Aromatase activity in genital skin fibroblasts from normal and androgen-insensitive individuals

Human genital skin fibroblasts were used to study aromatase activity by analysing the [3H]H2O released as [1 beta-3H]androstenedione is converted to oestrone. 4-Hydroxyandrostenedione was shown to be a competitive inhibitor of this aromatase activity, the concentration of inhibitor producing 50% inhibition being 1.29 nmol/l. Dexamethasone stimulated the enzyme complex in a dose-dependent manner with half-maximal stimulation at 11.5 nmol/l. A peak of induction occurred after 16 h of preincubation. Measurement of aromatase activity in normal cell strains provided a normal range for the Michaelis-Menten constant (Km) and the maximum velocity (Vmax) of 6.72 +/- 0.54 nmol/l and 215.3 +/- 33.9 fmol/mg protein per h (mean +/- S.E.M., n = 20) respectively. Km values obtained for partial and complete androgen insensitivity syndrome (PAIS and CAIS) patient cell strains were all within the normal range. The mean Vmax +/- S.E.M. in cell strains from patients with PAIS (n = 13) and CAIS (n = 11) were 127.4 +/- 19.2 and 54.8 +/- 19.3 fmol/mg protein per h respectively. Vmax values for patients with CAIS were significantly (P less than 0.001) lower than normal subjects. This suggests that aromatase expression in genital skin fibroblasts is androgen-dependent.

Response to treatment of congenital adrenal hyperplasia in infancy

Nine infants with congenital adrenal hyperplasia were started on replacement doses of hydrocortisone (20.6-32.6 mg/m2/day) without receiving a high dose for an initial period first. Plasma adrenal steroid concentrations fell to acceptable levels by 3 months of age. Adequate biochemical control was maintained and satisfactory growth achieved even though the mean dose of hydrocortisone had been reduced to 15 mg/m2/day by the age of 3 years. Inadvertent overtreatment and growth suppression in infants with congenital adrenal hyperplasia may be avoided by using replacement doses from the start, and by permitting the relative dose of hydrocortisone to fall as the body surface area increases during the first year of life.

Dexamethasone treatment for congenital adrenal hyperplasia

Ten patients with congenital adrenal hyperplasia (three males, seven females; aged 12-29 years) had their usual glucocorticoid treatment changed to dexamethasone in three crossover dosage regimens. A starting dose of 5 micrograms/kg/day is suggested but as no one dose regimen resulted in adequate control the timing of the dose must be decided for each patient.

Congenital adrenal hyperplasia

An autosomal recessive disorder, congenital adrenal hyperplasia, results from a deficiency in the activity of one of the five enzymes required for cortisol biosynthesis. More than 90% of cases are related to deficiency in 21-hydroxylase enzyme activity, which is required for the conversion of 17OH-progesterone to 11-deoxycortisol. Treatment of congenital adrenal hyperplasia consists of steroid replacement to ensure normal growth and reproductive potential.

Growth and body proportions in congenital adrenal hyperplasia

Total height, sitting height, and subischial leg length were measured in 27 patients (19 girls and eight boys aged 4.3-21.1 years) with congenital adrenal hyperplasia to determine the influence of chronic hyperandrogenaemia on body proportions. Proportions were normal in 24 patients with classical congenital adrenal hyperplasia who had received steroid treatment since birth, but one of three patients with non-classical (late onset) congenital adrenal hyperplasia had a disproportionately large trunk. Eleven patients with classical congenital adrenal hyperplasia had completed growth, of whom seven had height standard deviation (SD) scores for chronological age less than zero, and one had extremely short stature (SD score -3.25). In 13 patients who were still growing, nine had height SD scores for chronological age of less than zero despite having mean (SD) advances in bone age over chronological age of 1.64 (1.68) years. Height SD scores for bone age were less than 0 in all 13 patients, indicating a loss of height despite advanced skeletal maturation. Doses of glucocorticoid that permit mild chronic or intermittent hyperandrogenaemia also seem to be associated with mild growth retardation. An adult height below average may be an inevitable consequence for many patients with congenital adrenal hyperplasia receiving conventional glucocorticoid treatment.

