bluuebunny/crossref_metadata_2025 huggingface dataset:
Growth Patterns in Children With Multiple Endocrine Neoplasia Type 2B: Small Stature in Childhood
Authors: van den Broek Medard F M , van Santen Hanneke M , Valk Gerlof D , Verrijn Stuart Annemarie A
Published: May 2021

Background: Multiple Endocrine Neoplasia 2B (MEN2B) is characterized by medullary thyroid carcinoma (MTC) before the age of one, pheochromocytoma and several non-endocrine manifestations. Marfanoid habitus is considered to be an important related feature, leading to the assumption that children with MEN2B have a tall stature. However, very little is known about actual growth patterns in children with MEN2B and its implication for final height.

Aim: To describe the growth patterns during childhood and adolescence and relate final height to target height (TH) in MEN2B patients.

Methods: Growth during childhood was investigated in eight patients with MEN2B under care in a Dutch MEN expertise center. Growth charts were assessed in relation to parental height, age at diagnosis and at thyroidectomy, body mass index (BMI), pubertal development and extensiveness of disease manifestations.

Results: Four out of eight patients showed longitudinal growth below their TH range. Three others showed prepubertal growth in the lowest margin of their TH range. Small stature was accompanied by delayed bone maturation. Arm span to height ratio was not increased in any of the (six) patients studied. All four patients who reached adulthood attained final height within their TH range, despite small stature during childhood. Small stature in childhood was not associated with age at diagnosis, age at thyroidectomy, extensiveness of MTC, BMI or endocrine deficiencies.

Conclusions: Children with MEN2B did not present with marfanoid features regarding height or arm span. In contrary, short stature may be prevalent, with longitudinal growth beneath the individual TH range. Nevertheless, a normal final height within the TH range may well be reached. Growth patterns seem to be independent of both age at diagnosis and thyroidectomy as well as disease severity.
The Functional Glomerulosa Cells Define the Unicity of the Adult Human Adrenal Cortex
Authors: Camponova Pamela , Duparc Céline , Roy Malanie , Lefebvre Herve , Thomas Michael
Published: May 2021

The zonation of the human adrenal cortex has long been established morphologically and histologically as three distinct layers of cells. The outer zona glomerulosa (ZG) comprises densely packed cells arranged in clusters that produce aldosterone; the zona fasciculata (ZF) is composed of cells with large cytoplasm, containing lipid droplets arranged in radial columns that synthetize cortisol; and the zona reticularis is composed of compact and pigmented cells producing androgens. The main purpose of this work was to study the expression of aldosterone synthase (CYP11B2 which catalyzes the last steps of aldosterone synthesis) and 11β-hydroxylase (CYP11B1 which catalyzes the last step of cortisol synthesis) in normal adrenal glands to address issues regarding the zonation and the fate of the cells constitutive of each zone through the expression of Ki-67 and cleaved Caspase-3. Thirty eight normal human adrenals (16 females, 22 males, ranging in age from 22 to 81 years old with a median age of 52 years old) were obtained from brain-dead organ donors (kindly provided by the Organ Transplant Clinics, University Hospital of Rouen). As early as 22 years old, we found that the histological ZG (h-ZG) does not correspond to the functional ZG (f-ZG) expressing CYP11B2. Moreover, the h-ZG CYP11B2- cells were CYP11B1+ showing that these cells ascribed to the h-ZG are in fact cortisol producing cells. The progressive replacement of CYP11B2+ cells by CYP11B1+ cells in the h-ZG might demonstrate the role of the extracellular matrix in the morphological maintenance of the adrenal cortex. Our analysis also showed that steroidogenic cells were either CYP11B1 or CYP11B2 positive. By immunofluorescence, we observed in many cases isolated or clusters of CYP11B2+ cells located deeply in the h-ZF and sometimes in the vicinity of the central vein. We were able to show that those cells were probably issued from CYP11B2+ cell clusters located in h-ZG which migrated centripetally. Ki-67 immunoreactivity was highly variable and observed throughout the entire cortex. We also found a positive correlation between the steroidogenic and endothelial cells proliferation. It is interesting to note that some Ki-67+ cells located in the h-ZG were CYP11B1+. Cortical cells positive for cleaved Caspase-3 were extremely rare but detected in all zones when present. These findings challenge the classic view of lineage conversion of differentiated ZG cells and show a new pathway where the CYP11B2+ cells migrate without changing their phenotype.
Novel Pathogenic Variants in LHX3, LHX4 and GLI2 Identified in Pediatric Patients With Congenital Hypopituitarism: From Variant Calling To Variant Testing
Authors: Vishnopolska Sebastian , Mercogliano María Florencia , Camilletti Maria Andrea , Mortensen Amanda Helen , Braslavsky Debora Giselle , Keselman Ana Claudia , Bergada Ignacio , Marino Roxana Marcela , Ramirez Pablo , Garrido Natalia Perez , Ciaccio Marta , Di Palma María Isabel , Belgorosky Alicia , Miras Mirta , Nicola Juan Pablo , Marti Marcelo , Kitzman Jacob , Camper Sally Ann , Perez-Millan Maria Ines
Published: May 2021

