The effects of anti-TNF-α treatment with adalimumab on growth in children with Crohn's disease (CD)

INTRODUCTION

Adalimumab is used to treat children with Crohn's disease (CD), but the effects of adalimumab on growth in CD have not been studied.

AIM

To study growth and disease activity over 12 months (6 months prior to (T-6), baseline (T0) and for 6 months following (T+6) adalimumab).

SUBJECTS AND METHODS

Growth and treatment details of 36 children (M: 22) who started adalimumab at a median (10th, 90th) age of 14.7 years (11.3, 16.8) were reviewed.

RESULTS

Of 36 cases, 28 (78%) went into remission. Overall 42% of children showed catch up growth, which was more likely in: (i) those who achieved remission (median change in height SDS (ΔHtSDS) increased from -0.2 (-0.9, 1.0) at T0 to 0.2 (-0.6, 1.6) at T+6, (p=0.007)), (ii) in those who were on immunosuppression ΔHtSDS increased from -0.2 (-0.9, 1.0) at T0 to 0.1 (-0.8, 1.3) at T+6, (p=0.03) and (iii) in those whose indication for using adalimumab therapy was an allergic reaction to infliximab, median ΔHtSDS increased significantly from -0.3 (-0.9, 1.0) at T0 to 0.3 (-0.5, 1.6) at T+6, (p=0.02). Median ΔHtSDS also increased from -0.4 (-0.8, 0.7) at T0 to 0.0 (-0.6, 1.6) at T+6, (p=0.04) in 15 children who were on prednisolone therapy when starting adalimumab.

CONCLUSION

Clinical response to adalimumab therapy is associated with an improvement in linear growth in a proportion of children with CD. Improved growth is more likely in patients entering remission and on immunosuppression but is not solely due to a steroid sparing effect.

Impact of inflammatory bowel disease on pubertal growth

BACKGROUND

Puberty is thought to be commonly affected in adolescents with inflammatory bowel disease (IBD).

AIMS

To determine the impact of Crohn's disease (CD) and ulcerative colitis (UC) on the pubertal growth spurt.

METHODS

Retrospective study of 30 boys with CD (CD-M), 11 girls with CD (CD-F), 14 boys with UC (UC-M) and 12 girls with UC (UC-F). Pubertal growth was assessed by calculating peak height velocity SDS (PHV SDS), height SDS at diagnosis (Ht(Diag)) and height SDS at PHV (Ht(PHV)) and age at PHV (Age(PHV)). Systemic markers of disease activity were also collected.

RESULTS

Altered parameters of pubertal growth were observed in the CD groups compared to the normal population: in the CD-M group, median Ht(Diag) was -0.56 (p = 0.001) and median Age(PHV) was 14.45 years (p = 0.004), and in the CD-F group, median Ht(Diag) was -1.14 (p = 0.007) and Ht(PHV) was -0.79 (p = 0.039). Individually, 8/30 CD-M cases had one or more parameter affected: 2 boys had Ht(Diag )<-2, 3 boys had Ht(PHV) <-2, 2 boys had an Age(PHV) >2 years above population mean, and 2 boys had a PHV SDS <-2. In the whole group, Age(PHV) showed an association with erythrocyte sedimentation rate (r = 0.4; p = 0.005) and an inverse association with BMI (r = 0.4; p = 0.001).

CONCLUSION

Disorders of pubertal growth are more likely to occur in CD and, particularly, in boys.

The chaperone-assisted E3 ligase C terminus of Hsc70-interacting protein (CHIP) targets PTEN for proteasomal degradation

The tumor suppressor, PTEN is key to the regulation of diverse cellular processes, making it a prime candidate to be tightly regulated. The PTEN level is controlled in a major way by E3 ligase-mediated degradation through the Ubiquitin-Proteasome System (UPS). Nedd 4-1, XIAP, and WWP2 have been shown to maintain PTEN turnover. Here, we report that CHIP, the chaperone-associated E3 ligase, induces ubiquitination and regulates the proteasomal turnover of PTEN. It was apparent from our findings that PTEN transiently associates with the molecular chaperones and thereby gets diverted to the degradation pathway through its interaction with CHIP. The TPR domain of CHIP and parts of the N-terminal domain of PTEN are required for their interaction. Overexpression of CHIP leads to elevated ubiquitination and a shortened half-life of endogenous PTEN. On the other hand, depletion of endogenous CHIP stabilizes PTEN. CHIP is also shown to regulate PTEN-dependent transcription presumably through its down-regulation. PTEN shared an inverse correlation with CHIP in human prostate cancer patient samples, thereby triggering the prospects of a more complex mode of PTEN regulation in cancer.

