Diagnosis of growth hormone (GH) deficiency in adults with hypothalamic-pituitary disorders: comparison of test results using pyridostigmine plus GH-releasing hormone (GHRH), clonidine plus GHRH, and insulin-induced hypoglycemia as GH secretagogues.

The insulin tolerance test (ITT) is widely accepted as the method of choice to evaluate GH secretion capacity in adults with hypothalamic-pituitary disorders. However, the test is not suitable in the elderly or in patients with cardiovascular disease or seizure disorders. In recent years alternatives to the ITT have been introduced. The purpose of the present study was to investigate the diagnostic outcome with the ITT, the pyridostigmine plus GHRH (PD + GHRH) test, the clonidine plus GHRH (CLO+GHRH) test, and insulin-like growth factor I (IGF-I) in an unselected group of patients with hypothalamic-pituitary disease. An evaluation of the reproducibility of the different stimulation tests was included in the study. Based on repeated testing with the various GH stimulation tests in healthy adult males and females, the lower limits of normality for the ITT, the PD+GHRH test, and the CLO+GHRH test were 3.92, 12.8, and 19.0, microg/L, respectively. A consecutive group of 26 unselected patients with hypothalamic-pituitary disorders, 13 males and 13 females (median age, 44 ys), were tested twice with all stimulation tests, except that only 10 patients were tested once with the CLO+GHRH test due to side-effects related to clonidine. The peak GH responses between test 1 and test 2 correlated significantly in both the ITT and the PD + GHRH test (P < 0.02), and no significant difference was observed in the median peak response to repeated testing. In addition, no sex difference was observed. The coefficients of variation (CV) were 96% (ITT) and 45% (PD + GHRH), but in the majority of patients low values were repeatedly low. The peak GH response was significantly higher during the PD+GHRH test than during the ITT (P = 0.008). In the 10 patients tested with the PD+GHRH and CLO+GHRH tests there was no significant difference in the peak GH response (P = 0.398). When the test specific cut-off values were used, no significant difference in diagnostic outcome was observed between the various tests (P > 0.3). In contrast, the diagnosis obtained with IGF-I differed significantly from all GH stimulation tests (P < 0.03). Twenty (77%) and 22 (85%) patients were diagnosed to be GH deficient with the ITT and the PD+GHRH test, respectively. Of the 14 patients with multiple pituitary failure (>2 hormones affected), GH deficiency was present in more than 90% regardless of the type of stimulation test used. The IGF-I levels were only subnormal in 42% of the patients and did not correlate with the peak GH responses in any of the stimulation tests (P > 0.05). Except for 1 patient all patients with subnormal IGF-I were GH deficient in all stimulation tests. It is concluded that in patients with hypothalamic-pituitary disease and a normal IGF-I level 2 stimulation tests should be performed to establish a diagnosis of GH deficiency. In patients with a subnormal IGF-I value a single GH stimulation test should be sufficient to confirm the presence of GH deficiency.

Differences in reproducibility and peak growth hormone responses to repeated testing with various stimulators in healthy adults.

