Administering 25-hydroxyvitamin D3 in vitamin D-deficient young type 1A diabetic patients reduces reactivity against islet autoantigens

BACKGROUND & AIMS

We investigated whether improving 25-hydroxyvitamin D status in young type 1A diabetic patients reduces reactivity of peripheral blood mononuclear cells against islet autoantigens and associates with beta-cell functional changes.

METHODS

Eight patients with 25-hydroxyvitamin D deficiency (<20 ng/ml), out of 15 consecutive young type 1A diabetic subjects received 25-hydroxyvitamin D3 to achieve and maintain levels above 50 ng/ml for up to one year. Peripheral blood mononuclear cell reactivity (Interferon-γ spots) against beta-cell autoantigens (glutamic acid decarboxylase 65-kD isoform, proinsulin and tyrosine phosphatase-like protein IA-2) and C-peptide during mixed meal were assessed before and after 25-hydroxyvitamin D3 replenishment.

RESULTS

Target 25-hydroxyvitamin D blood levels were safely reached and maintained. Peripheral blood mononuclear cell reactivity against glutamic acid decarboxylase 65-kD isoform (3.8 ± 4.0 vs. 45 ± 16) and proinsulin (3.5 ± 3.2 vs. 75 ± 51) decreased significantly (p < 0.001 and p < 0.02) upon 25-hydroxyvitamin D3 replenishment, which was correlated with 25-hydroxyvitamin D concentrations. C-peptide values remained stable after one year of treatment.

CONCLUSIONS

Safely restored and maintained 25-hydroxyvitamin D levels associated with reduced peripheral blood mononuclear cell reactivity against beta-cell autoantigens with no significant decrease of beta-cell function in this cohort of patients.

Vitamin D status and predictors of hypovitaminosis D in Italian children and adolescents: a cross-sectional study

Hypovitaminosis D affects children and adolescents all around the world. Italian data on vitamin D status and risk factors for hypovitaminosis D during pediatric age are lacking. Six hundred fifty-two children and adolescents (range 2.0-21.0 years) living in the northwestern area of Tuscany were recruited at the Department of Pediatrics, University Hospital Pisa. None of them had received vitamin D supplementation in the previous 12 months. 25-hydroxyvitamin D (25-OH-D) and parathyroid hormone (PTH) levels were analyzed in all subjects. Severe vitamin D deficiency was defined as serum levels of 25-OH-D<25.0 nmol/L (10.0 ng/mL) and vitamin D deficiency a<50.0 nmol/L (20.0 ng/mL). Serum 25-OH-D levels of 50.0-74.9 nmol/L (20.0-29.9 ng/mL) indicated vitamin D insufficiency, whereas 25-OH-D levels ≥ 75.0 nmol/L (30.0 ng/mL) were considered sufficient. Hypovitaminosis D was defined as 25-OH-D levels<75.0 nmol/L (30.0 ng/mL). The median serum 25-OH-D level was 51.8 nmol/L, range 6.7-174.7 (20.7 ng/mL, range 2.7-70.0), with a prevalence of vitamin D deficiency, insufficiency, and sufficiency of 45.9, 33.6, and 20.5 %, respectively. The prevalence of severe vitamin D deficiency was 9.5 %. Adolescents had lower median 25-OH-D levels (49.8 nmol/L, range 8.1-174.7; 20.0 ng/mL, range 3.2-70.0) than children (55.6 nmol/L, range 6.8-154.6; 22.3 ng/mL, range 2.7-61.9, p=0.006). Non-white individuals (n=37) had median serum 25-OH-D levels in the range of deficiency (28.2 nmol/L, range 8.1-86.2; 11.3 ng/mL, range 3.2-34.5), with 36/37 having hypovitaminosis D. Logistic regression showed significant increased risk of hypovitaminosis D in the following: blood samples taken in winter (odds ratio (OR) 27.20), spring (OR 26.44), and fall (OR 8.27) compared to summer; overweight (OR 5.02) and obese (OR 5.36) subjects compared to individuals with normal BMI; low sun exposure (OR 8.64) compared to good exposure, and regular use of sunscreens (OR 7.06) compared to non-regular use. Gender and place of residence were not associated with vitamin D status. The 25-OH-D levels were inversely related to the PTH levels (r=-0.395, p<0.0001). Sixty-three out of the 652 (9.7 %) subjects showed secondary hyperparathyroidism.

CONCLUSION

Italian children and adolescents who were not receiving vitamin D supplementation had high prevalence of hypovitaminosis D. Careful identification of factors affecting vitamin D status is advisable to promptly start vitamin D supplementation in children and adolescents.

C-type natriuretic peptide plasma levels are reduced in obese adolescents

The high prevalence of obesity in children may increase the magnitude of lifetime risk of cardiovascular disease (CD). At present, explicit data for recommending biomarkers as routine pre-clinical markers of CD in children are lacking. C-type natriuretic peptide (CNP) is assuming increasing importance in CD; in adults with heart failure, its plasma levels are related to clinical and functional disease severity. We have previously reported five different reference intervals for blood CNP as a function of age in healthy children; however, data on plasma CNP levels in obese children are still lacking. Aim of this study was to assess CNP levels in obese adolescents and verify whether they differ from healthy subjects. Plasma CNP was measured in 29 obese adolescents (age: 11.8 ± 0.4 years; BMI: 29.8 ± 0.82) by radioimmunoassay and compared with the reference values of healthy subjects. BNP was also measured. Both plasma CNP and BNP levels were significantly lower in the obese adolescents compared to the appropriate reference values (CNP: 3.4 ± 0.2 vs 13.6 ± 2.3 pg/ml, p<0.0001; BNP: 18.8 ± 2.6 vs 36.9 ± 5.5 pg/ml, p=0.003). There was no significant difference between CNP values in males and females. As reported in adults, we observed lower plasma CNP and BNP levels in obese children, suggesting a defective natriuretic peptide system in these patients. An altered regulation of production, clearance and function of natriuretic peptides, already operating in obese adolescents, may possibly contribute to the future development of CD. Thus, the availability of drugs promoting the action of natriuretic peptides may represent an attractive therapeutic option to prevent CD.

Intrafamilial spread of enterovirus infections at the clinical onset of type 1 diabetes

BACKGROUND

At the clinical onset of type 1 diabetes mellitus (T1D), enterovirus (EV) infections are suspected to play a role. EVs in blood are seen as a possible biomarker of T1D. EV infections may occur in temporal and geographic clusters and may spread within families.

OBJECTIVE

We checked whether EVs were present in the blood of newly diagnosed diabetic probands and of their consenting siblings and parents. We aimed at evaluating the frequency of EV infection, whether infections were spreading within families, and which EV species were involved.

SUBJECTS AND METHODS

Blood was drawn from 24 newly diagnosed diabetic children/adolescents and their family members (20 siblings and 41 parents). Blood donors and non-diabetic children/adolescents diagnosed with overweight/short stature were used as controls. RNA was extracted from plasma/leukocytes. Reverse-transcription polymerase chain reaction assays capable of detecting virtually all EV types and of giving preliminary species identification were used.

RESULTS AND CONCLUSIONS

EV genomes were found in the blood of 19 of 24 (79%) diabetics, 12 of 20 (60%) non-diabetic siblings, 26 of 41 (63%) parents, and 1 of 29 (3%) pediatric controls. EVs of the A, B, C, and D species were detected, with the B and C species more prevalent. Probands and virus-positive members of each family consistently shared the same EV species. During follow-up, 4 of 20 (20%) siblings of diabetic probands developed T1D with a latency of 3-25 months. In conclusion, infection by different EV species is highly prevalent at the clinical onset and extends to family members. EV may represent a precipitating factor of T1D. However, the disease only develops in a subset of infected individuals.

Circulating endothelial progenitor cells and large artery structure and function in young subjects with uncomplicated type 1 diabetes

Background

Carotid intima-media thickness (IMT), indices of large artery stiffness and measures of endothelium function may be used as markers of early atherosclerosis in type 1 diabetes mellitus (T1DM). The aim of the present study was to compare the indices of large artery structure and function as well as endothelial function and regenerating capacity between adolescents with T1DM and healthy control of similar age. In addition, the associations of different vascular measures with endothelial progenitor cells (EPCs), glyco-metabolic control and serum levels of advanced glycation endproducts (AGEs), soluble receptors for AGEs (sRAGE) and adiponectin were evaluated.

