The effects of growth hormone deficiency and growth hormone replacement therapy on intellectual ability, personality and adjustment in children

Traditionally, it has been assumed that intellectual development in children with growth hormone deficiency (GHD) is distributed between ranges of a normal population based on the observation that it does not differ substantially from that of children of the same age. Nevertheless, few studies have investigated this assumption. This Spanish Collaborative study was prospectively planned with two main purposes: to study a possible influence of GHD on intelligence quotient (IQ), personality traits and adaptative capacity and to study the evolution of these parameters during substitution therapy with growth hormone (GH). Although the overall intellectual ability of children with GHD is comparable to that of a normal reference population, some areas such the motor-component scale (evaluated by McCarthy test) and performance IQ (evaluated by WISC-R) were below the mean at the beginning of the study, showing significant improvement during therapy. Emotional adjustment (normal at study start) also improved significantly during treatment. Females showed better adjustment capacity before and during GH therapy. Longer studies with an increased number of cases are needed to confirm these effects of GHD and its treatment in children.

[Low height and rare diseases]

Low stature is the main reason of consultation in paediatric endocrinology. In a high percentage of cases, its etiology is clear and fundamentally answers to variants of normality. However, in approximately 20% of cases low stature is pathological and requires exhaustive studies. The association of rare diseases (RD) with low height is very frequent. In this article we review the etiology of low height, describing: - The genetic forms of the growth hormone (GH), whether isolated or associated with malformations of the average line or others. - Those which are of great importance due to their clinical repercussion, such as Turner's Syndrome, Noonan's Syndrome and Willi-Prader's Syndrome. - The frequent osseous dysplasias, in some cases with genetic alterations of the SHOX gene, situated in the short arm of the Xp chromosome. The importance of these diagnoses lies in the possibility of carrying out early and efficient treatment, in some of them, with GH. In conclusion, the diagnosis of rare diseases with low height is a current and normal challenge in paediatric endocrinology due to the great advances in molecular genetics and the possibility of treatment in some of them. It always involves a multidisciplinary approach due to the frequent association of pathology it presents, and, in its turn, it offers the possibility of carrying out timely genetic counselling.

Gene-gene interaction between PPAR gamma 2 and ADR beta 3 increases obesity risk in children and adolescents

AIMS

Multiple genes are likely to be involved in obesity and these genes may interact with environmental factors to influence obesity risk. Our aim was to explore the synergistic contribution of the two polymorphisms: Pro12Ala of the PPAR gamma 2 gene and Trp64Arg of the ADR beta 3 gene to obesity risk in a Spanish children and adolescent population.

METHODS

We designed a sex- and age-matched case-control study. Participants were 185 obese and 185 control children (aged 5-18 y) from the Navarra region, recruited through Departments of Pediatrics (Hospital Virgen del Camino, Navarra University Clinic and several Primary Health Centers). The obesity criterion (case definition) was BMI above the 97th percentile according to Spanish BMI reference data for age and gender. Anthropometric parameters were measured by standard protocols. The genotype was assessed by PCR-RFLP after digestion with BstUI for PPAR gamma 2 mutation and BstNI for ADR beta 3 variants. Face-to-face interviews were conducted to assess the physical activity. Using a validated physical activity questionnaire, we computed an activity metabolic equivalent index (METs h/week), which represents the physical exercise during the week for each participant. Statistical analysis was performed by conditional logistic regression, taking into account the matching between cases and controls.

RESULTS

Carriers of the polymorphism Pro12Ala of the PPAR gamma 2 gene had a significantly higher obesity risk than noncarriers (odds ratio (OR)=2.18, 95% CI=1.09-4.36) when we adjusted for sex, age and physical activity. Moreover, the risk of obesity was higher (OR=2.59, 95% CI=1.17-5.34) when family history of obesity was also taken into account in the model. The OR for obesity linked to both polymorphisms (PPAR gamma 2 and ADR beta 3) was 5.30 (95% CI=1.08-25.97) when we adjusted for sex, age and physical activity. After adjustment for family history of obesity, the OR for carriers of both polymorphisms was 19.5 (95% CI=2.43-146.8).

CONCLUSIONS

A synergistic effect between polymorphism Pro12Ala of the PPAR gamma 2 gene and Trp64Arg of the ADR beta 3 gene for obesity risk was found in a case-control study including children and adolescents.

Gene conversion (655G splicing mutation) and the founder effect (Gln318Stop) contribute to the most frequent severe point mutations in congenital adrenal hyperplasia (21-hydroxylase deficiency) in the Spanish population

This study addresses the contributions of gene conversion and a founder effect to the distribution of the two most frequent severe point mutations of the 21-hydroxylase (21OH) gene causing congenital adrenal hyperplasia: the 655G splicing mutation at intron 2, and Gln318Stop in a Spanish population. Direct and indirect analyses of segregated mutant and normal 21OH genes in 200 Spanish families (classic and nonclassic 21OH deficiency) were performed. Both mechanisms were found to contribute to different degrees to the defective investigated alleles. The 655G splicing mutation (62 alleles, 15.5%) seemed to be almost exclusively related to recent conversion events, whereas Gln318Stop (33 alleles, 8.3%) is more likely to be due to the dissemination of remotely generated mutant alleles. Other severe defective alleles, 8 bp-deletion (13 alleles, 3.3%), 306insT (5 alleles, 1.3%), and gene deletions (43 alleles, 11%), as well as the mild mutation Val281Leu (120 alleles, 30%), also appear to be strongly associated with particular D6S273 alleles. Although gene conversion contributes to the generation of severe 21OH alleles, the high frequency of some severe mutations in different geographic areas is consistent with a founder effect.

