Insights from an advisory board: Facilitating transition of care into adulthood in brain cancer survivors with acquired pediatric growth hormone deficiency

OBJECTIVE

Children with growth hormone deficiency (GHD) face multiple challenges that can negatively impact the transition from pediatric to adult endocrinology care. For children with GHD resulting from brain cancer or its treatment, the involvement of oncology care providers and possible disease-related comorbidities add further complexity to this transition.

DESIGN

An advisory board of pediatric and adult endocrinologists was convened to help better understand the unique challenges faced by childhood cancer survivors with GHD, and discuss recommendations to optimize continuity of care as these patients proceed to adulthood. Topics included the benefits and risks of growth hormone (GH) therapy in cancer survivors, the importance of initiating GH replacement therapy early in the patient's journey and continuing into adulthood, and the obstacles that can limit an effective transition to adult care for these patients.

RESULTS/CONCLUSIONS

Some identified obstacles included the need to prioritize cancer treatment over treatment for GHD, a lack of patient and oncologist knowledge about the full range of benefits provided by long-term GH administration, concerns about tumor recurrence risk in cancer survivors receiving GH treatment, and suboptimal communication and coordination (e.g., referrals) between care providers, all of which could potentially result in treatment gaps or even complete loss of follow-up during the care transition. Advisors provided recommendations for increasing education for patients and care providers and improving coordination between treatment team members, both of which are intended to help improve continuity of care to maximize the health benefits of GH administration during the critical period when childhood cancer survivors transition into adulthood.

Congenital Hyperinsulinism and Hypopituitarism Attributable to a Mutation in FOXA2

CONTEXT

Persistent hypoglycemia in the newborn period most commonly occurs as a result of hyperinsulinism. The phenotype of hypoketotic hypoglycemia can also result from pituitary hormone deficiencies, including growth hormone and adrenocorticotropic hormone deficiency. Forkhead box A2 (Foxa2) is a transcription factor shown in mouse models to influence insulin secretion by pancreatic β cells. In addition, Foxa2 is involved in regulation of pituitary development, and deletions of FOXA2 have been linked to panhypopituitarism.

OBJECTIVE

To describe an infant with congenital hyperinsulinism and hypopituitarism as a result of a mutation in FOXA2 and to determine the functional impact of the identified mutation.

MAIN OUTCOME MEASURE

Difference in wild-type (WT) vs mutant Foxa2 transactivation of target genes that are critical for β cell function (ABCC8, KNCJ11, HADH) and pituitary development (GLI2, NKX2-2, SHH).

RESULTS

Transactivation by mutant Foxa2 of all genes studied was substantially decreased compared with WT.

CONCLUSIONS

We report a mutation in FOXA2 leading to congenital hyperinsulinism and hypopituitarism and provide functional evidence of the molecular mechanism responsible for this phenotype.

Recent research on inhaled corticosteroids and growth

PURPOSE OF REVIEW

Description of recent studies evaluating growth and inhaled corticosteroids.

RECENT FINDINGS

Corticosteroids are the gold standard of asthma maintenance treatment, but effects on growth remain controversial. This is a review of recent research in this area, which has focused on medications causing less adrenal suppression as well as alternative regimens for chronic illness such as asthma.

SUMMARY

The use of newer corticosteroids and regimens shows short-term evidence of minimal growth effects without worsening of asthma control.

A stepwise increase in recombinant human growth hormone dosing during puberty achieves improved pubertal growth: a National Cooperative Growth Study report

The magnitude of the pubertal growth spurt contributes to adult height. Children treated with increased doses of recombinant human growth hormone (rhGH) during puberty have shown improved near adult height (NAH) outcomes that varied by treatment duration.

METHODS

Males, in a single clinic, treated with a prepubertal dose of rhGH (0.3 mg/kg/wk) received 0.1 mg/kg/wk dose increases with successive Tanner stages up to 0.6 mg/kg/wk. Changes in height and height SDS from pubertal onset to NAH were assessed in patients attaining NAH after > or =3 years (n = 23) and > or =4 years (n = 16). Using ANCOVA, outcomes were compared to closely matched patients (n = 758) from the National Cooperative Growth Study treated with a fixed dose (0.3 mg/kg/wk) throughout puberty.

