The Association of Incidental Radiation Dose to the Heart Base with Overall Survival and Cardiac Events after Curative-intent Radiotherapy for Non-small Cell Lung Cancer: Results from the NI-HEART Study

AIMS

Cardiac disease is a dose-limiting toxicity in non-small cell lung cancer radiotherapy. The dose to the heart base has been associated with poor survival in multiple institutional and clinical trial datasets using unsupervised, voxel-based analysis. Validation has not been undertaken in a cohort with individual patient delineations of the cardiac base or for the endpoint of cardiac events. The purpose of this study was to assess the association of heart base radiation dose with overall survival and the risk of cardiac events with individual heart base contours.

MATERIALS AND METHODS

Patients treated between 2015 and 2020 were reviewed for baseline patient, tumour and cardiac details and both cancer and cardiac outcomes as part of the NI-HEART study. Three cardiologists verified cardiac events including atrial fibrillation, heart failure and acute coronary syndrome. Cardiac substructure delineations were completed using a validated deep learning-based autosegmentation tool and a composite cardiac base structure was generated. Cox and Fine-Gray regressions were undertaken for the risk of death and cardiac events.

RESULTS

Of 478 eligible patients, most received 55 Gy/20 fractions (96%) without chemotherapy (58%), planned with intensity-modulated radiotherapy (71%). Pre-existing cardiovascular morbidity was common (78% two or more risk factors, 46% one or more established disease). The median follow-up was 21.1 months. Dichotomised at the median, a higher heart base Dmax was associated with poorer survival on Kaplan-Meier analysis (20.2 months versus 28.3 months; hazard ratio 1.40, 95% confidence interval 1.14-1.75, P = 0.0017) and statistical significance was retained in multivariate analyses. Furthermore, heart base Dmax was associated with pooled cardiac events in a multivariate analysis (hazard ratio 1.75, 95% confidence interval 1.03-2.97, P = 0.04).

CONCLUSIONS

Heart base Dmax was associated with the rate of death and cardiac events after adjusting for patient, tumour and cardiovascular factors in the NI-HEART study. This validates the findings from previous unsupervised analytical approaches. The heart base could be considered as a potential sub-organ at risk towards reducing radiation cardiotoxicity.

Phenotypic variability in 17beta-hydroxysteroid dehydrogenase-3 deficiency and diagnostic pitfalls

OBJECTIVE

17beta-hydroxysteroid dehydrogenase type 3 isoenzyme (17beta-HSD3) is required to produce testosterone for male sex differentiation. Mutations in the HSD17B3 gene cause 17betaHSD3 deficiency and result in XY sex reversal of varying degree. We report the phenotypes of 14 subjects with 17betaHSD3 deficiency in relation to sex of rearing, androgen production, and HSD17B3 mutations.

DESIGN

Cases were identified through the Cambridge Disorders of Sex Development Database where detailed clinical information was recorded, results of hCG stimulation tests were available, and HSD17B3 mutation was identified.

RESULTS

Fourteen subjects from seven pedigrees (four consanguineous) had the following seven mutations: A56T, N130S, E215D, S232L, C268Y, V205E, and a novel mutation M197K. XY sex reversal was classified as complete in 10 infants at birth. Inguinal masses suggestive of androgen insensitivity syndrome (AIS) occurred in five infants. Contrasexual virilization reminiscent of 5alpha-reductase deficiency occurred in four subjects at puberty. The median (range) testosterone : androstenedione (T/A) ratio after a short hCG stimulation test was 0.32 (0.12-3.4). The S232L mutation identified in three affected family members caused isolated, severe hypospadias in one member who was raised male; virilization occurred despite in vitro studies showing an inactive mutant enzyme. Ratios of T/A in this pedigree were more than 0.8.

CONCLUSION

XY sex reversal is sufficiently variable in 17betaHSD3 deficiency to cause problems in accurate diagnosis, particularly in distinguishing it from AIS. It should be considered in undervirilized male infants with normal Wolffian duct structures, absent Müllerian ducts, and normal adrenal steroid biosynthesis; or when an assigned female subject virilizes at puberty. Elevated hCG-stimulated T/A ratio may occur, and sex of rearing may not be concordant within affected families with the same HSD17B3 mutation. The T/A ratio, mutation analysis and functional analysis of the mutant enzyme taken in isolation, respectively, may not conclusively establish a diagnosis of 17betaHSD3 deficiency in undervirilized male subjects; the reasons for these discrepancies remain unknown.