Recent trends and clinical features of childhood vitamin D deficiency presenting to a children's hospital in Glasgow

BACKGROUND

The incidence of vitamin D deficiency is unclear in the context of continuing demographic changes and the introduction of new public health measures.

METHODS

All cases in which vitamin D deficiency was suspected as the primary cause of the clinical presentation were studied.

RESULTS

Between 2002 and 2008, 160 cases of symptomatic vitamin D deficiency were identified with twice as many cases in 2008 (n, 42) as in the previous years. The median age of the cohort was 24 months (range 2 weeks-14 years).Three cases were recorded in children of European background, whereas the rest were in children of South Asian, Middle Eastern or sub-Saharan ethnic background. Presenting features included bowed legs in 64 (40%) and a fit in 19 (12%). In one infant, concerns were raised following a presentation with cardiac failure and hypocalcaemia.

SUMMARY

Symptomatic vitamin D deficiency remains prevalent in the West of Scotland. There is a need for effective public health education, action and surveillance.

Effect of testosterone therapy for delayed growth and puberty in boys with inflammatory bowel disease

BACKGROUND

pubertal delay and growth retardation are common in children with inflammatory bowel disease (IBD).

AIMS

To assess pubertal status and growth in a group of boys with IBD undergoing testosterone therapy for pubertal induction.

METHODS

retrospective study of height, weight and pubertal status in 8 boys with IBD before and after testosterone therapy. Height velocity (HV) over the 6 months before each assessment was converted to standard deviation score. Markers of disease activity and concomitant medication were recorded. Response was based on an advance in pubertal status and a greater than 50% increase in HV.

RESULTS

eight boys with IBD, median age 14.8 years, had pubertal induction using either monthly injections of 50 mg Sustanon or daily 2.5/5 mg Andropatch. Seven boys showed an advance of pubertal status. Six boys had a greater than 50% increase in HV; median HV at T0 was 1.6 cm/year (0, 5) compared with 6.9 cm/year (1, 11.7) at T6 (p = 0.005). C-reactive protein during testosterone therapy had a significant association with HV at T6 (r = -0.786; p = 0.021).

CONCLUSION

in most cases, testosterone therapy in boys with IBD and delayed growth and puberty is associated with an advance in pubertal status and an improvement in growth.

Factors that influence the decision to perform a karyotype in suspected disorders of sex development: lessons from the Scottish genital anomaly network register

BACKGROUND

Although a karyotype represents the first objective evidence of investigating a case of suspected disorder of sex development (DSD), the factors that influence the clinician's decision to initiate investigations are unclear.

METHODS

Cases of suspected DSD in Scotland were identified through the Scottish Genital Anomaly Network (SGAN) Register. The timing as well as other factors that influence the decision to perform a karyotype were subsequently studied.

RESULTS

Out of the 572 cases on the register, 383 (67%) were classified as having a non-specific disorder of under-masculinisation. In 463 (81%) cases, the sex of rearing was male, in 71 (12%) female, and in 38 (7%) cases data regarding sex of rearing were unavailable. A karyotype was reported to have been performed in 153/572 (27%) cases. Infants in Scotland with suspected DSD are more likely to have a karyotype performed in the presence of a low external masculinisation score, bilateral impalpable testes, proximal hypospadias, or associated malformations.

DISCUSSION

These data represent the first attempt at benchmarking the decision to check a karyotype and investigate infants with suspected DSD. Whilst this decision may be related to the complexity of the genital anomaly, there are other factors that may influence this decision, and these require further exploration through more rigorous systems for data collection.

Skeletal morbidity in children receiving chemotherapy for acute lymphoblastic leukaemia

BACKGROUND

Children receiving chemotherapy for acute lymphoblastic leukaemia (ALL) may be susceptible to skeletal morbidity.

