Sex non-specific growth charts and potential clinical implications in the care of transgender youth

Introduction

The Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) created separate growth charts for girls and boys because growth patterns and rates differ between sexes. However, scenarios exist in which this dichotomizing "girls versus boys" approach may not be ideal, including the care of non-binary youth or transgender youth undergoing transitions consistent with their gender identity. There is therefore a need for growth charts that age smooth differences in pubertal timing between sexes to determine how youth are growing as "children" versus "girls or boys" (e.g., age- and sex-neutral, compared to age- and sex-specific, growth charts).

Methods

Employing similar statistical techniques and datasets used to create the CDC 2000 growth charts, we developed age-adjusted, sex non-specific growth charts for height, weight, and body mass index (BMI), and z-score calculators for these parameters. Specifically, these were created using anthropometric data from five US cross-sectional studies including National Health Examination Surveys II-III and National Health and Nutrition Examination Surveys I-III. To illustrate contemporary clinical practice, we overlaid our charts on CDC 2000 girls and boys growth charts.

Results

39,119 youth 2-20 years old (49.5% female; 66.7% non-Hispanic White; 21.7% non-Hispanic Black) were included in the development of our growth charts, reference ranges, and z-score calculators. Respective curves were largely superimposable through around 10 years of age after which, coinciding with pubertal onset timing, differences became more apparent.

Discussion

We conclude that age-adjusted, sex non-specific growth charts may be used in clinical situations such as transgender youth in which standard "girls versus boys" growth charts are not ideal. Until longitudinal auxological data are available in these populations, our growth charts may help to assess a transgender youth's growth trajectory and weight classification, and expectations surrounding these.

Switch Data From the Open-Label Extension of the Pivotal Phase 3 Study of Once Weekly Somatrogon Compared to Daily Somatropin in Pediatric Patients With Growth Hormone Deficiency (pGHD)

Objectives: Somatrogon (hGH-CTP) is a long acting recombinant human growth hormone, consisting of the amino acid sequence of hGH and three copies of the carboxy-terminal peptide (CTP) of human chorionic gonadotropin (hCG) being developed as a once weekly treatment for children with pGHD. This report summarizes data from the first year of the optional open-label extension (OLE) of the pivotal phase 3 global trial (ClinicalTrials. gov: NCT02968004), comparing the efficacy and safety of children switched from Genotropin (rhGH; somatropin) to somatrogon (Geno/Soma) and children maintained on somatrogon (Soma/Soma).

Methods: During the main study, 224 children were randomized to receive either once weekly somatrogon (0.66 mg/kg, n=109) or once daily Genotropin (0.24 mg/kg/wk, n=115) for 12 months. Of these, 222 completed the 12-month main study, and 212 chose to enter the OLE study. By Sept 30, 2020, 161 children (including 76 Geno/Soma) had complete auxological data at month 12 of the OLE.

Results: At the end of the main study, mean height velocity and gain in height SDS for the somatrogon cohort were 10.10 cm/year and 0.92; for the Genotropin cohort these were 9.78 cm/year and 0.87. Baseline values for the OLE (Soma/Soma group and Geno/Soma group, respectively): height SDS was -1.95 and -1.84, BMI was 17.03 and 15.48 kg/m2 while bone age was 6.54 and 6.40 years. At month 12 (of the OLE), the mean height velocity and the change in height SDS was 8.04 cm/year and 0.41 (Soma/Soma group) and 8.21 cm/year and 0.47 (Geno/Soma group); BMI was 18.07 and 17.49 kg/m2 and bone age was 8.48 and 8.41 years. IGF-1 SDS values were 1.15, and 1.28, while the IGFBP-3 SDS were 0.29 and 0.42, respectively. Dose reductions were required in 16.3% and 20.4% of patients due to IGF-1 SDS >2. Pubertal status changed from Tanner 1 (at OLE baseline) for 13.6% of Soma/Soma patients and 14.6% of Geno/Soma patients. Mean glucose, HbA1c, thyroid function (free T4 and TSH) and cholesterol (total, LDL and HDL) values remained similar to baseline in both groups across the 12 months OLE. The majority of adverse events in both cohorts were mild to moderate (Soma/Soma 94.2%, Geno/Soma 93.5%) and there were no clinically concerning safety observations. During the first 12 months of the OLE six patients discontinued in the Geno/Soma group due to AEs vs zero in the Soma/Soma group.

Conclusions: Height velocities and change in height SDS in the OLE were similar between the Geno/Soma and Soma/Soma cohorts. The main phase of the global pivotal phase 3 trial demonstrated that somatrogon (hGH-CTP) given once weekly is non-inferior to Genotropin (hGH) while the OLE demonstrated that catch-up growth continued into the second year of treatment, with ‘switch’ from Genotropin to somatrogon non-inferior to somatrogon given for two years. Metabolic (glycemic, lipid and thyroid) parameters were similar between groups and not meaningfully different from the main study.

