bluuebunny/crossref_metadata_2025 huggingface dataset:
Effect of Experimentally Induced Sleep Fragmentation and Hypoestrogenism on Fasting Nutrient Utilization in Pre-Menopausal Women
Authors: Grant Leilah K , Coborn Jamie E , Cohn Aviva , Abramson Mathena , Elguenaoui Elkhansaa , Russell Julia A , Wiley Aleta , Nathan Margo D , Scheer Frank A J L , Klerman Elizabeth B , Kaiser Ursula B , Rahman Shadab A , Joffe Hadine
Published: May 2021

Background: Both sleep disturbance and menopause have independently been associated with weight gain in women. Possible mechanisms contributing to this weight gain may be changes in resting energy expenditure (REE) and/or nutrient utilization. Therefore, in the current study we aimed to examine the effects of experimentally induced sleep fragmentation and pharmacologic estradiol (E2) withdrawal on REE and nutrient utilization in the fasted state. Design: We studied pre-menopausal women during 5-night inpatient studies repeated in the mid-to-late follicular phase (high-E2; n=21) and following leuprolide-induced hypoestrogenism (low-E2; n=9 completed second visit). During each admission there were two nights of unfragmented sleep [8-h time in bed (TIB)] and three nights of fragmented sleep [9-h TIB]. Sleep was fragmented using an auditory stimulus delivered every 15 minutes that sustained wake for 2 minutes, producing 1 hour of wake after sleep onset. Study diets consisted of 3 meals and a snack each day and were iso-caloric across the two visits. REE and nutrient utilization were assessed in the fasted state via indirect calorimetry and compared between E2 states following unfragmented and fragmented sleep using linear mixed models. Results: Sleep fragmentation in the high-E2 state increased the respiratory quotient (RQ; +3%; p=0.03) with an accompanying increase in carbohydrate oxidation (+20%; p=0.02) and decrease in fat oxidation (-16%; p=0.03). The same effect was observed in response to E2-withdrawl during unfragmented sleep [increased RQ (+5%; p=0.01) and carbohydrate oxidation (+33%; p=0.01), and decreased fat oxidation (-26%; p=0.01)]. There was no additive effect of sleep fragmentation on nutrient utilization in the low-E2 state suggesting a possible ceiling (RQ and carbohydrate oxidation) and floor (fat oxidation) effect. There was no effect of sleep fragmentation or E2 state on REE. Conclusion: Both sleep fragmentation and hypoestrogenism were shown to alter fasting nutrient utilization, but not REE, in a manner that may contribute to weight gain in menopausal women. These findings are important for understanding weight gain during menopause, which is characterized by estrogen withdrawal and often accompanied by sleep disturbances.
Diagnosis of Sertoli-Leydig Cell Tumor of the Ovary Complicated by the Pattern of Hyperandrogenemia and Results of Imaging
Authors: Jaju Amruta , Williams Vanessa , Ansari Mohammad Jamal Uddin , Ali Mariam Murtaza , Jakoby Michael G
Published: May 2021

Introduction: Virilization in a postmenopausal woman requires evaluation for an androgen-secreting tumor. The differential diagnosis includes adrenal carcinomas and adenomas and Sertoli-Leydig cell tumors, granulosa-theca cell tumors, and hilus-cell tumors of the ovaries. We present a case of virilization in a postmenopausal woman caused by a Sertoli-Leydig cell tumor (SLCT) in which evaluation was complicated by the pattern of androgen elevation, bilateral adrenal nodules, and absence of an adnexal mass. Case: A 64-year-old female was referred for evaluation of hyperandrogenism. Hirsutism, temporal hairline regression, and unusually deep voice were noted on examination. Two total testosterone levels obtained one month apart were 146 ng/dL (2-45), and measurements of dehydroepiandrosterone sulfate (DHEAS) and androstenedione were 299 mcg/dL (12-133) and 1.84 ng/mL (0.130-0.820), respectively. Abdominal CT revealed bilateral adrenal nodules - 2 cm and - 5 Hounsfield units (HU) on the left, and 1.5 cm and 5 HU on the right - but no ovarian masses. Transvaginal ultrasonography also failed to identify a discrete ovarian mass but showed endometrial hyperplasia. Virilization, magnitude of testosterone elevation, and results of imaging were felt to be most strongly indicative of ovarian hyperthecosis, and the patient underwent laparoscopic bilateral salpingo-oophorectomy and hysterectomy. The right ovary was 2.3 cm in largest diameter and approximately 90% replaced by an orange-red mass that showed Sertoli and Leydig cells on microscopy, immunohistochemical staining for the sex cord proteins inhibin and calretinin, and presence of the Leydig cell marker melan A. It was classified as well differentiated. Additional CT imaging and robotic assisted laparoscopy confirmed a stage IA tumor. One month after surgery, hyperandrogenemia had completely resolved (total testosterone < 10 ng/dL, androstenedione 0.379 ng/mL, and DHEAS 99 mcg/dL), and changes of virilization had mostly regressed at an eight months appointment. Discussion: SLCTs are a type of sex-cord stromal ovarian tumor. They constitute < 0.5% of ovarian tumors but account for approximately 75% of testosterone-secreting ovarian masses. This patient’s case was unusual for multiple reasons: 1. Age - most SLCTs are diagnosed in the second or third decade, 2. Imaging - CT and ultrasonography usually show a solid or solid and cystic adnexal mass, and co-existing adrenal nodules are rare, likely due to typical young age of presentation, and 3. Pattern of androgen elevation - DHEAS was more than two-fold elevated, and usually < 10% of DHEA and DHEAS are produced by the ovaries. However, DHEAS fell significantly after oophorectomy. SLCTs are a potential etiology of virilization in postmenopausal women even in the absence of a detectable adnexal mass and when biochemistries and imaging raise the possibility of an adrenal source of androgen.
Euglycemic Diabetic Ketoacidosis in a Patient With Gestational Diabetes Mellitus and COVID-19 Infection
Authors: Karuppasamy Gowri , Saud Arwa Al , Abuhaliqa Wajeeha Mousa
Published: May 2021

