De Novo Crohn's Disease in Children With Ulcerative Colitis Undergoing Ileal Pouch-Anal Anastomosis: A Multicenter, Retrospective Study From the Pediatric IBD Porto Group of the ESPGHAN

BACKGROUND AND AIMS

We sought to define the prevalence and to characterize possible predictive factors of Crohn's disease (CD) occurring in children with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA).

METHODS

This was a multicenter, retrospective study including 15 centers of the Porto IBD group of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition. Children with a confirmed diagnosis of UC undergoing colectomy with IPAA and a minimal follow up of 6 months were identified. The following data were collected: demographic data; endoscopic and histologic data; disease activity; laboratory exams; therapeutic history; indication for surgery, type, and timing; and IPAA functional outcomes and complications. In de novo CD cases, time of diagnosis, phenotype, location, and therapies were gathered.

RESULTS

We identified 111 UC children undergoing IPAA from January 2008 to June 2018 (median age at colectomy: 13 years; age range: 1-18 years; female/male: 59/52). The median time from diagnosis to colectomy was 16 (range, 0-202) months. At the last follow-up, 40 (36%) of 111 children developed pouchitis. The criteria for de novo CD were met in 19(17.1%) of 111 children with a 25-month median (range, 3-61 months). At last follow-up, 12 (63.1%) of 19 were treated with biologics and in 5 (26.3%) of 19 children, the pouch was replaced with definitive ileostomy. In a multivariable logistic regression model, decreased preoperative body mass index z scores (odds ratio, 2.2; 95% confidence interval, 1.1-4.4; P = .01) resulted as the only variable associated with CD development.

CONCLUSIONS

Children with UC undergoing IPAA carry a high risk of developing subsequent CD. De novo CD cases showed decreased preoperative body mass index z scores, identifying a poor nutritional status as a possible predictive factor.

Malignancy and mortality in paediatric-onset inflammatory bowel disease: a 3-year prospective, multinational study from the paediatric IBD Porto group of ESPGHAN

BACKGROUND

Risk benefit strategies in managing inflammatory bowel diseases (IBD) are dependent upon understanding the risks of uncontrolled inflammation vs those of treatments. Malignancy and mortality in IBD have been associated with disease-related inflammation and immune suppression, but data are limited due to their rare occurrence.

AIM

To identify and describe the most common causes of mortality, types of cancer and previous or current therapy among children and young adults with paediatric-onset IBD.

METHODS

Information on paediatric-onset IBD patients diagnosed with malignancy or mortality was prospectively collected via a survey in 25 countries over a 42-month period. Patients were included if death or malignancy occurred after IBD diagnosis but before the age of 26 years.

RESULTS

In total, 60 patients were identified including 43 malignancies and 26 fatal cases (9 due to cancer). Main causes of fatality were malignancies (n = 9), IBD or IBD-therapy related nonmalignant causes (n = 10; including 5 infections), and suicides (n = 3). Three cases, all fatal, of hepatosplenic T-cell lymphoma were identified, all were biologic-naïve but thiopurine-exposed. No other haematological malignancies were fatal. The 6 other fatal cancer cases included 3 colorectal adenocarcinomas and 3 cholangiocarcinomas (CCAs). Primary sclerosing cholangitis (PSC) was present in 5 (56%) fatal cancers (1 colorectal carcinoma, 3 CCAs and 1 hepatosplenic T-cell lymphoma).

CONCLUSIONS

We report the largest number of paediatric-onset IBD patients with cancer and/or fatal outcomes to date. Malignancies followed by infections were the major causes of mortality. We identified PSC as a significant risk factor for cancer-associated mortality. Disease-related adenocarcinomas were a commoner cause of death than lymphomas.

Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn's disease

Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.

Management of pediatric ulcerative colitis: joint ECCO and ESPGHAN evidence-based consensus guidelines

BACKGROUND AND AIMS

Pediatric ulcerative colitis (UC) shares many features with adult-onset disease but there are some unique considerations; therefore, therapeutic approaches have to be adapted to these particular needs. We aimed to formulate guidelines for managing UC in children based on a systematic review (SR) of the literature and a robust consensus process. The present article is a product of a joint effort of the European Crohn's and Colitis Organization (ECCO) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).

METHODS

A group of 27 experts in pediatric IBD participated in an iterative consensus process including 2 face-to-face meetings, following an open call to ESPGHAN and ECCO members. A list of 23 predefined questions were addressed by working subgroups based on a SR of the literature.

