Use of nonautologous microencapsulated fibroblasts in growth hormone gene therapy to improve growth of midget swine

The aim of the present study was to investigate the expression activity, both in vitro and in vivo, of the porcine growth hormone complementary DNA (pGH cDNA) in porcine fetal fibroblast (PFF) cells. The pGH gene had been constructed inside the bicistronic retroviral vector PSN and subsequently transfected into PFF cells further encapsulated with immunoprotective microcapsules. This would provide a way to evaluate the improvement in growth performance of Tao-Yuan swine by the use of nonautologous microencapsulated fibroblasts carrying the pGH cDNA via the technique of somatic gene therapy. Results from Southern blot analysis confirmed that the full length of the pGH cDNA was completely integrated into the genome of the PFF cells after they had been infected one to four times using a PSN retroviral vector. Moreover, Northern blot analysis showed that high transcription activity was present in clones infected twice, and exogenous pGH secretion was found when the pGH-infected PFF had been further cultured for 48 hr in vitro and subjected to immunoblot assay. Encapsulation of the pGH-PFF with an alginate-poly-L-lysine-alginate membrane did not show any deterioration in their proliferation and survival both in vitro and in vivo. The pGH gene in encapsulated recombinant fibroblasts was fully expressed after it had been transplanted into the peritoneal cavity of the Tao-Yuan swine, and reverse transcription-polymerase chain reaction (RT-PCR) analysis was performed on the microcapsules retrieved 1 month later. The feasibility of pGH gene therapy to improve midget Tao-Yuan swine growth enhancement is further supported by the fact that transplantation of the encapsulated recombinant fibroblast cells resulted in a much more significant increase in weight gain than in those swine in either the age-matched untreated control group or in those that had been transplanted with uncapsulated recombinant PFF cells (10.56 +/- 1.01 kg versus 6.95 +/- 0.94 and 5.27 +/- 1.30 kg; p < 0.05). These experimental data suggest that growth hormone gene therapy did provide an alternative approach for growth improvement in midget Tao-Yuan swine.

Growth impairment and growth hormone therapy in children treated for malignant brain tumours

Eighty-two children with malignant brain tumours were treated according to the "8 in 1" chemotherapy protocol in Finland during 1986 to 1993. Thirty-seven with brain tumours not involving the hypothalamic-pituitary region are still alive and tumour-free. The growth and response to growth hormone (GH) therapy in these children was analysed. Children who received craniospinal irradiation had the most severe loss of height SDS, being -1.07 within 3 years of the diagnosis. Even children with no irradiation to the hypothalamic-pituitary axis had a mean change in height SDS of -0.5 after 3 years. Fifteen of 23 children who received craniospinal irradiation and two out of eight children who received cranial irradiation have received GH therapy. A catch-up growth response to the daily GH therapy with the mean dose of 0.7 IU/kg per week was complete in 3 years (+1.87 SDS), irrespective of craniospinal irradiation, in children who were treated at prepubertal age but was seen in none of the children who had reached pubertal age.

CONCLUSION

Growth impairment and GH deficiency are common in children treated for malignant brain tumours. The response to GH therapy is good in prepubertal children in terms of increased growth velocity, although the final height is not yet known.

Short- and long-term (final height) data in children with normal variant short stature treated with growth hormone

Seventeen children with normal variant short stature and a predicted height below -2 SDS were treated with growth hormone (GH) six times a week for a period of 5 years. Patients were randomly selected to receive three different doses of GH, group 1 (n = 6) 3 IU/m2 per day, group 2 (n = 6) 4.5 IU/m2 per day and group 3 (n=5) 3 IU/m2 per day in the 1st year and 4.5 IU/m2 per day thereafter. There was a significant increase in height after 1 and 2 years for all patients and for all subgroups. However, this increase was not dependent on GH dose. The decrease in height velocity during the 2nd year was not prevented by the increase of GH dose in group 3. The change of predicted height after 2 years was +0.75 SDS (according to Tanner Whitehouse). Fourteen children have been treated for 4 years and 8 children for 5 years without a further change in height prediction. Nine patients have reached final height which was 2.4 cm (+0.41 SDS) above pretreatment height prediction. Final height was nearly identical to predicted height after 1 year of therapy.

