Serum cholesterol level in infancy is inversely associated with subsequent allergy in children and adolescents. A 20-year follow-up study

BACKGROUND

Previous studies suggest an association between an altered lipoprotein profile and atopy. The association has been hypothesized to be due to alterations in the dietary fat intake, a factor possibly contributing to the increase of allergic diseases in industrialized countries.

OBJECTIVE

We aimed at assessing whether there is an association between the serum lipid levels in infancy and subsequent development of allergic symptoms in childhood and adolescence.

METHODS

A cohort of 200 unselected newborns was prospectively followed up from birth to age 20 years (from 1981 to 2002) with repeated measurements of total cholesterol from birth and throughout the first year of life. The subjects were re-examined at the ages of 5, 11 and 20 years, with assessment of the occurrence of allergic symptoms, skin prick testing (SPT) and measurement of total IgE and of the total, high- and low-density lipoprotein cholesterol.

RESULTS

Children and adolescents with allergic symptoms, SPT positivity and an elevated IgE had lower total cholesterol levels in infancy and childhood than the non-atopic subjects. The difference was not detectable in cord blood, but became significant from age 2 months onward.

CONCLUSION

The inverse association between the cholesterol level in infancy and subsequent manifestations of atopy seems not to be due to atopy-related dietary alterations, because it was already present in early infancy, when virtually all the infants were on a similar diet, i.e. on exclusive breastfeeding.

Retinol concentrations after birth are inversely associated with atopic manifestations in children and young adults

BACKGROUND

Vitamin A has anti-inflammatory and immunomodulatory effects, and its deficiency results in impaired specific and innate immunity. Vitamin A is essential for inducing the gut-homing specificity on T cells.

OBJECTIVE

As an impaired gut immune response in early infancy may contribute to the development of atopic sensitization, we looked for an association of plasma retinol concentrations and the subsequent development of allergic symptoms in healthy infants.

METHODS

A cohort of 200 unselected, full-term newborns were followed up from birth to age 20 years. The plasma retinol concentration was determined in cord blood (n=97), at ages of 2, 4 and 12 months (n=95), and at ages 5 years (n=155) and 11 years (n=151). The subjects were re-examined at the ages of 5, 11 and 20 years with assessment of the occurrence of allergic symptoms during the preceding year, skin prick testing and measurement of serum total IgE.

RESULTS

subjects with allergic symptoms or a positive skin prick test (SPT) in childhood or adolescence had lower retinol concentrations in infancy and childhood than symptom-free subjects. The difference was most pronounced at age 2 months. Retinol concentration at 2 months correlated inversely with positive SPT at ages of 5 and 20 years, and with allergic symptoms at age 20 years.

CONCLUSION

Retinol concentration in young infants is inversely associated with the subsequent development of allergic symptoms. We propose that an inborn regulation of retinol may play a role in atopic sensitization, possibly through regulating the intestinal T cell responses.

Prolonged exclusive breastfeeding is associated with increased atopic dermatitis: a prospective follow-up study of unselected healthy newborns from birth to age 20 years

BACKGROUND

Exclusive breastfeeding for the first 6 months is recommended by the World Health Organization and considered allergy preventive. However, it is not known whether prolonging exclusive breastfeeding for over 6 months provides further benefit in allergy prevention.

OBJECTIVE

The aim of this prospective 20-year follow-up study was to find out whether the allergy protective effect can be enhanced by prolonging strictly exclusive breastfeeding for > or =9 months of age. A total of 200 unselected healthy newborns were enrolled in the study. Their mothers were encouraged to maintain exclusive breastfeeding for as long as possible. The number of infants on strictly exclusive breastfeeding was 167 at 2, 116 at 6, 36 at 9 and 7 at 12 months of age. Of the 200 infants, 42% had a family history of allergy. The children were re-assessed at ages 5 (n=163), 11 (n=150) and 20 years (n=164) with clinical examination, skin prick testing, and parental and personal structured interviews.

RESULTS

Exclusive breastfeeding prolonged for > or =9 months was associated with atopic dermatitis (P=0.002) and symptoms of food hypersensitivity (P=0.02) at age 5 years, and with symptoms of food hypersensitivity at age 11 years (P=0.01), in children with a family history of allergy.

CONCLUSION

Prolonging strictly exclusive breastfeeding for > or =9 months was not helpful in atopy prevention, instead, it was associated with increased atopic dermatitis and food hypersensitivity symptoms in childhood.

Long-term results in children with AML: NOPHO-AML Study Group--report of three consecutive trials

In all, 447 children with acute myeloid leukaemia (AML) have been treated on three consecutive NOPHO studies from July 1984 to December 2001. NOPHO-AML 84 was of moderate intensity with an induction of three courses of cytarabine, 6-thioguanine and doxorubicin followed by four consolidation courses with high-dose cytarabine. The 5-year event-free survival (EFS), disease free survival (DFS) and overall survival (OS) were 29, 37 and 38%. NOPHO-AML 88 was of high intensity with the addition of etoposide and mitoxantrone in selected courses during induction and consolidation. The interval between the induction courses should be as short as possible, that is, time intensity was introduced. The 5-year EFS, DFS and OS were 41, 48 and 46%. In NOPHO-AML 93, the treatment was stratified according to response to first induction course. The protocol utilised the same induction blocks as NOPHO-AML 88, but after the first block, children with a hypoplastic, nonleukaemic bone marrow were allowed to recover before the second block. Consolidation was identical with NOPHO-AML 88. The 5-year EFS, DFS and OS in NOPHO-AML 93 were 48, 52 and 65%. The new NOPHO-AML protocol has been based on experiences from previous protocols with stratification of patients with regard to in vivo response and specific cytogenetic aberrations.

Long-term prognosis of children with Down's syndrome and leukaemia: a 34-year nation-wide experience

BACKGROUND

Although the characteristics of leukaemia in patients with Down's syndrome (DS) have been well documented, little is known about the long-term results of treatment.

METHOD

Retrospectively from 1968 to 1981 and prospectively from 1982 to 2002, the present authors collected data on every child with DS in Finland who had been diagnosed with leukaemia between 1968 and 1994.

RESULTS

Forty-one children with DS had acute leukaemia: 28 had acute lymphoblastic leukaemia (ALL); and 13 had acute non-lymphoblastic leukaemia (ANLL). The median age of the subjects at diagnosis was 3.8 years (range = 0-15.9 years). Patients with ANLL were significantly younger (P = 0.001) and all patients under 2 years of age had ANLL. Out of the 28 patients with ALL, 23 (82%) entered primary remission, and of these 23 individuals, 10 remained alive and in continuous remission (CR) after a median of 11.6 years (range = 8.9-20.0 years). Out of the 13 patients with ANLL, five (38%) entered remission and four remained in CR after a median of 16.0 years (range = 9.1-19.2 years). Treatment -related toxicities were common: eight patients with ALL and two with ANLL died of septicaemia. Actuarial, event-free survival rates at 5 years were 53% and 43% for adequately treated subjects with ALL and ANLL, respectively.

CONCLUSIONS

Standard leukaemia chemotherapy is effective in patients with DS. However, because toxicities are unacceptably frequent, specific anti-leukaemia regimens are needed for subjects with DS design.

Transferrin receptor in children and its correlation with iron status and types of milk consumption

AIM

This study compared transferrin receptor (TfR) concentrations with iron parameters relative to a child's intake of cow's milk and follow-on formula.

METHODS

TfR, beta-haemoglobin, serum ferritin and mean corpuscular volume (MCV) of red blood cells were analysed in a study population of 263 children aged 2.5 y. The amounts of cow's milk and follow-on formula consumed were recorded.

