A prospective guide for clinical implementation of selected OGTT- derived surrogate indices for the evaluation of β- cell function and insulin sensitivity in patients with transfusion-dependent β- thalassaemia

The gold standard for the measurement of insulin secretion is the hyperglycemic clamp and for insulin sensitivity the hyperinsulinemic euglycemic clamp, respectively. A number of surrogate indices, derived from plasma glucose and insulin levels at a fasting state or after oral glucose load, have been proposed to estimate β-cell response, and the ability of β-cells to compensate for changes of insulin sensitivity by modulating insulin secretion (disposition index). Starting from the current recommendations for the annual screening of glucose dysregulation in patients with transfusion dependent β-thalassemia (β-TDT), this article summarizes the most frequently used indirect indices of insulin secretion and resistance derived from the oral glucose tolerance test (OGTT) and discusses the strengths and weaknesses of selected indices and the basic concepts underlying each method for the appropriate evaluation of glucose regulation. Basal indices for β-cell function and insulin sensitivity, albeit simple and cheap, have limited usefulness due to a high coefficient variation and the lack of data about response to glucose load. Therefore, measurement of indices during an OGTT, despite being costly and time-consuming, is suggested since it can detect, even subtle, dynamic changes in insulin secretion and glucose handling. In patients with β-TDT, the indices derived from OGTT may offer an additional factor to evaluate the efficiency of iron chelation therapy and detect patients who may need intensification of iron chelation therapy and/or pharmacological intervention.

A Multicenter ICET-A Study on Age at Menarche and Menstrual Cycles in Patients with Transfusion-Dependent Thalassemia (TDT) who Started Early Chelation Therapy with Different Chelating Agents

Introduction

To evaluate the effect of early chelation therapy (≤ 3 years) with a variety of chelating agents on age at menarche and menstrual characteristics in patients with transfusion-dependent thalassemia (TDT).

Design

A retrospective multicenter study promoted by the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A).

Setting

Eight of 13 International Thalassemia Centers (61.5%) in the ICET-A Network participated.

Patients

Fifty-seven female TDT patients, aged 11 to 26 years, and with early iron chelation therapy, were eligible for the present study. They were enrolled from one center from Iran (33 patients), 3 centers from Bulgaria (9), 1 from Greece (8), one from Oman (4), 1 from Cyprus (2), and 1 from Italy (1). Seven patients were excluded, four still prepubertal (age 12-14 years) and 3 with primary amenorrhea. Therefore 50 patients were finally enrolled.

Results

All fifty TDT patients developed spontaneous menarche at a mean age of 14.2 ± 2.24 years (range 9 - 20). A significant positive correlation was observed between age at menarche and serum ferritin levels (r: 0. 41, p=0.005). Regular menstrual cycles were reported from 32 (64%) patients, of whom 28 (83.3%) get menarche at age ≤ 14 years. Complications were more frequent in patients older than 14 years at menarche and in those with secondary amenorrhea.

Conclusions

Age at menarche greater than 14 years was a forerunner of menstrual irregularities and associated complications in 36% of patients despite precocious chelation therapy. The poor adherence to treatment, to be demonstrated in future studies, could explain the finding.

Retrospective study on long-term effects of hormone replacement therapy (HRT) and iron chelation therapy on glucose homeostasis and insulin secretion in female ß- thalassemia major (β-TM) patients with acquired hypogonadotropic- hypogonadism (AHH)

BACKGROUND AND AIM

Hypogonadism and abnormalities of glucose homeostasis, resulting from iron-induced pituitary and pancreatic β-cell dysfunction respectively, are the most frequently reported endocrine abnormalities in patients with ß-thalassemia major (β-TM), also identified as transfusion-dependent thalassemia (TDT).

STUDY DESIGN AND PATIENTS

The aim of the present retrospective study was to evaluate the long-term effects of hormone replacement therapy (HRT) on glucose metabolism and insulin secretion/sensitivity during 3-h oral glucose tolerance test (OGTT) in adolescent and young β-TM women with acquired hypogonadototropic -hypogonadism (AHH).Twelve hypogonadal β-TM females with AHH on HRT were followed for 8.26 ± 1.49 years.

RESULTS

At baseline, 10 patients (83.3%) had normal OGTT, 1 patient presented with impaired glucose tolerance (IGT) and 1 patient had an isolated PG level of 165 mg/dL at 1-h during OGTT (H-NGT). At last evaluation, 7 patients (58.4 %) had normal OGTT, while 5 patients (41.6%) had abnormal OGTT. Reduced insulin sensitivity and impaired first-phase insulin secretion were also documented. Three of 4 β-TM patients on treatment with estradiol hemihydrate MX 50 patches plus oral medroxyprogesterone acetate (MPA), associated with a very effective iron chelation therapy, maintained normal glucose tolerance from baseline to last evaluation. Significant adverse events due to HRT or additional endocrine complications were not documented in any cases during the follow-up.

CONCLUSION

Deterioration of glycemia (dysglycemia) occurred in 45.4% (5/11) of thalassemic females on long-term HRT. Additional studies are needed to elucidate the validity of our preliminary observations.

Assessment of glucose homeostasis in young adult female β-thalassemia major patients (β-TM) with acquired hypogonadotropic hypogonadism (AHH) never treated with sex steroids compared to eugonadal β-TM patients with spontaneous menstrual cycles

BACKGROUND

Acquired ypogonadotropic hypogonadism (AHH) is the most prevalent endocrine complication in thalassemia major (TM).

STUDY DESIGN

Considering the detrimental effect of estrogen deficiency on glucose metabolism, the ICET-A Network promoted a retrospective study on the long-term effects of estrogen deficiency on glucose homeostasis in female β-TM patients with HH without hormonal replacement therapy (HRT).

PATIENTS AND METHODS

Seventeen β-TM patients with AHH (4 had arrested puberty; Tanners' breast stage 2-3), never treated with sex steroids, and 11 eugonadal β-TM patients with spontaneous menstrual cycles at the time of referral were studied. A standard 3-h OGTT was performed in the morning, after an overnight fast. Six-point plasma glucose and insulin level determinations, indices of insulin secretion and sensitivity, early-phase insulin insulinogenic index (IGI), HOMA-IR and β-cell function (HOMA-β), oral disposition index (oDI), glucose and insulin areas under the OGTT curves were evaluated.

RESULTS

Abnormal glucose tolerance (AGT) or diabetes was observed in 15 (88.2%) of 17 patients with AHH and 6 (54.5%) of 11 patients with eumenorrhea. The difference between the two groups was statistically significant (P: 0.048). However, the group of eugonadal patients was younger compared to AHH patients (26.5 ± 4.8 years vs. 32.6 ± 6.2 years ; P: 0.010). Advanced age,  severity of iron overload, splenectomy, increased ALT levels and reduced IGF-1 levels were the main clinical and laboratory risk factors for glucose dysregulation observed in β-TM with AHH compared to eugonadal β-TM patients with spontaneous menstrual cycles.

CONCLUSION

These data further support the indication for an annual assessment of OGTT in patients with β-TM. We believe that a registry of subjects with hypogonadism is necessary for a better understanding of the long-term consequences of this condition and  refining treatment options.

Unilateral breast enlargement in males during adolescence (10-19 years): Review of current literature and personal experience

Idiopathic unilateral breast enlargement (UBE) in males is a, commonly overlooked, diagnosis of exclusion that requires careful history, meticulous physical examination, and pertinent laboratory studies to exclude the possible pathologic causes. The aims of the present update are to review the current literature on UBE in subjects during adolescent age (10-19 years) in 18 cases, and to report the personal experience in 13 adolescents referred to our unit during the last four decades. In total, our survey and personal experience include 31 UBE cases, 10 of whom (32.2 %) being idiopathic or familial gynecomastia (GM). In 3/31 (9.6%) UBE was due to breast sarcoma/ carcinoma; one patient (11-years old) had a 5-year history of painless lump in the right breast, which increased gradually in size followed by bloody nipple discharge. In the personal cases of 13 adolescents, a moderate to marked UBE was secondary to: treatment with androgens (2 β-thalassemic patients with hypogonadism), high estrogen/androgen ratio in 2 Klinefelter syndrome patients, peripheral aromatization of androgens in 1 patient with non-classical 21-hydroxylase deficiency (NC-21-OH-D). One patient had subareolar hematoma due to injury. In 2 patients (15,3%) marked UBE was due to cystic lymphangioma (histologically proved). Furthermore, 5 patients were characterized as idiopathic UBE In clinical practice, the persistence of UBE for long period before diagnosis necessitates attention and further evaluation. Underlying causes should be treated, when possible, while surgery can be offered to patients with persistent or atypical signs and/or symptoms of UBE. For the optimal management of this condition, better collaboration between primary care physician and specialists is mandatory.

