1
|
Gardner M, Brinkman WB, Carley M, Liang N, Lightfoot S, Pinkelman K, Speiser PW, Schafer-Kalkhoff T, Suorsa-Johnson KI, VanderBrink B, Weidler EM, Wisniewski J, Stacey D, Sandberg DE. Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development. Front Urol 2023; 3:1089077. [PMID: 37920725 PMCID: PMC10621652 DOI: 10.3389/fruro.2023.1089077] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Introduction Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support. Methods 34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted. Results Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information. Discussion Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.
Collapse
Affiliation(s)
- Melissa Gardner
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William B. Brinkman
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Noi Liang
- Patient / parent / caregiver stakeholder partners, Denver, CO, USA
| | | | - Kendra Pinkelman
- Patient / parent / caregiver stakeholder partners, Ann Arbor, MI, USA
| | - Phyllis W. Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | | | | | - Brian VanderBrink
- Division of Urology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | - Erica M. Weidler
- Division of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, AZ
- Accord Alliance, USA
| | | | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
- Accord Alliance, USA
- Division of Pediatric Psychology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
2
|
Suorsa-Johnson KI, Gardner MD, Brinkman W, Carley M, Gruppen L, Liang N, Lightfoot S, Pinkelman K, Speiser PW, VanderBrink B, Wisniewski J, Sandberg DE, Stacey D. A survey of healthcare professionals' perceptions of the decisional needs of parents with an infant born with a disorder/difference of sex development. J Pediatr Urol 2023; 19:39-49. [PMID: 36244898 PMCID: PMC10603597 DOI: 10.1016/j.jpurol.2022.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 07/12/2021] [Revised: 08/05/2022] [Accepted: 09/18/2022] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Parents of infants born with differences in sex development (DSD) face many difficult decisions. As part of a larger project designed to develop educational interventions to promote shared decision making, this study assessed healthcare professionals' (HCPs) perceptions of parental decision-making needs when an infant is born with a DSD. METHODS A cross-sectional web-based survey following the Ottawa Decision Support Framework was conducted in two waves, between October 2020 and June 2022. Survey domains included: common DSD decisions, indicators of parents' decisional needs, and resources and approaches to support parental decision making. Eligible participants were HCPs working within interprofessional pediatric DSD centers in the USA. Up to three reminders were sent. Descriptive analysis was conducted. RESULTS 71 HCPs participated; most (>90%) reported parents experience signs of decisional conflict including feeling unsure, worrying about what could go wrong, and fear of choosing a "wrong," irreversible option. The majority (90%) reported parents experience strong emotions interfering with their receptivity to information or deliberation. The majority (>70%) identified inadequate parental knowledge of the DSD as a barrier to decision making, coupled with information overload (>90%). HCPs rated several factors as "very" important, including: parents having information on benefits, harms, and other features of options (93%), having information about all the available options (87%), and having access to providers to discuss the options (84%). Providers endorsed using a variety of approaches to support parents' decision making; however, access to decision aids was not universally rated as highly important (very, 44%; somewhat, 46%; a little, 10%). IMPLICATIONS Overall, HCPs expressed favorable attitudes toward supporting active parental participation in medical decision making. Opportunities for enhanced support of shared decision making included: a) recognizing and addressing parental emotional distress and informational overload at a time when parents need to consider complex options for their infant or young child; and b) the need for HCPs to encourage values clarification in decision-making encounters with parents.
Collapse
Affiliation(s)
- Kristina I Suorsa-Johnson
- Department of Pediatrics, Division of Psychiatry and Behavioral Health, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, UT, USA
| | - Melissa D Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA
| | - William Brinkman
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Meg Carley
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Larry Gruppen
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | | | | | - Phyllis W Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA; Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Brian VanderBrink
- Division of Urology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - David E Sandberg
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, MI, USA; Department of Pediatrics, Division of Pediatric Psychology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dawn Stacey
- Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Nursing, University of Ottawa, Ottawa, ON, Canada.
| |
Collapse
|
3
|
Lightfoot S, Carley M, Brinkman W, Gardner MD, Gruppen LD, Liang N, Pinkelman K, Speiser PW, Suorsa-Johnson KI, VanderBrink B, Wisniewski J, Sandberg DE, Stacey D. Co-creating a suite of patient decision aids for parents of an infant or young child with differences of sex development: A methods roadmap. Front Urol 2023; 2:1020152. [PMID: 37885597 PMCID: PMC10601605 DOI: 10.3389/fruro.2022.1020152] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Introduction Parents and guardians of infants and young children with differences of sex development (DSD) often face numerous health and social decisions about their child's condition. While proxy health decisions can be stressful in any circumstance, they are further exacerbated in this clinical context by significant variations in clinical presentation, parental lack of knowledge about DSD, irreversibility of some options (e.g., gonadectomy), a paucity of research available about long-term outcomes, and anticipated decisional regret. This study aimed to engage clinicians, parents, and an adult living with DSD to collaboratively develop a suite of patient decision aids (PDAs) to respond to the decisional needs of parents and guardians of infants and young children diagnosed with DSD. Methods We used a systematic co-development process guided by the Ottawa Decision Support Framework and the International Patient Decision Aids Standards (IPDAS). The five steps were: literature selection, establish the team, decisional needs assessment, create the PDAs, and alpha testing. Results We developed four PDAs to support parents/guardians of infants or young children diagnosed with DSD about four priority decisions identified through our decisional needs assessment: genetic testing, gender of rearing, genital surgery and gonadal surgery. All four PDAs include information for parents about DSD, the options, reasons to choose or avoid each option, and opportunities for parents/guardians to rate the importance of features of each option to clarify their values for these features. Qualitative feedback was positive from clinicians, parents and an adult living with DSD. Conclusions These PDAs are clinical tools designed to support parents/guardians and to promote making an informed and shared DSD-related decision. While these tools are specific to DSD, they contain themes and elements translatable to other pediatric populations.
Collapse
Affiliation(s)
| | - Meg Carley
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - William Brinkman
- Division of General and Community Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Melissa D. Gardner
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
| | - Larry D. Gruppen
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
| | - Noi Liang
- Patient / Parent / Caregiver Partners
| | | | - Phyllis W. Speiser
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
- Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Kristina I. Suorsa-Johnson
- Division of Pediatric Psychiatry and Behavioral Health, Department of Pediatrics, University of Utah Spencer Fox Eccles School of Medicine, Salt Lake City, USA
| | - Brian VanderBrink
- Division of Urology, Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
| | | | - David E. Sandberg
- Susan B. Meister Child Health Evaluation & Research (CHEAR) Center, University of Michigan, Ann Arbor, Michigan, USA
- Department of Pediatrics, Division of Pediatric Psychology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Dawn Stacey
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| |
Collapse
|
4
|
Bhangoo A, Gupta R, Shelov SP, Carey DE, Accacha S, Fennoy I, Altshuler L, Lowell B, Rapaport R, Rosenfeld W, Speiser PW, Ten S, Rosenbaum M. Fasting Serum IGFBP-1 as a Marker of Insulin Resistance in Diverse School Age Groups. Front Endocrinol (Lausanne) 2022; 13:840361. [PMID: 35586622 PMCID: PMC9108162 DOI: 10.3389/fendo.2022.840361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/14/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The known markers of insulin resistance in obese children are well studied. However, they require serial measurements and complicated calculations. The objective is to study IGFBP-1 and its relation with other known risk measures. Materials and Methods The study included 98 New York City school students of diverse ethnic/racial backgrounds (57 males and 41 females), 11-15 years of age. Subjects were enrolled in a cross-sectional study, and anthropometric measures were collected. They underwent fasting intravenous glucose tolerance tests (IVGTT), and glucose, insulin, lipids, IGFBP-1, adiponectin and inflammatory markers were collected. Results The subjects were stratified into 3 groups based upon the BMI Z-score. Out of all the subjects, 65.3% were in the group with a BMI Z-score <1 SDS, 16.3% subjects were in the group with a BMI Z-score of 1 to 2 SDS, and 18.4% of the subjects were in the group with a BMI Z-score of more than 2 SDS. The group with a BMI Z-score of more than 2 SDS had increased waist circumference (WC), body fat, increased fasting insulin, and triglycerides (TG). This group had decreased levels of adiponectin and HDL and low IGFBP-1 as compared to the group with BMI <1 SDS. The group with a BMI Z-score of 1 to 2 SDS had a decreased level of IGFBP-1 as compared to the group with a BMI Z-score less than 1 SDS. IGFBP-1 inversely correlated with age, WC, BMI, body fat, TG, and insulin levels. IGFBP-1 positively correlated with adiponectin and HDL levels. Conclusion IGFBP-1 in children can identify the presence of insulin resistance in the group with BMI 1 to 2 SDS, even before the known markers of insulin resistance such as elevated triglycerides and even before decreased HDL and adiponectin levels are identified.
