Ceftazidime-Avibactam for the Treatment of Multidrug-Resistant Pathogens: A Retrospective, Single Center Study

Background: Ceftazidime/avibactam is a new cephalosporin/beta-lactamase inhibitor combination approved in 2015 by the FDA for the treatment of complicated intra-abdominal and urinary tract infection, hospital-acquired pneumoniae and Gram-negative infections with limited treatment options. Methods: In this retrospective study, we evaluate the efficacy of ceftazidime/avibactam treatment in 81 patients with Gram-negative infection treated in our center from January 2018 to December 2019. The outcome evaluated was 30-days survival or relapse of infection after the first positive blood culture. Results: the majority of patients were 56 male (69%), with median age of 67. Charlson’s Comorbidity Index was >3 in 58 patients. In total, 46% of the patients were admitted into the medical unit, 41% in the ICU, and 14% in the surgical ward. Of the patients, 78% had nosocomial infections, and 22% had healthcare-related infections. The clinical failure rate was 35%: 13 patients died within 30 days from the onset of infection. The outcome was influenced by the clinical condition of the patients: solid organ transplantation (p = 0.003) emerged as an independent predictor of mortality; non-survival patients most frequently had pneumonia (p = 0.009) or mechanical ventilation (p = 0.049). Conclusion: Ceftazidime−avibactam showed high efficacy in infections caused by MDR Gram-negative pathogens with limited therapeutic options.

Development of the optimal touchscreen interface for patients with scleroderma

Impaired hand function is a major contributor to overall disability and reduced health-related quality of life in scleroderma patients. A relevant issue concerns interaction of scleroderma subjects with touchscreen interfaces. This study aims at investigating this problem assessing scleroderma patients’ performance with a novel, aptly designed, touchscreen application in order to identify critical items of touchscreen technology which may impair or facilitate the use by scleroderma subjects. Eighty scleroderma patients performed this novel application including three games, each of which tested a different gesture: tapping, dragging/dropping, and pinching-to-zoom. Eighty healthy subjects without hand impairments were recruited as controls. Scleroderma patients performed worse than healthy users in each game, and statistically significant negatively impacting items were identified. In the second phase of the study, the 10 worst touchscreen performers within the scleroderma cohort were recruited for a physio-rehabilitation trial based on the daily use at home of a modified version of the software application downloaded into the personal devices of patients. The results of this study allow introduction of guidelines to design accessible touchscreen interfaces for subjects with scleroderma and suggest that touchscreen technology may be included in self-administered physio-rehabilitation programs for scleroderma hand.

Immediate and delayed loading of fixed dental prostheses supported by single or two splinted implants: A histomorphometric study in dogs

To evaluate presumptive differences in osseointegration at implants supporting crowns that are physiologically loaded either immediately or 3 months after installation. All premolars and first molars were extracted bilaterally in six dogs. After 3 months of healing, three implants were installed on the premolar region and two in the molar region in one side of the mandible. Likewise, after another 3 months, five implants were installed in the contralateral side, and impressions were taken bilaterally. Within 48 hours, two single crowns were screwed bilaterally onto two implants in the premolar region, and two splinted crowns reproducing the shape of the first molar were screwed bilaterally onto the implants in the molar region. The mesial implants were used as no-loaded controls. Sacrifices were performed after 3 months, and histological analyses were performed. At the premolar sites, mineralised bone-to-implant contact (MBIC%) was 78.0 ± 4.0% and 70.9 ± 7.9% at the delayed and immediately loaded sites, respectively. This difference was statistically significant. At the control implants, MBIC% was 61.4 ± 14.7% and 63.1 ± 13.1% at the delayed and the immediately loaded sites, respectively. At the molar sites, MBIC% was 79.2 ± 10.9% and 61.1 ± 10.3% at the delayed and immediately loaded sites, respectively. Applying a delayed loading to fixed dental prostheses supported by single or two splinted implants yielded higher proportions of bone-to-implant contact (osseointegration) compared to immediately loaded implants. Moreover, both types of loading protocols yielded a higher rate of osseointegration compared to unloaded implant sites after 3 months following implant installation.