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening medical emergency requiring urgent treatment. Euglycemic DKA may occur in patients with both type 1 and type 2 Diabetes Mellitus (DM), as well as pregnancy. The absence of marked hyperglycemia can result in delayed diagnosis and treatment, resulting in potential adverse outcomes. Diabetes is a major comorbidity associated with severe hospital course and high fatality rate among patients with COVID-19 infection. We report our experience in a patient with gestational diabetes mellitus who developed euglycemic DKA and COVID-19 infection in her third trimester of pregnancy. Clinical Case: A 30-year-old lady at 29weeks gestation presented with two-day history of vomiting, diarrhea and abdominal pain. She reported good fetal movements. She had been diagnosed with Gestational Diabetes Mellitus (GDM) at 20 weeks gestational age, receiving treatment with multiple daily injections of insulin. 5 days earlier, she had tested positive for COVID-19 infection. She was asymptomatic; testing was performed as she had been in contact with a confirmed case. On examination she was afebrile and vitally stable, but dehydrated. Her initial laboratory investigations showed ketonemia with normal glucose level and normal anion gap. She was treated as a case of starvation ketosis and dehydration, with intravenous fluids and electrolyte replacement. However, 3 days later, the patient complained of worsening nausea and vomiting with dry cough and she developed hypotension. Chest X-ray showed bilateral mid and lower

zone pulmonary infiltrates. She was treated as COVID-19 pneumonia, received 2 units of COVID-19 convalescent plasma and broad-spectrum intravenous antibiotics. Repeated investigations showed worsening ketosis with high anion gap metabolic acidosis, consistent with a diagnosis of euglycemic DKA. Insulin infusion was initiated, isotonic saline with electrolyte replacement was also continued. She symptomatically improved over the next two days, with resolution of ketonemia and acidosis. The patient was discharged and she was well at her outpatient follow up visit. She underwent emergency Cesarean Section at 37 weeks gestational age, due to non-reassuring electronic fetal monitoring. She delivered a healthy female infant weighing 2445grams. Conclusion: Pregnancy is a high-risk period for DKA particularly when associated with other stressors that were identified in our patient – GDM, restricted calorie intake and COVID-19 infection. Diabetes is a risk factor for developing severe forms of COVID-19 and on the other hand, COVID-19 infection is associated with poor glycemic control and higher risk of hyperglycemic emergencies including ketoacidosis in diabetic patients. Prompt recognition of euglycemic DKA is critical in pregnancy, as this condition is associated with high fetal mortality rates.
Hypomagnesemia and Hypokalemia: The Possible Role of Vasopressinase in This Rare Presentation of Gestational Diabetes Insipidus
Authors: Okafor Anderson , Dhillon Vikramjit , George Joshua , Addepalli Aradhana
Published: May 2021

Background: Gestational diabetes insipidus (GDI) is a rare but recognized complication of pregnancy. We are reporting the case of a 33-year-old patient who presented in her 3rd trimester with GDI, severe asymptomatic hypokalemia & hypomagnesemia. This presentation of GDI has not been reported yet to our knowledge.

Clinical Case: A 33-year-old G2P1 patient who presented to the hospital due to the discovery of new onset severe asymptomatic hypokalemia on routine labs. Further evaluation revealed K of 2.8 mEq/L, Mg of 1.4 mg/dL & Na of 142mEq/L. She endorsed polyuria & polydipsia and a 24-hour urine collection of 9.35L confirmed diabetes insipidus. Labs also revealed a serum osmolality of 286mOsm/kg & urine K of 15mEq/L. Her urine osmolality was inappropriately low at 138mOsm/kg. She received K & Mg supplementation. In pregnant patients suspected of having GDI who have normal serum Na, water restriction test can be done for further evaluation. It must performed with close monitoring because dehydration can lead to uteroplacental insufficiency. Given her history of previous fetal demise & report of headaches with attempts of water restriction, we opted not to do the test. She was given subcutaneous 1 mcg of desmopressin overnight with her thirst & polyuria improving only briefly. Due to her suboptimal response, we began her on 10 mcg of intranasal spray of desmopressin once in the evening. Her symptoms resolved on this regimen after a few days of observation. Her Mg & eventually K levels reached and remained at normal levels after repletion. The rest of her pregnancy went on without complications and she delivered a healthy male infant via scheduled cesarean section at 36 weeks gestation. She discontinued intranasal desmopressin after 2 weeks and has remained asymptomatic. Labs at follow up 4 weeks later remained normal. It is known that vasopressinase which is made by placental trophoblasts during pregnancy degrade endogenous ADH1. We are hypothesizing that since ADH has been shown to be effective in conserving magnesium in rats by stimulating its uptake in the distal convoluted tubule cells2, a similar mechanism could be present in humans. We believe that the loss of endogenous ADH, leads to the depletion of Mg and consequently hypokalemia in susceptible patients.

Conclusion: To our knowledge this is the first case presenting the possible role of vasopressinase in the development of hypomagnesemia & hypokalemia in a patient with GDI.

