Clinical outcomes after long-term treatment with alglucosidase alfa in infants and children with advanced Pompe disease.

PURPOSE: A clinical trial was conducted to evaluate the safety and efficacy of alglucosidase alfa in infants and children with advanced Pompe disease. METHODS: Open-label, multicenter study of IV alglucosidase alfa treatment in 21 infants 3-43 months old (median 13 months) with minimal acid alpha-glucosidase activity and abnormal left ventricular mass index by echocardiography. Patients received IV alglucosidase alfa every 2 weeks for up to 168 weeks (median 120 weeks). Survival results were compared with an untreated reference cohort. RESULTS: At study end, 71% (15/21) of patients were alive and 44% (7/16) of invasive-ventilator free patients remained so. Compared with the untreated reference cohort, alglucosidase alfa reduced the risk of death by 79% (P < 0.001) and the risk of invasive ventilation by 58% (P = 0.02). Left ventricular mass index improved or remained normal in all patients evaluated beyond 12 weeks; 62% (13/21) achieved new motor milestones. Five patients were walking independently at the end of the study and 86% (18/21) gained functional independence skills. Overall, 52% (11/21) of patients experienced infusion-associated reactions; 95% (19/20) developed IgG antibodies to recombinant human lysosomal acid alpha-glucosidase; no patients withdrew from the study because of safety concerns. CONCLUSIONS: In this population of infants with advanced disease, biweekly infusions with alglucosidase alfa prolonged survival and invasive ventilation-free survival. Treatment also improved indices of cardiomyopathy, motor skills, and functional independence.

Functional studies of new TSH receptor (TSHr) mutations identified in patients affected by hypothyroidism or isolated hyperthyrotrophinaemia.

OBJECTIVES: To establish the role of new TSH receptor (TSHr) variants (P27T, E34 K, R46P, D403N, W488R and M527T) recently identified in children with congenital hypothyroidism (CH) or subclinical hypothyroidism (SH) with a thyroid gland of normal size. DESIGN AND MEASUREMENTS: TSHr variants were obtained by mutagenesis. Wild-type (wt) and TSHr mutants were expressed in COS cells and cAMP assay, (125)I-TSH binding and microchip flow cytometry analyses were performed. RESULTS: D403N and M527T mutants showed a lower cAMP response to bovine TSH (bTSH) with respect to the wtTSHr. R46P and W488R mutants did not show any response to bTSH stimulation in terms of cAMP production. The E34 K mutant showed a significantly lower cAMP response to stimulation with bTSH, while P27T had a lower cAMP response only to the highest dose of bTSH used. P27T, E34 K, D403N and M527T mutants showed a lower TSH binding capacity with respect to the wtTSHr. R46P and W488R mutants did not show any TSH binding. CONCLUSIONS: E34 K, D403N, M527T, R46P and W488R TSHr variants seem to cause a functional abnormality of the receptor which is responsible for the observed phenotype. The P27T TSHr variant does not seem to play a functional role in the pathogenesis of CH and should be considered as a polymorphism.

Fat cell size, insulin sensitivity, and inflammation in obese children.

OBJECTIVE: To assess the association between adiposity indexes (body mass index [BMI], fat mass, adipocyte size) and circulating inflammation markers with known metabolic relevance or insulin sensitivity in overweight/obese children. STUDY DESIGN: Twenty-eight children (males/females: 13/15) with different degrees of overweight (BMI z-score: 1.64-3.1; fat mass: 14.1-49.8 kg) were studied. BMI, body composition (dual-energy x-ray absorptiometry scanning), subcutaneous adipocyte diameter (needle biopsy of subcutaneous abdominal fat), blood tumor necrosis factor-alpha and interleukin-6 concentrations and insulin sensitivity (frequently sampled intravenous glucose tolerance test) were assessed. RESULTS: Adipocyte diameter, more than BMI and fat mass, was significantly associated with interleukin-6 (r = 0.62, P < .001) and tumor necrosis factor-alpha (r = 0.61, P < .001). Moreover adipocyte size was associated with insulin sensitivity (R2 = 0.15, F = 4.69, P = .04) independently from fat mass. CONCLUSIONS: Adipocyte size is a factor linked to both inflammation and insulin resistance in overweight/obese children. This is similar to the findings in adults and lends support to the tenet that the earlier obesity ensues, the more severe the biologic consequences may be.

