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Objectives Prader–Willi syndrome (PWS) is a complex genetic disorder with severe hypotonia, failure to thrive, childhood obesity, hypogonadism/hypogenitalism and learning/behavioral problems with endocrine-related growth and other hormone deficiencies. The prevalence of central adrenal insufficiency (CAI) using dynamic testing ranges from rare to 60%. We compared routine morning plasma cortisol (MPC) and ACTH levels in large cohorts of PWS and control children to address CAI. Methods Retrospective analysis of MPC and ACTH levels was undertaken in 128 PWS growth hormone (GH)-treated children under medical care before considering dynamic testing for CAI and 128 non-syndromic control children with short stature evaluated for GH deficiency. Results The average MPC level in PWS was 9.7 ± 3.7 μg/dL with no difference in age, gender or PWS genetic subtype and 13.4 ± 5.7 μg/dL in the control group. MPC levels were significantly lower (p ± 8.0 pg/mL with one individual having an initial low plasma ACTH level (8 pg/mL), but normal upon repeat. Conclusions MPC levels in PWS are normal and comparable with control children, without evidence or increased risk of CAI. Lower but normal MPC levels were seen in PWS and suggestive of reduced local regeneration of cortisol from cortisone in adipose tissue by the GH-IGF-I system. Hence, MPC measures alone or in combination with ACTH should be considered for initial screening for CAI in PWS but prior to dynamic testing.

Baseline a.m ACTH and Cortisol levels in Children with Prader-Willi-syndrome are no different from general population. Moris Angulo, MD1 & Mariano Castro-Magaña, MD1 1Dept of Peds, NYU-Winthrop Hospital, New York, NY Background Prader-Willi syndrome (PWS) is a multi-system genetic disorder resulting from the lack of expression of the paternal genes from chromosome 15q11.2-q13 due to paternal deletion, uniparental disomy (UPD) or an imprinting center defect. Many of their features are explained by hypothalamic dysfunction, therefore individuals with PWS are at high risk for pituitary hormonal deficiency. When the pituitary begins to fail, there is generally a specific sequential failure of pituitary hormones, starting with GH, continuing through LH and FSH deficiency, and culminating in loss of TSH and ACTH. Generally, ACTH is the last to be lost. A high prevalence (60%) of central adrenal insufficiency (CAI) however, has been reported in Prader-Willi syndrome (PWS) using the metyrapone test. Many children, including infants have undergone stimulation testing to confirm or rule out CAI. Several studies however, using same test and other different testing methods including insulin tolerance test (ITT), low dose/high dose ACTH stimulation, glucagon stimulation tests have reported differing results with prevalence between 0 to 7·5%. Previous study has shown that basal cortisol is closely correlated with adrenal response to stimulation. Methods: We studied 105 children with genetic diagnosis of PWS, age 2 to__years. (60 males and 45 females) after basal Cortisol and ACTH level collected at 0800 h. Sixty eight children (60 %) had deletion I and II, 24 (23%)UPD and 13 had only positive DNA Methylation testing . All participant were already on GH treatment without illness or any other stressful condition during testing. Results: All had normal morning Cortisol and ACTH level but 2 children, age 2 and 5 years with low and 4 y.o. male with increased cortisol level. These 3 children had normal ACTH level. Repeat sample after a week, revealed normal both Cortisol and ACTH level. Conclusion: suggesting that clinically significant adrenal insufficiency in PWS is rare

The following corrections are found in the original publication of the article and corrected as below.

A 3-year and 11-months-old boy presented with a 9-month history of increasing penile enlargement, pubic hair, deepening of the voice, and rapid growth. The erect penile length was 14 cm with bilateral testicular volume of 3 mL. Laboratory evaluation revealed suppressed follicle-stimulating hormone and luteinizing hormone, elevated total testosterone (259 ng/dL), elevated alpha feto-protein (AFP 79 ng/mL), rapidly increasing β-human chorionic gonadotropin (β-hCG 14–399 mIU/mL) over 2 weeks, and a karyotype revealed 47, XYY. Radiographic evaluation revealed a 1.5-cm mixed solid/cystic mass in the pineal gland. Chemotherapy was initiated to attempt to normalize the tumor markers (AFP and β-hCG). This is the first report of a nongerminomatous germ cell tumor (NGGCT) in a 47, XYY karyotype male. Tumor markers (hCG and AFP) should be included in the workup of adult males with 47, XYY as they are in children with precocious puberty.

The hypophysectomized rat has been used as a model to study the effects of growth hormone deficiency on bone. Here, we have investigated the influence of growth hormone administration to hypophysectomized rats (HX) for 6 wk on accumulation of triglycerides in bone marrow and on the differentiation of primary marrow stromal cells into adipocytes under in vitro conditions. We found that hypophysectomy significantly increased triglyceride concentration in bone marrow, which was attenuated by growth hormone administration. Primary bone marrow stromal cells derived from HX rats also had more adipocytes at confluence compared with growth hormone-treated hypophysectomized (GH) rats. When stimulated with 3-isobutyl-1-methylxanthine plus dexamethasone (IBMX-Dex), preadipocyte colony counts increased more significantly in GH rats. Markers of adipocyte differentiation were higher in HX than in control or GH rats at confluence. However, after stimulation with IBMX-Dex, increased expression of markers was seen in GH compared with HX rats. In conclusion, growth hormone administration to hypophysectomized rats attenuated triglyceride accumulation in bone marrow and inhibited the differentiation of stromal cells into adipocytes in vitro.

