Hot off the presses! Apr 01 J Clin Endocrinol Metab

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Latest Articles Include:

• The Approach to the Adult with Newly Diagnosed Adrenal Insufficiency
  - J Clin Endocrinol Metab 94(4):1059-1067 (2009)
  Adrenal insufficiency, primarily presenting as an adrenal crisis, is a life-threatening emergency and requires prompt therapeutic management including fluid resuscitation and stress dose hydrocortisone administration. Primary adrenal insufficiency is most frequently caused by autoimmune adrenalitis, and hypothalamic-pituitary tumors represent the most frequent cause of secondary adrenal insufficiency. However, the exact underlying diagnosis needs to be confirmed by a stepwise diagnostic approach, with an open eye for other differential diagnostic possibilities. Chronic replacement therapy with glucocorticoids and, in primary adrenal insufficiency, mineralocorticoids requires careful monitoring. However, current replacement strategies still require optimization as evidenced by recent studies demonstrating significantly impaired subjective health status and increased mortality in patients with primary and secondary adrenal insufficiency. Future studies will have to explo! re the potential of dehydroepiandrosterone replacement and modified delayed-release hydrocortisone to improve the prospects of patients with adrenal insufficiency.
• Reversible Bone Marrow Edema of the Hip Due to Severe Hypothyroidism
  - J Clin Endocrinol Metab 94(4):1068 (2009)
  
• Secular Trends in the Presentation and Management of Functioning Insulinoma at the Mayo Clinic, 1987-2007
  - J Clin Endocrinol Metab 94(4):1069-1073 (2009)
  Objective: The objective of the study was to assess changes in the presentation and diagnostic and radiological evaluation of patients with surgically confirmed insulinoma at the Mayo Clinic 1987-2007. Methods: A retrospective analysis of patients with insulinoma was conducted. Patients with prior gastric bypass were excluded. Results: A total of 237 patients [135 women (57%)] were identified. Hypoglycemia was reported solely in the fasting state in 73%, the fasting and postprandial state in 21%, and exclusively postprandially in 6%. There was a predominance of men in the postprandial symptom group. Considering the period of study by quartile, outpatient evaluation increased from 35 to 83% and successful preoperative localization improved from 74 to 100% comparing the first to the fourth quartiles. Although the rates of localization by noninvasive techniques remained static at approximately 75%, the addition of invasive modalities has resulted in successful preoperat! ive localization in all patients in the past 10 yr. The sensitivity and specificity of the established diagnostic criteria using insulin, C-peptide, proinsulin, {beta}-hydroxybutyrate, and glucose response to iv glucagon were greater than 90% and greater than 70%, respectively. Conclusions: Although fasting hypoglycemia is characteristic of patients with insulinoma, postprandial symptoms have been reported with increasing, albeit low, frequency. Trends in the evaluation and preoperative management include a shift to outpatient diagnostic testing, an emphasis on successful preoperative localization to avoid blind pancreatic exploration, and a validation of the diagnostic criteria for hyperinsulinemic hypoglycemia.
• Localization of Insulinomas to Regions of the Pancreas by Intraarterial Calcium Stimulation: The NIH Experience
  - J Clin Endocrinol Metab 94(4):1074-1080 (2009)
  Context: Selective intraarterial calcium injection of the major pancreatic arteries with hepatic venous sampling [calcium arterial stimulation (CaStim)] has been used as a localizing tool for insulinomas at the National Institutes of Health (NIH) since 1989. The accuracy of this technique for localizing insulinomas was reported for all cases until 1996. Objectives: The aim of the study was to assess the accuracy and track record of the CaStim over time and in the context of evolving technology and to review issues related to result interpretation and procedure complications. CaStim was the only invasive preoperative localization modality used at our center. Endoscopic ultrasound (US) was not studied. Design and Setting: We conducted a retrospective case review at a referral center. Patients: Twenty-nine women and 16 men (mean age, 47 yr; range, 13-78) were diagnosed with an insulinoma from 1996-2008. Intervention: A supervised fast was conducted to confirm the diag! nosis of insulinoma. US, computed tomography (CT), magnetic resonance imaging (MRI), and CaStim were used as preoperative localization studies. Localization predicted by each preoperative test was compared to surgical localization for accuracy. Main Outcome: We measured the accuracy of US, CT, MRI, and CaStim for localization of insulinomas preoperatively. Results: All 45 patients had surgically proven insulinomas. Thirty-eight of 45 (84%) localized to the correct anatomical region by CaStim. In five of 45 (11%) patients, the CaStim was falsely negative. Two of 45 (4%) had false-positive localizations. Conclusion: The CaStim has remained vastly superior to abdominal US, CT, or MRI over time as a preoperative localizing tool for insulinomas. The utility of the CaStim for this purpose and in this setting is thus validated.
• Elevated High-Density Lipoprotein (HDL) Levels due to Hepatic Lipase Mutations Do Not Reduce Cardiovascular Disease Risk: Another Strike against the HDL Dogma
  - J Clin Endocrinol Metab 94(4):1081-1083 (2009)
  
• Heirarchical Clustering and Beyond in PCOS Endometrium: Brave New World
  - J Clin Endocrinol Metab 94(4):1084-1085 (2009)
  
• A Vision for the Surgical Management of Papillary Thyroid Carcinoma: Extensive Lymph Node Compartmental Dissections and Selective Use of Radioiodine
  - J Clin Endocrinol Metab 94(4):1086-1088 (2009)
  
• Whither Recombinant Human Leptin Treatment for HIV-Associated Lipoatrophy and the Metabolic Syndrome?
  - J Clin Endocrinol Metab 94(4):1089-1091 (2009)
  
• MrOs Is D-ficient
  - J Clin Endocrinol Metab 94(4):1092-1093 (2009)
  
• Obesity and the Emergence of Sleep-Wake Gonadotropin Secretion in Girls during Early Pubertal Development
  - J Clin Endocrinol Metab 94(4):1094-1096 (2009)
  
• Prediction of Changes in Bone Mineral Density in Postmenopausal Women Treated with Once-Weekly Bisphosphonates
  - J Clin Endocrinol Metab 94(4):1097-1103 (2009)
  Background: In clinical practice, bone mineral density (BMD) determined by dual-energy x-ray absorptiometry is used to monitor response to osteoporosis therapy. However, 1 to 2 yr are usually required to assess patients' BMD responses. The possibility of earlier indicators of a response or nonresponse to treatment, such as changes in bone turnover markers (BTMs), is of interest to physicians and patients. Methods: In this post hoc analysis of women treated with once-weekly bisphosphonates, we examined the association of tertile percentage change from baseline in BTMs at 3 or 6 months and association of several baseline clinical characteristics with 24-month percentage change from baseline in BMD and with percentage of patients showing BMD nonresponse (defined as BMD loss at two or more of four sites) at 24 months. Multivariable analysis was performed to determine which factors were independently associated with BMD nonresponse. Results: Patients in the tertile with t! he greatest decrease in each of the BTMs had the greatest mean increase in BMD and the lowest percentage of BMD nonresponders at 24 months. Several characteristics were independently associated with BMD nonresponse, including smaller 3-month reductions from baseline in serum C-terminal telopeptide of type 1 collagen, bone-specific alkaline phosphatase, and N-terminal propeptide of type 1 procollagen; younger age of menopause; a family history of osteoporosis; and higher baseline trochanteric BMD. Baseline BTMs were not predictive of 24-month BMD response to therapy. The strongest associations were for changes in BTMs with treatment. Conclusion: In groups of patients, short-term changes in markers of bone turnover appear to be predictors of longer term BMD response and nonresponse to bisphosphonate therapy.
• Adipokines, Inflammation, and Visceral Adiposity across the Menopausal Transition: A Prospective Study
  - J Clin Endocrinol Metab 94(4):1104-1110 (2009)
  Context: Postmenopausal women have greater visceral adiposity compared with premenopausal women. Adipokines are associated with increased adiposity, insulin resistance, and atherosclerosis. Objective: The objective of the study was to assess changes in adipokines and inflammatory markers through the menopausal transition and correlate them with changes in visceral adiposity. Design and Setting: This was a prospective cohort study of women through the menopausal transition conducted at the University of Washington. Participants: Sixty-nine healthy women were followed up longitudinally from premenopausal (aged 45-55 yr) to postmenopausal status (aged 49-60 yr). Outcome: On premenopausal and postmenopausal visits, fasting blood was drawn for adiponectin, leptin, serum amyloid A (SAA), C-reactive protein (CRP), monocyte-chemotactic protein-1, tissue plasminogen activator antigen (tPA), IL-6, and TNF-{alpha}. Body composition measures were assessed by body mass index, w! hole-body dual x-ray absorptiometry scan, and computed tomography scan of the abdomen at the lumbar 4-5 level. Results: Women had a statistically significant increase in SAA, tPA, monocyte-chemotactic protein-1, and adiponectin between the two measurement occasions (P = 0.04, P = 0.02, P = 0.001, and P < 0.001, respectively). The increase in intraabdominal fat was correlated positively with the change in SAA (r = 0.31, P = 0.02), CRP (r = 0.56, P < 0.001), tPA (r = 0.40, P = 0.002), and leptin (r = 0.41, P = 0.002) and negatively correlated with the change in adiponectin (r = -0.37, P = 0.005). After adjustment for change in sc abdominal fat, the correlation between change in CRP, tPA, leptin, and adiponectin remained significantly associated with change in intraabdominal fat. Conclusions: Women going through the menopausal transition have deleterious changes in inflammatory markers and adipokines that correlate with increased visceral adiposity.
• Small Vessel Remodeling and Impaired Endothelial-Dependent Dilatation in Subcutaneous Resistance Arteries from Patients with Acromegaly
  - J Clin Endocrinol Metab 94(4):1111-1117 (2009)
  Context: Patients with acromegaly have increased morbidity and mortality, predominantly from cardiovascular disease. Hypertension and diabetes are more prevalent, and both cause small vessel remodeling and endothelial dysfunction. Objective: To understand the structure and function of small arteries in acromegaly, sc blood vessels from gluteal fat biopsies were harvested from 18 patients with active disease (AD; age, 56 {+/-} 15 yr; 14 males), 23 patients in remission (CD; age, 55 {+/-} 12 yr; 15 males), and 20 healthy controls (age, 55 {+/-} 11 yr; 10 males) and examined in vitro using pressure myography. Design: Contractile responses to cumulative noradrenaline concentrations were recorded and followed by dose-dependent dilator responses to acetylcholine. The acetylcholine protocol was repeated after incubation with a nitric oxide synthase inhibitor (N-nitro-L-arginine methyl ester) and cyclooxygenase inhibitor (indomethacin). After perfusion with Ca2+-free physiol! ogical saline solution, structural measurements were recorded at varying intraluminal pressures (3-180 mm Hg). Results: Wall thickness and wall:lumen ratio were increased in AD, reduced with treatment but remained greater in CD than controls. Wall cross-sectional area was increased in AD vs. controls (P < 0.001), decreased with treatment (AD vs. CD, P < 0.001), but remained higher than controls (CD vs. controls, P = 0.015). Growth index was increased in AD (20%) compared to controls (CD, 9%). Contractility was similar in all groups. Endothelial-dependent dysfunction was evident in AD compared with CD (P < 0.001) and controls (P < 0.01). Dilation did not change after N-nitro-L-arginine methyl ester but was impaired after indomethacin incubation. Conclusion: Active acromegaly is associated with hypertrophic remodeling of the vascular wall and embarrassed endothelial function due to reduced nitric oxide and endothelium-derived hyperpolarizing factor bioavailability, both of ! which may contribute to the early mortality from cardiovascula! r disease.
• Coexpression of Dopamine and Somatostatin Receptor Subtypes in Corticotroph Adenomas
  - J Clin Endocrinol Metab 94(4):1118-1124 (2009)
  Context: Previous studies have demonstrated the expression of somatostatin receptor subtypes (mainly sst5) and dopamine (DA) receptor subtypes (mainly D2) in smaller series of human corticotroph adenomas. In line with these findings, sst5 and D2-targeting agents have already been used clinically in patients with Cushing's disease (CD) and have shown promising results in subsets of patients. To what extent these receptor subtypes are coexpressed within individual adenomas, is not known however. Objective: The aim of the study was to investigate the (co-)expression of both sst and DA receptors in a large series of human corticotroph adenomas. Design: We performed in vitro analysis of corticotroph adenoma tissue obtained via transsphenoidal adenomectomy. Setting: The study was conducted at two university medical centers. Patients: Adenoma tissue from 30 patients with CD was analyzed in this study. Results: Analyzed by quantitative RT-PCR, D2 and sst5 were significant! ly (co-) expressed in the majority (60%) of adenomas, whereas 23% of adenomas only expressed D2, but not sst5. The remaining 17% of adenomas did not significantly express either sst5 or D2. Overall, expression of sst1-4 and D4 was low to nondetectable. Corticotroph adenomas with invasive growth invariably showed loss of sst5 and D2 expression. Autoradiography revealed clear D2 and/or SS-14 binding in a subset of cases, which correlated well with their respective mRNA data. Conclusions: Sst5 and especially D2 are highly expressed in the majority of human corticotroph adenomas, with coexpression of sst5 and D2 being a common phenomenon. These findings support the current studies with sst5 and D2-targeting agents in patients with CD and highlight the rationale behind sst5-D2 combination therapy.
