[There are alot of abstracts available. It is worth a quick look. Following are examples.]
We are delighted to provide you with details of the Society for Endocrinology BES 2011 meeting, taking place in Birmingham on 11-14 April 2011.
http://www.endocrinology.org/meetings/2011/sfebes2011/prog/prog.aspx
http://www.endocrine-abstracts.org/ea/0025/default.htm
The following are more abstracts from the meeting. They are varied dealing with almost all aspects of endocrinology.
The endocrinology of extramarital affairs
The endocrinology of extramarital affairs
There are three types of academic research studies into the origins and maintenance of monogamous as opposed to promiscuous relationships in humans – economic, sociological, and biological – with seemingly little continuity between them. It may be obvious that all three influences can modify sexual behaviour, but it is a fact that though many reproductive strategies exist throughout the animal kingdom – and monogamy is perhaps surprisingly well represented in all groups – relatively few species have the capacity for ‘facultative’ monogamy seen in humans. It seems important to understand the reasons for it, in biological, and also in specifically endocrinological terms.
Among the hormones thought to be involved in pair bonding behaviours, prolactin, vasopressin, and above all testosterone have received attention. Testosterone levels are relatively high in promiscuous males, and several studies have shown that they are reduced in monogamous relationships, triggered apparently by proximity to young children. The task is now to identify the causes of this.
One possibility is that the effect is pheromonal, and although previous attempts to identify human pheromones have not uniformly stood the test of time, a recent study claims that a pheromone in teardrops has a testosterone reducing effect.
There are undoubted rewards to be gained from elucidation of these mechanisms. There is apparently a huge market for Viagra. Is there similarly a demand for an agent with the reverse activity?
Kisspeptin-54 injection stimulates activity of the human GnRH pulse generator in healthy women
Kisspeptin-54 injection stimulates activity of the human GnRH pulse generator in healthy women
Background: Kisspeptin is a novel hypothalamic hormone with powerful stimulatory effects on the hypothalamo-pituitary–gonadal (HPG) axis. Inactivating mutations in the kisspeptin receptor lead to pubertal failure. We have previously demonstrated that injection of kisspeptin-54 stimulates LH release in healthy men and women. Recent studies in animals suggest that endogenous kisspeptin may be involved in stimulating the GnRH pulse generator. Determining whether exogenous administration of kisspeptin can stimulate the human GnRH pulse generator, has important therapeutic implications.
Aim: To determine if kisspeptin-54 administration can stimulate the GnRH pulse generator in healthy female volunteers.
Methods: Six healthy female volunteers underwent frequent blood sampling for serum LH measurement every 10 min for 8 h (as a surrogate marker of the GnRH pulse generator) during the follicular phase of menstrual cycle. A s.c. injection of saline or kisspeptin-54 (0.3–0.6 nmol/kg) was administered 4 h after commencing the study. LH pulsatility within each subject was compared between the 4 h pre-injection and 4 h post-injection.
Results: No significant differences in number of LH pulses and LH pulse amplitude were observed before and after saline injection. A 6-fold increase in mean number of LH pulses was observed following kisspeptin-54 injection when compared the pre-injection period (mean number of LH pulses during 4 h: 0.50±0.48, pre-injection; 3.00±0.69, post-injection, P<0.05 versus pre-injection). The LH pulse amplitude was nearly 2-fold higher after kisspeptin-54 injection when compared with the pre-injection period (mean pulse amplitude in IU/l during 4 h: 1.31±0.09, pre-injection; 2.31±0.25, post-injection, P<0.05 versus pre-injection).
Conclusions: We have demonstrated for the first time that kisspeptin-54 stimulates activity of the GnRH pulse generator in humans. A single injection of kisspeptin-54 injection increases LH pulse frequency and LH pulse amplitude in healthy women. This data has important therapeutic implications for the future development of kisspeptin to treat patients with disorders of reproduction.
Nesfatin stimulates the hypothalamic–pituitary–gonadal axis in male rats
Nesfatin stimulates the hypothalamic–pituitary–gonadal axis in male rats
Nesfatin is an 82 amino acid peptide identified as a novel hypothalamic regulator of feeding. In rodents, central administration of nesfatin acutely inhibits feeding and chronic administration reduces weight gain. Subsequent research has demonstrated nesfatin is involved in the control of puberty in female rats. During puberty i.c.v. administration of nesfatin stimulates release of LH and FSH but has no effect in adult female rats.
We investigated the effects of i.c.v. injection of nesfatin on the release of pituitary hormones in ad libitum fed unanaesthetised adult male rats. In contrast to the data from adult female rats, i.c.v. administration of nesfatin (1 nmol) significantly increased plasma LH and FSH levels 30 min post injection. There were no significant changes in plasma ACTH, TSH and prolactin. In a second experiment, i.c.v. administration of nesfatin (1 nmol) significantly increased plasma testosterone 60 min post injection. To further investigate the role of nesfatin in the hypothalamic–pituitary–gonadal (HPG) axis we examined the effect of nesfatin on the release of GnRH from static hypothalamic explants. Treatment with 100 and 1000 nM nesfatin significantly increased GnRH release from in vitro hypothalamic explants. Data from these studies suggests nesfatin is a novel regulator of the HPG axis in adult male rats.
Neuromedin B stimulates the hypothalamo-pituitary–gonadal axis in male rats
Neuromedin B stimulates the hypothalamo-pituitary–gonadal axis in male rats
Neuromedin B (NMB) is a highly conserved bombesin-related peptide found in mammals. The mammalian bombesin family of receptors consists of three closely related G protein coupled receptors, BB1, BB2 and BB3. The BB1 receptor subtype has the highest affinity for NMB. NMB mRNA is detected in the CNS and is expressed at relatively high levels in the rat hypothalamus, in particular the medial preoptic area and the arcuate nucleus.