AIM

To determine the incidence and risk factors for skeletal morbidity in ALL children.

PATIENTS AND METHODS

The medical records of all (n=186, boys=110) children presenting to a single centre with ALL between 1997 and 2007 and treated on UKALL97, UKALL97/01 or UKALL2003 were studied. Skeletal morbidity included musculoskeletal pain, fractures and osteonecrosis (ON). Musculoskeletal pain was classified as any event of limb pain, muscle pain, joint symptoms or back pain that required radiological examination. Fractures and ON were confirmed by x-rays and MRI, respectively.

RESULTS

Skeletal morbidity, presenting as musculoskeletal pain, fractures or ON were reported in 88 (47%) children of whom 56 (63%) were boys. Of 88 children, 49 (55%), 27 (30%) and 18 (20%) had musculoskeletal pain, fracture(s) or ON, respectively. 6 (7%) had fractures and ON. The median (10th, 90th centiles) age at diagnosis of ALL in those children without skeletal morbidity was 3.9 (1.4-12) years which was lower than in those with skeletal morbidity at 8.2 (2.2-14.3) years (p<0.00001, 95% CI 1.7 to 4.4). Children with ALL diagnosed over 8 years of age were at increased risk of developing fracture(s) (p=0.01, OR=2.9, 95% CI 1.3 to 6.5) whereas the risk of ON was higher in those who were diagnosed after 9 years of age (p<0.0001, OR=15, 95% CI 4.1 to 54.4). There was no sex difference in the incidence of skeletal complications. Children who received Dexamethasone had a higher incidence of skeletal morbidity than those who were treated with Prednisolone (p=0.027, OR=2.6, 95% CI 1.1 to 5.9).

CONCLUSION

The occurrence of skeletal morbidity in ALL children may be influenced by age and the type of glucocorticoids. These findings may facilitate the development of effective bone protective intervention.

The effect of GH and IGF1 on linear growth and skeletal development and their modulation by SOCS proteins

Circulating signalling proteins have often been divided into hormones and cytokines, but it is increasingly being recognised that these substances have a number of common characteristics and mechanisms of action. This is clearly illustrated by the suppressor of cytokine signalling (SOCS) proteins which are increasingly seen as a central component of the regulation of the action of hormones and cytokines that signal through the cytokine receptor complex. The SOCS protein family is probably more extensive than currently recognised; its members may have differential tissue expression and their potency for suppressing cytokine signalling may vary. Recent knockout and transgenic studies in mice have highlighted the role that these proteins play in growth and skeletal development as well as in inflammation. Chronic inflammation is associated with altered growth and skeletal development, and it is possible that SOCS proteins may have an important role to play in mediating these effects.

The growth hormone insulin-like growth factor 1 axis in children and adolescents with inflammatory bowel disease and growth retardation

CONTEXT

There is scarce knowledge about the growth hormone (GH) insulin-like growth factor-1 (IGF1) axis in children & adolescents with inflammatory bowel disease (IBD) and growth retardation.

OBJECTIVE

To describe the pattern of GH and IGF1 secretion in children & adolescents with IBD.

DESIGN

A retrospective review of 28 patients (23 M) of IBD (25 Crohn's Disease and three Ulcerative Colitis) and growth retardation who had investigation of the GH/IGF-1 axis. Height velocity (HV) and serum IGF1 were converted to standard deviation score (SDS); to account for delayed puberty in girls over 11 years and boys over 12 years, HV and serum IGF1 SDS were adjusted for bone age.

RESULTS

Median (range) age and Ht SDS at the time of endocrine evaluation was 14.3 years (7.7,17.0) and -2.0(-3.6,-0.9), respectively. Median HVSDS over the prior 12 months was -2.2(-7.7,2.8). Median peak serum GH on insulin tolerance test (ITT) was 5.8 mcg/l (1.3, 24.0), and median serum IGF1 SDS was -0.9(-3.1, 0.1). Five of 28 (18%) had a peak serum GH of >12 mcg/l. Overall, four had biochemical evidence of functional GH deficiency (peak GH < 3 mcg/l and IGF1 SDS < 0) and 11 children had biochemical evidence suggesting GH resistance (peak GH > 6 mcg/l and IGF1 SDS < 0). However, only one child had a peak serum GH > 6 mcg/l and a very low IGF1 SDS of <-2.0. There was a negative association between peak serum GH and Ht SDS (r = -0.49, P = 0.008), but there was no association with HV and there was no association between IGF1 SDS and Ht or HV SDS. IGF1 SDS showed a negative association with erythrocyte sedimentation rate (r = -0.41, P = 0.04).

