1
|
Attia N, Moussa K, Altwaim A, Al-Agha AE, Amir AA, Almuhareb A. Tackling access and payer barriers for growth hormone therapy in Saudi Arabia: a consensus statement for the Saudi Working Group for Pediatric Endocrinology. J Pediatr Endocrinol Metab 2024; 37:387-399. [PMID: 38547465 DOI: 10.1515/jpem-2024-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/13/2024] [Indexed: 05/05/2024]
Abstract
Prompt diagnosis and early treatment are key goals to optimize the outcomes of children with growth hormone deficiency (GHD) and attain the genetically expected adult height. Nonetheless, several barriers can hinder prompt diagnosis and treatment of GHD, including payer-related issues. In Saudi Arabia, moderate-to-severe short stature was reported in 13.1 and 11.7 % of healthy boys and girls, respectively. Several access and payer barriers can face pediatric endocrinologists during the diagnosis and treatment of GHD in Saudi Arabia. Insurance coverage policies can restrict access to diagnostic tests for GHD and recombinant human growth hormone (rhGH) due to their high costs and lack of gold-standard criteria. Some insurance policies may limit the duration of treatment with rhGH or the amount of medication covered per month. This consensus article gathered the insights of pediatric endocrinologists from Saudi Arabia to reflect the access and payer barriers to the diagnostic tests and treatment options of children with short stature. We also discussed the current payer-related challenges endocrinologists face during the investigations of children with short stature. The consensus identified potential strategies to overcome these challenges and optimize patient management.
Collapse
Affiliation(s)
- Najya Attia
- Department of Pediatric Endocrinology, 4917 King Abdulaziz Medical City/King Saud bin Abdulaziz University for Health Sciences/King Abdullah International Medical Research Center , Jeddah, Saudi Arabia
| | | | - Abdulaziz Altwaim
- King Saud bin Abdulaziz University for Health Sciences (KSAU-HS), Riyadh, Saudi Arabia
- International Diabetes Care Center, Jeddah, Saudi Arabia
| | - Abdulmoein Eid Al-Agha
- Pediatric Department, Pediatric Endocrinology & Diabetes Section, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | | | | |
Collapse
|
2
|
Cai M, Chen X, Li Y, Lin N, Huang H, Xu L. Genetic analysis, ultrasound phenotype, and pregnancy outcomes of fetuses with Xp22.33 or Yp11.32 microdeletions. J Perinat Med 2024; 52:96-101. [PMID: 37846158 DOI: 10.1515/jpm-2023-0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/27/2023] [Indexed: 10/18/2023]
Abstract
OBJECTIVES The phenotypes of Xp22.33 or Yp11.32 microdeletions comprising the short-stature homeobox (SHOX) gene have been extensively described in adults and children. Herein, the prenatal ultrasound phenotype and pregnancy outcomes of fetuses with Xp22.33/Yp11.32 microdeletions were analyzed to improve our understanding, diagnosis, and monitoring of this genetic condition in the fetal stage. METHODS A total of 9,100 pregnant women referred to tertiary units for prenatal diagnosis were evaluated by chromosomal microarray analysis(CMA). RESULTS Seven (0.08 %) fetuses had Xp22.33/Yp11.32 microdeletions, ranging from 243 kb to 1.1 Mb, that comprised SHOX. The ultrasonic phenotypes differed among these fetuses, with three fetuses presenting abnormal bone development, one had labial-palatal deformity and strawberry head, two had an abnormal ultrasonic soft marker, and one had no abnormalities. After genetic counseling, only one couple underwent pedigree assessment, which confirmed the paternal origin of the microdeletion. This infant presented delayed speech development, whereas other three infants showed a typical postnatal development. In three cases, the parents chose to terminate the pregnancy. CONCLUSIONS The ultrasonic phenotype of fetuses with Xp22.33/Yp11.32 microdeletions resulting in SHOX heterozygosity loss is variable. Prenatal CMA can quickly and effectively diagnose Xp22.33/Yp11.32 microdeletions and SHOX loss, which may help prenatal counseling.
Collapse
Affiliation(s)
- Meiying Cai
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| | - Xuemei Chen
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| | - Ying Li
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| | - Na Lin
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| | - Hailong Huang
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| | - Liangpu Xu
- Medical Genetic Diagnosis and Therapy Center, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Key Laboratory for Prenatal Diagnosis and Birth Defect, Fuzhou, P.R. China
| |
Collapse
|
3
|
Vodopiutz J, Steurer LM, Haufler F, Laccone F, Garczarczyk-Asim D, Hilkenmeier M, Steinbauer P, Janecke AR. Leri-Weill Dyschondrosteosis Caused by a Leaky Homozygous SHOX Splice-Site Variant. Genes (Basel) 2023; 14:genes14040877. [PMID: 37107635 PMCID: PMC10138022 DOI: 10.3390/genes14040877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/01/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
SHOX deficiency is a common genetic cause of short stature of variable degree. SHOX haploinsufficiency causes Leri-Weill dyschondrosteosis (LWD) as well as nonspecific short stature. SHOX haploinsufficiency is known to result from heterozygous loss-of-function variants with pseudo-autosomal dominant inheritance, while biallelic SHOX loss-of-function variants cause the more severe skeletal dysplasia, Langer mesomelic dyschondrosteosis (LMD). Here we report for the first time the pseudo-autosomal recessive inheritance of LWD in two siblings caused by a novel homozygous non-canonical, leaky splice-site variant in intron 3 of SHOX: c.544+5G>C. Transcript analyses in patient-derived fibroblasts showed homozygous patients to produce approximately equal amounts of normally spliced mRNA and mRNA with the abnormal retention of intron 3 and containing a premature stop codon (p.Val183Glyfs*31). The aberrant transcript was shown to undergo nonsense-mediated mRNA decay, and thus resulting in SHOX haploinsufficiency in the homozygous patient. Six healthy relatives who are of normal height are heterozygous for this variant and fibroblasts from a heterozygote for the c.544+5G>C variant produced wild-type transcript amounts comparable to healthy control. The unique situation reported here highlights the fact that the dosage of SHOX determines the clinical phenotype rather than the Mendelian inheritance pattern of SHOX variants. This study extends the molecular and inheritance spectrum of SHOX deficiency disorder and highlights the importance of functional testing of SHOX variants of unknown significance in order to allow appropriate counseling and precision medicine for each family individual.