A novel frameshift mutation in the first exon of the 21-OH gene found in homozygosity in an apparently nonconsanguineous family

Congenital adrenal hyperplasia is most frequently due to steroid 21-hydroxylase (21-OH) deficiency. Due to the existence of a pseudogene in tandem duplicated with the 21-OH gene, asymmetric recombination causes the majority of the molecular defects underlying this deficiency: gene conversions and deletions of the functional gene. Screening for a small array of mutations, those existing in the pseudogene together with deletions, allows the characterization of most mutated alleles, 91% in the Spanish population. We report the case of a boy from a nonconsanguineous family, diagnosed during the neonatal period of a salt-wasting form of the deficiency, in which this screening did not allow the characterization of the paternal or the maternal allele. This infrequent finding in a nonconsanguineous family was further investigated. Single-strand conformation polymorphism screening for new mutations revealed an abnormally migrating pattern when polymerase chain reaction fragments from 21-OH gene exon 1 of the patient and relatives were analyzed. Upon direct sequencing, the insertion of a T at position 64 (64insT, frameshift generating a stop codon at exon 2) was found in homozygosity in the patient. Microsatellite typing in the HLA region revealed the patient to be homozygous for five markers (heterozygosities 0.62 to 0.74). Apparently this new mutation was generated several generations ago and has been preserved for years. Consanguinity had been discarded for several generations, although both families could be traced back to a small rural area in Navarra (Spain).

[Child obesity in Navarra: evolution, tendency and relation between child and adult obesity. Pecna study]

INTRODUCTION

Excess of weight at an adult age is linked to an increased risk of dying. Obesity during childhood has been increasing in recent years in the developed countries. The aim of this study is to determine the prevalence of obesity in an infant-youth population of Navarra and its follow up over six years.

MATERIAL AND METHODS

Longitudinal study of a cohort formed by 1,164 children of both sexes of 4, 10 and 17 years of age at the start of the study, with data collection in 1987 and 1993. Obesity was calculated using the Index of Corporal Mass or Quetelet Index (QI) higher than percentile 90 for their age and sex.

RESULTS

The rate of response obtained was 63.3% (n=737). Between 1987 and 1993 there was an increase of 5% in the obese population (p<0.01). There is a significant correlation (r=0.72) between the values of the QI at the start of the study and those obtained at its conclusion. Some 61.4% of the individuals belonging to the higher quintile of the sample at the start of the study continued belonging to this quintile after six years of follow up.

CONCLUSIONS

There was an increase in obesity, in correspondence with the findings of similar studies. There is good "tracking" between obesity during childhood and its presence at an adult age. The strategies for prevention of obesity must start from infancy.

[Neonatal screening of congenital Hypothyroidism: result of the Navarra program]

The incidence of congenital Hypothyroidism is estimated at one case per 3,000-4,000 newly born. It is a proven fact that early diagnosis and treatment of this problem prevents mental retardation, which has led to the design and utilisation of methods of systematic detection in the newly born. The implantation of the screening program is relatively recent and progressive in some autonomous communities. With respect to the achievements that are being obtained by the program outstanding is the shorter time with respect to initiation of the treatment, but there still remain some shortcomings such as that of carrying out a longitudinal follow up of these infants, with respect to the evaluation of the development quotient, hence the need to have available hospital psychologists to carry out these evaluations. The expectations of achieving a mental development within normality in the children affected by congenital Hypothyroidism detected by the neonatal screening is a fact confirmed by many authors, for which reason it is highly encouraging to view the results of early detection of this neonatal screening.

[The costs for a health center in relation to its activities]

OBJECTIVE

To establish a system of attributing costs of Health Centres (HC) in the Primary Care network in function of health care activity.

DESIGN

Crossover study with a descriptive component.

SETTING

Management. Primary Care.

PATIENTS OR OTHER PARTICIPANTS

22 Health Centres open during December 1991 within the Health Area.

MEASUREMENTS AND MAIN RESULTS

Two groups for cost attribution per Health Centre were agreed: articles from Chapter II relating to health care activity and Pharmacy spending-->costs relating to activity (CRA); the remaining articles from Chapter II and Chapter I (staff payments)-->costs not relating to activity (CNRA). Costs relating to activity made up 62.51% of the total cost per HC (2.72% articles from Chapter II and 59.79% Pharmacy). The remaining 37.49% corresponded to costs not relating to activity (1.38% to the remaining articles from Chapter II and 36.11% to staff payments).

CONCLUSIONS

We consider that the attribution of costs in function of the activity per HC is useful for the planning and management of Area resources and assists the application of efficiency criteria in Health Centres.

[Precocious puberty associated with Von Recklinghausen's disease. Developmental follow-up under cyproterone acetate treatment]

Authors describe a case of a boy aged 8-10/12 years with precocious puberty associated with Von Recklinghausen's disease. He was treated with cyproterone acetate (100 mg/m2/24 h oral doses) and controlled for a period of two years. He shows very few effects of puberal physical signs and improvement of his sexual behavioral area. They have evaluated growth evolution by different parameters and couldn't appreciate any improvement because of the advanced bone age (13-6/12 years) when treatment was started.

[Leopard syndrom. Four observations (author's transl)]

Four cases of Leopard syndrom in a mother and in three children of hers are reported. The main clinical and electrocardiographic features characterizing the syndrome are exposed and analyzed in relation with phacomatosis and pathoetiologic mechanism.

[Neurological alterations due to metoclopramide in children (author's transl)]

Some clinicals and epidemiological considerations are made on the base of eleven children affected by ingestion on this drug.