17q12 microduplications: a challenge for clinicians

In the recent years, some cases of 17q12 deletions and duplications have been reported, but the clinical impact of these imbalances is still to be fully elucidated. In particular, 17q12 duplications elude syndrome classification, since they are associated with a wide phenotypic spectrum, ranging from very mild to quite severe phenotypes. Here, two unrelated patients with the same 1.2 Mb microduplication of 17q12 are reported. Comparing these patients' phenotype with those previously published, it emerges that the more patients reported, the more difficult is finding common characteristics, even in presence of exactly the same genetic anomaly. The role of the genes duplicated in this region and the impact of this chromosomal imbalance are discussed.

GH therapy in transition age: state of the art and future perspectives

Growth hormone (GH) has been recently approved by the Italian Health Authorities for use in transition patients with childhood onset-growth hormone deficiency (CO-GHD). GH in addition to promote linear growth influences several key metabolic processes. In particular, in the transition period, from late adolescent to early adulthood, GH plays an important role in the achievement of a complete somatic development including body composition, muscle mass maturation, full skeletal mineralization and reproductive maturation, as well as in the prevention of metabolic and cardiovascular risk. Therefore, GH replacement should be restarted if a GH stimulation test at the re-evaluation fulfills established criteria. Endocrinologists experienced in the care of GHD adolescent patients held a workshop in Rome, Italy in July 2012 to review in detail the literature data and compare experiences of five Italian endocrinological centers on the negative consequences of interrupting GH treatment and the positive effects of continued GH replacement on intermediary metabolism, heart, muscle, pubertal development, and bone. The aim of the meeting was to delineate the state of the art on GH therapy in transition age and provide suggestions to pediatric and adult endocrinologists for a smooth transition care.

Growth hormone treatment of adolescents with growth hormone deficiency (GHD) during the transition period: results of a survey among adult and paediatric endocrinologists from Italy. Endorsed by SIEDP/ISPED, AME, SIE, SIMA

Treatment of adolescents with growth hormone deficiency (GHD) during the transition period is a controversial issue. This paper is a contribution from the Italian community of paediatric and adult endocrinologists surveyed in a Delphi panel. The Delphi method is a structured communication technique, originally developed as a systematic, interactive forecasting method that relies on a panel of experts. The experts answer questionnaires in two or more rounds. There was substantial agreement on the definition of the problems associated with the diagnosis and treatment of adolescents with GHD in the transition period, as well as on the identification of the controversial issues which need further studies. There is general consensus on the need of re-testing all isolated idiopathic GHD after at least 30-day withdrawn from treatment, while in patients with multiple pituitary deficiency and low IGF-I levels there is generally no need to re-test. In patients with permanent or confirmed GHD, a starting low rhGH dose (0.01-0.03 mg per day) to be adjusted according to IGF-I concentrations is also widely accepted. For those continuing treatment, the optimal therapeutic schedule to obtain full somatic maturation, normalization of body composition and bone density, cardiovascular function and Quality of Life, need to be evaluated.

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.

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.

Diet and physical activity "defeated" Tuberil® in treatment of childhood obesity

AIM

Childhood obesity is remarkably spreading worldwide, involving both industrialized and low-income countries. Its prevalence, outcome and socioeconomic impact call for the attention of medical community. We conducted a monocentric, open, two-arm, parallel-group study to evaluate the efficacy at reducing appetite and increasing dietary compliance of obese children of Tuberil®, a weight-loss supplement derived from potato and devoid of side effects.

METHODS

We recruited participants, children with BMI ≥ 85th, through direct referrals in pediatrician's surgeries. Children were randomized to receive Tuberil® (group A) or nothing (group B), following a chronological order (A-B-A-B). Every child received a nutritionally balanced diet and had to record their appetite and to describe their meals in a diary.

RESULTS

Even if we found a significant reduction in BMI, weight and waist circumference in both groups, no statistically significant differences between groups were noted. We did not found any significant differences in appetite between group A and B.

CONCLUSION

Our data show that Tuberil® has no efficacy neither in reducing appetite in children nor in increasing dietary compliance. We believe that only a nutritionally balanced diet and our attention in verifying their compliance led to the reduction in BMI, weight and waist circumferences noted in our series.

