Lino Piotto

Folate and vitamin B6 rapidly normalize endothelial dysfunction in children with type 1 diabetes mellitus.

BACKGROUND. Endothelial dysfunction, a precursor of vascular disease, begins early in type 1 diabetes mellitus and is associated with folate status. METHODS. A randomized, double-blind, placebo-controlled study of folate (5 mg daily) and vitamin B6 (100 mg daily) in 124 children with type 1 diabetes determined the immediate and 8-week effects of these vitamins, alone and in combination, on endothelial function. Endothelial function, assessed as flow-mediated dilation and glyceryltrinitrate-induced dilation with high-resolution ultrasound of the brachial artery, was measured at baseline, at 2 and 4 hours after the first dose (n = 35), and at 4 and 8 weeks of treatment (n = 122). RESULTS. Flow-mediated dilation normalized in all treatment groups. From baseline to 8 weeks, flow-mediated dilation improved with folate from 2.6% ± 4.3% (mean ± SD) to 9.7% ± 6.0%, with vitamin B6 from 3.5% ± 4.0% to 8.3% ± 4.2%, and with folate/vitamin B6 from 2.8% ± 3.5% to 10.5% ± 4.4%. This improvement in flow-mediated dilation occurred within 2 hours and was maintained at 8 weeks for each treatment. Flow-mediated dilation in the placebo group, and glyceryltrinitrate-induced dilation in all groups, did not change. Increases in serum folate, red cell folate, and serum vitamin B6 levels related to increases in flow-mediated dilation. Improvement in flow-mediated dilation was independent of changes in total plasma homocyst(e)ine, glucose, hemoglobin A1c, and high-sensitivity C-reactive protein levels. Baseline red cell folate levels and baseline diastolic blood pressure were related inversely to improvement in flow-mediated dilation. Serum triglyceride and low-density lipoprotein cholesterol inversely related to baseline flow-mediated dilation. CONCLUSIONS. High-dose folate and vitamin B6 normalized endothelial dysfunction in children with type 1 diabetes. This effect was maintained over 8 weeks, with no additional benefit from combination treatment.

Ultrasound examination of extensive limb swelling reactions after diphtheria-tetanus-acellular pertussis or reduced-antigen content diphtheria-tetanus-acellular pertussis immunization in preschool-aged children.

OBJECTIVE. The aim of this study was to determine the site, extent, and resolution of tissue involvement when extensive limb swelling occurred in the injected limb for children who received diphtheria-tetanus-acellular pertussis or reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine at 4 to 6 years of age. METHODS. Children who had experienced an injection site reaction at 18 months of age were assigned randomly to receive an intramuscular injection of either reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine or diphtheria-tetanus-acellular pertussis vaccine between 4 and 6 years of age. Children who developed extensive limb swelling were recruited for assessment by clinical examination; ultrasound studies of the affected and opposite (control) arms were performed 24 to 48 hours after immunization and 48 to 96 hours later. RESULTS. Twelve children with extensive limb swelling were enrolled in the study. Ultrasound examinations demonstrated swelling of both the subcutaneous and muscle layers of the vaccinated arm. Ultrasound assessment showed that the swelling exceeded the clinical measurements of skin redness and swelling. Subcutaneous and muscle tissues expanded to 281% and 111% of the tissue thicknesses of the control arm, respectively. Repeat ultrasound examinations after 48 to 96 hours showed considerable resolution of muscle swelling, compared with subcutaneous tissue swelling. There was no significant difference in the extent of swelling detected between children who received diphtheria-tetanus-acellular pertussis vaccine and those who received reduced-antigen content diphtheria-tetanus-acellular pertussis vaccine. CONCLUSION. Extensive limb swelling reactions after diphtheria-tetanus-acellular pertussis or reduced-antigen content booster immunizations involved swelling of subcutaneous and muscle tissues with swelling and duration more marked in subcutaneous tissue.

Hs-CRP is associated with weight, BMI, and female sex but not with endothelial function in children with type 1 diabetes.

Background:  Atherosclerosis is an inflammatory process, and high‐sensitivity C‐reactive protein (Hs‐CRP), a marker of inflammation, predicts cardiovascular events in adults. Vascular endothelial and smooth muscle dysfunction, measurable precursors of atherosclerosis, begin in childhood. Therefore, we sought to determine if Hs‐CRP is associated with vascular endothelial and smooth muscle dysfunction in children with type 1 diabetes mellitus (T1DM) and healthy control subjects.

Longitudinal study of normal hip development by ultrasound.

In the management of a newborns hips, ultrasonography has proven to be useful. The progression of measurements at different ages in normal hips has not been thoroughly investigated. The purpose of this prospective study was to assess the longitudinal development of clinically stable hips. Forty newborns (80 hips) were assessed by ultrasonography at birth and at 6 and 12 weeks of age. Femoral head coverage (FHC), alpha angles, and beta angles were measured. The results showed a significant change in values between the three points in time for all measurements (P < 0.001). The mean FHC progressed from 58.4% to 65.6% to 69.3%, the mean alpha angle from 70.2° to 76.8° to 80.3°, and the mean beta angle from 52.1° to 45.7° to 42.9°. In clinically stable hips, the FHC and alpha and beta angles change significantly over time; therefore, it is important to consider the childs age when interpreting ultrasound images.

