bluuebunny/crossref_metadata_2025 huggingface dataset:
International Clinical Practice Guidelines for Gender Minority/Trans People: Systematic Review & Quality Assessment. How Does the Endocrine Society Fare?
Authors: Bewley Susan , Dahlen Sara , Connolly Dean , Arif Isra , Junejo Muhammad , Catherine Meads
Published: May 2021

Aim: High quality care depends on evidence being used in clinical practice guidelines (CPGs) & processes to create recommendations. This study identified & critically appraised published international CPGs regarding health care of gender minority/ trans people. Methods: Prospectively registered systematic review(1); searched 6 databases & 6 CPG websites & approached international key opinion leaders; quality assessment using AGREE II, Appraisal of Guidelines for Research & Evaluation tool(2); & stakeholder domain prioritization. CPGs relating to gender minority/ trans adults &/or children were included, with any health-related intervention connected to their care & no exclusions for comorbidities except differences in sex development. Outcome measures: number & quality of relevant international CPGs, information on estimated changes in mortality or quality of life (QoL), recommendation consistency across CPGs & appraisal of key messages for patients. Results: A 2017 Endocrine Society Guideline(3) was one of 12 international CPGs found. Five higher-quality CPGs focused on HIV & other blood-borne infections (overall assessment scores 69-94%). Six lower-quality CPGs concerned transition-specific interventions (overall assessment scores 11-56%). None dealt with primary care, mental health, or longer-term medical issues. Sparse information on estimated changes in mortality & QoL was conflicting. None provided key messages for patients. Endocrine Society was ranked 6th by overall assessment score (56%), the highest of CPGs addressing transition-related care. Domain scores were; scope & purpose 65%, stakeholder involvement 40%, rigour of development 41%, clarity & presentation 73%, applicability 29%, editorial independence 65%. Conclusion: Future iterations of the Endocrine Society CPG might be strengthened by referencing AGREE II, greater use of systematic reviews, considering applicability, independent external review, encouraging stakeholder participation & producing patient facing material. Lack of primary research into gender minority/trans health was noted & ought to be addressed.

References: 1. PROSPERO CRD42019154361, 2. AGREE Next Steps Consortium (2017) The AGREE II Instrument [Electronic version]. http://www.agreetrust.org, 3. Hembree WC, Cohen-Kettenis PT, Gooren L, et al (2017) Endocrine treatment of gender-dysphoric/ gender-incongruent persons: An endocrine society clinical practice guideline. J Clin Endocrinol Metab 102:3869-3903
Magnetic Resonance Spectroscopy in Gender Dysphoria
Authors: Collet Sarah Marie , Bhaduri Sourav , Kiyar Meltem , Mueller Sven , T’sjoen Guy G
Published: May 2021

Background: Much research has been conducted on sexual dimorphisms of the human brain to determine whether and to what extent a brain gender exists. Consequently, a variety of studies using different neuroimaging techniques attempted to identify the existence of a brain phenotype in people with gender dysphoria (GD). However, to date, brain sexual dimorphisms at the metabolite level in transgender people have not been explored using magnetic resonance spectroscopy (1H-MRS). Methods: In this study, 29 transgender men, 30 cisgender men and 35 cisgender women underwent 1H-MRS at 3 Tesla MRI to characterize common brain metabolites. Specifically, absolute levels of N –acetyl aspartate (NAA), choline (Cho), creatine (Cr), glutamate (Glu), myo-inositol (mI) and their respective ratios were assessed in two brain regions, i.e. the amygdala-anterior hippocampus and the lateral parietal cortex. Influences of nicotine consumption, physical activity, education and psychopathology were considered. Results: The results indicated a sex-assigned at birth pattern for choline and glutamate ratios in the amygdala-anterior hippocampus of trans men. In the lateral parietal cortex cis men and cis women differed in the majority of metabolites (i.e. mI; Cr; NAA/Cr; Cho/Cr; mI/Cr; NAA/mI). Moreover, except for mI, trans men did not differ from either cisgender group, showing a pattern subtly moving towards the experienced gender identity. Post-hoc, careful exploration of the age of onset of GD in transgender men demonstrated the possibility of a developmental trend in absolute NAA levels, as a measure of neuronal function. Conclusion: We found sex-typical 1H-MRS spectra and they appear to be brain region specific. While the brain metabolite levels in trans men mostly resembled that of cis women, interesting findings such as modulation by age of onset warrant future enquiry to address potential neurobiological underpinnings of GD.
Understanding, Communication and Concerns Around Sexual Development Differences by Patients’ Perspectives
Authors: Lousada Lia Mesquita , Domenice Sorahia , Costa Elaine Maria Frade , Bachega Tania A , Batista Rafael Loch , Fontenele Eveline Gadelha Pereira , Mendonca Berenice Bilharinho
Published: May 2021

