bluuebunny/crossref_metadata_2025 huggingface dataset:
Longer term outcome in females with congenital adrenal hyperplasia (CAH): the Cardiff experience
Authors: Premawardhana L. D. K. E. , Hughes I. A. , Read G. F. , Scanlon M. F.
Published: November 2003

OBJECTIVE The outlook for fertility and attaining full adult height is poor in women with congenital adrenal hyperplasia. Such outcomes have followed treatment regimes with variable ages at onset, compliance rates and monitoring. We review final height, vaginal anatomy, ovulation rates and fertility in a group of adult females with the disease.

DESIGN AND PATIENTS Sixteen adult females first diagnosed in infancy or early childhood were reviewed (age range 17–33 years; 11 with salt‐wasting disease; five with simple virilizing disease). Case note and clinical review were combined with daily saliva progesterone and weekend 17‐hydroxyprogesterone estimation in three consecutive menstrual cycles in a subgroup of eight patients in the ovulation study.

MEASUREMENTS AND ANALYSIS Daily saliva progesterone concentrations were transformed into a cumulative sum curve using a computer program. T95 (defined as the number of days from the start of the luteal phase saliva progesterone rise, in which 95% of total saliva progesterone for the menstrual cycle was obtained) and log C95 (where C95 was defined as 95% of total saliva progesterone for the same cycle) were plotted for each cycle on a boundary diagram obtained from a normal reference population. Weekend saliva 17‐hydroxyprogesterone concentrations were compared with published nomograms.

RESULTS The majority of patients attained a final height below the parental target. Mean standard deviation scores (±SEM) and ranges were −1.49 (±0.34) and −4.2 to 0.8 for the patients and −0.38 (±0.24) and −1.89 to 0.97 for their parents. Of the combined group two‐thirds had regular menses and one‐third hirsutism; 94% had reconstructive genital surgery with 50% requiring second procedures; 77% had an adequate vaginal introitus (of them 84% in the salt‐wasting group and 75% in the simple virilizing group were sexually active). Three of five patients with salt‐wasting disease and 2/3 with simple virilizing disease who had both an adequate introitus and were sexually active conceived, resulting in eight pregnancies. In the ovulation study, a 40% ovulation rate was observed with good correlation between plasma testosterone concentrations and degree of control as assessed by weekend 17‐hydroxyprogesterone concentrations.

CONCLUSIONS Our study highlights the potential for improved fertility in female patients with congenital adrenal hyperplasia, who are treated early, comply with long‐term treatment and have adequately reconstructed external genitalia. Attaining full adult height potential remains a problem.
Cystic glucagonoma with loss of heterozygosity on chromosome 11 in multiple endocrine neoplasia type 1
Authors: Sarui Hiroshi , Yoshimoto Katsuhiko , Okumura Shoji , Kamura Masanori , Takuno Hiroshi , Ishizuka Tatsuo , Takao Hiroshi , Shimokawa Kuniyasu , Itakura Mitsuo , Saji Shigetoyo , Yasuda Keigo
Published: November 2003

A 52‐year‐old man with a past history of a pituitary adenoma and hyperparathyroidism due to a parathyroid adenoma was admitted because of a solitary tumour of the pancreas revealed by ultrasonography. His family history was unremarkable. Plasma glucagon levels were slightly elevated (280 ng/l, normal range, 40–180 ng/l) with decreased plasma amino acid levels. Plasma glucagon levels disclosed an exaggerated response during an arginine infusion test and paradoxical elevation during a 75 g oral glucose tolerance test. Endoscopic ultrasonography revealed a monolocular cystic mass of about 3 cm in diameter in the body of the pancreas. A pancreatic tumour was diagnosed before surgery as a cystic glucagonoma. Intra‐operative ultrasonography showed one cystic mass in the body of pancreas and two other solid tumours, about 1 cm and 0.5 cm in diameter, in the tail of the pancreas. Histologically, all three tumours showed neoplastic epithelial cells with round nuclei forming cords and/or a ribbon‐like arrangement. They showed positive staining for Grimelius' silver stain and immunopositive cells for glucagon. Genetic analysis of the main cystic tumour revealed loss of heterozygosity (LOH) on chromosome 11. After the operation, the responses of plasma glucagon to arginine infusion and oral glucose became normal. Here we describe the usefulness of these provocation tests for early diagnosis and post‐operative follow‐up in a rare cystic glucagonoma associated with multiple endocrine neoplasia type 1 (MEN 1) which had LOH on chromosome 11.
An account of the quality of life of patients after treatment for non‐functioning pituitary tumours
Authors: Page Renee C. L. , Hammersley Margaret S. , Burke Chris W. , Wass John A. H.
Published: November 2003

OBJECTIVE Studies assessing quality of life in GH‐deficient adults have shown varying results. This may be due to a number of factors including varying causes of GH deficiency, the use of radiotherapy in treatment and patient selection. We aimed to assess whether anterior pituitary hormone deficiency or external pituitary radiotherapy influenced the quality of life of patients with non‐functioning pituitary tumours.

PATIENTS We studied 48 patients treated and under follow up for non‐functioning pituitary tumours on standard hormone replacement therapy excluding GH. There were 21 females and 27 males with a mean age of 59±12 years. We also studied 42 control patients who had undergone mastoid surgery and were followed at least annually. There were 17 females and 25 males with a mean age of 61±14 years.

DESIGN All patients attended a research clinic and completed the Short Form 36 (SF36) and General Well Being Schedule (GWBS) to assess quality of life. Thyroid function tests, IGF1 and IGFBP3 were measured on all patients. Gonadotrophin and cortisol measurements were made on the patients with pituitary disease where appropriate.