Reference: 1. Gordge MP, Williams DJ, Huggett NJ, Payne NN, and Neild GH. Loss of biological activity of arginine vasopressin during its degradation by vasopressinase from pregnancy serum. Clinical Endocrinology, vol. 42, no. 1, pp. 51- 58, 1995. 2. Dai LJ, Bapty B, Ritchie G, Quamme GA. Glucagon and arginine vasopressin stimulate Mg2+ uptake in mouse distal convoluted tubule cells. Am J Physiol. 1998 Feb;274(2):F328-35. doi: 10.1152/ajprenal.1998.274.2.F328. PMID: 9486227.
Lack of Hirsutism in an XX Woman With History of Hyperandrogenism and Oligomenorrhea: Two Coexisting Disorders or Novel Syndrome of Androgen Insensitivity?
Authors: Ueda Masako , Amorosa Louis F
Published: May 2021

Polycystic ovary syndrome (PCOS) is one of the most common causes of infertility in women, and its etiologies have not been clearly elucidated. Non-classical congenital adrenal hyperplasia (NC-CAH) with mild to moderate enzyme deficiency of 21-hydroxylase due to bi-allelic mutations in its gene (CYP21A2) is a cause of secondary PCOS that should always be considered. Common clinical features of NC-CAH include menstrual irregularities, hirsutism, acne, advanced bone age with accelerated linear growth, and short stature, associated with hyperandrogenism. Androgen insensitivity syndrome (AIS) is another cause of hyperandrogenism due to lack of response to androgen typically in genetic male (XY) presenting with female physical characteristics, most commonly due to a mutation in the androgen receptor (AR) gene on the X chromosome. Here, we present a 61 years old woman, with a diagnosis of PCOS based on oligomenorrhea and high testosterone ~90 pg/mL at age 18, meeting both NIH and Rotterdam PCOS diagnostic criteria. She took oral contraceptive pills only for one year, despite continued menstrual irregularities. After age 42, her menstrual cycles became and remained regular without further intervention until menopause at age 51, while her testosterone levels fluctuated between 80 and 250 pg/mL. After menopause, her testosterone levels drastically increased to >350 pg/mL. The patient has been recommended, but reluctant to undergo oophorectomy for enlarged non-cystic ovaries. Other potentially related clinical features include the presence of a pituitary adenoma, and a thyroid nodule. She has no notable adrenal mass or myelolipoma. Patient is lean and well-fit, at 5’11” and 151 lb. The most puzzling feature has been a lack of virilization and hirsutism. During laboratory evaluation, high 17-hydroxyprogesterone was identified, and NC-CAH became a potential etiology of PCOS, but this did not explain the lack of apparent virilization. The finding of unimpressive levels of DHEA implied that this pathway probably was unlikely the major cause of high testosterone. Investigation for hyperandrogenism focusing on AIS revealed normal female karyotype XX, and no identifiable mutations or abnormal copy number in AR. The findings thus far have provided no unifying diagnosis for her clinical features, especially for androgen insensitivity, and additional studies are being performed. Assessment of other genes recently reported to be associated with AIS is being performed as well as genetic confirmation of NC-CAH by analyzing CYP21A2. Steroid 5-alpha reductase 2 (SRD5A2), whose mutations and polymorphism interestingly are associated with AIS and PCOS, respectively, and nuclear receptor subfamily 5, group A, member 1 (NR5A1) is another gene associated with AIS. It remains to be determined whether she has AIS as a coexisting disorder with NC-CAH or a novel syndrome with a feature of androgen insensitivity.
Ovarian Hyperthecosis: Hyperandrogenism in a Post-Menopausal Woman
Authors: Fayad Christine , Champion Amber , Izuora Kenneth E
Published: May 2021

Introduction: Ovarian Hyperthecosis (OH) is a disorder characterized by severe hyperandrogenism and insulin resistance. It is a rare cause of hyperandrogenism primarily among postmenopausal women. We present a case report about a patient with adrenal incidentalomas and later found to have ovarian hyperthecosis during her evaluation.

Case Description: 62-year-old post-menopausal female was referred to the Endocrinology clinic for evaluation of adrenal incidentalomas which were discovered on imaging work-up for hematuria. MRI Abdomen and Pelvis revealed a 17mm right and 14mm left sided adrenal nodules, with signal dropout suggesting benign adenomas. Patient stated she had menopause at age 39 years old, one child, and multiple miscarriages during her reproductive years. Examination revealed BMI of 31.1 kg/m2, moderate hirsutism, and skin tags near the neck. There was no evidence of hyperpigmentation or abdominal striae. Patient had phenotype suggestive of insulin resistance-without diagnosis of diabetes.

Results: Laboratory workup revealed normal levels of 24-hour metanephrines, cortisol, renin, aldosterone, and DHEA-S suggesting that the adrenal adenomas were not hyperfunctioning. Further workup revealed: Total Testosterone: 220 [2 - 45 ng/dL]; Free Testosterone 23.8 [0.1 - 6.4 pg/mL]; DHEA-S 43 [12 - 133 mcg/dL]. Prolactin 6.3 [Postmenopausal 2.0-20.0 ng/mL]. A1c 5.4 [<5.7%]. Serum FSH, LH, PRL, and IGF-1 were within normal reference ranges. The patient, with adrenal adenomas, elevated testosterone, and a normal DHEA-S suggested a non-adrenal source. Patient was evaluated by OB/GYN with finding of normal postmenopausal ovaries on transvaginal ultrasonography. Based on a high suspicion for OH, patient underwent hysterectomy with bilateral salpingo-oophorectomy which confirmed pathological diagnosis of Bilateral OH. On follow-up 2 months post-op, Total/Free Testosterone had normalized 36 [2 - 45 ng/dL] and 3 [0.1 - 6.4 pg/mL] respectively).

Conclusion: In women presenting with elevated testosterone (>150 ng/dL) and clinical features of hyperandrogenism, proper laboratory and imaging evaluation is imperative to determine the source of excess androgen production. Untreated, OH is associated with increased mortality from type 2 diabetes, cardiovascular disease, and endometrial carcinoma. The diagnosis of OH can be confirmed only by histologic examination of the ovaries. Often, ovarian imaging is negative, therefore, surgical intervention is recommended. Hence, clinicians should rely on the clinical assessment in making management decisions in patients with OH.
Primary Hyperparathyroidism in Pregnancy - Two Case Reports
Authors: Mehta Anku , Galliford Thomas , Tauni Rahat , Chan Yik Lam
Published: May 2021

Introduction: Primary hyperparathyroidism in pregnancy is rare, with a reported incidence of 1%. The physiological changes of pregnancy can mask its diagnosis. Primary hyperparathyroidism is characterized by the overproduction of parathyroid hormone (PTH) and results in hypercalcemia and a raised or inappropriately normal PTH.

