Normal or elevated prolactin is a good indicator to show pituitary stalk interruption syndrome in patients with multiple pituitary hormone deficiency

OBJECTIVES

To determine the importance of serum prolactin (PRL) in the detection of pituitary stalk interruption syndrome (PSIS) in children with multiple pituitary hormone deficiency (MPHD). We hypothesized that PRL elevation might be a diagnostic indicator of pituitary stalk pathologies.

METHODS

Clinical, radiological, and laboratory features of the 50 cases of MPHD were studied.

RESULTS

The median age at presentation of the 50 cases (52%, n=26 were female) was 6.61 (0.02-18.9) years. PSIS was detected in 60% (n=30), pituitary hypoplasia in 32% (n=16), partial empty sella in 6% (n=3), and only 2% (n=1) was reported as normal. Out of 50 patients, 21.3% (n=10) were hypoprolactinemic, 44.7% (n=19) were normoprolactinemic, and 34% (n=16) were hyperprolactinemic. The median PRL value was 27.85 (4.21-130) ng/mL in patients with PSIS and 5.57 (0-41.8) ng/mL in patients without PSIS. Additional hormone deficiencies, especially ACTH and LH were detected in follow-up.

CONCLUSIONS

Patients with normal or high prolactin levels deserve special attention regarding the possibility of PSIS. Furthermore, we emphasize the importance of regular follow-up and monitoring for multiple pituitary hormone deficiencies in all patients with a single pituitary hormone deficiency.

Telemedicine experiences at a pediatric endocrinology clinic during the COVID-19 pandemic

BACKGROUND

The coronavirus 19 (COVID-19) pandemic has affected all aspects of life, including the routine follow-up of patients with chronic illnesses. In this study, we aim to share our experience of telemedicine in our pediatric endocrinology clinic during the pandemic.

METHODS

We were able to continue caring for children with endocrine disorders using various communication methods such as e-mail and e-message.

RESULTS

A total of 267 patients received telemedicine care over the course of 608 contacts. The number of hospital visits and physical contact was effectively reduced to help protect against the COVID-19 infection. The patients were supported in terms of receiving their prescriptions and patient education also continued. No complications were observed.

CONCLUSION

The advantages and disadvantages of telemedicine were discussed and consequently, we propose that telemedicine can be utilized to maintain and continue the care of children with endocrine disorders during and even after the pandemic. Further studies are needed to standardize this method for general use.

Homozygous loss-of-function mutations in SLC26A7 cause goitrous congenital hypothyroidism

Defects in genes mediating thyroid hormone biosynthesis result in dyshormonogenic congenital hypothyroidism (CH). Here, we report homozygous truncating mutations in SLC26A7 in 6 unrelated families with goitrous CH and show that goitrous hypothyroidism also occurs in Slc26a7-null mice. In both species, the gene is expressed predominantly in the thyroid gland, and loss of function is associated with impaired availability of iodine for thyroid hormone synthesis, partially corrected in mice by iodine supplementation. SLC26A7 is a member of the same transporter family as SLC26A4 (pendrin), an anion exchanger with affinity for iodide and chloride (among others), whose gene mutations cause congenital deafness and dyshormonogenic goiter. However, in contrast to pendrin, SLC26A7 does not mediate cellular iodide efflux and hearing in affected individuals is normal. We delineate a hitherto unrecognized role for SLC26A7 in thyroid hormone biosynthesis, for which the mechanism remains unclear.

Chromhidrosis due to exogenous oxidizing heavy metals: Clinical and laboratory findings

BACKGROUND/OBJECTIVES

Chromhidrosis is a rare condition of which there are only a few case reports in the literature. The aim of this study was to evaluate clinical, laboratory, and possible environmental factors in 13 patients with chromhidrosis to elucidate causative agents.

METHODS

Data were obtained from the medical records of 13 patients with colored sweating between October 2015 and November 2016 (7 infants <1 year of age, 5 adults, 1 adolescent).