Collapse
Affiliation(s)
- Julia Vodopiutz
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
- Vienna Bone and Growth Center, 1130 Vienna, Austria
| | - Lisa-Maria Steurer
- Vienna Bone and Growth Center, 1130 Vienna, Austria
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Florentina Haufler
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Pulmonology, Allergology and Endocrinology, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Franco Laccone
- Institute of Medical Genetics, Medical University of Vienna, 1090 Vienna, Austria
| | | | - Matthias Hilkenmeier
- Department of Pediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
| | - Philipp Steinbauer
- Department of Pediatrics and Adolescent Medicine, Division of Neonatology, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University of Vienna, 1090 Vienna, Austria
| | - Andreas R Janecke
- Department of Pediatrics I, Medical University of Innsbruck, 6020 Innsbruck, Austria
- Division of Human Genetics, Medical University of Innsbruck, 6020 Innsbruck, Austria
| |
Collapse
|
4
|
Gevers EF, de Winter JP. New developments and therapies in pediatric endocrinology. Eur J Pediatr 2023; 182:1439-1443. [PMID: 36567374 DOI: 10.1007/s00431-022-04772-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Evelien F Gevers
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom.
- Department of Paediatric Endocrinology and Diabetes, Barts Health NHS Trust - The Royal London Children's Hospital, London, United Kingdom.
| | - J Peter de Winter
- Department of Pediatrics, Spaarne Gasthuis, Haarlem/Hoofddorp, The Netherlands
- Leuven Child and Health Institute, KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| |
Collapse
|
5
|
Ungureanu MC, Hrisca A, Caba L, Teodoriu L, Bilha S, Preda C, Leustean L. SHOX Deletion and Idiopathic Short Stature: What Does the Clinician Need to Know? Case Series Report. Diagnostics (Basel) 2022; 13:diagnostics13010105. [PMID: 36611397 PMCID: PMC9818503 DOI: 10.3390/diagnostics13010105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 12/23/2022] [Accepted: 12/24/2022] [Indexed: 12/31/2022] Open
Abstract
Children diagnosticated with idiopathic short stature (ISS) are probably, in most cases, underdiagnosticated. The genetic causes of ISS may be mutations of genes involved in local regulation of the growth plate or genes involved in the GH-IGF1 axis physiology. We present a kindred of five children evaluated for short stature or low normal stature, initially diagnosticated as idiopathic short stature, familial short stature, or being small for gestational age. Clinical signs suggestive of SHOX deletion screening in a child with short stature are low arm span/height ratio, increased sitting height/height ratio, BMI > 50% percentile, Madelung deformity, cubitus valgus, bowing and shortening of the forearm, dislocation of the ulna (at the elbow), and the appearance of muscular hypertrophy. Radiological characteristics suggestive of SHOX deficiency are triangularisation of the distal radial epiphysis, an enlarged diaphysis of the radius plus bowing of the radius, the convexity of the distal radial metaphysis, short fourth and fifth metacarpals, pyramidalization of the carpal row. Treatment with rGH is approved for children with SHOX gene deficiency and short stature. This kindred is an example that familial short stature, idiopathic short stature, and short stature due to a small gestational age are not final diagnoses. Complex investigations are necessary to identify the precise cause, leading to optimal clinical management. Treatment with rGH is an option for some of them; for others, it has no therapeutic response and, in some cases, is even harmful.
Collapse
Affiliation(s)
- Maria-Christina Ungureanu
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| | - Anamaria Hrisca
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
- Correspondence:
| | - Lavinia Caba
- Medical Genetics Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| | - Laura Teodoriu
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| | - Stefana Bilha
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| | - Cristina Preda
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| | - Letitia Leustean
- Endocrinology Department, “Grigore T. Popa” University of Medicine and Pharmacy, 700111 Iasi, Romania
| |
Collapse
|
6
|
Abstract
Growth hormone (GH) is an injectable medication originally used to replace the deficiency of the hormone, but has expanded to treating conditions that may reduce growth and adult height even when the body maintains endogenous GH production. In the United States, there are 8 Food and Drug Administration (FDA)-approved indications for pediatric GH therapy: GH deficiency, Prader-Willi Syndrome, small for gestational age (SGA) without catch-up growth, idiopathic short stature, Turner syndrome, SHOX gene haploinsufficiency, Noonan Syndrome, and chronic renal insufficiency. We characterize the growth patterns and effects of GH treatment in each of these indications. We also review patterns of growth that warrant referral to a pediatric endocrinologist, as well as safety updates. This review is intended to guide practitioners on the initial evaluation and management of patients with short stature, and the indications for GH therapy.