• Cardiovascular and Cerebrovascular Comorbidities of Hypokalemic and Normokalemic Primary Aldosteronism: Results of the German Conn's Registry
  - J Clin Endocrinol Metab 94(4):1125-1130 (2009)
  Context: Primary aldosteronism (PA) is associated with vascular end-organ damage. Objective: Our objective was to evaluate differences regarding comorbidities between the hypokalemic and normokalemic form of PA. Design and Setting: This was a retrospective cross-sectional study collected from six German centers (German Conn's registry) between 1990 and 2007. Patients: Of 640 registered patients with PA, 553 patients were analyzed. Main Outcome Measures: Comorbidities depending on hypokalemia or normokalemia were examined. Results: Of the 553 patients (61 {+/-} 13 yr, range 13-96), 56.1% had hypokalemic PA. The systolic (164 {+/-} 29 vs. 155 {+/-} 27 mm Hg; P < 0.01) and diastolic (96 {+/-} 18 vs. 93 {+/-} 15 mm Hg; P < 0.05) blood pressures were significantly higher in hypokalemic patients than in those with the normokalemic variant. The prevalence of cardiovascular events (angina pectoris, myocardial infarction, chronic cardiac insufficiency, coronary angioplasty! ) was 16.3%. Atrial fibrillation occurred in 7.1% and other atrial or ventricular arrhythmia in 5.2% of the patients. Angina pectoris and chronic cardiac insufficiency were significantly more prevalent in hypokalemic PA (9.0 vs. 2.1%, P < 0.001; 5.5 vs. 2.1%, P < 0.01). Overall, cerebrovascular comorbidities were not different between hypokalemic and normokalemic patients, however, stroke tended to be more prevalent in normokalemic patients. Conclusions: Our data indicate a high prevalence of comorbidities in patients with PA. The hypokalemic variant is defined by a higher morbidity than the normokalemic variant regarding some cardiovascular but not cerebrovascular events. Thus, PA should be sought not only in hypokalemic but also in normokalemic hypertensives because high-excess morbidity occurs in both subgroups.
• Decreased Bone Turnover Despite Persistent Secondary Hyperparathyroidism during Prolonged Treatment with Imatinib
  - J Clin Endocrinol Metab 94(4):1131-1136 (2009)
  Context: The tyrosine kinase inhibitor imatinib mesylate has an established role in the management of a number of malignant and proliferative conditions. Cross-sectional and short-term prospective studies have demonstrated secondary hyperparathyroidism during imatinib therapy, and variable changes in markers of bone turnover. Objective: Our objective was to determine the biochemical and skeletal effects of imatinib during long-term therapy. Design: This was a 2-yr prospective study. Setting: The study was performed at an academic clinical research center. Patients or Other Participants: Nine patients with bcr-abl positive chronic myeloid leukemia were included in the study. Interventions: Patients received Imatinib mesylate 400 mg/d. Main Outcome Measures: Serum and urine biochemistry, markers of bone turnover, and bone mineral density were measured. Results: Participants developed mild secondary hyperparathyroidism, with significant decreases in serum calcium a! nd phosphate (P < 0.05 and P < 0.0001 vs. baseline, respectively) and an increase in PTH (P < 0.0001 vs. baseline). Biochemical markers of bone turnover demonstrated a biphasic response, with an initial increase in markers of bone formation being followed by a decrease in markers of both formation and resorption. Bone density at the lumbar spine increased [mean (95% confidence interval) change from baseline 3.6% (1.6, 5.5); P = 0.003] as did that at the total body [1.4% (0.2, 2.5); P = 0.065], whereas that at the proximal femur did not change [-0.12% (-3.0, 2.7); P = 0.93]. Body weight and fat mass increased significantly (P < 0.0001 vs. baseline). Conclusions: Long-term treatment with imatinib leads to persistent mild secondary hyperparathyroidism. Despite this, bone turnover is decreased, and bone density is stable or increased. Evaluation of the skeletal actions and safety of imatinib during longer-term therapy is warranted.
• The Effects of Recombinant Human Leptin on Visceral Fat, Dyslipidemia, and Insulin Resistance in Patients with Human Immunodeficiency Virus-Associated Lipoatrophy and Hypoleptinemia
  - J Clin Endocrinol Metab 94(4):1137-1144 (2009)
  Context: Leptin deficiency is associated with dyslipidemia and insulin resistance in animals and humans with lipoatrophy; leptin replacement ameliorates these abnormalities. Objective: The objective of the study was to evaluate the effects of leptin therapy in lipoatrophic HIV-infected patients with dyslipidemia and hypoleptinemia. Design: This was a 6-month, open-label, proof-of-principle pilot study. Setting: Metabolic ward studies were performed before and 3 and 6 months after leptin treatment. Participants: Participants included eight HIV-infected men with lipoatrophy, fasting triglycerides greater than 300 mg/dl, and serum leptin less than 3 ng/ml. Intervention: Recombinant human leptin was given by sc injection (0.01 mg/kg and 0.03 mg/kg twice daily for successive 3 month periods). Outcome Measures: Measures included fat distribution by magnetic resonance imaging and dual-energy X-ray absorptiometry; fasting lipids; insulin sensitivity by euglycemic hyperin! sulinemic clamp; endogenous glucose production, gluconeogenesis, glycogenolysis, and whole-body lipolysis by stable isotope tracer studies; oral glucose tolerance testing; liver fat by proton magnetic resonance spectroscopy; and safety. Results: Visceral fat decreased by 32% (P = 0.001) with no changes in peripheral fat. There were significant decreases in fasting total (15%, P = 0.012), direct low-density lipoprotein (20%, P = 0.002), and non-high-density lipoprotein (19%, P = 0.005) cholesterol. High-density lipoprotein cholesterol increased. Triglycerides, whole-body lipolysis, and free fatty acids decreased during fasting and hyperinsulinemia. Fasting insulin decreased. Endogenous glucose production decreased during fasting and hyperinsulinemia, providing evidence of improved hepatic insulin sensitivity. Leptin was well tolerated but decreased lean mass. Conclusions: Leptin treatment was associated with marked improvement in dyslipidemia. Hepatic insulin sensitivity i! mproved and lipolysis decreased. Visceral fat decreased with n! o exacerbation of peripheral lipoatrophy. Results from this pilot study suggest that leptin warrants further study in patients with HIV-associated lipoatrophy.
• Serum Levels of Angiogenic Molecules in Autoimmune Thyroid Diseases and Their Correlation with Laboratory and Clinical Features
  - J Clin Endocrinol Metab 94(4):1145-1153 (2009)
  Context: Because angiogenesis has a role in the pathogenesis of inflammatory conditions, we studied angiogenesis soluble markers in autoimmune thyroid diseases. Objective: The aim of the study was to measure concentrations of angiopoietins, Tie-2, and vascular endothelial growth factor in sera from autoimmune thyroid disease patients. Design: Soluble Tie-2 (sTie-2), angiopoietin-1, angiopoietin-2, and vascular endothelial growth factor were quantified by ELISA in sera from 44 untreated Graves' disease (GD) patients, 25 untreated Hashimoto's thyroiditis (HT) patients, 13 non-GD hyperthyroid patients, and 22 age-matched controls. Subgroups of patients with active and non-active Graves' ophthalmopathy (GO) were analyzed. Correlations among these markers and clinical parameters were assessed by bivariate and multivariate analyses. Results: sTie-2 levels were higher in GD or HT patients compared to controls (P < 0.01). In addition, serum Ang-2 concentrations were higher ! in untreated GD patients compared to controls, HT patients, or non-GD hyperthyroid patients (P < 0.01), and no difference was observed between HT patients and controls. Significant correlations were found between free T4/sTie-2 and free T4/Ang-2 levels (r = 0.464, P < 0.01; and r = 0.463, P < 0.01, respectively) as well as between sTie-2/anti-TSH receptor antibody (r = 0.527; P < 0.01) and sTie-2/Ang-2 (r = 0.563; P = 0.001). Furthermore, sTie-2 levels were significantly higher in patients with active GO when compared to those with inactive GO (P < 0.05). Interestingly, Ang-2 levels decreased significantly after treatment with antithyroid drugs (P < 0.01). Conclusions: Ang-2 and sTie-2 could participate in the pathogenesis of GD and potentially be used as markers of GO activity. Antithyroid drugs affect the angiogenic pattern in GD.
• A Novel Mutation in the LIM Homeobox 3 Gene Is Responsible for Combined Pituitary Hormone Deficiency, Hearing Impairment, and Vertebral Malformations
  - J Clin Endocrinol Metab 94(4):1154-1161 (2009)
  Context: The LIM homeobox 3 (LHX3) LIM-homeodomain transcription factor gene, found in both man and mouse, is required for development of the pituitary and motor neurons, and is also expressed in the auditory system. Objective: The objective of this study was to determine the cause of, and further explore, the phenotype in six patients (aged 6 months to 22 yr) with combined pituitary hormone deficiency (CPHD), restricted neck rotation, scoliosis, and congenital hearing impairment. Three of the patients also have mild autistic-like behavior. Design: Because patients with CPHD and restricted neck rotation have previously been shown to have mutations in the LHX3 gene, a candidate gene approach was applied, and the gene was sequenced. Neck anatomy was explored by computed tomography and magnetic resonance imaging, including three-dimensional reformatting. Results: A novel, recessive, splice-acceptor site mutation was found. The predicted protein encoded by the mutated g! ene lacks the homeodomain and carboxyl terminus of the normal, functional protein. Genealogical studies revealed a common gene source for all six families dating back to the 17th century. Anatomical abnormalities in the occipito-atlantoaxial joints in combination with a basilar impression of the dens axis were found in all patients assessed. Conclusions: This study extends both the mutations known to be responsible for LHX3-associated syndromes and their possible phenotypical consequences. Previously reported traits include CPHD and restricted neck rotation; patients examined in the present study also show a severe hearing defect. In addition, the existence of cervical vertebral malformations are revealed, responsible for the rigid neck and the development of scoliosis.
• Prophylactic Lymph Node Dissection for Papillary Thyroid Cancer Less Than 2 cm: Implications for Radioiodine Treatment
  - J Clin Endocrinol Metab 94(4):1162-1167 (2009)
  Objective: Prophylactic neck dissection for small papillary carcinoma remains controversial. Radioiodine ablation is not recommended for tumors less than 10 mm and depends on various factors for tumors between 10 and 20 mm. The aim was to determine the effect of lymph node (LN) staging on the indication for treatment with radioiodine. Patients and Methods: We conducted a retrospective study of 115 patients presenting with papillary thyroid carcinoma less than 2 cm without ultrasonographically detectable cervical LN treated by total thyroidectomy and complete selective dissection of the central and lateral compartment. Radioiodine treatment was based on definitive pathology (tumor and LN). Follow-up was based on neck ultrasound and thyroglobulin levels. Results: LN were found for 41.7% of cases. Radioiodine was not used for 42% of patients with tumors less than 20 mm and no metastatic LN. Fifty-eight percent of patients were treated with radioiodine due to LN metastas! is, extracapsular thyroid invasion, or unfavorable histological subtype. LN status affected the indication for radioiodine in 30.5% of cases classified as T1, 12 cases with tumors less than 10 mm but with LN metastases (who received radioiodine), and 13 cases with tumors between 10 and 20 mm but without LN metastases (who did not receive radioiodine). Definitive vocal fold paralysis and hypoparathyroidism each occurred in 0.9% of cases. At 1 yr, ultrasound was normal in all patients, and recombinant human TSH-stimulated thyroglobulin was undetectable for 97% of the patients. Conclusion: Precise LN staging by prophylactic neck dissection for tumors initially staged T1N0 modified the indication for radioiodine ablation for 30% of patients.
• Blunted Sleep-Related Luteinizing Hormone Rise in Healthy Premenarcheal Pubertal Girls with Elevated Body Mass Index
  - J Clin Endocrinol Metab 94(4):1168-1175 (2009)
  Objective: Our objective was to determine whether excessive adiposity is associated with alteration of the normal hormonal changes of early pubertal girls. Design and Participants: Healthy 6.4- to 9.5-yr-old, prepubertal (PRE, n = 20) and 9.4- to 13.0-yr-old pubertal premenarcheal volunteers (PUB, n = 20) were divided into excessive-weight (EW) or normal-weight (NW) groups according to the 85th percentile body mass index. Interventions and Setting: Overnight blood sampling; GnRH agonist (GnRHag), low-dose ACTH, oral glucose tolerance tests, and pelvic ultrasonograms were performed in our Clinical Research Center. Results: EW girls were similar in age and baseline and ACTH- and GnRHag-stimulated androgen levels to stage-matched NW girls. However, the sleep-related LH rise was blunted in EW-PUB girls compared with NW-PUB girls. The sleep-related rise of mean LH in EW-PUB [0.68 {+/-} 0.35 (SEM) U/liter] was insignificant, less than that of NW-PUB (2.1 {+/-} 0.45, P < 0! .05) and not significantly different from that of PRE girls (0.08{+/-}0.03). EW-PUB had slower LH pulse frequency and a lower rise in LH pulse amplitude during sleep than NW-PUB girls (both P < 0.05). Overnight FSH patterns paralleled LH patterns, whereas estradiol levels were similar in stage-matched NW and EW groups, differing between stages as expected. Early morning and peak LH, FSH, and estradiol responses to GnRHag were similar in EW-PUB and NW-PUB and significantly greater than those of PRE girls. Conclusions: Healthy EW-PUB girls have significantly blunted sleep-related LH production. These data suggest that excess adiposity, in the absence of sex steroid excess, may subtly suppress hypothalamic-pituitary-gonadal function in premenarcheal pubertal girls.