Myelodysplastic syndrome with trisomy 8 in an adolescent with Fanconi anaemia and selective IgA deficiency

We describe a patient with growth failure and multiple congenital anomalies characteristic of Fanconi anaemia, but without the classical feature of progressive bone marrow hypoplasia. Following treatment with growth hormone for a period of 8 years, he presented with myelodysplastic syndrome and a karyotypically abnormal clone in the bone marrow (47,XY,+8). The diagnosis of Fanconi anaemia was supported by the induction of abnormally high levels of characteristic chromosome aberrations in peripheral lymphocytes following exposure in vitro to the bifunctional alkylating agent mitomycin C. Immune function studies also identified a selective IgA deficiency. The relative importance of interacting constitutional and exogenous factors involved in the development of preleukaemia in this patient is discussed.

Value of selective screening for congenital adrenal hyperplasia in Hungary

Measurement of the 17-hydroxyprogesterone concentration in blood spots was used to identify cases of congenital adrenal hyperplasia among patients with inappropriate virilisation, or salt wasting, or both. Between 1978 and 1986 61 were identified among 707 patients (278 neonates, 204 infants, and 225 children). The incidence of classic congenital adrenal hyperplasia was calculated for a seven year prospective trial period using the blood spot 17-hydroxyprogesterone method in selective screening. There were 38 salt losers and 14 simple virilisers in 968,303 live births, an incidence of congenital adrenal hyperplasia of 1:18,000 in the Hungarian population. Selective screening led to earlier diagnosis of congenital adrenal hyperplasia and a pronounced decrease in mortality. A central laboratory to measure the blood spot 17-hydroxyprogesterone concentrations is valuable for the investigation of patients at risk for congenital adrenal hyperplasia in countries where blood steroid assays are not readily available.

17OH-progesterone response to acute dexamethasone administration in congenital adrenal hyperplasia

Glucocorticoid-related changes in 17OH-progesterone (17P) concentrations were studied in 13 patients receiving treatment for 21-hydroxylase deficiency congenital adrenal hyperplasia (CAH). Blood spot and saliva 17P levels were elevated, with or without loss of diurnal rhythm, within 24 h of stopping maintenance glucocorticoid therapy. A single dose of dexamethasone (0.01 mg/kg) given either intravenously or orally at 09.00 h resulted in rapid onset of complete pituitary-adrenal suppression characterised by a prompt and exponential fall in 17P levels (first-order elimination half-life, mean 2.87 h, range 1.98-3.98 h). Concentrations of 17P remained low throughout the day until the onset of an abrupt nocturnal rise, which occurred between 24.00 and 05.00 h. There were individual differences in both the rate of fall and the timing of the nocturnal rise in 17P levels which may partly explain the need to vary individual steroid requirements in the treatment of CAH.

The pharmacokinetics of low-dose dexamethasone in congenital adrenal hyperplasia

The pharmacokinetics of dexamethasone, given at low dose, were studied in 13 patients with congenital adrenal hyperplasia (CAH) to ascertain whether kinetics differed in this inherited disorder of cortisol metabolism from those seen in healthy individuals. Changes in plasma dexamethasone concentration after intravenous bolus, measured using a simple novel radioimmunoassay, were well described by a two-compartment open model with first-order kinetics. Values for lambda 2: 0.206 h-1, t1/2: 3.53 h, Vc: 24.41 and f: 0.64 were similar to those previously reported for normal subjects. There were considerable interindividual differences in parameter values and Cmaxp.o. (range 22-67 nmol/l). As suppression of the hypothalamo-pituitary-adrenal axis correlates with plasma dexamethasone levels, this variability may partly explain the differing dose and dose schedule requirements necessary to achieve adequate therapeutic control in the clinical management of CAH.