Methods

Sixteen uncomplicated young T1DM patients (mean age 18 ± 2 years, history of disease 11 ± 5 years, HbA1c 7.7 ± 1.1%) and 26 controls (mean age 19 ± 2 years) were studied. A radiofrequency-based ultrasound system (Esaote MyLab 70) was used to measure carotid IMT and wave speed (WS, index of local stiffness), applanation tonometry (PulsePen) was applied to obtain central pulse pressure (PP) and augmentation index (AIx), and carotid-femoral pulse wave velocity (PWV, Complior) was used as index of aortic stiffness. Peripheral endothelium-dependent vasodilation was determined as reactive hyperemia index (RHI, EndoPAT). Circulating EPCs, glycometabolic profile, AGEs (autofluorescence method), sRAGE and adiponectin were also measured.

Results

After adjusting for age, sex and blood pressure, T1DM adolescents had significantly higher carotid IMT (456 ± 7 vs. 395 ± 63 μm, p < 0.005), carotid WS (p < 0.005), PWV (p = 0.01), AIx (p < 0.0001) and central PP (p < 0.01) and lower EPCs (p = 0.02) as compared to controls. RHI was reduced only in diabetic patients with HbA1c ≥7.5% (p < 0.05). In the overall population, EPCs were an independent determinant of carotid IMT (together with adiponectin), while fasting plasma glucose was an independent determinant of carotid WS, AIx and central PP.

Conclusions

Our findings suggest that young subjects with relatively long-lasting T1DM have a generalized preclinical involvement of large artery structure and function, as well as a blunted endothelium regenerating capacity. Hyperglycemia and suboptimal chronic glycemic control seem to deteriorate the functional arterial characteristics, such as large arteries stiffness, wave reflection and peripheral endothelium-dependent vasodilation, whereas an impaired endothelium regenerating capacity and adiponectin levels seem to influence arterial structure.

Usefulness of serum insulin-like growth factor I assessment in the diagnosis of childhood-onset growth hormone deficiency

The diagnosis of childhood-onset growth hormone (GH) deficiency (GHD) is not straightforward, requiring a comprehensive clinical, anthropometric, biochemical, endocrine, and neuroradiological assessment. Although pharmacological GH stimulation tests are still considered the gold standard for GHD diagnosis, they are burdened by both poor specificity and side effects. The measurement of insulin-like growth factor I (IGF-I), due to its close GH dependency, was proposed for diagnosing GHD. However, a number of factors may affect the measurements. Herein, we propose an algorithm based on both IGF-I determination and anthropometry, aimed at simplifying the diagnosis of GHD in prepubertal children.

Nuclear damage in peripheral lymphocytes of obese and overweight Italian children as evaluated by the gamma-H2AX focus assay and micronucleus test

Childhood obesity, often characterized by a chronic low-grade inflammation, has been associated with an increased risk of developing some types of cancer later in life. Nuclear γ-H2AX foci represent the first detectable response of cells to DNA tumorigenesis lesions, such as the double-strand breaks (DSBs). An excess of micronucleated peripheral lymphocytes was found in subjects with cancer or inflammation-based diseases. We set out to investigate the expression of genome damage, from DNA lesions to chromosome mutations (micronuclei), in overweight and obese children. Using the γ-H2AX focus assay and micronucleus (MN) test, we analyzed peripheral lymphocytes from 119 Italian children classified as normal weight (n=38), overweight (n=20), or obese (n=61). Cultures treated with bleomycin (BLM) were also set up for each child in both assays to check functioning of the apparatus that ensures DNA integrity. We measured serum TNF-α, IL-6, and C-reactive protein (CRP) as markers of inflammation. Overweight and obese children had significantly higher levels of H2AX phosphorylation (0.0191±0.0039 and 0.0274±0.0029 γ-H2AXF/n) and increased MN frequencies (2.30±0.25 and 2.45±0.22‰) than normal-weight children (0.0034±0.0006 γ-H2AXF/n, and 0.92±0.12‰ MN), while all subjects responded to BLM induction, irrespective of their weight status. The fold increase of spontaneous MN frequencies in overweight and obese subjects was 2.5 and 2.7, respectively, well below the corresponding increase in the γ-H2AX foci (5.6- and 8.0-fold, respectively). IL-6 and CRP mean values were significantly higher in obese and overweight children than in controls. Here, we demonstrated that peripheral cells of overweight and obese children showed increased levels of DSBs, which were not completely repaired as part of them has been converted into micronuclei. Characterization of childhood obesity inflammation could be implemented using molecular markers of genome damage.

Etanercept induces improvement of arthropathy in chronic infantile neurological cutaneous articular (CINCA) syndrome

Chronic infantile neurological cutaneous articular (CINCA) syndrome is a rare disorder of unknown aetiology with neonatal onset, characterized by severe arthropathy, persistent skin rash and central nervous system disease. Joint involvement may vary from minimal swelling to destructive arthritis, with inability to stand or walk. The most striking findings of CINCA syndrome are cartilage anomalies with epiphyseal modifications and abnormal ossification, for which a pathogenetic role of tumour necrosis factor-alpha (TNF-alpha) is postulated. We describe a 4-year-old child affected with CINCA syndrome and presenting progressive joint disease, in whom non-steroidal anti-inflammatory drugs (NSAID) and systemic corticosteroidal therapy had been ineffective. Etanercept, anti-TNF-alpha therapy, was administered over a 6-month-period resulting in a dramatic improvement of the arthropathy. This good response to anti-cytokine treatment supports our hypothesis that TNF-alpha might play an important role in the pathogenesis of CINCA syndrome, which needs to be evaluated and confirmed in further studies.

Growth outcome during GnRH agonist treatments for slowly progressive central precocious puberty

BACKGROUND

Gonadotropin-releasing hormone agonists (GnRHa) represent the gold-standard treatment for central precocious puberty (CPP). In CPP children, GnRHa treatment slows bone age progression and preserves adult height (Ht) by suppressing sexual steroid secretion. In some patients, however, GnRHa induce an inappropriate growth deceleration impairing Ht outcome. Furthermore, slowly progressive CPP (spCPP) forms were reported which do not need GnRHa treatment.

METHODS

We evaluated the growth outcome of 26 spCPP girls treated with triptorelin (TR) and 21 with leuprorelin acetate (LA) for 36.5 +/- 0.7 months.

RESULTS

GnRHa treatment induced a progressive growth deceleration in both spCPP groups. No difference in bone maturation was detected (p > 0.05; TR vs. LA group), however compared to LA, TR treatment resulted in significantly higher Ht after 24 months (p < 0.05; LA vs. TR group). Although target height (TH) standard deviation score (SDS) and predicted adult height (PAH)-SDS at diagnosis were similar in both spCPP groups (p > 0.05; LA vs. TR group), final height (FH-SDS) was lower in LA-treated subjects (p < 0.05; LA vs. TR group). In both spCPP groups, FH-SDS was significantly lower than TH-SDS (p < 0.001) but not lower than PAH-SDS at diagnosis (p > 0.05). Ht-SDS correlated with 17beta-estradiol (E(2)) blood levels in both spCPP groups (p < 0.0001) throughout GnRHa treatment, and E(2) values were higher in the TR- than in the LA-treated patients during the 12 months after GnRHa administration (p < 0.05; LA vs. TR group). GnRHa-induced E(2) secretion and Ht-SDS at GnRHa withdrawal correlated positively with FH (p < 0.01 and p < 0.001, respectively).

CONCLUSIONS

The effectiveness of GnRHa treatment in improving FH in spCPP girls was doubtful.

Multiple malaria infection in a pregnant woman from Nigeria: detection by multiplex PCR

For the last 100 years, diagnosis of malaria has been based on examination of Giemsa-stained thick and thin blood films under the microscope. This is a time-consuming procedure which often fails to correctly diagnose the infecting species--especially when carried out by inexperienced technicians or when blood levels of parasite are low. Rapid Diagnostic Tests (RDTs) for antigen detection can distinguish between Plasmodium falciparum and Plasmodium vivax but cannot identify the species present in mixed infections. In the case reported here we used multiplex PCR to investigate suspected mixed infection in a pregnant woman from Nigeria. The results suggest that the method used is highly specific and can be very sensitive and that it has several advantages with respect to microscopy and RTDs.