RESULTS IGF1 and IGFBP3 levels were lower in the pituitary patients compared with controls: 104±98 vs 143±37 μg/l (P<0.0001) and 2.9±0.75 vs 3.3±0.52 mg/l (P<0.004). There were no significant differences in the quality of life scores between the pituitary patients and the control subjects. There was also no difference in quality of life between pituitary patients with two or more hormone deficiencies (n=29) compared with controls. Patients who had received radiotherapy (n=18), when compared with controls, had a decreased mental health score using the SF36 71±21 vs 81±17 (P<0.05) and decreased total GWBS score 70±20 vs 82±17 (P<0.05). Subscore analysis of GWBS showed this to be due to depression and decreased control of emotions.

CONCLUSIONS We found that the quality of life of patients treated and under follow up for non‐functioning pituitary tumours was similar to that of patients treated by mastoid surgery and under similar follow up. The pituitary patients deficient in two hormones and thus most likely to be GH deficient were also similar to the controls. These results suggest that adding GH replacement in this patient group may not be routinely indicated for improvement in quality of life and needs careful assessment. Patients who had received radiotherapy were more depressed and anxious than controls. Further investigation into the psychological and psychomotor effects of radiotherapy in this group of patients is required.
The basal rate of cell proliferation in normal human parathyroid tissue: implications for the pathogenesis of hyperparathyroidism
Authors: Wang Q. , Palnitkar S. , Parfitt A. M.
Published: November 2003

BACKGROUND The basal rate of cell proliferation in the human parathyroid gland is generally believed to be low, but has never previously been measured directly, although, as in other tissues, it is relevant to the pathogenesis of neoplasia.

METHODS We retrieved embedded tissue blocks of parathyroids removed at autopsy from 39 patients without hypercalcaemia or abnormal renal function, aged 18 to 76 years (mean 47.6). New sections were cut and examined for expression of Ki‐67, a cell‐cycle marker, using the MIB‐1 antibody with microwave antigen retrieval, and tonsil as positive control. Using an eyepiece graticule with unbiased square‐counting frame, positively labelled chief cells were counted in large squares and total chief cells in small squares in fields selected by systematic random sampling from multiple regions. A minimum of 15 ×103 chief cells were accumulated in each case. The prevalence of Ki‐67 positive cells per 104 cells (label index or LI) was converted to cell birth rate assuming that the duration of Ki‐67 expression was 24 hours. In ten cases, the entire section was examined; a map of the distribution of the positive cells was reconstructed, and divided into outer and inner regions.

RESULTS The geometric mean value for LI was 1.44/104, and multiplicative SD 2.54. The corresponding geometric mean cell‐birth rate was 5.24%/year and 95% confidence interval 0.81–33.8%/year. We found no significant effect of age, sex, race, or duration of tissue storage. The distribution of cells conformed to a Poisson distribution, and there was no difference between central and peripheral regions.

CONCLUSIONS (1) Our results establish the human parathyroid gland as a conditionally renewing tissue with very low basal cell‐birth rate; other reports of much higher LI values are probably due to selective and consequently biased sampling. (2) Since the total number of cell divisions is a major determinant of the total number of mutations, our results place some constraints on possible mechanisms for parathyroid neoplasia.
Abnormal effect of cigarette smoking on pituitary hormone secretions in insulin‐dependent diabetes mellitus
Authors: Chiodera P. , Volpi R. , Capretti L. , Speroni G. , Necchi‐Ghiri S. , Caffarri G. , Colla R. , Coiro V.
Published: November 2003

OBJECTIVE We observed the effect of smoking two cigarettes on GH, AVP and cortisol secretion in patients with diabetes and normal subjects.

DESIGN AND PATIENTS We tested 10 male smokers with insulin‐dependent diabetes mellitus (IDDM) and 10 normal smokers. On a different occasion, normal and diabetic smokers were tested with an insulin (0.15 U/kg body weight) tolerance test (ITT).

MEASUREMENTS Hypoglycaemia‐induced hormonal responses in smokers were compared with those observed in 10 diabetic and 10 normal non smokers.

RESULTS All subjects showed similar basal GH, cortisol and AVP levels. In the normal subjects, cigarette smoking induced a significant increase in circulating GH, AVP and cortisol levels, with mean peaks 3.3, 3 and 1.58 times higher than baseline, respectively. Smoking‐induced hormonal responses were significantly higher in diabetics (mean peak was 5.2 times higher than baseline for GH, 4.0 for AVP and 1.83 for cortisol). Insulin induced a similar hypoglycaemic nadir in all subjects at 30 minutes, even though the diabetic subjects had a delayed recovery in blood glucose levels. GH and AVP responses to hypoglycaemia were significantly higher in diabetic (mean peaks 11.5 and 3.2 times higher than baseline, respectively) than in normal (mean peaks 7.3 and 1.9) non‐smokers, whereas these groups showed similar cortisol responses (mean peak 2.3 times higher than baseline). Smoking did not change any hypoglycaemia‐induced hormonal rise in the normal controls, whereas it significantly enhanced GH, AVP and cortisol levels (mean peaks 14.5, 4 and 3.8 times higher than baseline, respectively) in diabetics.

CONCLUSIONS In patients with IDDM, cigarette smoking not only elicits higher GH, AVP and cortisol responses than in normal subjects, but also enhances the counter‐regulatory hormone responses to insulin‐induced hypoglycaemia. These findings suggest interactions between nicotine inhaled with cigarette smoking and diabetes‐induced neuroendocrine alterations.
Heterogeneity of nuclear DNA pattern and its relationship with cell cycle activity parameters in multinodular goitre
Authors: Francia Giuseppe , Azzolina Luigi , Mantovani Toscana , Vittoria Daví Maria , Brazzarola Paolo , Valerio Adriano , Petronio Renato , Sussi Pierluigi
Published: November 2003

OBJECTIVE

Recent studies suggest that the malignancy rate in multinodular goitre is not significantly different from that observed in solitary nodules and that chromosomal aberrations are not infrequent in multinodular goitre. To further investigate this topic we determined the DNA pattern in multinodular goitres.

