Increased incidence of non-insulin-dependent diabetes mellitus among adolescents

OBJECTIVE

To determine whether a rise in the diagnosis of non-insulin- dependent diabetes mellitus (NIDDM) has accompanied the rise in obesity in the pediatric population, as it has among adults.

STUDY DESIGN

Medical records of 1027 consecutive patients from birth to age 19 years with a diagnosis of diabetes from 1982 to 1995 at a regional, university-affiliated pediatric diabetes referral center were reviewed and classified according to criteria of the National Diabetes Data Group.

RESULTS

The number of patients with a diagnosis of NIDDM rose from approximately 4% of new diagnoses of diabetes in patients from birth to age 19 years before 1992, to 16% in 1994. Among patients 10 to 19 years of age, NIDDM accounted for 33% of diagnoses of diabetes in 1994. The incidence of adolescent NIDDM in Greater Cincinnati increased tenfold, from 0.7/100,000 per year in 1982 to 7.2/100,000 per year in 1994. The mean (+/- SD) age and body mass index at presentation were 13.8 +/- 1.9 years and 37.7 +/- 9.6 kg/m2, respectively. The overall female/male ratio was 1.7:1, and female patients were seen 1 year earlier than male patients (p < 0.01). Male subjects had a higher body mass index than female subjects (p < 0.05). A first-degree relative with NIDDM was identified for 65% of patients. At presentation, 21% of the patients had had a diagnosis of at least one other condition associated with obesity.

CONCLUSION

There is an increasing incidence of NIDDM among adolescents in Greater Cincinnati, accompanying the national rise in adolescent obesity. Obesity and strong family histories of NIDDM are important risk factors. Because NIDDM leads to long-term morbidity, the prevention of obesity as well as early identification of overt disease, is critical.

Absence of molecular defect in the type II 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) gene in premature pubarche children and hirsute female patients with moderately decreased adrenal 3 beta-HSD activity

To date the molecular basis and hormonal criteria for inherited mild late-onset 3 beta-hydroxysteroid dehydrogenase (3 beta-HSD) deficiency congenital adrenal hyperplasia (CAH) have not been defined. We have thus investigated the presence or absence of mutation in the type II 3 beta-HSD gene encoding adrenal/gonadal 3 beta-HSD in each of five premature pubarche children and hirsute female patients manifesting moderately decreased adrenal 3 beta-HSD activity. ACTH-stimulated hormonal levels in all patients compared with mean levels in pubertal stage-matched normal subjects were between 2.5 and 6.5 SD for 17-hydroxypregnenolone levels, and between 2.5 and 7 SD for dehydroepiandrosterone levels in all except one patient. 17-Hydroxypregnenolone to cortisol ratios were between 2.5 and 4.3 SD, and dehydroepiandrosterone to androstenedione ratios were between 3 and 8.6 SD. The type II 3 beta-HSD gene regions of a putative promoter, exons I, II, III, and IV, and exon-intron boundaries in all subjects were amplified by polymerase chain reaction and then sequenced. All patients had normal sequences of the type II 3 beta-HSD gene in both alleles. Three female patients heterozygotic for severe 3 beta-HSD deficiency CAH with one allele mutation of the gene demonstrated normal ACTH-stimulated hormone profiles. These data indicate that moderately decreased adrenal 3 beta-HSD activity resulting in modestly increased delta 5 precursor steroid levels and delta 5 to delta 4 steroid ratios in premature pubarche and hirsute patients is not caused by a mutation in the type II 3 beta-HSD gene.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular status in young patients with insulin-dependent diabetes mellitus

BACKGROUND

Although the existence of diabetic cardiomyopathy in adults is firmly established, the presence of cardiac abnormalities in young diabetic patients is not universally accepted. We sought to determine the early stages of cardiac derangement and whether they are associated with renal dysfunction.

