ACTA ENDOCRINOLOGICA (BUC)

Objective. To monitor the iodine status in Romanian schoolchildren and neonates after 20 years of mandatory salt iodization. Subjects and methods. In a national representative sample of 1352 children (7-12 years) we measured median urinary iodine concentration (mUIC) and creatinine (UCC) in spot urine samples and investigated household use of iodized salt. From 18349 neonates registered in the MEDILOG program for TSH screening we calculated the percentage of neonatal TSH >5 mIU/L (<3% indicating adequate iodine intake). Results. mUIC in schoolchildren was 141 μg/L (bootstrapped 95% CI 134, 146), showing adequate iodine intake in all but 1 county; mUIC was similar in historical endemic and non-endemic counties (140 μg/L and 143 ug/L, respectively) and in urban and rural areas (140 μg/L and 142 μg/L, respectively); mUIC/UCC = 118 ug/g. Iodized salt was used in 62% of households. In children using iodized salt (61.7%), mUIC was higher than in those using coarse (non-iodized) salt (24.6%): 150 vs. 121 μg/L (p<0.001). The percentage of nTSH >5 mIU/L was 14.7% (3.2%-27.3%), higher in non-endemic counties and urban areas. Conclusion. The current salt iodization program for households and bakery industry ensures an adequate iodine intake in schoolchildren. Discordantly, nTSH levels indicate a mild-moderate ID in neonates, suggesting ID in pregnant women. The percentage of households using iodized salt is below the recommended >90% needed for an efficient ID prevention program. More efforts should be directed to increase the public awareness on the health risks of ID and the benefits of ID prevention, notably for the neurointellectual development in children.

OBJECTIVE: To report an unusual cause of respiratory failure in a 33-year old Caucasian woman, diagnosed at 26 years with pulmonary lymphangioleiomyomatosis (LAM) and treated with gonadoliberin analogs (aGnRH) four years.\r\nMETHODS: The respiratory failure was diagnosed on functional tests (spirometry, oxymetry, diffusing capacity of carbon monoxide). High resolution chest computed tomographic (HRCT) scan and open lung biopsy with specific immunohistochemistry certified the diagnosis.\r\nRESULTS: The diagnosis of pulmonary LAM was established after one year on chest HRCT and lung biopsy which revealed the proliferation of smooth muscle of pulmonary vessels, positive for actin, desmin, vimentin, estrogen- and progesterone- receptors. Spirometry revealed mixed obstructive and restrictive dysfunction. A correlation between worsening of dyspnea and estradiol peaks occurred during three gestation periods. Despite a short treatment with medroxyprogesterone 10 mg/day and tamoxifen (20 mg/day), the patient?s symptoms and pulmonary function tests worsened. aGnRH treatment improved both symptoms and pulmonary function tests during the first year and was associated with a slow decline in pulmonary function tests and stabilization of the cystic lesions during the following 3 years. The patient did not develop LAM-complications such as: pneumothorax, chylothorax, or hemoptysis.\r\nCONCLUSION: Treatment with aGnRH is effective in slowing the evolution of pulmonary LAM.

Phenylketonuria (PKU) is the most frequent inherited amino acid metabolic disorder, and it may also be treated by dietary means. The determination of phenylalanine (Phe) levels in the blood plasma is important not only in early diagnostic, but also in monitoring the treatment of PKU. Purpose. The aim of our work was to develop a simple, sensitive and highly accurate procedure to determine the plasma concentration of Phe. Procedure. The measurement of plasma Phe concentration involves two steps: a) separation of plasma (from the blood taken on heparin), isolation and preparation of a concentrated solution of amino acids (by ion-exchange column chromatography on Dowex-50X8 and evaporation of the eluate in vacuum at 40˚C), and b) determination of Phe concentration in the solution of amino acids by HPLC. This analysis was performed using a Dionex Ultimate 3000 instrument equipped with a Ultimate 3000 diode array detector (DAD). The values of Phe concentration in the plasma of several patients were calculated using a calibration curve made with standards of Phe (dilutions of a stock solution of 50 mg/ dL). The measurements in duplicate (plasma Phe) or a greater number of samples from the same concentration of standards of Phe showed extremely small sample to sample differences. Concentrations as low as 0.2 mg/dL could be determined. Conclusion. The whole procedure presented here is relatively simple, rather inexpensive, however very sensitive and highly accurate. Consequently, it is very adequate for confirming the diagnosis of PKU in patients with neonatal hyperphenylalaninemia, as well as for monitoring the plasma concentration of Phe in patients with PKU.