Cranio-Spinal Subdural Empyema due toS. Intermedius: a Case Report

BACKGROUND AND PURPOSE

Subdural empyema represents a loculated infection between the dura and the arachnoid. It has been described either intracranially or in the spinal canal, the latter localization being quite rare. While treatment guidelines for a single (either brain or spinal) localization of a subdural empyema are more or less established, its management when a massive involvement of CNS is evident represents a challenge.

METHODS

The authors describe a unique case of a 65-year-old woman having a massive involvement of the entire CNS with multiple localizations, both intracranial and spinal. Early diagnosis was obtained through brain CT scans followed by cranio-spinal contrast enhanced MRI scans. Patient was treated with external ventricular drainage and suboccipital craniectomy, while on antibiotic therapy.

RESULTS

Patient's neurological condition gradually improved. By the end of the eighth hospital week, she was discharged without any neurological deficit.

CONCLUSIONS

Spinal subdural empyema and brain subdural empyema are not always, as in our case, two different entities. Prompt diagnosis and treatment constitute the major variables affecting outcome.

Increased TNF-alpha production by peripheral blood mononuclear cells in patients with Krabbe's disease: effect of psychosine

BACKGROUND

Inflammatory and/or immune activation occurs both in animal models (twitcher mice) and in the brain of patients with Globoid cell leukodystrophy (GLD) or Krabbe's disease (KD). In this study we evaluated in vitro the cytokine profile of KD patients and the effect of psychosine, the toxic metabolite which plays a role in the demyelination process in these patients.

MATERIALS AND METHODS

We studied cytokine production by peripheral blood mononuclear cells (PBMCs) isolated from four KD patients, diagnosed on the basis of clinical criteria. Cells were cultured and stimulated with appropriate agents and the supernatants collected before and after the addition of psychosine. Tumour necrosis factor-alpha (TNF-alpha), interleukin-8 (IL-8) and monocyte chemoattractant factor (MCP)-1) production was evaluated (ELISA method) and compared with a group of 10 normal subjects.

RESULTS

We found a significant increase of TNF-alpha release by PBMCs of KD patients compared with healthy subjects; TNF-alpha production was significantly increased after LPS addition. Psychosine was able to induce a further significant increase (P < 0.05) only in cells obtained from KD patients and not from control subjects. No changes were found in IL-8 and MCP-1 production.

CONCLUSIONS

The increased TNF-alpha production permits us to confirm the presence of an inflammatory-immune stimulus in KD patients, which may be induced and potentiated by the pathogenetic metabolite psychosine.

Serum macrophage migration inhibitory factor (MIF) in the intercritical phase of hereditary periodic fevers and its relationship with the MIF-173G/C polymorphism

OBJECTIVES

To examine the association of the -173 single-nucleotide G/C polymorphism of the macrophage migration inhibitory factor gene (MIF) and serum macrophage migration inhibitory factor (MIF) concentrations in a group of Italian patients with hereditary periodic fevers (HPF), tested during a symptom-free phase of their disease.

METHODS

Genomic DNA for MIF and serum MIF were evaluated in 22 patients with HPF and compared with healthy controls of the same ethnic group. The MIF-173G/C polymorphism was genotyped using polymerase chain reaction (PCR) and visualized by ethidium bromide staining. Serum MIF levels were measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

MIF-173*C allele frequency and MIF serum concentrations were significantly higher in patients with HPF than in controls, with no statistically significant difference between familial Mediterranean fever (FMF) and hyperimmunoglobulinaemia D/periodic fever syndrome (HIDS) and no correlation with specific MIF genotypes.

CONCLUSIONS

The MIF-173*C allele was found more frequently in patients with HPF than in controls and MIF serum concentrations were considerably elevated in attack-free phases, suggesting a persistent state of subclinical cytokine activation with MIF involvement in the autoinflammatory cascade.

Thyroid outcome during long-term gonadotropin-releasing hormone agonist treatments for idiopathic precocious puberty

PURPOSE

To examine the effects of long-term gonadotropin-releasing hormone agonist (GnRHa) administration on thyroid function in children affected by central precocious puberty (CPP).

METHODS

We retrospectively evaluated circulating thyroid hormones in 73 GnRHa-treated girls who were diagnosed with idiopathic CPP. Monthly depot injections (.1 mg/body kg) of leuprorelin acetate (LA) and of triptorelin (TR) were continuously administered for 40.4 +/- .7 months to 34 and 39 CPP patients, respectively. Serum levels of thyrotropin (TSH), free triiodothyronine (FT3), free thyroxine (FT4), and thyroid antibodies were determined at baseline and after 6, 12, 18, 24, 30, 36, and 40 months of GnRHa administration.

RESULTS

While there was no difference in FT4 release (p > .05), FT3 levels significantly declined during both LA and TR treatments from untreated baseline (p < .05). Opposite to circulating FT4 and FT3 values (p > .05), FT3/FT4 ratio was significantly different among LA and TR groups (p < .05). Both GnRHa treatments did not affect TSH secretion (p > .05); however, LA induced lower TSH values than TR (p < .05).

CONCLUSIONS

There is no evidence of thyroid dysfunction during both GnRHa treatments, though changes in TSH, FT3, and FT3/FT4 ratios were noted. Finally, monitoring of thyroid activity during GnRHa administration is not required.

17beta-hydroxysteroid dehydrogenase-3 deficiency: a rare endocrine cause of male-to-female sex reversal

Deficiency of 17beta-hydroxysteroid dehydrogenase type 3 (17beta-HSD3), due to mutations in the gene encoding the enzyme, results in a rare autosomal recessive form of male-to-female sex reversal. Mutated genes encode an abnormal enzyme with absent or reduced ability to convert Delta4-androstenedione to testosterone in the testis. Affected individuals are genetically males who developed internal male Wolffian structures but female external genitalia. Such individuals are usually raised as females and diagnosis is made at puberty, when they show virilization. Correct diagnosis is mandatory to optimize treatment and follow-up. In the present paper we report the clinical history, endocrine evaluation and molecular genetics of a prepubertal girl affected by 17beta-HSD3 deficiency, in whom an erroneous diagnosis of androgen insensitivity syndrome was made. The clinical, endocrine and genetic features of 17beta-HSD3 deficiency are also reviewed.

Assessment of serum IGF-I concentrations in the diagnosis of isolated childhood-onset GH deficiency: a proposal of the Italian Society for Pediatric Endocrinology and Diabetes (SIEDP/ISPED)

The diagnosis of GH deficiency (GHD) is based on the measurement of peak GH responses to pharmacological stimuli. Pharmacological stimuli, however, lack precision, accuracy, are not reproducible, are invasive, non-physiological and some may even be hazardous. Furthermore, different GH commercial assays used to measure GH in serum yield results that may differ considerably. In contrast to GH, IGF-I can be measured on a single, randomly-obtained blood sample. A review of the available data indicates that IGF-I measurement in the diagnosis of childhood-onset isolated GHD has a specificity of up to 100%, with a sensitivity ranging from about 70 to 90%. We suggest an algorithm in which circulating levels of IGF-I together with the evaluation of auxological data, such as growth rate and growth, may be used to assess the likelihood of GHD in pre-pubertal children.