6-Month Subcutaneous Leuprolide Acetate Effectively Suppresses Clinical Signs of Puberty in Children With Central Precocious Puberty

Objective: Gonadotropin-releasing hormone (GnRH) agonists, such as intramuscular leuprolide acetate, triptorelin and the subcutaneous histrelin implant, are standard treatment for central precocious puberty (CPP). Implants require surgery and sometimes anesthesia, while frequent intramuscular injections can be painful. A shift to longer acting-formulations and subcutaneous injections has been proposed for the treatment of CPP. Therapies with convenient administration, prolonged duration of action and favorable safety profile may be beneficial, improving patient adherence. 87% of subjects achieved stimulated LH suppression to <4 IU/L by Week (W) 24 in a Phase III trial evaluating the efficacy and safety of the first6-month subcutaneous injectable in situ gel leuprolide acetate for CPP. We present secondary analyses of bone age (BA) advancement, weight, BMI, and pubertal maturation from this trial.

Methods: 62 children (60 girls, 2 boys) with CPP (naïve to treatment) received 2 doses of 45 mg subcutaneous leuprolide acetate at 24-week intervals, constituting the intent-to-treat population. Radiographs of the left hand and wrist were used to determine BA using the Greulich and Pyle method. BA was assessed by a blinded central reader. Rate of BA advancement was determined by the ratio of BA to chronological age (CA, BA/CA). Pubertal maturation was categorized with the Tanner staging system using breast development, external genitalia, and pubic hair. Safety outcomes were measured.

Results: Mean age at onset of treatment was 7.5 ± 0.9 (SD) (range 4-9) years. BA/CA consistently declined throughout treatment, from 1.4 ± 0.2 at baseline, to 1.3 ± 0.1 at W24 and 1.3 ± 0.1 at W48. Although mean weight increased 8.7% from screening to W24 (34.8 kg vs 37.7 kg) and 16.9% from screening to W48 (40.4 kg), mean BMI remained stable throughout the study. The proportion of girls with early breast Tanner stage development (stage 1 and 2) increased from 9% at baseline to 37% at W48. The proportion of girls with late breast Tanner stage development (stage 4 and 5) decreased from 18% at baseline to 5% at W48. Both boys regressed from Tanner stage 3 to stage 2 for external genitalia development by W48. Tanner staging for pubic hair development remained stable for approximately 80% and decreased for 7% of children by W48. 52/53 treatment emergent adverse events were mild or moderate.

Conclusions: 6-month 45 mg subcutaneous leuprolide acetate is a promising treatment for CPP. It effectively suppressed LH, suppressed clinical signs of pubertal maturation and demonstrated a good safety profile. It also has the beneficial features of subcutaneous administration, small injection volumeand twice a year dosing. This may be a welcome addition to the armamentarium given the proposed shift in CPP therapies towards longer-acting formulations and subcutaneous injections.

Hydrocortisone Suspension Provides Similar Growth Outcomes as Hydrocortisone Tablets in Young Children With Congenital Adrenal Hyperplasia: A Cross Sectional Study

Young children with CAH require small doses (0.1–1.25mg) and incremental adjustments of hydrocortisone (HC) to control excess androgen production and avoid the negative effects of overtreatment. A recent 6 hour pharmacokinetic/pharmacodynamic study reported that alcohol-free HC suspension provides similar cortisol exposure to tablets (1), but more data is needed to assess its clinical efficacy. We performed a chart review to determine the effect of the alcohol-free HC suspension compared to tablets on height, weight, BMI, bone age z-scores and corrected height z-scores to target height z-scores in children aged 2 yrs and 4 yrs in a cohort with classic CAH. Independent 2-sample t-tests examined cumulative and average HC dose at 2 and 4 yrs. Triple logistic modeling of longitudinal heights were used to calculate predicted near-adult height. Adjusted linear regression models assessed the effect of HC suspension compared to tablets on final adult height. Charts of 130 children (70 females, 100 salt wasting and 30 simple virilizing) were reviewed. At 2 yrs, 97 were treated with tablets and 33 with suspension (17 previously switched from tablets). At 4 yrs, 89 were treated with tablets and 41 with suspension (25 switched). No significant differences in height or BMI z-scores at both 2 and 4 yrs, before or after adjusting for age at diagnosis and sex were found. Bone age z-scores averaged 7.2 SDs lower for patients treated with HC suspension only compared to patients on HC tablets at age 4 (p&lt;0.001), and 5.93 SDs lower for patients switched from tablets to suspension compared to tablets (p&lt;0.001). The suspension group received 16% lower (p=0.055) and 25% lower (p=0.002) cumulative HC doses by the ages of 2 yrs and 4 yrs respectively. Average daily HC dose was lower by 3.44 and by 4.46 mg/m2/d over the first 2 and 4 yrs of life respectively. No significant differences were found between patients treated with tablets and suspension in the predicted final adult height, its z-score or its corrected z-score to target height after adjusting for age at diagnosis, sex and diagnosis. Our data indicates that treatment with alcohol-free HC suspension decreased androgen exposure as shown by lower bone age z-scores, generated no significant differences in SDS in observed height, BMI or predicted near-adult height, and allowed for lower average and cumulative daily HC dose compared to HC tablets in children with CAH. Reference: (1) Sarafoglou et al., J Clin Pharmacol.2015;55(4):452–7.