Objective. To compare two chromatographic methodologies for determination of plasma phenylalanine (Phe) and their usefulness for diagnosing hyperphenylalaninemia (HPA) and phenylketonuria (PKU). Methods. The plasma amino acids were isolated and concentrated from blood collected from infants with HPA detected by newborn screening. The plasma Phe was determined in parallel by HPLC and by image-densitometry of 2D-TLC plates. Results. Typical examples of 2D-TLC plates and HPLC chromatograms from infants with HPA and PKU are presented and evaluated. The Phe spot was visible on 2D - TLC plates at Phe concentrations higher than 300 μmol/L. The standard calibration curve traced after imagedensitometry of the Phe spot presented high dispersion of values at each concentration of Phe, high SD values, the equation of the curve having a low R-squared value (0.862). In contrast, the standard calibration curve obtained by HPLC shows linearity on the range of concentrations from 100 - 16,000 μmol/L, extremely small SD values, the equation of the curve has a very high R-squared value (0.999). Conclusions. The HPLC methodology is appropriate to confirm HPA detected by newborn or selective screening of PKU. The 2D - TLC methodology is adequate to detect patients with severe PKU.

Objective. Congenital hypothyroidism (CH) is one of the common preventable causes of intellectual disability in neonates, by early detection through neonatal screening. We present the 8-year experience of the National Institute for Mother and Child Health (INSMC) in using MEDILOG national registry for the neonatal screening of CH. Methods. Neonatal screening for CH, done by TSH measurement in dried blood spot, is organized in 5 regional centers, each with a reference laboratory. Results. In 2018 80% of all the newborns, from 80% of the maternity hospitals, were registered in MEDILOG. After re-testing of TSH and T4/FT4 from venous blood in positive cases, the incidence of confirmed CH in 2018 was 1/3576 - 1/ 4746. In INSMC center (which includes 26 counties and Bucharest, out of 41 counties), in 2018 the incidence of positive CH cases at screening was 1/2094 (TSH cut-off ≥17 mIU/L) and of confirmed CH cases 1/3576 newborns. For positive screening cases, the median duration from birth to the INSMC laboratory result was 19 days: median of 9 days between screening and laboratory registration and 6 days between registration and test result. Conclusion. MEDILOG registry is a practical instrument for monitoring the steps of neonatal CH screening, the incidence of CH, the evolution of the diagnosed cases, for evaluation of iodine deficiency (by neonatal TSH), and also for research, with the aim of improving early disease detection and treatment.

Context. Patients with diabetes mellitus have high-risk of coronary artery disease that is often silent. NT-proBNP is a\r\nneurohormone that in recent studies proved useful in detecting ischemic heart disease.\r\nThe objective was to evaluate whether NT-proBNP can detect silent myocardial ischemia and can predict cardiovascular outcome and mortality in asymptomatic patients with type 2 diabetes.\r\nMethods. This study was conducted on 250 patients with type 2 diabetes mellitus without known coronary heart disease and heart failure. All patients were evaluated at baseline and were followed-up prospectively for 3 years for major cardiac events. Exercise ECG and Holter ECG were performed for silent ischemia detection. NT-proBNP was determined on a ROCHE cardiac reader.\r\nResults. NT-pro BNP was significantly raised in patients with silent ischemia (p<0.0001) and remained independent and the strongest predictor of silent ischemia in multiple regression analysis (p<0.0001). NTproBNP levels in patients who experienced major cardiac events were significantly higher (p<0.0001). In multiple regression analysis only silent ischemia (p<0.0001, r=0.20) and NT-proBNP (p<0.0001, r=0.67) remained independent predictors for major cardiac events.\r\nConclusions. NT-proBNP can be useful in screening for silent ischemia in asymptomatic type 2 diabetic patients and also is a strong predictor for major cardiac events.