• Bromocriptine Reduces Augmented Thyrotropin Secretion in Obese Premenopausal Women
  - J Clin Endocrinol Metab 94(4):1176-1181 (2009)
  Context: Diurnal TSH secretion is enhanced in obese premenopausal women. Dopamine inhibits TSH secretion through activation of dopamine D2 receptors (D2R). Dopamine D2R availability in the brain is reduced in obese humans in proportion to body adiposity. We hypothesized that deficient dopamine D2R signaling is involved in the enhanced TSH secretion associated with obesity. Objective: The effect of short-term bromocriptine treatment on spontaneous TSH secretion in obese women was studied while body weight and caloric intake remained constant. Design and Setting: We conducted a prospective, fixed-order, crossover study in a Clinical Research Center. Participants: Seventeen obese women (body mass index, 33.2 {+/-} 0.6 kg/m2) were studied twice in the early follicular phase of their menstrual cycle. Intervention: Subjects were treated for 8 d with placebo and bromocriptine. Main Outcome Measure(s): Blood was collected for 24 h at 10-min intervals, and TSH and leptin w! ere analyzed with deconvolution and correlation techniques, approximate entropy, and cosine regression. Results: Bromocriptine reduced 24-h TSH secretion (placebo, 29.8 {+/-} 4.6 mU/liter {middle dot} 24 h, vs. bromocriptine, 22.4 {+/-} 3.7 mU/liter {middle dot} 24 h; P = 0.001), whereas free T4 and total T3 concentrations did not change. Bromocriptine administration reduced the mesor and amplitude of the 24-h rhythm without resetting the phase. The regularity of the subordinate TSH pattern and synchrony between leptin and TSH were unaffected by bromocriptine. Conclusion: Activation of dopamine D2R by bromocriptine reverses enhanced diurnal TSH secretion in obese women. Thus, reduced dopaminergic neuronal signaling might be involved in the perturbation of the thyrotrope hormonal axis in obese premenopausal women.
• Effects of Dehydroepiandrosterone Therapy on Pubic Hair Growth and Psychological Well-Being in Adolescent Girls and Young Women with Central Adrenal Insufficiency: A Double-Blind, Randomized, Placebo-Controlled Phase III Trial
  - J Clin Endocrinol Metab 94(4):1182-1190 (2009)
  Context and Objective: The efficacy of oral dehydroepiandrosterone (DHEA) in the treatment of atrichia pubis and psychological distress in young females with central adrenal insufficiency is unknown. Our study aimed to evaluate this therapy. Design and Patients: A total of 23 young females (mean age 18 yr, range 13-25) was enrolled in a double-blind randomized placebo-controlled trial. Inclusion criteria were ACTH deficiency plus two or more additional pituitary deficiencies, serum DHEA less than 400 ng/ml, and pubertal stage more than B2. Exclusion criteria were cerebral radiation with more than 30 Gy, tumor remission less than 1 yr, amaurosis, hypothalamic obesity, psychiatric disorders, and unstable hormone medication. Intervention: Patients were randomized to placebo (n = 12) or 25 mg HPLC-purified DHEA/d (n = 11) orally for 12 months after stratification into a nontumor (n = 7) and a tumor group (n = 16). Main Outcome Measures: Clinical scoring of pubic hair st! age was performed at 0, 6, and 12 months (primary endpoint), and psychometrical evaluation (Symptom Check-List-90-R and the Centre for Epidemiological Studies-Depression Scale) at 0 and 12 months (secondary endpoint). Androgen levels and safety parameters were measured at 0, 6, and 12 months; 24-h androgen urinary excretion rates were calculated at 0 and 12 months. Results: In the placebo group, four patients dropped out because of recurrence of craniopharyngioma, manifestation of type 1 diabetes, and change of residence (n = 2); in the DHEA group, one patient dropped out because of recurrent anxiety attacks. DHEA substitution resulted in normalization of DHEA sulfate and androstanediol glucuronide morning serum levels 2 h after drug intake (P < 0.006), and of its 24 h urinary metabolite levels (P < 0.0001), placebo had no effect. Morning serum levels of androstenedione increased in the DHEA group (P < 0.02) but did not normalize. The DHEA group exhibited significant progr! ess in pubic hair growth from Tanner stage I-III to II-V (mean! : +1.5 stages), whereas the placebo group did not (relative risk 0.138; 95% confidence interval 0.021-0.914; P = 0.0046). Importantly, eight of the 10 Symptom Check-List-90-R scores, including those for depression, anxiety, and interpersonal sensitivity, and the global severity index improved in the DHEA group in comparison to the placebo group (P < 0.048). DHEA was well tolerated. Conclusions: In adolescent girls with central adrenal insufficiency, daily replacement with 25 mg DHEA orally is beneficial: atrichia pubis vanishes, and psychological well-being improves significantly.
• Intrarenal Hemodynamics in Primary Aldosteronism before and after Treatment
  - J Clin Endocrinol Metab 94(4):1191-1197 (2009)
  Context: Elevated urinary albumin excretion has been reported in primary aldosteronism and might partially reflect reversible abnormalities initiated by glomerular hyperfiltration. Objective: The aim of the study was to examine the outcome of renal function and intrarenal Doppler velocimetric indices in primary aldosteronism. Design: We conducted a prospective study of patients with primary aldosteronism who were reevaluated 1 yr after either adrenalectomy or treatment with spironolactone. Setting: The study was conducted at a university referral center. Patients: Fifty-four patients with tumoral or idiopathic aldosteronism were followed after either surgical (n = 24) or medical (n = 30) treatment. Patients with primary aldosteronism were compared with 100 patients with primary hypertension and comparable severity and duration of disease. Main Outcome Measures: Changes in renal function and intrarenal echo-Doppler indices were measured. Results: Patients with pri! mary aldosteronism had greater creatinine clearance and urinary albumin excretion than patients with primary hypertension. Patients with primary aldosteronism and creatinine clearance above the median (105 ml/min per 1.73 m2) had significantly lower resistance and pulsatility index than patients with creatinine clearance below the median, independent of disease subtype. After 1 yr, creatinine clearance and albuminuria declined, and resistance and pulsatility index increased to the same extent in patients with primary aldosteronism treated with either adrenalectomy or spironolactone. Changes in glomerular filtration and albuminuria were inversely related with baseline values of the resistance index. In primary hypertension, echo-Doppler velocimetric indices did not change during follow-up. Conclusions: In primary aldosteronism, sonographic evidence of decreased intrarenal vascular resistance is associated with glomerular hyperfiltration. Both adrenalectomy and spironolacton! e revert the intrarenal hemodynamic pattern and decrease urina! ry protein losses.
• Effects of an Oral Growth Hormone Secretagogue in Older Adults
  - J Clin Endocrinol Metab 94(4):1198-1206 (2009)
  Context: GH secretion declines with age, possibly contributing to reduced muscle mass, strength, and function. GH secretagogues (GHS) may increase muscle mass and physical performance. Objectives/Design: We conducted a randomized, double-masked, placebo-controlled, multicenter study to investigate the hormonal, body composition, and physical performance effects and the safety of the orally active GHS capromorelin in older adults with mild functional limitation. Intervention/Participants: A total of 395 men and women aged 65-84 yr were randomized for an intended 2 yr of treatment to four dosing groups (10 mg three times/week, 3 mg twice a day, 10 mg each night, and 10 mg twice a day) or placebo. Although the study was terminated early according to predetermined treatment effect criteria, 315 subjects completed 6 months of treatment, and 284 completed 12 months. Results: A sustained dose-related rise in IGF-I concentrations occurred in all active treatment groups. Eac! h capromorelin dose prompted a rise in peak nocturnal GH, which was greatest with the least frequent dosing. At 6 months, body weight increased 1.4 kg in subjects receiving capromorelin and decreased 0.2 kg in those receiving placebo (P = 0.006). Lean body mass increased 1.4 vs. 0.3 kg (P = 0.001), and tandem walk improved by 0.9 sec (P = 0.02) in the pooled treatment vs. placebo groups. By 12 months, stair climb also improved (P = 0.04). Adverse events included fatigue, insomnia, and small increases in fasting glucose, glycosylated hemoglobin, and indices of insulin resistance. Conclusions: In healthy older adults at risk for functional decline, administration of the oral GHS capromorelin may improve body composition and physical function.
• Homocysteine Levels and Risk of Hip Fracture in Postmenopausal Women
  - J Clin Endocrinol Metab 94(4):1207-1213 (2009)
  Background: Recent studies suggest that high homocysteine levels are associated with an increased risk of fractures. Homocysteine levels are known to be influenced by vitamin B and folate supply or status, and poor renal function can result in higher levels independent of nutritional adequacy. Objective: The aim of the study was to determine the associations between fasting homocysteine levels and incident hip fractures, and the effects of other factors on hip fracture risk. Design: We conducted a case-control study in the Women's Health Initiative Observational Study, a study of postmenopausal women (n = 93,676) recruited in the United States. We selected 400 incident cases of hip fracture and 400 controls matched on age, ethnicity, and blood draw date among women not on osteoporosis therapies. Outcome measures included physician-adjudicated, incident hip fractures. Baseline lifestyle and nutritional questionnaires were performed. Results: The risk of hip fracture ! increased 1.38-fold [95% confidence interval (CI), 1.14, 1.66] for each SD increase in serum homocysteine level after adjustment for fracture risk factors. This association was not affected by adjustment for dietary folate, B6, or B12 intake, but it diminished after adjustment for cystatin-C level (odds ratio, 1.08; 95% CI, 0.66-1.79), a measure of renal function not affected by muscle mass. Among women in the highest quartile of homocysteine and cystatin-C compared to those without elevations in either biomarker, the risk of hip fracture was substantially elevated (odds ratio, 2.8; 95% CI, 1.61-4.87). Conclusions: This study indicates that high homocysteine levels are associated with an increased risk of hip fracture, which could be accounted for by poor renal function.
• Vitamin D Deficiency in Older Men
  - J Clin Endocrinol Metab 94(4):1214-1222 (2009)
  Context: Vitamin D deficiency is not adequately evaluated in older men. Objective: The aim of the study was to determine the prevalence of vitamin D deficiency and identify risk factors for its occurrence. Design and Setting: We conducted a cross-sectional evaluation of 1606 older men in the general community who were enrolled in the Osteoporotic Fractures in Men Study. Participants: A randomly selected subcohort of a large population of men from six U.S. communities participated in the study. Main Outcome Measures: Serum concentrations of 25-hydroxyvitamin D2 [25(OH)D2] and 25(OH)D3 were measured using mass spectrometry. Results: Deficiency [25(OH)D <20 ng/ml] was present in 26%, and insufficiency (<30 ng/ml) was present in 72%. Deficiency was particularly common among men during the winter and spring (especially in the northern communities) and in the oldest and more obese men. For instance, in Caucasian men in winter or spring who were >80 yr old, did not engag! e in lawn/garden work, and had a body mass index greater than 25 kg/m2 and vitamin D intake below 400 IU/d, the prevalence of vitamin D deficiency was 86%. 25(OH)D2 levels were present in a small fraction of men and accounted for a low proportion of total 25(OH)D levels. The use of vitamin D supplements was reported by 58% of men, but supplement use had a small effect on total 25(OH)D levels and, despite supplement use, low levels remained frequent. Conclusions: Vitamin D deficiency is common in older men and is especially prevalent in obese, sedentary men living at higher latitudes. Use of vitamin D supplements at levels reported here did not result in adequate vitamin D nutrition.
• Increased Hypothalamic-Pituitary-Adrenal Axis Activity in Huntington's Disease
  - J Clin Endocrinol Metab 94(4):1223-1228 (2009)
  Context: Huntington's disease (HD) is a fatal hereditary neurodegenerative disorder characterized by motor, cognitive, and behavioral disturbances. Hypothalamic-pituitary-adrenal (HPA) axis dysfunction could contribute to a number of HD signs and symptoms; however, no data are available on cortisol diurnal variations and secretory dynamics in HD patients. Objective: The aim of the study was to perform a detailed analysis of HPA axis function in HD patients in relation to clinical signs and symptoms. Design, Setting, and Participants: Twenty-four-hour cortisol secretion was studied in eight early-stage, medication-free HD patients and eight age-, sex-, and body mass index-matched controls in a clinical research laboratory. Cortisol levels were measured every 10 min. Main Outcome Measures: Multiparameter autodeconvolution and cosinor regression were applied to quantify basal, pulsatile, and total cortisol secretion rates as well as diurnal variations in cortisol level! s. Results: Total cortisol secretion rate and the amplitude of the diurnal cortisol profile were both significantly higher in HD patients compared with controls (3490 {+/-} 320 vs. 2500 {+/-} 220 nmol/liter/24 h, P = 0.023; and 111 {+/-} 14 vs. 64 {+/-} 8 nmol/liter, P = 0.012, respectively). Cortisol concentrations in patients were particularly increased in the morning and early afternoon period. In HD patients, mean 24-h cortisol levels significantly correlated with total motor score, total functional capacity, as well as body mass index. Conclusions: HPA axis hyperactivity is an early feature of HD and is likely to result from a disturbed central glucocorticoid feedback due to hypothalamic pathology. HPA axis dysfunction may contribute to some signs and symptoms in HD patients.