Circulating ghrelin levels in girls with central precocious puberty are reduced during treatment with LHRH analog.

UNLABELLED: Decreased levels of ghrelin have been measured in growing children during puberty. No data are available for girls with central precocious puberty (CPP). AIMS: To explore ghrelin changes before, during, and after GnRH analog treatment in girls with CPP. SUBJECTS AND METHODS: A sample of 20 Caucasian girls (8.08 +/- 0.65 years of age) with CPP was recruited. Height and weight, bone age, LH, FSH, 17beta estradiol (E(2)), and ghrelin were measured before starting treatment with GnRH analog, 18 months after therapy began and again 6 months after therapy discontinuation. RESULTS: LH and E(2) serum levels decreased significantly during treatment (2.45 +/- 2.03 vs 0.67 +/- 0.49 UI/l, P < 0.01 and 28.17 +/- 9.7 vs 15 pmol/l, P < 0.01 respectively), returning to baseline levels after the discontinuation of therapy (4.75 +/- 1.66 UI/l and 29.23 +/- 6.99 pmol/l respectively). LH peaked following LHRH stimulation significantly (P < 0.01) decreased during treatment (24.45 +/- 14.17 vs 1.3 +/- 0.18 UI/l) and then increased after therapy discontinuation (12.58 +/- 6.09, P < 0.01). Ghrelin decreased significantly (P < 0.05) during treatment (1849 +/- 322 vs 1207 +/- 637 pg/ml), and increased, though not significantly (P = 0.09) after therapy withdrawal (1567 +/- 629 pg/ml). CONCLUSIONS: Contrary to what is expected in physiologic puberty, where ghrelin is progressively reduced, the prepubertal hormone milieau induced by GnRHa treatment in patients suffering from central precocious puberty (CPP) did not promote an increase in ghrelin circulating levels. Therefore, in CPP, ghrelin secretion seems to be independent from pubertal development per se. Concomitant estrogen suppression during treatment may play a potential role in the regulation of ghrelin secretion in these girls.

Implementation of a congenital hypothyroidism newborn screening procedure with mutation detection on genomic DNA extracted from blood spots: the experience of the Italian northeastern reference center.

After a couple of decades from the institution of nationwide congenital hypothyroidism (CH) newborn screening program, the first generation properly treated is now displaying normal reproductive rate and the causative molecular defects are spreading from one generation to the next. In the present study we propose a method of detection of mutations in the thyrotropin receptor (TSHR) and in the paired box 8 (PAX8) genes that have been proved to be responsible for some forms of CH. The method, carried out by means of denaturing high-performance liquid chromatography (DHPLC) followed by direct sequencing, takes advantage of the CH newborn screening procedure, because genomic DNA for the analysis is extracted from the same blood spot collected for recall confirmation. Among 16 hypothyroid newborns with thyroid hypoplasia born between January 1999 and April 2005 in northeastern Italy, three heterozygous causative mutations in the TSHR gene were evidenced, whereas the analysis of the PAX8 gene revealed an unknown heterozygous substitution that could interfere with the start of transcription.

Ghrelin, insulin sensitivity and postprandial glucose disposal in overweight and obese children.

