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Type 1 diabetes is a chronic disease affecting ∼3 million Americans (1). The disease is characterized by autoimmune destruction of insulin-producing cells; affected individuals depend on insulin therapy for survival. Although type 1 diabetes is the third most common chronic disease in childhood, 85% of individuals with type 1 diabetes are adults (2). Optimal management of type 1 diabetes comes at the expense of heavy burden for those with the disease. Although major advances have been made both in the pharmacology of insulin analogs and technological tools to assist in glucose management, only 21% of individuals with type 1 diabetes are able to meet their glycemic targets (3). These struggles are more apparent during adolescence and young adulthood, a developmental period during which adherence levels are low and glycemic control is poorest. In fact, only 17% of youth achieve glycemic targets (3). Type 1 diabetes increases morbidity and mortality from microvascular and macrovascular disease. The Diabetes Control and Complications Trial and its Epidemiology of Diabetes Interventions and Complications follow-up study examined the effect of intensive blood glucose control on the risk of future complications in patients >13 years of age with type 1 diabetes. These studies demonstrated that intensive blood glucose control profoundly reduces the risk of future microvascular complications (4–6). Despite the many technological advances during the past several years, A1C has worsened rather than improving in the adolescent years, and the period from late adolescence through early adulthood remains a challenging time for youth with type 1 diabetes. The unrelenting day-to-day management of type 1 diabetes becomes particularly difficult (7) at this time of many transitions, as these emerging adults make important decisions about their education, career, and health care. Some move away from their home support to attend college, whereas others face …

Purpose: Multidisciplinary weight management (MDM) significantly improves outcomes in youth, when compared to their routine care. However, this progress may be undermined by high follow-up attrition. We hypothesized that a pre-defined time-limited MDM clinic follow-up plan given to families from the “get-go” will improve individual clinic participation, weight, and metabolic parameters.Methods: Participant follow-up rates in 7 consecutive visits in a retrospective cohort of youth followed at an urban MDM clinic between April 2017 to September 2019 after the clinic follow-up protocol was changed (Post-PC) were compared to our previously published data (Pre-PC, December 2014 to January 2017). Secondary outcomes include changes (Δ) in body mass index z-score (z-BMI), body composition analysis (BCA), and laboratory parameters. Results: 615 records (12.3 + 3.7 years, 46% male) were reviewed. Participants’ follow up rates improved significantly starting visit 3 (Post-PC (49.2%) vs. Pre-PC (40.2%); p=0.03). With continued MDM participation, mean z-BMI Δ progressively improved. BCA Δ included a mean total body fat mass (FM) decrease (-2.07+7.3 kg) along with total body muscle mass (MM) increase (3.3+5.6 kg). Significant improvements were noted with hemoglobin A1c %, total cholesterol (TC), triglyceride, AST, and ALT concentrations. FM Δ correlated significantly with glucose and HOMA-IR Δ, while MM Δ was inversely associated with TC and LDL-cholesterol Δ.Conclusion: A protocolized MDM follow plan resulted in a small but significant improvement in the participants’ follow-up along with significant improvements in weight and metabolic outcomes. Further improvements will likely require additional behavioral economic strategies.

We describe a full term infant born to a 28-year-old mother. Pregnancy was uncomplicated except for maternal signs of virilisation: hoarseness of voice, excess facial hair and a significant nasal enlargement. Perinatal vitamins were the only medication taken by the mother during pregnancy. Family

Efficacy of multi-disciplinary weight management (MDM) in youth has not been compared to their routine care. To compare body mass index z-score (zBMI) and blood test (lab) changes (Δ) in youth before and after MDM and to correlate bio-impedance analysis (BIA) and lab measurements. We compared zBMI Δ (from referring providers’ records), within 3 months prior to MDM, to monthly zBMI Δ after MDM, in a retrospective cohort of youth at a tertiary MDM center. BIA and lab measurements after 6 months, MDM were compared to baseline. We reviewed 316 records (12.9 ± 3.5 years, 49% males, 104.8 ± 35.1 kgs). The pre-MDM zBMI Δ (0.02 ± 0.1) was reversed after MDM (−0.03 ± 0.09, visit 2, P

Obesity in pediatric patients is rising with nearly one third of children in the USA classified as overweight and up to 16-18% of the adolescent population obese with at least one comorbid condition. Consequently, bariatric procedures in this population have increased without consistent recommendations for follow-up and transition to adult providers. This review describes the known and potential long-term consequences of bariatric surgery in pediatric patients, reviews the current literature on transitions of care for adolescent patients with chronic illnesses. Additionally, this review summarizes recommendations from the literature for developing a standardized program for transitioning care for post-bariatric surgical patients and offers useful tools and guidelines for doing so.