Introduction: The approach to Differences of Sexual Development (DSD) patients is complex. It involves discussion on karyotype, gonads, genital phenotypes, hormonal treatment, genitoplasty, sexual activity and fertility. A satisfactory understanding by the patients optimize the follow up and the acceptance of the condition. Objective/Methods: To analyze the understanding of DSD patients about their condition, the doubts and concerns, the barriers to communication and repercussion in gender, sexual orientation and relationships in a cohort of patients followed at a reference center, through a semi directed interview. Results: 57 patients were interviewed. The mean ages were 36.5y. Around 90% of all patients concluded at least the high school. Only 50% of all patients knew the condition’s name and how they were affected by it. Still 92% knew the treatment. 63% of the patients presented doubts, mainly related to diagnosis. The median level of satisfaction about the condition understanding (on a scale from 1 to 5) was 4. Most of the patients were first informed by doctors (65%) or mothers (27%). The mean age of diagnostic disclosure was 13 y among patients with atypical genitalia. However, 67% of them preferred be first informed in childhood. Around communication, 60% of them reported no dialogue at home about the condition, 82% feel uncomfortable in talking to other people and 57% experienced negative comments related to DSD. Only four 46,XY DSD presented gender dysphoria: 3 with partial gonadal dysgenesis (who were admitted at the reference service after genitoplasty) and one 5-α-reductase 2 deficiency. About affective relationships, 42% of the patients were single and 70% had already experienced sexual activity. The mean age at first sexual activity was 22y. 72% considered that condition influences negatively on relationships because the stigma, the genitalia appearance, the insecurity in sexual intercourse and fertility. The concern related to stigma was higher among patients with atypical genitalia. The patients’ self-evaluation (scale from 0 to 10) about their condition understanding improved after the interview: 6 to 8.9 (p<0.01). Conclusion: There is lack of knowledge about DSD among patients even treated in a referral center. The atypical genitalia arouses curiosity and stigma. Educational acts for patients, health team and community are needed to make DSD conditions popular, to improve the understanding and communication and to decrease the stigma.
AR Is Not an Independent Marker for TNBC: The Lesson We Learn From Two PDX Models
Authors: Wang Xiaoqiang , Petrossian Karineh , Huang Miao-Juei , Saeki Kohei , Kanaya Noriko , Chang Gregory , George Somlo , Chen Shiuan
Published: May 2021

Extensive efforts, through cell line-based models, have been made to characterize the androgen receptor (AR) signaling pathway in triple-negative breast cancer (TNBC). However, these efforts have not yet reached a consensus with regards to the mechanism of AR in TNBC. On the other hand, patient-derived xenografts (PDXs) are generally considered more appropriate than cell line-based models for recapitulating the structural and molecular features of a patient’s tumor, but only a few have been reported to be AR-positive TNBC. In our study, we identified and molecularly characterized two new, AR-positive TNBC PDX models and assessed the impacts of AR agonist (DHT) and antagonist (enzalutamide) on tumor growth and gene expression profiles by utilizing immunohistochemistry (IHC), western blots, and RNA-Seq and TNBC subtyping analyses. Two PDX models, termed TN1 and TN2, were derived from two grade 3 TNBC tumors, each containing 1~5% of AR positive tumor cells. DHT activated AR in both PDX tumors by increasing AR nuclear localization and protein levels. However, the endpoint tumor volume of DHT-treated TN1 was 3-folds smaller than that of non-treated TN1 tumors. Conversely, the endpoint tumor volume of DHT-treated TN2 was 2-folds larger than that of non-treated TN2. Moreover, enzalutamide failed to antagonize DHT-induced tumor growth in TN2. The RNA-Seq analyses revealed that DHT suppressed gene expression in TN1 (961 down-regulated genes versus 149 up-regulated genes), while the DHT promoted gene expression in TN2 (673 up-regulated genes versus192 down-regulated genes). TNBC subtyping analyses based on RNA-Seq data predicted distinct molecular subtypes of TN1 and TN2: TN1 correlated to a basal-like 1 (BL1) subtype, and TN2 correlated to a basal-like 2 (BL2) subtype. These analyses suggest that TN1 and TN2, which both express functional AR, are two molecularly distinct PDX models that expand our current knowledge of AR-positive TNBC. Our results do not support that AR is a suitable therapeutic target in TNBC. To our best knowledge, the molecular mechanisms of AR in TNBC are equivocal and should be evaluated using clinically relevant models, considering both the heterogeneous expression of AR in TNBC and the general complexities of AR signaling.
Investigating the Role of Farnesoid X Receptor in Heme Biosynthesis and Ductular Reaction
Authors: Dean Angela E , Jungwirth Emilian , Panzitt Katrin , Wagner Martin , Anakk Sayeepriyadarshini
Published: May 2021

Bile acids (BAs) have gained traction not just as emulsifiers of fat, but also as hormones. Nuclear receptor Farnesoid X receptor (FXR) is the master regulator of BAs and can also control glucose and lipid metabolism. We examined if FXR contributed towards heme biosynthesis and induction of a ductular reaction. Male and female whole body Fxr knockout (FxrKO) mice, as well as liver- and intestine-specific knockouts (LFxrKO and IFxrKO, respectively) were treated with 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC, a ferrochelatase inhibitor) for two weeks. At the end of the two weeks, mice were fasted for four hours and euthanized. All groups of mice had lost a similar percentage of body weight when fed the DDC diet. However, female FxrKO mice had significantly increased liver to body weight ratio, while male FxrKO mice had significantly decreased liver to body weight ratio when fed the DDC diet compared with their wild type counterparts. Serum liver injury markers were analyzed and liver histology and changes in genes involved in the heme biosynthesis pathway were examined. Both male and female whole body FxrKO livers had decreased ductular reaction with minimal bile plugs (porphyrin accumulation) compared with their wild type counterparts. LFxrKO mice mimicked diminished ductular reaction, while IFxrKO mice exhibited severe ductular reaction similar to that of wild type mice, indicating that the ductular reaction is dependent on hepatic FXR. ChIP-Seq for FXR revealed binding peaks in the heme biosynthesis genes, Alas1, Alad, Uros, and Fech, suggesting that FXR may act as a transcription factor for these genes. Further investigation revealed that Pbgd gene expression was increased, while Fech gene expression was decreased in female FxrKO mice compared to wild type mice. In male mice, Pbgd, Uros, Urod, and Cpox gene expression was increased in the absence of Fxr. In conclusion, Fxr is necessary to mount a ductular reaction and plays a key role in heme biosynthesis in the liver.
RNA-Binding Protein Musashi-2 Inhibits Aldosterone Production
Authors: Bartholomay Kathryn , Baldwin Amber , Mukherjee Neelanjan
Published: May 2021