OBJECTIVE: To explore the changes of ghrelin circulating levels induced by a mixed meal and their relationship with postprandial substrate oxidation rates in overweight and obese children with different levels of insulin sensitivity. METHODS: A group of ten boys (age 9-12 years) with different levels of overweight (standard deviation score of body mass index: 1.6-3.2) was recruited. Body composition was measured by dual-energy X-ray absorptiometry. Insulin sensitivity was assessed by a frequently sampled i.v. glucose tolerance test. Pre-prandial and postprandial (3 h) substrate oxidation was measured by indirect calorimetry. The energy content of the test meal (16% protein, 36% carbohydrate and 48% fat) was 40% of pre-prandial energy expenditure (kJ/day). RESULTS: Pre-prandial serum concentration of total ghrelin was 701.4+/-66.9 pg/ml (S.E.M.). The test meal induced a rapid decrease in ghrelin levels and maximal decrease was 27.3+/-2.7% below baseline. Meal intake induced a progressive increase of the carbohydrate oxidation rate for 45 min after food ingestion, followed by a slow decrease without returning to pre-prandial values. Postprandial cumulative carbohydrate oxidation was 16.9+/-0.8 g/3 h. Insulin sensitivity and postprandial maximal decrease of ghrelin concentration showed a significant correlation (r = 0.803, P < 0.01). Moreover, the postprandial carbohydrate oxidation rate correlated with the area under the curve for both insulin (r = 0.673, P < 0.03) and ghrelin (r = -0.661, P < 0.04). CONCLUSIONS: A relevant association between postprandial insulin-mediated glucose metabolism and ghrelin secretion in children with different levels of overweight was found. It is possible that the maintenance of an adequate level of insulin sensitivity and glucose oxidation may affect appetite regulation by favoring a more efficient postprandial ghrelin reduction.

Osteogenesis imperfecta and its molecular diagnosis by determination of mutations of type I collagen genes.

Osteogenesis Imperfecta is a genetic disorder of increased bone fragility and low bone mass. Most cases are caused by a mutation in one of the two genes coding for the type I collagen protein. The correct clinical diagnosis of OI can be difficult sometimes, because of the wide phenotypic range. Therefore collagen I genes mutation identification can be helpful. We screened 23 patients by direct sequencing of the exons encoding the collagen protein. We identified 18 different mutations, while 5 cases were negative because of an uncertain clinical diagnosis or an atypical form of OI not related to collagen I genes. The current medical and pharmaceutical treatments are only symptomatic and do not alter the course of collagen mutations. Cells and gene therapies as potential treatments for OI have therefore to be actively investigated.

Intravenous neridronate in children with osteogenesis imperfecta: a randomized controlled study.

UNLABELLED: In a randomized controlled study, we investigated the effect of treatment with intravenous neridronate in prepubertal children with OI. Our study suggests that quarterly intravenous infusions of the bisphosphonate significantly raise the rate of increase in BMD at both the spine and hip, the projected area of the lumbar vertebrae, and height. These results are associated with a significant decrease in the risk of clinical fractures. INTRODUCTION: Osteogenesis imperfecta (OI) is a heritable disease of connective tissue, characterized by increased bone fragility. Bisphosphonates currently seem to be the most promising therapy, but randomized, controlled studies are scarce and have never been carried out in prepubertal children. MATERIALS AND METHODS: This was a randomized, controlled 3-year clinical trial. The Italian Patients' Society of OI (AsItOI) sent their members affected by any type of OI to two centers at the University of Verona (Italy) to participate in the study. Sixty-four children, 6-11 years of age for boys and 6-9 years of age for girls, with no signs of puberty and who were never treated with bisphosphonates, were randomized to either intravenous neridronate (2 mg/kg infused IV in 30 minutes every 3 months) or no treatment, with a ratio of 2:1. Control patients were given the same bisphosphonate therapy at the end of the first year. BMD and projected bone areas, as measured by DXA, at spine and hip, height, and peripheral fracture incidence, both prospective and retrospective (2 years preceding randomization), were the main outcomes of the study. RESULTS: At the end of the first year, spine and hip BMD rose by 3.5-5.7% in control patients and by 18-25% (p < 0.001 versus controls) in the active group, respectively. During the following 2 years, the treatment in all patients was associated with BMD increases of 10-25% per year. Height and the DXA-derived projected area of lumbar spine rose during the first year of observation significantly more in the active group than in the control group (<0.01 and <0.05, respectively). Both height and spine projected area continued to rise in the treated patients toward levels found in healthy individuals. During the first year of treatment, 45% of the control patients and 27% of the active group had a nonvertebral fracture, but this difference was not statistically significant (p = 0.2). The total number of fractures was 18 in the 22 control patients and 13 in the active group (relative risk, 0.36; 95% CI, 0.15-0.87; p < 0.05). CONCLUSION: Intravenous neridronate infusions, administered quarterly, significantly increase BMD and lower the risk of clinical fracture in prepubertal children with OI.

