Genotype-phenotype correlation in Taiwanese children with diazoxide-unresponsive congenital hyperinsulinism

Objective

Congenital hyperinsulinism (CHI) is a group of clinically and genetically heterogeneous disorders characterized by dysregulated insulin secretion. The aim of the study was to elucidate genetic etiologies of Taiwanese children with the most severe diazoxide-unresponsive CHI and analyze their genotype-phenotype correlations.

Methods

We combined Sanger with whole exome sequencing (WES) to analyze CHI-related genes. The allele frequency of the most common variant was estimated by single-nucleotide polymorphism haplotype analysis. The functional effects of the ATP-sensitive potassium (KATP) channel variants were assessed using patch clamp recording and Western blot.

Results

Nine of 13 (69%) patients with ten different pathogenic variants (7 in ABCC8, 2 in KCNJ11 and 1 in GCK) were identified by the combined sequencing. The variant ABCC8 p.T1042QfsX75 identified in three probands was located in a specific haplotype. Functional study revealed the human SUR1 (hSUR1)-L366F KATP channels failed to respond to intracellular MgADP and diazoxide while hSUR1-R797Q and hSUR1-R1393C KATP channels were defective in trafficking. One patient had a de novo dominant mutation in the GCK gene (p.I211F), and WES revealed mosaicism of this variant from another patient.

Conclusion

Pathogenic variants in KATP channels are the most common underlying cause of diazoxide-unresponsive CHI in the Taiwanese cohort. The p.T1042QfsX75 variant in the ABCC8 gene is highly suggestive of a founder effect. The I211F mutation in the GCK gene and three rare SUR1 variants associated with defective gating (p.L366F) or traffic (p.R797Q and p.R1393C) KATP channels are also associated with the diazoxide-unresponsive phenotype.

Adult height of children with congenital adrenal hyperplasia due to 21-hydroxylase deficiency

BACKGROUND/PURPOSES

Congenital adrenal hyperplasia attributable to 21-hydroxylase deficiency (21-OHD) is a disorder of adrenal steroidogenesis. Achievement of optimal growth by such patients is challenging. We evaluated the adult height of Taiwanese children with 21-OHD and the effect of a gonadotropin-releasing hormone analogue (GnRHa) in patients with central precocious puberty (CPP) complicating 21-OHD.

METHODS

Among 116 patients with 21-OHD in Taiwan, 90 who had attained adult height were subjected to an analysis of height outcomes. Nine with progressive CPP were treated with GnRHa and the effects of this therapy on adult height were further analyzed.

RESULTS

In the pre-screening era, the percentage of boys with 21-OHD was lower than expected. Although neonatal screening can prevent mortality caused by adrenal crisis, some cases may be missed. The pooled mean adult height of the 78 patients treated with conventional therapy were -1.1 SD and -0.5 SD adjusting for the genetic potential. The disease features affecting height outcomes are the genetic height potential and in boys the simple virilizing type. Nine patients with CPP were treated with GnRHa in addition to conventional therapy; the mean adult height increased from the predicted -4.1 SD to -1.0 SD after 6.0 ± 2.5 years of treatment.

CONCLUSION

Patients with 21-OHD had poorer mean adult height. A high caregiver's index of suspicion is required for the early diagnosis of patients with 21-OHD missed on neonatal screening. Adjuvant therapy with GnRHa can improve the adult height of patients with CPP complicating 21-OHD.

Endocrine and Growth Disorders in Taiwanese Children With 22q11.2 Deletion Syndrome

BACKGROUND

Endocrine disorders are common in patients with 22q11.2 deletion syndrome (22q11.2DS). This study aimed to elucidate the clinical manifestations of endocrine disorders, including parathyroid, thyroid and growth disorders, in Taiwanese patients with 22q11.2DS.

METHODS

From 1994 to 2020, the medical records of 138 patients with 22q11.2DS diagnosed at a tertiary referral medical center in Taiwan were thoroughly reviewed retrospectively.

RESULTS

Hypocalcemia was detected in 57 of 135 patients (42%); 33 of 104 patients (32%) had hypoparathyroidism, and in 87% of them, hypocalcemia was detected before the age of one. Most patients had precipitating stressors during symptomatic hypocalcemic episodes. Eighteen of 29 patients had overt hypoparathyroidism at the last visit: 11 had persistent hypoparathyroidism and the other seven had recurrent hypoparathyroidism. Four of 84 patients had thyroid disorders, including thyroid developmental anomalies in two, dyshormonogenesis in one and Graves' disease in one. Fifty of 126 patients (40%) had short stature. Age (odds ratio (OR) 0.91; 95% confidence interval (CI) 0.86-0.96; P<0.001) and airway anomalies (OR 2.75; 95% CI 1.04-7.31; P<0.05) were significant risk factors for short stature in multivariate logistic regression model. Twenty-eight of the 30 patients with airway anomalies were associated with severe congenital heart disease. Adult height standard deviation score (SDS) in 19 patients was significantly lower than target height SDS (-1.15 ± 0.90 vs -0.08 ± 0.65, P<0.001).

CONCLUSIONS

Hypoparathyroidism is a common endocrine disorder in patients with 22q11.2DS. It is prudent to assess parathyroid function at diagnosis and during follow-up, especially in the presence of stress, to prevent symptomatic hypocalcemia. Although thyroid disorders are not so common as hypoparathyroidism, screening of thyroid dysfunction is justified in these patients. Patients with 22q11.2DS demonstrate a retarded growth pattern with a tendency of catch-up and regular monitoring of growth is indicated.

Serum neutrophil gelatinase-associated lipocalin as a potential biomarker of diabetic kidney disease in patients with childhood-onset type 1 diabetes

BACKGROUND/PURPOSE

Diabetic kidney disease (DKD) is a major complication in patients with type 1 diabetes (T1D). The aim of this study was to evaluate the role of serum neutrophil gelatinase-associated lipocalin (sNGAL) in the early detection of DKD in childhood-onset T1D patients.

METHODS

A total of 116 patients (mean age, 22.3 ± 6.9 years) with estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73 m² were enrolled in this prospective cross-sectional study. Persistent albuminuria (PA) was defined as a urine albumin-to-creatinine ratio ≥ 30 mg/g for at least two consecutive years; non-albuminuria (NA) was defined otherwise. The patients were divided into the adult (Ad) (≥18 years, n = 91) and pediatric (Ped) (<18 years, n = 25) groups and further into the Ad-PA (n = 8), Ad-NA (n = 83), Ped-PA (n = 2), and Ad-NA (n = 23) subgroups. In all groups, the sNGAL level was determined.

RESULTS

The mean diabetes duration was 14.2 ± 6.1 years, and 8.6% patients had PA. There was no significant difference in sNGAL levels between the PA and NA groups; notably, in adults, the sNGAL level was significantly higher in the Ad-PA than Ad-NA subgroups (P = 0.039). The sNGAL level was negatively correlated with the eGFR in adults (rho -0.41, P < 0.001). Multiple linear regression models showed that higher sNGAL levels in the adult group were independent and significant determinants of a lower eGFR (P < 0.001).

CONCLUSION

An elevated sNGAL was significantly correlated with a decreased eGFR even in the range of normal to mildly decreased renal function. Thus, it is a potential biomarker of early deterioration of DKD in childhood-onset T1D.

Increased Incidence of Pediatric Type 1 Diabetes With Novel Association With Coxsackievirus A Species in Young Children but Declined Incidence in Adolescents in Taiwan

OBJECTIVE

Type 1 diabetes (T1D) has been linked to enterovirus infection in small population-based epidemiological studies. We investigated the secular relationship of T1D incidence with enterovirus infection and enterovirus species using nationwide population-based analysis.

RESEARCH DESIGN AND METHODS

We accessed the National Health Insurance Research Database of Taiwan to identify T1D and enterovirus infection cases from 2001 to 2015. Enterovirus serotype isolation rates were obtained from the nationwide laboratory surveillance systems. Negative binomial regression models assessed the incidence trend, and extended Cox proportional hazards models analyzed the association of enterovirus infection with T1D incidence. Spearman correlation coefficients evaluated the correlation between T1D incidence and circulating enterovirus species.

RESULTS

T1D incidence rates in youth younger than 20 years were 6.30 and 5.02 per 100,000 person-years in 2001 and 2015 (P = 0.287), respectively. T1D incidence increased significantly in children aged 0-6 years (P < 0.001) but decreased in adolescents aged 13-19 years (P = 0.011). The T1D risk in children aged 0-6 years with enterovirus infection was significantly higher than that in noninfected subjects (hazard ratio 1.46; 95% CI 1.35-1.58; P < 0.001). Additionally, TID incidence in children aged 0-6 years was significantly correlated with the isolation rates of coxsackievirus A species (r = 0.60; P = 0.017), but no association was found beyond the age of 7.