Collapse
Affiliation(s)
- Amrit Bhangoo
- Division of Pediatric Endocrinology, Children’s Hospital of Orange County, Orange, CA, United States
| | - Rishi Gupta
- Division of Pediatric Endocrinology, Children’s Hospital of Orange County, Orange, CA, United States
- Department of Pediatrics, Division of Pediatric Gastroenterology and Endocrinology, University of Rochester Medical Center, Rochester, NY, United States
| | - Steve P. Shelov
- Department of Pediatrics, Winthrop University Hospital, Mineola, NY, United States
| | - Dennis E. Carey
- Division of Pediatric Endocrinology, Northwell Health, Lake Success, NY, United States
| | - Siham Accacha
- Department of Pediatrics, Winthrop University Hospital, Mineola, NY, United States
| | - Ilene Fennoy
- Division of Pediatric Endocrinology, New York Presbyterian Morgan Stanley Children’s Hospital, New York, NY, United States
| | - Lisa Altshuler
- Program for Medical Education Innovations & Research (PrMeir), New York University (NYU) Grossman School of Medicine, New York, NY, United States
| | - Barbara Lowell
- Laboratory of Diabetes, Obesity and Other Metabolic Disorders, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, United States
| | - Robert Rapaport
- Division of Pediatric Endocrinology and Diabetes at Mount Sinai Kravis Children’s Hospital, New York, NY, United States
| | - Warren Rosenfeld
- Department of Pediatrics, Winthrop University Hospital, Mineola, NY, United States
| | - Phyllis W. Speiser
- Cohen Children’s Medical Center of NY and Zucker School of Medicine, New Hyde Park, NY, United States
| | - Svetlana Ten
- Division of Pediatric Endocrinology, Richmond University Medical Center, Staten Island, NY, United States
| | - Michael Rosenbaum
- Department of Pediatrics, Division of Molecular Genetics, New York Presbyterian Medical Center, New York, NY, United States
| |
Collapse
|
5
|
Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 132] [Impact Index Per Article: 66.0] [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: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
Collapse
Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
| |
Collapse
|
6
|
Affiliation(s)
- Phyllis W Speiser
- Cohen Children's Medical Center of New York, Northwell Health, Zucker School of Medicine at Hofstra, Hempstead, NY
| |
Collapse
|
7
|
Speiser PW, Chawla R, Chen M, Diaz-Thomas A, Finlayson C, Rutter MM, Sandberg DE, Shimy K, Talib R, Cerise J, Vilain E, Délot EC. Newborn Screening Protocols and Positive Predictive Value for Congenital Adrenal Hyperplasia Vary across the United States. Int J Neonatal Screen 2020; 6:37. [PMID: 32832708 PMCID: PMC7422998 DOI: 10.3390/ijns6020037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 05/06/2020] [Indexed: 02/07/2023] Open
Abstract
Newborn screening for congenital adrenal hyperplasia (CAH) caused by 21-hydroxylase deficiency is mandated throughout the US. Filter paper blood specimens are assayed for 17-hydroxyprogesterone (17OHP). Prematurity, low birth weight, or critical illness cause falsely elevated results. The purpose of this report is to highlight differences in protocols among US state laboratories. We circulated a survey to state laboratory directors requesting qualitative and quantitative information about individual screening programs. Qualitative and quantitative information provided by 17 state programs were available for analysis. Disease prevalence ranged from 1:9941 to 1:28,661 live births. Four state laboratories mandated a second screen regardless of the initial screening results; most others did so for infants in intensive care units. All but one program utilized birthweight cut-points, but cutoffs varied widely: 17OHP values of 25 to 75 ng/mL for birthweights >2250-2500 g. The positive predictive values for normal birthweight infants varied from 0.7% to 50%, with the highest predictive values based in two of the states with a mandatory second screen. Data were unavailable for negative predictive values. These data imply differences in sensitivity and specificity in CAH screening in the US. Standardization of newborn screening protocols could improve the positive predictive value.
Collapse
Affiliation(s)
- Phyllis W. Speiser
- Division of Endocrinology, Cohen Children’s Medical Ctr of New York, Feinstein Institute for Medical Research, Zucker School of Medicine at Hofstra University, New Hyde Park, NY 11040, USA;
| | - Reeti Chawla
- Division of Endocrinology, Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
| | - Ming Chen
- Division of Endocrinology, CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Alicia Diaz-Thomas
- Division of Endocrinology, LeBonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN 18103, USA;
| | - Courtney Finlayson
- Division of Endocrinology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA;
| | - Meilan M. Rutter
- Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, OH 45229, USA;
| | - David E. Sandberg
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA;
| | - Kim Shimy
- Division of Endocrinology, Children’s National Medical Center, Washington, DC 20010, USA;
| | - Rashida Talib
- Division of Endocrinology, Cohen Children’s Medical Ctr of New York, Feinstein Institute for Medical Research, Zucker School of Medicine at Hofstra University, New Hyde Park, NY 11040, USA;
| | - Jane Cerise
- Feinstein Institute for Medical Research, Northwell Health, Manhasset, NY 11030, USA;
| | - Eric Vilain
- Children’s National Hospital, Children’s Research Institute and George Washington University, Washington, DC 20010, USA; (E.V.); (E.C.D.)
| | - Emmanuèle C. Délot
- Children’s National Hospital, Children’s Research Institute and George Washington University, Washington, DC 20010, USA; (E.V.); (E.C.D.)
| | | |
Collapse
|
8
|
Speiser PW, Auchus RJ, Merke DP, Miller WL, White PC. Response to Letter to the Editor: "Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline". J Clin Endocrinol Metab 2019; 104:1928. [PMID: 30561699 PMCID: PMC6615294 DOI: 10.1210/jc.2018-02629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 12/06/2018] [Accepted: 12/12/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, Lake Success, New York
- Zucker Hofstra University School of Medicine, New Hyde Park, New York
- Correspondence and Reprint Requests: Phyllis W. Speiser, MD, Division of Pediatric Endocrinology, Cohen Children’s Medical Center of New York, 1991 Marcus Avenue, Suite M100, Lake Success, New York 11042. E-mail:
| | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- The Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Walter L Miller
- University of California, San Francisco, Benioff Children Hospital, San Francisco, California
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
9
|
Abstract
Congenital adrenal hyperplasia has traditionally been treated with daily oral doses of glucocorticoids and mineralocorticoid supplements. Such therapy does not precisely replicate the adrenal cortex's circadian pattern. As a consequence, patients are intermittently overtreated or undertreated leading to growth suppression in children, excess weight gain and altered metabolism. Several new treatments are on the horizon. This article will summarize some new potential therapies as adjuncts to, or replacement for, standard therapy.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Pediatrics, Zucker School of Medicine at Hofstra-Northwell Health, Lake Success, New York, 11042-2062, USA
| |
Collapse
|
10
|
Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 505] [Impact Index Per Article: 84.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
11
|
Almasri J, Zaiem F, Rodriguez-Gutierrez R, Tamhane SU, Iqbal AM, Prokop LJ, Speiser PW, Baskin LS, Bancos I, Murad MH. Genital Reconstructive Surgery in Females With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:4089-4096. [PMID: 30272250 DOI: 10.1210/jc.2018-01863] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [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] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Females with congenital adrenal hyperplasia (CAH) and atypical genitalia often undergo complex surgeries; however, their outcomes remain largely uncertain. METHODS We searched several databases through 8 March 2016 for studies evaluating genital reconstructive surgery in females with CAH. Reviewers working independently and in duplicate selected and appraised the studies. RESULTS We included 29 observational studies (1178 patients, mean age at surgery, 2.7 ± 4.7 years; mostly classic CAH). After an average follow-up of 10.3 years, most patients who had undergone surgery had a female gender identity (88.7%) and were heterosexual (76.2%). Females who underwent surgery reported a sexual function score of 25.13 using the Female Sexual Function Index (maximum score, 36). Many patients continued to complain of substantial impairment of sensitivity in the clitoris, vaginal penetration difficulties, and low intercourse frequency. Most patients were sexually active, although only 48% reported comfortable intercourse. Most patients (79.4%) and treating health care professionals (71.8%) were satisfied with the surgical outcomes. Vaginal stenosis was common (27%), and other surgical complications, such as fistulas, urinary incontinence, and urinary tract infections, were less common. Data on quality of life were sparse and inconclusive. CONCLUSION The long-term follow-up of females with CAH who had undergone urogenital reconstructive surgery shows variable sexual function. Most patients were sexually active and satisfied with the surgical outcomes; however, some patients still complained of impairment in sexual experience and satisfaction. The certainty in the available evidence is very low.
