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Aim: To provide growth charts for clinical monitoring of extra-uterine growth from birth to full-term age, in infants born before 26 weeks of gestation, hospitalized at neonatal intensive care unit (NICU), and compare it to the commonly used Swedish preterm birth-size reference. Methods: This retrospective longitudinal cohort comprised all infants born before 26 + 0 weeks of gestation and surviving to full-term age (n = 162), admitted to the NICU, Karolinska Hospital during the period January 1990 to December 2002. Body weight was recorded daily, head circumference (HC) weekly and length twice a month. Results: Birth weight (BW), length and HC showed a normal distribution without significant gender difference. The majority of the infants showed a pronounced postnatal growth restriction for all growth variables with increasing deviation from the reference with age. The mean initial weight loss was 16% with nadir at 6 days of age and a mean time to regain BW of 18 days. At discharge from NICU, 75% of those initially appropriate for gestational age infants were below –2 standard deviation scores for at least one of the body size variables. Conclusion: The poor extra-uterine growth pattern points to the need of growth curves for extra-uterine growth of extremely premature infants.

Zusammenfassung Der Einflus von Nitrofurazon auf die endokrine, sekretorische und spermatogenetische Funktion des Rattenhodens In einer experimentellen Studie wurde an mannlichen Ratten der Einflus der anti-spermatogenetischen Substanz Nitrofurazon unter besonderer Berucksichtigung der Leydig-Zellen, der Sertoli-Zellen und der Keimzellen untersucht. Die Leydigzellfunktion wurde mittels der Serumtestosteronwerte und der Testosteronbildungskapazitat von Hodengewebe in vitro gemessen. Die Sertoli-Zellen wurden mittels Licht- und Elektro-nenmikroskopie untersucht; ihre Funktion wurde folgendermasen gemessen: 1) Testi-kulare ABP-Synthese-Kapazitat in vivo und in vitro; 2) Flussigkeitssekretion der Sertoli-Zellen innerhalb von 20 Stunden nach der Ligatur der Ductuli efferentes; 3) FSH-Serum-Werte als indirektes Mas der Inhibin-Produktion der Sertoli-Zellen; 4) Untersuchung der Fahigkeit der Verbindungen zwischen den Sertoli-Zellen, Lanthanumpraezipitat festzuhalten als ein Beweis fur die Integritat der Blut-Hoden-Schranke. Die Degeneration der Keimzellen wurde mittels Licht- und Elektronenmikroskopie verfolgt. Nitro-furazon wurde in einer Konzentration von 0,1% der Nahrung zugesetzt; verwendet wur-den normale Ratten und solche die vorher bestrahlt waren, um ein Sertoli-Zell-Syndrom auszulosen (Cobald-60, 150 rad, 1,1 rad/sec). Es wird festgestellt, das Nitrofurazon fur alle Keimzellen innerhalb der Blut-Hoden-Schranke schadlich ist. Die am starksten und am schnellsten eingetrenen Effekte wur-den an den meiotischen Zellstadien beobachtet. 28 Tage nach Nitrofurazonanwendung wurden lediglich Spermatogonien und einige fruhe Spermatozyten festgestellt. Bei Sertoli-Ratten kam gelegentlich eine scheinbar intakte Spermatogenese bis zu dem Stadium der elongierten Spermatiden auch nach 28 Tagen Therapie zur Beobachtung. Die Leydig-Zellen wurden nicht geschadigt; das ergab sich aus der erhaltenen bzw. angestie-. genen Kapazitat zur Produktion von Testosteron. In den Sertoli-Zellen selbst ergaben sich keine degenerativen Veranderungen; dennoch wurde ein verandertes Erscheinungs-bild der Lipid-Einschlusse und ein zahlenmasiger Anstieg der Cytoplasma-Vakuolen festgestellt. Die in vivo-ABP-Produktion zeigte anfangs (nach 2–4 Tagen) einen deutli-chen Abfall bei den Normal- und bei den Sertoli-Ratten. Nach langerer Anwendung von Nitrofurazon wurde die ABP-Produktion wiederhergestellt (Steroli-Ratten) bzw. stieg beachtlich an (Normal-Ratten). Abgesehen von einem vorubergehenden Anstieg am 10. Tag bei Normal-Ratten wurde die Flussigkeitssekretion der Sertoli-Zellen nicht durch Nitrofurazon beeinflust. Nach 10 und 28 Tagen Anwendung zeigten die Normal-Ratten ebenso wie die Kontrollen hohere FSH-Werte. Die Sertoli-Ratten hatten FSH-Werte, die den Kastrations-Werten angenahert waren wahrend der Studie; es konnte keinerlei Einflus von Nitrofurazon festgestellt werden. In dem Stadium der Behandlung, bei dem die Spermatogenese vollstandig gehemmt war, erwiesen sich die Leydig-Zellfunktion und verschiedene Parameter der Sertoli-Zell-Funktion als normal. Somit mus unterstellt werden, das Nitrofurazon seinen hauptsachlichen Einflus direkt auf die Keimzellen ausubt.

Purpose: To examine the influence of the ketogenicdiet (KD) on linear growth and insulin-likegrowth factor I (IGF-I) levels in children withpharmacotherapy-resistantepilepsy.Methods: A prospective study was designed toevaluate growth, serum IGF-I levels, bloodb-hydroxybutyric acid (b-OHB), and seizurefrequency before and during KD in 22 children(median age 5.5 years). Growth was assessed bymeasurements of weight, height, body mass index(BMI), and height velocity. Standard deviationscores (SDS) were calculated for all measuredparameters as well as for serum IGF-I to eliminatethe influence of age- and sex-related differencesamongpatients.Results: Fourteen of the 22 patients responded tothe KD. Weight, height, BMI, and height velocitydecreased significantly during the KD. We foundthat the KD had profound influence on growth andIGF-I levels. No correlation was found betweenseizure response and growth alterations. Heightvelocity correlated negatively with b-OHB duringthe KD. The slope of the regression of heightvelocity against IGF-I decreased significantly dur-ingtheKD.Conclusions: Height velocity was most affected inthose with pronounced ketosis, which impliesthat, in clinical practice, the level of ketosisshould be related to outcomes in seizure responseand growth. Our data indicate that growth dis-turbances and the decreased sensitivity of growthto similar IGF-I levels during KD are indepen-dent of seizure reduction. The metabolic statusinduced by KD may be the mechanism underlyingboth alterations of linear growth and seizurereduction.KEY WORDS: Growth, IGF-I, Ketogenic diet,Pharmacoresistantepilepsy.Theketogenicdiet(KD),introducedbyWilderin1921,isusedinthetreatmentofchildrenwithpharmacotherapy-resistant epilepsy (Wilder, 1921). Despite its long historyof clinical use, it is still not clear how the diet affects thebrain and what the mechanisms are that underlie itsseizure-suppressive action (Cheng et al., 2003a; Bough R Liuet al., 2003). Since an increasing number of patients aretreated with the KD, it is important to evaluate its effectsongrowthandnutritionalstatus.

