Depression and glycemic control in adolescent diabetics: evaluating possible association between depression and hemoglobin A1c.

OBJECTIVES: The objective of this study was to test whether glycemic control varies between adolescent patients diagnosed with type 1 or type 2 diabetes who are depressed and those who are not, after controlling for confounding factors. We hypothesized that diabetic children who have depression or a high risk to develop depression will have worse glycemic control, as indicated by higher hemoglobin A1c (HbA1c) values. STUDY DESIGN: This was a retrospective case-control study. METHODS: A chart review was conducted in the Section of Endocrinology at St. Christopher's Hospital for Children in Philadelphia. Multivariate linear regression was used to determine effects of individual variables. RESULTS: A total of 214 records were included out of 263 reviewed. Significant differences were observed in type 1 diabetics (n = 156) between depressed and non-depressed patients in the percentage of females in the group (P = .002), the duration of diabetes (P = .005), age at diagnosis (P = .01), hemoglobin A1c (P = .03), and the percentage of those with a HbA1c greater than 14% (P = .03). Depression was associated with significant increases in HbA1c values in type 1 diabetics (P < .001). An interaction effect (P = .055) was observed between sex and depression. Given the small sample of children with type 2 diabetes, we were unable to perform any meaningful statistical analysis in this subgroup of patients. CONCLUSIONS: We have detected a significant association between depression and glycemic control in adolescent girls with type 1 diabetes. This association appears to be moderated by sex. Depressed patients with type 2 diabetes generally display higher HbA1c values than their non-depressed counterparts.

Chryseobacterium gleum in a man with prostatectomy in Senegal: a case report and review of the literature.

BACKGROUND: Here we report a rare case of a urinary tract infection due to Chryseobacterium gleum. This widely distributed Gram-negative bacillus is an uncommon human pathogen and is typically associated with health care settings. CASE PRESENTATION: We describe a case of urinary tract infection caused by Chryseobacterium gleum in a 68-year-old man of Wolof ethnicity (an ethnic group in Senegal, West Africa) who presented to our Department of Urology in a university teaching hospital (Hôpital Aristide Le Dantec) in Dakar, Senegal, 1 month after prostatectomy. The strain isolated from a urine sample was identified as Chryseobacterium gleum by mass spectrometry (Vitek matrix-assisted laser desorption/ionization, time-of-flight, bioMérieux) and confirmed by 16S ribosomal ribonucleic acid sequencing. The organism was resistant to a wide range of antibiotics, including carbapenem, due to a resident metallo-ß-lactamase gene that shared 99% of amino-acid identity with Chryseobacterium gleum class B enzym. CONCLUSIONS: Infection by Chryseobacterium gleum is infrequent, and no such case has been previously reported in Africa. Despite its low virulence, Chryseobacterium gleum should be considered a potential opportunistic and emerging pathogen. Further studies on the epidemiology, pathogenicity, and resistance mechanisms of Chryseobacterium gleum are needed for better diagnosis and management.

Effects of oleate and insulin on glucose uptake, oxidation, and glucose transporter proteins in rat adipocytes.

We examined effects of Na oleate on glucose uptake, glucose transporter protein concentrations, and glucose oxidation in isolated adipocytes from fed rats. Na oleate increased basel 14C-glucose uptake in a dose-dependent manner (+42% with 1.0 mM, +79% with 2.8 mM Na oleate), but had no statistically significant effect on insulin-stimulated glucose uptake. Insulin (100 nM) resulted in a redistribution of GLUT4 protein concentration from the LDM fraction (-42%) to the PM fraction (+266%) but did not affect the distribution of GLUT1. Na oleate had no effect on basal or insulin-stimulated concentrations of GLUT1 or GLUT4 proteins in the PM or LDM fractions. Na oleate (2.8 mM) had no statistically significant effect on basal glucose oxidation, but inhibited insulin-stimulated glucose oxidation by 48% (P less than 0.01). In summary, Na oleate inhibited insulin-stimulated glucose oxidation and stimulated basal glucose uptake in isolated adipocytes without affecting PM or LDM distribution of GLUT1 or GLUT4 proteins. We conclude that the stimulatory effect of Na oleate on basal glucose uptake in adipocytes may be mediated by changes in the intrinsic activity of the glucose transporters.