RESULTS

There was a significant difference in concentrations of TfR/log ferritin between children whose milk intake was < 500 ml and those with a milk intake > or = 500 ml (p = 0.003). There were significantly higher values of TfR/log ferritin in children whose MCV of red blood cells was < or = 75 fl than in those with > 75 fl (p < 0.0001). The TfR concentrations were significantly lower after iron therapy than before treatment.

CONCLUSION

Higher concentrations of TfR were correlated with lower concentrations of haemoglobin and MCV of red blood cells. Milk consumption increases the risk of a higher ratio of TfR/log ferritin. TfR concentrations were significantly lower after iron therapy.

Antibody status to HHV-6 in children with leukaemia

Forty children with acute lymphoblastic (33) or myeloid leukaemia (seven) were studied for IgG and IgM antibodies and IgG avidity against human herpesvirus 6 (HHV-6) at the time of diagnosis, and compared with age-, sex- and season-matched children with various neurological diseases of suspected viral origin. Of the children with leukaemia, 97.5% had IgG antibodies and 40% IgM antibodies to HHV-6 compared with 92.3% and 7.7% of reference subjects (P = 0.005). A seronegative child with leukaemia seroconverted 3 weeks after the diagnosis. The avidity of IgG antibodies (based on the resistance to urea treatment) was high in all children with leukaemia. One reference child had HHV-6-specific IgG antibodies with low avidity, which together with his positive IgM indicated an acute infection. The presence of specific IgM antibodies in 40% of children with leukaemia and the high avidity of IgG suggest a reactivation or an inaproppriate primary response to HHV-6 infection. The results support the conclusion of the role of the HHV-6 infection at the onset of childhood leukaemia.

Iron-fortified and unfortified cow's milk: effects on iron intakes and iron status in young children

Iron intakes and iron status were evaluated in 36 young Swedish children given either iron-fortified or unfortified cow's milk. All children had good iron status and had received breast milk or iron-fortified formulae during infancy. Twenty 1-y-old children were randomized to a diet with iron-fortified milk (7.0 or 14.9 mg Fe l(-1) and 16 to a diet with unfortified milk. The iron intakes in the unfortified group at 15 and 18 mo (mean +/- SD 5.19 +/- 2.29 and 5.84 +/- 1.62 mg d(-1)) were low in relation to Nordic Nutrition Recommendations, while the intakes in the iron-fortified group (10.20 +/- 2.60 and 10.87 +/- 2.79mg d(-1)) were normal in relation to recommendations. The gain (increase) from receiving fortified diet during the study period was at most [upper limit for 95% confidence interval (CI)] 2.6 g l(-1) in blood haemoglobin, 1.9 fl in mean corpuscular volume, 2.7 micromol in serum iron and 4.5% in transferrin iron saturation, and the gain (decrease) was at most (lower limit for 95% CI) 0.29g l(-1) in serum transferrin and 0.9mg l(-1) in serum transferrin receptor (TfR). None of these differences was statistically significant. There was an almost significantly higher increase in serum ferritin (1.4 times higher relation of values at the end compared with the beginning, p = 0.06) and a significantly higher (1.2; p = 0.047) decrease in TfR/ log10 ferritin ratio in the fortified group.

CONCLUSION

One-year-old children starting out with good iron status given either iron-fortified or unfortified cow's milk from 12 to 18 mo maintain sufficient iron status during this period. However, children fed unfortified cow's milk have an iron intake which is low in relation to recommendations and the quantitative development of their reserve iron in iron stores seems to be weaker than that of the fortified group. The consequences of this require further study.

Impaired spermatogenesis: an unrecognized feature of cartilage-hair hypoplasia

BACKGROUND

Cartilage-hair hypoplasia (CHH), an autosomal recessive chondrodysplasia, is characterized by severe growth failure, hypoplastic hair, impaired immunity, and deficient erythropoiesis. These features may result from a generalized defect in cell proliferation.

AIM

In order to investigate whether an impairment of cell proliferation is present in spermatogenesis, we analysed fertility in a clinical and laboratory study of adult males with CHH.

METHODS

Eleven adult males (median age 29 years, range 21-49 years) with CHH were included in the study. The patients were examined clinically for testicular volume and other clinical characteristics. Blood samples were collected to determine serum concentrations of sex hormones, sex hormone-binding globulin, inhibin B and gonadotrophins (basal and gonadotrophin-releasing hormone-stimulated). Semen samples were analysed for volume, sperm concentration, motility, morphology, and antibody status.

RESULTS

The testicular size was subnormal in some patients, but the serum concentrations of testosterone, inhibin B and gonadotrophins were usually normal. The semen analyses were not within normal limits in any of the patients, as indicated by low sperm concentration, decreased motility and/or morphological changes.

CONCLUSIONS

The defect in cell proliferation in men with CHH also involves the spermatogenic cells and is evident as an impairment of spermatogenesis.

Elevated serum transferrin receptor concentration in children with juvenile chronic arthritis as evidence of iron deficiency

OBJECTIVES

Active juvenile chronic arthritis (JCA) is accompanied by anaemia of chronic disease, which may be indistinguishable from anaemia due to iron deficiency. We speculate that elevation of the serum transferrin receptor (sTfR) concentration, which should not be influenced by inflammation, would be useful for detecting the role of iron status in anaemic children with JCA.

METHODS

sTfR concentrations were measured in 30 children with JCA.

RESULTS

The median sTfR was elevated, 6.1 (range 3.4-13.0) mg/l. In 13 patients (43%) the concentrations exceeded the upper limit for healthy subjects. Haemoglobin (r = - 0.48, P = 0.008), mean corpuscular volume (r = - 0.47, P = 0.009) and mean corpuscular haemoglobin (r = - 0.65, P = 0.0001) correlated inversely with sTfR concentration.

CONCLUSIONS

In 13 of the 30 patients with JCA, the sTfR concentration, which is an indicator of iron status and erythropoiesis, was elevated. The results raise the possibility that sTfR is able to distinguish iron-deficiency anaemia from anaemia of chronic disease. It should be further explored as a candidate.

Anemia in children with cartilage-hair hypoplasia is related to body growth and to the insulin-like growth factor system

Cartilage-hair hypoplasia (CHH) is a metaphyseal chondrodysplasia characterized by severe short-limbed short stature, hypoplastic hair, and defective immunity. The patients also have anemia. As GH may regulate both body growth and erythropoiesis, we used CHH as a clinical model to study their interrelationships. Retrospective analysis of hematological data of 114 patients showed that the severity of the anemia and macrocytosis in CHH varies with age. The anemia was most severe in early childhood. A prospective study of 21 patients with CHH showed that height correlates with hemoglobin (P = 0.006) and mean corpuscular volume of red blood cells (P < 0.0001). The individual hemoglobin levels correlated with the GH parameters [P = 0.035 for insulin-like growth factor I (IGF-I) and P = 0.002 for IGF-binding protein-3], and the mean corpuscular volume of red blood cell values correlated with fetal hemoglobin. Bone marrow cultures obtained from six patients with CHH showed reduced or totally absent erythroid colony formation, which was not influenced by GH or IGF-I in vitro or by GH treatment in vivo. In patients with CHH, we observed an association between erythropoiesis and growth. We conclude that body growth and erythropoiesis share common regulators. One of these is the GH-IGF-I axis; other factors, as not yet identified, may also be important.

Military service of male survivors of childhood malignancies

BACKGROUND

The objective of this study was to assess the eligibility for and the course of compulsory military service of childhood cancer survivors.

