Community Attitudes and Practices of Urban Residents Regarding Predation by Pet Cats on Wildlife: An International Comparison

International differences in practices and attitudes regarding pet cats' interactions with wildlife were assessed by surveying citizens from at least two cities in Australia, New Zealand, the UK, the USA, China and Japan. Predictions tested were: (i) cat owners would agree less than non-cat owners that cats might threaten wildlife, (ii) cat owners value wildlife less than non-cat owners, (iii) cat owners are less accepting of cat legislation/restrictions than non-owners, and (iv) respondents from regions with high endemic biodiversity (Australia, New Zealand, China and the USA state of Hawaii) would be most concerned about pet cats threatening wildlife. Everywhere non-owners were more likely than owners to agree that pet cats killing wildlife were a problem in cities, towns and rural areas. Agreement amongst non-owners was highest in Australia (95%) and New Zealand (78%) and lowest in the UK (38%). Irrespective of ownership, over 85% of respondents from all countries except China (65%) valued wildlife in cities, towns and rural areas. Non-owners advocated cat legislation more strongly than owners except in Japan. Australian non-owners were the most supportive (88%), followed by Chinese non-owners (80%) and Japanese owners (79.5%). The UK was least supportive (non-owners 43%, owners 25%). Many Australian (62%), New Zealand (51%) and Chinese owners (42%) agreed that pet cats killing wildlife in cities, towns and rural areas was a problem, while Hawaiian owners were similar to the mainland USA (20%). Thus high endemic biodiversity might contribute to attitudes in some, but not all, countries. Husbandry practices varied internationally, with predation highest where fewer cats were confined. Although the risk of wildlife population declines caused by pet cats justifies precautionary action, campaigns based on wildlife protection are unlikely to succeed outside Australia or New Zealand. Restrictions on roaming protect wildlife and benefit cat welfare, so welfare is a better rationale.

Likelihood of persistent GH deficiency into late adolescence: relationship to the presence of an ectopic or normally sited posterior pituitary gland

OBJECTIVES

The presence of an ectopic posterior pituitary gland (EPP) in childhood is associated with isolated GH deficiency (IGHD) and multiple pituitary hormone deficiency. GHD in late adolescence has been defined as a peak GH level <5 microg/l. The aim of this study was to identify the likelihood of persistent GHD in late adolescence in patients with an EPP compared with those with a normally sited posterior pituitary (NPP).

METHODS

In 18 patients with an EPP and 15 patients with an NPP, clinical, biochemical and radiographic data were collected.

RESULTS

In the EPP vs. the NPP group, the change in peak GH levels at the end of growth was less (+0.4[95% confidence interval (CI) - 0.8 to 2.7] vs. +4.1[95%CI + 0.4 to +10.5] microg/l, P-value for ancova = 0.03, after adjustment for age and sex). Using a peak GH level of <5 microg/l as a cut-off for GHD, 66% of EPP subjects compared with 40% of NPP subjects had GHD (P = 0.3). Hundred per cent of EPP subjects had a peak GH level on retesting <10 microg/l, compared with 40% of NPP subjects (P < 0.001).

CONCLUSION

It is important to document GH status at the end of growth, even if there is a structural abnormality of the hypothalamic-pituitary axis. The presence of an EPP compared to an NPP increases the likelihood of persistent GHD by 26%. As all EPP patients had a peak GH level of <10 microg/l, the cut-off for persistent GHD in late adolescence may need to be revised.

Associations with multiple pituitary hormone deficiency in patients with an ectopic posterior pituitary gland

INTRODUCTION

The presence of an ectopic posterior pituitary gland (EPP) on magnetic resonance imaging (MRI) is associated with hypopituitarism with one or more hormone deficiencies. We aimed to identify risk factors for having multiple pituitary hormone deficiency (MPHD) compared to isolated growth hormone deficiency (IGHD) in patients with an EPP.

METHODS

In 67 patients (45 male) with an EPP on MRI, the site (hypothalamic vs. stalk) and surface area (SA) [ x (maximum diameter/2) x (maximum height/2), mm(2)] of the EPP were recorded and compared in patients with IGHD and MPHD in relation to clinical characteristics.

RESULTS

In MPHD (n = 32) compared to IGHD (n = 35) patients: age of presentation was younger (1.4 [0.1-10.7]vs. 4.0 [0.1-11.3] years, P = 0.005), major incidents during pregnancy were increased (47%vs. 20%, P = 0.02) as were admissions to a neonatal intensive care unit (NICU) (60%vs. 26%, P = 0.04), whilst EPP SA was lower (12.3 [2.4-34.6]vs. 25.7 [6.9-48.2] mm(2), P < 0.001). In patients with a hypothalamic (n = 56) compared to a stalk sited EPP (n = 11): prevalence of MPHD was greater (55%vs. 9%,P = 0.05) and EPP surface area was smaller (17.3 [2.4-48.2]vs. 25.3 [11.8-38.5] mm(2), P < 0.001). In regression analysis, after adjusting for age, presence of MPHD was associated with: major incidents during pregnancy (RR 6.8 [95%CI 1.2-37.7]), hypothalamic EPP site (RR 10.9 [1.0-123.9]) and small EPP SA (RR 2.5 [1.0-5.0] for tertiles of SA).

CONCLUSION

In patients with an EPP, adverse antenatal events, size (small) and position (hypothalamic) of the posterior pituitary gland on MRI were associated with MPHD. These findings suggest that adverse factors during pregnancy may be important for the development of an EPP.