Diastrophic dysplasia (DTD) is an autosomal recessive skeletal dysplasia caused by SLC26A2 mutations. Clinical features include short stature, joint contractures, spinal deformities, and cleft palate. SLC26A2 mutations also result in other skeletal dysplasias, including the milder recessive multiple epiphyseal dysplasia (rMED). DTD is overrepresented in Finland and we speculated that this may have influenced the prevalence and spectrum of SLC26A2-related skeletal conditions also in Sweden. We reviewed the patient registry at Department of Clinical Genetics, Karolinska University Hospital, Stockholm to identify subjects with SLC26A2 mutations. Seven patients from six families were identified; clinical data were available for six patients. All but one patient had one or two copies of the Finnish SLC26A2 founder mutation IVS1+2TC. Arg279Trp mutation was present in compound heterozygous form in five patients with phenotypes consistent with rMED. Their heights ranged from -2.6 to -1.4 standard deviation units below normal mean and radiographic features included generalised epiphyseal dysplasia and double-layered patellae. Two rMED patients had hypoplastic C2 and cervical kyphosis, a severe manifestation previously described only in DTD. Our study confirms a high prevalence of rMED in Sweden and expands the phenotypic manifestations of rMED.

Disturbances in the relations between insulin, growth hormone (GH) and insulin-like growth factor I (IGF-I) may be a major cause behind deteriorated metabolic control in adolescent girls with type I diabetes. These patients have increased GH secretion and low IGF-I concentrations. The aim of this study was to identify possible endocrine mechanisms behind good and poor glycaemic control in such girls, focusing on the insulin-GH-IGF-I axis. Ten girls with well-controlled insulin-dependent diabetes mellitus (IDDM), hemoglobin A1c (HbA1c) 6.5+/-0.4% (normal range 3.9-5.2%) and nine healthy controls were investigated and compared with 11 girls with poor glucose regulation, HbA1c 10.9+/-0.4%, and their corresponding controls. Serum profiles of glucose, insulin, GH and IGF-binding protein 1 (IGFBP1) were analysed in addition to IGF-I and HbA1c. Two interesting observations were made. GH concentrations were equally elevated in the two diabetic groups regardless of metabolic control (mean 24 h GH - girls with poorly controlled diabetes 10.0+/-1.0 mU/L vs 9.8+/-1.7 - girls with well-controlled diabetes; p=ns). Likewise, the IGF-I concentrations were reduced to the same extent (233+/-19 vs 242+/-23 microg/L; p=0.75). Secondly, despite similar insulin concentrations (mean 24 h insulin - girls with poorly controlled diabetes 22.9+/-2.6 and girls with well-controlled diabetes 27.3+/-2.9 mU/L, respectively; p=0.26), there was a marked difference in IGFBP1 concentrations between the two groups with IDDM (mean IGFBP1 - girls with poorly controlled diabetes 70.5+/-9.1 microg/L vs girls with well-controlled diabetes 28.6+/-3.3; p

OBJECTIVES Glycaemic control often deteriorates during puberty in girls with insulin dependent diabetes mellitus (IDDM). This may be due in part to the normal psychosocial changes associated with adolescen_ce. Puberty is, however, also characterized by rapid somatic development, orchestrated by hormonal changes. Some of these hormones play a major role in glucose homeostasis. We have examined the insulin-GH-IGF-I axis in 11 adolescen_t girls with poorly controlled insulin dependent diabetes and compared the data with those of 10 non-diabetic girls matched for age, pubertal stage and body mass index (BMI). METHODS Serum profiles of glucose, insulin, GH and IGF binding protein 1 (IGFBP1) were analysed in addition to IGF-I in serum and nocturnal urinary excretion of GH. MEASUREMENTS Serum glucose, insulin and IGFBP1 were measured every hour for 24 h, whereas GH in serum was measured every 30 minutes during the same period. Nocturnal urinary GH was analysed as a mean of three consecutive nights. RESULTS The insulin profiles of the IDDM patients were flat with low post-prandial peaks, corresponding to only one-third of the peaks of the non-diabetic girls. The integrated insulin levels, both during 24-h sampling and during daytime, were significantly lower in the diabetic group. There were no differences during night-time. The diabetic patients had elevated mean baseline levels of serum GH (IDDM 2.8 ± 0.5 mU/l, controls 0.7 ± 0.2; P

Objective To characterise early growth and neurocognitive development in children of mothers with a history of eating disorders (ED). Design A longitudinal cohort study. Setting Child-care centres in Stockholm, Sweden. Population Children born to mothers with previous ED (n = 47) (24 anorexia nervosa, 20 bulimia nervosa, 3 unspecified ED), and controls (n = 65). Methods Mean values and standard deviation scores of weight and height from birth to 5 years of age and head circumference up to 18 months of age were compared between groups. Neurocognitive development was studied at the age of 5 years by the validated parent questionnaire Five to Fifteen. Main outcome measures Head growth and neurocognitive development. Results We previously reported that mothers with a history of ED conceived infants with lower birthweight and head circumference than controls. At 3 months of age, body mass index (BMI) was no longer reduced but mean head circumferences of the children born to mothers with ED were smaller throughout the observation period. Similarly, the longitudinal results of the standard deviation scores of head circumference showed a significant overall group effect with lower levels in both subgroups of ED (anorexia nervosa and bulimia nervosa). The children of the ED mothers also had significantly higher Five to Fifteen scores than controls, reflecting difficulties in language skills. Head circumference at birth correlated with language skills in the children of mothers with ED. Conclusion Children of mothers with previous ED demonstrated an early catch-up in BMI, but the average head circumference continued to be delayed until at least 18 months of age. The reduced head growth was related to delayed neurocognitive development.