METHODS

The medical, military recruitment, conscription, and military service data of male Finnish childhood cancer survivors were collected from manually filed records. Inclusion criteria were: survivors born 1977 or earlier, treated for a malignancy between birth and age 15 years, and followed by a pediatrician until at least age 18 years. The documents of 207 survivors from the Pediatric Clinics of Finnish University Hospitals were examined, and 130 of these survivors were considered eligible for military service. Demographic factors, the predictors of fitness for military service, factors associated with service interruption, the attained level of military training, and the health status of conscripts during service were evaluated. Comparisons were made with the Finnish male population of the same age and with conscripts serving at the corresponding time.

RESULTS

Approximately 60% of studied survivors were enlisted. Positive predictors of fitness for service were year of birth of 1973 or later (odds ratio [OR], 3.2), height at call-up age of 170-174.9 cm (OR, 3.6), and the man's own positive opinion of his fitness for service (OR, 62.3). Negative predictors were age at diagnosis > or = 11 years (OR, 0.5), central nervous system radiotherapy (OR, 0.3), limb defects (OR, 0.02), and the group of sequelae concerning neurologic, cardiopulmonary, and gastrointestinal systems, or secondary malignancies (OR, 0.3). Survivors interrupted their service more often (20%) (P < 0.001). Leukemia survivors were less likely to interrupt their service (7%) compared with other survivors (P = 0.04). Factors associated with service interruption were: diagnosis (P = 0.04), the man's own opinion of his fitness for service (P = 0.013), surgery (P = 0.003), and height (P = 0.049), weight (P = 0.019), and body mass index (P = 0.035) at the beginning of military service. The attained level of military training was equal to that of controls. The survivors visited the garrison physician less frequently in total (mean, 5.9 times) (P < 0.001), visited because of infections as much as controls, and were off duty more (mean, 11.9 days) (P = 0.012) than controls.

CONCLUSIONS

The current study found that childhood cancer survivors were less likely to meet the requirements set for military service in Finland. The causes of rejection usually were obvious, but approximately 30% were rejected merely on the basis of a former cancer diagnosis. However, enlisted survivors coped well with military service if their treatment sequelae were taken into consideration carefully at the time of enlistment. Vocational opportunities within the armed forces might be an appropriate career option even for survivors of childhood malignancies.

Oral iron is sufficient for erythropoietin treatment of very low birth-weight infants

The aim of this study was to compare two different doses and means of administration of iron in recombinant human erythropoietin (rHuEPO)-treated very low birth-weight (VLBW) infants. VLBW infants (n = 41) were randomized to one of three groups. Fourteen infants were treated with rHuEPO (300 IU/kg three times a week s.c.) and oral iron (ferrofumarate, 6 mg of iron/kg per day). Another 14 infants received the same erythropoietin dose and intramuscular iron (ferroxypolymaltose, once 12 mg of iron/kg weekly). Thirteen infants were treated with the same dose of intramuscular iron but did not receive rHuEPO. After the 3-week study period, haemoglobin concentrations and reticulocyte counts were similar in the rHuEPO-treated groups and both were higher than in the group not receiving rHuEPO (P < 0.001). In both rHuEPO-treated groups the transferrin receptor concentration increased from 6.8-7.2 mg/l to 10.5-11.3 mg/l.

CONCLUSION

In erythropoietin-treated very low birth weight infants the iron need for erythropoiesis can be met by oral administration of iron.

Higher concentrations of serum transferrin receptor in children than in adults

BACKGROUND

The serum transferrin receptor (TfR) concentration in adults is suggested to provide a sensitive measure of iron depletion and together with the serum ferritin concentration to indicate the entire range of iron status, from iron deficiency to iron overload. However, little is known about TfR concentrations in children.

OBJECTIVE

Our objective was to compare serum TfR and ferritin concentrations and their ratios in children and adults and look for correlations between TfR concentrations and other measures of iron status.

DESIGN

Our study groups were healthy 1-y-old infants (n = 36), 11-12-y-old prepubertal boys (n = 35), and 20-39-y-old men (n = 40).

RESULTS

TfR concentrations were higher in infants (x; 95% reference interval: 7.8 mg/L; 4.5, 11.1) than in prepubertal boys (7.0 mg/L; 4.7, 9.2) and higher in prepubertal boys than in men (5.8 mg/L; 3.1, 8.5). Geometric mean TfR-ferritin ratios were higher in infants (316; 95% reference interval: 94, 1059) than in prepubertal boys (219; 78, 614) and higher in prepubertal boys than in men (72; 23, 223). By multiple linear regression analysis, the best predictors of TfR concentration were serum iron (P = 0.004) and log serum ferritin (P < 0.0001), both being inverse correlations (R2 = 0.32). Mean corpuscular volume, blood hemoglobin, transferrin iron saturation, transferrin, and even age seemed to not have an influence on the TfR concentration and erythropoiesis was not a determinant of TfR concentration.

CONCLUSIONS

Low serum ferritin and iron concentrations, even within the normal physiologic range, result in high TfR concentrations. The lower the iron stores, the stronger the influence of ferritin on TfR. A high TfR concentration in children, especially in infants, is a response to physiologically low iron stores. Age-specific reference concentrations for TfR are needed.

Efficacy and safety of lovastatin in adolescent males with heterozygous familial hypercholesterolemia: a randomized controlled trial

CONTEXT

Heterozygous familial hypercholesterolemia (HeFH) is a common disorder associated with early coronary artery disease, especially in men. The age at which drug therapy should be started is still controversial, as is the use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins).

OBJECTIVE

To assess the lipid-lowering efficacy, biochemical safety, and effect on growth and sexual development of lovastatin in adolescent boys with HeFH.

DESIGN

One-year, double-blind, placebo-controlled, balanced, 2-period, 2-arm randomized trial. In the first period (24 weeks), lovastatin was increased at 8 and 16 weeks and the dosage remained stable during the second period (24 weeks). The study was conducted between 1990 and 1994.

SETTING

Fourteen pediatric outpatient clinics in the United States and Finland.

PATIENTS

Boys aged 10 to 17 years with HeFH. Of 132 randomized subjects (67 intervention, 65 placebo), 122 (63 intervention, 59 placebo) and 110 (61 intervention, 49 placebo) completed the first and second periods, respectively.

INTERVENTION

Lovastatin, starting at 10 mg/d, with a forced titration at 8 and 16 weeks to 20 and 40 mg/d, respectively, or placebo.

MAIN OUTCOME MEASURES

The primary efficacy outcome measure was low-density lipoprotein cholesterol (LDL-C). Primary safety measures were growth and sexual development.

RESULTS

Compared with placebo, LDL-C levels of patients receiving lovastatin decreased significantly (P<.001) by 17%, 24%, and 27% receiving dosages of 10, 20, and 40 mg/d, respectively, and remained 25 % lower than baseline at 48 weeks. Growth and sexual maturation assessed by Tanner staging and testicular volume were not significantly different between the lovastatin and placebo groups at 24 weeks (P = .85) and 48 weeks (P = .33); neither were serum hormone levels or biochemical parameters of nutrition. However, the study was underpowered to detect significant differences in safety parameters. Serum vitamin E levels were reduced with lovastatin treatment consistent with reductions in LDL-C, the major carrier of vitamin E in the circulation.

CONCLUSIONS

This study in adolescent boys with HeFH confirmed the LDL-C-reducing effectiveness of lovastatin. Comprehensive clinical and biochemical data on growth, hormonal, and nutritional status indicated no significant differences between lovastatin and placebo over 48 weeks, although further study is required.

