Michael B. Foster

Phthalate Exposure and Precocious Puberty in Females

OBJECTIVE To determine whether phthalate exposure is associated with precocious puberty in girls. STUDY DESIGN This was a multicenter cross-sectional study in which 28 girls with central precocious puberty (CPP) and 28 age- and race-matched prepubertal females were enrolled. Nine phthalate metabolites and creatinine were measured in spot urine samples from these 56 children. RESULTS Levels of 8 of the 9 phthalate metabolites were above the limit of detection (LOD) in all 56 subjects. Mono (2-ethylhexyl) phthalate (MEHP) was below the LOD in 25/56 samples (14 subjects with precocious puberty and 11 controls). No significant differences between the children with CPP and the controls in either absolute or creatinine-normalized concentrations of any of the 9 phthalate metabolites were measured. CONCLUSIONS Although phthalates may be associated with certain other toxicities in humans, our study suggests that their exposure is not associated with precocious puberty in female children.

The impact of health insurance coverage on pediatric diabetes management

AIMS To examine the association between health insurance coverage, insulin management plans, and their impact on diabetes control in a pediatric type 1 diabetes mellitus clinic population. METHODS Retrospective cohort design drawn from the medical records of the Pediatric Endocrinology Clinic at the University of Louisville, Kentucky. RESULTS Out of 701 patients, 223 had public insurance, and 478 had private insurance. 77% of publically insured used two or three injections per day vs. 40% private. Conversely, 58% of privately insured used a multiple daily injection (MDI) plan or insulin pump (vs. 21%). 84% of MDI patients had private insurance with 93% using insulin pens compared with 38% of publically insured. Mean HbA1c was 8.6% for privately insured vs. 9.8% public, p<0.0001. Privately insured MDI and pump patients had the lowest HbA1cs. CONCLUSIONS Insurance type had a significant effect on the insulin management plan used and was the most significant factor in overall diabetes control. Limitations on insulin pen use and number of glucose test strips may play a role in the decreased use of MDI/insulin pumps by publicly insured patients. Addressing factors related to insurance type, including availability of resources, could substantially improve diabetes control in those with public insurance.

Association of Hyperglycemia, Glucocorticoids, and Insulin Use with Morbidity and Mortality in the Pediatric Intensive Care Unit

Background: Studies of pediatric intensive care unit (PICU) patients have shown a significant association of morbidity and mortality with hyperglycemia. We retrospectively evaluated the degree of hyperglycemia as well as its correlation with glucocorticoid and insulin use and assessed its association with hospital length of stay (LOS) and mortality. This study preceded the initiation of a standard glycemic control protocol. Methods: We examined medical records at Kosair Childrens Hospital for all PICU admissions from 2008 of patients without diabetes mellitus. Critical illness hyperglycemia (CIH) was defined by having three or more peak glucose values greater than thresholds of 110, 140, 180, and 200 mg/dl. These patients were evaluated for glucocorticoid, insulin use, and outcome measures. Results: We evaluated the eligible 1173 admissions, where 10.5% of these patients reached the highest threshold (200 mg/dl) of CIH. Glucocorticoids were used in 43% of these patients, with dexamethasone being the most common (58%). There was a significant correlation between glucocorticoids and higher peak glucose values, where 81% of the patients who were above the 200 mg/dl cutoff level were treated with glucocorticoids. Only 36.8% in that group were also treated with insulin. Patients at the 200 mg/dl cutoff had the highest median PICU and total hospital length of stays (4 and 10 days, respectfully). Mortality was associated with increasing glucose levels, reaching 18.7% among patients above the 200 mg/dl cutoff. Conclusion: Hyperglycemia was prevalent in the PICU and was associated with increased morbidity, as characterized by increased LOS and increased mortality. Glucocorticoid use was prevalent among patients exhibiting hyperglycemia. Insulin use was uncommon.

Hyperthyroidism presenting with hyperglycemia in an adolescent female.

Abstract A 15-year-old female presented to a pediatric emergency department with glycosuria, ketonuria, and hyperglycemia and was admitted with a presumed diagnosis of diabetes mellitus. The patient required no insulin therapy and only minor dietary modification to maintain euglycemia. Clinical examination and laboratory findings revealed a primary diagnosis of Graves’ hyperthyroidism with associated impaired glucose tolerance. Here, we review the mechanisms of thyrotoxicosis resulting in impaired glucose metabolism.

The impact of insurance coverage and the family on pediatric diabetes management

The impact of family composition on glycemic control in children with type 1 diabetes remains unclear. We sought to evaluate the relationship between health insurance coverage, family composition, and insulin management, and assess their impact on glycemic control in a pediatric type 1 diabetes population.

Hashimoto's encephalopathy: a rare pediatric brain disease.