Clinical features, diagnosis, treatment and molecular studies in paediatric Cushing's syndrome due to primary nodular adrenocortical hyperplasia

BACKGROUND

Primary nodular adrenocortical hyperplasia (PNAH) is a well recognized, but infrequently studied cause of paediatric Cushing's syndrome (CS).

OBJECTIVE

To assess presentation, diagnosis, radiological imaging, treatment and molecular analysis of patients with childhood-onset CS due to PNAH.

PATIENTS

Four males and two females (median age 12.9 years, range 10.9-16.9 years) were studied.

RESULTS

All had growth failure (mean height SDS -1.2; range -2.5-0.0), weight gain [mean body mass index (BMI) SDS 3.5; range 2.5-4.6] and clinical virilization, while five had hypertension [mean systolic blood pressure (SBP) 130 mmHg, diastolic blood pressure (DBP) 83 mmHg]. One patient had generalized lentigines, one had a tibial chondromyxomatous cyst and two had facial freckling. One patient had a family history of primary nodular adrenocortical disease. The diagnosis of CS was based on elevation of sleeping midnight serum cortisol and urinary free cortisol excretion, and impaired suppression of cortisol on both low- and high-dose dexamethasone suppression tests (DST). All patients had undetectable plasma ACTH with absent responses of both plasma ACTH and serum cortisol to an intravenous (i.v.) corticotrophin-releasing hormone (CRH) test. Computed tomography or magnetic resonance imaging showed normal or small adrenals, with nodules in two patients. All patients underwent bilateral adrenalectomy, performed by open (n = 2) or laparoscopic surgery (n = 4) at a mean of 0.4 years (range 0.2-0.8 years) from diagnosis. Hypercortisolaemia was treated preoperatively by metyrapone alone 0.50-0.75 g/day (n = 4), metyrapone 0.75-1.50 g/day + o'p'DDD/mitotane 1-2 g/day (n = 1), or ketoconazole (n = 1). Adrenal histology showed nodular cortical hyperplasia with shrinkage of intervening cortical tissue and pigmentation, present in four patients. Molecular analysis of the type 1-alpha regulatory subunit of protein kinase A (PRKAR1A) gene revealed a novel germline mutation in one patient. Postadrenalectomy, three patients, had catch-up growth with height velocities increasing from 3.0, 3.9 and 2.5-8.9, 8.3 and 9.0 cm/years, respectively. All six are well at a follow-up (mean 4.0 years; range 0.5-10.8 years).

CONCLUSIONS

PNAH was associated with cushingoid features, virilization and hypertension with a lack of cortisol suppression on high DST, undetectable plasma ACTH and absent cortisol and ACTH responses to CRH. Adrenals were normal or small on imaging. PRKAR1A gene analysis may be helpful in the assessment of these patients.

Short stature in Noonan syndrome: response to growth hormone therapy

BACKGROUND

Growth hormone (GH) has been used to promote growth in both the short and long term in a number of dysmorphic syndromes, including Turner syndrome. As this condition shares many clinical features with Noonan syndrome, it would seem logical to treat the latter group with GH.

AIMS

To assess the short and long term response to GH therapy in patients with Noonan syndrome.

METHODS

Analysis of patients with Noonan syndrome in the Pharmacia & Upjohn International Growth Study (this post-marketing database contains data on the majority of patients currently treated with GH in the UK). A questionnaire was also sent to participating clinicians.

RESULTS

Data on 66 patients (54 males) were available for study. At the start of GH therapy children were short, compared with both normal and Noonan children. During the first year of GH therapy height velocity increased from a mean of 4.9 to 7.2 cm per year. For patients treated long term with GH, mean height SDS increased from -2.9 pretreatment to -2.6 after one year and -2.3 after five years. Of the 10 patients at near final height, only one had a height above the 3rd centile for normal adults and above the mean for untreated Noonan patients. The mean increment in final height was 3.1 cm (range -1.1 to 6.5 cm).

CONCLUSIONS

GH therapy in patients with Noonan syndrome will improve height velocity in the short term. Longer-term therapy results in a waning of effect; initial indications are that final height is not improved substantially in most patients.

A multicentre trial of recombinant growth hormone and low dose oestrogen in Turner syndrome: near final height analysis

BACKGROUND

Turner syndrome accounts for 15-20% of childhood usage of growth hormone (GH) in the UK but final height benefit remains uncertain. The most effective strategy for oestrogen replacement is also unclear.