To define the hormonal criteria via genotypic proof for 3beta-hydroxysteroid dehydrogenase (3beta-HSD) deficiency in the adrenals and gonads, we investigated the type II 3beta-HSD genotype in 55 patients with clinical and/or hormonal presentation suggesting compromised adrenal with or without gonadal 3beta-HSD activity. Fourteen patients (11 males and 3 females) had ambiguous genitalia with or without salt wasting and with or without premature pubarche. One female neonate had salt wasting only. Twenty-five children (4 males and 21 females) had premature pubarche only. Fifteen adolescent and adult females had hirsutism with or without menstrual disorder. The type II 3beta-HSD gene, including the promoter region up to -1053 base, all exons I, II, III, IV, and exon and intron boundaries, was sequenced in all subjects. Eight patients had a proven or predictably deleterious mutation in both alleles of the type II 3beta-HSD gene, and 47 patients had no apparent mutation in the gene. ACTH-stimulated (1 h post iv bolus of 250 microg Cortrosyn) serum 17-hydroxypregnenolone (Delta5-17P) levels and basal and ACTH-stimulated ratios of Delta5-17P to cortisol (F) in the genotypic proven patients were unequivocally higher than those of age-matched or pubic hair stage matched genotype-normal patients or control subjects (n = 7-30 for each group). All other baseline and ACTH-stimulated hormone parameters, including dehydroepiandrosterone (DHEA) levels, ratios of Delta5-17P to 17-OHP and DHEA to androstenedione in the genotype-proven patients, overlapped with the genotype-normal patients or control subjects. The hormonal findings in the genotype-proven patients suggest that the following hormonal criteria are compatible with 3beta-HSD deficiency congenital adrenal hyperplasia (numeric and graphic reference standards from infancy to adulthood are provided): ACTH-stimulated Delta5-17P levels in 1) neonatal infants with ambiguous genitalia at or greater than 378 nmol/liter equivalent to or greater than 5.3 SD above the control mean level [95 +/- 53 (SD) nmol/liter]; 2) Tanner I children with ambiguous genitalia at or greater than 165 nmol/liter equivalent to or greater than 35 SD above the control mean level [12 +/- 4.3 (SD) nmol/liter]; 3) children with premature pubarche at or greater than 294 nmol/liter equivalent to or greater than 54 SD above Tanner II pubic hair stage matched control mean level [17 +/- 5 (SD) nmol/liter]; and 4) adults with at or greater than 289 nmol/liter equivalent to or greater than 21 SD above the normal mean level [25 +/- 12 (SD) nmol/liter]. ACTH-stimulated ratio of Delta5-17P to F in 1) neonatal infants at or greater than 434 equivalent to or greater than 6.4 SD above the control mean ratio [88 +/- 54 (SD)]; 2) Tanner I children at or greater than 216 equivalent to or greater than 23 SD above the control mean ratio [12 +/- 9 (SD)]; 3) children with premature pubarche at or greater than 363 equivalent to or greater than 38 SD above the control mean ratio [20 +/- 9 (SD)]; and 4) adults at or greater than 4010 equivalent to or greater than 221 SD above the normal mean ratio [29 +/- 18 (SD)]. Conversely, the hormonal data in the genotype-normal patients suggest the following hormonal criteria are not consistent with 3beta-HSD deficiency congenital adrenal hyperplasia: ACTH-stimulated Delta5-17P levels in children with premature pubarche up to 72 nmol/liter equivalent to up to 11 SD above the control mean level, and in hirsute females up to 150 nmol/liter equivalent to up to 12 SD above the normal female mean level [28 +/- 10 (SD) nmol/liter]; and ACTH-stimulated Delta5-17P to F ratio in children with premature pubarche up to 67 equivalent to up to 5 SD above the control mean ratio, and in hirsute females up to 151 equivalent to up to 10 SD above the normal mean ratio [32 +/- 12 (SD)]. These findings help define newly proposed hormonal criteria to accurately predict inherited 3beta-HSD deficiency.

