How to improve CPAP failure prediction in preterm infants with RDS: a pilot study.

We aimed to test the diagnostic accuracy in predicting continuous positive airway pressure (CPAP) failure in premature infants with respiratory distress syndrome (RDS) by integrating oxygen saturation (SpO2)/fraction of inspired oxygen (FiO2) (SF ratio) with the measurement of peak velocity of the right diaphragmatic excursions (RD-PV), during the inspiration (I-Peak) and expiratory (E-Peak) phases, performed by pulsed-wave Tissue Doppler imaging. This is a prospective, observational pilot study conducted over a 2-year period. Neonates at ≤ 32 weeks gestation supported by early CPAP were eligible. Natural surfactant was delivered via a minimally invasive technique. We performed serial measurements of SF ratio and RD-PV during the early post-natal hours to test the accuracy in predicting surfactant administration as well as invasive ventilation support within 72 h from birth because of the RDS worsening. Of 56 preterm infants enrolled, 34 (61%) failed CPAP support. SF ratio showed a significant inverse relationship with both Silverman-Andersen score at birth (rho = - 0.417; P = .001) and RD-PV [E-Peak] (rho = - 0.361; P = .007). We achieved a high accuracy in predicting CPAP failure (AUC = 95%; 95% CI, 89-100%) by integrating gender, SF ratio, and RD-PV [E-Peak] at the restricted, multivariate analysis.Conclusions: SF ratio and RD-PV, as measured by pulsed-wave Tissue Doppler, may help physicians to improve their confidence in optimizing therapeutic options in preterm infants with RDS. What is Known: • Continuous positive airway pressure is the recommended first-line treatment for respiratory distress syndrome in preterm infants, but failure rates remain unacceptably high. • Choosing the optimal treatment in terms of non-invasive ventilation effectiveness and timeliness of surfactant administration for these patients is often challenging, also due to our inability to identify a worsening respiratory failure. What is New: • The integration of oxygen saturation, as measured by SpO2/FiO2, with right diaphragm peak motion velocities, as measured by pulsed-wave tissue Doppler, allows for high prediction accuracy of non-invasive ventilation support failure in premature infants at risk of respiratory distress syndrome. • These measurements may help physicians in providing optimal supportive therapy for these patients.

Understanding Powder X-ray Diffraction Profiles from Layered Minerals: The Case of Kaolinite Nanocrystals.

Powder X-ray diffraction (PXRD) techniques are widely used to characterize the nature of stacking of submicrometer-wide nanometer-thick layers that form layered mineral nanocrystals, but application of these methods to infer the in-plane configuration of the layers is difficult. Line-profile-analysis algorithms based on the Bragg equation cannot describe the broken periodicity in the stacking direction. The Debye scattering equation is an alternative approach, but it is limited by the large-scale atomistic models required to capture the multiscale nature of the layered systems. Here, we solve the Debye scattering equation for kaolinite nanocrystals to understand the contribution of different layer-stacking defects to PXRD profiles. We chose kaolinite as a case study because its approximately constant composition and lack of interlayer expansion ensure that interstitial cations and/or molecules and substitutional ions can be ignored. We investigated the structure factor change as a function of crystal structural and microstructural features such as layer structure in-plane misorientation and shift (in or out of the 2D plane) and the diameter, number, and lateral indentation of the layers. Perfect and turbostratic stacking configurations bounded the range of intensity variation for hkl and 00l reflections, as well as for any scattering angle. A unique degree of disorder was computed by the average deviation from such limiting cases, and multivariate analysis was used to interpret the observed diffraction profiles. Analysis of the data for KGa-1, KGa-2, and API-9 standard kaolinites demonstrated that the estimated densities of different stacking defects are highly correlated. In addition, analysis of API-9 particle-size fractions revealed a dispersion of four or more components in the standard sample. The results illustrate that the use of a distribution of sizes, defects, and even individual kaolinite components is necessary to accurately characterize any sample of natural kaolinite.

Vitamin D and growth hormone in children: a review of the current scientific knowledge.