NMB has well documented roles in the regulation of the thyroid axis and the stress axis in rats. However, there is little available data regarding the role of NMB in the regulation of the hypothalamo-pituitary–gonadal (HPG) axis. It is known that the NMB receptor is expressed in immortalised GnRH-releasing GT1-7 cells, and that anterior pituitary NMB-immunoreactivity is altered by changes in the sex steroid environment. The objective of these studies was thus to further investigate the effects of NMB on the HPG axis.
I.c.v. administration of NMB (10 nmol) to adult male rats significantly increased plasma LH levels 30 min after injection (plasma LH ng/ml; saline 0.7±0.1, 10 nmol NMB 1.3±0.2, P<0.01). In vitro, NMB stimulated GnRH release from hypothalamic explants from male rats and from GT1-7 cells. NMB had no significant effect on LH release from anterior pituitary explants from male rats, or from L?T2 cells in vitro.
These results suggest a previously unreported role for NMB in the stimulation of the HPG axis via hypothalamic GnRH. Further work is now required to determine the receptor mediating the effects of NMB on the reproductive axis and the physiological role of NMB in reproduction.
Turbulent flow liquid chromatography--tandem mass spectrometry for the analysis of bio-available testosterone in serum
Turbulent flow liquid chromatography–tandem mass spectrometry for the analysis of bio-available testosterone in serum
Testosterone in serum may be unbound (free), or bound to either sex hormone binding globulin (SHBG) or albumin. Consequently, ‘total’ serum testosterone analysis may be misleading in situations where binding protein concentrations are abnormal. Current methods for estimating the biologically active (bio-available) serum testosterone concentration involve physical separation of testosterone fractions and are not amenable to high-throughput analysis. The use of automated immunoassays for total serum testosterone has also been questioned. Liquid chromatography–tandem mass spectrometric (LC–MS/MS) methods for measuring testosterone have gained favour due to their superior selectivity. The separation of testosterone fractions by turbulent flow chromatography (TFC – TurboFlow technology, ThermoFisher Scientific) prior to MS/MS analysis.was investigated. TFC is based on the direct injection of biological samples onto a column packed with relatively large particles at high flow-rates. In the resulting turbulent flow, smaller analytes can enter the column interstices but larger proteinaceous material is excluded. Serum from a male volunteer was analysed (i) following protein precipitation with equal volumes of methanol (total testosterone) and (ii) by direct injection onto the TFC column (retained fraction). By comparison of peak areas, it was found that 25% of the total serum testosterone was retained after direct injection. This agrees well with an ammonium sulfate precipitation method for bio-available testosterone (22%) used on the same sample. Based on the known binding affinities of SHBG and albumin for testosterone, it is likely that the more weakly bound albumin fraction was, to some degree, dissociated during the TFC process. Testosterone and SHBG were added separately to serum pools and analysed as previously described. The peak area ratio was independent of total testosterone concentration, but decreased at higher SHBG concentrations. Whilst further validation is required to prove the utility of TFC, it has considerable potential for the analysis of bio-available steroid hormones in serum.
Polycythaemia in men treated with transdermal and intramuscular testosterone
Polycythaemia in men treated with transdermal and intramuscular testosterone
Background: Testosterone replacement therapy has been shown to produce a wide range of benefits for men with hypogonadism with studies showing improvement in libido, bone density, muscle mass, body composition, mood, cognition, and erythopoiesis. The risks associated with testosterone replacement therapy are less well characterised and there is a lack of larger randomised trials. One recognised risk is polycythaemia. The aim of this study is to assess the frequency of polycythaemia in men treated with testosterone and to compare it’s frequency with different treatment modalities.
Methods: This is a retrospective observational study. We analysed biochemical and haematological parameters of all men on testosterone therapy who attended our endocrinology unit from the 1st of January 2009 until the 30th of June 2010. Of a total of 173 men, 86 (50%) were treated with testosterone undecnoate (Nebido), 57 (33%) with transdermal testosterone gel, and 30 with intramuscular testosterone in the form of Sustanon. Data were collected on haemoglobin concentrations and packed cell volumes. Polycythaemia was defined as haemoglobin concentration >17 g/dl or packed cell volume >0.505.
Results: Out of the 173 men 25 (14.5%) developed polycythaemia on at least one blood sample during the above period. 12 of the 86 men treated with Nebido (14%), 8 out of the 57 men treated with transdermal gel (14%), and 5 of the 30 men treated with Sustanon (17%) developed polycythaemia. There was therefore no significant difference between the different treatment groups.
Conclusion: In our experience polycthaemia is a common risk with any testosterone replacement therapy. Although previous studies have indicated that this is less likely with transdermal preparations we found the risk to be equally high in all treatment groups. This demonstrates the importance of careful monitoring of haematological variables during any testosterone treatment so that appropriate measures can be taken if erythrocytosis occurs.
Life-threatening adverse reaction following pituitary MRI
Life-threatening adverse reaction following pituitary MRI
Pituitary MRI is widely used in endocrine practice, and is regarded as entirely safe. We report here a life-threatening outcome from a routine pituitary MRI scan.
