Pineal cysts in children

OBJECTIVE: To describe the prevalence and characteristics of pineal cysts found on MRI in children. METHODS: This is a retrospective monocentric study of all brain magnetic resonance imaging (MRI) examinations performed under the same technical conditions for checking the idiopathic nature of short stature (ISS group, n = 116) and for the investigation of central precocious puberty (CPP) over a 3-year period (n = 56). Dimensions, wall and septal thickness, number of locules, signal intensity, and the presence of a solid component were analysed. Ten of 19 cysts were re-evaluated (follow-up interval 4-28 months). The prevalence of the pineal cysts was compared between the two groups using χ2 and Fisher's exact tests, and a significance threshold of p < 0.05. RESULTS: The prevalence of cysts was comparable in the two groups, CPP (10.7%) and ISS (11.2%). Cyst characteristics were similar in the two groups and 74% had thin septations. None of the cysts changed on follow-up. None of the children with pineal cysts exhibited neurological signs. CONCLUSION: Benign pineal cysts are a common finding in young children. High-resolution MRI demonstrates that these cysts are often septated. This pattern is a normal variant and does not require follow-up MR imaging or IV contrast media.

Pseudotumor of the pituitary due to PROP-1 deletion

Hypopituitarism associated with pituitary mass in childhood is most frequently the consequence of craniopharyngioma or Rathke's cleft cyst. We report a patient with an intrasellar pseudotumor associated with hypopituitarism, which led us to a misdiagnosis of intrasellar craniopharyngioma. After spontaneous involution of the mass, diagnosis was revised. DNA analysis showed a deletion in the Prophet of Pit-1 (PROP-1) gene, a pituitary transcription factor. It is important to recognize that a PROP-1 deletion can cause pituitary pseudotumor that can be mistaken for a craniopharyngioma or Rathke's pouch cyst.

Effects of prolonged administration of ultralente insulin on fasting and postbreakfast beta-cell function in normal adults

Treatment with small doses of subcutaneous insulin is being investigated as a possible approach to prevent type 1 diabetes in humans. The mechanism of prophylactic insulin therapy could involve the inhibition of beta-cell secretory activity and/or the initiation of an active immunoregulatory process. To evaluate the pure metabolic effect of exogenous insulin, the present study assessed whether daily subcutaneous administration of ultralente insulin alters beta-cell function in normal adults. Fourteen healthy adults were randomized to receive 0.2 U/kg x d ultralente insulin (Ultratard; Novo Nordisk, Bagsvaerd, Denmark) or placebo subcutaneously once daily for 30 days. Plasma glucose, C-peptide, and insulin concentrations were measured in the fasting state and 1 hour after a standardized breakfast, during treatment and during a recovery period of 10 days. Insulin administration induced a 15% to 40% decrease of fasting plasma C-peptide. In contrast, postbreakfast plasma C-peptide increased by 40% to 90% in subjects receiving insulin. Fasting and postbreakfast C-peptide concentrations were significantly different between groups during the injection period after adjustment for baseline concentrations (P < .05, ANOVA with repeated measures). These alterations disappeared 3 days after cessation of insulin treatment. The present regimen of exogenous insulin alters endogenous insulin secretion in normal subjects. Instead of the expected beta-cell rest, the effect appeared to be dual, with insulin secretion decreasing in the basal state and increasing after meals.

Prognosis of children with malignant pheochromocytoma. Report of 2 cases and review of the literature

Malignant pheochromocytomas are rare in childhood and the prognosis of children with this tumor is not well known. We present 2 pediatric observations of malignant pelvic pheochromocytoma. Symptoms in both cases were headache and hypertension. The tumor invaded the sacral bone. Angiogram helped to localize the tumor and metastases, and allowed preoperative embolization of the tumor in 1 case. The first child underwent incomplete surgical resection, (131)I-MIBG therapy and radiotherapy, and is still alive 2 years after diagnosis. The second child died from metastatic invasion a few weeks after discovery of the tumor. We reviewed previous reports of children with malignant pheochromocytomas (30 cases). Primary tumor was extraadrenal in 50% of cases. The 3-year survival rate was 73 +/- 9% (mean +/- SD). Apart from surgical resection, no particular treatment appeared to be more effective than others in reducing mortality.

Lack of effect of GnRH agonists on final height in girls with advanced puberty: a randomized long-term pilot study

GnRH agonists improve final height in girls with "true" precocious puberty. To test if a comparable effect can be obtained in older girls, we performed a long-term controlled study in 30 caucasian girls whose puberty started between 8.4 and 10 yr (9.4 +/- 0.1 yr), a variant of normal called "advanced" puberty. At entry into trial, these girls had clinical, biological, and sonographic manifestations of puberty and a bone age greater than 10.9 yr. They were randomized 2:1 to receive 3.75 mg triptorelin im every 4 weeks for 2 yr (n = 20, group I) or no treatment (n = 10, group II). Mean height at inclusion was 135.2 +/- 4.3 cm (+0.6 SDS) in group I, 136.1 +/- 4.2 cm (+0.8 SDS) in group II, with target height 157.6 +/- 4.3 cm (group I) and 157.8 +/- 4.7 cm (group II), and predicted height (Bayley-Pinneau) 154.1 +/- 3.9 cm and 155.2 +/- 3.7 cm. Although GnRH agonists transiently delayed sexual maturation as well as bone age and growth rate, they had no clear-cut long-standing effect, and final height was comparable in treated (157.6 +/- 4.0 cm) and untreated girls (156.1 +/- 5.3 cm) (NS).

T-cell response to proinsulin and insulin in type 1 and pretype 1 diabetes

Insulin-dependent diabetes mellitus (IDDM) results from the selective destruction of pancreatic beta cells by a T cell-mediated autoimmune process. Insulin and proinsulin are the only known beta cell-specific autoantigens. Using short-term cultures of freshly isolated peripheral blood mononuclear cells, we evaluated T-cell responses to proinsulin and to insulin in IDDM patients and individuals at risk for IDDM. A proliferative T-cell response to proinsulin was observed in only 2 of 26 recent-onset IDDM subjects and 2 of 12 long-standing IDDM subjects and was associated with a proliferative response to insulin. In contrast, 5 of 13 islet cell autoantibody-positive first-degree relatives of IDDM patients showed a proliferative response to proinsulin alone, 3 of 13 to insulin alone, and 1 of 13 to both insulin and proinsulin. Overall, 9 of 13 ICA-positive first-degree relatives responded to either proinsulin or insulin. We observed an inverse relationship between antiinsulin antibodies and T-cell responses to insulin in ICA-positive first-degree relatives but not in long-standing IDDM patients. Our data indicate that proinsulin is a major antigen in IDDM and, further, illustrate the difference between the autoimmune response to insulin and the immune response to exogenous insulin.