Aim To describe growth pattern from full-term age to 10 years in infants born before 26 weeks of gestation. Method This retrospective longitudinal cohort contained 123 children from Karolinska Hospital, Stockholm, during 1990-2002. Length/height (Ht), weight (Wt) and head circumference (HC) were recorded monthly during the first year, every 3 months until 2 years and yearly thereafter, but HC at 15 months and at median age of 8.1/9.7 years (range 2-14) in boys/girls. Results For boys/girls at birth, the mean Z-score for Ht was -0.2/-0.2, for Wt 0.0/-0.2 and for HC 0.0/-0.3. At term, the mean Z-score for Ht was -3.8/-3.1, for Wt -3.0/-2.5 and for HC -1.7/-1.2. At 1 year, the mean Z-score for Ht was-1.3/-1.3, for Wt -1.9/-1.7 and for HC -1.2/-1.0. At 2 years, the mean Z-score for Ht was -1.3/-1.1, for Wt -1.6/-1.2 and at 10 years for Ht -0.7/-0.4; that was on average -0.3 below mid-parental height; for Wt -0.2/-0.2. Long-term sequelae were found in 48% of the boys and 34% of the girls. Conclusion By 10 years of age, the attained mean Ht was in accordance with their genetic potential and almost half of these children had significant long-term sequelae.

To provide growth charts for clinical monitoring of extra-uterine growth from birth to full-term age, in infants born before 26 weeks of gestation, hospitalized at neonatal intensive care unit (NICU), and compare it to the commonly used Swedish preterm birth-size reference.This retrospective longitudinal cohort comprised all infants born before 26 + 0 weeks of gestation and surviving to full-term age (n = 162), admitted to the NICU, Karolinska Hospital during the period January 1990 to December 2002. Body weight was recorded daily, head circumference (HC) weekly and length twice a month.Birth weight (BW), length and HC showed a normal distribution without significant gender difference. The majority of the infants showed a pronounced postnatal growth restriction for all growth variables with increasing deviation from the reference with age. The mean initial weight loss was 16% with nadir at 6 days of age and a mean time to regain BW of 18 days. At discharge from NICU, 75% of those initially appropriate for gestational age infants were below -2 standard deviation scores for at least one of the body size variables.The poor extra-uterine growth pattern points to the need of growth curves for extra-uterine growth of extremely premature infants.

Noonan syndrome (NS) is a heterogeneous disorder caused by activating mutations in the RAS-MAPK signaling pathway. It is associated with variable clinical expression including short stature, congenital heart defect, unusual pectus deformity, and typical facial features and the inheritance is autosomal dominant. Here, we present a clinical and molecular characterization of a patient with Noonan-like syndrome with loose anagen hair phenotype and additional features including mild psychomotor developmental delay, osteoporosis, gingival hyperplasia, spinal neuroblastoma, intrathoracic extramedullary hematopoiesis, and liver hemangioma. Mutation analysis of PTPN11, SOS1, RAF1, KRAS, BRAF, MEK1, MEK2, NRAS, and SHOC2 was conducted, revealing a co-occurrence of two heterozygous previously identified mutations in the index patient. The mutation SHOC2 c.4A > G; p.Ser2Gly represents a de novo mutation, whereas, PTPN11 c.1226G > C; p.Gly409Ala was inherited from the mother and also identified in the brother. The mother and the brother present with some NS manifestations, such as short stature, delayed puberty, keratosis pilaris, cafe-au-lait spots, refraction error (mother), and undescended testis (brother), but no NS facial features, supporting the notion that the PTPN11 p.Gly409Ala mutation leads to a relatively mild phenotype. We propose that, the atypical phenotype of the young woman with NS reported here is an additive effect, where the PTPN11 mutation acts as a modifier. Interestingly, co-occurrence of RAS-MAPK mutations has been previously identified in a few patients with variable NS or neurofibromatosis-NS phenotypes. Taken together, the results suggest that co-occurrence of mutations or modifying loci in the RAS-MAPK pathway may contribute to the clinical variability observed among NS patients.

Disturbances in the relations between insulin, growth hormone (GH) and insulin-like growth factor I (IGF-I) may be a major cause behind deteriorated metabolic control in adolescent girls with type I diabetes. These patients have increased GH secretion and low IGF-I concentrations. The aim of this study was to identify possible endocrine mechanisms behind good and poor glycaemic control in such girls, focusing on the insulin-GH-IGF-I axis. Ten girls with well-controlled insulin-dependent diabetes mellitus (IDDM), hemoglobin A1c (HbA1c) 6.5+/-0.4% (normal range 3.9-5.2%) and nine healthy controls were investigated and compared with 11 girls with poor glucose regulation, HbA1c 10.9+/-0.4%, and their corresponding controls. Serum profiles of glucose, insulin, GH and IGF-binding protein 1 (IGFBP1) were analysed in addition to IGF-I and HbA1c. Two interesting observations were made. GH concentrations were equally elevated in the two diabetic groups regardless of metabolic control (mean 24 h GH - girls with poorly controlled diabetes 10.0+/-1.0 mU/L vs 9.8+/-1.7 - girls with well-controlled diabetes; p=ns). Likewise, the IGF-I concentrations were reduced to the same extent (233+/-19 vs 242+/-23 microg/L; p=0.75). Secondly, despite similar insulin concentrations (mean 24 h insulin - girls with poorly controlled diabetes 22.9+/-2.6 and girls with well-controlled diabetes 27.3+/-2.9 mU/L, respectively; p=0.26), there was a marked difference in IGFBP1 concentrations between the two groups with IDDM (mean IGFBP1 - girls with poorly controlled diabetes 70.5+/-9.1 microg/L vs girls with well-controlled diabetes 28.6+/-3.3; p0.001). Despite equally elevated GH concentrations that may induce insulin resistance, the markedly lower concentrations of IGFBP1 in the well-controlled group indicate a higher hepatic insulin sensitivity in these girls compared with those with a poor control. Furthermore, in spite of similar total IGF-I concentrations, the lower IGFBP1 concentrations may result in higher IGF-I bioactivity in the well-controlled group. This may be reflected in better growth of the well-controlled group whose height of 168.7+/-0.9 vs 163.6+/-1.2 cm was significantly different (p0.004). IGFBP1 may be a marker of overall insulinization in adolescents with type 1 diabetes, independent of the absolute insulin dose used for therapy.

