bluuebunny/crossref_metadata_2025 huggingface dataset:
Experience with transdermal testosterone replacement therapy for hypogonadal men
Authors: Parker Susan , Armitage Mary
Published: March 2003

BACKGROUND

None of the existing options for long‐term testosterone replacement therapy (TRT) for hypogonadal men are ideal. Depot replacement at frequent intervals and implants are effective but invasive and inconvenient for the patient. Oral therapy results in poor hormone levels. Both are associated with undesirable metabolic changes. A transdermal formulation therefore represents a potential therapeutic advance for testosterone replacement.

OBJECTIVE

To carry out a clinical audit of the acceptability and efficacy as a treatment for hypogonadism of the first transdermal testosterone therapy available in the UK (Andropatch, SmithKline Beecham) compared with existing androgen replacement options.

PATIENTS AND MEASUREMENTS

Serum testosterone and questionnaire data on treatment efficacy, side‐effects, therapy preference, sexual dysfunction and partner's attitudes to therapy were obtained from 50 hypogonadal men prescribed long‐term testosterone replacement.

RESULTS

Eighty per cent of the men returned analysable questionnaires. Eighty‐four per cent experienced adverse effects with transdermal therapy, most commonly dermatological problems; 22% of the sample elected to continue with transdermal therapy, 72% returned to depot and 5% returned to oral therapy. The reservoir patches were judged to be too large, uncomfortable, visually obtrusive and noisy. Testosterone levels were comparable to those obtained with depot replacement with the added advantage of a more physiological pharmacokinetic profile. Men taking oral preparations were consistently under‐replaced.

CONCLUSIONS

Adverse events were substantially higher than reported from clinical trials but in keeping with the spectrum of yellow card reports received by the Committee on Safety of Medicines. The pharmacokinetic advantages are thus largely outweighed by low patient acceptability. In its present form transdermal therapy remains an expensive option for those who cannot tolerate depot testosterone replacement.
Novel DAX1 mutations in X‐linked adrenal hypoplasia congenita and hypogonadotrophic hypogonadism
Authors: Bassett J. H. D. , O'Halloran D. J. , Williams G. R. , Beardwell C. G. , Shalet S. M. , Thakker R. V.
Published: March 2003

OBJECTIVE

Mutations of the DAX1 gene (Dosage‐sensitive sex reversal‐Adrenal hypoplasia congenita critical region on the X chromosome gene 1), which encodes a novel orphan nuclear receptor, have been identified in patients with X‐linked adrenal hypoplasia congenita (AHC) and hypogonadotrophic hypogonadism (HHG). We have investigated two kindreds with AHC and HHG for DAX1 mutations.

METHODS

Two kindreds with five affected males, four carrier females and four unaffected males were investigated. The gonadotrophin deficiency in three of the boys was observed to be partial until mid‐puberty. DAX1 mutations in the entire 1413 bp coding region were sought by DNA sequence analysis

RESULTS

Two DAX1 mutations, situated within exon 1, were detected. These consisted of an insertional mutation at codon 183 that led to a frameshift and a premature Stop at codon 184, and a missense mutation Leu278Pro that involved a highly conserved leucine residue within the proposed ligand binding domain. Co‐segregation of these mutations with the disease in each family, and their absence from 107 alleles in 73 (39 males and 34 females) unrelated control individuals, was demonstrated by allele specific oligonucleotide hybridization (ASO) analysis for the insertional mutation, and by Ban I restriction endonuclease analysis for the missense mutation.

CONCLUSIONS

Two novel DAX1 mutations have been detected in two families with adrenal hypoplasia and hypogonadotrophic hypogonadism. The finding of partial gonadotrophin deficiency in the affected males from these families is notable and an early recognition of such a possibility in a patient, which may be facilitated by DAX1 mutational analysis, may help to prevent the sequelae of delayed androgen replacement therapy.
High precursor level in maternal blood results from the alternate mode of proopiomelanocortin processing in human placenta
Authors: Raffin‐Sanson Marie‐Laure , Massias Jean Francis , Ankotche Amos , Coste Joël , De Keyzer Yves , Oliver Charles , Dumont Chantal , Cabrol Dominique , Ferré Francoise , Bertagna Xavier
Published: March 2003

OBJECTIVE

ACTH‐producing non‐pituitary tumours are often associated with altered precursor processing, particularly in the most aggressive ones. Since placental tissue is characterized by its ability to express the proopiomelanocortin (POMC) gene and rapid cellular proliferation, we examined whether intact POMC could be released physiologically during human gestation.

SUBJECTS

One hundred and fifty six normal pregnant women, 12 with multiple pregnancies, and 23 non‐pregnant controls. Twenty‐eight women were studied in the immediate postpartum period.

MEASUREMENTS

We measured plasma POMC levels with a specific immunoradiometric assay (IRMA) using a combination of antibodies directed against ACTH and β endorphin. Results obtained with this first IRMA were confirmed in 22 subjects with a second assay using the same β endorphin antibody and a more distal antibody directed against the N‐terminal fragment of POMC. Reverse transcription‐PCR detected full length, pituitary‐like, POMC mRNA in human placenta.

RESULTS

Plasma POMC was undetectable (<60 U/ml) in 23 normal subjects. In normal monofetal pregnancies, POMC became detectable in most women by the third month and then increased steadily until mid‐gestation: 168 ± 108 (U/ml; mean ± SD) between 12 and 15 weeks, 190 ± 103 between 16 and 19 weeks, 324 ± 180 between 20 and 23 weeks, 276 ± 171 between 24 and 27 weeks, 292 ± 177 between 28 and 31 weeks, 290 ± 235 between 32 and 35 weeks and 308 ± 210 between 36 weeks and parturition. Plasma POMC was significantly higher in multiple pregnancies with very high levels in three triplet‐bearing mothers: 671, 941, and 1731 U/ml at 31, 33 and 32 weeks, respectively. POMC levels felt quickly in post partum, becoming undetectable in five of 13 women on day 1, seven of eight on day 2 and five of six on day 3. Plasma POMC displayed no diurnal variation, was not suppressed by glucocorticoid administration and did not correlate with plasma ACTH or cortisol. In contrast, plasma POMC positively correlated with plasma CRH.

