Ece 2010 Abstracts

April 2010 Volume 22
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12th European Congress
of Endocrinology
2428 April 2010, Prague, Czech Republic
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CONTENTS
12th Enropcan Congrcss of EndocrnoIogg 2010
PRIZE LECTLRES AND BIOGRAPHICAL NOTES
Tlc luropcun }ournul ol lndocrinology Prizc lccturc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . l}l1
Tlc Ccollrcy Hurris Prizc lccturc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CH1
PLENARY LECTLRES
Twcnty ycurs' cxpcricncc witl post-Clcrnobyl tlyroid cunccr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl1
Tcsticulur dysgcncsis und cndocrinc disruptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl2
Hypotlulumic rcgulution ol gonudotroplin sccrction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl!
Tlyronumincs: bcyond T
4
und T
!
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl4
liscovcry und rclcvuncc ol tlc incrctin systcm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl5
Scx und S0X . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl0
Ncw trcnds in diugnosis und loculisution ol (ncuro) cndocrinc tumours . . . . . . . . . . . . . . . . . . . . . . . . . . Pl7
An updutc on tlc gcnctics ol obcsity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Pl
SYMPOSIA
luropcun nctworks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1.1S1.0
lndocrinc uspccts ubout tlc mctubolic syndromc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2.1S2.4
Bonc ccll biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S!.1S!.!
Tlc uging mulc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S4.1S4.!
Novcl turgcts lor tlyroid cunccr trcutmcnt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S5.1S5.!
Ncurocndocrinc control ol rcproduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S0.1S0.4
Approuclcs to prcscrvution ol gonudul lunction ultcr cunccr tlcrupy . . . . . . . . . . . . . . . . . . . . . . . S7.1S7.!
lndocrinc tumours: ncw gcncs und ussociution witl syndromcs . . . . . . . . . . . . . . . . . . . . . . . . . S.1S.!
Tlc rolc ol oxidutivc strcss in tlc dcvclopmcnt ol tlc mctubolic syndromc . . . . . . . . . . . . . . . . . . . . S9.1S9.!
Novcl uspccts in tlc trcutmcnt ol bonc discusc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S10.1S10.!
Prcmuturc ovuriun luilurc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S11.1S11.4
Tlyroid lormonc mctubolism und uction: ncw dcvclopmcnts . . . . . . . . . . . . . . . . . . . . . . . . . . S12.1S12.4
Tlc TSH rclcrcncc rungc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1!.1S1!.4
Novcl uctions ol vitumin l . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S14.1S14.4
Wnt signulling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S15.1S15.!
Hot topics in pituitury discusc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S10.1S10.!
Ccnctic busis ol inlcrtility: clinicul studics und clinicul modcls . . . . . . . . . . . . . . . . . . . . . . . . . . S17.1S17.!
liubctcs in prcgnuncy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S1.1S1.!
lctul microclimcrism us un cxplunution ol discusc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S19.1S19.!
Tlc cndocrinc incidcntulomu . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S20.1S20.!
Tlc curdiomctubolic intcrlucc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S21.1S21.!
MicroRNAs in cndocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S22.1S22.!
0bcsity: clinicul munilcstutions und tlcrupcutic intcrvcntion . . . . . . . . . . . . . . . . . . . . . . . . . . . S2!.1S2!.!
liugnosis und trcutmcnt ol cndocrinc mulignuncics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S24.1S24.!
Non-clussicul rcsponscs to lormoncs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S25.1S25.4
Advcrsc cllccts ol drugs on tlyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S20.1S20.!
Multilucctcd uspccts ol ncuroprotcction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S27.1S27.4
Hypotlulumic nctworks und cncrgy lomcostusis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . S2.1S2.!
HIGHLIGHTS
0rul Communicutions Higlliglts 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H1.1H1.5
0rul Communicutions Higlliglts 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . H2.1H2.5
ORAL COMMLNICATIONS
liubctcs und obcsity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C1.10C1.0
Tlyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C2.10C2.0
Pituitury . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C!.10C!.0
Adrcnuls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C4.10C4.0
Rcproduction & Tlyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C5.10C5.0
Bonc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0C0.10C0.0
POSTER PRESENTATIONS
Adrcnul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P1P00
BonclCulcium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P07P122
Curdiovusculur cndocrinology und lipid mctubolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P12!P170
Clinicul cusc rcports und clinicul pructicc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P171P250
Compurutivc cndocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P251P255
lcvclopmcntul cndocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P250P200
liubctcs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P207P!09
lndocrinc lisruptors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P!70P!75
lndocrinc tumours & ncoplusiu (Ccncrcnslg snppcrtcJ lg Ncvartis) . . . . . . . . . . . . . . . . . . . . . . . . . P!70P457
lcmulc rcproduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P45P501
Crowtl luctors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P502P510
Mulc rcproduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P517P544
Ncurocndocrinology und Pituitury (Ccncrcnslg snppcrtcJ lg Ncvartis) . . . . . . . . . . . . . . . . . . . . . . . P545P009
0bcsity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P070P719
Signul trunsduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P720P725
Stcroid mctubolism & uction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P720P744
Tlyroid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . P745P00
INDEX OF ALTHORS
Ncvartis lavc linJlg spcnscrcJ tlc pnllicaticn cf tlis alstract lccl. Tlcg wcrc nct invclvcJ witl tlc marlin anJ sclccticn cf alstracts.
Prize Lectures and
Biographical Notes
Endocrine Abstracts (2010) g_
Earapean Jaarna/ af Endacr/na/agy Prize Winner
The European Journal of Endocrinology Prize is awarded to a candidate who has significantly contributed to the advancement of the
knowledge in the field of endocrinology through publication. This year`s recipient is Dr Lorenz Hofbauer. The prize will be
presented as part of the ECE 2010 opening ceremony where Dr Hofbauer will deliver his lecture. Dr Hofbauer will also write a
review article based on this lecture to be published in the European Journal of Endocrinology. Further information can be found at
http://www.euro-endo.org/about/about_prizes.htm
Lorenz C Hofbauer, Germany
Lorenz Hofbauer was born in 1968 and studied Medicine at the University
of Munich where he obtained his MD degree in 1995 in the thyroid field.
His interest in bone research was stimulated during a Postdoctoral
Fellowship at the Mayo Clinic, Rochester (USA) under the mentorship of
Drs Larry Riggs and Sundeep Khosla from 1996 to 1999. In 1999 he moved to
Philipps-University of Marburg, Germany, where he established his own
research group focusing on the RANKL/OPG biology in skeletal, malignant,
and vascular diseases. In parallel, Dr Hofbauer completed his clinical
education in internal medicine, gastroenterology, endocrinology, and diabetes
with board exams. From 2004 to 2007 he was a Heisenberg Senior Fellow and
Consultant in Medicine. In May 2007, he became Head of the Division of
Endocrinology, Diabetes, and Bone Diseases, Department of Medicine III at the Technical University
Medical Center at Dresden, Germany.
Endocrine Abstracts (2010) Vol 22
The European Journal of Endocrinology Prize Lecture
Translating bone cell biology into clinical practice: target
identified as RANK ligand
Lorenz C Hofbauer, Dresden Technical University Medical Center, Dresden, Germany
Osteoclasts are derived from macrophagic/monocytic lineage cells and represent differentiated,
multinucleated cells specialized in resorbing bone. An increased number and activity of osteoclasts is
the hallmark of various bone diseases, including osteoporosis, rheumatoid arthritis, and skeletal
metastases. Recently, receptor activator of nuclear factor-B ligand (RANKL) has been identified as
the stem cell factor for osteoclasts. RANKL promotes osteoclast formation, function, and survival.
The discovery and characterization of RANKL, its receptor RANK, and its decoy receptor
osteoprotegerin (OPG) has led to a molecular understanding of bone cell biology. In addition, this
progress has created a translational novel approach of treating a wide spectrum of bone diseases in
which RANKL becomes up-regulated and causes severe bone loss. This includes, amongst others,
glucocorticoid-induced osteoporosis, bone loss following estrogen or androgen withdrawal, and
myeloma bone disease. Several strategies have been developed to specifically inhibit RANKL actions
on bone. Initially, OPG fusion protein was used in preclinical animal models of various forms of
osteoporosis, inflammatory and malignant bone disease metastases and proved the concept that RANKL
inhibition is able to inhibit osteoclasts and to prevent bone loss in these conditions. More recently,
denosumab a fully human monoclonal antibody that neutralizes RANKL was developed. The major
advantages of denosumab over OPG fusion proteins include a higher affinity and specificity for
RANKL, improved pharmacokinetics, and lower immunogenicity. Randomized controlled trials
employing denosumab have been conducted in postmenopausal women with low bone mass and men on
androgen-ablation therapy for prostate cancer. Denosumab induces a rapid, profound and sustained
suppression of bone resorption and bone turnover, increases bone mineral density at all sites, and
reduced the vertebral fractures by 62% (osteoporosis following androgen-ablation) and 68%
(postmenopausal osteoporosis), respectively. In conclusion, RANKL inhibition by denosumab has
emerged as a novel treatment principle across a wide spectrum of bone diseases.
Geoffrey Harris Prize Winner
This prestigious prize is intended for established workers in field of basic and clinical neuroendocrinology, and is generously
supported by Ipsen. This year`s recipient is Professor Iain Robinson. The prize will be presented as part of the ECE 2010 opening
ceremony where Professor Robinson will deliver his lecture. Professor robinson will also deliver two other lectures at future ESE
Scientific meetings. Further information can be found at http://www.euro-endo.org/about/about_prizes.htm
Iain Robinson, UK
After training in Physiology and Medicine in Oxford, Dr Iain Robinson held
post-doctoral fellowships at Magdalen College, and in the Department of
Physiology in Copenhagen. In 1977, he joined the MRC`s National Institute
for Medical Research at Mill Hill, London, establishing a long-term research
program in neuroendocrine physiology and molecular genetics. He became
Head of the Division of Molecular Neuroendocrinology, and in 2009, Head
of Neurosciences, and Director of the NIMR. He is a Visiting Professor at
University College, London and Fellow of the UK Academy of Medical
Sciences. He has also spent time as a visiting scientist and research director
in pharmaceutical companies in the US and Sweden, and was a co-founder of
the Biotech company, Tercica, that made IGF1 available for clinical
therapeutic use.
His research interests are in the hypothalamic control of the pituitary gland, including its
development and molecular genetics, the regulation of hormone production and secretion, and the
physiological consequences of hormone action. His initial studies were on the posterior pituitary
oxytocin system, developing assays still in use today. However his main focus has been on the
neuroendocrine control of growth, developing the first automated blood microsampling techniques to
study patterns of growth hormone (GH) secretion and action. His work showed how GH is regulated by
the hypothalamic GHRH and somatostatin systems, and how the resulting secretory patterns were
important in controlling growth and metabolism. His pioneering work using transgenic animal models
has unraveled several genetic mechanisms responsible for different types of pituitary endocrine
dysfunction in children, and opened up new possibilities for cellular repair. Combining insights from
molecular genetics in humans and new imaging approaches in animals, his work has shed new light on
the neuroendocrine physiology and pathophysiology of the GH system.
The Geoffrey Harris Prize Lecture
Transgenes and physiology in the Growth Hormone axis: a view
from the portal
Iain Robinson, Plymouth, UK
Neuroendocrine cascades regulate essential processes in integrative physiology, such as growth and
metabolism, reproduction, and responses to stress. The pioneering work of Geoffrey Harris showed
that the pituitary gland, the major endocrine regulator of these processes, is itself controlled by
hypothalamic neurones that secrete their products into the hypophysial portal circulation. Intermingling
of pituitary cell types and the complex anatomical distribution of the different hypothalamic neuronal
systems makes them difficult targets for selective physical or chemical manipulation. However, their
strong expression of major secretory products from genes with well characterised promoters makes
them excellent targets for physiological transgenesis. We have been using a variety of transgenic
approaches to image and manipulate different cellular processes in the hypothalamo/pituitary growth
hormone (GH) axis and studying the consequences in vivo. The results have often been surprising,
sometimes informative about the generation of GH pulses, and occasionally useful in elucidating
mechanisms of pathology in animal models of human pituitary dysfunction. The adult pituitary gland
is a dynamic structure that can adapt its cell populations, their 3D organisation, vascular flows and
hormone outputs in response to changing physiological demands. Some of the mechanisms involved
in normal pituitary development also contribute to its post-natal plasticity, not least via a population
of stem/progenitor cells in the adult gland, which can give rise to new pituitary cells of all types.
Integrative physiology has been characterised in the past as seeing how black boxes interact
functionally in the context of the living organism. We are now beginning to look inside some of
these boxes.
Plenary Lectures
Twenty years` experience with post-Chernobyl
thyroid cancer
PL1
Twenty years experience with post-Chernobyl thyroid cancer
Dillwyn Williams
Cambridge University, Cambridge, UK.
Millions of people were exposed in 1986 to radioactive isotopes in fallout from
the Chernobyl accident, with in the frst 20 years a large increase in thyroid
carcinoma incidence. There is a possible radiation related increase in breast
cancer but as yet no general increase in malignancies.
The increase in thyroid carcinoma, attributable to the very large amounts of iodine
131 released, was frst noticed in children, with a strong relationship between
young age at exposure and risk of developing papillary thyroid carcinoma (PTC).
The extent of the increase, the reasons for the relationship to age at exposure, the
reduction in attributable fraction with increasing latency, and the role of
environmental factors will be discussed.
The large number of radiation induced PTCs has allowed new observations. The
subtype, molecular and clinical fndings change with latency. The molecular
fndings will be considered; the gene rearrangements common in these radiation
induced tumours are regarded as refecting their aetiology. More information is
needed on germline mutations conferring susceptibility to radiation induced
PTCs, particularly DNA repair genes.
Current knowledge of radiation effects is largely dependent on evidence from
exposure to atomic bomb whole body radiation, which led to increases in a wide
range of malignancies including thyroid carcinomas. The radiation exposure to
fallout after Chernobyl was very different from the whole body radiation after the
atomic bombs. The type and molecular pathology of the thyroid tumors is
predicted to continue changing with increasing latency, long latency tumors in
other organs could occur in the future. A comprehensive follow up must continue
for the lifetime of those exposed.
Testicular dysgenesis and endocrine disruptors
PL2
Testicular dysgenesis and endocrine disrupters
Niels E Skakkebaek
Rigshospitalet, Copenhagen, Denmark.
Several recent animal studies have revealed that the gonad is particularly sensitive
to exposures to endocrine disrupters during the early fetal period, when sex
differentiation occurs. Thus exposure to doses of phthalates, which have small or no
effects when given to adult rats, can have pronounced effects in male offspring of
pregnant rats exposed to the same doses of DEHP and DBP. At certain dose levels
the effects include severe dysgenesis of the testis, undescended testis, low sperm
count, subfertility and hypospadias. Several international research groups are these
years focusing on the possibility that endocrine disrupters may be to blame for
some cases of human adult male reproductive problems, including poor semen
quality and testis cancer, which may share etiology with congenital malformations
like hypospadias and undescended testis. We have suggested that such disorders
sometimes may be due to a testicular dysgenesis syndrome (TDS). An important
part of the research puzzle was the demonstration that the precursor-cells of testis of
young adults with cancer are gonocyte-like and have stem cell characteristics.
A rapid increase in some of the mentioned reproductive abnormalities, e.g. testis
cancer, lends support to the idea that environmental factors including lifestyle play
a role. In several studies, we and others have seen associations between mothers`
exposures to endocrine disrupters and reproductive problems in their sons. The
signifcance of the fndings should be seen in light of the widespread occurrence of
poor semen quality among young men and the high and increasing need for
management of male infertility by the use of ICSI.
Hypothalamic regulation of gonadotrophin secretion
PL3
Novel regulator of gonadotropin
Robert Millar
MRC Human Reproductive Sciences Unit, 47 Little France Crescent,
Edinburgh EH16 4TJ, UK.
The central role of GnRH in gonadotropin was established over four decades ago.
The development of agonist and antagonist analogs and the understanding of its
interaction with the GnRH receptor has revolutionized the treatment of hormone-
dependent diseases and controlled induction of ovulation for IVF.
The absence of steroid and metabolic product receptors in GnRH neurons has
presented a conundrum for understanding feedback and mechanisms for
gonadotropin regulation. The discovery that mutations in receptors for kisspeptin
and neurokinin B (and in the ligands themselves) gives rise to a failure to progress
through puberty led to the recognition that these neuropeptides are regulators of
the GnRH neurons and mediators of steroid and metabolic regulators of
reproduction.
These discoveries have opened up a new era of the neuroendocrine regulation of
reproduction which will facilitate a comprehensive understanding of physiologi-
cal and pathophysiological mechanisms involved. They also herald the
development of new therapeutics with potentially more subtle intervention.
Thyronamines: beyond T
4
and T
3
PL4
Thyronamines: beyond T
4
and T
3
Thomas Scanlan
Oregon Health and Science University, Portland, Oregon, USA.
In 2004, we reported the discovery of a new signaling molecule chemically
related to thyroid hormones called 3-iodothyronamine (T
1
AM). T
1
AM is formally
a decarboxylated and deiodinated derivative of thyroxine (T
4
) and was detected in
tissues and circulation of rodents. Single-dose administration of T
1
AM to mice
resulted in unique biological activities including hypothermia, bradycardia, and
hyperglycemia. The T
1
AM-induced hyperthermia could have useful therapeutic
applications as T
1
AM has been found to be neuroprotective against stroke in
mice. In hibernating rodents single-dose T
1
AM induces a dramatic shift in energy
utilization away from carbohydrates and toward lipids. T
1
AM does not bind to or
activate thyroid hormone receptors (TR, TR), yet does bind and/or activate a
few G protein-coupled receptors (GPCRs) of the biogenic amine receptor family
including trace amine-associated receptor 1 (TAAR1), -adrenergic receptor 2a
(Adra2a), and serotonin receptor 2c (5HT2c). This lecture will cover the
developments in this area and highlight recent work on T
1
AM serum protein
binding and distribution, and biological effects from chronic T
1
AM treatment in
normal and diet-induced obese mice.
Discovery and relevance of the incretin system
PL5
Discovery and relevance of the incretin system
Daniel J Drucker
Samuel Lunenfeld Research Institute, Banting and Best Diabetes Centre,
Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
Incretins are gut peptides that potentiate nutrient-dependent insulin secretion
following meal ingestion. The two dominant incretins glucose-dependent
insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1) stimulate
insulin secretion and promote expansion of -cell mass in preclinical models via
control of cell proliferation and inhibition of apoptosis. GLP-1, but not GIP,
decreases the rate of gastric emptying, inhibits glucagon secretion, and diminishes
appetite and food intake. GLP-1 is cardioprotective via effects on the heart and
blood vessels, and the GLP-1 metabolite GLP-1(9-36) amide, generated by
dipeptidyl peptidase-4 (DPP-4) exerts metabolic activities independent of the
known GLP-1 receptor, predominantly in the liver and cardiovascular system. In
contrast, GIP exerts acute and chronic anabolic and metabolic actions in adipose
tissue that promote insulin resistance in rodents. Experimental data will be
reviewed illuminating how GLP-1 receptor activation and DPP-4 inhibition
regulate glucose homeostasis through overlapping yet distinct pathways. The
risk:beneft ratio for GLP-1R agonists and DPP-4i will be discussed with an
emphasis on defning putative mechanisms for adverse events associated with
incretin-based therapies. Understanding how incretin hormones exert their
various actions will aid clinicians in their decision as to how to safely incorporate
incretin-based therapies, principally DPP-4 inhibitors and GLP-1 receptor
agonists, into the treatment paradigm for the management of type 2 diabetes.
Sex and SOX
PL
Sex and SOX
R Lovell-Badge
UK.
Abstract Unavailable.
New trends in diagnosis and localisation of (neuro)
endocrine tumours
PLI
New trends in diagnosis and localization of (neuro)endocrine tumors
Karel Pacak
NIH, Bethesda, Maryland, USA.
Endocrine tumors differ from other tumors in that that they use specifc pathways
to synthesize, store, and release hormones, their metabolites, or precursors; these
tumors may differentially express specifc receptors or transporters located in
either the cell membrane or intracellular space. Additionally, they can uptake
released hormones back into their cells. These characteristics allow for the
existence of several (neuro)endocrine, tumor-specifc markers that can be used to
diagnose these tumors. These markers can also be used to monitor progression,
recurrence, and/or therapeutic responses to various treatment modalities.
Whereas anatomical imaging modalities may well defne the size, shape, and
structure of tumors, they lack the ability to explore their functional characteristics.
Various functional imaging methods exist, of which positron emission
tomography (PET) is becoming most popular, in part due to its use in a clinical
as well as experimental procedures. One of the advantages of PET scanning is the
ability to measure tumor characteristics in vivo, including such processes as
glucose and energy metabolism, DNA and protein synthesis, angiogenesis,
apoptosis, and blood fow, among others. Thus, PET in endocrine oncology
provides specifc tumor detection ('in vivo` histology); identifes of specifc tumor
function and targets for therapy; predicts and assesses responses to therapy
regardless of size changes ('early` tumor response); determines the prognosis
even before metastatic lesions occur; and eliminates unnecessary treatments, if,
for example, a target molecule is not found. The use of PET/CT has dramatically
improved detection, localization, and characterization of various tumors,
including (neuro)endocrine ones. The emerging technology of PET coupled
with MRI is on the horizon and will revolutionize how we study the molecular and
functional aspects of tumors.
The most updated use of diagnostic markers as well as functional imaging in the
evaluation of (neuro)endocrine tumors and clinical approaches on how to use
them for optimal tumor assessment will be presented. Finally, future trends in
functional imaging, including its use in pharmacodynamics and molecular
imaging tightly linked to individualized medicine to 'secure` the optimal
therapeutic plan, will also be outlined.
Acknowledgements
This research was supported by the Intramural Research Program of the
NICHD/NIH.
An update on the genetics of obesity
PL8
An update on the genetics of obesity
Stephen O`Rahilly
University of Cambridge, Cambridge, UK.
The recent and rapid increase in the prevalence of obesity in most developed and
developing countries has correctly focused attention on environmental
determinants of that secular trend. However, a fuller understanding of the factors
determining any individual person`s adiposity requires appropriate consideration
of inheritance. Studies of twins, adoptees and adopted twins provide
incontrovertible evidence that heritable factors play a major, perhaps even the
major factor, in determining a person`s fatness. Until recently, the precise
mechanisms whereby such genes might infuence fatness were obscure. However,
in the past decade we have witnessed an explosion of information regarding the
molecular mechanisms underlying the control of mammalian energy balance.
That information, much of it originating from animal models, is beginning to
demonstrate its clear relevance to human energy balance. Thus, defects in several
individual genes have now been demonstrated to result in human obesity. One of
these (MC4R defciency) is not uncommon, being responsible for up to 5% of
severe obesity in childhood, and one rare form (congenital leptin defciency) is
amenable to life-saving treatment. Importantly, the vast majority of single gene
defects causing human obesity do so through the impairment of satiety. Evidence
is accumulating that more subtle genetic variants affecting these pathways
underlie susceptibility and resistance to common forms of obesity in the general
population. Far from encouraging a mood of deterministic nihilism, the more
precise knowledge of biological pathways that genetic information provides
should assist the prevention and treatment of human obesity by allowing the
design of better therapies and improving the focus and precision of behavioural
strategies for treatment and prevention.
Symposia
European networks
$1.1
Endocrinology of the aging male: the European Male Ageing Study
(EMAS)
F Wu
Andrology Research Unit, Manchester Academic Health Science
Centre, Central Manchester University Hospitals Foundation Trust,
Manchester, UK.
The relationships between alterations in hormones with the clinical features of
senescence remain unclear in ageing men. We have investigated the natural
history of and risk factors for potential adverse consequences associated with low
testosterone in the European Male Ageing Study (EMAS), a population-based
prospective cohort study of 3369 men (aged 40-79 years) from the general
population of 8 European countries. A wide variety of clinical variables pertinent
to general, sexual, physical, musculo-skeletal and mental health were documented
by standardised methods together with centrally-measured biochemical,
hormonal and genetic markers. Some of the baseline cross-sectional data will
be discussed in the context of the diagnosis of subclinical late onset
hypogonadism, frailty and bone health and their relationship to testosterone
defciency and testosterone action will be presented. These data show that
changes in many domains of health in ageing men are only weakly associated
with alterations in hormone function. The concept of an ageing-related syndrome
of hypogonadism may not be as widely applicable to men in the general
population as previously suggested. The challenge is to identify the minority who
may be appropriate candidates who are likely to beneft from hormone
intervention.
$1.2
NECTAR: network for environmental chemical toxicants affecting
reproduction
Jorma Toppari
University of Turku, Turku, Finland.
NECTAR (http://www.nectarcluster.eu/index.htm) is a cluster of EU-funded
projects set up to investigate the potential impact of chemicals and pollutants on
male and female reproductive health. NECTAR is coordinated by Andreas
Kortenkamp. It was launched on May 1st 2008 and joins together the REEF
(Reproductive Effects of Environmental chemicals in Female, coordinated by Paul
Fowler), DEER (Developmental Effects of Environment on Reproduction,
coordinated by Jorma Toppari), and CONTAMED (Contaminant mixtures and
human reproductive health - novel strategies for health impact and risk assessment
of endocrine disrupters, coordinated by Andreas Kortenkamp) projects. A year
later, the CLEAR project (Climate Change, Environmental Contaminants and
Reproductive Health, coordinated by Jens Peter Bonde) joined the cluster.
The four projects examine endocrine disruptors - chemicals that interfere with
normal hormone function. These include both natural and man made substances -
such as compounds used in plastics and pesticides, together with heavy metals - to
which European citizens are exposed every day. NECTAR has promoted
interaction and cooperation between the projects that have already produced
important knowledge on trends in reproductive health and associated exposures to
environmental chemicals and novel data on mechanisms of action of endocrine
disruptors.
Supported by EU Fp7 Environment.
$1.3
EUGOGO
Wilmar Wiersinga
Academic Medical Center, University of Amsterdam, Amsterdam,
The Netherlands.
The European Group on Graves` Orbitopathy was established in 1999 in the
conviction that a multidisciplinary approach is required in order to make progress
in the management of Graves` Orbitopathy (GO). Consequently, one criterion for
EUGOGO membership is the presence of combined thyroid-eye clinics, staffed
by endocrinologists and ophthalmologists. EUGOGO nowadays consists of 13
centers in 9 European countries. The group objectives are to contribute towards
understanding of the pathogenesis of GO and its management, and to contribute
towards education, teaching and training of health professionals involved in the
care of GO patients.
After reaching consensus on standardized assessment of eye changes, EUGOGO
has published 7 clinical papers on GO (e.g. on dysthyroid optic neuropathy,
outcome of surgical decompression, and questionnaire surveys). A consensus
statement on management of GO was published in 2008. A number of randomized
clinical trials is performed by EUGOGO; the results of the frst one on mild GO
will be published in 2010.
EUGOGO edited a higly successful textbook on GO. So far four teaching courses
have been organized, all overbooked; their attractiveness is attributable to a large
extent to life demonstrations how to investigate GO with the help of patient
volunteers.
At the occasion of the 10th anniversary of EUGOGO an international symposium
on GO was organized in Amsterdam. Here the so-called Amsterdam declaration on
GOwas signedby 82organizations inthe feldof endocrinologyandophthalmology,
setting specifc 5-year targets focussing on raising awareness on GO and
implementing measures to reduce the incidence and morbidity of the disease.
$1.4
The EuroDSD project and consortium
Olaf Hiort
University of Lubeck, Lubeck, Germany.
EuroDSD is an acronym for a collaborative project of clinical and basic scientists
working in the feld of disorders of sex development (DSD). Research in DSD is
desperately needed to provide a basis for diagnostic pathways, medical decision
making, and distinct treatment advice. EuroDSD is currently supported by the
European Commission under the 7th European Framework Programme (FP7) and
receives funding from May 2008 until April 2011 within the topic of the natural
course and pathophysiology of rare diseases. EuroDSD has 13 partners from 6
European countries; combining 6 clinical centres with 6 research institutions plus
a private administrative partner.
EuroDSD aims at linking a European patient-based data collection and analysis
tool with research on development of novel diagnostic strategies to identify
currently unknown causes of DSD. It will design and validate a DSD GeneChip to
offer the opportunity for rapid genetic analysis in DSD. Aselected group of patients
will be characterized by genome analysis with CGH array technology. EuroDSD
will study steroid analysis by GC/MS and LC/MS/MS in urine and plasma to
identify unique steroid metabolomes that will be a 'fngerprint` to diagnosis.
A special focus is on elucidation of androgen action as a major impact of genital
differentiation. Selected mutations of the androgen receptor are investigated to
correlate in vitro function with long-term post-pubertal outcome. Also, the
molecular functions of the androgen receptor during embryology are elucidated
due to identifcation of relevant co-regulators of androgen action. Sex-specifc
methylation target genes will be identifed in patients with androgen insensitivity
syndrome. The EuroDSD project is complemented by the elaboration of a DSD
e-learning webportal, which is targeted within the ESPE e-learning activities.
The EuroDSD project offers a unique networking opportunity for European-based
research on rare disorders of sex development, and we hope that this consortium
can lead to a sustainable association of clinicians and basic scientists propagating
research in this feld.
$1.5
EurAdrenal
Eystein Husebye
University of Bergen, Bergen, Norway.
Autoimmune Addison`s disease (AAD) is an endocrine disease resulting from the
immune system`s destruction of hormone producing cells in the adrenal cortex.
Diagnosis is frequently frst established after a life-threatening adrenal crisis,
often resulting in untimely fatalities. The disease is rare, more common in women
than in men, and also affects children. AAD very frequently occurs with other
autoimmune diseases, such as type 1 diabetes mellitus, autoimmune thyroid
disease and/or premature ovarian failure. Based on a European network of patient
registry and biobanks, a translational approach using genetics, immunology,
clinical management, and epidemiology, the EurAdrenal project aims to unravel
the pathogenesis and natural course of AAD, ultimately to improve diagnosis and
treatment as well as to offer strategies for disease prevention.
Euradrenal aim to describe the natural course of the AAD with focus on factors
limiting quality of life. To this end an Addison-specifc quality-of-life
questionnaire has been developed (ADDIQoL). Another major task is to identify
and characterise the disease-causing genes, using the corresponding disease in a
spontaneous dog model and a gene targeted mouse model. In parallel, the cellular
and molecular mechanisms of autoimmunity directed at the adrenal cortex will be
studied both in humans with ADD and in the genetic mouse model. Moreover,
clinical studies are underway for early identifcation of patients at risk of
developing Addison`s disease in order to intervene, and to study continuous
subcutaneous infusion of hydrocortisone as an alternative treatment modality.
As an autoimmune model disease the results of the project could not only lead to
the development of novel diagnostic and therapeutic interventions for Addison
patients, but also increase our understanding of the pathogenesis of autoimmune
diseases in general.
$1.
The European Registry on Cushing`s syndrome (ERCUSYN) database:
hrst year experience
Susan Webb
1
, Alicia Santos
1
, Peter Trainer
2
, Christian Strasburger
3
,
Steven Lamberts
4
, John Wass
5
, Richard Feelders
4
& Holger Franz
6
1
IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant
Pau, UAB and Centro de Investigacion Biomedica en Red de Enfermedades
Raras (CIBER-ER, Unidad 747), ISCIII, Pare Claret 167, Barcelona, Spain;
2
Department of Endocrinology, Christie Hospital, Wilmslow Road,
Manchester, UK;
3
Division of Clinical Endocrinology, Department of
Medicine CCM, Charite-Universitatsmedizin, Berlin, Germany;
4
Department of Internal Medicine, Erasmus Medical Center, Rotterdam,
The Netherlands;
5
Department of Endocrinology, Oxford Centre for
Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK;
6
Lohmann and Birkner, Berlin, Germany.
The ERCUSYN (European Registry on Cushing`s syndrome (CS)) study is
a project funded by the European Commission Public Health Program
(PHP 800200), of which the ESE is one of the 41 Partners from 25 countries.
The aims include obtaining prospective and follow-up data at EU level on
epidemiology, mortality, outcome of therapies, co-morbidities, assessment of
diagnostic and therapeutic strategies, quality of life evaluation using a disease-
generated questionnaire (CushingQoL) and to increase awareness of CS in
Primary Care to shorten delay to diagnosis, aimed at improving long-term
prognosis. On the project`s webpage (www.ercusyn.eu) information for patients
and general practitioners in different languages are available and a database
where newly diagnosed patients -since 2005- with CS are prospectively collected
at baseline and periodically after treatment, from centres of excellence
throughout Europe.
The ERCUSYN database after 1 year contains data on 154 patients (80% women),
with a mean age at diagnosis of 44.913.9 years. Only 48 (31%) were actively
employed; 72 (47%) were of pituitary, 36 (23%) of adrenal, 12 (8%) of ectopic,
and 6 (4%) of other (including cyclical) origin, while data were missing in 28
(18%). Basal morbidity was high: $BP in 66%, skin problems in 58%, weight
gain in 62%, muscle weakness in 50%, hirsutism in 45% and menstrual
irregularities in 37% of females, diabetes mellitus in 31%, depression in 25%,
fractures in 21% and libido in 15%. The rhythm of inclusion has doubled from 6
to 12 months and reached 200 at the end of 2009. The potential of the ERCUSYN
database to gather real-life information on diagnosis, treatment and outcome of
patients diagnosed with CS throughout Europe is important and can contribute to
better evaluate 'residual` morbidity present in endocrinologically 'cured` CS,
especially on cardiovascular, body composition and QoL outcome, which fail to
normalize completely.
Endocrine aspects about the metabolic syndrome
$2.1
Brain~adipose and brain~liver connections in the metabolic syndrome
Eric Fliers
1
, Lars Klieverik
1
, Chun-Xia Yi
2
, Mariette Ackermans
1
& Andries Kalsbeek
1,2
1
Academic Medical Center, University of Amsterdam, 1105 AZ
Amsterdam, The Netherlands;
2
The Netherlands Institute for Neuroscience,
1105 BA Amsterdam, The Netherlands.
Pre-autonomic neurons in the hypothalamic paraventricular nucleus (PVN)
project to sympathetic and parasympathetic motor nuclei in the brain stem, from
where the liver and white adipose tissue (WAT) are innervated by both branches
of the autonomic nervous system (ANS). Studies by our group and by others have
shown that these neural pathways modulate glucose and lipid metabolism in liver
and WAT. Given the abundant thyroid hormone receptor (TR) expression in the
PVN we hypothesized that thyroid hormone modulates hepatic glucose
metabolism via the ANS. Moderate thyrotoxicosis increased endogenous glucose
production (EGP) as measured by stable isotope dilution, while inducing hepatic
insulin resistance. Selective hepatic sympathectomy partly prevented these
effects. Bilateral T
3
microdialysis in the PVN of euthyroid rats increased plasma
glucose and EGP independently of serum T
3
and corticosterone. In addition,
selective hepatic sympathectomy completely prevented the stimulating effect of
hypothalamic T
3
administration on EGP. These experiments demonstrate that
stimulation of T
3
-sensitive neurons in the PVN of euthyroid rats increases EGP
via sympathetic projections to the liver, independently of circulating glucor-
egulatory hormones. This novel route may explain in part the benefcial effects of
beta-adrenergic blockers in patients with severe thyrotoxicosis. As estrogen (E
2
)
and corticosterone are additional endocrine determinants of glucose metabolism
and in view of the abundant estrogen and glucocorticoid receptor expression in
the PVN, we currently investigate if similar neural routes exist for metabolic
effects of estrogen and corticosterone. In addition, we aim to unravel the
hypothalamic pathways that transmit the actions of these hormones onto the
autonomic nervous system, focusing on pituitary adenyl cyclase-activating
polypeptide (PACAP), TRH and orexin. These studies add a new dimension to the
complex metabolic actions of classical hormones and may help to uncover a role
for the brain in the pathogenesis of the metabolic syndrome.
$2.2
Combined GH and IGF1 therapy
D B Dunger
Epidemiological studies indicate that low circulating concentrations of IGF1 are
associated with increased adult risk for the development of type 2 diabetes (T2D)
and the metabolic syndrome (MS). Although comparable epidemiological data
relating to GH concentrations are lacking, GH defciency (GHD) is associated
with many of the features of the MS and increased T2D risk. These data indicate
that reduced activity of the GH/IGF1 axis is a risk factor for MS yet IGF1 and GH
have contrasting effects on metabolism. IGF1 is an insulin sensitisor and low
levels are associated with insulin resistance. Although it has little direct effect on
lipid metabolism, low IGF1 conditions are commonly associated with
hyperinsulinaemia which is associated with visceral fat accumulation. GH has
potent lipolytic actions and it is an insulin antagonist: GHD being associated with
visceral adiposity and insulin resistance. Both GH and IGF1 may have important
roles in the maintenance of beta cell mass and insulin secretion. Thus, there is a
clear rational for combined GH and IGF1 therapy in these subjects.
rhIGF1 therapy has been shown to improve insulin sensitivity in subjects with
T1D and T2D and there are preliminary data to indicate it could improve glucose
tolerance in subjects with MS. Low dose GH therapy has been explored in adult
subjects with the MS and it leads to reductions in visceral adiposity but with
variable effects on insulin sensitivity and other elements of the MS. Elevations in
FFA and ectopic deposition may be a limiting factor. Combined GH/IGF1 therapy
appears attractive as it could lead to reduction in visceral fat whilst maintaining
insulin sensitivity: both agents having the potential to improve beta cell function.
There are limited animal data but human studies should be encouraged. Such
studies will need to take particular care to identify potential benefts of
normalisation of the GH/IGF1 axis and avoid perceived risks relating to excess
GH/IGF1 activity and cancer risk.
$2.3
Unacylated ghrelin: a metabolic hormone
Riccarda Granata
University of Turin, Turin, Italy.
Ghrelin was identifed in the stomach as the endogenous ligand of the GH
secretagogue receptor type 1a (GHS-R1a). Acylated ghrelin (AG), through
interaction with GHS-R1a, exerts many central and peripheral effects, including
stimulation of GH secretion and food intake. Unacylated ghrelin (UAG), although
unable to bind the GHS-R1a and devoid of endocrine actions is an active peptide,
exerting pleiotropic effects through an unknown receptor. UAG has been shown
to act as an antagonist of AG in glycemic control. Indeed, AG induces
hyperglycemia and reduces insulin secretion in humans, whereas UAG
antagonizes these effects. Moreover, AG-induced decrease in insulin sensitivity
is counteracted by coinjection of UAG in GH defcient patients. Furthermore, AG
stimulates whereas UAG inhibits glucose output by primary hepatocytes
Transgenic mice overexpressing UAG in pancreatic islets show increased insulin
sensitivity, and UAG overexpression in adipose tissue results in improved glucose
tolerance and insulin sensitivity. UAG even inhibits isoproterenol-induced
lipolysis in rat adipocytes. These fndings suggest positive effects of UAG on
glucose metabolism, likely through a receptor(s) different from the GHS-R1a. In
the endocrine pancreas, UAG protects -cells and human islets against cytokine-
and glucolipotoxicity-induced apoptosis, stimulates -cell proliferation and
enhances glucose-induced insulin secretion. Interestingly, small UAG fragments
also display insulinotropic, survival and antiapoptotic effects in -cells and
human islets, suggesting that UAG biological activity is not strictly dependent on
length of the peptide. UAG increases glucose uptake in -cells and human islets,
further indicating a role in glucose homeostasis. In streptozotocin-treated
newborn rats, UAG prevents diabetes by improving glucose metabolism and
preserving islet cell mass. Importantly, UAG has been also shown to exert
cardioprotective effects, both in vitro and in vivo. Therefore, UAG and its analogs
may be considered as promising lead compounds for the development of novel
therapeutic strategies in the cure of metabolic syndrome and diabetes.
$2.4
Testosterone treatment in the metabolic syndrome
G Corona
Italy.
Abstract unavailable.
Bone cell biology
$3.1
Skeletal stem cells and mechanisms of bone formation
Moustapha Kassem
University Hospital of Odense and University of Southern Denmark,
Odense, Denmark.
Human bone marrow stromal cells (hMSC) contain a population of stem cells
known as skeletal (mesenchymal) stem cells that are capable for differentiation
into several mesodermal-type lineages including osteoblasts, adipocytes and
chondrocytes. The aim of our research program is to understand the biological
characteristics of hMSC so that it is possible to make full use of them in the
context of clinical applications. The following topics will be discussed: i)
approaches to isolated homogenous population of hMSC with stem cell
characteristics from the bone marrow using specifc criteria, ii) one major
challenge for use of hMSC in clinical application is their limited in vitro
proliferative potential and the senescence-associated growth arrest phenotype
exhibited by the cells during long-term culture. I will present results from studies
in our lab showing that transducing hMSC with human telomerase reverse
transcriptase (hTERT) extended the life span of the cells and maintained their
'stemness` characteristics, iii) I will present recent data regarding the molecular
control of hMSC differentiation into osteoblastic cells and the identifcation of
new factors that maintain hMSC in undifferentiated state or promote their
differentiation into osteoblastic phenotype. I will also present our experience with
applying state-of-the-art proteomic approaches to studying the biology of hMSC,
iv) Finally, I will present the status of some current clinical trials employing MSC
for a number of clinical indications.
$3.2
Cross talks between leptin and the skeleton
T Thomas
France.
$3.3
The role of the hypothalamic~pituitary~thyroid axis in bone
J H Duncan Bassett
Molecular Endocrinology Group, Department of Medicine and Medical
Research Council Clinical Sciences Centre, Imperial College London,
Hammersmith Hospital, London, UK.
Disruption of the HPT-axis during growth profoundly infuences skeletal
development and effects may not be reversed fully following correction of
thyroid status. Adult thyrotoxicosis leads to increased bone turnover and is an
established risk factor for osteoporotic fracture. The conventional view that
skeletal responses to abnormal thyroid status result solely from altered T
3
action in bone has, however, been questioned by studies proposing TSH as a
negative regulator of bone turnover. Osteoblasts and osteoclasts were found to
express the TSH receptor (TSHR) whilst characterization of TSHR null mice
revealed high bone turnover osteoporosis. These fndings were interpreted to
indicate that bone loss in thyrotoxicosis results from TSH defciency. This
model is, however, inconsistent with the increased risk of osteoporotic fracture
seen in Graves` disease, in which TSHR stimulating antibodies are
pathognomonic. Studies in genetically modifed mice in which the HPT-axis
or the action of T
3
is disrupted have addressed the relative importance of T
3
and TSH action in bone. Mutation of thyroid hormone receptor (TR), the
predominant TR isoform in bone, results in decreased T
3
action in bone but
does not affect systemic thyroid status. Delayed ossifcation and increased bone
mass in these animals indicates that responses to reduced T
3
action in bone
predominate when TSH levels are normal. Similarly, mutation of TR results
in increased T
3
action in bone and increased levels of TSH. Accelerated
ossifcation and osteoporosis in these animals confrms that effects of T
3
excess
predominate even when TSH levels are also increased. The similar skeletal
phenotypes in Pax8
/
and hyt/hyt mice, in which severe T
3
defciency is
accompanied by extremes of TSH action, demonstrate that during development
the effects of T
3
defciency are independent of TSHR activity. Together, these
studies suggest that skeletal responses to hypo- and hyperthyroidism are
mediated by T
3
acting via TR.
The aging male
$4.1
Genetic aspects of ageing in men
Ilpo Huhtaniemi
Department of Surgery and Cancer, Imperial College London, London, UK.
The ageing of men is affected by gender-specifc environmental and lifestyle
factors. In addition, hereditary factors in the form of gene polymorphisms
apparently contribute to the large interindividual variability of the basal
activity and age-related decline of the male pituitary-gonadal function. Only
limited information is currently available on polymorphisms in genes affecting
the regulation, production, actions and metabolisms of androgens. Therefore,
the assessment of selected polymorphisms in genes involved in the production,
metabolism and actions of sex steroids was included in the European Male
Ageing Study (EMAS), a comprehensive multi-national prospective cohort
observational study. A total of 43 polymorphisms in 9 genes (AR, ESR1,
ESR2, SRD5A2, CYP17A1, CYP19A1, SHBG, LHB, and LHCGR) were
determined in 2749 men, aged 40-79 years, from 8 European centres, and
related to the levels of selected hormones, their alterations upon ageing and
phenotypic effects. In general, in ageing men, polymorphisms in the genes
studied signifcantly infuenced circulating reproductive hormone levels, but
the downstream effects are apparently too small to infuence secondary
phenotypic parameters. More specifcally, the length of the CAG repeat in
exon 1 of AR correlated signifcantly with serum testosterone and oestradiol
(E
2
) levels of ageing men. Weaker transcriptional activity of the AR encoded
by alleles with longer CAG repeats appeared to be totally or nearly totally
compensated for by higher testosterone levels. The residual phenotypic
correlations (e.g. on bone density) may refect differences in oestrogen
levels/actions after aromatization of the higher testosterone levels respectively
to higher E
2
levels. Furthermore, our data confrm the evidence for association
between polymorphisms in CYP19A1 and bone health in a male population.
Only minor differences in the polymorphisms and their phenotypic effects
were found between the centres.
$4.2
Osteoporosis in the aging male
Dirk Vanderschueren
University of Leuven, Leuven, Belgium.
Until recently, osteoporosis was considered a disease affecting mostly women.
However, 30%of all hip fractures occur in men, suggesting that male osteoporosis
is a major health issue as well. Low trauma fractures may also arise at other sites
such as the vertebrae, distal forearm and proximal humerus. Although these
osteoporotic fractures in elderly men occur less frequent than in women, mortality
and disability following these fractures is greater in men than women. Beside
advancing age, personal and familial history of fractures and low bone density -
as measured by dual-energy absorptiometry (DEXA) - is also associated with an
increased risk for fractures in elderly men. The cost-effectiveness of DEXA
screening remains however a matter of debate. In addition, other risk factors such
as use of corticosteroids, the presence of signifcant concomitant medical
conditions and smoking are now well established not only in women but also in
men. The association between osteoporosis and many of these risk factors is only
partly explained by bone loss. Frailty of elderly men and subsequent risk of falls
appears an independent risk factor for osteoporosis as well. Therefore, every
model that aims to assess the absolute risk of osteoporosis in an individual should
include many different cumulative risk factors. For instance, vitamin D
insuffciency is common in elderly men as well as women, but low vitamin D
is associated with low bone density, bone loss, risk of falls as well as risk for hip
fractures in men. Recently, low estrogen as well as increased sex hormone
binding globulin concentrations were also related to both bone loss as well as
fracture risk in men. In contrast, the impact of age-related decline of serum
testosterone concentrations in ageing men on the risk of osteoporosis as well as
frailty is less well established, at least in the absence of overt hypogonadism.
Therapy of osteoporosis is also less well defned in elderly men than in
postmenopausal women. Nevertheless, current recommendations justify not only
adequate calcium and vitamin D supplementation but also anti-osteoporotic
medications such as bisphosphonates in elderly men at risk for osteoporosis.
Bisphosphonates appear to have similar effects in men than women. Although the
available studies in osteoporotic men are relatively small, parathyroid hormone
(Teriparatide) also appears to have similar effects on bone remodeling and
vertebral fracture risk in men and women. In conclusion, our current
understanding of the risk factors, the diagnosis as well as therapy of osteoporosis
in men is increasing rapidly.
$4.3
The natural history of symptomatic androgen dehciency in men:
longitudinal results from the Massachusetts Male Aging Study
T Travison
USA.
Novel targets for thyroid cancer treatment
$5.1
Novel targets for thyroid cancer treatment
Christine Spitzweg
Ludwig-Maximilians-University, Munich, Germany.
The sodium iodide symporter (NIS) is an intrinsic plasma membrane glycoprotein
that mediates the active transport of iodide in the thyroid gland and a number of
extrathyroidal tissues, in particular lactating mammary gland. In addition to its
key function in thyroid physiology, NIS-mediated iodide accumulation allows
diagnostic thyroid scintigraphy as well as therapeutic radioiodine application in
benign and malignant thyroid disease. Functional NIS expression in differentiated
thyroid carcinomas allows not only postoperative localization and ablation of the
thyroid remnant as well metastases, but also provides the possibility of
postablative
131
I total body scanning that can diagnose local and metastatic
residual and recurrent disease followed by
131
I ablation. Thyroidal NIS expression
therefore provides the molecular basis for the most effective form of systemic
anticancer radiotherapy available to the clinician today, as long as the degree of
tumor cell differentiation provides a suffcient level of endogenous NIS
expression. In dedifferentiated thyroid tumors different approaches for
reinduction of functional NIS expression have been investigated, including
redifferentiation by retinoids and thiazolidinediones, as well as epigenetic
modifcation by histone deacetylase inhibition or demethylation. Furthermore,
cloning and characterization of the NIS gene has paved the way for the
development of a novel cytoreductive gene therapy strategy based on targeted
NIS expression in thyroidal and nonthyroidal cancer cells followed by therapeutic
application of
131
I or alternative radionuclides, including
188
Re and
211
At. In
addition, the possibility of direct and non-invasive imaging of functional NIS
expression by
123
I- and
99m
Tc-scintigraphy or
124
I-PET-imaging allows the
application of NIS as a novel reporter gene. In conclusion, NIS represents one of
the oldest and most successful targets for molecular imaging and targeted
radionuclide therapy. Its dual role as reporter and therapy gene opens promising
perspectives for diagnostic and therapeutic application of NIS in cancer treatment
in and outside the thyroid gland.
$5.2
Molecular mechanisms in thyroid cancer
Massimo Santoro
Dipartimento di Biologia e Patologia Cellulare e Molecolare, Universita` di
Napoli Federico II, Italy.
There are four major types of thyroid cancer: well-differentiated papillary (PTC)
and follicular (FTC) carcinoma, undifferentiated anaplastic carcinoma (ATC), and
neural-crest derived medullary carcinoma (MTC). In the past two decades, some
genetic lesions associated with these tumor types have been unveiled, with
mutations in RET and BRAF, RAS and PPAR, RAS, BRAF and PI3K/AKT, and
RET, associated to PTC, FTC, ATCand MTC, respectively. PTCand FTCpatients
are treated by surgical resection, adjuvant radioiodine treatment and thyroid
hormone replacement. However, some of them may have recurrent disease with
loss of responsiveness to radioiodine. MTC patients, particularly those with RET-
mutated sporadic tumors, are often incurable because the cancer has already
metastasized before being diagnosed. ATC, though extremely rare, has a dismal
prognosis with an average survival of less than 1 year. This has suggested
molecularly targeted therapy as one possibility for patients with iodine refractory
thyroid cancer. A major problem in exploiting this possibility is our only partial
understanding of the molecular lesions that alone or in combination are associated
to the various types of thyroid cancer. Nonetheless, it is feasible that therapeutic
targeting of some specifc proteinor lipidkinases might be potentially benefcial for
the treatment of thyroid cancer. Multitarget RET inhibitors that function in the nM
range are undergoing clinical testing in patients with MTC and PTC. These
compounds are multi-target and share the ability of inhibitingnot only RETbut also
the VEGFRs, thereby exerting both anti-tumor and anti-angiogenic activity. BRAF
or MEK inhibitors are promising, alone or in combination with other pathway
inhibitors, for the treatment of PTC or ATC; importantly, these compounds are
more effective in BRAF mutant than BRAF wild type cancer cells. These
approaches exploit the so called 'oncogene addiction, i.e. the dependency of
cancer cells on the genetic lesions that have initiated the transformation process. A
second possibility has emerged for treating cancer and referred to as 'non-
oncogene addiction. This second approach exploits the dependency that cancer
cells have onproteins that are not mutated per se but still essential for their viability.
Some specifc mitotic kinases, such as PLK1, can be promising targets to exploit
the non-oncogene addiction phenomenon in ATC cells. One problem that could
emerge with the use of pathway inhibitors is molecular resistance formation. This
may be caused by regulatory circuits that compensate for the blocked kinase or by
mutations in the targeted kinase that abrogate drug binding. Understanding
regulatory pathways as well as mutations causing resistance is crucial to further
develop targeted approaches for thyroid cancer treatment.
$5.3
Tyrosine kinase inhibitors in thyroid cancer
Johannes Smit
Leiden University Medical Center, Leiden, The Netherlands.
Although the role of radioiodine (RaI) in recurrent or metastatic thyroid cancer
is beyond dispute, the effcacy of this therapy is hampered by the decreased
expression of the sodium iodide symporter (NIS) in DTC during the process of
dedifferentiation. At present, there are no effective therapies available for RaI
non-avid DTC. Conventional chemotherapy is hardly effective in DTC, and no
longer recommended in international guidelines. In DTC, many genetic
alterations have been identifed, involving tyrosine kinase signaling pathways.
In nearly all cases of PTC, genetic defects involving the RET, RAS, RAF
protein kinase signaling cascade are identifed. The BRAF
V600E
mutation has
been found in 29-69% of PTC and has been associated with aggressive
features including extrathyroidal extension and advanced stage. Translocations
of RET observed in PTC result in a chimeric protein consisting of an activated
RET tyrosine kinase domain. Follicular thyroid carcinomas (FTC) frequently
harbor mutations in one of the three RAS genes. The RET-RAS-RAF pathway
is interconnected with the EFGR activated cascade that among others leads to
VEGF and VEGFR synthesis. Therefore, compounds targeting the activated
RET-RAS-RAF pathway and beyond may be effective in non-RaI avid DTC.
The anti EGFR compound geftinib was not successful in 27 patients with
DTC, medullary or anaplastic thyroid carcinoma. In a phase II study in 60
thyroid carcinoma patients with various histologies, the VEGFR inhibitor
axitinib showed a partial response of 30% (median PFS 18 months). Recently,
phase II studies have been published, using multi-kinase inhibitors, including
motesanib and sorafenib. Especially promising results have been reported for
Sorafenib (BAY 43-9006), which is an inhibitor of RET, CRAF, wild-type
and mutant (V600E) BRAF, VEGFR1, -2, -3, Flt3 and c-KIT, although no
complete remissions are reported. Questions to be addressed are the
relationship between genetic profle and therapy response, selection of patients
for particular drugs, the combination of treatment strategies rather than using
monotherapy, the response of bone metastases and the reinduction of RaI
uptake and the organization of multinational clinical trials.
Neuroendocrine control of reproduction
$.1
Sexual differentiation of hypothalamic \j neurons
Alexander Kauffman
University of California San Diego, La Jolla, California, USA.
The status of the neuroendocrine reproductive axis differs between various stages of
development and adulthood, and also differs between the sexes, including earlier
onset of sexual maturation in females than males and the ability to generate a
preovulatory gonadotropin surge in adult females but not adult males. The
reproductive axis is controlled by various hormonal and neural pathways that
converge upon forebrain GnRH neurons, and many of the developmental and sex
differences in the reproductive axis likely refect differences in the afferent circuits
and factors that regulate GnRH neurons. Recently, the neuropeptide kisspeptin,
encoded by the Kiss1 gene, has been implicated as an important regulator of GnRH
neurons. Accumulatingevidence supports a critical role of kisspeptinsignalinginthe
brain at different stages of life, including puberty and adulthood. It was also recently
determined that Kiss1 neurons in the hypothalamus are sexually dimorphic, and that
sexual differentiationanddevelopment of the Kiss1systemis regulated bysexsteroid
signaling at critical periods of development. Moreover, I recently found that sex
differences in at least one Kiss1 population is age-dependent, being present at only
certain developmental stages. Although the exact function(s) of sexual dimorphisms
in Kiss1 neurons is not entirely known, it is likely that sex differences in
hypothalamic kisspeptin signaling relate to known sex differences in puberty onset
and/or the ability to display a gonadotropin surge in adulthood.
$.2
KNDy (kisspeptin/neurokinin B/dynorphin) cells of the arcuate nucleus:
a central node in the control of GnRH secretion
M N Lehman
Canada.
We recently identifed a group of neurons in the arcuate nucleus of the
mammalian hypothalamus that co-localize three neuropeptides, kisspeptin,
neurokinin B and dynorphin, each of which has been shown to play a critical
role in the central control of reproduction. Growing evidence suggests that this
subpopulation, abbreviated as the 'KNDy` subpopulation, plays a key role in
mediating hormonal feedback control of GnRH secretion. KNDy cells are a major
target for steroid hormones and have direct projections to GnRH cell bodies and
terminals, features that position them well to convey the infuence of gonadal
steroids to GnRH neurons. In addition, the observation that KNDy neurons form
an interconnected network presumably capable of producing a synchronous burst
of fring has led to speculation that they may represent an important component of
the hypothalamic pulse generator that drives episodic secretion of GnRH. Finally,
recent work involving prenatal steroid-treated animal models indicates that
alterations in KNDy cell peptides and/or their release may underlie defcits in
steroidal feedback control of GnRH secretion and consequent LH excess as seen
in clinical reproductive disorders such as polycystic ovarian syndrome (PCOS).
Taken together, this evidence suggests a key role for the KNDy subpopulation as
a focal point in the control of reproductive function in both health and disease.
$.3
Consequences of non-classical ER signaling in brain
Jon Levine
Northwestern University, Evanston, Illinois, USA.
Ovarian estrogens exert critically important actions in hypothalamic neurons to
regulate ovulatory cyclicity, reproductive behaviors, and energy homeostasis.
Estrogen receptor alpha (ER) appears to mediate most of these effects, as
disruption of ER signaling leads to infertility and metabolic syndrome. ER
signaling mechanisms may include 'classical genotropic` effects mediated by
direct binding of receptor dimers to DNA, 'non-classical genotropic` effects
involving tethering of ERs to other transcription factors, and 'non-classical non-
genotropic` actions mediated by cytoplasmic ERs coupled to membrane-initiated
signal transduction pathways. Our studies make use of novel ER mutant mouse
models to ascertain the cellular mechanisms by which ER mediates E
2
effects on
these physiological and behavioral processes. We have utilized a novel mutant ER
knock-in mouse model, which confers non-classical genotropic and non-
genotropic signaling in the absence of classical signaling, to determine that
non-classical ER signaling can convey E
2
effects integral to homeostatic feedback
control of reproductive hormone secretions, as well as E
2
actions governing
paracopulatory behavior and body weight regulation. Supported by NIH P50
HD44405 and NIH P01 HD21921.
$.4
Insulin regulation of reproductive brain: rodent and human studies
Francois Pralong
Service of Endocrinology, University Hospital, Lausanne, Switzerland.
Insulin has been shown to participate in the long-term regulation of satiety, and it
is emerging as a peripheral modulator of the activity of the neuroendocrine
reproductive axis as well. Following the observation that mice lacking the
expression of brain insulin receptors exhibit central hypogonadism and infertility,
we could show that peripheral insulin can stimulate LH secretion in rodents. This
effect is likely mediated at the level of the hypothalamus, as suggested by the
increases in GnRH expression and secretion resulting from direct insulin
stimulation of primary hypothalamic neurons in culture. We were then able in
further studies to confrm that insulin accelerates LH pulsatile secretion in normal
humans as well. Our fnding that the GnRH-expressing GnV-3 cells do express a
functional insulin receptor is suggestive of a direct modulation of hypothalamic
GnRH neurons, although neuropeptide Y-ergic or GABA-ergic cells are also
likely involved. Together, these data establish insulin as a metabolic signal to the
neuroendocrine reproductive axis, involved in subtle but potentially important
regulations of the hypothalamic GnRH pulse generator. Given the increasingly
recognized importance that metabolic changes play in the relationships between
the periphery and the central nervous system, we hypothesize that other gastro-
intestinal hormones may participate in these modulations. All these signals are
then integrated by a network of frst and second order neurons, including GnRH
cells, at the level of the hypothalamus.
Approaches to preservation of gonadal function after
cancer therapy
$I.1
Ovarian transplantation
Claus Yding Andersen
Laboratory of Reproductive Biology, University Hospital of Copenhagen,
Copenhagen, Denmark.
Increased survival rates especially among young cancer patients have resulted in
more and more fertility centers worldwide have acknowledged that fertility
preservation is becoming an important quality of life issue to the growing
population of cancer survivors treated during their fertile years. If the ovaries
become depleted of follicles the woman will become sterile, loose menstrual
cycles and many women experience profound effects on the physical and
psychological status. For young girls it may further imply that pubertal
development fails. Cryopreservation of ovarian tissue involves removal of one
ovary prior to treatment. When the women have been cured and is considered ft,
the thawed ovarian tissue with a viable pool of follicles can be transplanted to
women who entered menopause. The surviving pool of primordial follicles will
start to grow and the patients will regain fertility and will experience cyclic
variation in sex hormone levels.
In Denmark where our laboratory is the only center that performs ovarian freezing
almost 425 girls and women have had ovarian tissue cryopreserved. The youngest
girl was 0.5 years old and the oldest 38 years.
In Denmark a total of ffteen women (10 having their tissue transported prior to
cryopreservation) have experienced transplantation of frozen/thawed ovarian
tissue a total of 21 times (6 women having tissue transplanted twice). All women
regained ovarian function and none have experienced relapse as a consequence
of the transplantation. Over a period of 20-25 weeks levels of FSH gradually
return to pre-menopausal levels and menstrual cycles are regained. Most women
experience return of ovarian function for some years with just a fraction of tissue
from one ovary being replaced.
Five of the women have been pregnant; in most cases as a result of assisted
reproduction. Two women have delivered three healthy babies as a result of
transplanted frozen/thawed ovarian tissue. The presentation will review our
experience with this method.
$I.2
ART/IVF and cryopreservation
Michael von Wolff
University of Bern, Bern, Switzerland.
IVF and ICSI are fully established methods of assisted reproduction which can be
used for patients awaiting cytotoxic therapy:
Following the data of the German, Swiss and Austrian network Fertiprotekt
(www.fertiprotekt.eu), 164 of 1388 counselled patients have chosen ovarian
stimulation and cryopreservation of oocytes as a fertility preservation technique
in 2007-2009. Among those patients 2417 oocytes were collected (Mean: 11.8,
Range 0-41, STD 7.3). In 125 patients oocytes were fertilized and cryopreserved,
resulting in an fertilisation rate of 70.5%/aspirated oocyte. Only in one patient,
chemotherapy needed to be postponed due to severe ovarian hyperstimulation
syndrome.
These data reveal that ovarian stimulation can result in adequate numbers of
oocytes. However, they also demonstrate, that this technique is not successful in
all patients. Combination with cryopreservation of ovarian tissue should therefore
be considered. FertiPROTEKT performed a study in which 50% of one ovary was
removed by laparoscopy in 12 patients. Patients received ovarian stimulation
around 2 days after the operation. The number of oocytes was on average 12.1 and
the fertilization rate 77.1% in comparison to an unoperated control group with 28
patients (13.1 respectively 60.6%). As none complications occurred, this
technique can yield a high chance for a later pregnancy due to the combination
of both therapies.
Finally, ovarian stimulation can easily be performed in breast cancer and
hodgkins lymphoma patients due to the time frame until the onset of the
chemotherapy. Ovarian stimulation can be performed in all patients within only
2 weeks if patients receive gonadotropin antagonists in parallel with recombinant
FSH, as demonstrated in 12 patients treated in the network Fertiprotekt (Wolff
et al. Fertil Steril 2009 92 1360-1365).
$I.3
Oocyte cryopreservation
Andrea Borini
Tecnobios Procreazione, Bologna, Italy.
IVF treatment would gain considerable advantage from a safe and effcient oocyte
cryopreservation method. Embryo freezing, which involves important legal and
ethical drawbacks, would be no longer needed. Women facing a destiny of
premature ovarian failure or requiring oocyte donation would also beneft from
oocyte cryopreservation. Studies conducted in the last few years suggest that
oocyte cryopreservation can be applied in a systematic and reproducible fashion,
in some cases with success rates which appear to compete with those routinely
achieved with embryo freezing. Vitrifcation techniques, recently introduced in
the feld of human IVF, have further enhanced the hope of developing oocyte
storage as a viable assisted reproduction strategy. Nevertheless, doubts have been
raised against oocyte freezing, especially with respect to its safety. Several
investigations have been conducted to detect possible freezing-induced cellular
alterations which might compromize oocyte viability and, indirectly, long term
effects on the conceptus. From a clinical perspective, the options by which the
stored material can signifcantly infuence the clinical outcome of oocyte freezing,
and make the comparison between different experience diffcult. Since the
introduction in Italy of an IVF law in 2004, the approach of thawing at each
treatment cycle a small number of oocytes has been adopted in various studies
(Borini et al. 2006, Levi Setti et al. 2006, De Santis et al. 2007, Parmegiani et al.
2008), in compliance with the legal restriction of not producing more than three
embryos. In other contexts, oocyte thawing cycles has been performed without
limitations to the number of embryos which may be generated and therefore the
number of oocytes which may be thawed and used at each cycle (Chen et al. 2005,
Boldt et al. 2006). The two approaches clearly are not directly comparable. The
thawing of only a few oocytes per cycle involves a higher risk of premature
treatment interruption as a consequence of increased incidence of failed
fertilization or cleavage (Borini et al. 2004). Besides, the option of embryo
selection is not practicable and in some cases the number of transferred embryos
may be insuffcient. Obviously, this scenario, which does not occur when an
excess of oocytes are thawed in individual attempts, can signifcantly affect the
clinical outcome in terms of pregnancy rate per thawing cycle and per transfer, as
well as the implantation rate classically defned as the ratio between implantations
and embryos transferred. For such a reason, it is diffcult to compare the
pregnancy rate of studies in which the mean number of embryos transferred was
as different as 1.1 (Borini et al. 2004) and 4.6 (Lucena et al. 2006). An example of
the inadequacy of the rate of pregnancy per transfer as an effcacy measure is
offered by a study (De Santis et al. 2007) in which the conventional slow-freezing
method was reported to produce a success rate of 16.7%. In reality, the rate of
pregnancy per thawing cycle was much lower (7.7%), with more than 50% of
cycles interrupted as a consequence of no oocyte survival after thawing or failed
fertilization. Crucially, the validity of a criterion to assess the effciency of oocyte
cryopreservation depends on the inclusion in the calculation of all the events of
attrition at pre- and post-storage stages. Only under such conditions do certain
differences between alternative methods become apparent. For example, it is well
known that a major improvement (from 35-40 to 70-75%) in the survival rate of
oocytes frozen and then thawed via slow cooling may be obtained by increasing
the sucrose concentration in the freezing solution from 0.1 to 0.3 mol/l (Fabbri
et al. 2001). This change also improves the rate of fertilization (Borini et al. 2006,
Levi Setti et al. 2006, De Santis et al. 2007). However, the different degree of
attrition at the steps of survival after thawing and on fertilization in the 0.3 mol/l
sucrose protocol is counterbalanced by a higher implantation rate of embryos
generated by the protocol involving the lower sucrose concentration (Borini et al.
2004, De Santis et al. 2007). The overall outcome, considered as the proportion of
implantations per thawed oocyte, ultimately makes the effcacy of the two
methods very similar (2.4 vs 2.6%) and in any case insuffcient for competing with
embryo freezing. Other methods have suggested that implantation rates in excess
of 5% per oocyte used could be obtained, approaching a success rate which
normally is attained with frozen embryos. Using a freezing protocol involving the
replacement of sodium with the less toxic cation cholin and the inclusion of Hepes
as a pH buffer, Boldt et al. (2006) reported a remarkable implantation rate of 5.3%
per oocyte used. It should be mentioned, however, that this result is derived from
the treatment of only 23 patients and so far it has never been confrmed with a
larger series of treatments. Our group reported a similar value (5.9%) of
implantation rate per oocyte used, following the application of a protocol based
on differential concentration of sucrose in the freezing (0.2 mol/l) and thawing
(0.3 mol/l) solutions (Bianchi et al. 2007). A similar implantation rate per thawed
oocyte has been more recently reported by another Italian group (Parmegiani
et al. 2008).
In recent years, the alternative cryopreservation approach of vitrifcation has
raised several hopes. By adopting the cryotop vitrifcation method in cycles
involving young donors (mean age 26.7 years), Cobo et al. (2008) achieved an
implantation rate per embryo transferred of more than 40%. Nevertheless, when
this study is analyzed considering the original number of oocytes used the
implantation rate corresponds to a value (8.6%). Such a rate is not very dissimilar
from the one (7.3%) resulting from a study conducted by a slow cooling method
and including patients with a mean age of 33.7 years (Bianchi et al. 2007).
After February 2004, as an effect of the above mentioned IVF law, our program
contemplated oocyte cryopreservation as an alternative to embryo freezing in
order to maximize the potential of all oocytes retrieved from individual
stimulation cycles. The cumulative pregnancy rate, including pregnancies from
both fresh and frozen-thawed oocytes, was over 47%. Recently tested oocyte
freezing methods which have shown to give rise to embryos with higher
implantation ability (Bianchi et al. 2007) could further raise the hopes of
achieving cumulative pregnancy rates well over 50%.
Evidence gained from approximately one thousand babies born from frozen
oocytes, although still insuffcient and incomplete, has not suggested so far that
the process of freezing and thawing is associated with an increase in birth
abnormalities. Although the number of published studies is relatively still modest,
the number of oocyte cryopreservation treatments is dramatically increasing. This
will have undoubtedly a signifcant impact on the practice of human IVF in the
near future.
Bianchi V, Coticchio G, Distratis V, Di Giusto N, Flamigni C & Borini A.
Differential sucrose concentration during dehydration (0.2 mol/l) and rehydration
(0.3 mol/l) increases the implantation rate of frozen human oocytes. Reprod
Biomed Online 2007 14 64-71.
Boldt J, Tidswell N, Sayers A, Kilani R & Cline D. Human oocyte
cryopreservation: 5-year experience with a sodium-depleted slow freezing
method. Reprod Biomed Online 2006 13 96-100.
Borini A, Bonu MA, Coticchio G, Bianchi V, Cattoli M&Flamigni C. Pregnancies
and births after oocyte cryopreservation. Fertil Steril 2004 82 601-605.
Borini A, Sciajno R, Bianchi V, Sereni E, Flamigni C & Coticchio G. Clinical
outcome of oocyte cryopreservation after slow cooling with a protocol utilizing a
high sucrose concentration. Hum Reprod 2006 21 512-517.
Chen SU, Lien YR, Chen HF, Chang LJ, Tsai YY & Yang YS. Observational
clinical follow-up of oocyte cryopreservation using a slow-freezing method with
1,2-propanediol plus sucrose followed by ICSI. Hum Reprod 2005 20 1975-1980.
Cobo A, Kuwayama M, Perez S, Ruiz A, Pellicer A & Remohi J. Comparison of
concomitant outcome achieved with fresh and cryopreserved donor oocytes
vitrifed by the Cryotop method. Fertil Steril 2008 89 1657-1664.
De Santis L, Cino I, Rabellotti E, Papaleo E, Calzi F, Fusi FM, Brigante C &
Ferrari A. Oocyte cryopreservation: clinical outcome of slow-cooling protocols
differing in sucrose concentration. Reprod Biomed Online 2007 14 57-63.
Fabbri R, Porcu E, Marsella T, Rocchetta G, Venturoli S & Flamigni C. Human
oocyte cryopreservation: newperspectives regarding oocyte survival. HumReprod
2001 16 411-416.
Levi Setti PE, Albani E, Novara PV, Cesana A&Morreale G. Cryopreservation of
supernumerary oocytes in IVF/ICSI cycles. Hum Reprod 2006 21 370-375.
Lucena E, Bernal DP, Lucena C, Rojas A, Moran A & Lucena A. Successful
ongoing pregnancies after vitrifcation of oocytes. Fertil Steril 2006 85 108-111.
Parmegiani L, Cognigni GE, Bernardi S, Ciampaglia W, Infante F, Pocognoli P,
de Fatis CT, Troilo E & Filicori M. Freezing within 2 h from oocyte retrieval
increases the effciency of human oocyte cryopreservation when using a slow
freezing/rapid thawing protocol with high sucrose concentration. Hum Reprod
2008 23 1771-1777.
Endocrine tumours: new genes and association with
syndromes
$8.1
Pituitary adenoma predisposition caused by AIP germline mutations
L Aaltonen
Finland.
$8.2
New multiple endocrine neoplasias: endocrine tumors associated with
gastrointestinal stromal tumors (GISTs)
Constantine Stratakis
NIH, Bethesda, Maryland, USA.
Carney triad (CT) describes the association of paragangliomas (PGLs) with
gastrointestinal stromal tumors (GISTs) and pulmonary chondromas (PCH). In
addition to pheochromocytomas, a number of other lesions have been described in
the condition including pheochromocytomas, esophageal leiomyomas, and
adrenocortical adenomas; CT, therefore, is a novel form of multiple endocrine
neoplasia (MEN). CT appears to be a genetic condition with a female predilection.
Inactivating mutations of the mitochondrial complex II succinate dehydrogenase
(SDH) enzyme subunits SDHB, SDHCand SDHDhave been found in familial and
sporadic PGLs, and gain-of-function mutations of the oncogenes c-kit (KIT) and
platelet-derived growth factor receptor A (PDGFRA) cause sporadic and familial
GISTs. Comparative genomic hybridization (CGH) revealed a number of DNA
copy number changes. The most frequent and greatest contiguous change was a
deletion within the 1pcen13-q21 region, which harbors the SDHC gene. Another
frequent change was loss of 1p. Although GISTs showed more frequent losses of
1p than PGLs, the pattern of chromosomal changes was similar in the two tumors
despite their different tissue origin and histology; the fndings were consistent with
a common genetic etiology of these two tumors in CT. In a separate condition, in
which the association (or dyad) of GISTs with PGLs is inherited in an autosomal
dominant manner (Carney-Stratakis syndrome, CSS), germline mutations of the
SDHB, SDHC and SDHD genes (but not KIT or PDFGRA) were found; GISTs in
this condition were caused by SDH defciency. In conclusion, CT is a novel MEN
syndrome whose genetic defect remains elusive. CSS is caused by SDH defects,
suggesting that sarcomas (GISTs) can be caused by defective mitochondrial
oxidation, consistent with recent data implicating this enzyme in a variety of
endocrine and other tumors. The above have clinical implications i) for patients
with GISTs that are cKIT- and PDGFRA-mutation negative: these tumors are
usually resistant to treatment with currently available tyrosine kinase inhibitor and
may be part of a syndrome such as CT or CSS; and ii) for patients with an inherited
PGL syndrome: family history should be explored to identify any other tumors in
the family, and in particular other endocrine lesions and GISTs.
$8.3
Update on familial pituitary tumors: from multiple endocrine neoplasia
type I to familial isolated pituitary adenomas
Albert Beckers
University of Liege, Liege, Belgium.
Inherited genetic conditions associated with pituitary tumours include multiple
endocrine neoplasia type I (MEN-I) and Carney complex. Pituitary tumours that
occur in the setting of MEN-I and Carney complex have specifc clinical
characteristics in terms of severity, which can help to guide clinical management.
In 2000, we reported the frst series of 27 patients with FIPA. Later on, the number
of FIPA families has increased to more than 130 today.
In 2006, Vierimaa and coworkers found inactivating mutations in the gene
encoding AIP in familial pituitary adenoma patients. AIP mutations were found in
15% of FIPA families (50% in families homogeneous for GH secretion).
In FIPA families, adenomas usually occur earlier and are more aggressive than in
sporadic cases. Also, FIPA patients who bear an AIP mutation have more
aggressive tumours that occur earlier than patients without AIP mutations.
Responses to treatment may not be as favourable in AIP mutated patients. The
FIPA cohort includes all types of adenomas, as can occur in AIP mutated FIPA
cases. However in AIP mutated patients, GH or GHPRL secreting adenomas
are predominant. In a study of 76 young patients with Cushings disease, only one
had an AIP mutation. In another study of more than 150 supposedly sporadic
adenomas in young patients (,30 years) with macro-adenomas more than 15%
had AIP mutations (all of which were GH or PRL secreting).
FIPA is not uncommon (more than 2% of all pituitary adenomas). AIP mutation
screening should be considered in all patients with FIPA and in young patients
suffering from aggressive GH or PRL secreting adenomas.
The role of oxidative stress in the development of the
metabolic syndrome
$9.1
Mitochondrial dysfunction and insulin resistance
M Roden
Germany.
$9.2
Macrophage dysfunction and insulin resistance
Petri T Kovanen
Wihuri Research Institute, Kalliolinnantie 4, 00140 Helsinki, Finland.
Obesity and associated insulin resistance are associated with increased numbers
of infltrating macrophages at various sites of white adipose tissue. The adipose
tissue macrophages are considered to be a major cause of obesity-associated
chronic low-grade infammation. The macrophages present in adipose tissue
secrete a wide variety of proinfammatory molecules including tumor necrosis
factor- (TNF-), interleukin-6 (IL-6), monocyte chemoattractant protein-1
(MCP-1), and plasminogen activator inhibitor-1 (PAI-1). These infammatory
molecules may have both local effects on neighboring adipocytes and systemic
effects on cells in other tissues. The combination of such paracrine and endocrine
actions of the macrophage-derived molecules contributes to insulin resistance in
white adipose tissue, muscle and liver observed in obese patients with type 2
diabetes and metabolic syndrome.
eu
Marked improvement of insulin resistance by reduced age intake; a
non-pharmacologic, non-nutrient based intervention for type 2 diabetes
Helen Vlassara
Mount Sinai School of Medicine, New York, New York, USA.
The clinical effcacy of strict glucose control against risk of diabetic
macrovascular complications, despite effective treatment, has been disappointing,
pointing to non-glucose related etiologic factors. Elevated infammatory
advanced glycation end products (AGEs), or Glycotoxins, known to increase
the incidence and severity of diabetic complications, are recently shown to impair
insulin production and insulin actions, hence are involved in the etiology of
diabetes and insulin resistance. Further evidence indicates that high levels of
AGEs in western diet may help precipitate diabetes, as well as diabetic
complications, by a process which involves increased oxidant stress (OS) and
depletion of anti-infammatory reserves, including anti-AGE receptor, AGE-
receptor-1 (AGER1). Attention has been drawn recently to the suppression of the
longevity associated mammalian de-acetylase, Sirt-1 in type 2 diabetes (T2D).
We found that both, AGER1 as well as Sirt-1 are down-regulated by AGEs
in vitro and by high AGE feeding in vivo, leading to insulin resistance, T2D and
vascular disease in mice. We now report strong correlations in diabetic patients
between fasting insulin (r0.526, P0.001), BMI (r0.4, P0.0001) and
sAGEs, factors which were profoundly infuenced by dietary AGE intake,
independent of glycaemia, nutritional or caloric intake. Isocaloric restriction of
dietary AGEs (by ^50%) over 4 months markedly improved fasting insulin
(P0.001) and HOMA levels (P0.023), reduced plasma leptin (P0.05) and
increased serum adiponectin (by 100%, P0.002). Importantly, under reduced
AGE intake, mononuclear (PMNC) AGER1 (P0.018), and Sirt-1 levels
(P0.040) were restored to normal, IRS-1 Tyr-phosphorylation was enhanced,
while Nf-kB p65 acetylation was ameliorated, indicating that the intervention
improved both, the infammatory and the metabolic states in these patients.
Thus, AGE-rich foods promote insulin resistance in T2D, possibly by interfering
with key mechanisms, regulated by Sirt-1 and adiponectin. Reduced AGE intake
may be required for the optimal treatment of T2D patients.
Novel aspects in the treatment of bone disease
juj
Principles of bone biology (the major pathways, RANKL, SOST,
Wnt etc)
G Russell
UK.
ju
Preclinical and clinical effects of RANK ligand inhibition
Serge Ferrari
Hopitaux Universitaires de Geneve, Geneva, Switzerland.
The RANK/RANK ligand (RANKL) pathway is key to promote osteoclast
formation and activation, and prolong osteoclast survival. Osteoprotegerin (OPG)
acts as a decoy receptor for RANKL and prevents its interaction with RANK
thereby inhibiting osteoclast formation, function and survival. In turn RANKL
inhibitors, and more specifcally a human monoclonal antibody against
RANKL, Denosumab, have been developed to treat a variety of bone disorders,
including osteoporosis and skeletal complications of malignancy.
The effcacy of RANKL inhibition to suppress bone turnover and improve bone
mass, microstructure and strength has been demonstrated in a variety of animal
models. In OPG transgenic rats for instance, long-term suppression of osteoclasts
led to an increase in bone mass and volume, associated with increased bone
strength versus their wild-type littermates. In ovariectomized (OVX) mice
expressing a humanized RANKL (huRANKL mice), denosumab was superior to
alendronate on improving bone mass, trabecular and cortical bone micro-
architecture. Similarly, in OVX cynomologus monkeys, denosumab signifcantly
increased BMD and reduced cortical porosity. Furthermore, in this model
switching from alendronate to denosumab after 6 months led to greater reductions
in BTMs and further improvement in bone mass and microarchitecture.
Randomized clinical trials (RCTs) have demonstrated that denosumab (60 mg
s.c., q6m) inhibits bone resorption markedly and reversibly, and improves BMD
in postmenopausal women with low bone mass. In two head-to-head studies,
denosumab effects on BMD were greater than QW alendronate. Two large RCTs
in osteoporotic post-menopausal women (23% prevalent vertebral fracture) and
hypogonadal men on androgen-deprivation for non-metastatic prostate cancer,
showed that denosumab reduces the incidence of vertebral fractures (68 and
62% respectively), and in women of hip (40%) and non-vertebral fractures
(20%). Active treatment was well tolerated (compliance rate 80% after
3 years), and overall serious adverse events were balanced vs placebo, including
cancer and infections.
ju
Teriparatide and parathyroid hormone in the treatment of ostoporosis
Marius E Kraenzlin
Division of Endocrinology, Diabetology and Clinical Nutrition, University
Hospital Basel, Basel, Switzerland.
The pharmacologic armamentarium available to clinicians to reduce fracture risk
in women with postmenopausal osteoporosis consists essentially of antiresorptive
agent. Recently, peptides from the parathyroid hormone (PTH) family, which
under specifc modalities of administration act as anabolic agents have become
available. The interest generated by these alternatives to antiresorptive treatment
resides in their greater potential for restauration of bone mass and possibly also
bone structure in osteoporotic subjects who have already suffered substantial
skeletal deterioration.
The anabolic effects of intermittent administration of low dose PTH are exerted
through stimulation of the PTH-PTHrP recpeptor. The anabolic actions involve
augmentation of the number of osteoblasts through stimulation of cell replication
and inhibition of osteoblast apoptosis, and probably also stimulation of osteoblast
activity. The molecular mechanisms underlying these anabolic effects are still
poorly understood, but appear to include both direct actions on osteoblastic cells
as well as indirect effects such as through stimulation of IGF1 production and
down-regulation of sclerostin, a physiologic antagonist of the important anabolic
Wnt--catenin pathway.
The anabolic effects of intermittently administered PTH (PTH1-34 or PTH1-84)
are manifest as increases in skeletal mass, bone turnover markers, and bone
strength. The effects of teriparatide (PTH1-34) on bone have been studied in
postmenopausal women and men with advanced osteoporosis. The administration
of teriparatide (PTH1-34) 20 g daily in postmenopausal women increased BMD
by 8-9% at the spine and by about 3% at the hip. There was an associated
reduction in vertebral fracture incidence by 65% and incidence of non-vertebral
fractures by 54%. The full length molecule of PTH, PTH1-84, reduced the risk
of new vertebral fracture by 58%. Regarding non-vertebral fracture, a
non signifcant reduction of the risk was observed in the patients with BMD
,3.0 T-score and one prevalent fracture.
Treatment with PTH might also be particularly effective in glucocorticoid-
induced osteoporosis, because impaired bone formation is a important
pathogenetic feature. The results of a controlled trial comparing teriparatide
with alendronate, over an 18-month period, in patients with glucocorticoid
induced osteoporosis showed greater increases in vertebral BMD and a greater
reduction in new vertebral fractures with teriparatide than with alendronate.
The most common adverse effects associated with teriparatide include injection-
site pain, nausea, headaches, leg cramps, and dizziness.
After a maximum of 2 years of PTH therapy, the drug should be discontinued and
antiresorptive therapy begun to preserve the gains achieved during PTH
treatment, as there is rapid bone loss after stopping PTH treatment. On the
other hand, patients who are candidate for treatment with PTH have often
previously been treated with an antiresorptive agent. Available data suggest that
prior treatment with antiresorptive drugs does not compromise the treatment
effects of teriparatide.
Premature ovarian failure
jjuj
A pivotal role for NR5A1 in human reproductive processes
A Bashamboo
Unit of Human Developmental Genetics, Institut Pasteur, Paris, France.
NR5A1, a member of the nuclear receptor superfamily, is a key transcriptional
regulator of genes involved in the hypothalamic-pituitary-gonadal steroidogenic
axis. Newborn mice defcient in NR5A1 lack both gonads and adrenal glands and
have impaired expression of pituitary gonadotrophins. NR5A1 is expressed in
foetal and adult Sertoli and Leydig cells of testis. NR5A1 is also expressed in
multiple cell types in the foetal, postnatal, prepubertal and mature ovary. Up until
2008, 18 NR5A1 mutations were described in the human. Three of these were
identifed in individuals with adrenal insuffciency, two associated with 46,XY
DSD and the third a 46,XX female with conserved ovarian function. Other
mutations were associated with various anomalies of testis development with no
evidence of adrenal failure. We have identifed further 19 mutations in NR5A1
including mutations in 4 familial cases having individuals with 46,XY DSD as
well as primary ovarian insuffciency (POI). A further analysis of 25 sporadic
cases of POI revealed two additional mutations. Functional analysis revealed that
each mutant protein had altered transactivational properties on gonadal
promoters. These data reveal novels insights into the role of NR5A1 in ovarian
developmental and function and indicate that mutations of the NR5A1 gene may
be a signifcant cause of human ovarian insuffciency. Further work in our lab
continues to unveil additional gonadal phenotypes associated with mutations in
NR5A1, adding to the complexity of role of NR5A1 in development and function
of mammalian gonad.
jju
Premature ovarian failure due to overactivation of primordial follicles
in mice
Kui Liu
Department of Medical Biochemistry and Biophysics, Umea University,
Umea, Sweden.
In humans and other mammalian species, the pool of resting primordial follicles
serves as the source of developing follicles and fertilizable ova for the entire
length of female reproductive life. In recent years, molecular mechanisms
underlying follicular activation have become more evident, mainly through the
use of genetically-modifed mouse models. As hypothesized in the 1990s, the pool
of primordial follicles is now known to be maintained in a dormant state by
various forms of inhibitory machinery, which are provided by several inhibitory
signals and molecules. Several recently reported mutant mouse models have
shown that a synergistic and coordinated suppression of follicular activation
provided by multiple inhibitory molecules is necessary to preserve the dormant
follicular pool. Loss of function of any of the inhibitory molecules for follicular
activation, including PTEN (phosphatase and tensin homolog deleted on
chromosome ten), Tsc1 (tuberous sclerosis complex 1), Tsc2, Foxo3a, p27, and
Foxl2, leads to premature and irreversible activation of the primordial follicle
pool. Such global activation of the primordial follicle pool leads to the exhaustion
of the resting follicle reserve, resulting in premature ovarian failure (POF) in
mice. We believe that information obtained from mutant mouse models may also
refect the molecular machinery responsible for follicular activation and POF in
humans. These advances may provide a better understanding of human ovarian
physiology and pathophysiology for future clinical applications.
jju
Ovarian AMH: implications for the diagnosis of premature ovarian
failure
Axel Themmen
Erasmus MC, Internal medicine, Rotterdam, The Netherlands.
In addition to markers such as FSH and inhibin A or B, anti-Mullerian hormone
(AMH) has recently received much attention as a marker of ovarian function. It
has become clear that AMH is secreted by the postnatal ovary and is specifcally
produced by the granulosa cells in growing follicles from the primary to the small
antral stage (in mice) or the larger antral follicle stage (in women) that have not
undergone cyclic recruitment by FSH.
Since AMH is expressed in small growing follicles and not in the larger FSH-
dependent follicles, its serum values may be a measure of the size of the
primordial follicle pool. Indeed, serum AMH correlated very well with a measure
of ovarian reserve, the antral follicle count. We found that AMH nicely decreases
in serum from women between the ages of 25 and 50 years and is not detectable in
post-menopausal women. In two independent cohorts, AMH was found to be
constant during the menstrual cycle and cycle-to-cycle determinations at day 3 of
the cycle showed that serum AMH does not change between two consecutive
cycles. In young women undergoing chemotherapy treatment, serum AMH was
found to correlate with residual ovarian function, while serum AMH is
undetectable in the majority of women with premature ovarian failure. In
women with normogonadotrophic anovulatory infertility (WHOII), AMH is
elevated, especially in those patients exhibiting polycystic ovaries (PCO).
Studies in AMH knockout (KO) mice show that AMH is important for the
regulation of the rate of primordial recruitment. Thus, ovaries of AMH KO mice
show an increased number of small growing follicles accompanied by a decrease
in the primordial follicle stock. These results could be validated in vitro using
cultured ovaries from 2-day-old mice, where AMH also inhibited expression of
marker genes of growing follicles. A second role of AMH was found to be the
attenuation of FSH-sensitivity of small antral follicles. In mice, it is this class of
follicles that is selected for further growth to the pre-ovulatory stage. Both in vivo
and in vitro, AMH KO follicles were more sensitive to FSH in terms of growth.
These results indicate that AMH is a promising marker for ovarian function: it has
a clear functional role in the ovary, it can be determined with great sensitivity in
serum and serum AMH levels show excellent correlation to a marker of ovarian
reserve, antral follicle count.
jjuO
Genetic defects in ovarian growth/differentiation factors
Luca Persani
1,2
, Raffaella Rossetti
1,2
& Chiara Cacciatore
1,2
1
Dipartimento di Scienze Mediche, Universita` di Milano, Milan, Italy;
2
Laboratory of Experimental Endocrinology, Ist Auxologico Italiano,
Milan, Italy.
The pathogenesis of premature ovarian failure (POF) is largely unknown.
However, the evidence of a frequent familiarity for the anticipation of menopause
among POF women supports the concept of a strong genetic component at the
origin of POF. This is further supported by the fndings of several candidate genes
and by data coming from natural and experimental animal models. On these
bases, several groups are involved in the search for markers able to predict the risk
of POF. The identifcation of natural models, such as the sheep strains affected
with female fertility disorders caused by inherited mutations of ovarian
growth/differentiation factors (GDFs) and related receptors, opened novel
perspectives on the mechanisms involved in ovarian folliculogenesis and on
human ovarian disorders. Several studies in the last 10 years have contributed to
understand the relevant role played by GDF9 and its analog BMP15 in ovarian
folliculogenesis. In our lab, we have described several missense variations in the
BMP15 gene of women affected with primary or secondary amenorrhea due to
hypergonadotropic ovarian failure. To understand the functional impact of these
variants, we have produced wild-type and variant protein in vitro and designed
specifc bioassays based on human granulosa cells. All variations found in the
Italian and North-American POF populations were located in the part of the gene
encoding the proregion or the signal peptide and several of them cause a defective
production of bioactive BMP15 protein. The percentage of POF women carrying
these defective BMP15 variants reaches 4-5% among more than 300 Italian POF
women. The percentage of POF women carrying GDF9 variants is instead quite
poor (,1%). Therefore, ovarian GDFs defects score second after FMR1
premutations among the genetic factors known to be associated with POF
pathogenesis. We therefore propose to include the screening of BMP15 gene
among the analyses for the prediction of POF risk.
The fnancial support of Telethon - Italy (Grant no. GGP09126) is gratefully
acknowledged.
Thyroid hormone metabolism and action: new
developments
juj
Thyroid hormone transporters
Edith Friesema
Erasmus MC, Rotterdam, The Netherlands.
Thyroid hormone (TH) plays an essential role in the proper development of the
brain and peripheral tissues. Lack of suffcient TH results in abnormal
development, including mental retardation. TH transporters are necessary for
the intracellular availability of TH to have access to the deiodinases and nuclear
receptors inside the cell. Different specifc TH transporters are known to date
including the monocarboxylate transporters 8 (MCT8) and 10 (MCT10), and the
organic anion transporting polypeptide 1C1 (OATP1C1). MCT8 and MCT10 are
widely expressed throughout the body, whereas expression of OATP1C1 is rather
restricted to specifc areas in the brain and testis.
The clinical importance of TH transporters is dramatically shown in patients with
mutations in MCT8, suffering from severe X-linked psychomotor retardation in
combination with disturbed TH levels, especially high serum T
3
levels. This
disease is now referred as the Allan-Herndon-Dudley Syndrome (AHDS).
Worldwide 45 families have been identifed with MCT8 mutations. Most
MCT8 mutations result in a complete loss of TH transport function when tested
in vitro, but some mutations show signifcant residual activity and are associated
with a somewhat milder clinical phenotype.
Different Mct8 defcient mouse strains have been generated. The analysis of these
mouse mutants showed that they have the same marked disturbed TH serum
levels as found in the AHDS patients. However, these mice do not show any overt
neurological defcits. Apparently, mice have a different subset of TH transporters
important for TH transport into the brain.
Until now, no patients have been identifed with mutations in MCT10 or
OATP1C1. It is expected that more TH transporters will be identifed to explain
the cell-specifc subsets of TH transporters in normal tissue and brain.
ju
Life without T
4
to T
3
conversion
Valerie Anne Galton, Donald St Germain & Arturo Hernandez
Dartmouth Medical School, Lebanon, New Hampshire, USA.
Abundant evidence indicates that the three deiodinases (D1, D2 and D3) function
at the pre-receptor level to infuence both extracellular and intracellular thyroid
hormone levels and hence thyroid hormone action. Indirect evidence supports the
concept that a major function of the D1 is to generate T
3
for export to plasma
whereas the D2 generates T
3
primarily for local use. To obtain direct evidence
concerning their individual physiological roles we have generated mice defcient
in one, two or all three deiodinases. Data obtained in C57Bl/6 mice defcient in
one or both 5
-deiodinases indicate that: i) maintenance of a normal serum T

3
level is not dependent on the generation of T
3
from T
4
either in peripheral tissues
or in the thyroid; ii) iodothyronines other than T
4
are the principal substrates for
the D1; iii) consistent with the conclusion based on indirect evidence, the D2 is
important for local generation of T
3
in pituitary, brown fat and the CNS.
However, although brain T
3
content in neonatal D2KO mice is reduced to a level
comparable to that in age-matched hypothyroid WT mice, the molecular and
functional phenotype of the D2KO mouse is much milder than that of the
hypothyroid mouse. Possible reasons for this paradoxical fnding include the
potential importance of serum as a source of T
3
for the developing brain and a
direct action of T
4
per se. The phenotype of the D3KO mouse is much more
severe than that of mice defcient in D1 and D2, and is lethal in the C57Bl/6 strain.
However, viability is improved if the D1 and D2 are also absent; many C57Bl/6
mice defcient in all three deiodinases thrive and can raise litters. In summary,
mice maintained in a stress-free environment function very well in the absence of
one or both of the 5
-deiodinases.
ju
Thyroid hormone signalling in the heart
Warner Simonides
VU University Medical Center, Amsterdam, The Netherlands.
Cardiac contractility, electrophysiology and energy metabolism are markedly
dependent on the level of circulating thyroid hormone. Some of the effects are
secondary to changes in heart rate and systemic blood pressure, but most genes
involved in the effects on cardiac function are transcriptionally regulated by T
3
.
Knock-out models in which expression of the various T
3
-receptors (TR) was
manipulated indicate a principal role of TR, although signalling through TR is
possible. Cardiac conversion of T
4
to T
3
is minimal, at least in rodents, and the
level of plasma T
3
is the determining factor under normal conditions. Impaired
T
3
-signalling may in part explain the critical changes in cardiac gene expression
that are seen in pathological hypertrophy of the heart following chronic
hemodynamic overload or following myocardial infarction (MI). Reduced
expression of TRs was indeed found in some rodent models of heart failure and
normalizing TR expression through viral transfection improved contractile
function. However, other studies reported increased expression of TRs at later
stages of remodeling. Several studies now report the re-expression of cardiac
deiodinase type 3 (D3) in pathological hypertrophy. D3 inactivates T
3
and T
4
and
is mainly expressed in tissues during development. The stimulation of D3 activity
in pathological hypertrophy is associated with severe impairment of cardiac T
3
signaling. Hypoxia-induced signaling appears to drive D3 expression, which is
also seen in other metabolically stressed cell types. Impairment of T
3
signaling
will reduce energy turnover and the induction of D3 may be seen as an adaptive
response. However, in the heart it will also aggravate the changes in gene
expression that contribute to contractile dysfunction in pathological remodeling.
juO
Signihcance of thyroid hormone receptor in metabolism
Jens Mittag
Karolinska Institutet, Stockholm, Sweden.
Thyroid hormone (TH) is long known for its profound effects on metabolism.
Novel studies have revealed that these effects are not restricted to the cellular and
organ level, and that TH also affects metabolism by altering the autonomic
nervous system via TH receptor 1. Mice expressing a mutant R384C TH
receptor 1 display a central sympathetic hyperactivation of their brown adipose
tissue, which causes severe hypermetabolism and resistance to high-fat diet-
induced obesity. Moreover, the autonomic control of cardiac activity is also
impaired and the mice fail to adapt their heart rate to environmental changes.
Analysis of hepatic glucose metabolism and glycogen storage, both severely
disrupted in the mutant animals, revealed that this defect that is founded during
the embryonal development of the autonomic nervous system. Although the
precise mechanism remains yet to be elucidated, several dysregulated genes such
as KCNA1 and Atp1a2 have been identifed in the hypothalamus of these mice,
which could constitute the missing link between TH and the development of the
autonomic nervous system.
The TSH reference range
juj
Determinants of the TSH reference range
Henry Volzke
University of Greifswald, Greifswald, Germany.
There is controversy on the upper thyrotropin (TSH) reference level. Currently
available studies are based on cross-sectional data leaving uncertainty about the
prognostic signifcance of the upper TSH reference level. Studies establishing
TSH reference values should be evaluated using strict quality criteria including
population representativeness and sample size. In addition, not only subjects with
known thyroid disorder, but also those with subclinical disorders including goiter
and nodules should be excluded from the reference population.
The clinical value of TSH reference values depends on the study design.
Reference values are only of diagnostic signifcance if analyzed from cross-
sectional data, but they are of prognostic signifcance if established from
longitudinal studies.
ju
Health outcomes related to TSH values within the reference range
Bjrn Olav A
svold
1,2
1
Norwegian University of Science and Technology, Trondheim, Norway;
2
St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
There is increasing evidence that differences in thyroid function within the
clinically normal range, as defned by TSH within the reference range, is
associated with health outcomes.
TSH within the reference range is positively associated with presence of thyroid
antibodies and with risk of overt hypothyroidism. Some cross-sectional studies
indicate that low-normal thyroid function may be associated with adverse serum
lipid levels, high blood pressure, high body mass, endothelial dysfunction, and
atherosclerosis, whereas high-normal thyroid function may be associated with
atrial fbrillation and osteoporosis. Among prospective studies, one indicated that
women with low-normal thyroid function may be at increased risk of fatal
coronary heart disease. Another study showed that people with high-normal
thyroid function may have increased risk of atrial fbrillation. Others found no
association between TSH within the reference range and vascular mortality or
coronary heart disease events. In very old age, there is evidence that high-normal
thyroid function may be associated with higher mortality.
In summary, several studies indicate that low-normal thyroid function is
associated with increased risk of autoimmune hypothyroidism, with adverse
levels of cardiovascular risk factors, and possibly with increased risk of
atherosclerosis. On the other hand, high-normal thyroid function may be
associated with increased risk of atrial fbrillation and osteoporosis. However,
few prospective studies have addressed health outcomes related to differences in
TSH within the reference range, and the results have not been consistent. There is
almost no evidence from clinical trials to suggest that treating TSH levels within
the reference range may be benefcial.
ju
A critical synopsis of meta-analysis in the held of subclinical thyroid
disease
Brigitte Velkeniers
1
, Alain Van Meerhaeghe
2
, David Unuane
1
& Patrick Haentjens
3
1
Departments of Endocrinology and General Internal Medicine, Universitair
Ziekenhuis Brussel, Brussels, Belgium;
2
ISPPC CHU A Vesale, Service de
Pneumologie, Montigny-le-Tilleul, Belgium;
3
Laboratory for Experimental
Surgery, Center for Outcomes Research, Centre for Evidence Based
Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel,
Brussels and CEBAM, Belgian Branch o, Brussels, Belgium.
Background
Currently, physicians remain uncertain whether to screen and/or treat subclinical
thyroid disease. Many observational studies, including cross-sectional,
case-control, and prospective cohort studies, have reported on the association
between subclinical thyroid disease and an 'outcome of interest`. All cause
mortality, coronary heart disease, fracture risk, and pregnancy outcome may
drive the decision to screen or treat subclinical thyroid disease.
As systematic reviews usually provide more comprehensive and robust
conclusions, we conducted a critical synopsis of published meta-analyses in
the feld of subclinical thyroid disease.
Methods
We searched Medline, Web of Science, EMbase and the Cochrane Library to
identify relevant meta-analyses investigating the association between subclinical
thyroid disease and the previously mentioned endpoints.
Results
We identifed a total of 10 meta-analyses.
The currently best evidence suggests that subclinical hypothyroidism (S Hypo) is
a risk factor for coronary heart disease in young persons and a protection factor
for all-cause mortality in older patients. S Hypo is associated with higher
cholesterol values, and intervention with thyroid hormones has some benefcial
effects on blood lipids and heart function. Data on health-related quality of life
and symptoms, on the other hand, do not demonstrate signifcant differences
between placebo and thyroid hormone therapy groups, even though cognitive
function improves. Adverse effects are inadequately addressed.
Subclinical hyperthyroidism (S Hyper) may be a risk factor for all cause mortality,
especially in men and with advancing age, but the evidence is limited to one
meta-analysis.
In postmenopausal women S Hyper is a risk factor for osteoporosis (BMD
measurements), but data on fracture risk are lacking.
We found no meta-analyses addressing pregnancy outcomes.
Conclusions
The evidence to screen and treat subclinical thyroid disease is mainly
observational. The beneft of therapeutic interventions needs further validation
by randomised controlled trials with long-term follow-up.
juO
Solving the dilemma: what to do as a simple clinician
Stefano Mariotti
Endocrinology, Department of Medical Sciences 'M. Aresu`, University of
Cagliari, Cagliari, Italy.
Serum TSH is universally considered the best laboratory test to evaluate thyroid
function. Current TSH reference ranges are 0.3-5.0 mU/l, but a narrower range
(0.4-2.5) has been recently advocated, which better defnes normal thyroid
function. The question is still debated and matter of controversy, since it has been
argued that with the narrower range, an additional 10% of the general population
could be diagnosed as mild or subclinically hypothyroid, although most of them
do not have thyroid disease or do not require thyroid hormone therapy. How to
establish a TSH reference range, the health outcomes of borderline-normal serum
TSH and the meta-analysis of studies on subclinical thyroid diseases are discussed
in other lectures of this Symposium. This presentation will be focused on some
practical points useful in the current clinical practice. i) The within-individual
variation of serum TSH is lower than between-individual variation, implying that
any given euthyroid individual will have a narrower TSH range than that of the
general population. ii) Any serum TSH value must be correctly interpreted in the
peculiar clinical, laboratory and instrumental context including exclusion of
coexistent non-thyroidal illness or technical artifacts. iii) When employed to
check the adequacy of therapy in hypo- and hyperthyroid conditions, the target
value of serum should be within a narrower range (0.5-2.0), with the possible
exception of elderly patients. iv) Although still not currently available, the
clinician should be aware that different reference ranges are found in particular
conditions (elderly, iodine defciency, pregnancy) and clinical decisions on when
and how to treat should be taken accordingly.
In summary, although TSH is a test associated with a good specifcity, sensitivity
and predictive value in the evaluation of thyroid function, physician must not
consider only the laboratory result, but should employ all of the other skills of
medical practice, always remembering the Hippocrates` aphorism: Vita brevis,
ars longa, occasio praeceps, experimentum periculosum, iudicium diffcile.
Novel actions of vitamin D
jOuj
Vitamin D and diabetes
Chantal Mathieu
Belgium.
Vitamin D has become an important player beyond bone and calcium metabolism.
Receptors for 1,25(OH)
2
D
3
or calcitriol as well as the machinery to produce
1,25(OH)
2
D
3
locally are present all over the immune system. Regulation of the
enzyme responsible for the fnal activation of 1,25-dihydroxyvitamin D3
(CYP27B1) is however completely different in immune cells than in kidney
cells. Particular immunomodulating effects of 1,25(OH)
2
D
3
are observed on
dendritic cells, the central cell in the immune system, determining the balance
between tolerance and autoimmunity.
Type 1 diabetes is an autoimmune disease where the insulin producing cell of the
pancreas, the -cell, is under attack. Vitamin D not only has effects on the
immune system, but also affects the behaviour of the -cell in a way that will alter
its fate. Vitamin D defciency dramatically affects disease presentation in an
animal models of type 1 diabetes, whereas NOD mice lacking the vitamin D
receptor have an unaltered diabetes presentation. Thus, vitamin D and its
structural analogues may provide tools for the prevention or cure of type 1
diabetes.
jOu
Vitamin D and Wnt signalling in colon cancer
Alberto Munoz
Instituto de Investigaciones Biomedicas, Madrid, Spain.
Wnt/-catenin signalling pathway is abnormally activated in most colorectal
adenomas and tumours. Wnt factors are secreted glycoproteins that upon binding
to their heterodimeric membrane receptors trigger a signal transduction pathway
that leads to the accumulation of -catenin in the cytosol and its nuclear
translocation. Within the cell nucleus, -catenin regulates a vast number of genes
involved in cell proliferation and invasiveness via binding to members of the TCF
(T-cell factor) family of transcription factors. In human colorectal cancer, this
pathway is activated due to mutation in APC or AXIN1 tumour suppressor genes,
or in CTNNB1/-catenin.
1,25-dihydroxyvitamin D
3
(1,25(OH)
2
D
3
), the most active vitamin D
3
metabolite, inhibits proliferation and induces differentiation of human colon
cancer cells. Our results show that 1,25(OH)
2
D
3
antagonizes Wnt/-catenin
signaling by at least three mechanisms: i) the induction of direct binding between
vitamin D receptor and -catenin, which inhibits formation of transcriptionally
active -catenin/TCF complexes; ii) the upregulation of CDH1/E-cadherin, which
leads to the relocation of -catenin from the nucleus to the plasma membrane; and
iii) the induction of the DKK-1 gene, which encodes an extracellular inhibitor of
Wnt proteins.
DKK-1 is silenced in 25% of advanced colorectal tumours due to promoter
methylation, which implies the loss of this negative control of the Wnt/-catenin
pathway. Moreover, ectopic expression of DKK-1 in non-expressing DLD-1 cells
reduced cell proliferation in vitro and tumour formation in immunodefcient mice.
DLD-1 cells bear a truncated APC gene and so, they have a constitutively active
Wnt/-catenin pathway. Together with data in other cell types, this suggests that
DKK-1 has antitumoural effects that are independent of the antagonism of Wnt
signalling at the plasma membrane and of -catenin/TCF transcriptional activity.
In summary, our results indicate that the antagonism of the Wnt/-catenin
signalling is relevant for the complex antineoplastic activity of 1,25(OH)
2
D
3
.
$14.3
Vitamin D dependent anti-microbial pathways
Martin Hewison
UCLA, Los Angeles, California, USA.
Vitamin D is a pluripotent secosteroid whose actions extend far beyond classical
effects on calcium homeostasis and bone metabolism. Vitamin D is known to
exert powerful effects on both innate and adaptive immunity, with important
consequences for both infectious and autoimmune diseases. Innate immune
activities of vitamin D include the attenuation of antigen presentation by dendritic
cells. However, recent attention has focused on the ability of vitamin D to
stimulate antibacterial responses, notably in monocytes and macrophages,
involving localized induction of the enzyme responsible for synthesis of active,
1,25-dihydroxyvitamin D (1,25D), namely CYP27B1, and the nuclear vitamin D
receptor (VDR). The mechanism for this involves pathogen-sensing by toll-like
receptors (TLRs) but may also be infuenced by other tissue-specifc factors such
as growth factors. Enhanced expression of CYP27B1 and VDR facilitates
intracrine conversion of the main serum form of vitamin D, 25-hydroxyvitamin D
(25D) to 1,25D. The resulting rise in cellular 1,25D is then able to promote VDR-
mediated transcriptional activity. In particular, locally synthesized 1,25D has
been shown to induce antibacterial proteins such as cathelicidin which are central
to the killing of bacteria and mycobacteria. As a result of these observations it
appears that vitamin D may be a key factor in infectious diseases such as
tuberculosis. The effcacy of vitamin D in promoting innate immune responses is
dependent on several factors including the expression and induction of TLRs.
However, the most important consideration appears to be the availability of 25D
for intracrine conversion to 1,25D. Given that 25D refects the vitamin D status of
individuals, it has been proposed that vitamin D-insuffciency may compromise
innate immunity and predispose to infectious disease. These issues will be
discussed in the symposium with specifc reference to the mechanisms involved in
mediating the interaction between vitamin D and the immune system.
$14.4
Vitamin D and differentiation of mesenchymal stem cells and
osteoblasts
Hans van Leeuwen
Vitamin D is one of the major factors involved in calcium and phosphate
homeostasis via actions on intestine, kidney, parathyroid gland, and bone. In
addition, vitamin D has effects on various cells and tissues not primarily related to
calcium, phosphate and bone metabolism, including the immunesystem, brain, and
various cancer cells. Vitamin D defciency is linked to incidence and progress of
various diseases. Currently there is an increase in discussion on the question about
vitamin Ddefciencies and there is an increasing awareness. The biologically most
active form of vitamin D is 1,25-dihydroxyvitamin D
3
(1,25D
3
). 1,25D
3
is
synthesized from the parental vitamin D molecule by sequential hydroxylations
in the liver (25-hydroxylation) and kidney (1-hydroxylation).
1,25D
3
is involved in bone formation and mineralization and it is used to prevent
and treat osteoporosis. These infuences on bone can be indirectly established
through the control of calciumuptake in the intestine or reabsorption in the kidney.
However, direct effects are also likely as the vitamin D receptor is present in
osteoblasts. In addition, 1,25D
3
can directly affect osteoblasts as shown by
stimulating in vitro mineralization in osteoblast cultures and by altering gene
regulation. Moreover, we were able to show that osteoblasts themselves can
synthesize 1,25D
3
, emphasizing the importance of local 1,25D
3
for osteoblasts. In
the current presentation the direct regulation of osteoblast differentiation by
vitamin D and interaction with other signaling pathways will be discussed. The
effect of vitamin D on composition of the extracellular bone matrix and the impact
on mineralization will be presented.
Wnt signalling
$15.1
Wnt/-catenin controls stem cells in regeneration and tumor formation
Walter Birchmeier
1
, Peter Wend
1
, Christoph Loddenkemper
2
& Ulrike Ziebold
1
1
Max-Delbrueck Center for Molecular Medicine, Berlin, Germany;
2
Charite
University Clinic Berlin, Berlin, Germany.
Our laboratory works on Wnt/-catenin signaling in precursor and stem cells of
various organs. The data show that Wnt/-catenin controls cell lineage
specifcation in embryogenesis and organogenesis. General interest sparked
anew by recent evidence suggesting that organ as well as cancer stem cells share
core signaling and transcriptional modules. We used genetic mouse models to
study the necessity of Wnt/-catenin signaling in stem cells of the salivary gland.
Remarkably, the combined activation of Wnt/-catenin and blocked Bmp signals
produced highly aggressive squamous cell carcinomas. These tumors contained a
high number of CD24
CD29
stemcells, and as fewas 500 of these cells induced

tumors following transplantation into NOD/SCID mice. If the Wnt/-catenin and
Bmp pathways were individually mutated, stem cells showed an increased
potential for tissue regeneration but no tumors ensued. The switch fromorgan stem
cells to cancer stemcells involves a global increase in histone 3K4 methylation and
a decrease of H3K27 methylation. Our work thus defnes a switch in stem cell
potency from single to double mutations. Human squamous cell carcinomas are
also characterized by activated Wnt/-catenin and suppressed Bmp signaling.
$15.2
Wnt-signaling and the metabolic syndrome
Sven Schinner
University Hospital, Dusseldorf, Germany.
Wnt-signaling has been discovered as a regulator of adipocyte biology,
pancreatic -cell proliferation and insulin secretion. In addition, this pathway
has been implicated in the regulation of aldosterone and cortisol secretion by
the adrenal cortex. There is evidence that Wnt-signaling molecules can mediate
a crosstalk between adipocytes and endocrine cells like pancreatic -cells and
adrenocortical cells.
In addition, the recent genome-wide association studies in humans affected by
diabetes mellitus type 2 have pointed out that variations in the TCF7L2 gene have
the strongest association with the diabetic phenotype. TCF7L2 is a transcription
factor in the canonical Wnt-signaling pathway and can be coactivated by
-catenin. It is not yet completely understood how variants in the TCF7L2 gene
can contribute to the diabetic phenotype but the available data suggest impaired
insulin secretion as the underlying cause.
Finally, a link between the Wnt-signaling pathway and the incretin system has
been found on the cellular level. Incretin-based therapies are novel therapeutic
approaches to type 2 diabetes mellitus. Current data imply that GLP-1 agonists
exert their effects on pancreatic -cells in part through the canonical Wnt-
signaling pathway. In summary, the recent data on Wnt-signaling as a novel
regulator of metabolic control will be discussed in this talk.
*Correspondence to Dr Sven Schinner, Department of Endocrinology, Diabetes
and Rheumatology, University Hospital Dusseldorf, Moorenstrae 5, 40225
Dusseldorf, Germany, Tel.: 49-211-8117810, Fax: 49-211-8117860,
e-mail: sven.schinner@uni-duesseldorf.de
$15.3
Adipogenesis, diabetes and wnt signalling
Jaswinder Sethi
The concept of adipose tissue plasticity is well known, as is the fact that a positive
energy balance drives increased adiposity in vivo. Less well accepted or indeed
understood, are the molecular mechanisms that negatively regulate adipose tissue
plasticity particularly under physiological and/or patho-physiological conditions.
The latter is clearly relevant when one considers the possibility that there may be
a limit in the extent to which adipose tissue can expand. Our laboratory has been
investigating two candidate signalling networks that are likely to be important
negative local regulators of adipogenesis, In vivo. The Wnt/-catenin signaling
network is implicated in lineage determination of mesenchymal stem cells but is
also a good candidate for adipose tissue remodeling during normal physiology. In
contrast, pro-infammatory cytokines such as TNF- are also potent anti-
adipogenic signals and are good candidates for limiting adipose tissue expansion
during pathological disease states such as cachexia and obesity-associated
metabolic syndrome. Signifcant strides are now being made in elucidating the
regulation, physiological relevance, and molecular effectors of these anti-
adipogenic signals. One of our recent studies have identifed the Wnt modulator
Dapper1 as a new preadipocyte gene involved in the regulation of murine and
human adipogenesis. Our fndings from this and related studies will be presented.
These new insights provide functional networks with therapeutic potential for
treating diseases such as obesity and associated metabolic disorders.
Hot topics in pituitary disease
$1.1
Pros and cons of large scale screening of Cushing`s syndrome
A Tabarin & P Perez
Endocrinology and Clinical Epidemiology Unit, Bordeaux University
Hospital, 33604 Pessac, France.
Data from the literature suggest that endogenous Cushing`s syndrome (CS) is an
unusual disorder in the general population with a reported incidence of 2-3 cases
per 1 million inhabitants per year. Patients who are not cured from CS have a poor
prognosis with an increased mortality due to cardiovascular disease and
signifcant morbidity that impairs quality of life. Recently published screening
studies performed in obese patients with type 2 diabetes or patients with
osteoporosis reported an unexpectedly high prevalence (2-9%) of occult CS.
These data raise the question of the possible relevance of screening for CS in
high-risk populations who have clinical conditions that may be caused by
hypercortisolism. However, such strategy has to be carefully weighted,
considering the extremely elevated number of patients with these conditions.
We examined the question through the methodological framework of indication
for screening applied to data currently available in the literature. The indication
for screening must consider the frequency of the disease and the accuracy of
diagnostic methods and balance the severity of untreated disease with the
beneft/risk ratio of the whole screening strategy and its consequences including
interventions. In this perspective it should be emphasized that screening studies
have revealed that a number of patients with occult CS have mild
hypercortisolism that is due to moderately hyperactive and autonomous adrenal
tumors. In such patients, the biological defnition of CS is controversial and no
single criteria with accurate diagnostic performances can be easily used for
screening purposes. In addition, the role of mild occult CS in the pathogenesis of
type 2 diabetes and osteoporosis remains controversial since no large scale
prospective intervention study has been performed to date. The available
evidence on these points and the possible needs for additional research will be
discussed in the perspective of large scale screening for CS.
$1.2
The safety of dopamine agonists: clinical perspectives
Alberto Pereira
Leiden Univresity Medical Center, Leiden, The Netherlands.
Dopamine agonists (DA) are very effective and the frst-line treatment for
hyperprolactinemia. In prolactinoma, DA therapy is the treatment of choice.
DA decrease prolactin levels, restore gonadal function, improve visual feld
defects and reduce tumor size. In some patients drug therapy can lead to a
complete remission, including eradication of the tumor, and thereby allow
discontinuation of treatment. The majority of the patients, however, have to be
treated for many years. Cabergoline is the most potent DA and, due to its
favorable pharmacokinetic profle and good tolerance, is the most commonly used
DA in the treatment of prolactinoma. Recently, however, questions regarding
safety of medical treatment of prolactinoma patients with cabergoline emerged
when reports indicated an increased risk of fbrotic valvulopathy in patients with
Parkinson`s disease treated with the ergot-derived DA pergolide or cabergoline.
These ergot-derived DA have binding affnity for D
2
-receptors as well as
serotonin receptors, especially 5HT
2B
which are highly expressed on cardiac
valves. Stimulation of 5-HT
2B
receptors activates fbroblast mitogenesis, leading
to valvular fbrosis and subsequent valvular dysfunction. Prospective trials
evaluating the effect of DA on cardiac valves in patients with prolactinoma have
not been performed, but to date, observational studies have not reported clinical
relevant cardiac valve disease after treatment with cabergoline for prolactinomas.
The fndings obtained with much higher cumulative doses of cabergoline in
Parkinson patients, however, underscore that unnecessary prolongation of
treatment is undesirable. Another safety issue in the treatment of prolactinomas
with DA is pregnancy: Restoration of ovulation and fertility might expose early
fetal development to potential effects of DA before a pregnancy is diagnosed.
Bromocriptine and cabergoline appear to be safe, although data on pregnancy
outcome for the latter are limited. Finally, the safety and effcacy of DA
after reintroduction for symptomatic growth of a macroprolactinoma, will
be discussed.
$1.3
Problems with GH and IGF1 assays: progress?
Martin Bidlingmaier
Ludwig Maximilians University, Munich, Germany.
Measuring circulating concentrations of GH and insulin-like growth factor
(IGF1) is crucial to biochemically establish the diagnosis of GH-related
disorders such as acromegaly and GH defciency. Many commercial or in-house
immunoassays are in use. Controlled studies and regular external quality
assessment schemes document considerable disparities in GH and IGF1
concentrations reported when different assays are used. Among the reasons
for the differences are the molecular heterogeneity of the analytes and standard
preparations, epitope specifcity of the antibodies used but also differences in the
techniques used to reduce interference from binding proteins. Obviously, poor
comparability of assay results between laboratories impedes wider application of
evidence based guidelines for diagnosis and treatment. Therefore, endocrinol-
ogists and clinical chemists started an international collaborative to discuss steps
to improve the situation. Recently, the GH Research Society (GRS) in
collaboration with the International Federation for Clinical Chemistry and
Laboratory Medicine (IFCC), the International Society for IGF Research and the
Pituitary Society organized an expert workshop to defne strategies towards
harmonization of GH and IGF1 assays. One recommendation from this meeting
is the adoption of one defned international standard for GH- and one for IGF1-
assays. For GH assays, the isoform specifcity of the antibodies must be known,
but ideally assays should specifcally recognize the 22 kDa isoform only. Assay
specifc normative data for dynamic tests were considered mandatory until better
harmonization is achieved. For IGF1 assays, appropriate measures to exclude the
interference from IGF binding proteins (IGFBPs) and the quality of the
normative data were indentifed as key issue for assay quality. In addition to
assay specifc recommendations, the participants encouraged the improvement
of internal quality control procedures and the development of external quality
control programs on an international level to improve assay comparability and
patient care.
Genetic basis of infertility: clinical studies and clinical
models
$1I.1
Genetically modihed mouse models for the analysis of reproductive
disorders
William Colledge & Xavier dÀnglemont de Tassigny
The mammalian reproductive axis is activated at puberty by neuroendocrine
events within the hypothalamus that initiate the pulsatile secretion of GnRH.
GnRH acts on the anterior pituitary to stimulate production of the
gonadotrophic hormones (LH and FSH) which bring about maturation of the
gonads. Both naturally occuring and genetically modifed mutant mice have
provided insights into the molecular events that maintain the function of each
part of this reproductive axis. The crucial role that GnRH plays in activating
the reproductive axis is illustrated by the sterility of mutant mice that cannot
synthesize GnRH. Transgenic mice have also led to the identifcation of two
key proteins that are important regulators of GnRH release; these are the
G-protein coupled receptor, GPR54, and its ligands (kisspeptins) encoded by
the Kiss1 gene. Kisspeptins are expressed by neurons in the AVPV and the
ARC regions of the hypothalamus while Gpr54 is expressed by GnRH
neurons. Kisspeptin expression is differentially regulated by gonadal steroids
which provides a mechanism by which sex steroids can regulate GnRH release
under different physiological conditions. Gpr54 and Kiss1 mutant mice are
sterile, hypogonadal and have very low gonadotrophic and sex steroid hormone
levels. Spermatogenesis and ovulation are severely impaired and mutant
females do not show estrous cycling. The Gpr54 and Kiss1 mutant mice
cannot produce the pre-ovulatory LH surge after appropriate hormonal
stimulation and cannot activate kisspeptin or GnRH neurons as judged by
c-fos induction. Recently, injection of kisspeptin antagonists into the ARC has
been shown to inhibit pulsatile LH release. Thus, kisspeptin signalling in the
hypothalamus is required for activation of the reproductive axis at puberty, to
generate the pre-ovulatory LH surge and to maintain tonic GnRH/LH
pulsatility.
$1I.2
Neurokinin B signaling in human puberty
A Kemal Topaloglu
Department of Pediatric Endocrinology, Faculty of Medicine, Cukurova
University, Adana, Turkey.
The control of the onset of human puberty remains an enigma. According to current
understanding, the 'GnRH pulse generator`, a functionally interconnected and
synchronizednetwork of GnRHneurons, is inhibited throughout childhoodfollowing
a period of pubertal level activity during fetal life. Release of this inhibition at the
early second decade of life signifes the reawakening of the pulse generator.
Recently, we have identifed loss-of-function mutations TAC3 or TACR3 (encoding
neurokinin Band its receptor, NK3R, respectively) in 11 patients fromfve multiplex
families affected by normosmic idiopathic hypogonadotropic hypogonadism. These
fndings provide compelling evidence for the involvement of Neurokinin B (NKB)
signaling in puberty. Recent studies suggest that a network of sex-steroid responsive
neurons in the infndubular (arcuate) nucleus in the hypothalamus coexpress NKB,
kisspeptin, Dynorphin and ERalfa and probably communicating via NKB-NKR3
signaling these neurons project to ipsi- and contralaterally to the infndubular
(arcuate) nucleus as well as to GnRH terminals in the median eminence to put out a
synchronized intermittent secretion of GnRH.
The facts that the discovery of both kisspeptin and NKB signaling in puberty was
thanks tomultiplex human families and that in the great majority of such families, the
genetic causes are still waiting to be unraveled imply that there are more single genes
to be discovered, which will help understand the elusive developmental process of
puberty.
$1I.3
Genetics of Kallmann syndrome
Catherine Dode & Jean-Pierre Hardelin
Paris-Descartes University, Paris, France.
Kallmann syndrome (KS) typically combines severe congenital hypogonadotropic
hypogonadism(HH) with anosmia. The degree of the hypogonadismand that of the
smell defciency can, however, vary signifcantly, not only between unrelated
patients, but also within affected families. Some patients may also have non-
reproductive, non-olfactory additional anomalies. Five causal genes have been
identifed to date, namely, KAL1, FGFR1, FGF8, PROKR2, and PROK2.
Mutations (mainly nonsense or frameshift mutations) in KAL1 encoding the
extracellular glycoprotein anosmin-1, underlie the X chromosome-linked form,
which accounts for roughly 8%of all KScases. Loss-of-function mutations (mainly
missense mutations) in FGFR1 or FGF8 encoding fbroblast growth factor
receptor-1 and fbroblast growth factor-8, respectively, underlie an autosomal
dominant form with incomplete penetrance, which accounts for ^10% of KS
cases. Notably, as many as 30%of the FGFR1 mutations found in the patients could
be de novo mutations. Finally, putative loss-of-function mutations in PROKR2 and
PROK2, encoding prokineticin receptor-2 and prokineticin-2, respectively, have
been detected in ^9% of the KS patients. Most of these mutations are missense
mutations, and many are also present in apparently unaffected individuals, thus
initially raising questions regarding their pathogenic role in the disease. For most of
these mutations, however, deleterious effects on prokineticin-signalling have been
shown. The fnding of both heterozygous and homozygous unrelated patients for
given PROKR2 and PROK2 mutations is quite remarkable, and raises the question
of a possible digenic or oligogenic mode of inheritance in heterozygous patients.
Digenic inheritance has indeed been shown in a few patients who carry missense
mutations both in PROKR2 and PROK2, KAL1, FGFR1, or genes responsible for
normosmic HH such as GNRHR and KISS1R. Most patients heterozygous for
PROKR2 or PROK2 mutations, however, are expected to carry additional
mutations in as-yet-undiscovered KS genes. Indeed, mutations in the genes
identifed so far have been found in ,30% of all KS patients, indicating that other
disease genes remain to be discovered.
Diabetes in pregnancy
$18.1
Progress towards new criteria for diagnosis and classihcation of glucose
metabolism during pregnancy
Alexandra Kautzky-Willer
Meduniwien, Vienna, Austria.
Gestational diabetes (GDM) is defned as any degree of glucose intolerance with
onset or frst recognition during pregnancy and is associated with increased
feto-maternal morbidity as well as long-term complications in mothers and
offspring. GDM is diagnosed by an oral glucose tolerance test (OGTT) or overt
hyperglycemia. In case of a high risk for GDM or type 2 diabetes measurement of
fasting glucose and HbA1c and/or performance of the OGTT (120 min; 75 g
glucose) is recommended already in the frst trimester and - if normal - the OGTT
should be repeated in the second/third trimester. In case of clinical symptoms of
diabetes (glucosuria, macrosomia) the test has to be performed immediately. All
other women should undergo a diagnostic test between 24 and 28 gestational
weeks. Based on the results of the hyperglycemia and adverse pregnancy outcome
(HAPO) study an international consensus suggests new criteria for the diagnosis
of GDM with the following plasma glucose values: fasting 92 mg/dl, 1 h
180 mg/dl and 2 h 153 mg/dl. In case of one pathological value a strict metabolic
control is recommended. The women should receive nutritional counseling and be
instructed in blood glucose self-monitoring. If blood glucose levels cannot be
maintained in the normal range insulin therapy should be initiated. Maternal and
fetal monitoring is required in order to minimize maternal and perinatal morbidity
and mortality. After delivery all women with GDM have to be reevaluated as to
their glucose tolerance by a 75 g OGTT (WHO criteria) 8 weeks postpartum and
informed about their increased risk of development of diabetes and potential
prevention strategies at follow-up.
$18.2
New treatment modalities in diabetic pregnancy
Christof Worda
Medical University Vienna, Vienna, Austria.
Gestational diabetes affect about 5% of all pregnancies and is associated with
increased risk for mother and fetus. It has been shown to be associated with
increased risk for preeclampsia, postpartal bleeding, and cesarean section rate as
well as intrauterine fetal death, macrosomia, shoulder dystocia, and neonatal
hypoglycaemia. Several studies have shown the benefcial effect of tight blood
glucose control even in mild gestational diabetes. Diet and insulin treatment are
the frst choice and recommended by the most national committees.
Different oral antidiabetic agents seem to be as effective as insulin to achieve
suffcient glycaemic control. They share the advantage of oral administration
which might increase the acceptability of this medication by the patients and
might be more cost effective than insulin.
Glyburide, a second generation sulfonylurea which does not signifcantly cross
the placenta and metformin, an oral agent in the biguanide class, have shown no
teratogenic effects on the fetus and seem to be safe for the use during pregnancy.
Nevertheless oral antidiabetic agents are not generally recommended during
pregnancy.
Several issues have to be addressed before the use of these agents as a frst line
therapy of gestational diabetes. The safety and teratogenic potency have to be
clearly documented and the best dosage has to be established to promote maternal
well-being and avoid adverse neonatal outcomes.
$18.3
Gestational diabetes: high risk for future diabetes and cardiovascular
disease
Guntram Schernthaner
Rudolfstiftung Hospital Vienna, Vienna, Austria.
Gestational diabetes mellitus (GDM) is a common condition affecting 2-10% of
pregnant women in the USA and in Europe and is associated with adverse
outcomes for both the fetus and the mother. Previous GDM is a major risk factor
for type 2 diabetes (T2DM), which occurs in 20-60% of affected women within
5 years of the pregnancy
1
. In studies comparing women with GDM with those
with unaffected pregnancies, relative risks for the development of diabetes after
pregnancy range from 3 to 20. In a large Canadian study
2
of 21 823 women with a
previous GDM, the probability of diabetes developing after gestational diabetes
was only 3.7% at 9 months, but 18.9% at 9 years after delivery.
Women with a history of GDM are also at increased risk of other cardiovascular
risk factors
3,4
, such as obesity, hypertension, dyslipidemia, and the metabolic
syndrome, as well as subclinical atherosclerosis. In a population-based retro-
spective cohort study
5
from Ontario-Canada 8191 women with GDM and 81 262
women without GDM were followed-up for a median of 11.5 years. Diabetes
developed during follow-up in 2214 (27.0%) of the women with GDM and 2596
(3.2%) of the women without GDM. The hazard ratio for cardiovascular disease
(CVD) events was 1.71, but after adjustment for subsequent T2DM, the hazard
ratio was attenuated to 1.13. Thus, young women with GDM have a substantially
increased risk for CVD compared with women without GDM, however much of
this increased risk is attributable to subsequent development of T2DM. These
fndings are in line with a cross-sectional study, which reported that women with a
history of GDM had odds ratios for CVD and coronary artery disease of 1.85
and 1.58
6
.
Clinical trials now provide strong evidence for the impact of multiple
interventions to prevent the progression to T2DM in women with a history of
GDM. Both lifestyle modifcation and pharmacological therapies (metformin and
pioglitazone) have been shown to reduce diabetes development by 50% or more.
The diagnosis of GDM should initiate a long-term intervention and diagnostic
process to minimize the risk of developing diabetes and CVD as early in the
course of disease as possible.
References
1. England LJ et al. Am J Obstet Gynecol 2009 200 365.e1-365.e8.
2. Feig DE et al. CMAJ 2008 179 229-234.
3. Krzyzanowska K et al. Diabetologia 2008 51 1115-1122.
4. Kautzky-Willer et al. JCEM 2008 93 1689-1695.
5. Shah BR et al. Diabetes Care 2008 31 1668-1669.
6. Carr DB et al. Diabetes Care 2006 29 2078-2083.
Fetal microchimerism as an explanation of disease
$19.1
Microchimerism: introduction and animal models
K O`Donoghue
UK.
$19.2
Molecular microchimerism detection: its importance for non-invasive
prenatal diagnosis and preeclampsia
W Holzgreve
Switzerland.
$19.3
The role of microchimerism in autoimmune diseases
Klaus Badenhoop
University Hospital, Frankfurt am Main, Germany.
Autoimmunity has been associated with maternal-fetal microchimerism both in
animal models and in human observational studies. The concept has been studied
in various model systems, organ involvements and epidemiological studies. The
sensitivity to detect such microchimers (fetal cells in maternal tissue: fetal-
maternal microchimerism, maternal-fetal: maternal cells in a child`s compart-
ment) varies with the methods applied and the reproducibility of detection limits
for Y-chromosomal cells in maternal thyroid tissue obtained at surgery is also
variable. There is transplacental exchange of cells between mother and fetus
during any pregnancy, whereas long-term persistence in either organism is not
infrequent but less common. We have shown that mothers that have given birth to
sons have Y-chromosome positive cells within their thyroids more frequently if
they are affected by either Hashimoto`s thyroiditis or Graves` disease than if they
have non-autoimmune thyroid disesase such as adenomas. Furthermore this
fnding is associated with the susceptibility alleles HLA DQA1*0501-
DQB1*0201 or -DQB1*0201. This has served as a model to test a hypothesis
that organ specifc autoimmunity might in fact represent alloimmunity by a graft-
versus-host disease mechanism through fetal cells acting against maternal
antigens. Thyroid autoimmunity is exacerbated in the year following parturition
as Graves` disease or can be underrecognised as postpartum thyroiditis.
Postpartum thyroiditis occurs in Denmark with 1.5 per 100 000 person-years,
where in a study of randomly selected individuals no association could be
observed between thyroid antibody titres and the history for childbirth. However a
recent study on twins with opposite sex fnds a signifcantly higher prevalence of
thyroid antibodies in female twins from male-female twin pairs than in females
from female-female twin pairs with similar fndings in males (Brix TH 2009).
Thereby microchimerism may contribute to the pathogenesis of thyroid and other
autoimmune disease.
The endocrine incidentaloma
$20.1
The endocrine incidentaloma
Paolo Vitti
University of Pisa, Pisa, Italy.
Small, non-palpable thyroid nodules, detectable by thyroid ultrasound (US) in
30-50% of the general population, are likely to cause no signifcant health
problem, thus deserving the defnition of 'thyroid incidentalomas`. Although
clinically overt thyroid cancer is relatively rare, the most relevant issue for thyroid
incidentalomas is the exclusion of malignancy by cytological examination of
material obtained by fne needle aspiration (FNA). However, in about 30% of
samples FNA cytology does not give conclusive results, being non-diagnostic or
indeterminate, i.e. unable to discriminate between benign follicular adenoma and
thyroid carcinoma. Genetic alterations, such as BRAF mutations or RET/PTC
rearrangements, can be detected in FNA material, but for the low specifcity and
sensitivity, this molecular analysis is not recommended as a routine procedure
(ATA GL).
US features associated with malignancy are microcalcifcations, hypoecho-
genicity, irregular margins or absent halo sign, solid pattern, intranodular
vascularization and shape (taller rather than wide). However these patterns
taken singularly do not have a suffcient predictive value. When combined
in the same nodule have a high specifcity, but the sensitivity becomes
unacceptably low.
US elastosonography (USE) is a new powerful diagnostic technique that assesses
hardness as indicator of malignancy. USE performed on selected series of patients
has displayed a sensitivity of 97% and a specifcity of 100%. The predictivity of
USE was independent from the nodule size, being optimal also in nodules ,1 cm.
Conventional US maintains a pivotal importance to defne which nodules are
suitable for USE. USE seems to have a great potential as a new tool for the
diagnosis of thyroid cancer, especially in small nodules with indeterminate or non
diagnostic cytology.
$20.2
Pituitary incidentalomas
Mihail Coculescu
University Davila, Bucharest, Romania.
Current issues relating to pituitary incidentalomas include defnitional limits,
diffculties in their diagnosis resulting in hidden dangers, unknown pathogeny
and management based on expectation. The prevalence of pituitary
incidentalomas depends on the method of investigation: 3.2-27% in necroptic
studies or 10-23% by imaging (MRI or CT), compared to only 0.1% clinically
expressed pituitary adenomas. Diagnosis requires at least imaging and
hormonal assays. However, pituitary masses conceal different histopathological
features. Besides adenomas there are frequent autoimmune lymphocytic
hypophisitis and many other lesions without clinical expression. Non-
histological terminology is necessary before the diagnosis of adenomas. PET
and SPECT did not signifcantly improve diagnosis. Non-specifc or unexplored
symptoms /signs (for example, headaches or sleep disturbances) accompanying
the incidentalomas are observed frequently (61/182 in our series). Differential
diagnosis is diffcult in some cases: incidentaloma with hyperprolactinemia
against prolactinomas, incidentaloma with paraneoplasic Cushing syndrome
against Cushing's disease, incidentaloma with premature ovarian failure against
gonadotropinoma and pituitary hyperplasia against adenoma. Dynamic tests
with aGnRH and gonadotropins can be useful. Hidden dangers include
misdiagnosis with subclinical secreting adenomas (including subclinical
acromegaly) or growing adenomas. Pathology shows the predominance of
small ,1 mm-adenomas. Immunohistochemistry may reveal multiple 'mute`
pituitary hormones, often gonadotropins (25/141 in our series). In foliculos-
tellate cells there are many paracrine products with unknown clinical
expression (for example annexin, follistatin, VEGF). Paracrine secretory
products are also found in other pituitary cells, as is hypoxia inducible
factor-2- alfa in somatotrophs and TRH in gonadotrophs. The pathogeny of
pituitary adenomas, especially incidentalomas, is unknown. PTTG seems to be
more involved in proliferation of non-functioning cells than of hormone-
secreting cells. The role of stem cells is currently in discussion. Therapy is
recommended only for growing incidentalomas. The follow-up is not well
established: initially every 6 months, thereafter up to 3 years. Screening is
neither recommended nor cost-effcient.
$20.3
Adrenal incidentalomas
Stylianos Tsagarakis
Athens Polyclinic Hospital, Athens, Greece.
Incidentally detected adrenal masses are increasingly encountered in clinical
practice due to better availability and accessibility of imaging procedures and
are considered to be amongst the most common tumors in humans, with an
estimated prevalence ranging from 0.4 to 4.4%. Malignancy is rare amongst
patients with adrenal incidentalomas presenting in an endocrine clinic. The
imaging phenotype is very helpful in distinguishing benign adenomas from
malignant lesions. From the endocrine standpoint, catecholamine and
aldosterone producing tumors are infrequent but subtle abnormalities of cortisol
secretion are commonly encountered. Subtle autonomous glucocorticoid
hypersecretion has a reported prevalence that varies from 1 to 47%, according
to the applied diagnostic criteria. Currently there is no consensus on the
defnition of subclinical hypercortisolism. Nevertheless the dexamethasone
suppression tests seem to better accomplish the task of unmasking subtle
abnormalities of cortisol secretion. Although the clinical implications of
subclinical hypercortisolism remain elusive, it has been associated with the
occurrence of various metabolic abnormalities, such as diabetes, hypertension,
obesity and dyslipidemia. Moreover, impaired bone mass density and even a
higher fracture rate have been reported. Although incidentally discovered
adrenal masses are most commonly unilateral, a substantial proportion of
patients, ranging from 8.9 to 17% of cases, are presenting with bilateral lesions.
In these patients the prevalence of subclinical hypercortisolism is much higher
compared to those presenting with unilateral lesions. Involvement of aberrant
receptors as shown by the demonstration of paradoxical responses to meal,
posture or LHRH has been detected in few patients with bilateral
incidentalomas. Surgical intervention in selected cases results in some benefcial
effects but more data are required in order to routinely support surgery in this
clinical setting.
The cardiometabolic interface
$21.1
Endothelial dysfunction in type 2 diabetes
Thomas Nystrom
Goteburg University, Stockholm, Sweden.
Cardiovascular disease (CVD) is by far the most common complication of type 2
diabetes. Suffering from type 2 diabetes does not only signifcantly increase the
risk of CVD but is also associated with poor survival, both acutely and in the long
term, after a myocardial infarction (MI). In fact, total mortality from coronary
artery disease (CAD) in subjects with type 2 diabetes without a previous MI is as
high as that of non-diabetic individuals with a previous infarction. Regardless of
the risk factors are involved, atherosclerosis is an infammatory disease in which
endothelial dysfunction plays an essential role at all stages of the atherosclerotic
process. Endothelial dysfunction is commonly observed in association with type 2
diabetes and other situations characterized by insulin resistance, and are related to
the risk for initial or recurrent cardiovascular malfunction. In states of insulin
resistance; hyperglycemia, dyslipidemia, obesity, hypertension and low-grade
infammation all affect the endothelial function negatively, in a multifaceted and
complex manner. Many different alterations in lifestyle and pharmacological
interventions designed to improve endothelial function may also lower CVD risk.
Besides the documented insulinotropic effects of glucagon-like peptide-1
(GLP-1) mimetics, their effects on the cardiovascular function is of high interest.
GLP-1 receptors are expressed in the vasculature and heart. Recent studies have
demonstrated that GLP-1 mimetics have wide-ranging cardiovascular actions
such as improvement of endothelial dysfunction and left ventricular ejection
fraction in subjects with CAD. The physiological and potential pharmacological
role of GLP-1 and its analogues will be discussed in this context.
$21.2
Role of PPAR signalling in diabetic dyslipidemia
Bart Staels
UMR1011 Inserm, Institut Pasteur de Lille, Universite Lille Nord de France,
Lille, France.
Despite that statin treatment substantially reduces cardiovascular morbidity and
mortality, many treated patients still experience a high residual risk. Statins lower
LDL-cholesterol (LDL-C), with limited effects on other lipid parameters. A meta-
analysis from 14 randomised trials conducted in high-risk patients reported that
statin therapy is effective in reducing the proportional risk for major vascular
events by 21% for each mmol/l lowering of LDL-C. However, on average 14% of
patients still experienced an event despite being allocated to statin. Beyond
LDL-C, other factors, including triglycerides, non-HDL-C, HDL-C and
apolipoprotein B and CIII, have been identifed as factors determining residual
risk, and normalization of these parameters may further decrease cardiovascular
disease in patients treated with statins. PPAR activation improves atherogenic
dyslipidemia characterized by high triglyceride and/or low HDL-C levels and
elevated concentrations of small dense LDL particles, with or without high LDL-
C levels. Data from fbrate trials indicate that these drugs are particularly effective
in reducing cardiovascular morbidity in patients with atherogenic dyslipidemia
and the metabolic syndrome. The ACCORD trial is testing the effect of fenofbrate
and statin combination therapy on cardiovascular disease in diabetic patients. In
addition, results from the FIELD trial have demonstrated a benefcial action of the
PPAR activation on microvacular complications (retinopathy) and amputation
in diabetic patients. Moreover, PPAR agonists improve dyslipidemia, glucose
and energy homeostasis in preclinical animal models of (pre)diabetes. These
observations provide a rationale to target PPAR and PPAR in the management
of patients with high residual cardiovascular risk related to atherogenic
dyslipidemia and persisting after single therapy.
$21.3
Mechanisms and treatment of diabetic dyslipidemia
Michal Vrablik
1st Medical Faculty, Charles University, Prague, Czech Republic.
Type 2 diabetes and insulin resistance are associated with a complex change of
metabolism of plasma lipoproteins that conveys a substantial part of increased
cardiovascular (CV) risk of the diabetics. While quantity of lipoprotein
particles (lipid concentrations) remain close to normal, their quality
(composition) changes markedly. Lipoprotein metabolism in type 2 diabetes
differs from normal at three levels. First, the production of very low-density
lipoproteins (VLDLs) in the liver is elevated because of increased free fatty
infux from enlarged intraabdominal adipose tissue mass. This leads to changes
HDL metabolism as well as production of small dense LDL particles. Second,
catabolism of lipoproteins decreases due to lower activity of lipolytic enzymes
and receptor changes. Third, insulin resistance is associated with profound
changes of lipoprotein assembly and traffcking in the enterocyte and, thus,
postprandial lipoprotein metabolism.
Management of diabetic dyslipidemia must be based on a combination of
lifestyle changes and pharmacotherapy together with maximum effort to
achieve optimal diabetes control. Pharmacological treatment is based on a
statin, which has been shown effective in all subgroups analysed. However, in
statin-treated patients high rate of CV events has been documented and to
impact on this 'residual risk` a combination lipid-lowering treatment is
necessary. Fibrates effectively reduce the risk of macrovascular complications
in diabetics with hypertriglyceridemia and slow down microvascular changes.
Niacin, despite its deteriorating impact on glucose homeostasis, leads to a
broad and positive change of lipoprotein metabolism. Ezetimibe is as effective
in diabetics as in non-diabetics, nevertheless, the data on its effects on vascular
events is limited. Bile-acid sequestrants (resins) decrease levels of atherogenic
lipoproteins and may even improve diabetes control.
Only comprehensive approach to diabetic dyslipidemia including lifestyle
modifcation, proper control of diabetes and (combination) pharmacotherapy
can reduce not only the levels of atherogenic lipoproteins but also
cardiovascular risk of diabetics.
MicroRNAs in endocrinology
$22.1
MicroRNAs in biology
H Leffers
Denmark.
$22.2
MicroRNAs in thyroid cancer
Krystian Jazdzewski
1,2
1
Medical University of Warsaw, Warsaw, Poland;
2
Ohio State University,
Columbus, Ohio, USA.
The frst evidence of a potential role for microRNAs in papillary thyroid
carcinoma (PTC) was an overexpression of several miRs in tumor tissue
compared with unaffected tissue of the thyroid gland. The list of highly
upregulated miRs (up to 19.3 fold) included miR-146, miR-221/222, miR-155,
miR-34, and miR-181 and was soon confrmed. This fnding suggests that altered
microRNAs might be factors playing a role in the tumorigenesis of PTC. Further
evidence supporting this argument came from the study showing a genetic
association between PTC and a single nucleotide polymorphism (SNP,
rs2910164) in the precursor of miR-146a. Individuals heterozygous for the SNP
had an increased risk of acquiring PTC (OR-1.62, 95% CI 1.3-2.0, P0.000007).
It was further demonstrated that the processing of the microRNA was affected by
the SNP. Heterozygosity as a genetic risk rather than either homozygosity is a rare
phenomenon and should be critically evaluated. It was later shown that the
phenomenon is caused by the existence of additional mature microRNAs
generated from the passenger strand of the miR-146a precursor. In the case of
miR-146a the presence of the SNP generates two isoforms (marked *): miR-
146a*G from the allele carrying G, and miR-146a*C from the C allele, each with
its distinct set of target genes. Thus, GG and CC homozygotes each produce two
mature molecules (miR-146a from the leading strand, and miR-146a*G or *C,
respectively, from the passenger strand) while GC heterozygotes differ from both
homozygotes by producing three mature miRs (miR-146a and both miR-146a*G
and miR-146a*C). The microarray data showed that widely different tran-
scriptomes occurred in the PTC tumors from heterozygous and homozygous
patients. The modulated genes are mainly involved in regulation of apoptosis
leading to exaggerated DNA-damage response in heterozygotes potentially
explaining the predisposition to cancer.
$22.3
The role of miRNAs in hormone signaling
Deo Prakash Pandey, Marcela Bennesch & Didier Picard
University of Geneva, Geneva, Switzerland.
Steroid receptors belong to a family of transcription factors whose
transcriptional activities are regulated by their respective hormonal ligands.
Mechanisms that affect the receptor levels and/or the expression of their
regulators and target genes can be expected to shape hormonal responses.
miRNAs are newly recognized regulatory molecules that act at all these levels.
We have done a comprehensive survey of miRNAs that might regulate the
expression of the estrogen receptor (ER), and identifed several that affect its
levels. They target the long 3
UTR of the ER mRNA to reduce its stability

and/or translation. Amongst the identifed miRNAs, miR-22 inhibits ER
expression and thereby ER functions. Therefore, in breast cancer cells that
depend on ER function for proliferation, miR-22 can be considered a tumor
suppressor. Intriguingly, other miRNAs appear to increase ER expression.
While we are currently investigating the mechanism of this unusual effect,
increased ER levels may explain why some of these miRNAs have previously
been associated with more aggressive breast cancers. Additional complexity
stems from the facts that miR-22 might also regulate the expression of other
nuclear receptors and that the expression of miRNAs themselves can be affected
by steroid hormones. Thus, miRNAs play a multifaceted role in fne-tuning
steroid hormone responses at multiple different levels.
Obesity: clinical manifestations and therapeutic
intervention
$23.1
Obesity: clinical manifestations and therapeutic: does the choice of diet
make any difference?
Christos Mantzoros
Harvard Medical School, Boston, Massachusetts, USA.
Different diets have been used clinically and/or have been rigorously assessed in
the context of clinical trials in the past several years. Relative effcacy in terms of
weight loss and improvement of cardiovascular outcomes will be presented. In
addition, recent data have emerged on the role of leptin in mediating the
neuroendocrine response to long-term caloric derivation and will also be
presented along with novel data on leptin resistance. Leptin, alone or in
combination with amylin, emerges as a potentially useful adjunct to dietary
interventions for weight loss in obese humans.
$23.2
Lifestyle intervention and pharmacological approaches to weight loss
Jeremy Tomlinson
University of Birmingham, Birmingham, UK.
The global epidemic of obesity and its associated complications has hastened the
need with which we must understand both the patho-physiological process that
contribute to its development, and also the urgency with which we need
therapeutic solutions that offer clinically meaningful and sustained weight loss.
There is clear evidence as to the benefcial impact of exercise upon health, in
particular cardiovascular health, in normal weight and obese individuals as well
as those with type 2 diabetes. Exercise training is associated with decreased
cardiovascular risk, less atherogenic lipid profles, improvements in blood
pressure and insulin sensitivity. Importantly, the decline in insulin sensitivity
once exercise training is discontinued exemplifes the need for permanent lifestyle
modifcation and regular exercise. Pharmacological approaches have become
more limited in recent years with the demise of several anti-obesity medications,
most recently Sibutramine, due to increased non-fatal cardiovascular and
cerebrovascular events. Orlistat is now the only available licensed anti-obesity
therapy in the UK. However, new therapies are emerging fast, including the use of
GLP-1 analogues, which in the context of the treatment of patients with type 2
diabetes are an exciting advance. The feld of anti-obesity medication is full of
exciting prospects, yet the challenge remains to fnd effcacious, safe and well
tolerated drugs that will serve as an important component of the holistic approach
to weight management.
$23.3
Hormonal changes after bariatric surgery
Marie Guldstrand
Department of Clinical Science and Education, Karolinska Institutet,
Stockholm South Hospital, Stockholm, Sweden.
A better understanding of the endocrine changes following bariatric surgery
becomes increasingly important as the prevalence of obesity and obesity-related
diseases is rising worldwide. Bariatric surgery is the most effective therapy for
severe obesity in terms of weight loss, quality of life improvement, reduction of
mortality and morbidity. Gastric procedures for severe obesity can yield
dramatic and long-term weight reduction with an average weight loss of two-
thirds of excess weight within 1-2 years. Weight becomes stable at this level
and is well maintained at long-term follow-up. Improvement of the carbohydrate
metabolism following gastric bypass surgery occurs within a few days and is
partially independent of weight loss and caloric restriction and sustained.
The effects of weight reduction by different types of bariatric surgery on
islet function and on leptin have been studied by our group and others over the
past years.
The mechanism allowing massive weight reduction and diabetes resolution
after bariatric surgery is only partially understood but there is little doubt that
the gastrointestinal incretin hormones glucagon-like-peptide-1 (GLP-1) and
gastric inhibitory peptide/glucose-dependent insulinotropic peptide (GIP) are
important and exciting contributors. The GLP-1 response to oral glucose or
meal ingestion increase after gastric bypass and jejunoileal bypass (JIB)
surgery, but not after restrictive bariatric surgery, such as vertical banded
gastroplasty (VBG). Because the changes in incretin hormones after bariatric
surgery seem to be different after different types of surgery we have compared
the GLP-1 and GIP responses after VBG and JIB. Malabsorptive and restrictive
surgical procedures will be presented in short for a better understanding of the
'foregut and hindgut hypothesis` as to why bariatric surgery ameliorates type
2 diabetes. Finally, we will discuss the implications of the hindgut hypothesis
for GLP-1 and for the appetite-suppressant hormone peptide YY (PYY) and
their contribution to satiety after bariatric surgery.
Diagnosis and treatment of endocrine malignancies
$24.1
Malignant pheochromocytomas or paragangliomas
P-F Plouin
France.
$24.2
Diagnosis and treatment of adrenocortical carcinomas
Martin Fassnacht
Department of Medicine I, University Hospital of Wurzburg, Wurzburg,
Germany.
Adrenocortical carcinoma (ACC) is a rare malignancy and most of the diagnostic
and therapeutic strategies are not fully established according to criteria of
evidence based medicine. However, pre-operatively a thorough endocrine work-
up is strongly recommended (www.ensat.org/acc.htm). In addition an adequate
visualization of the tumor and potential metastases is mandatory for best patient
care. Computerized tomography and magnetic resonance imaging are currently
equally effective - when performed according to state of the art. Open
adrenalectomy is treatment of choice for localized tumors. However, it is an
open question whether minimal invasive surgery is an alternative in smaller
ACCs. In most patients, adjuvant therapy with mitotane is recommended and
some patients might beneft from additional radiotherapy of the tumorbed. In all
patients regular staging every 3 months is recommended.
In addition to mitotane, cytotoxic drugs are standard treatment in advanced ACC.
The best results have been reported for mitotane plus etoposide, doxorubicin and
cisplatin (response rate: 49%; Berruti 2005). A response rate of 36% was
published for mitotane and streptozotocin (Khan 2000). These two regimens are
currently compared in a phase-III-trial. The calculated patient accrual (n300) of
this FIRM-ACT trial has been completed in 10/2009 and frst results are available
later in 2010. In contrast to earlier reports, ACC is not radio-resistant. Therefore,
palliative radiotherapy may be used in symptomatic metastatic lesions.
The frst experience using targeted therapies is disappointing. Geftinib, sorafenib,
erlotinibgemcitabine, or bevacizumabcapecitabine exhibited only limited
effcacy in pretreated patients. However, trials testing IGF1 receptor inhibitors or
sunitinib are ongoing and will hopefully hold more promise.
Overall the prognosis of ACC is still poor and data from the German ACC
Registry (n584) indicate a 5-year survival rate of 47%. However, recent
collaborative efforts (e.g. by the European adrenal network ENSAT) and
international trials will advance the feld in the near future.
$24.3
Parathyroid carcinoma
Bela Szende
1st Department of Pathology and Experimental Cancer Research,
Semmelweis University, Budapest, Hungary.
Proliferative processes of the parathyroid gland cause hyperparathyrosis (HP),
Primary HP-s (carcinoma, adenoma, hyperplasia) are characterised by absence of
feedback to seCa level. Out of estimated 20-40/100 000 cases of hypercalcemia
(HC), mainly due to HP, only 25% becomes detected. The relative incidence of
parythyroid carcinoma (PCc) among causes of HC is 1-2%, but the highest seCa
and parathormone (PH) levels are caused by PCc. Clinical diagnosis of PCc is
based on palpable mass, seCa above 14 mg/dl, decreased seP, increased serum
alkaline phosphatase, urine Ca and 3-10 times increased PH level. Renal calculi,
renal calcinosis, osteoporosis and Engel-Recklinghausen`s disease (1%) develop
and may be the frst symptoms of PCc. Nearly all imaging methods, including
Tc99-labelled radiopharmacon scan are used in localisation of PCc. The diameter
of PCc may reach or exceed 3 cm. PCc has rich stroma, causing lobulation.
Cellular polymorphism is usually present, but mitotic and also apoptotic ratio is
relatively low. Infltrative growth, vascular invasion and metastatic spread (lymph
nodes, lung, liver, bones) ensure diagnosis of malignancy. Recurrance rate is
40-60%, 10 years postoperative survival is 77%. Literary data and our studies
show balance between pro- and anti-apoptotic genes in hyperplasia and adenoma,
some similarities between normal parathyroid tissue and PCc. Overexpression of
Ki67, MIB1, Galectin3,apollon, underexpression of RB, parafbromin, p27, bcl2,
fip, cyclinD1 and ck8 are valuable signs in favour for diagnosis of PCc. Etiology
of PCc is still uncertain. Data on heredity, especially on gene mutation of HRPT2,
underexpressing parafbromin and consequently cyclinD1 may lead to better
understanding pathogenesis of PCc. Primary therapy of PCc should be surgical.
To avoid consequences of HC, bisphosphonates, Ca sensor receptor blocking
calcimimetics, Gallium nitrate, calcitonin, Vitamin D1 analogs are recommended.
Gene therapy is in experimental phase.
Non-classical responses to hormones
$25.1
Rapid androgen action in epithelial and stromal cells
Gabriella Castoria, Antimo Migliaccio, Pia Giovannelli, Tiziana Giraldi
& Ferdinando Auricchio
Department of General Pathology, II University of Naples, Naples, Italy.
Androgen stimulation triggers rapid activation of signaling pathways in target
cells. The initial event is a rapid interaction of classical androgen receptor (AR)
with Src. Activation of these pathways fosters cell cycle, prevents apoptosis and
leads to cytoskeleton changes in reproductive as well as non-reproductive cells.
The role of Src activation in the androgen proliferative action has been recently
corroborated by fndings showing that specifc interference in Src/AR association
by synthetic peptide impairs prostate cancer cell growth in mouse model of
tumorigenesis. Furthermore, androgen activation of signalling pathways controls
cell migration and wound healing in fbroblasts. These fndings may account for
the role of AR in promoting tissue remodelling as well as cell spreading and
metastasis. Examples of the functions of signalling pathways in androgen action
will be here presented.
$25.2
Non-classical actions of estrogens in endocrine pancreas
Sergi Soriano
1
, Ana Ropero
1
, Paloma Alonso-Magdalena
1
, Cristina Ripoll
1
,
Esther Fuentes
1
, Ivan Quesada
1
, Birgit Gassner
2
, Michaela Kuhn
2
,
Jan-Ake Gustafsson
3,4
& Angel Nadal
1
1
Instituto Bioingenieri a and CIBERDEM, Universidad Miguel Hernandez
de Elche, Elche, Spain;
2
Institute of Physiology, University of Wurzburg,
Wurzburg, Germany;
3
Department of Biosciences and Nutrition, Huddinge,
Sweden;
4
Center for Nuclear Receptors and Cell Signaling, University of
Houston, Houston, Texas, USA.
The estrogen receptors ER and ER are currently considered important
molecules in glucose and lipid metabolism, although their specifc roles in
pancreatic -cells are still greatly unknown.
The function of pancreatic -cells is the biosynthesis and release of insulin,
the only hormone able to decrease blood glucose levels. It has been recently
described that ER plays an essential role in the regulation of insulin biosynthesis
by 17-estradiol, contributing to an enhancement of glucose-induced insulin
secretion (Alonso-Magdalena et al. 2008). In addition, 17-estradiol rapidly (in
min) decreases K
ATP
channel activity and increases insulin release in a cGMP
dependent manner (Nadal et al. 1998, Ropero et al. 1999). The 17-estradiol-
induced reduction of K
ATP
channel activity is mimicked by the ER agonist,
DPN; this action is missing in -cells from ER knock-out mice (ERKO). Both
the blockade of K
ATP
channels and the release of insulin are abolished in -cells
obtained for guanylyl cyclase A knock out mice (GC-A KO). Therefore, evidence
indicate that the estrogen receptor ER and the guanylyl cyclase-A receptor
(GC-A) are involved in the 17-estradiol triggered action in -cells (Soriano
et al. 2009). These results may be relevant to clarify the role of estrogen receptors
in the endocrine pancreas adaptation to pregnancy and point to ER agonists as
effective insulinotropic agents.
Alonso-Magdalena et al. PloS ONE 2008 3 e2069.
Nadal et al. FASEB J 1998 521 397-407.
Ropero et al. J Physiol 1999 12 1341-1348.
Soriano et al. Mol Endocrinol 2009 23.
$25.3
Protein kinase D as a modulator of aldosterone action in the kidney
Warren Thomas, Ruth Dooley & Brian Harvey
Royal College of Surgeons in Ireland, Dublin, Ireland.
The distal nephron is the principal site for salt conservation in the body. Through its
action on basolateral and apical membrane transporters, aldosterone regulates ion
fuxes across the cells of the distal nephron. Aldosterone elicits physiological
responses by modulating the expression of the transporter subunits; for example in
the case of the epithelial Na
channel (ENaC) and Na
/K
-ATPase, and also