DESIGN DNA

ploidy and cell cycle activity parameters were determined in multinodular goitres.

PATIENTS

We evaluated 235 patients (185 female, 50 male, mean age 52 ± 13 years), who had undergone thyroidectomy; 11 of them harboured occult differentiated microcarcinoma.

MEASUREMENTS DNA

index (DI), coefficient of variation of G0/G1 phase (CV), percentage of cells in S phase (%S) and in G2 + M phase (%G2‐M) and proliferative index (PI = %S + %G2‐M) were determined by flow cytometric analysis (FCM) in tissue samples taken from 3 different areas of the thyroid gland.

RESULTS

Aneuploid DNA was found in 50 goitres without carcinoma (22.3%) and in 5 goitres with carcinoma (45.5%). The mean PI of euploid cells in the goitre without carcinoma was significantly higher in the goitres with an aneuploid component compared to the goitres without aneuploidy (10.8 ± 1.3 SEM vs 6 ± 0.32; P ± 0.001). Also, the percentage difference between maximal and minimal PI found within each goitre (δPI %) was higher in the former group (373 ± 49 SEM vs 142 ± 11.3; P < 0.0001). The PI was significantly higher in goitres with carcinoma compared to the goitres without carcinoma (12.9 ± 3.2 SEM vs 7.07 ± 0.40; P < 0.05).

CONCLUSIONS

The finding of increased proliferation rate in goitres with an aneuploid or neoplastic component suggests that some factors involved in goitrogenesis could also be responsible for the development of chromosomal aberrations and/or for the selection of cellular clones endowed with high growth potential.
Post‐menopausal and chronological age have divergent effects on pituitary and hypothalamic function in episodic gonadotrophin secretion
Authors: Lambalk C. B. , De Boer L. , Schoute E. , Popp‐Snyders C. , Schoemaker J.
Published: November 2003

OBJECTIVE Ageing is known to reduce gonadotrophin secretion in post‐menopausal women. To what extent the hypothalamus and pituitary are involved in this process is not clear. The aim of this study was to compare pulse characteristics of FSH and LH in relation to chronological and post‐menopausal age. Based on the gonadotrophin response to GnRH, we assessed the extent to which pituitary and/or hypothalamic ageing is responsible for the observed changes.

DESIGN Blood samples were obtained from post‐menopausal women every 10 minutes for 6 hours. Subsequently, 100 μg GnRH was administered intravenously and blood samples taken after 30, 60 and 90 minutes.

PATIENTS Twenty healthy women aged 47–72 years and between 1 and 30 years after the menopause.

MEASUREMENTS Plasma LH and FSH were measured by immunoradiometric assay. Pulses were identified by a computerized pulse detection program. End points were the mean number and amplitude of pulses, the mean LH and FSH concentrations during the 6‐hour study period and the maximal LH and FSH increments following GnRH.

RESULTS Mean LH and FSH levels did not change with chronological age but the LH pulse frequency declined significantly and the response to GnRH increased. Mean LH levels declined with post‐ menopausal age without alteration in LH pulse frequency but with a significant decrease in pituitary LH response to GnRH. FSH levels remained unchanged.

CONCLUSIONS Post‐menopausal ageing seems to have a major suppressive effect on pituitary gonadotroph function, while chronological ageing mainly affects the hypothalamic regulation of LH secretion.
Urinary IGF and IGF binding protein‐3 in children with disordered growth
Authors: Gill M. S. , Whatmore A. J. , Tillman V. , White A. , Addison G. M. , Price D. A. , Clayton P. E.
Published: November 2003

OBJECTIVE Both IGF‐l and IGFBP‐3 reflect spontaneous GH secretion in healthy individuals. We have evaluated the clinical usefulness of urinary IGF‐I and IGFBP‐3 measurements in the diagnosis of children with disordered growth.

DESIGN Serum IGF‐I and IGFBP‐3 radioimmunoassays (RIA) were developed, and modified for quantitation in urine. The relationship between serum and urine levels, and the performance of these tests in the diagnosis of GH deficiency (GHD) were examined.

PATIENTS Sixty‐nine children (age 9.5±3.6 years; 37 boys, 32 girls) provided a timed overnight urine collection and a serum sample collected on the same morning. Subjects were defined as GHD (n=22) or short normal (SN; n=47) on the basis of medical history, clinical examination, auxology and peak response to a GH stimulation test (<20 mU/l in GHD patients).

MEASUREMENTS IGF‐I and IGFBP‐3 in serum and urine were measured by RIA, urinary GH (uGH) by immunoradiometric assay (IRMA) after dialysis and urinary creatinine by the alkaline picrate method. Urine results were expressed as total amount excreted (tulGFBP‐3 (μg), tulGF‐I (ng), tuGH (ng), tuCrt (mmol).

RESULTS Urine IGF‐I and IGFBP‐3 excretion correlated significantly to serum levels of IGF‐I and IGFBP‐3 and also to tuGH excretion. There was a strong positive relationship between both urinary peptides and tuCrt, which suggested that renal filtration was the source of these peptides in urine. In addition, there were significant correlations with age, bone age and height SD score, of similar magnitude to those for tuGH. In prepubertal children, serum IGF‐I and IGFBP‐3 were significantly lower in GHD compared with SN children, while in puberty only serum IGFBP‐3 was significantly lower in GHD. There was no difference, however, in tulGF‐I or tulGFBP‐3 between GHD and SN children either prepubertally or in puberty with near complete overlap of the values between groups.

