bluuebunny/crossref_metadata_2025 huggingface dataset:
Sertoliform Endometrioid Carcinomas of the Right Ovary
Authors: Alhubail Humoud , Aljenaee Khaled , Hajji Sulaiman
Published: May 2021

Background: Endometrioid carcinomas of the ovary are a sub-type of epithelial ovarian tumors. The vast majority are malignant and invasive. On imaging, they are usually characterized as complex nonspecific solid-cystic masses and found associated with endometriosis. However, endometrioid carcinoma of ovary resembling sex cord-stromal tumor is a rare variant of endometrioid adenocarcinoma that focally looks like a sex cord-stromal tumor with sertoli, leydig, or granulosa cells. Sertoliform endometrioid carcinoma of the ovary (SEC) is one variant that bears histologic similarity to Sertoli and Sertoli-Leydig cell tumors (SLTs).

Clinical Case: A 47 year old, premenopausal female, presented with rapid growing hirsutism, frontal hair loss, abdominal distension and constipation for less than one year. On clinical examination modified Ferriman-Gallwey (mFG) score was 17/36. Abdominal examination showed a palpable mass in lower abdomen, 25cm in size, rounded, and hard in nature. CT abdomen and pelvis revealed large pelvic abdominal mass (21x20.5x17 cm) with cystic and basal soft tissue components related to right ovary. Preoperatively laboratory investigations showed FSH 9.96 mIU/mL, LH 15.4, Estradiol (E2) 94.7 pg/ml, raised total testosterone 4.38 nmol/l, normal SHBG 34 nmol/l and normal DHEA-S 161 microg/dl.

Total abdominal hysterectomy and bilateral salpingo-oophorectomy was done, in which the right ovary was seen to be replaced by a solid cystic tumor with ruptured capsule. Grossly, the right ovary was enlarged measuring 9.5 cm × 8 cm × 4.8 cm. Microscopy showed round to solid tubules lined by pseudostratified columnar epithelium with elongated nuclei resembling sertoli tumor-like pattern along with conventional endometrioid tumor. A histopathological diagnosis of SEC of right ovary was made. Immunohistochemistry showed tumor cells strongly immunoreactive for epithelial membrane antigen (EMA), cytokeratin (CK) but negative for inhibin, thus confirming the diagnosis of SEC of right ovary.

Conclusion: SEC is extremely rare variant of endometrioid carcinomas and tend to present at an earlier stage as compared with most endometrioid carcinomas of the ovary. Recognition of SEC in virilizing patients is important as it is a well-differentiated, low-grade malignancy that displays a good prognosis when confined to the ovary.
Body Composition of Transgender Women After Long-Term Hormone Therapy - a Cross-Sectional Study
Authors: Alvares Leonardo A M , Santos Lívia M , Santos Marcelo R , Souza Francis R , Almeida Victor P , Mendonca Berenice Bilharinho , Costa Elaine Maria Frade , Alves Maria-Janieire N Nunes , Domenice Sorahia
Published: May 2021

Introduction: Few studies of transgender women (TW) body composition (BC) in long-term gender-affirming hormone therapy (GAHT) have been reported. Objective: To evaluate BC parameters of TW in long-term GAHT. Methods: A cross-sectional study was carried out with 8 TW (average age of 34.0 yo ±4.8), 8 cisgender men (CM) and 8 cisgender women (CW) matched to age and body mass index (BMI). All TW were non-gonadectomized subjects and were in estrogen [(E); transdermal estradiol (n=2), oral estradiol (n=3) and conjugated estrogen (n=3)], plus cyproterone acetate (CA) (n=8) therapy in an average time of 15.6 ±8.7 years of treatment. Total testosterone (ng/dL) levels of TW, CW and CM were 83,5 (range 12,0-637,0), 20,5 (range 12,0-41,0) and 480,5 (range 264,0-843,0) at the time of the study, respectively. BC was assessed by InBody 720. Percentage of fat mass (%FM), skeletal muscle mass (SMM) were evaluated. Baumgartner Index was calculated. Results: Regards %FM, that of TW was lower than CW (29,59 ±7,56 vs 32,9 ±3,99; p=0,5394) and higher than CM (23,58 ± 6,44; p=0.1512). SMM of TW was 33.6% higher than that of CW (p<0.001) and 14,7% lower than that of CM (p=0,014). Baumgartner Index of CM group was 17.7% higher than TW group (p=0,001), which presented rates 20.3% higher than the CW (0,002). Discussion: BC changes in the first two years of GAHT in TW were consistent with loss of lean mass and gained fat mass associated with an increase of body weight. This profile was identified in adults and youth transgender after short-term hormone therapy. Conclusion: Our data shown a similar profile of short-term treatment, with a body composition intermediate between BMI-matched cisgender males and females. However, unlike young TW undergoing short-term GAHT, the parameters of BC in the TW using estrogens plus cyproterone acetate in the long term did not present %FM statistically different from CW and CM, in contrast to the lean mass that maintained significant differences in the long term.
Management of Recurrent Deep Vein Thrombosis in a Transgender Woman
Authors: Oguz Seda Hanife , Buyukasik Yahya , Yildiz Bulent O
Published: May 2021