• Retinol-Binding Protein 4 in Polycystic Ovary Syndrome--Association with Steroid Hormones and Response to Pioglitazone Treatment
  - J Clin Endocrinol Metab 94(4):1229-1235 (2009)
  Context: Polycystic ovary syndrome (PCOS) is frequently associated with insulin resistance. Objective: The aim of the study was to investigate a putative role of the adipokines retinol-binding protein 4 (RBP4), adiponectin, and visfatin in a cohort of patients with PCOS and their response to treatment with pioglitazone. Design and Setting: We conducted a randomized, controlled, double-blind study at a tertiary referral center. Patients and Interventions: Forty premenopausal women with PCOS were allocated to receive treatment with either pioglitazone (30 mg/d) or a placebo for a period of 3 months. Main Outcome Measures: Serum concentrations of RBP4, adiponectin, and visfatin were determined along with metabolic and hormonal parameters before and after treatment. Results: Serum adiponectin concentrations were higher after treatment with pioglitazone (P = 0.003), whereas RBP4 levels tended to decrease (P = 0.06), and visfatin concentrations remained unchanged. We fo! und RBP4 serum concentrations at baseline to be positively correlated with serum levels of testosterone (R = 0.446; P = 0.005), 17-OH progesterone (R = 0.345, P = 0.037), and dehydroepiandrosterone sulfate (R = 0.347; P = 0.041). However, these correlations were abolished after treatment with pioglitazone. Patients with high RBP4 levels had significantly higher hirsutism scores (P = 0.038 before and P = 0.034 after treatment). In contrast, serum adiponectin concentrations were related to parameters of impaired glucose metabolism, and no significant associations were detected for visfatin. Conclusions: Our results suggest that RBP4 may contribute to endocrine changes and to the phenotypic manifestation of patients with PCOS because higher RBP4 concentrations are associated with higher androgen levels and higher clinical hirsutism scores independently of pioglitazone treatment. The molecular involvement of RBP4 in human steroid metabolism requires further clarification.
• Vildagliptin Enhances Islet Responsiveness to Both Hyper- and Hypoglycemia in Patients with Type 2 Diabetes
  - J Clin Endocrinol Metab 94(4):1236-1243 (2009)
  Context: Dipeptidyl peptidase-4 inhibitors act by increasing plasma levels of glucagon-like peptide-1 and suppressing excessive glucagon secretion in patients with type 2 diabetes. However, their effects on the glucagon response to hypoglycemia are not established. Objective: The aim of the study was to assess effects of the dipeptidyl peptidase-4 inhibitor vildagliptin on {alpha}-cell response to hyper- and hypoglycemia. Design: We conducted a single-center, randomized, double-blind, placebo-controlled, two-period crossover study of 28-d treatment, with a 4-wk between-period washout. Patients: We studied drug-naive patients with type 2 diabetes and baseline glycosylated hemoglobin of 7.5% or less. Intervention: Participants received vildagliptin (100 mg/d) or placebo as outpatients. Primary Outcome Measure(s): We measured the following: 1) change in plasma glucagon levels during hypoglycemic (2.5 mM glucose) clamp; and 2) incremental ({Delta}) glucagon area under! the concentration-time curve from time 0 to 60 min (AUC0-60min) during standard meal test. Before the study, it was hypothesized that vildagliptin would suppress glucagon secretion during meal tests and enhance the glucagon response to hypoglycemia. Results: The mean change in glucagon during hypoglycemic clamp was 46.7 {+/-} 6.9 ng/liter with vildagliptin treatment and 33.9 {+/-} 6.7 ng/liter with placebo; the between-treatment difference was 12.8 {+/-} 7.0 ng/liter (P = 0.039), representing a 38% increase with vildagliptin. In contrast, the mean glucagon {Delta}AUC0-60min during meal test with vildagliptin was 512 {+/-} 163 ng/liter {middle dot} min vs. 861 {+/-} 130 ng/liter {middle dot} min with placebo; the between-treatment difference was -349 {+/-} 158 ng/liter {middle dot} min (P = 0.019), representing a 41% decrease with vildagliptin. Conclusions: Vildagliptin enhances {alpha}-cell responsiveness to both the suppressive effects of hyperglycemia and the stimulato! ry effects of hypoglycemia. These effects likely contribute to! the efficacy of vildagliptin to improve glycemic control as well as to its low hypoglycemic potential.
• Relationships of Serum 25-Hydroxyvitamin D to Bone Mineral Density and Serum Parathyroid Hormone and Markers of Bone Turnover in Older Persons
  - J Clin Endocrinol Metab 94(4):1244-1250 (2009)
  Context: Serum 25-hydroxyvitamin D [25(OH)D] may influence serum PTH and other parameters of bone health up to a threshold concentration, which may be between 25 and 80 nmol/liter. Objective: The aim of the study was to assess the threshold serum 25(OH)D with regard to PTH, bone turnover markers, and bone mineral density (BMD). Design and Setting: This was part of the Longitudinal Aging Study Amsterdam, an ongoing cohort study. Participants: A total of 1319 subjects (643 men and 676 women) between the ages of 65 and 88 yr participated in the study. Main Outcome Measures: Serum 25(OH)D, PTH, osteocalcin, urinary deoxypyridinoline/creatinine, quantitative ultrasound of the heel, BMD of lumbar spine and hip, total body bone mineral content, and physical performance. The relationship between the variables was explored by analysis of covariance and the locally weighted regression (LOESS) plots. Results: Serum 25(OH)D was below 25 nmol/liter in 11.5%, below 50 nmol/lite! r in 48.4%, below 75 nmol/liter in 82.4%, and above 75 nmol/liter in 17.6% of the respondents. Mean serum PTH decreased gradually from 5.1 pmol/liter when serum 25(OH)D was below 25 nmol/liter to 3.1 pmol/liter when serum 25(OH)D was above 75 nmol/liter (P < 0.001) without reaching a plateau. All BMD values were higher in the higher serum 25(OH)D groups, although only significantly for total hip (P = 0.01), trochanter (P = 0.001), and total body bone mineral content (P = 0.005). A threshold of about 40 nmol/liter existed for osteocalcin and deoxypyridinoline/creatinine, 50 nmol/liter for BMD, and 60 nmol/liter for physical performance. Conclusions: Low serum 25(OH)D concentrations are common in the elderly. Bone health and physical performance in older persons are likely to improve when serum 25(OH)D is raised above 50-60 nmol/liter.
• Extreme Longevity Is Associated with Increased Serum Thyrotropin
  - J Clin Endocrinol Metab 94(4):1251-1254 (2009)
  Context: The distribution of serum TSH shifts progressively to higher concentrations with age. Objective: The aim of the study was to determine whether the population shift in TSH distribution to higher concentrations with aging extends to people of exceptional longevity, namely centenarians, and to assess the relationship between concentrations of TSH and free T4 (FT4). Design/Setting/Patients: We analyzed TSH, FT4, and TSH frequency distribution curves in thyroid disease-free Ashkenazi Jews with exceptional longevity (centenarians; median age, 98 yr), in younger Ashkenazi controls (median age, 72 yr), and in a population of thyroid disease-free individuals (median age, 68 yr) from the U.S. National Health and Nutrition Examination Survey 1998-2002 (NHANES controls). Results: Serum TSH was significantly higher in centenarians [1.97 (0.42-7.15) mIU/liter] than in Ashkenazi controls [1.55 (0.46-4.55) mIU/liter] and NHANES controls [1.61 (0.39-6.29) mIU/liter] (median! , 2.5 and 97.5 centiles) (P < 0.001). The TSH frequency distribution curve of centenarians was relatively similar in shape to controls but shifted significantly to higher TSH, including TSH concentration at peak frequency. The TSH distribution curve of the NHANES control group was superimposable to and not significantly different from the Ashkenazi controls. FT4 was similar in centenarians and Ashkenazi controls, and there was a significant inverse correlation between FT4 and TSH in both groups. Conclusions: The TSH population shifts to higher concentrations with age appear to be a continuum that extends even to people with exceptional longevity. The inverse correlation between TSH and FT4 in our populations suggests that changes in negative feedback may contribute to exceptional longevity.
• Medical Therapy in Patients with Acromegaly: Predictors of Response and Comparison of Efficacy of Dopamine Agonists and Somatostatin Analogues
  - J Clin Endocrinol Metab 94(4):1255-1263 (2009)
  Context: Acromegaly is associated with increased morbidity and mortality. Treatment options include surgery, radiotherapy, and medical therapy. Aims: The objective of the study was to examine the role of prolactin status, prior surgery, and radiotherapy on the response to medical therapy in patients with acromegaly and assess the relative efficacy of dopamine agonist therapy compared with somatostatin analog therapy. Materials and Methods: A total of 276 patients with acromegaly received either dopamine agonists (DA) and/or somatostatin analogs (SSA). One hundred seventy-two patients had received surgery and 73 radiotherapy prior to receiving medical therapy. One hundred ninety-eight of 276 received DA, and 143 of 276 received SSA. GH and IGF-I values at baseline and after 12 months on therapy were analyzed. Results: In the DA group, basal prolactin concentration did not predict response to therapy, GH percent reduction: hyperprolactinemia, 26.7% (-10.4 to 48) vs. n! ormoprolactinemia, 34.8% (0.2-53.2), P = 0.58; IGF-I percent reduction: hyperprolactinemia 30.0% (9.2-43.1) vs. normoprolactinemia 16.8% (4-37), P = 0.45. Prior surgery was not associated with any difference in response to DA: GH percent reduction (P = 0.1) and IGF-I percent reduction (P = 0.08). By contrast, prior radiotherapy was associated with an enhanced efficacy of GH response to DA, P = 0.02. In the SSA group, there was no effect of prior surgery or radiotherapy on response of GH, but radiotherapy was associated with less marked IGF-I percent reduction (P = 0.05). SSA were more potent than DA at decreasing both GH [62.8% (20.7-85%) vs. 42.4% (-6.5 to 68.6), P < 0.008] and IGF-I [SSA 40.4% (0-64.3) vs. 8% (0-40.8), P = 0.05]. Conclusions: The effects of DA are irrespective of baseline prolactin concentrations. Prior radiotherapy is associated with differences in GH and IGF-I response to DA and SSA therapy.
• Hepatic Lipase, Genetically Elevated High-Density Lipoprotein, and Risk of Ischemic Cardiovascular Disease
  - J Clin Endocrinol Metab 94(4):1264-1273 (2009)
  Context: Hepatic lipase influences metabolism of high-density lipoprotein (HDL), a risk factor for ischemic cardiovascular disease (ICD: ischemic heart disease and ischemic cerebrovascular disease). Objective: We tested the hypothesis that genetic variation in the hepatic lipase genetic variants V73M, N193S, S267F, L334F, T383M, and -480c>t influence levels of lipids, lipoproteins, and apolipoproteins and risk of ICD. Design: For the cross-sectional study, we genotyped 9003 individuals from the Copenhagen City Heart Study; hereof were 8971 individuals included in the prospective study, 1747 of whom had incident ICD during 28 yr of follow-up. For the case-control studies, 2110 ischemic heart disease patients vs. 4899 controls and 769 ischemic cerebrovascular disease patients vs. 2836 controls, respectively, were genotyped. Follow-up was 100% complete. Results: HDL cholesterol was higher by 0.21 mmol/liter in S267F heterozygotes, by 0.06 mmol/liter in -480c>t heterozy! gotes, and by 0.13 mmol/liter in -480c>t homozygotes, as compared with noncarriers. These HDL increases theoretically predicted hazard ratios for ICD of 0.87 [95% confidence interval (CI) 0.84-0.90], 0.96 (95% CI 0.95-0.97), and 0.91 (95% CI 0.89-0.94), respectively; this calculation assumes that genetically elevated HDL levels confer decreased risk similar to common HDL elevations. In contrast, when all cases and controls were combined, the observed odds ratios for ICD for these three genetic variants vs. noncarriers were 1.19 (0.76-1.88), 1.04 (0.96-1.13), and 1.08 (0.89-1.30), respectively. Hazard/odds ratios for ICD in carriers vs. noncarriers of the four remaining hepatic lipase genetic variants did not differ consistently from 1.0. Conclusion: Hepatic lipase genetic variants with elevated levels of HDL cholesterol did not associate with risk of ICD.
