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Kiremitci Yilmaz S, Yilmaz Ovali G, Ozalp Kizilay D, Tarhan S, Ersoy B. Pitfalls of diagnosing pituitary hypoplasia in the patients with short stature. Endocrine 2024:10.1007/s12020-024-03951-9. [PMID: 38969909 DOI: 10.1007/s12020-024-03951-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 06/27/2024] [Indexed: 07/07/2024]
Abstract
PURPOSE Height age (HA) and bone age (BA) delay is well known in the patients with short stature. Therefore assessing pituitary hypoplasia based on chronological age (CA) might cause overdiagnosis of pituitary hypoplasia. We aimed to investigate the diagnostic and prognostic value of the PH and PV based on CA, HA, or BA in the patients with GHD. METHODS Fifty-seven patients with severe and 40 patients with partial GHD and 39 patients with ISS assigned to the study. For defining the most accurate diagnosis of pituitary hypoplasia, PH and PV were evaluated based on CA, BA and HA. The relationship of each method with clinical features was examined. RESULTS The mean PV was significantly larger in patients with ISS compared to the GH-deficient patients. PV was more correlated with clinical features including height SDS, stimulated GH concentration, IGF-1 and IGFBP-3 SDS, height velocity before and after rGH therapy. We found BA-based PV could discriminate GHD from ISS (Sensitivity: 17%, specificity: 98%, positive predictive value: 94%, negative predictive value: 39%), compared to the other methods based on PH or PV respect to CA and HA. 3% of patients with ISS, 17% of patients with GHD had pituitary hypoplasia based on PV-BA. CONCLUSION PV based on BA, has the most accurate diagnostic value for defining pituitary hypoplasia. But it should be kept in mind that there might be still misdiagnosed patients by this method. PV is also a significant predictor for the rGH response.
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Affiliation(s)
- Seniha Kiremitci Yilmaz
- Division of Pediatric Endocrinology, Health Sciences University, Istanbul Haseki Training and Research Hospital, Istanbul, Turkey.
| | - Gülgün Yilmaz Ovali
- Department of Radiology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Deniz Ozalp Kizilay
- Division of Pediatric Endocrinology and Metabolism, Ege University, Faculty of Medicine, İzmir, Turkey
| | - Serdar Tarhan
- Department of Radiology, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
| | - Betul Ersoy
- Division of Pediatric Endocrinology and Metabolism, Celal Bayar University, Faculty of Medicine, Manisa, Turkey
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Smyczyńska J, Hilczer M, Smyczyńska U, Lewiński A, Stawerska R. Transient Isolated, Idiopathic Growth Hormone Deficiency-A Self-Limiting Pediatric Disease with Male Predominance or a Diagnosis Based on Uncertain Criteria? Lesson from 20 Years' Real-World Experience with Retesting at One Center. Int J Mol Sci 2024; 25:5739. [PMID: 38891927 PMCID: PMC11171613 DOI: 10.3390/ijms25115739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
In the majority of children with growth hormone (GH) deficiency (GHD), normal GH secretion may occur before the attainment of final height. The aim of the study was to assess the incidence of persistent and transient GHD and the effectiveness of recombined human GH (rhGH) therapy in children with isolated, idiopathic GHD with respect to the moment of therapy withdrawal and according to different diagnostic criteria of GHD. The analysis included 260 patients (173 boys, 87 girls) with isolated, idiopathic GHD who had completed rhGH therapy and who had been reassessed for GH and IGF-1 secretion. The incidence of transient GHD with respect to different pre- and post-treatment criteria was compared together with the assessment of GH therapy effectiveness. The incidence of transient GHD, even with respect to pediatric criteria, was very high. Normal GH secretion occurred before the attainment of near-final height. Application of more restricted criteria decreased the number of children diagnosed with GHD but not the incidence of transient GHD among them. Poor response to GH therapy was observed mainly in the patients with normal IGF-1 before treatment, suggesting that their diagnosis of GHD may have been a false positive. Further efforts should be made to avoid the overdiagnosis GHD and the overtreatment of patients.
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Affiliation(s)
- Joanna Smyczyńska
- Department of Pediatrics, Diabetology, Endocrinology and Nephrology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Maciej Hilczer
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland; (M.H.); (A.L.); (R.S.)
| | - Urszula Smyczyńska
- Department of Biostatistics and Translational Medicine, Medical University of Lodz, 90-419 Lodz, Poland;
| | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland; (M.H.); (A.L.); (R.S.)
- Department of Pediatric Endocrinology, Medical University of Lodz, 90-419 Lodz, Poland
| | - Renata Stawerska
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital–Research Institute, 93-338 Lodz, Poland; (M.H.); (A.L.); (R.S.)
- Department of Pediatric Endocrinology, Medical University of Lodz, 90-419 Lodz, Poland
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3
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Lanzetta MA, Dalla Bona E, Tamaro G, Vidonis V, Vittori G, Faleschini E, Barbi E, Tornese G. Clinical and laboratory characteristics but not response to treatment can distinguish children with definite growth hormone deficiency from short stature unresponsive to stimulation tests. Front Endocrinol (Lausanne) 2024; 15:1288497. [PMID: 38495788 PMCID: PMC10940512 DOI: 10.3389/fendo.2024.1288497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction It has been proposed that not all children with short stature displaying an inadequate response to tests for growth hormone (GH) secretion truly suffer from GH deficiency (GHD). Only children with a monogenic cause of GHD or an identifiable combined hormonal deficiency or anatomical anomaly in the hypothalamic-pituitary axis should be considered definite GHD (dGHD). The remaining patients can be defined as a separate group of patients, "short stature unresponsive to stimulation tests" (SUS). The aim of this proof-of-concept study, was to assess whether SUS patients treated with rhGH exhibit any differences compared to GHD patients undergoing the same treatment. Methods Retrospective analysis on 153 consecutive patients with short stature and pathological response to two GH stimulation tests. Patients with dGHD were defined as those with a clear genetic or anatomical hypothalamic-pituitary anomaly, as well as those with combined pituitary hormone deficiencies and those with a known insult to the hypothalamic-pituitary axis (i.e. total brain irradiation) (n=38, 25%); those without any of the previous anomalies were defined as SUS (n=115, 75%). Results At diagnosis, dGHD and SUS populations did not differ significantly in sex (F 32% vs 28%, p=0.68), age (11.9 vs 12.1, p=0.45), height SDS at diagnosis (-2.2 vs. -2.0, p=0.35) and prevalence of short stature (height <-2 SDS) (56% vs 51%, p=0.45). IGF-1 SDS were significantly lower in dGHD (-2.0 vs -1.3, p<0.01). After 1 year of treatment, the prevalence of short stature was significantly reduced in both groups (31% in dGHD vs. 21% in SUS, p<0.01) without any significant differences between groups (p=0.19), while the increase in IGF-1 SDS for bone age was greater in the dGHD category (+1.9 vs. +1.5, p<0.01), with no further difference in IGF-1 SDS between groups. At the last available follow-up, 59 patients had reached the near adult height (NAH) and underwent retesting for GHD. No differences in NAH were found (-0.3 vs. -0.4 SDS, 0% vs. 4% of short stature). The prevalence of pathological retesting was higher in dGHD (60% vs. 10%, p<0.01) as well as of overweight and obesity (67% vs. 26%). Conclusion Stimulation tests and the equivalent benefit from rhGH therapy, cannot distinguish between dGHD and SUS populations. In addition, lower IGF-1 concentrations at baseline and their higher increase during treatment in dGHD patients, and the lack of pathological retesting upon reaching NAH in SUS patients, are facts that suggest that deficient GH secretion may not be the cause of short stature in the SUS studied population.
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Affiliation(s)
- Maria Andrea Lanzetta
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Eva Dalla Bona
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Gianluca Tamaro
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Viviana Vidonis
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Giada Vittori
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Elena Faleschini
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Egidio Barbi
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
| | - Gianluca Tornese
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
- Institute for Maternal and Child Health IRCCS “Burlo Garofolo”, Trieste, Italy
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Mericq V, Iñiguez G, Pinto G, Gonzalez-Briceño LG, Samara-Boustani D, Thalassinos C, Flechtner I, Stoupa A, Beltrand J, Besançon A, Brabant S, Ghazal K, Leban M, Touraine P, Cavada G, Polak M, Kariyawasam D. Identifying patient-related predictors of permanent growth hormone deficiency. Front Endocrinol (Lausanne) 2023; 14:1270845. [PMID: 37881494 PMCID: PMC10597646 DOI: 10.3389/fendo.2023.1270845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/27/2023] [Indexed: 10/27/2023] Open
Abstract
Objective Isolated childhood growth hormone deficiency (GHD) can persist into adulthood, and re-testing at the transition period is needed to determine whether continued growth hormone therapy is indicated. Here, our objective was to identify predictors of permanent GHD. Design Retrospective single-centre study of patients with childhood-onset GHD who were re-tested after adult height attainment. Methods Auxological, clinical, laboratory, and MRI data throughout follow-up were collected. Results We included 101 patients. At GH treatment initiation, age was 8.1 ± 0.4 years, height -2.25 ± 0.8, and BMI -0.27 ± 0.1 SDS. The 29 (28.7%) patients with persistent GHD had lower height SDS (-2.57 ± 0.1 vs. -2.11 ± 0.1, p<0.001) and mean GH peaks (8.4 ± 1.0 vs.13.2 ± 0.5 mIU/L, p<0.001) at GHD diagnosis; at adult height, they had lower IGF1 (232 ± 19.9 vs. 331 ± 9.1 ng/mL, p<0.001) and higher BMI SDS (-0.15 ± 0.27 vs. -0.73 ± 0.13, p<0.005). By multivariate analysis, the best predictive model included height and BMI SDS, both GH peaks, and MRI findings at diagnosis. Patients with height at diagnosis <-3 SDS had a 7.7 (95% IC 1.4-43.1, p=0.02) fold higher risk of persistent GHD after adjustment on BMI SDS. An abnormal pituitary region by MRI was the strongest single predictor (7.2 times, 95% CI 2.7-19.8) and after multivariate analysis adjustment for GH peaks and height SDS at diagnosis, the risk increased to 10.6 (1.8 - 61.3) times. Conclusions Height <-3 SDS at GHD diagnosis and pituitary MRI abnormalities should lead to a high index of suspicion for persistent GHD.
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Affiliation(s)
- Veronica Mericq
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - German Iñiguez
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
| | - Graziella Pinto
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Laura G. Gonzalez-Briceño
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Dinane Samara-Boustani
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Caroline Thalassinos
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Isabelle Flechtner
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Athanasia Stoupa
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Institut Imagine, Paris, France
| | - Jacques Beltrand
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Université Paris Cité, Paris, France
| | - Alix Besançon
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Séverine Brabant
- Functional Exploration Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Khaldoun Ghazal
- Functional Exploration Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Monique Leban
- Functional Exploration Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Touraine
- Endocrinology Department, La Pitié-Salpêtrière University Hospital, Paris, France
| | - Gabriel Cavada
- Public Health Department, Faculty of medicine, University of Chile, Santiago, Chile
| | - Michel Polak
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Institut Imagine, Paris, France
- Université Paris Cité, Paris, France
| | - Dulanjalee Kariyawasam
- Paediatric Endocrinology, Diabetology, and Gynaecology Department, Necker-Enfants Malades University Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
- Institut Imagine, Paris, France
- Université Paris Cité, Paris, France
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Brettell E, Högler W, Woolley R, Cummins C, Mathers J, Oppong R, Roy L, Khan A, Hunt C, Dattani M. The Growth Hormone Deficiency (GHD) Reversal Trial: effect on final height of discontinuation versus continuation of growth hormone treatment in pubertal children with isolated GHD-a non-inferiority Randomised Controlled Trial (RCT). Trials 2023; 24:548. [PMID: 37605233 PMCID: PMC10440873 DOI: 10.1186/s13063-023-07562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/02/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Growth hormone deficiency (GHD) is the commonest endocrine cause of short stature and may occur in isolation (I-GHD) or combined with other pituitary hormone deficiencies. Around 500 children are diagnosed with GHD every year in the UK, of whom 75% have I-GHD. Growth hormone (GH) therapy improves growth in children with GHD, with the goal of achieving a normal final height (FH). GH therapy is given as daily injections until adult FH is reached. However, in many children with I-GHD their condition reverses, with a normal peak GH detected in 64-82% when re-tested at FH. Therefore, at some point between diagnosis and FH, I-GHD must have reversed, possibly due to increase in sex hormones during puberty. Despite increasing evidence for frequent I-GHD reversal, daily GH injections are traditionally continued until FH is achieved. METHODS/DESIGN Evidence suggests that I-GHD children who re-test normal in early puberty reach a FH comparable to that of children without GHD. The GHD Reversal study will include 138 children from routine endocrine clinics in twelve UK and five Austrian centres with I-GHD (original peak GH < 6.7 mcg/L) whose deficiency has reversed on early re-testing. Children will be randomised to either continue or discontinue GH therapy. This phase III, international, multicentre, open-label, randomised controlled, non-inferiority trial (including an internal pilot study) will assess whether children with early I-GHD reversal who stop GH therapy achieve non-inferior near FH SDS (primary outcome; inferiority margin 0.55 SD), target height (TH) minus near FH, HRQoL, bone health index and lipid profiles (secondary outcomes) than those continuing GH. In addition, the study will assess cost-effectiveness of GH discontinuation in the early retesting scenario. DISCUSSION If this study shows that a significant proportion of children with presumed I-GHD reversal generate enough GH naturally in puberty to achieve a near FH within the target range, then this new care pathway would rapidly improve national/international practice. An assumed 50% reversal rate would provide potential UK health service cost savings of £1.8-4.6 million (€2.05-5.24 million)/year in drug costs alone. This new care pathway would also prevent children from having unnecessary daily GH injections and consequent exposure to potential adverse effects. TRIAL REGISTRATION EudraCT number: 2020-001006-39.
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Affiliation(s)
- Elizabeth Brettell
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Wolfgang Högler
- Department of Paediatrics and Adolescent Medicine, Johannes Kepler University Linz, Krankenhausstrasse 26-30, Linz, 4020, Austria.
| | - Rebecca Woolley
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Carole Cummins
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jonathan Mathers
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Raymond Oppong
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Laura Roy
- Child Growth Foundation, Aston House, Redburn Road, Newcastle Upon Tyne, UK
| | - Adam Khan
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Charmaine Hunt
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
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Borghammar C, Boije V, Becker C, Lindberg B, Elfving M. Prevalence of refractoriness when testing growth hormone levels in children. Growth Horm IGF Res 2023; 71:101549. [PMID: 37562165 DOI: 10.1016/j.ghir.2023.101549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/19/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE Late night spontaneous growth hormone (GH) pulses may influence the pituitary GH response to provocation tests. We evaluated GH response during arginine-insulin-tolerance test (AITT) after a GH peak during a short spontaneous nocturnal profile (SSNP) in children with short stature or low growth velocity. DESIGN Using SSNP and subsequent AITT, we examined 257 children 4-18 years old (138 (53.7%) males) recruited from three hospitals. Medical records were reviewed retrospectively. Refractory children were defined as a GH peak ≥7 μg/L during SSNP but no GH peak ≥7 μg/L during AITT. RESULTS In total, 201/257 children had a GH peak ≥7 μg/L at SSNP and/or AITT. Of these, 21.9% were refractory. The proportion of males (p = 0.033) and body mass index (BMI) standard deviation score (SDS) (p = 0.037) were higher in the refractory group than in children with a GH peak ≥7 μg/L during AITT. The median period between last GH peak ≥7 μg/L during SSNP and GHmax at AITT was 210 (30-390) minutes. The GHmax at AITT occurred 30 min earlier for children without a peak ≥7 μg/L during the SSNP (p = 0.004). The number of refractoriness differed somewhat between the hospitals (p = 0.025). CONCLUSIONS Many children with short stature were refractory at testing; among them we found few clinical characteristics. Refractoriness might be influenced by some differences in procedure, but needs to be considered when evaluating GH response in children.
