Growth hormone therapy for short stature: is the benefit worth the burden?

Which training load indicators are greater correlated with maturation and wellness variables in elite U14 soccer players?

BACKGROUND

Monitoring of training load is done to improve physical performance and minimize the incidence of injuries. The study examined the correlation between accumulated training load parameters based on periods with maturity (i.e., maturity offset and peak height velocity -PHV- and wellness variables -e.g., stress and sleep quality-). The second aim was to analyze the multi-linear regression between the above indicators.

METHODS

Twenty elite young U14 soccer players (M = 13.26 ± 0.52 years, 95% CI [13.02, 13.51]) were evaluated over 26 weeks (early, mid, and end-season) to obtain stress, sleep quality, and measures of workload in the season (accumulated acute workload [AW], accumulated chronic workload [CW], accumulated acute: chronic workload ratio [ACWLR], accumulated training monotony [TM], accumulated training strain [TS]).

RESULTS

The analysis revealed a moderate, statistically significant negative correlation between sleep quality and training monotony (r = -0.461, p < 0.05). No significant correlations were observed between other variables (p > 0.05). In the multi-linear regression analysis, maturity, PHV, sleep, and stress collectively accounted for variances of 17% in AW, 17.1% in CW, 11% in ACWLR, 21.3% in TM, and 22.6% in TS. However, individual regression coefficients for these predictors were not statistically significant (p > 0.05), indicating limited predictive power.

CONCLUSION

The study highlights the impact of sleep quality on training monotony, underscoring the importance of managing training load to mitigate the risks of overtraining. The non-significant regression coefficients suggest the complexity of predicting training outcomes based on the assessed variables. These insights emphasize the need for a holistic approach in training load management and athlete wellness monitoring.

Growth Velocity and Economic Aspects of Human Growth Hormone Treatment in an Egyptian Cohort with Multiple Pituitary Hormone Deficiency: A Retrospective Minireview

Abstract Background: Multiple pituitary hormone deficiency (MPHD) is a chronic lifelong disease. Human recombinant growth hormone (hGH) treatment is the optimal therapy for short stature in children with growth hormone (GH) deficiency in patients with MPHD and can effectively increase growth velocity (GV) to attain adult heights within the target range. Objective: to assess the GV during hGH treatment of children with MPHD, to analyze the characteristics of patients and to investigate the possible factors that might affect their height gain. Methods: Data from 18 (8 females) children and adolescents with MPHD with GH, thyroid stimulating hormone, gonadotropin and adrenocorticotropic hormone deficiencies were collected. Subjects were divided into groups: 12 pubescent patients and 6 pre-pubescent patients. Anthropometric measurements were reported regularly for one year. Results: age at onset of study was 13.44±4.66 years. CT and MRI findings were positive in 77.8 %. Peak GH levels after Clonidine and Insulin were 4.06±2.61 and 5.39±4.2 ng/ml respectively. GH was received in a dose of 0.95±0.5 mg/day. Height gain during the period of the study was 3.5±0.47cm /year. The predicted adult height at the first and last visits and delta predicted adult height between the first and last visits were 155.78±10.159, 156.71±7.22 and 0.93±4.64 cm respectively. The cost in dollars was identified using Markov cost-effectiveness simulation model as 98.87±52.4 dollars per one cm height gain, with a total of 346.07±183.42 US dollars/patient/year. For a hGH dose of 0.02±0.01 mg/kg/d (0.95±0.5mg/day). There was a positive correlation between height gain during the study period and both the height SDS at presentation and dose of GH mg/kg/d. Conclusion: the height gain and the cost were higher amongst females than males with MPHD. Height at presentation and hGH dose seemed to be an effective predictor for height gain in patients with MPHD.  

