Are we confident that final-year medical students know at least basics about diabetes?: A preliminary report from the multicenter, survey-based Diabetes Know-Me study.

BACKGROUND: We present the results of the pilot study of a multinational "Diabetes Know-Me" project investigating knowledge regarding diabetes of medical students. This is the first collaborative project of the ISPAD JENIOUS group. METHODS: Students of the final year of medical studies from six countries answered a 25-question survey regarding basic knowledge concerning diabetes (1091 surveys handed out, response rate 86%). RESULTS: Among the responders (58% female) 90% confirmed attending diabetology classes; 11% planned to specialize in diabetology. There were significant differences between countries in the median score of correct answers ranging from 10/25 to 22/25. Attending diabetes classes (20 vs. 13/25, p < 0.0001) was the strongest factor associated with improved knowledge about diabetes (other factors analyzed were: gender, familiar/personal experience of diabetes, interest to specialize in diabetology). CONCLUSIONS: Basic knowledge about diabetes remains a challenge. Participating in classes concerning diabetes contributed the most to the diabetes-related knowledge among students of the final year of medical faculties.

The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention.

PURPOSE: The most frequent impact sites for head injury patients who require surgical intervention are the temporo-parietal regions. However, most recent guidelines for indication of neuroimaging for head injury sparsely address the impact site as a risk factor. Our purpose was to determine the association between the site of impact in a minor mechanism pediatric head injury and neurosurgical intervention. METHOD: A retrospective cohort study of head injury patients seen between 2000 and 2016 in a large trauma center was carried out. We looked at all children ages 0-18 years who underwent neurosurgical intervention for head traumas. A major mechanism was defined as a fall of >1 m, being struck by a fast-flying object, or a motor collision involving an estimated speed of >40 kph. All other mechanisms were classified as minor. RESULTS: Out of 533 patients, we excluded patients with non-accidental trauma, patients with a relevant chronic illness, patients with a major mechanism of injury, and patients with missing important data, leaving 43 as the study group. Of the 43 patients with a minor mechanism, none had a site of impact that was outside the temporo-parietal region. CONCLUSION: We studied one of the largest cohorts of pediatric patients undergoing neurosurgical intervention for a head injury. In our cohort, none of the children who sustained a minor mechanism of injury suffered a site of impact in the occipital or frontal bone regions outside the temple region. These data suggest that injury location should be considered in assessing the need for neuroimaging in minor mechanism head trauma patients.

Presenting characteristics of children who required neurosurgical intervention for head injury.

PURPOSE: The purpose of this study is to describe the presenting characteristics of a large group of children who required neurosurgical intervention (NSI) following a head injury and to retrospectively assess which of the criteria for imaging from Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) clinical decision rules (CDRs) were met by these patients. STUDY DESIGN: We retrospectively reviewed all patients undergoing NSI following a head injury, between 2000 and 2008, at a large tertiary pediatric trauma center. We excluded patients having non-accidental injury, other neurosurgical interventions, penetrating injuries, and patients with incomplete data. To those who presented initially with mild head injury (GCS 14-15), we retrospectively applied the criteria for imaging of the CHALICE, PECARN, and CATCH CDRs. RESULTS: Out of 289 patients undergoing NSI, 182 met inclusion criteria and comprised our cohort. Of the 72 (39.6 %) with mild head injury (GCS 14-15), 71 (98.6 %) met at least one criteria for imaging from each of the three CDRs, including severe mechanism of injury (68, 94.4 %), clinically evident skull fracture (35, 48.6 %), neurological deficit (19, 26.3 %), or severe headache (6, 8.3 %). Of the 182 patients in the entire cohort, only 1 (0.5 %) did not present with an obvious indication for CT on all three CDRs. CONCLUSIONS: In a large sample of children requiring NSI after head trauma, the vast majority met CT criteria listed in each of the three CDRs. The most common indication for CT was a severe mechanism of injury. This, combined with clinically evident skull fracture, neurological deficit, and severe headache, identifies almost all patients requiring NSI.

Van Wyk Grumbach Syndrome and Ovarian Hyperstimulation in Juvenile Primary Hypothyroidism: Lessons From a 30-Case Cohort.

Context: Prolonged hypothyroidism in children commonly causes short stature with delayed bone maturation, and delayed puberty. However, a paradoxical occurrence of peripheral precocious puberty and pituitary enlargement in chronically untreated juvenile hypothyroidism was first reported by Van Wyk and Grumbach in 1960. Objective: To create increased awareness and a better understanding of this clinical entity among emergency room physicians, pediatricians, surgeons, gynecologists and oncologists. Methods: Case records of children diagnosed with Van Wyk-Grumbach syndrome (VWGS) were analyzed retrospectively. Results: Twenty-six girls and 4 boys were identified (2005-2020). All had profound primary hypothyroidism (total thyroxine [T4]: 2.5-33.5 nmol/L, thyrotropin: > 75-3744 µIU/mL). Hypothyroidism was not the referral diagnosis in any of the girls. Among them, 17 were referred for precocious puberty, 5 with a diagnosis of pituitary tumor on magnetic resonance imaging, and others for acute surgical abdomen in 7 girls (painful abdominal mass-2, ovarian tumor-2, ovarian torsion-2, ruptured ovarian cyst-1), acute myelopathy in 1, and menorrhagia with headache in another. All girls were successfully managed with levothyroxine replacement alone, except for the 2 with ovarian torsion, who required surgery. Menstruation ceased promptly with T4 therapy in all girls, occurring at an age-appropriate later date. All boys had testicular enlargement at presentation that regressed partially after T4 treatment. Catch-up growth was remarkable during the first treatment year, but the final height was compromised in all. Conclusion: Increased awareness of varied presentations of VWGS is vital among pediatricians to facilitate early diagnosis and targeted investigations, and to help in the initiation of the simple yet highly rewarding T4 replacement therapy to avoid all possible complications.