A 23-year-old female with a 3-year history of microprolactinoma confirmed by MRI underwent a routine repeat MRI scan with gadolinium. During injection of Gadovist she experienced minimal chest tightness which rapidly resolved. Four hours after the injection she rapidly became very breathless. On admission to hospital she was shocked, profoundly breathless, with cyanosis, hypotension and marked hypoxia (HR 162 bpm, BP 72/50 mmHg, PaO2 7 kPa despite FiO2 60%); there were diffuse crepitations throughout both lung fields and no signs of cardiac disease or angioedema. CXR showed bilateral perihilar alveolar shadowing, indicating pulmonary oedema/ARDS.
She was treated with high-flow oxygen, adrenaline, hydrocortisone, chlorpheniramine and furosemide. She remained critically ill and was admitted to ITU, where she required inotropes and CPAP non-invasive ventilation for persistent acute respiratory failure. Echocardiogram confirmed normal cardiac function. She made a rapid recovery and was discharged home well 2 days later. She subsequently recalled that she had felt slightly unwell after her first MRI scan 3 years earlier.
Acute lung injury has not previously been reported after gadolinium administration. Gadolinium-induced serious adverse reactions are extremely rare (1–3 per million administered doses). Gadovist is a modern contrast agent regarded as having a very low potential for anaphylactoid reactions; it includes a macrocyclic chelate which is thought to give less risk of gadolinium toxicity than older agents with a linear chelate such as Omniscan. However, macrocyclic gadolinium agents may be associated with a higher frequency of allergic reactions.
Pituitary disease is rarely fatal. Endocrinologists should be aware that pituitary MRI carries a small risk of iatrogenic adverse reaction which may be life-threatening.
Hormone profile of patients referred for Bariatric surgery
Hormone profile of patients referred for Bariatric surgery
Aim: An increasing proportion of patients are referred to endocrine clinics for assessment of an endocrine reason for obesity. The aim of our study was to assess the hormone profiles of patients referred for bariatric surgery.
Methods: Patients referred to bariatric surgery clinic were investigated for hypothyroidism (TSH, T4), Cushing’s disease (2 mg-overnight dexamethasone suppression test), acromegaly (IGF1) and Vitamin D deficiency (PTH, Ca and Vitamin D) based on clinical suspicion. A retrospective observational analysis was conducted to analyse the prevalence of endocrine disorders and distribution of comorbidities.
Results: Demographics: n=159 patients; mean age: 42.6 years (17–67); females: 80%; mean BMI 49.5 kg/m2 (35–73).
Distribution of comorbidities: Clinical Diabetes mellitus: 30.2%, Hypertension: 37.7%, Dyslipidemia: 34%, Severe arthritis: 39%, Obstructive sleep apnoea: 6.3%.
Cushing’s syndrome: n=85; None of the patients had documented cushingoid morphology. Apart from one patient who had unsuppressed cortisol (=68 nmol/l; urinary free cortisol normal – not investigated further), all the others were negative.
Thyroid status: n=159; 13% were known hypothyroidism on replacement; 33% of them were inadequately replaced. 1.4% had sub-clinical hypothyroidism not being treated so far.
Acromegaly: n=52; All had normal age-related IGF1 levels.
Bone: PTH: n=105; 61% had high PTH (>6.4 pmol/l). Serum calcium was within normal range in all patients. PTH values correlated positively to BMI (r=0.1). Vitamin D: n=81; 16.1% deficient (<10 ?g/l); 60.5% were insufficient (11–30 ?g/l); 23.4% were Vitamin D replete (>30 ?g/l). Vitamin D correlated negatively to BMI (r=?0.2).
Conclusion: A vast majority of patients with morbid obesity, who are referred for bariatric surgery, do not have an endocrine aetiology. Vitamin D deficiency or insufficiency is present in a high proportion of this cohort (77%) and hence should be treated prior to surgery and reassessed post-operatively. Thyroxine treatment should be optimized in patients with prior hypothyroidism. Screening for Cushing’s syndrome or acromegaly need not be performed unless clinically indicated.
Pituitary thyroid hormone resistance (PTHR)
Pituitary thyroid hormone resistance (PTHR)
A 32-year-old lady was referred to our centre with thyrotoxicosis and elevated FT4 and TSH levels. She was already on carbimazole. Interestingly, her symptoms started at childhood. She was nicknamed ‘shaky’ by her school friends because of her tremors. There was no family history of thyroid disease.
She was clinically and biochemically thyrotoxic with FT4 of 12.4–38.8 pmol/l and TSH of 7.24–38.8 mIU/l.
After excluding assay interference as a possibility, Investigations revealed a normal ?-subunit/TSH molar ratio, an appropriate rise in TSH during TRH test and no evidence of a pituitary adenoma on MRI. This suggested a diagnosis of pituitary thyroid hormone resistance (PTHR). However, sequencing thyroid hormone receptor-? (THR-?) gene did not identify any abnormality.
Following a TSH day curve to assess response to cabergoline and octreotide, carbimazole was switched to cabergoline which only resulted in partial clinical and biochemical improvement. She underwent further assessment at Addenbroke’s Hospital. Negative genetic testing raised doubts about initial diagnosis. Re-sequencing THR-? gene and repeat MRI scan again did not identify any abnormality. Also, measurement of BMR, sleeping heart rate, SHBG and BMD to assess peripheral thyroid hormone actions confirmed the initial diagnosis.
Her thyrotoxicosis improved after adding triiodo-thyroacetic acid (TRAIC) to her treatment regimen. However, following MHRA guidance, a routine echocardiogram revealed severe MR. Therefore, cabergoline was switched to quinagolide following a repeat TSH day curve.
She underwent successful cardiac surgery. Currently, she is clinically and biochemically euthyroid and in addition to nadolol is taking TRAIC 700 ?g BD and quinagolide 150 mg daily.