Relationship between fetal adrenal morphology and anterior pituitary function

A comparative study of adrenal morphology between normal fetuses and those with anencephaly or congenital adrenal hyperplasia (CAH) was performed in order to examine the hypothesis that fetal adrenal mass and structure are adrenocorticotrophin (ACTH)-dependent throughout gestation. Combined adrenal weight in 102 normal fetuses was used to establish a reference range for the gestational ages of 15-27 weeks. During this period, mean adrenal weight showed a 6-fold linear increase. In 38 anencephalic fetuses of similar gestation age, adrenal weight was below the normal range and did not show a rise. Three fetuses with CAH (18, 22 and 30 weeks gestation) had adrenal weights considerably above the normal range. Adrenal cortical thickness was significantly increased in CAH fetuses, largely as a consequence of cell hypertrophy, whereas decreased cortical thickness in the anencephalic group represented cellular hypoplasia. Conspicuous secretory granules in the cytoplasm was the electron-micrographic feature of the adrenal gland in the 22-week fetus with CAH. These observations are consistent with close dependency of fetal adrenal growth and development upon fetal pituitary function from an early age, mediated primarily through ACTH.

Congenital hypothyroidism, spiky hair, and cleft palate

Two brothers are described with athyroidal hypothyroidism, spiky hair, choanal atresia, cleft palate, and bifid epiglottis. Polyhydramnios was present in the third trimester of each pregnancy. These abnormalities appear to represent a new syndrome.

170H-progesterone rhythms in congenital adrenal hyperplasia

Serial blood spot and saliva samples were collected at home by 18 patients being treated for congenital adrenal hyperplasia to determine the circadian rhythm of 170H-progesterone as an index of therapeutic control. There was a strong correlation between the magnitude of the circadian fall and a single morning measurement of the plasma testosterone concentration taken near the time of the 170H-progesterone rhythm samples. Poor control in pubertal girls produced an exaggerated circadian fall in 170H-progesterone concentrations that were raised at all sampling times. Optimal control (plasma testosterone 1.5-2.5 nmol/l) was associated with blood spot and salivary 170H-progesterone concentrations at 0800 hours of between 30-70 nmol/l and 260-1000 pmol/l, respectively, falling thereafter to less than 10 nmol/l and less than 150 pmol/l, respectively. Similar results were obtained in prepubertal patients. Nomograms have been constructed to interpret the daily profiles of blood spot or salivary measurements of 170H-progesterone, or both. The analysis of 170H-progesterone circadian rhythms is useful in monitoring treatment in patients with congenital adrenal hyperplasia, particularly those who may be overtreated.

Androstenedione rhythms in saliva in congenital adrenal hyperplasia

Serial samples of saliva were collected at home by 17 patients being treated for congenital adrenal hyperplasia to determine the circadian rhythm of androstenedione as an index of therapeutic control. Single samples of blood for measurement of plasma testosterone, 170H-progesterone, and androstenedione concentrations were collected from these and a further seven patients for comparison. Plasma androstenedione concentrations showed a close correlation with plasma concentrations of 170H-progesterone and testosterone. There was a strong correlation between the salivary androstenedione profiles and plasma testosterone concentrations in pubertal girls. Concentrations of androstenedione in saliva decreased during the day but remained raised at each sampling time in relation to plasma testosterone concentrations. Salivary androstenedione profiles are shown as nomograms to distinguish the degree of therapeutic control. The concentration of androstenedione, measured in plasma or saliva, is an alternative marker to monitor control of treatment in congenital adrenal hyperplasia. The measurement in saliva is a useful index of androgen production when blood sampling is difficult.

Cranial diabetes insipidus in early infancy

We report an infant who developed cranial diabetes insipidus after septicaemic shock. This condition should be considered in any child who suffers an acute collapse and it may be more common in the high risk neonate than has previously been recognised.

Unusual dual genital duct remnants in true hermaphroditism

A case of true hermaphroditism is reported in which a 46,XY karyotype was associated with a testis and an ovotestis. The dual presence of a Fallopian tube and a vas deferens on the side of the ovotestis is documented as a previously unreported finding.