Hypochondroplasia is characterized by a disproportionate short stature with rhizomelic shortening of the limbs. Amino acid substitutions Asn540Lys, Asn540Thr and Ile538Val in the fibroblast growth factor receptor 3 (FGFR3) are considered to cause hypochondroplasia. In this study we examined the FGFR3 gene for the previously described hypochondroplasia mutations and the phenotype of 23 probands with clinically and radiologically diagnosed hypochondroplasia. For the phenotype comparison, the patients were divided into two groups: Group 1: hypochondroplasia with Asn540Lys substitution; Group 2: hypochondroplasia with no mutations identified so far. A three-generation family negative for the known hypochondroplasia mutations was examined with polymorphic markers flanking the FGFR1, FGFR2 and FGFR3 genes. Nine (39%) of 23 probands were found to be heterozygous for the Asn540Lys substitution. The individuals positive for the Asn540Lys substitution were significantly more disproportionate than the individuals without this mutation. In this respect, a genotype-phenotype correlation was found in our patients. However, some individuals belonging to the group without mutations identified so far showed similarly abnormal proportions. Genotyping/haplotyping in the three-generation family with hypochondroplasia showed that FGFR1, FGFR2 and FGFR3 genes were not linked to the hypochondroplasia phenotype in this family, thus further confirming the genetic heterogeneity of hypochondroplasia.Individuals with hypochondroplasia heterozygous for the Asn540Lys substitution are significantly more disproportionate than individuals without this mutation. Our study further confirms the clinical and genetic heterogeneity of hypochondroplasia.

Several studies have now been published on the effect of one or several years of growth hormone treatment on growth and body composition of children with Prader-Willi syndrome. The majority of the patients have responded with greatly increased growth rate, decreased body fat and increased muscle volume. Many of these children seem to have a functional growth hormone deficiency, probably secondary to their hypothalamic dysfunction. Further studies are needed to establish the long-term effect of this treatment on somatic and psychological well-being.

This study was undertaken to investigate the prevalence of coeliac disease in children and adolescents with Turner syndrome. Eighty-seven children and adolescents with Turner syndrome were screened for IgA-antiendomysium antibodies (EMA) and IgA-antigliadin antibodies (AGA), 5% (4/87) being found to be EMA-positive, and 15% (13/87) to have AGA levels above normal. Of the 10 patients who were either AGA- or EMA-positive and further investigated with intestinal biopsy, four manifested villous atrophy (i.e. all three of the EMA-positive patients, but only one of the seven AGA-positive patients). The results suggest EMA-positivity to be a good immunological marker for use in screening for coeliac disease, and such screening to be justified in patients with Turner syndrome.

Insulin and glucose homeostasis have been studied during growth hormone (GH) treatment in 19 prepubertal children with Prader-Willi syndrome (PWS) and compared with 11 healthy prepubertal obese children. Before treatment, insulin levels in children with PWS were lower (p0.01) than in healthy obese children. During GH treatment, fasting insulin levels increased in children with PWS (p0.001). Glucose levels were similar for PWS and obese children before treatment. Children with PWS showed a slow glucose disappearance rate (k = 1.7%) which deteriorated (k = 1.3%, p0.001) during GH treatment. HbA1c and fasting glucose levels remained normal. Thus, GH treatment of children with PWS resulted in increased insulin blood levels, unchanged fasting glucose and HbA1c but decreased glucose elimination rate after an intravenous glucose test. However, the observed dose-dependent increase in insulin levels during GH treatment, that reached supranormal concentrations in 6/19 patients, and the occurrence of NIDDM in 1 patient during follow-up suggest that close surveillance and low doses of GH should be applied, especially if the PWS patient is very obese.

Hypochondroplasia and achondroplasia are skeletal dysplasias, characterized by autosomal dominant inheritance and disproportionate short stature, which occurs mainly due to growth failure of the extremities. Both dysplasias have been mapped to fibroblast growth factor receptor 3 (FGFR3) gene. For hypochondroplasia, two point mutations, both responsible for the Asn540Lys substitution in the region coding the tyrosine kinase domain have been reported. Here we report an A to G transition at position 1651, predicting an Ile538Val substitution in the FGFR3, in hypochondroplasia. The substitution is found in a swedish family with three affected members. The criteria for hypochondroplasia were disproportionate short stature and radiological evidence of shortened long bones and decrease or absence of normal increase in interpedicular distances of the lumbar column. The mutation was detected by direct sequencing and restriction enzyme Tai I digestion. The base change was not found in the FGFR3 genes of unaffected members of the family nor in seventy-five unrelated unaffected individuals, suggesting that it was not a polymorphism. The Ile538Val substitution is a conservative amino acid change (a hydrophobic amino acid incorporated for another hydrophobic amino acid). Nevertheless, it is located in the stretch of nine amino acids, which is highly conserved among all the human fibroblast growth factor receptors. Considering the location of this substitution and the segregation with the phenotype in this family, we propose that it is a causative mutation of hypochondroplasia. It is difficult to establish whether the Ile538Val substitution is rare in hypochondroplasia patients or whether the individuals, who have a moderate degree of short stature, rarely seek medical help for the short stature and consequently are rarely diagnosed as affected by hypochondroplasia.