The Italian screening program for primary congenital hypothyroidism: actions to improve screening, diagnosis, follow-up, and surveillance

The Italian screening program for primary congenital hypothyroidism (CH) is an integrated system including neonatal screening, diagnosis, treatment, follow-up, and nationwide surveillance of the disease. The aim of the Italian screening program for CH is to identify not only babies with severe permanent CH (core target), but also babies with mild persistent and transient forms of CH who could have a benefit from an early replacement therapy (secondary target). In the last years, despite the important results obtained in terms of standardization of screening and follow-up procedures, it has become clear the need of optimizing the program in order to harmonize the screening strategy and the screening procedures among Regions, and to improve the diagnostic and therapeutic approach in all affected infants. On the basis of available guidelines, the experience of the Italian screening and clinical reference centers, and the knowledge derived from the nation-wide surveillance activity performed by the Italian National Registry of Infants with CH, the Italian Society for Pediatric Endocrinology and Diabetology together with the Italian Society for the Study of Metabolic Diseases and Neonatal Screening and the Italian National Institute of Health promoted actions aimed at improving diagnosis, treatment, follow-up and surveillance of CH in our country. In this paper the most important actions to improve the Italian screening program for CH are described.

Influence of gender and pubertal stage at diagnosis on growth outcome in childhood thyrotoxicosis: results of a collaborative study

OBJECTIVE

To evaluate the influence of sex as well as pubertal stage at diagnosis on the growth outcome of childhood thyrotoxicosis.

DESIGN

Retrospective, collaborative study.

PATIENTS AND METHODS

Longitudinal auxological evaluation in 101 patients (M/F 23/78) for 4.7 +/- 3.1 years subdivided according to pubertal stage at diagnosis into prepubertal (group I) and pubertal (group II).

RESULTS

At diagnosis height and bone age (BA) standard deviation score (SDS) were positive both in girls and boys of groups I and II. In boys of group II, height SDS was significantly higher than in girls of the same group (P = 0.007) and in boys of group I (P = 0.026). During the follow-up, in group I, height SDS remained positive without significant differences between boys and girls, and in group II, height SDS remained significantly lower in girls than in boys. The age at onset of puberty and the age at menarche were within the normal range. Final height (FH) was within target height (TH) range in all groups The FH SDS and the height gain (FH-TH) were similar in girls and in boys in group I and significantly higher in boys than in girls (P < 0.05) in group II. The boys of group II showed a mean height gain significantly greater than that found in all the other groups.

CONCLUSIONS

Despite the advancement of BA at presentation, there were no adverse effects on subsequent growth and FH; the growth outcome seems to be better in boys than in girls in group II.

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.

Accuracy of fine needle aspiration biopsy of thyroid nodules in detecting malignancy in childhood: comparison with conventional clinical, laboratory, and imaging approaches

In childhood the traditional diagnostic approach to thyroid nodules consists of clinical, laboratory, and imaging evaluations. A safe and accurate procedure is needed to promptly identify patients who require surgery. In regard to the usefulness of fine needle aspiration biopsy, the data in the literature concerning children and adolescents are scanty. The aim of this study was to evaluate and compare the diagnostic accuracies of clinical, laboratory, and imaging data collected retrospectively in a group of pediatric patients with thyroid nodules submitted to fine needle aspiration biopsy. Forty-two patients who underwent surgery for thyroid nodules, recruited in 9 Italian pediatric endocrine units, were retrospectively studied. According to histological diagnosis, they were divided into 2 groups, 22 patients with benign lesions and 20 patients with malignant lesions. From clinical records we obtained data about 1) symptoms of neck compression; 2) cervical adenopathy; 3) thyroid function, calcitonin level, and antithyroid antibody titers; 4) ultrasonography; 5) (99m)Tc scintiscanning; and 6) cytology obtained with fine needle aspiration biopsy. Patients and nodule characteristics were analyzed statistically for associations with the presence of thyroid cancer. Among clinical findings, only adenopathy was significantly higher in the group with cancer (8 of 22 benign lesions vs. 16 of 20 malignant lesions; P = 0.006). Thyroid function and antibody titers were similar in the 2 groups, whereas the serum calcitonin level was elevated only in 1 patient with malignant lesions. Among ultrasonography findings, no significant statistical difference was found between the 2 groups with regard to number, dimensions, growth progression, or hypoechogenic pattern of the nodules. Regarding scintigraphic findings, no significant difference was found between the 2 groups. However, a positive correlation (r = 0.90; P < 0.0001) was found between fine needle aspiration biopsy cytological findings and histological diagnoses. The sensitivity, specificity, and accuracy of fine needle aspiration biopsy were 95%, 86.3%, and 90.4%, respectively. A multiple regression analysis showed that only fine needle aspiration biopsy (beta coefficient = 0.963; P < 0.0001) significantly contributed to detecting malignancy (multiple r = 0.973; P < 0.0001). This study provides strong evidence that fine needle aspiration biopsy is a safe technique even in childhood and adolescence, offering the best sensitivity, specificity, and accuracy in detecting malignancy compared with conventional approaches.

