Hypoglycemia in diabetes among children and adolescents

Hypoglycemia is one of the most common early complications in insulindependent diabetes mellitus (IDDM). Hypoglycemia in children may be considered a risk factor for brain damage and later intellectual impairment, and carries with it a high degree of child and parental anxiety. Recent studieshave shown that in IDDM patients, and especially in those on intensive therapy,there is a defect in glucose counter-regulation, increased frequency of hypoglycemic episodes, loss of hypoglycemic awareness and responsiveness. Autonomie neuro-pathy, glucagon deficiency and low catecholamine responsewere implied in the pathogenesis of these disorders. In addition, uncontrolled IDDM patients show hypoglycemic symptoms at a higher blood glucose level. These recent observations may suggest that attempts to improve metabolic control may increase the risk of severe hypoglycemia. If so, some alterations in our therapeutic goals must be considered.     

Cardiac metastasis of liposarcoma

The authors describe a retroperitoneal liposarcoma with secondary involvement of the left ventricle. Therapy has been disappointing, and is guided by the nature of the primary tumor, previous therapy, extent of metastatic spread, and feasibility of cardiac resection. In selected patients whose primary tumor is well-controlled and progressing slowly, with no evidence of widespread disease, resection of the cardiac metastases can be performed when technically feasible.     

Acute limb ischemia due to malignant arterial embolism from a metastatic germ cell tumor

Arterial tumor embolization is a rare but serious complication of neoplastic disease. The majority of these tumors are associated with primary or secondary lung malignancies, originating from pulmonary vein metastasis or from an atrial mass. Malignant germ cell tumors primarily disseminate to the retroperitoneal lymph nodes and lung, and to the brain and liver later in the course of the disease. A germ cell tumor metastasis embolizing to the iliac-femoral arterial system has not yet been reported. We report a metastatic embolism in a patient with disseminated embryonal cell carcinoma causing acute limb ischemia, managed by surgical embolectomy. The sudden development of limb ischemia in a patient with a germ cell tumor should alert the physician to the possibility of tumor embolism. © 1995 Wiley-Liss, Inc.     

Cerebellar astrocytoma presenting as deterioration of handwriting in a child

Deterioration of handwriting in an 11-year-old boy over a 2 month period was found to be caused by a cerebellar astrocytoma. The clinical picture was characterised by a lack of the classic symptoms of increased intracranial pressure. The only positive neurological findings pointed to an isolated right cerebellar symptomatology expressed by mild intention tremor and decreased tone of the right hand.Progressive deterioration of handwriting can be an ominous sign and it should be known to all professionals, as a lack of awareness can cause delay in expert referral and diagnosis.     

Prenatal protein-energy malnutrition alters various biochemical components of the membranous bones in fetal rats

The effects of prenatal protein-energy malnutrition on the biochemical parameters of the membranous bone were studied using fetal rats. Timed pregnant rats were fed a protein-deficient diet as an experimental group from day 13 of gestation, whereas control dams were fed a normal protein diet. By day 15, radioactive Na2SO4 was injected. On day 22, all fetuses were delivered by cesarean section. The hexosamine content per milligram dry tissue, and the protein and hexosamine contents per guanidine-HCl extract were greater in the mandibles but less in the calvaria of the malnourished group than in those of the controls. Calcium content per gram dry tissue was lower in both bones of the malnourished group. 35S-sulfate uptake per milligram dry tissue or milligram proteoglycan was greater in the malnourished group than in the controls in both bones. The mandible in the malnourished group had less lower-weight molecular proteoglycan subunits in the dissociative condition. Protein-energy malnutrition affects the mandible and calvaria in different ways, although both bones originate from membranous bone. Insufficient degradation of proteoglycan could be the reason for the delay of mineralization in the malnourished bones.     

Pregnancy Outcome in Gestational Diabetes with Preconceptional Diabetes Counselling

One hundred and thirty-six women with known previous gestational diabetes and normal glucose tolerance between pregnancies attended a preconceptional clinic at least 2 months before conception, and were regularly consulted by a diabetological team. Evaluation consisted of oral glucose tolerance test (OGTT), mean blood glucose, glycosylated haemoglobin and management by self-blood-glucose monitoring (SBGM) and nutritional counselling. When these patients were compared to a group of 154 patients with gestational diabetes who attended our clinic at different stages of pregnancy, the former had improved glucose homeostasis whereas the latter had more frequent elevations of fasting and postprandial glucose levels throughout pregnancy. This group had also more maternal complications and higher Caesarean section rates. Congenital anomalies were 0.65% among offspring of nonattenders, while none occurred in those with preconceptional counselling. Macrosomia and hypoglycaemia were significant neonatal complications in infants of nonattending mothers. We concur with the recommendation that preconceptional counselling in gestational diabetics is required to improve glucose homeostasis throughout pregnancy, and that appropriate evaluation of glucose intolerance should be included as part of prospective family planning.     

Transsphenoidal surgery for Cushing's disease: endocrinological follow-up monitoring of 82 patients

OBJECTIVE: Transsphenoidal surgery is the preferred treatment modality for adrenocorticotropic hormone-secreting pituitary adenomas. In the past 2 decades, several institutions in the United States and Europe have reported remission rates of 70 to 85% after transsphenoidal surgery for treatment of Cushing's disease. We analyzed our postoperative results for a large cohort of patients with Cushing's disease. METHODS: Eighty-two patients with adrenocorticotropic hormone-secreting adenomas (79 microadenomas and 3 macroadenomas) underwent transsphenoidal surgery between 1990 and 2000. Seventy-seven patients were surgically treated for the first time, and 13 patients underwent reoperations (5 had undergone the first operation elsewhere) because of previous surgical failure (10 patients) or recurrence (3 patients). The mean postoperative follow-up period was 4.2 +/- 2.8 years. Biochemical remission was defined as postoperative normalization of elevated 24-hour urinary free cortisol secretion and suppression of morning cortisol levels with 1 mg of dexamethasone. RESULTS: Remission was achieved for 78% of all patients after one operation and for 62% of patients who underwent a second operation. The recurrence rate was 5%. Ten patients did not exhibit a visible tumor on magnetic resonance imaging scans, and the other patients were divided according to adenoma size (2-5 or 6-10 mm). Remission rates were similar for the three groups of patients (78-80%). Pituitary tumor stained for adrenocorticotropic hormone was detected in 78% of resected pituitary tissue specimens obtained from patients who achieved remission, compared with 53% from patients who experienced surgical failure (P = 0.06). CONCLUSION: Our series demonstrates the efficacy of transsphenoidal surgery for Cushing's disease resulting from pituitary microadenomas. Microadenoma size had no effect on the remission rate. Reoperations are indicated after initial surgical failures.