Background: Transgender people using hormone treatment require lifelong medical care. Although cross-sex hormone treatment (CSHT) is usually considered safe, serious adverse events may occur. Here we report a case of deep vein thrombosis associated with estradiol treatment in an otherwise healthy young transgender woman. Case Presentation: A 21-year-old transgender woman using CSHT applied to our outpatient clinic with the complaint of painful swelling in her left leg. She was diagnosed with deep vein thrombosis (DVT) in the same leg one year earlier when she was admitted to the emergency room of another hospital with similar symptoms, and was given warfarin treatment for 3 months which has improved the symptoms. Three months after cessation of warfarin, symptoms re-occurred, but she was only able to apply to our clinic after another 3 months due to COVID-19 pandemic. Physical examination was unremarkable except asymmetrical swelling in the left leg. She has been receiving oral estradiol 6 mg/day and spironolactone 200 mg/day for 2 years. She denied taking estradiol in higher doses than recommended. She did not have any predisposing factors for DVT including obesity, immobilization and smoking. She had no prior history of venous thromboembolic events (VTE). Family history was also negative for thrombophilia except her uncle was diagnosed with ischemic cerebrovascular event at the age of 60. Lower extremity venous doppler ultrasonography revealed a thrombus in the left popliteal vein that caused total obstruction of blood flow to the distal. Plasma levels of d-dimer and fibrinogen were 0.35 mg/L and 262 mg/dL, respectively. Serum levels of sex hormones were estradiol: 204 pg/mL, total testosterone: 22.4 ng/dL, FSH: 0.22 mIU/mL, LH: 1.5 mIU/mL. Thrombophilia panel revealed a homozygous mutation in MTHFR (1296), and heterozygous mutations in both Factor V Leiden and plasma activator inhibitor (4G/5G). She was given enoxaparin in addition to warfarin until INR was elevated up to desired levels. Oral estradiol treatment was switched to transdermal route. Life-long anticoagulant treatment was suggested since the thrombotic event was triggered by estradiol treatment which will be continued. Conclusions: Limited data are available on incidence and management of VTE associated with estradiol treatment in male-to-female individuals. As in general population, routine screening for thrombophilia is not recommended in transgender women prior to the initiation of CSHT if no personal or family history of VTE is present. Even in the absence of predisposing factors, life-long anticoagulant therapy may be considered since the VTE-provoking estradiol treatment will be continued. Switching the route of estradiol treatment from oral to transdermal may be beneficial.
Improving Residents’ Competency in Caring for Transgender Individuals Through Development of a Curriculum
Authors: Gortakowski Michele , Gordner Chelsea
Published: May 2021

Objectives: Several recent publications have described the lack of education in transgender health care among providers across all levels of medical training. Here we describe a QI project that developed and implemented a transgender health care curriculum for the University of Massachusetts Medical School-Baystate Medical Center (UMass-Baystate) pediatric and combined internal medicine-pediatrics residency programs.

Methods: We designed a curriculum for the UMass-Baystate pediatric (9 residents/yr) and med-peds (8 residents/yr) residency programs. The curriculum included grand rounds presentations on transgender health care, didactic sessions integrated into the residents’ protected educational time throughout the academic year, and a panel discussion with non-binary and transgender individuals from the community. The didactic sessions included a mixture of lectures, role- playing, and case-based discussion. The curriculum development was guided by a curriculum design specialist and adapted each year based on feedback. Residents’ self- reported comfort and competency level were assessed through a survey at baseline and at the end of each year.

Results: Ninety-eight percent (42/43) completed the baseline survey. Forty percent (17/42) had received no formal training in medical school, and 21% (9/42) had never taken care of a transgender patient. At baseline, 62% felt a little less comfortable and 50% felt somewhat competent, 2.4% very competent caring for transgender individuals compared to cisgender individuals. After three years, 25% felt a little less comfortable and 44% felt somewhat competent, 19% felt very competent caring for transgender individuals compared ot cisgender individuals. The community panel was very well received. Free text comments regarding the curriculum included “very helpful,” “loved the panel,” “clinically relevant.”

Conclusions: This QI initiative served as the groundwork for the development of a formal curriculum to enhance medical education among residents in caring for transgender individuals. After three years, residents felt more comfortable and competent in caring for transgender individuals as compared to the baseline survey. We will continue to adapt the curriculum as it continues. The curriculum has expanded to include the pediatric nurses and the UMass medical students.
Betamethasone Induces a Unique Transcriptome in Neural Stem Cells
Authors: Silswal Neerupma , Bean Joe , Gupta Herschel , Talib Fatma , Burale Suban , Goyal Archita , Shabbir Ahmed , DeFranco Donald Benedict , Monaghan-Nichols Paula
Published: May 2021