Binocular field in pigeons: behavioral measures of stimulus detection and coding

The extension of the binocular visual field of pigeons is measured using a pecking behavioral method. Our estimate of the binocular field derived at the animal near point of accommodation indicates a 50 degrees width on the horizontal axis and more than 50 degrees on the vertical axis. Within the binocular field there is a core of about 24 degrees, named coding area, in which the stimulus is detected and coded by only one head fixation before accomplishing the pecking response, in both binocular and monocular viewing conditions. Outside the coding area, lies the detection area, in which the stimulus can be detected, but it needs a second head fixation to be coded in all viewing conditions. Our results are in agreement with the hypothesis that the coding area corresponds to the red field projection of each retina. In binocular vision an overlap of the two areas occurs, thus promoting the image fusion useful for a stereoscopic vision during the pecking to the seed.

[Missed diagnosis: a case of congenital hypothyroidism treated after three years]

Congenital hypothyroidism (CH) is the most common cause of preventable mental retardation. Thyroid hormone deficiency in utero and in the first neonatal months is responsible for permanent damage. While foetal hypothyroidism is at present unavoidable, earlier diagnosis and initiation of treatment in neonates with CH is important and highly recommended. At the moment, the Italian screening program for CH allows diagnosis and treatment within the first month of life. In Italy, screening programs became obligatory only a short time ago. In some regions, they started a few years ago, whereas in others they have been carried out only in an irregular way and only a part of the population has been investigated. Therefore CH was diagnosed just on the basis of clinical signs, with a consequent delay in the initiation of substitutive therapy. We describe the case of a little girl with CH diagnosed when she was three years old. We report the results of this case follow-up study and we describe the features of her neuropsychological development to point out her improvement and permanent disorders. The little girl was clearly hypothyroid with delayed achievement at three, but with pharmacological treatment she showed a dramatic amelioration in growth, language, motor skills and cognitive performances.

Testosterone-induced increase of insulin-like growth factor I levels depends upon normal levels of growth hormone

Pubertal development is associated with a rise in plasma insulin-like growth factor I (IGF-I) levels that is related both to the increase in sex steroids and/or to the sex steroid-induced augmentation in endogenous growth hormone (GH) secretion. In order to investigate the relationship between IGF-I, GH and testosterone, we examined 42 male subjects with various clinical conditions (classical GH deficiency (CGHD, N = 5), non-classical GH deficiency (NCGHD, N = 7), short idiopathic stature (N = 6), nutritional obesity (N = 8), GH-treated CGHD (N = 4), GH-treated NCGHD (N = 5) and normal stature (N = 7)) in which , for evaluation of hypogonadism (i.e. the absence of one or both testes from the scrotal sac), human chorionic gonadotropin (hCG) tests were performed. We measured IGF-I, total and free testosterone and dehydroepiandrosterone sulfate (DHEAS) by radioimmunoassays before and 48 and 96 h after the start of the test. The values of IGF-I were lower (0.001 < p < 0.005) in CGHD and NCGHD than in the other groups. In comparison to basal levels, IGF-I values increased (0.005 < p < 0.05) both 48 and 96 h after the start of the hCG test in short idiopathic and normal stature children and in GH-treated subjects with NCGHD, but only 96 h in subjects with untreated NCGHD and GH-treated CGHD. No difference was demonstrated in basal values of total testosterone among any of the groups, while basal free testosterone levels were higher (0.001 < p < 0.05) in GH-treated subjects with NCGHD than in all the other groups except nutritional obesity; furthermore, free testosterone was higher (p < 0.05) in nutritional obesity than in CGHD. The values of total and free testosterone obtained both 48 and 96 h after the start of the hCG test were higher (0.001 < p < 0.05) than basal values in all groups. The DHEAS values did not show any significant change during the hCG test. Basal values were higher (0.01 < p < 0.05) in nutritional obesity than in the other groups. Considering all groups, chronological age, bone age and bone age/chronological age ratio were correlated with basal free testosterone, IGF-I and DHEAS levels (0.001 < p < 0.05), while basal free testosterone and IGF-I values were correlated with DHEAS levels (p < 0.005 and < 0.01, respectively). In conclusion, our study during the hCG test in boys with various clinical conditions demonstrated an increase in IGF-I concentrations only in those boys with sufficient GH secretion or GH replacement therapy. These findings indicate that both sex steroids and GH are necessary to allow for the pubertal increase in IGF-I levels.

