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Henry RK, Mamilly L, Chaudhari M, Klamer BG, Nikahd M, Pyle-Eilola AL. Beyond the bias! Sex distribution in paediatric growth hormone deficiency reexamined. Clin Endocrinol (Oxf) 2024; 100:441-446. [PMID: 38463009 DOI: 10.1111/cen.15047] [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: 10/10/2023] [Revised: 02/23/2024] [Accepted: 02/29/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES Various biases pertaining to stature account for a male sex predominance in growth hormone deficiency (GHD) cases diagnosed by endocrinology clinics. This manuscript will assess the sex distribution when biases are minimised. METHODS Retrospective chart review was conducted on patients diagnosed with GHD between 3 and 16 years of age. The sex distribution of cases was ascertained according to: (1) peak GH (pGH) by groups; based on growth hormone provocative testing, (2) pituitary gland imaging results, and (3) isolated GHD (IGHD) versus multiple pituitary hormone deficiencies (MPHD). The relative frequency of each sex was compared according to these subgroups with significance evaluated at α = .05 level. RESULTS Of the 5880 clinic referrals for short stature, there were 3709 boys (63%) and 2171 girls (37%). Of these, 20% of boys (n = 745) and 15.3% of girls (n = 332) underwent provocative testing for GHD. Of those tested, 39.2% of boys (n = 292) and 32.2% of girls (n = 107) were diagnosed with GHD, all p < .001. There was a male predominance in GHD cases based on pGH or GHD severity. Though not significant, girls were more likely than boys to have MPHD (p = .056), even across pGH groups (p = .06). Both boys and girls had a similar distribution of imaging abnormalities. CONCLUSION Stratifying by sex, we found similar percentages of pituitary imaging abnormalities (including tumours) and the number of pituitary hormone deficiencies in boys and girls as the cause of GHD. For these classifications, we did not find the historically reported male sex predominance.
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Affiliation(s)
- Rohan K Henry
- Department of Pediatrics, Section of Endocrinology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Leena Mamilly
- Department of Pediatrics, Section of Endocrinology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Monika Chaudhari
- Department of Pediatrics, Section of Endocrinology, Nationwide Children's Hospital/The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Brett G Klamer
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Melica Nikahd
- Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Amy L Pyle-Eilola
- Department of Pathology and Laboratory Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
- Department of Pathology, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Roberts JE, Williams K, Dallas J, Eckert M, Huie L, Smitherman E, Soulsby WD, Zhao Y, Son MBF. Insurance Status and Tumor Necrosis Factor Inhibitor Initiation Among Children With Juvenile Idiopathic Arthritis in the CARRA Registry. J Rheumatol 2023; 50:1047-1057. [PMID: 36521922 PMCID: PMC10303749 DOI: 10.3899/jrheum.220871] [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] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Prompt escalation to tumor necrosis factor inhibitors (TNFis) is recommended for children with juvenile idiopathic arthritis (JIA) and ongoing disease activity despite treatment with conventional disease-modifying antirheumatic drugs (cDMARDs). It is unknown whether these recommendations are equitably followed for children with different insurance types. We assessed the association of insurance coverage on the odds and timing of TNFi use. METHODS We conducted a retrospective study of children with newly diagnosed JIA in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry. We compared the odds of starting a TNFi in the first year and time from cDMARD to TNFi initiation between those with public and private insurance. RESULTS We identified 1086 children with new JIA diagnoses. Publicly insured children had significantly higher active joint counts and parent/patient global assessment scores at the enrollment visit. They were also more likely to have polyarticular arthritis compared to those with private insurance. Odds of any TNFi use in the first year did not differ between publicly and privately insured children. Publicly insured children were escalated from cDMARD to TNFi more quickly than privately insured children. CONCLUSION Children who were publicly insured had more severe disease and polyarticular involvement at registry enrollment compared to those who were privately insured. Whereas overall TNFi use did not differ between children with different insurance types, publicly insured children were escalated more quickly, consistent with their increased disease severity. Further research is needed to determine why insurance coverage type is associated with disease severity, including how other socioeconomic factors affect presentation to care.
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Affiliation(s)
- Jordan E Roberts
- J.E. Roberts, MD, MPH, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, and Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Kathryn Williams
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Johnathan Dallas
- K. Williams, MS, J. Dallas, BA, M.B.F. Son, MD, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mary Eckert
- M. Eckert, BS, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Livie Huie
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Emily Smitherman
- L. Huie, BA, E. Smitherman, MD, MSc, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - William D Soulsby
- W.D. Soulsby, MD, University of California at San Francisco, San Francisco, California
| | - Yongdong Zhao
- Y. Zhao, MD, PhD, Seattle Children's Hospital, University of Washington School of Medicine, and Seattle Children's Research Institute, Center for Clinical and Translational Research, Seattle, Washington, USA
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Kamoun C, Miller VA, Feudtner C, Friedrich EA, Grimberg A. Views on Short Stature of Female vs Male Endocrine Pediatric Patients Undergoing Provocative Growth Hormone Testing and Their Parents. Endocr Pract 2023; 29:517-524. [PMID: 37088146 PMCID: PMC10330208 DOI: 10.1016/j.eprac.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/08/2023] [Accepted: 04/14/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Boys outnumber girls in short stature evaluations and growth hormone treatment despite absence of gender differences in short stature prevalence. Family views on short stature influence medical management, but gender-based analysis of these views is lacking. This study explored endocrine patients' and their parents' perceptions of short stature and its impact on quality of life by patient gender. METHODS Patients aged 8 to 14 years undergoing provocative growth hormone testing and 1 parent each completed semistructured interviews. Clinical data were extracted by chart review. RESULTS Twenty-four patient-parent dyads (6 female patients, 22 mothers; predominantly non-Hispanic White) participated. Six major themes emerged: (1) patients' perceptions of their short stature were similar by gender, (2) physical experiences of short stature were similar by gender, (3) social experiences of short stature were both similar and different by gender, (4) parental perceptions of short stature as a factor limiting their child's functionality were similar by gender, (5) concern about societal stigma related to short stature arose for both genders, and (6) patients' perceptions of parental messaging about the import of their short stature were similar by gender. CONCLUSION Our data reveal more similarities than differences between genders in patient perceptions and patient and parent-reported experiences of short stature. Worry about stature-related stigma was noted for patients of both genders. Parental messaging about short stature emerged as an important area to explore further by patient gender. Our findings suggest that clinicians should be wary of making gender or stigma-based assumptions when evaluating children with short stature.
