Background
Intestinal malrotation and particularly volvulus are potentially devastating conditions. Upper gastrointestinal (UGI) contrast studies have been considered the gold standard for diagnosis. ...However the use of ultrasonography (US) has been increasingly described. We describe a method for delineating the duodenal anatomy with US as a means to exclude malrotation.
Objective
To report our experience using US to assess intestinal rotation.
Materials and methods
We conducted a retrospective audit of US scans performed at a tertiary referral centre to exclude malrotation for paediatric surgery between 2008 and 2011.
Results
One hundred thirty-nine infants were included, of whom 114 had a normal US scan. Of the 114, nine had subsequent upper gastrointestinal contrast studies that confirmed the initial results; there were no false-negatives. There were abnormal US scans in four infants associated with midgut volvulus and malrotation; there were no false-positives. The other 21 US scans were equivocal, and 11 of these had a confirmatory UGI contrast study; only one required surgery to correct malrotation.
Conclusion
US has been a safe and effective tool in the assessment of intestinal rotation at our institution. The main advantages of US imaging are its lack of ionising radiation and its rapid and accurate diagnosis of volvulus.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, VSZLJ, ZAGLJ
Objective To compare aortic intima media thickness (aIMT) to carotid intima media thickness (cIMT) as a marker of early atherosclerosis in children with type 1 diabetes mellitus and to examine the ...associations of aIMT to known cardiovascular risk factors. Study design 66 children with type 1 diabetes mellitus (age, 14.1 ± 2.5 years; 37 male) and 32 healthy control subjects (age, 14.2 ± 3 years; 15 male) underwent assessment of vascular structure (cIMT and aIMT) and vascular function (flow mediated dilatation FMD and glyceryl trinitrate induced dilatation GTN). Fasting blood tests were taken to measure levels of hemoglobin A1c, high sensitive C reactive protein, total homocyst(e)ine, serum folate, red cell folate, and lipids. Results aIMT, but not cIMT, was significantly greater in the children with type 1 diabetes mellitus than in control subjects ( P < .001). In children with type 1 diabetes mellitus, aIMT correlated with glycosylated hemoglobin (r = 0.31, P = .01) and was independently associated with age (β = 0.38, P = .001) and low-density lipoprotein cholesterol level (β = 0.38, P = .001). Vascular function (GTN) was worse in children with type 1 diabetes mellitus who had an aIMT >95th percentile, as defined with the control subjects. Conclusions aIMT is an earlier marker than cIMT of preclinical atherosclerosis in children with type 1 diabetes mellitus and relates to known cardiovascular risk factors and metabolic control.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Context: Endothelial and smooth muscle dysfunction are critical precursors of atherosclerosis. These can be detected in children at risk of cardiovascular disease.
Objective: The objective of this ...study is to evaluate endothelial and smooth muscle function and their determinants using flow-mediated dilatation (FMD) and glyceryl trinitrate-mediated dilatation (GTN) in obese, nonobese, and type 1 diabetes mellitus (T1DM) children.
Design: This is a cross-sectional study.
Subjects: The study subjects were 270 children 140 males, mean age 13.7 (2.8) yr including 58 obese, 53 nonobese, and 159 T1DM children.
Measurements: Vascular function (FMD and GTN), body mass index (BMI) z-score, blood pressure, glucose, glycosylated hemoglobin, lipids, folate, homocysteine, and high sensitive C-reactive protein were measured.
Results: FMD and GTN were significantly lower in obese and T1DM compared with nonobese subjects (P < 0.001, P < 0.001). FMD and GTN were similarly reduced in obese and T1DM subjects (P = 0.22, P = 0.28). In all nondiabetic subjects (n = 111), both FMD and GTN were significantly and independently related to BMI z-score (r = −0.28, P = 0.003, β = −0.36, P < 0.001) and weight z-score (β = −0.31, P = 0.002; r = −0.52, P < 0.001). FMD related independently to total cholesterol (β = −0.22, P = 0.02). GTN related independently to vessel diameter (β = −0.49, P < 0.001). GTN related to glucose within the normal range (r = −0.34, P = 0.001).
Conclusions: Children with obesity and T1DM have a similar degree of vascular dysfunction. BMI and weight adjusted for age and sex relate to endothelial and smooth muscle function in nonobese and obese children. Glucose relates to smooth muscle function in nonobese nondiabetic children. This suggests a continuum effect of BMI and glucose within the normal range on vascular function in childhood.