through the expression of the regulatory proteins which affect the activity of these
transporters such as the serum and glucocorticoid regulated kinase-1. The
interaction of aldosterone with its specifc receptor the mineralocorticoid receptor
(MR) also stimulates the rapid activation of protein kinase signal transduction
cascades and the trans-activation of the epidermal growth factor receptor (EGFR).
The Protein kinase D (PKD) family of serine/ threonine kinases are important
regulators of key cellular processes including proliferation and sub-cellular
traffcking. Aldosterone treatment of renal cortical collecting duct (CCD) cells
resulted in the EGFR-dependent activation of PKD1. The activation of this
signalling cascade was coupled to c-Src-dependent phosphorylation of EGFR.
Silencing of PKD1 expression inhibited aldosterone-induced membrane insertion
of ENaC and the stimulation of an amiloride-sensitive trans-epithelial current. We
found that PKD1 also modulated the activation of ERK1/2 in response to
aldosterone in CCD cells and that PKD1 suppression attenuated the growth
response to aldosterone in these cells. Aldosterone promoted the sub-cellular
redistribution of ERK1/2 to the nuclei of M1-CCDcells after 2 min treatment and to
sites, proximal to the nuclei after 30 min. The sub-cellular redistribution of ERK1/2
was inhibited in PKD1 knock-down cells. Stabilization of ERK1/2 activation by
PKD1 and ERK1/2 sub-cellular redistribution are a pre-requisite for aldosterone-
induced CCD cell growth. Since aldosterone stimulates the growth of renal stem
cells in culture, so PKD1 activation by aldosterone may be an important factor in
both renal differentiation and proliferative disease.
$25.4
Extranuclear effects of thyroid hormones
Sandra Incerpi
University Roma Tre, Roma, Italy.
Thyroid hormones T
3
and T
4
have fundamental roles in development,
differentiation and metabolism. Many of these actions can be explained by the
well-known binding of T
3
to specifc nuclear receptors TR and TR, which
regulate the expression of numerous genes. However, more and more examples of
extranuclear or nongenomic effects of thyroid hormones are now appearing, based
on mechanisms that are independent of the nuclear receptors and protein synthesis.
These rapid effects have their origin at the plasma membrane, the cytoskeleton, in
mitochondria or in the cytosol. The V3 integrin of the plasma membrane act as a
thyroid hormone receptor, and the binding of T
4
to the integrin Arg-Gly-Asp
(RGD) recognition site gives rise to stimulation of tumor cell proliferation and
angiogenesis, through activation of the MAPK pathway. Also T
3
is able to bind to
the integrin although with less affnity, but at variance with T
4
, T
3
may bind to more
than one site. The intracellular thyroid hormone receptors TRand TRcan shuttle
between cytosol and nucleus, and mediate different types of extranuclear effects.
This process can be affected by the V3 integrin activity, showing that different
thyroid hormone receptors may interact with each other. In particular thyroid
hormones produce short-term effects on fundamental Na-dependent transport
systems, such as the Na/H exchanger, the amino acid transport System A and the
Na/K-ATPase, through signal transduction mechanisms involving protein kinase
C, protein kinase A and phosphatidyl inositol-3 kinase pathways. A survey of the
present scenario of nongenomic actions of thyroid hormones will be given, and the
possible physiopathological implications of these fndings will be discussed.
Adverse effects of drugs on thyroid
$2.1
Tyrosine kinase inhibitors and thyroid
Patrice Rodien
University of Angers, Angers, France.
The use of targeted therapies such as Tyrosine kinase inhibitors is becoming a
common strategy in several advanced cancers. Several tyrosine kinases are targeted
by the drugs, andthe anti-neoplastic actions involves bothanti-proliferative andanti-
angiogenesis effects. Initial case reports, have been followed by series reporting
treatment induced thyroid dysfunctions. They include thyrotoxicosis and hypothy-
roidismsometimes with a biphasic course, reminiscent of silent subacute thyroiditis,
in previously euthyoid patients. In addition, in treated hypothyroid patients, these
drugs mayjeopardize the maintenance of euthyroidismbythe thyroxine treatment, as
well as the TSH suppression in the case of thyroid differentiated cancer. The
mechanisms of the thyroid dysfunctions are not fully elucidated up to now and they
may be differences in the mechanisms involved between the different drugs. Thyroid
dysfunction should be screened for in patients on tyrosine kinase inhibitors since
well-being and quality of life may be severely affected.
$2.2
Treatment of amiodarone-induced thyrotoxicosis (AIT) type 2: a RCT
Silvia A Eskes & Wilmar M Wiersinga
Department of Endocrinology and Metabolism, Academic Medical Center,
Amsterdam, The Netherlands.
Background
AIT type 2 is self-limiting in nature and therefore discontinuation of amiodarone
may not be necessary; however, the feasibility of continuing amiodarone has
never been tested formally. Potassium perchlorate (KClO
4
) may have advantage
when prednisone is unsuccessful in AIT type 2, possibly due to mixed cases of
types 1 and 2. KClO
4
also mitigates the cytotoxic effect of desethylamiodarone on
thyrocytes in vitro.
Objectives
i) To demonstrate the feasibility of continuation of amiodarone in AIT type 2.
ii) To evaluate if KClO
4
is useful in AIT type 2, given either alone or in
combination with prednisone (to shorten time to euthyroidism).
Patients
We included patients with AIT type 2 (TSH,0.1 mU/lFT
4
25 pmol/l, TPO-
Ab,50 kU/l, TBII,2.0 kU/l, poor or no visualisation of thyroid gland on 99mTc-
pertechnate scintigraphy, no nodular goiter on ultrasound) in whom amiodarone
was continued. Exclusioncriteria: severe co-existent illness, no informed consent.
Research design and methods
Randomised multicenter study, central randomisation in 3 treatment arms: i) 30 mg
prednisone/day30 mg methimazole/day, ii) 500 mg perchlorate 2,/day
30 mg methimazole/day, iii) 30 mg prednisone/day500 mg perchlorate
2,/day30 mg methimazole/day. If thyrotoxicosis persisted after 12 weeks of
treatment, perchlorate was added in group A and prednisone in group B. In all
groups amiodarone was continued. Total follow up time was 24 months.
Results
Fifty-six patients were registered of whom 42 patients randomised. 9 had no
inclusion criterion (5 FT
4
,25 pmol/l, 3 because the cardiologist preferred to stop
amiodarone, 1 AIT type 1). Five were excluded (4 no informed consent, 1 severe
co-existent illness). Six were excluded after randomisation (3 high TBII or TPO-
Ab, 2 because amiodarone was inadvertently withdrawn, 1 emigration). Thirty-six
patients completed the study (12 group A, 14 group B, 10 group C). Euthyroidism
ensued in all patients. Mean time to euthyroidism was shortest in group A
(11 weeks; group B 14.9 and group C 13.2). Secondary therapy was required in
4 patients (group B) and recurrent thyrotoxicosis occurred in 5 (1 group A,
1 group B, 3 group C). There were no severe side effects.
Conclusions
Continuation of amiodarone is feasible in AIT type 2. Continuation of amiodarone
after successful treatment of AIT type 2 is associated with 14% recurrences in
2 years. Treatment with prednisone is preferable to perchlorate and adding
perchlorate to prednisone does not shorten time to euthyroidism in AIT type 2.
$2.3
Interferons and the thyroid
Yaron Tomer
Mount Sinai Medical Center, New York, New York, USA.
Interferon-alpha (IFNa) is used for the treatment of various disorders, including
chronic hepatitis C virus (HCV) infection and certain malignancies. One of the
commonest side effects of IFNa therapy is thyroiditis, with up to 40% of HCV
patients on IFNa developing clinical or subclinical disease. In some cases interferon
induced thyroiditis (IIT) may cause complications such as atrial fbrillation resulting
in discontinuation of therapy. IIT can manifest clinically as thyrotoxicosis or
hypothyroidism. Both thyrotoxicosis and hypothyroidism can present as auto-
immune thyroid disease or non-autoimmune. The commonest etiology of IIT
presenting with hypothyroidismis Hashimoto`s thyroiditis, and less commonly non-
autoimmune hypothyroidism. Thyrotoxic IIT can be caused by destructive
thyroiditis or Graves` disease. While the epidemiology and clinical presentation of
IIT have been well characterized the mechanisms causing IIT are still poorly
understood. Several risk factors for IIT have been identifed including genetic
predisposition and the presence of thyroid antibodies prior to initiation of IFNa
therapy. It is likely that the hepatitis C virus (HCV) itself plays a role in the disease.
Indeed, new data from our lab show that HCV can bind to thyroid cells and induce
cytokine production. Bothimmune andthyroid-toxic effects of IFNa contributetothe
etiology of IIT. Immune effects of IFNa include increased expression of HLAclass I
molecules, inducing Th1 responses, and activation of lymphocytes, macrophages
and NK cells. Thyroid toxic effects of IFNa include induction of thyroid specifc
protein expression, activation of heat shock proteins, and induction of thyroid cell
deathbynecrosis. Earlydetectionand therapy of this conditionare important inorder
to avoid complications of thyroid disease such as cardiac arrhythmias.
Multifaceted aspects of neuroprotection
$2I.1
Relationship between oestrogen and cholesterol in neuroprotection
Alessandro Peri
Endocrine Unit, Department of Clinical Physiopathology, Center for
Research, Transfer and High Education on Chronic, Infammatory,
Degenerative and Neoplastic Disorders for the Development of Novel
Therapies, Florence, Italy.
Alzheimer`s disease (AD), the most common neurodegenerative disease
associated with ageing, is still an incurable condition. Although in vitro evidence
strongly indicates that oestrogen exerts neurotrophic and neuroprotective effects,
the role of this class of hormones in the treatment of AD is still a debated issue. In
2000 a newgene, named seladin-1 (for Selective Alzheimer`s Disease indicator-1),
was identifed and found to be down regulated in vulnerable brain regions in AD.
Seladin-1 was considered a novel neuroprotective factor, because of its anti-
apoptotic activity. Subsequently, it was demonstrated that seladin-1 has also
enzymatic activity (3-hydroxysterol delta-24-reductase, (DHCR24)), which
catalyzes the synthesis of cholesterol from desmosterol. There is evidence that
an appropriate amount of membrane cholesterol is important in order to generate a
barrier against toxic insults and also to prevent the production of -amyloid. We
demonstrated that seladin-1 overexpression increases the amount of membrane
cholesterol and determines resistance against -amyloid aggregates in neuroblas-
troma cells, whereas a specifc inhibitor of DHCR24 increased cell vulnerability.
We also hypothesized that seladin-1 might be a mediator of the neuroprotective
effects of oestrogen. We frst demonstrated that, in human fetal neuroepithelial
cells (FNC), 17-oestradiol, raloxifene and tamoxifen exert protective effects
against -amyloid toxicity and oxidative stress. In addition, these molecules
signifcantly increased the expression of seladin-1 and the amount of cell
cholesterol. Then, we showed that, upon seladin-1 silencing, the protective effects
of oestrogen were abolished, thus indicating that this factor is a fundamental
mediator of oestrogen-mediated neuroprotection, at least in FNC cells.
Furthermore, we detected the presence of functionally active half-palindromic
oestrogen responsive elements upstream the coding region of the seladin-1 gene.
Overall, our results indicate that seladin-1 may be viewed as a multi-faceted
protein, which conjugates both the neuroprotective properties of oestrogen and the
important functions of cholesterol in maintaining brain homeostasis.
$2I.2
Relationship between oestrogen and cholesterol in neuroprotection
L M Garcia-Segura
Spain.
$2I.3
Progesterone and the nervous system
Michael Schumacher & Rachida Guennoun
UMR 788 Inserm and University Paris-Sud 11, Kremlin-Bice`tre, France.
The neuroprotective and promyelinating actions of progesterone, now well
documented by experimental studies, make it a particularly promising therapeutic
agent for neuroinjury. This concept has recently been translated into clinical
practice. Progesterone can also be locally produced in the nervous system by
neurons and glial cells. Importantly, increased progesterone synthesis after brain
injury may be part of endogenous neuroprotective responses. However, the
mechanisms by which progesterone exerts its actions in the nervous system are
still not well understood, and its multiple signaling mechanisms present not only a
challenge, but also opportunities for new therapeutic targeting. Mapping of the
recently discovered membrane progesterone receptors in the central nervous
system has revealed the wide distribution of their alpha isoform (mPRalpha),
which is expressed in most populations of neurons, as well as in astrocytes,
oligodendrocytes and neural progenitor cells. Interestingly, although mPRalpha
binds natural progesterone with high affnity, it does not bind many of the
synthetic progestins, which have been designed to target the classical intracellular
progesterone receptors (PR). This is only one of the differences between the
modes of action of natural progesterone and synthetic progestins, currently used
in contraception or hormone replacement therapy. Thus, in contrast to progestins,
progesterone is converted to its GABAA receptor-active metabolite allopregna-
nolone. While the membrane actions of progesterone need to be further explored,
it should be emphasized that even PR-mediated non-reproductive functions of
progesterone in the nervous system are still not well defned. Indeed, with the
exception of their roles in reproduction, the signifcance of the widely distributed
brain PR remains to be elucidated. Our recent experimental studies demonstrate a
key role for PR in neuronal survival after cerebral ischemia. These fndings
suggest new therapeutic benefts for progestin ligands in the treatment of lesions
and diseases of the nervous system.
$2I.4
Oestrogen and corticotrophin releasing hormone: two hormones with
different targets in neuroprotection
C Behl
Sweden.
Hypothalamic networks and energy homeostasis
$28.1
PYY and the regulation of appetite control
R Batterham
UK.
$28.2
Brain lipogenesis and the control of food intake: the lipostatic
hypothesis revisited
Miguel Lopez
Department of Physiology, University of Santiago de Compostela, and
'CIBER Fisiopatologi a de la Obesidad y Nutricion (CIBERobn) ISCIII`,
Santiago de Compostela, Spain.
The 'classical` hypothalamic neuropeptide view of feeding regulation has been
extensively reviewed and revised during the last few years. Accumulating
evidence indicate that pharmacological and genetic modulation of lipogenesis
de novo in the hypothalamus, through selective pharmacologic and genetic
manipulation of acetyl-CoA carboxylase (ACC), AMP-activated protein kinase
(AMPK), carnitine palmitoyltransferase-1 (CPT1), fatty acid synthase (FAS) and
malonyl-CoA decarboxylase (MCD) enzymes, has a severe impact on food intake
and body weight homeostasis. Furthermore, since these manipulations alter the
hypothalamic pool of lipids, such as malonyl-CoA and/or long chain fatty acids-
CoA (LCFAs-CoA), the concept of lipids as signals of nutrient abundance able to
modulate feeding in the hypothalamus has recently re-emerged.
Despite these pharmacological and genetic data, confrmation that it is a
physiologically relevant regulatory system of feeding is still incomplete. Our
current investigations have revealed that hypothalamic FAS, AMPK and CPT-1
expression and activities are modulated by peripheral signals regulating feeding,
specifcally in the ventromedial nucleus of the hypothalamus (VMH). Our data
also identify the fatty acid biosynthetic pathway in the VMH as a potentially
important physiological mediator of feeding behaviour of relevance for the
understanding and treatment of obesity.
$28.3
Hypothalamic plasticity and the central control of energy balance
T Horvath
USA.
Highlights
Oral Communications Highlights 1
h1.1
PEX11 dehciency impaired ossihcation by indirectly activating
PPAR expression and diminishing Runx2 activity
Guofeng Qian, Barbara Ahlemeyer, Martin Obert, Horst Traupe &
Eveline Baumgart-Vogt
Justus Liebig University, Giessen, Germany.
Ossifcation defects have been described in patients with peroxisomal disorders,
autosomal-recessivediseases duetotheimpairment of peroxisomebiogenesis. However,
the functions of peroxisomes in skeletal tissues are unknown. In the present study, we
used a knockout (KO) mouse model, defective in the PEX11 gene, to investigate the
molecular pathogenesis of the ossifcation defect. Alizarin Red/Alzian Blue stainings,
fat-panel volume-CT (fpvCT), and immunofuorescence (IF) preparations of paraffn
sections were performed to showdifferences in ossifcation. Primary cultures of calvaria
osteoblasts with subsequent subcellular fractionation and western blot analyses were
used to study the molecular pathogenesis of the ossifcation defect. Skeleton stainings
showed impairment in ossifcation of distal bone elements of the limbs, sacral and
coccygeal vertebrae as well as parts of the skull and the sternum in KO mice. FpvCT
analyses revealed a substantially lower total bone volume and a decreased whole-body
bone mineral density in PEX11 KOanimals. The ossifcation impairment in KOmice
was corroborated by analyses of Alizarin red S preparations and IF stainings for
osteopontin on paraffn sections. Subcellular fractionation and western blot analyses
revealed a signifcant increase of peroxisomal catalase in KO osteoblasts. Additionally,
the levels of other antioxidant enzymes (SOD1, SOD2 and hemoxygenase-1) were
upregulated as well. Most interestingly, a higher level of p-GSK-3was present and less
-catenin was shifted into the nucleus in KO osteoblasts. Furthermore, these changes
were accompanied with the increasing PPAR expression and the alteration of Runx2
localization in KO osteoblasts, showing a more prominent abundance in the cytoplasm
and a reduction in the nuclear area. Taken together, our data suggest that peroxisomes
might playa vital role in osteoblast ROSmetabolismandossifcation. PPARactivation
and Runx2 inactivation through less active Wnt signaling could contribute to impaired
ossifcation due to peroxisomal defciency.
h1.2
Novel pathogenetic pathways of adrenocortical tumors revealed by
meta-analysis of genomics data
Peter Szabo
1
, Viola Tamasi
1
, Marton Andrasfalvy
2
, Attila Patocs
3
,
Miklos Toth
1
, Andras Falus
1,3
, Karoly Racz
1
& Peter Igaz
1
1
Semmelweis University, Budapest, Hungary;
2
Kromat Ltd, Budapest,
Hungary;
3
Hungarian Academy of Sciences and Semmelweis University,
Budapest, Hungary.
Objective
Sporadic adrenocortical tumors are common, but their pathogenesis is poorly
elucidated. Several mRNA profling and comparative genome hybridization
(CGH) studies have been performed on adrenocortical tumors to date. Meta-
analysis of these results may be warranted due to the low number of tumor
samples examined in several individual studies. Here, we present an integrative
meta-analysis of gene expression microarray and CGH studies performed to date
on sporadic adrenocortical tumors, including our own data.
Methods
Rawdata of whole genome microarray studies fromaltogether 164 tumors (97 benign,
67 malignant) and 18 normal tissues were regrouped and reanalyzed. Signifcant gene
sets and cytogenetic changes from publications without available genomic data were
also examined including 269 benign, 215 malignant tumor and 30 normal tissues. In
our experimental study (approved by the Ethical Committee of the HealthCouncil), 11
tumor and 4 normal samples were analyzed by parallel mRNA and CGH profling.
Data were examined byan integrative bioinformatics approach (GeneSpring, Gene Set
Enrichment Analysis and Ingenuity Pathway Analysis softwares) searching for
common gene expression changes and paralleling chromosome aberrations.
Results
A two-gene signature (overexpression of anillin and underexpression of
5-hydroxytryptamine receptor 2B) was identifed as a predictor of malignancy. Both
meta-analysis of available mRNAand CGHprofling data and our experimental study
revealed the involvement of three major pathogenetic pathways that could be relevant
in adrenocortical tumorigenesis: i) cell cycle, ii) retinoic acid signaling (including
lipopolysaccharide/Toll like receptor 4 pathway), iii) complement and antigen
presentation. The observation that the same pathways were found by both approaches
supports the feasibility of in silico meta-analysis.
Conclusions
These pathways include novel, previously undescribed pathomechanisms of
adrenocortical tumors, and associated gene products may serve as diagnostic
markers of malignancy and potential therapeutic targets.
h1.3 - E$E Young |nvest|gator AWard
Frequent phosphodiesterase 11a (pde11a4) gene mutations in patients
with carney complex (cnc) due to prkar1a mutations and adrenal
(ppnad) and Sertoli cell tumors (lccsct): a digenic disorder?
Rossella Libe
1,3
, Anelia Horvath
2
, Amato Fratticci
3
, Delphine Vezzosi
3
,
Joel Coste
1
, Marine Guillaud-Bataille
1
, Lionel Groussin
1,3
, Eric Clauser
1
,
Marie Laure Raffn Sanson
1,3
, Xavier Bertagna
1,3
, Constantine Stratakis
2
& Jero`me Bertherat
1,3
1
Hopital Cochin, Paris, France;
2
National Institute of Child Health and
Human Development, National Institutes of Health, Bethesda, Maryland,
USA;
3
Inserm U567, Paris, France.
Background
Cushing syndrome due to PPNAD is the main endocrine disorder of CNC, an
autosomal dominant multiple neoplasia caused by germline inactivating
mutations of the subunit type 1A (PRKAR1A) of the protein kinase A (PKA).
In addition, germline inactivating mutations in the gene encoding phosphodi-
esterase 11A (PDE11A) have been identifed in patients with PPNAD.
Aim of the study
To investigate the role of PDE11A genetic alterations in patients with CNC and
PRKAR1A mutations.
Materials and methods
One hundred and ffty patients with CNC and PRKAR1A mutation (74 index cases)
were investigated. PPNADwas the main endocrine manifestation: 104/150 (69.3%).
DNA from 279 healthy volunteers examined to rule out endocrine tumors was also
studied. Sequencing of the PDE11A4 20 coding-exons (3-23) was performed.
Results
In the CNCpatients 38/150 (25.3%) PDE11Amutations were found: 31/38 missense
and 7/38 nonsense mutations. In the controls 19/279 PDE11A4 missense mutations
(6.8%) were observed but no nonsense mutations. The frequency of PDE11A4
mutations was signifcantly higher in CNC patients than in controls (
2
29,
P,0.00001). The frequency of PDE11A4 mutations was signifcantly higher in
patients with PPNAD than in patients without PPNAD (30 vs 13%,
2
5.3,
P0.025). There was a tendency for a younger age at diagnosis of Cushing
syndrome in patients with PDE11A4 mutation. The frequency of PDE11A4
mutations was signifcantly higher in the male patients with testicular tumors
(LCCSCT) than in patients without (47 vs 22%,
2
5.5, P0.025). No association
was observed with cardiac myxoma, thyroid tumors, lentiginosis nor acromegaly.
Conclusions
The higher frequency of PDE11A mutations in CNC patients with PRKAR1A
mutations and PPNAD or LCCSCT (compared to controls and CNC patients
without these tumors) suggests a role of PDE11A in the genetic predisposition to
adrenal Cushing syndrome and testicular tumors, as previously proposed. This
suggests the possibility that PRKAR1A and PDE11A4 mutations act additively or
even in synergy in CNC.
h1.4
Physiological rescue by functional complementation of mutated LH
receptors in transgenic mice
Adolfo Rivero-Muller
1
, Yen-Yin Chou
1,3
, Svetlana Lajic
2
,
Aylin Hanyaloglu
2
, Kim Jonas
2
, Nafs Rahman
1
, Tae Ji
4
& Ilpo Huhtaniemi
2
1
Department of Physiology, University of Turku, Turku, Finland;
2
Department of Reproductive Biology, Imperial College London,
Hammersmith Campus, London, UK;
3
Institute of Clinical Medicine,
National Cheng Kung University Medical College and Hospital, Tainan,
Taiwan, ROC;
4
Department of Chemistry, University of Kentucky,
Lexington, Kentucky, USA.
The LH receptor (LHR) is a 7-transmembrane domain G-protein coupled receptor
(GPCR) mainly expressed in the gonads with a major role in the development and
maintenance of gonadal steroidogenesis and gametogenesis. Its ligand LH,
secreted by the pituitary gland, binds to the extracellular domain of LHR
triggering a conformational change in the transmembrane domain and leading to
activation of intracellular signalling cascades.
As a member of the GPCR family, LHR activates G-proteins as the principal
means of signalling. How GPCRs generate the specifc cascades of intracellular
responses and gene-specifc transcription is not yet fully understood. One
important aspect of GPCR function is that they form dimeric and oligomeric
complexes during their biosynthesis, activation, inactivation and internalisation.
However, evidence for the functional importance of these receptor complexes has
so far been obtained exclusively from functional in vitro and crystallography data.
The proof for functional signifcance of GPCR interactions and cooperation in the
physiological context in vivo is still missing.
Using the LHR as a model GPCR, we studied whether receptor-receptor
interaction can result in full physiological response. The LHR null (LuRKO)
phenotype of male mice with low testosterone production, infertility and
underdeveloped gonads and genitals was completely rescued in double-transgenic
(BAC) mice expressing both a binding- and a signalling-defcient mutants of LHR
in the LuRKO background. The rescue normalised LH-dependent gene
expression, sex steroid production, full testicular and gonadal development, as
well as fertility. These results provide compelling in vivo evidence for the
physiological relevance of di/oligomeric functional complementation in GPCR
activation.
Different genes are involved in Pendred`s syndrome and in enlarged
vestibular aqueduct syndrome
Valentina Cirello
1,2
, Marina Muzza
1,2
, Pierangela Castorina
3
,
Paolo Beck-Peccoz
1,2
& Laura Fugazzola
2
1
Department of Medical Sciences, University of Milan, Milan, Italy;
2
Endocrine Unit-Fondazione IRCCS Ca` Granda-Ospedale Maggiore
Policlinico, Milan, Italy;
3
Medical Genetics Fondazione IRCCS Ca`
Granda-Ospedale Maggiore Policlinico, Milan, Italy.
Mutations in SLC26A4 cause Pendred syndrome (PS) and a non syndromic
deafness associated with the enlargement of the vestibular aqueduct (LVAS). In
many patients with a PS/LVAS phenotype, mutation screening of SLC26A4 fails
to identify two disease-causing allele variants, suggesting that other genetic
factors could be involved. Indeed, mutations in the SLC26A4 promoter (FBS1), in
FOXI1, a transcriptional activator of SLC26A4, and in a K channel gene
(KCNJ10) have been very recently found in few patients with a PS/LVAS
phenotype, some of whom carriers of a single SLC26A4 mutation. In the present
study, 12 patients (6F and 6M, age range 6 months-55 years) with PS or LVAS
have been submitted to the genetic analysis of SLC26A4, FBS1, FOXI1, and
KCNJ10. All patients had a severe to profound sensorineural hearing loss (SNHL)
associated with inner ear malformations. In three patients, a multinodular goiter
with subclinical hypothyroidism were documented, whereas the remaining
patients were euthyroid with normal thyroid volume. All patients were connexins
26 and 30 negative. In three patients, homozygous or double heterozygous
SLC26A4 mutations, one of which novel and lying in exon 2, were found. In one
patient a single SLC26A4 mutation was documented, while in another case a
novel FOXI1 mutation was identifed. Finally, a variant in the KCNJ10 gene has
been found in 3 patients. As far as genotype-phenotype correlation concerns, it is
interesting to note that the only 3 patients with two SLC26A4 mutations had a
classic PS with SNHL and goiter, whereas in all the other cases no thyroid
alterations were observed.
In conclusion, SLC26A4 is the gene more frequently mutated in patients with
PS/LVAS, and seems to be specifcally linked with the typical Pendred`s
phenotype. Nevertheless, mutations in FOXI1 and KCNJ10 have been also found,
further suggesting that PS/LVAS is a multigenic complex disease.
Oral Communications Highlights 2
The endocannabinoid action in the regulation of energy balance is
mainly due to the CB
1
receptor in the forebrain neurons
Carmelo Quarta
1
, Luigi Bellocchio
2
, Giacomo Mancini
3
, Roberta Mazza
1
,
Daniela Cota
2
, Lutzie J Braulke
4
, Csaba Fekete
5,6
, Enzo Nisoli
7,8
,
Renato Pasquali
1
, Beat Lutz
3
, Giovanni Marsicano
2
& Uberto Pagotto
1
1
Endocrinology Unit and Centro Unifcato di Ricerca BioMedica Applicata,
Department of Clinical Medicine, University of Bologna, Bologna, Italy;
2
NeuroCentre Magendie U862 INSERM Universite Bordeaux 2, Bordeaux,
France;
3
Department of Physiological Chemistry, University Medical
Center of the Johannes Gutenberg University, Mainz, Germany;
4
Depart-
ment of Biology Animal Physiology, Philipps University Marburg,
Marburg, Germany;
5
Department of Endocrine Neurobiology, Institute of
Experimental Medicine, Hungarian Academy of Sciences, Budapest,
Hungary;
6
Division of Endocrinology, Tupper Research Institute and
Department of Medicine, Diabetes, and Metabolism, Tufts Medical Center,
Boston, Massachusetts, USA;
7
Integrated Laboratories Network,
Department of Pharmacology, Chemotherapy and Medical Toxicology,
Center for Study and Research on Obesity, Universita` degli Studi di Milano,
Milano, Italy;
8
Istituto Auxologico Italiano, Milano, Italy.
The pharmacological blockade of cannabinoid receptor type 1 (CB
1
) has been
shown to counteract diet induced obesity (DIO). An unsolved question is whether
the effects of CB
1
blockade on energy balance are due to peripheral or central
mechanisms. This is an important clinical issue since the CB
1
antagonist drugs
have recently been withdrawn from the market due to their psychiatric side
effects, and novel drugs selectively acting at peripheral level are now under
investigation. To unveil the differential role of brain versus peripheral CB
1
in the
control of DIO, we characterized conditional mutant mice lacking the expression
of CB
1
only in forebrain neurons (CaMK-CB
1
-KO mice), comparing their
phenotype to those of complete CB
1
-KO and wild-type mice. The systemic
administration of rimonabant (a drug antagonizing both central and peripheral
CB
1
) did not affect metabolic functions in CaMK-CB
1
-KO mice, whether on
standard (SD) or high fat diet (HFD). CB
1
expression demonstrated to be
knocked-out at central level (hypothalamus, nucleus of solitary tract) and
preserved in peripheral organs of CaMK-CB
1
-KO mice. The analysis of the
phenotype revealed that CaMK-CB
1
-KO mice were leaner than WT whether on
SD or HFD; interestingly CaMK-CB
1
-KO mice on HFD displayed a metabolic
profle (plasma levels of leptin, insulin, glucose, free fatty acids, circulating and
intrahepatic triglycerides) and fat content (measured by CT-scan) undistinguish-
able from CB
1
-KO mice. By measuring energy expenditure we found that CB
1
deletion in forebrain neurons infuences metabolized energy and lipid utilization
under HFD. These effects occurred by an increased brown adipose tissue function
activated by the sympathetic nervous system (SNS), as demonstrated by in vivo
PET analysis of BAT activity of CaMK-CB
1
-KO mice before and after
sympathectomy. These data indicate that the forebrain CB
1
receptor plays a
key regulatory role in SNS activity and thus regulates energy balance in the body.
h2.2
Human recombinant GH replacement therapy in children with
pseudohypoparathyroidism type Ia and GH dehciency: hrst study on
the effect on growth
Giovanna Mantovani
1
, Emanuele Ferrante
1
, Agnes Linglart
5
,
Marco Cappa
2
, Mariangela Cisternino
3
, Mohamad Maghnie
4
,
Paolo Beck-Peccoz
1
& Anna Spada
1
1
Endocrinology Unit, Department of Medical Sciences, University of Milan,
Fondazione Ospedale Maggiore Policlinico IRCCS, Milan, Italy;
2
Bambino
Gesu`, Children`s Hospital, Rome, Italy;
3
Department of Pediatrics,
Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy;
4
Department of Pediatrics, Istituto Giannina Gaslini IRCCS, University of
Genova, Genova, Italy;
5
Pediatric Endocrinology and INSERM U561,
St Vincent de Paul Hospital, Paris, France.
Pseudohypoparathyroidism (PHP) refers to a heterogeneous group of rare
metabolic disorders characterized by hypocalcemia and hyperphosphatemia due
to PTH resistance. Heterozygous loss of function mutations in the gene encoding
the alpha-subunit of Gs (GNAS) inherited from the mother lead to PHP type Ia.
PHP type Ia (PHP-Ia) is a disease in which the physical features (short stature,
obesity, round face, brachydactyly and subcutaneous ossifcations) that constitute
Albright hereditary osteodystrophy (AHO) are classically associated to resistance
to the action of different hormones that activate Gs-coupled receptors, the
hallmarks being PTH, TSH and gonadotropins. Since the identifcation in 2003 by
us and others of GH defciency due to resistance to GHRH in PHP-Ia patients, no
study investigated the effects of recombinant human GH (rhGH) therapy on
height velocity in these subjects. To address this question, 7 pre-pubertal PHP-Ia
children with GH defciency (6 girls and 1 boy, mean age 8.01.1 years)
underwent a 3 to 7 years-treatment with standard doses of rhGH. Height and
height velocity were measured before and at 6-month intervals during therapy.
Nine sex and age matched children with isolated, idiopathic GH defciency were
monitored over the same period of rhGH therapy for comparison. In PHP-Ia
children height SDS increased from 2.750.6 to 2.210.5 (P,0.05),
height velocity (HV) from 3.20.9 cm/year to 8.1 0.6 cm/y (P,0.001) and
HV S.D. from 2.870.89 to 3.30.7 (P,0.001) after 12 months. Despite a
non-signifcant reduction, the HV increase was maintained after the second and
third years of therapy and started to signifcantly decrease at puberty when
pubertal growth spurt was not observed. The response to GH treatment in terms of
height S.D. and HV during the frst 3 years therapy was comparable to that
recorded in children with idiopathic GH defciency Data on fnal height will be
soon available for the majority of patients.
In conclusion, we report the frst study on the effcacy of rhGH replacement
therapy on height velocity in children with PHP-Ia, and provide indication that
replacement treatment of GH defciency should be started soon, due to the rather
limited time window for a potentially effective therapy.
Subtle cognitive impairments in patients with long-term cure of
Cushing`s disease
Jitske Tiemensma, Nieke Kokshoorn, Nienke Biermasz, Bart-Jan Keijser,
Moniek Wassenaar, Huub Middelkoop, Alberto Pereira & Johannes Romijn
LUMC, Leiden, The Netherlands.
Context and objective
Active Cushing`s disease is associated with cognitive impairments. We
hypothesized that previous hypercortisolism in patients with Cushing`s disease
results in irreversible impairments in cognitive functioning. Therefore, our aim
was to assess cognitive functioning after long-term cure of Cushing`s disease.
Design
Cognitive assessment consisted of 11 tests, which evaluated global cognitive
functioning, memory, and executive functioning.
Patients and control subjects
We included 74 patients cured of Cushing`s disease and 74 matched controls
(18% male, mean age 52 years). Furthermore, we included 54 patients previously
treated for non-functioning pituitary macroadenomas (NFMA), and 54 matched
controls (56% male, mean age 61 years). The protocol was approved by the
Medical Ethics Committee.
Results
Compared to NFMA patients, patients cured from Cushing`s disease had lower
scores on the Mini Mental State Examination (P0.001), and on the memory
quotient of the Wechsler Memory Scale (P0.050). Furthermore, patients cured
from Cushing`s disease tended to recall less words on the imprinting trial
(P0.013), immediate recall trial (P0.012), and delayed recall trial (P0.003)
of the Verbal Learning Test of Rey and also recalled more intrusions on all trials
of this test (P0.002, P0.003, and P0.003 respectively). On the Rey
Complex Figure Test, patients cured form Cushing`s disease had lower scores on
both trials (P0.002 and P0.007) compared to NFMA patients. Patients cured
from Cushing`s disease also made less correct substitutions on the Letter-digit
substitution test (P0.039), and came up with less correct patterns on the Figure
Fluency Test (P0.003) compared to treated NFMA patients.
Conclusions
Cognitive function, refecting memory and executive functions, is impaired in
patients despite long-term cure of Cushing`s disease. These observations indicate
irreversible effects of previous hypercortisolism on cognitive function, and, thus,
on the central nervous system. These observations may also be of relevance for
patients treated with high dose exogenous glucocorticoids.
h2.4
TAC3 and TACR3 'Knockouts` cause hypothalamic congenital
hypogonadotropic hypogonadism in humans
Jacques Young
1,2
, Jero`me Bouligand
1,2
, Bruno Francou
1,2
,
Marie-Laure Raffn-Sanson
3
, Stephanie Gaillez
4
, Marc Jeanpierre
5
,
Sylvie Brailly-Tabard
1,2
& Anne Guiochon-Mantel
1,2
1
INSERM U693, Le Kremlin-Bice`tre, France;
2
Ho`pital Bice`tre, Le
Kremlin-Bice`tre, France;
3
Ho`pital Ambroise Pare,
Boulogne-Billancourt, France;
4
Centre de Genetique Humaine, Lie`ge,
Belgium;
5
INSERM U567, Paris, France.
Missense loss-of-function mutations in TAC3 and TACR3, the genes encoding
neurokinin B (NKB) and its receptor NK3R, respectively, were recently
discovered in kindreds with non syndromic normosmic congenital hypogonado-
tropic hypogonadism (nCHH), thus identifying a fundamental role of this
pathway in the human gonadotrope axis.
We investigated the consequences on gonadotrope axis of TAC3 and TACR3
invalidations in adult patients with complete nCHH.
We identifed 3 unrelated patients with the same homozygous substitution
in the TAC3 intron 3 acceptor splicing site (c.209-1GC) and 3 siblings who
bore a homozygous mutation in the TACR3 intron 2 acceptor splicing site
(c.738-1GA). We demonstrated that these 2 mutations invalidate respectively
neurokinin B and its receptor NK3R. We found in three patients with TAC3
mutation originating from Congo and Haiti, a founding event in a more distant
ancestor by means of haplotype analysis. We calculated that time to this common
ancestor was ^600 years.
In several patients, we observed a dissociation between the very low LH and
normal or nearly normal FSH levels, this gonadotropin responding excessively to
the GnRH challenge test. This particular hormonal profle, suggest the possibility
of a specifc neuroendocrine impairement in patients with alteration of neurokinin
B signaling.
Finally, in these patients, pulsatile GnRH administration normalized circulating
sex steroids, LH release and restored fertility.
In conclusion, our data demonstrate the hypothalamic origin of the gonadotropin
defciency in these genetic forms of nCHH. Neurokinin B and NK3R therefore
both play a crucial role in hypothalamic GnRH release in humans.
h2.5
Effects of leptin administration on starvation-induced alterations in
hepatic thyroid hormone metabolism in mice
Anita Boelen, Mieke Van Beeren, Xander Vos, Olga Surovtseva,
Joan Kwakkel & Eric Fliers
Department of Endocrinology and Metabolism, Academic Medical Center,
Amsterdam, The Netherlands.
Fasting induces profound metabolic changes in order to decrease energy
expenditure and to conserve energy. One of the major adaptations is down-
regulation of the hypothalamus-pituitary-thyroid (HPT) axis, characterized by
decreased serum thyroid hormone levels without an increase in serum TSH or in
TRH expression in the hypothalamic paraventricular nucleus (PVN). Leptin has
been proposed as a critical signal initiating the neuroendocrine response to fasting
as it decreases dramatically during fasting, while the fasting-induced suppression
of the HPT axis at the central level can be restored by leptin administration. It is,
however, unknown to what extent leptin affects peripheral thyroid hormone
metabolism in this setting.
The aim of this study was to evaluate the effect of leptin on starvation-induced
alterations of peripheral thyroid hormone metabolism in mice. We therefore
performed two experiments: 1) mice were fasted for 24 h while leptin was
administered twice (at 0 and 8 h, 1 g/g BW i.p.), 2) mice were fasted for 24 h and
subsequently, leptin was given once (i.p.) at 24 h (f at 28 and 32 h). All groups
had appropriate controls. Liver thyroid hormone receptor (TR)1, TR1, TR2,
type 1deiodinase (D1) and type 3 deiodinase (D3) mRNA expression was
measured by qPCR. Liver D3 activity was measured using HPLC and serum T
3
and T
4
levels were measured by RIA.
Starvation for 24 h decreased serum T
3
and T
4
levels and liver TR1 mRNA
expression while liver TR1 and TR2 mRNA expression did not change. Liver
D1 mRNA decreased only after 28 and 32 h starvation while liver D3 mRNA and
activity increased upon 24 h starvation, indicating increased inactivation of
thyroid hormone. The observed changes are in keeping with decreased thyroid
hormone action in the liver during fasting. Leptin administration after 24 h fasting
restored liver D3 expression at 28 and 32 h (mice continued fasting) while serum
thyroid hormone levels and liver TR1 expression remained low. Liver D1
expression was not affected by leptin administration at any time point.
In conclusion, leptin plays a role in fasting-induced alterations in peripheral
thyroid hormone metabolism by selectively affecting liver D3 mRNA expression
and activity. The fasting-induced decrease in liver D1 expression, however, is not
modulated by leptin.
Oral Communications
Diabetes and obesity
001.1
Role of newly identihed immunosuppressive NK cells
in autoimmunity
Margret Ehlers, Claudia Papewalis, Benedikt Jacobs, Annette Thiel,
Sven Schinner, Holger S Willenberg, Werner A Scherbaum &
Matthias Schott
Department of Endocrinology, Diabetes, and Rheumatology, University
Hospital Duesseldorf, Duesseldorf, Germany.
Most recently, a completely new subset of NK cells with immunosuppressive
functions has been identifed. These cells are able to downregulate conventional
NK cells in a PD1-ligand dependent manner and are, therefore, responsible for
tumor outgrowth.
The aim of our present study was to investigate the role of this new NK subset in
autoimmunity. For this purpose, we used two independent mouse models. In the
NOD mice, we found a large increase of suppressive NK cells at 8 weeks of age, a
time point when strong T cell infltrations are detected in pancreatic islets.
Besides, we used an alternative T1DM mouse model for detailed analyses by the
multiple administration of low-dose streptozotozin (STZ). We detected an
increase of suppressive NK cells in the pancreas of STZ-mice within the days
after application of the antibiotic. At that time mice have still relatively low levels
of blood glucose in contrast to those, who developed diabetes within day 10 to 21
after frst STZ administration. In vitro, we showed that these cells haven`t only a
direct lysis activity towards conventional NK cells but also towards activated
CD8T cells and primed insulin beta-chain specifc CD8T cells for more than
40%. While the immunosuppressive NK cells can be generated by IL-18 over
night we performed an adoptive cell transfer by systemic repetitive injections.
In vivo, we were able to delay the normal increase of blood glucose after STZ in
40% of mice treated with immunosuppressive NK cells. These animals were still
alive at week 20 with only a mild form of T1DM. In contrast, all mice which
received conventional NK cells did not survive week 14.
This is the frst report describing the role of immunosuppressive NK cells in
autoimmunity proving a direct link between innate immunity and adapted
immunity in T1DM.
001.2
Glucose insulinotropic peptide (GIP) secretion in type 2 diabetic and
obese non-diabetic persons examined by meal test
Jan S
`
krha
1
, Jirina Hilgertova
1
, Marcela Jaroli mkova
1
, Marie Kunesòva
2
& Martin Hill
2
1
Third Department of Internal Medicine, First Faculty of Medicine, Charles
University, Prague, Czech Republic;
2
Department of Endocrinology,
Prague, Czech Republic.
Glucose-dependent insulinotropic peptide (GIP) contributes to incretin effect of
insulin secretion which is impaired in type 2 diabetes mellitus. The aim of this
study was to develop a simple meal test for evaluation of GIP secretion and
action and to examine GIP changes in type 2 diabetic patients. Seventeen type 2
diabetic patients, 10 obese non-diabetic and 17 non-obese control persons have
been examined before and after 30, 60 and 90 min stimulation by meal test. In a
mixed meal challenge, breakfast composed from 200 ml Resource drink
containing 28 g saccharides, 7 g fats and 18.8 g protein with one roll (50 g)
and 10 g butter. The total caloric content of this standard testing breakfast was
445 kcal (1850 kJ). Serum concentrations of insulin, C-peptide and GIP were
estimated during the test. Impaired GIP secretion was found in type 2 diabetic
patients as compared with obese non-diabetic and non-obese control persons.
The AUC
GIP
during 90 min of the meal stimulation was signifcantly lower in
diabetic patients than in other two groups (13.63.8 vs 17.56.5 and 18.8
3.8, P,0.03). Insulin concentration in 30 min was lower in diabetic than in
non-diabetic persons (P,0.05) and the GIP action was delayed. The IRI/GIP
ratio increased during the test in diabetic patients whereas it progressively
decreased in obese and non-obese control persons. Simple meal test could
demonstrate impaired GIP secretion and delayed insulin secretion in type 2
diabetic patients as compared to obese non-diabetic and non-obese healthy
control individuals. No signifcant difference was found in GIP secretion
between obese and non-obese non-diabetic persons.
001.3
NME7: a new candidate gene for T2DM
Josef Vcelak
1
, Ondrej Seda
2
, Marketa Vankova
1
, Petra Lukasova
1
,
Jana Vrbikova
1
, Johanne Tremblay
2
, Bela Bendlova
1
& Pavel Hamet
2
1
Institute of Endocrinology, Prague, Czech Republic;
1
Research Centre,
CHUM, Montreal, Quebec, Canada.
The identifcation of genomic determinants responsible for common multi-
factorial diseases like type 2 diabetes mellitus (T2DM) is facilitated in large
families from relatively genetically-isolated populations and can extend results
from GWS based on a case-control cohort to detect rare alleles with strong
effects. In order to search for sequence variants conferring risk of T2DM we
previously conducted a genome-wide linkage study in 108 French-Canadian
families from the Saguenay-Lac-St-Jean region of Quebec (Canada). One of the
most signifcant statistical results was a linkage of insulin resistance index
HOMA-IR with locus on chr. 1 (NME7 rs4656671), LOD2.97 conjoined with
association for LDL-cholesterol levels. These results were validated by
replication in the case/control association study in Czech population.
The replication study (approved by Ethical Committee) involved 1465 Czech
Caucasian subjects: 347 patients with T2DM; 327 women with PCOS defned
according to ESHRE consensus; 263 gestational diabetics; 149 offspring of
T2DM and 379 controls. For better assessment of insulin secretion and sensitivity,
the oral glucose tolerance test (oGTT) and insulin tolerance test were performed
(except of T2DM patients). Moreover, 16 anthropometric parameters, 29
biochemical parameters and hormones, 32 oGTT-derived indices were evaluated.
The rs4656671 (GA) was assessed by TaqMan SNP Genotyping Assay.
Statistics was done using nonparametric Mann-Whitney test and
4
-test.
Results
In spite of the similar oGTT stimulated glucose levels, the carriers of the A allele
had signifcantly lower insulin and C-peptide secretion (areas under curves
0-180 min. (AUCs) are presented), levels of total- and LDL-cholesterol and
higher some steroids in comparison with non-carriers.
AUCoGTT IRI, P0.025; AUCoGTT C-peptide, P0.024; total Cholesterol,
P0.0006; LDL-Cholesterol, P0.001; DHEA-S, P0.0051; DHEA,
P0.042; testosterone, P0.031.
Conclusion
We show that SNP rs4656671 is associated with lower insulin secretion and is
accompanied with change in lipid and steroid spectrum.
Supported by IGA MH CR NS/10209-3/2009 and NS/9839-4.
001.4
The effect of statin therapy on testosterone levels in subjects consulting
for erectile dysfunction
Giovanni Corona
1,3
, Valentina Boddi
1
, Giancarlo Balercia
2
,
Rastrelli Giulia
1
, Giulia de Vita
1
, Alessandra Sforza
3
, Gianni Forti
1
,
Edoardo Mannucci
4
& Mario Maggi
1
1
Andrology Unit, Department of Clinical Physiopathology, University of
Florence, Florence, Italy;
2
Endocrinology Unit, Polytechnic University of
Marche, Ancona, Italy;
3
Endocrinology Unit, Medical Department, Azienda
Usl, Maggiore-Bellaria Hospital, Bologna, Italy;
4
Diabetes Section Geriatric
Unit, Department of Critical Care, University of Florence, Florence, Italy.
Introduction
Previous clinical studies on effect of statins treatment on testosterone levels have
produced mixed results. The aim of the present study is to evaluate the association
between statin therapy and hormonal parameters in a large series of subjects
seeking medical care at our Unit for ED.
Methods
A consecutive series of 3484 (mean age 51.613.1 years) patients with ED was
studied.
Several hormonal and biochemical parameters were investigated, along with
ANDROTEST structured interview measuring hypogonadism-related symptoms.
Results
Among the patients studied, 244 (7%) patients were being treated with statins.
After adjustment for confounding factors (including BMI and Progetto Cuore
cardiovascular risk engine score) both total and calculated free testosterone levels
were signifcantly lower in subjects taking statins, when compared to the rest of
the sample (HR0.93 (0.90; 0.96) and 0.26 (0.01; 0.18) for each decrement of
total testosterone and calculated free-testosterone respectively; both P,0.0001).
The use of statins was also associated with a reduced testis volume and a higher
prevalence of hypogonadism-related symptoms and signs, as assessed by higher
ANDROTEST score (HR1.12 (1.03; 1.21); P,0.01 after adjustment for
confounders). FSH levels were signifcantly higher in subjects treated with statins
when compared to the rest of the sample while there was a trend toward higher LH
levels, but this did not reach statistical signifcance. The lower levels of total and
calculated free testosterone observed in subjects treated with statins were also
confrmed comparing them with age-waist circumference and cardiovascular risk
score matched controls. Finally, subjects being treated with statins showed lower
prolactin levels when compared to the rest of the sample.
Conclusions
Our data demonstrated that statin therapy might induce an overt primary
hypogonadism and should be considered as a possible confounding factor for the
evaluation of testosterone levels in patients with ED.
001.5
Role of PKA regulatory subunit R2B in murine and human adipocyte
differentiation
Federica Ermetici
1
, Erika Peverelli
1
, Giovanna Mantovani
1
,
Sabrina Corbetta
2
, Laura Avagliano
1,3
, Gaetano Bulfamante
1,3
,
Paolo Beck-Peccoz
1
& Anna Spada
1
1
Endocrinology and Diabetology Unit, Department of Medical Sciences,
University of Milan, Fondazione IRCCS Ca` Granda-Ospedale Maggiore
2
Endocrinology and Diabetology Unit, Department
of Medical-Surgical Sciences, University of Milan, IRCCS Policlinico San
Donato, Milan, Italy;
3
Prenatal and Neonatal Pathology Unit, Department of
Medicine, Surgery and Dentistry, University of Milan, A.O.S. Paolo, Milan,
Italy.
PKA regulatory subunit 2B (R2B) is the most expressed in mouse adipose tissue,
where it plays an important role in regulating energy balance. We previously
demonstrated that R2B is the most abundant R subunit in human adult
subcutaneous and visceral adipose tissues. We further showed that R2B
expression and PKA activation are reduced in adipose tissues from obese as
compared to non-obese subjects. Normal adipose tissue development and
increases in fat mass associated with obesity require the formation of mature
adipocytes from preadipocytes or stromal progenitor cells and this process needs
intracellular cAMP increases. Here, we investigated the role of R2B subunit in the
differentiation of preadipocytes to mature adipocytes. R2B subunit was expressed
at low levels in 3T3-L1 preadipocytes, which expressed high levels of the
preadipocytes marker and cell fate determinant, Pref-1. A treatment with a
mixture of methylisobutylxanthine, dexamethasone and insulin increased R2B
expression levels 48 h after differentiation induction, when the expression of
Pref-1 dramatically decreased. This pattern of R2B expression was evaluated
in vivo in the adipocytes differentiation process during human fetal development.
Immunostaining for PKA R2B, R2A and R1A showed that R2B protein was
highly expressed in retroperitoneal mesenchymal cells from 14 and 20 weeks
fetuses, as well as in the retroperitoneal adipocytes and subcutaneous adipose
tissue from 37 weeks fetuses. On the contrary, R1A and R2A subunits were absent
or very weakly expressed in all samples. Pref-1 colocalized with R2B in
retroperitoneal mesenchymal cells from fetuses of early gestational ages,
dramatically decreased at later gestational ages, while R2B expression levels
increased, and it was absent in full term mature adipose tissue.
In conclusion, R2B is the PKA regulatory subunit mainly expressed in both
preadipocytes and adipocytes during human fetal development. These
preliminary data suggest that R2B might be involved in adipocyte differentiation
and that it might be a target for future obesity treatment.
001.
Variation in response to exercise in type 2 diabetes associated to
VEGFA and PGC1- expression
Henrik Wagner
1
, Helene Fischer
2
, Marie Degerblad
1
, Peter Bavenholm
3
,
Suad Efendic
1
& Thomas Gustafsson
2
1
Department of Molecular Medicine and Surgery,
2
Department of
Laboratory Medicine,
3
Department of Medicine, Karolinska Institutet,
Stockholm, Sweden.
Objective
The individual changes in insulin sensitivity in response to exercise demonstrate a
large variation. The mechanisms contributing to improved insulin sensitivity by
training in type 2 diabetes are not fully known but presumably involve both
metabolic and structural adaptations. The present study investigates if
associations exist between changes in expression of key genes and improved
insulin sensitivity, VO
2max
and glycemic control following exercise training in
type 2 diabetes.
Methods
Nineteen subjects with type 2 diabetes were randomized to a 12 week intervention
with structured exercise. Nine of the subjects were also randomized to acarbose
treatment. Hyperinsulinemic euglycemic clamp, maximal exercise test and
HbA1c were performed before and after the intervention. Muscle biopsies were
obtained in resting state for quantifcation of mRNA-expression. Statistical
analyses of relative change in gene expression were performed by multiple linear
regression with sex, acarbose treatment and relative changes in insulin sensitivity,
VO
2max
and HbA1c as independent variables. All subjects gave informed consent
to study participation and the protocol was approved by an Independent Ethics
Committee.
Results
Sixteen subjects (4 females and 12 males) completed the study per protocol and
were included in the analyses. Change in VEGFA expression was positively
associated to an increase in insulin sensitivity (P0.003) and to a decrease in
HbA1c (P0.02). Change in VEGFA receptor 1 expression was also positively
correlated with an increase in insulin sensitivity (P0.03) and a decrease in
HbA1c (P0.007). An increase in PGC1- expression showed a signifcant
association with an improvement of insulin sensitivity (P0.05).
Conclusions
In this study, the variation in physical adaptation to exercise in type 2 diabetes
was associated to relative changes in VEGFA and PGC1- expression in muscle.
The difference in training induced expression of these factors could participate in
the known variation in the exercise training generated changes in insulin
sensitivity.
Thyroid
002.1
Calcitonin screening and pentagastrin testing: predictive value
for diagnosis medullary carcinoma in nodular thyroid disease
Burkhard Herrmann
1,2
, Kurt Schmid
4
, Andreas Bockisch
1
, Mathias Kemen
3
& Klaus Mann
1
1
Division of Laboratory Research, Department of Endocrinology,
University Duisburg-Essen, Essen, Germany;
2
Division of Endocrinology,
Diabetology and Laboratory, Technology Center Bochum,
Bochum, Germany;
3
Department of Visceral Surgery, Ev. Hospital Herne,
Herne, Germany;
4
Department of Pathology and Neuropathology,
University Duisburg-Essen, Essen, Germany.
Context
Serum calcitonin (hCT) measurement may be useful for detecting medullary
carcinoma (MTC), but the routine use of hCT and after pentagastrin stimulation to
screen patients with nodular thyroid disease remains controversial.
Patients
One thousand and seven patients (667 females, 440 males) with nodular thyroid
disease and a mean age of 5514 (meanS.D.) years were included in the study.
All patients did not have impaired renal function, bacterial infection, alcohol- and
drug-abuse, pseudohypoparathyroidism, or proton pump inhibitor therapy.
Individuals referred with known elevation of hCT, Graves` disease or
autoimmune thyroid disease were not considered or included to be part of this
investigation.
Methods
Serum hCT levels were determined under basal conditions, and when basal values
were more than or equal to 10 and ,100 pg/ml, testing was repeated after
pentagastrin stimulation. Basal or stimulated levels more than 100 pg/ml were
indicated for surgery.
Results
hCT levels 10 pg/ml were increased in 17 patients (1.7%). One patient had a
basal hCT level of 4400 pg/ml with a histological confrmation of a MTC. In this
patient, pentagastrin test was not performed. Sixteen patients with basal hCT
between 10 and 100 pg/ml underwent pentagastrin-stimulated hCT measurement.
4/16 had stimulated hCT 100 pg/ml. 2/4 patients had MTC and 2 patients C cell
hyperplasia. In sum, 3 patients (0.30%) had histological verifed MTC.
Conclusions
Basal together with pentagastrin-stimulated hCT measurement in case of basal
hCT 10 pg/ml detect MTC in 0.30% of patients with nodular thyroid disease
and should be consider as a useful and recommended tool for early detection of
MTC and to save the patient`s life.
002.2
Systemic sodiumiodide symporter (NIS) gene transfer in hepatocellular
carcinoma using EGF-receptor targeted non-viral gene delivery vectors
Kathrin Klutz
1
, David Schaffert
3
, Wolfgang Rodl
3
, Michael J Willhauck
1
,
Arzu Cengizeroglu
3
, Nathalie Wunderlich
1
, Franz Josef Gildehaus
2
,
Ernst Wagner
3
, Burkhard Goke
1
, Manfred Ogris
3
& Christine Spitzweg
1
1
Internal Medicine II, Munich, Germany;
2
Nuclear Medicine, Munich,
Germany;
3
Pharmaceutical Biology-Biotechnology, Munich, Germany.
We have recently demonstrated induction of tumor-selective accumulation and
therapeutic effcacy of radioiodine in neuroblastoma tumors after systemic non-
viral polyplex-mediated sodium-iodide-symporter (NIS) gene delivery.
In the current study, we evaluated the effcacy of novel synthetic nanoparticle
vectors based on linear polyethylenimine (LPEI), shielded by polyethylene glycol
(PEG), and coupled with the synthetic peptide GE11 as an epidermal growth
factor (EGF) receptor-specifc ligand for systemic sodium-iodide-symporter
(NIS) gene transfer in EGF-receptor-expressing human hepatocellular carcinoma
(HCC) cells.
We used LPEI-PEG-GE11 to form targeted polyplexes with a NIS-expressing
plasmid at two different conjugate/plasmid (c/p) weight ratios to transfect HCC
(Huh7) cells in vitro and in vivo.
In vitro incubation of Huh7 cells with LPEI-PEG-GE11/NIS polyplexes resulted
in an 11-fold increase in iodide uptake activity when using a c/p ratio of 0.8 as
compared to a 3.5-fold increase when using a c/p ratio of 2. After establishment of
subcutaneous Huh7 tumors in nude mice, LPEI-PEG-GE11/NIS polyplexes were
injected via the tail vein followed by analysis of radioiodine distribution after
injection of 18.5 MBq
123
I using gamma camera imaging. After administration of
LPEI-PEG-GE11/NIS polyplexes at c/p 0.8 and 2, Huh7 tumors showed a
perchlorate-sensitive iodide uptake of 7.5 and 6.8% ID/g
123
I with a biological
half-life of 5 and 3 h, respectively. In mice receiving LPEI-PEG-GE11/NIS at c/p
0.8 non-target organs like liver, lungs and kidneys exhibited no signifcant iodide
uptake, whereas at c/p 2 signifcant iodide uptake activity was induced in lungs
and liver as shown by ex vivo biodistribution analysis.
These results indicate that optimization of conjugate/plasmid ratios has
signifcant impact on specifcity and effcacy of non-viral nanoparticle vectors.
After individual optimization, EGF receptor targeted nanoparticles represent an
effective gene delivery system for systemic NIS gene transfer opening the
prospect of targeted NIS-mediated radionuclide therapy of EGF receptor-
expressing tumors, even in metastatic disease.
002.3
Allelic discrimination in the diagnosis of somatic BRAF V600E
mutation on hne-needle aspiration biopsies
Mattia Buratto, Federico Tagliati, Giorgio Trasforini, Stefania Leoni,
Roberta Rossi, Ettore C degli Uberti & Maria Chiara Zatelli
Section of Endocrinology, Department of Biomedical Sciences and
Advanced Therapies, University of Ferrara, Ferrara, Italy.
Many studies demonstrated that somatic BRAF gene mutation analysis increases
diagnostic accuracy for papillary thyroid carcinoma (PTC), even from very small
samples. The gold standard for point mutations research is direct sequencing, that
implies DNA extraction, PCR with specifc primers, sequencing reaction and run
on an automatic sequencer. This is an expensive and time consuming method, and
the possible contamination with wild-type DNA not coming from the nodule
signifcantly reduces sensitivity. Allelic discrimination is a real-time PCR
application that can discriminate between two alleles differing for the insertion,
substitution or deletion of a single base, due to the presence of two real time
Taqman probes, each labelled with a different fuorochrome (FAM for the
mutated allele and VIC for the wild-type allele).
The aim of our study is to verify whether allelic discrimination can be useful in
the diagnosis of BRAF somatic mutation, starting from fne needle aspiration
biopsies (FNAB). In each allelic discrimination reactions three positive controls
are present, one for each possible genotype; omozygous controls are
oligonucleotides containining the target sequence (wild-type or mutated),
whereas the eterozygous control is a 4:1 mix of wild-type omozygous control
and mutated omozygous control, respectively, in order to mimic wild-type
contamination. To evaluate the method sensitivity, mutated DNA has been diluted
in wild-type DNA at variable concentrations (1:2, 1:4, 1:10, 1:20, 1:100) and
analyzed both by direct sequencing and allelic discrimination. Allelic
discrimination was more sensitive since it detected the presence of mutated
DNA in all dilutions, while direct sequencing detected the mutation until 1:20
dilution.
Five hundred FNAB have been analyzed with both methods; allelic
discrimination identifed 55 V600E mutated samples, while direct sequencing
identifed only 50 V600E mutated samples. Post surgical histological examination
confrmed 54 PTC and one anaplastic carcinoma. In conclusion, allelic
discrimination is more sensitive (P,0.05) and more accurate (P,0.05) than
direct sequencing, and its use in diagnostic procedures is very useful, even when
samples (i.e. FNAB) are contaminated with wild-type DNA.
002.4
Polyglandular autoimmunity in autoimmune thyroid disease behaves
differently from polyglandular autoimmunity in type 1 diabetes
Janneke Wiebolt, Annette den Boer, Roos Achterbergh, Britt Suelmann,
Stephanie van der Leij, Renske de Vries & Timon van Haeften
University Medical Centre Utrecht, Utrecht, The Netherlands.
Aim
Patients with autoimmune thyroid disease (AITD) or type 1 diabetes (T1DM) are
prone to develop other autoimmune diseases. This has led to the concept of
autoimmune polyglandular syndromes (APS). It has been proposed that AITD and
type 1 diabetes are both part of the same APS (subtype 2). This would imply that
they associate with the same diseases. We evaluated whether the clustering of
autoimmune antibodies differs between AITD and T1DM.
Methods
Anti-thyroid peroxidase antibodies (anti-TPO), parietal cell antibodies (PCA),
intrinsic factor antibodies (IF), celiac antibodies and anti-adrenal antibodies (AA)
were assessed in 853 AITD patients, 658 type 1 diabetes patients, and 102 patients
affected by both entities.
Results
Prevalences of PCA and AA antibodies were signifcantly increased in patients
affected by both AITD and T1DM, compared to those with either AITD or type 1
diabetes (P,0.05). However, celiac antibodies did not associate with thyroid
autoimmunity (i.e. anti-TPO or AITD) in the type 1 diabetes group (OR 0.34, 95%
CI 0.08-1.5). In AITD patients, having PCA was associated with celiac antibodies
(OR 4.8, 95% CI 1.1-21.9) and with adrenal antibodies (OR 7.0, 95% CI 2.0-
24.5). In contrast, in type 1 diabetes, associations between PCA with AA (OR 2.4,
95% CI 0.7-8.6) or with celiac antibodies (OR 0.28, 95% CI 0.04-2.2) were not
signifcant. The same analyses including IF antibodies led to same conclusions.
Conclusion
Autoimmune thyroid disease shows clustering of gastric autoimmunity with
celiac and adrenal autoimmunity, which is consistent with the proposed entity of
the autoimmune polyglandular syndrome type 2. The fnding that such clustering
is not seen in type 1 diabetes suggests that type 1 diabetes and thyroid
autoimmunity may be part of different subtypes of autoimmune polyglandular
syndromes.
002.5
Thyroid dysfunction related abnormalities in adiponectin and glucose
metabolism before and after treatment
Didem Ozdemir, Selcuk Dagdelen & Aydan Usman
Department of Endocrinology and Metabolism, Faculty of Medicine,
Hacettepe University, Ankara, Turkey.
Objective
Thyroid dysfunctions have various effects on glucose and lipid metabolism.
Adiponectin (ADP) is an adipokine decreased in obesity and insulin resistance. In
this study, we aimed to investigate the role for ADP in thyroid dysfunction related
changes in glucose and lipid metabolism.
Methods
Newly diagnosed overt hypothyroid (n20) and thyrotoxic (n23) adult
patients with a body mass index (BMI),30 kg/m
2
were included. Patients with a
known insulin resistance related disease and chronic disease were excluded.
Patients were matched with healthy controls (n20) according to age, sex and
BMI. Thyrotropin (TSH), free T
3
, free T
4
, fasting plasma glucose (FPG), insulin,
HOMA-IR, HOMA-bcf, lipid profle and ADP levels were evaluated at the time
of diagnosis and after the restoration of euthyroidism.
Results
Hypothyroid patients had signifcantly lower FPG and higher HOMA-bcf
compared to thyrotoxic patients (P,0.001 and P0.15, respectively). Fasting
plasma insulin and HOMA-IRwere similar in groups. Restoration of euthyroidism
in hypothyroidism and thyrotoxicosis resulted in increased and decreased FPG,
respectively (P0.002 and P0.001, respectively), but no signifcant change in
fasting plasma insulin, HOMA-IRand HOMA-bcf. Basal plasma ADP levels were
14.558.4, 13.799.13 and 11.686.0 g/ml in hypothyroid, thyrotoxic and
healthy controls, respectively (P0.503). Adiponectin decreased signifcantly in
hypothyroidism (P0.047), while did not change in thyrotoxicosis (P0.770)
with achievement of euthyroidism. There was no correlation between basal ADP
and TSH, thyroid functions, FPG and insulin, HOMA-IR, HOMA-bcf and lipid
parameters in hypothyroid and thyrotoxic patients.
Conclusion
We showed that FPG increased in hypothyroid and decreased in thyrotoxic
patients with restoration of euthyroidism. HOMA-IR and HOMA-bcf did not
change in thyroid dysfunctions before and after restoration of euthyroidism.
Decreased ADP in hypothyroidism after achievement of euthyroidism may be
related with increased FPG in these patients, however lack of change in
thyrotoxicosis indicates need for further studies with larger sample sizes.
002.
Percutaneous laser ablation (PLA) in non-functioning benign thyroid
nodules: a 3-year follow-up study
Roberto Valcavi
1
, Fabrizio Riganti
1
, Angelo Bertani
1
, Debora Formisano
2
& Claudio M Pacella
3
1
Endocrine Unit and Thyroid Disease Center, Arcispedale Santa Maria
Nuova, Reggio Emilia, Italy;
2
Statistics and Clinical Epidemiology
Unit, Arcispedale Santa Maria Nuova, Reggio Emilia, Italy;
3
Department of
Interventional Radiology and Diagnostics Imaging, Ospedale San Camillo,
Rome, Italy.
Aim of the study
To evaluate effcacy and safety of ultrasound-guided percutaneous laser ablation
(PLA) on benign thyroid nodule size reduction, thyroid function and
autoimmunity.
Methodology
This study was approved by local institutional review committee. All data are
meanS.D. Two hundred and ninety-eight euthyroid outpatients (F241, M
57; age 50.712.0 years) with a benign thyroid nodule (volume 23.121.3 ml)
causing either local discomfort or cosmetic complaint, were submitted to PLA.
Under US guidance, optic fbers were carefully placed into the length of the
lesion, then illuminated with Nd:YAG laser. According to nodule dimension, 1-4
fbers were used simultaneously. An output power of 2-4 W and a mean energy
delivery of 87695311 J in a single session were used. Side effects, US images
and hormonal changes were recorded at baseline and during a 3-year follow-up.
Results
Nodule volume changes are summarized in the following table.
Mean TSH and fT
4
values slightly and signifcantly changed immediately after
PLA (baseline versus day 1: TSH1.161.06 vs 0.620.81 mU/l; fT
4
11.681.88 vs 13.203.32 pg/ml) and returned to baseline within 1 month. No

change in fT
3
value was observed. Two patients developed overt hyperthyroid-
ism, whereas two patients developed hypothyroidism during follow-up. Anti-Tg
and anti-TPO antibodies did not change signifcantly as a mean value. No major
side effect was observed.
Conclusions
In our study, PLA was highly effective and safe in benign thyroid nodule size
reduction. Energy delivery and number of optic fbers should be tailored to nodule
size. Patients` compliance and satisfaction was very high. On these basis, PLA
may be a new promising therapeutic modality in benign thyroid nodule
management.
Pituitary
003.1
Sgk1 effects on POMC transcription and ACTH release are opposite to
those of glucocorticoids
Marie Helene Reiter
1
, Greisa Vila
1
, Sabina M Baumgartner-Parzer
1
,
Engelbert Knosp
2
, Ludwig Wagner
1
, Gunter K Stalla
3
& Anton Luger
1
1
Clinical Division of Endocrinology and Metabolism, Department of
Medicine III, Medical University of Vienna, Vienna, Austria;
2
Department
of Neurosurgery, Medical University of Vienna, Vienna, Austria;
3
Department of Neuroendocrinology, Max Planck Institute of Psychiatry,
Munich, Germany.
Glucocorticoid feed-back in pituitary corticotrophs represses POMC transcription
and ACTH release. Serum and glucocorticoid-induced kinase 1 (Sgk1) has been
identifed as an immediate early target of glucocorticoids in many tissues,
however its expression and function in corticotrophs are unknown.
We show here that Sgk1 is present in the human pituitary gland at both mRNA
and protein levels. Double-immunohistochemistry revealed that Sgk1 is
expressed in different cell types and, among others, co-localises with ACTH.
The AtT-20 corticotroph cell line was used for functional experiments.
Dexamethasone at 100 nM increases Sgk1 transcription within 30 min as
identifed by real time PCR. Twenty-four hours after dexamethasone, Sgk1
protein levels increase in all cellular subfractions in western blotting. This effect
is abolished by RU486, confrming the mediation of dexamethasone response by
the glucocorticoid receptor. The increase in phosphorylated Sgk1 is reduced by
co-stimulation with LY294002, pointing towards post-translational activation via
a PI3K-dependent pathway. Independently of glucocorticoids, Sgk1 over-
expression increases CREB- and AP-1-dependent transcription, c-jun phos-
phorylation, POMC luciferase reporter values and ACTH secretion. Within one
experiment, Sgk1 overexpression increases POMC promoter activity similarly to
CRH. Nevertheless, there is an additive effect of both stimulants on POMC
transcription, implying the existence of additional signalling pathways down-
stream of Sgk1. Sgk1 knockdown via siRNA decreases POMC promoter activity
without signifcantly changing ACTH release.
In summary, Sgk1 is strongly stimulated by glucocorticoids in pituitary
corticotrophs; however its effects on POMC transcription are antagonistic to
the classical glucocorticoid-mediated inhibition, suggesting Sgk1 may protect
cells from possibly detrimental glucocorticoid action.
003.2
Copeptin, an arginine vasopressin (AVP) marker, as a diagnostic aid in
SIADH of cancer
Kashinath Dixit
1
, Nils Morgenthaler
2
& Georg Brabant
1
1
The Christie, Manchester, UK;
2
B.R.A.H.M.S. AG, Hennigsdorf,
Germany.
Copeptin is a stable AVP marker and stoichiometrically released with AVP. It
closely refects changes in water balance. Its stimulation in severe stress has
recently has been suggested in various pathophysiological conditions including
myocardial infarction and stroke. Paraneoplastic stimulation of AVP/copeptin is
expected in patients with cancer leading to hyponatraemia due to SIADH.
Here, we evaluated copeptin levels in 50 patients with hyponatraemia due to
various forms of cancer to assess the likelihood of SIADH. Only patients with
hyponatremia of ,128 mmol/l were selected for the study. Copeptin levels were
sampled in parallel to serum sodium levels and osmolality. Serum copeptin was
measured with a specifc immunoassay (detection limit of 1.7 pmol/l; maximal
inter- and the intraassay CV 6.5%).
As compared to a control group and to the physiological variation found in a 24 h
pattern of copeptin obtained in healthy subjects by sampling every 20 min, 20
patients exceeded the maximal range of copeptin obtained in these healthy controls
by more than double of the S.D. (mean 130 vs 14 pmol/l). Copeptin levels in the
remaining group of patients was not signifcantly different to the control group.
Our data support the idea that measurement of copeptin serumlevels may provide a
rapid and reliable means to distinguish patients with hyponatremia of cancer as
compared to other forms of hyponatremia in the setting of cancer therapy. These
determinations may guide the decision for treatment with blockers of the AVP
receptor.
BaseIine 1 week 1 month 6 months 1 year 3 years
Patients 298 219 281 284 298 122
Mean vol
(ml)S.D.
23.121.3 24.022.3 20.520.5 12.815.1 11.714.9 12.815.7
Mean
Delta vol
(% versus
baseline)
8.3% 6.2% 47.5% 54.3% 48.5%
,0.01 * * * * *
003.3
Trauma severity, but not hypopituitarism, affects cognitive function
after traumatic brain injury: a multi-center study in The Netherlands
Nieke Kokshoorn
1
, Jan Smit
1
, Willy-Anne Nieuwlaat
3
, Nienke Biermasz
1
,
Peter Bisschop
2
, Ronald Groote Veldman
4
, Ferdinand Roelfsema
1
,
Anton Franken
5
, Moniek Wassenaar
1
, Jitske Tiemensma
1
,
Johannes Romijn
1
& Alberto Pereira
1
1
Leiden University Medical Center, Leiden, The Netherlands;
2
Academic
Medical Center, Amsterdam, The Netherlands;
3
St Elisabeth Hospital,
Tilburg, The Netherlands;
4
Medical Spectrum Twente, Enschede,
The Netherlands;
5
Isala Clinics, Zwolle, The Netherlands.
Background
Hypopituitarism after traumatic brain injury (TBI) is considered to be a prevalent
condition, and may affect quality of life (QoL) and cognitive function. However,
the prevalence of hypopituitarism differs considerably among reported studies
due to differences in defnitions, endocrine assessments of hypopituitarism, and
confounding factors, like timing of evaluation and the severity of the trauma.
Aim
To evaluate the prevalence of hypopituitarism, QoL, and cognitive function in a
large cohort of TBI patients after long term follow-up.
Patients and methods
Ninety-one patients (62M, median age 46 years) with follow-up duration after
TBI 1 year and hospitalized for a minimum of 4 days were recruited from 5
centers in The Netherlands. Pituitary function was evaluated by fasting morning
samples combined with insulin tolerance test (ITT, n77) or, when contra-
indicated, by ACTH and GHRH-arginine test (n14). QoL was assessed by 4
health related questionnaires (HADS, NHP, MFI-20, and SF-36); cognitive
function by the Minimal Mental State Examination (MMSE) for global cognitive
functioning; Verbal Learning Test of Rey (VLTR) and Rey Complex Figure test
(RCF) for memory; and Trail Making Test (TMT), Stroop Color-Word test
(SCWT) and Letter Digit Substitution test (LDST) for executive functioning.
Results
Hypopituitarism was present in 6.6% (6/91) of cases (severe GHD 4.4% (n4),
hypogonadism 1.1% (n1); hypocortisolism 2.2% (n2)). Hypopituitarism
affected QoL (several items in all questionnaires), but not cognitive function.
However, trauma severity (moderate/severe versus mild injury) affected cognitive
function: memory: VLTR: immediate and delayed repeats: P0.032, and 0.025,
respectively) and executive functioning: SCWT: total interference P0.021, and
LDST: correct answers P0.047.
Conclusion
The prevalence of hypopituitarism after TBI was low after long-term follow-up.
QoL was affected by hypopituitarism, but not by the severity of the trauma. In
addition, trauma severity, but not hypopituitarism, signifcantly affected cognitive
function.
003.4
Inuence of the d3-GH receptor polymorphism on the metabolic and
biochemical phenotype of GH dehcient adults at baseline and during
short- and long-term rhGH replacement therapy
Claudia Giavoli
1
, Emanuele Ferrante
1
, Eriselda Profka
1
, Luca Olgiati
1
,
Silvia Bergamaschi
1
, Cristina L Ronchi
1
, Elisa Verrua
1
,
Marcello Filopanti
1
, Elena Passeri
2
, Laura Montefusco
3
, Andrea G Lania
1
,
Sabrina Corbetta
2
, Maura Arosio
3
, Bruno Ambrosi
2
, Anna Spada
1
& Paolo Beck Peccoz
1
1
University of Milan, Fondazione IRCCS Ca` Granda-Ospedale Maggiore
2
Endocrinology Unit, Department of Medical and
Surgical Sciences, University of Milan, Policlinico San Donato IRCCS,
Milan, Italy;
3
Unit of Endocrinology, University of Milan, Ospedale San
Giuseppe Milan, Milan, Italy.
A common polymorphic variant of the GH receptor (exon-3 deletion, d3GHR) has
been linked with increased response to recombinant human GH (rhGH) in some,
but not all, GH defcient (GHD) and non-GHD patients. Aim of this study was to
investigate the impact of the GHR genotype on the phenotype of GHD adults and
on the metabolic effect of short- and long-term rhGH therapy, with particular
focus on glucose homeostasis (1 year: n100 and 5 years: n50). Effects of
rhGH on IGF1 serum levels, body composition (BF%), BMI, lipid profle and
glucose homeostasis (fasting insulin and glucose, insulin sensitivity determined
by HOMA and QUICKI) were evaluated according to the presence or absence of
the d3GHR variant. Forty-eight percent of patients had two wild-type alleles
(f/f), 45% one allele and 7% two alleles encoding the d3GHR isoform. Patients
bearing at least one d3 allele (d3/d3 or d3/f) were grouped together and indicated
as d3GHR. The different genotype did not infuence the phenotype of GHD adults
at baseline. Short-term rhGH determined normalization of IGF1 levels, decrease
in BF% and transient worsening of insulin sensitivity, independently from the
presence of the d3GHR allele. A signifcant increase in HDL cholesterol occurred
only in the d3GHR group (from 5016 to 5518 mg/dl, P,0.05). Concerning
long-term effects, normalization of IGF1 levels and decrease of BF% maintained
after 5 years. Insulin sensitivity restored to baseline values, though in d3GHR
patients fasting glucose remained signifcantly higher than at baseline. Moreover,
both after 1 and 5 years, proportion of subjects with impaired glucose tolerance,
similar in the 2 genotype-groups at baseline, decreased in f/f while doubled in
d3GHR patients. In this last group a long-term signifcant reduction of total and
LDL cholesterol was also observed (from 20850 to 18841 mg/dl and from
13635 to 10553, respectively, P,0.05). In conclusion, present results seem
to support the view that functional difference of d3GHR may infuence at least
some of the metabolic effects of rhGH in GHD adults.
003.5
Cortisol, but not ACTH/CRH, increases circulating ghrelin in man
Ibrahim Azzam, Rona Limor, Naftali Stern & Yona Greenman
Tel Aviv-Sourasky Medical Center and Sackler School of Medicine,
Tel Aviv University, Tel Aviv, Israel.
We have recently explored the involvement of ghrelin in the eating response to
stress in humans and found that ghrelin levels increased in parallel to cortisol after
a standardized psychological stress. To further elucidate this interaction, we
examined the ghrelin response to pharmacological manipulation of the HPA axis.
Following approval from the local Ethical Committee, six lean, healthy male
volunteers were examined on two occasions. Blood samples were collected every
30 min for two sequential periods of 2 h. Initially, a baseline period was followed
by i.v. injection of ACTH 250 g. Subsequently, metyrapone (2-3 g) was
administered at midnight and in the following morning the initial 2-h sampling
was followed by i.v. injection of hydrocortisone 100 mg.
Mean total ghrelin levels during the 2-h period after metyrapone administration
was signifcantly lower than during the period following ACTH administration
(P0.033). After ACTH stimulation, there was a positive correlation between
total ghrelin and cortisol AUC (r0.876; P0.021). Mean acylated ghrelin
levels were lower during the post metyrapone sampling than in the baseline period
(P0.058). Furthermore, acylated ghrelin levels signifcantly increased after
acute hydrocortisone administration (P0.032) and was positively correlated
with the decrease in ACTH (r0.825; P0.043) and the increase in cortisol
(r0.86, P0.06). There was a highly positive correlation between total and
acylated ghrelin levels during all phases of the study (r0.96, P0.002).
In conclusion, increased cortisol levels secondary to ACTH stimulation or
hydrocortisone administration is associated with increments in plasma ghrelin
levels, whereas central stimulation of the HPA axis by blocking cortisol synthesis
with metyrapone is associated with decreased plasma ghrelin levels. Collectively,
this suggests that stress-induced elevations in ghrelin levels may be secondary to
the rise in peripheral cortisol, independent of central elevation of ACTH and
possibly CRH levels.
003.
Young patients with sporadic macroadenomas as target population
for AIP mutations screening
Maria Tichomirowa
1
, Anne Barlier
2
, Adrian Daly
1
, Marie-Lise
Jaffrain-Rea
3
, Renato Cozzi
4
, Maria Yaneva
5
, Luciana Naves
6
,
Christina Ronchi
7
, Caroline Sievers
8
, Dominique Maiter
9
, Carmen
Fajardo Montanana
10
, Sabine Zacharieva
5
& Albert Beckers
1
1
University of Liege, Liege, Belgium;
2
Universite de la
Mediterranee, Marseille, France;
3
University of LÀquila, Pozzili, Italy;
4
Ospedale Niguarda, Milan, Italy;
5
Clinical Center of Endocrinology and
Gerontology, Sofa, Bulgaria;
6
University of Brasilia, Brasilia, Brazil;
7
Fondazione IRCCS Osp. Maggiore Policlinico Mangiagalli Regina Elena,
Milan, Italy;
8
Max-Planck Institute for Psychitry, Munich, Germany;
9
St Luc University Hospital, Brussel, Belgium;
10
Hospital Universitario de
la Ribera, Valencia, Spain.
Methods
We undertook an assessment of patients which were diagnosed with or had their
frst symptoms of pituitary tumor before the age of 30 and had tumor diameter
more than 1 cm without familial history of pituitary adenomas. In patients that
consented to genetic analysis, germline mutations in the AIP gene were sought.
Results
The study population consisted of 164 patients (61 prolactinomas, 84
somatotropinomas, 16 non-secreting tumors, two patients with Cushing disease
and one TSH-oma). In general we have diagnosed 28 AIP variations (17%) and 17
variations we supposed being pathogenic (10.4%) in 164 young patients with
pituitary macroadenomas. In 84 acromegalic patients we have identifed ten
distinct pathogenic mutations in 11 patients (13%). In 61 subjects with
macroprolactinomas we have identifed 8 variations in AIP gene and fve
mutations or (8.2%) we presumed as pathogenic. We found one novel mutation
out of 14 nonsecreting tumors which comprise 7.1%.
Conclusion
Screening of young patients with large pituitary adenomas for germline AIP
mutations were positive in 10.4% of cases.
Adrenals
004.1
Subtype differentiation in primary hyperaldosteronism: evaluation of
alternative algorithms avoiding a controversial gold standard
Katharina Lang
1
, Stefanie Hahner
1
, O Vonend
2
, L C Rump
2
, M Quninkler
3
,
Sven Diederich
3
, Katharina Maier
1
, Felix Beuschlein
4
,
Martin Bidlingmaier
4
, S Endres
4
, C Engelke
1
, Ralph Kickuth
1
,
Martin Fassnacht
1
, Martin Reincke
4
& Bruno Allolio
1
1
University of Wuerzburg, Wuerzburg, Germany;
2
Heinrich-Heine-
University, Duesseldorf, Germany;
3
Charite Campus Mitte, Berlin,
Germany;
4
LMU-Medizinische Klinik Innenstadt, Muenchen, Germany.
Context
Primary aldosteronism (PHA) is the most common cause of secondary
hypertension. Distinguishing unilateral (UAH) from bilateral (BAH) and other
causes of PHA is one of the greatest challenges in the diagnostic process. Adrenal
venous sampling (AVS) is widely considered to be the gold standard for subtype
differentiation.
Methods
Technical and diagnostic outcome of AVS was analysed retrospectively in 59
patients with PHA who underwent AVS at the University of Wurzburg and was
compared to imaging, clinical and laboratory data. As cut off for selective
sampling during AVS a cortisol central/peripheral ratio of 2 was chosen.
Results
AVS: only 47.5% were bilaterally selective, 25.4% were unilaterally selective but
still suitable for subtype differentiation. Of the informative AVS cases (n43)
83.7% led to the correct diagnosis whereas in 16% the diagnosis remained
uncertain or even turned out to be wrong. In 27.1% of cases AVS was not
informative due to lack of selective sampling. Imaging: CT (n42) or MRI
(n17) both revealed only moderate sensitivity (CT 67.8%, MRI 62.5%) and
specifcity (CT 70%, MRI 80%). Saline infusion test: 11% showed an increase of
serum aldosterone (10%). Eighty percent of this subgroup had UAH.
Aldosterone-renin-ratio at baseline did not differ signifcantly between UAH
and BAH (UAH 120.286.7; BAH 83.060.2). Posture testing: 65.2% of the
patients with UAH and none with BAH showed a fall of aldosterone or unchanged
(increase ,5%) serum aldosterone leading to a specifcity and a positive
predictive value of 100%.
Conclusion
AVS as current gold standard for subtype differentiation is invasive, often not
informative and may even lead to the wrong diagnosis. In selected cases clinical
and laboratory data in combination with CT may allow successful subtype
differentiation without AVS. Diagnostic algorithms based on our observations
will be evaluated prospectively with the aim to reduce the need of AVS.
004.2 - E$E Young |nvest|gator AWard
A mouse model with hyperaldosteronism carrying an ENU induced
mutation on chromosome 9
Ariadni Spyroglou
1
, Sibylle Wagner
2
, Martin Bidlingmaier
1
, Tarik Bozoglu
1
,
Birgit Rathkolb
3
, Anja Schrewe
2
, Martin Hrabe de Angelis
2
&
Felix Beuschlein
1
1
Medizinische Klinik Innenstadt, Ludwig-Maximilians University, Munich,
Germany;
2
Institute of Experimental Genetics, Helmholtz Centre, Munich,
Germany;
3
Chair of Molecular Animal Breeding and Biotechnology,
In an attempt to defne novel genetic loci involved in the pathophysiology of
primary aldosteronism a mutagenesis screen after treatment with the alkylating
agent N-ethyl-N-nitrosourea was established for the parameter aldosterone. One
of the established mouse lines with hyperaldosteronism was phenotypically and
genetically characterized. Affected animals showed an increased aldosterone to
renin ratio (males unaffected, 1.10.1 pg/ml per ng per ml per hour versus
affected, 3.90.8 pg/ml per ng per ml per hour, P,0.01, females unaffected,
1.80.2 pg/ml per ng per ml per hour versus affected, 4.40.7 pg/ml per ng per
ml per hour, P,0.01), normal potassium, urea and creatinine, and an increase of
blood pressure only in female animals (systolic BP unaffected 1243 vs 118
3 mmHg, P,0.05). Furthermore, immunohistochemistry revealed increased
collagen deposits in hearts of affected animals. Surprisingly, however, while
gross adrenal morphology was similar between the groups, lower adrenal
Cyp11b2 expression levels were evident in affected littermates (males, 378%
and females, 258% versus unaffected, 100%), whereas StAR and P450scc
expression showed no signifcant differences. In addition aldosterone release
from adrenals kept in organ culture was signifcantly lower in affected animals
(males affected 215 ng/ml versus unaffected 454 ng/ml, P,0.005 and
females affected 8212 ng/ml versus unaffected 1229 ng/ml, P,0.05). As
lack of Cyp11b2 expression in a variety of tissues did not support extra-adrenal
aldosterone secretion, ongoing functional characterization aims at the
elucidation of mechanisms involved in the observed elevation of aldosterone
levels. A SNP analysis revealed signifcant linkage (
2
of 9.94) with
chromosome 9, locus 80.06. Further microsatellite and heteroduplex analyses
by TGCE technique are in process for fne mapping and eventually identifcation
of the mutation causative for the described phenotype.
004.3
Novel mutations in the glucocorticoid receptor gene: from familial
bilateral adrenal hyperplasia to glucocorticoid receptor
haploinsufhciency
Jacques Young
1,3
, Severine Trabado
1,3
, Jerome Bouligand
1,3
,
Larbi Amazit
1
, Say Viengchareun
1
, Anne Guiochon-Mantel
1,3
,
Brigitte Delemer
2
& Marc Lombes
1,3
1
Inserm U693, Le Kremlin Bicetre, France;
2
CHU Reims, Reims, France;
2
APHP, Le Kremlin Bicetre, France.
Glucocorticoid receptor (GR or NR3C1) is a ligand-dependent transcription
factor that plays an essential role in differentiation, development, infammatory
responses and energy balance and is implicated in several human diseases. Eleven
germinal GR mutations have been described so far, responsible for glucocorticoid
resistance with variable clinical presentation.
We report original heterozygous GR mutations in three independent patients,
which have been incidentally discovered in the context of bilateral adrenal
hyperplasia and subclinical hypercorticism.
Investigation of adrenal incidentaloma leads to the discovery of a family (eight
affected individuals spanning three generation) carrying the frst nonsense GR
mutation. This stop mutation (R469X) results in a non-functional 50-kDa
truncated GR, lacking hormone and DNA binding capacity and devoid of
hormone-dependent nuclear translocation and transactivation properties in vitro.
We further provide evidence for an in vivo mechanism of a nonsense-mediated
mRNA decay, which accounts for the lack of expression of the defective allele
and GR hapoinsuffciency. In this kindred, we describe the natural history of the
disease, as demonstrated by the degree of adrenal hyperplasia, the severity of the
hypertension and the intensity of the apparent mineralocorticoid excess (urinary
THE/THF) which exacerbated over time.
Two missense GR mutations (one in the N terminal domain, the other in the hinge
region) did not lead to major functional alterations in terms of hormone binding,
subcellular traffcking or transactivation. We exclude rare polymorphisms and are
currently exploring transdominant negative effect and modifcation in coragulator
recruitment.
Altogether, our results indicate that alteration of GR signaling may constitute an
underestimated cause of bilateral adrenal hyperplasia and suggest a prominent
role of intra-adrenal GR impacting adrenal cortical cell proliferation and function.
Thus, we propose that GR genetic defects should be sought in patients with
adrenal incidentalomas and subclinical hypercorticolism without signs of
Cushing, especially when associated with hypertension and hypokalemia.
004.4
Combined anticortisolic therapy by metyrapone, ketoconazole and
mitotane: an alternative to adrenalectomy in severe Cushing`s
syndrome
Peter Kamenicky
1,2
, Celine Droumaguet
1,2
, Eric Baudin
1,3
,
Sylvie Salenave
1,2
, Severine Trabado
1,4
, Laure Cazabat
1,2
,
Philippe Chanson
1,2
& Jacques Young
1,2
1
Universite Paris Sud-11, 94275 Le Kremlin-Bice`tre, France;
2
Service
dÈndocrinologie et des Maladies de la Reproduction, CHU de Bice`tre,
94275 Le Kremlin-Bice`tre, France;
3
Service de Medecine Nucleaire et de
Cancerologie Endocrinienne, Institut Gustave-Roussy, 94805 Villejuif,
France;
4
Service de Genetique Moleculaire, Pharmacogenetique et
Hormonologie, CHU de Bice`tre, 94275 Le Kremlin-Bice`tre, France.
Context
Mitotane due to its adrenolytic action is highly effective in long-term
management of ACTH-dependent Cushing`s syndrome (CS). However, the
slow onset of its anticortisolic effect makes its use problematic in severe CS, when
very rapid therapeutic response is required. Association with metyrapone and
ketoconazole, rapidly acting steroidogenesis inhibitors, could warrant CS control
while waiting for the full effciency of mitotane and thus avoid urgently
performed bilateral adrenalectomy.
Ten patients, aged 18-75 years, presenting with serious CS were included: 6 had
ectopic ACTH CS, 3 Cushing`s disease and 1 macronodular adrenal hyperplasia.
All patients had clinical features of serious CS, 3 subjects had pulmonary
embolism, 2 had serious specifc cardiomyopathy, 1 developed pelvic abscesses
and bedsore and 6 had severe hypokalemia. Their 24 h urine free cortisol
excretion (UFC) ranged from 330 to 7080 g/24 h (normal ,50 g/24 h). High
dose combined medical therapy associating metyrapone (3-4.5 g/24 h), ketoco-
nazole (800-1000 mg/24 h) and mitotane (3-6 g/24 h) was started concomitantly.
UFC, morning plasma cortisol (F8h) and liver enzymes were monitored daily
during the frst week, once a week during the frst month and then once monthly.
Results
In all cases, a rapid and dramatic improvement of clinical symptoms of
hypercortisolism was observed. UFC levels normalized in 1-3 days ranging from
5 to 65 g/24 h and remained low to normal at frst and second month after the
treatment onset. F8h was low: 1-10 g/dl. Metyrapone and ketoconazole could be
discontinued after 2-4.5 months of treatment and CS control was maintained by
mitotane alone (UFC: 5-60 g/24 h). Clinical tolerance was acceptable and no
signifcant liver toxicity was observed.
Conclusion
In severe hypercortisolism, when no etiological treatment is possible, combined
anticortisolic therapy allows to avoid bilateral adrenalectomy which is associated
with increased morbidity and results in permanent hypoadrenalism requiring
lifelong steroid replacement.
004.5
Effects of mitotane on testicular adrenal rest tumors size, sperm count
and adrenal steroidogenesis in patients with congenital adrenal
hyperplasia due to 21-hydroxylase dehciency
Anne Bachelot
1
, Sylvie Salenave
2
, Raphaelle Renard
1
, Laurence Rocher
2
,
Jerome Dulon
1
, Christiane Coussieu
1
, Sylvie Brailly-Tabard
2
, Yves Morel
3
,
Philippe Touraine
1
& Jacques Young
2
1
Groupe Hospitalier Pitie-Salpe`trie`re, Paris, France;
2
Ho`pital Bice`tre, Le
Kremlin-Bice`tre, France;
3
Ho`pital Debrousse, Lyon, France.
Testicular adrenal rest tumors (TART), described in patients with classic
congenital adrenal hyperplasia (CAH) secondary to 21-hydroxylase defciency,
are responsible for Leydig cell failure and impaired spermatogenesis. These
tumors, often unresponsive to intensifed glucocorticoid therapy and surgical
resection, may lead to infertility or even sterility. Here, we studied the effects of
long term treatment with mitotane (Lysodren), a specifc adrenolytic agent, on
TART in 4 CAH adult patients. These patients were 24-26 years old at the
beginning of the study. Patient 1, 2 and 3 were diagnosed as newborns with a salt-
wasting form of CAH and patient 4 was affected by a simple virilising form.
Testicular ultrasonography revealed bilateral TART in all patients. Semen
analysis showed azoospermia in 2 patients and severe oligoasthenoteratospermia
in the 2 other. All patients were treated before with high glucocorticoid doses
with important side effects (hypertension, weight gain and osteopenia) in response
to this therapy whereas none had optimal adrenal ACTH and suppression. After
24-54 months of Lysodren treatment, a dramatic decrease of both serum
17OHprogesterone and androstenedione levels was noted in all patients, despite
persistent increase in serum ACTH levels. Testicular sonograms showed 41-
100% reduction of TART volume. Sperm count improved clearly in patients 1, 2
and 3, enabling cryopreservation of the subjects` semen. Weight loss was
observed for all patients during treatment. One episode of moderate adrenal
insuffciency was noted in 2 patients, which required transient withdrawal of
mitotane treatment and a substantial increase in steroid replacement therapy.
Circulating total and LDL cholesterol increased in all patients. On the basis of
these preliminary results, we suggest that mitotane might represent a new
conservative approach in the management of patients with TART, and a
pharmacological tool to improve fertility in men with CAH and TART.
004.
Serum cortisol predicts increased cardiovascular mortality in patients
with acute coronary syndrome: the Ludwigshafen Risk and Cardio-
vascular Health (LURIC) Study
Andreas Tomaschitz
1
, Stefan Pilz
1
, Eberhard Ritz
2
, Tanja Grammer
3
,
Christiane Drechsler
4
, Bernhard Boehm
5
& Winfried Maerz
3,6
1
Division of Endocrinology and Nuclear Mecicine, Department of
Internal Medicine, Medical University of Graz, Graz, Austria;
2
Division of
Nephrology, Rupertus Carola University Heidelberg, Nierenzentrum,
Heidelberg, Germany;
3
Synlab Center of Laboratory Diagnostics,
Heidelberg, Germany;
4
Division of Nephrology, Department of Internal
Medicine 1, University of Wurzburg, Wurzburg, Germany;
5
Division of
Endocrinology, Department of Medicine, University Hospital Ulm, Ulm,
Germany;
6
Clinical Institute of Medical and Chemical Laboratory
Diagnostics, Medical University of Graz, Graz, Austria.
Over the past several years, growing evidence suggested that serum cortisol is
associated with increased cardiovascular (CVD) mortality in patients with chronic
heart failure. The prognostic signifcance of serum cortisol concentration (SCC)
in patients with acute coronary syndrome (ACS) however is unknown.
In the prospective Ludwigshafen Risk and Cardiovascular Health (LURIC) study
3316 patients (median age: 63.5 (56.3-70.6) years; 30.2% women) were referred
for coronary angiography. Of these, 1036 participants revealed an acute coronary
syndrome and were followed-up for almost 8 years. Mean SCC (22.510.5 vs
22.28.3 g/dl; P0.386; (normal range: 9.4-23.9 g/dl)) as well as
norepinephrine levels (P0.378), frequency of severe heart failure (NYHA
III/IV; P0.156)) and left ventricular dysfunction (P0.062) did not differ
signifcantly between patients with and without ACS, respectively. During a
median follow-up of 7.75 years 146 (14.1%) patients with ACS at baseline died
due to cardiovascular causes. Multivariate adjusted Cox proportional hazard
analysis was performed to assess the risk for death from CVD as a function of
SCC quartiles. The hazard ratio for highest versus lowest quartile of SCC was
1.89 (1.12-3.19; P0.018). Addition of plasma aldosterone and norepinephrine
levels to the fully adjusted model only marginally impacted this association (1.85
(1.04-3.27; P0.035)).
To the best of our knowledge, this is the frst prospective study that found a
specifc and independent association between SCC and incident fatal CVD events
in patients with ACS.
Reproduction & Thyroid
005.1
Therapeutic concentrations of mitotane inhibit thyrotroph cell viability
and TSH secretion in a mouse cell line model
Erica Gentilin
1
, Fulvia Daffara
2
, Giuseppe Reimondo
2
, Gianni Carandina
3
,
Maria Rosaria Ambrosio
1
, Massimo Terzolo
2
, Ettore C degli Uberti
1
&
Maria Chiara Zatelli
1
1
Advanced Therapies, University of Ferrara, Ferrara, Italy;
2
Division of
Internal Medicine I, Department of Clinical and Biological Sciences,
Faculty of Medicine San Luigi Gonzaga, University of Turin, Orbassano
(TO), Italy;
3
Laboratorio Analisi Chimico-Cliniche e Microbiologia, S.
Anna Hospital, Ferrara, Italy.
Mitotane therapy is associated with many side effects, including thyroid function
perturbations mimicking central hypothyroidism, possibly due to laboratory test
interference or pituitary direct effects of mitotane. Therefore, we aimed at
investigating whether increasing concentrations of mitotane in the therapeutic
range might interfere with thyroid hormone assays and evaluate the effects of
mitotane on a mouse TSH- producing pituitary cell line. TSH, FT
4
and FT
3
levels
do not signifcantly change in sera from hypo-, hyper- or euthyroid patients after
addition of mitotane at concentrations in the therapeutic window. In the mouse
TT1 cell line mitotane inhibits both TSH expression and secretion, blocks TSH
response to TRH and reduces cell viability, inducing apoptosis at concentrations
in the therapeutic window. TRH is not capable of rescuing TT1 cells from the
inhibitory effects of mitotane on TSH expression and secretion, that appear after
short time treatment and persist over time. Our results demonstrate that mitotane
does not interfere with thyroid hormone laboratory tests but directly reduces both
secretory activity and cell viability on pituitary TSH-secreting mouse cells. These
data represent a possible explanation of the biochemical picture consistent with
central hypothyroidism in patients undergoing mitotane therapy, and open new
perspectives on the direct pituitary effects of this drug.
005.2
The inuence of cure of subclinical hyperthyroidism on diastolic
diameters of heart chambers and cardiac index
Grzegorz Kaminski, Zbigniew Podgajny & Norbert Szalus
Military Institute of Health Sevices, Warsaw, Poland.
Introduction
Subclinical hyperthyroidism (SH) affects about 1% of population. The diagnosis
of this disease leans on the laboratory criteria only: decreased of TSH and normal
FT
3
and FT
4
levels. SH increases mortality mostly due to cardiovascular diseases
including arrhythmia and overload of the heart. Enlarging of heart chambers is
one of the cause of arrhythmia, and cardiac index is one of indicators of heart
after load.
Aim
To estimate an infuence of cure of SH on heart chambers diastolic volumes (left
ventricle - LV, right ventricle - RV, left atrium LA) and cardiac index (CI)
measured by echocardiography (echo) and to fnd the relationships between these
parameters and TSH, FT
3
and FT
4
concentrations.
Method
Forty-four patients (37 women, 7 men) aged 45.911, with 12.89.8 month
history of only autonomous endogenous SH (TSH0.160.1 IU/l), were
examined with echo twice: before and 5.74.2 months after TSH normalization
(TSH1.320.1 IU/l) with radioiodine treatment (dose 12.15.7 mCi). The
average time between examinations was 12.56 months. The Local Ethical
Committee approval has been obtained.
Results
The cure of SH caused decrease of LV (P0.011), RV (P0.010), LA
(P,0.000) and CI (P,0.000). During SH the level of FT
3
was positively
correlated with LA (P0.008).
Conclusions
1. Cure of autonomous subclinical hyperthyroidism with radioiodine decreases
risk of atrial and ventricular arrhythmia, it also decreases heart after load.
2. In autonomous subclinical hyperthyroidism, the level of FT
3
positively
correlates with left atrium diastolic diameter.
3. Above fndings support the decision to treat endogenous subclinical
hyperthyroidism.
005.3
Socio-economic factors and mortality in Turner syndrome: a registry
study
Kirstine Stochholm & Claus Gravholt
Aarhus University Hospital, Aarhus, Denmark.
In Turner persons questionnaire surveys have identifed quality of life, perception
of health and education to be at a similar or higher level compared to the
background population. To shed further light on these seemingly paradoxical
fndings in Turner persons we aimed to analyze various socio-economic
parameters in Turner persons compared to an age-matched female background
population.
All diagnosed Turner syndrome women nationwide (n977) were identifed and
compared with an age-matched cohort of the female background population
(n94 883). The socio-economic parameters were marital status, education,
retirement, income, unemployment, children, and convictions. All were related to
age, study period, and time of diagnosis. Furthermore, we analyzed mortality
adjusted for marital status and education.
Our major fnding was signifcantly different socio-economic parameters in
Turner persons, only convictions and unemployment were comparable to
controls. In Turner persons, the educational level was signifcantly higher,
whereas income and the number of children were signifcantly reduced; however
the latter was surprisingly high. Being diagnosed with Turner syndrome had a
clear association with marital status and retirement. All-cause mortality adjusted
for gender and age and calendar time was signifcantly increased with a hazard
ratio (HR) of 3.2 (95% confdence interval: 2.6-3.9). Further adjusted for socio-
economic parameters, the HR only changed little.
A divergent socio-economic profle in Turner persons is apparent, with similar
educational level, but lower chance of cohabiting and higher risk of early
retirement. As previously reported, the mortality among Turner persons was
increased; it did not change when adjusted for socio-economic parameters.
005.4
One hormone, two functions: the chorionic gonadotropin in New World
Monkeys
Christian Adams
1
, Alexander Henke
2
& Jorg Gromoll
1
1
Centre of Reproductive Medicine and Andrology, Munster, Germany;
2
Medical Research Council, Human Reproductive Science Unit,
Edinburgh, UK.
Objective
The LH and chorionic gonadotropin (CG) are essential for reproduction and male
sexual development. While LH induces tesosterone production, CG is essential
for the establishment of pregnancy. In the New World Monkeys (NWM) the
initial duplication of the ancestral LH-beta subunit (LHB) gene, which gave rise
to the novel CG-beta subunit (CGB) gene, was followed by a genomic
rearrangement event, leading to CGB expression in pituitary and placenta,
whereas LHB became a pseudogene.
The aim of this study was to analyse the regulatory mechanisms triggering
pituitary and placenta specifc CGB expression in the marmoset (Callithrix
jacchus).
Methods
DNA-isolation, RT-PCR, DNA sequencing of the CGB gene, bisulfte analyses,
Dual-Luciferase-Assays and transfection of BeWo cells.
Results
The marmoset employs a system in which two different promoters, joined to two
different exon 1, regulate the expression of the CGB gene. In the pituitary
conventional exon 1 (including the exons of CGB 2 and 3) is driven by a pituitary-
specifc promoter, while novel exon 1 (plus the other two exons) is the pre-
dominant form in the placenta. The placental full length core promoter (600 bp)
displays a very high luciferase activity when transfected into the trophoblastic
BeWo cell line. No change can be observed in promoter activity in when the
promoter was truncated up to 360 bp. Additional trucation, when several
transcription binding sites were removed decreases activity by 50%. Furthermore
the placental promoter contains a distinct CpG island, which is absent in the
pituitary promoter. This might indicate that CpG methylation plays a role in the
tissue-specifc expression of CGB.
Conclusion
Our fndings in the marmoset give an insight into the tissue-specifc regulation of
of CGB by different promoter and start exons. This underlines the plasticity of the
primate LH/CG hormonal system and represents an interesting trait in the
evolution of hormones.
005.5
Predictive factors of intermittent ovarian function in patients with
premature ovarian failure
Maud Bidet, Estelle Bissauge, Jerome Dulon, Anne Bachelot &
Philippe Touraine
Department of Endocrinology and Reproductive Medicine, Paris, France.
Objective
Premature ovarian failure (POF) is not an early menopause and intermittent
ovarian function can be spontaneously observed in POF patients. We sought to
characterize these patients and determine which factors were predictors of
intermittent ovarian function.
Among 391 patients with idiopathic POF followed from 1997 in our department,
67 (17.1%) patients (Group 1) had POF fuctuating criteria: FSH ,15 IU/l,
resumed spontaneous menstrual cycles and/or spontaneous pregnancies.
We compared the clinical criteria, biological, ultrasonographic, histological and
genetic characteristics of these patients to other patients from the cohort of POF
patients (Group 2, n324). The mean follow-up period was 25.164 months in
Group 1 and 29.939 in Group 2 (NS).
Results
Sixty-four percent of Group 1 patients showed an intermittent ovarian function in
the year following their diagnosis. Primary amenorrhea was infrequently
observed in patients with fuctuating POF (2.98 vs 24.3% in Group 2, P,0.05).
FSH was more variable in Group 1 patients: 79.932.7 IU/l at POF diagnosis
versus 52.342.2 IU/l during hospitalisation and signifcantly lower than in
Group 2 (83.037.9 UI/l). Estradiol and Inhibin B were also signifcantly
higher in patients with fuctuating POF. Follicular structures were more
frequently visualized on ultrasound in patients with fuctuating POF (73.7 vs
43.8%, P,0.05). However, AMH levels were not signifcantly different
between the 2 groups. Ten patients (2.5%) experienced a pregnancy after
diagnosis of POF. Issues of pregnancies in POF patients were 8 deliveries, 2
miscarriages and 1 current pregnancy.
Conclusion
An intermittent ovarian function in POF patients is not a rare phenomenon and
seems more prevalent within a short time from the installation of a secondary
amenorrhea. Moreover, presence of follicles by ultrasound and FSH levels appear
to be more predictive than the AMH level.
005.
Universal screening detects twice more thyroid disorders in early
pregnancy than targeted high-risk case hnding
Jiri Horacek
1
, Sylvie Spitalnikova
2
, Blanka Dlabalova
1
, Eva Malirova
1
,
Jaroslav Vizda
1
, Ioannis Svilias
1
, Catherine McGrath
1
& Jaroslav Maly
1
1
Faculty of Medicine and University Hospital Hradec Kralove, Charles
University in Prague, Hradec Kralove, Czech Republic;
2
District Hospital
Havlickuv Brod, Havlickuv Brod, Czech Republic.
Screening of thyroid disorders in pregnancy has been a matter of controversy.
Recent recommendations favour targeted high-risk case fnding though this
approach may miss a signifcant number of those affected (Vaidya et al.
JCEM 2007).
Among 398 non-selected women in the 10th week of pregnancy, thyrotropin
(IRMA) 3.5 mIU/l was found in 10.3%, free thyroxine (RIA) ,10 pmol/l in
2% and thyroperoxidase antibodies (RIA) 50 IU/ml in 8.3%; a total of 65
(16.3%) had at least one abnormality. After exclusion of those already treated for
autoimmune thyroiditis, those identifed were offered further endocrine
examination.
Of these, 51 were seen in our endocrine clinic (incl. ultrasonography) and
followed up; only 2 were left untreated, while levothyroxine was started in 49
(mostly 50 g/day, range 50-100): in 42 for autoimmune thyroiditis and in 34 for
hypothyroidism (in 27 for both).
They were also assessed according to 10 accepted high-risk criteria (Abalovich
et al. JCEM 2007). Only 23 (45%) of positively screened women fulflled at least
one high-risk criterion: most commonly positive family history (31%), history of
miscarriage or preterm delivery (14%), and positive personal history (8%).
In our cohort, therefore, over half (55%) of pregnant women with clear
abnormalities suggestive of autoimmune thyroiditis and/or hypothyroidism, and
indicated for treatment, would be missed if only those with high-risk criteria were
examined.
Bone
00.1
A proteomic approch to study parathyroid glands
Filomena Cetani
1
, Laura Giusti
2
, Federica Ciregia
2
, Chiara Banti
1
,
Ylenia Da Valle
2
, Elena Donadio
2
, Antonio Lucacchini
2
&
Claudio Marcocci
1
1
Endocrinology and Metabolism, Environment and Endocrine and Nervous
Systems High Technology Center for the Study of the Effects of Harmful
Agents, University of Pisa, Pisa, Italy;
2
Psychiatry, Neurobiology,
Pharmacology and Biotechnology, Pisa, Italy.
The molecular basis of parathyroid tumorigenesis has increased greatly over
the last years and the variety of described abnormalities suggests different
genetic defects leading to dysfunction of parathyroid cells. Using a combined
approach based on two-dimensional electrophoresis (2DE) and mass
spectrometry (MS) we performed a comparative proteome analysis to examine
the global changes of parathyroid adenoma tissues protein profle with respect
to the normal parathyroid tissue.
Sixteen parathyroid adenomas were studied. Three normal parathyroid biopsies
obtained from Italian normocalcemic patients were used as control. Adenoma and
normal samples from parathyroid tissue were compared by 2DE. Silver staining of
2DE gels detected 1293110 and 1122238 protein spots within a pH range
from 3 to 10 from normal and adenoma parathyroid tissue respectively. By
computational 2D gel image comparison, a total of 37 protein spots were found to
be differentially expressed each exhibiting 2 fold-change (either increase or
decrease) of mean value spot intensity in the adenoma with respect to normal
samples. Among these 32 spots were identifed by mass spectrometry. Western
blot analysis was used to validate the expression changes of some proteins
(i.e. Calmodulin, BSpry, Erk2, CCT-5, Parvalbumin and Peroxiredoxin-1) in
parathyroid adenoma with respect normal samples. Among the proteins identifed,
a variety of biological functions were noted including programmed death cell,
electron transport, cell proliferation, response to biotic stimulus, catabolism, lipid
metabolism, cell organisation and biogenesis and organogenesis, transport,
protein metabolism, signal transduction and chaperon activities. Furthermore
pathway analysis indicated that 14 of these proteins are involved in a Cellular
Development, Cellular Growth and Proliferation, Renal and Urological System
Development and Function-associated network based on current literature. Our
results demonstrate that proteomic analysis of parathyroid tissue may be an useful
tool to identify potential biomarkers implicated in parathyroid cancer progression.
00.2
Association between serum osteocalcin and insulin sensitivity in
primary hyperparathyroidism
Laura Gianotti, Francesco Tassone, Micaela Pellegrino, Claudia Baffoni,
Chiara Giulia Croce, Flora Cesario & Giorgio Borretta
Division of Endocrinology and Metabolism, Santa Croce and Carle
Hospital, Cuneo, Italy.
A regulatory role of the skeleton on glucose metabolism has been supposed both
in animals and in humans. Osteocalcin (OC) seems to be involved in this
regulation and has been reported to be inversely associated with insulin resistance
and measures of adiposity in different populations of adult subjects. Primary
hyperparathyroidism (PHPT) is a condition mostly affecting elderly subjects and
characterized by both marked increased bone turnover and increased insulin
resistance. The aim of the study was to evaluate whether OC levels maintained the
association with blood markers of insulin resistance and BMI in a large series of
subjects with PHPT at the time of the diagnosis. In a consecutive series of
219 patients with PHPT (age, meanS.E.M., 59.113.6 years; BMI: 25.5
5.2 kg/m
2
; PTH: 200.9164.8 pg/ml; Ca: 11.11.1 mg/dl) we measured
serum and urinary bone markers including serum OC, ALP, bone ALP and
urinary cross-links as well as fasting insulin and glucose levels. In all patients
insulin sensitivity was estimated by homeostatic model assessment (HOMA). In
PHPT patients mean serum OC was clearly higher than normal range. After
dividing PHPTpatients according to glucose tolerance to OGTT, we found that OC
was similar in NGT and IGT (52.354.7 and 51.250.7 ng/ml, respectively) and
higher than DM (28.720.2 ng/ml, P,0.02 and ,0.04 versus NGT and IGT,
respectively). In all PHPT patients, OC was negatively associated with fasting
glucose (R0.24, P,0.0002), while positively with index of insulin sensitivity
Homa-2S (R0.16, P,0.025). After multivariate analysis, among all bone
markers, serum OC resulted independently associated with HOMA2S ( 0.031,
P,0.02). Our fndings show that in PHPT, a condition connoted by high bone
turnover and increased OC, the relationship between OC and insulin sensitivity is
maintained. These results provide support for a role of OC in regulating glucose
tolerance and insulin sensitivity in humans. The protective effect of high OC
levels on the PHPT-related diabetogenic risk is still to be established.
00.3
Six novel mutations in 25-hydroxyvitamin D3 1 hydroxylase gene in
patients with pseudovitamin D dehciency rickets
Genevie`ve Abeguile
1,2
, Nadia Coudray
1,2
, Nicolas Richard
1,2
,
Agnes Linglart
2,3
& Marie-Laure Kottler
1,2
1
Molecular Genetics-CHU de Caen, 14121 Caen, France;
2
Reference Center
for Rare Disorders of Calcium and Phosphorus Metabolism, 75014 Paris,
France;
3
Endocrinology; Saint Vincent de Paul Hospital, 75014 Paris,
France.
Pseudovitamin D defciency rickets also called vitamin D-defciency rickets type
1 (VDDR 1) is an autosomal recessive disorder in which 25-hydroxyvitamin D3 1
alpha-hydroxylase gene (CYP27B1) is defcient. VDDR1 is characterized by
hypocalcemia,hypophosphatemia elevated serum PTH levels and low or
undetectable serum concentrations of 1,25(OH)
2
D.
We screened for mutations CYP27B1 in ten individuals from seven unrelated
families with VDDR-1. In three families parents were consanguineous. The frst
symptoms appeared within the frst year of life except in F5 et F7 where diagnosis
was made in two boys at 8 and 5 years respectively. In these patients laboratory
abnormalities were mild with normal serum 1,25(OH)D3 but elevated serum
alkaline phosphatase activity and PTH. Patients responded well to treatment with
1-OHD.
The nine exons were amplifed by PCR and sequenced. We identifed eight
unclassifed variants including six new one which were not found in a panel of
normal control.
The classical laboratory criteria for the diagnosis of VDDR1 may fail to identify
patients with partial but signifcant defect in this enzyme and hence, this
syndrome may be more common than previously appreciated.
00.4
Age-dependent features of bone mineral density changes in male rats
with hyperthyroidism
Vladyslav Povoroznyuk
1
& Iryna Gopkalova
2
1
Institute of Gerontology AMS Ukraine, Kyiv, Ukraine;
2
Institute of
Endocrine Pathology Problems AMS Ukraine, Kharkov, Ukraine.
The aim of the study was to evaluate the infuence of high levels of thyroid
hormones on bone mineral density in male rats as a function of experimental
hyperthyroidism duration and age.
Research object
Research is conducted on 56 white male rats of 'Wistar` breed. There were three
age-dependent groups (1.5 month rats are pre-pubertal, 5-6 month are
reproductive animals and 24 month - old). Animals were subdivided into 6
groups: group 1 - 10 pre-pubertal male rats (mass - 0.1050.01 kg) made up a
control group; group 2 - 10 pre-pubertal rats of experimental group (mass -
0.0940.006 kg) getting L-thyroxin injection in a dose of 25 g/100 g of body
weight/day i.m., during 15 or 30 days;. group 3 - 10 reproductive males of control
group (mass - 0.180.005 kg); group 4 - 8 reproductive males (mass - 0.20
0.007 kg) getting L-thyroxine; group 5 - 10 old males of control group
(mass - 0.3170.010 kg); group 6 - 8 old males experimental group (mass -
0.3000.011 kg) getting L-thyroxine.
Research methods
Bone mineral density (BMD) was measured using dual energy X-ray
densitometry (DEXA) and 'Experimental animals` software. Examination was
made before and over 15 and 30 days after start of experiment. Increase of
percentage of bone mineral density at various skeletal sites was determined. The
index was calculated according to the formula:
BMD (%)(BMD/BMD ref.),100.
BMD ref. - initial indexes of bone mineral density of the entire body.
Research results
Comparative dynamics indexes of bone mineral density in male rats of control
group and of experimental group: group 1 (BMD
0
0.0810.002 g/cm
2
,
BMD
15
11.050.83%, BMD
30
24.892.41%), group 2 (BMD
0

0.0840.002 g/cm
2
, Student`s t-criterion0.036, P
1-2
0.972; BMD
15
2.874.97%, Student`s t-criterion2.76, P
1-2
0.013; BMD
30
8.46
3.60%, Student`s t-criterion4.48, P
1-2
,0.0001), group 3 (BMD
0
0.105
0.001 g/cm
2
; BMD
15
1.872.208%; BMD
30
9.630.97%); group 4
(BMD
0
0.1210.004 g/cm
2
, Student`s t-criterion4.29, P
3-4
,0.0001;
BMD
15
3-4
,0.0001;
BMD
30
3-4
,0.0001); group
5 (BMD
0
0.1230.003 g/cm
2
; BMD
15
2.941.99%; BMD
30
1.43
1.20%); group 6 (BMD
0
0.1430.009 g/cm
2
, Student`s t-criterion 2.30,
P
5-6
0.035; BMD
15
15.342.97%, Student`s t-criterion 3.58, P
5-6
0.002; BMD
30
9.7073.66%, Student`s t-criterion 3.16, P
5-6
0.006).
Conclusions
It was revealed that high doses of thyroid hormones would cause the decline of
BMD in all age-dependent groups. The maximum loss of BMD occurred among
the male rats of reproductive and old age. The development of experimental
osteoporosis under the infuence of high levels of thyroid hormones may be
divided in two phases: the frst phase is an acute loss of BMD (15 days), while the
second phase is a slower loss of BMD (30 days).
00.5
The ratio of PTH as measured by third and second generation assays as
a marker for parathyroid carcinoma
Etienne Cavalier
1
, Adrian F Daly
1
, Daniela Betea
1
, Pierre Delanaye
1
,
Phil Stubbs
2
, Athur R Bradwell
2
, Jean-Paul Chapelle
1
& Albert Beckers
1
1
Centre Hospitalier Universitaire, University of Liege, Liege, Belgium;
2
The Medical School, University of Birmingham, Birmingham, UK.
Background
Parathyroid carcinoma (PCa) is a rare disease that can be diffcult to differentiate
initially from benign parathyroid adenoma. PCa over-secrete the amino form of
parathyroid hormone (PTH), which is recognized by 3rd generation but not by
2nd generation ('intact`) PTH assays. In normal individuals, the 3rd
generation/2nd generation PTH ratio should always be ,1.
Material and methods
We studied the utility of the 3rd generation/2nd generation PTH ratio as a means
of distinguishing PCa patients (n24) from control groups with and without
disorders of calcium secretion, including patients on renal hemodialysis (n73),
post-renal transplantation (60), elderly healthy (n82) and primary hyper-
parathyroidism (PHP; n30). 2nd and 3rd generation PTH were assayed with the
PTH Duo kit (Scantibodies, Shantee, CA, USA).
Results
The mean 3rd generation/2nd generation PTH ratio was 0.580.10 in the dialysis
patients, 0.540.10 in the renal transplant group, 0.540.12 in the elderly
healthy patients and 0.680.11 in the PHP group. All 245 of these patients
presented a 3rd generation/2nd generation PTH ratio of ,1. In contrast, we
observed an inverted 3rd generation/2nd generation PTH ratio 1 in 20 PCa
patients, whereas only 4 PCa patients had a 'normal` ratio of ,1.
Conclusions
An inverted 3rd generation/2nd generation PTH ratio occurred in the majority of
patients with advanced PCa and was absent in all 245 relevant controls. A 3rd
generation/2nd generation PTH ratio 1 had a sensitivity of 83.3% and a
specifcity of 100% amongst PHP patients as a marker for PCa; among all
published cases, the sensitivity was 75.8% and the specifcity was 98.9%. This
ratio may be useful to identify patients with PCa earlier, and to detect patients
either at risk of developing PCa or those in whom recurrence is occurring.
00.
Suppression of circulating hbroblast growth factor-23 by cinacalcet in
patients with primary hyperparathyroidism
Yasuo Imanishi, Masafumi Kurajoh, Keisuke Kobayashi, Akira Ishii,
Tomoki Nagata, Takami Miki, Masaaki Inaba & Yoshiki Nishizawa
Osaka City University Graduate School of Medicine, Osaka, Japan.
While the importance of fbroblast growth factor 23 (FGF-23) is established in the
pathogenesis of phosphate wasting disorders, little is known about the
mechanisms regulating its circulating level. To investigate the role of parathyroid
hormone (PTH) in FGF-23 homeostasis, cinacalcet hydrochloride, a calcimimetic
compound to suppress PTH secretion, was administered to the patients with
primary hyperparathyroidism (PHPT). Fourteen patients with PHPT, who met the
guidelines of the National Institutes of Health for parathyroidectomy, were
enrolled in this study with written informed consent. Thirty milligrams cinacalcet
was administered twice daily, 12 h apart. Fasting serum was obtained before
administration of cinacalcet on designated days. For further examinations, serum
was obtained at 0, 2 and 4 h after administration on day 1 and 3. Fasting serum
examinations revealed that corrected Ca decreased signifcantly from 3 days after
administration, P increased from 3 days, FGF-23 decreased from 8 days, however,
no signifcant changes were observed in serum whole PTH and 1,25(OH)
2
D,
compared to pre-administrations. On day 1, FGF-23 and whole PTH decreased
signifcantly at 2 and 4 h after administration, however, no signifcant changes
were observed in corrected Ca, P and 1,25(OH)
2
D. Similar results were obtained
at day 3. Signifcant but transient suppression of PTH at 2 and 4 h after cinacalcet
administration enabled to distinguish the role of PTH and Ca on FGF-23
regulation. PTH is suggested to elevate circulating FGF-23, in part not via Ca
increment, in PHPT.
j O L
VS1 and
exon 8
Exon 2 Exons 2
and 8
Exon 2 Exon 7 Exon 8 Exon 8
c.196-2AG
c.1319_1325
a
dupCCCACCC
p.P105F p.E106X
p.R459C
p.A129T p.G398S c.1319_1325
a
dupCCCACCC
p.R453H
F F C C/F C/F
Splice site
mutation
Heme
binding
site
Substrate
binding-
site
Truncated
protein
Heme site
C, consanguineous; F, familial.
a
Wang A !_u (1998).
Poster Presentations
Adrenal
P1
Differentiation between benign and malignant adrenal mass using
contrast-enhanced ultrasound
Mireen Friedrich-Rust, Timo Glasemann, Katharina Holzer,
Susanne Kiener, Eva Herrmann, Andreas Polta, Stefan Zeuzem
& Joerg Bojunga
J.W.Goethe-University Hospital, Frankfurt a.M., Germany.
Background
Adrenal masses can be detected by ultrasound with high sensitivity and
specifcity. However, a differentiation between benign and malignant adrenal
masses is not possible with conventional ultrasound. Contrast-enhanced
ultrasound (CEUS) is a established method for the characterization of focal
liver lesions. A frst pilot study (n35) analyzing the dynamics of contrast-
enhancement during CEUS reported a high sensitivity for differentiation of
benign and malignant adrenal mass. The aim of the present study was to evaluate
CEUS in a larger patient population using the CEUS patterns identifed in the
pilot study.
Methods
One hundred and eight patients with 116 adrenal incidentaloma received an
ultrasound of the adrenal mass, including Duplex and Doppler ultrasound,
followed by CEUS with the contrast agent Sonovue. The dynamic of contrast-
enhancement (CE) was analyzed using time-intensity curves. The time of CE in
the adrenal mass was used to defne four CEUS-patterns: pattern Iearly arterial
CE, pattern IIarterial CE, pattern IIIlate CE, pattern IVno CE. In addition,
all patients received CT or MRI and a detailed laboratory testing including
hormone profle. In susceptive cases biopsy or adrenalectomy was performed.
Results
CEUS-pattern I&II was seen in all patients with primary or secondary malignant
lesions of the adrenal gland (n16). Sensitivity and specifcity of CEUS for the
diagnosis of malignant adrenal mass using pattern I&II to defne malignancy and
pattern III&IV to defne benign lesion was 100% (CI (75;100)) and 67% (CI
(56;75)), respectively. Eight benign pheochomocytoma, one ganglioneuroma,
two myelolipoma and four adenoma showed a perfusion pattern I/II and therefore
were misclassifed as malignant using CEUS. Overall 38 patients received
adrenalectomy of together 40 adrenal masses. In 70% of the surgically removed
adrenal masses MRT/CT and CEUS were congruent concerning the character-
ization of adenoma versus non-adenoma.
Discussion
Contrast-enhanced ultrasound may be a useful method in the diagnostic work-up
of adrenal incidentaloma with excellent sensitivity for the diagnosis of malignant
adrenal mass.
P2
Alterations in lipid and carbohydrate metabolism in patients with
classic CAH due to 21-hydroxylase dehciency
Anca Zimmermann
1
, Paula Grigorescu Sido
1,2
, Camelia Al Khzouz
1,2
,
Karen Patberg
1
, Simona Bucerzan
1,2
, Egbert Schulze
1,3
, Tim Zimmermann
1
& Matthias M Weber
1
1
Johannes Gutenberg University of Mainz, Mainz, Germany;
2
Iuliu
Hatieganu University of Medicine and Pharmacy, Cluj, Romania;
3
Laboratory for Molecular Genetics, Heidelberg, Germany.
Background
Classic 21-hydroxylase defciency (21HD) presents some traits of the metabolic
syndrome. We aimed to characterize discrete alterations of lipid and carbohydrate
metabolism in children and young adults with classic 21HD, which could predict
early atherogenesis.
Design
Cross-sectional comparative.
Of 27 Caucasian patients with classic 21HD (4-31 years); 27 sex-, age- and BMI-
matched controls. Clinical parameters, hormonal status and genotype were
assessed in all patients. Lipid parameters, including the relative (%) and absolute
(mg/dl) small-dense LDL subfractions (sd-LDL) were measured in patients and
controls. Oral glucose tolerance tests were performed in both groups; insulin
resistance indexes were calculated. All patients and controls and where underage
their parents or legal guardians gave their written informed consent for
participation in this observational study.
Results
sd-LDL (%) was signifcantly higher in patients than controls (39.75.9 vs
35.55.7%, P0.008). The same applies for absolute sd-LDL (mg/dl) (42.6
11.9 vs 36.47.5, P0.029). HDL-CL was lower in patients than controls
(P0.032). Fasting glucose and insulin were signifcantly higher in patients than
controls. The same differences were noticed for HOMA-IR (2.421.48 vs 1.24
0.68; P0.001), IRI (2.900.29 vs 2.630.26; P0.001), HOMA-B
(42.123.41 vs 25.0613.43; P0.002) with inverse signifcant relations
regarding glucose/insulin ratio. IRI correlated directly and signifcantly with the
total hydrocortisone dose and the duration of treatment. Fasting glucose
correlated with absolute sd-LDL. No obvious differences were seen between
clinical forms or genotype groups.
Conclusions
Children and young adults with 21HD present with increased atherogenic sd-LDL
subfractions, decreased HDL-CL concentrations and insulin resistance. Sub-
stitution therapy should be adapted particularly at this life period to prevent early
atherogenesis and cardiovascular risk in later life.
P3
Glucocorticoid receptor polymorphisms and metabolic-cardiovascular
impairment in adult patients with Addison`s disease under glucocorti-
coid replacement therapy
Roberta Giordano
1
, Alberto Falorni
2
, Giorgia Mandrile
3
, Daniela Gioachino
3
,
Marcella Balbo
4
, Rita Berardelli
4
, Ioannis Karamouzis
4
, Elisa Marinazzo
4
,
Andreea Picu
4
, Stefania Marzotti
2
, Serena Romagnoli
2
, Ezio Ghigo
4
& Emanuela Arvat
4
1
Department of Clinical and Biological Sciences, University of Turin,
Orbassano (Turin), Italy;
2
Department of Internal Medicine, University of
Perugia, Perugia, Italy;
3
Medical Genetics, Department of Clinical and
Biological Sciences, University of Turin, Orbassano (Turin), Italy;
4
Division of Endocrinology, Diabetology and Metabolism, Department of
Internal Medicine, University of Turin, Turin, Italy.
Object
In Addison`s disease (AD), although glucocorticoid (GC) replacement is essential
for health and, indeed, life, several studies showed that conventional GCs doses
are involved in metabolic and cardiovascular alterations observed in this disease.
As the effects of GCs are mediated by the glucocorticoid receptor (GR), encoded
by NR3C1 gene, different polymorphisms in the NR3C1 gene have been linked to
altered glucocorticoid sensitivity in general population as well as in patients with
obesity or metabolic syndrome.
Design
We investigated the impact of GR gene polymorphisms, including the BclI
(rs41423247:CG), N363S (rs6195:AG) and ER22/23EK (rs6189:GA and
rs6190:GA) variants, on waist circumference and metabolic profle (HOMA,
OGTT and serum lipids) in 38 AD patients (12 M and 26 F; range of age: 20-72
years; BMI: 24.60.4 kg/m
2
) under conventional GC replacement, compared
with 38 age-, sex- and BMI-matched controls (CS).
Results
Allelic frequencies of the three polymorphisms between AD and CS were similar.
Considering overweight and obese subjects (n18), mean waist was higher
(P,0.05) in AD (94.22.3 cm) than in CS (85.81.9 cm), being a higher
percentage of AD compared to CS connoted by an abdominal fat distribution (83
vs 44%). Neither N363S nor ER22/23EK variants were signifcantly related to
waist in both groups, while AD patients carrying the homozygous BclI
polymorphism GG (2 out of 38) had higher (P,0.05) waist circumference
(95.55.5 cm) than those with wild-type genotype CC (24 out of 38 patients;
90.31.9 cm) or heterozygous CG (12 out of 38 patients; 83.93.5 cm). A
higher percentage of AD compared to CS were IGT (8 vs 0%), hypercholester-
olemic (18 vs 8%) and hypertriglyceridemic (18 vs 8%). All AD patients with the
GG genotypes had IGT, hypercholesterolemia and hypertryglyceridemia, while
33% of CC and 16% of CG showed metabolic alterations. No statistically
signifcant differences between heterozygous or homozygous BclI carriers and
noncarrieres were found for metabolic parameteres in CS.
Conclusion
These preliminary results show that the BclI polymorphism may infuence the
sensitivity to glucocorticoids in patients with Addison`s disease and may
contribute, together with GC therapy, to the increase of the risk for central
adiposity, impaired glucose tolerance and dyslipidemia.
P4
Clinically silent adrenal incidentalomas: their relation to metabolic
syndrome and to GNB3 C825T gene polymorphism
Ivica Lazurova, Daniela Spisàkova, Hedviga Wagnerova, Viera Habalova,
Ingrid Dravecka, Darina Petrasòva & Lydia Pundova
Medical Faculty University Kosìce, Kosìce, Slovakia.
Objectives
Aim of the study was frstly to assess the prevalence of metabolic symptoms in
patients with clinically silent and benign adrenal incidentalomas (AI) and
secondly to determine the prevalence of C825T GNB3 gene polymorphism in AI
as well as its relation to metabolic variables.
Subject and methods
Group of patients consisted of 50 patients with AI of mean age 57.915 years
and group of controls consisted of 22 subjects without AI and metabolic disorders
(mean age 53.54.2 years). Prevalence of insulin resistance calculated as HOMA
index was signifcantly higher in AI than controls (38 vs 9%) as was the
prevalence of overweight or obesity (78 vs 45%).
Results
Patients with AI had signifcantly higher BMI, HOMA, triacylglycerols (P,0.05)
and signifcantly lower serum adiponectine (P,0.05) than controls. There were
no signifcant differences in metabolic parameters between group with and
without subclinical Cushing syndrome (SCS). There was no relation of metabolic
parameters to the size of the tumor although patients with tumor larger than 3 cm
had signifcantly higher serum cortisol after dexamethasone. The prevalence of T
allele of GNB3 gene was not signifcantly higher than the prevalence of C allele
(32 vs 47%). However carriers of T allele had signifcantly lower serum
adiponectin than those with C allele only (P,0.01).
Conclusion
We conclude that patients with AI have signifcantly higher cardiovascular risk
factors that are not related to the presence of SCS. Moreover patients with AI and
with TC or TT genotype have signifcantly lower serum adiponectin which may
be an early symptom of metabolic synrdrome in patients with AI.
P5
Evaluation of haemostatic and hbrinolytic markers in patients with
Cushing`s syndrome: a longitudinal study
Valentina Raffaelli
1
, Luca Manetti
1
, Lucia Ruocco
2
, Clara Giovannetti
1
,
Maura Genovesi
1
, Giovanni Pellegrini
2
, Fausto Bogazzi
1
& Enio Martino
1
1
Department of Endocrinology, University of Pisa, Pisa, Tuscany, Italy;
2
Department of Laboratory Medicine, University of Pisa, Pisa, Tuscany,
Italy.
Patients with active Cushing`s syndrome (CS) have an increased coagulability
and thrombotic tendency. High glucocorticoids concentrations increase plasma
clotting factors, especially von Willebrand factor (vWf) and reduced fbrinolytic
capacity. Thromboemobolic complications, mainly in the postsurgical phase,
have been reported.
Aim of this longitudinal study was to evaluate haemostatic and fbrinolytic
markers in patients with active Cushing`s syndrome during the activity and after
the remission or the persistency of the disease.
Forty patients (32 women and 9 men) with CS were enrolled in the study: 36 were
affected by ACTH-secreting pituitary adenoma and 4 by an adrenal adenoma. All
patients, at the starting of the study, had an active CS. All patients were
re-evaluated after 12-24 months after surgery: 27 presented the remission of the
disease (Group 1), 13 had persistent hypercortisolism (Group 2). Haemostatic and
fbrinolytic markers were evaluated in all patients during the activity of the
disease and after surgery. No patients were taking drugs to affect coagulations
tests.
von Willebrand factor (P,0.0001), plasminogen activator inhibitor (PAI-1)
activity (P0.003), antithrombin III (P0.0002) and plasmin-antiplasmin
complex (P0.006) were statistically different in Group 1. No differences
between active and remission patients were observed in other markers
(fbrinogen, prothrombin fragment 12, factor V, factor VII, factor IX, factor
XII, activated partial thromboplastin time, thrombin-antithrombin complex,
plasminogen, and D-dimer). No statistical differences of haemostatic and
fbrinolytic markers were observed between patients of Group 2.
The study confrms that CS is associated with a thrombophilic state and to the
alteration of the fbrinolytic system. Recent studies provide evidence that
polymorphisms in the vWf and PAI-1 can infuence the corticosteroid-mediated
transcriptional regulation of these factors. Therefore, further studies are necessary
to defne the modifcations of coagulation cascade in hypercortisolism.
P
Supine and upright plasma renin (PR) and aldosterone (ALD) in
patients with adrenal incidentaloma (AI)
Miomira Ivovic, Milos Stojanovic, Milina Tancic-Gajic, Ljiljana Marina,
Marija Barac & Svetlana Vujovic
Institute of Endocrinology, Diabetes and Metabolic Diseases, Belgrade,
Serbia.
AI are incidentally discovered adrenal masses without any prior suspicions of
adrenal disease. They are most frequently hormonally inactive, with arterial
hypertension (AH) as a common fnding.
The aim was to determine upright and supine PR and ALD levels in patients with
AI, normotensive and hypertensive.
Two hundred and eight patients (148 women and 60 men, mean age 55.08
11.02 years, mean BMI 27.914.6 kg/m
2
) with AI (confrmed by
CT/MRI) were admitted to our Institute. After endocrine testing 91
normokaliemic patients had nonfunctional adrenal mass, in which we
determined PR and ALD. We divided them in two groups: I: 49 patients (38
women and 11 men, mean age 56.6210.33 years, mean BMI 28.6
4.32 kg/m
2
) with confrmed AH; II: 42 patients (27 women and 15 men,
mean age 53.3411.58 years, mean BMI 26.994.81 kg/m
2
), normotensive.
Blood samples were taken in supine and after 2 h upright position. PR and
ALD levels were determined by RIA kits. Statistical analysis was done by
Wilcoxon signet rank, Mann-Whitney and Fisher Exact Test.
In the whole group mean supine PR values were 1.131.59 ng/ml per h, and
mean postural PR values were 2.923.87 ng/ml per h; mean supine ALD
values were 69.1692.16 ng/l, and mean postural ALD values were 217
184.18 ng/l. ALD/PR over 30 was detected in 18.61% patients. Supine PR
values were signifcantly lower in hypertensive group (1.6 vs 0.71 ng/ml per h;
P,0.01) as well as were postural values (4.11 vs 1.89 ng/ml per h; P,0.01).
There was no signifcant difference in supine and upright mean ALD values
between the groups (supine 77.21 vs 62.27 pg/ml; P0.679; upright 216.8 vs
219.9 pg/ml, P0.400). A difference in percentage of patients with ALD/PR
ratio 30 between tested groups was signifcant (19.61 vs 31.25%, P,0.01).
In our study, hypertensive patients with adrenal tumors had lower PR activity
than normotensive patients in light of normal ALD supine and upright values
without signifcant difference between the groups.
PI
Benehcial metabolic effects of surgical treatment in patients with an
adrenal incidentaloma causing subclinical hypercortisolism
Iacopo Chiodini
1
, Valentina Morelli
1
, Antonio Stefano Salcuni
1,2
, Cristina
Eller Vainicher
1
, Massimo Torlontano
2
, Francesca Coletti
3
, Laura Iorio
4
,
Antonello Cuttitta
2
, Angelo Ambrosio
2
, Leonardo Vicentini
1
,
Fabio Pellegrini
2,5
, Massimiliano Copetti
2
, Paolo Beck-Peccoz
1
,
Maura Arosio
1,3
, Bruno Ambrosi
4
, Vincenzo Trischitta
2,6
& Alfredo Scillitani
2
1
Fondazione IRCCS Ca` Granda - Ospedale Maggiore Policlinico,
University of Milan, Milan, Italy;
2
Ospedale 'Casa Sollievo della
Sofferenza` IRCCS, San Giovanni Rotondo, Foggia, Italy;
3
Ospedale San
Giuseppe di Milano, Milan, Italy;
4
IRCCS Policlinico San Donato Institute,
San Donato Milanese, University of Milan, Milan, Italy;
5
Consorzio Mario
Negri Sud, Santa Maria Imbaro, Chieti, Italy;
6
Sapienza University, Rome,
Italy.
Objective
In patients with adrenal incidentalomas (AI) the metabolic effect of the recovery
of subclinical hypercortisolism (SH) is debated. The aim of this study was to
determine the effect of the surgical and conservative approaches on the metabolic
syndrome in AI patients with and without SH.
Patients
One hundred and eight AI patients were studied; SH was diagnosed in the
presence of 2 out of: urinary free cortisol 70 g/24 h (193 nmol/24 h),
cortisol after 1mg-dexamethasone-suppression-test 3.0 g/dl (83 nmol/l),
ACTH ,10 pg/ml (2.2 pmol/l). Surgery was performed in 25 patients with SH
(Group TrSH) and 30 without SH (Group TrSH), while the conservative
approach was chosen by 16 patients with SH (Group UntrSH) and 37 without
SH (Group UntrSH).
Methods
During the follow-up (18-48 months), the improvement/worsening of body
weight, blood pressure or glucose and cholesterol levels was defned in the
presence of a 5% weight decrease/increase and following the European Society
of Cardiology or the ATPIII criteria, respectively.
Results
In Group TrSH, weight, blood pressure and glucose levels improved (32%,
56%, 48%, respectively) more frequently than in Group UntrSH(12.5%,
P0.05; 0.0%, P,0.0001; 0.0%, P0.001; 0.0%, P0.0014, respectively). In
Group UntrSH, blood pressure, glucose and LDL levels worsened more
frequently (50.0%, 37.5%, 50.0%, respectively) than in Group TrSH(0.0%,
P,0.0001; 0.0%, P0.001, 20.0%, P0.05, respectively). The surgical
treatment was associated with weight loss (OR 6.5, 95% CI 1.2-36.5,
P0.034), improvement of blood pressure (OR 5.9, 95% CI 1.9-18.0,
P0.002), and fasting glucose levels (OR 4.4, 95% CI 1.2-16.9, P0.031),
regardless of age, duration of follow-up, and for the presence of obesity or arterial
hypertension or diabetes mellitus at baseline. A treatment-by-SH group
interaction was present for fasting glucose (P0.36) and tended to the statistical
signifcance for blood pressure levels (P0.073).
Conclusions
Regarding the various components of the metabolic syndrome, in AI patients with
SH, surgery is benefcial.
P8
The consideration of external steroid therapy history and skin bruising
sign with morning serum cortisol measurement predicts better results
of rapid ACTH stimulation test than morning serum cortisol only
Sun Ok Song, Se Hwa Kim & Hyeong Jin Kim
Myongji Hospital, Goyang, Gyeonggi, Republic of Korea.
The morning serum cortisol measurement has long been used as an index of
adrenal function in the unstressed patient, but does not necessarily differentiate
normal subjects from those with adrenal dysfunction. We investigate causes and
clinical fndings of adrenocortical insuffciency in this study, and will propose a
model predicting results of rapid ACTH stimulation test. A consecutive series of
363 subjects who were examined rapid ACTH stimulation were recruited.
Adrenocortical insuffciency was diagnosed in 103 of 363 subjects. After
adjusting sex and age, morning serum cortisol level (P,0.0001), external steroid
therapy history (P0.046), and skin bruising (P0.01) were independent factors
predicting adrenocortical insuffciency by rapid ACTH stimulation test in
biliniary logistic regression analysis. When morning serum cortisol level were
,3, 4, and 5 g/dl, probabilities of adrenocortical insuffciency were 83.3, 76.4,
and 70.8%. When morning serum cortisol level of subjects with external steroid
therapy history and skin bruising was ,5 g/dl, probability of adrenocortical
insuffciency was 100%. When morning serum cortisol level of subjects without
external steroid therapy history or skin bruising were more than 10, 11, 14, and
19 g/dl, probabilities of adrenocortical insuffciency were 91.4, 92.7, 95.4, and
92.9%. When morning serum cortisol level is used to predict the result of rapid
ACTH stimulation test, it rases predictive power to take together external steroid
therapy history and the presence of skin bruising into consideration.
P9
A high prevalence of primary hyperaldosteronism in hypertensive
patients
Agnieszka Jagodzinska, Wojciech Zieleniewski & Renata Michalak
Department of Endocrinology, Medical University of Lodz, Lodz, Poland.
Hypertension remains one of the most common diseases affecting more than
25% of the whole population. It is associated with high mortality risk
due to cardiovascular complications. Usually hypertension is of idiopathic
origin, however, several other diseases, including hormonal abnormalities may
cause hypertension.
Here, we present the frequency of primary hyperaldosteronism in a group of 310
hypertensive patients.
Previously, they had excluded other potential causes of hypertension, such as
renal diseases, diabetes mellitus, cardiac malformations other hormonal
disturbances or drugs affecting blood pressure.
All subjects underwent saline infusion test with determination of plasma
aldosterone (RIA assay) and active renin concentration (radioimmunoenzymatic
assay) before and after 2.0 l of isotonic standard saline infusion for 4 h i.v).
Moreover, they had measured ACTH, cortisol, DHEA-S and chromogranin A
concentrations. Ultrasonography was performed in all patients and abdominal CT
scan in those with abnormal hormonal results.
Primary hyperaldosteronism was confrmed in 55 patients (18%), 36 women and
19 men. Idiopathic hyperaldosteronism was found in 36 patients (65%), whereas
adrenal adenoma in 19 patients (35%). Hypokalaemia was found in 23 patients
(42%). Moreover, an aldosterone/active renin ratio above 8.25 strongly suggest
the existence of primary hyperaldosteronism.
In conclusion, we suggest screening for hyperaldosteronism in young
hypertensive patients with poorly controlled blood pressure with standard
antihypertensive therapy and tendency to low kalium concentration.
P10
Cushing`s syndrome: screening and diagnosis aspects
Corina Crista
1
, Anda Cismas
2
, Roxana Voicu
3
, Nagaraj Manjunath
4
,
Maria Dana Bobu
5
& Bogdan Alin Nes
5
1
Clinic of Endocrinology, University of Medicine and Pharmacy 'Victor
Babes`, Timisoara, Romania;
2
Student in the VIth year, University of
Medicine and Pharmacy 'Victor Babes`, Timisoara, Romania;
3
Clinic of
Metabolic Diseases, County Hospital No. 1, Timisoara, Romania;
4
Institute
of Cardiology, Timisoara, Romania;
5
Clinic of Nephrology, County
Hospital No. 1, Timisoara, Romania.
The diagnosis of Cushing`s syndrome, in the clinical practice, requires
investigations necessary for distinguishing it from obesity with reactive
hypercorticism and for differentiating its forms.
The study group was represented by 85 cases of hypercorticism (hospitalized in
the Clinic of Endocrinology Timisoara during the period 2000-2009) divided in
two groups: obesity with reactive hypercorticism (81.18%) respectively,
Cushing`s syndrome with its forms (18.82%).
The medical history accompanied by the clinical examination is very important in
revealing the clinical features of Cushing`s syndrome. Loss of circadian rhythm of
cortisol is a sensitive screening test. The assessment of the basal plasma cortisol
levels, inthe study group, showedsignifcant higher levels (P,0.01) in patients with
Cushing`s syndrome in comparison to obesity with reactive hypercorticism. Low-
dose (1-2 mg) overnight dexamethasone suppression tests are useful for Cushing`s
syndrome screening (it was observed that there was no cortisol suppression in
patients with Cushing`s syndrome in comparison to those with obesity with reactive
hypercorticism(P,0.00001)); while, high-dose (8 mg) dexamethasone suppression
tests helps in differentiating some Cushing`s syndrome forms (a lowering in the
cortisol level over 50%, in patients with Cushing`s disease and no response in cases
with Cushing`s syndrome caused by an adrenal adenoma/carcinoma - P,0.01).
The patients with Cushing`s syndrome also presented a signifcant decreased values
of the serum TSH (P,0.0001), FT
4
(P,0.00001), FSH (P,0.01) and LH
(P,0.00001) versus those with obesity.
P11
Effects of atenolol add-on treatment on plasma renin activity (PRA) and
aldosterone escape in hypertensive patients with diabetes receiving
valsartan
Gen Yasuda, Keisuke Yatsu, Nobuhito Hirawa, Yuichiro Yamamoto
& Satoshi Umemura
Yokohama Center Hospital, Yokohama, Japan.
Angiotensin II receptor antagonists (ARB) decrease plasma aldosterone
concentration (PAC) for cardiovascular protection. However, long-term ARB
therapy increases PRA and PAC, which is known as 'aldosterone escape.`
-Blockers are the noble antihypertensive agents to decrease PRA. Nevertheless,
little is known about the effect of coadministration of both agents on PRA and
aldosterone escape. The study was designed to compare the effects of adding
atenolol (-blocker) to valsartan (ARB) and doubling the dose of valsartan in
diabetic patients whose blood pressure did not reach the therapeutic goal
(140/90 mmHg) by valsartan monotherapy. This study was approved by the local
!)_A j Effects of atenolol and valsartan (AV) or double-dose valsartan
(V,2) on PAC and PRA (MeanS.E.M.; *,0.05 versus week 0)
0 week 4 week 12 week 24 week 48 week
AV (PAC,
pg/ml)
10815 9718* 10814 12315 10612
V,2 (PAC,
pg/ml)
9810 9111* 9013* 10912 9710
AV (PRA,
ng/ml per h)
3.60.6 1.00.6* 1.30.5* 1.20.4* 1.50.5*
V,2 (PRA,
ng/ml per h)
3.10.5 5.31.3* 3.30.5 3.60.5* 4.00.7*
ethical committee. Fifty-four hypertensive patients (6210 years old, 27 men
and 27 women, serum creatinine levels ,2 mg/dl) already on valsartan
80 mg/day were assigned to receive either a double dose of valsartan (160 mg)
or atenolol (50 mg) added to valsartan (80 mg) for 48 weeks. PRA and PAC were
measured. Two groups showed signifcant decreases (P,0.05) in blood pressure
during the treatment period. In the both groups, PAC decreased initially but
returned to the baseline level at 24 weeks. PRA decreased in the atenolol add-on
group but it increased in the valsartan double-dose group (Table 1). These
fndings indicate that adding atenolol to valsartan counteracts the PRA-
stimulating effects of ARB but aldosterone escape still occurs, suggesting that
hyperreninemia caused by the interruption of negative feedback of angiotensin II
does not induce aldosterone escape and there is another pathway for maintaining
aldosterone secretion in diabetes.
P12
Autoimmune disorders in Addison`s disease and in isolated secondary
adrenal insufhciency
Anna A Kasperlik-Zaluska
1
, Barbara Czarnocka
2
, Wojciech Jeske
1
,
Lucyna Bednarek-Papierska
1
, Anna-Lena Hulting
3
, Sophie Bensing
3
,
Patricia Crock-Ludecke
4
& Olle Kampe
5
1
Endocrinology Department, Medical Centre for Postgraduate Education,
Warsaw, Poland;
2
Biochemistry Department, Medical Centre for Post-
graduate Education, Warsaw, Poland;
3
Molecular Medicine Department,
Karolinska Institutet, Stockholm, Sweden;
4
Pediatric Endocrinology
Department, University of Newcastle, Newcastle, Australia;
5
Medical
Sciences Department, University Hospital, Uppsala, Sweden.
Autoimmunity is the most frequent cause of Addison`s disease (AD). Isolated
secondary adrenal insuffciency (ISAI) in patients not treated with corticosteroids
seems to be an autoimmune disease too. In the registry of the Department of
Endocrinology in Warsaw we have 328 patients with AD and 305 patients with
ISAI. Autoimmune AD was diagnosed in 262 of 328 patients (77%) and in 217 of
them (83%) some associated autoimmune disorders were found, while in the
group with ISAI such disordes appeared in 200 cases (66%). Primary
hypothyroidism was the most frequent autoimmune disease in both the groups
(35%), while thyrotoxicosis was more frequent in AD (11 vs 6%). Vitiligo, IDDM
and premature ovary failure were more frequent in AD (13, 11 and 10%
respectively) and less frequent in ISAI (5, 3, 3%).The incidence of pernicious
anemia hypoparathyroidism and alopecia areata ranged 1-5% in both groups. In
each group there was one patient with rheumatoid arthritis and another one with
collagen disease. In one patient with AD a Duhring`s disease was diagnosed. In
ISAI some more rare autoimmune diseases were observed: thrombocytopenia
(three cases), celiakia (2), Sjogren`s disease (2), and in single cases, myasthenia
gravis and cystitis interstitialis. Thyroid autoantibodies were present in 70% of
AD patients and in 65% of ISAI, adrenal antibodies in 65% out of 114 patients
with AD, while pituitary autoantibodies were detected in 34% of ISAI patients
under study. In summary, autoimmune diseases were more frequent in AD, while
prevalence of rare autoimmune diseases was characteristic for ISAI.
Supported by European Union Framework Program 7, Euradrenal and by a
501-2-1-07-23/09 CMKP grant.
P13
Pharmacokinetic evidence for hydrococortisone under and over
replacement in adrenal insufhciency
Frederic Castinetti
1
, Nicolas Simon
2
, Floriane Ouliac
1,3
, Nathalie Lesavre
4
,
Thierry Brue
1
& Charles Oliver
1
1
Department of Endocrinology, Timone Hospital, Marseille, France;
2
Pharmacology Department, Faculty of Medicine, Marseille, France;
3
Department of Endocrinology, North Hospital, Marseille, France;
4
Clinical
Investigation Centre, Marseille, France.
Aim and methods
Cortisol substitution in adrenal insuffciency (AI) is a matter of debate. We
performed a pharmacokinetic analysis of plasma and salivary cortisol following
oral hydrocortisone intake in patients with AI, and a pharmacokinetic modelling
simulation. Fifty patients with primary (n20) or secondary (n30) AI were
recruited. After 24-h plasma and salivary cortisol measurements under usual
hydrocortisone treatment, a pharmacokinetic modelling with different simulated
hydrocortisone dosing at different times of the day was performed.
Results
Thirteen different treatments regimens were observed: plasma and salivary
cortisol levels were not in the normal range in the majority of patients.
Pharmacokinetic modelling showed that there was a wide variability in cortisol
concentrations whatever the scheme simulated, with the majority of patients
under or over-replaced: the regimen with the higher proportion of simulated
patients within the biological targets was 1055 mg at 0730 h, 1200 and
1630 h respectively; however, even with this scheme, about 40% of patients
would remain over or under-replaced.
Conclusions
Most patients are imperfectly treated. Our pharmacokinetic modelling showed
that optimal substitution remains diffcult with current tablets of hydrocortisone,
whatever dose and time of administration used.
P14
Serum dehydroepiandrosterone and dehydroepiandrosterone sulfate as
markers of disease severity in community-acquired pneumonia
Claudine A Blum
1
, Philipp Schuetz
1
, Daiana Stolz
3
, Roland Bingisser
4
,
Christian Mueller
2
, Michael Tamm
3
, Michael Trummler
6
, Beat Mueller
5
&
Mirjam Christ-Crain
1
1
Department of Endocrinology, Diabetology and Clinical Nutrition,
University Hospital Basel, Basel, Switzerland;
2
Department of Internal
Medicine, University Hospital Basel, Basel, Switzerland;
3
Department of
Pneumology, University Hospital of Basel, Basel, Switzerland;
4
Department
of Emergency Medicine, University Hospital Basel, Basel, Switzerland;
5
Department of Internal Medicine, Kantonsspital, Aarau, Switzerland;
6
Bioanalytica AG, Luzern, Switzerland.
Background
Rapid and accurate risk stratifcation in patients with community-acquired
pneumonia (CAP) is an unmet clinical need. Cortisol to DHEA ratio was put
forward as a prognostic marker in sepsis. We herein validated the prognostic
value of DHEA and DHEAS and of cortisol/DHEA- and cortisol-DHEAS - ratios,
respectively, in patients with CAP as the most common (disease resulting) sepsis-
defning illness.
Methods
We assessed clinical parameters and severity of illness defned by the pneumonia
severity index (PSI) and measured DHEA, DHEAS and cortisol concentrations in
181 serum samples of prospectively recruited patients with CAP. First, we
calculated a linear regression model adjusted for age and gender to assess the
associations of hormones and PSI. Second, we calculated a logistic regression
model adjusted for age and gender to assess associations of hormones and in
hospital mortality.
Results
A total of 181 patients (median age 73, 34% females) with confrmed CAP
were included. Linear regression analysis showed that total cortisol (: 0.99,
P,0.001), DHEAS (: 2.7, P,0.001) and DHEA (: 0.9, P,0.001) were all
positively associated with CAP severity as assessed with the PSI. In logistic
regression analysis, cortisol (OR: 1.08, P,0.001) and DHEA (OR: 1.06,
P,0.01), and to a lesser extend DHEAS (OR 1.1, P0.07) were predictors of
mortality. The ratios of cortisol/DHEA, cortisol/DHEAS and DHEA/DHEAS
were not associated with the PSI and were not predictors of survival (all PNS).
Conclusion
Cortisol, DHEA and DHEAS, but not the different ratios correlate with severity
and survival in CAP. The prognostic accuracy of DHEA and DHEAS is
comparable to the one of the PSI. Cortisol remains the best prognostic marker for
outcome in this analysis. Thus, not only cortisol, but adrenal function in general
and its possible exhaustion in severe pneumonia is an important factor for
outcome and survival.
P15
Pheochromocytoma in an incidentally discovered cystic adrenal mass: a
case report
Ayten Oguz
1
, Pamir Eren Ersoy
2
, Melike Metin Sugutlugil
3
, Gulnur Guler
4
,
Reyhan Ersoy
1
& Bekir Cakir
1
1
Department of Endocrinology and Metabolism, Ankara Ataturk Education
and Research Hospital, Bilkent, Ankara, Turkey;
2
Department of 3. General
Surgery, Ankara Ataturk Education and Research Hospital, Bilkent, Ankara,
Turkey;
3
Department of Radiology, Ankara Ataturk Education and Research
Hospital, Bilkent, Ankara, Turkey;
4
Department of 2. Pathology, Ankara
Ataturk Education and Research Hospital, Bilkent, Ankara, Turkey.
Introduction
Adrenal cysts are rare usually benign and asymptomatic. Histologically, they are
classifed as epithelial, endothelial, parasitic and pseudocysts. Although
extremely rare and clinically more dramatic cystic adrenal carcinoma and
cystic pheochromocytoma must be considered in the differential diagnosis of
adrenal cysts. In this report, we presented a patient with a large cystic
pheochromocytoma.
Case report
A 30-year-old female patient admitted our clinic with a left sided adrenal mass
detected incidentally on a routine control. Her passed medical history was
unremarkable. She had no episodic hypertensive attack, no complaint of sweating
or headache. Vital signs were normal, with a heart rate of 72 beats/min and a
blood pressure of 110/70 mmHg. Physical examination was completely normal.
Adrenal MRI revealed a 72,59,75 mm lesion at the left adrenal lodge with
septations. The mass did not show any contrast enhancement and was reported as
type III hydatid cyst. In contrast, the hemmaglutination test was negative. The
eosinophil count was normal. Serum potassium levels were normal. Urine
normetanephrine and VMA were markedly increased. Left adrenalectomy was
performed. The patient`s intra-operative and postoperative courses were
uncomplicated. The surgical specimen revealed pure cystic pheochromocytoma.
Postoperatively the urine normetanephrine and VMA levels returned in to the
normal range.
Conclusion
Cystic pheochromocytomas may not present with the classic prodromal
symptoms, which are commonly associated with solid pheochromocytomas.
This case represents an unsuspected presentation of an extremely rare functional
cystic neoplasm. Pheochromocytoma should be considered in patients presenting
with an incidental cystic adrenal mass, even in the absence of hypertension.
P1
Secondary adrenal failure due to sepsis
Atif Munir, Sath Nag & Rudy Bilous
James Cook University Hospital, Middlesbrough, UK.
Introduction
Hypothalamic-pituitary adrenal axis dysfunction is common in severely ill
patients. Even slight impairment of adrenal response to severe illness can increase
morbidity and mortality. Relative adrenal insuffciency has been associated with
severe sepsis.
Case report
We report a case of 48-year-old lady who was admitted with septic shock
secondary to epiglottitis requiring intubation and intensive care. Short synacthen
test performed in view of her refractory hypotension confrmed adrenal
insuffciency. Her concurrent ACTH level was suppressed which suggested
possible secondary adrenal insuffciency. Patient made an uneventful recovery
with hydrocortisone treatment. She was investigated further to assess her pituitary
function and structure. Anterior pituitary hormonal profle and MRI scan of
pituitary fossa were normal. Adrenal auto antibodies were not detected. Long
synacthen test performed ten months later revealed a fat cortisol profle with an
increment after 24 h consistent with persistent secondary adrenal insuffciency
hence steroid replacement was continued.
Conclusion
A high index of suspicion for adrenal insuffciency is required in all critically ill
patients with refractory hypotension.
P1I
Salivary cortisol in the diagnosis of Cushing`s syndrome: clinical
experience with liquid chromatography/tandem mass spectrometry on
outpatient basis
Dana Erickson, Ravinder Singh, Airani Sathananthan, Adrian Vella &
Sandra Bryant
Mayo Clinic, Rochester, Minnesota, USA.
Late night salivary cortisol measurements have been increasingly used as an
initial diagnostic test for the evaluation of patients with a clinical suspicion of
Cushing syndrome (CS). Published studies include varying numbers of cases and
controls and importantly various assay methods (usually immunoassays), as well
as various methods of generating normative values.
We examined the diagnostic utility of salivary cortisol measurement in 258
patients evaluated for the possibility of CS because of various clinical conditions
using liquid chromatography/tandem mass spectrometry method (LC-MS/MS).
CS was confrmed in 56 patients (21.7%) and excluded in 202 (78.3%) patients at
the time of analysis. The patient population with CS included 39 (69.6%) with
pituitary CS, 8 (14.9%) with ectopic CS, 9 (16.1%) with adrenal CS. Salivary
specimen were collected at 1100 h using Sarstedt Salivette and LC-MS/MS was
used for analysis. Normal values ,100 ng/dl between 1100 h and midnight were
previously established using two standard deviations from the mean of a healthy
population.
Results
Late night salivary cortisol was elevated (100 ng/dl) in 39/56 patients providing
a sensitivity of 69.9% for the diagnosis of CS and elevated in 20/202 patients who
were found not to have CS, specifcity of 90.1%. When only patients with
pituitary or ectopic CS were considered the sensitivity was 76.6% with specifcity
90%. Using ROC to calculate the cut-off providing optimal sensitivity and
specifcity a late night salivary cortisol of 61 ng/dl provided a sensitivity of
82.1% and a specifcity of 78.2%.
Conclusion
Analysis of data at one referral institution showed the somewhat limited
sensitivity of late night salivary collection of cortisol. Therefore in patients with a
high suspicion of CS and negative tests results other complementary tests for
diagnosis of CS should be used and periodically repeating of testing should be
implemented.
P18
The aldosterone renin ratio based on the plasma renin activity and
the direct renin assay for diagnosing aldosterone-producing adenoma
GianPaolo Rossi
1
, Marlena Barisa
1
, GiovanBattista Desideri
2
, Claudio
Letizia
3
, Mauro Maccario
4
, Alberto Morganti
5
, Gaetana Palumbo
6
,
Anna Patalano
7
, Anna Realdi
1
, Elisabetta Roman
1
, Teresa Maria Seccia
1
& Achille Cesare Pessina
1
1
DMCS, Internal Medicine 4, University of Padova, Padova, Italy;
2
Internal
Medicine and Public Health, University of LÀquila, LÀquila, Italy;
3
Internal Medicine, University of Rome, Rome, Italy;
4
Endocrinology,
University of Turin, Turin, Italy;
5
Internal Medicine, University of Milan,
Milan, Italy;
6
Internal Medicine, Legnano, Italy;
7
Endocrinology,
University of Padova, Padova, Italy.
The screening for primary aldosteronism (PA) is based on the aldosterone/renin
ratio (ARR), which is calculated with the plasma renin activity (PRA) as
denominator. A direct measurement of active renin (DRA) is being used as an
alternative to PRA, but its diagnostic performance remains uncertain.
Aim of the study was to head-to-head compare the ARR based on PRA (ARR-P)
to on DRA (ARR-D), at baseline and post-captopril, for identifying aldosterone-
producing adenoma (APA) in a subset (251 patients) of the PAPY Study.
The area (AUC) under the ROC curves was employed for estimating the accuracy
of ARR-D and ARR-P for identifying APA and for between tests comparison. PA
was found in 13.2% patients, 6.4% of whom had APA and 6.8% idiopathic
hyperaldosteronism (IHA); 218 (86.8%) had primary hypertension. The PRA and
the DRA showed a weaker correlation at baseline (r0.26, P,0.0001) and a
stronger post-captopril (r0.65, ,0.0001). Both the ARR-D and the ARR-P
were useful for identifying APA, as shown by AUC under the ROC curves
(0.8700.058 and 0.9730.028, respectively) 0.50 (both P,0.0001); at a
between-test comparison the ARRs did not differ signifcantly. For the ARR-D the
optimal cut-off value for identifying APA was 27.3, remarkably similar to that
previously determined for the ARR-P. Thus, the ARR-D represents a reasonable
alternative to the ARR-P for detecting APA.
P19
Adrenal incidentalomas accompanying malignant tumours: clinical
study of 1888 patients
Anna A Kasperlik-Zaluska
1
, Jadwiga Slowinska-Srzednicka
1
,
Elzbieta Roslonowska
1
, Wojciech Jeske
1
, Andrzej Cichocki
2
, Maciej Otto
3
& Wojciech Zgliczynski
1
1
Department of Endocrinology, Medical Centre for Postgraduate Education,
Warsaw, Poland;
2
Department of Surgery, Maria Sklodowska-Curie Centre
and Institute of Oncology, Warsaw, Poland;
3
Department of General,
Vascular and Transplant Surgery, Medical University of Warsaw, Warsaw,
Poland.
Diagnostic procedures reveal that majority of incidentally found adrenal tumours
(adrenal incidentalomas, AI) appear to be benign adenomas. However, AI
accompanying malignant tumours must be diagnosed very carefully to take a
proper decision concerning their management. In the registry of the Department
of Endocrinology in Warsaw, there are 1888 patients (1388 women, 500 men,
F/M ratio 2.8) with AI, 10-87 years old. Primary malignant tumours were
diagnosed in 155 patients (adrenal cancer in 141 cases). Metastatic infltrations in
the adrenals were detected in 53 patients (3%), with F/M ratio 0.8, originating the
most frequently from renal (19) or pulmonary (17) carcinoma, next fromthe colon
(6), stomach (4) and mammary carcinoma (3). All metastatic tumours were
characterized by high density in CT 20 HU (1st phase), their size ranged 3.0-
18.0 cm. In 27 patients bilateral adrenal metastases were found, in 16 of them
resulting in Addison`s disease and in 11 cases - in preclinical Addison`s disease.
In two women endometrial carcinoma was followed by adrenal cancer. In two
other women pulmonary carcinoma was associated with adrenal cancer. In 84
patients (4%) detection of AI was preceded by surgery for a malignant tumour, the
most frequently pulmonary (21), renal (20), mammary (19) or colorectal cancer
(8). The density of these tumours did not exceed 15 HU, and their size ranged 1.8-
4.5 cm. A careful observation with imaging investigations has been conducted in
this group of patients. Eight patients were treated by surgery because of a slow
enlargement of the tumour or density exceeding 10 HU, and an adenoma was
diagnosed microscopically. Almost all patients with metastatic infltrations of the
adrenal glands were treated by open surgery, however prognosis in this group was
poor. In summary, metastatic tumours were characterized by higher density,
frequent bilateral localization with tendency to adrenal hypofunction and majority
of them exceeded 5.0 cm in size.
This work was supported by a 501-1-1-07-16/06 CMKP Grant.
P20
Comparison between ultrasonography versus other standard imaging
procedure in diagnostics of pathological changes of adrenal glands
Snjezana Pejicic
1
, Vaskrsija Gotovac
2
, Anja Pejicic
3
& Severin Dunovic
4
1
Clinical Center of Banja Luka, Clinic for Endocrinology, Diabetes and
Metabolic Diseases, Banja Luka, Bosnia and Herzegovina;
2
Private Practice
'Inea`, Teslic, Bosnia and Herzegovina;
3
Faculty of Stomatology, Medical
University of Vienna, Vienna, Austria;
4
Medical Care 'Sveti Vracevi`,
Celinac, Bosnia and Herzegovina.
The aim of this study was to fnd out sensitivity and specifcity of ultrasonography
(US) versus other imaging modalities such as computed tomography (CT) and
magnetic resonance (MR) in diagnostics of pathologic changes of adrenal glands. In
a sample of 310 patients with pathological process in retroperitoneum, we diagnosed
pathological changes of adrenal glands (adrenals tumor) in 57 patients. The patients
were examined by US Aloka SSD 500 with convex transducer of 3.5 MHz and then
proceeded to CTand MRexamination. Adrenals tumor was confrmed in 52 patients
(91.2%) andpathological changes in vicinity of adrenals (pseudotumors) in not more
then fve patients (8.8%). The size of least detected focal lesion was 10,9 mm
(incidentalom), US identifcation accuracy being 91.2%.
By adrenal glands ultrasonography it is possible to assess: the site of tumor (lateral or
bilateral); type (focal, diffuse, cysticor solid); sizeandshape of change; homogeneity
or non-homogeneity; limitation of the change, so as to follow growth and extension
of the tumor. Only in fve patients (8.8%) CTand MRgave close results. Due to high
sensitivity and specifcity, ultrasonography is the frst step in algorithm of imaging
modalities indiagnosing pathologic changes of adrenal glands. It is a dependable and
necessary diagnostic procedure in detecting and follow up the adrenal tumors.
P21
Subclinical hypercortisolism: correlation between biochemical
diagnostic criteria and clinical aspects
Valentina Morelli
1
, Benedetta Masserini
1
, Antonio Stefano Salcuni
1
,
Cristina Eller-Vainicher
1
, Chiara Savoca
1
, Raffaella Viti
1,2
,
Francesca Coletti
1,4
, Giuseppe Guglielmi
1,3
, Claudia Battista
1,2
,
Laura Iorio
1,5
, Paolo Beck-Peccoz
1
, Bruno Ambosi
1,5
, Maura Arosio
1,4
,
Alfredo Scillitani
1,2
& Iacopo Chiodini
1
1
Unit of Endocrinology and Diabetology, Department of Medical Sciences,
Universita` degli Studi di Milano, Fondazione IRCCS Ca` Granda - Ospedale
Maggiore Policlinico, Milan, Italy;
2
Unit of Endocrinology 'Casa Sollievo
della Sofferenza`, IRCCS, San Giovanni Rotondo, Italy;
3
Unit of Radiology
'Casa Sollievo della Sofferenza`, IRCCS, San Giovanni Rotondo, Italy;
4
Unit of Endocrinology, Ospedale San Giuseppe, Universita` degli
Studi di Milano, Milan, Italy;
5
Unit of Endocrinology, Department of
Medical and Surgical Sciences, Universita` degli Studi di Milano, IRCCS
Policlinico San Donato Institute, San Donato Milanese, Italy.
Objective
Subclinical hypercortisolism (SH) has been associated with increased prevalence
of hypertension, type 2 diabetes mellitus, dyslipidemia, central obesity,
osteoporosis and vertebral fractures. We aimed to investigate the accuracy of
different SH diagnostic criteria in predicting the concomitant presence of these
complications.
Patiets
In this retrospective study we evaluated data of 231 patients (120 females and 111
males) affected with adrenal incidentalomas (AI).
Methods
We studied the accuracy of different SH diagnostic criteria (cortisol after 1 mg
overnight dexamethasone suppression test - 1 mg-DST - at different cut-off such
as 50, 83, 138 nmol/l, elevated urinary free cortisol, reduced ACTH levels alone
or various combination of these parameters) in predicting the concomitant
presence of the following three complications: hypertension, type 2 diabetes and
vertebral fractures.
Results
The criterion characterized by the presence of two out of 1 mg-DST 83 nmol/l,
elevated UFC, reduced ACTH, struck the best balance between sensitivity and
specifcity reaching a good accuracy in predicting the cluster of complications
(61.9; 77.1 and 75.8%, respectively). The presence of the cluster of complications
was associated with this criterion (OR 4.75, 95% CI 1.8-12.7, P0.002)
regardless for gonadal status, BMI and age. Indeed, the SH diagnostic criterion
defned as cortisol after 1 mg-DST 138 nmol/l, showed the higher specifcity
(93.3%) but a poor sensitivity (lower than 23.8%), whereas the criterion by
cortisol after 1 mg-DST 50 nmol/l showed the higher sensitivity (71.4%) but a
low specifcity and accuracy (49.5 and 51.5 respectively).
Conclusions
The SH criterion characterized by the presence of two out of 1 mg-DST
83 nmol/l, elevated UFC, reduced ACTH, seems the best in predicting the
presence of chronic manifestations of subtle cortisol excess.
P22
Comparison of the \d \g effects of ketoconazole and uconazole on
human primary adrenocortical cultures and on the adrenocortical
carcinoma cell line HAC15
Rob van der Pas, Leo Hofand, Marlijn Waaijers, Frank de Jong,
Piet Uitterlinden, Wouter de Herder, Peter van Koetsveld &
Richard Feelders
Introduction
Ketoconazole is an antifungal agent that, in a high dose, suppresses adrenocortical
steroidogenesis by inhibition of cytochrome P-450 dependent enzymes.
Currently, ketoconazole is used to decrease cortisol production in patients with
Cushing`s syndrome. However, ketoconazole often causes gastrointestinal side
effects and hepatotoxicity. Fluconazole may also inhibit steroidogenesis and has
the advantage over ketoconazole that it has less side effects. Therefore, we
compared the effects of ketoconazole and fuconazole on primary cultures of
adrenocortical tissue, as well as on the human adrenocortical carcinoma cell line
HAC15.
Methods
Primary cultures of human adrenocortical tissue and HAC15 cells were incubated
with ketoconazole (0.05-100 M) and fuconazole (10-1000 M). Supernatant
cortisol concentrations were measured after 96 h (primary cultures) or 72 h
(HAC15) of incubation.
In addition, the effects on cell growth and DNA fragmentation (measure of
apoptosis) were measured.
Results
Both ketoconazole and fuconazole decreased cortisol production in a dose-
dependent fashion by ^70-90% (highest concentration), but not cell number in
primary cultures of adrenocortical cells. Ketoconazole was signifcantly more
potent than fuconazole with a 7- to 30-fold potency difference, depending on the
culture.
In HAC15 cells, ketoconazole reduced cortisol production by 80%, while
fuconazole reduced cortisol production by only 55%, corrected for cell number
(IC
50
0.42 and 11 M, respectively). Additionally, we found that ketoconazole
(IC
50
9 M) and fuconazole (IC
50
74 M) dose- and time dependently inhibited
HAC15 cell growth, at least in part by inducing apoptosis.
Discussion
Both ketoconazole and fuconazole inhibit cortisol production in primary
adrenocortical cells and HAC15 cells and decrease HAC15 cell growth in a
dose-dependent fashion. Since our IC
50
values are within the range of earlier
reported steady state serum concentrations, fuconazole, as an alternative to
ketoconazole, may be applied to decrease cortisol production in Cushing`s disease
or cortisol producing adrenocortical adenomas and carcinomas.
P23
Sunitinib decreases adrenocortical cancer cell proliferation and
specihcally inhibits adrenal steroidogenesis
Miriam Reuss
1
, Matthias Kroiss
1
, Sarah Johanssen
1
, Melanie Beyer
1
,
Martina Zink
1
, Michaela Hartmann
2
, Vivek Dhir
3
, Stefan Wudy
2
,
Wiebke Arlt
3
, Silviu Sbiera
1
, Bruno Allolio
1
& Martin Fassnacht
1
1
Medicine I, Endocrine and Diabetes Unit, University Hospital Wurzburg,
Wurzburg, Germany;
2
Centre for Child and Adolescent Medicine,
University Hospital Gieen, Gieen, Germany;
3
Centre for Endocrinology,
Diabetes and Metabolism, University of Birmingham, Birmingham, UK.
Background
The multi-tyrosine kinase inhibitor sunitinib is approved for advanced renal cell
carcinoma and gastrointestinal stroma tumors. It targets both tumor vessels and
malignant cells. Animal experiments have pointed to a direct adrenotoxic effect of
the drug.
Aims
We hypothesized that sunitinib may inhibit proliferation of adrenocortical cancer
(ACC) cells and infuence adrenal steroid hormone synthesis.
Results
Sunitinib reduced cell viability in both ACC cell lines NCI-h295 and SW13 in a
dose-dependent manner (MTT assays SW13: 967% (0.1 M), 909%*
(1 M), 799%* (2 M), 629%* (5 M), and 573%* (10 M) vs 1009%
in control cells, *P,0.01). Analyses of selected steroid hormones in supernatant
of NCI-h295-cells indicated a signifcant decrease of glucocorticoid secretion
after incubation with sunitinib, while precursor hormones accumulated. Using
isotope dilution gas chromatography mass spectrometry a complete steroid
profle exhibited an increased ratio of DHEA/androstenedione (0.1 M: 1.02
0.04; 1 M: 1.300.06*; 5 M: 1.500.05*; *P,0.01) and 17-OH-pregne-
nolone/17-OH-progesterone. This suggested a dose-dependent inhibition of
3-hydroxysteroid dehydrogenase (HSD3B) catalyzing these reactions. Whilst no
direct inhibition of HSD3B activity by sunitinib was detected in yeast microsome
assays, we found a dose-dependent down-regulation of HSD3B in real time PCR
and western blot after 24 h incubation with sunitinib (relative RNA expression:
1 M 477%*; 5 M 337%*; 10 M 276%*; protein expression: 1 M
828%; 5 M 628%*; 10 M 559%*; *P,0.05), whereas the expression
of other adrenal enzymes like CYP11A1 remained unaffected.
Conclusion
Our data demonstrate a specifc blockade of adrenal steroidogenesis by sunitinib via
downregulation of HSD3B. Studies inpatients treated withsunitinibare warrantedto
assess the clinical impact of this fnding. Whether inhibitionof ACCcell proliferation
by sunitinib is clinically relevant is currently investigated in the SIRAC-trial.
P24
Two cousins with 17- hydroxylase enzyme dehciency
Muge O
zsan, Ersin Akarsu, Sebnem Aktaran & Mustafa Araz

