Growth hormone (GH) responses to GH-releasing hormone during pubertal development in normal boys and girls: comparison to idiopathic short stature and GH deficiency

The normal ranges for GH responses to GH-releasing hormone (GHRH) have previously been defined for adult men and women. To determine whether the GHRH responses of normal children differ from those of adults and whether children with GH deficiency (GHD) and children who are growing below the first percentile but are otherwise normal (ISS) have GH responses comparable to those of normal children, we studied 90 normal children, 46 girls and 44 boys, with heights between the 10th and 95th percentiles for age, at different pubertal stages. Their responses were compared to those of 24 children with ISS and 32 children with GHD and to values previously measured in young adult men and women. Girls were grouped by Tanner breast stages and boys by testicular volumes. Plasma somatomedin-C, estradiol or testosterone, and bone age were measured in all children. All received a 1 microgram/kg iv bolus dose of GHRH-(1-44)NH2, and GH responses were measured during a 2-h sampling period. Incremental serum GH responses in girls did not change throughout pubertal development and were similar to those of adult women. The responses in boys at midpuberty were somewhat lower (P less than 0.05) than those in either prepubertal boys or adult men. ISS children had mean GH responses [23 +/- 4 (+/- SE) ng/ml] similar to those of normal children. GHD children had significantly lower mean GH responses (11 +/- 3.7 ng/ml) than normal prepubertal children (35 +/- 4.0 ng/ml; P less than 0.01), but the responses of 17 of the 32 GHD children overlapped with the normal range. GH responses to GHRH were not correlated with bone age, weight, height, SmC levels, or estradiol or testosterone concentrations. These results indicate that GH responses to GHRH testing are relatively constant throughout puberty and young adulthood, that ISS children respond normally to GHRH, and that the GHRH test is not a reliable discriminator between individual normal and GHD children.

Proximate determinants of fertility in the Kathmandu Valley, Nepal: an anthropological case study

This article employs the analytical model of Bongaarts and Potter to compare the proximate determinants of fertility among three populations in Nepal's Kathmandu valley with the following characteristics: (1) high and low caste, (2) urban and urban fringe residence, and (3) users and non-users of contraception. It is shown that while Nepal, as a whole, is firmly entrenched in Phase 1 of the fertility transition, each of the populations studied has begun to experience a demographic transition to different degrees. In fact, greater progress in controlling fertility has been made than previously known.

Physician-patient power struggles: their role in noncompliance

Physicians have tended to label the patient who doesn't follow their advice as resistant and noncompliant. However, compliance studies have not identified the physician's sometimes unwitting complicity in the noncompliance. Some physician-patient partnerships are marked by an intensifying power struggle which may have more to do with the emotional needs of each party than with the specific content around which the struggle is focused. This article discusses how these power struggles can be activated and what the physician can do to defuse the struggle and work effectively with noncompliant patients.

Ovine corticotropin-releasing hormone stimulation test in normal children

We administered ovine corticotropin-releasing hormone (CRH) as a bolus iv injection (1 microgram/kg) to 21 normal boys and girls, aged 6-15 yr. CRH stimulated release of immunoreactive ACTH and cortisol in all children. The peak plasma ACTH and cortisol levels after CRH were 15.7 +/- 9.4 (SD) pg/ml and 14.3 +/- 3.6 micrograms/dl, respectively, in the girls, and 20.7 +/- 9.7 pg/ml and 16.6 +/- 3.3 micrograms/dl, respectively, in the boys. Plasma ACTH and cortisol responsiveness to CRH did not differ between girls or boys, or between children and adults. Cortisol-binding globulin concentrations in plasma did not change with age. We conclude that CRH provides a safe means of stimulating the pituitary-adrenal axis in children.