Blood spot glucocorticoid concentrations in ill preterm infants

The adrenocortical response to stress was studied longitudinally in 10 ill preterm infants using measurements of cortisol and 170H-progesterone concentrations in filter paper blood spots. Mean cortisol and 170H-progesterone concentrations reached a peak of 2200 nmol/l and 65 nmol/l, respectively, between the third and fifth days of life. These concentrations far exceeded those observed in older children and adults subjected to stress as a result of surgery. Further pulses of endogenous cortisol production of 4000 nmol/l or more occurred in association with clinical complications such as intraventricular haemorrhage. These results indicate that infants undergoing intensive care are unduly stressed. Consideration should be given to providing enough sedation and appropriate analgesia for ill preterm infants during painful procedures such as insertion of venous cannulae and arterial puncture.

Non-adenomatous inappropriate TSH hypersecretion and euthyroidism requires no treatment

The syndrome of inappropriate TSH secretion is described in a euthyroid girl and her father. Based on nuclear T3 binding studies in fibroblasts, generalized tissue resistance was associated with a lower binding affinity for T3 in nuclear extracts suggestive of a structurally abnormal receptor for T3. Early recognition of the syndrome and observation of the short-term response to thyroid medication prevented unnecessary trials of antithyroid medication and later radical ablative thyroid treatment.

United Kingdom multicentre clinical trial of somatrem

In a multicentre clinical trial 54 children aged 4.0 to 17.3 years, who had growth hormone deficiency that had not previously been treated, were given biosynthetic methionyl growth hormone (somatrem) 4 units three times a week by subcutaneous or intramuscular injection for one year. Height was measured every three months for at least one year before and during treatment. Forty two patients responded to treatment with an increase in growth of greater than 1.5 cm/year. The remaining 12 who grew more slowly were less obviously short and had a higher pretreatment growth than those who responded. The three who responded and the one who did not had undergone therapeutic spinal irradiation before starting the drug. If a whole year's pretreatment growth rate of less than 5 cm/year had been used as a diagnostic criterion the prediction of those who responded would have slightly improved. About two thirds of the patients developed antibodies against growth hormone and Escherichia coli protein; these were, however, of low and fluctuating titre and binding capacity, and did not influence the response to treatment. No adverse side effects were encountered. We conclude that somatrem is a safe and effective alternative to pituitary growth hormone.

Prenatal diagnosis of congenital adrenal hyperplasia: reliability of amniotic fluid steroid analysis

The concentration of 170H-progesterone was measured in amniotic fluid samples collected from 55 mothers who had previously had a child with congenital adrenal hyperplasia due to 21-hydroxylase deficiency. In eight pregnancies the levels of 170H-progesterone were raised; the parents elected to terminate in four and examinations of the fetus confirmed the diagnosis of congenital adrenal hyperplasia. In each case, the affected sib was a salt loser. The remaining four affected pregnancies proceeded to term and each infant had salt losing 21-hydroxylase deficiency. All 47 infants predicted to be unaffected were normal at birth. However, an increased plasma concentration of 170H-progesterone was documented in a male non-salt loser at three months of age. Prenatal diagnosis of congenital adrenal hyperplasia by amniotic fluid steroid analysis is reliable only for the salt losing variant of 21-hydroxylase deficiency. Of the affected sibs in this study, 20% died during infancy in a salt losing crisis. This simple and rapid prenatal test is sufficiently reliable to predict the group of infants most at risk in early infancy.

Characterization of nuclear thyroid hormone receptors of cultured skin fibroblasts from patients with resistance to thyroid hormone

Nuclear thyroid hormone receptors of patients with the syndrome of resistance to thyroid hormone were investigated in cell lines from seven patients in four affected families and compared to results from six normals. Fibroblasts cultured from skin biopsies were used. When binding affinity and capacity for L-triiodothyronine (T3) were examined by incubating whole cells or isolated nuclei, no significant differences were found. The amount of receptor released during the incubation of nuclei (9.3% to 19.0% of total nuclear receptors) was also within the normal range in these patients. When T3 binding assays were performed on 0.3 mol/L KCl extracted receptor, a significant decrease in binding capacity (MBC) without a difference in binding affinity (Ka) was observed in four patients and a lower Ka with normal MBC was found in two patients. Recovery of receptors in saline extracts, from patients' fibroblasts showing a low MBC, was low in comparison to normals. Lability of salt extracted receptors at 38 degrees C was normal and salt extractability of T3 occupied receptors, examined by incubation of [125I]-T3 labeled nuclei with various concentrations of KCl, was only slightly decreased. This lower salt extractability of receptors was insufficient to account for the low MBC obtained by Scatchard analysis of T3 binding to nuclear extracts. Gel filtration and density gradient sedimentation of salt-extracted receptors showed Stokes radius of 34 A, and sedimentation coefficient of 3.4 S in all patients and normals. From these values, molecular weight of 49,000 and total frictional ratio (f/fo) of 1.4 were calculated for nuclear receptors from patients and normals, suggesting a somewhat asymmetrical shape of receptors.(ABSTRACT TRUNCATED AT 250 WORDS)

