Clinical Presentations of Acquired Hypothyroidism in Children: Experience in a Tertiary Care Hospital in Bangladesh

A cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with acquired hypothyroidism during the period of January 2012 to December 2016. The study was done to find out the clinical presentations and associated disorders of all patients diagnosed with acquired hypothyroidism during the study period. Data were obtained by reviewing the medical records of the patients. Total 277 children were diagnosed of having thyroid disorders. Among them 145(52.3%) had acquired hypothyroidism. The commonest clinical presentations of children with acquired hypothyroidism were short stature (35.0%), excessive weight gain (31.5%), goiter (23.1%) and poor school performance (14.0%). Autoimmune hypothyroidism was found in 34.4% of children, sub-clinical hypothyroidism in 27.5% children and positive family history was found in 15.2% children with acquired hypothyroidism. The common associated diseases were diabetes and impaired glucose tolerance (4.9%), Down syndrome (3.5%), congenital heart disease (2.1%) and primary adrenal insufficiency (1.4%).

Clinical Presentation of Congenital Adrenal Hyperplasia in Children: Experience in a Tertiary Care Hospital of Bangladesh

This cross sectional study was conducted in Paediatric Endocrine Outpatient Department of BIRDEM General Hospital, a tertiary care centre in Dhaka, Bangladesh among patients diagnosed with congenital adrenal hyperplasia (CAH) from January 2005 to December 2018. The study was aimed to find out the clinical and laboratory profile of all patients at presentation diagnosed with CAH during the study period. Data were obtained by reviewing the medical records of the patients. Total 102 children with CAH were diagnosed during the study period. Among them 68 were female and 34 were male (female to male ratio of 2:1). Median age was 3.5 month (range 0.2-158 month) and 5.5 month (range 1-108 month) in female and male respectively (p=0.42). Family history was available in 93 patients. Consanguinity was present in 16(17.2%), history of sib death in 12(12.9%), other family members were affected in 8(8.6%). Sixty patient (58.8%) had salt-wasting (SW), 39(38.2%) had simple virilizing (SV) and 3(2.9%) had non- classic form of CAH. Median age of presentation was 2 month (range 0.2-70 month) and 42 month (range 0.8-158 month) in SW and SV group respectively (p=0.001) and 119 month (range 108-152 month) in non- classic group. Common presentations were: genital ambiguity (64.7%), vomiting (46.5%), failure to thrive (41.6%), features of early puberty (precocious pseudopuberty) (24.5%), diarrhea (12.0%). Hyperpigmentation was noted in 49.0% of patients. Among the salt-wasting type in male failure to thrive (FTT) was the most common presentation (83.3%), followed by vomiting (75.0%). In female genital ambiguity was the commonest presentation (97.2%), followed by vomiting (77.1%). Among the simple virilizing type in male early puberty was the commonest presentation (100%) and genital ambiguity was the presenting feature in all the female (100.0%).

Higher HbA1c was observed in young people with diabetes who fasted during COVID-19 pandemic lockdown of 2020 Ramadan in Bangladesh - A Post Ramadan survey

OBJECTIVE

Muslim people with T1DM should be actively discouraged from fasting during the COVID-19 pandemic, as diabetes has emerged as a significant risk factor for adverse outcomes of COVID-19 infection. We report the experience of young patients with type 1, type 2 and other types diabetes who fasted during Ramadan 2020 at the time of the COVID-19 pandemic time lockdown.

RESEARCH DESIGN AND METHODS

A Post- Ramadan survey was designed for young patients who fasted during Ramadan in 2020 during COVID pandemic time. The study was conducted to compared the basal characteristics and other parameters in children and adolescents (<18 years), with young adults (≥18 years) with diabetes at Paediatric Diabetes Center in BIRDEM in Bangladesh.

RESULTS

Among the study participants, a significantly higher number of participants were in older age group who fasted for more than 15 days (p = 0.045). A considerable proportion (30.7%) of patients developed mild hypoglycaemia, and only eight patients (2.6%) developed moderate to severe hypoglycemia. There was significant reduction of post Ramadan basal insulin dose in both groups (p = 0.001). Although increased bolus insulin dose requirements were observed in older age group, but decreased requirement was observed in younger age group during Ramadan (p = 0.001). Post Ramadan median HbA1C in both groups was increased with marked increase in older age group compared to younger age group though it did not reach the statistical significance. (p = 0.239) CONCLUSIONS: COVID-19 pandemic had minor impact on fasting during Ramadan in our cohort, they could fast safely with less complications during Ramadan. Our data supports Ramadan focused diabetes education with ample self-care, young people with diabetes can fast safely during Ramadan.