METHODS

Fifty eight girls who, at start of treatment, were of mean age 9.1 years and projected final height 142.2 cm were randomised to receive in year 1, either low dose ethinyloestradiol 50-75 ng/kg/day, GH 28 IU/m(2) surface area/week as a daily injection, or a combination of ethinyloestradiol and GH. After the first year, the ethinyloestradiol treated girls received combination treatment. After two years, girls aged over 12 years were given escalating ethinyloestradiol to promote pubertal development.

RESULTS

Near final height was available for 49 girls at age 16.5 years, 146.8 cm, representing a gain of 4.6 cm, range -7.9 to +11.7 cm. Twelve of the 49 girls gaining 7.5 cm or more were less than 13 years at the start and had received GH for at least four years. Height gain was correlated with greater initial height deficit. Fifteen girls (31%) reached 150 cm or more compared to a predicted 10%. Early supplementation with ethinyloestradiol provided no final height advantage.

CONCLUSIONS

Final height gain was modest at 4.6 cm. Younger, shorter girls gained greatest height advantage from GH. Low dosage ethinyloestradiol before planned induction of puberty was not beneficial.

A decade of growth hormone treatment in girls with Turner syndrome in the UK. UK KIGS Executive Group

Fifteen per cent of children treated with growth hormone (GH) are receiving treatment for Turner syndrome, but few results are available on final height in the UK. In this study, data were obtained from the UK KIGS database for 485 girls with Turner syndrome who were treated from 1986, allowing an audit of practice and outcome over 10 years. Over the decade, the mean age of starting growth hormone treatment fell from 10.4 to 8.5 years and the starting dose increased from 0.55 to 0.95 IU/kg/week. The frequency of injections increased from three to six or seven/week. Some girls received suboptimal doses, which also differed depending on whether they were based on weight or surface area. To assess what height gain might be expected at final height, all 52 girls who were prepubertal at the start of treatment, which continued for four years or more, and who had reached final height or had a growth velocity < 2 cm/year were selected. Their mean gain in final height was 5.2 cm and the GH dose was 0.78 IU/kg/week over 5.8 years. Final height gain correlated significantly with duration of treatment, total dose received, and first year response, which itself related to starting dose. This audit shows a changing pattern of treatment over the past decade, which in many instances has been inadequate. When treatment starts before puberty and continues through to final height, with a dose of 30 IU/m2/week in six or seven injections, a mean increase in final height of 5 cm or more would be expected.

Neutral lipid storage disease. Case report and lipid studies

A 9-year-old boy of Greek-Cypriot origin had been diagnosed at the age of 3 years as suffering from non-bullous ichthyosiform erythroderma. However, he also had hepatomegaly and abnormal liver function tests, biochemical evidence of myopathy, early cataracts, and lipid vacuoles in white blood cells and basal keratinocytes. A diagnosis of neutral lipid (triglyceride) storage disease was confirmed by lipid studies on cultured fibroblasts.

Haemorrhagic shock encephalopathy and sudden infant death

In 2 pairs of non-identical twins, haemorrhagic-shock encephalopathy syndrome developed in 1 co-twin while the other died of sudden infant death syndrome. The twin pairs were aged 3 and 4 months, respectively, and no cause was identified. We suggest that stress protein deficiency may underlie both syndromes.

An investigation of ring and dicentric chromosomes found in three Turner's syndrome patients using DNA analysis and in situ hybridisation with X and Y chromosome specific probes

We have studied three patients with features of Turner's syndrome, two with a 45,X/46,X,r(?) and the third with a 45,X/46,X,dic?(Y) karyotype. Because Turner's syndrome patients with a mosaic karyotype containing a Y chromosome are known to have a high risk of developing gonadal tumours, we used DNA analysis and in situ hybridisation with X and Y specific probes to identify the chromosomal origin of the rings and dicentric chromosomes in the three index patients. Both ring chromosomes were shown to be of X origin, while the dicentric was composed of Y chromosome material. We discuss the importance of using a combination of molecular and cytogenetic analyses in such cases.

Seasonal variation of haemoglobin A1 in children with insulin-dependent diabetes mellitus

The results of three controlled trials performed on children with insulin-dependent diabetes mellitus were examined for evidence of seasonal variation in concentrations of glycosylated haemoglobin (HbA1). All three studies showed lower levels during the summer months. Multiple regression analysis showed that the month of sampling accounted for a significant proportion of the total variance in HbA1 levels (P less than 0.001 in all three studies). We suggest that exercise, dietary changes and the frequency of minor illnesses may all contribute to this fluctuation which has important implications for the design of clinical trials in childhood diabetes.