Congenital hypopituitarism (CH), septo-optic dysplasia (SOD), and holoprosencephaly (HPE) constitute an important group of structural birth defects that cause significant morbidity and life-long consequences for quality of life and care. The genetic causes are highly overlapping. As such, these disorders can be considered as a spectrum of related disorders. Improved insight into genetic causes would be valuable for patients, families, and medical geneticists. Very few systematic genetic screens have been carried out for patients with CH. We implemented genetic screening using single-molecule molecular inversion probes sequencing to identify causative mutations in a set of 67 genes previously reported in CH patients and the spectrum encompassing SOD and HPE. We captured genomic DNA from 170 Argentinean pediatric patients with CH, and 54% of the patients in this cohort have craniofacial, ophthalmologic, and/or central nervous system defects. We found candidate pathogenic, likely pathogenic and variants uncertain significance (VUS) in 23% of the cases. In order to evaluate the functional consequences of VUS in LHX3, LHX4, and GLI2, we performed in-vitro functional assays to study the activity of the mutated proteins. To test LHX3/4 variants we co-transfected HEK293T cells with wild type (WT) or mutated LHX3/4 variant plasmids and luciferase reporter genes driven by the ɑGSU promoter or GH1 promoter and assayed for luciferase activity. For GLI2 functional analysis we used the cell line NIH/3T3-CG, stably transfected to express GFP under the presence of GLI2 activated form. Endogenous Gli2 was knocked out by CRISPR-Cas9 and clones were selected for absence of GFP expression upon activation of the sonic hedgehog pathway. We tested the ability of transfected WT or mutated GLI2 expression plasmids to restore GFP fluorescence. We concluded that variants LHX3:p.Pro187Ser LHX4:p.Arg84His, p.Gln100His and p.Trp204Leu and GLI2:p.1404Lfs impair activation of the reporter gene, while the LHX3:p.Leu220Met and GLI2:p.L761P have WT activity on their respective assays. Identification of disease-causing variants in CH is complicated by phenotypic variation, incomplete penetrance, and VUS. Functional testing of potentially pathogenic variants is critical to arrive at a definitive molecular diagnosis. A full catalogue of variant effects in known causative genes would be invaluable for clinicians in order to simplify the interpretation of novel variants and reduce the diagnostic odyssey that families often experience.
Are Vitamin D Deficiency and VDR Gene Polymorphisms Associated With Higher Blood Pressure Defined by the 2017 ACC/AHA in Postmenopausal Women?
Authors: dos Santos Betânia Rodrigues , Casanova Gislaine , Silva Thaís Rasia , Marchesan Lucas Bandeira , Oppermann Karen , Spritzer Poli Mara
Published: May 2021

Postmenopausal status has been associated with an unfavorable phenotype tied to hormonal and metabolic changes, which collectively could contribute to an increased risk of cardiovascular disease. Vitamin D deficiency is frequent in postmenopausal women and may be linked to this phenotype and especially to an increased risk of developing hypertension. Vitamin D actions are modulated by the vitamin D receptor (VDR), and metabolic abnormalities have been associated with VDR gene variants in different populations. The aims of the present study were to assess the vitamin D levels, prevalence of vitamin D deficiency and genotypes of Fok-I, Bsm-I, Apa-I and Taq-I polymorphisms in the VDR gene and to determine whether vitamin D deficiency and VDR gene variants are associated with blood pressure levels and systemic arterial hypertension by the 2017 ACC/AHA definition in postmenopausal women. We conducted a cross-sectional study of biobanked blood samples from 339 postmenopausal women with no evidence of clinical disease. Blood pressure strata were defined according to the 2017 ACC/AHA cutoffs. Circulating 25(OH)D levels were considered deficient if <20 ng/mL. Genotype analysis was performed by RT-PCR with allelic discrimination assays. Mean serum total 25(OH)D levels were 22.99±8.54 ng/mL, and 40.1% of participants were deficient in vitamin D. Overall, 7.7% had elevated blood pressure, 36.6% had stage 1 and 37.8% had stage 2 hypertension. Mean total (p=0.014) and free 25(OH)D levels (p=0.029) were lower in women with stage 2 hypertension than in those with normal blood pressure. The CC+CT genotypes of Bsm-I and the AA+AG genotypes of Taq-I polymorphisms were more frequent in women with stage 2 hypertension (Bsm-I CC+CT: 85.8% vs. TT: 14.2%, p=0.045; Taq-I AA+AG: 91.3% vs. GG: 8.7%, p=0.021). A higher prevalence ratio of stage 2 hypertension was associated with age (PR 1.058; 95%CI 1.033-1.083; p<0.001), BMI (PR 1.046; 95%CI 1.025-1.068; p<0.001), vitamin D deficiency (PR 1.333; 95%CI 1.016-1.749; p=0.038) and Taq-I polymorphism (PR 1.764; 95%CI 1.030-3.019; p=0.039). Women with vitamin D deficiency and the AA+AG genotype of Taq-I polymorphism were 33% and 76% more likely to have stage 2 hypertension, respectively, but these analyses lost significance when adjusted for age and BMI. In conclusion, the present results suggest that vitamin D deficiency and Taq-I polymorphism are associated with stage 2 hypertension, depending on age and BMI, in postmenopausal women.
Cross-Method Comparison of Serum Androstenedione Measurement Using Three Different Assays: The Siemens Immulite Immunoassay, the Roche Elecsys Immunoassay, and an LC/MS-MS Assay
Authors: Wei Ruhan , Bowers Kathleen , Kroner Grace M , Payto Drew , Franco Jessica Colon
Published: May 2021