BACKGROUND: Human growth is a complex mechanism that depends on genetic, environmental, nutritional and hormonal factors. The main hormone involved in growth at each stage of development is growth hormone (GH) and its mediator, insulin-like growth factor 1 (IGF-1). In contrast, vitamin D is involved in the processes of bone growth and mineralization through the regulation of calcium and phosphorus metabolism. Nevertheless, no scientific study has yet elucidated how they interact with one another, especially as a dysfunction in which one influences the other, even if numerous biochemical and clinical studies confirm the presence of a close relationship. MAIN BODY: We reviewed and analyzed the clinical studies that have considered the relationship between vitamin D and the GH/IGF-1 axis in pediatric populations. We found two main areas of interest: the vitamin D deficiency status in patients affected by GH deficit (GHD) and the relationship between serum vitamin D metabolites and IGF-1. Although limited by some bias, from the analysis of the studies presented in the scientific literature, it is possible to hypothesize a greater frequency of hypovitaminosis D in the subjects affected by GHD, a reduced possibility of its correction with only substitution treatment with recombinant growth hormone (rGH) and an improvement of IGF-1 levels after supplementation treatment with vitamin D. CONCLUSIONS: These results could be followed by preventive interventions aimed at reducing the vitamin D deficit in pediatric age. In addition, further research is needed to fully understand how vitamin D and growth are intertwined.

Right Diaphragmatic Peak Motion Velocities on Pulsed Wave Tissue Doppler Imaging in Neonates: Method, Reproducibility, and Reference Values.

OBJECTIVES: To test the reproducibility and report the reference ranges of the right diaphragmatic excursion's peak velocities recorded by pulsed wave tissue Doppler imaging in healthy term neonates. METHODS: We formerly assessed intraobserver and interobserver variability of the method for the right hemidiaphragm in a small group of neonates, including ventilated neonates. We did not attempt to test the approach for the left hemidiaphragm because of the recognized high failure rate of visualization. Next, we recorded the peak velocities of both hemidiaphragms throughout inspiration and expiration in 229 healthy term neonates near birth to establish weight-dependent reference ranges for the measurements. RESULTS: The study population included 116 male and 113 female neonates. The reproducibility of the technique was excellent even in neonates supported by ventilation. We always recorded the right diaphragmatic peak velocities in the normative study group, whereas the left ones were only recorded in 110 of 229 (48%) and 148 of 229 (65%) neonates from the anterior and lateral views, respectively. The modality of delivery and sex showed no influence on diaphragmatic kinetics. The mean inspiratory peak velocities ± SD were 1.4 ± 0.2 cm/s for the right hemidiaphragm and 1.5 ± 0.3 cm/s for the left hemidiaphragm. The mean expiratory peak velocities were 1.3 ± 0.2 cm/s for the right hemidiaphragm and 1.4 ± 0.3 cm/s for the left hemidiaphragm. CONCLUSIONS: Measurement of right diaphragmatic kinetics as assessed by pulsed wave tissue Doppler imaging was found to be a reliable technique. Its clinical applicability for the prompt diagnosis and effective management of neonatal respiratory failure deserves further investigation.

Strain in atomistic models of nanocrystalline clusters.

Strain, as an easy and clearly defined concept in continuum mechanics, has no direct counterpart in atomistic models. Existing methods, relying on the concept of atomic coordination number, do not provide a complete description of volumetric and deviatoric strains across metallic nanocrystalline microstructures. To overcome those limitations a new method is proposed: the Voronoi Cell deformation (VCD) fully accounts for the local geometry and provides a description of the strain field independent of the atomic coordination. As a typical case of study, a large atomic cluster of 200 Al grains (ca 2 million atoms) and overall size of 33 cubic nanometres was considered.

Efficient solution of particle shape functions for the analysis of powder total scattering data.

Structural characterization of powder samples via total scattering methods, in either real or reciprocal space, must take into account the effect of particle shape. Here, the shape contribution of a set of ideally isolated particles to the small-angle scattering (SAS) component of the intensity profile is modelled using the shape function [Svergun & Koch (2003). Rep. Prog. Phys. 66, 1735-1782]. The shape function is obtained by orientational averaging of common volume functions (CVFs) for a discrete set of directions. The effects of particle size and size dispersity are accounted for via scaling of the CVFs and their convolution with the underlying probability distribution. The method is applied to shapes with CVFs expressed analytically or by using discrete tables. The accurate calculation of SAS particle shape contributions up to large momentum transfer demonstrates the reliability and flexibility of modelling shape functions from sets of CVFs. The algorithm presented here is computationally efficient and can be directly incorporated into existing routines for analysis of powder total scattering data.