CONCLUSIONS

We demonstrated that T1D incidence increased in children aged 0-6 years but decreased in adolescents aged 13-19 years in Taiwan. Enterovirus-infected subjects younger than 7 years had a higher risk of T1D than noninfected subjects.

Clinical and molecular features of idiopathic hypogonadotropic hypogonadism in Taiwan: A single center experience

BACKGROUND

Idiopathic (isolated) hypogonadotropic hypogonadism (IHH) is a rare disease that can be classified as Kallmann syndrome (KS) or normosmic IHH (nIHH). This study investigated the phenotype and genotype of IHH in Taiwanese patients.

METHODS

Twenty-six unrelated IHH patients were included in this study and their clinical, hormonal, and radiological findings were analyzed retrospectively. Whole exome sequencing (WES) was performed to identify the etiology.

RESULTS

The 26 patients (M:F = 19:7) were divided into a KS group (n = 11) and a nIHH group (n = 15). The diagnosis was earlier in boys than in girls. Fifteen patients were found to have pathogenic/likely pathogenic (P/LP) variants of IHH-associated genes, and the mutation detection rate was 58%. CHD7, FGFR1, and ANOS1 were the most common genetic etiologies identified in this group. Two patients with nIHH were found to have de novo SOX11 mutations and Coffin-Siris syndrome features. After treatment, the height outcomes and secondary sexual characteristics were significantly improved. There were no obvious differences between the genetically resolved (GR), variants of uncertain significance (VUS) and genetically unresolved groups (GUR).

CONCLUSION

Whole exome sequencing is useful in patients with IHH, and we identified the SOX11 gene as a causal factor in this study. We described the clinical, hormonal, and molecular characteristics, and the treatment outcomes, of Taiwanese patients with IHH, which should aid therapeutic planning and further research.

Resistance to thyroid hormone due to a novel THRB p.Val349Ala mutation in a Taiwanese boy

Resistance to thyroid hormone (RTH) is a rare congenital disorder characterized by impaired sensitivity of target tissues to thyroid hormone. The disease is mostly caused by heterozygous mutations of thyroid hormone receptor β (THRB) gene. We present a ten-year-old Taiwanese boy with goiter, mood disturbances and attention deficit hyperactivity disorder (ADHD). Blood tests showed elevated serum thyroxine (T4) and triiodothyronine (T3) levels with nonsuppressed thyrotropin (TSH) levels. Sella MRI failed to detect any pituitary adenoma. Initial treatment with anti-thyroid drugs resulted in increased TSH levels and goiter size. His medication was discontinued after his visit to our hospital for a second opinion. A thyrotropin-releasing hormone (TRH) stimulation test showed a normal TSH response to TRH stimulation. Molecular analysis identified a novel heterozygous THRB p.Val349Ala mutation. The patient attained normal growth and a paucity of symptoms without any medication during the follow-up period. We hope that the presentation of this case can make the early diagnosis of RTH possible so that inappropriate management of these patients can be avoided in the future.

Thyroid disorders in Taiwanese children with Down syndrome: The experience of a single medical center

BACKGROUND/PURPOSE

Thyroid disorders are common in children with Down syndrome (DS), however, such data have rarely been reported in Taiwanese children. This study presents our experience with the management of these children.

METHODS

Between 2006 and 2016, 51 children (31 boys and 20 girls) with DS were enrolled. Thyroid function was evaluated and natural course of thyroid status were analyzed.

RESULTS

Of 51 patients with DS, 2 had congenital hypothyroidism due to dyshormonogenesis. Of the remaining 49 patients, 30 (61%) had euthyroidism (EuT), and 19 (39%) had subclinical hypothyroidism (SH). Eighteen (37%) had detectable thyroid antibodies. It occurred at any age and the incidence was not affected by sex. The mean follow-up duration for 39 DS children was 3.8 ± 2.4 years. Of the 26 children who had EuT at enrollment and were followed up, 22 remained EuT, 2 developed SH, 1 developed overt hypothyroidism, and 1 developed overt hyperthyroidism. Of the 13 patients with SH who were followed up, 1 was treated for high thyroid-stimulating hormone levels, 8 became EuT, and 4 maintained SH status. Children with DS and persistent SH had significantly higher maximum thyroid-stimulating hormone levels during follow-up than did those with transient SH. Fluctuation in thyroid status during follow-up was not uncommon in children with DS.

CONCLUSION

The prevalence of thyroid disorders is higher in Taiwanese children with DS than in the general population. Because symptoms of hypothyroidism overlap those inherent to DS, regular follow-up of thyroid function in children with DS is indicated.

Mosaic paternal haploidy in a patient with pancreatoblastoma and Beckwith-Wiedemann spectrum

Pancreatoblastoma is a rare type of pancreatic cancer in children. Here, we describe a case in which Beckwith-Wiedemann syndrome (BWS) was first suspected because of placental mesenchymal dysplasia. Although the baby did not show the stigmata characteristic of BWS or abnormal peripheral blood methylation, she developed a massive pancreatoblastoma 2 months later. She survived after partial excision of the tumor and chemotherapy. The methylation pattern of the pancreatoblastoma tissue was typical of BWS. Single nucleotide polymorphism (SNP) array analyzes revealed that the pancreatoblastoma tissue had genome-wide loss of maternal alleles. Peripheral blood and nontumor pancreatic tissue showed normal biparental genomic contribution. Interphase fluorescence in situ hybridization analysis with centromeric probes for chromosomes 2 and 11 revealed haploid pancreatoblastoma cells, whereas the placental mesenchymal dysplasia tissue and nontumor pancreas tissue showed diploidy. SNP genotype analysis suggested the presence of mosaicism with the pancreatoblastoma tissue having a different paternal haplotype than that of the peripheral blood and nontumor pancreatic tissue. We report for the first time mosaic paternal haploidy associated with pancreatoblastoma. Babies with placental mesenchymal dysplasia, even those without a definitive diagnosis of BWS, need to be closely followed for the occurrence of embryonic tumors.

Comprehensive human leukocyte antigen genotyping of patients with type 1 diabetes mellitus in Taiwan

BACKGROUND

Type 1 diabetes (T1D) mellitus is an autoimmune disorder involving both complex genetic and environmental factors. The incidence rates are low in Asian countries, and the specific, explanatory genetic factors underlying this have been investigated. The aim of this study was to elucidate the association of human leukocyte antigen (HLA) alleles/haplotypes with T1D in Taiwan.

METHODS

We performed direct comprehensive genotyping of 6 classical HLA loci (HLA-A, -B, -C, -DPB1, -DQB1, and -DRB1) to 4-digit resolution in 104 unrelated T1D patients and 504 controls. Twenty-four of the 104 patients also exhibited thyroid autoimmunity.

RESULTS

Three major susceptibility haplotypes were identified: DRB1*03:01-DQB1*02:01 (odds ratio [OR] = 5.39 under the dominant model, P = 2.3 × 10^-13 ), DRB1*04:05-DQB1*04:01 (OR = 2.44, P = 5.0 × 10^-4 ), and DRB1*09:01-DQB1*03:03 (OR = 2.02, P = 1.4 × 10^-3 ); one protective haplotype was identified: DRB1*08:03-DQB1*06:01 (OR = 0.10, P = 1.6 × 10^-3 ). DRB1*03:01-DQB1*02:01, the major T1D susceptibility haplotype, was found at a lower frequency in T1D patients with thyroid autoimmunity. The T1D protective allele DRB1*12:02 was shown to be protective against Graves' disease in our previous report.

CONCLUSION

In addition to clarifying the roles of several known T1D HLA alleles and haplotypes, we discovered that the DRB1*08:03-DQB1*06:01 haplotype is protective against T1D. The DRB1*12:02 allele protected against both T1D and Graves' disease.

SHOX deficiency in short Taiwanese children: A single-center experience

BACKGROUND

SHOX deficiency is a common cause of idiopathic short stature. The aim of this study was to describe the clinical characteristics and molecular findings of patients with SHOX deficiency in Taiwan.

METHODS

A phenotype scoring system was used to evaluate several anthropometric measures in patients with idiopathic short stature. Twenty-three patients with a phenotype score >7 were enrolled for SHOX gene analysis by MLPA and sequencing. Another patient with a deletion/insertion of the short arm of the X chromosome containing the SHOX gene was enrolled for the assessment.