Are we undertreating calcium deficiency in metabolic bone disease of prematurity? A case report and review.

Background: Both calcium (Ca) and phosphorus (P) are needed to prevent and treat metabolic bone disease (MBDP). However, the predominant focus of many treating neonatologists lies in supplementing P and vitamin D. In this report, we describe a VLBW infant with severe MBDP due to inadequately treated calcium deficiency and discuss the need to recognize this entity. Case details and management: A 25-week, 700 gm baby boy had chronic lung disease and necrotizing enterocolitis. He received total parenteral nutrition, budesonide, furosemide, and caffeine. With high serum alkaline phosphatase (ALP: 1,700 IU/L) and low P (2.8 mg/dl), MBDP was diagnosed at 12 weeks, started on oral phosphate, human milk fortifier, and 1,400 IU/d of vitamin D before discharge. He was readmitted 2 weeks later with decreased lower limb mobility and respiratory distress. X-rays revealed severe osteopenia and fractures of both femurs. Serum P was 4.6 mg/dl but ALP was high (1,700 IU/L), and Ca was low (6.4 mg/dl). Parathyroid hormone (PTH: 605 pg/ml) and 25-hydroxy Vitamin D (25 OHD > 200 ng/ml) were very high. We discontinued his P and vitamin D, hypocalcemia treated with IV Ca gluconate, later oral Ca citrate, and calcitriol. Phosphate was added after normalization of Ca. Over the next many weeks, X-rays and biochemistry improved. Discussion: MBDP results from both Ca and P deficiencies, especially in VLBW infants with comorbidities. P supplementation without treating underlying calcipenia can precipitate hypocalcemia and worsen osteopenia with disastrous consequences. In severe calcipenia, active vitamin D might have a role in addition to an appropriate dose of elemental calcium.

New onset diabetes, type 1 diabetes and COVID-19.

BACKGROUND AND AIMS: New data has emerged regarding higher risk of coronavirus disease 2019 (COVID-19), and its severity and complications in patients with type 2 diabetes mellitus (T2DM). However, there is a dearth of evidence regarding type 1 diabetes mellitus (T1DM). This article explores the possibility of COVID 19 induced diabetes and highlights a potential bidirectional link between COVID 19 and T1DM. METHODS: A literature search was performed with Medline (PubMed), Scopus, and Google Scholar electronic databases till October 2020, using relevant keywords (COVID-19 induced diabetes; COVID-19 and type 1 diabetes; COVID-19 induced DKA; new-onset diabetes after SARS-CoV-2 infection) to extract relevant studies describing relationship between COVID-19 and T1DM. RESULTS: Past lessons and new data teach us that severe acute respiratory syndrome coronaviruses (SARS-CoV and SARS-CoV-2) can enter islet cells via angiotensin converting enzyme-2 (ACE-2) receptors and cause reversible ß-cell damage and transient hyperglycemia. There have been postulations regarding the potential new-onset T1DM triggered by COVID-19. This article reviews the available evidence regarding the impact and interlink between COVID-19 and Τ1DM. We also explore the mechanisms behind the viral etiology of Τ1DM. CONCLUSIONS: SARS-CoV-2 can trigger severe diabetic ketoacidosis at presentation in individuals with new-onset diabetes. However, at present, there is no hard evidence that SARS-CoV-2 induces T1DM on it's own accord. Long term follow-up of children and adults presenting with new-onset diabetes during this pandemic is required to fully understand the type of diabetes induced by COVID-19.

High aldosterone and cortisol levels in salt wasting congenital adrenal hyperplasia: a clinical conundrum.

BACKGROUND: Salt wasting syndrome (hyponatremia, hyperkalemia, dehydration, metabolic acidosis) in early infancy could be caused by either mineralocorticoid deficiency as in congenital adrenal hyperplasia (CAH) and adrenal insufficiency or mineralocorticoid resistance as in pseudohypoaldosteronism (PHA). In salt wasting CAH, serum aldosterone and cortisol levels are expected to be low. Cross reactivity between high levels of adrenal steroid precursors and aldosterone has recently been reported resulting in elevated aldosterone levels in CAH, leading to difficulty in differentiating between CAH and PHA. CASE PRESENTATION: We report four such cases of salt wasting CAH, where high aldosterone levels and high normal cortisol levels led to initial diagnostic confusion with PHA. Diagnosis of CAH was later established on the basis of significantly elevated adrenocorticotropic hormone (ACTH) stimulated 17-hydroxyprogesterone (17-OHP) values. CONCLUSIONS: By reporting these cases we draw attention to the possibility that high levels of adrenal steroid precursors can cross react with aldosterone and cortisol, and underscore the significance of ACTH stimulated 17-OHP values in differentiating CAH and PHA.

The changing clinical presentation of hypertrophic pyloric stenosis: the experience of a large, tertiary care pediatric hospital.

The authors reviewed the clinical and laboratory data from cases of hypertrophic pyloric stenosis (HPS) diagnosed at their institution from 2006 to 2008. They assessed and compared presentation of patients with HPS over time at their institution. A total of 118 patients were included in this study. An "olive" was palpated in only 13.6% of cases. This is in contrast to older studies, where more than 50% of the patients were reported to have a palpable "olive" depending on when the study was conducted. In patients from this institution, hypochloremia was present in 23% and alkalosis in 14.4%, which are less frequent than the incidence of these abnormalities in older studies. There was a change in the additional "classical" symptoms, represented by the lower percentage of infants in whom an "olive" was palpated and the lower numbers of patients with severe electrolyte imbalances. The reason for this change appears to be the frequent use of ultrasound.