This paper reports results from an ongoing, randomized, multicentre national trial. The aim is to elucidate whether a dose of growth hormone (GH) of 0.2 IU/kg (0.07 mg/kg), given either as once-daily or twice-daily injections during puberty, is more effective than a once-daily dose of 0.1 IU/kg/day (0.03 mg/kg/day) in improving final height in children with GH deficiency (GHD). The twice-daily regimen comes closer to the spontaneous GH secretion pattern in puberty. Ninety-two children with GHD who had been receiving GH therapy for at least 1 year, and with spontaneous puberty or who were prepubertal and due to be started on replacement therapy to induce puberty, were randomly assigned to receive GH as follows: group A, 0.1 IU/kg/day (0.03 mg/kg/day), administered once daily; group B, 0.2 IU/kg/day (0.07 mg/kg/day), administered once daily; and group C, 0.2 IU/kg/day (0.07 mg/kg/day), divided into two equal injections given at 12-hour intervals. Pubertal height gain was 0.7, 0.7 and 1.3 SDS for groups A, B and C, respectively. The gain in height during puberty was thus most marked in group C. Mean final height, when corrected for parental height, was between 0 and 1 SDS in all treatment groups. All but seven children reached a final height within +/- 2 SD of the general population. There was a wide range of final heights in all three treatment groups. This variation in response suggests the need to individualize treatment in order to achieve an appropriate final height for most individuals.

Although Klinefelter's syndrome is the most common sex chromosome anomaly, affecting one in 5-800 boys, our knowledge of the syndrome is still poor. This is reflected in the paucity of published literature as compared, for example, with the vastly greater number of publications on Turner's syndrome with its lower incidence of 1/2,500 girls. Klinefelter's syndrome is manifestly underdiagnosed. Existing knowledge mainly derives from cases characterised by prominent symptomatology. Early diagnosis is important if additional support and resources are to be made available to the patient and his family. Testosterone replacement therapy should be initiated as soon as clinical and laboratory evidence becomes available. In selected cases, testosterone treatment can be started already during adolescence. At present, there is no established treatment for the infertility which almost always accompanies the condition.

The aims of this study were to evaluate the efficacy and safety of different doses of growth hormone (GH) treatment in prepubertal short children born small-for-gestational-age (SGA). Forty-eight children born SGA from Sweden, Finland, Denmark and Norway were randomly allocated to three groups: a control group of 12 children received no treatment for 2 y, one group was treated with GH at 0.1 IU/kg/d (n=16), and one group was treated with GH at 0.2 IU/kg/d (n=20). In total 42 children completed 2 y of follow-up, and 24 children from the treated groups completed 3 y of treatment. Their mean (SD) age at the start of the study was 4.69 (1.61) y and their mean (SD) height was -3.16 (0.70) standard deviation scores (SDS). The children remained prepubertal during the course of the study. No catch-up growth was observed in the untreated group, but a clear dose-dependent growth response was found in the treated children. After the third year of treatment, the group receiving the higher dose of GH, achieved their target height. The major determinants of the growth response were the dose of GH used, the age at the start of treatment (the younger the child, the better the growth response) and the family-corrected individual height deficit (the higher the deficit, the better the growth response). Concentration of insulin-like growth factor-I (IGF-I) and IGF-binding protein-3 increased during treatment. An increase in insulin levels was found without negative effects on fasting glucose levels or glycosylated haemoglobin levels. GH treatment was well tolerated. In conclusion, short prepubertal children born SGA show a dose-dependent growth response to GH therapy, and their target height SDS can be achieved within 3 y of treatment given GH at 0.2 IU/kg/d. However, the long-term benefit of different regimens of GH treatment in children born SGA remains to be established.

We have compared the growth and the body composition in children with Prader-Willi syndrome (PWS) with and without growth hormone treatment (recombinant GH 0.1 IU/kg/day) after a 1-y period. Twenty-nine prepubertal children with PWS, with mean body mass index (BMI) SDS of 2.2, and 10 (control) healthy obese children with mean BMI SDS of 5.6, underwent 24-h frequent blood sampling. Both PWS and control obese children had low and similar GH levels (0.7 microg/l +/- 0.4SD). Serum IGF-I levels, however, were significantly lower in children with PWS (-1.5SDS +/- 0.8SD vs -0.2SDS +/- 0.8SD). The 29 PWS children were randomized into 2 groups of 15 and 14 subjects for GH treatment and no treatment, respectively. Height velocity increased from -1.9SDS to + 6.0SDS in the treated group (p0.001) and decreased from -0.1SDS to -1.4SDS in the control PWS group during the study year. BMI decreased significantly for the treated group (+3.0SDS to +2.0SDS). Relative fat mass decreased significantly, while fat-free mass increased (p0.001) for the treated group. No significant changes were noticed in body composition in the control PWS group. In conclusion, the low spontaneous 24-h GH secretion, regardless of body weight, and the exceptional response to growth hormone treatment together with the finding of low IGF-I levels suggest that growth hormone deficiency is a common feature of PWS, as a result of hypothalamic dysfunction. Treatment with growth hormone is beneficial for the majority of PWS children.

A controlled, randomized study was conducted to assess the effect of growth hormone (GH) treatment on growth, body composition and behaviour in prepubertal children (3-12 years of age) with Prader-Willi syndrome. GH treatment was given to one group of 15 patients (group A) at a dose of 0.1 IU/kg/day for 2 years. The second group (group B; n = 12) was not treated for the first year and was then given GH at a dose of 0.2 IU/kg/day for the second year. All patients had low 24-hour levels of GH and insulin-like growth factor I before GH treatment. Height velocity SDS increased from -1.9 +/- 2.0 to 6.0 +/- 3.2 during the first year of GH treatment in group A, and from -1.4 +/- 1.2 to 10.1 +/- 3.9 in the second year of the study in group B. When GH treatment was stopped, height velocity declined dramatically. Height SDS followed a similar pattern. GH treatment reduced the percentage body fat and increased the muscle area of the thigh. Isometric muscle strength was also increased. In addition, GH treatment appeared to have psychological and behavioural benefits, which were reversed after cessation of treatment. It was concluded that GH treatment improves growth, body composition and behaviour in children with Prader-Willi syndrome.