RESULTS

SHOX deficiency was detected in 26% of short children with a phenotype score >7. The arm-span-to-height ratio was significantly lower in SHOX-D patients than in non-SHOX-D patients. In patients with SHOX deficiency, an arm-span-to-height ratio <96.5% and short forearm were the most common characteristics. Three patients also exhibited typical radiological findings. A molecular analysis of the SHOX gene revealed five patients with intragenic deletions, one with a deletion in the regulatory region, and one with a missense mutation at exon 5.

CONCLUSION

The phenotype scoring system is useful to select children with SHOX deficiency in Taiwan. Family history and radiological image of the radius are also of value for the diagnosis. This study may aid physicians in the early diagnosis of children with SHOX deficiency.

Abstract PD4-05: Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study

PURPOSE: Adjuvant therapy is associated with improved survival for women with breast cancer, but not all women who could benefit initiate treatment. Women's belief systems are related to treatment initiation. It has been hypothesized that complementary and alternative (CAM) use is associated with decreased initiation of standard oncology treatments because patients may be exploring alternative treatment approaches. However, there are limited data on the association between CAM use and cancer treatment initiation. We examined the association between CAM use and initiation of adjuvant breast cancer chemotherapy in a prospective cohort of early stage breast cancer patients.

PATIENTS AND METHODS: Subjects participated in a multi-center prospective cohort study of women with early stage invasive breast cancer (n=1,156). National Comprehensive Cancer Network guidelines were used to define groups based on whether chemotherapy was indicated. Three subgroups were created: chemotherapy indicated for subjects &lt;70 years, chemotherapy discretionary for subjects &lt;70 years, and chemotherapy discretionary for subjects ≥70 years. CAM use was assessed based upon self-reported use of 5 CAM modalities, including vitamin/mineral supplements, herbal supplements, other over-the-counter natural products, mind-body based approaches, and body/energy-based treatments. Psychosocial factors potentially related to chemotherapy initiation were assessed. Multivariable logistic regression models evaluated the associations between CAM use and chemotherapy initiation, adjusted for demographic, clinical and psychosocial factors.

RESULTS: Current CAM use was reported by 87% of women and 38% reporting current use of ≥3 modalities. The most commonly used CAM modalities were mind body therapies (63%) and other natural products (41%). In bivariate analyses, among women &lt;70 years where chemotherapy was indicated, women who reported current use of vitamins/minerals or current use of all 5 CAM modalities were less likely to initiate chemotherapy compared to non-users (P&lt;.0001), but this was not observed among women for whom chemotherapy was discretionary. Psychosocial factors were also associated with high levels of current CAM use in this group, including higher expectations of adverse effects from chemotherapy, more concerns about the physical effects of chemotherapy, lower beliefs in the benefits of chemotherapy, and lower positive decision balance while making chemotherapy decisions (all P&lt;.05). Among women age &lt;70 years for whom chemotherapy was indicated, 89% initiated treatment, and current use of all 5 CAM modalities was inversely associated with initiation in multivariable analyses adjusted for demographic and clinical factors (OR=0.08, CI: 0.02-0.32). The association remained after separately adjusting for psychosocial factors (all P&lt;.05), except for positive decision balance, which was no longer statistically significant.

CONCLUSIONS: High use of CAM was associated with decreased chemotherapy initiation among women with breast cancer for whom chemotherapy was indicated. It is important for oncologists to discuss CAM use with their patients, especially since high CAM use is associated with negative expectations and beliefs about chemotherapy.

Citation Format: Greenlee H, Neugut AI, Falci L, Hillyer GC, Buono D, Roh JM, Ergas IJ, Kwan ML, Lee M, Tsai WY, Shi Z, Lamerato L, Mandelblatt JS, Kushi LH, Hershman DL. Complementary and alternative medicine use and breast cancer chemotherapy initiation: The BQUAL study. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr PD4-05.

Galactosylated liposome as a dendritic cell-targeted mucosal vaccine for inducing protective anti-tumor immunity

Mucosal surfaces contain specialized dendritic cells (DCs) that are able to recognize foreign pathogens and mount protective immunity. We previously demonstrated that intranasal administration of targeted galactosylated liposomes can elicit mucosal and systemic antibody responses. In the present study, we assessed whether galactosylated liposomes could act as an effective DC-targeted mucosal vaccine that would be capable of inducing systemic anti-tumor immunity as well as antibody responses. We show that targeted galactosylated liposomes effectively facilitated antigen uptake by DCs beyond that mediated by unmodified liposomes both in vitro and in vivo. Targeted galactosylated liposomes induced higher levels of pro-inflammatory cytokines than unmodified liposomes in vitro. C57BL/6 mice thrice immunized intranasally with ovalbumin (OVA)-encapsulated galactosylated liposomes produced high levels of OVA-specific IgG antibodies in their serum. Spleen cells from mice receiving galactosylated liposomes were restimulated with OVA and showed significantly augmented levels of IFN-γ, IL-4, IL-5 and IL-6. In addition, intranasal administration of OVA-encapsulated beta-galactosylated liposomes resulted in complete protection against EG7 tumor challenge in C57BL/6 mice. Taken together, these results indicate that nasal administration of a galactosylated liposome vaccine mediates the development of an effective immunity against tumors and might be useful for further clinical anti-tumoral applications.

Effect of menarche onset on the clinical course in females with chronic hepatitis B virus infection

OBJECTIVE

To investigate the impact of menarche on the natural course of chronic hepatitis B virus (HBV) infection in women.

STUDY DESIGN

Young women who are positive for hepatitis B e antigen (HBeAg; n = 101) chronically infected with genotypes B and C HBV were recruited at a mean age of 4.57 ± 3.08 years, and a mean follow-up duration of 23.98 ± 3.77 years. Clinical data, including age at menarche, HBV genotypes, serum HBV viral loads, hepatitis B surface antigen (HBsAg) titers, and serial liver functional profiles were analyzed.

RESULTS

Women with earlier onset of menarche had earlier spontaneous HBeAg seroconversion than others (hazard ratio, 2.0; P = .02) adjusting for HBV genotype and peak alanine aminotransferase levels before HBeAg seroconversion. The annual decrease in HBsAg titer from 15 to 20 years of age also was greater in the early menarche group compared with the late menarche group (0.11 ± 0.11 vs 0.05 ± 0.11 log10 IU/mL, P = .04). The baseline HBV viral load was also borderline low in female subjects with earlier menarche as compared with others (P = .06). Earlier menarche onset was associated with higher spontaneous HBeAg seroconversion, HBsAg seroclearance, and HBsAg seroconversion rate before 15 years of age in females with chronic HBV infection.

CONCLUSIONS

Earlier puberty-onset, indicated by menarche-onset, was associated with earlier spontaneous HBeAg seroconversion and greater rate of HBV clearance before 15 years of age in female subjects with chronic HBV infection.

Endocrine dysfunction in Taiwanese children with human chorionic gonadotropin-secreting germ cell tumors

BACKGROUND/PURPOSE

Human chorionic gonadotropin (HCG)-secreting germ cell tumors (GCTs) are rare childhood malignancies with unique clinical manifestations but delayed diagnosis is common. The purpose of this study is to investigate the clinical manifestations and endocrine dysfunction of Taiwanese children with HCG-secreting GCTs.

METHODS

From 1991 to 2011, 24 children (19 boys and five girls) with HCG-secreting GCTs were evaluated for their clinical findings and endocrine functions.

RESULTS

The mean age at diagnosis of the study patients was 10.8 ± 3.1 years. Of the 24 patients, 20 had central nervous system (CNS) GCTs and four had primary mediastinal GCTs (PMGCTs). The most common pathologic findings were germinomas and mixed type GCTs. The common initial symptoms and signs included polyuria, polydipsia, rapid growth, neurologic deficit,sexual precocity, and growth retardation. There was a delay in diagnosis in about 60% of patients. Diabetes insipidus and hypopituitarism were common endocrine dysfunctions in patients with CNSGCTs. Twelve boys had gonadotropin-independent puberty upon diagnosis, which were related to their high serum β-hCG levels. None of the five girls had this disorder despite their high serum β-hCG levels. Three of the four PMGCTs patients had the classic form of Klinefelter syndrome.

CONCLUSION

Taiwanese children with HCG-secreting GCTs often have clinical manifestations related to endocrine dysfunction. High index of suspicion is important to avoid delayed diagnosis in these children.

Abstract P3-08-12: Influence of a clinic-based survivorship intervention on dietary change and lifestyle recommendations among Hispanic and non-Hispanic women following adjuvant therapy for breast cancer

BACKGROUND: In 2006, the IOM released a report citing the importance of “survivorship plans” to improve quality-of-life. Little has been done to evaluate their efficacy with regard to uptake of dietary and lifestyle recommendations.