The adrenal cortex is the site of steroid hormone synthesis. These hormones control important physiological processes like metabolism, blood pressure and volume, and sexual characteristic development. While the signaling pathways, transcription factors, and steroidogenic enzymes are well-characterized, surprisingly little is known about the contribution RNA-binding proteins (RBPs). RBPs exert post-transcriptional control by interacting with specific elements within target mRNAs. Here we focus on the RBP, Mushashi-2 (MSI2), which binds to UAG sequences in the 3’UTR of its target transcripts. MSI2 is required for development of steroidogenic tissues which is consistent with its higher mRNA levels in human ovaries and testis. MSI2 also exhibits high expression levels in human adrenal tissue and the immortalized human adrenocortical cell line (H295R). Based on the compelling MSI2 expression pattern, we set out to determine the role of MSI2 on aldosterone production. Depletion of MSI2 using siRNA led to significantly lower aldosterone levels in H295R cells stimulated with AngII. We also employed an orthogonal loss-of-function approach by co-treating cells with AngII and increasing concentrations of Ro-08-2750 (Ro), a direct and selective inhibitor of MSI2-RNA interactions. Ro inhibited aldosterone production in a dose-dependent manner at 1 µM with almost complete inhibition at 5 µM. The molecular mechanism by which MSI2 regulates target RNA translation and/or decay is unknown. Moreover, whether MSI2 acts as a repressor or activator appears to be context dependent. Our goal is to determine the precise molecular mechanism by which MSI2 promotes aldosterone production. Specifically, we will identify MSI2 targets, temporally resolved consequences of MSI2 inhibition, and protein interaction partners. This work will impact our understanding of fundamental principles of RBP-mediated regulation, as well as novel regulatory mechanisms underlying human steroid hormone synthesis. Indeed, Ro (or further optimized compounds) may represent new therapeutic avenues for adrenal disease.
Spiral Steroids During Pregnancy - It’s All About Potassium
Authors: Chasalow Fred I
Published: May 2021

This presentation has two parts. The 1st section describes processes during pregnancy with unknown, underlying biochemistry. The 2nd section shows the role of spiral steroids (SS) in these processes. 1] Fetal nutrition is provided through the placenta. Plasma electrolytes are 145 mM Na+ and 3-5 mM K+. Fetal K+ requirements reach a maximum during the 3rd trimester and must be pumped into cells against the plasma- intracellular gradient. 2] During the 3rd trimester, aldosterone is present in fetal plasma but the signal for endothelial sodium channel (ENaC) synthesis is blocked, leading to fetal Na+ wasting. The mechanism is unknown. 3] After parturition, infants are fed by nursing. Human milk contains 100 mM K+ and 10 mM Na+. Newborn infants are Na+ wasting, despite normal levels of aldosterone. Na+ wasting ends during the 2nd week post-partum without change in serum aldosterone levels. Infant physiology changes from K+ saving to Na+ saving by an unknown mechanism.4] Pre-eclampsia syndrome (proteinuria and hypertension during the 2nd half of pregnancy) affects 3-5 % of pregnant women. These symptoms usually resolve after parturition. 5] Women who have had pre-eclampsia have long-term, excess risk of cardiac and renal disorders.

In 2018, we discovered Ionotropin, a SS. SS are phosphocholine esters of steroids with a lactone E-ring, similar to that of spironolactone. SS compounds function as aldosterone antagonists and regulate the NaK-ATPase. SS are involved in each of the 5 steps.1] SS are present in high levels in cord serum and were probably present in fetal plasma throughout gestation. SS stimulate the NaK-ATPase to pump K+ into cells against the gradient, just as does spironolactone.2] SS interfere with aldosterone signaling, just as does amiloride. This leads to increased fetal Na+ wasting, which becomes amniotic fluid.3] SS disappear from the infant circulation during the 1st week after parturition and decrease to adult levels during the 2nd week post-partum. Simultaneously, Na+ wasting ends and growth resumes.4] Women with pre-eclampsia have excess precursors for SS. These would be converted to SS in the fetal-placental unit and, during the 3rd trimester, diffuse into the maternal circulation and could cause pre-eclampsia.5] Ouabain, a plant toxin with a lactone E ring, causes renal and cardiac disorders in rat models. In women with pre-eclampsia, persistent excess SS may cause long-term damage.

During gestation, the fetus requires K+ for growth. Our theory is, if (when) a fetus has inadequate K+ (hypokalemia), [a] the mother is signaled to produce SS precursors, [b] the feto-placental unit converts the precursors to SS, [c] fetal SS increase K+ transfer into tissues, and [d] excess SS transfuse back into the maternal circulation and damage maternal organs. We propose that pre-eclampsia is a side effect of fetal efforts to increase supply of K+. There are many possible origins of fetal hypokalemia.
Time of Day Regulates Renal Mineralocorticoid Receptor Transcriptional Control of Electrolyte Balance
Authors: Kanki Monica , Morgan James , Fuller Peter J , Young Morag Jennifer
Published: May 2021