Combination treatment with growth hormone and gonadotropin-releasing hormone analogs in short normal girls

To improve final adult height, we treated with growth hormone (0.65 +/- 0.07 (mean +/- SD) IU.kg-1.wk-1) and gonadotropin-releasing hormone analogs (66 +/- 9 micrograms.kg-1 every 28 days) a group of seven short normal girls in early puberty with a chronologic age (CA) of 11.50 +/- 0.95 years, predicted adult height (PAH) lower (0.003 < p < 0.001) than mean target height, and without any endocrine abnormalities. The results were compared with those obtained in a similar group of seven untreated girls considered as control subjects. The mean period of combined therapy was 2.01 +/- 0.52 years; in two subjects treatment is still in progress. The value of height standard deviation score for bone age (BA) improved from -1.69 +/- 0.47 to -1.04 +/- 0.56 (p = 0.001); height age (HA)/BA ratio also increased from 0.83 +/- 0.05 to 0.90 +/- 0.04 (p < 0.01), as did PAH (from 146.8 +/- 4.4 to 152.9 +/- 3.6 cm; p < 0.002). The ratio of gain in HA to gain in BA was 2.08 +/- 0.78. Pubertal stages showed an arrest in five cases and a regression in the other two girls. After administration of gonadotropin-releasing hormone analogs was interrupted, in four of five girls growth hormone was administered alone for a further period of 6 to 18 months to improve their physiologic growth spurt. The present height in five girls is higher than PAH before therapy. In the treated girls the height values for BA, for BA/CA and HA/BA ratios, and for PAH were higher (0.002 < p < 0.04) than those in control subjects. This preliminary study demonstrates that combination therapy with growth hormone and gonadotropin-releasing hormone analogs in short, endocrinologically normal girls may be useful in improving both height prognosis and predicted adult height. Further studies are necessary to reach definitive conclusions regarding the efficacy of this kind of therapy.

The evaluation of 24-hour spontaneous GH secretion in short children: relationship between mean concentration and pulsatile parameters

In 116 short children (height < -1.6 SDs), the authors examined GH secretion over 24 hours, by taking blood samples every 20 min and performing an electroencephalographic sleep control. The following GH parameters were evaluated: 24-h mean GH concentration (MGHC); maximum GH peak during the initial cycle of sleep (iMGHP), the nocturnal 12 h (nMGHP) or diurnal 12 h (dMGHP), the number of GH pulses over 24 h (NP), or nocturnal 12 h (nNP) or diurnal 12 h (dNP), the mean pulse amplitude over 24 h (MPA), or nocturnal 12 h (nMPA) or diurnal 12 h (dMPA). The subjects were divided into 3 groups: group 1, 12 subjects with low responses to provocative tests and MGHC < 3 ng/ml; group 2, 36 subjects with normal responses to provocative tests and MGHC < 3 ng/ml; group 3, 68 subjects with MGHC > 3 ng/ml. MGHC was highly correlated (p < 0.001) with iMGHP (r = 0.80), nMGHP (r = 0.82), dMGHP (r = 0.59), MPA (r = 0.85), nMPA (r = 0.86), dMPA (r = 0.56), NP (r = 0.70), nNP (r = 0.68), dNP (r = 0.46). By the analysis of the regression equations, the values corresponding to 3 ng/ml for MGHC were 11.08 ng/ml for iMGHP, 11.66 ng/ml for nMGHP, 5.21 ng/ml for dMGHP, 7.29 ng/ml for MPA, 8.40 ng/ml for nMPA, 4.25 ng/ml for dMPA, 3.2 for NP, 2.41 for nNP and 0.78 for dNP. By using these values as cut-off points, the diagnostic accuracy yielded 83.6% for iMGHP, 84.5% for nMGHP, 69.8% for dMGHP, 92.2% for MPA, 90.5% for nMPA, 81.9% for dMPA, 80.2% for NP, 77.6% for nNP, 71.5% for dNP. In conclusion, we found a strong correlation between mean GH secretion over 24 h and the number or amplitude of pulses: particularly, nocturnal pulsatile GH parameters show a higher correlation in comparison with diurnal pulsatile GH parameters, so that the examination of GH values during nocturnal hours may be considered a reliable index of GH secretory status.

[Correlation between growth velocity and hematologic levels of somatomedin C during the treatment with growth hormones (GH) in subjects with "classic" and "non-classic" deficits of GH]

In this study the authors examined 14 subjects with "classic" growth hormone (GH) deficiency and 40 with "non classic" GH deficiency treated with GH for a period of 6-36 months. Height velocity (HV) and plasma Somatomedin C (SmC) levels have been evaluated every 6 months during GH therapy. Both HV and SmC significantly increased (p < 0.001) during GH therapy in comparison to pretreatment values, but without any difference between the two groups; furthermore no significant difference was present among each six-monthly value of SmC. During GH treatment the following correlations resulted between SmC and HV: at time 0, r = 0.494 (p = 0.0004); after 6 months, r = 0.779 (p < 0.0001); after 12 months, r = 0.660 (p = 0.0001); after 18 months, r = 0.657 (p = 0.0001); after 24 months, r = 0.593 (p = 0.0038); after 30 months, r = 0.550 (p = ns); after 36 months, r = 0.465 (p = ns). Furthermore, mean value of SmC (y) correlated with mean value of HV (x) during GH treatment: r = 0.697, p < 0.0001; regression equation: y = 242x + 576. Finally no correlation was present among six-monthly SmC values, including those pre-treatment, and HV values in each of following periods. In conclusion, during GH treatment in subjects with GH deficiency plasma SmC levels correlate with HV, but have not a predictive value of the growth response to GH treatment itself.

