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Stein D, Ovadia D, Katz S, Brar PC. Association of hepatokines with markers of endothelial dysfunction and vascular reactivity in obese adolescents. J Pediatr Endocrinol Metab 2024; 37:309-316. [PMID: 38404032 DOI: 10.1515/jpem-2023-0339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 02/05/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES Obesity-induced insulin resistance (IR) is known to influence hepatic cytokines (hepatokines), including fibroblast growth factor (FGF-21), fetuin-A, and chemerin. This study aimed to investigate the association between hepatokines and markers of endothelial dysfunction and vascular reactivity in obese adolescents. METHODS A total of 45 obese adolescents were categorized into three groups based on glucose tolerance: normal glucose tolerance (NGT), prediabetes (PD), and type 2 diabetes (T2D). We examined the relationships between FGF-21, fetuin-A, and chemerin with endothelial markers (plasminogen activator inhibitor-1 [PAI-1], intercellular adhesion molecule-1 [ICAM-1], and vascular cell adhesion marker-1 [VCAM-1]) and vascular surrogates (brachial artery reactivity testing [BART] and peak reactive hyperemia [PRH]). RESULTS Obese adolescents (age 16.2±1.2 years; 62 % female, 65 % Hispanic) with NGT (n=20), PD (n=14), and T2D (n=11) had significant differences between groups in BMI; waist-hip ratio (p=0.05), systolic BP (p=0.008), LDL-C (p=0.02), PAI-1 (p<0.001). FGF-21 pg/mL (mean±SD: NGT vs. PD vs. T2D 54±42; 266±286; 160±126 p=0.006) and fetuin-A ng/mL (266±80; 253±66; 313±50 p=0.018), were significantly different while chemerin ng/mL (26±5; 31±10; 28±2) did not significantly differ between the groups. Positive correlations were found between chemerin and both PAI-1 (r=0.6; p=0.05) and ICAM-1 (r=0.6; p=0.05), FGF-21 and PAI-1 (r=0.6; p<0.001), and fetuin-A with TNFα (r=-0.4; p=0.05). Negative correlations were found between chemerin and PRH (r= -0.5; p=0.017) and fetuin-A and PRH (r=-0.4; p=0.05). CONCLUSIONS In our cohort, IR predicted higher FGF-21 levels suggesting a linear relationship may exist between the two parameters. Hepatokines can augment alterations in the microvascular milieu in obese adolescents as demonstrated by their associations with the markers PAI-1, ICAM-1, and PRH.
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Affiliation(s)
- David Stein
- Faculty of Medicine, 26745 Tel Aviv University , Tel Aviv, Israel
| | | | - Stuart Katz
- NYU Grossman School of Medicine Department, 5894 NYU Langone Health , New York, NY, USA
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, 5894 New York University Grossman School of Medicine , New York, NY, USA
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Brar PC, Mehta S, Brar A, Pierce KA, Albano A, Bergman M. Value of 1-Hour Plasma Glucose During an Oral Glucose Tolerance Test in a Multiethnic Cohort of Obese Children and Adolescents. Clin Med Insights Endocrinol Diabetes 2023; 16:11795514231177206. [PMID: 37323220 PMCID: PMC10262663 DOI: 10.1177/11795514231177206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 05/04/2023] [Indexed: 06/17/2023] Open
Abstract
One hour plasma glucose (1-hr PG) concentration during an oral glucose tolerance test (OGTT) is steadily emerging as an independent predictor of type 2 diabetes (T2D). Methods We applied the current cut off thresholds reported in the pediatric literature for the 1-hr PG, 132.5 (7.4 mmol/l) and 155 mg/dL (8.6 mmol/l) during an OGTT, to report abnormal glucose tolerance (AGT) using ROC curve analyses. We determined the empirical optimal cut point for 1-hr PG for our multi ethnic cohort using the Youden Index. Results About 1-hour and 2-hours plasma glucose showed the highest predictive potential based on Areas under the curve (AUC) values of 0.91 [CI: 0.85, 0.97] and 1 [CI: 1, 1], respectively. Further comparison of the ROC curves of the 1-hour and 2-hour PG measurements as predictors of an abnormal OGTT showed that their associated AUCs differed significantly (X2(1) = 9.25, P < .05). Using 132.5 mg/dL as the cutoff point for plasma glucose at 1-hour yielded a ROC curve with an AUC of 0.796, a sensitivity of 88%, and a specificity of 71.2%. Alternatively, the cutoff point of 155 mg/dL resulted in a ROC AUC of 0.852, a sensitivity of 80%, and a specificity of 90.4%. Conclusion Our cross-sectional study affirms that the 1-hr PG can identify obese children and adolescents at increased risk for prediabetes and/or T2D with almost the same accuracy as a 2-hr PG. In our multi-ethnic cohort, a 1-hr PG ⩾ 155 mg/dL (8.6 mmol/l) serves as an optimal cut-point, using the estimation of the Youden index with AUC of 0.86 and sensitivity of 80%.We support the petition to consider the 1-hr PG as integral during an OGTT, as this adds value to the interpretation of the OGTT beyond the fasting and 2-hr PG.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA
| | - Shilpa Mehta
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York Medical College, Valhalla, New York, USA
| | - Ajay Brar
- Biology and Public Health, College of Arts and Science, New York University, New York, USA
| | - Kristyn A Pierce
- Department of Pediatrics, New York University Grossman School of Medicine
| | | | - Michael Bergman
- Departments of Medicine and Population Health, Division of Endocrinology, Diabetes and Metabolism, New York University Grossman School of Medicine, New York, USA
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Abstract
PURPOSE OF REVIEW Non-invasive measurements such as arterial stiffness serve as proxy surrogates for detection of early atherosclerosis and ASCVD risk stratification. These surrogate measurements are influenced by age, gender, and ethnicity and affected by the physiological changes of puberty and somatic growth in children and adolescents. RECENT FINDINGS There is no consensus of the ideal method to measure surrogate markers in youth (< 18 years of age), nor standardized imaging protocols for youth. Currently, pediatric normative data are available but not generalizable. In this review, we provide rationale on how currently used surrogates can help identify subclinical atherosclerosis in youth and affirm their role in identifying youth at risk for premature CVD.