Cross-sectional reference data for phalangeal quantitative ultrasound from early childhood to young-adulthood according to gender, age, skeletal growth, and pubertal development

Bone mineral status by phalangeal quantitative ultrasound (QUS, DBM Sonic, IGEA, Carpi, Modena, Italy) was examined in 3044 (1513 males and 1531 females) healthy subjects, aged 2-21 years. The aim of the study was to provide a reference database for phalangeal QUS parameters, amplitude-dependent speed of sound (AD-SoS) and bone transmission time (BTT), both expressed as centiles and Z score, according to gender, age, height, weight, body mass index (BMI), and pubertal stage to be used for estimating bone mineral status in patients with disorders of growth or of bone and mineral metabolism. In both sexes, AD-SoS and BTT increased significantly (P<0.0001) according to all the anthropometric variables. Females showed higher values than males in the age groups 9-14 for AD-SoS (P<0.04-P<0.0001) and in the age groups 11-13 for BTT (P<0.02). Males had higher BTT values than females in the age groups 6-8 and 15-21 (P<0.04-P<0.0001). AD-SoS was higher (P<0.02-P<0.0001) in females than in males at pubertal stages 2, 3, and 4, but it was higher (P=0.001) in males compared with females at pubertal stage 5. BTT was higher in males than females at pubertal stages 1 (P<0.0001), 2 (P<0.01), and 5 (P<0.0001). In both sexes, AD-SoS and BTT were significantly correlated between them (r=0.92, P<0.0001) and with all the anthropometric variables (r=0.53-r=0.85, P<0.0001). Age, weight, BMI, and pubertal stage were independent predictors of AD-SoS in males; age and pubertal stage were independent predictors of AD-SoS in females. In both sexes, height and pubertal stage, and also age only in females, were independent predictors of BTT. In conclusion, our data show that gender, age, height, and timing of sexual maturation are main determinants of bone structure and geometry, and that both these two processes may be captured by phalangeal QUS. It may be a useful tool to assess bone mineral status from early childhood to young-adulthood with a very small confounding effect related to bone sizes and without exposing the subjects to a source of radiation.

Analysis of bone mineral density and turnover in patients with cystic fibrosis: associations between the IGF system and inflammatory cytokines

BACKGROUND

Cystic fibrosis (CF) patients present an increased risk of osteoporosis, and increased fracture rate. Several factors have been identified as modulators of bone metabolism and bone mineral density (BMD).

AIMS

To evaluate BMD and serum markers of bone turnover and establish their relationships with serum concentrations of interleukin (IL)-1beta, IL-6, tumour necrosis factor (TNF)-alpha, IGF-I, IGF-II, IGF binding protein (IGFBP)-2, IGFBP-3, and parathyroid hormone (PTH) in young adult CF patients.

METHODS

Seventeen young adult CF patients (4 M, 13 F; mean age: 26.6 +/- 1.1 years) were enrolled in the study and analysed as a whole and as two subgroups according to the Shwachman-Kulczycki score. BMD was assessed at the lumbar spine (L1-L4) by dual energy X-ray absorptiometry (DXA Hologic QDR 2000). Bone turnover was assessed by measuring serum levels of osteocalcin (OC) and serum carboxyterminal propeptide of type I collagen (PICP) as markers of bone formation, and serum cross-linked carboxyterminal telopeptide of type I collagen (ICTP) as a marker of bone resorption. Serum IGFs, IGFBPs, and cytokines were assayed using special commercial kits. Daily calcium intake and weekly physical activity were estimated by questionnaires. Forced expiratory volume in one second was used to assess pulmonary function.

RESULTS

Lumbar BMD was normal, although there was a tendency to be lower in the patients with a lower clinical score. Both OC and PICP were increased, whereas ICTP was normal. Lumbar BMD was positively correlated with pulmonary function. IL-6 and C-reactive protein (markers of inflammation) were inversely correlated with PICP. Serum ICTP levels were correlated with serum IGF-I levels. No significant relationship was detected among lumbar BMD, markers of bone turnover and PTH, IGF-I, IGF-II, IGFBP-2, IGFBP-3, TNF-alpha, IL-1beta, and body mass index Z-score.

CONCLUSIONS

Bone turnover is abnormal in CF patients. Young adult CF patients with satisfying clinical status and nutritional conditions have normal BMD and increased serum OC and PICP levels.

How do environmental estrogen disruptors induce precocious puberty?

Puberty is regulated by the endocrine system. Disruption of that system by exposure to environmental hormone-mimicking substances (i.e. endocrine disruptors) may, therefore, affect this development profoundly. There has been a great secular trend in the earlier timing of puberty such as both puberty onset and menarche age. This is apparently caused by environmental factors such as improved socioeconomic status, better healthcare and improved nutrition. However, part of the phenomenon could be associated with exposure to endocrine disruptors that have intrinsic estrogen activity or increase endogenous sex hormone levels. These estrogen pollutants tend to degrade slowly in the environment, to bioaccumulate in the food chain and to have long half-lives in humans. Because most of environmental chemicals, called estrogen disruptors or xenoestrogens, are toxic and estrogen/antiandrogen active, they can disregulate hypothalamic-pituitary-gonadal axis potentially inducing reproductive disorders. There are several case reports of accidental exposure to estrogenic compounds in cosmetic products, food and pharmaceuticals. The outbreak of epidemics of premature thelarche in some geographical areas has also been suggested to be linked to exposure to estrogen disrupters such as dioxins, furans and organohalogens. We review data on adverse health and reproductive outcomes have been attributed to estrogen disruptors in laboratory animals and in wildlife as well as in humans, specially focusing on the puberty timing.

Prolactin secretion before, during, and after chronic gonadotropin-releasing hormone agonist treatments in children

OBJECTIVE

To examine the effect of long-term administration of GnRH agonists (GnRHa) on PRL secretion in children affected by central precocious puberty (CPP) and growth hormone deficiency (GHD).

DESIGN

Prospective analysis of blood sampling before, during, and after GnRHa treatments.

SETTING

Pediatric endocrine center.

PATIENT(S)

One hundred nineteen and 93 children with a diagnosis of CPP and GHD, respectively.

INTERVENTION(S)

Monthly depot injections of GnRHa drugs (leuprorelin acetate 3.75 mg [LA] and triptorelin 3.75 mg [TR]) administered to CPP and GHD patients for 40 and 24 months, respectively.

MAIN OUTCOME MEASURE(S)

Serum PRL levels at baseline and after 6, 12, 18, 24, 30, 36, and 40 months of treatment with GnRHa were compared between CPP and GHD groups. PRL levels at 6 and 12 months after GnRHa withdrawal were also examined.

RESULT(S)

Although serum PRL levels tended to be higher in TR- than in LA-treated patients, no significant difference in circulating PRL in basal condition and during GnRHa treatment was detected between the CPP and GHD groups. However, five children (3.8%) developed hyperprolactinemia during TR treatment.

CONCLUSION(S)

Although there are no general concerns about GnRHa treatment safety, careful PRL monitoring is required in GnRHa-treated children.

[Evaluation of sexual activity after prostatic surgery for benign prostatic hyperplasia assessed by pre-operative and post-operative questionnaire]

AIM

Different authors showed a 5-40% incidence of erectile dysfunction after prostatic surgery for benign prostatic hyperplasia. The aim of our study was to evaluate the effect of prostatic surgery due to benign prostatic hyperplasia on sexual activity.

METHODS

We evaluated 56 patients (mean age 63 years, range 49-70) who underwent transurethral resection of the prostate (30 patients, mean age 64 years, range 56-70) and open prostatectomy (26 patients, mean age 59 years, range 49-70) with a questionnaire regarding the presence of sexual dysfunction before and 3, 6, 12 months after surgery. All patients were not affected by previous or present metabolic, neurological, cardiovascular diseases.

RESULTS

Twenty percent of the patients with a normal sexual activity before treatment presented erectile dysfunction after surgery. However, 35% of patients with erectile dysfunction before treatment presented an improvement of their erectile function after surgery.

CONCLUSIONS

A high incidence of erectile dysfunction was observed in patients undergoing prostatic surgery. Patients with erectile dysfunction should also recover a normal behaviour after prostatic surgery as well as an improvement of the erectile dysfunction.

Human breast milk and xenoestrogen exposure: a possible impact on human health

Human milk is the best natural and optimal food for neonates with several immunologic, developmental and practical advantages throughout childhood. Although the World Health Organization strongly supports breastfeeding, it recognizes the potential health risks posed by the presence of environmental toxicants in breast milk. Contamination of human milk is widespread and due to decades of inadequately controlled pollution by toxicants, persistent pesticides or chemical solvents. These chemicals tend to degrade slowly in the environment, to bioaccumulate in the food chain and to have long half-lives in humans. Many of these environmental pollutants have estrogen-like activities and, thus they are called environmental estrogen disruptors or xenoestrogens. Certain adverse health and reproductive outcomes are attributed to these chemicals in laboratory animals and in wildlife as well as in humans. Here, we review available data from breast milk monitoring studies suggesting the environmental chemicals that may affect child health through breastfeeding.