Adrenal Insufficiency in an Adolescent Boy With Type 1 Diabetes Mellitus - the Importance of Considering X-Linked Adrenoleukodystrophy

Background: Primary adrenal insufficiency (PAI) is the rare, life-threatening failure of the adrenal glands to produce sufficient glucocorticoids and mineralocorticoids, presenting with fatigue, weakness, weight loss, hyperpigmentation, hypoglycemia, and hypotension. In adults, PAI is primarily autoimmune, occurring independently or in conjunction with thyroiditis and/or Type I diabetes mellitus (T1DM) as a component of Autoimmune Polyglandular Syndrome-2 (APS-2, Schmidt syndrome). APS-2 is rare (prevalence 1 in 20,000) and more common in females with a peak incidence in the third and fourth decades of life. In children, PAI is most often due to congenital adrenal hyperplasia (CAH), followed by autoimmune disease, but as many as 50% of cases of non-CAH pediatric PAI are not autoimmune. PAI is often the first documented clinical finding in boys with X-linked adrenoleukodystrophy (X-ALD), a rare disorder (prevalence 1 in 15,000) in which deficiency of a peroxisomal membrane protein leads to very long chain fatty acid (VLCFA) accumulation and progressive destruction of the adrenal cortex. A subset of boys with X-ALD develop cerebral ALD (cALD), characterized by progressive central demyelination, neurocognitive decline, and death. 70–80% of boys with X-ALD present with PAI prior to demonstrating neurologic symptoms. Diagnostic workup for X-ALD in pediatric patients presenting with PAI is crucial as timely intervention with hematopoietic stem cell transplant (HSCT) can stop progression of cerebral disease. Clinical Case: An eleven-year-old male was diagnosed with PAI after presenting with poor school performance, growth delay and skin hyperpigmentation. Medical history was significant for well controlled T1DM diagnosed at eight years old. Given his history of T1DM, his PAI was presumed to be autoimmune and further diagnostic testing was not performed. Eleven months later, a brain MRI performed for complaints of visual disturbance and chronic headaches revealed extensive demyelination with gadolinium enhancement consistent with cALD. Elevated VLCFAs and a mutation in the ABCD1 gene confirmed the diagnosis of X-ALD. Unfortunately, the extent of cerebral involvement was so severe that HSCT would not be of significant clinical benefit. In these situations, progressive neurological decline that leads to disability and ultimately death would be expected. Clinical Lessons: This case illustrates that VLCFA testing should be performed in all boys with PAI to rule out X-ALD. In boys, PAI should not be assumed to be autoimmune, even with co-existing autoimmune diseases since APS-2 (Schmidt syndrome) is rare and more likely to occur in adult women. PAI presents early and precedes neurologic symptoms in a majority of boys with cALD. Early identification of X-ALD through VLCFA testing prior to development of severe cALD is critical to allow early intervention with lifesaving HSCT.

Adjusting for Pubertal Status Reduces Overweight and Obesity Prevalence in the United States

OBJECTIVE

To compare pediatric overweight and obesity prevalence among non-Hispanic white, Mexican American, and non-Hispanic black US youths before and after adjusting body mass index (BMI) for pubertal status, as assessed by Tanner stage.

STUDY DESIGN

We analyzed cross-sectional anthropometric and pubertal data from non-Hispanic white, Mexican American, and non-Hispanic black youths in the National Health and Nutrition Examination Survey (NHANES) III. We developed specialized Tanner stage and chronological age-adjusted models to establish Tanner-stage adjusted BMI z-scores, which were then used to determine adjusted overweight/obesity prevalence. We compared pediatric overweight/obesity prevalence before and after pubertal status adjustment.

RESULTS

Among 3206 youths aged 8-18 years (50% male; 26% non-Hispanic white, 35% Mexican American, 39% non-Hispanic black), adjusting BMI for Tanner stage significantly reduced overweight (males, from 29% to 21%; females, from 29% to 17%) and obesity (males, from 14% to 7%; females, from 11% to 5%) prevalence across all races/ethnicities. The obesity prevalence reduction was more pronounced in Mexican Americans (males, 11% reduction; females, 9% reduction) and non-Hispanic blacks (males and females, 10% reduction) compared with non-Hispanic whites (males, 6% reduction; females, 5% reduction). Similar patterns were seen in overweight prevalence.

CONCLUSIONS

Adjusting for pubertal status reduced the prevalence of overweight/obesity in non-Hispanic white, Mexican American, and non-Hispanic black youth. This suggests that adjusting for puberty incorporates changes otherwise not captured when only considering the age of a child. Adjusting BMI for pubertal status may be important when interpreting a youth's weight status and consideration for obesity management, as well as when interpreting pediatric overweight/obesity prevalence data.

South Georgia blue whales five decades after the end of whaling

Blue whales Balaenoptera musculus at South Georgia were heavily exploited during 20th century industrial whaling, to the point of local near-extirpation. Although legal whaling for blue whales ceased in the 1960s, and there were indications of blue whale recovery across the wider Southern Ocean area, blue whales were seldom seen in South Georgia waters in subsequent years. We collated 30 yr of data comprising opportunistic sightings, systematic visual and acoustic surveys and photo-identification to assess the current distribution of blue whales in the waters surrounding South Georgia. Over 34000 km of systematic survey data between 1998 and 2018 resulted in only a single blue whale sighting, although opportunistic sightings were reported over that time period. However, since 2018 there have been increases in both sightings of blue whales and detections of their vocalisations. A survey in 2020 comprising visual line transect surveys and directional frequency analysis and recording (DIFAR) sonobuoy deployments resulted in 58 blue whale sightings from 2430 km of visual effort, including the photo-identification of 23 individual blue whales. Blue whale vocalisations were detected on all 31 sonobuoys deployed (114 h). In total, 41 blue whales were photo-identified from South Georgia between 2011 and 2020, none of which matched the 517 whales in the current Antarctic catalogue. These recent data suggest that blue whales have started to return to South Georgia waters, but continued visual and acoustic surveys are required to monitor any future changes in their distribution and abundance.

