Henry J. Rohrs

Antenatal Diagnosis and Treatment of a Dyshormonogenetic Fetal Goiter

Received June 18, 2008, from the Department of Obstetrics and Gynecology, Division of MaternalFetal Medicine (K.A.M.-L., A.C.C., D.R.), and Department of Pediatric Endocrinology (H.J.R., J.H.S.), University of Florida College of Medicine, Gainesville, Florida USA. Revision requested July 14, 2008. Revised manuscript accepted for publication August 4, 2008. Address correspondence to Kathleen A. MayorLynn, MD, Department of Obstetrics and Gynecology, University of Florida College of Medicine, 1600 SW Archer Rd, Box 100294, Gainesville, FL 32610-0294 USA. E-mail: mayorlyn@obgyn.ufl.edu Abbreviations TSH, thyroid-stimulating hormone Case Report

Disparities in Social Support Systems for Youths With Type 1 Diabetes

IN BRIEF Low socioeconomic status (SES) is consistently identified as a major risk factor for poor health outcomes in youths with type 1 diabetes, yet little is known about the social factors that yield such disparities. This study used survey research to examine the role of SES by focusing on differential resourcing in social support systems for youths with type 1 diabetes and their parents/caregivers. We identified significant inequalities in social support systems and found that parents from lower-income households engage in few coping activities and rarely identify a primary care provider as the main point of contact when facing a diabetes-related problem. Our findings underscore the need to better connect low SES families to diabetes-specific professional resourcing and to raise awareness about the importance of extracurricular activities as a form of social support for youths.

Using photography as a method to explore adolescent challenges and resilience in type 1 diabetes.

Patient-centered approaches to disease management are consistently recognized as valuable tools for improving health outcomes, yet studies are rarely designed to elicit adolescent perspectives. This study sought to better understand the perspectives of youths with type 1 diabetes according to key demographic variables. We conducted an exploratory study through which 40 youths were provided with disposable cameras and prompted to take five photographs each that captured what diabetes meant to them and to provide narratives to accompany their photo choices. Demographic variables examined included sex, age, disease duration, socioeconomic status (SES), race, and glycemic control (A1C). Content analysis was used for photos and open-ended responses to assign photo index scores, which were then analyzed by demographic variables using Mann-Whitney U tests for statistical significance. Analysis of photos/narratives (n = 202) revealed five main types of representations depicted by at least 50% of the young people. “Challenge” photos included diabetes supplies as tethering, food as a source of frustration, and the body as a territory for disease encroachment. “Resilience” photos included coping mechanisms and symbols of resistance. Overall, these representations were consistent across demographic categories with two exceptions. Males took more food depictions than females (P <0.005) and had fewer coping depictions (P <0.05). Youths from more affluent households were more likely to take photos of resistance (P <0.05). The use of photo index scores expands previous studies using photography by comparing demographic variation within a sample. Our findings provide insight into coping strategies and indicate that SES may provide an advantage for affluent youths in meeting diabetes-specific challenges.

Thyroid storm following radioactive iodine (RAI) therapy for pediatric graves disease

Patient: Female, 11 Final Diagnosis: Thyroid storm Symptoms: Diarrhea • tachycardia • tachypnea • tremor • wheezing Medication: — Clinical Procedure: — Specialty: — Objective: Rare disease Background: A growing number of pediatric endocrinologists treat Graves disease with radioactive iodine (RAI) therapy due to the typically definitive nature of I-131 therapy. Given the published benefits and perceived low risks of RAI when compared to surgery or long-term anti-thyroid medication, the trend towards therapy with RAI is likely to continue. Nevertheless, RAI is not without significant risk. Case Report: An 11-year-old girl with newly diagnosed Graves disease received RAI for definitive treatment of her hyperthyroidism. Within 24 hours of receiving I-131, she developed increasing sleepiness and eventually became unresponsive. Upon arrival at the emergency department she had a tonic-clonic seizure and was diagnosed with thyroid storm. Despite best efforts to manage her hyperthyroidism, she suffered a stroke of the left cerebral hemisphere that left her with persistent neurological deficits. Conclusions: Although thyroid storm after thyroid ablation is rare, the significant morbidity and potential mortality of pediatric thyroid storm warrant further studies to determine if children with markedly elevated thyroid hormone concentrations at diagnosis should receive prolonged pretreatment with anti-thyroid drugs. While such an approach may reduce the efficacy of I-131 ablation, it can also reduce and hopefully eliminate the risk of post-ablative thyroid storm.

