[Show abstract][Hide abstract] ABSTRACT: Children with thalassemia are living longer due to better care. Physicians dealing with this group of patients now have to contend with new challenges resulting from iron overload. Endocrine complications represent the most common morbidities encountered. To provide a better quality of life, these complications have to be addressed in a consistent way. For this purpose, we have compiled a set of recommendations to help physi-cians provide the best care possible to these patients.
[Show abstract][Hide abstract] ABSTRACT: Abstract Children with thalassemia are living longer due to better care. Physicians dealing with this group of patients now have to contend with new challenges resulting from iron overload. Endocrine complications represent the most common morbidities encountered. To provide a better quality of life, these complications have to be addressed in a consistent way. For this purpose, we have compiled a set of recommendations to help physicians provide the best care possible to these patients.
[Show abstract][Hide abstract] ABSTRACT: Rates of overweight and obesity are continually rising worldwide. Recent data show that the highest prevalence
rates are reported from regions in the Middle East, North Africa, and Asia. Excess weight is a major contributor to cardiovascular disease, type 2 diabetes, and premature death. Obese children and adolescents are at increased risk of developing obesity related co-morbidities before reaching adulthood. Six of the top ten countries with the highest prevalence of diabetes are Arab speaking countries located in the Middle East and North Africa. This review summarizes the magnitude of childhood and adolescent obesity and its consequences in the Middle East and North Africa.
Key words: Adolescents, obesity, epidemiology, co-morbidities.
Rivista italiana di Medicina dell' Adolescenza. 04/2014; 12(1):9-12.
[Show abstract][Hide abstract] ABSTRACT: Abstract: Introduction: Constitutional delay of growth and puberty (CDGP) is a common cause of psychosocial upset among adolescents and their families. Concerns about reduced final height often urge patients to ask for urgent treatment rather than to wait for observation.
Aim: The main objective is to evaluate the concerns, knowledge, understanding, and expectations of a group of children with CDGP and their families. Secondary objective is to study the auxological and socioeconomic characteristics of the patients.
Patients and Methods: Forty nine patients with CDGP were included. Fifteen were followed for two years, and seven until final height. Patients and parents completed a designed question sheet to identify their concerns, knowledge, expectations from treatment, and willingness to follow up for observation. Socioeconomic standard scoring and anthropometric evaluation were performed.
Results: 59.2% presented because of the concern of the whole family. There was a delay of 1.8 years between the time when patients were concerned about short stature and/or delayed puberty and presentation to clinic The delay was greatest in patients who stopped following up. Twenty seven patients (55.1%) were of low socioeconomic background, 17 (34.7%) were medium low, and 5 (10.2%) were medium high. 69.4% of patients were concerned about their height, not puberty. Two thirds were not convinced that shortness was not due to growth hormone deficiency and that treatment if needed would be sex hormones. 69.4% were not convinced to follow up without treatment.
Conclusion: Short stature rather than late puberty is usually the reason for consultation in CDGP. Incomplete
understanding of the condition among families and dissatisfaction with the treatment options available remains a problem even after detailed explanation. Extra effort is needed to raise the awareness and avoid the adverse psychosocial sequels in patients with CDGP.
Keywords: Constitutional delay of growth and puberty, psychosocial satisfaction
Journal of Endocrinology and Diabetes Mellitus. 03/2014; 2(1):26-32.
[Show abstract][Hide abstract] ABSTRACT: Background
Abdominal obesity is a strong determinant of obesity related metabolic complications. Data about pre-pubertal children are scarce.
The aim of this study is to assess the presence of insulin resistance using different insulin sensitivity indices and investigate its relationship with abdominal fat distribution by Dual energy X-ray absorptiometry scan (DXA). Secondary outcome is to determine the frequency of the metabolic syndrome components.
Subjects and methods
Twenty-three pre-pubertal obese children were recruited (14 females, 9 males). Height, weight, body mass index (BMI), waist and hip circumferences, waist to hip ratio, and blood pressure were measured. Fasting blood samples were withdrawn for glucose, insulin, lipid profile, thyroid and liver functions. Patients underwent oral glucose tolerance testing (OGTT) and DXA scan for body composition. Insulin sensitivity was determined using homeostasis model assessment for insulin resistance (HOMA-IR), fasting glucose to insulin ratio, Matsuda, and Cederholm indices.