Combined treatment with growth hormone and gonadotropin-releasing hormone analogues in children with isolated growth hormone deficiency

In subjects with an isolated GH deficiency the inhibition of puberty by GnRH-analogue administration may be attempted to delay the onset, or to prolong the duration, of pubertal maturation in order to improve final height. We report our experience on the matter in 10 subjects (6M, 4F) suffering from isolated GH deficiency with a chronological age ranging from 6.5 to 10.6 years at diagnosis. After a period of 1-5.1 years of GH treatment, GnRH-analogues (long-acting D-Trp-6-GnRH) were added to GH for 12 months, when six subjects were still prepubertal and four in early puberty. During combined therapy, a regression in pubertal development was shown in three out of four children in early puberty, while serum testosterone or estradiol decreased. Height velocity decreased (from 5.23 +/- 1.49 (mean +/- SD) to 4.12 +/- 0.67 cm/year; p < 0.02), whereas height SD scores for bone age increased (from -0.75 +/- 0.42 to -0.47 +/- 0.55; p < 0.02). During the year of combined therapy, bone age increased only 0.57 +/- 0.27 years. The values for predicted height (TW2 and Bayley-Pinneau method) after combined treatment were also higher than those after treatment with GH alone (p < 0.02 and p < 0.001, respectively). Our preliminary data showed that the addition of GnRH-analogues to GH in subjects with isolated GH deficiency reduces the effect of GH on height velocity, but determines an improvement in statural prognosis, although a proper answer will not be obtained until final height has been achieved.

[Growth hormone secretion in response to the administration of thyrotropin releasing hormone (TRH) in children with insulin-dependent diabetes mellitus]

In this study the Authors examined the response in growth hormone (GH) to thyrotrophin releasing hormone (TRH) administration in a group composed of 29 children (17 males, 12 females) suffering from insulin-dependent diabetes mellitus (IDDM) (group 1). All subjects were prepubertal, had a chronological age of 8.82 +/- 1.76 years (m +/- SD), a bone age of 8.60 +/- 1.65 years; the time elapsed since the diagnosis was 2.45 +/- 1.51 years, glycosylated hemoglobin (HbA1c) was 7.33 +/- 1.80%. Some of the same subjects (all those with a response in GH to TRH higher than 4 ng/ml; no. 11; group 2) were examined again 12-18 months later; as controls, 13 short children were also examined (group 3). All the subjects of the three groups showed a TSH peak ranging from 10-25 microU/ml, whereas GH peak resulted higher than 4 ng/ml ("paradoxical" response) in 6 subject of the group 1 and in an only subjects of the group 2. All the responders of the 3 groups showed a value in HbA1c higher than 8%. A significant difference was not present between males and females in GH and TSH values. Cortisol levels and glycaemia remained almost constant during the performance of the tests. By considering all the groups, TSH and GH values during TRH-test were not correlated with glycaemia, chronological age, bone age, the time elapsed since the diagnosis, height, height velocity, HbA1c values. In conclusion, our data demonstrated that "paradoxical" response in GH to TRH administration was present only in some subjects and particularly in those with a poor metabolic control of the disease.

[The effects of l-dopa administration on the prolactin levels in short-stature subjects]

In this study, on the basis of the inhibiting action of l-dopa administration on prolactin (PRL) secretion, we evaluated in a number of short children the levels of PRL during the provocative stimuli test with l-dopa in order to identify an index able to give reliability to the test and to investigate whether some differences may exist among the subjects showing a different response in growth hormone (GH) secretion to l-dopa. We examined 76 subjects (44 boys and 32 girls) with chronological age from 4.5-15.17 years. The subjects, on the basis of the GH peaks during two provocative stimuli tests [l-dopa and insulin-induced hypoglycemia (IIH)], were subdivided into 3 groups: group 1 (n = 24) with both deficient responses (peak less than 10 ng/ml); group 2 (n = 28) with discordant responses and further subdivided into group 2a (n = 14) with normal responses to IIH and 2b (n = 14) with a normal response to l-dopa; group 3 (n = 24) with both normal responses. PRL levels peaked between times -20' (58 cases) and +20' (2 cases) whereas nadir occurred between +80' (4 cases) and +120 (48 cases) without any significant difference (p = ns) among the groups. PRL levels significantly decreased in all groups, also in those with a deficient response to l-dopa (1 and 2a); furthermore no significant correlation between PRL and GH levels was demonstrated. In conclusion, this study showed the importance of PRL evaluation during l-dopa test in order to give reliability to the test and did not demonstrate any difference in PRL levels among the examined groups of short children.