Giant multilocular prostatic cystadenoma: a distinctive lesion of the retroperitoneum in men. A report of two cases.

Two examples of large, multiloculated, cystic tumors that arose within the pelvis in men of 28 and 37 years of age are described. The tumors were composed of glands and cysts lined by prostatic-type epithelium lying in a hypocellular fibrous stroma. The prostatic nature of the lesions was confirmed by immunohistochemical staining of the epithelium for prostate-specific antigen and prostatic acid phosphatase. Two apparently similar lesions were found in the literature; one tumor was attached to the prostate by a pedicle, and the other arose in the retrovesical space. These tumors, for which we propose the designation "giant multilocular prostatic cystadenoma," appear to be benign, although they may recur if incompletely excised. They may pose considerable diagnostic difficulty if the prostatic nature of the epithelium is not appreciated, an error that is likely if a relationship to the prostate is not recognized. This lesion should be included in the differential diagnosis of retroperitoneal cystic tumors in men.

Pediatric abdominal trauma: evaluation by computed tomography.

When indications for immediate laparotomy are not present, CT of the abdomen and pelvis can be used to evaluate pediatric blunt abdominal trauma. During 2-year period, the medical records and abdominal/pelvic CT scans of 100 consecutive pediatric patients who were evaluated for blunt abdominal trauma were retrospectively reviewed. The scans appeared normal for 73 children. Of these children, 30 had severe head injuries and a depressed sensorium. A total of 27 abdominal/pelvic CT scans were interpreted as abnormal. Findings included nine splenic fractures, six renal contusions, nine hepatic lacerations, one duodenal hematoma, one traumatic pancreatitis, four bony injuries, six miscellaneous abnormalities, and one intraperitoneal bleed. Only two of these 27 patients required abdominal surgery. The remaining 25 patients were treated conservatively based upon a stable clinical state and CT delineation of the extent of injury. No mortality resulted. CT is the radiographic examination of choice for hemodynamically stable pediatric patients with blunt abdominal trauma. CT provided a reliable adjunct examination technique when a physical examination could not be performed and a complete history could not be obtained. The extent of abdominal/pelvic injuries is well delineated and can often be followed by diagnostic imaging, usually allowing for conservative therapy.

Nonoperative management of splenic and hepatic trauma in the multiply injured pediatric and adolescent patient.

OBJECTIVE: To determine whether nonoperative management of splenic and hepatic injury in the multiply injured pediatric and adolescent patient is both safe and efficacious. DESIGN: Retrospective case series. SETTING: Level 1 trauma center. PATIENTS: All patients younger than 19 years old who suffered trauma to the spleen or liver between February 1978 and December 1991 (n = 103) were retrospectively identified by a trauma registry. These patients were divided into three groups: the group as a whole, those suffering multiple injuries, and those suffering either head injury or injury remote from the abdomen that required operative repair. MAIN OUTCOME MEASURES: Injury severity and outcome within each group of patients were compared based on whether the splenic or hepatic injury was managed operatively or nonoperatively. RESULTS: Mean Injury Severity Scores among the multiply injured patients were not different depending on whether the splenic or hepatic injury was managed nonoperatively or operatively. Except for a higher incidence of transfusion requirement among patients who were treated operatively, measures of morbidity among the multiply injured patients did not differ based on treatment. The success rates of nonoperative treatment among all patients, those with multiple injuries, and those with either head injury or remote injury that required surgery were 94%, 90%, and 86%, respectively. CONCLUSION: Nonoperative management of splenic and hepatic injury in multiply injured pediatric and adolescent patients, including those with head injury and injury remote from the abdomen that requires surgical intervention, is successful and is not associated with a prohibitive morbidity.

