Volume 31, Issue 2

Cortisol is a hydrophobic molecule that is largely bound to corticosteroid-binding globulin (CBG) in the circulation. In the assessment of adrenal insufficiency, many clinicians measure a total serum cortisol level, which assumes that CBG is present in normal concentrations and with a normal binding affinity for cortisol. CBG concentration and affinity are affected by a number of common factors including oral contraceptive pills (OCPs), fever and infection, as well as rare mutations in the serine protease inhibitor A6 ( SERPINA6 ) gene, and as such, total cortisol levels might not be the ideal way to assess adrenal function in all clinical circumstances. This paper reviews the limitations of immunoassay and liquid chromatography-tandem mass spectrometry (LC-MS/MS) in the measurement of total cortisol, the challenges of measuring free serum cortisol directly as well as the difficulties in calculating an estimated free cortisol from total cortisol, CBG and albumin concentrations. Newer approaches to the evaluation of adrenal insufficiency, including the measurement of cortisol and cortisone in the saliva, are discussed and a possible future role for these tests is proposed.

Background: This study aimed to evaluate the relationship between sodium intake and insulin resistance indices. Methods: A total of 718 Korean children and adolescents (411 boys) aged 10–18 years who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) were included in the study. The urinary sodium to urinary creatinine ratio was used as a surrogate for sodium intake. The homeostatic model assessment of insulin resistance (HOMA-IR) and the quantitative insulin sensitivity check index (QUICKI) were used as indices of insulin resistance. Results: The mean urinary sodium to urinary creatinine ratio was 11.34 in males and 10.17 in females. The urinary sodium to urinary creatinine ratio was significantly positively correlated with HOMA-IR (r=0.165, p<0.001) and inversely correlated with QUICKI (r=−0.181, p<0.001) in Pearson’s correlation analyses. In a multivariate linear regression analysis, the urinary sodium to urinary creatinine ratio was independently and significantly positively associated with HOMA-IR (β=0.073, p=0.018) and significantly inversely associated with QUICKI (β=−0.080, p=0.007) after adjustment for possible confounders. HOMA-IR was independently and significantly positively associated with the urinary sodium to urinary creatinine ratio (β=0.087, p=0.018), whereas QUICKI was independently and significantly negatively associated with the urinary sodium to urinary creatinine ratio (β=−0.097, p=0.009) after controlling for confounders. Conclusions: Our results suggest that sodium intake, as estimated by the urinary sodium to urinary creatinine ratio, may be independently associated with insulin resistance in children and adolescents.

Background: The objective of this study was to determine the effects of a 4-week aerobic exercise plus dieting intervention on serum chemerin in obese female adolescents and its possible role in mitigating cardio-metabolic risk including glucose and lipid metabolism, central fat and inflammation. Methods: Fifty obese female adolescents were randomly divided into two groups: exercise plus dieting group (n=30) and dieting group (n=20). The participants in the exercise plus dieting group completed 4 weeks of moderate aerobic exercise combined with dieting, while the subjects in the dieting group undertook only dieting. Before and after the experiments, anthropometric index, parameters of glucose and lipid metabolism, serum chemerin and classic inflammatory indicators (C-reactive protein [CRP], tumor necrosis factor-α [TNF-α], interleukin-1β [IL-1β], IL-6, leptin and adiponectin) were measured. Results: Compared with the dieting group, a decrease in serum chemerin was found in the exercise plus dieting group, accompanied by significant improvements in anthropometric index, glucose and lipid metabolism and inflammatory factors. In addition, a higher serum chemerin level was found in obese adolescents with metabolic syndrome (MetS), and the disappearance of MetS induced by exercise plus dieting might be related to the decrease in chemerin. Correlation analysis showed the correlations of the decrease in chemerin with the changes in body fat, glucose and lipid metabolic index, leptin and adiponectin/leptin ratio. Conclusions: This is the first report that as short a duration as 4-week aerobic exercise plus dieting decreased serum chemerin in obese female adolescents, which might be associated with the improvement in glucose and lipid metabolism, mitigation of inflammation and decrease in MetS incidence, thus lowering cardio-metabolic risk, while no health benefit resulted from slight dieting.