RESULTS

Compared to matched patients, a 3.6 cm greater increase in mean height gain and a 0.49 greater increase in mean height SDS (p <0.0001) during puberty was observed in patients attaining NAH after > or =3 years. Corresponding values were 3.9 cm and 0.54 (p <0.0001) in patients attaining NAH after > or =4 years.

CONCLUSION

Stepwise increases in rhGH improved pubertal height gain when compared to a fixed dose and may represent an alternate approach to managing the patient during puberty.

Lack of influence of COMT and NET genes variants on executive functions in schizophrenic and bipolar patients, their first-degree relatives and controls

Abnormal dopaminergic function in the prefrontal cortex (PFC) may be a key factor in the etiopathogeny of schizophrenia and bipolar disorder. Both schizophrenic and bipolar subjects have executive functions (EF) deficits, thought to reflect abnormal PFC function. The main inactivation pathways for dopamine in the PFC are enzymatic cleavage by the Carboxy-O-Methyl-Transferase (COMT) and reuptake by the nor-epinephrine transporter (NET). Our aim in this study was to replicate previous studies that investigated influence of the COMT genotype on EF in schizophrenic subjects, their relatives and controls and extend their scope by including bipolar patients, and their relatives and by exploring NET gene polymorphisms influence on executive performances. We investigated one functional polymorphism of the COMT gene and two polymorphisms of the NET gene. EF were assessed by means of the Trail Making Test (TMT) and the Wisconsin Card Sorting Test (WCST). We assessed the effect of each of the three genotypes on EF for the whole sample (N = 318) and separately in schizophrenic (N = 66), bipolar (N = 94) and healthy subjects (i.e., relatives and controls N = 158). Separate analyses were performed because of the presence, in patients samples, of potentially confounding factors, especially medication. Genotype had no significant effect on the cognitive measures in any of the analyses (for the two EF measures, the three polymorphisms, and the four groups). In our sample we found no evidence in favor of a major effect of COMT or NET polymorphisms on the two tests of EF.

Omodysplasia: an affected mother and son

We describe a second family with mother to son transmission of omodysplasia, a rare skeletal dysplasia characterized by shortened humeri, shortened first metacarpals and craniofacial dysmorphism. The mother in this family had been diagnosed previously with Robinow syndrome; subsequently, her diagnosis was reclassified. Her pregnancy was closely monitored antenatally with serial ultrasound examinations. Delayed ossification of the humerus was noted prenatally. Her son had ambiguous genitalia and similar skeletal manifestations as his mother. A comparison to other known and suspected cases of dominant omodysplasia is presented. Our observations confirm the existence of a dominant variant of omodysplasia, document genital hypoplasia as an important feature of this syndrome in males and highlight the need to differentiate this entity from Robinow syndrome.

Growth hormone use in pediatric growth hormone deficiency and other pediatric growth disorders

The diagnosis and management of growth disorders in children, particularly disorders that respond to therapy with growth hormone (GH), raise challenging clinical and economic issues. Several such issues are presented in the following article in which Dr. Ron Rosenfeld examines the evaluation and diagnosis of the child with short stature; Dr. David B. Allen discusses the anabolic and metabolic indications for GH treatment in children; Dr. Margaret H. MacGillivray reviews GH dosing, height outcomes, and follow up; and Dr. Craig Alter presents the payer's perspective on the diagnosis and treatment of pediatric GH deficiency. In addressing the use of GH in other pediatric populations, Dr. Paul Saenger focuses on Turner syndrome, Dr. Henry Anhalt on chronic renal insufficiency of childhood, and Dr. Ray Hintz on idiopathic short stature. Dr. Harvey P. Katz presents one managed care organization's policy and implementation plan that is used to guide decisions regarding coverage for GH treatment.