RESULTS

A total of 40 formal recommendations and 68 practice points were endorsed with a consensus rate of at least 89% regarding initial evaluation, how to monitor disease activity, the role of endoscopic evaluation, medical and surgical therapy, timing and choice of each medication, the role of combined therapy, and when to stop medications. A management flowchart, based on the Pediatric Ulcerative Colitis Activity Index (PUCAI), is presented.

CONCLUSIONS

These guidelines provide clinically useful points to guide the management of UC in children. Taken together, the recommendations offer a standardized protocol that allows effective, timely management and monitoring of the disease course, while acknowledging that each patient is unique.

Limitations of fecal calprotectin at diagnosis in untreated pediatric Crohn's disease

BACKGROUND

Fecal Calprotectin (FC) is a validated screening test for intestinal inflammation in Crohn's disease (CD). The objective of the study was to prospectively evaluate the limitations of FC for identifying CD in newly diagnosed untreated pediatric patients and to assess the association of FC levels with disease location and serum inflammatory markers.

METHODS

Consecutive children with new onset untreated CD participating in the ongoing ESPGHAN GROWTH CD study were evaluated at diagnosis for disease activity, extent, C-reactive protein (CRP), and FC.

RESULTS

In all, 60 children met the inclusion criteria (mean age 12.6 ± 4.6 years,), 25 (42%) with mild disease, 17 (28%) moderate disease, and 18 (30%) severe disease. Twenty-seven (45%) had small bowel disease only. Median FC levels did not differ between children with small bowel only (2198 μg/g interquartile range [IQR] 696-2400) and those with colonic involvement (with or without small bowel disease; 2400 μg/g (IQR 475-2400) (P = 0.76). FC was elevated in 95% of patients, in comparison to CRP (86%) and erythrocyte sedimentation rate (ESR) (83%). Three children (5%) who had normal calprotectin levels also had low or normal CRP and/or ESR. There was no correlation between calprotectin levels and either the pediatric CD activity index (r = -0.11; P = 0.94) or physicians global assessment.

CONCLUSIONS

FC levels in active disease confined to the small bowel were elevated in the vast majority of children and site of disease was not a confounding factor in this setting. Patients with low FC had a trend toward low levels of inflammatory markers as well. We did not find a significant correlation between FC and clinical indices of activity.

Prevention of acute adverse events related to infliximab infusions in pediatric patients

OBJECTIVE

To study whether premedication with an oral antifebrile agent (acetaminophen) and antihistamine (cetirizine) could decrease the frequency of acute infusion reactions in pediatric patients.

METHODS

All pediatric patients scheduled for infliximab infusions at the Helsinki University Central Hospital, a tertiary care center, were prospectively introduced to a standard oral premedication of acetaminophen (20 mg/kg) and cetirizine (10 mg) prior to infliximab infusions for a period of 1 year. All acute adverse events related to infliximab infusions given according to the guidelines of pediatric rheumatologists or gastroenterologists were registered for this time period and retrospectively during the preceding year.

RESULTS

During the study period, infliximab infusions with premedication were given to 64 pediatric patients (48 with rheumatic disease and l6 with inflammatory bowel disease, mean age 13 years, n = 34 boys, and n = 30 girls). Infliximab was introduced to 14 children; the rest were on maintenance therapy. Twelve infusion reactions, 4 mild and 8 severe, were observed in 8 (12.5%) of the 64 subjects, and in 1 subject 4 times. During the preceding year, 60 pediatric patients had received infliximab infusions without premedication. In this latter group, infusion reactions occurred in 5 children (8.3%; P > 0.05). The presentation of an acute infusion reaction was not related to the sex or diagnosis of the patient.

CONCLUSION

In pediatric patients, acute infusion reactions related to infliximab could not be prevented with premedication with oral acetaminophen and cetirizine.

Molecularly defined adult-type hypolactasia among working age people with reference to milk consumption and gastrointestinal symptoms

AIM: To study milk consumption and subjective milk-related symptoms in adults genotyped for adult-type hypolactasia.

METHODS: A total of 1900 Finnish adults were genotyped for the C/T_-13910 variant of adult-type hypolactasia and filled in a structured questionnaire concerning milk consumption and gastrointestinal problems.

