Plasma lipids can be reliably assessed within 24 hours after acute myocardial infarction

Total serum cholesterol and triglycerides were measured in 159 Indian patients (134 males) with acute myocardial infarction during their stay in hospital (days 1 and 2) and 3 months later in order to assess whether lipid levels measured soon after acute myocardial infarction represent basal values. Early and 3 month lipid levels were also compared according to the sex and glucose tolerance of the patients. The mean total cholesterol levels on admission (day 1) were comparable to the 3 month values in both men (6.09 +/- 0.10 vs 6.18 +/- 0.09 mmol/l) and women (6.75 +/- 0.30 vs 6.44 +/- 0.22 mmol/l) irrespective of glucose tolerance. In the entire group cholesterol levels on day 2 were significantly lower than the admission and 3 month values. Nevertheless there was a significant correlation between day 2 and 3 month values (P less than 0.0005). Serum triglyceride levels on day 2 were influenced by glucose tolerance and were significantly lower than the 3 month values in patients with normal glucose tolerance but not in patients with abnormal glucose tolerance. However there with a significant correlation between day 2 triglyceride values in patients with both normal and abnormal glucose tolerance. These results suggest that serum cholesterol measured on admission after acute myocardial infarction may be reliably used to represent basal values in both men and women irrespective of glucose tolerance. Although cholesterol and triglycerides measured on day 2 vary with either the gender or glucose tolerance of the patients, these values are still a useful guide to the patients' basal lipid state.

Investigation and management of hypocalcaemia

Hypocalcaemia is a common clinical scenario in children with a range of aetiological causes. It will often present with common symptoms but may occasionally be identified in an asymptomatic child. An understanding of the physiological regulation of plasma calcium is important in understanding the potential cause of hypocalcaemia and its appropriate management. The age of presentation will influence the likely differential diagnosis. We have presented a stepwise approach to the investigation of hypocalcaemia dependent on the circulating serum parathyroid hormone level at the time of presentation. The acute and long-term management of the underlying condition is also reviewed.

New Developments in the Treatment of X-Linked Hypophosphataemia: Implications for Clinical Management

X-linked hypophosphataemia (XLH) is due to mutations in phosphate-regulating gene with homologies to endopeptidases on the X chromosome (PHEX) and represents the most common heritable form of rickets. In this condition, the hormone fibroblast growth factor 23 (FGF23) is produced in excessive amounts for still unknown reasons, and causes renal phosphate wasting and suppression of 1,25-dihydroxyvitamin D, leading to low serum phosphate concentrations. Prolonged hypophosphataemia decreases apoptosis of hypertrophic chondrocytes in growth plates (causing rickets) and decreases mineralisation of existing bone (causing osteomalacia). In contrast to historical conventional treatment with oral phosphate supplements and active vitamin D for the last 50 years, the new anti-FGF23 antibody treatment (burosumab) targets the primary pathology by blocking FGF23, thereby restoring phosphate homeostasis. In this review, we describe the changes in treatment monitoring, treatment targets and long-term treatment goals, including future opportunities and challenges in the treatment of XLH in children.

Growth status of small for gestational age Indian children from two socioeconomic strata

AIMS

To assess growth and factors associated with growth in children born small for gestational age (SGA) from two socioeconomic strata in comparison to age- and sex-matched healthy controls.

METHODS

Retrospective study conducted at two hospitals in Pune, 0.5-5 years, 618 children: 189-SGA from upper socioeconomic strata (USS), 217-SGA from lower socioeconomic strata (LSS), and 212 appropriate for gestational age healthy controls were randomly selected. Birth and maternal history, socioeconomic status, length/height, and weight of children were recorded. Anthropometric data were converted to Z scores (height for age Z-score [HAZ], weight for age Z-score [WAZ]) using WHO AnthroPlus software.

RESULTS

The HAZ and WAZ of the SGA group were significantly lower as compared to the controls and that of the LSS SGAs were lower than USS SGAs (P < 0.05). Thirty two percent children were stunted (HAZ <-2.0) in USS and 49% in LSS (P < 0.05). Twenty nine percent children in the USS SGA group were stunted at 2 years and 17% at 5 years. In the LSS SGA group, 54% children were stunted at 2 years and 46% at 5 years. Generalized linear model revealed normal vaginal delivery (β = 0.625) and mother's age (β =0.072) were positively associated and high SES (β = -0.830), absence of major illness (β = -1.01), higher birth weight (β = -1.34) were negatively associated for risk of stunting (P < 0.05).

CONCLUSION

Children born SGA showed poor growth as compared to controls. Special attention to growth is necessary in children from LSS, very low birth weight babies, and those with major illnesses during early years of life.