CONCLUSION

An increment in height prediction was observed during the first 2 years of GH treatment and maintained thereafter. However, there was only a minor increase in final height over predicted height which does not justify the general use of GH in children with normal variant short stature.

Phenotypic correction of dwarfism by constitutive expression of growth hormone

GH is normally secreted in a pulsatile fashion. When GH is deficient, dwarfism is the result in both rodents and humans. An adenoviral vector containing the rat GH complementary DNA was used to induce constitutive GH expression in hepatocytes of GH-deficient lit/lit mice. Elevated serum GH increased circulating insulin-like growth factor I concentrations, corrected the growth deficiency, and normalized body composition. The results indicate that correction of the dwarf phenotype can be achieved by constitutive expression of GH at an ectopic site by gene transfer.

[Growth hormone therapy in childhood. Growth hormone therapy in small children without growth hormone deficiency]

The availability of unlimited amounts of recombinant human growth hormone (rhGH) has now made it possible to investigate its growth-promoting effect in children in whom growth hormone production is not deficient. In girls suffering from the Ullrich Turner syndrome, treatment with rhGH increases final height by some 6 to 8 cm. An increase in growth rate has also been observed in children with renal insufficiency, and in children with intrauterine growth retardation. Favourable results have also been reported in children receiving glucocorticoids for such chronic conditions as rheumatoid arthritis, and in youngsters with hypochondroplasia. In a further group of children with various disorders an improvement in the growth rate has been observed, although nothing can yet be said about the outcome in terms of final height. To achieve an increase in growth rate, pharmacological doses of growth hormone higher than those used in children with growth hormone deficiency are necessary. For this reason, the risk of unwanted side effects might be higher than in the latter.

Bone marrow transplantation in cartilage-hair hypoplasia: correction of the immunodeficiency but not of the chondrodysplasia

We diagnosed cartilage-hair hypoplasia (CHH) in a female child with prenatal-onset short stature, metaphyseal chondrodysplasia, and severe combined immunodeficiency leading to recurrent, severe respiratory tract infections. The patient required several hospital admissions during her 1st year of life and failed to thrive in spite of antimicrobial therapy and hypercaloric nutrition. Bone marrow transplantation (BMT) from an HLA-identical sister was performed at age 16 months after conditioning with busulphan and cyclophosphamide, using 9 x 10(8) nucleated bone marrow cells/kg body weight. Graft-versus-host disease prophylaxis consisted of cyclosporine and methotrexate. The post-transplantation period was uneventful. She developed full and sustained chimerism as demonstrated by DNA analysis of granulocytes and mononucleated cells on days 44, 69 and 455 post BMT. Cellular immunity was completely reconstituted at 4 months, humoral immunity at 15 months post BMT. The patient is alive and well 24 months post BMT without medication, but the radiological osseous changes persist, and longitudinal growth remains markedly below the 10th percentile for CHH standards; her height at age 3 years 4 months is 66 cm.

CONCLUSION

In this patient with unusually severe CHH, bone-marrow transplantation has fully corrected the immune deficiency but has had no influence on the course of the chondrodysplasia.

Growth hormone treatment in Noonan syndrome

Growth responses to growth hormone (GH) treatment in Noonan syndrome are compared with those in short children with the other growth disorders. The responses in Noonan syndrome are much less than those in children with GH deficiency, a little less than those in children with non-endocrine short stature and almost the same as those in children with Turner syndrome. As it is speculated that GH induces puberty earlier that expected in Noonan Syndrome, the efficiency of GH treatment for final height in Noonan syndrome is not promising.