We identified two homozygous missense mutations in the human type II 3beta-hydroxysteroid dehydrogenase (3/betaHSD) gene, the first in codon 6 of exon II [CTT (Leu) to TTT (Phe)] in a male infant with hyperpigmented scrotum and hypospadias, raised as a male and no apparent salt-wasting since neonatal age, and the second in codon 259 of exon IV [ACG (Thr) to ATG (Met)] in a male pseudohermaphrodite with labial scrotal folds, microphallus, chordee, and fourth degree hypospadias, raised as a female and with salt-wasting disorder since neonatal age. In vitro transient expression of mutant type II 3betaHSD complementary DNAs of L6F, T259M, as well as T259R for comparison was examined by a site-directed mutagenesis and transfection of construct into COS-1 and COS-7 cells. Northern blot analysis revealed expression of similar amounts of type II 3betaHSD messenger ribonucleic acid from the COS-1 cells transfected by L6F, T259M, T259R, and wild-type (WT) complementary DNAs. Western immunoblot analysis revealed a similar amount of L6F mutant protein compared to WT enzyme from COS-1 cells, but neither L6F from COS-7 cells nor T259M or T259R mutant protein in COS-1 or COS-7 cells was detectable. Enzyme activity in intact COS-1 cells using 1 micromol/L pregnenolone as substrate in the medium after 6 h revealed relative conversion rates of pregnenolone to progesterone of 46% by WT enzyme, 22% by L6F enzyme, and 8% by T259M enzyme and less than 4% activity by T259R enzyme. Using 1 micromol/L dehydroepiandrosterone as substrate, the relative conversion rate of dehydroepiandrosterone to androstenedione after 6 was 89% by WT enzyme, 35% by L6F enzyme, 5.1% by T259M enzyme and no activity by T259R enzyme. However, the L6F mutant 3betaHSD activity, despite its demonstration in the intact cells, was not detected in homogenates of COS-1 cells or in immunoblots of COS-7 cells, suggestive of the relatively unstable nature of this protein in vitro, possibly attributable to the decreased 3betaHSD activity. In the case of T259M and T259R mutations, consistently undetectable proteins in both COS cells despite detectable messenger ribonucleic acids indicate severely labile proteins resulting in either no or very little enzyme activity, and these data further substantiate the deleterious effect of a structural change in this predicted putative steroid-binding domain of the gene. In conclusion, the findings of the in vitro study of mutant type II 3betaHSD enzyme activities correlated with a less severe clinical phenotype of nonsalt-wasting and a lesser degree of genital ambiguity in the patient with homozygous L6F mutation compared to a more severe clinical phenotype of salt-wasting and severe degree of genital ambiguity in the patient with homozygous T259M mutation in the gene.

Hyperglycemia is the major cause of diabetic vascular complications. Advanced glycation end products (AGEs) accumulate under hyperglycemic conditions and contribute to atherosclerosis. ATP binding cassette transporters (ABC) A1, ABCG1, and cholesterol 27-hydroxylase are reverse cholesterol transport proteins (RCT) that facilitate cholesterol removal from macrophages and constitute a first line of defense against atherosclerosis. ABCA1 and ABCG1 are known to be suppressed by AGEs. Here we investigate the effects of AGEs on the expression of RCT proteins and scavenger receptors in THP-1 human macrophages and peripheral blood mononuclear cells (HPBMC). Adherent THP-1 macrophages and HPBMC were incubated in the presence or absence of 50 μg/ml carboxymethyl lysine-human serum albumin over a time course. Following incubation, RNA and protein were isolated and subjected to quantitative real-time PCR with specific primers for the 27-hydroxylase, ABCA1, ABCG1, CD36, lectin-like oxidized low density lipoprotein receptor (LOX) 1, scavenger receptor (SR)A1 and chemokine CXC ligand 16 (CXCL16). PCR results were confirmed by Western blot. Expression of ABCA1 and ABCG1 were diminished in the presence of AGEs in both cell lines. For the first time, we demonstrate that AGEs decrease message and protein level for 27-hydroxylase (by 54.5 ± 2.9% and 48.7 ± 9.23%, respectively). In our study uptake of AGE products in THP-1 macrophages and HPBMC occurs mainly through the CD36 and CXCL16 receptors, leading to increased oxidized LDL uptake upon lipid overload and transformation of macrophages into foam cells. Expression of SRA1 and LOX- 1 were not affected by introduction of AGEs. Therefore, we conclude that AGEs may contribute to accelerated atherosclerosis in diabetes through effects on both forward and reverse cholesterol movement. AGEs promote lipid overload through enhancing expression of proteins that facilitate lipid uptake (CD36 and CXCL16) and through suppressing RCT proteins 27-hydroxylase, ABCA1 and ABCG1. Our present study provides a novel atheromapromoting effect of AGEs on lipid handling.

17-Ketosteroid reductase deficiency results in male pseudohermaphroditism because conversion of the weak androgen androstenedione to the more potent androgen testosterone is impaired. If a late-onset form exists, hypogonadism and gynecomastia caused by decreased testosterone production and increased estrogen production, respectively, would be expected as the major clinical manifestations in men.We studied 48 male subjects, ranging from 14 to 26 years of age, who had idiopathic pubertal gynecomastia. Serum concentrations of gonadal and adrenal steroid hormones were measured before and after the administration of corticotropin and after the combined administration of chorionic gonadotropin and dexamethasone for three days.We identified three unrelated subjects (ages, 16, 17, and 26 years) with results indicative of a partial deficiency of testicular 17-ketosteroid reductase. The three subjects had gynecomastia as well as decreased libido and impotence. Their mean (+/- SD) base-line serum androstenedione and estrone concentrations were elevated as compared with the levels in the 45 subjects without this enzyme deficiency (androstenedione, 380 +/- 70 vs. 110 +/- 70 ng per deciliter [13 +/- 2 vs. 4 +/- 2 nmol per liter]; estrone, 138 +/- 12 vs. 46 +/- 9 pg per milliliter [511 +/- 44 vs. 170 +/- 33 pmol per liter]). After the administration of chorionic gonadotropin, the mean serum androstenedione concentration in these three subjects was 910 +/- 48 ng per deciliter (32 +/- 2 nmol per liter) and the mean serum estrone concentration was 260 +/- 16 pg per milliliter (962 +/- 59 pmol per liter). The mean serum testosterone concentration at base line was 210 +/- 80 ng per deciliter (7.4 +/- 2.8 nmol per liter) in the 3 subjects, as compared with a value of 410 +/- 12 ng per deciliter (14.4 +/- 0.42 nmol per liter) in the 45 other subjects, and it did not increase in response to the administration of chorionic gonadotropin. The concentrations of androstenedione and estrone in spermatic venous serum were 19 times higher and 73 times higher, respectively, than in normal men. The serum concentrations of follicle-stimulating hormone and luteinizing hormone in these three subjects were inappropriately low, suggesting the presence of hypogonadotropic hypogonadism.A late-onset form of testicular 17-ketosteroid reductase deficiency can cause gynecomastia and hypogonadism in men.