Biomechanical and densitometric bone properties after callus distraction in sheep

Assessment of biomechanical stability of diaphyseal bone lengthened by callus distraction is an unsolved problem. A middiaphyseal corticotomy was performed in the left tibia of 24 sheep. After 7 days, callus distraction was begun at a rate of 0.5 mm every 12 hours for 30 days using a standard unilateral fixator system. Animals were euthanized 4, 8, or 12 weeks after the end of distraction. The lengthened tibia and the contralateral control tibia from each animal were evaluated by radiographic, densitometric (dual energy xray absorptiometry, quantitative computed tomography), and biomechanical (axial compression testing, torsion testing to failure) methods. The bone mineral density and maximum torque for the lengthened tibia were significantly greater in the 8-week group than in the 4-week group. However, the values in the 12-week group were significantly smaller than in the 8-week group. In the lengthened tibias, there was a correlation between the maximum torque and the bone mineral density, and between the maximum torque and the bone density. Bone density measurements are useful prognosticators for the safe removal of external fixators after leg lengthening procedures. By using these methods, clinical fractures after leg lengthening could be avoided in the future.

[Possibilities of follow-up imaging after implantation of a carbon fiber-reinforced hip prosthesis]

INTRODUCTION

There are many problems in the radiological diagnosis of aseptic loosening in total hip arthroplasty. Computed tomography (CT) and magnetic resonance tomography (MRT) are not usable for metallic implants (stainless steel, cobalt alloy, titanium alloy).

MATERIAL AND METHODS

From April 1993 to December 1993 15 CFRP non-cemented hip prostheses have been implanted. In a prospective clinical study plane radiographs, CT and MRT have been analysed.

RESULTS

Three stems were revised (1 femoral fracture, 1 severe thigh pain, 1 aseptic loosening). CFRP are not visible in plane radiographs. There was a complete (two-third of the cases) or nearly complete (one-third of the cases) small sclerotic interface between the prosthesis and the bone, these were apparent in CT and MRT in stable implant cases and did not have any clinical correlations.

DISCUSSION

The small sclerotic interface is quite different in comparison to so called "Reactive Lines". In one case of aseptic loosening there was an interposition of soft tissue between prosthesis and bone in MRT and CT. CFRP inaugurates new diagnostic possibilities in aseptic loosening of hip prosthesis and in tumour surgery too.

The effects of bereavement on adult sibling bone marrow donors' psychological well-being and reactions to donation

As living organ, tissue, and bone marrow donation become increasingly prevalent treatments for a variety of diseases, better understanding of living donors' experiences, especially when the recipient does not survive after the transplant, also becomes more critical. Although some psychological outcome data exist concerning living donation, there have been no systematic prospective investigations, to date, of the psychological impact of bereavement among sibling bone marrow donors. Studies of bereavement effects in other donation settings such as unrelated bone marrow donation and related kidney donation, suggest that bereavement may have a significant impact on donors' reactions. The present investigation studied a panel of sibling bone marrow donors at three key points in the donation process in order to (1) examine donor psychological well-being across time, and (2) investigate the effect of the sibling recipient's death on donor well-being. We surveyed sibling donors by mail 1-2 weeks prior to donation, 1-2 weeks following donation, and again 1 year after their donation. In general, all donors reported high levels of predonation self-esteem, mastery, happiness and life satisfaction. As might be expected, bereaved donors felt less as if their donation had really helped their sibling as time passed. However, despite such donation-specific perceptions, bereaved donors experienced global psychological gains following bereavement including enhanced self-esteem, happiness, and life satisfaction compared to donors whose siblings were still living. These findings suggest that physicians and mental health practitioners should monitor donors' psychological well-being for extended periods post-donation, and should consider clinical interventions for bereaved and nonbereaved sibling donors.

[Diagnosis of intraorbital meningioma]

Demonstration of radiological appearance and the differential diagnosis of intraorbital meningeomas in two cases. CT-assisted core needle biopsy offers a reliable and easy-to-perform possibility of minimal invasive diagnosis in tumours which are difficult to classify.

Glycogen storage disease in adults

OBJECTIVE

To identify complications amenable to prevention in adults with glycogen storage disease (GSD) types Ia, Ib, and III and to determine the effect of the disease on social factors.

DESIGN

Case series and clinical review.

SETTING

Referral medical centers in the United States and Canada.

PATIENTS

All patients with GSD-Ia (37 patients), GSD-Ib (5 patients), and GSD-III (9 patients) who were 18 years of age or older.

MEASUREMENTS

Ultrasound or radiographic studies identified liver adenomas, nephrocalcinosis, or kidney stones. Radiographic studies identified osteopenia. Reports of the clinical examination, serum chemistry results, and social data were obtained.