Clinical and prognostic aspects of adrenocortical neoplasms in childhood

BACKGROUND

A retrospective study of 54 children was undertaken to define the clinical presentation and secretory patterns of adrenal tumors and to evaluate the outcome of surgical resection and medical therapy.

PROCEDURES

Different factors were studied in univariate and multivariate analysis by using the Cox proportional hazard model.

RESULTS

Median age at diagnosis was 4 years. Boys and girls were affected equally. The disease was revealed by virilization (61%) or by a palpable mass (39%) with a 0.1-5.5 year delay from initial symptoms. At initial examination, we found that 76% of children were virilized. Ninety-four percent of the tested tumors secreted androgens, which were associated with glucocorticoids in 36%. Adrenal tumors in children were smaller than in adults. Half of them measured less than 10 cm. There were recurrences in 40% of children. The survival rate at 5 years was 49%, 70% if resection was microscopically complete and 7% if not (P < 0.001).

CONCLUSIONS

In children, rare adrenal tumors have different diagnostic and prognostic characteristics than in adults; however, recurrences remain frequent. The efficacy of chemotherapy, mainly o,p'-DDD (Mitotane), remains to be evaluated in comparative trials.

Low dose linomide in Type I juvenile diabetes of recent onset: a randomised placebo-controlled double blind trial

The quinoline-3-carboxamide, linomide, protects non-obese diabetic mice from diabetes. The effects of linomide on insulin needs and beta cell function were studied in recent juvenile Type I diabetes in a double-blind trial. Patients with recent onset diabetes were randomly assigned to treatment with a fixed dose of 2.5 mg linomide (42 patients) or placebo (21 patients) for 1 year, in addition to insulin and diet. Glycated haemoglobin was 10-15% lower at 9 months (p = 0.003) and 12 months (p < 0.05) in the linomide group. The insulin dose was 32-40% smaller in the linomide group at 3 (p < 0.03), 6 (p < 0.02), 9 (p < 0.001) and 12 months (p = 0.01). Insulin doses correlated negatively with C peptide values (p = 0.001-0.002). The trend for higher C peptide values in the linomide group did not reach significance. In a post hoc subgroup analysis performed in 40 patients (25 from the linomide group and 15 from the placebo group) who still had detectable residual beta cell function at entry, linomide was associated with 45-59% higher C peptide value at 6 months (p < 0.05), 9 months (p < 0.05) and 12 months (p < 0.05). The main adverse effects of linomide were mild transitory anaemia (45 vs 10% in the linomide and placebo groups), thrombocytopenia (24 vs 10%), and mild joint discomfort (45 vs 5%) with no clinical signs. In conclusion, low-dose linomide reduced the insulin needs in patients with juvenile Type I diabetes of recent onset and improved beta cell function in patients who still had detectable beta cell function at entry. These results support further clinical and experimental studies to define the effects of linomide in Type I diabetes provided the safety of linomide is reliably established.

Factors associated with glycemic control. A cross-sectional nationwide study in 2,579 French children with type 1 diabetes. The French Pediatric Diabetes Group

OBJECTIVE

To determine on a large scale the multiple medical and nonmedical factors that influence glycemic control in the general population of children with diabetes, we performed a nationwide French cross-sectional study.

RESEARCH DESIGN AND METHODS

We enrolled 2,579 patients aged 1-19 years with type 1 diabetes of > 1 year's duration. The study was center based: 270 centers were identified, 206 agreed to participate, and 147 included at least 90% of their patients. Questionnaires were completed by physicians interviewing patients and family, and HbA1c measurements were centralized. To identify explanatory variables for HbA1c level and frequency of severe hypoglycemia, we performed multiple regression analysis using all the quantitative variables collected and stepwise logistic regression for the qualitative variables.

RESULTS

Mean HbA1c value for the whole population was 8.97 +/- 1.98% (normal 4.7 +/- 0.7% [SD]). Only 19 children (0.7%) had ketoacidosis during the 6 months before the study, whereas 593 severe hypoglycemia events occurred in 338 children (13.8%). Control was better in university-affiliated hospitals and centers following > 50 patients, reflecting the importance of access to experienced diabetologists. Children had a mean of 2.3 injections, allegedly performed 2.8 glucose measurements per day, and were seen an average of 4.6 times per year at the center. In the multiple regression analysis, 94% of the variance of HbA1c was explained by our pool of selected variables, with the highest regression coefficient between HbA1c and age (Rc = 0.43, P < 0.0001), then with daily insulin dosage per kilogram (Rc = 0.28, P < 0.0001), mother's age (Rc = 0.26, P < 0.0001), frequency of glucose measurements (Rc = 0.21, P < 0.0001), and diabetes duration (Rc = 0.14, P < 0.0001). Logistic regression identified quality of family support and dietary compliance, two related qualitative and possibly subjective variables, as additional explanatory determinants of HbA1c. The frequency of severe hypoglycemia was 45 per 100 patient-years and correlated with diabetes duration, but not with HbA1c levels or other variables.

CONCLUSIONS

Although overall results remain unsatisfactory, 33% of studied French children with type 1 diabetes had HbA1c < 8%, the value obtained in Diabetes Control and Complications Trial adolescents treated intensively. Diabetes management in specialized centers should be encouraged.