Maternal and fetal/neonatal complications are estimated to occur in 67 and 80% of untreated cases respectively. Maternal complications include nephrolithiasis, pancreatitis, hyperemesis gravidarum, pre-eclampsia and hypercalcemic crises. Fetal complications include intrauterine growth restriction; preterm delivery and an increased risk of miscarriage.

Case reports

Case 1: An 18-year old woman presented in her first pregnancy with a known history of MEN type 1. She was diagnosed at the age of 17 following an appendectomy. She has a strong family history and subsequent genetic test confirmed the diagnosis of MEN1. Pre-pregnancy parathyroid sestamibi scan showed bilateral parathyroid adenoma. MRI pituitary was in keeping with a pituitary microadenoma. She had a corrected calcium ranged between 2.7-3.3mmol/L and an inappropriately raised PTH of 24.1pg/ml. She underwent elective parathyroidectomy at 15 week gestation. Post operatively she remained normocalcaemic. She subsequently developed gestational diabetes and was induced at 34 + 3 weeks due to multiple episodes of hypoglycaemia, reduced fetal movement and suspected placental insufficiency. She had a good fetal outcome.

Case 2: A 29-year-old woman in her first pregnancy presented with recurrent episodes of renal colic and imaging confirmed significant bilateral renal calculi. A diagnosis of primary hyperparathyroidism was made with adjusted calcium of 2.94 mmol/L (2.20-2.60) and inappropriately unsuppressed parathyroid hormone of 20.1pg/ml (1.6-6.9), along with ultrasound parathyroid. She was managed with fluid rehydration initially and parathyroidectomy was performed at 12 weeks due to persistently elevated serum calcium. Her genetic screening for MEN (multiple endocrine Neoplasia) was negative. Fetal growth was closely monitored and the rest of her pregnancy was uncomplicated. She had an assisted vaginal delivery at term with good fetal outcome.

Learning Points: 1. The physiological changes of pregnancy can mask its diagnosis; hence a high index of suspicion is needed to diagnose primary hyperparathyroidism in pregnancy.2. Management with rehydration forms the cornerstone in mild cases and Parathyroidectomy is the definitive treatment and recommended in second trimester.

3. Ultrasound is the only recommended imaging modality in pregnancy.4. Primary hyperparathyroidism can be genetically determined in 10% of cases. Genetic testing enables patients to be screened for the development of other syndrome-related diseases e.g. neuroendocrine tumours in MEN1.
Comparative Transcriptional Analysis of Patient Responders Versus Non-Responders to Glucocorticoid Treatment for Bronchopulmonary Dysplasia
Authors: Shi Victoria J , Burale Suban , Lewis Tamorah , Silswal Neerupma , Monaghan-Nichols Paula
Published: May 2021

Bronchopulmonary Dysplasia (BPD) is a common heterogeneous lung disease that can result from preterm birth at less than 28-weeks gestation, prenatal and postnatal inflammatory insults, ventilator associated lung injury, and oxygen-related injury. Synthetic glucocorticoids (sGCs) are commonly used pre- and postnatally to treat inflammation and improve lung physiology. Clinical responses to sGC therapy for BPD vary in patients. We hypothesize that genetic background differences in transcriptional response to sGC therapy dictate the efficacy in infants with BPD. Identifying pathways and genes that mediate these differences will allow prospective determination of which infants would respond to sGC treatment.

26 preterm infants that received sGC treatment for BPD were identified. Respiratory Severity Score (RSS), an indication of BPD severity, was measured at diagnosis, 4 days, and 7 days post-sGC treatment. Patients were stratified into Responders versus Non-Responders by improvement in respiratory function after treatment. Changes in RSS were used to discriminate Responders (R >3 decrease in RSS) to treatment from Non-Responders (NR <3 decrease). 13 Responders and 13 Non-Responders were selected. They included 7 females and 19 males with an average gestational age of 24.3 weeks, and were 46% Caucasian, 31% African American, 19% Hispanic, and 4% other. 100µL of blood was collected before and after seven days of a dexamethasone treatment course.

To examine differences in transcription response between Responders (n = 13) and Non-Responders (n= 13), RNA was isolated and analyzed using the Clariom S Human Transcriptome Affymetrix array. 21,500 expressed genes were profiled. Results: were imported into the Transcriptome Analysis Console (TAC) software, and genes with a significant difference (fold change >1.48 or < -1.48 and p-value <0.05) in Responders and Non-Responders were identified. Of those, 133 genes were upregulated and 74 downregulated. Ingenuity Pathway Analysis (IPA) was used to identify signaling pathways and disease processes that were uniquely altered in Responders versus Non-Responders. Non-Responders showed significant activation of neuroinflammatory signaling pathways, degranulation pathways, and lymphocyte activation disease pathways. Target genes in the top dysregulated pathways were evaluated using quantitative Polymerase Chain Reaction (qPCR). Expression changes in Matrix Metalloproteinase-25, Interleukin-12 Receptor beta, and Microsomal Glutathione Transferase-1, key mediators of inflammation, were validated in independent studies using qPCR. While response to systemic glucocorticoids in neonates with BPD is variable, these studies identified pathways that are altered in Responders versus Non-Responders and are a step towards developing pre-screening tools to stratify infants for response to sGC BPD therapy.
Physical and Sociodemographic Features Associated With Quality of Life in Transgender Individuals Using Gender-Affirming Hormone Therapy
Authors: Da Silva Eliane Dias , Fighera Tayane Muniz , Allgayer Roberta Martins Costa Moreira , Lobato Maria Inês Rodrigues , Spritzer Poli Mara
Published: May 2021