CONCLUSIONS

Pregnancy is the only condition in which POMC is produced and released physiologically, similar in some respects to the ectopic ACTH syndrome. POMC is derived solely from the placenta, with no interference from maternal pituitary secretion, and is thus a new and specific placental marker.
Recombinant interferon α (rIFN‐α) does not potentiate the effect of iodine excess on the development of thyroid abnormalities in patients with HCV chronic active hepatitis
Authors: Minelli Roberta , Braverman Lewis E. , Valli Maria Antonietta , Schianchi Claudia , Pedrazzoni Mario , Fiaccadori Franco , Salvi Mario , Magotti Maria Grazia , Roti Elio
Published: March 2003

OBJECTIVE

To determine whether the administration of pharmacological quantities of iodine during interferon‐alpha (rIFN‐α) treatment of chronic viral hepatitis B and C (HCV) would exacerbate the potential adverse effects of rIFNα on thyroid function.

DESIGN

Thyroid function tests were carried out in 48 euthyroid patients before and during rIFN‐α therapy of HCV. Twenty‐one of these patients were also treated with 10 drops saturated solution of potassium iodine (SSKI, ∼350 mg iodine daily). Eight patients with HCV but not treated with rIFN‐α received 10 drops SSKI.

PATIENTS

All patients were enthyroid prior to rIFN‐α therapy for HCV or iodine and thyroid function tests were similar in the three groups.

MEASUREMENTS

Serum free T4, free T3, and TSH concentrations were measured prior to and at 30 and 60 days of rIFN‐α therapy in the three groups of patients. The serum TSH response to TRH was assessed before rIFN‐α therapy and on day 60. Thyroid peroxidase antibodies were measured before and during therapy.

RESULTS

During the 2‐month study period, similar small but significant decreases in serum FT4 and FT3 and compensatory small significant increases in TSH concentrations were observed in the patients treated with rIFN‐α + iodine and iodine alone but not in the patients receiving rIFN‐α alone. Abnormal thyroid function tests were observed more frequently in patients receiving rIFN‐α + iodine and iodine alone compared to those receiving rIFN‐α alone.

CONCLUSIONS

Excess iodine administered to patients treated with rIFN‐α induced small changes in thyroid function similar to those observed in patients treated with iodine alone. Thus, rIFN‐α and iodine do not appear to be synergistic in the development of abnormal thyroid function tests over a 2‐month treatment period.
Evaluation of bone metabolism after the use of an inhaled glucocorticoid (flunisolide) in patients with moderate asthma
Authors: Hauache  , Amarante  , Vieira  , Faresin  , Fernandes  , Jardim  , Lazaretti‐Castro
Published: March 2003

OBJECTIVE

We have investigated the effects of the inhaled corticosteroid flunisolide on bone metabolism and adrenal function in patients with moderate asthma.

SUBJECTS AND DESIGN

Twenty ambulatory patients (13 females, 7 males, mean age ± SD of 36.4 ± 12.4 years) with moderate asthma were recruited. None had taken corticosteroids for at least 1 month. Flunisolide 500 μg was given twice a day for 10 weeks, without any other medication. Blood and urine were collected before and at the end of treatment course. Cortisol (basal and 1 h after ACTH 250 μg i.v.) was measured to evaluate adrenal function. A peak cortisol response of 496 nmol/l was considered an adequate response. Serum ionized calcium, intact PTH, plasma osteocalcin (OC) and urinary pyridinoline (Pyr) and deoxy‐pyridinoline (D‐Pyr) were measured to evaluate bone metabolism. Wilcoxon paired test was performed for statistical analysis. Results are expressed as mean ± SD.

RESULTS

In most patients (85%), there was no difference after treatment with flunisolide on basal and stimulated cortisol levels. We found a significant decrease of OC (3.55 ± 1.42 to 2.97 ± 1.05 nmol/l) and Pyr (66.4 ± 20.0 to 59.5 ± 24.9 pmol/μmol creatinine) levels after treatment (P < 0.05). We also observed a positive correlation between the variations seen in pre and post treatment values of OC and Pyr/D‐Pyr.

CONCLUSIONS

The use of inhaled flunisolide 1000 μg/day for 10 weeks had no suppressive effect on adrenal function in the majority of asthmatic patients studied. However, the effects seen on bone and mineral metabolism, evidenced by the significant fall in osteocalcin and pyridinoline levels, may indicate a possible systemic effect of this drug. Clinical consequences of long‐term treatment with flunisolide need to be further evaluated.
Circadian variation of plasma cortisol in prepubertal children with normal stature, short stature and growth hormone deficiency
Authors: Hermida Ramón C. , García Leopoldo , Ayala Diana E. , Fernández José R.
Published: March 2003

OBJECTIVES

When studying the relationship between spontaneous secretion of growth hormone (GH) and cortisol in children, most studies show no correlation in mean levels of these two hormones, while others found positive or even strongly negative correlations. These contradictory results could be partly due to the inability to properly compare hormones that are characterized by circadian and ultradian variations in their secretory profiles. We aim here to study possible differences in rhythm characteristics of plasma cortisol with stature and to compare the circadian secretory patterns of cortisol and GH.