Gonadotropin receptors and the control of gonadal steroidogenesis: physiology and pathology

Over the past few years, knowledge of the structure of gonadotropin receptors and their mode of action has rapidly advanced. The cDNA corresponding to the luteinizeng hormone (LH) receptor (LHR) has been cloned, leading to the identification of a novel family of G-protein-coupled receptors. The follicle stimulating hormone (FSH) receptor (FSHR) was thereafter cloned by cross-hybridization with the LHR. Structure-function relationships have been studied by mutagenesis experiments in several laboratories. The cloning and chromosomal localization to chromosome 2p21 of the two human gonadotropin receptor genes has provided insights into their evolutionary relationships. The LHR and FSHR genes are very large and contain 10 and 11 exons respectively. The obtention of monoclonal antibodies against the receptors resulted in the characterization of the receptor proteins. These antibodies also allowed the study of receptor expression in target cells in physiological and pathological conditions. The internalization of the LHR has been studied by electron microscopy. A mechanism of receptor-mediated transcytosis through the endothelial cells of the testes has been described for the LHR. The polarized expression of receptors has been studied. The cloning of gonadotropin receptor genes has opened the field of genetic study of the receptors. Inactivating mutations of the LHR have been described in Leydig cell agenesis or hypoplasia. Different phenotypes, including complete pseudohermaphroditism, ambiguous genitalia and male phenotype, have been described. In the case of the FSHR, only one mutation has been reported in familial ovarian dysgenesis with primary amenorrhea. Related males have variable alterations of spermatogenesis and fertility. Constitutive mutations of the LHR have been reported in familial testotoxicosis. One similar mutation has also been described for the FSHR. Such mutations may lead to the development of a model of receptor activation.

Circulating leptin in normal children and during the dynamic phase of juvenile obesity: relation to body fatness, energy metabolism, caloric intake, and sexual dimorphism

In 112 obese compared with 42 lean children, we found that serum leptin is elevated early in the evolution of childhood-onset obesity (28.4 +/- 1.4 vs. 4.5 +/- 0.4 ng/ml in lean children, P < 0.0001) and correlates with adiposity. Obese children also had higher serum leptin normalized to fat mass. Despite high serum leptin, obese children ingested 2-3 times more calories than did lean control subjects (P < 0.0001) and gained weight rapidly (10.2 +/- 0.3 vs. 2.9 +/- 0.1 kg/year in control subjects, P < 0.0001). Girls had higher leptin levels than did boys, in obese as well as in nonobese children, and showed a closer correlation between adiposity and serum leptin. Elevation of serum leptin was comparable before and after puberty in obese boys, but puberty further increased leptin levels in obese girls (36 +/- 3 ng/ml), resulting in a clear sexual dimorphism with pubertal obese boys (22 +/- 5 ng/ml, P < 0.005). In conclusion, increased serum leptin reflects but does not halt fat deposition in childhood obesity. After normalization to body adiposity, leptin was found to be increased independently by obesity status, female sex, and female sexual maturation.

Cyclosporine delays but does not prevent clinical onset in glucose intolerant pre-type 1 diabetic children

We conducted a pilot study of immunosuppression with low dose cyclosporine in first degree relatives of diabetic patients with immunologic and metabolic criteria for preclinical diabetes: islet cell antibodies (ICA) > or = 20 Juvenile Diabetes Foundation (JDF) units, first phase insulin response < 10th percentile and impaired glucose tolerance. Cyclosporine was given at an initial dose of 7.5 mg/kg*d and tapered after the end of the first year. Six cyclosporine-treated relatives were compared to nine historical controls followed at the same or at different centres. All untreated patients developed diabetes within 12 months (5.9 +/- 1.1 months). Four of the cyclosporine-treated subjects developed diabetes at 5, 24, 24 and 47 months while the other two are non diabetic 47 and 57 months after entry into the trial (time to diabetes > 34 +/- 8 months, P < 0.001 vs the control group; Mann-Whitney test). First phase insulin response increased to normal values in two patients. These results suggest that reversible functional impairment, in association with beta-cell destruction, contributes to the failure of insulin secretion in preclinical type 1 diabetes.

Alterations of plasma lactate and glucose metabolism in obese children

Using a double stable isotope infusion method, we quantified plasma glucose and lactate inter-relationships in five recently obese children. Compared with five age-matched controls, obese children had an approximately 50% increase of total body lactate turnover [167 +/- 20 vs. 111 +/- 20 (SE) mg/min, P < 0.05]. The rate of lactate conversion to glucose was double the normal rate (96 +/- 21 vs. 46 +/- 10 mg/min, P < 0.05). Increased gluconeogenesis from plasma lactate correlated with total glucose production (r = 0.74), with plasma lactate contributing to 58% of glucose production in obese children vs. 38% in normal children (P < 0.05). Conversion into glucose correlated with the rate of lactate release in the circulation (r = 0.76). In turn, the obese children converted a larger fraction (35 +/- 2 vs. 27 +/- 2%, P < 0.02) and amount (58 +/- 10 vs. 34 +/- 5 mg/min, P < 0.05) of glucose into plasma lactate. The amount of lactate originating from plasma glucose correlated (r = 0.70) with lipid oxidation, which was increased in the obese children (58 +/- 4 vs. 23 +/- 5 mg/min, P < 0.02). Our data suggest that increased gluconeogenesis from lactate is associated with increased lipid oxidation and could contribute to the progressive development of insulin resistance and glucose intolerance in juvenile obesity.

[Adrenocortical carcinoma in children: retrospective study of 54 cases]

BACKGROUND

Adrenal tumors rarely occur in childhood. Their criteria for malignancy, as well as the effects of chemotherapy remain poorly defined.

POPULATION

Fourty-five children (median age: 4 years) with an adrenal tumor diagnosed between 1973 and 1993 were included in this study.

RESULTS

Seventy-six percent of the children showed various degrees of virilization. Tumor was palpable in 57%. Most patients (80%) had local disease, 7% loco-regional disease and 13% distant metastases. Forty-five children underwent an apparently complete surgical resection. Recurrence occurred 2 to 17 months after surgery in 18 of them (40%). Twenty-four children received medical treatment (o.p'-DDD or chemotherapy) and one-third had a tumoral response. The overall 5 year survival rate was 49%.

CONCLUSIONS

Adrenocortical neoplasms have a poor prognosis in childhood. Complete resection is the only effective and potentially curative treatment. Currently no effective chemotherapy exists, and the value of adjuvant therapy remains unproven. Multicentric studies are underway to evaluate the efficacy of therapeutic approaches.