The mineralocorticoid receptor (MR) has an established role in blood pressure control and cardiovascular homeostasis via many actions in the heart and kidney. We recently identified a role for the MR in controlling the circadian clock in cardiac cells and demonstrated that time-of-day impacts MR activation in the heart. While time dependent behaviours such as upright posture and fluid intake control aldosterone release via the renin-angiotensin-aldosterone system (RAAS), we hypothesise that the circadian clock controls aldosterone signalling by modifying MR transcriptional outcomes. Two established MR target genes and core circadian clock genes are period 1 (Per1) and period 2 (Per2). We have previously shown that a bolus dose of aldosterone (i.p.) induced cardiac expression of Per1 and Per2 in wildtype mice treated at 8AM (start of rest period) but not when administered at 8PM (start of active period). Whether MR activation in the kidney is similarly dependent on time of day and aligns with MR actions in the heart remains to be assessed. We also sought to determine if the MR directly regulates the molecular clock in a ligand-dependent manner. In contrast to the heart, renal Per1 and Per2 expression was not upregulated at four hours following aldosterone administration at either 8AM or 8PM. Interestingly, aldosterone administered at 8AM, but not at 8PM, significantly down-regulated expression of the circadian clock gene, nuclear receptor reverse strand c-ERBA (ReverbA); ReverbA was not regulated in the heart following aldosterone treatment. Investigation of renal-MR target genes involved in sodium ion transfer, showed a down-regulation of epithelial sodium channel 1 alpha (ENaC-α), by aldosterone administered only at 8AM. Conversely, aldosterone administered at 8AM induced gene expression of FKBP Prolyl Isomerase 5 (Fkbp5), an immunophilin that is important in nuclear trafficking of the MR. These data provide new insights for tissue sensitivity to MR activation in the heart and the kidney, which may play differing roles in contributing to regulating circadian patterns of several cardiovascular and renal parameters. Moreover, our data suggest that in addition to the accepted entrainment role of the glucocorticoid receptor (GR), the MR may also play a role in the entrainment of the circadian clock in peripheral tissues. Ongoing mechanistic studies will determine whether the MR can directly control the periodicity of the renal cellular clock, as it does in the heart. Key outcomes will be assessed in population databases to determine the clinical relevance of these findings. We propose that understanding of time-of-day dependent vulnerability to MR signalling in the heart versus the kidney may offer the rationale for the development of novel temporal or tissue specific-MR modulators in the management of cardiovascular disease.
Vitamin D and Lumisterol Hydroxyderivatives Can Act on Liver X Receptors (LXRs)
Authors: Slominski Andrzej , Kim Tae-Kang , Qayyum Shariq , Song Yuwei , Janjetovic Zorica , Oak Allen , Slominski Radomir , Raman Chander , Stefan Joanna , Mier-Aguilar Carlos , Atigadda Venkatram , Crossman David , Golub Andriy , Bilokin Yaroslav , Tang Edith , Tuckey Robert C , Jetten Anton M , Song Yuhua
Published: May 2021

New pathways of vitamin D3 (D3) activation initiated by CYP11A1 and involving other CYPs have been discovered. At least 15 hydroxyderivatives, including 20(OH)D3 as the major product, are generated by these pathways (1,2) with some being present in human serum, epidermis, and pig adrenals. CYP11A1 can also metabolize 7-dehydrocholesterol to produce 7-dehydropregnenolone, which can be further modified by steroidogenic enzymes generating Δ7-steroids (1,2). Lastly, CYP11A1 and CYP27A1 act on lumisterol (L3) producing at least 9 biologically active derivatives (1,2). Thus, new pathways generating a large number of biologically active secosteroids and lumisterol-derivatives have now been described. These compounds interact with the vitamin D receptor (VDR), retinoic acid receptors (RORs) α and γ, and the aryl hydrocarbon receptor (AhR)(1). These findings challenge dogmas that lumisterol is biologically inactive and that 1,25(OH)2D3 is the only active form of D3 exerting its effects exclusively through interaction with the VDR. In view of the above and since liver X receptors (LXRs) can be activated by oxysterols, we investigated the interactions of novel products of L3 and D3 metabolism with LXRs. Molecular docking, using crystal structures of the ligand binding domains (LBDs) of LXRα and β, revealed high docking scores for L3 and D3 hydroxymetabolites, like those of the natural ligands, predicting good receptor binding. RNA sequencing of murine dermal fibroblasts stimulated with D3-hydroxyderivatives revealed LXR as the second major nuclear receptor signaling pathway for several D3-hydroxyderivatives, including 1,25(OH)2D3. The involvement of LXRs was validated by the induction of several genes downstream of LXR. Furthermore, L3 and D3-hydroxyderivatives activated an LXR-response element (LXRE)-driven reporter in CHO cells and human keratinocytes. For keratinocytes, enhanced expression of LXR target genes was also observed supporting the involvement of LXR. Importantly, L3 and D3 derivatives showed high affinity binding to the LBD of the LXRα and β in LanthaScreen TR-FRET LXRα and β coactivator assays. The majority of metabolites functioned as LXRα/β agonists; however, 1,20,25(OH)3D3, 1,25(OH)2D3, 1,20(OH)2D3 and 25(OH)D3 acted as inverse agonists of LXRα, but as agonists of LXRβ. Molecular dynamics simulations performed for selected compounds, including 1,25(OH)2D3, 1,20(OH)2D3, 25(OH)D3, 20(OH)D3, 20(OH)L3 and 20,22(OH)2L3, showed overlapping and different interactions with LXRs. Identification of D3 and L3 derivatives as ligands for LXRs changes the accepted paradigms on their biological role and mechanism of action. 1. Cell Biochem Biophys. 2020;78(2):165-180. 2. J Steroid Biochem Mol Biol. 2019;186:4-21.
Daily Versus Weekly Levothyroxine Tablet Replacement in Adults With Hypothyroidism: A Meta-Analysis
Authors: Chang Chiu Harold Henrison , Larrazabal Ramon Bagaporo , Uy Angelique Bea Cariaga , Jimeno Cecilia A
Published: May 2021

Background and Objectives: Hypothyroidism is a common hormone deficiency with a prevalence ranging from 4-5% worldwide. It is a very treatable condition with treatment in the form of thyroid hormone replacement, with an overall excellent prognosis if patients are compliant to regular treatment. Daily levothyroxine (LT4) is the treatment of choice and standard of care, sufficient to restore the thyroid stimulating hormone (TSH) to the normal range. For many patients, daily and lifelong therapy is required, and compliance/adherence then becomes a major issue. In such cases, weekly replacement may be a suitable alternative in terms of improving patient compliance. In this study, we aimed to determine the efficacy and safety of weekly versus daily levothyroxine replacement in patients with hypothyroidism.

