Central precocious puberty. An overview of diagnosis, treatment, and outcome

Central precocious puberty (CPP) is physiologically normal puberty beginning early. It is the consequence of early increased regulation of gonadotropin releasing hormone (GnRH) stimulation of pituitary gonadotropin release causing pubertal changes and accelerated growth. GnRH stimulation testing is the definitive diagnostic test--pubertal gonadotropin responses being indicative of CPP. Among patients with progressive CPP, GnRH analogue therapy is effective by decreased regulation of gonadotropin secretion. Pubertal progression is stopped, and accelerated growth rate and compromised adult height are precluded or alleviated. Outcome data have not identified unusual sequelae.

Leptin concentrations in precocious puberty or untimely puberty with and without GnRH analogue therapy

Nutritional status and body composition influence the development and maintenance of reproductive competence in mammals. It has been suggested that leptin concentrations communicate nutritional status to the neuroendocrine reproductive axis. To determine the interrelationship between circulating gonadotropin and leptin concentrations, leptin concentrations were measured in 39 children treated for GnRH dependent precocious or untimely puberty. Leptin concentrations were obtained during pubertal suppression with GnRH analogue therapy and during spontaneous pubertal gonadotropin secretion. The status of gonadotropin secretion (suppressed vs not suppressed) was verified by simultaneous GnRH stimulation tests and sex steroid concentrations. Leptin concentrations were similar at both time-points and correlated only with body mass index. Thus, no relationship was apparent between circulating concentrations of gonadotropins, sex steroids, and leptin.

Age at unilateral orchiopexy: effect on hormone levels and sperm count in adulthood

PURPOSE

We determined whether there are differences in hormone levels, such as inhibin B, follicle-stimulating hormone (FSH), luteinizing hormone and testosterone, and sperm density in men with a history of unilateral cryptorchidism as stratified by age at orchiopexy.

MATERIALS AND METHODS

A total of 84 men with a history of unilateral cryptorchidism presented to our institution for serum hormone measurement and semen analysis. These parameters were compared using Pearson's correlations and analysis of variance among 4 groups stratified according to age at orchiopexy (range 1 month to 11 years).

RESULTS

Comparison by Pearson's correlation analysis showed that age at orchiopexy significantly correlated inversely with inhibin B (r = -0.274, p = 0.012) and positively correlated with FSH (r = 0.229, p = 0.036). Comparison of mean hormone levels and sperm density by analysis of variance for linear trend revealed a significant relationship between age at surgery with inhibin B (p = 0.032) and testosterone (p = 0.029), while sperm density, FSH and luteinizing hormone were not significantly related. Post hoc comparison of individual means at surgery and at the time of this study demonstrated a significantly higher inhibin B level in the youngest age group than in 2 of the 3 older groups.

CONCLUSIONS

Men who previously had unilateral cryptorchidism and who underwent orchiopexy by age 2 years have higher inhibin B and lower FSH profiles than those who underwent surgery later in life. This finding suggests an overall beneficial effect of early orchiopexy in boys born with unilateral cryptorchidism.

Age at unilateral orchiopexy: effect on hormone levels and sperm count in adulthood

PURPOSE

We determined whether there are differences in hormone levels, such as inhibin B, follicle-stimulating hormone (FSH), luteinizing hormone and testosterone, and sperm density in men with a history of unilateral cryptorchidism as stratified by age at orchiopexy.

MATERIALS AND METHODS

A total of 84 men with a history of unilateral cryptorchidism presented to our institution for serum hormone measurement and semen analysis. These parameters were compared using Pearson's correlations and analysis of variance among 4 groups stratified according to age at orchiopexy (range 1 month to 11 years).

RESULTS

Comparison by Pearson's correlation analysis showed that age at orchiopexy significantly correlated inversely with inhibin B (r = -0.274, p = 0.012) and positively correlated with FSH (r = 0.229, p = 0.036). Comparison of mean hormone levels and sperm density by analysis of variance for linear trend revealed a significant relationship between age at surgery with inhibin B (p = 0.032) and testosterone (p = 0.029), while sperm density, FSH and luteinizing hormone were not significantly related. Post hoc comparison of individual means at surgery and at the time of this study demonstrated a significantly higher inhibin B level in the youngest age group than in 2 of the 3 older groups.