RESULTS

Physical examination was normal in all patients. Nine of 12 had high calculated serum free copper (75%). Urine glutamine was measured in 13 patients and was high in 11 (84.6%). Ten patients drank natural mineral water from Uludag Mountain, and two were exposed to an intrauterine device containing copper. One patient (8%) was not exposed to Uludag Mountain natural water or an intrauterine device.

CONCLUSION

We propose that chronic exposure to water or devices that contain high amounts of heavy metal and ammonium may contribute to CH.

Rare Causes of Primary Adrenal Insufficiency: Genetic and Clinical Characterization of a Large Nationwide Cohort

CONTEXT

Primary adrenal insufficiency (PAI) is a life-threatening condition that is often due to monogenic causes in children. Although congenital adrenal hyperplasia occurs commonly, several other important molecular causes have been reported, often with overlapping clinical and biochemical features. The relative prevalence of these conditions is not known, but making a specific diagnosis can have important implications for management.

OBJECTIVE

The objective of the study was to investigate the clinical and molecular genetic characteristics of a nationwide cohort of children with PAI of unknown etiology.

DESIGN

A structured questionnaire was used to evaluate clinical, biochemical, and imaging data. Genetic analysis was performed using Haloplex capture and next-generation sequencing. Patients with congenital adrenal hyperplasia, adrenoleukodystrophy, autoimmune adrenal insufficiency, or obvious syndromic PAI were excluded.

SETTING

The study was conducted in 19 tertiary pediatric endocrinology clinics.

PATIENTS

Ninety-five children (48 females, aged 0-18 y, eight familial) with PAI of unknown etiology participated in the study.

RESULTS

A genetic diagnosis was obtained in 77 patients (81%). The range of etiologies was as follows: MC2R (n = 25), NR0B1 (n = 12), STAR (n = 11), CYP11A1 (n = 9), MRAP (n = 9), NNT (n = 7), ABCD1 (n = 2), NR5A1 (n = 1), and AAAS (n = 1). Recurrent mutations occurred in several genes, such as c.560delT in MC2R, p.R451W in CYP11A1, and c.IVS3ds+1delG in MRAP. Several important clinical and molecular insights emerged.

CONCLUSION

This is the largest nationwide study of the molecular genetics of childhood PAI undertaken. Achieving a molecular diagnosis in more than 80% of children has important translational impact for counseling families, presymptomatic diagnosis, personalized treatment (eg, mineralocorticoid replacement), predicting comorbidities (eg, neurological, puberty/fertility), and targeting clinical genetic testing in the future.

Pediatric patients with pheochromocytoma: Experience of a tertiary health center

BACKGROUND

The aim of this retrospective study was to investigate pheochromocytoma (pheo), which is a rare endocrine tumor in the pediatric population.

METHODS

The medical records of five children with pheo were studied. The age, gender, clinical presentation, family history, physical findings, coexisting pathology, laboratory evaluation, surgical treatment, and postoperative course were investigated.

RESULTS

The patients were four girls and one boy with a mean age of 13.2 years (range, 9.57-15.95 years). None of the patients had paroxysmal hypertension and one had normal blood pressure. No malign pheo was identified. Mean height and weight standard deviation scores (SDS), body mass index (BMI), and BMI SDS were -0.24, 0.04, 20.9 kg/m(2), and 0.20 at the time of diagnosis, and 0.03, 0.43, 23.8 kg/m(2) and 0.49 1 year after operation, respectively. BMI increased significantly after operation. Three patients had normal epinephrine and metanephrine, but elevated norepinephrine and normetanephrine on 24 h urine. Vanillylmandelic acid on 24 h urine sample was elevated in all patients. Ultrasonography failed to visualize tumors in two patients with bilateral pheo. One patient had postoperative severe hypotension. Insulin resistance associated with severe acanthosis nigricans observed in one patient regressed postoperatively.

CONCLUSIONS

Pheo in children may present with different symptoms and findings. Decreased catecholamine in the postoperative period may lead to weight gain.