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Affiliation(s)
- Camilla Borghammar
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund, Sweden.
| | - Victoria Boije
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund, Sweden
| | - Charlotte Becker
- Department of Clinical Chemistry and Pharmacology, University and Regional Laboratories, Region Skåne, Sweden
| | - Bengt Lindberg
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund, Sweden
| | - Maria Elfving
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Pediatrics, Pediatric Endocrinology, Lund, Sweden
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Clinical Features of Transient Growth Hormone Deficiency. ENDOCRINES 2023. [DOI: 10.3390/endocrines4010009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
Background: Most patients with idiopathic growth hormone deficiency (iGHD) in childhood have normal GH stimulation test results in adulthood. The present study aimed to investigate the characteristics and possible etiology of transient iGHD. Methods: Patients with childhood-onset iGHD who completed their GH treatment between March 2010 and March 2021 were retrospectively studied. Patients with a clear history of child abuse or constitutional delay of growth and puberty were excluded. Ten patients with a diagnosis of iGHD based on a decreased growth rate and growth hormone stimulation test findings at the time of onset were included. Retesting demonstrated that these patients had a normal GH level. Results: Five patients had insufficient weight gain (BMI SD score < −1.0 at the start of treatment or a decrease in BMI SD score > 1.0 from one year before treatment to the start of treatment). The other five patients had no remarkable clinical features. One patient had decreased height velocity at the same time as their sibling. Conclusion: Insufficient pre-treatment weight gain or a familial cluster of cases may be related to low GH peaks of GHST, leading to a diagnosis of transient GHD.
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Yalovitsky G, Shaki D, Hershkovitz E, Friger M, Haim A. Comparison of glucagon stimulation test and low dose ACTH test in assessing hypothalamic-pituitary-adrenal (HPA) axis in children. Clin Endocrinol (Oxf) 2023; 98:678-681. [PMID: 36750758 DOI: 10.1111/cen.14887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/27/2023] [Accepted: 02/05/2023] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Children with a pituitary hormone deficiency are at risk for secondary adrenal insufficiency (AI). A stimulation test is usually performed for diagnosing AI, evaluating both the hypothalamic-pituitary-adrenal and growth hormone (GH)-IGF-1 axes. This single test is preferred by clinicians and is considerably more tolerable by patients. The objective of this study was to evaluate the glucagon stimulation test (GST), which is commonly used to assess both axes. Its diagnostic capability for GH deficiency is high and well accepted, however its utility for determining secondary AI has not been well established. METHODS This retrospective study involved 120 patients under 18 years of age with short stature who had undergone both a GST and low dose ACTH stimulation test (LDACTH test). Twenty-six children who had more than 6 months elapsed between the two tests were excluded from the study. The study was conducted on patients of the Pediatric Endocrinology Department at Soroka University Hospital, a tertiary medical centre in Beer Sheva, Israel. Statistical analyses were carried out via IBM SPSS (v. 22), with a significance level determined at p < .05. RESULTS Different cortisol cut-off values were assessed for GST and it was determined that the highest combined sensitivity and specificity yielded a cut-off point of 320 nmol/L (56% sensitivity and 83% specificity) while the currently accepted cut-off value (500 nmol/L) yielded 100% sensitivity and 6% specificity. CONCLUSION The results of this study show that GST is not an optimal tool for diagnosing secondary AI. Therefore, clinicians using this test should interpret its results with caution.
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Affiliation(s)
- Guy Yalovitsky
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - David Shaki
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
| | - Eli Hershkovitz
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
| | - Michael Friger
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Alon Haim
- Goldman Medical School at the Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
- Pediatric Endocrinology Unit, Soroka University Medical Center, Be'er Sheva, Israel
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Vakharia JD, Stanley TL. Facilitating the transition from paediatric to adult care in endocrinology: a focus on growth disorders. Curr Opin Endocrinol Diabetes Obes 2023; 30:32-43. [PMID: 36384873 DOI: 10.1097/med.0000000000000785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
PURPOSE OF REVIEW Many childhood-onset growth disorders (COGDs) require continued care into adulthood, and the time of transition between paediatric and adult providers carries a high risk for interruptions in medical care and consequent worsening of disease management. RECENT FINDINGS Research into best practices for healthcare transition (HCT) describes three distinct stages. Stage 1, transition planning and preparation, begins in the paediatric setting during early adolescence and ensures that the patient has adequate medical knowledge, self-management skills, and readiness for transition. Stage 2, transfer to adult care, occurs with variable timing depending on transition readiness and is best facilitated by warm hand-offs and, when possible, joint visits with the paediatric and adult provider(s) and/or involvement of a care coordinator. Stage 3, intake and integration into adult care, entails retaining the patient in the adult setting, ideally through the involvement of a multidisciplinary approach. SUMMARY This review covers general principles for ensuring smooth transition of adolescents and young adults (AYA) with COGD, disease-specific medical considerations for paediatric and adult endocrinologists during the transition process, and general and disease-specific resources to assess transition readiness and facilitate transition.
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Affiliation(s)
- Janaki D Vakharia
- Division of Pediatric Endocrinology, Department of Pediatrics, Mass-General Hospital for Children and Harvard Medical School
- Division of Endocrinology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Takara L Stanley
- Division of Pediatric Endocrinology, Department of Pediatrics, Mass-General Hospital for Children and Harvard Medical School
- Division of Endocrinology, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Bidlingmaier M, Gleeson H, Latronico AC, Savage MO. Applying precision medicine to the diagnosis and management of endocrine disorders. Endocr Connect 2022; 11:e220177. [PMID: 35968864 PMCID: PMC9513637 DOI: 10.1530/ec-22-0177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/05/2022] [Indexed: 12/02/2022]
Abstract
Precision medicine employs digital tools and knowledge of a patient's genetic makeup, environment and lifestyle to improve diagnostic accuracy and to develop individualised treatment and prevention strategies. Precision medicine has improved management in a number of disease areas, most notably in oncology, and it has the potential to positively impact others, including endocrine disorders. The accuracy of diagnosis in young patients with growth disorders can be improved by using biomarkers. Insulin-like growth factor I (IGF-I) is the most widely accepted biomarker of growth hormone secretion, but its predictive value for recombinant human growth hormone treatment response is modest and various factors can affect the accuracy of IGF-I measurements. These factors need to be taken into account when considering IGF-I as a component of precision medicine in the management of growth hormone deficiency. The use of genetic analyses can assist with diagnosis by confirming the aetiology, facilitate treatment decisions, guide counselling and allow prompt intervention in children with pubertal disorders, such as central precocious puberty and testotoxicosis. Precision medicine has also proven useful during the transition of young people with endocrine disorders from paediatric to adult services when patients are at heightened risk of dropping out from medical care. An understanding of the likelihood of ongoing GH deficiency, using tools such as MRI, detailed patient history and IGF-I levels, can assist in determining the need for continued recombinant human growth hormone treatment during the process of transitional care.
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Affiliation(s)
- Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig-Maximilians University, Munich, Germany
| | - Helena Gleeson
- Department of Endocrinology, Queen Elizabeth Hospital, Birmingham, UK
| | - Ana-Claudia Latronico
- Department of Internal Medicine, Discipline of Endocrinology and Metabolism, Sao Paulo Medical School, University of Sao Paulo, Sao Paulo, Brazil
| | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, London, UK
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11
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Laurer E, Sirovina A, Blaschitz A, Tischlinger K, Montero-Lopez R, Hörtenhuber T, Wimleitner M, Högler W. The landscape of retesting in childhood-onset idiopathic growth hormone deficiency and its reversibility: a systematic review and meta-analysis. Eur J Endocrinol 2022; 187:265-278. [PMID: 35670597 DOI: 10.1530/eje-21-1179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/07/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Children diagnosed with idiopathic isolated growth hormone deficiency (IGHD) are frequently observed to no longer be GH-deficient at a later stage of growth as a result of 'GHD reversal'. Reevaluation of GH status by stimulation test is currently incorporated into management guidelines at attainment of final height (FH). Over the past three decades, numerous studies have evaluated reversal rates using different methodologies including crucial parameters like GHD aetiology, GH cut-off and retesting time point, with heterogeneous results. We aimed to systematically analyse the reversibility of childhood-onset IGHD dependent on retesting GH cut-offs and retesting time points. METHODS PubMed, Cochrane Library, TRIP database and NHS Evidence were searched for publications investigating the reversibility of IGHD from database initiation to 30 June 2020 following PRISMA recommendations. Study cohorts were pooled according to retesting GH cut-off and time point. Reversal rates were calculated using random-effects models. RESULTS Of the 29 studies initially identified, 25 provided sufficient detail for IGHD analysis, resulting in 2030 IGHD patient data. Reversal rates decreased significantly as the retesting GH cut-off increased (P = 0.0013). Pooled (95% CI) reversal rates were 80% (59-92%, n = 227), 73% (62-81%, n = 516) and 55% (41-68%, n = 1287) for cohorts using retesting GH cut-offs of 3-4 ng/mL, 5-6 ng/mL and 7.7-10 ng/mL, respectively. Individuals retested at FH (n = 674) showed a pooled reversal rate of 74% (64-82%) compared to 48% (25-71%) when retested before FH (n = 653). CONCLUSION Provided evidence supports reevaluation of current IGHD management guidelines. The high reversal rates should instigate consideration of early retesting.
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Affiliation(s)
- Elisabeth Laurer
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Antonio Sirovina
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Alexandra Blaschitz
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Katharina Tischlinger
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Rodrigo Montero-Lopez
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Thomas Hörtenhuber
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Marlene Wimleitner
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
| | - Wolfgang Högler
- 1Department of Pediatrics and Adolescent Medicine, Johannes Kepler University Linz, Linz, Austria
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12
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Cerbone M, Katugampola H, Simpson HL, Dattani MT. Approach to the Patient: Management of Pituitary Hormone Replacement Through Transition. J Clin Endocrinol Metab 2022; 107:2077-2091. [PMID: 35262704 PMCID: PMC9202712 DOI: 10.1210/clinem/dgac129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Indexed: 11/19/2022]
Abstract
Hypopituitarism in childhood is a rare, complex disorder that can present with highly variable phenotypes, which may continue into adult life. Pituitary deficits can evolve over time, with unpredictable patterns resulting in significant morbidity and mortality. Hypopituitarism and hypothalamic dysfunction may be associated with challenging comorbidities such as obesity, learning difficulties, behavioral issues, sleep disturbance, and visual impairment. Transition is the purposeful planned movement of adolescents and young adults with chronic conditions from child-centered to adult-oriented health care systems with a shift from parent- to patient-focused care. To achieve effective transition within a health care setting, the inherent challenges involved in the evolution from a dependent child to an independent adult must be recognized. Transition is a critical time medically for patients with hypopituitarism. Complex issues with respect to puberty, attainment of optimal stature, adherence to treatment, and acceptance of the need for life-sustaining medications need to be addressed. For health care professionals, transition is an opportunity for reassessment of the pituitary deficits and the need for lifelong replacement therapies, often against a background of complex psychological issues. We present 4 illustrative cases of hypopituitarism of differing etiologies with diverse clinical presentations. Diagnostic and management processes from clinical presentation to young adulthood are discussed, with a particular focus on needs and outcomes through transition.
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Affiliation(s)
- Manuela Cerbone
- London Centre for Paediatric Endocrinology and Diabetes at Great Ormond Street Children’s Hospital and University College London Hospitals, London WC1N 1EH, UK
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Harshini Katugampola
- London Centre for Paediatric Endocrinology and Diabetes at Great Ormond Street Children’s Hospital and University College London Hospitals, London WC1N 1EH, UK
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
| | - Helen L Simpson
- Section of Molecular Basis of Rare Disease, Genetics and Genomic Medicine Programme, University College London Great Ormond Street Institute of Child Health, London WC1N 1EH, UK
- Department of Diabetes and Endocrinology, University College London Hospitals NHS Trust, London NW1 2BU, UK
| | - Mehul T Dattani
- Correspondence: Mehul T. Dattani, MD, GOS UCL Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK. E-mail:
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13
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Boguszewski MCS, Boguszewski CL, Chemaililly W, Cohen LE, Gebauer J, Higham C, Hoffman AR, Polak M, Yuen KCJ, Alos N, Antal Z, Bidlingmaier M, Biller BMK, Brabant G, Choong CSY, Cianfarani S, Clayton PE, Coutant R, Cardoso-Demartini AA, Fernandez A, Grimberg A, Guðmundsson K, Guevara-Aguirre J, Ho KKY, Horikawa R, Isidori AM, Jørgensen JOL, Kamenicky P, Karavitaki N, Kopchick JJ, Lodish M, Luo X, McCormack AI, Meacham L, Melmed S, Mostoufi Moab S, Müller HL, Neggers SJCMM, Aguiar Oliveira MH, Ozono K, Pennisi PA, Popovic V, Radovick S, Savendahl L, Touraine P, van Santen HM, Johannsson G. Safety of growth hormone replacement in survivors of cancer and intracranial and pituitary tumours: a consensus statement. Eur J Endocrinol 2022; 186:P35-P52. [PMID: 35319491 PMCID: PMC9066587 DOI: 10.1530/eje-21-1186] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/23/2022] [Indexed: 12/02/2022]
Abstract
Growth hormone (GH) has been used for over 35 years, and its safety and efficacy has been studied extensively. Experimental studies showing the permissive role of GH/insulin-like growth factor 1 (IGF-I) in carcinogenesis have raised concerns regarding the safety of GH replacement in children and adults who have received treatment for cancer and those with intracranial and pituitary tumours. A consensus statement was produced to guide decision-making on GH replacement in children and adult survivors of cancer, in those treated for intracranial and pituitary tumours and in patients with increased cancer risk. With the support of the European Society of Endocrinology, the Growth Hormone Research Society convened a Workshop, where 55 international key opinion leaders representing 10 professional societies were invited to participate. This consensus statement utilized: (1) a critical review paper produced before the Workshop, (2) five plenary talks, (3) evidence-based comments from four breakout groups, and (4) discussions during report-back sessions. Current evidence reviewed from the proceedings from the Workshop does not support an association between GH replacement and primary tumour or cancer recurrence. The effect of GH replacement on secondary neoplasia risk is minor compared to host- and tumour treatment-related factors. There is no evidence for an association between GH replacement and increased mortality from cancer amongst GH-deficient childhood cancer survivors. Patients with pituitary tumour or craniopharyngioma remnants receiving GH replacement do not need to be treated or monitored differently than those not receiving GH. GH replacement might be considered in GH-deficient adult cancer survivors in remission after careful individual risk/benefit analysis. In children with cancer predisposition syndromes, GH treatment is generally contraindicated but may be considered cautiously in select patients.