Prediction of response to growth hormone treatment in pre-pubertal children with growth hormone deficiency

BACKGROUND

GH therapy response varies substantially among patients. Several models were developed to predict the efficacy of GH therapy in children.

AIM

To evaluate the accuracy of a growth prediction model using data from an Italian pediatric GH deficiency (GHD) cohort (GeNeSIS, Growth Prediction Sub-study).

METHODS

Open-label, multicenter study in 22 Italian pre-pubertal GH treatment- naïve patients with GHD (8 female, 14 male, 0.5 to 12.2 yr), 18 isolated GHD, 4 multiple pituitary hormone deficiency given recombinat human GH therapy (0.025-0.035 mg/kg/day) for 12 months. Growth prediction was performed, after 3 months of treatment, using baseline data [bone age (BA) and IGF-I], a urinary marker of bone turnover [deoxypyridinoline crosslinks (DPD)] at 4 weeks, and height velocity (HV) at 3 months. Results were expressed as 1st-yr HV using the following equation: 1-yr HV (cm) = 3.543 - (2.337 × BA) - (0.010 × IGF-I) + (0.100 × DPD) + (0.299 × 3-month HV). Predictions were compared to the 1st-yr HV and accuracy was calculated as percentage of the difference between mean calculated HV and the real 1st-yr HV.

RESULTS

For females predicted HV was 12.98 ± 4.82 cm/yr and actually was 13.05 ± 3.91 cm/yr after the 1st year; for males predicted HV was 13.95 ± 5.39 cm/yr and actually was 12.93 ± 5.02 cm/yr.

CONCLUSIONS

In this paediatric Italian cohort with GHD, a growth prediction model seems to be a valid tool to assess 1st-yr response to GH treatment in Italian children.

Could the savory taste of snacks be a further risk factor for overweight in children?

INTRODUCTION

The quantity, type and composition of snack foods may play a role in the development and maintenance of obesity in children. A high consumption of energy-dense snacks may promote fat gain.

AIMS

To assess the type and number of snacks consumed weekly by a large sample of 8- to 10-year-old children, as well as to assess its relationship with body size.

RESULTS

The children consumed on average 4 snacks per day. There was no statistical difference in the number of servings per day between obese and nonobese children. However, the mean energy density of the foods consumed was significantly higher for obese and overweight children than for normal weight children [6.8 (0.3) kJ/g, 6.8 (0.16) kJ/g, and 6.3 (0.08) kJ/g, respectively; P < 0.05]. Logistic regression analysis showed that the energy density of the snacks (kJ/g), their savory taste (servings/week), television viewing (hours/day) and sports activity (hours/week) independently contributed to predict obesity in children. However, when the parents' body mass index was included among the independent variables of the regression, only salty foods and sports activity showed an independent association with childhood obesity.

CONCLUSIONS

Parents' eating habits and lifestyle influence those of their children, as suggested by the association between parents' obesity and their children's energy-dense food intake at snacktime, the savory taste of snacks and sedentary behavior. However, regardless of parents' body mass index, the preference for savory snacks seems to be associated with overweight in prepubertal children.

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.

Child thyroid disruption by environmental chemicals

Laboratory experiments and animal evidences support the fact that thyroid function can be altered by a large number of chemicals routinely found in the environment and in samples of human and wildlife tissues. Although humans are commonly exposed to low pollutant doses, disrupting effects on endocrine function (e.g. thyroid) from such chemical exposures represent major health concerns. Thyroid is essential for mammalian brain development both before and after birth, and recent clinical evidences strongly suggest that brain development is much more sensitive to thyroid hormone excess or deficit than previously believed. Thyroid hormone deficit or excess during development can have permanent, pervasive and profound effects on the neurological function of the child. In addiction, maternal thyroid hormones play a role in fetal brain development before the onset of fetal thyroid function, and thyroid hormone deficit in pregnant women can produce irreversible neurological effects in their offspring. Considering that thyroid hormones are important in fetal brain development and child neurological outcome, environmental factors affecting maternal/fetal/infant thyroid function, or thyroid hormone action directly, may affect fetal brain development and child neurological outcome. The aim of this paper is to discuss how environmental chemicals can interfere with the normal production, metabolism, and excretion of thyroid hormones, and their known impact on the thyroid system during child development.