PATIENTS

We analysed data from 135 prepubertal children: (1) 14 GH‐deficient children; (2) 36 children with short stature (2–3 SD below their peer group mean); (3) 57 children with very short stature (3–4 SD below their peer group mean); and (4) a reference group of 28 children with normal stature (± 2 SD). Subjects were living in a hospital setting on a diurnal waking (07.30–22.30 h), nocturnal resting routine during sampling, consuming the usual hospital diet at fixed times.

MEASUREMENTS

Cortisol and GH concentrations were determined by radioimmunoassay in plasma obtained at about 2–3 h intervals during most of the day and at half‐hour intervals between 22.00 and 02.00 h. Circadian rhythm characteristics obtained by least‐squares estimation were compared between groups divided according to gender and stature with a parameter test.

RESULTS

show a statistically significant circadian rhythm in cortisol secretion for all groups studied (P < 0.001 in all cases). A comparison of circadian parameters indicated similar characteristics between subjects of short, very short and normal stature. Despite a borderline statistically significant difference in rhythm‐adjusted mean and amplitude of GH between nondeficient and GH‐deficient children, there was no difference in the circadian pattern of cortisol secretion between these two groups. No correlation was found in circadian mean, amplitude, average, standard deviation, standard error, minimum or maximum between GH and cortisol for any of the groups of children.

CONCLUSIONS

Any possible relation between GH and cortisol remains unclear. Moreover, GH‐deficient children are not necessarily characterized by either hyper‐ or hypocortisolaemia.
Evaluation of free insulin‐like growth factor‐I measurement on the diagnosis and follow‐up treatment of growth hormone‐deficient adult patients
Authors: Musolino Nina Rosa C. , Da Cunha Neto Malebranche B. , Marino Raul , Giannella‐Neto Daniel , Bronstein Marcello D.
Published: March 2003

OBJECTIVE

Insulin‐like growth factor I (IGF‐I) and IGF binding protein‐3 (IGFBP‐3) are GH‐dependent and their concentrations have been used in the diagnosis of GH deficiency. Recently, the free fraction of IGF‐I has received more attention. The aim of the study was to assess the role of free IGF‐I in the diagnosis of GH deficiency in adults, and in follow‐up during treatment with recombinant human GH (rhGH).

DESIGN AND PATIENTS

We studied 24 adult patients with pituitary disease and GH deficiency and 25 matched controls. Nine patients were re‐evaluated after 6 months of treatment with rhGH (0.25 U/kg/week).

MEASUREMENTS

Serum levels of IGF‐I, free IGF‐I, IGFBP‐3 and IGFBP‐1 were measured by immunoradiometric assay.

RESULTS

Serum free IGF‐I levels were significantly lower in the GH deficient group than in the normal group (mean: 0.84 and 1.32 μg/l respectively, P = 0.0009). Furthermore, serum IGF‐I levels were also lower (mean: 92.24 and 230.47 μg/l respectively, P < 0.0001). 63% of patients had serum IGF‐I concentration below the normal range. For free IGF‐I, 52% of the GH deficient patients showed levels below the lowest value obtained for the normal group. Seventy‐five percent of the patients showed at least one of the two determinations below the normal range. The free‐total IGF‐I ratio was significantly higher (P = 0.025) in GH deficient group (range: 0.19–21.29, mean: 2.53) than in normal controls (range: 0.2–2.15, mean: 0.6). Regarding IGFBP‐3 and IGFBP‐1 no differences were observed between the two groups. During rhGH treatment the increase in serum total and free IGF‐I and IGFBP‐3 paralleled the beneficial effects on body composition.

CONCLUSIONS

Free IGF‐I may be another useful method for the diagnosis of GH deficiency, particularly if related to total IGF‐I concentration.
Female sex hormone replacement therapy increases serum free 1,25‐dihydroxyvitamin D3: a 1‐year prospective study
Authors: Van Hoof  , Van Der Mooren  , Swinkels  , Sweep  , Merkus  , Benraad Th. J.
Published: March 2003

OBJECTIVE

Currently, hormone replacement therapy is applied successfully to reduce post‐menopausal bone resorption. However, the exact mechanism by which oestrogen exerts its effect has not yet been fully elucidated. In order to determine whether changes in the biologically active 1,25‐dihydroxyvitamin D3 may be of importance in this process, the concentrations of both total and free 1,25‐dihydroxyvitamin D3 in serum were assessed.

DESIGN

In 36 post‐menopausal women the effect of hormone replacement therapy, with a combination of 17β‐oestradiol and norethisterone acetate, on the serum levels of total and free 1,25‐dihydroxyvitamin D3 was studied after 0, 3, 6 and 12 cycles.

MEASUREMENTS

The total concentration of 1,25‐dihydroxyvitamin D3 in serum was assessed using a radioreceptor assay after diethylether extraction of the samples followed by paper chromatography. The free fraction of 1,25‐dihydroxyvitamin D3 was measured using symmetric dialysis. The free 1,25 dihydroxyvitamin D3 concentration was calculated by multiplying the total concentration by the free fraction.

RESULTS

During therapy, mean serum total 1,25‐dihydroxyvitamin D3 concentrations (± SD) were 106.4 pmol/l (± 27.5), 155.0 pmol/l (± 49.5), 176.7 pmol/l (± 70.0) and 161.1 pmol/l (± 55.3) at 0, 3, 6 and 12 cycles, respectively. Serum free 1,25‐dihydroxyvitamin D3 concentrations were 68 fmol/l (± 22), 107 fmol/l (± 35), 120 fmol/l (± 43) and 108 fmol/l (± 37), respectively. Baseline values of both total and free 1,25‐dihydroxyvitamin D3 were significantly lower than those during therapy at all time (P ≤ 0.001).