Growth hormone (GH) deficiency causes decreased bone mineral density and osteoporosis, predis- posing to fractures. We investigated the mechanism of action of GH on bone modeling and remodeling in hypophysectomized (HX) female rats. Thirty female Sprague-Dawley rats at age 2 months were divided into three groups with 10 rats each: control (CON) group, HX group, and HX ? GH (3 mg/kg daily SC) group, for a 4-week study. Hypophysectomy resulted in cessation of bone growth and decrease in cancellous bone mass. Periosteal bone formation decreased and bone turnover rate of endocortical and trabecular surfaces increased as compared to the CON group. GH administration for 4 weeks restored weight gain and bone growth and mitigated decrease in bone density after hypophysectomy. However, trabecular bone mass in the proximal tibial metaphysis remained lower in group HX ? GH than in group CON. Dynamic histomorphometric analysis showed that bone modeling of periosteal bone formation and growth plate elongation was significantly higher in group HX ? GH than in group HX. New bone formed beneath the growth plate was predomi- nately woven bone in group CON and group HX ? GH. Bone remodeling and modeling-remodeling mixed modes in the endocortical and PTM sites were enhanced by GH administration; both bone formation and resorption activi- ties were significantly higher than in group HX. In con- clusion, GH administration to HX rats reactivated modeling activities in modeling predominant sites and increased new bone formation. GH administration also increases remodeling activities in remodeling predominant sites, giving limited net gain in the bone mass.

Background/Aims: Growth hormone (GH) deficiency in pediatric patients results in short stature and osteopenia. We postulated that the GH and parathyroid hormone (PTH) combination would result in improvement in bone growth and bone formation. Methods: Forty hypophysectomized female rats at age 8 weeks were divided into hypophysectomy (HX), HX + PTH (62.5 µg/kg, s.c. daily), HX + GH (3.33 mg/kg, s.c. daily), and HX + PTH + GH for a 4-week study. Results: GH increased body weight, bone growth, bone mineral content (BMC) and bone mineral density (BMD), whereas PTH increased BMC and BMD without a significant effect on bone size. GH increased both periosteal and endocortical bone formation and cortical size, while PTH increased only endocortical bone formation. GH mitigated the trabecular bone loss by increasing bone formation, while PTH increased bone mass by increasing bone formation and suppressing osteoclast number per bone area. The result of combined intervention shows an increase in trabecular, periosteal and endocortical bone formation and suppression of bone resorption resulting in a synergistic effect on increasing trabecular and cortical bone volume and BMD. Conclusion: The combination treatment of PTH and GH increases bone growth, bone formation, decreases bone resorption and has a synergistic effect on increasing bone density and bone mass.

Growth hormone (GH) deficiency in children causes severe growth retardation, vitamin D deficiency, and osteopenia. We investigated whether alfacalcidol (1OHD) alone or in combination with GH can improve bone formation. Forty hypophysectomized female rats (HX) at the age of 8 wk were divided into HX, HX + 1OHD (oral 0.25 microg/kg daily), HX+GH (0.666 mg/0.2 mL SC daily) and HX+GH + 1OHD groups for a 4-wk study. Results showed that GH increased body weight, bone area, bone mineral content (BMC), and bone mineral density (BMD), whereas 1OHD only increased BMC and BMD. In cortical bone, GH increased both periosteal and endocortical bone formation resulting in a significant increase in cortical size and area in percentage, whereas 1OHD suppressed endocortical erosion surface per bone surface (ES/BS) without a significant effect on bone formation rate per bone surface (BFR/BS). In trabecular bone, GH mitigated the bone loss by increasing BFR/BS, whereas the 1OHD effect was by suppression of trabecular bone turnover in the HX rats. The combination of GH and 1OHD had no additive effect on increasing trabecular bone mass. In conclusion, GH activates new bone formation and increases bone turnover whereas 1OHD suppresses bone turnover. The combination intervention does not seem to provide any additive benefit.

The clinical manifestations of male hypogonadism will depend on when the testicular failure occurs. Therefore, based on the timing of testicular failure, different types of male hypogonadism can be identified. A correlation between physiopathology, clinical manifestation, and treatment is attempted

The incidence of varicoceles in adolescent boys ranges from 5% to 19.5%. We studied five adolescent boys aged 17 to 20 years with visible left-sided varicoceles. All of them had public hair and testicular volumes between 20 to 25 mL and had achieved stage V of pubertal development. Serum gonadotropin response to the intravenous administration of 100 micrograms of gonadotropin-releasing hormone (GnRH) and testosterone response to the administration of 2,000 IU human chorionic gonadotropin (hCG) daily for 3 days before and 3 months after varicocelectomy were measured. Basal levels of both gonadotropins were in the pubertal range, and there was no significant difference between serum levels before and after varicocelectomy. Both gonadotropins, however, showed increased responses to the administration of GnRH (luteinizing hormone [LH]: basal, 12.0 +/- 5.1 mIU/mL; peak, 105.0 +/- 36.0 mIU/mL; follicle-stimulating hormone [FSH]: basal, 11.6 +/- 4.2 mIU/mL, peak, 60.0 +/- 18.0 mIU/ml) that decreased after varicocelectomy (LH: basal, 14.3 +/- 6.0 mIU/mL; peak, 58.6 +/- 12.0 mIU/mL; FSH: basal, 6.8 +/- 4.6 mIU/mL; peak, 38.0 +/- 8.1 mIU/mL). Serum testosterone response to hCG was also significantly improved by varicocelectomy (testosterone peak: before, 780 +/- 210 ng/dL; after, 1850 +/- 170 ng/dL). Testicular biopsy specimens showed no histologic abnormalities and normal spermatogenesis. Endocrine evaluation in adolescent boys with varicoceles could detect an early Leydig cell dysfunction that could be corrected by varicocelectomy.