The serum transferrin receptor concentration in seven fetuses with hemolytic disease

Six pregnant women who received intrauterine transfusions and their seven fetuses were followed during gestation. Hemoglobin concentration, hematocrit value, serum ferritin, and serum transferrin receptor (TfR) concentrations were measured. In the fetal samples, there was a tendency for the TfR concentration to decrease during gestation and after the intrauterine transfusions. Serum TfR values varied between 0.7 and 5.2 mg/L, which is near the postnatal level measured in premature infants. On the contrary, one would have expected to find highly elevated values due to the active fetal erythropoiesis. The fetal regulation of TfR production may differ from that described postnatally.

Evaluation of an ELISA test for determination of the serum transferrin receptor. Demonstration of discordance between results obtained with two methods

We undertook this study to evaluate a recently introduced ELISA kit for determining serum transferrin receptor (TfR) concentration (TfR, Ramco Laboratories, Inc.), to produce reference values for healthy adults, and to compare the results with another commercially available reagent system. The mean (SD) recovery of added TfR was 88% (6%). In dilution studies, the ratio between the measured and expected values was 0.98 (0.11). The intra-assay and interassay coefficients of variation were from 5% to 7% and from 6% to 9% in a physiological and a supraphysiological concentration range, respectively, and from 13% to 16% in a subnormal concentration range. In healthy adults between 20 and 60 years of age, we observed no age- or sex-related differences in TfR values. Thus, the same reference interval, 3.0-8.2 mg l(-1), may be used for this population. The correlation between the results obtained with the Ramco TfR test and the Amgen Diagnostics Clinigen test was satisfactory (r=0.79). The Ramco TfR test produced higher values (Tf=0.40 (-0.45-1.25)+1.46 (1.16-1.75)* Clinigen). The number of samples that fell within the same concentration interval with both methods (low, normal or high in relation to the respective reference interval) was only 45% (27/60). The Ramco TfR test had fewer values falsely suggesting iron deficiency than the Clinigen test. Serum TfR methods need to be uniformly standardized.

Biphasic increase in serum inhibin B during puberty: a longitudinal study of healthy Finnish boys

We investigated the concentrations of serum inhibin B and the pro-alphaC-containing inhibins (pro-alphaC inhibin) and their relations to serum FSH levels in 38 healthy boys during their progression through puberty. Furthermore, we studied the effect of recombinant human FSH (rhFSH) on pro-alphaC inhibin production in three prepubertal gonadotropin-deficient boys. The serum inhibin B level increased between Tanner stages G1 and G2 (p < 0.02), simultaneously with the serum LH and testosterone concentrations. In advanced puberty, inhibin B changed less, and at stage G4, correlated negatively with serum FSH level (r = -0.57, p < 0.001, n = 37). The serum pro-alphaC inhibin level changed differently and increased also in advanced puberty. In prepubertal healthy subjects, the serum pro-alphaC inhibin and FSH levels correlated positively (r = 0.50, p = 0.051, n = 16), and during the rhFSH treatment of gonadotropin-deficient boys, serum pro-alphaC inhibin levels increased. These findings suggest that an increased production of inhibin B is an early event in puberty and that inhibin B can inhibit pituitary FSH secretion in the course of sexual maturation. Furthermore, they suggest that during puberty free inhibin (pro)-alpha-subunits, detected by the pro-alphaC inhibin assay, are present in large amounts and that FSH stimulates their production by prepubertal testes.

The apolipoprotein E phenotype has a strong influence on tracking of serum cholesterol and lipoprotein levels in children: a follow-up study from birth to the age of 11 years

The extent to which an individual maintains his position relative to the rest of the population is called tracking. The objective of this study was to examine the effect of the apolipoprotein E (apoE) phenotype on the tracking of serum cholesterol and lipoproteins from birth to the age of 11 y. In a longitudinal follow-up study of healthy children, concentrations of total serum cholesterol and triglyceride were determined at birth (n = 193), and at the ages of 2 (n = 192), 4 (n = 192), 6 (n = 190), 9 (n = 188), and 12 mo (n = 196), and 5 (n = 162) and 11 y (n = 153). Concentrations of total HDL, HDL2, and HDL3, VLDL, and LDL cholesterol were determined at 2, 6, 9, and 12 mo (n = 36), and 5 (n = 162) and 11 y (n = 153). The apoE phenotype was determined in 151 children. The children had the following apoE phenotypes: 4 had type 4/4 and 40 type 3/4 (group apoE4), 94 had type 3/3 (group apoE3), and 11 had type 2/3 and 2 type 2/4 (group apoE2). The correlation coefficients for total cholesterol levels during childhood compared with the level at 11 y of age were: 0.03 at birth, 0.26 (p < 0.001) at 2 mo, 0.24 (p < 0.001) at 4 mo, 0.24 (p < 0.001) at 6 mo, 0.28 (p < 0.001) at 9 mo, 0.41 (p < 0.001) at 12 mo, and 0.60 (p < 0.001) at 5 y. When the children were divided into three groups according to their apoE phenotypes, these three groups had the following correlation coefficients at 4 mo, 12 mo, or 5 y of age compared with the level at the age of 11 y; group apoE2: r = 0.65 (p < 0.01), r = 0.59 (p < 0.01), and r = 0.72 (p < 0.01); group apoE3: r = 0.27 (p < 0.01), 0.43 (p < 0.001), and r = 0.64 (p < 0.001); and group apoE4: r = 0.14 (p = NS), r = 0.33 (p < 0.05), and 0.42 (p < 0.01). The apoE phenotype also strongly influenced the tracking of the LDL cholesterol levels; the correlation coefficients between 5 and 11 y of age were for group apoE2 r = 0.84 (p < 0.001), for group apoE3 r = 0.70 (p < 0.001), and for group apoE4 r = 0.37 (p < 0.05). Our results indicate that the apoE phenotype strongly influences the tracking of lipids. The children having apoE 2/3, 2/4, and 3/3 phenotypes maintained their relative cholesterol and lipoprotein levels better than the others throughout the first 11 y of age. Because the apoE phenotype strongly affects the tracking of serum cholesterol, the usefulness of cholesterol screening in predicting future cholesterol values should be analyzed, keeping the apoE phenotype in mind.

Young female survivors of childhood leukaemia do not have increased somatic concerns

OBJECTIVE

This study examined whether experience of cancer in childhood leaves a hypersensitivity to various somatic symptoms. Further, are self-reported somatic symptoms explained by medical late-effects or a worry of recurrence of the cancer?

METHODS

Of the total of 44 female survivors of leukaemia, 42 were compared with 69 age-matched healthy controls. We used a questionnaire to study self reported somatic symptoms and a face-to-face interview to explore worries about recurrence of the illness. Health status and medical late effects were evaluated by a paediatric haematologist.

RESULTS

In contrast to our assumptions, young survivors of leukaemia reported fewer somatic symptoms than healthy age-matched comparison subjects (p < 0.001). Late physical sequelae were uncommon except in the survivors of allogeneic bone marrow transplantation. Of the survivors, 52% were afraid of recurrence of the illness. The presence of physical or visible impairment and worry of recurrence were unrelated to frequency of somatic symptoms.

CONCLUSIONS

The results suggest that experience of childhood leukaemia and its treatment does not result in increased somatic concerns or hypochondriacal tendencies.