RESULTS

For patients with GSD-Ia, problems included short stature (90%), hepatomegaly (100%), hepatic adenomas (75%), anemia (81%), proteinuria or microalbuminuria (67%), kidney calcifications (65%), osteopenia or fractures or both (27%), increased alkaline phosphatase (61%) and gamma-glutamyltransferase (93%) activities, and increased serum cholesterol (76%) and triglyceride (100%) levels. Hyperuricemia was frequent (89%). Patients with GSD-Ib had severe recurrent bacterial infections and gingivitis. In patients with GSD-III, 67% (6 of 9) had increased creatinine kinase activity. Four of these patients had myopathy and cardiomyopathy.

CONCLUSIONS

For GSD-Ia, hyperuricemia and pyelonephritis should be treated to prevent nephrocalcinosis and additional renal damage. For GSD-Ib, granulocyte-colony-stimulating factor may prevent bacterial infections. For GSD-III, more data are required to determine whether the myopathy and cardiomyopathy can be prevented. Most of the patients with GSD-I and GSD-III had 12 or more years of education and were either currently in school or employed.

Cognition-activated low-frequency modulation of light absorption in human brain

Animal model studies indicate light-absorption changes of the exposed animal brain in response to visual stimulation. Here we report observations of red-light absorbance changes, attributable to repetitive blood concentration changes in response to stimulation in the human brain frontal region by a cognitive process. These responses are observed as low-frequency recurrence of changes by Fourier transform analysis and are attributed to blood concentration change stimulated by the increased metabolic rate of brain tissue in cognitive function. A simple, portable dual wavelength spectrophotometer was attached noninvasively to the human forehead to measure the low frequency and power spectra of fluctuations of absorbances attributed to variations of brain blood concentration in the frontal region. The responses are associated with brain activity in responses to problem solving of analogies presented visually that require an associative function in the frontal region. The method of subtraction of test -rest Fourier transforms minimizes the arterial pulse frequency contributions and identifies specific frequencies--for example, 0.8, 1.6, 1.8 Hz in 24 of 28 tests of nine individuals (85%). Tests in which no increased brain activity was elicited (rest-rest) showed small differences. It is concluded that low-frequency recurrences of brain activity linked to blood concentration increases can be detected in human subjects with an optical device of potentially for simplified tests of cognitive function in the 0- to 3-Hz region and with modifications for wider band recordings in localized tissue volumes by time-resolved spectroscopy.

Subcutaneous emphysema: report of a case and review of the literature

We report the association of subcutaneous emphysema with the use of a suprapubic bladder catheter. Review of the literature has revealed no prior reports of this complication. We have reviewed the literature on causes of tissue emphysema.

Cerebral energy metabolism and oxygen state during hypoxia in neonate and adult dogs

The relationship between a noninvasive determination of relative oxygen saturation of Hb circulating in brain tissue (StO2) and energy metabolism was investigated with respect to age [dogs in three age groups (0 to 6-d-old, 7- to 21-d-old, and adults)] and to severity of brain hypoxia using double beam spectroscopy of Hb deoxygenation and nuclear magnetic resonance spectroscopy of energy metabolism. The in vivo oxy-Hb dissociation was determined from the relationship between StO2 curve in the adult dog brain and sagittal sinus oxygen partial pressure during graded hypoxemia and found to be sigmoidal with an oxygen dissociation constant of 26.6 mm Hg. This agreed with an in vitro determination for oxygen dissociation constant of 28.2 mm Hg in adult dog red cells. The arterial oxygen pressure at which brain StO2 was reduced by 50% was shifted toward the right with increasing age (22.2, 33.8, and 40.8 mm Hg, respectively). This correlated with an in vitro oxygen dissociation constant of red cell Hb of 17.0, 22.3, and 28.2 mm Hg in the three age groups, respectively. The phosphocreatine-inorganic phosphate ratio (PCr/Pi) was used to relate changes in cellular energy metabolism during hypoxia with changes in StO2. There was no change in PCr/Pi when StO2 had decreased to 50% of the control value. However, when the brain StO2 had decreased to between 7 and 15%, a reduction of PCr/Pi to 50% of the normoxic value occurred.(ABSTRACT TRUNCATED AT 250 WORDS)