CONCLUSIONS

Men who previously had unilateral cryptorchidism and who underwent orchiopexy by age 2 years have higher inhibin B and lower FSH profiles than those who underwent surgery later in life. This finding suggests an overall beneficial effect of early orchiopexy in boys born with unilateral cryptorchidism.

Internal and temporal reliability estimates for informant ratings of personality using the NEO PI-R and IAS. NEO Personality Inventory. Interpersonal Adjective Scales

This study examines the internal consistency and temporal stability of informant ratings from two widely used instruments for normal personality assessment, the revised NEO Personality Inventory (NEO PI-R) and the Interpersonal Adjective Scales (IAS). Well-known adult targets were selected by 109 undergraduate students and rated on two occasions separated by a 6-month interval. With few exceptions, estimates of internal consistency are adequate to good for both instruments. NEO PI-R domain scores yield coefficient alphas ranging from .89 to .96, with a median of .80 for the 30 facet scales. IAS octant scales show coefficient alphas ranging from .83 to .92. Retest Pearson correlations are above .70 for each of the NEO PI-R domain scores and both IAS axis coordinates, and intraclass correlations are above .60 for all scales from both instruments. Score changes were small but statistically significant for three of the five NEO PI-R domains at retest. The retest stability of IAS type classifications varies as a function of the extremity of the associated octant scores.

Secretory leukocyte protease inhibitor prevents allergen-induced pulmonary responses in animal models of asthma

Secretory leukocyte protease inhibitor (SLPI) is a naturally occurring protein of human airways that exhibits broad spectrum inhibitory activity against mast cell and leukocyte serine proteases implicated in asthma pathology. To assess the potential therapeutic utility of SLPI in this disorder, its effects on antigen-induced pulmonary responses were evaluated. In Ascaris-sensitized sheep, SLPI (3 mg) administered by aerosol daily for 4 days, with the final dose 0.5 h before antigen challenge, reduced the areas under the curve for early- and late-phase bronchoconstriction (73 and 95%, respectively; p <.05 versus control responses). SLPI also inhibited the development of airway hyperresponsiveness to carbachol (84%, p <. 05 versus control response) measured 24 h after antigen challenge. In ovalbumin-sensitized guinea pigs, intratracheal administration of SLPI daily for 3 days, with the final dose 1 h before antigen challenge, inhibited the development of airway hyperresponsiveness to histamine with an ED50 of <0.05 mg/kg. Prolonged pharmacodynamic activity of SLPI was observed in both species. In a murine model of atopic asthma, SLPI inhibited leukocyte influx into the airways after chronic allergen challenge. SLPI administered to sheep by the predosing protocol described above also prevented the antigen-induced decrease of tracheal mucus velocity (p <.05). In addition, a single aerosol administration of SLPI (30 mg) to sheep 1 h after antigen challenge inhibited the subsequent late-phase bronchoconstriction and development of hyperresponsiveness and reversed the stimulated decrease in tracheal mucus velocity. These results suggest that SLPI may provide therapeutic intervention against the pathophysiology of asthma and its underlying pathology.

The development of ethnic identity in Asian-American adolescents: status and outcome

Ethnic identity status and outcome were assessed in a heterogeneous group of 342 Asian-American adolescents. Developmental progression in both ethnic identity status (from foreclosure to moratorium to achievement) and ethnic identity outcome (from unidimensional separation to bidimensional integration) was found, as was an association between ethnic identity status and outcome. Implications of the findings are discussed.

Absence of microdeletions in the Y chromosome in patients with a history of cryptorchidism and azoospermia or oligospermia

OBJECTIVE

To determine if cryptorchidism is associated with microdeletions of interval 6 of the Y chromosome, we evaluated this locus in men with a history of cryptorchidism with and without azoospermia or oligospermia and in a control group.

DESIGN

Clinical study.

SETTING

Academic research environment.

PATIENT(S)

Men in whom surgical treatment of cryptorchidism had been performed in childhood and healthy control male subjects.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Genotyping of interval 6 of the Y chromosome.