CONCLUSION SMeasurements of tulGF‐I and tulGFBP‐3 have no place in the diagnosis of childhood GHD. Nonetheless, the significant correlations between serum and urinary IGF‐I and IGFBP‐3 levels and their correlation to uGH indicate that these peptides could be used as non‐invasive physiological markers of the GH‐IGF axis.
Clinico‐pathological study of Cushing's disease with large pituitary adenoma
Authors: Ikeda H. , Yoshimoto T. , Ogawa Y. , Mizoi K. , Murakami O.
Published: November 2003

OBJECTIVE

To explore the biological and morphological differences between large Cushing's adenomas and small adenomas, we investigated the clinical, endocrinological, neuroradiological, and histological features of patients with large Cushing's adenomas and compared them with patients with small Cushing's adenomas.

PATIENTS

Five of 250 patients with Cushing's disease undergoing trans‐sphenoidal operations from 1989 to 1995 had large adenomas with maximum diameters greater than 30 mm. The clinical characteristics of these five patients were compared with the 14 patients with Cushing's disease with small adenomas in our series.

RESULTS

Oedema, myopathy, and mental disturbance were more frequent and hypertension was less frequent among patients with large adenomas. The high‐dose (8 mg) dexamethasone test did not suppress cortisol production in any of the five patients. Invasion into surrounding tissue was demonstrated by magnetic resonance imaging in all five cases. All five large adenomas had scarce or no periodic acid‐Schiff‐positive granules and were sparsely granulated ultrastructurally. Three tumours contained cells with honeycomb Golgi apparatus which rarely contained immature secretory granules. One Crooke's cell adenoma contained trapped or displaced secretory granules. The other tumour had dilated trans‐Golgi network‐derived vacuoles that contained reticular or circular electron‐dense material. These findings were in striking contrast to those of small Cushing's adenomas, which showed strong PAS positivity, densely‐packed granulation, and had prominent Golgi complex harbouring developing secretory granules.

CONCLUSIONS

We found that the tumour cells in large adenomas produced only small amounts of ACTH, and showed indications of disturbances in the regulated exocytotic pathways. These factors may account for the different clinical characteristics of Cushing's disease with large pituitary adenomas.
Leptin levels do not change acutely with food administration in normal or obese subjects, but are negatively correlated with pituitary‐adrenal activity
Authors: Korbonits Márta , Trainer Peter J. , Little John A. , Edwards Ray , Kopelman Peter G. , Besser G. Michael , Svec Frank , Grossman Ashley B.
Published: November 2003

BACKGROUND

Leptin is a peptide secreted by white adipose tissue which has been shown to have a major influence on body weight regulation, while animal studies have revealed widespread interconnections between leptin and other endocrine systems, especially with insulin. However, its acute regulation has been little studied in the human. We have therefore investigated the effect of a 1000 kcal meal and fasting on the levels of leptin, insulin and cortisol, in both normal and obese subjects.

SUBJECTS AND DESIGN

We have studied the effect of food and fasting on circulating leptin levels in 20 subjects of normal body mass index (BMI range 18–25) and in a group of 12 moderately‐severely obese subjects (BMI range 34–61). We also studied the effect of food and fastina in a patient both before and after the successful removal of a pancreatic insulinoma as a model of excess insulin secretion.

RESULTS

Mean leptin levels were significantly higher in the obese than in the lean group (42.7 ± 3.41 vs 5.35 ± 1.55 μg/l, mean ± SEM; P<0.001), and showed a positive correlation with body mass index (r=+0.71; P<0.001). Frequent (every 20 minutes) sampling for 3 hours after food did not show any acute changes in circulating leptin levels. On the fasting day we observed a small but significant fall in circulating leptin levels in the last 4 hours of a 20‐hour fast in our subjects as a group (92 ± 0.03% of basal, P=0.03); however, in the lean subjects the fall was greater (88 ± 0.04% of basal, P=0.02) than in the obese, where it did not reach statistical significance (96 ± 0.05% of basal). Pre‐meal and peak insulin levels showed a positive correlation with circulating mean leptin levels (r=+0.65; P<0.001 and r=+0.78; P<0.001, respectively) in all subjects, while pre‐meal and peak serum cortisol levels showed an inverse relation with leptin levels (r=−0.53; P=0.002 and r=−0.41; P=0.02, respectively); this effect was independent of BMI in the obese subjects. In the patient with the insulinoma the markedly elevated insulin and leptin levels measured before the operation returned to normal after removal of the tumour, in accord with reports of experimental animal data that long‐term insulin excess per se is associated with increased circulating leptin concentrations.

CONCLUSIONS

Leptin is a robust indicator of BMI and insulin levels, both basal and stimulated, but does not change acutely following food. Fasting causes a proportionately greater decline in leptin levels in lean subjects than in obese subjects. Circulating leptin is inversely correlated with the activity of the hypothalamo‐pituitary‐adrenal axis: whether this is a direct influence of leptin on hypothalamo‐pituitary‐adrenal activity, or whether both are indirect indicators of body fat stores, requires further investigation.
Components of biological variation, including seasonality, in blood concentrations of TSH, TT3, FT4, PRL, cortisol and testosterone in healthy volunteers
Authors: Maes M. , Mommen K. , Hendrickx D. , Peeters D. , D’Hondt P. , Ranjan R. , De Meyer F. , Scharpe S.
Published: November 2003

OBJECTIVEThere are few detailed studies of annual or seasonal variations in hormone concentrations in man. This study examines the components of biological variation, including seasonality, in plasma TSH, total T3 (TT3), free T4 (FT4), PRL, cortisol and testosterone in healthy volunteers.

DESIGNMonthly blood samplings for the assay of the above hormones were collected during one calendar year.

SUBJECTSThirteen normal men and 13 normal women participated in the present study (mean age 38.7 ± 13.4 years).

MEASUREMENTSAssays of TSH, TT3 and FT4 were carried out by means of Immunoradiometric assays (IRMA), PRL by ELISA, cortisol by a fluorescence immunoassay, and testosterone with RIA. The time series were analysed by means of (bivariate or multivariate) spectral and cosinor analyses.