Amniotic fluid steroid levels and fetal adrenal weight in congenital adrenal hyperplasia

The concentration of 17-OH-progesterone was determined in second trimester amniotic fluid collected from 58 pregnancies at risk for fetal 21-hydroxylase deficiency. The prediction was incorrect in 1 male nonsalt-loser who had an increased plasma 17-OH-progesterone concentration at 3 months of age. All 11 infants predicted to be affected were salt-losers. The adrenals from 2 affected fetuses available for study were significantly enlarged in comparison with adrenal size in 84 normal fetuses from 15 to 26 weeks' gestation. Amniotic fluid steroid analysis reliably predicts the fetus with 21-hydroxylase deficiency most at risk in early infancy. There is no evidence from this study to indicate that ACTH is not the main trophic factor for fetal adrenal growth and steroidogenesis.

Androgen insensitivity in forty-nine patients: classification based on clinical and androgen receptor phenotypes

Androgen receptor binding was studied in genital skin fibroblasts from 49 patients with androgen insensitivity syndrome (AIS) classified as complete (CAIS) or partial (PAIS) based on the clinical phenotype. The majority (64%) of CAIS and a minority (7%) of PAIS patients were receptor negative. Only 3 receptor-positive AIS cell strains of 30 studied failed to show an increase in specific receptor binding after prolonged androgen exposure in vitro. The gene coding for the androgen receptor in such patients appears intact.

The relationship between diabetic control and individual and family characteristics

Thirty eight children and adolescents between the ages of 10 and 17 years were examined for an association between diabetic control and psychological health determined by questionnaires to examine self concept, locus of control and family cohesion and adaptability. The group as a whole had a high score on the self esteem dimension, were moderately external on the locus of control scale and the families were considered close and flexible. HbA1 showed modest correlations with adaptability (p less than 0.05) and with locus of control (not significant on this small sample size). The data suggests, surprisingly, that there is a tendency for good diabetic control sometimes to be achieved by individuals with an external locus of control by a rigid family organisation when there is a danger that the development of autonomy and independence may be at risk. There is also the suggestion that a few individuals have achieved a balance between moderately good diabetic control and psychological health.

Radioimmunoassay of blood-spot 17 alpha-hydroxyprogesterone in the management of congenital adrenal hyperplasia

A robust assay for routine measurement of blood-spot 17 alpha-hydroxyprogesterone (17-OHP) concentrations has been developed using a magnetizable, solid-phase antiserum and an 125I-radioligand. The working range of this assay (13.5-500 nmol/L) is well suited for the initial diagnosis of congenital adrenal hyperplasia (CAH) and for monitoring replacement therapy in CAH patients. Data derived from multiple blood-spot samples, collected on two consecutive days, provide 17-OHP profiles. These profiles have been used to construct a chart allowing a rapid visual assessment of the efficacy of replacement therapy in CAH patients. Measurement of 17-OHP in the blood-spots of overtreated patients and accurate determination of normal range values in healthy infants relied on development of a sensitive assay (range 1.7-34 nmol/L). In the blood-spots of normal male (n = 50) and female (n = 50) infants collected 5-7 days after birth, 17-OHP concentrations were 7.62 +/- 2.55 nmol/L and 7.32 +/- 2.87 nmol/L respectively. Retrospective measurement of this steroid in samples from known CAH patients (n = 4), which had values ranging from 224 to 2145 nmol/L, support a role for measurement of blood-spot 17-OHP in high-risk screening programmes.