All patients had BMI, waist circumference, and DXA trunk fat more than 2 SDS. Mean fasting glucose, insulin, fasting glucose to insulin ratio, 120 min glucose and HOMA-IR were within normal limits, but mean Matsuda and Cederholm indices exceeded cut off limits. Dyslipidaemia was detected in 13 patients (56.5%), disturbed glucose homeostasis in 8 patients (34.8%), and systolic hypertension in 1 patient (4.3%). Metabolic syndrome diagnosis was established in three patients (13%). More insulin resistant patients were detected by Matsuda index. Trunk fat SDS correlated with Matsuda and Cederholm indices only.
Dysglycaemia and dyslipidaemia are common among pre-pubertal obese children. Insulin sensitivity indices based on OGTT are superior to fasting indices in identifying at risk children. OGTT should be included in assessing obese children with BMI > 2 SDS. DXA scanning has limited value for this purpose in clinical settings.
Egyptian Journal of Medical Human Genetics 01/2014;
[Show abstract][Hide abstract] ABSTRACT: It is a common knowledge that GH exhibits a large number of metabolic effects, involving lipid and glucose homeostasis. The aim of the study was to investigate the effect of one year GH therapy on metabolic parameters and adipokines in GH deficient (GHD) children. Sixteen prepubertal children (11 M and 5 F) with complete GHD (age range: 3.4-14.7 years) and 20 (13 M and 7 F) age and sex-matched healthy children (age range: 4.6-12.3 years) were studied. Blood was collected from patients before starting GH therapy (0.025 mg/kg/day) and one year later, and from healthy children to measure adiponectin, leptin, osteoprotegerin, resistin, interleukin (IL)-6, tumor necrosis factor (TNF)-α levels, and other glucose and lipid metabolism parameters. Adiponectin and resistin levels were significantly higher (49 980 ng/ml vs. 14 790 ng/ml and 11.0 pg/ml vs. 6.3, respectively) in GHD children before GH therapy than in controls. Serum IGF-I levels (p=0.0001) and height SDS (p<0.0001) significantly increased after 12 months' of GH therapy. There was a loss of body fat reflected by a significant decline in tricep (p=0.0003) and subscapular skinfold thickness SDS (p=0.0023). After 12 months, there was a significant rise in insulin (p=0.0052) and leptin levels (p=0.0048) and a significant decrease in resistin (p=0.0312) and TNF-α (p=0.0137). We observed that lipid and glucose metabolisms are only slightly affected in GHD children. Growth hormone replacement therapy affects some factors, such as leptin, resistin and fat mass, suggesting that also in children, GH treatment has a role in the regulation of factors secreted by adipose tissue.
Hormone and Metabolic Research 12/2013; · 2.15 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In recent years, the issue of osteopenia/osteoporosis in children, adolescents and young adults with thalassaemia major (TM) has attracted much attention because it is a prominent cause of morbidity despite adequate transfusion and iron chelation therapy. The reported frequency of osteoporosis, even in well treated TM patients varies from 13.6% to 50% with an additional 45% affected by osteopenia. The pathogenesis of TM-induced osteoporosis is multifactorial. Genetic and acquired factors play role in demineralization of bones in thalassemia. Osteoporosis is characterized by low bone mass and disruption of bone architecture, resulting in reduced bone strength and increased risk of fractures. The significant predictors of fracture prevalence include male gender, hypothyroidism, age, lack of spontaneous puberty in females, active hepatitis, heart disease and diabetes. The early identification of osteopenia and osteoporosis is of paramount importance. This is because delayed diagnosis and inadequate treatment have led to severe osteoporosis, skeletal abnormalities, fractures, spinal deformities, nerve compression and growth failure. dequate hormonal replacement, has been posponed, Effective iron chelation adequate hormonal replacement, improvement of hemoglobin levels, calcium and vitamin D administration and physical activity are currently the main measures for the management of the disease. The use of bisphosphonates in TM patients with osteoporosis is increasing and their positive effect in improving bone mineral density is encouraging. The recommendations of the International Network on Growth Disorders and Endocrine Complications in Thalassaemia (I-CET) for diagnosis and management of osteoporosis in TM are also briefly included in this review.
Pediatric endocrinology reviews: PER 12/2013; 11(2):167-80.
