Insulin-resistant diabetes during growth hormone therapy in a child with SHORT syndrome

We report the case of a 13-year-old boy with SHORT syndrome, including lipoatrophy and insulin resistance, who developed diabetes mellitus while receiving growth hormone therapy. The diabetes persisted after cessation of exogenous growth hormone but oral hypoglycaemic therapy was successful and could be discontinued eight months later.

Prevalence and risk factors for retinopathy in adolescents with type 1 diabetes

OBJECTIVES

To establish the prevalence of, and risk factors associated with, diabetic retinopathy in an Australian adolescent diabetes clinic population.

DESIGN

A prospective longitudinal study; baseline findings.

PATIENTS

Two hundred and fifty-five patients with Type 1 (insulin-dependent) diabetes mellitus assessed by our service were studied. Entry criteria were: age 11.0-19.9 years; diabetes duration of at least two years; and gradable fundus photographs of at least one eye.

MAIN OUTCOME MEASURES

The presence and severity of retinopathy, as assessed by the grading of stereoscopic fundus photographs. Possible risk factors assessed were age, sex, diabetes duration, pubertal stage, blood pressure, glycaemic control and total cholesterol level.

RESULTS

The prevalence of retinopathy was 42%; all of those affected had mild background retinopathy. Highly significant associations were found with glycaemic control and both total and prepubertal duration of diabetes. No associations were found with age, sex, pubertal stage, blood pressure or total cholesterol level.

CONCLUSIONS

The high prevalence of early diabetic retinopathy in this group of Australian adolescents is comparable to recent reports from other centres. The significant associations with glycaemic control and duration of diabetes provide further strong evidence for the benefit of optimal glycaemic control during adolescence. Our finding that the prepubertal years of diabetes contribute to the development of retinopathy suggests that glycaemic control before puberty should also be optimised. The planned follow-up of this cohort will establish the risk of progression to vision-threatening retinopathy and allow risk factors to be further evaluated.

Autonomic and peripheral nerve function in adolescents with and without diabetes

In this study reference ranges were established for autonomic and peripheral nerve tests in 122 non-diabetic adolescents. Regression analysis was used to evaluate the effect of age and gender on neurological function. Increasing age was associated with: less heart rate variability during deep breathing (p = 0.03), higher thermal threshold for cold at the wrist (p = 0.009), and higher vibration threshold at the toe (p = 0.001) and medial malleolus (p = 0.01). Male gender was associated with higher Valsalva ratio (p = 0.0004), higher thermal threshold for hot at the foot (p = 0.002), and higher vibration threshold at the malleolus (p = 0.03). The REFVAL programme was used to determine parametric or non-parametric reference limits: the 5% limits for autonomic and 95% limits for peripheral tests. One hundred and eighty-one adolescents with diabetes were studied under identical conditions and similar effects of age and gender were found. Twenty-eight percent of the group with diabetes had at least one abnormal autonomic test result out of four (expected 18.5%); 24% had at least one abnormal peripheral test result out of six (expected 26.5%). Glycaemic control was associated with autonomic (p = 0.04) but not peripheral abnormalities. Using multiple regression analysis and adjusting for age and gender, there was no effect of diabetes duration or glycaemic control on neurological function.

Growth in children with X-linked hypophosphataemic rickets

Currently, X-linked hypophosphataemic rickets (XLHR) is most commonly treated with a combination of phosphate and vitamin D, but there is conflicting evidence about the effects of this treatment on linear growth. In all, 25 patients with XLHR (current age range, 4.1-22.1 years; median, 8.2 years) were studied to determine whether there was any improvement in height SDS during treatment. The duration of therapy was 2.9-15.0 years (median, 5.7 years). Measurements before the age of 2 years or after the onset of puberty were excluded to remove the effects of measurement difficulties in small infants and of variation in pubertal timing. The growth of these patients was compared with a similar group of untreated historical controls. Patients treated with calcitriol and phosphate for at least 2 years before the onset of puberty (n = 22) had a significantly better mean height SDS than the historical controls (-1.23 compared with -2.05 for the historical controls; p = 0.02). Among patients treated with calcitriol and phosphate for at least 2 years (n = 21), the change in height SDS had a positive correlation with the duration of therapy (r = 0.51; p = 0.02). The growth of children with XLHR treated with combination therapy was thus significantly better than that of historical controls.

Absence of ultradian rhythm or diurnal variation in insulin-like growth factor-I in rats

We studied the variation in plasma insulin-like growth factor-I (IGF-I) concentrations in unrestrained, cannulated rats. To detect rapid changes, 6 rats were sampled every 15 min for 6 h. Plasma was assayed for growth hormone (GH), and for IGF-I before and after acid-ethanol (AE) extraction to reduce the masking effect of plasma binding proteins. AE increased the immunoreactivity of freshly collected rat serum and heparinized plasma by 3-fold, but had no effect on serum after 4 weeks of storage at -20 degrees C. In contrast, heparinized plasma maintained its sensitivity to AE for many months after collection. AE-extracted serum was identical in potency to serum that was subjected to acid gel chromatography. GH showed high amplitude, synchronized pulses every 3.3 +/- 0.15 h. Despite variations in IGF-I concentrations that resembled pulsations, when the data from both unextracted and AE-extracted plasma were subjected to 2 computer algorithms designed to detect hormone pulses, no pulses were identified in 8 of the 24 series of analyses. The two programs concurred only 4 times in their identification of a pulse in unextracted plasma, and in only one instance was a pulse identified in both unextracted and AE-extracted plasma from a given sample. Based on repeated measurements of a single serum sample, the program of Santen and Bardin (S&B) had a false-positive rate of 11%, and that of Merriam and Wachter (M&W) less than 10%. There was no positive correlation between summed GH and IGF-I concentrations over the 6 h of sampling, or after a 1- or 2-hour lag period. To detect diurnal variations, a second group of 5 rats was sampled every 2 h for 36 h. These animals showed little fluctuation of IGF-I concentrations and no differences between the light and dark periods. Our studies provide no evidence for episodic release of IGF-I or diurnal variations entrained to light or feeding cycles.

Amiodarone. The dilemma of hyperthyroxinaemia and the treatment of thyrotoxicosis

The use of amiodarone, a drug which is prescribed increasingly as an anti-anginal and anti-arrhythmic agent, necessitates a high index of suspicion for the development of thyroid disorders, especially thyrotoxicosis. Two cases, which illustrate the diagnostic dilemma of hyperthyroxinaemia and the poor response to antithyroid medication, are described. During amiodarone therapy, the clinical features of thyrotoxicosis may be masked or atypical, and the choice of therapy is complicated by a delayed response to thioamide drugs and possible contraindication for beta-blocking agents which necessitates the use of glucocorticoid drugs in some patients.