Short stature is characteristic of children with Prader-Willi syndrome (PWS). While previous studies have demonstrated acceleration of linear height velocity with growth hormone (GH) treatment, the long-term benefit on final adult height (AH) has not been reported. The objective of this study was to compare AH attained in PWS subjects with and without GH treatment. We reviewed the records of 21 children (aged 8.3 +/- 2.7 years) with PWS and confirmed GH deficiency that attained AH after receiving human GH treatment (0.25 +/- 0.06 mg/kg/week) for a period of 7.9 +/- 1.7 years. A group of 39 non-GH-treated adults with matched initial height standard deviation score (SDS) at age 6.8 +/- 1.3 years was used as control. In the GH-treated group the mean initial height and AH-SDS was -1.9 +/- 1.7 and -0.3 +/- 1.2 respectively (P < 0.0001), whereas the mean initial and AH-SDS in the control group was -1.9 +/- 1.3 and -3.1 +/- 1 respectively (P < 0.0001). Scoliosis was seen in 43% and 39% in the GH-treated and control group respectively. Premature adrenarche (PA) was noticed in 57% of GH-treated group. Six subjects in the control group but none of the GH-treated subjects developed type 2 diabetes mellitus. Our data show that administration of GH to children with PWS restores linear growth and final AH without significant adverse effects other than PA. Further studies will be necessary to determine related morbidity and mortality in individuals with PWS that reached final AH with or without GH treatment.

Prolactin secreting pituitary adenomas are a rare finding in prepubertal children /1/. As in adults, their incidence is higher in girls than in boys; however, the macroadenomas are predominant in boys /20-16/. Two prepubertal boys who presented with short stature and linear growth deceleration were diagnosed to have prolactin secreting pituitary macroadenoma associated with growth hormone (GH) deficiency. They were treated with bromocryptine and exogenous recombinant hGH. They achieved a normal adult stature, full sexual maturation and tumor regression on the therapy. In addition, both boys developed macrotestes. Further evaluation ruled out other etiologies for macrotestes. We presume that the elevated prolactin caused local testicular growth factors to induce testicular cell division and/or hypertrophy resulting in an increased testicular volume.

Obesity, short stature, decreased growth rate and delayed skeletal maturation are common features of children with Prader-Willi syndrome (PWS). In contrast to PWS, children with simple exogenous obesity have normal or increased growth rate and normal or advanced skeletal maturation. Decreased growth hormone (GH) secretion evaluated by pharmacological or physiological testing associated with increased plasma insulin-like growth factor (IGF-I) and GH-binding protein (GH-BP) levels are also characteristic of simple obesity. In order to understand whether the suboptimal GH secretion in PWS is an artifact of the obesity, we studied 33 obese and 11 non-obese PWS children, aged 2-16 years.GH secretion was evaluated with three pharmacological stimuli (insulin, clonidine and L-dopa) and by spontaneous 24-hour GH secretion. Skeletal maturation was delayed in 70% whereas plasma IGF-I and GH-BP were either low or normal. Forty subjects, including ten non-obese children, had GH deficiency by standard testing (failure to respond to two pharmacological stimuli), and all but one had blunted spontaneous 24-h GH secretion. No significant correlation between body mass index (wt/ht2) and spontaneous 24-h GH secretion (r = 0.145), p > 0.06) or GH-BP levels (r = 0.19, p > 0.07) was found. Thirty documented GH deficient children have completed at least two years of GH therapy. With treatment the overall mean height SD and weight SD changed from -2.2 to -0.8 and from 3.5 to 2.4 respectively (p < 0.0001). No patient has developed diabetes mellitus. In conclusion, growth velocity, skeletal maturation, GH secretion and GH dependent proteins in PWS resemble GH deficiency more than simple obesity. Our ongoing study suggests that GH deficiency in PWS is not an artifact of obesity. Although it is unlikely that GH deficiency is the only cause of decreased growth velocity and increased adiposity in PWS, it is a common feature and significant contributory factor. Long term observation will be required until achievement of adult height to determine whether GH therapy actually improves final height.