METHODS: Women with early-stage breast cancer were randomized within 6 weeks of completing adjuvant therapy to a survivorship intervention or a control group. Randomization was stratified by ethnicity and subjects were not aware that they were randomized. All subjects were provided the NCI publication, “Facing Forward: Life after Cancer Treatment.” The survivorship intervention group also met with a nurse (1 hour) and nutritionist (1 hour) to receive a treatment summary, surveillance and personalized lifestyle recommendations, based on guidelines from the American Cancer Society and American Institute for Cancer Research. At baseline, 3 and 6 months, both groups completed questionnaires on diet, lifestyle, and perceived health. Linear regression analyses adjusted for ethnicity evaluated the effects of the intervention on comprehension and uptake of lifestyle recommendations. Additional models were run to evaluate the interaction between intervention and ethnicity.

RESULTS: Among 126 women (60 control group, 66 survivorship intervention) mean age was 54 yrs, 48% were Hispanic, and randomized groups were well-balanced by baseline characteristics. Of note, at baseline, compared to non-Hispanics, Hispanics reported lower SES, poorer knowledge of healthy lifestyle behaviors (e.g., diet, physical activity, weight, dietary supplements), lower intake of fruits and vegetables, less recreational physical activity, lower consumption of alcohol, and a lower overall health rating (all P&lt;0.05). After adjusting for ethnicity, at month 3 the intervention group compared to the control group reported greater knowledge of how to eat a healthy diet (P = 0.047), greater knowledge of appropriate use of dietary supplements (P = 0.006), higher levels of physical activity (P = 0.03), and higher intake of fish (P = 0.005). At month 6, the only difference that persisted was greater knowledge of a healthy diet (P = 0.01). In models assessing an interaction between intervention condition and ethnicity, compared to Hispanics, the intervention had a stronger effect on increasing non-Hispanics’ belief that a healthy diet was important to prevent breast cancer recurrence (P = 0.02).

CONCLUSIONS: Compared to only receiving written survivorship materials, a survivorship intervention that included written materials plus a 1 hour personalized lifestyle counseling session was associated with short-term increased knowledge of lifestyle recommendations, change in physical activity and change in dietary behaviors among a multi-ethnic group of breast cancer survivors. Behavioral effects were not observed beyond 3 months. A single 1 hour lifestyle consultation is likely not enough to achieve and maintain lifestyle recommendations. To facilitate long-term behavioral change among breast cancer survivors in the adjuvant setting, culturally competent behavioral interventions should be developed to increase knowledge of and the capabilities needed to meet lifestyle recommendations.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P3-08-12.

Abstract OT2-6-06: Pre-surgical “window of opportunity” trial of metformin and atorvastatin in newly diagnosed operable breast cancer

Background: Breast cancer requires energy homeostasis shifts with enhanced anabolism to enable rapid growth and continued proliferation. The main energy regulatory system is the AMP-activated kinase (AMPK) pathway triggered by changes in the AMP/ATP ratio. AMPK pathway closely interacts with the PI3K/AKT signaling pathway, with both pathways affecting downstream function of the master regulator mTOR. “Window of opportunity” studies with metformin alone, an AMPK inhibitor, have resulted in mixed results in reducing tumor proliferation in women with early-stage operable breast cancer. Reduction in tumor proliferation has been demonstrated with statins alone (i.e. HMG CoA reductase inhibitors) in pre-surgical trials. Dual therapy with both metformin and atorvastatin demonstrate synergistic activity in preclinical studies in cancer cell lines, showing enhanced anti-proliferative effect. The purpose of this study is to determine the effects of dual therapy with metformin and atorvastatin in women with newly diagnosed BC between breast biopsy and surgery.

Trial Design: Patients (n = 40) will receive metformin 1500mg (500 mg am/1000 mg pm) and atorvastatin 80mg pm, for 2-4 weeks following a diagnostic biopsy and prior to surgery (goal: at least 2 weeks). The main eligibility criteria for this open-label, single-institution, pre-surgical trial include operable stage 0-III BC. Patients must have at least 1 cm of tumor based on palpation or imaging to ensure sufficient pre-treatment tissue. Patients not considered for neoadjuvant chemotherapy are eligible. Specific Aims: Our hypothesis is that pre-surgical metformin plus atorvastatin will result in a significant decrease in the tumor proliferation marker Ki-67. Ki-67 will be log-transformed ln(ki-67), per international guidelines. Secondary objectives include evaluation of functional proteomic changes, such as AMPK/mTOR pathway signaling and apoptosis, by reverse phase protein array (RPPA), as well as assessment of changes in serum insulin, lipids, and markers of the insulin growth factor pathway.

Statistical Methods: Paired t-tests will be calculated to assess modulations in ln(ki-67) before and after treatment. Compared to historical control, we will achieve 80% power with 40 patients, anticipating a -0.523 reduction of ln(ki-67) and standard deviation of 1.15 before and after metformin plus statin (significance level, p = 0.05). We will also be comparing changes in ln(ki-67) in the treated patients to historical controls matched by age, stage, and BMI, using a two-sample t-test at level 0.05. Frequency distributions and summary descriptive statistics will be calculated for all other biomarkers in the two groups. Correlations between all biomarkers and changes in Ki-67 proliferation marker will be analyzed in exploratory fashion. We will also explore differences in modulation of tumor proliferation and functional proteomics in grade III tumors as compared to other tumors. We anticipate accrual 2-3 patient/month, completing the trial within 18 months. Contact information: kk2693@columbia.edu.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-6-06.

Clinical characteristics of central diabetes insipidus in Taiwanese children

BACKGROUND/PURPOSE

Data on the clinical features of children with central diabetes insipidus (CDI) are lacking in Taiwan. This study investigated the clinical manifestations and etiology of CDI in Taiwanese children.

METHODS

From 1983 to 2012, 62 children with permanent diabetes insipidus were enrolled in the study. They were diagnosed at the Department of Pediatrics of National Taiwan University Hospital. Their medical records were thoroughly reviewed and their clinical symptoms and signs, laboratory data, and etiologies were analyzed.

RESULTS

The patients' median age at diagnosis was 10 years and the median interval between initial manifestations and diagnosis was 0.5 years. The most common symptoms and signs were polyuria, polydipsia, nocturia, and growth retardation. Most patients had low urine osmolality and elevated plasma osmolality on diagnosis. Absence of a posterior pituitary hyperintense signal and thickening of the pituitary stalk were common findings on magnetic resonance imaging. Approximately 80% of the patients had anterior pituitary hormone deficiency and all patients had growth hormone deficiency. Approximately 60% of patients had intracranial lesions, the most common causes of which were germ cell tumor and Langerhans cell histiocytosis. Two patients were initially believed to have idiopathic CDI but intracranial lesions were detected during the follow-up period.

CONCLUSION

Because a delayed diagnosis of CDI is common in Taiwanese children, a high index of suspicion is important. The underlying etiology of CDI in children may not initially be obvious. Long-term surveillance is therefore necessary, especially for the early detection of evolving treatable intracranial lesions.

Expression of cytochrome P450 1A1/2 and 3A4 in liver tissues of hepatocellular carcinoma cases and controls from Taiwan and their relationship to hepatitis B virus and aflatoxin B1-and 4-aminobiphenyl-DNA adducts

Cytochrome P450 enzymes play a major role in the metabolism of several of the chemical carcinogens involved in the development of hepatocellular carcinoma (HCC). To investigate by immunohistochemistry interindividual differences in these enzymes, polyclonal antisera and immunoperoxidase staining were used to detect the expression of CYP1A1/2 and 3A4 in 37 surgical control tissues and 105 tumour and adjacent nontumour tissues of HCC cases from Taiwan. There was variability in the expression and staining pattern for both CYP1A1/2 and 3A4 in all tissue types. In tissues from controls, there was no correlation between P450 expression and smoking history or hepatitis B virus antigen status. Since these samples had been previously analysed for the DNA adducts of aflatoxin B1 (AFB1), a dietary mould contaminant, and 4-aminobiphenyl (4-ABP), a component of cigarette smoke, we also investigated the relationship between P450 levels and DNA adducts. 4-ABP-DNA adducts were higher in tissues with elevated levels of CYP1A1/2 (p = 0.02). Overall there was no relationship between CYP1A1/2 or CYP3A4 and AFB1-DNA adducts in control tissues. Staining intensity for CYP1A1/2 and 3A4 followed the order: tumour tissues < control tissues < adjacent non-tumour tissues. CYP1A1/2 levels tended to be lower in tumour and adjacent non-tumour tissues than for CYP3A4. In HCC cases, 4-ABP-DNA adducts were higher in subjects with higher levels of CYP1A1/2, stratified by tissue type, but these differences were not significant. For CYP3A4, in contrast to control tissues, there was a significant association with AFB1-DNA adducts in tumour and adjacent non-tumour tissue of HCC cases. These results suggest that one factor influencing carcinogen-DNA adducts is levels of specific P450 enzymes. However, adduct formation in vivo is a complex processes dependent upon numerous genetic and environmental factors.