Gaziantep U
niversitesi Medical Faculty Endocrinology and Metabolism

Department, Gaziantep, Turkey.
We present two cases because 17OHD is the rare cause of congenital adrenal
hyperplasia (1%) and our patients are frst cousins (their fathers are brothers).
Genetically female patients with congenital adrenal hyperplasia due to 17-
hydroxylase enzyme defciency (17OHD) represent with sexual infantilism,
hypertension and genetically male patients represent with male pseudohermaph-
roditisim, hypertension at pubertal age. The cousins applied for primer
amenorrhea and hypertension to our Endocrinology and Metabolism Department
at different times at age of 18 and 22 and their karyotypes were 46, XX and
46, XY respectively. 17OHD was diagnosed with clinical fndings and laboratory
investigations. Blood pressure was improved with glucocorticoid therapy and
secondary sexual characteristics were developed with estrogen therapy.
P25
Morphological, functional and metabolic features in a series
of 63 patients with adrenal incidentalomas
Charalampos Tsentidis, Athanasios Antoniou-Tsigos, Vasiliki Skarpa,
Vasilios Dimarakis, Ioannis Prokovas & Argyris Argyropoulos
Department of Endocrinology, Metabolism and Diabetes, Nikaia General
Hospital 'Ag. Panteleimon`, Athens, Nikaia, Greece.
Background
The prevalence of incidentally discovered adrenal masses has increased during
last decades, due to longer life expectancy and to the extended use of new imaging
techniques like high defnition C/T and MRI. Diagnostic approach and possible
therapeutic management are considered nowadays fascinating challenges for
clinical practice, not only for the probability of hormonal hypersecretion but also
for the risc of malignancy.
Methods
We investigated 63 patients with adrenal masses, incidentally discovered in
imaging techniques performed for non-adrenal disorders (21 male, 42 female,
mean 5713 years, median 60 years), according to NIH criteria of 2002.
Results
Of 47.6% (30/63) of incidentalomas, sized from 10 to 140 mm in max diameter
(mean 35.520 mm), were located to the right, 39.7% (25/63) to the left and
12.7% (8/63) to both adrenals. Out of the total number of incidentalomas 19%
(12/63) found to be functional and 81% (53/63) non-functional. Subclinical
hypercortisolism accounted for 6.4% (4/63), pheochromocytoma for 6.4% (4/63)
and hyperaldosteronism for 4.8% (3/63) of cases. Non-functioning adenomas
were 72.8% (45/63), non-malignant cysts were 4.8% (3/63) and the remaining
4.8% included one myelolipoma, one metastasis and one bilateral teratoma. The
prevalence of metabolic syndrome, as defned with IDF criteria of 2005, was also
evaluated among these patients. Most patients (59/63) 93.7% where obese,
(21/63) 33.3% of patients had diabetes mellitus while (20/63) 31.8% had
prediabetes (IFG or IGT). 60.3% (38/63) had hyperlipidemia and 68.3% (43/63)
had hypertension. Metabolic syndrome was present in 66.7% (42/63) of patients
with adrenal incidentaloma (AI). There was no difference between patients with
functional and non functional tumors.
Conclusions
The prevalence of metabolic syndrome parameters was quite high in patients with
AI, thus associated with an increased risk for CVD. The prevalence of metabolic
syndrome in patients with AI (66.7%) was much higher compared with the overall
prevalence of metabolic syndrome in general population (25-30%), suggesting
there might be a common pathophysiologic pathway, need to be elucidated with
further prospective studies.
P2
Conhrmation of vitamin D receptor polymorphism TaqI and detection
of a new single nucleotide polymorphism (SNP) in the CTLA4-region
(CTLA4-CT60) as susceptibility markers for Addison`s disease
Gesine Meyer
1
, Elizabeth Ramos-Lopez
1
, Marissa Penna-Martinez
1
,
Heinrich Kahles
1
, Holger Willenberg
2
& Klaus Badenhoop
1
1
Internal Medicin I, Department of Endocrinology and Diabetes, University
Hospital Frankfurt, Frankfurt, Germany;
2
Clinic for Endocrinology,
University Hospital Duesseldorf, Duesseldorf, Germany.
Objective
Addison`s disease (AD) is a rare and complex endocrine disorder. Genetic
susceptibility loci known so far are predominantly shared with other, more
frequent autoimmune endocrinopathies. We therefore investigated polymorph-
isms of the CTLA4-region, the vitamin D system (vitamin D receptor VDR,
CYP24 and CYP27B1 gene) as well as cytokine CXCL10 gene for their
association in AD.
Methods
Patients with AD (n203) and healthy controls (n746) were genotyped for
polymorphisms of VDR (ApaI, BsmI, FokI, TaqI), CYP27B1 hydroxylase
gene (CYP27B1 C(1260)A, CYP-1a-Intron 6, CYP2R1-57), CYP24 gene
(CYP 24-26, CYP24-rs2248137, CYP24-rs2296241), vitamin D binding protein
gene (DBP DBP-HaeIII-rs7041, DBP-Sty-rs4458), the CTLA-4 gene region
(CTLA4-A/G, CTLA4-1661G, CTLA4-CT60, CTLA4-24HM30, CTLA4-PR)
and CXCL10 gene (CXCL10-90, CXCL10-89).
Results
VDR polymorphism TaqI allele t as well as the CTLA4-region SNP
CTLA4-CT60 allele g were signifcantly more frequent in patients with AD
compared with healthy controls (43.3 vs 35.9%, P0.02 respectively 67 vs
57%, P0.012).
We could not fnd any signifcant differences in the other examined polymorphisms
including CYP27B1 C(1260)A (P0.4).
Conclusions
Investigating an extended number of German patients we confrm an association
of VDR polymorphism TaqI and AD. There was no association of the CYP27B1
promoter polymorphism C(1260)A in contrast to previous fndings.
The CTLA4-region SNP CTLA4-CT60 however is signifcantly associate with
AD which we also fnd similarly in Graves`s disease, AIH as well as type 1
diabetes.
Owing to the high prevalence in the population these genetic susceptibility
markers appear to be neither distinctive nor predictive of AD but may unravel
pathophysiological pathways suitable for immune intervention.
P2I
Spontaneous recovery of bone mass after cure of endogenous
hypercortisolism
Erika Grossrubatscher
1
, Paolo Dalino Ciaramella
1
, Maria Elena Randazzo
1
,
Angelo Vanzulli
2
& Paola Loli
1
1
Endocrinology. Ospedale Niguarda, Milan, Italy;
2
Radiology, Ospedale
Niguarda, Milan, Italy.
Patients with Cushing`s syndrome (CS) commonly develop osteopenia-
osteoporosis; the recovery of bone mass after remission of hypercortisolism is
not well documented. The present study addresses this issue.
Twenty patients (6M, 14F, 2 post-menopausal), aged 15-64 years (median 36), 15
with Cushing`s disease, 2 with ectopic ACTH syndrome, 3 with ACTH-
indipendent CS were studied. BMD (t and z scores) at lumbar spine and proximal
femur were assessed by dual-energy X-ray absorptiometry before and 7-33
months (median 19) after successful surgical treatment of hypercortisolism. Five
patients were treated with bisphosphonates. Four patients had hypogonadism
(treated in two) and four untreated GH-defciency.
Results
At baseline the spine (BMD, t score) appeared more damaged than the femur
(P,0.01); femur BMD/t score were positively related with body mass index
(BMI). A trend for a negative correlation between femur BMD/t score and age
was observed. No correlations were observed between spine and femur BMD,
z, t scores and the duration of disease or severity of hypercortisolism (UFC levels).
After cure of hypercortisolisma signifcant improvement in spine BMD(P0.002),
z (P0.01) and t (P0.001) scores and in femur z (P0.02) and t (P0.01) scores
was observedwithnormalizationinthree patients; there was nosignifcant difference
in percent improvement of bone parameters between femur and spine. The increase
in bone parameters at spine and femur was independent fromBMD, t and z scores at
baseline. The percent increase in spine t score was positively related with the time
elapsed since cure (P0.02). Treatment with bisphosphonates did not infuence the
recovery of bone mineralization.
Conclusions
Spontaneous improvement of steroid-induced osteoporosis after cure of
hypercortisolism occurs both at spine and femur. The improvement is independent
from basal conditions and treatment with bisphosphonates. The improvement at
spine depends on time since cure.
P28
Predictors for cure and normotension after adrenalectomy for primary
aldosteronism
Cristina Volpe
1
, Marja Thoren
1
, Martin Backdahl
2
, Jan Calissendorff
1
,
Henrik Falhammar
1
, Hans Wahrenberg
3
, Bertil Hamberger
2
& Ulla Enberg
2
1
Endocrine Unit, Department of Molecular Medicine and Surgery,
2
Department of Molecular
Medicine and Surgical Unit, Karolinska Institutet, Stockholm, Sweden;
3
Department of Endocrinology Metabolism and Diabetes, Karolinska
University Hospital, Stockholm, Sweden.
Background
Primary aldosteronism (PA) accounts for 5-10% of all hypertension. In about
30% of PA patients the disease is unilateral caused by an adenoma or rarely
unilateral hyperplasia. Cure rate from unilateral adrenalectomy, defned as
normalized aldosterone secretion, is high but only 30-35% will obtain complete
resolution of hypertension. We have studied pre- and postoperative characteristics
potentially important for biochemical cure and normotension after adrenalectomy
for PA.
Seventy-seven patients with PA (41 women, 36 men) aged 16-78 years
underwent unilateral adrenalectomy with follow-up of 7.50.7 years. Clinical
information was obtained from hospital charts and in addition to routine
histopathology in situ hybridization of steroidogenic enzymes was performed.
Results
PA was cured in 92 and 4% improved. In the cured group normotension without
medication was achieved in 38%. Normotensives had shorter duration of
hypertension (P0.009), higher u-aldosterone (P0.007) and lower potassium
(P0.033) but similar age as hypertensives. There was no signifcant difference
in age or duration of hypertension between men and women. However,
normotension was achieved in 59% of women and in 20% of men.
Histopathology revealed an adenoma in 85% of cases. Expression of the gene
CYP11B2 (aldosterone synthetase) in tumours was positively associated with
biochemical cure. Expression of CYP11B1 and CYP17, coding for enzymes in
the cortisol synthesis was frequent, and the only enzymes expressed in tumours
from four patients that were not cured.
Conclusions and discussion
Older age, longer duration of hypertension and unrelated hypertension are the
most commonly reported reasons for persistent hypertension after adrenalectomy
for PA. There was no impact of age in our cohort, but risk factors may vary
between populations. Our results also suggest a more favourable outcome for
women than for men. Expression of steroidogenic enzymes may predict cure and
improve understanding of underlying pathophysiology.
P29
Beneht to risk ratio of mitotane high starting dose strategy in 22 patients
with adrenocortical carcinoma (ACC): a prospective evaluation
Sophie Maucle`re-Denost
1
, Sophie Leboulleux
1
, Isabelle Borget
1
,
Abir Al Ghuzlan
1
, Jacques Young
2
, Laurence Drouard
1
, Angelo Paci
1
,
Philippe Chanson
2
, Martin Schlumberger
1
& Eric Baudin
1
1
Institut Gustave Roussy, Villejuif, France;
2
Ho`pital Kremlin Bice`tre,
Le Kremlin Bice`tre, France.
Background
The beneft to risk ratio of mitotane high starting dose regimen in ACC remains
unknown.
Methods
To evaluate a high starting dose strategy, we performed a single-center,
prospective study with three main objectives: 1) to assess the time taken to
reach a mitotane plasma level above 14 mg/l (beneft); 2) to evaluate mitotane
tolerance (risk) in the frst 3 months of treatment and 3) to analyse the correlation
using a regression analysis test between the shortest length of time to reach the
mitotane therapeutic window (1 month) and the following parameters: age, BMI,
treatment for dyslipidemia, tumour weight and size, hormone production, Weiss
score, ENSAT Staging and mitotane dose.
Twenty-two patients with ACC have been prospectively enrolled. Mitotane has
been administrated at a starting dosage of 2-3 g/d which was rapidly increased up
to the maximal tolerated dose (max 9 g/d) within 2 weeks. Plasma mitotane levels
were measured monthly using HPLC.
Results
The mitotane high starting dose strategy (median 6 g/d within two weeks) allowed
the therapeutic threshold of 14 mg/l to be reached at 1, 3 or 6 months in 6/22
patients (27%) 7/22 patients (32%) and 10/19 patients (53%), respectively.
Finally, 16 out of 22 patients (73%) reached the therapeutic window during the
total follow-up period (median, 2 months; range 1-27 months). Eleven patients
(50%) interrupted transiently the treatment for toxicity. Grade 3-4 neurological or
haematological toxicities were observed in three patients (13.6%). There was
a tendency for an association between a concomitant lipid-lowering treatment and
a shorter time for reaching mitotane therapeutic window (OR0.143; CI 0.016-
1.265; P0.08).
Conclusions
High starting dose of mitotane allows o,p`DDD therapeutic levels to be reached
within 1 month in 27% of patients with an acceptable tolerance. Lipid-lowering
therapy could be associated with a shorter time to achieve mitotane therapeutic
levels.
P30
Primary adrenocortical sarcomatous carcinoma: case report
Imre Zoltan Kun
1
, Zsuzsanna Szanto
1
, Emilia Let
1
, Vasile Bud
2
&
Doina Milutin
3
1
Endocrinology Clinic, UMPh, Targu Mures, Romania;
2
Clinic of Surgery
no. I, UMPh, Targu Mures, Romania;
3
Institute of Pathology, UMPh, Targu
Mures, Romania.
Adrenocortical carcinoma is a rare disease, its estimated incidence being
1-2/million per year in general population. Age distribution shows two peaks: the
frst in early childhood (70% of patients having a benign evolution), and the
second between 40 and 50 years of age (with a dismal prognosis).
The 38-years-old male patient (C A) hospitalized in our Clinic in September 2008
presented hypertension (to 250/150 mmHg) for about 3 months, lumbar pain with
irradiation into left fossa iliaca, weight loss, anorexia and anxiety. Both
abdominal US and CT-scan showed a great tumor mass (124,111 mm) in the
left adrenal gland that dislocated the pancreas and the left kidney, so we supposed
frstly a phaeochromocytoma or an adrenal adenoma. The investigations (normal
urinary AVM and metanephrines, slightly elevated basal cortisolaemia,
responding normal to the suppression with DXM 1 mg, normal ACTH,
DHEA-S, aldosterone) did not confrm our presumptions. 17-OH-progesterone
was slightly elevated (3.82 ng/ml, normal range: 0.5-2.1 ng/ml). After an
adequate cardiovascular stabilization the patient underwent operation in
December 2008. The histology completed with immunohistochemistry showed
a primary adrenocortical carcinoma with sarcomatous transformation, a very rare
form of adrenocortical malignant tumors. The abdominal CT-scan did not fnd
local recurrence or metastases in April 2009, and the patient did not receive
chemotherapy. In October 2009 a second surgery was needed for a local
recurrence (190,140,100 mm) and pancreatic metastases. In November 2009
the CT-scan showed a tumor mass of 27 mm in diameter in the left suprarenal
region and peritoneal microlymph nodes (3-4 mm). Post-surgical chemotherapy
was recommended.
In the accessible literature only seven cases have been detailed until 2007, three of
them with osteo-, chondro- or rhabdomyosarcoma components, and four others
only with sarcomatous spindle cell component. The case is discussed under
different aspects (nosological evaluation, differential diagnosis, management and
prognosis), based on recent references.
P31
Adrenocortical cancer: any hope? case reports
Zsuzsanna Valkusz
1
, Sandor Magony
1
, E
va Csajbok
1
, Janos Gardi
1
,
Ildiko Kiss
2
& Janos Julesz
1
1
First Department of Internal Medicine, University of Szeged, Szeged,
Hungary;
2
Euromedic Diagnostics, Szeged, Hungary.
Adrenocortical cancer is a rare and heterogenous malignancy with incompletely
understood pathogenesis and poor prognosis. Sometimes patients present with
hormonal excess symptoms (e.g. virilization, Cushing`s syndrome) or local
symptoms consistent with abdominal space-occupation (median tumor size at the
time of diagnosis may be 10 cm). Three cases are presented to give an overview
of how adrenocortical cancer is currently managed. Tumors typically appear
inhomogenous on computed tomography or magnetic resonance imaging showing
signs of necrosis, irregular borders and they differ from benign adenomas by their
low fat content. Hormonal evaluations are important additives for the diagnosis.
All patients with suspected adrenocortical carcinoma should be carefully
evaluated for signs and symptoms of hormonal syndromes Prognosis depends
on many factors. Complete surgical resection is the treatment of choice. Mitotane
is given when surgery is not possible, after incomplete resection or in cases of
metastatic disease. Chemotherapeutic combination is frequently used (etoposid,
doxorubicin and cisplatin plus mitotane or streptozotocin plus mitotane). New
treatments, such as insulin-like growth factor I receptor antibodies, tyrosine-kinase
inhibitors and antiangiogenic compounds, are now being intensively investigated
to fnd more effective therapies for this extremly severe malignant neoplasia.
P32
Utility of midnight salivary cortisol measurement in the diagnosis of
overt and subclinical Cushing`s syndrome
Marta Sereg
1
, Judit Toke
1
, Attila Patocs
2
, Peter Igaz
1
, Nikolett Szucs
1
,
Ibolya Varga
2
, A
gnes Szappanos
1
, Edit Glaz
1
, Karoly Racz
1
& Miklos Toth
1
1
Second Department of Medicine, Faculty of Medicine, Semmelweis
University, Budapest, Hungary;
2
Molecular Medicine Research Group,
Hungarian Academy of Sciences and Semmelweis University, Budapest,
Hungary.
Background
Midnight salivary cortisol (SalC2400) measurement has been recently suggested
as one of the frst-line screening tests for hypercortisolism.
Aims
In our present study, we evaluated the clinical utility of the salivary cortisol
(SalC) measurement in the diagnosis of both overt and subclinical Cushing`s
syndrome.
Patients with overt Cushing`s syndrome (n23, group A) and those with
subclinical Cushing`s syndrome due to incidentally discovered adrenal adenomas
(n18, group B) were sampled for serum cortisol (SerC) and SalC at 2400 and
0800 h. Urinary cortisol excretion (UFC) was measured and overnight low dose
dexamethasone test (LDDST, 1 mg) was performed. The control group consisted
of patients with the fnal diagnosis of inactive adrenocortical adenomas (n40,
group C) and of patients investigated for various reasons (severe obesity,
hypertension, etc.) fnally proved to be non-hypercortisolemic (n70, group D).
Receiver operating characteristics (ROC) analysis was performed to determine
optimal cut-offs for diagnosis of both overt and subclinical hypercortisolism.
Diagnostic power of each test was expressed as area under the curve (AUC)
obtained by ROC analysis.
Results
Cortisol concentrations in each test except SerC0800 were higher in group A than
in group B. The AUCs for discrimination of patients with overt or subclinical
Cushing`s syndrome (n41, groups AB) fromcontrols (n110, groups CD)
in decreasing order were: LDDST 0.930, SeC2400 0.924, SalC2400 0.907, UFC
0.828, SalC0800 0.645 and SerC0800 0.642. SalC and UFC concentrations
signifcantly correlated with body mass index in group D but not in the other
groups.
Conclusion
The diagnostic utility of SalC2400 for the diagnosis Cushing`s syndrome was
similar to LDDST and SerC2400. The differences in SalC2400 between overt and
subclinical Cushing`s syndrome as well as the signifcant correlations between
SalC/UFC and body mass index indicate that the diagnostic utility of SalC2400 is
highly dependent on the composition of patient and control groups.
P33
Adrenal incidentalomas and low grade hormonal activity
Dimitris Stefanopoulos, Ifgenia Kostoglou-Athanassiou,
Aikaterini Michou, Aikaterini Chronaiou, Razvan Alexandros Badila,
Georgia Vassiliou, Vassiliki Loi & Areti Karf
Department of Endocrinology, Red Cross Hospital, Athens, Greece.
Adrenal incidentalomas are increasingly recognized today as a result of
technology use, such as computed tomography and magnetic resonance imaging.
Adrenal incidentalomas are of diverse nature and their secretory activity is
currently on research focus.
The aim was to describe 39 consecutive patients with adrenal incidentalomas
presenting over a period of 1 year.
A group of 39 consecutive patients with adrenal incidentalomas are described. All
patients were investigated for hormonal activity of the incidentalomas. Morning
and evening cortisol, urine free cortisol, aldosterone and renin in supine and
upright position, catecholamines, metanephrines and urine VMA were measured.
A low dose dexamethasone suppression test was performed in all patients. The
imaging characteristics of the incidentalomas were fully characterized on
computed tomography and magnetic resonance imaging. In the case where
surgery was decided the histology of the removed adrenal tumor was noted.
Results
Within the group of 39 consecutive patients with adrenal incidentalomas 14
(36%) had abnormal suppression of morning cortisol after the low dose
dexamethasone suppression test, although morning and evening cortisol were
normal and the cortisol diurnal rhythm was normal. Within the group of 39 cases
of adrenal incidentalomas two patients had clearly abnormal ratio of aldosterone
to plasma renin activity and were found to have primary hyperaldosteronism
and seven (17.9%) patients had a ratio of aldosterone to plasma renin activity of
20-50, suggestive of aldosterone hypersecretion. A patient had a pheochromo-
cytoma and another had a myelolipoma.
Conclusion
Adrenal incidentalomas represent a diverse group of adrenal pathology. Many
appear to have low grade secretory activity which may not be enough to cause the
appearance of the respective clinical picture in the patient, remaining thus
subclinical. The natural history, pathology and secretory activity of adrenal
incidentalomas is a subject of extreme interest and needs further investigation.
P34
Aberrant adrenal LH receptors leading to subclinical Cushing`s
syndrome: long-term effect of medical treatment with leuprolide acetate
Theodora Stratigou, Vasileios Tsatlidis, Sylvina Sangova-Grigoriadi,
Nikolaos Kypraios, Katerina Papadopoulou, Metaxia Tampourlou &
Slylianos Tsagarakis
Department of Endocrinology and Diabetes, Athens Polyclinic Hospital,
Athens, Greece.
Aberrant adrenal LH expression is a rare cause of adrenal Cushing`s syndrome
(CS) leading to transient hypercortisolism during pregnancies and
ACTH-independent macronodular adrenal hyperplasia (AIMAH) after the
sustained postmenopausal increase of LH secretion. Subclinical CS due to
aberrant LH expression has very rarely been described. Herein, we report a case
with aberrant LH/hCG adrenal receptor mediated subclinical CS in a patient with
incidentally discovered AIMAH and the outcome following long-term leuprolide
acetate administration.
Case report
A 54 postmenopausal female presented with bilaterally enlarged adrenals
discovered incidentally following abdominal CT-scan performed for assessment
of a uterine bleed. She had no hypertension, osteoporosis, diabetes, hirsutism,
weight gain or other stigmata of CS. Urinary free cortisol (UFC) excretion was
borderline high associated with incomplete cortisol (F) suppression on a low dose
dexamethasone suppression test (LDDST). She was initially treated with
hysterectomy and left adrenalectomy. Subsequent investigations in our unit
revealed borderline elevated midnight plasma F and UFC excretion and,
incomplete F suppression following a LDDST. Investigations for aberrant
receptor expression revealed no F response following upright posture and meal
tests but a marked F increase following LHRH (100 g i.v.) and hCG (10 000 U
i.m.) administration. Treatment with leuprolide acetate (3.75 mg i.m. every
4 weeks) led to a gradual reduction of UFC and midnight F and, complete F
suppression after LDDST. Moreover a gradual increase of basal ACTH levels was
observed. The size of the hyperplastic right adrenal remained unchanged.
Conclusions
This case illustrates the necessity to include LH aberrant receptor expression
screen in asymptomatic patients with bilateral adrenal incidentalomas. Moreover,
since the LH decrease induced by leuprolide acetate leads to normalisation of
pituitary-adrenal function, this treatment may be recommended even in patients
with subtle glucocorticoid excess.
P35
Conservation and divergence in transcriptional regulation of human
CYP11B1 and CYP11B2 genes
Lih-Ann Li
1
, Li-Chuan Cheng
1
& Tun-Wen Pai
2
1
National Health Research Institutes, Zhunan, Miaoli, Taiwan, ROC;
2
National Taiwan Ocean University, Keelung, Taiwan, ROC.
CYP11B1 and CYP11B2 are responsible for the fnal steps in cortisol and
aldosterone synthesis, respectively, in human. These two genes share 95%identity
in coding regions and 90% identity in introns, but have very dissimilar promoter
regions. To investigate whether there is a regulatory link between human CYP11B1
and CYP11B2 genes, we analyzed their upstream sequences using a pattern-search
program termed multiple index sequence alignment. Three common sequence
segments, cre, Ad5 and SF-1 binding site, were located in the proximal upstream
regions. The Ad5 site is essential for basal expressionof both genes. Mutation of the
Ad5 site of CYP11B1 reduced promoter activity to a minimum level in the human
adrenocortical cells. Overexpression of COUP-TFI increased CYP11B1 and
CYP11B2 promoter activities. However, COUP-TFI probably exerted its
stimulatory effect through cre, not Ad5 as previously reported. The presence of
the SF-1 binding site also exhibited a positive effect on both promoters, but to a
lesser extent compared to Ad5. Additionally, we discovered two clusters of
common sequence segments in the distal upstreamregions. Each cluster represents
a short Alu repeat. Alu modulated CYP11B1 and CYP11B2 promoter activities as
an enhancer. Copy number but not orientation affected its enhancement. Three
truncated long L1 repeats were found in the CYP11B1 promoter, while one was
located in the CYP11B2 promoter. The one situated 343-bp upstream of CYP11B1
diminished promoter activation of the gene. Removal of this L1 repeat regained
promoter activity. The inhibition was colocalized with a putative open reading
frame ORF2 encoded within L1. Although this ORF2 is nonfunctional owing to a
premature termination, inhibition may arise from transcriptional expression of
ORF2. Our results denied this possibility because no sign of expression was
detected when ORF2 was replaced by a fuorescent protein. L1 apparently contains
negative regulatory sequences or structures.
P3
Free cortisol in plasma and saliva samples after synacthen testing in
a routine exploration of patients in endocrinology
Julie Brossaud, Laurence Dolomie, Blandine Gatta, Antoine Tabarin &
Jean-Benoi `t Corcuff
University Hopital of Bordeaux, Pessac, France.
Cortisol ([C]) biological activity depends on its free fraction diffusion into the
intracellular compartment. The diagnosis of adrenal insuffciency requires
investigations such as the synacthen test and studies in intensive care units
suggest that free plasma [C] could provide a better indicator of effcient [C] than
total plasma [C]. We undertook this study to compare various determinations of
free [C] levels with regard to adrenal status evaluated on total plasma [C] after a
1 g synacthen test.
Tests were performed in 130 patients from an endocrinology department (81 F) to
investigate adrenal insuffciency (saliva and serum samples). We assayed saliva
[C] and plasma CBG, albumin, total and free [C] (after ultrafltration). Free
cortisol (F) also estimated with quadratic equations (either with concentrations of
CBG alone or CBG and albumin) or with the [C]/CBG index.
Statistically signifcant correlations were seen between all free [C] assays or
calculations; Spearman`s % coeffcient were: 0.85, 0.63, 0.57, 0.51 between [C]
saliva and i) [C] levels in ultrafltrated serum, ii) after quadratic calculation
(CBG&Albumin), iii) after quadratic calculation (CBG) and iv) for [C]/CBG
index, respectively.
When a post synacthen serum total [C] level of 550 nmol/l was used as threshold
to diagnose adrenal insuffciency (36/130 patients) the ROC AUCs were: 0.97,
0.92, 0.90, 0.89, 0.83 for [C] levels in ultrafltrated serum, after quadratic
calculation (CBG&Albumin), in saliva, after quadratic calculation (CBG) and for
[C]/CBG index, respectively. For a sensitivity set at 100% specifcities were: 46,
40, 27, 8 and 1% for [C] levels after quadratic calculation (CBG&Albumin), in
ultrafltrated serum, in saliva, after quadratic calculation (CBG) and for [C]/CBG
index, respectively.
Thus, despite good general agreement between the synacthen test and the various
methods to evaluate free cortisol (except [C]/CBG index) individual
discrepancies mar their use without addressing their clinical relevance in
endocrinology.
P3I
Inactivation of PRKARIA or PRKAR2B increases cell proliferation and
decreases apoptosis, delineating distinct molecular mechanisms in
adrenocortical human H295R cell line
Bruno Ragazzon
1
, Jero`me Bertherat
1,2
& Marthe Rizk-Rabin
1
1
Institut Cochin, Universite Paris Descartes, CNRS UMR 8104, Inserm
U1016, Paris, France;
2
Service dÈndocrinologie, Groupe Hospitatlier
Cochin Saint Vincent de Paul, Paris, France.
The cAMP signaling cascade is one of the main pathways involved in the
pathogenesis of adrenocortical tumors (ACT). Protein kinase A (PKA) is a key
element of this pathway. The R1A and R2B proteins are the most abundant
regulatory subunits in endocrine tissues. Inactivating mutations of PRKAR1A are
observed in Carney complex and a subset of ACT. We have recently reported
that inactivation of PRKAR1A dysregulates cAMP pathway and reduces TGF-
induced apoptosis in the human adrenocortical cell line (H295R) (Ragazzon et al.
Cancer Res 2009). A dramatic decreased in R2B protein levels are observed in a
subset of adrenocortical adenomas. However, no information is available on the
role of PRKAR2B in H295R. This study aims to compare the potential role of
R1A and R2B subunits in cell proliferation, control of cell cycle and apoptosis.
We have inactivated PRKAR1A and PRKAR2B in HEK293 and H295R cell lines
by RNA interference.
Both inactivation lead to an increased PKA enzymatic activity, disturbs the cell
cycle progression by increasing the G2 phase. This increases proliferating cells
(BrdU incorporation) and confers resistance to TGF- and TNF-induced
apoptosis (Annexine V). However, these apparently similar global cellular
responses are mediated by different mechanisms. Differential regulations of
cyclins are observed. PRKAR1A inactivation acts on G1/S phase, decreasing the
expression and the transcriptional activity of cyclin E and A. PRKAR2B
inactivation acts on S/G2 phase increasing the expression and transcriptional
activity of cyclin A and B. The resistance to apoptosis displays distinct regulation.
The expression of Bax is decreased and Bcl2 is increased under TNF stimulation
in PRKAR2B inactivated cells only.
The effects of PRKAR1A and PRKAR2B inactivation are not antagonist in H295R.
However these similar effects of PKA type I or type II on the cell cycles are in fact
mediated by different mechanisms.
P38
Cortisol resistance in a HIV infected patient
Francois Djrolo
Endocrine and Metabolsm Unit, Faculte des Sciences de la Sante, Cotonou,
Benin.
A few endocrine disturbances had been reported in HIV infected patients but
cortisol resistance was exceptional.
A 24 years old lady was admitted in the internal medicine unit of the teaching
hospital in Cotonou (Benin) unconscious. Her illness has began since 3 months
ago with hyperthermia, diarrhoea, wasting and recurrent convulsive crisis and was
unsuccessful treated by traditional healers. At physical examination, there was a
severe dehydration, fever (38.7 ?C) and arterial hypotension. Research of malaria
infestation was negative and macro and microscopic examination of cephalo-
rachidian fuid was normal excluding meningo-encephalitis. Other biological
examinations showed anything else than a moderate anemia and hypokalemia.
A diagnosis of adrenal failure in a HIV infected patient was suspected.
Rehydration with electrolyte compensation resulted in the recovery of
consciousness. HIV infection was confrmed by a positive HIV serology.
Surprisingly, plasma level of cortisol was very high suggesting a resistance to
cortisol action. Since common disturbance of adrenal function reported in HIV
infected patients was adrenal failure, it seams interesting to report this case, which
was likely a case of cortisol resistance in a HIV infected patient. If mechanism of
adrenal failure in HIV infected patients is quite clear, cortisol resistance needs to
be confrmed by more other observations and it`s mechanism to be investigated.
P39
The measurement of epicardial fat thickness is an index of
cardiometabolic risk in patients with adrenal incidentaloma
Laura Iorio
1
, Roberta Zelaschi
1
, Calin Coman
2
, Alexis Elias Malavazos
1
,
Giada Dogliotti
3
, Massimiliano Marco Corsi
3
& Bruno Ambrosi
1
1
Endocrinology Unit, Department of Medical and Surgical Sciences,
University of Milano, IRCCS Policlinico San Donato, San Donato Milanese,
Italy;
2
Echocardiographic Unit, IRCCS Policlinico San Donato, San Donato
Milanese, Italy;
3
Department of Human Morphology and Biomedical
Sciences 'Citta` Studi`, University of Milano, Milano, Jamaica.
An augmented cardiovascular risk is present in adrenal incidentalomas (AI), as in
overt hypercortisolism. Recent studies recommended epicardial fat (EF) thickness
as a new marker of visceral adiposity and an indicator of cardiometabolic risk.
In this study, we evaluated the possible relationship between EF thickness, indices
of left ventricular (LV) hypertrophy and adipocytokines levels in AI.
We studied 26 patients with AI (62.310.3 years, BMI 27.23.3 kg/m
2
, mean
S.D.) and 21 controls matched for age and BMI (59.96.7 years, BMI 25.3
3.6 kg/m
2
). In all patients basal ACTH, cortisol, urinary free cortisol, IL-6 and
resistin levels were measured. One mg dexamethasone test was performed. EF
thickness and indices of LV hypertrophy were assessed by transthoracic
echocardiography.
Four patients had a subclinical Cushing`s syndrome (SCS) and 22 had non
functioning masses. Overall, the prevalence of arterial hypertension was 69.2%,
type 2 diabetes was 19.2%, dyslipidemia 26.9%, overweight 50% and obesity
19.2%.
Patients with AI had greater EF thickness and LVMI values than controls (8.1
2.1 vs 1.30.2 mm, P,0.0001; 111.025.8 vs 96.93.6 g/m
2.7
P,0.01,
respectively). In AI patients, LV hypertrophy (defned as LV mass indexed for
height
2.7
(LVMI) 51 g/m
2.7
or relative wall thickness 0.45) was present in
84.6%. Interestingly, EF thickness correlated with LVMI (r0.40, P,0.05) and
with BMI (r0.44, P,0.05).
Plasma IL-6 and resistin levels were higher in AI than in controls (14.922.9 vs
4.16.9 pg/ml, 11.66.1 vs 7.22.5 ng/ml, respectively, P,0.05).
Basal cortisol positively correlated (P,0.05) with indices of LV hypertrophy
(LVMI, IVST, PWT), but not with EF thickness and adipocytokines levels.
Conclusions
a) The increase of EF thickness and adipocytokines levels, together with the high
prevalence of LV hypertrophy indicate an high cardiometabolic risk in AI;
b) a possible role of cortisol on cardiac alterations is suggested; c) the
measurement of EF should be helpful during follow-up.
P40
Higher cortisol response to glucose load in patient with adrenal
adenomas and subclinical Cushing (SC)
Valentina Vicennati, Guido di Dalmazi, Elena Casadio, Andrea Repaci,
Uberto Pagotto & Renato Pasquali
UO Endocrinologia, Bologna, Italy.
Aims
SC can be discovered in 5-20% of the incidentalomas. Subclinical secretion is
defned by the failure to suppress plasma cortisol after 1 mg-overnight
dexamethasone ,50 nmol/l, but there is no agreement in literature. The aim of
our study was to evaluate cortisol response to oral glucose tolerance test (OGTT)
as potential marker of autonomous activity of these adenomas.
Methods
Ninety subjects, 47 females and 43 males, underwent the protocol of study
running in our Unit, which included clinical evaluation, basal hormonal and
biochemical evaluation, OGTT, 1 mg-dexamethasone suppression test, and CT
scan when not available. Primary hyperaldosteronism, hyperandrogenism,
malignancy and other adrenal pathologies were excluded; subjects with type 2
diabetes were also excluded from the study.
Results
SC had signifcantly larger adenomas than non secreting adenomas (NSA)
(P,0.005). There were no signifcant differences in metabolic parameters
between the two groups. Glucose and insulin levels during the OGTT were not
signifcantly different between the groups. There were no signifcant differences in
the prevalence of metabolic syndrome between the two groups. Cortisol
OGTT-tAUC
were signifcantly higher in SC than in NSA (P,0.05). Glucose
OGTT-tAUC
were higher in SC than in NSA, even though this difference did not reach
the statistical signifcance (P0.058). OGTT-tAUC were similar between the
two groups.
Post-dexamethasone cortisol (Fdex) was positively and signifcantly related to
adenoma size (r0.292, P,0.01) and to glucose
OGTT-tAUC
(r0.254,
P,0.05). The relationship between cortisol
OGTT-tAUC
and glucose
OGTT-tAUC
was statistically signifcant in SC (t6.86, P0.010) but not in NSA (t
0.230, P0.631), without any effect of gender.
Conclusions
SC showed a lower reduction of cortisol levels following oral glucose load. This
fnding should be red as a partial autonomic secretion by adenomas. Thus, cortisol
response to OGTT should represent another element to evaluate, together with
Fdex, in order to defne the secretion of the adrenal mass.
P41
Response of human adrenocortical carcinoma to mitotane treatment
/n r/tra
Peter van Koetssveld, Karlijn van Rutte, Marlijn Waaijers, Ronald de
Krijger, Steven Lamberts, Richard Feelders, Wouter de Herder &
Leo Hofand
Introduction
Adrenocortical carcinoma (ACC) is a rare, but highly malignant endocrine tumor.
Surgery is the primary choice of treatment. In case of inoperable disease or tumor
recurrence, therapy with the adrenolytic drug mitotane is usually applied. Plasma
mitotane concentrations of 14 mg/l (50 M) seem required for an effect on
tumor mass. Despite its clinical use, the effects of mitotane on cell proliferation
and hormone production have been poorly investigated in vitro.
Aim of the study
To study the effect of mitotane on cell number and hormone production in
primary cultures of human ACC.
Methods
Freshly isolated primary cultures of ACC (n21) cells were cultured in DMEM-
F125% FCS. Cells were treated for up to 144 h with increasing concentrations
of mitotane (range: 10
7
10
4
M). After 144 h, media were collected for
hormone measurement and cells were harvested for determination of cell number.
Results
Three groups of cultures were arbitrarily defned on the basis of response to
50 M mitotane. Non-responders (NR): ,33% inhibition of cell number (n12,
IC
50
: 10
4
M); partial responders (PR): 33-66% inhibition (n5, IC
50
: 40
1 M); responders (R): 66% response (n4, IC
50
: 201 M). 10/21 (49%)
ACC produced cortisol (n9) or estradiol (n1) in vitro. There was no
difference in the effect of mitotane on cortisol in PRR (IC
50
: 2.41.2 M,
n6), compared with NR (IC
50
: 3.61.2 M, n3). Functional ACC were
signifcantly more sensitive to mitotane treatment than non-functional ACC
(7/9 PRR and only 3/12 NR were functional; P,0.03, Fisher`s exact test).
Conclusions
Mitotane inhibits cortisol production in primary functional ACC cultures. Only
4/21 (19%) of the primary AAC showed a response of more than 66% inhibition
of cell number by 50 M mitotane, in agreement with the estimated in vivo
effcacy of the drug. Cell number of functional ACC is signifcantly more potent
inhibited by mitotane, compared with non-functional ACC.
P42
Increased prevalence of metabolic syndrome in patients with subclinical
autonomous cortisol hypersecretion by adrenal incidentalomas
Andromachi Vryonidou
1
, Dimitrios Ioannidis
2
, Evangelina Vassilatou
3
,
Kostas Katsoulis
2
, Maria Panagou
2
, Kostas Panayiotopoulos
2
,
Stamatina Michalopoulou
2
& Ioanna Tzavara
2
1
Department of Endocrinology, Diabetes and Metabolism, Red Cross
Hospital, Athens, Greece;
2
Department of Endocrinology, Diabetes and
Metabolism, 'Amalia Fleming` General Hospital, Athens, Greece;
3
Endocrine Unit, Second Department of Internal Medicine, 'Attikon`
University Hospital, Athens, Greece.
Background
Subclinical autonomous cortisol hypersecretion is the most common hormonal
abnormality in patients with adrenal incidentalomas, which is characterized by
subtle abnormalities of the hypothalamic-pituitary-adrenal axis (HPA) due to
adrenal autonomy. Possible detrimental effects of subclinical hypercortisolism in
these patients are still under investigation.
Objective
To investigate the prevalence of the metabolic syndrome (MS) in patients with
adrenal incidentalomas.
Patients-methods
From a group of 194 patients with newly diagnosed adrenal incidentalomas by CT
who were evaluated in our Departments, 121 patients under the age of 70 and
without overt disease or a previous history of DM2 were studied for the presence
of metabolic syndrome. All patients underwent a hormonal and biochemical
evaluation. The diagnosis of subclinical Cushing`s syndrome was based on a post-
LDDST plasma cortisol level 1.8 g/dl combined with an abnormal result of at
least one other test of the HPA axis and the absence of clinical signs of cortisol
excess. The detection of MS was based on ATPIII criteria.
Results
Of 87 patients had a normal adrenal function (NF) and 33 had subclinical
Cushing`s syndrome (SC). Patients with SC did not differ in clinical
characteristics or the prevalence of hypertension from patients with NF, but
had larger masses (3.11.0 vs 2.11.1 cm, P,0.01), higher fasting glucose
(99.020.8 vs 9214.4 mg/dl, P,0.05) and triglycerides levels (127.858 vs
107.342.4 mg/dl, P0.037) than patients with NF. MS was more prevalent in
patients with SC (15/33) than patients with NF (18/87) (45.4 vs 20.6%, P,0.01).
Conclusion
Patients with adrenal incidentalomas and subclinical autonomous cortisol
hypersecretion have an increased prevalence of metabolic syndrome. These
data support that even slight cortisol excess may have clinical implications but
this needs to be clarifed with prospective studies.
P43
Comparison of physiological and endocrine responses of rainbow trout
(Oncarhynchas myk/ss) after electroanesthesia and anesthesia with
MS222 and clove oil
Amir Sattari
1
, Saed Mirzargar
2
, Adib Abrishamifar
3
& Hoseinali
Ebrahimzadeh Mosavi
2
1
University of Kerman, Kerman, Islamic Republic of Iran;
2
University of
Tehran, Tehran, Islamic Republic of Iran;
3
Iran University of Science and
Technology, Tehran, Islamic Republic of Iran.
This study investigated electro-anesthesia of rainbow trout (Oncorhynchus
mykiss) in comparison with MS222 and clove oil by using plasma cortisol and
glucose level as stress indicators. A microcontroller-based apparatus was
designed and constructed to allow a programmable voltage-time pulse-width
modulated (PWM) electrical wave (AC) application through 19,20 cm
submersible electrodes for 91 s in a 33 cm long tank to induce loss of equilibrium
and immobility with recovery after 5227 s. Recovery after 660102 s was
observed in MS222-anesthetized fsh (after induction for 72072 s) and a
recovery time of 546102 s was observed in clove oil-anesthetized fsh (after
induction for 14442 s) both are signifcantly longer recovery times in
comparison to electro-anesthesia (P,0.001). Direct ELISA for cortisol and
enzymatic and colorimetric method for glucose assessments was used at 0, 1, 6,
12 h after anesthesia in all treatments. Trend of cortisol responses during 12 h of
investigation was similar in all groups. The dilatory trend of glucose changes and
response derived from anesthetics and electricity and its surge at 6 h after
anesthesia (P,0.05) confrmed glucose as a second order indicator of stress-
responses. Electro-anesthesia is a fast, economic, eco-friendly and safe anesthetic
method provides desirable trout immobility for aquaculture activities.
P44
Pheochromocytoma of the adrenal gland scaled score (PASS) as a
predictor of aggressive biologic behaviour
Mari a Riestra Fernandez, Pedro Boix Pallares, Edelmiro Menendez Torre,
Cecilia Sanchez Ragnarsson, Javier Aller Granda, Antonio Rabal Artal,
Eli as Delgado A
lvarez, Antonio Lavilla Corcovado, Joaquin Petierra

de la Uz, Marta Dieguz Felechosa & Virginia Bellido Castaneda
Hospital Universitario Central of Asturias, Oviedo, Asturias, Spain.
Background
Up to 15% of pheochromocytomas are malignant. The only defnite criterion for
malignancy is the presence of metastases. The histological differentiation
between benign and malignant tumours is diffcult, being a challenging problem
nowadays.
Aim
To asses if postoperative histological evaluation using the previously proposed
pheochromocytoma of the adrenal gland scales scored (PASS) can predict
malignancy.
Methods
Twenty-nine pheochromocytomas have been retrieved from 1985 to 2009.
A single pathologist, blinded to clinical outcome, reviewed the histopathologic
characteristics of all cases using the PASS system. This score includes 12
different features, for instance tumour necrosis, mitotic rate, tumour cell spindling
or the presence of large cell nests. It has been suggested that a score 4 can be
used to separate tumours with aggressive potencial behaviour.
Results
Twenty-six patients had a benign outcome while three had a clinically malignant
pheochromocytoma. The mean PASS score punctuation in benign tumours was
eight, whereas in malignant tumors it was 8.3. None of the histopathologic
features included in the PASS system was present in the 100% of the malignant
tumours. None of the benign pheochromocytomas obtained a PASS ,4. 38% of
the benign tumours had a score 9, compared with the 68% of the malignant
pheochromocytomas.
Conclusions
In our experience, the PASS system does not appear to have a major role in
predicting the behaviour of pheochromocytomas. We consequently suggest that
PASS requires further refnement and validation, before it can be recommended
as a valuable tool for clinical prognostication.
P45
High prevalence of subclinical hypercortisolism in patients with
bilateral adrenal incidentalomas: implications to management
Dimitra Vassiliadi, Georgia Ntali, Eirini Vicha & Stylianos Tsagarakis
Department of Endocrinology, Athens` Polyclinic Hospital, Athens, Greece.
Although the prevalence of subclinical hypercortisolism (SH) in unilateral
incidentalomas (UI) has been extensively reported, patients with bilateral
incidentalomas (BI) have not been thoroughly investigated. Moreover, the
management of BI poses great dilemmas if surgery is considered, since bilateral
adrenalectomy leads to life-long replacement. In the present study, we aimed to
describe the characteristics of patients with BI in comparison to their unilateral
counterparts. We also report the surgical outcome in a small number of such
patients.
Methods
Measurement of morning cortisol (F), ACTH, DHEA-S, midnight F, 24-h urinary
free cortisol (UFC), F-post low-dose dexamethasone suppression test (LDDST),
fasting glucose/insulin and OGTT in 172 patients with adrenal incidentalomas
(AI) (41 with BI). SH was defned as F-post-LDDST2.5 g/dl) and one more
HPA axis abnormality.
Results
There was no difference in age, BMI, prevalence of diabetes mellitus and IGT
between patients with UI and those with BI. UI were signifcantly smaller
(2.31.1 cm vs 3.81.2 cm, P,0.001). Patients with BI had signifcantly
higher F-post-LDDST (4.34.1 vs 2.02.6, P,0.001) and lower DHEA-S
levels (59.455.5 vs 92.484.2, P0.003) but similar levels of UFC, ACTH
and midnight F compared to UI. SH was signifcantly more prevalent in BI (41.5
vs 12.2%, P,0.001). The size of the AI correlated positively with F-post-LDDST
(r0.44, P,0.001) and negatively with ACTH (r0.21, P0.007) and
DHEA-S (r0.34, P,0.001). Fourteen patients with BI were operated; two
underwent total bilateral adrenalectomy, ten unilateral adrenalectomy (largest
lesion) and two had unilateral and cortical-sparing contralateral adrenalectomy.
Patients who had unilateral adrenalectomy showed signifcant improvement of
SH. Patients who underwent unilateral and cortical-sparing contralateral
adrenalectomy showed complete remission of SH.
Conclusions
SH is signifcantly more prevalent in patients with BI. Its optimum management
remains debatable; if surgery is decided an approach aiming to preserve
adrenocortical function seems more sensible.
P4
Prohle of cortisol changes during early stages of development in
rainbow trout
Gholam Reza Ghaedi
1
, Vahid Yavari
1
, Bahram Falahatkar
2
,
Amir Parviz Salati
1
& Reza Sahraeian
1
1
Khoramshahr Marine Science and Technology University, Khoramshahr,
Islamic Republic of Iran;
2
University of Guillan, Rasht, Islamic Republic of
Iran.
Whole-body cortisol content was measured in oocyte, embryo and larvae of
rainbow trout by extraction and RIA. The cortisol content of oocyte was 2.55
0.06 ng/ml that probably has a mathernal origin. After fertilization cortisol
level decreased to 1.840.07 ng/ml, then reached to the lowest level (0.30
0.06 ng/ml) by day 10 where it remained unchanged until eyed stage on day 18.
After that cortisol increased at hatching to 0.600.06 ng/ml, suggested that
cortisol biosynthesis was occurred. Cortisol level was increased to 3.010.14 at
2-week-old fsh. Result of this study showed that cortisol biosynthesis could be
observed in rainbow trout during the late stages of embryo development, before
hatching will be started.
P4I
Genomic DNA alterations in adrenocortical tumors (ACTs): diagnostic
and prognostic value
Guillaume Assie
1,2
, Olivia Barreau
1
, Aurelien De Reynie`s
3
,
Fredrique Tissier
1,4
, Lionel Groussin
1,2
, Xavier Bertagna
1,6
,
Jero`me Bertherat
1,6
& Eric Clauser
1,5
1
INSERM U567, CNRS UMR8104, Institut Cochin, Departement
Endocrinologie, Metabolisme and Cancer, Universite Paris Descartes, Paris,
France;
2
Service dÈndocrinologie, Assistance Publique Ho`pitaux de Paris,
Ho`pital Cochin, Paris, France;
3
Programme Cartes dÌdentite des Tumeurs
(CIT), Ligue Nationale Contre Le Cancer, Paris, France;
4
Service
dànatomopathologie, Assistance Publique Ho`pitaux de Paris, Ho`pital
Cochin, Paris, France;
5
Service dÒncogenetique, Assistance Publique
Ho`pitaux de Paris, Ho`pital Cochin, Paris, France;
6
Service
dÈndocrinologie, Assistance Publique Ho`pitaux de Paris, Ho`pital Cochin,
Centre des Maladies Rares de la Surrenale, Reseau des cancers rares-
COMETE, INCA, Paris, France.
The outcome of ACTs can be determined by gene expression level at the RNA
level. However RNA handling is challenging. In contrast tumor DNA is robust
and therefore easier to use.
Aim
To characterize the ACTs DNA alterations; to identify markers with diagnostic
and prognostic value using tumor DNA.
Methods
The mapping of chromosomal gains and losses of 60 ACTs (39 adenomas
(ACAs), 21 carcinomas (ACCs)) was performed with CGH arrays (4452 probes
BAC arrays). DNA copy number determination at specifc loci was performed
with quantitative PCR (qPCR), in the same tumors (training cohort), and 79
independent ACTs (49 ACAs, 30 ACTs, validation cohort). Patient informed
consents and local ethic committee approval were obtained. Statistics were
performed in R (www.R-project.org).
Results
The number of chromosomal gains and losses measured by CGH differs between
ACAs and ACCs (10 vs 44%, P2
10
). Common gains in ACCs include
chromosome 5, 7, 12, 16, 19 and 20, and common losses include chromosome 13
and 22. Using qPCR, the best discrimination between ACAs and ACCs was
obtained by substracting the DNA copy numbers at 6 loci (5q, 7p, 16q and 11p,
13q, 22q) in the training cohort (sensitivity 100%; specifcity 100%). This result
was confrmed in the validation cohort (sensitivity 100%; specifcity 80%).
In ACCs, interestingly, the number of chromosomal gains and losses was not
associated with survival (Cox P0.84). However comparison of bad and good
prognosis ACCs showed specifc differences (good prognosis: gain in 5q; bad
prognosis: gain in 1q and losses in 10p and 17q). Using qPCR, the substraction of
DNA copy numbers at 1q-17q showed the strongest association with survival in
the training cohort (Cox P5.10
4
), and was confrmed in the validation cohort
(P0.02).
Conclusion
Tumor DNA can be used for the diagnosis of malignancy and the prognosis of
ACTs.
P48
Combined primary aldosteronism and preclinical Cushing`s syndrome
due to a large adrenocortical adenoma
Jasmina Ciric, Biljana Beleslin, Mirjana Stojkovic, Bozo Trbojevic &
Milos Zarkovic
Institute of Endocrinology, Belgrade, Serbia.
The rarest causes of primary aldosteronism are aldosterone producing carcinoma,
ectopic aldosterone secretion and familial aldosteronism. There are also few cases
reported of aldosterone and cortisol tumor cosecretion. We present a 38-year-old
woman admitted to our hospital because of resistant hypertension, large adrenal
tumor and hypokalemia. At age 32 hypertension was diagnosed, but routine
laboratory and abdominal ultrasound examination were normal. Few months
before admission, hypokalemia was registered and abdominal CT showed left
adrenal adenoma of 6 cm in diameter. Endocrinological tests revealed high
upright plasma aldosterone level (1380 ng/l) and low plasma renin activity
(0.7 ng/ml per h) suppressed by 2 l of saline infusion to 160 ng/l and ,0.2 ng/ml
per h, respectively. Supine aldosterone level was 156 ng/l and plasma renin
activity ,0.2 ng/ml per h. Morning cortisol level was not suppressed by 1 mg
(259 nmol/l), or 8 mg (337 nmol/l) of dexamethasone. ACTH level was low,
3.5 pmol/l. After high dose dexamethasone, a stimulation with 250 g of ACTH
was performed and a sharp increase of aldosterone from 376 to 1380 ng/l was
detected, as well as an increase of cortisol to 1286 nmol/l. Plasma DHEAS level
was low. Left adrenalectomy was done and a tumor of yellow cut surface was
found. It was a benign cotical adenoma mostly consisting of light clear cells.
Normal adrenal gland tissue was atrophic. On the bases of endocrinological
testing this rare case of combined aldosterone and cortisol tumor secretion
demonstrated that although autonomous, aldosterone secretion could be both
ACTH and angiotensin dependant.
P49
In r/tra effect of dopastatins on hormone secretion in adrenal tumors
Claudia Pivonello, Tiziana Napolitano, Monica De Leo, Alessia Cozzolino,
Pasquale Vitale, Gaetano Lombardi, Annamaria Colao & Rosario Pivonello
Federico II University, Naples, Italy.
Somatostatin (SSTRs) and dopamine (DRs) receptors are expressed in adrenal
tumors. It has been demonstrated in pituitary and neuroendocrine tumors that
somatostatin-dopamine chimeric molecules, namely dopastatins, which bind both
somatostatin (SST2 and/or SST5) and dopamine (D2) receptors, exert a more
potent action compared with the single receptor agonists in experimental settings.
The aims of this study were to evaluate the expression of DRs and SSTRs, and the
effects of dopastatins on hormone secretion in two aldosterone-secreting
adenomas, two cortisol-secreting adenomas, as well as in two different
adrenocortical carcinoma cell lines (H295R and Hac-15).
The expression of SSTRs and DRs was detected by RT-PCR. Hormone secretion
was evaluated by measuring cortisol and aldosterone, before and after the
administration of Lanreotide, Cabergoline, BIM 23A765, BIM 23A387 and BIM
23A370 in concentrations ranging from 10
12
to 10
7
M, using a chemi-
luminescent immunoenzimatic assay.
At RT-PCR, D1 and D5 together with SST1, SST2 and SST5 were expressed in
one case of aldosterone-secreting adenoma whereas D2 and D4, together with
SST1, SST2 and SST5 were expressed in the other case. Both cortisol-secreting
adenomas expressed different SSTRs, together with D1 and D2 in one case and
D1, D2 and D4 in the other case. H295R and Hac-15 cell lines showed the same
receptor profle expressing D2 and D4 receptors and all SSTRs. In aldosterone
and cortisol-secreting adenomas, lanreotide and cabergoline decreased aldoster-
one and cortisol secretion whereas dopastatins induced a higher inhibition of
hormone secretion. A decrease of aldosterone and/or cortisol secretion by both
lanreotide and cabergoline, and more potently by dopastatins were found
respectively in the H295R and Hac-15 cell lines.
The results of the current study demonstrated that dopastatins are able to modulate
aldosterone and cortisol secretion in adrenal tumors, so that they might be
potentially useful in the management of adrenal tumors.
P50
Under-expression of the TWIK-related acid-sensitive K
channel 2
(TASK-2) gene is a hallmark of aldosterone producing adenoma causing
human primary aldosteronism
Livia Lenzini
1
, Teresa Maria Seccia
1
, Brasilina Caroccia
1
, Chiara Recarti
1
,
Maria Rosa Pelizzo
2
& GianPaolo Rossi
1
1
DMCS, Internal Medicine 4, University of Padova, Padova, Italy;
2
Department of Medical and Surgical Sciences, Padova, Italy.
Background
Primary aldosteronism is a common cause of arterial hypertension, but its
underlying molecular mechanisms are unknown. K
is a key regulator of
aldosterone secretion: it interacts with physiological secretagogues of aldosterone
as angiotensin II (Ang II) end endothelin-1. In vivo genetic manipulation of a
widely distributed class of channels, which generate background or 'leak`
potassium (K
) currents, the twik-related acid-sensitive K channel 1 (TASK-1)

and 3 (TASK-3), resulted in a phenotype which closely mimics human primary
aldosteronism.
Objective
To investigate the expression of the K
channels of the TASK family in a series

of aldosterone producing adenoma (APA).
Results
The most expressed TASK channel gene in both the normal ZG and in APAs was
TASK-1, followed by TASK-2 while the expression of TSAK-3 was scant. With a
whole transcriptome analysis followed by confrmation with quantitative real time
RT-PCR we found a consistent and marked under expression of TASK-2 channel
in all studied APA (n24), while TASK-1 and TASK-3 were heterogeneously
expressed, as compared to the normal adrenal cortex. Immunohistochemistry was
used to confrm the expression of the 3 TASK K
chennels in the adrenal cortex

at the protein level and quantitative immnunoblotting will be used to confrm the
differences detected at the transcript level.
Conclusions
These results suggest that a blunted activity of TASK-2 results into lowering the
membrane potential and thereby in opening of the voltage-gated T-type calcium
channels, thus rendering zona glomerulosa cells more sensitive to aldosterone
secretagogues. These ex vivo fndings, while pointing to TASK-2 channels under-
expression as an important role in the pathophysiology of primary aldosteronism,
mandates further studies to conclusively establish their functional relevance.
P51
d \g effect of serotonin (5-HT) on cortisol secretion in primary
pigmented nodular adrenal disease
Estelle Louiset
1
, Celine Duparc
1
, Veronique Perraudin
1
, Sylvie Renouf
1
,
Rossella Libe
2
, Constantine A Stratakis
3
, Jero`me Bertherat
2
&
Herve Lefebvre
1,4
1
INSERM U982, University of Rouen, Mont Saint Aignan, France;
2
INSERM U567, Cochin Institute, University Paris V, Paris, France;
3
NIH,
NICHHD, Bethesda, Maryland, USA;
4
University Hospital of Rouen, Rouen, France.
Illegitimate membrane receptors are known to play a role in cortisol secretion in
adrenal adenomas and ACTH-independent macronodular adrenal hyperplasia
(AIMAH) causing Cushing`s syndrome. Conversely, illegitimate receptors have
never been described in primary pigmented nodular adrenal disease (PPNAD). In
the normal adrenal gland, serotonin (5-HT) has been shown to stimulate cortisol
secretion through activation of 5-HT receptor type 4 (5-HT4) whereas, in some
AIMAH tissues, the corticotropic effect of 5-HT is mediated by ectopic 5-HT7
receptors. The aim of the present study was to evaluate in vitro the effect of 5-HT
on cortisol release by cultured adrenocortical cells removed from four patients
with PPNAD. Graded concentrations of 5-HT induced a dose-response increase
in cortisol production. The potency and effcacy of 5-HT to stimulate cortisol were
higher in PPNAD than in normal adrenocortical cells. Conversely, the 5-HT4
receptor agonists cisapride and metoclopramide did not infuence corticoster-
oidogenesis. The action of 5-HT on PPNAD cells was also investigated in the
presence of the specifc 5-HT4 receptor antagonist GR113808 and the specifc
5-HT7 receptor antagonist SB269970. GR113808 (10
7
M) signifcantly
inhibited the stimulatory effect of 5-HT on cortisol by both reducing the potency
and effcacy of the indolamine. Similarly, the cortisol response to 5-HT was
inhibited by SB269970 (10
7
M). These data indicate that, in PPNAD cells, the
stimulatory action of 5-HT on cortisol release is mediated, at least partly, by an
ectopic 5-HT7 receptor. In addition, they suggest that 5-HT-induced cortisol
production also involves an isoform of the 5-HT4 receptor with an atypical
pharmacological profle. The present study constitutes therefore the frst
demonstration of the occurrence of functional ectopic receptors in PPNAD
cells. Finally, as 5-HT has been shown to be produced in the adrenal gland by
perivascular mast cells, our results show that, in PPNAD tissues, 5-HT may
modulate cortisol secretion through a paracrine mechanism. This work was
supported by INSERM U982, the Carney Complex and COMETE (PHRC
AOM06179) networks and ANR Genopat 2008.
P52
Expression of mTOR and IGF2 and \d \g effects of mTOR inhibitor
drugs on cell proliferation and cortisol production in human
adrenocortical cancer cells
Maria Cristina De Martino
1
, P M van Koetsveld
1
, D M Sprij-Mooij
1
,
Richard A Feelders
1
, Wouter W de Herder
1
, Steven W J Lamberts
1
,
Annamaria Colao
2
, Rosario Pivonello
2
& Leo J Hofand
1
1
Erasmus MC, Rotterdam, The Netherlands;
2
Federico II University,
Naples, Italy.
Background
Adrenocortical carcinoma (ACC) is an uncommon malignancy with a still
scantily understood pathogenesis and generally poor prognosis. Many patients
with ACC need new treatment options. mTOR inhibitors, as sirolimus (S) and
temsirolimus (T), are promising antineoplastic drugs in several kinds of tumors.
Methods
In three human ACC cell lines (H295, HAC15 and SW13), we evaluated the
mTOR and IGF2 expression at mRNA level (by qPCR) and at protein level by
immunohistochemistry (IHC) in AgarCyto cell blocks and we tested the dose- and
time-dependent effects of S and T on cell growth by the analysis of DNA-
measurement. In HAC15 cells we have measured the effects of compounds on
cortisol production.
Results
The IGF2 mRNA levels expression in H295 and HAC15 cells were high, whereas
very low in SW13. In the three cell lines, no signifcant differences have been
found in the mRNA expression levels of mTOR.
The IHC for IGF2 showed a very strong protein expression in H295 and HAC15
and a very low expression in SW13. However, the IHC for mTOR showed a
strong positivity in all three cell types.
S and T were able to suppress the cell growth in all cell lines, in a dose- and time-
dependent manner. SW13 (IC`10
10
; maximum effect 90% at the dose 10
8
)
was signifcantly more sensitive to these treatment than H295 (IC50`10
8
;
maximum effect `50% at the dose 10
5
) and HAC15 (IC50`10
8
; maximum
effect `50% at the dose 10
5
). In HAC15 6 days of treatment with S or T
induced a signifcant inhibition of cortisol production, corrected for cell number,
suggesting a direct effects of the compounds on hormonal synthesis.
Conclusion
The results of the current study demonstrated that sirolimus and temsirolimus
inhibit the in vitro proliferation and cortisol production of ACC cell lines,
suggesting that mTOR-inhibitors drugs may have a role in the treatment of ACC.
P53
Primary bilateral adrenal lymphoma without adrenal insufhciency: a
case report
Cavit Culha, Ziynet Alphan Uc, Esra Nur Ademoglu, Ahmet Yildirim,
Dilek Dellal, Suheyla Gorar, Gonul Koc & Yalcin Aral
Department of Endocrinology and Metabolism, Ankara Training and
Research Hospital, Ankara, Turkey.
Although adrenal gland involvement may be seen in patients with diffuse (non-
Hodgkin) lymphoma, primary adrenal lymphoma is quite rare and adrenal
insuffciency accompanies the clinical picture in 2/3 of cases.
Case
A 70-year-old male patient presenting with anorexia and weight loss was referred
to our clinic for bilateral adrenal masses, which were detected by abdominal
computerized tomography (CT) as 5.2,5.2,2.7 cm in the right adrenal and
11,9,7 cm in the left adrenal. Plasma cortisol was normal (20 g/dl) and
suppressed with 1 mg of dexamethasone. Hypertension was not reported in the
history and was not detected in the follow-up of the patient. ACTH (34 pg/ml),
aldosterone, renin and 24-h urine catecholamine levels were normal. Bilateral
adrenal masses were inactive. Initially, hemogram and peripheral blood smear
were normal and sedimentation rate was 120 mm/h. In the second evaluation,
hemoglobin was 8 g/dl, leukocyte 3500/mm
3
(67.9% neutrophils, 15.9%
lymphocytes and 13.9% monocytes) and platelet 591.000/mm
3
. Tuberculin skin
test and chest tomography was normal. No adrenal insuffciency was detected
clinically or in laboratory testing. The diagnosis of large diffuse large B-cell (non-
Hodgkin) lymphoma was made by tru-cut biopsy of the left adrenal gland
performed concomitantly with CT. The patient was referred to medical oncology
department. CHOP regimen chemotherapy was begined. The symptoms and signs
of the patient was reduced after the early phase of ongoing treatment.
Conclusion
The total number of reported cases with primary bilateral adrenal lymphoma in
the literature so far is around 70. We should keep in mind that bilateral adrenal
masses detected by imaging techniques may not always be metastases, but
sometimes the primary malignancy itself, even if very rarely; and take into
consideration that, as in our present case, there may be no accompanying adrenal
insuffciency even if the bilateral adrenal masses are large.
P54
Cushing`s syndrome in children: new faces of the old one
Slavica Dautovic, Dragan Katanic & Jovan Vlaski
Institute for Child and Youth Health Care of Vojvodina, Novi Sad, Serbia.
The incidence of endogenous Cushing`s syndrome (CS) is ^2-5 new cases per
million people per year; ^10% of these new cases occur in children. The most
common cause of endogenous CS in children is an ACTH-secreting pituitary
adenoma (^75% of all cases in children older than 7 years). CS is still diagnostic
and therapeutic challenge, especially in childhood. One of the most important
diagnostic steps is thinking about it. The evaluation of children with the clinical
manifestations of CS is more complex because many of the diagnostic tests are
based on studies in adults, and then extrapolated for children. One major concern
is the appropriate screening test for obese children to exclude CS. We report 16
years old obese girl (BMI97.percentile), with hirsurtism, amenorrhea and short
stature. She is referred the frst time to pediatric endocrinologist after 3 years of
ambulatory treatment for obesity. The frst suspicion is raised after detail history
and clinical examination. After differential diagnostic approach, diagnosis of
morbus Cushing is established. The transsphenoidal surgery by experienced
pituitary neurosurgeon performed. Follow up shown total success: appropriate
weight, high velocity and normal menstrual cycle. This girl is the frst child with
CS in our institution. Besides all tests and neuroimaging techniques, this case
reminds us that the old skills as detail history and clinical examination represent
the most important diagnostic step in all conditions.
P55
Inuence of various clinical variables and storage conditions on urinary
cortisol levels: gas chromatography~mass spectrometry (GC~MS)
versus immunoassay
Timo Deutschbein
1,2
, Martina Broecker-Preuss
2
, Michaela Hartmann
3
,
Stefan Wudy
3
, Ricarda Althoff
2
, Klaus Mann
2
& Stephan Petersenn
2,4
1
University Hospital Bergmannsheil, Bochum, Germany;
2
University of
Duisburg-Essen, Essen, Germany;
3
Justus Liebig University, Giessen,
Germany;
4
ENDOC Center for Endocrine Tumors, Hamburg, Germany.
Introduction
Measurement of urinary cortisol is often used to assess disease activity in patients
with suspected or proven hypercortisolism. However, specifc reference ranges
are lacking for some of the newer assays. This study analyzed upper limits of
normal (ULN, mean2S.D.) for two analytical procedures (GC-MS, ECLIA) in
relation to various independent variables. Besides, the infuence of different
storage conditions was investigated (by ECLIA).
Methods
Each ten healthy subjects were grouped by age (18-30; 31-50; 50), BMI (,25;
25), and sex (60 males, 60 females; age 39.31.3; BMI 25.90.4). Subjects
collected 24 h urines on two (n120) to three (n11) separate days. Total
urinary cortisol was measured - after enzymatic hydrolysis - by GC-MS and
urinary free cortisol (UFC) was measured by ECLIA (Roche). ULN were
calculated for each procedure and then applied to 12 patients with histologically
confrmed hypercortisolism (four males, eight females; age 53.13.1; BMI
29.11.8). In order to determine degradation, samples were stored at 4 ?C
(without light) or 22 ?C (with and without light) for 0, 24, and 72 h.
Results
Results of both procedures were signifcantly correlated (r0.77, P,0.001).
For each procedure, multiple stepwise regression analysis identifed sex as the
only signifcant predictor, resulting in sex-dependent ULN (each males versus
females): 900 vs 679 nmol/d for GC-MS, 344 vs 255 nmol/d for ECLIA. These
ULN classifed samples from patients as hypercortisolemic in 100% (GC-MS),
and 96% (ECLIA). Mean coeffcients of variation (CV) for three collection
periods were 42% (24-70%) for ECLIA. Different storage conditions over 72 h
did not alter UFC levels signifcantly.
Conclusion
Results of the two analytical procedures for urinary cortisol were well correlated.
ECLIA as well as GC-MS allowed excellent identifcation of hypercortisolic
states if assay- and sex-specifc ULN were used. Although patients were
intensively educated to provide adequate 24 h urines, we observed relevant
variation between different collection periods. UFC is stable over 72 h
irrespective of the storage conditions applied when measured by ECLIA.
P5
Arterial and venous thrombotic events in Cushing`s syndrome
Catalina Poiana
1,2
, Corina Chirita
2
, Mara Carsote
1
, Cristina Ene
2
,
Ramona Samoila
2
, Raluca Trifanescu
1,2
, Monica Gheorghiu
1,2
&
Mihail Coculescu
1,2
1
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania;
2
CI Parhon National Institute of Endocrinology, Bucharest, Romania.
Background
Cushing`s syndrome (CS) is associated with a hypercoagulable state and an
increased risk for acute coronary syndromes, stroke, and deep vein thrombosis
(DVT).
Aim
To assess the prevalence of thrombotic events in a series of patients with CS.
Notes of 113 patients with CS were retrospectively reviewed.
Results
Instable angina was diagnosed in ten women, aged 52.112.2 years. Three cases
had Cushing`s disease (CD), four adrenal Cushing`s (AC), one had independent
ACTH bilateral adrenal hyperplasia, two iatrogenic CS.
Acute myocardial infarction was diagnosed in one woman, aged 41 years, with CS
due to ACTH independent bilateral macronodular hyperplasia. Several risk
factors for thrombosis were associated: obesity, diabetes mellitus, hypertension.
Bilateral adrenalectomy was performed.
A 48 years old woman with android phenotype, hirsutism, secondary amenorrhea
had a history of two strokes. AC was diagnosed and left adrenalectomy
performed.
DVT occurred in four patients. One woman with CD, aged 31, developed DVT of
the calf. Estroprogestin pills`s use was an additional risk factor. Pituitary
radiotherapy and bilateral adrenalectomy were performed. The second women,
aged 41, with CS due to ACTH independent bilateral macro nodular adrenal
hyperplasia, associating a parathyroid carcinoma, was diagnosed with extensive
DVT of ilio-femuro-popliteal axis. Bilateral adrenalectomy was performed. The
third case, a 60 years old diabetic, hypertensive woman with CD, showed an
extensive thrombosis of the left inferior cave vein 3 months after left
adrenalectomy. The fourth case was a 46 years female with right adrenalectomy
for adrenal carcinoma with hepatic metastasis, secondary hypertension and
diabetes mellitus. After surgery, inferior cave vein thrombosis occurred.
Anticoagulation was initiated in all cases.
Conclusions
Arterial or venous thrombotic events are an important clue in CS diagnosis or a
complication in cases already diagnosed.
P5I
Inuence of short-term glucocorticoid therapy on regulatory T cells
Thomas Dexneit
1
, Silviu Sbiera
1
, Sebastian Schmull
1
, Jens van den Brandt
2
,
Luitgart Kraus
1
, Melanie Beyer
1
, Robert Mlynski
1
, Holger Reichardt
1
,
Bruno Allolio
1
& Martin Fassnacht
1
1
Department of Internal Medicine I, University of Wurzburg, Wurzburg,
Germany;
2
Department of Cellular and Molecular Immunology, University
of Gottingen, Gottingen, Germany;
3
Ept. of Oto-Rhino-Larnygology,
University of Wurzburg, Wurzburg, Germany.
Introduction
Glucocorticoids (GC) are used for immunosuppression in many clinical
conditions. Pre-clinical and early clinical studies suggested that the induction
of regulatory T (Treg) cells contributes to the immunosupressive effects of GCs.
However, in the hitherto reported clinical studies only patients with ongoing
autoimmune diseases were included. Our goal, therefore, was to determine the
infuence of exogenous GCs in vivo in immunocompetent subjects and mice.
Methods
Sixteen otherwise healthy patients with sudden hearing loss that were treated with
GCs (modifed 'Stennert scheme': day 1-3: 250 mg prednisolone i.v., day 4-14
dose reduction to 10 mg prednisolone p.o.) were included. Circulating Treg cells,
defned as CD4CD25 high FoxP3, were characterized on day 0 and 14 of GC
administration using FACS analysis. In addition, Balb/c mice were treated with
dexamethasone (day 1-3: 100 mg/kg i.p., day 4-14 dose reduction to 1 mg/l p.o.)
to further evaluate the effects of very high dose GCs, comparable to the dosage
e.g. used in multiple sclerosis.
Results
In contrast to our expectations, GCs induced an increase of lymphocytes in our
subjects (mean T cells before and after GCs 1503 vs 2327/l (P,0.001) without
any relevant change of the relative frequency of T cell subpopulations (e.g.
CD4cells 75.5 vs 75.7%). The percentage of Treg cells even slightly dropped
(4.2 vs 3.4%; P0.02).
In mice, GCs led to a strong decrease of CD4 T cells in blood (3.7*105 to
0.8*105/ml) and spleen (1.5*107 to 0.3*107/ml) after 14 days. Accordingly the
absolute number of Treg cells was also signifcantly reduced. However, relative
frequency of Treg cells amongst all CD4T cells remained unchanged in spleen
(8.0 vs 7.5%) and decreased in peripheral blood (7.5 vs 1.75%; P,0.01).
Conclusion
Neither in immunocompetent humans nor in mice short-term GC therapy induced
the supposed increase of circulating Treg cells. Thus, it is doubtful whether GCs
act via infuencing Treg cells.
P58
Long-term follow-up of patients with adrenal incidentalomas: a single
center experience
Panagiotis Anagnostis, Zoe Efstathiadou, Stergios Polyzos,
Konstantina Tsolakidou, Ioannis Litsas, Athanasios Panagiotou &
Marina Kita
Endocrinology Clinic, Hippokration Hospital of Thessaloniki, Thessaloniki,
Greece.
Introduction
Adrenal incidentalomas (AIs) constitute an emerging clinical entity due to the
increased use of abdominal imaging for diagnostic purposes.
Objective
To investigate the morphological and hormonal alterations of AIs in a cohort of
patients, who were followed-up in a single centre.
Methods
Sixty-four patients (22 males and 42 females; mean age 61.61.2 years), with
AIs and follow-up of 3.10.4 years (range 0-19) were retrospectively evaluated.
The patients underwent basal and dynamic evaluation of the hypothalamic-
pituitary-adrenal axis, renin-angiotensin-aldosterone system and adrenomedul-
lary function. Mass enlargement and adrenal hyperfunction were estimated at
yearly intervals.
Results
Adrenalectomy was performed in fve patients (four benign cortical adenomas
and one pheochromocytoma). Abnormal manifestation, based on clinical,
laboratory and histological evaluation, was observed in four patients (one
(1.56%) with SCS, two (3.12%) with pheochromocytoma and one (1.56%) with
aldosteronoma), three of which were diagnosed at their initial evaluation and 1 at
the 3rd year of follow-up. The remainders (60 patients (93.75%)) were harbouring
a nonsecretory mass (eight potential myelolipomas, eight nodular hyperplasias,
three cystic lesions). Eleven patients (17.2%) had bilateral AIs. Mass enlargement
(5-13 mm) was observed in nine patients (14%), 10 mm four (6.25%), while
mass shrinkage (5-19 mm) in three (4.7%) during follow-up. No hormonal
evolution was noticed.
Conclusions
AIs present usually as benign, non-secretory lesions. Criteria for surgical
intervention were met at initial assessment for the majority of AIs. Size alterations
during follow-up are uncommon and functional evolution is rare.
P59
QTc and P wave dispersion in patients with Cushing`s syndrome
Nihal Akar Bayram
1
, Reyhan Ersoy
2
, Dilek Tuzun
2
, Serap Soytac Inancli
2
,
Engin Bozkurt
1
& Bekir Cakir
2
1
Ankara Ataturk Education and Research Hospital, Department of 2.
Cardiology, Bilkent, Ankara, Turkey;
2
Ankara Ataturk Education and
Research Hospital, Department of Endocrinology and Metabolism, Bilkent,
Ankara, Turkey.
Introduction
The clinical implications of QTc and P wave dispersion in patients with Cushing`s
syndrome have not been studied previously. In this study, we aimed to compare
QTc dispersion and P wave dispersion in patients with Cushing`s syndrome and
healthy subjects.
Material and method
Sixteen patients with Cushing`s syndrome diagnosed on clinical, laboratory and
imaging fndings and 16 age and sex matched control subjects were included. All
subjects underwent a routine standart 12- lead suface electrocardiograpy recorded
at a paper speed of 25 mm/s and gain of 100 mm/mV. Maximum, minimum and
mean QT intervals were calculated. Measured maximum and minimum QT
intervals were corrected by Bazett`s formula (QTcQT/RR), and were defned
as corrected QT interval (QTc). The difference between the maximum and
minimum QTc interval was defned as QTc dispersion and the difference between
maximum P wave duration (P
max
) and minimum P wave duration (P
min
) was
calculated as P wave dispersion (PWD).
Results
Maximum QTc interval (429.924.8 vs 408.424.7; P0.02), QTc interval
(389.022.0 vs 375.511.6; P0.04) and QTc dispersion (84.917.6 vs
70.913.2; P0.02) were signifcantly longer in patients with Cushing`s
syndrome compared to healthy subjects. There was no signifcant difference in
P
max
, P
min
and P wave dispersion between groups (P0.05).
Conclusion
We showed that QTc interval and QTc dispersion were increased in patients with
Cushing`s syndrome compared to healthy subjects; however P wave dispersion
did not change. Accordingly, signifcant electrical heart function disturbances
which might be life-threatening may occur in patients with Cushing`s syndrome
indicating need for early monitorization by a cardiologist in these patients.
P0
Laparoscopic adrenalectomy: 12-year experience in a single institution
Igor Hartmann, Vladimir Student, Zdenek Frysak, Oldrich Smakal &
Michal Grepl
University Hospital, Olomouc, Czech Republic.
Introduction
Laproscopic adrenalectomy (LA) was frst described in the literature in 1992 and
has become the preferred method for the removal of functioning and non-
functioning tumours. More than 75% of Las are performed for endocrine causes
of hypertension such as Conn`s or Cushing`s syndrome and pheochromocytoma.
The majority of centers (80%) perform laparoscopic transabdominal adrena-
lectomy. The frst LA in our institution was performed in 1998 and the procedure
is routinely done from 2000.
Methods
We have retrospectively evaluated the records of patients who underwent the
laparoscopic adrenalectomy between 1998 and 2010 in our institution.
Results
LA was performed in 171 cases in above mentioned period for functional or non-
functional adrenal mass. Every patient underwent endocrinologic and radio-
graphic evaluation, from 2007 adrenal venous sampling in functional tumours. As
contraindication we considered carcinoma suspicion and tumours larger than
12 cm. The transperitoneal approach with 4 or 5 trocars was used in all of the
cases. The average size of the specimen was 4.5 cm (1.5-12 cm). The partial
adrenalectomy was performed in seven cases for adenoma of solitary gland or
bilateral aldosterone producing adenoma. The average operating time was 62 min
(38-200 min.). In 15 cases there was a blood loss more than 100 ml (100-600 ml).
We have experienced three serious signallingsh complications - pancreas lesion
in two cases and lesion of the colon in one case. We had to convert to open surgery
in six cases. We did not experience severe postoperative complications.
Conclusions
The laparoscopic adrenalectomy is a safe procedure with low occurrence of
complications. LA is ideal for all benign tumours ,12 cm. The transperitoneal
approach offers large operative feld with good orientation.
P1
Comparison of plasma aldosterone/signal activity and aldosterone/
active signal ratios in different clinical conditions
Zoltan Locsei
1
, Erzsebet Toldy
2,5
, Dora Horvath
1
, Rita Nagy
1
,
Karoly Racz
3
, Istvan Szabolcs
6
& Gabor L Kovacs
4,5
1
First Department of Internal Medicine, Markusovszky Teaching Hospital
of County Vas, Szombathely, Hungary;
2
Central Laboratory of Marku-
sovszky Teaching Hospital and Institute of Diagnostics and Man,
Szombathely, Hungary;
3
Second Institute of Internal Medicine, Semmel-
weis University, Budapest, Hungary;
4
Institute of Laboratory Medicine,
University of Pecs, Pecs, Hungary;
5
Institute of Diagnostics and Manage-
ment, University of Pecs, Pecs, Hungary;
6
Faculty of Health Sciences,
Semmelweis University, Budapest, Hungary.
Because measurement of plasma signal activity (PRA) is time-consuming an
automated method directly measuring active signal (REN) may be more suitable
for clinical practice. The aim of the study was to analyse the diagnostic utility of
REN and aldosterone (ALD)/REN ratio as compared to PRA and ALD/PRA ratio.
PRA, REN (DiaSorin) and ALD (Immunotech) were simultaneously measured in
123 plasma samples (83 females and 40 males; mean age, 4216 years)
including samples from 38 healthy volunteers with normal blood pressure and
without medication (controls), 25 healthy females taking oral contraceptives and
60 patients with verifed hypertension (22 treated and 38 untreated). In the latter
group 15 patients have adrenal adenomas.
Results
In the whole group of samples there was a weak but signifcant correlation
(r0.59; P,0.001) between PRA (1.241.26 ng/ml per h) and REN
(28.744.4 U/ml). In the lower concentration (PRA: 0.450.25 ng/ml per h;
REN: 9.410.1 U/ml) the correlation was weaker (r0.38; P,0.001). PRA
was undetectable in 11%, while REN in 4% of the samples. The ALD/REN ratio,
but not the ALD/PRA ratio, was signifcantly (P,0.05) higher in women taking
oral contraceptives than in those who did not (ALD/REN ratio, (40.637.9 vs
22.521.9 pmol/l per U per ml). In hypertensive patients treated with
blockers the ALD/REN ratio was signifcantly higher (P,0.001, 119
111 pmol/l per U per ml) than in controls, and in hypertensive patients
taking medications other that blockers (2316 and 2526 pmol/l per U per
ml, respectively). In patients with adrenal adenoma the ALD/PRA ratio, but not
the ALD/REN ratio, was signifcantly higher than in controls (ALD/PRA ratio
41104 vs 1123 ng/dl per ng per ml per h).
Conclusions
There is a poor analytical correlation between the two methods, especially in the
lower range of PRA/REN concentrations. The widely used screening method
(ALD/PRA) should be replaced by the ALD/REN ratio only after careful
interpretation of the different clinical conditions.
P2
Adrenal incidentaloma; a case report
Danda Vijay Shekar Reddy & Paidipally Srinivas
1
Yashoda Hospital, Hyderabad, Andhra Pradesh, India;
2
Gandhi Medical
College, Hyderabad, Andhra Pradesh, India.
Incidentally found adrenal tumour is one of the most frequent adrenal disorders
due to increased availability and use of imaging studies. But a well circumscribed,
homogenous calcifed adrenal incidentaloma are extremely rare.
We present a case of 68-year-old women who underwent X-ray chest examination
for routine health check up, which revealed hyper intense lesion in left sub
diaphragmatic area. Further evaluation by a CT scan abdomen revealed hyper
dense well circumscribed, homogenous 1000 HU mass of 4.8,3.8 cm in left
adrenal area. Her medical history, physical examination results and routine
laboratory values are unremarkable except for palpable right thyroid nodule and
fndings suggestive of follicular neoplasm on FNAC examination. Serum cortisol
was supressable, 24 h. urinary VMA and metanephrines were normal. To our
knowledge such a adrenal incidentaloma is not reported in literature. Though
most of the calcifed incidentalomas recquire surgical resection we followed up
the case at 3, 6, and 12 months with no change in size.
Careful evaluation and management of adrenal incidentaloma should be
individualised based on clinical circumstances, the imaging phenotype and age
of the patient rather than more aggressive approach, which is used for younger
patients.
P3
Adrenal non-producing adenomas show indirect signs of glucocorticoid
excess and hypercortisolism correlates with differential blood counts
Cornelia Sagert, Hana Hruskovicova, Matthias Haase, Georg Mansmann,
Sven Schinner, Matthias Schott, Werner A Scherbaum & Holger
S Willenberg
Department of Endocrinology, Diabetes and Rheumatology, University
Despite their nature of being clinically inapparent, subtle laboratory abnormalities
are sometimes detected in patients with adrenal incidentalomas and the question
arises whether these changes justify surgical intervention in a patient with an
otherwise benign adrenal tumour. Therefore, we aimed at fnding further
expressions of adrenal hormone excess that refect net glucocorticoid action.
Since glucocorticoids are potent immune suppressants we studied blood counts
and differential blood counts along with basal concentrations of cortisol,
signalling shin and DHEAS, and cortisol values after overnight 1 mg
dexamethasone suppression. We correlated the results in normal individuals,
patients with adrenal adenomas and normal hormone profles, with subclinical
autonomous glucocorticoid hypersecretion, and with overt cortisol excess.
We found that almost all indices of the blood counts were signifcantly different
between the patient groups. In particular, patients with adrenal non-producing
adenomas already show signs of glucocorticoid excess, including relative
lymphocytopenia, lowered DHEAS and ACTH concentrations.
We also found that the extend of lymphocytopenia correlated well with the
concentrations of DHEAS and ACTH, and DHEAS correlated well with ACTH
values.
We conclude that the basal ACTH and DHEAS values along with the differential
blood counts give good information on the extent of glucocorticoid excess and
that silent adrenal adenomas seem to oversecrete glucocorticoids at concen-
trations that already alter these parameters.
P4
Endothelial cell-derived products regulate -catenin-dependent
transcription in human adrenocortical cells
Carolin Schwafertz
1
, Sven Schinner
1
, Markus Kuhn
1
, Ishrath Ansurudeen
2
,
Elke Oetjen
3
, Matthias Schott
1
, Werner A Scherbaum
1
& Holger
S Willenberg
1
1
Hospital Duesseldorf, Duesseldorf, Germany;
2
Division of Molecular
Neurobiology, Department of Neuroscience, Karolinska Institute,
Stockholm, Sweden;
3
Department of Pharmacology, University of
Goettingen, Goettingen, Germany.
Objective
Recently, we have shown that endothelial cell-conditioned medium (ECCM)
stimulates aldosterone secretion and the expression of proteins, essential for
steroidogenesis and adrenal development. Also, we have found that fat cells
regulate adrenal steroidogenesis through the wnt-signaling pathway. In addition,
-catenin was implicated in adrenal tumorigenesis, including aldosterone-
producing adenomas.
Methods
We studied the infuence of endothelial cell-derived products on transcription of
-catenin in cultured NCI-H295R cells using transfected reporter-plasmid assays
and western blot analysis. Cells were stimulated with ECCM, derived from
HUVEC cells for 24 h in the presence or absence of various signalling pathway
inhibitors.
Results
Exposure of NCI-H295R cells to ECCM at a concentration of 50% showed a
robust increase in -catenin-dependent transcription, which was not reversed by
inhibitors of wnt-signaling (sFRP-1 and Dkk-1). Blockade of protein kinases A, B
or C did not interfere with the activation of -catenin-mediated transcription,
elicited by ECCM. However, -catenin-mediated transcription could be blocked
when inhibitors of PI3-kinase (LY294002) or MAP-kinases (U0126 and
PD98059) were used. ECCM exposure also increased the amount -catenin
protein and its translocation into the nucleus, a process blocked by inhibitors of
the MAP kinase pathway.
Conclusion
These in vitro studies indicate that endothelial cell-derived products regulate
-catenin-dependent transcription in adrenocortical cells through a wnt-ligand
independent, PI3-kinase dependent pathway that involves signalling through
MAP kinases. The endothelium may be essential for adrenal development and
play a permissive role in adrenal tumorigenesis.
P5
Sporadic solitary aldosterone- and cortisol-cosecreting adenomas: a
subtype of primary aldosteronism
Holger S Willenberg
1
, Martin Spath
1
, Christiane Maser-Gluth
2
, Rainer
Engers
3
, Martin Anlauf
3
, Gabriele Dekomien
4
, Matthias Schott
5
&
Werner A Scherbaum
1
1
2
Department of Pharma-
cology, University of Heidelberg, Heidelberg, Germany;
3
Institute of
Pathology, University Hospital Duesseldorf, Duesseldorf, Germany;
4
Department of Human Genetics, Ruhr-University, Bochum, Germany;
5
Department of General, Visceral and Pediatric Surgery, University
Subtype identifcation is necessary for making diagnostic and therapeutic
decisions in primary aldosteronism. We studied clinical, hormonal and
histological features of sporadic solitary aldosterone- and cortisol-cosecreting
(C/APA) adenomas in detail.
We here present the endocrine evaluation at baseline, after suppression with
fudrocortisone and dexamethasone as well as after therapy with spironolactone
and after unilateral adrenalectomy in two patients with (C/APA). Also, the
expression of corticotropin- (MC2R) and angiotensin II type 1 (AT1R) receptors
and 17-hydroxylase in the tumors of these two patients was analyzed by
immunohistochemistry.
Aldosterone, 18-hydroxycorticosterone (18-OH-B) and 18-hydroxycortisol (18-
OH-F) were not suppressible with fudrocortisone in both patients and partially
suppressible with dexamethasone in one patient. Aldosterone and hybrid
corticosteroids returned to normal 8 weeks after adrenalectomy. In both cases,
immunostaining showed a weak expression of AT1R and MC2R but strong
expression of 17-hydroxylase. The most common germline mutations in the
aldosterone synthase gene and the aldosterone synthase/11-hydroxylase hybrid
gene were excluded.
These two cases document that sporadic A/CPA is a subtype of primary
aldosteronism. Correct subtype identifcation is necessary to interprete adrenal
venous sampling and to adequately treat adrenal insuffciency after operation.
Presence of an A/CPA should be considered if a patient has i) primary
aldosteronism and ii) hypercortisolism.
P
The HLA-DRB1 shared epitope and trans-encoded HLA-DQ-hetero-
dimers hypothesis in autoimmune Addison disease
Mikulas Pura
1
, Daniel Kuba
2
, Peter Kentos
1
, Silvia Chrenova
2
&
Peter Vanuga
1
1
Department of Endocrinology, National Institute of Endocrinology and
Diabetology, Lubochna, Slovakia;
2
Slovak Centre for Organ Trans-
plantations, Slovak Medical University, Bratislava, Slovakia.
Background
The MHC is the most important susceptibility locus for human autoimmune
diseases (AID). Although associations between MHC class II DRB1 alleles and
Addison disease (AD) have been repeteadly proven in various populations, the
biological mechanisms underlying this association remains unknown. Peptide
presentation to T cells may be important in the initiation or progression of AID.
Disease-linked polymorphisms map to the peptide-binding sites of MHC
molecules class II - pockets. The P
4
pocket of HLA-DR makes an important
contribution to susceptibility to AID. This is readily explained by the fact that the
P
4
pocket is the most polymorphic pocket of the HLA-DR binding site.
The presence of the RAA sequence at positions 72-74 of the HLA-DR -chain
molecule for all HLA-DRB1 alleles known to be associated with rheumatoid
arthritis led to the shared epitope (SE) hypothesis.
Aim
To evaluate the possibility that the SE hypothesis could be applicated in other
autoimmune diseases, we have investigated the complete HLA-DRB1-DQA1-
DQB1 haplotype status in Slovak patients with autoimmune Addison disease.
Subjects and methods
We analysed DRB1-DQA1-DQB1 haplotypes from 57 patients with autoimmune
AD. Subsequently, sequences of the amino acids at positions 70-74 of the HLA-
DR -chain molecule were evaluated.
Results
In 117 alleles analysed, the most frequent amino acid sequences found were as
follows: QK-RGR (30,), DR-RAA (28,), QA-RAA (16,), QR-RAA (10,),
DE-RAA (9,), QR-RAE (7,), QK-RAA (5,).
Conclusions
Building on the HLA genotype classifcation could lead to improvement in our
understanding of the genetics and pathophysiology of AID, namely AD.
The structural information on the P
4
pocket of different DR molecules may be
useful for the development of small organic molecules that inhibit peptide
presentation by DR molecules associated with particular AID.
Bone/Calcium
PI
Estimation of ionized calcium levels after thyroidectomy at King Abdul
Aziz University Hospital (Jeddah)
Faiza Qari
King Abdul Aziz Unversity, Jeddah, Saudi Arabia.
Aim
To determine the incidence of hypocalcaemia and the need for calcium
supplementation after thyroid surgery in 120 patients.
Methods
A prospective study to determine the incidence of hypocalcaemia by measuring
ionized calcium level in 120 patients underwent thyroidectomy at King Abdul
Aziz University Hospital, the data included pre- and post-operative ionized
calcium level, albumin, free thyroxine, thyrotopin and alkaline phosphatase. As
well include age, gender, type of thyroidectomy and pathological characteristics
of resected thyroid tissue and aoutotransplantion of parathyroid gland. Treatment
of post-operative hypocalcaemia and duration of treatment was recorded.
Results
Hypocalcaemia occurred in (15%) 18 patients from total of 120 patients who
underwent total thyroidectomy, had a signifcant lower calcium level of 1.78
0.054 mmol/l compared to 102 (85%) patients with normal calcium level.
Sixteen patients required calcium supplementation with or without oral vitamin
D3. Three patients developed hypoparathyroidism with PTH level of 23 pg/l. Two
patients developed laryngeal stridor and were treated initially by i.v. infusion of
calcium gluconate.
Conclusion
Measuring or calculating ionized calcium level post thyroidectom, to avoid
unnecessary calcium supplementation resulting from diagnosing hypocalcaemia
from measuring total calcium level alone is more accurate and more appropriate.
P8
Imatinib mesylate disturbs bone growth and remodellation in postnatal
rats
Mirja Nurmio
1
, Henna Joki
1
, Jenny Kallio
1
, Jorma Maatta
1
, Kalervo
Vaananen
1
, Jorma Toppari
1
, Kirsi Jahnukainen
2,3
& Tiina
Laitala-Leinonen
1
1
University of Turku, Turku, Finland;
2
Karolinska Institutet and University
Hospital, Stockholm, Sweden;
3
Hospital for Children and Adolescents,
Helsinki, Finland.
Imatinib mesylate is a well-tolerated receptor tyrosine kinase inhibitor that has
gained interest as a potential treatment for osteoporosis and other metabolic
bone diseases. It is clinically approved for the treatment of chronic myelogenous
leukaemia (CML), Philadelphia-positive acute lymphoblastic leukaemia and
gastrointestinal stromal tumors (GIST), and targets the receptors for PDGFs,
ABL-related gene, c-Abl, c-Kit and c-Fms. Altered bone and mineral
metabolism has been described in patients receiving imatinib mesylate, and
recent clinical data show that treating children with imatinib may result in bone
loss. However, the precise effects on the bone microenvironment are unclear.
We therefore exposed young rats to imatinib (150 mg/kg) on postnatal days 5-7,
and studied the effects of tyrosine kinase inhibition on bone physiology on
postnatal days 8 and 77.
Short-term imatinib treatment disturbed growth plate organization and
eliminated all osteoclasts from the endochrondral junction. Peripheral
quantitative computer tomography (pQCT) and micro-CT analysis confrmed
that short-term imatinib treatment lead to a long-term resorption arrest at the
growth plate and simultaneous bone loss at distal bone trabeculi. The impaired
bone remodellation observed on postnatal day 8 remained signifcant until
adulthood. The adverse effects were even more pronounced in another series
of 14-day old animals that were given 100 mg/kg of imatinib on postnatal days
5-13. Therefore, clinicians prescribing tyrosine kinase inhibitors of receptors for
c-Kit, c-Fms, PDGF- or PDGF- for children, should monitor their cancer
patients also for possible adverse effects on bone growth and remodelling.
P9
Parathyroid hormone levels in hemodialysis patients
Ioanna Passalidou & Paraskevi Karapavlidou
General Hospital, Kastoria, Greece.
Introduction
Parathyroid hormone (PTH) starts to rise very early in the course of kidney
disease. As kidney disease progresses, plasma levels of vitamin D and calcium
begin to decline, thus contributing to greater secretion of PTH. In addition, the
retention of phosphate further increases PTH secretion independent of calcium
and vitamin D levels. Continued stimulation of PTH secretion leads to irreversible
parathyroid gland hyperplasia.
Objectives
To measure the PTH levels in hemodialysis patients and relate with the duration
of hemodialysis.
Methods
Forty-two stable hemodialysis patients, 22 (52.4%) women and 20 (47.6%) men
with a mean age of 66.110.7 of years were included in the study. The average
duration of hemodialysis was 2-13 years, with two or three dialysis session
per week.
Blood samples were obtained prior to a dialysis session, after an overnight fast.
The serum PTH concentrations were determined using an immunoreactive
measuring (Elecsys, Roche).
Results
Six (14.3%) patients exhibited elevated PTH levels (250 pg/ml).
- in two patients the duration of hemodialysis was 13 years
- in two patients was 8 years
- in one patient was 6 years and
- in one patient was 5 years.
The PTH level was positively correlated with the duration of hemodialysis.
Conclusion
PTH is the major determinant of rates of bone remodeling and turnover in
hemodialysis patients with end-stage renal disease; accurate assessments of
plasma PTH levels are essential not only for estimating the bone metabolism
of renal osteodystrophy but also for appropriately monitoring the treatment of
secondary hyperparathyroidism.
PI0
Bone mineral density in Ukrainian women of different age with
thyrotoxicosis
Vladyslav Povoroznyuk & Olexandr Oliynyk
1
2
Kiev Clinical
Endocrinology Centre, Kyiv, Ukraine.
Thyrotoxicosis has been linked to osteoporosis and increased fracture risk. On the
other hand, decreasing serum levels of estrogens in postmenopausal women
potentially may increase effect of thyroid hormones on bone tissue. Dual-energy
X-ray absorptiometry is an accurate and precise method of determining BMD,
and has been wildly-used for diagnosing osteopenia and osteoporosis. The aim of
our study was to study by means of DXA the peculiarities of bone loss in women
of different age suffering from thyrotoxicosis.
There were examined 44 Ukrainian women with thyrotoxicosis aged from 25 up
to 72 years (mean 50.11.9 years), who have a history of disease from 3 months
to 20 years (mean 488.7 month). All patients receive a methimazole therapy
and have a medicinal subcompensation. Subjects were divided into four age
groups (25-39 years - 10 patients, 40-49 years - 11 patients, 50-59 years - 12
patients, 60-69 - 11 patients). BMD measurements of the spine (L
1
-L
4
), proximal
femur and radial shaft (33%-site) were determined by DXA using a Prodigy
densitometer (GE Medical systems, Lunar). Data were analyzed using Statistica
6.0. ANOVA was used to examine differences among the groups as for different
variables.
Results
There were found no differences in BMI and thyrotoxicosis duration between the
groups. BMD was decreased in all age groups (total body Z score 0.720.19
S.D.; L
1
-L
4
Z score 0.760.22 S.D.; femur 0.540.16 S.D.; 1.540.24
S.D.). The most signifcant loss of bone tissue was observed in radial shaft
especially in 60-72 year group (T score 3.840.59 S.D.; Z score 2.470.56
S.D.; P,0.05).
Conclusion
The most prominent decrease of BMD in females with thyrotoxicosis is observed
in radial shaft, especially in aged patients. Thus, it is necessary to perform BMD
measurement of radial shaft during DXA examination for thyrotoxic patients.
PI1
Relationship of serum leptin and bone mineral density in patients with
type 2 diabetes mellitus
Olga Vasilkova
1
& Tatiana Mokhort
2
1
The Republican Research Centre for Radiation Medicine and Human
Ecology, Gomel, Belarus;
2
Belorussian State Medical University, Minsk,
Belarus.
Aim
To clarify the contribution of leptin to bone mineral density (BMD) in men with
type 2 diabetes mellitus (DT2).
Materials
We screened 168 Belorussian men aged 50-65 years. Plasma TC, HDL-C,
LDL-C, VLDL-C, TG concentrations, HbA1c, IRI, CRP, total testosterone were
assessed. BMD was evaluated using dual-energy X-ray absorptiometry (DXA).
BMD was expressed as a T score. All statistical analyses were performed using
SPSS v11.0 software.
Results
The mean age was 54.14.8 years, duration of diabetes was 7.0 (3.0-12.0) years
and HbA1c was 8.2% (7.0-9.7). BMD L
1
-L
4
was 1.160.15 g/cm
2
, BMD LF
was 1.070.13 g/cm
2
, BMD RF was 1.060.01 g/cm
2
. By univariate linear
regression analysis, leptin was signifcantly correlated with body mass index
(r0.72, P,0.001), waist/hip ratio (r0.39, P,0.001) and BMD femur
(r0.21, P0.006). By multivariate regression analysis, there was a signifcant
positive correlation between serum leptin level and BMD femur after adjusting
for log total testosterone (0.070, P,0.001) and/or IRI and/or TC but the
signifcant relationship disappeared after adjusting for BMI (0.047, P0.054)
. Correlations between serum leptin level and BMD L
1
-L
4
were not signifcant.
In conclusion, our study revealed that BMD of the femur was positively
associated with leptin in male patients with DT2. Further research is necessary to
confrm this association and to develop ways to correct abnormalities of bone
metabolism in patients with DT2.
PI2
Study implications osteoporosis in gonadal disgenesias
Iulia Bistriceanu
1
, Magda Elvira Preda
1
, Marian Bistriceanu
2
,
Liliana Putinelu
3
, Simona Bondari
2
& Aurora Covei
1
1
Department of Endocrinology, Emergency Hospital, Craiova, Romania;
2
Department of Endocrinology, University of Medicine and Pharmacy,
Craiova, Romania;
3
Department of Geriatry, Chronics Affections and
Geriatric Hospital`s, Stefanesti-Arges, Romania.
All the defects of gonad formation during intrauterine development have been
grouped under the name of gonadal disgenesias. Disturbances of the whole body
appears in gonadal disgenesias, the disruption process of sexualization remaing
the major event. In the absence or scarcity oestrogen, progesterone or androgens,
hypogonadal sexoidoprive osteoporosis develops.
Objectives
Early diagnosis of gonad disgenesias; study of bone mineral metabolism
alterations; evaluation of the mass and bone turnover at the enrolled patients;
assesment of proflaxy measures for bone changes since early stages -
prepubertal, pubertal and postpubertal - in order to ensure maximal bone mass
linked to sex and age; establish diferent treatment measures.
Methods
We studied 11 cases of Turner syndrome, females aged 12-25, and fve cases of
Klinefelter syndrome, aged 18-28. For assessing the diagnosis of gonadal
disgenesia, the cytogenetic (Barr chromatin and cariotype) and hormonology
(LH, FSH, PRL, oestradiol, progesterone, testosterone, TSH, FT
4
) evaluations
were performed. As biochemical markers of bone turnover we assessed: serum
Cross Laps and osteocalcine by means of ELISA method. Bone mineral density
was tested using dual X-ray absorption (DXA).
Results
In all cases, Cross Laps and osteocalcin values are comparable to those in
premenopausal and postmenopausal women, ranging 29.4-112.96 ng/ml for
osteocacine and 0.197-1.768 ng/ml for the Cross Laps. Osteoporosis was reveald
by DEXA in seven cases of Turner syndrome females and three cases with
Klinefelter syndrome, for the other cases T score suggested osteopenia (1.70 to
2.10 S.D).
Conclusions
Early diagnosis is necessary for stabilizing gonadal disgenesia (increased bone
mass and reducing fractures). The therapeutical solution associates oestro-
progestive/androgenic substitution with specifc drugs for bone remineralization
(bisphospho-nates, calcium products and vitamin D derivates).
PI3
Bone mineral density study and biochemical markers of bone turnover
in premature ovarian failure
Iulia Bistriceanu
1
1
, Marian Bistriceanu
2
,
Liliana Putinelu
3
, Simona Bondari
2
& Aurora Covei
1
1
Department of Endocrinology, Emergency Hospital, Craiova, Romania;
2
Craiova, Romania;
3
Geriatric Hospital`s, Stefanesti-Arges, Romania.
Objectives
The premature ovarian failure (the poor ovaries` syndrome) is characterized by
the ovaries inability to normally sexualize, due to a poor sexoidogenetic device
(low gonocyte population).
Analysis of subjective and objective clinical criteria of patients with premature
ovarian failure, early diagnosis of the premature ovarian failure, establish the
etiology of premature ovarian through basal and dynamic hormones evaluation,
assesment of proflactic and therapeutical measures.
Methods
We studied 31 cases of attenuated premature ovarian failure, aged 20-33. Plasma
levels of the two bone turnover markers (Osteocalcin and CrossLaps) were
evaluated using ELISA method. To all patients the bone mineral density (BMD)
was measured by dual X-ray absorbtion (DXA) at lumbar spine, by antero-
posterior incidence, and the hip.
Results
Osteocalcin ranged values of 29.48.3 ng/ml in 18 cases, comparable to those of
postmenopausal women. In sevene cases osteocalcin limits were 16.87.6 ng/ml
(as in premenopausal stage), in contrast to six patients with normal values (below
14 ng/ml). CrossLaps plasma levels showed values ranging 0.1511.230 ng/ml
in 14 patients) similar to those in postmenopausal women, nine patients had
similar values to those of premenopausal (0.1150.210 ng/ml), and eight
cases had normal values (0.1100.522 ng/ml). Measurement of BMD revealed
osteoporosis in 15 cases osteopenia at seven patients and nine having
normal BMD.
Conclusions
In premature ovarian failure, assessment of BMD and bone turnover biochemical
markers must be done regularly (1-2 times per year) in order to identify patients
who rapidly lose bone mass leading to increased risk of osteoporosis. Oestro-
progestative substitution should be the frst therapeutic attitude in premature
ovarian failure so as to prevent osteoporosis as well as metabolic and visceral
involvements.
PI4
Delayed puberty and bone turnover biochemical markers
Marian Bistriceanu
1
, Iulia Bistriceanu
2
2
,
Simona Bondari
1
, Aurora Covei
2
& Liliana Putinelu
3
1
Craiova, Romania;
2
Department of Endocrinology, Emergency Hospital,
Craiova, Romania;
3
Geriatric Hospital`, Craiova, Romania.
Background
Delayed puberty means the absence of secondary sexual characters until the age
of 16 or the lack of puberty development until the limit of 2DS regarding the
age when the puberty normally begins at considered population. Considering the
major ethiological factor implied in delayed puberty, three mechanisms can be
distinguished: hypothalamic, hypophyseal and gonadal. Osteoporosis depends
mainly on the defciency of one or of all sexual hormones, arised during the
ontogenesis process.
Methods
We enrolled 26 cases of delayed puberty, aged 12-35, of which 14 cases (53.85%)
of hypergonadotropic hypogonadism (female Turner syndrome - 10 cases;
Klinefelter - four cases) and 12 cases (46.15%) of hypogonadotropic
hypogonadism (hypophyseal dwarfsm with sexual infantilism - three cases;
functional adipose-genital syndrome - seven cases; tumor-like hypophyseal
insuffciency - two cases). Plasmatic level of the two markers of bone turnover
(osteocalcine and CrossLap) was evaluated by ELISA method. Dual absorption
with X-rays assesed bone mineral density.
Results
DEXA identifed, 10 cases (38.46%) of osteoporosis, where the osteocalcine
values (29.4-112.96 ng/ml) and CrossLap (0.197-1.768 ng/ml) were comparable
with those of women in postmenopausal period, six cases (23.08%) of osteopenia,
and 10 cases (38.46%) of T score value and biochemical markers in normal range.
Conclusions
Our study suggests two major objectives of therapy for existent osteoporosis/os-
teopenia at delayed puberty pacients: precocious diagnosis of gonadal
insuffciency, in to apply some prophylaxis measures for bone modifcations
beginning from pre-puberty, thus insuring the stabilization or increasing bone
mass corresponding to sex and age; therapy associates estro-progestative/
androgenic substitution and antiresorbtion or proformation medication.
PI5
Structural heart disease in osteogenesis imperfecta: a case~control
study
Patricia Di az Guardiola
1
, Vanesa Bonilla Jimenez
2
, Jesus Saavedra Falero
2
,
Maria Teresa Alberca Vela
2
, Paloma Iglesias Bolanos
3
& Isabel Pavon de Paz
3
1
Endocrinology Service. Hospital Infanta Sofi a, San Sebastian de los Reyes,
Madrid, Spain;
2
Cardiology Service. Hospital Universitario de Getafe,
Getafe. Madrid, Spain;
3
Endocrinology Service. Hospital Universitario de
Getafe, Getafe. Madrid, Spain.
Background
Osteogenesis imperfecta (OI) is a few frequent disease with abnormal synthesis of
type 1 collagen. That affects skeletal but also extra-skeletal tissues. Aortic root
(AR) dilatation and valvular dysfunction have been described. Other studies, to
estimate the size of the AR, index it by the body surface area (BSA), however,
although these patients are shorter their internal organs have a relatively normal
growth, so we could fnd overestimated AR values. Therefore, we propose to use
the size of the left ventricle telediastolic diameter (LVDD) to calculate the
indexed AR. We try to evaluate the incidence of cardiac involvement in patients
with OI in comparison with an age-matched control group.
We enrolled 26 patients with OI and compared them with 25 healthy people. In
the control group we excluded patients with coronary disease or systemic chronic
diseases. One patient of the OI group was excluded because of the incidental
diagnosis of hypertrophic cardiomiopathy. A transtoracic ultrasound was
performed in all patients. Quantitative variables were compared with Student`s
t-test and qualitative variables with the
2
test. A P value of ,0.05 was
considered relevant.
Results
The incidence of valvulopathy was similar in both groups. The dimensions
of the AR, left atrium and LVDD when indexed by BSA were signifcantly
larger in OI patients. However there was a signifcantly difference in the
AR/LVDD ratio independent of the BSA, that was larger in the patients with
OI (Table 1).
Conclusions
The incidence of valvular disease in osteogeneis imperfecta is similar to that of
normal population. Indexed AR is larger in OI patients related with LVDD.
PI
Osteomalacia: important cause of bone loss in a patient with
inamatory bowl disease: case report
Adina Ghemigian, Irina Popescu, Evghenia Petrova, Elena Neacsu &
Constantin Dumitrache
'C.I. Parhon` National Institute of Endocrinology, Bucharest, Romania.
Bone densitometry (DEXA) is the best bAYg: !!\_!)_A today for diagnosing
low bone density. However, DEXA is not able to differentiate osteoporosis from
osteomalacia. The defnitive diagnosis of osteomalacia is made by bone biopsy -
rarely used in medical practice - which shows excess unmineralized bone.
TabIe 1 Echocardiographic parameters
OI ControI
Valvulopathy d3 (12%) d5 (20%) NS
AR (cm) 2.70.45 2.50.39 NS
AR/BSA (cm/m
2
) 1.980.61 1.520.19 0.01*
AR/LVDD (cm/cm) 0.80.10 0.50.01 0.03*
Tests of blood and urine may also be helpful: concentration of serum and urinary
calcium and phosphorus, 25-hydroxyvitamin D and parathyroid hormone blood
levels and bone turnover markers. We present the case of a patient with important
bone loss of multiple causes, osteomalacia being the most important of them.
Case report
Forty-three years woman, with precocious menopause at age 29 years and protein-
losing exudative enteropathy at age 31 years presented with important bone loss
(lumbar T score4.8 and Z score3.8). She was under quasi-continuous
cortisone therapy (Prednisone 10-15 mg/day). Laboratory results included: low
normal/slightly decreased serum calcium and phosphorus, extremely low
25-hydroxyvitamin D level and secondary hyperparathyroidism. After one year
of oral treatment with bisphosphonates, high doses of calcium (2000-
3000 mg/day) and cholecalciferol (2000 UI/day), lumbar T score was 3.1, Z
score2.2 and 25-hydroxyvitamin D level was still low. We switched oral to
parenteral cholecalciferol therapy, also in high doses: 400.000 then
600.000 UI/month. The results were spectacular: normalization of plasma
25-hydroxyvitamin D level and of lumbar T score: 0.1.
Although early installed estrogen defciency and chronic corticotherapy are
determinants of bone loss, in this case the main cause was vitamin D defciency
secondary to it`s malabsorption in infammatory bowel disease.
Conclusion
We emphasize the importance of assessing vitamin D status in all patients with
osteoporosis diagnosed by DEXA. Adequate doses of vitamin D supplementation
are indispensable for therapeutic succes.
PII
The effect of zoledronic acid on serum homocysteine, folate and vitamin
B12 in patients with Paget`s disease of bone
Stergios Polyzos
1
, Athanasios Anastasilakis
2
, Zoe Efstathiadou
1
,
Ioannis Litsas
1
, Marina Kita
1
, Athanasios Panagiotou
1
,
Athanasios Papatheodorou
3
, Georgios Arsos
4
, Efstratios Moralidis
4
,
Georgios Barmpalios
5
, Efthimia Zafeiriadou
5
& Evangelos Terpos
3
1
Department of Endocrinology, Ippokration General Hospital, Thessaloniki,
Greece;
2
Department of Endocrinology, 424 General Military Hospital,
Thessaloniki, Greece;
3
Department of Medical Research, 251 General
Airforce Hospital, Athens, Greece;
4
Department of Nuclear Medicine,
Ippokration General Hospital, Aristotle University, Thessaloniki, Greece;
5
Department of Radiology, Ippokration General Hospital, Thessaloniki,
Greece.
Purpose
High serum homocysteine (HCY) and indirectly defciency of folate and/or
vitamin B12 stimulate bone resorption and adversely affect collagen cross-
linking. The aim of this study was the evaluation of serum levels of HCY, folate
and vitamin B12 in patients with Paget`s disease of bone (PDB) and the effect of
zoledronic acid (ZOL) on their serum levels.
Methods
This was a prospective open-label cohort study, with a control arm at baseline.
Nine consecutive patients with polyostotic PDB (median age 66 years) received a
single 5 mg ZOL infusion. Blood samples for HCY, folate, vitamin B12, total
serum alkaline phosphatase (TSAP), bone-specifc serum alkaline phosphatase
(BSAP) and C-terminal cross-linking telopeptide of type I collagen (CTX) were
obtained at baseline and 3, 6 and 12 months after ZOL infusion. Twelve age-
gender- and BMI-matched healthy individuals were recruited for control group at
baseline assessment. The study protocol was approved by the local ethics
committee. Data are presented as median (interquartile range).
Results
Patients with PDB had signifcantly higher serum HCY (16.3 (13.4-19.0) vs 12.6
(8.9-14.1) mol/l, P0.028), folate (7.6 (7.1-11.2) vs 3.0 (2.3-4.2) ng/ml,
P,0.001) and bone markers: TSAP (241 (152-517) vs 71 (56-90) IU/l,
P,0.001; BSAP 96 (58-160) vs 23.2 (18.2-29.6) IU/l, P,0.001; CTX 1.46
(0.83-2.11) vs 0.54 (0.31-0.80) ng/ml, (P,0.001)) compared with the control
group at baseline. In the pagetic group, serum HCY signifcantly decreased 3
months after ZOL infusion (14.7 (10.5-16.2) mol/l) and remained essentially
unchanged up to the end of the study (12.4 (12.3-16.0) mol/l, P0.005
(ANOVA)). Serum vitamin B12 and folate remained unaffected throughout the
study.
Conclusions
Our data suggest that serum HCY levels are increased in patients with PDB. A
single ZOL infusion results in a decrease in HCY levels that might represent
another mechanism for the reduction of the activity of PDB achieved by ZOL.
PI8
Angiotensin converting enzyme I/D and M235T angiotensinogen gene
polymorphism in patients with acromegaly
Dana Bucuras, Dorin Grigoras, Doru Anastasiu & Dan Poenaru
University of Medicina and Pharmacy 'V.Babes`, Timisoara, Romania.
Backgound
ESRD is associated with a sustained decrease in bone mineral density compared
with aged-matched healthy controls. DXA is the standard noninvasive method to
asses BMD. QUS is inexpensive, mobile, easy to perform, radiation free,
recognize for screening abilities and risk fracture prediction in normal population.
This study assessed the ability of QUS versus DXA in determine low bone mass in
haemodialised population.
Patients in the evidence of the Haemodialysis and Renal Transplantation Center
from the County Hospital nr.1, performed DXA (anteroposterior technique,
Delphi W device, Hologic Inc.), and also QUS (Sahara device, Hologic Inc).
Receiver operator characteristic curves (ROC) were plotted for BUA, SOS and
QUI and used to defne cut-off values for best sensitivities and specifcities for all
parameter. Bone demineralisation was defned as a T score on DXA lower than 1,
with increased markers of bone turnover.
Results
We analised 131 patients (63 females and 68 males), mean age 47.77612, 32
years, being in haemodialysis for a mean period of mean 51.4884.686 months.
BUA (r0.613/0.447) and QUI (r0.613/0.502) seem to be the parameters of
choice when considering BMD at cortical level. Areas under ROC for BUA and
SOS in diagnosis of osteoporosis and osteopenia, have a sensitivity of 76, 1%-76,
1%, respectively a specifcity of 72, 5%-77, 8%. The identifed cutoff levels for
QUI are 76.1 (osteopenia) and 69.6 (osteoporosis). The diagnostic value of
QUS,when reporting QUI, are even higher when we did defne the proper interval.
Conclusion
DXA and QUS parameters correlate signifcantly. The best QUS diagnostic
parameter comoared to DXA is QUI. It has the ability to identify low bone mass
(sensitivity of 60/80%), but also can discriminate very well the 'healthy bone`
subjects (specifcity of 75%).
PI9
Cutoff point, upper and lower QUS parameters values in diagnosing
demineralisation in cases with ESRD
Dana Bucuras, Dan Poenaru & Ovidiu Golea
University of Medicine and Pharmacy 'V.Babes`, Timisoara, Romania.
Background
The British Society for Osteoporosis proposed a method for comparing different
diagnostic measurements for BMD. It defnes the upper and the lower limit for the
investigated assay, that will identify osteoporosis with a sensitivity of 90% (the
upper limit) and a specifcity of 90% (the lower limit), compared with the defned
golden standard method, mainly DXA for spine or hip. This rationale generate
small number of false positive or negative results.
One hundred and thirty-one cases with ESRD were evaluated by means of
DXA and QUS with ISCD validated devices: Hologic Sahara/Hologic Hologic,
aparat Delphi W (S/N 70489), lumbar L
1
-L
4
, anteroposterior technique,
nondominant hip.
TabIe 1 Upper limit, lower limit and threshold value for QU compared with
DXA results
Upper Iimit
(90% sensitivity)
Lower Iimit
(90% specifcity)
ThreshoId
vaIues
score , 1
femural neck
93.90 65.50 74.40
score , 2.5
femoral neck
76.90 61.40 69.60
score , 1
total hip
93.90 67.20 76.10
score , 1
total hip
76.50 59.20 69.60
score , 1
spine
94.50 69.70 80.90
score , 1
spine
85.70 62.20 67.50
Results
We defned bone demineralisation in cases of T score below 1, confrmed by
increased markers of bone turnover. We identifed than the limits for each QUS
parameter in diagnosis bine demineralisation. We also performed ROC diagnostic
curves, comparing QUS parameters with DXA results, and we identifed the best
threshold value for QUI.
The best parameter seemed to be QUI. We selected different values for each
measured sites. Table 1.
The threshold values were identifed by fnding the best specifcity and sensitivity
from the series of number. This values are listed in Table 2.
The most precise interval is that one compared with the femoral neck
compartment. When a patient has QUS result between the to limits, there is a
very good sensitivity and specifcity in diagnosing bone demineraslisatoin. QUS
can be used as a screening tool, for decreasing the unnecessary DXA
measurements, also in these patients. The 90-90 approach seems to be better
then the threshold value method, because of the higher NPV and PPV.
Conclusion
QUS can be used as a screening method to identify the target population with
decreased bone mass, also in patients with ESRD.
P80
Secondary hypoparathyroidism in thalassaemia and sickle cell anaemia
Katerina Thisiadou
1
1
, Stella Arampatzi
1
,
Kiriaki Chalvatzi
1
, Eleni Hasapopoulou
2
& Despoina Michailidou
1
1
Biochemistry Laboratory, Faculty of Medicine Aristotle University,
2
Department of Thalassaemia, Ahepa University
Hospital, Thessaloniki, Greece.
Background
The diagnosis of hypoparathyroidism, a clinical situation characterised by
reduced production of parathyroid hormone despite the low calcium level,
depends on patient`s anamnesis, clinical aspect and the biochemical parameters.
Thalassaemia, an inherited autosomal recessive blood disease, caused by the
reduced capacity of erythroblasts to synthesize one of the chains that build up
hemoglobine. The combination of transfusion and chelation therapy has
dramatically extended the life`s patients with thalassaemia. However, despite
of chelation therapy, the regular blood transfusions lead to iron overload and
frequently to endocrine complications such as hypoparathyroidism.
Aim
The aim of this study was to determine the prevalence and characterize the role of
secondary hypoparathyroidism in -thalassaemia, intermedia thalassaemia and in
sickle cell anaemia, by measuring serum calcium, phosphorus and intact
parathyroid hormone levels.
Fifty patients with -thalassaemia (-thal), intermedia thalassaemia (int.thal)and
sickle cell anemia (s.c.-an) were sudied. We also used a control group of 35
healthy subjects (h.s), The serum calcium (Ca), phosphorus (P) and intact
parathyroid hormone (i-PTH) levels were checked. Ca and P levels were
determined using photometric method while PTH was measured by electro-
chemiluminescence immunoassay.
Results
No statistically signifcant difference was found in the concentrations of Ca, P and
i-PTH, in comparison to healthy individuals.
In our study, we didn`t observed an overall low calcium and i-PTH levels in
contrast to what expected. Nevertheless a small number of patients presented
reduced i-PTH levels (,1.6 pmol/l). The phosphorus levels were normal.
Conclusions
During the study neither disturbances in the infusion of i-PTH, or in the
homeostasis of calcium and phosphorus were noticed, probably because of
transfusion programs and chelation therapy. Our results are comparable to those
of similar projects.
P81
Abnormalities in calcium, phosphorus and parathyroid hormone in
patients with end stage chronic kidney disease on hemodialysis
Katerina Thisiadou
1
1
, Stella Arampatzi
1
,
Alexandra Tsolakidou
1
, Athanasios Sioulis
2
& Despoina Michailidou
1
1
2
Nephrology Unit, First Medical Department, Ahepa
Hospital, Aristotle University, Thessaloniki, Greece.
Introduction
The decline of renal function is closely associated to increased parathyroid
hormone secretion, resulting to secondary hyperparathyroidism because of:
1) hypocalcemia; 2) hyperphosphatemia; 3) reducedactivityof calcitriol; 4) skeletal
resistance to the calcemic action of parathyroid hormone (PTH) and 5) reduced
secretion of the calcium-sensing receptor (CaSR) in the parathyroid glands.
The retention of phosphorus is considered to take an important role in the evolution
of secondary hyperparathyroidism.
The recent use of vitamin Danalogues (3rd Gof calcitriol-elocalcitol, paricalcitol-)
which bare eclectic affnity to its receptors repress the infusion of PTHand improve
the secondary hyperparathyroidism.
Aim
The study of calcium(Ca), phosphorus (P) and intact parathyroid hormone (i-PTH)
serum disturbances in end stage renal disease patients who were on haemodialysis
(eGFR,15 ml/min per 1.73 m
2
).
In 27 individuals undergoing hemodialysis (HD), the levels of calcium, phosphorus
were determined using photometric method by the Roche biochemical analyser
Modular P 800 and the i-PTH levels were measured by electrochemiluminescence
method in Modular Analytics E 170 immunoassay analyser. The same parameters
were determined in a control group (CG) consisting of 44 normal subjects.
Results
There was a statistically signifcant difference in i-PTH levels among HD and
controls groups (P,0.001).
Statistically signifcant difference (P,0.001) is also observed in the levels of P
between the patients (5.621.29 mg/dl) and the control group (3.780.51 mg/dl).
The levels of Ca in the control group (9.440.47 mg/dl) were signifcantly higher
than the HD group (8.351.07 mg/dl) (P,0.001).
Conclusions
Even after the use of the new calcitriol analogues, secondary hyperparathyroidism
continues to exist in chronically undergoing hemodialysis patients, though a
number of patients present normal i-PTH values. The disturbances in calcium and
phosphorus concentrations are noticed to be milder.
P82
An unusual cause of life-threatening hypercalcaemia treated with
haemodialysis
Panos Thefanoyiannis, Vooi Lee Loh & Leighton J Seal
St George`s Hospital, London, UK.
We present a case of a 71-year-old Jamaican man who presented with a 4 weeks
history of backache, lethargy, night sweats, decreased appetite, and weight loss.
There was no signifcant medical history.
Physical examination revealed tachypnoea, sinus tachycardia with evidence of
short QT interval on the ECG, generalised lymphadenopathy with frm, rubbery
glands up to 3,3 cm in diameter. Arterial blood gases were consistent with type
1 respiratory failure.
His blood tests showed corrected calcium of 4.78 mmol/l, phosphate 1.60 mmol/l,
urea 22.6 mmol/l, creatinine 142 mol/l, PTH ,0.7 pmol/l (NR 1.1-6.9), and
PTHrP level was about 10-fold higher (10.0 pmol/l) than the upper normal limit
with no paraprotein detected.
A CT scan of the brain, thorax and abdomen revealed pulmonary embolism,
widespread lymphadenopathy with multiple lytic lesions within the bones
including the skull vault suggestive of a lymphoproliferative process. Lymph
node biopsy confrmed a diagnosis of adult T-cell lymphoma.
He was rehydrated aggressively with crystalloids; in addition, he was treated with
furosemide, calcitonin, bisphosphonates and steroids.
The corrected calcium did not improve after initial treatment and due to
worsening confusion, a decision was made to give him a short course of
hemodialysis, which resulted in marked biochemical (Ca 2.87 mmol/l) and
clinical improvement.
The human T cell lymphotrophic virus (HTLV) type 1/2 antibody was positive.
Adult T-cell leukaemia/lymphoma is an aggressive and often fatal malignancy of
CD4 T-cells caused by infection with HTLV-1. HTLV-1 infection is endemic in
Japan, the Caribbean and parts of Africa.
TabIe 2 Diagnostic quality and power for each identifed QU threshold
value
ThreshoId
vaIues Sensitivity Specihcity PPV NPV
74.40 60.25 77.5 77.38 77.71
69.60 76.19 66.48 25.39 92.42
76.10 64.77 73.17 83.33 47.61
69.60 80.0 66.9 30.7 94.8
80.90 59.15 70.4 65.6 67.7
67.50 70.23 62.5 67.7 86.4
The mechanism for hypercalcemia has been described as increased bone
resorption mediated by PTHrP or lymphokines, such as interleukin 1 (IL-1),
IL-2, IL-6, and tumour necrosis factor.
There are currently no guidelines for the treatment of hypercalcaemia associated
with malignancy. In cases of resistant, life-threatening hypercalcaemia,
haemodialysis is effective and may reduce mortality.
P83
The markers of bone remodelling in postmenopausal osteoporosis
Camelia Gurban
1
, Ioana Zosin
2
, Melania Balas
2
, Smaranda Gotia
3
,
Laura Gotia
3
& Doina Drugarin
4
1
Department of Biochemistry, University of Medicine and Pharmacy 'V.
Babes`, Timisoara, Romania;
2
Department of Endocrinology, University
of Medicine and Pharmacy 'V. Babes`, Timisoara, Romania;
3
Department
of Physiology, University of Medicine and Pharmacy 'V. Babes`, Timisoara,
Romania;
4
Department of Immunology, University of Medicine and
Pharmacy, 'V. Babes`, Timisoara, Romania.
The aim of the study
The paper analyzes the levels of soluble receptor activator of nuclear factor-B
ligand-(sRANKL), osteoprotegerin (OPG), bone alkaline phophatase (BAP),
osteocalcin (BGP), estradiol, serum and bone levels of zinc [Zn
(2)
], magnesium
[Mg
(2)
], calcium [Ca
(2)
], phosphate [HPO4
(2)
], and their correlation with
bone mineral density (BMD).
Material and method
The study included 74 patients with postmenopausal osteoporosis, divided in two
groups: group I (n48, below 15 years of estrogenic deprivation) and group II
(n26, over 15 years of estrogenic deprivation). The control group comprised 20
postmenopausal women without osteoporosis.
The serum levels of the bone markers were measured by ELISA technique. Serum
levels of the ions were measured by VitrosSlides quantitative technique and bone
levels of the ions were assessed by means of bone fame atomic absorption
spectrometry. Bone mineral density was measured using the DXA technique.
Results
The levels of sRANKL are signifcantly higher in postmenopausal osteoporosis
versus controls, demonstrating the activation of osteoclastogenesis.
Serum OPG and BGP levels in postmenopausal osteoporosis were increased in
group I, attesting the osteoblastic activation, and decreased in group II, secondary
to the stimulation of osteoblastic apoptosis.
BAP is increased in postmenopausal osteoporosis, showing osteoblastic
activation.
Estradiol levels are signifcantly lower in both groups, associated with low BMD.
Serum Ca
(2)
and HPO4
(2)
concentrations increase transitory, as a result of
bone demineralization through hidroxiapatite microcrystal solubilization and
mobilization of these ions in the circulation.
Conclusion
The decreased concentrations of ions in bone leads to localized bone
demineralization, facilitating osteoporotic bone microfractures.
P84
Effect of strontium ranelate on vertebral pain syndrome in post-
menopausal women with systemic osteoporosis treatment
Vladyslav Povoroznyuk, Nataliia Dzerovych & Tetyana Orlyk
Institute of Gerontology AMS Ukraine, Kyiv, Ukraine.
Aim
To evaluate the effect of strontium ranelate in treatment of systemic osteoporosis
in postmenopausal women.
There were examined 82 postmenopausal women with systemic osteoporosis
(average age 58.44.5 years). Evaluation of pain syndrome and level of physical
activity was carried out with VAS (the questionnaire developed by the 'Servier`
company). Bone mineral density (BMD) was determined by means of dual-
energy X-ray absorptiometer 'Prodigy` (GE Medical systems) in 18 patients
(average age 61.21.8 years). Examination was performed before onset of
treatment and after a 3 and 6 months treatment course. Strontium ranelate
(Bivalos, 'Servier`) was taken in a dose of one 2 g sachet as a suspension in water
once a day and one tablet of calcemin-advance (Calcium - 500 mg, Vit. D -
400 IU) two times a day during 6 months.
Results
We observed a reliable decrease of vertebral pain syndrome after three (from
9.061.44 up to 5.670.34; t1.93; P0.06) and six months (from 8.521.32
up to 4.660.32; t2.88; P0.005) and increase of functional abilities of
patients after three (from 6.590.33 up to 5.850.34; t3.94; P0.0002) and 6
months (from 6.800.34 up to 4.970.36; t6.91; P,0.0001). The patients
have noted that their sleeping improved after three (from 5.700.37 up to 4.91
0.35; t3.16; P0.002) and 6 (from 0.393.32 up to 3.460.36; t7.29;
P,0.0001) months. The fear of fractures occurrence has decreased signifcantly
after three (from 7.720.34 up to 7.050.37; t3.19; P0.002) and 6 (from
7.810.35 up to 6.620.43; t4.10; P0.0001) months. After six months,
BMD of femur (total) signifcantly increased in comparison with indexes before
treatment (BMD of femur before treatment - 0.790.02; after 6 months - 0.81
0.02; t2.49; P0.03).
Conclusion
It has been demonstrated that strontium ranelate treatment signifcantly decreases
pronounced vertebral pain syndrome and improves functional abilities of patients,
as well as BMD of femur after six-month therapy in the postmenopausal women.
P85
Giant mediastinal parathyroid adenoma, a rare cause of severe acute
hyperparathyroidism
Salwan Maqdasy
1,3
, Francoise Desbiez
3
, Elena Robu
2,3
, Marie Batisse
2,3
,
Beatrice Roche
3
, Jean Baptiste Chadeyras
2,3
& Igor Tauveron
2,3
1
Hawler Medical University, Erbil/kurdistan, Iraq;
2
Universite dÀuvergne,
Clermont Ferrand, France;
3
Centre Hospitalier universitaire Gabriel
Montpied, Clermont Ferrand, France.
Introduction
Ectopic parathyroid adenoma is a rare cause of primary hyperparathyroidism, it
accounts for 10% of parathyroid adenomas.
Observation
A 56 years old man with no past medical history developed sudden acute renal
failure after few weeks of fatigability, polydypsia and emesis. Hypercalcemia of
4.20 mmol/l (2.2-2.5 mmol/l), serum creatinine of 306 mmol/l, hypophospatemia
0.72 mmol/l (0.80-1.5 mmol/l) and high alkaline phosphatase 205 IU/l were the
abnormalities detected on basic biochemistry. Parathyroid hormone assessment
(PTH 1750 ng/ml (15-65 ng/ml)) and high urinary calcium levels confrmed the
diagnosis of primary hyperparathyroidism.
Hemodialysis, hydration and bisphosphonates were suffcient to normalize hyper-
calcemia and to improve his renal function.
I
123
-Tc
99
Sesta MIBI scan with a hybrid camera demonstrated an intense hyper
fxation of a mediastinal mass, confrmed when coupled with CT scan, to be
necrotic, of 5.5 cm just in front of aortic arch.
Osteoporosis was confrmed on DXA absorbiometry with T score 3.4 DS on
femoral head.
Via thoracoscopy, the tumour was removed completely and confrmed
histologically. Per operative parathyroid hormone levels reduced with in
30 min to 150 ng/ml.
Multiple endocrine neoplasia genetic screening is proceeding, as he had severe
hyper gastrenemia on hormonal analysis.
Conclusion
(1) Ectopic parathyroid tissue is rare but may be a cause of severe
hyperparathyroidism of acute presentation.
(2) Sesta MIBI scan is important preoperative imaging in the evaluation of
primary hyperparathyroidism to localize all active parathyroid tissues. Its role is
magnifed when coupled with a tomography via hybrid camera to describe and
localize the tumour directly.
(3) Most ectopic parathyroid adenomas are of small size, yet Large mediastinal
tumours might be mistakenly understood as paraneoplasic causes of hypercalce-
mia, but can easily be ruled out by intact parathyroid hormone sampling
confrming the diagnosis of parathyroid adenoma.
P8
Mandibular radiomorphometric indices as predictors of osteopenia and
osteoporosis in postmenopausal women
Homayoun Sheikholeslami, Maryam Tofangchiha, Samaneh Rastegary &
Sara Sheikholeslami
Qazvin University of Medical Sciences, Qazvin, Islamic Republic of Iran.
Introduction
Osteoporosis affects a large percentage of the elderly population. Since the
disease is preventable, diagnostic techniques are of major importance.
Furthermore, the dentist is the most regularly visited doctor in this population
and panoramic radiographs are the most frequently used imaging modalities for
these patients. The purpose of this study was to evaluate the radiomorphometric
indices on panoramic radiographs of post-menopausal females.
An assessment of nine indices was performed on dental panoramic radiographs in
groups of postmenopausal women. Bone mineral density (BMD) at the lumbar
spine was measured by absorptiometry criterions of T score were used to diagnose
normal patients, patients with osteoporosis or osteopenia.
Results
Antegonial angle (AA), antegonial index (AI) and mental index (MI) were
signifcantly smaller in individuals with low bone mass (P,0.05). Antegonial
depth (AD) was signifcantly greater in osteoporotic difference among the three
subgroups of mandibular cortical index (MCI). Multivariable logistic regression
analysis used AI and ADindices to generate the following equation for probability
of having osteoporosis for a new subjects: Z5.4(0.8,AD)(1.8,AI).
Conclusion
Panoramic radiographs may be applicable for the early diagnosis of osteopenia
in postmenopausal women. The smaller AI and greater AD were signifcantly
associated with lower bone mass. Osteopenic women have a deeper antegonial
region and smaller cortical width in the antegonial and mental region.
P8I
Asymptomatic primary hyperparathyroidism: current indications for
hnal solution
Helena S
`
iprova
1,3
& Zdenek Frysàk
2,3
1
St Anne University Hospital in Brno, Brno, Czech Republic;
2
University
Hospital in Olomouc, Olomouc, Czech Republic;
3
Medical Faculty of
Palacky University in Olomouc, Olomouc, Czech Republic.
Primary hyperparathyroidism (PHPT) belongs to the most common endocrine
disorders. It is increasingly reported in patients without any symptoms and
hypercalcemia. In the 3rd international workshop on asymptomatic PHPT
(Orlando 2008) the normocalcemic PHPT was recognised as a stand-alone entity
that needs more attention.
Aim
The purpose of this study is to analyse data from patients with normocalcemic
asymptomatic PHPT and to create an effective source database for a future
prospective study.
Methods
Data acquired from a group of eligible normocalcemic asymptomatic PHPT
patients that were diagnosed in two tertiary endocrinologic centres in the Czech
Republic during the last 3 years has been analysed.
Results
The study included 128 normocalcemic asymptomatic PHPT patients age between
20 and 86 (median 64), 18 males and 110 females. The range of serum PTH was
7.2-37.9 ng/l with the median of 9.5 (reference range 1.5-7.1). The serumcalcium
levels varied at the baseline visit between 2.08 and 2.60 mmol/l (median 2.43,
reference range 2.05-2.60). The serum phosphate levels ranged from 0.53 to
1.81 mmol/l (median 1.0, reference range 0.9-1.32). Alkaline phosphatase and
vitamin D, as well as bone density have been monitored. A slight but statistically
signifcant association between the serum phosphate and serum parathyroid
hormone levels has been found (Spearman`s rank correlation coeffcient 0.208).
During the follow-up period, some patients with repeatedly normal calcium levels
have developed hypercalcemia and a surgical intervention was inevitable,
including the elderly patients.
Conclusions
Females highly prevail among patients with normocalcemic asymptomatic PHPT
and the average age of these patients is high. It should be verifed whether low
plasma phosphates may be suffcient to indicate the examination of the levels of
PTH. The results of the cross-sectional retrospective study support the usefulness
of a wider longitudinal prospective follow-up study focused also to elderly people.
P88
Vitamin D and calcium status in women with postmenopausal
osteoporosis
Jovanka Novakovic-Paro, Branka Kovacev-Zavisic, Milica Medic-
Stojanoska, Ivana Bajkin, Tijana Icin & Ljiljana Todorovic-Djilas
Clincal Centre of Vojvodina, Clinic of Endocrinology, Diabetes and
Metabolic Disorders, Novi Sad, Serbia.
Many studies show insuffcient and inadequate vitamin D and calcium levels in
postmenopausal women with osteoporosis, thus emphasising the need for
supplementation therapy.
Aim of the study
To determine vitamin D (25(OH)D) and ionised calcium levels in women treated
for postmenopausal osteoporosis at our Clinic in the course of year 2009.
We prospectively followed up 116 women at the age of 59.385.55 (minimal age
48, maximum age 69). The diagnosis of osteoporosis was established by dual
X-ray absorptiometry (DXA) of spine and hip. Levels of 25(OH)D and ionised
calcium were determined by standard laboratory measurements.
Results
Mean spine T score value was 3.070.47 (minimal - 4.5, maximal - 2.6).
Average 25(OH)D level was 45.1216.68 nmol/l (minimal 10 nmol/l, maximal
81 nmol/l). Fifteen women (12.93%) had levels of ,25 nmol/l (group I). In the
group II there were 57 women (49.14%) with the levels between 25 and 50 nmol/l
(group II). Group III consisted of 39 women (33.62%) with 25(OH)D levels
between 51 and 75 nmol/l. Only fve women (4.31%) had 25(OH)D levels over
75 nmol/l and they comprised group IV. Average ionised calcium level was
0.970.07 nmol/l (minimal 0.90 mmol/l, maximal 1.2 mmol/l). In our groups I,
II, III and IV ionised calcium levels were 0.970.05, 0.980.07, 0.970.05 and
1.060.08 mmol/l respectively.
Conclusion
Our results show inadequate vitamin D and calcium levels in about 50% women
with postmenopausal osteoporosis. Measurements of vitamin D and calcium
together with their supplementation in necessary in prevention and treatment of
postmenopausal osteoporosis.
P89
Comparison of alendronate and raloxifene as a medical treatment
option in patients with primary hyperparathyroidism
Gulhan Akbaba, Serhat Isik, Yasemin Tutuncu, Ufuk Ozuguz, Dilek Berker
& Serdar Guler
Ministry of Health, Ankara Numune Research and Education Hospital,
Ankara, Turkey.
Introduction
Primary hyperparathyroidism (pHPT) is the most frequent cause of hypercalce-
mia in ambulatory patients. Most persons have no symptoms, and pHPT usually is
diagnosed after an elevated serum calcium (Ca
2
) level is found incidentally.
Parathyroidectomy is the defnitive treatment for pHPT. There have been several
different approaches to the medical management of pHPT. Our aim in this study is
to compare alendronate sodium (ALN) and raloxifene (RLX) effciency in
postmenopausal female pHPT patients with osteoporosis.
Methods
Twenty postmenopausal patients with osteoporosis that were diagnosed with
pHPT and rejected the surgical treatment were included in the study. Patients
were sequentially randomized into ALN 70 mg/week (n10) and RLX
60 mg/day (n10) treatment groups. Serum and urine laboratory parameters of
patients were compared with baseline, 6th and 12th month values. Baseline and
12th month bone density values were compared.
Results
Initial age, total Ca
2
, phosphorus (P), parathormone (PTH), 25-hydroxyvitamin-
D (25-OH-D), 24-h urine Ca
2
, adenoma volume and bone densitometry T scores
among groups taking ALN and RLX treatments demonstrated resemblance.
While total Ca
2
levels of ALN group were signifcantly lower compared with
baseline at the 6th month, such a difference disappeared at the 12th month (11.2
0.6, 10.30.7, and 10.60.4 respectively, between baseline and 6th month
P0.003, and between baseline and 12th month P0.070). However, a
signifcant difference was not observed between baseline, 6th and 12th month
P, PTH, 25-OH-D, 24-h urine Ca
2
(P0.05 for all). Although some recovery in
lumbar and femur neck T score was observed at the 12th month compared with the
beginning, a statistical difference was not established. (3.61.2 vs 2.71.7,
P0.202; 1.42.02 vs 1.80.7, P0.495, respectively). In the RLX
group, a statistical difference was not found between initial, 6th and 12th month
total Ca
2
, P, PTH, 25-OH-D, 24-h urine Ca
2
and initial and 12th month bone
density (P0.05 for all).
Conclusion
A positive effect of ALN and RLX on Ca levels and osteoporosis was not
observed in postmenopausal female patients with pHPT. However, due to the
signifcant Ca
2
decrease in the ALN group in the frst 6 months in our study, a
short-term oral ALN treatment may be utilized for patients waiting for surgery in
order to keep Ca
2
levels under control.
P90
Primary hyperparathyroidism: retrospective evaluation
Jacinta Santos, Isabel Paiva, Lui sa Barros, Alexandra Vieira, Marcia Alves,
Sofa Gouveia & Manuela Carvalheiro
Endocrinology Department, Coimbra`s University Hospital, EPE, Coimbra,
Portugal.
Introduction
Primary hyperparathyroidism (PHP) results from an excessive secretion of
parathyroid hormone (PTH), typically leading to hypercalcaemia. This disorder is
more common than previously expected, since it is frequently diagnosed in
asymptomatic patients.
Objectives
To characterize a group of patients with PHP, in what concerns to: age, clinical
presentation, biochemical and imaging evaluation, treatment and evolution.
Retrospective analysis of the clinical fles of patients with PHP followed in our
Department.
Results
We studied forty-two patients (21.4% male, 78.6% female), mean age 52.417.3
years (21-80). Hypercalcemia was incidentally diagnosed during routine analysis
(54.8%), thyroid evaluation (16.7%), investigation of asthenia (9.5%), multiple
endocrine neoplasia (7.1%), bone tumours (7.1%) and renal colic (4.8%). In what
concerns to clinical presentation, 61.9% were asymptomatic. The symptomatic
patients referred mostly asthenia, bone and joint pain. At the diagnosis,
biochemical evaluation: total calcium 11.71.6 mg/dl (N: 8.8-10.6), ionized
calcium 1.50.2 mmol/l (0.9-1.1), PTH 310.3355.4 pg/ml (9-72), phosphorus
2.50.9 mg/dl (2.5-4.5) and 24 h-urinary calcium excretion 294.2152.8 mg
(100-300). Ultrasound localized the enlarged parathyroid gland in 90.5% of the
patients, (sensitivity 92.8%; mean size 1.70.8 cm). Imaging with technetium-
99m sestamibi presented fxation in 76.4% (sensitivity 76.2%). Reduced bone
mineral density was already present in 78.5% and renal lithiasis in 45.2%. In what
concerns to the treatment, 90.5% were submitted to parathyroidectomy (7.9%
maintained PHP and 7.9% relapsed). There were some surgical complications:
transitory (2.4%) or defnitive hypocalcaemia (9.5%) and dysphonia (7.1%).
Histology: adenoma (69.2%) or hyperplasia (25.6%). In the frst endocrine
evaluation after surgery: PTH 63.935.8 pg/ml and total calcium 8.90.9
mg/dl. At the present moment, 84.2% are cured (PTH 46.2518.3 pg/ml).
Conclusions
The authors emphasize that 88% of the cases were sporadic and 12% included in a
familiar syndrome. Although patients were mostly asymptomatic, there were
important bone and kidney consequences. Ultrasound was more sensitive than
cintigraphy in the localization of the hyperfunctioning parathyroid gland.
P91
Long-term follow-up of the changes in serum 25-hydroxivitamin D to
oral treatment with vitamin D3 in patients with postmenopausal
osteoporosis
Daniel Grigorie, Alina Sucaliuc, Mirela Ivan, Elena Neacsu &
Alina Diaconescu
National Institute of Endocrinology, Bucharest, Romania.
The oral dosing with cholecalciferol needed to achieve and maintain optimal
serum concentration 25-hydroxyvitamin D (25OHD) is still controversial.
This study reports on the effcacy of supplementation with oral vitamin D3
1000 U/day for 3-18 months on serum 25OHD levels in 87 ambulatory patients
with postmenopausal osteoporosis (mean age 63.5 years). Serum 25OHD,
parathyroid hormone (PTH), calcium (serum, urine), phosphate, alkaline
phosphatase and creatinine were measured before and after 3 mo (54 pts), 6 mo
(27 pts), 9 mo (15 pts), 12 mo (25 pts), 18 mo (5 pts) of oral vitamin D
supplementation.
At baseline, using a cut-off point of suffciency of 30 ng/ml, 10.34% of patients
were defcient (mean7.77 ng/ml), 82.76% were insuffcient (mean16.19
ng/ml) and 6.9% were suffcient (mean35.86 ng/ml).
After 3 months of supplementation none of the patients was defcient, 64.81%
were insuffcient (mean22.91 ng/ml) and 35.19% were suffcient
(mean36.79 ng/ml). The increment in serum 25OHD was inversely related to
the starting level (r0.78). The average increments were: 20.24 ng/ml
(0.81 ng/ml for every g), 11.89 ng/ml (0.47 ng/ml), and 3.86 ng/ml
(0.15 ng/ml) in defcient, insuffcient and suffcient groups, respectively. Mean
serum PTH concentrations decreased signifcantly (PL0.001), as did alkaline
phosphatase (P0.002).
In 28 patients with follow-up data beyond 3 mo of supplementation there were 22
patients still insuffcient at 3 or 6 mo, 15 of them reaching optimal concentration
up to 18 mo. Six patients suffcient after 3 or 6 mo maintained their levels until the
end of the follow-up.
In conclusion, oral vitamin D3 supplementation with 1000 UI/day is adequate to
achieve (time-dependent) and maintain optimal serum 25OHD concentration for
more than half of them. As many patients do not achieve these goals even after a
long follow-up we suggest that checking of vitamin D status and refning of the
dose are required.
P92
Management of primary hyperparathyroidism in Spain: a national
survey
Manuel Munoz Torres, on behalf of Calcium Study Group
Hospital Universitario San Cecilio, Granada, Spain.
Background
At the Third International Workshop on asymptomatic primary hyperparathyr-
oidism (PHPT), recent data on the disease were reviewed, but limited information
of the PHPT management in Europe is available.
Methods
We performed an online questionnaire survey in hospital endocrinology services
to determine knowledge of current PHPT recommendations and its management
in the clinical practice during 2009 Spain.
Results
Ninety-nine of 131 sites (76%) (giving health coverage to 32.3 million people,
70% of Spanish population) completed the survey. The number of PHPT patients
visited in all hospitals during the last year was 7235, from whom 39% were new
diagnoses (incidence: 9.95/100 000 person/year), and 61% were follow-up visits
of non-parathyroidectomized patients. 80% of cases were asymptomatic. Each
centre performed a median (Q1, Q3) of 12 (6, 20) parathyroidectomies per year.
The median (Q1, Q3) percentage of curative interventions (at frst trial) was 90%
(80, 95). The main reasons for not performing surgery were, by decreasing
frequency: surgery contraindication, patient`s refusal, loss of monitoring, limited
surgery experience. Most of endocrinologists based diagnosis of PHTP on
elevated serum calcium (Ca) and PTH levels (48% required Ca10.5 mg/dl and
elevated PTH). Differential diagnosis with familiar hypocalciuric hypercalcemia
was based mainly on urine Ca/creatinine (Cr) ratio (63%). Imaging techniques
were applied in 83% of cases. The main criteria for parathyroidectomy in
asymptomatic patients were Ca11.5 mg/dl (79%), T score , 2.5 SD at
any site (91%), age , 50 years (80%) and glomerular fltration rate (GFR)
,60 ml/min (82%). Minimally invasive surgery was performed in 42% of
centres. Among preferred pharmacological treatments for patients in whom
surgery is contraindicated, calcimimetics were the frst choice in 69% of cases,
followed by bisphosphonates in 28%. Frequency of biochemistry and bone
density determinations for non-surgically managed patients were in accordance
with international guidelines (100 and 99% of sites ordered Ca and Cr
measurements, respectively, at least once a year).
Conclusions
Overall, the Spanish endocrinologists are implementing the recommendations of
the guidelines from the Third International Workshop for the management of
primary hyperparathyroidism.
P93
Glucocorticoid replacement therapy and vertebral fractures in
hypopituitary adult males with GH dehciency
Gherardo Mazziotti
1
, Teresa Porcelli
1
, Antonio Bianchi
2
,
Vincenzo Cimino
2
, Carola Mejia
1
, Ilaria Patelli
1
, Alessandra Fusco
2
,
Antonella Giampietro
2
, Laura De Marinis
2
& Andrea Giustina
1
1
Endocrine Service, Department of Medical and Surgical Sciences,
University of Brescia, Montichiari, Brescia, Italy;
2
Pituitary Unit,
Department of Endocrinology, Catholic University of the Sacred Heart,
Rome, Italy.
GH defciency (GHD) and excess of glucocorticoids are associated with increased
risk of fragility fractures. Most adult GHD patients have other pituitary
defciencies, but it is unclear whether these defciencies or their overreplacement
therapies may infuence the bone disease occurring in GHD. The aim of this study
was to evaluate whether the prevalence of vertebral fractures may be infuenced
by glucocorticoid replacement therapy in hypopituitary males with GHD. We
studied 58 adult hypopituitary patients (all males; mean age 49 years, range: 22-
81) with severe GHD (replaced in 22 patients, untreated in 36 patients). Fifty-two
patients (89.6%) had also glucocorticoid defciency and all of them were replaced
with cortisone or hydrocortisone. All patients were evaluated for bone mineral
density (BMD) by lumbar DXA and for vertebral fractures by a radiological and
morphometric approach. The patients gave informed consent to the study that was
approved by local ethical committee. Vertebral fractures were observed in 35
patients (60.3%) without signifcant correlation with BMD. Fractured patients
received higher daily doses of cortisone acetate or equivalent (36.0 mg, range:
12.5-75 vs 25.0 mg, range: 12.5-50.0; P0.02) and had higher urinary cortisol
values (83 g/24 h, range: 24-135 vs 69 g/24 h, range: 21-133; P0.05) than
patients who did not fracture. In untreated GHD, vertebral fractures occurred
more frequently in patients with high urinary cortisol values (3rd tertile) as
compared with patients with low urinary cortisol values (1st tertile) (92.3 vs
50.0%; P0.03) regardless of BMD. In treated GHD, by contrast, the prevalence
of vertebral fractures was signifcantly lower as compared with untreated GHD
and it was not infuenced by urinary cortisol values. Glucocorticoid replacement
therapy may increase the prevalence of vertebral fractures in patients with
untreated GHD. However, GH treatment in GHD seems to protect the skeleton
from the deleterious effects of glucocorticoid overtreatment.
P94
Dissimilar PTH, gastrin, and ionized calcium response to oral peptones
in normocalcemic primary hyperparathyroidism, hypercalcemic
primary hyperparathyroidism and normal subjects
Maurizio Bevilacqua
1
, Marco Invernizzi
2
, Stefano Carda
2
& Carlo Cisari
2,3
1
L. Sacco Hospital (Vialba) - University of Milan, Milan, Italy;
2
University
of Eastern Piedmont 'A. Avogadro`, Novara, Italy;
3
CRRF 'Mons. L.
Novarese` - SODC, Moncrivello (VC), Italy.
It has been hypothesized that primary hyperparathyroidism (PH) has a biphasic
disease course. During the frst phase hypercalcemia is not yet present.
Subsequently, the second phase starts with the development of hypercalcemia.
In an attempt to identify differences in the calcium regulating hormonal handling
in the clinical setting, we evaluated the hormonal responses of gastrin, PTH,
phosphate and ionized calcium to oral peptones (a mixture containing L-amino
acids with known CaSR-activation properties) in patients with normocalcemic
PH (PH-N) and hypercalcemic PH (PH-H) compared to a control group of
healthy subjects.
Fifteen PH-H patients, ffteen PH-N patients and 30 healthy controls were
enrolled. Both controls and patients had normal renal function and normal
25(OH) vitamin D serum levels. The inclusion criteria for PH-N patients were:
presence of high serum levels of intact PTH, serum ionized calcium levels in the
high normality range and absence of potential causes of secondary hyperpara-
thyroidism. All subjects performed a peptone-meal test (10 g Liebig meat
extract diluted in 250 ml of 0.9% saline) and subsequent blood samples collected
every 15 min for 2 h. Ionized calcium, phosphate, gastrin and PTH levels
were evaluated.
PTH increased signifcantly at 60 and 90 min after oral peptone load in PH-H
patients and ionized calcium signifcantly decreased in PH-H patients since
60 min from oral peptone load. Controls and PH-N didn`t show signifcant
modifcations in PTH and ionized calcium serum levels. The increase in
gastrin levels in PH-H patients was about one-half the one observed in PH-N
and controls.
These data suggest that in PH-N patients the CaSR-dependent pathway is still
preserved and produces responses similar to those of healthy subjects. However,
in the later phase of the disease a disregulation occurs, leading to altered response
to peptones meal.
P95
Cross-validated calculation procedure to assess the cholecalciferol
loading dose for rapid correction of vitamin D dehciency
Lenneke van Groningen, Adriaan van Sorge, Darryl Telting, Astrid Giessen
& Hans de Boer
Rijnstate Hospital, Arnhem, The Netherlands.
Introduction
Vitamin D defciency is very common in Northern Europe. Recently, we
developed an equation to calculate the vitamin D defcit, based on the serum
25-OH vitamin D
3
(25OHD
3
) level and body weight: vitamin D defcit
(IU)40,(75serum 25OHD
3
),body weight. The calculated defcit gives
the amount of cholecalciferol that is required to raise the serum 25OHD
3
level to
the target of 75 nmol/l.
Objective
To cross-validate the vitamin D defcit calculation procedure.
Fifty subjects (age range 24-74 years, female/male ratio 2.8:1, body weight
45-230 kg) with vitamin D defciency (defned as a serum vitamin D
, 50 nmol/l) were treated with oral, solubilised Cholecalciferol
FNA
50.000 IE
three times a week until the calculated cumulative dose was reached. Serum
creatinine, phosphate, albumin, PTH, 25OHD
3
were measured at baseline and
10 days after the fnal dose of cholecalciferol.
Results:
Of 78% had severe vitamin D defciency (25OHD
3
,30 nmol/l). The calculated
cumulative dose ranged from 75.000-300.000 IU. Treatment was completed
within 2 weeks in all patients. Mean serum 25OHD
3
increased from 26.411.8 to
76.721.4 nmol/l (meanS.D). Ninety percent of the patients reached a
serum 25OHD
3
50 nmol/l. Vitamin D intoxication, defned as a serum level
220 nmol/l, was not observed. The highest post-treatment level was 148 nmol/l.
Serum creatinine increased slightly, whereas serum calcium, phosphate, albumin
and PTH levels did not change signifcantly.
Conclusion
The equation predicting the cholecalciferol loading dose required for rapid
correction of vitamin D defciency is effective and can be safely used in daily
practice.
P9
Hypoparathyroidism mimicking ankylosing spondylitis
Arzu Gedik, Merve Yilmaz, Ayten Eraydin, Mustafa Gunes &
Sevinc Eraslan
Dokuz Eylul University Medical Faculty, Izmir, Turkey.
Idiopathic hypoparathyroidism (IHP) is an uncommon disease in which soft tissue
calcifcations may be seen. We report a case with IHP with asymptomatic
hypocalcemia and features of ankylosing spondylitis (AS).
Case
A 58-year-old male patient was referred to our department due to incidentally
discovered hypocalcemia when admitted with blurred speech, gait and posture
abnormalities. He had had a generalized convulsion 19 years ago. On physical
examination, patient`s posture was typical for AS. Cervical and lumbal vertebral
motion and chest expansion were limited. Trousseau`s and Chvostek`s signs
were both negative. Laboratory fndings were as follows: calcium: 5.4 mg/dl
(8.4-10.2), inorganic phosphorus: 6 mg/dl (2.3-4.7), albumin: 4.2 g/dl (3.5-5),
PTH: ,3 pg/ml (15-65). Lumbosacral radiographs revealed bamboo spine
appearance of thoracal and lumbal vertebrae with calcifcation of anterior-
posterior longitudinal and interspinous ligaments mimicking ankylosing
spondylitis. But unlike AS, sacroiliac joints were spared. Cranial computarized
tomography showed severe parenchymal calcifcation of cerebellum, basal ganglia
and corona radiata, giving the image of a rocky brain. The extreme calcifcation of
paravertebral structures and the brain were attributable to the long duration of the
disease before the diagnosis. Calcitriol and supplemental calcium were initiated.
Conclusion
Idiopathic hypoparathyroidism, when undiagnosed for a long period, may result
in extreme calcifcation of soft and bony tissues. The vertebral calcifcation may
be so intense that it may result in an AS like clinical picture. Patients may present
with clinical and radiographic fndings of skeletal changes with no evidence of
hypocalcemic symptoms. In a patient with spondyloarthropathy with vertebral
involvement without sacroiliitis, IHP may come into mind as an alternative cause.
P9I
Multiple osteoporotic fractures in myasthenia gravis patient receiving
short-term prednisolone therapy
Andreja Maric
1
, Mirna Belovari
1
, Jasna Mundjar Palasek
1
,
Damira Pevec
1
, Maja Mikolaj
1
& Milan Vrkljan
2
1
General Hospital Cakovec, Cakovec, Croatia;
2
Sisters of Mercy, University
Hospital, Zagreb, Croatia.
A 74-year-old female patient was admitted to Department of Neurology due to
bilateral ptosis and diplopia she suddenly felt 3 weeks prior to admission. She also
complained of weakness, dizziness and swallow disability. Her medical history
revealed hypertension and minor depressive disorder. Body mass index was
32 kg/m
2
. Electrocardiogram, chest X-ray and complete laboratory fndings were
normal, except elevated TSH, so levothyroxin was included in therapy. She had
partial palsy of the left abducens nerve. Visual felds and visual acuity were not
impaired, ocular fundus was clear. Neck ultrasonography and CT scan of the brain
were also normal. Prostigmin test was positive, with almost complete resolution
of motoric symptoms. Pyridostigmine bromide and metyl prednisolone therapy
was started, 4,60 mg and 64 mg/day, respectively. Four months later, the patient
was admitted again, due to strong continuous pain in thoracal and lumbal region,
spreading to both legs, she felt for 1 week. There was no history of trauma. X-ray
of thoracal (Th) and lumbal (L) spine revealed multiple osteoporotic fractures, in
Th V-VII, Th XII, and L II-III region. The endocrinologist was consulted. Dual
energy X-ray absorptiometry scanning showed T score 2.1 in lumbal region,
and 3.5 in femoral neck. Vitamin D, calcium supplement, and daily s.c.
administration of teriparatide were prescribed, and levothyroxin and prednison
(daily dose 60 and 30 mg alternately) were continued. Surgeon applaied Jewett
orthosis for lumbal region. On the basis of presented case of secondary
osteoporosis and multiple osteoporotic fractures, all myasthenia gravis patients
need osteoporosis diagnostic procedures and prophylaxis treatment at the onset of
prednisolone therapy, especially in postmenopausal period, because multiple
fractures may happen during short-term, high dose glucocorticoid treatment.
P98
Teriparatide in the treatment of severe osteoporosis: results of a
multicenter prospective study
Juraj Payer
1
, Sona Tomkova
2
, Zdenko Killinger
1
, Peter Jackuliak
1
,
Peter Vanuga
3
, Alexandra Letkovska
4
, Pavol Masaryk
4
& Zlata Kmecova
5
1
Fifth Department of Internal Medicine, Medical Faculty of Comenius
University, Bratislava, Slovakia;
2
Osteocentrum, Hospital Kosice - Saca,
Kosice, Slovakia;
3
National Institute of Endocrinology and Diabetology,
Lubochna, Slovakia;
4
National Institute of Rheumatic Diseases, Piestany,
Slovakia;
5
Osteocentrum of Faculty Hospital F.D. Roosevelt, Banska
Bystrica, Slovakia.
Introduction
Teriparatide (TPTD) is a recombinant aminoterminal fragment (1-34) of the
human parathyroid hormone (PTH), which has a predominantly stimulating effect
on bone formation. We report results of an 18-month prospective multicenter
study with daily s.c. application of 20 g of teriparatide in 85 elderly women with
severe osteoporosis, the effcacy, safety and compliance of the treatment.
Outcomes
The primary outcomes were defned as changes from basal/basic BMD of femoral
neck, total hip and lumbar spine after 12 and 18 months. Another primary outcome
was defned as an analysis of serum level changes of bone turnover markers after 6
and 18 months. Secondary outcomes included prevalence of clinical fractures,
tolerability and safety of the treatment.
Design and participants
The prospective, open label, non-randomized, single-armed 18-month study in fve
centers in the Slovak republic. The inclusion criteria were: 1) bone mass density
(BMD) T score ,2.9 in the region of the femoral neck, or hip and two or more
vertebral fractures and 2) the failure of previous antiresorptive treatment. All
patients were daily applicated subcutaneously 20 g of recombinant humane
parathyroide hormone (1-34) - teriparatide (Forsteo, Eli Lilly and Company,
Nederland BV). All enrolled women received daily supplements of 500-1000 mg
of calcium and 400-800 IU of Vitamin D.
Methods
The bone mineral density of lumbar spine (L
1
-4), femoral neck and total hip was
measured before treatment (base line) and at 12 and 18 months usingdual-energy
X-ray (DXA Hologic). We measured the concentration of C-telopeptide of collagen
CTx) and osteocalcin (OC) at base line and at 6 and 18 months. Statistical analyses
were performed according to the intention-to-treat principle. T-test was used to
determine the changes in percentage of BMD and levels of serum markers in 6, 12
and 18 months compared to baseline.
Results
Treatment with TPTD resulted in increase of bone mineral density of the total hip
during 12months (3.5%, P0.066) and signifcant increase of BMDin18months
of treatment (3.7%, P0.026). The BMDchanges inthe femoral neckregionwere
also signifcant, we observed an increase of BMD4.6%(P0.041) in 18 months.
The most signifcant increase of BMDwas found in the lumbar spine region, 9.2%
(P0.002) during 12 months of treatment and an increase of 10.6%after 18 months
of treatment with TPT (P0.001). Over 18 months of teriparatide therapy led to
signifcant increase of CTx and osteocalcin. The increase of CTx was 173% after 6
months and 93% after 18 months (P,0.001). As for osteocalcin, the increase of
serum level represented 134% after 6 and also 18 months of therapy (P,0.001).
Treatment was well tolerated and no serious side effects were observed. Borderline
hypercalcemia was present in 5.3% of patients, but it has no clinical relevance.
Conclusion
Osteoanabolic treatment using teriparatide was effective, well tolerated and safe.
According to or results parathormone could be a drug of choice in postmenopausal
women with severe osteoporosis.
P99
Vitamin D dehciency and comorbidity
Ifgenia Kostoglou-Athanassiou
1
, Aikaterini Chronaiou
1
,
Panagiotis Athanassiou
2
, Aikaterini Michou
1
, Dimitris Stefanopoulos
1
,
Razvan Alexandros Badila
1
, Thomais Terzi
1
& Areti Karf
1
1
Department of Endocrinology, Red Cross Hospital, Athens, Greece;
2
Department of Rheumatology, St Paul`s Hospital, Thessaloniki, Greece.
Vitamin D defciency is increasingly recognized today having taken the form of a
modern epidemic. Vitamin D, being synthesized in the skin under the effect of
ultraviolet light has been originally thought of as occurring only in areas of the
world where people are not exposed to the sun. However, it has recently been
observed that vitamin D defciency exists even in sunny areas. Recent
observations suggest that vitamin D defciency is related to signifcant
comorbidity, specifcally to the occurrence of diabetes mellitus and cardiovas-
cular disease.
The aim of the study was to describe the associated comorbidity in a group of 52
consecutive patients diagnosed with vitamin D defciency.
A group of 52 consecutive patients diagnosed with vitamin D defciency aged
(62.7710.48 years, meanS.D.), 45 women and 7 men are described. Vitamin
D was measured by RIA.
Results
BMI was 30.265.83 (meanS.D.), glycosylated hemoglobin HbA1c was 7.5
2.11% (meanS.D.) and 25(OH)D
3
was 11.84.03 ng/ml. Amongst the
group of 52 patients with vitamin D defciency 26 had diabetes mellitus type 2, 22
had thyroid disease, 10 had osteoporosis, 2 osteopenia, 14 had undergone
cholocystectomy and had gastritis and 13 had arterial hypertension and coronary
artery disease.
Conclusion
These data show that vitamin D defciency is associated with signifcant
comorbidity. In particular, it appears that it may predispose to the development of
diabetes mellitus type 2 and may be implicated in the development of
cardiovascular diseases. Cholocystectomy and gastritis may affect the absorption
of vitamin D2 from the gastrointestinal tract and may thus be related to the
aetiology and pathophysiology of vitamin D defciency in this group of affected
patients.
P100
Vitamin D status among adults in the Aegean region of Turkey
Zeliha Hekimsoy, Gonul Dinc, Sabriye Kafesciler, Ece Onur,
Yesim Guvenc, Tumer Pala, Feyzullah Guclu & Bilgin O
zmen
Celal Bayar University Medical Faculty, Manisa, Turkey.
Vitamin D is a lipid-soluble hormone found in certain foods and synthesized from
precursors in the skin when exposed to ultraviolet light. Vitamin D plays a critical
role in bone metabolism and many cellular and immunological processes; and low
levels have been associated with several chronic and infectious diseases. Vitamin
D status is assessed by measuring the concentration of serum 25-hydroxy vitamin
D (25(OH) D). Vitamin D defciency is reported to be common worldwide, but
little has been reported about the vitamin D status of adults in Turkey. In this
cross-sectional study, we determined the prevalence of 25(OH) D defciency in
adults residing in a city in the Aegean region of Turkey.
A survey was conducted on a representative sample of adults over 20 years old in
a non-coastal city. Of the 209 households selected by random sampling, 8.6%
(n18) were unoccupied and 21.5% (n45) refused to participate. Questions
about medical history, vitamin supplementation, sunlight exposure, and dietary
vitamin D intake were asked by face to face interview to 391 adults living in the
remaining households. Blood samples of the study population were taken once
during the winter (n391) and again during the summer (n95).
The mean serum 25(OH) D concentration in winter was 16.913.1 ng/ml, with
74.9% of the subjects having 25(OH) D defciency (,20 ng/ml), 13.8% having
insuffciency (20-29.99 ng/ml), and 11.3% of the subjects having a suffcient
25(OH) D concentration (30 ng/ml). In the summer, the mean serum
concentration was 12.68.5 ng/ml, with 84.2% having defciency, 10.5%
insuffciency, and 5.3% suffcient levels of 25(OH) D. Defciency of 25(OH) D
was more common among females (78.7%) compared to males (66.4%, P,0.05).
In conclusion, adults living in an urban, non-costal setting in Turkey have a high
incidence of vitamin D defciency.
P101
Fine needle aspiration of parathyroid gland with PTH analysis in
washouts: is it worthy?
Miguel Melo, Cristina Ribeiro, Sandra Paiva, Alexandra Vieira,
Francisco Carrilho & Manuela Carvalheiro
Department of Endocrinology, University Hospital of Coimbra, Coimbra,
Portugal.
Introduction
Primary hyperparathyroidism (PHPT) is the most common cause of hyper-
calcaemia in the outpatient setting. Surgical remove of an adenoma or
hyperplastic glands results in cure, but an accurate localization, preoperative
whenever possible, is essential for success. Taking into consideration that
parathyroid carcinoma is a rare event, FNA of parathyroid glands, complemented
by PTH measurement in washouts (FNA/PTH), may be a useful tool in the
diagnostic workout.
Objectives
To determine if FNA/PTH may add valuable information to our standard
localization workout for primary hyperparathyroidism (neck ultrasound
Sestamibi scan).
The study group consisted of seven consecutive patients with confrmed PHPT
(mean PTH275.4166.4 ng/ml (140-622); corrected calcium11.3
0.9 mg/dl (10.2-13.2)). Neck ultrasound (US), Sestamibi scan and FNA/PTH
were performed in all of them. The diagnosis of a parathyroid adenoma was
confrmed after surgical treatment in every one.
Results
Neck US was able to identify images suspected of enlarged parathyroid glands in
all the patients. In three patients US identifed two suspected lesions; only one of
the lesions in each patient was confrmed to correspond to a parathyroid by
FNA/PTH and Sestamibi scan. The results of FNA/PTH and Sestamibi scan were
concordant in these cases. Sestamibi scan revealed hyperfxation in six patients
(85.7%). In two cases the FNA Cytology was non-diagnostic but the PTH
washout analysis confrmed that the lesions corresponded to parathyroid tissue.
Conclusions
Neck ultrasound was the localization exam with the best performance in our
patients. FNA/PTH added valuable information when more than one suspected
lesion was detected by ultrasound. FNA/PTH was also important when the
cytology was non-diagnostic and when the Sestamibi scan was negative.
P102
Positive effect of human adipocyte-secreted factors on human osteoblast
proliferation and the OPG/RANKL ratio /n r/tra
Markus C Kuhn, Werner A Scherbaum & Sven Schinner
University Hospital Dusseldorf, Dusseldorf, Germany.
Objectives
Reduced bone mass and compromised bone quality characterise osteoporosis.
A positive relationship of the body-mass-index or the body fat mass and the bone
density has been reported by several clinical studies. However, it is not clear
whether this observation is attributable to higher mechanical stress or whether
adipocytes secrete products that directly affect the bone structure.
Methods
Isolation of human primary adipocytes to generate fat-cell conditioned
medium (FCCM). Isolation of primary human preosteoblasts. Local Ethical
Committee approval has been obtained. Measurement of cell proliferation
using
3
H-thymidine incorporation assay. Real-time reverse transcription PCR
to assess gene expression.
Results
The stimulation of MC3T3-E1 cells with FCCM led to a 2.8-fold increase in
proliferation (P, 0.05) after 48 h. Similarly, FCCM treatment increased the
proliferation of primary human preosteoblastic cells (1.5-fold, P,0.05). This
effect of FCCM on the proliferation could be reduced with inhibitors of the
receptor tyrosine kinase, of the FGFR1 and of the PI3K. Primary human
preosteoblasts treated with FCCM for 14 days showed an increase in OPG mRNA
expression and a decrease in RANKL mRNA expression.
Conclusions
These data demonstrate the direct infuence of human adipocyte-secreted factors
on preosteoblasts in vitro. Human adipocyte-secreted factors stimulate the
proliferation of preosteoblasts leading to more cells capable of differentiating into
mature osteoblasts. Furthermore, these factors might reduce the paracrine
stimulation of osteoclasts by osteoblasts as they increase the OPG/RANKL ratio
in preosteoblasts in vitro. These fndings could explain the higher bone mass in
obese people and attribute it to a direct effect of adipocyte-secreted factors.
P103
Tumoral calcinosis likely due to end-organ resistance to FGF23
Luisella Cianferotti, Edda Vignali, Filomena Cetani, Giulia Galli,
Tamara Giacomelli, Aldo Pinchera & Claudio Marcocci
Department of Endocrinology, University of Pisa, Pisa, Italy.
Tumoral calcinosis is a rare autosomal recessive disease characterized by
hyperphosphatemia due to increased renal phosphate reabsorption leading to soft
tissue calcifcations. The levels of fbroblast growth factor 23 (FGF23), a hormone
required for normal renal phosphate reabsorption, are typically low in the classic
form of the disease due to homozygous missense mutations in FGF23 or in the
UDP-Nacetyl-alpha-D galactosamine:polypeptide N-acetylgalactosaminyl trans-
ferase (GALNT3). Recessive inactivating mutation in Klotho, a coreceptor for
FGF23, also result in tumoral calcinosis, most likely due to an end-organ defect in
renal responsiveness to FGF23, as reported in one case. A 35-year-old man, son of
a frst-cousin marriage, presented with a phenotype consistent with tumoral
calcinosis, with a young-onset ectopic calcifc lesion at the hip (size: 330 ml)
recurred after multiple resections. Serum phosphate was persistently elevated
(6.6 mg/dl), renal phosphate reabsorption (TmP/GFR1.74, 0.7-1.45) and
1,25(OH)
2
vitamin D (105 pg/ml, 20-67) were increased, with normal serum
calcium, PTH and urinary calcium excretion. The induction of renal acidosis with
acetazolamide along with the use of aluminium-based phosphate binders led to a
normalization of renal phosphate reabsorption leading to a marked decrease of
serum phosphate (5.2 mg/dl) and a shrinkage of the calcifed mass (down to
75 ml). Intact and C-terminal FGF23 levels were inappropriately high in this
patient (101 pg/ml and 504 RU/ml, respectively), suggesting an end-organ
resistance to FGF23. Mutational analysis of FGF23, GALNT3 and Klotho
genes revealed a previously unreported 4 bp omozygous deletion in the third exon
of GALNT3 gene (c.249, del. TCAG) leading to a 256 AA truncated protein. No
mutations in FGF23 gene were found. Three polymorphisms in Klotho gene were
detected. The high intact FGF23 levels could be explained, at least in part, by an
alteration in signal transduction or a biologically inactive form of FGF23.
P104
Wermer syndrome revealed by primary hyperparathyroidism: a case
report
Mchirgui Nadia, Hadj Ali Insaf, Khiari Karima, Cheikhrouhou Hela,
Lakhoua Youssef & Ben Abdallah Nejib
Department of Internal Medicine and Endocrinology, Charles Nicolle
Hospital, Tunis, Tunisia.
Multiple endocrine neoplasia type 1 (MEN1) is a rare but misleading disease. The
diagnosis is evocated when two main lesions are present (parathyroid, pituitary
gland, endocrine pancreas tumor: Gastrinoma). We studied a 36 year-old woman
hospitalized in orthopedics for a neck femur fracture. A hypercalcaemia
(Ca2.84 mmol/l) with elevated PTH500 pg/ml were discovered before
intervention. The bone biopsy concluded to primary hyperparathyroidism lesions.
The history-taking revealed that the propositus had 11 years of secondary
amenorrhea without galactorrhea before the time of parathyroidectomy.
Hormonal results
FSH0.4 mUI/ml, LH,0.1 mUI/ml, oestradiol20 pg/ml, prolactine
24 947 mUI/l (1133 pg/ml). In front of this tumoral rate of prolactine, the
MRI of the pituitary gland had found an enlarged sella turcica related to a
macroprolactinoma. After parathyroid adenoma resection, the patient had
normalized her calcemia (2.18 mmol/l) and PTH rate (55 pg/ml). For
prolactinoma, she had received bromocriptine treatment (5 mg/day) and the
rate of prolactine had decreased.
The Wermer syndrome was diagnosed and the genetic diagnosis was on going.
An abdominal CT scan did not found any endocrine pancreas abnormality.
We conclude that, as a general rule, any apparently isolated endocrine lesion such
hyperparathyroidism must prompt the endocrinologist to look for another
endocrine lesion and to look for an abnormal family tree with recurrent
monoglandular or pluriglandular lesions.
P105
Severe primary hyperparathyro dism related multiple clear cell
adenome
Khiari Karima, Hadj Ali Insaf, Lakhoua Youssef, Mchirgui Nadia,
Cheikhrouhou Hela & Ben Abdallah Nejib
Department of Internal Medicine A and Endocrinology, Charles Nicolle
We report a 25 years old man who admitted in our department for primary
hyperparathyroidism. He has previously been diagnosed with urolithiasis in 2006
and two pathological fracture of the humerus in 2009.
Physical exam was normal laboratory fndings showed hypercalcemia
(4.06 mmol/l) associated to a high parathyroid hormone level (PTH: 1930 pg/ml).
Ultrasound examination of the neck showed two enlarged parathyroid adenoma.
Surgical exploration noted three adenoma witch are excised.
Histopathological examinationshowedclear cell adenoma. The postoperative course
was marqued by persistent hyperparathyroidism (calcemia: 2.62 mmol/l, PTH:
410.3 pg/ml). Imaging studies (scintigraphy and magnetic resonance imaging)
showed a parathyroid adenoma in the posterior on the left lobe of the thyroid. The
excised parathyroid was larged adenoma (clear cell adenoma). The postoperative
course was excellent and serum PTH, calcemia levels returned to normal. There are
no found argument for multiple endocrine neoplasias in our patient.
In summary, we report a rare case of severe primary hyperparathyroidismcaused by
multiple clear cell parathyroid adenoma.
P10
Osteocalcin, OPG and RANKL circulating levels in adolescent
idiopathic scoliosis
Oana Popa
1
, Mariana Chiru Anton
2
, Susana Vladoiu
1
, Dana Manda
1
& Olga Ianas
1
1
C. I. Parhon National Institute of Endocrinology, Bucharest, Romania;
2
Emergency Hospital, Calarasi, Romania.
Background
Idiopathic scoliosis is a pathological entity of unknown etiology, characterized
by a three-dimensional deformity of the spine and a low bone mass. The exact
mechanism of bone loss in idiopathic scoliosis is unknown yet. However is well
known that RANKL is a potent stimulator of bone resorption by binding receptor
activator of nuclear factor-kB (RANK) in the osteoclasts cell membrane. OPG is a
decoy receptor for RANKL, which interferes with RANKL/RANK binding and
inhibits the maturation and activation of osteoclasts.
Objective
Evaluation of osteocalcin, OPG and RANKL circulating levels and of
RANKL/RANK and OPG balance in adolescent with idiopathic scoliosis
comparing with normal subjects at the same age.
Fifteen adolescents - four boys and 11 girls - with idiopathic scoliosis and eight
healthy adolescents - two boys and six girls - were enrolled. The study had the
Ethical Committee approval. Radiological, biochemical, haematological and
hormonal evaluations were made. Blood samples were collected every 4 h during
day and 2 h during night for 24 h period. Serum levels of osteocalcin, OPG and
RANKL were measured.
Results
Signifcantly higher levels of osteocalcin (P,0.01) and RANKL (P,0.01) were
observed in adolescents with idiopathic scoliosis compared with control group.
OPG showed no differences between the too groups of study. RANKL/OPG ratio
was signifcantly higher (P,0.01) compared with control group.
Conclusion
Higher levels of RANKL in the presence of increased levels of osteocalcin may
induce bone-remodelling changes due to an imbalance in RANK/RANKL/OPG
system.
P10I
Parathyroid FNA with PTH determination as a tool in primary
hyperparathyroidism diagnosis ~ case report
Jeanina Idriceanu
1
, Lidia Ionescu
2
, Claudia Miron
1
, Roxana Balcan
1
,
Safae ElMekkaoui
1
, Ioana Vasiliu
1
, Voichita Mogos
1
& Carmen Vulpoi
1
1
Department of Endocrinology, UMF Gr.T.Popa, Iasi, Romania;
2
Department of Surgery, UMF Gr.T.Popa, Iasi, Romania.
I fne-needle aspiration (FNA) is the gold standard in thyroid nodules
management, but it is less common in the evaluation of parathyroid nodules.
When imagery fails to localize a parathyroid adenoma, morphological and
functional investigations, like FNA of the suspected area and scintigraphy may be
useful. We present the case of a 58 years-old woman, menopaused at 47 years,
who consulted for lombalgia. Vertebral DXA confrmed osteoporosis (Tscore
3.8). She was not treated with HRT or calcium and vitamin D. Biological
assessments revealed hypercalcemia (10.92 mg/dl), low normal phosphorus
(2.94 mg/dl) and hypercalciuria (400 mg/24 h) suggesting primary hyper-
parathyroidism, confrmed by elevated PTH (111.8 pg/ml, N:1565 pg/ml).
Specifcally associates forearm osteoporosis (Tscore 3.2). Thyroid function
was normal (TSH1.8 UI/ml, fT
4
1.3 ng/dl) and thyroid ultrasound described
a right inferior nodule of 1.4 cm, izoechoic, with well defned margins and mild
internal vascularization. CT identifed thyroid hypoechoic nodules bilateral of
maximum 7 mm in diameter, without signs of a parathyroid adenoma.
Ultrasound-guided FNA of the nodule with dosage of PTH level in the needle-
wash was performed. Cytology was not conclusive, but the high levels of
intranodular PTH (1021 pg/ml) confrmed that the nodule was a parathyroid
adenoma.
Parathyroidectomy was successfully performed (pathology: clear cells adenoma),
followed by normalization of PTH and calcium parameters. Minimally invasive
parathyroid surgery is the treatment of choice in primary hyperparathyroidism but
a successful removal requires the clear localization of a parathyroid lesion.
US-guided FNA is a useful technique, literature data confrming a high specifcity
and sensitivity (90%). In our case, very high level of PTH in the needle-wash
identifed parathyroid adenoma, avoiding extensive surgery for a mild
hyperparathyroidism. The post surgery normalization confrmed the the good
localization, proving the effcacy of the method in primary hyperparathyroidism
diagnosis.
P108
Bone turnover, serum osteoprotegerin and soluble receptor activator of
nuclear factor-K ligand levels in patients with hyperthyroidism
Zeliha Hekimsoy, Sabriye Kafesciler, Fatma Taneli, Feray Aras,
Bilgin O
zmen & Feyzullah Guclu