RESULTSSignificant annual, four‐monthly and biannual rhythms were detected in serum TSH; the lowest TSH values were observed in spring. A significant annual rhythm was detected in TT3, with lower values in spring and summer than in the other seasons. The peak–trough differences in the yearly variation expressed as a percentage of the mean were 29.1% and 8.2% for TSH and TT3, respectively. The yearly variation in plasma cortisol was significantly different between men and women: in men, 5.9% of the variation was explained by an annual rhythm, while in women 14.7% was explained by the fourth and seventh harmonical wave. The peak–trough differences in the yearly variation in plasma cortisol were 17.6% and 31.8% in men and women, respectively. There were no significant seasonal rhythms in PRL, FT4 or testosterone. The intraindividual/interindividual CV values were: TSH 29.3/48.4%, TT3 9.4/18.5%, FT4 7.1/9.1%, PRL 39.2/65.0%, cortisol 21.7/46.2%, and testosterone 12.6/40.8%.

CONCLUSIONSThe degree of individuality measured in the plasma hormones is such that conventional population‐based reference ranges may not correctly identify major alterations in these hormones in individual subjects.
The c‐erbB‐2/neu proto‐oncogene in human pituitary tumours
Authors: Ezzat Shereen , Zheng Lei , Smyth Harley S. , Asa Sylvia L.
Published: November 2003

OBJECTIVEThe aetiology of most pituitary tumours remains unknown. We have examined the potential role of the neu receptor proto‐oncogene in human pituitary tumorigenesis.

MATERIALS AND METHODSTen non‐tumorous pituitary glands and 16 morphologically characterized functional and clinically non‐functioning pituitary adenomas were studied. Protein expression was examined by immunohistochemistry, mRNA expression by RT‐PCR and competitive PCR, gene amplification by differential PCR, and point mutations by DNA sequencing.

RESULTSCytoplasmic positivity for neu was identified in a few scattered cells of the non‐tumorous adenohypophysis using an antibody to the intracytoplasmic domain of neu, but no membrane staining was found with an antibody to the extracellular domain; the latter is said to reflect gene amplification. mRNA transcript signals of the expected size were identified in the normal adenohypophysis and in all 16 adenomas examined. No increase in the degree of mRNA expression, however, was noted in the different tumour types compared to normal human pituitary tissue as determined by competitive PCR. As neu can be activated to an oncogene by a point mutation in the transmembrane region, nucleotide substitutions in this domain were investigated. Direct sequencing of codon 659 revealed no point mutations in any of the tumours. Furthermore, since amplification of neu has been noted in various human malignancies, DNA from these tumours was examined by differential PCR. No detectable differences were noted between the neu gene and the single‐copy reference gene IFN‐γ.

CONCLUSIONThe neu gene is expressed in adenohypophysial cells and their tumours. In pituitary adenomas, this expression is not associated with gene amplification or activating mutations to suggest a direct role in pituitary tumorigenesis.
Growth deficiency in polytransfused β‐thalassaemia patients is not growth hormone dependent
Authors: Cavallo Luciano , Gurrado Raffaele , Gallo Francesco , Zecchino Clara , De Mattia Domenico , Tatò Luciano
Published: November 2003

OBJECTIVE

Growth deficiency is commonly seen in polytransfused β‐thalassaemia patients, especially in adolescence. It is not completely dependent on the lack of their pubertal growth spurt. GH impairment at different levels (hypothalamic or pituitary) and/or a reduced IGF‐1 synthesis have been suggested the main causes of stunted growth in these patients. We evaluated the relationship between GH reserve and growth in short β‐thalassaemia patients.

PATIENTS

Twenty‐nine short patients (height <−1.8 SDS for chronological age) were divided into two groups (low and normal responders) on the basis of their GH peak during insulin and clonidine tests (≤ and > 20 mU/l, respectively). All but one low responders underwent the GHRH test to exclude the impairment of somatotroph function and in eight of them an IGF‐1 generation test was also performed. The two groups were compared with each other with respect to growth (height deficiency, height velocity, bone age and bone delay), haematological characteristics (serum ferritin levels, age at the start both of low (subcutaneous) s.c. infusion of desferrioxamine and of transfusional therapy) and serum IGF‐1 and IGF‐1 binding protein 3 levels.

RESULTS

Thirteen patients (45%) (11 males, two females) were low responders, all but two having serum IGF‐1 < 5th centile (< 0.1 centile in 42%); the GHRH test excluded the impairment of somatotroph function in 8/12. Height deficiency, serum ferritin levels, and age at the start of s.c. chelating therapy did not differ in low compared to normal responders. Height was negatively correlated both with the age at the start of s.c. chelating therapy and with serum ferritin levels.

CONCLUSION

The reduction of GH reserve, more frequently due to a hypothalamic than to a pituitary dysfunction, is frequent in polytransfused β‐thalassaemia patients, especially in males. The height function is not related to the GH reserve, given the current methods for testing GH reserve. Late start of s.c. chelating therapy as well as haemosiderosis seem to play a role in the height deficiency, but not in GH reserve. Impairment of GH secretory reserve, therefore, cannot be considered the main cause of height deficiency in these patients.
Metyrapone pre‐treated inferior petrosal sinus sampling in the differential diagnosis of ACTH‐dependent Cushing's syndrome
Authors: Cuneo Ross C. , Lee Winnifred , Harper John , Mitchell Ken , Ward Greg , Leigh Atkinson R. , Salkield Ian , Cameron Donald P.
Published: November 2003

BACKGROUNDInferior petrosal sinus sampling (IPSS) is a useful investigative technique in the differential diagnosis of ACTH‐dependent Cushing’s syndrome. Diagnostic accuracy is improved by the administration of corticotrophin releasing‐factor (CRF) during the procedure to stimulate ACTH secretion. We hypothesized that, given the unavailability of CRF in Australia, stimulation of ACTH secretion from tumorous corticotrophs with metyrapone treatment before IPSS may be useful.