RESULTS: The C/C_-13910 genotype of adult-type hypolactasia was present in 18% of the study population. The prevalence of the C/C_-13910 genotype was higher among subjects who were undergoing investigations because of abdominal symptoms (24%, P < 0.05). Those with the C/C_-13910 genotype drank less milk than subjects with either the C/T_-13910 or the T/T_-13910 genotype of lactase persistence (18% vs 38%; 18% vs 36%, P < 0.01). Subjects with the C/C_-13910 genotype had experienced more gastrointestinal symptoms (84%) during the preceding three-month period than those with the C/T_-13910 (79%, P < 0.05) or the T/T_-13910 genotype (78 %, P < 0.05). Only 9% (29/338) of the subjects with the C/C_-13910 genotype consumed milk and reported no symptoms from it.

CONCLUSION: Gastrointestinal symptoms are more common among adults with the C/C_-13910 genotype of adult-type hypolactasia than in those with genotypes of lactase persistence.

Dental caries is common in Finnish children infected with Helicobacter pylori

Childhood factors such as low socioeconomic status are risk factors for Helicobacter pylori infection and Streptococcus mutans-related dental caries. We examined whether H. pylori infection and dental caries are present today in the same group of children examined previously. We reviewed the public dental health service files of 21 H. pylori-positive children (upper gastrointestinal endoscopy at a median age of 13.5 y) and 27 H. pylori-negative children (endoscopy at a median age of 12.5 y) examined during 1995-98 at the Helsinki University Central Hospital, Finland. All H. pylori-positive children had experienced dental caries in their primary or permanent teeth or in both whereas among H. pylori-negative children the respective proportion was 70% (p < 0.01). At the age of 7 y, 18% (3/17) of the H. pylori-positive children had experienced caries in permanent teeth as compared to 0% among H. pylori-negative children (0/24; p < 0.05). At the age of 12 y, H. pylori-positive children had more decayed, missing or filled permanent teeth than H. pylori-negative children (80% vs. 38%; p < 0.05). Although a causal relationship between H. pylori and dental caries is unlikely, it is possible that H. pylori-infected children have an increased risk of other health problems, such as dental caries, for which proper treatment is needed.

cagA, vacA and iceA virulence genes of Helicobacter pylori isolates of children in Finland

cagA, vacA s and m genotypes and iceA alleles were analyzed from Helicobacter pylori strains isolated from 17 Finnish children and 32 children of non-Finnish origin living in Finland. Twelve children in the latter group were eastern European and 15 were of African origin. Only three children of non-Finnish origin were born in Finland. The vacA sla subtype was more prevalent in the isolates from Finnish children than African children (76% vs. 7%, P<0.001); vacA s1b frequencies were 5% and 67%, respectively (P<0.001). The iceA1 allele was significantly more prevalent in African than Finnish isolates (93% vs. 35%, P< 0.01). Considerable variation was noted in the frequency of vacA s1 subtypes and iceA alleles in children originating from different geographic regions, but the geographic variation of s1 subtypes resembled that described in other reports.

Ethnic differences in intestinal disaccharidase values in children in Finland

BACKGROUND

Intestinal disaccharidase activities tend to be low in villous atrophy, but there are only a few reports of enzyme activities in children with normal villous architecture.

METHODS

In the current study the data were reviewed on disaccharidase activities in duodenal biopsy specimens of normal villous structure in 223 children undergoing upper gastrointestinal endoscopy in 1997 and 1998. The ancestry was Finnish in 188 children (median age 8.0 years; range, 0.2-18 years), African in 27 children (median age 5.0 years; range, 1-13 years), and other in eight children.

RESULTS

The mean activities of lactase, sucrase, and maltase were significantly higher in Finnish children than in children of African origin (P < 0.0001, P < 0.002, and P < 0.02, respectively). Lactase activity decreased with increasing age (P < 0.001), but age had no significant effect on maltase and sucrase activities. Among Finnish children, 31% (59/188) had lactase activity below the established reference range of 20 units (units are micromoles of substrate hydrolyzed per minute at 37 degrees C per gram of protein) and one child had a probable sucrase-isomaltase deficiency. When these 60 children with low enzyme activities were excluded, the geometric means were lactase, 35.7 units (95% confidence interval [CI], 32.8-38.6 units); maltase, 241 units (95% CI, 225-258 units); and sucrase, 57.5 units (95% CI, 53.5-61.6 units). Among the children of African origin, lactase activity was decreased in 67% (18/27). All three enzyme activities were decreased in parallel more often among the African children (8/27) than among the Finnish children (9/188; P < 0.002).

CONCLUSIONS

Ethnicity has a strong effect on disaccharidase values in children with normal villous structure. African children have lower activities of lactase, sucrase, and maltase in duodenal specimens than do children of Finnish origin.