Have whales returned to a historical hotspot of industrial whaling? The pattern of southern right whale Eubalaena australis recovery at South Georgia

Around 176500 whales were killed in the sub-Antarctic waters off South Georgia (South Atlantic) between 1904 and 1965. In recent decades, whales have once again become summer visitors, with the southern right whale (SRW) the most commonly reported species until 2011. Here, we assess the distribution, temporal pattern, health status and likely prey of SRWs in these waters, combining observations from a summertime vessel-based expedition to South Georgia, stable isotope data collected from SRWs and putative prey and sightings reports collated by the South Georgia Museum. The expedition used directional acoustics and visual surveys to localise whales and collected skin biopsies and photo-IDs. During 76 h of visual observation effort over 19 expedition days, SRWs were encountered 15 times (~31 individuals). Photo-IDs, combined with publicly contributed images from commercial vessels, were reconciled and quality-controlled to form a catalogue of 6 fully (i.e. both sides) identified SRWs and 26 SRWs identified by either left or right sides. No photo-ID matches were found with lower-latitude calving grounds, but 3 whales had gull lesions supporting a direct link with Península Valdés, Argentina. The isotopic position of SRWs in the South Georgia food web suggests feeding on a combination of copepod and krill species. Opportunistic reports of SRW sightings and associated group sizes remain steady over time, while humpback whales provide a strong contrast, with increased sighting rates and group sizes seen since 2013. These data suggest a plateau in SRWs and an increasing humpback whale presence in South Georgia waters following the cessation of whaling.

SAT-LB11 Adult Growth Hormone Deficiency Transition Care From Pediatric to Adult Services: Insights From a US Advisory Board

Background: Transition care of patients with childhood-onset GH deficiency (CO-GHD) who were treated with GH during childhood remains an ongoing challenge with substantial variation in coordination of care, clinical assessment, and management among pediatric and adult services. Despite the availability of clinical guidelines providing a framework for transition care of adolescents with CO-GHD, many patients discontinue therapy during the transition phase. Methods: A panel of pediatric and adult US endocrinologists with extensive experience in treating transition patients convened in October 2019 as part of an advisory board to address current clinical unmet needs and to share learnings based on a structured transitional plan to strive for optimal management of these patients. Results: It is acknowledged that pediatric endocrinologists play a crucial role in initiating the transition process, which involves close communication and direct collaboration between pediatric and adult services to reduce delays in identifying patients and resuming GH therapy in adulthood; adult endocrinologists need to increase their awareness of the importance of potential benefits and extent of long-term safety of GH therapy in adult patients. There is also a need for consensus guidelines or a white paper that focuses on transition care and endorsed by pediatric and adult organizations. Because not all patients with CO-GHD will have persistent GHD as adults, there is a need to improve the identification and timely retesting of those who will require continuity of GH therapy into adulthood. An increase in accessibility for retesting and guidance on appropriate GH dosing once persistent GHD is confirmed are other important factors. Certain subpopulations of pediatric patients (e.g., cancer survivors; patients with congenital hypopituitarism, optic nerve hypoplasia, treated sellar masses, and traumatic brain injury) should be prioritized in determinations of when and how retesting should be performed. The viewpoints of both pediatric and adult endocrinologists were presented at this meeting, and comprehensive considerations and suggestions were discussed. Conclusion: Transition care of patients with CO-GHD requires a collaborative multidisciplinary approach to ensure continuity of care between pediatric and adult services and to improve bone health and reduce long-term cardiometabolic risks. The major challenge is to effectively ensure that transition patients are retested and offered adult GH therapy without delay. Current guidelines should be more focused on transition patients, addressing key areas of uncertainty as evidenced by variable clinical practices. A clearly structured transition protocol is vital, and these insights provide useful, practical guidance to clinicians to establish best practices when transitioning adolescents with persistent CO-GHD to adult services.

MON-LB014 Autosomal Dominant Growth Hormone Deficiency Due to a Novel c.178g&gt;A Mutation in the GH1 Gene Is Caused by Alternative Splicing to Produce a Small GH Isoform