Celal Bayar University Medical Faculty, Manisa, Turkey.
Osteoprotogerin (OPG) and the receptor activators of nuclear factor-k (RANK)
and nuclear factor-k ligand (RANKL) play an important role in bone
metabolism. RANKL binds to RANK, which is expressed by osteoclasts,
whereas OPG acts as its decoy receptor, blocking the RANK-RANKL
interaction.
The aim of our study was to evaluate bone turnover parameters (serum calcium,
phosphorus, alkaline phosphatase, parathormone, osteocalcine, 24-h urinary
calcium level, urinary deoxy-pyridinoline), osteoporosis-associated cytokines
(IL-1, IL-6, TNF), RANKL and OPG serum levels in patients with overt
hyperthyroidism before antithyroidal treatment (while in the hyperthyroid state)
and after achieving euthyroidism. Forty-six patients (30 men, 37% pre-
menopausal women, 33% postmenopausal women) participated in this
observational study: 22 with Graves` disease (mean age 385 years), 14 with
toxic multinodular goiter (mean age 554 years) and 10 with toxic adenomas
(mean age 4412 years). Serum levels of bone formation and resorption markers
were abnormally high before treatment and decreased to normal levels as the
patients became euthyroid. However, no signifcant change was observed at
osteoporosis-associated cytokine levels and RANKL and OPG levels (0.360.05
vs 0.350.05 and 6.53.1 vs 6.43.0 pmol/l, respectively) in these endogenous
hyperthyroid patients.
In conclusion, although endogenous hyperthyroidism increases the levels of bone
formation and resorption markers, no change is observed in the serum levels of
osteoporosis-associated cytokines, RANKL and OPG.
P109
Primary hyperparathyroidism at pregnancy
Goknur Yorulmaz, Nur Kebapci, Kevser Onbasi, Belgin Efe
& Aysen Akalin
Division of Endocrinology and Metabolism, Internal Medicine Department,
Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey.
Primary hyperparathyroidism during pregnancy is a rare condition associated
with a high frequency of complications in both mother and fetus. Operation in the
second trimester is offered. Here we report about a case with hyperemesis and
hyperparathyroidism during routine laboratory examinations.
A 30-years-old pregnant woman attendant our policlinic with hyperemsis
gravidarum. Her calcium and parathormone level were elevated; 11.6 mg/dl
and 135 pg/ml, respectively. Calcium excretion rate was 456 mg/per day, tubular
phosphorus reabsorbtion rate was 91% and chlor-phosphorus ratio was 41.3. With
all these fndings the patient was diagnosed to have primary hyperparathyroidism.
Neck ultrasound revealed a parathyroid adenoma (12,7,27 mm) at the inferior
right thyroid lobe. At the frst trimester the patient was given calsitonin treatment
and hydration. At the second trimester she was sent to surgery because of high
calcium levels despite medical treatment. After the operation her calcium levels
turned to low levels.
P110
Comparative evaluation of bone density measurement with DXA or
quantitative ultrasound of bone in the diagnosis and treatment
monitoring of osteoporosis ~ a held study
Andreas Knauerhase
1
, Susanne Beier
1
, Christiana Zingler
2
,
Gerritt Tolkemitt
3
& Rainer Hampel
1
1
Universitatsklinik fur Innere Medizin, Rostock, Germany;
2
Institut fur
klinische Chemie und Laboratoriumsmedizin, Rostock, Germany;
3
Radiologische Praxis, Rostock, Germany.
Question
Can be reliably diagnosed osteoporosis with quantitative ultrasound of bone? Can
the therapeutic progress of a specifc osteoporosis therapy reliably judged by that?
Three hundred and twenty patients were enrolled between July 1999 and October
2004. All patients were studied in the osteoporosis clinic at time 0, after 1, 2 and 3
years. BMD was done with Hologic QDR-1000 (low back or hip) and the
Osteometer DTU one (parameters SOS and BUA, measured heel). We also
recorded anamnestic and anthropometric parameters and laboratory values and
treatment data. The statistical analysis covered in the normal arithmetic means
and standard deviation, correlation coeffcient, correlation analysis, the Mann-
Whitney test and the Wilcoxon test.
Results
At time 0 quantitative ultrasound and DXA correlated signifcantly (P,0.001).
Among the other times, the signifcances are inconsistent. This is true for the
whole group and all subgroups.
Conclusion
The Osteosonometrie is suitable for the diagnosis of osteoporosis. Its importance
in assessing the course of therapy is much lower.
P111
Osteoporosis and osteopenia in patients after the organ transplantation
Jana Brunova
IKEM, Prague, Czech Republic.
Background
Survival of patients after the transplantation (Tx) of solid organs is improving.
Osteoporosis and bone fractures belong to their long-term complications. The
contributing factors are disturbances of bone metabolism in pre-transplant period
and immunosuppressive therapy including corticosteroids after the trans-
plantation.
We investigated the prevalence of osteoporosis and osteopenia in 248 diabetic
patients after the Tx of kidney for renal failure due to diabetic nephropathy and we
compared them with 232 non-diabetic patients after the kidney Tx and 70 patients
after the liver Tx. The bone loss was diagnosed with densitometry (DEXA) using
Lunar Prodigyapparatus. In diabetic patient we followed some characteristics of
bone metabolism: Ca, P, parathormone (PTH), osteocalcin, 1,25(OH)2 D3,
25OHD3, ICTP and bone ALP (BALP).
Results
In diabetic patients after Tx was osteopenia present in 50% and osteoporosis in
26%. Patients with Tx for non-diabetic nephropathy had osteopenia in 45% and
osteoporosis in 28%. Patients after liver Tx showed osteopenia in 43% and
osteoporosis in 18%. In diabetic patients the mean levels bone metabolism
characteristics were: 2.380.12 mmol/l, P 1.120.21 mmol/l, ALP: 1.52
0.59 kat/l, creatinine: 121.3439.4 mol/l, osteocalcin 61.051.3 g/l,
PTH 11.177.3 pmol/l, KALP 14.425.5 g/l, ICTP 10.76.5 g/l,
1,25(OH)2D3 vit. 58.827.8 ng/l, 25 OHD3 vit. 18.87.4 g/l. Low levels of
D vitamin were identifed in 63% of diabetic patients.
Conclusions
In this study of patients with organ transplantation we found increased prevalence
osteopenia and osteoporosis. The highest percentage of diminished bone density
was present in diabetics (76%), than in non-diabetic patients with kidney Tx
(73%) and lowest among patients after liver Tx (61%). Diabetic patients had
frequently impaired characteristics of bone metabolism and low D vitamin levels.
P112
Risk of vertebral fractures in osteoporotic women: dehnition of a
clinically relevant scale of risk
Alessandra Fusco
1
, Enrico Pola
2
, Marilda Mormando
1
, Debora Colangelo
2
,
Luigi Aurelio Nasto
2
, Antonio Bianchi
1
, Carlo Ambrogio Logroscino
2
& Laura De Marinis
1
1
Division of Endocrinology, Department of Internal Medicine, Universita`
Cattolica del Sacro Cuore School of Medicine, 'A.Gemelli` University
Hospital, Rome, Italy;
2
Division of Spinal Surgery, Department of
Orthopedics and Traumatology, Universita` Cattolica del Sacro Cuore
School of Medicine, 'A.Gemelli` University Hospital, Rome, Italy.
Introduction
Osteoporosis is a disease characterized by a low bone mass and the development
of nontraumatic fractures, most commonly in the spine. However, bone mineral
density (BMD) alone is not completely satisfactory in vertebral fracture risk
assessment.
Aim of the study
To identify clinical and laboratoristic factors associated with an increased risk of
vertebral fractures in osteoporotic Caucasian women and to defne a new
clinically relevant scale of risk.
Four hundred patients (age: 55-87 years) consecutively admitted at our
ambulatory for the treatment of post-menopausal osteoporosis were included in
the study. The vertebral fractures were diagnosed by Morphometric CT and MRI
for each patient.
Results
One hundred and forty-six patients of the entire population presented at least one
vertebral fracture for a total of 411 fractures. When considered alone, age (65
years), lumbar T-score (B3.5), lumbar Z-score (B2.5), lumbar BMD
(B 0.800), femoral T-score (B 3.5), femoral Z-score (B 2.5), L3 volume
(B2.0 S.D.) and T7 volume (B 2.0 S.D.) were signifcantly associated with
an increased risk of vertebral fractures. Considering only the patients with two
fractures or more, the same parameters with the exception of the femoral T-score
resulted strongly associated with the risk of new vertebral fractures. Moreover,
there was a signifcantly increased risk of vertebral fractures when two or more of
these parameters were present together (P0.02). On the base of the obtained
data we have then defned a new scale of risk (from grade I-low risk in patients
without risk factors to grade IV-very high risk in patients with three or more risk
factors) confrmed in a prospective study conducted on 60 osteoporotic patients
followed for 2 years.
Conclusion
Our fndings indicate that clinical and laboratoristic variables may have a
synergistic effect on the risk of vertebral fractures.
P113
Diagnostic challenge in child`s bone cystic lesions
Marioara Cornianu
1,2
, Ioana Micle
1,3
, Ioana Golu
1,4
, Mihaela Vlad
1,4
,
Alis Dema
1,2
, Sorina Taban
1,2
, Anca Muresan
1,2
& Codruta Lazureanu
1,2
1
University of Medicine and Pharmacy, 'V. Babes` Timisoara, Romania;
2
Department of Pathology, Timisoara, Romania;
3
Pediatric Clinic I,
Timisoara, Romania;
4
Endocrinology Department, Timisoara, Romania.
Introduction
Primary hyperparathyroidism (PHP) affects predominantly the adult age
(incidence 1/10 000) and it is unusual.
Is to present a rare pathology in a child, which implied interdisciplinary
collaboration.
Material and method
We present a teenager girl of 16 years old, diagnosed with osteomalacia after a
thoracic and pelvis trauma, based on knee and pelvis radiographs (diffuse bone
demineralization, trabecular rarefaction). The persistence and increasing bone
pelvic pain, imposed a complete evaluation (multiple admissions in Pediatric
Clinic no. I, Timisoara), with phosphocalcic metabolism (total serum calcium
3.19 mmol/l, alkaline phosphatase 1639 U/l), MRI (multiple cystic lesions in
pelvic bones, bilateral femoral diaphyses and patellae) and bone biopsy, which
established the diagnosis of osteoclastoma.
Multiple osteolysis foci (right humerus), along with serum calcitonin levels
(6.5 pg/ml) and excessive parathormone secretion (PTH 1428 pg/ml) established
the diagnosis of PHP and von Recklinghausen fbrocystic osteitis.
Cervical imagistic explorations (ultrasonography, MRI) revealed a solid nodule
of 3.2/1.7/1.6 cm, clearly delimitated, located on the posterior side of the right
thyroid lobe and multiple cystic lesions, in the sternum, ribs and right scapula,
raising the suspicion of a parathyroid adenoma.
Results
The diagnosis of parathyroid adenoma was confrmed by right superior
parathyroidectomy (performed in Surgical Clinic, County Hospital Timisoara).
After surgery, the substitution therapy was commenced and bone lesions
presented a favourable evolution.
Conclusion
The peculiarity of this case is based on the young age of the patient, the diagnosis
made in fbrocystic osteitis stage, and the differentiation of the osteoclastoma
from hyperparathyroid brown tumor based on phosphocalcic metabolism results.
P114
Male osteoporosis of multiple drug aetiology
Georgios Klangos
1
, Panagiotis Athanassiou
2
, Ifgenia Kostoglou-
Athanassiou
1
1
, Aikaterini Michou
1
,
Dimitris Stefanopoulos
1
, Stylianos Kotanoglou
1
& Areti Karf
1
1
2
Male osteoporosis is a reality and in many cases appears to be secondary to drug
administration. Many pharmaceutical agents are related to the appearance of
osteoporosis, affecting bone metabolism by multiple and diverse mechanisms.
The aim was to describe the case of a patient who presented with male
osteoporosis of multiple drug aetiology.
A patient, male aged 52 years, an orthodox priest, presented with spontaneous
fractures and diffuse bone pain. The patient had a history of diabetes mellitus type
2, having been given metformin and thiazolidinediones. At the age of 46 years the
patient was a victim of violence and subsequently developed bipolar disorder. For
the management of bipolar disorder he received treatment with selective serotonin
reuptake inhibitors. At presentation normal gonadal and thyroid function was
found and severe vitamin D defciency was documented, 25(OH)D
3
levels being
7.4 ng/ml. Radiological investigations revealed compressive vertebral fractures
and a fracture of the right 4th metacarpal. Bone mineral density was severely
impaired, T score being 4.2. Vitamin D was administered for the repletion of
vitamin D. Consequently, intact parathyroid hormone was administered along
with calcium and vitamin D. The administration of thiazolidinediones was
withdrawn but selective serotonin reuptake inhibitors were continued, for the
management of the severe psychotic syndrome.
Conclusion
Many pharmaceutical agents may be implicated in the development of
osteoporosis, amongst them the antidepressants and thiazolidinediones. The
patient described also had severe vitamin D defciency, which is known to cause
osteomalacia and is a predisposing factor for the development of osteoporosis.
The administration of selective serotonin reuptake inhibitors seems to be
associated with the development of osteoporosis in the patient described and
shows that patients suffering from depression on therapy with antidepressants
should be followed up, screened and managed properly preventively and
therapeutically for osteoporosis.
P115
Extraosseous effects of raloxifene in osteoporotic postmenopausal
women
Arantzazu Sebastian-Ochoa
1
, Diego Fernandez-Garcia
1
, Rebeca Reyes
Garci a
2
& Manuel Munoz Torres
3
1
Servicio Endocrinologi à y Nutricion, Hospital Virgen de la Victoria,
Malaga, Spain;
2
Servicio Endocrinologi à y Nutricion, Hospital Rafael
Mendez, Lorca, Murcia, Spain;
3
Servicio Endocrinologi à y Nutricion,
Unidad de Metabolismo O
seo, Hospital Universitario San Cecilio,

Granada, Spain.
Raloxifene is a selective estrogen receptor modulator which has shown to
decrease bone resorption, increase bone density and reduce vertebral fracture rate
in women with postmenopausal osteoporosis. Recent studies have shown a
decrease on breast cancer incidence after raloxifene treatment. Although the
mechanism is not clear, its mixed agonist and antagonist properties in different
tissues could partially explain this effect.
Objective
To evaluate the effects of a 12 month administration of raloxifene on serum
gonadotropin, thyrotropin (TSH), serum free T
4
(FT
4
), 17estradiol (E
2
), sex
hormone-binding globulin (SHBG), dehydroepiandrosterone (DHEAs), testoster-
one, insulin-like growth factor (IGF1) and insulin-like growth factor binding
protein 3 (IGFBP3).
Design
Forty seven postmenopausal women (mean age 637 years) with densitometric
criteria of osteoporosis were treated with raloxifene 60 mg/day for 12 months.
Serum IGF1, FSH, LH, E
2
(kit DSL-39100 3rd Generation Estradiol RIA,
Diagnostic System Laboratories, Inc., Texas, USA), DHEAs, testosterone, TSH,
and anthropometric parameters were evaluated at baseline and after 12 months of
treatment.
Results
No signifcant variations in serum FSH, LH, testosterone, SHBG, TSH, FT
4
values were observed. Serum E
2
(17.938 vs 23.26.8; P0.001) and DHEAs
(P0.001) levels increased after one year of treatment with raloxifene. Serum
IGF1 (133.6 vs 88.8; P0.001) and IGF1/IGFBP3 ratio (48.23 vs 33.4; P,0.01)
were both decreased after one year of raloxifene treatment.
Conclusions
Antineoplastic action of raloxifene treatment can be mediated at least in part by
the decrease in IGF1 and E
2
levels.
P11
Polyunsaturated fatty acids omega-3, but not the omega-6, stimulates
the differentiation to osteoblasts of mesenchymal stem cell
Antonio Casado-Di az
1,2
, Raquel Santiago-Mora
1
, Pilar Manso
3
& Jose Manuel Quesada
1,2
1
Unidad de Metabolismo Mineral Hospital Universitario Reina Sofi a
de Cordoba, RETICEF, Cordoba, Spain;
2
IDI, Sanyres XXI,
Cordoba, Spain;
3
Grupo Ferrer, Barcelona, Spain.
The compounds derived from the oxidative stress and lipid peroxidation
stimulate the bone loss, in part because they enhance the adipogenesis and
blunt the osteoblastogenesis from mesenchymal stem cell (MSC), increasing
the marrow adiposity that accompanies the osteoporosis. The consumption of
omega-3 seems to have a protective effect on bone. This effect has been
associated with the production of 15-hydroxy-eicosapentaenoic acid and
17-hydroxy-docosahexaenoic acid, which do not trigger the adipogenic
transcription factor PPAR-2, while the peroxidation of omega-6, produces
13-hydroxy octadecadienoic acid (HODE) and 15-hydroxytetraenoic acid
(HETE), both PPAR2 activators.
In this study MSCs were induced to differentiate to osteoblasts with 10
8
M
dexamethasone, 10 mM -glycerophosphate and 0.2 mM ascorbic acid, or to
adipocytes with 5,10
7
M dexamethasone, 0.5 mM isobutylmethylxanthine
and 50 M indometacine 40 or 20 M of Araquidonic acid (AA) (omega-6),
Docosahexaenoic acid (DHA) and Eicosapentaenoic acid (EPA) (omega-3).
In MSC cultures induced to osteoblasts the AA treatment decreased the
expression of osteogenic markers and the ratio OPG/RANKL, while the DHA
and EPA treatment increased it. Both treatments led the development of
adipocytes. However, their number was always signifcantly higher in cultures
treated with omega-6. In adipogenesis, the number of cells with vesicles of fat
and adipogenesis markers increased signifcantly with the AA treatment. The
AA treatment, also increase the production of 13-HODE and 15-HETE, as well
as the expression of the gene lipoxygenase ALOX15B, both in the cultures
induced to osteoblasts and induced to adipocytes.
This results indicate that the omega-3 stimulate the osteogenesis, and the
omega-6 the adipogenesis of MSC, probably because the products of lipid
peroxidation of the latter, produced by the lipoxygenase ALOX15B induces the
expression of PPAR-2. Our data support preliminary observations, which
have shown that a higher dietary omega-3/omega-6 fatty acids ratio is
associated with benefcial effects on bone health.
P11I
Evaluation of age and sex inuence on the morphometric parameters of
vertebrae in densitometric morphometry ~ results of EPOLOS study
Elzbieta Skowronska-Jozwiak
1
, Andrzej Lewinski
1
, Pawel Pludowski
2
,
Elzbieta Karczmarewicz
2
& Roman Lorenc
2
1
Department of Endocrinology and Metabolic Diseases, Mothers` Memorial
Health Institute, Medical University of Lodz, Lodz, Poland;
2
Department of
Biochemistry and Experimental Medicine, Children`s Memorial Health
Institute, Warsaw, Poland.
Vertebral morphometric X-ray absorptiometry (MXA) is a new tool developed to
evaluate the presence of vertebral fractures - main symptoms of osteoporosis. The
study aimed at comparing selected morphometric parameters of vertebrae in men
and women in various age groups. 965 healthy persons have been involved in the
study: 616 female and 349 male, their age ranging from 18 to 79 years. Lateral
densitometric scans of the thoracic-lumbar spine were made using Expert-XL
densitometer. T4-L4 vertebrae were demonstrated.
Results
The analysis comprised 9675 vertebrae. While assessing the infuence of patient
age, statistically signifcant higher values of Ha, Hc and Hp were found in the
younger age groups. For Th5, Th6 and Th7 vertebrae - higher Ha/Hp and Hc/Hp
values were observed and in case Th8, Th9, Th10, Th11, Th12, L2 and L3, only
Hc/Hp was increased. In L1 and L4 vertebrae, no differences were identifed
between Ha/Hp and Hc/Hp values with regards to the age of the patients. In men,
statistically signifcantly higher values of Ha, Hc and Hp were found in
comparison with the group of women. In women, statistically signifcantly higher
values of the Ha/Hp ratio in Th5-Th6 vertebrae were observed, when compared
with the male group, higher values of the Hc/Hp ration in Th12, L2 and L3
vertebrae, while in Th7, 8, 9, 10, 11 and L1, both the Ha/Hp ratio and the Hc/Hp
ratio demonstrated elevated values.
Conclusion
Morphometric parameters of the vertebrae vary, depending on sex and age of
patients, what is to be considered, when designing reference groups.
P118
Primary hyperparathyroidism diagnosis ~ new insights of an old
dilemma
Carmen Vulpoi
1
, Cipriana Stefanescu
2
, Lidia Ionescu
3
, Felicia Crumpei
4
,
Ioana Vasiliu
1
, Roxana Balcan
1
, Jeanina Idriceanu
1
& Voichita Mogos
1
1
Department of Endocrinology UMF Gr.T.Popa, Iasi, Romania;
2
Department of Nuclear Medicine UMF Gr.T.Popa, Iasi, Romania;
3
Department of Surgery UMF Gr.T.Popa, Iasi, Romania;
4
Department of
Imagery, University Hospital St Spiridon, Iasi, Romania.
Primary hyperparathyroidism (PHPT) is a relatively frequent problem in clinical
endocrine practice. Minimally invasive parathyroid surgery is the treatment of
choice but requires precise preoperatory localization. The most commonly
investigation methods are ultrasonography and scintigraphy, but they are not
always diagnostic. PTH assay of the aspirate from an ultrasound-guided fne-
needle aspiration (USFNA) may confrm the location of pathological parathyroid
tissue. The aim of this study was to analyze the role of preoperative localization
techniques for primary HPT in 40 patients (7 men and 33 women, aged between
19 and 75 years old) evaluated in the Endocrine Department in 2009. All patients
had confrmed PHPT. PTH values were between 112 and 823.9 pg/ml (median
n15-65 pg/ml), with hypercalcemia (10.9-17.7 mg/dl), hypercalciuria (350-
182 mg/24 h), and hypophosphoremia (1.6-2.3 mg/24 h). Clinical expression
varied from asymptomatic to severe symptoms. All patients had both
ultrasonography (not always conclusive for parathyroid), and scintigraphy with
99m
Tc-tetrofosmin, diagnostic in 25% cases (increased persistent uptake), and
negative in 15% cases. The remaining 60% cases showed moderate uptake,
concordant with the ultrasound localization in 40% cases, and discordant in 20%
(no uptake on the presumed parathyroid adenoma and/or uptake in other areas).
USFNA with PTH dosage in the needle-wash was performed in 7 patients. High
PTH values of 1000 pg/ml confrmed parathyroid adenoma in 3 cases. Of the
60% patients already operated, 80% are cured -all those localized by concordant
ultrasonography and scintigraphy and/or USFNA. CONCLUSION. Preoperative
diagnosis of primary hyperparathyroidism implies more than one exploration
aiming localization. The lack of correlation between ultrasound and scintigraphy
may express the presence active lesions other than those supposed on
ultrasonography. US FNA with PTH determination is an effective tool in
diagnosing abnormal parathyroid gland but it should be carried out in conjunction
with the other investigations and reserved for selected cases.
P119
PTH treatment in adult hypophosphatasia: signihcant increase in S-AP,
improvement of pain and fracture healing in two siblings with ALPL
gene mutations G339R and E191K
Camilla Schalin-Jantti
1
, Matti Valimaki
1
& Etienne Mornet
2
1
Division of Endocrinology, Department of Medicine, Central Hospital,
Helsinki University, Helsinki, Finland;
2
Laboratoire SESEP, Centre
Hospitalier de Versailles, Le Chesnay, France.
Background
Hypophosphatasia (HPP) is characterized by low serum alkaline phosphatase
(S-AP) activity due to loss-of function mutations in the ALPL gene. A hallmark of
adult HPP is painful, slowly healing metatarsal and femur stress fractures. There
is no treatment for the disease but benefcial effects of parathyroid hormone
(PTH) treatment was previously demonstrated in one patient. It is unclear how
parathyroid hormone (PTH) can stimulate S-AP despite loss-of function
mutations.
Aim
To study the effects of PTH treatment on S-AP, bone markers, S-Ca-ion, S-Pi,
pain, mobility and femur fracture healing in two siblings with adult HPP and to
characterize the underlying molecular defects.
Results
PTH treatment (100 ug s.c daily) signifcantly increased S-AP in both patients,
from 8 U/l (reference 35-105) to a peak value of 22 U/l in Patient 1 and 39 U/l in
Patient 2, respectively. The increase in S-AP was due to increased bone specifc
AP. Corresponding increases in S-P1NP were 56.5 to 789 and 61.1 to 552 ug/l,
respectively and for U-NTX 43 to 408 nmol/mmolKr and 22 to 98 nmol/mmolKr.
Slight increases in S-Ca-ion and S-Pi concentrations were observed. Pain and
mobility improved signifcantly in both patients. For both patients, imaging
demonstrated femur fracture healing. Molecular analysis of the ALPL gene
revealed two distinct mutations in both patients, a severe G339R and a mild
E191K mutation, which is associated with signifcant residual enzyme activity.
Conclusion
PTH treatment signifcantly increases S-AP and bone turnover, improves
mobility, pain and fracture healing in adult HPP. Despite a severe G339R
mutation, the signifcant residual activity of the E191K ALPL mutation provides
an explanation for why PTH is able to stimulate S-AP in these patients.
P120
Estradiol and testosterone levels in diabetic type 2 men with low bone
density and osteoporosis
Mario Rui Mascarenhas
1,2
, Ana Paula Barbosa
1
, Ema Nobre
1
,
Ana Goncalves
1
, Vera Simoes
1,3
, Jose Camolas
2,3
, Maria Raquel Carvalho
2
,
Joana Ferreira
1
, Joao Vieira
2
, David Santos Pinto
3
, Manuel Bicho
1
&
Isabel do Carmo
2
1
Metabolism and Endocrinology Center (Genetics Lab, Lisbon`s Faculty
of Medicine), Lisboa, Portugal;
2
Endocrinology, Diabetes and Metabolism
Department (Santa Maria University Hospital, CHLN-EPE), Lisboa,
Portugal;
3
CEDML-Lisbon`s Endocrinology, Diabetes and Metabolism
Clinic (Osteoporosis Unit), Lisboa, Portugal.
Osteoporosis and diabetes mellitus type 2 (DM2) have severe health
consequences, with high morbidity and mortality risks.
Aims
To study the differences of the sex steroid hormones levels and the free androgen
index (FAI) in DM2 men with low BMD and osteoporosis and their relationships
with BMD.
In 317 men with DM2, the BMD (g/cm
2
) was evaluated at the lumbar spine
(L
1
-L
4
), at the hip and at the distal radius, using a radiological densitometer
(Hologic Inc.).
According to the T-score obtained in at least one of those skeletal sites, this
population was divided in normal and low BMD and osteoporosis groups.
Glycemia, HbA1c, total (testosterone) and free (FT) testosterone and 17beta-
estradiol (E
2
), sex hormone binding globulin (SHBG) were measured. The BMI
was also calculated.
ANOVA and multiple regression analysis tests were used to differentiate the
several parameters.
Results
The mean age was increased in the osteoporosis group (P,0.05) but the mean
BMI and the mean height were reduced in this group (P,0.05). However, the
mean testosterone and the mean E
2
were signifcantly decreased in the low BMD
and in the osteoporosis groups (P,0.05). The BMD at the lumbar spine and at the
hip were signifcantly related with E
2
blood levels, but not with testosterone blood
levels. The mean glycemia and the mean HbAc1 levels were identical among the
studied groups.
Conclusions
These results suggest that the males with DM2 (duration more than 10 years) over
60-year-old may have an increased risk for osteoporosis. The low sex steroid
hormone plasma levels appear to be signifcant risk factors for osteoporosis in
DM2 males. The data of this study imply that increased E
2
plasma levels may
also play an important role for the relative protection of bone loss mechanisms in
DM2 males.
P121
The circadian rhythm of bone resorption: comparison between patients
treated with teriparatide and patients with primary
hyperparathyroidism
Maria Luchavova, Ivan Raska, Dana Michalska & Vit Zikan
Department of Internal Medicine 3, Faculty of Medicine 1, Charles
University, Prague, Czech Republic.
Parathyroid hormone (PTH) has a biphasic effect on bone cells and can induce
opposing responses resulting in both net bone loss and net bone formation.
Patients with primary hyperparathyroidism (PHPT) lose the circadian rhythm for
PTH and bone mass decreases. PTH administered intermittently resulting in
increase in bone mass. We studied the differences in the circadian variability of
bone turnover markers between women with PHPT and women with
postmenopausal osteoporosis treated with teriparatide (TPD). Methods: Blood
samples were obtained at 3-h intervals from 18 patients: postmenopausal women
with osteoporosis treated with TPD given either in the morning (n6) or evening
(n6), and elderly women with mild PHPT (n6). Serum type I collagen
C-telopeptide (CTX), procollagen I N-terminal propeptide (P1NP), plasma
intact PTH and serum calcium were measured. General linear model was used to
determine circadian and group effect on measured variables (SPSS v.16). Results:
There was a signifcant time effect on marker of bone resorption serum CTX in
TPD group, indicating presence of circadian variation. No circadian rhythm in
serum CTX was observed in patients with PHPT. There was also a signifcant
group effect with the evening TPD group having daytime nadir and nocturnal
peak of CTX. The morning TPD blocked the morning decrease and the night
peak of CTX. Marker of bone formation P1NP showed no circadian rhythm in
any group studied; however, absolute levels of P1NP were higher in patients
treated with evening TPD as compared with either morning dosing regimen or
PHPT. Conclusion: The timing of TPD treatment is able to signifcantly modify
the circadian rhythm in serum CTX in women with postmenopausal
osteoporosis. More pronounced circadian variability in serum CTX and higher
levels of P1NP in the evening dosing regimen suggest that the circadian
fuctuation in bone resorptive activity might be important to stimulate bone
formation.
P122
Primary hyperparathyroidism: laboratory associations and thyroid
pathologies
Kemal Agbaht
1
, Emrah Eraslan
2
, Ozlem Karaarslan
2
& Sevim Gullu
1
1
Department of Endocrinology and Metabolic Diseases, Ankara University
Faculty of Medicine, Ankara, Turkey;
2
Department of Internal Medicine,
Ankara University Faculty of Medicine, Ankara, Turkey.
Background
Diagnosis of primary hyperparathyroidism (PHP) is sometimes challenging and
needs supportive evidence. We aimed to document laboratory fndings (ratio of
calcium clearance to creatinine clearance, ratio of phosphorus clearance to
creatinine clearance, serum chloride to phosphorus ratio, serum alkaline
phosphatase) and thyroid pathologies associated with established PHP that may
provide supplementary clues to the diagnosis.
Methods
We documented all PHP cases diagnosed at our institution during January 2005-
November 2009. We analysed preoperative calcium, phosphorus, creatinine
values (serum and 24-h urine collections), serum albumin, chloride, alkaline
phosphatase, 25(OH)D levels, thyroid function and autoantibodies, and thyroid
ultrasonography records.
Results
One hundred forty-fve (120 (82.8%) women, age 54.114.1 years)) PHP cases
(94 surgically treated (72 solitary adenomas, 4 cases with double adenomas, 16
hyperplasia, 2 carcinomas) and 51 medically treated) were identifed. The ratio of
calcium clearance to creatinine clearance was 1% in 90.1% of all cases, ratio of
phosphorus clearance to creatinine clearance was 10% in 96.7% of all cases,
chloride to phosphorus ratio was 33 in 88% of cases. Serum alkaline
phosphatase levels were elevated in only 29 (20%) of all PHP cases, although it
correlated well (r:0.608, P,0.001) with parathyroid hormone levels. Thyroid
pathology was present in 62.1% cases (Hashimoto thyroiditis 26 (17.9%), Graves
Disease 3 (2.1%), euthyroid nodular goiter 53 (36.6%), toxic nodular goiter 6
(4.1%), papillary carcinoma 2 (1.4%) cases).
Discussion
Elevated ratio of calcium clearance to creatinine clearance, ratio of phosphorus
clearance to creatinine clearance and serum chloride to phosphorus ratio may
support PHP diagnosis. Additionally, thyroid pathologies are present in two third
of PHP cases. All these four parameters may be valuable confrmatory practical
tests in unsure cases.
Cardiovascular endocrinology and lipid metabolism
P123
Interrelation between bone mineral density and lipid prohle in
postmenopausal women
1
& Olga Nishkumay
2
1
2
Lugansk State
Medical University, Lugansk, Ukraine.
Menopause is a special period in women`s life when various physiological
changes occur, for example, dyslipidemia, atherosclerosis, and decrease of BMD.
During menopause, atherosclerosis and osteoporosis develop simultaneously.
This period is typically characterized by increasing frequency of ischemic heart
disease and myocardial infarction. The risk factors including atherogenic
dyslipidemia, insulin resistance, smoking, low physical activity are common
for the development of atherosclerosis and osteoporosis.
In Department of Clinical Physiology and Pathology of Locomotor Apparatus,
Institute of Gerontology AMS Ukraine, 52 women aged 41-82 (average age is
63.969.5) were subdivided into groups based on the duration of posmenopausal
period: I group (n17) - up to 10 years; II group (n17) - 10-19 years; III group
(n18) - 20 and more years. Bone mineral density (BMD) was determined by
means of Dual-energy X-ray absorptiometer 'Prodigy` (GE Medical systems).
Serum total cholesterol (Chol), triglyceride levels (Tr), low-density lipoprotein
cholesterol (LDC), low serum high-density lipoprotein cholesterol (HDC), very
low-density lipoprotein cholesterol (VLDC) were measured.
The results showed a scarce positive correlation between the data of BMD and
lipid profle data in patients of I group; strong negative correlation between Chol
and Z-score of Femur neck (r0.7; P0.002), BMD Femur neck and Chol
(r0.49, P0.04); LDC and BMD Femur neck in II group (r0.5;
P0.03); LDC and Z-score of Femur neck (r0.7; P0.003) and strong
positive correlation between whole data of BMD and atherogenic lipid profle
data in III group: BMD Femur neck and LDC (r0.73; P0.001); BMD Total
body and LDC (r0.58, P0.01); BMD Femur neck and Tr (r0.73;
P0.001); BMD radius UD and Tr (r0.85; P0.0001). The results point to
the necessity of prescribing hypolipidemic treatment to women of II group.
P124
Levels of adiponectin and tumor necrosis factor-alpha in members of
families with familial combined hyperlipidemia
David Karasek, Helena Vaverkova, Milan Halenka, Dagmar Jackuliakova,
Zdenek Frysak, Ludek Slavik & Dalibor Novotny
University Hospital Olomouc, Olomouc, Czech Republic.
Introduction
The aim of this study was to evaluate the plasma levels of adiponectin and tumor
necrosis factor-alpha (TNF-) in asymptomatic, nonsmoking members of families
with familial combined hyperlipidemia (FCH). We investigated the association
between these cytokines and selected risk factors for atherosclerosis, markers of
insulin resistance and infammation.
Methods
Eighty-two members of 29 FCH families were divided into two groups: HL
(probands and hyperlipidemic frst-degree relatives, n47) and NL (normolipi-
demic frst-degree relatives, n35). The control groups - C-HL (n20) and
C-NL (n20) - consisted of sex- and age-matched healthy individuals.
Results
Compared with healthy controls, hyperlipidemic subjects had signifcantly lower
levels of adiponectin (13.024.58 vs 16.195.39 mg/l, P,0.05), there was not
a signifcant difference in levels of TNF- (24.1028.31 vs 21.3320.18 ng/l,
NS). In normolipidemic relatives there were no signifcant differences in
adiponectin (15.772.95 vs 16.534.26 mg/l, NS) or TNF- (25.8834.39 vs
23.6817.38 ng/l, NS) levels. In members of FCH families, a signifcant
negative correlation was found between adiponectin and trigycerides, proinsulin,
C-reactive protein, body mass index, waist circumference. TNF- did not
correlate with any parameters. By using a multiple regression model in
hyperlipidemic subjects, adiponectin was predicted by apolipoprotein B and
C-reactive protein.
Conclusions
Clinically asymptomatic individuals with FCH showed decreased levels of
adiponectin. Adiponectin was negatively associated with markers of insulin
resistance, chronic infammation and visceral obesity. In hyperlipidemic
individuals decreased adiponectin levels were predicted by apolipoprotein B
and C-reactive protein, independently of insulin resistance and obesity.
Supported by grant IGA MZCR NS/10284-3.
P125
Cardiovascular disease and risk factors in patients with type 2 diabetes
in IRAN
Shokoufeh Bonakdaran
1,2
, Sepideh Hejazi Noghabi
1,2
& Saeed Ebrahimzadeh
1,2
1
Mashhad University of Medical Science, Mashhad, Islamic Republic of
Iran;
2
Endocrine and Metabolism Research Center, Mashhad, Islamic
Republic of Iran.
Objective
Cardiovascular disease (CVD) is mainly responsible for the high mortality and
morbidity in type 2 diabetes. The aim of this study was to determine the
prevalence and risk factors of CVD in type 2 diabetes.
Methods
A total of 752 patients were included. History and physical examination were
recorded. Laboratory tests included fasting blood sugar (FBS), glycated
hemoglobin, lipid profle, uric acid, serum creatinine and microalbuminuria. In
patients without history or physical examinations regards to CVD, 12 lead resting
electrocardiogram and exercise stress test was performed.
Results
The prevalence of CVD was 20.1%. It was associated with age (P,0.001),
duration of diabetes (P,0.001), hypertension (P,0.001), diabetic retinopathy
(P0.01), metabolic syndrome (P0.04), renal insuffciency (P,0.001),
triglyceride (P0.02), HDL (P0.04), uric acid (P0.02) and triglyceride to
HDL ratio (P0.04). Using multinomial logistic regression model, age,
metabolic syndrome and HDL were signifcant independent predictors of CVD.
Conclusion
The high prevalence of CVD in Iranian type 2 diabetic patients was found to
highlight the need for more improvement in metabolic risk factors of CVD.
Keywords: CVD, CHD, type 2 diabetes, metabolic syndrome.
P12
The effect of erythropoietin treatment on insulin resistance and
inammatory markers in patients on maintenance hemodialysis
Zorica Rasic-Milutinovic
1
, Marina Vujovic
1
, Gordana Perunicic-Pekovic
2
,
Vesna Popovic
1
, Jelena Tica
1
, Zoran Gluvic
1
, Milena Lackovic
1
&
Ljiljana Bokan
3
1
Zemun-Department of Endocrinology, University Clinical Center,
Belgrade, Serbia;
2
Zemun-Department of Nephrology, University Clinical
Center, Belgrade, Serbia;
3
Zemun-Biochemical Laboratory, University
Clinical Center, Belgrade, Serbia.
Background and aim
Iron overload and infammation might participate in the pathogenesis of insulin
resistance in community. The improvement of insulin resistance in hemodialysis
(HD) patients is frequently seen after correction of anemia. The aim of this study
was to investigate the infuence of recobinant humam erythropoietin (Epo)
treatment on insulin resistance in non-diabetic HD patients.
We investigated the effects of 6 months-duration treatment with Epo on insulin
resistance and infammatory parameters in 16 (6 male/10 female) patients on
maintenance HD with renal anemia (hemoglobin concentration B105 g/l). The
control group consisted of 15 patients on HD with renal anemia, without Epo
treatment. Further clinical and laboratory variables were observed: fasting blood
glucose (FBG), insulin, albumin, iron, total iron binding capacity (TIBC),
transferrin saturation (TSAT), ferritin, TNF-, and IL-6. Independent predictors
for changes of calculated insulin resistance index by homeostasis model
assessment (HOMA-IR) were identifed by multivariate linear regression
analysis.
Results
A signifcant reduction of insulin levels and therefore signifcant lowering of
HOMA-IR was registered in Epo treated group. It was observed improvement of
anemia (Hb 93.9017.34 vs 116.4021.03 g/L, P0.01; Hct 0.28 (0.24-0.31)
vs. 0.33% (0.31-0.37), P0.01) as well as a trend toward iron stores decrease
(ferritin 466.45 (174.40-886.90) vs 279 g/l (137.00-648.50), P0.06). A
signifcant decrease of TNF- (2.30 pg/ml (1.48-2.95) vs 1.65 pg/ml (0.11-1.96),
P0.01) and IL6 levels (8.32 pg/ml (2.31-9.83) vs. 2.60 pg/ml (2.00-3.05),
P0.01) was presented. After adjustment for confounding variables (age, sex,
and Kt/v), a model consisting of BMI, ferittin, and TNF- accounted for 96% of
the variance in HOMA-IR in Epo treated patients.
Conclusions
The present study demonstrated that Epo treatment could participate in reducing
insulin resistance through iron stores reduction and improvement of chronic
infammation in patients on maintenance HD.
P12I
Subjects homozygous for the BCL1 polymorphism of glucocorticoid
receptor gene may have an increased risk for impaired endothelial
function
Kimon Stamatelopoulos
2
, Katerina Saltiki
1,3
, Emily Mantzou
3
,
Paraskevi Voidonikola
2
, Christos Papamichael
2
& Maria Alevizaki
1,3
1
Endocrine Unit, Department of Medical Therapeutics, Alexandra Hospital,
Athens University School of Medicine, Athens, Greece;
2
Vascular
Laboratory, Department of Medical Therapeutics, Alexandra Hospital,
3
Department of
Endocrinology and Metabolism, 'Evgenidion` Hospital, Athens University
School of Medicine, Athens, Greece.
Objectives
Glucocorticoids may affect cardiovascular risk. Polymorphisms in the gluco-
corticoid receptor (GlucR) gene have been associated with increased risk for
cardiovascular disease. We investigated whether the common Bcl1 poly-
morphism of the GlucR gene (associated with increased sensitivity to
glucocorticoids) may be associated with early markers of atherosclerosis.
Methods
Two hundred and fourteen middle aged apparently healthy subjects (age J46.8
8.8, BMI 27.24.8, 45.4% males) attending a preventive medicine program
were examined for unrecognised features of the metabolic syndrome and early
indices of cardiovascular disease. BMI, waist and hip circumference, basal
cortisol levels, insulin, glucose and lipids were measured. A detailed vascular
examination was performed including evaluation of fow mediated dilatation
(FMD) and carotid intima media thickness (IMT).
Results
The prevalence of the Bcl1 polymorphism was 26.6% (52.8% wild type, 41.2%
heterozygous and 6.0% homozygous for the variance). Homozygous subjects had
a signifcantly lower FMD compared to wild type or heterozygous subjects
P0.029). FMD quartiles were calculated. In logistic regression analysis
homozygocity for the Bcl1 polymorphism and LDL levels were the only
parameters that remained signifcant when other confounding factors, which
might infuence FMD such as age, arterial pressure, smoking, were taken into
account. We found that homozygous subjects had a 3.5 higher risk to belong to
the lowest FMD quartile compared to heterozygous or wild type subjects (CI:
1.1-11.5, P0.035). No signifcant differences were found in IMT between
the various genotypes. No differences were found in BMI, WHR, cortisol, insulin,
glucose, lipid levels, HOMA-IR index and arterial pressure between the 3 groups.
Conclusions
The Bcl1 polymorphisms of the GlucR gene may be associated with impaired
endothelial function, which is an early marker of atherosclerosis. This fnding
may imply that increased sensitivity to GC might be implicated in this process.
P128
Leptin and its associations with complications of acute myocardial
infarction in patients with the metabolic syndrome
Kamila Kholmatova
1,2
, Irina Dvoryashina
1
& Tatyana Supryadkina
2
1
Northern State Medical University, Arkhangelsk, Russian Federation;
2
First City Municipal Hospital of Emergency Care, Arkhangelsk, Russian
Federation.
Background
Increased leptin levels are revealed in obese patients and known to predict the
development of the ischemic heart disease, but the information about leptin`s
effects on the course of the acute myocardial infarction (AMI) in patients with the
metabolic syndrome (MetS) is scarce.
Aim
To assess plasma leptin levels in patients with AMI and MetS and to study the
relationships between leptin and early complications of AMI.
Methods
Fifty-nine subjects (84.5% of men, mean age 56.79.0 years) with ST-segment
elevation AMI without diabetes mellitus were included. According to the IDF
criteria 39 patients had MetS. Group differences in patients` clinical and
anthropometrical data, blood level of fasting and postprandial glucose and insulin
during oral glucose tolerance test, held after patients` condition stabilization,
leptin, lipids, C-reactive protein, and echocardiography data were analyzed by
Mann-Whitney and
2
tests. Associations of leptin with occurrence of the
complications during AMI in-hospital period were studied by logistic regression
analysis.
Results
Patients with MetS had signifcantly higher levels of leptin (120.57, 75.89-162.00
vs 44.24, 19.16-76.51 ng/ml; P,0.001), postpload glucose (8.10, 6.30-9.50 vs
6.35, 5.17-6.75 mmol/l; P0.002), basal insulin (11.85, 9.54-20.81 vs 6.74,
5.56-10.26 microIU/ml; P,0.001), systolic blood pressure (SBP) on admission
(140.00, 130.00-160.00 vs 107.50, 90.00-140.00 mmHg; P0.049), while there
were now differences in gender (0.132), age (P0.450), basal glucose
(P0.678), stimulated insulin (P0.062), stimulated/basal insulin ratio
(0.885), and C-reactive protein (P0.981). There were no statistically signifcant
associations between leptin and any of in-hospital complications of AMI in all
patients, including cardiogenic shock (OR0.98; 95% CI0.96-1.01,
P0.197), congestive heart failure (OR1.01; 95% CI0.99-1.01, P0.577),
and low left ventricular ejection fraction (OR1.01; 95% CI0.99-1.01,
P0.966).
Conclusion
Although basal leptin and insulin levels and SBP are abnormally high in patients
with AMI and MetS, leptin is not associated with the early prognosis after AMI.
P129
Obesity and metabolic syndrome during the menopausal transition of
women in Serbia
Teodora Beljic Zivkovic
1
, Marina Andjelic Jelic
1
, Jelena Stojanovic
1
,
Miljanka Vuksanovic
1
, Bogdan Buric
1
, Biljana Jojic
1
, Natasa Milic
2
&
Milena Lazarevic
3
1
Zvezdara University Medical Center, Belgrade, Serbia;
2
Medical Faculty,
Institute for Medical Statistics, Belgrade, Serbia;
3
Sanof-Aventis,
Belgrade, Serbia.
Abdominal obesity and metabolic syndrome are known to increase in prevalence
from premenopause to postmenopause in women. Both are well recognized
predictors of cardiovascular disease and diabetes in women.
The objective of this study was to assess the presence of obesity and metabolic
syndrome during the menopausal transition in women from Serbia.
Methods
Our results present a part of the National epidemiological cross-sectional study
(SEMINAR) that assessed the presence of cardiovascular disease and diabetes in
Serbia. We evaluated the presence of obesity and metabolic syndrome in 1076
women attending six primary and 14 secondary health care centers in Serbia.
Women were divided into 4 groups: premenopausal 35-45 years (n95),
perimenopausal 46-50 years (n105), early postmenopausal 51-55 years
(n176) and late postmenopausal 56-80 years (n700). Endocrinologists
evaluated 40%, cardiologists 26% and general practitioners 34% of women.
Blood glucose, lipids, blood pressure and waist circumference were registered.
Results
Waist circumference over 80 cm was present in 66.3% of premenopausal, 81% of
perimenopausal, 81.8% of early and 88.2% of late postmenopausal women
(P,0.01 premenopausal to other groups). The mean waist circumference of all
women was 92 cm. Mean body mass index (BMI) was 28.5 kg/m
2
. Premeno-
pausal women had a BMI of 26.95.7 kg/m
2
. It was signifcantly smaller than the
BMI of women in other groups (perimenopausal 28.85.6, P,0.05; early
28.65.2, P,0.05 and late postmenopausal 31.95.7 kg/m
2
, P,0.0001).
Metabolic syndrome was present in 72% of women with a signifcant difference
between premenopausal and other groups (P,0.004). In all, 57.9% of
premenopausal, 75.2% of perimenopausal, 77.8% of early and 87.1% of late
postmenopausal women had metabolic syndrome.
Conclusion
Women in Serbia that go to doctors mostly have abdominal obesity and metabolic
syndrome. The prevalence of obesity and metabolic syndrome signifcantly
increases in the age group 46-50 years. This points to perimenopause as the
period of life when preventive measures for diabetes and cardiovascular disease
should be undertaken in women.
P130
The effects of adiponectin gene polymorphisms on the progression
of carotid intima-media thickness
Hyeong Jin Kim
College of Medicine, Kwandong University, Goyang, Republic of Korea.
Background and aims
Previous studies have documented environmental risk factors for the progression
of carotid intima-media thickness (IMT); however, few have examined genetic
risk factors for the progression of carotid IMT and none has specifcally examined
subjects with type 2 diabetes. This study examined the association between single
nucleotide polymorphisms in the adiponectin gene and the progression of carotid
IMT in patients with type 2 diabetes.
We performed common carotid ultrasonography at baseline and 33-39 months
later in 324 consecutive subjects with type 2 diabetes. The genotypes of the
adiponectin gene were determined using a single base primer extension method.
Results
The A allele of 11426A/G (P,0.05), G allele of 10066C/G (P0.001), A
allele of 8564G/A (P,0.01), A allele of 450A/G (P,0.05), and G allele of
276G/T (P,0.01) were associated with progressive carotid IMT. In the haplotype
analysis, the AC/AC haplotype combination in block 1, GAA/GAA haplotype
combination in block 2, and GGA/GAG and GGA/TAG haplotype combinations
in block four of the adiponectin gene were associated with progressive carotid
IMT (P,0.05).
Conclusion
Variation in the adiponectin gene is associated with the rate of carotid IMT
progression and is an important genetic factor for the progression of
atherosclerosis in subjects with type 2 diabetes.
P131
Associations between the metabolic syndrome and bone mineral density
in Ukrainian women in postmenopausal period
1
, Larisa Martynyuk
2
, Mykola Shved
2
,
Nataliia Dzerovych
1
, Volodymyr Vayda
1
& Lilya Martyntyuk
2
1
2
I. Hobachevsky
Ternopil State Medical University, Ternopil, Ukraine.
Objective
The metabolic syndrome (MS), which includes obesity, dyslipidemia, impaired
glucose tolerance, and hypertension, is a major public health problem. The
prevalence of MS among women in postmenopausal period is nearly 24%. In
postmenopausal period the accelerated bone loss, contributing to the development
of osteoporosis begins. Obesity or increased body mass index (BMI) is known to
have a protective effect against osteoporosis. However, recent studies
demonstrated that the MS can raise the risk of osteoporotic fractures. The
purpose of our study was to reveal associations between components of the MS
and BMD in postmenopausal women.
Design and method
The sample consisted of 47 postmenopausal women (age: mean62.1; S.D.1.2;
duration of menopause: mean12.7; S.D1.2). Women were considered to have
the MS (according to IDF (2005 years) criteria) if they had waist circumference
80 cm and two or more of the following abnormalities: hypertriglyceridemia
1.7 mmol/l; low high-density lipoprotein (HDL) cholesterol , 1.29 mmol/l;
high blood pressure 130/85 mm Hg or use of antihypertensive medication; high
fasting glucose 5.6 mmol/l or use of antidiabetic medication (insulin or oral
agents). Total body, lumbar spine, femoral neck, ulna radius bone mineral density
(BMD) measured by dual-energy X-ray absortiometry were compared for the
cohorts with and without the MS. Other parameters including age, weight, height,
waist circumference, the level of glucose, lipids were taken into account. Data
were analyzed using Statistical Package 6.0 (Statsoft).
Results
Findings revealed that 28 (59.6%) of these postmenopausal women had MS. 18
(64.3%) of them had three components of MS, 8 (28.6%) had four components
and 2 (7.1%) had all of them. In patients with and without MS compared, BMD
was lower in the former group at lumber spine (1.010.03 and 1.170.04,
respectively; F10.2; P0.002), femoral neck (0.830.02; 0.970.03,
respectively; F14.6; P0.0004), ulna radius (0.590.02; 0.690.02,
respectively; F13.1; P0.0008), total body (1.030.02; 1.160.02,
respectively; F20.5; P0.00005). Increasing quantity of the MS components
in women during the postmenopausal period had a negative correlation with BMD
at every site. Frequency of osteoporosis (according to WHO (2004 years)
recommendations) was higher at all sites exept femoral neck in patients with MS.
Data is shown in a table.
Conclusion
Development of MS in postmenopausal women increases the risk for the
negative changes in BMD (such as osteopenia and osteoporosis). Furthermore,
postmenopausal women need observation to prevent the development
osteoporotic fractures.
P132
Prevalence of metabolic syndrome in a working population of strategic
services
Gloria Jesus Garcia Domi nguez
1
, Beatriz Sainz Vera
1
, Nuria Alonso Blasi
2
,
Oliva Mera Gallardo
1
, Maria del Mar Cortes Pena
2
& Antonio Ares
Amerino
3
1
Servicio de Medicina Interna, Hospital Universitario, Puerto Real, Cadiz,
Spain;
2
Servicio de Prevencion FREMAP, Cadiz, Spain;
3
Servicio Salud
Laboral CBPC, Cadiz, Spain.
Background
The increased incidence of metabolic syndrome (MetS) is one of the causes of
expansion of Type II diabetes and cardiovascular disease. Persons with Mets have
higher chance of suffering a cardiovascular disease and dying from this cause that
people without this disorder.
The MetS is characterized by glucose intolerance, dyslipidemia, obesity and
hypertension. In certain populations has a high prevalence rate, exceeding 20%.
Objective
Knowing the prevalence of MS in a working population of fre-fghters.
Methodology
Cross sectional descriptive study.
From a workforce of 600 people, analyzed data from health surveillance of a
group and 352 (342 men and 10 women). Year 2009.
Variables were studied: blood glucose, triglycerides, weight, height, body mass
index, abdominal obesity, hypertesion.
For the diagnosis of MetS criteria were followed NCEP-ATP III (Adult Treatment
Panel III. Cholstestrol National Education Program).
Statistical calculations were performed with the program Stagrphics Plus.
Results
The prevalence of MetS was 12.78%. All were male.
Average age: 38.77 years (S.D. 8.27). Glucose: 93.62 mg/dl (S.D 10.52). Total
Cholesterol: 200.17 mg/dl (S.D 36.62). HDL Cholesterol: 51.51 mg/dl (S.D 12.50).
LDL Cholesterol: 125.86 mg/dl (31.34). Weight: 78.58 kg (S.D 10.15). Size:
173.31 cm (S.D 46.03). BMI: 26.23 (S.D 2.97).
They had at least one criterion of MetS 35.79% of the population.
At least two criteria of MetS 20.74% of the population.
Three criteria of MetS 12.78% of the population.
Four criteria for MetS 3.12% of the population.
Five criteria for MetS 0.57% of the population.
Conclusion
The prevalence of MetS in this group of workers is below average in the reference
population.
P133
Are the thyroid functions associated with widespread of acute coronary
syndromes?
Dilek Tuzun
1
, Nihal Akar Bayram
2
, Omer Faruk Cicek
2
, Reyhan Ersoy
1
,
Engin Bozkurt
2
& Bekir Cakir
1
1
Department of Endocrinology and Metabolism, Bilkent, Ankara Ataturk
Education and Research Hospital, Bilkent, Ankara, Turkey;
2
Department of
Cardiology, Ankara Ataturk Education and Research Hospital, Bilkent,
Ankara, Turkey.
Introduction
Serum thyroid hormone levels have been described in several systemic non-
thyroideal illnesses, among them acute heart diseases. The aim of this study was
to investigate the relationship between thyroid functions and widespread of ACS,
and to evaluate the potential changes in thyroid hormone profle in acute coronary
syndromes (ACS) at the time of diagnosis and compare them between two groups,
based on therapeutic implications and distinct prognoses: unstable angina/
non-ST-segment elevation acute myocardial infarction (UA/NSTEMI) and
ST-segment elevation acute myocardial infarction (STEMI).
Material and method
Ninety-four patients admitted to the coronary care unit of our center were
evaluated. Patients were excluded if they were known to have thyroid function
test abnormalities. Coronary artery angiogram was performed in all patients.
Signifcant stenosis was defned as the internal diameter decreased by more than
50%. Groups were re-grouped according to the number of signifcantly stenotic
vessels into normal, 1-vessel, 2-vessel, and 3-vessel diseased groups. Thyroid
functions were evaluated in groups.
Results
There were 67 patients with UA/NSTEMI (46 men, 21 women, and the mean age
60.311.3 years), and 27 patients with STEMI (13 men, 14 women, and the
mean age 64.013.0 years) included. Thyroid hormone levels (thyroid-
stimulating hormone (TSH), free triiodothyronine (fT
3
), free thyroxine (fT
4
))
were compared in UA/NSTEMI and STEMI groups on admission. There were no
signifcant differences between two groups for fT
3
, fT
4
and TSH levels (P0.05).
Also, thyroid functions were not associated with the widespread of coronary
artery disease according to coronary angiography (P0.05).
Conclusion
Thyroid function tests are altered in patients with ACS. The changes are
characterized by euthyroid sick syndrome. However, our results show that the
thyroid functions are not different between UA/NSTEMI and STEMI groups.
Also thyroid functions in acute stage are not seems to be associated with the
widespread of coronary artery disease.
P134
Effects of cross-sex hormone treatment in young transsexual subjects
Oscar Levalle
1
, Alberto Nagelberg
1
, Adrian Helien
2
, Horacio Rey
2
,
German Cheliz
2
, Eduardo Mormandi
1
& Patricia Otero
1
1
Endocrine Division, Durand Hospital, Buenos Aires, Argentina;
2
Urology Division, Durand Hospital, Buenos Aires, Argentina.
Sex differences in the metabolic syndrome and the associated cardiovascular risk
profle are attributed to sex-specifc sex steroid profles, but the effects of sex
steroid treatment remain incompletely understood.
We evaluated the impact of low doses of sex-steroids on cardiovascular risk
parameters in 41 young (age range 19-46 years), healthy, nonobese (BMI ,29),
transsexual subjects. 30 male-to-female (M-F) transsexuals received transdermal
17Betaestradiol (50 ug/day) cyproterone acetate (up to 50 mg/day) and 11
female-to-male (F-M) transsexuals received testosterone-undecanoate (1000 mg
i.m./12 weeks). We analized waist circumference, BMI, serum LH, FSH,
testosterone, oestradiol, SHBG, lipid spectrum, glucose, insulin and HOMA index
at baseline and after 1-year cross-sex hormone administration. The protocol was
approved by the local Ethical Committee.
No changes in the anthropometric variables were detected in both groups. In M-F
transsexuals, oestrogensantiandrogens increased serum HDL-Cholesterol
(P,0.02) without changes in LDL-Cholesterol or triglycerides but the ratio
Chol/HDL-Chol and the HOMA index decreased signifcantly (P,0.02 and
P,0.03, respectively). By contrast, testosterone in M-F transsexuals, reduced
serum HDL-Cholesterol (P,0.03) and increased the Chol/HDL-Chol ratio,
insuline and HOMA index (P,0.02, P,0.04 and P,0.05, respectively). No
major adverse effects were detected.
The cross-sex hormone treatment -with the low-doses regimen used here -
showed that oestrogens in genetically men induced benefcial effects on
cardiovascular parameters. On the other hand, epidemiological studies indicate
an association between male hypogonadism and metabolic syndrome, while the
androgen replacement reverse that profle. However, in our study, testosterone
was detrimental on cardiovascular risk in genetically women.
These results seems to support the hypothesis that oestrogens have benefcial
effects in men and women but the dual action of testosterone (in genetically men
and women) seems to be associated to a gender-specifc effect.
Nevertheless, studies of long-term follow-up are needed to establish the real
prevalence of morbi-mortalitity with these treatments.
P135
Insulin secretion and HOMA-IR in patients who underwent coronary
angiography
Tatjana Isailovic, Milan Petakov, Sanja Ognjanovic, DJuro Macut,
Bojana Popovic, Ivana Bozic, Valentina Elezovic & Svetozar Damjanovic
School of Medicine, Institute of Endocrinology, Diabetes and Metabolic
Diseases, Clinical Centre of Serbia, University of Belgrade, Belgrade,
Serbia.
Introduction
Several population-based studies have shown that hyperinsulinemia and insulin
resistance could be an independent predictive factor for development of coronary
artery disease (CAD).
Aim
The aim of this cross-sectional study was to analyze insulin secretion in patients
with proven coronary artery disease.
Methods
We have analyzed 151 consecutive patients (35-79 years old, men 68%, women
32%) referred for coronary angiography due to suspected myocardial ischemia, as
well as 62 age, sex and BMI matched healthy control subjects. Diabetes mellitus
was excluded in all patients. Severity of CAD was estimated by the number of
affected arteries (one, two or three major epicardial arteries) and by degree of
luminal stenosis (less or more than 50%). Insulin resistance was assessed by
HOMA-IR.
Results
Among those who underwent coronary angiography, 45 (29.8%) had normal
coronary angiogram (NA) while CAD was diagnosed in 106 (70.2%) patients.
More than 50% stenosis was found in 91(85.8%) patient. One artery was affected
in 45(42.5%) patients, two arteries in 25(23.6%) while three arteries were affected
in 36(33.9%) patients. Basal insulin concentration (17.20.9 vs. 18.20.7,
P0.05) as well as HOMA-IR (3.80.2 vs. 4.20.2, P0.05) were not
different in patients with NA and those with CAD. However, control subjects had
signifcantly lower basal insulin and HOMA-IR in comparison to both NA and
CAD (13.95.5 and 2.90.1, P,0.01, respectively). There was no correlation
between the number of affected arteries and insulin concentration and HOMA-IR.
Conclusion
Similar clinical presentation and the level of insulin resistance in patients who
underwent coronary angiography do not necessarily means the same pathological
substrate.
P13
Serum ferritin and risk of the metabolic syndrome in cross-sex
hormone-treated transsexuals
Antonio Becerra Fernandez
1,4
, Gilberto Perez Lopez
2
, Miriam Menacho
3
,
Mari a Jesus Lucio Perez
1
, Nuria Asenjo Araque
1
, Jose Miguel Rodriguez
Molina
1
& Jose Luis Llopis Agelan
5
1
Gender Dysphoria Unit, Department of Endocrinology, Hospital Ramon y
Cajal, Madrid, Spain;
2
Department of Endocrinology, Hospital Ramon y
3
Department of Biochemistry, Hospital Ramon y
4
Universidad de Alcala Madrid, Spain;
5
Universidad
Complutense, Madrid, Spain.
Moderately elevated body iron stores may be associated with several components
of the metabolic syndrome (MetSyn). Elevated serum ferritin levels (Fer)
independently predicted incident type 2 diabetes in prospective studies in
apparently healthy men and women.
Aims
To analyze the association between Fer and components of MetSyn in
transsexuals before and after 2-year cross-sex treatment (CST).
Methods
Before starting the CST in 90 transsexuals (54 male-to-female (MFTs) and 36
female-to-male transsexuals (FMTs)), aged 30.69.0 years, we analyzed the
relations between Fer and several parameters of insulin resistance (IR) (serum
insulin, HOMA-IR and QUICKI) and components of MetSyn (waist
circumference (WC), systolic (SBP) and diastolic blood pressure (DBP), and
serum levels of glucose (G), triglycerides (TG) and HDL-cholesterol (HDL)) by
ATP III criteria. To analyze the effect of CST on Fer we compared the basal
values with those after 2-year treatment with conjugated estrogen (3.75 mg/day)
and cyproterone acetate (100 mg/day) in MFT and testosterone gel (50 mg/day)
in FMT.
Results
Baseline Fer was signifcantly correlationed with HOMA-IR and QUICKI
(r0.242, P0.014; and r0.330, P0.016, respectively), and with those of
WC, G, DBP, TG and HDL, but not with those of SBP or insulin. After treatment,
in MFTs the Fer increased from 104.960.9 to 151.085.3 ng/ml (P0.001)
and in FMTs decreased from 41.553.6 to 39.648.6 ng/ml (P0.001).
Conclusion
In our study the Fer is associated with IR markers and components of MetSyn. So,
the transsexual patients are at risk of diabetes mellitus and cardiovascular disease.
In MFTs the CST increased this risk due to the elevation in Fer, and on the
contrary in FMTs the CST decreased this risk due to the fall in Fer.
P13I
FABP4 inhibitor strongly depresses cardiac function
Valeria Lamounier-Zepter
1
, Christiane Look
1
, Stefan Bornstein
1
&
Ingo Morano
2
1
University of Technology Dresden, Dresden, Germany;
2
Max-Delbruck-Center for Molecular Medicine, Berlin, Germany.
Adipocyte fatty acid binding protein (FABP4) is emerging as a novel risk marker
for metabolic syndrome and atherosclerosis. In this context we recently showed
that FABP4 released by human adipocytes suppresses cardiomyocyte contraction,
thus suggesting a pathogenic role for FABP4 in the cardiac dysfunction in obesity.
Since a new FABP4 inhibitor which competitively inhibits the binding of
endogenous fatty acids to FABP4 was effective in the treatment of atherosclerosis
and diabetes mellitus in mouse models, we investigated the cardiac effect of this
FABP4 inhibitor using isolated cardiomyocytes and heart preparations in a
Langendorff system. FABP4 inhibitor depresses cardiomyocyte contraction
in vitro without attenuating Ca
2
-levels. The inotropic negative effect of FABP4
inhibitor was concentration-dependent at a maximal effective concentration of
500 nmol/l. In Langendorff heart preparations, FABP4 inhibitor induced a
dramatic effect on cardiac contractility leading to asystoly expressed by a total
breakdown of left ventricular pressure after a small period of irregular cardiac
contraction, without interfering in the electrocardiographic activity. Thus, FABP4
may be a novel therapeutic target for treating metabolic and cardiovascular
complications of metabolic syndrome although other inhibitors lacking this
dramatic deleterious effect on cardiac function must be developed.
P138
Calculation of cardiovascular risk in hrehghters
Oliva Mera Gallardo
1
, Beatriz Sainz Vera
1
, Nuria Alonso Blasi
2
,
Gloria Jesus Garci a Domi nguez
1
, Mari a del Mar Cortes Pena
2
& Antonio Ares Camerino
3
1
Servicio de Medicina Interna, Hospital Universitario, Puerto Real, Cadiz,
Spain;
2
Sociedad de Prevencion, FREMAP, Cadiz, Spain;
3
Servicio Salud
Laboral, CBPC, Cadiz, Spain.
Background
Cardiovascular disease (CVD) is the major cause of premature mortality
throughout the western world and a major cause of disability. Most cases of
CVD are related to lifestyle behaviors, biochemical and physiological factors
modifable. The modifcation of cardiovascular risk has shown its ability to reduce
mortality and morbidity from CVD, particularly in high-risk subjects.
Objective
Measuring cardiovascular risk at 5 and 10 years in a working population of
fre-fghters.
Method
Cross sectional descriptive study.
Of a population of 600 workers was carried out cardiovascular risk measurement
to a group of 352 (342 men and 10 women). Year 2009.
Following the recommendations of the European Guidelines on Cardiovascular
Disease Prevention in Clinical Practice 2008, SCORE model was used to
calculate the risk (age, sex, systolic blood pressure, total cholesterol, HDL
cholesterol, diabetes and smoke).
Results
The average age in the study population was 38.77 years (S.D. 8.27). The 97.16%
were men. The 19.89% were smokers, with an average of 12.67 cigarettes/day.
SBP raised the 25.28% of the 17.01% high blood glucose elevated total
cholesterol 49.43%, low HDL cholesterol, 17.61%.
The average 5-year cardiovascular risk was 2.03%, and 10-year 4.59%.
The distribution of risk s discussed in the following Table:
P139
Echocardiographic epicardial fat thickness in acromegaly patients
Gulsum Gonulalan
1
, Mustafa Ozbek
2
, Evrim Cakir
2
, Nujen Colak
2
,
Erman Cakal
2
& Tuncay Delibasi
2
1
Department of Internal Medicine, Ankara Diskapi Training and Research
Hospital, Ankara, Turkey;
2
Department of Endocrinology and
Metabolism, Ankara Diskapi Training and Research Hospital, Ankara,
Turkey.
Objective
Acromegaly is associated with increased morbidity and mortality, mostly due to
cardiovascular complications. The objective of the present study was to evaluate
the echocardiographic epicardial fat thickness in acromegaly patients.
Methods and results
We evaluated 25 consecutive patients with acromegaly (15 females, 10 males,
mean age 44.510.1 years), and 22 age-matched control subjects (12 females, 10
males, mean age 37.407.5 years). LVEDD (left ventricular end diastolic
diameter) was signifcantly elevated in acromegaly patients when compared with
control subjects, 4.700.30 cm, and 4.400.20 cm, respectively (P,0.011).
LVESD (left ventricular end systolic diameter) was signifcantly elevated in
patients with acromegaly when compared in control subjects, 2.900.20 cm, and
2.600.20 cm, respectively (P,0.012). IVS (interventricular septum) parameter
was signifcantly elevated in acromegaly patients when compared with control
subjects 1.010.12 cm, and 0.890.80, respectively (P,0.001). Epicardial fat
thickness was signifcantly elevated in acromegaly patients when compared with
control subjects, 0.610.19 cm, and 0.300.11 cm, respectively (P,0.001).
Conclusions
Patients with acromegaly have an increased risk of death from cardiovascular
disease. Epicardial fat thickness was signifcantly elevated in patients with
acromegaly. Epicardial fat thickness may be a possible cardiovascular risk factor
in acromegaly. Further studies are required to investigate the relation between the
value of epicardial fat thickness and the development of cardiac pathologies in
patients with acromegaly.
P140
Atrial natriuretic peptide (ANP) attenuates lipid peroxidation in
anesthetized atherosclerotic male rabbits by reduction of renin-
angotensin-aldosterone system (RAAS) activity
Konstantinos Kallaras
1
, Michael Karamouzis
2
, Vassiliki
Stergiou-Michailidou
1
& Thomas Zaraboukas
3
1
Department of Experimental Physiology, Faculty of Medicine, Aristotle
University, Thessaloniki, Greece;
2
Department of Biological Chemistry,
Faculty of Medicine, Aristotle University, Thessaloniki, Greece;
3
Department of Pathology, Faculty of Medicine, Aristotle University,
Thessaloniki, Greece.
Reactive oxygen species (ROS) are involved in the pathogenesis of athero-
sclerosis. Atrial natriuretic peptide (ANP) reduces thioredoxin in heart failure
patients, whereas adrenomedullin, acting as an antioxidant, protects rat
cardiomyocytes from infarction and mouse vascular smooth muscle cells from
angiotensin II (AII) oxidative effect. Besides AII, aldosterone (Aldo) is also an
activator of ROS. Aim of the study was the investigation of the eventual
antioxidant effect of ANP on lipid peroxidation in male normal and cholesterol-fed
(2% cholesterol-loaded feeding for 4 weeks) anesthetized (under urethane) New
Zealand White rabbits. Blood samples for lipids, ANP, plasma renin activity
(PRA), Aldo and 8-iso-prostaglandin-F
2
(8-iso-PGF
2
) were taken from
cannulated right jugular vein. Rabbits were classifed into two main groups:
normal and hyperlipidemic. Each group`s individuals were divided into two
subgroups of fve animals each. Blood samples for hormones measurement (by
RIA) and 8-iso-PGF
2
(by enzyme-immunoassay) were taken at 0 min and 20, 40,
60 min following an intravenous (iv) 20-min administration of either 0.2 g/kg
per min hANP in 5 ml normal saline or only 5 ml saline. Rings of ascending aorta
were taken for histology. Mild to moderate atherosclerosis was found. The results,
analyzed by paired t-test and repeated measures ANOVA, demonstrated that
plasma 8-iso-PGF
2
was reduced (P,0.05) at 40 and 60 min after ANP
administration only in atherosclerotic rabbits. This reduction was coincident in
these animals to a fall (P,0.05) of PRA at 20 min and Aldo at 40 and 60 min.
There was a negative correlation between ANP and Aldo levels (r 0.28,
P,0.01) and a positive correlation between Aldo and 8-iso-PGF
2
(r0.3,
P,0.01). These results demonstrate that ANP (administered iv in a dose
suffcient for achieving plasma levels 3fold the basal) attenuates lipid
peroxidation in the presence of mild to moderate atherosclerosis, by reduction
of RAAS activity.
P141
Serum IGF1 levels correlate to improvement of functional indepen-
dence after ischemic stroke
Daniel Aberg
1
, Katarina Jood
2
, Christian Blomstrand
2
, Christina Jern
3
,
Claes Ladenvall
3
, Michael Nilsson
2
, Jorgen Isgaard
1
& David Aberg
1
1
Department of Internal Medicine, Sahlgrenska University Hospital,
University of Gothenburg, Gothenburg, Sweden;
2
Department of
Neurology, Insitute of Physiology and Neuroscience, University of
Gothenburg, Gothenburg, Sweden;
3
Department Clinical Genetics, Insitute
of Physiology and Neuroscience, University of Gothenburg, Gothenburg,
Sweden.
Context and objective
GH and IGF1 both have neuroprotective and regenerative effects in experimental
stroke. Our aim was to investigate whether the endogenous serum-IGF1 (s-IGF1)
levels were correlated to recovery of functional independence in stroke patients.
The analysis of s-IGF1 was performed in 400 patients of both sexes, aged 18-69
years old, and 40 controls previously included in the Sahlgrenska Academy Study
on Ischemic Stroke (SAHLSIS) study. Recovery after ischemic stroke was
evaluated by the modifed Rankin scale (mRS) and the Scandinavian stroke scale
(SSS). Serum samples were collected at two occasions: subacutely (approxi-
mately 4 days) and 3 months after stroke.
Results
s-IGF1 increased and reached a plateau 3-5 days after stroke (P,0.05) and
s-IGF1 were lower in the elderly patients. Subacute s-IGF1 and 3-month s-IGF1
were both correlated to improvement in mRS between 3 months and 2 years
(P,0.01 and P,0.001 respectively).
Conclusions
A high s-IGF1 in the rehabilitation phase of stroke correlate to better recovery of
functional independence.
P142
Insulin mediates the glucagon-induced decrease in atrial natriuretic
peptide: a randomized controlled trial
Ayman Arafat
1
, Natalia Rudovich
1
, Aikaterini Adamidou
1
, Joachim
Spranger
1
, Martin Weickert
1,2
, Matthias Mohlig
1
& Andreas Pfeiffer
1
1
Department of Endocrinology, Diabetes and Nutrition, Charite-University
Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany;
2
Warwickshire Institute for the Study of Diabetes, Endocrinology and
Metabolism, University Hospitals Coventry and Warwickshire,
Coventry, UK.
Objectives
Atrial natriuretic peptide (ANP) is a cardiac hormone that is known to play an
essential role in regulation of blood pressure and vascular endothelial function.
However, the metabolic regulation of ANP is not fully understood. In patients
5 Years 10 Years
Low risk 348 (98.86%) 320 (90.91%)
Medium risk 4 (1.14%) 18 (5.11%)
High risk 0 14 (3.98%)
suffering from metabolic syndrome hypertension, hyperinsulinemia and
postprandial hyperglucagonemia are common features. It was the aim of the
present study to evaluate the impact of glucagon on proANP and the possible
mechanisms underlying this effect.
Methods
We studied the endocrine and metabolic responses to intramuscular glucagon or
placebo administration in 13 patients with type 1 diabetes mellitus (DM1) (6/7
males/females; BMI 24.80.95 kg/m
2
), in 14 lean (LS) (6/8; 21.60.5 kg/m
2
)
and in 12 obese healthy subjects (OS) (6/6; 33.91.6 kg/m
2
).
Results
Age, fasting glucose, glucagon and proANP levels were comparable between
groups.
Glucagon signifcantly decreased proANP in LS (proANP-AUC240: 205.82.6
(glucagon) vs 245.89.2 (placebo), P,0.001) and OS (203.44.8 vs 226.6
6.9, P,0.001) but failed to affect proANP concentrations in DM1
(P0.737).
After glucagon administration, glucagon levels increased in all study groups and
were comparable between groups. Insulin levels increased in LS and OS
(P,0.001) and were comparable between both groups, whereas no signifcant
change in insulin in DM1 was observed (P0.05).
Conclusions
We show that glucagon signifcantly decreases proANP in both lean and obese
healthy subjects, but fails to affect it in type 1 diabetic patients pointing out to the
role of insulin in mediating this effect.
P143
Osteopontin, adiponectin and peripherical arterial disease in patients
with type 2 diabetes
Maria Belovici, Jean-Marie Ketelslegers & Martin Buysschaert
Cliniques Universitaires, 'Saint-Luc`, Bruxelles, Belgium.
Objective
Osteopontin (OPN) is a proinfamatory cytokine involved in the pathogenesis of
insulin resistance and atherosclerosis. Adiponectin (ADP), an adipocyte-derived
vasoactive and insulin-sensitizing peptide, exerts anti-infamatory and anti-
atherosclerotic effects on endotheliocytes. We aimed at determining in type 2
diabetes patients the relationship between serum OPN, serum ADP and either
lower-limb atherosclerotic peripheral arterial disease (PAD) and/or mediacalci-
nosis (MC).
Serum OPN and ADP were determined in 60 adult patients with type 2 diabetes
using an ELISA method. Patients were divided into three groups: group 1:
PAD()/MC() (n19); group 2: PAD()/MC() (n18); and group 3:
PAD(/)/MC() (n23).
Results
Serum OPN and ADP were signifcantly increased in group 3 (patients with
mediocalcinosis) versus group 2 (atherosclerosis) or group 1 (without
macrovascular disease) (Table).
There were no signifcant correlations between osteopontin and HBA1c nor
HOMA insulin sensitivity of B-cell function. Signifcant correlations were found
between serum OPN and homocysteine (P0.04), serum adiponectin (P0.03)
and estimated glomerular fltration rate (Cockcroft-Gault`s formula; P0.03).
Conclusion
Among type 2 diabetic patients, the circulating levels of both osteopontin and
adiponectin were signifcantly increased in patients with lower-limb mediacalci-
nosis compared to those free of both peripheral arterial disease and
mediacalcinosis or presenting only with lower-limb atherosclerosis.
P144
Clinical approach to hypertensive patients: matter of trust between
doctor and patient
P Pavlovic
1
, Zoran Hajdukovic
2
, Dragana Bubanja
3
& Aleksandra Jovelic
4
1
Clinic of Cardiology Military Medical Academy, Belgrade, Serbia;
2
Clinic
of Endocrinology Military Medical Academy, Belgrade, Serbia;
3
Center of
Endocrinology, Kragujevac, Serbia;
4
Institute for Cardiovascular Diseases,
Sremska Kamenica, Serbia.
What happens if the prescribed medication makes the patient 'worse` than he was
before comint to the doctor? Putting aside the world wide accepted JNC
clasiffcation of hypertension, we colud consider the following:
The 'cat-walk` (moderate) hypertension (,150/95 mmHg) 2. Pts with serious
hypertension with symptoms 3. Pts with seerious hypertension without symptoms.
Having moderate hypertension and no side effeects of the disease, pts from the
frst group wil listen to the doctor, take medications as prescribed, come to regular
check-ups and feel fne, mostly because they having no symptoms at the frst
plase, except for the doctor`s conclusion that they condition is fne. The result:
both sides satisfed.
Pts from the second group decide to come to the doctor and start prescribed
therapy their dreadfull symptoms will be gone with normalised blood pressure.
The result: both sides are satisefed.
Pts from the third group are most diffcult to deal with. Over months/years, their
cardiovascular system has got adopted to register abnormal blood pressure as
'normal` so they have no symptoms.Once starting taking prescribed medication
the blood pressure will normalise and such pts will paradoxlly feel worse despite
the fact that their blood pressure condition is improved. The result.: satisfed
doctor and a very unsatisfed and still 'ill` patient. Also, these pts tend to not to
take medications because that paradoxslly makes them feel 'better`. The only
solution for this 'hard core` group is to have extreme patience in persuading them,
over and over, again, explaining that it takes some time for their body to recognise
and adopt that the normal state is 'really normal`. It takes a lot of time and
perssuasion but the fnal result is: Both sides satisfed.
P145
Ligands of receptor for advanced glycation end-products in stable
coronary artery disease: their potential contribution to atherogenesis
exceeds beyond diabetes mellitus
Justyna Kuliczkowska-Plaksej
1
, Wlodzimierz Bednorz
1
,
Grazyna Bednarek-Tupikowska
1
, Rafal Plaksej
2
, Roksolana Derzhko
2
,
Adam Spring
2
& Andrzej Milewicz
1
1
Department of Endocrinology, Diabetology and Isotope Treatment,
Wroclaw Medical University, Wroclaw, Poland;
2
Department of
Cardiology, Wroclaw Medical University, Wroclaw, Poland.
Receptor for advanced glycation end-products (RAGE) signalling, crucial for
diabetic macroangiopathy, is also highly suspected to be involved in
atherogenesis in the setting of preserved glucose metabolism.
Aim
To determine the relationships between peripheral blood concentrations of RAGE
agonists, namely amfoterin (HMBG1) and carboxy-methylo-lisine (CML) as well
as RAGE inhibitor Endogenously Secretory RAGE (esRAGE), and the severity of
atherosclerosis in coronary arteries in patients (pts) with stable coronary artery
disease (CAD).
Methods
A total of 84 pts aged 569.2 years (43 males, 30 pts with diabetes mellitus
/DM/) were classifed as one-, two- or three-vessel CAD (n32, n31 and
n21, respectively) based on coronary angiography. Atherosclerotic lesions
were also evaluated according to Sullivan`s score. HMBG1, CML and esRAGE
were measured using ELISA tests. The control group comprised 43 healthy
counterparts.
Group 1 Group 2 Group 3
Serum OPN (ng/ml) 337 (134-841) 340 (140-1154) 558 (140-2289)*
Serum ADP (ng/ml) 3787 (1364-12 500) 4244 (1480-6967) 5812 (3491-25 000)**
Median values (interquartile range).
*Group 3 versus, group 1 0.024, group 3 versus group 2 0.05.
**Group 3 versus group 1 0.002, group 3 versus group 2 0.006.
TabIe ndependent correlates of coronary atherosclerosis.
1-,2-,3-vesseI
CAD;
2
0.44
Stenosis score;
2
0.46
Extend
score;
2
0.59
Male gender 0.19; ,0.01 NS 0.27; ,0.001
Hypertension 0.27; ,0.001 0.21; ,0.01 0.16; ,0.02
DM NS NS 0.15; ,0.03
HMBG1 0.39; ,0.0001 0.51; ,0.0001 0.44; ,0.0001
esRAGE NS 0.26; ,0.001 NS
NS, non signifcant
Results
The levels of HMBG1 and CML were higher (P,0.05 and P,0.01, respectively)
and esRAGE was lower (P,0.001) in CAD pts than in the controls. In
multivariate analyses, HMBG1 and esRAGE were among independent correlates
of parameters describing the severity of coronary atherosclerosis regardless the
presence of DM (Table).
Conclusions
In pts with stable CAD (1) RAGE ligands concentrations are altered and (2)
signifcantly associated with the extension of coronary atherosclerosis, thus
underlining the notion of RAGE axis contributing to atherogenesis in general
population.
P14
Acromegaly and endothelial dysfunction: is there any relation between?
Adina Simona Dragomir, Corin Badiu, Irina Popescu, Adina Ghemigean,
Catalina Boanta & Constantin Dumitrache
'C. I. Parhon` National Institute of Endocrinology, Bucharest, Romania.
Objectives
Endothelial dysfunction has been described as a predictor of cardiovascular
complications. Most important cause for early mortality in acromegaly is
cardiovascular involvement, cut-off nadir GH ,2.5 ng/ml predicting longer
survival The aim of our study was to determine the correlations between
endothelial dysfunction and GH oversecretion, associated or not with other
cardiovascular risk factors.
Design and method
Cross-sectional study including 31 active acromegalic patients aged 42.88.66
years (20 women and 11 men) referred to 'C.I.Parhon` National Institute of
Endocrinology. All subjects were evaluated for cardiovascular risk factors (BMI,
smoking, high blood pressure, dyslipidemia, diabetes mellitus), for nadir GH
during 75 g glucose OGTT and IGF1 oversecretion. All the risk factors were used
to calculate the cardiovascular risk by Framingham Risk Score. Endothelial
dysfunction was calculated by ultrasound assessment of endothelial dependent
fow mediated vasodilation of brachial artery (FMD%,10%). Considering GH
oversecretion, patients were divided into 2 groups: GH ,2.5 ng/ml (eight
patients), respectively GH 2.5 ng/ml (23 patients).
Results
There was no statistical difference between men and women regarding the
cardiovascular risk score and prevalence for cardiovascular risk factors except
smoking for men (P,0.05). Endothelial dysfunction (11 patients) was correlated
with the history of hypertension (5 years) (P,0.05), systolic blood pressure
(160 mmHg) (P,0.05) and diabetes mellitus (P,0.05) and was not correlated
with nadir GH (P0.08). Only high Framingham Risk Score was correlated with
endothelial dysfunction (P,0.05).
Conclusions
Endothelial dysfunction, an end point for atherosclerosis, can provide incremental
beneft in risk stratifcation for patients at high cardiovascular risk. This approach
could help clinicians to initiate preventive treatment and to evaluate the benefts
in a short period of time just retesting endothelial dysfunction by ultrasound fow
mediated vasodilation.
P14I
Gender variations of serum Paraoxonase-1 activities in healthy young
men and women: association with carotid intimae media thickness
Dilek Gogas Yavuz, Ozlem Tarcin, Palmet Gun, Onder Sirikci &
Sema Akalin
Marmara University School of Medicine, Istanbul, Turkey.
Aim
Paraoxonase-1 (PON-1), an HDL-associated enzyme has been shown to possess
antioxidant properties that protect against atherosclerosis. The aim of this study is
to evaluate serum paraoxanase activities, lipid profles and carotid intimae media
thickness (CIMT) as an early marker of atherosclerosis in healthy man and
women.
Method
Four hundred healthy volunteers (F/M: 250/150, 19-23 years) included in the
study. Serum paraoxonase and arylesterase activities, lipids and Apo a levels were
measured. CIMTwas evaluated with Doppler ultrasonography.
Results
Biochemical parameters are shown at the Table 1.
CIMT measurement was signifcantly higher in man (0.4600.02 cm) compared
to women (0.4500.02 cm, P0.006). Body mass index was lower in women
(20.83.4 kg/m
2
) than man (23.54.1 kg/m
2
) (P,0.001). Serum paraoxonase
activity was positively correlated with arylesterase (r0.31, P,0.001) and HDL
levels (r0.14, P0.03), negatively correlated with CIMT (r16, P0.03)
in women. Arylesterase activity was positively correlated with HDL levels
(r0.14, P0.04) in women. In men paraoxonase activity showed signifcant
correlation with arylesterase activity (r0.20, P,0.01) but not with CIMT.
Conclusion
A Serum PON-1 activity varies between young man and women. PON-1 activities
against different substrates and mass of the enzyme need to be studied for
antioxidant properties of PON-1 enzyme.
P148
Searching for the metabolic syndrome criteria in young adults with
hypogonadism
Alper Sonmez
1
, Cem Haymana
2
, Erol Bolu
1
, Serkan Tapan
3
, Cem Barcin
4
,
Aydogan Aydogdu
1
, Abdullah Taslipinar
1
& Mustafa Kutlu
1
1
Department of Endocrinology and Metabolism, Gulhane School of
Medicine, Ankara, Turkey;
2
Department of Internal Medicine, Gulhane
School of Medicine, Ankara, Turkey;
3
Department of Biochemistry,
Gulhane School of Medicine, Ankara, Turkey;
4
Department of Cardiology,
Gulhane School of Medicine, Ankara, Turkey.
Introduction
The evidence shows that the prevalence of metabolic syndrome is increased in
patients with hypogonadism. However, much of the data regarding this
association comes from the elderly patients with obesity, hypertension or type
2 diabetes. The total testosterone levels alter physiologically in these conditions
and thus can falsify the association. We aimed to investigate the prevalence of the
metabolic syndrome in young adults with hypogonadism who do not have any
confounders.
Methods
A retrospective design was performed. The demographic data and the laboratory
values of the 318 hypogonad men (age: 21.682.09 years, BMI: 21.93
3.1 kg/m
2
) were compared with those of 1089 healthy volunteers matched
for age (21.391.49 years) and BMI (22.041.6 kg/m
2
).
Results
The patients had higher waist circumferences, systolic and diastolic blood
pressures, triglycerides (P,0.001 for all), total cholesterol (P0.02), LDL
cholesterol (P0.03) and lower HDL cholesterol levels (P0.001) than the
controls. Blood glucose levels of the two groups were similar.
Conclusion
Although the waist circumferences, blood pressures and lipid profles of the
young adults with hypogonadism do not fulfll the metabolic syndrome criteria,
they are signifcantly different from those of the healthy young adults. Whether
this profle poses an increased cardiovascular risk in this population, merits
further investigation.
TabIe 1 Biochemical parameters of the study groups.
Women (d:250) Men (d:150)
Paraoxonase
activity (U/l)
239.4 266.6 0.08
Arylesterase
activity (U/l)
90 287 102 757 0.008
Triglyceride
(mg(dl)
59.6 85.9 ,0.0001
HDL (mg/dl) 58.5 47.3 ,0.0001
LDL (mg/dl) 84.4 94.4 0.0002
VLDL (mg/dl) 11.9 16.2 ,0.0001
Apo a (g/l) 1.38 1.17 ,0.0001
Patients (d318) ControI (d1089)
Waist circumference (cm) 81.6010.7 77.065.2 ,0.001
Arterial BP (mmHg) 114.1811.2/ 73.688.5 107.6611.2/ 68.029.58 ,0.001
HDL-Chol. (mg/dl) 45.2310.6 47.279.39 0.001
Triglyceride (mg/dl) 102.3048.7 82.6629.9 ,0.001
Fasting glucose (mg/dl) 85.607.97 85.787.04 0.74
P149
Low testosterone is associated with an increased risk of MACE lethality
in subjects with erectile dysfunction
Giovanni Corona
1,2,5
, Matteo Monami
3,5
, Valentina Boddi
1,5
,
Alessandra Fisher
1,5
, Giulia De Vita
1,5
, Cecilia Melani
4,5
, Daniela Balzi
4,5
,
Alessandra Sforza
2,5
, Gianni Forti
1,5
, Edoardo Mannucci
3,5
&
Mario Maggi
1,5
1
Andrology Unit, University of Florence, Florence, Italy;
2
Endocrinology
Unit, Maggiore_Bellaria Hospital, Bologna, Italy;
3
Diabetes Section
Geriatric Unit, University of Florence, Florence, Italy;
4
Epidemiological
Unit, Azienda Sanitaria Locale 10, Florence, Italy;
5
Endocrinology Unit,
University of Florence, Florence, Italy.
Introduction
Although testosterone has been suggested to play a protective role against the
development of atherosclerosis, studies demonstrating an association between
low testosterone, and incident major adverse cardiovascular events (MACE) are
scanty in the general population and absent in subjects with erectile dysfunction
(ED). The aim of this study is to investigate whether low testosterone in subjects
with ED predict incident fatal or non fatal MACE.
Methods
This is an observational prospective cohort study evaluating a consecutive series
of 1687 patients attending our Andrological Unit for ED. Patients were
interviewed using SIEDY and ANDROTEST structured interviews measuring
components relative to ED and hypogonadal-related symptoms, respectively.
Total testosterone was evaluated at baseline. Information on MACE was obtained
through the City of Florence Registry Offce.
Results
Among the patients studied 5.2, 13.8 and 22.4% were hypogonadal according to
different thresholds (testosterone ,8, 10.4 and 12 nmol/l or 230, 300 and
350 ng/dl, respectively). During a mean follow-up of 4.32.6 years, 139 MACE,
15 of which were fatal, were observed. Unadjusted incidence of MACE was not
associated with T levels. Conversely, the proportion of lethal events among
MACE was signifcantly higher in hypogonadal patients, using either 10.4 nmol/l
(300 ng/dl) or 8 nmol/l (230 ng/dl) thresholds. However, after adjustment for age
and Chronic diseases score in a Cox regression model, only the association
between incident fatal MACE and testosterone ,8 nmol/l (230 ng/dl) was
confrmed (HR7.1 (1.8-28.6); P,0.001). Interestingly, measuring hypogona-
dal-related symptoms and signs through ANDROTEST, only fatal MACE were
also associated with a higher score (HR1.2 (1.0-1.5) for each ANDROTEST
score increment; P0.05 after adjustment for age and Chronic diseases score).
Conclusions
Testosterone levels are associated with a higher mortality of MACE. The
identifcation of low testosterone levels should alert the clinician thus identifying
subjects with an increased cardiovascular risk.
P150
Genetic polymorphisms associated with cardiovascular risk correlate
with dyslipidaemia in healthy postmenopausal women
Dimitra Papadimitriou
1
, George Kaparos
2
, Dimitrios Rizos
2
, Eleni Armeni
1
,
Maria Creatsa
1
, Andreas Alexandrou
3
, George Christodoulakos
1
&
Irene Lambrinoudaki
1
1
2nd Department of Obstetrics and Gynecology, Aretaieio Hospital,
University of Athens, Athens, Greece;
2
Hormonal and biochemical
Laboratory, Aretaieio Hospital, University of Athens, Athens, Greece;
3
1st Department of Surgery, Laiko Hospital, University of Athens Medical
School, Athens, Greece.
Objective
To assess the impact of genetic polymorphisms associated with increased
cardiovascular risk on the lipid profle in healthy postmenopausal women.
Methods
The study population consisted of 84 women between 49-69 years who had been
menopausal for at least one year. The genetic polymorphisms examined were the
following: Glycoprotein IIIa leu33pro, Apolipoprotein E2/E3/E4, Methylenote-
trahydrofolate reductase ala222val, Apolipoprotein B arg3500gln, Paraoxonase 1
gln192arg, Plasminogen activator inhibitor 1 4G/5G, cholesterol 7 alpha
hydroxylase A-204C and cholesterol ester transfer protein (TaqIB) B1/B2
polymorphism. Biochemical markers assessed were the following: Total
cholesterol (TC), low-density Lipoprotein (LDL), high-density Lipoprotein
(HDL), triglycerides (TGL), Apolipoprotein A (ApoA), Apolipoprotein B
(ApoB) and Lipoprotein (a) (Lp(a)). Written informed consent was obtained by
all participants. The local Institutional Review Board has approved the present
study.
Results
Cholesterol ester transfer protein (TaqIB) B1/B2 polymorphism associates with
low levels of HDL and ApoA (P0.001, P0.0001 respectively), while
Glycoprotein IIIa leu33pro polymorphism is associated with suppressed levels of
ApoB (P0.019). A statistically signifcant positive association was observed
between Apolipoprotein B arg3500gln polymorphism and levels of total
cholesterol (P0.032) and HDL cholesterol (P0.048). Additionally, plasmino-
gen activator inhibitor 1 4G/5G polymorphism was marginally associated with
increased levels of triglycerides (P0.058).
Conclusions
The presence of certain polymorphisms predisposes postmenopausal women to
dyslipidaemia. Cholesterol ester transfer protein (TaqIB) B1/B2 polymorphism
favours dyslipidaemia, while Glycoprotein IIIa leu33pro polymorphism has a
positive impact on lipid profle in women after menopause. Apolipoprotein B
arg3500gln polymorphism associates ambiguously with the lipid profle in
postmenopausal women. Further studies are required to elucidate the signifcance
of these genetic polymorphisms with respect to dyslipidaemia in postmenopausal
women.
P151
Is obesity a further cardiovascular risk factor in patients with erectile
dysfunction?
Giovanni Corona
1,4
, Matteo Monami
2
, Valentina Boddi
1
, Balzi Daniela
3
,
Cecilia Melani
3
, Nelli Federico
5
, Alessandra Sforza
4
, Carlo Rotella
6
,
Gianni Forti
6
, Edoardo Mannucci
2
& Mario Maggi
1
1
2
Diabetes Section
Geriatric Unit, Department of Critical Care, University of Florence,
Florence, Italy;
3
Epidemiological Unit, Azienda Sanitaria Locale 10,
Florence, Italy;
4
Endocrinology Unit, Maggiore-Bellaria Hospital, Bologna,
Italy;
5
Urology Unit, University of Florence, Florence, Italy;
6
Endocrinology Unit, University of Florence, Florence, Florence, Italy.
Introduction
Erectile dysfunction (ED) and, in particular, arteriogenic ED have been proposed
as new markers of risk for incident major adverse cardiovascular events (MACE).
Reduced penile blood fow is more common in obese people than in leaner ED
subjects. The aim of this study is to explore the interaction of overweight/obesity
and penile blood fow in the prediction of incident MACE.
Methods
This is an observational prospective cohort study evaluating a consecutive series
of 1687 patients attending our Andrological Unit for ED. Different clinical,
biochemical and instrumental (penile fow at color doppler ultrasound: PCDU)
parameters were evaluated. According to body mass index (BMI) subjects were
divided into three groups: normal weight (BMI18.5-24.9 kg/m
2
), overweight
(BMI25.0-29.9 kg/m
2
) and obese (BMI30.0 kg/m
2
). Information on MACE
was obtained through the City of Florence Registry Offce.
Results
Among patients studied, 39.8% were normal weight, while 44.1 and 16.1%
showed BMI 25-29.9 and 30 kg/m
2
or higher, respectively. During a mean
follow-up of 4.32.6 years, 139 MACE, 15 of which were fatal, were observed.
Cox regression model, after adjusting for age and Chronic Diseases Score,
showed that obesity classes along with the presence of arteriogenic ED (peak
systolic velocity at PCDU ,25 cm/s) were signifcantly and independently
associated with incident MACE (HR1.47(1.1-1.95), P,0.05 and 2.58(1.28-
5.09); P,0.001, respectively). When a separate analysis was performed for
classes of obesity, reduced peak systolic velocity at PCDU (,25 cm/s) was
signifcantly associated with incident MACE in obese (BMI 30 kg/m
2
), but not
in leaner, subjects.
Conclusions
In obese subjects, more than in leaner ED subjects, impaired penile blood fow is
associated with an increased risk of incident cardiovascular disease. The
interaction with concomitant risk factors, such as obesity, should be taken into
account when assessing the predictive value of penile blood fow for
cardiovascular diseases.
P152
Relationship between serum IL-12 and p40 subunit concentrations and
lipid parameters in obese subjects
Agnieszka Nikolajuk, Irina Kowalska, Agnieszka Adamska,
Monika Karczewska-Kupczewska, Elzbieta Otziomek,
Agnieszka Lebkowska, Maria Gorska & Marek Straczkowski
Department of Endocrinology, Diabetology and Internal Medicine, Medical
University of Bialystok, Bialystok, Poland.
Numerous studies indicate an association between low-grade chronic infam-
mation and predisposition to type 2 diabetes and atherosclerosis. IL-12 is a
proinfammatory cytokine with proatherogenic properties. IL-12 is a disulfde-
linked, 70 kDa (p70) heterodimeric glycoprotein composed of a 40 kDa (p40)
subunit and a 35 kDa (p35) subunit. Many data reported higher levels of p40
subunit than total IL-12. The aim of the present study was to estimate serum IL-12
and p40 subunit in lean and obese subjects and to investigate the associations of
these parameters with insulin sensitivity and serum lipids. A total 77 women with
normal glucose tolerance, 40 with overweight or obesity (BMI25 kg/m
2
) and
37 lean were recruited for the present study. Anthropometric measurements,
blood biochemical analyses and euglycemic hyperinsulinemic clamp were
performed in the studied group. We demonstrated an increase in plasma p40 in
obese subjects (P0.029). We found positive correlations between p40 and fat
mass (r0.24, P0.04) and signifcant negative associations with HDL-
cholesterol (r0.27, P0.02). Detectable concentrations of plasma IL-12
was observed in 55% subjects. Individuals with detectable serum concentrations
of IL-12 had signifcantly higher levels of serum triglycerides (P0.049).
A signifcant association between IL-12 and serum total cholesterol (r0.32,
P0.042) was observed in this subgroup. Our data indicate that IL-12/IL-12p40
system may be associated with lipid abnormalities in obese subjects.
P153
Heart rate variability in adults with hypopituitarism and severe growth
hormone dehciency
Oya Topaloglu
1
, Ferhat Gokay
1
, Dilek Berker
1
, Erkan Kahraman
2
,
Serkan Topaloglu
2
& Serdar Guler
1
1
Endocrinology and Metabolism Department, Numune Education and
Research Hospital, Ankara, Turkey;
2
Cardiology Department, Turkiye
Yuksek Ihtisas Hospital, Ankara, Turkey.
Objective
Hypopituitary patients receiving convensional hormone substitution, but
without growth hormone (GH) replacement, have an increased mortality from
cardiovascular disease. The aim of the present study was to assess the heart
rate variability(HRV) in hypopituitary patients with severe GH defciency.
Material and method
Thirty-fve patients (20 women, 15 men, aged 23-75 years) with severe GH
defciency, all of 35 patients with low insulin-like growth factor-1 (IGF1) levels,
and 18 sex- age-matched healthy controls. The causes of hypopituitarism were as
follows: 17 patients had operated pituitary adenoma, 14 had empty sellae, three
had Sheehan syndrome, one patient had prolactinoma. Twenty-four-hour ECG
monitoring was performed to detect HRV parameters. HF was accepted as a
marker of parasympathetic activity and LF as sympathetic activity. As an
indicator of sympatho-vagal equilibirium LF/RF ratio was measured. The
decrease in SDNN has been used as decreased in vagal activity and increased
sympathetic activity in sinus node.
Results
Patients with GH defciency had lower values of SDNN, RMSSD, PNN50, LF,
HF compared to controls but these were not statistically signifcant. HF/RF ratio
was minimally higher in patients than in controls. The average heart rate and
maximal heart rate values were lower signifcantly compared to controls
(respectively 75.118.9 vs 80.67.49, P0.03, and 133.2015.77 vs
149.2218.55, P0.002). There was no difference in minimum heart rate
values between patients and controls.
Conclusion
Hypopituitary GH defcient patients have increased mortality due to cardiovas-
cular disease. However their autonomic functions don`t appear to contribute this
mortality rate.
P154
Increased plasma resistin concentrations are associated with
atherogenic small, dense low-density lipoproteins in patients
with type-2 diabetes
Manfredi Rizzo
1
, Beatrice Amann-Vesti
2
, Cornelia Zwimpfer
3
,
Giatgen Spinas
3
& Kaspar Berneis
3
1
Division of Internal Medicine, University of Palermo, Palermo, Italy;
2
Division of Angiology, University Hospital Zurich, Zurich, Switzerland;
3
Division of Endocrinology, Diabetes and Clinical Nutrition, University
Hospital Zurich, Zurich, Switzerland.
Background
Resistin was originally proposed in animal models as a link between obesity and
insulin resistance, but later studies in humans have shown a divergent role. Yet,
resistin seems to be involved in the development of atherosclerosis in humans by
promoting the formation of foam cells; further, its expression is induced by
oxidized low-density lipoproteins (LDL) in human macrophages.
Methods
We assessed the relationships between resistin and markers of insulin resistance
and atherogenic dyslipidemia, including small, dense LDL, in subjects with type-
2 diabetes (n31, age: 6710 years, BMI: 283 kg/m
2
). Serum resistin was
assessed by ELISA and LDL size and subclasses by non-denaturing gradient gel
electrophoresis of whole plasma. Correlation analysis was performed using the
Spearman rank correlation method.
Results
No associations were found between resistin and age, BMI, waist and hip
circumferences as well as markers of insulin resistance, including fasting or
postprandial glucose, insulin, HOMA and HbA1c, with the exception of a
signifcant association with C-peptid levels (r0.435, P,0.05). Further, no
associations were found between resistin and plasma lipids or LDL size.
Regarding LDL subclasses, resistin was inversely associated with larger
LDL-I (r0.414, P,0.05) and positively with smaller, denser LDL-III and
-IV (r0.345, P0.05).
Conclusion
These fndings suggest that increased plasma resistin concentrations may be
associated with atherogenic small, dense LDL in subjects with type-2 diabetes.
Yet, whether these fndings affect the atherogenic process and clinical end-points
in this category of patients remains to be determined by future prospective studies.
P155
Increased plasma viscosity is a predictor of high cardiovascular risk in
women with PCOS
Filiz Eksi Haydardedeoglu
1
, Melek Eda Ertorer
1
, Bulent Haydardedeoglu
2
,
Ilknur Kozanoglu
3
, Inan Anaforoglu
1
& Neslihan Bascil Tutuncu
1
1
Department of Endocrinology and Metabolism, Faculty of Medicine,
Baskent University, Adana, Turkey;
2
Division of Reproductive
Endocrinology, Department of Obstetrics and Gynecology, Faculty of
Medicine, Baskent University, Adana, Turkey;
3
Department of Physiology,
Faculty of Medicine, Baskent University, Adana, Turkey;
4
Department of
Endocrinology and Metabolism, Faculty of Medicine, Baskent University,
Ankara, Turkey.
Introduction
Polycystic ovary syndrome (PCOS) is a common endocrinopathy that affects
5-10% of women of reproductive age. It is now recognized as not only a
reproductive but also a metabolic disorder with co-morbidities, such as; diabetes,
dyslipidemia, hypertension, etc. All these metabolic abnormalities predispose
women with PCOS to atherosclerosis. Plasma viscosity is a major determinant of
blood fow in microcirculation. Preliminary data indicate that elevated plasma
viscosity is an early predictor of cardiovascular disease.
Materials and method
To investigate the correlation between plasma viscosity and cardiovascular risk
factors, 96 patients with PCOS and 67 age and body-mass-index matched healthy
controls were recruited. Hormonal profles, lipid parameters, plasma glucose,
insulin and fbrinogen levels were evaluated. 'Homeostasis Model Assesment of
Insulin Resistance` (HOMA-IR) formula was used to calculate insulin sensitivity.
Parameters Patients ControIs vaIues
SDNN 134.6541.33 139.6138.95 0.67
LF 517.38244.20 622.81284.77 0.16
HF 276.55230.55 332.04244.18 0.42
LF/HF 2.871.91 2.711.98 0.77
EDTA-blood was centrifuged and a Brookfeld DV- II Pro Viscometer was used
to measure plasma viscosity.
Results
Plasma viscosity was signifcantly elevated in PCOS patients; 1.470.28 vs
1.340.25 mPas, (P0.004). The study group had higher HOMA-IR, fbrinogen
and triglyceride levels; 2.8 vs 2.16 and 3.570.92 vs 3.270.66 (g/l) and 109 vs
87.95 (mg/dl), (P0.017, P0.022, P0.002) respectively. Plasma viscosity
exhibited statistically signifcant positive correlation with fbrinogen (r0.223,
P0.029) and negative correlation with DHEA-S levels (r0.211, P0.04).
No correlation was detected between plasma viscosity and other biochemical
parameters.
Conclusion
Plasma viscosity is an important hemorrheologic parameter and directly
determines blood fow at the microcirculatory level. In this study, we clearly
demonstrated that plasma viscosity is increased in patients with PCOS, indicating
that they had high cardiovascular risk.
P15
The impact of testosterone replacement therapy on endothelial function
in hypogonadal men with type 2 diabetes
Marija Pfeifer, Anze Resman & Rok Dezman
Department of Endocrinology, University Medical Centre Ljubljana,
Ljubljana, Slovenia.
Background
Cross sectional studies in type 2 diabetic men have shown the 50% prevalence of
hypogonadism. Testosterone defciency worsens glycaemic control and accel-
erates the development of cardio-vascular disease. Therefore we investigated the
effects of testosterone replacement therapy (TRT) on endothelial function in
hypogonadal men with type 2 diabetes.
Thirty-three hypogonadal patients with type 2 diabetes, aged 35 years or older
with testosterone levels below 8 nmol/l, were put on TRT (Nebido 1000 mg i.m).
Before and seven months after TRT the parameters of metabolic control (HbA1c,
lipids) and body composition using Dual energy X-ray absorptiometry (DXA)
were measured. The endothelial function was assessed by measuring the
endothelium-dependent fow-mediated vasodilation (FMD) of the brachial artery
using a high resolution ultrasound. Patients flled out the AMS questionnaire
before and after TRT.
Results
Serum testosterone levels increased from 6.61.7 to 8.62.1 nmol/l (P0.000)
after 7 months of TRT. FMD increased from 4.24.5% to 7.44.8%,
(P0.009). An increase in lean body mass from 73.99.5 to 74.99.5 kg
(P0.045) and a decrease in total body fat mass from 23.25.2 to 22.25.6 kg
(P0.006) was observed. There were no signifcant changes in lipid and HbA1c
levels. The AMS score improved signifcantly.
Conclusions
Our trial was the frst to examine the infuence of TRT on the endothelial function
in hypogonadal men with type 2 diabetes. TRT signifcantly improved endothelial
function, body composition and symptoms of late-onset hypogonadism without
infuencing parameters of metabolic control. The benefcial effects of TRT on the
endothelium might be testosterone mediated directly or indirectly via
aromatisation to estradiol.
P15I
Alterations of plasminogen activator inhibitor-1, myeloperoxidase and
matrix metalloproteinase-9 in coronary artery disease patients with
type-2 diabetes mellitus
Peteris Tretjakovs
1,3
, Antra Jurka
1,2
, Inga Bormane
1
, Guntis Bahs
1,3
,
Kristine Cirule
3
, Agris Martinsons
1
, Jurijs Verbovenko
1,3
& Valdis Pirags
1,2
1
University of Latvia, Riga, Latvia;
2
Pauls Stradins Clinical University
Hospital, Riga, Latvia;
3
Riga Stradins University, Riga, Latvia.
Aim
To evaluate alterations in plasminogen activator inhibitor-1 (PAI-1), myelo-
peroxidase (MPO) and matrix metalloproteinase-9 (MMP-9) levels, and their
relation to insulin resistance (IR) in coronary artery disease (CAD) patients with
stable and unstable angina with and without type-2 diabetes mellitus (T2DM).
CAD patients were recruited into four groups: 16 CAD patients with stable angina
and T2DM (SD); 16 CAD patients with stable angina, without T2DM (S); 16
CAD patients with unstable angina and T2DM (UD); and 16 CAD patients with
unstable angina, without T2DM (U). 16 healthy subjects were selected as controls
(C). The study groups were matched for age and sex. IR was measured by
HOMA-IR method. Serum PAI-1 (total), MPO and MMP-9 were determined by
xMAP technology (Luminex-200 analyzer).
Results
All patient groups demonstrated a signifcant increase in PAI-1, MPO and MMP-9
levels (P,0.05) and IR (P,0.05). The increase of PAI-1, MPO and MMP-9 was
more pronounced in UD and U groups compared to SD and S groups (P,0.05),
but the IR elevation was more pronounced in both diabetics groups (UD and SD).
Only the concentration of PAI-1 and MMP-9 correlated with IR (P,0.05).
Conclusion
Our fndings show that CAD patients independently of 2TDM have elevated IR,
besides CAD patients with unstable angina have higher levels of PAI-1, MPO and
MMP-9 than patients with stable angina.
P158
Osteoprotegerin and angiotensin II in type 2 diabetes
Maria Belovici, Martin Buysschaert & Jean-Marie Ketelslegers
Cliniques Universitaires ST LUC, Bruxelles, Belgium.
Objectives
The bone-related peptide osteoprotegerin (OPG) was recently found in high
concentration inside vascular tissues in diabetic patients. OPG is produced by
vascular smooth muscle cells and endotheliocytes, and inhibits progression of
advanced plaque by delaying size progression as well as plaque calcifcation. We
aimed at determining in type 2 diabetes patients the relationship between serum
OPG and circulating level of angiotensin II (AngII), but also the relationship
between serum OPG and either lower-limb atherosclerotic peripheral arterial
disease (PAD) and/or mediacalcinosis (MC). Research design and methods:
Serum OPG was determined in 37 adult patients with type 2 diabetes using an
ELISA method. Circulating level of AngII were measured by conventional
methods. Patients were divided into three groups: group 1: PAD()/MC()
(n12); group 2: PAD()/MC() (n11); and group 3: PAD()/MC()
(n14). The groups were matched regarding pharmacotherapy with either
angiotensin-converting enzyme inhibitors or sartans. Results: Whereas all type 2
diabetic patients had high levels of OPG (between two- to threefold higher), there
were no signifcant correlations between OPG and the presence of macroangio-
pathy (either PAD or mediacalcinosis) nor between OPG and aldosteronemia
P0.05), Signifcant correlations were found between serum OPG and
circulating levels of AngII (P0.03, t ratio 2.13), patient`s age (P0.0012),
gender (P0.0084), von Willebrand factor levels (P0.03) and serum matrix
protein Gla level (P0.02). Conclusion: All type 2 diabetic patients in this study
had an increased circulating level of OPG. Serum OPG levels were signifcantly
and positively associated with circulating level of von Willebrand factor. These
correlations suggest that OPG is a candidate marker for endothelial dysfunction in
type 2 diabetes. The negative correlation between OPG and AngII also point
toward a novel potential mechanism for the benefcial pharmaco-therapeutic
effect of angiotensin-converting enzyme inhibitors in vascular protection against
arterial calcifcation.
P159
Changes in serum concentrations and tissue expression of hbroblast
growth factor-21 during and after elective major cardiac surgery
Jana Drapalova
1
, Tomas Kotulak
2
, Petr Kopecky
1
, Milos Mraz
1
,
Hynek Riha
2
, Jan Blaha
1
, Petr Kramar
2
, Ivan Netuka
2
, Jan Maly
2
,
Jaromir Kremen
1
, Eva Kotrlikova
1
, Stepan Svacina
1
& Martin Haluzik
1
1
General University Hospital of Charles University, Prague, Czech
Republic;
2
Institute of Clinical and Experimental Medicine, Prague, Czech
Republic.
Introduction
Fibroblast growth factor-21 (FGF-21) is a novel regulator of glucose and lipid
metabolism and insulin sensitivity. Possible role of FGF-21 in the development of
insulin resistance in critically ill patients has not been studied yet.
Objective
To study the changes in FGF21 production and adipose tissue and skeletal muscle
FGF-21 mRNA gene expression in cardiac surgery patients.
Methods
Sixteen patients (16 men, aged 661.8 years, BMI 29.20.79 kg/m
2
)
undergoing elective aorto-coronary by-pass were included into the study.
Serum FGF-21 levels along with selected biochemical, hormonal and cytokine
parameters were measured by commercial ELISA and RIA kits at several
timepoints before, during, at the end and up to 3 days after the operation. FGF-21
mRNA expression was assessed from epicardial and subcutaneous adipose tissue
and intercostal muscle taken at the beginning and end of the surgery. The study
was approved by the Ethical Committee of Thomayer University Hospital in
Prague.
Results
Serum concentrations of FGF-21 signifcantly increased along with the increase in
glycemia, insulinemia, hsCRP, interleukin-6, interleukin-8, MCP-1 and TNF-
levels during and for up to 24 h after the operation and returned to nearly baseline
levels at 96 h after the procedure. Baseline FGF-21 mRNA expression in skeletal
muscle was more than 350-times higher than in adipose tissue and did not change
signifcantly during the operation. FGF21 mRNA gene expression in epicardial
adipose tissue signifcantly increased over the operation period, while no change
was found in subcutaneous fat.
Conclusions
Circulating FGF-21 levels and its mRNA gene expression in epicardial fat were
signifcantly stimulated by major cardiac surgery. This increase may play a role in
the regulation of peri- and postoperative insulin sensitivity in these patients.
Skeletal muscle may constitute another important source of FGF-21.
Acknowledgement
Supported by MZOVFN2005 and MSM0021620814.
P10
MRI-assessed visceral adipose tissue (VAT) in different lipodystrophic
(LD) syndromes
Dieudonne Lucile
1
, Migaud Maria Claire
1
, Boury Samuel
4
, Lascols
Olivier
3
, Lacroix Dominique
2
, Mathurin Philippe
5
, Wemeau Jean-Louis
1
&
Vantyghem Marie-Christine
1
1
Departement of Endocrinology, Lille University Hospital, Lille, France;
2
Departement of Cardiology, Lille University Hospital, Lille, France;
3
Departement of Biochemistry, St Antoine Hospital, Paris, France;
4
Departement of Radiology, Lille University Hospital, Lille, France;
5
Departement of Gastroenterology, Lille University Hospital, Lille, France.
Lipodystrophy (LD) and obesity are opposites in terms of a defciency versus
excess of adipose tissue mass, yet these conditions are accompanied by similar
metabolic consequences. VAT has not been well quantifed in LD. The aim of this
study was to compare the metabolic profle and VAT in different kinds of LD.
Six-eight adult patients (45 females) referred for LD were classifed in four
groups: 23 LMNA-mutated patients (LMNA), 14 non-mutated related to the
LMNA-mutated (control group C), 15 lipomatosis (LPS) and 16 patients with
other types of anomalies of fat mass repartition (A group).
Methods
Gender, age, BMI, diabetes, glycemia, insulin, HbA1c, and leptin levels,
percentage of fat mass (%FM) (dual-X absorptiometry), VAT and liver steatosis
(MRI) were determined.
Results
The frequency of diabetes (P,0.001), mean weight and BMI (P,0.001), HbA1c
(P,0.05), insulin and leptin (P,0.01) differed signifcantly across the four
groups. Mean weight and BMI in LMNA were 66/24 kgs per m
2
, signifcantly
lower than in LPS (98/35) and A (82/29), but not different from C (76/26) groups.
HbA1c was signifcantly lower in C (5.4%) vs A (7.4%) not different from LMNA
(6.6%) and LPS (6.4%). Mean insulinemia was signifcantly higher in LMNA
(25 mUI/ml) compared to the three other groups (9 to 10). The mean of leptin
(8 ng/ml) was signifcantly lower in LMNA versus LPS (27 ng/ml). The %FM
and VAT and frequency of steatosis were respectively 2413%/112
62 cm
2
/75% in LMNA, 439/ 11751/48% in LPS and 339/14379/38%
in A groups.
Conclusion
A BMI ,25, diabetes and steatosis in more than

P
O
of cases, an insulinemia
20 mUI/l and leptinemia ,10 ng/ml were the most common fndings in
LMNA. Referred to BMI and despite LD, the LMNA patients had a high volume
of VAT (4.6), similar to A patients (4.9) who were also more often diabetic and
higher than LPS (3.3).
P11
Possibility for the Metformin administration in post-infarction period
in patients with the 2-nd type of DM
Natallia Yaroshevich, Anastasiya Hlazkova, Larissa Danilova, Irina Burko
& Anastasiya Hlazkova
Belarussian Medical Academy of Post-Graduate Education, Minsk, Belarus.
In our study during the period of 6 months we were monitoring lactate and other
biochemical parameters levels in patients with diabetes mellitus and myocardial
infarction after introducing Metformin into their treatment protocols.
Fifteen persons with the DM 2 (eight males and seven females) were included into
the frst group. Metformin was administrated in a daily dosage of 1700 mg. Some
patients (7/15) were receiving antidiabetic therapy with the sulphonyl urea of the
second generation - Gliclazide in the dosage from 60 to 120 mg/day. Second
control group has been formed by 19 patients with DM 2 (11 males and 8
females), after myocardial infarction, receiving only Gliclazide, without
Metformin.
On each visit we evaluated the body weight, waist and hip measurements,
contamination of the visceral fat (%), blood pressure, fasting glycemia, HbA1c,
Total Cholesterol (TC), triglycerides (TG), cholesterol of the lipoproteins of low
density (LDLP), cholesterol of the lipoproteins of high density (HDLP) and basal
insulinemia level (IRI). Insulin resistance index - Homeostasis model assessment
(HOMA-IR) has been calculated according to standard formula.
Results
i) During the administration of Metformin to the complex therapy of the patients
with DM2 in post infarction period we did not registered any case of lactate of
creatinine elevation for the duration of the whole follow-up period. ii) Myocardial
infarction except the acute phase cannot be considered as contraindication to
Metformin administration. iii) During the Metformin administration for the
period of 6 months we observed signifcant decrease of the insulin resistance
index (HOMA-IR), HbA1c levels and decrease of the serum level of TG, TC and
LPLD.
P12
The effect of testesterone replacement therapy on HDL subfraction
levels in hypogonadotropic hypogonadism
Abdullah Taslipinar
1
, Y Alper Sonmez
1
, Erol Bolu
1
, Serkan Tapan
2
,
Gokhan Uckaya
1
, Aydogan Aydogdu
1
& Mustafa Kutlu
1
1
Department of Endocrinology, Gulhane Military Medical Faculty, Ankara,
Turkey;
2
Department of Biochemistry, Gulhane Military Medical Faculty,
Ankara, Turkey.
The high-density lipoprotein (HDL) levels are decreased in paitents with
hypogonadotropic hypogonadism (HH). Although testosteron regulates lipopro-
tein metabolism, the effect of testosterone replacement therapy on HDL
metabolism is not clearly shown in HH. The aim of this study is to determine
the effects of testesterone replacement on HDL subfractions in young patients
with HH. Forty-three cases with HH (mean age 212.45 years) were enrolled.
Fifty-one healthy volunteer matched for age and BMI were enrolled as controls.
All patients were treated with testosterone esthers (250 mg, IM in every 3 weeks
for 3 months) both before and after treatment. HDL subfractions HDL2 and
HDL3 were measured by precipitation with polyethylene glygol (PEG). Serum
samples were treated with precipitation reagent 'Quantolip`. Total HDL, HDL2
and HDL3 levels of the patients and controls were not statistically different before
the treatment. Sixteen of the 43 cases patients fnished the therapy and the
remaining are still under treatment. Total HDL and HDL2 levels after therapy did
not change signifcantly. However, the HDL3 subfraction reduced signifcantly
following testosterone replacement (P0.02). In this study, we observed that
young men with HH did not have signifcant HDL profle alterations compared to
eugonadal men matched for age and BMI. Although the HDL3 subfraction was
reduced after the testosterone replacement, HDL3 subfraction is not reported to
have a major role in the antherosclerothic process. Thus, the role of testosterone
treatment on the atherosclerothic process is not expected to be related to the
alterations in HDL subfractions.
P13
Pitfalls in endocrine assessment of systemic hypertension in young
people
Raluca-Alexandra Trifanescu
1,2
, Catalina Poiana
1,2
,
Andra Caragheorgheopol
2
, Anamaria Stefanescu
2
& Mihail Coculescu
1,2
1
'Carol Davila` University of Medicine and Pharmacy, Bucharest, Romania;
2
'C.I.Parhon` Institute of Endocrinology, Bucharest, Romania.
Background
Endocrine hypertension accounts for around 3% of the secondary forms of
hypertension and screening of young hypertensive patients for secondary causes
is mandatory.
Aim
To present diffculties in endocrine assessment of arterial hypertension in people
younger than 40 years.
Twenty-two patients (15 M/7 F), aged 27.17.7 years (range:16-40 years), with
systemic hypertension (systolic blood pressure187.524.6 mmHg) were
evaluated for endocrine hypertension. Cardiac and renal causes of secondary
hypertension were previously excluded. Plasma catecholamines were measured
by ELISA, aldosterone by radioimmunoassay or ELISA, plasma cortisol, direct
renin by immunochemiluminescence.
Results
Essential hypertension with normal hormonal assessment was diagnosed in 21
patients (95.4%) and one patient presented subclinical Cushing due to a right
adrenal tumour. Hormonal assessment in our series revealed: basal 0800. cortisol
levels18.64.6 (g/dl, 0800 cortisol levels after 1 mgovernight dexamethasone
suppression test10.1 g/dl; median plasma metanephrines14.5 pg/ml (25th
percentile:10 pg/ml; 75th percentile: 26 pg/ml), median plasma normetanephri-
nes34 pg/ml (25th percentile:20.75 pg/ml; 75th percentile: 70.5 pg/ml), upright
morning aldosterone161.865.7 pg/ml with aldosterone:renin ratio3.5
1.6 ng/mIU. One male patient, aged 18, presented with paroxysmal hypertension
(240/130 mmHg) and mild hypokaliemia (3.1 mmol/l). The patient`s morning
upright plasma aldosterone concentration was normal (247.1 pg/ml; reference
range 38.1-313.3), but his plasma active renin concentration was extremely high
(500 mIU/l) with very low aldosterone:renin ratio. CT scan revealed a 17 mm
lesion in the right renal kidney, suggesting a possible reninoma. Because therapy
with sartans was stopped only 4 days prior to renin measurement, a prolonged 6
weeks withdrawal was made prior to a second renin assessment, which showed
normal values (54.8 mIU/l). Renal MRI revealed cystic nature of the renal lesion.
Conclusion
Drugs interfering with renin-aldosterone axis should be stopped a longer period
for avoiding false increase of direct renin.
P14
Correlation of plasma B-type natriuretic peptide (BNP) levels with
electrocardiographic (ECG) signs of right ventricular strain in patients
with acute pulmonary embolism
Alina Mihaela Pascu
1,2
, Mariana Radoi
1,2
, Elena Bobescu
1,2
& Mihail Coculescu
3,4
1
Faculty of Medicine, Transilvania University of Brasov, Brasov, Romania;
2
Clinical Emergency County Hospital Brasov, Clinic of Cardiology, Brasov,
Romania;
3
Carol Davila University of Medicine and Pharmacy Bucharest,
Bucharest, Romania;
4
Department of Endocrinology, Bucharest, Romania.
Background
We previously demonstrated plasma BNP to be a valuable biomarker of right
ventricular dysfunction (RVD) in patients with acute pulmonary embolism (PE).
Several specifc ECG abnormalities related to the right ventricular strain were
described in patients with PE.
Objective
Assessment of the correlation of plasma BNP levels with ECG signs of RVD in
patients with PE.
Methods
Seventy patients with confrmed acute PE, 42(60%) men, mean age 52.58.8,
were prospectively investigated. BNP was measured on admission, using a
quantitative immunofuorescence assay (Triage BNP, Biosite Inc). Twelve-lead
ECG was registered in all 70 patients in the frst hour after admission. ECGs were
independently interpreted by two observers blinded to patient data. RV function
was assessed by echocardiography (ECHO), performed by an investigator blinded
to other results. Study protocol was approved by local Ethical Committee.
Statistics: SPSS 17.0.2; MedCalc 11.1.1.
Results
Plasma BNP levels were signifcantly higher in patients with RVD on
ECHO: 79.75(45.77, 329.75) pg/mL compared to patients with normal RV
function: 7.85(6.22, 16.07) pg/ml, P,0.0001, values expressed as medians (25th,
75th percentiles). There was a signifcant correlation between plasma BNP and a
heart rate 100 bpm: r0.602 (95% confdence interval CI0.427-0.733),
P,0.0001. Qr in V
1
lead (a prominent Q wave of 0.2 mV and a ventricular
depolarisation ,120 ms) was also signifcantly correlated with plasma BNP:
R0.635 (95% CI0.471-0.757), P,0.0001. Plasma BNP was signifcantly
associated with the presence of incomplete right bundle branch block (RBBB),
R0.440 (95%CI0.229-0.612), P,0.0001; S
1
subtypes (S
1
Q
3
/S
1
rSr`
3
/S
1
S
2
S
3
),
R0.339(95% CI0.113-0.532), P0.004; inversed T wave in anterior leads
(V
2
or V
3
), R0.632 (95% CI0.467-0.755), P,0.001.
Conclusions
Plasma BNP was signifcantly correlated with ECG signs of RVD in patients
with acute PE. Multivariate logistic regression analysis showed that heart rate
100 bpm and the presence of a Qr ventricular complex in V
1
lead proved to be
the best ECG indicators of right ventricular strain in patients with PE.
P15
Male sexuality and cardiovascular risk: a cohort study in patients with
erectile dysfunction
Giovanni Corona
1,4
, Matteo Monami
2
, Michela Cameron-Smith
1
,
Francesco Lotti
1
, Giulia de Vita
1
, Ceclilia Melani
3
, Daniela Balzi
3
,
Alessandra Sforza
4
, Gianni Forti
1
, Edoardo Mannucci
2
& Mario Maggi
1
1
2
Diabetes Section Geriatric Unit, Department of
Critical Care, University of Florence, Florence, Italy;
3
Epidemiological
Unit, Azienda Sanitaria Locale 10, Florence, Italy;
4
Endocrinology Unit,
Maggiore-Bellaria Hospital, Bologna, Italy.
Introduction
No study has ever assessed the possible association of penile blood fow (PBF)
and the relational component of sexual function with incident major
cardiovascular events (MACE). The aim of this study is to investigate whether
severity of erectile dysfunction (ED), PBF and other factors related to a couple`s
relationship predict incident (MACE).
Methods
A subset of 1687 patients was longitudinal studied. Different clinical, biochemical
and instrumental (penile fow at color doppler ultrasound: PCDU) parameters
were evaluated. Information on MACE was obtained through the City of Florence
Registry Offce.
Results
During a mean follow-up of 4.32.6 years, 139 MACE, 15 of which were fatal,
were observed. Cox regression analysis, after adjustment for age and Chronic
disease ccore, showed that severe ED predicted MACE (hazard ratio (HR) 1.75;
95% confdence interval (CI) 1.10 to 2.78; P,0.05). In addition, lower PBF,
evaluated both in faccid (before) and dynamic (after PGE1 stimulation)
conditions, was associated with an increased risk of MACE (HR2.67
(1.42-5.04) and 1.57 (1.01-2.47) respectively for faccid (, 13 cm/s) and
dynamic (,25 cm/s) peak systolic velocity; both P,0.05). Perceived partner`s
hypoactive sexual desire (HSD) proved to have a negative and independent effect
against MACE. A longer and hostile coupler relationship, as well as stressful job
and both alcohol and smoking abuse were signifcantly associated with perceived
women`s HSD. In addition, the perceived women`s HSD was signifcantly
associated with a stepwise increase of free-foating anxiety and depressive
symptoms (adj r0.081, P,0.05 and 0.158, P,0.0001 respectively).
Conclusions
The investigation of male sexuality could provide insights not only into present
cardiovascular status but also into prospective risk. Perceived women`s sexual
interest (eros) can bee seen for men not only as an enjoyable behavior, but also a
safe strategy for improving men`s overall health and life expectancy.
P1
CRH and Urn2 regulate NO bioavailability, ROS levels and antioxidant
defence systems in endothelial cells
Sofa Gougoura
1
, Panagiotis Liakos
1,2
& George Koukoulis
1
1
Department of Endocrinology and Metabolic Diseases, Larissa, Thessaly,
Greece;
2
Laboratory of Biochemistry, School of Medicine, University of
Thessaly, Larissa, Thessaly, Greece.
Corticotropin-releasing hormone (CRH) and Urocortin 2 (Urn2) are secreted
locally in peripheral tissues and play a direct immunomodulatory role as
endocrine or paracrine mediators of infammation. Studies on CRH as well as
Ucn2 and vascular endothelial cells suggest that CRH may play a pivotal role in
the regulation of vascular endothelial function under normal and pathological
conditions. The present study was undertaken to determine whether CRH and
Urn2 affect the endothelial redox state. Therefore, in macroendothelial EAhy926
cells exposed in vitro to CRH and Urn2 for 2 h, at concentration10
7
M, were
measured the intracellular reactive oxygen species (ROS), nitric oxide (NO) and
glutathione levels in addition to endothelial nitric oxide synthase (eNOS) and
catalase activity, in the presence or absence of selective CRH/Urn2 receptor
inhibitors, antalarmin and astresin-2b respectively. CRH acting through both
receptors induced a signifcant increase of intracellular ROS content (P,0.001)
and catalase activity (P,0.001) accompanied by a simultaneous signifcant
decrease of eNOS activity and NO levels (P,0.001). Urn 2 acting through
CRHR2 receptor induced a signifcant increase of eNOS and catalase activity
(P,0.001) and NO levels (P,0,001) but did not affect considerably the
intracellular levels of ROS. Our data indicate that CRH and Urn2 may act as
regulators of pro-infammatory mechanisms inducing adaptation of endothelial
cell function to local stress.
P1I
Structural and functional carotid wall alterations in controlled versus
active acromegaly
Simona Galoiu
1,2
, Ruxandra Jurcut
1,3
, Aurora Vladaia
3
, Oana Savu
3
,
Ionela Baciu
1
, Mariana Purice
2
, Carmen Ginghina
1,3
& Mihail Coculescu
1,2
1
2
'C.I.Parhon` National Institute of Endocrinology, Bucharest, Romania;
3
'C.C.Iliescu` Institute of Cardiovascular Diseases, Bucharest, Romania.
The structural and functional effects upon arterial vessels of GH and IGF1,
chronically elevated in active acromegaly, are risk factors for premature
atherosclerosis, but current therapies can normalize GH and IGF1 production.
Aims
To evaluate if carotid wall alterations in acromegaly are reversible after disease
control.
Fifteen patients with controlled acromegaly (CA) after multimodal therapy
(45.511.4 years) were compared with 30 patients with active acromegaly (AA)
(49.69.9 years) and a control group of 21 age-, sex- and risk factors-matched
patients without acromegaly (W) (40.711.8 years) using right common carotid
echography, studying both structural (carotid diameter, intima-media thickness
index - IMT), and functional parameters (augmentation index, arterial
compliance and local pulse wave velocity - PWV) with e-tracking.
Results
The estimated acromegaly duration was 12.38.4 years and the disease free
interval in CA group was 0.71.5 years. There were no signifcant differences
between disease duration, sex distribution, age, high blood pressure or diabetes
mellitus prevalence in studied groups.
All patients with acromegaly showed structural changes of carotid artery: higher
diameters (6.30.5 mm) and IMT (0.70.1 mm) versus control (5.70.6 mm
and 0.50.1 mm, respectively), P,0.01. IMT, a marker of subclinical
atherosclerosis, was dependent on age (r0.3, P0.02), systolic blood pressure
(r0.3, P0.04) and disease duration (r0.3, P0.05). Carotid diameter and
IMT did not differ between CA and AA, irrespective of the type of therapy.
The functional test PWV was signifcantly higher in CA group vs. controls (6.4
1.3 m/s vs 5.40.7 m/s, P0.001) and not different fromAAgroup (6.81.6 m/s).
Conclusions
Structural and functional alterations of the carotid in acromegaly were not
improved after six months of GH and IGF1 normalization. A longer disease free
interval would establish if these modifcations are truly irreversible in the long-term.
P18
Sexual dimorphism of cardiovascular ischemia susceptibility is
mediated by heme-oxigenase synthase
Aniko Posa
1
, Peter Szablics
2
, Beata Vari
2
, Zita Szalai
1
,
Gyongyi Karcsune Kiss
1
, Csaba Varga
1
& Ferenc Laszlo
1
1
Department of Physiology, Anatomy and Neurosciences, University of
Szeged, Szeged, Hungary;
2
Institute of Physical Education and Sport
Sciences, University of Szeged, Szeged, Hungary.
In the reproductive age, it is well-known that males are more sensitive to
cardiovascular ischemic disease than females. In our study, we investigated the
role of heme-oxigenase synthase (HO), which produce endogenous vascular
protective carbon monoxide, in the development of sexual dimorphism in rats. We
found that HO synthase enzyme activity, and the expression its HO-1 and HO-2
isoenzyme were increased in female rat aorta and left heart ventricle compared
to males. Moreover, under in vivo circumstances, we demonstrated that
i) administration of vasopressin provoked an increased mean arterial blood
pressure response in the male; ii) the female myocardium was less sensitive
towards angina than the male; iii) both differences could be aggravated by the
inhibition of HO synthase. Finally, under in vitro circumstances, it was shown that
i) aorta rings were more susceptible towards vasoconstriction by vasopressin in
males compared to females; ii) isolated heart perfusion decrease was higher
in males; iii) HO inhibition aggravated vasoconstriction in both sexes.
In conclusion, the increased HO activity and HO isoenzyme expression in
females might play a role in the sexual dimorphism of cardiovascular ischemia
susceptibility in the reproductive age.
P19
2_j polymorphysm of glucocorticoid receptor gene in coronary artery
disease
Bojana Popovic, Djuro Macut, Tatjana Isailovic, Ivana Bozic,
Jadranka Antic, Sanja Ognjanovic, Milan Petakov & Svetozar Damjanovic
Institute of Endocrinology, Diabetes and Metabolic Diseases, Belgrade,
Serbia.
Introduction and aim
Obesity epidemic contributes to the increasing prevalence of high blood sugar,
high blood pressure, and dyslipidemia, which are all known risk factors for
coronary artery disease (CAD). Metabolic syndrome (MS) describes the common
clinical fnding wherein component CAD risk factors cluster within a single
patient. Since obesity shares common clinical characteristics with both metabolic
syndrome (MS) and Cushing`s syndrome it is speculated about obesogenic role of
glucocorticoids. The response to glucocorticoids is determined by the
glucocorticoid receptor gene variants that can be associated with enhanced or
reduced responsiveness to endogenous glucocorticoids. The aim of our study was
to investigate a relationship of Bcl1 polymorphism of GR gene and MS in patients
who underwent coronary artery angiography.
We examined 145 patients with CAD and 60 healthy controls matched by age, sex
and body mass index. The presence of MS was determined according to the
criteria of International Diabetes Federation (IDF) using waist circumference
(cm), arterial blood pressure (mmHg), basal glycemia, HDL cholesterol and
triglicerides (mmol/l). Characterization of Bcl1 polymorphysm was done by PCR
using restriction fragment lenght polymorphism (RFLP) analysis. Persons with
wild type genotype (GG) were marked as those without Bcl1 polymorphysm, and
persons with GC and CC genotype as those with Bcl1 polymorphysm.
Results
The presence of MS was more frequent in patients with CAD than in healthy
controls (P,0.001). When the individual parameters of MS were analyzed
separately after adjusting to IDF criteria for MS, there was a statistically signifcant
difference between waist circumference, level of arterial blood pressure and basal
glycemia between patients with CAD and healthy controls (P,0.001).The Bcl1
polymorphism was more frequent in patients with CAD (P,0.001).
Conclusion
Bcl1 polymorphysm of glucocorticoid receptor gene is more frequent in people
with coronary artery disease.
P1I0
Formation of neutralizing anti human growth hormone (hGH)
antibodies does not explain the lack of IGF1 increase after recombinant
hGH treatment in mice
Svetlana Mustafna, Oksana Rymar, Galina Simonova, Sofa Malyutina &
Yuri Nikitin
Institute of Internal Medicine SB RAMS, Novosibirsk, Russian Federation.
We previously have reported that short-term treatment of mice with recombinant
hGH leads to signifcant increases in bodyweight (BW), lean body mass (LBM)
and liver weight, but - unlike in humans - does not robustly increase circulating
levels of IGF1. We now tested the hypothesis that formation of neutralizing
antibodies in mice treated with rhGH could explain the lack of IGF1 response.
Therefore, we intentionally induced antibody formation against hGH in female
FVB mice by repeated immunization (6,) using rhGH and adjuvans (Titermax
Gold, Sigma). Subsequently, the 8 months old mice were treated with daily doses
of rhGH (Nordifex, Novo Nordisk, 0.5 mg/d i.p.) for 2-weeks. Age matched
control mice were sham immunized using adjuvans only prior to daily rhGH
treatment. Before start of rhGH treatment, BW was not signifcantly different
between groups, but rhGH immunized mice showed signifcantly higher anti-hGH
antibody titers (P,0.01). After 2-weeks of treatment, control mice had
signifcantly higher BW (control: 30.22.5 g, immunized: 262.4 g;
P,0.05), LBM (control: 11.30.8 g, immunized: 9.50.9 g; P,0.05) and
liver weights (control: 1.770.15 g, immunized: 1.410.23 g; P,0.05) when
compared to hGH immunized mice. In contrast, serum IGF1 levels were not
signifcantly different between controls and immunized animals (controls:
44481 ng/ml, immunized: 35653 ng/ml, P0.1). The IGF1 concentrations
were in the range we had seen in previous experiments in young mice treated daily
with either the same dose of rhGH or equal volumes of 0.9% NaCl for 2-weeks
(rhGH-group: 48188 ng/ml NaCl-group: 45094 ng/ml). In conclusion,
2-weeks of daily rhGH treatment in mice do not lead to signifcant formation
of neutralizing antibodies against rhGH. Intentionally induced anti-rhGH
antibodies are capable to block hGH effects on BW, LBM and liver weight, but
have no effect on IGF1 levels obtained after rhGH treatment. These data suggest
that formation of neutralizing antibodies does not explain the lack of IGF1
response after rhGH treatment in mice.
Clinical case reports and clinical practice
P1I1
Parathyromatosis coincidentally associated with papillary (Sclerosing)
microcarcinoma of the thyroid
Mihai Radu Diaconescu, Mihai Glod & Mirela Grigorovici
University of Medicine and Pharmacy 'Gr T Popa`, Lasi, Romania.
Background
The aim of this report is to describe a fortuitely discovered association between
parathyromatosis and occult sclerosing papillary carcinoma of the thyroid.
Case description
A 56-year-old woman presented with pyelic relapsed stone, bone pains and
iPTH348 ng but normal calcemia as manifestations of recurrent primary
hyperparathyroidism after a right inferior parathyroid adenoma resection done
elsewere 6 years ago Sonography showed a 5 mm hypo and isoechoic zone at the
lower pole of the right lobe of the thyroid with irregular tracer activity at the
parathyroid scan. At the operation done in a 'hostile` surgical feld an unbounded
mass was identifed lateral and below the thyroid pole extending in the
thyrothymic ligament together with several graytan nodules of 1-3 mm scattered
on distal surface of the thyroid lobe and also in the areolar fbrofatty atmosphere
of the tracheoesophageal groove. Excision and biopsy of the mass and of two
main nodules showed the presence of parathyroid tissue and the intervention is
fnally completed with a near-total thyroid lobectomy including about 4 cm of
thyrothymic ligament retrosternally. Pathology evidencied multiple poorly
outlined nests of parathyroid cells but also a minute focus of papillary sclerosing
thyroid carcinoma. One year after operation the patient is well-doing without any
local recurrence and normal biological parameters.
Discussion
Coexistence between parathyromatosis - a rare but challenging cause of
re-current hyperparathyroidism - and thyroid occult carcinoma, a more frequent
encountered lesion is an entirely coincidental ocurrence. The preoperative
diagnosis of both conditions particularly of the latter one - is rarely proved, these
lesions being unlikely clinically signifcant. There is almost always a history of
previous parathyroidectomy therefore in such intraoperative fortuitely fndings,
the resection for parathyromatosis include also an en bloc thyroid lobectomy with
superior retrosternal tissue removal. The further therapy of coincidental thyroid
carcinoma is conditioned by its clinical and pathological characteristics.
Conclusions
Preoperative and intraoperative evaluation for recurrent primary and renal
hyperparathyroidism must be meticulous and complete considering possible
coexisting thyroid lesions. Indeed to our knowledge there have been no reports in
the literature mentioning this unprecedented entity the over described entity.
P1I2
Carcinoid syndrome: case report
Juan Marti
Hospital Zumarraga, Zumarraga, Spain.
Introduction
Carcinoid tumors are neuroendocrine tumors derived from enterochromaffn or
Kulchitsky cells (that secretes serotonin or other chemicals into bloodstream),
which are widely distributed in the body, but they are traditionally described as
originating from the foregut, midgut, and hindgut. A case of carcinoid syndrome
is reported.
Case
A 55-year-old man with medical history of Parkinson disease. Was admitted to
internal medicine outpatient clinic for with history of diarrhea, abdominal pain,
irregular bowel movements dyspepsia and weight loss, asthenia and anorexia,
associated with occasional fushing episodes for 10 months. Physical examination
revealed: red facial fush and facial spider-like veins and hepatomegaly.
Laboratory
Complete blood count cells was normal. AST 114 U7L. ALT 118 U/l. Bilirrubin
2.1 mg/dl. GGT 482 U/l. ALP 371 U/l.CA-125 52 U/l. Urinary 5-HIAA:
320 mg/24 h (range,10). Chromogranin A 1200 ng/ml (range,98 ng/ml).
Barium enema, flling defect in ileocecal valve. Colonoscopy, suggested
lipomatosis of ileocecal valve. Abdominal ultrasound; liver metastases.
Abdominal CT. Liver metastases. Tumor in ileum with infltration of the
mesentery and carcinomatous peritonitis. Somatostatin receptor scintigraphy,
liver metastasis from a carcinoid tumour. The primary tumour located in the distal
ileum.
Echocardiography was normal. The patient was treated with sandostatin Lar
20 mg monthly.
Discussion
The prognosis for patients with metastatic carcinoid tumors has improved during
the last decade. Due to longer survival times, follow-up should be focused on
monitoring tumor size and extension of metastases by CT scan and nuclear
scanning. During follow-up, hormonal activity must be monitored on a regular
basis. Routine examinations every 6-12 months to detect carcinoid-related heart
disease at an early stage are important in order to adjust therapy and, hence,
improve prognosis. Combining new diagnostic and treatment modalities
(somatostatin analogues have also been reported to inhibit tumor growth, hepatic
artery embolization, radiofrequency ablation)in metastatic carcinoid patients may
result in better quality of life and longer survival times.
P1I3
Insulin-induced lipohypertrophy, past, present and future-are we losing
the battle?
Gideon Mlawa
1,2
, Dauda Balami
3
, Sandeep Deshmukh
1
, Maureen Croft
2
,
Charles Bodmer
2
& Mayank Patel
1
1
Southampton General Hospital, Southampton, UK;
2
Colchester University
Hospital, Colchester, UK;
3
Newham University Hospital, London, UK.
Background
Poor glycaemic control with erratic blood glucose levels manifesting as recurrent
hyperglycaemia with unpredictable episodes of hypoglycaemia is problem still
faced today in daily practice. The causes include poor compliance and failure of
oral hypoglycaemic. Despite being on insulin (38% of type 2 diabetes patients
who require insulin treatment after 10 years) and type 1 diabetes patients continue
to have fuctuing glucose concentration. The poor glycaemic control in insulin
treated patients is due to insulin-induded lipohypertrophy. Lipohypertrophy has
been known to be due to complication of insulin therapy for decades, but its
prevalence is still high despite advance in technology. Around 20-30% of type 1
diabetes patients, and around 4% of type2 diabetes patients, develop
lipohypertrophy.
Methods
We present a case report of a 64 years old man, type 2 diabetes for 20 years, and
was on insulin therapy for 7 years. He was followed up by his General practioner
but referred to diabetic team due to erratic blood glucose level, ranging from
1.6-23 mmols/l.
Results
On assessment he had peripheral neuropathy with background diabetic
retinopathy, and injection sites revealed signifcant lipohypertrophy on both
thighs. His HbA1c was 10.9% with normal lipid profle, urea and electrolytes.
He was advised to rotate injection sites and also reduce the dose of insulin by
2-4 units. His glycaemic control improved over the following 3 months with
glucose levels of 4.6-11 mmol/l and his HbA1c fell to 7.8% despite reducing the
dose of insulin.
Conclusion
Despite advance in technology insulin-induced lipohypertrophy remains common
but neglected cause of poor glycaemic control today, in the past, and we should
not allow this to be the case in future. All patients should be closely examined
for lipohypertrophy during diabetic clinic review, using inspection,and palpation
of injection sites in order not to miss subtle form of lipohypertrophy. Education to
both doctors and patient about recognising and dealing with lipohypertrophy
is advisable. The pathophysiology of lipohypertrophy is discussed in this
case report.
P1I4
'Sound mind` and lithium-induced hyperparathyroidism
Gideon Mlawa
1,2
, Sandeep Deshmukh
1
, James Alegbeleye
2
,
Rebecca Cowen
2
, Cecil Eboh
2
, Robert Kelly
2
& Charles Bodmer
2
1
2
Colchester General
Hospital, Colchester, UK.
Background
Lithium remains a frst-line treatment for bipolar affective disorder and acute
maniac state despite the introduction of newer and effective treatment. Lithium
therapy is associated with a variety of side effects. Although thyroid dysfunction
is the most widely recognised endocrine side effect, hypercalcaemia and more
rarely a biochemical picture resembling primary hyperparathyroidism or familial
hypocalciuric hypercalcaemia may develop. Recognition of this less common but
potential life threatening side effect is of vital importance as an increasing number
of patients with bipolar disorder are on long -term lithium therapy.
Methods
We present a case report of a 65 years old lady with history of recurrent
admissions with hypercalcaemia. On her last admission to the medical admission
unit she was confused with slurring of speech. She had a background of bipolar
disorder and was on long term lithium therapy 300 mg bd, and depakote. Patient`s
calcium level was normal prior to starting lithium treatment.
Results
The patient calcium level was 3.15 mmol/l (normal range 2.20-2.60 mmol/l),
lithium level was high 2.03 mmol/l (normal range 0.4-1.00), ECG was
unremarkable. Chest X-ray and CT brain were normal. She was treated with
intravenous fuids and iv pamidronate with improvement of her presenting
symptoms. She had elevated parathyroid hormone level (PTH) of 20, her serum
vitamin D level as well as ACE was normal. Ultrasound parathyroid and sestamibi
scan were negative, and 24 h urinary calcium was 0.54, her urine calcium
creatinine ratio was ,0.01. Lithium was withdrawn after consultation with
psychiatrist in charge of the patient, initially tapering the dose to 200 mg bd, then
100 mg bd and then it was stopped. The dose of depakote (Valproic acid) was
increased. 6 months after stopping lithium patient`s calcium normalised. The
patient is being followed up, with monthly blood tests.
Conclusion
Lithium-induced hypercalcaemia is common but underreported complications of
lithium theraphy. Most patients have mild asymptomatic hypercalaemia. This
case and other similar previously reported cases support the diagnoses of lithium
induced hypercalcaemia as there is a temporary relationship between lithium
exposure and hyperthyroid state. Measurement of serum calcium levels and PTH
levels as well as thyroid function test periodically after initiation of lithium
treatment is advisable. The mechanism underlying lithium-induced hyperpara-
thyroidism is discussed in this case report.
P1I5
Fenohbrate-induced rhabdomyolysis and acute renal failure in patient
with occult hypothyroidism
Basak Karbek
1
, Ragip Kadi
2
, Ugur Alp Goksu
2
& Nurol Arik
2
1
Department of Endocrinology, Diskapi Yildirim Beyazit Teaching and
Research Hospital, Ankara, Turkey;
2
Medical Faculty, Ondokuz Mayis
U
niversty, Ankara, Turkey.