[Show abstract][Hide abstract] ABSTRACT: Background: Homozygous loss-of-function mutations in the FOXE1 gene have been reported in several patients with partial or complete Bamforth syndrome (congenital hypothyroidism [CH] with thyroid dysgenesis [usually athyreosis], cleft palate, and spiky hair, with or without choanal atresia and bifid epiglottis). Here, our objective was to evaluate potential functional consequences of FOXE1 mutation in a patient with a similar clinical phenotype. Methods: FOXE1 was sequenced in 8 patients with thyroid dysgenesis. Transient transfection was performed in HEK293 cells using the thyroglobulin (TG) and thyroid peroxidase (TPO) promoters in the luciferase reporter plasmid to assess the functional impact of the FOXE1 mutations. Primary human thyrocytes transfected with wild-type and mutant FOXE1 served to assess the impact of the mutation on endogenous TG and TPO expression. Results: We identified and characterized the function of a new homozygous FOXE1 missense mutation (p.R73S) in a boy with a typical phenotype (athyreosis, cleft palate, and partial choanal atresia). This new mutation located within the forkhead domain was inherited from the heterozygous healthy consanguineous parents. In vitro functional studies in HEK293 cells showed that this mutant gene enhanced the activity of the TG and TPO gene promoters (1.5-fold and 1.7-fold, respectively vs. wild-type FOXE1, P<0.05), unlike the five mutations previously reported in Bamforth syndrome. The gain-of-function effect of the FOXE1-p.R73S mutant gene was confirmed by an increase in endogenous TG production by primary human thyrocytes. Conclusion: We identified a new homozygous FOXE1 mutation responsible for thyroid-function gene activation in a boy whose phenotype is similar to that reported previously in patients with loss-of-function FOXE1 mutations. This finding further delineates the role for FOXE1 in both thyroid and palate development and shows that enhanced gene activity should be considered among the mechanisms underlying Bamforth syndrome.
Thyroid: official journal of the American Thyroid Association 11/2013; · 2.60 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This review paper provides a summary of the current state of knowledge regarding GHD provides recommendations for the diagnosis and treatment of GHD in adult patients with thalassaemia major (TM). The reported prevalence of adult GHD and /or IGF-I deficiency in TM patients varies from 8% to 44 % in different centers. Because GH treatment requires analysis of many factors, including the effect of treatment on cardiac functions, metabolic parameters and psychosocial functioning, along with safety, ethical considerations, financial cost and other burdens of therapy, stringent diagnostic criteria are needed. The authors report the diagnostic recommendations of the International Study Group of Endocrine Complications in Thalassemia (I-CET) for adult TM patients.The pros and cons of GH treatment must be discussed with each patient, after which GH doses should be individualized and titrated to maximum efficacy with minimal side effects. Prospective studies to monitor potential benefits versus possible side-effects will enable endocrinologists to define recommendations on dosage and the long term effects, particularly on cardiovascular and bone status of GH therapy in adult TM patients.
[Show abstract][Hide abstract] ABSTRACT: Abstract This is an attempt to establish the normal stretched penile length and prevalence of male genital anomalies in full-term neonates and whether they are influenced by prenatal parental exposure to endocrine-disrupting chemicals. A thousand newborns were included; their mothers were subjected to the following questionnaire: parents' age, residence, occupation, contact with insecticides and pesticides, antenatal exposure to cigarette smoke or drugs, family history of genital anomalies, phytoestrogens intake and history of in vitro fertilization or infertility. Free testosterone was measured in 150 neonates in the first day of life. Mean penile length was 3.4±0.37 cm. A penile length <2.5 cm was considered micropenis. Prevalence of genital anomalies was 1.8% (hypospadias 83.33%). There was a higher rate of anomalies in those exposed to endocrine disruptors (EDs; 7.4%) than in the non-exposed (1.2%; p<0.0001; odds ratio 6, 95% confidence interval 2-16). Mean penile length showed a linear relationship with free testosterone and was lower in neonates exposed to EDs.