An immunologically anomalous LH with two point mutations in its beta-subunit gene (Trp8Arg and Ile15Thr) has recently been described. This polymorphism is common in Finland; 28% of the population are homo- or heterozygous for the variant allele. To assess the effect of the LH variant on LH action, we correlated its presence in a group of 49 healthy boys with the onset and progression of puberty. This group was followed-up longitudinally from a mean age of 11.7 +/- 0.1 yr for 3 yr at 3-month intervals. In addition, we studied the prevalence of the variant LH in boys with constitutional pubertal delay (testicular volumeor = 4 mL after 13.5 yr of age). The LH beta gene status of each subject in this study was judged from a single venous blood sample using two immunofluorometric LH assays with different combinations of monoclonal antibodies: one detecting both the variant and wild-type LH, and the other detecting only wild-type hormone. Of the boys with pubertal onset at a normal age, 36 (74%) were homozygous for the wild-type LH beta allele, 12 (24%) were heterozygous, and 1 (2%) was homozygous for the variant LH beta allele. Clear differences in pubertal parameters were found between the boys with normal and mutated (homo- or heterozygous) LH genotypes. During the follow-up, the boys with the mutated genotype had smaller testicular volumes (P0.03), were shorter (P0.02), had slower growth rates (P0.04), and had lower serum insulin-like growth factor I-binding protein-3 levels (P0.03) than the boys with the normal LH genotype. In the boys with delayed onset of puberty, the frequency of the variant LH beta allele did not differ from that in the reference population, indicating that the variant LH is not associated with conditions due to disturbed control of the reactivation of GnRH secretion. We conclude that during the progression of puberty, the variant LH may be less active in stimulating testicular growth than wild-type LH. Thus, the gene may affect tempo, contributing to the wide normal variation in pubertal progression in healthy boys. Our results also suggest that the variant LH not only affects the course of puberty, but is already involved in the regulation of the GH-insulin-like growth factor I axis during childhood.

The spontaneous growth process in Turner's syndrome is characterized by a progressive decline in height velocity during childhood and no pubertal growth spurt. Therefore, therapy aimed at improving height during childhood as well as increasing final height is desirable for most girls with Turner's syndrome. Forty-five girls with Turner's syndrome, 9-16 yr of age (mean age, 12.2 yr), were allocated to three study groups. Group 1 (n = 13) was initially treated with oxandrolone alone; after 1 yr of treatment, GH without (group 1a; n = 6) or with (group 1b; n = 7) ethinyl estradiol was added. Group 2 (n = 17) was treated with GH plus oxandrolone. Group 3 (n = 15) was treated with GH, oxandrolone, and ethinyl estradiol. The dosage were: GH, 0.1 IU/kg.day; oxandrolone, 0.05 mg/kg.day; and ethinyl estradiol, 100 ng/kg.day. A height of 150 cm or more was achieved in 61%, 75%, and 60% of the girls in groups 1, 2, and 3, respectively. The most impressive increase in height was seen in group 2. In this group the mean final height was 154.2 cm (SD = 6.6), which is equivalent to a mean net gain of 8.5 cm (SD = 4.6) over the projected final height. In group 3, in which ethinyl estradiol was included from the start of therapy, the initially good height velocity decelerated after 1-2 yr of treatment. Their mean final height was 151.1 (SD = 4.6) cm, equivalent to a mean net gain of 3.0 cm (SD = 3.8). A similar growth-decelerating effect of ethinyl estradiol was seen in group 1b. We conclude that in girls with Turner's syndrome who are older than 9 yr of age, treatment with GH in combination with oxandrolone results in significant growth acceleration, imitating that in normal puberty, leading to a more favorable height during childhood. This mode of treatment also results in a significantly increased final height, permitting a great number of the girls to attain a final height of more than 150 cm. However, early addition of estrogen decelerates the height velocity and reduces the gain in height.

The prevalence of thyroid autoantibodies, i.e. thyroglobulin antibodies and antibodies to thyroid peroxidase, was analyzed in 89 girls, aged 3-16 years (mean age 10 years), with Turner's syndrome. The analyses were performed before the start of growth-promoting treatment and during a follow-up period of 1-5 years. The patients were divided into four groups according to karyotype as follows: group 1, 45, X (n = 63); group 2 with structural abnormalities of the X chromosome (n = 10); group 3 with mosaicism but no structural abnormalities of the X chromosome (n = 10); and group 4, with isochromosome X of the long arm (n = 12): 199 healthy girls aged 12 years, served as controls. Thyroid autoantibodies were demonstrated in 46 of 89 (52%) patients with Turner's syndrome compared with 34 of 199 (17%) age-matched control girls (p < 0.001), thus confirming the relationship between thyroid abnormalities and Turner's syndrome. There was also an increase in the prevalence of thyroid antibodies with age. Simultaneous presence of both autoantibodies was significantly more frequent in group 1 (45, X) and group 4 (isochromosome X of the long arm) than in group 3 (mosaicism) (p = 0.04 and p < 0.002, respectively) and significantly more frequent in group 4 than in group 1 (p < 0.05). During 12-60 months of growth-promoting treatment, no increase in the prevalence of thyroid antibodies was observed. The findings demonstrate the importance of continuous monitoring of thyroid function in girls with Turner's syndrome.

Achondroplasia, an autosomal dominant inherited disorder, is one of the most common forms of skeletal dysplasia resulting in disproportionate extreme shortness. Recently, two point mutations, both affecting nucleotide 1138 in the fibroblast growth factor receptor type 3 (FGFR3) gene, were found to be the cause of the disorder. We investigated DNA from 16 Swedish patients with achondroplasia for the presence of these mutations. All patients were found to be heterozygous for the G to A transition at nucleotide 1138. Our data thus support previous reports showing a striking genetic homogeneity, in that almost all achondroplasia patients have the FGFR3 G380R mutation at the protein level.

The differentiation of rat seminiferous tubules have been studied in 13 to 19 days old. Testicular weight and tubular cross-sectional area were more than doubled during this period. The percentage of tubules with more than 10 primary spermatocytes increased from 4% to 90%, and the lanthanum excluding ability of the inter-Sertoli cell junctions (the blood-testis barrier) showed a similar increase but two days later. ABP production in vitro increased more than twentyfold from day 13 to day 19 of age. It is concluded that the differentiation of Sertoli cell function and the appearance of primary spermatocytes are temporally correlated which supports the assumption that the function of the Sertoli cells is important for initiation and maintenance of spermatogenesis.