The function of the adrenal zona glomerulosa was studied in 18 patients with 11-hydroxylase deficiency confirmed by elevated plasma levels of 11-deoxycortisol. Patients were divided into two groups. Group I (4 males, 7 females; aged 1.2-2.8 yrs) had symptoms at birth or shortly after (classic form), and Group II (4 males, 3 females; aged 7.3-20.1 yrs) had their first clinical manifestation during childhood (non-classic form). To study zona glomerulosa function, patients were given dexamethasone p.o. 2 mg/m2/day x6 days, thus suppressing the zona fasciculata. Six hours after the last dose of dexamethasone, the zona glomerulosa was stimulated by i.v. administration of furosemide 1.0 mg/kg as a single dose. Blood was drawn 2 h later. In the untreated state, all patients had striking elevation of ACTH (Group I: 1,070 +/- 380 pg/ml; Group II: 764 +/- 180 pg/ml), 11-deoxycortisol (Group I: 63,000 +/- 22,000 ng/dl; Group II: 17,200 +/- 5,200 ng/dl) and deoxycorticosterone (Group I: 1,100 +/- 67 ng/dl; Group II: 499 +/- 27 ng%) while plasma renin activity (< 0.5 ng/ml/h in both groups) and aldosterone (Group I: 3.0 +/- 1.8 ng/dl; Group II: 2.3 +/- 1.8 ng/dl) were markedly suppressed. After the administration of furosemide 4 patients in Group I were unable to increase aldosterone (2.8 +/- 0.9 ng/dl) secretion in spite of marked elevation of plasma renin activity (28 +/- 7 ng/ml/h), suggesting an impairment of 11-hydroxylase in the zona glomerulosa.(ABSTRACT TRUNCATED AT 250 WORDS)

Prader–Willi Syndrome (PWS) is characterized by infantile hypotonia, obesity, hypogonadism, mental deficiency, short stature, characteristic facial features, small hands and feet, and an interstitial deletion of chromosome 15(q11–13) in about one–half of the patients. Short stature and delayed skeletal maturation occur in 90% of children with PWS. The basis for the short stature, however, remains uncertain. Pituitary evaluation of growth hormone (GH) deficiency by pharmacological tests have varied from normal to impaired in PWS children (Bray et al, 1983; Lee et al, 1982).

To investigate the testicular function in adolescents with pubertal gynecomastia associated with varicocele before and after varicocelectomy.We have studied six male adolescents 15 to 19 years of age with bilateral gynecomastia. They were selected among other adolescents with gynecomastia because of the presence of visible varicoceles. All of them had normal physical examination and secondary sexual characteristics. This was prospective study of 3 months' duration. All the patients that were included finished the study.All the patients were evaluated in the Endocrine Clinic of Winthrop-University Hospital, a tertiary care unit.Serum testosterone (T), androstenedione (A), and estradiol (E2) responses to the administration of human chorionic gonadotropin (hCG) 2,000 IU for 3 consecutive days before and 3 months after varicocelectomy were determined.Varicocelectomy did not cause any significant changes in the basal (pre-hCG) levels of the steroid. However, the increase in T levels achieved with hCG was significantly (P less than 0.005) higher after varicocelectomy (before T, 925 +/- 212 ng%; after T, 1,649 +/- 406 ng%). Simultaneously, the stimulated levels of E2 and A were significantly lower (P less than 0.005) after varicocelectomy (E2, 62 +/- 12 pg/mL; A, 326 ng% +/- 80 ng%) than before (E2, 106 +/- 13 pg/mL; A, 580 ng% +/- 95 ng%).The reciprocal effect on the levels of T and its immediate precursor, A, suggests an impairment of the 17-ketoreductase enzyme activity. The increased levels of E2 after hCG and its normalization after varicocelectomy suggests that varicoceles may play a pathogenetic role in the development of gynecomastia.

Hypopituitarism results in a cessation of bone growth, a decrease in bone formation and cancellous bone volume in humans and animals, mechanism still remaining unclear. Growth hormone (GH) replacement to the hypophysectomized(HX) young rats restored the growth of long bone, but only partially prevented the loss of cancellous bone volume. This study is to examine the efficacy of GH with or without 17b-estradiol(E) on cortical and cancellous bones of the HX rats. 2 month old female Sprague-Dawley rats, were divided into basal(B), age matched intact control(AMC), HX, HX+GH(2.25mg/kg/day), HX+E(100ug/kg/wk) and HX+GH+E groups with 10 rats in each group. The basal group was sacrificed at two months of age and the remaining after 3 weeks of treatment. Prior to sacrifice, they were labeled with flurochrome chemicals at fixed time intervals for the estimation of mineral apposition rate(MAR) and bone formation rate(BFR). Our results showed that HX rats had atrophy of adrenal glands and uterus, cessation of systemic growth (tibial length, body and muscle weight) and a decrease in tibial and the 6th lumbar vertebral (L6) dry weight as compared to the B and AMC groups. The bone histomorphometry revealed that HX induced a decrease in periosteal MAR(0.2±0.4um/d vs AMC:3.1±0.5, P

Two Novel Homozygous Mutations in the Type II 3β-Hydroxysteroid Dehydrogenase(3β-HSD) Gene Causing Non-Salt Wasting and Salt Wasting 3β-HSD Deficiency Congenital Adrenal Hyperplasia (CAH) and the Utility of Hormonal Profiles for Diagnosising Bonafide 3β-HSD Deficiency CAH• 505