Short term, low dose estradiol accelerates ulnar growth in boys

We previously described a biphasic dose-response curve for ethinyl estradiol on short term growth in patients with Turner's syndrome. To investigate whether there is a similar phenomenon in boys, we measured the 3-week ulnar growth velocity (TUG) after administration of different doses of estradiol to five prepubertal or early pubertal boys. Basal TUG was determined initially. Subsequently, the boys received a 4-day iv infusion of estradiol at each of three doses (4, 20, and 90 micrograms/day) given double blind in a randomized sequence. TUG was determined before and after each infusion and was allowed to return to baseline before giving the second and third infusions. Mean TUG increased from 0.45 +/- 0.11 (+/- SEM) to 1.38 +/- 0.51 mm/3 weeks after the 4 micrograms/day infusion (P less than 0.05), from 0.49 +/- 0.11 to 1.0 +/- 0.4 mm/3 weeks after the 20 micrograms/day infusion (P = NS), and from 0.46 +/- 0.1 to 0.84 +/- 0.12 mm/3 weeks after the 90 micrograms/day infusion (P = NS). The mean serum estradiol level was 10 +/- 2.3 pg/ml during the 4 micrograms/day infusion, 16 +/- 2.3 pg/ml during the 20 micrograms/day infusion, and 96 +/- 12 pg/ml during the 90 micrograms/day infusion. Mean serum somatomedin-C levels were significantly higher only after the 20 and 90 micrograms/day estradiol infusions. We conclude that low dose estrogen can stimulate ulnar growth in boys and may play a role in the male pubertal growth spurt.

Effects of pulsatile administration of growth hormone (GH)-releasing hormone on short term linear growth in children with GH deficiency

To assess the efficacy of GH-releasing hormone (GHRH) in the treatment of GH deficiency, we measured the effects of pulsatile iv GHRH administration on GH secretion, plasma levels of somatomedin-C (SmC), and short term linear growth (as determined by lower leg measurements) in seven GH-deficient children in a placebo-controlled study. Either GHRH, at a dose of 1 microgram/kg (seven patients), or 0.9% saline (NS; four of these patients) was given iv every 3 h for 9-12 days; all patients also received GH for a similar period. Lower leg length was measured every 3 weeks before and after each treatment. GHRH was more effective than placebo in accelerating linear growth (P less than 0.05). The responses, however, were heterogeneous; four of the children responded with accelerated growth, and three did not. Two of the children who failed to grow had no increase in plasma GH or SmC during GHRH administration, and one had an attenuated GH response. The four children who grew had induction of pulsatile GH secretion [mean peak GH, 10.4 +/- 1.3 (+/- SEM) ng/ml after GHRH vs. 1.5 +/- 0.5 ng/ml after NS; P less than 0.05] and elevation in SmC levels (maximum, 0.5 +/- 0.1 U/ml during GHRH vs. 0.19 +/- 0.05 during NS; P less than 0.01). The lower leg growth velocity during GHRH treatment (2.8 +/- 0.2 mm/3 weeks) was greater than their own basal rate (0.6 +/- 0.2 mm/3 weeks; P less than 0.01) or their growth during placebo treatment (0.4 +/- 0.2 mm/3 weeks; P less than 0.01). Thus, repeated administration of GHRH stimulated increases in GH and SmC in some but not all GH-deficient children. The growth response appears to be related to the magnitude of the GHRH-stimulated rise in GH levels. GHRH increases short term linear growth in some children with GH deficiency and holds promise as an alternative to GH as a form of therapy in these patients.

Growth hormone secretory dynamics in Turner syndrome

We investigated whether a decrease in serum growth hormone contributes to the short stature of adults with Turner syndrome by measuring the 24-hour profile of serum growth hormone in 30 patients aged 2 to 20 years. Growth hormone pulses were defined as a rise from nadir to peak that exceeded three times the intraassay coefficient of variation. Girls with Turner syndrome aged 2 to 8 years did not have statistically different growth hormone levels, peak amplitudes, and peak frequencies compared with those in age-matched controls. By contrast, girls with Turner syndrome aged 9 to 20 years had significantly decreased mean 24-hour growth hormone levels, peak amplitudes, and peak frequencies compared with those in age-matched normal girls. Patients with Turner syndrome of all ages had decreased serum somatomedin-C concentrations and delayed bone ages. We conclude that a relative deficiency of growth hormone in pubertal patients with Turner syndrome may contribute to their adult short stature.