Parietal cell antibodies and Helicobacter pylori in children

BACKGROUND

Gastric autoantibodies are common in Helicobacter pylori-infected adults, and the presence of these antibodies is associated with atrophic gastritis. The role of H. pylori in the autoimmune type of atrophic gastritis is unresolved, and it is not known at what stage the autoantibodies appear in serum during H. pylori infection. Therefore, we screened children with and without H. pylori infection for gastric parietal cell antibodies.

METHODS

Seventy-one children with H. pylori infection verified by examination of gastric biopsy specimens (mean age, 9.4 years), 8 children with positive serology but negative histology for H. pylori (mean age, 11.6 years), and 130 children with negative serology for H. pylori (mean age, 7.7 years) were screened for the presence of gastric parietal cell antibodies in serum by indirect immunofluorescence. In addition, 61 children with celiac disease (mean age, 7.1 years) were screened for gastric parietal cell antibodies and H. pylori antibodies.

RESULTS

None of the children with H. pylori infection had gastric parietal cell antibodies in serum. Only three positive parietal cell antibody reactions were found: a 14-year-old boy with positive serology for H. pylori but no other signs of infection (titer 5000), a 14-year-old girl with tuberculosis (titer 1250, seronegative for H. pylori) and a 10-year-old girl with insulin-dependent diabetes mellitus (titer 6250, seronegative for H. pylori).

CONCLUSIONS

Although gastric autoantibodies are often found in adults with chronic H. pylori gastritis, it seems that H. pylori-infected children are not positive for gastric parietal cell antibodies. It remains to be studied in which H. pylori infections and at what stages gastric autoantibodies appear.

Gastric inflammation is enhanced in children with CagA-positive Helicobacter pylori infection

BACKGROUND

Helicobacter pylori infection is likely to be acquired at an early age. The factors leading to active inflammation in childhood, however, are largely unknown.

SUBJECTS AND METHODS

We determined the CagA status, the best characterized virulence factor of H. pylori, and serum antibodies of IgG and IgA classes to H. pylori in 39 infected children.

RESULTS

Mononuclear cell infiltration in the antrum but not in the gastric body was more intense in CagA-positive children than in CagA-negative children. The degree of polymorphonuclear cell infiltration on the other hand was independent of the CagA status. The antibody titers of IgG and IgA classes to H. pylori were higher in CagA-positive than in CagA-negative infections (P<0.001 and P<0.01, respectively). IgG antibody titers to H. pylori correlated directly with the density of mononuclear and polymorphonuclear cell infiltration in the gastric antrum but not in the gastric body.

CONCLUSION

H. pylori-infected children with CagA antibodies seem to have a more severe inflammation in the gastric antrum than CagA-negative children as shown by an increase in the density of antral mononuclear cells. A finding of higher serum antibody titers to H. pylori in CagA-positive children may be related to this enhancement of inflammation.

Screening for coeliac disease in women with a history of recurrent miscarriage or infertility

Because subclinical coeliac disease may decrease fertility or complicate pregnancy, we screened women with recurrent miscarriage of unknown aetiology (n = 63), unexplained infertility (n = 47) and infertility with a known cause (n = 82), for anti-endomysium antibodies in serum to find undiagnosed coeliac disease. One woman (1-6%) with recurrent miscarriage, another woman (2.1%) with unexplained infertility and one woman (2.0%) in the control group (n = 51), were considered to have coeliac disease. We could not demonstrate a higher frequency of coeliac disease in women with infertility or recurrent miscarriage, but suggest that undiagnosed coeliac disease is common in women.

Tissue transglutaminase autoantibody enzyme-linked immunosorbent assay in detecting celiac disease

BACKGROUND & AIMS

Tissue transglutaminase has been reported to be the target for endomysial antibodies in celiac disease. We sought to establish whether immunoglobulin (Ig) A class tissue transglutaminase autoantibodies can be considered specific for celiac disease.

METHODS

Serum samples from 136 patients with untreated celiac disease (diagnosed according to the criteria of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition) and 207 disease controls were studied. Enzyme-linked immunosorbent assay (ELISA) and Western blots were performed using calcium-treated and untreated tissue transglutaminase as antigen. Reticulin, endomysial, and mouse monoclonal tissue transglutaminase antibodies were studied by an indirect immunofluorescence method and gliadin antibodies with ELISA.