An essential splice site mutation (c.317+1G>A) in the TSHR gene leads to severe thyroid dysgenesis

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and 2% of cases have familial origin. Our aim in this study was to determine the genetic alterations in two siblings with CH coming from a consanguineous family. Because CH is often inherited in autosomal recessive manner in consanguineous/multicase-families, we first performed genetic linkage studies to all known causative CH loci followed by conventional sequencing of the linked gene. The family showed potential linkage to the TSHR locus, and we detected an essential splice site mutation (c.317+1G>A) in both siblings. RT-PCR analysis confirmed the functionality of the mutation. The mutation was homozygous in the cases whereas heterozygous in carrier parents and an unaffected sibling. Here we conclude that thyroid agenesis in both siblings in this study originates from c.317+1G>A splice site mutation in the TSHR gene, and this study underlines the importance of detailed molecular genetic studies in the definitive diagnosis and classification of CH.

Etiological evaluation of adolescents with primary amenorrhea

OBJECTIVES

To determine causes of amenorrhea in adolescents with primary amenorrhea and to emphasize general approach to primary amenorrhea.

METHODS

Thirty-nine patients, evaluated between January 2007 and May 2011, were divided into normogonadotropic hypogonadism, hypergonadotropic hypogonadism and hypogonadotropic hypogonadism groups. Means of age, height, weight, body mass index and standard deviation scores, gonadotropin levels, and accompanying diseases were evaluated.

RESULTS

Mean values of age, height, height standard deviation score, weight and, weight standard deviation score were 15.54 ± 1.52 y. 152.0 ± 1.1 cm, -1.37 ± 1.3, 48.2 ± 14.3 kg, 0.96 ± 1.75, respectively. There were no statistical significances in the auxological parameters. Patients were distributed as 18 cases (46.1 %) with normogonadotropic hypogonadism, 12 cases (30.8 %) with hypergonadotropic hypogonadism, 9 cases (23.1 %) with hypogonadotropic hypogonadism. In the group of normogonadotropic hypogonadism, there were 6 patients with chronic diseases, 5 patients with insulin resistance, 4 patients with prolactinomas, 3 patients with müllerian agenesis. Of the hypergonadotropic hypogonadic patients, 3 were idiopathic primary ovarian failure, 3 were 46,XY disorders of sex development, 2 were Turner syndrome, 2 were ovarian insufficiency due to drug, one was 17 alpha-hydroxylase deficiency and one was autoimmune oophoritis. The group of hypogonadotropic hypogonadism included 5 patients with normosmic hypogonadism, 2 patients with constitutional delay of growth and puberty, 1 patient with panhypopituitarism and 1 patient with anosmic hypogonadism.

CONCLUSIONS

Chronic diseases, prolactinoma, and insulin resistance may lead to hypogonadism without altering gonadotropin levels. Turner syndrome, primary ovarian failure, and autoimmune oophoritis should be investigated in cases with hypergonadotropic hypogonadism. 46, XY disorders of sex development also should be elucidated. Constitutional delay of growth and puberty should be distinguished from isolated hypogonadotropic hypogonadism.

A deletion including exon 2 of the TSHR gene is associated with thyroid dysgenesis and severe congenital hypothyroidism

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and 2% of cases have a familial origin. Our aim in this study was to determine the genetic alterations in two siblings with CH coming from a consanguineous family. As CH is often inherited in an autosomal recessive manner in consanguineous/multi case-families, we first performed genetic linkage studies to all known causative CH loci followed by conventional sequencing of the linked gene. The family showed potential linkage to the TSHR locus and our attempts to amplify and sequence exon 2 of the TSHR gene continuously failed. Subsequent RT-PCR analysis using mRNA and corresponding cDNA showed a large deletion including the exon 2 of the gene. The deletion was homozygous in affected cases whilst heterozygous in carrier parents. Here we conclude that CH in both siblings of this study originates from a large deletion including the exon 2 of the TSHR gene. This study demonstrates that full sequence analysis in a candidate CH gene might not always be enough to detect genetic alterations, and additional analyses such as RT-PCR and MLPA might be necessary to describe putative genetic causes of the disease in some cases. It also underlines the importance of detailed molecular genetic studies in the definitive diagnosis and classification of CH.