Effect of GH treatment on bone mass in children with GH deficiency

Children with GH deficiency have reduced bone mass and mineral density in comparison with normal individuals. GH treatment improves the accrual of bone mass during childhood and adolescence, but suboptimal GH treatment may cause a reduced bone mass in adulthood. At final height, treated patients with GH deficiency have normal mean values of bone mass, but some patients showed reduced lumbar bone mineral density (BMD) values. Lumbar peak bone mass (PBM) in treated patients who discontinued the treatment at final height is delayed and reduced. GH treatment during the transition from late adolescence to young adulthood can increase bone mass and mineral density. In patients with GH deficiency a possible strategy for avoiding acquisition of a suboptimal bone mass in the young-adult, could be to continue GH treatment during the transition to adulthood up to the acquisition of PBM.

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.

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.

From Bone Biology to Bone Analysis

Bone development is one of the key processes characterizing childhood and adolescence. Understanding this process is not only important for physicians treating pediatric bone disorders, but also for clinicians and researchers dealing with postmenopausal and senile osteoporosis. Bone densitometry has great potential to enhance our understanding of bone development. The usefulness of densitometry in children and adolescents would be increased if the physiological mechanisms and structural features of bone were given more consideration in the design and interpretation of densitometric studies. This review gives an overview on the most relevant techniques of quantitative noninvasive bone analysis. Furthermore it describes the relationship between bone biology, selected surrogates describing the biological processes and the possibilities of measuring these surrogates specifically and precisely by the different devices. The overall recommendation for researchers in this field is to describe firstly the biological process to be analyzed (bone growth in length, remodeling or modeling, or all together), secondly the bone parameter which describes this process, and thirdly the reason for selecting a special device.

Final height in congenital adrenal hyperplasia due to 21-hydroxylase deficiency: the Italian experience

OBJECTIVE

To investigate the influence of target height (TH), gender, phenotype, glucocorticoid formulation and age at onset of treatment on final height (FH) in patients with 21-hydroxylase deficiency (21OHD).

PATIENTS

Clinical data of 93 patients--46 simple virilizing (SV), 35 salt-wasting (SW) and 12 late onset (LO)--were collected in six pediatric endocrinology units in Italy.

RESULTS

FH and TH were always below the mean height of the general population (mean FH, SDS: SW patients -1.3 +/- 1.2, SV patients -1.8 +/- 0.9, LO patients -1.7 +/- 1.1; mean TH, SDS: SW patients -0.6 +/- 0.8, SV patients -0.7 +/- 0.9, LO patients -1.4 +/- 1.3). FH was significantly below TH in patients with classic form (SW and SV, p <0.001), but not in LO patients. In classic form, TH seems to be related to FH, followed by age at onset of therapy and by steroid formulation, these variables explaining 30% of FH variance.

CONCLUSIONS

In the classic form, substitutive therapy started before 21 months of age improved the long-term outcome. Lower TH in LO patients could be due to undiagnosed non-classic 21OHD in some of their parents. FH in LO patients seems not to benefit from corticosteroid therapy, even if late diagnosis may partly account for this result.

Effect of gonadotropin-releasing hormone agonist treatment in boys with central precocious puberty: final height results

OBJECTIVE

The small number of boys present in most studies on final height (FH) after gonadotropin-releasing hormone agonist (GnRHa) treatment for central precocious puberty (CPP) offers difficulties in the evaluation of the effects of treatment on FH in males.

METHOD

We therefore combined FH data from The Netherlands, Italy and France to study the effect of GnRHa treatment in a large group of 26 boys with CPP.

RESULTS

The mean chronological age at the start of treatment was 7.6 +/- 2.0 (SD) years, bone age (BA) was 11.0 +/- 2.1 years. All boys were treated with depot formulations of the GnRHa triptorelin with established gonadal suppression for a mean treatment period of 4.7 +/- 2.1 years. FH was 172.9 +/- 6.6 cm. FH standard deviation score (SDS) was -0.66 +/- 1.22, not significantly different from the target height SDS of -0.23 +/- 0.75. FH-SDS was significantly lower in the subgroup of 12 patients with organic CPP compared to patients with idiopathic CPP (-1.34 +/- 1.06 vs. -0.08 +/- 1.06, respectively; p = 0.01), but no difference in height gain was observed. The mean estimated height gain, defined as the difference between predicted and actual adult height was 6.2 +/- 8.7 cm using the average tables of Bayley and Pinneau, and 0.3 +/- 8.6 cm using the BA advance adjusted tables. Regional differences in height gain were observed between the different countries, reflecting different local practices.