• Randomized Controlled Trial to Investigate the Effects of Growth Hormone Treatment on Scoliosis in Children with Prader-Willi Syndrome
  - J Clin Endocrinol Metab 94(4):1274-1280 (2009)
  Context: The prevalence of scoliosis in children with Prader-Willi syndrome (PWS) is 30-80%, depending on age. Although reports about effects of GH treatment on scoliosis in children with PWS are limited, scoliosis is generally considered a contraindication for GH treatment. Objective: The aim was to study the effects of GH treatment on the onset of scoliosis and curve progression in children with PWS. Design: We conducted a multicenter, randomized, controlled GH study in infants and prepubertal and pubertal children. Infants and prepubertal children were randomized into a GH-treated group (1.0 mg/m2 {middle dot} d) and a control group for 1 and 2 yr, respectively. Pubertal children were randomized to receive somatropin 1.0 or 1.5 mg/m2 {middle dot} d. Yearly, x-rays of the spine were taken, and height, weight, truncal lean body mass (with dual energy x-ray absorptiometry), and IGF-I were measured. Patients: A total of 91 children with PWS (median age, 4.7 yr; inter! quartile range, 2.1-7.4) participated in the study. Main Outcome Measures: We measured the onset of scoliosis (Cobb >10{degrees}) and scoliotic curve progression. Results: GH-treated children had similar onset of scoliosis and curve progression as randomized controls (P = 0.27-0.79 and P = 0.18-0.98, respectively). GH treatment, IGF-I SD score (SDS), and catch-up growth had no adverse effect on the onset of scoliosis or curve progression, even after adjustment for confounders. Height SDS, truncal lean body mass, and IGF-I SDS were significantly higher in GH-treated children than in randomized controls. At baseline, a higher IGF-I SDS was associated with a lower severity of scoliosis. Conclusions: Scoliosis should no longer be considered a contraindication for GH treatment in children with PWS.
• FTO Genotype Is Associated with Body Mass Index after the Age of Seven Years But Not with Energy Intake or Leisure-Time Physical Activity
  - J Clin Endocrinol Metab 94(4):1281-1287 (2009)
  Context: A common variant in the FTO gene, rs9939609, associates with body mass index (BMI) in adults and in children aged 7 yr or older. Objective: Our aim was to examine the associations of the FTO genotype with BMI, cardiovascular risk factors, energy intake, and leisure-time physical activity in children followed up since infancy. Methods: Healthy participants of the STRIP Study, genotyped for rs9939609, were followed from age 7 months (n = 640) to 15 yr (n = 438). The children were randomly assigned to lifestyle intervention and control groups. Height, weight, blood pressure, and serum lipids were measured annually. Food records and physical activity index were obtained at age 15 yr. Results: The FTO genotype did not associate with BMI in children younger than 7 yr of age. From age 7 yr onward, the children homozygous for the A allele had progressively higher BMI than the children with one or two T alleles (P = 0.029 for FTO by age interaction). Furthermore, in! longitudinal, BMI Z-score-adjusted analysis, the AA genotype associated with higher systolic and diastolic blood pressure and with elevated serum total and low-density lipoprotein-cholesterol (P = 0.01, P < 0.001, P = 0.05, and P = 0.04 for main effect, respectively). The FTO genotype did not associate with energy intake or physical activity index at age 15. The FTO*Study group interactions were not significant. Conclusions: Our results suggest that the effect of the FTO genotype on BMI becomes evident only after age 7 yr. These results further suggest that the FTO gene is not directly associated with energy intake or physical activity.
• Keratinocyte Growth Inhibition through the Modification of Wnt Signaling by Androgen in Balding Dermal Papilla Cells
  - J Clin Endocrinol Metab 94(4):1288-1294 (2009)
  Context/Objective: Androgen induces androgenetic alopecia (AGA), which has a regressive effect on hair growth from the frontal region of the scalp. Conversely, Wnt proteins are known to positively affect mammalian hair growth. We hypothesized that androgen reduces hair growth via an interaction with the Wnt signaling system. The objective of this study was to investigate the effect of androgen on Wnt signaling in dermal papilla (DP) cells. Design: The effect of androgen and Wnt3a on keratinocyte proliferation was measured by use of a coculture system consisting of DP cells and keratinocytes. The molecular mechanisms of androgen and Wnt pathway interactions in DP cells were examined by analyzing the expression, intracellular localization, and activity of the androgen receptor (AR) and also downstream Wnt signaling molecules. Results: Wnt3a-dependent keratinocyte growth was suppressed by the addition of dihydrotestosterone in coculture with DP cells that were derived f! rom AGA patients, but growth was not suppressed in coculture with DP cells from non-AGA males. Whereas DP cells from both scalp regions expressed AR protein, the expression levels of AR and cotranslocation with {beta}-catenin, a downstream Wnt signaling molecule, were higher in DP cells of AGA patients than in DP cells from non-AGA males. In addition, significant suppression of Wnt signal-mediated transcription in response to dihydrotestosterone treatment was observed only in DP cells from AGA patients. Conclusion: These results suggest that Wnt signaling in DP cells is regulated by androgen and this regulation plays a pivotal role in androgen's action on hair growth.
• Impact of Fluorodihydroxyphenylalanine-(18F) Positron Emission Tomography on Management of Adult Patients with Documented or Occult Digestive Endocrine Tumors
  - J Clin Endocrinol Metab 94(4):1295-1301 (2009)
  Context and Objectives: Fluorodihydroxyphenylalanine-(18F) (FDOPA) positron emission tomography (PET) is a recent imaging modality used to localize endocrine tumors. This study was conducted to evaluate the impact of FDOPA-PET on the management of patients referred for carcinoid or noncarcinoid digestive tumors and the clinical relevance of the treatment decisions based on this examination. Methods and Patients: Between March 2002 and December 2006, 101 FDOPA-PET examinations were performed in 78 adult patients for follow-up of histologically documented carcinoid tumor of the ileum (23 patients) or noncarcinoid digestive tumor (26 patients) or to screen for occult digestive endocrine tumors (29 patients). More than one FDOPA-PET examination was performed in 12 patients. The impact of FDOPA PET was evaluated on a per-patient basis by means of a questionnaire completed by the referring physician, and the relevance of the treatment decision was assessed on the basis of f! ollow-up data. Results: The survey response rate was 91% (71 of 78). The overall impact rate of FDOPA-PET on patient management was 25% (18 of 71). The greatest impact was observed for carcinoid tumors (50%: 11 of 22) and was clinically relevant in every case, followed by occult endocrine tumors (16%: four of 25), and was clinically relevant in three of the four cases, and noncarcinoid tumors (13%: 3 of 22), clinically relevant in only one case. Conclusion: FDOPA-PET appears to be a major tool for the management of carcinoid tumors with excellent diagnostic performances and induced relevant changes in patient management. FDOPA-PET was less sensitive and less useful for the management of noncarcinoid tumors.
• Genetic Modifiers Play a Substantial Role in Diabetes Complicating Cystic Fibrosis
  - J Clin Endocrinol Metab 94(4):1302-1309 (2009)
  Context: Insulin-requiring diabetes affects 7-15% of teens and young adults, and more than 25% of older adults with cystic fibrosis (CF). Pancreatic exocrine disease caused by CF transmembrane conductance regulator (CFTR) dysfunction underlies the high rate of diabetes in CF patients; however, only a subset develops this complication, indicating that other factors are necessary. Objective: Our objective was to estimate the relative contribution of genetic and nongenetic modifiers to the development of diabetes in CF. Design/Patients: This was a twin and sibling study involving 1366 individuals at 109 centers in the CF Twin and Sibling Study, from which were derived 68 monozygous twin pairs, 23 dizygous twin pairs, and 588 sibling pairs, all with CF. Main Outcome Measure: Chronic, insulin-requiring diabetes in the setting of CF, as established using longitudinal clinical and biochemical data, was studied. Results: About 9% of this predominantly pediatric population ! (mean age = 15.8 yr) had diabetes. Key independent risk factors identified by regression modeling included having a twin or sibling with CF and diabetes, increasing age, pancreatic exocrine insufficiency or two mutations causing severe CFTR dysfunction, decreased lung function or decreased body mass index, and longer duration of glucocorticoid treatment. The concordance rate for diabetes was substantially higher in monozygous twins (0.73) than in dizygous twins and siblings with CF (0.18; P = 0.002). Heritability was estimated as near one (95% confidence interval 0.42-1.0). Conclusions: Diabetes is a frequent complication of CF that is associated with worse outcomes. Although a nongenetic factor (steroid treatment) contributes to risk, genetic modifiers (i.e. genes other than CFTR) are the primary cause of diabetes in CF.
• Assessment of the Incremental Value of Recombinant Thyrotropin Stimulation before 2-[18F]-Fluoro-2-Deoxy-D-Glucose Positron Emission Tomography/Computed Tomography Imaging to Localize Residual Differentiated Thyroid Cancer
  - J Clin Endocrinol Metab 94(4):1310-1316 (2009)
  Purpose: The purpose of the study was to assess prospectively the impact of recombinant human TSH (rhTSH) administration on positron emission tomography (PET)/computed tomography (CT) imaging in differentiated thyroid cancer patients who, after primary treatment, had a suppressed or stimulated serum thyroglobulin greater than 10 ng/ml and no radioactive iodine uptake consistent with thyroid cancer on a whole body scan. Patients and Methods: PET/CT was performed before (basal PET) and 24-48 h after rhTSH administration (rhTSH-PET) in 63 patients (52 papillary and 11 follicular thyroid cancers). Images were blindly analyzed by two readers. The proposed treatment plan was prospectively assessed before basal PET, after basal PET, and again after rhTSH-PET. Results: A total of 108 lesions were detected in 48 organs in 30 patients. rhTSH-PET was significantly more sensitive than basal PET for the detection of lesions (95 vs. 81%; P = 0.001) and tended to be more sensitive ! for the detection of involved organs (94 vs. 79%; P = 0.054). However, basal PET and rhTSH-PET did not have significantly different sensitivity for detecting patients with any lesions (49 vs. 54%; P = 0.42). Changes in treatment management plan occurred in 19% of the patients after basal PET. Lesions found only by rhTSH-PET contributed to an altered therapeutic plan in eight patients, among whom only four were true-positive on pathology (6%). Conclusion: The use of rhTSH for 2-[18F]-fluoro-2-deoxy-D-glucose-PET/CT significantly increased the number of lesions detected, but the numbers of patients in whom any lesion was detected were no different between basal and rhTSH-stimulated PET/CT scans. Treatment changes due to true positive lesions occurred in 6% of cases.
• TSHR Mutations as a Cause of Congenital Hypothyroidism in Japan: A Population-Based Genetic Epidemiology Study
  - J Clin Endocrinol Metab 94(4):1317-1323 (2009)
  Context: The prevalence of congenital hypothyroidism (CH) associated with mutations in the TSH receptor gene (TSHR) has not been established. Objective: We examined the frequency of TSHR mutations among patients with permanent primary CH and in the general population in Japan. Subjects and Methods: We enrolled 102 patients with permanent primary CH [70 with "moderate to severe CH" (TSH, [≥]10 mU/liter) and 32 with "mild CH" (TSH, 5-10 mU/liter)], who were identified through newborn screening among 353,000 newborns born in Kanagawa prefecture from October 1979 to June 2006. These subjects were tested for TSHR mutations by PCR-based direct sequencing. We further characterized molecular functions of identified mutant TSHRs in vitro. Results: We found three patients with moderate to severe CH who had biallelic mutations in TSHR and three patients with mild CH who had monoallelic mutations. Observed mutations included one previously characterized mutation (p.R450H) an! d three uncharacterized mutations (p.G132R, p.A204V, and p.D403N). In vitro experiments confirmed loss of functions of these four mutants. Among four mutations, p.R450H was particularly frequent: six of nine mutant alleles harbored p.R450H. All six alleles with p.R450H commonly carried a minor single nucleotide polymorphism, suggesting a founder effect. We estimated the prevalence of biallelic TSHR mutations to be 4.3% (three in 70) in Japanese patients with moderate to severe CH, and 1 in 118,000 (three in 353,000) in the general Japanese population. Conclusions: In Japan, TSHR mutations are relatively common among patients with CH, and a founder mutation (p.R450H) accounts for about 70% of mutants.
• Discontinuation of Smoking Increases the Risk for Developing Thyroid Peroxidase Antibodies and/or Thyroglobulin Antibodies: A Prospective Study
  - J Clin Endocrinol Metab 94(4):1324-1328 (2009)
  Context: Autoimmune thyroid disease develops in genetic susceptible subjects, provoked by environmental factors. Little is known of the environment in the early stages of autoimmunity. Objective: We evaluated environmental factors contributing to de novo occurrence of thyroid antibodies. Design: We conducted a prospective cohort study of 521 euthyroid women without thyroid antibodies in serum who were relatives of autoimmune thyroid disease patients. Follow-up was 5 yr. Baseline characteristics were related to the occurrence of thyroid peroxidase (TPO) and/or thyroglobulin (Tg) antibodies. Exposure to environmental factors in the year prior to the occurrence of antibodies was investigated in a nested case-control study. Results: The 5-yr probability for conversion to TPO antibodies (TPO-Ab) and/or Tg antibodies (Tg-Ab) was 20.1%, and for TPO-Ab alone the probability was 14.5%. None of the baseline characteristics except TSH contributed to the risk of seroconversion.! Each case (occurrence of antibodies) was matched for age and duration of follow-up with two controls (no seroconversion). Exposure to environmental stimuli was similar between cases and controls except for smoking. At study entrance, current smokers among cases and controls were 31.3 and 35.5%, respectively (nonsignificant). Current smoking decreased in cases during follow-up. Consequently, the odds ratios (OR) of smoking for developing TPO-Ab and/or Tg-Ab were 0.62 [95% confidence interval (CI), 0.37-1.04] 1 yr before seroconversion and 0.59 (95% CI, 0.35-0.99) at seroconversion; for conversion to TPO-Ab, these figures are 0.58 (95% CI, 0.31-1.09) and 0.54 (95% CI, 0.29-1.02), respectively. Conclusion: Discontinuation of smoking is associated with an increased risk for occurrence of TPO-Ab and/or Tg-Ab in serum. The observation is in line with the decreased risk of hypothyroidism in smokers.