Stimulated growth hormone (GH) secretion in children with delays in pubertal development before and after the onset of puberty: relationship with peripheral plasma GH-releasing hormone and somatostatin levels

A reduced GH secretion has often been shown in prepubertal children with delays in pubertal development. In order to study the mechanism underlying this finding, we evaluated peripheral circulating levels of GH, GHRH, and somatostatin (SRIH) before and after the onset of sexual development in a group of eight late maturing children (six boys, two girls), comparing the results with those obtained in two groups of five prepubertal and four pubertal short children with familial short stature. GH was measured by a two-site immunoradiometric assay. Both GHRH and SRIH were assayed by specific RIAs after an acetone-petrolether extraction from plasma. Our data showed a significant increase (P less than 0.001) in GH, GHRH, and SRIH levels (peak vs. basal values) in response to L-dopa administration in all groups. In pubertal children with delays in pubertal development GH and GHRH peak values (15.8 +/- 2.2 micrograms/L and 120 +/- 18 pg/mL, respectively) were significantly greater (P less than 0.001) than in the same subjects before puberty (8.2 +/- 0.9 micrograms/L and 79 +/- 9 pg/mL, respectively), whereas SRIH peak values did not significantly change (41 +/- 6 vs. 41 +/- 5 pg/mL; P = NS). Furthermore, prepubertal subjects with delays in pubertal development showed GH and GHRH peak values lower (P less than 0.001) than those of prepubertal subjects with FSS (13.3 +/- 1.8 micrograms/L and 120 +/- 13 pg/mL, respectively), whereas no statistical difference was present between the two groups of subjects after pubertal development (18.2 +/- 2.9 micrograms/L and 128 +/- 11 pg/mL, respectively). In conclusion, these findings support the assumption that in late maturing subjects during prepubertal period the decreased GH secretion may be ascribed to a reduced GHRH secretion, reversible with the onset of puberty, without change in circulating SRIH levels.

[The correlation between blood concentrations of somatomedin C and the auxological characteristics in short-stature subjects]

In this study the authors evaluated the correlation between plasma somatomedin C (SmC) levels and auxological features in 129 short children, who have been subdivided into four groups: classical growth hormone (GH) deficiency (14 prepubertal subjects), normal responses to provocative stimuli tests, but diminished spontaneous GH secretion (40 prepubertal subjects), normal responses to provocative stimuli tests and normal spontaneous GH secretion (45 prepubertal subjects and 30 subjects at stage G2/B2-Ph2 of puberty). The following correlations with SmC are resulted, when all the subjects were considered: chronological age (r = 0.415, p = 0.0002), bone age (r = 0.557, p less than 0.0001), bone age/chronological age ratio (r = 0.493, p less than 0.0001), height SDs (r = 0.574, p less than 0.0001), height velocity SDs (r = 0.599, p less than 0.0001), but not weight variation % (r = -0.020, p: ns). In conclusion, the results of the study demonstrate a high correlation between SmC levels and auxological features, with the exception of weight.

[Endocrine study in the Prader-Willi syndrome. Apropos of 5 cases]

Five children (3 boys and 2 girls) ranging in age form 5-12 years and suffering from Prader-Willi syndrome have been evaluated. In each subject the Authors have examined auxological parameters and the following hormonal values: GH after two pharmacological stimuli tests, gonadotropins after LHRH, TSH and prolactin after TRH, cortisol rhythm, testosterone after hCG in males, thyroid hormones and steroids. The results have shown a height less than 3 degrees centile only in a subjects and ranging from 10 degrees-50 degrees in the others, a weight greater than 97 degrees centile for the height age in all, a low response in GH to both stimuli in two subjects, an increased response to LHRH in FSH in two subjects. All other endocrine evaluations were in the normal range with the exception of insulin that resulted augmented in spite of normal glycaemic values. In conclusion, our data would suggest the existence of an eventual alteration of the hypothalamus-pituitary structures.

[Hydrocarbon poisoning in childhood]

The authors report the experience of a pediatric clinic on hydrocarbon poisoning. Among the reported cases was that of a girl showing a serious pneumonitis.