RESULT(S)

Analysis of semen obtained from men treated for cryptorchidism in childhood showed azoospermia or oligospermia in 14 of 38 (37%) men. No microdeletions were identified with polymerase chain reaction amplification of 17 distinct sequence tagged sites located on the long arm of the Y chromosome and the sex determining region on Y (SRY) gene.

CONCLUSION(S)

Microdeletions of interval 6 of the Y chromosome were not detected in either the formerly cryptorchid or in the healthy subjects. Although we cannot exclude the possibility of point mutations, we conclude that cryptorchidism or cryptorchidism associated with azoospermia or oligospermia is not due to microdeletions involving interval 6 of the Y chromosome.

Allergic contact dermatitis due to para-tertiary-butylcatechol in a resin operator

Para-tertiary-butylcatechol (PTBC) is a rare but potent contact allergen. This is a report of occupational allergic contact dermatitis to PTBC in a resin operator.

Testicular suture: a significant risk factor for infertility among formerly cryptorchid men

BACKGROUND/PURPOSE

Although fertility is decreased after cryptorchidism, the importance of risk factors, including parenchymal testicular suture, is unknown. The aim of this study was to examine the relationship between parenchymal testicular suture and failure to conceive a child for 1 year or longer among formerly cryptorchid men.

METHODS

Men who underwent orchidopexy between 1955 and 1972 at the Children's Hospital of Pittsburgh (n = 619) were surveyed by questionnaire and their medical records reviewed. Only the men who attempted to conceive a child (n = 387) are included.

RESULTS

Logistic regression analysis determined significant risk factors for infertility. Testicular suture was strongly related to infertility (RR, 7.56; 95% CI, 1.66, 34.39) as were bilateral cryptorchidism (RR, 5.51; 95% CI, 1.58, 19.24), varicocele (RR, 4.72; 95% CI, 1.42, 15.75), hormone treatment before surgery (RR, 3.69; 95% CI, 1.22, 11.11), and partner conception problem (RR, 3.32; 95% CI, 1.11, 9.90).

CONCLUSIONS

Testicular suture was a potent independent determinant of infertility among formerly cryptorchid men who have orchidopexy. Bilateral cryptorchidism, hormone treatment, varicocele, and partner conception problems also were associated with increased infertility.

How accurate is male recall of reproductive information?

The purpose of this study was to determine how well men recall reproductive information. By using a questionnaire, the authors surveyed men who had undergone orchiopexy for undescended testes and a group of matched control men, all of whom had had surgery at the Children's Hospital of Pittsburgh in Pittsburgh, Pennsylvania (n = 77), and their spouses. Subjects were a random subset of a larger (n = 1,212) male fertility study, which has been ongoing since 1992. In 1994, the spouses of men who participated in the study completed a short telephone survey that contained questions previously asked of their partners. Pearson correlations and kappa statistics were calculated to evaluate the accuracy of male recall of reproductive information. For the continuous measures, such as time to conception and frequency of intercourse, the correlations were high to moderate (r = 0.84 (p < 0.001) and r = 0.45 (p < 0.001), respectively). Agreement between the men and their spouses on the majority of bivariate (yes/no) questions, such as those concerning the use of birth control, as measured by the kappa statistic, was moderate to very good (K ranged from 0.14 to 0.69). Statistics were similar for formerly cryptorchid and control men. Male participants' responses to questions about their reproductive histories were accurate as compared with the responses given by their spouses. In this sample from a large cohort study, men appeared to recall reproductive information with acceptable accuracy.

Correlations among hormone levels, sperm parameters and paternity in formerly unilaterally cryptorchid men

PURPOSE

We compared characteristics related to fertility between formerly unilaterally cryptorchid men.

MATERIALS AND METHODS

We compared sperm counts and gonadotropin levels before and after gonadotropin-releasing hormone stimulation between formerly unilaterally cryptorchid men and controls who had completed a detailed questionnaire on fertility and other pertinent paternity information. These parameters were also compared between the subsets of formerly cryptorchid men who reported paternity and unsuccessful attempts at paternity.