This case that revealed symptoms of thyrotoxicosis since childhood (nickname ‘shaky’) highlights important learning points including: diagnostic approach to a patient with TSH-induced thyrotoxicosis, value of TSH day curve, use of TRIAC and the relationship between cabergoline and fibrotic valvular heart disease.
Tramadol-induced adrenal insufficiency. A case report.
Tramadol-induced adrenal insufficiency. A case report.
Background: The effect of long term opioids on the hypothalamo-pituitary–adrenal (HPA) axis is conflicting. We present a case of a 21-year-old female who presented with adrenal insufficiency (AI) secondary to chronic tramadol use.
Case summary: Our patient presented with a three year history of non-specific abdominal pain, lethargy and dizziness. No cause was found for these symptoms despite thorough investigations. One month before referral to Endocrinology outpatients, she was hospitalised with a three day history of dizziness, vomiting and pressure-like headaches. An MRI scan showed an incidental pituitary microadenoma whilst the pituitary profile revealed a mildly abnormal Synacthen test with a baseline 0900 h cortisol of 54 nmol/l and a 30-min cortisol of 537 nmol/l. Her medications included Tramadol 50 mg TDS besides Sumatriptan, Metoclopramide, Omeprazole and Ibuprofen. Her Synacthen test normalized when advised to stop tramadol.
Two months later, she was readmitted with similar symptoms. Tramadol 100 mg QDS had been inadvertently restarted by her GP for persistent abdominal pain. Cortisol levels from the Synacthen test were 45 and 307 nmol/l at 0 and 30 min respectively. ACTH was relatively low at 9.7 ng/l. The rest of the pituitary profile was normal. A diagnosis of tramadol-induced AI was made. Repeat Synacthen tests and ACTH normalized when stopping tramadol. Her quality of life improved significantly.
Conclusion: The sequence of events and development of AI on re-challenge with tramadol support this drug as the cause for this event. To our knowledge this is the first clinical case of tramadol-induced AI although this effect on the HPA axis has been previously reported with other opioids. There are currently no guidelines recommending routine screening of adrenal status in patients on opioids but clinicians should be aware of the possibility of AI in opioid users. Systematic studies on the effects of opioids on the HPA axis are necessary.
Recreational jaundice
Recreational jaundice
A young fit male readmitted with three weeks history of malaise, pale stool, dark urine, pruritus with recent travel to Greece. He denied alcohol, illicit drug abuse. Examination revealed jaundice.
Investigation showed cholestatic liver impairment with Bilirubin: 448 ?mol/l (7-35), ALT: 134 IU/l (17–63), ALP: 190 IU/l (32–91), HDL 0.34 mmol/l (>0.9). Viral Screen, autoantibody, porphyria and tumour markers were negative. CT Abdomen showed tiny gall stone with normal bile duct and pancreas. MRI MRCP was normal.
Testosterone: 11.7 nmol/l (6–27), 17 B Oestradiol: 556 pmol/l (up to 73), LH: 4 U/l (0.7–11), FSH: 1 U/l (0.8–7.7), TFT: Normal, SHBG: 30.3 nmol/l (13–71), PRL: 165 mU/l (0–280).
Cause of Cholestasis remains unidentified at this point.
Pt admits taking Creatin/Protein powder but denied taking any steroid. When asked repeatedly informed taking ALPHA SD (2a 17a dimethyl eticholan 3-one 17b-01) 10 mg BD for one month. Patient improved without treatment after stopping AAS.
Impression: Anabolic steroid induced cholestasis and deranged lipid profile.
Discussion: Anabolic-androgenic steroids (AAS) are the synthetic derivatives of testosterone and altered to reduce metabolism, achieve desirable anabolic effects and difficult detection. AAS use is associated with side effects of Cardiovascular, hepatic, gynaecological, behavioural, skin and endocrinological disorders.
Hepatic: With AAS abuse there is an elevated risk for liver tumours, cholestasis, toxic hepatitis and peliosis hepatitis. This is likely due to the liver being the primary site of steroid clearance. The alkylated AAS are highly hepatotoxic.
Cardiovascular: AAS can induce hypertension, MI, abnormal lipoproteins and possibly LVH. AAS can affect lipid profile adversely leading to reduction in HDL cholesterol raised LDL leading to early atherosclerosis.
Conclusion: As there is rise in unregulated abuse of AAS, so we need to be aware and consider anabolic steroid as cause of unexplained liver failure, deranged lipid profile and endocrinological abnormalities.
Main treatment is stopping the drugs and monitoring regularly.
Testosterone undecanoate has a beneficial effect on lipid profile in men with hypogonadism in routine clinical practice
Testosterone undecanoate has a beneficial effect on lipid profile in men with hypogonadism in routine clinical practice
Background: There is a close association between low testosterone and metabolic syndrome. Testosterone replacement therapy (TRT) has beneficial effects on cardiovascular (CV) risk factors in men with hypogonadism.
Aim: This is a retrospective audit of CV parameters in hypogonadal men treated with testosterone undecanoate (Nebido) in standard clinical practice.
Methods: Patients with hypogonadism on testosterone undecanoate injections from 2005 to 2009 were identified from hospital data base. Weight, blood pressure, non-fasting lipid profile and HbA1c (diabetic men n=42) were collected at 3, 6, and 12 months.
Results: Of the 120 patients 99 (82%) had previous TRT with other preparations. Mean age was 48±16 years. After excluding patients with changes in lipid lowering medications over the treatment period, the total cholesterol (TC) and calculated LDL cholesterol (cLDL) demonstrated significant improvement.