Background: Gender dysphoria is defined as a feeling of distress resulting from the incongruence between the gender assigned at birth and the identity gender and lasting longer than 6 months. In individuals with gender dysphoria, gender-affirming hormone therapy(GAHT) may improve quality of life (QoL). Objectives: Here, we aimed to assess perceived QoL and possible contributing factors in a sample of transgender women and transgender men using GAHT. Methods: In this cross-sectional study, transgender women and men were recruited by availability sampling from a national transgender health service. Individuals over 18 years old with a confirmed diagnosis of gender dysphoria receiving medically prescribed GAHT for at least 6 months were consecutively included. Also included were trans men who had undergone mastectomy and trans women who had received breast augmentation surgery. Individuals who had undergone gender affirmation surgery (specifically genital surgery) or with uncontrolled clinical/psychiatric conditions at the time of the initial assessment were excluded. Sociodemographic, physical, and hormone data were collected from all participants. The WHOQOL-BREF questionnaire was used to evaluate QoL. A total of 135 transgender individuals were invited. Seventeen individuals with previous genital surgery (12.6%) and five who refused to participate (3.7%) were excluded. Therefore, 113 patients were enrolled in the study (60 trans women and 53 trans men). Results: There was no significant difference in QoLbetween the groups. In trans women, greater breast development and stable relationships, and higher body mass index were associated with higher QoLdomain scores. In trans men, higher domain scores were found in individuals with a stable relationship, increased body hair, physical activity practice, and being employed. Conclusion: Data from this study suggest that GAHT-related physical characteristics are associated with higher QoLscores, and that sociodemographic parameters may impact these associations. Healthcare providers might consider these factors when planning interventions to improve QoLin transgender individuals.
Copy Number Variations Are More Frequent on Chromosome 14 as Compared to X Chromosome in Suspected Turner Syndrome Girls - A Chromosomal Microarray Analysis
Authors: Purwar Naincy , Tiwari Pradeep , Saxena Aditya , Mathur Nitish , Sharma Himanshu , Sharma Balram , Mathur Sandeep Kumar
Published: May 2021

Introduction: Turner syndrome(TS) is defined by complete/partial monosomy of X chromosome in association with classic clinical manifestations. Conventional karyotyping is the gold standard test for diagnosis of TS. However it is labour intensive and inaccurate for detecting mosaicism, marker chromosomes and sub-microscopic deletions/duplications. TS is characterized by heterogeneous phenotypes despite identical karyotypes and precise genotype-phenotype correlations have not yet been deciphered. Presence of TS specific features in absence of X chromosome abnormality, evokes the hypothesis of possible autosomal involvement. Here, we report detailed Chromosomal microarray (CMA) analysis of 47 girls with clinically suspected TS, using Affymetrix CytoScan 750K array. Materials and Methods: The clinical diagnosis of TS was based on recommendations by clinical practice guidelines from 2016 Cincinnati International TS meeting. Peripheral venous sample was collected in EDTA tubes and DNA was extracted using Qiagen-DNAeasy Blood and Tissue kit (Cat No. 69504). DNA samples were then hybridized to the Affymetrix CytoScan 750K array as per manufacturer’s instructions. The data obtained was analysed using Chromosomal Analysis suite software and public genomic databases- ISCA, OMIM, DGV, DECIPHER. For bioinformatic analysis, all the genes (172) implicated in TS were retrieved from DisGeNET database. A TS-interactome of 4033 genes was then constructed from these genes and their first-degree neighbours from complete human interactome. Thereafter compilation was done based on CMA results and a protein-protein interaction network of 316 nodes was constructed. Results: Mean age of study cohort was 15.8 ± 3.64 years with short stature being the most common presenting phenotype (91.4%). CMA analysis detected copy number variations (CNVs) on chromosome 14 in 42 (89.3%) of 47 cases while X chromosome CNVs were present in only 28 (59.5%) cases, with all patients clinically qualifying as TS. Total 445 CNVs were discovered on X chromosome and 64 CNVs were found on Chromosome 14 exhibiting either CNV gain at 14q32.33 or CNV loss at 14q11.2 or both. The 30 cell karyotype was available for 27 patients and was found to be false negative in 7 (14.8%) patients. Also, 6 out of 47 cases had Y chromosome translocation detected on CMA that failed detection by karyotype. On enrichment analysis, thirty KEGG pathways were found to be enriched by the overlapping genes between TS-interactome and the interactome constructed by genes located within 14q11.2, and 14q32.33 67% of genes (212) in this network overlap with TS-interactome.

Conclusions: CMA is a superior diagnostic modality for TS than karyotyping. Functional interactomes between Chromosome X and Chromosome 14 on enrichment analysis reveal novel pathways underlying phenotypic manifestations.
Evaluation of Turner Syndrome International Consensus Guideline Compliance in Multiple Subspecialty Clinics Verses a Coordinated Multidisciplinary Clinic Format
Authors: Hoag Benjamin Donald , Tsai Sarah J L , Cernich Joseph Theodore , Williams David
Published: May 2021