CONCLUSION

Growth retardation in children and adolescents with IBD is commonly associated with a range of biochemical abnormalities ranging from functional GH deficiency to GH resistance. In these children, poor relationship between systemic markers of growth and height velocity point to an important role of growth factors at the target organ level in modulating growth in children with IBD. The value of assessing the GH/IGF-1 axis and whether it predicts subsequent response to growth-promoting therapy requires further exploration.

The concordance between serum anti-Mullerian hormone and testosterone concentrations depends on duration of hCG stimulation in boys undergoing investigation of gonadal function

BACKGROUND

In boys undergoing investigation of gonadal function, the relationship between a single measurement of serum anti-Mullerian hormone (AMH) and hCG stimulated serum testosterone is unclear.

AIM

The aim of the study was to assess concordance between serum AMH and testosterone concentrations following hCG stimulation of two different durations.

METHODS

Samples from 284 children (M : F, 154 : 130) with a median age of 8 years (10th, 90th centiles, 0.25, 14) were used to establish an AMH reference range. Clinical data were reviewed in boys undergoing investigation of gonadal function and who had an AMH measurement and a hCG stimulated (3-day or 3-week) (n = 26) testosterone. Of these 26 boys, 11 had combined genital anomalies, whereas the rest had conditions such as isolated hypospadias, undescended testes or microphallus. Normal testosterone response to hCG stimulation was defined as a level greater than 3.5 nmol at day 4 and 9.5 nmol/l at day 22.

RESULTS

In the reference group, the 5th centile AMH for boys below 1 year was 215 pmol/l and between 1 and 8 years 180 pmol/l. The 95th centile for girls for these respective age groups was 30 pmol/l and 25 pmol/l. In those cases where serum testosterone concentrations were available at day 1, day 4 and day 22 of the 3 week-hCG test, five cases had a normal serum testosterone at day 4 and three cases only showed such a response by day 22. In those where serum AMH was less than 180 pmol/l, a poor testosterone response of less than 3.5 nmol was observed in approximately seven of eight (88%) cases with a 3-day hCG stimulation test or the 3-week test. An AMH of greater than 180 pmol/l was associated with a normal testosterone response at day 4 in 10 out of 15 (67%) cases and at day 22 in eight of 11 (73%) cases. However, a low serum testosterone concentration of less than 3.5 nmol after the 3-day hCG test was only associated with a likelihood of a low AMH in three of eight (37%) cases. With the 3-week hCG test, a low day 22 testosterone of 9.5 mmol/l or less was associated with a low AMH of 180 pmol/l or less in four of seven (57%) cases.

CONCLUSION

In boys undergoing investigation of gonadal function, the concordance between AMH and testosterone is better at day 22 than day 4. A normal AMH may provide useful information on overall testicular function but does not exclude the need for an hCG stimulation test.

The European disorder of sex development registry: a virtual research environment

Disorders of sex development (DSD) are a rare group of conditions which require further research. Effective research into understanding the aetiology, as well as long-term outcome of these rare conditions, requires multicentre collaboration often across national boundaries. The EU-funded EuroDSD programme (www.eurodsd.eu) is one such collaboration involving clinical centres and clinical and genetic experts across Europe. At the heart of the EuroDSD collaboration is a European DSD registry and a targeted virtual research environment (VRE) that supports the sharing of DSD data. Security, ethics and information governance are cornerstones of this infrastructure. This paper describes the infrastructure that has been developed, the inherent challenges in security, availability and dependability that must be overcome for the enterprise to succeed and provides a sample of the data that are stored in the registry along with a summary analysis of the current data sets.

Exaggerated adrenarche in a cohort of Scottish children: clinical features and biochemistry

OBJECTIVE

To investigate the reported association between exaggerated adrenarche (EA) and reduced foetal growth and to identify possible risk factors for future morbidity in Scottish children with clinical features of EA.

DESIGN

Three-year prospective study.