RESULTS

The calcium-activated tissue transglutaminase autoantibody ELISA was highly sensitive (129 of 136) and specific (194 of 207) in detecting celiac disease. The new autoantibody ELISA test correlated well with the endomysial antibody test. Tissue transglutaminase autoantibody ELISA showed a clearly better predictive potential than the IgA class gliadin antibody ELISA. Immunoblots and ELISA blocking studies showed that calcium is needed for the specific antigen-antibody reaction to occur. Double immunofluorescence staining in human umbilical cord with sera from patients with celiac disease and with monoclonal tissue transglutaminase antibodies showed complete overlap.

CONCLUSIONS

Calcium-activated tissue transglutaminase autoantibody ELISA is highly accurate in detecting untreated celiac disease. Tissue transglutaminase seems to be the target self-antigen for endomysial antibodies.

Undiagnosed coeliac disease is common in Finnish adults

BACKGROUND

Large-scale screening for coeliac disease has suggested that the disease is more prevalent than anticipated. In the screening studies published, only a minor proportion of those with a positive result have undergone jejunal biopsy to confirm the diagnosis. Our aim was to search for previously undiagnosed patients with coeliac disease by means of antiendomysium antibodies, which are more specific for the disease than serum antigliadin antibodies, and to study jejunal histology in each with a positive titre.

METHODS

Serum from 1070 adults working at Helsinki University Central Hospital were screened for untreated coeliac disease with IgA antiendomysium antibodies. All adults with positive titres underwent jejunal biopsy for villous structure analysis and counting of CD3-positive cells and cells bearing the gamma/delta T-cell receptor.

RESULTS

Coeliac disease was confirmed in a jejunal biopsy specimen from 8 of the 11 subjects with positive antiendomysium titres--that is, a frequency of 1 in 130. Seven of these eight coeliac patients had had minor abdominal discomfort for years, and one patient had a diagnosis of hyperthyroidism. None of the patients had osteoporosis, four had low iron storages, but only two were anaemic; no other nutritional deficiencies were found. The three other adults had a positive antiendomysium titre but a normal villous structure. One of these three was regarded as a false-positive case (titre, 1 in 5). The two other subjects (titres, 1 in 400) had increased numbers of CD3-positive T cells and gamma/delta T-cell receptor-bearing cells, suggesting a predisposition for coeliac disease.

CONCLUSIONS

Undiagnosed coeliac disease is common in the adult population in Finland; in this study the prevalence was 1 in 130. Screening for coeliac disease is recommended on minor suspicion.

Helicobacter pylori-positive gastritis in pediatric patients with chronic inflammatory bowel disease

BACKGROUND

Gastritis is a common finding in patients with inflammatory bowel disease. However, the association of gastritis with Helicobacter pylori is unclear in these patients.

METHODS

The prevalence of antibodies for H. pylori in serum was determined in 47 pediatric patients with inflammatory bowel disease (19 with Crohn's disease, 21 with ulcerative colitis, and 7 with unclassified disease). H. pylori antibodies of the IgG and IgA classes were measured by enzyme immunoassay in 24 patients at the time of diagnosis of inflammatory bowel disease and in 23 more patients during the follow-up of inflammatory bowel disease (mean follow-up, 3.5 years; range 1-10 years). Esophagogastroduodenoscopy was performed on 40 patients during the examination for inflammatory bowel disease.

RESULTS

In contrast to earlier findings, no patient was determined to be positive for H. pylori, either in serologic or histologic examination. This negative finding was unexpected, because it is known that approximately 10% of asymptomatic Finnish children have antibodies for H. pylori in serum and approximately 10% of analyses of specimens obtained in gastric antral biopsies obtained at the Hospital for Children and Adolescents, Helsinki, Finland, are positive for H. pylori.

CONCLUSIONS

Permanent colonization of the stomach with H. pylori is unusual in children with inflammatory bowel disease.

IgA endomysium antibodies on human umbilical cord: an excellent diagnostic tool for celiac disease in childhood

BACKGROUND

An improvement in screening for celiac disease has recently been described that uses human umbilical cord as a substitute for monkey esophagus to determine IgA endomysium antibodies in adults. As using monkey esophagus is ethically questionable for large-scale screening, we studied whether substitution of umbilical cord would be suitable for pediatric patients as well.

METHODS

Serum from 53 children with untreated celiac disease, 22 in remission and 13 on challenge, were screened for antigliadin IgA, antigliadin IgG, and IgA reticulin antibodies, in addition to IgA endomysium antibodies tested both on monkey esophagus and on human umbilical cord. Controls included 20 patients with cow-milk-sensitive enteropathy, 23 with inflammatory bowel disease, and 23 with diabetes mellitus, and 48 patients who were biopsied to exclude celiac disease either because of positive gliadin antibody test or disturbed growth.