• Effect of Roux-en-Y Gastric Bypass Surgery on the Sex Steroids and Quality of Life in Obese Men
  - J Clin Endocrinol Metab 94(4):1329-1332 (2009)
  Context: The effect of bariatric surgery on the reproductive function of obese men is not entirely elucidated. Objective: The aim of the study was to define the effect of Roux-En-Y gastric bypass surgery on the reproductive hormones and sexual function in obese men. Design and Setting: The cohort was followed for 2 yr at a clinical research center. Patients: Sixty-four severely obese men (22 who had gastric bypass surgery and 42 controls) participated in the study. Intervention(s): Anthropometrics [weight, body mass index (BMI), and percentage body fat] and reproductive hormones were measured. The sexual quality of life was assessed using the Impact of Weight on the Quality Of Life-Lite questionnaire. Main Outcome Measure(s): Reproductive hormones and sexual quality of life were measured. Results: The mean age was 48.9 {+/-} 1.2 yr. At baseline, mean weight was 333.0 {+/-} 7.1 lb, BMI was 46.2 {+/-} 0.9 kg/m2, and total testosterone was 339.9 {+/-} 21.32 ng/dl. B! MI correlated positively with estradiol and negatively with total and free testosterone. Indices of dissatisfaction with sexual quality of life correlated positively with measures of obesity. Difficult sexual performance and low sexual desire correlated negatively with free and total testosterone (r = -0.273, P = 0.038; and r = -0.267, P = 0.042, respectively). After 2 yr, the gastric bypass surgery group had a significant decrease in BMI (-16.6 {+/-} 1.2 vs. -0.46 {+/-} 0.51 kg/m2) and estradiol (-8.1 {+/-} 2.4 vs. 1.6 {+/-} 1.4 pg/ml) and had an increase in total testosterone (310.8 {+/-} 47.6 vs. 14.2 {+/-} 15.3 ng/dl) and free testosterone (45.2 {+/-} 5.1 vs. -0.4 {+/-} 3.0 pg/ml). Sexual quality of life was improved after gastric bypass surgery. Conclusion: Hormonal alterations and diminished sexual quality of life among obese men are related to degree of obesity, and both are improved after gastric bypass surgery.
• Gonadal Function, First Cases of Pregnancy, and Child Delivery in a Woman with Lipoid Congenital Adrenal Hyperplasia
  - J Clin Endocrinol Metab 94(4):1333-1337 (2009)
  Context: Mutations in the steroidogenic acute regulatory protein (StAR) gene often cause lipoid congenital adrenal hyperplasia (LCAH). In this disorder an impairment of steroid synthesis leads to adrenal and gonadal insufficiencies with a particular female genital phenotype in both human karyotypes. Pregnancy in LCAH has not been yet reported. Objective: We describe the first cases of pregnancy in a LCAH female patient bearing the L275P mutation in the StAR gene. Design: We studied the gonadal function, pubertal development, and apply the appropriate hormonal therapy to support pregnancies. Patient: A 46,xx patient of French Canadian descent was diagnosed with LCAH at the age of 4.5 months. Substitution therapy with glucocorticoids and mineralocorticoids led to normal growth and development. Progressive pubertal development started at the age of 11 7/12 yr. Menarche occurred at 14 2/12 yr with normal regular menstruations thereafter but without ovulation. Results: ! Clomiphene stimulation induced the first pregnancy at 25 4/12 yr of age. Spontaneous abortion occurred after 6 wk gestation. The second pregnancy (with clomiphene stimulation) was induced at the age of 26 yr. Progesterone (Prog) therapy was added at the 17th day of the cycle to protect pregnancy. Vaginal delivery of dichorionic-diamniotic twin pregnancy occurred at 30 wk gestation (two normal weight male babies). Two years later, again under clomiphene stimulation, she underwent another successful singleton pregnancy and delivered a normal weight female baby at 36 wk. The pregnancies were almost uncomplicated. Conclusion: Despite the dysfunctional StAR, pregnancy is possible under the proper therapeutic strategy.
• Euthyroid Hyperthyrotropinemia in Children Born after in Vitro Fertilization
  - J Clin Endocrinol Metab 94(4):1338-1341 (2009)
  Context: Assisted reproduction techniques are now commonly used. Although classic in vitro fertilization (IVF) started almost 30 yr ago, few long-term systematic prospective studies of children conceived with assisted reproduction have been performed. Objective: Our objective was to investigate thyroid function in children conceived after IVF vs. naturally conceived controls. Populations and Methods: A total of 106 children conceived after classic IVF and 68 naturally conceived controls, aged 4-14 yr, were studied. All children were thoroughly examined, and serum T3, T4, TSH, anti-thyroid peroxidase, and anti-thyroglobulin antibodies were measured. A second TSH determination and a thyroid ultrasound were performed for TSH higher than 5 {micro}IU/ml, and children were considered to have persistent hyperthyrotropinemia, if the TSH elevation was confirmed. Results: Seven IVF children but none of the controls had persistent elevations of circulating TSH, suggesting euth! yroid hyperthyrotropinemia or subclinical primary hypothyroidism (P = 0.044). TSH was significantly higher in the IVF group than in controls (P = 0.046), whereas no significant differences in the concentrations of T3 or T4 were observed. None of the children had detectable circulating antithyroid antibodies in either group. Conclusions: A significant elevation of serum TSH compatible with a mild TSH resistance of the thyroid were found in IVF children compared with controls. This was not due to the presence of antithyroid autoantibodies. We suggest that this might represent a slight epigenetic developmental abnormality related to the preimplantation manipulation of the embryo. Further studies are needed to confirm these findings and to better determine their etiopathogenesis and clinical significance.
• High Frequency of and Factors Associated with Thyroid Hormone Over-Replacement and Under-Replacement in Men and Women Aged 65 and Over
  - J Clin Endocrinol Metab 94(4):1342-1345 (2009)
  Context: Thyroid hormone use is common in older populations, but the frequency of over- or under-replacement is debated. Objective: We sought to describe the frequency of and factors associated with thyroid hormone over- or under-replacement in a population of older men and women. Design: Participants were 3678 U.S. community dwelling individuals aged 65 yr or older enrolled in the Cardiovascular Health Study who had thyroid function tests in 1989-1990. Thyroid hormone users (n = 339) were identified and classified into low TSH (<0.45 mU/liter), euthyroid (0.45-4.5 mU/liter), and high TSH (>4.5 mU/liter). Results: Of the 339 thyroid hormone users, 41% had a low TSH, 16% had a high TSH, and 43% were in the euthyroid range. In multivariable analyses, lower weight (P < 0.001) was independently associated with low TSH status. For every 10 kg lower weight, the likelihood of having low TSH increased by 65% [odd ratio (OR) 1.65; 95% confidence interval (CI) 1.31-2.07]. Tho! se with renal insufficiency were less likely to have low TSH levels (P = 0.02). The presence of diabetes was independently associated with having low (OR 3.35; 95% CI 1.46-7.65) and high TSH levels (OR 2.66; 95% CI 1.14-6.21). Conclusions: There is a very high prevalence of thyroid function testing abnormalities in older people taking thyroid hormone preparations, particularly in those of low weight or with diabetes. Because of potential adverse cardiovascular and skeletal effects from over-replacement, older people represent a key population for increased TSH monitoring on therapy.
• Combined Receptor Antagonist Stimulation of the Hypothalamic-Pituitary-Adrenal Axis Test Identifies Impaired Negative Feedback Sensitivity to Cortisol in Obese Men
  - J Clin Endocrinol Metab 94(4):1347-1352 (2009)
  Context: Hypothalamic-pituitary-adrenal (HPA) axis dysregulation may underlie disorders including obesity, depression, cognitive decline, and the metabolic syndrome. Conventional tests of HPA axis negative feedback rely on glucocorticoid receptor (GR) agonists such as dexamethasone but do not test feedback by endogenous cortisol, potentially mediated by both GR and mineralocorticoid receptors (MR). Objective: The objective of the study was to use a combination of GR (RU38486, mifepristone) and MR (spironolactone) antagonists to explore the poorly understood activation of the HPA axis that occurs in obesity. Design: This was a double-blind, placebo-controlled, randomized, crossover study. Setting: The study was conducted at a clinical research facility. Participants: Participants included 15 lean (body mass index 22.0 {+/-} 1.6 kg/m2) and 16 overweight/obese (body mass index 30.1 {+/-} 3.5 kg/m2) men. Intervention: Subjects attended on four occasions for blood and ! saliva sampling every 30 min between 1800 and 2200 h. At 1100 and 1600 h before visits, subjects took 200 mg spironolactone, 400 mg RU38486, 200 mg spironolactone + 400 mg RU38486, or placebo orally. Main Outcome Measures: Serum cortisol levels after drug or placebo were measured. Results: Cortisol levels did not differ between lean and obese after placebo. Spironolactone and RU38486 alone had modest effects, increasing cortisol by less than 50% in both groups. However, combined spironolactone plus RU38486 elevated cortisol concentrations substantially, more so in lean than obese men [2.9- (0.3) vs. 2.2 (0.3)-fold elevation, P = 0.002]. Conclusions: Combined receptor antagonist stimulation of the HPA axis reveals redundancy of MR and GR in negative feedback in humans. Obese men have impaired responses to combined receptor antagonist stimulation, suggesting impaired negative feedback by endogenous cortisol. Such an approach may be useful to dissect abnormal HPA axis contr! ol in neuropsychiatric and other disorders.
• Association of Common Genetic Variation in the FOXO1 Gene with {beta}-Cell Dysfunction, Impaired Glucose Tolerance, and Type 2 Diabetes
  - J Clin Endocrinol Metab 94(4):1353-1360 (2009)
  Context: The transcription factor forkhead box protein (FOX) O1A plays a crucial role in regulation of {beta}-cell function and metabolic effects of insulin in the liver. Objective: The objective of the study was to investigate whether common genetic variation within the FOXO1 gene encoding FOXO1A contributes to prediabetic phenotypes, such as insulin resistance or {beta}-cell dysfunction, and to risk of type 2 diabetes. Design and Settings: Study I was a study enrolling thoroughly phenotyped subjects from Germany at increased risk for type 2 diabetes. Study II was a population-based study of Finnish men for the assessment of the prevalence of type 2 diabetes and metabolic syndrome. Participants: Study I included 941 nondiabetic subjects (353 males, 588 females, aged 39 {+/-} 1 yr, body mass index 29.2 {+/-} 0.3 kg/m2). Study II included 5957 middle-aged men (870 type 2 diabetic and 5087 nondiabetic subjects). Interventions: Genotyping for 10 single-nucleotide poly! morphisms (SNPs) covering 100% of common genetic variation (minor allele frequency [≥]10%) within the FOXO1 gene (r2 [≥] 0.8) based on HapMap data, oral glucose tolerance test, and in a subset additionally a hyperinsulinemic-euglycemic clamp. Main Outcome Measurements: Parameters of insulin secretion, insulin resistance, and glucose tolerance status were measured. Results: In the German subjects at increased risk for type 2 diabetes, SNPs rs2721068 and rs17446614 were significantly (P = 0.0045 and P = 0.0018, respectively) and SNPs rs17446593 and rs2297627 were nominally (P = 0.0091 and P = 0.0387, respectively) associated with {beta}-cell dysfunction. rs2721068, rs17446614, and rs2297627 were also nominally associated with impaired glucose tolerance (P = 0.0264, P = 0.0162, and P = 0.0221, respectively). Minor allele carriers showed reduced insulin secretion and elevated glucose levels during an oral glucose tolerance test. Investigating the relevance of our findin! gs in a separate cohort, we found that SNP rs2721068 was signi! ficantly associated with type 2 diabetes in the additive (P = 0.002) and dominant model (P = 0.009) in Finnish men. Conclusions: Common genetic variation within the FOXO1 gene affects insulin secretion and glucose tolerance and associates with an increased risk of type 2 diabetes.
• Differential Effects of Chlorthalidone Versus Spironolactone on Muscle Sympathetic Nerve Activity in Hypertensive Patients
  - J Clin Endocrinol Metab 94(4):1361-1366 (2009)
  Context: Previous studies in rats indicated that thiazide-type diuretics reduced blood pressure (BP) and triggered baroreflex-mediated increase in sympathetic nerve activity (SNA), whereas spironolactone exerted central sympathoinhibitory action in addition to diuretic effects. Objectives: The objectives were to determine effects of spironolactone and chlorthalidone on SNA and the role of SNA on diuretic-induced insulin resistance in human hypertension. Methods: We conducted a randomized crossover study in 23 untreated hypertensive patients in which we measured muscle SNA at baseline, after 1 and 3 months of chlorthalidone (12.5-25 mg/d), and after 1 and 3 months of spironolactone (50-75 mg/d). Ambulatory BP, baroreflex sensitivity, and indices of insulin resistance were also assessed at baseline and after 3 months of each drug treatment. Results: Chlorthalidone caused a similar reduction in ambulatory BP from baseline when compared with spironolactone (11 {+/-} 2/4! {+/-} 2 and 10 {+/-} 2/4 {+/-} 2 mm Hg, respectively). However, chlorthalidone increased SNA by 23% (P < 0.01) within 1 month of treatment, whereas spironolactone had no effect in the same subjects. SNA continued to be elevated after 3 months of chlorthalidone when compared with baseline and spironolactone. Baroreflex control of SNA was unaffected by either drug. Chlorthalidone increased indices of insulin resistance, which were significantly correlated with increases in SNA from baseline, whereas spironolactone had no effect in the same subjects. Conclusions: Our data suggest that chlorthalidone, the first-line drug therapy for hypertension, causes persistent activation of sympathetic nervous system and insulin resistance in hypertensive patients. These side effects, however, are avoided by spironolactone despite similar reduction in BP.
