bluuebunny/crossref_metadata_2025 huggingface dataset:
The Impact of Cannabinoid Exposure on Glucocorticoid Receptor Signaling in Neural Stem Cells
Authors: Gill Nikki , Burale Suban , Silswal Neerupma , DeFranco Donald Benedict , Monaghan-Nichols Paula
Published: May 2021

Preterm birth-birth before 37 weeks of pregnancy-can cause many short- and long-term complications in newborns, including respiratory distress syndrome (RDS). RDS results from incomplete lung development and a surfactant deficiency, and it is a major factor of pre-term mortality. Synthetic glucocorticoids (sGCs) such as Betamethasone or Dexamethasone (Beta, Dex) are administered prenatally to women at risk of pre-term birth to prevent preterm complications. While sGCs are known to improve outcome, they also cause alterations in brain development and neural stem cell biology that are associated with long-term neurological defects.

One common recreational drug used during pregnancy is cannabis. Some of the active components of cannabis include cannabinoids, which interact with the endocannabinoid receptor pathway in cells. Cannabinoids have been shown to induce proliferation and differentiation of embryonic neural stem cells (NSCs). We hypothesized that maternal cannabis use activates cannabinoid signaling pathways and leads to changes in glucocorticoid signaling in the developing brain. The purpose of this study was to determine whether cannabis use leads to a better or worse neurological outcome for children born pre-term and treated with sGCs for RDS.

Neural stem cell neurospheres (NSCs) were isolated from the cerebral cortex of mice and treated with Vehicle (ethanol), Dex, cannabinoid receptor agonist WIN-55,212-2 (Win), or a combination WinDex. The transcriptional profile induced by exposure to Vehicle, Dex, and WinDex RNA were analyzed using microarray analyses examining the complete expressed genome. Gene Chip profiles indicated that both glucocorticoids and cannabinoids induce distinct transcriptional responses in E14.5 NSCs. The genes involved in proliferation-including S100a11, Jun, and Bex2-were repressed by Dex whereas WinDex rescued some of these expression profiles. Some genes encoding microRNA that inhibit our top target coding genes implicated in proliferation showed a greater induction by Dex compared to WinDex.

Quantitative Polymerase Chain Reaction (qPCR) was performed to validate our genes of interest, including Adm, which has been shown to induce neural stem cell proliferation and differentiation. The biological impact of Winn on Dex-induced changes in NSC function were examined by in-vitro proliferation and differentiation studies using antibodies to Tuj1 (neurons), GFAP (glia), and CNPase (immature oligodendrocytes). The experiments indicate that Dex increased neuronal and oligodendrocyte differentiation, while WinDex appeared to reverse this phenotype in neurons.

These studies suggest that cannabis use during pregnancy may limit the biological impact sGCs for preterm birth and lead to distinct cellular responses.
The Relationship Between Iodine Status and Thyroid Function in Congenital Hypothyroidism With Eutopic Thyroid Gland
Authors: Lee Yun Jeong , Heo You Joung , Choe Yunsoo , Park Sang Hee , Ko Jung Min , Shin Choong Ho , Lee Young Ah
Published: May 2021

Background: We investigated the relationship between iodine status and thyroid function in children with congenital hypothyroidism (CH) with eutopic gland. We also evaluated whether the presence of iodine organification defect (IOD) or pathogenic genetic variants affects the association between iodine status and thyroid function. Methods: A total of 31 children (14 boys) with CH participated in the study, who repeatedly underwent thyroid function test and urine iodine concentration (UIC) without levothyroxine (LT4) medication after 3 years of age (1-5 times per patient). After confirming eutopic gland, IOD was demonstrated by the positive perchlorate discharge test with a discharge rate >10%. Genetic analysis was performed using targeted gene sequencing including 23 genes. Results: We identified likely pathogenic or pathogenic variants in 14 cases (45.2%): 1 case with triallelic (digenic) variants (DUOX2 and TSHR), 4 cases with biallelic variants (3 DUOX2 and 1 TSHR), and 9 cases with monoallelic variants (7 DUOX2, 1 DUOXA2, and 1 TSHR). Among 26 cases treated with LT4 from neonatal period, thyroid function after LT4 discontinuation was euthyroid (n = 7), subclinically hypothyroid (n=15), and overtly hypothyroid requiring LT4 (n = 3). The other 5 cases without LT4 treatment remained subclinical hypothyroid. After excluding 2 cases with TSHR, 29 cases (with 72 samples) were included to analyze the relationship between iodine status and log-transformed TSH (log-TSH) using generalized estimating equation models. The positive IOD (n = 17) was not associated with presence of DUOX2/DUOXA2 variants (n = 12). Iodine status of urine samples was categorized into adequate (UIC < 300 μg/L, n = 25), mild excessive (UIC = 300-599 μg/L, n = 14), and severe excessive (UIC ≥ 600 μg/L, n = 33) groups. When stratified by the presence of IOD, log-TSH significantly increased in severe excessive group (β = 0.52, P = 0.014 vs. iodine adequate group) among negative IOD group, but rather decreased in mild excessive group (β = -0.84, P < 0.001 vs. iodine adequate group) among positive IOD group. Meanwhile, when stratified by the presence of DUOX2/DUOXA2 variants, no significant association was found between iodine status and log-TSH levels. Conclusion:DUOX2 mutation was most common in CH patients with eutopic gland. The relationship of iodine status with thyroid function differed by presence of IOD.
Growth Plate Genes Are Key Regulators of Growth: Lessons Learned From Children of Consanguineous Families From Kurdistan, Iraq
Authors: Amaratunga Shenali Anne , Tayeb Tara Hussein , Dusatkova Petra , Elblova Lenka , Pruhova Stepanka , Lebl Jan
Published: May 2021