Longitudinal study of ICET-A on glucose tolerance, insulin sensitivity and β-cell secretion in eleven β-thalassemia major patients with mild iron overload

BACKGROUND

Iron chelation therapy (ICT) is the gold standard for treating patients with iron overload, though its long-term effects are still under evaluation. According to current recommendations regarding  transfusion-dependent  (TD)  β-thalassemia major (β-TM) patients, their serum ferritin (SF) levels should be maintained below 1,000 ng/mL and ICT should be discontinued when the levels are <500 ng/mL in two successive tests. Alternatively, the dose of chelator could be considerably reduced to maintain a balance between iron input and output of  frequent transfusions.

STUDY DESIGN

Due to the paucity of information on long-term effects of ICT  in β-TM with low SF levels on glucose homeostasis, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine (ICET-A) promoted a retrospective and an ongoing prospective observational study with the primary aim to address the long-term effects of ICT on glucose tolerance and metabolism (β-cell function and peripheral insulin sensitivity) in adult β-TM patients with persistent SF level below 800 ng/mL.

PATIENTS AND METHODS

11 β-TM patients (mean age: 35.5 ± 5.5 years; SF range: 345-777 ng/mL) with normal glucose tolerance test (OGTT) or abnormal glucose tolerance (AGT) for a median of 5.3(1.1-8.3) years.

RESULTS

Abnormal glucose tolerance (AGT) was observed in 7 patients (63.6%) at first observation and ) persisted in 6 patients (54.5%) at last observation. None of them developed diabetes mellitus. AGT was reversed in two patients. One patient with NGT developed early glucose intolerance (1-h PG ≥155 and 2-h PG <140 mg/dL). Three out of  5 patients with isolated impaired glucose tolerance presented a variation of  ATG. Stabilization of low indices for β-cell function and insulin sensitivity/resistance was observed. One patient developed hypogonadotrophic hypogonadism. Three out of 6 patients with SF below 500 ng/dL had hypercalciuria.

CONCLUSION

Despite low SF level, the burden of endocrine complications remains a challenge in β-TM patients. The ability to keep iron at near "normal" level with acceptable risks of toxicity remains to be established.

Screening for glucose dysregulation in β-thalassemia major (β-TM): An update of current evidences and personal experience

Glucose dysregulation (GD) in patients with β-thalassemia major (β-TM) usually develops gradually. Prediabetes consists of two abnormalities, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT), the latter detected by a standardized oral glucose tolerance test (OGTT). Diagnosis of prediabetes is essential for an early identification of high-risk individuals who will benefit from intensive iron chelation therapy and lifestyle modification. Therefore, patients with β-TM should undergo annual screening for glucose abnormalities, according to international recommendations, starting from the age of 10 years. OGTT remains the preferred screening method as it is more sensitive for GD than fasting plasma glucose (FPG), although it is poorly reproducible. The use of HbA1c measurement has limited use as it is generally considered unreliable in patients with thalassemia. Continuous glucose monitoring system (CGMS) is an accurate method to detect the variability of glucose fluctuations and offers the opportunity for better assessment of glucose homeostasis in a selected group of β-TM patients. Pancreatic Magnetic Resonance Imaging (MRI) associated with insulin secretion-sensitivity index-2 (ISSI-2) could be a complementary test, minimizing the necessity for OGTT and identifying high-risk patients before irreversible pancreatic damage occurs. The aims of this short report are to give practical guidance for an early identification of GD in β-TM patients, to summarise our experience, and to offer an impetus for further research in the field.

Hypomenorrhea in Adolescents and Youths: Normal Variant or Menstrual Disorder? Revision of Literature and Personal Experience

Menstrual health affects a large number of women throughout reproductive life since adolescence. Knowledge of the duration and variation of the menstrual cycle is necessary for patient education and to identify deviations from normal  to guide clinical evaluation. The average duration of menstrual flow is between 4 to 6 days, with anormal range from 2 up to 8 days ; the mean blood loss per menstrual cycle is 25- 30 mL. In general, descriptive data falling outside the normal range are considered to be indicative of menstrual disorders. Although the American Academy of Pediatrics and American College of Obstetricians and Gynecologists advocate for clinicians to consider the menstrual cycle as a vital sign in adolescents, the identification of subjects with hypomenorrhea is neither well defined nor routinely practiced. In this paper we have summarized the published prevalence of hypomenorrhea (lighter and/or shorter menstrual bleeding) in adolescents and youths in different countries and report the personal experience in four adolescents.

Oral glucose tolerance test: Ηow to maximize its diagnostic value in children and adolescents

BACKGROUND

Recently, the validity of the oral glucose tolerance test (OGTT) as a gold-standard test for the diagnosis of glucose dysregulation (GD) has been questioned due to the pre-analytical, analytical, and post-analytical variables which can potentially affect its reproducibility and accuracy.

AIMS

In this short update, the many  variables that affect the reproducibility and accuracy of the OGTT are described and discussed aiming to enhance its diagnostic value  in  clinical practice.

SEARCH STRATEGY

A systematic search was implemented in June 2022, using Scopus, PubMed, Embase and Google Scholar focusing on OGTT relevant  papers published in the last 10 years. Moreover,  the reference lists of these  articles were checked for additional pertinent studies. The research and selection of articles was also supported by the long-term authors' experience in the use of OGTT for the diagnosis of GD in children and adolescents.

CONCLUSION

The complexity of diagnosing GD presupposes that clinicians have specific knowledge and experience to perform rigorous assessment of glucose metabolism. It is worth mentioning that during OGTT, subjects with glucose levels  close to the cut-off values proposed  by WHO (World Health Organization)/ADA (American Diabetes Association) require careful evaluation in order to avoid misclassification and unnecessary interventions. For this reason, ADA recommends a second test to confirm the diagnosis of diabetes.

Insulin-Like Growth Factor -1 (IGF-1) and Glucose Dysregulation in Young Adult Patients with β-Thalassemia Major: Causality or Potential Link?

BACKGROUND

Insulin-like growth factor-1 (IGF-1) has been shown to lower blood glucose through stimulating glucose transport to fat and muscle and inhibiting hepatic glucose output. Although previous cross-sectional reports reported an association between low circulating concentrations of IGF-1 and glucose dysregulation (GD), its role is still debated.

AIMS OF STUDY

The present retrospective study was designed to assess the circulating IGF-1 levels in β-thalassemia major (β -TM) patients with normal oral glucose tolerance test (NGT-OGTT) and (GD) referred for an endocrine evaluation to explore the potential link between low IGF-1 and GD.

STUDY DESIGN AND METHODS

Our study included 34 young adult patients with β-TM; 12 patients with NGT after OGTT, 7 with impaired glucose tolerance (IGT), 9 with impaired fasting glucose (IFG) plus IGT, and 6 patients with β-TM-related diabetes mellitus (β-TM- DM).

RESULTS

Twenty-two β-TM patients with GD or β-TM- DM and 1 patient with NGT had IGF-1 levels below the 2.5th percentile. Correlation of IGF-1 with fasting plasma glucose, HOMA-IR (homeostatic model assessment for insulin resistance) and OGIS (oral glucose insulin sensitivity) was found. Moreover, a negative correlation was documented between ALT and the Insulinogenic Index (IGI) and a positive correlation between serum ferritin and PG 2-h after OGTT.

CONCLUSION

This study reports for the first time an association between low levels of IGF-1 and GD in β-TM patients. Despite some limitations, our study can serve to generate proposals for more convenient and efficient methods to identify and treat early GD in patients with β-TM, and to conduct more extensive studies. www.actabiomedica.it).