Rhabdomyolysis is a syndrome characterized by muscle necrosis and the release
of intracelluler muscle contents into systemic circulation. It can became a life-
threatening disorder when complicated by acute tubuler necrosis and renal failure.
Fenofbrate, a fbric acid derivate, is used to treat diabetic dyslipidemia,
hypertriglyceridemia and combined hyperlipidemia alone or in combination with
statins. Rhabdomyolysis associated with fenofbrate is extremely rare. In nearly
all of the present cases, there is a predisposing factor for rhabdomyolysis.
Hyopothyroidism frequently leads to myalgias, muscle stiffness, cramps and
sometimes elevated levels of muscle enzymes, but rhabdomyolysis is quite rare.
We report a case of unrecognized hypothyroidizm presenting with rhabdomyolitic
acute renal failure precipitated by use of fenofbrate. A male patient - at the age of
52 - was admitted to the department with the complaints of fatigue, myalgia,
oliguria. As a result of the clinical and laboratory examinations, rhabdomyolysis
and acute renal failure which developed secondary to the fenofbrate treatment,
was diagnosed. Further examinations showed the presence of outoimmune
thyroiditis and hypothyroidism. Despite the treatment with saline, furosemide,
sodium bicarbonate infusions, the patient who failed to urinate, received a total of
ten hemodialysis procedure. Thyroid replacement treatment was started. After
a 2 month treatment period, the renal function and thyroid function tests and
muscle enzymes returned to normal. To our knowledge this case illustrates the
frst example of rhabdomyolitic acute renal failure induced by fenofbrate
treatment with underlying hypothyroidizm.
P1I
Quality management system of regional and general hospital medical
laboratory in relation to ISO 15189:2007, Thailand
Dhitiwass Suvagandha
Bureau of Laboratory Quality Standards, Department of Medical Sciences,
Ministry of Public Health, Nonthaburi, Thailand.
The objectives of this study were to assess the quality management system of 95
medical laboratories at regional and general hospitals under the jurisdiction of the
offce of the permanent secretary, Ministry of Public Health, Thailand, in relation to
ISO 15189:2007 and determine the relationships between role perception,
leadership and organization climate with medical laboratory quality management.
This study was a cross-sectional study. Data were collected by self-assessment
questionnaire distributed to 95 medical laboratory unit chiefs fromAugust 2008 to
January 2009. The response rate was 100%. Statistical analysis used were
Pearson`s product moment correlation coeffcient and stepwise multiple
regression. Results revealed that role perception, leadership and organization
climate were signifcantly related to overall quality management of ISO
15189:2007 (p,0.001). Leadership of the medical laboratory unit chiefs and
organization climate were the variables that could explain the quality management
of ISO 15189:2007 at 17.1% (R
2
adj
0.171). It is recommended that medical
laboratory unit chiefs should enhance their leadership and be responsible for
design, implementation, maintenance and improvement of the quality manage-
ment. Top management should ensure that the organization structure, organization
policy, surrounding and technology which contribute to a quality management
system have been made in relation to requirements of ISO 15189:2007.
P1II
Pursuit endocrinology ~ perceptions, understanding and reactions of
students undertaking internal medicine training regarding
endocrinology
Sanjay Kalra
1
, Navneet Agrawal
2
, AG Unnikrishnan
3
, Rakesh Sahay
4
&
Bharti Kalra
1
1
Bharti Hospital, Karnal, India;
2
Medical College, Gwalior, India;
3
AIMS,
Kochi, India;
4
Osmania Medical College, Hyderabad, India.
This paper studies the attitudes of postgraduate medical students towards
endocrinology and diabetology as a career.
Fifty post graduate students, pursuing residency in internal medicine, at various
colleges throughout India, were requested to fll up a pre-tested, fve point Likert
scale questionnaire designed to assess their likings for various branches and
aspects of medicine.
The average age of the respondents was 27 years, with 90% males. Most (92%)
wanted to settle in India, with all opting for a job in a town/metro city, and 50%
hoping for a government job.
The most preferred speciality was cardiology (favourite ranking: 3.1), followed
by diabetology (3.4) and endocrinology (4.2). These subjects were followed by
gastroenterology (5.4), nephrology (5.4), neurology (5.7), hematology (6.7),
rheumatology (7.2), oncology (7.5), and geriatrics (9.1), in descending order of
liking. Coeffcient of concordance W was 0.40, X
2
36.19 (P,0.01), indicating a
high level of agreement amongst respondents.
Respondents believed that diabetes would contribute to 26-50% of their patient
load, and earning, after graduation. The preferred aspects of a medical career were
OPD practice (preference score 4.3), followed by indoor practice (4.1), academics
(3.7), clinical research (2.9) and public awareness (2.9). The difference between
these values, as measured by one-way classifcation analysis of variance, after
square root transformation, was signifcant (F2.70; P0.05).
Amongst the endocrine subspecialities, diabetes was the preferred subject (4.6),
followed by thyroid (3.4), growth disorders (3.3), adrenal (2.9), bone mineral
metabolism (2.7), reproductive endocrinology (2.5), andrology (2.4) and
paediatric endocrinology (2.2).
Differences in preference were signifcant (F2.59; P0.05).
This study reveals the preference of internal medicine residents for cardiology,
diabetology and endocrinology. The liking for endocrinology is fuelled by a
feeling that diabetes contributes signifcantly to earning and patient load. Thyroid
and growth disorders are the other preferred endocrine subspecialities.
A signifcant preference for outdoor and indoor work is also noted, wit ha dislike
for research and public awareness work.
P1I8
Glass hber containing materials ~ a rare cause of granulomatous
mastitis
Adina Ghemigian, Irina Popescu, Evghenia Petrova, Dumitru Ioachim,
Mircea Ghemigian & Constantin Dumitrache
Foreign bodies represent a rare cause of granulomatous mastitis. In the last three
years we diagnosed three women with granulomatous mastitis consecutive to
exposure at building materials containing glass fbers. All of them were young
(21-34 years), with regular menses, without any pathological histories and were
admitted to our hospital for bilateral galactorrhea spontaneous in one case and by
squeezing the nipple in the other two cases. Clinical and ultrasonographic
evaluations revealed no breast nodules. Serum prolactin levels were normal or
slightly elevated. Erythrocyte sedimentation rate was moderately increased.
Histological examination of the breast secretion showed ductular epithelial
hyperplasia with intracellular, intragranulomatous and extracellular needle-like
birefringent fbers. Theese were appreciated as glass fbers originating from the
recent building sites in their dwellings neighbourhood.
Nonsteroidal antiinfamatory drugs were the treatment of choise. Dopamin
agonists were avoided in order to enable needle-like foreign bodies drainage.
In conclusion, the breast behaves like an isolation and evacuation organ of the
needle-like foreign bodies that can be absorbed at the lung and skin level and
partially discharged through milk-like secretion, causing ductular epithelial
hyperplasia and granulomatous giant cells reactions.
We emphasize the importance of breast secretion cytologic examination in the
differential diagnosis of galactorrhea.
P1I9
Screening for nutritional status in the elderly
Irina Popescu, Adina Ghemigian, Evghenia Petrova
& Constantin Dumitrache
The population of the world is aging and is estimated that by 2030 - 21%of global
population will be aged 65 years and older. At present, under-nutrition in older
people is a serious and growing global problem affecting even developed
countries. As one ages, several physiological and pathlogical changes may
contribute towards the development of protein energy malnutrition. This syndrom
brings with it many adverse health outcomes and a signifcant cost to the
individual, families, communities and the healthcare system. There is strong
evidence that good nutrition can decrease complications, hospitalisation and even
mortality. Old people should eat nutrient-dense foods with lower amounts of fat
and sugar (empty calories). Normal changes of aging require fortifed foods and
certain mineral and vitamin supplements.
It is important to systematically screen for under-nutrition and actively look for
causes that can be reversed. There are validated screening tools such as Mini
Nutritional Assessment (MNA) that should be used for this purpose (score 24
normal, 17-23.9risk for malnutrition, ,17malnutrition). We administered
Mini Nutritional Assessment questionnaire to 50 persons aged 65 years and older
hospitalised in our Institute of Endocrinology. The average MNA score was
21.495.3. Women 75 years had the worst nutritional status: average MNA
score: 16.61. Men ,75 years had the best mean MNA score: 24.66.
P180
Papillary thyroid carcinoma in a patient with intestinal
ganglioneuromatosis
Margarita Gonzalez Boillos, Zhuraida Salman Monte,
Eladio Jose Losada Grande, Ines Caudet & Paula Lopez
Hospital Can Misses, Ibiza, Baleares, Spain.
A 16-years-old male, with familiar precedents of familiar macrocephaly, he has
been visited in external consultations of digestive in 2008 because he had rectal
bleedings. A colonoscopy was made two times, in those situations some intestinal
polyps have been extirpated. The result of the pathological antomy was polyps
ganglioneuromas.
Due to the pathological compatible anatomy with ganglioneuromas, it stemmed to
external consultations of endocrinology to reject the asociated syndrome of MEN
2B. The study was negative results but an ultrasound scan of thyroid showed
diffuse affectations of both lodes and thyroid isthmus for multiple nodules.
With the existence of family macrocephaly as well as ganglioneuromas and
thyroid nodules, genetic study was requested to reject Syndrome of Cowden. That
study detected that the patient was a carrier of the mutation C-1033-CT,
p.R335X in the gene PTEN.
There was made a request to make a new ultrasound scan of thyroid to control,
6 months late which was informed as a diffuse affectation of both thyroid lodes by
solid nodules 2 cm. FNA was performed that was informed like a suggestive
about malice by what whole realized thyroidectomy. The result of the defnitive
pathological anatomy was informed as a papillary thyroid carcinoma an oncocytic
variety with two focal points of 2.5 and 0.5 cm.
P181
Syndrome of inappropiate antidiuresis hormone associated with
multiple sclerosis
Eladio Losada, Raquel Bernal & Margarita Gonzalez Boillos
Hospital Can Missesm, Ibiza, Balearic Islands, Spain.
Syndrome of inappropriate antidiuresis hormone (SIADH) with many disorders of
the nervous system have been reported frequently but its association with multiple
sclerosis (MS) is extremely rare (only six cases reported in the literature).
A 46 years old woman was admitted to our hospital because of hypersomnolence,
confusion and visual disturbances. She presented 6 months before a variety of
neurological symptoms suggestive of demyelinating disease without radiological
or biochemical confrmation.
GSC on admission was 12/15, clinically euvolemic and hemodinamically stable.
Laboratory evaluation showed hyponatremia (Na pl 110 mEq/l), hypoosmolality
(Posm 246 mosmol/kg), increased urine osmolality (U osm 663 mosm/kg) and
inappropriate natriuresis (Na ur 76 mEq/l). There were no clinical, radiologic or
laboratory fndings of impaired renal function, thyroid or adrenal disfunction,
head injury, lung or neoplasic disease. The diagnosis of MS was made on the basis
of radiologic (hyperintense signals in optic chiasm and in the hypothalamus in
MRI), clinical (optic neuritis) and biochemical fndings (oligoclonal protein
bands in CSF). The severe hyponatremia was attributed to SIADH secondary to
MS and was treated with water restriction, 2% saline infusion and diuretic drugs.
The patient was discharged three weeks later with serum sodium levels and the
rest of the laboratory data within normal levels.
In summary, the association of SIADH and MS was not coincidental. The cause
might be the demyelinating process in the hypothalamus that produced and
abnormal infuence in ADH secretion resulting in SIADH.
P182
Occult ACTH-secreting pheochromocytoma
Martina De Martin, Francesca Pecori Giraldi, Luca Pagliardini,
Francesca Cassarino, Alberto G Ambrogio & Francesco Cavagnini
Chair of Endocrinology, Ospedale San Luca, Istituto Auxologico Italiano
IRCCS, University of Milan, Milan, Italy.
A 69-year-old woman developed hypertension, polyuria and hyperglycemia over
the course of several months. The initial biochemical investigation revealed
ACTH-dependent hypercortisolism (UFC 409.7 g/24 h, NR 10-80; ACTH
43.3 pg/ml, NR 8-50; OST 28 g/dl) and moderately elevated urinary
catecholamines (E 80.5 g/24 h, NR 2.5-33.6; norE 235.8 g/24 h, NR
18.1-128.2). Further investigations disclosed absent ACTH and cortisol
responses to CRH and a paradoxical cortisol increase after 8 mg dexamethasone
(from 19.5 to 42.3 g/dl). Imaging studies were inconclusive as pituitary MR
showed only slight pituitary stalk deviation and abdominal and thoracic CT failed
to identify mass lesions except for enlargement of the left adrenal gland. Indeed,
increased uptake by the left adrenal gland was shown by FDG-PET. Plasma
catecholamines proved to be very high (E 835 ng/l NR 10-196; norE 2789 ng/l
NR 78-521) and did not suppress after clonidine (1076 and 3525 ng/l,
respectively). However, MIBG scintigraphy was negative and MR failed to
visualize an adrenal or extraadrenal pheochromocytoma. She was then submitted
to PET/CT scanning with F18-DOPA, an alternative tracer for chromaffn tissue,
which visualized abnormal uptake between the middle third of left kidney and
pancreatic tail. Re-evaluation of imaging allowed the identifcation of a
previously misclassifed pararenal mass. The lesion was removed and pathology
revealed a pheochromocytoma. The tumoral specimen also produced ACTH and
synthesized POMC, as assessed by RT-PCR. After surgery, urinary catechol-
amines levels fell abruptly (E 1.4 g/24 h and norE 11.6 g/24 h) as did UFC
(11.9 g/24 h). ACTH and cortisol responses to CRH normalized (from 29.3 to
52.3 pg/ml for ACTH and from 8 to 11 g/dl for cortisol) as did cortisol
suppression after 1 mg dexamethasone (1.5 g/dl). Hypertension and diabetes
disappeared and the patient is doing well without steroid replacement therapy.
Conclusion
This case illustrates the complexities in visualizing the source of certain
endocrine disorders. In the present case, localization of the pheochromocytoma,
who secreted ACTH as well as catecholamines, proved particularly diffcult.
P183
Metastasis to the thyroid gland with thrombo embolic jugular
involvement as initial presentation of renal carcinoma: a Case Report
Massimiliano Andrioli
1
, Antonio Brescia
2
, Chiara Carzaniga
1
& Francesco Cavagnini
1
1
Chair of Endocrinology, Ospedale San Luca IRCCS, Istituto Auxologico
Italiano, University of Milan, Milan, Italy;
2
Robotic Oncologic Urology,
Ospedale San Giuseppe, Milan, Italy.
Introduction
Metachronic metastasis of renal carcinoma to the thyroid gland, a rare entity
occurring sometimes many years after nephrectomy, have been already reported
by literature. Thyroidal synchronous metastasis, instead, are more uncommon.
We herein report a patient with thyroidal metastasis and intrajugular thrombo
embolic involvement as initial presentation of a misunderstood renal carcinoma.
Case Report
A 83-years-old woman, with silent medical history, was referred to our
department for toxic multinodular goiter. She presented an enlarged thyroid
containing multiple solid nodules in the left lobe, and a single lesion in the right
one. A new ultrasound performed two months later confrmed multiple nodules in
the left lobe some of which presented ultrasonographic and elastosonographic
features suspicious for malignancy, i.e. hypoechogenicity, irregular margins,
intralesional vascularization, spot microcalcifcations and stiffness; on the
contrary, the single nodule in the right lobe was homogeneous and elastic.
Nevertheless it was remarkable increased in size, i.e. 47 vs 30 mm, and it partially
infltrated thyroid capsule in its upper third with at least three thrombo-embolic
lesions involving omolateral jugular vein.
Therefore, we performed a fne-needle-aspiration on right nodule and cytological
examination reported a lesion made of clear cells compatible with metastasis of
renal carcinoma. Therefore, a tumour was localized in the right kidney by TC and
then confrmed by pathology after laparoscopic robot assisted right radical
nephrectomy. Total thyroidectomy was also performed and only the right nodule
turned out to be a metastatic lesion at histology, resulting all the others
hyperplastic nodules.
Conclusion
Although uncommon, metastatic renal carcinoma to the thyroid gland should be
considered even in patients with thyroid nodules not presenting a medical history
of renal cell carcinoma. Thyroid metastasis of renal carcinoma might not
necessary present ultrasonographic and elastographic characteristics suspicious
for malignancy. A careful neck-ultrasound might be decisive in making the
correct diagnosis.
P184
Emergency use of etomidate in acute steroid psychosis for an adrenal
cancer causing Cushing`s syndrome
Anupam Brahma, Mark Karaczun & Ketan Dhatariya
Norfolk and Norsich University Hospital, Norwich, UK.
Introduction
The psychiatric consequences of inoperable Cushing`s syndrome can be diffcult
to manage medically. Etomidate, an imidazole derived anaesthetic agent, inhibits
cortisol synthesis and may be useful in this circumstance.
The case
A 57-year-old woman presented with symptoms and signs of hypercortisolism.
She gave a history of recent onset intermittent right sided stabbing chest pain and
worsening breathlessness.
Two 24 h urinary free cortisol measurements confrmed the diagnosis of
hypercortisolism. Imaging showed a 14.6,11.2,12.4 cm adrenal mass, with
an intra-hepatic IVC thrombus extending into the right atrium and left pulmonary
artery.
A provisional diagnosis of a cortisol secreting adrenal adenocarcinoma was made.
On multidisciplinary review, the tumour was deemed inoperable. She was started
on metyrapone 250 mg 8 hourly and reviewed 3 days later, where she admitted to
medication non-adherence and exhibited symptoms of a forid acute steroid
psychosis.
To facilitate management a decision was made to treat her with etomidate to
reduce steroid levels. She was sedated and ventilated and given 7 mg/h of
etomidate in the ITU. Daily 09.00 cortisol levels showed rapid resolution of her
cortisol levels. She was subsequently successfully extubated and was expected to
restart the metyrapone. However, she suddenly deteriorated and died. Post
mortem examination ascribed the cause of death to possible systemic sepsis or a
systemic infammatory response secondary to the necrotic adrenal cancer.
Discussion
Etomidate inhibits 11 hydroxylase activity (1) with a swift decrease in cortisol
synthesis. Rise in mortality on the intensive care unit coincided with introduction
of etomidate as a 'safe` induction agent (2). The rationale behind the clinical
decision to use this drug should be fully explained to patient, and when possible
their informed consent should be obtained. Etomidate is an effective
steroidogenesis inhibitor (3,4). Research is needed, to explain and possibly
avoid the higher mortality associated with it`s use.
P185
Primary biliary cirrhosis and Graves` disease ~ combination rarely
found
Alexandra Vieira
1
, Sandra Paiva
1
, Cristina Ribeiro
1
, Jacinta Santos
1
,
Mariana Martinho
2
, Marcia Alves
1
, Sofa Gouveia
1
, Francisco Carrilho
1
& Manuela Carvalheiro
1
1
Endocrinology, Diabetes and Metabolism Department, Coimbra University
Hospital, EPE, Coimbra, Portugal;
2
Endocrinology Department, Portuguese
Institute of Oncology, EPE, Coimbra, Portugal.
Introduction
The association of autoimmune diseases in the same individual is common. It is
well documented that Graves` disease (GD) is associated to various autoimmune
diseases, including: pernicious anemia, vitiligo, type 1 diabetes, Addison`s
disease, systemic sclerosis, myasthenia gravis, Sjogren`s syndrome, rheumatoid
arthritis and systemic lupus erythematosus. In addition, primary biliary cirrhosis
(PBC) may be associated with rheumatoid arthritis, Sjogren`s syndrome,
Raynaud`s phenomenon and autoimmune thyroiditis, often observed the presence
of hypothyroidism. However, the association of PBC and GD is rare. It is
described in the literature only 5 cases.
Case report
Female, 63 years old, sent to the endocrinologist for hyperthyroidism. The patient
had a history of cholecystectomy and PBC diagnosed 9 years ago. She was treated
with ursodeoxycholic acid 500 mg twice a day. She reported palpitations,
excessive sweating, irritability and weight loss.
Physical examination: heart rate of 80 bpm, coarse tremor, bosselated thyroid and
non-pulsatile. Laboratory fndings: TSH 0.01 UI/ml (0.27-4.20), free T
4
3.76 ng/dl (0.93-1.7), anti-TPO 244 UI/ml (,34) and TRAbs 4.2 U/l (,1.5).
Thyroid ultrasonography showed an enlarged, lobulated, slightly heterogeneous
gland and a nodule with 1 cm in diameter in the left lobe. Fine-needle aspiration
biopsy was performed: colloid nodule. The patient was treated with methimazole
15 mg/day and propranolol 10 mg twice a day. For persistence of hyperthyroid-
ism, although the increasing of methimazole dose, the patient underwent
radioiodine therapy (7.4 mCi). The patient developed hypothyroidism, therefore
was treated with levothyroxine. She is currently euthyroid.
Conclusions
Despite frequent association of autoimmune diseases in the same individual, the
authors present this case for the rare association between PBC and GD.
P18
Pseudophaeochromocytoma: case series of a common cause
Hassan Kahal
1
, Narayana Prasad Pothina
2
, Abd Tahrani
3,4
&
Mohamed Malik
2
1
Department of Diabetes and Endocrinology, Hull Royal Infrmary, Hull,
UK;
2
Department of Diabetes and Endocrinology, Scunthorpe General
Hospital, Scunthorpe, UK;
3
School of Clinical and Experimental Medicine,
University of Birmingham, Birmingham, UK;
4
Department of Diabetes and
Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK.
Introduction
Phaeochromocytomas commonly present with episodes of sweating, palpitations,
and hypertension. Urinary catecholamines measurement is the most common
screening test for suspected phaeochromocytoma in the UK. We report a series of
three cases in which the reason for hypertension and raised catecholamines was
not a phaeochromocytoma and treating the underlying condition corrected the
clinical and biochemical abnormality.
Cases
Three patients were referred to the endocrine clinic with symptoms suggestive of
phaeochromocytoma, and isolated elevation in 24 h urinary Noradrenaline (NA)
levels. (Table 1) Imaging for phaeochromocytoma was negative.
On further questioning, all patients mentioned a history of snoring, and daytime
somnolence. Polysomnography suggested severe degree of sleep apnoea (OSA)
with Aponea/Hypopnea Index (AHI) of 52 events/h in case1 and 40 events/hour in
case 2. CPAP treatment resulted in better BP control, symptomatic improvement
and normalisation of urinary catecholamines. In case 3, the patient managed to
lose 6 kg in weight and his symptoms improved with an AHI of 10.4 events/hour.
Repeat 24 h urinary catecholamine levels after weight loss were normal.
Discussion
OSA is characterized by short intervals of partial or complete upper airway
obstruction during sleep resulting in blood oxygen desaturation. Oxygen
desaturation may explain the increased sympathetic activity widely demonstrated
in patients with OSA. Patients with OSA could present in a similar picture to
phaeochromocytoma.
Conclusions
OSA should be considered in the differential diagnosis of phaeochromocytoma in
patients with raised catecholamines and negative imagining for phaeochromo-
cytoma. Treatment for OSA results in normalization of raised catecholamines and
improvement in patients` symptoms and blood pressure.
P18I
An uncommon case of Carney`s triad
Wojciech Zieleniewski, Renata Michalak & Agnieszka Jagodzinska
Carney`s triad is a very rare syndrome, which comprises three tumors of different
origin: gastrointestinal stromal tumor (GIST), thoracic chondroma and
extraadrenal pheochromocytoma. It is found mainly in young female patients
with blood group A. Two of the tumors need to be present for the diagnosis.
Here we present the case of a 58-year-old male with blood group B. In July 2004
patient underwent resection of a part of small intestine with two GISTs removed.
In July 2005 he had a tumor in left atrium, histologically chondroma. In October
2006 CT scans revealed a pathological mass in left atrium, but in a different
location than in 2005. A high concentration of chromogranin A - 379.3
(N: 0-40 ng/ml) was found in February 2007. However no pathological masses
were found in abdominal CT. Also MIBG scintigraphy did not revealed any
paraganglioma.
In most previously presented cases chondroma was found in the lungs. However,
the presence of multiple GISTs and chodroma in the heart in a man with blood
group B induced us to concede this case as a rare case of Carney`s triad.
P188
Case report of gA_\! )Q:gJA\ infection as a possible trigger of
Riedel`s thyroiditis
Gabor Laszlo Kovacs, Istvan Szabolcs, Zoltan Gorombey, Laszlo Kovacs,
Erika Hubina, Judit Denes & Miklos Goth
Division of Endocrinology, Department of Internal Medicine, State Health
Centre, Budapest, Hungary.
Background
The detectable levels of thyroid antibodies in patients suffering from Riedel`s
chronic fbrosing thyroiditis (RT) suggest a link between RT and Hashimoto`s
thyroiditis, but the pathogenesis of RT is not really known. Lyme disease is the
most frequent tick-borne infection with variable manifestations in different organs
caused by Borrelia burgdorferi (Bb).
Case report
A 59-year-old woman presented in our outpatient clinic with a painful swelling
and cervical discomfort in the anterior area of the neck. 30 years ago she was
treated with thiamazol for Graves` disease. The symptoms started following two
tick bites on the neck. She presented with elevated infammatory markers
(westergren 91 mm/h, CRP 88.6 mg/l), anaemia, and thrombocytosis (haemo-
globin 112 g/l, PLT 513 G/l) with normal level of procalcitonin and white blood
cells. Primary hypothyroidism was detected (TSH 37.8 IU/ml, fT
4
6.22 pmol/l).
Ultrasonography showed bilateral enlargement, hypovascularisation of the
thyroid with multiple hypoechogenic nodular formation and bilateral large
lymph nodes. Tc scintigraphy showed a low Tc uptake (0.69%). Transitional
methylprednisolone treatment with thyroxin substitution was started. The planned
near total thyroidectomy was unsuccessful. The histological investigation
suggested the diagnosis of RT. The microbiological tests confrmed a Bb
acute infection with elevated IgM/IgG levels. Amoxicillin treatment
(3,500 mg/21 days) was advised, then pulsatile steroid therapy administered
(250 mg methylprednisolone/7 day cycles up to 1500 mg). After treatment the
symptoms and infammatory laboratory results improved; the former trachea
compression did not worsen. According to the literature data some parts of the
human TSH receptor match outer surface protein A, fagellar rotation protein A,
DNA recombinase/ATP dependent helicase of Bb.
Conclusion
Our case strengthens the former hypothesis: Bb might be an environmental trigger
of autoimmune thyroid disease through a molecular mimicry mechanism. To our
knowledge this is the frst case of Bb infection and Riedel`s thyroiditis
co-morbidity.
P189
Liver toxicity after methylprednisolone treatment of Graves
orbitopathy
Renata Orlowska-Florek, Marek Grzywa & Elzbieta Wozny
Szpital Wojewodzki nr 2, Rzeszow, Poland.
Introduction
Intravenous methylprednisolon pulses (IVMP) are commonly accepted treatment
in Graves orbitopathy (GO) However acute and severe liver damage has been
reported in sporadic cases during such therapy. The aim of this study was to
present the cases of severe liver damage after second and third course of IVMP.
Case report
The white women 60 years of age with Graves disease diagnosed in 1983. Firstly
she was treated with antythyroid drugs for 2 years without complication. After
this therapy she was euthyroid for 15 years. In 1999 year thyreotoxicosis has
recurred. The drug therapy was conducted again for 1.5 years. She was euthyroid
after this therapy. In 2001 year the signs of Graves orbitopathy (exophthalmus,
diplopia, swelling of eyelids, redness of conjunctivae, deterioration of visual
acuity) appeared. She was treated with IVMP (total dose 12.4 g during 4 months)
We didn`t observed elevation of aminotranspherase or bilirubin. The improve-
ment of orbitopathy was observed.
In 2007 year the subclinical thyreotoxicosis and exacerbation of orbitopathy was
observed again. In 03.2008 patient received 131-I. She was also treated with
IVMP - total dose 6 g IVMP during 2 months (from 02.08 to 04.2008). The rise of
aminotranferase level was observed (GOT 640 U/l, GPT 1060 U/l) so we
interrupted the IVMP therapy. There were no changes in USG and CT of abdomen
The test for antibodies against hepatitis, B, C were negative. The normalization of
labs was observed in 06.2008 The treatment with IVMP was effective but some
signs of orbitopathy didn`t disappear.
The exacerbation of orbitopathy was observed again in 01.09. In this time she was
treated because of hypothyroidism. She received the IVMP in reduced doses (only
250 mg two times in 2 weeks period). After second dose the hepatic labs raised so
we didn`t continue this therapy The orbital irradiation was recommended.
Conclusion
i) The liver dysfunction after IVMP can appear in the successive course of therapy
even when the were no changes during frst course. ii) The monitoring of liver
enzymes should be conducted during IVMP therapy. iii) IVMP should be
withdrawn immediately when the elevation of liver enzymes is observed.
TabIe 1
Age/gender
(M) Presentation BMI
BP
(mmHg)
Urinary NA
(0-530 nmol/24 h) X3
Case 1 39 Hypertension,
episodic
fushing,
erectile
dysfunction
35 168/105 574 828 821
Case 2 51 Uncontrolled
hypertension
42 174/133 556 708 804
Case 3 68 Excessive
sweating
36 125/74 536 567 738
P190
Cryopreserved organ culture of endocrine glands for hormonal
insufhciency treatment
Ievgen Legach, Galyna Bozhok & Tatyana Bondarenko
Institute for Problems of Cryobiology and Cryomedicine of the NAS of
Ukraine, Kharkov, Ukraine.
Transplantation of endocrine cell/tissue can be considered as an alternative
method of treatment for hormonal insuffciency (type I diabetes, hypocorticism,
hypothyroidism, hypogonadism). Compared with replacement therapy trans-
plantation of hormonal active cells provides a big advantage, especially, in the
cases of individual intolerance or hypersensitivity to hormonal preparations.
In order to make this method of hormone level restoration more preferred in
endocrinology, it needs to solve a number of problems including long term
preservation of biomaterial.
We developed the method of cryopreservation and implantation of cryopreserved
organ culture of endocrine glands. The developed method of transplantation of
cryopreserved organ cultures of endocrine glands can be applied in endo-
crinology, transplantology and biotechnology.
Endocrine glands were crushed up to fragments (0.5-1 mm
3
) and cultured during
5 days in 199 medium supplemented with 10% fetal bovine serum.
Cryopreservation was performed under 7% DMSO. Samples were frozen in
plastic 1.5 ml ampoules by the programmed freezer. Transplantation was
performed under local anesthesia to subcutaneous fat tissue of anterior abdominal
wall by means of injection through Dufo`s needle in 4-5 areas.
Combined approach to culture and transplantation allows increase the
effectiveness of hypothyroidism, type 1 diabetes mellitus, hypocorticism and
androgen defciency treatment.
Clinical trials. Patient SS, 43 years old. Woman, 1st group invalidity. Diagnosis:
rheumatoid arthritis, polyarthritis, I-st grade of the process` activity, weakly
progressing course of disease, manifested pain syndrome. Secondary adrenal
insuffciency. 3 months after transplantation of cryopreserved organ culture of
adrenal glands we observed an increase of blood plasma cortisol level, absolute
scarring of the ulcer in the ankle joint, rheumatic test was negative.
P191
Nonclassic 11-hydroxylase dehciency with hypofunctional
polymorphisms on both haplotype
Sang-Yong Kim, Hak-Yeon Bae & Jin-Hwa Kim
Chosun University Hospital, Gwang-Ju, Republic of Korea.
11-hydroxylase defciency (11-OHD), an autosomal recessive disorder, is the
second most common cause of congenital adrenal hyperplasia. It is caused by the
mutation of the CYP11B1 gene that encodes the enzyme. In classical 11-OHD,
genetic mutations of CYP11B1 lead to activity decrease or loss, but mutations in
nonclassical 11-OHD are not defnite. The vast majority of mutations are
associated with classic 11-OHD, and only a few mutations causing nonclassic
11-OHD have been described as yet. We report analysis of the CYP11B1 genes
of adult man thought to suffer from nonclassic 11-OHD.
A 24-year-old man presented with hypokalemia and borderline hypertension.
Hormonal studies and physical fnding established diagnosis of nonclassic
11-OHD; elevated plasma levels of ACTH, 11-deoxycortisol, 17-hydroxypro-
gesteron, androstenedione, low levels of cortisol. ACTH stimulated serum
cortisol levels were low. Basal and ACTH stimulated serum 11-deoxycortisol
levels were 138 and 739 ng/ml, respectively (normal, 0-120 ng/ml). Basal and
ACTH stimulated serum 17-hydroxyprogesteron levels were 47.6 and 272 ng/ml,
respectively (normal, 0.6-3.42 ng/ml). Abdomen computed tomography revealed
both adrenal gland hyperplasia. To determine the molecular genetic defects,
genomic DNA was isolated from the leukocytes. The coding and intron-exon
junction regions of CYP11B1 were totally sequenced. We fnd two hypofunc-
tional genetic polymorphisms of CYP11B1 gene that were c.128GA and
c.59512GA. Each polymorphism were located on different haplotype. These
fndings suggest that this hypofunctional polymorphisms on both haplotype
affects 11-hydroxylase function, resulting in the clinical features of nonclassic
11-OHD.
P192
Approaches to the diagnosis and management of primary
hyperparathyroidism in Europe results from a European Survey
in hve countries
Stuart Ralston & Bente Langdahl
1
Head of the School of Molecular and Clinical Medicine and ARC Professor
of Rheumatology, Molecular Medicine Centre, Edinburgh, Scotland, UK;
2
Department of Endocrinology and Metabolism, Aarhus University
Hospital, DK-800 Aarhus C, Denmark.
Background
Primary hyperparathyroidism (PHPT) is a common condition, which in some
patients can lead to complications such as osteoporosis and renal stones. This
survey investigated diagnosis and treatment strategies for PHPT across Europe.
Methods
The survey was conducted in fve European countries (France, Germany, UK,
Italy and Spain). 286 of the 421 interviewed physicians were endocrinologists; the
remainder were rheumatologists (46), internists (50) and urologists (39). Survey
topics included: perception of the severity of the disease, referral for
parathyroidectomy (PTX), diagnosis and treatment.
Results
Diagnostic methods were similar across Europe with serum PTH and serum
calcium being the most common diagnostic tests (94% of cases). Urinary
calcium was measured in 80-90% of patients. About 50% of physicians in each
country followed national guidelines for treatment. Most physicians (66%)
thought that not treating PHPT has serious implications. PTX was considered to
be the therapy of choice for symptomatic patients by most respondents (77%).
About half of the respondents (53%) recommended surgery in asymptomatic
patients only if they meet specifc criteria. 37% delayed surgery where possible
and conducted regular follow-ups and/or treated pharmacologically. The
respondents reported that about 43% of PHPT patients did not wish to undergo
surgery and in 28% contraindications to surgery were identifed. The respondents
reported that approximately 10% of patients had a failed PTX. Regarding the
pharmacological treatment, about half of all PHPT patients (49%) received
bisphosphonates in combination with a diuretic (17%); about 13% had received a
calcimimetic and 18% hormone-replacement therapy. Physicians in Italy (32%)
and UK (28%) were more likely to treat asymptomatic patients pharmacologically
than those in Spain (14%), France (14%) and Germany (13%).
Conclusion
The survey has demonstrated that although the approach to diagnosis of PHPT is
similar across Europe, there are some notable differences in the pharmacological
treatment of asymptomatic patients.
P193
An unusual case of acromegaly
Wojciech Zieleniewski, Renata Michalak & Agnieszka Jagodzinska
Acromegaly is a chronic disease with typical clinical signs evoked by
overproduction of growth hormone (GH) and insulin-like factor 1 (IGF1). It is
nearly always caused by somatotroph adenoma which can be visualized by MRI
scanning. Other causes of acromegaly are very rare and comprises ectopic
secretion of GH or GH-RH by other neoplasms.
Here, we present a case of 62-year old acromegalic woman. Acromegaly was
frstly diagnosed 9 years ago. Her GH concentration was 77.6 ng/ml (N: 0-10) and
IGF-1 level 1446.9 ng/ml (N: 81-225). Surprisingly, MRI scan of the sellar region
(repeated several times) revealed slightly enlarged pituitary, but without any signs
of adenoma.
Moreover, chest X-ray showed mediastinal tumor about 5 cm of diameter,
confrmed by a CT scan. The patient refused bronchoscopy or other diagnostic
procedures of the tumor. We performed a test with short-acting octreotide
(100 mcg) which effciently decreased GH concentration: 0-122.0 ng/ml, and
after 2 h 2.2 ng/ml. Therefore a prolonged treatment with long-acting octreotide
(30 mg each 4 weeks). The treatment is well tolerated with GH concentration
3.67 ng/ml and IGF-1 level 448 ng/ml.
Unfortunately we were unable to measure GH-RH level.
In conclusion we strongly believe that this case of acromegaly is due to
benign mediastinal tumor (no progression was noticed) producing ectopically
GH-RH or GH.
P194
Thyroid storm accompanied by H1N1 inuenza infection
Ayten Oguz
1
, Reyhan Ersoy
1
, Rahmet Guner
2
& Bekir Cakir
1
1
and Research Hospital, Ankara, Turkey;
2
Department of Infectious Diseases
and Clinical Microbiology, Ankara Ataturk Education and Research
Hospital, Bilkent, Ankara, Turkey.
Case report
A 56-year-old woman admitted to emergency department with fever, dyspnea,
productive cough, palpitations, diffuse myalgia, and malasia. Physical exami-
nation revealed an anxious-appearing woman with fne tremor in the hands. Her
pulse was 140 beats/minute and irregular; blood pressure, 140/90 mmHg;
temperature 38.6 ?C, respiratory rate 40 breaths per min, and oxygen saturation
91% without supplemental oxygen. In auscultation, bilaterally rales and bronchial
breath sounds were heard. Chest radiography at admission showed bilaterally
patchy pneumonia. The leukocyte count was 3.400/l with 45% polymorpho-
nuclear cells, 50% lymphocytes and 5% monocytes. In physical examination, her
thyroid gland was enlarged diffusely and non tender. Electrocardiogram showed a
trial fbrillation with a rapid ventricular response. Because of her symptoms and
the fndings on the physical examination, laboratory tests for thyroid function
were done. The test revealed a decreased level of thyroid-stimulating hormone, an
elevated level of free thyroxine, and free triiodothyronine. The patient`s condition
continued to worsen, and she was admitted to the intensive care unit for further
evaluation and management. Propylthiouracil, propranolol, and supportive
therapy were started. Nasopharyngeal-swab samples were taken for infuenza
H1N1 virus. On day 4 of admission, samples were positive for infuenza H1N1
virus by PCR. No other organisms were detected from blood, urine or respiratory
tract. A 5 days course of oseltamivir was added to the therapy. The diagnosis was
thyroid storm accompanied by H1N1 infuenza infection. After 12 days, patient`s
levels of thyroid hormones had decreased, vital signs returned to completely
normal.
Conclusion
Thyroid storm is a rare and life- threatening endocrinologic emergency that may
be precipitated by trauma, surgery, systemic illness, particularly infection and
sepsis. We think that, our patient highlights the potential impact of H1N1
infuenza infection for thyrotoxic patients.
P195
A rare cutaneous manifestation in Cushing`s syndrome: generalized
pustular psoriasis
Neslihan Cuhaci
1
, Dilek Arpaci
1
, Rifki Ucler
1
, Ahmet Metin
2
,
Reyhan Ersoy
1
& Bekir Cakir
1
1
2
Department of
Dermatology, Ankara, Ataturk Education and Research Hospital, Bilkent,
Ankara, Turkey.
Introduction
Generalized pustular psoriasis is a rare and the most severe form of psoriasis. It is
usually seen in adults. Generalized pustular psoriasis is characterized with sudden
eruption of yellowish pustule groups on the shiny erythematous skin, measuring
2 to 3 mm, and cover the all body in a short time. In this report, we presented
a patient with Cushing`s syndrome (CS) who had determined pustular psoriasis.
Case report
A 35 years old woman was admitted because of a widespread erythematous and
millimetric brown maculopapular lesions and sterile pustular eruption associated
with postinfammatory hyperpigmentation on the head, face, trunk, and
extremities. In addition, in her physical examination, she had a facial plethora,
hair loss, purple striaes, and hirsutismus. Her biochemical and hormonal tests
indicated glucocorticoid excess. Cushing`s syndrome was confrmed by the
dynamic tests. Magnetic resonance imaging (MRI) revealed a pituitary lesion of
3.2 mm in diameter. Inferior petrosal sinus sampling (IPSS) was performed. After
the results of laboratory tests and imaging procedures, Cushing`s disease was
determined. Biopsy from the skin lesions revealed early period of pustular
psoriasis.
Conclusion
The classic cutaneous manifestations of CS are; facial plethora, acne, purpura,
cutaneous atrophy, hirsutism, vellous hypertrichosis, and wide purplish striae
over the abdomen, fanks and upper arms. Acanthosis nigricans can occur but it is
usually mild. In the literature, in our knowledges, there is no case together with
Cushing`s syndrome and pustular psoriasis. This case is reported since these two
conditions are rarely seen together.
P19
A rare cause of elevated liver enzymes: Addison`s disease
Neslihan Cuhaci
1
, Aylin Bolat Demirezer
2
, Didem Ozdemir Sen
1
,
Reyhan Ersoy
1
, Osman Ersoy
2
& Bekir Cakir
1
1
2
Department of
Gastroenterology, Ankara Ataturk Education and Research Hospital,
Bilkent, Ankara, Turkey.
Introduction
Common reasons of chronically elevated liver enzymes are; fatty liver associated
with alcohol abuse or obesity, chronic viral hepatitis, autoimmune hepatitis,
chronic bilier disease and hereditary metabolic disorders. Adrenocortical
insuffciency can also cause elevated liver enzymes. Until now, there are few
cases in the literature with abnormal liver function associated with Addison`s
disease. We reported this case to kept mind the Addison`s disease while
investigating the hypertransaminasaemia.
Case report
A 49-years-old woman admitted to our hospital with a 2 months history of
weakness, fatigue and increased skin pigmentation. Her laboratory tests revealed
low serum cortisol (2.9 g/dl), increased adrenocorticotrophing hormone
(ACTH) (1250 pg/ml), aspartate transaminase (AST) and alanine transaminase
(ALT) levels (120 U/ml and 87 U/ml respectively). Nevertheless, hyponatremia
and hyperkalemia were not noted. Increased skin pigmentation, low serum
cortisol, and high ACTH levels suggested Addison`s disease. Diagnosis was
confrmed by ACTH stimulation test. No cortisol response was taken to ACTH
stimulation test. 21-hydroxylase antibody was found positive. She had also
evaluated for hypertransaminasaemia. Liver and spleen were not palpable. No
lymphadenopathy was found. Other liver function tests were all normal. All viral
hepatitis markers and tests for autoimmune hepatitis (antibodies against smooth
muscle, mitochondria and nuclei) were negative. Abdominal tomography
showed no pathology for liver and adrenal glands. When the Addison`s disease
was confrmed by ACTH stimulation test, glucocorticoid therapy was given.
Nearly 2 weeks after replacement therapy aminotransferase activity returned in
normal range.
Conclusion
For patients with constantly elevated liver enzymes extra-hepatic diseases should
have to be considered. Although rare, Addison`s disease should be kept in mind.
P19I
Genetic pattern of sex development disorders: cases report
Nicoleta Andreescu, Valerica Belengeanu, Monica Stoian,
Dorina Stoicanescu, Simona Farcas, Alina Belengeanu, Anca Muresan
& Daniela Amzar
University of Medicine and Pharmacy 'Victor Babes`, Timisoara, Romania.
Objective
To study the spectrum of chromosomal anomalies in three cases as related to the
phenotypic variability of patients with anomalies of disorder of sexual
development.
Female 18 years old with secondary amenorrhea, stigmata of Turner`s syndrome,
Tanner stage II. Ultrasound showed streak gonads. Hormonal analysis revealed
elevated levels of FSH, LH and a low plasma estradiol level. The chromosomal
investigation showed gonosomal mosaicism 45,X(40%)/46,XY(60%). FISH
analysis identify the presente of clone XY in 65% of the cells. Molecular
analysis for 20 polymorphic markers and SRY region of Y chromosome revealed
normal structure. The patient was reffered for gonadectomy.
Female 20 years old with primary amenorrhea, showed infantile but otherwise
normal external genitalia. Gonadal failure is indicated by high levels of serum
FSH, LH and a very low plasma estradiol level. Using laparoscopy in the right
part were observed one small tumor and histological analysis from gonadal
biopsy revealed characteristic aspect of gonadoblastoma. Cytogenetic analysis
evidentiate in 30 metaphases examinated the karyotype 46,XY. The patient was
diagnosed with Swyer syndrome and she had a gonadectomy.
Newborn investigated for ambiguity of the phenotypic sex and for establishing the
gender. The patient presented labioscrotum, micropenis and hypospadias.
Ultrasonography did not reveal the presence of the testes in the scrotum nor
along the inguinal canals. The gonads were discovered by laparascopy and
histopathological investigation revealed immature testes. Normal values of
testosterone and FSH were found. The cytogenetic analysis showed the presence
of chromosome Y in all evaluated cells. FISH analysis was performed to evaluate
the gonosomal chromosomes regarding SRY gene. The SRY gene was found on
the Y chromosome. The surgical intervention and testosterone therapy were
recommended.
Detailed molecular cytogenetic characterization and the clinical follow-up of the
patients are very useful in defning the phenotypic range of these chromosomal
patterns.
P198
Administration of testosterone to elderly hypogonadal men with Crohn`s
disease improves their Crohn`s disease activity index: a pilot study
Farid Saad
1,2
, Ahmad Haider
3
, Winfred Kurtz
4
, Erik Giltay
5
& Louis Gooren
6
1
Bayer Schering Pharma, Scientifc Affairs Men`s Healthcare, Berlin,
Germany;
2
Gulf Medical University, Ajman, UAE;
3
Private Urology
Practice, Bremerhaven, Germany;
4
Department of Internal Medicine,
Klinikum Bremerhaven, Bremerhaven, Germany;
5
Department of
Psychiatry, Leiden University Medical Center, Leiden, The Netherlands;
6
Department of Endocrinology, VuMC Amsterdam, Amsterdam,
The Netherlands.
Objectives
To investigate effects of testosterone in hypogonadal men with Crohn`s
disease (CD).
Design and methods
Thirteen men, aged 45-67 years were diagnosed with subnormal plasma
testosterone. They received treatment with parenteral testosterone undecanoate.
They also suffered from CD. The Crohn`s disease activity index (CDAI) (1) was
used to assess the severity of the disease. Levels of testosterone and C-reactive
protein (CRP) were compared between the 13 men with CD and the other 109
hypogonadal men in this study.
Results
Levels of CRP were 22.7 mg/dl (95% confdence interval of the mean (CI):
14.9-34.3) in 13 men with CD versus 3.5 (2.9-41) in 107 control men (P0.001).
Levels of testosterone were lower in men with CD versus controls
(2.60.4 ng/ml; 95% CI: 2.3-2.9 vs 2.90.4; 95% CI: 2.8-3.0; P0.02).
Upon normalization of testosterone, there was a signifcant decline in the CDAI
occurring over the frst 15 months, with stabilization of the improvement over the
next 9 months. CRP levels declined progressively. Body mass index and waist
circumference declined and the metabolic profle improved. Hemoglobin levels
and the hematocrit increased signifcantly.
Conclusion
Upon normalization of plasma testosterone an improvement of the CDAI and
CRP was noted. Also hemoglobin improved. The interpretation of the mechanism
of this improvement is speculative. i) There is an inverse relationship between
testosterone and levels of some infammatory markers. ii) Endogenous cortisol
combats infammation. The local activation of glucocorticoids is mediated by
11-hydroxysteroid dehydrogenase type 1 (11-HSD1) increasing cortisol, and
11-HSD2 decreasing cortisol. Expression of 11-HSD1 is elevated in infamed
tissue in CD, whereas 11-HSD2 expression is decreased. Little is known about
the effects of testosterone on local activation/deactivation of cortisol in the gut.
P199
Papillary thyroid carcinoma metastasis to the parapharyngeal space
Gilberto Perez Lopez, Marta Carrasco de la Fuente, Marta Cano Megi as,
Macarena Alpanes Buesa, Jesus Gomez Marti n & Pilar Zurita Sepulveda
Department of Endocrinology, Hospital Ramon y Cajal, Madrid, Spain.
Objective
Describe a case of a patient diagnosed with papillary thyroid carcinoma by a
retropharyngeal tumor.
Methods
A 46-year-old male was referred from the otorhinolaryngology consult to our
department with the post-operative diagnosis of papillary thyroid carcinoma, with
6 months history of upper airway dyspnea and dysphagia to solids. Physical
examination: right side adenopathies, not painful on palpation. No goitre.
Laryngoscopy: hypertrophy of right posterior pharyngeal wall, epiglottis with
rotation. Glotis was permeable. Mobile vocal cords. Pyriform sinus free. Cervical
and thoracic TC: right retropharyngeal and internal jugular adenopathic
conglomerates. Subcentimetrical mediastinal lymph nodes. Nasopharyngeal MRI:
right retropharyngeal paracentral mass rejecting adjacent structures. FNAof cervical
lymph node: lymph node with metastases of papillary thyroid carcinoma.
Results
Surgical treatment is decided. Transcervical excision was performed in right
parapharyngeal tumor, sacrifcing laryngeal pedicle and right superior laryngeal
nerve, and total thyroidectomy with cervical emptying of areas: bilateral VI, right II
(A and B) and V. Tracheostomy. Pathological diagnosis: thyroid: papillary thyroid
microcarcinoma (7 mm) located in the right upper pole, partially encapsulated and
behind the capsule without infltrators. Right cervical lymphadenopathy: multiple
lymph node metastases of papillary carcinoma. Retropharyngeal mass: extensive
infltration of papillary carcinoma. Six weeks after surgery is given an ablative dose
of I131.
Conclusions
Approximately 0.5%of all head-and-neck tumors present in the parapharyngeal space
(PPS). The neoplastic processes, which may involve the PPS, include primary PPS
tumors, the direct extension of tumors fromregions adjacent to the PPSand regional or
distant metastases to the PPS. Thyroid papillary carcinoma presenting as a pharyngeal
mass is a rare clinical occurrence and has only been reported sporadically.
P200
Evolution of thyroid angiosarcoma under complex therapy: a case
report
Dan Niculescu
1,2
, Dumitru Ioachim
2
, Dana Terzea
2
, Ionela Baciu
1
,
Anda Dumitrascu
2
, Dan Hortopan
2
& Mihail Coculescu
1,2
1
Carol Davila University, Bucharest, Romania;
2
'C. I. Parhon` Institute of
Endocrinology, Bucharest, Romania.
Abstract
Thyroid angiosarcoma is an aggressive and very rare type of thyroid
malignancy originally diagnosed in iodine-defcient areas. The prognosis is
poor and in most cases surgery proved to be ineffcient. The fne needle
aspiration biopsy (FNAB) and histology can rarely differentiate angio-
sarcoma from anaplastic carcinoma, and the fnal diagnosis is based on
immunopositivity for vascular markers and absence of epithelial markers. We
present here the case of primary thyroid angiosarcoma in a 52 years old male
from a non-endemic area. He frst presented with a rapidly enlarging cervical
mass and the FNAB revealed anaplastic features. The patient received
external beam radiotherapy with a total dose of 40 Gy. After an apparent
tumoral volume reduction he underwent total thyroidectomy. Hematoxilin-
eosin staining confrmed the undifferentiated malignant proliferation but the
immunohistochemistry showed CD31, vimentin and FVIII positivity and
thyroglobulin, calcitonin, TTF-1 and MNF116 negativity indicating an
angiosarcoma. The patient started chemotherapy with pharmorubicin and
cisplatin for tumor remnants yet with no effect on the tumor volume.
Following three cycles of chemotherapy, 19 months after the diagnosis, the
patient died due to respiratory failure. Whenever an apparently anaplastic
thyroid carcinoma is associated with good outcomes in terms of survival and
performance status we should look for a differential diagnosis.
P201
A successfull case of pregnancy in a woman with ACTH-independent
Cushing`s syndrome
Agnieszka Jagodzinska, Renata Michalak & Wojciech Zieleniewski
Medical University of Lodz, Department of Endocrinology, Lodz, Poland.
The most typical signs of Cushing`s syndrome (CS) are easy bruising,
hypertension and 'cushingoid` phenotype with central deposits of fat tissue.
Moreover, hypercortisolemia may affect also reproductive systemleading to loss of
libido and impotence in men and menstrual disturbances and infertility in women.
However, some of the patients remains fertile, althoughpregnancy is uncommonand
is associated withfetal morbidity and mortalityin about 70%of cases. Most common
are premature births, stillbirths and spontaneous abortions.
Here, we present a case of 31-year old woman with easy bruising, hypertension,
oligomenorrhea and muscle weekness. Hormonal results performed in January 2008
showed undetectable ACTH concentration and stiff diurnal rhythm of cortisol
without suppression after 1 and 8 mg of dexamethasone what confrmed ACTH-
independent CS. Moreover, elevated BhCG might suggest 3-5 weeks of gestation.
US scan revealed a 2 cm adenoma of the left adrenal gland, confrmed by CT after
parturition.
She was given metyrapone (0.5 g t.i.d.), but as this treatment was not signifcally
effcient, ketoconazole (0.4 g twice a day) was added. The treatment was well
tolerated.
She delivered a healthy boy in September 2008 by a cesarean section. Avideoscopic
adrenalectomy was performed later and hitopathological exam confrmed a 23 mm
adenoma of the left adrenal.
Concluding, we think that medical treatment of CS in pregnant women is
well-tolerated and safe both for the mother and fetus.
P202
Oral bisphosphonates - therapeutical results after two years treatment
in osteogenesis imperfrecta type Ia
Corina Galesanu
1
, Alexandru Florescu
1
, Ilinka Grozavu
1
, Petronela Iovita
1
& Mihail-Romeo Galesanu
2
1
University of Medicine and Pharmacy, IASI, Romania;
2
Centre of Imaging
and Radiological Diagnosis, IASI, Romania.
Introduction
Osteogenesis Imperfecta (O.I.) is a genetic disorder commonly known as brittle
bone disease. The majority of people with O.I. have a mutation in one of two
genes, COL 1A1 or COL 1A2, that encode type I collagen. In most families, O.I.
is inherited in an autosomal dominant pattern. Dual Energy X-ray Absorptiometry
- bone mineral density (DXA-BMD) test provides information about bone
quantity, not quality. The bisphosphonates - treatment can minimizing fractures
by increasing bone density and reducing bone fragility.
Objectives
We followed the goal of BMD and the new fractures under the treatment with oral
bisphosphonates, lengthways two years in six teen-agers affected by O.I. type IA.
Two boys and four girls were treated with risedronate (Actonel) 35 mg/weekly,
two years or more. The mean age for girls was 15.5 years and for boys 17.7 years
at the debut of treatment. The boys were brothers and the girls sisters two by twos.
All patients had more than four fractures in the past. At the beginning of the
therapy and each 12 months the lumbar spine and whole body BMD were
measured by DXA (Hologic - Delphi W; SN 7044990).
Results
At baseline the lumbar spine BMD- mean for boys was 0.782 g/cm
2
and increased
at 0.959 g/cm
2
(22.6%) after 24 months. For the girls, mean BMD lumbar
spine the baseline was 0.670 g/cm
2
and increased at 0.751 g/cm
2
(12.0%) after
24 months. The whole body BMD mean was 0.882 g/cm
2
before the treatment
and increased at 1.105 g/cm
2
(34.4%) after 24 months for boys. For girls the
whole body mean BMD was for the beginning 0.782 g/cm
2
and increased at
0.872 g/cm
2
(11.5%) at 24 months. No new fractures under the treatment.
Conclusions
The BMD remain lower than normal in O.I., even under the treatment. In our
study the goal of BMD under bisphosphonates was signifcantly in the both sites.
Oral bisphosphonates in standard doses seems to be effective therapy in patients
with O.I.
P203
Long-standing testicular adrenal rest tissues in a patient with congenital
adrenal hyperplasia due to 11-beta hydroxylase dehciency with
homozygous mutation l299p in the Cyp11b1 gene
Taner Bayraktaroglu
1
, Egbert Schulze
2
& Faruk Alagol
1
1
Istanbul University, Istanbul Faculty of Medicine, Department Of Internal
Medicine, Division of Endocrinology and Metabolism, Istanbul, Turkey;
2
Molekulargenetisches Labor Endokrinologisch-Humangenetische
Gemeinschaftspraxis, Heidelberg, Germany.
Background
A testicular adrenal rest tumor in an adult males who complaint with testicular
enlargement and fertility request, and diagnosed with congenital adrenal
hyperplasia due to 11-beta hydroxylase defciency with homozygous mutation
L299P in the CYP11B1 gene and accompanied by impaired spermatogenesis and
Leydig cell failure was reported.
Case Report
A 27-year-old man was complaint with bilateral progressive painful enlargement
of the testes, continuing for several years, and fertility request. On examination,
his height was 156 cm and weight was 66 kg. His blood pressure and pulse rate
were 190/120 mmHg and 70 beat per minute respectively. Bilateral testes were
abnormal on palpation, being nodular and knobby, irregular margin and hard.
Bilateral testes were abnormal on palpation, being nodular and knobby, irregular
margin and hard. The right and left testes were measured 5,7 cm within excess
of 25 ml. A clinical diagnosis of adrenal rests in the testes was made, and
supported on a testicular ultrasound and catheterization of the venae cava and
gonadal veins. Genetic analyses showed homozygous mutation Leu299Pro in
CYP11B1 gen. The patient has treated with prednisolone 5 mg po daily and
amlodipin 10 mg per day, and referred to fertility unit for in vitro fertilisation.
Conclusion
The mutation Leu299Pro has been described a reduction of the enzymatic activity
of the mutated protein to 1.2%. The testes of affected males should be carefully
examined throughout childhood, adolescence, and adulthood. A local negative
effect of the tumor on the normal testicular tissue possibly contributed to impaired
Leydig cell function. At this location, large tumors can easily compress the rete
testis and cause obstructive azoospermia. The preferred treatment of testicular
adrenal rest tumors and/or impaired spermatogenesis in patients with CAH is
intensifying glucocorticoid therapy.
P204
Ganglioneuroblastoma: a rare cause of adrenal mass in adults
Gulsah Elbuken
1
, Zuleyha Karaca
1
, Ilkay Cakir
1
, Fatih Tanriverdi
1
,
Mustafa Gulec
2
, Alper Akcan
3
, Hulya Akgun
1
, Kursad Unluhizarci
1
& Fahrettin Kelestimur
1
1
Erciyes University Medical School Department of Endocrinology, Kayseri,
Turkey;
2
Erciyes University Medical School Department of Radiology,
Kayseri, Turkey;
3
Erciyes University Medical School Department
of General Surgery, Kayseri, Turkey;
4
Erciyes University Medical School
Department of Pathology, Kayseri, Turkey.
Introduction
Neurogenic tumors in abdomen arise from ganglion cell origin and usually seen in
the distribution of the sympathetic ganglia along paraspinal areas or adrenal
medulla or the organ of Zuckerkandl.
Ganglioneuroblastomas are the tumors of sympathetic cell origin which have the
features of both malignant and benign neuroblastoma. The presence of immature
tissue indicates potentially a malignant behavior. Ganglioneuroblastomas are
most often seen in the earlier ages of childhood, especially 2 to 4 years with
similar frequency in boys and girls. It is extremely rare in adults. Because of this,
the radiographic and pathological features of the tumor have not been clearly
understood.
Case
A 29-year-old man with adrenal mass is presented. Laboratory evaluation was
compatible with a non-functioning adenoma. The computed tomography revealed
a well-circumscribed tumor with central hypodens area which was 3.5,4.5 cm
in size and had 38 Hounsfeld unit (HU). Based on the non-benign radiological
features of adrenal mass, it was removed laparoscopically. The lesion was
diagnosed as ganglioneuroblastoma with adrenal gland and surrounding fatty
tissue invasion.
Conclusion
The predictive value of CT and MRI characteristics of adrenal incidentalomas is
quite consistent with histopathologic fndings. To exclude malignancy, adrenal
masses with suspicious imaging should be removed. Ganglioneuroblastoma
should be kept in mind in differential diagnosis of adrenal masses with increased
HU on adrenal CT.
P205
Amiodarone induced thyreopaties
Marianna Bystrianska, Adrian Bystriansky, Gabriela Kaliska
& Iveta Wildova
F.D. Roosevelt Faculty Hospital, Banska Bystrica, Slovakia.
We would like to point out that the incidence of amiodarone induced
thyreotoxicosis is considerable. It is essential that both cardiologists and
endocrinologists tightly cooperate when treating patients with amiodarone.
Methods
We analysed retrospectively data of 150 pacients (100 male and 50 female), whith
average age 63.9712.13 years, treated with amiodarone, followed-up on
arythmologic outpatient clinic from 1.1.2005 till 31.12.2006. All of the patients
had TSH a fT4 examined on regular basis.
Results
The average value of TSH of all the patients during the 24 months of follow-up
was 4.246.6 mIU/l, the average value of fT4 was 22.1218.38 pmol/l.
Amiodarone induced hypothyroidism was confrmed in 9 (6%) pacients (median
TSH:15.43 mUI/l a median fT4 12.2 pmol/l). The average time of treatment by
amiodarone in this group was 22 months.
Amiodarone induced thyreotoxicosis was confrmed in 12 (8%) pacients (median
fT4 33.6 pmol/l and median TSH 0.015 mIU/l). The average time of treatment by
amiodarone in this group was 30 months.
We include two interesting case reports of patients with implanted ICD. The frst
case presented with oligosymptomatic form of amiodarone induced thyreothox-
icosis. The second case presented with thyreotoxic crisis requiring acute total
thyreoidectomy.
Conclusions
Despite the new antiarhytmic drugs that have been evolved lately, amiodarone is
still a potent antiarhytmic which is in some cases a medicine of choice. One of the
feared side effects is amiodarone induced thyreotoxicosis, which is a serious
(potentially fatal) condition that requires prompt diagnosis and treatment. Regular
checks of TSH and fT4 in pacients using amiodarone are essential.
P20
The role of salivary -amylase in prediction of failure of smoking
cessation
Michaela Duskova
1
, Katerina Simunkova
1,2
, Martin Hill
1
,
Hana Hruskovicova
1
, Petra Hoskovcova
1
, Eva Kralikova
2
&
Luboslav Starka
1
1
Institute of Endorinology, Prague, Czech Republic;
2
3rd Medical
Departement General University Hospital, Prague, Czech Republic.
Background
A high percentage of adult smokers try to quit, but most of these attempts fail. The
ability to predict the success or failure of smoking cessation efforts will be useful
for clinical practice. Stress response is regulated by two primary neuroendocrine
systems. Salivary cortisol has been used as a marker for the hypothalamus-
pituitary-adrenocortical axis and salivary -amylase as a marker for the
sympathetic adrenomedullary system.
Methods
We studied 62 chronic smokers (34 women and 28 men with an average age of
45.212.9 years). The levels of salivary cortisol and -amylase (SAA) were
measured during the period of active smoking, and 6 weeks and 24 weeks after
quitting. The local Ethics Committee approved the study.
Results
The men who were unsuccessful in cessation showed signifcantly higher levels of
salivary -amylase over the entire course of the cessation attempt. Before
stopping smoking, salivary cortisol levels were higher among the men who were
unsuccessful in smoking cessation. After quitting, there were no differences
between this group and the men who were successful in cessation. In women we
found no differences between groups of successful and unsuccessful ex-smokers
during cessation. In both groups of men, there was a signifcant and acute decrease
in salivary cortisol levels after smoking cessation. The women, on the other hand,
showed only a slight but insignifcant decrease in salivary cortisol after smoking
cessation. Neither the men nor the women showed any change in sAA
concentrations over the course of cessation.
Conclusion
Increased levels of salivary -amylase before and during smoking cessation may
predict failure to quit in men. On the other hand, no advantage was found in
predicting the failure to quit in women. The results of our study support
previously described gender differences in smoking cessation.
The study was supported by grant 10215-3 IGA MZCR.
P20I
Childhood nephrogenic diabetes insipidus revealed by urinary
megabladder in two adult male brothers
Carmen Barbu
1,2
, Dariana Ionita
2
, Liudmila Minea
2
& Simona Fica
1,2
1
2
Elias Hospital, Bucharest, Romania.
We present the history of two brothers, 19 and respectively 21 years old who were
admitted in our department for reevaluation in the context of renal complications.
From their medical history we keep in mind that central DI was diagnosed
15 years ago and desmopresin treatment was indicated. Meanwhile, patients
received desmopresin unsteady for very short periods of time (less than 2 years)
due to poor adherence and obvious ineffciency of the treatment. They claim
medical care when clinical signs of megabladder appered raising the suspicion of
obstructive renal disease.
At the admission, biological parameters were within normal limits. Abdominal
ultrasound revealed hydronephrosis grade I respective III and megabladder in
both brothers. CT scans confrmed these issues without no evidence of an
obstructive cause. The thirst and desmopresin treatment test revealed the
diagnosis of nephrogenic DI with minimal response to desmopresin in the eldest
brother.
Treatment was started and urine volume was reduced to 4 l/day with 3 tablets
hydrochlorothiazide and 2 tablets indometacinum associated to desmopresin in
the eldest brother.
The important aspects of the cases could be pointed as: in the childhood,
ineffcient treatment was interpreted as psychogenic polydipsia, lowering the
adherence to treatment or further investigations. Consequently they drop off the
treatment until complications appeared. Moreover, lack of medical records in this
period of time raised the question whether renal disease is cause or the
complication of the DI.
This case showed us that nephrogenic DI could have a signifcant impact in terms
of biological complications and psycho-social feld due to both diagnosis and
treatment diffculties.
In this case severe hydronephrosis and megabladder appeared to be an adaptative
response of the body in the attempt of young patients to manage the polyuria from
social point of view.
P208
A family with Von Hippel - Lindau disease (VHL)
Ioannis Svilias
2
, Jan Cap
1,2
& Tomas Vasatko
1
1
Charles university, Hradec Kralove, Czech Republic;
2
University hospital,
Hradec Kralove, Czech Republic.
We present a family with Von Hippel - Lindau disease (VHL). First two brothers
were diagnosed with pheochromocytoma, one of them consecutively in both
adrenals in a 16-years` interval. Then the daughter of one of these two men was
diagnosed with pheochromocytoma in both adrenals and one extraadrenal
tumour. Later the daughter of the second man was successfully operated for
unilateral pheochromocytoma. No neurological signs were present, no other
tumours found, and the ocular investigation was normal. Genetic investigation did
not prove suspicion on succinatedehydrogenase mutation, but Von Hippel-Linau
disease was proved instead.
The NMR image showed cerebellar and spinal cord haemangioblastoma in both
brothers and one of the young ladies. These lesions were asymptomatic until
pregnancy. In the13th week of pregnancy the cerebellar haemangioblastoma
grew in this 33 years old lady and caused obstruction of the third ventricle
and hydrocephalus. The tumour was successfully excised via suboccipital
craniectomy with favourable outcome for both the mother and the foetus.
Solid vascular tumour of the pancreatic head compatible with insular tumour,
without any evidence of hormonal production was recently diagnosed in the
younger of the two ladies (28 years old) and surgical enucleation is indicated.
We conclude that this family suffers from VHL type A, with low risk of renal
cancer. The hemangiomas were asymptomatic for many years and were
diagnosed only after the genetic diagnosis has been determined. Interesting is
the sudden growth of cerebellar hemangiona during pregnancy.
P209
The use of an algorithm to aid diagnosis and treatment of patients with
hyponatraemia secondary to SIADH
Joseph Verbalis
1
& Ewout Hoorn
2
1
Georgetown University Medical Center, Washinton DC, USA;
2
Erasmus
Medical Center, Rotterdam, Netherlands.
Hyponatraemia is the most common electrolyte disorder encountered in clinical
practice, occurring in 15% to 30% of both acutely and chronically hospitalised
patients. Hyponatraemia is important clinically because: 1) acute severe
hyponatraemia can cause substantial morbidity and mortality; 2) mortality is
higher in hyponatraemic patients with a wide range of underlying diseases; 3)
overly rapid correction of chronic hyponatraemia can cause osmotic demyelina-
tion; 4) even mild 'asymptomatic` hyponatraemia can be accompanied by
neurocognitive disturbances, gait instability, and increased falls; 5) chronic
hyponatraemia causes bone loss in animals and is associated with a greater risk of
osteoporosis in humans. Optimal treatment strategies have not been well defned,
in part because of marked differences in symptomatology and clinical outcomes
based on the acuteness or chronicity of hyponatraemia. As a result, hyponatraemia
is frequently mismanaged, and incorrect management has been associated with
increased mortality. Tolvaptan, a selective vasopressin V2 receptor antagonist
that reliably reduces urine osmolality, increases electrolyte-free water excretion
(aquaresis), and safely raises the serum sodium concentration, was approved by
the EMEA for the treatment of hyponatraemia caused by the syndrome of
inappropriate antidiuretic hormone secretion (SIADH) in 2009. A critical review
of the clinical data related to correction of hyponatraemia using various
therapeutic modalities has prompted the development of an algorithm for
selecting the appropriate therapy for hyponatraemia patients based primarily on
the presenting symptoms rather than on the level of serum sodium. Application of
this algorithm to clinical practice should aid physicians both with making a
correct diagnosis of SIADH, and with selecting the most appropriate initial
treatment for hyponatraemia caused by SIADH. Future studies will enable
assessment of the effects of using the algorithm to improve clinical outcomes
across a variety of different disease states by virtue of reducing morbidity and
mortality associated with hyponatraemia in patients with SIADH.
P210
Two rare genetic causes of aberrant growth: Robinow syndrome with
partial GH dehciency and dwarhsm and Simpson-Golabi-Behmel
syndrome with gigantism
Dumitru Branisteanu, Ionut Repede, Roxana Novac, Serban Turliuc,
Simona Mogos, Dana Turliuc & Voichita Mogos
University of Medicine and Pharmacy 'Gr. T. Popa`, Iasi, Romania.
We describe two very rare genetic diseases characterized by particular physical
features and deviation from normal growth. The frst patient, CM, was admitted
for delayed growth (113 cm at 8 years of age, -3 S.D.). The child had short lower
arms with small hands and clinodactyly of the ffth fnger. He had round widely
spaced eyes with long eyelashes, a fat profle and prominent forehead, short
upturned nose, misaligned teeth and gum hypertrophy. We diagnosed a rare
(incidence of 1/500 000) autosomal dominant 'foetal face` Robinow syndrome.
The recessive syndrome is more severe and is related to mutations of a tyrosine
kinase gene located on chromosome 9q22. The mutation for the dominant form is
currently unknown. Our patient responded poorly to GH stimulation tests, so GH
therapy was initiated. The second patient, IU, a 31 year old adult with a height of
220 cm, large extremities, horse-like face and severe mental handicap, was
admitted with initial suspicion of acromegalic gigantism. The patient`s weight at
birth was of 4500 g and he was the tallest of his generation from an early age.
Clinical examination revealed a large mouth, macroglossy with incomplete mouth
occlusion, defects in dental implantation with supernumerary teeth and sharp
canines ('bulldog teeth`), and a short nail bed. The GH/IGF-I axis and the
pituitary gland visualised by MRI were normal. Interestingly, the patient has a
younger brother with comparable, although less dysmorphic features, with a
height of 'only` 195 cm and a normal intellect. The patient was diagnosed with
Simpson-Golabi-Behmel (SGB) syndrome, a rare X-linked disease whereby
glypican-3 is inactivated, leading to enhanced activation of various growth
factors. The SGB syndrome is a true rarity - only 130 cases described until 2008.
Perturbed growth process added to mysterious clinical features could be the
diagnostic tip for rare diseases with genetic background.
P211
Unilateral Graves` orbitopathy and autoimmune atrophic thyroiditis:
case report
Mihaela Vlad, Ioana Golu & Ioana Zosin
'Victor Babes` University of Medicine and Pharmacy, Timisoara, Romania.
Graves` orbitopathy (GO) represents ophthalmic symptoms that affect, usually,
patients with Graves` disease. Rarely, it can occur in subjects without thyroid
dysfunction or with hypothyroidism (2-5% of the cases).
In this report we present a rare case with unilateral GO and initial euthyroidism,
which progressed to hypothyroidism, due to an autoimmune atrophic thyroiditis.
A 39-year-old woman, long-term smoker, was referred to our department for
investigations due to right eye exophthalmia. On admittance the patient didn`t
show symptoms or signs typical for hypo- or hyperthyroidism. Laboratory results
indicated normal TSH and FT
4
. Immunological determinations revealed elevated
titers of anti-TSH receptor antibodies (7.7 IU/l, normal range 0-1 IU/l) and anti-
thyroid peroxidase antibodies (917.3 UI/ml, normal range 0-50 UI/ml). Thyroid
ultrasonography presented a normal thyroid volume with decreased echogenicity
of the parenchyma, without nodules. Magnetic resonance image of the orbits
showed right exophthalmia due to thickening of all the orbital muscles and of the
adipose tissue, allowing us to exclude a mass that could induce the protrusion of
the right eye.
The CAS score was 3 and NOSPECS index - 4. A moderate active form of
unilateral thyroid orbitopathy was diagnosed and methylprednisolone pulse
therapy was given.
Despite the glucocorticoid therapy, nine months later the patient was hospitalized
again due to progression of orbitopathy. Symptoms and signs of hypothyroidism
were detected and hormonal determinations revealed high TSH (68.8 UI/ml,
normal range 0.49-4.67) and low FT
4
(,0.4 ng/dl, normal range 0.71-1.85).
Levothyroxine therapy was started and methylprednisolone pulse therapy was
given, with partial remission of the ophthalmic symptoms.
Conclusions
This report describe a rare case with unilateral GO and atrophic autoimmune
thyroiditis. The unexpected evolution to hypothyroidism has worsened the
exophthalmia. The correct detection and treatment of the thyroid insuffciency
resulted in a signifcant improvement of the clinical state.
P212
The difhculties of Cushing` s disease ~ case report
Ilinka-Andreea Grozavu, Alexandru Florescu, Natalia Lisnic,
Luminita Apostu, Tamara Bostaca, Liliana Moisii, Dan Niculescu
& Corina Galesanu
University of Medicine and Pharmacy 'Gr. T. Popa` Iasi, Romania.
Cushing`s disease is relatively rare and affects most commonly adults aged 20 to
40. It is associated with high morbidity and mortality; early detection and
diagnosis of Cushing`s disease may lead to decreased this two facts and improved
quality of life.
We present a 32-year-old man with abdominal purple striae, central obesity with
typical 'moon face` and oscillatory blood pressure values.
Hormonal exams revealed normal plasmatic cortisol value but elevated urinary
free cortisol (UFC) value - 350 g/24 h(N9-180). ACTH10 pg/ml(N,46).
Eye fundus and lateral skull X-ray were in normal range. Abdominal CT showed a
5 mm diameter left adrenal tumor. DXA-BMD spinal Z score-2.2 S.D, Tscore
-2.2 S.D. The diagnosis was: Cushing`s syndrome (left adrenal adenoma),
osteopenia, obesity. The frst treatment was left adrenalectomy (histology: diffuse
and nodular hyperplasia). After the frst month post surgery: UFC300 g/24 h,
abdominal echography: right adrenal hyperplasia. The new treatment was
right adrenalectomy (histology: diffuse hyperplasia). After 3 weeks UFC
109.2 g/24 h. After two months post surgery, the simptomatology persisted
and the UFC level was high (511 g/24 h); MRI - pituitary fosa with
homogeneous content. Abdominal CT- glandular tissue (1 cm diameter) on
the left adrenal locus. Surgical resection was performed for the remaining tissue,
but the hypercortisolism persisted with ACTH302 pg/ml. In order to exclude
the ectopic ACTH syndrome, we performed also chest and abdominal
CT, thyroid echography, chromogranin A and 5-Hydroxy-indolacetic acid.
We decided that the pituitary surgery by transsphenoidal approach is the next
step. ACTH post surgery 265 pg/ml; Cortisol pl.639.2 mmoli/l. After 1 year,
UFC 1545.8 nmoli/24 h, MRI -pituitary tumor (8/6 mm). A new trans-
sphenoidal resection was proposed (histology:acidophil pituitary adenoma).
Plasmatic cortisol postsurgery 9 ng/ml. Long term treatment recomanded:
Prednisone 5 mg/day, Fludrocortisone 0.1 mg/day.
The initial false 'normal` level of ACTH and the variability of the normal ranges
for plasmatic and urinary free cortisol depending on assay methodology created
the diffculties in diagnosing and managing Cushing`s disease.In our case, the
clinical and biological parameters return to normal after 48 months since the frst
sign of the disease.
P213
The role of octreotide in the management of young patients with
acromegaly
Alexandru Florescu, Ilinka Grozavu, Natalia Lisnic, Luminita Apostu,
Liliana Moisii, Ion Poeata & Corina Galesanu
University of Medicine and Pharmacy 'GR. T. Popa`, Iasi, Romania.
The last decade has provided major progress in the development of highly specifc
and selective pharmacological agents that have facilitated a more aggressive
approach to the treatment of patients with acromegaly. Initial transsphenoidal
surgery still appears to be the frst line of treatment, but in many cases the
biochemical cure targets are not reached and the patient needs adjuvant therapy.
Somatostatin analogues have become the mainstay of the medical treatment of
acromegaly, with dopamine agonists and GH-receptor antagonists as an
alternative medication.
This is our experience regarding two patients treated with Octreotide.
First patient (29-year-old male) was diagnosed with acromegaly in September
2004 and in the same year transsphenoidal surgery was performed. From January
2008 we started Lanreotide (Somatuline) 30 mg/14 days for 12 months, a period
in which his GH levels increased from 17, 5 g/l to 42 g/l and his IGF1 levels
from 550 ng/ml to 917 ng/ml. We decided to change the somatostatin analogue
and from July 2009 he received Octreotide (Sandostatin LAR) 20 mg/28 days.
After 6 months of treatment his GH and IGF1 levels signifcantly decreased
(IGF1 by 55% and GH by 70%).
The second patient (26-year-old-male) had a GH level of 52 g/l and an IGF1
level of 839 ng/ml at the time of diagnosis. After 6 months of therapy with
Octreotide (Sandostatin LAR) 20 mg/28 days both of them decreased (IGF1 by
70% and GH by 80%).
The patients with acromegaly who are not responding to Somatuline therapy may
beneft from Sandostatin LAR treatment. This is also a good option for the young
patients, where fertility is a priority.
P214
Thyroid antibodies and renal function
Razvan Alexandros Badila
1
, Ifgenia Kostoglou-Athanassiou
1
,
Aikaterini Chronaiou, Aikaterini Michou
1
, Olympia Karagianni
1
,
Georgios Ntatsis
2
, Areti Karf
1
& Konstantinos Tzioras
1
1
2
Department of Nephrology, Red Cross Hospital, Athens, Greece.
Thyroid antibodies are a heterogenous group of antibodies with diverse and partly
unknown properties. The effect of these antibodies on other organ systems and
especially on the renal system is unknown. There is however some evidence that
thyroid, in particular thyroglobulin antibodies, may affect renal function and may
cause glomerulonephritis and possibly nephrotic syndrome. Nephrotic syndrome
may alter thyroxine metabolism, as it affects its renal excretion and its albumin
conjugation and may increase its turnover.
The aim of the study is to present a case of a patient with hypothyroidism, a large
goiter and nephrotic syndrome which appeared in parallel with the emergence of
extremely high thyroid, specifcally thyroglobulin, antibody levels.
A male patient, aged 64 years, presented with a large goiter, hypothyroidism,
nephrotic syndrome and extremely high thyroid antibody concentrations,
thyroglobulin antibody and thyroid peroxidase antibody levels being
9.833 IU/ml (normal values ,100 IU/ml) and 596.9 UI/ml (normal values
,10 IU/ml), respectively. Levothyroxine 0.2 mg daily was initially administered
for 3 weeks, TSH levels increasing from 40 mIU/l to 49 mIU/l. Thereafter
levothyroxine dose was increased to 0.3 mg daily and TSH levels normalized
after 2 months. Urinary albumin levels were 7.738 g/24h increasing to
12.79 g/24 h. Methylprednisolone 48 mg and levothyroxine 0.3 mg daily were
administered. Euthyroidism was achieved, goiter size decreased and urinary
albumin levels decreased to 3.0 g/24 h. Despite the remission of the clinical
syndrome thyroid antibody levels persisted.
Conclusion
The case of a patient with autoimmune Hashimoto thyroiditis is described who
presented with goiter and hypothyroidism in parallel with nephrotic syndrome. It
appears that several forms of thyroid antibodies in extremely high concentration
may affect the kidney and cause the appearance of nephrotic syndrome. It seems,
also, that in the nephrotic syndrome the metabolism of therapeutically
administered levothyroxine and its action are multiply affected.
P215
The etiologic prohle of short stature in the south west of Romania
between 2004-2009
Otilia Marginean
1
, Ioan Simedrea
1
, Dana Bucuras
2
, Ecaterina Pavel
1
,
Adrian Craciun
1
, Ioana Maris
1
& Camelia Daescu
1
1
Clinical Children`s Hospital 'Louis Turcanu`, Timisoara, Romania;
2
Endocrinology Department, Bega Hospital, Timisoara, Romania.
Background
Short stature can be a sign of a wide variety of pathologic conditions or inherited
disorders.
Aim
To show the etiology of short stature in our region in order to asses the rationale
treatment and genetic advice.
Between January 2004 and December 2009, we have studied the prevalence and
etiologic profle of the children admitted in the Endocrinology Department of
Children`s Clinical Hospital Timisoara. The working protocole included: weight
and length birth, gestational age, auxological parameters at admission in the
hospital, morphogram, laboratory studies (usual BCC, GH level -basal and after
stimulation, IGF1, DHEA, 17 OH progesterone, karyotype, in selected cases),
bone age, MRI - in selected cases.
Results
During a 5 years period, out of 71015 children, 9570 have been diagnosed
with short stature, with a prevalence of 13.47%. The etiology of short stature
was complex: Gh defciency, 98 cases (1.024%), Idiophatic short stature, 5
cases (0.052), IGF1 defciency, 6 cases (0.062%),Turner Syndrome, 6 cases
(0.062%), Noonan syndrome, 1case (0.01%), Sekel Syndrome, 2 cases (0.02%),
Crit du Chat, 1 case (0.01%), Cornelia de Lange, 3 cases (0.03%), Silver
Russel, 1 case (0.01%), Prader-Willy, 2 cases (0.02%). Some of this children
(Gh defciency, Idiophatic short stature, Turner, Noonan and Silver Russel
syndroms) have been treated with somatotropin according to the European and
National standards and with the parents agreement.In all cases genetic advice
was made.
Conclusions
1. In our region the prevalence of short stature is relatively high.
2. The etiologic profle is quite various.
3. The incidence of genetic short stature is high and neonatal screening needs
to be developed in order to achieve a prenatal diagnose.
4. A lot of parents don`t have enough information about somatotropin and refuse
the treatment.
P21
10 years experience with somatostatin analogue (SSA) treatment in
multiple endocrin neoplasia type 1 (a case report)
Sepp Krisztian
1
, Valkusz Zsuzsanna
1
, Kiss Ildiko
3
, Pavics Laszlo
2
& Julesz Janos
1
1
Endocrinology Unit, University of Szeged, Szeged, Hungary;
2
Department
of Nuclear Medicine, University of Szeged, Szeged, Hungary;
3
Euromedic
Diagnostics, Szeged, Hungary.
Multiple endocrine neoplasia (MEN-1) is a rare congenital disease with genetic
background. The MEN-1 gene encodes the menin protein, which acts as a tumour
suppressor. Mutation of one allele and the inactivation of the other allele of this
gene lead to clonal proliferation and to the development of tumours. The clinical
manifestation of MEN-1 is a combination of endocrine (most commonly
parathyreoid adenomas, entero-pancreatic endocrine tumours, pituitary tumours)
and non-endocrine tumours.
In 1993 a 42-year-old primary hyperparathyroidic male patient was operated on
an adenoma located in one of his right parathyreoid glands. Six years later, the
patient was treated because of repeated gastrointestinal bleedings due to multiple
jejunal ulcers. Magnetic resonance imaging (MRI) and octreotide scintigraphy
showed a 15 mm tumour in the pancreas, consistent with high level of serum
gastrin. A diagnosis of gastrinoma was established and somatostatin analogue
(SSA) treatment was started. One year later, primary hyperparathyroidism
recurred due to an adenoma in the left parathyroid gland. For this reason,
parathyreoidectomy was completed and a quarter of one gland was auto-
transplanted subcutaneously. Furthermore, increased level of prolactin was
measured repeatedly, and sella MRI showed a 3 mm microadenoma in the
adenohypophysis. Bromocriptine (Br) medication was then commenced. Under
continuous SSA and Br therapy for 10 years, abdominal CT (computer
tomography) and MRI check-ups disclosed an arenal incidentaloma whereas no
pancreatic tumour could be detected by these techniques. In this report, we
present a successful 10-year SSA treatment of a MEN-1 related gastrinoma with
the disappearence of its clinical symptoms.However, a temporary withrawal of
SSA in the 10 year resulted in clinical relaps and octreoscan revealed the
pancreatic tumour again. The disease is now under effective control of further
SSA administration.
Before treatment
(medium values)
After 6 months of
treatment
(medium values)
GH (g/l) (0.1-3.5) 47 11
GF1 (ng/ml) (150-350) 878 340
Clinical status Poor Good
P21I
Malignant corticotrophinoma ~ a clinical report
Marcia Alves
1
, Isabel Paiva
1
, Jacinta Santos
1
, Mariana Martinho
2
,
Alexandra Vieira
1
, Sofa Gouveia
1
, Francisco Belo
3
, Margarida Bastos
1
1
1
Servico de Endocrinologia, Diabetes e Metabolismo, Hospitais da
Universidade de Coimbra, EPE, Coimbra, Coimbra, Portugal;
2
Servico de
Endocrinologia, Instituto Portugue`s de Oncologia de Coimbra, Coimbra,
Portugal;
3
Servico de Neurocirurgia, Hospitais da Universidade de Coimbra,
EPE, Coimbra, Portugal.
Pituitary carcinoma is rare (0.1-0.2% of pituitary tumors), with a poor prognosis.
It usually presents as invasive and secretory (ACTH or prolactin) macroadenoma.
The diagnosis is confrmed by the presence of metastases. The latency period
between the diagnosis of adenoma and carcinoma is variable (9.5 years
for corticotrophinoma). The treatment includes surgery, radiotherapy and
chemotherapy.
We report a 58-year-old male, complaining of visual disturbances and headache,
without endocrine stigmata. Cranial MRI, performed after an ischemic stroke,
detected a sellar mass lesion (24,19,17 mm) with optic chiasmcompression and
sphenoid sinus invasion. Perimetry was normal. Hormonal study showed: failure of
the gonadal, thyroid and GH axis; normal PRL; high levels of cortisol and ACTH
with increased response of ACTH to CRH: basal 408 pg/ml (NR:9-52 pg/ml), at
60 min 4646 pg/ml; free urinary cortisol 585 ug/24 h (NR:10-80 ug/24 h);
overnight 1mg dexametasone test: cortisol 31 ug/dl (NR:,1.8 ug/dl). Transphe-
noidal surgery was performed with macroscopically total tumorectomy (histology -
corticotrophinoma). Postoperative evaluation showed: normal levels of ACTHand
cortisol; gonadal, thyroid and GH insuffciency and diabetes insipidus. He began
replacement therapy. Recurrences were detected, with re-interventions: transphe-
noidal at 3rd, 6th, 7th, 9th and 10th year after initial surgery and subfrontal at 10th
year. At the 6th year the histology changed: cellular atypia and progressive increase
of proliferative index (PI-27%, p53 positive, Ki-67-11%). Radiotherapy (54Gy/30
sessions) was performed 7 years after diagnosis. After 10 years, lesions suspicious
of metastases were found in the right lung, mediastium and bilateral bronchial
lymph nodes. Biopsy by mediastinoscopy was performed, but inconclusive. He
died with intracranial hypertension one month later.
This case illustrates the slow and progressive evolution of pituitary carcinomas,
supporting the hypothesis of progressive loss of differentiation of an adenoma.
Therapy available to date is ineffective. There is need to identify markers of
malignant potential, to allow early treatment.
P218
Differences in TSH lowering effect of metformin in hypothyroid and
euthyroid type 2 diabetic patients
Dragan Dimic, Milena Velojic Golubovic, Sasa Radenkovic, Danijela Stojic
& Slbodan Antic
Clinic of endocrinology, Clinical Center Nis, Nis, Serbia.
Objectives
It has been reported that metformin administration lowered TSH levels in patients
with type 2 diabetes mellitus and hypothyreosis. The aim of the study was to
investigate effect of metformin on TSH levels in type 2 diabetic patients with
primary hypothyroidism and also in patient with type 2 diabetes mellitus only.
Methods
We included in our study 9 type 2 diabetic patients with primary hypothyroidism
on stable l-thyroxine replacement doses and 9 euthyroid type 2 diabetic patients.
In all patients 2000 mg daily metformin therapy was initiated. Thyroid hormones,
FT3 and FT4, and TSH was measured in all subjects at baseline and 3 months
after metformin therapy initiation.
Results
There was decrease of TSH levels in all hypothyroid diabetic patients after
metformin administration. The mean TSH levels decreased from 2.86
0.97 mU/l on baseline to 0.960.49 mU/l after three months, which has
statistical signifcant, P,0.05. In euthyroid type 2 diabetic patients the level of
TSH show no signifcant difference, TSH at baseline was 2.051.32 mU/l and
after three months TSH 2.211.44 mU/l. There was no signifcant changes in
FT3 and FT4 levels in both groups.
Conclusion
Our results shows that in subjects with primary hypthyreoidism and diabetes
mellitus type 2 metformim administration is associated with signifcantly lower
TSH levels after three months of therapy, without signs of clinical and
biochemical hyperthyreoidism. The mechanism of thyreotropin suppression by
metformin is not clear and there is several possible explanations. Metformin has
no effect on TSH levels in euthyroid diabetic patients.
P219
Secondary osteoporosis and secondary hyperparathyroidism in patient
with Hashimoto thyroiditis and coeliac disease (case report)
Tijana Icin, Branka Kovacev-Zavisic, Jovanka Novakovic-Paro,
Ivana Bajkin, Milica Medic-Stojanoska & Ljiljana Todorovic-Djilas
Clinical Centre of Vojvodina, Clinic of endocrinology, diabetes and
metabolic disorders, Novi Sad, Serbia.
Introduction
Autoimmune thyroid disease is often associated with other autoimmune diseases.
Coeliac disease is one of those autoimmune diseases, together with is wide
spectrum of intestinal and extraintestinal manifestations. Atrophy of intestinal
mucosa, one of the characteristics of coeliac disease, among everything else, leads
to poor absorption of l-tyroxine used in therapy of hypothyroidism.
Aim and results
We like to present a clinical case of our patient with Hashimoto thyroiditis who
remain hypothyroid in despite of high doses of l-thyroxine during ffteen years of
therapy. She was admitted to our Clinic when she was 58 years old with signs of
hypothyroidism, hypoalbuminemia and severe anemia. We doubt there is a
malabsorption syndrome associated with this signs. We perform a small bowel
biopsy and laboratory testing of transglutaminase antibody which was positive for
celiac disease. Also, bone mineral density in this moment was in reference range of
severe osteoporosis, andbiochemical markers of bonewere appropriatefor secondary
hyperparathyroidism. Patient was give the specifc gluten free diet. During next
7 months there is an improvement of anemia, hypoalbuminemia, but nowwe have an
iatrogenic hyperthyroidism, and no improvements in bone metabolism. Dose of
l-thyroxin was decreased gradually and therapy with vitamin D was started. After
19 months fromdiagnosing the celiac disease, patient is euthyroid, without anemia or
hapoalbuminemia. Parameters of bone metabolismare withinnormal range and there
is no hyperparathyroidism, bone mineral density is improved to level of osteopenia.
Conclusions
Coeliac disease can be a cause of low absorption levels of l-thyroxine in small
intestines. Iatrogenic hyperthyroidism could be a consequence of improved
absorption. In cases like this, secondary hyperparathyroidism is an reversible and
osteoporosis is mainlyreversible conditionwithadequatevitaminDsupplementation.
P220
Primary ovarian carcinoid presenting as right heart failure ~ case
report
Narayana Prasad Pothina, Hassan Kahal & Mohamed Malik
Scunthorpe General Hospital, Scunthorpe, Lincolnshire, UK.
Introduction
Carcinoid tumours commonly originate from the gastrointestinal tract. Cardiac
manifestations occur in 10-41% of patients with carcinoid syndrome, usually
associated with liver metastases. We report an atypical case of a carcinoid tumour
associated with right sided heart disease without distant metastases.
Case description
A 75-year-old lady with no signifcant past medical history and a lifelong non-
smoker, was admitted with 3 months history of worsening shortness of breath. She
had features of right heart failure confrmed on echocardiography and cardiac
catheterisation with an estimated RVSP of 53 and tricuspid regurgitation. Basal
biochemistry, Chest radiograph and CTPA were normal. On further review,
she was noted to have disproportionate facial fushing to the degree of failure,
and subsequent carcinoid screening was positive with raised urinary 5HIAA at
258(0-50) and Chromogranin-A of 379(0-4). Detailed investigations for
pulmonary and gut primary were negative and there was no evidence of liver
metastasis. Thin slice CT showed small right ovarian mass, which was confrmed
on MRI and subsequent octreoscan was consistent with isolated high uptake on
the right ovary. She underwent laproscopic right oophorectomy and histology
confrmed carcinoid tumour of the insular type.
Both urinary 5HIAA and Chromogranin-A were normal 4 weeks after surgery and
she is currently enjoying normal activity off Somatostatin analogues, and
minimum cardiac supportive medications.
Discussion
Primary ovarian carcinoids are uncommon and their association with carcinoid
heart disease is very rare; only 21 reported cases in the literature. Cardiac
involvement develops without liver metastases, since the vasoactive mediators
are released directly into systemic circulation. Absence of distant metastases
provides these tumours with good prognosis.
Conclusions
Ovarian carcinoids, diagnosed early, are potentially surgically curable. Our case
highlights the importance of considering ovarian carcinoids in patients presenting
with right sided failure, features of carcinoid syndrome and unknown primary.
P221
Two therapeutic approaches for thyrotropin-secreting pituitary
adenomas
Marcel Sambo, Rogelio Garci a, Elisa Fernandez, Victor Andi a,
Diego Lezcano, Pilar Alvarez & Paloma Rodri guez
Hospital general Universitario Gregorio Maranon, Madrid, Spain.
Case 1
Thirty-eight year woman consulted to gynecologist for oligomenorrhea in the last
4 years; PRL 51 g/l and TSH 8.4 mU/l were discovered, initiating treatment with
levotiroxine (f-T4). She got pregnant, persisting elevated levels of TSH and
increasing f-T4, with normal campimetry. With the diagnostic of hyperthyroidism
due to inadequate TSH secretion, treatment with PTU was initiated. After normal
delivery, MRI showed a 22 mm. hypophisary macroadenoma and a transe-
sphenoidal surgery was made. After this procedure, she had regular menses, but
distal tremor, palpitations and tumour rests persisted with f-T4: 2.49 ng/dl,
TSH:5.53 mU/l; besides IGF1: 729 g/l, IGFBP-3: 7.93 mg/l and GH:10.8 g/l
with no response to oral glucose tolerance test. Because of these fndings
intramuscular Octreotide LAR treatment is introduced until 30 mg/28 days, with
decrease of GH and IGF1 but thyroid hormones remained elevated. Due to this we
are planning to start treatment with Pasireotide.
Case 2
Seventy-three year male with asthenia and weight loss, TSH and f-T4 levels were
15.7 mU/l and 1.08 g/dl respectively, reason because we decided therapy with
levotiroxine (from 25 to 150 g/day) but in the follow-up he maintained elevated
TSH levels and increasing f-T4 reaching 3.01 g/dl, so L-T4 was dropped out and
TRH stimulation test was made with basal TSH 26.26 and 26.7 after stimulus;
MIR showed a 25 mm. hypophisary macroadenoma infltrating both cavernous
sinuses but did not compress ocular way, and positive octreoscan. Surgical
treatment was refused so Octreotide LAR (20 mg/28 days) treatment was started,
with normalization of hormonal parameters and with no evidence of tumour
growing one year later.
Discussion
TSH-secreting pituitary tumours are rare. Often are plurisecretory and only about
40% of cases are cured with surgery due to their size and fbrous characteristics.
Medical treatment with somatostatin analogues could be a good therapeutic
option.
P222
A retroperitoneal neuroendocrine tumour pre-diagnosed as an adrenal
incidentaloma - a case report
Joanna Malicka
1
, Maria Kurowska
1
, Jerzy Tarach
1
& Jolanta Kijek
2
1
Endocrinology Department, Medical University, Lublin, Poland;
2
Nuclear Medicine Department, Medical University, Lublin, Poland.
Introduction
Neoplastic lesions in the retroperitoneum may originate from kidneys, ureters,
adrenal glands or peripheral nervous, connective, muscle and adipose tissues.
Neuroendocrine tumours are exceptionally located in the retroperitoneum.
The case study
A woman aged 51, with a tumour of the left adrenal gland found incidentally
during an ultrasound examination of the abdominal cavity, which was performed
because of dysuria. A CT confrmed the presence of a 3.5-inch tumour with high
initial density (22.6HU) in the retroperitoneum. It showed marked heterogeneous
contrast enhancement (up to 98HU), which suggested foci of necrosis. A receptor
scintigraphy (
99
Tc Hynic-TATE) did not show somatostatin analogue accumu-
lation. The chromogranin A level was 3 U/l (n. 2.0-18.0). In a clinical evaluation
hormonal activity of the tumour was excluded. Due to the anatomical features of
the tumour and the nature of contrast enhancement in the CT, the patient with
suspected adrenal cancer was qualifed for urgent adrenalectomy. During surgery
a 4-inch tumour was removed together with the left adrenal gland. Only in the
postoperative evaluation it was established that the lesion had developed from an
extra-adrenal tissue and had only adhered close to the adrenal gland and pressed
it. The histopathological diagnosis was a neuroendocrine carcinoid. Immunohis-
tochemistry was used to identify: cytokeratin MNF116 (), synaptophysin
(positive, but only in some cells), chromogranin (/), Grocott silver staining
() and MIB1 1.7%. The patient has been monitored for 3 years and so far the
disease has not progressed. The authors discuss a case study of a neuroendocrine
tumour in a rare location. It imitated an adrenal cancer, however, postoperative
histopathological examination showed that the carcinoid was not located inside
the gland, but closely adhered to it.
P223
Hypoparathyroidism related epilepsy
Marta Alves, Celestino Neves, Daniel Carvalho-Braga & Jose Lui s Medina
Endocrinology Service, Sao Joao Hospital, Faculty of Medicine, University
of Porto, Porto, Portugal.
Background
Permanent hypoparathyroidism can result from immune-mediated destruction of
the parathyroid glands. Alternatively it may result from activating antibodies to
the calcium sensing receptor that decrease parathyroid hormone (PTH) secretion.
Autoimmune hypoparathyroidism is a common feature of poliglandular
autoimmune syndrome type I. Other causes, all very rare, include irradiation
and storage of infltrative diseases of the parathyroid glands. Neurological signs of
hypoparathyroidism include symptomatic or latent tetany, seizures, hemiparesis,
diffculty in speaking, ischemic attacks, in case of basal ganglia and cerebral
calcifcations also choreatetosis, parkinsonism and cerebellar syndrome.
Case report
The authors present the case of a 22-year-old man that was referred to the
endocrinology consultation because of undertreated hypoparathyroidism. He also
had a personal history of epilepsy, depression, anxiety, agoraphobia, and panic
attacks. Partial complex crises started when he was 13 years old (2000).
Hypoparathyroidism was diagnosed in 2003 and he developed anxiety disorders
1 year ago. He was medicated with calcium carbonate calcium lactogluconate
(3500 mg/day), calcitriol 0.5 g/day, valproic acid (1200 mg/day), paroxetine
(20 mg/day) and alprazolam (1 mg/day). Laboratory results revealed severe
hypocalcemia and hyperphosphatemia, and serum low levels of parathyroid
hormone. Medication was adjusted accordingly. We also performed cerebral and
parathyroid glands` imagiologic study. This patient did not have other features of
poliglandular autoimmune syndrome type I. Other aetiologies were also excluded.
Conclusion
The authors wish to draw attention to this unusual manifestation of idiopathic
hypoparathyroidism and the need to assess serum calcium levels in patients with
seizures and other neuropsyquiatric symptoms.
P224
Graves` disease, systemic lupus erythematosus, hypoparathyroidism:
autoimmune polyglandular syndrome or coincidence?
Eugen Melcescu
1
, Elizabeth H Kemp
2
, Vikas Majithia
1
,
Vani Vijayakumar
1
, Gabriel I Uwaifo
1
& Christian A Koch
1
1
University of Mississippi, Jackson, MS, USA;
2
University of Sheffeld,
Sheffeld, S210 2JF, UK.
Data on coexisting Graves` disease (GD), systemic lupus erythematosus (SLE),
and hypoparathyroidism (hypop) are limited. Scanty case reports have described
hypoparathyr or hypothyroidism (late complication) following external irradi-
ation to the neck. The thyroid and parathyroid glands may be sensitive to the
immunologic or irradiation damage.
A 34-year old AA woman presented with tetanic-like cramps, easy skin bruising,
fatigue, weight gain, nocturia and back pain. No signs of Cushing syndrome or
adrenal insuffciency were identifed. She was diagnosed previously with GD in
2001 and underwent radioiodine therapy (RAI) in 9/01 using 6 mCi. PostRAI
(Nov 2001) low serum calcium (5.2 mg/dl) and PTH (11 pg/ml) were recorded
and she received calcium and vitD. Approx. 5-6 mo postRAI (2002), overt
hypothyroidism was diagnosed with wt gain of 30 lbs, fatigue, depression, and
TSH of 80 uU/ml. In 2007, SLE was diagnosed based on ACR criteria: malar rash,
nephritis with proteinuria 0.5 g/d, positive Smith antibodies (1038 H U/ml),
RNP antibodies (764H U/ml), Sjogren anti-SS-A (902 H U/ml) and positive ANA
(1036H U/ml, speckled pattern). In Oct 2009, s-calcium and PTH were still low at
7.1 mg/dl and 9 pg/ml, respectively, although the patient denied symptoms on
vitD and calcium supplementation. To identify possible autoimmune damage of
the parathyroids we evaluated the presence of activating antibodies to the CaSR
and also analyzed the DNA sequence of all 6 translated exons and fanking
intronic sequences of her CaSR gene for a functionally signifcant CaSR mutation
but neither was positive. The initial autoimmune damage to her thyroid and
possibly parathyroid glands followed by irradiation of them seems to have
contributed to her developing both hypoparathyroidism(11/01) and hypothyroidism
(2002). The patient could potentially have had parathyroid autoantibodies in 2001
that disappeared by 2009 when the patient was tested for them. We consider that
the multiple autoimmune conditions developed over the past decade of her life
with the concurrent irradiation contributing to her brittle hypoparathyroidism.
Select patients with GD and perhaps parathyroid autoantibodies with a slowly
developing destructive impact on the parathyroid glands may then develop overt
hyoparathyroidism with rather low dose RAI. Finally, we favor the hypothesis of
mixed (radioimmunological) damage in this case.
P225
Necrotizing fasciitis as a complication of subcutaneous injection of
insulin in a diabetic patient: a case report
Sofa Teixeira, Ana Maia Silva, Anabela Giestas, Daniel Vaz
& Claudia Amaral
Hospital Santo Antonio - Centro Hospitalar do Porto, Porto, Portugal.
Necrotizing fasciitis is a rare infection of the soft tissues with consequent necrosis
of fascial planes and surrounding tissues. If misdiagnosed or not properly treated
it can be fatal. It typically follows trauma and it have already been described after
intramuscular or intravenous injection of insulin.
The authors present a case of a 24-year-old man, with type 1 diabetes mellitus for
more than ten years, admitted to the emergency room for diabetic ketoacidosis
and abdominal pain with extensive infammatory signs of the abdominal wall
despite being taking oral antibiotics for 5 days. He was diagnosed a necrotizing
fasciitis of the abdominal wall as a consequence of a subcutaneous injection of
insulin. He was treated with immediate extensive surgical debridement,
antibiotics and intravenous insulin and in the frst 4 days he was admitted to
the intensive care unit for ventilation. A Streptococcus constellatus was identifed
in the pus. He recovered and was defnitively treated with an abdominoplasty after
2 months of hospitalization.
The authors present this case because subcutaneous administration of insulin can
be a rare cause of necrotizing fasciitis.
P22
Pancreatic graft arterial thrombosis after coronary artery
catheterization - an unusual case of pancreas allograft rejection
Ana Maia Silva, La Salete Martins, Leoni dio Dias, Antonio
Castro Henriques, Anabela Giestas, Sofa Teixeira, Filomena Oliveira,
Paulo Almeida, Rui Machado, Claudia Freitas, Rui Almeida,
Manuel Teixeira & Jorge Dores
Hospital Santo Antonio, Centro Hospitalar Do Porto, Porto, Portugal.
Introduction
Successful whole pancreas transplantation is at the present the most effective
treatment for type 1 diabetes but allograft dysfunction related with infection,
vascular compromise or immunological causes are not uncommon. Usually, graft
vascular thrombosis or haemorrhage, as well as infectious complications are
responsible for early pancreas graft failure; late cases occur more frequently by
immunological causes, either allograft rejection or recurrence of the 'auto-
immunity` state that is characteristic of type 1 Diabetes.
Objective
To discuss a case of pancreas graft loss with coexistent graft arterial thrombosis
and newly elevated anti-GAD antibodies.
Case report
A 43-year-old type 1 diabetic woman with end-stage renal disease and ischemic
heart disease underwent a successful pancreas-kidney transplant and became free
of insulin and dialysis for 5 years. Several days after coronariography there was a
sudden appearance of hyperglycaemia (879 mg/dl), dehydration-related elevated
serum creatinine (1.43 mg/dl), low C-peptide (0.37 ng/ml), normal serum
amylase and lipase and newly elevated anti-GAD antibodies (120 U/ml).
Vascular study was undertaken due to athero-embolization suspicion; angio-
graphy showed distal graft artery occlusion (donor`s superior mesentery artery).
No graft biopsy was made. Alteplase treatment was performed during the
angiography and the patient was treated with metilprednisolone bolus but
unfortunately there was no radiological or clinical improvement and insulin-
dependence remained.
Discussion
In the present case, graft loss seemed to occur due to arterial embolization after
coronary catheterization. The rising of anti-GAD antibodies levels probably
occurred due to antigenic expression because of the graft ischemia and not due to
type 1 diabetes recurrence, but this complexity makes it very important to have a
multidisciplinary team approach in the follow-up of these patients.
P22I
Hypogonadotropic hypogonadism in POEMS syndrome ~ case report
Pedro Rodrigues
1
, Jose Lui s Castedo
1
, Madalena Rocha
2
,
Patri cia Guimaraes
2
, Jose Eduardo Guimaraes
2
& Jose Lui s Medina
1
1
Endocrinology Department, Sao Joao Hospital, Oporto, Portugal;
2
Hematology Department, Sao Joao Hospital, Oporto, Portugal.
Introduction
POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammo-
pathy and skin changes) syndrome is a rare multisystemic disease. Diagnosis
requires two major criteria and at least one minor criterion. Major criteria include
polineuropathy and a monoclonal plasma proliferative disorder (almost always
lambda). Minor criteria include osteosclerotic bone lesions, Castleman disease,
organomegaly (including lymphadenopathy), oedema, pleural effusion or ascites,
endocrinopathy (excluding diabetes mellitus and thyroid disease) and skin
changes.
Case report
We report a 49-year-old female patient, admitted to the hospital with a 4-month
history of severe symmetric sensory-motor peripheral neuropathy that began in
her lower limbs with gradual proximal spread. Serum immunofxation was
consistent with IgG lambda monoclonal gammopathy. Radiographic skeletal
survey showed multiple sclerotic bone lesions. Biopsy of an osteoslerotic
vertebral lesion revealed monoclonal plasma cell infltration and bone marrow
biopsy was consistent with infltration by plasma cell aggregates. Hormonal
assays showed hypogonadotropic hypogonadism with FSH 2.61 mUI/ml (3.4-
21.6), LH 0.31 mUI/ml (2.4-6.6) and estradiol 15.0 pg/ml (21-251). Diabetes
mellitus, thyroid dysfunction, adrenal insuffciency, hyperprolactinemia and
calcium abnormalities were excluded. Pituitary MRI was normal. The patient was
diagnosed with POEMS syndrome and treated with autologous hematopoietic cell
transplantation following high-dose melphalan. She refers improvement of the
sensory-motor function and waits neurological and endocrine reassessment at day
100 of transplant.
Discussion
Two-thirds of patients have at least one endocrine abnormality at presentation.
Hypogonadism has a high prevalence and is secondary in the majority of reported
series. All patients with POEMS syndrome should have a thorough and systematic
endocrine evaluation at diagnosis.
P228
Cushing`s syndrome as presentation of an ACTH-producing pulmonary
tumour
Pedro Rodrigues
1
, Jose Lui s Castedo
1
, Eduardo Cernadas
2
,
Davide Carvalho
1
& Jose Lui s Medina
1
1
Endocrinology Department, Sao Joao Hospital, Oporto, Portugal;
2
Surgery
Department, Sao Joao Hospital, Oporto, Portugal.
Introduction
Ectopic Cushing`s syndrome is a rare disease, with a reported incidence of
0.1/million per year. This disorder accounts for approximately 12-17% of
patients with ACTH-dependent Cushing`s syndrome. Small cell lung carcinoma
is responsible for about 20% of cases, although ectopic ACTH hypersecretion
occurs in only 0.5-2% of these tumours. Hypercortisolaemia is usually severe and
of rapid onset. Optimal treatment is surgical excision of the tumour, although not
always possible. Prognosis is poor in most cases, with a short mean survival.
Case report
We report a 52-year-old male patient admitted to the hospital in 1993 with a
6-month history of hypertension and temporal headaches. He presented plethoric
facies, central obesity and wide and red skin striae. Laboratory assays showed
high plasma ACTH and markedly elevated urinary cortisol excretion that was
not suppressed with high dose dexamethasone administration. Pituitary MRI and
adrenal glands CT scans were normal. No central-peripheral ACTH gradient was
observed in the bilateral inferior petrosal sinus catheterism. Thoracic CT scan
showed a 1.7 cm nodule in the superior lobe of the left lung. Pulmonary fne
needle citology and immunocytochemical and ultrastructural studies led to the
diagnosis of an ACTH-producing neuroendocrine carcinoma. He was initially
submitted to chemotherapy and, in 1995, started octreotide, presenting a
favorable clinical response. Last octreotide scintigraphy (May 2009) showed
persistence of a small enhanced nodule in the left pulmonary parenchyma. He is
on treatment with octreotide LAR (long acting release) having the disease
clinically controlled.
Discussion
We highlight the ectopic ACTH secretion as a rare feature of neuroendocrine lung
carcinoma and its favorable evolution, 16 years after it was diagnosed.
P229
Dose of growth hormone (GH) and not IGFI level at treatment start
inuences treatment outcome in GH dehcient adults (GHDA): Data
from the NordiNet International Outcome Study (IOS)
Jens Otto L Jrgensen
1
, Matthias M Weber
2
, Charlotte Hoybye
3
,
Birgitte T Pedersen
4
, Viatcheslav Rakov
5
& Jens Sandahl Christiansen
1
1
Aarhus University Hospital, Aarhus, Denmark;
2
Klinikium der Johannes
Gutenberg-Universitat, Mainz, Germany;
3
Karolinska Hospital,
Stockholm, Sweden;
4
Novo Nordisk AS, Soeborg, Denmark;
5
Novo
Nordisk Health Care AG, Zurich, Switzerland.
Background
Serum IGFI measurements are used during GH replacement in GHDA for titration
of the GHdose, to monitor compliance and to avoid overdosing, but it is uncertain if
pretreatment IGFI is a determinant of the GH dose or the response to GH treatment.
Methods
Data from the NordiNet IOS have been analyzed to determine pretreatment serum
IGFI concentrations in GHDA and to analyze if they infuence the GH starting dose
and/or the therapeutic response after one year. The patients were divided in two
groups: A) with a normal IGFI level before GHtreatment start (1 SDS), and B)
with a low IGFI level at treatment start (,1 SDS).
Results
Two hundred and seventeen patients (98 females/119 males) with IGFI
measurements at treatment start and after one year of treatment were included in
this analysis. MeanS.D. IGFI was 15887 ug/l in group A and 6838 ug/l in
group B. This corresponds with 0.11.0 SDS and 2.01.0 SDS for IGFI levels
respectively. Baseline characteristics were slightly different in groups A and B.
Mean age was higher in group A than in group B. Patients in group A also had a
higher weight and a higher BMI which may have been infuenced by age. Starting
mean GH dose was 0.260.19 mg/day in group A and 0.240.19 mg/day in
group B. After one year of treatment the GH dose increased more in patients from
group B. Serum IGFI levels changed accordingly and increased more in group B
achieving normal range: 0.21.6 SDS, comparing to 0.81.2 SDS in group A.
We observed a signifcant decrease in mean LDL level in group B together with a
more pronounced reduction in waist circumference. However, multivariate analysis
revealed that only the GH dose was a signifcant predictor of the change in waist
circumference during treatment (P,0.05).
Conclusion
1) GHDA patients with 'low` IGFI levels prior to treatment were younger and less
obese as compared to patients with 'normal` IGFI levels, 2) Pretreatment IGFI
levels did not seem to determine the starting dose of GH treatment, but the increase
in GH dose after one year of treatment was higher in patients with 'low`
pretreatment levels of IGFI, 3) The observation that GH dose was the main
predictor of the therapeutic response does not obviate the use of serum IGFI
measurements to avoid overdosing with GH.
P230
Fluctuating bilateral abducent palsy leading to the diagnosis of pituitary
mass without cavernous sinus involvement. How does this match?
Ilonka Kreitschmann-Andermahr
1
, Flverly Francis
1
, Michael Mull
2
,
Christine Streetz-van-der-Werf
3
& Franz-Josef Hans
1
1
Department of Neurosurgery, RWTH Aachen University Hospital, Aachen,
Germany;
2
Department of Neuroradiology, RWTH Aachen University
Hospital, Aachen, Germany;
3
Section for Endocrinology, RWTH Aachen
University Hospital, Aachen, Germany.
We report a 61-year-old lady with sudden onset diplopia caused by abducent
palsy which was initially right- and later left-sided. MRI scanning revealed an
extensive sellar and suprasellar mass and the lady was referred to our department
for transphenoidal surgery with the imaging diagnosis of pituitary adenoma.
Upon close inspection of the flms, cavernous sinus invasion of the tumour as a
morphologic correlate of the N. VI palsy was missing; however, there was an
unusual contrast enhancement in the sphenoid sinus. Endocrinologic investigation
gave evidence of partial anterior hypopituitarism. Because of the clinical and
imaging incongruence, CCT was performed, revealing extensive metastatic
infltration of the skull base with osteoblastic and osteolytic elements. Tumour
masses extended into the sphenoid sinus and the sellar and suprasellar space.
The apex of the petrous bone both sides had osteolytic lesions explaining the
bilateral abducent palsy. 18 years ago, the patient had been diagnosed with breast
cancer with a local recurrence 5 years later. Because of the long tumour-free
interval, the patient had failed to mention this part of her medical history at prior
appointments. Further osseous metastatic lesions were diagnosed in the cervical
spine and left hip. Radiotherapy of the metastases was initiated and up to now,
6 months after the initial diagnosis, the disease is stable. Breast and lung cancer
are the most common primary tumours metastasizing into the pituitary. Diabetes
insipidus or anterior hypopituitarism are frequent presenting symptoms, whereas
oculomotor symptoms are less commonly observed.
This case illustrates the necessity for the treating physician to assure himself of
the accordance of clinical and imaging features, and - if this is not given - to
initiate further examinations to come to the right diagnosis. CCT scan is a very
useful imaging tool to uncover osseous changes which are not conspicuous
on MRI.
P231
Isolated parietal-skull metastasis from a thyroid papillary carcinoma
Cristina Preda, Roxana Novac, Delia Ciobanu, Alexandru Grigorovici,
Letitia Leustean, Maria-Christina Ungureanu, Cristina Cristea
& Eusebie Zbranca
University of Medicine and Pharmacy 'Gr. T. Popa`, Iasi, Romania.
Papillary carcinoma is the most common differentiated malignant thyroid
neoplasm. Metastasis commonly occur in regional lymph nodes and distant
metastasis ia a late and rare occurrence.
Papillary thyroid carcinoma with metastasis to the parietal skull is very rare.
We present the case of a parital skull metastasis arising from a papillary
carcinoma prior to the diagnosis of thyroid tumor. The patient was a 58 caucasian
woman with presentation of a 3.5 cm painless, immobile, frm mass on the left
side of the head (parietal area). The X-ray and computer tomography detected an
osteolitic tumor involving the skull and overlying skin. The tumor was removed
and the histological examination revealed the presence of clusters of oval cells
with squamoid cytoplasm and oval nuclei. At that moment it was the question
regarding the differential diagnosis between colon carcinoma or thyroid
carcinoma metastasis. With immunocytochemical stain the neoplastic cells
were positive for thyroglobuline. The ultrasound of the thyroid showed multiple
hypoechoic solid nodules with microcalcifcations in both lobes. Ultrasound-
guided fne-needle biopsy was performed and cytological exam. was conclusive
for papillary carcinoma. The patient underwent total thyroidectomy with central
and lateral node dissection. Final pathological exam. conclude for papillary
carcinoma (follicular variant).
Even if skull metastasis of thyroid carcinoma is rare, it should be considered in the
differential diagnosis when a skull mass lesion is encountered.
P232
Benign symmetric lipomatosis (Madelung`s disease): a case report
Ozen Oz Gul
1
, Mustafa Merter
2
, Soner Cander
1
, Oguz Kaan Unal
1
,
Erdinc Erturk
1
& Sazi Imamoglu
1
1
Department of Endocrinology and Metabolism, Uludag University Medical
School, Bursa, Turkey;
2
Department of Internal Medicine, Uludag
University Medical School, Bursa, Turkey.
Benign symmetric lipomatosis (BSL) is a very rare disorder characterized by the
growth of uncapsulated masses of adipose tissue, predominantly located in the
neck and shoulders. Benign symmetric lipomatosis is usually described in adults
between 30 and 60 years of age and is slightly more frequent in men with heavy
alcohol consumption. A 70-year-old woman presented with a great growth of soft
tissues in the cervico-occipital region who had never consumed any alcohol.
Laboratory evaluation revealed a chronic anemia, mild leukopenia, increased
erythrocyte sedimentation rate. Cervical magnetic resonance imaging (MRI)
showed large amounts of fatty masses in the posterior neck and occipital region
TabIe Changes from baseline to frst year follow up under GH treatment in
GHD adults dependent on serum level of GF at baseline.
Group A Group B
Measurement n Mean
a
n Mean
a
GF ug/l 72 44.58 ,.0001 80 88.37 ,.0001
GF SDS 72 0.73 ,0.001 80 1.89 ,0.001
Weight kg 62 1.23 0.17 75 0.14 0.9
BM 60 0.48 0.16 74 0.14 0.78
Waist cm 25 1.02 0.29 31 1.58 0.07
LDL mmol/l 35 0.07 0.59 28 0.45 0.01
HDL mmol/l 37 0.03 0.66 36 0.05 0.18
Total cholesterol
mmol/l
37 0.1 0.52 38 0.3 0.07
Absolute GH
dose (mg/day)
103 0.06 ,0.0001 114 0.12 ,0.0001
a
Silgnifcance level in comparison to baseline measurement.
with no mediastinal involvement. Fine-needle aspiration led to the diagnosis of
nonspecifc fbroadipose tissue. Since she could not lay down on her back we
recommended her surgery but she didn`t accept. At this writing there has no
history dyspnea or dysphagia during one year of follow-up observations. Benign
symmetric lipomatosis may be asymptomatic, but in some cases, due to
mediastinal involvement, dyspnea or dysphagia can occur. The ethiology of
BSL is unknown, but an abnormal lipogenesis induced by catecholamines has
accused. Diagnosis of BSL can be established with the clinical signs and image
tests. The treatment for BSL is surgery (open approach and/or liposuction), and it
is reserved for patients with aesthetic deformities, psychological problems or
aerodigestive dysfunctions.
P233
Pheochromocytoma associated with thyroid papillary carcinoma:
a report of an unusual case
Ozen Oz Gul, Oguz Kaan Unal, Soner Cander, Erdinc Erturk
& Sazi Imamoglu
Department of Endocrinology and Metabolism, Uludag University Medical
School, Bursa, Turkey.
A 50-year-old man admitted to our institution with labile hypertension. His blood
pressure was 150/90 mmHg and the pulse rate was 96 beats per minute. He had
hypertensive attacks every 2-3 days. His blood pressure was found 210/110 mmHg
at hypertensive attact. He had palpable thyroid nodule. Ultrasonography of the
thyroid gland showed a 2.6 cm sized, irregularly marginated, calcifed thyroid
nodule. His serum free thyroxine (fT4), free triiodothyronine (fT3), thyrotropin
stimulating hormone (TSH) and thyroglobulin levels were 0.89 ng/dl, 2.5 pg/ml,
1.586 IU/ml and 116.7 ng/ml respectively. His parathyroid hormone and calcium
levels were found in normal reference range (42 pg/ml and 9.2 mg/dl respectively).
Since the fne needle aspiration biopsy revealed papillary thyroid carcinoma total
thyroidectomy was performed. A 24-h urine metanephrine excretion was
signifcantly elevated of approximately 100 times the upper limit of normal.
5,3 cm left adrenal mass was found and resected laparoscopically. Pathological
examination proved pheochromocytoma. The relationship between papillary
thyroid carcinoma and pheochromocytoma which was rarely reported is unclear.
Although pheochromocytomas secrete mainly catecholamines and their metab-
olites, they can also secrete many other peptides such as insulin-like growth factor
II, hypotalamic like and pituitary-like hormones. These peptides might cause the
development and growth of papillary thyroid carcinoma.
P234
Primary adrenal failure of tuberculous aetiology and vitamin D
dehciency
Dimitris Stefanopoulos, Ifgenia Kostoglou-Athanassiou,
Aikaterini Michou, Aikaterini Chronaiou, Razvan Alexandros Badila,
Nicolaos Klonaris, Olympia Karagianni & Areti Karf
Primary adrenal failure may be of autoimmune or infectious aetiology,
tuberculosis being a well known cause. In tuberculosis vitamin D defciency
has been described, while vitamin D suffciency has been reported to be necessary
for the mounting of an effcient immune response to the mycobacterium.
The aim was to describe the case of a patient with primary adrenal failure of
tuberculous aetiology and severe vitamin D defciency.
A female patient, aged 74 years, presented with weakness, nausea and
hypotension. Abnormally low blood cortisol levels were measured. Hydrocorti-
sone was administered for the management of the acute syndrome and the patient
improved. A Mantoux test was intensely positive despite the administration of
large hydrocortisone doses. During laboratory investigations abnormally low
calcium and phosphorus levels were measured. Further tests revealed low vitamin
D levels, 25(OH)D
3
being 4 ng/ml and secondary hyperparathyroidism. Vitamin
D was administered for the repletion of vitamin D defciency. The patient also had
hyperthyroidism caused by autonomous multinodular goiter and antithyroid drugs
were administered, resulting in the remission of hyperthyroidism. Consequently,
antituberculous therapy was initiated, and symptoms such as cough were cured
and the patient was given long term substitution therapy with hydrocortisone.
Conclusion
The case of a patient with primary adrenal failure of tuberculous aetiology is
described. The patient also had severe vitamin D defciency. It appears that
vitamin D defciency may exist in patients with tuberculosis. Vitamin D
suffciency may be necessary for the effective eradication of tuberculosis in an
affected patient.
P235
Carbimazole induced neutropenia: are we too cautious?
Robert Smith, Sanjay Saraf, Kattepura Madhusudana, Mahesh Katreddy
& Khaled Ashawesh
Dudley Group of Hospitals, West Midlands, UK.
Carbimazole is a commonly used antithyroid drug with a rare but potentially
life-threatening side effect of agranulocytosis. We present a case of a 47-year-old
lady who was diagnosed with hyperthyroidism four years previously and treated
with carbimazole despite persistent neutropenia.
At diagnosis the patient had clinical features of hyperthyroidism and thyroid
function test (TFT) showed free T
4
40.8 pmol/l (10.6-21.0), free T
3
12.7 pmol/l
(3.2-5.9) and TSH ,0.03 mIU/l (0.4-4.0). Initial neutrophil count was
2.45,10
9
/l. Carbimazole was titrated to 20 mg/day and maintained for four years.
She was admitted to hospital with symptoms of uncontrolled hyperthyroidism
and neutropenia (neutrophil count 0.98,10
9
/l). TFTs showed free T
4
76.0 pmol/l,
free T
3
43.4 pmol/l and TSH ,0.03 mIU/l.
Review of past blood results showed that she had neutropenia for the entire
four years of treatment with no incidence of infection. Other elements of the full
blood count (FBC) remained normal.
She was managed in an isolated room, monitored with daily FBC and weekly
TFTs. Carbimazole was increased to 60 mg/day. Patient improved symptomati-
cally and TFTs returned to normal limits with free T
4
20.2 pmol/L, free T
3
7.3 pmol/l and TSH ,0.03 mIU/l. She had uneventful total thyroidectomy.
Interestingly, on day one post-operatively, neutrophil count increased to
3.2,10
9
/l. Post operatively she was commenced on Levothyroxine. Her euthyroid
status was confrmed at follow up with TSH ,0.03, free T
4
14.5 pmol/l and free
T
3
2.8 pmol/l.
No other case reports have been found of continuing carbimazole despite
agranulocytosis, indeed most literature states carbimazole should be discontinued
in neutropenia. This case report supports the argument that mild neutropenia
should not be an absolute contraindication to carbimazole therapy for
hyperthyroidism.
P23
Carbimazole pseudo-resistance: two case reports
Kattepura Madhusudana, Sanjay Saraf, Robert Smith, Mahesh Katreddy
& Khaled Ashawesh
Dudley Group of Hospitals, West Midlands, UK.
Introduction
Weight gain following treatment of hyperthyroidism is well recognised. This may
lead to compliance problems both in patients with/without eating disorders and
subsequent failure of therapy. We describe two cases where this was successfully
managed with supervised in-patient therapy.
Case 1
A 30-year-old overweight lady was diagnosed with Grave`s disease following
childbirth. Thyroid function test (TFT) at initiation of treatment showed free T
4
75.6 pmol/l (10.6-21.0), free T
3
40.2 pmol/l (3.2-5.9) and TSH,0.03 mIU/l
(0.4-4.0). As the initial response to therapy with prophylthiouracil was
minimal, she was switched to carbimazole. Despite being on carbimazole
80 mg/day, she continued to be hyperthyroid both clinically and biochemically
with free T
4
66.8 pmol/l, free T
3
30.4 pmol/l and TSH,0.03 mIU/l. During
this period she lost 38 kg of weight and had to undergo abdominoplasty. She
was admitted for in-patient supervised carbimazole therapy (80 mg) and made
excellent progress with TFT showing free T
4
21.5 pmol/l, free T
3
7.9 pmol/l
and TSH ,0.03mIU/l (4 weeks post admission). Presently, she has been
referred for thyroidectomy.
Case 2
A 47-year-old lady was diagnosed with hyperthyroidism four years previously
and treated with carbimazole 20 mg once/day. At the time of diagnosis, TFT
showed free T
4
40.8 pmol/l, free T
3
12.7 pmol/l and TSH,0.03 mIU/l. Despite
being on carbimazole for four years, she continued to be hyperthyroid. Up
titration of carbimazole dose to 60 mg/day had made no difference, so she was
admitted for supervised carbimazole therapy. There was symptomatic and
biochemical improvement with free T
4
20.2 pmol/l, free T
3
7.3 pmol/l and TSH
,0.03 mIU/l. She had total thyroidectomy as defnite treatment.
Discussion
Though the causes of failure of treatment with carbimazole can be multifactorial,
problems with compliance can be very important. We suggest supervised therapy
should be considered before resorting to other measures as compliance related
problems are more than likely.
P23I
Estimation of parathyroid hormone level in patients with primary
hyperparathyroidism (PHPT) and negative SPECT scans in the
material obtained during hne needle aspiration biopsy (FNAB) of the
focal neck lesions
Zbigniew Adamczewski
1
, Marek Dedecjus
2
, Jan Brzezinski
2
& Andrzej Lewinski
1
1
Department of Endocrinology and Metabolic Diseases, Medical University
of Lodz, Polish Mother`s Memorial Hospital - Research Institute, Lodz,
Poland;
2
Department of General, Oncological and Endocrine Surgery,
Medical University of Lodz, Polish Mother`s Memorial Hospital - Research
Institute, Lodz, Poland.
Objective
The presence of a single parathyroid adenoma is a cause of primary
hyperparathyroidism in most cases. Minimally invasive parathyreoidectomy is
a treatment of choice in PHPT patients and precise localization of the changed
parathyroids is crucial for successful removal.
The aim of the study was to assess usefulness of parathormone level estimation in
the material obtained during FNAB of the focal neck lesions in order to
differentiate structures such as enlarged parathyroid glands from other focal
lesions in patients with HPTH and negative SPECT scans.
Design
Eighteen female patients with elevated PTH levels (range: 160-617 pg/ml,
median, 224 pg/ml), coexisting calciumand phosphate disorders typical for PHPT
and negative SPECT scans, were prospectively evaluated. Patients age range was
from 6 months to 76 years old (median, 51 years). All patients underwent
ultrasound examination (Toshiba Aplio XG, 14 MHz transducer). 23 focal
changes were qualifed for FNAB (the volume range was from 0.1 cm
3
to 3.0 cm
3
,
median: 0.85 cm
3
). After FNAB examination the needle was washed out with
1 cm
3
of 0,9% NaCl and PTH level was measured in the obtained material.
Results
PTH levels exceeded 5000 pg/ml in 13 patients and were lower than serum PTH
levels in the remaining group (range 24-35 pg/ml, median, 29 pg/ml). Patients
with elevated PTH levels were offered minimally invasive surgical intervention.
In all operated cases parathyroid adenoma was removed. In 2 cases neck revision
- modifed by PTH level determinating method of the suspected lesions
intraoperatively - was performed and retrotracheal parathyroid glands were
removed.
Conclusions
PTH level determination in the needle wash-out obtained during FNAB has
demonstrated 100% specifty in differentiating parathyroid and nonparathyroid
tissues.
Identifcation of parathyroid lesions using described procedure is a timesaving
and cost-cutting method. Negative-PTH value should suggest further need for
diagnostic imaging or applying modifcations while performing the surgery.
P238
A case of severe hypocalcaemia post liver transplantation
David Hughes, Amy Kennedy & Mark Cooper
Queen Elizabeth Hospital, Birmingham, UK.
Background
There are over 650 liver transplants performed in the UK each year and about
5000 throughout Europe. After transplantation patients suffer from bone loss due
to multiple factors. We present a unique case of severe Vitamin D defciency
resulting in life threatening hypocalcaemia following liver transplantation.
Case
A 65-year-old Indian lady underwent an uncomplicated liver transplant, for
hepatocellular carcinoma related to Hepatitis C. Pre and immediately post
operatively, her calcium measurements were normal. By day 13 her corrected
calcium had dropped to 1.38 mmol/l. She was suffering from jaw spasm and her
ECG showed a dangerously prolonged QT interval of 618 ms. Subsequent
investigations revealed a magnesium of 0.83 mmol/l, creatinine of 139 umol/l,
PTH of 527 ng/l, 25-OH Vitamin D of ,14 nmol/l (,5.6 ng/ml) and the
transplanted liver appeared to be functioning with no signs of rejection. She was
initially treated with 20 ml of 10% Calcium Gluconate and 5 mcg of
1-alfacacidiol. However, her Corrected Calcium remained low at 1.43 mmol/l.
She was then given a further 100 ml of 10% Calcium Gluconate infusion over
10 h, resulting in a corrected calcium to 1.98 mmol/l. She was commenced on
regular Adcal D3 two tablets three times a day and Calcitriol 1mcg once a day.
She also received a once off dose of Ergocalciferol 300000 IU intramuscularly.
Over the following 6 weeks we were able to successfully titrate down her dose of
calcitriol and Adcal D3.
Conclusion
This unusual case highlights the importance of monitoring for hypocalcaemia and
its prompt management in order to prevent arrhythmias and signifcant bone loss
in the postoperative care of transplant patients.
P239
Causes and patterns of death in an endocrinology clinic: data of six
years
Didem Ozdemir Sen, Dilek Arpaci, Rifki Ucler, Neslihan Cuhaci,
Reyhan Ersoy & Bekir Cakir
and Research Hospital, Bilkent, Ankara, Turkey.
Introduction
Periodic review of hospital deaths is important to know the changing pattern of
mortality in our environment. Ankara Ataturk Education and Research Hospital is
a tertiary center with 18 in-patient beds in Endocrinology and Metabolism Clinic.
Critical patients with endocrine-related diseases are also followed in intensive
care unit. In this study, we aimed to evaluate demographic characteristics,
hospitalization indications and causes of death in patients who died since the
foundation of our endocrine clinic 6 years ago.
Data of patients hospitalized and died between January 2004 and December 2009
in our in-patient clinic were analyzed retrospectively. Age, sex, hospitalization
indications and durations and mortality causes were evaluated. Among 5664
patients hospitalized during this period, 34 patients (0.6%) died.
Results
There were 20 female (58.8%) and 14 male (41.2%) patients with a mean age
of 7018.7 (18-96). Hospitalization indications were diabetes mellitus
(DM) related hyperglycemic emergencies in 22 (64.6%), oral hypoglycemic
or insulin related hypoglycemia in 4 (11.8%), metabolic disturbances secondary to
nutritional problems in 3 (8.9%), diabetic foot infection in 1 (2.9%), leukocytoclastic
vasculitis and renal failure secondary to insulin therapy in 1 (2.9%), acute
adrenocortical failure in 1 (2.9%), pituitary macroadenoma in 1 (2.9%), and
hypocalcemia due to hypoparathyroidismin 1 (2.9%) patient. 28 (82.4%) of patients
had type 1 or type 2 DM. Duration of hospitalization until death was 6.26.6 days
(1-25 days). Descriptive data showed that patients were generally in geriatric
age group and had chronic diseases (hypertension, coronary heart disease,
cerebrovascular disease, cancer) in addition to endocrine-related diseases.
Conclusion
At the present day, more than 80% of diseases and deaths are associated with
chronic diseases diagnosed in middle and old ages. Diabetes mellitus and DM
related emergent states, particularly in geriatric age group, are the leading causes of
death in our endocrine clinic.
P240
Synergic effect of Cabergoline in acromegaly treated with somatostatin
analogues. Report of two cases
Miguel Paja, Josu Perez-Yeboles, Aitzol Lizarraga, Cristina Moreno,
Ana Isusquiza & J Ramon Elorza
Hospital de Basurto, Basque Country, Bilbao, Spain.
Current treatment for acromegaly includes dopamine agonists (DA), somatostatin
receptor ligands (SRL) and GH receptor antagonists (GHRA). DA in
monotherapy, is less than 10% effective achieving control of the disease, and
its effcacy in addition to ongoing SRL is less studied, without obvious
determining factors of response. We report 2 operated patients with incomplete
response to SRL and to whom Cabergoline addition led to disease control.
Case 1
A man 36 years old was transesphenoidally operated of an intrasellar GH
producing macroadenoma. Basal GH and after glucose (OGTT; GHOGTT) was
16.1 and 16.2 ng/ml, and IGFI 907 ng/ml (N ,284). Four months after surgery
GHOGTT was 5.4 ng/ml and IGFI 708 ng/ml. Treatment with Octreotide, 20 mg
every 4 weeks, reduced GHOGTT 2.81 and IGFI to 470. Addition of Cabergoline
began with 1 mg leading to 1.5 mg per week, obtaining reduction of IGFI under
upper limit for age, with nadir of 113 ng/ml and basal GH of 0.2 ng/ml.
Case 2
A man 57 years old with long term acromegaly presented GHOGTT of 48 ng/ml,
IGFI of 846 ng/ml, and normal prolactin. MRI showed a macroadenoma with
right cavernous invasion. After surgery GHOGTT reduced to 5.15 and IGFI to
506. Treatment with Somatuline Autogel (120 mg monthly) got a GHOGTT of
1.11 and IGFI of 207. Addition of Cabergoline (up to 3 mg/week) reduced
GHOGTT to 0.62 and IGFI to 140 with reduction in Somatuline to 90 mg/week.
Employed drugs were well tolerated in both cases.
Combined treatment of SRL and DA resulted in control of the disease. Both
reached most restrictive criteria of control (GHOGTT , 1 ng/ml and levels of
IGFI under upper limits for age). One case could beneft lower dose of SRL.
The association of Cabergoline and SRLdeserves a relevant role in the acromegaly
treatment. It might be tried sistematically before the expensive use of Pegvisomant.
P241
Macroprolactinoma after chronic buserelin treatment in patient with
prostate cancer
Ferenc A Laszlo
1
, Mihaly Gervain
2
, Erika Voros
3
, Andor H Molnar
1
& Ferenc Laszlo
1
1
Department of Physiology, Anatomy and Neurosciences, University
of Szeged, Szeged, Hungary;
2
Department of Urology, City Hospital,
Oroshaza, Hungary;
3
Department of Radiology, University of Szeged,
Szeged, Hungary.
Twelve years following hemicolectomy for colon adenocarcinoma, a 75-year-old
patient with prostate cancer was treated for 4 weeks with the antiandrogen
nilutamide and then with the long-acting GnRH agonist buserelin. The serum
testosterone and prostate-specifc antigen (PSA) levels had decreased dramatically
after 3 months of treatment. After 2 years of buserelin administration, the hormonal
state was examined. Serum estradiol, testosterone, DHEA, DHEAS, FSH and LH
levels proved to be suppressed, but the serum PRL concentration was extremely
high (3 365 mIU/l). The pituitary MRI revealed a macroadenoma. The patient was
treated with the dopamine agonist cabergoline, together with buserelin. After 5
months of this combined treatment, the PSAand testosterone levels were very low;
the serum oestradiol, DHEA, DHEAS, FSH and LH concentrations remained
suppressed. The serum PRL level fell dramatically to 6.95 mIU/l, and a reduction
in tumor size was observed on MRI. In conclusion: Combined buserelin
cabergoline treatment proved a highly successful procedure to cure this patient
with prostate carcinoma and subsequent pituitary macroprolactinoma.
P242
Diagnostic performance evaluation of marking the concentration levels
of procalcitonin and ProGRP in monitoring disease cases of patients
with medullary thyroid carcinoma (MTC)
Aldona Kowalska, Danuta Gasior-Perczak, Iwona Palyga,
Grazyna Antczak, Anna Sluszniak & Stanislaw Gozdz
Holycross Cancer Centre, Kielce, Poland.
Introduction
Calcitonin is the main MTC marker. However, it has limitations: rapid in vitro
degradation, a concentration-dependent biphasic half-life, presence of different
isoforms and high cost of a single trial. Other markers of MTC can be
procalcitonin and ProGRP.
Aim
The aim of the study was to evaluate the diagnostic performance of marking the
levels of procalcitonin and ProGRP in monitoring patients with MTC.
Material
The study was carried out in a group of 41 MTC patients (32 women and 9 men,
aged 16-79), after the surgery, during the follow-up.
Methods
Marking the levels of procalcitonin and calcitonin in a test with pentagastrin and a
single marking of levels of ProGRP have been carried out. The results have been
compared.
Results
When elevated levels of calcitonin (basic and stimulated by pentagastrin)
occurred, the levels of procalcitonin were also elevated. In 0 min. it ranged
0.11-3.19 ng/ml, average 2.27 ng/ml; in 3 or 5 min. ranged 0.13-15.74 ng/ml,
average 7.45 ng/ml. None of the 33 patients with normal levels of calcitonin and
after stimulation with pentagastrin had elevated levels of procalcitonin. Markings
of the levels of ProGRP were within the reference range in cases with the normal
levels of basic calcitonin and stimulated by pentagastrin. In 7 of 8 patients with
elevated levels of basic and stimulated calcitonin, the levels of ProGRP were
elevated and ranged 77-237 pg/ml, average 135.9 pg/ml. In one case levels of
ProGRP were within a normal range - 17.06 pg/ml.
Conclusions
Procalcitonin can be useful for monitoring MTC patients - a full correlation with
marking of calcitonin in our material. ProGRP can also be used as a marker for
monitoring the disease course in MTC patients. According to our study the
correlation with calcitonin marking is 87.5%. Markings of procalcitonin and
ProGRP did not bring more information than calcitonin marking.
P243
Nesidioblastosis in adult patient with neurohbromatosis type1 and
synchronous multicentric duodenal somatostatinomas - case report
Sanja Ognjanovic
1
, Milan Petakov
1,2
, Djuro Macut
1,2
, Tatjana Isailovic
1
,
Valentina Elezovic
1
, Bojana Popovic
1
, Ivana Bozic
1
& Svetozar Damjanovic
1,2
1
Institute of Endocrinology, Clinical Center of Serbia, Belgrade, Serbia;
2
Belgrade University Medical School, Belgrade, Serbia.
Somatostatinomas are rare neuroendocrine tumors of the pancreas and small
intestine that can occur sporadically or in a syndromic form. Duodenal
somatostatinomas are often associated with neurofbromatosis type1 (NF1).
Their presenting features are mostly related to local effects of the tumor mass
rather than functional clinical syndrome. Nesidioblastosis is extremely rare cause
of persistant hyperinsulinemic hypoglycaemia in adults.
We present a case of a 34-year-old woman with NF1 admitted to our hospital for
evaluation two months after pylorus-preserving-duodenopancreatectomy and
cholecystectomy for incidental perioperative fnding of multiple duodenal tumors.
Preoperative abdominal MSCT showed dilatation of extrahepatic bile ducts and
cholelithiasis and it was initial indication for the surgery. In the previous year she
had occasional episodes of hunger, tremor and sweating that dissapeared after
food intake. Pathohistology revealed three well-differentiated periampullar
neuroendocrine tumors with identical histological and immunohistochemical
features (CgA, Syn, SMS, Ki-67 4%, p53 9%, proinsulin ,1% cells), with
psammoma bodies and regional lymph nodes metastases (2 out of 31 lymhnodes
positive). The histopathological study of the resected pancreatic tissue revealed
nesidioblastosis. Postoperatively prolonged OGTT (5-h test, glucose 75 g)
revealed normal glucose response without hypoglycemia. Hypoglycemia did
not occur during 72-h fast, although low plasma glucose level was detected
(2.9 mmol/l) with inappropriate insulin level (16.7 mIU/l). During the euglycemic
hyperinsulinemic clamp study, plasma C-peptide levels declined from 1.1 to
0.48 nmol/l, indicating supression of endogenous insulin secretion. Octreoscan
(99mTc-tektreotide) was negative. Chromogranin-A was in the normal range. In
conclusion ampullary somatostatinomas associated with NF1, usually are not
associated with somatostatinoma syndrome, although diabetes and cholelithiasis
have occasionally been described. Somatostatin exerts inhibitory infuence on
insulin secretion. But even after successful surgery for somatostatinomas no overt
hypoglycaemic episodes were noted in our patient in spite of nesidioblastosis.
P244
Polyuric-polydipsic syndrome after cranioencephalic traumatism in a
patient with multiple sclerosis
Selma B Souto
1,2
, Joana Mesquita
1,2
, Marta Alves
1,2
, Daniel
Carvalho Braga
1,2
, Ana Varela
1,2
, Elisabete Rodrigues
1,2
,
Celestino Neves
1,2
, Fernanda Guerra
1
& Jose Lui s Medina
1,2
1
Endocrinology department, Porto, Portugal;
2
Faculty of Medicine, Porto,
Portugal.
Introdution
Central diabetes insipidus(CDI) is a rare disease, with multiple aetiologies such as
cranioencephalic traumatism and multiple sclerosis (ME). However, the
association with ME is not commonly described. The clinical suspicion must
be made in the presence of polyuria and polydipsia.
Case report
Woman, 67 years-old, revealing history of ME relapsing-remitting subtype with
8 years of evolution, hypertension and dyslipidemia, medicated with interferon
beta 1a, valsartan 80 mg/day and pravastatine 20 mg/day. She referred polyuria
and polydipsia after frontal cranioencephalic traumatism. Her serum sodium level
and urine density were normal. She was submitted to a water deprivation test that
confrmed CDI (Table 1), and started nasal desmopressin therapy 5 g/day, with
clinical improvement. Pituitary resonance imaging revealed focal thickening of
the stalk and absence of the posterior pituitary bright spot. Serum levels of
gonadotrophines, IGF-I, PRL, TSH and ACHT were normal. The patient was
submitted to an insulin hypoglycaemia, TRH and LHRH test, with normal
pituitary response except for TSH. Currently, she is under nasal desmopressin
therapy 20 g/day, with clinical improvement.
Conclusion
The importance of this case report is related to the rarity of described cases of DIC
caused by ME. Nevertheless, for the present case it remains to be clarifed if the
DIC was caused by the patient history of cranioencephalic traumatism.
P245
The course of disease and treatment of patient with MEN2A syndrome
diagnosed in 9-th week of pregnancy
Aldona Kowalska
1
, Iwona Palyga
1
, Danuta Gasior-Perczak
1
, Piotr Chlosta
1
,
Janusz Sluszniak
1
, Artur Kowalik
1
, Jacek Walkowski
2
& Stanislaw Gozdz
1
1
Holycross Cancer Centre, Kielce, Poland;
2
Dept. of Gynecology City
Hospital, Starachowice, Poland.
Introduction
Diagnosis of pheochromocytoma is rarely established in pregnancy, although can
cause threat to health and life of foetus and mother. Exact and early diagnosis is
crucial for effective treatment.
Purpose
The purpose of our study is to present a case of patient with pheochromocytoma
and medullary thyroid carcinoma (MCT) - MEN2A syndrome - diagnosed in 9-th
week of pregnancy.
Material and method
Twenty nine-year-old female reported to our hospital for investigation for
MEN2A syndrome because of germline mutation of the RET proto-oncogene that
had been revealed in patient`s father. The patient felt healthy subjectively and was
in 9-th week of pregnancy. Diagnosis of MEN2A syndrome (bilateral
pheochromocytoma and MTC) was established on a base of diagnostic modalities
that had been done. On account of the fact that the patient had refused
adrenalectomy, decision on deep observation of the patient and postponing the
surgery till delivery was made. Because of hypertension the patient had been
treated with alpha-blocker since 16-th week of pregnancy with good effcacy.
The pregnancy was terminated by caesarean section in 34-th week of pregnancy.
After 4 weeks the patient underwent laparoscopic extirpation of adrenal glands,
followed by thyreoidectomy with central and lateral cervical lymph node
dissection. Low postoperative basic and stimulated calcitonin concentration
indicates oncological radical treatment.
Conclusion
1) Genetic screening of relatives of patients with MEN2A syndrome can lead to
diagnose the disease in asymptomatic state.
2) Careful pharmacological treatment leads to favourable course of pregnancy
and outcome in case of our patient.
3) Postponing of the surgery because of MTC, neither had an infuence on
oncological progression of the disease, nor in worsening the prognosis to our
patient.
P24
Serum prolactin levels in rheumatoid arthritis and other autoimmune
diseases
Erzsebet Toldy
1,5
, Barna Opra
2
, Dora Horvath
3
, Zoltan Locsei
3
, Gabor
L Kovacs
6,5
& Karoly Racz
7
1
Central Laboratory of Markusovszky Teaching Hospital of County Vas,
2
Department of Rheumatology, Markusovszky
Teaching Hospital of County Vas, Szombathely, Hungary;
3
1st Department
of Internal Medicine, Markusovszky Teaching Hospital of County Vas,
4
1st Department of Internal Medicine,
Markusovszky Teaching Hospital of County Vas, Szombathely, Hungary;
5
Institute of Diagnostics and Management, University of Pecs, Pecs,
Hungary;
6
Institute of Laboratory Medicine University of Pecs, Pecs,
Hungary;
7
2nd Institute of Internal Medicine, Semmelweis University,
Budapest, Hungary.
In certain patients with autoimmune diseases (AID) and with rheumatoid arthritis
(RA), moderate hyperprolactinemia can be present.
Aim
Our aim was to investigate free PRL levels in RA, using two different
PRL assays known to react with a different sensitivity to MPRL. The
relationship between PRL and the disease-specifc autoantibodies (antibody to
cyclic citrullinated peptide:cCP-Ab and antinuclear antibody:AN-Ab) were
analyzed also.
Methods
Eighty six patients were studied (68 women, 18 men, 5616 years of age). 34
patients suffered from RA, 27 from other AID. 25 non autoimmune patients with
osteoarthritis (NAI) were used for controls. AN-Ab (ELISA,Hycor), cCP-Ab
(ECLMA,Roche) and PRL levels before and after PEG treatment (FPRL) were
measured. PRL was assayed with two methods (Roche and Abbott). The latter
PRL method reacts stronger with MRPL.
Results
Four hyperprolactinemic patients were found (2 RA, 2 AID). Higher total PRL
levels were found in AI (RA and AID) patients (284116 IU/l) than in NAI
patients (19778 IU/l) with the ECLMA method but not by CLMA method.
FPRL levels were signifcantly lower in the NAI as compared to AID or RA
(216106 and 227117 U/l) patients. FPRL and cCP-Ab correlated negatively
(r-0.39; P,0.01) in RA, while FPRL and cCP-Ab correlated positively
(r0.84, P,0.001) in AID.
Conclusion
PRL levels are higher in AI than in NAI, but there was no difference between
RA and AID cases. The correlations between FPRL and autoantibodies may
explain the suspected role of PRL in the pathogenesis of RA and AID,
however further investigations are needed to estimate the value of these
fndings.
P24I
A tale to tell: how lupus led to Graves` disease
Madalina Musat
1,2
, Camelia Giurca
2
, Daniela Aforei
2
, Anca Lupu
2
,
Anda Dumitrascu
2
, Mihaela Milicescu
1,3
, Rucsandra Danciulescu
1,4
& Catalina Poiana
1,2
1
2
C.I Parhon National Institute of Endocrinology, Bucharest, Romania;
3
Department of Internal Medicine, Dr I. Cantacuzino Hospital, Bucharest,
Romania;
4
Institute of Diabetes, Nutrition and Metabolic Disease Prof. Dr.
N.C. Paulescu, Bucharest, Romania.
Introduction
Despite the presence of antinuclear (ANA) and anti DNA antibodies in
Graves` disease, the association with Systemic Lupus Erythematosus (SLE) is
rare. Responsible for this association seem to be mutations in the PTPN22
gene.
Case Report
We report a case of a 27-year-old woman, who presented in January 2009 in our
department, at 6 months postpartum, after extensive investigations for
autoimmune disease. She had negative results for polymyositis and SLE, but
positive for TSHR antibodies.
At presentation the patient had no signs or symptoms of Graves` disease, only a
mild rash of the zygomatic region, neck and anterior thorax, and hyperemic
oedema of the infrapalpebral region. Laboratory showed suppressed TSH, normal
FT3, FT4, and positive TSHR-antibody, ATPO and antitiroglobulin antibodies).
There were no CT signs of Graves orbitopathy, but infltrative aspect of the
bilateral inferior palpebral regions.
At this point the patient was diagnosed with subclinical Graves` disease and
commenced on antithyroid drug (methymazole) and continued with oral
glucocorticoids previously recommended.
Corticotherapy was tapered in 3 months and the patient returned after a pause of 2
more months, with an exacerbation of facial and thoracic rush during the
summertime.
She was rescreened for SLE (ANA, Ac antiADN ds) and found positive.
A diagnosis of SLE with multiple organ involvement was made and treatment
with methylprednisolone, hydroxichlorochine and azathioprine was started.
Conclusion
Screening for Graves` disease in young women suspected of SLE should be more
largely used, while facial rash in young women with controlled Graves` disease
could be relevant of SLE.
TabIe 1 Water deprivation test.
Times
Weight
(kg)
BIood
pressure
(mmHg)
PuIse
(bpm)
Urine
osmoIaIity
(mOsm/Kg)
Serum
osmoIaIity
(mOsm/Kg)
Urine
debite
(ml/h)
0' 88.0 150/67 79 107 0
1h 88.8 124/72 73 62 300
2 h 88.8 134/71 76 77 400
0' 78 302
Desmopressin administration (intravenous 1 g)
30' 151 294
60' 361 297
P248
Tertiary hypercorticotropinism and Cushing`s disease secondary to
impaired 21-hydroxylation
Matthias Haase
1
, Theresa Cox
1
, Elke Kaminski
2
, Dieter K Ludecke
3
,
Wolfgang Saeger
4
, Reimar Fritzen
5
, Matthias Schott
1
, Werner
A Scherbaum
1
& Holger S Willenberg
1
1
2
Praxis fur Humangenetik-
Altona, Hamburg, Germany;
3
Department of Neurosurgery, Section of
Pituitary Surgery, University Clinic of Hamburg, Hamburg, Germany;
4
Institute of Pathology of the Marienkrankenhaus Hamburg, Hamburg,
Germany;
5
Endocrine outpatient clinic, Duesseldorf, Germany.
Autonomy of ACTH secretion has been described in patients with chronic
dysinhibition of ACTH secretion. We here present the very unusual case of a
31-year old female patient who had congenital adrenal hyperplasia and developed
Cushing`s disease, including clinical examinations, laboratory data, endocrine
function tests, histological and genetic analyses.
The affected patient had clinical signs and a typical history of hypercortisolism.
Endocrine function tests revealed Cushing`s disease. After removal of a pituitary
microadenoma, serum-cortisol levels fell below normal and the symptoms
improved. However, hirsutism returned after four years ACTH levels were in the
upper range of normal. An ACTH challenge test showed a minor cortisol response
but a marked increase in 17-hydroxyprogesterone serum concentrations. The
genetic analysis revealed a homozygous mutation in exon 7 of the CYP21A2 gene
(CTGTTG, Val281Leu).
This is the third description of a case of Cushing`s disease with congenital adrenal
hyperplasia. It is suggested that a marked ACTH drive can override insuffcient
21-hydroxylation causing hypercortisolism in non-classical homozygous forms of
congenital adrenal hyperplasia. In this patient Cushing`s disease may have
developed on the basis of impaired 21-hydroxylation in the sense of tertiary
hypercorticotropinism.
P249
Cushing syndrome in patient with thyroid orbitopathy (case report)
Peter Vanuga, Michal Kulich & Dusan Pavai
Department of Endocrinology, National Institute of Endocrinology,
Lubochna, Slovakia.
Authors present a 35-year-old female with thyroid orbitopathy (EO) associated with
Graves disease. After initial antithyroid therapy, thyroidectomy was indicated and
performed uneventenfully. Due to persisting severe clinically active EO, thyroablative
therapy with
131
I was performed three years later, intravenous pulse of methyl-
prednisolone was given and consecutive oral therapy with prednisone initiated. This
caused weight gain (from 63 to 80 kg) and iatrogenic Cushing syndrome. Afterwards,
prednisone was changed to cyclophosphamide. After initial decrease of body weight,
we noticed repeated weight gain (from76 to 91 kg). Patient underwent an laparoscopic
cholecystectomyfor biliarycolic. This was complicatedbyhaemorrhage andcomputer
tomography (CT) was performed postoperatively. CT study showed a hypodense
expansion originating fromthe medial limb of left adrenal gland (30 mmin diameter),
indicating investigations of the adrenal hormonal status. Renin and aldosterone
in saline infusion test (6.40J3.40 IU/l, and 0.28J0.14 nmol/l, respectively) and
metanephrine and normetanephrine in clonidine test (0.156J0.241J0.145 nmol/l,
respectively 0.332J0.738J0.224 nmol/l) were normal. Surprisingly, elevated levels
of urinary free cortisol (UFC) (653J833 nmol/day, normal values 20-220 nmol/day)
were found. These fndings were confrmed by loss of diurnal variation of serum
cortisol (FP at 8 AM 559 nmol/l, FP at 12 PM 578 nmol/l), supressed ACTH values
(4.8J2.3 pg/ml) and lack of supression of FP and UFC in 2 mg and 8 mg
dexamethasone tests (FP 650 nmol/l, and 621 nmol/l, UFC 888 nmol/day, and
1018 nmol/day). Macroscopically, an ochre tumor was found at laparoscopic
adrenalectomy, confrmed by histological fnding of a cortical adenoma.
P250
Different manifestations of polyglandular autoimmune syndrome in
HLA-identical monozygous twins
E
va Csajbok
1
, Sandor Magony
1
, Zsuzsanna Valkusz
1
, Pal Panczel
2
& Janos Julesz
1
1
1st Dept. of Internal Medicine Endocrine Unit, University of Szeged,
Szeged, Hungary;
2
3rd Dept. of Internal Medicine, Semmelweis University,
Budapest, Hungary.
The polyglandular autoimmune syndromes (PAS) comprise a wide spectrum of
autoimmune disorders and are divided into a very rare juvenile (type I) and a
relatively common adult type with (type II) or without adrenal failure (PAS III).
For PAS II/III, susceptibility genes are known inreasing the risk for developing
autoimmune disorders, but without being causative. Actual diagnosis of PAS
involves serological measurement of organ-specifc autoantibodies and sub-
sequent functional testing.
We present the history of a 30-year-old monozygotic female twin pair. One of
them had Hashimoto`s thyroiditis as frst manifestation of PAS and, 4 years later,
Addison`s disease. The frst clinical sign of the second patient was type 1.
Diabetes with severe hyperglycemia and, at the same time, hypothyroidism was
also found due to Hashimoto`s thyroiditis, which was followed with Addison`s
disease 5 years later. These monozygotic twin girls had different manifestations
of PAS type II although they were HLA-identical.
Conclusions
Environmental factors can infuence the manifestation of PAS II in HLA-identical
twins?
Comparative endocrinology
P251
Relationship between essential amino acids and muscle mass,
independent of habitual diets, in pre- and post-menopausal women
Marie-Eve Filion, Annie Fex, Antony D Karelis & M Aubertin-Leheudre
UQAM, Quebec, Montreal, Canada.
When it is limited the amount and quality of protein intake plays a role in
determining the amount of skeletal muscle and the amount of essential amino
acids (EAA) may be the primary determinant in this process. The purpose of this
retrospective analysis was to examine the relationship between protein and EAA
intake and the level of muscle mass in healthy omnivore (Om), vegan (Veg), and
(OLV) Caucasian women. 21 Om, 22 OLV and 20 Veg were recruited. Women
were sedentary, as assessed by questionnaire. Muscle mass (urinary creatinine),
dietary intake (5-day dietary records), and biochemical analyses (urinary and
plasma sex hormones) were obtained. We observed no signifcant difference
between groups for muscle mass (P0.214), EAA intake (P0.206), leucine
(P0.111), isoleucine (P0.263), age (P0.439), and body mass index
(P0.133). However, we observed a signifcant difference between groups
for total dietary protein intake (P0.001), and total energy intake (P0.012).
These results were not infuenced by the hormonal profle in each group
(P 0.05 for plasma estrone, plasma estradiol, plasma testosterone and
sex-hormone-binding-globulin). In conclusion, our results showed that the type
of dietary protein habitually ingested (OM, OLV, or VEG) did not infuence
the level of muscle mass. Despite signifcant differences in total dietary protein
(Om: 74 g/day versus OLV: 56 g/day versus Veg: 52 g/day), the intake of
EAA (Om: 259 mg/kgBW per day versus OLV: 208 mg/kgBW per day versus
Veg: 222 mg/kgBW per day) was not signifcantly different between groups
indicating that EAA may be more important in determining the amount of muscle
mass. Each of these eating patterns appears adequate to maintain muscle mass.
These results are important because the loss of muscle mass is associated with
functional limitations, falls and fractures. Thus, further studies need to focus on
the role of the amount of EAA in muscle mass and in sarcopenia because the
mechanisms leading to this phenomenon are still unknown.
P252
Comparison of delayed puberty in girls and boys- Bosnian aspect
Adnan Bajraktarevic
1
, Slobodan Trninic
1
, Semira Penava
1
,
Lutvo Sporisevic
2
, Midhat Mujic
3
, Zaim Jatic
4
, Aida Djurdjevic Djulepa
5
& Jasmina Ceman Saric
6
1
Public Health Institution of Canton Sarajevo-Health Center Vrazova
Pediatrics Department, Sarajevo, Bosnia and Herzegovina;
2
First Medical
Aid Sarajevo -Pediatrics Department, Sarajevo, Bosnia and Herzegovina;
3
Pediatrics Clinic Sarajevo Department for Endocrinology, Sarajevo, Bosnia
and Herzegovina;
4
Medical Faculty Sarajevo Institution for Social and
Family Medicine, Sarajevo, Bosnia and Herzegovina;
5
General Hospital,
Sarajevo, Bosnia and Herzegovina;
6
Clinical Medical Center Sarajevo-
Biochemistry Department, Sarajevo, Bosnia and Herzegovina.
Background
Puberty is the growth process associated with appearance of both primary and
secondary sexual characteristics in children. Delayed puberty is defned clinically
by the absence or incomplete development of secondary sexual characteristics
bounded by an age at which 95 percent of children of that sex and culture have
initiated sexual maturation.
Methods
Some of the children participants were already being followed for constitutional
delay in growth and puberty for long periods by our colleagues at ours
institutions. The initial evaluation of delayed puberty should consist of a complete
history and physical, basic laboratory tests to look for signs of chronic disease,
and hormone level tests. These measurements are used to calculate linear height
velocities and establish a trajectory on the growth curve.
Results
Puberty may also considered to be delayed in girls if the whole process isn`t
complete in four years or fve years for boys or if menarche hasn`t occured by age
sixteen. Family history is often positive for siblings or parents with delayed
puberty. Puberty delayed but begins before sixteen years in girls and eighteen
years in boys in Bosnia and Herzegovina.
Discussion
Children with a constitutional delay in beginning puberty in beginning puberty
usually do not require treatment and they will eventually begin puberty and then
progress through the stages of puberty normally.
Conclusions
More then 250 causes of delayed puberty in boys and girls, including diseases and
drug side effect cause this diseases in Bosnia and Herzegovina. Tanner staging
method was considered critical to the collection of puberty-timing data, but
inclusion of breast tissue palpation and testicular volume assessment was
recommended to increase the reliability of estimating the ages of breast and
genital development onset.
P253
Osmoregulatory related alterations in plasma levels of triiodothyronine
and cortisol in a marine euryhaline teleost
Abdolali Movahedinia
1
, Ahmad Savari
1
& Hasan Morovvati
2
1
Khorramshahr University of Marine Science and Technology,
Khorramshahr, Islamic Republic of Iran;
2
Shahid Chamran University,
Ahwaz, Islamic Republic of Iran.
The aim of this study was to determine the changes of cortisol and T
3
(triiodothyronine) levels in Acanthopagrus latus, a marine euryhaline teleost, in
response to a wide range of salinities. The frst experiment was carried out
following exposure of juvenile yellowfn seabream to 5, 20, 42 and 607
environments. In the second experiment, the fsh were assigned to a gradual
adaptation to freshwater. Yellowfn seabream was capable of tolerating direct
exposure of salinities from 57 to 607 without showing mortalities. This species
was also able to tolerate gradual decrease in salinity in the surrounding medium
from seawater (427) to freshwater through a period of 10 days and successfully
adapt to freshwater without showing mortality. This is the shortest period reported
in a true marine fsh for adaptation to freshwater through an acceptable
experimental duration. The plasma cortisol level was increased in groups exposed
to 5 and 607. the highest cortisol level was observed in 607 treatment 12 h after
changing in salinity. The cortisol level of the groups adapted to 607 and 57
conditions were resumed to initial levels after 7 days and 24 h, respectively.
Following 24 h of treatment, the T
3
level resumed to the levels similar to the
control, after a little increase. There was no difference in cortisol and T
3
levels
among control and experimental groups during gradual adaptation to freshwater.
P254
Growth hormone releasing hormone (GHRH)-like peptide (LP)-2 is a
growth hormone (GH) releasing factor in chickens
Steve Harvey
1
, Cyrille Gineste
2
& Bruce Gaylinn
1
1
University of Alberta, Edmonton, Edmonton, Alberta, Canada;
2
University
of Virginia, Charlottsville, Virginia, USA.
Two growth hormone releasing hormone-like peptides (GHRH-LP-1 and GHRH-
LP-2) are expressed in chickens. Although GHRH-LP-1 displaces the binding of
labelled human GHRH to chicken pituitary membranes and stimulates the
accumulation of cAMP in HEK 293 cells transfected with the chicken (c) GHRH
receptor it has ,1% of the potency of human GHRH
1-32
and has little, if any,
growth hormone (GH) - releasing activity in chickens. GHRH-LP-1 is thus
unlikely to be the endogenous ligand for the cGHRH receptor, especially as two
GHRH-like peptides also exist in goldfsh, in which only one is active at the
goldfsh GHRH receptor. The possibility that GHRH-LP-2 is a GH-releasing
factor in chickens has therefore been investigated.
In vivo, circulating GHconcentrations in unanaesthetised 4-6 week old chicks were
signifcantly increased, in a dose-related way, in response to intravenous injections
of chicken GHRH-LP-2, with an EC
50
of 9.05 g/kg. Maximally effective doses of
GHRH-LP-2 (10 g/kg and 30 g/kg) induced GH responses that were comparable
to those induced by maximally effective doses of hGHRH
1-44
and thyrotropin-
releasing hormone, used as positive controls. The in vivo GH response to GHRH-
LP-2 was likely due to direct action, since GHRH-LP-2 promptly induced the
release of GH from perifused chicken pituitary glands in vitro.
These results demonstrate that GHRH-LP-2 stimulates GH release in vivo and
in vitro in chickens and it is therefore likely to be the endogenous ligand for the
recently discovered chicken GHRH receptor.
P255
Pituitary adenylate cyclase-activating polypeptide related peptide
(PRP) in an Anabantidae hsh: its mRNA expression in the brain during
gonadal development and sexual behavior and its hypophysiotropic
effect on pituitary hormonal gene expression
Gal Levy
1,2
, Yoav Gothilf
1
& Gad Degani
2,3
1
Department of Neurobiology, George S. Wise Faculty of Life Sciences,
Tel Aviv University, Tel Aviv, Israel;
2
MIGAL- Galilee Technology Center,
Kiryat Shmona, Israel;
3
School of Science and Technology, Tel-Hai
Academic College, Upper Galilee, Israel.
Pituitary adenylate cyclase activating polypeptide - related peptide (PRP)
(formerly known as growth hormone releasing hormone-like peptide GHRHLP)
can act as a hypophysiotropic factor in several teleosts by stimulating growth
hormone (GH) secretion. However, as yet, no information on this peptide as a
regulator of reproduction exists. Recently, the full-length PRP cDNA was cloned
in the blue gourami (Trichogaster trichopterus) and was found to be expressed in
the brain. Thus, the aims of the present study were to investigate the PRP gene
expression pattern during sexual behavior and oogenesis, as well as to learn its
effect on pituitary hormonal transcription in a primary culture of dispersed
pituitary cells using the quantitative real-time PCR method. Our results
demonstrated that the blue gourami PRP (bgPRP) mRNA levels were higher in
mature non-reproductively active males than in nest builders and juveniles. In
addition, higher mRNA levels were detected in females with oocytes in the fnal
maturation stage, as compared to in vitellogenic individuals. Stimulation of
pituitary cells with bgPRP increased LH and LH subunit levels only in females,
whereas in males only GH mRNA levels rose upon bgPRP stimulation. Based on
these results, we propose that in the blue gourami, bgPRP, as a hypophysiotropic
factor, may act differentially on the gonadotropic axes in females and males,
up-regulating their gonadotropin and GH mRNA levels, respectively. This
research provides a basis for the further understanding of the integrative network
that regulates growth and reproduction. Such knowledge may contribute to
hormonal treatments and manipulations in aquaculture.
Developmental endocrinology
P25
Similar developmental patterns of ghrelin and glucagon
immunoreactivity in the human pancreas
Sanja Vignjevic, Vera Todorovic, Mileva Micic, Neda Drndarevic,
Mirela Budec, Olivera Mitrovic, Dragoslava Djikic & Slavisa Djuricic
1
Institute for Medical Research, University of Belgrade, Belgrade, Serbia;
2
Mother and Child Health Institute of Serbia, Belgrade, Serbia.
Ghrelin is stored alongside glucagon in developing islet, although in a discrete
cellular compartment, the pancreatic +-cell. However, recent observations have
shown a subpopulation of ghrelin/glucagon-double-positive cells in developing
pancreas. The aimof the present study was to examine the developmental patterns of
ghrelin- and glucagon-immunoreactive (ir) cells expression and possible co-
localization of these hormones during human pancreas development. For this
purpose, paraffn-embedded pancreatic tissue sections fromhuman embryos (2) and
fetuses (24) were assessed by immunohistochemistry using antisera raised against
ghrelin and glucagon. The collection and use of human embryonic and fetal material
was carried out following ethical approval from the Local Ethics Committee.
Neither glucagon- nor ghrelin-ir cells were detected in the pancreas of 8-week-old
embryos. A few ghrelin-positive cells were already observed at gestational age of
11 weeks, and by week 15, both glucagon and ghrelin-ir cells were found either
within small cell clusters or as isolated cells adjacent to duct cells. From week
17 onwards, both cell types were observed at the periphery of the forming islet.
The number of ghrelin- and glucagon-ir cells progressively increased during the
second trimester of gestation, and slightly decreased during the third trimester.
The highest percentage of ghrelin- and glucagon-positive cells was observed in the
pancreas of second-trimester fetuses, where the cell density had reached 2.22% and
4.38%, respectively. Cells co-expressing ghrelin and glucagon were detected during
both early and late fetal period, but they represent merely a small fraction of the total
ghrelin- and glucagon-ir cells.
In conclusion, the similarities in developemental patterns of ghrelin- and glucagon-ir
cells together with the presence of double-positive cells suggest the involvement of
several common transcription factors that regulate cell-fate determination and
differentiation of these cell populations.
P25I
Mineralocorticoid pathway in newborns: evidence for a physiological
renal aldosterone unresponsiveness
Laetitia Martinerie
1
, Say Viengchareun
1
, Pascal Boileau
2
& Marc Lombes
1
1
INSERM U693, Le Kremlin Bicetre, France;
2
Hopital Antoine Beclere,
Clamart, France.
Aldosterone is the main steroid hormone controlling sodium homeostasis in
human. During the neonatal period, full term newborns and more specifcally
premature infants, are subjected to an impaired renal capacity to reabsorb sodium,
responsible for sodium loss and failure to thrive which could be linked to a renal
aldosterone unresponsiveness at birth. A clinical prospective study on 50
newborns and their mothers, revealed high aldosterone and renin levels in
umbilical blood samples compared to maternal plasma levels. This contrasted
with signs of functional hypoaldosteronism in newborns: hyponatremia,
hyperkalemia and urinary sodium loss, consistent with a partial aldosterone
resistance at birth. We also established a reference value for neonatal urinary
aldosterone concentration which represents the best index for accurate evaluation
of mineralocorticoid sensitivity at birth.
Given that the Mineralocorticoid Receptor (MR) mediates most renal aldosterone
effects, we investigated the ontogeny of renal MR expression by gene expression
studies and immunodetection experiments during development in mouse and
human. We show that MR mRNA and protein expression follows a biphasic
temporal profle with a transient peak during gestation, a low expression at birth
and a progressive increase during the postnatal period. This cyclic renal
expression was specifc to the mineralocorticoid signaling pathway and could
account for the partial aldosterone resistance observed at birth.
We have documented an aldosterone unresponsiveness at birth which was
accompanied by a low renal MR expression level. Molecular mechanisms
involved in the regulation of MR expression are under investigation. A
multicenter clinical investigation program, supported by a French national
PHRC grant, is currently ongoing in order to evaluate the intensity of aldosterone
resistance as a function of gestational age and to examine its evolution throughout
the frst year of life. This work could ultimately lead to new therapeutic strategies
for the management of sodium loss in preterms and neonates.
P258
A dgg cholesterol synthesis in developing mouse embryo is required
for embryonic survival
Heli Jokela
1
, Pia Rantakari
1,2
, Tarja Lamminen
1,2
, Leena Strauss
1
,
Roxana Ola
3
, Helena Gylling
4
, Tatu Miettinen
5
, Pirjo Pakarinen
1,2
,
Kirsi Sainio
3
& Matti Poutanen
1,2
1
Department of Physiology, Institute of Biomedicine, University of Turku,
Turku, Finland;
2
Turku Center for Disease Modeling, Institute of
Biomedicine, University of Turku, Turku, Finland;
3
Department of Medical
Biochemistry and Developmental Biology, Institute of Biomedicine,
University of Helsinki, Helsinki, Finland;
4
Department of Clinical Nutrition
and Department of Medicine, Kuopio University Hospital, University of
Kuopio, Kuopio, Finland;
5
Department of Medicine, Institute of Internal
Medicine, University of Helsinki, Helsinki, Finland.
Hydroxysteroid (17-) dehydrogenase enzymes (HSD17Bs) have an important
role in sex steroid hormone metabolism. They are known to catalyze reactions
between highly active 17-hydroxy steroids and less active 17-keto steroids. In
addition to sex steroid metabolism, it is becoming evident that HSD17Bs have
functions in other pathways as well, e.g. lipid and bile acid metabolism. HSD17B
type 7 enzyme is known to catalyze in vitro the activation of estrone (E1) to
estradiol (E2). However, it has also been shown that HSD17B7 catalyzes in vitro
the conversion of zymosterone to zymosterol, which is an essential step in
cholesterol biosynthesis. The hydroxysteroid (17-) dehydrogenase 7 defcient
mice (HSD17B7KO) are known to be embryonic lethal and they die at embryonic
day 10.5 (E10.5). In the present study, we analyzed HSD17B7KO mouse embryos
in order to fnd out the physiological function of the enzyme in vivo. We could
show that the function of HSD17B7 enzyme in cholesterol biosynthesis takes also
place in vivo. Accordingly, the amount of lanosterol and squalene were
accumulated, and concentrations of the cholesterol biosynthesis late intermedi-
ates in the HSD17B7KO embryos were markedly reduced. The total cholesterol
concentration in the HSD17B7KO embryos was unaltered at the time of death,
indicating that the normal maternal cholesterol supply was not able to rescue the
embryonic survival in the absence of de novo cholesterol synthesis. In line with
the normal cholesterol concentration in the embryo, sonic hedgehog and two of its
down stream targets, Ptch1 and Smo, showed normal expression pattern at E8.5.
The vascularization in the HSD17B7 defcient yolk sacs was disrupted, and by
E10.5, the embryos had pericardial effusion, reduced number of cardiomyocytes,
and the complexity of the vasculature was reduced. Increasing apoptosis was
observed in the neural structures of the HSD17B7KO mice at E9.5, and by the age
of E11.5, the HSD17BKO embryos were resorbed. The phenotype observed in the
HSD17B7KO embryos indicates the importance of HSD17B7 enzyme in sterol
metabolism rather than in steroid metabolism. This study, together with
previously published mouse models with disrupted cholesterol biosynthesis,
shows that HSD17B7 is the last essential enzyme in cholesterol biosynthesis
pathway needed for embryonic survival, and more specifcally, for the proper
differentiation of brain and cardiovascular structures.
P259
Partial loss of pancreas endocrine and exocrine cells of human
ARX-null mutation: consideration of pancreas differentiation
Masayuki Itoh
1
, Shin Okazaki
2
, Rie Miyata
3
, Takeshi Inoue
2
,
Takumi Akashi
4
, Masaharu Hayashi
3
& Yuichi Goto
1
1
National Center of Neurology and Pschiatry, Kodaira, Japan;
2
Osaka City
General Hospital, Osaka, Japan;
3
Tokyo Metropolitan Institute of
Neuroscience, Fuchu, Japan;
4
Tokyo Medical and Dental University, Tokyo,
Japan.
Aristaless-related homeobox gene (ARX) mutation leads to several neurological
disorders including X-linked lissencephaly with abnormal genitalia (XLAG),
West syndrome and Partington syndrome, with XLAG being the most severe
form. Although some of the brain pathology of XLAG has already been described,
the crucial extra-brain symptoms are severe growth retardation, transient
hyperglycemia and intractable diarrhea. Since ARX expresses in the islets of
Langerhans during the embryonic stage, these visceral phenotypes may be related
to a loss of ARX function, which develops endocrine cells in the pancreas. We
investigated the abnormal pancreatic development of XLAG patients with ARX-
null mutation. We performed immunohistochemistry of XLAG pancreases, using
the antibodies against glucagon, insulin, somatostatin, pancreatic polypeptide,
ghrelin, Brn4, Nkx2.2, Mash1, Pdx1, amylase and pancreatic lipase. As the
results, the glucagon- and pancreatic polypeptide-producing cells were found to
be completely defcient in the islets of Langerhans. We also discovered marked
interstitial fbrosis, small exocrine cells with loss of amylase-producing cells and
an enlargement of the central lumen of the glandular acini. These pathological
fndings indicate that ARX contributes not only to endocrine development, but
also to exocrine development of the human pancreas, and its defciency may lead
to the severe phenotypes of XLAG patients.
P20
Quality of life and emotional state of adult patients with adult-onset,
childhood-onset growth hormone dehciency and Turner syndrome
Lina Lasaite, Danute Lasiene & Liudvikas Lasas
Kaunas University of Medicine, Kaunas, Lithuania.
Though results of scientifc studies are rather controversial, it is known that adults
with growth hormone defciency (GHD) and Turner syndrome (TS) experience
disturbances in psychological well-being and quality of life. Results of our
previous studies confrm that quality of life and emotional state are worse in adult
patients with adult-onset, childhood-onset GHD and TS than in age- and sex-
matched controls.
Aim
The aim of the study was to compare quality of life and emotional state of adult
patients with adult-onset GHD, childhood-onset GHD and TS after discontinu-
ation of GH treatment.
Eighteen patients with adult-onset GHD (age 27.85.3 years), 40 patients
with childhood-onset GHD (age 24.06.9 years) and 18 patients with TS
(age 21.54.1 years) after discontinuation of GH treatment. Quality of life was
evaluated by adult growth hormone defcient quality of life questionnaire,
emotional state - by profle of mood states.
Results
Comparing quality of life in the researched groups of patients we did not fnd
signifcant differences. Global score of emotional state differed signifcantly
between patients with adult-onset GHD and TS (18.327.3 vs 36.338.2,
P0.0109) and between childhood-onset GHd and TS patients (12.40.4 vs
36.338.2, P0.0072). No signifcant differences in emotional state were
detected between adult-onset GHD patients and childhood-onset GHD patients.
In conclusion
Emotional state, but not quality of life is worse in adult patients with Turner
syndrome than in adult-onset and childhood-onset growth hormone defcient
patients after discontinuation of growth hormone treatment.
P21
An inadequate maternal dietary protein level during pregnancy in pigs
alters the expression of corticosteroid receptors and 11-hydroxysteroid
dehydrogenase isoforms in the placenta and fetal brain
Ellen Kanitz, Maria Grabner, Margret Tuchscherer, Klaus-Peter Brussow,
Bernd Stabenow, Charlotte Rehfeldt, Cornelia C Metges & Winfried Otten
Leibniz Institute for Farm Animal Biology (FBN), Dummerstorf, Germany.
Imbalanced maternal nutrition during pregnancy can cause fetal growth
retardation, metabolic changes and alterations of the hypothalamic-pituitary-
adrenal (HPA) system in the offspring. Here, we investigated the effects of
maternal low and high protein diets during pregnancy in pigs on materno-fetal
HPA regulation and expression of glucocorticoid receptor (GR), mineralocorti-
coid receptor (MR), 11-hydroxysteroid dehydrogenase 1 and 2 (11-HSD1 and
11-HSD2) mRNA in the placenta and fetal brain. Twenty-four German
Landrace sows were fed isoenergetic diets with high (HP, 30%), low (LP, 6%)
or control (CP, 12%) protein levels throughout pregnancy. On gestational day 93,
fetuses were recovered under general anaesthesia for the collection of blood and
brain samples. In pregnant sows, the LP diet reduced growth performance and
increased salivary cortisol levels. Number and body weight of fetuses were not
affected by the maternal diets. Total plasma cortisol concentrations in the
umbilical vein and artery as well as in endogenous blood circulation were
signifcantly elevated in fetuses from HP sows, whereas corticosteroid-binding
globulin levels were signifcantly decreased in LP fetuses compared to controls.
Indeed, the calculated free cortisol index displayed increased concentrations of
biologically active cortisol in fetuses from LP sows. In the placenta, the LP diet
caused a signifcant increase of GR mRNA expression, but affected neither the
11-HSD1 and 11-HSD2 mRNA expression nor the enzyme activity. However,
there was an effect of the LP diet on the 11-HSD mRNA expression in the fetal
brain. The hypothalamic 11-HSD1 mRNA expression was signifcantly
enhanced in LP fetuses compared to controls, whereas the 11-HSD2 mRNA
expression was decreased. There was no dietary effect on the expression of
glucocorticoid regulating genes in the fetal hippocampus. In conclusion, we
demonstrated that an inadequate maternal dietary protein level during pregnancy
in pigs tissue-specifcally affects the materno-fetal HPA regulation. Furthermore,
the present results suggest that a dietary protein defciency during pregnancy may
alter the expression of genes encoding key determinants of glucocorticoid
hormone action in the fetus.
P22
Lipid prohle in type 2 diabetic patients in Kragujevac
Jelena Petrovic, Violeta Mladenovic, Aleksandar Djukic & Sandra Sipetic
Clinical Center Kragujevac, Kragujevac, Serbia.
Introduction
High total cholesterol (tChol), LDL and trygliceride (TAG) level is independent
risk factor for cardiovascular disease. High prevalence of malignant atherogenic
profle is alarming in type 2 diabetics (high triglyceride, low HDL). It is very often
that dislipidemia is associated with diabetes and obesity, as well as hypertension.
Aim
The aim of this study is to analyse lipid profle in patients with type 2 diabetes in
Kragujevac depending on gender and therapy of diabetes.
This study included all patients registered in Primary Care with type 2 diabetes.
We determinated lipid profle: tChol, LDL, HDL and TAG. Patients were divided
according to therapy in 2 groups: oral agents and insulin therapy.
Results
We registered 3108 patients with type 2 diabetes in Kragujevac. Anamnestic,
previous lipid disorder had 23.5%. According to National guideline clinical
practise criteria: 83.3% had increased tChol level, 69.9% increased LDL, 55.2%
increased TAG i 76.8% decreased HDL cholesterol level. There is statisticaly
signifcance in average tChol level (men versus women): (5.71.19 vs
6.091.17 mM, P,0.001), as well as LDL (3.390.87 vs 3.661.04 mM,
P,0.001), but there is no signifcance in TAG (2.261.76 vs 2.171.3 mM,
P0.378) and HDL (1.410.37 vs 1.470.34 mM, P0.06). There is
statisticaly higher average HDL in patients with oral antidiabetics than in
patients with insulin therapy (1.460.34 vs 1.360.36 mM, P0.006), but
there is no signifcance inaverage LDL (3.570.99 vs 3.531.02 mM,
P0.699), tHol (5.981.2 vs 5.861.15 mM, P0.278) and TAG (2.231.5
vs 2.061.29 mM, P0.209) depending on therapy of diabetes.
Conclusion
The prevalence of lipid disorders in type 2 diabetics is high. There is statistically
signifcantly higher tHOL and LDL in women. Patients with oral therapy have
statistically higher values HDL than patients on insulin therapy. This values showed
not satisfed liporegulation in type 2 diabetics.
P23
Gonadal structures in a fetus with complete androgen insensitivity
syndrome and persistent Mullerian derivatives: comparison with the
normal fetal development
Sabrina Corbetta
1
, Muzza Marina
2
, Avagliano Laura
3
,
Bulfamante Gaetano
3
, Gaetti Luigi
4
, Eller-Vainicher Cristina
2
,
Beck-Peccoz Paolo
2
& Spada Anna
2
1
Endocrinology Unit, Department of Medical-Surgical Sciences, Universita`
di Milano, IRCCS Policlinico S.Donato, S.Donato Mse (MI), Italy;
2
Endocrine Unit, Department of Medical Sciences, Universita` di Milano,
IRCCS Fondazione Ospedale Maggiore Policlinico, Mangiagalli, Regina
Elena, Milan, Italy;
3
Prenatal and Neonatal Pathology Unit, Department of
Medicine, Surgery and Dentistry, Universita` di Milano, A.O.S. Paolo, and
IRCCS Fondazione Ospedale Maggiore Policlinico, Mangiagalli, Regina
Elena, Milan, Italy;
4
Pathology Unit, Azienda Ospedaliera 'Carlo Poma`,
Mantova, Italy.
Androgens, by signaling through the androgen receptor (AR), mediate a wide
range of male developmental processes. Complete androgen insensitivity
syndrome (CAIS), a X-linked disorder caused by AR gene mutations, represents
an in vivo model to study the role of androgens in sexual development. Here, we
reported a case with CAIS at 20 weeks of gestational age harbouring a novel AR
missense mutation (D767V), which was predicted to prevent androgen binding
and action. Morphological examination and immunostaining were carried out in
the index case, three male and one female normal 20-week-old fetuses for
comparison. CAIS fetus showed complete female external genitalia, intrabdom-
inal testis and persistence of Mullerian derivatives, as a uterus and the upper
portion of vagina, developed to a similar extent in the CAIS fetus than in normal
20-week-old female fetus, were found. The testis showed a dramatic increase in
the size and number of Leydig cells, resulting in doubling of the CAIS testis
volume compared with the normal male fetuses. Semineferous tubules and Sertoli
cells were normally developed. Leydig cells hyperplasia and persistence of
Mullerian duct were described both in CAIS and persistent Mullerian duct
syndrome. Direct sequencing of AMH and AMHR2 genes did not identify
genomic variants. AMH protein was expressed in the Sertoli cells of both CAIS
and normal male fetuses, though the immunostaining in CAIS Sertoli cells was
more intense. AMHR2 immunostaing was present in the mesenchymal
peritubular cells, which were defnitely reduced in the CAIS testis compared
with normal male fetuses. Finally, Leydig cells expressed bone morphogenetic
receptor type 1A (BMPR1A) at high levels both in CAIS and normal male fetuses.
These data suggested that AR deletion did not affect the testicular expression of
genes relevant for Mullerian duct regression and that Leydig cells hyperplasia
might be sustained by LH and BMPR1A-mediated AMH hyperstimulations.
P24
Baseline characteristics and serum IGF1 levels in GH dehcient (GHD)
patients treated in the transition phase from adolescence into
adulthood: data from the NordiNet International Outcome Study (IOS)
Matthias M Weber
1
, Oliver Blankenstein
2
, Jens Otto L Jrgensen
3
, Birgitte
T Pedersen
4
, Viatcheslav Rakov
5
& Jens Sandahl Christiansen
3
1
Klinikum der Johannes Gutenberg-Universitat, Mainz, Germany;
2
Charite-Universitatsmedizin, Berlin, Germany;
3
Aarhus University
Hospital, Aarhus, Denmark;
4
Novo Nordisk AS, Soeborg, Denmark;
5
Novo Nordisk Health Care AG, Zurich, Switzerland.
Background
Data fromseveral clinical studies have demonstrated the beneft of GHtreatment in
relation to bone mineral density and body composition in young adults who
received GHtreatment in childhood due to GHD
1-3
. There are recommendations to
use a higher GH dose in the transition phase compared to the GH dose required
during adulthood to mimic the endogenous GH secretion
4,5
.
Methods
Data from NordiNet IOS have been analyzed to determine the number of patients
recently treated in the transition phase and to obtain the baseline characteristics in
these patients and treatment dynamic over 2 years. Selection criteria for this
cohort: male patients above 16 years and female patients above 15 years at the
time of dosage reduction from growth promoting (adolescent) dose to a lowered
transition dose (paediatric database); patients with childhood onset of GHD who
were on an ongoing GH treatment at age 18 years and ,25 (adult database).
All patients had to have at least 2 years of follow up in the transition phase.
Results
Patients in transition were identifed in the NordiNet IOS database (15 females
and 18 males). The mean age at transition GH dose start was 19.02.3 years.
Mean BMI was 23.73.3, mean IGF1 SDS was 1.22.6, mean absolute GH
dose was 0.740.57 mg/day. The GH dose was higher than generally in the adult
GHD population, where mean GH dose is between 0.2 and 0.4 mg/day at
treatment start in accordance with the NordiNet IOS database. After 2 years of
GH treatment we observed a normalizing of the mean IGF1 SDS up to
0.391.95. The mean dose of GH after 2 years of treatment in this patient
population was 0.790.57 mg/day. It was slightly higher in female than in male
patients: 0.930.63 vs 0.710.44 mg/day respectively.
Conclusion
Transition patients seem to be underrepresented in the database comprising about
4000 children and adults with GHD. At the time of the transition dose start, these
patients are characterized by a relatively low IGF1 serum level which normalizes
during the GH treatment course. Initial GH dose in transition patients is higher
comparing to the initial dose in patients with an adult GHD onset.
References
1. Attanasio et al. 2004.
2. Conway et al. 2009.
3. Vahl et al. 2000.
4. Nguyen et al. 2009.
5. Clayton et al. 2005.
P25
Maternal stress in early pregnancy: the reason of endocrine and
behaviour disorders in female offspring
Lorianna Sergienko, Oksana Kartavtseva, Tatyana Bondarenko,
Olena Perets & Ganna Cherevko
Institute of Endocrine Pathology Problems, Kharkov, Ukraine.
Objective
It is known that mother`s stress during prenatal period of gestation provokes the
frm long-lasting disturbances of fetal functional systems. The consequences of
stress within early pregnance (SEP) are still researched poorly.
Aim
The aim of study was to evaluate hormonal and behaviour features in females -
offspring of rats with SEP.
For SEP creation the Wistar rat females were transferred daily into another rat`s
association within 2nd-8th days of gestation. At 12 months old the intact
offspring (n32) randomly divided into groups which were killed before (G-1)
and after (G-1
1
) functional tests. Correspondingly G-2 and G-2
1
were formed
from stressed offspring. Corticosterone, leptin, E
2
, testosterone, progesterone
were determined by the RIA method. Food consumption was determined by
placing 200 g of fodder and weighing the residual food before and after 24 h of
fasting. Perirenal, gonadal and mesenteric fat pads were removed and weighed.
Data were performed statistically.
Results
It has been established that 80% animals from G-2 were heavier by 15-25% than
G-1. G-2 corticosterone was not distinguished from G-1 but after 24 h of fasting
corticosterone was expressive increased (P,0.05, G-2
1
vs G-2, G-1, G-1
1
).
Offspring from G-2 had reduced leptin level after fasting and normal level
through 24 h after termination of food deprivation. G-2
1
food consumption was
increased by 15-17% than in G-1
1
within 1-24 h after fasting. Weight of
mesenteric fat G-2
1
increased by 5% through 24 h after termination of food
deprivation. The stressed offspring demonstrated a high anxiety level in elevated
plus-maze and decrease locomotor activity in the open feld. Their testosterone
level was increased by 7-12%, but E
2
and progesterone were decreased.
Conclusion
Our fndings evidence that fetus stress in the frst early gestation induced negative
alterations of hormonal status and behaviour in of offspring and leads to the
metabolic diseases in adulthood.
P2
Familial hypercalciuric hypercalcemia and severe neonatal
hyperparathyroidism: a clinico-biochemical and molecular
characterization in a Tunisian family
Kamel Monastiri
1,2
, Ahlem Bziouch
1
, Sana Sfar
1
, Sofane Bouaziz
1
, Fatma
Zahra Chioukh
2
, Manel Bizid
2
, Hayet Ben Hamida
2
& Fadhel Najjar
3
1
Research Unit 01/UR/08.14, Faculte de Medecine, Monastir, Tunisia;
2
Department of Neonatology, Teaching Hospital Of Fattouma Bourguiba,
Monastir, Tunisia;
3
Departement of Biochemistry, Teaching Hospital of
Fattouma Bourguiba, Monastir, Tunisia.
Mutations that inactivate one allele of the gene encoding the calcium sensing
receptor (CaSR) cause autosomal dominant familial hypocalciuric hypercalcemia
(FHH), whereas homozygous mutations cause neonatal severe hyperparathyroid-
ism (SNHPT).
Objective
We describe the identifcation and biochemical characterization of a novel CASR
gene mutation that caused SNHPT and FHH in a consanguineous kindred.
Design
The study design involved direct sequence analysis of the CaSR gene, clinical and
biochemical analyses of the patient and his family`s members.
Results
A novel inactivating mutation (p.S651_L655del) was identifed in exon 7 of both
alleles of the CASR in the proband, who presented with severe neonatal
hyperparathyroidism. The proband`s parents and two siblings were heterozygous
for the p.S651_L655del mutation consistent with autosomal dominant inheritance
of FHH. All heterozygous subjects were hypercalcemic and hypercalciuric with
normal PTH. The father and the two siblings had mental retardation with varied
degree.
Conclusion
We identifed a novel loss-of-function p.S651_L655del mutation in the CASR
gene that exhibits FHH with mental retardation in heterozygote and SNHPT in
homozygote. This study demonstrates the importance of biochemical and genetic
testing for FHH in family`s member of SNHPT to distinguish between de novo
and inherited mutations of the CASR gene and questioned about the relationship
between CASR gene mutation and cerebral development.
Diabetes
P2I
Have the glitazones anything to do with fractures?
Jose Suarez-Lledo
Hospital de Leon, (Ambulatorio Condesa) Sacyl, Leon, South Georgia and
the South Sandwich Islands.
Objective
Thiazolidinedione (glitazone) (GLT) use was reported to increase frequency of
fractures by the ADOPT study. Investigation of this discovery is the aim of the
present work.
The patients and their clinical histories were examined when each ambulatory
patient was personally visited by the author, for 6 months: 108 males and 160
females were seen. The GLT group was compared with the OAD and insulin user
group. Moreover, the relationships between the fractured and non-fractured
groups, with respect to sex, age and duration of treatment, were tested for each
type of treatment.
Results
There were 7 fractures in males and 20 in females. The sex association was
statistically signifcant (P,0.01). There were 2 fractures (Colles and cheek bone)
in the GLT group (102 patients) and 25 in the OADinsulin group (166 patients)
This difference was statiscally signifcant (P,0.01). Fracture incidence had
nothing to do with age in the OAD and insulin group, but did in the GLT group
(P,0.01). It was, as well, unassociated with treatment duration in either the GLT
or OAD group, but was so associated in the insulin group (P,0.01). Moreover,
the type of fractures observed was also unlike that reported by ADOPT.
Conclusion
For these reasons, GLT is not believed to cause fractures; they have, rather, a
protective effect, as was to be expexted by their action on NF-B and TNF.
P28
Insulin-induced lipohypertrophy, past, present and future: are we
losing the battle?
Gideon Mlawa
1,2
, Dauda Balami
3
, Sandeep Deshmukh
1
, Maureen Croft
2
,
Charles Bodmer
2
& Mayank Patel
1
1
2
Colchester
University Hospital, Colchester, UK;
3
Newham University Hospital,
London, UK.
Background
Poor glycaemic control with erratic blood glucose levels manifesting as recurrent
hyperglycaemia with unpredictable episodes of hypoglycaemia is problem still
faced today in daily practice. The causes include poor compliance and failure of
oral hypoglycaemic. Despite being on insulin (38% of type 2 diabetes patients
who require insulin treatment after 10 years) and type 1 diabetes patients continue
to have fuctuating glucose concentration. The poor glycaemic control in insulin
treated patients is due to insulin-induced lipohypertrophy. Lipohypertrophy has
been known to be due to complication of insulin therapy for decades, but its
prevalence is still high despite advance in technology. Around 20-30% of type 1
diabetes patients, and around 4% of type 2 diabetes patients, develop
lipohypertrophy.
Methods
We present a case report of a 64 years old man, type 2 diabetes for 20 years, and
was on insulin therapy for 7 years. He was followed up by his General practitioner
but referred to diabetic team due to erratic blood glucose level, ranging from 1.6
to 23 mmol/l.
Results
On assessment he had peripheral neuropathy with background diabetic
retinopathy, and injection sites revealed signifcant lipohypertrophy on both
thighs. His HbA1c was 10.9% with normal lipid profle, urea and electrolytes. He
was advised to rotate injection sites and also reduce the dose of insulin by 2-4
units. His glycaemic control improved over the following 3 months with glucose
levels of 4.6-11 mmol/l and his HbA1c fell to 7.8% despite reducing the dose of
insulin.
Conclusion
Despite advance in technology insulin-induced lipohypertrophy remains common
but neglected cause of poor glycaemic control today, in the past, and we should
not allow this to be the case in future. All patients should be closely examined for
lipohypertrophy during diabetic clinic review, using inspection, and palpation of
injection sites in order not to miss subtle form of lipohypertrophy. Education to
both doctors and patient about recognising and dealing with lipohypertrophy is
advisable. The pathophysiology of lipohypertrophy is discussed in this case
report.
P29
Body mass index, disease duration and rheumatologic presentations
in diabetes mellitus, Gorgan (North part of Iran)
Batool Emadi, Mehrdad Aghaie, Hamidreza Bazrafshan, Amir Banikarim
& Naser Behnampur
Medical Department of Golestan University, Gorgan, Iran.
Background
Diabetes mellitus has various characteristics in different organs. Some of the most
important signs and symptoms are seen in joints and musculoskeletal system.
Objectives
This study was designed to evaluate the effect of body mass index (BMI) on
rheumatologic presentations of diabetic patients in Gorgan, Northeast of Iran.
Methods
This was descriptive-analytic study which was done on DM patients whom
referred to endocrinology super specialty center in panjom azar hospital in
Gorgan province (North part of Iran) from 2008 till 2009. Questioners were
completed by patients after collecting data from clinical manifestations,
examinations, laboratory test and X-ray from lumbar spine. All data were
recorded and all patients had consents.
Results
In this study 256 diabetics were recruited with a 50.4112.29 years old mean
S.D. Fasting blood glucose level was calculated as 186.269.54 ng/dl. BMI
was reported 28.045.26 kg/m
2
and meanS.D. of duration of disease was
7.877.31 years. There was a two to one female/male ratio. Knee and lumbar
osteoarthritis and lumbar osteopenia were the most prevalent presentations. Knee
and lumbar osteoarthritis had signifcant relationship with BMI (P value De
poytren contracture, trigger fnger and refex sympathetic dystrophic had a
signifcant relationship with the duration of the disease (P value).
Mean FBS level showed a signifcant difference between whose with trigger
fnger and others (P value).
Conclusion
Body mass index is an important risk factor for osteoarthritis especially in patients
with an underlying disease like diabetes mellitus.
P2I0
A case of diabetic ketoacidosis with ECG abnormalities mimicking
acute coronary syndrome
Evrim C akir O
zkaya, Mustafa O
zbek, Nujen C olak Bozkurt, Erman C akal,