[The GHRH test in Turner's syndrome]

GHRH test was performed in 11 girls suffering from Turner's syndrome ranging in age from 5.6-13.5 years. GH peak resulted lower than 10 ng/ml in three subjects, who had also shown reduced GH values after two conventional pharmacological stimuli (L-dopa- and insulin-induced hypoglycemia) and a value of mean GH concentration over 24 hours lower than 3 ng/ml. Both GH peak and area under the curve were not correlated with height, height velocity, bone age/chronological age ratio, GH peak after conventional pharmacological stimuli and mean GH value of spontaneous secretion. The comparison with the results of GHRH test in other kinds of short stature evidenced in girls with Turner's syndrome the presence of GH values (peak and area under the curve) higher than those in subjects with "classical" GH deficiency, lower than those in "short normal stature" and similar to those in subjects with "non classical" GH deficiency. In conclusion, our data suggest, even if within a certain variability of the responses, a possible involvement of GH deficiency to the pathogenesis of short stature in Turner's syndrome, suggesting the existence of a prevalent hypothalamic nature of GH deficiency.

Evaluation of 24-hour growth hormone spontaneous secretion: comparison with a nocturnal and diurnal 12-hour study

Spontaneous growth hormone (GH) secretion in 116 short children was studied by sampling blood for GH measurement every 20 min over 24 h. We calculated 24-h mean GH concentration (MGHC), diurnal 12-h MGHC (dMGHC) and nocturnal 12-h MGHC (nMGHC). The children were subdivided into four groups: prepubertal children with 'classical' GH deficiency (group 1, n = 12, low responses to two provocative stimuli tests and MGHC less than 3 ng/ml), prepubertal children with 'nonclassical' GH deficiency (group 2, n = 36, normal GH responses to two provocative tests and MGHC less than 3 ng/ml), short normal children (normal GH responses to two provocative tests and MGHC greater than 3 ng/ml) at stage P1 of puberty (group 3, n = 41) and at stage P2 of puberty (group 4, n = 27). The values of MGHC, dMGHC and nMGHC were significantly higher in groups 3 and 4 than in groups 1 and 2, and in group 4 than in group 3. The values of MGHC and nMGHC were significantly higher in group 2 than in group 1. MGHC correlated highly with nMGHC and dMGHC (r = 0.97 and 0.94, respectively; p less than 0.001). On the basis of regression equations between MGHC and nMGHC or dMGHC, the study of the diagnostic accuracy showed values higher for nMGHC than for dMGHC: 94.1 vs. 89.6% for sensitivity, and 93.7 vs. 89.7% for specificity, respectively.

[Use of arginine hydrochloride in non-endocrine growth disorders]

We have examined a group composed of 60 short prepubertal children (height less than 3 degrees centile; 31 M, 29 F, age from 4.17-10.5 years) with a decreased height velocity (less than 10 degrees centile) and in which endocrine, systemic or specific causes of short stature have been ruled out by the performance of several instrumental or laboratory analyses. Auxological features of a 12-month period (from time -12 to time 0) without any treatment ("off" period) have been compared with an immediately following 12-month period (from time 0 to time +12), during which hydrochloride arginine was administered ("on" period); 2 phials per day in subjects older than 6 years and 1 phial per day in those less old than 6 years. In the absence of the pubertal development, height changed from -1.95 +/- 0.29 (m +/- 1 SD) standard deviation scores (SDS) at time -12 to -2.17 +/- 0.28 SDS at time 0 and -2.24 +/- 0.29 SDS at time +12 with a variation of -0.22 +/- 0.09 SDS in "off" period and of -0.07 +/- 0.14 SDS in "on" period (p less than 0.001) and therefore a difference between the two periods of 0.16 +/- 0.13 SDS. Height age (HA)/chronological age (CA) ratio was 0.74 +/- 0.05, 0.73 +/- 0.04 e 0.73 +/- 0.04, at time -12, 0 and +12, respectively. Height velocity changed from 4.18 +/- 0.47 cm/yr, -1.84 +/- 0.45 SDS for CA and -2.07 +/- 0.41 SDS for bone age (BA) during "off" period to 4.72 +/- 0.74 cm/yr, -1.05 +/- 0.83 SDS for CA and -1.31 +/- 0.77 SDS for BA during "on" period (p less than 0.001) with a variation of 0.53 +/- 0.56 cm/yr, 0.78 +/- 0.65 SDS for CA and 0.77 +/- 0.69 SDS for BA. BA resulted 6.57 +/- 1.55 years at time 0 and 7.34 +/- 1.54 years at time +12; HA/BA ratio changed from 0.86 +/- 0.07 at time 0 to 0.88 +/- 0.07 at time +12 (p less than 0.01) with a ratio between the two values of 1.01 +/- 0.02. Height and height velocity did not result statistically different between males and females or between subjects with delayed BA and those with non-delayed BA, while HA/BA ratio resulted significantly higher in the subjects with non-delayed BA than in those with delayed BA.(ABSTRACT TRUNCATED AT 400 WORDS)