• Adrenal Glucocorticoid and Androgen Precursor Dissociation in Anorexia Nervosa
  - J Clin Endocrinol Metab 94(4):1367-1371 (2009)
  Context: Anorexia nervosa is characterized by hypogonadism and relative hypercortisolemia. We have demonstrated that free testosterone levels are low in women with anorexia nervosa, with the lowest levels in those receiving oral contraceptives (OCPs), and that dehydroepiandrosterone (DHEA) sulfate is reduced only in those receiving OCPs. Objective: The aim of the study was to determine whether adrenal steroidogenesis dysregulation contributes to decreased androgen levels in anorexia nervosa. Design and Setting: We conducted a cross-sectional study in a General Clinical Research Center. Study Participants: We studied 20 women with anorexia nervosa [10 women with anorexia nervosa receiving OCPs (AN+E) and 10 not receiving OCPs (AN-E)] and 20 healthy controls [10 healthy controls receiving OCPs (HC+E) and 10 not receiving OCPs (HC-E)]. Main Outcome Measures: We measured DHEA and cortisol levels in response to 250-{micro}g cosyntropin stimulation after 1-mg overnight d! examethasone suppression. Results: Mean basal and stimulated, peak stimulated, and area under the curve (AUC) cortisol levels were higher in AN-E than HC-E, but mean basal and stimulated, peak and AUC DHEA were comparable. Mean AUC and peak cortisol were higher and DHEA AUC was lower in AN+E than AN-E. However, after controlling for cortisol binding globulin levels, peak and AUC cortisol were comparable between AN+E and AN-E. After controlling for albumin levels, AUC DHEA was comparable between AN+E and AN-E. Conclusions: Adrenal glucocorticoid and androgen precursor secretion are dissociated in anorexia nervosa, with relative hypercortisolemia and a preservation of DHEA secretion. Reduced DHEA response to cosyntropin in women receiving OCPs is attributable to decreased albumin levels. In the setting of relative hypercortisolemia, reduced adrenal androgen precursor secretion is not a mechanism underlying low testosterone levels in anorexia nervosa.
• Effect of Hyperglycemia on Mitochondrial Respiration in Type 2 Diabetes
  - J Clin Endocrinol Metab 94(4):1372-1378 (2009)
  Aim: Skeletal muscle mitochondrial content is reduced in type 2 diabetes mellitus (T2DM). Whether hyperglycemia inhibits mitochondrial biogenesis and/or function is unknown. This study examined the effect of different levels of glycemia on skeletal muscle mitochondrial function in patients with T2DM. Patients and Methods: Eleven patients with T2DM [9 males, 2 females; age, 52.8 {+/-} 2.5 yr (mean {+/-} SE); body mass index, 30.2 {+/-} 1.1 kg/m2] in poor glycemic control were treated with insulin aspart and NPH insulin for a median period of 46 d (range, 31-59). Mitochondrial respiration and citrate synthase activity (a marker of mitochondrial content) were measured before and after treatment. Eleven healthy subjects (age, 53.3 {+/-} 2.7 yr; body mass index, 30.6 {+/-} 1.1 kg/m2) were included as controls. Results: Hemoglobin A1c (9.1 {+/-} 0.5 to 7.5 {+/-} 0.3%; P < 0.001) and fasting plasma glucose (12.7 {+/-} 1.1 to 6.5 {+/-} 0.3 mmol/liter; P < 0.001) were reduced! after treatment. Mitochondrial respiration per milligram muscle was lower in T2DM compared to controls [substrates for complex I, 24% lower (P < 0.05); substrates for complex I+II, 17% lower (P < 0.05)]. Mitochondrial respiration and citrate synthase activity did not differ before and after improvements in glycemic control, but mitochondrial respiration correlated with fasting plasma glucose before (r2 = 0.53; P < 0.05) but not after treatment [r2 = 0.0024; not significant (NS)]. Mitochondrial respiration normalized to mitochondrial content did not differ between control subjects and patients with T2DM. Discussion: Mitochondrial respiration and content was not improved after significant improvements in glycemic control. However, severe hyperglycemia inhibited respiration reversibly, but moderate hyperglycemia and mitochondrial function were not correlated.
• Hyperglycemia Acutely Lowers the Postprandial Excursions of Glucagon-Like Peptide-1 and Gastric Inhibitory Polypeptide in Humans
  - J Clin Endocrinol Metab 94(4):1379-1385 (2009)
  Introduction: Impaired secretion of glucagon-like peptide 1 (GLP-1) has been suggested to contribute to the deficient incretin effect in patients with type 2 diabetes. It is unclear whether this is a primary defect or a consequence of the hyperglycemia in type 2 diabetes. We examined whether acute hyperglycemia reduces the postprandial excursions of gastric inhibitory polypeptide (GIP) and GLP-1, and if so, whether this can be attributed to changes in gastric emptying. Patients and Methods: Fifteen nondiabetic individuals participated in a euglycemic clamp and a hyperglycemic clamp experiment, carried out over 285 min. A mixed meal was ingested after 45 min. Plasma concentrations of glucose, insulin, C-peptide, glucagon, triglycerides, GIP, and GLP-1 were determined, and gastric emptying was assessed using a 13C-octanoate breath test. Results: Glucose levels were 160 {+/-} 1 mg/dl during the hyperglycemic clamp experiments and 83 {+/-} 3 mg/dl during the euglycemia (! P < 0.0001). Glucose infusion rates were higher during hyperglycemia, but meal ingestion led to a decline in glucose requirements in both experiments (P < 0.0001). Insulin and C-peptide levels were higher during the hyperglycemic clamp experiments (P < 0.0001), whereas glucagon levels were higher during euglycemia (P < 0.0001). The postprandial increases in GIP and GLP-1 concentrations were 46 and 52% lower during the experiments with hyperglycemia (P = 0.0017 and P = 0.021). Hyperglycemia also elicited a significant delay in gastric emptying (P < 0.0001). Conclusions: Hyperglycemia acutely reduces the postprandial levels of GIP and GLP-1, possibly through a deceleration of gastric emptying. This supports the concept that reduced incretin levels in some patients with type 2 diabetes are a consequence rather than a cause of type 2 diabetes.
• Insulin-Like Growth Factor-Binding Protein-1: Serum Levels, Promoter Polymorphism, and Associations with Components of the Metabolic Syndrome in Short Subjects Born Small for Gestational Age
  - J Clin Endocrinol Metab 94(4):1386-1392 (2009)
  Context: IGF binding protein (IGFBP)-1 is the only acute regulator of IGF-I bioavailability. Its production is suppressed by insulin, and low levels are associated with hyperinsulinemia and cardiovascular disease risk in adults. Data on IGFBP-1 levels in short, small for gestational age (SGA) subjects are scarce, and associations with IGFBP1 promoter single nucleotide polymorphisms have not been established. Objective: The aim of the study was to determine IGFBP-1 levels in short SGA subjects compared with those in controls, to assess genotype frequency of the -575 G/A single nucleotide polymorphism, and to determine its impact on IGFBP-1 levels. Subjects: A total of 272 short subjects born SGA and 330 subjects with normal stature (245 children, 85 young adults) participated in the study. Outcome Measures: We measured fasting levels of IGFBP-1, IGF-I, insulin and lipid parameters, and body composition. Results: IGFBP-1 SD score (SDS) was comparable to controls in l! ean, short, SGA children but significantly lower in short SGA adults with normal fat mass (P < 0.001). IGFBP-1 SDS correlated significantly with insulin levels, systolic blood pressure SDS, and various lipid parameters. Baseline IGFBP-1 SDS was lowest in SGA children with -575 GG genotype and significantly higher in SGA children with one or two copies of the A allele. In response to a given insulin level, children with the AA genotype had a significantly higher IGFBP-1 SDS compared to children with the GG genotype. Conclusion: Normal IGFBP-1 levels in lean, short, SGA children may reflect a normal metabolic state, despite reported hyperinsulinemia. IGFBP-1 is modulated by polymorphic variability and seems to be an additional player in the complex interaction between the IGF-IGFBP axis, glucose homeostasis, and lipid metabolism.
• In Vitro Hyperresponsiveness to Tumor Necrosis Factor-{alpha} Contributes to Adipokine Dysregulation in Omental Adipocytes of Obese Subjects
  - J Clin Endocrinol Metab 94(4):1393-1400 (2009)
  Context: In obesity, adipocyte hypertrophy and macrophage infiltration lead to overproduction of proinflammatory adipokines, which play a crucial role in the metabolic syndrome. The molecular mechanisms underlying this overproduction are still unsettled. The role of TNF-{alpha} also remains controversial in human obesity. Objective: We revisited the contribution of TNF-{alpha} to adipokine dysregulation in central obesity. We more particularly assessed the involvement of TNF-{alpha} vs. other stromal-vascular cell (SVC)-secreted factors and searched for potential differential responses to TNF-{alpha} between adipocytes of lean and obese individuals. Design and Participants: Primary cultures of omental adipocytes from obese and nonobese age- and sex-matched subjects were used. For some experiments, we generated media previously conditioned by SVCs, which mimic adipocyte microenvironment. Results: Adipocytes of obese subjects mainly overexpressed adipokines, in compar! ison with those of lean ones, when cultured in SVC-conditioned media. This was abrogated by immunoneutralization of TNF-{alpha}, indicating that among the numerous factors secreted by SVCs, TNF-{alpha} is a crucial contributor to adipokine dysregulation. Accordingly, adipocytes of obese subjects overproduced adipokines in response to direct exposure of TNF-{alpha}. This hyperresponsiveness was mediated by TNF-{alpha} receptor 1 and hyperactivation of the nuclear factor-{kappa}B (NF-{kappa}B) pathway. Correspondingly, NF-{kappa}B activity was increased in adipocytes of obese subjects and correlated with adipocyte size, adipokine expression, and in vivo insulin resistance. Eventually adipokine overexpression in adipocytes of obese subjects was prevented by NF-{kappa}B inhibitors. Conclusions: In obesity, TNF-{alpha}, i.e. over other SVC-secreted factors, a crucial determinant of adipokine dysregulation acts on enlarged adipocytes, which are hyperresponsive to this triggering! signal. This ultimately exacerbates adipokine production, inf! lammation, and the metabolic syndrome.
• Phenotypic and Molecular Evaluation of a Chromosome 1q Region with Linkage and Association to Type 2 Diabetes in Humans
  - J Clin Endocrinol Metab 94(4):1401-1408 (2009)
  Objective: Linkage to type 2 diabetes (T2D) is well replicated on chromosome 1q21-q23. Within this region, T2D was associated with common single nucleotide polymorphisms that marked an extended linkage disequilibrium block, including the liver pyruvate kinase gene (PKLR), in several European-derived populations. In this study we sought to determine the molecular basis for the association and the phenotypic consequences of the risk haplotype. Research Design and Methods: Genes surrounding PKLR were resequenced in European-American and African-American cases and controls, and association with T2D was tested. Copy number variants (CNVs) were tested for four regions with real-time PCR. Expression of genes in the region was tested in adipose and muscle from nondiabetic subjects with each genotype. Insulin secretion, insulin sensitivity, and hepatic glucose production were tested in nondiabetic individuals with each haplotype combination. Results: No coding variant in the ! region was associated with T2D. CNVs were rare and not associated with T2D. PKLR was not expressed in available tissues, but expression of genes HCN3, CLK2, SCAMP3, and FDPS was not associated with haplotype combinations in adipose or muscle. Haplotype combinations were not associated with insulin secretion or peripheral insulin sensitivity, but homozygous carriers of the risk haplotype had increased hepatic glucose production during hyperinsulinemia. Conclusions: Noncoding variants in the PKLR region likely alter gene expression of one or more genes. Our extensive physiological and molecular studies suggest increased hepatic glucose production and reduced hepatic insulin sensitivity, thus pointing to PKLR itself as the most likely candidate gene in this population.
• Maternal Levels of Corticotropin-Releasing Hormone during Pregnancy in Relation to Adiponectin and Leptin in Early Childhood
  - J Clin Endocrinol Metab 94(4):1409-1415 (2009)
  Background: Fetal glucocorticoid exposure is associated with later development of features of the metabolic syndrome such as central obesity and insulin resistance. Fat tissue, especially visceral fat, produces adiponectin, which is inversely associated with insulin resistance in older children and adults. Adipocytes also produce leptin, directly related to measures of adiposity. It is unknown how the secretion of these hormones in early childhood is related to pregnancy levels of CRH, a proxy of fetal glucocorticoid exposure. Aim: Our aim was to study the relationship of maternal midpregnancy CRH levels with offspring levels of adiponectin and leptin in early childhood. Methods: The study population consisted of 349 mother-children pairs from Project Viva, a prospective prebirth cohort study from eastern Massachusetts. We created a general linear model with log CRH levels in midpregnancy maternal blood as the predictor and adiponectin and leptin measured in the 3-yr! -old offspring as outcomes, adjusting for covariates. Results: The means (SD) of log CRH, adiponectin, and leptin were 4.97 (0.65) log pg/ml, 22.4 (5.8) {micro}g/ml, and 1.9 (1.8) ng/ml. For each unit increment in log CRH, mean value of offspring adiponectin was 1.10 {micro}g/ml (95% confidence interval = 0.06-2.14) higher. We found no association with leptin (-0.08 ng/ml; 95% confidence interval = -0.40-0.24). Conclusions: Higher maternal blood levels of CRH were associated with higher levels of adiponectin but unchanged levels of leptin at age 3 yr. The increased adiponectin levels might represent secretion from organs other than fat or reflect a compensatory mechanism to increase insulin sensitivity.