PD06-04: Uptake and Economic Impact of First-Cycle Colony Stimulating Factor Use during the Adjuvant Treatment of Breast Cancer

Background: In 2002, pegfilgrastim was approved by the FDA and the benefits of dose-dense breast cancer(BC) chemotherapy were reported. A meta-analysis revealed these benefits were limited to hormone receptor negative tumors (20% risk reduction), where hormone receptor positive cancers had a minimal 2% risk reduction. We examined first-cycle growth factor use(FC-CSF) before and after 2002 and estimated US expenditures for dose-dense chemotherapy by hormone receptor status.

Methods: We identified subjects in SEER-Medicare&gt;65 years oldwith stage I-III BC between 1998 and 2005who had≥1 chemotherapy claim within one year of diagnosis. We classified those with an average cycle length &lt;21 days as having had dose-dense therapy. The associations of patient, tumor, and physician-related factors with receipt of any CSF and FC-CSF use were analyzed using GEE. Costs and event-free life-years saved were estimated for patients by HR status.

Results: Among the 11,143 patients identified, 5,356(48.1%) hada CSF claim during therapy and 2095(18.8%) had FC-CSF. CSF use increased from 25.4% to 70.9%, FC-CSF increased from 6.4% to 46.9% and pegfilgrastim increased from 5% to 85%. During this time receipt of the combination of an anthracycline and a taxane increased from 12% to 47%. In a multivariable analysis, any CSF use was associated with age, treatment by an oncologist, and chemotherapy type; and negatively associated with black/Hispanic race, rural residence and shorter chemotherapy duration. FC-CSF use was associated also with higher SES. For hormone receptor negative patients, the cost per event-free life year saved was $5,512, with annual costs of $19.5 million. For hormone receptor positive patients, however, there was no savings in life years (and therefore no relevant cost per event-free life year saved) with annual costs of $38.8 million for those over 65. The annual costs were estimated at $86.1 million for the hormone receptor positive patient population incorporating all ages.

Conclusions: Our study demonstrated a widespread increase in the use of CSF's and specifically first cycle pegfilgrastim in elderly women receiving adjuvant chemotherapy for breast cancer. This 4-fold increase came shortly after published reports of the benefits of dose-dense therapy. While this approach is very cost-effective in women with hormone receptor negative tumors, it has come at great financial cost in women with hormone receptor positive tumors who are less likely to have a meaningful benefit. In order to reduce the total costs of cancer-care, efforts should be made to ensure that these treatments are reserved for only those who benefit substantially from their use.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr PD06-04.

Congenital hypopituitarism due to POU1F1 gene mutation

POU1F1 (Pit-1; Gene ID 5449) is an anterior pituitary transcriptional factor, and POU1F1 mutation is known to cause anterior pituitary hypoplasia, growth hormone and prolactin deficiency and various degree of hypothyroidism. We report here a patient who presented with growth failure and central hypothyroidism since early infancy. However, treatment with thyroxine gave no effect and he subsequently developed calf muscle pseudohypertrophy (Kocher-Debre-Semelaigne syndrome), elevation of creatinine kinase, dilated cardiomyopathy and pericardial effusion. Final diagnosis was made by combined pituitary function test and sequencing analysis that revealed POU1F1 gene C.698T > C (p.F233S) mutation. The rarity of the disease can result in delayed diagnosis and treatment.

Abstract P2-13-02: Phase II Study of Glucosamine with Chondroitin on Joint Symptoms Induced by Aromatase Inhibitors in Breast Cancer Patients

Background: Aromatase inhibitors (AIs) are commonly used as adjuvant endocrine therapy in postmenopausal women with hormone receptor-positive breast cancer (BC). However, many patients treated with AIs experience joint symptoms which may lead to non-adherence to treatment. We examined whether glucosamine plus chondroitin improves AI-induced arthralgias in women with early stage BC.

Methods: This is a single-arm Phase II study evaluating the efficacy of glucosamine and chondroitin in postmenopausal BC patients with moderate to severe AI-induced arthralgias. Patients took glucosamine sulfate (1500mg/d) + chondroitin sulfate (1200mg/d) for 24 weeks, and were assessed every 6 weeks. The primary endpoint was change in Outcome Measure in Rheumatology Clinical Trials and Osteoarthritis Research Society International (OMERACT-OARSI) criteria at 24 weeks. Secondary endpoints include changes in Brief Pain/Stiffness Inventory-Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis (WOMAC), Modified Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (M-SACRAH), quality of life, grip strength and estradiol level. A Simon two-stage design was used. If 7/22 responses were observed, the trial would continue. Results: Of 36/46 patients enrolled to date, 21 were evaluable at 24 weeks. Median age: 61 (46-80); White/Hispanic/Black/Asian: 11/5/4/1. At 24 weeks, 12/21 patients (57%) had improved pain/stiffness or function in their knees or hips, and 14/21 patients (67%) had improvement in their hands, and 80% had improvement in hands and/or knees. There were also decreases in BPI pain/stiffness severity and functional interference (P&lt;0.05). Reassuringly, there was no increase in serum estradiol levels. Conclusion: Glucosamine and chondroitin is a well-tolerated and potentially effective treatment for AI-induced arthralgia. Evaluation of these agents in a placebo controlled phase III study is warranted.

Epigenetic profiling of the H19 differentially methylated region and comprehensive whole genome array-based analysis in Silver-Russell syndrome

Silver-Russell syndrome (SRS) is a clinically and genetically heterogeneous congenital disorder characterized by severe growth retardation. Hypomethylation of the differentially methylated region (DMR) of the H19 gene and uniparental disomy of maternal chromosome 7 is present in ∼45% of the patients with SRS so more than half of these patients have no known genetic etiology. We combined several molecular technologies including multiplex methylation polymerase chain reaction, methylation-sensitive multiple ligation probe-dependent amplification, and methylation-sensitive high-resolution melting to assess the epigenetic status of 34 patients with SRS. Additionally, we applied a whole genome strategy to detect copy number changes and loss of heterozygosity. Thirteen patients (38.2%) had hypomethylation of the DMR of the H19 gene and none had uniparental disomy of maternal chromosome 7. The whole genome arrays identified five patients (14.7%) with microdeletions on chromosomes 1q23q24.3, 7p15.3, 13q31.3, 14q32.31, and 15q26.2qter, respectively. The overall mutation detection rate was 52.9% by the epigenetic study and the whole genome strategy. Although epimutation may be the major cause of SRS and can be identified by multiplex methylation polymerase chain reaction, the whole genome approach also provides information on the etiology of SRS. If no epimutation is identified in the patients with typical SRS, microdeletions should be suspected.

Premature thelarche in Taiwanese girls

This study was conducted to understand the clinical features and natural course of Taiwanese girls with premature thelarche (PT). The medical records of 91 Taiwanese girls with PT who were diagnosed younger than six and have been regularly followed up for more than two years were reviewed. For comparison, GnRH test was also done in 25 girls with central precocious puberty (CPP) and 10 normal prepubertal girls. The age of onset of these patients was 1.5 +/- 1.6 years and 79% of them developed PT before the age of two. Girls with PT had intermediate degree of hypothalamic-pituitary-ovarian activity between prepuberty and CPP with FSH-predominant response to GnRH stimulation. 87% of patients have complete regression of breast development during 3.8 +/- 2.5 years' follow-up but 19% of them have progressed to CPP during follow-up. We conclude that Taiwanese girls with PT more often developed within the first two years of life. Activation of hypothalamic-pituitary-gonadal axis with predominant FSH activity during infancy may contribute to its development. In addition, PT is not always a benign self-limited condition, and clinicians should be cautious about pubertal development of these patients.

Effect of puberty onset on spontaneous hepatitis B virus e antigen seroconversion in men

BACKGROUND

Male predominance is a remarkable phenomenon in hepatitis B virus (HBV)-related liver disease. This study elucidated the effects of puberty on spontaneous hepatitis B virus e antigen (HBeAg) seroconversion in boys.

