Comparison of two different GnRH analogs' impact on final height in girls with early puberty: Triptorelin acetate vs. leuprolide acetate

Context

GnRHa treatment has been a standard of care in progressive early puberty (EP). Choice of the GnRHa formulation is dependent on the preference of the clinician.

Objective

To compare the effects of triptorelin acetate (TA) and leuprolide acetate (LA) on anthropometry in girls with EP.

Design

A descriptive observational study.

Subjects and Methods

Girls diagnosed with central EP and treated with GnRHa at least for one year were included; treated with TA (n=46) and LA (n=35). First year anthropometric response and final height were evaluated.

Results

The mean age at the initiation of GnRHa treatment of girls was 8.5±0.5 years. The ratio of obesity and of overweight was 7.4 and 25.9%, respectively. In both TA and LA groups, anthropometric data of the patients at initiation and at the first year of treatment were similar. Although growth velocity was similar in each group, in LA group height SDS at the first year of the treatment showed a significant decrease (p=0.045), but not in TA group (p=0.317). No significant ΔBMI was observed with treatment. The differences between FH - PAH at initiation (height gain) in TA and LA groups were 2.9±4.7 and 4.0±5.8 cm, respectively (p=.316). Height gain per treatment year was 1.7±3.0 cm.

Conclusions

There was a significant decrease in height SDS at the first year of leuprolid treatment, but not in triptorelin. Although these two analogs show similar effects on treatment, a not significant but slightly better benefit in leuprolide was observed.

Variants in Pharmacokinetic Transporters and Glycemic Response to Metformin: A Metgen Meta-Analysis

Therapeutic response to metformin, a first-line drug for type 2 diabetes (T2D), is highly variable, in part likely due to genetic factors. To date, metformin pharmacogenetic studies have mainly focused on the impact of variants in metformin transporter genes, with inconsistent results. To clarify the significance of these variants in glycemic response to metformin in T2D, we performed a large-scale meta-analysis across the cohorts of the Metformin Genetics Consortium (MetGen). Nine candidate polymorphisms in five transporter genes (organic cation transporter [OCT]1, OCT2, multidrug and toxin extrusion transporter [MATE]1, MATE2-K, and OCTN1) were analyzed in up to 7,968 individuals. None of the variants showed a significant effect on metformin response in the primary analysis, or in the exploratory secondary analyses, when patients were stratified according to possible confounding genotypes or prescribed a daily dose of metformin. Our results suggest that candidate transporter gene variants have little contribution to variability in glycemic response to metformin in T2D.

Organic cation transporter 1 variants and gastrointestinal side effects of metformin in patients with Type 2 diabetes

AIMS

Metformin is the most widely used oral anti-diabetes agent and has considerable benefits over other therapies, yet 20-30% of people develop gastrointestinal side effects, and 5% are unable to tolerate metformin due to the severity of these side effects. The mechanism for gastrointestinal side effects and their considerable inter-individual variability is unclear. We have recently shown the association between organic cation transporter 1 (OCT1) variants and severe intolerance to metformin in people with Type 2 diabetes. The aim of this study was to explore the association of OCT1 reduced-function polymorphisms with common metformin-induced gastrointestinal side effects in Type 2 diabetes.

METHODS

This prospective observational cohort study included 92 patients with newly diagnosed Type 2 diabetes, incident users of metformin. Patients were genotyped for two common loss-of-function variants in the OCT1 gene (SLC22A1): R61C (rs12208357) and M420del (rs72552763). The association of OCT1 reduced-function alleles with gastrointestinal side effects was analysed using logistic regression.

RESULTS

Forty-three patients (47%) experienced gastrointestinal adverse effects in the first 6 months of metformin treatment. Interestingly, the number of OCT1 reduced-function alleles was significantly associated with over two-fold higher odds of the common metformin-induced gastrointestinal side effects (odds ratio = 2.31, 95% confidence interval 1.07-5.01, P = 0.034).

