Acylated/unacylated ghrelin ratio in cord blood: correlation with anthropometric and metabolic parameters and pediatric lifespan comparison

CONTEXT

Ghrelin is a peptide with multiple functions that circulates in acylated (AG) and unacylated (UAG) forms. However, the role of ghrelin in neonates (NN) remains to be clarified.

OBJECTIVE

The aim of this study was to determine ghrelin concentrations of the two forms in NN to clarify their biological roles. As such, ghrelin levels at birth were compared with those in later life.

SETTING AND DESIGN

Tertiary Care Center. In this cross-sectional study, we evaluated AG, UAG, AG/UAG ratio, and insulin levels in venous cord blood from NN and in fasted normal weight (NW) and obese (OB) children, both prepubertal and pubertal.

SUBJECTS

We studied 82 NN, 82 NW, and 58 OB children.

RESULTS

AG levels were lower in NN than in NW and OB children (P<0.0001), more specifically the prepubertal NW and OB children (P<0.0001). UAG levels were higher in NN than in NW and OB children (P<0.0001). Therefore, the AG/UAG ratio was lower in NN than in NW and OB children (P<0.0001). NN showed insulin levels similar to NW and lower than OB children (P<0.0001). At birth UAG was positively correlated with AG (Pearson: 0.425; P<0.0001) and negatively with insulin (-0.253; P<0.02). In NW and OB, UAG and AG were positively correlated to each other and negatively correlated with insulin and body mass index (-0.566; P<0.0001).

CONCLUSIONS

NN compared with children, showed higher UAG and lower AG levels. The AG/UAG ratio showed a very different profile in NN, being lower than in NW and OB children, thus suggesting a different metabolic function for the two forms in NN. Further studies are needed to clarify the exact role of the different ghrelin forms in NN.

[Growth hormone deficiency associated with 22q11.2 deletion: a case report]

The 22q11.2 microdeletion produces many syndromes, characterized by similar phenotypical features. The most known syndromes are: the DiGeorge syndrome, the velocardiofacial syndrome, the conotruncal anomaly face syndrome. The hallmark features are represented by cardiac anomalies, palate defects, immune and cognitive deficiencies, facial dysmorphisms. Less common disorders include: genito-urinary abnormalities, visual defects, autoimmune disorders and pituitary anomalies, being the last represented by growth hormone and/or insulin growth factor-I deficiency. We present the case of a 8 years old male admitted to our Division for failure to thrive. We found growth hormone deficiency and pituitary hypoplasia associated with some of the anomalies shown above, thus we suspected and confirmed the 22q11.2 deletion syndrome. In literature few cases of associated 22q11.2 deletion syndrome with growth hormone deficiency are described, while short stature between children with and children without cleft palate is reported to be more frequent in the first ones, suggesting that the 22q11.2 deletion syndrome remains undetected in many affected children and that the growth hormone deficiency prevalence in affected children has to be investigated. The wide phenotypical presentation of 22q11.2 deletion syndrome requires a multidisciplinary approach to the affected subject and, from the auxologic point of view, is good to monitoring the growing trend and, if short stature is present, check for the growth hormone deficiency.

[Early diagnosis of Fabry disease in children]