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Baby M, Ilkowitz J, Cheema Brar P. Impacts of the COVID-19 pandemic on the diagnosis of idiopathic central precocious puberty in pediatric females in New York City. J Pediatr Endocrinol Metab 2023:jpem-2022-0628. [PMID: 37114861 DOI: 10.1515/jpem-2022-0628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND The COVID-19 pandemic had profound effect on physical and mental health. Stress was due physical inactivity, increased screen time, social isolation, fear of illness/death, as well as relative lack of resources including healthy food and finances. These stressors may be associated with an increase in idiopathic central precocious puberty (ICPP). OBJECTIVES To assess the incidence of ICPP in females during the COVID-19 pandemic and compare biochemical and radiological parameters of females diagnosed in the previous two years, looking at associations among BMI, screen time, isolation, and stress in relation to the development of early puberty. METHODS A retrospective chart review was performed of females diagnosed with ICPP. We divided subjects into a pandemic group and pre-pandemic group based on time of diagnosis. We compared anthropometric, serologic and radiologic data between the two groups. To assess psychosocial stress, we reviewed a COVID-19 impact survey which was administered to families at our endocrine clinic. RESULTS There were a total of 56 subjects in the study; 23 subjects in the pre-pandemic group and 33 in the pandemic group. The pandemic cohort had significantly higher estradiol and LH levels and larger ovarian volumes. Survey results showed parental report of stress was moderate in 38 % of subjects and severe in 25 % of parents. In children, reported stress was moderate in 46 % of subjects. CONCLUSIONS As puberty is influenced by exogenous factors including weight gain and psychosocial stress, we suspect that the environmental stress surrounding the pandemic influenced the increase in ICPP.
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Affiliation(s)
- Merilyn Baby
- Pediatric Endocrine Fellow, Division of Pediatric Endocrinology and Diabetes, NYU, New York, USA
| | - Jeniece Ilkowitz
- Clinical Research Nurse, Division of Pediatric Endocrinology and Diabetes, NYU, New York, USA
| | - Preneet Cheema Brar
- Pediatric Endocrine Attending, Associate Professor, Division of Pediatric Endocrinology and Diabetes, NYU, New York, USA
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Bansal N, Kumar S, Brar PC. Update on management of paediatric dyslipidaemia. Curr Opin Endocrinol Diabetes Obes 2023; 30:52-64. [PMID: 36541082 DOI: 10.1097/med.0000000000000794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Atherosclerosis and associated cardiovascular risk factors originate in childhood; hence, early management of dyslipidaemia is vital. However, hypercholesterolemia remains untreated or undertreated in many youths. We review current therapies, drugs under investigation and consider potential future directions for the management of paediatric dyslipidaemia to highlight the recent evidence and new therapeutic options for future use. RECENT FINDINGS Cardiovascular disease (CVD) risk factors in childhood, including dyslipidaemia, are associated with CVD risk and clinical CVD events in adulthood. Recent data show that initiation of statin therapy in childhood in children with familial hypercholesterolemia reduces the risk of CVD in adulthood. Several well tolerated and efficacious treatment options have become available in recent times for the management of dyslipidaemia in youth. Many new lipid-lowering drugs are under investigation to widen the available choices. Some of these drugs are now available for use in paediatrics, while some remain targets for future use. SUMMARY We review available treatment options for paediatric dyslipidaemia management, discuss potential limitations and propose future directions. We also acknowledge the need for continued research in paediatrics for optimal paediatric dyslipidaemia management.
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Affiliation(s)
- Nidhi Bansal
- Division of Pediatric Endocrinology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, New York, USA
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Gutierrez Alvarez A, Yachelevich N, Kohn B, Brar PC. Genotype - phenotype correlation in an adolescent girl with pathogenic variant in PPARƴ gene causing severe hypertriglyceridemia and early onset type 2 diabetes. Ann Pediatr Endocrinol Metab 2021; 26:284-289. [PMID: 34991302 PMCID: PMC8749027 DOI: 10.6065/apem.2142056.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022] Open
Abstract
Severe hypertriglyceridemia (HTG) (>885 mg/dl) can be caused by familial partial lipodystrophy Type 3 (FPLD 3), an autosomal dominant disorder caused by a loss of function of the peroxisome proliferator activated receptor gamma (PPARG), characterized by abnormal distribution of fat and metabolic derangements. A 16-year-old female (body mass index, BMI 23.5 kg/m2) was hospitalized twice for pancreatitis (TG level >2200 mg/dl). She was managed with bowel rest, insulin infusion, and plasmapheresis. On a low fat 10 g daily diet and fenofibrate 160 mg daily her fasting TG had decreased to 411 mg/dL (range 0-149). She had a normal leptin level. Panel testing of genes involved in triglyceride metabolism revealed a known pathogenic variant in PPARG gene (c.452A>G p.Tyr151Cys). A second variant detected in this gene, c.1003G>C (p.Val335Leu), is considered benign. HbA1C of 6.6% and two-hours oral glucose tolerance test confirmed Type 2 diabetes (T2DM). We outline the earliest description of T2DM in an adolescent with a pathogenic variant of PPARG. PPARG related FLPD 3 should be considered in lean children presenting with severe HTG and insulin resistance and treatment with PPARy agonists Thiazolidinediones should be considered.
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Affiliation(s)
- Ana Gutierrez Alvarez
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Naomi Yachelevich
- Division of Clinical Genetics, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Brenda Kohn
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA
| | - Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, NY, USA,Address for correspondence: Preneet Cheema Brar Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, 150 East 32nd street, L2, New York, NY 10016, USA
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Lahoti A, Yu C, Brar PC, Dalgo A, Gourgari E, Harris R, Kamboj MK, Marks S, Nandagopal R, Page L, Raman V, Reynolds DG, Sarafoglou K, Terrell C, Stanley TL. An endocrine perspective on menstrual suppression for adolescents: achieving good suppression while optimizing bone health. J Pediatr Endocrinol Metab 2021; 34:1355-1369. [PMID: 34388330 DOI: 10.1515/jpem-2020-0539] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 07/19/2021] [Indexed: 11/15/2022]
Abstract
Suppression of menstruation and/or ovarian function in adolescent girls may be desired for a variety of reasons. Numerous medical options exist. The choice of the appropriate modality for an individual patient depends on several factors based on differences in the efficacy of achieving menstrual suppression as well as in their side effect profiles. Adolescence is also a period of bone mass accrual in girls, and several of these modalities may negatively influence peak bone mass. This review focuses on the efficacy of achieving menstrual suppression and the effect on bone health of the various options through an overview of the current literature and also highlights areas in need of further research.
