Accuracy of thyroid nodule sonography for the detection of thyroid cancer in children: systematic review and meta-analysis

INTRODUCTION

Thyroid ultrasound (US) is a widely used tool for evaluating thyroid nodules. Various US features have been suggested as predictors of thyroid cancer in children.

OBJECTIVE

To conduct a systematic review and meta-analysis to assess the diagnostic accuracy of different thyroid US features in detecting thyroid cancer in children.

METHODS

We searched multiple online databases for cohort studies that enrolled paediatric patients with thyroid nodules (age <21 years) and evaluated the accuracy of 12 relevant ultrasound features. Diagnostic measures were pooled across studies using a random effects model.

RESULTS

The search strategy yielded 1199 citations, of which 12 studies met the predefined inclusion criteria (750 nodules). The prevalence of thyroid cancer was 27·2% (40·8% in patients with a history of radiation exposure and 23·2% in patients without a history of exposure to radiation). The most common cancer was papillary thyroid cancer (86·7%). The presence of internal calcifications and enlarged cervical lymph nodes were the US features with the highest likelihood ratio [4·46 (95% CI: 1·87-10·64) and 4·96 (95% CI: 2·01-12·24), respectively] for thyroid cancer. A cystic nodule was the feature with highest likelihood ratio for benign nodules [1·96 (95% CI: 0·87-4·43)].

CONCLUSION

Thyroid US features are not highly accurate predictors of benign or malignant aetiology of thyroid nodules in children. Internal calcification may predict malignancy, and cystic appearance may suggest benign aetiology.

ACTH Stimulation Tests for the Diagnosis of Adrenal Insufficiency: Systematic Review and Meta-Analysis

CONTEXT

The diagnosis of adrenal insufficiency is clinically challenging and often requires ACTH stimulation tests.

OBJECTIVE

To determine the diagnostic accuracy of the high- (250 mcg) and low- (1 mcg) dose ACTH stimulation tests in the diagnosis of adrenal insufficiency.

METHODS

We searched six databases through February 2014. Pairs of independent reviewers selected studies and appraised the risk of bias. Diagnostic association measures were pooled across studies using a bivariate model.

DATA SYNTHESIS

For secondary adrenal insufficiency, we included 30 studies enrolling 1209 adults and 228 children. High- and low-dose ACTH stimulation tests had similar diagnostic accuracy in adults and children using different peak serum cortisol cutoffs. In general, both tests had low sensitivity and high specificity resulting in reasonable likelihood ratios for a positive test (adults: high dose, 9.1; low dose, 5.9; children: high dose, 43.5; low dose, 7.7), but a fairly suboptimal likelihood ratio for a negative test (adults: high dose, 0.39; low dose, 0.19; children: high dose, 0.65; low dose, 0.34). For primary adrenal insufficiency, we included five studies enrolling 100 patients. Data were only available to estimate the sensitivity of high dose ACTH stimulation test (92%; 95% confidence interval, 81-97%).

CONCLUSION

Both high- and low-dose ACTH stimulation tests had similar diagnostic accuracy. Both tests are adequate to rule in, but not rule out, secondary adrenal insufficiency. Our confidence in these estimates is low to moderate because of the likely risk of bias, heterogeneity, and imprecision.

Fasting Glucose Changes in Adolescents with Polycystic Ovary Syndrome Compared with Obese Controls: A Retrospective Cohort Study

STUDY OBJECTIVE

To compare changes in fasting glucose among adolescents with polycystic ovary syndrome (PCOS) with those in obese adolescents without PCOS.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 310 adolescents with PCOS and 250 obese adolescents (age range 13 to 18 years) seen at Mayo Clinic, Rochester, MN, from 1996 to 2012.

METHODS

Included for analysis were 98 adolescents with PCOS and 150 obese adolescents who had 2 or more fasting glucose measurements separated by at least 6 months. Adolescents with impaired fasting glucose (IFG) or diabetes were excluded. Multivariate models were used to assess predictors of change in fasting glucose.

RESULTS

At diagnosis, adolescents with PCOS had lower body mass index (BMI) (kg/m(2)) and older age than obese adolescents (P < .001). Adolescents with PCOS had shorter follow-up (P = .02). Baseline fasting glucose was not different between groups. Mean change in fasting glucose was 2.4 ± 9.4 mg/dL per year for PCOS and 2.2 ± 6.2 mg/dL per year for obese adolescents (P = .83). Significant predictors for change in fasting glucose were BMI and fasting glucose at diagnosis (P < .01). Within the PCOS cohort, BMI was a significant predictor for development of IFG (P = .003). Prevalence of hypertension increased in the PCOS cohort from baseline to follow-up (P = .02). PCOS and BMI were significantly associated with development of HTN in the entire cohort.