Downregulation of the GHRH/GH/IGF1 axis in a mouse model of Börjeson-Forssman-Lehman syndrome

Börjeson-Forssman-Lehmann syndrome (BFLS) is an intellectual disability and endocrine disorder caused by plant homeodomain finger 6 (PHF6) mutations. Individuals with BFLS present with short stature. We report a mouse model of BFLS, in which deletion of Phf6 causes a proportional reduction in body size compared with control mice. Growth hormone (GH) levels were reduced in the absence of PHF6. Phf6 ^{- /Y} animals displayed a reduction in the expression of the genes encoding GH-releasing hormone (GHRH) in the brain, GH in the pituitary gland and insulin-like growth factor 1 (IGF1) in the liver. Phf6 deletion specifically in the nervous system caused a proportional growth defect, indicating a neuroendocrine contribution to the phenotype. Loss of suppressor of cytokine signaling 2 (SOCS2), a negative regulator of growth hormone signaling partially rescued body size, supporting a reversible deficiency in GH signaling. These results demonstrate that PHF6 regulates the GHRH/GH/IGF1 axis.

Branding of subjects affected with genetic syndromes of severe short stature in developing countries

In Ecuador, a developing South American country, subjects affected with genetic syndromes of severe short stature are commonly referred to as dwarfs or midgets. Furthermore, and because in earlier studies some patients had evidenced mental retardation, such abnormality is assumed to exist in all affected subjects. Herein, we present two discrete instances in which this type of branding occurs. The first is that of individuals with Laron syndrome who are still called 'dwarfs' and considered as having a degree of mental retardation despite evidence showing otherwise. A similar problem, that of a girl affected with a genetic syndrome of short stature, which might include mental retardation, is also discussed. Considering that stigmatising is a form of discrimination, it concerns us all. Hence, the use of derogatory terms such as midget, dwarf or cretin, that might unintentionally occur even when delivering the best and most devoted medical care, must be eliminated.

Height Gain and Safety Outcomes in Growth Hormone-Treated Children with Idiopathic Short Stature: Experience from a Prospective Observational Study

BACKGROUND/OBJECTIVES

Growth hormone (GH) treatment of idiopathic short stature (ISS) received US Food and Drug Administration approval in 2003. We assessed height gain and safety in 2,450 children with ISS treated with GH in US clinical practice.

METHODS

Short-term height gain, near-adult height (NAH), and safety outcomes were investigated using Genetics and Neuroendocrinology of Short Stature International Study data.

RESULTS

Compared to children with isolated idiopathic GH deficiency (IGHD), those with ISS were shorter at baseline but had similar age and GH dose. Mean ± SD height SD score (SDS) increase was similar for ISS and IGHD, with 0.6 ± 0.3 (first), 0.4 ± 0.3 (second), 0.3 ± 0.3 (third), and 0.1 ± 0.3 (fourth year) for ISS. Girls with ISS (27% of subjects) were younger and shorter than boys but had similar height gain over time. At NAH in the ISS group (n = 467), mean ± SD age, GH duration, and height SDS were 17.3 ± 2.3 years, 4.6 ± 2.7 years, and -1.2 ± 0.9, respectively. Height gain from baseline was 1.1 ± 1.0 SDS and was greater for boys than girls (1.2 ± 1.0 vs. 0.9 ± 0.9), but boys were treated longer (5.1 ± 2.8 vs. 3.6 ± 2.5 years). Adverse events were reported for 24% with ISS versus 20% with IGHD - most were common childhood conditions or previously reported in GH-treated patients.

CONCLUSIONS

GH-treated children with ISS achieved substantial height gain, similar to patients with IGHD. Fewer GH-treated girls were enrolled than boys, but with similar height SDS gain over time. No ISS-specific safety issues were identified. Thus, GH treatment of ISS appears to have a safety/effectiveness profile similar to that of IGHD.

Cost-Conscious Growth-Promoting Treatment: When Discretion Is the Better Part of Value

Assessing cost-effectiveness of human growth hormone (hGH) treatment to augment height is complicated by uncertainty about how best to measure its therapeutic effect. Cost-conscious growth promotion practice, however, is possible and likely an emerging practical requisite as health care payers increasingly deny the medical necessity of and restrict support for short stature treatment. The increase in denials is not surprising given the expansion and continued high cost of hGH treatment, debate about the value of such treatment, and universal need to restrain burgeoning health care costs. Renunciation of sweeping payer rejection of hGH-for-height treatment is strengthened by cost-conscious practices that (1) recommend no treatment for most short children and restrict treatment to severe, likely disabling short stature; (2) initiate hGH treatment only after evidence-based informed assent; (3) utilize alternative less costly and less invasive options when possible; (4) minimize hGH treatment duration and dosage; and (5) resist enhancement of normal adult stature. A new era of cost-conscious hGH prescribing that prompts thoughtful restraint in hGH use could help preserve hGH approval for children most in need of treatment.