Tanner Stage 4 Breast Development in Adults: Forensic Implications

BACKGROUND AND OBJECTIVE: Forensic testimony in alleged child pornography cases commonly asserts that Tanner stage (TS) 4 breast development, characterized by secondary mounding of the areola that is obliterated in TS 5, is evidence of age <18 years. Clinical experience does not support this notion, but there are no relevant studies. We sought to estimate how frequently TS 4 might be interpreted from nonclinical images by individual forensic experts. METHOD: Published images of 547 adult women were independently examined by the authors and classified as having TS 4 or TS 5 breast development. RESULTS: There was concordance among all 4 of the examiners for 17 of the images, agreement of 3 of the examiners on another 36 images, of 2 examiners on 39 images, and 53 images were designated TS 4 by only 1 examiner, for a total of 153 (26.5%) images that could have been considered by a single forensic expert to represent TS 4. CONCLUSIONS: A substantial number of adults have persistent TS 4 breast development. This observation, and the frequent difficulty distinguishing TS 4 from TS 5, even by adolescent development specialists, especially in nonclinical images, renders testimony based on this distinction invalid. Without clinical relevance for distinguishing these advanced stages of breast development, they should both be considered indicative of full maturation. Testimony based on this inappropriate test of maturity should no longer be allowed.

Puppy love, adolescence, and chronic illness: the importance of pets for youth with type 1 diabetes

The benefits of animal-companion ties to well-being are consistently documented, yet few studies use patient-centered methodologies to examine how youth living with chronic illnesses rely on domestic pets for support. Youth with type 1 diabetes (T1D) aged 12 to 19 years (N=40) completed surveys involving a prompt to take five photos of “what diabetes means to you,” with an accompanying narrative. Content analysis was conducted for photos/narratives and numeric variables analyzed including socio-economic status (SES: measured by total household income and years of parental education) and HbA1C. More than half of the youth participants took pictures of coping mechanisms, including pictures of their pets. In fact, pictures of pets outnumbered pictures of people three to one. Pet depictions were captured by youth from all SES levels. Youth with T1D identify pets as an important source of support. More research is needed to understand how pets may offset disease burden for youth with T1D.

Framing Food and Diabetes Exploring the Perspectives of Youth With Type 1 Diabetes Through Photography

To better elucidate the experiences and perspectives of youth and families living with type 1 diabetes mellitus (T1D), we conducted survey research with 40 youth and their parents/caregivers. Youth were provided with disposable cameras and prompted to take 5 pictures that captured what diabetes meant to them accompanied by narratives explaining their photo choices. Demographic data were collected to examine possible variations in photos/representations, including gender, age, disease duration, socioeconomic status, race, and glycemic control (measured with glycated hemoglobin). Qualitative content analysis was conducted for photos and open-ended survey responses. Quantitative analysis included a comparison of means through Mann-Whitney U tests for statistical significance. In all, 68% of youth took at least 1 photograph of food, and 90% of parents/caregivers addressed food-specific issues, demonstrating 3 broad categories of representation: food as off limits, food as laborious, and food as exclusionary. ...

Erratum: Disparities in Social Support for Youths With Type 1 Diabetes. Clinical Diabetes 2015;33:62–69

[This corrects the article on p. 62 in vol. 33, PMID: 25897185.].

P42.04: Antenatal diagnosis and treatment of dyshormonogenetic fetal goiter

Purpose: In up to 20–30% of myelomeningocele (MMC) cases corrected in utero, fetal skin closure cannot be accomplished due to the size of the defect (myeloschisis). Our aim was to develop a new technique to correct myeloschisis. Method: A skin defect at lumbar fetal region (4 × 3cm) was created at 100 days’ gestation in 7 ovine fetuses, and was correct applying a new endoscopic ‘‘gasless’’ technique (Pedreira et al., 2008). The skin edges were approximated under tension (but not closed) using a continuous running suture and an interposed bovine tendon derived dermal matrix (Integra USA) (3 × 2 cm). This was placed above a biosynthetic cellulose material (Nexfill Brazil) to be used as duramater substitute. At term, fetuses where harvested and the wound was analysed both macro and microscopically. Results: A total of 7 fetuses were operated, in the first two cases we needed to change to an open surgery approach and the other 5 where successfully closed endoscopically. All fetuses survived to the end of the procedure. One maternal death (infection related) occurred the day after the procedure. Two pre-term deliveries occurred days 3 and 4 after the procedure. At birth matrix adherence to the wound edges was observed in all cases. Pathological analysis performed at 3, 4, 15, 21, 25 and 35 days after surgery showed the expected normal fibroblast migration into the dermal matrix and its integration with the adjacent fetal dermis. Conclusions: Dermal matrix can be used as an alternative in cases where primary skin closure in spina bifida cannot be accomplished.