Fabry disease, a rare X-linked lysosomal storage disorder, is caused by deficiency of the enzyme α-galactosidase A. The incidence, ranging from one over 40 000 to one over 11 7000 worldwide is probably underestimated due to its unspecific pattern of presentation. The symptoms, including neurological, gastrointestinal, renal, ophthalmological and dermatologic manifestations, start in childhood and adolescence, cause a significant morbidity and are likely to affect the patient's quality of life. Furthermore, Anderson-Fabry disease always progress leading to a multiorgan dysfunction and life-threatening complications with end-stage renal disease, cardiomyopathy and high incidence of stroke. The estimated life in untreated patients is reduced by 15-20 years respectively in men and women. The enzyme replacement therapy, available in Europe from 2001, results in a reduction of major organs failure, morbidity and mortality. We present the case of an 8-year-old male admitted to our Division for overweight with a previous history of acroparesthesias, severe acute pain in hands and feet, abdominal pain, diarrhoea, constipation, bitemporal headache, dyshidrosis, recurrent fever, exercise intolerance and reduced quality of life. The physical examination was within normal limits. The α-galactosidase A activity was deficient in plasma and normal in peripheral leukocytes; the GLA gene showed a nucleotide substitution c.352C>T (p.Arg 118 Cys) in the eson 2 with a residual enzyme activity of the 29% suggesting the diagnosis of Fabry disease. Blood and urine chemistry, the slit-lamp examination and MRI of kidneys, heart and brain excluded any major organ involvement. The enzyme replacement therapy was then started almost three months ago using agasidase alfa at a dose of 0.2 mg/kg infused intravenously every two weeks but, unfortunately, no relief in the symptoms have been reported so far without any severe adverse reactions. This case report aims to point out the importance of an early diagnosis in order to prevent the progression of the disease, the multiorgan failure and to improve the long-term prognosis.

[Neurofibromatosis type 1 and hypertension in pediatrics: case report]

Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder characterized by cafe-au-lait spots, axillary and inguinal freckling, cutaneous neurofibromas with a variable clinical expression, iris Lisch nodules, and multiple tumors, in particular optic nerve and other central nervous system gliomas. About 6% of patients develop hypertension due to renovascular diseases, mid-aortic syndrome, or pheochromocytoma. We present a case of a 8 year old girl with primary diagnosis of NF1suffering of skin and encefalic neurofibromas, inguinal freckling, café-au-lait spots, optic nerve glioma, headache, facial flushing. The 24-h ambulatory blood pressure revealed hypertension without paroximal attacks. Urinary metanephrines, serum aldosteron, renin and kalemia were constantly normal. Magnetic resonance imaging (MRI) and angioMRI excluded stenoses of the renal arteries or adrenal masses. Standard 2D echocardiography was normal. The antihypertensive medication controlled pressure values. We concluded for hypertension due to a low-grade vasculopathy. The periodic monitoring of blood pressure in NF1 patients, accompanied by appropriate diagnostic modalities and physical examination, is essential to precociously diagnose hypertension and avoid life-threatening organ damages and increased mortality.

[Maria Sandrucci: up-to-date with science, supporter of equal rights]

This is the first scientific study on Mary Sandrucci, who has been director of the Pediatric Clinic of the University of Turin from 1965-1966 up to 31 December 1989. Prof. Sandrucci led major studies on congenital heart disease, was the first Italian and among the first in Europe to describe phocomelia cases, to report on valuable studies antibiotics, uric acid, pediatric nephrology, nuclear medicine and genetics. She promoted the development of pediatric specialties, but at the same time promoted the study and practice of paediatrics as a whole. This study describes the past half century of medicine, history of Italian pediatrics and progress of the conquest of rights and equal opportunities for women.

Etiopathogenetic advances and management of holoprosencephaly: from bench to bedside

Holoprosencephaly (HPE) is a complex brain malformation caused by impaired or incomplete midline division of the prosencephalon. It's characterized by cerebral and facial anomalies of different levels of severity. Both genetic and environmental factors are known to cause HPE, but they cover only few cases. Genetic causes are responsible for about 20% of cases: they are chromosomal abnormalities and gene mutations: up to date, nine genes (SHH, ZIC2, SIX3, TGIF, PATCHED1, TDGF1/CRIPTO, FAST1, GLI2 and DHCR) are definitely associated with HPE, but many others candidate gene are under investigation. The diagnosis of HPE is usually prenatal and is based on systematic ultrasound scan (US) and magnetic resonance imaging (MRI). Children with HPE have many medical problems in agreement with the severity of the brain malformation: craniofacial abnormalities, neurological signs, endocrine disorders, oromotor and dysautonomic dysfunction, thus requiring a multidisciplinary team for symptomatic treatment of manifestations, prevention of complications and parental support. Genetic counselling is an important step, often made difficult by extreme phenotypic variability, genetic heterogeneity, and a high risk of recurrence in apparently sporadic cases. In conclusion it can be concluded that we are far from a complete explanation of the etiopathogenesis. Future researches on genomic rearrangements all over the genome with techniques like the CGH array should lead to the identification of other causal genes and could improve diagnosis and prognosis. A skill multidisciplinary approach is mandatory to offer the better clinical assistance to patients and their parents.