United Kingdom multicentre clinical trial of somatrem

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

Prenatal diagnosis of medium-chain acyl-coenzyme A dehydrogenase deficiency

A fatal case of medium-chain acyl-coenzyme A dehydrogenase deficiency is described in a patient who presented with hypoglycaemia and a gross non-ketotic dicarboxylic aciduria. Cultured skin fibroblasts released 14CO2 from [1-14C] octanoic acid at half the normal rate. Prenatal diagnosis was undertaken in a subsequent pregnancy in which cultured amniotic fluid cells revealed a marked reduction in octanoate oxidation indicative of an affected fetus. The pregnancy was terminated and the diagnosis was confirmed by enzyme analysis of skin fibroblasts taken from the fetus. The high residual octanoate oxidation by affected fibroblasts together with the absence of any characteristic abnormality of amniotic fluid organic acids are a potential limitation to the reliability of this type of prenatal diagnosis.

Two or three insulin injections in adolescence?

Morning hyperglycaemia remains a challenge to conventional insulin regimens. Eighteen adolescents participated in a one year crossover study to examine the effect of delaying the evening intermediate acting insulin from before the evening meal to bedtime. This three injection regimen caused slightly higher blood glucose concentrations in the early part of the night, and lower concentrations in the morning, but no overall change in glycosylated haemoglobin concentrations (HbA1c). Seasonal change accounted for substantially more of the variance in HbA1c concentrations than did the regimen change. The three injection regimen did not alter the frequency of hypoglycaemic episodes. Metabolic control on both regimens might have been improved by more intensive monitoring and medical attention. This study suggests that factors beyond medical control, such as seasonal variation, may contribute more to the control of diabetes in adolescents than changes in conventional insulin regimens, particularly when unaccompanied by intensive monitoring.

Bedtime insulin injections: an alternative regimen

Sixteen children (aged 3 to 12 years) participated in a 12 month crossover study comparing bedtime with teatime insulin injections in an endeavour to reduce morning hyperglycaemia. Blood glucose values were lower at lunch and at teatime on the later injection, but higher at bedtime and midnight. There was no overall change in glycosylated haemoglobin. Despite more frequent mild hypoglycaemic attacks, parents preferred the convenience of the later injection. Analysis of individual children's glycosylated haemoglobin values showed that those whose metabolic control improved on the later injection were younger and went to bed earlier, indicating that this regimen may have a place in the management of younger children with diabetes mellitus.

Haemoglobin A1c concentrations in men and women with diabetes

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Improvement in metabolic control in diabetic adolescents by the use of increased insulin dose

Ten diabetic adolescents who had poor blood glucose control during the preceding year were recruited into a crossover insulin dosage study. Diabetic control was assessed on two insulin dosage regimens; either 1.0 U/kg/day ("limited dosage") or 1.4 U/kg/day ("increased dosage"). The study had a 1-mo run-in period followed by two treatment periods each of 3-mo duration. Improvement in control occurred during "increased" insulin dosage with reduction of glycosylated hemoglobin levels (P less than 0.001), self-monitored blood glucose levels (P less than 0.001), and 24-h urine glucose excretion (P less than 0.01). Overnight studies did not reveal hypoglycemia (blood glucose less than 2 mmol/L) in either group, but improved overnight glucose profiles were demonstrated on the "increased" dosage and were associated with higher free insulin levels. The study supports the case for a higher maximal insulin dosage than commonly recommended during adolescence.

A prospective study to evaluate the benefits of long-term self-monitoring of blood glucose in diabetic children

The benefits of self-monitoring of blood glucose (SMBG) in diabetic children have been assessed in an 18-mo prospective study by comparison of two groups, one receiving intensive education (N = 20) and the other, education combined with SMBG (N = 19). Regular home visits were made with all children during which attempts were made to optimize diabetes control. Mean blood glucose levels in the SMBG group showed a downward trend throughout the study; however, values at baseline (11.7 mmol/L) were not significantly different from those at completion of the study (10.8 mmol/L). Hemoglobin A1c levels showed a seasonal fluctuation, but values at the beginning and end of the study were nearly identical to each other in both groups. The SMBG group showed a reduction in the number of hospital admissions for stabilization of control and for ketoacidosis (P less than 0.04).