Factor analysis as a tool in community diagnosis

For the family physician, community diagnosis can be likened to individual diagnosis by the application of methods of information acquisition and analysis. This paper describes the technique of factor analysis, applied to data from an urban inner-city area, for reducing a multitude of factors to a manageable number without an appreciable loss of information. The variables were selected from four broad categories which have been shown to influence both health states and health care needs: demography, socioeconomics, social disorganization and morbidity/mortality. A correlation matrix based on 40 of the most accessible indices served as input for a principal axes factor analysis. Six factors accounted for 74% of the total variance and were interpreted as: 'Poverty and social disorganization', 'Distribution and problems of the elderly', 'Ethnic composition', 'Fertility', 'Infant mortality' and 'Foetal mortality'. Representative indices from each factor were then mapped to identify and display census tract differences. Finally, the application of the factors to a specific community illustrated important differences within the community and identified areas of high risk and need.

A comparison of two methods for detecting hormone peaks: the effect of sampling interval on gonadotropin peak frequency

There is no consensus on the optimum method to identify gonadotropin pulses in serum. We compared two approaches for detecting gonadotropin peaks. The first employed the conventional criterion of an increment from nadir to peak of 3 times the intraassay coefficient of variation (3 CV). The second identified peaks by Student's t test to quadruplicate measurements at each time point. We obtained blood samples every 5 min for 6 h from four women in the follicular phase. We also constructed control or noise series by subdividing single serum pools into consecutively labeled aliquots. Any variations in hormone concentration in the noise series that were identified as peaks were, by definition, false positive peaks. We evaluated the effect of sampling interval on gonadotropin peak detection by omitting data to simulate sampling every 10, 15, or 20 min. The 3 CV approach identified numerous false positive peaks in the noise series and detected as many peaks in the noise series as it did in the patient series. Increasing the sampling frequency from every 20 to every 5 min nearly doubled the apparent peak frequencies in both the patient and the noise series (P less than 0.025). By contrast, the t test method detected far fewer false positive peaks and significantly more peaks in the patient series than in the noise series. Increasing the sampling frequency from every 20 to every 5 min resulted in a 50-75% increase in peak frequency by the t test method. This increase in peak frequency appeared to result from improved detection of small peaks, because samples were obtained nearer the true peaks and nadirs. The resulting increase in the nadir to peak increment made it more likely that a small peak would achieve statistical significance. We conclude that increasingly stringent criteria for pulse detection should be applied as one increase the sampling frequency, and that the t test approach is a more valid method than the 3 CV approach because it yields significantly fewer false positive peaks.

Variable response to a long-acting agonist of luteinizing hormone-releasing hormone in girls with McCune-Albright syndrome

Six girls with McCune-Albright syndrome were treated for at least 2 months with the long-acting LHRH agonist D-Trp6-Pro9-NEt-LHRH, which previously was found to be an effective treatment for true precocious puberty. Nocturnal and LHRH-stimulated serum gonadotropin levels and plasma estradiol levels were measured before treatment and after 2-3 months of treatment. Five of the six girls had no decrease in serum gonadotropin or plasma estradiol levels during therapy, and their pubertal signs were unaffected by treatment. All five of these girls had serum gonadotropin levels that were within or below the normal prepubertal range. The sixth girl, who had gonadotropin levels in the normal pubertal range before treatment, had decreased serum gonadotropin and plasma estradiol levels during 1 yr of LHRH analog therapy. This was associated with cessation of menses and regression of secondary sexual changes. The failure of LHRH analog to modify the course of precocious puberty in the five patients with prepubertal serum gonadotropin concentrations is further evidence that the mechanism of precocious puberty in most girls with McCune-Albright syndrome differs from that in patients with true precocious puberty.

Ocular findings in Turner syndrome. A prospective study

We performed complete ophthalmological examinations of 30 consecutive patients with Turner syndrome. Twenty-three had 45XO and 7 had 45XO/46XX karyotypes (mosaicism). Non-familial strabismus was the most prominent ocular abnormality and was present in 33% of the patients. Other eye findings included ptosis (16%), hypertelorism (10%), epicanthus (10%), and antimongoloid slants (10%). Red-green color deficiency was found in 10% of the patients. One patient had congenital periodic alternating nystagmus.