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Affiliation(s)
- Camilia Kamoun
- Division of Endocrinology, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina.
| | - Victoria A Miller
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chris Feudtner
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth A Friedrich
- Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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Diaz-Thomas AM, Golden SH, Dabelea DM, Grimberg A, Magge SN, Safer JD, Shumer DE, Stanford FC. Endocrine Health and Health Care Disparities in the Pediatric and Sexual and Gender Minority Populations: An Endocrine Society Scientific Statement. J Clin Endocrinol Metab 2023; 108:1533-1584. [PMID: 37191578 PMCID: PMC10653187 DOI: 10.1210/clinem/dgad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Indexed: 05/17/2023]
Abstract
Endocrine care of pediatric and adult patients continues to be plagued by health and health care disparities that are perpetuated by the basic structures of our health systems and research modalities, as well as policies that impact access to care and social determinants of health. This scientific statement expands the Society's 2012 statement by focusing on endocrine disease disparities in the pediatric population and sexual and gender minority populations. These include pediatric and adult lesbian, gay, bisexual, transgender, queer, intersex, and asexual (LGBTQIA) persons. The writing group focused on highly prevalent conditions-growth disorders, puberty, metabolic bone disease, type 1 (T1D) and type 2 (T2D) diabetes mellitus, prediabetes, and obesity. Several important findings emerged. Compared with females and non-White children, non-Hispanic White males are more likely to come to medical attention for short stature. Racially and ethnically diverse populations and males are underrepresented in studies of pubertal development and attainment of peak bone mass, with current norms based on European populations. Like adults, racial and ethnic minority youth suffer a higher burden of disease from obesity, T1D and T2D, and have less access to diabetes treatment technologies and bariatric surgery. LGBTQIA youth and adults also face discrimination and multiple barriers to endocrine care due to pathologizing sexual orientation and gender identity, lack of culturally competent care providers, and policies. Multilevel interventions to address these disparities are required. Inclusion of racial, ethnic, and LGBTQIA populations in longitudinal life course studies is needed to assess growth, puberty, and attainment of peak bone mass. Growth and development charts may need to be adapted to non-European populations. In addition, extension of these studies will be required to understand the clinical and physiologic consequences of interventions to address abnormal development in these populations. Health policies should be recrafted to remove barriers in care for children with obesity and/or diabetes and for LGBTQIA children and adults to facilitate comprehensive access to care, therapeutics, and technological advances. Public health interventions encompassing collection of accurate demographic and social needs data, including the intersection of social determinants of health with health outcomes, and enactment of population health level interventions will be essential tools.
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Affiliation(s)
- Alicia M Diaz-Thomas
- Department of Pediatrics, Division of Endocrinology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Sherita Hill Golden
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Dana M Dabelea
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Adda Grimberg
- Department of Pediatrics, Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Sheela N Magge
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Joshua D Safer
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, NY 10001, USA
| | - Daniel E Shumer
- Department of Pediatric Endocrinology, C.S. Mott Children's Hospital, University of Michigan School of Medicine, Ann Arbor, MI 48109, USA
| | - Fatima Cody Stanford
- Massachusetts General Hospital, Department of Medicine-Division of Endocrinology-Neuroendocrine, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard (NORCH), Boston, MA 02114, USA
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Birdus N, Grant M, Stevenson PG, Choong CSY, Siafarikas A. Ten year analysis of the clinic profile of the tertiary paediatric endocrine service in Western Australia. J Pediatr Endocrinol Metab 2022; 35:785-794. [PMID: 35506613 DOI: 10.1515/jpem-2022-0055] [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: 01/30/2022] [Accepted: 04/05/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES There is a paucity of information regarding the profile of entire paediatric endocrine clinics and how they are changing. This study aimed to analyse the clinic profile of the Western Australian tertiary paediatric endocrine outpatient service over 10 years and compare to national and international data. METHODS Retrospective analysis of the Western Australian Paediatric Endocrine Database (WAPED) between 2007 and 2017 looking at the frequency, proportion and longitudinal change of diagnosis categories, specific diagnoses, and gender breakdown. RESULTS In total, 2,791 endocrine diagnoses were recorded for 2,312 patients. The most frequent reason for referral (22.1% of patients), was for evaluation of abnormalities in thyroid function. The most common diagnosis being hypothyroidism (76.7%). Evaluation of short stature was the reason for referral in 19.2% of patients, 14.6% of whom were diagnosed with growth hormone deficiency. Evaluation of puberty disorders, syndromes with endocrine features and disorders of calcium and phosphate metabolism were other common reasons for clinic referral, seen in 11.3, 9.8 and 8.2% of patients respectively. Between 2007 and 2017, the odds ratio of a thyroid diagnosis increased by 1.07 per year (95% CI: 1.02-1.12), whilst the odds ratio of a short stature diagnosis decreased by 0.91 per year (95% CI: 0.87-0.95). CONCLUSIONS The profile of the WAPED is similar to previously published national and international data. The analysis of the profile of diagnoses and its longitudinal change over a ten-year period offer a unique opportunity to guide clinic planning, resource allocation and future research.
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Affiliation(s)
| | - Maree Grant
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia
| | - Paul G Stevenson
- Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia
| | - Catherine S Y Choong
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia.,Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,Medical School, The University of Western Australia, Nedlands, WA, Australia
| | - Aris Siafarikas
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Nedlands, WA, Australia.,Telethon Kids Institute, The University of Western Australia, Nedlands, WA, Australia.,Medical School, The University of Western Australia, Nedlands, WA, Australia.,Institute for Health Research, The University of Notre Dame, Fremantle, WA, Australia
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Beliard K, Wu V, Samuels J, Lipman TH, Rapaport R. Identifying and addressing disparities in the evaluation and treatment of children with growth hormone deficiency. Front Endocrinol (Lausanne) 2022; 13:989404. [PMID: 36093098 PMCID: PMC9448989 DOI: 10.3389/fendo.2022.989404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022] Open
Abstract
Health disparities are a significant cause of concern globally and in the United States. Disparities have been additionally highlighted throughout the ongoing COVID-19 pandemic during which populations of color have been the most affected by the disease. Social determinants of health, race, ethnicity, and gender have all contributed to disparate outcomes and disparities spanning all age groups. Multiple socio-ecological factors contribute to disparities and different strategies have been proposed. The purpose of this paper is to provide an overview of disparities in pediatric treatment and outcomes, with a focus on children with endocrine disorders.