Collapse
Affiliation(s)
- Jehad Almasri
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Feras Zaiem
- Department of Pathology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital Dr. Jose E. Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | | | - Anoop Mohamed Iqbal
- Division of Pediatrics and Adolescent Medicine, Department of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center and Zucker Hofstra Northwell School of Medicine, Lake Success, New York
| | - Laurence S Baskin
- Department of Urology, University of California, San Francisco, California
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
12
|
Tamhane S, Rodriguez-Gutierrez R, Iqbal AM, Prokop LJ, Bancos I, Speiser PW, Murad MH. Cardiovascular and Metabolic Outcomes in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:4097-4103. [PMID: 30272185 DOI: 10.1210/jc.2018-01862] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Individuals with congenital adrenal hyperplasia (CAH) require glucocorticoid therapy to replace cortisol and to control androgen excess. We sought to evaluate the effects of glucocorticoid therapy on cardiovascular and metabolic outcomes in individuals with CAH. METHODS We searched bibliographical databases through January 2016 for studies evaluating cardiovascular risk factors in individuals with CAH treated with glucocorticoids compared with controls without CAH. We used a random-effects model to synthesize quantitative data. RESULTS We included 20 observational studies (14 longitudinal, six cross-sectional) with a moderate to high risk of bias. The average dose of glucocorticoids (in hydrocortisone equivalents) was 9 to 26.5 mg/m2/d. In the meta-analysis (416 patients), compared with controls without CAH, individuals with CAH had increased systolic blood pressure [weighted mean difference (WMD), 4.44 mm Hg; 95% CI, 3.26 to 5.63 mm Hg], diastolic blood pressure (WMD, 2.35 mm Hg; 95% CI, 0.49 to 4.20 mm Hg), homeostatic model assessment of insulin resistance (WMD, 0.49; 95% CI, 0.02 to 0.96), and carotid intima thickness (WMD, 0.08 mm; 95% CI, 0.01 to 0.15 mm). No statistically significant differences were noted in fasting blood glucose, insulin level, glucose, or insulin level after 2-hour glucose load or serum lipids. Data on cardiac events were sparse, and most of the literature focused on surrogate outcomes. CONCLUSION Individuals with CAH demonstrate a high prevalence of cardiovascular and metabolic risk factors. The current evidence relies on surrogate outcomes. Long-term prospective studies are warranted to assess strategies for reducing cardiovascular risk in individuals with CAH.
Collapse
Affiliation(s)
- Shrikant Tamhane
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
| | - Rene Rodriguez-Gutierrez
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota
- Division of Endocrinology, Hospital Universitario "Dr. José E. Gonzalez," Universidad Autonoma de Nuevo León, Monterrey, México
| | - Anoop Mohamed Iqbal
- Department of Pediatric Endocrinology, Division of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center and Zucker Hofstra Northwell School of Medicine, Lake Success, New York
| | | |
Collapse
|
13
|
Barillas JE, Eichner D, Van Wagoner R, Speiser PW. Iatrogenic Cushing Syndrome in a Child With Congenital Adrenal Hyperplasia: Erroneous Compounding of Hydrocortisone. J Clin Endocrinol Metab 2018; 103:7-11. [PMID: 29029106 DOI: 10.1210/jc.2017-01595] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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] [Received: 07/14/2017] [Accepted: 09/19/2017] [Indexed: 11/19/2022]
Abstract
CONTEXT Patients with 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH) require lifelong treatment with glucocorticoids. In growing children, the drug of choice is hydrocortisone. Commercially available hydrocortisone tablets do not conform to very low doses prescribed to infants and toddlers, and compounded hydrocortisone is often dispensed to meet therapeutic needs. However, safety, efficacy, and uniformity of compounded products are not tested. We report a case of Cushing syndrome in a child with CAH who was inadvertently receiving excessive hydrocortisone in compounded form. DESIGN A 20-month-old girl with CAH developed growth deceleration, excessive weight for length, irritability, increased facial fat, plethora, and excess body hair while receiving hydrocortisone from a local compounding pharmacy. The signs and symptoms persisted despite decreasing hydrocortisone dose. Iatrogenic Cushing syndrome was suspected. The prescribed hydrocortisone capsules were sent for analysis to the Sports Medicine Research & Testing Laboratory, where testing revealed that each 1-mg hydrocortisone capsule contained five to 10 times the dose prescribed and listed on the label. CONCLUSION Physicians must be aware that errors in compounded medications may lead to unanticipated adverse effects. Iatrogenic Cushing syndrome should be suspected in any child receiving compounded glucocorticoid treatment who develops growth arrest and excess weight gain.
Collapse
Affiliation(s)
- Julia E Barillas
- Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York
| | - Daniel Eichner
- The Sports Medicine Research & Testing Laboratory, Salt Lake City, Utah
| | - Ryan Van Wagoner
- The Zucker Hofstra Northwell School of Medicine, Hempstead, New York
| | - Phyllis W Speiser
- Steven and Alexandra Cohen Children's Medical Center of New York, New Hyde Park, New York
- The Zucker Hofstra Northwell School of Medicine, Hempstead, New York
| |
Collapse
|
14
|
Ernst MM, Gardner M, Mara CA, Délot EC, Fechner PY, Fox M, Rutter MM, Speiser PW, Vilain E, Weidler EM, Sandberg DE. Psychosocial Screening in Disorders/Differences of Sex Development: Psychometric Evaluation of the Psychosocial Assessment Tool. Horm Res Paediatr 2018; 90:368-380. [PMID: 30783028 PMCID: PMC6512800 DOI: 10.1159/000496114] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 05/01/2018] [Accepted: 12/10/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND/AIMS Utilization of a psychosocial screener to identify families affected by a disorder/difference of sex development (DSD) and at risk for adjustment challenges may facilitate efficient use of team resources to optimize care. The Psychosocial Assessment Tool (PAT) has been used in other pediatric conditions. The current study explored the reliability and validity of the PAT (modified for use within the DSD population; PAT-DSD). METHODS Participants were 197 families enrolled in the DSD-Translational Research Network (DSD-TRN) who completed a PAT-DSD during a DSD clinic visit. Psychosocial data were extracted from the DSD-TRN clinical registry. Internal reliability of the PAT-DSD was tested using the Kuder-Richardson-20 coefficient. Validity was examined by exploring the correlation of the PAT-DSD with other measures of caregiver distress and child emotional-behavioral functioning. RESULTS One-third of families demonstrated psychosocial risk (27.9% "Targeted" and 6.1% "Clinical" level of risk). Internal reliability of the PAT-DSD Total score was high (α = 0.86); 4 of 8 subscales met acceptable internal reliability. A priori predicted relationships between the PAT-DSD and other psychosocial measures were supported. The PAT-DSD Total score related to measures of caregiver distress (r = 0.40, p < 0.001) and to both caregiver-reported and patient self-reported behavioral problems (r = 0.61, p < 0.00; r = 0.37, p < 0.05). CONCLUSIONS This study provides evidence for the reliability and validity of the PAT-DSD. Given variability in the internal reliability across subscales, this measure is best used to screen for overall family risk, rather than to assess specific psychosocial concerns.
Collapse
Affiliation(s)
- Michelle M. Ernst
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Melissa Gardner
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| | - Constance A. Mara
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Emmanuèle C. Délot
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Patricia. Y. Fechner
- Department of Pediatrics, University of Washington, Seattle Children’s DSD Program, Seattle, Washington
| | - Michelle Fox
- Department of Pediatrics, UCLA School of Medicine, Los Angeles, California
| | - Meilan. M. Rutter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio and Disorders of Sex Development Center, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Phyllis W. Speiser
- Department of Pediatrics, Cohen Children’s Medical Center of New York and Zucker School of Medicine at Hofstra University, New Hyde Park, New York
| | - Eric Vilain
- Center for Genetic Medicine Research, Children’s National Medical Center, Washington, DC
| | - Erica M. Weidler
- Department of Pediatric Surgery, Phoenix Children’s Hospital, Phoenix, Arizona; Accord Alliance, Whitehouse Station, New Jersey
| | | | - David E. Sandberg
- Department of Pediatrics and Communicable Diseases and the Child Health Evaluation & Research Center, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
15
|
Abstract
Adrenarche is when a child's adrenal cortex starts to secrete adrenal androgen precursors. Dehydroepiandrosterone (DHEA) is the most abundant product of the adrenal cortex, and is a weak androgen agonist thought to be responsible for the clinical signs of pubarche by conversion to more potent androgens, testosterone, and dihydrotestosterone. DHEA's extra-adrenal sulfation product, dehydroepiandrosterone sulfate, is a stable marker for adrenal androgenic activity. Pubarche is the physical manifestation of androgenic hormone production, and includes the development of pubic and axillary hair, adult body odor, and acne. This stage is usually considered premature if it commences before age 8 years in girls or age 9 years in boys. Premature adrenarche is a diagnosis of exclusion, as true centrally mediated precocious puberty, congenital adrenal hyperplasia, exogenous androgen exposure, and androgen-secreting tumors must be ruled out. Premature adrenarche may be associated with a history of an infant who was small for gestational age at birth who then gained weight rapidly thereafter or became obese. In some instances, premature adrenarche may predict functional ovarian hyperandrogenism in adolescence. Management of premature adrenarche is largely aimed at observation, lifestyle adjustments for weight concerns, and monitoring for future possible persistent androgen excess and insulin resistance. [Pediatr Ann. 2018;47(1):e7-e11.].