MEASUREMENTS

Auxology, blood pressure (BP), biochemical analysis of blood and urine, pelvic ultrasound in girls.

RESULTS

Fifty-two patients were recruited of whom one girl had nonclassical congenital adrenal hyperplasia (17-OHP 17 nmol/l) and one had insufficient blood for analysis. The final cohort comprised 42 girls of mean (SD) age 7.7 (0.99) and eight boys of 8.8 (0.67) years. Mean (SD) birth weight was 3.27 (0.49) and 3.10 (0.76) kg in girls and boys respectively. Height/weight SDS were 1.13/1.69 in girls and 1.69/1.88 in boys. Mean systolic/diastolic BP was 107.8/60.4 (50th-75th centile) in girls and 115.5/63.9 (75th-91st centile) in boys. Uterine and ovarian development was prepubertal. Median serum dehydroepiandrosterone sulphate (DHEAS) was 2.1 and 4.1 mumol/l, androstenedione 3.1 and 3.8 nmol/l in girls and boys respectively, with DHEAS within the reference range/undetectable in 18/2 and androstenedione in 12/6 patients. Fasting insulin was 9.0 and 15.0 mU/l in girls and boys respectively, with concomitant low normal SHBG. Anti-Mullerian hormone (AMH) was 15.7 pmol/l in 27 girls, compared with 5.0 pmol/l in normal girls aged 5-8 years.

CONCLUSIONS

Our Scottish EA cohort showed female predominance, no evidence of reduced foetal growth, a tendency to overweight with commensurate mild hyperinsulinaemia and modest elevation of serum androgens in some patients. We have found raised AMH levels in the girls, indicating advanced ovarian follicular development.

Chondrocyte p21(WAF1/CIP1) expression is increased by dexamethasone but does not contribute to dexamethasone-induced growth retardation in vivo

It has been shown that cell cycle genes play an important role in the coordination of chondrocyte proliferation and differentiation. The inhibitory effects of glucocorticoids (GCs) on chondrocyte proliferation are consistent with GCs disrupting cell cycle progression and promoting cell cycle exit. Cyclin-dependent kinase inhibitors (CDKIs) force cells to exit the cell cycle and differentiate, and studies have shown that expression of the CDKI p21(CIP1/WAF1) is increased in terminally differentiated cells. In this study, p21 mRNA and protein expression was increased during chondrocyte differentiation and after exposure to dexamethasone (Dex, 10(-6 )M) in murine chondrogenic ATDC5 cells. In 4-week-old mice lacking a functional p21 gene, Dex caused a reduction in body weight compared to saline control null mice, but this was consistent with the reduction in body weight observed in Dex-treated wild-type littermates. In addition, p21 ablation had no effect on the reduction in width of the growth plate or reduced mineral apposition rate in Dex-treated mice. However, an alteration in growth rate and epiphyseal structure is evident when comparing p21(-/-) and wild-type mice. These findings suggest that p21 does not directly contribute to GC-induced growth retardation in vivo but is involved in the maintenance of the growth plate.

Short‐term growth and bone turnover in children undergoing occlusive steroid (‘Wet‐Wrap’) dressings for treatment of atopic eczema

To assess the effects of steroid wet-wrap therapy on short-term growth and bone turnover, eight prepubertal (M:F,5:3) children with a median age of 5.1years (range 3.3-8.8) were studied over a 2-week period prior to therapy and at 2-week intervals during therapy. Short-term growth was assessed by measuring lower leg length velocity (LLLV) by knemometry and bone and collagen turnover was assessed by urinary deoxypyridinoline crosslink excretion corrected for creatinine excretion (DPD). Median duration of study during occlusive dressings was 12 weeks (range 2-18). Topical beclomethasone dipropionate diluted 1:10 or 1:4 in white soft paraffin was applied under tubular (Tubifast) bandages in 7/8 children. Median LLLV before and during therapy were 0.43 mm/week (10(th),90(th) centile; 0.0,0.7) and 0.42 mm/week (10(th),90(th) centile; -0.35,1.01), respectively (not significant). Median DPD before and during therapy were 25.9 nmol/l/creatinine (10(th),90(th) centile; 20.8, 33.0) and 26.3 nmol/l/creatinine (10(th),90(th) centile; 21.7, 34.1) respectively (not significant). Non-invasive assessment of the effects of steroid wet-wrap therapy can be performed in children with eczema. These preliminary results show no substantial growth promoting or adverse effects of therapy.