[Show abstract][Hide abstract] ABSTRACT: The current management of thalassemia includes regular transfusion programs and chelation therapy. It is important that physicians be aware that endocrine abnormalities frequently develop mainly in those patients with significant iron overload due to poor compliance to treatment, particularly after the age of 10 years. Since the quality of life of thalassemia patients is a fundamental aim, it is vital to monitor carefully their growth and pubertal development in order to detect abnormalities and to initiate appropriate and early treatment. Abnormalities should be identified and treatment initiated in consultation with a pediatric or an adult endocrinologist and managed accordingly. Appropriate management shall put in consideration many factors such as age, severity of iron overload, presence of chronic liver disease, thrombophilia status, and the presence of psychological problems. All these issues must be discussed by the physician in charge of the patient's care, the endocrinologist and the patient himself. Because any progress in research in the field of early diagnosis and management of growth disorders and endocrine complications in thalassemia should be passed on to and applied adequately to all those suffering from the disease, on the 8 May 2009 in Ferrara, the International Network on Endocrine Complications in Thalassemia (I-CET) was founded in order to transmit the latest information on these disorders to the treating physicians. The I-CET position statement outlined in this document applies to patients with transfusion-dependent thalassemia major to help physicians to anticipate, diagnose, and manage these complications properly.
Indian journal of endocrinology and metabolism. 01/2013; 17(1):8-18.
[Show abstract][Hide abstract] ABSTRACT: Most of the endocrine complications in thalassaemia are attributable to iron overload which may be the result of economic circumstances (expense of the chelation therapy), late onset of chelation therapy or poor compliance with the iron chelation therapy. The major difficulties reported by hematologists or pediatric endocrinologists experienced in thalassaemias or thalassaemia syndromes in following growth disorders and endocrine complications were: lack of familiarity with medical treatment of endocrine complications (40%), interpretation of endocrine tests (30%), costs (65%), absence of paediatric endocrinologist for consultation on growth disorders and endocrine complications (27%), facilities (27%), other (e.g. lack of collaboration and on-time consultation between thalassaemic Centers supervised by hematologists and endocrinologists) (17%). Because any progress we make in research into growth disorders and endocrine complications in thalassaemia should be passed on to all those suffering from it, guaranteeing them the same therapeutic benefits and the same quality of life, on the 8th of May, 2009 in Ferrara (Italy), the International Network on Endocrine Complications in Thalassemia (I-CET) was founded. The I-CET group is planning to conduct, in Ferrara in May 2012, a workshop, "MRI and Endocrine Complications in Thalassaemia", and in Doha (Qatar) in September 2012, a 3-day intensive course entitled, "Growth disorders and Endocrine Complications in Thalassaemia", to provide interested pediatricians, physicians and hematologists from all over the world with an in-depth approach to the diagnosis and management of growth and endocrine disorders in thalassaemic patients.
[Show abstract][Hide abstract] ABSTRACT: It was hypothesized that some children with idiopathic short stature (ISS) may have partial insensitivity to growth hormone (GH). In this study analysis of the GH/IGF-I axis as well as GH receptor (GHR) gene was done in children with ISS to determine the possible underlying factor(s) to their short stature.
Forty-eight patients with a diagnosis of ISS were studied; 33 boys and 15 girls aged 13.6 ± 3.7 years. Molecular analysis of the GHR was performed and GH sensitivity was tested by the IGF-I generation test.
Basal IGF-I levels were <-2 SD in 22.9%, and 53.5% showed an IGF-I response below 40% (0-38%) to GH stimulation. GH-binding protein (GHBP) levels were below the normative mean in almost all patients. Mutations in the region of the GHR gene that codes for the extracellular domain of the receptor were found in 15.5%; one newly described mutation was recorded.
With the possible exception of the novel G62V mutation, functional studies of the other 2 heterozygous mutations found in 6 of our patients are needed in order to prove their impact on short stature.
Hormone Research in Paediatrics 08/2011; 76(5):300-6. · 1.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Several studies reported a significant prevalence of adrenal insufficiency, ranging from 18-45%, in patients with thalassemia. Evidence for dissociation of cortisol and adrenal androgen secretion in patients with beta-thalassemia was previously reported.
We measured adrenal androgen response along with cortisol to the standard (250 mg) dose ACTH test.