Pediatric diabetes care in Sri Lanka and Bangladesh: Reaching the community

Diabetes is a major non-communicable disease with long-term complications. Over one million children and adolescents are affected with type 1 diabetes in the world. The number of children and adolescents with type 2 diabetes is also on the rise due to the increase incidence of childhood diabetes. South East Asian (SEA) contributes 184 100 children and adolescents with type 1 diabetes under the age of 20 years for this global health issue as at 2019. Countries of SEA region share same socio demographic, cultural, and economic challenges when it comes to holistic care of affected children. It is timely to discuss common concerns of these countries to give the best possible care for children affected with diabetes to minimize the burden of diabetes related complications, which would potentially affect the socioeconomic development of the respective countries.

Individualized care for patients with intersex (disorders/differences of sex development): Part 3

The focus of this article is to review the complex determinants of gender assignment in a child with a disorder of sex development using four different clinical cases. While the care of patients with DSD may be shared across several specialties and opinions regarding their management may vary, this may be further complicated by psychosocial, cultural and economic factors. In this regard, access to behavioral health specialists with experience and specialization in the treatment of patients with DSD should be a foundational component of the standard of care and can greatly assist in the complex decision-making regarding gender assignment. We recommend an individualized approach by a multidisciplinary team utilizing a range of evolving strategies, including outcome data (or lack thereof) to support families during the decision-making process.

Health utility scores from EQ-5D and health-related quality of life in patients with esophageal cancer: a real-world cross-sectional study

Esophageal cancer and its treatment can cause serious morbidity/toxicity. These effects on health-related quality of life (HRQOL) can be measured using disease-specific scales such as FACT-E, generic scales such as EQ-5D-3L, or through symptoms. In a two-year cross-sectional study, we compared HRQOL across esophageal cancer patients treated in an ambulatory clinic and across multiple disease states, among patients with all stages of esophageal cancer. Consenting patients completed FACT-E, EQ-5D, a visual analog scale, and patient reported (PR)-ECOG. Symptom complexes were constructed from FACT-E domains. Responses were categorized by disease state: pre-, during, and post-treatment, surveillance, progression, and palliative chemotherapy. Spearman correlation and multivariable linear regression characterized these associations. In total, 199 patients completed 317 questionnaires. Mean FACT-E and subscale scores dropped from baseline through treatment and recovered during post-treatment surveillance (P < 0.001); EQ-5D health utility scores (HUS) displayed a similar pattern but with smaller differences (P = 0.07), and with evidence of ceiling effect. Among patients with stage II/III esophageal cancer, mean EQ-5D HUS varied across disease states (P < 0.001), along with FACT-E and subscales (P < 0.001). Among patients with advanced disease, there was no significant difference between baseline and on-treatment total scores, but improved esophageal cancer-specific scales were noted (P = 0.003). Strong correlation was observed between EQ-5D and FACT-E (R = 0.73), along with physical and functional subscales. In addition, the association between FACT-E and EQ-5D HUS was maintained in a multivariable model (P < 0.001). We interpret these results to suggest that in a real-world clinic setting, FACT-E, EQ-5D HUS, and symptoms were strongly correlated. Most HRQOL and symptom parameters suggested that patients had worse HRQOL and symptoms during curative therapy, but recovered well afterwards. In contrast, palliative chemotherapy had a neutral to positive impact on HRQOL/symptoms when compared to their baseline pre-treatment state.

Melioidosis in a Patient with Type I Diabetes Mellitus - A Case Report

Melioidosis is a relatively uncommon but fatal infectious disease caused by the gram negative bacterium, Burkholderia pseudomallei which is usually found in the wet soil, mud and pooled surface water in tropic and subtropics. Documented reports of melioidosis from Bangladesh have been few and sporadic. All of the reported cases in Bangladesh were on adult. Melioidosis is commonly associated with underlying diseases like diabetes mellitus, renal diseases and immunodeficiency disorders. Early and correct diagnosis is important, as mortality in untreated melioidosis is high. Our patient, an eleven years old boy, a known case of diabetes mellitus, presented with fever for one month associated with right sided neck swelling, abdominal distension & pain for 10 days. He had an abscess on the right side of the neck and hepatosplenomegaly. Ultrasonography of abdomen showed multiple abscesses in the liver and spleen. Culture of pus drained from the neck abscess revealed growth of Burkholderia pseudomallei. After getting parenteral antibiotics and insulin, his abscesses gradually resolved and cured completely.Bangladesh J Child Health 2018; VOL 42 (1) :46-48

Descriptive epidemiology of metabolic syndrome among obese adolescent population

AIMS

The study was done to assess the magnitude of problems of metabolic syndrome among obese adolescents.