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Affiliation(s)
- Amit Lahoti
- Pediatric Endocrine Division, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Christine Yu
- Section of Adult and Pediatric Endocrinology, Diabetes, & Metabolism, University of Chicago, Chicago, IL, USA
| | - Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, NYU Grossman School of Medicine, New York, NY, USA
| | - Austin Dalgo
- Center for Bioethics and Health Equity, Le Bonheur Children's Hospital and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Evgenia Gourgari
- Pediatric Endocrinology Division, Department of Pediatrics, Georgetown University, Washington, DC, USA
| | - Rebecca Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Manmohan K Kamboj
- Section of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital at The Ohio State University, Columbus, OH, USA
| | - Seth Marks
- Section of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, Children's Hospital HSC Winnipeg, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Radha Nandagopal
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Laura Page
- Division of Endocrinology, Department of Pediatrics, Duke University, Durham, NC, USA
| | | | - Danielle G Reynolds
- Diabetes and Endocrinology Center, University of South Florida, Tampa, FL, USA
| | - Kyriakie Sarafoglou
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA.,Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, MN, USA
| | - Carrie Terrell
- Division of General Obstetrics, Gynecology, Midwifery and Family Planning at the University of Minnesota Medical School, Minneapolis, MN, USA
| | - Takara L Stanley
- Pediatric Endocrine Unit and Metabolism Unit, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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Ashraf AP, Sunil B, Bamba V, Breidbart E, Brar PC, Chung S, Gupta A, Khokhar A, Kumar S, Lightbourne M, Kamboj MK, Miller RS, Patni N, Raman V, Shah AS, Wilson DP, Kohn B. Case Studies in Pediatric Lipid Disorders and Their Management. J Clin Endocrinol Metab 2021; 106:3605-3620. [PMID: 34363474 PMCID: PMC8787854 DOI: 10.1210/clinem/dgab568] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Identification of modifiable risk factors, including genetic and acquired disorders of lipid and lipoprotein metabolism, is increasingly recognized as an opportunity to prevent premature cardiovascular disease (CVD) in at-risk youth. Pediatric endocrinologists are at the forefront of this emerging public health concern and can be instrumental in beginning early interventions to prevent premature CVD-related events during adulthood. AIM In this article, we use informative case presentations to provide practical approaches to the management of pediatric dyslipidemia. CASES We present 3 scenarios that are commonly encountered in clinical practice: isolated elevation of low-density lipoprotein cholesterol (LDL-C), combined dyslipidemia, and severe hypertriglyceridemia. Treatment with statin is indicated when the LDL-C is ≥190 mg/dL (4.9 mmol/L) in children ≥10 years of age. For LDL-C levels between 130 and 189 mg/dL (3.4-4.89 mmol/L) despite dietary and lifestyle changes, the presence of additional risk factors and comorbid conditions would favor statin therapy. In the case of combined dyslipidemia, the primary treatment target is LDL-C ≤130 mg/dL (3.4 mmol/L) and the secondary target non-high-density lipoprotein cholesterol <145 mg/dL (3.7 mmol/L). If the triglyceride is ≥400 mg/dL (4.5 mmol/L), prescription omega-3 fatty acids and fibrates are considered. In the case of triglyceride >1000 mg/dL (11.3 mmol/L), dietary fat restriction remains the cornerstone of therapy, even though the landscape of medications is changing. CONCLUSION Gene variants, acquired conditions, or both are responsible for dyslipidemia during childhood. Extreme elevations of triglycerides can lead to pancreatitis. Early identification and management of dyslipidemia and cardiovascular risk factors is extremely important.
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Affiliation(s)
| | | | - Vaneeta Bamba
- Department of Pediatrics, Division of Endocrinology, Children’s Hospital of Philadelphia, The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Emily Breidbart
- Department of Pediatrics, Division Pediatric Endocrinology and Diabetes NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division Pediatric Endocrinology and Diabetes, NYU Langone Medical Center, NYU Grossman School of Medicine, New York, NY 10016, USA
| | - Stephanie Chung
- Section on Pediatric Diabetes, Obesity, and Metabolism, National Institutes of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, MD 20814, USA
| | - Anshu Gupta
- Department of Pediatrics, Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, VA 23219, USA
| | - Aditi Khokhar
- Department of Pediatrics, Rutgers New Jersey Medical School, NJ 07103, USA
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Marissa Lightbourne
- Pediatric and Adult Endocrinology Faculty, NICHD, National Institutes of Health, Bethesda, MD 20814, USA
| | - Manmohan K Kamboj
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH 43205, USA
| | - Ryan S Miller
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD 21093, USA
| | - Nivedita Patni
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Vandana Raman
- Department of Pediatrics, University of Utah, Salt Lake City, UT 84108, USA
| | - Amy S Shah
- Department of Pediatrics, Adolescent Type 2 Diabetes Program, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Don P Wilson
- Cardiovascular Health and Risk Prevention, Pediatric Endocrinology and Diabetes, Cook Children’s Medical Center, Fort Worth, TX 76104, USA
| | - Brenda Kohn
- Correspondence: Brenda Kohn, MD, Division Pediatric Endocrinology, NYU Medical Center, NYU Grossman School of Medicine, 530 1st Ave, New York, NY 10016, USA.
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Brar PC, Tell S, Mehta S, Franklin B. Hyperosmolar diabetic ketoacidosis-- review of literature and the shifting paradigm in evaluation and management. Diabetes Metab Syndr 2021; 15:102313. [PMID: 34731818 DOI: 10.1016/j.dsx.2021.102313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 09/22/2021] [Accepted: 10/10/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Hyperosmolar diabetic ketoacidosis (H-DKA), a distinct clinical entity, is the overlap of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS). AIM We describe the clinical presentation, metabolic aberrations, and associated morbidity/mortality of these cases with H-DKA. We highlight the problem areas of medical care which require particular attention when caring for pediatric diabetes patients presenting with H-DKA. METHODS In our study we reviewed the literature back to 1963 and retrieved twenty-four cases meeting the criteria of H-DKA: glucose >600 mg/dL, pH < 7.3, bicarbonate <15 mEq/L, and serum osmolality >320 mOsm/kg, while adding three cases from our institution. RESULTS Average age of presentation of H-DKA was 10.2 years ± 4.5 years in females and 13.3 years ± 4 years in males, HbA1c was 13%. Biochemical parameters were consistent with severe dehydration: serum osmolality = 394.8±55 mOsm/kg, BUN = 48±22 mg/dL, creatinine = 2.81±1.03 mg/dL. Acute kidney injury, present in 12 cases, was the most frequent end-organ complication. CONCLUSION Multi-organ involvement with AKI, rhabdomyolysis, pancreatitis, neurological and cardiac issues such as arrhythmias, are common in H-DKA. Aggressive fluid management, insulin therapy and supportive care can prevent acute and long term adverse outcomes in children and adolescents.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA.