METHODS

One-hundred HBeAg-positive chronic HBV-infected males recruited at younger than 10 years of age who had been followed for >10 years were selected randomly from our long-term followed cohort into this study. Serum testosterone levels, androgen receptor exon-1 CAG repeat number and steroid 5alpha reductase type II (SRD5A2, valine vs leucine alleles) polymorphism were determined. Serial clinical data, HBV genotype, and spontaneous HBeAg seroconversion age were also analyzed.

RESULTS

Seventy-two subjects had spontaneous HBeAg seroconversion during the follow-up period. Subjects with serum testosterone levels > or =2.5 ng/mL at 15 years old (earlier-onset puberty, n = 87) had earlier HBeAg seroconversion (median age, 13.2 vs 22.5 years; hazard ratio = 2.95; P = .005), higher peak alanine aminotransferase levels when HBeAg positive (305.7 +/- 372.7 vs 154.8 +/- 126.0 IU/L; P = .006), and a greater HBV viral load reduction from 10 to 20 years of age (1.6 +/- 2.4 vs 0.2 +/- 1.4 log10 copies/mL; P = .009) than those with serum testosterone levels <2.5 ng/mL (later-onset puberty, n = 13). Valine allele carrier at the SRD5A2 V89L polymorphism was also associated with earlier spontaneous HBeAg seroconversion (median age, 11.7 vs 18.7 years; hazard ratio = 1.88; P = .028).

CONCLUSION

Earlier-onset puberty and increased SRD5A2 enzyme activity are associated with earlier HBeAg seroconversion, higher serum alanine aminotransferase levels, and a greater HBV viral load decrement in chronic HBV infected males.

Etiology and clinical features of isosexual precocious puberty in Taiwanese girls: twenty-three years' experience in National Taiwan University Hospital

The aim of this study was to elucidate the etiology and clinical features of Taiwanese girls with isosexual precocious puberty. 460 girls with precocious puberty were enrolled in this study. 284 of them had a GnRH test and 179 girls with gonadotropin-dependent precocious puberty (GDPP) underwent brain MRI. Our results showed 7% of these 460 girls had gonadotropin-independent precocious puberty (GIPP). The other 93% patients had GDPP and 96% of them were idiopathic. Functional ovarian cyst and hypothalamic hamartoma were leading causes of GIPP and organic GDPP, respectively. The presence of undetectable basal serum FSH and LH levels had a specificity of 95% in girls with GIPP. Among girls with GDPP, those aged < 5 years had a higher percentage of detected CNS lesions than older girls (8% vs 3%). Girls with organic CNS lesions also had more advanced bone age SDS (6.9 +/- 3.3 vs 3.3 +/- 1.9), larger uterine volume (13.8 +/- 12.1 vs 6.6 +/- 8.1 cm3), higher basal serum estradiol (33.5 +/- 17.1 vs 26.8 +/- 18.2 pg/ml), and higher peak LH level after GnRH stimulation (45.2 +/- 36.2 vs 25.8 +/- 27.3 U/l) than those with idiopathic GDPP. In conclusion, GIPP is uncommon in Taiwanese girls with precocious puberty. Functional ovarian cyst and hypothalamic hamartoma are leading causes of GIPP and organic GDPP, respectively. The presence of neurological deficit, younger age at onset of puberty, presence of menstruation, rapid advance of bone age, markedly enlarged uterus, high serum estradiol, and high peak LH level after GnRH stimulation are suggestive of organic GDPP.

Caloric restriction in Alström syndrome prevents hyperinsulinemia

Alström syndrome (AS; OMIM 203800) is an autosomal recessive disorder characterized by cone-rod dystrophy, dilated cardiomyopathy, sensorineural hearing impairment, developmental delay, and most case had both childhood-onset obesity and hyperinsulinemia. Currently, the pathogenesis of this disease is not clear. Here we report on an 18-month-old boy with Alström syndrome. He had obesity but with normal insulin and glucose levels. Molecular analysis of the ALMS1 gene revealed a 19 base pair homozygous deletion 11116_11134del in exon 16. His body mass index decreased from 25.0 to 20.7 after calorie restriction for 9 months, and his insulin and glucose levels remained normal. Finding in this case suggests that hyperinsulinemia is a secondary event in Alström syndrome, and early-commenced treatment prevents hyperinsulinemia.

Evaluation of beta-cell function in diabetic Taiwanese children using a 6-min glucagon test

This study evaluates the effects of glucagon 30 mug/kg (maximal 1 mg) on beta-cell function in children by C-peptide determined before and 6 min after intravenous administration. From 1990 to 2005, 118 Taiwanese children with newly diagnosed diabetes mellitus (98 children with type 1 and 20 children with type 2) and 29 normal Taiwanese children were enrolled in this study. Fasting and 6-min post-glucagon C-peptide levels were analyzed. In the pre-pubertal group, the median fasting serum C-peptide levels were 0.2 and 0.8 nmol/l in type 1 diabetes and normal children, respectively. These levels rose to 0.3 and 1.9 nmol/l after glucagon stimulation. In the pubertal group, the median fasting serum C-peptide levels were 0.3, 1.0 and 0.9 nmol/l in type 1 diabetes, type 2 diabetes and normal children, respectively. They rose to 0.4, 2.5 and 2.7 nmol/l after glucagon stimulation. Both fasting and post-glucagon C-peptide levels in type 1 diabetes patients were significantly lower than those of normal children and children with type 2 diabetes. The optimal cut-off values to distinguish type 1 diabetes patients from those with type 2 as determined by the receiving operating characteristic curve were 0.7 and 1.1 nmol/l, respectively. The sensitivities of both C-peptide values were 93%. The post-glucagon C-peptide level was more powerful in distinguishing type 1 diabetes from type 2 diabetes with higher specificity (95% vs. 85%). The 6-min glucagon test is valuable in assessing beta-cell function in children and can help pediatricians in the differential diagnoses of diabetes mellitus in children.

Slipped Capital Femoral Epiphysis as a Complication of Growth Hormone Therapy

Slipped capital femoral epiphysis (SCFE) is a rare complication of growth hormone (GH) therapy. Here, we report three patients who developed SCFE during GH therapy. The first two patients had hypopituitarism and had started GH therapy at the age of 15 years 6 months and 13 years 9 months, respectively. SCFE developed 4 years and 1 year after GH therapy, respectively. The third patient had Prader-Willi syndrome with obesity and hypogonadism and began GH therapy at the age of 12 years and 11 months. SCFE developed 2 months after starting GH therapy. Pain over the hip joints or over the knees is an early sign of SCFE. Despite recommendation, none of the three patients continued GH therapy. A high index of suspicion during GH therapy in patients at high risk of SCFE is important for early diagnosis and appropriate management.

Long-term outcome of hormonal status in Taiwanese children with Hashimoto's thyroiditis

The objective of this prospective study was to evaluate both thyroid function in children with Hashimoto's thyroiditis and the necessity of lifetime thyroxine replacement therapy. A total of 47 patients with goiter and positive thyroid auto-antibodies participated in the study. Serum thyroxine and thyrotropin levels and titers of thyroid auto-antibodies were checked regularly throughout the follow-up period. At the beginning of the study, 25 patients were diagnosed as euthyroid, but at the end of the study, 22 patients initially diagnosed with euthyroidism remained euthyroid, while eight patients with subclinical hypothyroidism and three patients with overt hypothyroidism had become euthyroid. Thus, of the 22 patients with thyroid dysfunction at diagnosis, subclinical or overt, 11 became euthyroid during the follow-up period. The effect of thyroxine treatment on thyroid auto-antibody titers was not significant.

CONCLUSION

Our data shows that Hashimoto's thyroiditis in children has a benign course and that thyroid function in one half of the patients with thyroid dysfunction at diagnosis reverts to normal. Careful follow-up of thyroid function is important in order to determine the necessity and timing of thyroxine replacement therapy.

Carbonyl compounds in the roadside environment of Hong Kong

The levels of carbonyl compounds were determined at the roadside urban station at the Hong Kong Polytechnic University (HKPU) campus during January 2002 to February 2002. Nine carbonyl compounds were quantified in this study. Temperature and solar radiation were found to affect the photochemical reactions of the carbonyls. Formaldehyde/acetaldehyde ratio ranged from 1.27 to 1.35. Strong correlations between formaldehyde and acetaldehyde were found, in the time period 1800-2100, which indicated that they were originated from the same sources during this time period. Roadside carbonyl samples were also collected at four other roadside environments during 2001. Kwai Chung (KC) station showed the highest average formaldehyde and acetaldehyde concentrations due to its highest traffic flow, especially for diesel vehicles. High concentration of toluene emitted from gasoline-fueled vehicles was believed to be the cause of high benzaldehyde level at the Central (CT) station through the photochemical oxidation of toluene. The average concentrations of formaldehyde and acetaldehyde in Hong Kong are well within the ranges reported in roadside environments of other urban cities. However, Mexico City in Mexico and Cairo in Egypt had much higher concentration levels of formaldehyde and acetaldehyde than in Hong Kong roadside environment due to the incomplete combustion of different fuel compositions.