RESULTS

Sensitivity (0.94) and specificity (1.0) were similar for umbilical cord and esophageal determinations in active celiac disease. Both substrates detected identical positive cases and neither gave false-positive results. In celiac patients on a gluten-free diet, endomysium antibodies with either substrate were positive in seven identical cases and negative in 15 of 22 cases. Correlations with reticulin antibodies were comparable with human umbilical cord and monkey esophagus (0.83 and 0.85, respectively; Spearman Correlation Section Pair-Wise deletion).

CONCLUSIONS

Human umbilical cord is an excellent substitute for monkey esophagus to determine endomysium antibodies in celiac diagnosis in children and adolescents.

Neonatal treatment of male rats with a gonadotropin-releasing hormone antagonist results in altered function of the pituitary-testicular axis in adult age

In most mammals, pituitary-testicular hormone secretion is very active during the perinatal period, but the physiological significance of this function for later pituitary-gonadal interactions and sexual maturation is largely unknown. Short-term neonatal treatment with gonadotropin-releasing hormone (GnRH) antagonist results in delayed sexual maturation and infertility in male rats. We have now extended our earlier findings and studied in more detail the pituitary-gonadal function in adult rats after such neonatal treatment. In this study, the pituitary-testicular activity of newborn male rats was temporarily blocked by treatment with a GnRH antagonist analogue (N-Ac-4-Cl-D-Phe1, 4-Cl-D-Phe2, D-Trp3, D-Phe6, des-Gly10-GnRH-D-alanylamide; Organon 30039; 2 mg/kg s.c. twice daily) on Days 1-5 of life. Timing of puberty was slightly delayed in the treated rats (average: 2 days, p less than 0.05), as determined by the age of the balano-preputial separation. In adult rats (90-110 days), only 3 of the 17 rats treated neonatally with GnRH antagonist were fertile (14 of 17 controls, p less than 0.01), despite normal circulating androgen levels. Pituitary and serum follicle-stimulating hormone (FSH) levels were slightly but consistently elevated (20-30%; p less than 0.05) in antagonist-treated animals, whereas luteinizing hormone (LH) levels (both immunoreactive and bioactive) were unaffected. The pituitary contents of GnRH receptors were increased in antagonist-treated animals 85 +/- 6.6 (mean +/- SEM, n = 19) vs. 58 +/- 4.1 fmol/gland in controls (n = 20; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Suppression of pituitary-testis function in rats treated neonatally with a gonadotrophin-releasing hormone agonist and antagonist: acute and long-term effects

The acute and long-term effects of pituitary-testis suppression with a gonadotrophin-releasing hormone (GnRH) agonist, D-Ser(Bu(t))6des-Gly10-GnRH N-ethylamide (buserelin; 0.02, 0.1, 1.0 or 10 mg/kg body weight per day s.c.) or antagonist, N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (RS 68439; 2 mg/kg body weight per day s.c.) were studied in male rats treated on days 1-15 of life. The animals were killed on day 16 (acute effects) or as adults (130-160 days; long-term effects). Acutely, the lowest dose of the agonist decreased pituitary FSH content and testicular LH receptors, but with increasing doses pituitary and serum LH concentrations, intratesticular testosterone content and weights of testes were also suppressed (P less than 0.05-0.01). No decrease was found in serum FSH or in weights of accessory sex organs even with the highest dose of the agonist, the latter finding indicating continuing secretion of androgens. The GnRH antagonist treatment suppressed pituitary LH and FSH contents and serum LH (P less than 0.05-0.01) but, as with the agonist, serum FSH remained unaltered. Testicular testosterone and testis weights were decreased (P less than 0.01) but testicular LH receptors remained unchanged. Moreover, the seminal vesicle and ventral prostate weights were reduced, in contrast to the effects of the agonists. Pituitary LH and FSH contents had recovered in all adult rats treated neonatally with agonist and there was no effect on serum LH and testosterone concentrations or on fertility.(ABSTRACT TRUNCATED AT 250 WORDS)

Neonatal treatment of male rats with a gonadotropin-releasing hormone antagonist impairs ejaculation and fertility