The investigation of neonatal obstructive jaundice using 123I rose bengal

With the development of new surgical techniques the outlook for infants with biliary atresia has improved significantly. It has therefore become increasingly important to identify these patients quickly in order to allow prompt surgical intervention. Differentiation of biliary atresia from other causes of jaundice, in particular idiopathic neonatal hepatitis, is often difficult as there is considerable clinical and histological overlap of the two conditions. Demonstration of biliary patency using radiopharmaceuticals is a well established technique. 131I rose bengal and the 99Tcm-labelled iminodiacetic acid derivatives have both been used, but are not completely satisfactory, and controversy still exists as to which is the most suitable agent. Nine infants with prolonged jaundice have been studied using 123I-labelled rose bengal. All infants with biliary atresia and neonatal hepatitis were correctly identified. The results indicate that 123I rose bengal provides a reliable tracer for assessing biliary patency and is the agent of choice in the investigation of neonatal obstructive jaundice.

Human insulin and porcine insulin in the treatment of diabetic children: comparison of metabolic control and insulin antibody production

Semisynthetic human insulin and highly purified porcine insulin were compared in a double blind crossover study in 21 diabetic children. Glycosylated haemoglobin values at the end of four month treatment periods were higher after treatment with human insulin than after treatment with porcine insulin (mean 15.7% (SD 2.3%) v 14.2% (2.3%); p less than 0.01). Higher fasting blood glucose concentrations occurred during treatment with human insulin than with porcine insulin (mean 12.0 (SD 2.1) v 11.0 (2.4) mmol/1; mean 216 (SD 38) v 198 (43) mg/100 ml; p less than 0.05), but there were no significant differences at other time points during the day. The incidence of hypoglycaemia was similar for both treatment groups. Concentrations of antibody reactive with porcine and human insulins were similar for the two treatment groups, although greater fluctuation was observed in the amount of antibody reactive with human insulin. Semisynthetic human insulin is safe and effective in diabetic children, although further work is needed to devise regimens which achieve optimal blood glucose control.

Limited finger joint mobility in diabetes

Limited finger joint mobility was assessed in 112 diabetic children, in their first-degree relatives, and in 50 unrelated non-diabetic children. In 42% of the diabetic children there was limited joint mobility, but 14% of them had more severe involvement. Limited joint mobility was correlated with increasing age, early presentation, and longer duration of diabetes. First-degree relatives of affected diabetic children had a higher incidence (35%) of limited joint mobility compared with relatives of nonaffected diabetic children (13%).

Café-au-lait spots in schoolchildren

This paper reports a study of café-au-lait spots of a minimum diameter of 1 cm in 732 white schoolchildren. Three groups were identified, according to the number of café-au-lait spots on each child: (1) those with none (74%), (2) those with fewer than 5 (25%), and (3) those with at least 5 (5 children, 2 considered to be normal, and 3 siblings each presumed to have neurofibromatosis, one having died from leukaemia). Excluding the last group, the number of café-au-lait spots in the sample was not significantly related to age or sex. Some support is given for using the number of café-au-lait spots as an empirical threshold to diagnose neurofibromatosis.

Total glycosylated haemoglobin (HbA1) levels in diabetic children

Total glycosylated haemoglobin (HbA1) levels from capillary blood were studied retrospectively during a 1-year period in 148 diabetic children aged between 1.9 and 16.8 years. The clinic range for HbA1 was 6.7 to 22.2% and the results were normally distributed (mean +/- SD 13.2 +/- 2.8%). The normal range in non-diabetics using this method is 4.9 to 8.0%. Results from children who had had diabetes for more than 5 years were higher than those from children with diabetes of 2 to 5 years' duration. Girls had higher average values during the 1-year period than boys. HbA1 measurement serves to identify the deficiencies of current diabetic treatment regimens. It also has more immediate practical benefits in focusing attention on children whose control is deteriorating.

Gut-hormone profile in coeliac disease

Patients with coeliac disease have a highly significant reduction in the release of secretin and gastric inhibitory polypeptide from the upper small intestine, but a greatly increased release of enteroglucagon, and also of neurotensin, from the lower part of the small intestine. The release of gastrin and pancreatic polypeptide, from the antrum and pancreas respectively, is, however, normal. Thus the pattern of hormone release reflects the location of the mucosal lesion. The gut-hormone profile may also help to characterise other gastrointestinal diseases.