Methods: Electronic databases were searched, supplemented with manual searches. Two reviewers independently screened the abstracts, reviewed full-text papers, independently critically appraised the quality of included studies and abstracted the data. A meta-analysis was performed using the random-effects model on randomized controlled trials (RCTs) that reported standard doses of daily versus weekly levothyroxine administration in the treatment of hypothyroidism. The primary outcome is the difference in serum TSH levels between daily versus weekly levothyroxine administration, while secondary outcomes included clinical symptoms and adverse events using the hypothyroidism symptom scale.

Results: The study included two randomized trials (N = 109) in the primary analysis. The difference in TSH levels was 1.78 mIU/mL higher (95% CI: 1.28, 2.28; P < 0.00001) at 6 weeks and 1.22 mIU/mL higher (95% CI: 0.76,1.67; P < 0.00001) at 12 weeks for the weekly replacement regimen, respectively. There was no significant heterogeneity noted between the two groups. There was no significant difference in terms hyperthyroid symptoms and adverse events measured by the hypothyroid symptom scales and echocardiographic parameters, respectively, before and after LT4 within each group.

Conclusions: Our results showed that weekly LT4 administration has less suppression of TSH levels, while still remaining within the reference range of normal. It may be an alternative for patients especially in setting of noncompliance. However, more randomized trials with larger sample sizes and a longer duration of follow-up are needed to firmly establish the definite role of weekly LT4.
The Pitfalls of Using Research Grade Immunoassays for Thyroid Health Measurements
Authors: Boggs Ashley S P , Galligan Thomas M , Kemp Jennifer V , Ravinder Singh J , Grebe Stefan Karl Gunther
Published: May 2021

Introduction: Immunoassay technology is subject to matrix interferences that can produce inaccurate results and incorrect conclusions when using samples not previously validated. While many commercially available research grade (RG) immunoassay kits are available, caution should be applied when using RG kits for thyroid health assessments, particularly on samples from pregnant individuals whose blood chemistry is unique to non-pregnant individuals. Question: Do RG immunoassay kits reliably provide precise and accurate measurements of thyroid health biomarkers in serum Standard Reference Materials (SRMs) from pregnant and non-pregnant donors? Methods: T4, T3, rT3, Tg and TSH measurements were conducted on SRMs 971, Hormones in Frozen Human Serum, and SRM 1949, Frozen Prenatal Serum, using RG immunoassay kits. When available, performance was assessed against validated FDA approved immunoassays or mass spectrometric (MS) methods. Results: RG kits were variable, inaccurate, or imprecise for four of the six biomarkers assessed. RG kit total thyroid hormone measurements overall performed comparably to MS methods, except rT3 measurements, which were twofold greater than mass spectrometric measurements (971M RG mean = 0.51 ng/mL, MS mean = 0.20 ng/mL, p < 0.0001; 971F RG = 0.48 ng/mL, MS = 0.18 ng/mL, p < 0.0001) and had CVs over 30 %. RG kit Tg measurements varied sometimes by as much as tenfold (971M means of 6.50 ng/mL up to 63.3 ng/mL, p < 0.0001; 971F means of 0.350 ng/mL up to 14.5 mg/mL, p < 0.0001). TSH values differed by RG kit manufacturer (971M means of 1.27 µIU/mL up to 1.82 µIU/mL, p < 0.0001; 971F means of 1.36 µIU/mL up to 2.27 µIU/mL, p < 0.0001) and by dilution scheme using the same manufacturer with one case indicating a diagnosis of hypothyroid versus normal TSH levels (1949 non-pregnant undiluted mean = 2325 pg/mL, half dilution mean = 1631 pg/mL, p < 0.0001). Conclusions: RG immunoassays are often used for research projects because they do not require expensive equipment and are simple to conducted. However, we demonstrate here that not all kits are accurate for all patient samples. By utilizing a matrix matched SRM with well-defined quantities of thyroid health biomarkers, one can assess method accuracy, making measurements from different methods comparable. Thereby, data can be harmonized to contribute reliable data on thyroid biomarkers to advance the field of thyroid health.
The Efficacy of Teprotumumab for Chronic, Progressive Thyroid Eye Disease Greater Than 9 Months
Authors: Sears Connie Martin , Kang Julia Y , Cockerham Kimberly , Kossler Andrea L
Published: May 2021

Purpose: To evaluate the efficacy of teprotumumab for the treatment of patients with chronic, progressive Thyroid Eye Disease (TED) who do not meet the inclusion and exclusion criteria used in prior clinical trials. Methods: This is a prospective case series of patients with chronic, progressive TED, defined as ocular symptoms of more than 9 months prior to treatment initiation with teprotumumab, an insulin-like growth factor I receptor inhibitor (10 mg/kg for the first infusion then 20 mg/kg for subsequent infusions, every three weeks for a total 8 infusions). This study included patients with a Clinical Activity Score (CAS) greater than or equal to 4. Data collected included patients’ age, sex, race, baseline thyroid status, thyroid stimulating immunoglobulin, CAS, smoking status, best corrected visual acuity, intraocular pressure, Schirmer’s, pupil exam, extraocular motility, Gorman diplopia score, and exophthalmometer measurements. Pre-infusion and post-infusion external photos in all 9 gazes, orbital imaging (CT or MRI), Humphrey visual fields and optical coherence tomography were obtained when possible.