AIMSTo describe our clinical experience with a novel diagnostic test, and to compare results between IPSS with and without metyrapone pre‐treatment.

SETTINGMetropolitan, Australian university teaching hospital.

PATIENTS18 patients were studied on 21 occasions: three with Cushing’s disease without metyrapone treatment prior to IPSS (M−), 11 with Cushing’s disease with metyrapone pretreatment (M+), three with ectopic ACTH syndrome, and one with pseudo‐Cushing’s syndrome.

TREATMENTPatients received oral metyrapone, median dose 750 mg 6 hourly, for 24 h before IPSS.

RESULTSNo major side effects were noted. Metyrapone increased serum 11‐deoxycortisol concentration to a median of 400 nmol/l (range 36–1310) on the morning of the test. Radiological confirmation of correct catheter placement was shown in 36/42 inferior petrosal sinuses (86%). Median peak central : peripheral ACTH ratios were 9.8 for M− pituitary adenomas (range 5.7–13.6), 12.9 for the technically successful M+ pituitary adenomas (range 8–54.1), and 1.6 for M+ ectopic ACTH syndrome cases (range 1.2–3.4). Repeat studies in unoperated patients with ectopic ACTH syndrome showed ratios <1.6. IPSS showed median peak ACTH concentrations of 190 ng/l for M− pituitary adenomas (range 83–205), 595 ng/l for the technically successful M+ pituitary adenomas (range 80–7630; P = 0.035 compared to M−), and 62 ng/l for M+ ectopic ACTH syndrome cases (range 47–220). IPSS correctly identified the pituitary source of ACTH production in all cases of Cushing’s disease (except one technical failure where MRI revealed a lesion). MRI scanning correctly identified a lesion in 3/14 operated Cushing’s disease cases. IPSS correctly lateralized 1/3 M− and 7/8 M+ Cushing’s disease cases where the procedure was technically successful and surgical descriptions adequate. Pituitary exploration revealed a visible lesion in 75% of cases corresponding to the side predicted by IPSS; ‘blind’ hemi‐hypophysectomy was performed on the side predicted from IPSS in the remainder. All cases of Cushing’s disease were cured or improved following surgery, with a median follow‐up of 2.8 years (range 0.7–5.9).

CONCLUSIONSMetyrapone pre‐treated inferior petrosal sinus sampling is safe, and appears to induce high ACTH output from pituitary corticotroph adenomas. The technique has allowed accurate localization and treatment of pituitary corticotroph microadenomas.
Expression of adrenocorticotrophic hormone receptor mRNA in human adrenocortical neoplasms: correlation with P450scc expression
Authors: Reincke Martin , Beuschlein Felix , Latronico Anna‐Claudia , Arlt Wiebke , Chrousos George P. , Allolio Bruno
Published: November 2003

OBJECTIVEAdrenocorticotrophin (ACTH) is the main hormone‐regulating steroid secretion from the adrenal cortex. The ACTH receptor (ACTH‐R) has recently been cloned, allowing systematic evaluation of its expression and function in adrenal tumorigenesis. We investigated ACTH‐R and P450 side‐chain cleavage enzyme (P450scc) mRNA expression in a variety of neoplastic adrenocortical tissues by Northern blot and reverse‐transcriptase‐PCR (RT‐PCR).

PATIENTS AND MEASUREMENTSWe studied tissue from eight normal adrenals, six diffuse adrenocortical hyperplasias in patients with ACTH‐dependent Cushing's syndrome, 22 adrenal adenomas, six carcinomas and two carcinoma cell lines. Poly A mRNA was electrophoresed, immobilized on a nylon membrane and hybridized using α32P‐CTP labelled human ACTH‐R and P450scc cDNAs.

RESULTSMean ACTH‐R mRNA expression showed significant differences between groups (P=0.0001), but appeared to be independent of plasma ACTH concentrations. Compared to normal adrenal =100±12%), expression was low in non‐functional adenomas (23±11%) and carcinomas (19±12%), intermediate in adrenocortical hyperplasias (88±6%) and cortisol‐producing adenomas (81±15%) and high in aldosteronomas (175±29%). In adenomas, ACTH‐R mRNA expression correlated closely with the expression of P450scc mRNA r=0.8, P=0.0001) suggesting regulation by similar factors. However, carcinomas and cancer cell lines did not show a positive correlation between these two parameters r=−0.44, P=0.2).

CONCLUSIONSWe have demonstrated that plasma ACTH is not the major factor influencing ACTH‐receptor mRNA expression in neoplastic adrenal tissue. In benign tumours of the adrenal cortex there was a close positive correlation between ACTH‐receptor mRNA and P450scc mRNA which was missing in adrenocortical carcinomas, probably as a result of tumour dedifferentiation.
Ocular naevus and melanoma in acromegaly
Authors: Corcuff J.‐B. , Ogor C. , Kerlan V. , Rougier M. B. , Bercovichi M. , Roger P.
Published: November 2003

Acromegaly favours the development of extrapituitary neoplasms presumably promoted through increased GH and IGF‐I levels. We describe here two patients with acromegaly and benign and malignant melanocytic tumours of the eye choroid. The first patient had a 15 year history of progressive acromegaly despite trans‐sphenoidal surgery, radiation and bromocriptine therapy when she presented with melanoma of the eye and a contralateral benign melanocytic tumour. The second patient was referred with typical acromegaly. The initial fundal examination revealed a right sided benign melanocytic tumour of the choroid. Subsequent follow up of the naevi has not shown any change in the tumours after one and three years respectively. The occurrence of melanoma has not been reported in acromegaly. Increased growth of benign naevi might be expected as GH and IGF‐I receptors have been described on melanocytes. As naevi may degenerate into melanomas in normal subjects and radiation therapy could trigger their transformation, we suggest that prior to irradiation, acromegalic subjects should undergo a careful ocular examination in order to assess the presence of ocular naevi.
The thyrotrophic role of human chorionic gonadotrophin (hCG) in the early stages of twin (versus single) pregnancies
Authors: Grün Jean‐Paul , Meuris Sylvain , De Nayer Philippe , Glinoer Daniel
Published: November 2003

OBJECTIVE

Human chorionic gonadotrophin (hCG) is known to possess thyroid‐stimulating activity. The aim of the present study was to assess the role of hCG in stimulating the maternal thyroid gland in the early stages of normal gestation.