Collapse
Affiliation(s)
- Melinda Danowitz
- CHOP Division of Pediatric Endocrinology, Abramson Building, Office 804F, 3401 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Adda Grimberg
- Children's Hospital of Philadelphia, The Hub for Clinical Collaboration, Division of Endocrinology, 7th floor, 3500 Civic Center Boulevard, Philadelphia, PA 19104, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
7
|
Giordano M, Stuppia L. Editorial: Novel Insights Into the Genetics of Growth Disorders. Front Genet 2022; 13:920469. [PMID: 35754806 PMCID: PMC9214029 DOI: 10.3389/fgene.2022.920469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Mara Giordano
- Laboratory of Genetics, SCDU Clinical Biochemistry, University Hospital "Maggiore della Carità", Novara and Department of Health Sciences, University of Eastern Piedmont, Novara, Italy
| | - Liborio Stuppia
- Department of Psychological, Health and Territorial Sciences and Center for Advanced Sciences and Technology (CAST), G. d'Annunzio University, Chieti-Pescara, Italy
| |
Collapse
|
8
|
Savage MO, Storr HL. Balanced assessment of growth disorders using clinical, endocrinological, and genetic approaches. Ann Pediatr Endocrinol Metab 2021; 26:218-226. [PMID: 34991299 PMCID: PMC8749028 DOI: 10.6065/apem.2142208.104] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 11/01/2021] [Indexed: 12/15/2022] Open
Abstract
Determining the pathogenesis of pediatric growth disorders is often challenging. In many cases, no pathogenesis is identified, and a designation of idiopathic short stature is used. The investigation of short stature requires a combination of clinical, endocrinological, and genetic evaluation. The techniques used are described, with equal importance being given to each of the 3 approaches. Clinical skills are essential to elicit an accurate history, family pedigree, and symptoms of body system dysfunction. Endocrine assessment requires hormonal determination for the diagnosis of hormone deficiency and initiation of successful replacement therapy. Genetic analysis has added a new dimension to the investigation of short stature and now uses next-generation sequencing with a candidate gene approach to confirm probable recognizable monogenic disorders and exome sequencing for complex phenotypes of unknown origin. Using the 3 approaches of clinical, endocrine, and genetic probes with equal status in the hierarchy of investigational variables provides the clinician with the highest chance of identifying the correct causative pathogenetic mechanism in a child presenting with short stature of unknown origin.
Collapse
Affiliation(s)
- Martin Oswald Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary, University of London, London, UK,Address for correspondence: Martin Oswald Savage Centre for Endocrinology, William Harvey Research Institute, Charterhouse Square, London EC1M 6BQ, UK
| | - Helen Louise Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, Queen Mary, University of London, London, UK
| |
Collapse
|
9
|
Graber E, Reiter EO, Rogol AD. Human Growth and Growth Hormone: From Antiquity to the Recominant Age to the Future. Front Endocrinol (Lausanne) 2021; 12:709936. [PMID: 34290673 PMCID: PMC8287422 DOI: 10.3389/fendo.2021.709936] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 06/17/2021] [Indexed: 12/03/2022] Open
Abstract
Since antiquity Man has been fascinated by the variations in human (and animal) growth. Stories and art abound about giants and little people. Modern genetics have solved some of etiologies at both extremes of growth. Serious study began with the pathophysiology of acromegaly followed by early attempts at treatment culminating in modern endoscopic surgery and multiple pharmacologic agents. Virtually at the same time experiments with the removal of the pituitary from laboratory animals noted the slowing or stopping of linear growth and then over a few decades the extraction and purification of a protein within the anterior pituitary that restored, partially or in full, the animal's growth. Human growth hormone was purified decades after those from large animals and it was noted that it was species specific, that is, only primate growth hormone was metabolically active in primates. That was quite unlike the beef and pork insulins which revolutionized the care of children with diabetes mellitus. A number of studies included mild enzymatic digestion of beef growth hormone to determine if those "cores" had biologic activity in primates and man. Tantalizing data showed minimal but variable metabolic efficacy leading to the "active core" hypothesis, for these smaller peptides would be amenable to peptide synthesis in the time before recombinant DNA. Recombinant DNA changed the landscape remarkably promising nearly unlimited quantities of metabolically active hormone. Eight indications for therapeutic use have been approved by the Food and Drug Administration and a large number of clinical trials have been undertaken in multiple other conditions for which short stature in childhood is a sign. The future predicts other clinical indications for growth hormone therapy (and perhaps other components of the GH?IGF-1 axis), longer-acting analogues and perhaps a more physiologic method of administration as virtually all methods at present are far from physiologic.
Collapse
Affiliation(s)
- Evan Graber
- DO Division of Pediatric Endocrinology, Nemours/Alfred I. Dupont Hospital for Children, Wilmington, DE, United States
| | - Edward O. Reiter
- Baystate Children’s Hospital, UMassMedical School-Baystate, Springfield, MA, United States
| | - Alan D. Rogol
- Pediatrics/Endocrinology, University of Virginia, Charlottesville, VA, United States
| |
Collapse
|
10
|
Pellegrin MC, Tornese G, Barbi E. Pubertal boy presenting with mild disproportionate short stature. Arch Dis Child Educ Pract Ed 2021; 106:149-151. [PMID: 31467065 DOI: 10.1136/archdischild-2019-317564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 08/02/2019] [Indexed: 11/03/2022]
Abstract
A boy aged 12 years was referred with short stature. He was born at term, of adequate weight (10-25th centile) and length (10-25th centile), which settled to just below the third centile from 18 months of age, with a growth deceleration in the last 6 months (growth velocity -2.1 standard deviation score, according to Tanner charts). He was otherwise asymptomatic. His mother's height was 155 cm, and father's height 158 cm, and he was growing near his target height centile (-2.26 SDS, <3rd centile).On examination, his height was -2.22 SDS, with normal weight and body mass index (BMI). Pubertal stage corresponded to Tanner 2, with a testicular volume of 4 mL. His legs and forearms appeared shorter, with arm span/height ratio 0.93 (normal value >0.965) and sitting height/height ratio 0.56 (slightly above the normal upper value of 0.55). He resembled his father, whose wrists were abnormally curved (figure 1). The patient's hand X-ray showed that bone age was similar to chronological age.