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Affiliation(s)
- Kara Beliard
- Division of Pediatric Endocrine and Diabetes, Mount Sinai Kravis Children’s Hospital, New York, NY, United States
| | - Vickie Wu
- Division of Pediatric Endocrine and Diabetes, Mount Sinai Kravis Children’s Hospital, New York, NY, United States
| | - Julie Samuels
- Division of Pediatric Endocrine and Diabetes, Mount Sinai Kravis Children’s Hospital, New York, NY, United States
| | - Terri H. Lipman
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, United States
| | - Robert Rapaport
- Division of Pediatric Endocrine and Diabetes, Mount Sinai Kravis Children’s Hospital, New York, NY, United States
- *Correspondence: Robert Rapaport,
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Orr J, Freer J, Morris JK, Hancock C, Walton R, Dunkel L, Storr HL, Prendergast AJ. Regional differences in short stature in England between 2006 and 2019: A cross-sectional analysis from the National Child Measurement Programme. PLoS Med 2021; 18:e1003760. [PMID: 34582440 PMCID: PMC8478195 DOI: 10.1371/journal.pmed.1003760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Short stature, defined as height for age more than 2 standard deviations (SDs) below the population median, is an important indicator of child health. Short stature (often termed stunting) has been widely researched in low- and middle-income countries (LMICs), but less is known about the extent and burden in high-income settings. We aimed to map the prevalence of short stature in children aged 4-5 years in England between 2006 and 2019. METHODS AND FINDINGS We used data from the National Child Measurement Programme (NCMP) for the school years 2006-2007 to 2018-2019. All children attending state-maintained primary schools in England are invited to participate in the NCMP, and heights from a total of 7,062,071 children aged 4-5 years were analysed. We assessed short stature, defined as a height-for-age standard deviation score (SDS) below -2 using the United Kingdom WHO references, by sex, index of multiple deprivation (IMD), ethnicity, and region. Geographic clustering of short stature was analysed using spatial analysis in SaTScan. The prevalence of short stature in England was 1.93% (95% confidence interval (CI) 1.92-1.94). Ethnicity adjusted spatial analyses showed geographic heterogeneity of short stature, with high prevalence clusters more likely in the North and Midlands, leading to 4-fold variation between local authorities (LAs) with highest and lowest prevalence of short stature. Short stature was linearly associated with IMD, with almost 2-fold higher prevalence in the most compared with least deprived decile (2.56% (2.53-2.59) vs. 1.38% (1.35-1.41)). There was ethnic heterogeneity: Short stature prevalence was lowest in Black children (0.64% (0.61-0.67)) and highest in Indian children (2.52% (2.45-2.60)) and children in other ethnic categories (2.57% (2.51-2.64)). Girls were more likely to have short stature than boys (2.09% (2.07-2.10) vs. 1.77% (1.76-1.78), respectively). Short stature prevalence declined over time, from 2.03% (2.01-2.05) in 2006-2010 to 1.82% (1.80-1.84) in 2016-2019. Short stature declined at all levels of area deprivation, with faster declines in more deprived areas, but disparities by IMD quintile were persistent. This study was conducted cross-sectionally at an area level, and, therefore, we cannot make any inferences about the individual causes of short stature. CONCLUSIONS In this study, we observed a clear social gradient and striking regional variation in short stature across England, including a North-South divide. These findings provide impetus for further investigation into potential socioeconomic influences on height and the factors underlying regional variation.
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Affiliation(s)
- Joanna Orr
- Queen Mary University of London, London, United Kingdom
- * E-mail:
| | - Joseph Freer
- Queen Mary University of London, London, United Kingdom
| | - Joan K. Morris
- St George’s University of London, London, United Kingdom
| | | | - Robert Walton
- Queen Mary University of London, London, United Kingdom
| | - Leo Dunkel
- Queen Mary University of London, London, United Kingdom
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Liu M, Liu M, Liang X, Wu D, Li W, Su C, Cao B, Chen J, Gong C. Clinical and genetic characteristics of hypophosphatasia in Chinese children. Orphanet J Rare Dis 2021; 16:159. [PMID: 33827627 PMCID: PMC8028151 DOI: 10.1186/s13023-021-01798-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/30/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Hypophosphatasia (HPP) is a rare inherited disorder, which is caused by loss-of-function mutations in the ALPL gene. HPP is a heterogeneous disease that has a wide spectrum of phenotypes. Few studies were carried out in the Chinese population with HPP, especially in children. METHODS The clinical and genetic characteristics of 10 Chinese children with HPP who were referred to the Beijing Children's Hospital were described. Previously reported HPP cases of children in China were also reviewed. RESULTS A total of 33 cases were identified, which included 2 perinatal lethal HPP, 10 infantile HPP, 10 childhood HPP, and 11 odonto HPP. The male-to-female ratio was 24:9. The average age at onset was 0.69 years (ranged from 2 h after birth to 14 years), while the average age at clinical diagnosis was 3.87 years (ranged from 2 h after birth to 19 years). Serum alkaline phosphatase (ALP) levels were significantly decreased in patients with perinatal lethal/infantile HPP when compared with those with the mild forms of HPP childhood/odonto HPP (P < 0.01). Although serum phosphate levels were not different (P > 0.05), serum calcium levels were elevated, and serum intact parathyroid hormone levels were decreased in patients with perinatal lethal/infantile HPP in comparison with those with the childhood/odonto HPP (P all < 0.01). Genetic analyses identified 40 mutations in 31 HPP cases, including 28 missense mutations, 9 frameshift mutations, 2 splice junction alterations, and 1 regulatory mutation. Of which, 5 novel mutations were identified in our present study: 2 frameshift mutations (p.Arg138GlyfsTer27, p.Leu511Profs*272); 2 missense mutations (p.Ala176Val, p.Phe268Leu), and 1 splice junction alteration (c.297+5G>A). Compound heterozygous mutations accounted for 80.6% of all variants. No mutational "hot-spot" was found. Most mutations of ALPL were located in exons 5, 7, 10, and 3. Notably, subjects that carrying single heterozygous mutations showed milder phenotypes of HPP, while subjects with nonsense mutations were associated with a severer phenotype. CONCLUSIONS HPP is a rare disease with often delayed diagnosis, and the incidence of HPP in China may be seriously underestimated. The present study expands the phenotypic and genotypic spectrum and the understanding of HPP in Chinese children. These findings will be useful for clinical assessment and shorten the diagnosis time for pediatric HPP in China.
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Affiliation(s)
- Meijuan Liu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Min Liu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Xuejun Liang
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Di Wu
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Wenjing Li
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Chang Su
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Bingyan Cao
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Jiajia Chen
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China
| | - Chunxiu Gong
- Department of Endocrinology, Genetics and Metabolism, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, 100045, China.
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Smart SJ, Nikaj AN, Yu L, Li H, Yan F, Zhang J. Association between maternal smoking during pregnancy and offspring overweight in U.S.-born children. Pediatr Obes 2021; 16:e12717. [PMID: 32924334 DOI: 10.1111/ijpo.12717] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND The criticism of the literature on smoking during pregnancy and offspring overweight was the confounding from postnatal factors. Interaction between gestational age and prenatal maternal smoking has not yet assessed. METHODS We used the Third National Health and Nutrition Examination Survey (1988-1994), linked with natality files of US-born singletons aged 2 to 6 years. A body mass index in the 85th percentile or higher were considered overweight, including obesity. Gestational age was dichotomized as preterm (<37 weeks, n = 240) or full-term (n = 2125). Smoking status during pregnancy was ascertained by a questionnaire-based interview during National Health and Nutrition Examination Survey. RESULTS The prevalence of offspring overweight and obesity combined was 17.3% (SE = 1.3%). And 24.0% (1.3%) of mothers smoked while pregnant. A significant interaction was observed between maternal smoking and gestational age. In preterm children, a higher prevalence of overweight (34.3% [6.7%]) was found among the offspring of smoking mothers compared to non-smoking mothers (15.8% [3.6%]). After adjustment for socio-demographics, prenatal and postnatal factors, in preterm born offspring, the odds ratio of being born to smoking mothers was 2.46 (95% confidence intervals: 1.13-5.37) among children with overweight/obesity compared to children with healthy weight born to non-smoking mothers. In full-term children, the OR of being born to smoking mothers was 0.72 (0.50-1.03) among offspring with overweight/obesity relative to offspring with healthy weight born to non-smoking mothers. CONCLUSIONS Maternal smoking during pregnancy was strongly associated with offspring overweight and obesity in preterm births after control for postnatal factors. Preterm children of smoking mothers should be prioritized for obesity prevention.