The incidence of type 1 diabetes is increasing in both children and young adults in Northern Italy: 1984-2004 temporal trends

AIMS/HYPOTHESIS

A shift towards younger age at onset of diabetes in susceptible people has been suggested as a possible explanation for the increasing temporal trend in incidence of type 1 diabetes. We aimed to test this hypothesis by assessing trends in incidence rates in the period 1984-2004 in children and young adults in Northern Italy.

METHODS

The study bases were: (1) children resident in the Province of Turin in the period 1984-2004 and in the remaining areas of the Piedmont Region in the period 1990-2004; and (2) young adults (15-29 years) resident in the Province of Turin in the period 1984-2003. Temporal trends in rates were analysed using Poisson regression models.

RESULTS

A total of 1,773 incident cases were identified. Overall incidence rates/100,000 person-years in the age groups 0-14 and 15-29 years were 11.3 (95% CI 10.7-12.0) and 7.1 (95% CI 6.6-7.7), respectively, with sex differences among young adults only (incidence rate ratio [IRR] in males vs females 1.41 [95% CI 1.20-1.64]). Average annual increases in incidence rates were similar in children and young adults at 3.3% (95% CI 2.5-4.1). Compared with the period 1984-89, in 2000-2004 a 60% higher risk was found in both age 0-14 years (IRR 1.60, 95% CI 1.31-1.95) and 15-29 years (IRR 1.57, 95% CI 1.26-1.96) groups. The Poisson modelling showed no interaction between calendar period and age at onset.

CONCLUSIONS/INTERPRETATION

Incidence of type 1 diabetes in Northern Italy is increasing over time in both children and young adults, not supporting the hypothesis of a shift towards younger age as the main explanation for the increasing temporal trend in children.

Transition process of patients with type 1 diabetes (T1DM) from paediatric to the adult health care service: a hospital-based approach

INTRODUCTION

The outcomes of different types of transitions of young people with chronic diseases have been poorly investigated.

OBJECTIVE

To evaluate and compare a structured transition from the paediatric diabetes services (PDS) into the adult diabetic services (ADS) with an unstructured one.

DESIGN

We retrospectively investigated 62 adolescents and young adults with type 1 diabetes discharged from the PDS from 1 January 1994 to 31 December 2004. Thirty-two patients (group A) were transferred to the ADS of the same hospital with an unstructured method (letter) and 30 patients after a structured transfer planned with adult physicians (group B). We analysed the date of the first admission in ADS, the glycated haemoglobin (HbA1c), the clinic attendance rate in PDS and in the first year in ADS, and a phone questionnaire on the transition experience.

RESULTS

The duration of the transfer was longer in A than in B with a lack of medical assistance during the unstructured transition (P < 0.001). At the first visit in ADS, before any medical intervention, HbA1c was improved in B compared to the last in PDS (P < 0.01), and had a trend in worsening in A. After 1 year in the ADS there was a better clinical attendance, and a lower HbA1c in B than in A (P < 0.05). All the subjects of group B reported a favourable opinion for the structured transition (P < 0.0001).

CONCLUSION

The transition process plays an important role in diabetic care and a structured plan is mandatory to avoid to lose the patients and to get worse their health.

A novel recessive splicing mutation in the POU1F1 gene causing combined pituitary hormone deficiency

BACKGROUND

Mutations in the gene encoding the pituitary transcription factor POU1F1 (Pit-1, pituitary transcription factor-1) have been described in combined pituitary hormone deficiency (CPHD).

AIM

The aim of this study was the characterisation of the molecular defect causing CPHD in a patient born to consanguineous parents.

SUBJECT AND METHODS

The case of a 12.5-yr-old girl presenting with severe growth failure at diagnosis (-3 SD score at 3 months) and deficiency of GH, PRL, and TSH was investigated for the presence of POU1F1 gene mutations by denaturing high performance liquid chromatography analysis.