Two different high-affinity androgen binding proteins have been demonstrated in the rat testis. The smaller protein (ABP, MW 90,000) is produced in the testis, and transported with the testicular fluid into the epididymis. ABP is found in tubules but not in interstitial tissue or in testicular lymph. Destruction of the spermiogenic cells by physical or chemical agents does not decrease the concentration of ABP in the testis, indicating Sertoli cells to be the site of production. ABP disappears from the testis following hypophysectomy, but reappears following FSH treatment. Other pituitary hormones have no effect. Another androgen binding component, different from ABP, has also been recovered from rat testis tubules. This protein shows characteristics different from ABP but identical to cytoplasmic receptors of epididymis and prostate, indicating the presence of androgen target cells in the testis. Large doses of testosterone or dihydrotestosterone are known to maintain spermatogenesis in the hypophysectomized rat. We postulate that a major action of FSH on spermatogenesis may be mediated by ABP. ABP may facilitate androgen transport into the seminiferous tubules and provide the germ cells with the milieu of androgenic hormones which is required for normal spermatogenesis.

Spermatogenesis as well as Sertoli cell function, monitored by ABP secretion, is severely impaired at 37°C in vivo and in vitro. A closer understanding of the biochemical mechanisms behind this phenomenon may lead to future methods for fertility control. The cryptorchid Sertoli cell was shown to be exposed to normal or increased levels of the two main stimulatory hormones, testosterone and FSH. Androgen receptor concentrations in hypophysectomized rat testes were not changed by cryptorchidism. However, FSH and to some extent LH receptors showed a gradual decline during 28 days of cryptorchidism. Even in the absence of hormones, Sertoli cells in vitro produced less ABP at 37 than at 32°C. This shows that 1) Testicular FSH receptors can be practically eliminated in vivo. 2) The basal secretion of protein by the Sertoli cell, in the absence of hormones, is impaired at elevated temperature. An elucidation of the biochemistry involved in that impairment may also yield possible points of attack in the search for a male contraceptive.

The intratesticular concentration of androgens seems to be of more importance for normal spermatogenesis than the concentration of androgens in the peripheral blood. Therefore, the levels of testosterone, 5α - dihydrotestosterone (DHT), androstenedione and FSH in the interstitial fluid of the rat testis were determined by radioimmunoassay. The following concentrations were obtained from the interstitial fluid of normal rats and from rats cryptorchid between 60 and 90 days of age: Testosterone 137 ± 25 (mean ± SEM) and 271 ± 34 ng/ml, DHT 11 ± 2 and 22 ± 5 ng/ml, androstenedione 8 ± 2 and 20 ± 4 ng/ml, respectively. The sum of testosterone and DHT in serum did not differ in the two groups. Serum FSH concentrations were significantly increased in the cryptorchid rats (942 ± 73 ng/ml) as compared to the control rats (600 ± 38 ng/ml). These elevated levels were also found in the testicular interstitial fluid (425 ± 33 ng/ml in controls, 641 ± 43 ng/ml in cryptorchid rats). It is thus evident that in the cryptorchid rat, both FSH and androgens are available to the seminiferouse tubules in significantly elevated amounts. Since these are the only hormones which are known to be of importance in spermatogenesis, the impaired Sertoli cell function and depletion of germinal cells in cryptorchidism is not due to an absolute shortage of stimulatory hormones.

The effects of experimental unilateral cryptorchidism on the scrotal testis regarding weight, morphology and secretion of tubular fluid and the Sertolicell specific androgen binding protein (ABP) were studied. In the intact guinea pig testis and epididymis an androgen binding component similar to rat ABF was found. In juvenile and adult rats cryptorchid for 17 and 21 days, respectively, and in guinea pigs cryptorchid for ***11 weeks, the scrotal testis seemed unaffected regarding all parameters studied. With reference to previous findings of lowered fertility in unilateral cryptorchidism in man the possible mechanisms by which unilateral cryptorchidism may influence the scrotal testis are discussed.

Androgen binding protein (ABP) was first demonstrated in the rat epididymis (1,2). It was subsequently shown that it originates in the testes, is secreted into the lumen of the seminiferous tubule and transported to the caput epididymidis where it is partially (in the rat) or completely (in the rabbit) degraded (3,4,5). ABP is produced in the Sertoli cells (6–12) and specifically stimulated by FSH (6,7,9,10,13). Being hitherto the only well characterized specific product of the Sertoli cell, it offers itself as an index of the functional activity of the Sertoli cell, as well as a specific end point of FSH action in the testis.

TESTICULAR androgen is the principal stimulus for spermatogenesis1. Androgens alone are capable of maintaining spermatogenesis in hypophysectomised rats when treatment is begun immediately following hypophysectomy2. Following posthypophysectomy regression of the seminiferous epithelium, however, neither luteinising hormone (LH) nor androgen given alone is capable of initiating spermatogenesis when the same dose and time schedule is used for the treatment. Follicle stimulating hormone (FSH) has to be given together with LH or androgen to effectively restore spermatogenic activity1. This difference between maintenance (treatment started immediately after hypophysectomy) and initiation (treatment started after regression of the germinal epithelium) of spermatogenesis, has been known for more than 30 yr (ref. 3), but no data have been provided which could explain this phenomenon.

In this report it is suggested that the specific adrogen-binding protein (ABP), previously shown to originate in the testis of rat and other species, is produced by the Sertoli cells. This suggestion is based upon the following experimental findings: 1) ABP was found in high concentrations in testicular efferent duct fluid but only in trace amounts in inter-tubular lymph. i) ABP could be recovered from crude preparations of testis tubules, but not from Leydig cells from the same testes. 3) Testes whose germinal epithelium had been severly damaged by gamma irradiation showed no decrease in ABP content. The transport of ABP to epididymis was also preserved as judged from the levels of ABP in caput epididymis. 4) Testes that were completely devoid of germ cells following prenatal gamma irradiation showed high levels of ABP, These high levels approached zero following hypophysectomy, but could be restored by FSH administration to the hypophysectomized animals. ABP has been well characterized and now provides a valuable experimental tool as an indicator of Sertoli cell function.