Twelve percent of pregnant women receive glucocorticoids (sGCs) to reduce the risks to reduce morbidity and mortality associated with preterm birth in infants. The two most commonly administered sGC are Dexamethasone (Dex) and Betamethasone (Beta) and they serve to decrease the severity of respiratory distress, intraventricular hemorrhage and necrotizing enterocolitis. However, repeated administration of sGC has been shown to be associated with adverse neurological outcome and depends on the type of sGCs used, dose, timing of sGCs administration and sex. We have previously shown that prenatal exposure to Dex in a murine model lead to sex specific changes in the transcription response and in the biological function of neural stem cells and to long-term changes in brain architecture and behavior. Beta is the predominant sGC used prenatally in the United States, therefore these studies investigated the cellular and molecular responses to beta exposure on the neural stem cells in-vitro and anatomical organization of the brain in-vivo. Murine NSCs were isolated from the E14.5 cerebral cortex and exposed to 10-7 M Dex, 10-7 M Beta, or Vehicle for 4 or 24 hours and the immediate and long-term impact on transcription, proliferation and neuronal, glial and oligodendrocyte differentiation examined. Affymetrix genome transcriptional analyses reveal sex specific responses to Dex vs Beta in 4 hours. In females 682 genes were differentially regulated by Dex compared to 576 by Beta. In contrast, 875 were altered by Dex and 576 by Beta in males (Fold change > +/- 1.5, P< 0.05). Select target genes were independently validated by QPCR. Ingenuity Pathway Analysis was used to identify unique and overlapping pathways that were altered by Dex vs Beta. In males, Dex uniquely altered 34 pathways including, Thyroid Hormone Metabolism, ERK5 Signaling and Opioid Signaling while Bata altered 33 pathways including, Phagasome formation, IL-7 Signaling and JAK STAT signaling. In Females, Dex altered 45 pathways including Calcium Signaling, Serotonin Receptor Signaling and Xenobiotic Signaling, while Beta altered 46 pathways including, FXR/RXR Activation, Tec Kinase Signaling and D-myo-Inositol-5-Phosphate Metabolism. Another 35 pathways were altered by both Dex and Beta but they showed differences in genes activated or repressed. Dex and Beta, both significantly altered genes involved in proliferation and differentiation therefore the biological response of NSC to sGCs stimulation in vitro and the long term consequences of sGC exposure in-vivo was compared. Distinct differences in cell proliferation, glial and oligodendrocyte differentiation were observed. These results reveal gene targets, cellular pathways and processes that are differentially altered by prenatal Dex vs Beta exposure. Our finds may provide insights into the sex specific neurological outcomes observed in children exposed to sGCs in-utero.
One Hormone for Two Receptors: Exploring Glucocorticoid Actions Mediated by the Glucocorticoid and Mineralocorticoid Receptors
Authors: Petrillo Maria G , Jewell Christine , Bortner Carl D , Oakley Robert H , Cidlowski John A
Published: May 2021

Glucocorticoids are indispensable for mediating the response to stress, energy demands, development, and limiting inflammation. Once in the cell, these hormones exert their actions by activating nuclear receptors, transcription factors that regulate gene expression. The glucocorticoid receptor (GR) is the transcription factor that predominantly mediates both physiological and pharmacological glucocorticoid effects. Yet glucocorticoids can also bind and activate the mineralocorticoid receptor (MR), a transcription factor known to bind aldosterone thus maintaining whole-body fluid homeostasis. Phylogenetically, GR and MR are closely related and share a remarkable structural similarity. Indeed, the DNA-binding domain of MR is 96% identical to that of GR; thus MR is recruited to many of the same DNA response elements that bind GR. Moreover, GR has a low affinity for glucocorticoids but is expressed in nearly every cell, whereas MR shows a higher affinity for glucocorticoids although knowledge of MR’s expression levels is somewhat limited. These characteristics suggest that, while GR and MR can compensate for each other’s actions in many tissues, there are specific glucocorticoid and mineralocorticoid-mediated responses indicating GR-MR functional diversity. To investigate the similarities and differences between GR and MR signaling in the presence of glucocorticoid hormones, we generated U-2 OS (human osteosarcoma) cell lines stably expressing GR, MR, and both GR and MR (MRGR). Immunofluorescence analysis showed that the treatment of these cell lines with 1 nM of the synthetic glucocorticoid dexamethasone (Dex) induced nuclear translocation of both GR and MR. Moreover, Proximity Ligation Assay revealed that, in the absence of ligand, GR associated with MR in the cytoplasm and, upon 1 nM Dex exposure, GR-MR complexes were detected in the nucleus of MRGR cells. To decipher the functional contribution of GR-MR complexes in the transcriptional response to Dex, we performed RNA-seq in GR, MR, and MRGR cells treated with 1 nM of Dex. Transcriptome analysis revealed that Dex-activated GR regulated the transcription of 6180 genes. Co-expression of MR resulted in a greatly blunted Dex-mediated gene response which reduced the glucocorticoid-dependent transcriptome size by 75%. This phenomenon was also observed using a higher concentration of Dex. Indeed, 40% of genes commonly regulated by Dex in GR and MRGR cells showed a reduced magnitude of regulation when MR is co-expressed. These results suggest a functional antagonism between GR and MR in which MR inhibits GR function. Understanding the molecular mechanisms governing the cross-talk between GR and MR is crucial for the development of new therapies that address the adverse effects of glucocorticoid treatment as well as for the discovery of novel glucocorticoid-based therapeutics with minimal side effects.
Quantifying the Protein Levels of All Nuclear Hormone Receptors by Mass Spectrometry
Authors: Saikali Michael Fadi , Cummins Carolyn L
Published: May 2021