Long-term results of early cyclosporin therapy in juvenile IDDM

In juvenile IDDM patients, immunosuppression with cyclosporin A allows partial beta-cell function recovery and transient remissions of insulin dependency. The effects of this therapeutic approach, however, have not been evaluated in the long-term, since no reported trial exceeded 1 year. Here we analyze 130 diabetic children followed at our institution during the first years of their disease. Cyclosporin was given to 83 of them at an initial dose of 7.2 +/- 0.1 mg.kg-1.day-1, which was decreased stepwise then interrupted after 6-62 months, depending on the response to therapy. A total of 47 diabetic children, who served as control subjects in two trials, were pooled for comparison. Over 4 years, the cyclosporin-treated group kept plasma C-peptide approximately twice as high as the control group (P < 0.02). It took 5.8 +/- 0.6 years for C-peptide secretion stimulated by glucagon to become undetectable in the cyclosporin group versus 3.2 +/- 0.6 years in the control group (P < 0.02). Average insulin dose remained lower by 0.2-0.4 U.kg-1.day-1 and glycated hemoglobin by approximately 1% in cyclosporin-treated patients (P < 0.02), who also had less hypoglycemia than the diabetic control subjects (P < 0.05). After 4 years, differences between the groups became nonsignificant. We observed no significant secondary effects of cyclosporin. In conclusion, positive effects of low-dose cyclosporin in recently diagnosed clinical IDDM patients are prolonged beyond interruption of the drug. The magnitude and duration of the benefit, however, do not appear sufficient to justify this immunosuppressive treatment in clinical practice.

Treatment of prediabetic patients with insulin: experience and future. European Prediabetes Study Group

Administration of insulin by a variety of routes can prevent the onset of diabetes and the destruction of pancreatic beta-cells in prediabetic animals. Moreover, intensive insulin therapy improves beta-cell function in patients with recent-onset type 1 diabetes. Preliminary trials have suggested that treatment of high-risk prediabetic patients with insulin can prevent the onset of diabetes. In addition, long-term insulin treatment appears to have no significant side-effects in non-diabetics. However, the mechanism of the protective action of insulin is not yet understood. Several large-scale controlled trials have been organized (e.g. the Diabetes Prevention Trial 1, DPT-1, and the European Paediatric Prediabetes Subcutaneous Insulin Trial, EPP-SCIT), to evaluate the effect of prophylactic insulin therapy in the prevention or delay of diabetes in high-risk paediatric individuals.

Stable isotope determination of plasma lactate conversion into glucose in fasting infants

To quantify lactate gluconeogenesis, we developed a gas chromatography-mass spectrometry method based on the infusion of [6,6-2H2]glucose and [3-13C]lactate tracers to 12 infants aged 1-25 mo fasting for 11.5 +/- 1.5 h. Both rates of appearance of plasma glucose (26.7 +/- 2.6 mumol.kg-1.min-1, 4.8 +/- 0.5 mg.kg-1.min-1) and lactate (30.8 +/- 3.1 mumol.kg-1.min-1, 2.8 +/- 0.3 mg.kg-1.min-1) were remarkably elevated compared with adult values. The interconversion of plasma lactate and glucose was determined by 1) measuring the incorporation of 13C from [3-13C]lactate into plasma glucose; 2) correcting for the metabolic exchange of carbon atoms in the tricarboxylic acid cycle. For this purpose, an additional group of six infants was infused with [3-13C]lactate, and the distribution of 13C at specific carbon positions in the glucose molecule was determined using relevant ions in the electron-impact mass spectrum of its 1,2,5,6-diisopropylidene-3-O-acetyl-alpha-furanosyl derivative; and 3) measuring the reverse conversion of glucose to lactate in five other infants infused with [1-13C]glucose. We found that 54 +/- 2% of glucose was derived from plasma lactate (14.4 +/- 1.3 mumol.kg-1.min-1, 2.6 +/- 0.2 mg.kg-1.min-1). Lactate and glucose rates of appearance were correlated (r = 0.58, P < 0.05) and decreased with fasting duration (r = 0.66, P < 0.02). The correction factor for carbon exchange in the tricarboxylic acid cycle was 1.14 +/- 0.11.(ABSTRACT TRUNCATED AT 250 WORDS)

Retroviral-mediated gene transfer corrects very-long-chain fatty acid metabolism in adrenoleukodystrophy fibroblasts

Adrenoleukodystrophy (ALD), a lethal demyelinating disease of the brain, is caused by mutations of a gene encoding an ATP-binding transporter, called ALDP, localized in the peroxisomal membrane. It is associated with a defective oxidation of very-long-chain fatty acids, leading to their accumulation in many tissues. This study reports that the retroviral-mediated transfer of the ALD cDNA restored very-long-chain fatty acid oxidation in ALD fibroblasts in vitro following abundant expression and appropriate targeting of the vector-encoded ALDP in peroxisomes. The same method may be used in hematopoietic cells as a further step of a gene therapy approach of ALD.

Ketone body turnover at term and in premature newborns in the first 2 weeks after birth

Using the infusion of D-(-)-3-hydroxy-[1,2,3,4,-13C4]butyrate at tracer doses, we measured total ketone body turnover in 13 premature and 10 at term infants in the first 2 weeks after birth. The premature infants received parenteral and/or oral feeding. The normal newborns were either recently fed or briefly fasting. The premature and the fed at term infants had comparable concentrations of ketone body (476 +/- 86 and 406 +/- 78 mumol/l) and free fatty acids (FFA) (309 +/- 47 and 325 +/- 75 mumol/l). In the premature newborns, ketone body turnover rates (3.2 +/- 0.2 mumol kg-1 min-1) were 74% that of fed newborns at term (4.3 +/- 0.3 mumol kg-1 min-1, p < 0.05), and 18% that of normal newborns during a brief fast (17.3 +/- 1.3 mumol kg-1 min-1, p < 0.01). Ketone body production rates correlated with plasma FFA concentrations in both groups (r = 0.62 and 0.69, p < 0.05). However, for a similar plasma FFA content, ketone production was 2- to 3-fold lower in the premature, indicating an immature hepatic capacity to convert FFA into ketones. Our study therefore shows that ketogenesis is already active in infants born 10 weeks before normal term and continuously fed, but that daily ketone production is lower than at term.

[Endocrine evaluation and evolution of intrasellar craniopharyngioma (CPIS): study of 8 cases]

BACKGROUND

Craniopharyngiomas generally develop either in the suprasellar region or in both suprasellar and intrasellar regions. Purely intrasellar craniopharyngiomas are rare in children; they have special clinical and radiological features and pose specific therapeutic problems.