Skewed X inactivation is associated with phenotype in a female with adrenal hypoplasia congenita

Adrenal hypoplasia congenita (AHC) can occur due to deletions or mutations in the DAX 1 (NR0B1) gene on the X chromosome (OMIM 300200). This form of AHC is therefore predominantly seen in boys. Deletion of the DAX 1 gene can also be part of a larger contiguous deletion including the centromeric dystrophin and glycerol kinase (GK) genes. We report a girl with a de novo deletion at Xp21.2 on the maternal chromosome, including DAX1, the GK gene and 3′ end of the dystrophin gene, who presented with salt losing adrenal insufficiency and moderate developmental delay, but relatively mild features of muscular dystrophy. Investigation using the androgen receptor as a marker gene identified skewed inactivation of the X chromosome. In the patient’s leucocytes, the paternal X chromosome was completely inactive, but in muscle 20% of the active chromosomes were of paternal origin. Thus skewed X inactivation (deletion on the active maternal X chromosome with an inactive paternal X chromosome) is associated with AHC in a female. Variability in X inactivation between tissues may account for the pronounced salt loss and adrenal insufficiency but mild muscular dystrophy.

Novel mutations in LHX3 are associated with hypopituitarism and sensorineural hearing loss

Homozygous loss-of-function mutations in the transcription factor LHX3 have been associated with hypopituitarism with structural anterior pituitary defects and cervical abnormalities with or without restricted neck rotation. We report two novel recessive mutations in LHX3 in four patients from two unrelated pedigrees. Clinical evaluation revealed that all four patients exhibit varying degrees of bilateral sensorineural hearing loss, which has not been previously reported in association with LHX3 mutations, in addition to hypopituitarism including adrenocorticotropic hormone deficiency and an unusual skin and skeletal phenotype in one family. Furthermore, re-evaluation of three patients previously described with LHX3 mutations showed they also exhibit varying degrees of bilateral sensorineural hearing loss. We have investigated a possible role for LHX3 in inner ear development in humans using in situ hybridization of human embryonic and fetal tissue. LHX3 is expressed in defined regions of the sensory epithelium of the developing inner ear in a pattern overlapping that of SOX2, which precedes the onset of LHX3 expression and is known to be required for inner ear and pituitary development in both mice and humans. Moreover, we show that SOX2 is capable of binding to and activating transcription of the LHX3 proximal promoter in vitro. This study therefore extends the phenotypic spectrum associated with LHX3 mutations to encompass variable sensorineural hearing loss and suggests a possible interaction between LHX3 and SOX2 likely to be important for development of both the inner ear and the anterior pituitary in human embryonic development.

The Relationship between Nocturnal Urinary Leptin and Gonadotrophins as Children Progress towards Puberty

BACKGROUND/AIMS

Leptin is necessary for normal human pubertal development but its exact role in the period leading up to the onset of puberty has not been defined. This study has assessed the relationship between leptin and gonadotrophin secretion over time as children progress into puberty.

SUBJECTS AND METHODS

Twenty children (13 boys and 7 girls) judged to be close to the initiation of puberty were recruited. Three consecutive first morning urine samples were collected from each subject each month over 6 months. At the end of the study, the children were classified into those who remained physically prepubertal (n = 7) and those that had advanced in puberty (n = 13). Leptin and gonadotrophins were measured by immunoradiometric and immunofluorometric assay, respectively.

RESULTS

Total urinary leptin excreted over 6 months was higher in girls than in boys, both prepubertally and in early puberty, and in both sexes, was higher in those advancing into puberty than in those remaining prepubertal (girls 8.0 vs. 3.4 ng/l and boys 3.6 vs. 1.7 ng/l; both p < 0.05). In the whole group, when controlling for gender, there was a significant correlation between both leptin and luteinizing hormone (LH; r = 0.43, p < 0.001) and leptin and follicle-stimulating hormone (FSH; r = 0.32, p = 0.001). The possibility of a lead relationship was explored by pairing leptin values with the gonadotrophin values in the following month. Leptin was significantly correlated with FSH but not LH in both pre- and peripubertal children (prepubertal r = 0.45, p = 0.01; peripubertal r = 0.32, p = 0.01).

CONCLUSIONS

This study has shown that in children approaching and progressing into puberty, leptin is associated with LH and FSH over the same time frame, and with FSH when leptin is acting as the lead hormone. These data imply that leptin is an important facilitator of the early phases of human puberty.

Efficacy of a Monthly Compared to 3-Monthly Depot GnRH Analogue (Goserelin) in the Treatment of Children with Central Precocious Puberty

AIMS

To compare the efficacy of goserelin 10.8 mg (Zoladex LA-ZLA) administered 9-12 weekly with 3.6 mg (Zoladex-Z) given monthly in suppressing pubertal development, and effect on body mass index (BMI).

METHODS

Children with central precocious puberty (CPP) treated with Z (n = 34) or ZLA (n = 28) were studied retrospectively. Pubertal scores and BMI SDS during 24 months' treatment were compared.

RESULTS

To attain adequate pubertal suppression, more patients on ZLA than Z required increase in injection frequency (p = 0.02) and this was so for 7/8 patients with a structural aetiology for CPP on ZLA and 2/8 on Z. A greater proportion of patients on ZLA had BMI >+2 SDS before (p = 0.05), and at 18 and 24 months (p = 0.02 and 0.04). BMI SDS transiently increased during the first 6 months on ZLA (p = 0.04).

CONCLUSION

Both Z and ZLA were effective in suppressing puberty. To achieve adequate suppression, increased injection frequency was more likely with ZLA than Z, and particularly in patients with structural defects. Children with CPP had an elevated BMI at the onset of therapy and ZLA had a transient positive influence on BMI.

Diabetes mellitus following paediatric renal transplantation: a single centre experience

BACKGROUND/AIMS

Post-transplant diabetes mellitus (PTDM) has a variably reported incidence of 4-41% among adults and children. We describe our recent experience of four children with PTDM in a paediatric renal transplantation centre.

METHODS

We undertook a retrospective analysis of the glycaemic status of all paediatric patients undergoing renal transplantation at our centre in the 2-year study period. The clinical features and investigations of those who developed PTDM were further reviewed.