The Myxedema coma in children and adolescents: A rare endocrine emergency - Personal experience and review of literature

Decompensated hypothyroidism, formerly known as myxedema coma, represents the most extreme clinical expression of severe primary or secondary hypothyroidism in which patients exhibit multiple organ abnormalities and progressive mental deterioration. The exact incidence of myxedema coma in adults is not known, but some authors have estimated that is approximately 0.22 per 100.0000 per year in the western world. Myxedema coma is more common in females and during winter months. The diagnosis of myxedema coma is primarily clinical with supportive evidence of the abnormal thyroid function tests. Clinical features vary depending on a several factors including the age of onset and the severity of the disease. In the majority of patients (95%), the cause of underlying hypothyroidism is autoimmunity, i.e., Hashimoto thyroiditis or congenital abnormalities. Rarely it occurs in secondary (central) hypothyroidism, due to thyrotropin deficiency related to pituitary disease, or pituitary-thyroid damage due to iron overload. Treatment consists of thyroid hormone replacement, correction of electrolyte disturbances, passive rewarming, treatment of infections, respiratory and hemodynamic support, and administration of stress-dose glucocorticoids. Prognosis seems to be better in children and adolescents compared to adults. The present review reports personal experience and the literature data on 13 patients. (www.actabiomedica.it)

For Debate: Assessment of HbA1c in Transfusion Dependent Thalassemia Patients

At present, assessment of haemoglobin A1c (HbA1c) is widely used for the diagnosis and monitoring of treatment in diabetes mellitus (DM). However, the HbA1c level is affected by many factors such as those influencing the lifespan of red blood cells and the structure, function and amount of normal HbA. Therefore, the clinical significance of HbA1c assessment in thalassemia patients needs careful consideration, especially in transfusion dependent thalassemia patients (TDT) in whom circulating Hb is that of blood donors. Preliminary reports have documented that HbA1c estimation in efficiently transfused patients seems valuable in diagnosis and monitoring of treatment in DM and other glucose disturbances in TDT patients. Herein, a short review of HbA1c measurement in anemias, blood transfusions and hemoglobinopathies, and the debate of the credibility of Hb A1c assessment in TDT patients is reported.

Evaluation of endocrine complications in beta-thalassemia intermedia (β-TI): a cross-sectional multicenter study

BACKGROUND

Data on the prevalence and type of endocrine disorders in β-thalassemia intermedia (β-TI) patients are scarce. This multicenter study was designed to determine the prevalence of endocrine complications and the associated risk factors in a large group of β-TI patients.

METHODS

In this cross-sectional multicenter study, 726 β-TI patients, aged 2.5-80 years, registered at 12 thalassemic centers, from nine countries, were enrolled during 2017. In a subgroup of 522 patients (mean age 30.8 ± 12.1; range: 2.5-80 years) from Qatar, Iran, Oman, Cyprus, and Jordan detailed data were available.

RESULTS

Overall, the most prevalent complications were osteopenia/osteoporosis (22.3%), hypogonadism (10.1%), and primary hypothyroidism (5.3%). In the subgroup multivariate analysis, older age was a risk factor for osteoporosis (Odds ratio: 7.870, 95% CI: 4.729-13.099, P < 0.001), hypogonadism (Odds ratio: 6.310, 95% CI: 2.944-13.521, P < 0.001), and non-insulin-dependent diabetes mellitus (NIDDM; Odds ratio: 17.67, 95% CI: 2.217-140.968, P = 0.007). Splenectomy was a risk factor for osteoporosis (Odds ratio: 1.736, 95% CI: 1.012-2.977, P = 0.045). Hydroxyurea was identified as a "protective factor" for NIDDM (Odds ratio: 0.259, 95% CI: 0.074-0.902, P = 0.034).

CONCLUSIONS

To the best of our knowledge, this is the largest cohort of β-TI patients with endocrine disorders evaluated in extremely heterogenic thalassemic populations for age, clinical, hematological, and molecular composition. The study demonstrates that endocrine complications are less common in patients with β-TI compared with β-TM patients. However, regular monitoring with timely diagnosis and proper management is crucial to prevent endocrine complications in β-TI patients.

Coronavirus Disease 2019 (COVID-19) in adolescents: An update on current clinical and diagnostic characteristics

The current outbreak of infections with SARS-CoV-2 is defined as Coronavirus Disease 2019 (COVID-19). The clinical symptoms of COVID-19 include fever, fatigue, cough, breathing difficulty that may lead to respiratory distress; a small population of patients may have diarrhea, nausea or vomiting. The highest infection rate occurs in adults; however, neonates, children, and adolescents can also be infected. As the outbreak continues to spread worldwide, attention has switched toward determinants of clinical manifes- tations and disease severity. The situation surrounding the outbreak is rapidly evolving and the information and recommendations are changing as new information becomes available. This paper summarises the cur- rent findings (April 3,2020) from a systematic literature review on the current knowledge of COVID-19 in adolescents (10-19 years according to the WHO definition) and reports the preliminary epidemiological data stated by the Italian National Institute of Health.

Prevalence, attitude and practice of self-medication among adolescents and the paradigm of dysmenorrhea self-care management in different countries

Self-medication (SM) is an important worldwide public health issue affecting children and adolescents. The pattern of SM varies in different communities, affected by factors such as age, sex, income, expense, self-care orientation, educational level and medical knowledge. It is a fairly common practice: for minor health problems, it often provides cheap, rapid, and convenient solutions, outside of the health care system of many countries. Painkillers, antipyretics, cough medicines, cold preparations, dermatological products, nutritional supplements and antibiotics are the drugs most frequently used. Potential risks include incorrect self-diagnosis, improper dosage, inappropriate choice of therapy, masking of severe disease and drug interactions. Lack of awareness of warnings and precautions, storage conditions, the recommended shelf-life and adverse reactions increase the risk of side effects. Little is known about the SM of dysmenorrhea by adolescent girls. Attitudes towards treatment are influenced by cultural, ethnic, and religious factors. Some girls discuss dysmenorrhea with family and friends, and the majority may not seek medical advice. As dysmenorrhea is a common problem for adolescents, it is essential that these girls be aware of the normal and abnormal symptoms of menstruation. In the light of these findings, the roles of family, school, health professionals and health authorities are of utmost importance for the implementation of measures to approach this health problem in a more efficient way. (www.actabiomedica.it)

Long-term effects and significant Adverse Drug Reactions (ADRs) associated with the use of Gonadotropin-Releasing Hormone analogs (GnRHa) for central precocious puberty: a brief review of literature

Central precocious puberty (CPP) is defined as an early pubertal development that occurs before the age of 9 years in boys and 8 years in girls. It results from premature activation of the hypothalamic-pituitary-gonadal axis. Gonadotropin-releasing hormone agonists (GnRHa) have been the gold standard therapy for CPP for more than 30 years. These compounds have a high affinity for the pituitary LHRH receptor and are resistant to enzymatic degradation. Through continuous stimulation, GnRHa inhibit the pulsatile secretion of gonadotropin, resulting in hormonal suppression, cessation of pubertal development, and normalization of growth and skeletal maturation rates. The goal of therapy is to halt pubertal progression and delay epiphyseal maturation that leads to improvement of final adult height. There are no widely accepted guidelines for how long to continue treatment with a GnRHa for CPP, and individual practice varies widely. Furthermore, conflicting results have been published on the long-term effects of GnRHa therapy in patients with CPP. Therefore, we reviewed the current literature focusing our attention on the long-term effects and the significant adverse drug reactions (ADRs) observed during treatment with GnRHa in patients with CPP. Our review may provide the necessary data to enable clinicians to administer GnRHa in the safest and most appropriate way. Further studies are necessary to identify the mechanisms of development of potential adverse drug reactions related to GnRHa therapy in CPP.