Introduction: Androstenedione is a common precursor of male and female sex hormones produced by the adrenal glands and gonads. Serum androstenedione is a helpful biomarker in the diagnostic workup of a subset of patients with polycystic ovary syndrome (PCOS), the investigation of virilizing endocrinopathies, and for monitoring pediatric patients with congenital adrenal hyperplasia. The gold standard for the measurement of androstenedione is LC-MS/MS. A newly developed androstenedione competitive immunoassay is now available in the US, the Roche Elecsys Androstenedione (ASD) immunoassay. Until recently, the Siemens Immulite assay was the only non-radioimmunologic immunoassay available. We characterized the analytical and clinical performance of the ASD across different patient populations and in comparison to the Immulite and an LC-MS/MS assay. Methods and materials: The experiments performed were: linearity and analytical measuring range (AMR), precision (intra- and inter-assay), and accuracy. Androstenedione was measured on de-identified residual serum samples (n=40) using the ASD and Immulite immunoassays and an LC-MS/MS assay. The reference intervals (RIs) provided by Roche for healthy male (0.280-1.52 ng/mL), healthy female (0.490-1.31 ng/mL), postmenopausal women (0.187-1.07 ng/mL), healthy children (<0.519 ng/mL), and patients with PCOS (0.645-3.47 ng/mL) were verified with at least 20 specimens, according to CLSI C28A3. Statistical analysis was performed using EP Evaluator and R program. Results: The ASD had a linear response across the AMR of 0.3 to 10.0 ng/mL. The inter- and intra-assay coefficients of variation were 4.5% and 2.0% or lower, at concentrations 0.5-6.7 ng/mL, respectively. The ASD and LC-MS/MS assays had a mean bias of -0.0542 ng/mL (-2%), Deming regression of y = 1.000 [0.961; 1.039] x - 0.0548 [-0.1806; 0.0709], and r = 0.9930. The Immulite assay had a mean bias of 1.15 ng/mL (44%) and 1.22 ng/mL (32%) compared to the LC-MS/MS and ASD assays, respectively. The recommended RIs from Roche for healthy male, female, and postmenopausal female groups were successfully verified in our patient population. However, the androstenedione concentrations for the healthy children and PCOS groups were outside of the suggested RIs, with concentrations up to 1.41 ng/mL and 0.527-2.24 ng/mL, respectively. Unlike published elsewhere, hormone therapies such as contraceptive pills and steroid treatments did not significantly affect serum androstenedione concentrations in healthy females and patients with PCOS. Conclusion: The ASD is superior to the Immulite immunoassay, and it has excellent comparability with the LC-MS/MS for serum androstenedione measurement. The RIs published by Roche may not be universally transferable; verification is recommended, and establishing RIs for the pediatric population may be necessary.
Circulating HMGB1 Levels Are Associated With Glucose Clamp-Derived Measures of Insulin Resistance in Women With PCOS
Authors: Migazzi Matteo , Dauriz Marco , Cirillo Francesca , Catellani Cecilia , Villani Michela , Tosi Flavia , Street Maria Elisabeth , Moghetti Paolo
Published: May 2021

Context: High mobility group box 1 (HMGB1) is a nuclear constitutive and highly conserved mammalian protein which shows several important physiologic functions, playing a crucial role in local and systemic inflammation. It also seems to be implicated in the development of metabolic syndrome, whereas some in vitro and animal models and recent preliminary human studies suggested its potential role in polycystic ovary syndrome (PCOS) pathophysiology. In particular, some data suggested a potential role of HMGB1 in follicular maturation block. Moreover, increased blood and follicular fluid HMGB1 concentrations have been reported in PCOS women, showing a direct correlation with surrogate indexes of insulin-resistance (IR) (i.e. HOMA-IR).

Objective: The purpose of the present study was to investigate the relationships between serum HMGB1 levels and clinical, endocrine and metabolic parameters of PCOS patients.

Design and patients: Sixty women with PCOS, 30 with IR and 30 with normal insulin sensitivity (IS), and 30 healthy controls were included in the study. In these subjects, body fat was quantified by bioelectrical impedance; plasma HMGB1 levels were measured using a specific ELISA method (Tecan, Mannedorf, Switzerland); and serum androgens were measured by liquid chromatography/mass spectrometry and equilibrium dialysis. In PCOS women, IR was measured using the gold standard hyperinsulinemic-euglycemic clamp technique, combined with indirect calorimetry.

Results: HMGB1 levels did not differ between PCOS women and healthy controls (4.11 ± 3.22 vs 3.77 ± 2.50 ng/mL, respectively; p=0.61). Moreover, HMGB1 levels did not differ between PCOS phenotype subgroups. However, PCOS IR women showed higher levels of this protein as compared with PCOS IS (5.00 ± 3.53 vs 3.16 ± 2.59 ng/mL, respectively; p=0.017). In women with PCOS, HMGB1 levels were associated with several metabolic parameters, including IR measured by glucose utilization during the clamp (rho -0.37, p=0.005). This correlation was preserved after adjusting for potential confounding parameters, such as age, fat mass and serum free testosterone. HMGB1 levels did not change during glucose-clamp induced acute hyperinsulinemia, either in the whole cohort of patients or in IR and IS subgroups analyzed separately. Both in the whole population under study and in PCOS women, HMGB1 levels did not correlate with anthropometric parameters, hormonal features and ovarian morphology.