Basak Karbek & Tuncay Delibasi
Diskapi Yildirim Beyazit Training and Research Hospital Endocrinology
and Metabolism Department, Ankara, Turkey.
Diabetic ketoacidosis (DKA) seen in 10-70% of patients with type 1 diabetes
mellitus (DM1) has a signifcant risk of mortality. We present a DKA in a patient
with DM1 resulted in hypokalemia related ECG abnormalities that the diagnosis
needed to be differentiated from acute coronary syndrome. A 18-year-old women
without any signifcant past medical history admitted to hospital with a two day
history of fatique, weakness, nausea, vomiting. Patient appeared hipovolemic.
Vital signs were within normal limits. Physical examination revealed dry tongue
with normal cardiovascular and abdominal examination. Initial laboratory studies
revealed a high anion gap metabolic acidosis and hyperglycemia. The patient was
found to have ketonemia, ketonuria, leukocytosis and hyponatremia. Additional
data, including a serum chloride, potassium, liver functions, lipid fractionation,
serum troponin, creatinin kinase- MB and plain chest radiography were within
normal limits. The patient was diagnosed to be in diabetic ketoacidosis. Following
insulin therapy, K level was decreased (K: 2.1 mmol/l). At that time ECG pattern
was in the form as it is seen acute coronary syndrome that is described as D1-D3
and V1-V6 derivations ST segment depression and T negativity. Then patient
were taken to cardiology intensive care unit and was started acute coroner
syndrome medication with anticoagulan therapy and followed for cardiac enzyme
and chest pain. She had never complained of chest pain and cardiac enzymes were
all in normal limits during follow up. After 1 week of her hospitalization she had
no symptom and ECG fndings, hypokalemia were improved and medication for
acute coronary syndrome was stopped. ECG abnormalities were related with
diabetic ketoasidosis and electrolite imbalances, patient was not considered to be
having myocardial infarction. She remained normoglycemic for the remainder of
her hospitalization stay. ECG fndings of DKA caused hypokalemia may mimic
the fndings seen in acute coronary syndrome and should be differentiated in
critically ill patient.
P2I1 - E$E Young |nvest|gator AWard
The role of ATP-sensitive potassium (KATP) channel in skeletal muscle
insulin resistance: possible correlation with GLUT4 gene
Milano Felipe dos Santos Ferreira Marques, Rosana Cristina Tieko Mori,
Maristela Mitiko Okamoto & Ubiratan Fabres Machado
Institute of Biomedical Sciences, University of Sao Paulo, Sao Paulo, SP,
Brazil.
Introduction
GLUT4 protein is the most important isoform of glucose transporters in skeletal
muscle. Reduction in its content and/or translocation is related to insulin
resistance and type 2 diabetes mellitus. In skeletal muscle cells there is also an
ATP-sensitive potassium (KATP) channel with two subunits, sulfonylurea
receptor type 2A, ABCC9 (SUR2A) and KIR6.2 (KCNJ11). In pancreatic B
cells, this channel triggers insulin secretion in response to the rise in glucose
levels, but in skeletal muscle its role is still unknown. Considering these aspects
the aim of this study was to investigate whether KATP channel can infuence
glucose uptake in skeletal muscle by regulating GLUT4 expression and/or
translocation.
Methods
Insulin resistance was induced in male Wistar rats by neonatal treatment with
monosodium glutamate (MSG) (4 mg/g per day, s.c). At the age of three months,
both control (C) and MSG treated animals received glimepiride (0.1 mg/kg per
day, in the drinking water) for 4 weeks, and were divided into non-treated (C and
MSG) and glimepiride treated (CG and MSG-G) groups. Animals were submitted
to insulin tolerance test (ITT) and samples of glycolytic (EDL-extensor
digitorium longus) and oxidative (soleus) skeletal muscles were excised for
quantifcation of SUR2A, KIR6.2 and GLUT4 mRNA expression by real time
RT-PCR.
Results
In ITT, MSG obese rats showed a signifcant decrease in glucose decay in
response to insulin (30%, P,0.05 versus C and MSG/G) and the glimepiride
treatment improved the insulin sensitivity to the control level. In soleus muscle, a
^45% increase in SUR2A mRNA level was observed in MSG/G obese rats
(P,0.01 versus MSG and C), but in EDL no difference occurred among groups.
In EDL, GLUT4 mRNA was 40% reduced in MSG rats (P,0.01 versus C), and
increased back to control level after glimepiride treatment in MSG/G rats
(P,0.01 versus MSG). In soleus muscle, an increase of 15% in GLUT4 mRNA
was found in MSG obese rats (P,0.01 versus C). After treatment with
glimepiride, a further 17% increase in GLUT4 mRNA occurred (MSG/G versus
MSG, P,0.05). No signifcant differences (P0.05) in mRNA expression of
KIR6.2 (EDL and soleus) were found.
Conclusion
In insulin resistant animals, glimepiride increased insulin sensitivity which could
be associated to enhanced GLUT4 and SUR2A genes expression in soleus
muscle.
Financial support
Fapesp (# 2008/57798-6).
P2I2
Depression, anxiety, quality of life and sleep in patients with type 1
diabetes mellitus
Inan Anaforoglu, Volkan Atasoy, Ekrem Algun & Remzi Kutanis
Trabzon Numune Education and Research Hospital, Trabzon, Turkey.
Aim
The aim of this study was to investigate the quality of life, depression, anxiety and
quality of sleepiness and to determine the variables of illness and socio-
demographic features among type 1 diabetic patients.
SF-36 quality of life (QOL) Scale, beck depression inventory, state-trait anxiety
inventory form and epworth sleepiness scale have been used to evaluate 58
diabetic patients and 58 control subject (31.98.5 vs 31.87.4 years/P0.926,
respectively and 53.4% of patients were female in diabetic group and 51.7% in
control group/P0.852).
Results
Role physical, general health, role emotional and mental health scores were worse
than control group in diabetic patients, physical function, bodily pain, vitality and
social function scores were similar between groups. Depression and anxiety were
detected to become more frequent among diabetic patients. There was no
difference in terms of quality of sleepiness. The QOL was found to be related with
presence of depression and anxiety. It was revealed that diabetic retinopathy has a
negative impact on role emotional as well as diabetic nephropathy. Anxiety was
more common among patients who had diabetic nephropathy and history of
previous hospitalisation. Role physical, general health, role emotional were
impaired in patients with diabetic neuropathy. There was no relationship between
duration of ilness, body mass index, HbA1c and QOL, depression, anxiety.
Conclusion
Diabetic patients are more prone to have depression, anxiety and to have
deterioration of QOL. These patients should be observed carefully during their
management in terms of depression, anxiety and QOL.
P2I3
The effect of diabetes treatment on non alcoholic fatty liver disorder
Sahar Ghareh, Zohreh mousavi & Haleh Rokni
Mashad Medical Science University, Mashad, Islamic Republic of Iran.
Nonalcoholic fatty liver disorder is common among diabetics. Few studies have
shown that there is association between type of diabetes treatment and prevalence
of NAFLD.
The prevalence of NAFLD has been evaluated in 236 diabetic patients and the
association between type of diabetes treatment and NAFLD was surveyed.
Results
Patients of 63.3% were female. Average age was 50.8311.21 years. Average
weight was 71.9512.63 kg/m
2
. Average duration of diabetes diagnosis was 8
years. Average abdominal circumference was 98.5412.32 cm. Average BMI
was 28.14.72 kg/m
2
. Average FBS was 158.3246.19 mg/dl and average
HbA1c was 9.86.6%. Six patients (2.6%) were just on diet as diabetes
treatment. One hundred and eighty pateints (78.6%) received oral antidiabetics
and 23 patients (10%) were on insulin therapy. 20 (8.7%) patients received
combination therapy with insulin and oral agents. NAFLD was diagnosed in
38.6% of patients on oral agents and 6.7% of insulin treated patients and 22.2% of
patients who received combination therapy.
Conclusion
NFALD was more common in patients who received antidiabetic oral agents than
in insulin treated patients.
P2I4
Insulin resistance in smokers and non-smokers in young healthy
population
Emel Acar
1
, Yusuf Aydin
2
, Elif Onder
2
, Hakan Cinemre
1
, Seher Kir
1
,
Hulya Coskun
1
, Ozlem Kudas
1
& Mehmet Turgut
1,2
1
Internal Medicine Department, Duzce University Faculty of Medicine,
Duzce, Turkey;
2
Endocrinology Department, Duzce University Faculty of
Medicine, Duzce, Turkey.
Introduction
Insulin resistance is the decrease sensitivity of tissues in the body to insulin effect.
Obesity, advanced age, sedentary life and smoking are the factors leading to an
increase in insulin resistance. In our study, we aimed to evaluate the relationship
between the insulin resistance and smoking in individuals without advanced age,
obesity, high blood glucose levels and hypertension.
We included in this study 100 patients (50 non-smokers, 50 smokers) who
admitted to internal medicine and endocrinology outpatient clinics of Duzce
University School of Medicine, from February 2009 to July 2009. Patients`
waist/hip ratio, body mass index, systolic and diastolic blood pressure,
triglyceride, LDL cholesterol, HDL cholesterol, fasting blood glucose, insulin,
HbA1c were measured. HOMA values were calculated.
Results
Between both groups, body mass index, systolic and diastolic blood pressure,
triglyceride, LDL cholesterol, fasting blood glucose, insulin, HbA1c and HOMA
values were similar (P0.05). HDL cholesterol levels in smokers compared to
non-smokers was statistically signifcant (P,0.05). In stepwise multiple linear
regression analysis, triglyceride and waist/hip ratio were identifed as an
important independent predictor of an increase in HOMA in smokers.
Conclusion
Our study has shown that there is no relationship between cigarette smoking and
insulin resistance in young population. We are in thought of that the presence of
cigarette smoking with conditions causes increase in insulin resistance such as the
advanced age, obesity, genetic predisposition, sedentary life and abnormal blood
glucose levels can contribute to an increase in insulin resistance.
P2I5
Beneht of switching from rosiglitazone to pioglitazone on cardiovas-
cular markers in routine clinical practice
Jessica Triay, Rajeev Raghavan, Andrew Day & Parag Singhal
Weston Area Health Trust, Weston-Super-Mare, UK.
Background and aims
Thiazolidinediones have been extensively used as second line agents in the
management of type 2 diabetes. A small increased incidence of ischaemic heart
disease was suggested by a meta-analysis of studies using Rosiglitazone. Similar
meta-analysis of Pioglitazone did not show adverse cardiovascular outcomes. Our
aim was to objectively evaluate the changes in glycaemic and lipid control in a
controlled conversion from Rosiglitazone to Pioglitazone.
Thirty-fve patients identifed from Primary and Secondary care were
converted from Rosiglitazone (4 or 8 mg) to equivalent dose Pioglitazone
(30 or 45 mg). Blood tests taken at baseline and 3 to 6 months late for fasting
plasma glucose, HbA1c, liver function tests, full lipid profle and creatinine.
Apolipoprotein-B total cholesterol:HDL and non-HDL were taken as
additional markers of cardiovascular risk. Patients requiring additional
treatment changes for their glycaemic or lipid control during this period
were excluded from the analysis.
Results
Using paired Wilcoxon two-tailed, conversion from Rosiglitazone to Pioglitazone
resulted in a signifcant improvement in mean fasting plasma glucose from
median of 7.8 to 6.3 mmol/l (P0.005) and median HbA1c from 7.2 to 6.8%
(P0.0001). Lipid parameters also showed a signifcant improvement with
median total cholesterol falling from 4.1 to 3.9 mmol/l (P0.0013), and HDL
cholesterol from 1.0 to 1.2 mmol/l (P0.0008) with non-HDL levels falling from
3.1 to 2.6 mmol/l (P,0.0001). Overall total cholesterol:HDL cholesterol fell
from 3.9 to 3.4 with P,0.0001. ApoB levels (20 cases) improved from 0.7 to
0.6 g/l (P0.0023). Improvement in triglycerides was also signifcant
(1.6-1.1 mmol/l, P0.0179).
Conclusions
Our data in a real clinical setting suggests that Pioglitazone is more effective than
Rosiglitazone at plasma glucose control. Pioglitazone also showed better lipid
profles. There is clinical merit in converting patients to Pioglitazone.
P2I
Advanced glycation end products (AGEs) and high glucose in
endothelial cells: gene expression analysis
Tali Zitman-Gal
1
, Janice Green
1
, Metsada Pasmanik-Chor
2
,
Varda Oron-Karni
2
& Jacques Bernheim
1,3
1
Renal Physiology Laboratory, Department of Nephrology and
Hypertension, Meir Medical Center, Kfar-Saba, Israel;
2
The G. S. Wise
Faculty of Life Sciences, Bioinformatics Unit Tel Aviv University,
Tel- Aviv, Israel;
3
Sackler Faculty of Medicine Tel Aviv University,
Tel-Aviv, Israel.
Background
Elevation of blood and tissue concentrations of glucose and advanced glycation
end products (AGEs) may play a relevant role in the occurrence of atherosclerosis,
arteriosclerosis and diabetic complications. To evaluate the impact of elevated
extracellular AGEs and different glucose concentrations we studied the gene
expressions and the underlying pathways which may lead to endothelial
infammation.
Methods
Fresh human umbilical vein cord endothelial cells (HUVEC) were treated in vitro
in the presence of elevated extracellular glucose concentrations (150-500 mg/dl)
with and without AGE-HSA. The ethics review committee of Meir Medical
Center approved the study. Affymetrix GeneChip Human arrays were used for
gene expression analysis. Genes of interest differentially expressed (P,0.05)
were further validated using real-time PCR and western blot.
Results
Microarray analysis revealed signifcant changes in some gene expressions in
the presence of the different stimuli, suggesting different pathways for
activation. Validation of the increased expressions of selected genes was
examined as follows: thioredoxin-interacting protein (TXNIP), NFKB p50, IL6,
IL8 and receptor of AGEs (RAGE). The combined incubation of AGEs and the
highest glucose concentrations (500 mg/dl) induced a blunting action on the
expression of these genes. A signifcant decrease in NF-B p65 and TXNIP
protein expressions was also observed in the highest glucose concentration in
comparison with the results observed with the lower extracellular glucose
concentrations.
Conclusion
A diabetic like environment showed an unexpected blunting action of AGEs in
the presence of the highest glucose concentrations on endothelial infammatory
gene expressions. Such phenomenon will have to be explained through the
cellular interactive pathways involved in such processes.
P2II
Comparison of lymphomononuclear cell energy metabolism between
healthy, impaired glucose intolerance and type 2 diabetes mellitus
patients
Levent Ozsari
1
, Nuri Karadurmus
1
, Mustafa Sahin
2
, Gokhan Uckaya
2
,
Ali Ugur Ural
3
, Ugur Musabak
4
& Mustafa Kutlu
2
1
Department of Internal Medicine, Gulhane Military Medical Academy,
Ankara, Turkey;
2
Department of Endocrinology and Metabolism, Gulhane
Military Medical Academy, Ankara, Turkey;
3
Department of Haemetology,
Gulhane Military Medical Academy, Ankara, Turkey;
4
Department of
Immunology, Gulhane Military Medical Academy, Ankara, Turkey.
Objective
Diabetes mellitus (DM) is a complex disease that affects many systems. The most
important cells of the immune system are lymphomononuclear (LMN) cells.
Here, we aimed to evaluate the energy metabolism of LMN cells in patients with
diabetes and impaired glucose tolerance.
Methods
We measured LMN cell energy metabolism in patients with type 2 diabetes
mellitus, impaired glucose tolerance (IGT) and healthy subjects. Cells were
freshly isolated from peripheral blood and the subgroups were determined by fow
cytometric method.
Results
Lactate production and glycogen utilization were signifcantly increased in the
LMN cells of patients with type 2 DM and IGT when compared with healthy
volunteers. No statistical difference was observed between the patients with type
2 DM and IGT. There was a signifcant correlation between fasting plasma
glucose and lactate production in LMN cells. LMN cells changed their energy
pathway in a diabetic state and preferred anaerobic glycolysis. Prediabetic range
also affected energy metabolism in LMN cells. This abnormal energy production
might cause dysfunction in LMN cells and the immune system in diabetic and
prediabetic patients.
Conclusion
We concluded that impaired glucose metabolism could change energy
metabolism.
P2I8
Assessment of the therapeutic effectiveness of gliclazide MR after
short-term application
Koviljka Milenkovic-Vulovic
1
, Dragan Micic
2
& Snezana Polovina
3
1
General Hospital, Cacak, Serbia;
2
Institute of Endocrinology, Belgrade,
Serbia;
3
General Hospital, Subotica, Seychelles.
The research included 20 patients of average age 598.5 years (ranging from 45
to 75 years of age), of whom there were 8 male patients (40%) and 12 female
patients (60%), with average diabetes duration of 4.83.16 years. In this group
HbA1c levels ranged from 6.6% to 9.4%, while the average BMI level was 30
3.39 kg/m
2
. Prior to the introduction of gliclazide MR with the daily dosage of
30 mg, all the patients had been treated with metformin with the daily dosage of
2000 mg.
Before the new drug was introduced, plasma lipids, glycaemia, plasma insulin and
HOMA-IR had been measured in the studied group (glycaemia and plasma insulin
being measured before and 2 h after main meals).
After the introduction of gliclazide MR, on the 7th and 14th days glycaemia and
plasma insulin were measured before and 2 h after the main meals. HOMA-IR
was measured on the same days, while the level of plasma lipids was measured on
the 14th day.
Results
In this group of patients, two weeks` application of gliclazide MR resulted in:
5 Statistically highly signifcant decrease of FPG after 7 and 14 days.
5 Statistically highly signifcant decrease of glycaemia in the course of the day
after 7 and 14 days (assessed according to the area under the curve of glycaemia),
without plasma insulin levels being increased at the same time.
5 Statistically insignifcant decrease of postprandial glycaemia as well as
HOMA-IR after 7 and 14 days.
5 Statistically signifcant decrease of cholesterol after 14 days.
Conclusion
The short-term application of gliclazide MR in the studied group of patients
resulted in signifcant improvement of glycaemic control (FPG, PPG), without
plasma insulin levels being increased at the same time, thus indirectly suggesting
possible extrapancreatic effects of the drug.
P2I9
Effectiveness of patterns of intensihcation of premixed insulin analogue
therapy
Sanjay Kalra
1
, Bharti Kalra
1
, A G Unnikrishnan
2
& Navneet Agrawal
3
1
2
AIMS, Kochi, India;
3
Medical College,
Gwalior, India.
This study was designed as a retrospective multicentric study to assess the
effcacy of various methods of effective intensifcation and optimization of
premixed insulin analogue therapy. 200 consecutive OPD charts of patients
poorly controlled on premixed insulin twice daily were reviewed for changes
advised by the treating physician. Data was assessed for cues, methods and
effcacy of intensifcation of therapy.
A casual blood glucose value 250 mg% was used as the sole reason for
intensifcation in 14% patients, while high fasting glucose (126 mg%) and high
postprandial glucose (200 mg%) were the cues in 36 and 28% respectively.
An HbA1c 8.5% was the motive for intensifcation in 15.5% and patients`
symptoms formed the cue in 32.5%.
Of the 200 cases reviewed, 144 demonstrated effective control (as assessed by
HbA1c reduction 1%) at 6 weeks, and were compared with the 56 non-
responders.
Increasing the dose of premixed analogue was the commonest method of
optimization (48%) while increase in frequency of premixed injections (4%) or
addition of lunchtime regular insulin (8%) was less frequent. Of 22% were shifted
to three dose regime (regular before breakfast and lunch; premixed aspart before
dinner), 8% were shifted to 50:50 analogue mixture before breakfast and 25:75
before dinner, and 10% to basal-bolus regime. Oral hypoglycemics were
increased in 76% patients (10% prescribed repaglinide/sulfonylurea, 66%
metformin, 8% pioglitazone, 16% voglibose/acarbose).
The most effective method of intensifcation was shifting to three or four dose
regime (86.36% response), and adding metformin (45.45%). Increasing the dose
of insulin worked only in 33.33% patients, while changing the type of insulin to
50:50 was effective in 50.00%. Adding oral drugs other than metformin helped
achieve response only in 23.52%.
This study highlights the effectiveness of various methods available for
intensifcation and optimization of premixed insulin analogue therapy. The
most effective methods of intensifcation are increasing the number of doses of
insulin per day, with addition of or substitution by regular aspart or a 50:50 mix,
and addition of metformin.
P280
Knowledge, attitudes and practices of type 1 diabetes patients regarding
complementary and alternative medicine (CAM)
Sanjay Kalra
1
, Satish Kumar
1
, Bharti Kalra
1
, Navneet Agrawal
2
,
Amit Sharma
1
& Vinay Prusty
3
1
2
Medical College, Gwalior, India;
3
Novo
Nordisk, Bangalore, India.
This multicentric, observational, non interventional study of patients with type 1
diabetes observed their knowledge, attitudes and practices regarding comp-
lementary and alternative medicine (CAM), including nutraceuticals. One
hundred and thirty-fve subjects with type 1 diabetes, aged ,20 years, and
their parents were surveyed using a structured pre-tested questionnaire.
The cohort included 65.92% boys, 37.04% rural dwellers and 31.85% patients
with duration of diabetes ,1 year. 51.85% were aware of nutraceuticals, while
100% were aware of alternative systems of medicine (Ayurveda, homeopathy,
Unani).
Of 100% respondents felt that CAM had no adverse effects, but only 51.85%
thought that CAM was effective. Of these (n70), 94.28% were taking
nutraceuticals, 22.85% homeopathy and 11.43% Ayurvedic drugs, along with
insulin. The nutraceuticals included aloe vera, bitter gourd and fenugreek seeds
(35.71%, 58.57%, 44.28% respectively).
All the patients who were taking CAM (n66) said they would continue doing
so. The common reasons for this were cited: reduction of dose of insulin
(100.00%), feeling of well being (50.00%), prevention of complications
(36.36%), and lack of harmful effects (60.60%).
The average HbA1c of CAM-taking and non-CAM patients did not differ
(9.122.24 vs 9.552.22; PNS). Quality of life, as measured by WHO-5
score was better in the CAM group (4.640.50 vs 3.910.83; P,0.05).
This study highlights the high usage of nutraceuticals and CAM in patients of type
1 diabetes in north and central India. It also reveals a higher quality of life with
CAM, the signifcance of which needs to be studied further.
P281
The frequency of depression estimation among patients with diabetes
mellitus
Yana Navmenova
1
& Tatiana Mokhort
2
1
Gomel State Medical University, Gomel, Belarus;
2
Belarussian State
Medical University, Minsk, Belarus.
One of the most frequent psychological disturbances at patients with diabetes
mellitus are depressions. According to the literature, the prevalence of
depressions at patients with diabetes mellitus are ranging widely from 3.8 to
60.7%. This differences depend on diabetic population and the method of
depression estimation.
Objectives
To estimate the frequency of depression in patients with type 1 and type 2 diabetes
mellitus (T1DM and T2DM)).
We studied 56 diabetic patients, including 24 patients with T1DM and 32 patients
with T2DM (36 females (64.3%) and 20 males (35.7%) and 36 healthy persons
including 17 males (47.2%) and 19 females (52.8%). Mean age at the moment of
observation was 49.2311.42 years; age at diabetes duration 10.889.47years.
Diabetic and non-diabetic subgroups were matched for age and gender. Anxiety
and depression hospital scale (HADS) and Beck depression scale were used for
depression verifcation in both groups.
Results and discussion
The frequency of depression by the results of axiety and depression hospital scale
(HADS), depression consist 33.9% as it were verifed in 19 diabetic patients. The
average index of HADS has made up 11.002.32 scores versus 16.7% and
4.033.26 points in the control group (P0.007). By the results of estimation
with using of Beck scale the depression was detected in 14 patients with diabetes
(25%). The average score has made 14.213.84 vs 3 persons (10%) and
4.124.51 scores in the control group (P0.05). We analysed the frequency of
depressions in dependence of diabetes duration and there were detected no
reliable distinctions.
Conclusion
We can assume that diabetic patients with diabetes are at risk of depression. So in
patients with diabetes depression were detected authentically more often up to
34% (using different diagnostics approaches) than among healthy population.
Further study is required to develop differentiated approach for depression
diagnostics and treatment of diabetes.
P282
The Gly972Arg polymorphism in the insulin receptor substrate-1 gene
(IRS1) and the impact on type 2 diabetes mellitus
Darko Katalinic
1
, Nora Nikolac
2
, Vanja Zjacic-Rotkvic
2
, Elizabeta Topic
2
,
Miljenko Solter
2
& Stjepko Plestina
1
1
Hospital Center Zagreb, Zagreb, Croatia;
2
Sisters of Charity University
Hospital, Zagreb, Croatia.
Background
Genetics may play an important role in type 2 diabetes (T2D). In the last 20 years,
there has been a surge in the number of genetic studies in attempts to identify
some of the underlying risk factors. Mutations in a wide variety of genes
contribute to the deregulation of glucose homeostasis, and seem to confer the risk
for developing T2D. Insulin receptor substrate-1 (IRS1) is a substrate of the
insulin receptor tyrosine kinase and appears to have a control role in the insulin-
stimulated signal transduction pathway. Therefore, the IRS1 gene, and
particularly his Gly972Arg polymorphism, hase been studied extensively as a
candidate gene for type 2 diabetes (T2D), but fndings have been inconsisted.
The aim of this study was to investigate the correlation of Gly972Arg gene
polymorphism with the development of T2D.
The group consisted of 214 patients with T2D and 216 healthy control subjects
without any fndings of glucose metabolism impairment. Genomic DNA was
isolated from peripheral venous blood while analysis of Gly972Arg gene
mutation was performed with polymerase chain reaction-restriction fragment
length polymorphism method (PCR-RFLP). The study was approved by the local
Ethical Committee and was in accordance with the principles of the Declaration
of Helsinki.
Results
We observed no signifcant difference in Gly972Arg polymorphism distribution
or allele frequencies between the two examined groups (P0.9341).
Conclusion
The present study show that the IRS1 Gly972Arg variant is not associated
with T2D.
P283
Impact of the SUR1 16-3 C/T and INSR His 1085 C/T genetic variability
on type 2 diabetes mellitus development
Darko Katalinic
1
, Nora Nikolac
2
, Vanja Zjacic-Rotkvic
2
, Elizabeta Topic
2
,
Miljenko Solter
2
& Stjepko Plestina
1
1
University Hospital Center Zagreb, Zagreb, Croatia;
2
Sisters of Charity
University Hospital, Zagreb, Croatia.
Background
Type 2 diabetes (T2D), which is multifactorial, inherited and progressive chronic
disorder, is characterised by hyperglycemia due to defects in insulin secretion
and action. The sulfonylurea receptor (SUR1) and the insulin receptor (INSR) are
critical elements in insulin-signalling pathways, and mutations in the SUR1
and INSR genes have been reported to have a role in determining susceptibility
to T2D.
The aim was to study whether the -3 C/T polymorphism of the SUR1 gene exon
16 and His 1085 C/T polymorphisms of the INSR gene exon 17, increase the risk
of T2D in type 2 diabetic subjects.
The group consisted of 214 patients with T2D and 216 healthy control subjects
without any fndings of glucose metabolism impairment. Genomic DNA was
isolated from peripheral venous blood while analysis of 16-3 C/T and His 1085
C/T gene mutations were performed with polymerase chain reaction-restriction
fragment length polymorphism method (PCR-RFLP). The study was approved by
the local ethical committee and was in accordance with the principles of the
Declaration of Helsinki.
Results
Our results show that polymorphism 16-3 C/T of SUR1 gene is a key factor that
impacts the manifestation of T2D (P0.0068). We observed no signifcant
difference in INSR His 1085 C/T polymorphism distribution or allele frequencies
between the two examined groups (P0.7674).
Conclusion
These fndings provide evidence which genes involve in T2D. Furthermore, our
observations may help to better target various therapies that will be available in
the future for the treatment of T2D.
P284
Left ventricular hypertrophy and its relation with inammation in type
2 diabetic patients
Ergita Nelaj, Margarita Gjata, Edite Sadiku, Ledio Collaku & Mihal Tase
Department of Internal Medicine, UHC 'Mother Teresa`, Tirane, Albania.
Introduction
The association between diabetes and adverse cardiovascular outcome may be
partially explained by the strong independent association of type 2 diabetes with
cardiovascular target organ damage, such as left ventricular hypertrophy (LVH), a
well-known predictor of cardiovascular events independent of coronary artery
disease. The aim of the present study is to evaluate the relation of LVH to
fbrinogen and C-reactive protein (CRP) as markers of infammation and
susceptibility to atherothrombosis.
Methods and subjects
We selected 50 adults with type 2 diabetes. 32 were women and 18 were men,
mean age 4514. Hypertension was defned by systolic blood pressure (sBP)
140 mmHg and/or diastolic blood pressure (dBP) 90 mmHg. Diabetes was
defned by fasting plasma glucose levels 126 mg/dl or by specifc treatment. BMI
was calculated by the standard formula.
Echocardiography methods
The prevalence of left ventricular abnormalities has been determined by
bidimensional echocardiography. The left ventricular mass index (LVMI) has
been evaluated according to the method of Devereux and Reichek.
Participant`s laboratory data were examined in the morning after an overnight fast
12 h. The levels of CRP and fbrinogen have been measured.
Results
From 50 participants, 22 (44%) presented LVH, which was associated with higher
BMI and CRP, fbrinogen levels, left ventricular hypertrophy, markers of
infammation. We found relationships between fbrinogen and concentric LVH
(P,0.001) and also between CRP with concentric hypertrophy (P,0.005).
Conclusions
Twenty-two patients presented concentric LVH, 10 patients eccentric LVH, and
18 patients normal LV mass. Concentric LVH was associated with elevated
markers of systemic infammation and susceptibility to atherothrombosis (CRP
and fbrinogen levels) independently of clinically overt cardiovascular disease
and traditional cardiovascular risk factors. No correlation was found between
CRP and fbrinogen and eccentric LVH.
P285
Abstract withdrawn.
P28
It`s time to put the 'age` and the 'face` on HbA1c in elderly patients with
diabetes mellitus
Gideon Mlawa
1,3
, James Alegbeleye
1,3
& Raymond DÈsouza
1,2
1
2
Chasefarm Hospital,
London, UK;
3
Colchester General Hospital, Colchester, UK.
Introduction
Older patients with diabetes mellitus often have concomitant comorbidities and
physical disabilities which may lead to poor quality of life. The present diabetic
guidelines available to clinicians in their practice suggest aggressive and
meticulous diabetic control for target HbA1c (,7%). This is aimed at delaying or
preventing complications. Such practice may predipose majority of older patients
to experience recurrent hypoglycaemic epidodes and therefore compounding to
their poor quality of life.
Methods
This is a cross-sectional survey of 46 diabetic patients aged between 65 and 90
years old who were seen in diabetic clinic. They were given questionnaire (SF36)
to assess their quality of life (Mental and Physical component) in relation to blood
glucose levels and other comorbidities.
Results
Older patients and especially those with other comorbidities such as chronic
kidney disease, chronic obstructive airways disease, cognitive impairement,
rheumatoid arthritis and peripheral vascular disease reported one or more
episodes of hypoglycaemia per month due to tight glycaemic control. We found
increased poor quality of life in such patients. Older patients responded that they
were more likely to be less anxious and more comfortable if their blood glucose
level was in the range of 7-10 mmol/l than below 5 mmol/l.
Conclusion
We suggest that clinician`s practice should aim at supporting the well-being, good
quality of life and healthy lifestyle of the older people with diabetes. Glycaemic
control in this age group should be individualised to refect patient`s clinical and
personal needs and according to patient`s informed choice. By putting the 'age`
and the 'face` on HbA1c both patients and clinicians will be able to achieve a
better balance between good quality of life and acceptable glycaemic control.
P28I
Depression, anxiety, quality of life and sleepiness in family members of
type 2 diabetic patients
Inan Anaforoglu
1
, Ibrahim Ramazanogullari
2
, Remzi Kutanis
3
&
Ekrem Algun
1
1
Department of Endocrinology and Metabolism, Trabzon Numune Training
and Research Hospital, Trabzon, Turkey;
2
Department of Family Medicine,
Trabzon Numune Training and Research Hospital, Trabzon, Turkey;
3
Department of Psychiatry, Trabzon Numune Training and Research
Hospital, Trabzon, Turkey.
Aim
The aim of this study was to investigate the quality of life, depression, anxiety and
quality of sleepiness and to determine the variables of illness and socio-
demographic features among family members of type 2 diabetic patients.
SF-36 quality of life (QOL) scale, beck depression inventory (BDI), state-trait
anxiety inventory form (STAI TX-I, STAI TX-II) and epworth sleepiness scale
(ESS) have been used to evaluate frst degree family member of 50 diabetic
patient and 50 control subject. The groups were similar in terms of age, sex, health
insurance, educational status, marital and fnancial status.
Results
BDI scores were higher in family members; depression was detected to become
more frequent among diabetic patients` family members (P0.001). The QOL of
control subjects was found to be better than family members, but the difference
was not signifcant for the components of QOL (role physical, role emotional,
general health, mental health scores, physical function, bodily pain, vitality;
P0.088, 0.069, 0.067, 0.114, 0.089, 0.307, 0.239 respectively) except the social
function (P0). There was no difference in terms of quality of sleepiness and
anxiety (ESS; P0.534, STAI TX-I; P0.637, STAI TX-II; P0.896).
Conclusion
Diabetic patients` family members are more prone to have depression and to have
deterioration of QOL.
P288
Comparative and metabolic study of glycosylated hemoglobin,
magnesium, nitrogenous metabolites, and lipid prohle in diabetics
and non-diabetics patients
Vinit Mehrotra
1
& G Awasthi
2
1
Himalayan Institute of Medical Sciences, JollyGrant, Dehradun, India;
2
Dolphin Institute of Biomedical and Natural Sciences, Dehradun, India.
Diabetes is the major health care problem in developing countries like India.
According to WHO survey total number of diabetics patients in India alone is 3.2
cores with fastest growing population of diabetics. This is not a single disease,
rather a group of disorders associated with rearrangement in carbohydrate, protein
and fat metabolism.
Diabetes is characterized by the elevation of blood glucose level resulting from
defects in insulin secretion or action or both. It is not a pathogenic entity but a
group of etiologically different metabolic defects. The present study designed for
their comparative and metabolic study of HbA1c, magnesium, nitrogenous
metabolites and lipid profle in diabetic and non diabetic patients.
Serum glucose concentration elevation is the hallmark of uncontrolled diabetes
which refects the immediate status of carbohydrate metabolism. HbA1c is an
essential indicator for diabetes whose levels are increased in all diabetic patients.
There are some alterations in micronutrients status of diabetic patients. These
micronutrients include magnesium which plays role in more than 320 enzymatic
reactions in energy metabolism. Serum magnesium levels were decreased in
diabetic patients.
The serum urea and creatinine concentration-indicator of diabetic nephropathy
were found to be increased which are the major products of protein metabolism
and are important index of kidney and renal diseases. Creatinine is a waste
product formed in muscles from creatinine phosphate which is usually associated
with diabetes mellitus.
Elevated levels of serum triglyceride, LDL, VLDL and total cholesterol were
observed but there was profound decrease in HDL serum levels. The liver cell
shows a marked increase in lipid concentration during diabetes.
P289
Association of diabetes mellitus with thalassaemia and sickle cell disease
Katerina Thisiadou, Ioannis Karamouzis, Stella Arampatzi,
Kostantinos Tomos & Despoina Michailidou
Biochemistry Laboratory, Faculty of Medicine, Aristotle University,
Thessaloniki, Greece.
Background
The majority of complications in transfusion dependent thallasemic and with
sickle cell anemia patients are due to iron overload. This is responsible for the
beginning of haemosiderosis, clinical symptoms and dysfunction of important
systems, specially after the 2nd decade of life. The increase of the iron
accumulation is caused by hemolysis, high iron absorbance and mainly by
transfusion treatment. The appearance of diabetes mellitus depends on the
signifcance and duration of hemosiderosis, that has direct concequences to the
secretive function of pancreatic -cells.
Aim
The purpose of this study was to investigate glucose and ferritin levels and
determine whether hyperglycemia is associated with iron overload in patients
with thalassaemia and sickle cell anemia.
Our groups consisted of 31 patients with -thalassaemia (-thal), intermedia
thalassaemia (int.thal) and sickle cell anemia (s.c-an). We also used a control
group of 26 healthy subjects. (h.s). The serum glucose levels (Glu)) were
determined using photometric method while ferritin levels (Fer) were measured
by electrochemiluminescence immunoassay.
Results
The mean value of the Glu and Fer in patients with omozygous -thalassaemia
gave a statistically signifcant difference (P,0.05) compared to the average value
of the Glu and Fer in normal subjects. Glu was signifcantly and positively
correlated with Fer (r0.882, P,0.01) in patients with -thalassaemia. The
same conclusion goes for the patients with sickle cell anemia where the
concentration of Glu was positively correlated with Fer (r0.709, P,0.05).
Conclusions
Despite the systematic chelation therapy for the treatment of haemosiderosis,
which is caused from the regular blood transfusions, there is a risk of iron
overload which leads to endocrine complications such as diabetes mellitus as it is
confrmed from our study.
P290
Response of interleukin-6 during euglycaemic and hyperglycaemic
exercise in patients with type 1 diabetes mellitus
Stefan Jenni
1,2
, Stephan Wueest
3,4
, Daniel Konrad
3,4
& Christoph Stettler
1
1
Division of Endocrinology, Diabetes and Clinical Nutrition, Inselspital,
University Hospital Bern, University of Bern, Bern, Switzerland;
2
International Centre for Circulatory Health, Imperial College at St. Mary`s,
London, UK;
3
Department of Endocrinology and Diabetology,
University Children`s Hospital, Zurich, Switzerland;
4
Zurich Center for
Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
Background
Secretion of IL-6 during exercise is hypothesised to be regulated according to
substrate availability within the working muscle. We have previously shown that
energy supply in type 1 diabetes during aerobic exercise in hyperglycaemia
strongly relies on carbohydrate oxidation whereas a physiological shift from
carbohydrate to lipid oxidation occurs in euglycaemia. The present study
investigated whether IL-6 response to exercise is different in euglycaemia
compared with hyperglycaemia in patients with type 1 diabetes mellitus.
Methods
Seven male patients with type 1 diabetes were examined at two occasions in a
randomized, single-blinded cross-over design. Glucose was clamped to eu- or
hyperglycaemia (5 vs 11 mmol/l) with identical insulin levels. After clamp
conditions were achieved the patients cycled at 55-60% of their individual peak
oxygen uptake over 120 min. The study was approved by the local ethics
committee.
Results
Mean ageS.E.M. was 33.52.4 years and HbA1c was 6.70.2%. Before
exercise levels of IL-6 were similar in euglycaemia and hyperglycaemia
(2.1 pg/ml, 95% confdence interval 0.9-5.1, and 3.4 pg/ml, 95%CI 1.2-10.0,
respectively). Over the entire study period levels of IL-6 signifcantly increased in
euglycaemia (P for trend 0.014) but not in hyperglycaemia. After 2 h of
euglycaemic exercise IL-6 increased by 2.01.3 pg/ml (meanS.E.M.) but
decreased by 2.61.6 pg/ml in hyperglycaemia (P for difference 0.058).
Increments in IL-6 from baseline up to 2 hours post exercise were signifcantly
higher in euglycaemia compared with hyperglycaemia (9.26.0 vs 3.3
4.4 pg/ml, P0.047).
Conclusions
In patients with well controlled type 1 diabetes levels of IL-6 increased in
response to prolonged aerobic exercise in euglycaemia, but not in hyperglycae-
mia. This fnding is consistent with a regulation of IL-6 secretion by carbohydrate
availability within the myocyte during exercise. Further studies are needed to
better characterise the potential role of IL-6 in the regulation of fuel metabolism
during aerobic exercise.
P291
Coagulation inhibitors in type 2 diabetes mellitus
Katerina Thisiadou
1
1
, Stella Arampatzi
1
& Despoina Lazaridou
2
1
2
Microbiology Laboratory, Faculty of Medicine
Aristotle University, Thessaloniki, Greece.
Background
Diabetes mellitus (DM) is related to hypercoagulability.
The predisposition for thrombosis disorders is caused by increased accumulation
of platelets, by high concentrations of prothrombotic factors and by the reduced
concentration and activity of the inhibitor factors. Abnormalities of coagulation
inhibitors have been reported in many studies on diabetes over the last years, but
unfortunately, the results have often appeared contradictory.
Aim
The aim of our research was to investigate the modifcation of hemostasis and
evaluate the three inhibitors of coagulation in patients with diabetes mellitus.
Methods
We studied 50 patients with DM Type 2 (20 men-30 women, mean age 57.5 years
- median duration of diabetes diagnosis 5 years) with mean value of glucose
(GLU): 156.8859.73 and mean value of glycosylated hemoglobin (HbA1c):
8.072.78. In these patients, we evaluated the plasma levels of protein C (PC),
free protein S (FPS) and antithrombin III (AT III). The plasma levels of PC were
determined by chromatometric-amidolytic assay while FPS were measured with
immuno-enzymatic-method and antithrobin III (AT III) with chromogenic assay.
All these markers were also evaluated in a control group of 30 healthy subjects
(H.S); (15 men-15 women-matched age).
Results
There were not statistically signifcant difference in PC levels among the patients
and the control group. However it is remarkable that plasma levels of PS and AT
III were noticeably lower than the concentrations of the healthy individuals
(P,0.05).
Conclusions
Our fndings suggest that in poorly controlled diabetic patients there is
modifcation in plasma levels and in functional activities of coagulation
inhibitors.
The low levels of protein S and antithrombin III notify the hypercoagulant state
and the high risk of atherothrombotic disorders that exist in diabetic patients.
P292
Linagliptin, a potent and selective DPP-4 inhibitor, does not prolong the
QT interval when given in therapeutic and 20-fold supratherapeutic
doses
Arne Ring
1
, Ulrike Graefe-Mody
1
, Andreas Port
1
, Ivette Revollo
1
,
Beate Walter
1
, Hans-Juergen Woerle
1
, Mario Iovino
1
& Klaus Dugi
2
1
Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany;
2
Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany.
Background
Cardiovascular safety is important for antidiabetic agents. This study followed
the ICH E14 guideline to examine the effect of the oral dipeptidyl peptidase-4
(DPP-4) inhibitor linagliptin on the cardiac QT interval in healthy volunteers.
Methods
This thorough QT study of linagliptin was performed in healthy subjects, using
5 mg (therapeutic dose) and 100 mg. The randomised, single-dose, placebo-
controlled, double-blind, four-way crossover study used open-label moxifoxacin
(400 mg) as positive control. Triplicate 12-lead ECGs of 10 s duration were
recorded for all subjects pre-dose and at various time points over a 24-h period
after each treatment. The primary parameter was the subject-specifc heart rate
corrected QT interval (QTcI). Fourty-four subjects were enrolled, 26 (59.1%) of
whom were male. The mean age was 36.4 (22-48) years.
Results
After single oral administration of 5 and 100 mg linagliptin, geometric mean
(gMean) maximum concentrations of 7.05 nmol/l (28.5% geometric coeffcient of
variation (gCV)) and 267 nmol/l (66.6% gCV) were reached at a median Tmax of
2 and 1.5 h, respectively. The upper limits of the two-sided 90% confdence
intervals (CIs) of the adjusted mean QTcI change from baseline (1-4 h) of
linagliptin compared with placebo were 0.5 ms (5 mg) and 0.9 ms (100 mg)
with mean estimates of 1.1 and 2.5 ms, respectively. Over the 24 h
observation period, the maximum upper limits of the one-sided 95% CIs for the
adjusted QTcI changes from baseline compared with placebo were below 2.5 ms
for both doses and thus well below the non-inferiority margin of 10 ms. Assay
sensitivity of the trial was shown by the largest estimated effect size of the QTcI
difference between moxifoxacin and placebo being 10.5 ms with a lower limit of
the two-sided 90% CI of 8.1 ms. There were no relevant changes in heart rate or
other ECG parameters, and the safety assessment was good and comparable for all
treatments.
Conclusions
Single dose administration of therapeutic (5 mg) and supratherapeutic (100 mg)
doses of linagliptin did not prolong the QT interval. The supratherapeutic dose
resulted in maximum plasma concentrations that were about 38-fold higher than
those obtained after the administration of the therapeutic dose of 5 mg, further
confrming the very favourable safety profle of linagliptin within the DPP-4
inhibitors class.
P293
b)_\2! gJK2\d!_\ stimulates the secretion and action of insulin and
inhibits starch digestion and protein glycation
Violet Kasabri
1
, Peter Flatt
2
& Yasser AbdelWahab
2
1
University of Jordan, Amman, Jordan;
2
University of Ulster, Northern
Ireland, UK.
Traditional plant treatments have been used throughout the world for the therapy
of diabetes mellitus. The aim of this study was to investigate the effcacy and
mode of action of Emblica offcinalis Gaertn (Euphorbiaceae) used traditionally
for treatment of diabetes in India. E. offcinalis aqueous extract stimulated basal
insulin output and potentiated glucose-stimulated insulin secretion concentration-
dependently in the clonal pancreatic beta cell line, BRIN-BD11 (P,0.001). The
insulin secretory activity of plant extract was abolished in the absence of
extracellular Ca
2
and by inhibitors of cellular Ca
2
uptake, diazoxide
(P,0.001, n8). Furthermore, the extract increased insulin secretion in
depolarised cells and further augmented insulin secretion triggered by IBMX
and tolbutamide. Emblica offcinalis aqueous extract (1 mg/ml) displayed insulin
mimetic activity (230%, P,0.001), furthermore, it enhanced insulin-stimulated
glucose transport in 3T3 L1 adipocytes by 460% (P,0.001). Emblica offcinalis
augmented also synergistically (P,0.001) insulin action, when co-incubated
with insulin sensitizers; metformin (2.4-fold), vanadate (4.9-fold), tungstate
(4.8-fold) and molybdate (sixfold). At higher concentrations (5-50 mg/ml), the
extract also produced 8-74% (P,0.001) decrease in starch digestion in vitro.
E. offcinalis (1-50 mg/ml) inhibited protein glycation 44-87% (P,0.001). This
study has revealed that bioactive principles in E. offcinalis extract stimulate
insulin secretion, enhance insulin action and inhibit both protein glycation and
starch digestion. The former actions are dependent on the bioeffective
component(s) in the plant being absorbed intact. Future work assessing the use
of Emblica offcinalis as adjunctive therapeutic nutraceutical or as a source of
bioactive antidiabetic principles may provide new opportunities for the integrated
management/prevention/reversal of diabetes.
P294
In-patients insulin therapy protocol: establishment and valuation
Clara Garcia, Cristobal Morales, Juan Garcia-Quiros, Monica Tome,
Ignacio Fernandez, Isabel Serrano & Angel Sendon
Hospital Virgen Macarena, Seville, Spain.
Introduction
An insulin therapy protocol (ITP) was created during 2007 in our hospital by
endocrinologists, internal physicians and nurses. The aim was to establish the
basal-bolus therapy as the treatment for the non-critical diabetic in-patients in
order to ease the management and lead a better glycemic control of these patients.
A poster was presented to all the hospital departments in several meetings during
2008. This poster showed the way to calculate the initial insulin doses, how adjust
them, how to use intravenous insulin and the best treatment at the time of
discharge.
Objectives
The purpose of this project is to valuate the use and comprehension of this ITP.
Method
A cross-sectional study was made in a random day checking the treatment of the
diabetic in-patients. In addition, a test was made for nurses and physicians asking
about knowledge, use and valuation of the ITP. They were also asked about the
reason to avoid the use of the ITP and glycemic values considered optimal in
critical and non-critical patients.
Results
1. ITP valuation test: 23 nurses and 38 physicians were tested. All the doctors
and 95% of the nurses knew ITP. 50.8% admitted the use of the protocol in
80% or more of the patients. The main reason to avoid using the protocol was
to consider it not applicable to some patients. 57% thought the protocol was
clear. Glycemic values considered optimal for critical patients were between 90
and 150 mg/dl (4.7 and 8 nmol) and between 80 and 140 mg/dl (4.25 and
7.5 nmol) for non critical patients. Most of the staff thought the ITP was
needed to improve the diabetic patient treatment. They also suggested it
was easy to use. Hyper and hypoglycemia occurred less frequently whith this
protocol.
2. Protocol application: the day the study was made 25% of the in-patients
were diabetics. ITP was used in the 79% of the diabetic in-patiets (96% in
medical departments, 45% in surgery departments, 77% in Alerts and
Emergencies department and 0% in Intensive Care Unit). Other treatments
used were regular insulin therapy every 6 h and oral drugs.
Conclusions
5 ITP was the main treatment used in the diabetic in-patients.
5 The ITP has been well valuated by most of the staff although it has been better
established in the medical areas so further efforts are needed to extend its use to
the rest of departments.
P295
Insulin treatment intensihcation to basal-bolus in diabetic patients
Juan Garcia-Quiros, Monica Tome, Ignacio Fernandez, Clara Garcia,
Cristobal Morales, Isabel Serrano & Angel Sendon
Hospital Virgen Macarena, Seville, Spain.
Objectives
To valuate the insulin treatment intensifcation effcacy (from three premixed
insulin doses to basal-bolus therapy) in type 1 and 2 diabetic patients wrongly
controlled.
The 61 patients were included. 29 (47.5%) type 1 diabetes mellitus (DM) and 32
(52.5%) type 2 DM, attended in the Day Diabetes Hospital (DDH) during 2008.
50.8% were females and 49.2% were males. Mean age was 34.214.4 in type1
DM and 63.68.6 in type 2 DM. Illness mean duration was 15.6 years in type 1
DM and 17.0 years in type 2 DM.
HbA1c was analyzed before and 2 months after the new treatment. Other issues
studied were weight, insulin doses, mean glycemia and glycemic variability. The
insulin treatment intensifcation meant to change from three premixed insulin
doses to basal-bolus therapy. All patients were re-educated on their condition.
Data were analyzed with a Wilcoxon test for related data using SPSS version 15.0.
Results
In type 1 DM there was a reduction in the mean HbA1c of 1.941.1% (from
9.942.14 to 8.01.4%; P,0.01), an improvement in the mean glycemia (from
194.1 to 172.9 mg/dl; P,0.01) and in the glycemic variability (from 79.73 to
76.60; P,0.01). There was a light increase on weight (from 79.3 to 79.4 kg) and
insulin doses (0.760.2 to 0.830.2 UI/kg) non statistically relevant.
In type 2 DM there was an improvement in HbA1c of 1.451.26% (from 9.26
1.0 to 7.81.3%; P,0.01), mean glycemia (from 224.1 to 184.7 mg/dl;
P,0.01) and glycemic variability (from 63.5 to 54.9; NS). Weight worsened
(from 78.9 to 79.9 kg; NS). There was also an increase in insulin requirements
(from 0.920.4 to 1.61.1 UI/kg; P,0.01).
Patients whose HbA1c before treatment intensifcation was under 8% had a
modifcation from 7.450.6 to 7.121.2% (NS), patients whose HbA1c before
the new treatment was between 8 and 10% changed from 9.030.5 to 7.38
1.0% (P,0.05) and those whose initial HbA1c was over 10% improved
from 11.261.4 to 8.81.2%.
Conclusions
5 Insulin treatment intensifcation to basal-bolus therapy in non controlled
diabetic patients showed a signifcant improvement in HbA1c.
5 HbA1c values improved more in those patients whith higher initial levels.
5 There was a weight gain but non statistically signifcant.
P29
Prevalence of cardiovascular risk factors at the time of diagnosing type
2 diabetes mellitus: follow up in the endocrinologist`s consultation
Monica Tome, Cristobal Morales, Juan Manuel Garcia de Quiros,
Ignacio Fernandez, Clara Socorro Garci a, Isabel Serrano & Angel Sendon
Medical University Hospital Macarena of Seville, Seville, Spain/Andalucia,
Spain.
Objectives
Our aim is to assess the cardiovascular risk factors that are already present at the
time of diagnosing new-onset type 2 diabetes mellitus (DM).
This was an observational study. From each patient the following data were
retrospective collected between January 2008 and September 2009: age, sex, DM
in the family, smoking, HbA1c, hypertension (HTA) and dyslipidemia,
microangiopathy and macroangiopathy, lipids and medical treatment. We assess
the cardiovascular risk of our population with the UKPDS risk engine model v2.0
at the time of diagnosing DM and 3 months after initiating therapy.
Results
We studied 102 patients (62.7% men and 37.3% women) with a median age of
54.513.5 years old. The median BMI was 31.7 kg/m
2
(6.3). There was a
family history of DM in 60.8%, 42% smokers, 32.4% dyslipidemia, 41.2% HTA.
The prevalence of ischemic cardiopathy (CI), stroke (AVC) and peripheral
arterial disease was respectively 14.7, 7.8 and 3.9%. We found microangiopathy
and diabetic retinopathy in 14.7% and 8% respectively. After 3 months of follow
up there was a statistical signifcantly decrease (P,0.05) in HbA1c (10.62.5 vs
6.31.01%), in LDL cholesterol (12242.9 vs 9332.4 mg/dl), in triglycerides
(302582 vs 13479 mg/dl). We observed an increase in BMI from 31.76.3
to 32.16 kg/m
2
that did not reach statistical signifcance. Assesment of
cardiovascular risk (CVR) at diagnosing DM and after 3 months follow up:
Conclusion
Our patients with new-onset type 2 DM have a high prevalence of cardiovascular
risk factors and a global therapeutical approach results in a remarkable decrease
of cardiovascular events.
P29I
Evaluation of effect of dose and duration of treatment with metformin
on serum vitamin B12 levels in type 2 diabetic patients
K P Harsha
1
, G Niveditha
2
, Reddy Sanjay
2
, K M Prasanna Kumar
2
& M C Shivamurthy
2
1
S S Institute of medical Sciences, Davanagere, India;
2
M S Ramiah Medical
College, Bangalore, India.
Introduction
Metformin induced impaired vitamin B12 absorption leading to fall in serum
cobalamin levels has been described in literature as early as 1971. Approximately
10% of patients and in some studies 30% of patients on metformin therapy
developed metformin related cobalamin defciency. The risk of cobalamin
defciency is comparatively more among patients with vegetarian diet than in
non-vegetarians.
Objective
To evaluate the effect of dose and duration of treatment with metformin on serum
vitamin B12 levels in type 2 diabetic patients.
A total of 40 patients ON metformin therapy were chosen. By using a pilot tested
pro forma details were collected on demographic data, dietary habits. Duration of
treatment with metformin and dose of metformin was also noted. 5 ml of blood
will be collected and sent to the central laboratory for serum vitamin B12
estimation. Vitamin B12 estimation was done using a recently developed method
called as active vitamin B12 assay.
Results
Our results showed that mean vitamin B12 levels among patients on dose of
,1 g/day was 57.8 Pmol/dl and was 40.4 Pmol/l (picomoles/liter) in patients on
dose more than 1 g/day. The mean B12 levels were 39.7, 54.3 and 75.9 Pmol/l in
duration of treatments ,2, 3-5 and 5 years respectively.
Conclusion
Our study shows that dose and duration of metformin did not show any signifcant
relationship with serum vitamin B12 levels.
P298
The IMPERIAL study: physicians` perceptions regarding intensihca-
tion of insulin therapy
Sanjay Kalra
1
, Bharti Kalra
1
& Satish Kumar
2
1
2
Excel Life Sciences, NOIDA, India.
The Indian Medical Practitioners Expressions Regarding Drug Interventions in
All Aspects of Metabolic Syndrome (IMPERIAL) study-5 was planned to assess
physicians` perceptions regarding the relative importance and effectiveness of
various methods used to upgrade or intensify insulin therapy in patients not
achieving glycemic control.
! Smokers ! Non smokers Z Smokers Z Non smokers
Age 4910 6410 479 5411
CVR% CI IAM
|
AVC CI IAM
|
AVC CI IAM
|
AVC CI IAM
|
AVC
nitial 8.2 4 2 20.5 14.3 5.4 22.7 11.3 2.8 24.8 14.3 3.5
3 months
later
4.4 1.6 1.8 9.6 5.5 4.8 9.9 3.3 2.4 10.4 4.3 2.9
Seventy-four diabetologists/endocrinologists, with clinical experience of 20.25
5.0 years, attending a conference, were requested to complete a pretested,
structured fve point Likert scale questionnaire which listed 11 methods of insulin
intensifcation. Intensifcation of therapy was defned as a change in insulin
formulation, regimen, frequency or dosage, or addition of other therapeutic
modalities, with a view to improving glycemic control.
The most important/effective methods of insulin intensifcation were increasing
insulin dose (meanS.D. score 3.580.40), increasing the number of doses of
insulin (intensifying the regime) (3.430.36), and changing to insulin analogue
(3.280.32). Other effective methods were increasing the insulin-meal time gap
(2.630.20), addition of a DPP-4 inhibitor (2.610.20), improving insulin
technique (2.570.31) and using modern delivery devices (2.550.20). Less
effective methods of intensifcation were thought to be addition of a sensitizer
(2.40.21). Change of insulin brand (2.260.42), and adding a GLP-1 agonist
(1.720.18) or anxiolytic/anti-depressant (1.500.31).
Statistical signifcance was reached for the frst three methods versus the rest
(P,0.05).
This survey of experienced physicians reveals the preferred methods of insulin
intensifcation in patients of type 2 diabetes. Increasing dose or frequency of
insulin and shifting to modern analogues rank as the most effective methods of
insulin intensifcation.
P299
A case of spontaneous pneumomediastinum and diabetic ketoacidosis in
patient with diabetes mellitus which was undiagnosed before
Doo-Man Kim
1
, Sunwoo Kim
2
& Soonjib Yoo
3
1
Hallym University College of Medicine, Seoul, Republic of Korea;
2
School
of Medicine, Sungkyunkwan University, Seoul, Republic of Korea;
3
Catholic University College of Medicine, Seoul, Republic of Korea.
Introduction
Pneumomediastinum is a rare complication of diabetic ketoacidosis (DKA). The
pathophysiology of DKA commonly associated with changes in pressure
gradients in the pulmonary alveoli secondary to vomiting and/or Kussmaul
respiration. We report a 21-year-old male with DKA who have no history of
diabetes mellitus before and was found to have pneumomediastinum and
subcutaneous emphysema.
Case
A 21-year-old male without previous history of diabetes mellitus was admitted via
ER with complaints of general weakness and throat pain on swallowing. His BMI
was 19.6 kg/m
2
, white blood count 18.480/mm
3
, haemoglobin 16.5 g/dl, BUN/Cr
23.5/2.8 mg/dl. His serum glucose was 771 mg/dl, sodium/potassium/chloride/
bicarbonate 138/45/92/15.2 meq/l. His calculated anion gap was 31 with an
arterial pH of 7.31. Serum ketone was elevated to 5.7 mmol/l. Initial chest
radiograph showed mediastinal air along left cardiac border but this fnding was
ignored by ER doctor. On 2nd day of admission subcutaneous emphysema was
detected by physical examination, and initial chest X-ray flm was re-examined.
After then chest CT and gastrograffn swallowing study was followed. Chest
computerized tomography (CT) demonstrated the air in the soft tissues of the
neck, nasopharynx and within the anterior mediastinum. There was no evidence
of esophageal tear or extravasation of gastrograffn into the mediastinum.
His serum C-peptide was 0.7 ng/ml and HbA1c 16.9%. Test about anti-GAD
antibody and anti-islet cell antibody showed negative results.
His pneumomediastinum and subcutaneous emphysema resolved spontaneously
during the admission with oxygen therapy using facial mask, and he was
discharged in improved condition with the prescription of multiple daily insulin
injection.
P300
Inpatient hypoglycaemia: the continuing problem and need for
a proactive management protocol
Cassandra Sobajo & Prasanna Rao-Balakrishna
Central Manchester University Hospitals NHS Foundation Trust,
Manchester, UK.
Hypoglycaemia is defned as capillary blood glucose (CBG) of B4 mmol/l
irrespective of symptoms. We audited the recognition and management of
inpatient hypoglycaemia with a view to identify potential areas for improvement.
Methods
A total of 120 inpatients with diabetes were identifed in the hospital on a single
day, of whom n32 had 1 episode(s) of hypoglycaemia, as evidenced by their
CBG. Data relating to recognition and management of the event(s) by the
nursing/medical staff was collected from 79 hypoglycaemic events in total.
Results
The frontline staff failed to recognise hypoglycaemia in n10 (31% of 32); and
only 34% of the initial and 25% of the subsequent management was appropriate.
Recurrent hypoglycaemia was more likely to be recognised (100% at 5 events)
and better managed. Assessment of response to initial treatment was preformed in
only 6%. Hypoglycaemia was rarely documented in medical notes; only 3% with
one event and 13% with 4 events had both medical/nursing documentations.
Medication reassessment and dose titration was least likely in those with single
events (19 vs 50%). Referral to the diabetes team was made only in a quarter.
Discussion
The audit highlights the problems associated with recognition and management of
hypoglycaemia by frontline nursing staff. Delayed recognition of the low CBG as
hypoglycaemia resulted in inadequate initial management. Insuffcient documen-
tation in nursing/medical notes led to delays in the reassessment of regular
hypoglycaemic agents, recurrences of hypoglycaemia and lack of referral to the
inpatient-diabetes team. Literature suggests prolonged hospital stay and increased
mortality with inpatient hypoglycaemia
1
. Appropriate action is therefore
necessary to prevent hypoglycaemia whilst achieving good inpatient glycaemic
control. New hypoglycaemia management guidelines with standardised docu-
mentation sheets addressing these issues have been drawn-up and rolled out.
1. Turchin A, Matheny ME, Shubina M, Scanlon JV, Greenwood B &
Pendergrass ML. Hypoglycaemia and clinical outcomes in patients with diabetes
hospitalized in the general ward. Diabetes Care 2009 32 (7) 1153-1157.
P301
Hypovitaminosis D and microvascular complications in diabetic
patients
Elena Garcia, Guillermo Martinez, Raquel Sanchez & Federico Hawkins
Hospital 12 De Octubre, Madrid, Spain.
Background
High prevalence of hypovitaminosis D in diabetic patients has been reported and
has been associated with microvascular complications and insulin treatment in
type 2 diabetic patients.
Methods
Observational study in 92 inhospital patients with different types of diabetes. We
analyzed the relationship between serum 25-hydroxyvitamin D (25-OHD)
concentration and the clinical features associated with diabetes.
Results
Of 36.2% had type 1 diabetes, 57.4% had type 2 diabetes, 2.3% had
pancreatoprive diabetes and 4.3% had LADA. Of 51.1% were treated with
insulin while 14.1% were treated with antidiabetics drugs (with or without
insulin). Of 18.5% had retinopathy, 21.7% nephropathy, and 22.8% neuropathy.
Mean HbA1c was 11.52.7%. Mean serum concentration of 25-OHD was
19.611.9 ng/ml. The prevalence of hypovitaminosis D (,20 ng/ml) was
56.5%. Its concentration decreased according to the number of microvascular
complications without signifcance. Only serum albumin (P0.025) were
signifcantly associated with the decreased in 25-OHD. There was no signifcant
association between 25-OHD and age, gender, BMI, type of diabetes, duration of
diabetes, type of treatment, microvascular complications iPTH or HbA1c.
Conclusions
The mean serum concentration of 25-OHD in our subjects is considered as a
relative hypovitaminosis D. It is possible that a decrease of protein synthesis can
affect the concentration of serum 25-OHD. Progression of diabetic microangio-
pathy is possibly associated with the decreased of the vitamin. Statistically
signifcant differences in serum 25-OHD between patients treated with insulin and
with antidiabetic drugs were not found.
P302
Effects of interleukin-4 on energy metabolism
Yih-Hsin Chang
1
, Kuo-Ting Ho
2
& Ming-Yuh Shiau
3
1
Chung Shan Medical University, Taichung, Taiwan, ROC;
2
Chung Hsing
University, Taichung, Taiwan, ROC;
3
Hung Kuang University, Taichung,
Taiwan, ROC.
Abundant evidence has demonstrated that long-term cytokine-mediated infam-
mation is a risk factor for obesity and type 2 diabetes mellitus. In this study, we
focused on investigating the putative involvement of Th2-derived cytokine,
interleukin-4 (IL-4), in energy metabolism. Mice were i.p. injected with
adenovirus containing full-length IL-4 gene, or with recombinant mouse IL-4
every other day for 8 weeks. Effects of IL-4 on energy metabolism in insulin-
target cells and blood chemistry were examined. Signifcantly higher levels of
phosphorylated-AKT were observed in skeletal muscle from mice with IL-4
administration (PB0.002 versus control mice). In addition, IL-4 treatment
resulted in a signifcant attenuation of glycogen synthase kinase phosphorylation
in skeletal muscle (PB0.01 versus control mice) and adipose tissues (P0.032
versus control mice). Serum levels of free fatty acid were elevated while number
of epididymal fat- and liver-infltrated macrophages were increased by IL-4
treatment. The above results suggested that IL-4 could affect glucose and lipid
reservoir by regulate important signaling mediators of energy metabolism in
insulin target cells.
P303
Metabolic control in patients with type 1 diabetes mellitus in Belarus
Maryia Rusalenko
1
& Tatiana Mokhort
2
1
The Republic Research Center for Radiation Medicine and Human
2
Belarussian State Medical University, Minsk,
Belarus.
In spite of achievements in diabetology on insulinotherapy optimization, the
number of patients with T1DM, who do not achieve target indicators of
compensation, remains to be high.
Objective
To estimate compensation and frequency of self-control carrying out among
patients with T1DM in Belarus.
Total 965 patients with T1DM (467m, 498f), mean age (Mm) 34.330.51
years (1.80-72.75), age of T1D manifestation 22.170.43 years special form
including questions about T1DM. HbA1c (%) was measured by biochemical
analyzer 'ARCHITECT c8000` (Abbott).
Results
The level of HbA1c7.5% in all age groups. Among patients aged 40-59,
HbA1c is higher among females (8.740.13) than among males (8.350.16;
P,0.01). The greatest proportion comprised patients with HbA1c level 9%,
that was found in 31% of people above 60 years, in 71% of adolescents; and
patients with HbA1c level of 8-8.9% that was found in 13% of adolescents, 23%
of people above 60. Forty-two percent of patients (females above 40 years old)
were found to have overweight (BMI25 kg/m
2
). Frequency of self-control
(29.581.55 per month) and actual hypoglycemias (5.960.31 per month) is
higher among females (P,0.001). Maximal frequency of self-control were
revealed among children aged 1-9 (among boys 75.2918.49, among girls
82.0410.92) and minimal frequency - among patient above 60 years old
(among males 6.64.09, among females 7.91.85; P,0.01). Hypoglycemia
frequency was found to be maximal in girls aged 1-9 (6.631.19) and minimal in
males aged 40-59 (3.870.45; P,0.001).
Conclusion
Basic proportion (62.07%) of patients with T1DM have negative compensation
that is associated with high risk of late complications (HbA1c8%). Low level of
compensation is the result of self-control low frequency and hypoglycemia high
frequency, especially among children and adolescents, and is accompanied by
high frequency of overweight among females over 40 years old.
P304
Psychological rehabilitation efhciency in adolescents with type 1
diabetes
Mariya Rusalenko
1,2
& Tatiana Mokhort
1,2
1
The Republican Research Center for Radiation Medicine and Human
2
Belarus.
Objective
To estimate psychological rehabilitation effciency at adolescents with T1DM.
Total 58 adolescents with T1DM (30m, 28f), mean age (M&) 15.12.8 years
(13.00-18.00), age of T1DM manifestation 5.13.9 years, were provided with
the PedsQL4.0 questionnaire, scales of psychological well-being (SPWB). The
rehabilitation program was developed: medical unit (lessons in diabetes school
and doctor`s consultations) and psychological unit (individual and group lessons
with psychologist). HbA1c (%) was measured by biochemical analyzer
'ARCHITECT c8000` (Abbott). The self-control was measured by number of
measurements of glycemia level per month. The program was fully carried out
with group I (n30), with group II (n10) - only the medical unit was
performed, with group III (n18) the rehabilitation was not carried out. In 1 and
3 months the effciency was estimated by indicators of PedsQL4.0, SPWB, self-
control and HbA1c level.
Results
In 1 month, in group I the self-control frequency increased (77.54.45; P,0.01),
there were also increased the emotional functioning (88.01.37; P,0.01),
school life level (87.11.18; P,0.01), commutability (78.52.29; P,0.01),
positive attitude to people surrounding (64.82.26; P,0.05), autonomy (61.2
1.53; P,0.01) and personal growth (66.71.43; P,0.01), while treatment
barriers decreased (88.51.57; P,0.01). In 3 months the diabetic symptom
manifestation decreased (77.62.10; P,0.01), there were improved the
treatment regime observance (87.81.63; P,0.01), life aims (65.60.58;
P,0.05), self-acceptance (65.70.65; P,0.01), HbA1c (8.780.25; P,0.01).
In 1 month, in group II the treatment barriers decreased (91.42.84; P,0.05),
there were improved the treatment regime observance (88.42.23; P,0.05),
school functioning (75.52.63; P,0.05), self-control (75.510.97; P,0.05).
In 3 months there was observed the increase in treatment regime observance level
(89.81.71; P,0.05) as well as in self-control level (77.05.78; P,0.05). In 1
and 3 months, group III did not show any differences by PedsQL4.0, SPWB, self-
control and HbA1c level.
Conclusion
The rehabilitation of adolescents with T1DM is highly effective within
psychological correction implementation, based on study of QOL and SPWB.
P305
Latent autoimmune diabetes of adults and its clinical, immunological
and genetics markers
Tatyana Tikhonova, Yurii Karachentsev, Svetlana Shtandel &
Tamara Levchenko
The aim of the study was to determine the clinical, immunological and genetics
markers of latent autoimmune diabetes of adults (LADA) in early terms of disease
development.
Seventy-eight LADA patients (47 women, 31 men, age of manifestation 45.52
1.83 years, average age 49.371.17 years, insulindependence age 49.33
0.34 years with anti islet, GADA antibodies and low C-peptide levels) were
enrolled. The GADA, IA2A and ICA antibodies were measured with RIA. The
presence of C1858T PTPN22 gene polymorphism was estimated using the DNA
sequencing method.
Results
It has been shown, that the leading complaint during a manifestation of disease
was progressing body weight reduction from 6 up to 20 kg (on the average
12.670.73 kg). At 11.54% patients before insulin application short-term
acetonuria episodes were observed. The glycemia level at verifcation of the
diagnosis was determined within the limits of from 8 up to 20.0 mmol/l (on the
average 13.70.51 mmol/l). It has been shown, that defnition only one kind
of antibodies for LADA form fnal verifcation is not enough. Frequency a
positive tytres of each of immunologic LADA markers changed from 6.4%
(GAD ab, ICA ab) up to 16.67% (IA-2A ab). The least demonstrative were
defnition ICA abIA-2A ab, most - GAD abIA-2A ab. Verifcation of
LADA determination, are necessary at least two kinds of antibodies, in view of
clinical features of disease manifestation. LADA patients had the high C1858T
polymorphism of PTPN22 gene frequency: T/T genotype was 22.09%
(
2
LADAcontrol
4663; P0.000) and powerful association LADA with
C1858T polymorphism of PTPN22 gene: T/T genotype - OR
LADA
37.19
(8.30-166.57).
Conclusions
It has been shown, that progressing body weight reduction, two kinds of
antibodies and T/T genotype in 1858 position of PTPN22 gene are the important
LADA markers.
P30
Exercise-related levels of acetylcarnitine in skeletal muscle of
individuals with type 1 diabetes in Eu- and hyperglycaemia assessed
by
1
H-MR spectroscopy
Stefan Jenni
1,2
, Andreas Boss
3
, Roland Kreis
3
, Michael Ith
3,4
,
Emanuel Christ
1
, Chris Boesch
3
& Christoph Stettler
1
1
Division of Endocrinology, Diabetes and Clinical Nutrition, Inselspital
Bern, University Hospital and University of Bern, Bern, Switzerland;
2
International Centre for Circulatory Health, Imperial College at St Mary`s,
London, UK;
3
Department of Clinical Research, University of Bern, Bern,
Switzerland;
4
Institute for Diagnostic, Interventional and Pediatric
Radiology, Inselspital Bern, University Hospital and University of Bern,
Bern, Switzerland.
Background
Acetylcarnitine (AC) is involved in intramyocellular fuel metabolism during
exercise. So far, little is known on exercise-associated myocellular AC levels in
patients with type 1 diabetes. In particular, it is unknown whether AC levels differ
according to glucose values in diabetic patients.
1
H magnetic resonance
spectroscopy (MRS) of the skeletal muscle allows for the non-invasive
assessment of acetylcarnitine (AC) accumulation. The present study assessed
exercise-related intramyocellular AC levels in stable eu- and hyperglycaemic
conditions in individuals with type 1 diabetes.
Methods
Seven physically active men with type 1 diabetes (meanS.E.M. age 33.52.4
years, diabetes duration 20.13.6 years, HbA1c 6.70.2%, VO
2
peak 50.3
4.5 ml/min per kg) were studied twice while cycling 120 min at 55-60% of
VO
2
peak, with a glycaemia of either 5 or 11 mmol/l and identical insulinaemia.
1
H-MRS spectra were obtained before and 80 min after completion of exercise
from vastus intermedius. AC spectra were analyzed using a ft-strategy optimized
for the AC-peak and AC content was expressed in absolute arbitrary units (a.u.)
relative to the water signal intensity.
Results
In euglycaemia AC increased from 0.30.2 a.u. (meanS.E.M.) pre-exercise to
4.10.5 a.u. postexercise (P0.0001). In hyperglycaemia AC increased from
0.70.3 a.u. to 2.40.5 a.u. (P0.01). The increments were signifcantly higher
in euglycaemia compared with hyperglycaemia (P0.004). Higher AC
accumulation in euglycaemia was associated with higher lipid oxidation at end
of exercise.
Conclusions
In individuals with type 1 diabetes performing aerobic exercise intramyocellular
levels of AC differ according to glycaemic levels. The fnding of higher AC levels
in euglycaemia where fuel metabolism strongly relied on lipid oxidations is
compatible with previous reports in healthy individuals and implies comparable
mechanisms in patients with type 1 diabetes during physical exercise.
P30I
Association between dyslipidaemia and micro and macrovascular
complications in type 2 diabetic patients
Francisco Javier del Canizo-Gomez, Manuela Belen Silveira Rodri guez,
Tomas Gonzalez-Losada, Inmaculada Moreno-Rui z, Carlos de Gorospe
Perez-Jauregui & Amparo Segura-Galindo
Hospital Infanta Leonor, Madrid, Spain.
Various risk factors act synergistically for the development of micro and
macrovascular complications in type 2 diabetes mellitus (T2DM) patients. The
contributions of risk factors have yet to be clearly identifed and quantifed, but
diabetic dyslipidaemia has specifc importance.
Objective
To investigate the association of dyslipidaemia with micro and macrovascular
complications in a T2DM population.
Cross sectional study in 874 consecutive out-patients who visited our clinic in
Madrid, Spain for a routine follow-up. Total cholesterol (TCh), HDL-Ch, and
triglycerides (TGs) were measured and LDL-Ch was calculated (Friedewald) in
all of the subjects after an overnight fast. All patients were evaluated for the
presence of micro and macrovascular complications such diabetic nephropathy
(DN), diabetic retinopathy (DR) and coronary artery disease (CAD), using
standard techniques. Estimated values of TCh240 mg/dl; TGs150 mg/dl,
HDL-Ch,40 mg/dl and LDL-Ch130 mg/dl were considered as abnormal.
Multiple regression analysis was done to evaluate the association of micro and
macrovascular complications with abnormal lipid profle. A level of P,0.05 was
considered statistically signifcant (SPSS, version 13.0).
Results
The mean age of the study group was 65.612.6 years with average duration of
diabetes 13.010.2. Data regarding lipid profle showed that in all patients with
T2DM studied, TCh240 mg/dl was seen in 15% of patients, LDL-Ch
130 mg/dl in 27.9%, HDL,40 mg/dl in 18.9%, and TGs150 mg/dl in 37.8%.
Regression analysis revealed an association of high TCh (P0.015) and LDL-Ch
(P0.033), and low HDL-Ch (P0.001) with CAD; and low HDL-Ch
(P0.000, 0.001) and high TGs (P0.002, 0.048) with DN and DR respectively.
Conclusions
The present study has shown a strong association of abnormalities of lipid profle
and micro and macrovascular complications in the T2DM patients studied, mainly
low HDL-Ch levels. Hence, appropriate preventive and new treatment strategies
to increase the HDL-Ch should be considered timely in T2DM patients.
P308
Pattern of type 2 diabetes mellitus in Surabaya, Indonesia
Olivia Handayani & Hans Tandra
Diabetes, Obesity, Metabolic, Endocrine (DOME) Clinic, Surabaya,
East Java, Indonesia.
Objective
To observe the presentation, anthropometry, and complication of type 2 diabetes
(T2D) in diabetes clinic in Surabaya, Indonesia.
Methodology
It is a retrospective review of diabetic cases over 12 months. Data extracted from
medical records, DM patients demographic and clinical laboratory parameters.
Results
We investigated 302 T2D patients, 132 males and 170 female, with mean age of
55.921.1 years. Mean duration of DM was 6.934.13 years. Mean body mass
index (BMI) of the subjects was 26.33.1 kg/m
2
. Hyperglycemia presented in
235 (77.8%) T2D patients, with a mean fasting plasma glucose of 158.2
23.1 mg/dl and HbA1c 7.72.1%. Only 35 (11.6%) of patients visited our
clinic without complications. Others 267 (88.4%) with chronic complications
found, i.e. peripheral neuropathy in 177 (58.6%), CVD in 62 (20.5%), retinopathy
52 (17.2%), nephropathy 58 (19.2%), cataract 54 (17.9%), hypertension 61
(20.2%), ischemic heart disease 31 (10.3%), gall bladder stone 46 (15.2%), skin
fungal infection 30 (9.9%), and diabetic foot 22 (7.3%). Those complications
were more frequent found in poorly regulated diabetics (HbA1c7%).
Conclusion
Most of the diabetic patients visited diabetes clinic after suffering complications.
Those complications were related to poorly controlled of blood sugar. Diabetes
education is one of the most important things in the management of diabetes in
our country.
P309
Metabolic syndrome in patients with type 2 diabetes mellitus
in Surabaya, Indonesia
Diabetes, Obesity, Metabolism, Endocrine (DOME) Clinic, Surabaya,
East Java, Indonesia.
Objective
To determine the frequency of metabolic syndrome (MS) in adult patients with
type 2 diabetics (T2D) in Surabaya, Indonesia based on NCEP-ATP III.
Methods
This is a retrospective study. All consecutive adults with T2D were evaluated for
the presence or absence of MS. According NCEP-ATP III, metabolic syndrome
(MS-ATP III) was defned as two of four of the following: central obesity (waist
circumference 102 cm in males and 88 cm in females), hypertriglyceridemia
(150 mg/dl or specifc treatment), low HDL cholesterol (,40 mg/dl in males,
,50 mg/dl in females or specifc treatment) and hypertension (SBP 130 mmHg
or DBP 85 mmHg or specifc treatment).
Results
We analyzed 150 medical charts. The mean age was 58.711.2 years and had
been living with diabetes for more than 72.9 years. Fifty-two percent of patients
had a family history of T2D and 128 (85.3%) was correlated with MS defnition.
Most of the MS patients were females (72.7%) and middle-aged (mean 57.9
10.5 years). Of 81.2% among them were treated with oral hypoglycemic
agents (OHAs), 13.1% with the combination of insulin and OHAs, and only 6.7%
were on insulin therapy alone. Only (37.4%) of the subjects met the glycemic
target of HbA1cB6.5%. Whereas in 22 non MS diabetic patients (17.7%),
HbA1c,6.5% were found in 71.2%.
Conclusion
The diagnosis of MS is frequent in adult patients with T2D, mostly correlated
with female sex and middle-aged. Metabolic syndrome was signifcantly related
to poorly regulation of blood glucose in type 2 diabetic patients.
P310
Prohle of patients with type 2 diabetes mellitus in Surabaya, Indonesia
Diabetes, Obesity, Metabolic, Endocrine (DOME) Clinic, Surabaya, East
Java, Indonesia.
Objective
To document the anthropometrics indices and other characteristics of patients
with type 2 diabetes who attending the clinic of diabetes.
Methodology
The patient`s data, anthropometric indices, co-morbidities and pattern of
therapies were documented in a cross-sectional study of 500 patients attending
Diabetes Clinic of Surabaya, Indonesia over a 3-month period. Quantitative data
were analyzed using the statistic Student`s t-test and a P value of B0.05 was
regarded signifcant.
Three hundred and ffty-two (70.4%) of the subjects were women and their ages
ranged from 24 to 77 years and the mean (S.D.) age were 56.810.7 years. Men
55.911.2, was lower than that of the women 59.712.1, this however was not
statistically signifcant (P0.05). The mean body mass index (BMI) of the
subjects 26.95.4, women having a higher mean BMI (27.84.3) than men
(26.45.2). The proportion of central obesity was similar between men (53%)
and women (50%). Hypertension was documented in 300 (60%), and the male:
female ratio of these was 1.3:1. Most of the subjects (86.2%) were treated with
oral hypoglycemic agents (OHAs), 10.1% with the combination of insulin and
OHAs, and only 3.7% were on insulin therapy alone. Only 187 (37.4%) of the
subjects met the glycemic target of HbA1c B6.5%.
Conclusion
The type 2 diabetic patients who attend our diabetes clinic is mostly middle-aged
woman, overweight, some of them with systemic hypertension. OHAs are
averagely used in those patients. Only one third of them were well controlled. DM
education and lifestyle modifcation are recommended in achieving a better
profle of diabetic patients.
P311
Risk estimation of hypoglycemic episodes among patients with type 1
diabetes mellitus
Elena Makhlina
1,2
& Tatiana Mokhort
1,2
1
2
Bellarussian State Medical University, Minsk,
Belarus.
Study objective
To determine risk factors of hypoglycemic episodes among patients with type 1
diabetes mellitus (T1D) using the continuous glucose monitoring system(CGMS).
Total 120 female patients with T1D were examined. The 1st group was with
concealed hypoglycemic episodes (n79) that has made 66% and the 2nd group
was with frank hypoglycemic episodes (n41) that has made 31% of the total
number of the examined. The groups are compared by average age (29.147.33
years), T1D duration (10.007.33), HbA1c, % (9.282.07).
Results
The risk factors of hypoglycemic episodes are as follows: the age of 18 till 30
years (latent hypoglycemia cases OR1.18; 95% CI 1.06-1.30; P0.002,
manifestative hypoglycemic cases OR1.21; 95% CI 1.07-1.38; P0.004),
HbA1c above 7% (latent hypoglycemia cases OR0.71; 95% CI 0.59-0.85;
P,0,001, manifestative hypoglycemic cases OR0.74; 95% CI 0.58-0.94;
P0.014), level of average glucose of intercellular fuid below 13 mmol/l (latent
hypoglycemic cases OR0.74; 95% CI 0.62-0.89; P0.001, manifestative
hypoglycemic cases OR0.77; 95% CI 0.64-0.93; P0.007).
Conclusions
Latent hypoglycemic episodes dominated among the registered hypoglycemic
reactions. The risk factors of hypoglycemic episodes are as follows: young age,
HbA1c above 7%, level of average glucose of intercellular fuid below 13 mmol/l.
P312
The effects of short-term fasting on insulin sensitivity and inammation
in healthy subjects
Mirjana Sumarac Dumanovic
1
, Dragan Micic
1
, Danica Stamenkovic
Pejkovic
1
, Danka Jeremic
1
, Goran Cvijovic
1
, Darko Stefanovic
3
&
Vladimir Trajkovic
3
1
Institute of Endocrinology, Diabetes and diseases of Metabolism,
Belgrade, Serbia;
2
Institute of Immunology and Microbiology, School of
Medicine, Belgrade, Serbia;
3
Insitute of Physiology, School of Medicine,
Belgrade, Serbia.
It is well known that weight losses in the range of 2.5-5% are able to improve
factors of the metabolic syndrome such as insulin sensitivity. Several studies have
been published concerning weight loss and subsequent changes in infammatory
markers and indicate that higher weight losses are necessary to affect the
infammatory markers than are needed to affect insulin sensitivity. Some data
showed impairment of insulin sensitivity in diabetic patients during starvation.
The aim of our study was to investigate the effects of short-term fasting (72 h) on
hs-C-reactive protein (CRP) and insulin sensitivity (HOMA-IR) in patients with
normal glucose tolerance. Seven patients were included in the study (mean BMI
23.82.91 kg/m
2
; mean age: 37.294.40 years). CRP, basal plasma glucose,
insulin and C-peptide were measured every 6 h during 3 days. Values measured at
0600 h each day were used for comparison. CRP increased but not signifcantly
from day 0 to 4 (1.890.68 vs 1.630.71 vs 2.871.24 vs 3.471.59 mg/l,
P0.05, respectively). HOMA-IR decreased signifcantly during 72 h of fasting
(4.220.69 vs 2.120.37 vs 1.380.27 vs 0.970.17, P,0.05 respectively).
C-peptide values decreased signifcantly during fasting (0.860.18 vs 0.39
0.07 vs 0.280.09 vs 0.170.05 nmol/l, P,0.05, respectively). In
conclusion, short-term fasting in subjects with normal glucose tolerance increase
insulin sensitivity as well as non signifcantly increase hs-CRP. This could be part
of general body adaptation to starvation.
P313
Fifty-two-week treatment with diet and exercise plus transdermal
testosterone improves biomarkers of non-alcoholic fatty liver disease
and cardiovascular risk in hypogonadal men with the metabolic
syndrome
Farid Saad
1,2
, Armin Heufelder
3
, Mathijs Bunck
4
& Louis Gooren
4
1
Bayer Schering Pharma, Scientifc Affairs Men`s Healthcare, Berlin,
Germany;
2
Gulf Medical University, Ajman, UAE;
3
Private Diabetes
Practice, Munich, Germany;
4
Department of Endocrinology, VUMc
Amsterdam, Amsterdam, The Netherlands.
Objectives
Men with the metabolic syndrome (MetS) and type 2 diabetes (T2D) often have
low testosterone levels. Elevating low testosterone levels may improve features of
the MetS and glycemic control. In this analysis, we assessed effects of
normalization of circulating testosterone on biomarkers of non-alcoholic fatty
liver disease (NAFLD), and cardiovascular risk.
Design and methods
In a single-blind, 52-week clinical trial, 32 hypogonadal men with the MetS and
newly diagnosed T2D were randomized to supervised diet and exercise (D&E)
alone (n16) or with additional transdermal testosterone gel (50 mg QD; n16).
The MetS was defned by the Adult Treatment Panel-III and the International
Diabetes Federation. Hypogonadism was defned as a total testosterone
B12.0 nmol/l. Endpoint were baseline adjusted change in biomarkers of
NAFLD (GPT, GOT, g-GT, CRP) and cardiovascular risk (homocysteine,
PAI-1, fbrinogen, Apo(a) and TG).
Results
Fifty-two weeks of T treatment resulted in a signifcantly larger improvement in
all measured biomarkers of NAFLD in T treated patients as compared to
supervised D&E alone. Levels of homocysteine, PAI-1, fbrinogen, Apo(a) and
TG improved signifcantly in both treated groups, with PAI-1, fbrinogen and TG
showing a signifcantly larger improvement in T treated patients as compared to
supervised D&E alone.
Conclusions
Addition of testosterone to supervised D&E results in greater benefcial effects on
biomarkers of NAFLD and cardiovascular risk. Our results invite to consider the
signifcance of diagnosing and if warranted treating testosterone defciency in
men with diabetes type 2.
P314
Erythropoietin and vascular endothelial growth factor as risk markers
for severe hypoglycaemia in type 1 diabetes
Peter Lommer Kristensen
1
, Ulrik Pedersen-Bjergaard
1
, Niels
Vidiendal Olsen
2
, Caper Schalkwijk
3
& Birger Thorsteinsson
1,4
1
Hillerd Hospital, Hillerd, Denmark;
2
Copenhagen University Hospital
(Rigshospitalet), Copenhagen, Denmark;
3
University of Maastricht,
Maastricht, The Netherlands;
4
University of Copenhagen, Copenhagen,
Denmark.
Aims/hypothesis
Circulating erythropoietin (EPO) and vascular endothelial growth factor (VEGF)
increase during hypoglycaemia and may represent a protective hormonal counter-
regulatory response. We tested the hypothesis that low levels of EPO and VEGF
are associated with a higher frequency of severe hypoglycaemia in a cohort of
patients with type 1 diabetes.
Methods
Two hundred and nineteen patients with type 1 diabetes (41% females, age 46
13 years (meanS.D.), duration of diabetes 2112 years, and HbA1c (8.5
1.1%) were followed in a 1-year observational study. Plasma EPO and serum
VEGF levels were measured at baseline with ELISA. Events of severe
hypoglycaemia defned by third party assistance were recorded and validated in
telephone interviews within 24 h.
Results
Two hundred and thirty-fve episodes of severe hypoglycaemia (1.1 episode per
patient-year) were reported by 82 patients (37%). At baseline plasma EPO was 8.6
(3.1-34.3) U/l (median (range)) and serum VEGF was 52.2 (6.6-337) pg/ml.
Levels of EPO and VEGF were not associated with frequency of severe and mild
hypoglycaemia. Levels of EPO were not associated with age, sex, duration of
diabetes, body mass index, HbA1c, C-peptide level or hypoglycaemia awareness
status. Levels of VEGF were positively associated with age and female sex.
Conclusions/interpretation
Although several studies suggest that VEGF and EPO may affect brain function
during hypoglycaemia, this study does not support random VEGF or EPO levels
to determine future risk of severe hypoglycaemia in people with type 1 diabetes.
P315
Vitamin D dehciency and isolated fasting hyperglycemia in pregnancy
Vasiliki Vasileiou, Anastasia Athanasiadou, Athanasia Giakoumi,
George Papageorgiou, Evangelia Zapanti, Maria Alevizaki
& Eleni Anastasiou
Diabetes Center, 1st Endocrine Section, Alexandra Hospital, Athens,
Greece.
Introduction
The relation between vitamin D defciency and gestational diabetes mellitus
(GDM) has been rarely addressed in the literature with conficting results. The
aim is to determine the association between maternal serum 25(OH)D and glucose
metabolism in Caucasian pregnant women.
In a prospective study 157 pregnant women aged 31.25.8 years underwent a
100 g OGTT in the third trimester of pregnancy, during which serum 25(OH)D,
PTH, Ca, and P concentrations were also measured. For GDM diagnosis the ADA
2000 criteria were used. For 25(OH)D defciency a cut-off point of 20 ng/ml was
chosen. Age, height, pre-pregnancy weight, BMI and blood pressure (BP) were
recorded. Indices of insulin secretion and sensitivity were calculated. 25(OH)D
was converted to its natural logarithm (Ln).
Results
25(OH)D defciency was found in 88 out of 157 pregnant women (56%). There
was no difference in mean serum 25(OH)D between normal (n95, 20.2
7.0 ng/ml), isolated hyperglycaemia (n30, 22.17.7) and GDM (n32,
19.48.3) women. Ln-25(OH)D was negatively correlated with fasting plasma
glucose (r0.174, 95% CI 0.020-0.326, P0.029). The relationship remained
signifcant after adjustment for BMI, age, gestational age and seasonal variation.
The percentage of isolated fasting hyperglycaemia (Glu0
95 mg/dl) was
signifcantly increased in the subgroup of pregnant women with vitamin D
defciency (,20 ng/ml) compared to their counterparts with 25(OH)D
20 ng/ml (27.3 vs 7.2% respectively, P,0.01). The odds ratio of isolated fasting
hyperglycaemia in women with 25(OH)D,20 ng/ml was 4.8 (95% CI 1.7-13.3).
No correlation was found between Ln-25(OH)D and indices of insulin secretion
or resistance. We confrmed the expected negative correlation of Ln-25(OH)D
with PTH (r0.446, P,0.001) and also with systolic (r0.203, P0.011)
and diastolic BP (r0.238, P0.003).
Conclusion
We found an independent negative correlation of 25(OH)D with fasting glucose
in pregnant women. Furthermore 25(OH)D defciency was signifcantly
associated with increased risk for isolated fasting hyperglycaemia. Finally
25(OH)D defciency is common in Greek pregnant women.
P31
Pastpartam evaluation of patients with gestational diabetes and
newborns characteristics: differences between two periods
Beatriz Mantinan Gil, Reyes Luna Cano, Paula Sanchez Sobrino, Regina
Palmeiro Carballeira, Ines Seoane Cruz, Concepcion Paramo Fernandez
& Ricardo Victor Garci a Mayor
Compleho Hospitalario Universitario de Vigo, Vigo, Spain.
Introduction
Blood glucose control during pregnancy is essential in patients with gestational
diabetes (GD) to prevent fetal complications. Despite advances in its control,
neonatal morbidity and mortality still appears in a signifcant percentage of cases.
The presence of GD also implies consequences for the mother, as the GD
appearance in a new pregnancy and/or the future development of glucose
metabolism alterations.
Methods
We conducted a retrospective, observational study comparing patients
diagnosed of GD in our area in 1999 with those diagnosed in 2008. The
variables analyzed were: the required treatment (diet and/or insulin) during
gestation, the cesarean rate, newborn (NB) characteristics (weight, neonatal
complications and malformation) and mother`s postnatal evaluation through
oral glucose tolerance test.
Results
We included 384 patients, 131 from1999 (Group I) and 253 from2008 (Group II).
The treatment required, the type of delivery and postpartum evaluation are
summarized in Table 1. The mean weight of the NB was not signifcantly different
between both groups 3208 gr (Group I) versus 3276 gr (Group II). The rate of
macrosomy was also similar 6.1% (Group I) versus 5.5% (Group II). One NB of
Group I had a cardiac malformation and three cases had malformations (two
cardiac and one genitourinary) in Group II. We found two cases of neonatal
hypoglycemia, one in each group, and one case of neonatal hyperbilirubinemia
in Group II.
Conclusions
We found a signifcant dercrease in cesarean rate in Group II (18.5%), which is
close to the general population rate while in Group I this percentage was still
above this general rate (38.3%). A signifcant number of patients from both
groups give up postpartum evaluation. In postpartum evaluated patients, we
found a signifcantly higher impaired oral glucose tolerance rate in Group I.
Regarding NB characteristics we did no found differences between both groups.
P31I
Thyroid diseases in patients with type 1 diabetes mellitus
Ahmet Dirikoc, Meryem Kuru, Didem Ozdemir Sen, Cevdet Aydin,
Introduction
Coexistence of type 1 diabetes mellitus (DM) and autoimmune thyroid diseases
was shown in previous studies. Thyroid dysfunctions and thyroid autoantibody
positiveness were reported in 23-25 and 27-44% of patients with type 1 DM,
respectively. In recent years, thyroid ultrasonography (US) is widely used to
diagnose autoimmune thyroid diseases with regard to its ability to defne thyroid
morphology and echogenity. In this study, we aimed to evaluate thyroid
functions, autoantibodies and US features in Type 1 DM patients.
gp (%) gp (%)
Treatment nsulin 10.7 17.7 0.28
Delivery Cesarean 38.3 18.5 ,0.05
gp!b
evaluation
DM 3.8 0.4 0.05
GT 12.2 8.7 0.05
Material and method
We retrospectively analyzed 104 Type 1 DM patients (53 females, 51 males)
followed in our clinic. Patients were matched with 58 healthy controls (27
females, 31 males) according to age and sex. Serum thyrotropin (TSH), thyroid
hormones and thyroid autoantibodies were evaluated. Thyroid US was performed
in all subjects.
Results
Mean ages of Type 1 DM patients and control group were 31.089.38 and
27.597.17, respectively. Median TSH and fT3 were similar in Type 1 DM
patients and control subjects, however median fT
4
was signifcantly higher in
patient group (PB0.001). Of 26.3% of diabetic patients and 3.7% of control
subjects had at least one of the thyroid autoantibodies (PB0.001.). Prevalence of
thyroid dysfunctions was signifcantly higher in Type 1 DM patients compared to
control subjects (28.8 vs 3.4%, PB0.001). In thyroid US, thyroid parenchyma
was homogenous in 22.1% and heterogenous in 78.9% of patients, while it was
homogenous in 91.4% of healthy controls. Similar rates of thyroid nodules were
observed in the two groups.
Conclusion
Patients with Type 1 DM have higher rates of thyroid dysfunctions, autoantibody
positivity and ultrasonographical abnormalities. Morphological abnormalities of
thyroid gland are closely associated with thyroid autoantibody positivity and
thyroid dysfunctions in Type 1 DM patients indicating the need for close follow-
up in patients with abnormal US features.
P318
Proinammatory cytokines and serum lipids in patients with diabetes
mellitus 2
Constantinos Tzioras, Adromaxi Brionidou, Nikos Klonaris
& Alexandros Bantila
Red Cross Hospital, Athens, Greece.
Introduction
Recently, several cytokines attracted considerable attention as potential effectors
of insulin resistance and endothelium dysfunction, both associated with type 2
diabetes mellitus (T2DM) pathophysiology.
Serum lipids disturbances also observed in infammation and immunologic
disorders have been found to largely depend on proinfammatory cytokines
release.
Aim
To establish the presence of cytokines levels disturbances in patients with
diabetes mellitus 2 and investigate their correlation with serum lipids.
Forty patients with T2DM (20 women and 20 men, mean age 67.21.65 years)
and 35 control subjects matched for age, gender and BMI were studied.
Among diabetic patients, 31 were treated with antidiabetics and diet and 9 of them
were on diet alone and disease duration was ,3 years.
Plasma triglycerides, total and HDL-cholesterol were assayed by an enzymatic,
colorimetric method in an autoanalyzer (Roche Laboratory Systems) and LDL-
cholesterol was calculated according to the Friedewald formula.
Serum cytokines levels were measured by an immunoenzymatic method with
commercial kits obtained from R&D for the assay of TNF- and from Endogen
for the assay of IL-1, IL-2 and INF-.
Statistical analysis was perfomed by using Mann-Whitney test for comparisons
between groups and Pearson`s coeffcient for correlations.
Results
Diabetic patients had signifcantly increased levels of proinfammatory cytokines
compared to controls (IL-2 124.83.9 vs 743.6 pg/ml, IL- 56.11.0 vs
34.21.8 pg/ml, TNF- 43.91.0 vs 24.81.7 pg/ml, INF- 84.21.0 vs
51.22.5 pg/ml, all with P,0.001).
A strong positive correlation was found between IL-2 with total cholesterol and
triglycerides levels (r0.45, P,0.012 and r0.37, P,0.03 respectively) as
well as INF- with triglycerides levels (r0.35, P,0.04). No correlation was
found between other cytokines and lipid levels.
Conclusions
Increased levels of proinfammatory cytokines IL-2, IL-, TNF-, INF- in
T2DM patients indicate that the pathophysiological mechanisms leading to
insulin resistance and -cell damage, include an activation of the infammation
cascade. Whether, the observed parallel increase in lipids levels is the cause or the
result of this infammation remains to be elucidated.
The increase of pre-infammatory cytokines IL-2, INF- is followed by an
increase of serum cholesterol and triglycerides indicating a possible etiological
correlation between the over secretion of cytokines and lipid disorders observed
in diabetes mellitus 2.
P319
Non-invasive cytological method of diagnostics and monitoring of type 2
diabetes mellitus development
Rudolf Yui, Alma Mansharipova, Sholpan Mulkibayeva & Alisher Idrisov
Kazakh National Medical University, Almaty, Kazakhstan.
Material for cytological analysis was oral swab of investing type (lip, cheek) in 22
healthy people and 33 sick ones with type 2 diabetes mellitus at sub
compensational stage. The group under study was homogenous in age (45-65),
sex (men) and biorhythmic type. Experiments were performed on human subjects
and local Ethical Committee approval was obtained. Oral swabs were fxed in
spirit-acetone and were May-Grunvald`s and Romanovsky-Gimsa`s dyed. The
epithelial cells at various stages of differentiation were determined in swabs at the
rate of 1000 cells. Differentiation and cell keratinisation indexes of epithelium
were calculated in swabs according to cytograms. Moreover, blood glucose level
was determined. For mathematical data processing correlation analysis and
Student`s criteria were used. The obtained results show that in patients on the
2 days in hospital differentiation index in swabs cytogram was high - 495.312.4
over control level - 436.66.2 (P,0.01). Differentiation index increased due to
decrease of types 1 and 2 transient cells and increase of surface cells, especially
acaryotes. Differentiation index high level was proved by signifcant cell
keratinisation index - 22.22.1 which exceeded the norm by several times -
0.60.09 (P,0.01). Differentiation and cell keratinisation indexes of epithelium
signifcantly decreased on the 6 and 12 days of treatment by drugs of metformin
and sulfanilureal groups (P,0.01), but did not reach the norm. Strong correlative
connection was discovered between studied cytological indexes and blood
glucose level on the 2, 6 and 12 days of treatment. In this way, non-invasive
cytological method allows to diagnose and monitor the compensation level of
metabolic processes in type 2 diabetes mellitus and reduce the period of its
control. This method is simple enough and can be used in any standard
morphological laboratory, it is comparatively cheep.
P320
Calcaneal spur incidence is increased in patients with type 2 diabetes
mellitus
Aydogan Aydogdu
1
, Halil Akbulut
2
, Gokhan U
ckaya
1
,
Abdullah Taslipinar
1
, Y Alper Sonmez
1
, U
mit Aydogan
2
& Mustafa Kutlu
1
1
Department of Endocrinology, Gulhane School of Medicine, Ankara,
Turkey;
2
Department of Family Medicine, Gulhane School of Medicine,
Ankara, Turkey.
Obesity is a risk factor for calcaneal spur (CS) formation which is supposed to
originate from chronic plantar fasciitis. But histological fndings support the
thesis that 'plantar fasciitis` is a degenerative fasciosis without infammation.
Diabetes mellitus may contribute to the risk of CS by decreased ability of tissue
repair and increased reactive ossifcation. Thus, we aimed to determine CS
incidence in asymptomatic obese subjects with and without type 2 diabetes
mellitus. Ninety-three obese patients with type 2 diabetes mellitus (T2DM) and
42 obese subjects without any metabolic disturbances as control were evaluated
with lateral calcaneal X-ray in blinded fashion by a radiologist. All participants
were informed and written consents have been obtained. Control subjects were
subjected to 75 g glucose challenge test and glucose intolerant subjects were
excluded. Glycolysed hemoglobin levels were tested by high performance liquid
chromatography method. Characteristics were appropriately compared by
Mann-Whitney U or
2
-tests. T2DM and control groups were statistically similar
in mean age (5910.5 vs 558 years, P0.196, respectively) and mean body
mass index (BMI) (35.14.3 vs 33.13.3 kg/m
2
, P0.073, respectively).
Existence of calcaneal spur was 72 in 93 patients (77%) in T2DM group and 24 in
42 (57%) in control group. Groups were signifcantly different according to
existence of CS (P0.023). No signifcant relation was observed between
existence of CS and glycolysed hemoglobin levels, diabetes duration, BMI
(all P0.05) in T2DM group.
A recent study reported that incidence of CS 13.2% in general population and
39% of the cases were asymptomatic. Obesity and occupational exposure to
pressure on the heel are major causative reasons for CS, but our results emphasize
its frequency in patients with T2DM. Clinicians should pay attention the
increased incidence of CS in patients with T2DM to avoid foot complications.
P321
Analysis of the clinical course of patients with type 2 diabetes mellitus
from onset of insulin treatment (EDIN study): baseline characteristics
of patients
Angel Rodri guez, Elena Caveda & Jesus Reviriego
Clinical Research Department, Lilly Spain, Madrid, Spain.
Introduction
The EDIN study evaluated the clinical course of patients with type 2 diabetes
mellitus (T2DM) from the start of the insulin treatment to a minimum of 5 years,
within routine clinical practice in Spain.
Objective
To describe the characteristics of patients at onset of insulin treatment.
Methods
Observational study that consecutively included patients with T2DM, 30 years
old and treated with insulin for at least 5 years. Data were collected
retrospectively in 2008 from patients` clinical records.
Results
Fifty-three sites participated in the study. A total of 405 patients were enrolled and
377 were included in the analysis (52.0% males; mean age (S.D.) 65 (9.1) years;
mean body mass index (S.D.) 29.9 (4.7) kg/m
2
). Mean time from onset of T2DM
(S.D.) was 8.8 (6.9) years. Almost two-thirds of the patients had family history of
T2DM. Insulin treatment pattern showed that 48% of the patients were prescribed
human basal insulin and 29.4% were treated with premix human insulin. Three
hundred sixty patients (95.5%) were being treated with oral antidiabetic
medications. Collection of cardiovascular risk factors showed that 50% of
the patients presented overweight (75.1%), hypertension (50.4%) and dyslipide-
mia (59.2%); however, 60.2% of the patients were non-smokers. Microvascular
complications were identifed in 121 (32.1%) patients and the most frequent
conditions were diabetic retinopathy (n92, 76.0%), diabetic nephropathy
(n46, 38.0%) and diabetic neuropathy (n41, 33.9%). Macrovascular
complications were present in 66 patients (17.5%), among which coronary artery
disease (n38, 57.6%) and cardiovascular disease (n28, 42.2%) were the most
common conditions.
Conclusion
Patient characteristics at onset of insulin treatment showed family history of
T2DM, high presence of cardiovascular risk factors and micro/macrovascular
complications. Most of the patients were prescribed human basal insulin or
premix human insulin, showing treatment pattern in routine clinical practice in
Spain at that moment.
P322
Badly controlled hyperglycaemia provokes arrhythmia and may
increase cardiovascular risk in diabetic patients
Ivan Smirnov, Irina Ilchenko & Larysa Zhuravlyova
Kharkov National Medical University, Kharkov, Ukraine.
Cardiovascular risk (CR) in patients with diabetes mellitus (DM) is high.
Arrhythmias (Ar) could increase CR as well. We aimed to defne is there any
association between hyperglycemia and incidence of Ar. We studied 137 (75 F/62
M) type 2 diabetic patients with coronary artery disease (CAD). The age was
54.05.5 years (MS.D). The CAD and DM duration ,10 years was in 64
(47%) and in 47 (34%), 15 years and above - in 21 (15%) and in 34 (25%)
respectively. Seventy-seven patients (Group 1) had got A1c10%. Sixty controls
with A1c,7% were enrolled in the Group 2. Groups were matched for gender,
age and CAD duration. No signifcant differences in either serum total cholesterol,
triglycerides, HDL-C, or the history of myocardial infarction between groups
were found. Groups differed in serum potassium level (3.980.19 vs 4.040.16;
P,0.05). In 29 (38%) patients from Group 1 and in 13 (22%) patients from
Group 2 Ar were sustained and clinically seen (P,0.05), in 71 (92%) patients
from Group 1 and in 47 (78%) from Group 2 (P,0.05) Ar were sporadic and
found after 24-h ECG monitoring. There were episodes of atrial fbrillation in 57
vs 32 (P,0.02), atrial extrasystolia single in 64 vs 45 (NS) and group in 58 vs 34
(P,0.05), ventricular extrasystolia single in 61 vs 38 (P,0.05) and group in 51
vs 29 (P,0.05), atrial in 48 vs 22 (P,0.01) and ventricular tachyarrhythmia in
29 vs 13 (P,0.05), early ventricular extrasystolia in 27 vs 13 (NS) and early
atrial extrasystolia in 36 vs 17 (P,0.05) patients of Group 1 and Group 2
respectively. We concluded the glycaemic control is associated with Ar
incidence, and this could contribute to the higher CR in DM.
P323
Etiologies of patients admitted to emergency department with
hypoglycemia
Hakan Eren
1
, Haci Mehmet Caliskan
1
, Fatih Kilicli
2
, Ilhan Korkmaz
1
,
Fettah Acibucu
2
& Sebila Dokmetas
2
1
Deparment of Emergency, Cumhuriyet University, Sivas, Turkey;
2
Cumhuriyet University, Endocrinology and Metabolism, Sivas, Turkey.
Introduction
Hypoglycemia is the most common endocrinological problem in emergency
departments.
Objective
To explore the causes of hypoglycemia in patients who were admitted to the
emergency department with symptoms resembling hypoglycemia.
Design
In our study, 225 hypoglycemia cases were evaluated from January 2000 to
May 2008.
Results
Of 225 hypoglycemia cases, 158 (70.2%) receiving treatment for diabetes
mellitus are the most common group (94 using insulin, 55 receiving oral anti-
diabetics (OAD), and 9 using both OAD and insulin). Among other reasons, there
are reactive hypoglycemia cases (11.6%), insulinoma (2.7%), malignancies
(2.2%), Sheehan syndrome (0.9%), chronic liver disease (0.9%), gestational
diabetes mellitus (0.4%), OAD use by mistake (3.6%), and use of OAD for
suicidal purposes (13%). In eight of the cases, the reason cannot be identifed.
Conclusion
Diabetes mellitus is the most common reason for hypoglycemia in patients seen in
emergency departments. Efforts should be made as to prevent hypoglycemia
through training patients on better grounds.
Key words: emergency department, hypoglycemia, endocrine emergency.
P324
Dose~response characteristics for effects of insulin in patients with type
2 diabetes and severe insulin resistance: evidence for the utility of high
doses of insulin
Ulla Kampmann
1
, Pernille Hyem
1
, Anette Mengel
1
, Lotte rskov
2
& Niels Mller
1
1
Medical Department M, Aarhus University Hospital, Aarhus, Denmark;
2
Medical Department, Silkeborg Regional Hospital, Silkeborg, Denmark.
Background
To avoid the serious complications of diabetes glucose control must be tackled
aggressively in type 2 diabetes. However some patients with type 2 diabetes are
severely insulin resistant and although they are treated with large doses of insulin
their blood glucose is still not optimally controlled.
Aim
This project aims to determine the dose-response to insulin in patients with type 2
diabetes and severe insulin resistance.
Design and methods
The study is a single-blinded, randomized crossover study. We included eight
individuals with type 2 diabetes treated with more than 100 IU insulin/day. The
study protocol was reviewed and approved by the regional ethical committee. To
assess the dose-response to insulin the hyperinsulinemic-euglycemic clamp
method was used. The patients were studied on two occasions. On each occasion
the patients were given two sequential infusions of insulin at two different rates,
each for 3 h. Each patient was thus given four different doses of insulin (0.5, 1.5,
3.0 and 5.0 mU/kg per min).
Results
On average our patients were treated with 186 IU insulin/day, ranging from 106 to
264 IU/day.
The mean exogenous glucose infusion rates over the last 30-min period during the
0.5, 1.5, 3.0, and 5.0 mU/kg per min insulin infusions were 0.40.2 (S.E.M.),
2.60.6, 3.70.8, and 4.90.9 mg/kg per min, respectively.
Conclusion
Our results show that patients with severe insulin resistance respond to insulin
treatment, and even at very high insulin doses (5.0 mU/kg per min), a dose-
response effect is maintained. It therefore seems reasonable to increase insulin
doses in patients with severe insulin resistance in order to obtain optimal
metabolic control.
P325
Interrelation of changes of interval QT and indexes of metabolic control
in children with diabetes mellitus type 1
Galina Meraai & Angelika Solntseva
First Department of Pediatry, Belarus State University of Medicine, Minsk,
Belarus.
The basic manifestations of dystrophic changes in heart of children suffering from
diabetes mellitus type 1 (DM1) are disturbances of repolarization and
depolarization processes, including QT and QTc intervals prolongation. Research
objective: to evaluate indices of QT and QTc in children with DM1, to reveal
interrelation of the given changes with the duration of disease, age, sex, levels of
cholesterol (CH), of glycemie, BMI, blood pressure, pulse rate.
QT and QTc were evaluated on ECG in 164 children with DM1 (middle age
13.40.92 years, duration of disease 5.850.89 years). Level of HbA1c made
up 9.650.51% (N to 7.5%; P,0.0005) and in 60 sex- and age-matched healthy
children. Blood pressure, pulse rate were measured, level of CH was defned.
Results
QT and QTc are increased in children with DM1 in comparison with control
group (363.518.5 and 421.1312.5 ms, 352.9715.1 and 392.7313.0 ms
respectively, P,0.00025). The syndrome of early ventricular repolarization was
revealed by ECG in 54.27% of children suffered from DM1, phenomenon of
shortened PQ interval - in 21.95% of those children, changes in myocardium of
left ventricule - in 39.02% of patients, infringement of conductivity - in 49.4%
(6.67%; 10%; 13.33%; 28.3% in healthy children respectively). Values of QTc in
girls with DM1 are higher than that values in boys (425.3614.8 vs 416.24
14.8 ms, P,0.00025). Connection of QTc with age (r0.334, P,0.001)
and level of HbA1c (r0.37, P,0.0005) was established. Feedback connection
of QT with pulse rate was revealed (r0.48, P,0.0005). Reliable correlation
between QTc and values of BMI, level of CH, duration of the disease and values
of systolic and diastolic blood pressure was not established.
Conclusions
The increase of QT and QTc is noticed in children with DM1 caused. Age, level of
glycemie, pulse rate and sex are the factors defning values of QTc.
P32
Pancreatic insulin secretion in women with polycystic ovary syndrome
Jana Vrbikova, Radovan Bilek, Marketa Vankova, Karel Vondra
& Bela Bendlova
Inst Endocrinology, Prague, Czech Republic.
Aim
To study the insulin sensitivity and secretion in women with polycystic ovary
syndrome (PCOS).
Thirty-eight women with PCOS (age 26.14.1 years, BMI 20.92.0 kg/m
2
) and
81 control healthy women (age 25.85.2 years, BMI 21.12.3 kg/m
2
)
underwent oral glucose tolerance test (OGTT). Insulin resistance was evaluated
as oral glucose index (OGIS); Matsuda and HOMA-IR, insulin secretion was
calculated with our own deconvolution method based on
1
. The time (in min) when
blood glucose returned to the basal concentration was calculated for each subject
and is marked as T.
Results
PCOS had higher levels of blood glucose (0-Tmin: 715.8315 vs 594.9
262.5 nmol/l, P,0.04), insulin (0-Tmin: 34.818 vs 2421.6 nmol/l;
0-180 min: 43.915.8 vs 34.621.3 nmol/l; P,0.03) and C-peptide (0-Tmin:
263.9123.4 vs 210.9121.9 nmol/l, P,0.03; 0-180 min: 376.770 vs
343.794.3 nmol/l; P,0.05) and had higher calculated pancreatic insulin
secretion (0-Tmin: 246.978.4 vs 213.772.7 nmol/l, P,0.02; 0-120 min:
25029.3 vs 239.826.8 nmol/l; P,0.07). On the other hand, HOMA-IR,
Matsuda and OGIS did not signifcantly differ between PCOS and controls.
Conclusions
Increased insulin secretion is present in lean women with PCOS even when
insulin sensitivity is not decreased in comparison with healthy women.
Supported by grant IGA MH CR NS/9839-4 and NS/9831-4.
1. Van Cauter E, Mestrez F, Sturis J & Polonsky KS. Estimation of insulin
secretion rates from C-peptide levels. Comparison of individual and standard
kinetic parameters for C-peptide clearance. Diabetes 1992 41 (3) 368-377.
P32I
Chitotriosidase activity predicts endothelial dysfunction in type 2
diabetes mellitus
Cem Haymana
1
, Alper Sonmez
2
, Serkan Tapan
3
, Umut Safer
1
,
Gurkan Celebi
1
, Ozlem Ozturk
3
, Halil Genc
1
, Teoman Dogru
5
,
Ilker Tasci
1
, Gokhan Erdem
1
, Abdullah Taslipinar
2
, Aydogan Aydogdu
2
,
Mahmut I Yilmaz
4
, Ismail Kurt
3
& Mustafa Kutlu
2
1
Internal Medicine, Gulhane School of Medicine, Ankara, Turkey;
2
Endocrinology, Gulhane School of Medicine, Ankara, Turkey;
3
Biochem-
istry, Gulhane School of Medicine, Ankara, Turkey;
4
Nephrology, Gulhane
School of Medicine, Ankara, Turkey;
5
Gastroenterology, Gulhane School of
Medicine, Ankara, Turkey.
The enzyme chitotriosidase (ChT) is secreted by activated macrophages and play
active role in human immune response. ChT activity is increased in
atherosclerosis in association to the extent of the disease. We investigated the
relevance of ChT to endothelial functions and insulin resistance in patients
with T2DM.
Forty newly diagnosed and untreated patients with T2DM (male 17; age: 47.0
6.2 years) and 50 healthy volunteers (male 21; age: 50.28.8 years) were
enrolled. Plasma asymmetric dimethyl arginine (ADMA) levels were determined
by ELISA. ChT activity was measured by the fuorescence method. Insulin
resistance was calculated by the HOMA-IR formula.
The patients had higher systolic blood pressures, HOMA-IR, ADMA levels and
ChT activities (P,0.001 for all) and lower HDL cholesterol levels (P0.03)
than the control group. The ChT activities of the total group were signifcantly
correlated to the age (r0.031, P0.003), ADMA (r0.22, P0.04) and
plasma glucose levels (r0.27, P0.01). ChT was the independent determinant
of the plasma ADMA levels (r0.26, P0.02).
The results of the present study show that serum ChT activity is increased in
patients with newly diagnosed, untreated and uncomplicated patients with T2DM.
The results also imply that increased ChT activity may be a predictor of
endothelial dysfunction.
P328
Follow up of type 1 diabetic patients treated with insulin continuous s.c.
infusion
Victor M Andia, Elisa Fernandez, Antonino Jara, Rogelio Garcia,
Marcel Sambo & Diego A Lezcano
Hospital General Universitario Gregorio Maranon, Madrid, Spain.
Insulin continuous s.c. infusion (ICSI) is an alternative therapy in selected
diabetic patients when a good metabolic control is not achieved with multiple
insulin doses (MID). We report the follow-up of patients with ICSI at least during
1 year in our centre.
Twenty-fve patients (16 females, 9 males), with median age 38.412.5 years
and diabetes evolution mean time 16.87.8 years, were changed from MID to
ICSI due to defcient metabolic control (52%), non-correctable hypoglycemia
(28%) or gestation planning (20%).
Clinical and analytical revisions were done each 31 months during the frst 1.5
year and each 61 months thereafter.
One patient was missed 9 months after starting ICSI, reappearing 2 years later;
none patient left ICSI for any reason.
Weight (BMI), HbA1c and insulin dosage (U/kg per day) were registered in all
visits. Student`s t-test was used for comparisons with the basal values.
Results
A signifcant reduction in HbA1c levels along the frst year was observed, from
8.261.4 to 7.300.75%, remaining stable in the following revisions. Insulin
requirements followed a similar evolution, with reduction from 0.710.24 U/kg
per day to 0.530.14 at the end of the frst year.
A slight weight gain was observed, with a BMI increase from 24.533.11 to
25.323.79, but also remained stable afterwards.
There were no greater hypoglycemia frequency nor any other problem associated
with ICSI.
Conclusions
In our patients, ICSI therapy produces a signifcant and sustained reduction of
HbA1c levels that could be long-term cost-effective. The only secondary effect
observed is a slight weight gain produced in the frst 12 months and stable
afterwards.
P329
Effects of ghrelin treatment to promote proliferation of pancreatic islet
in BB rats
Maria Gloria Baena, Isabel Maria Lomas-Romero, Gonzalo Perez-Arana,
Manuel Blandino-Rosano, Carmen Segundo, Manuel Aguilar-Diosdado
& Alfonso M Lechuga-Sancho
Puerta del mar University Hospital, Cadiz, Spain.
Aims
BB rats develop diabetes as young adults by an autoimmune mechanism. Ghrelin
is a peptidic hormone synthesized mainly in the oxintic cells of the gastric
mucosae in adults. During intrauterine life however, this peptide is synthesized
mainly at the pancreas. Ghrelin exerts proliferative and survival promoting effects
in different cell types. We investigated the effect of ghrelin treatment in a diabetes
autoimmune animal model to analyze death rate and cellular proliferation of the
-cells in the pancreatic islets.
Methods
BB rats received ghrelin subcutaneously once a day at 10 ng/kg, since postnatal
week 4. Non treated animals received the same volume of buffer. Animals were
daily weighed and their diuresis and intake monitored. Glycaemia was measured
weekly. Animals were killed at postnatal weeks 5, 7, 9 and 11. Pancreata were
dissected and immediatelly frozen in liquid nitrogen and conserved at 80 ?C
until sectioned. Pancreata were sliced in eight micron-thick slices using a
cryostat. Infltrates were quantifed using hemotoxylin-eosin staining. -Cell
proliferation and apoptosis rate were assessed by BrdU and TUNEL
inmunuhistochemistry. Fifty islets were counted per animal.
Results
No animal became diabetic before week 10. On week 10, three out of the four BB
non treated rats presented diabetic onset (75%) and none of the fve BB rats
receiving ghrelin did (P,0.008). No different effects on weight gain, diuresis and
glycaemia until diabetes onset was found. Ghrelin treatment increased the number
of replicating cells from week 9 and 10. We found no difference in the
infammatory infltration of islets and the rate of apoptosis.
Conclusions
These fndings indicate that ghrelin promote proliferation of -cell in BB rats.
This suggests ghrelin plays a role in the control of islet cell survival. However,
this effect dies not seem to be mediated by modulation of the inmune response.
P330
Lipid prohle in patients with ST-segment elevation myocardial
infarction with or without diabetes
Violeta Mladenovic, Aleksandar Djukic, Jelena Petrovic
& Vladimir Zdravkovic
Clinical Center Kragujevac, Serbia, Kragujevac, Serbia.
Hyperlipidemia is common among patients with ST-elevation myocardial
infarction (STEMI) and is associated with high risk of mortality and morbidity.
Hypertriglyceridemia and low HDL cholstereol are independent risk factor for
cardiovascular disease.
Aim
The aim of this study is to analyse lipid profle in patients with STEMI with and
without diabetes.
This study included all patients registered in Coronary Unit, Department of
Cardiology, Clinical Center Kragujevac during 6 months. Patient`s lipid profle
was measured on admission: total cholesterol (tChol), LDL, HDL and
triglycerides (TAG).
Results
We studied 115 patients admitted consecutively with STEMI. There were 29
patients with previous diabetes. The majority of patients in the study were males
(69.6%). The mean age of patients was 64.2510.69 years. Anamnestic, only
13% STEMI patients had previous lipid disorder. According to National guideline
clinical practise criteria: 53.3% had increased tChol level, 47.7% increased LDL
35.8% increased TAG i 63.8% decreased HDL cholesterol level. There is
statisticaly signifcance in average tChol level (diabetics versus nondiabetics):
(5.171.48 vs 4.691.66 mM, P0.015), as well as LDL (3.271.23 vs
2.891.29 mM, P0.017), but there is no signifcance in TAG (1.781.05 vs
1.771.06 mM, P0.05) and HDL (1.090.35 vs 1.030.28 mM, P0.05).
Conclusion
Patients with diabetes mellitus have higher levels of tChol and LDL cholesterol
than patients without diabetes with STEMI. Our study showed not satisfed
liporegulation in STEMI patients, especially in patients with diabetes.
P331
Transient insulin resistance during the laparoscopic versus open
cholecystectomy
Dusan Micic Jr
1
, Snezana Polovina
3
, Jelena Micic
2
, Zlatibor Loncar
1
,
Dragan Micic
4
& Vladimir Djukic
1
1
Emergency Center Serbia, Belgrade, Serbia;
2
Clinic for Gynecology and
Obstetrition, Clinical Center Serbia, Belgrade, Serbia;
3
General Hospital
Subotica, Subotica, Serbia;
4
Clinic for Endocrinology, Diabetes and
Metabolic Disease Clinical Center Serbia, Belgrade, Serbia.
Aim
The aim of our study was to investigate is surgical stress induce alterations in
insulin sensitivity in the course of cholecystectomy performed in two differnt
procedures: as a open surgery and as laparascopic operation.
The homeostasis assessment model (HOMA) was used to determine insulin
sensitivity before and in the frst, third and seventh day after the operation.
Patients were divided int two groups: group A (open cholecystectomy; n8;
mean age 38.03.3; mean BMI 26.89381.5679) and group B (laparoscopic
cholecystectomy; n7; mean age 39.64.1; mean BMI 26.58671.8531).
Results
There were no diferences in HOMA index between group A and B before the
operation (mean 2.40100.3230 vs 1.97980.6985; P0.05) as well as for day
1 (2.54480.6044 vs 1.83700.5714; P0.05) and day 7 (0.64940.4349 vs
0.72320.3898; P 0.05). Group B had higher HOMA index at day 3 (7.5619
2.3360 vs 2.80160.7670; P,0.05).
Conclusion
There is transient increase in HOMA index after the operation in both procedures,
compatible with deterioration in insulin sensitivity due to stress-response that is
normalized a week after the operation.
P332
The mean HbA1c values in T2DM according a therapy regiments
Snezana Polovina
1
, Klara Tucic Nemet
1
, Dusan Micic
2
, Jelena Micic
2
& Dragan Micic
2
1
General Hospital Subotica, Subotica, Serbia;
2
Clinical Center Serbia,
Belgrade, Serbia.
Aim
To calculate mean HbA1c values in patients with type 2 diabetes mellitus in
different therapy regiments.
Ninety-nine diabetic persons was divided in three groups: group I (n33) on oral
hypoglucemic agents, group II (n33) on one or two doses of insulin and group
III (n33) on intensive insulin therapy. We have calculated the mean values of
HbA1c on the begining and 6 months after start of therapy regiment.
Results
The mean HbA1c value in group I was 8.92% (3.2), in group II 6.88% (2.1),
in group III 7.5% (3.3). HbA1c after 3 months in group I was increased 8.7%
(P0.05), in group II decreased 22.7% (P,0.05), in group III also decreased
20.1% (P,0.05). Good glycemic control (HbA1c ,7.0%) was in 10% patients in
group I, 57% in group II and 33% in group III.
Conclusion
The patients with one or two doses of insulin had the best metabolic control, and
there was signifcant improvement of glycoregulation a short time after insulin
administration in patients with secondary failure of oral agents. The worst control
had the patients on oral agents possible due to sub dosing of oral agents and delay to
combine therapy with two or three agents. The patients on intensive insulin therapy
had less improvement of glycoregulation perhaps because the 6 months is a short
time to establish better metabolic control in patients with high start value of HbA1c.
P333
Therapy with exenatide: our experience
Ignacio Fernandez, Cristobal Morales, Juan Manuel Garcia De Quiros,
Monica Tome, Clara Garcia, Isabel Serrano, Carmen De La Cuesta
& Angel Sendon
Virgen Macarena Hospital, Seville, Spain.
Objectives
Verify the effcacy of the GLP-1 analogue exenatide in patients with type 2 DM
assisted in our hospital area.
This study included patients who initiated this therapy in 2008 and 2009. Through
3 months were analyzed the outcomes of weight, HbA1c and the development of
adverse effects.
Results
The process included 32 patients, 21 men and 11 women, with ages between 26
and 73 years old (mean age 48.78 years) and mean DM evolution of 6.25 years.
Prior to introducing exenatide 35% of them were in treatment with one single type
of oral antidiabetic drug, 44% with two oral drugs and 20.6% with three oral
drugs. Initial data were weight (109.924.1 kg), BMI (38.586.4 kg/m
2
), and
HbA1c (8.241.8%). During the frst month of follow up, the mean weight
reduction was 2.62.2 kg, reaching in 3 months 6.64.9 kg. This difference was
statistically signifcant (P,0.01 Wilcoxon test). HbA1c showed a decrease of
1.61.4 points in 3 months (P,0.01 Wilcoxon test). 18.7% of patients had mild
adverse effects (nausea, dyspepsia) at the beginning of therapy, while in two of
them had to be retired because of emesis.
Conclusions
In general exenatide showed an important improvement of weight reduction and
glycemic control, being in most cases well tolerated by our obese type 2 DM
patients. Nevertheless, would be necessary a long-term study to confrm these
hopeful results.
P334
Prevalence of metabolic syndrome and diabetes mellitus type 2 under
the conditions of the primary component of public health
Barno Shagazatova, Viktoria Stareva & Gavhar Mukhiddinova
Tashkent Medical Academy, Tashkent, Uzbekistan.
Background and aims
The metabolic syndrome (MS) - pathology, that is in the center of the attention of
endocrinologists, cardiologists and therapeutics, is frequently diagnosed with the
development of vascular complications, or of diabetes mellitus type 2 (DMT2).
The aim of the present study is to investigate the occurrence of MS, according to
IDF (2005) and DMT2 according to criteria WHO (1999) under the conditions of
the primary component of public health.
The study of MS and DMT2 were conducted on the base of family polyclinic No.
37 in Tashkent-city in 2008. By random sampling method, there were selected
two sectors, where the people older than 35 years, living within the area, operated
by this polyclinic fell under the overall observation. Totally there were examined
628 people.
If body mass index (BMI) 30 kg/m
2
and more the diagnosis of obesity is made.
DMT2 and impaired glucose tolerance (IGT), 75-g glucose, were diagnosed
according to the WHO (1999) classifcation. The checkup showed dyslipidemia
(DL): total cholesterol (TCH) 5.2 mmol/l; triglyceride (TG) 1.7 mmol/l.
Waist circumference (Wc) is more then 94 cm males and 80 cm females;
abdominal index (AI) 0.95 for the men and 0.8 for the women is defned as
abdominal obesity (AO). MS was diagnosed at the presence of all the four criteria
and/or central obesity and two additional criteria IDF (2005).
Results
The investigation showed that among the checked up the occurrence of MS with
its different components reached 9.6%. The people with DMT2 were not
included. The newly revealed patients with DMT2 amounted to 4.1%.
Conclusion
Thus, the investigation showed that the occurrence of the MS under the
dispensary-polyclinic conditions composed 9.6%, DMT2 - 4.1%.
P335
Adiponectin time dependence secretion under 3 agonist, PPAR agonist
treatments
Jiri Hodis & Hassan Farghali
First Faculty of Medicine, Institute of Pharmacology, Charles University,
Background and aims
Adiponectin produced by visceral adipocytes is believed to be marker of insulin
sensitivity. Glitazones (PPAR agonists) induce adipocetin transcription and
secretion. 3 agonists are potencial antiobesity drugs with lipolytic activity. We
try to shed light on the relationship between PPAR, 3 signaling, and
adiponectin secretion.
Methods
Epididymal rat adipocytes were isolated and cultivated together with troglitazone
(PPAR agonist), BRL-37344 (3 agonist) alone and in combinations. After 1, 2,
12, 24, 48, 72 h, culture media were analyzed via ELISA for adiponectin level.
Results
Adiponectin reacted as expected to glitazone addition (adiponectin increased,
resistin decreased) after more than 24 h incubation. However, adiponectin level
was paradoxically decreased after 24 h but increased more than control after 48 h.
Interestingly BRL-37344 produced remarkable increase of adiponectin in 1 h of
cultivation with subsequent decrease to control level in 2 h. That means 3
agonist could enhance secretion of adiponectin as a very soon response. The
adiponectin level under PPAR agonist treatment remains in control level in frst
2 h. The two substances did not show signifcant interactions mediating
adiponectin secretion.
Conclusions
The time dependence of adiponectin secretion in response to Troglitazone is
demonstrated. 3 agonist effect on adiponectin secretion in visceral rat adipocytes
is described. The secretion of adiponectin is not modulated by PPAR3
interactions. Supported by VZ MSM 0021620807.
P33
Therapeutic objectives in the care of patients with diabetes mellitus type
2 in clinical practice at an endocrine department
Carmen Tenorio Jimenez
1
, Pablo Jose Lopez Ibarra
2
, Manuel Romero
Munoz
2
& Maria Jimenez del Valle
2
1
Hospital General de Ciudad Real, Ciudad Real, Spain;
2
Hospital Clinico
San Cecilio, Granada, Spain.
According to the American Diabetes Association (ADA), achieving specifc
treatment goals in type 2 diabetes can substantially reduce microvascular
complications, including retinopathy, nephropathy and neuropathy. Intensive
management has also been shown to have a benefcial effect on cardiovascular
disease. The objective of the study is to evaluate the degree of achievement of
appropriate target levels for A1C, as an index of chronic glycaemia, LDL-c and
blood pressure, in a large and homogeneous sample of type 2 diabetes patients,
evaluated periodically in an endocrine service. The study reviewed the clinical
and biochemical data of 200 adults with type 2 diabetes, diagnosed using ADA
criteria and followed by a specifc diabetes unit. The primary endpoints were
HBA1c B7%, blood pressure (BP) B130/80 mmHg and LDL-c B100 mg/dl. It
was also collected measures of body mass index (kg/m
2
) and waist (cm) and
reports about additional medical treatments: the use of statins, lowering pressure
medications and insulin therapy.
The mean age of the 200 patients was 61.110.2 years of which 53% were
female. The mean duration of diabetes was 11.79.4 years. 45.5% of the patients
were on insulin-therapy, 56% were on statins and 62.5% were on lowering-
pressure therapy. The mean body mass index (BMI) was 32.96.7 kg/m
2
; the
mean waist was 109.712.9 cm in men and 102.4016.5 cm in women.
(Table 1: baseline characteristics). 6.83% of patients achieved their HbA1c, LDLc
and BP targets; 17.17% achieved their combined HbA1c and BP targets and
24.22% their HbA1c and LDL-c goals. Target HbA1c was met by 44.7% of
patients. In conclusion, a high percentage of the patients treated by the Endocrine
Department achieved an optimal glycaemic control (HbA1cB7%). However,
when BP and lipids were evaluated together this percentage dropped, despite the
concomitant treatment with statins and lowering-pressure therapy. Therefore, the
study shows that it is essential to intensify the treatment of type 2 diabetes
patients, specially that one related to BP and lipids.
P33I
The effect of short-term metformin therapy on C-reactive protein and
insulin sensitivity in newly diagnosed patients with type 2 diabetes
mellitus
Dragan Micic
1
, Mirjana Sumarac Dumanovic
1
, Danka Jeremic
1
,
Goran Cvijovic
1
& Snezana Polovina
2
1
Clinic of Endocrinology, Diabetes and Diseases of Metabolism, Clinical
Center of Serbia, Belgrade, Serbia;
2
General Hospital Subotica, Subotica,
Serbia.
C-reactive protein (CRP) is closely associated with obesity and cardiovascular
disease in both diabetic and nondiabetic subjects. The aim of our study was to
investigate the effects of commonly prescribed antidiabetic agent metformin on
CRP and insulin sensitivity in type 2 diabetes patients after 12 weeks of therapy.
Twenty-three newly diagnosed type 2 diabetic patients (mean age: 49.742.03
years; mean BMI: 31.401.27 kg/m
2
) have been given metformin 2 g/day and
bA1c, HOMA-IR and hs-CRP were assessed at the baseline and after 12 weeks of
therapy. HbA1c was signifcantly decreased after 12 weeks of therapy (baseline
versus 12 weeks: 7.570.32 vs 6.140.14%, P,0.05), HOMA-IR index was
signifcantly improved (baseline versus 12 weeks: 10.821.68 vs 7.27
1.74 mmol,mU/l, P,0.05) while hs-CRP was decreased after 12 weeks of
metformin therapy (baseline versus 12 weeks: 6.840.83 vs 5.961.09 g/l,
P0.05). Baseline hs-CRP was not signifcantly correlated with homeostasis
model assessment of insulin resistance (HOMA-IR), HbA1c, BMI, waist
circumference, and waist-to-hip ratio. The change in hs-CRP values from
baseline to 12 weeks was not correlated signifcantly with changes in BMI,
HbA1c or HOMA-IR. In conclusion, 12 weeks of metformin treatment was
associated with signifcant reductions in HbA1c levels and insulin sensitivity
independent of changes in hs-CRP, implying other possible mechanism that could
infuence synthesis or secretion of CRP.
P338
Vitamin D and glycaemic control
Ifgenia Kostoglou-Athanassiou
1
, Razvan Alexandros Badila
1
,
Panagiotis Athanassiou
2
, Aikaterini Michou
1
1
,
Dimitris Stefanopoulos
1
, Thomais Terzi
1
& Areti Karf
1
1
2
Introduction
Research results from different countries show that vitamin D defciency is a
modern reality, affecting even sunny countries. Vitamin D defciency has been
related to predisposition to the development of diabetes mellitus type 2 and it may
affect the secretion and action of insulin.
Aim
The aim was to study the effect of vitamin D on glycaemic control in patients with
diabetes mellitus type 2.
The levels of HbA1c and 25(OH)vitaminD
3
(25(OH)D
3
) were measured in 132
patients with diabetes mellitus type 2 (aged 37-80 years) and 61 control subjects
aged 23-77 years.
Results
HbA1c levels were 7.240.17% (meanS.E.M.) and 5.050.06% in diabetes
mellitus type 2 patients and control subjects, respectively. Levels of 25(OH)D
3
were 20.350.97 and 25.841.59 ng/ml in diabetes mellitus type 2 patients and
control subjects, respectively. A reverse relationship was observed between the
levels of HbA1c and 25(OH)D
3
in diabetes mellitus type 2 patients (linear
regression analysis, P,0.005) and in the control subjects (linear regression
analysis, P0.005). The reverse relationship between HbA1c and 25(OH)D
3
persisted when the results of diabetes mellitus type 2 patients and the control
subjects were pooled and analyzed together (linear regression analysis, P,0.001).
Conclusion
These results show that patients with diabetes mellitus type 2 had lower vitamin
D
3
levels than the control subjects and that patients with poorly controlled
diabetes mellitus type 2 had lower vitamin D
3
levels than the better controlled
ones. Blood glucose values in both the diabetic and the control subjects appear to
be inversely related to vitamin D
3
levels. It appears that 25(OH)D
3
affects
glycaemic control in patients with diabetes mellitus 2.
P339
Maternal obesity and gestational diabetes mellitus
Anargyros Kourtis, Athina Giomisi, Kali Makedou, Maria Mouzaki,
Ioannis Kalogiannidis, Alexandros Traianos, Nikolaos Prapas
& Theodoros Agorastos
Aristotle University of Thessaloniki, Thessaloniki, Greece.
Objective
Numerous studies have reported an increased risk of gestational diabetes mellitus
(GDM) among women who are overweight or obese compared with lean or
normal-weight women. Obesity contributes to multiple health problems during
pregnancy and predisposes a woman to develop GDM. Obesity is defned as a
body mass index (BMI) of 30. Overweight is defned as a BMI of 25.0-29.9 and
normal weight is defned as a BMI 20-24.9. The aim of the present study was to
investigate BMI alterations throughout pregnancy in normal pregnancies and in
those complicated by GDM.
We studied 211 women from the outpatient clinic of metabolic disorders in
pregnancy. These women were ordered to perform the oral glucose tolerance test
(OGTT) with 75 g of glucose, between 26th and 28th week of pregnancy. In 14
(6.64%) women, GDM (two or three values above normal) was diagnosed, in 28
(13.27%) impaired glucose tolerance (IGT) (only one abnormal glucose value)
was the diagnosis and 169 (80.1%) women had normal OGTT results (controls).
Weight, height and age of the women were analyzed and BMI (weight/height
2
)
was calculated in the beginning of pregnancy (BMI-0), between 26th and 28th
week of pregnancy (BMI-1) and between 32nd and 34th week (BMI-2).
Results
Mean BMI-0 values were signifcantly elevated in women who presented GDM in
comparison to those with IGT or normal OGTT results (P,0.05). The increase in
BMI values was analogous in all three groups of pregnant women, without
statistically signifcant difference between BMI-0, BMI-1 and BMI-2 values of
women of the same group.
Conclusion
Our fndings confrm that high maternal weight is associated with a substantially
higher risk of GDM.
P340
Performances of the fully automated Liaison
systemfor determination
of insulin and C-peptide concentrations
Damien Gruson, Vanessa Preumont & Bernard Vandeleene
Cliniques Universitaires St-Luc, Brussels, Belgium.
Introduction
Circulating insulin levels are widely used to provide diagnostic information for
diabetes mellitus and hypoglycaemic syndromes. C-peptide concentration
provides an accurate assessment of residual B-cell function and reliable
information about insulin secretion in patients with diabetes. The aim of this
study was to evaluate the performances and reliability of the Liaison
fully
automated system for measurement of insulin and C-peptide concentrations.
Methods
Insulin and C-peptide concentrations were measured with the Liaison
system
(Diasorin) using immunoassays based on chemiluminescence detection. For
methods comparison, 81 patients with insulin concentrations previously
determined with the Immulite assay and 82 patients with C-peptides levels
measured by RIAs were included. The reliability of Liaison
assays was confrmed