Introduction: The genetic basis of human growth regulation has only been partly elucidated thus far. Therefore, finding causative genes in patients with short stature help in understanding precise pathophysiological mechanisms, establishing genotype-phenotype relationships and optimizing treatment. In order to extend our knowledge about the genes involved in short stature, we studied a unique cohort of consanguineous families with children with short stature from Sulaymani in Kurdistan, Iraq. Patients and Methods: Fifty-five consanguineous families, with children shorter than -2.3SDS at the time of examination (median height -3.3SDS, range -2.3 to -15SDS), who were examined at the endocrine outpatient clinic of the Department of Pediatrics, Sulaymani University College of Medicine between January 2018 and February 2020, were included in the study. In families with more than one child with short stature, the shorter sibling was selected as the proband (median age 8 years, range 1 - 15 years). Three probands were subsequently excluded due to the diagnosis of Turner’s syndrome and Edward’s syndrome Consent was obtained from all families and probands’ DNA was analyzed by Whole Exome Sequencing (WES) methods. The data were processed by a bioinformatic pipeline and detected variants were filtered using variant analysis software. Selected potentially pathogenic variants were confirmed using Sanger sequencing methods and evaluated by the American College of Medical Genetics (ACMG) standards and guidelines. Results: A monogenic cause of short stature, which explained the patient phenotype, was elucidated in 13 of 26 families who were analyzed thus far. Seven families had multiple affected children making a total of 22 patients with a positive genetic diagnosis. Pathogenic or likely pathogenic variants (according to the ACMG standards) were found in genes involved in the GH-IGF-1 axis (GHR), in the extracellular matrix of the growth plate (COL1A2, MMP13, LTBP3, and ADAMTS17), in the regulation of chondrocytes (NPR2 and CTSK), transporter coding genes (SLC34A3), and other genes (PTCH1, GALNS, DNACJ21, ZSWIM6, GNPTG). Among them, there are 9 novel variants and 10 homozygous variants including variants in genes causing syndromic short stature. Unexpectedly, we successfully identified three cases of autosomal dominant short stature (variants in genes NPR2, COL1A2, PTCH1) as well. The remaining probands from 26 families are still being analyzed. Conclusion: With the help of NGS methods, we have successfully elucidated the genetic cause of short stature in nearly 50% of patients who were analyzed thus far. These results further strength the concept that genes affecting the growth plate (chondrocytes and the extracellular matrix) play a crucial role in growth regulation. Acknowledgements: The study was co-funded by grants AZV 18-07-00283 and GAUK 340420.
11-oxyandrogen Concentrations in Adolescents With Polycystic Ovary Syndrome (PCOS)
Authors: Taylor Anya , Ware Meredith A , Breslow Emily , Pyle Laura , Severn Cameron , Chan Christine L , Kelsey Megan Moriarty , Cree-Green Melanie
Published: May 2021

PCOS is common in adolescents and includes excess testosterone concentrations. The clinical importance of 11-oxyandrogens in PCOS is unclear. We sought to determine if fasted morning 11-oxyandrogens: 1) better identify PCOS diagnosis compared to testosterone, 2) relate to clinical comorbidities of PCOS, 3) are altered with combined oral contraceptive pill (COCP) or metformin therapy. Data from 186 adolescent females aged 12-21 years, mostly obese, enrolled in one of 6 studies in our division were included: 115 untreated PCOS (13 lean, BMI 22.5±2.2 kg/m2; 102 overweight/obese, BMI 35.4±5.3), 9 obese PCOS treated with COCP (BMI 33.7±5.7), 6 obese PCOS treated with metformin (BMI 36.4±5.3) and 70 normally cycling controls (19 lean, BMI 19.9±1.4; 52 overweight/obese BMI 35.5±10.4). Three 11-oxyandrogens (11-hydroxyandrostenedione (11OHA), 11-hydroxytestosterone (11OHT), and 11-ketotestosterone (11KT) and total testosterone were analyzed via liquid chromatography tandem mass spectroscopy (LabCorp/Esoterix, Calabasas, CA). Data between 1) untreated PCOS and controls and 2) untreated PCOS and the 2 treatment groups were compared. ROC analysis was performed to evaluate accuracy of diagnosis of PCOS and Pearson’s correlation coefficient was calculated for 11-oxyandrogens and clinical measures. Untreated PCOS girls had higher 11OHA (129±77 ng/dL PCOS vs 97±52 control, p=0.003) and 11OHT (13.8±7.9 ng/dL PCOS vs 10.5±6.7 control, p=0.005) compared to controls, with no difference in 11KT (30.7±17.3 ng/dL PCOS vs 26.6±16.6 control, p=0.208). Only 11OHA remained significant after controlling for obesity via multiple linear regression. However, neither of these metabolites better predicted PCOS status compared to testosterone (ROC analysis: 11OHA AUC=0.620, p=0.006; 11OHT AUC=0.638, p=0.002; total testosterone AUC=0.840, p<0.001, free androgen index AUC 0.860, p<0.001). Among girls with PCOS, all three 11-oxyandrogens correlated with hirsutism severity as graded by Ferriman Gallwey score. COCP treatment decreased 11KT concentrations compared to untreated PCOS (32±17 untreated vs 17±8 ng/dL COCP; p=0.039) as well as total testosterone (46.9±21 untreated vs 28.1±12.9 ng/dL COCP; p<0.006). However, metformin treatment had no effect 11-oxyandrogens, although total testosterone was lower (46.9±21 untreated vs 26.5±5.9 metformin; p=0.01). Whereas 11-oxyandrogens would not aid in the diagnosis of PCOS, they relate to excess hair growth and 11KT decreases with COCP therapy. Further work is needed to determine the relationship with metabolic outcomes and the clinical utility of measuring these androgens in PCOS.
MRNA Expression of Adipocytokines and Glucose Transporter Type 4 (GLUT4) in Adipose Tissue in Women With and Without Polycystic Ovary Syndrome
Authors: Ozga Katarzyna Maria , Sendrakowska Magdalena Krzyczkowska , Milewicz Tomasz , Sanak Marek , Jach Robert
Published: May 2021