Conclusions: In women with PCOS, HMGB1 blood levels show an independent association with insulin resistance. However, no associations with other typical features of the syndrome were found. Further research is needed in order to establish whether this protein may play a role in the pathogenesis of PCOS.
Evaluation of Thyroid Function and Its Relationship With Metabolic Parameters in Indian Adolescents With PCOS
Authors: Talwar Vipan , Talwar Gourav
Published: May 2021

Background: Women with PCOS have high insulin resistance and a higher prevalence of raised TSH levels. Thyroid dysfunction can lead to the alterations in lipid and metabolic parameters. There is a very little data regarding the relationship between TSH and indices of insulin resistance in Indian adolescents with PCOS. Aim of Study: To assess the status of thyroid function and its impact on biochemical parameters and cardiovascular (CV) risk factors in Indian Adolescents with PCOS. Methods: Study group was 130 adolescents aged between 13 to 19 years, recently diagnosed with PCOS as per Revised Rotterdam criteria and a control group of 75 age matched, healthy, non PCOS females. Participants were subjected to an elaborate clinical, anthropometric and biochemical assessment. Hormonal analysis included serum FT3, FT4, TSH, anti-TPO antibody, LH, FSH, prolactin, free testosterone, 17 OH progesterone, Lipid profile. Fasting plasma glucose and Insulin were used to calculate HOMA-IR. Statistical analysis was done by SPSS. P value of <0.005 was significant. Results: Mean age of the subjects was 15.9 ± 3.1 years. Mean level of TSH was higher in PCOS group than in controls (4.1 ± 3.1 vs 2.8 ± 1.9; p-<0.001). There was significantly higher prevalence of subclinical hypothyroidism (SCH) (19.2%vs 6.7%;p-0.01), Anti TPO antibody titre (18.6 vs 4.7%; p,0.01) and goitre (14.1%vs 3.2%; p - 0.02) in PCOS subjects compared to controls. BMI and Systolic BP were higher in PCOS with SCH. Free testosterone (p-0.002), HOMA-IR (p- 0.03) and dyslipidaemia (p < 0.01) were significantly higher in PCOS subjects with SCH as compared to both euthyroid PCOS and euthyroid controls. Discussion: 50-70% women with PCOS, have been reported to have insulin resistance and hyperinsulinemia and are at a higher risk for developing metabolic and CV diseases. Literature supports the high prevalence of SCH/thyroid autoimmunity in PCOS. In this study we have found that Indian adolescents with PCOS have a high prevalence of SCH. Also we have observed significant changes in insulin resistance indices in PCOS subjects with SCH as compared to those with normal thyroid functions. The association between TSH level and insulin resistance indices is complex and one probable mechanism is that the hypothyroidism leads to increase in adiposity and pro inflammatory markers. This unique interplay of PCOS, adiposity, thyroid dysfunction and autoimmunity forms a complex pathophysiological pathway which leads to the potentiation of insulin resistance thereby resulting in a further increase in metabolic and CV risk in women with PCOS. Conclusion: There is a high prevalence of SCH in Indian Adolescents girls with PCOS and it is associated with significant changes in insulin resistance indices, which may increase the risk of metabolic and CV disorders in these already vulnerable young subjects.
Lifestyle and Weight Change in Women With Polycystic Ovary Syndrome During COVID19 Pandemic
Authors: Eyupoglu Nesrin Damla , Aksun Seren , Ozturk Mervenur , Yildiz Bulent Okan
Published: May 2021

Polycystic ovary syndrome (PCOS) is a complex disorder associated with obesity, sleep apnea, and disordered eating. We aimed to assess whether COVID19 related social isolation affects lifestyle and weight control in women with PCOS. We performed an online survey including 232 women with PCOS and 157 healthy controls on isolation characteristics, weight alterations, physical activity, sleeping and eating patterns by validated questionnaires. Three-Factor Eating Questionnaire (TFEQ-18), Pittsburgh Sleep Quality Index (PSQI), and International Physical Activity Questionnaire Short Form (IPAQ-SF) were used. PCOS-related quality of life questionnaire (PCOSQ) was also completed by patients. During over 14 weeks of isolation, 48.5% participants gained weight, 13.9% participants’ weight was stable, and 37.6% participants lost weight. The patient and control groups did not show any difference in weight alteration (p=0.44). Physical activity was reduced (p<0.001 for both), eating patterns did not show a significant change in both groups, whereas sleep quality was reduced in PCOS group only (p<0.001). Within the weight gainers, increase in BMI was more prominent in PCOS group (1.3±1 kg/m2) than controls (1.0±0.6 kg/m2) (p=0.01). In weight gainer group, delta BMI values showed positive correlations with delta PSQI scores (r = 0.24, p=0.004), delta sleep induction time (r=0.25, p=0.001) and delta TFEQ-18 scores (r=0.25, p=0.001). Weight changes during social isolation are similar in women with PCOS and healthy women. However, the increase in BMI of weight gainers is higher in PCOS and is mainly related to sleep quality and eating habits rather than reduced physical activity.
Lifestyle, Anxiety,Depression, and Clinical Profile in Women With Polycystic Ovary Syndrome: Initial Results From the Brazilian PCOS Study
Authors: Spritzer Poli Mara , Marchesan Lucas Bandeira , dos Santos Betania Rodrigues , Oppermann Karen , dos Reis Rosana Maria , Ferriani Rui A , Weiss Rita Vasconcellos , Meirelles Ricardo , Candido Ana L , Reis Fernando M
Published: May 2021