Collapse
Affiliation(s)
| | - Gianluca Tornese
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
- University of Trieste, Trieste, Italy
| |
Collapse
|
11
|
Plachy L, Dusatkova P, Maratova K, Petruzelkova L, Elblova L, Kolouskova S, Snajderova M, Obermannova B, Zemkova D, Sumnik Z, Lebl J, Pruhova S. Familial Short Stature-A Novel Phenotype of Growth Plate Collagenopathies. J Clin Endocrinol Metab 2021; 106:1742-1749. [PMID: 33570564 DOI: 10.1210/clinem/dgab084] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT Collagens are the most abundant proteins in the human body. In a growth plate, collagen types II, IX, X, and XI are present. Defects in collagen genes cause heterogeneous syndromic disorders frequently associated with short stature. Less is known about oligosymptomatic collagenopathies. OBJECTIVE This work aims to evaluate the frequency of collagenopathies in familial short stature (FSS) children and to describe their phenotype, including growth hormone (GH) treatment response. METHODS Eighty-seven FSS children (pretreatment height ≤ -2 SD both in the patient and his or her shorter parent) treated with GH were included in the study. Next-generation sequencing was performed to search for variants in the COL2A1, COL9A1, COL9A2, COL9A3, COL10A1, COL11A1, and COL11A2 genes. The results were evaluated using American College of Medical Genetics and Genomics guidelines. The GH treatment response of affected children was retrospectively evaluated. RESULTS A likely pathogenic variant in the collagen gene was found in 10 of 87 (11.5%) children. Detailed examination described mild asymmetry with shorter limbs and mild bone dysplasia signs in 2 of 10 and 4 of 10 affected children, respectively. Their growth velocity improved from a median of 5.3 cm/year to 8.7 cm/year after 1 year of treatment. Their height improved from a median of -3.1 SD to -2.6 SD and to -2.2 SD after 1 and 3 years of therapy, respectively. The final height reached by 4 of 10 children differed by -0.67 to +1.0 SD and -0.45 to +0.5 SD compared to their pretreatment height and their affected untreated parent's height, respectively. CONCLUSION Oligosymptomatic collagenopathies are a frequent cause of FSS. The short-term response to GH treatment is promising.
Collapse
Affiliation(s)
- Lukas Plachy
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Petra Dusatkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Klara Maratova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Lenka Petruzelkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Lenka Elblova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Stanislava Kolouskova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Marta Snajderova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Barbora Obermannova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Dana Zemkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, 150 06 Prague 5, Czech Republic
| |
Collapse
|
12
|
Rapaport R, Wit JM, Savage MO. Growth failure: 'idiopathic' only after a detailed diagnostic evaluation. Endocr Connect 2021; 10:R125-R138. [PMID: 33543731 PMCID: PMC8052574 DOI: 10.1530/ec-20-0585] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 01/29/2021] [Indexed: 01/02/2023]
Abstract
The terms 'idiopathic short stature' (ISS) and 'small for gestational age' (SGA) were first used in the 1970s and 1980s. ISS described non-syndromic short children with undefined aetiology who did not have growth hormone (GH) deficiency, chromosomal defects, chronic illness, dysmorphic features or low birth weight. Despite originating in the pre-molecular era, ISS is still used as a diagnostic label today. The term 'SGA' was adopted by paediatric endocrinologists to describe children born with low birth weight and/or length, some of whom may experience lack of catch-up growth and present with short stature. GH treatment was approved by the FDA for short children born SGA in 2001, and by the EMA in 2003, and for the treatment of ISS in the US, but not Europe, in 2003. These approvals strengthened the terms 'SGA' and 'ISS' as clinical entities. While clinical and hormonal diagnostic techniques remain important, it is the emergence of genetic investigations that have led to numerous molecular discoveries in both ISS and SGA subjects. The primary message of this article is that the labels ISS and SGA are not definitive diagnoses. We propose that the three disciplines of clinical evaluation, hormonal investigation and genetic sequencing should have equal status in the hierarchy of short stature assessments and should complement each other to identify the true pathogenesis in poorly growing patients.
Collapse
Affiliation(s)
- Robert Rapaport
- Division of Pediatric Endocrinology & Diabetes, Mount Sinai Kravis Children’s Hospital and Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jan M Wit
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin O Savage
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine & Dentistry, London, UK
| |
Collapse
|
13
|
Vukić V, Smajo A, Vidović M, Vukojević R, Harjaček M, Lamot L. Beyond the guidelines management of juvenile idiopathic arthritis: a case report of a girl with polyarticular disease refractory to multiple treatment options and Leri Weill syndrome. BMC Pediatr 2021; 21:40. [PMID: 33451288 PMCID: PMC7809853 DOI: 10.1186/s12887-021-02494-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 01/05/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The last two decades brought new treatment options and high quality guidelines into the paediatric rheumatologic practice. Nevertheless, a number of patients still present a diagnostic and therapeutic challenge due to combination of vague symptoms and unresponsiveness to available treatment modalities. CASE PRESENTATION We report a case of sixteen years old girl suffering from polyarticular type of juvenile idiopathic arthritis refractory to multiple treatment options. She first presented at the age of 4 with swelling and contractures of both knees. Her symptoms were initially unresponsive to nonsteroidal anti-inflammatory drugs and progressed despite treatment with intraarticular and systemic glucocorticoids and methotrexate. Throughout the years, she received several biologics together with continuous administration of nonsteroidal anti-inflammatory drugs and disease modifying anti-rheumatic drugs as well as intraarticular and systemic glucocorticoids in disease flares. However, none of this options provided a permanent remission, so various other modalities, as well as other possible diagnoses were constantly being considered. Eventually she became dependent on a daily dose of systemic glucocorticoids. In 2018, the treatment with Janus kinase inhibitor tofacitinib was initiated, which led to gradual amelioration of musculoskeletal symptoms, improvement of inflammatory markers and overall well-being, as well as to the weaning of systemic glucocorticoids. As the swelling of the wrists subsided for the first time in many years, Madelung's deformity was noticed, first clinically, and later radiographically as well. Genetic analysis revealed short-stature homeobox gene deficiency and confirmed the diagnosis of Leri Weill syndrome. CONCLUSIONS This case report emphasizes the need for reporting refractory, complicated cases from everyday clinical practice in order to build-up the overall knowledge and share experience which is complementary to available guidelines. Individual reports of difficult to treat cases, especially when additional diagnoses are involved, can be helpful for physicians treating patients with common rheumatological diseases such as juvenile idiopathic arthritis.