Background: The aim of the study was to determine the compliance with the clinical and ultrasonographic staging of pubertal breast development in obese children. Methods: Fifty-two obese children with Tanner stage 2 and stage 3 breast development accompanied by at least one pubertal clinical finding were included in the study. The staging of breast development was also performed according to the ultrasonographic morphostructural appearance. The subjects were then divided into subgroups according to their clinical and ultrasonographic breast stages. The stages given by both methods were compared for consistency with the hormonal values and other radiological (uterus long diameter, ovary sizes) findings. Results: The correlation between the clinical and ultrasonographic staging of pubertal breast development was determined to be weak (r=0.19). Estradiol levels, uterus long diameter and ovary sizes were significantly increased when the ultrasonographic stage increased among the subjects with clinically similar breast development stage. However, no statistical difference was determined in these parameters among the subjects with ultrasonographically similar but clinically different breast development. Conclusions: It was shown that the ultrasonographic staging of breast development could provide more accurate and objective data due to the possible mistakes caused in the breast development staging of obese children by their adipose tissue.

Background: We investigated whether cardiometabolic risk factors measured in serum (total cholesterol [TC], high-density lipoprotein [HDL], triglyceride, leptin, insulin, glucose and insulin resistance) are associated with the retinal microvasculature, a marker of cardiovascular aging, in healthy children and adolescents. Moreover, we tested whether these associations are due to direct biological effects or more indirectly due to adiposity-related side effects. Methods: We recruited 168 healthy Flemish children (7–16 years old, 54.8% boys). Blood samples and retinal photographs were taken during clinical examinations. Arteriolar and venular vessel calibers were calculated using a semi-automated computer program. Multivariable regression models were used and adjusted for age, sex, mean arterial pressure (MAP) and alternate retinal caliber. In a second step, we adjusted for body mass index z-score (zBMI). Results: Only continuous serum leptin was associated with retinal parameters, i.e. wider arterioles; however, this disappeared after adjustment for zBMI. Children with high cardiometabolic risk factors (>90th percentile for serum leptin, insulin and insulin resistance) had wider arterioles compared to children with lower concentrations, even after additional adjustment for zBMI. No significant associations were found with lipids. Conclusions: In this healthy population of children and adolescents, the hormones insulin and leptin and insulin resistance were associated with retinal microvasculature alterations, mainly in children with high cardiometabolic factors (>90th percentile), while lipids were not. These associations were independent of zBMI.

Background: Ghrelin, leptin and insulin, generally considered as regulators of energy homeostasis of the organism may be related to fetal and early postnatal growth. Numerous studies have confirmed the presence of these hormones in the cells of the fetus indicating their importance in development at early stages of life. Methods: This study analyzed active and total ghrelin by radioimmunoassay (RIA), leptin and insulin concentrations by enzyme-linked immunosorbent assay (ELISA) in 65 cord blood samples, from term newborns, and measured the birth anthropometric parameters [birth weight (BW), head circumference, chest, stomach, thigh and arm circumference]. Results: Active ghrelin (AG) concentrations correlated negatively with BW, head circumference, stomach and thigh circumference. When divided by gender, AG correlated negatively with males’ BW, stomach and thigh circumference. Females’ head circumference correlated negatively with AG. Cord leptin correlated positively with arm circumference. When divided by gender, cord leptin was positively associated with BW and stomach circumference in male newborns and with thigh and arm circumference in female newborns. Insulin concentrations tended to correlate positively with BW in male newborns. Conclusions: In summary, it was confirmed that cord blood ghrelin, leptin and insulin correlate with anthropometric parameters at birth. This study showed a negative correlation of AG with anthropometric parameters, which may emphasize that this hormone is an indicator of growth restriction. This is in contrast to cord leptin and insulin, which are more connected with overgrowth. Taking all the results into consideration, the metabolic status of the fetus and newborn is an essential component in understanding the regulation of perinatal development.