CONCLUSIONS

In conclusion, we showed for the first time the association between OCT1 variants and common metformin-induced gastrointestinal side effects. These results confirm recent findings related to the role of OCT1 in severe metformin intolerance, and suggest that high inter-individual variability in mild/moderate and severe gastrointestinal intolerance share a common underlying mechanism. These data could contribute to more personalized and safer metformin treatment.

Congenital lymphoedema, bronchiectasis and seizure: case report

A 10-year-old girl with facial anomalies, mental retardation, peripheral lymphoedema, convulsions, cerebral cortical dysgenetic changes, bronchiectasis and chronic sinusitis is presented. She had features of both yellow nail syndrome and Hennekam syndrome. We think that our case might be a new congenital lymphoedema syndrome or an intermediate form between these syndromes.

Comparison of ultrasonographic and anthropometric methods to assess body fat in childhood obesity

BACKGROUND

Pattern of fat distribution rather than obesity is of importance for cardiovascular morbidity and mortality. The accurate measurement of total and regional fat mass requires sophisticated and often expensive methods that have limited applicability in the clinical setting.

OBJECTIVE

The aim of this study is to evaluate body fat distributions by ultrasound (US) as a gold standard method for measuring visceral, preperitoneal and subcutaneous fat layers and comparing with anthropometric results, and then to find the most reliable anthropometric measurement in childhood obesity.

MATERIALS AND METHODS

Study group of 51 obese children (21 F, 30 M) (mean age+/-s.d.: 11.5+/-2.6 years) and control group of 33 non-obese children (17 F, 16 M) (mean age+/-s.d.: 12.2+/-2.7 years) were recruited for this study. Anthropometric measurements as body mass index (BMI), waist circumference (WC), waist/hip ratio (WHR), triceps and subscapular skinfold thicknesses were taken from all the participants. Abdominal preperitoneal (P), subcutaneous (S) fat at their maximum (max) and minimum (min) thickness sites, visceral (V), triceps (TrUS) and subscapular (SsUS) fat thicknesses were also measured ultrasonographically.

RESULTS

In the obese group, BMI was significantly correlated with US measurements of fat thicknesses, except Pmin and SsUS, whereas in the control group, BMI was significantly correlated with all US fat measurements. The relation of US measurements with skinfold thickness and WC was more significant in the control than in the obese group. No relation between WHR and US fat thickness measurements was found in both groups. Multiple regression analysis, using V as the dependent variable and anthropometric parameters, gender and the group as the independent variables, revealed BMI was the best single predictor of V (R(2): 0.53).

CONCLUSION

This study suggests that the validity of the anthropometric skinfold thickness in the obese children is low. Despite the limitations reported in the literature, in our study, BMI provides the best estimate of body fat. WHR in children and adolescents is not a good index to show intra-abdominal fat deposition.

Analysis of insulin signalling by RNAi-based gene silencing

Using siRNA-mediated gene silencing in cultured adipocytes, we have dissected the insulin-signalling pathway leading to translocation of GLUT4 glucose transporters to the plasma membrane. RNAi (RNA interference)-based depletion of components in the putative TC10 pathway (CAP, CrkII and c-Cbl plus Cbl-b) or the phospholipase Cγ pathway failed to diminish insulin signalling to GLUT4. Within the phosphoinositide 3-kinase pathway, loss of the 5′-phosphatidylinositol 3,4,5-trisphosphate phosphatase SHIP2 was also without effect, whereas depletion of the 3′-phosphatase PTEN significantly enhanced insulin action. Downstream of phosphatidylinositol 3,4,5-trisphosphate and PDK1, silencing the genes encoding the protein kinases Akt1/PKBα, or CISK(SGK3) or protein kinases Cλ/ζ had little or no effect, but loss of Akt2/PKBβ significantly attenuated GLUT4 regulation by insulin. These results show that Akt2/PKBβ is the key downstream intermediate within the phosphoinositide 3-kinase pathway linked to insulin action on GLUT4 in cultured adipocytes, whereas PTEN is a potent negative regulator of this pathway.