Nuclear Receptors (NRs) are a family of ligand-activated transcription factors that control the expression of genes involved in a wide range of physiological processes. An atlas detailing the expression of all NRs at the mRNA level was completed in 2006 using quantitative PCR [Bookout et al. Cell 2006]. The comparative measurement of NRs at the protein level, however, has been hindered by the poor quality of commercially available antibodies, as well as the absence of a high throughput method for quantitation. To address this need, we are developing a mass spectrometry-based targeted proteomic assay to quantify the absolute amounts of NR protein in a panel of mouse tissues. NRs were overexpressed in HEK293 cells by transient transfection and protein was isolated. The cell lysates were digested with a combination of trypsin and Lys-C following the Multi-Enzyme Digestion Filter Aided Sample Preparation protocol. The peptides were desalted using an in-house made C18 tip, separated on an EASY-Spray C18 column (75 um x 50 cm, 3Å), and analyzed on a Thermo QExactive HF in Top20 data-dependent acquisition mode. Protein identifications were made using MaxQuant software, and the identifications were mined for members of the NR family. The NR peptides detected were searched against an in silico generated list of optimal NR peptides (filtered for uniqueness, length, absence of post translational modifications, and conservation between human and mouse). The matching peptides were validated by parallel reaction monitoring (PRM) and purchased as synthetic isotopes with a heavy terminal arginine or lysine. Peptide linearity, and lower limits of detection (LLOD) were estimated by spiking digests from a C57Bl/6 mouse liver lysate with increasing amounts of the labeled peptides and analyzing by PRM. Peptides that displayed non-linear behavior were excluded for quantitation. The LLOD were between 100 amol and 1.5 fmol on column. A test panel of tissues (cerebrum, hippocampus, cerebellum, liver, spleen, brown/white adipose, and kidney) showed that we could detect endogenous expression of NRs. To date, we have purchased and validated peptides for 44 of the 49 receptors. We used this assay to quantify the changes in NR protein expression in mouse livers in response to 16 hours of fasting. We found significant changes in the nuclear expression of CAR (3.1-fold increase), RXRβ (1.8-fold increase), SHP (3.9-fold decrease) and RARβ (2.0-fold decrease) in the fasted vs. fed state. Increased CAR activity with fasting was further supported by label-free quantitative proteomics on the same lysates which revealed 210 differentially expressed proteins (2-fold change, p<0.05), with 61 (29%) identified as known CAR target genes. Once complete, this assay will provide researchers with a robust quantitative tool to investigate changes in NR protein expression that will be widely applicable to endocrine research.
The Impact of a Single Phosphorylation Site Mutation in the Glucocorticoid Receptor on the Molecular and Cellular Development of the Cerebral Cortex
Authors: Gupta Herschel Raj , Pitchyaiah Prathi , Silswal Neerupma , Burale Suban , Bean Joseph , Talib Fatma , Franks Alexis , Jaumotte Juliann Darcy , Berry Kimberly , Carry Tricia , Oakley Robert H , Cidlowski John A , DeFranco Donald Benedict , Monaghan-Nichols Paula
Published: May 2021

Premature birth leads to a significant increase in adverse clinical outcomes, including Respiratory Distress Syndrome, Bronchopulmonary Dysplasia, Necrotizing Enterocolitis and Intraventricular Hemorrhage. Synthetic Glucocorticoids (sGC) are administered prenatally to pregnant mothers at risk to reduce the chance of these complications. However, there is a correlation between long-term neurological defects in the infant and the clinical use of sGC prenatally. The use of the sGCs have been linked to the development of cerebral palsy and deficits in attention and concentration. To investigate the cellular basis of these abnormalities, we examined the consequences of sGC administration of the developing murine brain. Our studies demonstrated that premature exposure to sGC alters neural stem cell biology and has long term consequences for adult behavior in mice. In humans, site-specific phosphorylation of the Glucocorticoid Receptor (GR) on Serine 211 versus Serine 226 is associated with activated or repressed transcriptional states and clinical studies indicate that the ratio of S220/S226 phosphorylation is associated with increased predisposition to specific psychiatric disease states, including Major Depressive Disorder and Bipolar Disorder. To examine the role of these phosphorylation sites in the development of behavioral abnormalities, we utilized a knock-in mouse model where Serine 220 (equivalent to human Serine 211) was replaced with an alanine (S220A). In-vitro microarray analysis of neural stem cells and QPCR validation were performed to examine the expression changes in individual transcripts in critical pathways that may correlate with long-term neurologic disorders. Our results indicated that changing the phosphorylation status of GR alters the expression of 2570 genes. Ingenuity Pathway Analysis indicated that the major pathways altered include those involved in cellular proliferation, mitochondrial function, Valine degradation and G-coupled protein receptors involved in neurotransmission. Both in-vitro and in-vivo experiments indicated that the S220A mutation alters the cells response to sGC administration by impacting proliferation and differentiation. The long-term goal of these experiments was to demonstrate a role for S220 phosphorylation in the development of neuropsychiatric disorders.
White Button Mushroom Disrupts AR Signaling in Prostate Cancer: The Scientific Basis for a Diet-Based Chemoprevention
Authors: Wang Xiaoqiang , Ha Desiree , Mori Hitomi , Chen Shiuan
Published: May 2021