RESULTS

A novel mutation adjacent to the IVS2 splicing acceptor site (IVS2-3insA) was identified in the patient at the homozygous state. Analysis of patient's lymphocyte mRNA and an in vitro splicing assay revealed the presence of 2 aberrant splicing products: a) deletion of the first 71 nucleotides of exon 3, altering the open reading frame and generating a premature stop codon, b) total exon 3 skipping resulting in an in frame deleted mRNA encoding a putative protein lacking part of the transactivation domain and of the POUspecific homeodomain. Notably, the patient's relatives heterozygous for the mutation had PRL levels under the normal range with no evident clinical symptoms.

CONCLUSIONS

The IVS2- 3insAmutation, responsible for CPHD at the homozygous state, causes the presence of 2 aberrant splicing products encoding non-functional products. In the heterozygotes one normal allele might not guarantee a complete pituitary function.

Identification and management of dyslipidemic children

Atherosclerotic cardiovascular disease is a leading cause of morbidity and premature mortality in Western countries and dyslipidemia is a recognized major cardiovascular risk factor. Evidences demonstrate that the atherosclerotic process begins early in childhood. Children showing dyslipidemia, as well as other cardiovascular risk factors, including hypertension, overweight/obesity and diabetes mellitus, are defined at high risk. To identify these children a selective screening between 2 to 10 years of age is necessary. This program must be performed to those children showing a familiarity for primary dyslipidemia and/or precocious cardiovascular events. These subjects need to undergo lipid biochemical analysis and assessment of other emergent risk factors (as ApoB, ApoA-I and their ratio). Given that total cholesterol and low-density lipoprotein cholesterol (LDL-C) concentrations vary by age and sex, the use of percentile values according to these parameters is now recommended. In these high-risk subjects the first step to lower LDL-C under the value of 130 mg/dL is represented by an appropriate physical activities and Step II diet. This entails further reduction of saturated fatty acid intake to less than 7% of daily calories and of cholesterol to less than 200 mg/day (since two years of age). When diet therapy is insufficient to lower LDL-C to the acceptable concentration, the use of non-pharmacologic agents (soluble fibers, plant stanols, sterols) is suggested. The third approach, for children showing persistent elevated LDL-C >95(th) percentile, is represented by drugs, that are allowed only in children older than eight years.

Prevalence and risk factors for overweight and obesity in a population of Italian schoolchildren: a longitudinal study

Prevalence of childhood overweight and obesity have dramatically increased worldwide in the last decades. Overweight and obesity are the result of a complex interaction between genetic and environmental factors. The aim of our longitudinal study was to assess the prevalence of overweight and obesity in a population of Italian schoolchildren followed for 2 years and to identify main risk factors for obesity onset and persistence in childhood. We enrolled 632 children (males /females= 345/287), aged 3 to 8 yr.Weight and height were measured at time 0, 1 (1 yr later), and 2 (2 yr later). Overweight and obesity were defined using body mass index (BMI) (Italian growth charts). Data collected included: birth weight, gestational age,maternal weight gain during pregnancy, breast feeding, parents' BMI, educational level, and occupation type. At time 0, 1, and 2 the prevalence of overweight was 22%, 22%, and 25%, respectively, and the prevalence of obesity was 7%, 8%, and 8%, respectively. During follow-up 62%of children remained normal weight, 24% was always overweight or obese, 9% became overweight, while only 5% of overweight subjects became normal weight. Male gender, maternal weight gain during pregnancy >10 kg, parental overweight/obesity were positively associated with the presence of overweight during the entire follow-up. On the contrary, being small for gestational age at birth was negatively related to persistence of overweight. No influence was found for being breastfed, for parental low educational level, and manual occupation. A large prevalence of overweight/obesity was observed in Italian schoolchildren. Gender, maternal weight gain during pregnancy, and parents' BMI were the strongest predictors of the persistence of child overweight and obesity.