[Thyroid and thyrotropin functions in subjects with pituitary nanism treated with growth hormone]

We have evaluated thyroid and thyrotropin functions before the beginning and during Growth Hormone (GH) treatment for a 2-6-year period in a group composed of 21 children (age: 6.6 +/- 1.1 years, m +/- SD) suffering from classic GH deficiency. Circulating levels of thyroxine, and basal thyroid-stimulating hormone (TSH) always resulted in the normal range. TSH response to thyreotropin-releasing hormone administration showed in some subjects (one out of 21 before the start of treatment, 2 out of 16 after 2 years, 3 out of 12 after 4 years and 2 out of 10 after 6 years) a delayed (after 90-120 minutes) and higher peak in comparison to that of normal subjects. All these high and delayed values have been showed in only one occasion by different children, with the exception of a child who has presented the higher values in two occasions. Growth response to GH treatment has not been modified by the change in thyrotropin response, as subjects with high TSH peak have had a height velocity similar to that of the other children in the corresponding periods of study.

GHRH-test in short children with "non classic" GH deficiency. A comparison with "classic" GH deficiency and short normal stature

In this study GHRH-test has been performed (2 micrograms/Kg of an iv bolus of GHRH 1-44) sampling for GH measurement every 15 min over 2 hours in three groups of short children. Group 1 consisted of 10 subjects with classic GH deficiency (CGHD): GH response less than 10 ng/ml to two conventional tests and 24-h mean GH concentration (MGHC) less than 3 ng/ml; group 2 consisted of 16 subjects with non-classic GH deficiency (NCGHD): response greater than 10 ng/ml to at least one conventional test and MGHC less than 3 ng/ml; group 3 consisted of 18 subjects with short normal stature: GH response greater than 10 ng/ml to at least one conventional test and MGHC greater than 3 ng/ml. GH peak and area under the curve (AUC) values were significantly lower in group 1 than groups 2 and 3 and in group 2 than group 3. GH peak and AUC values statistically correlated with height, height velocity, bone age/chronological age ratio and MGHC. Six children in group 1, 14 children in group 2 and all 18 children in group 3 showed after GHRH a GH peak greater than 10 ng/ml and were considered as 'responders'. Considering only the responders, GH peak and AUC values were significantly lower in group 1 than groups 2 and 3 and in group 2 than group 3. In conclusion, our data have shown that 87% of children with NCGHD responded to a single bolus of GHRH with an increase in GH levels greater than 10 ng/ml and that their responses were intermediate compared to those of CGHD and short normal subjects.

Criteria for recognition of the growth-inefficient child who may respond to treatment with growth hormone

In this study three groups of short children composed of 104 subjects (61 boys, 43 girls) were evaluated for spontaneous secretion of growth hormone (GH). Group 1 consisted of 10 subjects (6 boys, 4 girls) with "classic" GH deficiency. Group 2 consisted of 31 subjects (17 boys, 14 girls) with "nonclassic" GH deficiency. Group 3 consisted of 63 subjects (38 boys, 25 girls) with short normal stature. Blood samples were drawn every 20 minutes over 24 hours, and the mean GH concentration, nocturnal GH concentration, diurnal GH concentration, pulse amplitude, and number of pulses with a GH peak above 5 micrograms/L were determined. The values for mean height, height velocity, bone age to chronological age ratio, somatomedin C concentration, GH concentration, nocturnal GH concentration, diurnal GH concentration, pulse amplitude, and number of pulses with a GH peak over 5 micrograms/L were significantly greater in group 3 than in group 2, and these same values, except for the mean diurnal GH concentration, were greater in group 2 than in group 1. The mean GH concentration correlated with the mean nocturnal GH concentration. Subjects in groups 1 and 2 were treated with GH for 1.23 +/- 0.53 years (mean +/- SD). All the group 1 subjects and 27 (87%) of the group 2 subjects responded with an increase in height velocity greater than 2 SDs per year of therapy. In conclusion, 87% of subjects with a normal GH response to provocative stimuli testing who had a mean height velocity of less than 4 cm/y, mean height lower than the third percentile, mean bone age to chronological age ratio of less than 0.8, and mean GH concentration less than 3 micrograms/L responded to GH therapy.

[Selective deficit of IgA and infantile rheumatoid arthritis. Case reports]

Three children with selective deficiency of serum IgA associated with oligoarticular juvenile rheumatoid arthritis (JRA) are presented. Before the appearance of JRA, all 3 children had shown frequently some respiratory infections. Indeed IgA deficiency may be asymptomatic or may cause a higher frequency of respiratory, gastrointestinal, allergic or autoimmune diseases, among which, JRA is one of the most important conditions.