Background: The main feature of polycystic ovary syndrome (PCOS) is hyperandrogenism, adipocytes hypertrophy and chronic low-grade inflammation. It is known that PCOS is closely linked to functional dysfunction in adipose tissue, which in turn are connected with metabolic disturbances such as insulin resistance. However, there is no complete characterization of the adipose tissue in women with PCOS. Aim: To compare the expression of adipocytokines between women with and without PCOS. Materials and Methods: The total number of twenty two participants were enrolled into the study. Study group included ten women with PCOS diagnosed according to the Rotterdam criteria, the control group- twelve women without PCOS. Approximately 3 g of tissue was excised from subcutaneous adipose tissue through a small incision in the suprapubic area. mRNA was isolated and gene expression profiling was performed including following genes: GLUT4, irisin, leptin, omentin, vaspin, adiponectin, visfastin, apelin, serum amyloid A1 and chemerin. Blood samples were taken between 3rd and 5th day of the menstrual cycle to evaluate serum hormonal levels. The oral glucose tolerance test (OGTT) was done simultaneously with the assessment of glucose and insulin plasma levels at 0, 60 and 120 minute. Results: Patients with PCOS presents different mRNA expression of adipocytokines compared with control group. There were statistically significant differences in irisin, leptin, omentin, visfastin, chemerin and serum amyloid A1 expression, that were higher in PCOS. GLUT-4 and adiponectin expression was significantly lower in PCOS patient compared to control. Due to an insufficient measurement of apelin and vaspin gene expression there were not included in following analysis. Conclusions: mRNA expression of adipocytokines in adipose tissue in women with and without polycystic ovary syndrome is different. In women with PCOS, there is a higher expression of genes for most of adipocytokines with lower for adiponectin and GLUT-4.
Obesity Induces Elevated Oxidative Stress in Uteri of Reproductive Age Mice
Authors: Huang Jane , Xiao Emily , Tal Aya , Kelly Kate Corbett , Kim Jung Dae , Whirledge Shannon Deanne , Flannery Clare Ann
Published: May 2021

Obesity is an independent risk factor for endometrial cancer. We hypothesize that obesity changes endometrial physiology, increasing cellular vulnerability to cancer development. We previously found widespread increases in cytochrome P450 (CYP) expression in the uteri of diet-induced obese mice. CYP enzymatic activity is associated with oxidative stress and altered intracellular estrogen metabolism, which increases the potential for oncogenesis. To assess oxidative stress and related DNA damage in uterine tissue, we measured protein carbonyl (PC) and 8-oxo-2’-deoxyguanosine (8-OHdG) levels, respectively, in obese and lean mice.

Post-pubertal C57BL/6 female mice were fed high-fat chow (HF; 45% fat; n=20) or normal chow (NC; 18% calories from fat; n=10) for either 10 or 22 weeks. The mice underwent insulin tolerance testing and MRI for body composition. Vaginal smears were analyzed over 10 days for estrous cycling (n=5 per group). PC and 8-OHdG levels were quantified from uterine tissue lysates and DNA fractions using colorimetric ELISAs and analyzed by 2-tailed t-tests.

The HF mice had 64% higher body fat than NC mice after 10 weeks of diet (24±2% vs. 15±1%; p<0.003) and 176% higher body fat after 22 weeks of diet (35±2% vs. 13±2%; p<0.0001). Additionally, compared to NC mice, insulin levels in HF mice were 1.6-fold higher after 10 weeks (0.89±0.05 vs. 0.55±0.03 ng/mL; p<0.0008) and 2.8-fold higher after 22 weeks (3.56±0.49 vs. 1.28±0.21 ng/mL; p<0.005). Estrous cycle analysis showed obesity-related disruptions by 22 weeks, with HF mice spending 30±3% of their time in the proestrus phase versus 18±2% in NC mice (p<0.03). After 10 weeks of diet, HF and NC mice had similar levels of PC (p=NS). By 22 weeks of diet, however, the HF mice had a 2.3-fold increase in PC compared to the NC mice (1.11±0.2 vs. 0.49±0.09 nmol/mg; p<0.02). While HF and NC mice had similar levels of 8-OHdG for each diet group (p=NS, respectively), 8-OHdG levels increased with age between 10 and 22 weeks of diet in both HF (7.51±1.25 vs. 12.41±1.87 ng/mL; p<0.03) and NC (6.87±1.28 vs. 15.16±2.88 ng/mL; p<0.01) mice.