Collapse
Affiliation(s)
- Vana Vukić
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Ana Smajo
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Mandica Vidović
- Division of Clinical Immunology and Rheumatology, Department of Pediatrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Rudolf Vukojević
- Department of Diagnostic and Interventional Radiology, Sestre milosrdnice University Hospital Center, University of Zagreb, Zagreb, Croatia
| | - Miroslav Harjaček
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
- Division of Clinical Immunology and Rheumatology, Department of Pediatrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Lovro Lamot
- Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia.
- Division of Clinical Immunology and Rheumatology, Department of Pediatrics, Sestre milosrdnice University Hospital Center, Zagreb, Croatia.
| |
Collapse
|
14
|
Lee JS, Kim HY, Lee YA, Lee SY, Cho TJ, Ko JM. Clinical and Genetic Characteristics of 23 Korean Patients with Haploinsufficiency of the Short-stature Homeobox-containing Gene. Exp Clin Endocrinol Diabetes 2020; 129:611-620. [PMID: 32932528 DOI: 10.1055/a-1247-4863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The short-stature homeobox-containing gene (SHOX) is one of the major growth genes in humans. The clinical spectrum of SHOX haploinsufficiency ranges from Léri-Weill dyschondrosteosis to idiopathic short stature. Herein, we describe the clinical and genetic characteristics of 23 Korean patients with SHOX deficiency disorders. METHODS Medical records of 23 patients (19 females and 4 males) from 15 unrelated families who were genetically confirmed to have SHOX deficiency were retrospectively reviewed. SHOX gene deletions or mutations were determined by sequence analyses using multiplex ligation-dependent probe amplification, chromosomal microarray, and/or Sanger sequencing methods. RESULTS In the 15 families, 9 probands were de novo cases. All 23 patients showed mesomelia. Madelung deformity and tibia vara were observed in 13 (56.5%) and 3 (13.1%) patients, respectively. Genetically, 11 (73.3%) of the 15 families showed SHOX deletions of various sizes, and the other 4 families harboured SHOX sequence variants. Four patients had undergone orthopaedic surgeries (3 for tibia vara and 1 for Madelung deformity). Among 7 patients who had received growth hormone treatment for ≥1 year, 5 showed good responses, with a median first-year change-in-height standard deviation score of +0.6. There were no significant differences in the clinical characteristics of the deletion and point mutation groups. CONCLUSIONS A high index of suspicion and the genetic confirmation of SHOX deficiency are helpful for the timely management of the condition and are needed to provide genetic counselling to the family members of the patients.
Collapse
Affiliation(s)
- Jeong-Seon Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul
| | - Hwa Young Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul
| | - Young-Ah Lee
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul
| | - Seong-Young Lee
- Department of Pediatrics, SMG-SNU Boramae Medical Center, Seoul
| | - Tae-Joon Cho
- Department of Orthopaedics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul
| | - Jung Min Ko
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul
| |
Collapse
|
15
|
Joustra SD, Kamp GA, Stalman SE, Donze SH, Losekoot M, Kant SG, de Bruin C, Oostdijk W, Wit JM. Novel Clinical Criteria Allow Detection of Short Stature Homeobox-Containing Gene Haploinsufficiency Caused by Either Gene or Enhancer Region Defects. Horm Res Paediatr 2020; 92:372-381. [PMID: 32344414 DOI: 10.1159/000507215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 03/11/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Short stature homeobox-containing gene (SHOX) haploinsufficiency is associated with short stature, Madelung deformity and mesomelia. Current clinical screening tools are based on patients with intragenic variants or deletions. However, recent discoveries showed that deletions of the enhancer elements are quite common. The majority of these patients show less body disproportion and respond better to recombinant human growth hormone treatment. We redefined clinical criteria for genetic analysis to facilitate detection of the full spectrum of SHOX haploinsufficiency. METHODS We analyzed 51 children with SHOX variants or deletions and 25 children with a deletion in its enhancer region. Data were compared to 277 children referred for suspicion of growth failure without endocrine or genetic pathology. RESULTS Only half of the patients with an enhancer region deletion fulfilled any of the current screening criteria. We propose new clinical criteria based on sitting height to height ratio >1 SDS or arm span ≥3 cm below height, with a sensitivity of 99%. When these criteria are combined with obligatory short stature, the sensitivity to detect SHOX haploinsufficiency is 68.1%, the specificity 80.6%, and the number needed to screen 21 patients. CONCLUSION Novel clinical criteria for screening for SHOX haploinsufficiency allow the detection of patients within the full genetic spectrum, that is, intragenic variants and enhancer region deletions.