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Affiliation(s)
| | - Cesar L Boguszewski
- SEMPR (Endocrine Division), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
| | - Wassim Chemaililly
- Division of Endocrinology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laurie E Cohen
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, New York, New York, USA
| | - Judith Gebauer
- Department of Internal Medicine I, University Medical Center Schleswig-Holstein, Luebeck, Germany
| | - Claire Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust, University of Manchester, and Manchester Academic Health Science Centre, Manchester, UK
| | - Andrew R Hoffman
- Stanford University School of Medicine, Stanford, California, USA
| | - Michel Polak
- Department of Pediatric Endocrinology, Gynecology and Diabetology, Hôpital Universitaire Necker Enfants Malades, AP-HP, Université de Paris, Paris, France
| | - Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, Phoenix, Arizona, USA
- Department of Neuroendocrinology, St. Joseph’s Hospital and Medical Center, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, Arizona, USA
| | - Nathalie Alos
- Division of Endocrinology, Sainte-Justine University Hospital Centre, University of Montreal, Montreal, Quebec, Canada
| | - Zoltan Antal
- Memorial Sloan-Kettering Cancer Center and Weill Cornel Medicine New York Presbyterian Hospital, New York, New York, USA
| | | | - Beverley M K Biller
- Neuroendocrine & Pituitary Tumor Clinical Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Brabant
- Department of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Catherine S Y Choong
- Department of Endocrinology and Diabetes, Perth Children’s Hospital, Child & Adolescent Health Service, Perth, Australia
- Division of Paediatrics, Faculty of Health & Medical Sciences, University of Western Australia, Perth, Australia
| | - Stefano Cianfarani
- Department of Systems Medicine, University of Rome Tor Vergata, Rome Italy
- Dipartimento Pediatrico Universitario Ospedaliero, IRCCS ‘Bambino Gesu’ Children’s Hospital, Rome Italy
- Department of Women’s and Children’s Health, Karolinska Institute and University Hospital, Stockholm, Sweden
| | - Peter E Clayton
- Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Regis Coutant
- Department of Pediatric Endocrinology, University Hospital, Angers, France
| | - Adriane A Cardoso-Demartini
- Pediatric Endocrinology Unit, Department of Pediatrics, Hospital de Clínicas, Federal University of Parana, Curitiba, Brazil
| | - Alberto Fernandez
- Endocrinology Department, Hospital Universitario de Mostoles, Mostoles, Spain
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kolbeinn Guðmundsson
- Children’s Medical Center, Landspitali – The National University Hospital of Iceland, Reykjavik, Iceland
| | - Jaime Guevara-Aguirre
- Department of Diabetes and Endocrinology, College of Medicine, Universidad San Francisco de Quito at Quito, Quito, Ecuador
| | - Ken K Y Ho
- The Garvan Institute of Medical Research and St. Vincent Hospital, Sydney, Australia
| | - Reiko Horikawa
- Division of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Roma, Italy
| | | | - Peter Kamenicky
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l’Hypophyse, Le Kremlin-Bicêtre, France
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Correspondence should be addressed to N Karavitaki;
| | - John J Kopchick
- Edison Biotechnology Institute and Heritage College of Osteopathic Medicine, Ohio University, Athens, Ohio, USA
| | - Maya Lodish
- Division of Pediatric Endocrinology and Diabetes, University of California, San Francisco, California, USA
| | - Xiaoping Luo
- Department of Pediatrics, Tongji Hospital, Tonji Medical College, Hu, China
| | - Ann I McCormack
- Department of Endocrinology, St Vincent’s Hospital, Sydney, Australia
- Hormones and Cancer Group, Garvan Institute of Medical Research, Sydney, Australia
- St Vincent’s Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Lillian Meacham
- Children’s Healthcare of Atlanta Aflac Cancer and Blood Disorders Service, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Shlomo Melmed
- Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Sogol Mostoufi Moab
- Divisions of Oncology and Endocrinology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hermann L Müller
- Department of Pediatrics and Pediatric Hematology/Oncology, University Children’s Hospital, Klinikum Oldenburg AöR, Carl von Ossietzki University Oldenburg, Oldenburg, Germany
| | | | - Manoel H Aguiar Oliveira
- Division of Endocrinology, Health Sciences Graduate Program, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| | - Keiichi Ozono
- Department of Pediatrics, Osaka University Graduate School of Children, Osaka, Japan
| | - Patricia A Pennisi
- Centro de Investigaciones Endocrinológicas ‘Dr. César Bergadá’, CEDIE-CONICET-FEI, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Vera Popovic
- Medical Faculty, University of Belgrade, Belgrade, Serbia
| | - Sally Radovick
- Department of Pediatrics, Rutgers Robert Wood, Johnson Medical School, New Brunswick, New Jersey, USA
| | - Lars Savendahl
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Division of Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine and Gynecological Disorders, Pitie Salpetriere Hospital, Sorbonne Université Medecine, Paris, France
| | - Hanneke M van Santen
- Department of Pediatric Endocrinology, Wilhelmina Chilrdren’s Hospital, University Medical Center and Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
| | - Gudmundur Johannsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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14
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Lee NY, Kim SE, Kim S, Ahn MB, Kim SH, Cho WK, Cho KS, Jung MH, Suh BK. Effect of body mass index on peak growth hormone level after growth hormone stimulation test in children with short stature. Ann Pediatr Endocrinol Metab 2021; 26:192-198. [PMID: 34015903 PMCID: PMC8505037 DOI: 10.6065/apem.2040246.123] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 02/15/2021] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The aim of this study is to evaluate the effect of body mass index (BMI) on peak serum growth hormone (GH) level after GH stimulation test in children with short stature. METHODS Data were obtained from retrospective medical record reviews of those who visited the pediatric endocrine clinic at St. Vincent's Hospital of Catholic University for short stature from January 2010 to June 2019. A total of 115 children (66 boys and 49 girls) whose height was less than the third percentile according to age and sex underwent GH stimulation testing. RESULTS Of the 115 subjects, 47 were diagnosed with GH deficiency (GHD) and 68 were diagnosed with idiopathic short stature (ISS). In patients with GHD, weight standard deviation score (SDS) (P<0.001) and BMI SDS (P≤0.001) were higher, and free thyroxine (T4) level (P=0.012) was lower than those in the ISS group. In total subjects, peak serum GH level after GH stimulation test showed negative correlations with weight SDS (r=-0.465, P<0.001), BMI SDS (r=-0.398, P<0.001), and thyroid stimulating hormone (r=-0.248, P=0.008) and a positive correlation with free T4 (r=0.326, P<0.001). In multiple regression analysis, BMI SDS (P=0.003) was negatively associated with peak serum GH level in GH stimulation testing after adjusting for age, sex, pubertal status, and type of pharmacological stimulus. CONCLUSION The BMI SDS influences peak serum GH level after GH stimulation testing. We should consider BMI factors when interpreting the results of GH stimulation testing.
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Affiliation(s)
- Na Yeong Lee
- Department of Pediatrics, Seoul St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung Eun Kim
- Department of Pediatrics, Seoul St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seulki Kim
- Department of Pediatrics, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Moon Bae Ahn
- Department of Pediatrics, Seoul St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Shin Hee Kim
- Department of Pediatrics, Incheon St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Won Kyoung Cho
- Depar tment of Pediatrics, St. Vincent ’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea,Address for correspondence: Won Kyoung Cho Depar tment of Pediatrics, St. Vincent ’s Hospital, College of Medicine, The Catholic University of Korea, 93, Jungbu-daero, Paldal-gu, Suwon 16247, Korea
| | - Kyoung Soon Cho
- Department of Pediatrics, Bucheon St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Bucheon, Korea
| | - Min Ho Jung
- Department of Pediatrics, Yeouido St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Kyu Suh
- Department of Pediatrics, Seoul St. Mary ’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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15
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Biller BMK, Höybye C, Carroll P, Gordon MB, Birkegård AC, Kelepouris N, Nedjatian N, Weber MM. Pregnancy outcomes in women receiving growth hormone replacement therapy enrolled in the NordiNet® International Outcome Study (IOS) and the American Norditropin® Studies: Web-Enabled Research (ANSWER) Program. Pituitary 2021; 24:611-621. [PMID: 33709288 PMCID: PMC8270875 DOI: 10.1007/s11102-021-01138-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 12/23/2022]
Abstract
PURPOSE Data on the safety of growth hormone (GH) replacement therapy during pregnancy are limited. We report a combined analysis of data from pregnant women treated with GH while enrolled in two non-interventional, multicenter studies: NordiNet® International Outcome Study (IOS) and the American Norditropin® Studies: Web-Enabled Research (ANSWER) Program. METHODS Pregnancy data were pooled from NordiNet® IOS and the ANSWER Program. Data were collected during routine clinic visits by participating physicians using a web-based system. Patients exposed to GH replacement therapy during pregnancy were included in the analysis. RESULTS The study population included 40 female patients with typical causes of adult GH deficiency (GHD). Overall, there were 54 pregnancies. Of these, 47 were exposed to GH between conception and delivery. In 48.9% of pregnancies exposed to GH, the dose was > 0.6 mg/day. GH was continued past conception and then stopped during the first, second, and third trimester, in 27.7%, 17.0%, and 2.1% of pregnancies, respectively. In 29.8%, GH was continued throughout pregnancy, with an unchanged dose in most cases. Of the 47 GH-exposed pregnancies, 37 (78.7%) progressed to normal delivery. There were three adverse events reported in two pregnancies. CONCLUSION These real-world data suggest that there were no new safety signals related to GH exposure in women with GHD during pregnancy. These results are consistent with findings from previous studies reporting data in pregnancies exposed to GH at conception or throughout pregnancy. This observational study in additional pregnancies provides further evidence that GH exposure does not adversely affect pregnancy outcome. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT00960128 (date of registration: August 13, 2009) and NCT01009905 (date of registration: November 5, 2009).
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Affiliation(s)
- Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Bulfinch 457B, Fruit St., Boston, MA, 02114, USA.
| | - Charlotte Höybye
- Department of Endocrinology, and Department of Molecular Medicine and Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Paul Carroll
- Department of Endocrinology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Murray B Gordon
- Allegheny Neuroendocrinology Center, Division of Endocrinology, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | | | - Navid Nedjatian
- Global Medical Affairs - Rare Endocrine Disorders, Novo Nordisk Health Care AG, Zurich, Switzerland
| | - Matthias M Weber
- Unit of Endocrinology, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Germany
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16
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Influence of biochemical diagnosis of growth hormone deficiency on replacement therapy response and retesting results at adult height. Sci Rep 2021; 11:14553. [PMID: 34267285 PMCID: PMC8282600 DOI: 10.1038/s41598-021-93963-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 06/18/2021] [Indexed: 02/06/2023] Open
Abstract
Isolated growth hormone deficiency (IGHD) is the most frequent endocrinological disorder in children with short stature, however the diagnosis is still controversial due to the scarcity of reliable diagnostic criteria and pre-treatment predictive factors of long term-response. To evaluate recombinant growth hormone (rGH) long-term response and retesting results in three different groups of children divided in accordance with the biochemical criteria of initial diagnosis. Height gain (∆HT) at adult height (AH) and retesting results were evaluated in 57 rGH treated children (M = 34, 59.6%) divided into 3 groups according to initial diagnosis: Group A (n = 25) with max GH peak at stimulation test < 8 µg/L, Group B (n = 19) between 8 and 10 µg/L and Group C (n = 13) with mean overnight GH < 3 µg/L (neurosecretory dysfunction, NSD). Retesting was carried out in all patients after at least one month off therapy upon reaching the AH. 40/57 (70.2%) patients were pre-pubertal at diagnosis and showed ∆HT of 1.37 ± 1.00 SDS, with no significant differences between groups (P = 0.08). Nonetheless, 46% patients in Group B showed ∆HT < 1SDS (vs 13% and 12% in Group A and C, respectively) and 25% children failed to reach mid-parental height (vs 6% and 0% in Group A and C, respectively). At AH attainment, IGHD was reconfirmed in 28% (7/25) and 10% (2/19) in Group A and B, respectively. A reduction of diagnostic cut-off at GH stimulation tests could better discriminate between "good" and "poor responders" and predict the persistence of IGHD through transition. Group C response and the predictive value of baseline IGF-I SDS bring back to light NSD: should we consider an underlying hypothalamic derangement when the clinical presentation is strongly consistent with IGHD but pharmacological stimulation test is normal?
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17
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Labarta JI, Ranke MB, Maghnie M, Martin D, Guazzarotti L, Pfäffle R, Koledova E, Wit JM. Important Tools for Use by Pediatric Endocrinologists in the Assessment of Short Stature. J Clin Res Pediatr Endocrinol 2021; 13:124-135. [PMID: 33006554 PMCID: PMC8186334 DOI: 10.4274/jcrpe.galenos.2020.2020.0206] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Assessment and management of children with growth failure has improved greatly over recent years. However, there remains a strong potential for further improvements by using novel digital techniques. A panel of experts discussed developments in digitalization of a number of important tools used by pediatric endocrinologists at the third 360° European Meeting on Growth and Endocrine Disorders, funded by Merck KGaA, Germany, and this review is based on those discussions. It was reported that electronic monitoring and new algorithms have been devised that are providing more sensitive referral for short stature. In addition, computer programs have improved ways in which diagnoses are coded for use by various groups including healthcare providers and government health systems. Innovative cranial imaging techniques have been devised that are considered safer than using gadolinium contrast agents and are also more sensitive and accurate. Deep-learning neural networks are changing the way that bone age and bone health are assessed, which are more objective than standard methodologies. Models for prediction of growth response to growth hormone (GH) treatment are being improved by applying novel artificial intelligence methods that can identify non-linear and linear factors that relate to response, providing more accurate predictions. Determination and interpretation of insulin-like growth factor-1 (IGF-1) levels are becoming more standardized and consistent, for evaluation across different patient groups, and computer-learning models indicate that baseline IGF-1 standard deviation score is among the most important indicators of GH therapy response. While physicians involved in child growth and treatment of disorders resulting in growth failure need to be aware of, and keep abreast of, these latest developments, treatment decisions and management should continue to be based on clinical decisions. New digital technologies and advancements in the field should be aimed at improving clinical decisions, making greater standardization of assessment and facilitating patient-centered approaches.
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Affiliation(s)
- José I. Labarta
- University of Zaragoza, Children’s Hospital Miguel Servet, Instituto de Investigación Sanitaria de Aragón, Unit of Endocrinology, Zaragoza, Spain,* Address for Correspondence: University of Zaragoza, Children’s Hospital Miguel Servet, Instituto de Investigación Sanitaria de Aragón, Unit of Endocrinology, Zaragoza, Spain Phone: +34 976 765649 E-mail:
| | - Michael B. Ranke
- University of Tübingen, Children’s Hospital, Clinic of Pediatric Endocrinology, Tübingen, Germany
| | - Mohamad Maghnie
- University of Genova, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, Genova, Italy,IRCCS Instituto Giannina Gaslini, Department of Pediatrics, Genova, Italy
| | - David Martin
- University of Witten/Herdecke and Tübingen University, Tübingen, Germany
| | - Laura Guazzarotti
- University of Milan, Luigi Sacco Hospital, Clinic of Pediatric, Milan, Italy
| | - Roland Pfäffle
- University of Leipzig, Department of Pediatrics, Leipzig, Germany
| | | | - Jan M. Wit
- Leiden University Medical Centre, Department of Paediatrics, Leiden, Netherlands
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Hwang J, Jo SW, Kwon EB, Lee SA, Chang SK. Prevalence of brain MRI findings in children with nonacquired growth hormone deficiency: a systematic review and meta-analysis. Neuroradiology 2021; 63:1121-1133. [PMID: 33611620 DOI: 10.1007/s00234-021-02665-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/01/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To verify and integrate the prevalence and phenotype of abnormalities in the sellar region in patients with growth hormone deficiency (GHD) using MRI data. METHODS We searched PubMed and EMBASE up to December 14, 2020. The inclusion criteria were as follows: (1) pediatric patients diagnosed with nonacquired GHD and (2) detailed data sufficient to assess the proportion of sellar and parasellar abnormalities on brain MRI scans. Finally, thirty-two studies with 39,060 children (mean or median age, 3.4-14.1 years) were included. The number and type of MRI findings from all included studies were pooled by two authors. The heterogeneity across studies was evaluated with the Q test or the inconsistency index (I2) statistic. Subgroup analyses were performed according to the type of GHD (isolated GHD [IGHD] vs. multiple pituitary hormone deficiency [MPHD]), MRI magnet, geographical region, and cutoff serum growth hormone (GH) level. RESULTS The pooled proportion of sellar and parasellar abnormalities was 58.0% (95% CI, 47.1-68.6%; I2, 98.2%). The MPHD group showed a higher proportion of sellar and parasellar abnormalities and pituitary stalk interruption syndrome than the IGHD group (91.4% vs. 40.1%, P<0.001; 65.3% vs. 20.1%, P<0.001). The patients in studies with low peak GH levels on stimulation tests were more associated with severe MR abnormalities (cutoff GH ≤ 5 μg/l vs. cutoff GH = 10 μg/l; 72.8 % vs. 38.0%; P<0.001). CONCLUSION The types and incidence of MRI abnormalities of the sellar region differ significantly between the IGHD and MPHD groups.
