Patricia S. Simmons

Increased proteolysis. An effect of increases in plasma cortisol within the physiologic range.

Prolonged exposure to glucocorticoids in pharmacologic amounts results in muscle wasting, but whether changes in plasma cortisol within the physiologic range affect amino acid and protein metabolism in man has not been determined. To determine whether a physiologic increase in plasma cortisol increases proteolysis and the de novo synthesis of alanine, seven normal subjects were studied on two occasions during an 8-h infusion of either hydrocortisone sodium succinate (2 micrograms/kg X min) or saline. The rate of appearance (Ra) of leucine and alanine were estimated using [2H3]leucine and [2H3]alanine. In addition, the Ra of leucine nitrogen and the rate of transfer of leucine nitrogen to alanine were estimated using [15N]leucine. Plasma cortisol increased (10 +/- 1 to 42 +/- 4 micrograms/dl) during cortisol infusion and decreased (14 +/- 2 to 10 +/- 2 micrograms/dl) during saline infusion. No change was observed in plasma insulin, C-peptide, or glucagon during either saline or cortisol infusion. Plasma leucine concentration increased more (P less than 0.05) during cortisol infusion (120 +/- 1 to 203 +/- 21 microM) than saline (118 +/- 8 to 154 +/- 4 microM) as a result of a greater (P less than 0.01) increase in its Ra during cortisol infusion (1.47 +/- 0.08 to 1.81 +/- 0.08 mumol/kg X min for cortisol vs. 1.50 +/- 0.08 to 1.57 +/- 0.09 mumol/kg X min). Leucine nitrogen Ra increased (P less than 0.01) from 2.35 +/- 0.12 to 3.46 +/- 0.24 mumol/kg X min, but less so (P less than 0.05) during saline infusion (2.43 +/- 0.17 to 2.84 +/- 0.15 mumol/kg X min, P less than 0.01). Alanine Ra increased (P less than 0.05) during cortisol infusion but remained constant during saline infusion. During cortisol, but not during saline infusion, the rate and percentage of leucine nitrogen going to alanine increased (P less than 0.05). Thus, an increase in plasma cortisol within the physiologic range increases proteolysis and the de novo synthesis of alanine, a potential gluconeogenic substrate. Therefore, physiologic changes in plasma cortisol play a role in the regulation of whole body protein and amino acid metabolism in man.

Fibroadenomas in adolescence.

Purpose of review Fibroadenomas are the most common breast masses in adolescent women, therefore it is important that health providers understand their assessment and management. This review discusses an approach to investigation and management of fibroadenomas in adolescents. Recent findings Fibroadenomas are benign tumors which commonly present in late adolescence. They are classified according to their histology and size. Simple fibroadenomas are the most common type and usually present as smooth mobile masses up to 3 cm in diameter. Giant fibroadenomas are more uncommon but typically present in adolescence. Fibroadenomas associated with other soft-tissue masses should raise the possibility of an inherited syndrome. Assessment of breast masses in this age group generally involves clinical assessment through history and physical examination and, when imaging is needed, ultrasonography. As the incidence of primary breast malignancy is very low in this age group, core biopsy is not routinely recommended. Large or rapidly growing tumors, or those associated with suspicious features, warrant surgical excision. New minimally invasive excision techniques are being introduced which are associated with high initial success rates. Summary Whereas the vast majority of fibroadenomas in teenagers may be monitored with surveillance alone, new minimally invasive techniques may play an important role in the management of selected patients.

Breast carcinoma in young women

OBJECTIVE: To estimate the incidence of breast carcinoma and survival in patients younger than 25 years old, and to describe presenting clinical signs and symptoms of breast cancer in this age group. METHODS: A population-based descriptive study and case review in Olmsted County, Minnesota, was conducted using the resources of the Rochester Epidemiology Project. Participants were Olmsted County girls and women younger than 25 years old with histopathologically confirmed breast carcinoma diagnosed between 1935 and 2005. Nonresidents who presented to a medical facility within Olmsted County during this time period were included in some portions of the analysis. Main outcome measures were age-adjusted incidence, 5-year survival, and clinical presentation of breast carcinoma in girls and women younger than 25 years of age. RESULTS: With four breast carcinomas observed in Olmsted County residents over 1,201,539 person-years, the annual age-adjusted incidence of breast cancer in this population was 3.2 per million (95% confidence interval, 0.1–6.2). All four cancers occurred in the 20- to 24-year age group (age-specific incidence, 16.2 per million). Eight additional cases of breast carcinoma were identified in nonresidents. Delay in diagnosis was common. All had at least one feature worrisome for an aggressive neoplasm identified in their clinical history, on physical examination or by imaging. CONCLUSION: Breast carcinoma in young women is very rare, associated with delayed diagnosis, and usually associated with concerning features requiring biopsy. LEVEL OF EVIDENCE: III

Acute myelogenous leukemia and malignant hyperthermia in a patient with type 1b glycogen storage disease

In conclusion, the diagnosis of toxoplasmosis after bone marrow transplant can be difficult. We believe that serologic studies for Toxoplasma should be obtained routinely prior to bone marrow transplant. The combination of positive pretransplant serology, unexplained fever, and neurologic changes, especially between days 20 to 100 after transplant, should alert the Clinician to the possibility of toxoplasmosis. Finally, possible prevention with TMPS M Z deserves special consideration in these patients; our data suggest that discontinuing T M P S M Z after transplant in the patien t who has positive pretransplant toxoplasma serology puts the patient at increased risk for reactivation of latent T. gondii infection.