Abstract We report a 9-year-old female who presented with new onset intractable seizure activity followed by a prolonged encephalopathic state. After ruling out common etiologies, Hashimoto’s encephalopathy (HE) was considered, and antibody levels to thyroid peroxidase and thyroglobulin were both markedly elevated in her serum. She was euthyroid at the time of presentation. Upon treatment with high dose methylprednisolone, the patient demonstrated a significant improvement in her encephalopathy. The diagnosis of HE requires strong clinical suspicion with evidence of antithyroid antibodies, as well as an encephalopathy not explained by another etiology. While well documented in the adult literature, only a handful of pediatric cases have been described to date. Patients with HE have a nearly universal response to high dose glucocorticoids. HE should be considered in the differential diagnosis of any patient, adult or pediatric, who displays prolonged, unexplainable encephalopathy.

Lateral pediatric ectopic thyroid

We present a case of a left‐sided neck mass in an 8‐year‐old female that proved to be ectopic thyroid tissue. After excision, this patient continues to do well and is euthyroid without recurrence after 8‐year follow‐up. This is a very rare anomaly in a child, especially in conjunction with a normally located thyroid that is functional. We reviewed the literature of displaced ectopic thyroid tissue. Laryngoscope, 2012

Case 2: Generalized Anasarca in 15-year-old Girl With Type 1 Diabetes Mellitus.

1. William T. Myers, MD* 2. Kupper A. Wintergerst, MD* 3. Suzanne E. Kingery, MD* 4. Michael B. Foster, MD* 1. *Department of Pediatrics University of Louisville, Louisville, KY. A 15-year-old girl with a history of poorly controlled type 1 diabetes mellitus presents to the emergency department with a 4-day history of generalized swelling. She initially noticed bilateral lower extremity edema and right-sided facial swelling that subsequently progressed to include both sides of her face, her abdomen, pelvis, and labia. She also reports a 9-lb (3.54-kg) weight gain. She denies pain, fever, vomiting, loose stools, chest pain, or shortness of breath. Current medications include insulin glargine and insulin aspart. She has only become compliant with this therapy in the past week. On physical examination, the teen’s weight is 51 kg (41st percentile), height is 155 cm (13th percentile), and body mass index is 20.1 (54th percentile). Her vital signs are within normal limits. She is in no acute distress. She has mild facial edema, moderate abdominal distention without …

Correlation Between Glycemic Control and Menstruation in Diabetic Adolescents

OBJECTIVE To determine if a correlation exists between the degree of glycemic control in insulin-dependent diabetic adolescents and menstrual regulation. STUDY DESIGN A retrospective review of charts of diabetic girls aged 10-18 was performed. Office visits were scheduled every three to six months, at which time pubertal development, menstrual function, growth and diabetic control, including hemoglobin (Hgb) A1C, and complications were assessed. Forty-six patients were eligible for data analysis. Descriptive and inferential statistics, including chi 2 and Student t tests, were applied. RESULTS Thirty-seven (81%) patients had regular menstrual cycles, and nine (19%) had menstrual disturbances, including secondary amenorrhea (one), oligomenorrhea (seven) and primary amenorrhea followed by oligomenorrhea (one). There were two pregnancies. Six patients used hormonal contraception but none for menstrual regulation. There was a statistically significant difference (P < .05) in mean Hgb A1C concentrations between those with menstrual disturbances (11.4) and those with regular menses (9.7). As Hgb A1C values increased, the percent of patients with menstrual disturbances increased, becoming statistically significant when the Hgb A1C was > 10 (odds ratio 7.3, 95% confidence interval 1.5-35.6). There was no difference (P > .05) between the two groups with respect to age at menarche (156 vs. 152 months), age at onset of diabetes (144 vs. 108 months) and interval between diabetes onset and menarche (54 vs. 41 months). There were no patients in either group with diabetic retinopathy or nephropathy. Four patients were hypertensive, but there was no statistically significant difference (P > .05) between groups. CONCLUSION Tighter glycemic control, as measured by Hgb A1C concentrations, corresponded to improved menstrual regulation in adolescent insulin-dependent diabetics.

Genetics of type 1 diabetes: Compounding effect of Dr3 and Dr4 alleles on diabetic risk in HLA identical sibs of affected children

Abstract A retrospective and prospective analysis of 43 HLA-identical sib pairs with at least one sib affected with type 1 diabetes mellitus (IDDM) revealed that 46% were heterozygous for both DR3 and DR4 alleles (DR3,4). Nineteen percent possessed only DR3, 30% only DR4, and 5% neither of these diabetes-associated alleles. Ninety percent (9 of 10) of pairs in which both sibs were diabetic (concordant) were DR3,4 vs. 33% (11 of 33) DR3,4 in nonconcordant pairs (p