Context. The role of cortisol in modulating the inflammatory response upon an immune challenge is well documented. Objectives. We aim to assess cortisol levels related to inflammatory status in children with persistent fever and low respiratory tract infection (LRTI). Patients and methods. Thirty five children hospitalised with fever above 38oC for more than 10 days and clinical features of LRTI were enrolled. Immunoglobulins, C-reactive protein (CRP) and cortisol were measured at the admission and after 12 days. Results. From 35 patients, 29 had a satisfactory evolution and 7 had a complicated course of disease. In patients with a satisfactory outcome, the mean value of cortisol at the admission was at the upper limit of the reference range, CRP and immunoglobulin G (IgG) are significantly higher versus reference limit (p<0.05). Children with a severe evolution had a significantly lower cortisol level than those with good evolution, at the lower limit of reference range (p<0.001), and correlated with low levels of CRP and immunoglobulins; cortisol and CRP showed a slight increase after 12 days corresponding with a prolonged course of disease.Conclusions. Cortisol measurement might aid value in early identification of patients requiring initiation of antibiotherapy, corticotherapy or other intensive management strategies.

Introduction. The determination of phenylalanine (Phe) and tyrosine (Tyr) levels in blood plasma is very important not only in early diagnostic, but also in monitoring the treatment of phenylketonuria (PKU). Purpose. We present a simple, sensitive and accurate procedure to determine simultaneously the plasma concentrations of Phe and Tyr. Procedure. The measurement involves two steps: a) separation of plasma (from blood prelevated on heparin), isolation and preparation of a concentrated solution of amino acids (by ion-exchange column chromatography on Dowex- 50X8), and b) determination of Phe and Tyr concentrations in the solution of amino acids by HPLC (using a Dionex Ultimate 3000 instrument equipped with a diode array detector). The analytical column was a Thermo Scientific Acclaim 120, C18, 5 μm Analitic (4.6 x 250 mm), coupled with an Acclaim C18 guard column. The values of Phe and Tyr concentrations in plasma of several patients were calculated using a calibration curve made with standards of Phe (1834.4 μmol/L in deionized water) and Tyr (600 μmol/L in deionized water). Concentrations as low as 24 μmol/dL of Phe and 15 μmol/dL of Tyr could be determined. Conclusion. The whole procedure presented here is relatively simple, rather inexpensive, however very sensitive and accurate. Consequently, it is very adequate for confirming the diagnosis of PKU in patients with neonatal hyperphenylalaninemia, as well as for monitoring the plasma concentrations of Phe and Tyr in patients with PKU.

Background. The modern management of phenylketonuria (PKU) consists of generalized newborn screening (NBS) for hyperphenylalaninemia (HPA), confirmation of HPA in children detected in the NBS, introduction of dietary treatment in the first weeks of life, followed by monitoring the treatment of PKU for decades to maintain phenylalaninemia within the limits that will not affect the brain. The present study aimed to evaluate the usefulness of two chromatographic methodologies for determination of plasma Phe level in the routine management of PKU: the two dimensional thin layer chromatography (2D - TLC) and the high performance liquid chromatography (HPLC) procedures, respectively. Material and Methods. Samples of blood from 23 children with HPA detected by neonatal screening or with confirmed PKU who received treatment by low-Phe diet were analyzed to estimate the plasma Phe level by the two chromatographic procedures. Results. In case of three subjects the very low concentrations of plasma Phe could not be detected by the 2D - TLC methodology, since the spot was not visible on the chromatogram. In four patients the differences between the values of plasma Phe determined by the two methodologies are not statistically significant, while in fifteen subjects the differences are highly statistically significant. This is due to the greater errors that appear in the case of 2D - TLC methodology. In the range of concentrations of plasma Phe higher than 360 μmol/L (which is the cut-off value for HPA), although in four cases there were statistically significant differences in the level of plasma Phe determined by the two methodologies, the value obtained by the 2D - TLC methodology was high enough to influence the decision of changing the diet so that HPA is kept under control. In addition, the intense spot of Phe on the 2D - TLC chromatogram may be detected even by un unexperienced laboratory specialist. Conclusion. The HPLC procedure for measurement of plasma Phe level is very suitable to be used in the routine management of PKU. The 2D - TLC procedure may be accompanied by relatively high errors; however, it detects patients with severe PKU.