Short stature, obesity, decreased lean mass, cryptorchidism, and hypogonadism are characteristic features of PWS. The growth pattern in PWS suggest an abnormality in GH secretion or action. Body composition changes in PWS including increased adipose and decreased muscle mass are similar to those children with IGHD. In GH deficiency, GH secretion is negligible and IGF levels are low, leading to decreased linear growth. In exogenous obesity the GH are low but the IGF levels however are normal or high. Contrary to exogenous obesity PWS children have decreased growth velocity, sexual development, muscle mass, and IGF levels. Other investigators and ourselves have shown blunted GH secretion in both obese and non-obese PWS children and the benefits of GH therapy (J of Ped End & Metab. 9,943-400, 1996.). We now compare the growth velocity in 96 PWS children and 6965 children with IGHD from the National Cooperative Growth Study (NCGS) after 4 years of GH therapy. The linear growth was similar in both groups. Although is unlikely that GHD is the only cause of short stature, decreased growth velocity and increased adiposity in PWS children, suggest that GHD is a common feature and significant contributory factor in expression of PWS phenotype. Figure

Nine of 15 boys with severe long-standing primary hypothyroidism were found to have macroorchidism. All 15 patients had elevated thyroid-stimulating hormone levels. However, only those patients with testicular enlargement had striking elevations of serum prolactin and gonadotropin values. The response to gonadotropin-releasing hormone in our patients was blunted, in contradistinction to that of children with true precocious puberty. In spite of the elevated levels of luteinizing hormone, the serum testosterone levels were in the prepubertal range, explaining the lack of peripheral manifestations of androgenic effect. Improvement of testosterone secretion followed decreasing prolactin levels with bromocriptine administration, suggesting an inhibitory effect of prolactin on luteinizing hormone action at the Leydig cell. We conclude that testicular enlargement is the result of continuous follicle-stimulating hormone stimulation and that the term "true precocious puberty" is not appropriate in children with hypothyroidism and macroorchidism unless the hypothalamic-pituitary gonadal axis is shown to be at the pubertal stage.

13 short children aged 7-13 years who had a retarded bone age and low hair zinc concentration (under 140 micrograms/g) were treated with oral zinc supplements for a year. There was a significant increase in the growth rate in the children whose hair zinc concentration increased. Growth hormone, testosterone and somatomedin C also increased after oral zinc supplementation. Data from 755 short healthy children who have attended our Growth Clinic are presented which describe their hair and serum zinc concentration at different ages. The data indicate a decline in hair zinc concentration after birth with a gradual increase at age 4-6 years, finally reaching adult normal levels after adolescence.

The intraperitoneal administration of l-norvaline and l-methionine-SR-sulfoximine to rats caused an increase in the concentration of ammonia in plasma as well as in liver. These compounds interfere with urea and glutamine formation, respectively. Subsequent injection of sodium benzoate failed to alleviate ammonia levels, and on the contrary, caused a further increase. Sodium benzoate itself, when administered, resulted in higher levels of ammonia in plasma and liver of the rats. Administration of glycine to rats treated with benzoate did not lower ammonia levels indicating that other factors besides glycine may also be necessary for the removal of sodium benzoate.

Using atomic absorption spectrophotometry, we have assayed zinc and copper concentrations in the hair of children with typical achondroplasia, familial short stature, or constitutional growth delay, and of unaffected parents of achondroplastic children and healthy adults of similar age and sex as the parents (Table). Specimens consisted of the terminal 2 to 3 inches of hair, obtained from the posterior scalp. Duplicate 60 to 80 mg hair specimens were digested in concentrated nitric:perchloric (3:1) acid mixture. The results are the mean of at least two determinations per specimen. The achondroplastic children were all confirmed as typical examples by physical examination and radiographs of skull, spine, long bones, and pelvis. Several of the parents were noted to have white flecks in their fingernails, which has been reported to be associated with zinc deficiency. The data indicate significantly reduced zinc and increased copper values, and reduced zinc:copper ratio, in the hair of parents and children with achondroplasia.

The incidence of varicoceles in adolescent boys has been reported to range from 5.7% at 10 years of age to 19.3% at age 14 years, with a mean of 16.2% for the whole group of boys aged 10 to i9 years. Oster 1 found no varicoceles before the age of 10 years among 1072 Danish schoolboys. After adolescence, the incidence of varicoceles remains constant. Steeno et al. 2 reported that 81% of school-age adolescents with visible varicoceles already had a decrease in testicular volume, consistency, or both. In fact, a pantesticular defect involving testosterone production and spermatogenesis has been reported ~in adult men with varicoceles. 3 However, there have been no studies of the endocrine function of the testes in male adolescents. We studied the hypothalamicpituitary-testicular axis in five male adolescents, aged 17 to 20 years, with visible varicoceles. The effect of Varicocelectomy on the endocrine function of the testes was also evaluated. METHODS Patients. Our patients were five male adolescents, aged 17 to 20 years, who were seen in the pediatric endocrine clinic for evaluation of testicular function. All these patients had visible left-sided varicoceles, big' enough so that the mass Of tortuous veins impeded examination of the testicle when the patients were in the upright position; the varicoceles were graded as severe. Two of these patients also had right-sided varicoceles graded as moderate, according to the classifica

A 14-year-old girl and a 13-year-old boy were found to be growth hormone deficient by insulin-arginine stimulation tests, and were also found to be zinc deficient. When oral zinc replacement was given, they both had a significant increase in growth rate which continued for at least 2 years, and subsequent growth hormone tests were normal.

Sixteen prepubertal children with constitutional growth delay (10 boys and six girls, mean age 7.2 +/- 2.1 years) were administered a daily dose of clonidine (0.15 mg/m2) for a period of 1 year. Growth hormone levels, plasma somatomedin C, and linear growth rate were significantly increased at the end of the treatment. Six of the children maintained the higher growth rate even 6 months after treatment. These and other studies suggest that prolonged stimulation of the hypothalamus by clonidine may ameliorate the impairment of growth hormone release seen in some children with constitutional growth delay. Because of the low cost and the convenience of the oral route, administration of clonidine could be a mode of treatment in some children with poor growth.