CONCLUSION

Both the serum total 1,25‐dihydroxyvitamin D3 and the serum free 1,25‐dihydroxyvitamin D3 concentrations are increased during combined 17β‐oestradiol and norethisterone acetate therapy for a year. Assuming that the free concentration 1,25‐dihydroxyvitamin D3 reflects the biologically active fraction, this rise may in part explain the preventive effect of hormone replacement therapy on osteoporosis.
Correlation between cortisol and insulin‐like growth factor‐binding proteins (IGFBPs) under physiological conditions in children
Authors: Martinelli Jr Carlos E. , Yateman Martin E. , Cotterill Andrew M. , Moreira Ayrton C. , Camacho‐Hübner Cecilia
Published: March 2003

OBJECTIVE

A positive correlation between 24‐h spontaneous growth hormone (GH) and cortisol secretion was previously reported in children. This observation prompted us to examine the relationship between physiological diurnal cortisol variation and the levels of insulin‐like growth factors (IGFs) and IGF‐binding proteins (IGFBPs) under physiological conditions.

DESIGN AND PATIENTS

Starting at 0800 h, blood was sampled every 20 minutes over 24 h for measurement of GH and cortisol concentration in nine non‐GH‐ deficient boys as part of a protocol for the investigation of short stature.

MEASUREMENTS

IGFBP‐1 and insulin were measured in samples drawn every 4 h over the 24‐h period while IGF‐I, IGF‐II, IGFBP‐2 and IGFBP‐3 were determined in samples collected at the end of the study.

RESULTS

No correlation was observed between IGF‐I or IGF‐II and mean cortisol levels. IGFBP‐1 concentrations showed a marked circadian variation that was superimposed on the circadian rhythm for cortisol while a significant positive correlation was found for single point measurements between IGFBP‐1 concentrations and cortisol levels measured in the same sample (r = 0.53) or at the preceding 20 minutes (r = 0.43), 40 minutes (r = 0.47) and 2 h (r = 0.38), suggesting an interplay between cortisol and IGFBP‐1. A negative correlation (r = − 0.54) was found between IGFBP‐1 and insulin levels determined in the same sample. A negative correlation (r = − 0.93) was also found between IGFBP‐2 levels and mean cortisol concentrations during the preceding 12 h. No correlation was observed between plasma IGFBP‐3 measured by IRMA and mean cortisol levels.

CONCLUSION

Our data indicate a clear correlation between cortisol and IGFBP‐1 and IGFBP‐2 levels. Thus, the interplay of spontaneous GH and cortisol secretion in children may involve changes in IGFBP‐1 and IGFBP‐2 levels.
Short‐term leptin infusion does not affect circulating levels of LH, testosterone or cortisol in food‐restricted pubertal male rhesus macaques
Authors: Lado‐Abeal Joaquin , Lukyanenko Yevgeniya O. , Swamy Sunita , Hermida Ramon C. , Hutson James C. , Norman Reid L.
Published: March 2003

OBJECTIVES

Although the adipocyte protein leptin has been implicated in the control of reproductive function in rodents, its role in primate reproductive physiology is poorly understood. Because primates in puberty show nighttime LH secretion and there is considerable evidence that the fertile state requires adequate nutrition, we reasoned that animals on the verge of reproductive competence would respond to leptin infusions by secreting LH. Food restriction reduces circulating leptin levels and slows or stops the GnRH pulse generator. Therefore, we examined the endocrine effects of leptin infusions in food‐restricted male pubertal primates during the night when they normally secrete LH. In addition, we investigated the effect of leptin on in vitro testosterone production by Leydig cells.

SUBJECTS

Four pubertal male rhesus macaques (Macaca mulatta), 4–5.5 kg in weight (2.5–4‐year‐old) were examined in this study. Leydig cells from adult male rats were to investigate in vitro effects of leptin.

DESIGN

To document that animals had entered puberty, blood samples were collected from each of the four animals at 15‐minute intervals for 15 h both during the day and at night. Since at this age animals secrete LH mainly at night, blood samples were collected at 15‐minute intervals from each of the four animals on two separate occasions for 15 h between 1500 and 0600h. During the experiment, animals were feeding from 0800 to 0830h, cages were completely cleaned of food at 0900h and the afternoon meal was not given to individual animals on the day they were studied. One of the studies served as the control (food restricted group) and during the other, 2 mg (n = 4) or 0.3 mg (n = 3) of recombinant human leptin was administered intravenously during 2000–0100h (food restricted plus leptin group). Blood samples (1 ml) were collected through the indwelling catheter and immediately transferred from the plastic syringe into chilled glass tubes containing 10 μl 14% EDTA. The samples were centrifuged at 5‐h intervals and the plasma withdrawn and stored frozen at − 20°C in polypropylene vials until assays were performed.

MEASUREMENTS

Bioactive LH was determined and testosterone, cortisol and leptin were measured by radioimmunoassay.

RESULTS

During daytime experiments in these animals, LH pulses were sometimes observed late in the day and generally continued for 12–15 h. Food‐restricted pubertal males showed delayed or absent LH pulses. Short‐term leptin administration to food‐restricted male rhesus macaques had no effect on LH, testosterone, or cortisol levels either during or after the infusion. Leptin also had no direct effect on basal or LH‐stimulated testosterone production in Leydig cells.