High incidence of central precocious puberty in a bounded geographic area of northwest Tuscany: an estrogen disrupter epidemic?

The potential health consequences of human exposure to environmental estrogen disrupters are not known. Because many chemical compounds are environmentally persistent, toxic and estrogen-active, they can dysregulate the hypothalamic-pituitary-gonadal axis, potentially inducing reproductive disorders such as central precocious puberty (CPP). We performed a multi-center analysis of CPP distribution in northwest Tuscany (NWT), an area of 5990 km2 with 1,280,895 inhabitants. Study criteria consisted of recorded CPP diagnoses and prescriptions of gonadotropin-releasing hormone analogs from January 1, 1998 to December 1, 2003. Although similar CPP prevalences were found in four major cities of NWT (Livorno, Lucca, Massa and Pisa) (mean 30.4 per 100,000 children, standard deviation 18.6; p > 0.05), Viareggio area (< 300 km2) with 19,219 child inhabitants (0-14 years of age) had the highest CPP prevalence: more than 161 CPP cases per 100,000 children. Living in Viareggio area significantly increased the risk of CPP (relative risk (RR) 5.73, 95% confidence interval (CI) 3.5-9.3; rate/risk difference 0.133%, p < 0.05). Annual CPP incidence in the Viareggio area was relatively constant and significantly higher than in other NWT areas (RR 5.04, 95% CI 2.3-11.2; rate/risk difference 0.03%, p < 0.05). Indeed, 47% of total NWT cases were distributed in the countryside (300?km2) surrounding Viareggio. Specifically, three villages - Camaiore, Pietrasanta and Stazzema - in Viareggio presented the highest CPP frequency: 216.1, 393.5 and 274.0 CPP cases per 100,000 children, respectively (RR 9.59, 95% CI 1.71-16.6; rate/risk difference 0.26%, p < 0.05). Owing to the definite geographic distribution of CPP and because increasing distance (km) from Pietrasanta rarefied CPP frequency, we suggest environmental factors (e.g. estrogen disrupter pollution) as major CPP determinants in NWT.

Vitamin D status in patients affected by Smith-Lemli-Opitz syndrome

Smith-Lemli-Opitz syndrome (SLOS) is an inborn error of cholesterol biosynthesis characterized by developmental delay and multiple malformations. Some of the patients have skin photosensitivity and therefore tend to avoid direct exposure to sunlight.SLOS patients typically have low concentrations of cholesterol and abnormally high concentrations of its precursor 7-dehydrocholesterol (7-DHC) in biological fluids and tissues. 7-DHC is also a precursor in the cutaneous synthesis of vitamin D. Sunlight exposure plays a major role in this pathway and reactions transforming 7-DHC into vitamin D and then into 25-hydroxyvitamin D are known not to be specifically regulated. The aim of this study was to evaluate vitamin D status in SLOS patients. We measured 25-hydroxyvitamin D and 1,25-dihydroxyvitamin D serum concentrations and markers of calcium metabolism in five SLOS patients. Despite abnormally high concentrations of 7-DHC, circulating concentrations of vitamin D metabolites were not significantly different from appropriate controls matched for sex, age and season of blood collection. The analysis of historical serum samples stored in our laboratory from the same cases plus 10 other SLOS patients further supported these findings. Our data suggest that SLOS patients have a peculiar vitamin D metabolism that protects them from vitamin D intoxication. This appears to be due in most cases to decreased transformation of 7-DHC into 25-hydroxyvitamin D, perhaps depending on reduced sunlight exposure as a consequence of photosensitivity. Possible alternative mechanisms are discussed.

The IGF-1--IGFBPs system in the crevicular fluid: its changes during orthodontic movement

IGF-1 (Insulin-like growth factor-1) is a growth factor whose biological activity at cellular level is regulated by 6 binding proteins (IGFBs); one of them, IGFBP-3, is the most abundant in blood. Both IGF-1 and IGFBP-3 are expressed by bone cells and may be important factors in bone remodelling (1-5). The aims of this study were to evaluate the presence of IGF-1 and IGFBP-3 in crevicular fluid and to assess whether their levels changed during orthodontic tooth movement in patients under orthodontic treatment. Orthodontic movement alters alveolar bone remodelling. Changes in the amounts of IGF-1 and IGFBP-3 in crevicular fluid may reflect changes in alveolar bone remodelling.

Indications and strategies for continuing GH treatment during transition from late adolescence to early adulthood in patients with GH deficiency: the impact on bone mass

GH plays an important role in longitudinal bone growth and maturation during childhood and adolescence. However, GH has important metabolic functions other than bone growth, which become more apparent during young adulthood, when growth has been completed. Indeed, GH deficiency (GHD) in adult life is a recognized clinical syndrome which includes symptoms such as increased central adiposity, decreased lean body mass, reduced bone mineral density (BMD), increased atherogenic risk, cerebrovascular and cardiac morbidity and mortality, and reduced quality of life. As approximately one quarter of the children with GHD should continue GH administration in adulthood, it is important to reconfirm GHD at the end of growth in order to select patients with severe GHD who need to resume GH therapy with an appropriate age-related dosage. Some evidence indicates that most peak bone mass (PBM) is achieved by the end of adolescence but small increases in BMD continue during the period of transition from late adolescence to young adulthood. Some young adults with GHD show a persistent increase of lumbar BMD after the completion of growth even after discontinuation of treatment suggesting a spontaneous progression towards lumbar PBM or a continuing effect of the treatment. The data indicates that adolescents with GHD who do not reach lumbar PBM at the time of discontinuation of GH treatment can achieve a BMD lower than their genetic potential if they are not treated during the transition to young adulthood.

Pubertal changes in biochemical markers of growth

Puberty is a crucial period of life during which dramatic hormonal changes induce notable modifications in linear growth, bone mass and body composition. These changes are associated with variations in some biochemical parameters such as markers of bone turnover and leptin, which may reflect changes in bone growth and fat mass, respectively. Children with growth hormone (GH) deficiency have reduced concentrations of bone markers, which increase during GH administration, while the levels of leptin decrease. There have been few studies analysing the behaviour of bone markers during puberty in GH-treated GH-deficient patients and no studies analysing the behaviour of leptin. Results from a longitudinal study showed that there was no change in serum osteocalcin, carboxy-terminal propeptide of type I procollagen, and cross-linked carboxy-terminal telopeptide of type I collagen levels during puberty in GH-treated GH-deficient children. Some studies have shown that changes in markers of bone turnover and leptin after short-term GH treatment may predict the growth response (at 6-12 months) to GH administration in GH-deficient children. At present, insufficient data are available for the clinical use of these parameters as markers of growth response during pubertal development and as predictors of long-term growth response to GH treatment in children with GH deficiency. Nevertheless, the use of more and possibly new markers might improve the accuracy of growth prediction models in the future.

High grade superficial (G3t1) transitional cell carcinoma of the bladder treated with intravesical Bacillus Calmette-Guerin (BCG)

OBJECTIVES

Immunotherapy with Bacillus Calmette Guerin (BCG) has been widely used recently as primary option for treatment of high grade superficial (G3T1) carcinoma of the bladder. We describe our long term experience of therapy of G3T1 bladder cancer.

METHODS

From January 1982 to December 2000, 785 patients were diagnosed with superficial bladder cancer. All patients underwent preoperative CT scan and transurethral resection of the bladder. Eighty-six patients (11%) had histological high grade superficial bladder cancer infiltrating the lamina propria. This group was treated with the following schedule of BCG Pasteur strain plus maintenance. Four cycles BCG, 6 instillations per cycle, first cycle weekly x 6, second cycle every 2 weeks x 6, third cycle monthly x 6, fourth cycle (maintenance) every 3 months x 6 instillations.