RESULTS

Five episodes of PTDM occurred in 4/32 children. There was a variable onset and a wide range of symptoms. Investigations revealed a combination of insulinopenia with peripheral insulin resistance. Insulin therapy was required for variable durations with resolution of PTDM in four episodes. PTDM did not adversely affect the renal graft function.

CONCLUSION

PTDM requires increased awareness among paediatric nephrologists and endocrinologists for early recognition and prompt effective intervention.

Phenotypic variation in constitutional delay of growth and puberty: relationship to specific leptin and leptin receptor gene polymorphisms

OBJECTIVES

Constitutional delay of growth and puberty (CDGP) is a variant of normal pubertal timing and progress, often with dominant inheritance. It is likely that one or more genes will be associated with CDGP. Possible candidates are the leptin (L) and the leptin receptor (LR) genes, as the leptin axis links nutritional status to pubertal development. This study has assessed whether a) L or LR gene polymorphisms were associated with CDGP and b) the CDGP phenotype was influenced by these polymorphisms.

DESIGN

Case-control and transmission disequilibrium tests were used to test genetic association of L and LR polymorphisms with CDGP.

METHODS

We genotyped L (3'CTTT repeat) and LR polymorphisms (Gln > Arg substitution, exon 6) in 81 CDGP children and 94 controls in the UK and 88 CDGP children from the US and assessed the effect of genotype on their anthropometric characteristics.

RESULTS

There was no association of these L or LR gene polymorphisms with CDGP. There was no difference in height or bone age delay within L or LR genotypes. However, UK CDGP children homozygous for the L short allele were heavier than heterozygotes and long allele homozygotes, with a similar trend in the US cohort. UK CDGP children with severe pubertal delay, who were thin, had significantly greater bone age delay and an increased frequency of parental pubertal delay than other groups and were less likely to be L short allele homozygotes.

CONCLUSIONS

There was no association of specific L or LR polymorphisms with CDGP, but L short allele carriage influenced the phenotype within CDGP.

Diagnostic accuracy of fracture detection in suspected non-accidental injury: the effect of edge enhancement and digital display on observer performance

AIM

To compare the effect of varying degrees of edge enhancement and method of digital image display on fracture detection in suspected non-accidental injury (NAI).

MATERIALS AND METHODS

Fifty radiographs from post-mortem skeletal surveys in 13 children with suspected NAI were selected. Images were obtained using a Fuji 5000R computed radiography system. Hard copies were printed with edge enhancement factors 0, 0.5 and 1.2. Images (edge enhancement 0.5) were also displayed on a 1K(2) monitor. Six observers independently evaluated all 200 images for the presence of abnormality. Observers also scored each image for visualization of soft tissues, visualization of trabecular markings and overall image quality. The paired Student's t-test and location receiver operating curve (ROC) analysis were used to compare quality scores and diagnostic accuracy of each display method. Individual and pooled true-positive rates (sensitivity) were determined. For the purposes of ROC analysis, histology was taken as the gold standard.

RESULTS

There was no difference in duration of hard and soft-copy reading sessions (p=0.76). After image manipulation soft-copy radiographs scored significantly better for image quality than hard copy (p<0.0001). Pooled observer sensitivity (at a specificity of 90%) was below 50% for all display methods. Diagnostic accuracy varied significantly between observers. Diagnostic accuracy of individual observers was not affected by display method.

CONCLUSION

In suspected NAI, diagnostic accuracy of fracture detection is generally low. Diagnostic accuracy appears to be affected more by observer-related factors than by the method of digital image display.

Optimal exposure parameters for digital radiography of the infant skull: A pilot study

AIM

To determine optimal exposure parameters when performing digital skull radiographs in infants with suspected non-accidental injury (NAI).

METHOD

Anteroposterior and lateral post-mortem skull radiographs of six consecutive infants with suspected NAI were made at six exposure levels for each projection. Entrance surface doses ranged from 75-351 microGy. Exposures were made with a Fuji 5000R computed radiography system onto a standard resolution imaging plate. In three patients exposures were repeated using a high-resolution imaging plate. Hard copy images with an edge-enhancement factor of 0.5 were produced. Six observers assessed and scored the radiographs from 1=poor to 5=excellent for visualization of five criteria. The criteria scored included outer table of skull vault, inner table of skull vault, suture margins, vascular markings and soft tissues of the scalp. Radiographs were then ranked in order of overall image quality. Film density and sensitivity values were recorded. Local research committee approval was obtained.

RESULTS

Current parameters give an average entrance surface dose of 253 microGy and 246 microGy for anteroposterior and lateral radiographs, respectively. The study demonstrated no perceived improvement in image quality above an entrance surface dose of 200 microGy (80% of current dose) or by the use of a high-resolution imaging plate.

CONCLUSION

The potential exists to reduce radiation exposure in infants. A study has commenced to determine the effects of dose reduction on diagnostic accuracy in suspected NAI.

Increased first-trimester fetal nuchal translucency thickness in association with chondroectodermal dysplasia (Ellis-Van Creveld syndrome)

Increased nuchal translucency thickness (NT) is an established sonographic marker of fetal chromosomal abnormality. Several structural fetal defects and genetic syndromes including a range of skeletal dysplasias have been reported in association with increased NT. We report the first case of fetal Ellis-Van Creveld syndrome presenting as raised fetal NT at 13 weeks' gestation. Ultrasonography at 18 weeks' gestation demonstrated a narrow thorax, marked shortening of the long bones with bowed femora and hexadactyly of hands and feet. Pregnancy was terminated at 23 weeks' gestation. The postmortem radiological examination revealed short and bowed long bones with rounded metaphyses, postaxial polydactyly of hands and feet, short ribs and narrow thorax. The acetabular roofs were horizontal with medial and lateral spurs. This case adds a further type of severe skeletal dysplasia to the list of genetic syndromes which may present as increased fetal NT in the late first trimester.