Turner syndrome’s (TS) lifelong association with multi-organ system comorbidities necessitates the effective implementation of, and adherence to, screening guidelines. Our team evaluated the effectiveness in implementing the 2016 Cincinnati International Turner Syndrome consensus guidelines [1] in a single, coordinated, multidisciplinary clinic (MDC) day format compared to multiple separate subspecialty clinic visits. A retrospective analysis of patients with TS followed at our pediatric tertiary referral center between December 2016 and April 2020 was conducted. Exclusion criteria included patients that were not seen in our pediatric endocrine clinic for over 24 months, age over 22 years, and those without confirmed genetic diagnosis of TS. The population was separated into two groups; girls who attended at least 1 MDC day each year and girls who had at least 1 endocrinology clinic visit in the last 14 months, but who were not part of the MDC (non-MDC). Age appropriate screenings included TSH, hepatic function test, Vitamin D level, blood glucose and/or HgA1C, celiac screening panel, hearing/auditory screening, eye examination, electrocardiogram, and echocardiogram. A total of 112 girls met study criteria. Sixty-eight were managed in the MDC and 44 managed in non-MDC. Only 36.6% of all the girls met all the above age-appropriate screening recommendations, 75.6% of which were managed in MDC (p-value 0.014). MDC girls had higher screening compliance rates vs non-MDC girls for TSH (95% vs 76%, p-value 0.017), auditory evaluation (85% vs 50%, p-value <0.001), HgA1c and/or serum blood glucose levels (97% vs 76%, p-value 0.017), and tissue transglutaminase levels (95% vs 83%, p-value 0.048). No statistically significant difference was found with overall screening guideline compliance and insurance status, race/ethnicity, or age at time of the patients last recorded clinic visit. In conclusion, the MDC day format showed superior screening guideline compliance, both overall and to multiple specific screening tests, compared to those seen in multiple uncoordinated, single-disciplinary individual provider clinics. Overall guideline adherence remained low (36.6%), highlighting the need for continued optimization and improvement in guideline compliance. Reference: [1] Gravholt, C.H., et al., Eur J Endocrinol, 2017. 177(3): p. G1-G70.
The Population Prevalence, Thyroid Cancer and Mortality Risk for Turner Syndrome in South Korea Based on National Health Insurance Service (NHIS) Data
Authors: Kim Sungeun , Park Sang Hyun , Han Kyungdo , Cho Won Kyoung , Suh Byung-Kyu , Park Yong-Gyu
Published: May 2021

Background: In the present study, we estimated the population prevalence, cancer and mortality risk for Turner syndrome (TS) using data from National Health Insurance Service (NHIS) and Rare Diseases Registry (RDR). Methods: We collected data on subjects with TS who were registered in the RDR between 2012 and 2017. To estimate cancer and mortality risk of TS, the data of TS subjects were compared with and 1:5 age and sex matched controls. Results: In 2017, 2054 individuals with TS were identified out of the total population of 26,249,201 South Korean females and the prevalence was 7.83 per 100,000 persons. In 2017, the distributions of TS prevalence across 10 year old age groups showed 11.44 per 100,000 persons in the group under the age of 10 years, 22.43 per 100,000 persons in teenagers, 18.40 per 100,000 persons in twentieth, 10.24 per 100,000 persons in thirtieth, 4.05 per 100,000 persons in fortieth and 0.39 per 100,000 persons after fiftieth. During 5.3 years, the cancer risk in patients with TS was higher than that of age matched controls [hazard ratio (HR) = 1.813, 95% CI 1.009-3.257]. When cancer is categorized by each organs, thyroid cancer risk in patients with TS was significantly higher than that of age matched controls [hazard ratio (HR) =2.697, 95% CI 1.025-7.097]. The all cause of mortality risk of TS was higher than that of age matched controls [hazard ratio (HR) =3.421, 95% CI 1.623-7.212]. Conclusions: In South Korea, the TS population prevalence was 7.83 per 100,000 persons in 2017. The subjects with TS have higher thyroid cancer and mortality risk than healthy controls. Key words: Prevalence, Turner syndrome, thyroid cancer risk, mortality risk.
Calcineurin-NFATc4 Pathway Is Activated Upon K+-stimulation of Adrenal Aldosterone Production
Authors: Berber Mesut , Leng Sining , Beuschlein Felix , Breault David T , Loffing Johannes , Ribas David Penton
Published: May 2021

The mineralocorticoid aldosterone secreted by the adrenal zona glomerulosa (ZG) cells promote renal K+ secretion and Na+ reabsorption; thereby it is critical for the control of ion homeostasis and blood pressure. While the Ca2+/calmodulin-dependent protein kinase (CAMK) pathway regulating K+ stimulated aldosterone production is well studied, little is known about the potentially involved phosphatases. Interestingly, immunosuppression therapy of transplanted patients with protein phosphatase 3 (calcineurin) inhibitors often results in rather low plasma aldosterone levels despite a concomitant hyperkalemia and hyperreninemia. Calcineurin (Cn) is a calcium and calmodulin-dependent protein phosphatase expressed in the adrenal cortex. We tested the hypothesis that Cn participates in the signal transduction pathway mediating the K+-dependent stimulation of aldosterone production. To address this question, we used the adrenocortical cell model NCI-H295R, mouse and human ex vivo adrenal preparations and a ZG-specific and inducible Cn knockout mouse model (ZG-CnB1-KO). Inhibition of Cn with tacrolimus abolished the K+-stimulated expression of CYP11B2 in NCI-H295R cell line as well as mouse and human adrenal pieces, ex vivo. Using a phosphoproteomics analysis, we identified nuclear factor of activated T-cells, cytoplasmic 4 (NFATc4) as a critical downstream factor mediating Cn function. In support of this result, genetic deletion of NFATc4 reduced the basal expression of CYP11B2 and impaired the K+-stimulated expression of this gene. Conversely, the expression of a constitutively active form of NFATc4 drastically increased the expression of CYP11B2 in NCI-H295R cells which remained unaltered upon treatment with K+ or tacrolimus. Finally, preliminary experiments using ZG-CnB1-KO mice suggest that Cn deletion in the ZG blunts the increase in aldosterone excretion triggered by high K+ diet. Altogether, our data indicate that Cn function is indispensable for the physiological regulation of aldosterone production. Moreover, Cn may represent a novel molecular target for the pharmacological treatment of primary aldosteronism.
Deliberate Compensated Vasoplegia - a Novel Pharmacological Regimen for Controlling Arterial Blood Pressure During Surgery for Pheochromocytoma
Authors: Mazeh Haggi , Weiss Daniel J , Peter Michael , Grozinsky-Glasberg Simona , Oleinikov Kira , Szalat Auryan , Ronen Ariel , Koganov Evgeny
Published: May 2021