with 135 other patient specimens requested for simultaneous determination of
insulin and C-peptide.
Results
A positive and signifcant correlation was observed between the two insulin
assays (r0.95; P,0.0001) and the Passing and Bablock regression analysis
provides a slope of 1.03 and an intercept of 1.52. The two C-peptides were also
signifcantly correlated (r0.95; P,0.0001) and the Passing and Bablock
regression analysis provides a slope of 1.29 and an intercept of 0.07. In the 135
patients followed for both parameters, mean C-peptide concentrations were 0.93,
1.35 and 1.73 pmol/ml for insulin concentrations between 3 and 10 UI/ml
(n44), between 10 and 20 UI/ml (n48) and higher than 20 UI/ml (n29),
respectively. In patients with insulin below 3 UI/ml (n13), C-peptide were
suppressed (,0.05) in eight patients and detectable in fve patients.
Conclusions
The results of this preliminary study demonstrate that the performance
characteristics of the Liaison
insulin and C-peptide assays allow their use for

the clinical assessment of diabetes, hypoglycemia and insulin secretion.
Nevertheless, larger studies are required to confrmthose results and the specifcity
of these assays.
P341
Role of regulatory T-cells in the development of the partial remission
period in patients with type 1 diabetes
Tatiana Nikonova, Vera Gorelysheva, Sergey Prokofev, Elena Pekareva
& Ivan Dedov
Endocrinology Research Center, Moscow, Russian Federation.
Background and aims
Remission period in type 1 diabetes (T1D), also known as the honeymoon period
has been acknowledged as an advantageous time for immune intervention.
However, not all subjects will go through this remission phase. It was suspected
that defects in regulatory T-cells number and activity are causally related to the
development of T1D.
The aim of the study was to fnd specifc T-cell assay that refects remission
period.
Twenty-three patients with T1D were examined in dynamics during the frst
3 years of the disease. Also 17 at-risk subjects and eight control subjects were
examined.
The HLA-DR and DQ alleles were detected by SSPPCR method. CD3, CD4,
CD8, CD25, CD4CD25, CD38, LTDRB and CD20 cells were analyzed by
fow cytometry.
Inclusion criteria for control subjects were random blood glucose ,5.6 mmol/l,
no history of any autoimmune disorder including T1D in the family and an
absence of T1D-specifc autoantibodies (aAbs). At-risk subjects had specifc aAbs
and were unrelated to the patients included in this study. T1D subjects were
defned according to WHO criteria.
Results
A rising tendency of CD25 (%) and CD4CD25 (%) T-cells between
control and at-risk subjects was observed (P,0.1). Signifcant differences were
found in content of CD38 and LTDRB cells (P,0.05) in those groups. Increased
values of CD25 and CD4T-cells (P,0.05) were detected in the group of
T1D patients with duration of diabetes ,6 months. These values were associated
with development of partial remission (HbA1c,7%; insulin requirement
B0.4 units/kg per 24 h) and increased C-peptide levels (P,0.1). On the
contrary, in longer - standing T1D (1 year) as compared with previous group in
majority of the patients CD25and CD4CD25T-cells levels were reduced
(P,0.05).
Conclusion
These results suggest that increased regulatory T-cells values seen in the recent -
onset T1D can be considered as a remission marker.
P342
Lipid prohle in women with gestational diabetes mellitus
Anargyros Kourtis, Kali Makedou, Athina Giomisi, Maria Mouzaki,
Sofa Masoura, Antonios Goutzioulis, Nikolaos Prapas
& Theodoros Agorastos
Aristotle University of Thessaloniki, Thessaloniki, Greece.
Background-aim
Increased serum cholesterol and triglycerides levels may have a role in the
development of gestational diabetes mellitus (GDM) and its complications. This
study was designed in order to provide a description of lipids profle by
gestational age during pregnancy.
We studied 211 women from the outpatient clinic of metabolic disorders in
pregnancy. These women were ordered to perform the oral glucose tolerance test
(OGTT) with 75 g of glucose, between 26th and 28th weeks of pregnancy. In 14
(6.64%) women, GDM (two or three values above normal) was diagnosed, in 28
(13.27%) impaired glucose tolerance (IGT) (only one abnormal glucose value)
was the diagnosis and 169 (80.1%) women had normal OGTT results (controls).
All women had lipid profle assessment, which included determination of total
cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL),
and triglycerides (TGs). An additional lipids test was obtained within 32nd and
33rd gestational weeks.
Results
Mean valuesS.D. of lipids are presented in the following table:
There was no statistical difference (P,0.05) in TC, HDL and LDL values of the
women of three groups in the second trimester, while signifcant difference was
observed in TGs values between controls and the other two groups (P,0.001).
Comparison of values between second and third trimester showed signifcant
increase in TC and TG in control group, whereas pregnant women with GDM
presented only signifcant increase in serum levels of TG, greater than that of
controls.
Conclusion
It is well known that hyperlipidemia of pregnancy is greater in cases of GDM. Our
results show that hypertriglyceridemia is the main lipid disorder in pregnant
women with GDM, with a remarkable increase observed between second and
third trimester.
P343
Increased insulin resistance is associated with increased urinary
excretion of chromium in non-diabetic, normotensive Saudi adults
Suhad Bahijri
1,2
& Eman Alissa
1
1
Department of Clinical Biochemistry, Faculty of Medicine, King
Abdulaziz University, Jeddah, Saudi Arabia;
2
Nutition Research Unit, King
Fahd Medical Research Center, King Abdulaziz University, Jeddah, Saudi
Arabia;
3
Saudi Diabetes Research Group, King Abdulaziz University,
Jeddah, Saudi Arabia.
Background
The role of trivalent chromium (Cr
3
) in improving glucose tolerance, and
decreasing insulin resistance is well documented in animals and humans, however
supplementation studies gave inconsistent results. Increased urinary excretion of
chromium has been reported in type 2 diabetes mellitus (DM). It was not known
whether this renal wasting had preceded DM, or was caused by it.
Aim
Our aim was to investigate the relationship between urinary chromium excretion
and the degree of insulin resistance (IR) in non-diabetic normotensive Saudi
adults; using a known index of insulin resistance; in order to clarify the above
point.
Of 357 healthy adults aged 18-50 years were recruited randomly from health
centers in Jeddah, in a cross-sectional study design. Individuals found to be
hypertensive or hyperglycemic were excluded. Anthropometric and demographic
information were taken. Insulin, glucose and free fatty acids (FFA) were
measured in fasting blood samples. Fasting urinary chromium and creatinine were
also determined. Using modifed QUICKI (MQUICKI1/(log(fasting insulin)
log(fasting blood glucose)log (fasting FFA)) and reported cutoff point, subjects
were labeled as high insulin resistant (HIR), or low insulin resistant (LIR). HIR
subjects were matched for age and sex to LIR subjects.
Results
Two hundred and nine subjects satisfed the selection criteria. Ninety-seven
subjects were found to have HIR. Matching was possible for 90 subjects. This
subgroup had higher mean BMI (P0), and waist circumference (P0.008). The
median urinary chromium(median2.92 and IQR1.5-10.28 ng/mg creatinine)
was signifcantly higher than that for LIR subgroup (0.55, and 0.27-1.38 ng/mg
creatinine) (P0).
Conclusion
Higher urinary chromium excretion in studied HIR subgroup indicates a renal
lesion leading to chromium defciency and possibly glucose intolerance and DM
eventually. Chromium supplementation might help to protect against the
development of DM in this group of HIR non-diabetic Saudi individuals.
P344
Systemic effect of insulin on local cytokine concentrations in adipose
tissue and muscle in healthy humans
Julia K Mader, Dimas Ikeoka, Heinz Weinhandl, Christoph Pachler,
Gerlies Bock, Johannes Plank, Martin Ellmerer & Thomas R Pieber
Department of Internal Medicine, Medical University Graz, Endocrinology
and Nuclear Medicine, Graz, Austria.
Introduction
Cytokines are produced in different tissues under physiological and pathophy-
siological conditions. The present study was performed to compare local
concentrations of cytokines in subcutaneous adipose tissue and muscle using the
open fow microperfusion (OFM) technique, as well as to investigate systemic
effects of insulin on interstitial concentrations of these mediators.
Methods
Ten healthy volunteers (age: 274 years, BMI: 22.61.6 kg/m
2
) underwent
hyperinsulinemic-euglycemic clamp (HEC) and saline control experiments in a
cross-over design. HEC was performed using primed continuous infusion of
insulin at a constant rate (1.2 mU/kg per min) at variable glucose infusion, aiming
to maintain blood glucose at basal levels. In each volunteer, two 18 gauge OFM
catheters were inserted into abdominal subcutaneous adipose tissue (SAT) and
GDM (d14) IGT (d28) ControIs (d169)
TC (mg/dl) 254.0075.69 276.4042.10 260.1448.00
TGs (mg/dl) 267.54142.47 270.22198.07 197.5674.86
HDL (mg/dl) 72.8512.90 71.2214.37 72.7713.95
LDL (mg/dl) 133.0062.74 150.8837.99 150.1437.83
rectus femoris muscle tissue, respectively. Both OFM catheters were perfused
with manitol solution at constant fow rate of 1 l/min. Effuent samples were
collected in microvials on ice and frozen at 20 ?C. For each study visit, pooled
samples were analyzed for the concentrations of TNF-, IL-6, IL-10, MCP-1,
adiponectin, leptin and C-reactive protein using multiplexed ELISA assays.
Results
Plasma glucose concentrations were comparable between experiments (912 vs
882 mg/dl; HEC versus saline). Expectedly, leptin concentrations were
signifcantly higher in SAT (1.21.6) versus muscle (0.30.4) tissue. No
signifcant differences were observed when comparing HEC versus saline
experiments.
Discussion
The results indicate that cytokines can be measured in SAT as well as in muscle of
healthy volunteers using OFM. The higher activation of leptin gene in SAT might
be the explanation for the observed difference of leptin between tissue sites. No
clear pro- or anti-infammatory effect of insulin on cytokine expression in
peripheral tissues was observed.
P345
Decreased serum brain-derived neurotrophic factor concentration in
young nonobese subjects with low insulin sensitivity
Monika Karczewska-Kupczewska, Agnieszka Adamska, Agnieszka
Nikolajuk, Elzbieta Otziomek, Maria Gorska, Marek Straczkowski &
Irina Kowalska
Medical University of Bialystok, Bialystok, Poland.
Insulin resistance and type 2 diabetes are associated with an increased risk of
neurodegenerative diseases. Brain-derived neurotrophic factor (BDNF) regulates
neuronal differentiation and synaptic plasticity and its decreased levels are
supposed to play a role in the pathogenesis of Alzheimer disease and other
disorders. Decreased circulating BDNF levels in obesity and type 2 diabetes were
reported, however, it is unclear, whether BDNF might be associated with insulin
resistance in young, nonobese population.
The aim of the present study was to estimate serum BDNF concentration in
apparently healthy, nonobese women divided into subgroups according to their
insulin sensitivity.
We studied 46 young (age: 25.155.16 years), apparently healthy, nonobese
(BMI: 24.022.84 kg/m
2
) women with normal glucose tolerance. Anthropo-
metric and biochemical parameters and serum concentrations of BDNF and
adiponectin were measured. Insulin sensitivity was estimated with the
euglycemic-hyperinsulinemic clamp technique. Then, participants were divided
into subgroups of high (high IS, above median from the clamp study, n23) and
low insulin sensitivity (low IS, below median, n23).
The difference in BMI and waist circumference between the groups did not reach
the level of signifcance, whereas the percent of body fat was higher in the low IS
group (P0.024). We observed decreased serum BDNF concentration in women
with low IS (P0.001), which remained signifcant after adjustment for the
difference in the percent of body fat. In the entire study population, serum BDNF
was positively related to insulin sensitivity (r0.43, P0.003). In multiple
regression analysis, this correlation remained signifcant after adjustment for
other estimated parameters. In the low IS group, relationship between serum
BDNF and adiponectin was also observed (r0.52, P0.027).
Our data show that serum BDNF is decreased in young nonobese women with low
IS. Thus, early detection and prevention of insulin resistance might be useful in
the prevention of neurodegenerative disorders.
P34
Microvascular reactivity and oxidative stress after standard breakfast
in patients with recently diagnosed type 2 diabetes
Eva Horova, Martin Prazny & Jan Skrha
Third Department of Internal Medicine, First Faculty of Medicine, Charles
University, Prague, Czech Republic.
Aim of the study
The aim of the study was to compare skin microvascular reactivity (MVR) with
oxidative stress and metabolic parameters at fasting status and postprandially in
patients with recently diagnosed type 2 diabetes.
Methods
Twenty patients with type 2 diabetes (mean age 586 years, HbA1C 4.80.5%,
diabetes duration 2.31.3 years, metformin treatment only) were included in the
study. Blood samples were taken before and after 60, 120 and 180 min after
standard breakfast. MVR was measured by the laser Doppler fowmetry during
post-occlusive (PORH) and thermal hyperemia (TH) before and after 60 and
180 min. Glycemia, insulinemia and -hydroxybutyrate (BHB) concentration
were evaluated and malonyldialdehyde (MDA) and conjugated dienes (CD) were
used for the estimation of oxidative stress.
Results
Blood glucose increased from baseline with maximum after 60 min and
consequently decreased down to baseline level after 180 min (baseline, 60,
120, 180 min: 6.90.6 - 8.01.6 - 7.61.2 - 6.20.8 mmol/l, P,0.01). Insu-
linemia increased signifcantly (3916 - 14282 - 10663 - 5539 mIU/l,
P,0.01) while BHB decreased (0.240.16 - 0.160.06 - 0.150.07 - 0.16
0.06 mmol/l, P,0.01). MDA concentration was signifcantly lower after
120 min than at baseline (3.020.48 vs 2.800.40 mol/l, P,0.05). Changes of
several parameters of MVR were detected: maximal perfusion during PORH
decreased after 180 min compared to baseline (23566 vs 19853 PU,
P,0.01) as well as maximal perfusion during TH compared in the same times
(11353 vs 14571 PU, P,0.05). Signifcant relations between MVR and
metabolic parameters was found.
Conclusions
Signifcant metabolic changes were observed postprandially in patient with early
stage of type 2 diabetes. MVR was probably mostly infuenced by vasodilatory
effect of insulin. Moreover, MVR may also be modulated by oxidative stress. The
relationship between MVR and insulinemia may imply that the B-cell dysfunction
can consequently lead to microvascular dysfunction through the effect of insulin.
P34I
Quantitative and qualitative changes in T regulatory lymphocytes
(Tregs) in newly-diagnosed patients with type 1 diabetes
Stavroula Paschou
1
, George Vartholomatos
2
, Nikolaos Kolaitis
2
,
George Papadopoulos
3
& Agathocles Tsatsoulis
1
1
Department of Endocrinology, University of Ioannina, Ioannina, Greece;
2
Unit of Molecular Biology, Laboratory of Hematology, University Hospital
of Ioannina, Ioannina, Greece;
3
Laboratory of Biochemistry and Biophysics,
Epirus Institute of Technology, Arta, Greece.
Introduction
T regulatory lymphocytes (Tregs) are defned as CD4
CD25
high
T lymphocytes
and are thought to regulate immune tolerance. The Foxp3 protein level in Tregs is
proportional to CD25 protein surface expression and regulatory function, but
inversely proportional to IL-7R (CD127) level, the receptor for the growth and
survival of T cells. We investigated possible differences in Tregs between newly
diagnosed type 1 diabetes (DM1) patients and controls.
Peripheral blood from 13 newly-diagnosed patients (9 M/4 F, ages 12.59.4
years) and 32 healthy controls (13 M/19 F, ages 25.311 years) was analyzed by
triple colour fow cytometry for various phenotypic characteristics of Tregs. We
used markers that had been linked to Treg function (FoxP3, CD28, CD45RO,
CD127, CD152, TGF and its type II receptor TGFRII), and proteins linked to
apoptosis (CD95) and cell proliferation (CD27).
Results
Patients had lower percent of Tregs (as percent of total CD4
T cells) compared to
controls: 1.2590.264 vs 3.0470.264% respectively, P,0.001. There was a
higher frequency of expression of CD27 (which is linked to T cell proliferation)
in patients compared to controls (meanS.D., P value): 94.723.94 vs 79.53
30.40% respectively, P0.012. Also, there was a decrease in the level of
expression (expressed as Mean Fluorescence Intensity) of membrane TGF:
23.6621.05 vs 53.8262.48, P0.029 and TGFRII: 38.9634.98 vs
123.72214.15, P0.043 in Tregs from patients compared to controls,
respectively.
Conclusions
There are quantitative and qualitative differences in Tregs between patients with
newly diagnosed DM1 and controls. This may account for the decreased immune
tolerance in DM1.
P348
Vanishing testes syndrome associated with diabetes mellitus
Francois Djrolo
Endocrine and Metabolism Unit, Faculte des Sciences de la Sante, Cotonou,
Benin.
A 30-year-old man complaining of polyuria, polydipsia and asthenia was seen in
consultation with a plasma glucose level of 3.97 g/l. He was discovered diabetic
1 year ago and treated with glibenclamide, which was stopped by the patient after
5 months because of lack of money. There was no family history of diabetes.
Physical examination showed an eunuchoid status man with micropenis,
hypoplastic scrotum with absence of testes confrmed by ultrasonographic
exploration. Three months treatment with glibenclamide felt to normalise plasma
glucose level and metformin was added to the treatment. Association of
glibenclamide and metformine at maximal doses did not normalise the plasma
glucose level which was well controlled by adding intermediate acting insulin two
times a day.
This patient presented a type 2 diabetes with need of small dose of insulin to get
tight glyceamic control. His clinical phenotype is compatible with vanishing
testes syndrome. In our condition of practice, genetic investigation was not
available. This case is with no doubt a case of type 2 diabetes associated with
vanishing testes syndrome. Several genetic syndromes associated with diabetes
mellitus has been described but vanishing testes syndrome rarely. The clinical
particularity observed in this case of diabetes associated with a genetic syndrome
is the need of insulin to achieve good glyceamic control like what is observed in
some cases of MODY.
P349
The high prevalence of abnormal cardiac function in diabetic patients of
a developing community
Hamid Bazrafshan
1
, Mohammad Ali Ramezani
2,3
, Ahmadali Shirafkan
2,3
,
Hasan Ahangar
1
& Ali Gholamrezanezhad
1
1
Department of Endocrinology, Golestan Medical University, Golestan,
Islamic Republic of Iran;
2
Department of Cardiology, Golestan Medical
Univeristy, Golestan, Islamic Republic of Iran;
3
Research Insitutite for
Nuclear Medicine, Tehran University of Medical Sciences, Tehran, Islamic
Republic of Iran.
Introduction
Cardiac complications are one of the most important long-term adverse effects of
diabetes mellitus (DM), which is usually under diagnosed, as it is frequently
asymptomatic. As it seems that the control of DM in developing nations is not
optimal, it can be predicted that the prevalence of cardiac complications of DM is
subsequently high. We assessed the prevalence of such complications in a
developing community in the north of Iran.
Method
Two hundred consecutive patients (mean age: 50/9 years) who returned to the
diabetic care clinic of the hospital for follow-up of their known DM were
assessed. For all patients, levels of HbA1C and B-mode echocardiography were
done. Their echocardiography systolic and diastolic dysfunction were assessed
and E (early diastolic flling phase) and A (A trial contraction phase) were
recorded. Ejection fraction (EF) was calculated using Simpson`s method.
Results
Overall 29.5% of the diabetic patients showed abnormal systolic function. The
study showed statistically signifcant association between the level of HbA1C and
EF (P,0.001). Also there was a signifcant association between the level of
HbA1C and diastolic function (P,0.001). Three percent of patients had mild
diastolic dysfunction (EA), while 45.5% showed moderate to severe
dysfunction. The mean reduction in EF was statistically correlated with the
duration of DM. Regression analysis showed that the associations were not
affected by the patients` age (P,0.001).
Conclusion
The frequency of abnormal cardiac function is signifcantly high in patients with
DM. Poor control of DM is a major contributing factor. Screening of patients
using echocardiography (especially when DM control is not favorable) is advised.
P350
The GG genotype of the G-11391A polymorphism might be
a risk factor for development of type 2 diabetes mellitus in women
Jacek Polosak
1
, Malgorzata Roszkowska-Gancarz
1
, Alina Kurylowicz
2
,
Olga Turowska
3
, Edward Franek
2,3
& Monika Puzianowska-Kuznicka
1,2
1
Department of Biochemistry and Molecular Biology, Medical Center of
Postgraduate Education, Warsaw, Poland;
2
Medical Research Center, Polish Academy of Sciences, Warsaw, Poland;
3
Department of Internal Medicine, Endocrinology and Diabetology, Central
Clinical Hospital MSWiA, Warsaw, Poland.
Background
Adiponectin is a protein hormone secreted by adipocytes. Its expression is higher
in lean than in obese individuals and in women than in men. It inhibits expression
of gluconeogenic enzymes and the rate of glucose production. It also stimulates
glucose utilization and fatty acids oxidation. Adiponectin is encoded by a highly
polymorphic ADIPOQ gene. The 11377CG, 11391GA, and
11426AG ADIPOQ polymorphisms modulate circulating adiponectin level.
Aim of the study
We sought to determine if the C-11377G, G-11391A and the A-11426G promoter
polymorphisms in the ADIPOQ gene are associated with the risk of development
of DM2.
Genomic DNA obtained from 189 patients who developed DM2 before the age of
55 years old (119 women, 70 men) and from 414 18-45 years old healthy controls
(233 women, 181 men) was analyzed for the presence of the selected ADIPOQ
polymorphisms by RFLP method.
Results
We found that the GG genotype of the G-11391A ADIPOQ polymorphism is
signifcantly more frequent in women diagnosed with DM2 than in young healthy
women (91.60 vs 83.19%, P0.026, OR2.26, 95% CI1.1-4.63). The
frequencies of the C-11377G and A-11426G polymorphisms in DM2 and in
healthy women were similar. No signifcant differences in the frequencies of all
tested polymorphisms were detected between DM2 male patients and healthy
males.
Conclusion
Our fnding is consistent with fndings of other authors who showed the
correlation of this genotype with obesity, high fasting insulin level, and with
insulin resistance. Our fnding supports hypothesis that carriers of this genotype
are at higher risk of development of DM2 than carriers of other genotypes of the
G-11391A ADIPOQ polymorphism.
P351
Increased serum nesfatin-1 levels in patients with impaired glucose
tolerance
Nese Ersoz Gulcelik
1
, Safak Cavus Akin
1
, Duygu Yazgan Aksoy
1
,
Jale Karakaya
2
& Aydan Usman
1
1
Department of Endocrinology and Metabolism, Hacettepe University
Medical School, Ankara, Turkey;
2
Department of Biostatistics, Hacettepe
University Medical School, Ankara, Turkey.
Objective
Nesfatin was found to be co-localized with insulin in pancreatic cells and its
levels were decreased in type 2 diabetic patients. In order to investigate the role of
nesfatin in carbohydrate metabolism, we measured baseline nesfatin-1 levels and
its response to glucose load in patients with impaired glucose tolerance (IGT) and
in healthy subjects.
Fourteen patients with IGT and, 13 age and body mass index matched controls
were included in the study. Oral glucose tolerance test was performed for each
subject and blood samples were taken at 0, 60 and 120 min at which glucose,
insulin and nesfatin-1 levels were measured.
Results
Baseline glucose, insulin and nesfatin-1 levels were signifcantly higher in
patients with IGT than controls. Two-way repeated-measures of ANOVA
revealed that change in time (CIT) for glucose and insulin was signifcant
(P,0.001 and P,0.001, respectively). CIT for glucose and insulin was
signifcantly different between IGT patients and controls (P,0.001 and
P0.003, respectively). CIT for nesfatin-1 was not signifcant (P0.467) and
it was not different between the two groups (P0.331). Since variables have
different units, two-way repeated measures of ANOVA on both factors were used
to evaluate percentage change of variables within times. Interactions of groups,
times and factors (glucose, nesfatin-1, insulin) were also examined. Percentage of
CIT was different for glucose, insulin and nesfatin-1 (P,0.001). Percentage of
CIT for each factor was similar in both groups (P0.120).
Conclusion
Nesfatin-1 levels were not affected by acute changes in glycemic status.
In contrast to the previous reports showing decreased levels of nesfatin-1 levels in
diabetic patients, we found elevated levels in patients with IGT. This
controversial fnding may be explained by a defensive increase in nesfatin-1 to
regulate impaired glucose metabolism in IGT patients, which is disturbed by the
development of diabetes.
P352
TCF7L2 gene variants and polycystic ovary syndrome
Marketa Vankova, Josef Vcelak, Petra Lukasova, Olga Bradnova,
Silva Prazakova, Katerina Dvorakova, Jana Vrbikova & Bela Bendlova
Institute of Endocrinology, Prague, Czech Republic.
Polycystic ovary syndrome (PCOS) is considered as a risk factor for diabetes type
2 (DM2), it is often associated with obesity, -cell dysfunction or insulin
resistance. Genetic factors underlying the association of PCOS with DM2 is
unknown. Recent human genetic studies have revealed that transcription factor
7-like (TCF7L2) polymorphisms are associated with DM2 through modulation of
-cell function.
The aim of this study was to test if TCF7L2 polymorphisms are risk factors for
impaired -cell function, insulin sensitivity or hepatic insulin extraction in PCOS.
The study involved 109 PCOS patients and 192 control women with different
glucose tolerance and BMI. Oral glucose tolerance test was performed in all
subjects, in subgroup of 50 PCOS and 23 control arginin secretion test and
euglycemic-hyperinsulinemic clamp were performed. The SNPs rs12255372,
rs7901695, rs7903146 were assessed by ABI-TaqMan Genotyping Assays.
Statistics (Kruskal-Wallis one-way ANOVA) was done (NCSS-2004).
PCOS versus controls had higher BMI. To exclude the infuence of BMI on
metabolic parameters, we focused on lean women. Despite it lean PCOS have
higher WHR and lower triglycerides than controls. PCOS have higher insulin and
C-peptide secretion, impaired whole body insulin sensitivity and lower hepatic
insulin extraction. The frequencies of risk aleles/haplotypes of TCF7L2 gene
polymorphisms were lower in PCOS in comparision with controls. The infuence
of the risk TCF7L2 haplotype (CTT) on decreased insulin secretion was evident in
controls during arginine test, but the secretion in lean PCOS was the same without
respect of haplotype carriership. This fnding could be explained by increased
hepatic insulin extraction in lean PCOS carrying the risk haplotype.
The DM2 risk TCF7L2 haplotype seems to be protective in PCOS because it
could normalize the increased insulin and C-peptide levels in periphery present in
PCOS patients.
Study was approved by ethical committee and supported by MHCR NS/10209-
3/2009 and NS/9839-4.
P353
Insulin sensitivity and acute insulin response in pateints with primary
hyperparathyroidism before and after surgical treatment
Goran Cvijovic, Dragan Micic, Aleksandra Kendereski, Svetlana Zoric,
Mirjana Sumarac-Dumanovic, Danica Stamenkovic-Pejkovic
& Danka Jeremic
Institute of Endocrinology, Diabetes and Diseases of Metabolism, Belgrade,
Serbia.
It was reported that patients with primary hyperparathyroidism (PHPT) are insulin
resistant, and that surgical treatment may improve insulin sensitivity in this group
of patients. The aim of our study was to evaluate the effect of surgical treatment
on insulin sensitivity and acute insulin response (AIR) in patients with PHPT.
Methods
In patients with PHPT (n37; age: 57.728.29 years, BMI 26.224.37 kg/m
2
)
euglycemic-hyperinsulinemic clamp (for calculation of M value), standard
OGTT (for calculation of areas under the curve (AUC) for glucose and insulin),
and IVGTT (for calculation of AIR) were performed before and 4 months after
surgical treatment.
Results
After operation serum calcium (2.330.15 vs 2.990.23, P,0.05) and PTH
(50.0037.59 vs 259.4554.52, P0.05) were normalized and there was no
change in BMI (26.224.37 vs 26.603.92 kg/m
2
, P0.05) before and 4
months after operation. We have observed signifcant improvement in insulin
sensitivity using clamp technique (M value: 5.694.35 vs 3.962.76, P,0.05)
after surgical treatment of PHPT. There was mild, but not signifcant
improvement in AUC insulin (6428.733714.45 vs 6027.973708.57,
P0.05), and AUC glucose (924.06367.98 vs 908.19330.36, P0.05),
while there was no change in AIR (44.3030.95 vs 35.3042.76, P0.05)
before and after operation. In conclusion, surgical treatment improves insulin
sensitivity in patients with PHPT. This improvement was not associated with
changes i AIR.
P354
Renal complications of aldosteronism and diabetes: role of oxidative
stress and protective effects of polyphenol extract
Eglantine Elowe-Gruau
1
, Stephanie Dal-Ros
1
, Nathalie Auberval
1
,
Elodie Seyfritz
1
, William Bietiger
1
, Michel Pinget
1,2
, Nathalie Jeandidier
1
& Severine Sigrist
1
1
Centre Europeen dÈtude du Diabe`te, Strasbourg, France;
2
HUS, Service
dÈndocrinologie, Diabe`te, Maladies Metaboliques, Strasbourg, France.
Hyperaldosteronism and diabetes are two providers of kidney disease, showing
molecular and cellular mechanisms in common, such as oxidative stress,
causing renal tubular damages. The objective of this study is to evaluate
in vitro the protective effect of a natural antioxidant (red wine polyphenols and
green tea extract) in the onset of renal dysfunction. Hyperglycemia and
hyperaldosteronism are induced respectively by increasing doses of glucose
and aldosterone in primary cultures of rat renal proximal tubular cells (PCPR),
and associated with a progressive loss of viability and apoptosis (quantifed by
Cell Titer and fow cytometry). In fact, the viability of PCPR in the presence of
6 g/l of glucose or 10
4
M of aldosterone is respectively 68.1 and 67.9%; 20.1
vs 8.9% and 45.7 vs 30.3% for apoptosis. Moreover, green tea extract (pre-
incubated 1 h) is able to normalize viability (102.8 and 128%) and reduce
apoptosis (10 and 18.2%) whereas red wine polyphenols have no effect. The
expression of two antioxidant enzymes, catalase (CAT) and superoxide
dismutase (SOD), is assessed by western blot. Expression of SOD is
maintained (98%) whereas CAT is upregulated with hyperglycemia (280%).
With hyperaldosteronism, CAT (345%) and SOD (122%) are upregulated.
Finally, red wine polyphenols are able to overexpressed CAT (980 and 125%)
and SOD (841 and 219%) respectively with hyperglycemia and hyperaldoster-
onism. This study suggests that polyphenols extract could be considered as an
antioxidant prophylactic treatment of renal failure in patients suffering from
aldosteronism or diabetes.
P355
Prediction of incident diabetes mellitus by baseline insulin-like growth
factor 1 levels
Harald Schneider
1
, Henri Wallaschofski
2
, Gunter-Karl Stalla
4
& Hans Ulrich Wittchen
3
1
Medizinische Klinik Innenstadt, Munich, Germany;
2
University of
Greifswald, Greifswald, Germany;
3
University of Dresden,
Dresden, Germany;
4
Max-Planck Institute of Psychiatry, Munich, Germany.
Objective
Insulin-like growth factor 1 (IGF1) is associated with metabolic parameters and
involved in glucose metabolism. Low IGF1 has been implicated in the etiology of
glucose intolerance. However, epidemiological data are scarce and the role of
IGF1 in prospective studies is not clear to date.
We measured IGF1 levels in 7665 subjects free of diabetes from two German
prospective cohort studies, the DETECT study and SHIP and assessed incident
diabetes mellitus during follow-up.
Results
There were 464 cases of incident diabetes during 32 229 person-years. There was
no heterogeneity among both studies (P0.4). The hazard ratio (HR) of incident
diabetes in subjects with IGF1 levels below the 10th or above the 90th age- and
sex-specifc percentile, compared to subjects with intermediate IGF1 levels were
1.45 (95% CI 1.11-1.89) and 1.39 (1.05-1.84), respectively, after adjustment for
age, sex, smoking status, education, family status, physical activity, alcohol
consumption, and study. After further adjustment for hypertension, glucose,
dyslipidemia, and waist-to-height ratio, the HR for low IGF1 became
insignifcant. Analysis of quintiles of IGF1 percentiles revealed a U-shaped
association with incident diabetes. If high and low IGF1 was included into a
prediction model of diabetes, high IGF1 remained a signifcant predictor.
Conclusions
Subjects with low or high IGF1 levels are at increased risk of developing diabetes.
High IGF1 is an independent predictor of diabetes.
P35
Fasting and postprandial effects of rosiglitazone on low- and
high-density lipoproteins size and subclasses in type-2 diabetes
Manfredi Rizzo
1
, Kaspar Berneis
2
, Jelena Vekic
3
, Giovam Battista Rini
1
,
Spyridon Koulouris
4
, Dimitrios Sakellariou
4
, Socrates Pastromas
4
& Antonis Manolis
4
1
Clinic of Internal Medicine, University of Palermo, Palermo, Italy;
2
Clinics
for Endocrinology, Diabetes and Clinical Nutrition, University Hospital
Zurich, Zurich, Switzerland;
3
Institute of Medical Biochemistry, University
of Belgrade, Belgrade, Serbia;
4
First Department of Cardiology,
Evagelismos Hospital, Athens, Greece.
Background
There is evidence that rosiglitazone may increase cardiovascular risk and, on this
basis, this agent has been recently advised for treatment of type-2 diabetes. Yet,
its effects on fasting and postprandial atherogenic dyslipidemia are still not fully
elucidated.
Methods
In an open-label study rosiglitazone (4 mg/day for 12 weeks) was added on top of
a maximum of two oral antidiabetic drugs to 18 patients with adequately
controlled type-2 diabetes (HbA1c: 6.5-8.0%), evaluating the effects on plasma
lipids and lipoproteins before and after an oral fat load. Low-density lipoproteins
(LDL) and high-density lipoproteins (HDL) size and subclasses were determined
by gradient gel electrophoresis.
Results
Rosiglitazone improved HbA1c (P0.0023), while no signifcant changes were
found in plasma lipids or lipoprotein (a), both fasting and post-prandially. Fasting
LDL size increased after therapy (1.4%, P0.0338), due to a reduction in
small, dense LDL-IIIA particles (25.1%, P0.0180). Postprandially,
rosiglitazone reduced larger HDL-2b (8.7%, P0.0056) and increased smaller
HDL-3b particles (12.2%, P0.0485), with no changes in HDL size. No other
effects on lipoproteins size and subclasses were found fasting or post-prandially.
By correlation analysis we further found that such changes in lipoproteins size
and subclasses were not related to changes in HbA1c or plasma lipids.
Conclusions
Rosiglitazone therapy in patients with type-2 diabetes led to anti-atherogenic
changes in LDL size and subclasses, with concomitant pro-atherogenic changes in
HDL subclasses, despite no effects on plasma lipids and lipoprotein (a). Further
studies may evaluate whether these fndings affect the clinical endpoints in
such patients.
P35I
Levels of adrenomedullin during low dose Synacthen test in
diabetics type 1
Katerina Simunkova
1,3
, Radovan Bilek
1
, Richard Hampl
1
,
Vaclav Zamrazil
2
, Denisa Janickova-Zdarska
2
, Martin Hill
1
& Karel Vondra
1
1
2
Department of
Internal Medicine, Second Medical School, University Hospital Motol,
Charles, Prague, Czech Republic;
3
Third Department of Medicine, First
Faculty of Medicine, General University Hospital, Charles University,
The aim of the study was to obtain the basic data about adrenomedullin after 1 g
ACTH stimulation.
Adrenomedullin has direct effect on adrenal cortex secretion, therefore we studied
the changes of its concentrations during ACTH stimulation in diabetic patients
suspected of hypocorticalism.
Thirty-two diabetics type 1 (DM1) were investigated; 16 with and 16 without
autoimmune thyroditis (AIT); age 4410 years (meanS.D.), age at diagnosis of
DM1 28.510 years, disease duration 158 year, BMI 24.52.7 kg/cm
2
,
HbA1c 7.21.2%. Control group had eight healthy subjects; age 276 years,
BMI 21.72.3 kg/cm
2
. Neither group showed laboratory signs of adrenal
autoimmunity. The study was approved by local ethical committee.
Adrenocortical reserve was tested by 1 g ACTH stimulus. Serum cortisol,
adrenomedullin were determined in times 0 (basal) and after 20th, 30th, 40th,
60th min.
We divided DM1 patients according to their response during low dose ACTH test
to the groups with low (LR) and normal (NR) response and control group (C).
Maximum stimulated value of cortisol in serum above 500 nmol/l excluded
adrenocortical insuffciency.
After ACTH stimulation, levels of adrenomedullin were increased in DM1 with
LR as compared with other groups, P,0.005. The peak levels of adrenomedullin
were found in 30th min in both groups of diabetics, LR and NR as well.
Stimulated levels of adrenomedullin did not differ from basal levels in DM1 with
AIT. Stimulated levels of adrenomedullin in DM1 with AITD LR did not differ
from NR and C.
In conclusion, we found distinct difference in adrenomedullin levels between
patients with isolated diabetes type l and diabetics with AIT, independently on
cortisol response during Synacthen test. These results may contribute to better
understandingof adaptationtolatent adrenocortical insufciency indiabetics type 1.
The study was supported by grant No. 9834-4, 9831-4, 10215-3 IGAMZCR,
NR 9154-3.
P358
Antioxidative effect of green tee and red wine polyphenol extracts on
RINm5F cells after oxidative stress induction
Nathalie Auberval
1
, Stephanie Ros
1
, Valerie Schini-Kerth
2
, Michel Pinget
3
& Severine Sigrist
1
1
Centre europeen dètude du diabe`te, Strasbourg, France;
2
UMR 7175
CNRS, Pharmacologie et Physicochimie, faculte de Pharmacie, UDS,
Strasbourg, France;
3
Service dèndocrinologie et de diabetologie, HUS,
Strasbourg, France.
Diabetes is associated with an oxidative stress (OS). Free radicals are responsible
of -cell destruction in type 1 diabetes and their dysfunction in type 2. The
purpose of this work is to evaluate preventive effect of antioxidative natural
compounds on several models of OS induced on -cells.
The models of oxidative stress were performed with 40 mol/l H
2
O
2
for 30 min,
with a mixture of 0.25 mmol/l hypoxanthine and 10 mU/ml xanthine oxidase
(HX/XO) for 1 h and with 25 mmol/l streptozotocine (STZ) for 2 h. Antioxidative
molecules used were polyphenolic extracts from red wine (RWPs) at 150 g/ml
and green tee extract, epigallocatechine gallate (EGCG) at 500 g/ml. Cell
viability was measured using cell proliferation assay (Cell Titer, Promega), H
2
O
2
intracellular production by fow cytometry (DCFH-DA) and expression of
antioxidative enzymes catalase (CAT) and superoxide dismutase (SOD) by
western blotting.
OS induced by H
2
O
2
, leads to a signifcant loss of cell viability of about 80%
(P,0.001) associated to an increase of intracellular H
2
O
2
(P,0.05) and a
decrease of CAT expression. RWPs and EGCG have permit to maintain cell
viability but only EGCG decreases intracellular H
2
O
2
and only RWPs decreases
SOD expression. STZ induces a decrease of cell viability, of intracellular H
2
O
2
(P,0.05), of SOD expression but an increase of CAT expression. Both
antioxidants maintain cell viability, but only EGCG decreases the expression of
both enzymes. HX/XO leads to a signifcant loss of cell viability of about 80%
(P,0.001), induces intracellular H
2
O
2
production and an overexpression of
CAT. Both antioxidants improve cell viability and only RWPs allows an
overexpression of SOD.
These results showed that natural antioxidant molecules could prevent oxidative
stress induced on RINm5F cells by different way. Antioxidant regimen could
improve -cells viability and could be a new strategy to protect -cells during
diabetes.
P359
Waiting time for emergency renal replacement therapy in patients with
end stage renal failure secondary to diabetes mellitus
Florisa Rodriguez
1,2
, Javier Triana
1
, Hector Eloy Tamez
1,2
& Sofa Daniela Robles
2
1
Hospital Universitario 'Jose Eleuterio Gonzalez`, Nuevo Leon, Mexico;
2
Subdireccion de Investigacion, Nuevo Leon, Mexico.
Introduction
The incidence of end stage renal failure (ESRF) secondary to diabetes mellitus
(DM) is increasing worldwide. Renal replacement therapy, which if started early
improves prognosis, is a common treatment for ESRF.
Objective
To determine the waiting time and factors that infuence the provision of
emergency renal replacement therapy in patients with ESRF secondary to DM
admitted to the emergency room of a tertiary care hospital.
Methods
We carried out a chart review of patients with ESRF secondary to diabetes that
were admitted to the emergency room between March and December 2009.
Patients with an indication for dialysis and ESRF secondary to DM were included
in the study. The admission time, initial diagnosis, time from admission to
dialysis, and the reasons for waiting were registered.
Results
We reviewed 156 medical charts. Of these, 44 (28.20%) were patients with ESRF
secondary to DM with an average age of 50.7 years. Sixty per cent were men. The
average waiting time for dialysis was 34.96 h. Among the factors that caused a
delay in replacement therapy were the patient`s diffculty to cover expenses for
the procedure, and economic administrative problems of the institution.
Conclusions
Although this study has a small number of patients, it shows that the waiting time
for renal replacement therapy, in our community, is long and can infuence
morbidity and mortality. Institutional norms and procedures must be created to
provide timely renal replacement therapy for patients with ESRF secondary to DM.
P30
Obestatin and ghrelin inhibit apoptosis of human pancreatic islet
endothelial cells in high glucose culture
Enrica Favaro, Maria Maddalena Zanone, Ilaria Miceli, Fabio Settanni,
Giovanni Camussi, Paolo Cavallo Perin, Ezio Ghigo & Riccarda Granata
University of Turin, Turin, Italy.
Pancreatic islet microendothelium exhibits unique structural and functional
features, in an interdependent physical and functional relationship with the
neighbouring -cells. Glucose toxicity is not solely restricted to -cells, but
affects also survival, proliferation of human pancreatic islet endothelial cells, thus
possibly contributing to -cell function impairment and -cell loss. It has been
previously demonstrated that the ghrelin gene derived peptides, namely acylated
ghrelin (AG), unacylated ghrelin (UAG) and obestatin (Ob), prevent apoptosis of
pancreatic -cells and human pancreatic islets. Therefore, based on our previous
fndings, we analyzed the effects of hyperglycemia on human pancreatic islet
microendothelial cells (MECs), the underlying signaling pathways, and whether
AG, UAG and would reverse the response of islet MECs to high glucose
conditions. Under high glucose treatment, proliferation of MECs progressively
decreased and apoptosis increased, accompanied by a reduced activation of the
survival signaling pathway PI3K/Akt. Incubation with AG, UAG or Ob (10 nM)
inhibited apoptosis and increased Akt phosphorylation. The antiapoptotic effect
of the peptides was blocked by inhibition of adenylyl cyclase (AC)/cAMP/protein
kinase A (PKA) and PI3k/Akt signaling pathways. These results suggest that the
ghrelin gene-derived peptides promote islet microendothelium survival. More-
over, their survival effect involves the PI3K/Akt signaling pathway. These
peptides could therefore represent a potential tool to improve islet vascularization
and, indirectly, islet function.
P31
Hepatic mitochondrial direct effects of thiazolidinediones: pioglitazone
and rosiglitazone
Maria Nieves Sanz
1
, Carlos Sanchez-Marti n
1
, Dominique Detaille
1
,
Saida Bouderba
2
& Mohammed Yehia El-Mir
1
1
Department of Physiology and Pharmacology, University of Salamanca,
Salamanca, Spain;
2
Laboratory of Biology and Animal Physiology,
University of USTBH, Argel, Algeria.
Introduction
Thiazolidinediones (TZDs) are synthetic insulin-sensitizing drugs used in the
treatment of type 2 diabetes. They work as agonists of peroxisome proliferator-
activated receptor (PPARg). TZDs action via PPARg does not exclude
independent PPARg-activation effects. Our research group has recently reported
that TZDs also execute direct effects implicated in glucose homeostasis.
However, its mitochondrial action PPARg-independent has not been fully
studied yet.
Aim
To investigate direct mitochondrial effect of pioglitazone (PIO) and rosiglitazone
(ROSI) on isolated liver mitochondria.
Liver mitochondria were obtained from fed male Wistar rats according to
standard differential centrifugation procedures. Oxygen consumption rates were
measured polarographically at 37 ?C using a Clark-type oxygen electrode,
whereas ROS (free radicals) production was assayed by incubating mitochondria
in a stirred 2 ml volume with 10 UI HRP and 2 M Amplex Red, and was
calibrated against H
2
O
2
standards. Moreover, activity of mitochondrial
respiratory chain complexes I, II and III were spectrometrically determined.
Results
Both TZDs, at all tested doses (10, 25, 50, and 100 M), inhibited oxygen
consumption (JO
2
) in a dose-dependent manner when glutamate and malate (GM)
was used as substrate. This inhibition affected the state 3 of respiration (in the
presence of ADP) and the uncoupled state (after addition of dinitrophenol).
Maximal JO
2
inhibition was about 50% with the highest dose of glitazones. On
the other hand, we found a constant inhibition of JO
2
in a non does-dependent
manner when we employed succinate and malate (SM) as substrate. PIO and
ROSI dramatically reduced ROS production from mitochondria energized with
GM or SM by 50 and 80%, respectively. Finally, by investigating the direct effect
of TZDs on the activity of respiratory complexes (I, II and III), we found that both
glitazones specifcally inhibited the activity of complexes I and III by 20 and 25%,
respectively.
Conclusions
Pioglitazone and rosiglitazone reduce both mitochondrial respiration and ROS
production acutely and PPARg-independent way, through inhibition of
respiratory complexes I and III activities. This new fnding could contribute to
their antidiabetic properties.
P32
Glycemic control and treatments in adults with type 1 diabetes mellitus
Husniye Baser, Cevdet Aydin, Ahmet Dirikoc, Dilek Arpaci, Reyhan Ersoy
& Bekir Cakir
Introduction
Survival is increased in childhood-onset type 1 diabetes mellitus (DM) and
approximately half of patients are diagnosed after the age of 15. Thus, a
considerable number of patients with type 1 DM are adults. In this study, we
aimed to investigate glycemic control and modalities of treatments in adult type 1
DM patients.
Data of type 1 DM patients hospitalized between January 2004 and December
2009 were evaluated retrospectively. Age at diagnosis, duration of diabetes,
HbA1c levels and type of insulin treatment were recorded. Data at the time of
initial hospitalization were analyzed in patients with multiple hospitalizations.
Results
Two hundred and ffty patients were included in the study. There were 123
(49.2%) female and 127 (50.8%) male patients. The mean age of patients at the
time of hospitalization was 31.99.7, mean age at diagnosis was 24.710.1, and
duration of diabetes was 7.28.4 years. Type 1 DM was diagnosed at the age of
0-14 in 15.2%, 15-30 in 54.8% and 30 in 30% of patients. HbA1c was 9.5%
in 49.6%, 7.5-9.5% in 27.6% and ,7.5% in 22.8% of patients. Sixty percent of
patients was using four daily injections of insulin treatment and 27% was using
one, two or three daily injections. 13% of patients was on insulin pump therapy.
When we compared HbA1c in patients using different insulin regimens, we found
that patients using insulin pump had signifcantly lower HbA1c levels (P,0.01).
Conclusion
In the adult population, type 1 DM is diagnosed with increasing frequency. In
adult type 1 DM patient`s metabolic control is not well and the goal of near
normoglycemia is achieved in few patients. Additionally, patients on insulin
pump therapy have the best glycemic control.
P33
Diabetic mastopathy: imaging and management
Zorica Milosevic
1
, Vesna Plesinac Karapandzic
1
, Biljana Markovic
2
,
Zoran Radojicic
3
& Nenad Borojevic
1
1
Medical Faculty, Instiute of Oncology and Radiology Serbia, University
Belgrade, Belgrade, Serbia;
2
Medical Faculty, Institute of Radiology,
Clinical Center Serbia, University Belgrade, Belgrade, Serbia;
3
Faculty of
Organizational Sciences, University Belgrade, Belgrade, Serbia.
Diabetic mastopathy or sclerosing lymphocitic lobulitis of the breast in the
patients with diabetes mellitus is a rare, benign disease that simulates breast
malignancy.
Among 489 women with frm breast lump(s), three women aged 32, 38 and 47
years with long standing diabetes mellitus type 1 were identifed. Mammography
and breast ultrasound were performed in all patients and contrast enhanced breast
MRI in one patient with bilateral lumps. The histological examination revealed a
sclerosing lymphocitic lobulitis.
In our study, the prevalence of mastopathy was 0.6% (P0.04, proportion test).
Total of eight masses were detected by palpation. Mammograms showed
unilateral asymmetric densities, without calcifcations in two patients and
bilateral dense parenchyma in one. Breast ultrasound showed nine lesions
measured from 0.8 to 3 cm (three hypoechoic lobulated lesions and six areas of
posterior acoustic shadowing). Breast MRI revealed irregular areas of low signal
intensity with poor enhancement in early phase after contrast material injection
and benign, gradual increase in enhancement in delayed phase, without typical
signs of malignancy.
If the physical examination is suggestive of diabetic mastopathy, the safe and
minimally invasive initial approach is recommended as follows: mammography,
ultrasound and MRI prior the core needle biopsy of dominant breast mass, with
6 months ultrasound follow-up after histological confrmation of disease. In the
case of recurrent disease, MRI can be used to differentiate the mastopathy from
malignancy and avoid an unnecessary biopsy.
P34
Evaluating the effects of vitamin D metabolism on glycemic parameters
and atherosclerosis markers in prediabetic patients
Hulya Parildar
1
, Mumtaz Takir
2
, Asli Dogruk Unal
2
, Ozlem Cigerli
1
,
Oyku Gulmez
3
, Feyza Dinc
4
& Nilgun Demirag Guvener
2
1
Department of Family Medicine, Faculty of Medicine, Baskent University,
Istanbul, Turkey;
2
Department of Endocrinology, Faculty of Medicine,
Baskent University, Istanbul, Turkey;
3
Department of Cardiology, Faculty
of Medicine, Baskent University, Istanbul, Turkey;
4
Department of
Biochemistry, Faculty of Medicine, Baskent University, Istanbul, Turkey.
Background and aims
Hypovitaminosis D may be associated with metabolic parameters in addition to its
well-known calcemic actions. There is increasing evidence that vitamin D
metabolism affects the risk of insulin resistance although the underlying
molecular mechanism of this association is not clear but on the basis of evidence
it is not clear whether or not vitamin D supplementation therapy in vitamin
D-defcient prediabetics affects the prevention of type 2 diabetes. Our study is
designed as a 1-year prospective interventional study. In this study our specifc
aims are to evaluate the changes in vitamin D metabolism and their effects on
glycemic parameters and atherosclerosis in prediabetic patients. We analysed the
data cross-sectionally and assessed the preliminary results.
Preliminary analysis included 81 prediabetic patients and 67 healthy volunteers as
control group attending to the Outpatient Clinics. We supplemented the vitamin
D-defcient patients. Descriptive statistics were presented as meanS.D. and
percentages. For statistical comparisons, Pearson Correlation, Fisher`s exact and
Student`s t-tests were used.
Results
The mean age was 50.211.9 years (24-79) in prediabetics and 45.113.5
(20-79) years in the control group. There was a positive correlation between
body mass index (BMI) and homeostasis model assessment of insulin resistance
(HOMA IR) and HsCRP in the whole group (r0.2, P,0.01, r0.1, P0.05
respectively). Mean HOMA IR and BMI values were statistically higher in the
prediabetic group compared to the control group (P0.001). The rate of vitamin
D insuffciency were statistically higher in prediabetics (34/81) than in the control
group (15/67) (P0.05). We found no correlation between vitamin D levels and
BMI, HOMA IR, HsCRP, age or sex in both groups. Mean carotis intima media
thickness (CIMT) values were not correlated with vitamin D levels but were
correlated with age in the whole group before and after supplementation (r0.5,
P,0.01, r0.6, P,0.01 respectively). As the data were analysed at the
6 months after the supplementation of vitamin D: the HsCRP levels were
decreased signifcantly in the prediabetic group (P0.05). There was no
signifcant change in the fasting plasma glucose (FBG), insulin and HbA1c levels
in the vitamin D supplemented group.
Conclusion
The levels of vitamin D were lower in the prediabetic group than the control
group. We found no correlation between vitamin D levels and CIMT and other
parameters. The supplementation of Vitamin D did not seem to positively effect
FBG, insulin and HbA1c levels except HsCRP levels. As our study continues, the
data will accrue and we should be able to reanalyse the data and concentrate on
evaluating the supplementation of vitamin D
3
in groups at high risk of developing
type 2 diabetes.
P35
Analysis of incidence and risks factors of gestational diabetes in our
area: comparison between two periods
Beatriz Mantinan Gil, Reyes Luna Cano, Paula Sanchez Sobrino,
Regina Palmeiro Carballeira, Concepcion Paramo Fernandez,
Manuel Penin Alvarez & Ricardo Victor Garci a Mayor
Complejo Hospitalario Universitario de Vigo, Vigo, Spain.
Introduction
Gestational diabetes (GD) is frequently associated with obesity and family history
of diabetes. Besides these, other risks factors have been proposed, as previous
GD, macrosomy or abnormal reproductive history.
Methods
We conducted a retrospective comparative study including all patients diagnosed
of GD during 1999 and 2008. The analyzed variables were incidence and risk
factors of GD.
Results
We included 384 patients, 131 from 1999 (group I) and 253 from 2008 (group II).
GD incidence rate was 3.4% in group I and 5.4% in group II. The average age of
the sample is 32.035.15 years (group I) and 33.74.84 (group II). Risk factors
of both groups are summarized in the following table.
Conclusion
We observed an increase GD incidence between the two periods studied, probably
caused by the introduction in the year 2000 of GD universal screening with oral
glucose tolerance test. Previously, diagnostic tests were confned only to
increased risk pregnant. GD patient characteristics were similar in the two
periods studied except for hypertension, which was observed more frequently in
patients diagnosed during 1999. This study showed an increase obesity incidence
in group II, as in the general population, without reaching statistical signifcance.
P3
Disease-modifying drugs in the treatment of intermittent claudication in
patients with diabetes mellitus: the pilot study
Irina Kuzina, Irina Gurieva, Sergey Smirnov, Inna Begma
& Svetlana Kalinchenko
Federal Bureau of Medical and Social Expertise, Moscow, Russian
Federation.
Neuropathy and ischemia play paramount roles in the pathogenesis of diabetic
vascular complications. Reduced tissue blood fow in experimental diabetic
complications can be corrected by several disease-modifying drugs. Actovegin
(deproteinised hemoderivative product) is considered to be a potential agent to
stimulate cellular energy metabolism and improve cell function. Testosterone
vascular effects can be mediated via increasing cardiac and muscle activity and
endothelium dependent vasodilatation.
Pilot open-labeled 8 weeks studies were conducted to evaluate the effcacy of
treating diabetic patients with peripheral neuropathy and ischemia with
Actovegin (1st trial) and testosterone undecanoate (2nd trial). Twenty-six type
2 patients aged 64.52.1 years (HbA1C7.61.2%) with intermittent
claudication and sensory-motor neuropathy (Neuropathy Score 14.51.2) were
enrolled in the 1st study. 8 men aged 465.5 years (HbA1C9.62.2%) with
androgen defciency, intermittent claudication and sensory-motor neuropathy
(Neuropathy Score 17.55.2) are enrolled into 2nd study (ongoing). Two
injections of testosterone undecanoate (1000 mg) were performed on the 1st visit
and in the 6th week of treatment. Evaluation of peripheral blood fow was
determined with toe plethysmography and ultrasound ankle Doppler; sensory and
autonomic neuropathy was assessed with battery of tests. Treadmill (Gardner
protocol) performed for evaluation of peak walking time (PWT) before study,
gp (%) gp (%)
Family history 43.5 37 0.31
Previous GD 10.7 17.7 0.11
Obesity 22.9 29.9 0.21
Hypertension 5.3 0.8 ujj
Previous macrosomy 2.3 4.3 0.37
Previous perinatal mortality 0.8 0 0.42
Previous malformation 0.8 1.6 0.51
Previous prematurity 0.8 0 0.42
Weight gain 9.714.07 kg 8.414.35 kg 0.005
after 2 weeks, and at the end of study. Both kinds of treatment brought about a
progressive increase in the maximum walking time during treadmill test. Relative
difference in PWT with Actovegin increased after 8 weeks: relative increase was
95.1%, (absolute increase 435.953, 2 s, P,0.01); treatment with testosterone
undecanoate increased PWT by 75% (absolute increase 537.983, 1 s, P,0.05).
Neuropathy Score decreased at termination of both studies.
Conclusion
Treatment over 8 weeks with Actovegin and testosterone undecanoate increased
peak walking time and neuropathy score. Effcacy can possibly be improved by
increasing the duration of treatment.
P3I
Evaluation of HbA1c levels for the detection of prediabetes
Asli Dogruk Unal
1
, Hulya Parildar
2
, Mumtaz Takir
1
, Ozlem Cigerli
2
,
Feyza Dinc
3
& Nilgun Demirag Guvener
1
1
Department of Endocrinology, Faculty of Medicine, Baskent University,
Istanbul, Turkey;
2
Department of Family Medicine, Faculty of Medicine,
Baskent University, Istanbul, Turkey;
3
Department of Biochemistry,
Faculty of Medicine, Baskent University, Istanbul, Turkey.
Objective
Recent recommendations suggest that HbA1c as a stable and standardised index
of chronic glucose exposure over time and could be used as a better biochemical
marker for the diagnosis of diabetes and prediabetes. Our aim in this cross-
sectional study is to assess the validity of HbA1c as a screening tool for the
detection of prediabetes in our patient population.
Methods
The study was done in 265 patients selected among the participants attended in
our outpatient clinics. All had fasting plasma glucose (FPG) and 2 h post glucose
measurements after 75-g glucose load, HbA1c, fasting insulin levels, lipid profles
and biometric measures. The participants were classifed as control and
prediabetic group in whom impaired glucose tolerance or impaired glucose
tolerance plus impaired fasting glucose. Descriptive statistics were presented as
meanS.D. and percentages. For statistical comparisons, Pearson Correlation and
Mann-Whitney U tests were used.
Results
The control group included 118 and the prediabetic group included 147 according
to oral glucose tolerance test. There was no difference for sex, age and body mass
index between groups. Mean HbA1c levels were signifcantly different in control
and prediabetic group (5.30.4 and 5.70.4% respectively) (P,0.001). HbA1c
was correlated with waist circumference, plasma fasting glucose levels and basal
insulin levels (P,0.001 for all), 2 h post glucose measurements and triglyceride
levels (P,0.005). There was no difference in the history of hyperlipidemia,
gestational diabetes, family history of diabetes and macrosomic baby except the
hypertension history (P,0.005) between two groups.
Conclusions
Our results may prove HbA1c as a valuable screening method for the diagnosis of
prediabetic state in our population.
P38
Comparative evaluation of serum concentrations of a novel
adipocytokine, hbroblast growth factor-21 in patients with type 2
diabetes and obesity
Beata Matuszek
1
, Monika Lenart-Lipinska
2
, Dariusz Duma
2
, Janusz Solski
2
& Andrzej Nowakowski
1
1
Chair and Department of Endocrinology, Medical University of Lublin,
Lublin, Poland;
2
Chair and Department of Laboratory Diagnostics, Medical
University of Lublin, Lublin, Poland.
Fibroblast growth factor-21 (FGF-21) is a novel adipocytokine, which is believed
to be involved in improvement of insulin sensitivity and pathogenesis of type 2
diabetes.
The aim of the study was comparative assessment of FGF-21 concentrations in
serum of patients with type 2 diabetes and evaluation of possible relationships
between the studied cytokine and selected clinical and biochemical parameters.
Forty-four patients with type 2 diabetes, 24 women and 20 men aged 47-72 with
the mean duration of diabetes 10.98.2 years. In fasting serum samples
concentrations of glucose, insulin, lipids profle parameters, creatinine, CRP,
fbrinogen, HbA1C, adiponectin and FGF-21 were determined at the time of
admission to hospital and after 2 years of follow-up. The control group comprised
20 healthy persons matched for age to the study group.
We found signifcant differences concerning the medians of BMI 32.4 vs
24.1 kg/m
2
, P,0.001; waist circumference 114 vs 81 cm, P,0.001; HDL 42.5
vs 62.5 mg/dl, P,0.001; TG 152 vs 99 mg/dl, P,0.01 in the studied group in
comparison with the control group, respectively. In patients with diabetes median
FGF-21 concentration was 239.9 pg/ml and was signifcantly greater in
comparison to the control group: 112.6 pg/ml P,0.01. After 2 years of follow-
up the median FGF-21 concentration was 158.5 (35.7-1480). Signifcant
correlations between FGF-21 concentrations and adiponectin (r0.24,
P,0.05), weight (r0.27, P,0.05), glucose (r0.27, P,0.05), HDL
(r0.26, P,0.05), TG (r0.27, P,005) and eGFR (r0.28, P,0.05)
were observed.
On the basis of the conducted studies it can be concluded that greater FGF-21
concentration observed in the examined group of patients with type 2 diabetes
may result from compensatory reaction to metabolic disturbances or tissue
resistance to this adipocytokine. Changes in parameters of metabolic control of
diabetes are not connected with changes of FGF-21 concentrations.
P39
The importance of the polymorphism of the AT1-receptor gene
in diabetic nephropathy patients
Melinda Kolcsar
1
& Emoke Endreffy
2
1
Department of Pharmacology, University of Medicine and Pharmacy, Tg.
Mures, Romania;
2
Department of Pediatrics, Albert Szent-Gyorgyi Medical
Centre, University of Szeged, Szeged, Hungary.
Objective of our study was to investigate the renoprotective effcacy of valsartan
and enalapril depending on the genetic polymorphisms of the angiotensinic
system.
In 32 type 2 diabetic patients with microalbuminuria, DNA extraction and
genotypization were performed. The studied polymorphism was A1166C of the
AT1-receptor gene. Two types of antiangiotensinic drugs were used in order to
reduce microalbuminuria: enalapril (20 mg/d) and valsartan (80 mg/d). The
evaluation period was 6 months for both type of drugs. A 28 days wash-out period
was insert when drugs were changed between groups. On the end of the study the
grade of microalbuminuria reduction and normalbuminuria attain were evaluated
and compared depending on genotypes.
Results
Using light cycler technology three genotypes of the angiotensin-receptor gene
A1166C polymorphism were obtained: the AA, AC and the CC one. In the
patients with CC genotype reduction of microalbuminuria was signifcantly lower
than in other patients and normalbuminuria attain was absent.
Conclusion
CC genotype of the AT1-receptor gene polymorphism represents a risk factor of
resistancy in type 2 diabetic nephropathy treatment with antiangiotensinic drugs.
Endocrine Disruptors
P3I0
Association between ischemia-modihed albumin and oxidative stress
markers in patients with metabolic syndrome
Mustafa O
zbek
1
, Evrim C akir
1
, Nujen C olak
1
, Erman C akal
1
,
Yuksel Aliyazicioglu
1,2
, Ahmet Mentese
1,2
, Ibrahim Turan
1,2
& Tuncay Delibasi
1
1
Diskapi Yildirim Beyazit Training and Research Hospital
Endocrinology and Metabolism, Ankara, Turkey;
2
Division of
Biochemistry, Faculty of Medicine, Karadeniz Technical University,
Ankara, Turkey.
Objective
The aim of this study was to determine the change in serum ischemia-modifed
albumin (IMA) level and oxidative stress markers (total antioxidant status, TAS,
total oxidant status, TOS) in patients with metabolic syndrome (metS).
We studied 52 metS patients (56.7412.75 mean age), and 36 control subjects
(54.476.52 mean age). The presence of metS was diagnosed according to
National Cholesterol Education Program Adults Treatment Panel III (NCEP-ATP
III). We measured serum IMA, TAS, TOS, and biochemical parameters in
patients with metS, and control subjects.
Results
No statistically signifcant difference was determined for serum IMA levels, in
metS patients and control group (0.2640.053, and 0.270.049 respectively)
(P0.208). There was no statistically signifcant difference between TAS and
TOS levels in metS patients (2.181.20, and 1.460.82, respectively), and in
control subjects (1.960.46, and 1.790.82 respectively) (P0.305, and 0.079).
No statistically signifcant difference was determined for serum IMA levels in
diabetic metS and control group (0.270.045, and 0.260.055, respectively)
(P0.533). Serum TOS levels were signifcantly higher in patients with
diabetic metS than in control subjects (1.310.41, and 0.750.95,
respectively) (P,0.023).
Conclusion
Results of our study revealed that IMA, TAS, and TOS levels in patients with
metS are not different from healthy controls. Further studies are required to
investigate the relation between the value of IMA and oxidative stress markers in
patients with metabolic syndrome.
P3I1
Effects of lambda-cyhalothrin on hematological parameters and
testicular functions in male rat
Mosbah Rachid
1
, Boulakoud Mohamed Salah
2
& Yousef Ibrahim Mokhtar
3
1
Department of Biology/Faculty of Sciences, University of
Boumerdes, Boumerdes, Algeria;
2
Department of Biology/Faculty of
Sciences, University of Badji Mokhtar-Annaba, Annaba, Algeria;
3
Department of Home Economic, Faculty of Specifc Education, University
of Alexandria, Alexandria, Egypt.
Lambda-cyhalothrin is a potent synthetic type II pyrethnoid used worldwide to
control a wide range of insects in agriculture, forestry, human health, and home.
The purpose of this study is to investigate the effects may occur on hematological
and testicular functions by this pesticide. Two groups of wistar rats were used, the
frst group served as control and the second experimental was received an
emulsion solution of Lambda-cyhalothrin by orale route at dose of 23 mg/kg
during 7 days. Blood samples were collected for measuring hematological
parameters. Testes and epididymes were removed for measuring semen quality
and histology. Our results showed that the insectide Lambda-cyhalothrin
decreased signifcantly the body weight (BW), and relative weight of testes
(RWT), seminal vesicles (RSV) and epididymes (RWE), whereas, weights of
liver (LW), kidney (KW) and adrenal (AW) were augmented. Hematological
analysis, revealed a reduction in red blood cells (RBC) count, hemoglobin
concentration (Hb) and in packed volume cell percent (PVC); while, the
leucocytes (WBC) count was increased. Also, the pesticide, altered the semen
quality by a reduction in spermatids number (SN), sperm count (SC) and mobility;
While, dead and abnormal sperm were increased. The histological examinations
of testes of treated rats shows testicular damage characterized by alteration of
spermatogenesis, degeneration of the germinal epithelium with presence of the
apoptotic cells and absence of the spermatozoids in certain lights. Thus, it may be
concluded that lambda-cyhalothrin can altered hematological parameters,
testicular functions and fertility in rat.
P3I2
Evaluation of paraxonase activity, malondialdehyde and thiol levels in
patients with hypogonadism before and after treatment
Fahri Bayram
1
, Gulden Baskol
2
, Umit Demirkoparan
1
, Kursad Gundogan
1
& Ilkay Cakir
1
1
Department of Endocrinology, Erciyes University Faculty of Medicine,
Kayseri, Turkey;
2
Department of Biochemistry and Clinical Biochemistry,
Erciyes University Faculty of Medicine, Kayseri, Turkey.
Objectives
Hypogonadism is associated with a higher risk of atherosclerosis and
cardiovascular disease, but the mechanisms underlying this association are not
yet fully understood. Increased oxidative stress has been associated with
development of cardiovascular and cerebrovascular diseases. We aimed to
determine serum PON1 activities, an established lipid antioxidant, MDA levels
which are end products of lipid peroxidation induced by ROS and thiol groups as
an antioxidant for evaluating oxidative stress in patients with hypogonadism
before and after replacement therapy.
Design and methods
A total of 18 male patients with untreated idiopathic hypogonadotropic
hypogonadism (mean age: 27.47.3 years) and age, sex, and weight matched
eugonadal healthy subjects (mean age: 32.67.2 years) were enrolled in the
study as a control group. Serum PON1 activity, MDA and thiol levels were
measured according to an enzymatic spectrophotometric method.
Results
Serum MDA and thiol levels were higher and PON1 activity was lower in patients
with hypogonadism than the controls before the treatment. Similarly the serum
MDA and thiol levels was higher and PON1 activity lower in patients with
hypogonadism after treatment than the controls. However, no differences were
observed between before treatment levels and after treatment levels.
Conclusions
We conclude that increased lipid oxidation and resultant decreased PON1 activity
may occur in patients with hypogonadism and that thiol levels increase to protect
these patients from oxidative stress. Since increased oxidative stress may be
related to atherosclerosis, further treatment protocols should possibly be adjusted
in the light of these fndings.
P3I3
Micronucleus evaluation in mitogen-stimulated lymphocytes of patients
with acromegaly
Ilkay Cakir
1
, Zuhal Hamurcu
2
, Hamiyet Donmez-Altuntas
2
,
Nazmiye Bitgen
2
, Zuleyha Karaca
1
, Gulsah Elbuken
1
& Fahri Bayram
1
1
Kayseri, Turkey;
2
Department of Medical Biology, Erciyes University
Faculty of Medicine, Kayseri, Turkey.
Aim
Acromegaly is an endocrine disorder characterized by sustained elevation of
circulating GH and insulin-like growth factor (IGF1). IGF1 is a potent mitogen
and has a role in the transformation of normal cells to malignant cells.
Micronucleus (MN) frequency is a biomarker of chromosomal damage, genome
instability and cancer risk. Our study aimed to evaluate spontaneous MN
frequency by using the cytokinesis block MN assay to determine genetic damage
in lymphoytes of patients with acromegaly.
The study was performed in 22 newly diagnosed patients with acrmegaly and
age/sex matched 16 healthy control subjects. MN values scored in binucleated
cells obtained from mitogen-stimulated lymphocytes of patients and control
subjects. The distribution of binucleated cells with 1, 2, 3 and more MN was
also scored.
Results
We found signifcantly higher MN frequency in lymphocytes of the patients with
acromegaly than the control subjects (P0.001). We observed that the number of
binucleated cells with two MN was greater for majority of patients with
acromegaly than for control subjects. The important fndings of this study were
the presence of binucleated cells with three but binucleated cells with three MN
were not found in any healthy subject.
Conclusion
Our results indicate that the increased MN frequency in lymphocytes of patients
with aromegaly may refect genomic instability and the increased MN frequency
in the patients may associate with elevated levels of circulating GH and IGF1.
P3I4
Paraoxonase is reduced in patients with GH dehciency: a risk factor for
atherosclerosis?
Fahri Bayram
1
, Gulden Baskol
2
, Fatih Tanriverdi
1
, Derya Kocer
2
& Ilkay Cakir
1
1
Kayseri, Turkey;
2
Department of Biochemistry and Clinical Biochemistry,
Erciyes University Faculty of Medicine, Kayseri, Turkey.
Objective
GH defciency is associated with an increased cardiovascular mortality. Increased
oxidative stress has been associated with development of cardiovascular and
cerebrovascular diseases. In the present study, we aimed to determine i) serum
PON1 activities, an established lipid antioxidant, ii) MDA levels which are end
products of lipid peroxidation induced by ROS and iii) thiol groups as an
antioxidant for evaluating oxidative stress in patients with GHD before and after
GH replacement therapy.
Methods
Fourteen patients with GHD were included in the study and compared with
healthy controls (n14). The patients were compared with 14 healthy controls
who were matched for age and sex. Serum paraoxonase 1 activity,
malondialdehyde and thiol levels were measured according to an enzymatic
spectrophotometric method.
Results
MDA levels were found as higher in the pre-treatment GHD according to both
post-treatment GHD and controls. MDA levels were also found to be decreased in
post-treatment GHD than in pre-treatment GHD. PON1 activity was found to be
lower in pre-treatment patient group when compared to both post-treatment GHD
and controls. Thiol levels were found to be lower in GHD patients in the pre-
treatment group when compared to control.
Conclusions
Increased ROS levels in GHD may result in a pro-oxidation environment, which
in turn could result in decreased antioxidant PON1 activity and thiol levels and
increased MDA levels; as a result, decrease in blood PON1 activity and increased
lipid peroxidation may have role in the pathogenesis of the atherosclerosis and
cardiovascular disease in patients with GHD.
P3I5
Normal cortisol response to high dose Synacthen and insulin tolerance
test in children and adults with Prader~Willi syndrome (PWS)
Stense Farholt
1
, Rasmus Sode-Carlsen
1
, Jens Sandahl Christiansen
2
,
John Rosendahl stergaard
1
& Charlotte Hybye
3
1
Department of Paediatrics, Centre for Rare Diseases, Aarhus University
Hospital Skejby, Aarhus, Denmark;
2
Department of Endocrinology M,
Aarhus University Hospital, Aarhus, Denmark;
3
Department of Endo-
crinology, Metabolism and Diabetology, Karolinska University Hospital,
Stockholm, Sweden.
Objective
PWS is associated with hypogonadism and partial GH insuffciency. In addition
partial insuffciency of the hypothalamic-pituitary-adrenal (HPA) axis recently
was suggested (de Lind van Wijngaarden 2008) based upon an insuffcient
response to an overnight single-dose metyrapone in 15 out of 25 (60%) children.
We aimed at further exploring this potentially dangerous condition.
Methods
During a 1-year period genetically verifed PWS patients were consecutively
enrolled. Twenty-nine women and 22 men, median age 22 years (range 0.5-44
years) and median BMI 22.6 kg/m
2
(range 13.6-42.7 kg/m
2
), were examined with
a standard high dose Synacthen test (HST). Two women and 6 men, median age
26 years (range 16-36 years) and median BMI 30.1 kg/m
2
(range 22.7-
53.0 kg/m
2
), were examined with a standard insulin tolerance test (ITT). Two
out of these 8 persons were also tested using the HST. Children admitted to our
department with acute illness had a spot cortisol measured.
Results
The HST median cortisol was 179 nmol/l (range 58-1020 nmol/l) at t
0 min
, and
was 698 nmol/l (range 474-1578 nmol/l) at t
30 min
. Three had a cortisol level
,550 nmol/l at t
30 min
, and one of them even ,500 nmol/l. In the latter the ITT
peak cortisol was 583 nmol/l.
The ITT median cortisol was 188 nmol/l (range 175-281 nmol/l) at t
0 min
, and
was 668 nmol/l (range 502-822 nmol/l) at t
30 min
.
Three children aged 0.42-4 years were admitted to the acute ward. Two had
febrile illness, and one had a frst episode of status asthmaticus. The spot cortisol
were 1372, 775 and 1080 nmol/l, respectively.
Conclusion
In this cohort of 57 children and adults with PWS we were not able to confrm an
increased risk of central adrenal insuffciency. Clinically signifcant insuffciency
of the HPA axis in PWS is rare.
Endocrine tumours & neoplasia (Generaas/y sapparted by
Narart/s)
P3I
Biochemical diagnosis strategy in pheochromocytoma
Ana-Maria Stefanescu
1
, Sorina Schipor
1
, Diana-Loreta Paun
1
,
2
& Corin-Virgil Badiu
2
1
National Institute of Endocrinology 'C. I. Parhon`, Bucharest, Romania;
2
University of Medicine and Pharmacy 'Carol Davila`, Bucharest, Romania.
Objective
The best biochemical strategy to follow in pheochromocytoma clinical diagnosis.
We selected two groups of patients: 24 pheochromocytomas (further diagnosed
by CT): 20 women and 4 men aged 20-68 years and a normotensive group: 100
subjects without endocrine disfunction: 83 women and 17 men aged 19-70 years.
In both groups we tested fve parameters: plasma normetanephrines/metane-
phrines (NMNp/MNp); urine normetanephrines/metanephrines (NMNu/MNu)
and chromogranin A (CgA) by Elisa and established median values as it follows:
NMNp: 688 vs 31.5 pg/ml; MNp: 224.5 vs 15 pg/ml; NMNu: 1526 vs
311 g/24 h; MNu: 307 vs 88 g/24 h; CgA: 269.5 vs 74.5 ng/ml. Then we
applied the analysis of receiver operating characteristic curves (ROC) with a
statistical comparison between ROC curves. The software relies on a non-
parametric test for the difference of the area under the ROC curve (AUC). For
each parameter assayed we calculated optimal threshold values corresponding to
the maximal accuracy: NMNp: 100 pg/ml; MNp: 89 pg/ml; NMNu: 741 g/ml;
MNu: 486 g/ml; CgA: 117 ng/ml. AUC values were established for each
parameter in decreased order: NMNp: 0.9783; NMNu: 0.9521; MNp:
0.9285;CgA: 0.8733; MNu: 0.8490. AUC differences between different
parameters and the confdence intervals (95% CI) were also calculated:
NMNp/MNp: 0.0498 (0.03404, 0.13363); NMNp/NMNu: 0.0263
(0.03404, 0.13363); NMNp/MNu: 0.1294 (0.02400, 0.23475), NMNp/CgA:
0.1050 (0.01374, 0.19626), MNp/NMNu: 0.0235 (0.11494, 0.06785);
MNp/MNu: 0.0796 (0.03630, 0.19547), MNp/CgA: 0.0552 (0.06270,
0.17312); NMNu/MNu: 0.1031 (0.00818, 0.21444); NMNu/CgA: 0.0788
(0.01197, 0.16947); MNu/CgA: 0.0244(0.16229, 0.11354). Signifcant
AUC differences were established between NMNp/CgA: P0.0241 and between
NMNp/MNu: P0.0161.Our statistics revealed NMNp as the best diagnosis
marker for pheochromocytoma, followed in decreased order by NMNu, CgA,
MNp, MNu.
Conclusions
Plasma NMNp proved to be the best biochemical test for clinical diagnosis of
pheochromocytoma.
P3II
Carcinoid syndrome: biochemical diagnosis
Sorina Schipor
1
, Ana-Maria Stefanescu
1
, Diana-Loreta Paun
1,2
,
1,2
& Corin-Virgil Badiu
1,2
1
National Institute of Endocrinology 'C. I. Parhon`, Bucharest, Romania;
2
University of Medicine and Pharmacy 'Carol Davila`, Bucharest, Romania.
Objective
To introduce the best biochemical strategy for carcinoid syndrome diagnosis.
We selected two groups of patients: one group of 75 patients suspected of
carcinoid syndrome: 57 women aged between 19 and 78 years and 18 men aged
17-81 years and a 80 healthy subjects group without endocrine disfunction: 56
women aged between 27 and 78 years and 24 men aged 17-81 years. We
established median values for all parameters in carcinoid group versus normal
group as it follows: serotonin (5-HT): 248 vs 124 ng/ml; 5-hydroxy-indole-acetic
acid (5-HIIA): 7 vs 2.7 mg/24 h and chromogranin A (CgA): 296 vs 59 ng/ml.
We introduced the analysis of receiver operating characteristic curves (ROC) for
all parameters assayed and it was possible to calculate optimal threshold values
corresponding to maximal accuracy (ACC) as it follows: for 5-HT: 200 ng/ml
(0.8452); for 5-HIIA: 4 mg/24 h (0.7548) and for CgA: 99 ng/ml (1.0000). The
software relies on a non-parametric test for the difference of the area under the
ROC curve (AUC). We calculated AUC differences between different parameters
and also the confdence intervals (95% CI) as it follows: CgA/5-HT: 0.0858
(0.04143, 0.13023); CgA/5-HIIA: 0.2318 (0.15486, 0.30881); 5-HT/5-HIIA:
0.1460 (0.07669, 0.21531).
Conclusion
Our statistics revealed CgA as the best diagnostic marker for carcinoid syndrome:
true positive results (tp): 100% followed by 5-HT: tp: 68% and by 5-HIIA: tp:
61.33%.
P3I8
Identihcation of a novel mutation of MEN1 gene in a patient with
persisting primary hyperparathyroidism
Labrini Papanastasiou
1
, Anastasia Prevoli
1
, Theodora Pappa
1
,
Smaragda Kamakari
2
, Paraskevi Kafritsa
1
, Vassiliki Metaxa-Mariatou
2
,
Athina Markou
1
& George Piaditis
1
1
Department of Endocrinology and Diabetes, General Hospital of Athens
'G.Gennimatas`, Athens, Attika, Greece;
2
Molecular Diagnostics
Laboratory 'Biogenomica`, Athens, Attika, Greece.
Background
Multiple endocrine neoplasia type 1 (MEN1) syndrome is an autosomal dominant
disorder characterized by the presence of endocrine and nonendocrine tumors. Until
recently, more than 450 different germline mutations have been reported in MEN1
patients involving frameshift deletions, insertions, as well as nonsense mutations.
Aim
To report a novel mutation in MEN1 gene in a young female with persisting
primary hyperparathyroidism.
Methods
A 28-year-old female was admitted to our Department with the suspicion of primary
hyperparathyroidism. The patient has a medical history of partial thyroidectomy with
removal of the two right parathyroid glands shown to be hyperplastic in histology.
Biochemistry revealed calcium levels in the upper normal limit with inappropriate
increased parathyroid hormone levels. Enlargement of the residual parathyroid glands as
well as a tumor in the head of pancreas were identifed. The presence of primary
hyperparathyroidismand a pancreatic tumor - despite the negative family history - made
the diagnosis of MEN1 syndrome plausible and the patient underwent genetic testing.
Results
DNA testing from peripheral lymphocytes revealed a deletion (1826delG) at codon
572 in exon 10 of MEN1 gene, resulting in early termination of the MEN1 transcript.
Conclusion
We report a novel germline mutation, i.e. a frameshift deletion of the MEN1 gene, in
a MEN1 subject.
P3I9
No secreting multiple glucagonoma: one case
Jean Paul Ory & Simona Barbat
CHI, Vesoul Haute Saone, France.
Glucagonoma is an exceptional tumor but malignant in 80% of cases. Characteristic
signs (migrating necrotic erythema, loss of weight) are connected with glucagon
secretion, therefore variable. In this case report, the connection with pre-existent
diabetes seems fortuitous.
Case report
Mr L, 60 years old, sent in November 2007 for type 2 diabetes 15 years old,
unbalanced (HbA1C: 13%), treated by metformin and sulfonylurea, neglected.
There is a polyneuropathy, an arterial hypertention, a renal failure (creatinine
clearance: 60 ml/min) with proteinuria (500 mg/24 h). After discussion, insuliniza-
tion (Premix 2/day) is accepted by patient.
Four months later, HbA1Cis at 6.8%. Three months later, the HbA1Cis stable without
hypoglycaemia but the proteinuria has worsened at 2 g/24 h. The established fact of a
lipasaemia at 80 u justifes the abdominal TDM: nodular formation of 1 cm in
diameter onthe anterior face of the pancreatic uncus. Echoendoscopy permits a biopsy
of two identifed lesions (8 and 2 mm): glucagonoma (confrmed by immunomarking)
but malignancy is impossible to specify. The search for NEM-1 is negative. The
positive octreoscan confrms the two localizations. Cephalic duodeno-pancreatect-
omy expanded to the body is executed. After effects are simple. Histologically, three
tumours are discovered of 7.2 and 1 mmin diameter, without any sign of malignancy.
This glucagonoma is no secreting, of quasi fortuitous discovery. The patient is now
treated by basal/bolus insulinization and carefully looked after. A posteriori, was it
necessary to operate this patient? Whithout strict proof of mildness of pancreatic
tumour, our choice was justifed.
P380
RET codon 618 mutations is the most frequent phenotype in Saudi
families with multiple endocrine neoplasia type 2A
Tariq Nasser
1
, Faiza Qari
2
, Abdullah Karawgh
1
& Jumanah Al Aama
2
1
King Abdulaziz National Guard Medical City, Jeddah/Western Region,
Saudi Arabia;
2
King Abdulaziz University, Jeddah/Western Region,
Saudi Arabia.
Objective
To evaluate the prevalence of the RET mutation and the genotype-phenotype
relation in Saudi patients (families) with multiple endocrine neoplasia type 2A
(MEN2A) or familial medullary thyroid carcinoma (FMTC).
Design
Cross-sectional study.
A total of ten unrelated Saudi families with germline mutation of the RET
protooncogene and/or immunohistochemistry diagnosis of MTC were identifed.
Before undergoing genetic testing, all patients and their at risk family members
had given their written informed consent in accordance with institutional ethic
guidelines and national regulations. The presence of pheochromocytoma (PHEO)
or hyperparathyroidism (HPT) was excluded by extensive testing of all affected
individuals and their at risk family. Seventy-eight family members were
evaluated by medical history, physical examination and biochemical measure-
ments of fasting serum calcium, basal plasma calcitonin (CT) levels, plasma
parathyroid hormone (1-84) (PTH), 24-h urinary excretion of catecholamines and
metabolites, and DNA analysis. Genomic DNA was isolated from peripheral
blood leucocytes using standard procedure. Exons 10, 11, 13, 14 and 16 of the
RET proto-oncogene were analyzed by single strand conformation polymorphism
analysis, direct DNA sequencing and/or restriction enzyme analysis.
Results
Among the 78 individuals, a total of 46 individuals with hereditary MTC were
enrolled in this study. Thirty (aged 12-65 years), were patients previously
thyroidectomized for MTC. In addition; molecular screening identifed another 16
individuals without clinical evidence of disease but at risk because of an affected
relative. From this MTC group ten patients had been operated on for PHEO and
four for HPT. The diagnosis of MTC, PHEO and parathyroid hyperplasia was
confrmed by pathological examination after operation. Of the ten families with
hereditary MTC analyzed, fve were diagnosed with MEN2A and fve with
FMTC. In two of fve MEN2A family`s mutation was located at codon 618 in
exon 10. The incidence of medullary thyroid carcinoma (MTC), pheochromo-
cytoma (PCC) and hyperparathyroidism (HPT) in the 25 MEN2A patients was
100%, 52 and 16%, respectively; the onset of MTC in MEN2A patients was
earlier than that of PCC and HPT. In our series, the most frequent phenotype was
the MEN2A syndrome with codon 618 mutations (46.6%), followed by 634
mutation 44.2%. In 1 of 10 families, screening of exons 10, 11, 13, 14 and 16 was
negative for RET mutations. Of the fve families classifed as MEN2A, three had a
mutation at codon 634, exon 11 while the other tow families presented the
syndrome of MEN2A had a mutation at codon 618.
Discussion
Mutations that cause activation of RET have been well characterized and several
groups have studied the disease phenotype-genotype. Differences in the
frequency of specifc RET mutations in MEN2A phenotypes have been found
in series from different countries, suggesting that the occurrence of these
mutations may be infuenced by genetic background. We analyzed the RET proto-
oncogene from 79 patients from 10 unrelated Saudi families. A total of 46
individuals with hereditary MTC were enrolled in this study. It is interesting to
report that the nature of the mutations in our MEN2A families was different from
the results of the International RET mutation consortium analysis which showed
that 634 mutation was found in 86% of all cases of MEN2A.
Although the small number of our families is not suffcient for statistical analysis,
the high frequency of 618 mutation may refect different hereditary factors in our
population.
Conclusion
We showed the frequency profle of RET proto-oncogene mutations in a sample
of 10 unrelated Saudi`s families with hereditary MTC. The most frequent RET
proto-oncogene mutations in Saudi`s families with MEN2A and familial
medullary thyroid carcinoma (FMTC) is mutation in codon 618.
P381
CYP24A1 haplotypes are associated with differentiated thyroid
carcinoma
Marissa Penna-Martinez
1
, Elizabeth Ramos-Lopez
1
, Julienne Stern
1
,
Heinrich Kahles
1
, Nora Hinsch
2
, Martin-Leo Hansmann
2
, Ivan Selkinski
3
,
Frank Grunwald
3
, Christian Vorlander
4
, Robert A Wahl
4
, Wolf
O Bechstein
5
, Stefan Zeuzem
1
, Katharina Holzer
5
& Klaus Badenhoop
1
1
Department of Internal Medicine I, University Frankfurt, Frankfurt am
Main, Germany;
2
Senckenberg Institute for Pathology, University Frankfurt,
Frankfurt am Main, Germany;
3
University Frankfurt, Frankfurt am Main, Germany;
4
Department of
Surgery, Buegerhospital Frankfurt, Frankfurt am Main, Germany;
5
Department of Surgery, University of Frankfurt, Frankfurt am Main,
Germany.
Background
Previously, we reported an association of vitamin D receptor (VDR)
polymorphisms and differentiated thyroid cancer (DTC) risk. The aim of the
present study was to investigate other vitamin D pathway genes such as
CYP27B1, CYP2R1 and CYP24A1 which code for enzymes that, respectively,
synthesize and degrade 1,25(OH)
2
D
3
in patients with DTC and healthy controls
(HC). Also its infuence on 25(OH)D
3
and 1,25(OH)
2
D
3
plasma levels in DTC
was evaluted.
Two hundred ffty-fve patients with DTC (papillary (PTC): n205; follicular
(FTC): n50) and HC (n269) German origin, were genotyped for CYP2R1
(rs10741657), CYP27B1 (rs10877012) and CYP24A1 (rs2248137, rs2296241)
using real time PCR. Furthermore, the 25(OH)D
3
, and 1,25(OH)
2
D
3
plasma levels
in patients were measured by RIA.
Results
No difference was observed between DTC patients and HC in the genotype
frequencies of the named polymorphisms. However, the haplotype rs2248137C/
rs2296241A for CY24A1 (13.1 vs 20.4%; p corrected (pc)0.02) was less
frequent in the PTC whereas the haplotype rs2248137C/rs2296241G (57.8 vs
41.4%; pc0.01) was more fequent in the FTC compared to HC. In addition there
was no correlation between 25(OH)D
3
or 1,25(OH)
2
D
3
levels and the
rs10741657, rs10877012, rs2248137 and rs2296241 polymorphisms in DTC
patients.
Conclusion
Haplotypes within of the CYP24A1 gene appear to be associated with
differentiated thyroid cancer in Germans. While the haplotype 'CA` for
CYP24A1 polymorphisms confer to protection from PTC, the haplotype 'CG`
appeared to be associated with an increased FTC risk. These fndings suggest
further alterations in the vitamin D system that possibly infuence the
pathogenesis of DTC. Such an alteration of vitamin D pathways may affect the
thyroid tissue and may not be apparent in the circulation. Since, this is the frst
report associating CYP24A1 polymorphisms with thyroid carcinoma, these
fndings need to be confrmed in studies with larger numbers of patients and in
other populations.
P382
Surgical treatment of insulinomas: a single-institution experience of
48 patients
Nicolas Carrere
1
, Corneliu Voronca
1
, Delphine Vezzosi
3
, Marie Danjoux
1
,
Antoine Bennet
3
, Charles Henri Julio
1
, Eric Bloom
1
, Janick Selves
1
,
Rosine Guimbaud
2
, Philippe Otal
2
, Louis Buscail
2
, Bernard Pradere
1
& Philippe Caron
3
1
CHU Purpan, Toulouse, France;
2
CHU Rangueil, Toulouse, France;
3
CHU Larrey, Toulouse, France.
In a monocentric study on 48 patients with insulinomas treated between 1988
and 2008, we evaluate the results of the radiological and surgical procedures,
and determine prognostic factors regarding the recurrence risk. Clinical,
radiological, and histopathological fndings were analysed along with long-term
follow-up after surgery. Kaplan-Meier analysis studies recurrence-free
survival, and uni- and multi-variable analyses determine prognostic factors
related to recurrence risk. The mean age of patients was 51 years (22-78).
Echoendoscopy and MRI-scan had a sensitivity of 90 and 85%, respectively.
The surgical procedures were duodenopancreatectomy (n12), left-sided
pancreatectomy (n21), central pancreatectomy (n5) and enucleation of
the tumor (n7). In three patients (6%) per-operative examination failed to
localize a tumor (nesidioblastosis2, insulinoma1). On histopathological
examination, the insulinomas were benign (n30), of uncertain behavior
(n11) and well differentiated endocrine carcinomas (n4). During a median
follow-up of 42 months, nine patients experienced a recurrence: three patients
with MEN1, four patients with well differentiated endocrine carcinomas, and
two patients with a tumor classifed as benign who presented liver and regional
lymph nodes during follow-up. Only one patient died out of carcinoma
progression. In patients with insulinoma totally removed by surgery, the
recurrence-free survival rate was 72% after 5 years. A uni-variable analysis
revealed that the following factors were predictive of recurrence: histopatho-
logical diagnosis of carcinoma (P,0.001), lymph node invasion (P,0.001),
expression of Ki67 1% (P0.003), and presence of MEN1 mutation. Only
endocrine carcinoma and MEN1 disease were identifed as signifcant
independent factors of recurrence. In conclusion, in this series of operated
patients with insulinoma, the high recurrence rate (28% after 5 years) is mainly
related to endocrine carcinomas. This underlines the importance of
histopathological criteria for the prognostic evaluation, and of the long-term
follow-up after surgical resection, even when the pancreatic endocrine tumor is
diagnosed as benign.
P383
Temozolomide treatment in aggressive pituitary tumors and pituitary
carcinomas: a French multicenter experience
Gerald Raverot
1,2
, Nathalie Sturm
3
, Florence De Fraipont
3
, Philippe Caron
4
,
Marie Muller
3
, Christine Cortet-Rudelli
5
, Sylvie Salenave
6
,
Richard Assaker
3
, Henry Dufour
7
, Stephan Gaillard
8
, Patrick Francois
9
,
Emmanuel Jouanneau
1,2
, Miche`le Bernier
8
, Dominique Figarella-Branger
7
,
Claude-Alain Maurage
5
, Jacqueline Trouillas
1,2
, Francoise Borson-Chazot
1
& Thierry Brue
7
1
Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France;
2
INSERM, U842, Universite de Lyon, Lyon 1, UMR-S842, Faculte de
Medecine Lyon-Est, Lyon, France;
3
CHU Grenoble, Grenoble, France;
4
CHU de Toulouse, Toulouse, France;
5
CHRU Lille, Lille, France;
6
Groupement hospitalier universitaire Sud, AP-HP, LE KREMLIN-
BICETRE, France;
7
Assistance-Publique Ho`pitaux de Marseille and
Universite de la Mediterranee, Marseille, France;
8
Ho`pital Foch, Suresnes,
France;
9
CHRU, Ho`pital Bretonneau, Tours, France.
Context
To date ten publications reporting only 16 patients with pituitary aggressive
tumors or carcinomas treated with temozolomide are available. Expression of
O
6
-methylguanine-DNA-methyltranferase (MGMT), a DNA repair protein
implicated in the resistance to temozolomide, was studied in only 10 out of
these 16 patients. It has been suggested that low expression of MGMT could
predict temozolomide effcacy.
Objective
The aim of this study was to describe the effects of temozolomide treatment in a
larger number of patients with aggressive pituitary tumors or carcinomas and to
evaluate the possible prognostic signifcance of MGMT promoter methylation
and protein expression.
Patient
From a French multicenter study, we report eight patients; fve carcinomas (three
PRL and two ACTH) and three aggressive pituitary tumors (one PRL and two
ACTH); treated with temozolomide administered orally for 4-24 cycles. Three
out of the eight patients were considered as responder to temozolomide because of
signifcant tumoral shrinkage and decreased of PRL/ACTH secretion.
Design
MGMT expression, assessed by immunohistochemistry and MGMT promoter
methylation analysed by pyrosequencing, were studied in seven patients.
Results
Temozolomide treatment was effective in three out of the eight patients (two
ACTH and one PRL tumors). Three cycles of temozolomide were suffcient to
identify patients responding to temozolomide treatment; in non-responders,
additional cycles did not improve treatment effcacy even in association with
carboplatine and etoposide. Tumoral response to temozolomide was not predicted
by MGMT expression since MGMT expression was positive (30%) in one
responder and negative in two out the fve non-responders patients. Similarly,
MGMT promoter methylation (3/7 tumors) did not predict MGMT expression.
Conclusion
Temozolomide treatment could be an effective option for some aggressive
pituitary tumors or carcinomas but MGMT status is a poor predictor of treatment
outcome that cannot be used to select patients who may beneft from this
treatment.
P384
Real-time PCR is useful to detect menin gene deletions
Maria Chiara Zatelli, Carlo Filieri, Federico Tagliati, Mattia Buratto,
Veronica Calabro`, Maria Rosaria Ambrosio & Ettore C degli Uberti
Familial pituitary adenoma is frequently associated with germinal mutations of
several genes, including menin gene. MEN1 syndrome is an autosomic dominant
disease, characterized by parathyroid adenomas, endocrine gastroenteropancrea-
tic tumors, and pituitary adenomas, due to inactivating mutations of the MenI
gene (11q13). MEN1 mutations are scattered within and around the menin open
reading frame and are mainly represented by single nucleotide polymorphisms
(SNPs), and small deletions/insertions, which can be detected by genomic DNA
direct sequencing. However, heterozygous wide deletions in the menin gene
cannot be detected by direct sequencing and other techniques have to be
employed to characterize the genetic base of some syndromic families. We
employed a real-time PCR application, the TaqMan Copy Number Assay, to
evaluate a family in which we failed to identify MEN1 SNPs or deletions/inser-
tions by direct sequencing, despite a clear clinical picture of MEN1 syndrome.
By directly evaluating the number of genomic copies by quantitative PCR, we
identifed a wide deletion of the MEN1 gene involving 50% of exon 1 and 100%
of exon 2, in three affected family members, but not in the other seven family
members, that are, so far, clinically unaffected. We also evaluated the presence of
the same genetic alteration in a group of ten unaffected subject, without family
history of endocrine tumors, and none of them displayed exon 1 and 2 deletion.
Therefore, this new approach allowed us to correctly diagnose three MEN1
patients that were, so far, considered as MEN1 phenocopies. More importantly,
we were able to exclude the presence of any MEN1 genetic alteration in the
unaffected family members. These results further underline the importance of the
new biotechnology approaches in the diagnosis of genetically determined
endocrine diseases.
P385
Role of piuitary tumour transforming gene 1 in medullary thyroid
carcinoma
1
, Federico Tagliati
1
, Mattia Buratto
1
,
Mariarosa Pelizzo
2
, Giancarlo Pansini
3
, Maria Rosaria Ambrosio
1
& Ettore C degli Uberti
1
1
2
Department of
Medical and Surgical Science, General Surgery III, University of Padua,
Padova, Italy;
3
Section of General Surgery, Department of Surgery,
University of Ferrara, Ferrara, Italy.
Pituitary tumour transforming gene 1 (PTTG1) is over-expressed in a variety of
endocrine-related tumors. We investigated PTTG1 expression in human C-cell
hyperplasia (CCH), human medullary thyroid carcinoma (MTC) and in the human
MTC cell line, TT. PTTG1 expression was signifcantly higher (P,0.01) in CCH
(threefold), in papillary thyroid cancer and in MTC (fvefold) than in normal
thyroid, and in MTC lymph-node metastases as compared to primary lesions
(approximately twofold; P,0.05). PTTG1 mRNA and protein correlated with
tumor diameter and TNM status (P,0.05). In TT cells, PTTG1 silencing did not
completely block DNA synthesis, but signifcantly reduced [
3
H]Thymidine
incorporation (^50%; P,0.01) for up to 3 days. Furthermore, PTTG1
overexpression signifcantly decreased cell proliferation, lasting for at least
3 days (30-60%; P,0.01). Therefore, PTTG1 levels correlate with tumor
aggressiveness. PTTG1 silencing and overexpression cause reduced MTC cell
proliferation, supporting the hypothesis that PTTG1 is an important determinant
of C-cell neoplastic proliferation.
P38
Everolimus reduces human ACTH-secreting pituitary adenoma /n r/tra
cell viability
1
, Mariella Minoia
1
, Carlo Filieri
1
, Federico Tagliati
1
,
Daniela Mole`
1
, Massimo Scanarini
2
, Maria Rosaria Ambrosio
1
& Ettore degli Uberti
1
1
2
Division of
Neurosurgery, University of Padova, Padova, Italy.
Everolimus (RAD001), an immunosuppressant drug, has antineoplastic activity in
human neoplasia, including endocrine tumors, due to its ability to inhibit the AKT
down-stream signaling pathway. It has been demonstrated that AKT is over-
expressed and up-regulated in pituitary tumor, including ACTH-producing
pituitary tumors, that are still orphan of an effective medical therapy. We therefore
investigated the effects of RAD001 on cell viability, apoptosis and mTOR
phosphorilation in 10 human ACTH-producing pituitary tumors in primary culture.
Cells were treated with 10 nM-1 M RAD001, 50 nM IGF1, and/or 10 nM
SOM230 (a somatostatin receptor multiligand). After 48 h, cell viability was
evaluated with a colorimetric method, apoptosis with caspase 3/7 assays and
mTOR phosphorylation by a specifc ELISA kit. RAD001 signifcantly and dose-
dependently reduced cell viability in eight out of ten cultures (15 to 25%;
P,0.05), promoted apoptosis (20 to 25%; P,0.05), reduced mTOR
phosphorylation (30 to 42%; P,0.05). IGF1 signifcantly promoted cell
viability (40%; P,0.01), inhibited apoptosis (34%; P,0.05) and induced
mTORphosphorylation (35%; P,0.05), effects that were completely abolished
by co-treatment with 100 nM and 1 M RAD001. SOM230 slightly but
signifcantly reduced cell viability (12%; P,0.05) and strongly potentiated
RAD001 inhibitory effects (58%; P,0.01). Our data demonstrate that RAD001
inhibits cell viability in selected ACTH-secreting pituitary adenomas, by inducing
caspase 3/7 activity with a mechanism involving IGF1 signaling, which is
enhanced by SOM230. Our results suggest that RAD001 acts as a pro-apoptotic
stimulus, inducing the extrinsic pathway, and might represent a possible medical
treatment aiming at controlling pituitary adenoma growth in Cushing`s disease.
P38I
GHinuences breast cancer chemoresistanec independently of cell cycle
perturbations
Mariella Minoia, Carlo Filieri, Federico Tagliati, Daniela Mole`,
Stefania Leoni, Maria Rosaria Ambrosio, Ettore C degli Uberti
& Maria Chiara Zatelli
GH and insulin-like growth factor 1 (IGF1) are known to promote breast
carcinogenesis. Even if breast cancer (BC) incidence in not increased in female
acromegalic patients, mortality is greater as compared to general population. In
order to evaluate whether GH/IGF1 excess might infuence BC response to
therapy, accounting for the increased mortality, we evaluated the effects of GH
and IGF1 on cell proliferation of a BC cell line, the MCF7 cells, in the presence of
doxorubicine (D), frequently used in BC chemotherapy. We found that in serum-
free conditions GH and IGF1 induce MCF7 cell growth and protect the cells from
the cytotoxic effects of D. GH effects are direct and not mediated by IGF1, since
they are apparent also in the presence of an IGF1 receptor blocking antibody and
disappear in the presence of the GH antagonist pegvisomant. resistance to
chemotherapic drugs may be due to MDR-1 gene expression, encoding for the
P-glycoprotein, a transmembrane pump which detoxifes the intracellular
compartment. However, RT-PCR for MDR1 and immunofuorescence for P-gp
and failed to identify any induction of P-gp expression by GH. In order to verify
whether other GH-induced gene transcription mechanisms were involved, we
transfected MCF7 cells with a plasmid encoding for the luciferase gene under the
control of the c-fos promoter. c-fos is an early response gene, classically induced
by GH. We found that luciferase activity was induced by treatment with GH, an
effect blocked by pegvisomant. Treatment with D did not modify basal luciferase
activity, but blocked GH transcriptional activity. Moreover, GH treatment did not
infuence the cell cycle progression abnormalities induced by D. These data
altogether indicate that GH can directly induce resistance to chemotherapic drugs
with a mechanism that does not involve GH-induced early gene transcription not
cell cycle progression and support the hypothesis that GH excess might hamper
BC treatment, possibly resulting in an increased mortality.
P388
Human presentation of MEN X syndrome
Caroline Maere
1
, Natalia Pellegata
3
, Marleen Praet
2
, Mimi Giri
1
& Guy T`Sjoen
1
1
Department of Endocrinology, Ghent University Hospital, Gent, Belgium;
2
N. Goormaghtigh Institute of Pathology, Ghent University Hospital, Gent,
Belgium;
3
Helmholtz Zentrum Munchen, Institute of Pathology,
Neuherberg, Germany.
Different multiple endocrine neoplasia (MEN) syndromes have been described in
humans. These conditions are characterised by different combinations of multiple
endocrine tumors based on specifc genetic mutations, mainly the MEN1 gene
(MEN type 1 syndrome) or in the RET proto-oncogene (MEN type 2).
A syndrome encompassing components of both MEN type 1 and type 2, but
which is caused by a mutation in the Cdkn1b gene encoding p27, has been
described in rats, the so-called MEN X syndrome.
We here present the case of a man with neurofbromatosis, who was diagnosed
with a pheochromocytoma, C-cell hyperplasia, and a silent corticotroph pituitary
adenoma.
Genetic testing confrmed the presence of the NF-1 mutation (split site mutation at
exon 17 (IVS172TC)) without mutations at the RET proto-oncogene (exon
10, 11, 13, 14, 15, 16; MEN type 2 syndrome), VHL-gene (exon 1-3, Von
Hipple-Lindau), or SDHD-gene (at exon 1-4). Immunohistochemical staining of
the pheochromocytoma and the pituitary mass showed reduced expression of the
p27 protein in both tissues. Blood DNA of the patient was sequenced, but did not
demonstrate the pathogenic mutations in CDKN1B/p27, as it occurs in the MEN
X-affected rats.
In conclusion, to our knowledge our case appears to be the frst human presenting
with features belonging to both MEN type 1 and MEN type 2B. However, we
could not confrm a genetic background similar to that reported for the MEN X
syndrome in a rat model.
P389
The diagnostic value of PTH concentration in the needle washout after
hne-needle biopsy of suspicious cervical foci in patients with
hyperparathyroidism
Slawomir Mikosinski
1
, Piotr Jarek
1
, Jacek Makarewicz
1
, Stanislaw Sporny
2
& Lech Pomorski
3
1
Department of Nuclear Medicine and Oncological Endocrinology, Maria
Sklodowska-Curie Memorial Hospital, Zgierz, Poland;
2
Department of
Pathology, Medical University of Lodz, Lodz, Poland;
3
Department of
General and Oncological Surgery, Medical University of Lodz,
Lodz, Poland.
Background
Successful parathyroidectomy depends on recognition and excision of all
hyperfunctioning parathyroid glands.
The aim of the study was to estimate the diagnostic value of PTH concentration in
the needle washout after fne-needle aspiration of foci suggestive of enlarged
parathyroids in patients (pts) with hyperparathyroidism (HP).
Of 18 pts were studied (15 females, 3 males); 16 pts with primary HP (two
recurrent), two with secondary HP, presenting with one or more intrathyroid foci
on US. Serum PTH (PTH intact; Immulite 2000), total and ionized calcium,
phosphate, alkaline phosphatase concentration were measured in all pts.
99m
Tc-sestamibi parathyroid SPECT scintigraphy was performed. Dual tracer
parathyroid
99m
Tc-pertechnetate/
99m
Tc-sestamibi planar subtraction scintigraphy
was recorded (X-Ring Mediso). Ultrasound guided (AU3 Partner, EsaoteBiome-
dica; 10 MHz) fne-needle biopsy was performed and sent for cytology. The
needle (25G) was washed out with 125 l (frst biopsy) and 400 l (second
biopsy) of 0.9% saline. PTH concentrations (using the same PTH intact kit) in the
washouts were measured. A positive cutoff value for PTH washout concentration
was defned as superior to the PTH serum level. A preoperative `map` of the
intrathyroid lesion was drawn. The drawing was placed above the patient`s head
to serve as a guide for the surgeon performing open, focused surgery.
Results
All pts revealed parathyroid lesions. Hyperplasia was found in 11 pts (11/18;
61.1%), adenoma in 6 pts (6/18; 33.3%) and in one case (1/18; 5.6%) parathyroid
cancer was suspected in pathology, but no metastatic foci have been diagnosed so
far. All but one patient had elevated PTH washout concentrations-sensitivity
94.4%; positive predictive value (PPV) 100%. Positive scintigraphy (visible
parathyroids) was found in 9 pts (9/18; 50.0%), positive cytology (detected
parathyroid cells) was found in 12 pts (12/18; 66.7%).
Conclusions
An elevated PTH washout concentration identifes an intrathyroid focus as
enlarged parathyroid gland with high PPV and high sensitivity. With this
diagnostic technique, minimally invasive surgery can be implemented even in
negative scintiscan cases, thus sparing the unchanged thyroid gland.
P390
Sex hormone-binding globulin (SHBG) gene pentanucleotide TAAAA
repeat and D327N polymorphism in breast cancer: link to estrogen
sensitivity
Claudia Piccioni
1
, Maria Graziella Catalano
1
, Giuseppe Boccuzzi
1,2
& Nicoletta Fortunati
2
1
Dipartimento di Fisiopatologia Clinica, Universita` di Torino, Torino, TO,
Italy;
2
SCDU Endocrinologia Oncologica, AUO San Giovanni Battista,
Torino, TO, Italy.
Sex hormone-binding globulin (SHBG) is characterized by the unique ability of
regulating estrogen free fraction and cross-talking with estradiol pathways in
breast cancer cells, therefore reducing breast cancer cell growth and
proliferation. In addition, the presence of the D327N (Asp327Asn, rs6259)
single nucleotide polymorphism (SNP) of SHBG exon 8 confers a protective role
to SHBG in breast cancer. Another polymorphism that has been receiving quite
a lot of attention is the pentanucleotide repeat polymorphism (PNRP
(TAAAA)
n
) within the human SHBG promoter that is characterized by a
number of repeats ranging from 6 to 11. However, it has already been studied in
different conditions, like PCOS, CAD, osteroporosis, at present no data are
available about the (TAAAA)
n
polymorphism and breast cancer. In the present
study, we evaluated the (TAAAA)
n
polymorphism of SHBG gene promoter in
198 breast cancer patients (age 5713 years) and 61 healthy women (age 45
18 years), previously characterized in our laboratory for D327N SNP
(Becchis et al. BCRT 1999; Costantino et al. BCRT 2008). The TAAAA repeat
region was amplifed, starting from genomic DNA of each patient, with PCR
using the following primers: forward 5
-GCTTGAACTCGAGAGGCAG;
reverse 5
CAGGGCCTAAACAGTCTAGCAGT; amplifed products were