Quinary, Senary, and Septenary High Entropy Alloy Nanoparticle Catalysts from Core@Shell Nanoparticles and the Significance of Intraparticle Heterogeneity.

Colloidally prepared core@shell nanoparticles (NPs) were converted to monodisperse high entropy alloy (HEA) NPs by annealing, including quinary, senary, and septenary phases comprised of PdCuPtNi with Co, Ir, Rh, Fe, and/or Ru. Intraparticle heterogeneity, i.e., subdomains within individual NPs with different metal distributions, was observed for NPs containing Ir and Ru, with the phase stabilities of the HEAs studied by atomistic simulations. The quinary HEA NPs were found to be durable catalysts for the oxygen reduction reaction, with all but the PdCuPtNiIr NPs presenting better activities than commercial Pt. Density functional theory (DFT) calculations for PdCuPtNiCo and PdCuPtNiIr surfaces (the two extremes in performance) found agreement with experiment by weighting the adsorption energy contributions by the probabilities of each active site based on their DFT energies. This finding highlights how intraparticle heterogeneity, which we show is likely overlooked in many systems due to analytical limitations, can be leveraged toward efficient catalysis.

Prognostic Role of Lung Ultrasound in Children with Bronchiolitis: Multicentric Prospective Study.

There is increasing recognition of the role of lung ultrasound (LUS) to assess bronchiolitis severity in children. However, available studies are limited to small, single-center cohorts. We aimed to assess a qualitative and quantitative LUS protocol to evaluate the course of bronchiolitis at diagnosis and during follow-up. This is a prospective, multicenter study. Children with bronchiolitis were stratified according to clinical severity and underwent four LUS evaluations at set intervals. LUS was classified according to four models: (1) positive/negative; (2) main LUS pattern (normal/interstitial/consolidative/mixed) (3) LUS score; (4) LUS score with cutoff. Two hundred and thirty-three children were enrolled. The baseline LUS was significantly associated with bronchiolitis severity, using both the qualitative (positive/negative LUS p < 0.001; consolidated/normal LUS pattern or mixed/normal LUS p < 0.001) and quantitative models (cutoff score > 9 p < 0.001; LUS mean score p < 0.001). During follow-up, all LUS results according to all LUS models improved (p < 0.001). Better cut off value was declared at a value of >9 points. Conclusions: Our study supports the role of a comprehensive qualitative and quantitative LUS protocol for the identification of severe cases of bronchiolitis and provides data on the evolution of lung aeration during follow-up.

Whole pair distribution function modeling: the bridging of Bragg and Debye scattering theories.

Microstructure-based design of materials requires an atomic level understanding of the mechanisms underlying structure-dependent properties. Methods for analyzing either the traditional diffraction profile or the pair distribution function (PDF) differ in how the information is accessed and in the approximations usually applied. Any variation of structural and microstructural features over the whole sample affects the Bragg peaks as well as any diffuse scattering. Accuracy of characterization relies, therefore, on the reliability of the analysis methods. Methods based on Bragg's law investigate the diffraction peaks in the intensity plot as distinct pieces of information. This approach reaches a limitation when dealing with disorder scenarios that do not conform to such a peak-by-peak basis. Methods based on the Debye scattering equation (DSE) are, otherwise, well suited to evaluate the scattering from a disordered phase but the structure information is averaged over short-range distances usually accessed by experiments. Moreover, statistical reliability is usually sacrificed to recover some of the computing-efficiency loss compared with traditional line-profile-analysis methods. Here, models based on Bragg's law are used to facilitate the computation of a whole PDF and then model powder-scattering data via the DSE. Models based on Bragg's law allow the efficient solution of the dispersion of a crystal's properties in a powder sample with statistical reliability, and the PDF provides the flexibility of the DSE. The whole PDF is decomposed into the independent directional components, and the number of atom pairs separated by a given distance is statistically estimated using the common-volume functions. This approach overcomes the need for an atomistic model of the material sample and the computation of billions of pair distances. The results of this combined method are in agreement with the explicit solution of the DSE although the computing efficiency is comparable with that of methods based on Bragg's law. Most importantly, the method exploits the strengths and different sensitivities of the Bragg and Debye theories.