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Affiliation(s)
- Shirley J Smart
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Aurela N Nikaj
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Lili Yu
- Department of Biostatistics, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
| | - Hongxia Li
- Shanghai East Hospital, Tongji University, School of Medicine, Shanghai, China.,Department of Social Medicine, School of Public Health, Fudan University, Shanghai, China
| | - Fei Yan
- Department of Social Medicine, School of Public Health, Fudan University, Shanghai, China
| | - Jian Zhang
- Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USA
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10
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Focused Revision: ACMG practice resource: Genetic evaluation of short stature. Genet Med 2021; 23:813-815. [PMID: 33514815 DOI: 10.1038/s41436-020-01046-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 11/12/2020] [Accepted: 11/16/2020] [Indexed: 01/31/2023] Open
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Kamoun C, Hawkes CP, Gunturi H, Dauber A, Hirschhorn JN, Grimberg A. Growth Hormone Stimulation Testing Patterns Contribute to Sex Differences in Pediatric Growth Hormone Treatment. Horm Res Paediatr 2021; 94:353-363. [PMID: 34662877 PMCID: PMC8821324 DOI: 10.1159/000520250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/15/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Males are twice as likely as females to receive pediatric growth hormone (GH) treatment in the USA, despite similar distributions of height z (HtZ)-scores in both sexes. Male predominance in evaluation and subspecialty referral for short stature contributes to this observation. This study investigates whether sex differences in GH stimulation testing and subsequent GH prescription further contribute to male predominance in GH treatment. METHODS Retrospective chart review was conducted of all individuals, aged 2-16 years, evaluated for short stature or poor growth at a single large tertiary referral center between 2012 and 2019. Multiple logistic regression models were constructed to analyze sex differences. RESULTS Of 10,125 children referred for evaluation, a smaller proportion were female (35%). More males (13.1%) than females (10.6%) underwent GH stimulation testing (p < 0.001) and did so at heights closer to average (median HtZ-score -2.2 [interquartile range, IQR -2.6, -1.8] vs. -2.5 [IQR -3.0, -2.0], respectively; p < 0.001). The proportion of GH prescriptions by sex was similar by stimulated peak GH level. Predictor variables in regression modeling differed by sex: commercial insurance predicted GH stimulation testing and GH prescription for males only, whereas lower HtZ-score predicted GH prescription for females only. CONCLUSIONS Sex differences in rates of GH stimulation testing but not subsequent GH prescription based on response to GH stimulation testing seem to contribute to male predominance in pediatric GH treatment. That HtZ-score predicted GH prescription in females but not males raises questions about the extent to which sex bias - from children, parents, and/or physicians - as opposed to objective growth data, influence medical decision-making in the evaluation and treatment of short stature.
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Affiliation(s)
- Camilia Kamoun
- Division of Endocrinology and Diabetes, Children’s
Hospital of Philadelphia, Philadelphia, PA, USA
| | - Colin Patrick Hawkes
- Division of Endocrinology and Diabetes, Children’s
Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA,Department of Paediatrics and Child Health, University
College Cork, Cork, Ireland
| | - Hareesh Gunturi
- Department of Biomedical and Health Informatics,
Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew Dauber
- Division of Endocrinology, Children’s National
Hospital, Washington, District of Columbia, USA,Department of Pediatrics George Washington University
School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Joel N Hirschhorn
- Division of Endocrinology, Boston Children’s
Hospital, Boston, MA, USA,Departments of Pediatrics and Genetics, Harvard Medical
School, Boston, MA, USA
| | - Adda Grimberg
- Division of Endocrinology and Diabetes, Children’s
Hospital of Philadelphia, Philadelphia, PA, USA,Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA, USA,Leonard Davis Institute of Health Economics, University of
Pennsylvania, Philadelphia, PA, USA
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12
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Galazzi E, Persani LG. Differential diagnosis between constitutional delay of growth and puberty, idiopathic growth hormone deficiency and congenital hypogonadotropic hypogonadism: a clinical challenge for the pediatric endocrinologist. MINERVA ENDOCRINOL 2020; 45:354-375. [PMID: 32720501 DOI: 10.23736/s0391-1977.20.03228-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Differential diagnosis between constitutional delay of growth and puberty (CDGP), partial growth hormone deficiency (pGHD) and congenital hypogonadotropic hypogonadism (cHH) may be difficult. All these conditions usually present with poor growth in pre- or peri-pubertal age and they may recur within one familial setting, constituting a highly variable, but somehow common, spectrum of pubertal delay. EVIDENCE ACQUISITION Narrative review of the most relevant English papers published between 1981 and march 2020 using the following search terms "constitutional delay of growth and puberty," "central hypogonadism," "priming," "growth hormone deficiency," "pituitary," "pituitary magnetic resonance imaging," with a special regard to the latest scientific acquisitions. EVIDENCE SYNTHESIS CDGP is by far the most prevalent entity in boys and recurs within families. pGHD is a rare, often idiopathic and transient condition, where hypostaturism presents more severely. Specificity of pGHD diagnosis is increased by priming children before growth hormone stimulation test (GHST); pituitary MRI and genetic analysis are recommended to personalize future follow-up. Diagnosing cHH may be obvious when anosmia and eunuchoid proportions concomitate. However, cHH can either overlap with pGHD in forms of multiple pituitary hormone deficiencies (MPHD) or syndromic conditions either with CDGP in family pedigrees, so endocrine workup and genetic investigations are necessary. The use of growth charts, bone age, predictors of adult height, primed GHST and low dose sex steroids (LDSS) treatment are recommended. CONCLUSIONS Only a step-by-step diagnostic process based on appropriate endocrine and genetic markers together with LDSS treatment can help achieving the correct diagnosis and optimizing outcomes.
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Affiliation(s)
- Elena Galazzi
- Department of Endocrinology and Metabolic Diseases, IRCCS Auxologico Italian Institute, Milan, Italy -
| | - Luca G Persani
- Department of Endocrinology and Metabolic Diseases, IRCCS Auxologico Italian Institute, Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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Halas JG, Grimberg A. Dilemmas of growth hormone treatment for GH deficiency and idiopathic short stature: defining, distinguishing, and deciding. Minerva Pediatr 2020; 72:206-225. [PMID: 32274914 DOI: 10.23736/s0026-4946.20.05821-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Worrisome growth can be a sign of underlying pathology but usually reflects healthy variation. It is often recognized through short stature, which is defined by arbitrarily separating height, a physical trait on a continuum, into "normal" and "abnormal." In some cases of worrisome growth, recombinant human growth hormone (rhGH) treatment is indicated to hasten growth/increase height. This review addresses the two most frequently treated indications for rhGH, growth hormone deficiency (GHD) and idiopathic short stature (ISS). A review of worrisome growth itself, of the history of GH treatment, of the blurry line between partial GHD and ISS, of the GH stakeholders, and of the outside pressures involved in these cases demonstrates the ambiguous platform upon which treatment decisions are made. The rhGH treatment decision process can be examined further by considering the three most impactful factors on parental height-related medical decision-making: treatment characteristics, child health, and psychosocial function. While it is important to note that treatment for classical GHD is uncontroversial and supported, treatment decisions for partial GHD and ISS are more complicated and require careful evaluation of both patient needs and the supporting evidence. As the rhGH community grows, physicians, parents, and patients are encouraged to engage in a shared decision-making process to navigate the many challenges facing the GH field. Although this review addresses GHD and ISS specifically, the issues discussed are often applicable to pediatrics as a whole.