Cholesterol and carotid artery wall in children and adolescents with familial hypercholesterolaemia: a controlled study by ultrasound

The carotid artery wall was studied with ultrasound in 23 children and adolescents with familial hypercholesterolaemia and in 23 age-matched healthy controls. The study revealed changes in the carotid artery wall related both to familial hypercholesterolaemia and to age. In the control subjects, the carotid artery wall became stiffer with age. In the patients with hypercholesterolaemia, no clear age-dependence was found, but wall stiffness correlated with total and low-density lipoprotein cholesterol. The intimal-medial wall thickness was associated with serum total cholesterol, low-density lipoprotein and triglyceride concentrations, and correlated inversely with the ratio of high-density lipoprotein to total cholesterol. Carotid artery wall properties seem to be associated with the degree of hypercholesterolaemia and the high-density lipoprotein-to-total cholesterol ratio even in children. In childhood and adolescence it is already possible, with ultrasound, to detect changes in the arterial wall related both to familial hypercholesterolaemia and to age.

Impaired androgen production in female adolescents and young adults after total body irradiation prior to BMT in childhood

Pubertal development and androgen production were evaluated 1-10 years after bone marrow transplantation (BMT) in 15 females aged 14-23 (mean 17) years. Before BMT, these patients had received combination chemotherapy for hematologic malignancy, and all had had a transplant program including total body irradiation (TBI). Of the nine patients who were pre-menarcheal at BMT, two had subsequently experienced spontaneous menarche at 11.5 and 13.3 years of age. Six were post-menarcheal, but became amenorrheic after BMT. Menstruation subsequently started spontaneously in one of them 6 years after BMT. At the time of the study, three patients were early to mid-pubertal and 12 late pubertal or post-pubertal. Twelve patients were receiving sex steroid substitution therapy. Serum concentrations of testosterone, androstenedione, dehydroepiandrosterone (DHEA) and DHEA sulfate (DHEAS) were determined. Androgen levels of late pubertal and post-pubertal transplanted patients were compared with 19 post-menarcheal patients aged 14-21 (mean 17) years who had been treated for hematologic malignancy with conventional chemotherapy. Testosterone levels of 52 healthy post-menarcheal females aged 14-29 (mean 19) years were measured as controls. Androgen levels of the BMT patients were lower than those of the conventionally treated patients. Differences in testosterone, androstenedione and DHEA levels were significant. Three spontaneously menstruating BMT patients had normal androgen levels. Testosterone levels of the conventionally treated patients and healthy controls were similar. Subnormal androgen production might be one factor behind the problems in pubertal development and sex life experienced by females after BMT. The use of these hormone levels for follow-up purposes and the potential value of androgen replacement therapy in females after TBI merit further study.

Serum markers of collagen metabolism and serum osteocalcin in relation to pubertal development in 57 boys at 14 years of age

We investigated whether levels of serum collagen markers and serum osteocalcin are related to pubertal growth and development in a cross-sectional study of 57 healthy boys at 14 y of age. The level of the soft tissue marker, serum amino-terminal propeptide of type III procollagen (PIIINP) was higher in boys at Tanner stages G3 versus G2 (p < 0.01). The levels of the markers of bone collagen matrix differed only at a more advanced pubertal stage: the formation markers, carboxy-terminal and amino-terminal propeptides of type I procollagen, and the degradation marker, carboxy-terminal telopeptide of type I collagen were higher only at stage G4 versus G3 (p < 0.01). The marker of bone mineralization, serum osteocalcin was also higher only at stage G4 versus G3 (p < 0.01). Stage G4 was associated with the pubertal growth spurt. The results demonstrate that pubertal development should be taken into account when serum levels of collagen markers and osteocalcin are evaluated, and suggest that an increase in serum PIINP in boys at G3 might predict a normal pubertal growth spurt, but the finding remains to be confirmed in longitudinal studies.

Iron status of children with short stature during accelerated growth due to growth hormone treatment

We determined the influence of human growth hormone (hGH) treatment on blood soluble transferrin receptor (sTfR) in 35 children with short stature. Whereas the serum concentration of ferritin decreased from 29.6 micrograms/l to 19.7 micrograms/l, and that of transferrin increased from 2.9 g/l to 3.2 g/l during 6 months (p < 0.001), only a minimum rise in the sTfR concentration was observed (7.12 +/- 0.20 mg/l vs 7.51 +/- 0.19 mg/l, p = 0.025). The prevalence of anaemia or microcytosis did not increase. Most of the changes in serum ferritin and transferrin concentrations occurred during the first week. The study demonstrates that rapid body growth per se does not affect the sTfR concentration, but it may affect the serum transferrin and ferritin concentrations. Alternatively, GH may have a specific effect on serum ferritin and transferrin concentrations.

Apoprotein E phenotype determines serum cholesterol in infants during both high-cholesterol breast feeding and low-cholesterol formula feeding

Our objective was to establish the role of the apoprotein (apo) E phenotype in determining serum cholesterol levels in infants fed exclusively on high-fat, high-cholesterol human milk and in those fed a low-cholesterol, high-unsaturated fat formula. The total and lipoprotein cholesterol, apoB, and triglyceride concentrations in serum were quantified and related to the apoE phenotype in 151 infants at birth and at 2, 6, 9, and 12 months of age. Forty-four had the E3/4 or 4/4 phenotype (E4 group), 94 had the E3/3 phenotype (E3 group), and 13 had the E2/3 or 2/4 phenotype (E2 group). In cord blood, cholesterol concentrations tended to be higher in the E4 than in the E2 group. With exclusive breast-feeding, the concentrations rose significantly faster and higher in the E4 group than in the E3 group or, especially, the E2 group. The values (mmol/L, mean +/- SEM) were 1.6 +/- 0.15, 1.5 +/- 0.05, 1.4 +/- 0.1 (P = n.s.) at birth; 4.2 +/- 0.1, 3.8 +/- 0.08, 3.4 +/- 0.2 (P < 0.001) at 2 months; 4.4 +/- 0.15, 3.9 +/- 0.1, 3.4 +/- 0.15 (P < 0.001) at 4 months; 4.3 +/- 0.17, 4.0 +/- 0.13, 3.7 +/- 0.26 (P < 0.001) at 6 months; 4.8 +/- 0.28, 4.4 +/- 0.11, 3.8 +/- 0.05 (P < 0.001) at 9 months; and 4.7 +/- 0.11, 4.4 +/- 0.08, 4.1 +/- 0.19 (P < 0.001) at 12 months, for the E4, E3, and E2 groups, respectively. Increases in LDL cholesterol and LDL apoB behaved similarly. The total triglyceride, and total HDL, HDL2, and HDL3 cholesterol concentrations did not depend on the apoE phenotype. Among infants fed high-fat, high-cholesterol human milk, the total and LDL-cholesterol concentrations and the LDL apoB concentration of those with the apoE phenotype 4/4 or 3/4 rose faster and to higher levels than in other infants. Among formula-fed infants, receiving a low-cholesterol, high-unsaturated fat diet, the differences between the apoE groups were smaller.

Sexuality of young women surviving leukaemia

This study was designed to assess the sexuality of young women surviving acute leukaemia in childhood or early adolescence. Thirty of 31 survivors were compared with 50 healthy age matched controls. Three methods were used: a self report questionnaire, a face to face interview conducted by a psychiatrist, and a projective psychological test. The age at initiation of dating and sexual activity, the frequency of sexual intercourse, and opinions on sexual behaviour were similar in the two groups. With regard to inner sexuality, however, the survivors differed significantly from the healthy controls. Their images of sexuality were more restrictive, and their attitudes, especially those concerning sexual pleasure, were more negative than those of the controls. Sexual identity among the survivors was less often feminine and more often infantile as compared with the controls. The findings obtained with the three methods of assessment were concordant.

Assessment of plasma fibronectin in malnourished Nigerian children

BACKGROUND

Severe malnutrition is associated with septic infections. The concentrations of fibronectin, albumin, and transferrin in plasma were measured in three groups of children with protein-energy malnutrition, aged 1-3 years, each group comprising 20 children. The aim of which was to test whether plasma fibronectin, being an opsonic protein, was reduced in such children, and if it was a useful index for assessing the severity of malnutrition.