Introduction: Growth hormone (GH) plays a vital role in human physiology. Mutations in GH1 cause isolated growth hormone deficiency (GHD). The most frequent cause of familial growth hormone deficiency is Type II autosomal dominant GHD (isolated GHD type II) due to several heterozygous GH1 mutations. These mutations have been shown to (a) produce shorter isoforms of GH that do not bind to growth hormone receptors, (b) cause diminished secretion of GH, or (c) result in misfolded GH protein. Methods: Genomic DNA from patients with familial GHD was enriched for the coding exons using hybrid capture technology, and GH1 was sequenced using Next Generation Sequencing technology. The p.A34T mutant protein was expressed in bacteria, and binding to GHR was studied by surface plasmon resonance technology. Computational prediction of transcription indicated that alternative splicing is likely to produce a shorter GH variant with skipping of exon 3 in GH1. Mammalian cell-based studies incorporating transfection of whole GH1 gene containing exons/introns were used to study transcriptional effects. RNA was isolated from cells transfected with WT and mutant GH1 gene and analyzed by RT PCR using primers in the second and fifth exons of GH1 that could identify all possible isoforms of GH1 mRNA. Results: GHD was identified in three female siblings aged 3.25-6.33 years (Ht SDS -3.21 to -1.13, peak GH 2.9-6.6 ng/mL); their mother had previously been diagnosed with GHD at age 12.33 years (Ht SDS -3.44, GH peak &lt 2 ng/mL). Sequencing of GH1 identified a novel heterozygous variant (c.178G&gtA; p.Ala34Thr) not found in the Broad ExAc dataset representing &gt60,000 children without the severe childhood-onset disease. Functional studies using whole gene transfection showed that the c.178G&gtA mutation leads to alternate splicing resulting in increased production of the shorter 17.5kD isoform of GH due to exon 3 skipping. Results were confirmed by quantitative RT-PCR as well as GH secretion assays, which showed a lower level of GH production from cells transfected with the GH1 gene containing the c.178G&gtA mutation. The SPR based receptor binding assay and cell proliferation assay using bacterially expressed proteins showed that once produced, the GH protein with the A34T mutation behaves similar to WT GH protein. All these results confirm that the cause of GHD due to the c.178G&gtA mutation in GH1 is due to altered transcription leading to the production of the shorter 17.5 kD isoform of GH protein and not due to the amino acid change A34T that is caused by the mutation. Conclusion: The presence of a heterozygous GH1 variant (c.178G&gtA, p.Ala34Thr) in four individuals with GHD suggests that this is a novel cause of IGHD type II. Production of the smaller 17.5 kD GH isoform results in reduced overall GH secretion and loss of binding to GHR due to competition with the normal GH protein, explaining the dominant-negative phenotype.

Use of Gonadotropin-Releasing Hormone Analogs in Children: Update by an International Consortium

This update, written by authors designated by multiple pediatric endocrinology societies (see List of Participating Societies) from around the globe, concisely addresses topics related to changes in GnRHa usage in children and adolescents over the last decade. Topics related to the use of GnRHa in precocious puberty include diagnostic criteria, globally available formulations, considerations of benefit of treatment, monitoring of therapy, adverse events, and long-term outcome data. Additional sections review use in transgender individuals and other pediatric endocrine related conditions. Although there have been many significant changes in GnRHa usage, there is a definite paucity of evidence-based publications to support them. Therefore, this paper is explicitly not intended to evaluate what is recommended in terms of the best use of GnRHa, based on evidence and expert opinion, but rather to describe how these drugs are used, irrespective of any qualitative evaluation. Thus, this paper should be considered a narrative review on GnRHa utilization in precocious puberty and other clinical situations. These changes are reviewed not only to point out deficiencies in the literature but also to stimulate future studies and publications in this area.

The characteristics of krill swarms in relation to aggregating Antarctic blue whales

We model the presence of rare Antarctic blue whales (Balaenoptera musculus intermedia) in relation to the swarm characteristics of their main prey species, Antarctic krill (Euphausia superba). A combination of visual observations and recent advances in passive acoustic technology were used to locate Antarctic blue whales, whilst simultaneously using active underwater acoustics to characterise the distribution, size, depth, composition and density of krill swarms. Krill swarm characteristics and blue whale presence were examined at a range of spatiotemporal scales to investigate sub meso-scale (i.e., <100 km) foraging behaviour. Results suggest that at all scales, Antarctic blue whales are more likely to be detected within the vicinity of krill swarms with a higher density of krill, those found shallower in the water column, and those of greater vertical height. These findings support hypotheses that as lunge-feeders of extreme size, Antarctic blue whales target shallow, dense krill swarms to maximise their energy intake. As both Antarctic krill and blue whales play a key role in the Southern Ocean ecosystem, the nature of their predator-prey dynamics is an important consideration, not only for the recovery of this endangered species in a changing environment, but for the future management of Antarctic krill fisheries.

Laparoscopic resection is inappropriate in patients with known or suspected adrenocortical carcinoma

BACKGROUND

Complete surgical resection is the mainstay of treatment for patients with adrenocortical cancer (ACC). Use of laparoscopy has been questioned in patients with ACC. This study compares the outcomes of patients undergoing laparoscopic versus open resection (OR) for ACC.

METHODS

A retrospective review (2003-2008) of patients with ACC was performed. Data were collected for demographics, operative and pathologic data, adjuvant therapy, and outcome. Chi-square analysis was performed.

RESULTS

Eighty-eight patients (66% women; median age, 47 (range, 18-81) years) were identified. Seventeen patients underwent laparoscopic adrenalectomy (LA). Median tumor size of those who underwent LA was 7.0 (range, 4-14) cm versus 12.3 (range, 5-27) cm for OR. Recurrent disease in the laparoscopic group occurred in 63% versus 65% in the open group. Mean time to first recurrence for those who underwent LA was 9.6 months (+/-14) versus 19.2 months (+/-37.5) in the open group (p < 0.005). Fifty percent of patients who underwent LA had positive margins or notation of intraoperative tumor spill versus 18% of those who underwent OR (p = 0.01). Local recurrence occurred in 25% of the laparoscopic group versus 20% in the open group (p = 0.23). Mean follow-up was 36.5 months (+/-43.6).

CONCLUSIONS

ACC continues to be a deadly disease, and little to no progress has been made from a treatment standpoint in the past 20 years. Careful and complete surgical resection is of the utmost importance. Although feasible in many cases and tempting, laparoscopic resection should not be attempted in patients with tumors suspicious for or known to be adrenocortical carcinoma.