Effect of lattice mismatch and shell thickness on strain in core@shell nanocrystals.

Bimetallic nanocrystals with a core@shell architecture are versatile, multifunctional particles. The lattice mismatch between core and shell regions induces strain, affecting the electronic properties of the shell metal, which is important for applications in catalysis. Here, we analyze this strain in core@shell nanocubes as a function of lattice mismatch and shell thickness. Coupling geometric phase analysis from atomic resolution scanning transmission electron microscopy images with molecular dynamics simulations reveals lattice relaxation in the shell within only a few monolayers and an overexpansion in the axial direction. Interestingly, many works report core@shell metal nanocatalysts with optimum performance at greater shell thicknesses. Our findings suggest that not strain alone but secondary factors, such as structural defects or structural changes in operando, may account for observed enhancements in some strain-engineered nanocatalysts; e.g., Rh@Pt nanocubes for formic acid electrooxidation.

Imaging the kinetics of anisotropic dissolution of bimetallic core-shell nanocubes using graphene liquid cells.

Chemical design of multicomponent nanocrystals requires atomic-level understanding of reaction kinetics. Here, we apply single-particle imaging coupled with atomistic simulation to study reaction pathways and rates of Pd@Au and Cu@Au core-shell nanocubes undergoing oxidative dissolution. Quantitative analysis of etching kinetics using in situ transmission electron microscopy (TEM) imaging reveals that the dissolution mechanism changes from predominantly edge-selective to layer-by-layer removal of Au atoms as the reaction progresses. Dissolution of the Au shell slows down when both metals are exposed, which we attribute to galvanic corrosion protection. Morphological transformations are determined by intrinsic anisotropy due to coordination-number-dependent atom removal rates and extrinsic anisotropy induced by the graphene window. Our work demonstrates that bimetallic core-shell nanocrystals are excellent probes for the local physicochemical conditions inside TEM liquid cells. Furthermore, single-particle TEM imaging and atomistic simulation of reaction trajectories can inform future design strategies for compositionally and architecturally sophisticated nanocrystals.

Giant epidermoid cyst of the spleen in a pediatric patient: A case report.

RATIONALE: Splenic cysts (SCs) are rare findings in children, particularly the youngest. Here, we discuss a case that is useful for the differential diagnosis and treatment of SCs. PATIENT CONCERNS: A 9-year-old Albanian boy was admitted for severe abdominal pain localized mainly in the left hypochondrium for approximately 24 hours. His medical history was without significant clinical problems. DIAGNOSIS: Splenomegaly was diagnosed during the first clinical examination, and laboratory tests showed an increase in CA 125 and CA19-9. Abdominal ultrasonography showed splenomegaly with a large hypoechoic oval formation with well-defined margins and the presence of internal fine suspension spots; abdominal magnetic resonance imaging revealed a well-defined SC. The cystic lesion caused major effects on the neighboring organs, shifting them from their normal sites. INTERVENTIONS: Considering the mass's volume, an open splenectomy was performed. Upon histopathological examination, the lesion was characterized by a stratified squamous keratinized thick lining and brownish liquid contents consisting of lymphocytes, erythrocytes, and hemosiderin-rich macrophages. These features informed the diagnosis of a giant epidermoid SC. OUTCOMES: No complications occurred in the post-operative period, and blood exams revealed the quick normalization of CA 19.9 and CA 125 levels. The boy was discharged on the eighth post-operative day. No complaints were documented during the regular follow-up. LESSONS: This case shows that modern imaging techniques are useful for the differential diagnosis between epithelial mass and SCs of different origins. Open splenectomy has been the treatment of choice for years, but future studies should clarify whether more conservative methods are associated with positive long-term outcomes and if they can also be used for large SCs.