Psychological complications of short stature in childhood. Some implications of the role of visual comparisons in normal and pathological development

This study examines the effect of short stature on the emotional development of a subgroup of children who were treated in psychoanalysis and psychotherapy. These children became capable of making accurate comparisons of body size in early latency as a result of advances in cognitive development. Recognizing their comparative smallness left them feeling vulnerable and humiliated. They responded with envy and rage toward normally endowed children and vindictively used their intellect to outwit and defeat others. They acted as if their suffering exempted them from ordinary social rules and expectations. Their preoccupation also resulted in arrests in cognitive and social development. Their distrust and intention to deceive and defeat posed particular problems for treatment. This outcome suggests that visual comparisons of size during early latency are implicated in pathological, and therefore in normal, development. Parallels are suggested between the subjective experiences of children in this group and the experiences of children with other kinds of physical deviations and compromising life circumstances.

How short is too short?

A review of growth parameters should be a routine part of pediatric care. Children and parents need to be helped in understanding normal growth and development. Variations in growth should be explained, and concerns of parents and children openly discussed. Age appropriate educational materials are often helpful. Children with abnormal growth should be referred promptly for definitive diagnosis, selection of treatable candidates, and monitoring.

Cardiovascular effects of high-dose growth hormone treatment in growth hormone-deficient children

Growth hormone (GH) hypersecretion is associated with an increased incidence of cardiac hypertrophy and subclinical abnormalities of left ventricular (LV) function. The unlimited availability of biosynthetic GH has led to progressively increased dosage when treating GH-deficient children, raising the question of its cardiovascular effects during long-term therapy. We compared 22 children (8 girls, 14 boys), mean age 12.1 years (range 3-17 years) with GH deficiency who were receiving chronic GH treatment (GH group) with 22 normal controls matched for sex and body size in order to evaluate: (1) LV volume, mass, and systolic function by two-dimensional guided M-mode echocardiography; (2) LV diastolic function by pulsed-wave Doppler sampling of the transmitral flow; and (3) cardiac output and systemic vascular resistance by Doppler echocardiography. All patients had been on chronic GH therapy for 13.8 +/- 7.6 months (range 5-30 months) with an average dose of 0.95 +/- 0.12 IU/kg per week (range 0.69-1.17 IU/kg per week). Blood pressure did not differ between the two groups. LV volume, mass, ejection fraction, and mean velocity of circumferential shortening did not differ significantly between the GH group and controls; nor did the peak- and end-systolic meridional stress. All patients had a normal contractile state as estimated by the relation between mean velocity of circumferential shortening and end-systolic meridional stress. The LV filling parameters did not differ between the two groups, and there was no difference in cardiac index and systemic vascular resistance.(ABSTRACT TRUNCATED AT 250 WORDS)

Disproportionate growth following long-term growth hormone treatment in short children with X-linked hypophosphataemia

Three short prepubertal children with X-linked hypophosphataemia were treated with 1 IU recombinant human growth hormone (rhGH)/kg per week sc in addition to calcitriol and phosphate supplementation over a period of 3 years. Improvement of height standard deviation score (SDS) ranged from 1.0-1.7 SD based on an increase in sitting height of 1.5-2.9 SD, whereas subischial leg length improved only slightly by 0.3-0.9 SD. In all three patients, renal phosphate threshold concentration increased slightly and transient hyperparathyroidism was noted.

CONCLUSION

Treatment of stunted children with X-linked hypophosphataemia is effective in improving growth velocity, but appears to aggravate the pre-existent disproportionate stature of such children.

Growth hormone treatment of idiopathic short stature: analysis of the database from KIGS, the Kabi Pharmacia International Growth Study

Within the Kabi Pharmacia International Growth Study (KIGS) database, there is information on 1017 (700 male/317 female) patients with idiopathic short stature (ISS). These patients were started on recombinant human growth hormone (GH) at a median age of 10.8 years, a bone age of -1.8 SDS, a height of -2.6 SDS and a predicted adult height (PAH) (Bailey-Pinneau method) of -2.5 SDS. The median dose of GH was 0.6 IU/kg body weight/week and the frequency of injections was six/week. According to the relationship with target height the patients were classified into 'familial short stature (FSS)' (height SDS > target height SDS -1.28) and into 'non-FSS' (height SDS < target height SDS -1.28). During the first year of GH treatment there was an overall increment in the median height velocity from 4.4 to 7.4 cm/year. Over 3 years of GH treatment, cross-sectional analysis demonstrated an overall increment in median PAH of 1.2 SDS. There was a positive correlation between gain in PAH and the GH dose (n = 202, r = 0.18, p < 0.01) during the first year. Longitudinal analysis in 84 patients showed an overall increment of PAH of 0.7 SDS over 2 years of treatment. When applying the KIGS first-year prediction model for patients with idiopathic GH deficiency on cohorts of prepubertal children with FSS and non-FSS, a lower responsiveness to GH in the non-FSS group was observed. It is concluded that higher than substitutive doses of GH are required for the long-term improvement of growth in ISS.