MATERIALS AND METHOD

It was a cross-sectional study done from January 2013 to June 2014 in paediatric endocrine outpatient department in BIRDEM General Hospital, Dhaka, Bangladesh. Total 172 adolescents having exogenous obesity aged 10-18 years were included. Impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and type 2 diabetes mellitus (DM) were defined as per WHO criteria.The adolescents having Body Mass Index (BMI) ≥95th centile were classified as obese.Waist circumference was measured at the level midway between the lower rib margin & the iliac crest, at the level of umbilicus with the person breathing out gently in centimeter. Hip circumference was measured at the maximum width over the buttocks at the level of the greater trochanters in centimeter.

RESULT

Among 172 obese adolescents, metabolic syndrome was found in 66 patients (38.4%). The commonest metabolic abnormality among those having metabolic syndrome was low HDL level (77.3%) followed by high triglyceride level(71.2%). Glucose intolerance (IFG and/or IGT) was found in 16.7%, Type 2 DM in 10.6%, systolic hypertension in 10.7% and diastolic hypertension in 12.1%. Triglyceride (p = 0.042) and Cholesterol level (p = 0.016) were significantly higher and HDL-cholesterol level (p = 0.000) was significantly lower among obese adolescents having metabolic syndrome. Less physical activity (p = 0.04) was significantly related to the development of metabolic syndrome. On logistic regression analysis male sex, family history of obesity and low HDL-cholesterol correlated to metabolic syndrome.

CONCLUSION

The High rate of metabolic syndrome among obese adolescents is alarming.

Neonatal management of pregnancy complicated by diabetes

Women with diabetes in pregnancy, either pre-gestational Diabetes Mellitus (Type 1 & Type 2) or Gestational Diabetes, are at increased risk for adverse pregnancy outcomes, including preterm labour and increased foetal mortality rate. Adequate glycaemic control before and during pregnancy is crucial for improving foetal and perinatal outcomes in these babies. Perinatal and neonatal morbidities and mortality rates have declined since the development of specialized maternal, foetal, and neonatal care for women with diabetes and their offspring. However, infants of diabetic mothers are at risk for developing complications as macrosomia, hypoglycaemia, perinatal asphyxia, cardiac and respiratory problems, birth injuries and congenital malformations. In this review article we describe the neonatal management of the offspring of diabetic mothers.

Characteristics of children and adolescents at onset of type 2 diabetes in a Tertiary Hospital in Bangladesh

INTRODUCTION

Recent data show that the prevalence of diabetes among children and adolescents is increasing in some ethnic groups. The worldwide epidemic of childhood obesity has been accompanied by an increase in the incidence of type 2 diabetes (T2D) in youth.

METHODS

The aim of this study was to describe the baseline characteristics of children and adolescents diagnosed ≤18 years who had features of T2D and presented at Changing Diabetes in Children, Paediatric Diabetes Clinic at Bangladesh Institute of Research and Rehabilitation of Diabetes, Endocrine, and Metabolic Disorders. All patients who were newly diagnosed and came to the clinic from March 2011 to March 2015 were included.

RESULTS

Among 939 newly registered patients, 77 (8%) had a diagnosis of T2D. The age at diagnosis was 9-10 years in 11 patients (14%), 11-14 years in 46 (60%) and 15-17 years in other 20 patients (26%). Majority of the children had a positive family history of T2D (94%) and 58% were obese. Median fasting insulin (27.9 [17.3-99.3]) was high in 76% patients. Insulin was started initially along with metformin in 40 patients and could be stopped in six patients in 3 months.

CONCLUSION

Our study reflects that T2D is emerging as a problem in children and adolescents in Bangladesh.

Should Type 1 diabetics fast in Ramadan

Fasting during the holy month of Ramadan is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. This involves abstaining from eating or drinking from early dawn (Suhur/Sehri) till sunset (Iftar).Fasting is not meant to create excessive hardships or impart any adverse effect to the Muslim individual. As such, Islam has exempted certain categories of people from fasting including young children, travelers, the sick, the elderly,and pregnant and lactating women. According to expert opinion, people with type 1 diabetes who fast during Ramadan are at very high risk of metabolic deterioration. However, some recent studies have demonstrated that individuals with type 1 diabetes who are otherwise healthy and stable, can fast during Ramadan provided they comply with the Ramadan focused management plan and are under close professional supervision. This article discusses how to assess, counsel, monitor and manage people with type 1 diabetes who wish to fast during Ramadan.

Fasting during Ramadan in adolescents with diabetes

BACKGROUND

Fasting (Sawm) during Ramadan, one of the five pillars of Islam is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. Some children with diabetes, despite their exemption insist on fasting in Ramadan. We evaluated the safety of fasting among children with type 1 diabetes.