Different Clinical Presentations and Management in Complete Androgen Insensitivity Syndrome (CAIS).

Complete androgen insensitivity syndrome (CAIS) is an X-linked recessive genetic disorder resulting from maternally inherited or de novo mutations involving the androgen receptor gene, situated in the Xq11-q12 region. The diagnosis is based on the presence of female external genitalia in a 46, XY human individual, with normally developed but undescended testes and complete unresponsiveness of target tissues to androgens. Subsequently, pelvic ultrasound or magnetic resonance imaging (MRI) could be helpful in confirming the absence of Mullerian structures, revealing the presence of a blind-ending vagina and identifying testes. CAIS management still represents a unique challenge throughout childhood and adolescence, particularly regarding timing of gonadectomy, type of hormonal therapy, and psychological concerns. Indeed this condition is associated with an increased risk of testicular germ cell tumour (TGCT), although TGCT results less frequently than in other disorders of sex development (DSD). Furthermore, the majority of detected tumoral lesions are non-invasive and with a low probability of progression into aggressive forms. Therefore, histological, epidemiological, and prognostic features of testicular cancer in CAIS allow postponing of the gonadectomy until after pubertal age in order to guarantee the initial spontaneous pubertal development and avoid the necessity of hormonal replacement therapy (HRT) induction. However, HRT is necessary after gonadectomy in order to prevent symptoms of hypoestrogenism and to maintain secondary sexual features. This article presents differential clinical presentations and management in patients with CAIS to emphasize the continued importance of standardizing the clinical and surgical approach to this disorder.

Corticosteroids in Moderate-To-Severe Graves' Ophthalmopathy: Oral or Intravenous Therapy?

BACKGROUND: Ophthalmopathy is a rare extra-thyroid manifestation of Graves' disease, in paediatrics. Intravenous corticosteroids are the main treatment of moderate-to-severe Graves' orbitopathy. In this paper, we describe a moderate-to-severe active Graves' ophthalmopathy in a child and the response to oral therapy with prednisone. CASE PRESENTATION: A nine-year-old male child suffering for a few months, from palpitations, tremors, and paresthesia was hospitalized in our Pediatric Clinic. At admission, the thyroid function laboratory tests showed hyperthyroidism with elevated free thyroxine (FT4) and free triiodothyronine (FT3) levels and suppressed thyroid-stimulating hormone (TSH) levels. These findings, combined with the clinical conditions-an ophthalmologic evaluation (that showed the presence of exophthalmos without lagophthalmos and visual acuity deficiency), thyroid ultrasound, and TSH receptor antibody positivity-led to a diagnosis of Graves' disease. Therefore, methimazole was administered at a dose of 0.4 mg/kg/day. After 4 months, thyroid function was clearly improved, with normal FT3 and FT4 values and increasing TSH values, without adverse effects. Nevertheless, an eye examination showed ophthalmopathy with signs of activity, an increase in the exophthalmos of the right eye with palpebral retraction, soft tissue involvement (succulent and oedematous eyelids, caruncle and conjunctival hyperaemia and oedema) and keratopathy, resulting from exposure. We began steroid therapy with oral administration of prednisone (1 mg/kg/day) for four weeks, followed by gradual tapering. After one week of therapy with prednisone, an eye assessment showed reduced retraction of the upper eyelid of the right eye, improvement of right eye exophthalmometry and reduction of conjunctival hyperaemia. After four weeks of therapy with prednisone, an eye assessment showed reduction of the right palpebral retraction without conjunctival hyperaemia and no other signs of inflammation of the anterior segment; after twelve weeks, an eye assessment showed a notable decrease in the right palpebral retraction and the absence of keratitis, despite persisting moderate conjunctival hyperaemia. No adverse event associated with steroid use was observed during the treatment period and no problem in compliance was reported. CONCLUSION: Prednisone seems a better choice than intravenous corticosteroids, for treating moderate-to-severe and active Graves' ophthalmopathy, keeping in mind the importance of quality of life in pediatric patients.

Growth Hormone (GH) Therapy During the Transition Period: Should We Think About Early Retesting in Patients with Idiopathic and Isolated GH Deficiency?