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Affiliation(s)
- Julia G Halas
- College of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - Adda Grimberg
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA -
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14
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Collett-Solberg PF, Ambler G, Backeljauw PF, Bidlingmaier M, Biller BM, Boguszewski MC, Cheung PT, Choong CSY, Cohen LE, Cohen P, Dauber A, Deal CL, Gong C, Hasegawa Y, Hoffman AR, Hofman PL, Horikawa R, Jorge AA, Juul A, Kamenický P, Khadilkar V, Kopchick JJ, Kriström B, Lopes MDLA, Luo X, Miller BS, Misra M, Netchine I, Radovick S, Ranke MB, Rogol AD, Rosenfeld RG, Saenger P, Wit JM, Woelfle J. Diagnosis, Genetics, and Therapy of Short Stature in Children: A Growth Hormone Research Society International Perspective. Horm Res Paediatr 2019; 92:1-14. [PMID: 31514194 PMCID: PMC6979443 DOI: 10.1159/000502231] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/18/2019] [Indexed: 12/28/2022] Open
Abstract
The Growth Hormone Research Society (GRS) convened a Workshop in March 2019 to evaluate the diagnosis and therapy of short stature in children. Forty-six international experts participated at the invitation of GRS including clinicians, basic scientists, and representatives from regulatory agencies and the pharmaceutical industry. Following plenary presentations addressing the current diagnosis and therapy of short stature in children, breakout groups discussed questions produced in advance by the planning committee and reconvened to share the group reports. A writing team assembled one document that was subsequently discussed and revised by participants. Participants from regulatory agencies and pharmaceutical companies were not part of the writing process. Short stature is the most common reason for referral to the pediatric endocrinologist. History, physical examination, and auxology remain the most important methods for understanding the reasons for the short stature. While some long-standing topics of controversy continue to generate debate, including in whom, and how, to perform and interpret growth hormone stimulation tests, new research areas are changing the clinical landscape, such as the genetics of short stature, selection of patients for genetic testing, and interpretation of genetic tests in the clinical setting. What dose of growth hormone to start, how to adjust the dose, and how to identify and manage a suboptimal response are still topics to debate. Additional areas that are expected to transform the growth field include the development of long-acting growth hormone preparations and other new therapeutics and diagnostics that may increase adult height or aid in the diagnosis of growth hormone deficiency.
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Affiliation(s)
- Paulo F. Collett-Solberg
- aDisciplina de Endocrinologia, Departamento de Medicina Interna, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, Rio de Janeiro, Brazil,*Paulo Ferrez Collett-Solberg, MD, PhD, Pavilhão Reitor Haroldo Lisboa da Cunha, térreo, Rua São Francisco Xavier 524, Maracanã, Rio de Janeiro 20550-013 (Brazil), E-Mail
| | - Geoffrey Ambler
- bInstitute of Endocrinology and Diabetes, The University of Sydney, Sydney, New South Wales, Australia
| | - Philippe F. Backeljauw
- cDivision of Endocrinology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Martin Bidlingmaier
- dEndocrine Laboratory, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, Munich, Germany
| | - Beverly M.K. Biller
- eNeuroendocrine Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Pik To Cheung
- gPaediatric Endocrinology, Genetics, and Metabolism, Virtus Medical Group and The University of Hong Kong, Hong Kong SAR, China
| | - Catherine Seut Yhoke Choong
- hDepartment of Endocrinology, Perth Children's Hospital, Child and Adolescent Health Service, Perth, Washington, Australia,iDivision of Paediatrics, School of Medicine, University of Western Australia, Perth, Washington, Australia,jThe Centre for Child Health Research, Telethon Kids Institute, University of Western Australia, Perth, Washington, Australia
| | - Laurie E. Cohen
- kDivision of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pinchas Cohen
- lLeonard Davis School of Gerontology, University of Southern California, Los Angeles, California, USA
| | - Andrew Dauber
- mDivision of Endocrinology, Children's National Health System, Washington, District of Columbia, USA
| | - Cheri L. Deal
- nEndocrine and Diabetes Service, CHU Sainte-Justine and University of Montreal, Montreal, Québec, Canada
| | - Chunxiu Gong
- oEndocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Yukihiro Hasegawa
- pDivision of Endocrinology and Metabolism, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Andrew R. Hoffman
- qDepartment of Medicine, Stanford University School of Medicine and VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Paul L. Hofman
- rLiggins Institute, University of Auckland, Auckland, New Zealand
| | - Reiko Horikawa
- sDivision of Endocrinology and Metabolism, National Center for Child Health and Development, Tokyo, Japan
| | - Alexander A.L. Jorge
- tUnidade de Endocrinologia Genética (LIM25), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Anders Juul
- uDepartment of Growth and Reproduction, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter Kamenický
- vService d'Endocrinologie et des Maladies de la Reproduction, Hôpital de Bicêtre, Assistance Publique-Hôpitaux de Paris, Université Paris-Saclay, Paris, France
| | - Vaman Khadilkar
- wHirabai Cowasji Jehangir Medical Research Institute (HCJMRI), Jehangir Hospital, Pune, India
| | - John J. Kopchick
- xEdison Biotechnology Institute and Department of Biomedical Sciences, HCOM Ohio University Athens, Athens, Ohio, USA
| | - Berit Kriström
- yInstitute of Clinical Science, Pediatrics, Umeå University, Umeå, Sweden
| | - Maria de Lurdes A. Lopes
- zUnidade de Endocrinologia Pediátrica, Area da Mulher, Criança e Adolescente, Centro Hospitalar Universitário de Lisboa Central-Hospital de Dona Estefânia, Lisbon, Portugal
| | - Xiaoping Luo
- ADepartment of Pediatrics, Tongji Hospital, Tongji Medical Colleage, Huazhong University of Science and Technology, Wuhan, China
| | - Bradley S. Miller
- BDivision of Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Madhusmita Misra
- CDivision of Pediatric Endocrinology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Irene Netchine
- DExplorations Fonctionnelles Endocriniennes, AP-HP Hôpital Trousseau, Centre de Recherche Saint Antoine, INSERM, Sorbonne Université, Paris, France
| | - Sally Radovick
- EDepartment of Pediatrics, Robert Wood Johnson Medical School, Child Health Institute of New Jersey-Rutgers University, New Brunswick, New Jersey, USA
| | | | - Alan D. Rogol
- GDepartment of Pediatrics, University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Jan M. Wit
- JDepartment of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Joachim Woelfle
- KPediatric Endocrinology Division, Children's Hospital, University of Bonn, Bonn, Germany
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15
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Golembiewski E, Allen KS, Blackmon AM, Hinrichs RJ, Vest JR. Combining Nonclinical Determinants of Health and Clinical Data for Research and Evaluation: Rapid Review. JMIR Public Health Surveill 2019; 5:e12846. [PMID: 31593550 PMCID: PMC6803891 DOI: 10.2196/12846] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 05/23/2019] [Accepted: 07/19/2019] [Indexed: 02/06/2023] Open
Abstract
Background Nonclinical determinants of health are of increasing importance to health care delivery and health policy. Concurrent with growing interest in better addressing patients’ nonmedical issues is the exponential growth in availability of data sources that provide insight into these nonclinical determinants of health. Objective This review aimed to characterize the state of the existing literature on the use of nonclinical health indicators in conjunction with clinical data sources. Methods We conducted a rapid review of articles and relevant agency publications published in English. Eligible studies described the effect of, the methods for, or the need for combining nonclinical data with clinical data and were published in the United States between January 2010 and April 2018. Additional reports were obtained by manual searching. Records were screened for inclusion in 2 rounds by 4 trained reviewers with interrater reliability checks. From each article, we abstracted the measures, data sources, and level of measurement (individual or aggregate) for each nonclinical determinant of health reported. Results A total of 178 articles were included in the review. The articles collectively reported on 744 different nonclinical determinants of health measures. Measures related to socioeconomic status and material conditions were most prevalent (included in 90% of articles), followed by the closely related domain of social circumstances (included in 25% of articles), reflecting the widespread availability and use of standard demographic measures such as household income, marital status, education, race, and ethnicity in public health surveillance. Measures related to health-related behaviors (eg, smoking, diet, tobacco, and substance abuse), the built environment (eg, transportation, sidewalks, and buildings), natural environment (eg, air quality and pollution), and health services and conditions (eg, provider of care supply, utilization, and disease prevalence) were less common, whereas measures related to public policies were rare. When combining nonclinical and clinical data, a majority of studies associated aggregate, area-level nonclinical measures with individual-level clinical data by matching geographical location. Conclusions A variety of nonclinical determinants of health measures have been widely but unevenly used in conjunction with clinical data to support population health research.