METHODS AND RESULTS

Thirty-nine patients (29 boys; mean age, 17.6 +/- 3.4 years) with insulin-dependent diabetes mellitus underwent echocardiography and timed overnight urine collection. Echocardiographic evaluation consisted of left ventricular mass, performance (shortening fraction, velocity of circumferential fiber shortening, stroke volume, and cardiac index), preload (end-diastolic dimension and volume), after-load (end-systolic wall stress and systemic vascular resistance), and contractility (velocity of fiber shortening relative to wall stress). Creatinine clearance and albumin excretion were measured from the urine sample. Glycosylated hemoglobin levels were measured; height and weight were measured; and Quetelet index (weight/height2) was calculated. These data were compared with control data. Left ventricular mass (26 +/- 6 versus 22 +/- 6 g/ht2.7, P < .01), the indexes of performance, blood pressure, and contractility (0.14 +/- 0.14 versus 0.003 +/- 0.03 circumference/s, P < .0003) were significantly higher in the diabetic patients than in control subjects. To evaluate the correlates of left ventricular mass and contractility in the diabetic patients, univariate and multiple regression analyses were performed. Significant univariate correlations of mass included albumin excretion (r = .36, P < .02), glycosylated hemoglobin (r = .35, P < .04), and stroke volume (r = .34, P < .03). A multivariate model included Quetelet index, albumin excretion, and duration of diabetes. Significant univariate correlations of contractility included insulin dosage (r = -.36, P < .02), creatinine clearance (r = .40, P < .02), and Quetelet index (r = .34, P < .03). A multivariate model included insulin dosage and creatinine clearance.

CONCLUSIONS

Early onset of diabetes mellitus is associated with increased left ventricular mass, performance, contractility, and blood pressure. These cardiovascular findings are correlated with increased creatinine clearance and microalbuminuria. These relations suggest that alterations in cardiovascular and renal function may occur in parallel in adolescents with insulin-dependent diabetes mellitus.

Genotoxicity and carcinogenicity in rats and mice of 2-amino-3,6-dihydro-3-methyl-7H-imidazolo[4,5-f]quinolin-7- one: an intestinal bacterial metabolite of 2-amino-3-methyl-3H-imidazo[4,5-f]quinoline

BACKGROUND

Compounds formed on the surface of fried or grilled meat and fish may be associated with increased risk of colon cancer. Normal intestinal bacteria can convert one of these compounds, 2-amino-3-methyl-3H-imidazo[4,5-f]quinoline (IQ), to the 7-hydroxy metabolite, 2-amino-3,6-dihydro-3-methyl-7H-imidazolo[4,5-f]quinolin-7-o ne (7-OHIQ), a direct-acting mutagen.

PURPOSE

We studied the genotoxicity and carcinogenicity of 7-OHIQ to determine if it is responsible for the colon-specific activity of IQ.

METHODS

The effects of pure, synthetic 7-OHIQ on DNA were evaluated in the Ames Salmonella typhimurium TA98 test, with and without an induced rat liver S9 fraction, and in the Williams DNA repair test using freshly explanted rat hepatocytes. 7-OHIQ was also subjected to an in vivo bioassay for 21 months by long-term intrarectal infusion in male F344 rats, using IQ and N-nitrosomethylurea (NMU) given intrarectally as positive tumor-producing controls. The standard NIH-07 rodent diet was supplemented with 15% corn oil to maximize any effect of the infused materials on the colon. A parallel bioassay involved intraperitoneal injection of 7-OHIQ in newborn mice, followed by dietary administration from week 11 to week 67. Again, IQ and NMU were used as positive controls.

RESULTS

We confirmed that 7-OHIQ is a direct-acting mutagen in the Ames test, with added S9 liver fraction giving higher mutagenicity. 7-OHIQ was negative in the Williams test, whereas IQ was positive. 7-OHIQ did not induce colon cancer in rats, and in the newborn mouse test it produced only a low incidence of liver neoplasms.

CONCLUSIONS

7-OHIQ is not genotoxic, for to be so classified it must be definitely positive in both the Ames and Williams tests; moreover, it is not carcinogenic, in marked contrast to IQ and NMU.

Distribution and correlates of creatinine clearance in children and adolescents with blood pressure elevation

The kidney has been implicated as both an etiologic factor and as a target organ in patients with essential hypertension. Renal function has not been studied extensively in children and adolescents with essential hypertension. Eighty-eight subjects, aged 6 to 23 years, with blood pressure persistently above the 90th percentile for age were studied. Creatinine clearance was determined from a single 24-hour urine collection. The mean creatinine clearance was 129.3 +/- 55.3 ml/min per 1.73 m2. Multiple regression analysis was used to investigate potential correlates of creatinine clearance. Because creatinine clearance was not normally distributed, the logarithm of creatinine clearance was used as the dependent variable. Body mass index, resting heart rate, and basal supine plasma renin activity were significant direct independent correlates. Peripheral vascular resistance at maximal exercise was an inverse correlate of the logarithm of creatinine clearance. These findings are consistent with previous studies of adults and may provide the basis for strategies to identify young patients with essential hypertension who are at risk for the development of renal dysfunction.