RESULTS

The median follow-up is 91 months (30-197 months). The overall recurrence rate was 35% (30/86). The median time to recurrence was 29 months (5-128 months). Of these patients, 12 (14%) had progression at a median follow-up of 16 months (range 8-58 months). Cystectomy was needed in 8 (9%) patients. Death due to disease occurred in 5/86 (6%) patients. One patient died due to adenocarcinoma at the ureterosigmoidostomy site. Sixty-four (74%) patients are alive at a median follow-up of 71 months (range 28-197 months). Sixty patients (70%) are alive with an intact bladder.

CONCLUSIONS

Treatment with BCG is a feasible conservative therapy for patients with primary G3T1 transitional bladder cancer. Long term results of BCG treatment are excellent. Cystectomy shouldn't be considered first line treatment for high grade superficial carcinoma of the bladder.

Heights, calories and welfare: a new perspective on Italian industrialization, 1854-1913

The height of Italian conscripts was increasing throughout the second half of the 19th century due primarily to an increases in food intake, but also to an improvement in sanitary conditions, and diffusion of primary schooling. The increase in food intake reflects a growth in agricultural production, contrary to the standard series of national accounts. We infer from an improved estimate of agricultural output, and from the increases in physical stature that the timing of the onset of modern economic growth in Italy was substantially different from the conventional Gerschenkronian perspective.

Assessment of bone quality by quantitative ultrasound of proximal phalanges of the hand and fracture rate in children and adolescents with bone and mineral disorders

Bone quality by quantitative ultrasound and fracture rate were assessed in 135 (64 males) children and adolescents aged 3-21 y with bone and mineral disorders such as chronic anticonvulsants or glucocorticoids treatment, juvenile rheumatoid arthritis, celiac disease, paucity of intrahepatic bile ducts, autoimmune hepatitis, genetic diseases, idiopathic juvenile osteoporosis, disuse osteoporosis, beta-thalassemia major, survivors of acute lymphoblastic leukemia, liver transplantation, calcium deficiency, and nutritional or X-linked hypophosphatemic rickets. Amplitude-dependent speed of sound through the distal end of the first phalangeal diaphysis of the last four fingers of the hand was measured by an ultrasound device. In the majority of patients cortical area to total area ratio by metacarpal radiogrammetry (n = 120) and lumbar bone mineral density (BMD) by dual-energy x-ray absorptiometry (n = 99) were also assessed. In patients with X-linked hypophosphatemic rickets radial BMD by single-photon absorptiometry instead of lumbar BMD was measured. Mean values of amplitude-dependent speed of sound, cortical area to total area ratio, lumbar BMDarea, or lumbar BMD corrected for bone sizes estimated by a mathematical model (BMDvolume), as well as mean values of radial BMD in patients with X-linked hypophosphatemic rickets, expressed as z score, were significantly reduced (p < 0.0001) in comparison with their reference values (-1.7 +/- 1.0, -2.0 +/- 0.9, -3.0 +/- 1.3, -1.9 +/- 1.0, -2.7 +/- 0.7, respectively). A positive relationship was found between amplitude-dependent speed of sound and cortical area to total area ratio (r = 0.90, p < 0.0001), lumbar BMDarea (r = 0.62, p < 0.0001), or lumbar BMDvolume (r = 0.66, p < 0.0001). Fifty-two patients (38.5%) had suffered fractures in the 6 mo preceding the bone measurements, the radial distal metaphysis being the most frequent fracture site (28.8%). Mean values of amplitude-dependent speed of sound, cortical area to total area ratio, lumbar BMDarea, or lumbar BMDvolume, expressed as z score, of fractured patients were significantly lower (p < 0.0001) than those of fracture-free patients (-2.2 +/- 1.0 and -1.4 +/- 0.8, -2.6 +/- 0.9 and -1.7 +/- 0.7, -3.5 +/- 1.2 and -2.5 +/- 1.0, -2.5 +/- 1.0 and -1.3 +/- 0.7, respectively). Phalangeal quantitative ultrasound may be a useful method to assess bone quality and fracture risk in children and adolescents with bone and mineral disorders.

Best approach for prostate cancer detection: a prospective study on transperineal versus transrectal six-core prostate biopsy

OBJECTIVES

To compare the efficacy of transperineal versus transrectal six-core prostate biopsy. Transrectal sextant biopsy is the most common method for prostate cancer detection. However, the cancer detection rate with this technique is increasingly considered inadequate. Different prostate biopsy procedures, mainly based on addition of additional transrectal cores to traditional sextant biopsy, have been proposed to increase the cancer diagnosis rate. The efficacy of the transperineal approach has not yet been fully established.

METHODS

In a prospective study, 107 patients with elevated prostate-specific antigen levels (greater than 4.0 ng/mL) underwent prostate biopsy with six transperineal cores, using a "fan" scheme, plus six transrectal cores, according to the sextant technique. The median prostate-specific antigen level was 8.2 ng/mL (range 4.1 to 240).

RESULTS

The overall cancer detection rate was 40% (43 of 107); prostate cancer was found in 38% (41 of 107) of patients with the transperineal approach and in 32% (34 of 107) of patients with the transrectal approach. Of 43 diagnosed cancers, 41 (95%) were found with the transperineal approach and 34 (79%) with the transrectal approach (P = 0.012). No patient had low-grade cancer (Gleason score 2 to 4), 25 patients had intermediate-grade cancer (Gleason score 5 to 6), and 18 patients had high-grade cancer (Gleason score 7 to 10).

CONCLUSIONS

This is the first report comparing in vivo two different approaches to prostate biopsy. Transperineal biopsy seems superior to transrectal biopsy to detect prostate cancer. Both the transperineal and the transrectal approach should be familiar to the urologist who needs to obtain an adequate cancer detection rate. Transrectal sextant biopsy cannot be considered the standard technique for prostate cancer detection.

Human immunodeficiency virus-1 tat induces hyperproliferation and dysregulation of renal glomerular epithelial cells

Human immunodeficiency virus-associated nephropathy (HIVAN) is etiologically related to the viral infection, but the mechanisms of virus-induced renal injury remain undetermined. Peculiar histopathological features of HIVAN are the enhanced proliferation and the loss of differentiation markers of glomerular epithelial cells (podocytes). We found that podocytes were not permissive to HIV-1 replication. In this study we investigated the effects of the HIV-1 regulatory protein Tat on primary cultures and on a continuous line of podocytes. Our results demonstrated that Tat induced hyperproliferation of these cells in a dose-dependent manner. This activity was primarily mediated by the basic domain of the viral protein. Proteoglycans were required for this phenomenon because Tat-induced increase of podocyte growth was significantly impaired by inhibition of proteoglycan synthesis with beta-D-xyloside. In podocyte cultures Tat promoted both the transcription and the release of basic fibroblast growth factor, which contributed to the enhanced cell proliferation. Moreover, Tat deregulated the podocyte phenotype causing down-regulation of maturity markers such as WT-1 and synaptopodin, alteration of cytoarchitecture, and impairment of permselectivity. Together, these results demonstrate that the interaction of extracellular Tat with podocytes can induce alterations that mimic the pathological changes of podocytes detected in HIVAN.

Effect of celiac disease and gluten-free diet on growth hormone-binding protein, insulin-like growth factor-I, and insulin-like growth factor-binding proteins

Failure to thrive is common in children with celiac disease. As alterations in the growth hormone-insulin-like growth factor I (GH-IGF-I) growth axis have been reported in these patients, we studied the behavior of growth hormone-binding proteins (GH-BPs I and II), IGF-I and its binding proteins in 14 children with celiac disease, either before or after a 6-month gluten-free diet. GH-BP II levels were significantly lower in patients during the active phase of the disease than after the diet or in comparison with control subjects, appropriate for age and sex. There was no difference in the GH-BP-I levels of patients and controls, nor did they change after the diet. Blood levels of IGF-I and IGFBP-3 were reduced before the diet in all patients while ligand blotting showed that IGFBP-2 and 1 were increased. All of these parameters normalized after the gluten-free diet. IGFBP-4 was not greatly influenced by the disease. Furthermore, we found a significant, positive correlation between GH-BP II and IGF-I or IGFBP-3 levels. The height standard deviation scores and body mass indices of the patients improved significantly after the diet. The body mass index significantly and positively correlated with GH-BP II, IGF-I or IGFBP-3 levels. In conclusion, our data show that celiac children had multiple alterations in the growth axis during the active phase of the disease which disappeared during the gluten-free diet.