Insulin-Like Growth Factor I Levels in Healthy Children

Measurement of insulin-like growth factor I (IGF-I) levels is used during the assessment of a child for the presence of growth hormone (GH) deficiency and to monitor the efficacy of GH replacement therapy. In either case, robust normative data are required to allow IGF-I values to be expressed as standard deviation scores, enabling comparison between individuals and assessment of change over time. However, IGF-I levels in healthy children are affected by a number of parameters, including age, gender, pubertal status, height, nutrient intake, body composition, intercurrent illness and ethnicity, and the generation of such data requires the collection of samples from significant numbers of healthy children. As external quality assurance schemes for IGF-I and an international standard based on authentic recombinant IGF-I are not widely used, it is imperative for the clinician to understand the performance characteristics and limitations of the IGF-I assay used and to be aware of the source and quality of control data. It must also be recognized that IGF-I measurement is only one component of the diagnostic process and has its limitations, as tissue sensitivity to circulating serum IGF-I levels will differ between individuals.

Female preponderance in congenital adrenal hyperplasia due to CYP21 deficiency in England: implications for neonatal screening

Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase (CYP21) deficiency causes symptoms ranging from life-threatening neonatal adrenal crises to minimal virilization in adulthood. The relationship between CYP21 genotype and phenotypic markers in a non-screened population of 73 CAH children (44 female, 29 male; 54 white, 19 Asian) treated at the Royal Manchester Children's Hospital was investigated and ethnic and sex differences assessed. The patients were categorized according to the mutation on the mildest allele. The age at the time of diagnosis differed significantly between the groups (p = 0.02): all 25 Null and 25 of 26 of the I2 splice patients were diagnosed during the neonatal period, whereas 7 of 11 I172N patients were diagnosed late. Degree of female genital virilization, 17-hydroxyprogesterone level at diagnosis, and fludrocortisone requirement during the 1st year of treatment correlated with the genotype, although Asian Null patients required more fludrocortisone than their white counterparts (p = 0.055). There was an equal sex ratio in both the I2 splice (12 female/14 male) and I172N (5 female/6 male) groups. However, in the Null group, the ratio was 4.0 (20 female/5 male; p = 0.003), suggesting that some Null male infants perish before being clinically detected to have CYP21 deficiency. Our findings strongly support the need for implementation of a neonatal screening programme for CAH in the UK which may reduce the male infant mortality.

Forearm blood glucose testing in diabetes mellitus

AIMS

To compare the accuracy and acceptability of capillary blood glucose testing from the forearm with finger prick testing in diabetic children.

METHODS

Blood glucose measurements from samples taken from the forearm and the finger were compared in an outpatient setting from 52 children and adolescents with diabetes mellitus aged 6-17 years. Opinions on forearm sampling were collected by questionnaire.

RESULTS

Blood glucose results obtained from forearm sampling correlated well with results from the finger measured by the Yellow Springs Instrument analyser. Error grid analysis showed that 100% of measurements were clinically acceptable; 61% of children reported that forearm testing was painless and 19% that it was less painful than finger prick testing.

CONCLUSION

Forearm testing is an acceptable alternative to finger prick testing for blood glucose measurement in children and adolescents.

Pseudarthrosis presenting as a late complication of meningococcal septicaemia and disseminated intravascular coagulation

Late skeletal complications of meningococcal septicaemia and disseminated intravascular coagulation are well recognised in children and are largely centred on the growing epimetaphyseal region of long bones. In this article we describe a case of pseudarthrosis of the mid-ulna presenting 18 months following a devastating episode of meningococcal septicaemia in a 3-year-old boy. Radiographs and MRI demonstrated the ulna abnormality. We briefly review the late skeletal complications of the disease and other causes of pseudarthrosis.

Variability in anterior pituitary size within members of a family with GH deficiency due to a new splice mutation in the GHRH receptor gene

OBJECTIVE

Mutations in the GHRH receptor (GHRHR) gene (GHRHR) cause autosomal recessive isolated GH deficiency (IGHD), and are usually associated with anterior pituitary hypoplasia (APH) (defined as pituitary height more than 2 SDS below normal). We searched for GHRHR mutations and studied pituitary morphology in three prepubertal sibs with severe IGHD, who were born from consanguineous parents.

DESIGN

We sequenced the 13 exons and the intron-exon boundaries of the GHRHR of the index patient. After identifying a novel mutation, we sequenced the same area in the other family members. In addition, we performed magnetic resonance imaging (MRI) study of the pituitary (at age 8, 4 and 3 years) in the three affected subjects.

RESULTS

The three children were homozygous for a new GHRHR mutation that alters the second base of the invariant 5' splice site (GT) of intron 12 [IVS12 + 2T-->A]. The parents and an unaffected sibling were heterozygous for the same change. MRI did not show frank APH (by height criteria) in any of the subjects: pituitary height was normal (5.6 mm, +1.8 SDS) in the oldest sibling, and it was low but not below 2 SDS by age-adjusted criteria in the second (3 mm, -1.4 SDS), and third sibling (2.8 mm, -1.7 SDS). Calculated pituitary volume was below -2 SDS in the youngest patient.

CONCLUSIONS

These data demonstrate that pituitary height may fall within 2 SDS from the norm in patients with severe IGHD due to a homozygous GHRHR mutation, and that pituitary size may vary within patients with identical mutations who belong to the same family.

Probable adverse reaction to a pharmaceutical excipient

Adverse reactions to medication are well recognised although information on the incidence in children is lacking. Adverse reactions have also been attributed to a range of pharmaceutical excipients. This is a report of an adverse reaction to the excipient in clindamycin injection.