We show that the uteri of reproductive age mice are altered by chronic diet-induced obesity and hyperinsulinemia. Uterine oxidative stress was higher with increased duration and severity of obesity, and may also be affected by the disrupted HPO axis. In contrast, obesity did not appear to promote DNA damage, suggesting that DNA repair mechanisms remain intact under conditions of increased oxidative stress. The age-dependent increase in 8-OHdG levels demonstrates an expected accumulation of DNA damage over time, which reinforces C57BL/6 mice as an adequate model for human endometrial disease. In sum, this study suggests that chronic high-fat consumption and long-term obesity increase oxidative stress over time and may contribute to the development of a pre-cancerous phenotype in human endometrium.
Factors Impacting Quality of Life in Patients With Klinefelter Syndrome: A Systematic Review with Narrative Synthesis and Meta-Analysis
Authors: Mehmet Brien , Llahana Sofia V
Published: May 2021

Objective: To identify how Klinefelter’s Syndrome affects patients’ quality of life (QoL) and to determine which subsections of QoL are affected guided by the WHOQOL100-tool as an overarching framework for QoL. To determine the effects and impact KS has on patients’ QoL when compared to the QoL of healthy controls and general population. DESIGN - Systematic review of studies reporting QoL factors among patients with KS which included narrative synthesis and thematic analysis of 17 studies and a meta-analysis of intelligence quotient (IQ) completed in 7 studies. QoL factors were reviewed based on the parameters of the WHOQOL-100: physical health, psychological, level of independence, social relations, environment, and religion/spirituality/personal beliefs. DATA SOURCES - Medline, Cochrane, Embase, Psychinfo, CINAHL, BASE and grey search from the reference lists of key publications. Eligibility Criteria: RCT’s, Cohort studies, cross sectional studies and Epidemiology studies involving patients with KS and reporting on QoL parameters. Only human studies published in English were considered with no limits for publication date. Results: Out of all studies included (n=1266), (87.5%) had suggested KS negatively affected the outcomes measures tested, where recorded (91.1%) of studies had small/medium/large effect sizes (Cohen’s d). Narrative synthesis suggests all subgroups of QoL excluding ‘environment’ and ‘spirituality/faith/personal beliefs’ were negatively impacted for patients with KS, whilst meta-analysis showed statistical significance (P <0.00001) which identified patients with KS having lower full-scale IQ compared to healthy controls. Psychological parameters were the most affected in this patient group, showing that patients with KS experienced greater social anxiety, distress during social interactions, self-esteem, self-injuries behaviours and symptoms or traits related to Autism spectrum. Conclusions: This review identifies the significant evidence supporting that QoL is reduced in patients with KS. There is a large spectrum of symptoms and no standard phenotype for KS suggesting that multiple facets of QoL are negatively impacted in these patients due to the complex nature of KS and the severity of symptoms and phenotype associated with KS. PROSPERO REGISTRATION NUMBER - CRD4202017343
Exploring NCX4040, an Aspirin Derivative, as a Potential Treatment for Benign Prostatic Hyperplasia
Authors: Shahagadkar Preksha Vaibhav , Munirathinam Gnanasekar
Published: May 2021

Benign Prostatic hyperplasia (BPH) is a leading cause of lower urinary tract symptoms which affects men above 50 years of age. Chronic inflammation and abnormal proliferation of stromal and epithelial cells are implicated in BPH disease onset. The symptoms of BPH include back pain and difficulty in emptying bladder. Finasteride, sildenafil and tamsulosin are some of the drugs used to ease difficulty urinating and relax the muscles of the gland. Transurethral resection of the prostate or laser surgery can be performed to treat severe symptoms. However, these therapies have deleterious effects such as low blood pressure, ejaculatory dysfunction, and lump formation. Hence, there is an unmet need for potential drugs against BPH. Nonsteroidal anti-inflammatory drugs (NSAIDs) have proven to be effective in cancers but their applicability in BPH condition is yet to be fully explored. Aspirin, one of the NDSAIDs, has anti-tumor and anti-inflammatory properties at higher doses. NCX4040, a nitric oxide releasing derivative of aspirin, could prove to be effective against BPH, since it can inhibit abnormal cell proliferation and serve as a vasodilator. We hypothesize that NCX4040 would be an effective drug to treat BPH. BPH-1 epithelial and WPMY-1 stromal cells were used as in vitro models of BPH. MTT assay was performed to check the inhibitory effect of NCX4040 and blocking agents like catalase and N-acetyl-L-cysteine (NAC) were explored on cells after treatment. Clonogenic assay was done to explore the colony formation ability of cells. Spheroid assay was performed to analyze the anti-proliferative effect of NCX4040. Annexin V/PI and cell cycle analysis was performed to check for apoptosis and cell cycle arrest in the cells. Western blot was done to assess the signaling molecules altered by NCX4040 in BPH-1 cells. Confocal immunofluorescence was employed to analyze the dynamics of actin filaments after treatment in cells. Our studies revealed that NCX4040 inhibited the cell viability of BPH-1 and WPMY-1 in a dose dependent manner with IC50 predicted at 5µM and 2.5µM respectively. Of note, catalase and NAC blocked the effect of NCX4040 on prostate cells. Colony formation assay result implied a gradual decrease in the number of colonies of cells treated with NCX4040 with 2.5µM and 5µM doses. Spheroid assay in BPH-1 cells showed inhibitory effects after treatment. Cell cycle analysis by flowcytometry inferred that cell cycle arrest at G2/M phase and annexin V analysis indicated that activation of apoptosis in cells following treatment. Phalloidin staining showed decrease in the actin filament intensity in cells. At the molecular level, NCX4040 downregulated the expression of key markers such as RhoA, p65, COX-2, PCNA, Cyclin D3, and PDE-5 in BPH-1 cells. Taken together, NCX4040 could be used as a potential agent to manage BPH with minimal side effects, which needs further evaluation in animal models.
Fadrozole-Mediated Sex Reversal Induces PAX2+Undifferentiated Supporting Cells in Female Chicken Gonads
Authors: Estermann Martin Andres , Smith Craig Allen
Published: May 2021