POPULATION AND METHODS

Eight patients (five girls and three boys), aged 7 to 17 years, were admitted from 1976 to 1992 with a diagnosis of intrasellar craniopharyngioma without extrasellar development. Search for endocrine deficiencies was performed in all these patients as well as radiological investigation (skull X-rays, CT scan and MRI).

RESULTS

Persistent delayed growth was the main complaint in seven out of the eight patients. Headache was seen in three patients. The tumor was fortuitously discovered after cranial traumatism in one. Initial endocrine investigations showed growth hormone deficiency in all patients; deficiency in thyrotropin was seen in five, in adenocorticotropin in six. Three patients had moderately increased levels of blood prolactin and four had delayed puberty with gonadotropin deficiency. Only one patient presented with diabetes insipidus. X-rays showed enlarged sella turcica in seven of the eight patients with calcifications in three and a cystic lesion in five. Two patients were operated on because of a doubtful diagnosis: their condition is stable 1.5 and 12 year later, respectively. The tumor volume remained stable with a follow-up of 1.5-9 years in five other patients; its volume gradualled increased in another patient requiring surgical removal 18 months after diagnosis. Antehypophysar deficiency generally increased in all patients, operated on or not, and five patients out of six have gonadotropin deficiency.

CONCLUSIONS

These intrasellar craniopharyngiomas remain generally stable so that the greatest care must be taken in proposing surgical treatment.

[Neonatal hyperglycemia and diabetes mellitus]

BACKGROUND

Hyperglycemia in the neonate may be permanent or more frequently transient. Its treatment is still debated.

PATIENTS AND METHODS

The files of 19 infants with hyperglycemia were retrospectively analysed. Their birth-weights were more than 900 g and their gestational ages more than 27 weeks. Plasma glucose, insulin, C-peptide, islet-cell and insulin autoantibodies were measured in each patient.

RESULTS

Blood glucose ranged from 1.2 to 10 g/l (mean: 5.05 +/- 1.0), between the second hour and the 60th day of life. Four infants presented with permanent neonatal diabetes mellitus: they were small for gestational age. Hyperglycemia was noted from the first day of life. C-peptide levels were less than 0.1 pmol/ml and autoantibodies were absent. Two sibs had hypothyroidism, one patient had unclassifiable chronic diarrhea plus renal disease, the fourth patient had ventricular septal defect. The 15 other patients presented with a transient hyperglycemia that appeared lately (6.1 +/- 3.4 day of life). Hyperglycemia was induced by glucose infusion in five patients, by potentially hyperglycemic drugs in five others. C-peptide levels ranged from 0.01 to 0.76 pmol/ml (mean 0.29 +/- 0.11). One patient and his mother had insulin antibodies. Another patient had congenital heart abnormalities. Hyperglycemia required insulin therapy in 17 cases (four with permanent and 13 with transient hyperglycemia).

CONCLUSION

There are no clinical or biological features permitting foresee the duration of neonatal hyperglycemia. Each patient with birth-weight below 2,500 g should be given insulin when glucosemia remains above 1.3 g/l and his weight does not increase.

Determination of 13C enrichment at specific positions of plasma glucose by gas chromatographic-mass spectrometric analysis of the 1,2:5,6-diisopropylidene-3-O-acetyl-alpha-furanosyl derivative

To determine 13C enrichment at specific positions of glucose, plasma samples (50-100 microliters) were deproteinized using ethyl alcohol, centrifuged, and evaporated to dryness, and the residues were derivatized with acetone/H2SO4 (100/1, v/v). After acetylation, the 1,2:5,6-diisopropylidene-3-O-acetyl-alpha-furanosyl derivative was analyzed by gas chromatography-mass spectrometry. The method was tested using mixtures of natural and 13C-labeled glucose molecules. Ions at m/z 113, 114, 143, 144, 287, and 288, corresponding to the C2-C4, C1-C4, and C1-C6 parts of natural or 13C-labeled glucose molecule, respectively, were selectively monitored to determine the 13C content of these fragments. This method was applied to the study of plasma glucose-labeling pattern following the infusion of [3-13C]lactic acid at tracer doses. Assuming equilibration of label through triose-phosphate isomerization in vivo, we determined the 13C enrichment of carbons 1, 2, and 3 of glucose; the values for E1/E3 and E2/E1 ratios of 8.1 and 0.77, respectively, are consistent with those obtained in studies using radioactive tracers.

[Medium-chain acyl-CoA dehydrogenase deficiency: contribution of molecular biology]

BACKGROUND

Medium-chain acyl-CoA dehydrogenase deficiency is the most frequent cause of defective congenital fatty acid oxidation. Its molecular characterization is now possible. Case n. 1. A girl, 15 month-old, was admitted because she suffered from fever and vomiting, requiring the administration of aspirin. One day later, she showed signs of drowsiness and hypotonia; her blood glucose concentration was 0.3 g/l. She was given intravenous glucose and this episode rapidly passed. Case n. 2. A boy, brother of the preceding patient, was routinely investigated; he was never symptomatic. Case n. 3. A boy, sibling of the two preceding children, was admitted at the age of 18 months because he had gone into a coma during a febrile episode. His blood glucose concentration was 0.15 g/l. This episode was rapidly resolved by a glucose infusion. His fasting blood concentrations of glucose, non esterified fatty acids. beta-hydroxybutyrate, lactate and pyruvate were normal as were his blood carnitine and ammonia, but he showed elevated urinary excretion of dicarboxylic acids.

METHODS

Genomic DNA was extracted from peripheral leukocytes of the three sibs and their parents. The A-->G mutation at nucleotide 985 of the MCAD gene was detected by amplification and creation of a restriction site (ACRS). The implicated segment of this gene was amplified by PCR.

RESULTS

ACRS showed that the symptomatic children were homozygous for the A-->G mutation, whereas their parents were heterozygous. The third asymptomatic child did not carry the mutation.

CONCLUSIONS

Molecular biology techniques are appropriate for diagnosing this potentially lethal disease and their use for screening is important for disease prevention.

[Localizing of Langerhans islets adenoma by transhepatic portal catheterization]

BACKGROUND

The procedures used to locate pancreatic endocrine tumors have only limited success in infants and children in whom the nodules may be small. Portal catheterization may therefore be useful.