Background: Intraoperative hemodynamic fluctuations are the most dreaded phenomenon associated with the treatment of pheochromocytoma. Preoperative alpha-adrenergic blockade protocols aimed at abating these fluctuations have achieved controversial results. No study to date has evaluated the use of intraoperative treatment protocols during surgery for pheochromocytoma. Deliberate compensated vasoplegia (DCV) is a novel pharmacological regimen developed at our institution intended to decrease severe hypertensive events. The aim of this study is to compare outcomes of pheochromocytoma resection with and without the DCV protocol. Methods: A retrospective analysis of all pheochromocytoma resections between the years 2012 and 2020 was performed. Resections performed with and without the DCV protocol were compared. The primary outcome measured was the incidence of severe intraoperative hypertension (mean arterial pressure ≥ 150 mmHg). Secondary outcomes included other abnormal blood pressure measurements as well as perioperative data and complications. Results: A total of 41 pheochromocytoma resections were included: 21 performed using standard practice and 20 with the DCV protocol. Analysis demonstrated no significant difference in preoperative parameters including tumor size, catecholamine levels, or alpha-blockade protocol. The use of the DCV protocol resulted in a significant decrease in the incidence of severe hypertensive episodes from 1.95±3.6 to 0.03±0.13 events/hour (p=0.008). The DCV protocol was not associated with any adverse events. Conclusions: This study demonstrates that DCV anesthesia protocol significantly decreases the incidence of severe hypertensive episodes during pheochromocytoma resection. This is the first study describing a highly effective protocol for controlling intraoperative hypertension and hemodynamic instability in pheochromocytoma patients.
Chronic Dexamethasone Treatment Leads to Less Weight Gain and Ameliorated Glucose Tolerance in Mice; Role of the Cytoprotective Nrf2 Pathway
Authors: Filippopoulou Fotini , Douni Eleni , Sophocleus Antonia , Habeos Ioannis , Chartoumpekis Dionysios
Published: May 2021

Introduction: Chronic glucocorticoid administration is necessary in a variety of conditions including but not limited to autoimmune, inflammatory and cancer-related diseases in order to relieve symptoms and sustain disease progression. However, there are adverse effects that include increase in glucose levels and others whose severity depends on the dose and duration of glucocorticoid exposure. It has been described that dexamethasone induces oxidative stress in cells by increasing reactive oxygen species (ROS) and this is one of the causes of insulin resistance at the cellular level. Nrf2 is a transcription factor which co-ordinates the antioxidant response and its activation has been shown to ameliorate insulin resistance in murine models. Hypothesis: We hypothesized that deletion of Nrf2 will lead to a more glucose intolerant insulin resistant phenotype in mice chronically treated with dexamethasone as cells would be exposed to higher ROS levels. Methods: To this end, 3-months old wild-type (WT) and Nrf2 knockout (KO) C57BL6J mice were treated intraperitoneally with 2 mg/kg dexamethasone or saline 3 times per week for 3 months. 5-10 mice were included per genotype per treatment and both male and female mice were used. Weekly measurements of body weights were performed and intraperitoneal glucose tolerance tests were done on the second and third month of treatment. Mice were sacrificed 24 hours after the last dose of dexamethasone and blood, white adipose tissue, soleus muscle and liver were collected for RNA preparation and quantitative RT-PCR analysis. Quantitative analysis of trabecular bone parameters was performed by micro-CT. Results: Both male and female mice treated with dexamethasone gained less weight over time and surprisingly were more glucose tolerant than the control group. Absence of Nrf2 did not seem to considerably affect the body weight but KO mice tended to have lower body weights after dexamethasone treatment in both genders with the effect on male mice being statistically significant (25% lower, p<0.05). Surprisingly, both WT and KO mice of both genders showed lower fasting blood glucose levels after 3 months of treatment and better glucose tolerance. Livers of KO mice showed lower levels (~50%) of the cytoprotective genes Nqo1 and Gclc as expected but no difference was observed after dexamethasone treatment. Sarcopenia muscle markers Mafbx1 and Murf1 showed no significant changes. Male mice showed increased expression of Pnpla3 in white adipose tissue indicating increased lipolysis upon dexamethasone exposure. Micro-CT showed minor changes in the bone parameters without difference between male WT and Nrf2KO mice. Conclusions: Dexamethasone unexpectedly led to better glucose tolerance and lower body weight which is uncommon in humans but it has been described previously in mouse models. More analyses are in progress to fully elucidate this phenotype.
Deletion of Nuclear Receptor Constitutive Androstane Receptor CAR Increases Anxiety and Lowers Androgen Levels
Authors: Hernandez Juan P , Asokakumar Anjana , Xiao Rui , Moore David D , Anakk Sayeepriyadarshini
Published: May 2021