White button mushroom (WBM) (Agaricus bisporus) is a potential prostate cancer (PCa) chemo-preventive and therapeutic agent. Our clinical phase trial of WBM powder in patients with biochemically recurrent PCa indicated that WBM intake reduced the circulating levels of prostate-specific antigen (PSA), with minimal side effects [1]. We hypothesized that WBM exerts its effects on PCa through the androgen receptor (AR) signaling axis. We thus conducted the reverse translational study. Androgen-sensitive PCa cell lines (LNCaP and VCaP) and patient-derived-xenografts (PDX), of a prostate tumor (TM00298) were used. In both LNCaP and VCaP cells, western blots and qRT-PCR assays indicated that WBM extract (6~30 mg/mL) suppressed DHT-induced PSA expression and cell proliferation in a dose-dependent manner. Immunofluorescence on AR revealed that the nuclear localization of AR was reduced upon WBM extract treatment, which agreed with the results of a PSA promotor-luciferase assay, suggesting that WBM extract inhibited DHT-induced luciferase activity. RNA-Seq on WBM-treated LNCaP cells confirmed that WBM treatment suppressed androgen response pathways and cell-cycle control pathways. Our prostate cancer PDX showed that oral intake of WBM extract (200 mg/kg/day) significantly suppressed tumor growth, as well as decreased PSA levels in both tumors and serum. Both in vitro and in vivo studies suggested that chemical(s) in WBM extract behave as AR antagonist(s). We previously identified a conjugated linoleic acid isomer (CLA-9Z11E) as an active component in WBM extract. In the present study, we extended these findings by performing LanthaScreen™ TR-FRET AR Coactivator Interaction Assays for a direct interaction of CLA-9Z11E with AR. We report here that CLA-9Z11E exerts a strong antagonist potency against the recruitment of an AR coactivator peptide towards AR. The inhibitory effect of CLA-9Z11E (IC50: 350 nM) was nearly two times stronger than the known AR antagonist, cyproterone acetate (IC50: 672 nM). The information gained from this study improves the overall understanding of how WBM may contribute to the prevention and treatment of PCa. It also serves as an important, scientific basis for developing diet-based chemoprevention and integrative therapeutic strategies for prostate cancer (supported by NIH R01 CA227230).

Reference: [1] Twardowski P, et al. A phase I trial of mushroom powder in patients with biochemically recurrent prostate cancer: Roles of cytokines and myeloid-derived suppressor cells for Agaricus bisporus-induced prostate-specific antigen responses. Cancer. 2015.121(17):2942-50.
Disruption of Adipose Tissue Metabolism by Glucocorticoids Is Attenuated With LXRβ Antagonism
Authors: Li Jia Xu , Cummins Carolyn L
Published: May 2021

Excessive exposure to glucocorticoids (GCs), either from endogenous overproduction of cortisol, or exogenous pharmacological GC treatment, potentiates the development of diabetes and obesity in a fat depot-specific manner. Undesirable metabolic side effects resulting from the activation of the glucocorticoid receptor (GR) remain a key limitation to the long-term therapeutic use of GCs as immunosuppressants. GC treatment disrupts the thermogenic function of brown adipose tissue (BAT) and enhances futile cycling within white adipose tissue (WAT). Mice lacking the liver X receptors (LXRs) were previously shown to have smaller AT depots with enhanced BAT activity compared to wildtype (WT) mice. We previously demonstrated that LXRβ is required to mediate the side effects of GCs in the liver but not the beneficial anti-inflammatory effects of GCs. The discovery of this GC/LXRβ cross-talk led to the hypothesis that LXRβ antagonism may be therapeutically beneficial to prevent GC-induced dysfunction in AT. To test this idea, LXRα-/- mice were treated for 5 days with vehicle, 5 mg/kg dexamethasone (Dex, a synthetic GC agonist), and/or 40 mg/kg GSK2033 (GSK, non-selective LXR antagonist). As expected, Dex-treated mice showed significant accumulation of lipids in BAT and were unable to maintain their body temperature when exposed to cold, yet GSK was able to protect against these effects. Dex increased body fat mass and caused adipocyte enlargement in WAT which was not observed in mice co-treated with GSK. At the transcriptional level, GSK attenuated Dex-mediated downregulation of thermogenic genes in BAT, and upregulation of lipogenic genes in WAT. Similar beneficial changes were confirmed in WT mice. The protection afforded by GSK against Dex-induced fat accumulation was confirmed to be cell-autonomous from studies in adipose-specific LXRβ-/- mice (AdβKO). Dex-dependent increases in lipolysis in gonadal WAT and plasma free fatty acids (FFA) were also attenuated by GSK co-treatment. With GSK co-treatment, Dex-induced liver steatosis was diminished suggesting that LXRβ antagonism attenuated FFA shuttling to the liver. The lipolytic and lipotoxic effects of Dex in AT and liver were largely abrogated in AdβKO along with improved systemic insulin sensitivity. Overall, our data suggest that LXRβ antagonism prevents disruption of BAT and WAT (and indirectly liver) function caused by GC treatment in an in vivo model, highlighting the potential role of LXRβ antagonists in combating the negative effects of excessive GC exposure on the development of diabetes and obesity. The identification of this novel mechanism of interrupting GC adipose tissue action suggests therapeutic targeting of LXRβ with an antagonist could improve the health of patients currently taking GCs to control inflammation but suffer the detrimental side effects of drug treatment.
Can Thyroidectomy Improve Quality of Life in Patients With Hashimoto’s Thyroiditis?
Authors: Latif Summaya A , Robbins Sarah E , MacDonald Cameron , Connor Nadine , Sippel Rebecca S
Published: May 2021

Introduction: Patients with Hashimoto’s often complain of persistent symptoms despite being on optimal medical therapy. Research suggests that thyroidectomy may have a role in improving this. We investigated the change in Quality of Life (QoL), symptom burden and mental health from baseline to 1 year after total thyroidectomy in patients with underlying thyroiditis.