METHODS

The concentrations of fibronectin, albumin, and transferrin in plasma were studied by enzyme immunoassay/ immunoblotting, spectrophotometry and immunoturbidimetry respectively.

RESULTS

All values were significantly lower in the patients with malnutrition than in the age- and sex-matched well-nourished Nigerian reference children. Within the malnourished group, the fibronectin value was evenly reduced in all subgroups. Albumin and transferrin values were lowest in the patients with kwashiorkor, highest in the marasmic patients, and intermediate in the patients with marasmic kwashiorkor; the values correlated mutually in individual cases as well, but not with the fibronectin levels. Neither plasma fibronectin fragmentation nor tissue fibronectin was detected in any patient with malnutrition or in the reference subjects.

CONCLUSIONS

The reduced plasma fibronectin values in these patients may be due to reduced synthesis by the liver, as evidenced by the equally reduced albumin and transferrin concentrations and/or to the multiple infections characteristic of the patients.

Collagen formation and degradation increase during growth hormone therapy in children

A comprehensive set of serum markers of collagen turnover and growth was investigated in a longitudinal study of short children during growth induced by growth hormone (hGH) treatment. The study comprised 18 prepubertal children with short stature who had no other current illness or continuous medication. The growth rates and endogenous GH secretions covered a continuum from subnormal to normal. Before treatment, the concentrations of carboxyterminal propeptide of type I procollagen (PICP), reflecting type I collagen formation, of carboxyterminal telopeptide of type I collagen (ICTP), a degradation product of type I collagen, of amino-terminal propeptide of type III procollagen (PIIINP), a marker for type III collagen formation, of alkaline phosphatase (AP), and of insulin-like growth factor binding protein-3 (IGFBP-3) were within the lower limits of normal. The median IGF-I concentration was lower than the reference. One week after the start of treatment, the serum concentrations of ICTP, PIIINP, and osteocalcin (OC), and the increments in ICTP, PIIINP, and IGF binding protein-3 (IGFBP-3) correlated with the subsequent height velocity. During the 12-month treatment, all markers were higher than those of age-matched references, but only the three collagen markers paralleled the changes in height velocity. In molar concentrations, ICTP increased less than PICP. Throughout the study period, the serum level of ICTP correlated with that of PIIINP, but not with that of PICP. The findings suggest that during hGH treatment, linear body growth is closely associated with collagen formation and degradation.

Very low rate of type I collagen synthesis and degradation in newly diagnosed children with acute lymphoblastic leukemia

In children with acute lymphoblastic leukemia (ALL), the metabolism of type I collagen, the major collagen of bones, may be changed at diagnosis and during early chemotherapy. In the present study, bone formation and degradation rates were evaluated longitudinally in 35 children with ALL, using two serum markers of bone collagen formation: the amino-terminal (PINP) and carboxyterminal (PICP) propeptides; and a marker of degradation: the carboxyterminal telopeptide of type I collagen (ICTP). These serum markers were determined at diagnosis, during induction treatment (at 1, 4, and 6 weeks), and during consolidation treatment (at 8 and 12 weeks). The changes in the serum markers suggested that, at diagnosis, type I collagen turnover (i.e., both synthesis and degradation) was remarkably low. The median serum levels of PINP, PICP, and ICTP were -2.6 SDS (standard deviation score), -1.5 SDS, and -2.5 SDS, respectively. The PICP and PINP levels declined further during the first week of therapy (p < 0.001), whereas the ICTP levels had risen by end of the induction phase (p < 0.05). By the end of the 12 week interval, the concentrations of the formation and degradation markers had returned to normal (p < 0.01). Our findings suggest that ALL is accompanied by low turnover of bone collagen. The abnormalities are at first aggravated, but then corrected, by treatment.

Childhood leukemia and body image: interview reveals impairment not found with a questionnaire

Twenty-eight adolescent leukemia survivors and 34 healthy controls were examined by means of a self-report questionnaire and a semi-structured face-to-face interview to appraise the quality of their body image. To protect against observer bias a blind-rater was used. The self-report inventory suggested that survivors have a perfectly normal body image, whereas in the interview 36% of the survivors were rated as having an impaired and 36% a diffuse, body image. The survivors' characteristic attitude towards their physical appearance--to evade the difficult issue--because evident when there were no ready answers from which to choose. Thus, in evaluating the impact of cancer on body image the choice of method of inquiry is vital.

Body iron stores decrease in boys during pubertal development: the transferrin receptor-ferritin ratio as an indicator of iron status

The transferrin receptor in serum provides a useful measure of tissue iron deficiency and the rate of erythropoiesis, whereas serum ferritin reflects the amount of storage iron in normal subjects. We studied the serum transferrin receptor and the transferrin receptor-ferritin ratio in 57 healthy prepubertal or early pubertal boys and followed them at 3-mo intervals for 24 mo to evaluate their iron status during puberty. The mean laboratory parameters changed as follows: Hb from 13.0 to 13.3 g/dL (p = 0.01), mean corpuscular volume from 85 to 84 fL (p = 0.0001), transferrin receptor from 6900 to 7200 micrograms/L (p = 0.03) ferritin from 36 to 23 micrograms/L (p = 0.0001), and transferrin receptor-ferritin ratio from 230 to 400 (p = 0.0001). At the start of the investigation, the serum transferrin receptor was elevated (> 9000 micrograms/l) or ferritin low (< = or 12 micrograms/L) in fewer than 2% of the boys. During the subsequent 2 y the proportion of boys with an elevated transferrin receptor or low ferritin value increased. The two parameters were simultaneously abnormal in none of the boys initially, but in about 3% of the boys 2 y later. The change in transferrin receptor-ferritin ratio was closely correlated with genital development. The proportion of elevated transferrin receptor-ferritin ratios increased 4.5-fold during the 2 y, indicating the high responsiveness of the ratio. At the end of the study, iron therapy was started to eliminate any iron deficiency. In response to the therapy, the mean transferrin receptor-ferritin ratio fell to 210 +/- 19, i.e. close to the level at the beginning of the study. The marked responses of the transferrin receptor and the receptor-ferritin ratio to iron therapy reflect the dependence of these parameters on iron status rather than on physiologic differences in the rate of erythropoiesis.

Body iron stores in relation to growth and pubertal maturation in healthy boys

During male puberty, erythropoiesis is exceptionally active. Pubertal development and iron status were followed in 60 healthy boys at 3-month intervals for 24 months to evaluate changes in body iron stores with the serum transferrin receptor-ferritin ratio. The estimated amount of stored iron declined by about 50% over a 2-year period. Remarkable changes in iron stores were found even after as short an interval as 3 months and pubertal development was closely linked with a decrease in stored iron. The annual increments of estimated red blood cell (RBC) iron showed strong positive correlations with velocities in testicular volume and certainly in body height and weight. In contrast, the estimated changes in individual iron stores were not associated with any of those parameters. The lacking associations between iron stores and growth parameters are probably indicative of increasing intestinal absorption. Despite the relatively small quantitative role of iron stores in supplying iron for growth, falling iron stores probably play a more important regulatory role by stimulating iron absorption.

Impaired body image of young female survivors of childhood leukemia

The purpose of this study was to assess the body image of young female survivors of leukemia. Young female survivors of leukemia (n = 42) were compared with healthy age-matched control subjects (n = 69). The study included a semistructured face-to-face interview and a psychological test. The data were separated into three distinct evaluations of each subject's body image: 1) the subject's self-assessment, 2) evaluation by a psychiatrist, and 3) the Rorschach test. The body images of the survivors were inferior to those of the control subjects in all three evaluations (P < 0.001). The preceding leukemia was assessed still as extremely threatening in 26% of the survivors.