TC at 3 months was 3.8±1.4 (compared with 4.6 mmol/l±1.4 at baseline P=0.006, n=47), at 6 months 4.2±1.3 (P=0.03, n=36) and at 1 year 4.1±1.1 (P=0.005, n=41).
cLDL at 3 months was 1.9 mmol/l±1 (vs 2.3±1.1 at baseline; P=0.006, n=43) at 6 months 2.1±1 (P=0.13, n=38) and at 12 months 2.1±1 (P=0.046, n=33).
HDL-cholesterol (HDL) did not show any significant change at 6 months 1.05±0.3 (vs 1.08±0.3 at baselineP=0.33, n=44) or at 12 months 1.04±0.28 (P=0.08, n=35).
At 12 months no significant changes in weight (98 vs 99 kg; P=0.09, n=67) or blood pressure (SBP 135 vs 137P=0.3 DBP 78 vs 80 P=0.2, n=69) were noted. HbA1c fell by 0.4% (P=0.07) at 6 months in diabetic patients.
Discussion: Testosterone undecanoate therapy in routine clinical practice had beneficial effects on total cholesterol and cLDL, but no significant effect on HDL. No effects were found on weight and blood pressure.
How reproducible are LC–MS testosterone results? A calibration exercise
How reproducible are LC–MS testosterone results? A calibration exercise
Introduction: It has been recognised in EQA schemes in Europe and America that the reproducibility between labs using LC–MS for testosterone analysis is not optimal for this technique. We decided to conduct a calibration exercise to investigate the variability seen between labs.
Methods: Aqueous and matrix matched serum samples were sent to labs participating in the NEQAS testosterone scheme. The labs were asked to measure these samples blind using their routine assays and their own calibration material. We then re-calculated the results for these samples using assigned values from our routine assay which has been shown to align closely to a reference method. Most labs used liquid–liquid extraction to prepare samples but a variety of different LC columns and calibration matrices were used.
Results: Re-calculating the results from serum samples using matched serum calibrators improved the inter laboratory precision (CV) from 10% down to 5%, likewise re calculating the results from aqueous samples using aqueous calibrators improved the inter laboratory precision from 7% down to 3%. Trying to re calculate the serum results using aqueous calibrators actually made the inter laboratory variability worse. This suggests that the matrix in which the calibrator is made will affect the result significantly.
Conclusion: All laboratories gave clinically acceptable results but the accuracy of the results and hence the variability between laboratories was improved if common calibration material was used. If labs are to use a variety of different LC columns it is important that they thoroughly evaluate the effects of ion suppression, caused by sample matrix, which can vary profoundly with LC columns from different suppliers. The choice of column will also have a bearing on the type of calibrator matrix that is suitable for use in the assay.
Spitting out the issues: Identifying optimal procedures for saliva collection and storage
Spitting out the issues: Identifying optimal procedures for saliva collection and storage
Background: Human saliva is a valuable and flexible source of endocrine biomarkers, from which several significant steroids representing indices of development, well being, stress and reproduction can be quantified. Although for many disciplines blood represents the ‘gold standard’ for endocrine measurement, it also has its limitations, specifically requiring trained phlebotomists and appropriate facilities. The painful and invasive nature of blood draws can deter research participation and restricts frequent collection. Alternatively, saliva collection is straightforward in settings beyond clinical and laboratory boundaries and advances our access to populations and behavioural contexts for which blood sampling is unfeasible.
Objectives: This validation project investigates optimal protocols to adopt when collecting and storing saliva to improve reliability and increase comparability across research sites and studies. Our primary objective was to investigate and validate methods to successfully preserve saliva in a manner compatible with Enzyme Immuno-Assay (EIA). Identification of a preservation method could enhance flexibility of both field site conditions and collection protocols. This work is critical as previously established preservatives, such as sodium azide that were compatible with RIA, interfere with Horseradish Peroxidase commonly found in most EIA preparations.
Methods: Ethical Approval was granted by the local recognised University Ethics Committee. Raw human saliva samples were collected, spiked with different concentrations of the preservative Proclin300 and stored at room temperature. Following defined time periods (7d, 1, 3 and 6 months) samples were analysed for reproductive steroids using commercially available EIA kits, estradiol and progesterone.
Results and conclusions: Early results suggest that Proclin300 has potential for preserving saliva samples. Further novel preservation data are presented. We also report the stability of saliva content in conjunction with collection vial material (e.g. polystyrene, polypropylene). Such validation data are essential to further develop opportunities to capture endocrine profiles that are beyond reach of clinical settings.
Accidental long-term ingestion of androgenic steroid in a young female: a case report
Accidental long-term ingestion of androgenic steroid in a young female: a case report
Aim: We present an unusual case of long-term accidental ingestion of androgenic steroid in a young female.
Case: A 28-year-old lady presented with male pattern of hair growth, weight gain of three stones, change in voice, and secondary amenorrhea. On direct questioning she admitted she was taking ‘fat bursting pills’ for nearly 6 months, obtained from a gym, to lose weight. Examination revealed a blood pressure of 150/77 mmHg, increased muscle bulk, hirsutism and significant clitoromegaly.