CONCLUSION

We conclude that GnRHa treatment in boys results in a FH close to target height.

[Clinical problem in managing adolescents with short stature]

Short stature in adolescence may cause some medical, psychological and social concerns, in addition to specific diagnostic and therapeutical problems. Among the various causes of short stature, the present review will examine in detail some forms such as constitutional delay of growth and puberty, growth hormone deficiency and Turner's syndrome, since these forms will benefit from an appropriate medical approach in adolescence. The diagnostic and therapeutical problems these forms may present in adolescence are also discussed.

[Young at risk. The adolescence pediatrician: interventions]

The major health problems in adolescents are represented by some conditions, known as "new morbidity", affecting about 20-25 % of young people. Pediatricians should be able to address the adolescents health needs by the development of specific health programs. In organizing such programs, the pediatricians should be able to co-ordinate the activities of other care-givers, such as neurologists, psychiatrist, gynecologists, dermatologists and other people working with young people as well (teachers, social assistants, etcetera). If the health programs will be developed, they could reduce the incidence of the new morbidity in the adolescents, improving their health status and those of adults as well.

A comparison between radiographic and sonographic assessment of hand and wrist bones for the estimation of skeletal age in the child patient

AIM

The purpose of this study was to examine, with a sonographic investigation, the hand and wrist bones of a group of young patients and to compare the results with those obtained with a classical radiographic assessment.

MATERIALS AND METHODS

Some 25 subjects, 9-18 years of age, who presented problems concerning their short stature or precocious puberty, were evaluated. Each subject was examined by a standard radiographic assessment and by a sonographic investigation with real-time imaging. Sonographic examination was performed on the metacarpus-phalanx articulation of the first finger in order to locate the sesamoid bone. Sonographic examination was also performed on the second and third phalanxes of the third finger and on the distal portion of the radius to evaluate the characteristics of growth cartilage in the area.

RESULTS AND STATISTICS

In all the cases where a sesamoid bone was present, this was correctly identified by the sonogram, even up to the initial appearance of its ossification nucleus. Sensitivity, specificity, and diagnostic accuracy were all 100%. The capping phenomenon seen in radiographs was not detected by sonographic investigation in any of the cases. Sonographic evaluation of the fertile cartilage of the third finger distal phalanx demonstrated a sensitivity of 89%, a specificity of 100% and a diagnostic accuracy of 92%. Sonographic evaluation of the radius cartilage showed a sensitivity of 95%, a specificity of 100% and a diagnostic accuracy of 96%.

CONCLUSION

Sonographic evaluation of hand and wrist bones cannot accurately reproduce the results of the classical radiographic evaluation. However, the sonographic investigation may be useful, when integrated in a radiographic investigation.

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.

Hormonal treatment for unilateral inguinal testis: comparison of four different treatments

BACKGROUND

Hormonal treatment of cryptorchidism has been used since the 30s, but controversies persist on its efficacy. It is also unclear whether there are differences with the use of different hormonal trials.

AIMS

To evaluate the efficacy of four hormonal treatments on testicular descent in a homogeneous group of cryptorchid boys.

PATIENTS

155 patients (age 10-48 months) with unilateral inguinal palpable testis were studied.

METHODS

The patients were subdivided into four groups according to hormonal treatment: group 1 = hCG [500 IU/week (if the chronological age was <2 years) or 1,000 IU/week (if the chronological age was >2 years) for 6 weeks]; group 2 = hCG + hMG (hCG as in group 1 + hMG 75 IU/week for 6 weeks); group 3 = GnRH (1,200 microg/daily for 28 days); group 4 = GnRH + hCG (1,200 microg/daily for 28 days + 1,500 IU/week for 3 weeks, respectively). The results were evaluated at the end of the treatment period and 6 months later to exclude temporarily positive results.

RESULTS

At the end of the hormonal therapy, scrotal testicular descent was present in 30 of 155 boys (success rate 19.3%). Seven testes relapsed during follow-up (23.3%). The long-term success rate was 14.8% (23/155 testes). No significant differences were observed in success rates as well as in relapse rates among the four groups.