CONCLUSION

Adolescent girls with PCOS do not show a significant change in fasting glucose or an increased risk for the development of IFG compared with obese adolescents. BMI, not PCOS status, was the strongest predictor for changes in fasting glucose and development of IFG over time.

Venous thromboembolism and underutilisation of anticoagulant thromboprophylaxis in hospitalised patients with inflammatory bowel disease

BACKGROUND

Venous thromboembolism (VTE) is a well-recognised extra-intestinal manifestation of inflammatory bowel disease (IBD). Despite the widespread support for anticoagulant prophylaxis in hospitalised IBD patients, the utilisation and efficacy in clinical practice are unknown.

AIMS

The aim of this study was to assess the prevalence and clinical features of VTE among hospitalised IBD patients and ascertain whether appropriate thromboprophylaxis had been administered.

METHODS

All patients with a discharge diagnosis of Crohn disease or ulcerative colitis and VTE were retrospectively identified using International Classification of Diseases, tenth revision codes from medical records at our institution from July 1998 to December 2009. Medical records were then reviewed for clinical history and utilisation of thromboprophylaxis. Statistical analysis was performed by Mann-Whitney test and either χ(2) tests or Fisher's exact tests.

RESULTS

Twenty-nine of 3758 (0.8%) IBD admissions suffered VTE, 13 preadmission and 16 during admission. Of these 29 admissions (in 25 patients), 24% required intensive care unit and 10% died. Of the 16 venous thrombotic events that occurred during an admission, eight (50%) did not receive anticoagulant thromboprophylaxis and eight (50%) occurred despite thromboprophylaxis. Most thromboembolism despite prophylaxis occurred post-intestinal resection (n = 5, 63%).

CONCLUSION

Thromboprophylaxis is underutilised in half of IBD patients suffering VTE. Prescription of thromboprophylaxis for all hospitalised IBD patients, including dual pharmacological and mechanical prophylaxis in postoperative patients, may lead to a reduction in this preventable complication of IBD.

Diagnostic performance of body mass index to identify obesity as defined by body adiposity in children and adolescents: a systematic review and meta-analysis

BACKGROUND

The ideal means of identifying obesity in children and adolescents has not been determined although body mass index (BMI) is the most widely used screening tool.

OBJECTIVE

We performed a systematic review and meta-analysis of studies assessing the diagnostic performance of BMI to detect adiposity in children up to 18 years.

METHODS

Data sources were EMBASE, MEDLINE, Cochrane, Database of Systematic Reviews Cochrane CENTRAL, Web of Science and SCOPUS up to March 2013. Studies providing measures of diagnostic performance of BMI and using body composition technique for body fat percentage measurement were included.

RESULTS

Thirty-seven eligible studies that evaluated 53 521 patients, with mean age ranging from 4 to 18 years were included in the meta-analysis. Commonly used BMI cut-offs for obesity showed pooled sensitivity to detect high adiposity of 0.73 (confidence interval [CI] 0.67-0.79), specificity of 0.93 (CI 0.88-0.96) and diagnostic odds ratio of 36.93 (CI 20.75-65.71). Males had lower sensitivity. Moderate heterogeneity was observed (I(2) = 48%) explained in meta-regression by differences across studies in race, BMI cut-off, BMI reference criteria (Center for Disease Control vs. International Obesity Task Force) and reference standard method assessing adiposity.

CONCLUSION

BMI has high specificity but low sensitivity to detect excess adiposity and fails to identify over a quarter of children with excess body fat percentage.

Association between thyrotropin levels and insulin sensitivity in euthyroid obese adolescents

BACKGROUND

Thyrotropin (TSH) levels display a positive association with body mass index (BMI), and the prevalence of isolated hyperthyrotropinemia is higher in obese adolescents compared to their normal weight controls. However, the metabolic significance of the higher TSH in obese adolescents is less clear. The objective of this study was to determine the relationship between TSH concentrations and insulin sensitivity, lipids, and adipokines in euthyroid, non-diabetic, obese adolescents.