Catheter-related candidemia caused by Candida lipolytica in a patient receiving allogeneic bone marrow transplantation

Candida lipolytica was recovered from the blood and the central venous catheter in a patient receiving allogeneic bone marrow transplantation. Two C. lipolytica strains from different geographical areas and the ATCC 9773 strain of C. lipolytica were used as controls. C. lipolytica was identified by standard methods. MICs indicated antifungal susceptibilities to amphotericin B, fluconazole, and itraconazole for all strains. In vitro testing and scanning electron microscopy showed that C. lipolytica was capable of producing large amounts of viscid slime material in glucose-containing solution, likely responsible for the ability of the yeast to adhere to catheter surfaces. Restriction fragment length polymorphisms revealed an identical profile for all clinical isolates, unrelated to those observed for the control strains. This finding suggested the absence of microevolutionary changes in the population of the infecting strain, despite the length of the sepsis and the potential selective pressure of amphotericin B, which had been administered to the patient for about 20 days. The genomic differences that emerged between the isolates and the control strains were indicative of a certain degree of genetic diversity between C. lipolytica isolates from different geographical areas.

Risk factors and prognostic indicators of bacterial meningitis in a cohort of 3580 postneurosurgical patients

In order to identify the incidence, risk factors and prognostic indicators of postneurosurgical bacterial meningitis, a 9-y retrospective cohort study was performed. The cohort comprised 3580 individuals who underwent neurosurgical operations at the Department of Neurosurgery of Catholic University, Rome, a 1,700-bed university hospital. We observed 52 episodes of postneurosurgical meningitis, with infection rates of 1.4/100 patients, 0.8/100 operations for craniotomies and 2.6/100 operations for internal cerebrospinal fluid (CSF) shunt or ventriculostomy with external drainage. The overall infection rate decreased from 2.5/100 operations in 1989 to 0.9/100 in 1997 (p = 0.03). Logistic regression analysis indicated that duration of ventriculostomy with external drainage [p < 0.01; odds ratio (OR) = 9.67; 95% confidence interval (CI) = 2.44-38.321 and increasing value of the APACHE III score (p <0.01; OR = 8.51; 95% CI = 2.15-33.68) were independent risk factors for development of meningitis. The overall case fatality rate was 8%. Predictors of mortality were low ( < 1.66 mmol/l) CSF glucose concentration (p = 0.001), increasing value of the APACHE IIl score (p = 0.002) and Gram-negative aetiology (p = 0.003).

The effect of administering gonadotropin-releasing hormone agonist with recombinant-human growth hormone (GH) on the final height of girls with isolated GH deficiency: results from a controlled study

To assess whether delaying puberty may improve final height in GH-deficient children with a poor height prediction at early puberty, we studied 24 girls with isolated GH deficiency until they reached their final height, in a controlled trial. Patients were taking recombinant human GH (r-hGH) substitutive therapy from 2.1 +/- 0.5 yr (0.1 IU/kg.day sc) before entering the study, without showing any improvement in height prediction (149.6 +/- 2.9 vs.150.3 +/- 2.2 cm) on entering puberty. Fourteen girls agreed to add a GnRH agonist (GnRHa) to r-hGH, whereas the remaining 10 decided against it and served as controls. At the start of the study, girls treated with or without GnRHa had similar auxological characteristics (bone age, 10.9 +/- 0.6 vs. 10.7 +/- 1.3 yr; height SD score for chronological age, -1.87 +/- 0.3 vs. -1.82 +/- 0.2), including pubertal development. The GnRHa (long-acting D-Trp-6-GnRH) was given at 60 microg/kg im every 28 days for 1.9 +/- 0.9 yr, then patients continued the r-hGH at the same dosage (3.1 +/- 0.7 yr). At the end of the study, bone age was 16.2 +/- 0.3 yr in GnRHa-treated girls and 16.6 +/- 0.9 yr in controls. Bone maturation was significantly slower during GnRHa (1.4 +/- 0.2 yr), and height SD score for bone age improved (-0.31 +/- 0.3) in comparison with controls (2.6 +/- 0.4 yr and -1.35 +/- 0.3 SD score; P < 0.001 and P < 0.0001, respectively). As a result, girls given the combined therapy reached a final height higher than that of controls (height SD score, -0.39 +/- 0.5 vs. -1.45 +/- 0.2; P < 0.0001) and also higher than their midparental height (-1.1 +/- 0.5; P < 0.0005). Controls reached their midparental height. In conclusion, our results demonstrate that slowing pubertal development with the administration of GnRHa for a limited time may improve final height in GH-deficient girls selected because of a poor height prediction at early puberty.

Bone quality assessment by quantitative ultrasound of proximal phalanxes of the hand in healthy subjects aged 3--21 years

Bone quality by quantitative ultrasound was assessed in 1083 (587 males) healthy white subjects aged 3--21 y. Amplitude-dependent speed of sound (AD-SoS) through the distal end of the first phalanx diaphysis of the last four fingers of the hand was measured by an ultrasound device (DBM Sonic 1200, IGEA, Carpi, Italy). Mean AD-SoS values increased progressively from 3 to 21 y (males, 1845.9--2119.1 m/s, p < 0.0001; females, 1842.3--2098.8 m/s, p < 0.0001). They did not differ (p = NS) between sexes up to age 11, but females showed higher (p < 0.05 - p < 0.0001) AD-SoS values than males in age groups 12, 13, and 14 y. There was no difference (p = NS) of AD-SoS values between sexes in pubertal stages 1, 2, and 5, but females had higher mean AD-SoS values than males in stages 3 (p < 0.01) and 4 (p < 0.001). Independent predictors of AD-SoS were weight, body mass index, pubertal stage, and mean width of fingers in males, and age, pubertal stage, and mean width of fingers in females (p < 0.01 - p < 0.0001). However, 7.8% in males and 3.6% in females of the increment of AD-SoS values can be related to the finger anatomy alone. AD-SoS values probably reflect the architectural organization of growing bone or changes in bone elasticity. Increased bone density and size may be additional factors influencing AD-SOS: Measurement of AD-SoS at the hand phalanxes may be a simple, noninvasive, and radiation-free technique to assess bone quality in children.

[In vivo and in vitro production of interleukin-1 after febrile convulsions]

Pathogenesis of febrile convulsions (FC) is still unknown, suggested causes include the role of antidiuretic hormone (ADH). ADH is an endogenous antypyretic and his excessive production of the consequent hyponatraemia may be the cause of FC in children with susceptibility to this type of seizure. Whereas, interleukin-1 (IL1) is a pyrogenic substances and is involved in the release of AVP. Helminen et al. have reported a significantly higher production of IL1 in culture of peripheral blood monocytes stimulated with lipopolysaccharide (LPS) of children with FC than in the others with fever but without convulsions. More recently Lahat et al. have compared plasma and cerebrospinal fluid ILI levels of children with FC with those of children with fever but without convulsions, but they did not find significant differences. The aims of this study were to determine the IL1 levels in vivo and in the supernatants of cultures of peripheral blood mononuclear cells (PBMC) stimulated or not with LPS in children with FC and in children with fever without FC and to evaluate the influence of ADH and diazepam (DZ) on IL1 production. Blood samples for PBMC cultures were obtained from 11 children with FC on the hospital admission, (group 1) and after 48 hours from treatment with DZ (group 2). The production of IL1 was measured by RIA in the supernatants of the PBMC stimulated with LPS, LPS + DDAVP (synthetic vasopressin), LPS + DZ and in vivo in plasma samples. The control groups were constituted by 9 children with fever and without convulsions (group 3), 4 of them were studied at the end of fever too (group 4), and finally by 9 children in good health (group 5). No significant differences were observed. These results do not support the hypothesis that increased production of IL1 is involved in the pathogenesis of FC in children.