Collapse
|
16
|
Lahoti A, Harris YT, Speiser PW, Atsidaftos E, Lipton JM, Vlachos A. Endocrine Dysfunction in Diamond-Blackfan Anemia (DBA): A Report from the DBA Registry (DBAR). Pediatr Blood Cancer 2016; 63:306-12. [PMID: 26496000 PMCID: PMC4829065 DOI: 10.1002/pbc.25780] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 06/11/2015] [Accepted: 09/07/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Diamond-Blackfan anemia (DBA) is a rare inherited bone marrow failure syndrome. The mainstays of treatment involve chronic red cell transfusions, long-term glucocorticoid therapy, and stem cell transplantation. Systematic data concerning endocrine function in DBA are limited. We studied patients in the DBA Registry (DBAR) of North America to assess the prevalence of various endocrinopathies. PROCEDURE In a pilot study, retrospective data were collected for 12 patients with DBA. Subsequently, patients with DBA aged 1-39 years were recruited prospectively. Combined, 57 patients were studied; 38 chronically transfused, 12 glucocorticoid-dependent, and seven in remission. Data were collected on anthropometric measurements, systematic screening of pituitary, thyroid, parathyroid, adrenal, pancreatic, and gonadal function, and ferritin levels. Descriptive statistics were tabulated and group differences were assessed. RESULTS Fifty-three percent of patients had ≥ 1 endocrine disorder, including adrenal insufficiency (32%), hypogonadism (29%), hypothyroidism (14%), growth hormone dysfunction (7%), diabetes mellitus (2%), and/or diabetes insipidus (2%). Ten of the 33 patients with available heights had height standard deviation less than -2. Low 25-hydroxy vitamin D (25(OH)D) levels were present in 50%. A small proportion also had osteopenia, osteoporosis, or hypercalciuria. Most with adrenal insufficiency were glucocorticoid dependent; other endocrinopathies were more common in chronically transfused patients. CONCLUSIONS Endocrine dysfunction is common in DBA, as early as the teenage years. Although prevalence is highest in transfused patients, patients taking glucocorticoids or in remission also have endocrine dysfunction. Longitudinal studies are needed to better understand the etiology and true prevalence of these disorders.
Collapse
Affiliation(s)
- Amit Lahoti
- Division of Endocrinology, Cohen Children’s Medical Center (CCMC), New Hyde Park, NY,Hofstra North Shore-LIJ School of Medicine, Hempstead, NY
| | - Yael T Harris
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY,Internal Medicine-Endocrinology, North Shore LIJ Health System (NSLIJHS), Manhasset, NY
| | - Phyllis W Speiser
- Division of Endocrinology, Cohen Children’s Medical Center (CCMC), New Hyde Park, NY,Hofstra North Shore-LIJ School of Medicine, Hempstead, NY,Feinstein Institute for Medical Research (FIMR); Manhasset, NY
| | | | - Jeffrey M Lipton
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY,Feinstein Institute for Medical Research (FIMR); Manhasset, NY,Division of Hematology/Oncology and Stem Cell Transplantation, CCMC, New Hyde Park, NY
| | - Adrianna Vlachos
- Hofstra North Shore-LIJ School of Medicine, Hempstead, NY,Feinstein Institute for Medical Research (FIMR); Manhasset, NY,Division of Hematology/Oncology and Stem Cell Transplantation, CCMC, New Hyde Park, NY
| |
Collapse
|
17
|
Abstract
Congenital adrenal hyperplasia associated with deficiency of steroid 21-hydroxylase is the most common inborn error in adrenal function and the most common cause of adrenal insufficiency in the pediatric age group. As patients now survive into adulthood, adult health-care providers must also be familiar with this condition. Over the past several years, F1000 has published numerous commentaries updating research and practical guidelines for this condition. The purposes of this review are to summarize basic information defining congenital adrenal hyperplasia and to highlight current knowledge and controversies in management.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Cohen Children's Medical Center and Hofstra North Shore LIJ School of Medicine, New Hyde Park, NY 11040, USA
| |
Collapse
|
18
|
Speiser PW. Adrenal Dysfunction. Adolesc Med State Art Rev 2015; 26:343-363. [PMID: 26999876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
|
19
|
Speiser PW. A Rationale for Mineralocorticoid Supplementation in Classic Congenital Adrenal Hyperplasia. Horm Res Paediatr 2015; 83:000375531. [PMID: 25924649 DOI: 10.1159/000375531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 01/26/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center of New York, Hofstra-North Shore LIJ School of Medicine, Lake Success, N.Y., USA
| |
Collapse
|
20
|
Accacha S, Rosenfeld W, Jacobson A, Michel L, Schnurr FJ, Shelov S, Ten S, Boucher-Berry C, Carey DE, Speiser PW, Lowell B, Conroy R, Klein M, Fennoy I, Rapaport R, Rosenbaum M. Plasma advanced glycation end products (AGEs), receptors for AGEs and their correlation with inflammatory markers in middle school-age children. Horm Res Paediatr 2014; 80:318-27. [PMID: 24217195 DOI: 10.1159/000354831] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 08/02/2013] [Indexed: 11/19/2022] Open
Abstract
AIM Advanced glycation end products (AGEs) and/or their receptors (RAGE) are significantly positively correlated with adiposity, inflammation, dyslipidemia, and insulin resistance in adults. However, the relationships between AGEs, RAGE, and adiposity-related comorbidites in children have not been well studied. METHODS In a cross-sectional study of 88 children (age 11-15 years) from the New York area enrolled in the Reduce Obesity and Diabetes (ROAD) study, we examined the correlation of the AGE N(ε)-(carboxymethyl)lysine (CML), soluble RAGE (sRAGE), and endogenous secretory RAGE (esRAGE) with adiposity, inflammatory markers [interleukin-6 (IL-6), C-reactive protein, tumor necrosis factor-α], adiponectin, lipids, insulin sensitivity, and insulin secretory capacity. RESULTS Pediatric CML levels were ~20% below average adult levels. CML was significantly (p < 0.05) positively correlated with age and insulin sensitivity and negatively with adiposity, dyslipidemia and IL-6. sRAGE correlated positively with esRAGE and negatively with adiposity and IL-6. Both sRAGE and esRAGE correlated negatively with insulin secretory capacity. CONCLUSION Our findings suggest that unlike adults, CML is negatively associated with adiposity and adiposity-related comorbidity risk in children. As in adults, sRAGE and esRAGE were, to varying degrees, negatively correlated with body fatness and risk factors for adiposity-related comorbidities.
Collapse
Affiliation(s)
- S Accacha
- Pediatrics, Winthrop University Hospital, Mineola, N.Y., USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Rosenbaum M, Fennoy I, Accacha S, Altshuler L, Carey DE, Holleran S, Rapaport R, Shelov SP, Speiser PW, Ten S, Bhangoo A, Boucher-Berry C, Espinal Y, Gupta R, Hassoun AA, Iazetti L, Jacques FJ, Jean AM, Klein ML, Levine R, Lowell B, Michel L, Rosenfeld W. Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children. Obesity (Silver Spring) 2013; 21:2081-90. [PMID: 23596082 PMCID: PMC3766484 DOI: 10.1002/oby.20483] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 03/24/2013] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To examine whether periadolescent children demonstrate the significant racial/ethnic differences in body fatness relative to BMI and in the prevalence and relationship of body composition to risk factors for type 2 diabetes (T2DM) as in adults. DESIGN AND METHODS Family history of obesity and T2DM, anthropometry, insulin sensitivity and secretory capacity, lipids, and cytokines (IL-6, CRP, TNF-α, and adiponectin) were examined in a cohort of 994 middle school students (47% male, 53%, female; 12% African American, 14% East Asian, 13% South Asian, 9% Caucasian, 44% Hispanic, and 8% other). RESULTS Fractional body fat content was significantly greater at any BMI among South Asians. There were racial/ethnic specific differences in lipid profiles, insulin secretory capacity, insulin sensitivity, and inflammatory markers corrected for body fatness that are similar to those seen in adults. Family history of T2DM was associated with lower insulin secretory capacity while family history of obesity was more associated with insulin resistance. CONCLUSIONS Children show some of the same racial/ethnic differences in risk factors for adiposity-related comorbidities as adults. BMI and waist circumference cutoffs to identify children at-risk for adiposity-related comorbidities should be adjusted by racial/ethnic group as well as other variables such as birthweight and family history.