Growth patterns and the use of growth hormone in the mucopolysaccharidoses

Short stature is characteristic of patients with mucopolysaccharidosis (MPS) diseases. For children with skeletal dysplasias, such as MPS, it is important to know the natural history of growth. An understanding of the natural growth pattern in each MPS disease provides a measurement to which treatments can be compared, as well as data which can help families and providers make individualized decisions about growth promoting treatments. Multiple advancements have been made in the treatment of MPS with both hematopoietic cell transplantation (HCT) and enzyme replacement therapy (ERT). The long term benefit of these treatments on growth is unknown. This article will review the published data on growth in children with MPS, and describe preliminary data on the use of human growth hormone (hGH) in children with MPS.

Complete reconstitution of human IkappaB kinase (IKK) complex in yeast. Assessment of its stoichiometry and the role of IKKgamma on the complex activity in the absence of stimulation

The IkappaB kinase (IKK) complex, composed of two catalytic subunits (IKKalpha and IKKbeta) and a regulatory subunit (IKKgamma), is the key enzyme in activation of nuclear factor kappaB (NF-kappaB). To study the mechanism and structure of the complex, we wanted to recombinantly express IKK in a model organism that lacks IKK. For this purpose, we have recombinantly reconstituted all three subunits together in yeast and have found that it is biochemically similar to IKK isolated from human cells. We show that there is one regulatory subunit per kinase subunit. Thus, the core subunit composition of IKKalpha.beta.gamma complex is alpha(1)beta(1)gamma(2), and the core subunit composition of IKKbeta.gamma is beta(2)gamma(2). The activity of the IKK complex (alpha+beta+gamma or beta+gamma) expressed in yeast (which lack NF-kappaB and IKK) is 4-5-fold higher than an equivalent amount of IKK from nonstimulated HeLa cells. In the absence of IKKgamma, IKKbeta shows a level of activity similar to that of IKK from nonstimulated HeLa cells. Thus, IKKgamma activates IKK complex in the absence of upstream stimuli. Deleting the gamma binding domain of IKKbeta or IKKalpha prevented IKKgamma induced activation of IKK complex in yeast, but it did not prevent the incorporation of IKKgamma into IKK and large complex formation. The possibility of IKK complex being under negative control in mammalian cells is discussed.

Alfalfa rapidly remediates excess inorganic nitrogen at a fertilizer spill site

By 19%, standard remediation techniques had significantly reduced the concentration of nitrate nitrogen (NO3- -N) in local ground water at the site of a 1989 anhydrous ammonia spill, but NO3- -N concentrations in portions of the site still exceeded the public drinking water standard. Our objective was to determine whether local soil and ground water quality could be improved with alfalfa (Medicago sativa L.). A 3-yr study was conducted in replicated plots (24 by 30 m) located hydrologically upgradient of the ground water under the spill site. Three alfalfa entries ['Agate', Ineffective Agate (a non-N2-fixing elite germplasm similar to Agate), and MWNC-4 (an experimental germplasm)] were seeded in the spring of 1996. Corn (Zea mays L.) or wheat (Triticum aestivum L.) was seeded adjacent to the alfalfa each year. Crops were irrigated with N-containing ground water to meet water demand. During the 3-yr period, about 540 kg of inorganic N was removed from the aquifer through irrigation of 4.9 million L water. Cumulative N removal from the site over 3 yr was 972 kg N ha(-1) in Ineffective Agate alfalfa hay, compared with 287 kg N ha(-1) for the annual cereal grain. Soil solution NO3- concentrations were reduced to low and stable levels by alfalfa, but were more variable under the annual crops. Ground water quality improved, as evidenced by irrigation water N concentration. We do not know how much N was removed by the N2-fixing alfalfas, but it appears that either fixing or non-N2-fixing alfalfa will effectively remove inorganic N from N-affected sites.

Osteochondromas of the distal aspect of the tibia or fibula. Natural history and treatment

BACKGROUND

There is little information on the natural history or treatment of osteochondromas arising from the distal aspect of either the tibia or the fibula. It is believed that there is a risk of deformation of the ankle if these exostoses are left untreated or if the physis or neurovascular structures are injured during operative intervention.

METHODS

We reviewed the records of twenty-three patients who had been treated for osteochondroma of the distal aspect of the tibia or fibula between 1980 and 1996. Four of the patients had hereditary multiple cartilaginous exostoses. There were seventeen male and six female patients, and the average age at the time of presentation was sixteen years (range, eight to forty-eight years).

RESULTS

Preoperative radiographs showed evidence of plastic deformation of the fibula in eleven patients who had a large osteochondroma. Four patients elected not to have an operation. The tumor was excised in nineteen patients. Postoperatively, all nineteen patients had a Musculoskeletal Tumor Society score of 100 percent for function of the lower extremity with pain-free symmetrical and unrestricted motion of the ankle at the latest follow-up examination. Partial remodeling of the tibia and fibula gradually diminished the asymmetry of the ankles in all nineteen operatively managed patients; however, the remodeling was most complete in the younger patients. Pronation deformities of the ankle did not change after excision of the tumor. Complications of operative treatment included four recurrences (only three of which were symptomatic), one sural neuroma, one superficial wound infection, and one instance of growth arrest of the distal aspects of the tibia and fibula.