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Affiliation(s)
- Jisun Hwang
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
| | - Sang Won Jo
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea.
| | - Eun Byul Kwon
- Department of Pediatrics, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
| | - Seun Ah Lee
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
| | - Suk-Ki Chang
- Department of Radiology, Dongtan Sacred Heart Hospital, Hallym University Medical Center, 7, Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
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19
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Spaziani M, Tarantino C, Tahani N, Gianfrilli D, Sbardella E, Isidori AM, Lenzi A, Radicioni AF. Clinical, Diagnostic, and Therapeutic Aspects of Growth Hormone Deficiency During the Transition Period: Review of the Literature. Front Endocrinol (Lausanne) 2021; 12:634288. [PMID: 33716984 PMCID: PMC7943868 DOI: 10.3389/fendo.2021.634288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/11/2021] [Indexed: 11/13/2022] Open
Abstract
The role of growth hormone (GH) during childhood and adulthood is well established. Once final stature is reached, GH continues to act during the transition, the period between adolescence and adulthood in which most somatic and psychological development is obtained. The achievement of peak bone mass represents the most relevant aspect of GH action during the transition period; however, equally clear is its influence on body composition and metabolic profile and, probably, in the achievement of a complete gonadal and sexual maturation. Despite this, there are still some aspects that often make clinical practice difficult and uncertain, in particular in evaluating a possible persistence of GH deficiency once final stature has been reached. It is also essential to identify which subjects should undergo re-testing and, possibly, replacement therapy, and the definition of unambiguous criteria for therapeutic success. Moreover, even during the transition phase, the relationship between GH substitution therapy and cancer survival is of considerable interest. In view of the above, the aim of this paper is to clarify these relevant issues through a detailed analysis of the literature, with particular attention to the clinical, diagnostic and therapeutic aspects.
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Affiliation(s)
- Matteo Spaziani
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
- *Correspondence: Matteo Spaziani,
| | - Chiara Tarantino
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
| | - Natascia Tahani
- Department of Diabetes, Endocrinology and Metabolism, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Daniele Gianfrilli
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Emilia Sbardella
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea M. Isidori
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Lenzi
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - Antonio F. Radicioni
- Section of Medical Pathophysiology and Endocrinology, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
- Centre for Rare Diseases, Policlinico Umberto I, Rome, Italy
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20
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Abstract
Pituitary stalk interruption syndrome (PSIS) is a distinct developmental defect of the pituitary gland identified by magnetic resonance imaging and characterized by a thin, interrupted, attenuated or absent pituitary stalk, hypoplasia or aplasia of the adenohypophysis, and an ectopic posterior pituitary. The precise etiology of PSIS still remains elusive or incompletely confirmed in most cases. Adverse perinatal events, including breech delivery and hypoxia, were initially proposed as the underlying mechanism affecting the hypothalamic-pituitary axis. Nevertheless, recent findings have uncovered a wide variety of PSIS-associated molecular defects in genes involved in pituitary development, holoprosencephaly (HPE), neural development, and other important cellular processes such as cilia function. The application of whole exome sequencing (WES) in relatively large cohorts has identified an expanded pool of potential candidate genes, mostly related to the Wnt, Notch, and sonic hedgehog signaling pathways that regulate pituitary growth and development during embryogenesis. Importantly, WES has revealed coexisting pathogenic variants in a significant number of patients; therefore, pointing to a multigenic origin and inheritance pattern of PSIS. The disorder is characterized by inter- and intrafamilial variability and incomplete or variable penetrance. Overall, PSIS is currently viewed as a mild form of an expanded HPE spectrum. The wide and complex clinical manifestations include evolving pituitary hormone deficiencies (with variable timing of onset and progression) and extrapituitary malformations. Severe and life-threatening symptomatology is observed in a subset of patients with complete pituitary hormone deficiency during the neonatal period. Nevertheless, most patients are referred later in childhood for growth retardation. Prompt and appropriate hormone substitution therapy constitutes the cornerstone of treatment. Further studies are needed to uncover the etiopathogenesis of PSIS.
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Affiliation(s)
- Antonis Voutetakis
- Department of Pediatrics, School of Medicine, Democritus University of Thrace, Alexandroupolis, Thrace, Greece.
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21
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Ibba A, Corrias F, Guzzetti C, Casula L, Salerno M, di Iorgi N, Tornese G, Patti G, Radetti G, Maghnie M, Cappa M, Loche S. IGF1 for the diagnosis of growth hormone deficiency in children and adolescents: a reappraisal. Endocr Connect 2020; 9:1095-1102. [PMID: 33112822 PMCID: PMC7774770 DOI: 10.1530/ec-20-0347] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/22/2020] [Indexed: 01/26/2023]
Abstract
A number of studies have evaluated the role of IGF1 measurement in the diagnosis of growth hormone deficiency (GHD). This study aimed to evaluate the accuracy and the best cut-off of IGF1 SDS in the diagnosis of GHD in a large cohort of short children and adolescents. One-hundred and forty-two children and adolescents with GHD ((63 organic/genetic (OGHD), 79 idiopathic (IGHD)) and 658 short non-GHD children (median age 10.4 years) were included in the analysis. The two groups were subdivided according to age (G1 <6, G2 6 <9, G3 9 <12, G4 ≥12) and to pubertal status. Serum IGFI was measured by the same chemiluminescence assay in all samples and expressed as age- and sex-based SDS. Receiver operating characteristic (ROC) analysis was used to evaluate the optimal IGF1 SDS cut-off and the diagnostic accuracy. Median IGF1 SDS was significantly lower in the GHD than in non-GHD patients. The area under the curve (AUC) was 0.69, with the best IGF1 cut-off of -1.5 SDS (sensitivity 67.61%, specificity 62.62%). The AUC was 0.75 for OGHD and 0.63 for IGHD. The accuracy was better in the pubertal (AUC = 0.81) than the prepubertal group (AUC = 0.64). In our cohort, IGF1 measurement has poor accuracy in discriminating GHD from non-GHD. Our findings confirm and reinforce the belief that IGF1 values should not be used alone in the diagnosis of GHD but should be interpreted in combination with other clinical and biochemical parameters.
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Affiliation(s)
- Anastasia Ibba
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Francesca Corrias
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Chiara Guzzetti
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | - Letizia Casula
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
| | | | - Natascia di Iorgi
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Gianluca Tornese
- SSD Endocrinologia Pediatrica, Clinica Pediatrica, IRCCS Materno-infantile Burlo Garofolo, Trieste, Italy
| | - Giuseppa Patti
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Giorgio Radetti
- Dipartimento di Pediatria, Ospedale Generale Regionale, Bolzano, Italy
| | - Mohamad Maghnie
- Dipartimento di Pediatria, IRCCS Istituto Giannina Gaslini, Università di Genova, Genova, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-infantili, Università di Genova, Genova, Italy
| | - Marco Cappa
- UOC di Endocrinologia, Dipartimento Universitario Ospedaliero, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica e Centro Screening Neonatale, Ospedale Pediatrico Microcitemico, ‘A. Cao’, AO Brotzu, Cagliari, Italy
- Correspondence should be addressed to S Loche:
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22
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Sbardella E, Crocco M, Feola T, Papa F, Puliani G, Gianfrilli D, Isidori AM, Grossman AB. GH deficiency in cancer survivors in the transition age: diagnosis and therapy. Pituitary 2020; 23:432-456. [PMID: 32488760 DOI: 10.1007/s11102-020-01052-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Survival rates among childhood cancer survivors (CCSs) have significantly risen in the last 40 years due to substantial improvements in treatment protocols. However, this improvement has brought with it serious late effects that frequently involve the endocrine system. Of the endocrine disorders, GH deficiency (GHD) is the most common among CCSs as a consequence of a history of cancers, surgery, and/or radiotherapy involving the hypothalamo-pituitary region. METHODS A comprehensive search of English language articles regardless of age was conducted in the MEDLINE database between December 2018 and October 2019. We selected all studies on GH therapy in CCSs during the transition age regarding the most challenging topics: when to retest; which diagnostic tests and cut-offs to use; when to start GH replacement therapy (GHRT); what GH dose to use; safety; quality of life, compliance and adherence to GHRT; interactions between GH and other hormonal replacement treatments. RESULTS In the present review, we provide an overview of the current clinical management of challenges in GHD in cancer survivors in the transition age. CONCLUSIONS Endocrine dysfunction among CCSs has a high prevalence in the transition age and increase with time. Many endocrine disorders, including GHD, are often not diagnosed or under-diagnosed, probably due to the lack of specialized centers for the long-term follow-up. Therefore, it is crucial that transition specialized clinics should be increased in terms of number and specific skills in order to manage endocrine disorders in adolescence, a delicate and complex period of life. A multidisciplinary approach, also including psychological counseling, is essential in the follow-up and management of these patients in order to minimize their disabilities and maximize their quality of life.
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Affiliation(s)
- Emilia Sbardella
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Marco Crocco
- Department of Pediatrics, IRCCS Giannina Gaslini Institute, University of Genoa, Genoa, Italy
| | - Tiziana Feola
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Fortuna Papa
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Naples, Italy
| | - Giulia Puliani
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Daniele Gianfrilli
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Ashley B Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford, OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London, EC1M 6BQ, UK
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23
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Weber MM, Gordon MB, Höybye C, Jørgensen JOL, Puras G, Popovic-Brkic V, Molitch ME, Ostrow V, Holot N, Pietropoli A, Biller BMK. Growth hormone replacement in adults: Real-world data from two large studies in US and Europe. Growth Horm IGF Res 2020; 50:71-82. [PMID: 31972476 DOI: 10.1016/j.ghir.2019.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/20/2019] [Accepted: 09/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This report describes the effectiveness and safety of growth hormone replacement in 3180 adult patients with growth hormone deficiency followed-up for 0.0-12.2 years in two completed, complementary, non-interventional, multicentre studies, NordiNet® International Outcome Study (IOS) (NCT00960128) and the American Norditropin® Studies: Web-Enabled Research (ANSWER) Program (NCT01009905). DESIGN In both studies, Norditropin® (somatropin; Novo Nordisk A/S, Denmark) was administered at the discretion of the treating physician and according to routine practice. We present data on baseline characteristics, growth hormone dose, safety data and change from baseline in waist circumference, body mass index and bioimpedance (NordiNet® IOS only). RESULTS Mean (SD) baseline characteristics (effectiveness analysis set) in NordiNet® IOS (n = 971) and ANSWER (n = 304): females, 45%; 69%; mean growth hormone dose (mg/day) (female, 0.338 [0.177]; male, 0.289 [0.157]); (female, 0.501 [0.313]; male, 0.505 [0.351]). Most patients had BMI ≥25 kg/m2. Median (P10,P90) exposure (females, 3.5 [0.42,11.0]; 1.6 [3.2; 0.3,8.6]; males, 4.1 [0.33,10.8]; 2.3 [2.9; 0.0,7.5] years). Mean (SD) change from baseline for waist circumference (-0.46 [6.38] cm [n = 403], BMI (0.30 [3.30] kg/m2 [n = 857]) and bioimpedance (-17.4 (59.19) ohm [n = 239]) were associated with growth hormone dose (waist/bioimpedance) and duration of follow-up (BMI/bioimpedance). No new safety signals were observed among patients in the full analysis set (NordiNet® IOS, n = 2321; ANSWER, n = 859). CONCLUSIONS Long-term growth hormone replacement is associated with an improvement in body composition. The accumulated data from >10 years of follow-up support the long-term effectiveness and safety of growth hormone replacement as prescribed in clinical practice.