Highlights • Ultrasound can be used effectively to visualise location of vaccine deposition. • 60° or 90° angle of injection resulted in an IM vaccination for most individuals. • Individuals with a ...BMI > 25 were less likely to receive IM vaccinations. • A 25 mm needle may not be sufficient for IM vaccination in obese individuals.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Objective To determine the effect of polymorphisms in NOS3 and folate pathway enzymes on vascular function and folate status and endothelial response to folate in children with diabetes or obesity. ...Study design A total of 244 subjects (age 13.8 ± 2.8 years, 125 males) were studied for NOS3 and/or folate pathway polymorphisms using polymerase chain reaction/restriction fragment length polymorphism, including at baseline: 139 with type 1 diabetes; 58 with obesity; and 47 controls. The effect of NOS3 genotype on endothelial response to folate (5 mg) was assessed in 85 subjects with diabetes and 28 obese subjects who received active treatment during intervention trials. Vascular function (flow-mediated dilatation FMD and glyceryl trinitrate-mediated dilatation), clinical, and biochemical measurements were assessed at baseline and 8 weeks in folate intervention studies. Results Folate pathway enzyme and NOS3 polymorphisms did not significantly affect baseline vascular function. The polymorphism in intron 4 of endothelial nitric oxide synthase altered endothelial response to folate significantly: in subjects with diabetes FMD improved by 6.4 ± 5% (insertion carriers) vs 2.3 ± 6.6% (deletion carriers), P = .01; in obese subjects FMD improved by 1.8 ± 5.4% (insertion carriers) and deteriorated by −3.2 ± 7.2% (deletion carriers), P = .05. More subjects carrying the insertion normalized FMD after folate supplementation (insertion 64% vs deletion 28%, χ2 = 10.14, P = .001). Conclusions A NOS3 polymorphism predicts endothelial response to folate in children with diabetes or obesity, with implications for vascular risk and folate intervention studies.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Advances in ultrasound technology and development of higher frequency transducers have enabled ultrasound to have a greater role in the evaluation of stomach pathology in children.1 Since Teele and ...Smith first described the use of ultrasound in the diagnosis of hypertrophic pyloric stenosis (HPS) in five infants in 1977, ultrasound has been the examination of choice for diagnosis of HPS and in most institutions has completely replaced fluoroscopy for this purpose.2 The obvious advantage of using ultrasound is the avoidance of ionising radiation. Another advantage of ultrasound is its ability to provide valuable information about the stomach wall and surrounding structures. It is important to recognise the many sonographic appearances of the normal stomach so that they are not interpreted as some sort of pathology. The principal aim of this article is to describe the normal and pathologic appearances of the neonatal stomach and potential interpretation pitfalls. Sonographic technique as performed in our institution is also briefly described.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SBCE, SBMB, UL, UM, UPUK, VSZLJ
Objective To evaluate the lowest effective dose-response of folic acid on endothelial function in children with type 1 diabetes. Study design A randomized, double-blind, crossover, placebo-controlled ...trial was conducted in 20 children with type 1 diabetes (age range 10-18 years) after mandatory folate fortification in Australia. Each child received orally 4 interventions (1 per month)—3 folic acid doses (0.5, 2, and 5 mg) and 1 placebo dose—in random order. The primary outcome was 2-hour postintervention change in endothelial function measured with flow-mediated dilatation (FMD). Thirty-five children with type 1 diabetes from our folic acid interventional trial before folate fortification were used for comparison. Results All children completed the study. There were no differences in baseline FMD or folate status between the visits. Folic acid supplementation increased serum folate ( P = .0001) and red cell folate ( P < .0001), but none of the doses improved FMD ( P = .96). Baseline serum folate and red cell folate levels and FMD and glyceryl trinitrate–mediated dilatation were significantly higher in these children compared with children from our trial before mandatory folate fortification ( P = .0001, .0001, .014, and .04, respectively). Conclusions Folate status and vascular function have improved in children with type 1 diabetes since the introduction of mandatory folate fortification, but the beneficial endothelial effects of additional folic acid are no longer present.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
OBJECTIVE:--Obese children have severe endothelial dysfunction as measured by flow-mediated dilation (FMD). We have shown that folic acid normalizes endothelial function in children with type 1 ...diabetes who have a similar degree of endothelial dysfunction but lower total plasma homocyst(e)ine (tHcy) and higher folate status. Our aim was to evaluate, for the first time, the effect of folate supplementation on endothelial dysfunction in obese children. RESEARCH DESIGN AND METHODS--A total of 53 obese subjects (26 male, mean ± SD age 13.3 ± 2.2 years, and BMI Z score 2.29 ± 0.25) participated in a randomized, double-blind, placebo-controlled, parallel trial of oral folic acid (5 mg/day) or placebo for 8 weeks. Before and after the intervention, we assessed endothelial function (FMD), smooth muscle function (glyceryl trinitrate-induced dilatation GTN), high-sensitivity C-reactive protein (hsCRP), tHcy, serum folate, red cell folate (RCF), and lipids. RESULTS:--There were no group differences at baseline. FMD did not change with the intervention (folic acid group pre- and postintervention: 6.42 ± 5.03 and 6.56 ± 4.79%, respectively, vs. placebo group: 5.17 ± 3.54 and 5.79 ± 4.26%, respectively; P = 0.6). Folate supplementation increased serum folate and RCF by 18.4 nmol/l (P < 0.001) and 240.1 nmol/l (P < 0.001), respectively, and decreased tHcy by 0.95 μmol/l (P = 0.008). The intervention did not change GTN, hsCRP, or lipids. CONCLUSIONS:--Folic acid supplementation does not improve endothelial function in obese children without diabetes despite increasing folate status and reducing tHcy. This is in contrast to the response to folate in children with type 1 diabetes.