Results: Ten patients with chronic TED were treated with teprotumumab either as a primary treatment or following other interventions including oral prednisone, intravenous methylprednisolone, orbital radiation, orbital decompression and/or eyelid surgery. The age range was 55 to 79, with 5 female patients and 5 male patients. Four of the patients were African American and 6 of the patients were White/Non-Hispanic. The number of years the patients had been diagnosed with Graves’ disease ranged from 4 to 33 years, with ocular involvement spanning 4 to 15 years. Patients had CT scans of the orbits to document muscle size prior to initiation, and external photos were taken at each visit. All patients improved subjectively after the first infusion and objectively by the fourth infusion. We will report the long-term follow-up after 8 infusions at ENDO2021.

Discussion: Teprotumumab is a fully human monoclonal IgG1 antibody that blocks the IGF-1 receptor, disrupting the cell-to-cell signaling of the immunologic cascade and is independent of the duration or severity of TED. At this time, FDA approval for teprotumumab is for the treatment of TED without any specific restrictions. However, our teprotumumab-treated patients included those who would have been excluded in the phase 2 and 3 clinical trials due to: (1) poor thyroid control, (2) previous orbital surgery, (3) previous therapeutic interventions including steroids and radiation, (4) visual loss due to compressive optic neuropathy or exposure keratopathy and (5) chronic TED greater than 9 months. In our series, we found that teprotumumab was as effective in a wider population of chronic TED patients than included in the clinical trials.
The Immune Microenvironment of Hashimoto’s Thyroiditis Regulates the Glycosylation Modification of IgG
Authors: Cao Yedi , Song Zhijing , Gong Yan , Zhao Keli , Zhao Xue , Huang Youyuan , Qu Chenxue , Li Yan , Gao Ying , Zhang Junqing , Guo Xiaohui
Published: May 2021

Objectives: Elevation of anti-thyroglobulin antibodies that are primarily IgG isotype is a hallmark of Hashimoto’s thyroiditis (HT). As for IgG,it bears two conserved repertoire of N-linked glycans attached to its crystallizable fragment (Fc) at the 297 asparagine residue (Asn297). In our previous study, we found that serum TgAb IgG from HT patients exhibits higher glycosylation levels than those observed from healthy controls. Previous studies confirmed that imbalance of Th1/Th2 and Th17/Treg leading to altered immune microenvironment with elevation of certain cytokines was found in the thyroid tissue of HT, including IFN-γ, TNF-α, IL-21, IL-17A, IL-6, BAFF, APRIL. Thus, the aim of our study was to investigate the influence of the elevated cytokines on the differentiation process of B cells and the glycosylation levels of IgG. Methods: We formed a two-phase culture system in vitro to promote B cells to differentiate to antibody-secreting cells (ASCs). In the process of cell culture, B cells were co-cultured with cytokines as followed: IFN-γ, TNF-α, IL-21, IL-17A, IL-6, BAFF and APRIL. Flow cytometry was performed to identify the percentage of plasmablasts (CD38+CD27high) and plasma cells (CD20-CD138+). ELISA was used to measure the yield of IgG in culture supernatants. The glycosylation levels of secreted IgG under different stimulation conditions were detected by lectin microarray. Results: We found that IL-21, TNF-α and BAFF can significantly promote the differentiation of B cells into ASCs in vitro culture system, and augment the production of IgG to over 4-fold. In addition, cytokines affected the glycosylation modification profile of IgG diversely: 1) IL-21, IL-17A, TNF-α, BAFF significantly increased the glycosylation level of sialic acid of total IgG; 2) IFN-γ significantly increased the level of galactose; 3) IL-21, IL-17A, IFN-γ, BAFF, and APRIL significantly increased the level of mannose; 4) IL-6 significantly decreased the level of sialic acid, galactose and mannose; 5) IL-17A, IFN-γ, TNF-α, BAFF significantly increased the level of GalNAc that was a component of O-Glycan,which only exists in the hinge region of IgG3 subclass. Conclusions: The abnormally elevated cytokines in microenvironment participated in the regulation of B cell terminal differentiation process and glycosylation level of IgG, thereby involving in the pathogenesis of AITD.
Thyroid Immune-Related Adverse Events Among Cancer Patients Treated With Combination of Anti-PD1 and Anti-CTLA4 Immune-Checkpoint Inhibitors: Clinical Course and Outcomes
Authors: Lui David T W , Lee Chi Ho , Tang Vikki , Fong Carol H Y , Lee Alan C H , Chiu Joanne W Y , Leung Roland C Y , Kwok Gerry G W , Li Bryan C W , Cheung Tan To , Woo Yu Cho , Lam Karen S L , Yau Thomas
Published: May 2021