CONCLUSIONS

Our data support the notion that leptin is not the missing signal for the acute suppression of reproductive hormones secretion in food‐restricted primates.
Differences in the levels of TSH‐binding inhibitor immunoglobulins in goitrous and agoitrous autoimmune thyroiditis after twelve months of l‐thyroxine therapy
Authors: Khoo  , Eng  , Ho  , Fok
Published: March 2003

OBJECTIVE

The aims were to study the prevalence of TSH binding inhibitor immunoglobulins (TBII) in newly diagnosed patients with autoimmune hypo‐thyroidism, to determine if clinical and biochemical parameters in these patients differed, and to study the course of these antibodies after 12 months of l‐thyroxine (LT4) therapy.

SUBJECTS AND DESIGN

In a prospective study, 111 consecutive patients with newly diagnosed auto‐immune hypothyroidism were enrolled. Patients were divided into groups according to the presence or absence of a goitre and TBII levels. Clinical and biochemical differences in these patients were analysed. Patients were then treated with l‐thyroxine (LT4) for 12 months and changes in their TBII monitored.

MEASUREMENTS

Free T4 and TSH levels were measured at baseline and then 6‐weekly during the titration of LT4 doses. Once TSH levels had normalized, these measurements were performed 3 monthly. TBII levels were measured in patients at baseline and 12 months. Thyroid stimulating blocking antibody (TSBAb) levels were measured 12–18 months after initiation of LT4 therapy.

RESULTS

Twenty patients were TBII‐positive, 10 goitrous and 10 agoitrous. Agoitrous TBII‐positive patients were found to have similar characteristics: these included TBII levels > 100 U/l, potent thyroid stimulating blocking antibody (TSBAb) activity and a tendency for TBII levels to remain unchanged or to rise after LT4 therapy. The degree of hypothyroidism seen in these cases was significantly greater than in all other groups. In contrast, goitrous TBII‐positive patients were heterogenous, most did not have significant TSBAb activity and TBII disappeared in 5 out of 10 cases after a year of LT4 treatment. While TBII disappeared in 6 of the 20 patients after a year, remission of hypothyroidism occurred in only 3 cases.

CONCLUSIONS

The degree of hypothyroidism in agoitrous TSH‐binding inhibitor immunoglobulins‐positive patients appears to be more severe than that seen in other forms of AIT. The differences in thyroid stimulating blocking antiboby activity and response to LT4 therapy in agoitrous and goitrous autoimmune thyroiditis suggest that the TSH‐binding inhibitor immunoglobulins in these patients are fundamentally different. The disappearance of TSH‐binding inhibitor immunoglobulins in hypothyroid patients was not accompanied by the reversal of hypothyroidism in 50% of patients.
Reduced human growth hormone (hGH) bioactivity without a defect of the GH‐1 gene in three patients with rhGH responsive growth failure
Authors: Binder  , Benz  , Elmlinger  , Pflaum  , Strasburger  , Ranke
Published: March 2003

BACKGROUND

A GH deficiency‐like phenotype with normal or high hGH secretion, pathologically low IGF‐I serum levels, and catch‐up growth under treatment with recombinant hGH is suggestive of the presence of biologically inactive hGH syndrome, whose presumably heterogenous molecular basis is substantially unknown.

DESIGN

Serum samples from patients who fulfilled the above criteria and from controls with idiopathic short stature were measured by polyclonal hGH‐RIA, Nb2 rat lymphoma proliferation assay, and hGH immunofunctional assay (IFA). If assays were suggestive of the presence of bioinactive GH, mutational analysis of the hGH‐1 gene was performed.

PATIENTS

Three patients were selected because of clinical and biochemical evidence. At the time of diagnosis mean age was 3.4 (2.2, 3.5, 4.5) years, mean height −3.5 (−2.8, −3.6, −4.2) SD score (SDS) and mean growth rate −1.5 (−1.4, −1.5, −1.6) SDS. Mean IGF‐I serum levels were −1.9 (−0.7, −2.4, −2.5) SDS and mean IGFBP‐3 serum levels −1.2 (−1.1, −1.2, −1.2) SDS. Stimulated and spontaneous GH peaks measured by a polyclonal radioimmunoassay were all above 14 μg/l. GHBP serum levels were normal, and antihGH antibodies were not detected. Therapy with rhGH was effective in causing catch‐up growth of the three children with an initial mean growth rate of + 2.9 (+ 1.7, + 2.1, + 5.0) SDS, and normalization of IGF‐I (mean: −0.66 SDS: −1.8, − 1.2, + 1.1 SDS) and IGFBP‐3 serum levels (mean: + 0.81 SDS: −0.2, + 0.8, + 1.8 SDS).

RESULTS

In comparison to controls, the patients' serum hGH levels were much lower when measured by Nb2 rat lymphoma cell proliferation bioassay (mean: −2.3 SDS, range: −1.7– −4.1) and by the immunofunctional assay (IFA) (−1.5 SDS, range: −0.2– −3.1) than by RIA. Retesting of two of the three patients including an one year break of therapy confirmed the rhGH dependence of growth in spite of normal endogenous GH secretion. Radioactive direct sequencing of both strands of PCR‐amplified genomic DNA and cDNA excluded a GH‐1 gene mutation in all three children.

CONCLUSION

Mutations of the GH‐1 gene are probably not the main genetic defect in children with biologically inactive hGH syndrome. Posttranslational processing of hGH might reduce the biological activity of the normal translation product.
Association of the large multifunctional proteasome (LMP2) gene with Graves' disease is a result of linkage disequilibrium with the HLA haplotype DRB1*0304‐DQB1*02‐DQA1*0501
Authors: Heward  , Allahabadia  , Sheppard  , Barnett  , Franklyn  , Gough
Published: March 2003

OBJECTIVE

The large multifunctional proteasome (LMP) molecules are over expressed in thyrocytes, the target cells of Graves' disease, and the LMP genes are found within the MHC class II region. The LMP genes may therefore play a role in susceptibility to Graves' disease. The aim of this this study was to determine whether polymorphisms of the LMP genes, LMP 2 and LMP 7 are in linkage disequilibrium with Graves' disease.