MATERIALS AND MATHODS

A prospective observational study was designed for diabetic children and adolescents who wish to fast during Ramadan 2012. Patients with their caregivers were given intensive education and instructions were provided by diabetic educators, dieticians and physicians on insulin adjustment, home blood glucose monitoring and dietary adjustments prior to Ramadan.

RESULTS

A total of 33 children and adolescents were included in this study. Of these, 16 were male and 17 were female. Majority (60.6%) of the patients could complete their fasting during the Ramadan. Patients were divided into two groups, those who completed fasting were considered as Group-I, whereas patients who broke the fast were in Group-ll. Blood glucose, hemoglobin A1c weight, and insulin dose before and after Ramadan in two groups showed no significant difference.

CONCLUSION

Children older than 11 years of age with type 1 diabetes mellitus with conventional twice-a-day regimen can fast safely during Ramadan provided they have proper education and intensive follow-up during Ramadan.

Precipitating factors, clinical features and outcome of diabetic ketoacidosis in children and adolescents admitted in a tertiary care hospital in Dhaka

Background Information: Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (DM). It is an acute complication of type 1 DM. Objective: This study was designed to identify the precipitating factors, clinical features and immediate outcomes of DKA in children and adolescents. Method: This was a retrospective study which was done in the department of Pediatrics, BIRDEM, from January 2002 to April 2007. Data were collected from the hospital record for all diabetic children below 18 years admitted with DKA. Result: Fourty nine children and adolescents were admitted with DKA. Sixty one percent were known cases and the remaining (39%) were new DM. Majority were female (63%). Most (49%) of the children were between 11- 15 years. Infection was the commonest (49%) precipitating factor followed by insulin omission (24%). Major clinical features were kussmaul breathing (94%) and dehydration (94%).Eighty eight percent patients improved after treatment and mortality was 12%. Conclusion: Infection was the commonest precipitating factor of DKA. Kussmaul breathing and dehydration were the commonest clinical features. Most of the patients improved after treatment.DOI: http://dx.doi.org/10.3329/bjms.v13i1.17429 Bangladesh Journal of Medical Science Vol. 13 No. 01 January2014: 53-57

Cataract in children and adolescents with fibrocalculous pancreatic diabetes

Cataracts have been infrequently reported in Fibrocalculous pancreatic diabetes (FCPD) which is a form of diabetes secondary to chronic, non-alcoholic pancreatitis in tropical countries. A retrospective study was carried out to find out frequency of cataracts in children and adolescents with FCPD admitted in the Paediatric Unit at Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic disorders (BIRDEM). A total of 83 patients with FCPD were admitted during the study period of 2000 to 2007. Among them twenty patients (24%) had bilateral cataracts who were enrolled in the study. Mean age at the onset of diabetes was 13.9±1.7 years. There was female preponderance. Ninety percent patients were girls. There was longer duration of symptoms in all patients. Mean duration of symptoms before diagnosis was 15.0±10.2 months. All patients had hyperglycaemia, mean HbA1c value was 18.4±5.1. Most of the patients had snowflake type cortical deposits and posterior subcapsular cataract.

Prevalence of Metabolic Syndrome among Obese Children and Adolescents

Objectives: The Prevalence and magnitude of childhood obesity are increasing dramatically. The study was undertaken to see the prevalence of metabolic syndrome among children and adolescents with obesity, attending the Paediatric Endocrine OPD, BIRDEM. Methods: A cross sectional study was conducted from January 2006 to December 2008 among obese children and adolescents (6-18 years) attending Paediatric endocrine out patient department of BIRDEM. Children with any other endocrine disorder, dysmorphism/syndrome were excluded. Obesity was defined as BMIe”95th percentile for age and sex using CDC growth chart. Children underwent two-hour oral glucose tolerance test, anthropometric and blood pressure measurement. Fasting serum insulin and lipid profile were measured. Impaired glucose tolerance (IGT) was defined as fasting plasma glucose (FPG) <7 mmol/L and 2 hr post glucose load e”7.8 mmol/L to<11.1 mmol/L. Metabolic syndrome was identified if 3 or more of following criteria were met: BMI > 97th percentile for age and sex, high triglyceride (TGe”150 mg/dl), low high-density lipoprotein cholesterol (HDL cholesterol<40mg/dl), Systolic or diastolic blood pressure>95th percentile for age and sex, IGT. Results: A total of 161 children presented with obesity. Male to female ratio was 1.3:1. Mean age was 10.3±2.5 years. Metabolic syndrome was identified in 36.6% subjects (59 out of 161, twenty five male and 34 female). Higher BMI and hip circumference, systolic and diastolic hypertension, high TG, low HDL cholesterol and IGT were significantly associated with metabolic syndrome. Conclusions: The prevalence of metabolic syndrome is high among obese children and adolescents. Factors contributing towards obesity needs to be identified and strategies should be planned for prevention and management of this health problem. DOI: http://dx.doi.org/10.3329/birdem.v1i1.12382 Birdem Med J 2011; 1(1): 21-25