Brazil is a large country with rich cultural and ethnic diversity among its different regions. In this ongoing nationwide collaborative study, we are evaluating modifiable lifestyle factors, metabolic and reproductive abnormalities and prevalence of anxiety/depression in a less-well represented population of women with PCOS from Brazil. The design of the Brazilian PCOS study has been published previously1. Briefly, the study is being conducted in the outpatient clinics of university hospitals within the public health care network (Unified Health System - SUS) across the country. The sample includes women with PCOS diagnosed according to Rotterdam criteria and a control group of healthy women matched by age and geographic region. Collected data are being incorporated into a unified cloud database. Two hundred five participants have been enrolled thus far (17% of an expected sample size of 1,200 women). Age, years of formal education and socioeconomic class were similar among PCOS phenotypes and the control group. The prevalence of PCOS phenotypes in this sample was 64.7% for phenotypes A + B, 25% for phenotype C, and 10.3% for phenotype D. Phenotypes A + B and D had higher prevalence of obesity (BMI>30) (p=0.001) and metabolic syndrome as compared to the other groups (32.4% in A + B and 50% in D vs. 16% in C and 5.9% in controls; p=0.002). Total testosterone levels, determined by mass spectrometry were higher in PCOS A+B than in the other phenotypes, even after adjustment for BMI (p<0.001). Sedentariness (<150 min/week of physical activity) was present in more than 60% of participants in all PCOS phenotypes and in controls, with no difference between the groups. More than 70% of participants in all PCOS phenotypes had a fruit and vegetable intake below 5 portions/day. Anxiety/depression (SRQ-20) was frequent in phenotypes A + B (41.6%) and D (56.3%) vs. phenotype C (23.1%) and controls (28.6%) (p=0.062). These initial results suggest that PCOS participants, besides often presenting metabolic abnormalities have an unhealthy lifestyle and high prevalence of psychological distress. Analysis of the full study sample will be useful to guide specific public strategies for primary and secondary prevention of psychological, metabolic and reproductive comorbidities in the PCOS population of Brazil. 1Spritzer PM, et al. BMJ Open. 2019; 9:e029191.
Contribution of Copy Number Variation in Idiopathic Hypogonadotropic Hypogonadism
Authors: Stamou* Maria , Brand* Harrison , Lippincott Margaret Flynn , Wong Isaac , Plummer Lacey , Balasubramanian Ravikumar , Talkowski Michael , Seminara Stephanie Beth
Published: May 2021

Introduction: While the role of single nucleotide variants (SNVs) in causal genes for Idiopathic Hypogonadotropic hypogonadism (IHH) is known, the contribution of copy number variants (CNVs) to IHH has not been systematically studied. Here, we examined the prevalence of CNVs in a large IHH cohort and their associated phenotypic spectrum.

Methods: Exome sequencing (ES) from 1,441 IHH probands was analyzed using the GATK-gCNV pipeline to identify CNVs that spanned known IHH genes with a site frequency of <1%. ES data was also analyzed for rare SNVs in all IHH genes. IHH subjects were evaluated for reproductive and non-reproductive phenotypes (kidney, eye, cardiovascular, midline/ facial, bone and neurological abnormalities).

Results: (i) CNV prevalence in IHH: Three percent of the IHH probands (46/1441 probands, 38 males and 8 females) harbored CNVs in 19/36 high confidence IHH genes (26 deletions 20 duplications). The vast majority of CNVs disrupted either the ANOS1 (26%) or FGFR1 (17%) genes. Intriguingly, CHD7 (a gene that carries SNVs in ~12% of our IHH subjects) did not harbor any CNVs. (ii) Phenotypic analysis: We found that CNVs were more common in IHH subjects with anosmia (Kallmann syndrome, N=33) compared to normosmic IHH (N=13). More than half of the subjects with CNVs affecting IHH genes carried at least 1 non-reproductive feature (26/46 IHH subjects, 56%). A syndromic presentation with multiple non-reproductive phenotypes was more common in IHH subjects harboring multigenic CNVs (IHH gene & additional genes) compared to IHH subjects with single IHH gene CNV or SNV in a single IHH gene (61% vs. 12% or 18%, respectively; p 0.0006).

Conclusions: CNVs in known IHH genes contribute to 3% of the IHH genetic architecture in our cohort. IHH subjects with larger multigenic CNVs displayed phenotypes consistent with contiguous gene syndromes. The absence of genic CNVs in genes frequently found to carry SNVs, such as CHD7, requires additional analysis to establish the biologic or mechanistic reasons for their rarity.
Novel Oral Testosterone Formulation Improves Male Well Being Without Compromising International Prostate Symptom Scores
Authors: Dhingra Om P , Bernstein James , Barnes Shaina D , VanLaanen Hannah , Wadlington Natasha , Chang Jessica
Published: May 2021

Introduction: Male hypogonadism results from insufficient secretion of testosterone (T) and is characterized by low serum T concentrations. Common symptoms of hypogonadism include decreased libido, impotence, weakness, low energy, depression and/or loss of motivation, memory and concentrating issues, and sleep disturbances. Several forms of T replacement are available. Testosterone undecanoate (TU) is a testosterone prodrug available in oral formulations. A novel TU formulation, SOV2012-F1, has been submitted for FDA consideration under the name KYZATREX®. While TU efficacy is measured by serum total T, patientfocused endpoints such as Patient Reported Outcomes (PROs) are valuable indicators of well-being and psychosexual symptom abatement. Methods: A Phase 3, randomized, multicenter, open-label, active-controlled trial, comparing SOV2012F1 (testosterone undecanoate capsules) (n=214) with AndroGel® (1.62% topical testosterone gel) (n=100) enrolled males aged 18 to 65 years with hypogonadism (serum total T levels ≤281 ng/dL). A key exploratory endpoint was change from Baseline (ΔBL) after 52 weeks of treatment in the following PROs: International Prostate Symptom Score (IPSS), Psychosexual Daily Questionnaire (PDQ), Short Form Health Survey 36 item (SF-36), and the International Index of Erectile Function (IIEF). Results: Total or overall scores for all PROs (IPSS, PDQ, SF-36 and IIEF) showed increased improvement in the SOV2012-F1 group relative to the Androgel group, and all but IPSS demonstrated improvement relative to BL. For IPSS, due to the potential that T could worsen urinary symptoms, the ΔBL would ideally be small to reflect minimal impact. Change for the SOV2012-F1 and AndroGel groups was, respectively, 0.6 and 1.0. Further, the IPSS total score was not significantly different from BL in the patients receiving SOV20212-F1 (p = 0.5659). For PDQ, a clinically meaningful improvement of sexual desire in hypogonadal men age ≥65 years is ≥0.7; mean ΔBL was 1.6 in the SOV2012-F1 group versus 1.4 in the AndroGel group. In the SF-36, the mean ΔBL total score was 83.7 in the SOV2012-F1 group and 70.2 in the AndroGel group. Further, post hoc analysis of the Health Change category found a significant (p ≤ 0.05) improvement in patient perspectives on health over the course of the study. The overall satisfaction score of the IIEF trended towards significance for the SOV2012-F1 group with a mean ΔBL score of 2.3 versus and 1.6 in the AndroGel group. The ΔBL for the 4 domains of male sexual function were small and consistent between the SOV2012-F1 and AndroGel groups. Comparable results were noted for Early Withdrawals and All Subjects across all PROs. Conclusion: Treatment with SOV2012-F1 for 52 weeks exceeded AndroGel patient satisfaction as measured by PROs including IPSS, PDQ, SF-36 and IIEF, demonstrating clinical distinction. Further analysis of SOV2012-F1 will be forthcoming.
Prohibitin-1 Transgenic Mice Revealed an Important Role of Prohibitin in Testicular Steroidogenesis
Authors: Bassi Geetika , Mishra Suresh
Published: May 2021