Background: Diffuse toxic goiter accounts for about 15% of all childhood thyroid diseases. There is great controversy over the management of Graves’ disease in children and adolescents. This article reports our experience in 304 children and juvenile patients with Graves’ disease. Methods: Between 1981 and 2015, 304 patients aged 5–19 years with diffuse toxic goiter were studied, of whom 296 patients were treated with antithyroid drugs (ATD) for 18 months. Patients with persistent or relapsed hyperthyroidism who refused ablative therapy with surgery or radioiodine were managed with continuous methimazole (MMI) treatment. Results: In 304 patients (245 females and 59 males), the mean age was 15.6±2.6 years. After 18 months of ATD therapy, 37 remained in remission and of the 128 who relapsed, two, 29 and 97 patients chose surgery, continuous ATD and radioiodine therapy, respectively. Of the 136 patients who received radioiodine, 66.2% became hypothyroid. Twenty-nine patients received continuous ATD therapy for 5.7±2.4 years. The mean MMI dose was 4.6±12 mg daily, no serious complications occurred and all of them remained euthyroid during the follow-up. Less abnormal thyroid-stimulating hormone (TSH) values were observed in these patients, as compared to patients who were on a maintenance dose of levothyroxine after radioiodine induced hypothyroidism. Conclusions: Original treatment with ATD and subsequent radioiodine therapy remain the mainstay of treatment for juvenile hyperthyroidism. Continuous ATD administration may be considered as another treatment modality for hyperthyroidism.

Background: Clinical suspicion of Turner syndrome (TS) may be challenging. Short stature and absent puberty are not mandatory and the dysmorphic picture is widely variable. The aim of the study was to describe a representative sample of patients with suspected TS in a single center and to verify which set of features may help discriminate those with TS. Methods: This was a retrospective study of patients with suspected TS evaluated between 1989 and 2012 with the same clinical and cytogenetic protocols. Data regarding reason for referral, age and height at diagnosis, birth data, pubertal features and dysmorphisms were analyzed. Results: TS was diagnosed in 36% of 516 patients; structural chromosome anomalies predominated (42%). Short stature was the main reason for referral of patients with and without TS. The mean age of patients at first visit, with TS or without TS was similar (11.89 and 11.35 years, respectively), however, infants and adolescents predominated in the TS group. The mean full-term birth weight was lower in patients with TS as well as height at diagnosis, but normal height z-score was found in 17% of patients. Spontaneous puberty occurred in 30% of TS patients aged 13 years or more, but most had pubertal delay. Residual lymphedema, webbed neck, cubitus valgus, hyperconvex nails, shield chest, abnormal nipples, pigmented nevi, short fourth metacarpal and shorter height were the best discriminators for girls with TS. Conclusions: Though short stature, pubertal delay and typical stigmata should prompt investigation of TS, lack of one of these features should not exclude this hypothesis. Dysmorphisms other than those considered “typical” should be sought on physical examination.

Background: The aim of the study was to assess the response to growth hormone (GH) treatment in very young patients with GH deficiency (GHD) through a national, multi-center study. Possible factors affecting growth response were assessed (especially mini-puberty). Methods: Medical reports of GHD patients in whom treatment was initiated between 0 and 3 years of age were retrospectively evaluated. Results: The cohort numbered 67. The diagnosis age was 12.4±8.6 months, peak GH stimulation test response (at diagnosis) as 1.0±1.4 ng/mL. The first and second years length gain was 15.0±4.3 and 10.4±3.4 cm. Weight gain had the largest effect on first year growth response; whereas weight gain and GH dose were both important factors affecting second year growth response. In the multiple pituitary hormone deficiency (MPHD) group (n=50), first year GH response was significantly greater than in the isolated GH deficiency (IGHD) group (n=17) (p=0.030). In addition first year growth response of infants starting GH between 0 and 12 months of age (n=24) was significantly greater than those who started treatment between 12 and 36 months of age (n=43) (p<0.001). These differences were not seen in the second year. Δ Length/height standard deviation score (SDS), Δ body weight SDS, length/height SDS, weight SDS in MPHD without hypogonadism for the first year of the GH treatment were found as significantly better than MPHD with hypogonadism. Conclusions: Early onsets of GH treatment, good weight gain in the first year of the treatment and good weight gain-GH dose in the second year of the treatment are the factors that have the greatest effect on length gain in early onset GHD. The presence of the sex steroid hormones during minipubertal period influence growth pattern positively under GH treatment (closer to the normal percentage according to age and gender).