A summary of recent findings on birth outcomes and developmental effects of prenatal ETS, PAH, and pesticide exposures

Inner-city minority populations are high-risk groups for adverse birth outcomes and also more likely to be exposed to environmental contaminants, including environmental tobacco smoke (ETS), benzo[a]pyrene B[a]P, other ambient polycyclic aromatic hydrocarbons (global PAHs), and residential pesticides. The Columbia Center for Children's Environmental Health (CCCEH) is conducting a prospective cohort study of 700 northern Manhattan pregnant women and newborns to examine the effects of prenatal exposure to these common toxicants on fetal growth, early neurodevelopment, and respiratory health. This paper summarizes results of three published studies demonstrating the effects of prenatal ETS, PAH, and pesticides on birth outcomes and/or neurocognitive development [Perera FP, Rauh V, Whyatt RM, Tsai WY, Bernert JT, Tu YH, et al. Molecular evidence of an interaction between prenatal environment exposures on birth outcomes in a multiethnic population. Environ Health Perspect 2004;12:630-62; Rauh VA, Whyatt RM, Garfinkel R, Andrews H, Hoepner L, Reyes A, et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol 2004;26:373-85; Whyatt RM, Rauh V, Barr DB, Camann DE, Andrews HF, Garfinkel R, et al. Prenatal insecticide exposures, birth weight and length among an urban minority cohort. Environ Health Perspect, in press]. To evaluate the effects of prenatal exposure to ETS, PAHs, and pesticides, researchers analyzed questionnaire data, cord blood plasma (including biomarkers of ETS and pesticide exposure), and B[a]P-DNA adducts (a molecular dosimeter of PAHs). Self-reported ETS was associated with decreased head circumference (P = 0.04), and there was a significant interaction between ETS and adducts such that combined exposure had a significant multiplicative effect on birth weight (P = 0.04) and head circumference (P = 0.01) after adjusting for confounders. A second analysis examined the neurotoxic effects of prenatal ETS exposure and postpartum material hardship (unmet basic needs in the areas of food, housing, and clothing) on 2-year cognitive development. Both exposures depressed cognitive development (P < 0.05), and there was a significant interaction such that children with exposure to both ETS and material hardship exhibited the greatest cognitive deficit (7.1 points). A third analysis found that cord chlorpyrifos, and a combined measure of cord chlorpyrifos, diazinon, and propoxur-metabolite, were inversely associated with birth weight and/or length (P < 0.05). These results underscore the importance of policies that reduce exposure to ETS, air pollution, and pesticides with potentially adverse effects on fetal growth and child neurodevelopment.

Novel deletion mutations of the DAX1 (NR0B1) gene in two Taiwanese families with X-linked adrenal hypoplasia congenita

OBJECTIVE

To analyze the DAX1 (NROB1) gene in Taiwanese families with adrenal hypoplasia congenita.

PATIENTS AND METHODS

Two unrelated Taiwanese patients were followed up at our pediatric endocrine clinic. Both patients presented with adrenal crisis. One patient entered puberty spontaneously. However, arrest of puberty was noted in the following years and hypogonadotropic hypogonadism was confirmed by GnRH test. The other patient was still prepubertal. Sequencing of the DAX1 (NROB1) gene was carried out in both patients and their respective family members.

RESULTS

Two different novel mutations were identified. The first patient had one base (G) deletion at nucleotide 159, resulting in a frame-shift and a premature stop codon at position 84. The other patient had one base (G) deletion at nucleotide 831, leading to a frameshift and a premature stop codon at position 371. Family studies revealed that their mothers and sisters were heterozygotes for the mutations while their maternal grandmothers did not carry the mutations.

CONCLUSIONS

Two Taiwanese patients with adrenal hypoplasia congenita were detected to have novel mutations of the DAX1 (NR0B1) gene. Family studies suggested that such mutations resulted from de novo mutation of the DAX1 (NROB1) gene in their mothers. These data indicate that molecular analysis of the DAX1 (NR0B1) gene is important for the diagnosis and genetic counseling of children with primary adrenal insufficiency.

New simple tests for age-at-onset anticipation: application to panic disorder

Recently, testing for anticipation has received renewed interest. It is well known that standard statistical methods are inappropriate for this purpose due to problems of sampling bias. Few statistical tests have been proposed for comparing mean age of onset in affected parents with mean age of onset in affected children. All of them are difficult to compute and lack software to perform the tests. In this report, we formulate the problem in terms of symmetry tests. We propose a simple generalized paired t-test and a Wilcoxon signed rank test to adjust for the bias caused by the right truncation of both the parent's and child's ages at onset. We also extend the generalized paired t-test to a random effects model that enables analysis of correlated data from nuclear families, and could be further extended to larger family structures. We illustrate the approaches with an example of panic disorder.

Adult height of patients with classical congenital adrenal hyperplasia

BACKGROUND AND PURPOSE

Data on factors that affect the final height of patients with classical congenital adrenal hyperplasia (CAH) are limited. This study investigated the factors that can affect height outcome of patients with classical CAH.

METHODS

A retrospective study of 44 patients (16 males, 28 females) with classical CAH who had attained the adult height without gonadotropin-releasing hormone analog therapy was conducted. Adult height standard deviation scores (AHSDS) and target height standard deviation scores (THSDS) were determined. The impact of type, gender, control of disease activity or occurrence of precocious puberty on height was analyzed.

RESULTS

The difference between AHSDS and THSDS of the 44 patients was -0.7 +/- 1.0 and was greatest in simple-virilizing males (-1.1 standard deviation score [SDS]). However, no significant differences in height outcomes were identified between genders and types. The differences between AHSDS and THSDS of patients with good control of disease activity or normal puberty were -0.3 SDS and -0.4 SDS, respectively, which were better height outcomes than those of the other groups (p < 0.05).

CONCLUSIONS

Classical CAH can lead to reduced adult height. Good control of disease activity and the prevention of the occurrence of precocious puberty is important to achieving normal adult height outcome.

Effect of cordycepin on Hantaan virus 76-118 infection of primary human embryonic pulmonary fibroblasts--characterization of apoptotic effects

The cDNA microarray technique was used to study gene epression in human embryonic pulmonary fibroblasts (HEPF) infected with Hantaan virus (HTNV) under the influence of cordycepin (Cor), an inhibitor of post-transcriptional pre-mRNA polyadenylation. Four apoptotic genes, the insulin-like growth factor binding protein 1, NFkB inhibitor alpha, caspase-3 and NFkB1 were up-regulated in both infected and uninfected Cor-treated cells and two cell cycle-associated genes, CDC-like kinase and beta-induced transforming growth factor were up-regulated in Cor-untreated cells but down-regulated in Cor-treated cells. Cell morphology examination, quantitative RT-PCR, and immunofluorescence (IF) test suggested that following the Cor treatment the HTNV infection took place, but late viral gene expression was slightly reduced. Three parameters, namely caspase-3 activity, annexin V binding, and cell cycle were used to detect apoptosis. The results suggested that the induction of apoptosis in HEPF by HTNV started at 6 hrs post infection (p.i.). Following the Cor treatment, however, the caspase-3 activity began to increase at 24 hrs p.i. Thus it is suggested that inhibition of de novo late viral protein synthesis by Cor changes the apoptosis pathway and cell cycle by delaying caspase-3 gene expression and by up/down-regulating of expression of other apoptotic and cell cycle-associated genes. This implicates that HTNV can induce apoptosis in HEPF even without de novo viral protein synthesis and with a reduced and slowed viral maturation.

Physiological changes of adrenal androgens in childhood

BACKGROUND AND PURPOSE

To investigate the change in serum dehydroepiandrosterone sulfate (DHEAS) and androstenedione concentrations during childhood and to clarify the relationship between adrenarche and gonadarche.

METHODS

A cross-sectional study of 577 healthy children (297 boys and 280 girls), with ages ranging from 5 days to 12 years was conducted. After complete physical examination and recording of any sign of puberty, blood samples were drawn for the determination of serum DHEAS and androstenedione concentrations. For comparison, blood samples were also drawn from 39 normal adults, 23 men and 16 women.