The orphan nuclear receptor, Constitutive Androstane Receptor (CAR, NR1I3) is primarily known to regulate the transcriptional networks involved in detoxification. We have identified a novel extra-hepatic role of CAR in regulating androgen levels and modulating testis function. Previous data has revealed that CAR activation by estradiol and inactivation by androstanol suggests an intricate link between sex hormones and CAR. We investigated control wild type and CARKO mice and found that the serum testosterone and androstenedione levels were lower in the absence of CAR. As expected, we did not find any induction of the genes in the detoxification machinery including, Cyp3a, Cyp2b, Cyp2c family, Sult2a1 and Mrp. The decrease in the androgen levels in the CARKO mice is consistent with decrease in the anogenital distance, increased anxiety as measured by marble burying and elevated plus maze but no change in testis weight. H&E staining of CARKO mice shows accumulation of fat in the Leydig cells and lower numbers of Leydig cells which are in accordance with the loss of androgen levels. In addition, we will examine the consequence of reduced androgen and the hypothalamus-pituitary-gonadal axis in the CARKO mice.
Melanocortin 2 Receptor Antagonists in Canine Cushing’s Disease: In Vitro Studies
Authors: Sanders Karin , Slob Adri , Betz Steven F , Kooistra Hans S , Galac Sara
Published: May 2021

Melanocortin 2 receptor antagonists in canine Cushing’s disease: in vitro studies

Cushing’s disease (CD), caused by an ACTH-secreting pituitary adenoma, is one of the most common endocrinopathies in dogs. The current medical treatment options involve adrenocortical steroid synthesis inhibitors, but a selective targeted approach to block ACTH receptor at its receptor would be much more attractive. The objective of this study was to preclinically investigate the effect of MC2R antagonists on adrenocortical hormone production, cell viability, and mRNA expression of steroidogenic enzymes in canine primary adrenocortical cell cultures from adrenal glands of healthy dogs. Three different MC2R antagonists were used: CRN.1, CRN.2, and CRN.4. Canine primary adrenocortical cell cultures (n = 8) were incubated with 50 nM ACTH for 24h, to mimic CD. Thereafter, 10 nM (IC50) and 2 μM (maximal concentration) of CRN.1, CRN.2, and CRN.4 were added. The two concentrations were established based on preliminary studies. After 24 hours of incubation, adrenocortical hormone concentrations were measured in the culture medium using liquid chromatography-mass spectrometry. RNA was isolated from the cells using the RNeasy Microkit (Qiagen) for subsequent real-time quantitative PCR analysis. Cell viability was assessed after 24 hours of incubation using alamarBlue™ Cell Viability Reagent. All CRN compounds effectively inhibited cortisol concentrations, while leaving aldosterone concentrations unaffected. In incubations with a maximal concentration of the three compounds, cortisol concentration decreased to undetectable levels. The mRNA expression levels of steroidogenic enzymes StAR, CYP11A1, CYP17A1, HSD3B2, CYP21, and CYP11B were significantly inhibited in most conditions when compared to the ACTH-stimulated control. The mRNA expression of melanocortin 2 receptor accessory protein (MRAP) was suppressed as well. Cell viability was not affected by CNR.1 or CNR.4, but was slightly inhibited by CRN.2. In summary, canine adrenocortical cell culture is a useful model system for drug testing. Incubation with MC2R antagonists demonstrated the potential of CNR.1 and CNR.4 as new treatment options for CD. Future in vivo studies in dogs with spontaneous CD are indicated.
The Effect of a Novel Glucocorticoid Receptor Antagonist (CORT113176) on Glucocorticoid and Insulin Receptor Sensitive Hepatic Gene (mRNA) Expression in a Neonatal Rat Model of Human Prematurity
Authors: Gehrand Ashley , Phillips Jonathan , Welhouse Kyle D , Schulgit Matthew , Siddiqui Hana , Raff Hershel
Published: May 2021

Preterm birth is a global health problem the sequelae of which are not well understood. Hypoxia, a common stressor with prematurity, can affect blood glucose via stress-induced increases in glucocorticoids (GC). GCs are also administered to preterm infants to improve oxygenation; however, this is controversial. CORT113176 (Corcept Therapeutics) is a novel, selective glucocorticoid receptor (GR) antagonist that does not bind to the progesterone receptor. We have demonstrated that CORT113176 (in our rat model of preterm birth) increases baseline corticosterone (due to loss of GC negative feedback) and attenuates hypoxia-induced increases in insulin resistance implicating endogenous corticosterone in post-natal metabolic adaptations to stress. We now propose that CORT113176 is useful to evaluate the hepatic effects of endogenous GCs in our rat model of preterm birth by measuring critical GC and insulin receptor sensitive gene mRNAs. Postnatal day (PD) 2 rat pups of both sexes (N=5 per treatment/sex) were pretreated with CORT113176 (600 mg/kg IP) or vehicle. After 60 minutes, a group of pups were euthanized with livers collected and preserved in RNAlater (baseline). The remaining pups were separated from their dams, exposed to normoxia (control) or hypoxia (8% O2) for 60 minutes, and livers obtained. Total hepatic RNA was extracted, and mRNA expression was analyzed (RT-qPCR) for GC and insulin receptor sensitive genes: GC: Fkbp5, Gilz, Nr3c1 (Gr), Nr3c2 (Mr), Per1, Ttpa. INSULIN: Akt2, G6Pase, Igf1r, Insr, Irs1, Irs2, Pik3cb, Pik3r1, Srebp1c. CORT113176 decreased the expression of all baseline hepatic insulin receptor mRNAs in both sexes, except for G6Pase. Pik3r1 mRNA expression significantly decreased with 60 minutes of normoxic separation (fasting) in males and females compared to baseline and hypoxic separation; this was blocked by CORT113176. In the GC receptor sensitive panel, CORT113176 decreased basal Nr3c1 (Gr) mRNA. Normoxic and hypoxic separation increased Per1 and Gilz mRNA expression; this effect was blocked by CORT113176. Interestingly, Fkbp5 expression, a proposed clinical marker for GR antagonism, was not altered by CORT113176. The hepatic GC and insulin receptor sensitive gene mRNA panels we developed are sensitive to GR antagonism suggesting they may be a useful addition to Fkbp5. The increase in endogenous corticosterone, acting via GR, is critical in the hepatic response to stress in our neonatal rat model of hypoxia and prematurity.