Temporary multiple cranial nerve palsies in a patient with type 1 diabetes mellitus

Remittent isolated palsy of peripheral or of upper cranial nerves in diabetic patients is well documented, but paralysis of a lower cranial nerve or an isolated branch of any cranial nerve has rarely been reported. In the case described, besides temporary hypoglossal and facial nerve palsies previously, unilateral temporary vocal cord palsy caused by right inferior laryngeal nerve (recurrent) paralysis associated with type 1 diabetes mellitus is presented. Hoarseness and vocal cord palsy of the patient, as in the case of her first admission with other complaints due to other cranial nerve palsies, totally remitted, presumably both owing to improved metabolic control.

Persistent hyperinsulinaemic hypoglycaemia of infancy: case report

Hyperinsulinism, although rare, is the most common cause of persistent hyperinsulinaemic hypoglycaemia in infancy. Because of persistent hypoglycaemia, serious difficulties are encountered in the long term management of this condition. A male neonate, after an uncomplicated full-term pregnancy, had been admitted to another hospital with convulsions on the third post-natal day. Meningitis had been suspected at that time and treated with phenobarbital and he had been discharged from the hospital. At three-months old he was referred to our department for persistent convulsions and lethargy. His parents were of 1st degree consanguinity. His blood glucose level was found to be 24 mg/dl (1.33 mmol/L). Because of the dangerously high insulin level during hypoglycaemia (insulin/glucose > 0.3), the absence of ketonuria, and the need for a high dose of glucose infusion (> 15 mg/kg/min) to achieve normoglycaemia and a glycaemic response to glucagon despite the hypoglycaemia, a diagnosis of persistent hyperinsulinaemic hypoglycaemia of infancy was made. Since maximal doses of prednisone, glucagon, diazoxide, octreotide and high infusion of glucose were ineffective in achieving normoglycaemia, a subtotal (80%) pancreatectomy was done. Postoperatively intermittent hypoglycaemic episodes continued. These were controlled with low doses of octreotide. Histology revealed diffuse adenomatous hyperplasia (nesidoblastosis). The boy is now in the sixth post-operative month and developing normally.

Correlation between age, body size and thyroid volume in an endemic area

Ultrasound is a safe, non-invasive technique that provides a more precise and objective method of determining thyroid volume than inspection and palpation, particularly in areas of mild endemicity, and generally whenever goiters are small. Thyroid volume is also correlated with age, weight, height and body surface area (BSA) in non-iodine-deficient areas. Different authors prefer different parameters to assess thyroid gland volumes. In this study, thyroid volumes were determined using ultrasound in 605 school children aged 6-11 yr who had been living for at least 5 years in Antalya. The correlation between age, BSA, height, weight, BMI and thyroid volume was sought in this mild to moderate iodine-deficient area. Somatic development of our children was in the normal range. Thyroid volume was significantly correlated with age (r=0.41, p<0.001), height (r=0.33, p<0.001), weight (r=0.30, p<0.001), BSA (r=0.33, p<0.001), and BMI (r=0.13, p<0.001). The most significant correlation was found to be with age. The application of the International Council for Control of Iodine Deficiency Disorders (ICCIDD) and the World Health Organization (WHO) thyroid volume references to our subjects resulted in prevalence estimates of enlarged thyroid of 31% based on BSA and of 34% based on age. In conclusion, when thyroid volumes are to be compared with reference values, assessment of thyroid volumes based on age is the most reliable method, in the event of normal somatic development.

Thyroid hormone profile in children with goiter in an endemic goiter area

The thyroid hormone profile was investigated in goitrous schoolchildren aged 6-11 years living in Antalya, an area with mild/ moderate iodine deficiency. With few exceptions, the serum levels of T4 and TSH were in the normal range in children with different grades of goiter. Compensatory elevated T3 levels were detected in 24% of the subjects. Thyroid hormones did not differ significantly with respect to the urinary iodine (UI) level. No correlations were found between thyroid volume, UI excretion level and thyroid hormones. It was concluded that thyroid hormones, except compensatory T3 elevation in some subjects, were not affected significantly in a mild/moderate iodine deficient area.