During early embryogenesis, the undifferentiated gonad is bipotential and subsequently commits to an ovarian or testicular fate. In birds, double dose of the Z-linked gene DMRT1 is required for testicular differentiation in male embryos (genetically ZZ). In female birds, estrogen plays a key role in ovarian differentiation. 17β-estradiol (E2) induces gonadal feminization when applied to male embryos (ZZ). Conversely, inhibition of estrogen synthesis with the drug fadrozole (FAD) results in testicular development in genetically female embryos (ZW). However, activation of male markers in sex-reversed ZW embryos is typically delayed, raising the possibility that FAD-treated embryos may transition through an undifferentiated state before masculinization. Recently, PAX2 was identified as a marker of undifferentiated supporting cells in the chicken embryo, being downregulated in both sexes at the onset of gonadal sex determination. To investigate the supporting cell differentiation process in estrogen-mediated sex reversal, we injected 1 mg of fadrozole in 100µl of PBS or vehicle into embryonic day 3.5 (E3.5) chicken eggs. Eggs were incubated until E9.5, genotypically sexed (ZZ or ZW) and processed for qRT-PCR and immunofluorescence. Quantitative RT-PCR confirmed that sex reversal had occurred in FAD-treated females, showing a reduction of pre-granulosa cell markers aromatase (P<0.005) and FOXL2 (P<0.05), compared to the control. Interestingly, PAX2 mRNA expression was up-regulated (P<0.05) in sex-reversed females, suggesting an increase in undifferentiated supporting cells (n=6). To confirm this observation, immunofluorescence was used to detect aromatase, SOX9 (male marker) and PAX2. In FAD-treated females, both SOX9+ (male) and aromatase+ (female) cells co-existed in the same gonad, but in separated defined regions. Aromatase positive cells were located in the most apical region of the gonad whereas SOX9 positive cells were detected in the basal region. We detected an increase in PAX2 positive cells in the gonadal medulla between the SOX9 and aromatase positive supporting cells. No SOX9 or PAX2 positive cells were detected in control female gonads (n=3). For feminization experiments 100µl of a 1mg/ml solution of E2 or vehicle (Oil) was injected into E3.5 chicken eggs. No significant increase in PAX2 was detected by qRT-PCR (p>0.05, n=6) and no PAX2 positive cells were detected in E2 treated gonads at E9.5. These results suggest that in fadrozole-mediated masculinization (but not in estrogen-induced feminization) there is an increase in undifferentiated supporting cells. The absence of both estrogens (feminizing) and elevated DMRT1 (masculinizing) could explain why the supporting cells remain in an undifferentiated state in ZW (genetically female) embryos. Further research is required to evaluate the fate of these undifferentiated cells in gonadal sex differentiation.
Lack of Association Between ACE2 Expression and Serum Testosterone Concentrations in Peripheral Mononuclear Cells in Males
Authors: Ling Guyou , Campbell Robert , Bruno Jonathan , Goffinet Aaron , Krebs Joseph , Jain Ajay , Dhindsa Sandeep S
Published: May 2021

Background: Male sex is a risk factor for developing severe COVID-19 illness, hospitalization, and mortality. It is possible that the male sex hormone, testosterone, contributes to the morbidity from COVID-19. SARS-CoV2 viruses use cell membrane protein Angiotensin-Converting Enzyme 2 (ACE2) receptor and undergo S protein priming by the Type II Transmembrane Serine Protease (TMPRSS2) to enter the cells. Hence, the expression level of ACE2 and TMPRSS2 may affect disease susceptibility and possible severity. TMPRSS2 is regulated by the androgen receptor. We, therefore, examined if an association exists between serum testosterone concentrations and ACE2 or TMPRSS2 expression level in men.

Methods: We analyzed fasting serum samples and peripheral blood mononuclear cells (MNC) from 42 men. Total and free testosterone and estradiol were measured by liquid chromatography/equilibrium dialysis. Sex hormone binding globulin (SHBG) was measured by chemiluminescence. mRNA was prepared from MNC. Quantitative RT-PCR was conducted using commercially available, pre-designed TaqMan primers and probes targeting ACE2. The ACE2 relative level was calculated after normalization to beta Actin and GAPDH, with lowest ACE2 level being set to 1.

Results: Subjects’ age ranged from 20 to 65 years. Type 2 diabetes was present in 74% of the men and the mean HbA1 was 7.2±1.6% (mean ± S.D.). Fifteen subjects had subnormal free testosterone (<50 pg/ml). Compared to the 27 subjects with normal free testosterone, they were older (49±12 vs 40±13 years, p=0.03) but had similar BMI (36±10, 35±10 kg/m2, p=0.71). As expected, they had lower total testosterone (Median [25th, 75th percentile]; 222 [171-266] vs 431 [335, 618] ng/dl, p<0.001) and free testosterone concentrations (39 [21, 44] vs 72 [59, 92], p<0.001). Total estradiol was also lower in this group (19±1 vs 29±13 pg/ml, p=0.03) but free estradiol (0.44±0.33 vs 0.56±0.34 pg/ml, p=0.44) and SHBG (27 [19, 33] vs 30 [21, 39] nmol/L, p=0.52) were similar. Quantitative PCR data showed there was a large inter-individual variation of ACE2 expression level, up to 15-fold difference. Average ACE2 level did not differ between subnormal and normal testosterone groups (3.4 [2.7, 5.0] vs 3.9 [2.5, 5.7] arbitrary units). ACE2 expression was not related to free testosterone (r=0.11), free estradiol (r=0.18) or sex hormone binding globulin (r=0.15) on linear regression analyses (p>0.30 for all). ACE2 expression was also not related to age (r= -0.15, p=0.34), BMI (r= -0.2, p=0.23) or presence of diabetes. We were not able to detect a significant expression of TMPRSS2 in MNC.