Marital status and paternity in patients with Transfusion- Dependent Thalassemia (TDT) and Non Transfusion-Dependent Thalassemia (NTDT): an ICET - A survey in different countries

BACKGROUND

More than five decades ago, thalassemia major (TDT) was fatal in the first decade of life. Survival and quality of life have improved progressively thanks to the implementation of a significant advance in diagnostic and therapeutic methods, consisting mainly of a frequent transfusion program combined with intensive chelation therapy. Improvement also includes imaging methods used to measure liver and cardiac iron overload. Improved survival has led to a growing number of adults requiring specialised care and counselling for specific life events, such as sexual maturity and acquisition of a family.

AIMS OF THE STUDY

The main aim is to present the results of a survey on the marital and paternity status in a large population of adult males with TDT and NTDT living in countries with a high prevalence of thalassemia and a review of current literature using a systematic search for published studies.

RESULTS

Ten out of 16 Thalassemia Centres (62.5%) of the ICET-A Network, treating a total of 966 male patients, aged above 18 years with β- thalassemias (738 TDT and 228 NTDT), participated in the study. Of the 966 patients, 240 (24.8%) were married or lived with partners, and 726 (75.2%) unmarried. The mean age at marriage was 29.7 ± 0.3 years. Of 240 patients, 184 (76.6%) had children within the first two years of marriage (2.1 ± 0.1 years, median 2 years, range 1.8 - 2.3 years). The average number of children was 1.32 ± 0.06 (1.27 ± 0.07 in TDT patients and 1.47 ± 0.15 in NTDT patients; p: >0.05). Whatever the modality of conception, 184 patients (76.6%) had one or two children and 1 NTDT patient had 6 children. Nine (4.8%) births were twins. Of 184 patients, 150 (81.5%) had natural conception, 23 (12.5%) required induction of spermatogenesis with gonadotropins (hCG and hMG), 8 (4.3%) needed intracytoplasmic sperm injection (ICSI) and 3 adopted a child. 39 patients with TDT and NTDT asked for medical help as they were unable to father naturally: 7 TDT patients (17.9%) were azoospermic, 17 (37.7%) [13 with TDT and 4 with NTDT] had dysspermia and 15 (33.3%) [13 with TDT and 2 with NTDT] had other "general medical and non-medical conditions".

CONCLUSIONS

Our study provides detailed information in a novel area where there are few contemporary data. Understanding the aspects of male reproductive health is important for physicians involved in the care of men with thalassemias to convey the message that prospects for fatherhood are potentially good due to progressive improvements in treatment regimens and supportive care.

For Debate: Testicular Volume Development along Ages: Evaluation by Different Methods

In the last five decades an increasing number of studies and clinical reports demonstrated the importance of testicular volume assessment in pediatric and adolescent population. Reliable and accurate determination of testicular volume (TV) through infancy and adolescence is of great importance for assessing normal pubertal development to diagnose disturbances in development and to suspect certain genetic and endocrine diseases. Various approaches are available for the assessment of TV, including orchidometry, rulers, callipers, and ultrasonography (USG). Our report focuses on the importance of the evolution of TV from birth to adulthood and debates the main factors influencing the accuracy of different TV measurements. We endorse that any method for the evaluation of TV must satisfy certain criteria: a. be applicable to persons of all ages from pre-adolescence, through the pubertal spurt to full maturity, b. be simple to use, c. be free from observer error as possible, and d. have a high degree of correlation with other observable developmental characteristics.

Adverse events during testosterone replacement therapy in 95 young hypogonadal thalassemic men

Background:

Hormonal treatment of hypogonadism in thalassaemia major (TM) is a complex issue due to the co-existence of other contributing factors such as severity of iron overload, associated chronic liver disease and other endocrine complications.

Objectives:

Data about adverse events (AEs) of testosterone replacement therapy (TRT) in hypogonadal males with TM is scarce. We report the adverse events registered during TRT in 95 young patients with TM.

Results:

These AEs included gynecomastia, documented in 41/95 (43.1%) TM patients of mild to moderate severity (90%). Persistent pain in the injection site and local reactions to testosterone (T) skin patch occurred in a third of patients. Priapism was reported in 2 patients on treatment with intramuscular T enanthate. In both patients, substitution with T gel was successful, and no recurrence during the following 24 months was observed.

Conclusions:

Clinicians should exercise caution when considering TRT for hypogonadal men with TM. (www.actabiomedica.it)

The juvenile fibromyalgia syndrome (JFMS): a poorly defined disorder

Juvenile fibromyalgia syndrome (JFMS) is a chronic condition characterized by symptoms of chronic diffuse musculoskeletal pain and multiple painful tender points on palpation. It is often accompanied by fatigue, disorders of sleep, chronic headaches, irritable bowel syndrome, and subjective soft tissue swelling. The complexity of the presenting clinical picture in JPFS has not been sufficiently defined in the literature. Similarities to adult fibromyalgia syndrome in JFMS are often difficult to compare, because many of the symptoms are "medically unexplained" and often overlap frequently with other medical conditions. However, a valid diagnosis of JFMS often decreases parents' anxiety, reduces unnecessary further investigations, and provides a rational framework for a management plan. The diagnostic criteria proposed by Yunus and Masi in 1985 to define JFMS were never validated or critically analyzed. In most cases, the clinical diagnosis is based on the history, the physical examination that demonstrates general tenderness (muscle, joints, tendons), the absence of other pathological conditions that could explain pain and fatigue, and the normal basic laboratory tests. Research and clinical observations defined that JFMS may have a chronic course that impacts the functional status and the psychosocial development of children and adolescents. This paper briefly reviews the existing knowledge on JFMS focusing on the diagnosis, clinical and the epidemiological characteristics in children and adolescents for better understanding of this disorder.

The experience of a tertiary unit on the clinical phenotype and management of hypogonadism in female adolescents and young adults with transfusion dependent thalassemia

BACKGROUND

Transfusion-dependent β-thalassemia (TDT) is associated with several complications necessitating a multidisciplinary approach for diagnosis, treatment and follow-up. Hypogonadism in female TDT patients is one of the most common endocrine complications, requiring hormone replacement therapy (HRT) throughout reproductive life. Little is known about the balance of benefits versus risks of treatment with sex steroids.

AIM

The aim of this manuscript is to review the action and the associated adverse effects of HRT in hypogonadal TDT females.

DESIGN

Retrospective medical database records from a single centre, over a period of 38 years (January 1980 to June 2018), were reviewed.

STUDY POPULATION

Forty-two cases of hypogonadism in TDT females followed in a pediatric and adolescent outpatient clinics, were in included in the study.

METHODS

Auxological, clinical, laboratory, hormonal and imaging investigations were reviewed, as well as all adverse events registered during HRT.

MAIN RESULTS

In general, HRT was safe for most patients. There were few minor side effects and a couple of rare but serious adverse events.

CONCLUSIONS

The study provides a representative clinical profile of long-term effects of HRT in hypogonadal adolescents and young adult TDT women. Our results highlight also the need for further research in other areas for which HRT may have a role.  We hope this will contribute to a wider understanding, and potential improvement, of patient safety and quality of life.

An ICET-A survey on occult and emerging endocrine complications in patients with β-thalassemia major: Conclusions and recommendations

In adult thalassemia major (TM) patients, a number of occult and emerging endocrine complications, such as: central hypothyroidism (CH), thyroid cancer, latent hypocortisolism, and growth hormone deficiency (GHD) have emerged and been reported. As the early detection of these complications is essential for appropriate treatment and follow-up, the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) promoted a survey on these complications in adult TM patients, among physicians (pediatricians, hematologists and endocrinologists) caring for TM patients in different countries. The data reported by 15 countries are presented. The commonest endocrine complications registered in 3.114 TM adults are CH and GHD (4.6 % and 3.0 %, respectively), followed by latent hypocortisolism (1.2%). In 13 patients (0.41%) a cytological papillary or follicular thyroid carcinoma was diagnosed in 11 and 2 patients, respectively, and a lobectomy or thyroidectomy was carried out. Of 202 TM patients below the age of 18 years, the reported endocrine complications were: GHD in 4.5%, latent hypocortisolism in 4.4% and central hypothyrodisim in 0.5%. Transition phase was an area of interest for many clinicians, especially as patients with complex chronic health conditions are responding to new treatments extending their lifespan beyond imagination.. In conclusion, our survey provides a better understanding of physicians’ current clinical practices and beliefs in the detection, prevention and treatment of some endocrine complications prevailing in adult TM patients. Regular surveillance, early diagnosis, treatment and follow-up in a multi-disciplinary specialized setting are recommended. (www.actabiomedica.it)