Spontaneous perforation of common bile duct in infants

Two infants with spontaneous perforation of the common bile duct are described. One presented with mild jaundice, dark urine, acholic stools, and hydroceles, the other with bilateral inguinal hernia. In both the diagnosis was unsuspected until bile-stained ascites was discovered. Both eventually developed bile-staining of the scrotum. Neither was acutely ill. The 131I-Rose Bengal faecal excretion test showed reduced faecal excretion at 8% and 12% of the injected dose with 16-5 and 17%/dl of the dose being recovered in the ascitic fluid 48 hours after intravenous injection. The ascitic:plasma ratio of isotope at that time was 32:1 and 28:1. Operative cholangiography in both showed a perforation at the junction of the cystic duct and common bile duct with no contrast entering the duodenum. Cholecystenterostomy using a Roux-en-Y loop of jejunum produced a rapid sustained recovery and is suggested as the treatment of choice. This condition should be considered in the differential diagnosis of obstructive jaundice in infancy since early surgical correction is necessary.

Serum alpha-fetoprotein levels in extrahepatic biliary atresia, idiopathic neonatal hepatitis and alpha-1-antitrypsin deficiency (PiZ)

Serum alpha-fetoprotein levels were measured using a sensitive radioimmunoassay in 77 infants presenting with persistent conjugated hyperbilirubinaemia. A breed range of alpha-fetoprotein concentrations occurred in both the 23 infants with extrahepatic biliary atresia and the 35 with idiopathic neonatal hepatitis but the 13 with alpha-1-antitrypsin deficiency had uniformly low levels. High alpha-fetoprotein concentrations (above 10 000 mug/1) favoured the diagnosis of neonatal hepatitis especially in the first ten weeks of life, but the overlap between neonatal hepatitis and extrahepatic biliary atresia was large and alpha-fetoprotein determination cannot be recommended as a reliable method for distinguishing the two conditions. Serial alpha-fetoprotein values showed no consistent relationship with standard liver function tests and gave no guide to prognosis. There was an association between alpha-fetoprotein production and needle biopsy evidence of hepatic giant cell transformation. The uniformly low alpha-fetoprotein levels in alpha-1-antitrypsin deficient infants with neonatal hepatitis is a new observation and possible mechanisms for disordered glycoprotein release are discussed.

Plasma glucagon levels in the term human infant and effect of hypoxia

The mean plasma pancreatic glucagon level at birth in 44 normal infants delivered vaginally was 140 pg/ml. The simultaneous maternal level was 122 pg/ml which was not quite significantly different at the P [unk]0.05 level. 2 hours after birth 30 of these infants had a mean rise in plasma glucagon of 51 pg/ml (P [unk] 0.01), and their mothers had a fall of 38 pg/ml (P [unk] 0.05). The mean plasma pancreatic glucagon level at birth in 12 normal infants delivered by caesarean section was 130 pg/ml which did not differ significantly from the group delivered vaginally. The glucagon level at birth in 20 infants with fetal distress (fetal scalp pH [unk] 7.2 or umbilical artery pH [unk] 7.15) was 244 pg/ml, and this was significantly higher than for normal infants at birth (P [unk] 0.01). Whereas the rise in neonatal glucagon 2 hours after birth might have been caused by a mean fall in blood glucose of 23 mg/100 ml, the infants with fetal distress had normal glucose levels, so that another mechanism must be responsible for their raised glucagon.

Persistent diarrhoea, eosinophilia, erythema annulare and fibrosing alveolitis in a female infant

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Failure of glucagon release in infants of diabetic mothers

Two hours after birth 30 normal infants had a fall in blood glucose of 20.6 mg/100 ml and a rise of plasma pancreatic glucagon of 50.7 pg/ml. Fifteen infants of diabetic mothers treated with insulin had a much greater fall in blood glucose of 77.5 mg/100 ml and a smaller rise of glucagon of 20.9 pg/ml. By comparison 14 small-for-dates infants, who are also prone to hypoglycaemia, had a blood glucose fall of 32.8 mg/100 ml and a larger rise of pancreatic glucagon of 96.0 pg/ml. It is suggested that the impaired pancreatic glucagon rise in the infants of diabetic mothers may be a significant factor in their hypoglycaemia.

Changes in glucagon level associated with anxiety or stress

A sudden loud noise produced a large and rapid rise in plasma glucagon in the conscious primate. A similar rise took place when stresses were applied to anaesthetized animals.