RESULTS

Sperm density and total count, and basal and gonadotropin-releasing hormone stimulated follicle-stimulating hormone (FSH) levels were different in the cryptorchidism and control groups. Higher FSH levels and lower sperm counts correlated inversely in the cryptorchidism group, while luteinizing hormone, testosterone and other results of semen analysis did not differ. Furthermore, FSH levels were higher and sperm counts were lower in the subset who reported unsuccessful attempts at paternity compared with those reporting paternity. Other measured parameters did not differ between these groups.

CONCLUSIONS

FSH levels are significantly higher and sperm counts are significantly lower in formerly cryptorchid men than in controls. In the cryptorchidism group the same differences are found in fertile and infertile men. Thus, elevated FSH and low sperm counts may be considered risks for infertility in formerly cryptorchid men.

17 alpha-hydroxylase/17,20-lyase dysregulation is not caused by mutations in the coding regions of CYP17

STUDY OBJECTIVE

To determine whether mutations occur in the 17 alpha-hydroxylase/17,20-lyase (CYP17) gene in patients with mild hyperandrogenism.

DESIGN

Clinical and molecular genetic study.

SETTING

Pediatric endocrine outpatient clinic in an academic research environment.

PARTICIPANTS

Girls (n = 11) referred for evaluation of premature pubic hair and adolescent girls (n = 16) referred for evaluation of hirsutism and/or oligomenorrhea.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Mutation detection analysis of the coding regions and intron/exon boundary regions of the CYP17 gene.

RESULTS

Two polymorphic nucleotides were identified in the CYP17 gene. No mutations were detected in the 27 subjects.

CONCLUSIONS

Mutation detection studies presented herein exclude CYP17 as a candidate gene for premature pubic hair and adolescent hyperandrogenism.

Variants of the type II 3beta-hydroxysteroid dehydrogenase gene in children with premature pubic hair and hyperandrogenic adolescents

To ascertain the potential role of heterozygosity for 3beta-hydroxysteroid (3beta-HSD) deficiency in children with premature pubic hair and adolescent girls with hyperandrogenism, we performed single-strand conformational polymorphism (SSCP) analysis of the 3beta-hydroxysteroid dehydrogenase type 2 (3beta-HSD2) gene in 34 hyperandrogenic patients. Three sequence variants, two missense mutations and a 3'-UTR sequence variant, were detected among seven patients and in none of 100 healthy control subjects. One of these seven patients carried Leu236 --> Ser on one 3beta-HSD2 allele and Glu318 --> STOP on one 21-hydroxylase (CYP21) allele. ACTH stimulation tests were performed in 5/7 patients with sequence variants and were compatible with decreased 3beta-hydroxysteroid dehydrogenase activity in three. Thus, 7 of 34 (20.6%) mildly hyperandrogenic patients carry heterozygous sequence variants of the 3beta-HSD2 gene. Since obligate heterozygotic carriers for congenital adrenal hyperplasia are typically asymptomatic, other genetic or environmental influences may contribute to the expression of hyperandrogenic symptoms in our patients.

Human chorionic gonadotropin stimulation to assess for ovarian hyperandrogenism

STUDY OBJECTIVE

To determine whether human chorionic gonadotropin (hCG) stimulation elicits an exaggerated 17-hydroxyprogesterone (17-OHP) response in patients with functional ovarian hyperandrogenism.

METHODS

In this clinical study, healthy volunteers and hyperandrogenic patients in an outpatient General Clinical Research Center (GCRC) setting were studied. Five adolescent girls with functional ovarian hyperandrogenism were studied. Six healthy women with regular menstrual cycles volunteered for this study. Steroid hormone responses to hCG stimulation were measured before and 30, 240, and 300 minutes after hCG injection. Congenital adrenal hyperplasia was excluded through ACTH stimulation testing and molecular genetic analysis.

MAIN OUTCOME MEASURE

17-OHP responses.

RESULTS

Mean basal 17-OHP concentrations were greater in the hyperandrogenic patients, 110.4+/-41.2 ng/dL versus 61.8+/-28.6 ng/dL. After hCG stimulation, 17-hydroxyprogesterone concentrations significantly increased in the patients and were unchanged in the healthy controls.

CONCLUSION

hCG stimulation elicited greater 17-hydroxyprogesterone responses in adolescent girls with functional ovarian hyperandrogenism compared with healthy controls. hCG stimulation may be helpful to confirm ovarian hyperandrogenism.