Adherence to growth hormone therapy in children and its potential barriers

BACKGROUND

One of the main concerns in chronic diseases such as growth hormone (GH) deficiency is adherence to the treatment, which significantly affects treatment outcomes.

METHODS

This cross-sectional study was conducted among 169 GH recipient children (2-12 years) and teens (13-19 years) referred to a GH distributing teaching pharmacy. The eight-item Morisky Medication Adherence Scale (MMAS) and auto-compliance method were used for the assessment of patients' adherence to GH. The potential barriers to GH therapy adherence and medication persistence were also explored.

RESULTS

Based on the MMAS method, 56.7% of the children and 57.9% of the adolescent groups were adherent to GH therapy. Conversely, according to the auto-compliance method almost all the patients were adherent in the children (95.2%) and adolescent (95.5%) groups. Forgetting to take the injection or refill the prescription, being away from home, exhaustion from long-term injection, drug shortage and inaccessibility to the pharmacy were barriers found to be significantly associated with a low adherence in the children group. While in the adolescent group, forgetting to take the injection, painful injection, concern about long-term complications and exhaustion from long-term injection revealed a significant association with low adherence. Persistence with GH therapy was reported in 75.3% and 67% of children and adolescent patients, respectively.

CONCLUSIONS

The current study revealed that overall adherence of the study population is low. Considering the barriers with significant association with adherence, different strategies can be incorporated to enhance adherence to GH therapy, i.e. providing early patient and parent education and support, medication reminder systems and longer duration of GH prescriptions.

Growth Promotion Ethics and the Challenge to Resist Cosmetic Endocrinology

The advancement of "human growth hormone (hGH)-for-height" - increasing height attainment in children short for reasons other than GH deficiency - arose from intuitive, deep-seated assumptions about the disability of short stature, its improvement with hGH-mediated height gain, and the safety of escalating dosages of hGH in healthy children. Evidence challenging these assumptions now strengthens criticism of hGH-for-height as cosmetic endocrinology. To counter this characterization, collective acceptance of guidelines is needed that advise nontreatment of the vast majority of short children, support strategies that minimize treatment duration and dosage, and restrain enhancement of normal adult stature. Through a clinical case analysis, ethical issues underlying these recommendations are explored. These include duties to provide informed assent and re-assent, protect children from unnecessary treatment, consider fairness to nontreated children, and allocate healthcare resources responsibly. Informed assent for hGH-for-height should ensure awareness of modest, variable height gain expectations, limited evidence for psychosocial benefit, ongoing studies for potential posttreatment adverse effects, and options for less expensive/invasive approaches, including nontreatment and counseling. Approaching growth pro-motion in this way fosters therapeutic restraint, resists the al lure of enhancement therapy, and minimizes contributions to society's perception that to be taller is to be better.
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Growth Hormone Utilization Review in a Pediatric Primary Care Setting

Objective:

One of the main problems facing public health providers and administrators in many countries is ensuring the rational use of high-cost drugs. In this regard, on-going process of medication use evaluation can be considered as a useful tool. In this study, we evaluated certain usage aspects of a highly-cost medication, that is, recombinant growth hormone (GH).

Methods:

This cross-sectional study conducted from August 2012 to August 2014. Children receiving GH ± gonadotropin releasing hormone (GnRH) analogs were included in the study. A researcher-designed checklist was developed to evaluate the GH utilization in these patients. Baseline demographic characteristics and background clinical and growth data, as well as any aspects of drug therapy including indications, dosing, monitoring, and discontinuation were collected from the patients' medical records.