Thyroid dyshormonogenesis is mainly caused by TPO mutations in consanguineous community

OBJECTIVE

In this study, we aimed to investigate the genetic background of thyroid dyshormonogenesis (TDH).

CONTEXT

Thyroid dyshormonogenesis comprises 10-15% of all cases of congenital hypothyroidism (CH), which is the most common neonatal endocrine disorder, and might result from disruptions at any stage of thyroid hormone biosynthesis. Currently seven genes (NIS, TPO, PDS, TG, IYD, DUOX2 and DUOXA2) have been implicated in the aetiology of the disease.

DESIGN

As TDH is mostly inherited in an autosomal recessive manner, we planned to conduct the study in consanguineous/multi-case families.

PATIENTS

One hundred and four patients with congenital TDH all coming from consanguineous and/or multi-case families.

MEASUREMENTS

Initially, we performed potential linkage analysis of cases to all seven causative-TDH loci as well as direct sequencing of the TPO gene in cases we could not exclude linkage to this locus. In addition, in silico analyses of novel missense mutations were carried out.

RESULTS

TPO had the highest potential for linkage and we identified 21 TPO mutations in 28 TDH cases showing potential linkage to this locus. Four of 10 distinct TPO mutations detected in this study were novel (A5T, Y55X, E596X, D633N).

CONCLUSIONS

This study underlines the importance of molecular genetic studies in diagnosis, classification and prognosis of CH and proposes a comprehensive mutation screening by new sequencing technology in all newly diagnosed primary CH cases.

TSHR is the main causative locus in autosomal recessively inherited thyroid dysgenesis

Congenital hypothyroidism (CH) is the most common neonatal endocrine disorder and results in mental retardation if untreated. Eighty-five percent of CH cases are due to disruptions in thyroid organogenesis and are mostly sporadic, but about 2% of thyroid dysgenesis is familial, indicating the involvement of genetic factors in the aetiology of the disease. In this study, we aimed to investigate the Mendelian (single-gene) causes of non-syndromic and non-goitrous congenital hypothyroidism (CHNG) in consanguineous or multi-case families. Here we report the results of the second part (n=105) of our large cohort (n=244), representing the largest such cohort in the literature, and interpret the overall results of the whole cohort. Additionally, 50 sporadic cases with thyroid dysgenesis and 400 unaffected control subjects were included in the study. In familial cases, first, we performed potential linkage analysis of four known genes causing CHNG (TSHR, PAX8, TSHB, and NKX2-5) using microsatellite markers and then examined the presence of mutations in these genes by direct sequencing. In addition, in silico analyses of the predicted structural effects of TSHR mutations were performed and related to the mutation specific disease phenotype. We detected eight new TSHR mutations and a PAX8 mutation but no mutations in TSHB and NKX2-5. None of the biallelic TSHR mutations detected in familial cases were present in the cohort of 50 sporadic cases. Genotype/phenotype relationships were established between TSHR mutations and resulting clinical presentations. Here we conclude that TSHR mutations are the main detectable cause of autosomal recessively inherited thyroid dysgenesis. We also outline a new genetic testing strategy for the investigation of suspected autosomal recessive non-goitrous CH.

Novel TSHR mutations in consanguineous families with congenital nongoitrous hypothyroidism

OBJECTIVE

Nonsyndromic autosomal recessively inherited nongoitrous congenital hypothyroidism (CHNG) can be caused by mutations in TSHR, PAX8, TSHB and NKX2-5. We aimed to investigate mutational frequencies of these genes and genotype/phenotype correlations in consanguineous families with CHNG.

DESIGN

Because consanguinity in individuals with a presumptive genetic condition is often an indicator of an autosomal recessive inheritance and allows firmer correlations to be established between genotype and phenotype, we planned to execute our study in consanguineous families.

PATIENTS

Hundred and thirty-nine children with CHNG phenotype born to consanguineous families.

MEASUREMENTS

First, we investigated cases for evidence of linkage to the four known CHNG genes by microsatellite marker analysis. Mutation analysis by direct sequencing was then performed in those cases in whom linkage to the relevant candidate gene could not be excluded. In addition, in silico analysis of the predicted structural effects of TSHR mutations was performed and related to the mutation-specific disease phenotype.