Nuclear localization domains in human thyroid transcription factor 2.

Thyroid transcription factor-2 (TTF2) is a nuclear protein involved in morphogenesis and gene expression in thyroid gland, belonging to the family of the forkhead/winged-helix transcription factors. In the present study we have investigated the sequence determinants for transport and accumulation into the nucleus of the TTF2 protein. By transient expression of fusion proteins constructed by joining different parts of TTF2 to the reporter gene of the jellyfish green fluorescent protein (GFP) and, in a separate set of deleted constructs, the glutathione S-transferase (GST) coding sequence, we have demonstrated that a basic amino acid stretch present at both ends of the DNA-binding domain is a bona fide nuclear localization signal (NLS). We have analyzed the subcellular localization of deleted GFP-GST-TTF2 fusion proteins and have shown that residues inside the forkhead domain (FHD) contributed to the complete nuclear TTF2 protein accumulation. Furthermore, by means of GST binding assays we have shown that distinct TTF2 fragments, containing the NLS, were able to bind the nuclear import receptor importin alpha. Taken together, our results provide the first documentation about nuclear targeting of a forkhead protein containing two identical NLS signal flanking the DNA-binding domain.

Body composition measurements: from the past to the future.

UNLABELLED: During growth, the human body increases in size and changes its proportions of various components due to hormone mediators. Growth is a complex, biological process regulated by multiple factors. These factors include genetics, nutritional intake, physical activity, age, gender and endocrine balance, all of which influence a child's body composition during the growth years. Quantifying the main components is integral to the study of growth, as the assessment of human physical characteristics is important both in the anthropological and medical fields. It is important to have the possibility to control the growth process and to predict adult status in order to reduce the risk factors of various diseases. CONCLUSION: This paper examines issues in the measurements of paediatric body composition, describing traditional and new tools in this field.

Bone mass at final height in precocious puberty after gonadotropin-releasing hormone agonist with and without calcium supplementation.

The aim of our longitudinal study was to evaluate bone mass in girls affected by central precocious puberty (CPP) that have reached final height, treated with GnRH agonist triptorelin (GnRHa), with or without calcium supplementation. We studied 48 Caucasian females affected by CPP (age at diagnosis, 7.19 +/- 0.96 yr), randomly assigned to two groups: group A (n = 21) treated with GnRHa and group B (n = 27) treated with GnRHa plus calcium gluconolactate and carbonate (1 g calcium/day in two doses) for at least 2 yr. Auxological parameters (standing height, weight, body mass index) and bone mineral density (BMD) at the lumbar spine [L2-L4, anteroposterior (AP)-BMD; lateral BMD; volumetric (v)BMD)] by dual-energy x-ray absorptiometry were evaluated at the beginning [chronological age (CA), 7.29 +/- 0.91 yr; bone age (BA), 8.80 +/- 1.24 yr] and end of treatment (CA, 11.27 +/- 0.97 yr; BA, 12.35 +/- 0.43 yr) and at final height (CA, 16.17 +/- 1.9 yr; BA, 16.93 +/- 0.98 yr, in each case >15 yr). Total bone mineral content, total BMD, and fat percentage were evaluated at the end of the study period using dual-energy x-ray absorptiometry. Final height was significantly higher than predicted height at diagnosis (159.9 +/- 6.3 cm vs. 152.9 +/- 9.6 cm; P < 0.05). Body mass index and fat percentage were not statistically different from control values. Densitometric values at final evaluation in groups A and B together were lower than in controls, but the differences were not statistically significant. The vBMD was significantly higher in group B than in group A at the end of treatment period (0.213 +/- 0.022 g/cm(3) vs. 0.192 +/- 0.021 g/cm(3); P < 0.01) and at final evaluation (0.246 +/- 0.023 g/cm(3) vs. 0.227 +/- 0.024 g/cm(3); P < 0.05). The percentage change (Delta%) between the start and end of treatment period in AP-BMD and vBMD was significantly higher in group B than in group A (Delta% AP-BMD: 20.36% +/- 1.10% vs. 16.16% +/- 1.90%, P < 0.01; Delta% vBMD: 19.08% +/- 3.52% vs. 9.26% +/- 5.15%; P < 0.01) and also between the start of treatment and final evaluation (Delta% AP-BMD: 61.23% +/- 1.61% vs. 56.97% +/- 1.45%, P < 0.01; Delta% vBMD: 36.69% +/- 5.01% vs. 28.01% +/- 5.76%, P < 0.01). In all our females with CPP treated with GnRHa, bone densitometric parameters were in the normal range for age and sex. However, bone mass achievement seemed to be better preserved in the group of patients supplemented with calcium.