Behavioral and physical masculinization are related to genotype in girls with congenital adrenal hyperplasia

Girls with congenital adrenal hyperplasia (CAH) exhibit behavioral masculinization. There is controversy about the roles of pre- and postnatal androgens, social factors, and chronic illness in its etiology. To assess the effect of chronic illness, we compared behavioral masculinity in 24 CAH girls and 25 diabetic girls aged 3-12 yr from Manchester using two sensitive questionnaires, and an overall masculinity score M (high = masculine) was derived. To assess the contributions of pre- and postnatal androgens, the CAH subjects were categorized into genotype groups (G) according to the reported severity of loss of CYP21 function: G1 (n = 10, null mutations), G2 (n = 9, intron 2G), G3 (n = 3, I172N), and G4 (n = 2, unknown loss of function). In CAH girls, relationships between G, Prader degree of genital masculinization at birth, bone age advance, and M were assessed. CAH girls were less feminine and more masculine than diabetic girls (P < 0.001), who were not significantly different from U.S. controls. Among the CAH girls, those in G1 and 2 were more genitally masculinized than those in G3 and 4 (P < 0.009) and had higher M (P < 0.025). M was negatively correlated with advanced bone age (r = -0.5; P = 0.02). CAH girls, but not diabetic girls, demonstrated behavioral masculinization. Both physical and behavioral masculinization were related to each other and to genotype, indicating that behavioral masculinization is a consequence of prenatal androgen exposure.

Intravenous Valproate Associated with Circulatory Collapse

OBJECTIVE

To report a case of severe circulatory collapse following an intravenous injection of sodium valproate.

CASE SUMMARY

A 5-year-old white girl, who was receiving vasopressor support, developed a severe circulatory collapse following an intravenous injection of valproate 480 mg. Her invasive arterial blood pressure dropped after valproate was started, and she went into cardiac arrest requiring full resuscitation including 2 doses of epinephrine. She was successfully resuscitated.

DISCUSSION

To the best of our knowledge, this is the first case report of such severe circulatory collapse associated with intravenous valproate. Although hypotension has been reported following the use of intravenous valproate, severe circulatory compromise leading to cardiorespiratory arrest has not been previously described. An objective causality assessment using the Naranjo probability scale revealed that the adverse drug event was highly possible.

CONCLUSIONS

In view of this patient's circulatory collapse associated with valproate, intravenous sodium valproate should be used with caution, particularly in hemodynamically unstable patients.

Evaluation of the Commission of the European Communities quality criteria for the paediatric lateral spine

The study aimed to evaluate the Commission of the European Communities (CEC) quality criteria for paediatric lateral spine radiographs, and to use these to assess and compare the quality of film-screen and digital images. 286 paediatric lateral spine radiographs (89 film-screen and 197 digital) were independently analysed by two observers according to the CEC criteria. Based on fulfilment of criteria, images were assigned two scores, an image criteria score and a visual grading analysis score. Sensitivity values (S) on digital radiographs were recorded and correlated with image quality. Variability for assignment of scores between observers was lower for the image criteria than the visual grading analysis technique. Analysis of variance for fulfilment of criteria between techniques, and (for digital images) age and sensitivity values was calculated. Film-screen did significantly better (p<0.05) than digital imaging for Criterion 6 (visually sharp reproduction of the cortex and trabecular markings consistent with age), but significantly worse for Criterion 7 (reproduction of the adjacent soft tissues). There was a significant difference in mean S values for each age group when Criterion 6 was or was not met. Results show that although interpretation between two observers was ambiguous, the CEC criteria were able to detect differences in quality of film-screen and digital images. It is also possible to use them when optimizing target S values.

Ghrelin concentrations in healthy children and adolescents

OBJECTIVE

In addition to its regulation by GH releasing hormone (GHRH) and somatostatin, release of GH from the pituitary is modulated by a third factor, ghrelin, which is expressed in high concentration in the stomach and is present in the circulation. Ghrelin has also been shown to cause weight gain by increasing food intake and decreasing fat utilization. Ghrelin is a potential candidate hormone to influence nutrient intake and growth. Its role through normal childhood and adolescence has not been fully defined.

DESIGN

Cross-sectional study in 121 healthy children (65 male, 56 female) aged 5-18 years, in whom height, weight, body mass index (BMI), pubertal status and measurements of IGF-I, IGFBP-3, IGFBP-1 and leptin were available.

METHODS

Serum ghrelin concentrations have been measured in radioimmunoassay (RIA; Phoenix, AZ, USA) that detects active and inactive human ghrelin. Relationships between ghrelin and anthropometric data and growth factors were assessed by correlation and regression analyses.

RESULTS

Ghrelin was detected in all samples, with a median concentration of 162 pg/ml, range 60-493 pg/ml. Prepubertal children had higher ghrelin concentrations than those in puberty [218 pg/ml (n = 42) and 157 pg/ml (n = 79), P < 0.001], with significant negative correlations between ghrelin and age (rs = -0.39, P < 0.001) and pubertal stage (rs = -0.42, P < 0.001). The decrease in ghrelin with advancing pubertal stage/age was more marked in boys than girls. In the whole group, ghrelin was negatively correlated to BMI SD (rs = -0.24, P = 0.006) and to weight SD (rs = -0.24, P = 0.008) but not height sds. Ghrelin was also negatively correlated to IGF-I (rs = -0.48, P < 0.001), IGFBP-3 (rs = -0.32, P < 0.001) and leptin (rs = -0.22, P = 0.02) but not IGF-II. It was positively related to IGFBP-1 (rs = +0.46, P < 0.001). In stepwise multiple regression, 30% of the variability in ghrelin through childhood could be accounted for by log IGF-I (24%) and log IGFBP-1 (6%).

CONCLUSIONS

The fall in ghrelin over childhood and with puberty does not suggest that it is a direct growth-promoting hormone. However in view of the negative relationship with IGF-I and the positive relationship with IGFBP-1, this fall in ghrelin could facilitate growth acceleration over puberty.