RESULTS

Homozygous germline TSHR mutations were detected in six families (5%), but no mutations were detected in PAX8, TSHB and NKX2-5. Four of TSHR mutations had not previously been described. Genotype-phenotype correlations were established and found to be related to the predicted structural effects of the mutations.

CONCLUSIONS

Known causative genes account for the development of CHNG only in a minority of cases, and our cohort should provide a powerful resource to identify novel causative genes and to delineate the extent of locus heterogeneity in autosomal recessively inherited CHNG.

Increased incidence of congenital hypothyroidism due to iodine deficiency

BACKGROUND

The incidence of congenital hypothyroidism (CH) is expected to be elevated in iodine-deficient areas. In this study, the authors aimed to determine the incidence of transient and permanent CH in a large city which is known to be in the zone of moderate iodine deficiency.

METHODS

Newborn babies in Bursa, Turkey, were screened by measurement of serum thyroid-stimulating hormone (TSH) obtained by heel prick. The babies who had a serum TSH >20 mIU/L were recalled for measurement of T4 and TSH in venous serum.

RESULTS

A total of 11 770 newborns were screened over a period of 9 years. The incidence of CH was found to be 1/840. However, after excluding the transient cases, permanent CH was diagnosed in 1/2354. It was impossible to distinguish transient patients from permanent CH by initial laboratory tests (P > 0.05). The estimated power of the study in determining the incidence of CH in the population was 90% (P < 0.05).

CONCLUSION

The authors conclude that the incidence of CH is very high in their population which warrants a country-wide neonatal screening program. Since transient cases cannot be distinguished and untreated transient hypothyroidism may also cause mental retardation, treatment must be started as early as possible with frequent monitoring to optimize the outcome and identify the transient patients.

Effects of iron deficiency anemia on hemoglobin A1c in type 1 diabetes mellitus

BACKGROUND

The relationship between hemoglobin A1c (HbA1c) and iron status in type 1 diabetes mellitus (DM) has not been adequately studied. In this prospective investigation, we aimed to determine the effect of iron deficiency on HbA1c in diabetic patients who also had insufficient iron stores.

METHODS

Thirty-seven patients with type 1 DM were included in the study. Eleven of them were also iron deficient (ID) and the remaining 26 were iron-sufficient (IS). Two non-diabetic control groups were selected for the ID and IS groups. All patients with ID were treated with iron at 6 mg/kg per day for 3 months. Glycemia in diabetic patients was monitored at home before breakfast and supper by a glycometer. Hemoglobin A1c was measured in all subjects at the beginning and the end of the study.

RESULTS

Patients with ID DM had higher levels of HbA1c than those in the control group (P < 0.001). There were no significant differences in the weekly average glucose concentration of the patients with ID DM before and after iron supplementation. In contrast, HbA1c decreased from a mean of 10.1 +/- 2.7% to a mean of 8.2 +/- 3.1% (P < 0.05). Additionally, HbA1c in ID non-diabetic patients decreased from a mean of 7.6 +/- 2.6% to 6.2 +/- 1.4% after iron therapy (P < 0.05).

CONCLUSIONS

We conclude that among type 1 DM patients with similar level of glycemia, iron deficiency anemia is associated with higher concentrations of HbA1c. In addition, iron replacement therapy leads to a drop in HbA1c in both diabetic and non-diabetic patients. The iron status of the patient must be considered during the interpretation of HbA1c concentrations in type 1 DM.

Serum prolactin in neonatal seizures

BACKGROUND

Prolactin is the most specific neurohormone that is elevated after seizures. This study was undertaken to determine the clinical usefulness of plasma prolactin as a diagnostic aid in differential diagnosis of neonatal convulsions.

METHODS

Forty-five patients followed for seizures were included in the study. Postictal serum prolactin levels were obtained 30 min after the onset of the seizures. A second sample obtained 24 h later was used to measure an unstimulated serum prolactin level.