Heterozygous mutation of HESX1 causing hypopituitarism and multiple anatomical malformations without features of septo-optic dysplasia

Isolated GH deficiency or combined pituitary hormone deficiencies have been associated with mutations in transcription factors encoding genes that control organogenesis or cell differentiation. Among these factors, Hesx1 is essential for the development of the optic nerve and regulates some of the earliest stages in pituitary development and is intimately involved in orchestrating the expression of other factors involved in pituitary organogenesis. Mutations in HESX1 are reported in patients with hypopituitarism either with typical septo-optic dysplasia (SOD) or with neuromorphological abnormalities not included in classical SOD. The present report describes clinical features, biochemical parameters, and characterization of a missense mutation (Gln6His) in exon1 of HESX1 in a pre-pubertal child who progressively developed multiple hypopituitarism, firstly GH and, afterwards, TSH and ACTH deficiencies, in a pluri-malformative syndrome characterized by short stature and anatomical malformations not associated with a classical SOD phenotype. This finding further supports the necessity to stay alert in evaluating a gene that plays a minor role in the pathogenesis of sporadic hypopituitarism, such as HESX1 gene even when the phenotype does not fit in with a classical SOD syndrome.

[Fluticasone in the therapy of asthmatic children: short-term effects on growth]

AIM

Inhaled corticosteroids (ICS), for years used in the therapy of low-moderate bronchial asthma, reduce the rate of asthmatic attack with improved pulmonary functioning and quality of life. Clinical trials have been addressed mainly to study the efficacy rather than the safety of drugs, so that the side effects of these drugs have not yet been accurately defined. Clinical experience shows that growth delay appears in the first months of therapy with ICS. The aim of the study was to evaluate the influence of the therapy with spacer-administered inhaled corticosteroid on short-term auxological development in prepubertal children.

METHODS

In a group of children with low asthma, height and weight have been evaluated before and after six months of inhaled therapy with dipropionate fluticasone at a dose of 100 microg per day.

RESULTS

Twenty-five patients (19 males and 6 females; age 5.5+/-1.6 years; range: 2.6-7.8 years) showed a regular growth during the six months of therapy (mean height 0.8 standard deviation score [SDS] before therapy and 0.8 SDS after therapy), while 21 (17 males and 4 females; age 10.0+/-1.5 years; range 8.0-12.7 years) showed an increment of growth rate (mean height from 0.5 SDS to 0.7 SDS, respectively).

CONCLUSION

Spacer-administered low dose fluticasone does not negatively influence short-term growth rate, regardless of the age of the patients.

Acute ghrelin response to intravenous dexamethasone administration in idiopathic short stature or isolated idiopathic growth hormone-deficient children

Acylated ghrelin has been originally described for its potent GH-releasing activity mediated by the activation of the GH secretagogue receptor type 1a. More recently, ghrelin has been reported to exert several other GH-independent biological actions, among which in the modulation of metabolic functions. Glucocorticoids are well known to exert important metabolic functions but also to modulate GH secretion, although through mechanisms that have not been fully clarified so far. Interestingly, the existence of a feedback link between glucocorticoids and ghrelin system has already been reported. The aim of our study was to evaluate the acute GH and ghrelin responses to dexamethasone (DEX) administration in children with idiopathic short stature (ISS) or isolated idiopathic GH deficiency (GHD). Eight children with ISS (age: 9.5+/-1.2 yr) and 7 with GHD (12.1+/-1.4 yr) underwent iv DEX administration (0.3 mg/body surface area at 0 min). IGF-I, GH, and ghrelin levels were assayed at baseline and every 30 min from 120 up to 240 min after DEX. Compared to baseline levels DEX decreased ghrelin in ISS at 120 min and 240 min (p<0.04). On the other hand DEX did not modify ghrelin levels in GHD. After DEX, ghrelin was reduced in ISS compared to GHD (p<0.02). DEX increased GH in ISS but not in GHD (peak: 11.1+/-1.2 vs 7.6+/-0.9 microg/l). Basal, as well as after-DEX ghrelin levels negatively correlated with IGF-I in GHD (p<0.03) and with height SD score (HSDS) in ISS (p<0.02). Acute DEX administration is able to decrease ghrelin in ISS, but not in GHD children. Both basal and after-DEX ghrelin levels negatively correlate with IGF-I and HSDS. All these data suggest the existence of a feedback link among ghrelin, glucocorticoids and the GH/IGF-I axis.