Endothelial Dysfunction Relates to Folate Status in Children and Adolescents With Type 1 Diabetes
Esko J. Wiltshire 1 ,
Roger Gent 2 ,
Craig Hirte 3 ,
Alexia Pena 4 ,
David W. Thomas 5 6 and
Jennifer ...J. Couper 4 6
1 Department of Paediatrics, Wellington School of Medicine and Health Sciences, Wellington, New Zealand
2 Department of Ultrasonography, Women’s and Children’s Hospital, Adelaide, Australia
3 Public Health Research Unit, Women’s and Children’s Hospital, Adelaide, Australia
4 Department of Diabetes and Endocrinology, Women’s and Children’s Hospital, Adelaide, Australia
5 Department of Clinical Pathology, Women’s and Children’s Hospital, Adelaide, Australia
6 Department of Paediatrics, University of Adelaide, Adelaide, Australia
Abstract
Endothelial dysfunction occurs early in the development of vascular disease in diabetes. Total plasma homocyst(e)ine (tHcy)
is associated with endothelial dysfunction. We therefore aimed to assess endothelial function in children with type 1 diabetes
in relation to tHcy and its determinants. Endothelial function was assessed in 36 children with type 1 diabetes aged 13.7
± 2.2 years and 20 age- and sex-matched control subjects using ultrasound assessment of flow-mediated dilatation (FMD) and
glyceryl trinitrate (GTN)-dependent brachial artery responses. von Willebrand factor (vWF) and thrombomodulin, markers of
endothelial activation, were measured in 64 children with type 1 diabetes and 52 control subjects. Fasting glucose, tHcy,
serum and red cell folate, vitamin B12, HbA 1c , creatinine, and lipids were also measured. FMD (5.2 ± 4.7 vs. 9.1 ± 4.0%, P = 0.002) and the ratio of FMD:GTN-induced dilatation (0.22 ± 0.39 vs. 0.41 ± 0.29%, P = 0.008) were significantly lower in diabetic subjects, indicating endothelial dysfunction. In diabetic subjects, red cell
folate correlated independently with FMD (β = 0.42, P = 0.028) and the ratio of FMD:GTN-induced dilatation (β = 0.59, P < 0.001). Resting vessel diameter correlated independently with tHcy (β = −0.51, P < 0.001) and height (β = 0.65, P < 0.001). vWF correlated independently with HbA 1c (β = 0.38, P = 0.003), and thrombomodulin correlated independently with red cell folate (β = −0.38, P = 0.005), tHcy (β = −0.37, P = 0.004), diastolic blood pressure (β = −0.28, P = 0.025), and creatinine clearance (β = 0.26, P = 0.033). Children with type 1 diabetes have early endothelial dysfunction. Better folate status is associated with better
endothelial function, as measured by higher FMD, higher FMD:GTN ratio, and lower thrombomodulin. Folate may therefore protect
against endothelial dysfunction in children with diabetes.
Footnotes
Address correspondence and reprint requests to Esko J. Wiltshire, Department of Paediatrics, Wellington School of Medicine
and Health Sciences, P.O. Box 7343, Wellington South, New Zealand. E-mail: esko{at}wnmeds.ac.nz .
Received for publication 3 January 2002 and accepted in revised form 12 April 2002.
CV, coefficient of variation; FMD, flow-mediated dilatation; GFR, glomerular filtration rate; GTN, glyceryl trinitrate; Lp(a),
lipoprotein (a); tHcy, total plasma homocyst(e)ine; vWF, von Willebrand factor.
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