Forty five beta-thalassemia major (TM) patients were enrolled. Their ages ranged between 12 and 20 years (14.9 ± 2.2 years). All patients underwent the 250 mg cosyntropin test in the morning before blood transfusion. Blood samples for total cortisol, dehdroepiandrosterone (DHEA) and androstendione (A) measurements were collected before and 60 min after IV injection of 250 mg cosyntropin. Adrenal insufficiency was observed in 7 of 45 (15.5%) patients. Adrenal androgen levels decreased significantly with advancing Tanner stage. No difference was noted between patients with and without adrenal insufficiency regarding anthropometric and laboratory parameters.
Adrenal insufficiency is not a rare complication in thalassemia. Adrenal androgen production declines with advancing puberty in thalassemic adolescents and might explain the poor development of pubic and axillary hair observed in this condition.
Pediatric endocrinology reviews: PER 03/2011; 8 Suppl 2:295-9.
[Show abstract][Hide abstract] ABSTRACT: Children with growth hormone insensitivity syndrome (GHIS) who receive insulin-like growth factor 1 (IGF-1) treatment and enter puberty with inadequate height gain are unlikely to reach adult height within the normal range. Final height standard deviation score (SDS) in most treated children is < or = -5. Combining IGF-1 with gonadotrophin-releasing hormone analogue (GnRHa) therapy may help to improve their final height. Three patients on IGF-1 treatment, two with primary GHI and one with secondary GHI, were started on GnRHa therapy at the onset of puberty. Their ages ranged from 6.4 years to 12.9 years at the start of IGF-1 therapy (120 microg/kg twice daily by subcutaneous injection). Gains in height/bone age SDSs under GnRHa therapy ranged from 0 to 0.9. Growth velocity on GnRHa therapy ranged from 4 cm/year to 4.8 cm/year. Bone maturation (measured as change in bone age divided by change in chronological age, deltaBA/deltaCA) decreased after the start of GnRHa therapy. Predicted adult height (PAH) improved in two patients and was maintained in one. Bone mineral density showed gradual improvement from baseline. Treatment with GnRHa resulted in a gain in PAH. Final height results will provide the definite answer on the effectiveness of this combined treatment.
[Show abstract][Hide abstract] ABSTRACT: The assessment that heterozygous SHOX mutations leading to SHOX haploinsufficiency play a role in patients with idiopathic short stature (ISS) is already documented in the literature as well as the suggestion that additional copies of SHOX are strongly implicated in a condition of tall stature. However, we report the first case of short stature in a male associated with the presence of three copies of the SHOX gene. Through chromosomal analysis, using Multiplex Ligation-dependent Probe Amplification method of SHOX salsa P018B kit and microsatellite analysis, we identify a new interstitial isolated duplication of the SHOX gene and its enhancer caused by a larger duplication of the PAR1 region in a boy with ISS. Consequently, we propose the hypothesis that this chromosome re-arrangement disrupts the regular interaction between the enhancer and promoter, resulting in a transcription block, thus producing a lack of gene activation, causing the clinical feature of short stature.
[Show abstract][Hide abstract] ABSTRACT: Bone disease in thalassemia in the form of low bone mass remains a frequent, debilitating and poorly understood problem, even among well transfused and chelated pre-pubertal and adult patients. In this work we attempted to delineate calcium status and bone mineral density in a group of transfusion dependent thalassemic adolescents of both sexes. Bone mineral density (BMD) at both the lumbar spine and femoral neck was measured in 40 adolescents with beta thalassemia major (TM) by DXA scanning and correlated to biochemical parameters including calcium, phosphorus, alkaline phosphatase, bone alkaline phosphatase, intact parathyroid hormone and 25-OH vitamin D as well as vitamin D receptor (VDR) gene polymorphisms at exon 2 (Fok1). Z-score of BMD at the lumbar spine (-3.3, +/-1.4) was significantly lower than at the femoral neck (-0.68, -/+1.3), (p=0.001). Serum ferritin and VDR genotype were related to BMD only at the femoral neck indicating that the factors determining the BMD at these 2 sites might be different. Seventy-five percent of patients had a low calcium level and hypoparathyroidism was present in 72.5% of patients. The low calcium level was probably caused by a combination of hypoparathyroidism and osteomalacia evidenced by elevated bone alkaline phosphatase presumably resulting from deficient calcium intake. To optimize BMD in TM, it is important to ensure adequate iron chelation and adequate intake of calcium and vitamin D.
Pediatric endocrinology reviews: PER 11/2008; 6 Suppl 1:132-5.