Background: Childhood obesity and its consequences have reached alarming proportions worldwide and in India. Wrist circumference is emerging as an easily measurable reproducible parameter for screening children at risk of obesity-related morbidities such as hypertension and insulin resistance. The objectives of this study were: (1) to compute age and gender-specific wrist circumference percentiles for 3–18-year-old apparently healthy Indian children and adolescents; (2) to assess the relationship of wrist circumference with measures of obesity and adiposity such as body mass index (BMI), fat percentage and blood pressure (BP) and (3) to suggest age and gender-specific cut-offs for wrist circumference percentile for the risk of hypertension in Indian children and adolescents. Methods: This was a cross-sectional study on samples of 10,199 3–18-year-old children (5703 boys) from randomly selected schools from five major cities in India. Height, weight, waist and wrist circumference and BP were recorded. Body composition was measured using bioelectrical impedance analysis (BIA). Wrist circumference percentiles were computed using the LMS method. Results: The average wrist circumference of boys and girls was 10.4 cm and 10.0 cm at 3 years and increased to 15.1 cm and 13.9 cm, respectively, at 18 years. Compared to their Caucasian counterparts, Indian children’s wrists were smaller. Receiver operating characteristic (ROC) curve analysis derived the 70th percentile of wrist circumference as the cut-off for identifying the risk of hypertension. Conclusions: Contemporary cross-sectional reference percentile curves for wrist circumference for 3–18-year-old Indian children are presented. The 70th percentile of the current study is proposed as the cut-off to screen children for cardiometabolic risk factors such as hypertension.

Background: Inhibin B is a hormone produced by the Sertoli cells that can provide important information for the investigation of disorders of sex development (DSD) with 46,XY karyotype. The aim of this study is to compare two enzyme-linked immunosorbent assay (ELISA) assays for dosage of serum inhibin B in patients with 46,XY DSD with normal testosterone secretion. Methods: Twenty-nine patients with 46,XY DSD and normal testosterone secretion (partial androgen insensitivity syndrome [PAIS] [n=8]; 5α-reductase deficiency [n=7] and idiopathic 46,XY DSD [n=14]) were included. Molecular analysis of the AR and SRD5A2 genes were performed in all patients and the NR5A1 gene analysis in the idiopathic group. Measurements of inhibin B were performed by two second-generation ELISA assays (Beckman-Coulter and AnshLabs). Assays were compared using the interclass correlation coefficient (ICC) and the Bland-Altman method. Results: ICC was 0.915 [95% confidence interval (CI): 0.828–0.959], however, a discrepancy was observed between trials, which is more evident among higher values when analyzed by the Bland-Altman method. Conclusions: It is recommended to perform the inhibin B measurement always using the same ELISA kit when several evaluations are required for a specific patient.

Background: Neonatal diabetes mellitus (NDM) is a rare disorder worldwide where diabetes is diagnosed in the first 6 months of life. However, Oman has a relatively high incidence of NDM. Methods: In this study, we investigated the genetic etiologies underlying NDM and their prevalence in Oman. We collected a cohort of 24 NDM patients, with and without genetic diagnosis, referred to our center from 2007 to 2015. All patients without a genetic diagnosis were tested for mutations in 23 NDM-associated genes using a custom-targeted next-generation sequencing (NGS) panel and methylation analysis of the 6q24 locus. Results: A genetic abnormality was detected in 15/24 (62.5%) of our Omani NDM patients. We report the detection of 6q24 methylation abnormalities and KCNJ11 mutations for the first time in Omani NDM patients. Unlike Western populations where NDM is predominantly due to mutations in the KCNJ11 , ABCC8 and INS genes, NDM due to homozygous GCK gene mutations were most prevalent in Oman, having been observed in seven out of 15 NDM patients in whom we established the genetic etiology. This reflects the high degree of consanguinity which makes recessive conditions more likely. Conclusions: The results of this study are likely to impact any future strategy to introduce genetic testing for NDM disorders within the national healthcare system in Oman.