Maternal side effects of prenatal dexamethasone therapy for fetal congenital adrenal hyperplasia

Prenatal treatment of virilizing congenital adrenal hyperplasia in female fetuses via maternal dexamethasone (Dex) therapy (1-1.5 mg/day) from first trimester to birth was associated with excessive weight gain (47-56 pounds at 35-37 weeks gestation), Cushingoid facial features, severe striae resulting in permanent scarring, and hyperglycemic response (8-11.7 nmol/L) to oral glucose administration in all our experience (three cases). Other symptoms included hypertension, gastrointestinal intolerance, or extreme irritability. Previous pregnancies were uncomplicated by these problems. In each case, first or second trimester amniotic fluid 17-hydroxyprogesterone (17OHP, 17-41 nmol/L; normal less than 0.4 nmol/L), androstenedione (22-31 nmol/L, normal less than 5 nmol/L), and testosterone levels (0.54-0.7 nmol/L, normal less than 0.4 nmol/L) during Dex treatment were elevated regardless of the newborn genital outcome. Maternal serum estriol (E3) levels in one mother (normal newborn genitalia) were consistently low (less than 0.2 nmol/L) during the second and third trimester. In two mothers (partially virilized newborn genitalia) initial second trimester E3 levels were unsuppressed (11, 17.4 nmol/L) and suppressed (less than 1.4 nmol/L) following short-term increased dose.

CONCLUSION

prenatal Dex treatment of virilizing congenital adrenal hyperplasia at a dose of 1-1.5 mg daily throughout gestation is associated with significant maternal side effects. Parents should be informed of these side effects before initiation of treatment. Careful monitoring for signs of side effects, medical intervention when necessary, and lowering of Dex dose during the second half of gestation would minimize the side effects. Maternal serum E3 levels appear useful for prediction of fetal outcome while amniotic fluid steroid levels may not.

Profile of Renal Permselectivity by Simultaneous Enzyme-Linked Immunosorbent Assay of Albumin, Transferrin, IgG, and α1-Microglobulin with a New Microplate Reader

A competitive enzyme-linked immunosorbent assay (ELISA) is described for determining a renal permselectivity profile involving the urinary proteins albumin, transferrin, IgG, and alpha 1-microglobulin (alpha 1-m). The ELISA reader uses a computer-controlled array of multiplexed light-emitting diode (LED)-photodiode pairs for rapid measurements of absorbance on microplates. A 3,3'-dimethylnaphthidine reagent adapts the 3,5,3',5'-tetramethylbenzidine chromophore to monochromatic LED emission at 550 nm. We applied this ELISA to the determination of renal permselectivity in healthy children and young adults and in children with insulin-dependent diabetes mellitus. The geometric means (and SD) of protein excretion rates in a group of 85 normal subjects were as follows: albumin, 3.5 micrograms/min (1.83); transferrin, 173 ng/min (2.76); IgG, 1.11 micrograms/min (2.22), and alpha 1-m, 0.98 microgram/min (2.36).

Profile of renal permselectivity by simultaneous enzyme-linked immunosorbent assay of albumin, transferrin, IgG, and alpha 1-microglobulin with a new microplate reader

A competitive enzyme-linked immunosorbent assay (ELISA) is described for determining a renal permselectivity profile involving the urinary proteins albumin, transferrin, IgG, and alpha 1-microglobulin (alpha 1-m). The ELISA reader uses a computer-controlled array of multiplexed light-emitting diode (LED)-photodiode pairs for rapid measurements of absorbance on microplates. A 3,3'-dimethylnaphthidine reagent adapts the 3,5,3',5'-tetramethylbenzidine chromophore to monochromatic LED emission at 550 nm. We applied this ELISA to the determination of renal permselectivity in healthy children and young adults and in children with insulin-dependent diabetes mellitus. The geometric means (and SD) of protein excretion rates in a group of 85 normal subjects were as follows: albumin, 3.5 micrograms/min (1.83); transferrin, 173 ng/min (2.76); IgG, 1.11 micrograms/min (2.22), and alpha 1-m, 0.98 microgram/min (2.36).