[Germinoma: a rare cerebral tumor causing central diabetes insipidus in childhood]

Germinoma represents 7.8% of cerebral tumors in pediatric age and 50-65% of germ cell cerebral tumors. Generally it is a definite lesion of the pineal gland or suprasellar region, frequently occurring in the first three decades of life. Clinical presentation depends on tumor localization. Pineal lesions generally determine symptoms due to the compression of cerebral structures, causing Parinaud syndrome, while hypothalamic lesions are often characterized by diabetes insipidus, hypopituitarism and visual defects. In the absence of these classic signs and symptoms, however, the diagnosis of germinoma can be difficult. We presented the case of an 8-year-old boy, referred to our clinic for polyuria and polydipsia. Hormonal evaluations demonstrated central diabetes insipidus (CDI), with normal anterior pituitary function. Magnetic resonance imaging (MRI) showed a lack of posterior pituitary gland and partial pituitary stalk enlargement. The patient started therapy with desmopressin (Minirin) with good hydro-electrolytic balance. During follow-up the pituitary function became insufficient with low growth velocity. A second MRI demonstrated a bifocal lesion with dyshomogeneous and cystic appearance, suggesting the diagnosis of germinoma. On the basis of this case report we would like to point out the importance of an early diagnosis in order to improve the prognosis of the disease and the necessity of a careful follow-up of these patients.

[Polyuria and polydipsia in a 5 year-old child: diagnostic problems]

Polyuria and polydipsia could be present in three groups of diseases; polydipsia psicogena characterized by an excessive water intake, central diabetes insipidus (CDI) with a defect in the production of AVP and nephrogenic diabetes insipidus in which a defect in the renal response to vasopressin is present. In particular, CDI can be caused by lesions like germinoma and craniopharyngioma, Langerhans'cell histiocytosis, inflammatory, autoimmune and vascular diseases, trauma resulting from surgery or an accident; and in rare cases, genetic defects in the synthesis of vasopressin that are inherited as autosomal dominant or X-linked recessive traits. However, 30% to 50% of cases are considered idiopathic. Nevertheless, 30-50% of cases is considered idiopathic. Here we present the case of a 5.5 year-old female patient, referred to our Department of Endocrinology Surgery for polyuria and polydipsia. Hormonal tests demonstrated the presence of CDI with normal anterior pituitary function. Magnetic resonance imaging showed the lack of hyperintensity of posterior pituitary. Pituitary stalk was median and of regular volume. Diagnosis of CDI has been confirmed and therapy has been started with desmopressin (Minirin) 0.2 mg/die. During the follow-up the patient was in good conditions, presented an adequate hydro-electrolytic balance and normal growth velocity. Anterior pituitary function was normal and MR remained stable. This case report highlights problems concerning differential diagnosis and the importance of a careful follow-up which must involve the whole family.

[Growth hormone and erythropoiesis. review of the literature]

In this analysis of hematopoiesis, the regrowth of colony-forming cells in the bone marrow was examined in patients who had undergone medullary ablation and bone marrow transplant. The various stages of erythropoeisis and the factors that influence blood cell production are discussed: hematopoietic microenvironment, cytokines, tissue oxygen. Drawing on results from rodent and human studies, growth hormone factor (GH) function is explained, its interaction with insulin-like growth factors I and II (IGF I and II), and their effects on hematopoiesis. The aim of the study was to show the close link between GH, IGF I and II and erythropoiesis, because patients with GH deficit may present with partially impaired erythyroid proliferation that leads to the onset of anemia.

Growth hormone therapy for short children born small for gestational age

Children born small for gestational age may demonstrate continued growth retardation, resulting in persistent short stature. In the majority of the cases, this is linked with abnormal growth hormone secretion and also abnormal insulin-like growth factor levels. This review discusses the treatment of such children with recombinant human growth hormone. It illustrates the importance of starting therapy early, the dose-dependent response, and the advantages of continuous therapy and describes safety considerations.