Prevalence of impaired glucose tolerance among children and adolescents with obesity

The study was undertaken to see the prevalence of impaired glucose tolerance among children and adolescents with obesity, attending the Paediatric Endocrine OPD, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders (BIRDEM), Dhaka, Bangladesh. A cross sectional study from January 2006 to December 2008 was conducted among obese children and adolescents (6-18 years). Children with any other endocrine disorder, dysmorphism/syndrome were excluded. Obesity was defined as BMI ≥ 95th percentile for age and sex using CDC growth chart. Children underwent two hours oral glucose tolerance test with 1.75 gm/kg or 75 gm of glucose, anthropometric and blood pressure measurement. Fasting serum insulin and lipid profile were measured. Impaired glucose tolerance (IGT) was defined as fasting plasma glucose (FPG) <7 mmol/L and 2 hours post glucose load ≥ 7.8 mmol/L to <11.1 mmol/L. Diabetes mellitus (DM) was defined as FPG ≥ 7 mmol/L or 2 hours post glucose load ≥ 11.1 mmol/L. Homeostasis model assessment was used to estimate insulin resistance. A total of 161 children presented with obesity. Male to female ratio was 1.3:1. Mean age was 10.3 ± 2 .5 years. Mean BMI was 27.86 ± 4.1 kg/m². IGT was found in 16.9% of children and adolescents. In children aged 6-10 years IGT was detected in 16.1% and in adolescents aged 11-18 years IGT was detected in 20%. Diabetes mellitus was detected in 2.1% of subjects, all were adolescents. Serum fasting insulin and hip circumference were significantly higher among children and adolescents with IGT compared to that of normal glucose tolerance. The high rate of IGT among obese children and adolescents is of concern. Factors contributing towards obesity needs to be identified and strategies should be planned for prevention and management of this health problem.

Fasting guidelines for diabetic children and adolescents

Fasting during the month of Ramadan, the ninth month of Islamic lunar calendar, is obligatory for all healthy adult and adolescent Muslims from the age of 12 years. Fasting starts from early dawn (Sohur/Sehri) till sunset (Iftar). During this period one has to abstain from eating and drinking. Islam has allowed many categories of people to be exempted from fasting, for example, young children, travelers, the sick, the elderly, pregnant, and lactating women. According to expert opinion, patients with type 1 diabetes (type 1 DM) who fast during Ramadan are at a very high risk to develop adverse events. However, some experienced physicians are of the opinion that fasting during Ramadan is safe for type 1 DM patients, including adolescents and older children, with good glycemic control who do regular self-monitoring and are under close professional supervision. The strategies to ensure safety of type 1 diabetic adolescents who are planning to fast include the following: Ramadan-focused medical education, pre-Ramadan medical assessment, following a healthy diet and physical activity pattern, modification in insulin regimen, and blood glucose monitoring as advised by the physician.

South Asian consensus statement on women's health and Ramadan

Fasting during Ramadan, the holy month of Islam, is mandatory for all healthy adult Muslims. It is estimated that there are 1.1-1.5 billion Muslims worldwide, comprising 18-25% of the world population. About 62% of the world's Muslim population resides in Asia. Women comprise approximately 50% of this population. There is great religious fervor and enthusiasm in the majority of Muslims the world over for observing the religious fasting. Many of the Muslim women perhaps due to the family and societal pressures or lack of proper information hesitate and fail to avail themselves of the generous provisions of temporary or permanent exemptions from fasting available in Islam. It is therefore important that medical professionals as well as the general population be aware of potential risks that may be associated with fasting during Ramadan. This familiarity and knowledge is as important in South Asia and the Middle East as it is in Europe, North America, New Zealand, and Australia. There has not yet been any statement of consensus regarding women's health issues during Ramadan, namely menstruation, sexual obligations of married life, pregnancy, and lactation. This document aims to put forward some of the general guidelines for these issues especially for the South Asian Muslim women.