Methods: We conducted semi-structured interviews with 96 patients at baseline and 1 year to discuss their thyroid-related symptom burden. Patients utilized prompt cards to identify and rank the severity of their thyroid-related symptoms (3 being most bothersome and 0 being no effect at all). Individual symptom scores were added to calculate a Cumulative Symptom Score (CSS). Patients also completed the validated Short Form-12 (SF-12) questionnaire for mental and physical health (scored from 0-100; higher score attributing to better health) and ThyCa-QoL questionnaire (scored from 0-100; higher score attributing more complaints) at these 2 time-points.

Results: Of the 96 patients with available CSS data, there were 37 patients in the Hashimoto’s group (97% had biopsy proven thyroiditis and 24% were on thyroid hormone at baseline) and 59 patients in the control group. At baseline, Hashimoto’s patients had a higher CSS than the control group (9.94 vs. 7.13, p=0.05). Overall, mean CSS, in both groups, declined from baseline to 1 year (7.74 to 6.08, p=0.04), and over half of the individual patients, had a decline in their CSS at 1 year (56% in Hashimoto’s and 54% in control). Although, the Hashimoto’s group started higher at their baseline, they also had a slightly larger decline in CSS at 1 year than the control patients (-2.2, p=0.11 vs. -1.2, p=0.19). On the SF-12, Hashimoto’s patients had a significant improvement in their mental health (+ 6.0 pts, CI 1.8-10.2, p value = 0.007) whereas the control patients did not (+2.4 pts, CI 0.3-5.2, p=0.08). On the ThyCa-QoL, Hashimoto’s patients had worse scores at baseline as compared to the control patients (20.8 vs 16.7, p=0.11) and there was a slight but clinically significant improvement from baseline to 1 year (decrease in mean of 1.18 pts, p=0.5). Analysis of the qualitative data showed that of the 10 patients who were on thyroid hormone pre-operatively, 9 described significant symptom improvement at 1 year, with fatigue being the major symptom that was reported as improved.

Conclusion: Based on the data above, we see that patients with Hashimoto’s do have a higher symptom burden at baseline and thyroidectomy may play a role in symptom alleviation as well as improving mental health and QoL. Our data supports recent findings that thyroidectomy may play a role in alleviating thyroid related symptoms in this patient population and further investigation to better understand this phenomenon is warranted.
Oral Liquid L-Thyroxine (L-T4) May Be Better Absorbed in Comparison to L-T4 Tablets in Patients With Lactose Intolerance
Authors: Fallahi Poupak , Ferrari Silvia Martina , Elia Giusy , Ragusa Francesca , Paparo Sabrina Rosaria , Ruffilli Ilaria , Patrizio Armando , Antonelli Alessandro
Published: May 2021

In patients with lactose intolerance (LI), L-thyroxine (L-T4) malabsorption is often present, that leads to the necessity to use elevated L-T4 doses in the substitutional treatment of hypothyroidism. After excluding non-compliance, the differential diagnosis should include such disorders as LI, atrophic gastritis, coeliac disease, and others. In case of a diagnosis of LI, a low lactose diet and a lactose-free L-T4 preparation should be administered, to decrease the dose of the L-T4 formulation, and restore euthyroidism. We report the normalisation of circulating thyrotropin (TSH) levels in 8 patients with LI who received L-T4 tablets, after switching to an oral liquid lactose-free formulation. After switching from oral tablets to the liquid L-T4 (at the same dose, 30 minutes before breakfast) TSH was significantly reduced (TSH, evaluated 1-3 months after the switch, decreased: from 7.5±3.1 to 3.2±2.4 μIU/mL, P<0.05). The return back to tablets (at the same dosage, 30 minutes before breakfast) caused thyrotropin levels to worsen again. This result leads us to believe that the absorption of oral liquid formulation of thyroxine is greater in these patients. In conclusion, these data suggest that the L-T4 oral liquid formulation could bypass the issue of malabsorption in patients with lactose intolerance.
Quality of Life in Patients With Hypothyroidism
Authors: Pereira Miguel , Neves Celestino , Neves João Sérgio , Carvalho Davide
Published: May 2021

Introduction: The quality of life (QoL) of thyroid diseases has been less studied than other chronic diseases. There is however evidence suggesting long lasting physical and psychological symptomatology related to thyroid diseases.

Objective: To analyze the QoL in patients with hypothyroidism.

Methods: We evaluated 274 patients with a mean age of 56.2 ± 14.2 years, 89.1 % female and divided them by diagnosis: autoimmune thyroiditis (AIT, n = 145), multinodular goiter (MG, n = 31), total thyroidectomy (TT) for thyroid cancer (n = 46), total thyroidectomy for MG (n = 36), TT for Graves disease (GD, n = 9) and radioactive iodine therapy (RAI) for GD (n = 7), and assessed thyroid function tests, thyroid antibodies, lipid profile, high-sensitivity C-reactive protein, vitamin B12, folic acid and applied the Thyroid Dependent Quality of Life questionnaire (ThyDQoL). Statistical analysis was performed with the One-way ANOVA test and Pearson’s correlation test. P values ≤ 0.05 were considered as statistically significant.

Results: In this sample, the subgroups who reported worse QoL were the TT for thyroid cancer (-2.47 points) followed by the RAI for GD (-2.14 points) and the AIT (-2.11 points), although these differences were not statistically significant. Regarding the internal domains of the ThyDQoL, we found a significant difference between the subgroup TT for thyroid cancer and MG in bodily discomfort (-4.03 ± 3.61 vs -1.47 ± 1.66; p = 0.04) and household tasks (-2.95 ± 2.92 vs -0.90 vs 1.61; p = 0.02). Within the subgroups, we observed significant correlations involving QoL and vitamin B12 in the AIT subgroup (r = 0.16; p = 0.05), between QoL and lipoprotein(a) (r = -0.50; p = 0.03) in the MG subgroup, between QoL and free T3 (r = -0.31; p = 0.03) in the TT for thyroid cancer subgroup and between QoL and free T3 (r = -0.76; p = 0.04) in the RAI for GD subgroup.