Investigations: FSH 1.8 IU/l, LH 0.9 IU/l, oestradiol 169 pmol/l (8–2500), prolactin 268 mU/l (0-445), SHBG 16 nmol/l (18–114), androstenedione 9.7 nmol/l (1.0–11.5), 17 OH progesterone of 2.9 nmol/l (0.7–17.4) and testosterone of 29.2 nmol/l (0–2.8). Ultra sonogram showed normal ovaries, MRI revealed normal adrenal glands. The pills were stopped immediately. Within 4 months she had substantial weight loss, her periods returned, her physical appearance changed and blood pressure dropped to 116/80 mmHg. The testosterone levels dropped to 3.7 nmol/l and SHBG improved to 31 nmol/l.
Discussion: Androgenic steroid hormones are increasingly used by male and some female athletes to improve their performance. In one survey with 1667 participants ~2.3% of women had taken androgenic steroid at some point. Our case is unique as the ingestion was accidental and had resulted in physical changes. Change in voice, increased facial hair growth, clitoromegaly, decreased body fat, menstrual irregularities and aggressiveness are some of the perceived side effects. Chronic administration results in supraphysiological concentrations of testosterone and decreased SHBG as seen in our case. Stopping the pills resulted in reversal of these values. The reversal of clinical and biochemical abnormalities, confirms the diagnosis of exogenous androgenic steroid ingestion.
Conclusion: Accidental ingestion of long term androgenic steroid is uncommon. A clear history and a high level of suspicion are helpful in such circumstances, for the managing physician.
The effects of recombinant human IGF1/IGF binding protein-3 on lipid and glucose metabolism in recreational athletes
The effects of recombinant human IGF1/IGF binding protein-3 on lipid and glucose metabolism in recreational athletes
Introduction: Recombinant human IGF1 (rhIGF1) improves insulin sensitivity and glycaemic control when administered to people with diabetes. The effects of rhIGF1 on lipid metabolism in vivo are unclear.
Objectives: To determine the effects of rhIGF1/rhIGFBP3 administration on fasting lipids, non-esterified fatty acids (NEFA) and glucose homeostasis in recreational athletes. This study was part of a randomised, double-blind, placebo-controlled trial studying detection methods for IGF1 abuse.
Methods: The study received approval from the local ethics committee. 56 recreational athletes (age 18–30 years, 30 males, 26 females) were randomly assigned to receive placebo, low dose rhIGF1/rhIGFBP3 complex (30 mg/day) or high dose rhIGF1/rhIGFBP3 complex (60 mg/day) by subcutaneous injection for 28 consecutive days. Variables measured before and immediately after the treatment period were: fasting lipids, NEFA, glucose, insulin and HbA1c. The homeostatic model assessment (HOMA-IR) was used to estimate insulin sensitivity. Intra-individual changes were assessed using paired t-tests.
Results: No significant changes in serum lipids were observed in the placebo group. In both women and men treated with rhIGF1/rhIGFBP3, there were significant reductions in fasting triglycerides (mean decrease 0.13±0.06 mmol/l, P=0.025 in women; 0.24±0.08 mmol/l, P=0.01 in men). In women, but not in men, there were significant increases in total cholesterol (mean increase 0.47±0.12 mmol/l, P=0.001), HDL (mean increase 0.16±0.03 mmol/l, P<0.001) and LDL (mean increase 0.37±0.1 mmol/l, P=0.001). No changes in cholesterol:HDL ratio or fasting NEFA were observed. Fasting insulin and HOMA-IR decreased in both women and men treated with rhIGF1/rhIGFBP3; there was also a significant decrease in HbA1c in women (mean reduction 0.3±0.1%, P<0.001) but not in men.
Conclusions: Fasting triglycerides decrease in recreational athletes after the administration of rhIGF1/rhIGFBP3 for 28 days; these changes are associated with increased insulin sensitivity. RhIGF1/rhIGFBP3 appears to have a more pronounced effect on lipid and glucose homeostasis in women than in men.
The effects of recombinant human IGF1/IGF binding protein-3 on body composition and physical fitness in recreational athletes
The effects of recombinant human IGF1/IGF binding protein-3 on body composition and physical fitness in recreational athletes
Introduction: GH is widely abused by athletes for its anabolic and lipolytic properties. As the tests for detecting GH abuse develop further, it is possible that athletes will exploit IGF1 as an alternative or additional doping agent. There is currently no evidence to suggest that IGF1 administration improves athletic performance.
Objectives: To determine the effects of rhIGF1/rhIGFBP3 administration on body composition and physical fitness in recreational athletes. This study was part of a randomised, double-blind, placebo-controlled trial studying detection methods for IGF1 abuse.
Methods: The study received approval from the local ethics committee. Fifty-six recreational athletes (age 18–30 years, 30 males, 26 females) were randomly assigned to receive placebo, low dose rhIGF1/rhIGFBP3 complex (30 mg/day) or high dose rhIGF1/rhIGFBP3 complex (60 mg/day). Treatment was self-administered by s.c. injection for 28 consecutive days. Body composition (assessed by dual energy X-ray absorptiometry) and cardiorespiratory fitness, measured in terms of maximal oxygen uptake (VO2 max), were assessed before and immediately after treatment. Data from subjects in low and high dose treatment groups were combined and intra-individual changes were analysed using paired t-tests.
Results: There were no significant changes in body fat percentage or lean body mass in women or men after administration of rhIGF1/rhIGFBP3 complex. In both women and men, there were significant increases in VO2 max after treatment (P=0.013 women, P=0.046 men, P=0.001 men and women combined). In women, the mean increase in VO2 max was 4.2±1.5 ml/min per kg, relative increase 10.5±3.8%. In men, the mean increase in VO2 max was 3.0±1.5 ml/min per kg, relative increase 7.9±3.6%. No significant changes in VO2max were observed in the placebo group.