CASE REPORT

A child aged 6 yrs 4 months was admitted because of several recent episodes of pallor and sweating associated with hypoglycemia. Further investigation showed moderate hyperinsulinemia and low blood levels of ketone bodies and branched amino-acids after a 15 hr fast. Celiac angiography was normal. The hypoglycemic episodes recurred despite treatment with diazoxide for 6 months. A transparietal portal catheterization was therefore performed. Selective pancreatic venous sampling showed high concentrations of insulin in two small veins draining one part of the head of the pancreas (117 and 89 microU/ml). The head of pancreas was removed 16 months later. Extemporaneous examination revealed an adenoma 0.8 cm in diameter. This patient has completely recovered, 8 months after surgery.

CONCLUSION

Transparietal portal catheterization can detect pancreatic areas with high insulin secretion. It may also help the interpretation of celiac angiographs in children, as diagnosis may be obscured by the normal rich vascularity of the pancreas in these patients.

Decreased insulin response to glucose in islet cell antibody-negative siblings of type 1 diabetic children

Measurement of beta-cell function is an important marker of progression to diabetes in individuals at risk for the disease. Although the peak incidence for the disease occurs before 17 years of age, normal values for insulin secretion were not available in this age group. We performed a simplified intravenous glucose tolerance test in 167 normal children, and in 98 islet cell antibody (ICA)-negative and 12 ICA-positive siblings of diabetic patients. Their age range was 1-16 yr. The first phase of insulin secretion, evaluated as the sum of plasma insulin concentrations at 1 and 3 min, increased with age and was significantly lower in ICA-negative siblings (86 +/- 6 microU/ml, P < 0.002) than in normal controls (115 +/- 6 microU/ml). This difference was not apparent before 8 yr of age. None of the ICA-negative siblings developed diabetes after an average of 4.5 yr. ICA-positive siblings at first study had a first phase insulin response similar to that of ICA negative siblings, but significantly lower than that of the normal controls (74 +/- 13 microU/ml, P < 0.02). The reason for the decreased insulin secretion in ICA-negative siblings is unknown, but could involve a defect in the growth of beta-cell mass or insulin secretion that could be part of the multifactorial pathogenesis of type 1 diabetes.

Time course of increased lipid and decreased glucose oxidation during early phase of childhood obesity

To determine the time course of metabolic dysfunctions in recent active obesity, we studied basal energy expenditure and lipid and glucose oxidation in 31 obese children (duration of obesity 1-11.5 yr), compared with 14 lean age-matched control subjects. Using indirect calorimetry in basal overnight fasting conditions, we found that obese children produced 15% more energy than control subjects. Obese children oxidized twice as much lipid (56 +/- 4 mg/min) as normal children (25 +/- 5 mg/min, P < 0.0005), so that lipid oxidation provided 61 +/- 6% of overall energy production (vs. 33 +/- 3% in control subjects, P < 0.0005). This increase of lipid oxidation was already present in the earlier stages of obesity. Glucose oxidation was diminished in the obese (93 +/- 6 mg/min) compared with the control children (136 +/- 6 mg/min, P < 0.0005) and accounted for only 39 +/- 3% of energy production (67 +/- 6% in control subjects, P < 0.0005). This decrease was not present initially and appeared after approximately 4 yr and worsened with obesity duration (r = 0.72, P < 0.0005). The results were similar when lipid and glucose oxidation were normalized to body surface area or lean body mass. We hypothesize that increased lipid oxidation is one of the earlier dysfunctions observed in recent-onset obesity and that lipid oxidation may induce a progressive decrease of glucose oxidation, insulin resistance, and increased fasting insulin secretion.

[The use of actapulgite for the treatment of acute diarrhea in infants and children. Review of pediatric studies]

Epidemiological data on diarrhea due to Rotavirus are similar enough across different regions of the world to allow the pooling of clinical studies of Actapulgite for the treatment of acute diarrhea in infants and children in France and Africa. A total of 7,616 infants and children were entered into these open or placebo-controlled trials. Most patients were under two years of age, results of the analysis confirmed the antidiarrheal efficacy and safety of Actapulgite.

Improvement of diabetic control and acceptability of a three-injection insulin regimen in diabetic adolescents. A multicenter controlled study

OBJECTIVE

To compare the effectiveness and acceptability of a three-injection insulin regimen with the conventional two-injection therapy in an unselected population of diabetic adolescents.

RESEARCH DESIGN AND METHODS

Some 205 patients aged 10-18 yr with IDDM, who were previously treated with two daily insulin injections, were included without any selection into a randomized trial. They were either switched to three (regular prebreakfast, regular prelunch, and [regular+ultralente] predinner) or remained on two ([regular+intermediary] prebreakfast and predinner) subcutaneous injections. They were evaluated after 1 yr of treatment. The major criteria of outcome of efficacy were the concentration of GHb, the frequency of severe hypoglycemia and DKA, and body weight.

RESULTS

Of the patients, 82% accepted the three-injection regimen, and 83% accepted the two-injection regimen. At entry into the trial, no significant differences appeared between the two treatment groups nor among patients refusing the allocated regimen. Significant explanatory variables predicting initial diabetes control were duration of disease and adherence to diet. GHb, decreased from 9.8 +/- 0.1 to 9.3 +/- 0.2% (P < 0.05) in the three-injection group, whereas it increased from 9.5 +/- 0.3 to 9.8 +/- 0.3% (P < 0.05) in the two-injection group, resulting in a modest (0.75%) but significant difference (P < 0.05) between GHb change in the two groups. The difference reached 1.4% (P < 0.0002) in patients with GHb > 11.2% at entry. The frequency of hypoglycemia and DKA was similar in the two groups. None of the parameters known to potentially influence glycemic control changed during the trial, and, therefore, the improvement of GHb could be attributed to the pattern of daily insulin distribution per se.

CONCLUSIONS

In the general diabetic adolescent population, the efficacy of a three-injection regimen is somewhat superior to that of a conventional two-injection regimen, particularly in patients previously poorly controlled. The acceptability of this regimen being excellent, its increased use should be considered in this age-group.

Growth hormone effects on carbohydrate and lipid metabolism in childhood

The effects of recombinant growth hormone (GH) at therapeutic doses were investigated in GH-deficient and nondeficient children with short stature, with respect to glucose turnover and insulin sensitivity. In both groups of patients, these parameters were normal after 6-12 months of recombinant GH administration.