Recent progress in immunoisolated cell therapy

Biohybrid implants represent a new class of medical device in which living cells, supported in a hydrogel matrix, and surrounded by a semipermiable membrane, produce and deliver therapeutic reagents to specific sites within a host. First proposed in the mid-1970s for diabetes, this treatment modality has progressed rapidly in the past four years and is now being investigated not just for endocrine disorders but also for alleviation of chronic pain, treatment of neurodegenerative disorders, and delivery of neurotrophic factors to sites within the blood brain barrier, and as a practical alternative to conventional ex vivo.

Reversibility of physiological growth hormone secretion in children with psychosocial dwarfism

OBJECTIVE

Reversibility of GH insufficiency with a change of environment is characteristic of psychosocial dwarfism, and excludes an organic endocrinopathy. However, the change in GH pulsatility has not previously been described. We therefore wished to study spontaneous GH secretion before and after change to a more favourable environment in 11 children with psychosocial deprivation and short stature in order to evaluate if separation from the families can modify their patterns of GH secretion.

PATIENTS AND DESIGN

We describe 11 prepubertal children (6 M and 5 F; 2.2-13.5 years of age) who had growth failure and psychosocial deprivation. They were diagnosed by a multidisciplinary team as having environmental growth failure after admission to hospital for 3 weeks. Six of them were discovered to have been sexually abused. During the uninterrupted hospital admission parental access was restricted. Three sets of 18-hour GH profiles were performed on each child, except one child who had only two, during the 3-week admission.

MEASUREMENTS

Pulse analysis of GH profiles was by Fourier transformation.

RESULTS

On the first day of admission spontaneous GH secretion demonstrated a spectrum of abnormalities in the pattern of basal values, pulse frequency and pulse amplitude. Such GH insufficiency showed reversibility during the 3 weeks in hospital. Indeed, there was a significant increase in GH secretion which was amplitude modulated without any significant modification in pulse frequency.

CONCLUSION

Our data indicate that there is abnormal physiological GH secretion in children with psychosocial deprivation, which is associated with growth failure. Despite a pathological situation, each child retained his own characteristic pattern of GH pulsatility. The pattern of reversibility of abnormal GH pulsatility provides information for the mechanism of the control of GH secretion.

Academic achievement and psychological adjustment in short children. The National Cooperative Growth Study

Limited information is available on the educational and behavioral functioning of short children. Through 27 participating medical centers, we administered a battery of psychologic tests to 166 children referred for growth hormone (GH) treatment (5 to 16 years) who were below the third percentile for height (mean height = -2.7 SD). The sample consisted of 86 children with isolated growth-hormone deficiency (GHD) and 80 children with idiopathic short stature (ISS). Despite average intelligence, absence of significant family dysfunction, and advantaged social background, a large number of children had academic underachievement. Both groups showed significant discrepancy (p < .01) between IQ and achievement scores in reading (6%), spelling (10%), and arithmetic (13%) and a higher-than-expected rate of behavior problems (GHD, 12%, p < .0001; ISS, 10%, p < .0001). Behavior problems included elevated rates of internalizing behavior (e.g., anxiety, somatic complaints) and externalizing behavior (e.g., impulsive, distractable, attention-seeking). Social competence was reduced in school-related activities for GHD patients (6%, p < .03). The high frequency of underachievement, behavior problems, and reduced social competency in these children suggests that short stature itself may predispose them to some of their difficulties. Alternately, parents of short, underachieving children may be more likely to seek help. In addition, some problems may be caused by factors related to specific diagnoses.