In healthy adults, GH responses to provocative testing are variable between subjects. Information on the intra-subject variability is limited, despite the importance attached to GH stimulation tests in the diagnosis of GH deficiency. We have investigated and compared the variability of different GH stimulation tests in a group of healthy control subjects. In 16 healthy non-obese adults, two insulin tolerance tests (ITT) (0.15 IU/kg body weight i.v. and a fall in blood glucose < or = 2.2 mmol/l) two GHRH tests (1 microgram/kg body weight i.v.), and two clonidine (CLO) (300 micrograms p.o.) + GHRH (60 min later) tests were performed in the morning after an overnight fast. A pyridostigmine (PD) (120 mg p.o. 60 min before GHRH) + GHRH test was performed twice in an extended group of 31 healthy adult subjects. A wide range of GH responses was observed. Both during the ITT and the GHRH test, low values in the range generally recognized to reflect impairment of GH secretory status were encountered. The median (range) peak GH responses in tests 1 and 2 were: (a) ITT: 14.4 micrograms/l (4.1-71.1) and 14.0 micrograms/l (0.09-69.5), (b) GHRH test: 21.7 micrograms/l (0.71-56.2) and 18.4 micrograms/l (1.6-55.1); (c) CLO + GHRH test: 57.4 micrograms/l (22.9-209) and 65.8 micrograms/l (12.2-206); (d) PD + GHRH test: 36.5 micrograms/l (9.1-125) and 44.6 micrograms/l (6.3-101). The coefficients of variation (CV) were: 58% (ITT), 45% (GHRH), 46% (CLO + GHRH) and 26% (PD + GHRH). The peak GH responses were significantly different in all tests (CLO + GHRH > PD + GHRH > GHRH > ITT). In the individual subject, there was no systematic correlation between the peak GH responses in the different stimulation tests. In conclusion, we found that the stimulated GH responses were highly variable in all tests, and that the peak GH responses differed. Test results in patients should be evaluated against test-specific reference values, and caution is justified in the interpretation of low responses in a single test.

Greenlanders in hospital; lack of language understanding is not always a hindrance to intercultural communication. Comparison of interviews of Greenlandic patients and their Danish therapists with respect to concepts of communication, patient satisfaction, disease, and health.

In four hospitals in Greenland, 50 Greenlandic patients and their Danish therapists have been interviewed about the same topics. The interviews were semistructured with open ended questions on the following subjects: Language difficulties, perception of diagnosis, patients satisfaction and points of criticism, perception of disease and treatment, and experience of health in general. In spite of language difficulties and insufficient communication, patient satisfaction occurred in most of the consultations. There was a tendency towards the elder patients being more satisfied than the younger. It does not seem to be a necessity to achieve a good treatment-result that the patients and the therapists speak the same language and share the same concepts of health and disease. Where the foreign health service can be limited so that it is not viewed as a menace to culturally related concept of disease, the consultations give rise to the best patient-satisfaction.

[Greenlanders' attitudes towards health and disease. A comparative interview study of patients' and therapists' attitude to disease and health]. / Grønlaenderes sygdoms- og sundhedsopfattelse. En sammenlignende interviewundersøgelse af patienters og behandleres opfattelse af sygdom og sundhed.

In four hospitals in Greenland, 50 Greenlandic patients and their Danish therapists (18 doctors, 26 nurses and six other staff) have been interviewed about their perceptions of disease and treatment and experiences of health in general. The Greenlandic patients' experiences of health were different and sometimes more articulate than those of their Danish therapists. Most of the Greenlandic patients expressed a trusting relationship towards the therapists, but most of the Danish professionals experienced that attitude as being authoritarian and dependent. It does not seem to be necessary in order to achieve a good treatment result that the patients and their therapists speak the same language and share the same concepts of health and disease. In those cases where the foreign health service's offers of treatment can be contained, and are not experienced as a threat to culturally related concepts of disease, the consultation presumably results in the best patient satisfaction.

[Greenlanders in hospital. An interview study of communication between patients and therapists, satisfaction and therapeutic preferences]. / Grønlaendere på hospital. En interviewundersøgelse af patienter og behandlere vedrørende informationsudveksling, tilfredshed og behandlingsproeferencer.

In four hospitals in Greenland, 50 Greenlandic patients and their Danish therapist (18 doctors, 26 nurses and six other staff) have been interviewed about the same topics. The interviews were semistructured with open ended questions on the following subjects: Language difficulties, perception of diagnosis and therapy, patients' satisfaction and points of criticism. Several of the patients had not understood the most important medical information about diagnosis and treatment. But most of the patients did not consider the information problem to be serious and patients were satisfied with most of the consultations. Language difficulties and insufficient communications do not correspond to patients' satisfaction but have to be analysed in the wider cultural context. There was a tendency towards the elder patients being more satisfied than the younger.