Congenital cystic dysplasia of the rete testis

Abstract. Cystic dysplasia of the rete testis (the network of straight seminiferous tubules within the mediastinum testis leading to the efferent ductules) is a rare congenital anomaly. There are only 15 cases reported in the literature to date and only one report of the US findings [1–5]. This report highlights the characteristic appearance of the lesion on ultrasound examination and its association with renal abnormalities in two patients.

Randomized trial using ultrasound to assess intramuscular vaccination at a 60° or 90° needle angle.

OBJECTIVE Globally, recommendations differ on the ideal angle of needle insertion to ensure vaccinate deposition in muscle for optimal safety and immunogenicity. This study aimed to compare the level of vaccinate deposition during vaccination, using two different needle angles (60° and 90°), in young children, adolescents and adults. METHODS In this randomized cross-over study, two doses of a licensed hepatitis vaccine, were administered to study participants, at a 60° or 90° angle using a fixed template. Ultrasonography was performed with a Philips iu22 ultrasound system. Real time clips and hard copies of images were recorded showing the injection and level of deposition of the vaccinate. Reactogenicity at the site of administration was assessed by participants/parents. RESULTS Nineteen participants were enrolled including children, adolescents and adults. Of the total 38 injections performed, 29 (76%) were confirmed by ultrasound as intramuscular (IM), 3 (8%) as not IM, and 6 (16%) unknown. For vaccinations visualised and administered at 60°, 87% (13/15) were intramuscular vs 94.1% (16/17) for those administered at 90°. A body mass index (BMI)≤25 was associated with a higher likelihood of IM injection compared to BMI>25 (p=0.038). There were no differences in reactogenicity for either 60° or 90° angle of administration. CONCLUSION For the majority of vaccinees, a 60-90° angle of vaccine administration is appropriate for IM deposition of vaccinate. The likelihood of intramuscular deposition is reduced for individuals with a BMI>25. The increasing rates of obesity globally highlight the importance of tailoring vaccination procedures accordingly.

Ultrasound features of omental infarction in children

At our hospital, abdominal ultrasound is routinely used to examine children with lower abdominal pain who are suspected of having acute appendicitis. When the ultrasound examination reveals a normal appendix, we routinely extend the study in an attempt to identify another cause for the child’s presentation. This includes visualisation of the distal ileum, ascending colon, paracolic area, central abdomen and gynaecological structures in adolescent girls. Alternative pathologies that we have diagnosed on an appendix scan have been mesenteric adenitis, inflammatory bowel disease, intussusception, epiploic appendagitis, pancreatitis, Meckel’s diverticulitis, midgut malrotation, volvulus, pyelonephritis and obstructive renal disease. In adolescent girls, gynaecological disturbances such as ovarian torsion, ovarian tumours, haemorrhagic ovarian cysts, pelvic inflammatory disease and pregnancy are other differential diagnoses that need to be excluded. A relatively rare cause of abdominal pain in children is omental infarction, a painful condition that often mimics appendicitis. An omental infarction occurs when the blood supply to a section of omentum is compromised through torsion, venous congestion or thrombosis. The exact aetiology is not fully understood, but as a result, part of the omentum becomes necrotic. Although uncommon, an omental infarct usually has characteristic ultrasound appearances and can be reliably diagnosed with ultrasound when sonographers are aware of the appearances of normal omentum. Normal omentum is not always seen, but sometimes it may be visualised in the right iliac fossa, more commonly in overweight patients. It is coarsely homogeneous, compressible with transducer pressure, has sparse but even blood flow and displays visceral slide with respiration (Figure 1).

The value of ultrasound in the investigation of ingested foreign bodies in children: Ingested foreign bodies in children

Although the use of radiography to locate and track radiopaque ingested foreign bodies in children is very sensitive, it may not be very specific. Using ultrasound, we can often not only detect the foreign body but be more precise in its location and movement.

Ectopic thymus: Diagnosis by ultrasound

Ultrasound is routinely used for the investigation of anterior neck masses or swelling in children. These masses are often asymptomatic, ill-defined, and vary in consistency from soft to hard when palpated. There are many pathologies that may present as a mass, with the most common being lymphadenopathy, branchial cleft cysts, fibromatosis colli and lymphangioma. Ectopic thymic tissue is an uncommon entity that needs to be considered in these patients and can be reliably diagnosed with ultrasound. The thymus gland is a T-cell-producing lymphoid organ in the anterior mediastinum that consists of two lobes usually touching each other in the midline. Relative to body size, the thymus is disproportionately large in the neonatal period. It continues to grow until maximum size is reached at puberty. Even when large, thymic tissue is soft and conforms to surrounding structures such as blood vessels, showing no mass effect. A normal thymus gland is hypoechoic to subcutaneous tissue but most commonly has an echotexture with bright speckles described as a ‘starry sky’ appearance (Figure 1).

Aggressive posterior retinopathy of prematurity: Aggressive posterior retinopathy of prematurity

Retinopathy of prematurity (ROP) is a potentially blinding vasoproliferative retinal disorder that occurs in premature infants born with immature retinal vasculature. Babies born at term, unlike premature neonates, have a fully vascularised retina and are not at risk of developing retinopathy of prematurity. The most rapidly progressing, virulent form of retinopathy is described as ‘aggressive posterior retinopathy of prematurity’ (AP-ROP). Ultrasound can evaluate the posterior segment in cases which are complicated by vitreous haemorrhage and aid when surgery is planned. This report discusses the clinical, sonographic and pathological features of this disease, which, to our knowledge, has not been published previously.