Introduction: Thyroid immune-related adverse events (irAEs) have been reported to have prognostic significance among cancer patients treated with anti-PD1 and anti-PDL1 monotherapies. There are scanty data in the literature thus far about the clinical course and prognostic significance of thyroid irAEs in the routine clinical use of combination anti-PD1/anti-CTLA4 treatment in advanced cancer patients. We evaluated the clinical course and predictors of thyroid irAEs, in relation to outcomes of advanced cancer patients treated with combination anti-PD1/anti-CTLA4. Method: We conducted a territory-wide study and identified advanced cancer patients who received ≥1 cycle of combination anti-PD1/anti-CTLA4 between 2015 and 2019 in Hong Kong. Patients were excluded if (i) they had a history of thyroid disorder or thyroid cancer, (ii) immune checkpoint inhibitor-related endocrinopathies occurred before the commencement of combination anti-PD1/anti-CTLA4, (iii) they were on concurrent tyrosine kinase inhibitor (TKI), (iv) baseline thyroid function tests (TFTs) were absent or abnormal, and (v) the duration of follow-up was <30 days. TFTs were monitored every three weeks. Thyroid irAE was defined by ≥2 abnormal TFTs after initiation of combination anti-PD1/anti-CTLA4 in the absence of other causes. The initial presentation was classified into hypothyroidism (overt if TSH >4.8 mIU/L and fT4 <12 pmol/L; subclinical if TSH >4.8 mIU/L and fT4 12-23 pmol/L) and thyrotoxicosis (overt if TSH <0.35 mIU/L and fT4 >23 pmol/L; subclinical if TSH <0.35 mIU/L and fT4 12-23 pmol/L). Results: One hundred and three patients were included (median age: 59 years; 71.8% men). Around half of patients had hepatocellular carcinoma. About 45% had prior anti-PD1 exposure. Upon median follow-up of 6.8 months, 17 patients (16.5%) developed thyroid irAEs, where 6 initially presented with thyrotoxicosis (overt, n=4; subclinical, n=2), and 11 with hypothyroidism (overt, n=2; subclinical, n=9). Eventually, 10 patients (58.8%) required continuous thyroxine replacement. Systemic steroid was not required in all cases. Prior anti-PD1 exposure (OR 3.67, 95% CI 1.19-11.4, p=0.024) independently predicted thyroid irAEs. Multivariable Cox regression analysis revealed that occurrence of thyroid irAEs was associated with better overall survival (adjusted hazard ratio 0.39, 95% CI 0.19-0.79, p=0.009), independent of prior exposure to anti-PD1 (p=0.386) and prior TKI exposure (p=0.155). Conclusion: Thyroid irAEs are common in routine clinical practice among advanced cancer patients treated with combination anti-PD1/anti-CTLA4, and might have potential prognostic significance. Regular TFT monitoring is advised for timely treatment of thyroid irAEs to prevent potential morbidities.
Low Rate of Guideline Adherence for the Diagnosis and Management of Adrenal Incidentalomas in the Nova Scotia Health Authority Central Zone
Authors: Pipe Stephanie , Costa Andreu , Siddiqi Ferhan
Published: May 2021

Background: Adrenal incidentalomas are prevalent and clinically significant, yet are often overlooked by clinicians. The objective of this study was to retrospectively examine the adherence to American College of Radiology (2017) and European Endocrine Society (2016) guidelines for the diagnosis and management of adrenal incidentalomas within a centre servicing a population of over 400,000. Methods: Relevant computed tomography (CT) and magnetic resonance (MR) scans from February 17th, 2019 to December 18th, 2019 were consecutively reviewed for the presence of adrenal incidentalomas. Radiographic reports and original imaging were reviewed to evaluate the completeness of reporting. A chart review was conducted to determine if biochemical investigations for cases were undertaken and whether referral to Endocrinology was made. Reports were checked for the inclusion of an addendum recommending Endocrinology referral. Results: A convenience sample of 148 cases were included in the study, with 176 distinct adrenal incidentalomas identified. Where relevant, attenuation values were provided for 20% of cases, and follow-up imaging was recommended in 59% of cases. Of the 124 cases where biochemical investigation was deemed appropriate, a complete work-up was conducted in 4% of cases, and 11% were referred to Endocrinology. Follow-up imaging was ordered appropriately in 36% of cases, and no cases had inappropriate follow-up imaging. The addendum was included for 19% of cases, and it did not impact biochemical investigation rates but did improve Endocrinology referral rates. Conclusions: There is poor adherence to guidelines for the diagnosis and management of adrenal incidentalomas within our study population. This poor adherence would be an ideal target for quality improvement initiatives, in order to minimize missed functional and malignant adrenal masses.
Should Mode of Presentation Influence Interpretation of Thyroid Nodule Ultrasounds?
Authors: Stevens Lisa , Davoren Peter M
Published: May 2021

Background: The American College of Radiology (ACR) TI-RADS is a standardized scoring system for thyroid ultrasound reports providing recommendations on the need for fine needle aspirations (FNAs) independent of patient presentation. Aim: The aim of this audit was to determine if the initial presentation of the patient should be considered during the work-up of thyroid nodules. Methods: Data was collected from electronic medical records on 133 patients who underwent thyroid FNAs (165 FNAs in total) and 98 patients who had thyroid surgery for the management of thyroid nodules at Gold Coast University Hospital from Jan 1st 2019 – Dec 31st 2019. Patient presentation, adequacy of the ultrasound report and FNA results were recorded. These results were aligned with final diagnosis after surgery. Results: 98 patients underwent surgery and 29 (29.6%) were found to have malignant nodules, including 12 (12.2%) with microcarcinomas. Of the 29 malignancies, 16 patients presented with a palpable neck lump. Conclusions: Our data suggests a palpable neck lump is a significant factor in determining the risk of malignancy. It may be possible to adjust the current TI-RADS algorithm used to interpret thyroid ultrasounds to include patient presentation. This would reduce unnecessary testing and burden on the healthcare system.
Phenotypic Differences in Thyroid Immune Related Adverse Events Following Treatment With Immune Checkpoint Inhibitors
Authors: Muir Christopher Alan , Menzies Alexander M , Clifton-Bligh Roderick John , Long Georgina V , Scolyer Richard A , Tsang Venessa
Published: May 2021