Prevalence of obesity among affluent school children in Dhaka

A cross sectional study was conducted in September 2006 in one of the private schools in Dhaka, Bangladesh to see the prevalence of obesity among affluent school children and adolescents. Informed consent was taken from school authority to take anthropometric measurement of all school children. Standing height was measured with a stadiometer and weight with a bathroom scale. Waist and hip circumference were measured with a measuring tape. The body mass index (BMI) was calculated using weight in kilogram/(height in meter)2 formula. Obesity was defined as BMI≥95th percentile for age and sex, over weight as BMI≥85th percentile for age and sex, normal weight as BMI between 5th and 84th percentile and underweight as BMI <5th percentile. Official centers for disease control (CDC) growth chart for boys and girls age 2-20 years was used. Children and adolescents were divided into group 1(3-5 years), Group 2(6-9years), group 3(10-13 years) and group 4(14-18 years). There were a total of 468 children and adolescents (male 266, female 202). In group 1 there were 110 children, in group 2 there were177 children, in group 3 and 4 there were 149 and 32 adolescents respectively. The prevalence of obesity was 17.9%, higher among males (19.9%), compared to females (15.3%). Obesity was highest (27.7%) in group 2, 14.5% in group 1, 10.7% in group 3 and 9.4% in group 4.

Oral rehabilitation in ectodermal dysplasia

Ectodermal dysplasia (ED) is an inherited heterogenous group of disorders causing mal formation of all tissues originating from ectoderm, like defect in hair, teeth, nail and sweat gland function. Numerous types have been described. Hypohydrotic ectodermal dysplasia (HED) is one of the common type; characterized by hypohidrosis, hypotrichosis (abnormal hair), onychodysplasia (abnormal nail) and hypodontia or anodontia (abnormal dentition). The significance of this disease lies in severe hypodontia. Dental clinicians can be the first to diagnose such cases. The dental team should be aware of its sign and symptoms in order to provide the correct therapies for the functional and psychologic needs of these patients. Here we have discussed oral rehabilitation of a 10 year old boy with ectodermal dysplasia. The objective of this case report is to make aware the people about such rare genetic disease and different methods of oral Rehabilitation of these patients for better social living, self esteem oral function.

Methylenetetrahydrofolate reductase and methionine synthase reductase gene polymorphisms and protection from microvascular complications in adolescents with type 1 diabetes

Folate status has been associated with endothelial dysfunction in adolescents with type 1 diabetes, and elevated total plasma homoocyst(e)ine (tHcy) is a risk for vascular disease in the non-diabetic population. Polymorphisms in genes involved in folate and homocysteine metabolism are implicated in vascular disease. We aimed to determine whether polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) and methionine synthase reductase (MTRR) genes are risk factors for early microvascular disease in a large group of adolescents with type 1 diabetes. Four hundred and eighty adolescents were screened annually for retinopathy and microalbuminuria for a median of 4 yr. Molecular analysis for the polymorphisms 677C-->T, 1298A-->C in MTHFR, and 66A-->G in MTRR was performed. The MTRR 66GG genotype reduced the risk for elevated albumin excretion rate (AER) (OR 0.47, CI 0.25, 0.88, p = 0.018) and showed a trend to reduced risk for microalbuminuria (OR 0.27, CI 0.06-1.21, p = 0.09). Survival without elevated AER was increased with the MTRR 66GG genotype (12.4 vs. 9.7 yr, p = 0.04) and with the MTHFR 1298CC genotype (15.2 vs. 10.2 yr, p = 0.007). Conversely, survival without retinopathy was reduced with the MTHFR 677TT and MTRR 66GG combined genotype (6.2 vs. 10.2 yr, p = 0.015). The MTRR 66GG and MTHFR 1298 CC genotypes may confer protection against early nephropathy, possibly because they are associated with lower tHcy. The MTHFR 677 TT was only related to earlier onset retinopathy in combination with MTRR 66GG.

Clinical Profile of Diabetes Mellitus in Children and Adolescents under Eighteen Years of Age