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Affiliation(s)
- Matthias M Weber
- Unit of Endocrinology, 1. Medical Department, University Hospital, Universitätsmedizin Mainz, der Johannes Gutenberg-Universität, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Murray B Gordon
- Allegheny Neuroendocrinology Center, Division of Endocrinology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Charlotte Höybye
- PA Endocrinology and Nephrology, Infection and Inflammation Theme Karolinska Hospital and Department of Molecular Medicine and Surgery, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Jens Otto L Jørgensen
- Department of Endocrinology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, 8000 C Aarhus, Denmark
| | - Gediminas Puras
- Novo Nordisk Health Care AG, Thurgauerstrasse 36, CH-8050 Zürich, Switzerland
| | | | - Mark E Molitch
- Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611, USA
| | - Vlady Ostrow
- Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ 08536, USA
| | - Natalia Holot
- Novo Nordisk Inc., 800 Scudders Mill Road, Plainsboro, NJ 08536, USA; Unit of Endocrinology, 1. Medical Department, University Hospital, Universitätsmedizin Mainz, der Johannes Gutenberg-Universität, Langenbeckstraße 1, 55131 Mainz, Germany
| | - Alberto Pietropoli
- Novo Nordisk Health Care AG, Thurgauerstrasse 36, CH-8050 Zürich, Switzerland
| | - Beverly M K Biller
- Neuroendocrine Unit, Massachusetts General Hospital, Bulfinch 457B, Massachusetts General Hospital, Fruit St., Boston, MA 02114, USA
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Yuen KCJ, Biller BMK, Radovick S, Carmichael JD, Jasim S, Pantalone KM, Hoffman AR. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY GUIDELINES FOR MANAGEMENT OF GROWTH HORMONE DEFICIENCY IN ADULTS AND PATIENTS TRANSITIONING FROM PEDIATRIC TO ADULT CARE. Endocr Pract 2019; 25:1191-1232. [PMID: 31760824 DOI: 10.4158/gl-2019-0405] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: The development of these guidelines is sponsored by the American Association of Clinical Endocrinologists (AACE) Board of Directors and American College of Endocrinology (ACE) Board of Trustees and adheres with published AACE protocols for the standardized production of clinical practice guidelines (CPG). Methods: Recommendations are based on diligent reviews of clinical evidence with transparent incorporation of subjective factors, according to established AACE/ACE guidelines for guidelines protocols. Results: The Executive Summary of this 2019 updated guideline contains 58 numbered recommendations: 12 are Grade A (21%), 19 are Grade B (33%), 21 are Grade C (36%), and 6 are Grade D (10%). These detailed, evidence-based recommendations allow for nuance-based clinical decision-making that addresses multiple aspects of real-world care of patients. The evidence base presented in the subsequent Appendix provides relevant supporting information for the Executive Summary recommendations. This update contains 357 citations of which 51 (14%) are evidence level (EL) 1 (strong), 168 (47%) are EL 2 (intermediate), 61 (17%) are EL 3 (weak), and 77 (22%) are EL 4 (no clinical evidence). Conclusion: This CPG is a practical tool that practicing endocrinologists and regulatory bodies can refer to regarding the identification, diagnosis, and treatment of adults and patients transitioning from pediatric to adult-care services with growth hormone deficiency (GHD). It provides guidelines on assessment, screening, diagnostic testing, and treatment recommendations for a range of individuals with various causes of adult GHD. The recommendations emphasize the importance of considering testing patients with a reasonable level of clinical suspicion of GHD using appropriate growth hormone (GH) cut-points for various GH-stimulation tests to accurately diagnose adult GHD, and to exercise caution interpreting serum GH and insulin-like growth factor-1 (IGF-1) levels, as various GH and IGF-1 assays are used to support treatment decisions. The intention to treat often requires sound clinical judgment and careful assessment of the benefits and risks specific to each individual patient. Unapproved uses of GH, long-term safety, and the current status of long-acting GH preparations are also discussed in this document. LAY ABSTRACT This updated guideline provides evidence-based recommendations regarding the identification, screening, assessment, diagnosis, and treatment for a range of individuals with various causes of adult growth-hormone deficiency (GHD) and patients with childhood-onset GHD transitioning to adult care. The update summarizes the most current knowledge about the accuracy of available GH-stimulation tests, safety of recombinant human GH (rhGH) replacement, unapproved uses of rhGH related to sports and aging, and new developments such as long-acting GH preparations that use a variety of technologies to prolong GH action. Recommendations offer a framework for physicians to manage patients with GHD effectively during transition to adult care and adulthood. Establishing a correct diagnosis is essential before consideration of replacement therapy with rhGH. Since the diagnosis of GHD in adults can be challenging, GH-stimulation tests are recommended based on individual patient circumstances and use of appropriate GH cut-points. Available GH-stimulation tests are discussed regarding variability, accuracy, reproducibility, safety, and contraindications, among other factors. The regimen for starting and maintaining rhGH treatment now uses individualized dose adjustments, which has improved effectiveness and reduced reported side effects, dependent on age, gender, body mass index, and various other individual characteristics. With careful dosing of rhGH replacement, many features of adult GHD are reversible and side effects of therapy can be minimized. Scientific studies have consistently shown rhGH therapy to be beneficial for adults with GHD, including improvements in body composition and quality of life, and have demonstrated the safety of short- and long-term rhGH replacement. Abbreviations: AACE = American Association of Clinical Endocrinologists; ACE = American College of Endocrinology; AHSG = alpha-2-HS-glycoprotein; AO-GHD = adult-onset growth hormone deficiency; ARG = arginine; BEL = best evidence level; BMD = bone mineral density; BMI = body mass index; CI = confidence interval; CO-GHD = childhood-onset growth hormone deficiency; CPG = clinical practice guideline; CRP = C-reactive protein; DM = diabetes mellitus; DXA = dual-energy X-ray absorptiometry; EL = evidence level; FDA = Food and Drug Administration; FD-GST = fixed-dose glucagon stimulation test; GeNeSIS = Genetics and Neuroendocrinology of Short Stature International Study; GH = growth hormone; GHD = growth hormone deficiency; GHRH = growth hormone-releasing hormone; GST = glucagon stimulation test; HDL = high-density lipoprotein; HypoCCS = Hypopituitary Control and Complications Study; IGF-1 = insulin-like growth factor-1; IGFBP = insulin-like growth factor-binding protein; IGHD = isolated growth hormone deficiency; ITT = insulin tolerance test; KIMS = Kabi International Metabolic Surveillance; LAGH = long-acting growth hormone; LDL = low-density lipoprotein; LIF = leukemia inhibitory factor; MPHD = multiple pituitary hormone deficiencies; MRI = magnetic resonance imaging; P-III-NP = procollagen type-III amino-terminal pro-peptide; PHD = pituitary hormone deficiencies; QoL = quality of life; rhGH = recombinant human growth hormone; ROC = receiver operating characteristic; RR = relative risk; SAH = subarachnoid hemorrhage; SDS = standard deviation score; SIR = standardized incidence ratio; SN = secondary neoplasms; T3 = triiodothyronine; TBI = traumatic brain injury; VDBP = vitamin D-binding protein; WADA = World Anti-Doping Agency; WB-GST = weight-based glucagon stimulation test.
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Nagaeva EV, Shiryaeva TY, Peterkova VA, Bezlepkina OB, Tiulpakov AN, Strebkova NA, Kiiaev AV, Petryaykina EE, Bashnina EB, Мalievsky OA, Тaranushenko ТЕ, Коstrova IB, Shapkina LA, Dedov II. Russian national consensus. Diagnostics and treatment of hypopituitarism in children and adolescences. ACTA ACUST UNITED AC 2019. [DOI: 10.14341/probl10091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The materials of the National Consensus reflect the modern domestic and international experience on this issue.
Before conducting a specialized endocrinological examination of a short child, all other causes of short stature should be excluded: severe somatic diseases in a state of decompensation that can affect growth velocity, congenital systemic skeletal diseases, syndromic short stature (all girls with growth retardation require a mandatory study of karyotype, depending on the presence or absence of phenotypic signs of Turner syndrome), endocrine diseases in decompensation.
A specialized examination of the state of GH-IGF-I axis is carried out when the proportionally folded child has pronounced short stature: if the child’s height is < –2.0 SDS, if the difference between the child’s height SDS and child’s midparental height SDS exceeds 1.5 SDS and/or a low growth velocity.
The consensus reflects clear criteria for the diagnosis of GH-deficiency, central hypothyroidism, central hypocorticosolism, central hypogonadism, diabetes insipidus, hypoprolactinemia, and also the criteria for their compensation.
The dose of somatropin with GH-deficiency in children and adolescents is 0.025–0.033 mg/kg/day. With total somatotropic insufficiency, especially in young children, it is advisable to start therapy with somatropin from lower doses: 25–50% of the substitution, gradually increasing it within 3–6 months to optimal. In children with a growth deficit when entering puberty, the dose may be increased to 0.045–0.05 mg/kg/day.
With the development of side effects, the dose of somatropin can be reduced (by 30–50%), or temporarily canceled (depending on the severity of the clinical picture) until the complete disappearance of undesirable symptoms. With swelling of the optic nerve, treatment is temporarily stopped until the picture of the fundus of the eye fully normalizes. If therapy has been temporarily discontinued, treatment is resumed in smaller doses (50% of the initial) with a gradual (within 1–3 months) return to the optimum.
GH treatment at pediatric doses not continue beyond attainment of a growth velocity below 2–2.5 cm/year, closure of the epiphyseal growth zones, or earlier, when: the achievement of genetically predicted height, but not more than 170 cm in girls, 180 cm in boys, the patient’s desire and his parents / legal representatives satisfied with the achieved result of the final height.
Re-evaluation of the somatotropic axis is carried out after reaching the adult height, after 1–3 months GH therapy will be discontinued. Patients with isolated GH-deficiency or patients with 1 (besides GH) pituitary hormone deficiencies in the presence of a normal IGF-1 level (against the background of somatropin withdrawal) and not having molecular genetic confirmation of the diagnosis need re- evaluation. Patients with two or more (besides GH) pituitary hormone deficiencies, acquired hypothalamic-pituitary lesions due to operations on the pituitary and irradiation of the hypothalamic-pituitary area (if the IGF-1 level is low against somatropin withdrawal), specific pituitary/ hypothalamic structural defect on MRI, gene defects of the GH-IGF-I system do not need re- evaluation.
If GH deficiency is confirmed, treatment with somatropin is resumed at metabolic doses of 0.01—0.003 mg/kg/day under the control of the IGF-I level in the blood (measurement 1 time in 6 months), the indicator should not exceed the upper limit of the reference value for the corresponding age and floor.
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Penta L, Cofini M, Lucchetti L, Zenzeri L, Leonardi A, Lanciotti L, Galeazzi D, Verrotti A, Esposito S. Growth Hormone (GH) Therapy During the Transition Period: Should We Think About Early Retesting in Patients with Idiopathic and Isolated GH Deficiency? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16030307. [PMID: 30678118 PMCID: PMC6388362 DOI: 10.3390/ijerph16030307] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 01/01/2019] [Accepted: 01/22/2019] [Indexed: 11/25/2022]
Abstract
To investigate growth hormone (GH) secretion at the transition age, retesting of all subjects who have undergone GH replacement therapy is recommended when linear growth and pubertal development are complete to distinguish between transitional and persistent GH deficiency (GHD). Early retesting of children with idiopathic and isolated GHD (i.e., before the achievement of final height and/or the adult pubertal stage) can avoid possible over-treatment. Here, we report data from our population with idiopathic and isolated GHD to encourage changes in the management and timing of retesting. We recruited 31 patients (19 males) with idiopathic GHD who received recombinant GH (rGH) for at least 2 years. All of the patients were retested at the transition age at least 3 months after rGH discontinuation. Permanent GHD was defined as a GH peak of <19 ng/mL after administration of growth hormone–releasing hormone (GHRH) + arginine as a provocative test. Permanent GHD was confirmed in only five of 31 patients (16.13%). None of these patients presented low serum insulin-like growth factor (IGF)-1 levels (<−2 standard deviation score (SDS)). Only one male patient with an IGF-1 serum level lower than −2 SDS showed a normal GH stimulation response, with a GH peak of 44.99 ng/mL. Few patients with idiopathic and isolated GHD demonstrated persistence of the deficit when retested at the transition age, suggesting that the timing of retesting should be anticipated to avoid overtreatment.
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Affiliation(s)
- Laura Penta
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Marta Cofini
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Laura Lucchetti
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Letizia Zenzeri
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Alberto Leonardi
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | - Lucia Lanciotti
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
| | | | - Alberto Verrotti
- Department of Paediatrics, University of L'Aquila, L'Aquila 67100, Italy.
| | - Susanna Esposito
- Paediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, 06132 Perugia, Italy.
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The 100 Most-Cited Reports About Craniopharyngioma. World Neurosurg 2018; 119:e910-e921. [PMID: 30099186 DOI: 10.1016/j.wneu.2018.08.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Our objective was to identify the 100 most-cited research reports on craniopharyngiomas. METHODS The Thomson Reuters Web of Science service was queried for the years 1900 to 2017 without language restrictions. The articles were sorted in descending order of the number of times they had been cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 reports. The number of citations per year was calculated. RESULTS We identified the 100 most-cited articles on craniopharyngioma, which, collectively, had been cited 20,994 times at the time of our report. The top cited report had been cited 718 times, with an average of 144 citations annually since publication. The oldest article had been published in 1969 and the most recent in 2013; the most prolific decade was the 2000s, with 38 of the included articles published during that period. Thirty-two unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 31). The most common country of article origin was the United States (n = 49), followed by United Kingdom (n = 12), Germany (n = 10), and Italy (n = 6). CONCLUSIONS The present study identified the 100 most-cited research articles in craniopharyngioma. These results highlight the multidisciplinary and multimodal nature of craniopharyngioma management. Recognition of important historical contributions to this field could guide future investigations.
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Vuralli D, Gonc EN, Ozon ZA, Alikasifoglu A, Kandemir N. Clinical and laboratory parameters predicting a requirement for the reevaluation of growth hormone status during growth hormone treatment: Retesting early in the course of GH treatment. Growth Horm IGF Res 2017; 34:31-37. [PMID: 28511077 DOI: 10.1016/j.ghir.2017.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Revised: 04/23/2017] [Accepted: 05/08/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We aimed to define the predictive criteria, in the form of specific clinical, hormonal and radiological parameters, for children with growth hormone deficiency (GHD) who may benefit from the reevaluation of GH status early in the course of growth hormone (GH) treatment. DESIGN AND METHODS Two hundred sixty-five children with growth hormone deficiency were retested by GH stimulation at the end of the first year of GH treatment. The initial clinical and laboratory characteristics of those with a normal (GH≥10ng/ml) response and those with a subnormal (GH<10ng/ml) response were compared to predict a normal GH status during reassessment. RESULTS Sixty-nine patients (40.6%) out of the 170 patients with isolated growth hormone deficiency (IGHD) had a peak GH of ≥10ng/ml during the retest. None of the patients with multiple pituitary hormone deficiency (MPHD) had a peak GH of ≥10ng/ml. Puberty and sex steroid priming in peripubertal cases increased the probability of a normal GH response. Only one patient with IGHD who had an ectopic posterior pituitary without stalk interruption on MRI analysis showed a normal GH response during the retest. Patients with a peak GH between 5 and 10ng/ml, an age at diagnosis of ≥9years or a height gain below 0.61 SDS during the first year of treatment had an increased probability of having a normal GH response at the retest. CONCLUSION Early reassessment of GH status during GH treatment is unnecessary in patients who have MPHD with at least 3 hormone deficiencies. Retesting at the end of the first year of therapy is recommended for patients with IGHD who have a height gain of <0.61 SDS in the first year of treatment, especially those with a normal or 'hypoplastic' pituitary on imaging. Priming can increase the likelihood of a normal response in patients in the pubertal age group who do not show overt signs of pubertal development.
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Affiliation(s)
- Dogus Vuralli
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey.
| | - E Nazli Gonc
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Z Alev Ozon
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayfer Alikasifoglu
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Nurgun Kandemir
- Hacettepe University, Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Di Iorgi N, Morana G, Allegri AEM, Napoli F, Gastaldi R, Calcagno A, Patti G, Loche S, Maghnie M. Classical and non-classical causes of GH deficiency in the paediatric age. Best Pract Res Clin Endocrinol Metab 2016; 30:705-736. [PMID: 27974186 DOI: 10.1016/j.beem.2016.11.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Growth hormone deficiency (GHD) may result from a failure of hypothalamic GHRH production or release, from congenital disorders of pituitary development, or from central nervous system insults including tumors, surgery, trauma, radiation or infiltration from inflammatory diseases. Idiopathic, isolated GHD is the most common sporadic form of hypopituitarism. GHD may also occur in combination with other pituitary hormone deficiencies, and is often referred to as hypopituitarism, combined pituitary hormone deficiency (CPHD), multiple pituitary hormone deficiency (MPHD) or panhypopituitarism. Children without any identifiable cause of their GHD are commonly labeled as having idiopathic hypopituitarism. MRI imaging is the technique of choice in the diagnosis of children with hypopituitarism. Marked differences in MRI pituitary gland morphology suggest different etiologies of GHD and different prognoses. Pituitary stalk agenesis and ectopic posterior pituitary (EPP) are specific markers of permanent GHD, and patients with these MRI findings show a different clinical and endocrine outcome compared to those with normal pituitary anatomy or hypoplastic pituitary alone. Furthermore, the classic triad of ectopic posterior pituitary gland, pituitary stalk hypoplasia/agenesis, and anterior pituitary gland hypoplasia is generally associated with permanent GHD. T2 DRIVE images aid in the identification of pituitary stalk without the use of contrast medium administration. Future developments in imaging techniques will undoubtedly reveal additional insights. Mutations in a number of genes encoding transcription factors - such as HESX1, SOX2, SOX3, LHX3, LHX4, PROP1, POU1F1, PITX, GLI3, GLI2, OTX2, ARNT2, IGSF1, FGF8, FGFR1, PROKR2, PROK2, CHD7, WDR11, NFKB2, PAX6, TCF7L1, IFT72, GPR161 and CDON - have been associated with pituitary dysfunction and abnormal pituitary gland development; the correlation of genetic mutations to endocrine and MRI phenotypes has improved our knowledge of pituitary development and management of patients with hypopituitarism, both in terms of possible genetic counseling, and of early diagnosis of evolving anterior pituitary hormone deficiencies.