• Transcriptional Profiling with a Pathway-Oriented Analysis Identifies Dysregulated Molecular Phenotypes in the Endometrium of Patients with Polycystic Ovary Syndrome
  - J Clin Endocrinol Metab 94(4):1416-1426 (2009)
  Context: Polycystic ovary syndrome (PCOS) is a common endocrine disorder characterized by chronic oligo/anovulation, hyperandrogenemia, infertility, and metabolic alterations related to insulin resistance. These abnormalities in PCOS may have complex effects on pathophysiology of the endometrium, contributing to infertility and endometrial disorders. Objective: The objective of this study was to examine dysregulated signaling pathways in the endometrium of patients with PCOS (PCOSE) by analyzing expression profiles with a pathway-oriented method. Design: Microarrays, RT-PCR, laser capture microdissection, and immunohistochemistry were performed with endometrial tissues. Setting: This study was performed at a university hospital laboratory. Patients: This study comprised 12 regularly cycling women and 12 PCOS patients. Main Outcome Measure: Dysregulated signaling pathways in PCOSE were identified as a gene set. Results: Hierarchical clustering revealed distinct ex! pression profiles for PCOSE and the endometrium of normal cycling women. Gene sets associated with androgen signaling were not enriched in PCOSE, although they affect ovarian physiology of PCOS patients. Several biological pathways including cell cycle, apoptosis, glycolysis, and integrin-Rho-cytoskeleton network were aberrantly down-regulated in PCOSE. Expression of genes constituting these gene sets enriched in normal cycling women was systemically down-regulated in PCOSE. Laser capture microdissection-coupled real-time RT-PCR and immunohistochemistry further demonstrated that cell proliferation in the stroma, but not the epithelium, is significantly reduced in PCOSE. Conclusions: Systemic down-regulation of various signaling pathways in PCOSE with extremely prolonged proliferative phase provides insight into the abnormal phenotypes that reflect pathophysiology of PCOS in the endometrium, possibly leading to increased risks of endometrial disorders.
• Gene Expression Analysis of Human Fetal Ovarian Primordial Follicle Formation
  - J Clin Endocrinol Metab 94(4):1427-1435 (2009)
  Context: Primordial follicle formation dictates the maximal potential female reproductive capacity and establishes the ovarian reserve. Currently, little is known about this process in the human. Objective: The aim of the study was to identify genes associated with the onset of human fetal primordial follicle formation in morphologically normal human fetuses. Design: We conducted an observational study of the female fetal gonad, comparing gene expression before and during primordial follicle formation. Setting: The study was conducted at the Universities of Aberdeen, Glasgow, and Nottingham. Patients/Participants: Ovaries were collected from 51 morphologically normal human female fetuses of women undergoing elective termination of normal second trimester pregnancies. Main Outcome Measures: We performed fetal ovarian transcript expression by Affymetrix array and quantitative RT-PCR and gene product expression and localization by Western blot and immunohistochemistr! y. Results: Five transcripts were down-regulated and 61 were up-regulated in ovaries from older fetuses (18-20 wk) in which primordial follicle formation had started compared with younger (15-16 wk) fetuses in which no primordial follicles were observed. The altered genes contribute to major functions, including gene expression, tissue morphology, and apoptosis, that are essential for ovarian development. NALP5, the most highly regulated transcript, is an oocyte-specific maternal effect gene that is regulated downstream of FIGLA. Conclusions: NALP5 probably plays a key role in the onset of human primordial follicle formation and thus the establishment of ovarian reserve in women.
• Nuclear Accumulation of E-Cadherin Correlates with Loss of Cytoplasmic Membrane Staining and Invasion in Pituitary Adenomas
  - J Clin Endocrinol Metab 94(4):1436-1442 (2009)
  Context: Loss of the cell adhesion protein E-cadherin is associated with invasion and metastasis in a number of malignancies. Recent studies have highlighted that loss of E-cadherin cell membrane expression may be accompanied by its detection in the nucleus, suggesting cellular redistribution during neoplasia. Pituitary tumors, although typically benign, may be locally invasive, and loss of membranous E-cadherin has been reported as a marker of invasion in prolactinomas. Objective: Our objective was to study E-cadherin expression in pituitary adenomas, specifically whether nuclear redistribution occurs in this setting. Methods: Immunohistochemistry, RT-PCR, and direct sequencing were performed. Results: Strong cytoplasmic membrane staining was present in all eight normal samples but completely absent in 21 of 44 adenomas (48%) with weak staining in an additional 11 adenomas using an antibody against the extracellular domain of E-cadherin. To identify nuclear translo! cation of the protein, immunohistochemistry was performed using an antibody against the cytoplasmic domain. Nuclear staining was present in 38 of 44 adenomas (86%) and absent in normal tissue. Nuclear E-cadherin inversely correlated with loss of E-cadherin cytoplasmic membrane staining and was associated with tumor invasion (P = 0.009). To investigate the mechanism of nuclear redistribution of E-cadherin, we performed RT-PCR of mRNA and sequenced tumor DNA. E-cadherin mRNA expression was reduced in only one of 30 samples (3%). No mutations were detected. Conclusions: E-cadherin was frequently lost at the cytoplasmic membrane but detected in the nucleus, suggesting that cleavage of the extracellular domain and nuclear translocation of E-cadherin is a common event that may determine local invasion in pituitary adenomas.
• Cortisol Inactivation by 11{beta}-Hydroxysteroid dehydrogenase-2 May Enhance Endometrial Angiogenesis via Reduced Thrombospondin-1 in Heavy Menstruation
  - J Clin Endocrinol Metab 94(4):1443-1450 (2009)
  Context: Heavy menstrual bleeding (HMB; menorrhagia) impairs quality of life for women and requires medication or surgery. Because glucocorticoids inhibit angiogenesis in other organs, we hypothesized that endometrium of women with HMB is subject to decreased local glucocorticoid exposure and enhanced angiogenesis, thereby increasing menstrual bleeding. Design: Endometrium was collected from 29 women with menstrual complaints. Menstrual blood loss was measured by alkaline-hematin assay (n = 12, > 80 ml (HMB); n = 17, < 80 ml). Quantitative RT-PCR for thrombospondin-1 (TSP-1) and glucocorticoid-metabolizing enzymes, 11{beta}-hydroxysteroid dehydrogenases-1 and -2 (11{beta}HSD1,2) was performed. Glucocorticoid effects on endometrial stromal cells and uterine endothelial cells (UECs) were determined. RNA interference studies in UECs examined the effect of TSP-1 ablation on cortisol action. Results: Secretory phase endometrium mRNA levels for the cortisol inactivating en! zyme 11{beta}HSD2 were higher [3.78 {+/-} 1.29 vs. 1.40 {+/-} 0.6 (arbitrary units), P < 0.05], whereas TSP-1 mRNA was lower [0.40 {+/-} 0.13 vs. 1.66 {+/-} 1.02 (arbitrary units), P < 0.05] in women with HMB. In cultured endometrial stromal cells and UECs, cortisol increased TSP-1 expression. Both cortisol and TSP-1 inhibited new vessel formation in endometrial explants embedded in Matrigel. In UECs cortisol inhibition of tube-like structure formation was blocked by small interfering RNA (siRNA) against TSP-1 (25 {+/-} 2.5% cortisol inhibition with scrambled siRNA vs. 0% cortisol inhibition with TSP-1 siRNA inactivation, P<0.01). Conclusions: Enhanced inactivation of cortisol by 11{beta}HSD2 in endometrium from women with HMB may explain reduced TSP-1 levels and hence endothelial cell dysfunction and abnormal angiogenesis. Inhibition of 11{beta}HSD2 may be a rational novel therapy for heavy menstrual bleeding.
• Scavenger Receptor Class B Type I Protein as an Independent Predictor of High-Density Lipoprotein Cholesterol Levels in Subjects with Hyperalphalipoproteinemia
  - J Clin Endocrinol Metab 94(4):1451-1457 (2009)
  Context: In mice, scavenger receptor class B, type I (SR-BI) receptor protein deficiency is associated with elevated high-density lipoprotein (HDL)-cholesterol (HDL-C) levels. Objective: Our objective was to determine the relationship between SR-BI protein and HDL-C levels in humans. Design: This was a prospective study of adults with hyperalphalipoproteinemia. Fasting blood was obtained for lipid and lipoprotein measurement, genomic DNA, and monocyte-derived macrophages. SR-BI protein levels were measured by Western blots, and SR-BI activity was measured by cholesteryl ester (CE) uptake of each donor's radiolabeled HDL with their monocyte-derived macrophages, or by degradation and specific cell association of dual-labeled HDL in vitro. Setting: The study was performed in a tertiary university teaching hospital. Results: The mean age was 57.2 {+/-} 10.9 yr (n = 65). SR-BI protein levels were inversely associated with HDL-C levels (P < 0.002), HDL particle size (P
• Autoimmune Thyroiditis and Diabetes: Dissecting the Joint Genetic Susceptibility in a Large Cohort of Multiplex Families
  - J Clin Endocrinol Metab 94(4):1458-1466 (2009)
  Context: Epidemiological data support a shared genetic susceptibility to autoimmune thyroid disease (AITD) and type 1 diabetes (T1D). Both diseases frequently occur within the same family and in the same individual. Patients developing both T1D and AITD are considered to have an autoimmune polyglandular syndrome type 3 variant (APS3v). Objective: The goals of this study were to identify the joint susceptibility loci/genes for T1D and AITD. Settings: The study was conducted at an academic medical center. Participants and Main Outcome Measures: We used whole genome and candidate gene approaches in a data set of 88 families multiplex for T1D and AITD (448 individuals). Results: We identified three loci, on chromosomes 2p, 6p, and Xp, showing linkage when individuals with either T1D or AITD were classified as affected. The 6p locus contained the human leukocyte antigen class II genes, and the Xp locus contained the FOXP3 gene. Three loci, on 2q, 6p (human leukocyte ant! igen class II), and Xp, showed evidence for linkage when only APS3v individuals (T1D+AITD) were classified as affected. Analysis of positional candidate genes strongly supported CTLA-4 as the gene on 2q associated with APS3v and FOXP3 as the gene on Xp associated with T1D or AITD and APS3v. In addition, the PTPN22 and insulin variable number tandem repeat genes showed significant associations with T1D or AITD in our families. Conclusions: Our results demonstrate a strong shared genetic susceptibility to T1D and AITD, with most shared genes involved in immune regulation, suggesting that immune dysregulation plays an important role in the joint susceptibility to T1D and AITD.
• Knockdown of IG20 Gene Expression Renders Thyroid Cancer Cells Susceptible to Apoptosis
  - J Clin Endocrinol Metab 94(4):1467-1471 (2009)
  Aim: The aim of the study was to investigate the expression and function of the IG20 gene in thyroid cancer cell survival, proliferation, and apoptosis. Methods: We determined the expression levels of the major isoforms of IG20 by quantitative RT-PCR in normal and thyroid tumor tissues/cell lines. We evaluated the functional consequence of IG20 knockdown in WRO (follicular carcinoma) and FRO (anaplastic carcinoma) thyroid cancer cell lines by measuring spontaneous, TNF{alpha}-related apoptosis-inducing ligand (TRAIL), and TNF{alpha}-induced apoptosis. Results: The IG20 gene expression levels were higher in benign and malignant thyroid tumors and in WRO and FRO cells relative to normal tissues. Predominantly, MADD and DENN-SV isoforms of IG20 gene were expressed. IG20 knockdown resulted in increased spontaneous, TRAIL-, and TNF{alpha}-induced apoptosis in WRO, but not FRO, cells. FRO cell resistance to apoptosis is likely due to caspase-8 deficiency. Conclusion: IG20! knockdown renders WRO cells more susceptible to spontaneous, TRAIL-, and TNF{alpha}-induced apoptosis and thus demonstrates the prosurvival function of the IG20 gene in thyroid cancer. These observations, combined with overexpression of IG20 noted in thyroid tumor tissues, may suggest a potential role in thyroid cancer survival and growth and indicate that IG20 may be targeted either alone or in conjunction with TRAIL or TNF{alpha} treatment in certain thyroid cancers.
• Minireview: Thyrotropin-Releasing Hormone and the Thyroid Hormone Feedback Mechanism
  - J Clin Endocrinol Metab 94(4):1472-a (2009)
  
• DISP3, a Sterol-Sensing Domain-Containing Protein that Links Thyroid Hormone Action and Cholesterol Metabolism
  Zikova M Corlett A Bendova Z Pajer P Bartunek P - J Clin Endocrinol Metab 94(4):1475-a (2009)