METHODS

Thirty-six euthyroid, non-diabetic, obese adolescents between the ages of 12 and 18 years underwent a 75 g oral glucose tolerance test. Insulin sensitivity (Si) and pancreatic β-cell function as assessed by disposition index (DI) were measured using the oral glucose minimal model approach. Cholesterol (total, low-density lipoprotein [LDL-C], and high-density lipoprotein [HDL-C]), triglycerides (TG), interleukin-6 (IL-6), total and high molecular weight (HMW) adiponectin, and retinol binding protein-4 (RBP4) were also determined. Associations between measures of thyroid function and Si, DI, lipids, and adipokines were computed using Pearson's correlation coefficient and multiple regression analysis.

RESULTS

The mean age of the subjects was 14.3±1.88 years, and the mean BMI was 32.5±4.65 kg/m2; 97% were non-Hispanic white and 47% were male. The mean TSH was 2.7±1.2 mIU/L. Increasing serum TSH was correlated with decreasing Si (log Si) in the entire cohort (p=0.03), but this relationship persisted only in males (p=0.02). The correlation between TSH and Si in males remained significant after adjusting for BMI (p=0.02). There was no correlation between TSH and pancreatic β-cell function as assessed by DI (p=0.48). TSH correlated positively with LDL-C (p=0.04) and IL-6 (p=0.03), but these associations vanished or weakened after adjusting for BMI (LDL-C p-value=0.44; IL-6 p-value=0.07).

CONCLUSIONS

This study suggests a sex-specific association between TSH and insulin sensitivity in euthyroid, non-diabetic, obese adolescent males. Prospective studies are warranted to explore further this sexual dimorphism in the relationship between thyroid function and insulin sensitivity and to determine if obese adolescents with insulin resistance receiving thyroid supplements for hypothyroidism would benefit from targeting TSH levels in the lower half of normal range.

Cholecalciferol supplementation does not influence β-cell function and insulin action in obese adolescents: a prospective double-blind randomized trial

BACKGROUND

There is increasing interest in the extraskeletal effects of vitamin D, particularly in the obese state with regard to the development of insulin resistance and diabetes.

OBJECTIVE

The objective of the study was to determine the effect of 2 doses of cholecalciferol (vitamin D3) supplementation on insulin action (Si) and pancreatic β-cell function in obese adolescents.

METHODS

We performed a 12-wk double-blind, randomized comparison of the effect of vitamin D3 supplementation on Si and β-cell function in obese Caucasian adolescents (body mass index > 95(th) percentile). The subjects were randomly assigned to receive either 400 IU/d (n = 25) or 2000 IU/d (n = 26) of vitamin D3. Each subject underwent a 7-sample 75 g oral glucose tolerance test, with glucose, insulin, and C-peptide measurements, to calculate Si and β-cell function as assessed by the disposition index (DI), with use of the oral minimal model before and after supplementation. A total of 51 subjects aged 15.0 ± 1.9 y were enrolled. Included for analysis at follow-up were a total of 46 subjects (20 male and 26 female adolescents), 23 in each group.

RESULTS

Initial serum 25-hydroxyvitamin D [25(OH)D] was 24.0 ± 8.1 μg/L. There was no correlation between 25(OH)D concentrations and Si or DI. There was a modest but significant increase in 25(OH)D concentration in the 2000 IU/d group (3.1 ± 6.5 μg/L, P = 0.04) but not in the 400 IU/d group (P = 0.39). There was no change in Si or DI following vitamin D3 supplementation in either of the treatment groups (all P > 0.10).

CONCLUSIONS

The current study shows no effect from vitamin D3 supplementation, irrespective of its dose, on β-cell function or insulin action in obese nondiabetic adolescents with relatively good vitamin D status. Whether obese adolescents with vitamin D deficiency and impaired glucose metabolism would respond differently to vitamin D3 supplementation remains unclear and warrants further studies. This trial was registered at clinicaltrials.gov as NCT00858247.

Hyperandrogenism in female athletes with functional hypothalamic amenorrhea: a distinct phenotype

Objective

To compare the reproductive, metabolic, and skeletal profiles of young athletic women with functional hypothalamic amenorrhea (FHA) as well as clinical or biochemical hyperandrogenism (FHA-EX+HA) with body mass index matched women with FHA due to exercise (FHA-EX) or anorexia nervosa (FHA-AN) alone.

Design

Retrospective cohort study.

Setting

Tertiary care teaching hospital.

Population

Adolescents and young women, 15–30 years of age, diagnosed with FHA along with concurrent signs of hyperandrogenism (n=22) and body mass index matched control groups consisting of 22 women in each group of FHA-EX and FHA-AN.