Insulin resistance and the persistence of obesity from childhood into adulthood.

Insulin resistance and obesity are associated in children as they are in adults. However, although insulin resistance seems to oppose further weight gain in adults, opposite results have been found in children. To investigate the relationship between childhood obesity, insulin resistance, and long-term weight gain, we selected 215 obese Caucasian children (120 males and 95 females) aged 10.5 (+/-2.4) yr, with a relative body mass index (BMI) of 153.8% (+/-27.7%) and normal glucose tolerance. Insulin resistance was assessed at baseline by using the homeostasis model assessment. Fourteen (+/-5) years later, 103 subjects returned for a follow-up examination of height and weight. At follow-up, 37 subjects (36%) were obese (BMI > or = 30), 33 (32%) were overweight (25 < or = BMI < 30), and 33 (32%) were of normal weight (20 < or = BMI < 25). In a multiple regression, relative BMI and insulin resistance at childhood were independent predictors of adulthood BMI (r(2) = 0.44; P < 0.01) in girls. A multivariate logistic regression analysis showed that high relative BMI [odds ratio, 1.06; 95% confidence interval, 1.00-1.13; P = 0.04] and low insulin resistance index at baseline (odds ratio, 0.58; 95% confidence interval, 0.34-0.99; P = 0.04) predicted obesity in adulthood for girls, no matter their age, Tanner stage, and their parents' BMI. In boys, insulin resistance was not a significant predictor of adult obesity. In conclusion, obesity tracks into adulthood for many obese Caucasian children. In obese girls, insulin resistance during childhood appears to oppose the risk of obesity in adulthood.

The acid-labile subunit of human ternary insulin-like growth factor-binding protein complex in girls with central precocious puberty before and during gonadotropin-releasing hormone analog therapy.

The aim of the study was to evaluate serum acid-labile subunit (ALS) concentrations and their relationship with other parameters of the human ternary IGF-I-binding protein (IGFBP) complex in girls with central precocious puberty (CPP) before and after pharmacological arrest of puberty. We studied serum ALS, free IGF-I, total IGF-I, IGFBP-3 levels and IGFBP-3 protease activity in 13 girls, aged 1.6-7.8 yr (mean, 5.9 +/- 2.2), diagnosed as having CPP before and after 6 and 12 months of GnRH analog (GnRHa) therapy. The ALS SD score before treatment was high (1.4 +/- 0.72) and decreased significantly after 6 and 12 months of GnRHa therapy [0.4 +/- 0.54 (P < 0.01) and -0.4 +/- 0.61 (P < 0.01), respectively]. Serum IGF-I and IGFBP-3 were also increased before treatment, but both of these factors remained elevated after 6 and 12 months of GnRH-A therapy [IGF-I SD score, 3.20 +/- 1.64, 2.92 +/- 1.82, and 3.68 +/- 1.94 (P = NS), respectively; IGFBP-3 SD score, 1.02 +/- 0.53, 0.94 +/- 0.68, and 1.22 +/- 0.87 (P = NS), respectively]. Serum free IGF-I levels and IGFBP-3 proteolytic activity did not vary significantly from their pretreatment values during GnRHa therapy. In conclusion, serum ALS levels were elevated in girls with CPP and decreased significantly during the first year of GnRHa therapy. Serum IGF-I and IGFBP-3 levels were also increased before therapy, but their levels were not influenced by treatment. The ALS decrease seems to be the sole GH-dependent factor that parallels the decreases in steroid levels and growth velocity during GnRHa therapy.