Publisher Summary This chapter elaborates the different aspects of androgen binding and transport in testin and epididymis. Along with the prostate and the seminal vesicles, the epididymis has long been known to be heavily dependent on androgenic hormones for its normal gross appearance. The testis, however, being the major source of circulating androgenic hormones, escaped detection as a major androgen-responsive tissue. The observations that most androgenic hormones not only stem from the testis, but also exert direct actions on testicular events, were made during studies on the regulation of spermatogenesis. The epididymis is completely dependent on androgenic hormones for its development during fetal life, as well as for its function in the mature male. The nuclear hormone can be extracted as a steroid-protein complex by high ionic strength buffers. The potent antiandrogen cyproterone acetate decreased nuclear uptake of radioactive hormone to the same degree as it inhibited binding to cytoplasmic receptors, also indicating the relationship between cytoplasmic receptors and binding to chromatin.

Summary In order to elucidate the mechanisms behind the deleterious effects on the germinal epithelium of experimental cryptorchidism the hypothesis that a leaking blood-testis barrier is the cause of the damage was tested. The permeability of the specialized inter- Sertoli cell junctions to lanthanum after experimental cryptorchidism for 0.5 to 12 days was studied in the rat. In none of the time periods studied lanthanum had penetrated beyond the inter-Sertoli cell junctions. A simple lanthanum immersion technique was used. Testes of 15-days old rats (before the development of the barrier) were used as a positive control of the method, and in these testes lanthanum had penetrated up to the future lumen. Zusammenfassung Um den Mechanismus zu erklaren, der fur die schadigenden Einflusse auf das Keimepithel bei experimentellem Kryptorchismus verantwortlich ist, wurde die Hypothese untersucht, wonach eine durchlassige Blut-Hoden-Schranke Ursache dieser Schaden ist. Die Permeabilitat der besonders ausgebildeten Inter-Sertoli-Zell-Verbindungen fur Lanthanum nach exp. Kryptorchismus wurde 0, 5 bis 12 Tage lang bei Ratten studiert. Zu keinem Zeitpunkt dieser Studie penetrierte Lanthanum durch die Inter-Sertoli-Zell- Verbindungen. Methodisch wurde eine einfache Lanthanum-Immersions-Technik benutzt. Man verwendete 15 Tage alte Ratten (vor der Entwicklung der genannten Schranke) als positive Kontrolle; in diesen Fallen war Lanthanum bis in das Lumen penetriert.

Two different high-affinity androgen binding proteins have been demonstrated in the rat testis. The smaller protein (ABP, MW 90,000) is produced in the testis, and transported with the testicular fluid into the epididymis. ABP is found in tubules but not in interstitial tissue or in testicular lymph. Destruction of the spermiogenic cells by physical or chemical agents does not decrease the concentration of ABP in the testis, indicating Sertoli cells to be the site of production. ABP disappears from the testis following hypophy-sectomy, but reappears following FSH treatment. Other pituitary hormones have no effect. Another androgen binding component, different from ABP, has also been recovered from rat testis tubules. This protein shows characteristics different from ABP but identical to cytoplasmic receptors of epididymis and prostate, indicating the presence of androgen target cells in the testis. Large doses of testosterone or dihydrotestosterone are known to maintain spermatogenesis in the hypophysectomized rat. We postulate that a major action of FSH on spermatogenesis may be mediated by ABP. ABP may facilitate androgen transport into the seminiferous tubules and provide the germ cells with the milieu of androgenic hormones which is required for normal spermatogenesis.

SUMMARY To study the hormonal dependence of the blood–testis barrier, adult rats were hypophysectomized and the ultrastructural integrity of the inter-Sertoli cell junctional complex was examined at various times with a lanthanum tracer technique. It was found that the structural integrity of the inter-Sertoli cell junctions and their capacity to exclude lanthanum from the adluminal compartment were preserved up to 35 days after hypophysectomy. Furthermore, transport of newly formed spermatocytes through the inter-Sertoli cell junctions still occurred 20 days after hypophysectomy. It is therefore concluded that the function of the inter-Sertoli cell junctional complex is not directly dependent on gonadotrophic or androgenic hormones, but is regulated by other mechanisms.

It has become increasingly evident that many factors affecting spermatogenesis are mediated by the Sertoli cells that carry the developing germ cells in a close embracement during the most critical periods of spermatogenesis. Due to the vital importance of the Sertoli cells, increasing interest has been devoted to finding a biochemical index of Sertoli cell function. Testicular androgen binding protein is so far the only known specific product of Sertoli cells.

The Sertoli cell appears to be a target cell for both FSH and androgen. FSH stimulates the Sertoli cell to produce an androgen-binding protein (ABP) which may serve to increase the accumulation of androgen in the seminiferous tubular epithelium and make it available for binding by intracellular androgen receptors. This might be one way by which FSH enhances the action of androgen on spermatogenesis. Androgen acts on the Sertoli cell to increase its response to FSH resulting in increased production of ABP and of other substances which exert trophic effects on spermatogenesis.

At 23yrs of age a CAH (21-OHase) was diagnosed in a woman complaining of (slight) hirsutism and oligomenorrhea. During dexa-methasone treatment she went through 3 normal pregnancies. The first child (boy) had a largely elevated 17-OHP at 2 days of age (280nmol/1) but was left untreated. At age seven he was healthy and had normal height and bone age. The second child (girl) when examined at 4 yrs of age showed no virilization, normal heigth and bone age. Both children then showed elevated basal levels of 17-OHP; 16,5 and 29nmol/1 which increased to 147 and 220nmol/1 60 after ACTH (0,25mg iv). The cortisol response to ACTH was poor (205 to 295nmol/1) for the girl and borderline low (215 to 488) for the boy. The third child was healthy in all mentioned respects. The three affected members of the family fell within the range of individuals with acquired or cryptic CAH ( M.I.New et al. J.Clin.Endocr. Metab. 57:320 (1983). HLA typing of the family was consistent with the biochemical classification. Conclusions: The present family indicates that even in the so-called late onset or acquired 21-OHase deficiency, the enzymatic defect is present and expressed at birth. If so all children detected in neonatal screening program may not need treatment.