STUDY DESIGN

Thirty euthyroid healthy women were investigated prospectively. In each, conception had been assisted by in vitro fertilization techniques, which allowed for the precise determination of gestational age. Women were subdivided into single (n = 17) and twin (n = 13) pregnancies. Serum intact hCG and its free α and β subunits, TSH and free T4 concentrations were measured at 6, 8, 9, 10, 11, 15, 19, 22 and 32 weeks.

RESULTS

In twin pregnancies compared with single pregnancies, peak hCG concentrations (9–11 weeks) were significantly higher (mean ± SE 171 000 ± 12 500 vs 65 500 ± 7600 U/l; P < 0.001), and also much more prolonged. Human CG concentrations above 75 000 U/l lasted for less than 1 week in single, compared with up to 6 weeks in twin pregnancies. Free β‐hCG subunit concentrations paralleled those of intact hCG in both groups. The ratios of free β‐hCG subunit/total hCG were similar in single and twin pregnancies, and did not vary with gestation time. Concerning thyroid function, twin pregnancy was more frequently associated with a lowering of TSH, which was also more profound than in single pregnancies. Furthermore, while free T4 levels remained normal in single pregnancies, they were transiently supranormal (up to 52 pmol/l) in four twin pregnancies.

CONCLUSION

In twin pregnancies the placenta produces larger amounts of hCG for a prolonged period of time than in single pregnancies. Both the amplitude and duration of hCG production (i.e. the global exposure of the thyroid gland to hCG) are responsible for increased thyroidal stimulation, leading more frequently to increased free T4 and suppressed TSH levels. The results emphasize the role of hCG in stimulating maternal thyroid function in the first trimester of pregnancy. Even though the production of a variant hCG molecule with potent thyrotrophic activity cannot be excluded, this hypothesis is not required to explain the data. Clinicians should be aware of the frequent occurrence of significant but transient biochemical hyperthyroidism associated with hCG stimulation in the early stages of gestation, particularly in twin pregnancies.
Growth hormone substitution in adult growth hormone‐deficient men augments androgen effects on the skin
Authors: Blok G.J. , De Boer H. , Gooren L.J.G. , Van Der Veen E.A.
Published: November 2003

OBJECTIVE

To assess whether growth hormone (GH) administration to adult GH‐deficient men leads to increased sexual hair. The sexual hair scores are subnormal in these patients, even in the presence of normal serum androgen levels.

PATIENTS

Forty‐six adult men with childhood‐onset of GH deficiency of whom 25 were androgen deficient and received replacement.

DESIGN

Double‐blind and placebo‐controlled. Of the 46 patients, 33 started immediately with GH administration; the remaining 13 received placebo for the first 6 months followed by GH for the next 6 months. Sixty‐one age‐matched healthy men with normal height and serum concentrations of IGF‐I served as a comparison group.

MEASUREMENT

Hair scores at 13 defined body regions were assessed before, and after 6 and 12 months of the intervention. At the same time levels of IGF‐I, dehydroepiandrosterone sulphate, androstenedione, dihydrotestosterone (DHT), testosterone and sex hormone binding globulin (SHBG) were measured. From the latter two, the free androgen index (FAI) was calculated.

RESULTS

Before GH administration, hair scores in the GH deficient patients were lower than in the comparison group. In the 33 men treated with GH from the beginning, there was an increase in hair scores after 6 months. The increase in hairscores was not seen during 6 months of placebo treatment. When the placebo group switched to GH administration, their hair scores had also significantly increased after 6 months of GH substitution therapy. Upon GH administration both levels of SHBG and testosterone/DHT declined while the FAI remained unchanged.

CONCLUSION

GH substitution therapy to GH deficient men has an auxiliary effect on androgen action in the skin without an increase of the FAI.
Hydrocortisone replacement therapy in children and adolescents with hypopituitarism
Authors: DeVile C. J. , Stanhope R.
Published: November 2003

OBJECTIVE

Appropriate replacement doses of glucocorticoid are important to determine in primary and secondary adrenal deficiency in children, both to avoid the risks of hypoglycaemia and adrenal crisis associated with undertreatment, and to avoid growth suppression and reduced final height potential associated with steroid excess. The aim of this study was to assess how closely conventional twice daily hydrocortisone administration mimics physiological cortisol secretion in a group of ACTH‐deficient children and adolescents.

PATIENTS

Fifty children and adolescents (aged 3–20 years) were studied who had had surgery ± radiotherapy to the hypothalamopituitary region for removal of a craniopharyngioma. The patients were subdivided into two groups: group I comprised 44 patients known to be ACTH deficient (as determined by glucagon or insulin provocation tests of anterior pituitary function performed after surgery) and maintained on twice daily oral hydrocortisone replacement; group II comprised six patients known to be ACTH sufficient at their last assessment of pituitary function and not on hydrocortisone replacement. A third group of 10 boys (aged 7–13 years) who had no known endocrinopathy were used as controls (group III).

MEASUREMENTS

After intravenous cannula insertion, blood samples were taken every 2 h for measurement of plasma cortisol and glucose over a period of 24 h. Patients in group I continued on their usual doses of hydrocortisone, prescribed at 0800 and 1800 h.