Endocrine status in patients with optic nerve hypoplasia: relationship to midline central nervous system abnormalities and appearance of the hypothalamic-pituitary axis on magnetic resonance imaging

We here: 1) describe the phenotypic spectrum, including magnetic resonance imaging (MRI) appearances of the pituitary stalk and anterior and posterior pituitary [H-P (hypothalamic-pituitary) axis], in children with optic nerve hypoplasia (ONH) with or without an abnormal septum pellucidum (SP); and 2) define endocrine dysfunction according to the MRI findings. Medical records of 55 children with ONH who had been assessed by ophthalmology and endocrine services were reviewed. All had MRI of the brain and H-P axis. Forty-nine percent of the ONH patients had an abnormal SP on MRI, and 64% had a H-P axis abnormality. Twenty-seven patients (49%) had endocrine dysfunction, and 23 of these had H-P axis abnormality. The frequency of endocrinopathy was higher in patients with an abnormal SP (56%) than a normal SP (39%). Patients were divided into four groups based on SP and H-P axis appearance: 1) both normal; 2) abnormal SP and normal H-P axis; 3) normal SP and abnormal H-P axis; and 4) both abnormal. The frequency of multiple pituitary hormone deficiency was highest (56%) in group 4, lower (35%) in group 3, and even lower (22%) in group 2. Precocious puberty was most common in group 2. None of the patients in group 1 had endocrine dysfunction. Thus, SP and H-P axis appearances on MRI can be used to predict the likely spectrum of endocrinopathy.

IGF-I and IGF-binding protein-3 measurements on filter paper blood spots in children and adolescents on GH treatment: use in monitoring and as markers of growth performance

BACKGROUND/AIM

In childhood an appropriate response to GH treatment is achieved by titration of growth response against dose administered, with careful observation for side-effects. In order to evaluate the potential use of IGF monitoring in children treated with GH, a cross-sectional study has been carried in 215 children and adolescents (134 with GH deficiency (GHD), 54 with Turner syndrome (TS) and 27 with non-GHD growth disorders) treated with GH for 0.2-13.7 years.

METHODS

IGF-I and IGF-binding protein-3 (IGFBP-3) were measured in ELISAs, using dried capillary blood collected onto filter papers. Results were expressed as the mean S.D. range (SDS). Values of either analyte < -2 or > +2 SDS were considered abnormal.

RESULTS

IGF-I and IGFBP-3 SDS were higher in the TS and non-GHD groups (mean +0.01 and +0.1 respectively) than in those with GHD (mean value -0.6). Nineteen per cent of the IGF-I values (13% low, 6% high) and 12% of IGFBP-3 values were abnormal (10% low, 2% high). Abnormalities, either low or high, were most common in the GHD group. There was a weak but significant relationship between change in height SDS over the Year up to the time of sampling in the whole group and IGF-I SDS. Satisfactory growth performance (+0.5>change in height SDS> -0.5) was found in those with high (7.2%), normal (60%) and low (9.3%) IGF-I levels. Overall, it was estimated that 26% of the tests would indicate that an adjustment to GH dose (up in 18% and down in 8%) could be considered.

CONCLUSIONS

From this cross-sectional study of IGF monitoring across a broad range of diagnoses and ages, it can be concluded that the majority of children on GH have normal levels of IGF-I and IGFBP-3, but 26% of tests could suggest that a change of GH dose should be considered. Regular monitoring of IGF-I and IGFBP-3 should be considered in any child on GH treatment.

Observational study of skeletal surveys in suspected non-accidental injury

AIM

To document variability in the standard of skeletal surveys received for a second opinion in suspected non-accidental injury (NAI).

MATERIALS AND METHODS

The skeletal surveys of 50 consecutive infants and children under 2 years of age were reviewed. A simple scoring system was developed based on fulfillment of specific parameters. Each radiograph was then assigned a score reflecting its overall clinical quality.

RESULTS

There was an average of 10 radiographs per skeletal survey (range 2-13). Of the 50 surveys assessed, there were 37 different combinations. These included five babygrams. No survey complied with the current draft guidelines of the British Society of Paediatric Radiologists (BSPR).

CONCLUSIONS

There is significant variability in skeletal surveys referred for a second opinion in suspected NAI. Standardization of projections and improvement in the quality of radiographs obtained for this indication is required. The study highlights the need for the development and dissemination of definitive national guidelines.

Leptin measurement in urine in children and its relationship to other growth peptides in serum and urine

OBJECTIVE

Leptin has been implicated in the interaction between nutrition, energy balance and sexual maturation in humans. A non-invasive method of measuring leptin would greatly facilitate longitudinal studies of changes in leptin in normal children. The aim of this study was to evaluate the use of urinary leptin as a surrogate for serum leptin measurements.

DESIGN

We have modified and validated a serum immunoradiometric assay (IRMA) kit for the measurement of leptin in urine, and subsequently investigated the relationship between urinary leptin and other growth-related proteins.

METHODS

Cross-sectional study: urinary leptin, measured in the first morning urine voided and expressed as ng excreted overnight, and serum concentrations of leptin, IGF-I, IGF-II, IGFBP-3 and IGFBP-1 were determined in a cohort of 188 healthy schoolchildren aged 5-19 years (88 males, 100 females). Height, weight and pubertal status were assessed in all children. Longitudinal study: urinary levels of leptin, IGF-I and GH were measured daily in two adults (one male, one female) over a period of 6 weeks.