CONCLUSIONS

Osteochondromas of the distal and lateral aspects of the tibia were more often symptomatic than those of the distal aspect of the fibula; they most commonly occurred in the second decade of life with ankle pain, a palpable mass, and unrestricted ankle motion. Untreated or partially excised lesions in skeletally immature patients may become larger and cause plastic deformation of the tibia and fibula and a pronation deformity of the ankle. Ideally, operative intervention should be delayed until skeletal maturity, but, in symptomatic patients, partial excision preserving the physis may be necessary for the relief of symptoms and the prevention of progressive ankle deformity. However, partial excision is associated with a high rate of recurrence, so a close follow-up is required. Skeletally mature patients who are symptomatic may require excision of the tumor.

A new mechanism of action of fluoride on streptococci

Addition of fluoride to the growth medium of Streptococcus sobrinus resulted in a loss of glucan-binding lectin activity. Upon removal of fluoride, the bacteria regained their ability to bind glucan in about one generation. Chloramphenicol prevented recovery of ability to produce the lectin, showing the requirement for protein synthesis. Fluoride also caused a significant reduction in the tendency of the streptococci to form chains of cells, although the spent medium from fluoride-containing growth media did not dechain control cells. The fluoride thus does not activate autolytic enzymes. Importantly, 2-D electrophoresis and SDS-PAGE revealed several proteins were synthesized in the presence of fluoride that were not synthesized in its absence. It seems possible that fluoride places a stress on the bacteria, causing the synthesis of proteins that may play a role in protecting the cells against the stress. Numerous stress proteins are known for bacteria, including those resulting from heat, enzymes and osmotic shocks. The ability of fluoride to cause loss of glucan-binding may be related to its reported beneficial effects on oral health.

Bradykinin induces tubulin phosphorylation and nuclear translocation of MAP kinase in mesangial cells

Glomerular hypertension and glomerular hypertrophy act early and synergistically to promote glomerular injury in diabetes. We have previously shown that increased renal kinin production contributes to the glomerular hemodynamic abnormalities associated with diabetes. Glomerulosclerosis, characterized by mesangial cell proliferation and matrix expansion, is the final pathway leading to renal failure. The signal(s) initiating mesangial cell proliferation is ill defined. In the present study, we utilized immunofluorescence, immunoprecipitation, and immunoblotting techniques to identify substrates that are tyrosine phosphorylated in response to bradykinin action in mesangial cells. Immunofluorescence microscopy of mesangial cells stained with anti-phosphotyrosine (anti-PY) antibodies following bradykinin treatment (10(-9)-10(-6) M) revealed a dose-dependent increase in the labeling of cytoplasmic and nuclear proteins. Immunoprecipitation with anti-PY, followed by immunoblot revealed bradykinin-induced tyrosyl phosphorylation of tubulin and mitogen-activated protein kinase (MAPK). Confocal microscopy of mesangial cells stained for MAPK indicated that bradykinin stimulation resulted in translocation of MAPK from the cytoplasm to the nucleus by 2 h. These data demonstrate that bradykinin action results in the tyrosine phosphorylation of cellular proteins in mesangial cells and suggest a role for tubulin and MAPK in the signaling cascade of bradykinin leading to altered mesangial function.

Activation of C-jun N-terminal kinase/stress-activated protein kinase in primary glial cultures

Glial cells in the mammalian CNS are subject to environmental stress resulting from a variety of neuro-pathological conditions. In this study, we have examined the activation of a stress signal responsive kinase, i.e., stress-activated protein kinase (SAPK) or c-Jun N-terminal kinase (JNK), in primary cultures of rat brain glial cells (i.e., astrocytes and oligodendrocytes) and an oligodendrocyte progenitor cell line, CG4, in response to cytokines and other stress inducers. JNK/SAPK activity was measured by an immune complex kinase assay using polyclonal anti-JNK antibodies along with GST c-Jun (1-79) as the substrate. Among the cytokines tested, TNF-alpha had the strongest effect on JNK activation followed by TNF-beta in both the glial cell types while a substantial level of kinase activation was observed in response to IL-1 in astrocytes. JNK activation by TNF-alpha in astrocytes, but not in oligodendrocytes, showed a biphasic response. An in-gel kinase assay of cell extracts and immunoprecipitated JNK confirmed the activation of JNK1 in cells treated with TNF-alpha. JNK was also activated by several other stress-inducing factors including. UV light, heat shock, inhibitors of protein synthesis, and mechanical injury. Incubation of cells with bacterial sphingomyelinase and a cell-permeable ceramide stimulated JNK activity, suggesting that the ceramide pathway may play a role in JNK activation, although the time course of activation did not correspond to that of TNF-alpha. The results are discussed in terms of possible roles of JNK activation in signaling for gliosis in astrocytes and as a protective/toxic response in oligodendrocytes.

Activation of cJun NH2-terminal kinase/stress-activated protein kinase by insulin

One of insulin's many biological effects is the increased transcription of AP-1-regulated genes. cJun is the principal component of the AP-1 transcription complex, which is regulated by the newly discovered members of the MAPK superfamily referred to as cJun NH2-terminal kinases (JNKs) or stress-activated protein kinases (SAPKs). We show that insulin stimulates a dose- and time-dependent increase in JNK activity in Rat 1 fibroblasts overexpressing human insulin receptors (Rat 1 HIR cells). Using two different polyclonal anti-JNK antibodies, JNK activity was measured after immunoprecipitation from whole cell extracts by phosphorylation of GSTcJun(1-79). Peak activation occurred 15 min after insulin addition, resulting in a 2.5-fold increase in GSTcJun(1-79) phosphorylation over unstimulated controls. Maximal JNK activation correlated with the onset of AP-1 DNA binding activity. Both insulin-stimulated JNK activity and insulin-induced AP-1 transcriptional activity were found to be Ras-dependent. These data suggest that in Rat 1 cells, JNK activation may play a role in insulin-regulated AP-1 transcriptional activity leading to a mitogenic response.