Collapse
Affiliation(s)
- Sjoerd D Joustra
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands,
| | - Gerdine A Kamp
- Department of Pediatric Endocrinology, Tergooi Hospital, Blaricum, The Netherlands
| | - Susanne E Stalman
- Department of Pediatrics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Stephany H Donze
- Department of Pediatrics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.,Dutch Growth Research Foundation, Rotterdam, The Netherlands
| | - Monique Losekoot
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarina G Kant
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Christiaan de Bruin
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilma Oostdijk
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan M Wit
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| |
Collapse
|
16
|
Plachy L, Dusatkova P, Maratova K, Petruzelkova L, Zemkova D, Elblova L, Kucerova P, Toni L, Kolouskova S, Snajderova M, Sumnik Z, Lebl J, Pruhova S. NPR2 Variants Are Frequent among Children with Familiar Short Stature and Respond Well to Growth Hormone Therapy. J Clin Endocrinol Metab 2020; 105:5716766. [PMID: 31990356 DOI: 10.1210/clinem/dgaa037] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/27/2020] [Indexed: 02/06/2023]
Abstract
CONTEXT The C-type natriuretic peptide receptor encoded by the NPR2 gene is a paracrine regulator of the growth plate; heterozygous NPR2 variants cause short stature with possible presence of different signs of bone dysplasia. To date, the effect of growth hormone (GH) treatment has been described in a few individuals with NPR2 gene variants with inconsistent results. OBJECTIVES To identify NPR2 gene variants among children with familial short stature (FSS) and to describe their phenotype, including GH treatment response. DESIGN, SETTINGS AND PATIENTS Out of 747 patients with short stature treated with GH in a single center, 87 with FSS met the inclusion criteria (pretreatment height ≤ -2 standard deviation in both the patient and the shorter parent, unknown genetic etiology). Next-generation sequencing methods were performed to search for NPR2 gene variants. The results were evaluated using the American College of Medical Genetics and Genomics guidelines. The GH treatment response (growth velocity improvement and height standard deviation score development over the first 5 years of treatment) was evaluated. RESULTS In 5/87 children (5.7%), a (likely) pathogenic variant in the NPR2 gene was identified (p.Ile558Thr [in 2], p.Arg205*, p.Arg557His, p.Ser603Thr). Two children had disproportionate short-limbed short stature, 1 a dysplastic 5th finger phalanx. The growth velocity in the first year of GH treatment accelerated by 3.6 to 4.2 cm/year; the height improved by 1.2 to 1.8 SD over 5 years of treatment. CONCLUSIONS NPR2 gene variants cause FSS in a significant proportion of children. Their GH treatment response is promising. Studies including final height data are necessary to assess the long-term efficacy of this therapy.
Collapse
Affiliation(s)
- Lukas Plachy
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Petra Dusatkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Klara Maratova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Lenka Petruzelkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Dana Zemkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Lenka Elblova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Petra Kucerova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Ledjona Toni
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Stanislava Kolouskova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Marta Snajderova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Jan Lebl
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University in Prague and University Hospital Motol, Prague, 150 06, Czech Republic
| |
Collapse
|
17
|
Shepherd S, Saraff V, Shaw N, Banerjee I, Patel L. Growth hormone prescribing patterns in the UK, 2013-2016. Arch Dis Child 2019; 104:583-587. [PMID: 30567827 DOI: 10.1136/archdischild-2018-316262] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/28/2018] [Accepted: 12/03/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Prescribing of recombinant human growth hormone (rhGH) for growth failure in UK children is based on guidance from the National Institute for Health and Care Excellence. In 2013, the British Society for Paediatric Endocrinology and Diabetes initiated a national audit of newly prescribed rhGH treatment for children and adolescents. In this review, we have examined prescribing practices between 2013 and 2016. METHODS All patients ≤16.0 years of age starting rhGH for licensed and unlicensed conditions in the UK were included. Anonymised data on indication and patient demographics were analysed. RESULTS During the 4 years, 3757 patients from 76 of 85 (89%) centres started rhGH. For each licensed indication, proportions remained stable over this period: 56% growth hormone deficiency (GHD), 17% small for gestational age (SGA), 10% Turner syndrome, 6% Prader-Willi syndrome (PWS), 3% chronic renal insufficiency (CRI) and 2% short stature homeobox deficiency (SHOXd). However, the unlicensed category decreased from 10% (n=94) in 2013 to 5% (n=50) in 2016. The median age of patients starting rhGH was 7.6 years (range 0.1-16.0). Patients with PWS were significantly younger (median 2.2 years, range 0.2-15.1) compared with other indications (p<0.0001) and were followed by the SGA group (median 6.2 years, range 1.3-15.6, p<0.0001). Boys predominated in all groups except for PWS and SHOXd. CONCLUSION We demonstrate significant engagement of prescribing centres in this audit and a decline in unlicensed prescribing by half in this 4-year period. Patients in the PWS group were younger at initiation of rhGH compared with other indications and had no male predominance unlike GHD, SGA and CRI.