Inflammatory cytokines and the GH/IGF-I axis: novel actions on bone growth

Longitudinal bone growth is a tightly regulated process that relies on complex synchronized mechanisms at the growth plate. Chronic paediatric inflammatory diseases are well accepted to lead to growth retardation and this is likely due to raised inflammatory cytokine levels and reduced growth hormone (GH)/insulin-like growth factor-1 (IGF-I) signalling. The precise cellular mechanisms responsible for this inhibition are unclear and therefore in this article, we will review the potential interactions between inflammatory cytokines and the GH/IGF-I axis in the regulation of bone growth. In particular, we will emphasis the potential contribution of the suppressors of cytokine signalling (SOCS) proteins, and in particular SOCS2, in mediating this process.

A 5-year-old boy with cryptorchidism and pubic hair: investigation and management of apparent male disorders of sex development in mid-childhood

BACKGROUND

Late presentation of congenital adrenal hyperplasia as a 46,XX disorder of sex development due to 11-beta hydroxylase deficiency is uncommon. Such a case raises issues regarding appropriate investigation and management.

CASE HISTORY

A 5-year-old boy who had recently moved to the United Kingdom presented at the endocrinology clinic with recurrent abdominal pain. He was normotensive and had a history of ambiguous genitalia since birth, a relatively small penis, bilateral cryptorchidism and pubic hair. A systematic workup revealed low anti-Mullerian hormone levels for age and sex and elevated serum testosterone, androstenedione and deoxycortisol levels. A urinary steroid profile confirmed a diagnosis of 11-beta hydroxylase deficiency. The child's karyotype was 46,XX. Further genetic analysis revealed a compound heterozygote mutation in the CYP11B1 gene. Ultrasound scan showed evidence of Mullerian structures and accumulation of menstrual blood in the vagina (haematocolpos). Following discussion at a multidisciplinary clinic, the patient did not undergo sex reassignment and subsequently proceeded to surgery for removal of the Mullerian structures.

CONCLUSIONS

This case emphasizes the importance of a systematic approach to investigation of older children presenting with apparent male undermasculinisation. It also raises important issues about gender reassignment in mid-childhood and the indications for removal of Mullerian organs in a 46,XX boy.

Secondary osteoporosis

Secondary osteoporosis is more difficult to define in children than in adults but clearer definitions have recently been provided by the International Society for Clinical Densitometry. Whereas in adults, osteoporosis is defined on the basis of reduced bone density on scanning, in children the definition requires additional clinical parameters to be fulfilled. Secondary osteoporosis may arise either as a result of the effects of underlying disease or as a result of the treatment of such diseases (e.g. with glucocorticoids). The normal balance of bone formation and removal, both by bone modelling and remodelling, is disturbed in such a way as to alter the normal accumulation of bone that occurs during childhood. A multitude of intrinsic and extrinsic factors contributes to these processes. The underlying principles of treatment of secondary osteoporosis is, where possible, to remove the underlying cause. Where this is not possible, minimising the effects of treatment with drugs that adversely effect bone may be sufficient to eliminate any deterioration in bone quality. If this is not possible, the use of bone sparing drugs such as the bisphosphonates may be necessary whilst ensuring that attention is paid to optimising calcium and vitamin D intake and encouraging exercise and mobility.

Increased bone mass, altered trabecular architecture and modified growth plate organization in the growing skeleton of SOCS2 deficient mice