Molecular characterization in a case of isolated growth hormone deficiency and further prenatal diagnosis of an unborn sibling

Familial isolated growth hormone deficiency (GHD) type 1 is characterized by an autosomal recessive pattern of inheritance with varying degrees of phenotypic severity. We report a proband, with isolated GHD (IGHD) with very early growth arrest and undetectable levels of GH. Homozygous complete deletion of the GH1 gene was identified by real-time/quantitative polymerase chain reaction (RT/q-PCR) and confirmed by an independent molecular genetic method; the multiplex ligation-dependent probe amplification (MLPA) technique. Prenatal diagnosis was offered for the subsequent pregnancy in the mother of our proband. Identical heterozygous deletion of the GH1 gene was detected in both parents. The fetus had a similar homozygous deletion of the GH1 gene. We thus report a unique case with a confirmed mutation in GH1 gene in the proband followed by prenatal detection of the same mutation in the amniotic fluid which to our knowledge hitherto has not been documented from India.

Hypophosphatasia mimicking hypoxic-ischaemic encephalopathy: early recognition and management

BACKGROUND

Hypophosphatasia (HPP) is a rare inherited disorder affecting bone and teeth development. Perinatal HPP is the most severe form and associated with a high mortality. Features include respiratory distress, skeletal abnormalities and low alkaline phosphatase (ALP) activity.

CASE

A baby boy developed respiratory distress, hypotonia and seizures within an hour of birth. Blood gas showed mixed acidosis and abnormal base deficit. Hypoxic-ischaemic encephalopathy (HIE) was suspected and managed with therapeutic hypothermia. Subsequent investigations identified low ALP activity and abnormal bone mineralisation, leading to a diagnosis of HPP. On day 5 of life, enzyme replacement therapy (ERT) was commenced, its first use via direct NHS England funding since UK licensing in 2017.

CONCLUSIONS

Early hypotonia is an atypical presentation for perinatal HPP. Combined with acidosis and encephalopathy, it can clinically mimic HIE. Early recognition of biochemical and radiological features of HPP is essential for rapid diagnosis and timely initiation of life-saving ERT.

Molecular genetics of growth hormone deficient children: correlation with auxology and response to first year of growth hormone therapy

BACKGROUND

With the paucity of available literature correlating genetic mutation and response to treatment, we aimed to study the genetic makeup of children with growth hormone (GH) deficiency in Western India and correlate the mutation with auxology and response to GH treatment at end of 1 year.

METHODS

Fifty-three (31 boys and 22 girls) children with severe short stature (height for age z-score <-3) and failed GH stimulation test were studied. Those having concomitant thyroid hormone or cortisol deficiencies were appropriately replaced prior to starting GH treatment. A magnetic resonance imaging (MRI) brain scan was done in all. Genetic mutations were tested for in GH1, GHRH, LHX3, LHX4 and PROP1, POU1F1 and HESX1 genes.

RESULTS

Mean age at presentation was 9.7±5.1 years. Thirty-seven children (Group A) had no genetic mutation detected. Six children (Group B) had mutations in the GH releasing hormone receptor (GHRHR) gene, while eight children (Group C) had mutation in the GH1 gene. In two children, one each had a mutation in PROP1 and LHX3. There was no statistically significant difference in baseline height, weight and BMI for age z-score and height velocity for age z-score (HVZ). HVZ was significantly lower, post 1 year GH treatment in the group with homozygous GH1 deletion than in children with no genetic defect.

CONCLUSIONS

Response to GH at the end of 1 year was poor in children with the homozygous GH1 deletion as compared to those with GHRHR mutation or without a known mutation.