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Affiliation(s)
- Natascia Di Iorgi
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Giovanni Morana
- Neuroradiology Unit, Istituto Giannina Gaslini, Genova, Italy
| | - Anna Elsa Maria Allegri
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Flavia Napoli
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Roberto Gastaldi
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Annalisa Calcagno
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Giuseppa Patti
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", Cagliari, Italy
| | - Mohamad Maghnie
- Department of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy; Department of Endocrine Unit, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
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30
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Chinoy A, Murray PG. Diagnosis of growth hormone deficiency in the paediatric and transitional age. Best Pract Res Clin Endocrinol Metab 2016; 30:737-747. [PMID: 27974187 DOI: 10.1016/j.beem.2016.11.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Growth hormone deficiency is a rare cause of childhood short stature, but one for which treatment exists in the form of recombinant human growth hormone. A diagnosis of growth hormone deficiency is made based on auxology, biochemistry and imaging. Although no diagnostic gold standard exists, growth hormone provocation tests are considered the mainstay of diagnostic investigations. However, these must be interpreted with caution in view of issues with variability and reproducibility, as well as the limited evidence-base for cut-off values used to distinguish growth hormone deficient and non-growth hormone deficient subjects. In addition, nutritional and pubertal status can affect results, with no consensus on the role of priming with sex steroid hormones. Difficulties with assays exist both for growth hormone as well as insulin-like growth factor-1. Pituitary magnetic resonance imaging is a useful diagnostic, and possibly prognostic, aid. Although genetic testing is not routine, the discovery of more relevant mutations makes it an increasingly important investigation. Children with growth hormone deficiency are retested biochemically on completion of growth, to assess whether they remain so into adulthood.
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Affiliation(s)
- A Chinoy
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK
| | - P G Murray
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Central Manchester Foundation Hospitals NHS Trust, Manchester, UK; Centre for Paediatrics and Child Health, Institute of Human Development, University of Manchester, Manchester, UK.
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Guzzetti C, Ibba A, Pilia S, Beltrami N, Di Iorgi N, Rollo A, Fratangeli N, Radetti G, Zucchini S, Maghnie M, Cappa M, Loche S. Cut-off limits of the peak GH response to stimulation tests for the diagnosis of GH deficiency in children and adolescents: study in patients with organic GHD. Eur J Endocrinol 2016; 175:41-7. [PMID: 27147639 DOI: 10.1530/eje-16-0105] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 05/04/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The diagnosis of GH deficiency (GHD) in children and adolescents is established when GH concentrations fail to reach an arbitrary cut-off level after at least two provocative tests. The objective of the study was to define the optimal GH cut-offs to provocative tests in children and adolescents. DESIGN Retrospective study in 372 subjects who underwent evaluation of GH secretion. GH and IGF-I were measured by chemiluminescence assay in all samples. Receiver operating characteristic (ROC) analysis was used to evaluate the optimal GH cut-offs and the diagnostic accuracy of provocative tests. METHODS Seventy four patients with organic GHD (GH peak <10μg/L after two provocative tests) and 298 control subjects (GH response >10μg/L to at least one test) were included in the study. The provocative tests used were arginine, insulin tolerance test (ITT) and clonidine. Diagnostic criteria based on cut-offs identified by ROC analysis (best pair of values for sensitivity and specificity) were evaluated for each test individually and for each test combined with IGF-I SDS. RESULTS The optimal GH cut-off for arginine resulted 6.5μg/L, 5.1μg/L for ITT and 6.8μg/L for clonidine. IGF-I SDS has low accuracy in diagnosing GHD (AUC=0.85). The combination of the results of provocative tests with IGF-I concentrations increased the specificity. CONCLUSIONS The results of the ROC analysis showed that the cut-off limits which discriminate between normal and GHD are lower than those commonly employed. IGF-I is characterized by low diagnostic accuracy.
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Affiliation(s)
- Chiara Guzzetti
- SSD Endocrinologia PediatricaOspedale Pediatrico Microcitemico "A. Cao", Cagliari, Italy
| | - Anastasia Ibba
- SSD Endocrinologia PediatricaOspedale Pediatrico Microcitemico "A. Cao", Cagliari, Italy
| | - Sabrina Pilia
- SSD Endocrinologia PediatricaOspedale Pediatrico Microcitemico "A. Cao", Cagliari, Italy
| | | | - Natascia Di Iorgi
- Clinica Pediatrica, Istituto Giannina Gaslini, Universitá di GenovaGenova, Italy
| | | | - Nadia Fratangeli
- Clinica Pediatrica, Istituto Giannina Gaslini, Universitá di GenovaGenova, Italy
| | | | | | - Mohamad Maghnie
- Clinica Pediatrica, Istituto Giannina Gaslini, Universitá di GenovaGenova, Italy
| | - Marco Cappa
- UOC di Endocrinologia e DiabetologiaOspedale Pediatrico Bambino Gesú IRCCS, Roma, Italy
| | - Sandro Loche
- SSD Endocrinologia PediatricaOspedale Pediatrico Microcitemico "A. Cao", Cagliari, Italy
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Dreismann L, Schweizer R, Blumenstock G, Weber K, Binder G. Evaluation of the GHRH-arginine retest for young adolescents with childhood-onset GH deficiency. Growth Horm IGF Res 2016; 27:28-32. [PMID: 26874855 DOI: 10.1016/j.ghir.2016.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/02/2016] [Accepted: 02/03/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Retesting of adolescents with childhood-onset GH deficiency (GHD) is recommended, but age-related reference data are scarce. We aimed to establish a cut-off value for the GHRH-arginine test (GHRH+ARG) at the typical age of retesting at near-adult height. DESIGNS We retrospectively studied 149 patients (108 males) with childhood-onset GHD aged 16.8 ± 1.7 years (mean ± SD) with a BMI of 20.9 ± 3.5 kg/m(2) who had received GHRH+ARG in one single center during 8 consecutive years. Based on the IGF-I serum concentration falling below -2 SDS when off GH, 22 patients suffered from severe GHD of adulthood while 122 were GH sufficient. Five patients could not be determined definitively. GH and IGF-I were measured by in-house RIAs. IGF-I values were transformed into age-related SDS values. ROC-analysis was used to determine the cut-off value. RESULTS For GHRH+ARG, a cut-off limit of 15.9 ng/ml had the highest pair of sensitivity (91%) and specificity (88%). GH peaks of the patients with a normal BMI between -1 and 0 SDS were higher than those with a high BMI >1 SDS (p<0.01). CONCLUSIONS When retesting adolescents at near-adult height for severe GHD of adulthood, a GH value of <15.9 ng/ml in GHRH+ARG is discriminatory with good accuracy. Conversion factors for other GH assays in use are provided. A rational decision for or against the continuation of GH therapy into adulthood can be made based on the clinical history of the patient and the combination of the GHRH+ARG retest result and the IGF-I serum concentrations when off GH.
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Affiliation(s)
- Laura Dreismann
- University Children's Hospital, Pediatric Endocrinology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Roland Schweizer
- University Children's Hospital, Pediatric Endocrinology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Silcherstraße 5, 72076 Tübingen, Germany
| | - Karin Weber
- University Children's Hospital, Pediatric Endocrinology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany
| | - Gerhard Binder
- University Children's Hospital, Pediatric Endocrinology, Hoppe-Seyler-Str.1, 72076 Tübingen, Germany.
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Ahmid M, Fisher V, Graveling AJ, McGeoch S, McNeil E, Roach J, Bevan JS, Bath L, Donaldson M, Leese G, Mason A, Perry CG, Zammitt NN, Ahmed SF, Shaikh MG. An audit of the management of childhood-onset growth hormone deficiency during young adulthood in Scotland. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2016; 2016:6. [PMID: 26985190 PMCID: PMC4793498 DOI: 10.1186/s13633-016-0024-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/27/2016] [Indexed: 02/08/2023]
Abstract
Background Adolescents with childhood onset growth hormone deficiency (CO-GHD) require re-evaluation of their growth hormone (GH) axis on attainment of final height to determine eligibility for adult GH therapy (rhGH). Aim Retrospective multicentre review of management of young adults with CO-GHD in four paediatric centres in Scotland during transition. Patients Medical records of 130 eligible CO-GHD adolescents (78 males), who attained final height between 2005 and 2013 were reviewed. Median (range) age at initial diagnosis of CO-GHD was 10.7 years (0.1–16.4) with a stimulated GH peak of 2.3 μg/l (0.1–6.5). Median age at initiation of rhGH was 10.8 years (0.4–17.0). Results Of the 130 CO-GHD adolescents, 74/130(57 %) had GH axis re-evaluation by stimulation tests /IGF-1 measurements. Of those, 61/74 (82 %) remained GHD with 51/74 (69 %) restarting adult rhGH. Predictors of persistent GHD included an organic hypothalamic-pituitary disorder and multiple pituitary hormone deficiencies (MPHD). Of the remaining 56/130 (43 %) patients who were not re-tested, 34/56 (61 %) were transferred to adult services on rhGH without biochemical retesting and 32/34 of these had MPHD. The proportion of adults who were offered rhGH without biochemical re-testing in the four centres ranged between 10 and 50 % of their total cohort. Conclusions A substantial proportion of adults with CO-GHD remain GHD, particularly those with MPHD and most opt for treatment with rhGH. Despite clinical guidelines, there is significant variation in the management of CO-GHD in young adulthood across Scotland.
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Affiliation(s)
- M Ahmid
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - V Fisher
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - A J Graveling
- JJR Macleod Centre for Diabetes, Endocrinology & Metabolism, Aberdeen Royal Infirmary, Aberdeen, UK
| | - S McGeoch
- JJR Macleod Centre for Diabetes, Endocrinology & Metabolism, Aberdeen Royal Infirmary, Aberdeen, UK
| | - E McNeil
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - J Roach
- Department of Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| | - J S Bevan
- JJR Macleod Centre for Diabetes, Endocrinology & Metabolism, Aberdeen Royal Infirmary, Aberdeen, UK
| | - L Bath
- Department of Endocrinology, Royal Hospital for Sick Children, Edinburgh, UK
| | - M Donaldson
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - G Leese
- Ninewells Hospital and Medical School in Dundee, Dundee, UK
| | - A Mason
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - C G Perry
- Department of Endocrinology, Queen Elizabeth University Hospitals, Glasgow, UK
| | | | - S F Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
| | - M G Shaikh
- Developmental Endocrinology Research Group, Royal Hospital for Children, School of Medicine, University of Glasgow, 1345 Govan Road, Glasgow, G51 4TF UK
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Wang CZ, Guo LL, Han BY, Wang AP, Liu HY, Su X, Guo QH, Mu YM. Growth Hormone Therapy Benefits Pituitary Stalk Interruption Syndrome Patients with Short Stature: A Retrospective Study of 75 Han Chinese. Int J Endocrinol 2016; 2016:1896285. [PMID: 27190512 PMCID: PMC4846761 DOI: 10.1155/2016/1896285] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 03/28/2016] [Accepted: 03/30/2016] [Indexed: 01/29/2023] Open
Abstract
Objective. We aim to investigate the long-term benefits of growth hormone (GH) therapy in short stature adolescents and adults with pituitary stalk interruption syndrome (PSIS), which would be beneficial for future clinical applications. Design and Methods. In this study, initial height, final height, total height gain, and GH treatment history were retrospectively investigated in 75 Chinese PSIS patients. We compared height gain between the GH treated cohort and untreated cohort and explored the impact of different GH therapy duration on height gain. Results. For GH treated patients, their final height (SDS) increased from -1.99 ± 1.91 (-6.93~2.80) at bone age (BA) of 11.2 (5.0~17.0) years to -1.47 ± 1.64 (-7.82~1.05) at BA of 16.6 (8.0~18.0) years (P = 0.016). And GH treated patients had more height gain than the untreated patients (P < 0.05). There was a significant difference between the different GH therapy duration groups (P = 0.001): GH 0 versus GH 3, P = 0.000; GH 1 versus GH 3, P = 0.028; GH 2 versus GH 3, P = 0.044. Conclusion. Adult Chinese PSIS patients with short stature benefited the most from at least 12 months of GH therapy. Although patient diagnosis age was lagged behind in the developing countries, GH treatment was still effective for them and resulted in a higher final height and more height gain.
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Affiliation(s)
- Cheng-Zhi Wang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Ling-Ling Guo
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Beijing Electric Teaching Hospital of Capital Medical University, Beijing 100073, China
| | - Bai-Yu Han
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - An-Ping Wang
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Hong-Yan Liu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Xing Su
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
| | - Qing-Hua Guo
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- Department of Endocrinology, Hainan Branch of Chinese PLA General Hospital, Sanya, Hainan 572000, China
- *Qing-Hua Guo: and
| | - Yi-Ming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing 100853, China
- *Yi-Ming Mu:
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Ciresi A, Cicciò F, Amato MC, Giordano C. Revaluation of the clinical and metabolic behavior of children with isolated growth hormone deficiency during GH treatment according to newly proposed note 39 of the Italian Medicines Agency (AIFA). J Endocrinol Invest 2015; 38:1301-7. [PMID: 26015317 DOI: 10.1007/s40618-015-0314-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/14/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE This study aimed at evaluating the clinical and metabolic behavior of children with isolated growth hormone (GH)-deficiency (GHD), grouped according to the new AIFA criteria for the appropriateness of use and reimbursement of GH treatment in children. METHODS The clinical and metabolic data of 310 prepubertal children (220 M, 90 F; mean age 10.8 years) grouped, according to new AIFA note 39, into Group A (No. 181 with a peak of GH <8 µg/l), Group B (No. 103 with a peak of GH ≥8 and <10 µg/l) and Group C (No. 26 with a peak of GH >10 µg/l) were retrospectively analyzed. Group A and B, diagnosed as having GHD, were treated with GH for at least 24 months, while Group C was analyzed only at baseline. RESULTS At baseline, Group A showed higher waist circumference than B (p = 0.031) and C (p = 0.041), while no difference in metabolic parameters was found between the three groups. After 12 and 24 months of treatment, Group B showed lower height velocity (p < 0.001 and p = 0.049, respectively) than Group A. As regards the metabolic parameters, both after 12 and 24 months of treatment, in Group B we found higher fasting glucose (p < 0.001 and p = 0.020), insulin (p = 0.002 and p = 0.011), Homa-β (p = 0.020 and p = 0.015) and Homa-IR (both p = 0.001) than Group A, with concomitant lower QUICKI (both p < 0.001) and HDL cholesterol (p = 0.020 and p = 0.011), without difference in other lipid parameters. The HbA1c levels, although always within the normal range, were found higher in Group B than Group A after 12 months (p = 0.015). CONCLUSIONS According to the new AIFA criteria, the reduction of GH cut-off for GHD diagnosis can be supported by auxological and metabolic data. The real benefits from GH therapy in children with higher stimulated GH levels at diagnosis remains to be better understand.