Suppressor of cytokine signalling-2 (SOCS2) negatively regulates the signal transduction of several cytokines. Socs2(-/-) mice show increased longitudinal skeletal growth associated with deregulated GH/IGF-1 signalling. The present study examined the role of SOCS2 in endochondral ossification and trabecular and cortical bone formation, and investigated whether pro-inflammatory cytokines associated with pediatric chronic inflammatory disorders mediate their effects through SOCS2. Seven-week-old Socs2(-/-) mice were heavier (27%; P < 0.001) and longer (6%; P < 0.001) than wild-type mice. Socs2(-/-) tibiae were longer (8%; P < 0.001) and broader (18%; P < 0.001) than that of wild-type mice, and the Socs2(-/-) mice had wider growth plates (24%; P < 0.001) with wider proliferative and hypertrophic zones (10% (P < 0.05) and 14% (P < 0.001) respectively). Socs2(-/-) mice showed increased total cross-sectional bone area (16%: P < 0.001), coupled to increased total tissue area (17%; P < 0.05) compared to tibia from wild-type mice. Socs2(-/-) mice showed increased percent bone volume (101%; P < 0.001), trabecular number (82%; P < 0.001) and trabecular thickness (11%; P < 0.001), with associated decreases in trabecular separation (19%; P < 0.001). TNFalpha exposure to growth plate chondrocytes for 48 h increased SOCS2 protein expression. Growth of metatarsals from 1-day-old Socs2(-/-) and Socs2(+/+) mice, as well as expression of Aggrecan, Collagen Type II and Collagen Type X, were inhibited by TNFalpha, with no effect of genotype. Our data indicate that physiological levels of SOCS2 negatively regulate bone formation and endochondral growth. Our results further suggest that pro-inflammatory cytokines mediate their inhibitory effects on longitudinal bone growth through a mechanism that is independent of SOCS2.

Inflammatory cytokines in juvenile idiopathic arthritis: effects on physical growth and the insulin-like-growth factor axis

OBJECTIVE

To investigate the relationship between markers of inflammation with physical growth and systemic markers of GH secretion in JIA.

DESIGN

This is a cross sectional prospective study of patients with JIA recruited during therapeutic arthrocentesis of 17 children with JIA (F,10): 8 oligoarticular (OJIA) and 9 polyarticular (PJIA).

RESULTS

Median adjusted height (AHt) SDS was -0.3 (-2.2 to 1.6). Serum ALS SDS (median -1.3, range -2.7 to -0.6) was reduced compared with serum IGFBP-3 SDS (median -0.5, range -7.7 to 2.3) and IGF-1 SDS (median -0.2, range -0.5 to 0.5). Log serum IL5 (95% CI -3.25, -0.81) and log serum IL15 (95% CI -9.58, -4.10) were independent factors associated with AHt SDS. Inflammatory cytokines individually showed no association with IGF-1, IGFBP-1, -2, -3 and ALS.

CONCLUSION

Children with JIA and mild degree of growth retardation show decreased ALS and IGFBP-3. Cytokines did not show an association to systemic markers of GH secretion. However, this study reports the novel, preliminary association between serum levels of IL5 and IL15 and the extent of short stature.

Auditing bone densitometry and fractures in children with chronic disease

In a retrospective analysis of bone densitometry scans performed in an audit of 576 children with chronic disease, lean-mass-adjusted bone mineral content (BMC) for the total body and the lumbar spine was marginally lower in children with fractures. However, the predictive ability of different bone mineral densities (BM) and BMC cut-offs to identify fracture risk in children with chronic disease needs to be tested for specific disease conditions in larger prospective studies.

Dexamethasone-induced expression of the glucocorticoid response gene lipocalin 2 in chondrocytes

Glucocorticoids (GC) are commonly used anti-inflammatory drugs, but long-term use can result in marked growth retardation in children due to their actions on growth plate chondrocytes. To gain an insight into the mechanisms involved in GC-induced growth retardation, we performed Affymetrix microarray analysis of the murine chondrogenic cell line ATDC5, incubated with 10(-6) M dexamethasone (Dex) for 24 h. Downregulated genes included secreted frizzled-related protein and IGF-I, and upregulated genes included serum/GC-regulated kinase, connective-tissue growth factor, and lipocalin 2. Lipocalin 2 expression increased 40-fold after 24-h Dex treatment. Expression increased further after 48-h (75-fold) and 96-h (84-fold) Dex treatment, and this response was Dex concentration dependent. Lipocalin 2 was immunolocalized to both proliferating and hypertrophic growth plate zones, and its expression was increased by Dex in primary chondrocytes at 6 h (3-fold, P < 0.05). The lipocalin 2 response was blocked by the GC-receptor antagonist RU-486 and was increased further by the protein synthesis blocker cycloheximide. Proliferation in lipocalin 2-overexpressing cells was less than in control cells (49%, P < 0.05), and overexpression caused an increase in collagen type X expression (4-fold, P < 0.05). The effects of lipocalin 2 overexpression on chondrocyte proliferation (64%, P < 0.05) and collagen type X expression (8-fold, P < 0.05) were further exacerbated with the addition of 10(-6) M Dex. This synergistic effect may be explained by a further increase in lipocalin 2 expression with Dex treatment of transfected cells (45%, P < 0.05). These results suggest that lipocalin 2 may mediate Dex effects on chondrocytes and provides a potential novel mechanism for GC-induced growth retardation.