Conclusion: Our results do not support a role for testosterone or estradiol as regulators of ACE2 expression in peripheral blood MNC in males.
Bioidentical Hormone Replacement Therapy at a Hormone Clinic Causing Significant Virilization in a Post-Menopausal Women
Authors: Tsushima Yumiko , Mikhael Alexandra
Published: May 2021

Introduction: Bioidentical hormones (BH) are compounds that have the exact chemical and molecular composition as hormones produced in our bodies. The term typically refers to testosterone, progesterone, and androgens. Compounding pharmacies market these products as being individually tailored, safer, and more effective than modified hormones synthesized under FDA supervision. These compounded products are not subject to FDA approval for dose, purity, safety, or efficacy, which poses a risk to patients. Our case highlights the dangers of unmonitored BH replacement therapy (BHRT) use and the importance of patient education regarding these products.

Clinical Case: A 48 year-old woman presented to our clinic for evaluation of elevated testosterone levels. She underwent a total hysterectomy and bilateral oophorectomies 8 years prior for heavy menses. She was briefly placed on estradiol replacement which was discontinued due to tobacco abuse. She presented to a “hormone clinic” where she was told that her testosterone levels were low and was started on BHRT pellets. The composition of these pellets were not disclosed on the manufacturer’s website. They were to be inserted every 3 months. The patient had received two pellet insertions prior to her initial visit.

The patient reported feeling miserable with nausea, headaches, hot flashes, severe hirsutism, hair loss, severe aggression, increased libido, and clitoromegaly (the size of a ping-pong ball). Physical exam was notable for hirsutism of the upper lip, cheeks, and chin. No obvious foreign objects were identified in the buttocks. Genital exam was declined. Lab results prior to pellet insertion showed: total testosterone 6 ng/dL (N: 8-60 ng/dL), FSH 96.4 mU/ml (post-menopausal: 20-100 mU/ml) and estradiol < 5 pg/mL (post-menopausal < 41 pg/mL). After the initial pellet insertion: total testosterone 320 ng/dL, FSH 85.3 mU/mL, and estradiol 36.2 pg/mL. Five months after the second pellet insertion, total testosterone was 112 ng/dL, DHEAS 15.2 ug/dL (N: 35.4-256.0 ug/dL), FSH 74.9 mU/mL, and estradiol 46 pg/mL. Ultrasound of the buttocks revealed 1 ovoid hypoechoic structure in each buttock.

The patient underwent surgical removal of the pellets. Post-procedural total testosterone was < 12 ng/dL (N < 40 ng/dL). Her aggression and hirsutism improved, but libido became low and clitoromegaly remained unchanged.

Conclusion: The misunderstanding that BHRT is safer and more effective than synthesized, FDA-regulated hormones can lead to harmful adverse effects as seen in our patient with significant signs and symptoms of virilization. Patient education regarding the safety and efficacy of unregulated use of these compounds is crucial along with heightened physician awareness for appropriate patient guidance.
Cyclical Premenstrual Psychosis - Sometimes It Is Your Hormones
Authors: Rawal Malika , Folsom Lisal J
Published: May 2021

Background: Menstrual psychosis is a broad term used to describe a number of disorders characterized by the acute onset of psychotic symptoms with brief duration, complete resolution of symptoms between episodes, with timing related to menses. This entity was first described in the 18th century, with only 27 confirmed cases using strict diagnostic criteria. While research into causation is limited, estrogen withdrawal is thought to precipitate psychotic symptoms. We describe a case of premenstrual psychosis successfully treated with use of transdermal hormonal contraception and extended menstrual cycling. Clinical Case: A 25-year-old non-binary biologic female (they/them/theirs) with bipolar disorder, anxiety, and psychogenic non-epileptiform seizures was referred to endocrinology for evaluation of recurrent psychotic symptoms associated with menses. They endorsed stable mental health symptoms on aripiprazole except during the seven days prior to their menstrual cycle. During this time they reported persistent auditory hallucinations along with dysmenorrhea, with symptoms resolving at the onset of menses. Timing of menarche was uncertain, however they reported oligomenorrhea until beginning oral contraceptives at age nineteen, after which they developed regular monthly cycles accompanied by psychotic symptoms. Pituitary and ovarian hormone levels were unable to be assessed due to hormonal contraception. Prolactin was 8.3 ng/mL (3-30 ng/mL). In order to limit hormonal fluctuations from daily oral contraceptive pills and monthly withdrawal, the decision was made to transition to transdermal norelgestromin and ethinyl estradiol patches changed weekly, with extended cycling to allow one menstrual cycle every three months. At follow-up visit nine months later they reported resolution of auditory hallucinations on this regimen, with symptoms recurring only during extreme stress. Conclusions: While the etiology of menstrual psychosis is unclear, described treatments include a combination of neuroleptics and hormonal therapy, including estrogen, progesterone, and GnRH agonists. As symptoms did not resolve until suppression of monthly menstrual cycles, this case supports the estrogen withdrawal hypothesis. Our case adds to the literature both in that transdermal, rather than oral or injectable therapy was used, and treatment was successful in alleviating the patient’s psychotic symptoms, improving their mental health and quality of life. References: (1) Brockington, I. Menstrual Psychosis. World Psychiatry 2005;4(1):9-17. (2) Reilly, T.J., Sagnay de la Bastida, V.C., Joyce, D.W., Cullen, A.E., McGuire, P. Exacerbation of Psychosis During the Perimenstrual Phase of the Menstrual Cycle: Systematic Review and Meta-analysis. Schizophrenia Bulletin 2020;46(1):78-90.
Effect of Omalizumab for Autoimmune Progesterone Dermatitis Refractory to Bilateral Oophorectomy: A Case Report
Authors: Varghese Akshay , Paul Terri Louise , Kim Harold , Vadas Peter , Van Uum Stan , Azzola Alescia Linda
Published: May 2021