Testosterone, the male sex hormone, plays an important role in the sexual development and fertility. Consequently, its deficiency causes infertility, obesity, osteoporosis and cardiovascular diseases. Leydig cells (LCs) are the testicular interstitial cells responsible for the biosynthesis of testosterone in response to luteinizing hormone (LH) from the pituitary. Cholesterol is the essential substrate for steroidogenesis which is translocated from the cytosol to the mitochondria where it gets converted to pregnenolone (by P450 side chain cleavage enzyme). Subsequently, pregnenolone translocate to endoplasmic reticulum where action of various enzymes results in the biosynthesis of testosterone. Prohibitin-1 (PHB1) is an evolutionary conserved ubiquitously expressed protein with cell compartment and cell-type specific functions. Mitochondrial function of PHB1 has been widely studied but its role in testicular steroidogenesis is unexplored. Recently, we have reported two transgenic mice models of PHB1, PHB-Tg and mutant-PHB-Tg (mPHB-Tg), expressing PHB1 or Y114F (mutant PHB1) respectively under the control of Fabp-4 gene promoter. During phenotypic characterization of these mice models, we observed a drastic size/weight difference in the testis of PHB-Tg and mPHB-Tg when compared with wild type mice. The mPHB-Tg mice testis was significantly smaller than the PHB-Tg and wild type mice. Further analysis of mPHB-Tg testis revealed wider testicular interstitium with LC hyperplasia and elongated seminiferous tubules. Ultrastructure investigation revealed that LCs of mPHB-Tg mice have prominent nucleus with increased number of mitochondria and lipid droplets. In addition, electron microscopic images of mPHB-Tg mice LCs revealed a sign of lipophagy and mitophagy. This prompted us to measure testosterone levels in these mice; surprisingly mPHB-Tg mice showed significantly higher testosterone levels as compared to PHB-Tg and wild type mice. Furthermore, testicular lysates and primary LCs cell lysates from transgenic mice models revealed that overexpression of PHB/mPHB in LCs inversely effect expression levels of steroidogenic acute regulatory protein (StAR). Moreover, co-immunoprecipitation of PHB1 displayed an interaction with StAR, P450scc and LC3 further revealing a key role of PHB1 in cholesterol translocation, testicular steroidogenesis and autophagy. Taken together, this finding suggests that PHB1 plays a multifaceted role in testicular steroidogenesis from determining testis size to the translocation of cholesterol into the mitochondria, in maintaining lipid homeostasis and biosynthesis of testosterone. Implications of our findings are broad because cholesterol translocation to the mitochondria and its subsequent utilization for steroidogenesis is conserved in all steroidogenic tissues.
A Case of Autoimmune Polyglandular Syndrome Type 3b Initially Presenting as Generalized Weakness in an Elderly Patient
Authors: Ayesh Hazem , Burmeister Cameron , Abdelrahman Ahmed , Beran Azizullah , Suri Pooja
Published: May 2021

Introduction: Autoimmune polyglandular syndrome (APS) is a multiorgan genetic autoimmune disease. APS-3B subtype is autoimmune thyroiditis with pernicious anemia. In this case, we will discuss an elderly female patient diagnosed with APS-3B.