Modulation of insulin like growth factor I (IGF-I) binding sites on erythrocytes by IGF-I treatment in patients with Laron syndrome (LS)

The in vivo regulation of IGF-I binding sites was evaluated using erythrocytes (RBC) from 8 patients with Laron syndrome (LS), before and after IGF-I treatment (120-150 micrograms/kg/day s.c.). Basal fasting IGF-I averaged 20.48 +/- 2.06 nmol/l (mean +/- S.E.M.) in the control group as compared to 4.72 +/- 0.84 nmol/l in the 8 LS patients (P = 0.0001). After 1 week of IGF-I treatment serum IGF-I levels increased to 6.53 +/- 1.58 nmol/l (a mean difference of 1.81 +/- 0.95, P = 0.05) and after 1 month of treatment to 14.37 +/- 4.56 nmol/l (a mean difference of 9.37 +/- 4.42, P = 0.03). Concomitantly, we found a significant decrease in the number of high affinity IGF-I binding sites, from 5.74 +/- 0.86 sites/cell (mean +/- S.E.M.) in the non-treated state to 2.29 +/- 0.64 sites/cell and 2.17 +/- 0.53 sites/cell after 1 week and 1 month of treatment, respectively (a mean difference of -3.44 +/- 0.94, P = 0.004 and -3.58 +/- 0.79, P = 0.002, respectively), values similar to those found in the control group. These data demonstrate that replacement treatment of LS patients with IGF-I down regulates its specific receptors. We propose IGF-I binding to RBC as a test to determine the responsiveness of patients considered for long term IGF-I treatment.

The insulin-like growth factor-I/binding protein axis: physiology, pathophysiology and therapeutic manipulation

Insulin-like growth factor-I (IGF-I) is a single-chain polypeptide which has multiple metabolic actions and effects on the differentiation and proliferation of a wide variety of cell types. IGF-I has endocrine, paracrine and autocrine actions and is bound in the circulation to a complex system of binding proteins which alter its bioavailability and activity. Thus its physiology is complex and is altered in a number of pathological states. This review will discuss these states and the actual and proposed therapeutic applications of recombinant human IGF-I (rhIGF-I).

Diagnostic imaging update in skeletal dysplasias

The mystique of bone dysplasias is gradually vanishing. A short historical overview introduces the subject of short stature. The pathogenesis and controversial classification of skeletal dysplasias are discussed and summarized in two tables; the use of different imaging modalities is laid out along the sequential diagnostic approach and review of common orthopedic complications. References to such advances in treatment as bone marrow transplantation, bone lengthening, and the encouraging positive effect of growth hormone therapy complete this updated revision.

Antibody deficiency and isolated growth hormone deficiency in a girl with Mulibrey nanism

A combination of humoral immunodeficiency and isolated growth hormone deficiency was observed in a girl with Mulibrey nanism. The humoral immunodeficiency consisted of subnormal concentration of serum IgG, in particular IgG2 and IgG4, and low concentration of serum IgM. Serum IgA and IgD were elevated, IgE was absent. Antibody response in vivo was very low or absent and opsonization in vitro was defective. Total B-cell number was low. In addition, the serum kappa/lambda light chain ratios within the immunoglobulin classes G, A, and M were abnormal. The defective antibody response may be linked to the abnormal kappa/lambda light chain ratios. Endocrine functions were normal except for isolated growth hormone deficiency. Therapy with human growth hormone resulted in increased growth velocity but did not improve humoral immune functions.

[Growth retardation of psychosocial origin. Clinical and biological aspects in four cases]

Four cases of psychosocial dwarfism are reported. The growth follow-up of these four children does not fit to the classical description of rapid improvement once separated from their defective or careless family. This illustrates the difficulties for some children to adapt themselves to a foster family and the need to refer them to an institutional center in order to solve their different somatic, nutritional and psychological problems, together with those of their family. In such cases the important growth retardation and hormonal changes may hide severe psychopathological troubles such as hyperkinetic syndrome, anxiety and, possibly, depression.