Recurrent gains of 1q, 8 and 12 in the Ewing family of tumours by comparative genomic hybridization

Comparative genomic hybridization (CGH) was used to detect copy number changes of DNA sequences in the Ewing family of tumours (ET). We analysed 20 samples from 17 patients. Fifteen tumours (75%) showed copy number changes. Gains of DNA sequences were much more frequent than losses, the majority of the gains affecting whole chromosomes or whole chromosome arms. Recurrent findings included copy number increases for chromosomes 8 (seven out of 20 samples; 35%), 1q (five samples; 25%) and 12 (five samples; 25%). The minimal common regions of these gains were the whole chromosomes 8 and 12, and 1q21-22. High-level amplifications affected 8q13-24, 1q and 1q21-22, each once. Southern blot analysis of the specimen with high-level amplification at 1q21-22 showed an amplification of FLG and SPRR3, both mapped to this region. All cases with a gain of chromosome 12 simultaneously showed a gain of chromosome 8. Comparison of CGH findings with cytogenetic analysis of the same tumours and previous cytogenetic reports of ET showed, in general, concordant results. In conclusion, our findings confirm that secondary changes, which may have prognostic significance in ET, are trisomy 8, trisomy 12 and a gain of DNA sequences in 1q.

Quality of life in pre-adolescence: a 17-dimensional health-related measure (17D)

Although interest in the health-related quality of life (HRQOL) of children has increased in the last years, validated methods for assessing the HRQOL- and especially the perceived HRQOL-of children have been missing. We introduced a 17-dimensional, illustrated, generic measure of perceived HRQOL (17D) for pre-adolescents, and demonstrated its application to three populations of children aged 8-11 years: (1) 244 normal schoolchildren; (2) 22 patients surviving organ transplantation and (3) 10 patients with genetic skeletal dysplasias. The HRQOL scores and profiles of the patients differed significantly according to the diagnosis, giving support to its construct validity. The reliability of the measure was high: its repeatability coefficient was 95%. As a structured interview of 20-30 minutes, the measurement burden is reasonable. We conclude that the assessment of quality of life of pre-adolescents can and should be based on data collected from the children themselves. Our initial experience indicates that 17D is comprehensive, reliable, and valid.

Mechanism underlying early anaemia in children with familial juvenile nephronophthisis

Familial juvenile nephronophthisis (NPH) is a hereditary form of chronic tubulointerstitial nephritis with onset in childhood. About one-third of patients develop anaemia before renal insufficiency. We investigated the pathogenetic mechanisms leading to anaemia by comparing 6 patients with NPH and 12 reference patients with other renal diseases. We studied their iron metabolism and measured transferrin receptor-ferritin ratios. There was no evidence for iron deficiency or haemolysis. The serum erythropoietin concentrations of the patients with NPH (12 +/- 2.3 U/I) were low compared with the 12 reference patients (25 +/- 18.9 U/I). In the 2 patients with NPH who were fully investigated, the pharmacokinetics of recombinant human erythropoietin appeared normal. Thus, anaemia in patients with NPH does not result from iron deficiency or correlate with impaired iron status. The mechanism underlying the anaemia of NPH appears to affect the function or regulation of the cells producing erythropoietin.

Fibrinolysis, antithrombin III, and protein C in neonates during cardiac operations

Fibrinolysis and coagulation were studied in 10 neonates undergoing cardiac operations for congenital heart defects. Coagulation was activated during cardiopulmonary bypass as evidenced by highly increased prothrombin fragment 1 + 2 levels compared with preoperative values. Prothrombin fragment 1 + 2 levels remained elevated until postoperative day 3. Unlike coagulation, fibrinolysis was not activated during cardiopulmonary bypass but did show late activation on postoperative day 3, as evidenced by elevated levels of the fibrin degradation product D-dimer. Lack of fibrinolytic activation during bypass and its appearance on postoperative day 3 were partly explained by changes observed in tissue plasminogen activator and its inhibitor. During bypass, levels of tissue plasminogen activator and its inhibitor increased by 3.4-fold and 3.2-fold, respectively. In the postoperative period, levels of plasminogen activator inhibitor normalized rapidly whereas tissue plasminogen activator remained elevated, resulting in late fibrinolytic activation on postoperative day 3. In accordance with elevated prothrombin fragment 1 + 2, platelet count, antithrombin III, protein C, prothrombin, and factor VII were decreased on postoperative day 2, indicating ongoing consumptive coagulopathy. Nine patients had antithrombin III and six had protein C levels below age-specific normal ranges, consistent with an acquired deficiency state. Three had central venous thrombosis by postoperative day 4 or 5. In all three, thrombosis was preceded by antithrombin III deficiency, protein C deficiency, and highly elevated plasminogen activator inhibitor (3.7 to 37 times the mean of the other patients) on postoperative days 1 to 3. In conclusion, cardiopulmonary bypass in neonates caused rapid and profound alterations in the coagulation and fibrinolytic systems and initiated consumptive coagulopathy lasting until at least postoperative day 3. Thrombophilic abnormalities in antithrombin III, protein C, and fibrinolysis were frequently found and were associated with serious thrombotic complications.

The role of luteinizing hormone-beta gene polymorphism in the onset and progression of puberty in healthy boys

An immunologically anomalous LH with two point mutations in its beta-subunit gene (Trp8Arg and Ile15Thr) has recently been described. This polymorphism is common in Finland; 28% of the population are homo- or heterozygous for the variant allele. To assess the effect of the LH variant on LH action, we correlated its presence in a group of 49 healthy boys with the onset and progression of puberty. This group was followed-up longitudinally from a mean age of 11.7 +/- 0.1 yr for 3 yr at 3-month intervals. In addition, we studied the prevalence of the variant LH in boys with constitutional pubertal delay (testicular volume < or = 4 mL after 13.5 yr of age). The LH beta gene status of each subject in this study was judged from a single venous blood sample using two immunofluorometric LH assays with different combinations of monoclonal antibodies: one detecting both the variant and wild-type LH, and the other detecting only wild-type hormone. Of the boys with pubertal onset at a normal age, 36 (74%) were homozygous for the wild-type LH beta allele, 12 (24%) were heterozygous, and 1 (2%) was homozygous for the variant LH beta allele. Clear differences in pubertal parameters were found between the boys with normal and mutated (homo- or heterozygous) LH genotypes. During the follow-up, the boys with the mutated genotype had smaller testicular volumes (P < 0.03), were shorter (P < 0.02), had slower growth rates (P < 0.04), and had lower serum insulin-like growth factor I-binding protein-3 levels (P < 0.03) than the boys with the normal LH genotype. In the boys with delayed onset of puberty, the frequency of the variant LH beta allele did not differ from that in the reference population, indicating that the variant LH is not associated with conditions due to disturbed control of the reactivation of GnRH secretion. We conclude that during the progression of puberty, the variant LH may be less active in stimulating testicular growth than wild-type LH. Thus, the gene may affect tempo, contributing to the wide normal variation in pubertal progression in healthy boys. Our results also suggest that the variant LH not only affects the course of puberty, but is already involved in the regulation of the GH-insulin-like growth factor I axis during childhood.

Cerebrospinal fluid activity of tissue plasminogen activator in patients with neurological diseases

AIM

To study cerebrospinal fluid (CSF) activity of tissue plasminogen activator (tPA) in patients with neurological diseases.