Case Presentation: A 69-year-old Caucasian female patient with a past medical history of autoimmune thyroiditis presented to the emergency department with a two-month history of generalized weakness and nausea. Associated symptoms included shortness of breath and diarrhea. Review of systems was otherwise unremarkable. Physical exam was positive for depigmented skin macules over the upper extremities. Lab results showed hemoglobin 8.2 [11.7 - 15.5 g/dL], MCV 121[80 - 100 fL], platelets 144,000 [150 - 450 X10E9/L], WBC 1.9 [4.0 - 11.0 X10E9/L], LDH 1153[100 - 235 U/L], TSH 0.28[0.49 - 4.67 uIU/mL], free T4 1.7 [0.61 - 1.60 ng/dL], direct Coombs test negative. Iron saturation 55%, vitamin B12 level <50 [180 - 914 pg/mL], folate >25[>5.8 ng/mL], total bilirubin 2.3 [0.3 - 1.2 mg/dL], haptoglobin <30 [32 - 228 mg/dL], AST 43 [0 - 41 U/L], reticulocyte 1.4%. Blood smear showed absolute neutropenia with flow cytometry unremarkable. Chest x-ray and urinalysis were negative. Immunofixation showed low IgM 44 [45 - 281 mg/dL], low IgG 619 [635 - 1,741 mg/dL]. Intrinsic factor antibodies (IF-Ab) were positive. Hematology reported that hemolytic anemia is less likely given Coombs test was negative. About 1.5% of Vitamin B12 deficiency present with a hemolytic picture due to ineffective erythropoiesis while Coombs test help to differentiate it from autoimmune hemolytic anemia. Diagnosis of pernicious anemia was made and the patient started on vitamin B12 injections. The combination of pernicious anemia, autoimmune thyroiditis, and vitiligo supported the diagnosis of autoimmune APS-3B. There was a normalization of vitamin B12 level and symptomatic improvement on a one-week follow-up.

Discussion: The patient was diagnosed with autoimmune thyroiditis in 2014 with positive anti-TPO antibodies and elevated TSH; she required levothyroxine supplementation since diagnosis. Hypothyroidism causes macrocytic anemia, which may delay pernicious anemia diagnosis. APS-3B is associated with HLA-B8 and/or DR3 and DR5. Many studies reported that autoantibodies can be detected before developing symptoms of organ involvement. Thorough family history provides support for autoantibody testing to detect cases of APS-3B earlier. Active surveillance and early diagnosis will help minimize invasive testing such as bone marrow biopsy, so proper history taking is a key factor to early diagnose these conditions.

Conclusion: APS-3B is a rare disorder. Diagnosis is difficult hypothyroidism causes macrocytic anemia. Early detection of APS-3B may help to prevent complications that increase the risk of mortality and morbidity, particularly in the elderly population.
Complete Androgen Insensitivity and Decreased Bone Mineral Density
Authors: Bauer Elizabeth M , Hoang Thanh Duc
Published: May 2021

Background: Complete androgen insensitivity syndrome (CAIS) is a rare disorder of sex development and primary amenorrhea results in an XY karyotype but female phenotype. Patients with this syndrome have lower bone mineral density (BMD) when compared to age matched controls.

Clinical Case: A 44-year-old phenotypic woman with a history of complete androgen insensitivity syndrome presented for follow-up. She was previously on hormone replacement therapy (HRT) at various doses from the age of 12 until her early 30s when her therapy became sporadic. At age 40, she was prescribed transdermal estrogen therapy but discontinued soon after a dermatologic reaction and had not been on any form of hormone replacement since that time. Past medical history was significant for karyotype 46 XY, osteochondritis dissecans of right ankle and bilateral orchiectomy at age 4. She was single with one adopted child. Physical examination showed a height 75 inches, weight 244 lbs and a normal heart, lung, and abdominal examinations. Laboratory results showed estradiol 12.3pg/mL(7.63-42.6), total testosterone 12.0 ng/dL(7-40), FSH 109.6 mIU/mL(25.8-134.8), LH 42.49 mIU/mL(7.7-58.5), anti-mullerian hormone < 0.015 ng/mL (0.26-5.81), inhibin B <7.0 pg/mL(<17), androstenedione 48 ng/dL(41-262), dihydrotestosterone 2.7 ng/dL(4-22) and dehydroepiandrosterone sulfate 209 ng/dL(31-701). A baseline DXA showed low bone density for age with T-score (Z-score) of -2.0 (-1.6) lumbar-spine; -1.6 (-1.2) femoral neck, -1.1 (-0.8) total hip and -2.5 (-2.0) forearm.

Discussion:CAIS is caused by a mutation in the androgen receptor (AR) located on the X-chromosome causing complete unresponsiveness to androgen hormone. Karyotype is XY but feminization occurs due to aromatization of androgen to estrogen. Gonadectomy for testicular malignancy prevention is controversial as testicular tumors in CAIS is generally low and gonadal resection subjects individuals to lifelong hormone replacement. These patients also have lower BMD when compared to female or male age matched controls. This is even more apparent in those with removed gonads. Low BMD is exacerbated by poor compliance, inadequate dose or inappropriate HRT. Whether or not fracture risk is higher has yet to be elucidated. Currently, there is no guideline on how to manage low BMD including osteoporosis in this patient population. It is important to counsel patients with CAIS on BMD loss and to ensure optimization of factors that affect bone health including compliance with HRT, vitamin D/calcium intake and exercise.

The views expressed in this article are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or the United States Government.
“It Wasn’t for the Sake of Me and My Mental Health”: Transgender People’s Perspective on the Role of Mental Health Providers in Initiating Gender-Affirming Hormones - a Qualitative Study
Authors: Maksutova Mariam , Wu Justine P , Indig Gnendy , Moravek Molly Bennette , Popoff Elliot , Trammell Racquelle , Ballard Jesse , Stroumsa Daphna
Published: May 2021

Introduction: Hormone therapy can be an essential part of medical transition for some transgender people. Despite ongoing debate on the role of mental health providers in the initiation of gender-affirming hormones, little evidence exists to guide the discussion. We seek to elucidate the patient perspective on the feasibility, utility, risks, and benefits of mandatory mental health evaluation (MHE) prior to hormone initiation.

Methods: We conducted semi-structured interviews with individuals who have initiated gender-affirming hormone therapy (n=21). We purposively sampled respondents to include those who indicated that they were required to have mental health evaluation prior to hormone initiation, and those who did not. A transgender advisory board helped develop the semi-structured interview guide. Interviews were transcribed verbatim and coded using emergent and a priori codes.