Findings:

Seventy children receiving GH entered the study, of which 23 patients (32.85%) received GH and GnRH analogs simultaneously. At the baseline, 67 children (95.7%) had GH stimulation test, whereas serum insulin-like growth factor-1 (IGF-1) levels were measured in 63 (90%) patients. Sixty-seven patients (95.71%) had thyroid function test, whereas bone age was determined in 68 children (97.14%). The mean ± standard deviation of GH dose for idiopathic short stature, GH deficiency, Turner's syndrome and born small for gestational age in our study was 0.22 ± 0.025 mg/kg/week, 0.23 ± 0.04 mg/kg/week, 0.22 ± 0.015 mg/kg/week, and 0.23 ± 0.02 mg/kg/week, respectively. Height and weight of all patients were followed every 3–6 months, regularly. Thirty patients were treated with GH for at least 1 year, of which thyroid hormones and IGF-1 levels were measured annually in 25 (83.33%) and 26 (86.66%) patients, respectively; while bone age was evaluated in 13 (43.33%) children, annually. GH treatment was discontinued in 15 patients (21.42%), while financial problem was the major reason.

Conclusion:

Diagnostic tests and monitoring of height, weight, IGF-1 level and thyroid function was properly performed in this setting. However, a number of patients with ISS and Turner's syndrome were under-dosed.

The future of growth-promoting therapy

Growth hormone (GH) has been in use for 50 years in children with short stature. Recent developments suggest that our traditional approaches to growth-promoting therapy will be challenged in the following areas:1)Diagnostic: The diagnosis of GH deficiency has always been problematic, largely due to limitations inherent in GH stimulation tests and related biochemical measures. The development of new tools for diagnosis of genetic etiologies of hormonal deficiencies and insensitivity, as well as the growing availability of such methodologies, will greatly strengthen existing diagnostic strategies. 2)Therapeutic: Long-acting GH preparations are already in clinical trials. IGF-I therapy is approved for treatment of IGF deficiency. Novel approaches to select skeletal dysplasias show promise and will potentially expand our therapeutic armamentarium. 3) Monitoring: Traditional weight-based dosing of GH will be supplemented by IGF-based and auxology-based strategies, allowing greater individualization of therapy. 4) Safety: Growth-promoting therapies will continue to require careful monitoring of safety. Recent consensus workshops have advocated life-time surveillance programs. 5) Ethics: Questions will continue to be raised concerning ethical issues related to growth-promoting therapy in children. The availability of new tools for diagnosis and monitoring will address some, but not all, of these issues.

Efficacy and safety of Samtropin™ recombinant human growth hormone; a double-blind randomized clinical trial

Background

Recombinant human growth hormone (rhGH) can increase the growth rate in growth hormone deficient children (GHD). In this randomized clinical trial, we compared the efficacy and side effects of an Iranian brand; Samtropin with Norditropin.

Methods

The GHD children were randomly treated either with standard dose of Samtropin or Norditropin rhGH for one year. Upstanding height, height standard deviation score (HSDS), growth velocity (GV), serum levels of insulin like growth factor-1 (IGF-1), and bone age (BA) were determined before and during one year treatment concomitant side effects of treatment.

Results

We evaluated 22 subjects; 12 on Samtropin and, 10 on Norditropin. In each group, mean age was 12 yr and 50% of them were male. The mean differences in height, HSDS, IGF-1 and BA by Norditropin before and after 12 months were 8.8 cm, 0.5, 49 ng/ml and 2.8 yr, respectively. These measures by Samtropin were 9.1 cm, 0.6, 133 ng/ml, and 1.7 yr, respectively without any significant difference. The mean of GV by Samtropin was 9.1 vs. 8.8 cm by Norditropin without significant difference. Since the efficacy of Samtropin was found to be similar to Norditropin after 12 months; we switched to use only Samtropin for the next 12 months. The mean differences in height, HSDS, GV and BA in 20 children between months 12 and 24 were 7.0 cm, 1.6, 2.1 cm/yr and 1.0 yr, respectively (P < 0.001). We also found a non-significant decrease in IGF-1 levels. No side effects were observed.

Conclusions

We need to conduct a post marketing surveillance with a large sample size in order to confirm our findings.

Trial registration

Registration code number in the Iranian Registry of Clinical Trials (IRCT): IRCT1138901181414N11.