Facilitating and understanding the family's choice of injection device for growth hormone therapy by using conjoint analysis

BACKGROUND

Conjoint analysis involves the measurement of consumer preferences between choice alternatives.

AIMS AND OBJECTIVES

To investigate the use of conjoint analysis in facilitating and understanding choice of growth hormone injection devices.

METHOD AND SUBJECTS

56 patients and their parents participated in an electronic, computer-based interview. The interview took a median time of 18 min (range 12-30) and allowed an immediate matching of injection devices to the family's preferences.

RESULTS

Amongst the key drivers of choice, lack of bruising was rated highest and designated an index of 100. Compared to this, the remaining attributes in order of desirability were: auto-injector (98), lack of pain (93), lightweight (88), silent (82), ready-mixed (77), ease of holding (69), telephone helpline (66), needle-free (62), small size (60), nurse support (47), hidden needle (45), stored in fridge (13) and home delivery (6). Out of the 17 families who had already chosen a device previously by discussion with the clinic nurse, the computer model placed their device either as first or second out of seven devices tested.

CONCLUSION

Adaptive or interactive conjoint analysis applied at the patient level can facilitate the choice-making process whilst providing an insight into the relative importance of the key features that influence choice.

The role of sex steroids in controlling pubertal growth

Longitudinal growth, which is primarily due to chondrocytic activity at the level of the epiphyseal growth plate, is influenced by many hormones and growth factors in an endocrine and paracrine manner. Their influence is even more complex during the accelerated growth period of puberty that accounts for about 20% of final adult height. Although abnormalities of growth during puberty are very common, the underlying mechanisms that govern the beginning and cessation of pubertal growth at the level of the growth plate are poorly understood. Sex steroids play a crucial role in pubertal growth both at the systemic level via the GH/IGF-1 axis and at the local level of the epiphyseal growth plate. In both sexes it is now accepted that oestrogen is the critical hormone in controlling growth plate acceleration and fusion. This paper reviews the mechanisms that influence pubertal growth and the problems that are associated with disorders of gonadal function.

The effects of recombinant human growth hormone on linear growth in children with Crohn's disease and short stature

BACKGROUND/AIMS

The efficacy of recombinant human growth hormone (rhGH) in treating the growth failure associated with Crohn's disease (CD) is unclear.

METHODS

Retrospective data analysis at 12 months before (T-12), 6 months before (T-6), at baseline (T+0), 6 months after (T+6) and 12 months after (T+12) rhGH treatment in seven patients with CD (five males).

RESULTS

Median chronological age (CA) and median difference between CA and bone age was 15.9 yr (range, 13.0 to 17.9) and 1.7 yr (-0.7 to 3.3), respectively. Median dose of rhGH at T+0 was 0.23 mg/wk (0.15 to 0.31). Pubertal status remained unchanged in 6/7 patients. Median albumin and C-reactive protein (CRP) were similar at T+0 and T+6. Median height SDS at T+0, T+6 and T+12 was -2.2 (-4.0 to -1.5), -1.9 (-4.1 to -0.8), -1.9 (-4.1 to -0.7), respectively (NS). Median height velocity (HV) SDS at T+0 and T+6 was -2.5 (-4.8 to 1.4) and -0.9 (-5.3 to 3.4), respectively (NS). There was a positive correlation between percentage change in HV SDS at T+6 and dose of rhGH at T+0 (r = 0.8, p = 0.03).

CONCLUSION

Introduction of rhGH therapy was associated with a cessation in the deterioration in linear growth. However, an improvement in height SDS was not observed over the period of the study. Future studies should explore the efficacy of a higher dose of rhGH in CD.