Background: Thyroid toxicity is common following immune checkpoint inhibitor (ICI) treatment. Published studies estimate the incidence at 10-20%, although rates vary widely between different ICIs. The etiology of ICI-associated thyroid immune related adverse events (irAEs) is unknown & not all patients develop a classic thyroiditis-like presentation of transient hyperthyroidism followed by a hypothyroid phase. Only small observational cohorts have been reported & the clinical & biochemical features of thyroid irAEs have not been well characterized. The current study aimed to describe thyroid irAEs in a large cohort of patients with melanoma. Methods: We reviewed outcomes in a prospective cohort of adult patients undergoing ICI treatment for advanced melanoma. Thyroid function was measured at baseline & at regular intervals during treatment. Thyroid irAEs were defined as new biochemical thyroid dysfunction developing over the course of routine follow-up. Results: Thyroid irAEs occurred in 518 of 1246 (42%) patients. Median follow-up was 11.3 months. Multiple patterns of thyroid-irAEs were observed, such as hyperthyroidism (subclinical or overt) in 31%, hypothyroidism in 8%, & euthyroid hyperthyroxinemia, hypothyroxinemia & isolated low FT3 syndrome each in 1% of participants. Thyroid irAEs were more frequent following combination (CTLA-4 + PD-1) ICI treatment (56%) than following PD-1 (38%) or CTLA-4 (25%) based monotherapies (p=0.001). The severity of thyroid irAEs differed by ICI, with higher rates of overt (vs. subclinical) thyroid dysfunction following combination ICI treatment (47%) relative to PD-1 (37%) & CTLA-4 (19%) monotherapies (p=0.001). Younger age (OR 0.88 per 10-yrs; 95% CI 0.81-0.96), female sex (OR 1.62; 95% CI 1.27-2.08) & combination ICI-treatment (vs. CTLA-4, OR 3.76, 95% CI 2.49-5.75; vs. PD-1, OR 1.90, 95% CI 1.45-2.49) were associated with higher odds of thyroid irAE. Time to onset of thyroid dysfunction was shorter in patients with overt hyperthyroidism relative to other types of thyroid irAE (log rank p=0.001). Overt hyperthyroidism was associated with increased irAEs in other organ systems (colitis, hepatitis, etc), increased irAE severity & increased multi-system irAEs than euthyroid patients or patients with other subtypes of thyroid irAE (p=0.003). Overt hyperthyroidism was also associated with improved progression free survival (HR 0.57; 95% CI 0.39-0.84; p=0.005) & overall survival (HR 0.68; 95% CI 0.49-0.94; p=0.02). No benefit to cancer survival was observed with other thyroid irAE subtypes. Conclusions: Thyroid irAEs were common. Combination ICI treatment resulted in more frequent, more severe, & earlier onset thyroid irAEs. Of thyroid irAE subtypes, overt hyperthyroidism was uniquely associated with increased immune responsiveness, as evidenced by higher incidence of extra-thyroidal irAEs & improvements in cancer survival.
A Subtype of Papillary Thyroid Carcinoma Bone Metastasis With Excellent Response to RAI-Therapy
Authors: Vodopivec Danica M , Reddy Niyoti , Lee Stephanie L
Published: May 2021

Introduction: Bone metastases from differentiated thyroid cancer are generally resistant to radioactive iodine (RAI) therapy and are associated with poor prognosis, except for RAI-avid bone metastases with no structural correlate on imaging studies. Case: A 59 y/o woman presented for the evaluation of non-toxic multinodular goiter. Thyroid US showed a 2.7 cm nodule meeting FNAB criteria and no suspicious cervical lymph nodes. Cytology reported a Bethesda IV category with ThyroSeq V3 positive for chromosomal copy number alterations and a high Na+/I− symporter (NIS) expression (27%) with an ~ 60% probability of cancer. The patient underwent left lobectomy with isthmusectomy without neck dissection. Surgical pathology showed a 3.5 cm papillary thyroid carcinoma with extensive angioinvasion (≥4 vessels), negative margins, no ETE, and did not contain a BRAF V600E mutation. Completion thyroidectomy, in anticipation of RAI treatment, showed no additional tumor. Post-operative Tg after 6 weeks was unexpectedly high at 69 ng/mL (negative Tg Ab, TSH 5.7 uIU/ml) which prompted a rhTSH I-123 RAI WBS with SPECT/ CT and a diagnostic chest CT to uncover possible distant metastases. There was RAI uptake in the thyroid bed and right anterolateral 9thrib without a CT correlate (no osteolytic lesion) but with a signal abnormality on MRI. She was categorized as T2NxM1, 8th Edition AJCC Stage IVB, and ATA high risk. She was treated with 148.3 mCi I-131. Unfortunately, 6 months later the Tg was elevated and rising (Tg 38.4 ng/mL, negative Tg Ab, TSH 0.05 uIU/ml). A second diagnostic I-123 WBS with SPECT/ CT showed a new recurrence in the neck but no uptake in the rib lesion on planar images or other distant sites. Because of the unusually high Tg without any RAI-avid metastatic disease, an 18-FDG PET/CT was ordered to search for non-RAI avid disease. This showed disease confined to the neck and increased sclerosis of the rib lesion without increased FDG-uptake consistent with treated disease status post-RAI. There were no other distant hypermetabolic lesions. The left thyroid bed lesion was biopsied and consistent with Bethesda VI cytology and she will soon undergo left central neck dissection with tumor resection. Discussion: RAI-avid bone metastases without structural correlate on high-resolution imaging are a subtype of bone metastases located in the marrow. They do not present as the typical lytic lesions from cortical destruction. They often resolve following RAI treatment, do not cause skeletal-related complications, and do not significantly affect prognosis. The combination of high NIS expression and increased vascularity in the bone marrow (as opposed to the protected microenvironment in the bone cortex) makes them vulnerable to RAI treatment. Recognition of this subset of bone lesions may prevent overtreatment with high doses of RAI treatment and avoid the use of bisphosphonates or external beam radiation.