Effects of laser acupuncture on longitudinal bone growth in adolescent rats

Longitudinal bone growth is the results of chondrocyte proliferation and hypertrophy and subsequent endochondral ossification in the growth plate. Recently, laser acupuncture (LA), an intervention to stimulate acupoint with low-level laser irradiation, has been suggested as an intervention to improve the longitudinal bone growth. This study investigated the effects of laser acupuncture on growth, particularly longitudinal bone growth in adolescent male rats. Laser acupuncture was performed once every other day for a total of 9 treatments over 18 days to adolescent male rats. Morphometry of the growth plate, longitudinal bone growth rate, and the protein expression of BMP-2 and IGF-1 in growth plate were observed. The bone growth rate and the heights of growth plates were significantly increased by laser acupuncture. BMP-2 but not IGF-1 immunostaining in growth plate was increased as well. In conclusion, LA promotes longitudinal bone growth in adolescent rats, suggesting that laser acupuncture may be a promising intervention for improving the growth potential for children and adolescents.

Modeling height for children born small for gestational age treated with growth hormone

The analysis of growth curves of children can be done on either the original scale or in standard deviation scores. The first approach is found in many statistical textbooks, while the second approach is common in endocrinology, for instance in the evaluation of the effect of growth hormone in children that are born small for gestational age that remain small later in childhood. We illustrate here that the second approach may involve more complex modeling and hence a worse model fit.

Lionel Penrose and the concept of normal variation in human intelligence

Lionel Penrose (1898-1972) was an important leader during the mid-20th century decline of eugenics and the development of modern medical genetics. However, historians have paid little attention to his radical theoretical challenges to mainline eugenic concepts of mental disease. Working from a classification system developed with his colleague, E. O. Lewis, Penrose developed a statistically sophisticated and clinically grounded refutation of the popular position that low intelligence is inherently a disease state. In the early 1930s, Penrose advocated dividing "mental defect" (low intelligence) into two categories: "pathological mental defect," which is a disease state that can be traced to a distinct genetic or environmental cause, and "subcultural mental defect," which is not an inherent disease state, but rather a statistically necessary manifestation of human variation in intelligence. I explore the historical context and theoretical import of this contribution, discussing its rejection of typological thinking and noting that it preceded Theodosius Dobzhansky's better-known defense of human diversity. I illustrate the importance of Penrose's contribution with a discussion of an analogous situation in contemporary medicine, the controversial practice of using human growth hormone injections to treat "idiopathic short stature" (mere diminutive height, with no distinct cause). I show how Penrose's contributions to understanding human variation make such treatments appear quite misguided.

Effect of switching recombinant human growth hormone: Comparative analysis of phase 3 clinical data

Introduction

Recombinant human growth hormone (rhGH) is effective and safe when used to treat growth hormone deficiency (GHD) in children. However, it has been suggested that switching between different types of rhGH can have a detrimental effect on patients.

Methods

The current analysis assessed the efficacy and safety of rhGH in children who received continuous Omnitrope® (Sandoz GmbH, Kundl, Austria) therapy either with lyophilized powder for solution or ready-to-use solution, with children who received 9 months of treatment with Genotropin® (Pfizer Limited, Sandwich, UK) followed by Omnitrope solution thereafter. Changes to height, height SD score (SDS), height velocity SDS, insulin-like growth factor (IGF-1) levels, and IGF binding protein (IGFBP-3) levels were assessed using data from three trials.

Results

Baseline demographics of the three study groups were similar. Over an 18-month period there were no observable differences between the three groups with respect to height, height SDS, height velocity SDS, IGF-1 levels, and IGFBP-3 levels. This result was corroborated by the model data, whereby most data points for Omnitrope-treated children fell within the defined limits of the prediction model based on Genotropin data. Few adverse drug reactions (ADRs) occurred.

Conclusions

Switching from Genotropin to Omnitrope solution has no impact on efficacy or safety in children with GHD, and the various rhGH preparations are well tolerated.