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Affiliation(s)
- A Ciresi
- Section of Cardio-Respiratory and Endocrine-Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - F Cicciò
- Section of Cardio-Respiratory and Endocrine-Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - M C Amato
- Section of Cardio-Respiratory and Endocrine-Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - C Giordano
- Section of Cardio-Respiratory and Endocrine-Metabolic Diseases, Biomedical Department of Internal and Specialist Medicine (DIBIMIS), University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
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Bar C, Zadro C, Diene G, Oliver I, Pienkowski C, Jouret B, Cartault A, Ajaltouni Z, Salles JP, Sevely A, Tauber M, Edouard T. Pituitary Stalk Interruption Syndrome from Infancy to Adulthood: Clinical, Hormonal, and Radiological Assessment According to the Initial Presentation. PLoS One 2015; 10:e0142354. [PMID: 26562670 PMCID: PMC4643020 DOI: 10.1371/journal.pone.0142354] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/14/2015] [Indexed: 01/13/2023] Open
Abstract
Background Patients with pituitary stalk interruption syndrome (PSIS) are initially referred for hypoglycemia during the neonatal period or growth retardation during childhood. PSIS is either isolated (nonsyndromic) or associated with extra-pituitary malformations (syndromic). Objective To compare baseline characteristics and long-term evolution in patients with PSIS according to the initial presentation. Study Design Sixty-seven patients with PSIS were included. Data from subgroups were compared: neonates (n = 10) versus growth retardation patients (n = 47), and syndromic (n = 32) versus nonsyndromic patients (n = 35). Results Neonates displayed a more severe hormonal and radiological phenotype than children referred for growth retardation, with a higher incidence of multiple hormonal deficiencies (100% versus 34%; P = 0.0005) and a nonvisible anterior pituitary lobe (33% versus 2%; P = 0.0017). Regular follow-up of growth might have allowed earlier diagnosis in the children with growth retardation, as decreased growth velocity and growth retardation were present respectively 3 and 2 years before referral. We documented a progressive worsening of endocrine impairment throughout childhood in these patients. Presence of extra-pituitary malformations (found in 48%) was not associated with more severe hormonal and radiological characteristics. Growth under GH treatment was similar in the patient groups and did not vary according to the pituitary MRI findings. Conclusions PSIS diagnosed in the neonatal period has a particularly severe hormonal and radiological phenotype. The progressive worsening of endocrine impairment throughout childhood justifies periodic follow-up to check for additional hormonal deficiencies.
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Affiliation(s)
- Céline Bar
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Charline Zadro
- Neuroradiology Unit, Purpan University Hospital, Toulouse, France
| | - Gwenaelle Diene
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Isabelle Oliver
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Catherine Pienkowski
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Béatrice Jouret
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Audrey Cartault
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Zeina Ajaltouni
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
| | - Jean-Pierre Salles
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
- INSERM UMR 1043, Center of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
| | - Annick Sevely
- Neuroradiology Unit, Purpan University Hospital, Toulouse, France
| | - Maithé Tauber
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
- INSERM UMR 1043, Center of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
| | - Thomas Edouard
- Endocrine, Bone Diseases, Genetics, Obesity, and Gynecology Unit, Children’s Hospital, University Hospital, Toulouse, France
- INSERM UMR 1043, Center of Pathophysiology of Toulouse Purpan (CPTP), University of Toulouse Paul Sabatier, Toulouse, France
- * E-mail:
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Khadilkar VV, Prasad HK, Ekbote VH, Rustagi VT, Singh J, Chiplonkar SA, Khadilkar AV. Response of Indian growth hormone deficient children to growth hormone therapy: association with pituitary size. Indian J Pediatr 2015; 82:404-9. [PMID: 24777622 DOI: 10.1007/s12098-014-1412-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 03/12/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To ascertain the impact of pituitary size as judged by Magnetic Resonance Imaging (MRI), on response to Growth Hormone (GH) therapy in GH deficient children. METHODS Thirty nine children (9.1 ± 2.7 y, 22 boys) with non-acquired GH deficiency (21 Isolated GH deficiency and 18 Combined pituitary hormone deficiency) were consecutively recruited and followed up for one year. Clinical, radiological (bone age and MRI) and biochemical parameters were studied. RESULTS Children with hypoplastic pituitary (pituitary height < 3 mm) had more severe height deficit (height for age Z-score -6.0 vs. -5.0) and retardation of skeletal maturation (bone age chronological age ratio of 0.59 vs. 0.48) at baseline as compared to children with normal pituitary heights (p < 0.05 for both). After one year of GH therapy, height for age Z scores and percentage change in height for age Z scores were significantly higher in children with hypoplastic pituitaries (13.8 ± 3.6 and 28.7 % vs. 11.2 ± 4.1 and 21.4 %). Significant co-relation was observed between pituitary height and height for age Z-scores at baseline (r = 0.39, p < 0.05). The predicted adult height using Tanner Whitehouse-2 equations improved from 140.8 to 152.3 cm in children with hypoplastic pituitary when compared to an increase from 145.8 to 153.5 cm observed in children with normal pituitary height (p < 0.05). CONCLUSIONS Indian growth hormone deficient children with hypoplastic pituitary respond better to therapy with GH in short term.
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Affiliation(s)
- Vaman V Khadilkar
- Department of Growth and Pediatric Endocrine Unit, Hirabai Cowasji Jehangir Medical Research Institute, Jehangir Hospital, Pune, India
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Rhee N, Oh KY, Yang EM, Kim CJ. Growth hormone responses to provocative tests in children with short stature. Chonnam Med J 2015; 51:33-8. [PMID: 25914878 PMCID: PMC4406992 DOI: 10.4068/cmj.2015.51.1.33] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 03/31/2015] [Accepted: 04/03/2015] [Indexed: 11/22/2022] Open
Abstract
Growth hormone deficiency (GHD) is defined as a serum peak GH concentration <10 ng/mL with provocation as tested by a combination of at least two separate tests. The aim of this study was to compare two standard tests, insulin and levodopa (L-dopa), with a primary focus on specificity and accuracy. Clinical data were collected retrospectively from a review of 120 children who visited the pediatric endocrine clinic at Chonnam National University Hospital for the evaluation of short stature between January 2006 and April 2014. Subjects underwent GH provocation tests with insulin and L-dopa. Blood samples were obtained at 0, 15, 30, 45, 60, 90, and 120 min after administration, and GH levels were measured. In the insulin test, serial glucose levels were also checked, closely monitoring hypoglycemia. A total of 83 children (69.2%) were diagnosed with GHD and 37 children (30.8%) were diagnosed with idiopathic short stature (ISS). Peak GH levels were achieved an average of 45 min after the administration of insulin and L-dopa for both groups. The specificity and accuracy were 78.4% and 93.6% for the insulin test and 29.7% and 79.2% for L-dopa test, respectively. In the ISS group, the cumulative frequency of a GH cutoff value of >10 ng/mL at 120 min was 75.6% after insulin stimulation compared with 35.1% after L-dopa stimulation. Considering these results, we recommend performing the insulin test first to exclude ISS and then the L-dopa test for the diagnosis of GHD. This way, ISS patients are diagnosed after a single test, thus reducing hospital days and the burden of undergoing two serial tests.
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Affiliation(s)
- Noorisaem Rhee
- Department of Pediatrics, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Ka Young Oh
- Department of Pediatrics, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Eun Mi Yang
- Department of Pediatrics, Chonnam National University Medical School and Hospital, Gwangju, Korea
| | - Chan Jong Kim
- Department of Pediatrics, Chonnam National University Medical School and Hospital, Gwangju, Korea
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39
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Bizzarri C, Pedicelli S, Boscherini B, Bedogni G, Cappa M, Cianfarani S. Early retesting by GHRH + arginine test shows normal GH response in most children with idiopathic GH deficiency. J Endocrinol Invest 2015; 38:429-36. [PMID: 25376365 DOI: 10.1007/s40618-014-0205-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/23/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Most children with idiopathic isolated GH deficiency (IGHD) normalize GH response to stimulation tests when retested at the completion of growth. The objective of this study was to test the effectiveness of early retesting in challenging the diagnosis of idiopathic IGHD and critically review the diagnostic workup leading to this diagnosis in children with short stature. METHODS We cross-sectionally retested 38 children with idiopathic IGHD and still on GH treatment. The initial diagnosis of idiopathic IGHD was based on subnormal GH responses to two stimulation tests and normal brain imaging or minor/nonspecific findings at magnetic resonance. The GH response normalization at retesting was considered as the main outcome measure. Clinical features of children who were falsely classified as idiopathic IGHD based on first GH testing were retrospectively analyzed. RESULTS GH secretion was normal in 36/38 children (95%). Two children showed slightly reduced peak GH responses and normal IGF-I levels. Fourteen children underwent GH retesting before puberty, 24 children during puberty. CONCLUSION The diagnostic process should be improved to minimize the rate of false positive at GH testing and, in case of unsatisfactory response to GH treatment, the diagnosis of isolated idiopathic GHD should be challenged with early retesting.
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Affiliation(s)
- C Bizzarri
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy.
| | - S Pedicelli
- D.P.U.O. Bambino Gesù Children's Hospital, "Tor Vergata" University, Rome, Italy
| | | | - G Bedogni
- Clinical Epidemiology Unit, Liver Research Center, Basovizza and Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - M Cappa
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Piazza S. Onofrio 4, 00165, Rome, Italy
| | - S Cianfarani
- D.P.U.O. Bambino Gesù Children's Hospital, "Tor Vergata" University, Rome, Italy
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
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Aimaretti G, Attanasio R, Cannavò S, Nicoletti MC, Castello R, Di Somma C, Garofalo P, Iughetti L, Loche S, Maghnie M, Mazzanti L, Saggese G, Salerno M, Tonini G, Toscano V, Zucchini S, Cappa M. Growth hormone treatment of adolescents with growth hormone deficiency (GHD) during the transition period: results of a survey among adult and paediatric endocrinologists from Italy. Endorsed by SIEDP/ISPED, AME, SIE, SIMA. J Endocrinol Invest 2015; 38:377-82. [PMID: 25362629 DOI: 10.1007/s40618-014-0201-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 10/10/2014] [Indexed: 10/24/2022]
Abstract
Treatment of adolescents with growth hormone deficiency (GHD) during the transition period is a controversial issue. This paper is a contribution from the Italian community of paediatric and adult endocrinologists surveyed in a Delphi panel. The Delphi method is a structured communication technique, originally developed as a systematic, interactive forecasting method that relies on a panel of experts. The experts answer questionnaires in two or more rounds. There was substantial agreement on the definition of the problems associated with the diagnosis and treatment of adolescents with GHD in the transition period, as well as on the identification of the controversial issues which need further studies. There is general consensus on the need of re-testing all isolated idiopathic GHD after at least 30-day withdrawn from treatment, while in patients with multiple pituitary deficiency and low IGF-I levels there is generally no need to re-test. In patients with permanent or confirmed GHD, a starting low rhGH dose (0.01-0.03 mg per day) to be adjusted according to IGF-I concentrations is also widely accepted. For those continuing treatment, the optimal therapeutic schedule to obtain full somatic maturation, normalization of body composition and bone density, cardiovascular function and Quality of Life, need to be evaluated.
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Affiliation(s)
- G Aimaretti
- Diabetology, Metabolic and Endocrinologic diseases, "Maggiore della Carità" Hospital, Novara, Italy
| | - R Attanasio
- Endocrinology, Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - S Cannavò
- Endocrinological Unit of Clinic-Sperimental Medicine and Surgery Department, University of Messina, Messina, Italy
| | - M C Nicoletti
- Department of Medical and Pediatric Sciences, University of Catania, Catania, Italy
| | - R Castello
- Endocrinology UOC, General Medicine, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - C Di Somma
- "Federico II" University of Naples, Naples, Italy
| | - P Garofalo
- UO of Endocrinology, Ospedale Villa Sofia-Cervello, Palermo, Italy
| | - L Iughetti
- Pediatric Clinic, University of Modena, Modena, Italy
| | - S Loche
- Pediatric Endocrinology Service, Ospedale Microcitemico, Cagliari, Italy
| | - M Maghnie
- Department of Pediatrics, University of Genova Pediatric Endocrine Unit, Children's Hospital Giannina Gaslini, IRCCS, Genoa, Italy
| | - L Mazzanti
- Pediatric UO, Programme of Endocrinology, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - G Saggese
- Department of Pediatrics, University of Pisa, Pisa, Italy
| | - M Salerno
- Department of Pediatrics, University "Federico II" of Naples, Naples, Italy
| | - G Tonini
- Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", Trieste, Italy
| | - V Toscano
- II Faculty of Medicine, "La Sapienza", University, Rome, Italy
| | - S Zucchini
- Pediatric UO, Programme of Endocrinology, Azienda Ospedaliero-Universitaria S.Orsola-Malpighi, Bologna, Italy
| | - M Cappa
- Endocrinology and Diabetology Unit, Department of Pediatrics, Bambino Gesù Children's Hospital, P.za Sant'Onofrio n. 4, 00165, Rome, Italy.
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Boguszewski CL, Lacerda CSD, Lacerda Filho LD, Carvalho JARD, Boguszewski MCS. Reappraisal of serum insulin-like growth factor-I (IGF-1) measurement in the detection of isolated and combined growth hormone deficiency (GHD) during the transition period. ACTA ACUST UNITED AC 2014; 57:709-16. [PMID: 24402016 DOI: 10.1590/s0004-27302013000900006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 08/13/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the accuracy of serum IGF-1 in the detection of isolated (IGHD) or combined growth hormone deficiency (CGHD) at the transition phase. SUBJECTS AND METHODS Forty nine patients with GHD during childhood [16 with IGHD (10 men) and 33 with CGHD (24 men); age 23.2 ± 3.5 yrs.] were submitted to an insulin tolerance test (ITT) with a GH peak < 5 µg/L used for the diagnosis of GHD at the transition phase. Pituitary function and IGF-1 measurements were evaluated in the basal sample of the ITT. Transition patients were reclassified as GH-sufficient (SGH; n = 12), IGHD (n = 7), or CGHD (n = 30). RESULTS Five (31%) patients with IGHD and 32 (97%) with CGHD at childhood persisted with GHD at retesting. One patient with IGHD was reclassified as CGHD, whereas 3 patients with CGHD were reclassified as IGHD. Mean GH peak was 0.2 ± 0.3 µg/L in the CGHD, 1.3 ± 1.5 µg/L in the IGHD, and 18.1 ± 13.1 µg/L in the SGH group. Serum IGF-1 level was significantly higher in the SGH (272 ± 107 ng/mL) compared to IGHD (100.2 ± 110) and CGHD (48.7 ± 32.8) (p < 0.01). All patients reclassified as CGHD, 86% reclassified as IGHD, and 8.3% reclassified as SGH had low IGF-1 level, resulting in 97.3% sensitivity and 91.6% specificity in the detection of GHD at the transition period; the cutoff value of 110 ng/mL showed 94.5% sensitivity and 100% specificity. Mean IGF-1 values did not differ in IGHD or CGHD associated with one, two, three, or four additional pituitary deficiencies. CONCLUSION IGF-1 measurement is accurate to replace ITT as initial diagnostic test for IGHD and CGHD detection at the transition phase.