The Management of Permanent Primary Hypoparathyroidism in Children and Adolescents: A Complex Task

Management of hypoparathyroidism (hypoPT), depends on the etiology and the severity of hypocalcemia. Treatment goals include control of hypocalcemic symptoms preserving serum calcium in the low-normal range and phosphate in the high normal range. While correction of serum calcium to low-normal range does not fully correct mineral and bone metabolism it may be associated with increased risk of complications such as nephrolithiasis, nephrocalcinosis and soft tissue calcifications. Therefore, it is imperative to find out ways to individualize treatment of patients with hypoPT to achieve the best prognosis while minimizing complications. Replacement therapy with recombinant human PTH (rhPTH) was recently tested for optimizing treatment of hypoPT in a small number of patients. For children and adolescents, further studies are needed to evaluate the long-term effects and safety of rhPTH. In this short review we summarize current knowledge on the management of hypoPT and debate our gaps on the long-term management of children and adolescents with hypoPT.

Testicular damage in children and adolescents treated for malignancy: a short review

Significant advances have been made over recent decades in the treatment of childhood malignancies. These advances had an incredible cost, as an increasing number of young survivors suffer subfertility or infertility, because of the high sensitivity of testicular cells, especially the rapidly dividing germ cells, to cytotoxic drugs and irradiation. Therefore, the impact of treatment on future fertility is of significant concern, both to parents and patients. Assessment of fertility damage in childhood remains problematic. For post-pubertal males, semen analysis represents a good indicator of spermatogenesis and testicular function, and allows for sperm cryopreservation. The available method for prepubertal children is only gonadal tissue cryopreservation. This method is still experimental and raises ethical concerns. Ideally, a multidisciplinary team approach needs to be used in addressing the needs of fertility preservation for this population. Precise knowledge of these issues would help pediatric oncologists and endocrinologists to counsel their patients and inform them for factors and resources that may protect or preserve parenthood options in the future. (www.actabiomedica.it)

Current treatment of hypoparathyroidism: Theory versus reality waiting guidelines for children and adolescents

The diagnosis of hypoparathyroidism(HPT)is readily made in the presence of hypocalcemia with markedly reduced or absent parathormone (PTH) levels. Currently available treatments for HPT include high dose vitamin D (ergocalciferol, D2 and cholecalciferol, D3) or, the active metabolite dihydroxy vitamin D (calcitriol), in addition to calcium supplements.This regimen, if not well monitored, can lead to hypercalciuria, as PTH deficiency impairs renal calcium reabsorption. Thus the goal of treatment, is to maintain serum calcium at the low end of the normal range. Undertreatment can cause symptomatic hypocalcemia, while overtreatment hypercalciuria, which may lead to nephrolithiasis, nephrocalcinosis, and renal insufficiency. At present, there is no consensus on the management of HPT in children and adolescents and only few studies are available on the long term outcome of patients with recombinant HPT treatment. The purpose of this article is to review, in a comprehensive manner, the major aspects of HPT management in children and adolescents waiting for authoritative guidelines for the treatment of HPT in this group of patients. Further research, addressing specific questions for this population are urgently needed to improve long-term safety of patients. Educational interventions are also needed for professionals, parents and patients to enable them to improve knowledge, quality of life and effective management care at home. (www.actabiomedica.it)

Is the Second to Fourth Digit Ratio (2D:4D) a Biomarker of Sex-Steroids Activity?

The second-to-fourth digit ratio (2D:4D) has been used as an indirect method to investigate the putative effects of prenatal exposure to androgens, and has been reported to be smaller in males than in females. This gender difference in digit length ratios has been linked with the in utero balance of androgens to oestrogen. This sexual dimorphism in 2D:4D ratios is apparent by 2 years of age and seems to be established early in life, possibly by the 14th week of gestation. Digits in females attain their maximum length at about 2.2 years (dextral subjects) or 5.1 years (sinistral subjects) earlier than those in males and increase slightly with age. It has also been reported that the 2D:4D ratio is correlated negatively with prenatal testosterone levels. This tentative theory is partially supported by lower 2D:4D in girls with congenital adrenal hyperplasia (CAH), higher 2D:4D in individuals with complete androgen insensitivity syndrome (CAIS) and a relationship between 2D:4D and polymorphisms in the androgen receptor. In contrast, individuals with Klinefelter syndrome (KS), who have reduced testosterone secretion throughout life, have a mean 2D:4D value similar to those found in female population norms. Nevertheless, its validity has not yet been conclusively demonstrated and is currently debated. In this context, our aim was to review and debate the relationship between 2D:4D ratio and sex-steroids activity in children, adolescents and young adults.

A focus on the distinctions and current evidence of endometriosis in adolescents

Endometriosis (EM) occurring in adolescents presents distinct clinical and histologic characteristics compared to the disease in women. Because the symptoms of EM are nonspecific, often overlapping with those experienced in a range of gynecological and gastrointestinal conditions, the process of reaching a diagnosis of EM is often delayed. The diagnosis of EM is suspected depending on the history and the symptoms and signs, is corroborated by physical examination and imaging techniques, and is finally proved by histological examination of specimens collected during laparoscopy. Currently, there is insufficient evidence to make strong recommendations for management in adolescents who may have EM. This short report reviews some peculiarities of EM in adolescents and provides an update of recent knowledge of the diagnosis and treatment of EM. We hope that the present contribution may help to bring more attention to the clinical diagnosis of EM and consequently aid in decreasing diagnostic delay.

Hypogonadism in male thalassemia major patients: pathophysiology, diagnosis and treatment

Failure of pubertal growth, delay or absence of sexual development, infertility and sexual dysfunction due to hypogonadism and defective spermatogenesis are frequent and well recognized disturbances among male patients with transfusion dependent (TD) thalassaemia major (β-thal). These problems are attributed mainly to the damage caused by chronic anaemia and the deposition of excess iron in the pituitary gland and testicles. This is a short review of male pubertal disorders in patients with β-thal written by pediatric endocrinologists and haematologists with an interest and active involvement, in the diagnosis and management of these complications in this group of patients. A vigilant clinical evaluation of growth and puberty, as well as an appropriate hormonal evaluation in poly-transfused (TD β-thal) patients is strongly recommended for early detection and treatment of endocrine dysfunction. Of crucial importance also, is the implementation of an efficient chelation regime from early life, to prevent severe iron load and permanent damage to the endocrine glands, particularly those responsible for gonadal function.

An ICET- A survey on Hypoparathyroidism in Patients with Thalassaemia Major and Intermedia: A preliminary report

Hypoparathyroidism (HPT) is a rare disease with leading symptoms of hypocalcemia, associated with high serum phosphorus levels and absent or inappropriately low levels of parathyroid hormone (PTH). In patients with thalassemias it is mainly attributed to transfusional iron overload, and suboptimal iron chelation therapy. The main objectives of this survey were to provide data on the prevalence, demographic and clinical features of HPT in thalassemia major (TM) and intermedia (TI) patients living in different countries, and to assess its impact in clinical medical practice. A questionnaire was sent to all Thalassemia Centres participating to the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescence Medicine (ICET-A) Network.Seventeen centers, treating a total of 3023 TM and 739 TI patients, participated to the study. HPT was reported in 206 (6.8%) TM patients and 33 (4.4%) TI patients. In general, ages ranged from 10.5 to 57 years for the TM group and from 20 to 54 years for the TI group. Of the 206 TM patients and 33 TI patients with HPT, 117 (48.9%) had a serum ferritin level >2.500 ng/ml (54.3% TM and 15.1% TI patients) at the last observation. Hypocalcemia varied in its clinical presentation from an asymptomatic biochemical abnormality to a life-threatening condition, requiring hospitalization. Calcium and vitamin D metabolites are currently the cornerstone of therapy in HPT. In TM patients, HPT was preceded or followed by other endocrine and non-endocrine complications. Growth retardation and hypogonadism were the most common complications (53.3% and 67.4%, respectively). Although endocrine complications were more common in patients with TM, non-transfused or infrequently transfused patients with TI suffered a similar spectrum of complications but at a lower rate than their regularly transfused counterparts.In conclusion, although a large international registry would help to better define the prevalence, comorbidities and best treatment of HPT, through the result of this survey we hope to give a clearer understanding of the burden of this disease and its unmet needs. HPT requires lifelong therapy with vitamin D or metabolites and is often associated with complications and comorbidities.Therefore, it is important for endocrinologists and other physicians, who care for these patients, to be aware of recent advances of this disorder.