Disorders of sex development (DSD) replaced the terms intersex, hermaphroditism, pseudohermaphroditism, sex errors of the body, and ambiguous genitalia in 2006; however, the terminology remains controversial. The current genetic-based classification system of DSD highlights the importance of chromosomal analysis in diagnosis and management of individuals with DSD. Despite advances in the domain of genetics, there has been little change in the endocrine treatment of DSD over the last few decades. On the other hand, there has been an evolving dynamic on many fronts including debates about the efficiency and timing of medically and nonmedically necessary genital surgery on infants and children with a DSD diagnosis; creation of a resolution by the Council of Europe in 2013 on the protection of children’s rights to physical integrity, demanding no one be “subjected to unnecessary medical or surgical treatment that is cosmetic rather than vital for health during infancy or childhood”; more transparency from physicians and other health professionals with families and patients; and an emphasis on the value of shared decision-making on issues such as genital surgery. In essence, there has been an evolving shift to a patient- and family-centered approach with the goal of optimizing quality of life. The aims of this chapter are to (1) provide a concise update on the mechanisms controlling normal and abnormal sexual differentiation, (2) share a protocol used at our institution for the practical management of infants born with DSD, (3) provide information to guide the physician when making a DSD diagnosis and designing medical management, (4) provide new behavioral information on DSD, and (5) highlight current differences of opinion regarding the care of infants born with DSD.

Cyclical patterns in business activity are a common feature of industry in market economies. This study identifies and describes industry cycles in the US softwood lumber industry from 198...

This study investigated the differences between multiple-objective-, timber-, and non-timber-motivated family forest landowner groups in the southeastern states of Alabama, Georgia, and South Carolina. Our focus was primarily to develop a classification scheme using easily available location-specific secondary data associated with family forest owners such that we may be able to identify the likely management direction for particular parcels of forestland in the future. Using nonparametric discriminatory analysis procedures we found that the biophysical, socioeconomic, and demographic factors best differentiated the landowner groups. With all the variables used to develop the classification scheme in this study known, a priori—that is, before the landowner on a Forest Inventory and Analysis (FIA) plot location is contacted for the National Woodland Owner Survey (NWOS)—it may be possible to predict the motivational membership type of a future landowner with known woodlot (FIA) and demographic (Census) attr...

Diversity is one of the major factors that define stability and efficient functioning of forest ecosystems, therefore maintaining biodiversity is important for sustainable forest management. Humans affect forest diversity in numerous ways. This paper analyzes the anthropogenic effects on diversity of forest trees in Alabama during the period 1972–2000. We use regression analysis to explore the influences of biological and climatic factors on two indicators of tree diversity namely, Shannon's diversity index and species richness. Explanatory variables in the regressions include population gravity index as the indicator of urbanization reflecting population density and proximity to populated places. Other variables in the model are presence of harvesting activity, stand origin, forest type, DBH, volume, site class, ownership, elevation, and slope. Our results indicate that urbanization affects tree species diversity in two ways. Directly, it negatively impacts tree species diversity in Alabama forests. Indirectly, urbanization adversely affects intensity of forest management, which in turn has a negative impact on tree species diversity. The combined effect of urbanization on species diversity is negative; however, its magnitude is lower than that of the direct effect.