| | - Shoshana Tell
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Anschutz Medical Campus & Children's Hospital Colorado, Aurora, CO, USA
| | - Shilpa Mehta
- Division of Pediatric Endocrinology and Diabetes, New York Medical College, Hawthorne, NY, USA
| | - Bonita Franklin
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York, USA
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Alex-Ann Beliard K, Shyamkumar S, Brar PC, Rapaport R. Graves disease in infancy: a patient presentation and literature review. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM200162. [PMID: 34156351 PMCID: PMC8240725 DOI: 10.1530/edm-20-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 05/24/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY We describe a case of an infant who presented with clinical features of hyperthyroidism. The child was found to be tachycardic, hypertensive and diaphoretic, she was noted to have poor weight gain and difficulty in sleeping. The child was admitted to the pediatric intensive care unit for care. She was found to have biochemical evidence of hyperthyroidism with positive thyroid stimulating immunoglobulin. She responded well to methimazole and propranolol and had a remarkable recovery. She is the youngest patient to be diagnosed with Graves disease in the English literature, at 12 months of life. LEARNING POINTS Hyperthyroidism must always be considered even at very young age, for patient presenting with poor weight gain and hyperdynamic state. Autoimmune diseases are becoming more common in infancy. Craniosynostosis and increased height for age are well-documented consequences of untreated hyperthyroidism in developing children.
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Affiliation(s)
- Kara Alex-Ann Beliard
- Icahn School of Medicine, Mount Sinai Department of Pediatric Endocrinology, Kravis Children's Hospital, New York, NY, USA
| | | | - Preneet Cheema Brar
- Division of Pediatric Endocrinology, New York University Grossman School of Medicine, New York, NY, USA
| | - Robert Rapaport
- Icahn School of Medicine, Mount Sinai Department of Pediatric Endocrinology, Kravis Children's Hospital, New York, NY, USA
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Brar E, Saxena A, Dukler C, Xu F, Saxena D, Cheema Brar P, Guo Y, Li X. Vaping, SARS-CoV-2, and Multisystem Inflammatory Syndrome: A Perfect Storm. Front Pediatr 2021; 9:647925. [PMID: 34055688 PMCID: PMC8149601 DOI: 10.3389/fped.2021.647925] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
The use of electronic cigarettes (e-cigarettes) and vaping among adolescents has risen exponentially in the last decade. E-cigarette flavors has driven adolescents to use these convenient, USB-like devices, designed to create a desired social image, while being seemingly unaware of the serious health consequences of their behavior. Vaping impacts protective pulmonary barriers by attenuating the mucociliary clearance and by increasing peribronchial inflammation and fibrosis. The recent SARS-CoV-2 (COVID-19) pandemic has been characterized by a plethora of unusual disease presentations. Among them, a unique presentation seen exclusively in children and adolescents was multisystem inflammatory syndrome (MIS-C). Seventy percent of adolescents who had MIS-C also had acute respiratory distress syndrome (ARDS), and we speculate that there may exist common denominator that links MIS-C and adolescents: the use of e-cigarettes. The virus targets the angiotensin converting receptor (ACE receptor), and studies have shown nicotine-based e-cigarettes or vaping cause oxidative stress and resulting in the upregulation of ACE2, which might worsen ARDS in MIS-C. Our mini-review highlights that adolescents using e-cigarette have alterations in their pulmonary defenses against SARS-CoV-2: an upregulation of the ACE2 receptors, the primary target of SARS-CoV-2. Their compromised immune system makes them more uniquely vulnerable to Covid-19 related MIS-C, increasing their risk for ARDS and related morbidities. Currently, studies have shown an association between MIS-C and vaping, we speculate that adolescents who vape/smoke might be especially vulnerable to serious respiratory symptoms if they develop a hyper-inflammatory state MIS-C.
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Affiliation(s)
- Esha Brar
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
| | - Anish Saxena
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
| | - Claudia Dukler
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
| | - Fangxi Xu
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
| | - Deepak Saxena
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States.,Department of Surgery, New York University School of Medicine, New York, NY, United States
| | - Preneet Cheema Brar
- Department of Pediatrics, New York University School of Medicine, New York, NY, United States
| | - Yuqi Guo
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
| | - Xin Li
- Department of Molecular Pathobiology, New York University College of Dentistry, New York, NY, United States
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Brar PC, Heksch R, Cossen K, De Leon DD, Kamboj MK, Marks SD, Marshall BA, Miller R, Page L, Stanley T, Mitchell D, Thornton P. Management and Appropriate Use of Diazoxide in Infants and Children with Hyperinsulinism. J Clin Endocrinol Metab 2020; 105:5894029. [PMID: 32810255 DOI: 10.1210/clinem/dgaa543] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The diagnosis of hypoglycemia and the use of diazoxide have risen in the last decade. Diazoxide is the only Food and Drug Agency-approved pharmacologic treatment for neonatal hypoglycemia caused by hyperinsulinism (HI). Recent publications have highlighted that diazoxide has serious adverse effects (AEs) such as pulmonary hypertension (2-3%) and neutropenia (15%). Despite its increasing use, there is little information regarding dosing of diazoxide and/or monitoring for AEs. METHODS We convened a working group of pediatric endocrinologists who were members of the Drug and Therapeutics Committee of the Pediatric Endocrine Society (PES) to review the available literature. Our committee sent a survey to its PES members regarding the use of diazoxide in their endocrine practices. Our review of the results concluded that there was substantial heterogeneity in usage and monitoring for AEs for diazoxide among pediatric endocrinologists. CONCLUSIONS Based on our extensive literature review and on the lack of consensus regarding use of diazoxide noted in our PES survey, our group graded the evidence using the framework of the Grading of Recommendations, Assessment, Development and Evaluation Working Group, and has proposed expert consensus practice guidelines for the appropriate use of diazoxide in infants and children with HI. We summarized the information on AEs reported to date and have provided practical ideas for dosing and monitoring for AEs in infants treated with diazoxide.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, New York University Grossman School of Medicine, New York City, New York