CONCLUSIONS

Hormonal therapy induced permanent testicular descent in a minority of young cryptorchid boys with inguinal palpable testis. Similar results were obtained with four different trials.

[Adolescent health care in pediatric departments of Tuscany]

BACKGROUND

Admission to Pediatric Departments for 0/18- year-old patients is an important issue for the best organization of pediatric hospital assistance. Aim of the study. To locate adolescent health care and identify the percentage of adolescent admissions to Pediatric Departments in an Italian region (Tuscany).

METHODS

Adolescent health care in pediatric departments and pediatric admissions (0-18 years old) in 1999 into the reference hospital of Pisa and into 5 other regional hospitals in Tuscany are reported. The percentages of patients, subdivided by age, hospitalyzed in Pediatric Departments have been determined.

RESULTS

In 1999 the admissions for subjects aged 0 to 18 years were 12573 of which 4966 adolescents (39.6 %). The percentage of adolescent admissions is not smaller than children's admissions (aged 0 to 1 year: 16.2%; aged 2 to 5 years: 26.2%; aged 6 to 9 years: 17.8%; aged 10 to 14 years: 20.4%; aged 15 to 18 years: 19.2%). Analysis by age demonstrated a continuous decrease of patient percentages admitted to Pediatric Departments with the increased age. A minority of 15/18- year-old subjects has been admitted to Pediatric Departments.

CONCLUSIONS

The percentage of adolescent admissions is similar to there of children. Most adolescents are admitted to structures unsuitable for assistance to subjects aged 0 to 18 years. These data underline the necessity for a strong recovery of adolescent admissions to pediatric structures also equipping suitable nursing rooms.

Osteoporosis in children and adolescents: diagnosis, risk factors, and prevention

Bone mass acquired during childhood and adolescence is a key determinant of adult bone health. Peak bone mass, which is achieved in late adolescence, is a main determinant of osteoporosis in adulthood. Therefore, any factor adversely impacting on bone acquisition during childhood or adolescence can potentially have long-standing detrimental effects on bone health predisposing to osteoporosis and fracture risk. Thus, osteoporosis can well have its origin in childhood and adolescence. Pediatricians should be playing an active role in osteoporosis diagnosis and prevention. It is increasingly recognized that osteoporosis may occur in some disorders of children and adolescents. In this paper we review the diagnostic criteria of osteopenia/osteoporosis by densitometric assessment of bone mineral density, the contributing factors, and the mechanisms whereby several disorders may affect the acquisition of bone mass in children and adolescents. Finally, some recommendations to optimize peak bone mass in order to prevent osteopenia/osteoporosis are suggested.

Critical ages and stages of puberty in the accumulation of spinal and femoral bone mass: the validity of bone mass measurements

In growing children, lumbar and femoral areal bone mineral density (aBMD), as measured by dual-energy X-ray absorptiometry (DXA), is influenced by skeletal growth and bone size. Correction of lumbar bone mineral density (BMD) for bone volume (volumetric BMD [vBMD]), by the use of mathematical extrapolations, reduces the confounding effect of bone size, but vBMD remains dependent on age and bone size during growth. Femoral (neck and mid-shaft) vBMD, assessed by DXA, is independent of age prior to puberty, but a slight increase occurs in late puberty and after menarche. Femoral (mid-shaft) cortical bone density and radial cortical and trabecular bone densities, assessed by quantitative computed tomography (QCT), show no peak during childhood or adolescence. Bone strength index, calculated by peripheral QCT, increases with age and correlates with handgrip strength, bone cross-sectional area and cortical area. Puberty is one of the main factors that influences lumbar bone mineral content and aBMD accumulation, but a high incidence of fractures occurs during this period of life, which may be associated with a reduced aBMD.

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.

Volumetric bone mineral density in young women with Turner's syndrome treated with estrogens or estrogens plus growth hormone

