Cortisol hyporesponsiveness to the low dose ACTH test is a frequent finding in a pediatric population with type 1 diabetes mellitus.

INTRODUCTION: In adults with type 1 diabetes mellitus (DM1), a 25% of risk of hypocortisolism has been found through a low dose ACTH test with negative antibodies suggesting other causes of hypothalamic-pituitary-adrenal axis dysfunction. AIM: To evaluate adrenal function in pediatric patients with DM1 and correlate the results with the frequency of hypoglycemia and metabolic control. METHODS: Sixty-nine patients were enrolled, age 12.3 (5.7-18.1); 50 boys and 19 girls. A 20% had additional autoimmune diseases. Mean hemoglobin A1c (HbA1c) was 8.1% and insulin dose was 1.14 U/kg/d. After an overnight fast, a low dose ACTH test (1 µg) was performed. Basal and stimulated cortisol concentrations, DHEAS, and plasma renin activity (PRA) were measured. A cortisol response post-ACTH below 18 µg/dL was considered abnormal. RESULTS: 58% of the tested patients had an abnormal response to ACTH test. These patients also had lower DHEAS concentrations, but were not different in diabetes duration, HbA1C, severe hypoglycemia, ACTH, or PRA concentrations compared to those who had a normal cortisol post-ACTH. One patient out of 59, had a positive anti-21-hydroxylase antibody (21OHA) and presented a poor response to ACTH. CONCLUSIONS: We found a significant proportion of our patients having a subnormal cortisol response independent of the presence of anti-adrenal cell antibodies. We did not find a correlation with metabolic control, probably due to the good metabolic control of this group. The absence of 21OHA does not rule out subclinical hypocortisolism in this population. Our results suggest testing adrenal function in children with DM1.

Resultados de un programa multidisciplinario de tratamiento intensificado de la diabetes mellitus tipo 1 (DM1) en un Hospital Público / Results of a multidisciplinary and intensified treatment program for type 1 Diabetes Mellitus in a Chilean Public Hospital

BACKGROUND: During the last decade, the importance of glycemic control in the prevention of the microvascular complications of type 1 Diabetes Mellitus (DM1) was clearly demonstrated. AIM: To evaluate the metabolic and anthropometric results of a multidisciplinary intensified treatment program of DMI in children and adolescents. PATIENTS AND METHODS: Report of 54 patients treated during 2001. The intensified treatment consisted of: multiple daily doses of insulin, frequent glycemic control, nutritional, psychological and educational support, and permanent availability of a diabetes nurse for telephonic support. RESULTS: Thirty one patients were female, their mean age was 10.4 +/- 0.5 years old and 52 per cent were experiencing puberty. Fifty three percent of the patients used 3 insulin doses per day, 95 per cent changed rapid insulin dose based on glucose levels and 18 per cent considered carbohydrates in their rapid insulin dosing. Mean glycosilated hemoglobin was 8.18 +/- 0.23 per cent without differences by sex or pubertal status. Sex, pubertal stage and the number of insulin doses did not contribute to glycosilated hemoglobin changes. There were no differences in weight or BMI, but there was a decrease in height Z score from the admission to the program until the last control (0.1 +/- 0.1 vs--0.3 +/- 0.1 DS; p < 0.01). CONCLUSIONS: A modified intensified modality of DM1 therapy for pediatric patients in a public hospital in Chile is feasible, achieving similar metabolic control, compared to international large centers.

[Has oligomenorrhea a pathological meaning? The importance of this symptom in internal medicine]. / Tiene la oligomenorrea un significado patológico? Importancia de este síntoma en medicina interna.

BACKGROUND: Oligomenorrhea, defined as a menstrual cycle lasting 36 to 90 days, can be a normal condition in the first years after the menarche. When it persists or appears after a period of normal menstrual cycles, an underlying illness must be sought. AIM: To assess ovulation and causes of anovulatory cycles in women with oligomenorrhea, compared with causes of secondary amenorrhea. PATIENTS AND METHODS: One hundred one women of less the 35 years old, presenting with oligomenorrhea persisting 5 years after menarche or lasting more than two years after a period of normal menstrual cycles, were studied. Ovulation was studied measuring serial plasma progesterone during normal or induced (with intramuscular progesterone) menstrual cycles. RESULTS: Eighty nine percent of women had anovulatory oligomenorrhea. The main causes were polycystic ovarian disease in 51% and hypothalamic dysfunction in 31%. Thirty percent of women with secondary amenorrhea had polycystic ovarian disease and 14% had hyperprolactinemia. Women older than 20 years old or with more than 10 years of gynecological age had a higher frequency of polycystic ovarian disease and a lower prevalence of hypothalamic dysfunction. CONCLUSIONS: There is a high frequency of anovulatory oligomenorrheas. Therefore, this symptom deserves a thorough endocrinological assessment to uncover underlying diseases. Special attention must be paid to polycystic ovary syndrome, due to its importance in internal medicine as a risk factor for myocardial infarction, high blood pressure, and type 2 diabetes mellitus.

[Prolonged remission of female hyperandrogenism after discontinuing glucocorticoid therapy]. / Remisión prolongada del hiperandrogenismo femenino después de suspender la terapia con glucocorticoides.

Adrenal androgen hypersecretion either produced by genetic defects or reticular disfunction, is reduced by exogenous glucocorticoid administration and, as with any suppression therapy, it should relapse when the therapy is discontinued. However, prolonged remissions of adrenal androgen hypersecretion after discontinuing glucocorticoids have been described. We report 15 patients with adrenal hyperandrogenism and elevated levels of dehydroepiandrosterone sulfate that received treatment with dexamethasone. After one month of treatment with dexamethasone 0.5 mg/day, dehydroepiandrosterone sulfate levels returned to normal and remained so during a mean of 19 months receiving dexamethasone 0.25 mg/day. One year after discontinuing therapy, hormone levels continued within normal range in all patients. It is concluded that a long remission period of adrenal hyperandrogenism was achieves after discontinuing glucocorticoid therapy.