Background: Autoimmune progesterone dermatitis (APD) is a rare skin condition caused by sensitivity to high levels of progesterone secreted during the luteal phase of the menstrual cycle. This may be due to various pathophysiological mechanisms including a Type I and Type IV hypersensitivity reaction, and potential cross-reactivity with other endogenous steroid hormones such as 17-α-hydroxyprogesterone. We present the case of a patient with APD who had her flare-up episodes controlled using omalizumab, after a bilateral oophorectomy failed to resolve her symptoms. Clinical Case: A 34-year-old female presented to our Endocrine Clinic with marked Cushingoid features secondary to high-dose oral prednisone prescribed for APD diagnosed six years earlier. She first developed a pruritic maculopapular rash on her arms and legs just after the birth of her second child in 2009. The rash was also associated with headaches and diffuse angioedema. It presented in a cyclical fashion, beginning one to two days before the start of her menstrual cycle, and ending shortly after it was complete. The severity of symptoms increased as time went on, and flare-ups began to also include dyspnea, nausea, vomiting and abdominal pain. After three years of persistent symptoms, the diagnosis of APD was confirmed by a progesterone skin test. Her symptoms were improved with oral prednisone use, however breakthrough episodes still occurred. After multiple failed treatment modalities, she elected bilateral oophorectomy in 2018. However, her symptoms of APD persisted and she still required high-dose oral prednisone. Her condition was further complicated by vasomotor menopausal symptoms and progressive iatrogenic Cushing’s syndrome. She eventually was started on Omalizumab, which helped resolve her APD symptoms and allowed her to wean off prednisone. Vasomotor menopausal symptoms were resolved using conjugated estrogens with bazedoxifene. However, her symptoms of diffuse bony indeterminate bony pain and arthralgias which started whilst on prednisone have persisted in spite of discontinuing prednisone. Conclusion: To our knowledge, this is only the third case of APD which was successfully treated with Omalizumab and the first case where a bilateral oophorectomy failed to resolve symptoms of APD in the literature. Our case also demonstrates the complications of vasomotor menopause symptoms secondary to a bilateral oophorectomy, as well as the adverse effects of long-term glucocorticoid therapy.
Need for Screening Triglyceride Levels in Women on Oral Contraceptives
Authors: Yau Alice , Idowu Abidemi , Elayaperumal Pramma , Gryguc-Saxanoff Agnieszka , Martinez Jose , Bahtiyar Gul , Rodriguez Giovanna
Published: May 2021

Introduction: Oral contraceptive pills (OCPs) are the most used form of reversible contraceptives by women. Major risks are cardiovascular but OCPs also cause secondary hypertriglyceridemia (HTG) through effects of estrogen, which decreases hepatic triglyceride lipase and lipoprotein lipase activity. This causes increased triglycerides, cholesterol and free fatty acids,1 which then in turn can lead to life-threatening acute pancreatitis.

Case Description: A 23-year-old morbidly obese (BMI 38.2 mg/kg2) female presented with severe epigastric pain, nausea and vomiting. She had a history of mild intermittent asthma, recently diagnosed pre-diabetes and recently started on OCPs. Initial labs were consistent with diabetic ketoacidosis with glucose 528 mg/dL (65-115 mg/dL), anion gap 21 mEq/L (5-15 mEq), and beta-hydroxybutyrate 2.00 mmol/L (0.02-0.27 mmol/L); and acute pancreatitis with triglyceride 4,425 mg/dL (30-200 mg/dL) and lipase >600 U/L (8-78 UL), confirmed on imaging.

She rapidly deteriorated, developing acute hypoxemic respiratory distress requiring intubation and distributive shock requiring three vasopressors. She progressed into multi-organ failure with acute respiratory distress syndrome, ischemic liver and acute renal failure despite insulin drip, colloidal fluid resuscitation, continuous veno-venous hemofiltration and high positive end-exploratory pressures. She developed rhabdomyolysis, followed by abdominal compartment syndrome requiring decompressive laparotomy that resulted in large volume blood loss and retroperitoneal necrosis needing multiple laparotomies. Ultimately, she became non-responsive off sedation, attributed to malignant cerebral edema that progressed to brain herniation.

While HTG was likely the cause of her pancreatitis, she had normal triglyceride levels on prior routine lab work while not on OCPs.

Discussion: Severe acute pancreatitis is a life-threatening complication of HTG which may be precipitated by use of OCPs. We believe that there is a need for more research in this field and even propose periodic monitoring of HTG in women taking OCPs given the severity of the consequences. While there are currently no guidelines for monitoring lipid levels in women on OCP, appropriate clinical awareness of physicians prescribing OCPs to patients may prevent fatal outcomes.

References: 1. Stumpf, M., Kluthcovsky, A., Okamoto, J., Schrut, G., Cajoeiro, P., Chacra, A. and Bizeli, R. (2018). Acute pancreatitis secondary to oral contraceptive-induced hypertriglyceridemia: a case report. Gynecological Endocrinology, 34(11), pp.930-932.
Development of Hip Bone Geometry in Transgender Adolescents Resembles the Experienced Gender if GnRHa Treatment Is Started in Early, but Not Late, Puberty
Authors: van der Loos Maria A T C , Hellinga Ilse , Vlot Mariska C , Klink Daniel T , Den Heijer Martin , Wiepjes Chantal M
Published: May 2021