For Debate: Should We Worry about Hematospermia in Adolescents and Young Men? A Report of Six Cases and Review of the Literature

Hematospermia or hemospermia is defined as the presence of blood in ejaculate. The true prevalence of the condition is unknown because many cases escape the patient's notice, and remain unrecognized and unreported. There are two main aims in the patient evaluation: first, to ensure that there is no specific condition that is treatable; second, to reassure the patient's parents that no causative factor is present. Many physicians are unfamiliar with this disorder and this forms the basis for our current review. We performed an essentially English language search (Medline since 1966 to present and reference list of articles) for "hematospermia", or "hemospermia" in combination with "adolescents", "young adults", "genital diseases", "management" and "review". The authors' personal experience with 6 adolescents and young men (up to the age of 20 years) is also reported. Several anatomical structures contributing to the ejaculate may be the source of the hematospermia: seminal vesicles, prostate, testis and epididymis. Hematospermia is a generally benign and self-limited condition that is infrequently associated with significant underlying pathology. Once the diagnosis is clear, it is important to reassure the adolescent about the benign nature and self-limiting course of the condition and to provide appropriate treatment to help ensure the adolescent's normal sexual development.

Gonadal dysfunction in adult male patients with thalassemia major: an update for clinicians caring for thalassemia

INTRODUCTION

Hypogonadism is the most frequently reported endocrine complication, affecting 40%-80% of thalassemia major (TM) patients. The prevalence and severity of hypogonadism in TM varies among studies, depending on patients' age, genotype, transfusion frequency and starting age and efficiency of iron chelation. Areas covered: The diagnosis requires careful clinical assessment and appropriate laboratory testing. Its management is more complex compared to other 'classical' causes of hypogonadism because of multiple associated disorders (cardiac, hepatic and endocrine) and other contributing factors basically iron overload and iron toxicity. Expert commentary: Early recognition and treatment of hypogonadism in TM patients is most important to prevent late complications and to enhance the chances of parenthood. The goal of management is to restore deficient glandular function. If fertility is the issue and the testis is under-stimulated because of gonadotropin deficiency, it is possible to induce or restore spermatogenesis with exogenous gonadotropins in some patients. Assisted reproductive techniques may supplementary help to overcome previously untreatable causes of male infertility. These positive achievements should encourage health care providers to pay closer attention to the reproductive health of TM patients. This would involve the collaboration of clinicians caring for thalassemia with endocrinologists and specialists in assisted reproductive technologies.

An adolescent with an asymptomatic adnexal cyst: To worry or not to worry? Medical versus surgical management options

Paraovarian cysts or paratubal cysts (PTCs) arise from either the mesothelium or from paramesonephric remnants. These present as either adnexal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cysts. Typically PCTs appear as simple cysts by ultrasound and are indistinguishable from ovarian cysts if one does not recognize the extraovarian location. Occasionally, PTCs have internal echoes due to hemorrhage. PTCs are usually asymptomatic and benign. The differential diagnosis includes a simple ovarian cyst, peritoneal inclusion cyst and hydrosalpinx. Malignant changes have been reported in about 2% to 3%, and it should be suspected if papillary projections are present. PTCs management depend upon the presence and severity of the symptoms, the cyst size and US characteristics, CA 125 results, age of the patient and the risk of malignancy. Simple PTCs can be expected to regress and may be managed expectantly. When surgery is indicated, a joint multidisciplinary management by the paediatric surgeons and trained paediatric gynaecologists should be the gold standard. (www.actabiomedica.it)

Caffeinated energy drink consumption among adolescents and potential health consequences associated with their use: a significant public health hazard

Caffeinated energy drinks (EDs) are increasingly popular among adolescents despite growing evidence of their negative health effects. The consumption of EDs has seen a substantial increase during the past few decades, especially in the Western and Asian countries. EDs contain high levels of caffeine, sugar, and novel ingredients, and are often marketed through youth-oriented media and venues. The known and unknown pharmacology of the constituents of EDs poses a risk of caffeine toxicity and other ill effects when consumed by young people. Caffeine intoxication may result in tachycardia, vomiting, cardiac arrhythmias, seizures, and even death. Other health concerns related to consumption of EDs include obesity and dental enamel erosion resulting from the acidity of EDs. Coingestion of caffeine and ethanol has been associated with increased risk-taking behaviors in adolescent users, impaired driving, and increased use of other illicit substances. Several researchers have demonstrated that consuming alcohol mixed with energy drinks leads to altered subjective states including decreased perceived intoxication, enhanced stimulation, and increased desire to drink/increased drinking compared to consuming alcohol alone. Caffeine’s effect on intoxication may be most pronounced when mixers are artificially sweetened, that is, lack sucrose which slows the rate of gastric emptying of alcohol. In conclusion: 1) health care providers should educate youth and their parents about the risks of caffeinated drinks; 2) emergency department clinicians should consider asking patients about ED and traditional caffeine usage and substance use when assessing patient symptoms; 3) policy makers should increase their attention on introducing regulatory policies on television food advertising to which youth are exposed; 4) failure to comply with standards for efficacious product labelling, and absence of broader education regarding guidelines, need to be addressed and 5) further studies must be done to improve our understanding of potential negative consequences of caffeinated energy drinks on health. (www.actabiomedica.it)

Hemi-transseptal Approach for Pituitary Surgery: A Follow-Up Study

Objectives The hemi-transseptal (Hemi-T) approach was developed to overcome the potential drawbacks of the nasoseptal flap (NSF) in endoscopic endonasal transsphenoidal skull base surgery. In this study, we describe further refinements on the Hemi-T approach, and report long-term outcomes as compared with traditional methods of skull base reconstruction. Design A retrospective case-control study. Setting Montreal Neurological Institute and Jewish General Hospital, Montreal, Canada. Participants Patients who underwent endoscopic endonasal transsphenoidal approach to skull base pathology. Main Outcome Measures Operative time, CSF rhinorrhea, and postoperative nasal morbidity. Results A total of 105 patients underwent the Hemi-T approach versus 40 controls. Operative time was shorter using the Hemi-T technique (180.51 ± 56.9 vs. 202.9 ± 62 minutes; p = 0.048). The rates of nasal morbidity (septal perforation [5/102 vs. 6/37; p = 0.029] and mucosal adhesion [11/102 vs. 10/39 p = 0.027]), fascia lata harvest (21/100 vs. 18/39; p = 0.0028), and postoperative CSF leak rates (7/100 vs. 9/38; p = 0.006) were lower in the Hemi-T group. Conclusion Advantages of the Hemi-T approach over traditional exposure techniques include preservation of the nasal vascular pedicle, shorter operative time, reduced fascia lata harvest rates, and decreased nasal morbidity.

Review and Recommendations on Management of Adult Female Thalassemia Patients with Hypogonadism based on Literature Review and Experience of ICET-A Network Specialists

BACKGROUND

Multi-transfused thalassemia major (TM) patients frequently develop severe endocrine complications, mainly due to iron overload, anemia, and chronic liver disease, which require prompt diagnosis, treatment and follow-up by specialists. The most common endocrine complication documented is hypogonadotropic hypogonadism which increases with age and associated comorbidities. It is thus important for physicians to have a clear understanding of the pathophysiology and management of this disorder. Also to be aware of the side effects, contraindications and monitoring of sex steroid therapy. In this paper, practical ICET-A recommendations for the management of hypogonadism in adult females with TM are addressed.