Some aspects of androgen insensitivity

The clinical and endocrine features of the syndromes of androgen insensitivity which display a wide phenotypic spectrum are reviewed. A simple, dispersed whole cell assay to study androgen receptor binding in genital skin fibroblasts has been used to determine the pathogenesis of androgen insensitivity. Classification of the disorders based on in vitro studies does not show absolute concordance with the clinical sub-groups. Androgen-induced augmentation of basal specific binding is proposed as a possible functional test of androgen responsiveness in disorders such as partial androgen insensitivity, isolated hypospadias and micropenis. Understanding the cause of androgen insensitivity in many receptor-positive patients awaits identification and isolation of DNA probes for the X-linked gene locus for the androgen receptor.

An autosomal dominant form of adolescent multinodular goiter

Eighteen members of an extended pedigree have been found to have a form of euthyroid adolescent multinodular goiter. Histological examination showed multiple adenomata with areas of epithelial hyperplasia, hemorrhage, and calcification. In two subjects there were focal areas of epithelial hyperplasia reminiscent of low-grade papillary carcinoma, but capsular and vascular invasion was not found. The pattern of inheritance appeared to be autosomal dominant, with diminished penetrance in males. Although the patients were euthyroid, the likely basis for this disorder is an abnormality in thyroglobulin structure and function.

Height in epilepsy

Longitudinal data on the height of prepubertal children with epilepsy are presented. Although both seizures and antiepileptic drugs may affect serum hormone concentrations, linear growth remains normal.

The relationship between von Willebrand factor antigen and fibronectin in human plasma, endothelial cells and fibroblasts in culture

The distribution of von Willebrand factor antigen (vWFAg) and fibronectin (Fn) in endothelial cells and in fibroblasts in culture was examined using immunohistological methods. Extracellular matrices were studied after removal of cells by mild hypotonic lysis. Co-distribution of these antigens was also examined after culture of fibroblasts in the presence of endothelial cell conditioned medium or of exogenous vWFAg. The presence of intracellular vWFAg and its association with extracellular Fn in confluent endothelial cells was confirmed. Furthermore, both antigens were detected in matrices from fibroblasts grown in the presence of human plasma and endothelial cell medium. vWFAg was not found, however, in the absence of endothelial cell conditioned medium or in experiments using human serum in place of plasma. Cross-linking of vWFAg was examined using quantitative and qualitative electrophoretic methods. Levels of vWFAg in serum from patients with severe Haemophilia A were approximately 50% of those found in the corresponding plasma. Furthermore, vWFAg was reduced to similar levels in serum from normal blood to which heparin was added. The lowest levels of vWFAg were found in the presence of sufficient heparin to totally inhibit the formation of fibrin. In contrast, levels of Fn remained unchanged in these circumstances. The results did not support the view that vWFAg was cross-linked to Fn in plasma by thrombin-activated factor XIII. In addition, immunoelectrophoresis of cultured endothelial cell products did not demonstrate cross-linking of vWFAg to Fn. The data are consistent with the concept that deposition of vWFAg on the subendothelium is dependent on viable endothelial cells or on another product of these cells.

Mild androgen insensitivity presenting with sexual dysfunction

A man presented with sexual dysfunction and was found to have elevated serum levels of both gonadotropins and T, suggesting AIS. Small external genitalia were the only phenotypic abnormality. Serum T levels increased appropriately in response to hCG and CC, but the patient was severely oligospermic, and testicular biopsy study revealed profoundly impaired spermatogenesis. Studied on androgen receptors in genital skin fibroblasts were normal. PAIS with a virtually normal male phenotype can present in adulthood with sexual dysfunction as well as infertility. As with the syndrome of complete AIS, androgen receptor studies indicate that this is a heterogeneous group of disorders.