Pituitary-gonadal suppression of neonatal male rats with a gonadotropin-releasing hormone antagonist N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (RS 68439; Syntex; 2 mg/kg/day) during days 1-10 of life resulted in infertility of adult animals, when studied at the age of 90, 115 and 150 days. Numbers of fertile animals per rats tested at these ages were 1/10, 2/14 and 4/14, respectively, in the antagonist treated animals (vs. 8/10, 9/13 and 9/13 in controls; p less than 0.01-0.05). The numbers of mounts and intromissions were unaffected by the antagonist treatment, but none of the treated animals (n = 10) ejaculated in four subsequent behavior tests. However, if the vaginal smears were checked in a group of rats after caging the males separately with a normal female for 8 days before the behavior tests, each male had ejaculated but the females were not fertilized. When the neonatally GnRH antagonist-treated rats were followed in the long-term, fertility slowly recovered, and at the age of 220 and 350 days, the number of successful pregnancies was similar to that of age-matched controls. It is concluded that short-term neonatal pituitary-gonadal suppression with GnRH antagonist results in impaired ejaculation and infertility of adult male rats, but fertility slowly recovers within a year.

Suppression and recovery of pituitary gonadotrophin secretion in intact and orchidectomized rats treated neonatally with a gonadotrophin-releasing hormone antagonist

Suppression of neonatal rat pituitary-testis function by gonadotrophin-releasing hormone (GnRH) antagonists results in delayed sexual maturation and infertility. Since the mechanism is not understood, the acute effects of a GnRH antagonist on gonadotrophin secretion in neonatal male rats has been studied in more detail. Treatment with a GnRH antagonist analogue, N-Ac-D-Nal(2)1,D-p-Cl-Phe2,D-Trp3,D-hArg(Et2)6,D-Ala10 -GnRH (2 mg/kg per day) on days 1-10 of life had prolonged effects on gonadotrophin secretion; serum LH and FSH recovered in 1 week, but the pituitary content took 2 weeks to recover. Likewise, LH and FSH responses to acute in-vivo stimulation with a GnRH agonist were still suppressed 1 week after the treatment. Interestingly, a rebound (86% increase) in basal serum FSH was found 16 days after treatment with the antagonist. Whether testis factors influence gonadotrophin secretion during treatment with the GnRH antagonist and/or in the subsequent recovery period was also assessed. Neonatal rats were castrated on days 1, 5 or 10 of the 10-day period of antagonist treatment. Orchidectomy on days 1 and 5 only marginally affected gonadotrophin secretion. When orchidectomy was performed at the beginning of the recovery period, no effects on pituitary recovery were seen within 1 week of castration. After 16 days, serum LH and FSH in the antagonist-treated and control castrated rats were equally increased but the pituitary contents of the antagonist-treated rats were still suppressed. Finally, the effect of testosterone treatment on the recovery of gonadotrophin secretion after antagonist suppression was studied in intact and orchidectomized animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Sexual maturation of male rats treated postnatally with a gonadotrophin-releasing hormone antagonist

Postnatal secretion of gonadotrophin by male rats was inhibited by a potent gonadotrophin-releasing hormone (GnRH) antagonist analogue (N-Ac-4-Cl-D-Phe1,4-Cl-D-Phe2,D-Trp3,D-Phe6,des-Gly10-GnRH-D-al anylamide; Org 30039; 2 mg/kg s.c. twice daily) on days 1-5, 6-10, 11-15 or 16-20 of life. The onset of puberty was determined by monitoring the separation of the preputium from the glans penis, i.e. balano-preputial separation (BPS). Rats treated on days 1-5 matured normally, whereas all treatments between days 6 and 20 delayed BPS (P less than 0.01). In adult rats (between 110 and 160 days of age), testis weights were reduced by 21-35% (P less than 0.01) in groups treated between days 1 and 15, although weights of the accessory sex glands were normal. Testicular FSH receptors were decreased by 31-47% (P less than 0.01) in all treatment groups, whereas the LH receptor content was decreased only in rats treated between days 1 and 5 (18%; P less than 0.05) and prolactin receptor content decreased only in rats treated up to day 10 (31-33%; P less than 0.01). Concentrations of serum testosterone, LH and FSH, and pituitary contents of LH and FSH were unaffected by neonatal treatment with Org 30039. Animals treated with Org 30039 had reduced fertility which was most pronounced (88%; P less than 0.01) in rats treated between days 1 and 5. However, motile sperm were detectable in the cauda epididymis of the infertile rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Kazal type trypsin inhibitor in amniotic fluid in fetal developmental disorders

The amniotic fluid concentrations of the Kazal type trypsin inhibitor were studied in pregnancies with fetal developmental disorders. The samples were obtained by amniocentesis between 14 and 19 weeks of gestation. In cases with fetal malformations, the level was below the normal 10th centile in 15 out of 28 cases (54 per cent, p less than 0.05) and above the normal 90th centile in 2 cases (7.1 per cent). Low values were common in cases with intrauterine fetal death or congenital nephrosis. The levels were normal in fetal chromosomal aberrations.