Atrial natriuretic factor during the perinatal period: equal depletion in both atria

Data in the literature concerning atrial natriuretic factor (ANF) physiology in the fetus and newborn, although limited, suggest significant activity during the perinatal period. To characterize further ANF physiology during this time, we documented immunoreactive ANF (IR-ANF) concentrations in the right and left atria before and immediately after birth as well as in the hearts of immature and adult rats. There was a significant decrease in the concentration of IR-ANF in both right and left atria on the d before birth that persisted for the first 48 h of life [d 20 fetal right 570 (106, 90), left 580 (86, 75); d 21 fetal right 270 (70, 55), left 214 (117, 75); 1 d right 206 (39, 33), left 229 (41, 35); 2-d right 352 (35, 32), left 237 (26, 23) [geometric mean (upper SE, lower SE) in ng ANF/mg protein]. Repletion of ANF stores began in the right atrium on d 2 of life and in the left atrium between d 2 and 5. The highest levels of IR-ANF were observed at d 15 [d 5 right 1439 (53,51), left 1547 (83,79); d 15 right 2034 (90,86), left 1943 (108, 102); adult right 1380 (119, 109), left 963 (118, 105)]. In contrast to normal adult animals, factors mediating the observed change affect both atria equally during the perinatal period. The concentration of IR-ANF in the right and left atrium of the fetal, newborn, and immature animals was equal. These data document significant alterations in intraatrial IR-ANF concentrations in the perinatal period.(ABSTRACT TRUNCATED AT 250 WORDS)

Hamartoma of the tuber cinereum: a comparison of MR and CT findings in four cases

Hamartoma of the tuber cinereum is a well-recognized cause of central precocious puberty. We report three patients with an isodense, nonenhancing mass within the interpeduncular cistern identified by CT. In a fourth patient, the CT scan was normal. MR imaging was obtained in all cases and demonstrated a sessile or pedunculated mass of the posterior hypothalamus arising from the region of the tuber cinereum. The smallest mass was 2 mm in diameter and was found in the patient in whom the CT scan was normal. The signal intensity of the masses was generally homogeneous and isointense relative to gray matter on T1- and intermediate-weighted images, and hyper-intense on T2-weighted images. MR imaging accurately diagnoses hypothalamic hamartomas, identifies small hamartomas of the tuber cinereum more sensitively than CT does, and provides optimal imaging for serial evaluation while the patient is being treated medically.

Atrial antinatriuretic factor in the developing Dahl hypertensive rat

In order to determine the developmental pattern of atrial concentrations of atrial natriuretic factor (ANF) in the Dahl hypertension-prone rat, atrial ANF concentrations were measured in inbred hypertension-prone (S/JR) and hypertension-resistant (R/JR) Dahl rats at 5, 15, 25, and 51 days of age. In both strains, atrial ANF concentrations peaked at 15 days of age. Atrial ANF concentrations did not differ between the two strains from 5 to 25 days of age. However, by 51 days of age, atrial ANF concentrations in the S/JR rat were significantly greater than those of the R/JR rat. Combining these data with developmental patterns of plasma renin activity in S/JR rats suggests the possibility that the S/JR rat may become intravascularly volume-expanded between 25 and 51 days of age. This volume expansion may contribute to the etiology of hypertension in this model of essential hypertension.

Atrial natriuretic polypeptide in the fetal rat: ontogeny and characterization

The presence of immunoreactive atrial natriuretic polypeptide (ANP) has been demonstrated in fetal atria early in gestation but further definition of fetal ANP has not been reported. To characterize the principal molecular forms of fetal ANP and to compare fetal ANP to that of the adult of the same species, we extracted the atria of pregnant adult and 20-day fetal rats, the hearts of 14-day fetuses, and intact 12-day fetuses in 1 M acetic acid. Tissue collected from littermates was pooled. We measured ANP by radioimmunoassay before and after gel filtration on Sephadex G-75 in each group. ANP concentrations (means +/- 1 SD) in ng/mg protein and ng/animal were 1296 +/- 505 and 7707 +/- 1877 in adult atria (n = 17), 174 +/- 44 and 62 +/- 13 in 20-day fetal atria (n = 7), and 33 +/- 5.3 and 3.7 +/- 0.9 in 14-day fetal hearts (n = 6), respectively. Acid extracts from intact 12-day fetuses did not dilute in parallel to the standard curve; therefore, concentrations of ANP for the 12-day fetuses are not reported. ANP concentration rose from the 20-day fetus to the adult (p less than 0.0001). The major species of ANP eluting from the Sephadex column had an apparent molecular weight of 16 K in all groups. We conclude: 1) ANP is present in the fetus shortly after the completion of organogenesis; 2) 16 K ANP is the principal intracardiac species in the fetus and the adult; and 3) the existence of ANP soon after cardiac development suggests a possible role for ANP in fetal blood pressure and sodium and water homeostasis.