Conclusions: In this study we found that patients submitted to TT for thyroid cancer had the worse QoL among patients with hypothyroidism. This may be related to the use of thyroid hormone suppressive therapy. We also observed that certain domains of QoL are more affected by some causes of hypothyroidism. Further studies are needed to analyze more deeply the symptomatology that contributes to worsening of QoL in these patients.
The Application of ThyPRO Questionnaire in Patients With Graves’ Disease Treated With Antithyroid Medications
Authors: Chng Chiaw Ling , Soh Shui Boon , Chiam Priscilla Pei Sze , Fook-Chong Stephanie Man Chung , Tay Wei Lin , Yew Jielin
Published: May 2021

Background: The ThyPRO-39 questionnaire assesses health-related QoL (HRQoL) in patients with benign thyroid disease and has been validated for use in the local setting. The aim of the study is to investigate disease specific health-related quality of life using ThyPRO-39 in patients with newly diagnosed Graves’ disease treated with antithyroid medications over one year. Methods: Patients with newly diagnosed Graves’ disease were recruited in the outpatient setting. The ThyPRO-39 questionnaire was administered at baseline, 6 and 12 months of antithyroid medication treatment. Relevant demographic and clinical information was collected at the three time points of the study. Results of clinical parameters and various ThyPRO scales were compared between baseline, 6 months and 12 months of treatment. Results: There were 32 patients with newly diagnosed Graves’ disease recruited between April 2018 and May 2019. All except 2 patients completed all 3 time points of the study. Two patients missed their 6 months questionnaire. There were 24 females (75%) and 8 males (25%) in the study. Analysis of the clinical parameters showed significant changes in weight from baseline (59.7 + 17.7kg) to 6 months (59.4 + 9.9kg) to 12 months (63.4 + 17.4Kg), all p<0.001, TSH receptor antibody level from baseline (17.3 + 12.9IU/L) to 12 months (7.1 + 10.8IU/L), NR <1.76IU/L, p<0.001, fT4 levels from baseline (49.9 + 18.1pmol/L) to 6 months (14.3 + 6.9pmol/L) and from baseline to 12 months (11.8 + 2.3pmol/L), NR 8.8-14.4pmol/L, all p<0.001 and TSH levels from baseline (0.011 + 0.009mU/L) to 6 months (1.38 + 1.74mU/L, p=0.001) and from baseline to 12 months (1.80 + 1.72mU/L, p<0.001), NR 0.65-3.70mU/L. After 6 months of treatment, 7 out of 13 ThyPRO scales improved and 9 out of 13 ThyPRO scales improved after 12 months of treatment. Large treatment effects were observed on 2 ThyPRO scales (Hyperthyroid symptoms and Anxiety) while moderate effects were seen in 5 ThyPRO scales (Tiredness, Cognitive complaints, Depressivity, Impaired daily Life and overall QoL) from baseline to 6 months. Large treatment effects were observed on 2 ThyPRO scales (Hyperthyroid symptoms and Anxiety) while moderate effects were seen in 5 ThyPRO scales (Tiredness, Depressivity, Emotional susceptibility, Impaired daily Life and overall QoL) from baseline to 12 months. Small treatment effects were observed in 2 ThyPRO scales (Goiter symptoms and Tiredness) from 6 to 12 months. Conclusion: There are significant improvements in many aspects HRQL during the first 6 months of antithyroid drug treatment, with hyperthyroid symptoms and anxiety showing the most improvements throughout the 12 month treatment period. Our results complement clinical monitoring of patients with Graves’ disease and provide realistic outcome measures of disease impact and treatment outcomes from the patient’s perspective.
Amiodarone-Induced Thyrotoxicosis, Risk Factors and Predictors of Outcome: A Retrospective Study
Authors: Khalaili Luai , Aker Amir , Naoum Ibrahim , Kassem Sameer
Published: May 2021

Background Amiodarone induced thyrotoxicosis (AIT) is not uncommon and is often associated with significant morbidity and mortality. Factors that predict poor prognosis in AIT have not yet been sufficiently investigated. Objective: To examine the characteristics and short-term clinical outcomes of patients with AIT (up to six months from diagnosis). We evaluated the relationship between T3 and T4 levels at the time of presentation and complications associated with AIT. Methods: A retrospective epidemiological study on patients admitted to Carmel Medical Center between the years 2004-2018. We reviewed electronic medical records of patients who bear the diagnosis of thyrotoxicosis and consumed amiodarone. Demographic and clinical characteristics of patients that develop AIT were evaluated. We evaluated the association between T3 and T4 levels at the time of presentation a poor prognosis. Three primary outcomes were defined: 1. Mortality. 2. Development of AIT-related complications that required hospitalization. 3. The need for thyroidectomy. Results: 400 patients bear a diagnosis of thyrotoxicosis and consumed amiodarone. However, only 39 patients met the full definition of AIT. The composite outcome of mortality, AIT-related complications and thyroidectomy was achieved in the vast majority of patients (94.8%, 37 out of 39 participants). Three patients (7.6%) died, 35 (89.7%) were hospitalized with AIT-related complications and 8 (20.5%) required thyroidectomy. There was a statistically significant relationship between high T4 levels and the composite of two main endpoints: mortality and the need for thyroidectomy in the first half year of diagnosis (P=0.009). Conclusions: AIT is associated with significant morbidity and mortality. An elevated level of free T4 reflects the severity of AIT. In patients with significantly increased T4 values, an early surgical intervention should be considered.
Hearing Loss and Teprotumumab
Authors: Kossler Andrea , Sears Connie Martin , Dosiou Chrysoula
Published: May 2021