Collapse
Affiliation(s)
- Sheila Shepherd
- Royal Hospital for Children, University of Glasgow, Glasgow, UK
| | - Vrinda Saraff
- Birmingham Children's Hospital, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Nick Shaw
- Endocrinology and Diabetes, Birmingham Women's and Children's NHS Foundation Trust, Manchester, UK.,Institute of Metabolism and Systems Research, University of Birmingham, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester, UK
| | - Leena Patel
- Division of Medical Education, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK.,Paediatric Endocrinology, Royal Manchester Children's Hospital, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| |
Collapse
|
18
|
Argente J, Tatton-Brown K, Lehwalder D, Pfäffle R. Genetics of Growth Disorders-Which Patients Require Genetic Testing? Front Endocrinol (Lausanne) 2019; 10:602. [PMID: 31555216 PMCID: PMC6742727 DOI: 10.3389/fendo.2019.00602] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 08/19/2019] [Indexed: 12/18/2022] Open
Abstract
The second 360° European Meeting on Growth Hormone Disorders, held in Barcelona, Spain, in June 2017, included a session entitled Pragmatism vs. Curiosity in Genetic Diagnosis of Growth Disorders, which examined current concepts of genetics and growth in the clinical setting, in terms of both growth failure and overgrowth. For patients with short stature, multiple genes have been identified that result in GH deficiency, which may be isolated or associated with additional pituitary hormone deficiencies, or in growth hormone resistance, primary insulin-like growth factor (IGF) acid-labile subunit deficiency, IGF-I deficiency, IGF-II deficiency, IGF-I resistance, and primary PAPP-A2 deficiency. While genetic causes of short stature were previously thought to primarily be associated with the GH-IGF-I axis, it is now established that multiple genetic anomalies not associated with the GH-IGF-I axis can result in short stature. A number of genetic anomalies have also been shown to be associated with overgrowth, some of which involve the GH-IGF-I axis. In patients with overgrowth in combination with an intellectual disability, two predominant gene families, the epigenetic regulator genes, and PI3K/AKT pathway genes, have now been identified. Specific processes should be followed for decisions on which patients require genetic testing and which genes should be examined for anomalies. The decision to carry out genetic testing should be directed by the clinical process, not merely for research purposes. The intention of genetic testing should be to direct the clinical options for management of the growth disorder.
Collapse
Affiliation(s)
- Jesús Argente
- Hospital Infantil Universitario Niño Jesús, Universidad Autónoma de Madrid, CIBER de Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III and IMDEA Institute, Madrid, Spain
- *Correspondence: Jesús Argente
| | - Katrina Tatton-Brown
- Institute of Cancer Research, St George's University Hospital NHS Foundation Trust, London and St George's University of London, London, United Kingdom
| | - Dagmar Lehwalder
- Global Medical Affairs, Merck Healthcare KGaA, Darmstadt, Germany
| | - Roland Pfäffle
- Department of Pediatrics, University of Leipzig, Leipzig, Germany
- Roland Pfäffle
| |
Collapse
|
19
|
Finken MJJ, van der Steen M, Smeets CCJ, Walenkamp MJE, de Bruin C, Hokken-Koelega ACS, Wit JM. Children Born Small for Gestational Age: Differential Diagnosis, Molecular Genetic Evaluation, and Implications. Endocr Rev 2018; 39:851-894. [PMID: 29982551 DOI: 10.1210/er.2018-00083] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 06/21/2018] [Indexed: 12/25/2022]
Abstract
Children born small for gestational age (SGA), defined as a birth weight and/or length below -2 SD score (SDS), comprise a heterogeneous group. The causes of SGA are multifactorial and include maternal lifestyle and obstetric factors, placental dysfunction, and numerous fetal (epi)genetic abnormalities. Short-term consequences of SGA include increased risks of hypothermia, polycythemia, and hypoglycemia. Although most SGA infants show catch-up growth by 2 years of age, ∼10% remain short. Short children born SGA are amenable to GH treatment, which increases their adult height by on average 1.25 SD. Add-on treatment with a gonadotropin-releasing hormone agonist may be considered in early pubertal children with an expected adult height below -2.5 SDS. A small birth size increases the risk of later neurodevelopmental problems and cardiometabolic diseases. GH treatment does not pose an additional risk.
Collapse
Affiliation(s)
- Martijn J J Finken
- Department of Pediatrics, VU University Medical Center, MB Amsterdam, Netherlands
| | - Manouk van der Steen
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Carolina C J Smeets
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Marie J E Walenkamp
- Department of Pediatrics, VU University Medical Center, MB Amsterdam, Netherlands
| | - Christiaan de Bruin
- Department of Pediatrics, Leiden University Medical Center, RC Leiden, Netherlands
| | - Anita C S Hokken-Koelega
- Department of Pediatrics, Erasmus University Medical Center/Sophia Children's Hospital, CN Rotterdam, Netherlands
| | - Jan M Wit
- Department of Pediatrics, Leiden University Medical Center, RC Leiden, Netherlands
| |
Collapse
|
20
|
Deal C, Kirsch S, Chanoine JP, Lawrence S, Cummings E, Rosolowsky ET, Marks SD, Jia N, Child CJ. Growth hormone treatment of Canadian children: results from the GeNeSIS phase IV prospective observational study. CMAJ Open 2018; 6:E372-E383. [PMID: 30201821 PMCID: PMC6182101 DOI: 10.9778/cmajo.20180020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Country-specific data on outcomes of treatment with recombinant human growth hormone are lacking. We present such data for children treated with growth hormone in Canada. METHODS We describe characteristics and outcomes of 850 children (mean age at baseline 8.5 yr) treated with growth hormone constituting the Canadian cohort of the multinational phase IV prospective observational Genetics and Neuroendocrinology of Short-stature International Study (GeNeSIS). The diagnosis associated with short stature was as determined by the investigator. Auxological data were evaluated yearly until near-adult height. Adverse events were assessed in all growth-hormone-treated patients. RESULTS The diagnosis ascribed as the cause of short stature was growth hormone deficiency in 526 children (61.9%), predominantly organic rather than idiopathic, particularly congenital pituitary abnormalities and intracranial tumours. All diagnostic groups with sufficient patients for analysis had increased height velocity standard deviation score (SDS) and height SDS during growth hormone treatment. For patients who reached near-adult height (n = 293), the mean height SDS was within the normal range for about 80% of patients with organic growth hormone deficiency (n = 131) or idiopathic growth hormone deficiency (n = 50), 50% of patients with idiopathic short stature (n = 10) and 46% of patients with Turner syndrome (n = 79). Eleven deaths were reported, 7 in patients with organic growth hormone deficiency. Serious adverse events considered related to growth hormone treatment (n = 19) were isolated except for medulloblastoma recurrence (n = 2) and adenoidal hypertrophy (n = 2). INTERPRETATION Growth hormone treatment was effective and had a good safety profile in Canadian children. Growth hormone dosages were lower than in the US and global GeNeSIS cohorts, and a greater proportion of treated Canadian children had organic growth hormone deficiency. STUDY REGISTRATION ClinicalTrials.gov, no. NCT01088412.