RESULTS

The detection limit of this modified assay was 0.59 ng/L. The intra- and interassay coefficients of variation range was 4-8% and 4-9%, respectively. The recovery of recombinant leptin added to urine was 98-108%, and the assay had a recovery rate for serial dilution in the range of 106-112%. Urinary leptin correlated significantly with serum leptin (r = +0.65, P < 0.01). Urinary leptin showed similar changes through puberty to those of serum leptin, with levels rising in females throughout puberty, whereas in males levels peaked at G2/G3 then decreased. BMI SDS was the main determinant of urinary leptin, as it was for serum leptin. In the cross-sectional study urinary leptin correlated significantly with serum IGF-I (r = +0.41, P = 0.001), IGF-II (r = +0.19, P = 0.05), IGFBP-3 (r = +0.29, P = 0.001) and IGFBP-1 (r = -0.25, P = 0.001). In the adult study, leptin was also detected in urine with similar night-to-night variability to that found for IGF-I and GH.

CONCLUSION

Urinary leptin is a valid marker of serum leptin concentrations, and therefore this non-invasive assay would be a useful tool for longitudinal assessment of changes in leptin in children.

Low serum concentrations of insulin-like growth factor-I in children with active Crohn disease: effect of enteral nutritional support and glutamine supplementation

Dept. of Paediatric Gastroenterology, Central Manchester Hospital, Manchester, UK.

Dysplastic cortical hyperostosis (Kozlowski-Tsuruta syndrome): report of a second case

We report a fetus from a pregnancy that was terminated at 26 weeks gestation for hydrops and short limb skeletal dysplasia. The parents were first cousins. Post mortem examination showed pulmonary hypoplasia and hepatomegaly. The radiographs showed shortening and cortical thickening of all long bones. The cortical thickening was most marked in the long bones, ribs, clavicles and scapulae but spared the skull vault, facial bones and pelvis. There were coronal clefts in the lower lumbar vertebrae. The clinical and radiological features of this fetus conform to those reported in a stillborn male by Kozlowski and Tsuruta in 1989 (Br J Radiol 62:376-378). This is the second reported case of this condition and confirms that it is a distinct and recognisable, lethal skeletal dysplasia. The parental consanguinity in our patient suggests that this condition may be inherited in an autosomal recessive manner.

Suppression of puberty with long-acting goserelin (Zoladex-LA): effect on gonadotrophin response to GnRH in the first treatment cycle

BACKGROUND AND OBJECTIVES

Depot GnRH analogues are widely used in the treatment of precocious puberty, or suppression of relatively early puberty where growth or psychosocial well-being may be compromised. One example is Zoladex (Z goserelin 3.6 mg), which can be given every 4 weeks. This injection frequency may not always achieve adequate suppression of pubertal signs. A long-acting form, Zoladex-LA 10.8 mg, has now been introduced with a potential duration of action of 12 weeks. In order to assess the efficacy of Zoladex-LA in gonadotrophin suppression we have measured LH and FSH responses to GnRH at diagnosis and 8 and 12 weeks after injection in a group of children treated with Zoladex-LA for central precocious or early puberty.

METHODS

Forty-nine children (40 girls) with clinical evidence of central precocious puberty (CPP) or early puberty (EP) were started on Zoladex-LA, either de novo (n = 29) or on changing from Zoladex. Ages at diagnosis ranged from 1.7 to 10.6 years (median 7.8 years). Twenty-three had a structural cause with abnormality on magnetic resonance/computerized tomography (MR/CT) head scan, nine had a syndrome or nonspecific brain injury, and in 17 the cause was idiopathic.

RESULTS

At diagnosis, in the de novo group, median peak LH was 13.6 IU/l and median peak FSH was 12.0 IU/l. By 12 weeks gonadotrophins were suppressed to 0.9 and 0.8 IU/l, respectively. In the previously treated group, median peak LH at diagnosis was 12.8 IU/l and median peak FSH was 15.0 IU/l with suppression to 0.8 and 1.1 IU/l, respectively, at 12 weeks. In the latter group peak FSH was higher than peak LH at both 8 and 12 weeks (P < 0.05) and there was a significant rise in peak LH (P < 0.05) and FSH (P = 0.01) between 8 and 12 weeks. There was no correlation between age at diagnosis and peak LH or FSH at 8 or 12 weeks. Nevertheless, individual patients in both groups showed evidence of incomplete gonadotrophin suppression at 12 weeks.

CONCLUSION

Zoladex-LA induces a significant reduction in gonadotrophins over 12 weeks. However, there are individuals, particularly those previously on Zoladex, in whom gonadotrophin suppression is waning by 12 weeks. As found with Zoladex, some children with precocious puberty treated with Zoladex-LA may require increased injection frequency, although correlation with clinical evidence of suppression needs to be studied further.

Craniosynostosis

Craniosynostosis, caused by premature fusion of the sutures, may be syndromic or non-syndromic. Radiology has an important role to play in the assessment, management and follow-up of these patients. Initial investigations may often be undertaken within general radiology departments. An understanding of the terminology and recognition of the predictable patterns of presentation are essential to enable appropriate referral to a craniofacial unit where further investigation and management are undertaken. We present the radiological features of several craniosynostoses with an emphasis on the role of plain radiography. We demonstrate the complementary role of computed tomography in their evaluation within the setting of a specialist centre.

Lethal acrofacial dysostosis, pre- and post-axial defects of the hands, and bilateral renal agenesis

We report a female fetus with a previously undescribed form of mandibulofacial dysostosis with mesomelic limb abnormalities, pre- and post-axial defects of the hands, bilateral renal agenesis, bicornuate uterus, and a single umbilical artery.

The dating of shallow faults in the Earth's crust

Direct dating of ductile shear zones and calculation of uplift/exhumation rates can be done using various radiometric dating techniques. But radiometric dating of shallow crustal faulting, which occurs in the crust's brittle regime, has remained difficult because the low temperatures typical of shallow crusted faults prevent the complete syntectonic mineral recrystallization that occurs in deeper faults. Both old (detrital) and newly grown (authigenic) fine-grained phyllosilicates are thus preserved in shallow fault zones and therefore their radiometric ages reflect a mixture of both mineral populations. Also, the loss of 39Ar during neutron irradiation in dating of clay minerals can produce erroneously old ages. Here we present a method of characterizing the clay populations in fault gouge, using X-ray modelling, combined with sample encapsulation, and show how it can be used to date near-surface fault activity reliably. We examine fault gouge from the Lewis thrust of the southern Canadian Rockies, which we determine to be approximately 52 Myr old. This result requires the western North America stress regime to have changed from contraction to extension in only a few million years during the Eocene. We also estimate the uplift/exhumation age and sedimentary source of these rocks to be approximately 172 Myr.