Short-term, high-dose, systemic steroids in children with asthma: the effect on the hypothalamic-pituitary-adrenal axis

Children with chronic asthma frequently receive "bursts" (less than 7 days) of short-term, high-dose prednisone (1 to 2 mg/kg/day) for acute exacerbations of their disease. Certain of these patients may also require inhaled corticosteroids (IC) for control. The effect of these "bursts" on the hypothalamic-pituitary-adrenal axis (HPAA) is unclear. To test the integrity of the HPAA in such patients, we measured plasma cortisol (F) in response to serial administration of insulin-induced hypoglycemia (nadir = 34 +/- 1.2 mg/dl; mean +/- SE), followed by 250 micrograms/1.73 m2 of synthetic ACTH in the following children with asthma: group I, seven patients who received no more than one "burst" per year (0.71 +/- 0.2); group II, six individuals who received more than one "burst" per year (3.6 +/- 0.2) and no IC; and group III, 10 subjects who received more than one "burst" per year (4.7 +/- 0.3) plus IC. All patients received daily theophylline and beta-agonists; seven patients were taking sodium cromolyn. No patients received troleandomycin. Compared to group I (control subjects), 16% of group II had a subnormal response of F to hypoglycemia. In addition, a subnormal response of F to hypoglycemia or ACTH was documented in 20% and 10% of group III, respectively. All individuals with a subnormal response of F to either hypoglycemia or ACTH received four or more "bursts" per year. We conclude that as a group, children affected by asthma treated with "bursts" alone or "bursts" plus IC appear to have a normal HPAA.(ABSTRACT TRUNCATED AT 250 WORDS)

Crossed fused ectopia with a blind left ureter in a young woman with Turner's syndrome: sonographic and radiological demonstration of a previously undescribed variant

A previously undocumented variant of crossed fused ectopia in a young woman with Turner's syndrome is reported, with emphasis on sonographic and radiological techniques for diagnosis and subsequent evaluation.

Idiopathic hyperaldosteronism. A possible role for aldosterone-stimulating factor

To test the hypothesis that idiopathic hyperaldosteronism is secondary to increased adrenal stimulation by aldosterone-stimulating factor, we measured the latter in seven patients with idiopathic hyperaldosteronism and in four patients who had undergone surgical removal of an aldosterone-producing adenoma. In the patients with hyperaldosteronism, plasma aldosterone concentrations (mean +/- 1 S.E.) were 38 +/- 10 and 78 +/- 19 ng per deciliter in the supine and upright position, respectively (P less than 0.01). Supine plasma aldosterone-stimulating factor was 81 +/- 5 ng per deciliter in 15 normal subjects and 185 +/- 10 (P less than 0.01) in the patients with idiopathic hyperaldosteronism. After removal of an aldosterone-producing adenoma, plasma aldosterone-stimulating factor was normal. The supine value in each patient with idiopathic hyperaldosteronism was above the normal range (61 to 91 ng per deciliter) and increased to 290 +/- 59 ng per deciliter after four hours of upright posture. Twenty-four hour urinary excretion of aldosterone-stimulating factor was 424 +/- 35 ng (normal, 145 +/- 3; P less than 0.01) by affinity chromatography and high-pressure liquid chromatography, and it was not suppressed after two days of treatment with dexamethasone (0.5 mg orally every six hours). At the end of 48 hours, plasma concentrations were 248 +/- 40 ng per deciliter. Plasma cortisol and ACTH concentrations were under 2 micrograms per deciliter and under 40 pg per milliliter, respectively. We conclude that increased secretion of aldosterone-stimulating factor may be the cause of idiopathic hyperaldosteronism.

18p - syndrome with a single central maxillary incisor

A child with a single central maxillary incisor and a deletion of the short arm of chromosome 18 (18p—) is presented. He is the first patient in whom this association has been found.