Premature infants have a lower selenium concentration in serum than full-term infants and children. The selenium concentration goes down quickly in infants treated for respiratory distress syndrome without supplementation. One premature infant with bronchopulmonary dysplasia had persistently low concentrations of selenium. Vitamin E supplements did not affect the serum selenium concentration in healthy premature infants. Supplementation with 3 µg/kg of selenium in parenteral fluids prevented the fall in the concentration seen in other infants not supplemented. Premature infants and especially those treated withoxygen may warrant selenium supplementation to the parenteral nutrition solution. Vitamin E supplements alone are apparently not sufficient to prevent selenium deficiency and potential oxygen toxicity.

Zinc levels were measured in hair and serum of boys with constitutional growth delay and familial short status and in several boys before and after oral administration of methyltestosterone. These results show the following: (1) zinc levels in boys beyond stage 3 of genital development are significantly higher than in stage 1 and 2; (2) there is a linear relationship between zinc levels and serum testosterone concentration (up to 250 ng/dL); and (3) methyltestosterone administration raised the zinc concentration in serum and hair, especially in boys with constitutional growth delay. Therefore, increased endogenous production or exogenous supply of testosterone are associated with increased zinc levels. We speculate that the relative testosterone deficiency and hypogonadotropism seen in constitutional growth delay may result in decreased zinc levels, which in turn could cause a further delay in the appearance of secondary sexual characteristics and greater growth retardation.

A pituitary evaluation was carried out in a 12-year-old girl who had early puberty, short stature, optic nerve hypoplasia, and agenesis of the corpus callosum. Her growth hormone (GH) response to insulin-induced hypoglycemia and arginine infusion was blunted. Basal and stimulated levels of prolactin were elevated. The association of GH deficiency and hyperprolactinemia suggests a disruption of the dopaminergic modulation of these hormones. The facial features seen in our patient, such as hypertelorism, V-shaped frontal hairline, and cleft nose and upper lip, are enough to justify the diagnosis of median cleft face (MCF) syndrome. However, the optic nerve hypoplasia and the GH deficiency are characteristics of septo-optic dysplasia, and, to our knowledge, they have never been described in patients with MCF syndrome. Our case fulfills the diagnostic criteria of both, representing a link between both ends of this spectrum.

Growth hormone deficiency has been reported in 10-20% of Russell-Silver dwarfs. Two siblings with all the classical features of Russell-Silver Syndrome were low in growth hormone (insulinarginine stimulation test), and blood and hair zinc (Zn). They received 50 mg elemental Zn orally each day for 2 months and 50 mg weekly for 4 more months. Growth hormone and Zn determinations were repeated at 6 months: It appears there is a direct relationship between the growth hormone response and Zn nutritional status. We have data indicating that growth hormone therapy increases hair Zn and decreases urinary Zn in children with growth hormone deficiency. These two children provide new data indicating that there are patients whose growth hormone production is affected by their Zn nutritional status.

Concentration of zinc in hair and serum of children with short stature (familial or constitutional) was measured by atomic absorption spectrophotometry. Some of them were treated with methyltestosterone (MT), 10 mg. daily. Our Zn values were similar to those reported for normal children. Nevertheless, children receiving MT had higher Zn levels than the children without medication. Since Zn deficiency is associated with growth retardation, these results raise the question of whether increased Zn retention may be one of the mechanisms by which androgens accelerate growth. We were unable to find any significant difference between the Zn levels from children with familial short stature and those from children with constitutional growth delay.

Concentration of zinc (Zn) in hair, urine and serum were measured by atomic absorption spectrophotometry in one 14-month old girl with typical features of Fetal Alcohol Syndrome (FAS) (peculiar facies, congenital malformations, pre and post natal growth deficiency). She was born to an alcoholic woman who continued drinking heavily throughout her pregnancy. Zinc level was low in hair (66 μg/g) and urine (266.8 μg/g of creatinine) but normal in serum(95 μg%), reflecting probable chronic depletion of Zn. (Normal values are: hair 193 ± 18 μg/g, serum 75-160 μg%, urine 400-600 μg/g.) It has been shown that the offspring of Zn-deficient rats have marked growth retardation and high incidence of congenital malformation, some of which are similar to those seen in FAS. Alcoholic patients have been found to lose increased amounts of zinc in urine. Therefore, it is tempting to speculate that congenital Zn deficiency plays an important role in the pathogenesis of this syndrome.

We have measured Zinc (Zn) levels in different tissues of castrated rats (CR) fed purified diet containing 100 pp Zn for 6 wks with and without injection of testosterone (T) enanthate (20 mg IM) 2 wks prior to sacrifice. CR had very low serum T (0.6 ± 0.1 ng/ml) as compared with the controls (8.2 ± 0.7 ng/ml) and T administration restored serum T to normal levels (9.1 ± 1.1 ng/ml). After castration, serum and tissue Zn levels were significantly decreased with concomitant increase in urinary Zn (see Table). Administration of T to CR increased the serum and tissue Zn levels almost to the normal level. Since food intake was similar in all groups, T in CR may have increased Zn retention. These results strongly suggest a positive relationship between Zn and T metabolism.