Thyroid eye disease (TED) is an unpredictable autoimmune inflammatory disease which can be sight-threatening, debilitating, and disfiguring. Teprotumumab (IV infusion every 3 weeks x 8 doses) was recently approved as the first and only FDA-approved drug for TED in 2020. Phase 2 and 3 studies showed significant improvement in proptosis, double vision, soft tissue inflammation and quality of life for patients with active moderate to severe TED. Side effects were experienced by 85% of patients on teprotumumab. Hearing loss symptoms were reported in 10% of patients and were reported to be reversible upon stopping the drug. Objective: To explore the incidence of hearing loss symptoms and sensorineural hearing loss in patients treated with teprotumumab. Methods: All patients, followed at one institution, treated with at least 4 infusions of teprotumumab were evaluated. Charts were evaluated for baseline hearing symptoms and hearing symptoms during or after therapy with teprotumumab. Those patients with hearing symptoms were referred for audiogram testing and patulous eustachian tube (PET) testing. Results: Twenty-eight patients were included in this analysis. Thirteen patients (46%) complained of hearing symptoms. The most common symptoms were autophony or an ear plugging sensation and hearing loss or muffled hearing. Hearing symptoms developed after a mean of 3.6 infusions. Of the patients with hearing symptoms, three patients (23%) had sensorineural hearing loss documented on audiogram (n=2) or patulous eustachian tube (n=1) documented on PET testing. To date, the patient with PET has experienced some improvement, but not resolution, of her symptoms. The two patients with documented sensorineural hearing loss have not experienced a significant improvement in hearing, on audiogram, on average 3 months after stopping teprotumumab. Conclusion: Teprotumumab is a promising new therapy for active moderate to severe thyroid eye disease. Providers should consider performing a baseline audiogram with PET testing and performing audiograms with PET testing for patients that develop hearing symptoms during or after therapy. Hearing loss is a concerning adverse event and its mechanism and reversibility should be further studied.
In Vitro Splicing Assay Proves the Pathogenicity of Intronic Variants in MRAP
Authors: Smith Chris , Maharaj Avinaash Vickram , Qamar Younus , Read Jordan , Williams Jack , Chan Li , Marimuthu Vidhya , Metherell Louise
Published: May 2021

Introduction: Familial glucocorticoid deficiency (FGD) is characterised by isolated glucocorticoid deficiency in a patient who retains normal mineralocorticoid production. FGD causing mutations in the MC2R accessory protein, MRAP, are often splice-site or nonsense mutations resulting in a truncated protein. Many of these mutations occur at the canonical donor splice-site of intron 3, where it has been shown previously that c.106 + 2_3dupTA, for example, results in skipping of the first coding exon with unknown consequences at the protein level. Patients and methods: DNA was isolated from three consanguineous individuals diagnosed with early onset FGD (0 - 13 months) with high ACTH and/or low cortisol levels and underwent whole exome sequencing. The proband in family 1 (P1) presented at 13 months and had a hyperpigmented sibling who died in neonatal period due to adrenal failure. Patient 2 (P2), who also had a family history of adrenal insufficiency, was noted to be hyperpigmented at birth with markedly raised ACTH, patient 3 (P3) was noted to have diffuse hyperpigmentation in the early neonatal period and on formal testing at 16m was found to have low serum cortisol. Variants were confirmed using Sanger sequencing and predicted splice-site mutations were investigated using an in vitro splicing assay. Results: Homozygous mutations in MRAP were identified in all three cases which were heterozygous in their parents. Previously described mutations, c.106 + 1delG (chr21:33671388delG; rs1476574441; CD050155) in P1 and c.106 + 2dupT (Chr21: 33671390_91insT; rs761576317; CI118288) in P2 at the canonical donor splice-site of intron 3, were identified, with the former predicted to destroy the splice site and the latter to weaken it. These mutations in vitro resulted in the complete skipping of exon 3, which contains the translational start site, and presumably result in no protein product. A novel homozygous mutation in intron 4, c.206 + 5G>T; (chr21:33679055G>T rs1064796398) was identified in P3, but was not predicted to alter splicing. In vitro, this mutation negates the canonical donor splice site and creates two different alternative sites, both resulting in frameshifts and predicted early termination of the protein (p.Val44fs*50, p.Pro72fs*90). Conclusion: All mutations reported here are predicted to produce no protein, either because the start site is excluded (for c.106 + 1delG and c.106 + 2dupT) or because the transcripts are likely to undergo nonsense mediated decay (for c.206 + 5G>T), resulting in the early onset FGD seen in the patients. Splice prediction protocols, although effective for variants within 2bp of exon/intron boundaries may not predict the true outcome of a base change whereas the splice assay conclusively revealed the effect of all three variants allowing us to assign pathogenicity to them.