Conclusions: The administration of rhIGF1/rhIGFBP3 for 28 days improves aerobic performance in recreational athletes although it has no significant effect on body composition.
Iodine induced thyrotoxicosis: the danger of over the counter slimming aids
Iodine induced thyrotoxicosis: the danger of over the counter slimming aids
Over recent years, the numbers of commercially available slimming aids have increased dramatically. Whilst the majority of these aids are harmless, their interaction with normal physiology is either not understood or not brought to the attention of the customer. We report the case of a 45-year-old woman who presented with clinical and biochemical thyrotoxicosis (fT4 31.5 pmol/l, fT3 14.3 pmol/l, TSH <0.02 mIU/l). She had elevated TPO antibodies (51 IU/ml). She denied taking any prescription or homeopathic medication or iodine containing compounds. There was no history of intravenous contrast use.
Her thyroid function settled rapidly suggesting a thyroiditis rather than Graves disease as the underlying cause for her condition.
At her follow up appointment, she asked if she could continue to take an over the counter slimming aid (Tesco slimming aid 60S, one tablet taken three times per day), having started this therapy 4 months previously. She was advised against this. According to the product literature, this slimming aid contains bladderwrack 32 mg. Bladderwrack (Fucus vesiculosus), a commonly used food supplement, is a significant source of iodine. This is known to increase the risk of thyrotoxicosis via the Jod-Basedow phenomenon.
The accompanying product literature advises against using these tablets in the presence of thyroid disease. However, the majority of patients will be unaware of their thyroid status. This case reinforces the need to take a full dietary history in patients with thyrotoxicosis. Furthermore, patients wishing to take over the counter medication should be advised to seek medical advice before doing so.
Optimal use of thyroid antibody assays in the identification of auto-immune thyroid disease
Optimal use of thyroid antibody assays in the identification of auto-immune thyroid disease
Background: A variety of thyroid antibody assays are used in the diagnosis of auto-immune thyroid disease (AITD). Commonly both thyroid peroxidase (TPOab) and thyroglobulin antibodies (TGab) are measured but the added value of testing two markers has not been established.
Method: We retrospectively collected clinical and laboratory data on 500 consecutive patients who had thyroid autoantibodies requested from a specialist endocrine department of a tertiary hospital from December 2008 to October 2010. TPOab and TGab were simultaneously analysed using the FIDIS multiplex bead assay (BMD, Marne La Vallee, France).
Results: There were 399 (79.8%) females and 101 (20.2%) males in the cohort, aged 43.5±15.3 (mean±SD) years. 163 (32.6%) patients had Graves’ disease and 118 (23.6%) had Hashimoto’s thyroiditis. The other diagnoses included; thyroid nodules 101 (20.2%), other autoimmune diseases e.g. type 1 diabetes 58 (11.6%), primary hypothyroidism 41 (8.2%) and transient thyroiditis 19 (3.8%). From the 163 patients with Graves’ disease 107 (65.6%) had TPOab, 64 (39.3%) had TGab. Of the 118 patients with Hashimoto’s thyroiditis, 103 (87.3%) were positive for TPOab and 73 (61.9%) positive for TGab.
TPO only TPO and TG TG only Both negative
Graves’ 53 (32.5%) 50 (30.6%) 14 (8.6%) 46 (28.2%)
Hashimoto’s 44 (37.3%) 60 (50.8%) 14 (11.9%) 0
Conclusion: TPOab testing was superior to TGab assay in identifying patients with both Graves’ disease and Hashimoto’s thyroiditis. Although there may be a rationale in reserving TGab testing as a second-line test in patients testing negative for TPOab, this would miss 8.6% of Graves’ and 11.9% of Hashimoto’s thyroiditis patients. The multiplex assay tests both antibodies concurrently and dual testing provides increased sensitivity for AITD. The higher cost of the multiplex assay would be offset by the need to test TGab separately in the anti-TPO negative patients, which constitute 34.4% of Graves’ disease and 12.7% of Hashimoto’s patients.
Pomegranate juice consumption influences urinary glucocorticoids, attenuates blood pressure and exercise-induced oxidative stress in healthy volunteers
Pomegranate juice consumption influences urinary glucocorticoids, attenuates blood pressure and exercise-induced oxidative stress in healthy volunteers
Background and aim: Antioxidants have been postulated to exert beneficial effects on cardiovascular and neurodegenerative diseases by neutralizing reactive oxygen species (ROS). Exercise and metabolic processes are known to produce ROS. Pomegranates are rich in polyphenolic antioxidants. The aim of this study is to investigate the effects of pomegranate pure juice consumption on blood pressure, lipid peroxidation and urinary glucocorticoid levels before and after a moderate exercise bout.
Methods: A randomized placebo controlled 2-arm study was conducted. Participants (2 groups of 10 each) attended two 30 min treadmill exercise sessions (50% Wmax); pre and one week post pomegranate juice (500 ml/day containing 1685 mg total phenolics/l) or water consumption. 24 h urine samples were collected and blood pressure monitored before and after each session. Urinary lipid peroxidation levels (TBARS), free cortisol and cortisone levels were determined in all urine samples using in house ELISA methods.