METHODS

In March 2015, the Coordinator of the International Network of Clinicians for Endocrinopathies in Thalassemia and Adolescent Medicine (ICET-A) conducted a two-step survey to assess the attitudes and practices of doctors in the ICET-A network taking care of adult female TM patients with hypogonadism. They were clinically characterized by the absence of pubertal development or discontinuation or regression of the maturation of secondary sex characteristics, and biochemically by persistent low FSH, LH and estradiol levels. Recently a supplementary survey on adult female hypogonadism in TM was undertaken within the ICET-A network.

RESULTS

The completed questionnaires were returned by 16 of 27 specialists (59.2%) following 590 female TM patients over the age of 18 years; 315 patients (53.3%) had hypogonadism, and only 245 (74.6%) were on hormone replacement therapy (HRT). Contraceptive oral pills (COC) were the first treatment choice in 11 centers (68.7%). A wide range of COCs was used with different progestin contents. In general, the patients' compliance to treatment was reported as good in 81.2 % of centers. The frequency of required tests for follow-up HRT, in addition to the regular check-up for thalassemia, was variable in the participating centers.

CONCLUSIONS

Doctors taking care of TM patients should have sound knowledge of the pathophysiology of hypogonadism in adult females with TM. They should know the potential effects of HRT including advantages and disadvantages of estrogen and progestins. Moreover, they should keep in consideration the emotional needs of these patients dreaming of attaining a full pubertal development.

Pros and cons for the medical age assessments in unaccompanied minors: a mini-review

Unaccompanied minors refer to immigrants who are under the age of 18 and are not under the care of a parent or legal guardian. Age assessment is used in Europe mainly to establish whether or not an individual is under 18 years of age and therefore eligible for protection under the United Nations' Convention on the Rights of the Child (UN - CRC). EU Member States use a combination of techniques to determine the age of a minor and to certify minor status, including interviews and documentation, physical examinations (anthropometric assessment; sexual maturity assessment; dental observation); psychological and sociological assessment; radiological tests (carpal, dental or collarbone x-rays). All such techniques are criticized as they are often arbitrary, do not take into account ethnic variations, and are based on reference materials that are outdated, invasive and may procure harm to the individuals whose age is assessed. They also generate a margin of error that makes them inaccurate to use. There is a debate about the risks and ethics associated with the use of X-rays for non-medical purposes versus the benefits of more accurate age assessments in the interest of justice. It appears that in European countries many individuals carrying out age assessment do not have sufficient training or are not sufficiently independent enough to be carrying out such assessments. Moreover, there is a lack of standardized approach between countries or even within the same country. Only some countries clearly indicate a margin of error in the results of age assessment examinations but there is no consensus - within and among countries - about the width of such margins in relation to each exams applied. It has been advised that the expert report should give the degree of age probability to allow Magistrate to interpret the age assessment results on the 'balance of probabilities' and give the detainee the right to the rule of the 'benefit of the doubt'. It also addresses concerns rested in the convention of the Rights of the Child.

SGA Children in Pediatric Primary Care: What Is the Best Choice, Large or Small? A 10-Year Prospective Longitudinal Study

BACKGROUND

Epidemiologic evidences suggest a strong association between low birth weight and some diseases in adult life ( hypertension, diabetes, cardiovascular diseases).Aim of this study was to evaluate the obesity/overweight prevalence in a population of children born small for gestation age, SGA children 400, 208 males and 192 females compared to a population of children born appropriate for gestational age 6818 AGA children, 3502 males and 3316 females, during childhood. Our intention was also to build the natural history of weight gain during prepubertal age in children born SGA and AGA.

DESIGN AND METHODS

Observational prospective longitudinal study. We followed our patients from January2001 up to December 2010; weight, height and body mass index (BMI) were evaluated in all the SGA and AGA children. BMI z-score range for defining overweight and obesity was, respectively, 1.13 to 1.7 and >1.7 according to CDC growth charts.

RESULTS

In transversal evaluation, we prove that 10-year-old SGA females are twice obese and more overweight compared to equal age AGA females. In longitudinal evaluation, we highlight different observations: SGA children obese at 2 years are still obese at 10 years; the number of obese SGA children increases gradually until the age of 10; AGA children, appear to be less obese than SGA children at 10 years.

CONCLUSION

SGA males and females are more obese at 5 and 10 years compared to the AGA population. Primary care pediatricians, through early detection of the children at risk, can carry out an effective obesity prevention project in SGA children.

Thyroid Hemiagenesis from Childhood to Adulthood: Review of Literature and Personal Experience

Thyroid hemiagenesis (TH) is a rare congenital abnormality of the thyroid gland, characterised by the absence of one lobe. The true prevalence of this congenital abnormality is not known because the absence of one thyroid lobe usually does not cause clinical symptoms by itself. Between 1970 and 2010, 329 cases of TH have been reported. It is interesting to note that most cases have an agenesis of the left lobe (80% of cases) followed by the isthmus (44-50% of cases). Although the female to male ratio was 1:1.4 in 24,032 unselected 11-to 14-yr-old schoolchildren from South-eastern Sicily, several other reports have documented a higher prevalence in women, which may indicate a possible gender association. Most cases of TH are diagnosed when patients present a lesion in the functioning lobe. The functioning lobe of the thyroid gland can be a site of pathological changes similar to a normally developed gland and may present a spectrum of diseases like multinodular goiter, colloid goiter, follicular adenoma, thyroiditis, hypothyroidism and hyperthyroidism. In three of our patients, TH was associated with Hashimoto thyroiditis (n = 1) and with subclinical hypothyroidism (n = 2). The frequency of thyroid abnormalities in patients with TH varies with age, due to the longer exposure of the hemi-agenetic gland to TSH overstimulation in older patients. This could explain the controversy about the benign character of this anomaly. Other extrathyroidal lesions, such as parathyroid adenoma or hyperplasia, cervical thymic cysts, ectopic sublingual thyroid gland and thyroglossal duct cyst have been reported with TH. Therefore, systematic follow-up of all identified cases is recommended.

Novel targeted therapies in chordoma: an update

Chordomas are rare, locally aggressive skull base neoplasms known for local recurrence and not-infrequent treatment failure. Current evidence supports the role of maximal safe surgical resection. In addition to open skull-base approaches, the endoscopic endonasal approach to clival chordomas has been reported with favorable albeit early results. Adjuvant radiation is prescribed following complete resection, alternatively for gross residual disease or at the time of recurrence. The modalities of adjuvant radiation therapy reported vary widely and include proton-beam, carbon-ion, fractionated photon radiotherapy, and photon and gamma-knife radiosurgery. As of now, no direct comparison is available, and high-level evidence demonstrating superiority of one modality over another is lacking. While systemic therapies have yet to form part of any first-line therapy for chordomas, a number of targeted agents have been evaluated to date that inhibit specific molecules and their respective pathways known to be implicated in chordomas. These include EGFR (erlotinib, gefitinib, lapatinib), PDGFR (imatinib), mTOR (rapamycin), and VEGF (bevacizumab). This article provides an update of the current multimodality treatment of cranial base chordomas, with an emphasis on how current understanding of molecular pathogenesis provides a framework for the development of novel targeted approaches.

Indicators of a Reduced Intercarotid Artery Distance in Patients Undergoing Endoscopic Transsphenoidal Surgery

Objective To identify clinicopathologic factors associated with a reduced intercarotid distance (ICD) and subgroups at risk for internal carotid artery injury during transsphenoidal surgery. Design A retrospective case-control study. Setting This study was conducted at the McGill University Health Centre, a university-affiliated tertiary care center. Participants Patients with a sellar or parasellar tumor and nontumor controls were included in the study. Main Outcome Measures The smallest distance between the internal carotid arteries at the clival, cavernous, and paraclinoid segments on coronal magnetic resonance imaging was measured. Demographic profiles, cephalometric measurements, tumor dimensions, and sphenoid configuration were assessed as potential determinants of the ICD. Results A total of 212 cases and 34 controls were analyzed. Widening of the ICD at the three segments of the internal carotid arteries was found in patients with pituitary macroadenomas (p < 0.01). Patients with a growth hormone-secreting adenoma had a markedly reduced ICD at the clivus compared with controls (1.59 cm versus 1.77 cm; p = 0.02; 95% confidence interval [CI], 0.03-0.32). The paraclinoid ICD was reduced in patients with an anterior fossa meningioma (1.24 cm versus 1.33 cm; p = 0.04; 95% CI, 0.01-0.45). Conclusion Identifying clinicopathologic factors affecting the ICD can help surgeons recognize constraints to endoscopic access of the skull base and avoid inadvertent arterial injury.