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Alatzoglou KS, Webb EA, Le Tissier P, Dattani MT. Isolated growth hormone deficiency (GHD) in childhood and adolescence: recent advances. Endocr Rev 2014; 35:376-432. [PMID: 24450934 DOI: 10.1210/er.2013-1067] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The diagnosis of GH deficiency (GHD) in childhood is a multistep process involving clinical history, examination with detailed auxology, biochemical testing, and pituitary imaging, with an increasing contribution from genetics in patients with congenital GHD. Our increasing understanding of the factors involved in the development of somatotropes and the dynamic function of the somatotrope network may explain, at least in part, the development and progression of childhood GHD in different age groups. With respect to the genetic etiology of isolated GHD (IGHD), mutations in known genes such as those encoding GH (GH1), GHRH receptor (GHRHR), or transcription factors involved in pituitary development, are identified in a relatively small percentage of patients suggesting the involvement of other, yet unidentified, factors. Genome-wide association studies point toward an increasing number of genes involved in the control of growth, but their role in the etiology of IGHD remains unknown. Despite the many years of research in the area of GHD, there are still controversies on the etiology, diagnosis, and management of IGHD in children. Recent data suggest that childhood IGHD may have a wider impact on the health and neurodevelopment of children, but it is yet unknown to what extent treatment with recombinant human GH can reverse this effect. Finally, the safety of recombinant human GH is currently the subject of much debate and research, and it is clear that long-term controlled studies are needed to clarify the consequences of childhood IGHD and the long-term safety of its treatment.
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Affiliation(s)
- Kyriaki S Alatzoglou
- Developmental Endocrinology Research Group (K.S.A., E.A.W., M.T.D.), Clinical and Molecular Genetics Unit, and Birth Defects Research Centre (P.L.T.), UCL Institute of Child Health, London WC1N 1EH, United Kingdom; and Faculty of Life Sciences (P.L.T.), University of Manchester, Manchester M13 9PT, United Kingdom
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Alvarez-Escolá C, Fernández-Rodríguez E, Recio-Córdova JM, Bernabéu-Morón I, Fajardo-Montañana C. Consensus document of the Neuroendocrinology area of the Spanish Society of Endocrinology and Nutrition on management of hypopituitarism during transition. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2014; 61:68.e1-68.e11. [PMID: 24200635 DOI: 10.1016/j.endonu.2013.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Revised: 07/29/2013] [Accepted: 08/08/2013] [Indexed: 06/02/2023]
Abstract
The transition period from child to adult represents a crucial phase in the growth process where multiple physical and psychosocial changes occur. It has been arbitrarily defined as the period extending from late puberty to full adult maturity (i.e., from mid to late teenage years until 6-7 years after achievement of final height). The aim of this guideline is to emphasize the importance of adequate hormone replacement during this period and to review reassessment of pituitary function. In patients with GH deficiency diagnosed in childhood, an attempt is made to answer when to retest GH secretion, when to treat and how they should be monitored. Thyroxine, glucocorticoid, and sex steroid replacement are also reviewed.
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Affiliation(s)
| | - Eva Fernández-Rodríguez
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, España
| | | | - Ignacio Bernabéu-Morón
- Servicio de Endocrinología y Nutrición, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, España
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Soliman AT, Yassin M, Majuid NMSA, Sabt A, Abdulrahman MO, De Sanctis V. Cortisol response to low dose versus standard dose (back-to-back) adrenocorticotrophic stimulation tests in children and young adults with thalassemia major. Indian J Endocrinol Metab 2013; 17:1046-1052. [PMID: 24381882 PMCID: PMC3872683 DOI: 10.4103/2230-8210.122620] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Thalassemia major patients with repeated blood transfusion have high prevalence of endocrinopathies due to iron overload. MATERIALS AND METHODS We examined the adrenocortical function in 23 thalassemic patients (10 children and 13 young adults) aged 8-26 years. Serum cortisol and dehydroepiandrosterone sulfate (DHEA-S) concentrations were determined in each subject before blood transfusion both in basal condition and after low dose (LD) (1 μg), followed by standard dose (SD) (250 μg, respectively) with synthetic corticotrophin beta 1-24 ACTH (Synacthen, Ciba). Normal controls were a group of 13 age- and sex-matched normal subjects. RESULTS Using a peak total cortisol cutoff level of 550 nmol/L and increments of 200 μg above basal cortisol, adrenal insufficiency (AI) was demonstrated in 8 patients (34.7%) after the LD ACTH and in 2 patients (8.7%) after SD cosyntropin (ACTH) test, but none of the controls. Using a peak total cortisol cutoff level of 420 nmol/L and increments of 200 μg above basal cortisol, AI was demonstrated in 5 patients (21.7%) after the LD ACTH and in 2 patients after SD ACTH test (8.7%), but none of controls. All patients with biochemical AI were asymptomatic with normal serum sodium and potassium concentrations and had no history suggestive of adrenal pathology. The peak cortisol concentrations in thalassemic patients with impaired adrenal function both after 1 μg and 250 μg cosyntropin (294 ± 51 nmol/L and 307 ± 58.6) were significantly lower than those with patients with normal (454 ± 79.7 nmol/L and 546.1 ± 92.2 nmol/L, respectively) and controls (460.2 ± 133.4 nmol/L and 554.3 ± 165.8 nmol/L, respectively). Adolescents and young adults, but not children with thalassaemia, had significantly lower peak cortisol concentration after SD ACTH versus controls. Peak cortisol response to LD ACTH was correlated significantly with peak cortisol response to SD in all patients (r = 0.83, P < 0.0001). In adolescents and young adults with thalassemia, DHEA-S levels before and after LD ACTH stimulation were significantly lower and the cortisol/DHEA-S ratios were significantly higher than the controls. CONCLUSION The use of LD ACTH test diagnoses more adrenal abnormalities versus SD ACTH in thalassemic patients. The relatively high prevalence of AI in thalassemic adolescents and young adults necessitates that these patients have to be investigated for AI before major surgery and those with impaired cortisol secretion should receive stress doses of corticosteroids during the stressful event.
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Affiliation(s)
| | - Mohamed Yassin
- Department of Hematology, Hamad Medical Center, Doha, Qatar
| | | | - Aml Sabt
- Department of Pediatrics, Hamad Medical Center, Doha, Qatar
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Lee J, Yoon J, Kang MJ, Lee YA, Lee SY, Shin CH, Yang SW. Influence of body mass index on the growth hormone response to provocative testing in short children without growth hormone deficiency. J Korean Med Sci 2013; 28:1351-5. [PMID: 24015042 PMCID: PMC3763111 DOI: 10.3346/jkms.2013.28.9.1351] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 07/02/2013] [Indexed: 11/25/2022] Open
Abstract
Obesity and its related factors are known to suppress the secretion of growth hormone (GH). We aimed to evaluate the influence of body mass index (BMI) on the peak GH response to provocative testing in short children without GH deficiency. We conducted a retrospective review of medical records of 88 children (2-15 yr old) whose height was less than 3 percentile for one's age and sex, with normal results (peak GH level > 10 ng/mL) of GH provocative testing with clonidine and dopamine. Peak stimulated GH level, height, weight, pubertal status and serum IGF-1 level were measured. Univariate analysis showed that the BMI standard deviation score (SDS) correlated negatively with the natural log (ln) of the peak stimulated GH level (ln peak GH). BMI SDS did not correlate significantly with sex, age, pubertal status, or ln IGF-1 level. BMI SDS correlated negatively with ln peak GH level induced by clonidine but not by dopamine. In stepwise multivariate regression analysis, BMI SDS was the only significant predictor of ln peak GH level in the combination of tests and the clonidine test, but not in the dopamine test. In children without GH deficiency, BMI SDS correlates negatively with the peak GH level. BMI SDS should be included in the analysis of the results of GH provocation tests, especially tests with clonidine.
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Affiliation(s)
- Jieun Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Juyoung Yoon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Min Jae Kang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yong Lee
- Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sei Won Yang
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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Quigley CA, Zagar AJ, Liu CC, Brown DM, Huseman C, Levitsky L, Repaske DR, Tsalikian E, Chipman JJ. United States multicenter study of factors predicting the persistence of GH deficiency during the transition period between childhood and adulthood. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2013; 2013:6. [PMID: 23406437 PMCID: PMC3605263 DOI: 10.1186/1687-9856-2013-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Accepted: 01/30/2013] [Indexed: 11/10/2022]
Abstract
Background Many patients with childhood-onset growth hormone (GH) deficiency do not fulfill diagnostic criteria for GH deficiency (GHD) after attainment of adult height and may not require long-term GH treatment. Patients with history of idiopathic GHD (IGHD) pose the greatest management dilemma, as data regarding factors predictive of persistent GHD in this group are lacking. Objectives The objective of this study was to assess potential predictors of persistent GHD in a US patient cohort during transition from childhood to adulthood, particularly in patients with history of IGHD. Methods We studied 73 US patients with history of childhood-onset GHD screened at 21 US pediatric endocrine centers for a randomized clinical trial of GH replacement after attainment of adult height. The cohort comprised 42 boys/men and 31 girls/women aged14–22 years, who had received ≥1 year of GH treatment and had completed linear growth. The main outcome measures were sensitivity, specificity, positive and negative predictive values (PPV, NPV) of clinical and hormonal factors for persistent GHD (defined a priori in this study as peak GH < 5 μg/L). Results For the cohort as a whole, the best predictors of persistent GHD (100% PPV) were history of organic hypothalamic-pituitary disorder or ≥2 additional pituitary hormone deficiencies (PHD). Best predictors of persistent GHD in patients with childhood history of IGHD were standard deviation scores (SDS) for serum insulin-like growth factor binding protein-3 (IGFBP-3) below -2.0, and for insulin-like growth factor-I (IGF-I) below -5.3 (measured ≥6 weeks after completion of GH treatment; PPV 100% for both), and age <4 years at original diagnosis (PPV 89%). IGF-I above -1.6 SDS had 100% NPV. Conclusions US patients with an organic cause of childhood-onset GHD or ≥2 additional PHDs may not require GH stimulation testing to reconfirm GHD after completion of childhood treatment. In contrast, patients with idiopathic childhood-onset GHD almost invariably require retesting, as GHD persists in only a minority (those who were very young at initial diagnosis and those who have subnormal IGFBP-3 or extremely low IGF-I after completion of childhood treatment). Subnormal posttreatment IGF-I (<-2.0 SDS) lacked predictive power for persistent GHD, whereas IGF-I > -1.6 SDS was 100% predictive of GH sufficiency.
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Inzaghi E, Cianfarani S. The Challenge of Growth Hormone Deficiency Diagnosis and Treatment during the Transition from Puberty into Adulthood. Front Endocrinol (Lausanne) 2013; 4:34. [PMID: 23577001 PMCID: PMC3602795 DOI: 10.3389/fendo.2013.00034] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Accepted: 03/05/2013] [Indexed: 11/13/2022] Open
Abstract
In children with childhood-onset growth hormone deficiency, replacement GH therapy is effective in normalizing height during childhood and achieving adult height within the genetic target range. GH has further beneficial effects on body composition and metabolism through adult life. The transition phase, defined as the period from mid to late teens until 6-7 years after the achievement of final height, represents a crucial time for reassessing children's GH secretion and deciding whether GH therapy should be continued throughout life. Evidence-based guidelines for diagnosis and treatment of growth hormone deficient children during transition are lacking. The aim of this review is to critically review the up-to-date evidence on the best management of transition patients in order to ensure the correct definitive diagnosis and establish the appropriate therapeutic regimen.
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Affiliation(s)
- Elena Inzaghi
- Molecular Endocrinology Unit, Bambino Gesù Children’s HospitalRome, Italy
| | - Stefano Cianfarani
- Molecular Endocrinology Unit, Bambino Gesù Children’s HospitalRome, Italy
- Department of Women’s and Children’s Health, Karolinska InstitutetStockholm, Sweden
- *Correspondence: Stefano Cianfarani, Molecular Endocrinology Unit, Bambino Gesù Children’s Hospital, P.zza S. Onofrio 4, 00165 Roma, Italy. e-mail:
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Huang YH, Wai YY, Van YH, Lo FS. Effect of growth hormone therapy on Taiwanese children with growth hormone deficiency. J Formos Med Assoc 2012; 111:355-63. [DOI: 10.1016/j.jfma.2011.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2011] [Revised: 06/09/2011] [Accepted: 06/09/2011] [Indexed: 11/24/2022] Open
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Jagtap VS, Acharya SV, Sarathi V, Lila AR, Budyal SR, Kasaliwal R, Sankhe SS, Bandgar TR, Menon PS, Shah NS. Ectopic posterior pituitary and stalk abnormality predicts severity and coexisting hormone deficiencies in patients with congenital growth hormone deficiency. Pituitary 2012; 15:243-50. [PMID: 21667124 DOI: 10.1007/s11102-011-0321-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Certain pituitary imaging abnormalities are a specific indicator of hypopituitarism. The objective of this study is to compare phenotypical features with radiological findings in patients with congenital growth hormone deficiency (GHD). Magnetic Resonance imaging (MRI) was performed in 103 patients [72 with Isolated GHD (IGHD) and 31 with Combined Pituitary Hormone Deficiency (CPHD)]. Images were assessed for the following abnormalities: (1) small/absent anterior pituitary, (2) thin or interrupted pituitary stalk (PSA), and (3) Ectopic posterior pituitary (EPP), and (4) others. Radiological findings were correlated with the clinical and biochemical parameters. MRI abnormalities were observed in 48.6% patients with IGHD, 93.5% with CPHD. Jaundice, hypoxia, hypoglycemia and breech deliveries were more common in EPP/PSA group. EPP/PSA was observed in 87.1% patients with severe GHD (peak GH < 3 μg/L) as compared to 12.9% with mild to moderate GHD (peak GH: 3-10 μg/L). Amongst CPHD, EPP/PSA was present in 80% of subjects with associated hypocortisolism ± hypothyroidism as compared to 18.2% of subjects with hypogonadism. Over a mean follow up period of 4.5 years, 5.4% of subjects with IGHD and abnormal MRI progressed to CPHD while none of those with normal MRI progressed. This study emphasizes a significant clinico-radiological correlation in Asian Indian GHD patients. MRI abnormalities in the hypothalamic pituitary area, especially EPP/PSA are more common in patients with CPHD and severe GHD. Among CPHD, EPP/PSA predicts association with hypothyroidism or hypocortisolism. IGHD with MRI abnormality may evolve into CPHD.
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Affiliation(s)
- Varsha S Jagtap
- Department of Endocrinology, Seth G S Medical College, Parel, Mumbai, Maharashtra, 400012, India.
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Abstract
PURPOSE OF REVIEW The diagnosis of growth hormone deficiency (GHD) in childhood is challenging, in large part because of the lack of a true gold standard and the relatively poor performance of available diagnostic testing. This review discusses the recent literature on this topic. RECENT FINDINGS Auxology and clinical judgment remain the foundation for the diagnosis of GHD. Provocative growth hormone testing is poorly reproducible, dependent on factors such as body composition and pubertal status, and further limited by significant variability among commercially available growth hormone assays. Measurement of insulin-like growth factor I and insulin-like growth factor-binding protein 3 is not diagnostically useful in isolation but is helpful in combination with other diagnostic measures. Neuroimaging is also useful to inform diagnosis, as pituitary abnormalities suggest a higher likelihood of GHD persisting into adulthood. Although genetic testing is not routinely performed in the diagnosis of GHD at the present time, multiple recent reports raise the possibility that it may play a more important role in diagnosing GHD in the future. SUMMARY Beyond physicians' integrated assessment of auxology, clinical presentation, and bone age, current tools to diagnose GHD are suboptimal. Recent literature emphasizes the need to reappraise our current practice and to consider new tools for diagnosis.
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Affiliation(s)
- Takara Stanley
- Pediatric Endocrine Unit, Program in Nutritional Metabolism, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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