Complete androgen insensitivity syndrome characterized by increased concentration of a normal androgen receptor in genital skin fibroblasts

Two siblings with the classical phenotype of complete androgen insensitivity syndrome (CAIS) and increased total cellular androgen receptor concentrations in genital skin fibroblasts (GSF) are described. Testosterone biosynthesis was normal, and there was no evidence of 5 alpha-reductase deficiency. Specific binding of [3H]dihydrotestosterone ([3H]DHT) in GSF was 7 SD above the mean value in normal fibroblast strains [maximum binding, 775 +/- 185 X 10(-18) mol/micrograms DNA (mean +/- SD)]. Binding at 40 C was stable, and the androgen-receptor complex dissociated at a normal rate (t1/2, 85 min). The androgen-receptor complex from GSF cytosol sedimented at 5-6S on sucrose density gradients in the presence of sodium molybdate. In a whole cell binding assay, the percentage of [3H]DHT that bound to a crude nuclear pellet was 60%. Preincubation of GSF with 2 nM [3H]DHT for 20 h before the standard 1-h whole cell binding assay produced a further augmentation in elevated total cellular androgen receptor concentrations. A new variant of CAIS is described which is characterized by an increased concentration of androgen receptors that appear to be quantitatively and qualitatively normal. Augmentation of the receptor by androgen suggests that the gene coding for the androgen receptor is intact and does not account for the androgen insensitivity.

Body proportions in Turner's syndrome

Body proportion was studied in Turner's syndrome by measurement of standing an sitting heights in relation to chronological and bone age. The mean standard deviation score for standing height was -3.8. Disproportionate growth of the legs was not a major determinant of short stature, either before or after oestrogen replacement.

Early diagnosis of 11 beta-hydroxylase deficiency in two siblings confirmed by analysis of a novel steroid metabolite in newborn urine

Plasma and urinary steroid measurements are reported in 2 normotensive newborn female siblings with virilized external genitalia due to 11 beta-hydroxylase deficiency. Plasma 11-deoxycortisol concentrations were markedly elevated whereas 17OH-progesterone concentrations were not raised. Plasma renin activity was suppressed, but increased to levels characteristic of infancy within 4 weeks of treatment. The enzyme defect was confirmed by measurement of increased urinary excretion of tetrahydro-11-deoxycortisol. A more polar steroid metabolite, 6 alpha-hydroxytetrahydro-11-deoxycortisol was also determined by gas chromatographic and mass spectrometric analysis. Analysis of metabolites in urine is an additional specific marker to plasma 11-deoxycortisol measurement for the diagnosis of 11 beta-hydroxylase deficiency in early infancy.

Response to ACTH in the newborn

Adrenocortical function was studied in 52 newborn infants who had been divided into three groups: preterm well, preterm ill, and term ill. Basal plasma 17-hydroxyprogesterone concentrations were significantly increased in both groups of preterm infants. There was no significant difference in basal plasma cortisol concentrations, although they were highest in preterm ill infants. All infants responded to adrenocorticotrophic hormone (ACTH) stimulation (36 micrograms/kg intramuscularly) with a two to three fold increase in the concentration of both steroids. The peak plasma 17-hydroxyprogesterone response was significantly higher in preterm ill infants. A subgroup of five infants, who were highly stressed but had undetectable basal plasma cortisol concentrations, also showed an appropriate response to ACTH. The results provide useful reference data to assess adrenal function in the infant of a mother given glucocorticoids during pregnancy. There is also a change from the pattern of fetal adrenal steroidogenesis soon after birth, which may be affected by exogenous ACTH stimulation. Roughly 10% of stressed newborns failed to synthesise cortisol basally; temporary glucocorticoid replacement for such infants may be appropriate.

Clinical aspects of congenital adrenal hyperplasia: early diagnosis and prognosis

The neonatal presentation of congenital adrenal hyperplasia is either virilization of females or salt loss in both sexes. Early diagnosis is based on the rapid measurement of plasma 17 alpha-hydroxyprogesterone. Milder forms of congenital adrenal hyperplasia can present later in life with abnormalities of somatic or sexual development. The majority of cases of congenital adrenal hyperplasia are clinically diagnosable in the first 2-3 weeks of life: the need for screening for the remaining missed cases and the late onset types remains to be established.