Synchronous esthesioneuroblastoma and growth-hormone-secreting pituitary macroadenoma: combined open and endoscopic management

Background Esthesioneuroblastoma is an uncommon malignant neoplasm that arises from the olfactory neuroepithelium. In this article we report a case of esthesioneuroblastoma presenting concomitantly with a growth-hormone (GH)-secreting pituitary macroadenoma. Results A 52 year old woman underwent surgery for suspected nasal polyps. Intralesional debulking of an intranasal tumor disclosed a low-grade esthesioneuroblastoma. Magnetic resonance imaging (MRI) demonstrated a large nasal and intracranial tumor, in addition to a separate sellar and suprasellar tumor. The patient was frankly acromegalic. She underwent a first-stage gross total resection of the esthesioneuroblastoma via a combined extended subfrontal and extended endonasal approach, followed by focused radiation therapy. She then returned for endoscopic removal of the GH-secreting pituitary macroadenoma. Conclusion The combined open and endoscopic management of this patient is described and a review of the literature presented. To our knowledge this is the first case of synchronous esthesioneuroblastoma and macroadenoma, in this case GH secreting, described in the literature.

Are the new automated methods for bone age estimation advantageous over the manual approaches?

Bone Age Assessment (BAA) is performed worldwide for the evaluation of endocrine, genetic and chronic diseases, to monitor response to medical therapy and to determine the growth potential of children and adolescents. It is also used for consultation in planning orthopedic procedures, for determination of chronological age for adopted children, youth sports participation and in forensic settings. The main clinical methods for skeletal bone age estimation are the Greulich and Pyle (GP) and the Tanner and Whitehouse (TW) methods. Seventy six per cent (76%) of radiologists or pediatricians usually use the method of GP, 20% that of TW and 4% other methods. The advantages of using the TW method, as opposed to the GP method, are that it overcomes the subjectivity problem and results are more reproducible. However, it is complex and time consuming; for this reason its usage is just about 20% on a world-wide scale. Moreover, there are some evidences that bone age assignments by different physicians can differ significantly. Computerized and Quantitative Ultrasound Technologies (QUS) for assessing skeletal maturity have been developed with the aim of reducing many of the inconsistencies associated with radiographic investigations. In spite of the fact that the volume of automated methods for BAA has increased, the majotity of them are still in an early phase of development. QUS is comparable to the GP based method, but there is not enough established data yet for the healthy population. The Authors wish to stimulate the attention on the accuracy, reliability and consistency of BAA and to initiate a debate on manual versus automated approaches to enhance our assessment for skeletal matutation in children and adolescents.

Endocrine check-up in adolescents and indications for referral: A guide for health care providers

The American Academy of Pediatrics recommends that young people between the ages of 11 and 21 years should be seen annually by their pediatricians, since annual checkups can be an important opportunity for health evaluation and anticipatory guidance. Parents of infants and young children are accustomed to regularly visiting a pediatrician for their child's checkups. Unfortunately, when children reach the teen years, these annual checkups may decrease in frequency. In routine check-ups and medical office visits, particular attention should be paid to the possibility of a developmental or endocrine disorder. Early diagnosis and treatment may prevent medical complications in adulthood and foster age-appropriate development. Our purpose is to acquaint readers with the concept, based on current scientific understanding, that some endocrine disorders may be associated with a wide range of deleterious health consequences including an increased risk of hypertension and hyperlipidemia, increased risk of coronary artery disease, type 2 diabetes, significant anxiety and lack of self-esteem. Understanding the milestones and developmental stages of adolescence is essential for pediatricians and all other health providers who care for adolescents. Treating adolescents involves knowledge of a variety of medical, social and legal information; in addition, close working relationships must be established within the adolescent's network to create an effective care system. In summary, we underline the importance of a periodic endocrine checkup in adolescents in order to identify endocrine problems early and develop an approach to treatment for those patients who need help during this time. Indications for endocrine referral for professional and other healthcare providers are also included. These lists are clearly not intended to be comprehensive, but will hopefully serve as a guide for specific clinical circumstances.

Hand X-ray in pediatric endocrinology: Skeletal age assessment and beyond

Skeletal age assessment (SAA) is a clinical procedure which is used in determining the SA of children and adolescents. Bone development is influenced by a number of factors, including nutrition, hormonal secretions, and genetics. There are several factors to be borne in mind when using methods of assessing skeletal maturity. These include: Variability among methods, degree of variability in the estimation of skeletal maturation, sources of low accuracy, and dispersion of the values of skeletal maturation. Currently, the main clinical methods for SAA are the Greulich and Pyle (GP) and Tanner and Whitehouse (TW) methods. The GP method has the advantage of being quick and easy to use. A well-trained radiologist takes few minutes to determine the bone age (BA) from a single hand radiograph. The method of TW, however, seems to be more reliable than the GP method. In recent years, the increasing speed in computer sciences and reduction of their cost has given the opportunity to create and use computerized BA estimation system. Despite the fact that the number of automated systems for BAA have increased, most are still within the experimental phase. The use of automated BA determination system, cleared for clinical use in Europe (BoneXpert), has been validated for various ethnicities and children with endocrine disorders. Ultrasound imaging has some limitations that include operator dependence, lower intra-rater and inter-rater reliability of assessment and difficulties with standardization of documentation and imaging transfer. Magnetic resonance imaging (MRI) is noninvasive alternative tool for SA assessment in children. However, few studies have been reported on this topic, and further research is needed to evaluate the reliability and validity of MRI BAAs. In conclusion, at present radiographic methods for the assessment of BA remain the gold standards. Whatever method one adopts, it is essential to minimize the causes of imprecision by taking care to consider the quality of the X-ray. Moreover, it is imperative to assume a correct hand positioning because poor positioning can change the appearance of some bones. It is also preferable to employ scoring methods to these techniques and percentiles rather than BA in years and months. In addition, the possible differences in maturation among different population should be kept in mind.

Analysis of Potential Determinants of a Reduced Intercarotid Distance in Patients Undergoing Endoscopic Transsphenoidal Surgery

Objectives:

(1) Evaluate the anatomic variability of the distance between the internal carotid arteries (ICA) at the paraclival, intracavernous, and paraclinoid segments in normal variants and in patients with sellar or parasellar lesions. (2) Identify clinicopathologic factors associated with a reduced intercarotid distance (ICD) and identify subgroups at higher risk for ICA injury during endoscopic skull base surgery.

Methods:

A retrospective case-control study was performed at an academic tertiary care center. The smallest distance between the ICAs at the paraclival, intracavernous. and paraclinoid segments on coronal T2-weighted magnetic resonance imaging was measured in patients with sellar or parasellar tumors and in nontumor controls. Factors such as demographic profiles, cephalometric measurements, tumor dimensions, and sphenoid configuration were assessed as potential predictors of the ICD.

Results:

In total, 154 cases and 34 controls were analyzed. Patients with growth hormone (GH) secreting adenomas had a markedly reduced ICD at the paraclival segment as compared to controls (1.59 cm and 1.77 cm, respectively; P = .02; 95% confidence interval [CI] [0.03-0.32]). The paraclinoid ICD was reduced in patients with a planum sphenoidale meningioma (1.09 cm and 1.33 cm, respectively; P = .04; 95% CI [0.01-0.45]). The transverse dimension of pituitary adenomas was linearly correlated to the ICD ( P < .001). No narrowing of the ICD was associated with sphenoid configuration or cephalometric measurements.

Conclusions:

Patients with a GH secreting adenoma or planum sphenoidale meningioma had a reduced ICD. Identifying these populations can help surgeons recognize constraints imposed by a reduced ICD to endoscopic access of the skull base and avoid inadvertent ICA injury.