A total number of 125 patients with diabetes mellitus (DM) under eighteen years of age were admitted in the Paediartic department of BIRDEM hospital between January 2001 to October 2002. Eighty-eight patients (71%) were newly detected. Female to male ratio was 3:1. Out of the total admission 38 (30.4%) patients had type 1 DM (group 1), 37 (29.6%) patients had fibrocalculous pancreatic FCPD diabetes (group II), 48 (38.4%) patient had malnutrition modulated diabetes mellitus MMDM (group III) and 2 (1.6%) patients had type 2. Mean age of onset was 9±3.9 yrs in group I and 13±2.3 yrs in group II and group III. All groups had very high glucose and HbA1c value at presentation. The mean fasting glucose (mmol/l) was 19±7.14, 22.39±9 and 19.54±7.9 in group I, group II and group III respectively. The Mean HbA1c (%) value in the three groups was 14.4±2.7, 16.72±2.26 and 15.27±3.05 respectively. FCPD patients had poorest glycaemic status. Acute complications were more common in type 1 patients. Twelve (31.5%) patients had diabetic ketoatin DKA and two (5%) patients had hypoglycaemia in group I. Chronic complications were present in all three groups. MMDM patients had highest rate of complications. which was present in 2.6%, 21.6% and 33.3% patients in group I, group II and group III respectively. The rate of microalbuminuria was 5.3%. 10.8% and 18.8% in the three groups respectively. The rate of neuropathy was 2.6%, 16.2% and 20.8% in the three groups respectively. Among the associated problems skin infection, pulmonary tuberculosis and bilateral parotid swelling were common. Malnutrition was present in 66%, 86% and 100% in group I, group II and group III respectively. Majority (50% in group I, 91.6% in group II and 100% in group III) of our patients came from poor socio-economic background. Ibrahim Med. Coll. J. 2007; 1(1): 11-15       Key words: Diabetes mellitus doi: 10.3329/imcj.v1i1.2889

Cleidocranial dysplasia

Cleidocranial dysplasia (CCD) is a disorder that affects mostly those bones which derived from endochrondal and intramembranous ossification, such as the cranium and the clavicles. CCD is present at a frequency of one in one million individuals. Over 500 cases have been reported. A 13 years old boy reported in the Paediatric Endocrinology outpatient department, Bangladesh Institute of Research and Rehabilitation on Diabetes, Endocrine and Metabolic Disorders (BIRDEM) on 6th April 2006 with complaints of not growing according to his age, a wide gap over the head since birth and delayed shedding of primary teeth and also eruption of secondary teeth. The boy had elongated facies with midfacial hypoplasia, depressed nasal bridge with hypertelorism. His anterior fontanelle was open about 3/1.5 cm. He had short clavicle and his shoulders could be easily apposed. Radiological findings showed anterior fontanellle and sutures were open and widened, all decidual teeth were intact and all secondary teeth were impacted beneath the primary teeth and hypoplastic clavicle. He was diagnosed as a case of Cleidocranial Dysplasia on the basis of history, clinical examination and investigation.

Vaginal bleeding with multicystic ovaries and a pituitary mass in a child with severe hypothyroidism

A seven year and ten months old girl presented with cyclic vaginal bleeding and a huge abdominopelvic mass. She had clinical features of hypothyroidism. The investigation results were consistent with the diagnosis of primary hypothyroidism with precocious puberty. She also had bilaterally enlarged cystic ovaries on CT scan of abdomen and CT scan of brain showed pituitary macroadenoma. After starting treatment with thyroxine, patient became euthyroid and her general condition improved. Treatment with thyroxine alone halted the cyclic vaginal bleeding, led to rapid resolution of the ovarian cysts and regression of the pituitary mass.

Complications of diabetes mellitus in childhood

Complications of diabetes include retinopathy, nephropathy, neuropathy, macrovascular disease, and associated autoimmune diseases. Clinical manifestations of complications uncommonly present in childhood and adolescence. Screening during the early years can identify subclinical disease and it offers an opportunity for early intervention. The Diabetes and Complications Control Trial has provided evidence for the long-term benefits of good glycemic control in preventing and delaying the onset of microvascular complications. Complications begin to manifest during adolescence, during which time all efforts should be made to educate and support young persons in achieving optimal diabetes control.

Discordant trends in microvascular complications in adolescents with type 1 diabetes from 1990 to 2002

OBJECTIVE

Since the Diabetes Control and Complications Trial, diabetes management goals have changed. The aims of the present study were to assess complication rates, including nerve abnormalities, in adolescents from 1990 to 2002 and to investigate associated risk factors.

RESEARCH DESIGN AND METHODS

Cross-sectional analysis of complications was assessed in three study periods (1990-1994 [T1], 1995-1998 [T2], and 1999-2002 [T3]) in adolescents matched for age and diabetes duration (n = 878, median age 14.6 years, median duration 7.5 years). Retinopathy was assessed by seven-field stereoscopic fundal photography, albumin excretion rate (AER) from three consecutive timed overnight urine collections, peripheral nerve function by thermal and vibration thresholds, and autonomic nerve function by cardiovascular reflexes.

