and oral conjugated estrogen at similar ages and were similarly followed to adult or near-adult height.

INTERVENTIONS

Depot estradiol, 0.2 mg/month i.m., was given initially and gradually increased; GH was 0.05 mg/kg daily.

MAIN OUTCOME VARIABLE

Adult or near-adult height was the main outcome variable.

RESULTS

Depot estradiol treatment resulted in height significantly taller than predicted at 12 yr of age (P < 0.02). All height potential was gained in the first 2 yr of the study, during which the early group grew 3.5 cm more than the late group, which was receiving GH alone (P < 0.01). The early depot estradiol group also gained 5.9 cm more height after starting estrogen than did the early National Cooperative Growth Study group (P < 0.05). Although feminization proceeded slowly on the lowest dose of estradiol, it advanced normally thereafter.

CONCLUSIONS

These results suggest that very low-dose parenteral estradiol permits relatively age-appropriate feminization without interfering with the effect of GH on the enhancement of height potential.

Optimizing estrogen replacement treatment in Turner syndrome

Estrogen has a biphasic effect on growth, stimulatory at low doses but inhibitory at higher doses. Therefore, designing optimal sex hormone replacement treatment in girls with Turner syndrome (TS) who are being treated with growth hormone (GH) involves considering the dose and form of the estrogen as well as the route and timing of its administration. We report here a preliminary analysis of a study to test the concept that an optimal estrogen replacement regimen should consist of estradiol administered in a low dose by a systemic route. The study population consisted of 9 girls with TS who had been treated with GH for 6 or more months. When the girls were 12 to 15 years old, we added depot estradiol at a monthly intramuscular dose of 0.2 mg and increased the dose at 6-month intervals to 0.4, 0.6, and, in 7 of the girls, 0.8 mg. We compared the results in these subjects with those in a matched group of 37 patients with TS in whom routine estrogen treatment had been started at similar ages and who were treated with a similar course of GH therapy. The gain in height at 2 years was 2.6 cm greater in those who were treated with depot estradiol than in those who were treated with routine estrogen. The bone age in the patients who were treated with depot estradiol increased in proportion to their chronologic age, suggesting that this difference indicates an increase in their predicted adult height. We conclude that using very low doses of systemic estradiol to induce puberty before the age of 15 years in girls with TS who are treated with GH, instead of using routine estrogen therapy, can result in increased final heights.

Computed tomography of complications of lung transplantation

In spite of improvements in single or double lung transplantation (LT) technique, complications after LT are not uncommon; the most frequent ale anastomotic complications, infections and rejection (acute or chronic). Early detection of complications of LT allows the optimal therapeutic option to be taken, yielding decreased morbidity and mortality. In some cases, CT plays a key role in early detection of several complications of LT that may not be depicted with other diagnostic modalities, so that knowledge of their CT features is important. In this pictorial review, the authors describe the spectrum of CT features of the complications of LT (including reimplantation response, mechanical problems, acute and chronic rejection, infection, lymphoproliferative disorders, recurrence of the initial disease and complications involving the pleura and the anastomotic sites). In addition, the authors analyze the value of CT compared to that of the other available modalities for the detection of complications of LT.

[Bronchial anastomotic complications after pulmonary transplantation. X-ray computed tomographic evaluation]

PURPOSE

To determine the sensitivity and specificity of CT in depicting bronchial anastomotic complications after lung transplantation.

MATERIALS AND METHODS

A retrospective, blinded review of 105 CT scans obtained after single (n = 17) or double (n = 10) lung transplantation in 27 patients was done by two radiologists in consensus. CT images, were analyzed with respect to the status of bronchial anastomoses, with three possible answers given to the readers: normal, dehiscence, or stenosis. CT features were correlated to bronchoscopic and follow-up findings, which were considered as standard of reference.

RESULTS

CT had a 60% sensitivity and 98% specificity for the diagnosis of bronchial dehiscence, and 40% and 99% for the diagnosis of anastomotic stenosis. One case of bronchial disruption was diagnosed on CT scan only and subsequently confirmed by repeated bronchoscopy.

CONCLUSION

In our study, CT has a low sensitivity but a high specificity in the detection of bronchial anastomotic complications after lung transplantation. However, CT remains useful in some cases, as it can show complications not seen bronchoscopically.

Hepatic pseudolesion around the falciform ligament: prevalence on CT examination

BACKGROUND

The purpose of this study was to determine the prevalence of hepatic pseudolesions seen around the falciform ligament on computed tomography (CT) of the abdomen obtained with intravenous administration of contrast material.

METHODS

We first retrospectively reviewed the CT scans of six patients in whom hepatic pseudolesions were seen around the falciform ligament. The abdominal CT scans of 587 patients were then prospectively analyzed for the presence of hepatic pseudolesions around the falciform ligament to determine the prevalence of this finding on CT examinations.

RESULTS

CT scans in the first six patients showed two types of hepatic pseudolesion around the falciform ligament. In three patients, hepatic pseudolesions were focal spared areas in fatty liver. In three patients, hepatic pseudolesions were developed in nonfatty liver. Prospectively, hepatic pseudolesions were found on five of 587 CT examinations (prevalence = 1%). A single hepatic pseudolesion was found in segment 4 on two examinations. Two hepatic pseudolesions (one in segment 4 and one in segment 3) were found together on three CT examinations.

CONCLUSION

Hepatic pseudolesions around the falciform ligament are seldom seen on CT scan. However, recognition of these pseudolesions is crucial because they may be interpreted as true tumors.

Splenic involvement in pancreatitis: spectrum of CT findings

The pancreas is located deep within the retroperitoneum in the anterior pararenal space. The distal portion of the pancreatic tail extends along the course of the splenic artery and vein (Fig. 1) and enters the splenic hilum contained within the splenorenal ligament. Because of these anatomic relationships, the spleen and splenic vessels may be involved by pancreatitis. Although rare (frequency, 1-5%), splenic involvement by pancreatitis includes intrasplenic pseudocyst, abscess, hemorrhage, infarction, splenic rupture, and vascular injury. Because these complications can be life-threatening, the extent and course of the disease are closely monitored with CT to determine whether and when aggressive intervention is necessary to avoid catastrophic clinical outcomes. The purpose of this essay is to illustrate the spectrum of CT findings in cases of pancreatitis with splenic involvement.

Period and cohort factors in the incidence of malignant melanoma in the state of Connecticut

The reasons for the increase in both incidence and mortality from malignant melanoma are not clear at this time, although there is an indication of a "generation effect" in the increasing frequency of the disease. The application of an age-period-cohort model to incidence data on malignant melanoma for the State of Connecticut indicate that, unlike mortality, the increase is almost entirely related to period factors. Two explanations are provided to explain this pattern of period factor increase. First, the increase in incidence could be artifically produced by better and earlier diagnosis. Second, a decrease in ozone level in the atmosphere may be responsible for the increase.