RESULTS

The mean total daily replacement dose of hydrocortisone for patients in group I was 12.3 mg/m2/day (range, 5.5–18.5). On the conventional twice daily dose regimen, there was a supraphysiological medium plasma cortisol level (629 nmol/l, range 185–1600; z = − 3.76, P = 0.0002) 2 h after the morning dose relative to the control group, and a prolonged and unphysiological nadir from 1400–1800 h (median at 1600 h 42 nmol/l, range 13–1170; z = − 3.13, P < 0.002) before the second dose of hydrocortisone was administered. Cortisol values were low, and often negligible, during the early hours of the morning (median at 0600 h 15 nmol/l, range 13–277, z = − 4.87, P < 0.00001) and spontaneous hypoglycaemia was documented in one patient on a single 0800 h sample. One patient in group II was shown to be unequivocally cortisol deficient and median cortisol values for the remaining five suggested a suboptimal rise in plasma cortisol during the early hours of the morning.

CONCLUSION

Our cohort of patients provides an excellent model for the study of glucocorticoid replacement in cortisol‐deficient children and adolescents and shows, as in adults, that the aim of mimicking the physiological nyctohemeral secretion of cortisol is difficult to achieve in practice and raises a number of important considerations unique to steroid substitution therapy in this age group.
Serum IGF‐I and IGF binding proteins 2 and 3 as potential markers of doping with human GH
Authors: Kicman Andrew T , Miell John P , Teale J. Derrick , Powrie Jake , Wood Peter J , Laidler Paul , Milligan Peter J , Cowan David A
Published: November 2003

OBJECTIVE

IGF‐I and IGF binding protein (IGFBP)‐3 levels in man are positively regulated by GH status; in contrast, evidence suggests an inverse relationship between GH status and IGFBP‐2. We investigated the effects of somatropin administration on the serum concentrations of these analytes, together with serum and urinary concentrations of GH, to evaluate their potential as markers in the development of a test for detecting doping with GH in sports competitors.

DESIGN

Somatropin was administered subcutaneously at a dose of 0.15 U/kg bodyweight/day at 1000 h for 3 days to eight healthy men (20–32 years old).

MEASUREMENTS

Serum concentrations of GH, IGF‐I, IGFBP‐2 and ‐3 were determined in blood samples collected at 1600 h on the days prior to (day −1), during (days 0, 1 and 2), and following administration (days 3 and 7). Urine was collected continuously from days −2 to 3 and then on day 7.

RESULTS

Serum and urinary concentrations of GH were only raised on the days of administration whereas, following cessation of somatropin, the increases in the serum concentrations of IGF‐I and IGFBP‐3 were sustained for at least 1 day (30 h). Serum IGFBP‐2 decreased during the period of administration and was still suppressed on day 3. The concentration ratios of IGFBP‐3 to IGFBP‐2 and IGF‐I to IGFBP‐2 increased markedly with administration and both ratios were still significantly augmented compared with basal values 30 h after the last administration.

CONCLUSION

With acute administration of somatropin to healthy men the serum concentration of IGFBP‐2 decreases and the ratios of serum IGF‐I/IGFBP‐2 and IGFBP‐3/IGFBP‐2 increase. These ratios should be considered in the development of a test for detecting somatropin administration in sport.
Insulin action and hepatic glucose cycling in Cushing's syndrome
Authors: Heaney A. P. , Harper R. , Ennis C. , Rooney D. P. , Sheridan B. , Atkinson A. B. , Bell P. M.
Published: November 2003

OBJECTIVE

Although it is well established that hypercortisolism causes insulin resistance, the mechanisms responsible for impaired insulin action in Cushing's syndrome are unclear. This study investigated the contribution of the glucose/glucose‐6‐phosphate substrate cycle (G/G6P).

PATIENTS

Eight patients with Cushing's syndrome and seven control subjects were studied. All had normal fasting plasma glucose.

DESIGN

Insulin action was assessed using the euglycaemic glucose clamp at insulin infusion rates of 0.4 and 2.0 mU/kg/min combined with a simultaneous infusion of [23H]‐ and [63‐H]‐glucose. Glucose/ glucose‐6‐phosphate cycle activity was calculated as the difference in glucose turnover rates determined separately for [23H]‐ and [63H]‐glucose by selective enzymatic detritiation.

MEASUREMENTS AND RESULTS

Exogenous glucose infusion rates required to maintain euglycaemia were significantly lower in Cushing's patients compared to controls, during the 0.4 mU/kg/min (7.8±1.2 vs 15.7±0.5 μmol/kg/min, P<0.001) and the 2.0 mU/kg/min insulin infusions (26.2±2.8 vs 51.5±3.5 μmol/kg/min, P<0.001). Endogenous glucose production was similar in both groups in the postabsorptive state (10.2±0.3 vs 10.8±0.4 μmol/kg/min, P=0.50) and suppressed to a similar degree during hyperinsulinaemia. G/G6P cycle activity was markedly increased in the Cushing's group in the postabsorptive state (5.4±1.1 vs 2.0±0.5 μmol/kg/min, P=0.028) and during the 0.4 mU/kg/min (3.2±0.6 vs 1.2±0.4 μmol/kg/min, P=0.014) and 2.0 mU/kg/min insulin infusions (3.3±0.8 vs 1.1±0.5 μmol/kg/min, P=0.049).

CONCLUSIONS

Patients with Cushing's syndrome show marked peripheral insulin resistance and enhanced hepatic G/G6P cycle activity. In the fasting state increased glucose/glucose‐6‐phosphate cycle activity may be a protective mechanism limiting hyperglycaemia. During hyperinsulinaemia G/G6P cycle activity was increased but insulin resistance was predominantly due to reduced peripheral glucose uptake.