Collapse
Affiliation(s)
- Michael Rosenbaum
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Ilene Fennoy
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Siham Accacha
- Pediatrics, Winthrop University Hospital, Mineola, NY
| | - Lisa Altshuler
- Pediatrics, Infant’s & Children’s Hospital of Brooklyn at Maimonides, Brooklyn, NY
| | - Dennis E. Carey
- Pediatrics, Cohen Children’s Medical Center, New Hyde Park, NY
| | - Steven Holleran
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | | | - Steven P. Shelov
- Pediatrics, Infant’s & Children’s Hospital of Brooklyn at Maimonides, Brooklyn, NY
| | | | - S. Ten
- Pediatrics, Infant’s & Children’s Hospital of Brooklyn at Maimonides, Brooklyn, NY
| | - Amrit Bhangoo
- Pediatrics, Infant’s & Children’s Hospital of Brooklyn at Maimonides, Brooklyn, NY
| | | | - Yomery Espinal
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Rishi Gupta
- Pediatrics, Winthrop University Hospital, Mineola, NY
| | - Abeer A. Hassoun
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | | | | | - Amy M. Jean
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | | | - Robert Levine
- Pediatrics, New York Presbyterian Hospital/Columbia University Medical Center, New York, NY
| | - Barbara Lowell
- Pediatrics, Infant’s & Children’s Hospital of Brooklyn at Maimonides, Brooklyn, NY
| | - Lesley Michel
- Pediatrics, Winthrop University Hospital, Mineola, NY
| | | |
Collapse
|
22
|
Boucher-Berry C, Speiser PW, Carey DE, Shelov SP, Accacha S, Fennoy I, Rapaport R, Espinal Y, Rosenbaum M. Vitamin D, osteocalcin, and risk for adiposity as comorbidities in middle school children. J Bone Miner Res 2012; 27:283-93. [PMID: 22068892 PMCID: PMC4597472 DOI: 10.1002/jbmr.550] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [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] [Indexed: 01/27/2023]
Abstract
Nonclassic actions of vitamin D include potential regulation of immune function and glucose homeostasis. The bone-metabolism loop has recently been expanded to include osteocalcin, which appears to play a more direct role in pancreatic beta cell function and energy metabolism. We hypothesized that both vitamin D and osteocalcin would correlate negatively with indices of adiposity-related comorbidity risk in periadolescents, varying by ethnic group. We analyzed anthropometric, metabolic, and inflammatory markers from a multiethnic population of 106 school children 11 to 14 years of age studied as part of the Reduce Obesity and Diabetes (ROAD) consortium. As expected, 25-hydroxyvitamin D (25-OH vitamin D) was inversely correlated with intact parathyroid hormone (iPTH); total osteocalcin (OCN) and uncarboxylated osteocalcin (uOCN) were directly correlated with each other. OCN and uOCN concentrations correlated inversely with age. Vitamin D deficiency was most prevalent among East Asians (EA) and African Americans (AA). The highest lipid risk scores and homeostatic model for assessment of insulin resistance (HOMA-IR) values were seen in the South Asian (SA) group. Overall, adiposity measures were inversely correlated with OCN and iPTH, whereas such relationships were not observed for vitamin D. Acute insulin response to glucose challenge correlated negatively with uOCN in all subjects; however, lipid risk score correlated negatively with uOCN only in whites. The relationships between markers of calcium metabolism and body composition, glucose homeostasis, lipids, and inflammation all showed racial and ethnic differences. No consistent relationship was found between vitamin D and adiposity or vitamin D and glucose metabolism; instead vitamin D levels varied by race and ethnicity in this school-based group. These findings are consistent with the hypothesis that markers of calcium and bone metabolism may reflect risk for adiposity-related comorbidities in children.
Collapse
Affiliation(s)
- Claudia Boucher-Berry
- Department of Pediatrics, Division of Pediatric Endocrinology, Cohen Children's Medical Center, New Hyde Park, NY 11040, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Congenital adrenal hyperplasia (CAH) in children, the majority of which is due to 21-hydroxylase deficiency, represents a group of disorders in which there is impaired cortisol synthesis and abnormalities in adrenal hormonal profiles. There continues to be debate regarding the optimal management of and treatment for these children. This review will highlight the most recent advances in neonatal screening for CAH, as well as the timeliest recommendations for the treatment and management of 21-hydroxylase deficiency, both the classic and nonclassic forms of the disorder. RECENT FINDINGS Substantive advancements have been made with regard to neonatal screening for CAH, allowing for earlier diagnosis, while minimizing the morbidity and mortality associated with delayed detection. Although the achievement of normal growth and development remains the ultimate goal of treatment, recent studies have provided further insight into the management and refinement of therapy in these children. SUMMARY The optimal management and treatment for children with CAH is still unclear. Although there have been recent advances in the diagnosis and treatment of this group of disorders, there is still much to learn in order to optimize therapy for these individuals.
Collapse
Affiliation(s)
- Christine M. Trapp
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
| | - Phyllis W. Speiser
- Division of Pediatric Endocrinology, Cohen Children’s Medical Center of New York, Hofstra University School of Medicine, New Hyde Park, New York 11040
| | - Sharon E. Oberfield
- Division of Pediatric Endocrinology, Children’s Hospital of New York-Presbyterian, Columbia University College of Physicians and Surgeons, New York, New York 10032
| |
Collapse
|
24
|
Conroy R, Espinal Y, Fennoy I, Accacha S, Boucher-Berry C, Carey DE, Close S, DeSantis D, Gupta R, Hassoun AA, Iazzetti L, Jacques FJ, Jean AM, Michel L, Pavlovich K, Rapaports R, Rosenfeld W, Shamoon E, Shelov S, Speiser PW, Ten S, Rosenbaum M. Retinol binding protein 4 is associated with adiposity-related co-morbidity risk factors in children. J Pediatr Endocrinol Metab 2011; 24:913-9. [PMID: 22308842 PMCID: PMC4758201 DOI: 10.1515/jpem.2011.297] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [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] [Indexed: 01/15/2023]
Abstract
OBJECTIVE In adults, elevated levels of retinol binding protein 4 (RBP4) have been associated with biochemical markers of adiposity-related co-morbidities including insulin resistance, dyslipidemia, hypertension, and abdominal obesity. This study examined the relationship between RBP4 and risk factors for co-morbidities of adiposity in a population of ethnically diverse children in early- to mid-adolescence in the public school system of New York City. MATERIALS/METHODS We analyzed anthropometric (body mass index, % body fat, waist circumference), metabolic (lipids, glucose), and inflammatory (TNF-alpha, interleukin-6, C-reactive protein, adiponectin) markers for adiposity-related co-morbidities and serum alanine aminotransferase (ALT) in 106 school children (65 males, 41 females) 11-15 years of age (mean +/- SD = 13.0 +/- 0.1 years) who were enrolled in the Reduce Obesity and Diabetes (ROAD) project. Insulin sensitivity was assessed by quantitative insulin sensitivity check index. Insulin secretory capacity was measured as acute insulin response and glucose disposal index. RESULTS Serum RBP4 was significantly correlated directly with ALT, triglycerides, and triglyceride z-score, and inversely correlated with adiponectin. Correlations with ALT and adiponectin remained significant when corrected for % body fat, age, and gender. There were significant ethnic differences in the relationship of RBP4 to ALT, glucose disposal index and adiponectin. CONCLUSIONS In early- to mid-adolescents, circulating concentrations of RBP4 are correlated with multiple risk factors for adiposity-related co-morbidities. The observation that many associations persisted when corrected for % body fat, suggests that RBP4 can be viewed as an independent marker of adiposity-related co-morbidity risk in children.