METHODS

CSF tPA and urokinase (uPA) activities were studied using an immunocapture assay and zymography in 44 patients with neurological disease and 20 reference subjects. The patient group comprised three patients with meningitis, 21 with encephalitis, nine with acute lymphoblastic (n = 7) and myeloid (n = 2) leukaemia, seven with multiple sclerosis, three with facial paresis, and one with polyradiculitis.

RESULTS

Raised tPA activities were observed in patients with multiple sclerosis, leukaemia and encephalitis. In contrast, there were no differences in the mean activities of tPA in patients with meningitis or other diseases compared with the reference subjects. The highest tPA activities were found in patients with multiple sclerosis. The mean activity in patients with leukaemia was higher than in those with meningitis and polyradiculitis, but not encephalitis and facial paresis. Although the CSF tPA activity correlated positively with age in reference subjects, no correlation was observed in patients. Samples were qualitatively screened for both tPA and uPA activity by zymography and positive samples were quantitated. Some of the samples had quantifiable levels of uPA activity: three of seven multiple sclerosis samples, 10 of 21 samples from patients with encephalitis and five of nine leukaemic samples. The highest activities were recorded in patients with leukaemia. uPA was not detected in the CSF of the patients with meningitis, facial paresis or polyradiculitis.

CONCLUSIONS

Plasminogen activator activity can be measured reliably in CSF and the assessment of tPA activity may be useful for studying the pathogenesis of neurological diseases.

Health-related quality of life of adults surviving malignancies in childhood

While sophisticated data on specific problems are available, very little is known about the overall quality of life of long-term survivors of malignancies in childhood. We used a previously validated 15-dimensional questionnaire to examine the perceived health-related quality of life of 168 survivors, currently aged 16-35 years, who had been treated for a malignancy at a single institution between 1961 and 1993. All had been off therapy for at least 1 year (median, 12 years). In statistical terms, the quality of life score of the survivors was significantly better than that of 129 normal controls [0.966 versus 0.941 (theoretical maximum 1), respectively; P < 0.001]; however, a difference of this magnitude is most likely not clinically significant. There were no associations between original diagnosis and present quality of life, but the numbers in each diagnostic group were small. The survivors reported significantly better levels of vitality, distress, depression, discomfort, elimination and sleeping dimensions than the controls. Although we are presently not able to identify all the contributing factors, we speculate that the high perceived quality of life of long-term survivors of childhood malignancies is at least in part a consequence of denial mechanisms which compensate or even overcompensate the objectively measurable late effects of childhood cancer.

A population-based study of 272 children with acute myeloid leukaemia treated on two consecutive protocols with different intensity: best outcome in girls, infants, and children with Down's syndrome. Nordic Society of Paediatric Haematology and Oncology (NOPHO)

From July 1984 the five Nordic countries (Denmark, Finland, Iceland, Norway and Sweden) have registered all children with acute myeloid leukaemia (AML) and treated them on two consecutive protocols of different intensity (NOPHO-84 and NOPHO-88). We probably have information on every child with this diagnosis in our region. We found an annual incidence of AML of 0.7 new cases per 100,000 children < 16 years of age. We observed a distinct peak of incidence in the first 2 years of life. Children with Down's syndrome accounted for 13% of all cases. Eighty of 105 cases treated on NOPHO-84 achieved remission (78%). In NOPHO-88, 100/118 patients entered remission (85%). The overall event-free survival (p-EFS) for the two studies was 0.32 for NOPHO-84 and 0.42 for NOPHO-88. The majority of relapses occurred within 2 years of diagnosis. When looking for prognostic factors the strongest significant adverse factor found was male sex. Children with Down's syndrome (n = 35) had a very favourable outcome if they received therapy according to protocol, and infants (n = 26) had a superior outcome compared to children 1-2 years or > 10 years of age at diagnosis.

Risk of low vitamin B6 status in infants breast-fed exclusively beyond six months

Our aim was to ascertain the adequacy of human milk as the sole source of vitamin B6 and the associations between maternal and infant status during extended exclusive breast-feeding. Vitamin B6 status was followed in lactating mothers and their exclusively breast-fed infants by determinations of erythrocyte pyridoxal 5'-phosphate concentration and the erythrocyte aspartate transaminase stimulation test at 2 months (n = 118), 4 months (n = 118), 6 months (n = 112), 7.5 months (n = 70), 9 months (n = 36), 10 months (n = 14), 11 months (n = 11), and 12 months (n = 7) postpartum. Of the mothers, 54% had used vitamin B6 supplement during pregnancy, and all received a pyridoxine hydrochloride supplement of 1 mg/day throughout lactation. The infants had a higher vitamin B6 status than their mothers. During the first 4 months, infant vitamin B6 status was generally adequate independently of the actual vitamin status of the nursing mother. Most of the infants with low status at 2 months were those born to mothers who were not supplemented during pregnancy. By 6 months of exclusive breast-feeding, 30% of cases of low vitamin B6 status in nursing mothers were reflected in their infants. Thereafter, the risk of low vitamin B6 status in exclusively breast-fed infants increased even if the mother's status was adequate. Our findings suggest that gestationally accumulated stores are important for the maintenance of adequate vitamin B6 status of infants during the early months and that for some infants, human milk alone, without supplementary foods, may be insufficient to meet vitamin B6 needs after 6 months of age.

Development of iron status and response to iron medication in pubertal boys

During male puberty, rapid growth of body mass and the rise in hemoglobin concentration require much iron. The increasing need for iron may carry a risk of iron deficiency. Criteria for iron deficiency in adolescence are difficult to assess, as indicated by prevalences ranging from 0.5 to 30% in five recent studies from developed countries. We followed 60 prepubertal or early pubertal boys, testing them at 6-month intervals for 24 months and relating hemoglobin levels and other iron parameters to age, pubertal development, and response to iron medication. A significant increase in mean hemoglobin was first seen at genital stage G4. In early puberty, in contrast, between stages G1 and G3, ferritin decreased. Mean transferrin increased slightly during the study. The prevalence of iron deficiency increased both with age and with advancing puberty. However, the early decline in ferritin may be a physiologic response to guarantee increasing intestinal absorption. After iron medication, we observed improvements in the levels of our parameters of iron status, which showed that hemoglobin levels had been limited by iron deficiency. In pubertal boys, evaluation of iron deficiency should not be based on laboratory parameters alone; age, pubertal development, and growth should also be taken into account.

Quality of life in early adolescence: a sixteen-dimensional health-related measure (16D)

While data on the health-related quality of life (HRQOL) of adults are accumulating, very little is known about the HRQOL--and especially the perceived HRQOL--of children. In our study we introduced a 16-dimensional, generic self-assessment measure of HRQOL (16D) for early adolescents, and demonstrated its use with four populations of children aged 12-15: (1) 239 normal schoolchildren, (2) patients waiting for organ transplantation (n = 5), (3) patients with genetic skeletal dysplasias (n = 19), and (4) patients with epilepsy (n = 32). The HRQOL profiles of the patients differed significantly according to the diagnosis, giving support to its construct validity. The reliability of the measure was high: its repeatability coefficient was 91%. The quality of life ratings of the healthy boys and their parents differed on the dimensions of distress, vitality, speech, mental function, and discomfort and symptoms (p < 0.05). In addition, there were significant differences in the health-related valuations between the girls, boys and their parents. We conclude that the assessment of quality of life of adolescents should be based on data collected from the adolescents themselves. Further, the 16D is so far the only generic HRQOL measure designed specifically for this purpose. It is capable of differentiating the HRQOL of healthy adolescents as well as patients with various diagnoses. Our experience also indicates that it is easy to use, yet it seems comprehensive, reliable, and valid.