Effects of filter pore size on efficacy of continuous arteriovenous hemofiltration therapy for Staphylococcus aureus-induced septicemia in immature swine

OBJECTIVE

To evaluate the effect of hemofilter pore size on the efficacy of continuous arteriovenous hemofiltration (CAVH) in improving morbidity and mortality in an immature swine model of Staphylococcus aureus-induced septicemia.

DESIGN

Prospective, randomized study with age-matched controls.

SETTING

Biomedical research facility.

SUBJECTS

Fourteen 4 to 8-wk-old, weaned Poland-China swine, weighing 5 to 10 kg.

INTERVENTIONS

Spontaneously breathing, ketamine-sedated swine (4 to 8 wks of age) were given an intravenous lethal dose of live S. aureus. Animals were then filtered with either a 50-kilodalton (kD) pore size filter (control) or a 100-kD pore size filter (experimental). No animals received antibiotics.

MEASUREMENTS AND MAIN RESULTS

Physiologic, biochemical, and hematologic parameters were measured in all animals every 1 to 3 hrs. Animals were monitored continuously and survival time (hr) was recorded (permanent survival = 168 hrs/7 days). Animals filtered with the 100-kD filter survived significantly longer than control animals (103 +/- 18 [SEM] vs. 56 +/- 9 hrs). The 100-kD-filtered group had one permanent survivor (168 hrs). Protein concentration of the ultrafiltrate obtained from the 100-kD-filtered animals was eight-fold higher than control ultrafiltrate. The protein removed did not contain a high percentage of albumin (as determined by autoanalyzer methods). No significant differences were seen in any of the other measured parameters.

CONCLUSIONS

CAVH significantly improved survival in swine with S. aureus-induced sepsis. The superior performance of the 100-kD filter vs. the 50-kD filter suggests that higher molecular weight mediators that are not removed efficiently by the 50-kD filter may be responsible for the morbidity and mortality seen in this model of sepsis. These mediators may be removed in greater proportion by our customized (100-kD pore size) filter.

Identification of heterozygotic carriers of 21-hydroxylase deficiency: sensitivity of ACTH stimulation tests

Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is a common autosomal-recessive disorder. To ascertain carrier status, adrenocorticotropin (ACTH) stimulation tests are often used. To determine the sensitivity of ACTH stimulation to detect heterozygotes and to correlate stimulated 17-hydroxyprogesterone responses with molecular genotype, we compared molecular genetic analysis of the 21-hydroxylase (CYP21) gene with 17-hydroxyprogesterone responses at 30 min in 51 individuals. Molecular genotype analysis and ACTH stimulation tests were performed in healthy volunteers (n = 20) and relatives of patients with congenital adrenal hyperplasia (n = 31). Polymerase chain reaction (PCR) amplification, single-strand conformational polymorphism (SSCP) analysis, allele-specific oligonucleotide hybridization (ASOH) analysis, and restriction fragment length polymorphism (RFLP) analysis were utilized to screen for 14 CYP21 mutations which account for >90% of the mutations associated with 21-hydroxylase deficiency. Molecular genotype analysis classified 28 individuals as heterozygotic carriers and 23 individuals as normal for all mutations tested. As a group, the heterozygotes had significantly greater stimulated 17-hydroxyprogesterone responses at 10 and 30 min (P < 0.0005). However, on an individual basis, 14/28 (50%) genotyped heterozygotic carriers had stimulated 17-hydroxyprogesterone concentrations, 17-hydroxyprogesterone/cortisol ratios, and 17-hydroxyprogesterone incremental elevations indistinguishable from the genotyped normal individuals. Thus, a normal 17-hydroxyprogesterone response to ACTH stimulation testing does not exclude carrier status for 21-hydroxylase deficiency. Molecular genotype analysis is a more reliable method to determine 21-hydroxylase heterozygotes.