Bone geometry can be described in terms of periosteal and endocortical growth and is partly determined by sex steroids. Periosteal and endocortical apposition are thought to be regulated by testosterone and estrogen, respectively. Gender-affirming hormone (GAH) treatment with sex steroids in transgender people might affect bone geometry. However, in adult transgender people no change in bone geometry during GAH was observed. In this study, we investigated changes in bone geometry among transgender adolescents using a gonadotropin-releasing hormone agonist (GnRHa) and GAH prior to achieving peak bone mass. Transgender adolescents treated with GnRHa and subsequent GAH at our center before the age of 18 years were eligible for inclusion. Participants were grouped based on their Tanner stage at the start of GnRHa treatment and divided into early, mid, and late puberty groups. Hip Strength Analysis software calculating subperiosteal width (SPW) and endocortical diameter (ED) was applied to dual-energy X-ray absorptiometry scans performed at start of GnRHa and GAH treatments, and after ≥ 2 years of GAH treatment. Mixed model analyses were performed to study differences over time. Data were visually compared with reference values of the general population retrieved from the literature. A total of 322 participants were included, of whom 106 trans women and 216 trans men. In both trans women and trans men participants resembled the reference curve for SPW and ED of the experienced gender, but only when GnRHa was started during early puberty. Those who started during mid- and late puberty remained within the reference curve of the gender assigned at birth. A possible explanation might be sought in the phenomenon of programming, which conceptualizes that stimuli during critical windows of development can have major consequences throughout one’s lifespan. Therefore, this study adds insights into sex-specific bone geometry development during puberty of transgender adolescents treated with GnRHa, as well as the general population.
Concomitant Pheochromocytoma and Primary Aldosteronism: A Case Series and Literature Review
Authors: Mao Jimmy J , Baker Jessica , Rainey William E , Young William F , Bancos Irina
Published: May 2021

Objective: The detection and management of concomitant pheochromocytoma (PHEO) and primary aldosteronism (PA) is not well understood. Our objectives were to investigate varying presentations and outcomes of cases with coexisting PHEO and PA to provide an approach to its diagnosis and management. Design: Retrospective case series from 2000–2020 at a single institution tertiary center; additional review of previously known cases before 2000 and from the medical literature. Patients and Measurements: Adult patients with concomitant PHEO and PA. Clinical, biochemical, radiologic, and histologic parameters were reviewed. Results: Fifteen patients (53% men, median age 53 years) were diagnosed with concomitant PHEO and PA. The majority presented with hypertension (13, 87%) and hypokalemia (13, 87%), but only 6 (40%) presented with symptoms suggestive of catecholamine excess. All patients with preoperative work-up for catecholamine excess (14, 93%) were found to have elevated plasma or urinary metanephrines/catecholamines above the upper limit of normal. Adrenal vein sampling (AVS) was performed in 9 (60%) patients, where 5 (56%) were diagnosed with bilateral PA, and 4 (44%) with unilateral PA. All patients underwent either unilateral (12, 80%) or bilateral (3, 20%) adrenalectomy to treat their PHEO and/or PA. Postoperative catecholamines and/or catecholamine breakdown products normalized or improved in 13 (87%) patients and were not measured in 2. Recurrence of PHEO was not observed. Six (40%) displayed persistent PA postoperatively, where 4 required long-term mineralocorticoid blockade. Conclusions: Concomitant PHEO and PA is a rare but likely under-reported condition. Hypertension with or without hypokalemia should prompt evaluation for PA, while any indeterminate adrenal mass should be worked up for PHEO. Coexisting disease warrants consideration of AVS to determine the laterality of PA to ensure appropriate management.
Stability of Weekly Intramuscular Estradiol Cypionate in a Transgender Woman
Authors: Calzada Stephanie , Sarvaideo Jenna Lynne
Published: May 2021

Background: Transgender women often take estrogen with or without an antiandrogen to achieve the physical and physiological changes of estrogen. Estradiol may be administered through intramuscular (IM) injection weekly or every other week (1). It is thought that weekly IM estradiol may be more stable than every other week administration. The objective of this case was to evaluate the levels of IM estradiol cypionate when administered weekly.

Clinical Case: A 38-year-old transgender woman with a past medical history of gender dysphoria, type 2 diabetes mellitus, hyperlipidemia, obstructive sleep apnea compliant with continuous positive airway pressure, class 3 severe obesity, anxiety, depression and a non-smoker, presented for evaluation for hormone replacement therapy (HRT). The patient wished to begin IM estradiol because she heard it was most effective. She was started on estradiol cypionate 0.5 mL (2.5 mg) IM every Sunday along with spironolactone 100 mg daily. Approximately one month later, her estradiol was 65.8 pg/mL on a Saturday, total testosterone by LC-MS/MS was suppressed to 7 ng/dL (male: 300-1080 ng/dL, female: 9 - 55 ng/dL), FSH <0.3 mIU/mL (1.5-12.4), LH <0.3 mIU/mL (1.7-8.6). We increased her estradiol cypionate to 0.8 mL (4 mg) IM every Sunday to achieve goal estradiol levels up to 100-200 pg/mL. Approximately 2 months later, estradiol was up to 160 pg/mL on a Thursday. FSH and LH remained suppressed. Spironolactone was stopped. Patient gave her estradiol dose every Sunday between 4:15-7 PM. She injected on the lateral thigh switching sides every week. At the patient’s request, blood was drawn on distinct days of the week going further from the day of injection as data collection progressed. The data we received: Monday: 153 pg/mL, Tuesday: 164 pg/mL, Wednesday: 147 pg/mL, Thursday: 122 pg/mL, Friday: 134 pg/mL, Saturday: 167 pg/mL. All labs were drawn between approximately 9:30-10:15 AM.

Conclusion: Our patient wanted to see just how stable weekly IM estradiol cypionate was. We found she was able to stay within target physiologic estrogen levels, 100-200 pg/mL, throughout the week. Overall mean +/- standard deviation levels for the six samples taken between injections were 148 +/- 17 pg/mL (range: 122-167). This case provides reassurance to clinicians concerned IM estradiol may cause supraphysiologic estradiol levels.

References: 1. Wylie C Hembree et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869-3903, https://doi.org/10.1210/jc.2017-01658