A simplified approach to the repair of pediatric pectus deformities.

For the past 14 years, a simplified operation utilizing a metal strut for internal fixation has been used to repair pectus anomalies in 123 children. Subperichondrial cartilage resection is preformed through small incisions in the pectoral muscles. No sternal osteotomy required. A malleable strut is passed transsternally and removed in four to six months, frequently under local anesthesia. All children who underwent this procedure were discharged within five to six days, and no transfusions were necessary. The use of the technique has shortened operative time and decreased the necessity for extensive postoperative pulmonary physiotherapy. In 75 children followed for over 5 years, cosmetic results have been excellent, and self-image has improved substantially. In only 1 child was there a recurrence impressive enough to warrant reoperation.

Neonatal septum transversum diaphragmatic defects.

Over 10 years, 8 infants required surgery for central diaphragmatic herniation. Contrast peritoneography and technetium-99m-sulfur colloid radionuclide scanning were the most definitive diagnostic aids. Associated anomalies included variations of the pentalogy of Cantrell. A midline gastroduodenal loop was found in two infants. Six infants are alive and well 6 months to 3 years postoperatively. An abdominal approach is preferred if there is an intestinal hernia, associated gastrointestinal anomalies, or if a bilateral defect is present.

Acute low-back pain. An objective analysis of conservative therapy.

The roles of bedrest, antiinflammatory medication, and analgesic medication in the treatment of acute back strain were objectively analyzed to determine whether they have a measurable effect on the return of patients to full daily activities as well as on the relief of pain. Two hundred patients were studied prospectively. Each patient had the diagnosis of acute back strain, which was defined as nonradiating low-back pain. The results of the patient's neurologic examination, straight leg raising test, and lumbosacral spine roentgenograms had to be within normal limits for the patient to be included in the study. The results showed that bedrest, as compared with ambulation, will decrease the amount of time lost from work by 50%. Bedrest will also decrease the amount of discomfort by 60%. Analgesic medication, when combined with bedrest, will further decrease the amount of pain incurred, particularly when used in the first three days of the healing process. However, analgesic medication will not allow a more prompt return to work. Antiinflammatory medication, when added to bedrest in the treatment of lumbago, does not provide an advantage over bedrest alone.

Surgical problems and outcome in infants less than 1000 grams at birth.

This study was undertaken to identify the pathologic processes in premature infants weighing less than 1000 gm who require surgery, and the outcome of such operations. These neonates required surgery for NEC and PDA. Congenital anomalies were not encountered in our series. No increased mortality due to surgery was observed, and overall mortality was comparable for infants less than 1000 gm and for premature infants with similar diseases. We conclude that surgery in premature infants less than 1000 gm is performed for acquired diseases, and mortality is not increased by the need for surgery.

Positive 99mTc-pertechnetate scan in a child with intestinal arteriovenous malformation.

A teenager with massive rectal bleeding had a positive 99mTc-pertechnetate abdominal scan. At laparotomy, an arteriovenous malformation of the jejunum was found. There was no evidence of a Meckel's diverticulum. The persistent problem of the positive technetium scan warrants increased utilization of preoperative visceral angiography.

External compression as initial management of giant omphaloceles.

The authors describe a noninvasive technique for the management of giant omphaloceles. Two patients with giant omphaloceles were managed with external compression. Dry sterile dressings were used, buttressed by an Ace bandage in the first case and by a handcrafted Velcro abdominal binder in the second. The binder was tightened every 2 or 3 days. Renal, cardiovascular, respiratory, and gastrointestinal parameters were measured regularly to determine whether the binder was too tight. The first patient had only occasional emesis, and the defect was repaired after 40 days of compression. The second patient experienced intermittent hypertension, occasional emesis, and mild oxygen desaturation, which resolved when the binder was loosened slightly. The fascia muscle and skin were closed after 30 days of external compression. Both patients are currently living at home and doing well. This form of external compression is an effective, inexpensive, and low-risk method for the gradual reduction of giant omphaloceles, and should be considered for patients born with this problem.