Collapse
Affiliation(s)
- Rushika Conroy
- Division of Pediatrics Endocrinology, Children's Hospita of New York, Presbyterian Hospital-Columbia University Medical Center, New York, NY 10032, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Affiliation(s)
- Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center of New York, New Hyde Park, NY 11040, USA.
| |
Collapse
|
26
|
Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP, Meyer-Bahlburg HFL, Miller WL, Montori VM, Oberfield SE, Ritzen M, White PC. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010; 95:4133-60. [PMID: 20823466 PMCID: PMC2936060 DOI: 10.1210/jc.2009-2631] [Citation(s) in RCA: 636] [Impact Index Per Article: 45.4] [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: 12/15/2022]
Abstract
OBJECTIVE We developed clinical practice guidelines for congenital adrenal hyperplasia (CAH). PARTICIPANTS The Task Force included a chair, selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), ten additional clinicians experienced in treating CAH, a methodologist, and a medical writer. Additional experts were also consulted. The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS We recommend universal newborn screening for severe steroid 21-hydroxylase deficiency followed by confirmatory tests. We recommend that prenatal treatment of CAH continue to be regarded as experimental. The diagnosis rests on clinical and hormonal data; genotyping is reserved for equivocal cases and genetic counseling. Glucocorticoid dosage should be minimized to avoid iatrogenic Cushing's syndrome. Mineralocorticoids and, in infants, supplemental sodium are recommended in classic CAH patients. We recommend against the routine use of experimental therapies to promote growth and delay puberty; we suggest patients avoid adrenalectomy. Surgical guidelines emphasize early single-stage genital repair for severely virilized girls, performed by experienced surgeons. Clinicians should consider patients' quality of life, consulting mental health professionals as appropriate. At the transition to adulthood, we recommend monitoring for potential complications of CAH. Finally, we recommend judicious use of medication during pregnancy and in symptomatic patients with nonclassic CAH.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Cohen Children's Medical Center of New York and Hofstra University School of Medicine, New Hyde Park, New York 11040, USA
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
27
|
|
28
|
Chatterjee M, Speiser PW, Pellizzarri M, Carey DE, Fort P, Kreitzer PM, Frank GR. Poor glycemic control is associated with abnormal changes in 24-hour ambulatory blood pressure in children and adolescents with type 1 diabetes mellitus. J Pediatr Endocrinol Metab 2009; 22:1061-7. [PMID: 20101892 DOI: 10.1515/jpem.2009.22.11.1061] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Twenty-four hour ambulatory blood pressure (ABPM) is emerging as a valuable tool to assess blood pressure (BP) changes in children with type 1 diabetes mellitus (DM1). Hypertension (HTN) is an important risk factor for, and may be an important indicator of diabetic nephropathy. Early accurate identification of HTN in DM1 may improve outcomes. AIM To evaluate BP in adolescents with DM1 using 24-hour ABPM, and to identify risk factors associated with abnormal blood pressure. METHOD The ABPM of 105 children with DM1 was reviewed. Mean systolic BP (sBP) percentile was determined from the National High Blood Pressure Education Program (NHBPEP) tables. The patients with abnormal sBP were compared to those with normal sBP with respect to age, race, sex, body mass index (BMI) percentile, duration of DM1, average hemoglobin A1c (HbA1c) over the preceding year, and family history of hypertension. RESULTS Mean sBP was normal in 71%, whereas 23% had pre-hypertension, and 6% had stage 1 hypertension. Those who had abnormal sBP (pre-hypertension and stage 1 hypertension) had higher HbA1c (p = 0.023) and were more likely to be male (p = 0.03) than those with normal sBP. CONCLUSION Stage 1 hypertension is present in 6%, and pre-hypertension in 23% of adolescents with DM1. Poor diabetes control and male gender appear to be risk factors for abnormal sBP as measured by 24-hour ambulatory blood pressure monitoring.
Collapse
Affiliation(s)
- Manjula Chatterjee
- Division of Pediatric Endocrinology, Schneider Children's Hospital, North Shore Long Island Jewish Health System, New Hyde Park, NY, USA.
| | | | | | | | | | | | | |
Collapse
|
29
|
Abstract
CONTEXT Combined 17alpha-hydroxylase/17,20-lyase deficiency is a rare autosomal recessive form of congenital adrenal hyperplasia presenting with hypertension and sexual infantilism. This disorder is caused by defects in P450c17, encoded by the CYP17A1 gene. OBJECTIVE We describe a 14-yr-old female with clinical and hormonal features of 17alpha-hydroxylase/17,20-lyase deficiency and identify and characterize the activities of her CYP17A1 mutations. METHODS The coding regions of the CYP17A1 gene were amplified by PCR and sequenced. Mutations were recreated in P450c17 cDNA expression vectors; activities in transfected COS-1 cells were assayed by conversion of radiolabeled precursor steroids. One mutant was also expressed in Escherichia coli, and the reduced adsorption spectrum was measured. RESULTS The patient carried the previously described mutation R96W and the novel missense mutation H373D. Neither mutant had detectable activity when expressed in COS-1 cells. Membrane preparations from E. coli expressing the H373D mutant vector produced an absorption peak at 420 nm, whereas the wild-type produced a peak at 450 nm, suggesting that the H373D mutation interferes with protein folding. CONCLUSION The novel P450c17 mutation H373D abolished enzyme activity because of protein misfolding. These data indicate an important role for this residue in P450c17 activity.
Collapse
|
30
|
Latzer Y, Edmunds L, Fenig S, Golan M, Gur E, Hochberg Z, Levin-Zamir D, Zubery E, Speiser PW, Stein D. Managing childhood overweight: behavior, family, pharmacology, and bariatric surgery interventions. Obesity (Silver Spring) 2009; 17:411-23. [PMID: 19131937 DOI: 10.1038/oby.2008.553] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [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] [Indexed: 01/08/2023]
Affiliation(s)
- Yael Latzer
- Psychiatric Division, Rambam Medical Center, Haifa, Israel.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Abstract
Nonclassic adrenal hyperplasia is most commonly attributable to mutations in CYP21A2 (also termed CYP21) encoding steroid 21-hydroxylase. Partial deficiency of this enzyme causes an imbalance in cortisol synthesis with consequent adrenal androgen excess. Unlike more severe forms of congenital adrenal hyperplasia, this condition is rarely recognized in infants, but rather is a potential cause of premature adrenarche and pubarche in children, virilization in young women, and variable symptoms in young men. This article will review relevant clinical, hormonal and genetic aspects of nonclassic adrenal hyperplasia.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Schneider Children's Hospital, 269-01 76th Ave., New Hyde Park, NY 11040, USA.
| |
Collapse
|
32
|
Abstract
OBJECTIVE The purpose of this study was to screen adolescents with type 1 diabetes using ambulatory blood pressure monitoring (ABPM) to 1) test the hypothesis that using a preset sleep time results in an overdiagnosis of abnormal nocturnal dipping in systolic blood pressure and 2) assess the reproducibility of an abnormal nocturnal systolic blood pressure dip. RESEARCH DESIGN AND METHODS For aim 1, ABPM from 53 adolescent patients with type 1 diabetes was reviewed. Nocturnal dips in systolic blood pressure calculated by actual sleep time were compared with those from a preset sleep time. For aim 2, blood pressure monitoring from 98 patients using actual reported sleep time was reviewed. Reproducibility of the nocturnal dip in systolic blood pressure was assessed in a subset of "nondippers." RESULTS For aim 1, the actual mean +/- SE decline in nocturnal systolic blood pressure was 11.6 +/- 4.7%, whereas the mean decline in nocturnal systolic blood pressure calculated using the preset sleep time was 8.8 +/- 4.9% (P < 0.0001). For aim 2, 64% of patients had a normal nocturnal decline in systolic blood pressure (14.9 +/- 3.1% mmHg), whereas 36% had an abnormal dip (5.7 +/- 2.8% mmHg). Repeat ABPM performed in 22 of the 35 nondippers revealed that only 36% had abnormal systolic dipping confirmed on the repeat ABPM. CONCLUSIONS The use of actual reported sleep time is required to accurately determine the nocturnal dip in systolic blood pressure. Repeating ABPM in nondippers is essential to confirm this abnormality.