Collapse
Affiliation(s)
- Cheri Deal
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Susan Kirsch
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Jean-Pierre Chanoine
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Sarah Lawrence
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Elizabeth Cummings
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Elizabeth T Rosolowsky
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Seth D Marks
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Nan Jia
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| | - Christopher J Child
- University of Montreal and Centre hospitalier universitaire Sainte-Justine (Deal), Montréal, Que.; Lilly Research Laboratories (Kirsch), Toronto, Ont.; Endocrinology and Diabetes Unit (Chanoine), British Columbia Children's Hospital, Vancouver, BC; Division of Endocrinology and Metabolism (Lawrence), Children's Hospital of Eastern Ontario, Ottawa, Ont.; Division of Endocrinology (Cummings), IWK Health Centre, Dalhousie University, Halifax, NS; Division of Endocrinology (Rosolowsky), Department of Pediatrics, University of Alberta, Edmonton Clinic Health Academy, Edmonton, Alta.; Department of Pediatrics and Child Health (Marks), Children's Hospital Health Sciences Centre Winnipeg, University of Manitoba, Winnipeg, Man.; Lilly Research Laboratories (Jia), Indianapolis, Ind.; Eli Lilly and Company (Child), Windlesham, UK
| |
Collapse
|
21
|
Ramachandrappa S, Kulkarni A, Gandhi H, Ellis C, Hutt R, Roberts L, Hamid R, Papageorghiou A, Mansour S. SHOX haploinsufficiency presenting with isolated short long bones in the second and third trimester. Eur J Hum Genet 2018; 26:350-358. [PMID: 29330548 DOI: 10.1038/s41431-017-0080-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 10/16/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022] Open
Abstract
Haploinsufficiency of the transcription factor short stature homeobox (SHOX) manifests as a spectrum of clinical phenotypes, ranging from disproportionate short stature and Madelung deformity to isolated short stature. Here, we describe five infants with molecularly confirmed diagnoses of SHOX haploinsufficiency who presented in utero with short long bones during routine antenatal scanning from as early as 19 weeks gestation. Other foetal growth parameters were normal. The molecular basis of SHOX haploinsufficiency was distinct in each case. In four cases, SHOX haploinsufficiency was inherited from a previously undiagnosed parent. In our de novo case, SHOX haploinsufficiency reflected the formation of a derivative sex chromosome during paternal meiosis. Final adult height in the SHOX-deficient parents ranged from -1.9 to -1.2 SDS. All affected parents had disproportionately short limbs and two affected mothers had bilateral Madelung deformity. To our knowledge, SHOX haploinsufficiency has not previously been reported to present in utero. Our experience illustrates that SHOX deficiency should form part of the differential diagnosis of foetal short long bones and suggests a low threshold for genetic testing. This should be particularly targeted at, but not limited to, families with a history of features suggestive of SHOX deficiency. Data on the postnatal growth of our index cases is presented which demonstrates that antenatal presentation of SHOX haploinsufficiency is not indicative of severe postnatal growth restriction. Early identification of SHOX deficiency will enable accurate genetic counselling reflecting a good postnatal outcome and facilitate optimal initiation of growth hormone therapy.
Collapse
Affiliation(s)
- Shwetha Ramachandrappa
- South West Thames Regional Genetics Unit, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Abhijit Kulkarni
- South West Thames Regional Genetics Unit, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Hina Gandhi
- Department of Obstetrics and Gynaecology, Surrey and Sussex Healthcare NHS Trust, Canada Avenue, Redhill, RH1 5RH, UK
| | - Cheryl Ellis
- Department of Obstetrics and Gynaecology, Epsom and St Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton, SM5 1AA, UK
| | - Renata Hutt
- Department of Obstetrics and Gynaecology, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK
| | - Lesley Roberts
- Department of Obstetrics and Gynaecology, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK
| | - Rosol Hamid
- Department of Obstetrics and Gynaecology, Croydon Health Services NHS Trust, London Road, Croydon, CR7 7YE, UK
| | - Aris Papageorghiou
- Fetal Medicine Unit, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Sahar Mansour
- South West Thames Regional Genetics Unit, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
| |
Collapse
|
22
|
Abstract
PURPOSE OF REVIEW This review highlights how skeletal dysplasias are diagnosed and how our understanding of some of these conditions has now translated to treatment options. RECENT FINDINGS The use of multigene panels, using next-generation sequence technology, has improved our ability to quickly identify the genetic etiology, which can impact management. There are successes with the use of growth hormone in individuals with SHOX deficiencies, asfotase alfa in hypophosphatasia, and some promising data for c-type natriuretic peptide for those with achondroplasia. One needs to consider that a patient with short stature has a skeletal dysplasia as options for management may be available.
Collapse
Affiliation(s)
- Sarah M Nikkel
- Provinical Medical Genetics Program, BC Women's Hospital and Health Centre, University of British Columbia, 4500 Oak Street, Vancouver, BC, V6H 3N1, Canada.
| |
Collapse
|
23
|
|