Bone development during GH and GnRH analog treatment.

Estrogens, GH and IGFs are essential in the development and growth of the skeleton and for the maintenance of bone mass and density. Treatment of precocious puberty with GnRH analogs (GnRHa), by reducing sex steroid levels, leads to a situation of hypoestrogenism that may theoretically have a detrimental effect on bone mass during pubertal development. A reduction in bone mineral density (BMD) during GnRHa treatment has been demonstrated, but GnRHa treatment in patients with central precocious puberty (CPP) does not seem to impair the achievement of normal peak bone mass (PBM) at final height. However, calcium supplementation is effective in improving bone densitometric levels and may promote better PBM achievement. In children and adolescents with GH deficiency (GHD), BMD assessed by dual-energy X-ray absorptiometry (DEXA) and bone turnover are significantly reduced, but they are stimulated by GH treatment. GH treatment leads to improved bone density, function of the dose and duration of treatment, and patients may require prolonged GH treatment beyond the time of growth to improve PBM. After the discontinuation of GH therapy, the more active population had higher bone mineral content (BMC) levels than patients with low physical activity. In our experience, the therapeutic association of GH and calcium also represents a valuable tool in pursuing a proper BMC in GHD patients. We concluded that nonhormonal factors, such as physical activity and nutritional factors, are important in determining bone metabolism and bone mass.

Neonatal birth parameters of positive newborns at PKU screening as predictors of false-positive and positive results at recall-testing.

OBJECTIVES: To investigate the predictive role that neonatal birth parameters of positive newborns at phenylketonuria (PKU) screening have on false-positive and positive results. We reviewed 195 newborns (115 males and 80 females) that had false-positive results between 1998 and 2001. A total of 4386 randomly selected neonates (2191 males and 2195 females) who tested normal at the first investigation in the same period, were used as negative-controls. A total of 38 PKU neonates (17 males and 21 females) diagnosed between 1990 and 2001 were used as positive-controls. METHODS: Phenylalanine concentration was measured with a fluorometric multitask plate counter Wallac 1420 VICTOR F (Perkin Elmer, Finland) and the fluorescent ninhydrine method (EG&G Wallac neonatal phenylalanine kit) using a recall cut-off level >120 micromol/l (2 mg/dl) of phenylalanine on dried blood spots. A multivariate logistic regression analysis was performed to evaluate the predictive role that body parameters (sex, gestational age, parity, weight, length and head circumference) of positive newborns at PKU screening had on false-positive and positive results at recall PKU tests. RESULTS: The risk of false-positive results is higher (~48%) in females than in males. Moreover, for each 100g of body weight reduction, the risk of false positive is around 4.2% higher. The risk of confirmation increased by 39% per week of gestational age. CONCLUSIONS: In conclusion, our results suggest that preterm or low-birth-weight neonates recalled at the first investigation are more likely to be due to false-positives, whereas the risk of confirmation is higher in at-term neonates. By implication, the phenylalanine cut-off value for premature or low-body-weight infants could be higher.

Reference values of the bioelectrical impedance vector in neonates in the first week after birth.