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Affiliation(s)
| | - Katie S Allen
- IUPUI Richard M Fairbanks School of Public Health, Indianapolis, IN, United States.,Regenstrief Institute, Inc, Indianapolis, IN, United States
| | - Amber M Blackmon
- IUPUI Richard M Fairbanks School of Public Health, Indianapolis, IN, United States
| | | | - Joshua R Vest
- IUPUI Richard M Fairbanks School of Public Health, Indianapolis, IN, United States.,Regenstrief Institute, Inc, Indianapolis, IN, United States
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16
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Grimberg A, Lindberg A, Wajnrajch M, Cucchiara AJ, Camacho-Hübner C. Racial/Ethnic Disparities in US Pediatric Growth Hormone Treatment. Horm Res Paediatr 2018; 90:102-108. [PMID: 30130795 PMCID: PMC6220671 DOI: 10.1159/000491793] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 07/03/2018] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND/AIMS To compare racial/ethnic proportions of subjects receiving growth hormone (GH) treatment to the expected proportions, and secondarily, to assess racial/ethnic differences in subject characteristics at GH treatment initiation. METHODS Race/ethnicity-based expected frequencies of height <-2.25 SD were determined by applying relative risks for short stature, calculated from a regional population of 189,280 pediatric primary care patients, to US census data, and compared to racial/ethnic proportions of US subjects enrolled in the Pfizer International Growth Study (KIGS) using the χ2 test. Characteristics of white and black subjects at GH treatment initiation were presented as medians and compared by the Wilcoxon rank sum test (significant p < 0.01). RESULTS White subjects exceeded the expected frequency (63%) for all indications (83%) and each separately, ranging from 73% for congenital GH deficiency (GHD) to 85% for idiopathic short stature (p < 0.001). Compared to white subjects, black subjects treated for idiopathic GHD had greater height deficits relative both to the population (-2.97 vs. -2.56 SD) and to their mid-parental heights (-2.47 vs. -1.89 SD), lower stimulated GH peak levels (4.9 vs. 6.0 ng/mL), and lower birth weights (-0.86 vs. -0.48 SD). Black subjects with congenital GHD had lower stimulated GH peaks (2.1 vs. 3.2 ng/mL) and started GH treatment at younger ages (2.9 vs. 4.8 years), while those with acquired GHD had lower birth weights (-1.12 vs. -0.08 SD). Male predominance did not differ by race for any or all indications. CONCLUSION Overrepresentation of white children among those receiving GH treatment in the US KIGS registry reflects racial/ethnic treatment biases, not just differences in growth rates.
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Affiliation(s)
- Adda Grimberg
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Division of Pediatric Endocrinology and Diabetes, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Michael Wajnrajch
- Pfizer Inc, New York, NY, USA
- New York University School of Medicine, Division of Pediatric Endocrinology, New York, NY, USA
| | - Andrew J. Cucchiara
- Center for Human Phenomics Science and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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17
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Velasco HM, Buelvas LP. [Characterization of patients with skeletal genetic diseases in a Colombian referral center]. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2017; 37:250-259. [PMID: 28527289 DOI: 10.7705/biomedica.v37i3.2980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 08/05/2016] [Indexed: 06/07/2023]
Abstract
INTRODUCTION Short height in Colombia has an estimated prevalence of 10%. The 2009 Nosology and Classification of Skeletal Genetic Diseases described 456 clinical conditions using biochemical, molecular and radiological criteria for diagnosis. OBJECTIVE To analyze demographic, epidemiological and clinical variables in a group of patients with skeletal genetic diseases referred to the Instituto de Ortopedia Infantil Roosevelt. MATERIALS AND METHODS Patients referred between 2008 and 2014 were analyzed filtering 167 diagnoses of the International Classification of Diseases, 10th revision (ICD 10), related to skeletal genetic diseases. Demographic, epidemiological and clinical variables were explored using descriptive statistics. An intervention score was generated contemplating different combinations of treatments. An inferential statistical analysis using Student's t test was performed on such variables. RESULTS The most frequent reason for consultation was suspicion of a genetic skeletal disorder. The types of treatments considered included support, surgical, pharmacological and orthotics, and it was established that genetic skeletal disorders were associated with higher intervention scores while tall and short height showed a lower score. CONCLUSIONS Most referred patients were classified with genetic bone diseases, short stature and other monogenic genetic diseases. Significant differences were found between the age at symptoms onset and the age of diagnosis. Diversity was found in the therapeutic approach among different groups of pathologies. Patients with tall and short height showed lower intervention scores, which may warn on the need to reassess the therapeutic requirements of these groups.
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Affiliation(s)
- Harvy Mauricio Velasco
- Instituto de Ortopedia Infantil Roosevelt, Bogotá, D.C., Colombia Facultad de Medicina, Departamento de Morfología, Maestría de Genética Humana, Universidad Nacional de Colombia, Bogotá, D.C., Colombia.
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18
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Lipman TH, Cousounis P, Grundmeier RW, Massey J, Cucchiara AJ, Stallings VA, Grimberg A. Electronic Health Record Mid-Parental Height Auto-Calculator for Growth Assessment in Primary Care. Clin Pediatr (Phila) 2016; 55:1100-6. [PMID: 26507248 PMCID: PMC5576174 DOI: 10.1177/0009922815614352] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Primary care providers are charged with distinguishing children with an underlying growth problem from those with healthy variant short stature. Knowing the heights of the biological parents aids in making that decision. This study sought to determine the feasibility and functionality of an electronic mid-parental height (MPH) auto-calculator in the clinical assessment of child growth in a pediatric primary care setting. Clinicians completed surveys for 62% of 6803 children (mean height 13 ± 7 percentile) with recorded parent heights. Collecting parent height data required <30 seconds in 91% of encounters. The MPH tool confirmed clinicians' initial growth assessment in 79% of cases and changed it in 4%; the remainder did not use the tool. Clinicians who changed assessment were more likely (P < .0001) to pursue more comprehensive evaluation. The MPH tool was a quick, functional resource as a component of an electronic health record system in actual, busy, pediatric primary care practices.