Urinary oxalate and glycolate excretion patterns in the first year of life: A longitudinal study

To determine the range of normal values, we studied urinary excretion of oxalate and glycolate prospectively and longitudinally in a cohort of 30 healthy term infants. Random urine samples were obtained at 2 days, 2 weeks, and 2, 4, 6, and 9 months of age. The results had a log-normal distribution. The mean oxalate/creatinine ratio, as determined by the oxalate oxidase method, was 0.08 (in milligrams of oxalate to milligrams of creatinine) with a normalized range of 0.02 to 0.31. The mean ratio when oxalates were measured by using the Olthuis assay was 0.13 (range 0.03 to 0.53). The mean glycolate/creatinine ratio was 0.07 (range 0.02 to 0.26). These values did not correlate with increasing age. The oxalate/creatinine ratios were higher in formula-fed infants than in those who were fed human milk (0.14 +/- 0.16 vs 0.08 +/- 0.04; p < 0.01).

Pediatricians' Preferences for Anticipatory Guidance Topics Compared with Parental Anxieties

Fellows of the American Academy of Pediatrics, randomized by the office of the Academy. Because of the low response rate, a second mailing was sent out to the same group. Pediatricians were asked if they discuss various issues with parents &dquo;a lot&dquo; (frequently), &dquo;a little&dquo; (occasionally), or &dquo;not at all.&dquo; Included were 17 physical health issues, 16 psychosocial problems, seven possible injuries, four forms of victimization (i.e., abuse or abduction), and four questions about the parents’ ability to provide discipline, affection, values, and financial support. Respondents were also asked to list areas of concerns

Breast disorders in adolescent females.

This article reviews the recent medical literature on breast disorders in female adolescents. Most of the articles are reviews or case reports, because there is a paucity of primary research, particularly controlled prospective studies, in this area. The papers reviewed are clinically relevant, particularly in the evaluation of an adolescent with a breast mass. The information on early life factors (genetic and acquired) on subsequent risk for breast cancer later in life should be useful in our provision of anticipatory guidance to our adolescent patients regarding their breast cancer risk. The emerging literature on ethical issues raised by BRCA genetic screening is particularly important as we consider testing for our young patients.

Levonorgestrel Contraceptive Implants in Female Patients 14 to 21 Years Old

OBJECTIVE To determine which factors are associated with duration of use of a levonorgestrel implant (Norplant) for contraception in adolescents and young adults. DESIGN We retrospectively studied 144 young women (14 to 21 years of age) who chose a levonorgestrel contraceptive implant at Mayo Clinic Rochester between April 1990 and December 1993. MATERIAL AND METHODS The following information was obtained at the time of insertion of the implant and from any follow-up visits: demographics, prior contraceptive experiences, frequency and management of complications, complications noted at removal of the implant, and subsequent contraceptive choice. The duration of use was examined. RESULTS Of the 144 young women who underwent insertion of a Norplant system, 75 telephoned or made a medical appointment because of implant-related side effects. During the follow-up period, 64 patients had the Norplant system removed. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83 % and for at least 24 months was 63 %. Duration of Norplant use was not found to differ with respect to age, prior contraceptive use, or timing of insertion, but it was significantly shorter among those with a prior pregnancy than in those who had never been pregnant. CONCLUSION These findings suggest that a group of young women who are likely to continue use of a contraceptive implant (with or without treatment for side effects) are those who have never been pregnant.

A Proposal for Obstetric and Pediatric Management of Adolescent Pregnancy

Of the 1 million pregnancies among adolescents in the United States each year, approximately 500,000 result in live births. These pregnancies are at high risk but are amenable to obstetric and pediatric intervention. Medical, social, and economic risks for both the adolescent mother and her infant are substantially decreased by early and comprehensive prenatal care. A combined obstetric and pediatric protocol for the management of adolescent pregnancy can improve both the perinatal and the long-term outcome.

Surgically Treated Breast Disease in Adolescent Females: A Retrospective Review of 185 Cases

Abstract Most breast disease in adolescents, including that resulting in surgery, is benign; however, malignant conditions do occur. The distribution of diagnoses in adolescent females undergoing breast surgery was determined. Records and histologic material were reviewed from 185 females under 18 years of age. The patients range in age from 11 to 17 years, median 16 years. One hundred patients (54%) had surgery for fibroadenoma. Twenty-four patients (13%) had reduction mammoplasty. Although juvenile or “virginal” hypertrophy is a subjective diagnosis, more than 500 g of breast tissue was excised in 10 patients. The spectra of “fibrocystic” and proliferative breast disease was identified in 44 patients (24%). Four patients (2.6% of those with breast mass) had malignant neoplasms: a 15-year-old with primary rhabdomyosarcoma, a 17-year-old with metastatic rhabdomyosarcoma, a 13-year-old with metastatic neuroblastoma, and a 12-year-old with non-Hodgkins lymphoma. The remaining diagnoses were 4 polythelia, 2 accessory breast tissue, 2 mastitis, 2 intramammary lymph node, 2 hemangioma, and 1 fat necrosis. Although fibroadenoma is the most common breast mass (65% of masses) in adolescents undergoing breast surgery, a variety of other conditions may necessitate surgery for diagnostic and/or therapeutic purposes. In this study, 2.6% of patients with breast mass had a malignant neoplasm. Therefore, malignancy must be considered in the diagnosis and the consideration for surgery in adolescent females presenting with breast mass.