OBJECTIVE: To determine the reference, bivariate, tolerance intervals of the whole-body impedance vector for healthy white neonates, we performed an observational, cross-sectional study in two university hospitals. METHODS: The impedance vector (standard, tetrapolar analysis at 50-kHz frequency) was measured in 163 consecutive subjects (87 boys and 76 girls) with postnatal ages of 1 to 7 d. Bivariate vector analysis was conducted with the resistance-reactance (RXc) graph method. RESULTS: The age-specific 95% confidence intervals of mean vectors and the 95%, 75%, and 50% tolerance intervals for individual vector measurements were plotted using R and Xc components standardized by the subject's crown-to-heel length (height). Mean vectors from the groups (1, 2, and 3 to 7 d) with overlapping 95% confidence ellipses were considered representative of only one age class of 1 to 7 d. The impedance vector distribution of neonates also was compared with healthy white children (1014 boys and 1030 girls, age 2-15 y) and adult subjects (354 men and 372 women, age 15-85 y) from the same geographic area. There was a definite, progressive, vector shortening from birth, through ages 2 to 15 y, toward the adults' vector position. CONCLUSIONS: We established the reference, bivariate, 95%, 75%, and 50% tolerance intervals of the impedance vector in the first postnatal week for healthy white neonates, with which the vectors from infants with altered body composition can be tested (free software is available from apiccoli@ unipd.it).

Incomplete gastric metaplasia in children with insulin-dependent diabetes mellitus and celiac disease. An ultrastructural study.

BACKGROUND: The association of insulin-dependent diabetes mellitus (IDDM) and celiac disease (CD) has been widely reported in children but the relationship between the two conditions is incompletely understood. Moreover, specific studies on intestinal biopsies of patients with the association of the two diseases are still lacking. METHODS: We studied the ultrastructure of the duodenal mucosa in 12 patients with both IDDM and CD. RESULTS: All patients had either total or partial atrophy of duodenal mucosa. In seven subjects, an accumulation of electrondense granules in the apical cytoplasm of groups of enterocytes was found. In four of them, a double population of granules existed (mean diameter: 400-800 nm and 100-200 nm respectively) showing a biphasic pattern. In the other three patients, only smaller granules (100- 200 nm) were found in the enterocytes. CONCLUSIONS: The present work suggests that patients with IDDM/CD may represent a subgroup in the context of the CD population. Intestinal biopsies of such individuals often show accumulation of electrondense granules in the apical cytoplasm of enterocytes that can be interpreted as incomplete gastric metaplasia.

A case of partial biotinidase deficiency associated with autism.

We report the case of a child with partial biotinidase deficiency and autistic developmental disorder. We arrived at the diagnosis of biotinidase deficiency when the child was almost 4 years of age. Consequently, he began cofactor biotin treatment (10 mg daily) which did not resolve his autistic behavior. His younger brother was affected by partial biotinidase deficiency diagnosed at birth through our neonatal screening program. He was precociously treated with cofactor biotin therapy (10 mg daily) and did not show any behavioral abnormality or developmental delay. Since the brain is quite vulnerable to biotin deficiency, delayed biotin therapy could result in neurological damage. Our patient is the first case of partial biotinidase deficiency associated with autism. We hypothesize that the low biotinidase activity could have caused biotin deficiency in his brain and cerebrospinal fluids and consequently serious neurological problems, such as stereotyped and autistic behaviors, which were irreversible in spite of biotin supplementation.

Onset of menstrual cycle and menses features among secondary school girls in Italy: A questionnaire study on 3,783 students.