Thyroid gland volume and urinary iodine excretion in children 6-11 years old in an endemic area

Goiter prevalence and urinary iodine excretion levels were assessed in 605 schoolchildren (301 males and 304 females), aged 6-11 years, living in the Antalya region, a well known endemic goiter area in Turkey. Goiter prevalence was evaluated by clinical examination and ultrasound of the thyroid gland. Urinary iodine levels were expressed as microg/g creatinine. Goiter by inspection and palpation was found in 35% (n = 212) of all subjects, in 37.5% (n = 114) of girls and 32.5% (n = 98) of boys. Iodine deficiency of moderate degree was detected from the point of goiter prevalence. With regard to the upper limits of reference thyroid volumes reported by WHO and ICCIDD, goiter by ultrasonography was found in 34% (n = 206) of all subjects, in 36.8% (n = 112) of girls and 31% (n = 94) of boys. Median iodine/creatinine ratios of all subjects, and goitrous and non-goitrous subjects, were 64.1+/-20.1, 62.8+/-21.8 and 64.9+/-19.1 microg/g, respectively. Urinary iodine excretion levels revealed mild iodine deficiency in the region. No significant correlation was observed between urinary iodine excretion levels and thyroid volumes (r = 0.12, p>0.05). Iodine deficiency of mild to moderate degree in schoolchildren aged 6-11 years was detected in Antalya. It was concluded that urgent measures must be undertaken to eradicate iodine deficiency in the region.

Summer camps for diabetic children: an experience in Antalya, Turkey

To evaluate the effectiveness of diabetic summer camps with objective parameters, we examined the data relative to summer camps organized by our department in Antalya in the last two years. The duration of the camps was 10 days. Twenty-eight diabetic children with an average age of 13.6 +/- 2.9 years (range 8-20) participated in the first camp, fourteen of whom participated in both camps. The medical personnel consisted of three pediatric endocrinologists, one psychologist, two diabetes nurses and two dietitians. Despite a mean 10% reduction in insulin dosage and 10% increment in daily calorie intake at the beginning of the camp, hypoglycemia was common (mean, 2.4 hypoglycemic episodes per subject). Ketoacidosis was not encountered in any of the subjects during and after camps. An increment in weight in children whose weights, with respect to heights, were under the ideal weight and a decrement in weight of overweight children were observed at the end of the first camp. A significant improvement in knowledge and self-management of the disease was noted at the end of the camps. Improvement in nutrition and diabetic knowledge level of the children who participated in these consecutive camps was more obvious in the second compared with that in the first camp. No significant change in HbA1c level was observed at follow-up. In conclusion, summer camps are an invaluable way for diabetic children to gain skills in managing their disease.

Renal functional reserve in insulin dependent diabetic children

BACKGROUND

Microalbuminuria has been shown to be predictive for clinical diabetic nephropathy. Renal functional reserve (RFR), as a response to protein loading in a short period of time, is a parameter to assess the ability of kidneys to increase the glomerular filtration rate (GFR). The aim of this study was to predict the early phase of diabetic nephropathy by measuring urinary albumin level and RFR capacity in patients with insulin-dependent diabetes mellitus (IDDM).

METHODS

Twenty-two patients with IDDM were studied: 11 with a disease duration of less than 5 years (group 1) and 11 with a disease duration of more than 5 years (group 2). As the control group, 15 healthy children (group 3) were included in the study. At the beginning of the study, glucose was measured and the urinary albumin/creatinine ratio was calculated. Average glycosylated hemoglobin (HbA1c) over 1 year was determined. After protein loading (red meat containing 2 g/kg of protein), the creatinine clearance was calculated at each hour for a duration of 4 h. The RFR was accepted as the peak percentage increase in GFR over the baseline value.

RESULTS

Although metabolic control in group 2 was better, the RFR in group 2 was significantly lower than in group 1 (P < 0.05). Urinary microalbumin levels between the groups did not differ (P > 0.05). In two patients in whom microalbuminuria was detected, the RFR was much lower.

CONCLUSIONS

Detecting lower RFR levels in patients with normal urinary albumin excretion, as well as in patients with microalbuminuria, may support the idea that the RFR capacity is more sensitive than microalbuminuria in assessing the early phase of diabetic nephropathy.