| | - Ryan Heksch
- Center for Diabetes and Endocrinology, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Kristina Cossen
- Division of Pediatric Endocrinology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Diva D De Leon
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia and the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Manmohan K Kamboj
- Division of Endocrinology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Seth D Marks
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bess A Marshall
- Division of Endocrinology and Diabetes, Department or Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Ryan Miller
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland
| | - Laura Page
- Division of Pediatric Endocrinology, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Takara Stanley
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Deborah Mitchell
- Division of Pediatric Endocrinology, Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Paul Thornton
- Congenital Hyperinsulinism Center, Cook Children's Medical Center, Fort Worth, Texas
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Brar PC, Chun A, Fan X, Jani V, Craft M, Bhatla P, Kutty S. Impaired myocardial deformation and ventricular vascular coupling in obese adolescents with dysglycemia. Cardiovasc Diabetol 2019; 18:172. [PMID: 31856856 PMCID: PMC6921397 DOI: 10.1186/s12933-019-0976-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/06/2019] [Indexed: 12/19/2022] Open
Abstract
Background It is unknown that dysglycemia in obese adolescents has effects on myocardial deformation that are more pronounced when compared to obesity alone. We hypothesized that obesity associated abnormal glucose tolerance (dysglycemia) would have adverse effects on two-dimensional speckle tracking echocardiography derived longitudinal, radial and circumferential strain (LS, RS, CS) compared to age and gender lean controls. We also examined if changes in deformation would be reflected in abnormal ventricular vascular coupling indices (VVI). Methods In a prospective cross-sectional design 39 obese adolescents (15.9 ± 1.7 years; 101.5 ± 39 kg; female − 58%) were compared to age and gender matched lean controls (15.7 ± 1.8 yrs, 60 ± 12.8 kg). Based on results from an oral glucose tolerance test (OGTT), obese adolescents were categorized as obese normoglycemic (ONG, n = 25) or obese dysglycemic (ODG, n = 14). Left ventricular (LV) global and average LS, CS, RS and strain rate were measured. LV ejection fraction and mass index were measured and VVI approximated as ratio of arterial elasticity (Ea) and end-systolic elastance (Ees). Results Adolescents with ODG had significantly (P = 0.005) impaired global LS (− 20.98% ± 2.8%) compared to controls (− 23.01% ± 2.3%). A similar (P = 0.0027) reduction was observed in average LS for adolescents with ODG (18.87% ± 2.5%) compared to controls (20.49% ± 2%). Global CS was also decreased (P = 0.03) in ODG (− 23.95%) compared to ONG (− 25.80). A similar trend was observed in average CS after multivariate regression for BMI and blood pressure. CS correlated with HbA1c in both groups (P = 0.05). VVI had a negative correlation with both LS (r = − 0.4, P = 0.025) and CS rate (r = − 0.36, P = 0.04). Conclusions Myocardial strain and strain rate were significantly altered in obese adolescents. Unfavorable subclinical reductions in global and average CS were more pronounced in adolescents with dysglycemia compared to obese adolescents with normoglycemia and controls. These data indicate progressive worsening of subendocardial function across the spectrum of glucose tolerance. Strain rate was predictive of VVI in obese adolescents, suggesting strain rate may be a sensitive marker for cardiac remodeling in abnormal glucose homeostasis states.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Endocrinology and Diabetes, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Anne Chun
- Division of Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Xiazhou Fan
- NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Vivek Jani
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, 1800 Orleans Street, Baltimore, MD, 21205-2196, USA
| | - Mary Craft
- Division of Pediatric Cardiology, University of Nebraska College of Medicine, Omaha, NE, 68918, USA
| | - Puneet Bhatla
- Division of Cardiology, Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, 10016, USA
| | - Shelby Kutty
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, 1800 Orleans Street, Baltimore, MD, 21205-2196, USA.
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Raisingani M, Brar PC. Characterization of the duration of treatment with diazoxide in infants with prolonged hyperinsulinism (PHI). J Pediatr Endocrinol Metab 2019; 32:1241-1245. [PMID: 31465295 DOI: 10.1515/jpem-2019-0066] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/05/2019] [Indexed: 01/13/2023]
Abstract
Background Prolonged neonatal hyperinsulinism (PHI) causes hypoglycemia in the neonatal period and is associated with perinatal stress. Even though diazoxide is an effective treatment option for PHI, it has serious adverse effects making an argument for safe yet expeditious wean off of diazoxide while ensuring normoglycemia. The objective of this study was to characterize clinical course, dose requirement and duration of treatment with diazoxide in our cohort of infants diagnosed with PHI. Methods A retrospective chart review of infants diagnosed with PHI during a 6-year period was done documenting the diagnostic workup and the duration of treatment with diazoxide. Results PHI was diagnosed (n = 20; mean ± standard deviation [SD]) at 14.3 ± 22.4 days. Elevated insulin (8.3 ± 8.4 mIU/L), normal cortisol (15.5 ± 6.6 μg/dL [6-21]), normal growth hormone (18.8 ± 15.7 ng/mL [0.1-6.2]) and inappropriate low serum free fatty acids (0.3 ± 0.2 mmol/L [>1.5]) levels were measured during hypoglycemia (plasma glucose <50 mg/dL). Detectable insulin at the time of hypoglycemia was measured in 17 of 20 infants while the same number (17/20) of infants had a positive glucagon stimulation test (GST). The dose of diazoxide was 10 ± 3.7 mg/kg/day and duration of treatment was 44.9 ± 27.9 days. Conclusions This study illustrates that the duration of treatment with diazoxide in infants with PHI can be shorter than previously reported in the literature. We speculate that active tapering of diazoxide started within a week after discharge from hospital as well an outpatient tapering of diazoxide based on glucose monitoring were possible reasons for this outcome.