[Treatments of diabetes in children]

The treatment of children with type I insulin dependent diabetes mellitus has been improved by the combination of multi-daily self blood glucose monitoring and insulin injections. Specific aspects of therapy in neonatal diabetes, as well as in infants, are discussed. Non insulin dependent diabetes is rarely observed in pediatric ages and is generally treated with simple diet control.

Glycerol production and utilization during the early phase of human obesity

To study the initial period of fat deposition in human obesity, we measured glycerol turnover in 12 children of 135-253% ideal body weight, who had continuously gained weight since the onset of obesity 2-9 yr previously. Hyperinsulinemia developed in these children depending on obesity duration (r = 0.74, P less than 0.01). Whole-body glycerol production was twofold greater in the obese children (311 vs. 156 mumol.min-1, P less than 0.01) and correlated with body fat (r = 0.67, P less than 0.005). Normalization of glycerol flux to fat mass revealed that the rate of triglyceride hydrolysis was in fact lower in the adipose tissue of obese children (9.4 vs. 17.7 mumol.min-1/kg body fat) and correlated with plasma insulin (r = 0.64, P less than 0.005). Euglycemic insulin clamps showed that the response of glycerol production to a unit increment in plasma insulin concentration was increased in obese children, suggesting increased insulin sensitivity of adipose tissue. As a direct consequence (r = 0.67, P less than 0.025) of their elevated plasma glycerol concentration (65 +/- 4 vs. 37 +/- 2 microM, P less than 0.05) obese children had an increased glycerol utilization by the whole body, as well as per unit of lean body mass (9.1 +/- 1 vs. 6.5 +/- 0.9 mumoles.min-1.kg lean body mass-1, P less than 0.025).

Near normalization of adolescent height with growth hormone therapy in very short children without growth hormone deficiency

Ten prepubertal children with stature at or below the 1st percentile for height and without growth hormone deficiency received 0.3 U recombinant growth hormone per kilogram daily for 2 years before puberty. Their growth velocity increased from 4 +/- 0.3 cm/yr before treatment to 10.7 +/- 0.6 and 8.8 +/- 0.6 cm, respectively, during the first and second years of treatment, and then remained at 5.7 +/- 0.7 cm the year after the end of growth hormone administration. This resulted in a near normalization of adolescent height. Bone maturation paralleled chronologic age, and therefore the expected final height of the children increased by approximately 10 cm. Administration of growth hormone induced a reversible hyperinsulinemia, with moderate and transient changes in glucose metabolism. A prospective, randomized study, including an untreated cohort, will be needed to confirm the effects on final height and to determine the magnitude of the response in familial short stature.

[Result of 3 years of screening for preclinical phase of juvenile insulin-dependent diabetes mellitus]

We screened 1,000 individuals for pre-type I diabetes mellitus: 927 were first degree relatives of patients treated at our institution, 31 other had related autoimmune diseases, 42 had fortuitously discovered slight hyperglycemia. Islet cell antibodies were present in 31 subjects, 13 adults and 18 children. Among these 18 children, 7 also had complement-fixing islet cell antibodies, and 5 anti-insulin antibodies. All but one initially had a normal insulin response to intravenous glucose. The child with the abolished response, as well as another whose insulin secretion fell down during the study period, became diabetic. Based on these preliminary data, we are developing large scale family screening of pre-type I diabetes.

Limited duration of remission of insulin dependency in children with recent overt type I diabetes treated with low-dose cyclosporin

Preliminary data from our group indicated that cyclosporin A induced frequent remissions of insulin dependency in a group of 40 insulin-dependent (type I) diabetic children if given at the onset of clinical manifestations of diabetes. We report a 2-yr analysis of the response to cyclosporin A in the group of 81 patients included in the initial study. As observed before, a remission could be obtained in most of the patients (65%) in association with a shorter duration of symptoms, less severe hyperglycemia, lower incidence of ketoacidosis, and higher plasma C-peptide concentrations. All remissions ended during the follow-up period after a mean +/- SE duration of 316 +/- 21 days (range 31-850 days). Two parameters were linked to the duration of remissions: the mean circulating level of cyclosporin during the first 3 mo and the duration of prediagnostic polyuria. We were unable to relate the end of a remission to variations in the cyclosporin regimen, titer of autoantibodies, or progression of beta-cell failure. The euglycemic clamp technique revealed that insulin sensitivity decreases with time in patients not taking insulin. At 24 mo, the patients who had a remission of insulin dependency had better glycemic control, lower insulin dosages, and C-peptide levels two- to threefold higher than the nonremission patients and four- to sixfold higher than the historical control subjects. The cyclosporin regimen was well tolerated over the observed period: more specifically, serum creatinine remained unchanged, and kidney biopsies performed at 18-24 mo of treatment were within normal limits.(ABSTRACT TRUNCATED AT 250 WORDS)

High-dose growth hormone treatment of non-growth hormone-deficient children: preliminary results after 2 years

The growth response to high-dose growth hormone (GH) therapy was investigated in 10 short, prepubertal, slowly-growing children. Two years treatment with recombinant human GH at a dose of 0.3 IU/kg daily 7 days per week resulted in a mean height increase of 19.5 cm (range 17-23 cm). There was a slight but not significant acceleration of bone age maturation. The treatment also induced a sustained increase in insulin secretion without detectable changes in glucose tolerance.

Capillary gas-liquid chromatographic/mass spectrometric measurement of plasma acetate content and (2-13C) acetate enrichment

In studies where (2-13C)acetate is employed as isotopic tracer in vivo, we have reported a selected ion monitoring gas-liquid chromatographic/mass spectrometric method which allows plasma tracer enrichment as well as plasma acetate content to be determined in the same 200-500 microliters sample through the use of methacrylic acid as the assay internal standard. For standard solutions in the range equivalent to plasma acetic acid concentrations of 10-200 microM, assay precision was +/- 4.3%. For plasma samples in the physiological range (approximately 20-300 microM acetate) assay precision averaged better than +/- 5%. The use of the method is illustrated by measuring acetate turnover in a young adult.