RESULTS

The most common cause of seizure was hypoxic ischemic encephalopathy (HIE) followed by sepsis. In patients with HIE, postictal serum prolactin levels were significantly higher than the unstimulated levels (P < 0.0002). Additionally, postictal prolactin levels were significantly higher than the unstimulated levels in clonic (P < 0.02) and tonic convulsions (P < 0.001).

CONCLUSIONS

We conclude that the postictal serum prolactin level may be a marker in the differentiation of seizures as well as providing important information about their etiology. Further studies are needed to assess the normal range of serum prolactin levels in unstressed newborns.

Delayed hemopericardium due to trivial chest trauma

We report two cases of hemopericardium occurring in seven-month-old and 12-year-old boys, who had no history of major trauma. The possible cause of the hemopericardium for the infant was falling from a bed which was 75 cm high two weeks prior to the admission. The 12-year-old boy had fallen from a chair and damaged his chest 4 weeks previously. Their coagulation tests were all normal. By means of pericardiotomy, we drained 120 ml and 1200 ml of blood, respectively. The boys have now been well over follow-up periods of 24 and 18 months, respectively.

Systemic candidiasis with acute Epstein-Barr virus infection

Systemic Candida infections are usually encountered as opportunistic infections in a setting of immunologic depression. Sepsis or arthritis due to Candida is not expected in healthy people. Epstein-Barr virus may infect B cells, but does not cause immunosuppression of any clinical significance. As far as we know, invasive non-albicans Candida infection complicating Epstein-Barr virus infection has not been reported in previously healthy children. In this report, two previously healthy children, one with sepsis due to Candida species and the other sepsis and arthritis due to Candida parapsilosis are described. Both patients were male and were aged 2 and 9 y. The diagnosis was confirmed by culture. Both children also had coincidental acute Epstein-Barr virus infection, confirmed by Epstein-Barr virus viral capside antigen-IgM. They were both cured with fluconazole given for 21 days and 48 days, respectively.

Effects of hypothermia on blood endogenous endotoxin levels during cardiopulmonary bypass

Endotoxin activates white blood cells and complement and produces a spectrum of clinical syndromes ranging from fever to septic shock. Although production of endogenous endotoxemia during cardiopulmonary bypass (CPB) has recently been reported, the role of hypothermia on endotoxemia is not clear. In this study, we evaluated the effects of moderate (24-28 degrees C) and mild (32-34 degrees C) hypothermia on blood endotoxin levels. The study population consisted of 20 patients who underwent coronary artery bypass grafting (CABG) with CPB. Moderate systemic hypothermia was applied during aortic cross-clamping in ten patients (group 1) and mild hypothermia in the remaining ten patients (group 2). The mean rectal temperatures were 26.8 +/- 1.2 degrees C in group 1 and 33.8 +/- 0.8 degrees C in group 2. The blood samples for endotoxin level measurements were obtained before CPB, during aortic cross-clamping, immediately after the release of the cross-clamp, 20 minutes after the release of the cross-clamp, after CPB, and 2 hours postoperatively. There were no endotoxins in any of the samples before CPB, but it was detected after CPB in both groups. The endotoxin levels were significantly higher in group 1 than in group 2. The present study suggests that when hypothermia is the technique of choice, the deleterious effects of endotoxemia on patients with comorbidity must be considered.

Evaluation of differential effects of carbohydrate and fat intake on weight gain, serum IGF-1 and erythrocyte Na+K+ATPase activity in suboptimal nutrition in rats

OBJECTIVE

Suboptimal nutrition leads to growth delay, frequently without over clinical or biochemical signs. We hypothesize that changes in serum IFG-1 and erythrocyte sodium-potassium ATPase activity (ENKA) may be indices of suboptimal nutrition.

METHODS

Male Sprague-Dawley rats were pair-fed for 4 weeks with balanced diets of different carbohydrate (CHO) to fat (FAT) ratios (3:1, 2:1, and 1:1) and three levels of energy intake (ad-libitum, 80%, and 60%), corrected for actual body weight). Daily weight gain and weekly tail growth were monitored while ENKA, serum total protein, T3, insulin and IGF-1 were measured after four weeks. Refeeding experiments were also performed with the 3:1 and 1:1 CHO:FAT diets, including 4 weeks of dietary restriction and one week of ad-libitum feeding.