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Affiliation(s)
- Manish Raisingani
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Arkansas for Medical Sciences, 1 Children's Way, Slot 512-6, Little Rock, AR 72202, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, New York University School of Medicine, New York, NY, USA
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Mehta S, Brar PC. Severe, persistent neonatal hypoglycemia as a presenting feature in patients with congenital hypopituitarism: a review of our case series. J Pediatr Endocrinol Metab 2019; 32:767-774. [PMID: 31211689 DOI: 10.1515/jpem-2019-0075] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 04/14/2019] [Indexed: 11/15/2022]
Abstract
Background Persistent hypoglycemia (PH) beyond 3 days of life warrants investigation which includes a critical sample. We report our case series of five neonates who presented with PH as the first sign of congenital hypopituitarism. Design This is a case series. Methods/Results This is a case series of five neonates evaluated at our academic institution in a 3-year period (2013-2016), who presented with persistent severe hypoglycemia and were subsequently diagnosed with congenital hypopituitarism. All neonates were full term (mean gestational age 39.8 ± 1.4 weeks) born by caesarian section with a mean weight of 3.5 ± 0.16 kg and a mean length of 51.2 ± 1.2 cm at birth. All five neonates had PH beyond 3 days with an average blood glucose (BG) <35 mg/dL at presentation, requiring a mean glucose infusion rate (GIR) of 7.22 ± 1.98 mg/kg/min. The average BG during the critical sample was 42 ± 0.16 mg/dL (three patients). The mean duration of requirement of the glucose infusion was 6.2 ± 3 days during the immediate neonatal period. Diagnosis of the hypopituitarism took 2-52 days from the initial presentation of hypoglycemia. Besides growth hormone (GH) deficiency, cortisol deficiency was diagnosed in all the five neonates. Neuroimaging findings in all the neonates were consistent with pituitary stalk interruption syndrome (hypoplastic anterior pituitary, ectopic posterior pituitary [EPP] and interrupted pituitary stalk). Conclusions Hypoglycemia is a common metabolic complication affecting an infant in the immediate neonatal period. Delay in the diagnosis of hypopituitarism presenting as hypoglycemia is the result of the lack of awareness among neonatologists and/or pediatricians. We propose that providers be cognizant that PH can be the only presentation of hypopituitarism in the neonatal period. Therefore, having a high index of suspicion about this condition can avoid a delay in the evaluation, diagnosis and treatment of hypopituitarism.
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Affiliation(s)
- Shilpa Mehta
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
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Brar PC. Update on the current modalities used to screen high risk youth for prediabetes and/or type 2 diabetes mellitus. Ann Pediatr Endocrinol Metab 2019; 24:71-77. [PMID: 31261470 PMCID: PMC6603607 DOI: 10.6065/apem.2019.24.2.71] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 06/11/2019] [Indexed: 01/08/2023] Open
Abstract
The modalities currently employed to screen for type 2 diabetes mellitus (T2DM)/prediabetes are HbA1c, fasting plasma glucose (FPG), and 2-hour plasma glucose (PG) during an oral glucose tolerance test (OGTT). The purpose of this review is to highlight the positive qualities and pitfalls of these diagnostic modalities and reflect on the most reasonable and effective approach to screen high risk youth. Given its inherent preanalytical advantages, glycated hemoglobin (HbA1c) continues to be the preferred diagnostic modality used by pediatricians to screen high risk youth. However, when the three aforementioned tests are performed in youths of different races/ethnicities, discrepant results for T2DM/prediabetes are observed. The prevalence rates for T2DM vary from 0.53% in Chinese youth (including youth of all body mass indexes) to 18.3% in high-risk, overweight, obese Korean youth. Moreover, the FPG is abnormal (>100 less than <126 mg/dL) in 15% of Korean youth versus 8.7% of Chinese youth. The prevalence rates for prediabetes are 1.49% in Chinese youth versus 21% in Emirati youth (HbA1c, 5.7%-6.4%). The coefficient of agreement, k, between these screening tests for T2DM are fair, 0.45-0.5 across all youth. However, using HbA1c as a comparator, the agreement is weak with FPG (k=0.18 in German youth versus k=0.396 in Korean youth). The American Diabetes Association (ADA) Standards of Medical Care Guidelines define "high risk youth" who need to be tested for T2DM and/or prediabetes. OGTT and HbA1c do not always detect T2DM in similar individuals. HbA1c may not be an ideal test for screening Hispanic and African American youth. FPG and OGTT are suitable screening tests for youth of ethnic minorities and those with cystic fibrosis or hemoglobinopathies. Performing all three tests either together or sequentially may be the only way to encompass all youth who have aberrations in different aspects of glucose homeostasis.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Pediatric Endocrinology and Diabetes, New York University School of Medicine, New York, NY, USA,Address for correspondence: Preneet Cheema Brar, MD Division of Pediatric Endocrinology and Diabetes, New York University School of Medicine, 135 E 31st Street, Second Floor, New York, NY 10016, USA Tel: +1-212-263-5940 Fax: +82-212-263-9696 E-mail:
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Brar PC. Clinical utility of stimulation tests in infants with suspected adrenal insufficiency (AI). J Pediatr Endocrinol Metab 2019; 32:529-531. [PMID: 31005951 DOI: 10.1515/jpem-2019-0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Accepted: 02/07/2019] [Indexed: 11/15/2022]
Abstract
Diagnosis of adrenal insufficiency (AI) in infants can be difficult. While a low random cortisol can signal AI, often confirmatory tests are required when clinical suspicion is strong but the cortisol levels are equivocal. Several studies have demonstrated that in sick preterm infants, there is relative adrenal insufficiency (RAI) defined as an inadequate cortisol production relative to the degree of stress or illness, a condition which can last for several weeks, while in term infants the adrenal axis is mature at birth (Bagnoli F, Mori A, Fommei C, Coriolani G, Badii S, et al. ACTH and cortisol cord plasma concentrations in preterm and term infants. J Perinatol 2013;33:520-4). Adrenocorticotrophic hormone (ACTH) and corticotrophin releasing hormone (CRH) stimulation tests have been validated in infants in several studies. In light of recent reports of false-negative results of stimulation tests, it is imperative to highlight the pitfalls of these tests. The purpose of this communication is to bring attention to the accuracy of timing of these tests in infants.