Clinical review: Lessons learned from the hGH era

Today, many medical interventions that begin as treatments for disease often expand into therapies that reduce disability, lessen disadvantage, or even confer advantage. Forces that propel profitable drugs, devices, and procedures dominate over considerations of efficient and equitable distribution of resources. This dominance is fueled by industry-physician collaborations often biased by prior assumptions, reliant on surrogate outcomes, and advantageous to marketing. Interventions are justified by "medicalization" of physiologic variations (e.g. short stature) as defects or disease, and nudged into "standard practice" by key opinion leaders. The story below of recombinant human growth hormone (hGH) treatment of short stature is one vivid example, but others (e.g. expansion of drug treatment to "optimize" cholesterol profiles, bone health, psychological well-being) can be found throughout medicine. In the new obesity era, lessons learned from the hGH era will be needed to keep the field of pediatric endocrinology empowered to make the key clinical decisions, and free of unintended consequences for patients and runaway health care inflation for society.

Expression of functional recombinant human growth hormone in transgenic soybean seeds

We produced human growth hormone (hGH), a protein that stimulates growth and cell reproduction, in genetically engineered soybean [Glycine max (L.) Merrill] seeds. Utilising the alpha prime (α') subunit of β-conglycinin tissue-specific promoter from soybean and the α-Coixin signal peptide from Coix lacryma-jobi, we obtained transgenic soybean lines that expressed the mature form of hGH in their seeds. Expression levels of bioactive hGH up to 2.9% of the total soluble seed protein content (corresponding to approximately 9 g kg(-1)) were measured in mature dry soybean seeds. The results of ultrastructural immunocytochemistry assays indicated that the recombinant hGH in seed cotyledonary cells was efficiently directed to protein storage vacuoles. Specific bioassays demonstrated that the hGH expressed in the soybean seeds was fully active. The recombinant hGH protein sequence was confirmed by mass spectrometry characterisation. These results demonstrate that the utilisation of tissue-specific regulatory sequences is an attractive and viable option for achieving high-yield production of recombinant proteins in stable transgenic soybean seeds.

Non-compliance with growth hormone treatment in children is common and impairs linear growth

BACKGROUND

GH therapy requires daily injections over many years and compliance can be difficult to sustain. As growth hormone (GH) is expensive, non-compliance is likely to lead to suboptimal growth, at considerable cost. Thus, we aimed to assess the compliance rate of children and adolescents with GH treatment in New Zealand.

METHODS

This was a national survey of GH compliance, in which all children receiving government-funded GH for a four-month interval were included. Compliance was defined as ≥ 85% adherence (no more than one missed dose a week on average) to prescribed treatment. Compliance was determined based on two parameters: either the number of GH vials requested (GHreq) by the family or the number of empty GH vials returned (GHret). Data are presented as mean ± SEM.

FINDINGS

177 patients were receiving GH in the study period, aged 12.1 ± 0.6 years. The rate of returned vials, but not number of vials requested, was positively associated with HVSDS (p < 0.05), such that patients with good compliance had significantly greater linear growth over the study period (p<0.05). GHret was therefore used for subsequent analyses. 66% of patients were non-compliant, and this outcome was not affected by sex, age or clinical diagnosis. However, Maori ethnicity was associated with a lower rate of compliance.

INTERPRETATION

An objective assessment of compliance such as returned vials is much more reliable than compliance based on parental or patient based information. Non-compliance with GH treatment is common, and associated with reduced linear growth. Non-compliance should be considered in all patients with apparently suboptimal response to GH treatment.

Observations of nonadherence to recombinant human growth hormone therapy in clinical practice

BACKGROUND

The effectiveness of all prescribed treatments is contingent on patient adherence. The reported levels of adherence to recombinant human growth hormone (r-hGH) therapy are highly variable, but it has been suggested that nonadherence might be as high as 36% to 49%.

OBJECTIVES

This commentary discusses the factors that affect long-term adherence to injection treatment, of which r-hGH therapy is a particular challenge. It also explores potential strategies to improve adherence to injection treatments in clinical practice.

METHODS

The opinion of the authors was validated and supported by published literature. A PubMed literature search was conducted in November 2006, identifying English-language articles containing key terms growth hormone, adherence, and compliance.