Background: Maple syrup urine disease (MSUD) is a rare metabolic autosomal recessive disorder caused by dysfunction of the branched-chain α-ketoacid dehydrogenase (BCKDH) complex. Mutations in the BCKDHA , BCKDHB and DBT genes are responsible for MSUD. The current study analyzed seven Iranian MSUD patients genetically and explored probable correlations between their genotype and phenotype. Methods: The panel of genes, including BCKDHA , BCKDHB and DBT , was evaluated, using routine the polymerase chain reaction (PCR)-sequencing method. In addition, protein modeling (homology and threading modeling) of the deduced novel mutations was performed. The resulting structures were then analyzed, using state-of-the-art bioinformatics tools to better understand the structural and functional effects caused by mutations. Results: Seven mutations were detected in seven patients, including four novel pathogenic mutations in BCKDHA (c.1198delA, c.629C>T) , BCKDHB (c.652C>T) and DBT (c.1150A>G) genes. Molecular modeling of the novel mutations revealed clear changes in the molecular energy levels and stereochemical traits of the modeled proteins, which may be indicative of strong correlations with the functional modifications of the genes. Structural deficiencies were compatible with the observed phenotypes. Conclusions: Any type of MSUD can show heterogeneous clinical manifestations in different ethnic groups. Comprehensive molecular investigations would be necessary for differential diagnosis.

Background: Classical congenital adrenal hyperplasia (CAH) is a potentially life-threatening condition, and adrenal crisis is a major cause of morbidity and mortality in affected children. Medical-alert identification (ID) could prevent complications of adrenal crisis by identifying the need for time-sensitive, critical treatment. Our objectives were to evaluate usage of medical-alert IDs by CAH youth, ownership and awareness of IDs amongst their parents, and the effect of an in-clinic educational intervention on ID utilization. Methods: Fifty families of youth with classical CAH secondary to 21-hydroxylase deficiency (11.2±5.0 years old, 58% female) were prospectively studied. An in-clinic needs assessment survey was administered at baseline to parents, paired with an educational intervention, and a follow-up needs assessment phone survey 1 month post-intervention. A quality improvement (QI) framework was utilized with plan-do-study-act (PDSA) process-improvement cycles. Results: At baseline, 20/50 (40%) CAH families owned a medical-alert ID, of which only 10/20 (50%) of ID owners reported usage >3 days per week. Only 26/50 (52%) parents were aware of ID options. Post-intervention, ID ownership doubled to 39/50 (78%; p<0.05), usage amongst ID owners reached 100% (39/39), and awareness increased to 42/50 (84%; p<0.05). A surprising barrier reported by five Spanish-speaking families was the inability to order medical-alert IDs online. Conclusions: Only a small percentage of CAH youth frequently wear a medical-alert ID, but utilization can be effectively improved with an in-clinic educational intervention. Further study is merited to assess a potential reduction in morbidity and mortality of adrenal crisis with increased medical-alert ID utilization.

Background: Androgen insensitivity syndrome (AIS) is the most frequent etiology of 46,XY disorders of sex development (DSDs), and it is an X-linked disorder caused by mutations in the androgen receptor ( AR ) gene. AIS patients present a broad phenotypic spectrum and individuals with a partial phenotype present with different degrees of undervirilized external genitalia. There are more than 500 different AR gene allelic variants reported to be linked to AIS, but the presence of somatic mosaicisms has been rarely identified. In the presence of a wild-type AR gene, a significant degree of spontaneous virilization at puberty can be observed, and it could influence the gender assignment, genetic counseling and the clinical and psychological management of these patients and the psychosexual outcomes of these patients are not known. Case presentation: In this study, we report two patients with AR allelic variants in heterozygous (c.382G>T and c.1769-1G>C) causing a partial AIS (PAIS) phenotype. The first patient was raised as female and she had undergone a gonadectomy at puberty. In both patients there was congruency between gender of rearing and gender identity and gender role. Conclusions: Somatic mosaicism is rare in AIS and nonsense AR variant allelic can cause partial AIS phenotype in this situation. Despite the risk of virilization and prenatal androgen exposure, the gender identity and gender role was concordant with sex of rearing in both cases. A better testosterone response can be expected in male individuals and this should be considered in the clinical management.