To investigate growth hormone (GH) secretion at the transition age, retesting of all subjects who have undergone GH replacement therapy is recommended when linear growth and pubertal development are complete to distinguish between transitional and persistent GH deficiency (GHD). Early retesting of children with idiopathic and isolated GHD (i.e., before the achievement of final height and/or the adult pubertal stage) can avoid possible over-treatment. Here, we report data from our population with idiopathic and isolated GHD to encourage changes in the management and timing of retesting. We recruited 31 patients (19 males) with idiopathic GHD who received recombinant GH (rGH) for at least 2 years. All of the patients were retested at the transition age at least 3 months after rGH discontinuation. Permanent GHD was defined as a GH peak of <19 ng/mL after administration of growth hormone⁻releasing hormone (GHRH) + arginine as a provocative test. Permanent GHD was confirmed in only five of 31 patients (16.13%). None of these patients presented low serum insulin-like growth factor (IGF)-1 levels (<-2 standard deviation score (SDS)). Only one male patient with an IGF-1 serum level lower than -2 SDS showed a normal GH stimulation response, with a GH peak of 44.99 ng/mL. Few patients with idiopathic and isolated GHD demonstrated persistence of the deficit when retested at the transition age, suggesting that the timing of retesting should be anticipated to avoid overtreatment.

Achieving Highly Durable Random Alloy Nanocatalysts through Intermetallic Cores.

Pt catalysts are widely studied for the oxygen reduction reaction, but their cost and susceptibility to poisoning limit their use. A strategy to address both problems is to incorporate a second transition metal to form a bimetallic alloy; however, the durability of such catalysts can be hampered by leaching of non-noble metal components. Here, we show that random alloyed surfaces can be stabilized to achieve high durability by depositing the alloyed phase on top of intermetallic seeds using a model system with PdCu cores and PtCu shells. Specifically, random alloyed PtCu shells were deposited on PdCu seeds that were either the atomically random face-centered cubic phase (FCC A1, Fm3m) or the atomically ordered CsCl-like phase (B2, Pm3m). Precise control over crystallite size, particle shape, and composition allowed for comparison of these two core@shell PdCu@PtCu catalysts and the effects of the core phase on electrocatalytic durability. Indeed, the nanocatalyst with the intermetallic core saw only an 18% decrease in activity after stability testing (and minimal Cu leaching), whereas the nanocatalyst with the random alloy core saw a 58% decrease (and greater Cu leaching). The origin of this enhanced durability was probed by classical molecular dynamics simulations of model catalysts, with good agreement between model and experiment. Although many random alloy and intermetallic nanocatalysts have been evaluated, this study directly compares random alloy and intermetallic cores for electrocatalysis with the enhanced durability achieved with the intermetallic cores likely general to other core@shell nanocatalysts.

Particle Shape Control via Etching of Core@Shell Nanocrystals.

The application of nanocrystals as heterogeneous catalysts and plasmonic nanoparticles requires fine control of their shape and chemical composition. A promising idea to achieve synergistic effects is to combine two distinct chemical and/or physical functionalities in bimetallic core@shell nanocrystals. Although techniques for the synthesis of single-component nanocrystals with spherical or anisotropic shape are well-established, new methods are sought to tailor multicomponent nanocrystals. Here, we probe etching in a controlled redox environment as a synthesis technique for multicomponent nanocrystals. Our Monte Carlo computer simulations demonstrate the appearance of characteristic non-equilibrium intermediate microstructures that are further thermodynamically tested and analyzed with molecular dynamics. Convex platelet, concave polyhedron, pod, cage, and strutted-cage shapes are obtained at room temperature with fully coherent structure exposing crystallographic facets and chemical elements along distinct particle crystallographic directions. We observe that structural and dynamic properties are markedly modified compared to the untreated compact nanocrystal.

Hashimoto's Disease and Thyroid Cancer in Children: Are They Associated?