RESULTS

This study found that factors associated with poor adherence to injection treatments include patients' lack of understanding of their disease, patient age, chronicity of the disease, complex treatment regimens, and insufficient information on the implications of nonadherence. Strengthening the patient-physician relationship by providing the patient with a clear understanding of his/her disease and the benefits of adherence, making improvements in injection devices, and eliminating subjective illness concepts, might increase adherence to SC injection treatments, thereby reducing increasing health care costs associated with nonadherence.

CONCLUSIONS

Poor adherence to r-hGH therapy has a dual effect, in that it leads to reduced efficacy out-comes and increased health care costs. Implementing strategies to improve adherence with injection treatment might be of particular clinical benefit to patients undergoing r-hGH therapy.

From genetics to genomics: ethics, policy, and parental decision-making

OBJECTIVE

Ethical evaluation of genetic testing in children is traditionally based on balancing clinical benefits and risks. However, this focus can be inconsistent with the general practice of respecting parental decision-making about their children's health care. We argue that respect for parental decision-making should play a larger role in shaping pediatric genetic testing practices, and play a similar role regarding decisions to use emerging genomic technologies.

METHODS

Genomic testing involves the examination of thousands of DNA markers spanning genes throughout the genome and their interrelationships, yielding virtually limitless interpretations. We presume that parents and providers should proceed cautiously in applying genomic testing in children, as we explore how genomic testing will stress the fault lines of the traditional ethical analysis.

RESULTS

Empirical data about the psychosocial risks and benefits of genetic testing of children do not reveal serious harms, yet virtually no such data exist yet about genomic testing. Unless empirical social and behavioral data indicate that genomic testing is highly likely to cause serious harms to the children, parental decisions to obtain comprehensive genomic testing in their children should be respected. Once comprehensive genomic testing of children becomes routine, resultant information may be more easily integrated by families than anticipated.

CONCLUSIONS

Research on the social and behavioral impact of comprehensive genomic testing on children and their families is needed to further inform parents, clinicians, and policy makers.

Effects of growth hormone treatment on height, weight, and obesity in Taiwanese patients with Prader-Willi syndrome

BACKGROUND

Information regarding the efficacy of growth hormone (GH) therapy in Asian Prader-Willi syndrome (PWS) patients is lacking. We report our experience with GH treatment in children with PWS in Taiwan.

METHODS

Forty-six PWS patients (27 males, 19 females; age range, 1 year 4 months to 13 years 7 months) who received and/or who are currently receiving GH treatment (0.1 IU/kg/day subcutaneously) for a period from 1 year to 3 years were retrospectively analyzed. We evaluated height, weight, body mass index (BMI) and Rohrer index, before and after GH treatment.

RESULTS

After patients had received GH for 1, 2 and 3 years, a significant improvement in mean height standard deviation score (SDS) was noted from -1.24 to -0.31 (p < 0.01), 0.00 (p < 0.001) and -0.26 (p < 0.001), respectively. Mean BMI SDS decreased significantly from 1.93 to 1.13 (p < 0.05) after 1 year of treatment; however, no significant changes were observed afterward. Mean Rohrer index decreased significantly, from 224.2 to 186.6 (p < 0.001), 178.9 (p < 0.001) and 169.3 (p < 0.001). No significant gender or genotype pattern differences were noted among the 4 parameters examined.

CONCLUSION

This 3-year, retrospective study indicates that PWS patients benefit from GH therapy in height increase and improved body composition.

EULAR evidence-based recommendations on the management of systemic glucocorticoid therapy in rheumatic diseases

OBJECTIVE

To develop evidence-based recommendations for the management of systemic glucocorticoid (GC) therapy in rheumatic diseases.

METHODS

The multidisciplinary guideline development group from 11 European countries, Canada and the USA consisted of 15 rheumatologists, 1 internist, 1 rheumatologist-epidemiologist, 1 health professional, 1 patient and 1 research fellow. The Delphi method was used to agree on 10 key propositions related to the safe use of GCs. A systematic literature search of PUBMED, EMBASE, CINAHL, and Cochrane Library was then used to identify the best available research evidence to support each of the 10 propositions. The strength of recommendation was given according to research evidence, clinical expertise and perceived patient preference.