SUN-525 Burosumab Experience In A UK Adolescent Population

Objectives X-linked hypophosphatemia (XLH) is a rare inherited form of osteomalacia characterised by low blood phosphate levels which lead to inadequate mineralization of bone:rickets leading in turn to a spectrum of skeletal abnormalities, physical impairment, weakness, and pain. Burosumab is an anti-FGF23 fully human monoclonal antibody, and the first treatment to target the underlying pathophysiology of XLH. The trials that formed the basis of regulatory approval of burosumab only included patients up to the age of 12 years old and so data are lacking on this important patient population. We report relevant biochemical data on this population for the first three months of burosumab treatment in a real-world setting. Methods An early access program (EAP) for burosumab was made available for children in the United Kingdom with XLH in 12 specialist centres. Inclusion criteria for the EAP included radiographic evidence of disease, XLH confirmed by genetic PHEX mutation, confirmed familial X-linked inheritance mutation or family history. Patients must have also had an unsatisfactory response to best available care and treatment. EAP enrolment was between January and March 2018. A total of 142 applications were received of which 135 were approved with 132 receiving treatment to date.¹ Of the 7 declined, 4 failed to meet diagnostic criteria and 3 had insufficient radiological evidence.¹ Treatment, including dose, was in accordance with the EMA marketing authorisation. Results Data are available on 41 patients who have completed the initial 12-week burosumab titration period. This includes 7 adolescents (13 years old or over) in whom results are available for the same period. The mean height and weight at week 0 was 147.79 cm (136.6-157.8 cm) and 48.23 kg respectively. The mean dose administered was 0.38 mg/kg at week 0 and 0.92 mg/kg at the end of the initial titration period at week 12. Mean serum phosphorus was 0.59 mmol/L (0.35-0.90 mmol/L) in week 0 rising to 0.92 mmol/L (0.57-1.13 mmol/L) at week 12 representing a 56% increase in serum phosphate levels. Mean serum ALP fell from 456 IU/L (288-554 IU/L) at week 0 to 328.9 IU/L (190-461 IU/L) at week 12, representing a 28% decrease in ALP. To date, no patients have discontinued treatment to date due to adverse events.¹Conclusions Early data from treating adolescents with XLH with burosumab in a real-world UK setting demonstrate that key biochemical responses are in line with findings from the clinical study program, which included only children 12 years and younger. This provides reassurance that the improvement in key biochemical parameters is consistent across all ages within its licensed indication. Further long-term evidence is required to confirm that the biochemical response translates to the expected impact on skeletal and non-skeletal outcomes in a clinical setting. References 1. Kyowa Kirin - data on file

Clinical applicability of rapid detection of SRY and DYS14 genes in patients with disorders of sex development using an indigenously developed 5' exonuclease based assay

BACKGROUND

Life threatening conditions are associated with atypical genitalia in newborns. Analysis of genetic sex provides a clue to the underlying etiology in newborns with disorders of sex development (DSD) and can guide further endocrine investigations. Rapid diagnosis of genetic sex would be immensely useful in this situation. Traditionally used methods such as karyotype and fluorescence in situ hybridisation are time-consuming.

OBJECTIVES

To study the clinical applicability of an indigenously developed rapid real-time polymerase chain reaction (RT-PCR) assay for the sex determining region on the Y chromosome (SRY gene) and the DYS14 locus in newborns with DSD.

METHODS

Clinical examination, endocrinological tests, RT-PCR analysis of SRY and DYS14 and karyotype was performed in 15 newborns with DSD.

RESULTS

RESULTS of PCR were available within 4 h. Based on this report, in SRY/DYS14 positive cases, further tests for assessment of testicular function were done. In SRY negative cases, tests for congenital adrenal hyperplasia were done. On comparing PCR results with other tests, the Y chromosome was present on karyotype and testicular tissue was detected by endocrinological and/or histological methods in all (8/15) SRY positive cases. The SRY and DYS14 negative cases (7/15) did not have Y chromosome in the karyotype. Congenital adrenal hyperplasia (CAH) was the most common diagnosis in this group.

CONCLUSIONS

The indigenously developed PCR for dual Y chromosome markers is rapid and sensitive. Further endocrine evaluation of newborns with DSD can be based on these results. Information of genetic sex partly allays the psychosocial distress associated with the condition.

Successful treatment approaches for tumoral calcinosis in children and young people: A condition of diverse pathogenesis

BACKGROUND

Ectopic calcification is inappropriate biomineralization of soft tissues occurring due to genetic or acquired causes of hyperphosphataemia and rarely in normophosphataemic individuals. Tumoral Calcinosis (TC) is a rare metabolic bone disorder commonly presenting in childhood and adolescence with periarticular extra-capsular calcinosis. Three subtypes of TC have been recognised: primary hyperphosphataemic familial TC (HFTC), primary normophosphataemic familial TC and secondary TC most commonly seen in chronic renal failure. In the absence of established treatment, management is challenging due to variable success rates with medical therapies and recurrence following surgery.

AIM

We outline the successful treatment approaches in four children with TC (2 normophosphatemic TC, 2 HFTC) aged 2.5-10 years at initial presentation.

CASES

Patient 1 (P1) presented at 10 years with a painless lump behind the right knee, P2 with swelling of the right knee anteriorly at 9 years, P3 and P4 with pain and swelling over the right elbow at 5 and 2.5 years respectively. All patients were of Black African-Caribbean origin and were previously reported to be fit and well with no family history of TC.

RESULTS

P1, P2 had normophosphataemic TC and P3, P4 had HFTC with genetically confirmed GALNT3 mutation. All four patients had initial surgical resection with TC confirmed on histology. P1 had complete surgical resection with no recurrence at 27 months post-operatively. P2 had significant overgrowth of the tumour following surgery and was subsequently successfully managed with 25 % topical sodium metabisulphite (total duration of 8 months with a 4 month gap during which there was recurrence). P3 had post-surgical recurrence of TC on the right elbow and a new lesion on left elbow which resolved with oral acetazolamide monotherapy (15-20 mg/kg/day). P4 had recurrence of right elbow lesion following surgery and developed an extensive new hip lesion on sevelamer therapy which resolved completely with additional acetazolamide therapy (18-33 mg/kg/day). Acetazolamide was well tolerated with normal growth for 5 years in P3 and 6.5 years in P4 and no recurrence of lesions.