Growth hormone treatment of children with short stature increases insulin secretion but does not impair glucose disposal

Pediatricians willing to administer GH to non-GH-deficient children with short stature are concerned about the potential adverse effects of this hormone on glucose homeostasis and insulin action. This study was designed to determine the effects of GH therapy on carbohydrate metabolism in 10 prepubertal non-GH-deficient children with short stature. After 12 months of treatment with 0.3 U GH/kg BW.day, which resulted in an increase in height velocity from 4.0 +/- 0.3 (+/- SE) to 11.0 +/- 0.4 cm/yr, glucose tolerance was not impaired in these children. Not only were their fasting and postprandial plasma glucose concentrations unchanged from the pretreatment values, but basal glucose turnover did not vary; it was 0.53 +/- 0.04 before and 0.64 +/- 0.06 mmol/m2.min after GH treatment. Using the euglycemic clamp technique, the dose-response curves describing the effects of insulin on glucose disposal were comparable before and after GH treatment. There was a consistent 1.5- to 2-fold increase in plasma insulin and C-peptide concentrations during GH treatment, in both the basal and postprandial states, and after oral glucose or iv glucagon stimulation. We conclude that the GH regimen employed was remarkably effective in increasing growth velocity and devoid of detectable diabetogenic effects during a 1-yr treatment period in these non-GH-deficient children. (glucose, 1 mmol/L = 18 mg/dL; insulin, 1 pmol/L = 0.139 microU/mL; C-peptide, 1 pmol/L = 0.003 ng/ml).

Medium-chain fatty acids increase glucose production in normal and low birth weight newborns

To study the pathogenesis of hypoglycemia in low birth weight infants, glucose production was measured in five hypotrophic and four premature newborns with glycemia of 45 +/- 6 and 59 +/- 10 mg/dl, respectively. Hepatic glucose output averaged 5.7 +/- 0.4 and 5.3 +/- 0.5 mg.kg-1.min-1 in these neonates vs. 8.2 +/- 0.5 mg.kg-1.min-1 in five normal at term newborns and was correlated with glycemia (P less than 0.02). Despite normal plasma free fatty acids, the low birth weight infants had low ketone levels of 163 +/- 72 and 126 +/- 65 vs. 263 +/- 60 microM in normals. Oral administration of medium-chain triglycerides to the neonates increased their circulating ketones by two- to threefold and restored near-normal glycemia (51 +/- 9 and 76 +/- 8 mg/dl) and production of glucose (6.7 +/- 0.7 and 6.6 +/- 0.8 mg.kg-1.min-1) in the hypotrophic and premature vs. normals (8.7 +/- 0.7 mg.kg-1.min-1). Individual rates of glucose production correlated with ketone concentrations (P less than 0.02). We conclude that the hypoglycemia characterizing low birth weight neonates is primarily due to impaired glucose production. That exogenous lipids were able to increase glucose production indicates that fatty acid oxidation plays an important glucoregulatory role in the human newborn.

Increased basal glucose production and utilization in children with recent obesity versus adults with long-term obesity

To characterize the abnormalities of glucose homeostasis and insulin action early in the course of human obesity, we studied in vivo glucose kinetics in seven children who were recently massively overweight. At time of study they were gaining weight at a rate of 13.5 +/- 1.4 kg/yr. They were compared with six age-matched control subjects. Six adults with long-term obesity and five normal adults were studied in parallel. The obese children and adults were normoglycemic and hyperinsulinemic. We found that glucose production and utilization were remarkably higher in obese children (295 +/- 18 mg/min; 7.6 mg.kg-1 lean body mass.min-1) than in control children (129 +/- 13 mg/min; 4.4 mg.kg-1 lean body mass.min-1, P less than .01) and obese adults (151 +/- 8 mg/min; 3.1 +/- 0.3 mg.kg-1 lean body mass.min-1, P less than .01). Obese adults had normal rates of glucose production and utilization. Insulin- and non-insulin-mediated glucose uptake, estimated with somatostatin-induced suppression of endogenous insulin secretion, contributed almost equally to the excess glucose utilization observed in the obese children. When studied with the euglycemic-hyperinsulinemic clamp, obese children could not increase glucose disposal to the same extent as normal children and were not able to adequately suppress their endogenous glucose production. Recently obese children are therefore characterized by an increased basal glucose turnover rate and an already established insulin resistance of the liver and probably the skeletal muscles.

[Clinical and biological data affecting insulin-dependent diabetes in French children at the time of its diagnosis]

In order to characterize Type I diabetes at its clinical onset in French children, we studied HLA-DR alleles, beta-cell function and autoantibodies to islet-cell antigens and insulin in 115 patients aged 1.8-17 years. Beta-cell function was markedly impaired, but with an unexpectedly wide range of individual variations. These variations showed no correlation with HLA alleles or circulating autoantibodies, as opposed to observations made by others. Age, however, had a clear influence on the degree of impairment of residual insulin secretion, the younger children having the more deteriorated beta-cell secretory capacity conditioning the severity of clinical manifestations (weight loss, ketonuria, ketoacidosis) and initial hyperglycemia.

Cyclosporin A suppresses insulin autoantibodies and heterologous insulin antibodies in type I diabetic children

We report that cyclosporin A (CsA) suppresses the insulin autoantibodies that are present before insulin therapy in the sera of one-third of studied type I (insulin-dependent) diabetic children. CsA also reversibly blocks the production of antibodies after exogenous insulin injection, whereas high titers of heterologous insulin antibody are observed in all type I patients not receiving CsA.

[Treatment of diabetes in children under 3 years of age. Indications, methods and results]

Before modern methods of diabetes management were available, the achievement of strict glycemic control was considered almost impossible in most children with early onset of the disease. The present results obtained over 2 years in 31 children aged 21 +/- 2 (SEM) months at the onset of the disease indicate the efficiency of intensive conventional therapy in 21 of them: glycosylated hemoglobin averaged 7.0 +/- 0.3% (N = 4.7 +/- 0.7%) during the observed 26 +/- 7 months, with only 0.02 +/- 0.01 hypoglycemic attack per patient-month and no diabetic ketoacidosis. In the remaining 10 children, who resisted intensive conventional therapy, we used insulin pumps to improve blood glucose control, with the following results over 21 +/- 4 months: Glycosylated hemoglobin decreased from 9.3 +/- 0.3% (before pump) to 8.0 +/- 0.4% (p less than 0.05). The frequency of hypoglycemia decreased dramatically from 1.7 +/- 0.7 to 0.03 +/- 0.01 episode per patient-month. The frequency of ketonuria and ketoacidosis was unchanged. We concluded that intensification of therapy through conventional means, or pump treatment if necessary, allows a long term efficient control of blood glucose in preschool children.