A modified feeding Roux-en-Y jejunostomy in the neurologically damaged child.

PURPOSE: Feeding tube access with an antireflux procedure is frequently necessary in children with severe neurological deficits. Fundoplication in this particular group of patients has many complications and a reported failure rate of 40% to 50%. Recently, the use of a feeding Roux-en-Y jejunostomy has been advocated in this population. METHODS: Since December 1993, over a 6-month period, the authors performed 12 Roux-en-Y jejunostomies. All children had documented gastroesophageal reflux. One patient had a prior failed Nissen fundoplication, and none of these patients were feeding significantly by mouth. Postoperative follow-up has been 12 months. RESULTS: There were no deaths in this series. One patient required early revision of the stoma because of marked prolapse. One 11-month-old infant required reoperation 7 days postoperatively because of tube dislodgment. Eight of the 12 patients required out-patient procedures to unplug or replace the jejunostomy tube. CONCLUSION: The operation may be beneficial in a subset of neurologically impaired children who will never be able to ingest significant calories by mouth. It may also be useful after a failed fundoplication. The main postoperative complications were plugging and dislodgment of the jejunostomy tube, which if they occurred early, required x-ray confirmation for catheter placement.

Child abuse as a cause of traumatic chylothorax.

Chylothorax is an uncommon condition that may be associated with significant morbidity and mortality. The authors report a case of traumatic chylothorax attributed to child abuse and describe our management with tube thoracostomy and nutritional support with medium-chain triglycerides. Child abuse should be suspected in any case of chylothorax when no other etiology is evident and particularly when other signs of abuse are present.

Pyloric stenosis in the age of ultrasonography: fading skills, better patients?

Hypertrophic pyloric stenosis can be diagnosed accurately by physical examination alone. However, ultrasonographic confirmation is obtained in the majority of cases, often before clinical evaluation by the surgeon. The present study examines whether the easy access to ultrasonography by the primary physician has affected the care of infants with pyloric stenosis. During a 24-month period, 100 infants were treated for pyloric stenosis at the authors' institution. There were 78 boys and 22 girls; the age range was 9 to 90 days (median, 30.0 days). The children were referred for surgical evaluation, but abdominal ultrasonography was ordered concomitantly (or within 1 hour of surgical consultation) in all cases. The median age at the onset of the first symptoms was 24.0 days. The time between onset and hospital admission was less than 7 days for 72 patients, and more than 2 weeks for seven. Metabolic alkalosis or acidosis, hypokalemia, hypochloremia, and dehydration were noted in 10%, 5%, 3% and 9%, respectively. Six infants had prolonged pre- and postoperative courses, because of prematurity (4) or associated conditions (2). For the remaining patients, total hospitalization period and postoperative stay were 3.8 +/- 0.9 days and 2.8 +/- 0.6 days, respectively. Although the diminished importance of clinical skills in the diagnosis of pyloric stenosis may be regrettable, the availability to the primary care physician of this easy, safe, inexpensive, and reliable imaging modality may contribute to prompter treatment. The patients were hospitalized, with a correct diagnosis, within days of the appearance of the initial symptoms. Because so little time had elapsed, water and electrolyte imbalances were not present, and the patients could be operated on within hours of admission.

Castleman's disease presenting as a pediatric surgical problem.

A 9-year-old girl presented with anemia, fever, and poor growth over a 2 1/2-year period. On physical examination, a right lower quadrant mass was palpated. Her signs and symptoms were consistent with Castleman's disease of the plasma cell type. The mass, a giant hyperplastic lymph node, was excised, and the patient's symptoms resolved. Castleman's disease is a benign lymph node disorder that occurs very rarely in the pediatric population and is cured by operative excision of the lymphatic mass.

Peritoneal drainage as definitive treatment for intestinal perforation in infants with extremely low birth weight (<750 g).