RESULTS

Weight gain, tail growth, and IGF-1 decreased (p < 0.05) in all groups after 1 week of dietary restriction. A decrease in ENKA (p < 0.05) was found in rats that consumed 60% of ad-libitum energy intake only after 4 weeks. At the end of dietary treatment, weight gain was higher (p < 0.05) in rats fed the 3:1 CHO:FAT diet. In contrast, when energy was restricted to 80% or 60% of ad-libitum intake, rats fed the 1:1 CHO:FAT diet gained more weight (p < 0.05) compared to the 3:1 and 2:1 CHO:FAT diets. After 1 week of refeeding body weight, tail growth and ENKA returned to control values while serum IGF-1 levels remained depressed.

CONCLUSIONS

Acute nutritional changes are clearly detected by a reduction of serum IGF-1 while ENKA may be a useful index for assessing chronic suboptimal nutrition.

Considerations about dietary fat restrictions for children

Expert panels recommend reduction of dietary fat and cholesterol, because excessive fat intake may lead to known health hazards. However, there are no data demonstrating beneficial effects of such diets starting in childhood for all children, including those with normal serum cholesterol levels. Dietary restrictions in early life may not necessarily induce a long-lasting decrease in blood cholesterol levels in children persisting into adulthood or reduce disease incidence. On the other hand, the result of such diets may be suboptimal growth and development. Furthermore, low fat diets may lower high density lipoprotein cholesterol levels and not specifically low density lipoprotein cholesterol. In addition, low serum cholesterol levels may be associated with increased mortality, including deaths due to accidents, which is most important in children. Recently, increased attention has been drawn to the association between short stature and/or nutritional status and deficiencies in intrauterine and early life with coronary artery disease in adulthood. Also, the problems of associated psychological consequences, family conflicts and cost should not be ignored while implementing a low fat diet. In this review, we discuss the controversies on dietary fat restrictions for children.

Nutrition in adolescence

Adolescence is often considered a nutritionally vulnerable period because of its characteristic rapid physical and psychological changes. Nutritional risks for both undernutrition and overnutrition are present and may be increased during physiologic stress such as athletics and pregnancy. Appropriate nutrition is important for maintaining optimal health and normal growth and development, as well as for preventing future chronic disease.

Thiamine-responsive megaloblastic anemia with diabetes mellitus and sensorineural deafness

This study introduces a patient who has thiamine and thiamine pyrophosphokinase (TPKase) enzyme deficiency associated with diabetes mellitus, sensorineural deafness and thiamine-responsive megaloblastic anemia. Diabetes mellitus was diagnosed when she was 20 months old. After 1 year, macrocytic anemia developed and the thiamine therapy was started at 75 mg/day. During the follow-up, the insulin requirement decreased and even ceased, and macrocytic anemia improved with thiamine treatment. After thiamine therapy was ceased an increase in insulin requirement was observed and macrocytic anemia developed again.

Sulbactam/ampicillin in the treatment of pediatric infections

Seventy eight pediatric patients (43 males, 35 females) aged 34 days to 17 years were treated with intravenous or intramuscular sulbactam/ampicillin 3 or 4 times daily for skeletal system infection (10 cases), systemic salmonellosis (2 cases), intrathoracic infection (12 cases), and soft tissue or miscellaneous infections (54 cases). The dose used to treat the majority of patients was 200 mg of ampicillin plus 100 mg of sulbactam per kg/day. The duration of treatment ranged from 8 to 23 days. Sulbactam/ampicillin alone was used in 68 patients. Ten patients were treated with an additional antibacterial agent. The overall cure rate was 98.7% for all 78 study patients. One patient with an abscess in the neck was shown to be infected with a strain of Escherichia coli resistant to sulbactam/ampicillin. Only one patient experienced a rash, but it did not necessitate discontinuation of therapy. This study shows that sulbactam/ampicillin is a safe and effective agent in the treatment of various pediatric infections.