DESIGN

Target DNA was amplified using the polymerase chain reaction. The distribution of an Arg‐His polymorphism in the LMP2 gene and a G/T polymorphism in the LMP 7 gene, both of which lead to the presence of an HhaI restriction site, were investigated in a population based case control and family based study in patients with Graves' disease.

PATIENTS

We obtained DNA from 306 patients with Graves' disease and 364 control subjects for the population based case‐control study. In an independent family based study, DNA was obtained from 129 families including both parents, an affected sibling with Graves' disease and an unaffected sibling. All families, patients and control subjects were white caucasians.

MEASUREMENTS

Frequencies of the alleles and genotypes of the LMP 2 and LMP 7 genes were compared between patients and control subjects using the χ2 test. Transmission of alleles from heterozygous parents to affected and unaffected offspring was assessed using the transmission disequilibrium test (TDT).

RESULTS

In the case control study, no difference in allele or genotype frequency was seen between patients and control subjects at the LMP7 locus. At the LMP2 locus the R allele and the RH genotype were increased in subjects with Graves' disease when compared with control subjects (R allele: 36.3% vs. 29.5%, pc = 0.0164; RH genotype: 56.5% vs. 45%, pc = 0.0102). However, the R allele was in linkage disequilibrium with the associated HLA DRB1*0304‐DQB1*02‐DQA1*0501 haplotype, δ = 0.102. Within the family based study, no preferential allelic transmission was seen from heterozygote parents to offspring at either loci.

CONCLUSION

These results show that association of the LMP 2 locus with Graves' disease is due to linkage disequilibrium with the associated HLA haplotype DRB1*0304‐DQB1*02‐DQA1*0501.
Fetal pituitary negative feedback at early gestational age
Authors: Rakover Yardena , Weiner Ehud , Mosh Netanel , Shalev Eliezer
Published: March 2003

We describe an early prenatal diagnosis and the successful treatment of fetal Graves' disease from transplacental transfer of maternal thyroid stimulating autoantibodies (TSAb). The diagnosis of fetal thyrotoxicosis was made by umbilical cord sampling (UBS) at 20 weeks gestation, based on suppressed TSH with elevated FT4 levels. Therapy with propylthiouracil (PTU) improved fetal thyroid function tests as well as the clinical signs of fetal Graves' disease. Three more UBS were conducted before delivery indicating persisting mild fetal hyperthyroidism.

Undetectable concentrations of thyrotrophin in fetal serum in the presence of markedly elevated FT4, suggests pituitary negative feedback at as early as 20 weeks gestation.

Amniotic fluid thyrotrophin levels were measured at 20,24 and 26 weeks and were shown to correlate better with (elevated) maternal rather than (suppressed) fetal TSH values; therefore, we believe that amniotic fluid thyrotrophin measurement is unreliable for prediction of fetal thyroid status.

Our observation is the first documentation of an intact feedback mechanism so early in fetal development and it suggests that pituitary maturation occurs earlier than previously believed.
Increased prevalence of type 2 diabetes mellitus and impaired glucose tolerance in first‐degree relatives of girls with a history of precocious pubarche
Authors: Ibáñez Lourdes , Castell Conxa , Tresserras Ricard , Potau Neus
Published: March 2003

OBJECTIVE

To assess whether abnormal responses to an oral glucose load, dyslipidaemia and hyperandrogenaemia, which are commonly found in girls with a history of precocious pubarche, can also be detected in first‐degree relatives of these patients.

PATIENTS AND DESIGN

Sixty first‐degree relatives (age, 41.4 ± 4.4 years; BMI, 26.9 ± 3.3 kg/m2) of girls diagnosed with precocious pubarche were studied. The prevalence of gestational diabetes mellitus and the hirsutism score were assessed in the females. The study was performed during the early follicular phase of the menstrual cycle in females and at random in males.

MEASUREMENTS

All subjects underwent a standard 75 g 2‐h oral glucose tolerance test (OGTT). Serum lipids and lipoproteins were measured in baseline blood samples in all subjects, while serum testosterone, sex hormone‐binding globulin (SHBG) levels and the free androgen indices were determined only in females. Impaired glucose tolerance (IGT) and type 2 diabetes mellitus were diagnosed according to the criteria of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.

RESULTS

Seven subjects (11.6%) had type 2 diabetes while a further 14 (23.3%) had IGT; prevalences significantly higher than those reported for the present population of the same age (type 2 diabetes, 2.5% and IGT, 7.5%; P < 0.001 and P < 0.001, respectively). BMIs were similar in patients with either normal or abnormal glucose tolerance. Abnormal levels of at least two lipid parameters were found in 40% of subjects. Four out of 10 hirsute women and six non‐hirsute women reported gestational diabetes. Mean serum SHBG levels were lower in female relatives compared with population controls (P < 0.0005).

CONCLUSIONS

First‐degree relatives of girls with precocious pubarche are at a higher risk of impaired glucose tolerance and type 2 diabetes which, in most cases, is accompanied by an unfavourable lipid profile. Hyperandrogenism and an increased prevalence of gestational diabetes mellitus are frequent among females. These data may prove useful in identifying a specific subset of the population at increased risk of developing metabolic disturbances known to predispose to cardiovascular disease.
RAD51 as a candidate parathyroid tumour suppressor gene on chromosome 15q: absence of somatic mutations
Authors: Carling Tobias , Imanishi Yasuo , Gaz Randall D. , Arnold Andrew
Published: March 2003

OBJECTIVE

Loss of heterozygosity (LOH) at chromosome 15q is frequent in parathyroid adenomas, but no tumour suppressor gene of importance to parathyroid tumour development has been isolated from this region. The RAD51 gene has been localized to chromosome 15q and possesses regulatory functions involving DNA stability and cell proliferation, suggesting its possible role in tumorigenesis. Additionally, mutations in the RAD51 gene cause reduced resistance to ionizing radiation, which is a major risk factor for primary hyperparathyroidism. RAD51 was therefore analysed as a candidate tumour suppressor gene in a group of parathyroid adenomas for which mutations in a 15q tumour suppressor should be most readily detectable.