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Affiliation(s)
- Preneet Cheema Brar
- Hassenfeld Childrens' Hospital, Division of Pediatric Endocrinology and Diabetes, New York University School of Medicine, 135 E 31st street, L-2, New York 10016-6402, NY, USA
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Contreras M, Raisingani M, Chandler DW, Curtin WD, Barillas J, Brar PC, Prasad K, Shah B, David R. Salivary Testosterone during the Minipuberty of Infancy
. Horm Res Paediatr 2019; 87:111-115. [PMID: 28073108 DOI: 10.1159/000454862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 11/01/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The hypothalamic-pituitary-gonadal axis is transiently activated during the postnatal months in boys, a phenomenon termed "minipuberty" of infancy, when serum testosterone (T) increases to pubertal levels. Despite high circulating T there are no signs of virilization. We hypothesize that free T as measured in saliva is low, which would explain the absence of virilization. METHODS We measured serum total T and free T in saliva using liquid chromatography-tandem mass spectrometry (LC-MS/MS) in 30 infant boys, aged 1-6 months, and in 12 adolescents, aged 11-17 years. RESULTS Total serum T in all infants was, as expected, high (172 ± 78 ng/dL) while salivary T was low (7.7 ± 4 pg/mL or 0.45 ± 0.20%). In contrast, salivary T in the adolescents was much higher (41 ± 18 pg/mL or 1.3 ± 0.36%) in relation to their total serum T (323 ± 117 ng/dL). We provide for the first time reference data for salivary T in infants. CONCLUSION Measurement of salivary T by LC-MS/MS is a promising noninvasive technique to reflect free T in infants. The low free T explains the absence of virilization. The minipuberty of infancy is more likely of intragonadal than peripheral significance.
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Brar PC, Dingle E, Ovadia D, Pivo S, Prasad V, David R. Interpretation of androgen and anti-Mullerian hormone profiles in a Hispanic cohort of 5- to 8-year-old girls with premature adrenarche. Ann Pediatr Endocrinol Metab 2018; 23:210-214. [PMID: 30599482 PMCID: PMC6312917 DOI: 10.6065/apem.2018.23.4.210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 08/18/2018] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Premature adrenarche (PA) often leads to polycystic ovary syndrome (PCOS). Higher anti-mullerian hormone (AMH) levels are reported in PCOS. We studied the androgen profile and AMH profiles in Hispanic girls with PA (aged 5-8 years) and age and body mass index (BMI) matched controls. METHODS Retrospective review of electronic medical records of girls who met the inclusion criteria for premature adrenarche were done. RESULTS PA girls (n=76) were matched to control girls (n=12) for age (mean±standard deviation) (6.7±1 years vs. 6.2±1.3 years) and BMI (20±10 kg/m2 vs. 17.8±2.7 kg/m2). Dehydroepiandrostenedione sulfate (63.3±51.3 μg/dL vs. 29.8±17.3 μg/dL, P<0.001) and testosterone levels (11.4±4.8 ng/dL vs. 8.2±2.9 ng/dL, P=0.001) were significantly higher in the PA group than controls. AMH values (<14 years: reference range, 0.49-3.15 ng/mL) were 3.2±2.2 ng/mL vs. 4.6± 3.2 ng/mL respectively in the PA and control groups and were not different (P=0.4). AMH did not show a correlation with bone age (P=0.1), and testosterone (P=0.9) in the PA group. 17-hydroxyprogesterone levels (17-OHP ng/dL) were 39.5±30.5 ng/dL vs. 36.8±19.8 ng/dL in PA versus control girls. The concentration of 17-OHP was not statistically different between the control and PA groups. CONCLUSION Higher AMH was not observed in PA girls and no correlation with BA and androgen levels was observed.
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Affiliation(s)
- Preneet Cheema Brar
- Division of Pediatric Endocrinology, Department of Pediatrics, New York University School of Medicine, New York, NY, USA,Address for correspondence: Preneet Cheema Brar, MD Division of Pediatric Endocrinology, Department of Pediatrics, New York University School of Medicine, 160 East 3nd street, L3, New York 10016, New York, USA Tel: +1-212-263-5940 Fax: +1-212-263-5808 E-mail:
| | - Elena Dingle
- Department of Pediatrics, Brookdale University Hospital and Medical Center, Brooklyn, NY, USA
| | - Daniela Ovadia
- Department of Pediatrics, University of Texas Health Science Center, Houston, TX, USA
| | - Sarah Pivo
- Deparment of Surgery, New York University School of Medicine, New York, NY, USA
| | - Veeramac Prasad
- Division of Pediatric Endocrinology, Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Raphael David
- Division of Pediatric Endocrinology, Department of Pediatrics, New York University School of Medicine, New York, NY, USA
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Brar PC, Contreras M, Fan X, Visavachaipan N. Effect of one time high dose “stoss therapy” of vitamin D on glucose homeostasis in high risk obese adolescents. Archives of Endocrinology and Metabolism 2018; 62:193-200. [PMID: 29641737 PMCID: PMC10118987 DOI: 10.20945/2359-3997000000024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 10/29/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To study the effect of using a one time high dose "stoss therapy" of vitamin D2 (ergocalciferol: VD2) on indices of insulin sensitivity {whole body sensitivity index: WBISI} and secretion {insulinogenic index: IGI} measured during an oral glucose tolerance test (OGTT) in obese adolescents with VDD (25 OHD; serum metabolite of vit D: < 30 ng/dL). SUBJECTS AND METHODS In a randomized placebo controlled cross over design 20 obese adolescents with vitamin D deficiency (VDD) had baseline OGTT. Arm A received one time high dose 300,000 IU of ergocalciferol and Arm B received placebo. After 6 weeks the adolescents were reassigned to Arm A if they were in Arm B and vice versa. 25OHD, calcium, parathyroid hormone, comprehensive metabolic panel, urine calcium creatinine ratio were measured at each study visit. OGTTs to assess indices of sensitivity and secretion were done at baseline, 6 weeks and 12 weeks respectively. RESULTS Adolescents were obese and insulin resistant (mean ± SD: mean age = 15.1 ± 1.9 years; BMI: 32.7 ± 9.8; homeostatic model of insulin resistance: HOMA-IR: 4.2 ± 2.8). Stoss therapy with VD2 increased 25OHD from baseline (16.7 ± 2.9 to 19.5 ± 4.5; p = 0.0029) when compared to the placebo. WBISI (2.8 ± 1.9) showed a trend towards improvement in Rx group (p = 0.0577) after adjustment for covariates. IGI (3 ± 2.2) showed an improvement in both Rx and placebo groups. CONCLUSIONS Our study demonstrated that using a high dose of VD2 (300,000 IU) did not have any beneficial effect on insulin sensitivity (whole body sensitivity index {WBISI}) and secretory indices (insulinogenic index {IGI}) in obese adolescents. High dose "stoss therapy" of VD2 did not appear to have any beneficial effect on glucose homeostasis on obese adolescents.