Mechanical ventilation is a life-saving therapy used in children in PICU. These critically ill children are usually extensively investigated in PICU. Chest radiograph is an irreplaceable investigation in these patients prior to ventilation. AIM: We studied the impact of initial chest radiograph on the final outcome of ventilated children. DESIGN: Retrospective. SETTING: Tertiary care teaching hospital. METHOD: One hundred and forty-one children were included in the study. Initial chest radiograph of all the ventilated children was evaluated and outcome of these children was correlated with the initial radiograph at admission. RESULTS: Abnormal initial radiograph was recorded in 60% (n = 84) ventilated children. Overall mortality in ventilated children was 24% (n = 34). Ventilated children with abnormal initial radiograph had significantly greater mortality (28/84) than those with initial normal chest radiograph (6/57) (P CONCLUSION: Initial chest radiograph at the beginning of ventilation may be useful to predict the outcome of these children

Youth with type 1 diabetes (T1DM) gain weight after insulin therapy initiation. We aimed to study the effects of Enhanced Dietary Counseling (EDC) compared to Standard of Care Dietary Counseling (SDC) on BMI trajectory in youth with new-onset T1DM. Youth with new-onset T1DM (n = 47; 8.9 + 4.2 years) were randomized 6 weeks post-diagnosis to either SDC per American Diabetes Association guidelines (n = 25) or EDC (n = 22: SDC plus monthly nutritional education and 3-day food records (FRs) at 6 and 24 weeks). Weights and heights were measured at diagnosis, 6 weeks, 3, 6, and 12 months post-diagnosis; pre-diagnosis BMI was obtained from pediatricians’ records. BMI Z score was used to track BMI change. Knowledge of recommended daily energy intake (DEI) and daily carbohydrate intake was assessed at follow-up visits. Changes in BMI Z scores were similar in SDC versus EDC subjects from pre-diagnosis to 12 months post-diagnosis. BMI Z score at 12 months exceeded pre-diagnosis level in 58.5 % subjects (54.5 % EDC vs. 63.1 % SDC, p = 0.75). From 6 weeks to 6 months, percentage of subjects correctly recalling recommended DEI increased in EDC along with percentage of subjects meeting recommended daily fruit servings intake from 25 % (6 weeks) to 64 % (6 months), p = 0.047). EDC did not prevent BMI Z score increases in youth with new-onset T1DM, and BMI Z score exceeded pre-diagnosis levels in >50 % 12 months post-diagnosis. A family-based approach and/or additional intervention may be needed to prevent excessive weight gain.

The aims of this chapter are the following: (1) provide a concise update on the mechanisms controlling normal and abnormal sexual differentiation, (2) provide a protocol used at our institution for practical management of infants born with DSD, (3) provide information to guide the physician on making a DSD diagnosis and its medical management, (4) provide new behavioral information on DSD, and (5) highlight current differences of opinions about the care of infants born with DSD. A discussion of infants who are born with DSD with normal-appearing genitalia is also included.

The purpose of this study was to determine low-grade inflammation associated with obesity that is mediated partially by TNF-α, an adipocytokine which stimulates sphingomyelinase activity in adipocytes. Circulating ceramide (Cer) and sphingosine 1-phosphate (S1P) are elevated in genetically obese (ob/ob) mice. We aimed to determine whether serum sphingolipid concentrations correlate with measures of obesity, insulin resistance, and lipid profiles in overweight versus lean adolescents. This cross-sectional study recruited 30 healthy overweight (body mass index, BMI ≥ 85%) and 15 lean (BMI 10–84%) adolescents. Anthropometric measurements and fasting blood samples were collected at one clinic visit. Serum glucose, insulin, and fasting lipid profiles were measured. Serum adipocytokine concentrations were measured by ELISA or colorimetric assay and sphingolipids were measured by HPLC–mass spectrometry. Between group differences in serum sphingolipid concentrations were assessed. Correlations between sphingolipid concentrations and (i) body mass index, (ii) calculated homeostasis model assessment of insulin resistance (HOMA-IR), (iii) adipocytokines, and (iv) lipoproteins were determined. The results showed that significant differences in HOMA-IR (4.5 ± 3.2 vs. 1.2 ± 0.7), free fatty acids (0.8 ± 0.3 mmol/l vs. 0.4 ± 0.3 mmol/l), and adiponectin (6.4 ± 3.8 vs. 12.6 ± 9.9 μg/ml) were seen between groups (overweight vs. lean). There were significant correlations between Cer and TNF-α (r = 0.429), S1P and TNF-α (r = 0.288), Cer and adiponectin (r = 0.321), Cer:S1P and adiponectin (r = 0.324), Cer and HOMA-IR (r = 0.307), and Cer:S1P and LDL cholesterol (r = 0.453); these associations persisted after adjustment for BMI Z-score, sex, and Tanner stage. We concluded that elevated sphingolipid concentrations correlate with TNF-α, adiponectin, lipoprotein profiles, and HOMA-IR. Ceramide is associated with atherogenic lipid profiles and the development of insulin resistance in obese adolescents, similar to adults.