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Affiliation(s)
- Terri H. Lipman
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,University of Pennsylvania, Philadelphia, PA, USA
| | | | - Robert W. Grundmeier
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,University of Pennsylvania, Philadelphia, PA, USA
| | - James Massey
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Virginia A. Stallings
- The Children’s Hospital of Philadelphia, Philadelphia, PA, USA,University of Pennsylvania, Philadelphia, PA, USA
| | - Adda Grimberg
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA University of Pennsylvania, Philadelphia, PA, USA
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19
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Zemel BS, Pipan M, Stallings VA, Hall W, Schadt K, Freedman DS, Thorpe P. Growth Charts for Children With Down Syndrome in the United States. Pediatrics 2015; 136:e1204-11. [PMID: 26504127 PMCID: PMC5451269 DOI: 10.1542/peds.2015-1652] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with Down syndrome (DS) have lower birth weights and grow more slowly than children without DS. Advances in and increased access to medical care have improved the health and well-being of individuals with DS; however, it is unknown whether their growth has also improved. Our objective was to develop new growth charts for children with DS and compare them to older charts from the United States and more contemporary charts from the United Kingdom. METHODS The Down Syndrome Growing Up Study (DSGS) enrolled a convenience sample of children with DS up to 20 years of age and followed them longitudinally. Growth parameters were measured by research anthropometrists. Sex-specific growth charts were generated for the age ranges birth to 36 months and 2 to 20 years using the LMS method. Weight-for-length and BMI charts were also generated. Comparisons with other curves were presented graphically. RESULTS New DSGS growth charts were developed by using 1520 measurements on 637 participants. DSGS growth charts for children <36 months of age showed marked improvements in weight compared with older US charts. DSGS charts for 2- to 20-year-olds showed that contemporary males are taller than previous charts showed. Generally, the DSGS growth charts are similar to the UK charts. CONCLUSIONS The DSGS growth charts can be used as screening tools to assess growth and nutritional status and to provide indications of how growth of an individual child compares with peers of the same age and sex with DS.
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Affiliation(s)
- Babette S. Zemel
- Divisions of Gastroenterology, Hepatology, and Nutrition, and,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and,Address correspondence to Babette S. Zemel, PhD, Division of Gastroenterology, Hepatology and Nutrition, The Children’s Hospital of Philadelphia, 3535 Market St, Room 1560, Philadelphia, PA 19104-4399. E-mail:
| | - Mary Pipan
- Behavioral Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia Pennsylvania;,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Virginia A. Stallings
- Divisions of Gastroenterology, Hepatology, and Nutrition, and,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | - Waynitra Hall
- Divisions of Gastroenterology, Hepatology, and Nutrition, and
| | - Kim Schadt
- Behavioral Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia Pennsylvania;,Department of Pediatrics, The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; and
| | | | - Phoebe Thorpe
- Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Georgia
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20
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Gender Bias in U.S. Pediatric Growth Hormone Treatment. Sci Rep 2015; 5:11099. [PMID: 26057697 PMCID: PMC4650610 DOI: 10.1038/srep11099] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 04/23/2015] [Indexed: 01/09/2023] Open
Abstract
Growth hormone (GH) treatment of idiopathic short stature (ISS), defined as height <−2.25 standard deviations (SD), is approved by U.S. FDA. This study determined the gender-specific prevalence of height <−2.25 SD in a pediatric primary care population, and compared it to demographics of U.S. pediatric GH recipients. Data were extracted from health records of all patients age 0.5–20 years with ≥ 1 recorded height measurement in 28 regional primary care practices and from the four U.S. GH registries. Height <−2.25 SD was modeled by multivariable logistic regression against gender and other characteristics. Of the 189,280 subjects, 2073 (1.1%) had height <−2.25 SD. No gender differences in prevalence of height <−2.25 SD or distribution of height Z-scores were found. In contrast, males comprised 74% of GH recipients for ISS and 66% for all indications. Short stature was associated (P < 0.0001) with history of prematurity, race/ethnicity, age and Medicaid insurance, and inversely related (P < 0.0001) with BMI Z-score. In conclusion, males outnumbered females almost 3:1 for ISS and 2:1 for all indications in U.S. pediatric GH registries despite no gender difference in height <−2.25 SD in a large primary care population. Treatment and/or referral bias was the likely cause of male predominance among GH recipients.
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Whyte MP, Zhang F, Wenkert D, McAlister WH, Mack KE, Benigno MC, Coburn SP, Wagy S, Griffin DM, Ericson KL, Mumm S. Hypophosphatasia: validation and expansion of the clinical nosology for children from 25 years experience with 173 pediatric patients. Bone 2015; 75:229-39. [PMID: 25731960 DOI: 10.1016/j.bone.2015.02.022] [Citation(s) in RCA: 163] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 02/12/2015] [Accepted: 02/19/2015] [Indexed: 01/06/2023]
Abstract
Hypophosphatasia (HPP) is caused by loss-of-function mutation(s) within the gene TNSALP that encodes the "tissue-nonspecific" isoenzyme of alkaline phosphatase (TNSALP). In HPP, inorganic pyrophosphate, an inhibitor of mineralization and substrate for TNSALP, accumulates extracellularly often leading to rickets or osteomalacia and tooth loss, and sometimes to craniosynostosis and calcium crystal arthropathies. HPP's remarkably broad-ranging expressivity spans stillbirth from profound skeletal hypomineralization to adult-onset dental problems or arthropathies without bone disease, which is largely explained by autosomal recessive versus autosomal dominant transmission from among several hundred, usually missense, TNSALP mutations. For clinical purposes, this expressivity has been codified according to absence or presence of skeletal disease and then patient age at presentation and diagnosis. Pediatric patients are reported principally with "odonto", "childhood", "infantile", or "perinatal" HPP. However, this nosology has not been tested using a cohort of patients, and the ranges of the clinical and laboratory findings have not been defined and contrasted among these patient groups. To evaluate the extant nosology for HPP in children, we assessed our 25 years experience with 173 pediatric HPP patients. Data were exclusively from inpatient studies. The childhood form of HPP was further designated "mild" or "severe". Here, we focused on demographic, clinical, and dual-energy X-ray absorptiometry parameters compared to data from healthy American children. The 173-patient cohort comprised 64 individuals with odonto HPP, 38 with mild childhood HPP, 58 with severe childhood HPP, and 13 with infantile HPP. None was a survivor of perinatal HPP. TNSALP analysis revealed a mutation(s) in all 105 probands tested. Thirteen mutations were unique. Most patients represented autosomal dominant inheritance of HPP. Mutant allele dosage generally indicated the disorder's severity. Gender discordance was found for severe childhood HPP; 42 boys versus 16 girls (p=0.006), perhaps reflecting parental concern about stature and strength. Key disease parameters (e.g., height, weight, numbers of teeth lost prematurely, grip strength, spine and hip bone mineral density) were increasingly compromised as HPP was designated more severe. Although data overlapped successively between the four patient groups, body size (height and weight) differed significantly. Thus, our expanded nosology for HPP in children organizes the disorder's broad-ranging expressivity and should improve understanding of HPP presentation, natural history, complications, and prognosis.