PATIENTS AND DESIGN

From a total of 55 parathyroid adenomas, nine were selected based on their LOH pattern showing DNA loss at chromosome 15q in the vicinity of the RAD51 gene. RAD51 mRNA expression was investigated by reverse transcription–polymerase chain reaction (RT‐PCR), and sequence analysis of the entire coding region of the RAD51 cDNA was performed in all nine adenomas.

RESULTS

RAD51 mRNA expression was substantiated in all parathyroid adenomas. Compared with the normal RAD51 cDNA sequence, no point mutations or microdeletions could be found in the parathyroid tumor cDNA.

CONCLUSION

These observations suggest that somatic inactivating mutations of the RAD51 gene are uncommonly, if ever, associated with parathyroid tumourigenesis.
Mutations in intron 3 of GH‐1 gene associated with isolated GH deficiency type II in three Japanese families
Authors: Kamijo Takashi , Hayashi Yoshitaka , Shimatsu Akira , Kinoshita Eiichi , Yoshimoto Masaaki , Ogawa Masamichi , Seo Hisao
Published: March 2003

OBJECTIVE

Isolated GH deficiency (IGHD) type II is a disorder inherited in an autosomal dominant manner. Three mutations at the donor splice site of intron 3 of the GH‐I gene have been identified in five families. In this report, we describe a novel mutation also at the donor splice site of intron 3 in patients with IGHD type II.

PATIENTS

Five individuals diagnosed as IGHD: two sporadic cases and one family with three affected individuals (two siblings and their father).

MEASUREMENT

Genomic DNA was extracted from peripheral mononuclear cells. All the exons and introns of the GH‐I gene were amplified by polymerase chain reaction (PCR) and subjected to sequence analysis.

RESULTS

A guanine to adenine transition at the fifth base of intron 3 (mutE), which has not been reported, was identified in the familial case but not in unaffected members of the family including the paternal grandparents. In the other two families with sporadic cases, a guanine to adenine transition at the first base of intron 3 (mutA) was identified in the affected subjects but not in other members of the families.

CONCLUSION

MutE has not been previously reported and is the fourth mutation associated with IGHD type II. The guanine residue mutated in mutA was the second nucleotide of a CpG dinucleotide, which is regarded as a hot spot for mutations by a methylation‐deamination mechanism. Since mutA has previously been identified in three type II IGHD kindreds belonging to different ethnic backgrounds, this appears to be the most frequent GH‐I gene mutation in IGHD with a dominant inheritance. Because de novo mutations appeared to have occurred in all three families analyzed in the present study and the presence or absence of these mutations can easily be tested by PCR and restriction enzyme digestion, not only the familial cases but also sporadic cases with IGHD should be examined for a possible mutation at the donor splice site of intron 3 in the GH‐1 gene.
Hexarelin as a test of pituitary reserve in patients with pituitary disease
Authors: Korbonits Márta , Kaltsas Gregory , Perry Leslie A. , Grossman Ashley B. , Monson John P. , Besser G. Michael , Trainer Peter J.
Published: March 2003

BACKGROUND

The insulin tolerance test (ITT) is the reference standard for the diagnosis of cortisol and growth hormone (GH) deficiency, but problems have occurred in small children in inexperienced hands and it is contraindicated in patients with cardiac disease and epilepsy. Hexarelin is a growth hormone‐releasing peptide with GH‐, ACTH/cortisol‐ and prolactin‐releasing effects which involve both hypothalamic and direct pituitary mechanisms. We therefore investigated whether it could be used to test GH and ACTH/cortisol reserve in patients with pituitary disease.

METHODS AND SUBJECTS

The changes in GH and cortisol in response to insulin‐induced hypoglycaemia (intravenous human Actrapid 0.15 IU/kg) and hexarelin (2 μg/kg) in 19 patients with possible pituitary disease (5 males, mean age 39 years, range 21–70) were compared. The patients' responses during the hexarelin test were also compared to normal ranges of GH and cortisol responses established in healthy volunteers following hexarelin administration.

RESULTS AND DISCUSSION

GH peak levels were significantly higher after hexarelin than after hypoglycaemia (mean ± SEM; 67.1 ± 16 vs. 26.9 ± 6.8 mU/l respectively; P < 0.001), while cortisol levels were significantly lower (420 ± 34 vs. 605 ± 50 nmol/l; P < 0.001). The peak responses of both hormones correlated significantly between the hexarelin and insulin‐induced hypoglycaemia tests (r = 0.80, P < 0.001 for cortisol). Peak GH levels after hexarelin and ITT showed a significant positive correlation with IGF‐I levels (r = 0.84 and r = 0.77, P < 0.001 for both). All patients with a subnormal GH response to hexarelin (<41.4 mU/l) had a peak GH response to ITT of <9 mU/l, and only one patient had a normal (although borderline) response to hexarelin with a subnormal GH response to the ITT. Although 17 of the 19 patients had corresponding cortisol responses to hexarelin and the ITT test (either failing or passing both), two patients had normal cortisol responses to hexarelin but subnormal responses to the ITT. A peak serum cortisol level following hypoglycaemia of >580 nmol/l is indicative of normal cortisol reserve, as established in patients undergoing surgery; only five of the normal volunteers and one of the thirteen patients with a normal ACTH/cortisol reserve on ITT had a peak cortisol >580 nmol/l in response to hexarelin.