Main outcomes

1) Reproductive hormone profile: luteinizing hormone (LH), follicle stimulating hormone (FSH), total testosterone, pelvic ultrasound features. 2) Metabolic function and skeletal health markers: fasting glucose, cholesterol, number of stress fractures and bone mineral density as assessed by spine dual-energy X-ray absorptiometry z scores.

Results

FHA-EX+HA group was older at diagnosis compared to the other groups with a median (interquartile range [IQR]) age of 22 (18.75–25.25) years versus (vs) 17.5 (15.75–19) for FHA-EX; (P<0.01) and 18 (16–22.25) years for FHA-AN (P=0.01). There were no differences among the groups based on number of hours of exercise per week, type of physical activity or duration of amenorrhea. Median (IQR) LH/FSH ratio was higher in FHA-EX+HA than both other groups, 1.44 (1.03–1.77) vs 0.50 (0.20–0.94) for FHA-EX and 0.67 (0.51–0.87) for FHA-AN (P<0.01 for both). Total testosterone concentrations were not different among the groups. Median (IQR) fasting serum glucose concentration was higher in FHA-EX+HA vs FHA-EX, 88.5 mg/dL (82.8–90 mg/dL) vs 83.5 mg/dL (78.8–86.3 mg/dL) (P=0.01) but not different from FHA-AN (P=0.31). Percentage of women with stress fractures was lower in FHA-EX+HA (4.5%) as compared to both FHA-EX (27.3%) and FHA-AN (50%); P=0.04 and 0.01 respectively. The LH/FSH ratio was weakly positively associated with serum glucose (adjusted r²=0.102; P=0.01) as well as with dual-energy X-ray absorptiometry spine score (adjusted r²=0.191; P=0.04) in the entire cohort.

Conclusion

In a small cohort of female athletes with hyperandrogenism, a distinct reproductive hormone profile consisting of higher LH to FHS ratio may be associated with adverse metabolic health markers but improved skeletal health.

Cosmetic side effects of antiepileptic drugs in adults with epilepsy

OBJECTIVE

Cosmetic side effects (CSEs) such as weight gain and alopecia are common, undesirable effects associated with several AEDs. The objective of the study was to compare the CSE profiles in a large specialty practice-based sample of patients taking both older and newer AEDs.

METHODS

As part of the Columbia and Yale AED Database Project, we reviewed patient records including demographics, medical history, AED use, and side effects for 1903 adult patients (≥16years of age) newly started on an AED. Cosmetic side effects were determined by patient or physician report in the medical record and included acne, gingival hyperplasia, hair loss, hirsutism, and weight gain. We compared the overall rate of CSEs and intolerable CSEs (ICSEs-CSEs that led to dosage reduction or discontinuation) between different AEDs in both monotherapy and polytherapy.

RESULTS

Overall, CSEs occurred in 110/1903 (5.8%) patients and led to intolerability in 70/1903 (3.7%) patients. Weight gain was the most commonly reported CSE (68/1903, 3.6%) and led to intolerability in 63 (3.3%) patients. Alopecia was the second most common patient-reported CSE (36/1903, 1.9%) and was intolerable in 33/1903 (1.7%) patients. Risk factors for CSEs included female sex (7.0% vs. 4.3% in males; p<0.05) and any prior CSE (37% vs. 2.9% in patients without prior CSE; p<0.001). Significantly more CSEs were attributed to valproic acid (59/270; 21.9%; p<0.001) and pregabalin (14/143; 9.8%; p<0.001) than to all other AEDs. Significantly less CSEs were attributed to levetiracetam (7/524; 1.3%; p=0.002). Weight gain was most frequently associated with valproic acid (35/270; 13.0%; p<0.001) and pregabalin (12/143; 8.4%; p<0.001). Hair loss was most commonly reported among patients taking valproic acid (24/270; 8.9%; p<0.001). Finally, gingival hyperplasia was most commonly reported in patients taking phenytoin (10/404; 2.5%; p<0.001). Cosmetic side effects leading to dosage change or discontinuation occurred most frequently with pregabalin and valproic acid compared with all other AEDs (13.3 and 5.6% vs. 2.3%; p<0.001). For patients who had been on an AED in monotherapy (n=677), CSEs and ICSEs were still more likely to be attributed to valproic acid (30.2% and 17.1%, respectively) than to any other AED (both p<0.001).