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Affiliation(s)
- Michael P Whyte
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA; Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
| | - Fan Zhang
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - Deborah Wenkert
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - William H McAlister
- Department of Pediatric Radiology, Mallinckrodt Institute of Radiology at St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA.
| | - Karen E Mack
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - Marci C Benigno
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - Stephen P Coburn
- Department of Chemistry, Indiana University-Purdue University, Fort Wayne, IN 46805, USA.
| | - Susan Wagy
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - Donna M Griffin
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA.
| | - Karen L Ericson
- Department of Chemistry, Indiana University-Purdue University, Fort Wayne, IN 46805, USA.
| | - Steven Mumm
- Center for Metabolic Bone Disease and Molecular Research, Shriners Hospital for Children, St. Louis, MO 63131, USA; Division of Bone and Mineral Diseases, Washington University School of Medicine at Barnes-Jewish Hospital, St. Louis, MO 63110, USA.
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Grimberg A, Cousounis P, Cucchiara AJ, Lipman TH, Ginsburg KR. Parental Concerns Influencing Decisions to Seek Medical Care for a Child's Short Stature. Horm Res Paediatr 2015; 84:338-48. [PMID: 26448482 PMCID: PMC5576168 DOI: 10.1159/000440804] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/01/2015] [Indexed: 11/19/2022] Open
Abstract
AIMS To examine parental concerns about child growth and factors that drive parents' decisions whether to intervene medically with their child's height. METHODS Parents of 9- to 14-year-old pediatric primary care patients of various heights, oversampled for those with short stature, participated in exploratory focus groups and nominal group technique sessions. Growth concerns expressed by the groups were incorporated into a survey, completed by 1,820 parents, and rated for their degree of impact on medical decision-making. Ordinal logistic regression modeled concern scores against parent traits. Explanatory focus groups clarified the survey results. RESULTS Research team consensus and factor analysis organized the 22 distinct concerns expressed by the parent groups into 7 categories. Categories rated as having the greatest influence on parental decision-making involved: treatment efficacy and side effects, child health and psychosocial function. Level of concern was highly associated with parental education and parenting style. CONCLUSION Psychosocial issues are influential, but parental decision-making is most impacted by concerns about treatment and child health. By discussing the real risks and benefits of hormone treatment and addressing parents' perceptions of what is needed for physical and psychosocial health, clinicians can be highly effective educators to assure that treatment is used only as medically indicated.
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Affiliation(s)
- Adda Grimberg
- Division of Pediatric Endocrinology and Diabetes, Philadelphia, Pa., USA,Department of Pediatrics, Philadelphia, Pa., USA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pa., USA
| | - Pamela Cousounis
- Division of Pediatric Endocrinology and Diabetes, Philadelphia, Pa., USA
| | - Andrew J. Cucchiara
- Clinical and Translational Research Center, Philadelphia, Pa., USA,Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, Philadelphia, Pa., USA
| | - Terri H. Lipman
- Division of Pediatric Endocrinology and Diabetes, Philadelphia, Pa., USA,University of Pennsylvania School of Nursing, Philadelphia, Pa., USA
| | - Kenneth R. Ginsburg
- Craig Dalsimer Division of Adolescent Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pa., USA,Department of Pediatrics, Philadelphia, Pa., USA
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Rogol AD, Hayden GF. Etiologies and early diagnosis of short stature and growth failure in children and adolescents. J Pediatr 2014; 164:S1-14.e6. [PMID: 24731744 DOI: 10.1016/j.jpeds.2014.02.027] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Accurate measurement of height and weight using standardized techniques is a fundamental component of pediatric medical visits. Calculation of height velocity over time enables comparison with standardized growth charts to identify potential deviations from normal. Growth deviations may be expressed as SD from the normal population mean for children of comparable age and sex; children with heights >2 SD below the mean are generally classified as short stature. In a child with suspected impaired growth, a detailed evaluation should be conducted to identify the cause. Such an evaluation may include a combination of personal, family, and social history; physical examination; general and perhaps specialized laboratory evaluations; radiologic examinations; genetic testing; and consultation with a pediatric subspecialist, such as a pediatric endocrinologist. Variants of normal growth include familial short stature, constitutional delay of growth and puberty, and small for gestational age with catch-up growth. Pathological causes of abnormal growth include many systemic diseases and their treatments, growth hormone deficiency, and a series of genetic syndromes, including Noonan syndrome and Turner syndrome. Children with short stature in whom no specific cause is identified may be diagnosed with idiopathic short stature. Early identification of abnormal growth patterns and prompt referral to specialist care offer children with growth failure and/or short stature the greatest chance for appropriate diagnosis, treatment, and improved clinical outcomes.
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Affiliation(s)
- Alan D Rogol
- Division of Pediatric Diabetes and Endocrinology, University of Virginia Medical School, Charlottesville, VA.
| | - Gregory F Hayden
- Division of General Pediatrics, University of Virginia Medical School, Charlottesville, VA
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24
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Chiniara L, Perry RJ, Van Vliet G, Huot C, Deal C. Quality of referral of short children to the paediatric endocrinologist and impact of a fax communication system. Paediatr Child Health 2014; 18:533-7. [PMID: 24497780 DOI: 10.1093/pch/18.10.533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES In 2001, a chart review of children referred to the authors' endocrine clinic because of short stature revealed that many were referred with insufficient baseline data, had normal height velocity and were within genetic target height. Therefore, a two-way fax communication system was implemented between referring physicians and the authors' service before the first visit. Aspects that were assessed included whether this system increased the information accompanying the patient at referral, resulted in children with nonpathological shortness not being seen in the clinic, and was used differently by paediatricians and general practitioners. STUDY DESIGN Between January and December 2006, 138 referrals for short stature, diagnosed with familial short stature, constitutional delay or idiopathic short stature, were audited (69 with and 69 without previous fax communication). Data collected included source of referral, clinical information provided, available growth measurements, and results from laboratory and imaging studies. RESULTS Fax communication resulted in growth curves being provided more often (95.6% of cases versus 40.5% of cases without fax communication [P<0.001]) and more investigations being performed by the referring physician (median [range]: six [zero to 13] investigations versus one [zero to 11]; P<0.001), as well as a diagnosis of nonpathological short stature being given to 31 children based on the growth curve, laboratory and imaging results, without the children being seen in the endocrine clinic. Fax communication was also used more frequently by paediatricians (84%) than by general practitioners (15%). CONCLUSION The fax communication system resulted in a more complete evaluation of referred patients by their physicians and reduced the number of unnecessary visits to the authors' specialty clinic while promoting medical education.
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Affiliation(s)
- Lyne Chiniara
- Endocrinology Service and Research Center, Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, Université de Montréal, Montréal, Québec
| | - Rebecca J Perry
- Endocrinology Service and Research Center, Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, Université de Montréal, Montréal, Québec
| | - Guy Van Vliet
- Endocrinology Service and Research Center, Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, Université de Montréal, Montréal, Québec
| | - Céline Huot
- Endocrinology Service and Research Center, Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, Université de Montréal, Montréal, Québec
| | - Cheri Deal
- Endocrinology Service and Research Center, Centre Hospitalier Universitaire Sainte-Justine and Department of Pediatrics, Université de Montréal, Montréal, Québec
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25
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Current world literature. Curr Opin Endocrinol Diabetes Obes 2012; 19:328-37. [PMID: 22760515 DOI: 10.1097/med.0b013e3283567080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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