Collapse
Affiliation(s)
- Angela Delaney
- Division of Pediatric Endocrinology, Schneider Children's Hospital, North-Shore Long Island Jewish Health System, New Hyde Park, New York, USA
| | | | | | | |
Collapse
|
33
|
August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, Silverstein JH, Speiser PW, Styne DM, Montori VM. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. J Clin Endocrinol Metab 2008; 93:4576-99. [PMID: 18782869 PMCID: PMC6048599 DOI: 10.1210/jc.2007-2458] [Citation(s) in RCA: 354] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 08/29/2008] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Our objective was to formulate practice guidelines for the treatment and prevention of pediatric obesity. CONCLUSIONS We recommend defining overweight as body mass index (BMI) in at least the 85th percentile but < the 95th percentile and obesity as BMI in at least the 95th percentile against routine endocrine studies unless the height velocity is attenuated or inappropriate for the family background or stage of puberty; referring patients to a geneticist if there is evidence of a genetic syndrome; evaluating for obesity-associated comorbidities in children with BMI in at least the 85th percentile; and prescribing and supporting intensive lifestyle (dietary, physical activity, and behavioral) modification as the prerequisite for any treatment. We suggest that pharmacotherapy (in combination with lifestyle modification) be considered in: 1) obese children only after failure of a formal program of intensive lifestyle modification; and 2) overweight children only if severe comorbidities persist despite intensive lifestyle modification, particularly in children with a strong family history of type 2 diabetes or premature cardiovascular disease. Pharmacotherapy should be provided only by clinicians who are experienced in the use of antiobesity agents and aware of the potential for adverse reactions. We suggest bariatric surgery for adolescents with BMI above 50 kg/m(2), or BMI above 40 kg/m(2) with severe comorbidities in whom lifestyle modifications and/or pharmacotherapy have failed. Candidates for surgery and their families must be psychologically stable and capable of adhering to lifestyle modifications. Access to experienced surgeons and sophisticated multidisciplinary teams who assess the benefits and risks of surgery is obligatory. We emphasize the prevention of obesity by recommending breast-feeding of infants for at least 6 months and advocating that schools provide for 60 min of moderate to vigorous daily exercise in all grades. We suggest that clinicians educate children and parents through anticipatory guidance about healthy dietary and activity habits, and we advocate for restricting the availability of unhealthy food choices in schools, policies to ban advertising unhealthy food choices to children, and community redesign to maximize opportunities for safe walking and bike riding to school, athletic activities, and neighborhood shopping.
Collapse
Affiliation(s)
- Gilbert P. August
- Professor Emeritus of Pediatrics, George Washington University School of Medicine (G.P.A.), Washington, D.C. 20037
| | - Sonia Caprio
- Yale University School of Medicine (S.C.), New Haven, Connecticut 06510
| | - Ilene Fennoy
- Columbia University (I.F.), New York, New York 10027
| | - Michael Freemark
- Duke University Medical Center (M.F.), Durham, North Carolina 27710
| | | | - Robert H. Lustig
- University of California San Francisco (R.H.L.), San Francisco, California 94143
| | | | | | - Dennis M. Styne
- University of California–Davis Medical Center (D.M.S.), Sacramento, California 95817
| | | |
Collapse
|
34
|
Pellizzari M, Speiser PW, Carey DE, Fort P, Kreitzer PM, Frank GR. Twenty-four hour ambulatory blood pressure monitoring in adolescents with type 1 diabetes: getting started. J Diabetes Sci Technol 2008; 2:1087-93. [PMID: 19885297 PMCID: PMC2769833 DOI: 10.1177/193229680800200617] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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] [Indexed: 01/22/2023]
Abstract
Twenty-four hour ambulatory blood pressure monitoring (ABPM) is a valuable tool in the pediatric and adolescent population with type 1 diabetes. It provides useful information not readily available from sporadic clinic blood pressure (BP) measurements and a more reliable estimation of the subject's BP over an extended period of time. Ambulatory blood pressure monitoring is gaining popularity with clinicians and investigators alike. The American Heart Association has recently issued recommendations for the use of ABPM in children and adolescents. We have incorporated ABPM into our adolescent diabetes practice and present useful information for clinicians planning to initiate 24 h ABPM in their clinical practice.
Collapse
Affiliation(s)
- Margaret Pellizzari
- Division of Pediatric Endocrinology, Schneider Children's Hospital, North-Shore Long Island Health System, New Hyde Park, New York 11042, USA.
| | | | | | | | | | | |
Collapse
|
35
|
Abstract
Dent disease, an X-linked recessive renal tubular disease, results from loss-of-function mutations in the CLCN5 chloride channel gene. The effects of Dent disease on growth have not been described. We report siblings who presented with proteinuria, calciuria, and phosphaturia and growth failure who responded to growth hormone (GH) treatment. Genotyping revealed a novel c.2179delG frameshift mutation at codon 727, exon 12 of the CLCNS gene. Two years after initial presentation, linear growth had slowed, and evaluation revealed isolated GH deficiency. GH therapy resulted in more than two-fold increases in height velocity and serum IGF-I levels. There was no net change in estimated glomerular filtration rate, proteinuria or calciuria in response to GH therapy, but there was a delayed improvement in phosphaturia. These cases provide insight into the effects of GH on growth and renal function in Dent disease. Furthermore, we have reported a novel CLCN5 mutation.
Collapse
|
36
|
Abstract
BACKGROUND Clinical management of patients with congenital adrenal hyperplasia (CAH) involves treating hormonal deficiencies, addressing issues related to genital ambiguity, avoiding morbidities and communicating with the family about risk of CAH in other members. This article briefly reviews the prenatal and neonatal diagnosis of CAH caused by steroid 21-hydroxylase deficiency, as well as treatment options and neonatal screening approaches. CONCLUSIONS Screening for CAH can reduce adrenal crises, avoid incorrect sex assignments, lower mortality (especially in males) and avoid inappropriate somatic growth and precocious puberty.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Pediatric Endocrinology, Schneider Children's Hospital, New York University, New Hyde Park, NY 11040, USA.
| |
Collapse
|
37
|
Abstract
We present a 16 month-old previously healthy boy with refractory hypercalcemia due to an overdose of an over-the-counter vitamin supplement. The patient presented to the emergency department with a few weeks' history of irritability, constipation and intermittent vomiting. His serum calcium was found to be 18 mg/dl. He was first treated with intravenous fluids, furosemide and glucocorticoids without significant improvement, but became eucalcemic within 24 hours after receiving a single dose of pamidronate. This case highlights the potential danger of high dose vitamin supplements in children, and the salutary effects of treatment with bisphosphonate.
Collapse
Affiliation(s)
- Manjula Chatterjee
- Division of Pediatric Endocrinology, Schneider Children's Hospital, New Hyde Park, NY 11040, USA.
| | | |
Collapse
|
38
|
Speiser PW. Interpretation of pediatric endocrine laboratory tests: pitfalls in steroid hormone measurements and genotyping. Pediatr Endocrinol Rev 2007; 5 Suppl 1:578-583. [PMID: 18167467] [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] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Accurate endocrine diagnosis depends on the integrity of laboratory determinations and appropriate interpretation of the test results in clinical context. This article will provide guidance to the pediatric endocrinologist and to the primary care provider in better understanding the selection and interpretation of laboratory tests.
Collapse
|
39
|
Moran C, Azziz R, Weintrob N, Witchel SF, Rohmer V, Dewailly D, Marcondes JAM, Pugeat M, Speiser PW, Pignatelli D, Mendonca BB, Bachega TAS, Escobar-Morreale HF, Carmina E, Fruzzetti F, Kelestimur F. Reproductive outcome of women with 21-hydroxylase-deficient nonclassic adrenal hyperplasia. J Clin Endocrinol Metab 2006; 91:3451-6. [PMID: 16822826 DOI: 10.1210/jc.2006-0062] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
CONTEXT Because many women with 21-hydroxylase (21-OH)-deficient nonclassic adrenal hyperplasia (NCAH) carry at least one allele affected by a severe mutation of CYP21, they are at risk for giving birth to infants with classic adrenal hyperplasia (CAH). OBJECTIVE Our objective was to determine the frequency of CAH and NCAH infants born to mothers with 21-OH-deficient NCAH. DESIGN AND SETTING We conducted an international multicenter retrospective/prospective study. PATIENTS AND METHODS The outcome of 203 pregnancies among 101 women with 21-OH-deficient NCAH was reviewed. The diagnosis of 21-OH-deficient NCAH was established by a basal or post-ACTH-stimulation 17-hydroxyprogesterone level of more than 10 ng/ml (30.3 nmol/liter). When possible, genotype analyses were performed to confirm CAH or NCAH in the offspring. RESULTS Of the 203 pregnancies, 138 (68%) occurred before the mother's diagnosis of NCAH and 65 (32%) after the diagnosis. Spontaneous miscarriages occurred in 35 of 138 pregnancies (25.4%) before the maternal diagnosis of NCAH, and in only four of 65 pregnancies (6.2%) after the diagnosis (P < 0.002). Four (2.5%; 95% confidence interval, 0.7-6.2%) of the 162 live births were diagnosed with CAH. To date, 24 (14.8%; 95% confidence interval, 9.0-20.6%) children, 13 girls and 11 boys, have been diagnosed with NCAH. The distribution of NCAH children and their mothers varied significantly by ethnicity (P < 0.0001, for both). CONCLUSIONS The risk of a mother with 21-OH-deficient NCAH for giving birth to a child affected with CAH is 2.5%; at least 14.8% of children born to these mothers have NCAH.