SIGNIFICANCE

Weight gain and alopecia were the most common patient-reported CSEs in this study, and weight gain was the most likely cosmetic side effect to result in dosage adjustment or medication discontinuation. Particular attention should be paid to pregabalin, phenytoin, and valproic acid when considering cosmetic side effects. Female patients and patients who have had prior CSE(s) to AED(s) were more likely to report CSEs. Knowledge of specific CSE rates for each AED found in this study may be useful in clinical practice.

Acute kidney injury in major gynaecological surgery: an observational study

OBJECTIVE

To assess the prevalence, outcomes and cost associated with acute kidney injury (AKI) defined by consensus risk, injury, failure, loss, and end-stage kidney (RIFLE) criteria after gynaecologic surgery.

DESIGN

Retrospective single-centre cohort study.

SETTING

Academic medical centre.

SAMPLE

Two thousand three hundred and forty-one adult women undergoing major inpatient gynaecologic surgery between January 2000 and November 2010.

METHODS

AKI was defined by RIFLE criteria as an increase in serum creatinine greater than or equal to 50% from the reference creatinine. We used multivariable regression analyses to determine the association between perioperative factors, AKI, mortality and cost.

MAIN OUTCOME MEASURES

AKI, combined major adverse events (hospital mortality, sepsis or mechanical ventilation), 90-day mortality and hospital cost.

RESULTS

Overall prevalence of AKI was 13%. The prevalence of AKI was associated with the primary diagnosis. Of women with benign tumour surgeries, 5% (43/801) experienced AKI compared with 18% (211/1159) of women with malignant disease (P < 0.001). Only 1.3% of the whole cohort had evidence of urologic mechanical injury. In a multivariable logistic regression analysis, AKI patients had nine times the odds of a major adverse event compared to patients without AKI (adjusted odds ratio 8.95, 95% confidence interval 5.27-15.22). We have identified several readily available perioperative factors that can be used to identify patients at high risk for AKI after in-hospital gynaecologic surgery.

CONCLUSIONS

AKI is a common complication after major inpatient gynaecologic surgery associated with an increase in resource utilisation and hospital cost, morbidity and mortality.

Development of the human breast

Mammalia are so named based on the presence of the mammary gland in the breast. The mammary gland is an epidermal appendage, derived from the apocrine glands. The human breast consists of the parenchyma and stroma, originating from ectodermal and mesodermal elements, respectively. Development of the human breast is distinctive for several reasons. The human breast houses the mammary gland that produces and delivers milk through development of an extensive tree-like network of branched ducts. It is also characterized by cellular plasticity, with extensive remodeling in adulthood, a factor that increases its susceptibility to carcinogenesis. Also, breast development occurs in distinct stages via complex epithelial-mesenchymal interactions, orchestrated by signaling pathways under the regulation of systemic hormones. Congenital and acquired disorders of the breast often have a basis in development, making its study essential to understanding breast pathology.

Female athlete triad and its components: toward improved screening and management

As female athletic participation has increased, the positive effects of exercise on health have become evident. However, with this growth in sports activity, a set of health problems unique to the female athlete has emerged. The female athlete triad as first described in 1992 by the American College of Sports Medicine consisted of disordered eating, amenorrhea, and osteoporosis; the definition was updated in 2007 to include a spectrum of dysfunction related to energy availability, menstrual function, and bone mineral density. For this review, a comprehensive search of databases-MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Scopus, from earliest inclusive dates to January 2013-was conducted by an experienced librarian with input from the authors. Controlled vocabulary supplemented with keywords such as female athlete triad, amenorrhea, oligomenorrhea, fracture, osteopenia, osteoporosis, bone disease, anorexia, bulimia, disordered eating, low energy availability was used to search for articles on female athlete triad. Articles addressing the prevalence, screening, and management of the female athlete triad were selected for inclusion in the review. This article reviews the current definitions of the triad components, epidemiology, pathophysiology, and recommended screening and management guidelines. The lack of efficacy of current screening of athletes is highlighted. Low energy availablity, from either dietary restriction or increased expenditure, plays a pivotal role in development of the triad. Athletes involved in "lean sports" (those that emphasize weight categories or aesthetics, such as ballet, gymnastics, or endurance running) are at highest risk. Treatment is centered on restoring energy availability to reverse adverse changes in the metabolic milieu. Prevention and early recognition of triad disorders are crucial to ensure timely intervention. Caregivers and physicians of female athletes must remain vigilant in education, recognition, and treatment of athletes at risk.

Temporal trends in the diagnosis and management of childhood obesity/overweight in primary care

OBJECTIVE

To determine the temporal trends in diagnosis and management of pediatric overweight/obesity by primary care providers at a single medical center.