CONCLUSION

The frequent post-surgical recurrence in TC and successful medical therapy on the other hand indicates that medical management as first line therapy should be adopted. Monotherapies with topical 25 % sodium metabisulphite in normophosphataemic and oral acetazolamide in HFTC are effective treatment strategies which are well tolerated.

SUN-524 Burosumab Initiation In A UK XLH Cohort: Real-World Use Resonates With Research Evidence

Objectives X-linked hypophosphatemia (XLH) is a rare inherited form of osteomalacia characterised by low blood phosphate levels which lead to inadequate mineralization of bone:rickets leading in turn to a spectrum of skeletal abnormalities, physical impairment, weakness, and pain. Burosumab is an anti-FGF23 fully human monoclonal antibody, and the first treatment to target the underlying pathophysiology of XLH. Real world evidence has an important role in validating the findings of clinical research studies; more data on dose regimen and relevant biochemical outcomes outside of the clinical research study environment is required. We report these criteria following the first three months of burosumab treatment in a real-world setting. Methods An early access program (EAP) for burosumab was made available for children in the United Kingdom with XLH in 12 specialist centres. Inclusion criteria for the EAP included radiographic evidence of disease, XLH confirmed by genetic PHEX mutation, confirmed familial X-linked inheritance mutation or family history. Patients must have also had an unsatisfactory response to conventional treatment. EAP enrolment was between January and March 2018. 135 of 142 applications were approved.¹ Of the 7 declined, 4 failed to meet diagnostic criteria and 3 had insufficient radiological evidence.¹ 132 have commenced treatment (dose in accordance with EMA marketing authorisation), of whom 41 have completed the initial 12-week burosumab titration period. Results The mean age enrolled was 7.2 years (range <1.6-16.7), 45% female, 43% male and 12% unspecified. The mean height and weight at week 0 was 110.45 cm (75-153 cm) and 25.36 kg respectively. The mean dose administered was 0.57 mg/kg at week 0 and 0.94 mg/kg at week 12 (end of the initial titration period). Mean serum phosphorus was 0.66 mmol/L (0.35-0.85 mmol/L) in week 0 rising to 1.00 mmol/L (0.57-1.58 mmol/L) at week 12 representing a 51.5% increase in serum phosphate. Mean serum ALP fell from 635.48 IU/L (269-2124 IU/L) at week 0 to 522.42 IU/L (190-1473 IU/L) at week 12, representing 18% decrease in ALP. No patients discontinued treatment due to adverse events.¹Conclusions Early data from treating children and young people with XLH with burosumab in a real-world UK setting demonstrate that key biochemical responses are in line with the clinical research program findings. Ongoing monitoring and research is required to confirm the biochemical response translates to the expected subsequent impact on skeletal and non-skeletal outcomes, including linear growth and deformities. References 1. Kyowa Kirin - data on file

Heterozygous CDC73 mutation causing hyperparathyroidism in children and adolescents: a report of 2 cases

OBJECTIVES

Primary hyperparathyroidism (PHPT), whilst common in elderly populations, is rare in adolescents. Hereditary cases make up less than 10% of patients with PH. We report two patients with CDC73 mutation presenting in early adolescence.

CASE PRESENTATION

Case 1: A 14-year-old patient was referred from an adolescent mental health unit with hypercalcaemia. Imaging revealed a parathyroid adenoma. Genetic testing of the patient showed a heterozygous deletion of CDC73. Case 2: A 10-year-old patient was admitted to the general paediatric ward with symptoms suggestive of hypercalcaemia. The patient was known to carry an autosomal dominant mutation of CDC73. Imaging of the parathyroid gland showed bilateral adenoma.

CONCLUSIONS

We present two patients with CDC73 defects, who both presented with symptoms of hypercalcaemia. The cases highlight the difference in paediatric populations with PHPT who are often symptomatic at the time of diagnosis when compared to adult patients.

Neonatal Bone Disorders

Neonatologists care for newborns with either an antenatal suspicion or postnatal diagnosis of bone disease. With improved ultrasound imaging techniques, more cases of neonatal bone disorders are identified antenatally and this requires further diagnostic/molecular testing either antenatally or soon after birth for confirmation of the diagnosis and facilitating subsequent management. Prompt diagnosis is vital in certain conditions where initiation of treatment is time critical and life saving. We outline an approach to diagnosis, investigation, and management of a neonate with a suspected bone disorder.