Condom and other contraceptive use among a random sample of female adolescents: a snapshot in time

This study examined the sexual practices of 235 females aged 15 to 19 years and their readiness to use specific contraceptive methods for birth control and sexually transmitted disease (STD) prevention. The investigation was based on the stages-of-change construct from the Transtheoretical Model (Prochaska & DiClemente, 1983, 1984). Results demonstrated that despite the availability of newer contraceptive methods (e.g., Depo-Provera), most sexually active adolescents were least resistant to using condoms and were further along in the stages of change for condom use as compared with other contraceptive methods. Moreover, the females perceived the male condom as an acceptable method for prevention of both pregnancy and STDs. These findings suggest that interventions designed to target consistent and correct condom use may result in better compliance, reducing the number of unintended pregnancies and STD cases among this populations.

Hyperandrogenism and manifesting heterozygotes for 21-hydroxylase deficiency

Premature adrenarche and functional adolescent androgen excess are common disorders which may evolve into polycystic ovary syndrome (PCOS). In all three disorders, ACTH-stimulated 17-hydroxyprogesterone concentrations are often somewhat elevated. To determine the role of 21-hydroxylase (CYP21) gene mutations in these disorders, we performed molecular genotype analysis on 48 children and adolescents referred for evaluation of hyperandrogenic findings and diagnosed as having premature adrenarche or functional androgen excess. For comparison, DNA samples from 80 healthy adults were genotyped. Seventeen of the 48 hyperandrogenic patients were found to be heterozygotic carriers of CYP21 mutations. The frequency of heterozygosity was significantly greater among symptomatic patients (35%) than among the healthy controls (6%), P < 0.001. Seven mutation-positive patients (50%) and only one mutation-negative patient had ACTH-stimulated 17-hydroxyprogesterone concentrations typical for heterozygotic carriers of 21-hydroxylase deficiency, 400-1000 ng/dl. The significant difference in heterozygote frequency between symptomatic patients and healthy controls suggests that heterozygosity for 21-hydroxylase deficiency may be associated with premature adrenarche and functional adolescent hyperandrogenism. Longitudinal studies are necessary to determine if heterozygosity for 21-hydroxylase deficiency predicts risk for PCOS.

Neuroblastoma and related tumors in Turner's syndrome

OBJECTIVES

The identification of constitutional cytogenetic abnormalities in patients with cancer may indicate loci of genes, abnormalities of which are responsible for tumor development or progression. This study was undertaken to determine whether girls with Turner's syndrome (TS) (partial or complete deletion of an X chromosome, short stature, gonadal dysgenesis) are at increased risk of neural crest-derived tumors.

STUDY DESIGN

Medical records of 394 patients with TS who were followed up at Thomas Jefferson Hospital and Children's Hospital of Pittsburgh were reviewed for documentation of TS phenotype, constitutional cytogenetics, and history of neuroblastoma or related tumors. Informative cases were reviewed for tumor pathology, primary site, disease stage, associated symptoms, treatment, and outcome.

RESULTS

Three patients were found to have neuroblastoma. A fourth child who died of neurofibrosarcoma was found to have extensive areas of ganglioneuroma, the benign counterpart of neuroblastoma, at autopsy. An additional four girls with TS and neuroblastoma were identified in the literature, as were two more patients with ganglioneuroma. These 10 patients ranged in age from 1 week to 16 10/12 years (median age, 3 years), and all but two of the children had localized lesions. Two of the seven children with neuroblastoma had courses complicated by opsoclonus-myoclonus, a syndrome found in fewer than 5% of all patients with neuroblastoma.

CONCLUSIONS

These data strongly suggest that girls with TS are predisposed to the development of neuroblastoma and related tumors. Because these tumors are often of limited stage and may be underdiagnosed, screening of urine of patients with TS for elevated catecholamine metabolite levels may strengthen this association.

The influence of estrogen on growth

The greatest advances in our understanding of the role of estrogens in growth and skeletal maturity have come from male and female patients who are devoid of estrogen or have estrogen insensitivity. Among males, the absence of an estrogen effect results in lack of completion of skeletal maturity and continued growth into adult life, resulting in very tall stature. This has been exemplified in one male with an estrogen-receptor defect and one male with aromatase deficiency. In females with aromatase deficiency, androgen levels are excessive, causing inappropriate virilization but failing to induce skeletal maturity. Thus, estrogen is the hormone necessary for normal skeletal growth and maturity. Estradiol concentrations measured using an ultrasensitive assay are similar in males and females at the time of the pubertal growth spurt; these data are consistent with the premise that estrogen has a role in growth.