To explore the effects of estrogen replacement therapy (ERT) and recombinant growth hormone (GH) treatment on bone mineral density (BMD) in Turner's syndrome, we assessed volumetric BMD (vBMD), which is less dependent on body and bone sizes, in these patients at final height. The areal BMD (aBMD) was measured in 26 young women with Turner's syndrome (age range 17.5-25.0 years) by dual-energy X-ray absorptiometry, and vBMD was calculated. Patients were subdivided as group 1 (n = 12; ERT alone) and group 2 (n = 14; GH + ERT). Years of estrogen exposure were not different between the groups (group 1: 6. 4 +/- 1.5 years; group 2: 5.3 +/- 1.7 years); in group 2, GH therapy was 5.3 +/- 1.4 years. Final heights were significantly higher in group 2 than in group 1 (148.1 +/- 3.0 vs. 142.0 +/- 2.8 cm; p < 0. 0001) as well as aBMD (1.073 +/- 0.118 vs. 0.968 +/- 0.122 g/cm(2); p < 0.04). vBMD was higher in group 2 but not significantly different from group 1 (0.374 +/- 0.030 vs. 0.358 +/- 0.027 g/cm(3); p = 0.169). aBMD was reduced with respect to the normative values in both groups (group 1: -1.97 +/- 1.04 SDS, p < 0.0001 vs. 0; group 2: -0.93 +/- 1.01 SDS, p < 0.005 vs. 0), whereas vBMD was not (group 1: -0.07 +/- 0.79 SDS; group 2: 0.42 +/- 0.82 SDS). Our data suggest that: in Turner's syndrome GH administration improves final height and aBMD, but it does not significantly increase vBMD; aBMD reduction in Turner's syndrome is likely due to the impaired growth and reduced bone size; Turner's patients on ERT from adolescence show vBMD values in the normal range in young adulthood.

Effect of growth hormone treatment on final height, phosphate metabolism, and bone mineral density in children with X-linked hypophosphatemic rickets

OBJECTIVE

To evaluate the effect of growth hormone treatment on final height, phosphate metabolism, bone markers, and bone mineral density in children with X-linked hypophosphatemic rickets.

STUDY DESIGN

Six patients (aged 7.8 +/- 1.8 years; height z score, -3.4 +/- 0.5) received conventional treatment (1,25-dihydroxyvitamin D(3) plus phosphate salts) combined with growth hormone (0.6-0.9 IU/kg per week, subcutaneously) (group A); 6 patients (aged 7.9 +/- 2.5 years; height z score, -2.1 +/- 0.6, P <.01 with respect to group A) received only conventional treatment (group B).

RESULTS

Final height z score significantly improved in group A (-2.4 +/- 0.5, P <.03 with respect to the value at entry), whereas it did not change in group B (-2.8 +/- 0.5, P = NS). At final height, degree of body disproportion was similar between the groups (group A, 1.3 +/- 0.2; group B, 1.2 +/- 0.1; P = NS). Phosphate retention, bone markers, and radial bone mineral density increased only in group A. No adverse effects were observed.

CONCLUSIONS

In poorly growing patients with X-linked hypophosphatemic rickets, growth hormone therapy combined with conventional treatment improves final height, phosphate retention, and radial bone mineral density, but it does not influence degree of body disproportion.

Hypophosphataemic rickets

X-Linked hypophosphataemic rickets (XLH) is frequently associated with short stature even when conventional treatment (1, 25-dihydroxyvitamin D(3) or 1alpha-hydroxyvitamin D(3) plus inorganic phosphate salts) is administered for a long time. The pathogenesis of growth retardation is probably multifactorial. Affected patients usually show normal growth hormone (GH) secretion. In some poorly growing XLH patients, long-term GH treatment associated with conventional therapy improves linear growth. GH treatment also increases phosphate retention but this effect is transient.

Diagnosis and treatment of growth hormone deficiency in children and adolescents: towards a consensus. Ten years after the Availability of Recombinant Human Growth Hormone Workshop held in Pisa, Italy, 27-28 March 1998

This article summarizes the content of an international workshop on the diagnosis and treatment of growth hormone deficiency (GHD) in children and adolescents that was held in Pisa, Italy, in March 1998. The issues discussed are divided into those addressing the definition and diagnosis, and the treatment of GHD in children and adolescents, and those concerning the transition of patients with GHD from adolescence to adulthood. Recommendations are presented for improving the diagnosis and management of children and adolescents with GHD and issues are highlighted that require further studies to be undertaken before recommendations can be made.

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.

Androgens and fetal growth

Boys are heavier than girls at term birth. Children with a 46,XY karyotype and androgen insensitivity syndrome (clinically complete form and/or proven mutations in the androgen receptor gene) were found to have a birth weight comparable to that of girls. These findings support the hypothesis that the difference in birth weight between boys and girls is generated by androgen action.