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Brar PC, Patel P, Katz S. The relationship between insulin resistance and endothelial dysfunction in obese adolescents. J Pediatr Endocrinol Metab 2017; 30:635-642. [PMID: 28525354 DOI: 10.1515/jpem-2016-0404] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 04/03/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Insulin resistance and endothelial dysfunction share a reciprocal relationship that links the metabolic and cardiovascular sequelae of obesity. We characterized the brachial artery reactivity testing (BART) and carotid artery-intima media thickness (CIMT) in adolescents categorized as obese insulin resistant (OIR) and obese not insulin resistant (ONIR). Lipoprotein particle (p) analysis and inflammatory cytokines in OIR and ONIR groups were also analyzed. METHODS Obese adolescents (n=40; mean body mass index [BMI] 35.6) were categorized as ONIR and OIR based on their homeostatic model assessment of insulin resistance (HOMA-IR) calculation (≤or> than 3.4). Ultrasound measured conduit arterial function BART, microvascular function (post-ischemic hyperemia) and conduit artery structure CIMT. RESULTS BART did not differ according to IR status (mean±SD: 7.0±4.3% vs. 5.9±3.4% in ONIR and OIR, respectively, p=0.3, but post-ischemic hyperemia was significantly greater in the ONIR group (4.5±2.2 vs. 3.5±3, p=0.04). Atherogenic lipoprotein particles; large VLDL particles and small LDL particles were higher in the OIR compared to ONIR group. CONCLUSIONS OIR adolescents demonstrate an inflamed atherogenic milieu compared to the ONIR adolescents. Microvascular function, but not conduit vessel structure or function, was impaired in association with IR.
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Affiliation(s)
- Elena Dingle
- 1 New York University School of Medicine, New York, NY, USA
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Dingle E, Palliyil-Gopi R, Contreras M, Kohn B, Brar PC. Myopathy in Pediatric Thyroid States: A Review of the Literature. Pediatr Endocrinol Rev 2016; 14:147-158. [PMID: 28508608 DOI: 10.17458/per.2016.dgc.myopathyinpediatric] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This review highlights the presentations of myopathy in children in both hypothyroid and hyperthyroid states with an emphasis on the pathophysiology, diagnosis and treatment. Based on our review of the literature data, myopathy should be considered in all children presenting with muscular weakness or altered muscle enzymes in the context of thyroid disease.
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Affiliation(s)
- Elena Dingle
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | | | - Maria Contreras
- Department of Pediatrics, Texas Tech University Health Science Center, Amarillo, Texas, USA
| | - Brenda Kohn
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, USA
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Brar PC. Vascular phenotype of obese adolescents with prediabetes and/or Type 2 diabetes (T2DM): Review of the current literature. Diabetes Metab Syndr 2016; 10:250-256. [PMID: 27381966 DOI: 10.1016/j.dsx.2016.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 06/06/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Preneet Cheema Brar
- Department of Pediatrics, Division of Pediatric Endocrinology, New York University School of Medicine, New York, NY, United States.
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Patel PR, Pappas J, Arva NC, Franklin B, Brar PC. Early presentation of bilateral gonadoblastomas in a Denys-Drash syndrome patient: a cautionary tale for prophylactic gonadectomy. J Pediatr Endocrinol Metab 2013; 26:971-4. [PMID: 23729537 DOI: 10.1515/jpem-2012-0409] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 04/01/2013] [Indexed: 11/15/2022]
Abstract
Mutation of the Wilms tumor gene (WT1) is associated with two well-described syndromes called Denys-Drash (DDS) and Frasier (FS). Both are associated with nephropathy and ambiguous genitalia and have overlapping clinical and molecular features. The known risk of Wilms tumor in DDS and gonadoblastoma (GB) in FS patients requires tumor surveillance. The literature reports the occurrence of GB in DDS as lower than FS. This case highlights a very early presentation of bilateral GB in DDS and the consideration of early prophylactic gonadectomy at the time of diagnosis with DDS.
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Katz K, Brar PC, Parekh N, Liu YH, Weitzman M. Suspected nonalcoholic Fatty liver disease is not associated with vitamin d status in adolescents after adjustment for obesity. J Obes 2010; 2010:496829. [PMID: 21331294 PMCID: PMC3038678 DOI: 10.1155/2010/496829] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2010] [Revised: 11/22/2010] [Accepted: 12/27/2010] [Indexed: 02/08/2023] Open
Abstract
This study investigated a potential independent association between hypovitaminosis D and suspected nonalcoholic fatty liver disease (NAFLD) in a nationally representative sample of the US adolescents. Data from 1630 subjects 12-19 years of age were examined using the National Health and Nutrition Examination Survey, 2001-2004. The vitamin D status of subjects was categorized into quartiles of serum 25-hydroxyvitamin D. Subjects with serum ALT > 30 U/L were classified as having suspected NAFLD. Data regarding age, sex, race, BMI, and poverty level were also analyzed in bivariate and multivariate analyses using SAS and SUDAAN software. Suspected NAFLD was identified in 12.1% of adolescents in the lowest quartile compared to 6.9% of adolescents in the second quartile, 8.0% in the third quartile, and 13.17% in the highest quartile of serum 25(OH)D concentrations (P = .05). In analyses utilizing vitamin D as a continuous variable, no independent association was found between Vitamin D levels and rates of elevated ALT levels. In multivariate analyses, higher risks for suspected NAFLD were observed in males and overweight adolescents; however, vitamin D status was not found to be independently associated with suspected NAFLD after adjusting for obesity.
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Affiliation(s)
- Karin Katz
- Department of Pediatrics, School of Medicine, New York University, New York, NY 10016, USA
| | - Preneet Cheema Brar
- Department of Pediatrics, School of Medicine, New York University, New York, NY 10016, USA
| | - Niyati Parekh
- Department of Nutrition, Food Studies and Public Health, New York University, New York, NY 10016, USA
| | - Ying-Hua Liu
- Department of Pediatrics, School of Medicine, New York University, New York, NY 10016, USA
| | - Michael Weitzman
- Department of Pediatrics, School of Medicine, New York University, New York, NY 10016, USA
- Department of Psychiatry, School of Medicine, New York University, New York, NY 10016, USA
- New York University, Institute of Community Health and Research, School of Medicine, New York University, New York, NY 10016, USA
- *Michael Weitzman:
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