Thermostable (SULT1A1) and thermolabile (SULT1A3) phenol sulfotransferases in human osteosarcoma and osteoblast cells

Sulfate conjugation is an important pathway in the metabolism of many drugs, xenobiotic compounds, and hormones. Sulfotransferases (SULTs) catalyze these reactions and have been detected and characterized in various human tissues including the liver and small intestine. Substrates for SULTs that include estrogen and thyroid hormones have well-established roles affecting skeletal integrity and disease processes. We performed the following studies to determine the presence of SULTs in human osteoblast-like cells, and to compare their characteristics to SULTs expressed in other human tissues. Four osteosarcoma cell lines (SaOS-2, U2-OS, PR, and HOS-TE85) were screened for the presence of four different SULT activities. Predominant activities were found for SULT1A1 in SaOS-2 cells, and SULT-1A3 in HOS-TE85 cells. Several biochemical properties of each enzyme that included apparent K(m) values, thermal stabilities, and responses to the inhibitors 2,6-dichloro-4-nitrophenol and NaCl were used to further characterize the SULT activities. High-performance liquid chromatography (HPLC) of the reaction products confirmed the known products of SULT1A1 and SULT1A3. When the mature human osteoblast HOB-03-CE6 cell line was tested for activity alone, the predominant activity was SULT1A3, with minimal SULT1A1. The results indicate that SULT1A1 and SULT1A3 are present in human osteosarcoma and mature osteoblast cell lines, and that the characteristics of the osteosarcoma cell SULTs are similar to those expressed in other human tissues. SULTs may have regulatory roles in the deactivation of thyroid hormones or estrogenic compounds in bone, and thus may affect hormone action and bone responses in the human skeleton.

Symmetrical enchondromatosis without vertebral involvement and with cone-shaped phalangeal epiphyses

A new type of enchondromatosis is described with a symmetrical distribution but not involving the spine and characterised by severe ankle deformity, shortening of metacarpals and phalanges, and cone-shaped phalangeal epiphyses.

An atypical case suggesting the possibility of overlap between Malpuech and Juberg-Hayward syndromes

Malpuech syndrome and Juberg-Hayward syndrome are considered to be distinct disorders of orofacial clefting. We present details of a patient whose clinical presentation closely resembles the profile of Malpuech syndrome, but whose radiological features are more in keeping with published observations in Juberg-Hayward patients.

Temperature taking in children

Tempa-Dot single-use thermometers have been compared with mercury and tympanic thermometers in a paediatric setting. The largest difference in mean temperature measured between devices was less than 0.2 degrees C. Differences between devices are less than the random scatter in any individual measurement. It is argued that differences in measured temperature between thermometers are not clinically significant. Tempa-Dot thermometers can be used with confidence to measure the temperatures of young children

Expression and localisation of IGF-binding protein mRNAs in regenerating rat skeletal muscle

The expression of the insulin-like growth factor-binding proteins (IGFBP) -3, -4, -5 and -6 was investigated in neonatal, in normal adult and in regenerating rat skeletal muscle. Semi-quantification was done by densitometric scannings of Northern blots. The expression of all investigated IGFBPs, with the exception of IGFBP-5, was higher in neonatal than in adult muscle. During postischaemic regeneration the expression of all IGFBPs increased, but with different time schedules. IGFBP-3 increased transiently during the early phase of regeneration, while IGFBP-4, -5 and -6 increased during the later phase of regeneration. In situ hybridisation on regenerating muscle showed that the expression of the various IGFBPs was cell specific; thus, IGFBP 3 was mainly expressed in macrophages, IGFBP-4 in connective tissue, IGFBP-5 in regenerating muscle cells, and IGFBP-6 in muscle cells, connective tissue and endothelium. Ligand blotting, using 125I-IGF-I as the ligand, showed a number of bands ranging between 24 and 44 kDa. Samples from neonatal and regenerating muscle contained much higher levels of all IGFBPs than those from normal adult muscle. An ordered and cell-specific expression of IGFBPs, allowing a strict regulation of IGF actions, is probably necessary to ensure an optimal regeneration process.

Sacral dysgenesis associated with terminal deletion of chromosome 7q: a report of two families

Most cases of sacral dysgenesis are considered to be sporadic events. We present two families in whom the presence of associated clinical features prompted specific investigation of chromosome 7, leading to the identification of an underlying chromosome 7q deletion causing sacral dysgenesis. All affected individuals had microcephaly and developmental delay. Detailed cytogenetic studies confirmed that all three affected individuals had a deletion of chromosome 7q associated with their sacral dysgenesis, developmental delay and related problems. The three affected patients were studied clinically, radiologically and cytogenetically. Eleven unaffected individuals from the two families were also investigated by genetic studies, specifically evaluating chromosome 7.

CONCLUSION

It is important that detailed family history, evaluation of associated malformations and the overall clinical picture be considered in identifying the underlying diagnosis in cases of anal stenosis/sacral agenesis. The cases we present demonstrate the value of detailed chromosome studies in such situations.

Lethal micromelic short-rib skeletal dysplasia with triangular-shaped humerus

We report two brothers with a new type of lethal, micromelic, short-rib, skeletal dysplasia characterised by short limbs with distinctive triangular-shaped humeri. This condition is most likely caused by either an autosomal recessive or X-linked recessive gene.