RESULTS

Retinopathy declined significantly (T1, 49%; T2, 31%; and T3, 24%; P < 0.0001), early elevation of AER (> or = 7.5 microg/min) declined (38, 30, and 25%, respectively, P = 0.022), and microalbuminuria (AER > or = 20 microg/min) declined (7, 3, and 3%, respectively; P = 0.017, T1 vs. T2 and T3). Autonomic nerve abnormalities were unchanged (18, 21, and 18%, respectively; P = 0.60), but peripheral nerve abnormalities increased (12, 19, and 24%, respectively; P = 0.0017). More patients were treated with three or more injections per day (12, 46, and 67%, respectively; P < 0.0001) and insulin dose increased (1.08, 1.17, and 1.22 units x kg(-1) x day(-1), respectively; P < 0.0001), but median HbA(1c) (A1C) was unchanged (8.5, 8.5, and 8.4%, respectively). BMI and height SD score increased: BMI 0.46, 0.67, and 0.79, respectively (P < 0.0001), and height -0.09, 0.05, and 0.27, respectively (P < 0.0001).

CONCLUSIONS

Retinopathy and microalbuminuria declined over time in this cohort, but the increased rate of peripheral nerve abnormalities is of concern. Despite intensified management (higher insulin dose and more injections), A1C has not changed and remains well above the recommended targets for adolescents.

Differentiating between lewy body dementia and Alzheimer's disease: a retrospective brain bank study

Recent research has shown that while Lewy body dementia. (LBD) may be the second most common form of dementia, it is difficult to confirm the disease before autopsy. Patients with LBD share many clinical signs and symptoms with patients diagnosed with Alzheimer's disease (AD), making it difficult to differentiate between the two diseases in patients who are still living. Still, our purpose in this study was to determine any clinical features which may differentiate between autopsy-confirmed cases of AD and cases of LBD. We compared 13 patients with autopsy-confirmed AD with 12 patients who had autopsy-confirmed LBD. Phone calls were made to family members of the deceased to help clarify and add any other information not documented in the patient's files. Significant differences were found in three areas, and trends approaching statistical significance were found in two other areas. Visual hallucinations were more prominent in the patients with LBD than in the patients with AD (10/12 LBD vs. 4/13 AD, P < 0.05). A nonspecific tremor was also found more often in the LB patients than in the Alzheimer's patients (8/12 LBD vs. 3/13 AD, P < 0.05). Finally, the LB patients were more prone to wandering, especially earlier in the disease course than were the patients with AD (10/12 LBD vs. 6/13 AD, P < 0.5). There was also a trend within the LB patients for higher use of anxiolytics (9/12 LBD vs. 6/13 AD, P = 0.14) as well as antidepressants (7/12 LBD vs. 4/13 AD, P = 0.16). Our data confirmed our hypothesis that LBD from a clinical perspective is indeed similar to AD. However, the higher incidence of visual hallucinations, tremor and wandering as well as the trend toward the use of anxiolytics and antidepressants among LB patients was noted. This gives hope that a clinical differentiation between these two diseases and more specific treatments may be possible in the future.

Diabetic Ketoacidosis in Children - An Experience in a Tertiary Hospital

A retrospective study was done in the in-patient department of paediatrics, BIRDEM from January 2002 to November 2006 to determine the clinico-laboratory features, precipitating factors and outcome of diabetic ketoacidosis. Over the five year period, 344 diabetic patients were hospitalized. Among them, 54 (15.6%) had diabetic ketoacidosis (DKA). Among those, 50 were Type I, one was Fibrocalculous Pancreatic Diabetes (FCPD) and 3 were of other specific types. More than half (51.9%) of the patients were newly diagnosed. Amongst the precipitating factors, 28% had missed insulin and 48% had overt infection. Infections, particularly those of the respiratory tract, were the main precipitating cause for the DKA. There was h/o both infection and missed insulin injections in 11.5% patients. The mean age of patients with DKA was 11.2 ± 4.4 years. Those in the age range 10-14 yrs suffered most frequently (p<0.0001) from ketoacidosis (n= 38, 70.4%) compared with those aged 0-4 yrs (9%) and 5-9 yrs. (20%). There was a significant difference between those newly diagnosed (group I) and known diabetics (group II) (p<.029). The frequency of DKA was higher in girls than in boys (66.7% vs. 33.3%; p =.0001). The median duration of polyuria and/or polydipsia was variable between newly diagnosed and known diabetics (3.2 - 25d) (p<.001). All patients presented with altered levels of consciousness and 35 (67.3%) were unconscious of different grades. Mean random blood glucose (RBG) and HbA1c were 27.6mmol/L and 13.4%. Complications noted were acute renal failure (n=2, 3.7%) and cerebral edema (n = 4, 7.5%). The outcome of treatment in the whole group was good, 46 (86.7%) patients recovered without complications, but 7 (13.4%) patients died. Ibrahim Med. Coll. J. 2008; 2(1): 17-20 Key words: Ketosis, children, diabetes, BIRDEM doi: 10.3329/imcj.v2i1.2926