PREMISE: Healthcare professionals need updated information about what is the range of "normal" variation of menstrual cycle features to support young girls and their parents in managing reproductive health, and to detect diseases early. MATERIALS AND METHODS: This cross-sectional study aimed to provide an updated picture of age at menarche and main menstrual cycle characteristics and complaints in an Italian population-based sample of 3,783 adolescents attending secondary school. Girls filled in a self-administered anonymous questionnaire including questions about demography, anthropometry, smoking and drinking habits, use of contraceptive, socioeconomic status, age at menarche, menstrual pattern, and physical/psychological menstrual complaints. Mean age at menarche and prevalence of polymenorrhea (cycle length < 21 days), oligomenorrhea (cycle length > 35 days), irregularity, dysmenorrhea, and of physical/psychological complaints were computed. Factors associated with age at menarche and menstrual disturbances were explored by using multiple logistic models. RESULTS: The girls' mean age was 17.1 years (SD 1.4 years) and the mean age at menarche was 12.4 years (SD 1.3 years); menarche occurred with two monthly peaks of frequency in July-September and in December-January (P < 0.0001). Age at menarche was significantly associated with geographic genetics (as expressed by parents' birth area), mother's menarcheal age, BMI, family size, and age at data collection. The prevalence of polymenorrhea was about 2.5%, oligomenorrhea was declared by 3.7%, irregular length by 8.3%, while long bleeding (>6 days) was shown in 19.6% of girls. Gynecological age was significantly associated with cycle length (P < 0.0001) with long cycles becoming more regular within the fourth year after menarche, while frequency of polymenorrhea stabilized after the second gynecological year. Oligomenorrhea and irregularity were both significantly associated with long menstrual bleeding (adjusted OR = 2.36; 95% CI = 1.55-3.60, and adjusted OR = 2.59; 95% CI = 1.95-3.44, respectively). CONCLUSIONS: The findings of the study support the levelling-off of secular trend in menarche anticipation in Italy and confirm the timing in menstrual cycle regularization. The study provides updated epidemiological data on frequency of menstrual abnormalities to help reproductive health professionals in managing adolescent gynecology.

Menstrual pattern and menstrual disorders among adolescents: an update of the Italian data.

BACKGROUND: The most striking event in the whole process of female puberty is the onset of menstruation. To our knowledge, no large population-based studies have been performed on the topic of menstrual health among Italian adolescents in recent years. The aims of this study were to produce up-to-date information on the menstrual pattern of Italian girls attending secondary school, and to estimate the prevalence of menstrual cycle abnormalities in this population. METHODS: This was a cross-sectional study on a population-based sample of Italian adolescents aged 13-21 years attending secondary school. Only girls who had already started menstruating were requested to participate. Information was collected by means of a questionnaire that included items on the girls' demographic details, anthropometrics, smoking and drinking habits, use of contraceptive pills, and socioeconomic status. The questions on the girls' menstrual pattern concerned their age at menarche, duration of the most recent menstruation intervals (<21, 21-35, >35 days, variable), average days of bleeding (<4, 4-6, >6 days), and any menstrual problems and their frequency. RESULTS: A total of 6,924 questionnaires were administered and 4,992 (71%) were returned. One hundred girls failed to report their date of birth, so 4,892 subjects were analyzed. The girls' mean age was 17.1 years (SD ±1.4); their mean age at menarche was 12.4 (±1.3) years, median 12.4 years (95%CI 12.3-12.5). In our sample population, 3.0% (95%CI 2.5%-3.4%) of the girls had menstruation intervals of less than 21 days, while it was more than 35 days in 3.4% (95%CI 2.9%-3.9%). About 9% of the girls (95%CI 7.7%-9.4%) said the length of their menstruation interval was currently irregular. Short bleeding periods (<4 days) were reported in 3.2% of the sample population (95%CI 2.7%-3.7%), long periods (>6 days) in 19% (95%CI 17.9%-20.1%). Menstruation-related abdominal pain was reported by about 56% of our sample. About 6.2% of the girls (95%CI 5.4%-7.0%) were suffering from dysmenorrhea. CONCLUSIONS: In conclusion, to the best of our knowledge, this is one of the largest studies on menstrual patterns and menstrual disorders among Italian adolescent girls. Adolescent girls referring persistent oligomenorrhoea, in first two years from menarche, had a higher risk for developing a persistent menstrual irregularity. They had longer bleeding periods (>6 days) and this has practical implications because it makes these adolescents potentially more susceptible to iron deficiency anemia. Clinicians need to identify menstrual abnormalities as early as possible in order to minimize their possible consequences and sequelae, and to promote proper health information.We recommend that adolescents should be encouraged to chart their menstrual frequency and regularity prospectively from the menarche onwards.