BACKGROUND: Advances in neonatal intensive care have improved the survival of the extremely premature infant. However, survival at less than 25 weeks' gestational age remains tenuous, with intestinal perforation presenting a significant mortality. METHODS: During an 18-month period from 1995 to 1996, nine patients weighing less than 750 g (range, 485 to 740 g; mean, 615 g) presented with intestinal perforation. All patients were treated with peritoneal drainage. Drains were removed after clinical improvement and the cessation of peritoneal drainage. RESULTS: Seven patients survived the initial drainage procedure (78%). At a mean follow-up of 12 months, the six long-term survivors are all tolerating full enteral feeds, and none developed intestinal strictures or intraabdominal abscess. No patient required subsequent celiotomy. Peritoneal drainage has previously been considered in some centers as temporary therapy in extremely ill neonates deemed unlikely to survive operation. The authors have adopted drainage as the sole treatment in selected patients. CONCLUSION: Peritoneal drainage alone may be considered definitive therapy for intestinal perforation in the majority of micropremature infants.

Incidence of contralateral inguinal hernia: a prospective analysis.

BACKGROUND/PURPOSE: Contralateral groin exploration in children with unilateral inguinal hernia is still controversial, particularly in infants. The authors have attempted to determine the age- and gender-stratified incidence of contralateral hernia and the necessity of routine bilateral procedures. METHODS: This is a prospective study of 656 patients during a 34-month period at a single institution. Patients with unilateral hernia underwent an ipsilateral procedure only, regardless of age, gestational age, or gender. Follow-up was 6 to 40 months (mean, 25.5 months). Chi-square analysis was used for intergroup comparison (P < .05 significant). RESULTS: Of 656 children, 108 (16.5%) presented with synchronous bilateral hernias. Bilateral inguinal hernia was significantly more common in premature infants (28.0%) and young children (33.8% if <6 months, 27.4% if <2 years). Of the remaining 548, a metachronous contralateral hernia developed in 48 (8.8%) at a median interval of 6 months (range, 4 days to 7 years). This incidence was 13 of 105 (12.4%) in infants less than 6 months of age, 20 of 189 (10.6%) in children less than 2 years of age, 8 of 54 (14.8%) in premature infants, 6 of 81 (7.4%) in girls, and 8 of 29 (27.6%) in children with an incarcerated hernia. In the latter group, P < .05, chi2 analysis. CONCLUSION: Routine contralateral inguinal exploration, without clinical evidence of a hernia, may be advisable in children with incarceration and possibly in premature infants. The low incidence of contralateral hernias in all other patients, regardless of gender or age, does not justify routine contralateral exploration.

Management of thoracolaryngopelvic dysplasia.

We report a family in which three members have thoracolaryngopelvic dysplasia (Barnes' syndrome). This family illustrates the phenotypic variability seen in this rare clinical entity and highlights the medical and surgical management necessary in such cases.

Primary repair of long-gap esophageal atresia by mobilization of the distal esophagus.

Long-gap esophageal atresia remains a difficult problem for the pediatric surgeon. Several strategies for lengthening of the proximal esophageal segment have been used with relative success. Autogenous tissue conduits have resulted in less than optimal long-term results. Five patients since 1991 with long gap esophageal atresia (2 with distal tracheo-esophageal fistula [Type C], and 3 with isolated esophageal atresia [Type A]) underwent mobilization of the distal esophagus to the level of the diaphragm in order to perform a primary anastomosis. A retrospective analysis evaluated the timing of repair, when oral feeds were successfully begun, with particular attention to any ischemic sequelae related to the distal esophageal dissection. Two patients underwent immediate repair, three had delayed repair. There were no anastomotic leaks. Three patients healed without stricture. Of four patients who survived long-term, three patients are eating well and only one still requires jejunoenteric supplementation. Classic teaching dictates that dissection of the distal esophagus should not be done because of disruption of its segmental blood supply. In this series, distal esophageal mobilization was successful in facilitating a primary anastomosis. These results are encouraging as an alternative to the high morbidity and marginal long-term results of interposition grafting or gastric transposition.