Absence of pubertal gonadotropin secretion in girls with McCune-Albright syndrome

Precocious puberty in girls with McCune-Albright syndrome has been attributed in some cases to early activation of the hypothalamic-pituitary-gonadal axis and in other cases to sex steroid secretion by apparently autonomous ovarian cysts. We evaluated serum gonadotropins and sex steroids in six girls (aged 1-9 yr) with McCune-Albright syndrome. The children had Tanner stage II-IV pubertal development. In five patients, nocturnal gonadotropin concentrations and the gonadotropin response to LHRH were within the normal range for prepubertal children. Thus, the precocious puberty in these patients could not be explained by activation of the hypothalamic-pituitary-ovarian axis. One child had high amplitude nocturnal pulses of serum LH and a LH-predominant response to LHRH. She was the oldest of the six girls and had a bone age of 13.5 yr which is within the range in which hypothalamic-pituitary-ovarian activation normally occurs. The children all had ovarian enlargement and ovarian cysts determined by ultrasound. It appears that precocious puberty in McCune-Albright syndrome may result from ovarian estrogen secretion in the absence of normal pubertal activation of the hypothalamic-pituitary-ovarian axis.

Social and economic forces affecting intergenerational relations in extended families in a Third World country: a cautionary tale from South Asia

This paper questions the implicit assumption derived from modernization theory that elderly persons in the Third World lead secure and satisfying lives because they still live in extended families. Data from elderly Hindus living in Kathmandu, Nepal, are presented and demonstrate that, although these elderly people do continue to live in extended families, social and economic changes have transformed the nature of intergenerational social relations within these families to the detriment of the elderly family members.

Developmental changes in neuroendocrine regulation of gonadotropin secretion in gonadal dysgenesis

Patients with gonadal dysgenesis have a marked increase in gonadotropin levels at the age when puberty normally occurs. To determine whether this increase results from a change in the frequency or the amplitude of gonadotropin pulses, we measured the 24-h profile of plasma LH and FSH by RIA in 31 patients with gonadal dysgenesis, aged 2-20 yr. Gonadotropin pulses were defined as a rise from nadir to peak that exceeded 3 times the intraassay coefficient of variation. This criterion, based on an empirical study of RIA noise, reduced the rate of false positive peaks to less than 3-4/24 h. Using this criterion, peak amplitude increased significantly at the time of puberty for both LH and FSH (P less than 0.01). The overall frequency of gonadotropin pulses (the sum of the FSH peaks plus the LH peaks that occurred without a concomitant FSH peak), however, did not differ among prepubertal (12.7 +/- 1.8 peaks/24 h), pubertal aged (14.3 +/- 2.3 peaks/24 h), and adult patients (14.7 +/- 0.9 peaks/24 h). Thus, the increase in gonadotropin concentration in pubertal aged patients with gonadal dysgenesis appears to result primarily from an increase in gonadotropin peak amplitude rather than an increase in peak frequency.

Noonan's syndrome and hypopituitarism

A 37-year-old man with Noonan's syndrome hypopituitarism is described. The patient had small stature, minor facial abnormalities, cubitus valgus and pectus excavatum. In addition, endocrine testing revealed deficiencies of growth hormone, gonadotrophins and TSH. Prolactin increased normally in response to TRH administration, but failed to rise after chlorpromazine. Although intrinsic pituitary dysfunction cannot be excluded, the dissociated response of prolactin to TRH and chlorpromazine suggests that the pituitary hormone deficiencies may be secondary to hypothalamic dysfunction.

Massive osteolysis. An unusual cause of bone destruction

A patient who presented with multiple lytic lesions of bone was found to have massive osteolysis. The clinical course of this patient is described and the literature on massive osteolysis reviewed. This disease of uncertain etiology is pathologically marked by resorption of bone, and replacement by angiomas and fibrosis. X-ray findings are usually more severe than expected from the patients' clinical presentation. Laboratory studies, including attempts at biopsy, are generally unrevealing. Drug therapy is of no value, and success of surgical attempts at bone union are unpredictable. Massive osteolysis should be considered in the differential diagnosis of osteolytic lesions, particularly since this disorder can result in serious morbidity.