Altered bone mineral density in patients with complete androgen insensitivity syndrome

Androgens have major influences on the regulation of bone mineralization. Because of their unique peripheral metabolism androgens may act on bone via activation of the androgen and/or estrogen receptor. Patients with complete androgen insensitivity syndrome (cAIS) are natural models to assess androgen actions on bone. We studied bone mineral density (BMD) in 10 patients with cAIS (mean age 13.70, range 4.7-19.8 years); 3 patients were studied before gonadectomy; the others were castrated and 6 were on hormonal replacement therapy. The BMD area (aBMD) was measured by dual energy X-ray; lumbar 'apparent' volumetric density (vBMD) was calculated using the formula vBMD = aBMD x [4/(pi x width)]. In the patients, aBMD (0.72 +/- 0.16 g/cm2) and vBMD (0.23 +/- 0.04 g/cm3) were significantly (p < 0.001) reduced in comparison with those of a control group (n = 15, age 5.0-20.5 years: aBMD 1.028 +/- 0.20 g/cm2; vBMD 0.35 +/- 0.04 g/cm3). Both aBMD and vBMD were also reduced in comparison with normal values for males (aBMD -2.66 +/- 0. 99 SDS, p < 0.001; vBMD -3.08 +/- 1.53 SDS, p < 0.0005) and females (aBMD -2.88 +/- 1.05 SDS, p < 0.001; vBMD -2.84 +/- 1.18 SDS, p < 0. 0007). Real lumbar bone density, assessed by computed tomography in 1 patient, was also reduced (-6.2 SDS and -3.5 SDS for male and female normal values, respectively). Biochemical markers of bone metabolism were normal and not significantly different in patients and controls. Girls with cAIS did not have more fractures than controls. In conclusion, both aBMD and vBMD are reduced in cAIS patients, while bone turnover and the fracture risk seem not to be increased. Our data indicate that both androgens and estrogens may be required for acquisition of bone density during childhood.

Is there a place for combined therapy with GnRH agonist plus growth hormone in improving final height in short statured children?

The availability of recombinant human growth hormone (GH) and the optimization of substitutive therapy have improved final growth in children with GH deficiency, but despite this some of them fail to grow to their genetic potential. In particular, this may occur in patients who started the substitutive therapy too late and/or in whom bone age progressed too fast during GH administration. In these patients, with unfavorable auxological characteristics, the administration of a GnRH agonist in combination with GH may slow down bone maturation and prolong prepubertal growth, mimicking, to some extent, the growth pattern of patients with GH + Gn deficiency who grow better than children with isolated GHD. A different condition in which such a combined therapy might be used is the short normal child. As they are short but normally-growing children, the onset of puberty is in general appropriate for their chronological age but precocious for their height age. Thus, slowing down pubertal maturation may increase the time available for growth. GH would sustain growth during both GnRHa administration and after its withdrawal, when puberty starts again. Our preliminary results suggest that the administration of GH + GnRHa in combination may have a positive effect on final height in selected children with isolated GHD and in short normal children.

Brief report: disseminated mycobacteriosis caused by drug-resistant Mycobacterium triplex in a human immunodeficiency virus-infected patient during highly active antiretroviral therapy

Mycobacterium triplex is a novel species that, until now, has been isolated only from limited clinical samples, and its clinical relevance has been largely unknown. In this report, we describe the first case of disseminated disease caused by M. triplex in a human immunodeficiency virus-infected patient.

Mononuclear cell reactivity to food allergens in neonates, children and adults

A model of antigen-specific T-cell proliferative responses based on reciprocal patterns of responses to dietary and inhalant allergens has been suggested, the former being frequent in infancy but rare in adults, whereas the latter are preserved and expand between infancy and adulthood. We have evaluated the age-related variations of mononuclear cell reactivity to food allergens. The cord blood mononuclear cells (CBMC) of 30 neonates without family history of atopy and the peripheral blood mononuclear cells (PBMC) of 20 healthy children and of 40 healthy adults were stimulated in vitro with beta-lactoglobulin (BLG) or ovalbumin (OVA) and the cultures were harvested after 7 days. Neonates, children and adults were compared for the percentages of positive responses and for the magnitude of response. Adult subjects showed significantly lower percentages of positive responses and reduced magnitude of response than those observed in neonates and children either in BLG or in OVA cultures. We have not observed a decrease of food allergen mononuclear cell reactivity between neonates and children for the frequency of positive responses. The magnitude of response of neonates was significantly lower than that of children in BLG cultures. Our results seem to confirm the loss of mononuclear cell reactivity to food allergens in adult age. However, other reports show conflicting data. We suggest that a rigorous standardization of the methodological steps of in vitro mononuclear cell stimulation with allergen is necessary.

Vitamin-D receptor genotype does not predict bone mineral density, bone turnover, and growth in prepubertal children

We examined whether the polymorphism for BsmI restriction enzyme in the vitamin-D receptor (VDR) gene influenced radial (distal third) and lumbar (L2-L4) bone mineral density (BMD), phospho-calcium metabolism (calcium, phosphate, intact parathyroid hormone, 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D), biochemical markers of bone formation (osteocalcin and carboxy-terminal propeptide of type-I procollagen) and bone resorption (carboxy-terminal telopeptide of type-I collagen and urinary cross-linked N-telopeptides of type I collagen), insulin-like growth factor I and insulin-like growth factor-binding protein 3, and growth in 209 healthy prepubertal children (112 males and 97 females) aged 7.1-10.0 years. Genotype frequencies were BB 19%, Bb 46%, and bb 35% in the pooled group of children. Clinical findings, dietary calcium intake, calcium density, and physical activity rate were not different (p NS) among the VDR genotypes. Radial BMD, lumbar BMDarea and lumbar BMD adjusted for the apparent bone volume (BMDvolume), and all the biochemical parameters did not differ (p NS) in relation to the VDR genotype. In conclusion, our data show that polymorphism for BsmI restriction enzyme in the VDR gene is not associated with radial and lumbar BMD, parameters of phospho-calcium metabolism and bone turnover, growth hormone-dependent growth factors, and growth in prepubertal children.

Mucus of the human olfactory epithelium contains the insulin-like growth factor-I system which is altered in some neurodegenerative diseases

Growth factors are believed to be involved in the mitotic regulation of the animal olfactory epithelium (OE). We investigated mucus covering the human OE area to see if it contained the insulin-like growth factor-I (IGF-I) and its binding proteins (IGFBPs) and to examine their behaviour in neurodegenerative diseases. Thirty patients with idiopathic late onset cerebellar ataxia (ILOCA), Parkinson's disease, and amyotrophic lateral sclerosis (ALS) and 30 age- and sex-matched healthy subjects were studied. In 10 controls, we also analyzed the mucus of the respiratory mucosa of the nose and tears. We detected IGF-I in the mucus covering the OE and Western ligand blot analysis (WLB) showed IGFBPs with an apparent Mr of 41, 500/38,500, 34,000 and 24,000, which were immunoprecipitated by specific antisera to IGFBP-3, -2 and -4, respectively. Their levels were higher than those observed in the respiratory mucosa of the nose or in tears. Mucus of the OE of the patients contained significantly reduced levels of IGF-I in comparison with those of controls. The intensity of all the IGFBPs-related bands were reduced in the ILOCA, while the remaining patients had a loss in the amounts of IGFBP-3. Plasma IGF-I and IGFBPs levels were similar in patients and controls. In conclusion, our data show that mucus covering the human OE contains IGF-I and IGFBPs, suggesting that these factors have a role in the activity of the OE. The amounts are reduced in the patients' mucus, possibly reflecting a dysfunction of the OE itself.

Management of puberty in growth hormone deficient children

The pubertal growth spurt accounts for approximately one-eighth of adult height and is regulated by complex hormonal interactions involving the somatotropic and gonadal axes. The observation that children with growth hormone deficiency (GHD) may fail to achieve an appropriate pubertal growth spurt led to the development of strategies to optimize GH therapy during puberty. In one strategy the dosage of GH is increased during puberty to support pubertal growth and in keeping with the physiological increase in serum levels of the hormone seen at that age. A different approach is to combine a GnRH analog (GnRHa) to GH to stop pubertal development, delaying epiphyseal fusion and prolonging peripubertal growth. Both strategies require caution. As regards the first strategy, too high doses of GH may shorten the pubertal time for growth; we found a small, nonsignificant, improvement in final height by increasing the dose by less than half. Preliminary results on the second strategy are more encouraging. However, manipulation of puberty should be limited to selected patients who show a statural height SDS for bone age unfavorable in terms of height prognosis.