Background: Increased adrenal androgen hormones in congenital adrenal hyperplasia (CAH) can rarely cause giant ovarian cysts in the neonatal period. Although the exact mechanism of the development of ovarian cysts is unknown, it is thought that increased androgen levels stimulate folicle development by increasing follicle stimulating hormone (FSH) levels. Case presentation: A 16-day-old newborn with ambiguous genitalia was presented to our clinic. Laboratory test results were as follows: sodium: 126 mEq/L, potassium: 5.4 mEq/L, renin: 132 pg/mL, adrenocorticotropic hormone (ACTH): 207 pg/mL, cortisole: 7.8 μg/dL, basal 17OH progesterone: 21 ng/mL, androstenedione: 5.1 ng/mL, testosterone: 1188 ng/dL and dehydroepiandrosterone sulfate (DHEAS)>1500 μg/dL. Karyotype analysis resulted in 46,XX . A homozygous mutation of R356W was detected in the CYP21A2 gene. The classical severe form of salt wasting 21 hydroxylase deficiency was diagnosed and treatment was started with hydrocortisone and fludrocortisone. Good metabolic control was ensured by monthly visits but the baby presented with vaginal bleeding as soiling at 4 months. The cystic lesion which extended to the epigastric area from the pelvis in the midline abdomen, had a size of 90×80×60 mm and medially, thin ovarian parenchyma was detected in ultrasonography. Conclusions: The findings in our patient suggest that a decline in adrenal androgens after glucocorticoid treatment resulted in an increase in gonadotropin levels and the giant cyst is developed by activation of gonadotropin cascade and increased gonadotropin receptors, instead of androgens.

Background: Insulin-mediated pseudoacromegaly is a rarely described pediatric phenotype. We present two patients displaying excessive growth associated with marked acanthosis nigricans, hyperinsulinemia and metabolic dysregulation. Case presentation: Both patients, of First Nations descent, presented with excessive growth – patient one at 3.92 years (height z-score +3.75) and patient two at 9.0 years (height z-score 5.15). Insulin-like growth factor-1 (IGF-1) levels were normal with appropriate growth hormone suppression, yet marked hyperinsulinemia. Prepubescent growth velocities exceeded 9 cm/year, resulting in final adult height predictions exceeding 3 standard deviations (SDs) of predicted. Clinical courses were complicated by type 2 diabetes, marked acanthosis nigricans and long-standing psychosocial distress. Conclusions: Pediatric patients with insulin-mediated pseudoacromegaly are at risk of significant physical, metabolic and psychosocial comorbidities. Unlike adults, the implications in childhood prompt consideration for therapies to decelerate linear growth and avert progression to metabolic dysregulation. Increased recognition of this condition may improve pathophysiological understanding, diagnostic criteria and therapeutic options.

Background: Leydig cell hypoplasia (LCH) is a rare disease and one of the causes of male disorder of sexual differentiation (DSD). Inactivating mutations in the luteinizing hormone/chorionic gonadotropin receptor ( LHCGR ) gene account for the underlying LCH pathogenicity. This study aimed to analyze the clinical presentation and diagnosis as well as highlight the molecular characteristics of a subject with LCH type 1. Case presentation: Clinical data were collected from the subject and analyzed. Next generation sequencing of the immediate family pedigree using peripheral blood genomic DNA was performed, and the relevant mutations were verified with Sanger sequencing. We describe the case of a 5-year-old patient with DSD, presenting with a lateral inguinal hernia accompanied by abnormal hormone tests. The genetic analysis revealed novel compound heterozygous variants in the LHCGR gene, including a splice site mutation (c.681-1 G>A) and a frameshift variant (c.1582_1585del ATAT, p.Ile528*). Conclusions: We identified novel compound heterozygous variants in the LHCGR gene, and expanded the genotype-phenotype correlation spectrum of LHCGR variants.