Anxiety disorders of childhood, Implications for adult psychopathology

Although the exact path of acquisition remains incompletely understood, research supports the association between anxiety disorders in children and psychopathologic conditions in adults. This article addresses this relationship; reviews findings on the temperamental profile and behavioral inhibition, which may be an early identifiable childhood predictor of later anxiety disorders; and discusses the importance of early intervention.

Insulin like growth factor 1 receptor signal transduction to the nucleus

The mechanism by which IGF-1Rs regulate the growth and maintenance of cells in normal and disease states provides an important setting for studies addressing signal transduction events at the nuclear level. With the identification of c-Jun/AP-1 as a nuclear target of IGF-1 action we are provided with a model system for pursuing the molecular mechanisms triggered by IGF-1 action.

Bacteriophage phi 105clz induces the GroEL-homologue protein in Bacillus subtilis

Using two-dimensional polyacrylamide gel electrophoresis, the GroEL homologue of Bacillus subtilis was shown to be induced upon infection with phi 105clz, a clear plaque mutant of the temperate bacteriophage phi 105. Western blotting of one dimensional polyacrylamide gels also showed the induction of the GroEL homologue when cells were infected with phi 105clz.

[X-ray diagnosis of aseptic necrosis of the femur head in adults at the preclinical stage]

The time course of an x-ray picture from the normal bone structure up to the appearance of positive x-ray signs of aseptic necrosis of the head of the femur (ANHF) was followed-up. The former, appearing long before the development of clinical signs of disease, were foci of the rarefaction of a round or oval shape in the upper, central parts of the head of the femur, and along its periphery in somewhat dense or normal structure of the head of the femur.

[Early diagnosis of aseptic necrosis of the femur head in adults]

Having analysed the case histories of 121 patients with unilateral aseptic necrosis of the femoral head the authors revealed early roentgenologic symptoms of aseptic necrosis in the other hip which was normal on admission in 19 patients with absence of the clinical signs of the disease. In other 13 patients at different terms after the exposure of the roentgenologic changes (up to 9 years) a clinical picture of aseptic necrosis of this previously normal joint developed. A picture that is characteristic both of the preclinical stage and of other stages of aseptic necrosis of the femoral head may be revealed in the roentgenograms during the initial examination of the patient, which is connected with some peculiarities of the course of the disease.

Young children's ability to infer spatial relationships: evidence from a large, familiar environment

Young (mean age = 3-9) and old (mean age = 5-0) nursery school children were tested on their ability to infer spatial relationships in a large, familiar environment. Each child in the younger group was matched to a child of the same sex in the older group who had been attending the nursery school for the same number of months. Subjects were taken to 3 different locations in their nursery school and were asked to point to 5 targets on the school grounds. Older children were more accurate than younger children on nursery school targets, but children's spatial representations were relatively nonintegrated at both age levels. Consistent sex differences in favor of males were discussed in the context of a new framework that could potentially explain the appearance of sex differences on spatial tasks conducted in large-scale environments. It was concluded that very young children have difficulty inferring spatial relationships, even in a large, familiar environment. This difficulty seems to be due to a relative lack of symbolic capacity.

Effects of benzo(a)pyrene on early development of flatfish

The ontogenetic effects of the environmental carcinogen benzo(a)pyrene (BAP) on three species of larval flatfish were investigated using concentrations (from 0.10 to 4.2 ppb) which were comparable to levels found in polluted harbors. BAP-treated sand sole (Psettichthys melanostichus) eggs displayed a significant decline in hatching success and a significantly higher incidence of developmental anomalies than did control eggs. Flathead sole (Hippoglossoides elassodon) eggs exposed to a single dose of a water-soluble BAP-bovine serum albumin complex demonstrated evidence of toxic injury with pycnotic nuclei present in the integument and, more commonly, in ocular and neural tissues. An increased incidence of morphological anomalies in English sole (Parophyrs vetulus) eggs and larvae exposed to BAP was not detected.

Uptake of benzo[a]pyrene by gonadal tissue of flatfish (family Pleuronectidae) and its effects on subsequent egg development

Accumulation of benzo[a]pyrene (BaP) by sexually mature flatfish gonad, its transfer to developing gametes, and its subsequent effects on developing embryos were studied. Thin-layer chromatography revealed both unmetabolized BaP and polar metabolites in the ovary, wolffian ducts, oocytes, and semen of English sole 24 h after ip injection with 200 microCi [3H]BaP. Concentrations of BaP and its metabolites were 3-11 times higher in oocytes and semen than in gonadal tissue. Fertilized eggs from flathead sole that had been fed 4.0 mg BaP 5 h before spawning demonstrated a significantly lower (p less than 0.001) hatching success (11.9%) than eggs from control fish (56.6%). Morphological abnormalities were found in only 1.6% of control embryos but in 5.6% of embryos from treated females.