Collapse
Affiliation(s)
- C Moran
- Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, 8635 West Third Street, Suite 160 W, Los Angeles, California 90048, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Speiser PW. Diagnosis and management of congenital adrenal hyperplasia. Expert Rev Endocrinol Metab 2006; 1:103-110. [PMID: 30743773 DOI: 10.1586/17446651.1.1.103] [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] [Indexed: 11/08/2022]
Abstract
Congenital adrenal hyperplasia is the name applied to a class of autosomal recessive disorders resulting from deficiency of one of five enzymes necessary for cortisol synthesis by the adrenal cortex. Congenital adrenal hyperplasia is most often attributable to steroid 21-hydroxylase deficiency, accounting for more than 90% of cases. This discussion will be limited to the most common form of the disease, highlighting methods of diagnostic screening and challenges in disease management.
Collapse
Affiliation(s)
- Phyllis W Speiser
- a NYU School of Medicine and Chief, Division of Pediatric Endocrinology, Schneider Children's Hospital269-01 76th AvenueNew Hyde Park, NY 11042, USA.
| |
Collapse
|
41
|
Speiser PW, Clarson CL, Eugster EA, Kemp SF, Radovick S, Rogol AD, Wilson TA. Bisphosphonate treatment of pediatric bone disease. Pediatr Endocrinol Rev 2005; 3:87-96. [PMID: 16361982] [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] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
The science of measuring bone mineral density has developed rapidly and, with it, an improved understanding of the efficacy and safety of various therapeutic interventions in adults. In contrast, the meaning and precision of such measurements in children are equivocal, and the concept of treatment for low bone density in the young patient is still largely undecided. In this report we review the present state of knowledge regarding the use of bisphosphonates during childhood to ameliorate the skeletal abnormalities associated with osteogenesis imperfecta, idiopathic juvenile osteoporosis, fibrous dysplasia of bone and cerebral palsy. Because of the paucity of long-term studies among children regarding the safety and efficacy of these drugs, it is difficult to formulate strong evidence-based recommendations for their use, except perhaps in children with osteogenesis imperfecta.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Schneider Children's Hospital and New York University School of Medicine, New Hyde Park, NY 11040, USA.
| | | | | | | | | | | | | |
Collapse
|
42
|
Speiser PW, Rudolf MCJ, Anhalt H, Camacho-Hubner C, Chiarelli F, Eliakim A, Freemark M, Gruters A, Hershkovitz E, Iughetti L, Krude H, Latzer Y, Lustig RH, Pescovitz OH, Pinhas-Hamiel O, Rogol AD, Shalitin S, Sultan C, Stein D, Vardi P, Werther GA, Zadik Z, Zuckerman-Levin N, Hochberg Z. Childhood obesity. J Clin Endocrinol Metab 2005; 90:1871-87. [PMID: 15598688 DOI: 10.1210/jc.2004-1389] [Citation(s) in RCA: 312] [Impact Index Per Article: 16.4] [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: 02/08/2023]
Abstract
In March 2004 a group of 65 physicians and other health professionals representing nine countries on four continents convened in Israel to discuss the widespread public health crisis in childhood obesity. Their aim was to explore the available evidence and develop a consensus on the way forward. The process was rigorous, although time and resources did not permit the development of formal evidence-based guidelines. In the months before meeting, participants were allocated to seven groups covering prevalence, causes, risks, prevention, diagnosis, treatment, and psychology. Through electronic communication each group selected the key issues for their area, searched the literature, and developed a draft document. Over the 3-d meeting, these papers were debated and finalized by each group before presenting to the full group for further discussion and agreement. In developing a consensus statement, this international group has presented the evidence, developed recommendations, and provided a platform aimed toward future corrective action and ongoing debate in the international community.
Collapse
Affiliation(s)
- Phyllis W Speiser
- Division of Pediatric Endocrinology, Schneider Children's Hospital, 269-01 76th Avenue, New Hyde Park, New York 11040, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Affiliation(s)
- Jocelyn B DeGuzman
- Department of Pediatrics, Divisions of Endocrinology, Schneider Children 's Hospital, New Hyde Park, NY, USA
| | | | | |
Collapse
|
44
|
Frank GR, Speiser PW, Griffin KJ, Stratakis CA. Safety of medications and hormones used in pediatric endocrinology: adrenal. Pediatr Endocrinol Rev 2004; 2 Suppl 1:134-45. [PMID: 16456492] [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] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Glucocorticoids have been prescribed for several decades in treating adrenal insufficiency of various etiologies. These drugs are also heavily used in treating non-endocrine disease. This article will focus on adverse side effects encountered in the chronic use of different types of glucocorticoids in children and young adults with endocrine causes of adrenal insufficiency. Dosing guidelines are discussed with a view toward minimizing the common co-morbidities of growth suppression, excess weight gain, and osteopenia, among others. This article also discusses the use of several inhibitors of adrenal steroid biosynthesis and one glucocorticoid receptor antagonist for the medical treatment of Cushing syndrome.
Collapse
Affiliation(s)
- Graeme R Frank
- Schneider Children's Hospital, New Hyde Park, NY 11040, and New York University School of Medicine, USA
| | | | | | | |
Collapse
|
45
|
|
46
|
Abstract
Perturbations in sex hormones occur in adults with liver disease; however, little is known about how liver disease affects hormone levels in children. To address this issue, we recruited 19 patients with portal hypertension and 21 non-hormone-deficient short children as controls. Serum sex hormones, sex hormone binding globulin (SHBG), IGF-I, IGFBP-3, gonadotropins, and thyroid hormones were measured; growth and pubertal status were recorded. There was no significant difference between groups for any of the sex hormones, SHBG, gonadotropins, or thyroid hormones. In contrast, IGF-I and IGFBP-3 were significantly lower among patients than controls, despite the fact that height SDS for the control group was significantly lower. We conclude from this cross-sectional study that children with portal hypertension do not have clinical evidence of growth failure or abnormal puberty, despite subtle changes in the growth axis.
Collapse
Affiliation(s)
- Cynthia M Yuse-Gabriel
- Division of Pediatric Endocrinology, Schneider Children 's Hospital of North Shore-Long Island Jewish Health System, New Hyde Park, NY, USA
| | | | | | | | | | | |
Collapse
|
47
|
Affiliation(s)
- Phyllis W Speiser
- Department of Pediatrics, Schneider Children's Hospital-North Shore-Long Island Jewish Health System, New Hyde Park, NY 11042, USA.
| | | |
Collapse
|
48
|
Clayton PE, Miller WL, Oberfield SE, Ritzén EM, Sippell WG, Speiser PW. Consensus statement on 21-hydroxylase deficiency from the European Society for Paediatric Endocrinology and the Lawson Wilkins Pediatric Endocrine Society. Horm Res Paediatr 2003; 58:188-95. [PMID: 12324718 DOI: 10.1159/000065490] [Citation(s) in RCA: 113] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
49
|
Abstract
Congenital adrenal hyperplasia (CAH) is an inherited disorder of steroid biosynthesis most often attributable to mutations in CYP21 (also termed CYP21A2) encoding the active steroid 21-hydroxylase enzyme. This review focuses on clinical and genetic aspects of CAH, and updates the reader on current methodology and applications for molecular genetic diagnosis. Genotyping patients with CAH has revealed > 50 mutations within CYP21, yet only 10 mutations account for approximately 95% of affected alleles. Many CYP21 mutations are gene conversions arising via transfer of gene sequences between the non-functional CYP21 pseudogene and CYP21. Phenotype is generally well-correlated with genotype. Historically, CAH has been divided into 3 types of disease: classic salt-wasting, classic simple virilizing (non-salt-wasting), and nonclassic. Recent findings support the notion that rather than discrete phenotypic categories, CAH is better represented as a continuum of phenotypes, from severe to mild. Molecular genetic diagnosis is most effectively employed now in prenatal diagnosis of classic CAH. As newborn screening for CAH becomes more widespread, genotyping may be implemented to resolve diagnostic difficulties encountered with hormonal testing. As automated methods of DNA diagnosis such as microarrays or gene chips are refined, it is likely that genetic screening will become less expensive and more readily available. The clinician should be aware of the potential for both false negatives and false positives with PCR-based gene screening. In short, whereas molecular genetic diagnosis is a valuable tool, it cannot replace clinical acumen and hormonal assays.
Collapse
|
50
|
Speiser PW. Impaired glucose tolerance in obese children and adolescents. N Engl J Med 2002; 347:290-2; author reply 290-2. [PMID: 12141330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
|