PATIENTS

Children 2 to 18 years old undergoing a general medical examination during 3 calendar years (2003, 2006, and 2009). The number of visits for general medical examination were 6390 in 2003, 6646 in 2006, and 7408 in 2009.

METHODS

We performed a retrospective review of the electronic medical records for weight related diagnostic and/or management terms and laboratory screening in children with body mass index at or greater than the 85th percentile (n = 1630 in 2003, 1495 in 2006, and 1730 in 2009).

RESULTS

There was a significant increase in the diagnosis of obesity among obese children seen in 2009 (53.3%) compared with 2006 (36%, P < .001) and 2003 (24.3%, P < .001). Weight-related counseling was documented in a higher proportion of obese children in 2009 (49.4%) compared with 2006 (34.8%) and 2003 (26.6%). There was a significant increase in counseling regarding screen time in 2009 compared with 2006. A significant increase in screening for nonalcoholic fatty liver disease was also noted (30.5% in 2009 vs 21.9% in 2006, P = .018).

CONCLUSIONS

There has been steady improvement in the rates of obesity diagnosis and obesity-related counseling by primary care providers. However, continued efforts to increase awareness of these issues are needed as nearly half of obese children remained undiagnosed and recommended laboratory screening for obesity-related comorbidities was performed in only a third of obese children.

Characteristics of children with asthma who achieved remission of asthma

OBJECTIVE

To characterize two groups of asthmatics who had achieved remission and those who had not achieved remission of asthma.

METHODS

The study was a retrospective cohort study based on 117 asthmatic children who participated in a previous study. We categorized the children into two groups: asthmatics with remission versus asthmatics without remission. We defined remission of asthma as lack of symptoms/signs of asthma or asthma-related medications or health care services for at least three consecutive years. Long-term remission was defined by no relapse of asthma after achieving remission. We characterized these groups.

RESULTS

Of the 117 subjects, 70 (60%) were male, 91 (78%) were Caucasians, and the mean age at index date of asthma was 8.1 years. A total of 59 asthmatic children (50%) achieved remission and 28 asthmatics (24%) achieved long-term remission. Asthmatics with remission were more likely to be Caucasian (87%) compared to those without (69%) (p = .039) There were no differences in the frequency of visits for viral (0.3 vs. 0.4 per person-years, p = .29) or bacterial infections (0.7 vs. 0.5 per person-years, p = .49) between asthmatics with and without remission. Gender, socioeconomic status, smoking exposure, family history of asthma or atopy, breastfeeding history, peak flow meter availability, asthma action plan, and influenza vaccinations were not associated with remission.

CONCLUSIONS

Only half of asthmatic children accomplished remission of asthma ever and 24% of asthmatic children had long-term remission. Ethnicity may affect remission of asthma but microbial infections may not influence the likelihood of remission of asthma and vice versa.

Pseudohypoaldosteronism presenting with thrombocytosis and bilateral pneumothoraces in an infant

Pseudohypoaldosteronism type 1 (PHA-1) is a rare salt-wasting syndrome caused by a peripheral resistance to aldosterone. Here, we describe an unusual presentation of the autosomal dominant PHA-1 featuring bilateral pneumothoraces at birth, thrombocytosis in infancy, and hypercalcemia in addition to the well-described findings of hyponatremia, hyperkalemia, and failure to thrive. These findings contribute to the limited case descriptions of PHA-1 and may suggest additional diagnostic considerations in a neonate presenting with hyperkalemia, hyponatremia, and failure to thrive.

Update on treatment strategies for optimization of final adult height in children with congenital adrenal hyperplasia

Congenital adrenal hyperplasia (CAH) is one of the most common autosomal recessive disorders, caused by deficiency of an enzyme involved in adrenal synthesis of cortisol. Due to lack of feedback from cortisol, an elevation in ACTH occurs, shifting precursors of steroidogenesis into androgen synthesis. Both the disorder itself due to excess androgens and replacement with glucocorticoids can compromise final adult height. Also, unpredictable progression to precocious puberty in some patients can further compromise height. The achievement of normal growth remains the ultimate goal of treatment. This review will first examine the evidence behind deficits in adult height in CAH and implicated factors behind such compromise. The primary goal of the review is to identify therapies to optimize height in CAH. This will include variations in 'standard' medical therapy and recent single and combination therapies with growth hormone, GnRH analogs, aromatase inhibitors and anti androgens to optimize final height in CAH.