RESULTS

In both genders, the DHEAS and androstenedione levels at birth were 3.0 +/- 1.3 mumol/L and 4.1 +/- 2.3 nmol/L, respectively. They fell rapidly within 6 months, and were maintained at a low level until 6 years of age. After the age of 6, the levels of both adrenal androgens were significantly increased (p < 0.05). Adrenarche occurred at the age of 7.7 +/- 1.1 years in boys and at the age of 7.7 +/- 1.0 years in girls. Gonadarche occurred at the age of 11.2 +/- 0.8 years in boys (n = 33) and at the age of 10.3 +/- 0.8 years in girls (n = 46). The onset of adrenarche occurred about 2 to 3 years earlier than the onset of puberty (p < 0.001).

CONCLUSIONS

Serum levels of adrenal androgens change dramatically during childhood. Serum concentration of DHEAS is a good marker for adrenal androgens production because gonadal androgens may interfere with serum concentration of androstenedione. For Taiwanese children, the onset of adrenarche occurred between the ages of 6 and 8 years, which was 2 to 3 years earlier than the onset of puberty.

Reversible mitral valve prolapse and mitral regurgitation in children with Graves' disease

An association between mitral valve prolapse (MVP) and hyperthyroidism has been described in adults. However, the long-term prognosis when associated with significant mitral regurgitation remains unclear. Three consecutive children with Graves' disease were found to have a loud mitral regurgitation murmur (grade III/VI) and echocardiographic evidence of MVP with moderate mitral regurgitation. The cardiac manifestations included palpitations, exertional dyspnea, and exercise intolerance. The electrocardiograms at presentation were sinus tachycardia in all cases. All had hyperthyroidism and positive thyroid antibodies. Exophthalmos occurred in two and appeared later than the cardiac symptoms in one. The cardiac murmur disappeared in all patients when antithyroid agents controlled the hyperthyroidism. Follow-up echocardiography showed normal in one and MVP with mild mitral regurgitation in two. We conclude that MVP and significant mitral regurgitation can occur in children with hyperthyroidism, especially those with Graves' disease. The prognosis is good after adequate medical control of the hyperthyroidism.

Seasonal and diurnal variations of volatile organic compounds (VOCs) in the atmosphere of Hong Kong

Ambient VOCs samples were collected at three locations (PolyU campus (PU), Kwun Tong (KT), Hok Tsui (HT)) in Hong Kong during the periods of November 2000-February 2001 and June 2001-August 2001. Also the concentrations of VOCs in Cross Harbor tunnel in Hong Kong were obtained in order to determine the vehicular sources of VOCs. Toluene was the most abundant VOC detected in Hong Kong. At the PU station, which is close to a main road, the concentrations of most VOCs were higher in summer than in winter. However, at the background location HT, the concentrations of all VOCs except tetrachloroethene were higher in winter than in summer. Regional physical dispersion/transportation and mixing depth may be the reasons for higher VOC concentrations in winter at HT. The BTEX (benzene:toluene:ethylbenzene:xylene) ratios of PU and KT during winter period were (1.9:10.1:1.0:1.8) and (1.9:10.4:1.0:1.5), and (0.9:8.3:1.0:2.2) and (0.8:29.6:1.0:1.8) for summer season, respectively. The xylene/ethylbenzene (X/E) ratio was used to assess the relative age of the air parcels in this study. The concentrations of VOCs in the atmosphere in Hong Kong were mainly affected by direct emissions from vehicles, evaporation of fuels, photochemical reactions and few industrial emissions. The BTEX ratio in the tunnel was 2:10.4:1:3.2. The BTEX ratios at PU and KT during the winter period were similar to that in tunnel (except for xylenes). The X/E ratio in the tunnel was higher than that in the ambient air. This indicated that the freshly emitted xylenes in the tunnel decayed at different rates from OH-oxidation in the atmosphere. Good BTEX correlations (r>0.8) were found at PU and KT in winter (**P<0.01). Vehicular exhaust was the dominant source at PU and KT stations, and less evaporation of fuel or additive occurred at low temperature in winter. Diurnal variations of mean BTEX concentrations at the roadside monitoring station (PU) showed two peaks associated with traffic density and vehicle type.

Arachnoid cyst with GnRH-dependent sexual precocity and growth hormone deficiency

The coexistence of gonadotropin-releasing hormone (GnRH)-dependent sexual precocity and growth hormone deficiency in patients with arachnoid cysts is rarely reported, and its pathogenesis is not well recognized. This report describes an 11-year-old female who had a huge intracranial arachnoid cyst with initial symptoms and signs of sexual precocity. Her brain magnetic resonance imaging revealed distorted hypothalamus with a thin and stretched pituitary stalk. After treatment with cysto-peritoneal shunting and gonadotropin-releasing hormone analogue, her puberty was arrested and subnormal growth rate was observed. Catch-up growth was detected after growth hormone therapy. Hence, coexistence of gonadotropin-releasing hormone-dependent sexual precocity and growth hormone deficiency in this patient was confirmed.

Hypopituitarism associated with neurofibromatosis type 1: report of one case

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder with a wide range of clinical manifestations. Hydrocephalus unrelated to brain tumors is rare in neurofibromatosis type 1. A 16-year-and-6-month-old girl with primary amenorrhea was found to have hydrocephalus associated with neurofibromatosis type 1. After endocrine and brain imaging study, the cause of primary amenorrhea was proven to be hypopituitarism due to hydrocephalus. She entered puberty soon after relieving the hydrocephalus with a ventriculoperitoneal shunt. However, arrest of puberty was noted three months later. Therefore estrogen replacement therapy was given. Early detection of hydrocephalus was difficult in this patient. From the experience of our case, MRI study of brain is indicated in patient with neurofibromatosis type 1 and endocrine dysfunction.

Permanent neonatal diabetes mellitus manifesting as diabetic ketoacidosis

Neonatal diabetes mellitus (NDM) is a very rare disease defined as hyperglycemia that occurs during the first month of life, requires insulin treatment, and lasts more than 2 weeks. There are 2 types of NDM: permanent neonatal diabetes mellitus (PNDM) and transient neonatal diabetes mellitus (TNDM). We report a case of PNDM in a 3-day-old female infant. This full-term neonate was born small for gestational age. Respiratory distress, poor activity, hypothermia, poor feeding, dehydration, and ketoacidosis were noted at the age of 3 days. After insulin therapy and fluid replacement, her condition became stable. Glucagon test done at the age of 26 days showed serum C-peptide level to be low for her age. During the first year of life she had catch-up growth, but insulin therapy was still required. Serum C-peptide level was undetectable at the age of 15 months. The course of this case indicates the importance of a high index of suspicion for patients with PNDM in order to correct metabolic derangement as early as possible and facilitate normal growth and development under insulin therapy.

Methimazole-induced lupus erythematosus: a case report

A 15-year-old girl had a history of diffuse goiter and received methimazole treatment 2 months before admission to the hospital. She developed bilateral lower leg edema 5 days before admission and the laboratory examinations revealed leukopenia, anemia, proteinuria, and granular cast. Positive antinuclear antibodies and anti-double strand (anti-ds) DNA antibodies were noted, although complement levels were not reduced. Myeloperoxidase antineutrophil cytoplasmic antibody was positive. A renal biopsy disclosed that there was focal segmental glomerulosclerosis. Methimazole was discontinued, and she was treated with prednisolone and Plaquenil, after which the symptoms and laboratory tests became normal within 40 days. The prednisolone was discontinued after treatment for seven months. Currently, the anti-dsDNA, C3, C4, CBC, urinalysis, and thyroid function tests are within normal limits. With hydroxychloroquine and levothyroxine, she was free of symptoms after discontinuation of methimazole until now (about 21 months).

Oral clodronate therapy for hypercalcemia related to extensive subcutaneous fat necrosis in a newborn

Hypercalcemia is occasionally found in newborns with subcutaneous fat necrosis and carries potential life-threatening risk. Bisphosphonates have been recently introduced in the treatment of subcutaneous fat necrosis in newborns. We report a case of extensive subcutaneous fat necrosis in a female infant complicated with intractable hypercalcemia. Standard treatment for hypercalcemia was given, including saline hydration, a low calcium diet, furosemide, and glucocorticoid, but without response. Serum 1,25-dihydroxyvitamin D level was elevated at 126 pg/mL, 25-hydroxyvitamin D level was normal, and intact parathyroid hormone was suppressed at < 1 pg/mL. Oral clodronate disodium, a second-generation bisphosphonate, was administered, and resulted in the normalization of serum calcium, urine N-telopeptide, urine calcium/creatinine ratio, and serum intact parathyroid hormone level. This case suggests that oral clodronate may be an effective treatment for subcutaneous fat necrosis with hypercalcemia in newborns.