Augmentation of androgen-receptor binding in vitro: studies in normals and patients with androgen insensitivity

Using a simple whole-cell binding assay, the effect of androgens on receptor binding activity was studied in genital skin fibroblasts (GSF) from normals and patients with either androgen insensitivity syndrome (AIS), isolated micropenis or hypospadias. Expressing the response as a ratio of augmented to basal specific dihydrotestosterone (DHT) binding, there was a 2.4 +/- 0.87 (mean +/- SD) increase following 20 h incubation with 2 nmol/l [3H]-DHT in normal GSF. Mibolerone, a synthetic nonmetabolizable androgen, produced a similar response. Augmentation was temperature dependent, independent of androgen metabolism and suppressed by protein and RNA inhibitors. All patients with isolated micropenis and hypospadias demonstrated normal augmentation of receptor binding activity. There was no response in patients with complete AIS who were receptor negative. In the majority of patients with partial AIS, there was an in vitro response to androgens; those reared as males all virilized with androgen therapy. In contrast, a male patient with partial AIS who failed to respond to high-dose androgen therapy, showed no augmentation of specific androgen binding in GSF preincubated with androgens. This technique may be a useful in vitro bioassay to predict androgen responsiveness in vivo in patients with androgen insensitivity, either soon after birth in the short-term, or later at puberty.

Weight gain and height velocity during prolonged first remission from acute lymphoblastic leukaemia

A retrospective analysis of the medical records of 86 children in prolonged remission from acute lymphoblastic leukaemia was performed to calculate changes in the rate of increase in height and weight gain. The rate of increase in height decreased during initial treatment, and the potential for final adult height was not regained. Weight gain was excessive; this started during treatment and persisted into the remission years. Values of weight adjusted for height did not return to values found before treatment until eight years after diagnosis. Several factors can account for this weight gain, but there is a practical need to provide dietary advice, particularly when chemotherapy is stopped.

A rapid assay for 17 alpha OH-progesterone in plasma, saliva and amniotic fluid using a magnetisable solid-phase antiserum

A radioimmunoassay suitable for measurement of 17 alpha OH-progesterone concentrations in small aliquots of plasma (20 microL), amniotic fluid (20 microL) and saliva (200 microL) is described. The assay features an antiserum raised against a 17 alpha OH-progesterone-3-(O-carboxymethyl)oxime/BSA conjugate coupled to a magnetisable, solid-phase support; the homologous radioligand is a 125I-iodohistamine conjugate. This combination of a gamma-emitting ligand and a magnetic-separation procedure has the advantage of reducing assay time and cost; it also allows processing of plasma and saliva samples in the same assay batch. The method has satisfactory sensitivity, precision and accuracy. Data derived from clinical studies of patients with congenital adrenal hyperplasia indicate the usefulness of this assay in routine practice.

The use of salivary progesterone assays in the assessment of ovarian function in postmenarcheal girls

Menstrual cycle profiles of salivary progesterone were derived from daily samples obtained from 75 postmenarcheal girls aged between 12 and 17 years. Data were analysed to establish the proportion of girls exhibiting ovulatory cycles in each of several age groups following menarche or in groups based solely on chronological age. 'Luteal'-phase profiles of salivary progesterone, which were similar in shape to those characteristic of mature premenopausal women, were taken to indicate the probable occurrence of ovulation. The percentage of cycles in those subjects judged to be ovulatory, grouped according to gynaecological age, rose from 14% in the first year to 56% in the fourth year. Those classified according to chronological age, and where sufficient data permitted reliable estimates of the percentage of subjects ovulating, rose from 11% at 12 years of age to 64% for girls aged 16. These data are in reasonable concordance with published data using plasma progesterone and urinary methods for establishing ovulatory incidence, and indicate the value of salivary progesterone measurements in studies of ovarian function in adolescence.

Hyponatraemia in diabetes without ketoacidosis

At diagnosis six of 18 diabetic children had hyponatraemia with hyperglycaemia but no signs of dehydration or lipaemia. With insulin treatment alone plasma sodium concentrations in two children returned to normal. These children do not require specific treatment to correct the hyponatraemia.