Central nervous system herpes simplex virus infection is suspected in patients presenting with acute-onset seizures and lethargy. The potential neurologic sequelae from untreated herpes infection can prompt empirical acyclovir therapy, even in afebrile subjects. The objectives of this study were to determine the frequency of central nervous system herpes simplex virus infection in children presenting with afebrile seizures and to assess the need for empirical acyclovir therapy. Clinical and laboratory data of children with acute-onset afebrile seizures and children with central nervous system herpes simplex virus infection were compared. Polymerase chain reaction and viral cultures of the cerebrospinal fluid for herpes simplex virus infection were negative in all subjects with afebrile seizures; 32.7% of these subjects were empirically treated with acyclovir. In conclusion, central nervous system herpes simplex virus infection is uncommon in children presenting with afebrile seizures, and acyclovir therapy is rarely necessary in subjects with normal neurologic examination and cerebrospinal fluid analysis.

"There is growing evidence suggesting that the United States??? roots are not in a state of 'pristine' nature but rather in a 'human-modified landscape' over which Native people have since long exerted vast control and use. The longleaf pine is a typical woodland use largely shaped by fires, lightning and by Native Americans. The frequent fires, which were used to reduce fuels and protect themselves from wildfires, enhance wildlife habitats and for hunting, protect themselves from predators and enemy tribes, led to the establishment of the fire dependent and fire tolerant longleaf pine across the southern landscape. In the last 3 centuries however, the range of longleaf ecosystem has been gradually replaced first by agriculture and then by loblolly pine farming. The joint effects of agricultural expansion, intense logging of the longleaf in the late 1800s, expanded fire control since the early 20th century, and subsequent bare-root planting beginning in the 1930s, has permitted loblolly pine to become dominantly established in the south. Longleaf and loblolly pines represent two distinct woodland uses and represent separate human values. This study investigated the change from longleaf pine use to loblolly pine farming in Southern US from perspectives of human values of land and natural resources."

This paper analyzes structural differences in holding size distribution of private forestland at the county level in Alabama, USA. The following categories are used to describe the timberland holding distribution: mean holding size, Gini coefficient of timberland holdings, and share of county timberland in holding sizes of fewer than 80 hectares and more than 800 hectares. Regressions are conducted to explore the socio-economic correlates of forestland holding size distribution. Results indicate that population density, age structure, urban-rural population structure, income structure and land tenure type are strongly associated with the forest holding size distribution.

This prospective, double-blind, placebo-controlled trial was designed to study the effect of iron therapy on the growth of iron-replete and iron-deficient children, and to study the change in iron status in iron-deficient children with iron therapy. One hundred and fifty children (aged 6-24 months) were included in the study. After an informed written consent, 100 healthy children, who were iron replete (group I) according to preset criteria, were randomly allocated to receive iron supplements 2 ng/kg/day (group IA) or placebo (group IB). Fifty iron-deficient children (group II) were administered iron syrup 6 mg/kg/day. Growth parameters (weight, length and head-circumference) and hematological parameters were studied for 4 months. Iron therapy, as compared with placebo, produced a significant improvement of mean monthly weight gain (p < 0.001) and linear growth (p < 0.001) in the iron-deficient children. However, it significantly decreased the weight gain (p < 0.001) and linear growth (p < 0.001) of iron-replete children. Caution should therefore be exercised while supplementing iron to children with apparently normal growth and when the iron status of the child is not known.