CONCLUSION

Adult patients who have a subnormal peak GH response to hexarelin are likely to be GH deficient on an insulin tolerance test. However, our data suggest that the hexarelin test is not a useful test of ACTH/cortisol reserve. The hexarelin test could be a useful first/screening test to diagnose adult GH deficiency, particularly in patients in whom an insulin tolerance test is contraindicated or who are already ACTH deficient and in whom the GH reserve alone is of interest.
Pseudohypoparathyroidism — another monogenic obesity syndrome
Authors: Ong Ken K. L. , Amin Rakesh , Dunger David B.
Published: March 2003

Obesity is a common feature of pseudohypoparathyroidism (PHP) type 1a, but is usually associated with short stature. We describe two children referred because of hyperphagia and excessive weight gain from early infancy. Tall stature in both children initially confounded the diagnosis of PHP, but on follow‐up both children developed the typical hormonal abnormalities and Case 2 developed typical skeletal features of Albright hereditary osteodystrophy.  PHP type 1a is caused by germline loss of function mutations in the α subunit of GS, the ubiquitously expressed G protein that couples many hormone receptors to the adenylate cyclase second messenger system. Recent evidence suggest that the hypothalamic GS protein coupled melanocortin‐4 receptor (MC4R) may mediate the central effects of leptin on inhibition of satiety. Similar patterns of infancy onset hyperphagia, excessive weight gain and tall stature are seen in subjects with congenital leptin deficiency and in subjects with MC4R mutations.  We suggest that the genetic mutations in GSαwhich underlie PHP type 1a may also directly result in severe obesity. This diagnosis should be considered in any child with a history of hyperphagia and early onset morbid obesity.
Increased urinary albumin excretion in Cushing's syndrome: remission after correction of hypercortisolaemia
Authors: Koh  , Kim  , Chung  , Park  , Shong  , Hong  , Kim  , Lee
Published: March 2003

OBJECTIVES

Increased urinary albumin excretion (UAE) in diabetic and nondiabetic subjects is frequently associated with insulin resistance syndrome and central obesity. Cushing's syndrome is also characterized by central obesity and insulin resistance. This study was undertaken to see whether increased UAE is found in Cushing's syndrome.

DESIGN

Cross‐sectional study.

PATIENTS

Thirteen consecutive patients with Cushing's syndrome.

MEASUREMENTS

Patients collected three overnight urine samples for the measurement of UAE by radioimmunoassay. UAE was also measured in 479 nondiabetic subjects who comprised the control population for this study. In the patients who had initial microalbuminuria, UAE was remeasured 2 months after successful removal of pituitary or adrenal tumours. Kidney biopsy was performed in three patients during adrenalectomy.

RESULTS

Eleven out of 13 patients (84.6%) had increased UAE (> 9.6 μg/min), and eight patients (61.5%) had microalbuminuria or overt proteinuria (> 20 μg/min). Kidney biopsy revealed apparently normal glomerular structures without evidence of diabetic nephropathy. After correction of hypercortisolaemia, UAE declined profoundly in all of the patients.

CONCLUSIONS

More than 80% of patients with Cushing's syndrome had increased UAE. This was almost completely reversed after successful treatment of hypercortisolaemia. These results indicate that endogenous hypercortisolaemia increases UAE by a mechanism that is presently unknown.
A novel mutation in the pendrin gene associated with Pendred's syndrome
Authors: Bogazzi Fausto , Raggi Francesco , Ultimieri Federica , Campomori Alberto , Cosci Chiara , Berrettini Stefano , Neri Emanuele , La Rocca Roberto , Ronca Giovanni , Martino Enio , Bartalena Luigi
Published: March 2003

OBJECTIVE

Pendred's syndrome is an autosomal recessive disorder characterized by goitre, sensorineural deafness and iodide organification defect. It is one of the most frequent causes of congenital deafness, accounting for about 10% of hereditary hearing loss. It is caused by mutations in the pendrin (PDS) gene, a 21 exon gene located on chromosome 7. The aim of this study was to examine an Italian family affected with Pendred's syndrome at the molecular level.

PATIENTS

Thirteen subjects belonging to a family from Southern Italy were evaluated for the clinical and genetic features of Pendred's syndrome.

MEASUREMENTS

Exons 2–21 of the PDS gene were amplified from peripheral leucocytes by the polymerase chain reaction; mutation analysis was performed by single strand conformation polymorphism, direct sequencing and restriction analysis.

RESULTS

The index patient had the classical triad of the syndrome and harboured two mutations in the PDS gene in the form of compound heterozygosity. He was found to be heterozygous for a cytosine to adenosine mutation at nucleotide 1523 in exon 13 and for a IVS 1001 + 1G → A mutation. The former is a novel mutation which results in a change of 508 threonine to asparagine in the putative eleventh transmembrane domain. The latter mutation in the donor splice site has already been described in other patients and is thought to lead to aberrant splicing and premature protein truncation. Three subjects who were heterozygous for one mutation had normal phenotypes. Two subjects had sensorineural deafness and were heterozygous for a single mutation. Goitre was found only in patients with Pendred's syndrome and was absent in all other individuals, albeit residing in an iodine‐deficient area.

CONCLUSIONS

We have identified a novel mutation in the pendrin gene causing Pendred's syndrome, and confirm that molecular analysis is a useful tool for a definitive diagnosis. This is particularly relevant in cases such as in the subjects of our family in which the clinical features might be misleading and other genetics factors might be responsible for deafness.