RESULTS

The 10 propositions were generated through three Delphi rounds and included patient education, risk factors, adverse effects, concomitant therapy (ie, non-steroidal anti-inflammatory drugs, gastroprotection and cyclo-oxygenase-2 selective inhibitors, calcium and vitamin D, bisphosphonates) and special safety advice (ie, adrenal insufficiency, pregnancy, growth impairment).

CONCLUSION

Ten key recommendations for the management of systemic GC-therapy were formulated using a combination of systematically retrieved research evidence and expert consensus. There are areas of importance that have little evidence (ie, dosing and tapering strategies, timing, risk factors and monitoring for adverse effects, perioperative GC-replacement) and need further research; therefore also a research agenda was composed.

Recombinant growth hormone for idiopathic short stature in children and adolescents

BACKGROUND

Idiopathic short stature (ISS) refers to children who are very short compared with their peers for unknown or hereditary reasons. Recombinant human growth hormone (GH) has been used to increase growth and final height in children with ISS.

OBJECTIVES

To assess the effects of recombinant human GH on short-term growth and final height in children with ISS.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE, The Cochrane Library, Science Citation Index, BIOSIS and Current Controlled Trials. Article reference lists were assessed for trials and experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with ISS with normal GH secretion. GH had to be administered for a minimum of six months and be compared with placebo or no treatment. A growth or height outcome measure had to be assessed.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. Data were extracted by one reviewer and checked by a second. The primary outcome was final height and secondary outcomes included short term growth, health related quality of life and adverse effects. To estimate summary treatment effects, data were pooled, when appropriate using a random effects model.

MAIN RESULTS

Ten RCTs were included. One trial reported near final height in girls and found that girls treated with GH were 7.5 cm taller than untreated controls (GH group, 155.3 cm +/- 6.4; control, 147.8 cm +/- 2.6; P = 0.003); another trial which reported adult height standard deviation score found that children treated with GH were 3.7 cm taller than children in a placebo-treated group (95% confidence intervals 0.03 to 1.10; P < 0.04). The other trials reported short term outcomes. Results suggest that short-term height gains can range from none to approximately 0.7 SD over one year. One study reported health related quality of life and showed no significant improvement in GH treated children compared with those in the control group, whilst another found no significant evidence that GH treatment impacts psychological adaptation or self-perception in children with ISS. No serious adverse effects of treatment were reported.

AUTHORS' CONCLUSIONS

GH therapy can increase short-term growth and improve (near) final height. Increases in height are such that treated individuals remain relatively short when compared with peers of normal stature. Large, multicentre RCTs are required which should focus on final height and address quality of life and cost issues.

Articular cartilage repair in the adolescent athlete: is autologous chondrocyte implantation the answer?

OBJECTIVE

To determine the evidence base for recommendations regarding autologous chondryocyte implantation in adolescent athletes.

MATERIALS AND METHODS

All literature on articular cartilage repair from MEDLINE search dated 1990 to 2006 was reviewed. The majority of articles describe surgical technique and indications. Three techniques for secondary articular cartilage repair have been identified: autologous chondrocyte implantation, autologous osteochondral implants, and marrow stimulation techniques. The initial literature search identified 4 studies that reported the effectiveness and durability of autologous chondrocyte implantation in adults and 2 studies that reported the outcomes of autologous chondrocyte implantation in adolescent athletes. No results of osteochondral implantation or marrow stimulation techniques in adolescent athletes have been published.

RESULTS

Acceptable repair rates with all 3 techniques have been reported in adult athletes. Two studies reported high success using autolgous chondrocyte implantation (ACI) in children.

CONCLUSIONS

Articular cartilage injury in young athletes remains a difficult problem. The ideal situation is early diagnosis and primary repair, particularly with lesions of the knee, elbow, and ankle. In cases where primary repair is not possible or has been unsuccessful and the lesion is large or symptomatic, secondary repair with either marrow stimulation, microfracture, autologous chondrocyte implantation, or autologous osteochondral grafting may be used. However, at present only the results of ACI repair have been reported for adolescent athletes.