Pancreatic secretory trypsin inhibitor from human amniotic fluid and fetal and neonatal urine: concentrations and physicochemical characterization

The levels and physicochemical properties of the pancreatic secretory trypsin inhibitor, also known as Kazal type trypsin inhibitor, were studied in human amniotic fluid. In the second trimester, the median concentration was 160 ng/ml, which exceeds the maternal serum levels 20-fold. Towards term, the amniotic fluid levels declined about 5-fold, whereas the maternal serum values remained constant. In fetal urine, the concentration of the trypsin inhibitor was similar to that in amniotic fluid in early gestation, whereas in newborn urine, the median level was 4-to 5-fold higher than in term amniotic fluid. The physiochemical characteristics of the trypsin inhibitor in amniotic fluid, neonatal urine and cancer urine from an ovarian cancer patient were similar, as studied by gel filtration, high performance reverse phase liquid chromatography, and complete immunological identity in immunodiffusion. The physicochemical similarity and levels in various compartments suggest fetal contribution to amniotic fluid levels of the trypsin inhibitor.

Zinc and alpha-fetoprotein in amniotic fluid from early pregnancies with fetal malformations

Zinc and alpha-fetoprotein concentrations were quantitated in second-trimester amniotic fluid from 111 normal pregnancies and 29 pregnancies with various fetal malformations. The zinc level varied between 0.3 and 4.0 mumol/L (median 1.3) in the normal samples and between 1.8 and 17.9 mumol/L (median 5.0) in cases with malformations. The level was above 2.5 times the normal median in 23 of the 29 (79%) gestations with the malformations. Amniotic fluid zinc and alpha-fetoprotein levels showed a positive correlation (r = 0.78), and the alpha-fetoprotein level was elevated in all gestations with fetal disorders and elevated zinc levels, as well as in five of the six cases with fetal defects but normal zinc concentrations. The elevation of zinc was more marked than that of alpha-fetoprotein in three cases of fetal malformations. Five samples were false positive on alpha-fetoprotein assay but contained normal zinc levels. Removal of alpha-fetoprotein from amniotic fluid had no effect on the zinc concentration, indicating that zinc is not bound to amniotic fluid alpha-fetoprotein.

Amniotic fluid pregnancy-specific beta 1-glycoprotein (SP1) in fetal developmental disorders

Concentration of pregnancy-specific beta 1-glycoprotein (SP1) was studied in second and third trimester amniotic fluid from pregnancies with various fetal developmental disorders. The material consisted of 26 cases with chromosomal disorders and 19 cases with non-chromosomal fetal malformations. The SP1 concentration was elevated in two cases of Meckel's syndrome (mean +2.7-4.0 S.D.) as well as in one case of fetal triploidy (mean +22 S.D.), while it was normal in all other 14 different fetal disorders.

Reactivity of amniotic fluid alpha-fetoprotein with concanavalin A-sepharose in pre-natal diagnosis of fetal malformations

The proportion of concanavalin A-non-reactive alpha-fetoprotein was determined in 215 amniotic fluid samples from second trimester pregnancies. the median percentage for concanavalin A-non-binding alpha-fetoprotein was 35.5% at the 15th week and 32.2% at the 18th gestational week. Nineteen of the 23 pregnancies with various fetal malformations showed highly elevated total alpha-fetoprotein levels. In this group, the value for non-reactive alpha-fetoprotein was below the normal range in 12 out of 13 samples collected at 15-17 weeks of pregnancy and in four out of six samples at 18-19 weeks. Four pathological pregnancies had only moderately elevated total alpha-fetoprotein levels (5.3-7.9 SD above the mean) and two of these samples had a low percentage of the concanavalin A-non-binding fraction. The amniotic fluid alpha-fetoprotein concentration was between 3 and 5 SD and over 5 SD above the mean in four and seven normal pregnancies, respectively. The concanavalin A-fractionation classified correctly 10 out of these 11 cases. The results indicate that the determination of the proportion of concanavalin A-non-binding alpha-fetoprotein is a useful supplementary test to the total alpha-fetoprotein assay.