Hashimoto's thyroiditis (HT) is the most common cause of thyroid disease in children and adolescents. Along with significant modifications of thyroid function, HT in pediatric age can be accompanied by relevant thyroid structural alterations. Over time, benign thyroid nodules, carcinoma and, rarely, primary non-Hodgkin lymphoma can develop. However, the relationships between HT and neoplasms are poorly defined. The main aim of this paper is to discuss what is presently known regarding the coexistence of HT and thyroid tumors. Moreover, we attempt to define the pathogenesis of cancer development in children with HT. Literature analysis showed that despite its rarity and relatively promising prognosis, thyroid cancer is associated with HT. Although not all reasons for the coexistence of these diseases are clearly defined, children with HT should be considered at higher risk for thyroid cancer development. Strict correlations between high levels of serum TSH and anti-thyroid antibodies with cancer must be remembered. The same is true for the presence of nodules, especially if multiple nodules are present and ultrasonography and thyroid fine needle aspiration cytology should be promptly used in uncertain cases.

Up-To-Date Review About Minipuberty and Overview on Hypothalamic-Pituitary-Gonadal Axis Activation in Fetal and Neonatal Life.

Minipuberty consists of activation of the hypothalamic-pituitary-gonadal (HPG) axis during the neonatal period, resulting in high gonadotropin and sex steroid levels, and occurs mainly in the first 3-6 months of life in both sexes. The rise in the levels of these hormones allows for the maturation of the sexual organs. In boys, the peak testosterone level is associated with penile and testicular growth and the proliferation of gonadic cells. In girls, the oestradiol levels stimulate breast tissue, but exhibit considerable fluctuations that probably reflect the cycles of maturation and atrophy of the ovarian follicles. Minipuberty allows for the development of the genital organs and creates the basis for future fertility, but further studies are necessary to understand its exact role, especially in girls. Nevertheless, no scientific study has yet elucidated how the HPG axis turns itself off and remains dormant until puberty. Additional future studies may identify clinical implications of minipuberty in selected cohorts of patients, such as premature and small for gestational age infants. Finally, minipuberty provides a fundamental 6-month window of the possibility of making early diagnoses in patients with suspected sexual reproductive disorders to enable the prompt initiation of treatment rather than delaying treatment until pubertal failure.

Rhabdomyolysis in a Young Girl with Van Wyk-Grumbach Syndrome due to Severe Hashimoto Thyroiditis.

Background: Autoimmune hypothyroidism (Hashimoto thyroiditis; HT) is the most common postnatal thyroid disease. Clinical manifestations of HT vary according to disease severity. Due to the pleiotropic effects of thyroid hormone, less common signs and symptoms of HT can occur, leading to a delay in diagnosis. Case presentation: A 9-year-old girl of Indian origin was admitted for a one-week history of widespread myalgia, fatigue, muscle weakness, difficulty walking, and a significant increase in weight (approximately 2 kg) without any changes in daily habits. The only relevant medical history was several intermittent vaginal bleeding episodes since four years of age. Breast development was consistent with Tanner stage 2 without pubic or axillary hair; while height and weight were at the 10th percentile and the 38th percentile; respectively. Bone age from a left wrist X-ray was delayed 1 year. Pelvic ultrasonography revealed a uterine body/neck ratio of >1 (pubertal stage) and multifollicular ovaries. Her external genitalia had a childlike appearance. Laboratory examinations showed an increased thyroid-stimulating hormone, decreased free thyroxine, and positive anti-thyroglobulin antibody titres, as well as elevation of creatine phosphokinase, myoglobin, lactate dehydrogenase, serum aspartate aminotransferase, hypercholesterolemia, and a basal serum prolactin near the upper limit of normal. Follicle stimulating hormone and estradiol were slightly and significantly elevated, respectively. Thyroid ultrasound showed an increased gland size with irregular echostructures and high vascularization. Levothyroxine replacement therapy led to complete normalization of clinical and laboratory findings, including rhabdomyolysis indices. No further vaginal bleeding episodes were reported. Conclusion: This case report highlights how various can be the clinical picture of HT in children, and how rare clinical manifestations can be the only signs of disease at presentation leading to delayed diagnosis and treatment. In this girl, a never-described association of Van Wyk-Grumbach syndrome and acute rhabdomyolysis in a young girl with previously unrecognized HT is described. The importance of recognizing the signs and symptoms of rare complications of HT in order to begin appropriate therapy is stressed.