Results: Pomegranate juice consumption was found to significantly decrease systolic blood pressure (pre-exercise: 141±20.7 to 136.1±17.3, P=0.03 and post-exercise:156.4±17.5 to 149.5±10.2 mmHg, P=0.04), diastolic blood pressure (90.9±11.6 to 87.1±8.7, P=0.04 and 102.6±23.9 to 94.6±20.4 mmHg, P=0.05) and TBARS levels (0.312±0.106 to 0.264±0.098 MDA mM/l, P=0.035). There was no significant change in lipid peroxidation or blood pressure for subjects consuming water. Urinary free cortisol was reduced from 39.1±26.6 to 26.4±16.5 nmol/24 h (P=0.064), however there was a statistically significant increase in urinary free cortisone (28.1±20.4 to 51.9±45.1 nmol/24 h, P=0.045), and decrease in free cortisol/cortisone ratio (1.81±1.24 to 0.82±0.56, P=0.009) following one week of pomegranate juice intake.
Conclusions: Our results suggest that pomegranate juice seems to exert beneficial effects in reducing blood pressure pre/post exercise and lipid peroxidation levels due to exercise-induced oxidative stress. The reduction in blood pressure could presumably be due to the inhibition of 11?-HSD1 activity as evidenced by the reduction in cortisol/cortisone ratio or other mechanisms yet to be investigated.
The prevalence of non alcoholic fatty liver disease in GH deficiency and the effect of GH replacement
The prevalence of non alcoholic fatty liver disease in GH deficiency and the effect of GH replacement
Background: Non-alcoholic fatty liver disease (NAFLD) is reported to be more prevalent in patients with GH deficiency (GHD) than in the general population. Case control studies have not however been undertaken. Recognition of NAFLD is important due to its association with cardiovascular disease and chronic liver disease.
Aims: To determine i) the prevalence of NAFLD in patients with severe GHD compared to age and BMI-matched controls, and, ii) the effect of 6 months GH replacement (GHR) onliver fat.
Patients and methods: Twelve patients (7 males) with GHD for >12 months (Peak GH <3 ?g/l on glucagon stimulation test) and 12 controls matched for age, gender and BMI were studied. GHD patients were studied before and 6 months after initiation of GHR. Anthropometric measures as well as AST, ALT ?GT, IGF1 and lipid profiles were measured at each visit. Intrahepatocellular lipid (IHCL) was measured by magnetic resonance spectroscopy, with NAFLD defined as liver fat >5.5%. Ethics committee approval was obtained.
Results: Values are quoted as median (range). Age of patients was 44.5 (35, 63) years versus controls 48.5 (33, 66) years (P=0.68). Patient BMI was 30.8 kg/m2 (22.4, 45.3) versus controls 31.7 kg/m2 (24.3, 43). IGF1 was significantly lower in the patient group, (11.5 vs 16 nmol/l P=0.03). There was no significant difference in ALT, AST, ?GT, Cholesterol, HDL, LDL or percentage IHCL (3.6% (0.2, 44.8) patients versus 6.6% (0.5, 32.1) controls, P=0.68). 5 patients and 6 controls had IHCL>5.5%. Of the patients with elevated IHCL, 4 commenced GH. Liver fat reduced from 28.1% (20.4, 44.8) pre treatment to 16.3% (5.5, 20.6) post treatment (P=0.06).
Conclusions: Patients with GHD do not have an increased prevalence of NAFLD compared to matched healthy controls. GH replacement may reduce liver fat in patients with GHD. This is significant as patients with GHD have elevated cardio-metabolic risk.
Low testosterone and severity of erectile dysfunction (ED) are independently associated with poor health related quality of life (HRQoL) in men with type 2 diabetes
Low testosterone and severity of erectile dysfunction (ED) are independently associated with poor health related quality of life (HRQoL) in men with type 2 diabetes
Introduction: Both low testosterone levels and erectile dysfunction (ED) are highly prevalent in men with type 2 diabetes. Lower testosterone levels are known to be associated with worsening severity of ED as assessed using the International Index of Erectile Function score (IIEF). Testosterone deficiency and erectile dysfunction are both independently correlated with increased risk of cardiovascular disease.
Aim: To investigate the effect of low testosterone and erectile dysfunction on Health-Related Quality of Life (HRQoL) in a cohort of 356 men with type 2 diabetes.
Method: Total testosterone (TT), bioavailable testosterone (BT) and SHBG levels were analysed from morning blood samples. Free testosterone (cFT) levels were calculated using Vermeulen’s equation. SF-36 scores were obtained from 356 patients, of whom 126 completed IIEF questionnaires. Data were analysed using PASW software. Local Ethical Committee approval was obtained.
Results: Mean baseline characteristics were: age 58.5 (±8.1), TT 12.17 nmol/l (±5.86), BT 3.84 nmol/l (±1.64), cFT 260 pmol/l (±0.14). Mean SF-36 score was 67.7 (±17.3) and mean IIEF score was 12.16 (±4.29).
Regression analyses were carried out correcting for age, BMI, HbA1c, smoking, alcohol consumption and cardiovascular disease.
Total testosterone levels significantly correlated with HRQoL scores (r=0.353, P=0.044, n=356) when corrected for SHBG.
In the 126 patients who completed IIEF questionnaires, IIEF scores significantly correlated with total SF-36 scores (r=0.491, P=0.003). IIEF scores also correlated with SF-36 domains: Physical (r=0.500, P=0.003), Physical role limitations (r=0.350, P=0.031), Social (r=0.445, P=0.022), Vitality (r=0.383, P=0.025), Pain (r=0.428,P=0.012), and General health (r=0.408, P=0.001).
IIEF scores significantly correlated with levels of TT (r=0.546, P<0.001), BT (r=0.506, P=0.004) and cFT (r=0.532, P<0.001). TT was corrected for SHBG in addition to the above factors.
Conclusion: This is the first study to report that lower testosterone and severity of erectile dysfunction are both independently associated with reduced quality of life in diabetic men.