Results: The majority of respondents saw the requirement for MHE prior to hormone initiation as distinct from, and often discordant with, their mental health care. We identified the following roles of mental health care as seen by patients: 1) General psychosocial support; 2) Identity formation: therapy as a safe space to explore gender and self; and 3) Logistics: assistance navigating the healthcare system. Themes that emerged regarding the MHE requirement included 1) Access: for some, the MHE requirement delayed access to gender-affirming care; 2) “pathologizing my existence”: the effects of having one’s identity result in a diagnosis of mental disorder; and 3) “auditioning” for care: fear of being denied care if one does not present with a stereotypical transgender narrative. Many participants drew direct connections between the MHE requirement and negative effects on their mental health and the patient/provider relationship, while concurrently identifying mental health care as essential for wellbeing.

Conclusion: While mental health care is appreciated, many transgender people see the universal MHE requirements as having significant negative implications on access, safety, and on even on their mental health. Guidelines should explicitly account for and mitigate the structural barriers preventing transgender individuals from accessing medical and mental health care.
A Cross Sectional Analysis of the Prevalence of Co-Morbidities in Older Transgender Individuals Receiving Hormone Affirming Therapy in Comparison With the General Population
Authors: Breda Ido , Yaish Iris , Sofer Yael , Tordjman Karen Michele , Greenman Yona
Published: May 2021

Background: Transgender individuals feel an incongruity between the assigned gender at birth and their gender identity. Because the prevalence of cardiovascular risk factors and morbidity associated with cross-sex hormonal therapy is not well established, particularly in the older transgender population, we set out to compare it to that of the general population. Methods: Data were collected from medical records of transgender patients treated in the Endocrine Institute at the Tel Aviv-Sourasky Medical Center until October 2018. Data from the Israel National Health Survey INHIS-3 2013-2015 were used as reference. Results: 104 (75 transgender women and 29 transgender men) patients over 35 y were identified. The median follow up time was 3 y (1-6.1). Transgender women had a high standardized prevalence rate (SPR) of overweight, smoking and engaging in physical exercise, but not of dyslipidemia compared with cisgender men and women. The SPR for overweight was high in transgender males compared with cisgender men and women. The SPR for smoking and dyslipidemia was high in transgender men compared with cisgender women but not men. Depression and anxiety were markedly increased in transgender women compared with cisgender men [SPR 5.5 (95% CI 3.3-8.5), p<0.001] and women [SPR 2.8 (95% CI 1.7-4.3), p<0.001] in the control population. The SPR of hypertension, diabetes and cerebrovascular disease was not elevated among transgender patients. Conclusions: The prevalence of cardiovascular risk factors but not cardiovascular morbidity was higher in the transgender patients compared with the general population. Further studies including a larger population and a longer follow up time are needed to better assess the impact of a high prevalence of risk factors on cardiovascular morbidity on the long run.
Achieving Physiologic 17-ẞ-Estradiol Levels in Transgender Females on Estradiol Transdermal Patches and Optimal Dosing
Authors: Trovato Alexa , Leinung Matthew C , Joseph Jalaja , Nguyen Son
Published: May 2021

Purpose: Gender dysphoria is defined as a significant incongruence between an individual’s experienced gender and the gender assigned at birth, leading to persistent distress. Hormone therapy and gender affirmation surgery improve gender dysphoria by mitigating or completely removing undesirable primary/secondary sexual characteristics which would better align with one’s physical and psychological features. Maintaining cross-sex hormone levels in the physiologic range for the preferred gender is the basis of transgender hormonal therapy. For trans females (MTF), estradiol is most commonly administered orally, and studies have shown this route is often successful in achieving therapeutic hormone levels. However, there is wide individual variability in the dose response to oral estradiol, and approximately 25% of patients will not reach therapeutic goal on maximum oral estradiol. Furthermore, high dose oral estrogen has been associated with increased thrombotic risk, especially in older individuals. The efficacy or optimal dose of adding or switching to the transdermal route is not known. We investigated the efficacy of estradiol transdermal patches and the optimal dose to reach therapeutic goal. Methods: A chart review was conducted of all MTF patients who were treated with estradiol transdermal patches in our transgender clinic from 2006 through 2020. We looked at the success of achieving physiologic serum 17-β-estradiol levels (with and without antiandrogens spironolactone and finasteride) on various doses of estradiol transdermal patches. Target serum level for estradiol >100 pg/mL is recommended (but may be lower in certain clinical circumstances). Results: 371 MTF patients were identified, 41 received an estradiol transdermal patch. Of these 41 patients, 16 of them were placed on a transdermal patch due to failure to achieve target 17-β-estradiol levels on maximal oral therapy. We found that 9 of these 16 patients achieved goal estrogen levels, as well as one patient very near goal. Of the 7 who did not reach goal, only 2 were on patch doses >60 mcg/day. The majority who reached goal serum estradiol levels were taking a dose of 100 mcg/daily. When considering all MTF patients on the highest dose (100 mcg) of transdermal estrogen, 11 of 18 attained goal level, as well as one just under goal. Of the 41 MTF patients taking a transdermal patch, only 6 of them had serum estrogen levels lowered from being at goal on oral therapy. Thirteen patients had their estrogen levels improve to reach goal when placed on patch (4 as add-on therapy). Conclusions: Our study supports the findings that using an estradiol transdermal patch can help MTF patients achieve goal 17-β-estradiol levels. This delivery method can be useful for patients unable to reach goal on oral agents and for patients at higher thrombotic risk. The highest dose patch available is often needed to achieve therapeutic goal.