analyzed by PAGE and the number of TAAAA repeats determined; results
were confrmed by DNA sequencing. Frequencies for the different alleles were
estimated by direct gene counting and compared with the
2
-test. Signifcance
test used a two-tailed P values and statistical signifcance was attained for
P,0.05. Breast cancer patients presented a signifcantly higher frequency of
(TAAAA)
8
with respect to healthy controls alleles (40 vs 24%; P,0.05). The
higher frequency of (TAAAA)
8
was also observed in tumours positive for
estrogen and progesterone receptors (ER/PR) (38%), but not in ER/PR
tumours (20%). Strong linkage disequilibrium between (TAAAA)
8
and D327N
SNP was also observed in these patients (healthy controls 39%; all breast
cancers 63%; ER/PRbreast cancers 76%; ER/PR33%). In conclusion,
the (TAAAA)
8
together with D327N SNP are strongly associated to estrogen
sensitivity of breast cancer. SHBG genetic background could therefore be a
useful tool in the evaluation of estrogen sensitivity of breast cancer.
P391
Anti-tumor activity of the tumor-vascular-disrupting agent ASA404
(vadimezan) in endocrine tumor models
Constanze Hantel
1
, Roman Franzev
1
, Alexandra Ozimek
2
,
Thomas Mussack
2
& Felix Beuschlein
1
1
Endocrine Research Unit, Medizinische Klinik-Innenstadt, Ludwig-
Maximilians-University, Munich, Germany;
2
Department of Surgery,
Vascular disrupting agents (VDAs) differ from angiogenesis inhibitors by
attacking established tumor blood vessels rather than preventing growth of new
ones. We investigated effects of the tumor-VDA ASA404 against neuroendocrine
tumors of the gastroenteropancreatic system (GEP-NETs) and adrenocortical
carcinoma (ACC) 24 h after treatment of BON and NCIh295 tumor bearing mice
with ASA404 (A), paclitaxel (P) or the combined administration (AP).
A signifcant decrease in cell proliferation (Ki 67 index, %) was detectable for
BON tumors after all treatments (A: 51.60.7, P: 55.20.8 and AP: 47.9
0.6; each P,0.0001 versus controls 60.20.8), for NCIh295 tumors only
after P treatment (A: 46.61.5, P0.87; P: 43.41.4, P,0.05 and AP: 45.8
0.9, P0.4; versus controls 46.881). BON tumors treated with A or AP
exhibited extensive necrotic areas not apparent in the control or P groups. TUNEL
and CD31 staining showed that A or AP treatments resulted furthermore in a
signifcant increase of apoptotic cells (%) in BON tumor (A: 28.82.7, AP:
34.33.6; each P,0.0001 versus controls 9.21.3 and P: 10.11.5) and a
signifcant loss of microvessels compared with controls and P treatment (A: 7.3
0.8, P0.0003 and AP: 5.420.4, P,0.0001 versus controls 11.50.64
and versus P: 12.61.1). Interestingly, no signifcant effects on tumor
morphology, apoptosis or microvessel density were detectable in NCIh295
tumors. To evaluate the mechanisms which cause these differences we initiated
further in vitro analyses. As TNF-signaling is assumed to mediate parts of ASA
404 induced effects we investigated induction of apoptosis and detected a fourfold
higher rate of apoptosis in BON cells after TNF treatment compared with
NCIh295 cells (basal: 100%2; BON: 823.1%34.5 versus NCIh295: 244.2%
12.4; P0.007). Thus, while ASA404 (vadimezan) treatment holds promise
in the treatment of GEP-NETs, the utilized tumor models might help to delineate
molecular mechanisms involved in VDA induced anti-tumor activity.
P392
Primary hyperparathyroidism and hyperuricaemia and bone turnover
Petr Broulik
Third Internal Clinic, Prague, Czech Republic.
As the major end product of purine metabolism urate is produced by most adults
at the rate of 700 mg/day. Although a small proportion of the urate pool may by
derived from the diet the greatest amount results from tissue breakdown. Both
hyperuricaemia and gout occur with increased frequency in hyperparathyroidism
(PHPT). PHPT is associated with a high bone turnover and increased turnover of
nucleic acid of cellular origin. Urate metabolism was studied in 106 patients with
PHPT. They had compared to controls signifcantly higher serum urate and
reduction of the clearance of urate. In 28 of the tested patients with PHPT serum
urate was increased above normal limits. Six months after parathyreoidectomy
serum urate fell signifcantly from 379.367 to 270.756 mol/l in 42 patients
where urate measurements were available before as well after surgery. Both serum
X-ALP and CTx were increased in our patiens with PHPT as the result of the
enhanced bone turnover. Serum urate levels did not correlate with severity of
skeletal changes expressed by serum B-ALP and CTx. We did not fnd any
correlations between serum urate level and biochemical variables of bone
turnover in 106 patients with PHPT. Serum urate level does not correlate with
severity of skeletal changes expressed by B-ALP and CTx. These results suggest
that parathormone does not increase the part of the urate pool coming from the
nucleic acids of the increased bone metabolism.
P393
Bilateral giant myelolipoma of adrenal glands: a case report and review
of the literature
Petra Sulentic & Milan Vrkljan
University Hospital Sisters of Mercy, Zagreb, Croatia.
Adrenal myelolipoma is rare benign tumor composed of mature adipose cells and
hematopoietic elements. Their mostly small size (,5 cm), unilateral site, and
clinical quiescence is accountable for predominantly incidental disclosure. We
report a case of 54-year-old man complaining of gradually aggravating pain in
right hemiabdomen in whom abdominal CT revealed bilateral and giant adrenal
masses composed of predominately adipose tissue with interspersed areas of solid
parts displacing the kidneys caudally. The right tumor measured 14,9 cm and
the left measured 7 cm in diameter. Hormone tests where within normal limits.
Right and left adrenalectomies were performed and pathohystological analysis
confrmed diagnosis of myelolipoma. Postoperatively, the patient`s recovery and
further follow-up was uneventful. Reports on large and bilateral adrenal
myelolipomas are very scarce. Current recommendations suggest that in all
patients with adrenal incidentalomas congenital adrenal hyperplasia should be
excluded. This is particularly important in myelolipomas since they are
occasionally associated with functional adrenal disorders, especially if they are
large and bilateral. In adrenal incidentalomas larger than 6 cm a surgical removal
is advocated because relatively signifcant preponderance of malignancy is found.
P394
A case of septo-optical dysplasia: are late complications inevitable in
spite of early diagnosis and regular follow-up?
Petra Sulentic & Milan Vrkljan
University Hospital Sisters of Mercy, Zagreb, Croatia.
Septo-optic dysplasia (SOD), previously termed De Morsier`s syndrome, is a rare
developmental disorder of midline brain structures characterized by optic nerve
hypoplasia (ONH), midline neuroradiological abnormalities, and pituitary-
hypothalamic dysfunction such as GH defciency. The phenotype is highly
variable and the clinical presentation may be mild or extremely severe. It is an
infrequent disease and its causation is most presumably multifactorial, involving
environmental factors as well as several recognized crucial developmental genes
(HESX1, SOX2, SOX3). A case of 35-year-old male with diagnosed SOD in early
childhood and manifestation of fully developed disease is presented. Diagnosis is
made on the basis of pituitary hypoplasia with panhypopituitarism as well as
bilateral ONH resulting in signifcant visual impairment and nystagmus. No other
midline brain abnormality was found. The course of disease was complicated by
short stature, developmental delay, sensorineural hearing loss, osteoporosis,
psychiatric co-morbidity (anxiety-depression disorder with elements of obses-
sive-compulsive behavior) with sleeping disorder, and fnally obesity. In spite of
regular follow-up and hormone substitution, aforementioned associated features
were unpreventable. SOD remains a rare, phenotypically variable disorder, which
can pose signifcant diagnostic and management challenges.
P395
Rare metastases localization in medullary thyroid carcinoma (MTC)
Pierre Lecomte
1
, Serge Guyetant
1,4
, Peggy Pierre
1
, Arnaud Murat
2
,
Christine Sagan
2
, Francois Dravet
3
, Ziev Benchellal
4
& Loi c de Calan
4
1
CHRU Bretonneau, Tours, France;
2
CHU Nantes, Nantes, France;
3
CLCC,
Nantes, France;
4
CHRU Trousseau, Tours, France.
Usual metastatic localizations in MTC are liver, bone and lung. We report two
cases with metastases in pancreas and breast.
In a 51-year-old woman were discovered several nodules in the thyroid gland:
29,19 mm in the right lobe and 5 mm in the left. Calcitonine (CT) levels were
2300 and ECA 44 ng/ml. Fine-needle aspiration of the main nodule confrmed
MTC. Total thyroidectomy and right jugulo carotidal lymph node dissection were
performed in 1998 with pretracheal and recurrent dissection. Pathological
examination confrmed that the main nodule was a non-encapsulated MTC with
two additional micro-MTC. Several lymph nodes were invaded. CT, ECA and
CgA ab. A RET mutation in codon 620 was found. Post surgical CT was never
normal: CT rising from 40 (until 2003) to 80 (2005), 90 (2006), 150 (2007), 270
(2008) and 490 (2009). Calcium, PTH and methoxyamine levels were normal.
Search for metastases was negative (repeated cervical and liver US with contrast,
FDG PET-scan (2005) and F-DOPA (2007), cervical and lung CT scan) but in
2009 MRI discovered a 13 mm lesion of the pancreatic uncus. It was enucleated
(CT 93) and the pathologist confrmed 18,13 mm metastasis (CT, synaptophy-
sine and CgA; Ki67 3-5%) with invasion of 2/5 lymph nodes.
In a 52-year-old woman, the increasing size of a nodule in the right thyroid lobe
with elevated CEA necessitated total thyroidectomy with right jugulo carotidal
and latero-tracheal lymph node dissection in 1990. MTC with lymph nodes
invasion (7/11) was found. A new surgery was performed by sternotomy with
additional lymph node invasion (2/23). The patient was not cured (calcitonin
845a3760 ng/ml in 1994). No RET mutation. A third surgery with recurrent
dissection found 5/13 lymph nodes invaded. CT level was 840 ng/ml post surgery
and increased to 1285 (1995), 2670 (1997), 6000 (2001), 7500 (2006), 9850
(2009). Repeated imaging was normal (cervical and liver US, CT scan, anti-CEA
immuno-scintigraphy, FDG PET-scan, MRI) and radioimmuno-therapy in 1997
was unsuccessful. In 2009, bone scintigraphy found several localizations and
X-ray of the breast discovered a 8 mm right mass. It was found a MTC breast
metastasis (CT and CgA; Ki67 ,3%) (three lymph nodes ). Post surgical CT
6100 increased to 8400. In summary, two unusual MTC metastases localizations
(pancreas 11 years after discovery; breast 19 years later).
P39
Outcome of two chemotherapies in the treatment of progressive,
undifferentiated neuroendocrine carcinomas: a single-center
experience
Timo Deutschbein
1,2
, Nicole Unger
2
, Ali Yuece
2
, Harald Lahner
2
,
Klaus Mann
2
& Stephan Petersenn
2,3
1
University Hospital Bergmannsheil, Bochum, Germany;
2
University
Hospital of Essen, Essen, Germany;
3
ENDOC Center for Endocrine Tumors,
Hamburg, Germany.
Introduction
Treatment of poorly differentiated neuroendocrine tumors (NET) usually includes
chemotherapeutic intervention. However, both the rarity and the heterogeneity of
the disease have led to relatively few clinical trials. This study evaluated the
outcome of two chemotherapy regimens in patients suffering from undiffer-
entiated and histologically confrmed NET.
Methods
Eighteen patients (11 males; age 56.72.5) with proven progressive disease were
enrolled (mean Ki-67 33.64.8%). Patients were treated as follows: from 2005 to
2007 with regimen A (carboplatin, paclitaxel, etoposide)
1
; and from 2007 to 2009
with regimen B (cisplatin, etoposide)
2
. This change was due to low tolerability of
regimen A. The standard procedure used for imaging-based evaluation was
computed tomography, which was performed every 3 months. After chemother-
apy, patients were followed up until progression.
Results
Eight patients underwent regimen A (mean 3.30.7 courses). Owing to severe
side effects (diarrhea, nausea, neurological symptoms) three patients had their
therapy prematurely discontinued. The treatment responses of the remaining fve
patients were: 0% complete response (CR), 20% partial response (PR), 40%
stable disease (SD), and 40% progressive disease (PD). The mean progression
free survival (PFS) was 6.41.2 months (range 3.2-10.0). In contrast, 12 patients
were treated with regimen B (mean 3.80.4 courses), and none of them dropped
out because of side effects. The overall responses were: 0% CR, 17% PR, 33%
SD, and 50% PD. The mean PFS was 7.42.2 months (range 2.8-26.4). The
response rates of both regimes were not statistically different.
Conclusion
Patients who were treated with regimen B demonstrated comparable PFS and less
severe side effects than patients who received regimen A. In order to improve
therapeutic outcome of patients with progressive undifferentiated NET, new
therapeutic approaches are needed.
References
1. Hainsworth J Clin Oncol 1997.
2. Moertel. Cancer 1991.
P39I
Incidence, clinical presentation and outcome of differentiated thyroid
cancer in young patients aged 10~24 years living in the French
Rhone-Alpes region
Genevieve Sassolas
1
, Zakia Nejjari
1
, Nicole Berger
2
, Claire Berger
3
,
Claire Bournaud
1
, Jean-Louis Peix
4
& Francoise Borson-Chazot
1
1
Registre des cancers thyroidiens, Hospices civils de Lyon, Lyon, France;
2
Laboratoire dànatomie-pathologique, Centre hospitalier Lyon-Sud, Lyon,
France;
3
Registre des cancers de lènfant, Saint Etienne, France;
4
Service de
chirurgie endocrinienne-centre hospitalier Lyon-Sud, Lyon, France.
Differentiated thyroid cancer is rare in children and adolescents. An aggressive
clinical presentation, together with a high rate of recurrences contrasting with low
mortality, has been reported, especially, before the age of 15 years. Data are
mainly issued from historical series from hospital databases.
The aim of the study was to analyze, from a population-based registry, the clinical
presentation and outcome of differentiated thyroid cancer in young subjects.
From the population-based thyroid cancer registry of the French Rhone-Alpes
region, 252 cases of incident histologically proven thyroid cancers have been
recorded from 1998 to 2006, They were 38 children (10-14 years), 81 adolescents
(15-19 years) and 133 young adults (20-24 years), leading to the following
annual incidence rates: 0.44 and 0.92/100 000 in children, 0.81 and 3.03/100 000
in adolescents, 2.31 and 6.54/100 000 in young adults, respectively in males and
females.
Of 87% were papillary cancers, with an equal proportion of classical and
follicular variants. According to pTNM grading, 30% of children and adolescent
and 19% of adults presented with large and/or invasive cancers (pT3). Metastatic
lymph nodes were present in 40% of the children, 30% of the adolescent and
adults. Microcancers, discovered in goiters, were found in 14% of the whole
series. The median follow-up was 4 years. At the last visit, persistent disease was
more frequently observed in patients with initial lymph node involvement than in
patients without (26 vs 8.5%; P,0.01). Remission rates were 85%, comparable
between the three age groups. Secondary cervical lymph nodes resection
performed in 6.4% of patients led to a remission in 1/4.
In conclusion, prognosis of thyroid cancer in children has improved, clinical
presentation remains aggressive but the remission rate is comparable to that
observed in young people from other age-groups.
P398
Clinical, hormonal and molecular differences in pituitary ACTH
adenomas without (silent corticotroph adenomas) or with Cushing`s
disease
Gerald Raverot
1,2
, Anne Wierinckx
1,3
, Emmanuel Jouanneau
1,4
,
Francoise Borson-Chazot
2
, Joel Lachuer
1,3
, Michel Pugeat
2
&
Jacqueline Trouillas
1,5
1
INSERM, U842, Universite de Lyon, Lyon 1, Lyon, France;
2
Federation
dÈndocrinologie, Groupement Hospitalier Est, Hospices Civils de
Lyon, Lyon, France;
3
ProfleXpert, Bron, France;
4
Service de Neurochir-
urgie, Groupement Hospitalier Est, Hospices Civils de Lyon, Lyon, France;
5
Centre de Pathologie Est, Hospices Civils de Lyon, Lyon, France.
Objective
Silent corticotroph adenomas (SCA) are rare pituitary tumours immunoreactive
for ACTH but without clinical evidence of Cushing`s disease. They have been
compared to non functioning pituitary adenomas or ACTH adenomas with
Cushing`s disease, but no distinction has been made between micro and macro
ACTH-adenomas. We characterize SCA on clinical, hormonal and molecular data
and compared the characteristic of these tumours with those of macro (MCA) and
micro ACTH-adenomas (mCA) with Cushing`s disease.
Methods
Twenty-one ACTH adenomas (9 SCA, 7 MCA, 5mCA) with complete clinical,
radiological and biochemical data and frozen tumoural samples were selected.
Quantifcation by qRT-PCR of the mRNA expression of genes associated with
corticotroph differentiation or function (T-Pit, POMC, GR, PC1/3, galectin 3)
was performed.
Results
Despite an absence of clinical hypercortisolism, elevated plasma ACTH levels
similar to mCA was observed in SCA. Cortisol/ACTH ratio was similar in SCA
and MCA and lower compare to mCA (P,0.05). This dissociation could be
explained by a lower expression of PC1/3 in SCA and MCA compared to in mCA
(P,0.05). Cytological and immunocytochemical analyses as well as mRNA
expression levels of T-pit, POMC and GR confrmed corticotroph differentiation
in both mCA and MCA and in half of the SCA, with a strong correlation
between t-Pit and POMC mRNA expression (R
2
: 0.72, P,0.01) in SCA and
MCA (R
2
0.65, P,0.05).
Conclusions
SCA are macroACTH tumours showing hormonal and molecular similarities to
macroACTH tumours with Cushing`s disease, suggesting common pathological
pathways which are distinct to those involved in microACTH tumours.
P399
Six members of a family with multiple endocrine neoplasia type 2A
Mira Siderova, Mila Boyadzhieva, Kiril Hristozov, Ljudmila Angelova,
Ivan Krasnaliev, Krasimir Ivanov, Radoslav Radev & Rumen Nenkov
University Hospital St Marina, Varna, Bulgaria.
We report three generations of a family with MEN-2 A characterized by
autosomal dominant inheritance and virtually 100% penetrance.
The proband, 35-year-old man, was diagnosed and operated for pheochromocy-
toma of the right adrenal gland and medullary thyroid carcinoma (MTC) with
lymph node metastasis in 2009. His mother turned out to be operated for bilateral
pheochromocytoma at the age of 47 (in 1994) and had had a thyroid nodule. She
died at the age of 51 probably of metastatic disease. The oldest of her three sons,
42 years old brother of the proband, was asymptomatic with negative medical
history. Laboratory data showed high plasma metanephrine, normetanephrine and
calcitonin. CT revealed bilateral adrenal tumors, histologically verifed as
pheochromocytoma after surgery. Neck US examination detected thyroid nodules
with FNAB of medullary carcinoma and cervical lymph node metastasis with the
same cytology and he will be soon operated. The second brother, now 40 years
old, had had thyroidectomy at the age of 28 because of MTC with lymph node
metastasis. Our investigations showed high plasma levels of metanephrine and
normetanephrine and CT detected bilateral masses, pheochromocytoma on
histology after the operation.
The genetic examination of the three brothers revealed RET mutation at codon
634, responsible for the MTC with lymph node metastasis in all of them, as well
as bilateral pheochromocytomas in two of the brothers and unilateral in the
youngest. Their plasma parathormone was normal and US and CT did not
discover any enlarged parathyroid glands.
Their asymptomatic children, a 16-year-old son of the second brother, and a
7-year-old daughter of the youngest brother, were also screened and turned out to
be gene carriers of the same mutation. A total prophylactic thyroidectomy will be
performed because of the high risk of developing aggressive MTC.
P400
Hepatic transplant and use of radionuclides as adyuvant therapies for
patients with metastasic disease from neuroendocrine tumors
Maria Isabel Del Olmo
1
, Maria Argente
1
, Agustin Ramos
1
, Rosa Camara
1
,
Maria Soledad Navas
1
, Vicente Campos
1
, Angel Moya
2
& Juan
Francisco Merino-Torres
1
1
Endocrinology Department University Hospital La Fe, Valencia, Spain;
2
Surgery Department University Hospital La Fe, Valencia, Spain.
Aim
Patients with malignant neuroendocrine tumors (mNETs) present frequently
metastatic disease at diagnosis or during their follow-up. Hepatic transplant (HT)
and radionuclide treatment have proved to be successful treatments. The aim of
this report is to study the progression of the disease in patients with metastasic
mNETs and HT.
Descriptive and retrospective study of patients diagnosed of metastasic mNETs
and submitted to HT during the period 1984-2009 in our hospital. Data regarding
demographic, clinical, analytical, anatomopathological and diagnostic variables
were collected. Results are expressed as meanS.D.
Results
Twelve patients (67% men) with 44.19.2 years at diagnosis and a BMI of
25.23.3 kg/m
2
were studied. Tumors were classifed as carcinoid (50%),
pancreatic neuroendocrine carcinoma (25%), insulinoma (8.3%), glucagonoma
(8.3%) and somatostatinoma (8.3%). Half of the patients presented typical clinical
syndrome of their mNETs. Of 83%had hepatic metastases at diagnosis and the rest
(17%) developed them29 months later. HT was performed 14.37.7 months after
the diagnosis of metastases. The complications due to transplant procedure and
inmunosupression described were: rejection (33.3%), hepatic arterial thrombosis
(8.3%) that required retransplantation and infectious disease (8.3%). Four patients
were submitted for radionuclide therapy with
177
Lu-DOTATATE and
90
Y-DOTATATE to a reference hospital. The total dose administered was of
408.5171.5 mCi with mean sessions of 4.31.7. The response to radionuclide
was satisfactory: 2 stable, 1 reduction and 1 progression. In the present moment
there is a 100% of survival and 25% present progression after a mean follow-up of
89.981.2 months.
Conclusions
HT is an effective therapeutic option in patients with mNETs and metastasic
disease, presenting a low morbility and adequate survival in long term follow-up.
Radionuclide therapy is useful in some of these patients, stabilizing the disease in
75% of them.
P401
Down-regulation of estrogen receptor- associates with transcriptional
coregulator PATZ1 delocalization in human testicular seminomas
Francesco Esposito
1
, Renato Franco
2
, Monica Fedele
1
, Alfredo Fusco
1
,
Paolo Chieff
1,3
& Francesca Bosica
1
1
University of Naples, 'Federico II`, Naples, Italy;
2
Istituto dei tumori, G.
Pascale, Naples, Italy;
3
II University of Naples, Naples, Italy.
PATZ1 is a recently discovered zinc fnger protein that, due to the presence of the
POZ domain, acts as a transcriptional repressor affecting the basal activity of
different promoters, and associates with a variety of transcription factors (i.e.
RNF4, HMGA1, gscl, SPBP). We have previously described, by using mice
lacking the PATZ1 gene, its crucial role in spermatogenesis. Consistently,
PATZ1-KO mice are unfertile and testes from these mice showed only few
spermatocytes, associated with increased apoptosis, and complete absence of
spermatids and spermatozoa. In addition, PATZ1 protein is expressed, among
germ cells, in spermatogonia, and in Sertoli cells.
Preliminary results indicate that PATZ1 interacts with estrogen receptor beta
(ER). Since PATZ1 has been indicated as a potential tumour suppressor gene, we
also looked at its expression in tumours deriving from testicular germ cells
(TGCTs). Although expression of PATZ1 protein was increased in these tumours,
it was delocalized in the cytoplasm, suggesting an impaired function. In addition,
in seminomas the PATZ1 cytoplasmic localization is associated with ER down
regulation.
These results indicate that PATZ1 plays a crucial role in normal male
gametogenesis and that its up-regulation and mis-localization, associated with
ER down-regulation, could have a crucial role in the development of
seminomas.
P402
High prevalence of dopamine excess in patients with head and neck
paragangliomas
Anouk van der Horst-Schrivers, Thamara Osinga, Ido Kema &
Robin Dullaart
University Medical Centre Groningen, Groningen, Netherlands.
Objective
We determined the prevalence of abnormal secretion of dopamine and other
catecholamines in relation to clinical symptoms in patients with head and neck
paragangliomas (PGL). The association of catecholamine production with nuclear
imaging was also assessed.
Methods
Thirty-six consecutive patients with head and neck PGLs, who were referred for
follow-up and/or treatment between 1993 and 2009, were included. Clinical
symptoms, dopamine excess (urinary 3-methoxytyramine (3-MT) or dopamine
and/or plasma dopamine or 3-MT) and (nor)epinephrine excess (urinary (nor)
metanephrine excess) as well as
111
In-octreotide and
123
I-metaiodobenzylguanide
(MIBG) scintigraphy were documented.
Results
Dopamine excess attributable to head and neck PGLs was found in 7 patients
(19.7%). Marginally elevated urinary (nor)metanephrine excretion was present
in 6 patients (16.7%); one additional patient had normetanephrine excess due
to adrenal pheochromocytoma. Clinical symptoms and blood pressure were
not signifcantly different in patients with and without dopamine excess.
111
In-octreotide was positive in 94.3% of patients.
123
I-MIBG uptake in the
head and neck region (36.1%) was associated with dopamine excess (P0.03).
Conclusion
Dopamine excess is present in a considerable percentage of patients with head and
neck PGLs, and is associated with functional imaging of the lesions. Abnormal
dopamine secretion seems unrelated to clinical symptoms in the majority of
patients. In view of potentially adverse clinical consequences, we propose routine
assessment of abnormal secretion of dopamine and other catecholamines in PGL
management. Serial measurement of dopamine or its metabolites could be useful
in the follow-up of PGL patients.
P403
Pheochromocytoma: seconds from disaster
Simona Verzea Jercalau
1
, Ruxandra Dobrescu
1
, Ana Maria Stefanescu
1
,
Mircea Beuran
2
& Corin Badiu
1,2
1
C.I.Parhon National Institute of Endocrinology, Bucharest, Romania;
2
Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.
A 50-year-old female with a 2 year-history of hypertension and diabetes was
admitted to a county hospital, where treatment with clonidine and beta-blockers
was started, without success. Abdominal CT showed a large left adrenal tumour,
and her initial blood pressure (BP) was over 300/170 mmHg, which dropped to
80/30 mmHg. She was transferred for evaluation of a possible pheochromocy-
toma (PHEO). At admission her BP was 260/160 mmHg, heart rate (HR)
120 bpm, with anxiety, diaphoresis, cyanosis and pallor, but no retrosternal pain.
ECG showed sinus tachycardia with ST segment depression and deep, symmetric
T wave inversion (10-14 mm) in V2-V6 leads and inverted T waves in I, II, aVL
leads suggesting acute ischemia-lesion; QT interval was prolonged. Blood
samples for cathecholamine metabolites were diffcultly taken due to
vasoconstriction. After alpha-beta blockers, calcium channels blockers and
nitroglycerine her systolic BP oscillated between 300 and 40 mmHg; after one
hour more, she developed persistent severe hypotension. Despite a perfusion with
cortisone was started, after a small improvement, her BP collapsed, the visual
acuity decreased and she became unresponsive, HR120 bpm. She was
transferred under ECG monitorisation and oxygen to the emergency hospital.
On the way, she became responsive but at arrival she repeated the vascular
collapse. A central catheter was placed and she received 2 litres saline and 400 mg
cortisone in less than one hour, allowing flling of the vascular space and better BP
control; she was admitted to the ICU under continuous monitorisation and
oxygen. Meanwhile, very high levels of catecholamine metabolites confrmed
PHEO: metanephrine 3365 pg/ml (N 10-90), normetanephrine 4943 pg/ml
(N 15-100) and chromogranin A1439 pg/ml (N 40-100). After two weeks
preoperative preparation with phenoxybenzamine, calcium channel blockers and
nitroglycerine for control of the BP and HR, and restoration of blood volume, the
patient underwent successful left adrenalectomy by open surgery with removal of
a 15/15/12 cm left medulla tumour. Pathology and immunohistochemistry
certifed benign PHEO. Postoperatively catecholamine metabolites normalized
(MN10 pg/ml, NMN30 pg/ml, CrA40 pg/ml) as well as ECG and glucose
metabolism. In addition, Takotsubo cardiomyopathy induced by PHEO resolved.
Our case illustrates how some PHEO can be at seconds from disaster, but with a
'happy end`. Intensive management and multidisciplinary team is compulsory.
P404
Ectopic insulin secretion from distant metastasis or ectopic
metaplasia after total pancreatectomy for ACTH-secreting
endocrine pancreatic tumor revealing a Von Hippel Lindau disease
Marie-Christine Vantyghem
1,4
, Damian Wild
5
, Barbara Neraud,
Amandine Nghi-Beron
3
, Violeta Raverdy
4
, Marc Steinling
3
,
Jean-Louis Wemeau
1
& Francois Pattou
2,4
1
Departement of Endocrinology-Lille University Hospital, Lille, France;
2
Department of Endocrine Surgery-Lille University Hospital, Lille, France;
3
Department of Nuclear Medecine - Lille University Hospital, Lille, France;
4
INSERM U859-Lille 2 University, Lille, France;
5
Division of endo-
crinology - Inselspital - University Hospital of Bern, Bern, Switzerland.
Von Hippel Lindau disease (VHL) induces tumors of kidneys, central nervous
system, pancreas and paragangliomas We report one case where ectopic Cushing
syndrome revealed VHL. A 19-year old was referred for hirsutism and
spaniomenorrhea revealing an ACTH-dependent Cushing syndrome. Miner-
alocorticoids, calcium metabolism, chromogranine A, calcitonine, pancreatic
hormones and urinary 5-HIA were normal. Blood nor- and metanephrine were
5.12 g/l (n,5) and 0.92 g/l (n,0.66) respectively. CTscan and MRI showed 5
pancreatic lesions and one nodule of the left adrenal gland, all hypervascularized
and uptaking in FDG TEP-scan. Retinal examination and cerebral MRI were
normal. Total pancreatectomy and left adrenalectomy were performed, showing a
pheochromocytoma and well-differentiated endocrine pancreatic tumors, with
positive immunoreactivity for ACTH in 1 nodule, insulin in the 2nd and glucagon
in the 3rd one, vascular emboli, venous sheathing, extension to peripancreatic fat
and uncertain diagnosis of malignancy. A neomutation F119L of the VHL gene
was identifed. The post-operative imaging showed several infracentimetric
lesions: angioblastomas of the spinal cord, cystic and solid tumor of the left
kidney, tumor of the right adrenal gland uptaking MIBG. During the 1st year post-
surgery, post-surgical corticotrope insuffciency regressed. Daily insulin need
dramatically decreased. C-peptide level proved to be in the normal range, leading
to discontinuation of insulin. Abdominal CT, FDG-Pet, Octreo- and GLP1re-
ceptor scans were normal. Conclusion i) Less than 15% of the VHL are associated
with an endocrine pancreatic tumor, exceptionally secreting ACTH. ii) The post-
surgical detectable C-peptide with insulin weaning and multiple immunohisto-
chemical staining argues for distant metastasis or ectopic metaplasia, not visible
by imagery techniques. iii) This case report also raises the question of the etiology
of pancreatic tumors when associated with adrenal tumor(s) (metastases, MEN1,
VHL, neurofbromatosis) and of the role of the VHL-protein, an 'oxygen-sensing
protein` in the endocrine cells development.
P405
Cinacalcet hydrochloride effectively controlled primary hyperpara-
thyroidism in patients unresponsive to bisphosphonates
Antongiulio Faggiano, Carolina Di Somma, Francesco Milone,
Valeria Ramundo, Francesca Rota, Laura Vuolo, Ermelinda Guerra &
Annamaria Colao
Department of Molecular and Clinical Endocrinology and Oncology,
'Federico II` University, Naples, Italy.
Context
Until now the role of medical therapy in patients with primary hyperparathyroid-
ism (PHP) was mainly based on the use of bisphosphonates. Recently, cinacalcet
hydrochloride was reported to be effective in control hypercalcemia in PHP. The
aim of this study was to evaluate the effcacy of cinacalcet in PHP patients who
were not effectively controlled with alendronate.
Fourteen PHP patients (mean age 64.12.6) were included in the study. All
patients had received a treatment with alendronate 70 mg a week for two years.
The medical therapy with cinacalcet was started at the dose of 30 mg a day after
withdrawal of alendronate. Serum concentrations of PTH and calcium as well as
bone mineral density (BMD) at the lumbar spine were evaluated before and after
treatment.
Results
Serum calcium levels were 10.70.2 mg/dl at baseline, raised to 10.9
0.2 mg/dl after two years of treatment with alendronate and decreased to
9.60.2 mg/dl after one year of treatment with cinacalcet. At this time, all
patients had serum calcium levels in the range of normality. PTH levels were
progressively increased during therapy with alendronate, while they were
signifcantly decreased (P,0.05) but not normalized after one year of treatment
with cinacalcet. BMD values were signifcantly increased after alendronate
(P,0.05) while unchanged after cinacalcet. Twenty-one % of patients required to
increase the dose of cinacalcet to 60 mg a day during follow-up. Cinacalcet was
safe and well tolerated.
Conclusion
In PHP patients unresponsive to a long-term treatment with alendronate,
cinacalcet rapidly and effectively normalizes calcium levels and signifcantly
reduce PTH levels. BMD was unchanged after one year of treatment with
cinacalcet. It remains to evaluate if a combined therapy with bisphosphonates and
cinacalcet may induce a better response on bone mineral density.
P40
Clinical and prognostic implications of the genetic diagnosis of
hereditary NET syndromes in asymptomatic patients
Antongiulio Faggiano, Valeria Ramundo, Francesco Milone, Rosa Severino,
Gaetano Lombardi & Annamaria Colao
'Federico II` University, Naples, Italy.
Context
Neuroendocrine tumors (NETs) are rare neoplasms, heterogeneous, with variable
biological behaviour. NETs can be sporadic or they can arise in complex
endocrine hereditary syndromes such as Multiple Endocrine Neoplasias (MEN),
Familial Paragangliomatosis (FPGL), Neurofbromatosis type 1 (NF1), von
Hippel-Lindau Disease (VHL), Tuberous Sclerosis (TSC) and Carney Complex
(CC). By performing genetic screening, patients with hereditary NETs can be
identifed before the development of tumors.
Objective
The aim of this study was to evaluate clinical and prognostic impact of a pre-
clinical genetic screening in patients with hereditary NET syndromes affected
with MEN1, MEN2 and FPGL.
Thirty-six patients with hereditary NET syndrome were included in this study and
were divided in two groups (group A, 16 patients with clinical diagnosis of
hereditary NET; group B, 20 patients with genetic diagnosis of hereditary NET
who were clinically asymptomatic). All patients were clinically, biochemically
and morphologically evaluated. The overall follow-up time was 33.64.0
months. The main outcome measures were age at onset, prognosis and survival.
Results
In patients of group B the prevalence of tumors associated to hereditary NET
syndrome was lower than in patients of group A (P,0.01). Severity of NET and
performance status were better in group B than in group A. Survival was
signifcantly higher in group B than in group A (P,0.05).
Conclusions
The genetic screening in patients with hereditary NET syndromes has relevant
clinico-prognostical implications. By identifying patients before the clinical
appearance of the tumors improve both survival and quality of life of these
patients.
P40I
Expression of Ki-67, RET and p53 in papillary thyroid
microcarcinomas with or without autoimmune thyroid diseases
Zsuzsanna Szanto
1
, Imre Zoltan Kun
1
, Simona Gurzu
2
, Janos Jung
2
&
Angela Borda
2
1
Endocrinology Clinic, UMPh, Targu Mures, Romania;
1
Institute of
Pathology, UMPh, Targu Mures, Romania.
Our objective was to investigate the expression of Ki-67, RET and p53 in papillary
thyroid micro-carcinomas (PTMCs) with or without autoimmune thyroid
diseases. We included in the study 36 patients thyroidectomized between
2002 2007 for benign or malignant thyroid lesions, registered at Endocrino-
logy Clinic and/or Institute of Pathology Targu Mures, at whom the histology
diagnosed PTMC. This cohort was divided into two groups: 19 PTMCs only and
17 PTMCs associated with Hashimoto`s disease. All cases were analysed
immunohistochemically for Ki-67, RET and p53. Our results showed that
PTMCs expressed Ki-67 two-times more frequent in cases without autoimmune
thyroid disease (52% versus 23.5%), indicating a higher proliferative activity.
Similarly, PTMCs harboring potential risk to transform into clinical overt forms
showed a 4-times higher proliferative activity in absence of thyroid autoimmunity
(54.5% versus 12.5%). 69.4% of PTMCs were immunomarked with RET. PTMCs
associated with Hashimoto`s thyroiditis expressed RET more frequent and with
greater intensity than those without this autoimmune disease (88.2% versus
52.6%). In PTMCs associated with extensive chronic auto-immune thyroiditis the
dense infammatory infltration was situated mainly around the malignant
microlesions. In RET-positive microcarcinomas coexisting with autoimmune
thyroiditis, malignant thyrocytes were intensively marked with RET if they were
surrounded by lymphocytic infltration. We did not obtain considerable differences
in p53-immunoreactivity between the two studied groups.
Chronic autoimmune thyroiditis associated with thyroid microcarcinomas
might be a defense reaction, arising when normal thyrocytes transform into
pre-cancerous/cancerous cells. When PTMCs have already developed, auto-
immune thyroid phenomena seem to have a protective role againts progression
towards clinical overt PTCs, reducing proliferative activity and spread of tumor
cells. This inter-pre-tation is in concordance with clinical studies that sustain
an improved disease-free survival if autoimmune thyroid diseases are associated.
P408
Familial acromegaly
Aikaterini Chronaiou, Ifgenia Kostoglou-Athanassiou, Dimitris
Stefanopoulos, Eleni Xanthakou, Razvan Alexandros Badila, Nicolaos
Klonaris, Areti Karf & Konstantinos Tzioras
Department Of Endocrinology, Red Cross Hospital, Athens, Greece.
Acromegaly is a disease characterized by the presence of a pituitary ademona
which secretes excessive amounts of growth hormone. The presence of an
adenoma causing acromegaly in the context of multiple endocrine neoplasia
syndromes has been described. However, the presence of solitary pituitary
adenomas causing acromegaly in siblings is extremely rare.
Aim
The aim was to describe acromegaly in 2 siblings.
A male patient, aged 56 years developed all the characteristics of acromegaly,
diabetes mellitus, megalacroid characteristics, headache, bilateral hemianopia,
carpal tunnel syndrome, fatigue, muscular weakness and decreased libido. GH
and IgF1 were abnormally elevated and were nonsuppressible after the
administration of glucose. Octreotide was administered for a period of 1 year
and thereafter the adenoma was removed transsphenoidally. On histology a GH
secreting adenoma was observed. The symptoms subsided. Later on pituitary
insuffciency was documented. Eight years after surgery acromegaly recurred and
somatostatin analogs were administered. After a period of 6 years from the
diagnosis of acromegaly in the 1st brother, the younger brother of the patient aged
then 54 years developed diabetes mellitus, coarce facial characteristics, change in
the size of shoes, headaches, voice hoarseness, carpal tunnel syndrome, and sleep
apnea. Acromegaly was diagnosed and the adenoma was removed surgically.
Histology showed a GH secreting pituitary adenoma. Postsurgery acromegaly
was not active. After a period of 4 years partial activity of the disease was
observed and somatostatin analogs were administered.
Conclusion
The extremely rare case of siblings presenting with pituitary adenomas causing
acromegaly is described. Both brothers presented with acromegaly in middle age,
both underwent surgery, both had full remission of the disease postsurgically and
later on acromegaly recurrence. This extremely rare occurrence of acromegaly in
siblings suggests the possibility of a genetic basis of the disease.
P409
Paraganglioma in a patient with atrophic gastritis
Aikaterini Michou
1
1
,
Aikaterini Chronaiou
1
, Dimitris Stefanopoulos
1
, Razvan Alexandros
Badila
1
, Vassiliki Loi
1
, Konstantinos Karaliotas
2
& Areti Karf
1
1
2
2nd Department of Surgery, Red Cross Hospital, Athens, Greece.
Gastric neuroendocrine neoplasms are rare. They are classifed clinically in types
1 to 3. Gastric neuroendocrine neoplasms type 1 are observed in chronic atrophic
gastritis as single or multiple small tumors. Their prognosis is excellent. Gastric
neuroendocrine neoplasms type 2 are part of MEN 1 syndrome.
The aim is to describe the case of a patient with a gastric neuroendocrine
neoplasm which was observed in a background of atrophic gastritis and an ectopic
pheochromocytoma arising from the sympathetic chain with atypical behaviour
not accompanied by arterial hypertension.
A patient, male aged 58 years, with megaloblastic anemia and atrophic gastritis
was subjected to gastroscopy which showed a polypoid tumor 3 cm in diameter
in the body of the stomach. A subtotal gastrectomy was performed and histology
showed neuroendocrine dysplasia of the stomach. During surgery a subhepatic
tumor was observed. In endocrinological investigation high urine VMA levels
were observed, VMA being 10.9 mg/g creatinine, urine catecholamines were
392 microg/24 h and urine metanephrines 1300 microg/24 h as well as high blood
gastrin levels 3130 pg/ml. Further investigation with magnetic resonance imaging
showed a cystic lobulated mass measuring 4.3,5,4.5 cm with calcifcations
under the right side of the diaphragm. The mass was visualized in scintigraphy
with
111
In octreotide, a fnding compatible with the presence of somatostatin
receptors. The patient did not have arterial hypertension. The mass was excised
and histology showed a paraganglioma deriving from the sympathetic chain. Two
days after surgery the patient experienced an episode of hypotension and is now
free of symptoms and well.
Conclusion
The extremely rare case of a paraganglioma not causing arterial hypertension in a
patient with a neuroendocrine neoplasm of the stomach in a background of
atrophic gastritis is described.
P410
Evaluation of respiratory function in acromegalic patient
Ayse Serap Yalin
1
, Seda Sancak
1
, Sule Temizkan
1
, Mutlu Gunes
1
,
Oguzhan Deyneli
1
, Dilek Yavuz
1
, Sait Karakurt
2
& Nefse Sema Akalin
1
1
Department of Internal Medicine, Section of Endocrinology and
Matabolism, Marmara University School of Medicine, Istanbul, Turkey;
2
Department of Pulmonary and Critical Care, Marmara University School of
Medicine, Istanbul, Turkey.
Acromegaly alters elasticity, structure and function of the respiratory system and
respiratory disorders constitute 25% of all deaths recorded in acromegalic
patients. Respiratory mortality is three fold higher than in normal subjects.
However, respiratory dysfunction in acromegaly has seldom been investigated.
We aimed to evaluate the extent of pulmonary dysfunction in acromegalic
patients with respiratory function tests (RFT). Sixty one acromegalic patients and
21 age and sex matched healthy controls were included. Lung volumes, fow
volume curves and diffusion capacity were evaluated with RFT. Serum growth
hormone (GH) and insulin like growth factor-1 (IGF1) were measured. Results of
RFT parameters are shown in Table 1. Differences in these parameters remained
signifcant in males after excluding females although GH levels were similar
between both sexes in acromegalic patients. Other parameters of RFT were not
different from controls. We found a weak but positive correlation between GH
and forced expiratory fow 25/75 (FEF 25/75) (R0.261, P,0.019) in
acromegalic patients.
Our results show that lung volumes (TLC) and diffusion capacity (DLCO) are
elevated in male acromegalic patients. Obstruction parameters (FEV1/FVC,
FEF25-27) were similar between groups. Our results indicate that acromegaly
increases lung volumes and diffusion capacity in males without causing airways
obstruction. Elevated lung volume and diffusion capacity may be a consequence
of GH induced organomegaly. We found a weak but positive correlation between
serum GH levels and FEF 25/75.
P411
Single hospital experience of carcinoid tumours of colon and rectum
Rohith Gopala Rao, Melissa Banks, Graeme Poston & James Arthur
University Hospital Aintree, Liverpool, UK.
Background
Carcinoid tumours of colon and rectum (CTCR) are a rare entity. A review of a
tertiary referral units experience is presented.
Aim
Reviewing our experience of CTCR with emphasis on tumour site, disease stage,
treatment and long term outcome.
Method
Retrospective analysis of our endocrine tumour database was performed. All
patients diagnosed with CTCR between 2000 and 2009 were included.
Findings
Twenty-two patients were identifed with CTCR. Seventeen were tumours
(15 right colon, 1 recto-sigmoid and 1 rectal), while 5 (23%) were incidental
polyps (1 transverse colon and 4 rectum). At presentation some 9 (41%) patients
had lymph node disease, 9 had liver metastases of which 3 had concurrent nodal
disease and 1 had bone, liver and peritoneal disease. Two patients developed
delayed metastases after undergoing colectomy (1 Liver and 1 Lung). Three
patients (14%) were deemed to have inoperable disease at diagnosis. Surgical
intervention consisted of 13 right colectomies (59%), 1 anterior resection,
2 Transanal Endoscopic resections and one hepatic resection for delayed
metastasis. Four of the incidental polyps had clear resection margins. Systemic
chemotherapy was given to the 3 patients (2 with inoperable disease), 2 patients
received MIBG therapy and 4 patients were managed with sandostatin for
symptom control. Majority of tumours were well differentiated (60%). Four
people (18%) have since succumbed to the disease with remainder being alive at
this point of time. Only 4 (22%) patients have had fve year disease free survival.
Conclusion
CTCR is rare with predilection for right colon. It`s infrequent in comparison with
small bowel and appendiceal carcinoids (147 in our database). Nodal and/or liver
involvement at presentation is frequent, but in those with operable disease,
tumour resection prolongs survival (12 of 13 colectomies). Incidental fnding in
polyps need no further intervention if margins are negative.
TabIe 1 Comparison of RFT parameters between acromegalic patients
and healthy controls.
Respiratory function
test parameters
AcromegaIic
patients
(Mean S.D.)
HeaIthy
controIs
(Mean S.D.)
vaIue
Lung capacity (voIume) parameters
Total lung capacity (TLC) (liter) 8.222.81 7.161.66 0.044
Obstruction parameters
Forced expiratory volume in 1
second/forced vital capacity
(FEV1/FVC) (%)
79.726.11 79.296.49 0.420
Forced expiratory fow 25-75
(FEF25-75)(%)
101.0035.56 89.0028.29 0.139
Diffusion capacity
DLCO(%) 145.3831.95 135.0046.70 0.046
P412
Long-term outcome of 65 patients with metastatic differentiated thyroid
carcinoma
Marta Dieguez, Edelmiro Menendez, Cecilia Sanchez, Javier Aller,
Pedro Boix, Elias Delgado, Antonio Lavilla, Joaquin Pertierra
& Antonio Rabal
Asturias University Central Hospital, Oviedo, Spain.
Aim
To assess survival rate and prognosis factors in a group of 65 patients with distant
metastases from differentiated thyroid carcinoma.
Methods
Patients with metastatic differentiated thyroid carcinoma (MDTC) were retro-
spectively identifed from the database of a single institution (1975-2008).
Disease-specifc survival (DSS) was analyzed by the Kaplan-Meier method.
Results
A total of 65 patients with MDTC were identifed. The median follow-up was 90
months (range 3-328). Metastatic lesions were treated with radioactive iodine
(77%), radiotherapy (18%), surgical resection (17%) and chemotherapy (3%).
Following RECIS criteria, after treatment 70% of metastases progressed, 14%
remained stable, 8% had a partial response and 9% had a complete response.
The overall survival rate was 59.5 months (CI 67-122). Disease-specifc survival
(DSS) was 39% at 5 years and 26% at 10 years.
Patients with micronodular pulmonary metastases and isolated bone metastases
had signifcant longer DSS than patients with other type of metastases: 71%
versus 25% at 5 years and 50% versus 16% at 10 years, respectively (P ,0.05).
Aged ,45 years and iodine-avid metastases were also associated with better
outcome.
No difference was observed for sex, TNM stage and time of diagnosis of
metastases.
Conclusions
The current study, as well as others, suggests that MDTC may have a long-term
survival.
Despite of treatment most metastases progress.
Age, site and extension of metastases and radioiodine uptake are the strongest
prognosis factors.
P413
Von Hippel-Lindau disease: a case report
Sofa Gouveia
1
, Cristina Ribeiro
1
, Sandra Paiva
1
, Maria Joao Bugalho
2
,
Jacinta Santos
1
, Alexandra Vieira
1
, Marcia Alves
1
1
1
Endocrinology, Diabetes and Metabolism Department, Coimbra`s
University Hospital, Coimbra, Portugal;
2
Endocrinology Department,
Portuguese Oncology Institute- Lisbon, Lisbon, Portugal.
Introduction
Von Hippel-Lindau disease (VHLD) is a rare autosomal-dominant syndrome,
characterized by the development of multiple cysts and tumours, namely retinal
and central nervous system hemangioblastomas, renal cell carcinoma (RCC),
phaeochromocytoma, pancreatic endocrine tumours (PET) and endolymphatic
sac tumours.
Most germinal mutations are missense, related to a high risk for presenting
phaechromocytoma (specially if Arg167Trp mutation implied), which allow us to
classify these patients as belonging to the type 2 VHLD.
Case report
Fifty seven years old woman with known thyroid nodule, hepatic and renal cysts
and an important tumours` family history. A follow-up ultrasound revealed a
pancreatic and right adrenal nodules; she underwent cephalic duodenopancrea-
tectomy and right adrenalectomy. Histological report of the surgical specimen
referred islet hyperplasia, diffuse microadenomatosis, three PET and a
phaechromocytoma with no malignancy evidence; all tissues stained for
neuroendocrine markers.
She was admitted to our department for further study: neuroendocrine markers,
gastrin, vasoactive intestinal peptide, serotonin, metanephrines and vanillylman-
delic acid were normal; 5-hydroindolacetic acid was slightly elevated.
Biochemical and MRI study for pituitary showed no signifcant changes;
parathyroid hormone, calcium and calcitonin levels were contained in normal
reference ranges and the result of fne needle aspiration biopsy of thyroid nodule
was benign.
The brain and spine MRI detected a injury located to the cerebellar fossa; no
hemangioblastomas were found. The renal CT didn`t reveal any RCC; the
ophthalmologic and otorhinolaryngologic evaluation was regular.
It was identifed the germinal mutation Arg167Trp at exon 3 of VHL gene.
Discussion
VHLD has a marked phenotypic variability with strong genotypic correlation.
It demands a strict follow-up accounting for the risk of emerging new tumours.
In this case, the identifcation of the implied mutation allows us to direct the
relatives` genetic study and, in the affected ones, to diagnose and treat
opportunely.
P414
Natural history and clinical features of metastatic differentiated thyroid
carcinoma
Marta Dieguez, Edelmiro Menendez, Cecilia Sanchez, Javier Aller,
Elias Delgado, Pedro Boix, Antonio Lavilla, Joaquin Pertierra &
Antonio Rabal
Asturias University Central Hospital, Oviedo, Spain.
Aim
To analyze clinical features in a group of 65 patients with differentiated thyroid
carcinoma and distant metastases.
Methods
Retrospective review of 65 patients with Metastatic Differentiated Thyroid
Carcinoma (MDTC) identifed from the database of a tertiary hospital between
1975 and 2008.
Results
Sixty fve patients were identifed (21 males, 44 females) with a mean age of 58,9
years. The median follow-up after discovery of the metastases was 90 months
(range 3-328) Histologically, there were 18 (28%) Papillary Carcinoma (PC), 33
(51%) Follicular Carcinoma (FC) and 14 (21%) Hurthle Carcinoma (HC).
Metastasis were initially present in 49% of patients and were diagnosed later in
51% (15.3% ,1 years, 15.3% 1-5 years, 8.2% 5-10 yr and 12.2% 10 years
after thyroidectomy).
We observed lung metastases (LM) in 63% of patients, bone metastases (BM) in
32% and other metastases in 5% of patients. Only 3 patients presented with
multisystemic metastases extension.
LM represented 83% of metastases in PC and 79% in CH. Among FC 52% were
LM and 48% BM. Most LM (93%), but only 50% of BM were multiple. 34% of
metastases were non-iodine-avid.
Conclusions
Our series is characterized by the high rate of FC and HC which could be
explained by the historical regional iodine defciency.
Distant metastases are often observed at initial presentation of DTC but later
diagnosis in the follow-up is about as common.
Iodine-avid lung metastases are the commonest between all histological subtypes
with a high rate of BM in FC patients.
P415
Atypical bronchopulmonary carcinoid tumor metastatic to endocrine
glands and bone marrow
Vasiliki Daraki, Konstantina Stamou, Evangelia Mamalaki,
George Kalikakis & Stathis Papavasiliou
University Hospital of Crete, Heraklio, Crete, Greece.
Bronchopulmonary neuroendocrine tumors (BP-NETs) comprise 20% of all lung
cancers. Typical low grade carcinoid tumors (TC) represent the majority of
BP-carcinoids. Intermediate grade atypical carcinoid tumors (AC) are less often
encountered but more aggressive. Although metastatic dissemination to
mediastinal lymph nodes as well as liver, skeleton, central nervous system, skin
and mammary glands is well known, the involvement of endocrine glands is
really rare.
Case report
A 54 year old man presented with severe headache, left temporal hemianopsia,
ptosis of the left eye lid, polyouria and polydipsia. MRI of the brain revealed a
large pituitary mass of 3.5 cm in diameter that compressed the optic chiasm and
infltrated the cavernous sinus. Chest x-ray shoewd a mass located by the right
hilum area that was confrmed by CT scan of the thorax. CT scan of the abdomen
demonstrated an enlargement of the right adrenal measuring 3 cm. Histological
examination of lung biopsy revealed the presence of an intermediate grade AC.
MIBG scan was performed to exclude the coexistence of a neuroendocrine
tumor and an adrenal pheochromocytoma. The latter showed high uptake of
the radioactive tracer in pituitary, right lung and right adrenal supporting the
diagnosis of a neuroendocrine malignancy metastatic to the endocrine glands.
A bone marrow biopsy, performed due to persistently increased white blood cell
counts in the absence of active infection, revealed infltration byf carcinoid. The
patient underwent cranial irradiation followed by chemotherapy using the
combination of etoposide and cisplatin. Despite an initial temporary improvement
of CNS symptoms after the cranial irradiation, the patient suffered rapidly
progressive deterioration of the disease in the lung, adrenal and pituitary
accompanied by leptomeningeal dissemination and eventually died.
P41
Prognostic markers of survival after combined mitotane- and
platinum-based chemotherapy in metastatic adrenocortical carcinoma
characterized for plasma mitotane level and ERCC1 protein expression
analyses
Pasqualino Malandrino
1
, Abir Al Ghuzlan
2
, Marine Castaing
3
,
Jacques Young
4
, Bernard Caillou
2
, Jean-Paul Travagli
5
, Dominique Elias
5
,
Thierry de Baere
6
, Clarisse Dromain
6
, Philippe Chanson
4
,
Martin Schlumberger
1
, Sophie Leboulleux
1
& Eric Baudin
1
1
Institute Gustave-Roussy, Service de Medecine Nucleaire et de
Cancerologie Endocrinienne, Villejuif, Paris, France;
2
Departement
dànatomo-pathologie, Institute Gustave-Roussy, Villejuif, Paris, France;
3
Integrated Tumor Registry of Catania-Messina-Siracusa, University of
Catania, Catania, Italy;
4
Ho`pital Kremlin-Bice`tre, Service
dÈndocrinologie, Paris, France;
5
Departement de chirurgie, Institute
Gustave-Roussy, Villejuif, Paris, France;
6
Departement dìmagerie,
Institute Gustave-Roussy, Villejuif, Paris, France.
Introduction
Mitotane and platinum-based chemotherapy are the main therapeutic choices for
treating inoperable and/or metastatic adrenocortical carcinoma (ACC).
Objective
To search for prognostic parameters of survival in patients with metastatic ACC
treated with combined mitotane- and platinum-based chemotherapy.
Patients
One hundred and thirty one consecutive patients with metastatic ACC treated at
the Gustave-Roussy Institute (from 1993 to 2007) were retrospectively reviewed.
Fifty-fve patients with clinical, pathological and morphological data available
together with detailed follow-up were enrolled.
Methods
Overall survival (OS) was evaluated from the start of platinum-based
chemotherapy and response rate (RR) according to the RECIST criteria.
Univariate and then multivariate analysis were used to check parameters
impacting on OS. The landmark method was applied to analyze OS according
to response to chemotherapy. Plasma mitotane levels at chemotherapy start
(39 patients) and ERCC1 protein staining, evaluated by immunohistochemic as
function of both percentage and intensity of cellular staining (33 patients), were
analyzed.
Results
Independent predictors of survival were: surgery of primary tumor (yes vs no:
median OS13.5 versus 7.7 months; P0.03); number of metastatic organs
(B2 vs 2: median OS15.6 versus 7.1 months; P0.03); response to
chemotherapy (yes vs no: median OS40.6 versus 9.6 months; P0.001).
Interestingly in case of plasma mitotane 14 mg/l median OS was 19.6 in respect
to 9.5 months when ,14 mg/l (P0.07). Median OS wasn`t different between
ERCC1-low and ERCC1-high patients (13.3 versus 10.1 months), but considering
only intensity staining, median OS was 14.5 and 7.6 months in patients with low
and high ERCC1 intensity, respectively (P0.42). Only the number of metastatic
organs infuenced RR (P0.04).
Conclusion
Surgery of primary tumor, number of metastatic organs and response to
chemotherapy are independent prognostic factors of survival after platinum-
based therapy. Plasma mitotane 14 mg/l leads to a better survival. ERCC1
expression warrants further investigation in prospective studies.
P41I
Rapid activation of cPLA
2
induced by oestrogen in ER-positive and
ER-negative breast cancer cell lines
Francesco Caiazza, Brian Harvey & Warren Thomas
Cytosolic phospholipase A2 (cPLA
2
) catalyzes the hydrolysis of membrane
glycerophospholipids to release arachidonic acid, which is converted to bio-active
eicosanoid lipid mediators, including prostaglandins (like PGE2) produced
through cyclo-oxygenases (COX). The eicosanoid signalling contributes to cell
proliferation in breast cancer, as demonstrated by numerous studies outlining a
crucial role of COX-2 and PGE2 in breast carcinoma progression. The specifc
role of cPLA
2
, however, is not established. Recent work from our group
demonstrated that 17-estradiol (E2) rapidly activated cPLA
2
in MCF-7 breast
carcinoma cells; leading to the hypothesis that the rapid release of bioactive lipids
may play a role in the proliferative signalling responses stimulated by E2 in breast
cancer. Breast carcinoma cell lines that differentially express the oestrogen
receptor (ER) were used to study the molecular mechanism involved in the E2-
induced rapid activation of cPLA
2
, and we found that this was dependent on
specifc ER-mediated trans-activation of EGFR/HER2 heterodimers and down-
stream signalling through ERK1/2 MAPK to phosphorylate cPLA
2
on Ser505.
E2 also promoted cPLA
2
traffcking to perinuclear membranes, and this effect
was subsequent to, and dependent on, MAPK-induced phosphorylation on
Ser505. The endocrine-resistant SKBR3 cell line, which over-expresses EGFR
and HER2, and is ER-negative, showed elevated cPLA
2
expression and activity
compared to MCF-7. E2 promoted rapid activation of cPLA
2
in this endocrine-
resistant cell line through EGFR/HER2 trans-activation that was mediated by the
G protein-coupled receptor GPR30. Inhibition of cPLA
2
with a specifc
antagonist or by siRNA-mediated gene silencing suppressed the growth of both
cell lines. cPLA
2
is likely to play a key role in regulating the already established
growth-promoting effects of oestrogen and COX-2 in breast cancer, balancing the
cytotoxic effects of free arachidonic acid with the proliferative effects of
prostaglandins.
P418
Adrenocortical carcinoma: is the surgical approach a risk factor of
peritoneal carcinomatosis?
Sophie Leboulleux
1
, Desiree Deandreis
1
, Abir Al Ghuzlan
1
, Anne Auperin
1
,
Clarisse Dromain
1
, Jacques Young
2
, Martin Schlumberger
1
& Eric Baudin
1
1
Institut Gustave Roussy, Villejuif, France;
2
Service dÈndocrinologie et
des Maladies de la Reproduction, Kremlin Bicetre, France.
Context
Peritoneal carcinomatosis (PC) is a rare site of distant metastasis in patients with
adrenocortical cancer (ACC). One preliminary study suggests an increase risk of
PC after adrenalectomy through laparoscopic approach of ACC.
Objective
The objective of the study was to search for risk factors of PC including surgical
approach. This was a retrospective cohort study conducted in an institutional
practice.
Patients
Sixty-four consecutive patients with ACC seen at our institution between 2003
and 2009 were included. Mean tumor size was 132 mm. Patients had stage I
disease in 2 cases, stage II in 32 cases, stage III in 7 cases, stage IV in 21 cases and
unknown stage in 2 cases. Surgery was open in 58 cases and laparoscopic in
6 cases.
Results
PC occurred in 18 (28%) patients. It was present at initial diagnosis in 3 cases and
occurred during follow-up in 15 cases. The only risk factor of PC occurring during
follow-up was the surgical approach with a 4-year rate of PC of 67% (95CI,
30-90%) for laparoscopic adrenalectomy and 27% (95CI, 15-44%) for open
adrenalectomy (P0.016). Neither tumor size, stage, functional status,
completeness of surgery or plasmatic level of op`DDD were associated with
the occurrence of PC.
Conclusion
We found an increase risk of PC after laparoscopic adrenalectomy of ACC.
Adrenal tumors bearing malignant characteristics preoperatively should be
referred for open adrenalectomy.
P419
Erythropoietin levels in endocrinopathies
Emilie Klein, Julie Brossaud, Blandine Gatta & Jean-Benoi `t Corcuff
CHU Bordeaux, Pessac, France.
Erythropoietin (EPO) is an oxygen-regulated hormone promoting the differen-
tiation of erythroid progenitor cells. Apart from hypoxia, few data is available
about EPO release by secretagogues including hormones. This retrospective study
evaluated serum EPO concentrations in serum leftovers from subjects routinely
investigated with various endocrine disorders displaying: peripheral hypothyr-
oidism or hyperthyroidism, acromegaly, endogenous Cushing`s syndrome or non
secreting pituitary tumour. Patients with the latter, chosen with no defciency in
the thyrotroph, gonadotroph, somatotroph and corticotroph axis, were included as
a control group.
EPO levels were all above the normal low limit - an important point as a low EPO
level is a sensitive and specifc diagnostic test of polycythemia vera. All 12 but 1
patients with elevated EPO levels had some reason to present, at least mildly,
hypoxemia (myocardiopathy, tobacco smoking).
No statistically signifcant relationship was evidenced between a given hormone
and EPO concentrations. In patients with thyroid dysfunction or Cushing`s
syndrome or non secreting pituitary diseases, multiple regression analysis showed
a statistically signifcant relation between EPO and Hb (P,0.05) but no
signifcant infuence of free T
3
or T
4
or free urinary cortisol (in patients with
thyroid dysfunction or Cushing`s syndrome). Interestingly, in patients with
acromegaly, multiple regression analysis showed no signifcant relationship
between EPO and Hb or IGFI or GH (i.e. the normal EPO- Hb relationship was
abolished). This may refect a dual action of GH and/or IGFI on erythroid
progenitors proliferation as well as on EPO synthesis.
In conclusion, EPO is not noticeably modifed by common endocrine disorders
although GH and or IGFI may alter EPO relationship with blood haemoglobin
concentration. This point may deserve further clinical investigation.
P420
Prolactinoma registry- usefulness of a web tool
Vadim Gavan
1
, Cristian Taslitchi
3
, Ruxandra Dobrescu
1
& Corin Badiu
3
1
C.I.Parhon National Institute of Endocrinology, Bucharest, Romania;
2
C Davila University of Medicine and Pharmacy, Bucharest, Romania;
3
Infoworld, Bucharest, Romania.
Prolactinoma registry is part of the Romanian national Registry of Endocrine
Tumors system (www.renate.ro), which allows the collection and provides
epidemiological data concerning the prevalence of age and sex distribution,
therapy and its basic results. The centers involved are the medical universities and
expertise centers in Romania, centers in which exist enough experience and
resources to diagnose, treat and monitor the evolution of these endocrine tumors.
The data entered are patients ID`s, age and date at diagnosis, the age at which the
suggestive symptoms frst appeared, tumor size, extension and complications,
type of treatment (chemotherapy, surgery and radiotherapy) and its outcomes on
parameters such as tumor dimensions, pituitary function and endocrine tumor
markers (PRL).
Up to date, over 60 cases are recorded with the following epidemiological data:
74% macroprolactinomas, 26% microprolactinomas, with a sex prevalence of
45% women and 55% men, and an average age at diagnosis of 38,4 years.
Prolactinomas were submitted to surgery (17% of all group), and/or radiotherapy
(10%). The average follow-up was 50 months.
The access to the site is secured. The network started with 10 centers and will be
developed afterwards using already existent hardware resources. This infra-
structure is the base of future epidemiological public health surveys in this
thematic area. The utility of the web-based registry with secured access is related
to the large access and communication capacity beween users of the system.
P421
Thyroid Incidentaloma identihed by
18
F-Fluorodeoxyglucose Positron
Emission Tomography with CT (FDG-PET/CT): clinical relevance
Loredana Pagano
1
, MariaTeresa Sama`
1
, Marco Rudoni
2
, Sara Belcastro
1
,
Arianna Busti
1
, Marina Caputo
1
, Eugenio Inglese
2
& Gianluca Aimaretti
1
1
Endocrinologia, Dipartimento di Medicina Clinica e Sperimentale,
Universita` del Piemonte Orientale, Novara, Italy;
2
SCDU Medicina
Nucleare, AOU Maggiore della Carita`, Novara, Italy.
Thyroid incidentalomas was defned as newly identifed thyroid lesions
encountered during imaging study for non-thyroid diseases. In the last years,
the use of FDG-PET/CT for staging of metastatic diseases was increased. The aim
of this retrospective study was to evaluate the FDG-PET/CT uptake, to identify a
SUVmax cut off predictive of malignancy and to determine the FDG-PET/CT
prognostic role in patients with thyroid incidentalomas. 42 patients (ptx) with
incidental thyroid uptake at FDG-PET/CT were included in the analysis (32 W,
mean age 66.7411.81 years). All ptx performed a thyroid function and an
ultrasonography (US) evaluation. 36/42 patients underwent an US-FNAC of the
thyroid nodules. Ptx with TIR 3, TIR 4 and TIR 5 FNAC-diagnosis underwent a
total thyroidectomy. A diffuse (group A) or focal (group B)
18
F-FDG uptake was
shown in 26.2 and 73.8% ptx, respectively. Differentiated thyroid cancer was
shown in 9% and 41.9% ptx in group A and B, respectively. A statistical
correlation was found between focal uptake and euthyroidism (P,0.0001) and
between diffuse uptake and thyroid dysfunction (P , 0.0001). A correlation
between the SUVmax value 5 and the presence of thyroid cancer (r0.377
P,0.01) was found in group B. The FDG-PET/CT sensitivity and specifcity was
85.7% and 53.6%, respectively; the PPV was 48% and the NPV was 88.2%. The
neck US increased FDG-PET specifcity from 53.6% to 75%. In particular
hypoechogenicity and the number of US risk factors correlate with the diagnosis
of thyroid carcinoma (r0.338; P,0.02 r0.287; P0.065 respectively). Our
data suggest that the incidental detection of diffuse thyroid uptake at FDG-
PET/CT is related to a benign disease, while focal thyroid uptake evidences an
high risk of malignancy, especially with a SUVmax value 5, euthyroidism and
suspicious US features.
P422
Juvenile hypertension due to coexistence of two very rare etiologies
Rosa Maria Paragliola, Francesca Ianni, Maria Pia Ricciato, Annapina
De Rosa, Francesca Gallo, Pietro Locantore, Paola Senes, Carlo
Antonio Rota, Alfredo Pontecorvi & Salvatore Maria Corsello
Department of Endocrinology, Catholic University School of Medicine,
Rome, Italy.
The coexistence of pheochromocytoma and hyperreninemia secondary to renal
artery stenosis, which both represent important causes of juvenile hypertension,
has been reported in Literature, while association between pheochromocytoma
and reninoma has never been described.
We evaluated a 24-year-old boy, which came to our attention for severe
hypertension, unresponsive to anti-hypertensive polytherapy. In 1996, because of
elevated calcitonin levels (180 pg/ml), he underwent total thyroidectomy with
lymphadenectomy. Histology confrmed 'medullary carcinoma pT4N`.
Laboratory evaluation excluded pheochromocytoma. Genetic testing showed
RET mutation at codon 918 (exon 16), which was not documented in other family
members, confrming the diagnosis of MEN2B. During follow-up, a progressive
increase of urinary metanephrines and catecholamines was recorded, in absence
of adrenal masses at MRI and with no clear pathological fndings at MIBG. Our
evaluation confrmed severe hypertension (220/140 mmHg) unresponsive to
doxazosine and atenolol at high doses, with initial left ventricular dysfunction.
Laboratory data showed a severe increase of urinary catecholamines
(epinephrine: 27 g/24 h, norepinephrine: 120.0 g/24 h) and metanephrines
(metanephrine: 3099 g/24 h; normetanephrine: 1272 g/24 h). Evaluation of
other causes of hypertension revealed hyperreninemia (236 UI/ml) with mild
hyperaldosteronism, and an increase of renal artery resistance at US.
Abdominal MRI showed multiple adrenal masses (16 and 18 mm at right gland
and 10 and 15 mm at left gland). In correspondence of the right kidney, a nodular
lesion of 20 , 20 mm, hyperintense in T2-weighted sequences, was described.
As frst hypothesis, the above mentioned lesion was interpreted as renal
oncocytoma. The patient underwent bilateral adrenalectomy and right
nephrectomy. Histology confrmed bilateral pheochromocytoma and right
reninoma, with normalization of blood pressure value. Laboratory evaluation
showed a sudden reduction not only of urinary metanephrines but also of
reninemia in spite of bilateral adrenalectomy without mineralocorticoid
supplementation.
P423
Reversible heart failure after sorafenib administration in advanced
metastatic differentiated thyroid carcinoma (DTC)
Massimo Giusti
1
, Maria Derchi
2
, Lorenzo Mortara
1
, Mario Canepa
2
,
Francesca Cecoli
1
, Francesco Minuto
1
& Paolo Spallarossa
2
1
DiSEM, University of Genova, Genoa, Italy;
2
DIMI, University of Genova,
Genoa, Italy.
Sorafenib (S) is a reasonably well-tolerated therapy in DTC. A large number of
side-effects have been reported. We report our data on the effectiveness and
tolerability of S in 6 patients with advanced metastatic epithelial (2 follicular, 1
papillary, 1 insular) and medullary DTCs (52-79 years). In all patients, heart
function was evaluated before and during S administration (400 mg/day) together
with the objective response rate and changes in serum markers. Underlying heart
function, clinical examination, EKG, echocardiographic assessment and N-
terminal type-B natriuretic peptide (NT-proBNP) and troponin I levels were
recorded before therapy, on therapy and after S discontinuation. Hypertension
was found in 50% of patients before therapy; in these patients, hypotensive
treatment did not change on therapy. In 2 of the remaining patients, hypotensive
therapy was started after a 1-month period of S. S therapy was discontinued in 3
cases owing to: disease progression after a 6-month period of stable disease;
patient request due to mucositis and skin rash after 3 months; and severe heart
failure (NYHA class 4) after 3 months. No patients showed changes in troponin I
levels. NT-proBNP levels sharply increased in a previously normotensive patient
with insular cancer after 2 months on S, when heart failure begun. A slight
NT-proBNP increases was seen in 2 further subjects. The table reports some of the
echo-cardiographic variables measured. In case 4, heart function returned to pre-S
levels in the 6-month after S discontinuation and BP normalized on hypotensive
therapy.
Our data seem to indicate a decrease in tumor markers and a partial response in
66% of subjects during a 3-6 month course of S. Hypertension and severe heart
failure may occur but they are not associated with cardiomyocyte death and are
reversible side-effects. Heart function should be carefully monitored during S
therapy in thyroid cancer patients.
P424
Serum concentration of o,p`DDD (mitotane), o,p`DDA and o,p`DDE as
predictors of tumour response in adrenocortical carcinoma: results of a
retrospective European Network for the Study of Adrenal Tumors
(ENS@T) multicentre study
Ilse Hermsen
1
, Martin Fassnacht
2
, Massimo Terzolo
3
, Saskia Houterman
4
,
Jan den Hartigh
5
, Sophie Leboulleux
6
, Fulvia Daffara
3
, Bruno Allolio
2
,
Alfredo Berruti
3
, Rita Chadarevian
7
, Harm Haak
1
& Eric Baudin
6
1
Department of Internal Medicine, Maxima Medical Centre, Eindhoven,
Netherlands;
2
University of Wurzburg, Wurzburg, Germany;
3
Department
of Clinical and Biological Sciences, University of Turin, Turin, Italy;
4
MMC Academy, Maxima Medical Centre, Veldhoven, Netherlands;
5
Department of Clinical Pharmacy and Toxicology University Medical
Centre Leiden, Leiden, Netherlands;
6
Department of Nuclear Medicine and
Endocrine Oncology, Institute Gustave-Roussy, Villejuif, Villejuif, France;
7
HRA-Pharma Paris, Paris, France.
Introduction
O,p`DDD is the drug of choice for patients with adrenocortical carcinoma (ACC).
Monitoring o,p`DDD serum level has been proposed as predictor of tumour
response. Measurement of o,p`DDD metabolites involved in the active pathway
may provide an improved prediction of o,p`DDD activity. The objective of our
study was to (1)to confrm the currently used threshold o,p`DDD serum level of
14mg/l for achieving a tumour response and (2)compare the value of o,p`DDD,
o,p`DDA, or o,p`DDE levels in predicting tumour response.
Methods
Retrospectively o,p`DDD and its metabolites were measured in available samples
from 91 patients with advanced ACC in 5 ENS@T centres. Samples within 3
months of best response were used for analyses. ROC curves were used to defne
cut-off values.
Results
Mitotane was given as monotherapy (30%) or in combination with chemotherapy
(70%). Tumour response was observed in 17 patients (19%). Metabolites
o,p`DDE and o,p`DDA showed signifcant correlation with o,p`DDD. Using cut-
off value of 14 mg/l for o,p`DDD, 11 out of 36 patients (31%) reaching o,p`DDD
levels 14 mgl were responders compared to only 11% responders in patients
with levels ,14 mg/l (P0.02). With o,p`DDD cut-off level of 18 mg/l, 5
patients were responders. Using a cut-off value of 92 mg/l for o,p`DDA, 6 out of
16 patients (38%) were responders above this level against 15% (11/75) below
that level (P0.03).
Conclusion
Our data confrm that serum concentrations of o,p`DDD, and also o,p`DDA
correlate with response in patients with advanced ACC. The ideal o,p`DDD target
level might be higher than 14 mg/l.
P425
Clinical features and outcome of sporadic medullary thyroid carcinoma
Paula Sanchez Sobrino, Concepcion Paramo Fernandez, Beatriz
Mantinan Gil, Alberto Perez Pedrosa, Regina Palmeiro Carballeiro,
Ines Seoane Cruz & Ricardo V Garci a-Mayor
Introduction
Medullary thyroid carcinoma (MTC) is a neuroendocrine tumour that arises from
c cells of the thyroid gland and accounts for less than 8% of thyroid neoplasms.
Some are familiar (MEN 2 syndrome) but most are sporadic. Genetic tests have
improved the outcome in hereditary forms, but survival in sporadic MTC has not
increased in last years. In most patients with sporadic MTC the disease has
already metastasized at the time of diagnosis.
Objective
To evaluate the clinical-pathological characteristics and outcome of our patients
with sporadic MTC.
We recruited 17 patients with confrmed sporadic MTC between 1994 and 2009
after excluding those with familiar history, RET mutation or other features
associated to MEN 2.
Results
A total of 17 patients with sporadic MTC were studied, 10 women, mean age
47.514.99 years old (range from 16 to 68). All of them had thyroid nodules;
81.8% solitary nodule (72.7% bigger than 3 cm) and 100% had radiologic
fndings of malignancy. Approximately a half of the patients complained about
compressive symptoms such as dyspnea, dysphagia or hoarseness. Three patients
had palpable cervical lymphadenopathies. Cytology by fne needle aspiration
(FNA) showed an accurate diagnosis in only 35.7% of cases. More than 50% were
diagnosed at stages III or IV. Of 7 patients in early stage 4 achieved clinical
remission and only 2 of the 10 patients at advanced stage.
Conclusion
Sporadic MTC is a rare malignancy that remains unnoticed until advanced stages
conditioning a worse prognosis. It appears clinically in the form of a thyroid
nodule with objective data of malignancy at imaging techniques and local
compressive symptoms in most cases. In our experience FNA has had low
sensibility for diagnosis.
P42
Adrenocortical carcinoma (ACC): our experience
Guido Di Dalmazi, Raffaella Ripani, Elena Casadio, Valentina Vicennati,
Uberto Pagotto & Renato Pasquali
UO Endocrinologia, Bologna, Italy.
Aim
ACC is an extremely rare heterogeneous aggressive disease. Clinical presentation
are various. The prognosis is very poor. There are limited data to defne
prognostic markers for survival beyond stage.
The aim of this study is to describe the experience of our institution with patients
affected by ACC.
This study was performed on 13 patients aged between 26 and 76 years, from
1992 to 2009 who turned to our Institution for an adrenal carcinoma.
Results
Only 15% of patients was asymptomatic at the time of onset. The 85% reported
symptoms attributable to cortisol or androgen hypersecretion, to the tumour mass,
gastrointestinal and more aspecifc symptoms. The CT showed that in 15.4% the
tumour was smaller than 5 cm, in 46.2% it was between 5 and 10 cm, in 23% the
size ranged from 10 to 15 cm and the 15.4% of the masses had a diameter greater
than 15 cm. The 38.5% of these masses were not secreting, the 23% secreted
cortisol, the 15.4% secreted androgens and the 23.1% had a mixed androgen-
cortisol secretion. No mass secreted mineralocorticoids or estrogens. Eleven
patients underwent surgery: laparotomy in 8 cases and laparoscopy in 3 cases. It
was possible to perform a radical resection in 72.7% of cases. The 46.2% of
patient underwent adjuvant therapy with mitotane. In 4 patients mitotane was
administered with different patterns of systemic cytotoxic chemotherapy. In our
series, 69.2% of patients are deceased. The median survival is 28.911.1 months.
The time to relapse is 1416.9 months.
Conclusion
Our data agree with literature, describing a highly aggressive disease with a poor
prognosis. Even in our series, the most important prognostic factor is the radical
surgery that signifcantly infuence the outcome of the disease.
#
Shortening fraction (%) Ejection fraction (%)
Baseline On-therapy Baseline On-therapy
1 ne Ne 50 50
2 40 36 57 60
3 50 39 60 57
4 30 20 48 35
5 35 35 57 57
6 31 39 47 45
P42I
Polymorphisms in gene are associated with
rearrangements in papillary thyroid carcinoma (PTC)
Vlasta Sykorova
1
, Eliska Vaclavikova
1
, Sarka Dvorakova
1
, Ales Ryska
2
,
Daniela Kodetova
3
, Petr Vlcek
3
& Bela Bendlova
1
1
2
The Fingerland`s
Department of Pathology, Hradec Kralove, Czech Republic;
3
2nd Faculty of
Medicine and Faculty Hospital Motol, Prague, Czech Republic.
RET proto-oncogene is activated in the development of PTC via RET/PTC
rearrangements. Single nucleotide polymorphisms (SNPs) of the gene are
associated with PTC in some studies. We investigated possible association of
SNPs with RET/PTC in Czech patients. We analyzed 234 patients with PTC (101
fresh frozen thyroid samples, 133 paraffn-embedded formalin-fxed samples) and
172 controls. RNA from frozen samples was reversely transcribed to cDNA.
RET/PTC was detected on agarose gel. DNA from all samples was used for
detection of polymorphisms in the RET gene - A432A, G691S, L769L, S836S and
S904S using specifc TaqMan probes. The statistic evaluation (Haploview 4.1.,
PHASE, Fisher`s exact test, odds ratio) was performed. The study was approved by
the Ethical Committee. RET/PTC was detected in 26 from 101 frozen samples of
PTC patients (25.5%) - 2 RET/PTC1 (2%), 2 RET/PTC3 (2%) and 22 RET/PTCX
(21.5%). No signifcant difference of SNPs and haplotypes frequencies between
patients and controls was found. However, in patients the minor allele Aof A432A
(G/A) was signifcantly under-represented in patients carring RET/PTC (19.2%
versus 41.2%, P0.006). Homozygotes with the major allele G of this
polymorphism have even 4.5 times higher risk of RET/PTC (P0.002). The
minor allele G of polymorphism L769L was signifcantly over-represented in
patients carring RET/PTC compared to patients without this alteration (36.5%
versus 21.5%, P0.049) and carriers of this allele have 3 times higher risk to
developthe rearrangement (P0.036). The distribution of haplotypes signifcantly
differed in PTC patients related to sex (P0.04) and presence of RET/PTC
(P0.02). The carriership of the most risk haplotypes (with both risk alleles) was
signifcantly associated with RET/PTC (P0.002). In conclusion, major allele G
of RETgene polymorphismA432Aand minor allele Gof polymorphismL769Lare
associated with high risk of RET/PTC development.
Supported by IGA MH CR NR/91653.
P428
Malignant paraganglioma ~ the story of a long time survival
Roxana Balcan
1
, Dan Iliescu
2
, Cipriana Stefanescu
3
, Radu Popa
4
,
Ioana Vasiliu
1
, Jeanina Idriceanu
1
, Eusebie Zbranca
1
& Carmen Vulpoi
1
1
2
Department of Cardiology, UMF Gr.T.Popa, Iasi, Romania;
3
Department
of Nuclear Medicine, UMF Gr.T.Popa, Iasi, Romania;
4
Department of
Vascular Surgery UMF Gr.T.Popa, Iasi, Romania.
Introduction
Pheochromocytoma and paraganglioma are catecholamine secreting tumours.
Malignancy is uncommon (approximately 10% for pheochromocytoma and 20%
for paraganglioma) and surgery, when possible, is the frst line treatment. However,
the prognosis is poor because of frequent local recurrence and/or metastases and the
lack of specifc chemotherapeutic agents. CASE-REPORT: We present the case of
a 60 years-old man who, at the age of 48, was diagnosed with paraganglioma. At
that specifc time, he presented episodes of paroxystic hypertension with spells,
the diagnosis of catecholamine excess being confrmed by high levels of VMA
( 50 mg/24 h at 3 determinations). CT was non-diagnostic, but
131
I-MIBG
scintigraphy showed the presence of a 1.5 cm nodule in the left abdominal
paraaortic region. Patient refused surgery and had a satisfactory evolution with
medical antihypertensive therapy. 11 years later, he was admitted in the Vascular
Surgery Department for acute ischemia of inferior members and a voluminous
tumour (5/6 mm) was excised. Pathology confrmed paraganglioma and described
some atypical cells, without being able to discriminate between benign or
malignant tumour. One year later he was admitted in the Endocrine Department for
the reappearance of the adrenergic syndrome (AVM30.8 mg/24 h). Thoracic
and abdominal scan showed sub diaphragmatic and pulmonary tumours.
Subsequently, octreotid scintigraphy confrmed local recurrence and metastatic
tumours in the lungs. He is proposed for experimental therapy with sunitinib
(multitargeted receptor tyrosine kinase inhibitor), which has been reported as an
effcient agent in malignant paraganglioma.
Discussion
Malignant paraganglioma with distant metastasis have a poor survival rate (11.8%
at fve years). Although the initial tumour was not resected for 11 years after the
diagnosis, our patient is one of the rare cases with indolent form, which permitted
a prolonged survival. The new treatment with sunitinib may contribute to a
continuation of this favourable evolution.
P429
Ectopic Cushing`s syndrome caused by a well differentiated
ACTH-secreting neuroendocrine carcinoma of the ileum
Joerg Singer
1,6
, Christian A Koch
2
, Michael Bartels
3
, Thomas Aigner
4
,
Thomas Lincke
5
, Mathias Fasshauer
1
& Ralf Paschke
1
1
Medical Department III, University of Leipzig, Leipzig, Germany;
2
Division of Endocrinology, University of Mississippi Medical Center,
Jackson, MS, USA;
3
Department of Surgery II, University of Leipzig,
Leipzig, Germany;
4
Institute of Pathology, University of Leipzig, Leipzig,
Germany;
5
Department of Nuclear Medicine, University of Leipzig,
Leipzig, Germany;
6
HELIOS Klinikum Aue, Aue, Germany.
Cushing`s syndrome can be caused by adrenocorticotropic hormone-secreting
solid tumors. We report a rare case of an ileal endocrine carcinoma that produced
ACTH and induced hypercortisolism. A now 47-year-old male patient presented
at the age of 41 with perspiration, weight gain, tremor and general fatigue.
Diabetes mellitus and hypercortisolism was diagnosed by laboratory testing.
Further examinations revealed ectopic Cushing`s syndrome. The search for the
location of the primary tumor proved to be diffcult. The patient underwent
subtotal thyroidectomy and surgical removal of a pituitary lesion. After resection
of an ACTH producing tumor of the mesentery, temporary remission of Cushing`s
syndrome ensued. This lesion was later found to be a metastasis. At the age of 45
the primary tumor was detected in the ileum by Ga-68 DOTATOC PET scan and
explorative laparotomy. After surgical removal of this well differentiated
neuroendocrine carcinoma the patient signifcantly improved clinically. He
experienced remission of his diabetes mellitus, an increase in muscular strength as
well as better blood pressure with 2 of 4 anti-hypertensive medications
discontinued. Follow-up laboratory testing confrmed remission of hypercortiso-
lism and diabetes mellitus. A 1 mg dexamethasone suppression test 18 months
after surgery and a Ga-68 DOTATOC PET showed normal results. Ectopic
ACTH secretion within the small bowel is very rare. This case accentuates the
diffculty in locating the source of ectopic ACTH secretion. In addition to standard
diagnostic procedures like CT or MRI scan it suggests using SSTR imaging, small
bowel barium study, tubus endoscopy or video endoscopy for preoperative
localization if the small bowel is suspected as tumor source.
P430
Intronic polymorphism IVS14-24G/A of the proto-oncogene seems
to be protective for sporadic medullary thyroid carcinoma development
Eliska Vaclavikova
1
, Vlasta Sykorova
1
, Sarka Dvorakova
1
, Petr Vlcek
2
& Bela Bendlova
1
1
2
2nd Faculty of
Medicine of Charles University and Teaching Hospital Motol, Prague,
Czech Republic.
Background and aims
Medullary thyroid carcinoma (MTC) occurs as a sporadic or less commonly as an
inherited form which comprises multiple endocrine neoplasia (MEN) type 2A and
2B and familial MTC. Whereas over 95% of patients with MEN2 syndrome have
a germline missense mutation in the RET proto-oncogene, the detection rate of
germline mutations in FMTC patients is lower as well as the detection rate of
somatic mutations in sporadic MTC tumor tissues. In this context, several
polymorphic variants are suspected to have a function as genetic modifers. Some
studies reported these polymorphisms to be associated with increased/decreased
risk of development of MTC. We focused on screening of 7 RET gene
polymorphisms - A45A (exon 2), A432A (exon 7), G691S (exon 11), L769L
(exon 13), S836S (exon 14), IVS14-24G/A (intron 14), S904S (exon 15) in MTC
patients and compare their occurrence with controls.
The cohort of MTC patients (n302) consisted of 14 MEN2A, 8 MEN2B, 11
FMTC and 269 sporadic MTC patients, the control group comprised 205 healthy
individuals. We used SNP genotyping (with TaqMan probes) and sequencing
analyses to detect mutations and polymorphisms in the RET proto-oncogene.
Results
Statistical evaluation of RET SNPs alleles revealed signifcant difference in
frequency of polymorphisms between patients with sporadic MTC and controls
only for intronic polymorphism IVS14-24G/A (P0.003). Minor allele A is
under-represented in patients with sporadic MTC compared to controls and
patients with inherited MTC.
Conclusion
This study contributes to the discussion about infuence of polymorphisms on the
development of the disease. It seems that minor allele A in intronic polymorphism
IVS14-24G/A might be protective for MTC development.
Supported by grant IGA MH CR NR/9165-3 and approved by local Ethical
committee.
P431
The Role of miRNA in reduction of type I 5`-iodothyronine deiodinase
expression (D1) in renal clear cell carcinoma (ccRCC)
Joanna Boguslawska, Adam Master, Anna Wojcicka, Piotr Poplawski,
Agnieszka Piekielko-Witkowska & Alicja Nauman
The Medical Centre of Postgraduate Education, Warsaw, Poland.
Type 1 deiodinase (D1) catalyses deiodination of tyroxine (T
4
), which leads
either to synthesis of triiodothyronine or reverse triiodothyronine (rT
3
).
Triiodothyronine (T
3
) regulates the expression of many tumour suppressor
genes and oncogenes. We previously revealed that the expression of the whole
pool of D1 transcripts was dramatically lowered in ccRCC tissues. One of the
mechanism resulting in this aberration could be miRNA-mediated repression of
target mRNAs.
The aim of our work was to study the potential regulation of D1 expression by
microRNAs in clear cell Renal Cell Carcinoma (ccRCC), which is the most
common type of renal cancers (75% of primary renal malignancies). Using semi-
quantitative real-time PCR we have analyzed 34 samples of ccRCC tumours (T)
and two types of control: the contralateral pole of the same kidney not infltrated
by cancer (C) and samples from patients suffering from other, nonneoplastic
kidney abnormalities (N).
Bioinformatic analysis revealed the presence of multiple sites for microRNAs in
3ÙTR of D1. We observed statistically signifcant (P,0.0001) over fve fold
increase in the expression of miR-224 and three fold increase in the expression of
miR-383, in samples T compared to control samples C. In order to evaluate
whether D1 was effectively a target of miR-224 and miR-383, the D1 3ÙTR was
cloned downstream of a luciferase reporter gene vector; the HeLa cell line were
then transfected with the over expressing vector and the reporter construct, with
the relative luciferase activity showing that miR-224 led to decreased activity
of the reporter gene, thus indicating binding with the 3ÙTR and destabilization
of productive translation of luciferase mRNA.
Conclusions
We identify the miR-224 as a regulator of the D1 mRNA expression.
P432
Unexplained hypoxemia in a patient with carcinoid syndrome
Presumey Pauline
1
, Longuet Catherine
1
, Dauphin Claire
3
,
Desbiez Francoise
1
, Maqdasy Salwan
1
, Charra Laure`ne
1
, Batisse Marie
1
& Tauveron Igor
1,2
1
Centre Hospitalier Universitaire Gabriel Montpied, service dèndocrino-
logie, diabetologie et maladies metaboliques., Clermont Ferrand, France;
2
Universite dÀuvergne EA 975, Faculte de Medecine., Clermont Ferrand,
France;
3
Centre Hospitalier Universitaire Gabriel Montpied, service de
cardiologie., Clermont Ferrand, France.
Introduction
The carcinoid heart disease is an uncommon valvular heart disease that may occur
in carcinoid syndrome.Valvulopathy is reported in 50% to 70% of patients of
carcinoid syndrome, due to the release of serotonin secreted by metastatic cells in
the liver, reaching directly right side of heart. The left side is preserved because of
inactivation of serotonin by lung parenchyma. Hypoxemia is an unusual
presentation of the carcinoid heart disease.
Case report
We present a case of 65 years-old woman admitted for repetitive falls. She was
known to have a carcinoid tumour of midgut origin with hepatic, pulmonary and
bone metastasis. She presented with hypoxemia (85%) and signs of right-sided
heart failure without severe dyspnoea (NYHA stage 1). Biologically, NT proBNP
was 1341 ng/l (usual value for the age: ,900), blood gas analysis showed a
shunt effect (PO
2
53 mmHg, PCO
2
34 mmHg). The hypoxemia did not correct
with oxygen and the use of diuretics. An angioscan ruled out a pulmonary
embolism. A transthoracic echocardiography showed an ejection fraction of left
ventricle at 53%, a carcinoid cardiopathy with a retracted and thickened tricuspid
valve with diastasis of the cusps, and a tricuspid insuffciency. The contrast
echocardiography showed a patent foramen ovale (PFO) with a continuous
right to left shunting, explaining the oxygen desaturation without left-sided
heart failure.
Discussion and conclusion
Once the opening of the foramen ovale occurs, the left side of the heart is exposed
to serotonin effects, leading to a risk of left, and then congestive heart failure
which, at least, may alter the prognosis of the disease. The discovery of a PFO is
an important marker of carcinoid heart disease progression and should be
systematically assessed with routine contrast transthoracic echocardiography in
patients with carcinoid syndrome.
P433
Pituitary adenoma mimicking a psychiatric disorder ~ a case report
Joana Mesquita
1,2
, Maria Joao Matos
1,2
, Ana Varela
1,2
, Eduardo Vinha
1
,
Daniel Braga
1,2
, Fernanda Guerra
1
, Josue Pereira
1
, Margarida Ayres
Bastos
1
, Li gia Castro
1
, Davide Carvalho
1,2
& Jose Lui s Medina
1,2
1
Sao Joao Hospital, Oporto, Portugal;
2
Faculty of Medicine, Oporto
University, Oporto, Portugal.
Introduction
People with intracranial organic lesions, including pituitary tumours, may
manifest initially as a psychiatric disorder, such as depression, emotional
disturbance, anxiety, apathy, neurobehavioral disturbance, cognitive dysfunction
and personality disturbance.
Case Report
A male patient 45 years old was sent to the Department of Endocrinology of Sao
Joao Hospital due to a pituitary macroadenoma. The patient referred asthenia,
muscle weakness, behaviour alteration and depression since about 3 years;
reduced left visual acuity since about 2 years. He was followed since about 3 years
in the Department of Neurology due to Parkinson diease and in the Department of
Psychiatry because of dementia and behaviour alteration. In the physical exam, he
had apathy and slow psychomotor skills. He performed a pituitary MRI that
showed a big expansive intracranial lesion in the sellar region, invading the
sphenoid sinus inferiorly and the suprasellar cistern superiorly. It caused
compression of the optic chiasm, deviation of the left anterior cerebral artery
and also invaded the cavernous sinus. It was T1 isointense and had a slight T2
hyperintensity. It had an uniform uptake of the contrast. In the biochemical
evaluation, it was detected hypopituitarism in the basal and dynamic endocrine
tests. It was initiated treatment with hydrocortisone (10 mg5 mg) and
levothyroxine 25 g/dia.
The patient was submitted to a transsphenoidal pituitary surgery and the histology
showed it was a pituitary adenoma with a slight expression of LH.
Conclusion
Patients with psychiatric manifestation often have delayed organic lesion
diagnosis. The presented case report highlights the importance of the doctor
evaluate the patient as a whole and be aware for the beginning of new symptoms,
even in a patient who has been diagnosed a psychiatric disturbance.
P434
Identihcation of hyperfunctioning parathyroids (HP) in primary
hyperparathyroidism (pHPT) in the presence of concomitant thyroid
diseases
Francesco Boi
1
, Maria Chiara Cocco
1
, Cira Lombardo
1
, Ivan Maurelli
1
,
Mario Piga
2
, Maria Letizia Lai
3
, Angelo Nicolosi
4
& Stefano Mariotti
1
1
Endocrinology, Department of Medical Sciences M. Aresu, University of
Cagliari, Cagliari, Italy;
2
Nuclear Medicine, Department of Medical
Sciences M. Aresu, University of Cagliari, Cagliari, Italy;
3
Department
of Cytomorphology, University of Cagliari, Cagliari, Italy;
4
Department of
Surgery, University of Cagliari, Cagliari, Italy.
Purpose
To characterize the interference of concomitant thyroid diseases in the
localization of HP in pHPT and develop a valuable diagnostic strategy.
Forty pHPT patients were selected for the presence of coexistent thyroid nodules
(TN) or Hashimoto`s thyroiditis (HT). Neck ultrasound (US) and sesta-MIBI
scintigraphy (MIBI) were performed in all cases. US and MIBI were concordant
in 16 cases (group I) while in the remaining 24 (group II) images were discordant
leading to the identifcation of 42 poorly defned nodular lesions within or nearby
the thyroid bed. In both groups all lesions were submitted to PTH assay in fne
needle aspiration fuid (FNA-PTH). Patients were eventually operated and HP
identifed at histology.
Results
US and MIBI correctly identifed HP in all group I patients. In group II US
correctly identifed 21/25 HP (sensitivity 84%; specifcity 82%) and MIBI only
13/25 HP (sensitivity 52%; specifcity 25%). The main causes of false positive
(8/1650%) MIBI images were represented by TN (3 oncocytic neoplasias, 2
hyperfunctioning adenomas, 2 hyperplastic nodules and 1 papillary thyroid
carcinoma), while 6/12 (50%) false negatives were associated with HT.
Interestingly, the percentage of false negative MIBI images was signifcantly
lower in the remaining cases without associated HT (3/2810.7%), P,0.01.
PTH-FNA correctly identifed all HP in both groups (100% sensitivity and
specifcity).
Conclusions
TN or HT may cause variable degrees of mismatch between MIBI and US in HP
localization with false positive and negative MIBI images. TN represent the most
frequent cause of false positive, while HT appears to be responsible of most false
negative images. PTH-FNA represents the best diagnostic tool for the
identifcation of HP and should be preferentially employed in the presence of
concomitant thyroid diseases.
P435
Molecular analysis of tumor tissue enabled selection of a successful
combined therapy of somatostatin and dopamine agonists in a case
of TSH-secreting pituitary adenoma
Ana Quintero
1
, M Angeles Galvez-Moreno
2
, Luis Jimenez-Reina
3
,
Antonio J Martinez-Fuentes
1
, Pedro Benito-Lopez
2
& Justo P Castano
1
1
Department of Cell Biology, Physiology & Immunology, University of
Cordoba, IMIBIC, and CIBERobn 06/03, Cordoba, Spain;
2
Service of
Endocrinology, Hosp. University Reina Sofa, Cordoba, Spain;
3
Depart-
ment. of Morphological Sciences, University of Cordoba, Cordoba, Spain.
TSH-secreting pituitary adenomas (thyrotropinomas or TSH-omas) are rare. At
diagnosis, TSH-omas are frequently macroadenomas presenting with variable
symptoms, and signs of hyperthyroidism. Somatostatin analogs (SSA) are a very
effcient treatment to improve clinical signs in patients with TSH-omas, reducing
hormone levels (90%) and causing tumor shrinkage (50%).Inhibitory effects of
SSA are mediated by a family of fve somatostatin receptor subtypes (sst1-5), with
sst2 and sst5 being most frequently expressed in most pituitary tumors and
enabling treatment with SSA. Dopamine receptor D2 has also been demonstrated
in TSH-omas; and its presence and intensity of expression predict the response to
treatment with dopamine agonists. Furthermore, a functional interaction between
D2 and sst5 receptors has recently been reported suggesting a potential beneft
from the combined targeting of these receptors. Here, we report a unique case of a
27-year-old woman diagnosed and managed of a TSH-secreting pituitary
macroadenoma by neurosurgical resection. During three months before surgery,
patient underwent combined therapy of octreotide LAR (OCT-LAR) and
carbimazol. After this period, GH and IGF-1 levels and thyroid function were
found to be normal although no changes were detected in magnetic resonance
imaging (MRI). After transphenoidal surgery, no intra or immediate post-
operative complications were registered. To study the molecular characteristics of
this TSH-oma, we evaluated the expression of different genes in a sample of this
tumor by conventional PCR. This confrmed expression of somatostatin receptor
2 (sst2) and 5 (sst5) and the dopamine receptor isoforms 2 (DR2 total) and 2 long
(DR2L). Taking these results into account, a combined treatment of somatostatin
and dopamine analogs was the chosen as therapy. Interestingly, MRIs at 12 and 18
month after combined treatment revealed a substantial reduction of tumor mass in
the pituitary gland. Thus, interactive relationship between clinical and molecular
studies served to select the most effective combined therapy in this patient.
Support: BIO139&CTS1705-J.Andalucia; BFU2007-60180-MEC/FEDER-
SPAIN.
P43
Aryl hydrocarbon receptor- interacting protein: mutational analysis
and functional validation in primary pituitary cell cultures
Robert Formosa, Cecilia Farrugia, Angela Xuereb-Anastasi, Marta
Korbonits & Josanne Vassallo
University of Malta, Msida, Malta.
Recently the Aryl hydrocarbon receptor - interacting protein (AIP) gene attracted
attention as a novel gene linked to familial cases of acromegaly. In Malta the
predicted prevalence of pituitary adenomas is particularly high, 4.67 per 10,000
population, thus suggesting a genetic predisposition.
Fourty seven maltese patients with acromegaly were screened for germ-line
mutations in the AIP gene. Pituitary tumour tissue, removed during transphenoi-
dal surgery from eight patients was cultured using a locally optimized protocol.
Functional analysis of wild-type and mutant AIP genes on cell survival and
proliferation of these primary cell cultures was carried out by transfection and
proliferation assays (MTT). Two variants of the AIP gene, the R304X mutant
(shown to generate a non-functional truncated protein, and R9Q, the mutant
identifed in a Maltese patient suffering from acromegaly (Farrugia et al. 2008,
unpublished data), were successfully transfected into the primary cells.
Transfection of wild-type, R304X and R9Q variants demonstrated that the
R304X variant loses the ability to reduce proliferation as compared to the wild-
type AIP, an effect previously demonstrated in other cell lines but not in primary
cells. Furthermore, the R9Q mutation shows an inverse behaviour, causing a
signifcant increase in proliferation in the primary cells, hence pointing to a gain-
of-function mutation in the AIP gene.
AIP protein has been postulated to interact with the cAMP pathway and cell cycle
regulators. Our results provide evidence supporting a role for AIP as a tumour
suppressor gene. The R9Q mutant could help clarify the role of the N-terminal of
the gene, which at present remains speculative Ongoing studies utilizing
immunohistochemistry, cAMP assays and q-PCR should help identify AIP
alterations downstream effects and verify whether specifc AIP variants may alter
cAMP levels and regulate gene expression of regulators and transcription factors.
P43I
RET mutation screening in multiple endocrine neoplasia type 2 (MEN2)
and medullary thyroid carcinoma patients (MTC) in Romania
Diana Loreta Paun
1,2
, Serban Radian
1,2
, Laura Iconaru
1,2
, Corin Badiu
1,2
,
Daniel Grigorie
1,2
, Ileana Marinescu
1
, Mihai Coculescu
1,2
&
1,2
1
C.I. Parhon National Institute of Endocrinology, Bucharest, Romania;
2
C. Davila University of Medicine, Department of Endocrinology,
Bucharest, Romania.
Background
According to current guidelines, RET mutation screening is indicated for MEN2
and familial MTC (FMTC) kindreds, as well as for apparently sporadic MTC
patients.
Aim
To investigate RET mutations in Romanian MEN2, FMTC and sporadic MTC
cases.
RET mutation screening was performed by high-resolution melting analysis
followed by direct sequencing of PCR products of exons 10-11 in 7 MEN2A
families, 2 FMTC families and 25 apparently sporadic MTC patients.
Results
In all MEN2A families (27 tested individuals) a RET mutation was present (4
Cys634Trp and 3 Cys634Arg). All subjects with clinical or biochemical disease
(15) were positive for RET mutation. 5 asymptomatic carriers were identifed and
7 subjects at risk were negative for their respective family mutations. Prophylactic
thyroidectomy was proposed to asymptomatic carriers and to pheochromocy-
toma-only individuals. Five subjects accepted and three denied thyroidectomy. In
one FMTC family we found a Cys634Tyr mutation in 2 affected individuals,
while in the other FMTC family there was no RET mutation (3 individuals tested).
Only one sporadic MTC patient had a RET mutation (Cys634Arg). Screening for
this mutation in the patients` family is pending.
Discussion
We detected a low number of asymptomatic mutation carriers, mainly because of
poor acceptance of screening by non-affected individuals.
Conclusions
RET mutation screening should be performed in MEN2 / FMTC families and
sporadic MTC. We are extending screening to exons 13-16 in our sporadic MTC
cohort.
P438
Gonadotrophinoma and parathyroid adenoma
Aikaterini Chronaiou, Ifgenia Kostoglou-Athanassiou, Georgios Klangos,
Dimitris Stefanopoulos, Aikaterini Michou, Razvan Alexandros Badila,
Stylianos Kotanoglou & Areti Karf
The coexistence of multiple adenomas in endocrine glands has been described in
the context of the syndromes of multiple endocrine neoplasia. However, recently
the presence of adenomas in multiple endocrine glands has been described in
patients not fulflling the criteria of the syndromes of multiple endocrine
neoplasia.
The aim was to describe the case of a patient with a pituitary gonadotrophinoma
who presented with primary hyperparathyroidism caused by a parathyroid
adenoma.
A patient, female aged 60 years, presented with headache. In MRI scan a pituitary
adenoma was observed, which was removed transsphenoidally. Histology showed
a gonadotrophinoma measuring 1,0.7,0.5 cm. Immunohistochemistry showed
intense positivity for beta-FSH and beta-LH. Four years later the patient
developed diffuse bone pain affecting the lower extremities and constipation.
Laboratory investigations revealed a blood calcium of 11 mg/dl and parathyroid
hormone of 150 pg/ml. Alendronate was administered. Three years later the
patient presented with kidney stones and underwent lithotripsy treatment. In
further investigation with ultrasonography a parathyroid adenoma was visualized
measuring 2.7,1.1 cm, which became also apparent in scintigraphy with
99 m
Tc
methoxyisobutylisonitrile under the left lower thyroid lobe. The adenoma was
removed surgically. Histology showed a parathyroid adenoma encapsulated by a
thin fbrous capsule and remnants of normal parathyroid tissue. Postsurgically the
patient is well and no recurrence of hypercalcemia was observed.
Conclusion
An extremely rare case of a patient with a pituitary gonadotrophinoma who
presented with primary hyperparathyroidism caused by a parathyroid adenoma is
described. The patient presented with adenomas in multiple endocrine glands, not
fulflling though the criteria of the syndrome of multiple endocrine neoplasia type
1, as this syndrome is known to be associated with parathyroid hyperplasia.
P439
Cushing`s syndrome, clinicaly non-functioning pituitary adenoma and
hypercalcemia
Valentina Elezovic, Tatjana Isailovic, Milan Petakov, Djuro Macut,
Sanja Ognjanovic, Bojana Popovic, Ivana Bozic & Svetozar Damjanovic
Institute of endocrinology, diabetes and diseases of metabolism, Clinical
Center of Serbia, Belgrade, Serbia.
A 25-year-old female, referred because of left hemianopsy, weight gain, fatigue,
muscle weakness, and secondary amenorrhea. Physical examination revealed
overt Cushingoid features and left temporal hemianopsy. Previously the diagnosis
of pituitary macroadenoma (MRI) with suprasellar, infrasellar, and right
parasellar propagation was made in regional hospital. Laboratory results showed
moderate hypercalcemia with hypophosphatemia and hypercalciuria with
inappropriately normal PTH. Unsupressible cortisol during low- and high-dose
Dexamethason (Dex) test confrmed the diagnosis of Cushing syndrome (CS),
with supressed basal ACTH level pointing to ACTH-independent CS. During
high dose Dex test severe headache and visual loss developed due to pituitary
apoplexy and urgent trancranial surgery was performed. Chromophobe pituitary
adenoma was confrmed by negative immunohistochemistry (LH, FSH, PRL,
ACTH, TSH). Clinical and biochemical signs of hypercortisolism persisted after
pituitary surgery. Further assesment revealed 4 cm adrenal mass (CT). After the
left adrenalectomy, CS resolved and pathohistology confrmed the diagnosis of
adrenal cortical adenoma. Substitution therapy with hydrocortisone was
instituted. Although MIBI scintigraphy was negative, subtotal parathyroidectomy
with total thyroidectomy was performed and primary hyperparathyroidism due to
parathyroid gland hyperplasia was diagnosed. Serum calcium and PTH levels
normalized. Her periods become regular. The persistence of hypocortisolism with
reduced IGF1 concentration one year after surgery, can be explained by
secondary hypocortisolism, rather than by prolonged supression of HPA axis.
Despite negative family history, genetic screening for MEN 1 mutation is in the
course. We presented here a rare case of Cushing`s in MEN I syndrome due to
adrenocortical adenoma.
P440
Use of recombinant human thyroid-stimulating hormone (rhTSH) in
children and adolescents with differentiated thyroid cancer
Marketa Mackova, Pavla Sykorova & Petr Vlcek
Department of Nuclear Medicine and Endocrinology, Charles University in
Prague, 2nd Faculty of Medicine and University Hospital Motol, Prague,
Czech Republic.
Paediatric thyroid cancer is rare but belongs to the most frequent malignancies in
children and its incidence increases. The difference from adult disease subsists in
good curability despite of quicker proliferation and earlier development of
metastases. Infuence of previous radioactivity exposure in the pathogenesis has
been proven.
For the optimal uptake of radioiodine
131
I in the post-operative thyroid remnants
it`s necessary to achieve level of serum TSH higher than 30 mIU/l. Stimulation
with rhTSH before diagnostic or therapeutic radioiodine administration is a
widely used effective and safe alternative of traditional 4-5 weeks lasting thyroxin
withdrawal.
Our department provides diagnostic and treatment with radioiodine to 85% of
patients with thyroid cancer in the Czech Republic. In years 2008 and 2009,
rhTSH was administered to 19 patients aged 7-17 years. Nine patients received
rhTSH before diagnostic administration of
131
I (140 MBq) within the follow-up
after previous radioiodine treatment. Ten patients were stimulated before
receiving the therapeutic activity of
131
I. 4 of them underwent radioiodine
ablation of post-surgical thyroid remnants. Other 4 patients were in need of
rhTSH stimulation because of prior fnding of metastases, 2 of them were
administered rhTSH twice in following courses. The remaining 2 patients were
administered rhTSH-assisted radioiodine therapy due to elevated level of serum
thyroglobulin during suppression thyroxin therapy in follow-up.
All these patients tolerated either the intramuscular administration of rhTSH and
following radioiodine diagnostic or treatment well with no specifc side effects.
We suppose the use of rhTSH in children is the same effcient and safe as in adult
patients, bringing more comfort to patients, less secondary morbidity associated
with hypothyroidism, reduced risk of tumour progression and lowered radio-
toxicity due to fully retained renal clearance of radioiodine in the euthyroid status.
However, wider use of this preparation is limited by the economical aspects.
P441
Metastatic mammary carcinomas with neuroendocrine features- a case
report
Andreea Brehar, Alexandra Bulgar & Constantin Dumitrache
National Institute of Endocrynology 'Prof. C. I. Parhon`, Bucharest,
Romania.
Mammary carcinomas with endocrine differentiation are an uncommon subtype
of breast carcinomas that are morphologically indistinguishable from low-grade
endocrine neoplasm arising in other organs.
Neuroendocrine cells are present in mammary tissue. Neuroendocrine differen-
tiation can be found in benign and malign lesions of various organs. Recent
studies have reported the existence of neuroendocrine differentiation in breast
carcinomas as being between 3% and 21%. Neuroendocrine differentiation
detected in breast carcinomas shows morphological similarities to carcinomas of
the gastrointestinal system and lung. However they are morphologically and
clinically different from the classical carcinoid tumor of other systems. Hormone
production of the tumor is rarely present.
We present a case of a forty-seven year old woman with mammary carcinomas
ER, PRG, HER2-, without neuroendocrine receptor with multiple metastases
who was operated and received chimiotherapies with completed remission. After
two years she developed cervical ganglionar metastases and the biopsy with IHC
indicated secondary determination of mammary carcinoma with neuroendocrine
differentiation. She started chimiotherapy with immunotherapy and the evolution
is better.
P442
The laterocervical unique masses ~ a challenging pathology
Costan Anca-Roxana
2
, Vulpoi Carmen
1
, Vicol Carmen
1
, Crumpei Felicia
2
,
Ferariu Dan
2
, Popescu Eugenia
1
& Costan Victor-Vlad
1
1
University of Medecine and Pharmacy 'Gr T. Popa`, Iasi, Romania;
2
'St Spiridon` Emergency Hospital, Iasi, Romania.
Introduction
Extrathyroidal unique laterocervical masses are infrequent, and their etiological
diagnosis is diffcult. Since clinical and imagistic features cannot distinguish
between different ethiologies, morphological data are mandatory in order to
establish a precise therapeutic strategy. Therefore the initial treatment is surgery,
followed by an adequate therapeutical scheme. We would like to report our
experience treating this pathology.
Patients and method
Twelve patients (7 males and 5 females, aged between 14 and 75 years-old) were
refered to our unit of Maxillofacial Surgery in a 4 years period (2006-2009) for
unique laterocervical masses without any other clinical or paraclinical fndings.
Cervical scan was used to describe tumoral size and rapports. Nine of the twelve
tumors were on the left side of the neck. Sizes was between 6-12 cm measured on
their long axis. Four masses had liquid content, the other 8 being solid. All of the
tumors were surgically removed by the same surgeon.
Results
Post operative evolution was without complication. Morpholgy diagnosed 4
lymph node metastasis of squamous cell carcinoma, 3 tuberculous adenopathies
(scrofula), 2 lymph node metastasis of thyroid papillary carcinoma, 2 branchial
cysts, and 1 hemangioma. Surgical treatment was differently completed, function
of thee etiology: radiotherapy and chemotherapy (for squamous cell carcinoma),
antituberculous medication, total thyroidectomy followed by radioiodine therapy
and hormonal substitution therapy (for thyroid carcinoma). No further treatment
was necessary for the cystic masses and hemangioma.
Conclusions
In our experience, most of the non-thyroidal laterocervical masses are malignant
lymphadenopathies. Treatment could not be established until after surgery
followed by morphology. Unique tumor masses have a high pathological variety
and treatment strategy involves a multidisciplinary team.
P443
Is In2-ghrelin variant, a ghrelin gene derived transcript, a novel player
in breast cancer tumors?
Manuel D Gahete
1
, Jose Cordoba-Chacon
1
, Marta Hergueta
2
,
Francisco Gracia-Navarro
1
, Rhonda D Kineman
3
, Gema Moreno-Bueno
2
,
Raul M Luque
1
& Justo P Castano
1
1
Department of Cell Biology, Physiology & Immunology. University of
2
Institute of
Biomedical Research Alberto Sols, Madrid, Spain;
3
Department of
Medicine, Section of Endocrinology, Diabetes and Metabolism. University
of Illinois at Chicago, Research & Development Division, Jesse Brown
Veterans Affairs Medical Center, Chicago, IL, USA.
Ghrelin has been classically known as a GH- and metabolism-regulating
hormone, mainly produced by stomach. However, it also acts as a paracrine or
autocrine factor in several tissues, where it can regulate tissue growth and
neoplastic cell proliferation. Of note, ghrelin needs to be acylated at Ser3 by the
ghrelin-O-acyltransferase (GOAT) enzyme to bind to its receptor GHS-R1a.
Interestingly, the ghrelin gene can give rise to distinct additional peptides,
generated by alternative splicing and/or from post-translational modifcations,
with some ghrelin-derived variants being up-regulated in breast cancer. In this
study, we have identifed an alternative human ghrelin variant transcript
containing Ex0, Ex1, In2, and Ex2 but lacking Ex3 and 4, named In2-ghrelin
variant, which was strongly up-regulated in a series of breast cancer samples as
compared with normal mammary gland (P,0.01). Translation of this splice
variant would originate a new pre-propeptide of 117 amino acids that conserves
only the signal peptide and the frst 12 amino acids of native-ghrelin, but retains
the acylation site on Ser3. This novel In2-ghrelin variant was thoroughly
expressed in the 22 human tissues analyzed. Interestingly, the expression of In2-
ghrelin variant but not that of native-ghrelin parallels the expression of the GOAT
enzyme in both, normal (R
2
0.921) and breast cancer (R
2
0.655) samples,
suggesting that In2-ghrelin variant could be a primary substrate for GOAT in
normal and tumoral tissues. Moreover, In2-ghrelin variant expression in breast
cancer was highly correlated with GHSR-type1b but not with GHSR-type1a. In
the MDA-MB-231 cell line, an in vitro breast cancer cell model, the expression
level of In2-ghrelin variant was inhibited by both acyl- and desacyl-ghrelin,
whereas it was increased by tamoxifen. In summary, overexpression of In2-
ghrelin variant, GOAT and GHSR1b in breast tumor samples coupled to the
regulation observed in in vitro models, suggests that this novel ghrelin variant
may play a relevant role in breast cancer. Support: RYC-2007-00186, BIO-0139,
CTS-01705, BFU2007-60180/BFI, BFU2008-01136/BFI, NIDDK 30677, VA
Merit Award.
P444
Gastroenteropatic Neuroendocrine tumors: multidisciplinary approach
in therapy
Sona Kinova, Lubos Kekenak, Eva Kovacova, Izabela Makaiova
& Michal Koren
Comenius University, Bratislava, Slovakia.
Introduction
Gastroenteropancreatic neuroendocrine tumors (GEP-NET) are classifed on the
basis of hormonal activity of tumor cells to functional and non-functional tumors.
Therapy of well differentiated NETs includes surgical procedures, debulking of
tumor mass, biotherapy and peptid receptor radionuclid therapy.
Aim of the study
Analysis of therapeutic modalities in group of patients with well differentiated
GEP-NETs.
Results
In time period from 1.1.2005 to 31.12.2009 we followed up 50 pts (19 men/31
women) with well differentiated GEP neuroendocrine tumors. Primary
localisation was: stomach - 6 times, pancreas - 9,, duodenum- 1,, jejunum-
4,, appendix- 3,, illeum- 23,, rectum- 4,. Metastatic dissease was affrmed
in time of diagnosis in 36 patients. Carcinoid syndroma had 20 pts, 4 pts
with pancreatic tumor had functional tumors (2,overproduction of calcitonine,
1, of gastrin,1 , of insuline). Surgical treatment was performed in 45 pts.-
resection of primary tumor and debulking of metastases, in 5 pts with pancreatic
tumor resection was not possible due to invasion to sorrounding tissue and
vessels. Biological treatment with long acting somatostatin analogues was
indicated in 20 pts with carcinoid syndroma and in 4 pts with functional
pancreatic tumors. In 3 pts with non resectable neuroendocrine carcinoma of
pancreas peptid radionuclide receptor therapy (PRRT) was indicated: in 2 of them
with 90 Ytrium -DOTA-octreotid and in 1 patient with MIBG. In all 3 pts a
reduction of tumor volume was noticed. Biotherapy with somatostatin analogues
reduced symptoms of hormonal activities and brought on stabilisation of dissease
in most of patients. In period of follow up 5 patient died.
Conclusion
Complex therapy - surgical procedure, biological therapy with somatostatin
analogues and PRRT in patients with well differentiated neuroendocrine tumors
markedly contributes to prolongation of survival of patients and also to
enhancement quality of their life.
P445
The use of receptor tyrosine kinase inhibitors in metastatic
differentiated thyroid carcinoma
Anastasios Gkountouvas
1
1
, Eirini Veniou
1
,
Dimitrios Thomas
1
, Anastasia Aggelopoulou
1
, Marios Nikas
1
,
Nicolaos Ziras
2
& Philippos Kaldrymides
1
1
Department of Endocrinology, Metaxa Hospital, Piraeus, Greece;
2
2nd
Department of Internal Medicine, Metaxa Hospital, Piraeus, Greece.
The management of metastatic differentiated thyroid carcinoma included until
recently the use of therapeutic
131
I, radiotherapy and in specifc cases
chemotherapy. However, recently new agents entered in the management of
differentiated metastatic thyroid carcinoma which aim at specifc cell receptors
and inhibit the growth of the carcinoma in a specifc and targeted way.
The aim was to present the experience of the use of the receptor tyrosine kinase
inhibitors, sorafenib and sunitinib in patients with advanced metastatic
differentiated thyroid carcinoma.
A group of 9 patients with advanced metastatic differentiated thyroid carcinoma
after subtotal thyroidectomy and
131
I therapy were studied. Within this group 4
patients had metastatic papillary, 3 had metastatic Hurthle cell thyroid carcinoma,
1 had follicular with pulmonary metastases at diagnosis and 1 had insular thyroid
carcinoma. Sorafenib or sunitinib or sequentially sorafenib and sunitinib were
administered, when progressive disease was observed after all other methods for
the management of thyroid carcinoma had been applied.
Results
All patients had partial remission of the disease or stable disease, none of them
entering full remission. Thyroglobulin decreased in all patients. The reduction in
the volume of the neoplastic disease was from zero to signifcant. The patients
have been followed up on therapy with the receptor tyrosine kinase inhibitors
for a period of 7 to 17 months. Adverse reactions included gastrointestinal
disturbances, diarrhea, hand foot syndrome, alopecia, hemorrhagic tendency,
stomatitis and yellow skin discoloration. In patients already having a mild blood
marrow suppression further suppression was observed, improving with
diminishing drug dosage. Within this group of patients 3 had secondary loss of
response to sorafenib after administration for a 4-month period and then sunitinib
was administered.
Conclusion
The use of receptor tyrosine kinase inhibitors is a signifcant progress in the
treatment of advanced metastatic thyroid carcinoma.
P44
The relationship of testosterone to PSA in men with sexual dysfunction
Giovanni Corona
1,3
, Valentina Boddi
1
, Francesco Lotti
1
, Mauro Gacci
2
,
Marco Carini
2
, Giulia De Vita
1
, Alessandra Sforza
3
, Gianni Forti
1
,
Edoardo Mannucci
4
& Mario Maggi
1
1
2
Department of Urology, University of Florence,
Florence, Italy;
3
Endocrinology Unit, Medical Department, Azienda Usl,
Maggiore-Bellaria Hospital, Bologna, Italy;
4
Diabetes Section Geriatric
Unit, Department of Critical Care, Florence, Italy.
Introduction
Concern about a testosterone-induced PSA increase is often perceived as one of
the main limitations in treating hypogonadism even when it is symptomatic, such
as in subjects with sexual dysfunction (SD). The aim of the present study is to
evaluate the relationship between testosterone (T) and PSA levels in subjects
with SD.
Methods
We retrospectively evaluated the relationship between T and PSA in 2291
subjects seeking medical care at our Outpatient Clinic for SD (Sample A). The
analysis was then repeated in a selected subpopulation of 1421 subjects
apparently free from prostatic diseases (Sample B). The specifc association
between PSA levels, circulating androgens and different clinical signs and
symptoms of hypogonadism, as assessed by ANDROTEST structured interview,
was evaluated.
Results
In both Sample A and B, subjects with higher PSA levels reported a lower
prevalence of hypogonadism related symptoms and signs, as well as higher total
T, analogue and calculated free-T. However, when the association between PSA
and T was evaluated as a function of T deciles, the upper 9 groups had similar
PSA values, with the lowest demonstrated a signifcantly reduced PSA (the lowest
vs. the rest of the sample: 0.61[0.38-1.23] ng/ml vs 0.86[0.57-1.44] ng/ml and
0.51[0.30-0.94] ng/ml vs 0.73[0.52-1.10] ng/ml, respectively for Sample A and
B; both P,0.0001). Furthermore, when the relationship between hypogonadism
(total T,8 nmol/l) and PSA levels was evaluated according to age, it was
signifcant only in younger subjects, but not in the older ones.
Conclusions
Our data demonstrated PSA is unrelated to T concentration across most of the T
range, except for the most severely T-defcient, and that a signifcant relationship
between T and PSA is seen in younger but not older men.
P44I
Primary carcinoid as an incidental hnding in a mature cystic teratoma
of the ovary: case report
Marioara Cornianu
1
, Alis Dema
1
, Ioana Golu
2
, Elena Lazar
1
, Sorina Taban
1
,
lexandra Faur
1
, Daniela Amzar
2
& Ioana Zosin
2
1
Department of Pathology, University of Medicine and Pharmacy
'V Babes`, Timisoara, Romania;
2
Department of Endocrinology, University
of Medicine and Pharmacy 'V Babes`, Timisoara, Romania.
Carcinoid tumors are distinct neuroendocrine neoplasms with characteristic
histological, clinical and biological features.
An extremely rare case of a primary carcinoid tumor arising in a mature cystic
teratoma is reported. A 23-year-old woman was admitted with pain in the lower
abdomen and for further examination of a tumor in the left anexa.
Transabdominal ultrasonography demonstrated a cystic mass measuring
110/70 mm, with irregularly thickened walls in the left anexa. The left ovary
could be visualized separate from this lesion.
Conservative surgery was performed (due to the age of the patient)- left saplingo-
oopherectomy.
Results
Macroscopically, the ovarian tumor was partly cystic and partly solid, and the
solid part measured 40 mm in diameter. On cut section, cyst was multiloculated,
and was flled with hair and sebaceous material. Microscopic examination of the
cystic area showed a cyst linied by stratifed squamous epithelium with sebaceous
glands, sweat ducts and hair shafts in the wall. The solid part showed thyroid
follicular structure and a tumor arranged in insular and trabecular pattern. On
immunohistochemistry, the tumor showed strong positivity for chromogranin A,
neurospecifc enolase and synaptophysin.
The pathological diagnosis was mature cystic teratoma with primary carcinoid.
Conclusions
Insular carcinoids are often associated with carcinoid syndrome, while in the
trabecular variant, endocrine manifestations are rarely present. The patient did not
have a carcinoid syndrome. She has been followed for 31 months with no
recurrence.
Primary ovarian carcinoids are rare, accounting for 0.3% of all carcinoid tumors
and developed in pure form or in association with other tumors.
P448
Conditions and implications of rhTSH application for ablation in
treatment of Differentiated thyroid cancer
Pavla Sykorova, Marketa Mackova & Petr Vlcek
Department of Nuclear Medicine and Endocrinology, Charles University in
Prague, 2nd Faculty of Medicine and University Hospital Motol, Prague,
Czech Republic.
A basic tool of the thyroidal cancer treatment is the total thyroidectomy.
Immediately after the thyroidectomy, the patients receive a thyroxin. In the case
of positive histology after lobectomy, we frst indicate the total thyroidectomy. If
the tumor is larger than 1 cm or if is a multifocal one, we indicate the ablation of
the remnant with
I
131.
Usually, the differentiated thyroid cancer is non-aggressive and we proceed with a
standard way of the ablation - after thyroxin 4 week withdrawal. We always use
the diagnostics scan with
I
131 74 MBq. Depending on the results, we administrate
4 different dosages in liquid: (1) 2900 MBq for negligible remnant, (2) 3700 MBq
for average remnant 3-7% accumulation in 24 h, (3) 5500 MBq for 7-10%, and
(4) 7500 MBq in the presences of distant metastasis.
Patients with more aggressive form of the cancer that is invasive into the thyroid
capsule or in a presence of a lymph node metastasis are in the risk of the tumor
growing in the remnant. If the result of diagnostic scan after 4 week thyroxin
withdrawal is larger than 10% of the 24 h accumulation then we cannot decide
whether it is a failure of the surgery or the growing up tumor. In these cases, we
indicate reoperation and afterwards we use rhTSH (Thyrogen) instead of the
thyroxin withdrawal. This situation appeared in 7 cases in the last year.
Economic aspects do not allow us to use rhTSH for all ablations which would
make the treatment easier for patients. But we can choose the patients with a high
risk of the growing tumor. This allows us to prevent them from stimulating
infuence of the TSH that would otherwise be used over long time (typically
4 weeks).
P449
Pheochromocytomas in the RET protooncogene mutations carriers
Kornelia Hasse-Lazar
1
, Aleksandra Krawczyk
1
, Sylwia Szpak-Ulczok
1
,
Agnieszka Pawlaczek
1
, Jacek Ziaja
2
& Barbara Jarzab
1
1
Maria Sklodowska-Curie Memorial Cancer Center and Institute of
Oncology, Gliwice, Poland;
2
Silesian University of Medicine, Katowice,
Poland.
Mutations in the RET protooncogene cause familial cases of medullary thyroid
cancer, which in some cases coexists with pheochromocytoma and primary
hyperparathyreoidism as the MEN2A syndrome.
Aim of the study
Evaluation of frequency of pheochromocytomas and their clinical course in the
RET protooncogene mutations carriers.
Material
One hundred and seventy nine patients, among them 109 probands and 70 family
members in whom RET germinal mutations were detected. 90 probands had DNA
analysis because of diagnosis of medullary thyroid cancer and 19 - because of
pheochromocytoma.
Methods
Analyzed DNA was isolated from peripheral blood leukocytes. Exons 10, 11, 13,
14, 15 and 16 were analyzed. From the beginning exons 10, 13, 14, 15 and 16
were analyzed with the use of direct DNA sequencing, and since 2007 also exon
11, which previously was analyzed with the use of RFLP.
Results
The frequency of pheochromocytoma/paraganglioma in the mutations carriers
was 29% (n51). Multiple lesions present at the time of diagnosis or occurring
during follow-up were present in 34 cases (66%). In 3 cases malignant tumors
were diagnosed. According to the type of mutation pheochromocytomas were
present in 1/1 cases with codon 534 mutation, 1/1 cases with codon 609 mutation,
1/3 cases with codon 611 mutation, 2/17 cases with codon 618 mutation, 0/9 cases
with codon 620 mutation, 33/66 cases with codon 634 mutations, 0/6 cases with
codon 768 mutation,0/4 cases with codon 790 mutation, 6/30 cases with codon
791 mutation, 0/14 cases with codon 804 mutation, 1/7 cases with codon 891
mutation and 4/14 cases with codon 918 mutation.
Conclusions
Pheochromocytomas are present in about 1/3 of RET mutations carriers and in
majority of cases are multiple and benign tumors located in adrenal medulla.
Their frequency depends on the type of mutation and only in patients with codon
634 mutations is up to 50%.
P450
Unusual cause of hyercalcemia in pheochromocytoma
Venkata M R Katreddy, Khalid Ashawesh, Sanjay Saraf & Tarek M Fiad
Russells Hall Hospital, Dudley, West Midlands, UK.
Introduction
Hypercalcemia with pheochromocytoma usually occurs as part of MEN
syndrome associated with parathyroid adenomas or hyperplasia. Here, we present
a case of malignant pheochromocytoma with hypercalcemia caused by the
secretion of PTHrP secretion tumour itself. Hypercalcemia was corrected on by
the removal of the malignant pheochromocytoma.
Case
A 75-year-old gentleman with PMHx of hypertension presented with a history of
fall and head injury due to postural hypotension. He also described weight loss for
about 1 year. US abdomen showed left supra renal mass, followed by a CT
abdomen and chest which confrmed a large 13.5/13.3/11.5 cm solid mass, with
central necrosis and no obvious metastasis. Twenty-four urine collection
showed raised urine normetadrenaline 142 mol/24 (0-3.30), noradrenaline
11 737 nmol/24 h (100-600), urine metadrenaline 3.03 mol/24 h (0-1.20), urine
adrenaline ,10 nmol/24 h. Repeat urine samples consistently showed elevated
noradrenalin and normetadrenaline. MIBG scan confrmed a left adrenal
pheochromocytoma. During investigation was found to have elevated calcium
on various occasions ranging from 2.72 to 3.23 mmol/l (2.1-2.6), phosphate
0.78-0.9 mmol/l (0.8-1.4), suppressed PTH ,0.3. US parathyroid showed no
adenomas or hyperplasia, bone scan did not reveal any metastatic disease.
Measurement of PTHrP showed elevated 2.2 pmol/l (0.7-1.8). Patient underwent
left adrenalectomy. Histology confrmed malignant pheochromocytoma with
capsular invasion and vascular invasion, stains for chromogranin and
synaptophysin, unfortunately not checked PTHrP staining. After surgery his
calcium returned to normal 2.52 mmol/l, with PTH normal at 4.56 pmol/l and
remained normal 18 months follow up.
Conclusion
Till now malignant pheochromocytoma with hypercalcemia secondary to PTHrP
has been reported on only three occasions. This case illustrates a rare phenomenon
of hypercalcemia with malignant phoechromocytoma due to humoral cause and
not as part of MEN syndrome.
P451
Prokineticin 1 stimulates prostate epithelial cell migration and
proliferation /n r/tra
Daniela Visonti
1
, Giuseppe Bellastella
1
, Valentina Rossi
1
, Paolo Chieff
2
,
Luigi Maione
1
, Paola Punzo
1
, Antonio Bellastella
1
& Antonio
Agostino Sinisi
1
1
Department of Clinical and Experimental Medicine and Surgery, Second
University of Napoli, Napoli, Italy;
2
Department of Experimental Medicine,
Napoli, Italy.
Prokineticin 1 (Prok1), the product of EGVEGF/PROK 1 gene, acts through two
G-coupled receptors (PKR1 and PKR2) and is involved in a wide spectrum of
actions, including tumorigenesis. Increased Prok1 expression has been found in
prostate hyperplasia and cancer, suggesting a role in prostate cancer and BPH.
Aim of this study was to elucidate the role of Prok1 on prostate cell function and
growth. We evaluated the effects of Prok1 on epithelial prostate cell (PC)
migration and proliferation, using two in vitro models: the androgen-dependent
epithelial PC line EPN, and a stabilized PC line derived from prostate cancer
(CPEC).
Methods
Semiconfuent starved cultures were treated with recombinant Prok1 (5 nM) alone
or associated with antiProk1 MoAb or solvent. Cells were harvested 48 h after the
treatment and stained with propidium iodide for fow cytometry of cell cycle by
FACS caliber or recovered for protein extraction for western-blot analysis, or for
mRNA extraction for semiquantitative RT-PCR. Cells grown on slides were also
treated ad harvested after 46 h for TUNEL assay. A wound assay was performed
for the evaluation of cell motility after overnight incubation. For ERK
phosphorylation assay cell cultures were recovered after 5, 10, 20 and 60 min
following treatment.
Results
An increase of the cell number in S phase, with a decrease of cell counts in pre-G
1
and G
0
/G
1
, and a signifcant reduction of percent of apoptotic nuclei was found
after Prok1 treatment (P,0.05 versus control). Treatment induced an increase of
migration in CEPC only. All these effects were abolished when antiProk1 MoAb
was added. Prok1 induced a rapid and transient phosphorylation of ERK in EPN
and more sustained effects on CEPC; these effects were abolished by pretreatment
with PD98059 (50 nM). Semiquantitative PCR showed an increase of Prok-R2
transcript in treated cells.
Conclusions
Our study demonstrates that Prok1 has stimulating effects on prostate epithelial
tumor cells growth and migration in vitro, suggesting a role in the neoplastic
progression. These effects are specifcally mediated by receptor activation and
induction. These data suggest that Prok1-ProkR signaling pathway may be target
of new therapeutic approach for the control of prostate tumor development and/or
progression.
P452
Cushing`s disease as the hrst manifestation of familial multiple
endocrine neoplasia syndrome type 1
Liliya Rostomyan, Natalya Mokrysheva, Anatoly Tiulpakov &
Ludmila Rozhinskaya
Neuroendocrinology Department, Centre for Endocrinology, Moscow,
Russian Federation.
MEN1 syndrome is an autosomal dominant inherited disease characterised by
primary hyperparathyroidism in association with endocrine enteropancratic
tumors and anterior pituitary adenomas. Tumours of the pituitary gland as the
frst manifestations of MEN1 are very rare in children.
Clinical case report
A 13-year-old boy presented with clinical signs suggestive of Cushing`s
syndrome. He had decreased growth rate, muscle weakness, headaches and
truncal obesity. The laboratory tests and cerebral magnetic resonance imaging
revealed hypercortisolism due to ACTH-producing pituitary microadenoma
(6 mm). Two repeated courses of proton therapy was done as there was
anatomical obstacle for transsphenoidal surgery. The complete remission of
Cushing`s syndrome was achieved within 18 months. Primary hyperparathyroid-
ism was subsequently diagnosed in age of 19 years with elevated serum calcium
(3.19 mmol/l), PTH (99 pg/ml), hyperparathyroid osteodystrothy and renal
stones. Parathyroid surgery was performed with postoperative severe hypopara-
thyroidism.
DNA-testing showed that he carried a heterozygous W188R mutation in MEN1
gene.
Serum calcium was evaluated in the asympomatic family members. PHPT was
revealed with increased serum calcium and serum PTH in patient`s 40-year old
mother. Subtotal parathyroidectomy was performed with intraoperative decrease
of PHT to normal range. Four months later an abdominal CT scan revealed a large
tumor mass located at the tail of pancreas. Despite of non-functioning behaviour
of pancreatic tumor a distal pancreatectomy was performed for it large size.
Histology confrmed the diagnosis of adenocarcinoma. Genetic testing of MEN1
gene showed that the woman carried the same mutation as was found in index
patient. Screening for hypercalcaemia in an 18-year-old brother was normal, and
he had no MEN1 related symptoms.
Conclusion
We present a clinical case of familial MEN1 syndrome that debuted with
hypercortisolism at a young age. This suggests the need of follow-up due to
possibility of MEN1 in patients with Cushing`s syndrome with clinical
manifestation in childhood. Screening for MEN1-related disorders including
genetic study is important in family members, and allows a precocious diagnosis
and treatment.
P453
Two exceptional etiologies of classic endocrinopathies
Brakni Lila, Chenak Lies, Iabassen Malek & Kemali Zahra
Hopital Central De Làrmee, Algiers, Algeria.
Introduction
Two patients admitted for evaluation of a hypercalcemia and hypothyroidism
whose etiologic diagnosis showed itself unusual.
Case no. 1
A 45 years old man allowed for disorders of consciousness, vomitings and
headaches, biology showed a hypercalcemia, a hypophosphoraemia, hyperPTH.
The imaging revealed parathyroidal adenoma with a compressive prolactinema.
Pet Scan-FDG showed a metabolic activity of the thymic cavity with a necrotic
aspect, fve pancreatic nodules and adrenal nodules without pheochromocytoma.
He has benefted from the resection of a parathyroidal adenoma from thymoma of
P3 type invasive and hypophyseal adenomectomy. Search of MEN1 was positive.
Case no. 2
A 58 years old Mrs admitted for hypothyroidism post-radiation of a thymic
carcinoma diagnosed 3 years earlier. Biology showed a hypercalcemia, a hypo
phosphoraemia, hyperPTH in touch with parathyroidal adenoma. Imaging
showed adrenal mass. Immunohistology ended has a pheochromocytoma.
Besides, she presents a gastritis. The search of one MEN1 was negative.
Conclusion
These cases illustrate the interest of a fne analysis of the usual clinical and
biological data as well as the contribution of the current techniques of biology and
imaging for the etiologic and topographic.
P454
Peptide receptor radionuclide therapy and NETs: how to select
patients?
Rupa Ahluwalia
2
, Gail McKane
1,2
, Jiten Vora
2
& Sobhan Vinjamuri
1
1
Department of Nuclear Medicine, The Royal Liverpool and Broadgreen
University Hospitals, Liverpool, UK;
2
Department of Diabetes and
Endocrinology, The Royal Liverpool and Broadgreen University Hospitals,
Liverpool, UK.
Neuroendocrine tumors (NETs) are rare tumours arising from the gastroentero-
pancreatic axis. They are slow growing and often metastatic. Diagnostic workup
requires imaging; both anatomical (ultrasound, CT, MRI) and functional
(somatostatin receptor scintigraphy, PET).
NETs strongly express somatostatin receptors (SSTRs) of fve different subtypes
(SSTRs1-5) with SSTR2 being the most common. Some NETs refect
hyperactivity of the guanethidine pathway. Imaging based on 'receptor
expression` helps to guide treatment in cases of inoperable or progressive
NETs. Imaging with radiolabelled receptor binding somatostatin analogues and
meta isobenzyl guanidine (MIBG) can be used to select patients for peptide
receptor radionuclide therapy (PRRT).
We describe two cases with differential uptake patterns on
123
I-MIBG,
111
In
octreotide and
111
In DOTATOC scanning affecting treatment options.
Case 1-20 years old male referred for PRRT with metastatic gastric small cell
NET.
111
In octreotide scan showed a focal hot spot in the skull but not on the
MIBG scan. An
111
In DOTATOC showed multiple hot spots in the skull
confrming brain metastasis. The patient received cranial radiotherapy instead of
PRRT.
Case 2-36 years old female with a mesenteric somatostatinoma referred for PRRT
after an incomplete excision. An
111
In octreotide scan showed signifcant uptake
at the site of the known mesenteric tumour with normal uptake on MIBG scan.
An
111
In DOTATOC scan confrmed presence of SSTRs bearing abnormal tissue
at the same site. She received PRRT with
90
Y DOTATOC with good tumour
response.
As NETS vary in their expression of SSTRs along with difference in affnity of
radiolabelled agents for SSTRs, tumoral uptake can vary with individual
functional imaging. Our cases highlight this variation. Therefore we recommend
imaging with at least two different radiolabelled somatostatin analogues, at the
pre-treatment stage.
PRRT remains a promising option for inoperable NETs but requires a careful
approach in patient selection.
P455
Clinical characteristics of incidentally discovered phaeochromocytomas
Monica Livia Gheorghiu
1,2
, Ionela Baciu
1
, Mara Mangalagiu
2
, Ana Banaru
2
,
Catalina Poiana
1,2
, Corin Badiu
1,2
& Mihai Coculescu
1,2
1
2
C.I. Parhon National Institute of Endocrinology, Bucharest, Romania.
Introduction
Phaeochromocytomas (PHEO) are tumours of the chromaffn cells and are usually
detected due to the typical symptom triad including headache, palpitations and
sweating associated with persistent and/or paroxysmal blood hypertension. An
increasing proportion of PHEO is incidentally discovered upon abdominal
imaging.
Objective
To analyse the clinical characteristics of the incidentally discovered phaeochro-
mocytomas.
Method
A retrospective analysis of the medical fles of 58 consecutive patients diagnosed
with PHEO in our clinic between 1983 and 2009.
Results
Fifteen PHEO (25.8%, nine women, six men) have been discovered upon imaging
performed for reasons unrelated to a blood pressure abnormality (one of them
during family screening for multiple endocrine neoplasia). Five of these patients
(33%) were asymptomatic for PHEO and one other patient was normotensive.
Only one patient (6.6%) had the classic symptom triad, eight patients (53.3%) had
hypertension, with paroxysms in 6 out of 15 patients (40%). From the 43 patients
in whom the diagnosis was suspected on clinical grounds (27 women, 16 men),
15 patients (34.8%) had the typical symptom triad (P,0.05 compared to
incidentally detected PHEO) and 42 (97.6%) were hypertensive (P,0.01), with
paroxysms in 39 out of 43 patients (90.6%, P,0.01). Patients with incidentally
detected PHEO are older at diagnosis than patients with clinically suspected
PHEO (52.213.5 vs 44.112.4 years, P,0.05), have larger tumours (5.52.3
vs 4.82.1 cm, P,0.05) and are less likely to have bilateral tumours (0 out of 15
patients versus 6 out of 43 patients, 14%) or malignant tumours (0 out of 15 versus
3 out of 43 patients, 7%). Urinary or free plasma metanephrines have been falsely
normal at initial work-up in 3/43 patients with clinically suspected PHEO (7%)
and in none of those with incidentally detected PHEO.
Conclusions
A signifcant proportion of patients with phaeochromocytoma (25% in our series)
are detected incidentally upon abdominal imaging. Since almost half of them may
be normotensive at diagnosis, screening for catecholamine hypersecretion in
every adrenal incidentaloma is mandatory in order to identify oligosymptomatic
phaeochromocytomas.
P45
The clonidine supression test with measurement of plasma
metanephrines by enzyme immunoassay
Peter Kentos
1
, Anna Moravcikova
2
, Peter Vanuga
1
, Miroslava Michalekova
2
,
Alexander Kreze Jr
3
& Mikulas Pura
1
1
Department of Endocrinology, National Institute of Endocrinology and
Diabetology, Lubochna, Slovakia;
2
Department of Clinical Biochemistry,
National Institute of Endocrinology and Diabetology, Lubochna, Slovakia;
3
Second Department of Internal Medicine, Lubochna, Slovakia.
Background
In pheochromocytomas, the measurement of fractionated metanephrines is the
frst-line test for diagnosis and the false-positive results remain a problem. Among
various parameters and tests used, only the suppression of normetanephrine
provides reliable evidence that a pheochromocytoma is not present.
Objective
Aim of the study was to analyse the role of clonidine suppression test in
laboratory diagnosis of pheochromocytoma.
Clonidine tests were carried out in 201 patients, 13 with and 188 without the
tumor. The presence of pheochromocytoma was confrmed by histology and the
absence by a disease-free extended follow-up. Plasma fractionated metanephrines
(expressed as median, 5th and 95th percentile) were measured by an enzyme
immunoassay (EIA) at baseline, 2 and 3 h after administration of clonidine.
Results
All tests performed were uneventful in all subjects. Clonidine decreased plasma
normetanephrine in patients without pheochromocytoma from 63 (30; 120) at
baseline to nadir 39 (14; 79). Plasma metanephrine concentrations (at baseline 36
(15; 92)) showed variable responses to clonidine (nadir 39 (14; 79)). Percent
decreases in plasma normetanephrine after clonidine varied from 0-76%, and on
average were similar to those of metanephrine (6857 vs 6135%), which
varied from 0 to 88%. In contrast, in patients with pheochromocytoma, plasma
concentrations of metanephrines remained unchanged - normetanephrine 797
(108; 4067) at baseline, and nadir 620 (101;3088), respectively metanephrine in
the basal state 123 (38; 603) and nadir 125 (31; 322).
Conclusions
The results obtained thus suggest clonidine suppression testing is worthwhile in
the diagnosis of pheochromocytoma by blood tests. Clonidine suppressive test is
valuable tool in diagnostic of adrenal medullary hyperfunction. The procedure is
safe and technically non-complicated. Moreover, EIAs in analysis of
metanephrines could be used comparable to more expensive and and widely
available HPLC method in metanephrines analyses.
P45I
Supradiaphragmatic ectopic ACTH: producing pituitary adenoma:
a case report
Zdravko Perkovic
IHC Sunce, Zagreb, Croatia.
This report presents a 44-year-old woman with ectopic ACTH-secreting pituitary
adenoma located in the supradiaphragmal region. Patient presented with a
classical clinical features of long lasting Cushing`s syndrome. She had right leg
amputation because of peripheral macrovascular atherosclerosis, severe
hypertension, non-regulated diabetes mellitus, hypokalemia and osteoporosis.
Baseline tests were suggestive of ACTH-dependent Cushing`s syndrome.
Magnetic resonance imaging revealed hypodensic lesion in the right side of the
pituitary 6 mm in diameter, and an oval and well-circumscribed supradiaph-
ragmal tumour 3-4 mm in diameter in the ventral and the left side of the stalk.
Both lesions enhaced by gadolinium. Transphenoidal resection of suspected
eutopic pituitary adenoma was performed. Histology revealed normal pituitary
tissue, and the cortisol level remained high after the operation. After the frst
operation, supraorbital 'key-hole` resection of suspected ectopic pituitary
adenoma was performed. Histology and imunohistology confrmed ACTH
producing adenoma. After the second operation plasma cortisol level became
low. Postoperative period was complicated by repeating urinary tract infections
and infection of left thumb. She was treated with hydrocortisone supplementation
and antibiotics. Ten days after discharge from the hospital she was admitted to the
local hospital in severe state and she died after few hours. This is the frst report in
the literature of the patient with ACTH dependent Cushing`s syndrome caused by
supradiaphragmatic ectopic ACTH-secreting adenoma with positive magnetic
resonance imaging for eutopic and ectopic supradiaphragmatic pituitary
adenoma. Bilateral inferior sinus petrosus catheterization and sampling could
be of help in the similar cases in order to fnd the correct localisation of the
secreting adenoma.
Female reproduction
P458
GnRH test as an additional investigation in the diagnosis of polycystic
ovary syndrome (PCOS): potential application of stimulated LH/FSH
ratio
Agata Cajdler-Luba
1
, Krzysztof Lewandowski
1
, Malgorzata Bienkiewicz
2
,
Ireneusz Salata
1
& Andrzej Lewinski
1
1
Department of Endocrinology and Metabolic Diseases, The Medical
University of Lodz and 'Polish Mother` Memorial Research Institute, Lodz,
Poland;
2
Department of Quality Control and Radiation Protection,
The Medical University of Lodz, Lodz, Poland.
Diagnosis of PCOS may be sometimes diffcult, e.g. due to limited sensitivity of
androgen assays and discrepancies in interpretation of ovarian ultrasound
imaging. As GnRH stimulation test can reveal a relative LH excess, then we
have endeavoured to assess whether this test might be useful in the diagnosis of
PCOS.
The study involved 154 subjects: PCOS group, n120, age (meanS.D.) 24.8
5.4 years, BMI 24.56.0 kg/m
2
and regularly menstruating controls, n34,
age 26.65.0 years, BMI 24.65.5 kg/m
2
. All subjects had pelvic ultrasound as
well as total testosterone, androstendione, DHEAS, 17OH-progesterone, thyroid
hormones and prolactin measured (early follicular phase). LH and FSH were
measured before (0 min) and at 30 and 60 min after GnRH stimulation (100 g
i.v). Insulin resistance was assessed by HOMA and insulin resistance index
(derived from glucose and insulin during OGTT).
Results
PCOS women and controls were matched for age and BMI, but had higher
testosterone (P0.0002), androstendione (P0.0021), 17OH-progesterone
(P,0.0001) and were more insulin resistant. Baseline and stimulated LH
concentrations were higher in PCOS (9.095.56 vs 4.831.71 IU/l, 35.48
31.4 vs 16.306.68 IU/l, 33.8631.8 vs 13.455.2 IU/l, at 0, 30 and 60 min.
Post GnRH, respectively, P,0.0001). There was no difference between baseline
and stimulated FSH concentrations between groups. Relative increases of LH or
FSH (i.e. LH
30 min
/LH
0 min
, LH
60 min
/LH
0 min
, FSH
30 min
/FSH
0 min
, FSH
60 min
/
FSH
0 min
) were similar in both groups. There was, however, a marked increase in
LH/FSH ratio in PCOS in comparison to controls (LH
0 min
/FSH
0 min
1.590.95
vs 0.760.2, LH
30 min
/FSH
30 min
4.073.0 vs 1.890.79, LH
60 min
/FSH
60 min
3.562.58 vs 1.550.63, P,0.0001 at all time points). Further analysis
revealed that LH
30 min
/FSH
30 min
2.0 or LH
60 min
/FSH
60 min
1.7 had 79 and
83% sensitivity and 72 and 75% specifcity for the diagnosis of PCOS,
respectively. In contrast LH
0 min
/FSH
0 min
2.0 had only 23% sensitivity, while
total testosterone, and androstendione had 38.6%, 34.7% sensitivity, respectively.
Conclusions
Our study indicates that raised LH/FSH ratio after GnRH stimulation might be
potentially useful as an additional diagnostic tool in the diagnosis of PCOS.
P459
CAG repeat polymorphism in women with PCOS and healthy controls
Ralitsa Robeva, Desislava Dobreva, Georgi Kirilov, Tcvetosar Mechandjiev,
Analia Tomova, Aleksey Savov & Filip Kumanov
Medical University, Sofa, Bulgaria.
The androgen receptor (AR) polymorphism is determined by a variable number of
CAG triplets in exon 1 of the AR gene, located on the X chromosome. CAG
polymorphism could modulate different hyper- or hypoandrogenic conditions, but
its infuence on the polycystic ovarian syndrome (PCOS) in different ethnic
populations is controversial. Therefore, we investigated the infuence of the AR
polymorphism on the hormonal factors and clinical signs in 52 women with PCOS
and in 41 non-hirsute healthy controls from Caucasian population. The short
allele, the long allele and the mean biallelic number were determined in each
person. The anthropometric values, modifed Ferriman-Gallwey score, and the
levels of testosterone, SHBG, free testosterone, LH, FSH, estradiol and insulin
were examined.
Mean numbers of CAG repeats in the long allele and the short allele as well as the
mean biallelic number did not differ between the patients and controls (P0.05).
In the group of PCOS women, those with longer CAG mean biallelic number had
higher LH/testosterone ratio (P0.026). Patients with higher CAG number in the
long allele had higher LH levels (P0.046) and tendency to higher
LH/testosterone ratio (P0.064) and SHBG levels (P0.068). The women
with mean biallelic number in the lower tertile had higher Ferriman-Gallwey
score in comparison to those in the intermediate tertile (P0.037) as well as
lower SHBG levels (P0.042) despite the similar concentrations of the free and
total testosterone.
In conclusion, CAG repeat polymorphism is not crucial for the development of
the PCOS. However, patients with lowest number of CAG repeats have most
pronounced hirsutism; while longer allele carriers have higher LH levels and
LH/testosterone ratio. Consequently, CAG polymorphism of the androgen
receptor could modulate the PCOS phenotype through its infuence on different
levels (pituitary, liver, pilosebaceous unit).
Supported by: National Science Fund, MOMN, L-1504/2005.
P40
CAG repeat polymorphism in healthy women
Ralitsa Robeva, Desislava Dobreva, Georgi Kirilov, Analia Tomova,
Aleksey Savov & Filip Kumanov
Androgen receptor (AR) containes a variable polyglutamine chain that is
determined by the different number of CAG repeats in the AR gene on the X
chromosome. The transactivational competence of AR is inversely related to the
length of the polyglutamine chain, respectively to the CAG repeat number.
Therefore, we investigated the role of the androgen receptor polymorphism in
healthy hirsute and non hirsute women.
CAG repeat length polymorphism was analyzed in 52 women with regular
menstrual cycle and normal ovarian function. Eleven of them were hirsute and in
all of them hormonal disturbances were excluded. The short allele, the long allele
and the mean biallelic number were determined in each person. The
anthropometric values, modifed Ferriman-Gallwey score, and the serum levels
of testosterone, SHBG, free testosterone, LH, FSH, estradiol, insulin and lipid
profle were also examined.
Mean numbers of CAG repeats in the long allele and the short allele as well as the
mean biallelic number did not differ between the hirsute and non hirsute women.
In the whole group the women with smaller mean biallelic number were a little
younger (28.964.63 vs 31.464.29, P0.049), with lower levels of the
HDL-cholesterol (1.280.28 vs 1.580.32 mmol/l, P0.024), higher levels of
LDL-cholesterol (2.760.58 vs 2.330.36 mmol/l, P0.037) and higher
DHEAS concentrations (9.074.86 vs 6.383.41 ml/ml, P0.033) in
comparison to the others. The women with higher CAG number in the long
allele had lower FG score (P0.049) and better lipid profle with higher
HDL-cholesterol (1.540.35 vs 1.240.18 mmol/l, P0.031) and lower
triglycerides (0.640.38 vs 0.980.49 mmol/l, P0.048). Women with lower
CAG number in the short allele did not differ in their hormonal indices in
comparison to the others.
In conclusion CAG repeat polymorphism could modulate the degree of body hair
growth and the lipid profle in healthy women.
Supported by: National Science Fund, MOMN, L-1504/2005.
P41
Estrogen plus progestin treatment: effect of different progestin
components on serum markers of apoptosis in healthy postmenopausal
women
Maria Karafou
1
, George Kaparos
2
, Demetrios Rizos
2
,
Emanuel Logothetis
1
3
, Leon Aravantinos
1
,
Maria Creatsa
1
1
, Irene Lambrinoudaki
1
& Evangelia Kouskouni
1
1
Second Department of Obstetrics and Gynecology, School of Medicine,
Aretaieio Hospital, University of Athens, Athens, Greece;
2
Hormonal and
Biochemical Laboratory, School of Medicine, Aretaieio Hospital,
3
First Department of Surgery, School
of Medicine, Laiko Hospital, University of Athens, Athens, Greece.
Objective
To investigate the effect of two hormone therapy (HT) regimens differing only in
their progestin component on serum markers of apoptosis.
Design
Randomized, double-blinded study.
Patients
One hundred healthy postmenopausal women.
Interventions
Patients were randomized to 17-estradiol 1 mg/drosperinone 2 mg (E
2
/DSP) or
17-estradiol 1 mg/norethisterone acetate 0.5 mg (E
2
/NETA) for 6 months.
Main outcome measures
Serum soluble Fas (sFas), soluble Fas Ligand (sFasL) and cytochrome-c (cyt-c) at
baseline and at 6 months.
Results
Serum sFas and serum sFasL signifcantly decreased in both groups. Serum cyt-c
in both groups was undetectable. sFas/sFasL ratios were reduced in both groups.
Conclusions
sFas/sFasL ratios decreased in both groups suggesting a decrease in apoptosis
associated with the above pathway. cyt-c levels were undetectable, suggesting an
absence of mitochondria-associated apoptosis.
P42
The effect of hormone therapy and tibolone on serum CD40L and
ADAM-8 in healthy postmenopausal women
Irene Lambrinoudaki
1
, Maria Karafou
1
, George Kaparos
2
,
Odysseas Grigoriou
1
3
, Constantinos Panoulis
1
,
Emanuel Logothetis
2
, Maria Creatsa
1
1
2
1
Second Department of Obstetrics and Gynecology, School of Medicine,
Aretaieio Hospital, Athens University, Athens, Greece;
2
Hormonal and
Biochemical Laboratory, School of Medicine, Aretaieio Hospital, Athens
University, Athens, Greece;
3
First Department of Surgery, School of
Medicine, Laiko Hospital, Athens University, Athens, Greece.
Background/aim
The role of neutrophils and platelets in atherothrombotic disease is well
established. The aim of our study was to investigate the effect of hormone therapy
and tibolone on the soluble markers of neutrophil and platelet activation, ADAM-
8 and CD40L respectively, in healthy postmenopausal women.
One hundred and six healthy postmenopausal women were randomly allocated to:
estradiol plus drospirenone (E
2
/DSP), estradiol hemihydrate 1 mg plus
norethisterone acetate (E
2
/NETA) 0.5 mg and tibolone 2.5 mg. Serum ADAM-
8 and CD40L were measured at baseline and at 6 months.
Results
Baseline values of ADAM-8 and CD40L were similar between groups.
No signifcant changes were observed between baseline values and values at
6 months.
Conclusions
No association has been revealed between estrogen plus progestin treatment or
tibolone on serum ADAM-8 and CD40L levels in healthy postmenopausal women.
Larger prospective studies are needed to further investigate the effect of low-dose
hormone therapy or tibolone on serummarkers of neutrophil and platelet activation.
P43
Ethnic differences in manifestations of PCOS in 1010 Danish women
Dorte Glintborg
1
, Pernille Ravn
2
, Hanne Mumm
1
& Marianne Andersen
1
1
Department of Endocrinology and Metabolism, Odense University
Hospital, DK-5000 Odense C, Denmark;
2
Department of Gynecology and
Obstetrics, Odense University Hospital, DK-5000 Odense C, Denmark.
Background
Clinical manifestations, metabolic risk factors and diabetes risk may differ in
ethnical subgroups of women with PCOS.
A total of 1010 premenopausal women were referred with the diagnoses hirsutism
or PCOS during 1997-2008. The patients underwent clinical evaluation, hormone
analyses and transvaginal ultrasound (US). Oral glucose tolerance tests (OGTT)
(n500) and ACTH tests (n434) were performed in a subgroup of patients.
The patients were divided according to ethnicity: Caucasian (CA, n792),
Middle East (ME, n190), Asian (n14), various (n14).
Results (CA versus ME women)
The median BMI (median (25-75% quartiles)) for the study population was
26 (22-32) kg/m
2
. CA women were signifcantly older (32 (25-37) vs 24 (18-32)
years), less hirsute (total FG-score 11 (6-15) vs 16 (11-22)) and had increased
waist circumference (90 (78-103) vs 82 (73-98) cm) than ME women. BMI
levels were not signifcantly different (P0.07). The Rotterdam criteria were
fulflled in 55% of both populations, but PCO was diagnosed during US in 47%
(314/672) CA versus 29% (50/172) ME women and clinical or paraclinical
hyperandrogenaemia in 86 vs 93%, both P,0.01.
CA women had signifcantly increased cholesterol, triglycerides, LDL and blood
pressure (systolic and diastolic) and smoked at a higher frequency (39.4 vs 22.5%)
. Glucose levels (fasting and during OGTT) were comparable in the two groups,
but insulin levels was decreased in CA versus ME women, P,0.05. Diabetes or
IGT was diagnosed in 12% and increased to 21% in obese patients (NS CA versus
ME). Cortisol and 17-hydroxyprogesterone responses during ACTH tests were
similar in the two ethnical groups.
Conclusion
In the present study, CA women had a more adverse cardiovascular profle than
ME women, whereas no signifcant differences were found in glucose tolerance.
The prevalence of the individual Rotterdam criteria differed signifcantly in the
two study populations.
P44
Kisspeptin levels in high risk pregnancies related to chronic
diseases: insulin dependent diabetes mellitus (IDDM) and arterial
hypertension (H)
Dragana Miljic
1
, Aleksandar Cetkovic
2
, Aleksandar Ljubic
2
,
Michael Patterson
3
, Mohammad Ghatei
3
, Steven Bloom
3
, Marina Djurovic
1
,
Mirjana Doknic
1
, Sandra Pekic
1
, Marko Stojanovic
1
& Vera Popovic
1
1
Institute of Endocrinology, University Clinical Center, Belgrade, Serbia;
2
Clinic for Obstetrics and Gynecology, University Clinical Center,
Belgrade, Serbia;
3
Department of Metabolic Medicine, Imperial College
London, London, UK.
Objective
Kisspeptin is hormone involved in the initiation and maintenance of fertility.
Placenta is the major source of kisspeptin but its role during gestation is still
matter of debate. Studies investigating kisspeptin levels during gestation in
patients with diabetes and hypertension are lacking. Our aim was to prospectively
evaluate kisspeptin levels in pregnant women with chronic diseases such as
IDDM and H.
Design and methods
Kisspeptin levels were evaluated in 61 singleton pregnancies (16 with IDDM, 20
with H and in 25 healthy pregnant women). Blood samples were collected in the
1st trimester (9-12 weeks), in the 2nd trimester (21-25 weeks) and in the 3rd
trimester (32-36 weeks). Maternal kisspeptin levels were correlated with
pregnancy outcome.
Results
In pregnant women with diabetes and hypertension mean plasma kisspeptin levels
were signifcantly lower compared to control group throughout gestation. In fve
pregnancies which ended in spontaneous abortion in the 2nd trimester (four in
patients with diabetes and one in patient with hypertension) plasma kisspeptin
levels were severely decreased in early pregnancy compared to control group. No
other adverse outcomes were recorded in patients with diabetes and hypertension
nor in healthy pregnant women in the study. ROC curve analysis of kisspeptin
levels in the 1st trimester showed cut-off value of 812.4 pmol/l as discriminating
between positive and negative pregnancy outcome (Sn76.4% and Sp75%).
Conclusions
Kisspeptin levels are signifcantly lower throughout pregnancy in women with
IDDM and H. Severely decreased kisspeptin levels, in these patients, during early
pregnancy may be associated with an increased risk of spontaneous abortion.
Larger studies are needed to investigate the role of kisspeptin in high risk
pregnancies related to various pathologies.
P45
Role of vitamin D treatment on metabolic and endocrine parameters in
PCOS women
Elisabeth Wehr, Stefan Pilz, Thomas R Pieber & Barbara Obermayer-
Pietsch
Medical University of Graz, Graz, Austria.
Background
Women affected by polycystic ovary syndrome (PCOS) frequently suffer from
obesity, insulin resistance and impaired glucose tolerance. There is evidence
showing an association of hypovitaminosis D with metabolic disturbances in
PCOS women. We aimed to investigate the infuence of vitamin D
supplementation on metabolic and endocrine parameters in PCOS women.
Design
Forty-eight women with PCOS were included in the study. Cholecalciferol was
administered orally 20 000 IU weekly for 12 weeks. 25-Hydroxyvitamin D
[25(OH)D], 1,25-dihydroxyvitamin D
3
, PTH, endocrine and metabolic par-
ameters were determined and oral glucose tolerance tests were performed at
baseline and after 12 weeks of vitamin D treatment. Insulin resistance was
determined using homeostasis model assessment (HOMA)-index.
Results
PCOS women were aged 266 years. Mean BMI was 25.56.5 at baseline.
Mean 25(OH)D levels increased from 25.611.8 to 51.618.1 ng/ml and mean
PTH levels decreased from 39.021.0 to 30.112.4 pg/ml after vitamin D
treatment (P,0.001 for all). Vitamin D treatment signifcantly lowered levels of
total testosterone, free testosterone, and triglycerides and increased LDL levels
(all P,0.05). BMI, HOMA-index, fasting and stimulated glucose and insulin
levels remained unchanged.
Conclusion
Vitamin D treatment in PCOS women results in decreased androgen levels after
12 weeks, whereas obesity and parameters of glucose homeostasis remained
unchanged. Large placebo controlled intervention trials are warranted to confrm
our fndings and to evaluate whether vitamin D supplementation is benefcial for
PCOS women.
P4
Serum soluble transferrin receptor (sTfR) concentrations and
sTfR/ferritin ratio in premenopausal women: associations with glucose
tolerance, insulin sensitivity and androgen excess
Hector F Escobar-Morreale
1
& Manuel Luque-Rami rez
1,2
1
Hospital Universitario Ramon y Cajal, Madrid, Spain;
2
Hospital
Universitario La Princesa, Madrid, Spain.
Context
Androgen excess may contribute to the increased body iron stores of polycystic
ovary syndrome (PCOS) by stimulating erythropoietic activity.
Objective
To estimate iron stores and erythropoietic activity in premenopausal women,
considering simultaneously the effects of PCOS, obesity and abnormal glucose
tolerance.
Design
Case-control study.
Settings
Academic hospital.
Patients
One-hundred four PCOS patients and 100 non-hyperandrogenic women.
Interventions
Basal blood sampling and oral glucose tolerance test.
Serum soluble transferrin receptor (sTfR) and ferritin concentrations, and indexes
of infammation, obesity, and insulin and glucose metabolism.
Results
Ferritin levels increased in women presenting with PCOS, obesity, and/or abnormal
glucose tolerance, but these disorders did not infuence sTfR concentrations. The
sTfR/ferritin ratio decreased with obesity and abnormal glucose tolerance and its
logarithm correlated inversely with BMI, free testosterone and C-reactive protein
levels, and directly with the insulin sensitivity and disposition indexes. Moreover, a
stepwise multiple regression analysis indicated the changes in the insulin sensitivity
and disposition indexes, and not those in other variables, explained 9% of the
variability of the logarithm of sTfR/ferritin ratio.
Conclusions
Enhancement of erythropoiesis by androgen excess does not explain the fnding of
increased ferritin levels in PCOS patients, yet reduced insulin sensitivity and
disposition increased ferritin levels in premenopausal women. However, the lack of
changes in sTfR with PCOS, obesity and abnormal glucose tolerance suggests that
the increased ferritin levels associated with these conditions indicate not only
augmented body iron stores, but also the role of ferritin as an infammatory marker.
Grants: FIS PI080944, CIBERDEM CB07/08/0005.
P4I
Serum lipocalin-2 as an insulin resistance marker in patients with
polycystic ovary syndrome
Erman Cakal
1
, Mesut Ozkaya
2
, Yaprak Engin-Ustun
3
& Yusuf Ustun
3
1
Department of Endocrinology, Yuksek Ihtisas Education and Research
2
Department of Endocrinology, Sutcu Imam
University Medical Faculty, Kahramanmaras, Turkey;
3
Department of
Obstetrics and Gynecology, Inonu University Medical Faculty, Malatya,
Turkey.
Background
Our aim was to investigate levels of lipocalin-2 and its relationship with
metabolic factors in women with polycystic ovary syndrome (PCOS).
Materials/subjects and methods
Inthis cross-sectional study, two groups of women were studied: group1 consistedof
women with PCOS (n30), and group 2 consisted of control women with normal
ovulatory function (n30). The circulating levels of lipocalin were measured.
Results
Serum lipocalin was signifcantly higher in PCOS subjects. We found a close
correlation between lipocalin and insulin, lipocalin and HOMA-IR, lipocalin and
testosterone and lipocalin and DHEAS. A cut-off level of 39.54 ng/ml for serum
lipocalin has a predictive value for insulin resistance of 81% sensitivity and 82.1%
specifcity.
Conclusion
In our study, lipocalin-2 levels were found to be signifcantly higher in women with
PCOS compared to body mass index-matched controls. Serum lipocalin-2 may
prove to be a useful marker for insulin resistance in patients with PCOS.
P48
Familial occurrence of hormonal and metabolic abnormalities in
hrst-degree relatives of women with PCOS
Agnieszka Lenarcik
1
, Bozena Bidzinska-Speichert
1
,
Urszula Tworowska-Bardzinska
1
& Katarzyna Krepula
2
1
Wroclaw, Poland;
2
Endocrinological Clinic for Outpatients, Wroclaw,
Poland.
Polycystic ovary syndrome (PCOS) is an endocrine disorder with a pathogenesis
in which hormonal and metabolic disturbances have been considered. There is
evidence of a familial aggregation of hormonal and metabolic abnormalities in
siblings of PCOS women. Some of the female relatives fulfll the diagnostic
criteria of PCOS. Premature balding in the age of ,30 has been proposed as the
male phenotype in PCOS families.
The aim of the study was to determine whether siblings of women with PCOS had
evidence of hormonal and metabolic abnormalities typical for PCOS.
Eighty-six siblings of women with PCOS (44 sisters, 42 brothers) were recruited.
Two control groups consisted of 70 healthy women and 30 healthy men.
Assessment of antropometric parameters, hormonal parameters (testosterone,
androstendione, DHEA-S, LH, FSH) and metabolic parameters (glucose and
insulin: fasting and during OGTT, insulin sensitivity and insulin resistance
indexes, lipidogram) were carried out in all subjects.
Results
Mean testosterone and DHEA-S levels were higher in the group of sisters in
comparision with the controls. Brothers of women with PCOS compared to the
controls had higher DHEA-S level and had tendency to higher testosterone level.
Siblings of women with PCOS had much more disadvantageous metabolic
parameters than the controls. There were no differences in age, antropometric
parameters and parameters of carbohydrate and lipid metabolism between
sisters with (8 sisters) or without (36 sisters) PCOS. Premature balding brothers
(11 brothers) did not differ from the brothers without balding (31 brothers)
in hormonal and metabolic parameters.
Conclusions
Siblings of women with PCOS are predisposed to hormonal and metabolic
abnormalities typical for PCOS. The symptom of premature balding in the age of
,30 in brothers of women with PCOS should not be considered as male PCOS
equivalent.
P49
Chronic inammation and Leu55Met PON1 polymorphism in
polycystic ovary syndrome
Agnieszka Lenarcik, Bozena Bidzinska-Speichert &
Urszula Tworowska-Bardzinska
Wroclaw, Poland.
Polycystic ovary syndrome (PCOS) is an endocrine disorder in women of
reproductive age. Hormonal disturbances, metabolic disorders, and more
recently, chronic infammation have been considered in pathogenesis of PCOS.
One of the determinants of infammation investigated in terms of insulin
resistance (IR) is paraoxonase 1 (PON1).
Aim
To evaluate PCOS patients for the existence of chronic infammation and to assess
the relationship among PON1 polymorphism and hormonal, metabolic and
infammatory parameters in these women.
We studied 130 PCOS women and 70 controls. Anthropometric, hormonal
(testosterone, androstendione, DHEA-S, LH, FSH), metabolic (fasting glucose
and insulin, OGTT, insulin sensitivity and resistance indices, lipids) and
infammatory parameters (hsCRP, fbrinogen, white blood cells count-WBC)
and analysis of PON1 Leu55Met polymorphism were carried out.
Results
WBC, fbrinogen and hsCRP levels did not differ signifcantly between the PCOS
women and the controls. Positive correlation of infammatory indicators with
anthropometric, metabolic parameters and the IR indices was observed in the
PCOS women. Negative correlation was observed between infammatory
markers, insulin sensitivity indices and the concentration of SHBG. A positive
correlation was shown between infammatory markers and FAI, negative with the
LH/FSH ratio.
Frequency of the Leu55Met PON1 polymorphism genotype was similar in both,
the PCOS and the control groups. A signifcantly greater number of leukocytes
was observed in the PCOS patients with the Met55Met and Leu55Leu genotypes
than those with the Leu55Met genotype. There were no relationships between
PON1 genotypes and hormonal, metabolic parameters in PCOS women.
Conclusions
Low-grade chronic infammation was not observed in PCOS women, thus there is
no direct link between infammation and PCOS markers per se. A low-grade
chronic infammation is related with central obesity and insulin resistance. None
of the variants of Leu55Met PON1 polymorphism was associated neither with
more frequent occurrence of PCOS nor metabolic disorders, including IR.
P4I0
Serum vaspin levels in women with polycystic ovaries and polycystic
ovary syndrome
Erman Cakal
1
, Yusuf Ustun
2
, Yaprak Engin-Ustun
2
, Mesut Ozkaya
3
& Metin Kilinc
4
1
Department of Endocrinology, Yuksek Ihtisas Education and Research
2
Department of Obstetrics and Gynecology,
Inonu University Medical Faculty, Malatya, Turkey;
3
Department of
Endocrinology, Sutcu Imam University Medical Faculty, Kahramanmaras,
Turkey;
4
Department of Biochemistry, Sutcu Imam University Medical
Faculty, Kahramanmaras, Turkey.
Objective
Our aim was to evaluate C-reactive protein (CRP) and serum vaspin levels in
women with polycystic ovary syndrome (PCOS) or polycystic ovaries (PCO).
Design
Twenty-four women with PCOS and 23 women with PCO constituted the study
groups. The control group comprised 24 healthy women.
Methods
Homeostatic model assessment for insulin resistance (HOMA-IR), CRP and
serum vaspin levels were measured. The receiver operating characteristic curve
(ROC) of vaspin for prediction of women with increased diabetogenic risk was
constructed.
Results
The three groups did not signifcantly differ in age and body mass index. HOMA-
IR was signifcantly higher in the PCOS and PCO groups than in control group.
Median CRP levels in the control, PCO, and PCOS groups were 0.66, 1.28, and
3.2 mg/l, respectively (P0.0001). Women with PCOS had signifcantly higher
serum vaspin levels than the healthy controls (3.521.38 vs 0.360.19 ng/ml,
P0.0001). Serum vaspin could differentiate between women with and without
increased diabetogenic risk at a cut-off value of: 1.82 ng/ml with a sensitivity of
83.3% and a specifcity of 66.1%.
Conclusion
The results of our study showed that the presence of the increased vaspin, CRP
and higher HOMA-IR levels in women with PCOS and PCO could contribute to
increased diabetogenic and atherogenic risk in these patients.
P4I1
Characteristics secretion of melatonin at women with polycystic ovary
syndrome
Tetiana Arkhypkina, Yuriy Karachentsev & Lidia Liubimova
V. Danilevsky Institute of Endocrine Pathology Problems of AMS Ukraine,
61002 Kharkov, Artema 10, Ukraine.
Objective
To determine the peculiarity of melatonin (M) at women with polycystic ovary
syndrome (PCOS).
Methods
Fifty-six women with PCOS from 18 to 29 years old have been included in
research. Control group 22 healthy women with regular menses, same age. Levels
M were determined in the blood at 2 and 8 o`clock in the morning on a ffth day
menstrual cycle in January and July.
Results
It is established, that the level of M in winter at patients with PCOS changed from
199.9 up to 288.5 pmol/l and did not differ (P0.05) from parameters of healthy
women (199.310.2 pmol/l). Levels of M decrease in both groups in summer,
however, the degree of this decrease was differ. So in the control group the level
of M has decreased on 75% and at patients with PCOS on 62.5%. Level of M in
summer at patients with PCOS was bigger (75.59.7 pmol/l, P,0.05) than M at
control group (49.86.4 pmol/l). It was signifcant that patients with PCOS have
increase level of M in the morning (75.95.2 vs 49.95.4 pmol/l, P,0.05) and
decrease night peak of M (52.03.1 vs 78.85.9 pmol/l, P,0.05) compared
with controls. Women with PCOS have inversion rhythm of M, that was showed
up reduction (P,0.05) secretions M at night relative to levels M in the morning.
Conclusions
Seasonal rhythm secretion of melatonin at patients with PCOS is stored, however,
this women have disturbance circadian rhythm of melatonin that enable to make
an proposes about an important role hormone of epiphysis in formation pathology
of reproductive system.
P4I2
HPA axis function in obese women with PCOS
Ivana Bozic, Djuro Macut, Bojana Popovic, Tatjana Isailovic,
Tamara Bogavac, Milan Petakov, Sanja Ognjanovic
Institute od Endocrinology, Diabetes and Metabolic Disorders, Clinical
Center of Serbia and University of Belgrade School of Medicine, Belgrade,
Serbia.
Objectives
Besides well known increased adrenal androgen production, an enhanced
peripheral cortisol metabolism was also observed in polycystic ovary syndrome
(PCOS). This could induce a compensatory rise of ACTH secretion, tending to
maintain normal plasma cortisol concentration at the expense of adrenal androgen
excess. On the other hand, obesity is associated with a hyperactivity of the
hypothalamic-pituitary-adrenal (HPA) axis and impaired androgen balance.
In this study we examined HPA axis sensitivity in obese women with PCOS.
Methods
Thirty-eight obese women with PCOS (age: 26.05.8 years, BMI: 32.3
4.7 kg/m
2
) and sixteen age and BMI matched obese healthy controls were
examined. PCOS was diagnosed using ESHRE/ASRM criteria. In all subjects
serum concentrations of glucose, insulin (with HOMA-IR calculation), C-peptide,
testosterone, SHBG (with FAI calculation), DHEAS, leptin, adiponectin and
basal cortisol were determined. Overnight dexamethasone supression test
(0.5 mg) was performed in all women: 0.5 mg of dexamethasone was taken
orally at 2300 h and blood samples for determination of cortisol were obtained at
0800 h the following day.
Results
There was no difference in glucose (P0.95), insulin (P0.30), HOMA-IR
(P0.45), C-peptide (P0.23), leptin (P0.40), adiponectin (P0.09) and
DHEAS (P0.06) concentrations between groups. SHBG concentration
(P0.005) was signifcantly lower and testosterone (P0.001), FAI
(P,0.001) and androstenedion (P0.046) concentrations were signifcantly
higher in obese PCOS women than in obese controls. Obese PCOS had
signifcantly higher basal cortisol concentrations then obese controls (452.8
151.5 vs 347.5107.1 nmol/l; P0.01). The percentage of cortisol
suppression in response to 0.5 mg of dexamethasone was similar between
obese PCOS and obese controls (81 vs 83%; P0.31). Only in PCOS group, there
was modest but statistically signifcant correlation between testosterone and
cortisol concentrations (%0.33, P0.04).
Conclusion
Our results showed an increased basal cortisol concentration in obese PCOS in
comparison to controls, and a possible alteration in the sensitivity of the adrenal
glands to ACTH in obese woman with PCOS.
P4I3
Metabolic syndrome indices and Framingham risk scoring in women
with polycystic ovary syndrome
Djuro Macut, Ivana Bozic, Bojana Popovic, Tamara Bogavac,
Milan Petakov, Sanja Ognjanovic, Tatjana Isailovic & Svetozar Damjanovic
Institute od Endocrinology, Diabetes and Metabolic Disorders, Clinical
Center of Serbia and University of Belgrade School of Medicine, Belgrade,
Serbia.
Objectives
It is well known that polycystic ovary syndrome (PCOS) can promote metabolic
syndrome (MetSy) and consequently cardiovascular diseases (CVD). In this study
we compared indices of MetSy and 10-year cardiovascular risk (CVR
10
) based on
Framingham risk scoring system (FRSS) in young obese PCOS women and
healthy obese controls.
Methods
We studied 25 obese women with PCOS (mean age: 29.554.6 years, mean
BMI: 31.84.4 kg/m
2
) diagnosed using Rotterdam 2003 Consensus criteria and
25 age and BMI matched obese controls. All women had waist circumference
80 cm. The following analyses were performed: total cholesterol, HDL,
triglycerides, glucose, insulin, C-peptide, testosterone, SHBG, DHEAS and
systolic blood pressure. Calculation of free androgen index (FAI) was performed
and insulin resistance was defned by HOMA-IR. MetSy was defned by
International Diabetes Federation criteria, and a CVR
10
according to FRSS.
Because subject age had major infuence to fnal CVR
10
estimation, we compared
gathered points as well.
Results
In comparison to obese controls, obese PCOS women had statistically signifcant
higher glucose (P,0.01), testosterone (P,0.001) concentrations, as well as
higher FAI (P,0.001). SHBG concentration was lower in PCOS than in controls
(P,0.01). There was no signifcant difference in other parameters, including
HOMA-IR. Both groups had the same prevalence of MetSy (PCOS versus
controls: 26 vs 22%, P0.05). There was similar number of smokers in PCOS
and control group (52 vs 44% respectively, P0.05). CVR
10
for PCOS women
was 1.6% and for controls 1.4% (P0.05). Framingham risk score points for
PCOS were 7.85.0 and for controls 6.86.6 (P0.05).
Conclusion
Young obese women with PCOS do not have greater 10-year risk for incident
cardiovascular diseases in comparison to age and body mass index matched
healthy women, based on Framingham risk score system. A different system for
CVD prediction in this population of women is needed.
P4I4
Serum ferritin in female-to-male transsexuals with polycystic ovary
syndrome
Gilberto Perez Lopez
1
, Antonio Becerra Fernandez
2,4
, Miriam Menacho
3
,
Mari a Jesus Lucio Perez
2
, Nuria Asenjo Araque
2
,
Jose Miguel Rodri guez Molina
2
& Jose Luis Llopis Agelan
5
1
Department of Endocrinology-Hospital Ramon y Cajal, Madrid, Spain;
2
Gender Dysphoria Unit/Department of Endocrinology-Hospital Ramon y
3
Department of Biochemistry-Hospital Ramon y
4
Universidad de Alcala, Madrid, Spain;
5
Universidad
Complutense, Madrid, Spain.
Elevated serum ferritin levels has been reported in premenopausal women
presenting polycystic ovary syndrome (PCOS) and hyperandrogenism, and thus
may be involved in the development of insulin resistance, type 2 diabetes y
cardiovascular disease. In female-to-male transsexuals (FMTs) PCOS is frequent
and this issue has been little studied.
Aims
To study the serum ferritin in FMTs with PCOS and their relations with markers
of insulin resistance (IR) and metabolic syndrome (MetSyn).
Methods
Fifty-eight were evaluated using the Rotterdam 2003 criteria for the diagnosis of
PCOS, aged 28.78.0 years (range 18-47). Their medical history was recorded,
and an antrhopometric and metabolic evaluation, serum chemistry profles
including serum ferritin, hormonal analyses, and ultrasound examinations were
performed. Insulin resistance (IR) markers were determined by HOMA-IR and
QUICKI index.
Results
Serum ferritin was signifcantly higher in 22 FMTs with PCOS than in 36 FMTs
without PCOS (76.177.4 vs 28.226.3 ng/ml, P0.016). Ferritin was
signifcantly correlationed with age (r0.329, P0.016), fast plasma glucose
(r0.499, P0.000), waist circumference (r0.496, P0.000), systolic blood
pressure (r0.361, P0.013), diastolic blood pressure (r0.367, P0.011),
triglycerides (r0.626, P0.000), HDL-cholesterol (r0.302, P0.033),
HOMA-IR (r0.373, P0.006), and QUICKI (r0.330, P0.016).
Conclusion
The FMTs with PCOS present higher levels of serum ferritin than those without
PCOS, that could be related with higher risk of type 2 diabetes and cardiovascular
disease, through its relationship with markers of IR and MetSyn.
P4I5
Endothelial structure and function in young women with polycystic
ovary syndrome: a 5 years follow-up study
Francesco Orio
1,2
, Francesco Giallauria
3
, Alessandra Grieco
1
,
Chiara Caggiano
4
, Gaetano Lombardi
1
, Domenico Caggiano
4
,
Stefano Palomba
5
& Annamaria Colao
1
1
'Federico II` University of Naples, Naples, Italy;
2
Endocrinology, Faculty of
Exercise Sciences, 'Parthenope` University of Naples, Naples, Italy;
3
Cardiac Rehabilitation Unit, Department of Clinical Medicine,
Cardiovascular and Immunological Sciences, 'Federico II` University of
Naples, Naples, Italy;
4
Endocrinology Unit, Hospital 'S. Giovanni di Dio e
Ruggi dÀragona` of Salerno, Salerno, Italy;
5
Department of Obstetrics and
Gynecology, 'Magna Graecia` University of Catanzaro, Catanzaro, Italy.
To date, studies focusing on long-term cardiovascular risk (CVR) of polycystic
ovary syndrome (PCOS) women are not available, as well as longitudinal data
regarding the endothelial structure and function.
The aim of this observational study was to examine both endothelial structure and
function in young women with PCOS at 5-year follow-up.
Thirty PCOS women (age 22.22.5 years, meanS.D.; BMI 22.42.1, kg/m
2
)
were evaluated at baseline and at 5-year follow-up (mean time follow-up5.2
0.4 years).
Primary outcomes were intima media thickness (IMT) by carotid ultrasonography
(US) and fow mediated dilation (FMD) by brachial artery US.
Secondary outcomes were clinical, hormonal, and metabolic parameters.
No signifcant differences in IMT and FMD were found between baseline and
5-years follow-up. No signifcant differences between baseline and 5-year
follow-up were found in androgen levels. Conversely, at 5-year follow-up, insulin
sensitivity index worsened; in fact, 5-year AUC
INS
was signifcantly increased
compared to baseline (72301520 vs 54041227, P,0.001, respectively).
In conclusion, the present data show that at 5 years follow-up, normal-weight,
non-dyslipidemic, non-hypertensive women do not worsen their early impairment
in endothelial structure and function; therefore, CVR does not seem to be
increased long-term in PCOS women.
P4I
Structured exercise training p/as hypocaloric diet improves ovarian
sensitivity to clomiphene citrate in polycystic ovary syndrome (PCOS)
patients
Stefano Palomba
1
, Francesco Giallauria
2
, Angela Falbo
1
, Tiziana Russo
1
,
Alessandra Grieco
3
, Annamaria Colao
3
, Gaetano Lombardi
1
& Francesco Orio
3,4
1
Department of Obstetrics and Gynecology, University 'Magna Graecia`
of Catanzaro, Catanzaro, Italy;
2
Department of Clinical Medicine,
Cardiovascular and Immunological Sciences, University 'Federico II`
of Naples, Naples, Italy;
3
Department of Molecular and Clinical
Endocrinology and Oncology, University 'Federico II` of Naples, Naples,
Italy;
4
Endocrinology, Faculty of Exercise Sciences, University
'Parthenope` of Naples, Naples, Italy.
Clomiphene citrate (CC) is the frst-line therapy for inducing ovulation in infertile
women with polycystic ovary syndrome (PCOS), but about 20% of them results
un-responsive. Lifestyle modifcation programs are effective in restoring ovarian
function and improving reproductive outcomes in PCOS patients.
The aim of the present randomized controlled trial was to test the hypothesis that a
very short-term intervention consisting in structured exercise training (SET) plus
hypocaloric diet improves ovarian response to CC in CC-resistant PCOS patients.
Ninety-six infertile CC-resistant PCOS patients were investigated.
SET plus hypocaloric diet for 6 weeks (group A), 2 weeks of observation followed
by one-cycle of CC therapy (group B), and SET plus hypocaloric diet for six
weeks plus one-cycle of CC added after the frst two weeks (group C).
After intervention, the ovulation rate was signifcantly (P,0.05) higher in group
C in comparison with groups A and B (12/32 (37.5%), 4/32 (12.5%) and 3/32
(9.4%) for group C, A and B, respectively). Compared to baseline, in both group
A and C, a signifcant improvement in clinical and biochemical androgen and
insulin sensitivity indexes was observed. In the same two groups, insulin
sensitivity indexes were signifcantly (P,0.05) better than group B.
In conclusion, in CC-resistant PCOS patients, a very short-term intervention
consisting of SET plus hypocaloric diet is effective at improving ovarian
sensitivity to CC by an acute and body weight independent effect on androgens
and insulin resistance.
P4II
An association between autoimmune thyroiditis and premature ovarian
failure: a cross-sectional study
Serap Soytac Inancli, Mutlucan Kurt, Husniye Baser, Fatma Saglam,
Introduction
Premature ovarian failure is cessation of ovarian function before the expected age,
which is usually accepted to be 40. Autoimmune diseases are a frequently seen
group of disorders causing premature ovarian failure. In this study, we aimed to
evaluate the frequency of autoimmune thyroiditis in patients with premature
ovarian failure.
Material and method
Patients who admitted to our thyroid out patient clinic were included to our study.
The patients were divided in to two groups according to their menopause age.
Group 1 were patients whose menopause age was before 40, and Group 2 were
patients whose menapause age was after 40. The patients were evaluated
according to their thyroid function tests (fT
3
, fT
4
, TSH), thyroid autoantibodies
(AntiTPO Ab, AntiTg Ab) and thyroid ultrasonography. The patients were
diagnosed as autoimmune thyroiditis when thyroid markers supported chronic
thyroiditis on ultrasonography.
Results
Forty-six of 80 patients were included in to Group 1, and 34 were included into
Group 2. In Group 1 mean age was 42.47.6 years, mean menopause age was
34.55.1 years. In Group 2 mean age was 48.55.4 years, mean menopause age
was 46.35.5 years. There was a statistically signifcant difference in age and
menopause age between two groups (P,0.001). 72.7% of the patients in Group 1
and 35.3% of the patients in Group 2 had autoimmune thyroiditis. Our study has
shown that autoimmune thyroiditis is statistically more common in patients who
enter menopause before the age of 40 then patients who enter menopause after the
age of 40 (P0.002). The limitation of our study is that the patients were selected
from our thyroid out patient clinic.
Conclusion
Autoimmunity is one of the most common causes of premature ovarian failure.
We suggest that patients who enter menopause before the age of 40 should be
investigated for autoimmune thyroiditis.
P4I8
The polymorphic A/a1 variant of ER may modulate the feedback
regulation of LH secretion
Katerina Saltiki
1
, Emily Mantzou
1
, Eleni Anastasiou
1
, Theodora Pappa
1
,
Ilpo Huhtaniemi
2
& Maria Alevizaki
1
1
Endocrinology, Metabolism and Diabetes Unit, Evgenidion Hospital and
Department of Medical Therapeutics, ALEXANDRA Hospital, Athens
University School of Medicine, Athens, Greece;
2
Imperial College London,
Institute of Reproductive and Developmental Biology, Hammersmith
Campus, London, UK.
A common polymorphism of the ER gene (AluI) located in 3
-UTR of exon 8 has

been shown to be associated with clinical features of altered estrogen action in
tissues where this gene is expressed. It has recently been shown that GnRH
neurons express ER, indicating that this receptor may participate in the feedback
regulation of gonadotrophin secretion. We therefore studied the association of
gonadotrophin levels and the AluI polymorphism of ER in a group of
postmenopausal women. Genomic DNA was studied by RFLP in 96
postmenopausal women. LH, estradiol, testosterone and DHEA-S levels were
estimated. 33 women were homozygous for the wild type (WT) variant, 53 were
heterozygous carriers (carr) and 10 women were homozygous (homoz) for the
polymorphic AluI ER gene variant. Mean estradiol levels were: WT, 13.82.2
(S.E.M.); carr, 12.11.6; homoz, 9.32.1 (NS). Mean LH levels were
signifcantly higher in carriers of the polymorphic variant: WT, 31.72.6; carr,
36.42.7; homoz, 45.510.46 (P0.014, ANOVA). There were no signifcant
differences in BMI or the levels of DHEA-S or testosterone between the three
groups of polymorphic variants. No differences were observed in the mean LH
levels according to the presence of the PvuII polymorphic variant of ER in the
same population. These fndings, if confrmed in a larger population sample,
provide further evidence that ER participates in the feedback regulation of LH
secretion. Whether the mechanism is by enhancing the positive feedback or
suppressing the negative feedback remains to be determined.
P4I9
Expression of StAR protein and steroidogenic enzyme mRNAs in
ovarian follicles of the domestic hen (Ga//as ga//as damest/cas)
Katarzyna Pawlowska & Andrzej Sechman
Department of Animal Physiology and Endocrinology, University of
Agriculture in Krakow, Krakow, Poland.
The aim of the study was to determine mRNA expression of genes involved in
steroidogenic pathways in chicken ovarian follicles by real-time PCR method.
Hy-Line Brown hens (n20), 28 weeks of age, laying regular sequences of about
20 or more eggs per clutch were used in the experiment. Birds were decapitated
^2 h after ovulation. From the ovary, white prehierarchical follicles (1-8 mm)
and the three largest yellow preovulatory follicles F3-F1 (F3,F2,F1; 22-35
mm) were dissected. White follicles were divided into two classes: small white
follicles (SWF, 1-4 mm) and large white follicles (LWF, 6-8 mm). Granulosa
and theca layers of F3-F1 follicles were separated according to the Gilbert`s
method. Total RNA extracted from the specifed tissues was reverse transcribed,
and real-time PCR analysis was performed using TaqMan Gene Expression
Assay (Applied Biosystems) designed for StAR, P450scc, 3-HSD, P450c17
and P450arom genes. Results showed that mRNA of all examined genes was
expressed in ovarian follicles. The expression profle of StAR protein mRNA
and P450scc enzyme were similar during follicular growth. Their levels were
4.6- and 7-fold higher in LWF than in SWF while a gradual decline in mRNA
levels was observed in the theca layer of F3-F1 (opposite effect was in granulosa).
A very low 3-HSD mRNA levels were found in SWF and LWF while in
preovulatory ones the mRNA levels were ^160- and 10-fold higher in granulosa
and theca layers, respectively. The expression of P450c17 and P450arom mRNAs
in the theca layers was higher in white follicles in comparison with theca layers
of F3-F1, where a gradual decline in mRNA levels was observed.
Obtained results show quantifed differences in mRNA expression of
steroidogenic genes during maturation and growth of the follicles in the chicken
ovary. This results can be useful for advanced studies of steroidogenic genes in
avian species.
Study supported by grant N N311 006436.
P480
Endocrine safety of ulipristal acetate, a selective progesterone receptor
modulator (SPRM): results from two phase II randomised,
placebo-controlled studies
Lynnette Nieman
1
, Nathalie Chabbert-Buffet
3
& Philippe Bouchard
2
1
NICHD, National Institutes of Health, Bethesda, Maryland, USA;
2
Hospital Saint Antoine, Paris, France;
3
Hospital Tenon, Paris, France.
Objective
Ulipristal acetate or UPA (PGL4001, formerly CDB-2914) is an oral SPRM with
the potential to be the frst in a new treatment class for uterine fbroids. As
treatment with frst-generation SPRMs led to modifcation of adrenal and thyroid
function and changes in prolactin secretion and because UPA binds to the
glucocorticoid receptor, we report here a detailed investigation of the endocrine
effects of UPA.
Methods
Endocrine function was assessed for women included in two studies of UPA.
In Study A, women with symptomatic fbroids received UPA 10 mg (n13), 20
mg (n13) or placebo (PLC; n12) for the equivalent of three menstrual cycles
(phase [ph] 1), after which they were offered surgical treatment or a 3-month
continuation of UPA (ph2; n12). Hormone levels were measured approxi-
mately every 2 weeks. In Study B (partially reported by Chabbert-Buffet et al.
J Clin Endocrinol Metab 2007 92 3582), healthy women received UPA 2.5 mg
(n11), 5 mg (n11), 10 mg (n10) or PLC (n11) for 84 days. Hormone
levels were measured before treatment and on Days 59, 63, 67, 70, 74, 77, 80
and 84.
Results
Of the women in Study A receiving UPA, 23/26 in ph1 and 11/12 in ph2 had
amenorrhea or spotting. Similarly, 18/21 women receiving UPA 5 or 10 mg in
Study B had amenorrhea during month 3. In both studies, serum oestradiol levels
fuctuated within physiological premenopausal limits. In Study A, values were
similar for PLC and UPA groups in ph1, but were lower in ph2 in the UPA group
(meanS.D. 103.762 vs 74.435.2 ng/ml; delta change P0.008). In Study
B, oestradiol levels were similar in UPA and PLC women. In Study A, elevated
prolactin levels (25 and ,90 g/l) were found in six women in both PLC and
UPA groups; two had high baseline levels (excluding a relationship to treatment),
the rest had occasional minor increases. There was no evidence for adrenal
blockade; two PLC- and one UPA-treated women had transient mild
adrenocorticotrophin elevations (49 pg/ml), with normal cortisol levels.
In Study B, prolactin, cortisol and testosterone levels did not vary signifcantly
between baseline and Day 84. During treatment, thyroid function was normal in
all but two patients (5 mg UPA group) who had subclinical disease before
enrolment.
Conclusions
These results demonstrate no endocrine safety concerns with UPA, with no
evidence of oestrogen suppression of relevance to bone health and no
antiglucocorticoid effects.
P481
Serum concentrations of carboxylated osteocalcin are increased and
associated with the components of the polycystic ovarian syndrome
Evanthia Diamanti-Kandarakis
1
, Sarantis Livadas
1
, Ilias Katsikis
2
,
Christine Piperi
3
, Aimilia Mantziou
1
, Athanasios G Papavassiliou
3
& Dimitrios Panidis
2
1
Endocrine Section, First Department of Medicine, University of Athens
Medical School, Athens, Greece;
2
Division of Endocrinology and Human
Reproduction, Second Department of Obstetrics and Gynecology, Aristotle
University of Thessaloniki, Thessaloniki, Greece;
3
Laboratory of Biological
Chemistry, University of Athens Medical School, Athens, Greece.
Objective
Intriguing studies suggest that osteocalcin (OC) and its carboxylated (Gla)/
uncarboxylated form are involved in the regulation of insulin secretion and action.
Additionally, advanced glycated end products (AGEs), directly regulate the
secretion of these osteoblast derived molecules. In PCOS among the
pathophysiological aberrations, deregulation of insulin secretion and action as
well as elevated AGEs levels have been demonstrated. In this study, we evaluated
the serum levels of OC and Gla and their possible associations with PCOS
metabolic, hormonal and ultrasonographic components.
Of 97 women were studied, 50 PCOS and 47 controls, age and BMI-matched.
In each subject the levels of bone metabolism markers have been evaluated and
metabolic, hormonal profles as well as ovarian ultrasound were carried out.
Results
Osteocalcin (4.301.74 vs 6.201.78 ng/ml, P,0.0005) values were signi-
fcantly lower, whereas Gla (37.936.87 vs 9.648.21 ng/ml, P,0.0005) and
RANKL (0.540.26 vs 0.160.15 pmol/l, P,0.0005) values were signifcantly
higher, in PCOS subjects compared to control group, independently of obesity.
A signifcant association was disclosed between osteocalcin and Gla with
androgens, insulin resistance, AGEs and ovarian morphology. ROC analysis
revealed that Gla (AUC 0.975 (95% CI 0.93-1.00)), as well as AGEs are
signifcant prognostic factor of PCOS existence (AUC 0.986 (95%CI 0.97-1.00)).
Conclusions
Lower osteocalcin and elevated serum levels of its carboxylated form are
displayed in PCOS subjects and are associated with several PCOS components.
These fndings suggest a potential interaction between bone derived markers and
metabolic/hormonal abnormalities observed in PCOS. However, the pathophy-
siological mechanisms and more over the possible clinical implications require
further investigation.
P482
Ascending aortic dilatation in Turner syndrome: the natural history
Kristian Mortensen
1
, Britta Hjerrild
1
, Kirstine Stochholm
1
,
Niels Andersen
2
, Keld Soerensen
2
, Erik Lundorf
2
, Jens Christiansen
1
& Claus Gravholt
1
1
Aarhus Hospital NBG, Aarhus University Hospital, Aarhus, Denmark;
2
Skejby Hospital, Aarhus University Hospital, Aarhus, Denmark.
Background
Aortic dissection causes excess mortality in Turner syndrome, and this increased
risk is associated with aortic dilation, congenital cardiovascular abnormalities,
karyotype, and blood pressure. But risk factor identifcation is inadequate, and the
natural course of aortopathy in Turner syndrome is poorly investigated.
Design and methods
Prospective follow-up study in women with Turner syndrome (n102, examined
twice) and healthy age-matched controls (n65, examined once), using
magnetic resonance imaging (MRI) of thoracic aorta combined with 24-h
ambulatory blood pressure monitoring and echocardiography (for aortic valve
morphology).
Results
The mean follow-up time was 2.40.4 years (range: 1.4 to 3.5 years). Of the 102
TS women enrolled at baseline, one had a chronic dissection, three died
unexpectedly, and eight were lost to follow-up. Eleven TS women were excluded
due to technically unsuccessful MRI scans, leaving 80 to participate. The
sinotubular aortic diameter enlarged with 0.16 mm/year (P0.02) and the mid-
ascending aorta with 0.23 mm/year (P0.001). The other thoracic aortic
diameters were unchanged. Twenty-two patients (30%) increased their aortic
diameter increment above the interobserver limits of agreement (rates ranging
from 0.7 to 2.7 mm/year). The aortic growth rates were not predicted by
congenital abnormalities, karyotype, age, or blood pressure. Pulse rates were
higher with faster aortic dilatation rates (P,0.03).
Conclusion
A general ascending aortopathy was evident with increment of sinutubular and
mid-ascending aortic size, and a third of the cohort has a seemingly more
pronounced aortic growth. The previously identifed indices of risk for aortic
dilatation and dissection did not predict the increase in aortic size.
P483
AMH secretion seems not to be inuenced by acute GnRH-analogue
administration in PCOS patients
Roberto Mioni
1
, Rosa Ritunnano
1
, Chiara Cosma
2
, Laura Zuliani
1
,
Letizia Glinski
1
, Sara Azzolini
1
, Luigi Bleve
1
, Marnie Granzotto
1
,
Piero Maffei
1
, Diego Faggian
2
, Nicola Sicolo
1
& Roberto Vettor
1
1
Medical and Surgical Sciences Department-Clinica Medica 3,
University-Hospital of Padua, Padua, Italy;
2
Laboratory Medicine
Department, University-Hospital of Padua, Padua, Jamaica.
Background
Hyperandrogenism and disrupted folliculogenesis are prominent features of
polycystic ovary syndrome (PCOS) and are causatively linked to ovarian
dysfunction. In PCOS, increased anti-Mullerian hormone (AMH) serum levels
have been observed and related to the severity of the phenotype. However, the
regulation of AMH in PCOS remains poorly understood. Therefore, we compared
AMH secretory pattern after acute exposure to a GnRH-analogue in women
affected by PCOS or by other causes of anovulation and hyperandrogenism,
such as functional hypothalamic amenorrhea (FHA) and extra-ovarian
hyperandrogenaemia (non-PCOSH).
Of 26 PCOS (23.94.8 years), 9 FHA (26.62.6 years) and 8 non-PCOSH
(21.24.5 years) women were studied. Testing was performed at 4-7 day/cycle,
after Liddle test. AMH, LH, FSH, DHEA-S, 17-OHP, A, T, DHT, E
2
, Inh-B were
evaluated at 0-h, and over a 20 and 24-h period after a s.c. injection of Triptorelin
(0.1 mg).
Results
Our results are summarized in Table:
Conclusions
AMH serum levels were increased in PCOS and FHA patients when compared
with non-PCOSH subjects, suggesting that extra-ovarian androgens may not be
directly involved in the complex AMH regulation network. In contrast with
conventional markers of early follicular growth, such as inhibin-B and E
2
, AMH
secretion appears to be independent of gonadotropin acute stimulation in vivo
both in PCOS and non-PCOS patients.
P484
Metabolic changes associated with hypogonadotropic hypogonadism in
women of reproductive age and effect of HRT
Irena Ilovayskaya
1,2
, Vita Zektser
2
, Alexandr Iljin
1
, Nikolay Goncharov
1
,
Galina Melnichenko
1,2
& Ivan Dedov
1,2
1
Federal Research Centre for Endocrinology, Moscow, Russian Federation;
2
Moscow Medical Academy named by Sechenov, Moscow, Russian
Federation.
We examined 56 normoprolactinemic women of reproductive age (18-45 y.o.)
with isolated hypogonadotropic hypogonadism (group 1) initially and on
treatment with 2 mg of 17-estradiol and 10 mg of dydrogesterone in sequenced
manner (HRT), duration of HRT was from 18 to 42 (median 36) months; 45
healthy women (20-38 y.o.) were included in control group 2.
Initially hypercholesterolemia was observed in 50% of cases in group 1 and 6.6%
in group 2 (z12.29 P0.0005); nevertheless, the difference in lipid levels
between groups 1 and 2 was not statistically signifcant: total cholesterol levels
5.2 (4.3; 6.0) mmol/l and 4.63 (4.15; 5.15) mmol/l respectively (1 vs 2 P0.1);
triglycerides 0.8 (0.62; 1.3) mmol/l and 0.76 (0.6; 0.85) mmol/l (1 vs 2 P0.08);
HDL 1.89 (1.24; 2.1) mmol/l and 1.79 (1.44; 2.8) mmol/l (1 vs 2 P0.85); LDL
2.7 (2.2; 3.2) mmol/l and 2.75 (2.3; 3.3) mmol/l (1 vs 2 P0.64). In group 1
decrease of total cholesterol and triglycerides concentrations was found on HRT:
total cholesterol 4.8 (3.95; 5.1) mmol/l (before versus on treatment P0.041),
triglycerides 0.65 (0.6; 0.9) (before versus on treatment p0.044) respectively,
changes in HDL and LDL levels were not revealed.
Initial concentrations of Ca
, P, and alkaline phosphatase (AP) were within

normal range in all women. However, concentrations of Ca
and AP were
higher in group 1 compared to group 2: Ca
1.13 (1.08; 1.19) mmol/l and 1.05

(1.03; 1.09) mmol/l (1 vs 2 P0.0016); AP 161.5 (141.8; 183) IU/l and 141.0
(119; 151) IU/l (1 vs 2 P0.044). On HRT reduce in Ca
and AP
concentrations was observed: Ca
concentrations 1.05 (1.03; 1.10) mmol/l

(before versus on treatment P0.004), AP 139 (112; 143) IU/l (before versus on
treatment P0.004).
Thus, despite lacking the expressed biochemical disorders, isolated hypogonado-
tropic hypogonadism in women of reproductive age have hidden impact on lipid
and mineral metabolism. HRT signifcantly improved parameters of lipid and
mineral homeostasis in this cohort of patients.
P485
The ovulatory capacity and related genes are altered in transgenic mice
hypersecreting human chorionic gonadotrophin hormone (hCG)
Laura Ratner
1
, Betina Gonzalez
1
, Matti Poutanen
2
, Ilpo Huhtaniemi
3
,
Ricardo Calandra
1
& Susana Rulli
1
1
Instituto de Biologi a y Medicina Experimental -CONICET, Buenos Aires,
Argentina;
2
Department of Physiology, Turku University, Turku, Finland;
3
Imperial College London, London, UK.
Hypersecretion of hCG in transgenic mice produces profound alterations in the
ovary, thus triggering failures in ovulation and affecting fertility. The objective of
this study was to analyze the response of immature female mice overexpressing
moderated (hCG; 0.1 IU/ml) and elevated (hCG; 7 IU/ml) levels of hCG
to an ovulation induction protocol (PMSG 7.5 IU i.p.; after 48 h, hCG 7.5 IU i.p).
Wild-type (WT) females subjected to the same protocol were used as controls.
The ovulatory capacity was determined by the number of ovulated oocytes
collected from the oviducts 18 h post-hCG: WT213, hCG245; no
oocytes were observed in the oviducts of hCG females. The expression of
genes involved in the ovulatory process, prostaglandin-endoperoxide synthase 2
(Ptgs2), progesterone receptor (Pgr), amphiregulin (Areg), epiregulin (Ereg),
betacellulin (Btc) and estrogen sulfotransferase (Sult1e1) was determined by
qRT-PCR. In WT and hCG females analyzed 4 h post-hCG showed a
signifcant increase respect to the basal levels in all the genes studied (P,0.05),
whereas in hCG females those changes were not observed. The cumulus-
oocyte complex (COC) expansion from WT and hCG ovaries was studied
in vivo by analyzing the histology 6 h post-hCG, and in vitro by incubating the
COC with FSH for 20 h. An impairement of the COC expansion in hCG
females was observed both in vivo and in vitro, when compared with the correct
expansion seen in WT mice. In conclusion, in hCG mice subjected to a
protocol of ovulation induction, the ovulatory capacity was restablished and the
induction of related genes were comparable with WT. In hCGfemales, the
mechanism of ovulation was signifcantly affected, indicating that elevated levels
of hCG would be producing an alteration in the correct expression of factors
involved in the intrafollicular signalling process, thus leading to anovulation.
P48
The prevalence and phenotypes of polycystic ovary syndrome in Korean
women
Yeon-Ah Sung
1
, Dong-Sun Kim
2
, Soon-Jib Yoo
3
, Sei-Hyun Baik
4
,
Jee-Young Oh
1
& Hye-Jin Lee
1
1
Ewha Womans Univerisity, Seoul, Republic of Korea;
2
Hanyang
University, Seoul, Republic of Korea;
3
Catholic University, Seoul, Republic
of Korea;
4
Korea University, Seoul, Republic of Korea.
The prevalence of polycystic ovary syndrome (PCOS) is generally estimated at
5-7% in women of reproductive age. But studies regarding the prevalence of
PCOS have largely been confned to non-Asians. We aimed to estimate
prevalence and phenotype of PCOS in Korean women. Cross sectional study
was done between November 2008 and May 2009. A questionnaire based on
menstrual history and clinical manifestations of hyperandrogenism was utilized to
PCOS FHA Non-PCOSH
Baseline Peak Baseline Peak Baseline Peak
E2 (pM) 16067 1546675 7627* 1453350 12336 1056537
nhB (ng/l) 11440 400121 15443 566100 8124.6 20597
AMH (pM) 4318 4414
7026* 7844
|,
2110*
,|
2412
,
*,0.05 versus PCOS baseline;
|
,0.05 versus FHA baseline;

,0.05 versus PCOS peak;
NS versus baseline values.

fnd out 'probable cases` of PCOS in 8080 women aged 16-39 years from three
women`s universities, fve girls` high schools and one hospital employees.
Selected 'probable cases` underwent detailed evaluation including a modifed
Ferriman-Gallwey hirsutism score, the anthropometric measure, serum screening
for hyperandrogenemia, hyperprolactinemia, and latent 21-hydroxylase defci-
ency and ovarian ultrasound. Hyperandrogenemia (HA) was defned as free
testosterone levels above the 95th percentile of the levels in the group of regular
cycling non-hirsute women.
A total of 846 (10.5%) 'probable cases (oligo/amenorrhea; OM)` were identifed
and 278 participated detailed examination. Further evaluation of the probable
cases confrmed 178 newly diagnosed cases of PCOS (prevalence 6. 3%) by the
2003 Rotterdam diagnostic criteria, 125 cases (4.4%) by 1990 NICHD criteria and
146 cases (5.1%) by androgen excess society criteria. Of the women with '(OM)
and/or hirsutism (HI),` 97.1% were confrmed to have PCOS; 100% of women
with 'regular cycles in the absence of HI` were confrmed as normal. Of
phenotypes of PCOS, 45.0% were OM-HA/HI-polycystic ovaries (PCO), 25.2%
OM-HA/HI, 18.0% OM-PCO, and 11.8% HA/HI-PCO. Of women with OM, 45.3
to 64.0% of cases were confrmed as PCOS by variable diagnostic criteria and
screening for PCOS should be considered in women with oligomenorrhea.
P48I
Hormonal correlates of different ejaculatory latencies in subjects with
sexual dysfunction
Giovanni Corona
1,2
, Emmanuele Jannini
3
, Francesco Lotti
1
,
Valentina Boddi
1
, Giulia de Vita
1
, Gianni Forti
1
, Andrea Lenzi
4
,
Edoardo Mannucci
5
& Mario Maggi
1
1
Andrology Unit, Univeristy of Florence, Florence, Italy;
2
Endocrinology
Unit, Ospedale Maggiore, Bologna, Italy;
3
Department of Experimental
Medicine, School of Sexology, University of LÀquila, lÀquila, Italy;
4
Department of Medical Pathophysiology (DFM-Fisiopatologia Medica,
Sapienza University, Rome, Italy;
5
Diabetes Section Geriatric Unit,
Department of Critical Care, University of Florence, Florence, Italy.
Introduction
Although it is well established that all the aspects of male reproduction are
hormonally regulated, the endocrine control of the ejaculatory refex is still not
completely clarifed. Sex steroids, thyroid and pituitary hormones (oxytocin and
prolactin) have been proposed to control the ejaculatory process at various levels,
however, only a few reports are currently available. The aim of the present study
is to evaluate the contribution of testosterone, TSH and prolactin (PRL) in the
pathogenesis of ejaculatory dysfunction in a large series of subjects consulting for
sexual dysfunction.
Methods
Among the 2652 patients studied, 674 (25.2%) and 194 (7.3%) reported
premature and delayed ejaculation (PE and DE) respectively. Categorizing
ejaculatory diffculties in an 8-point scale starting from severe PE and ending with
anejaculation (0severe PE, 1moderate PE, 2mild PE, 3no diffculties,
4mild DE, 5moderate DE, 6severe DE and 7anejaculation).
Results
PRL as well as TSH levels progressively increased from patients with severe PE
towards those with anejaculation. Conversely, the opposite was observed for
testosterone levels. All of these associations were confrmed after adjustment for
age (adj r0.050, 0.053 and 0.038 for PRL, TSH and testosterone respectively;
all P,0.05). When all hormonal parameters were introduced in the same
regression model, adjusting for age, MHQ (an index of general psychopathol-
ogy) and use of selective serotonin reuptake inhibitor antidepressants, they were
independently associated with ejaculatory problems (adj r0.056, 0.047 and
0.059 for PRL, TSH and testosterone respectively; all P,0.05).
Conclusions
This study indicates endocrine system is involved in the control of ejaculatory
function and that PRL, TSH and testosterone play an independent role.
P488
Cardiovascular risk in lean algerian PCOS
Ouldkablia Samia & Kemali Sahra
Central Hospital of the Army, Algiers, Algeria.
Polycystic ovary syndrome is the most common endocrine disorder of
reproductive women. This syndrome is often associated with cardiovascular risk.
Objective
Our objective was to assess the prevalence of cardiovascular factor in len PCOS
women.
Sixty-eight lean PCOS were prospectively evaluated for glucose intolerance,
dyslipidemie and high blood pressure from 2004 to 2007.
Results
In this population 4.4%had glucose intolerance, 45.5%had HDL-C,1.30 mmol/l,
5.5% had triglyceridemia 1.70 mmol/l and 4.5% had high blood pressure.
Conclusion
Lean PCOS women are also at risk of IGT and hypoHDL-C so they should be
screened for IGT and HDL-C.
P489
Polymorphisms in the estrogen receptor gene and reproductive axis in
women
Olga Ianas
1
, Dana Manda
1
, Lorand Savu
2
, Suzana Vladoiu
1
, Oana Popa
1
,
Roxana Rosca
1,3
& Carmen Iordachescu
1
1
2
Genetic Lab SRL, Bucharest, Romania;
3
Carol Davila University of
Medicine and Farmacy, Bucharest, Romania.
Background
ER- gene (ESR1) polymorphisms have been associated with a variety of
disorders including human infertility. In this study, we examined two
polymorphisms of the estrogen receptor (ESR1) gene, IVS-1 397 T/C
(dbSNP: rs2234693) and IVS-1 351 A/G (dbSNP: rs9340799) in a sample of
healthy women of reproductive age to determine whether are associated with
hormonal levels for a better understanding of its biological actions in human
development, with special emphasis on the reproductive process.
Women (168) of age between 20 and 40 years, without signifcant medical illness
participated as volunteers in this study that had the ethical committee approval.
Total morning levels of serum estradiol, estrone, 17-OHP, DHEA, DHEAS,
androstendion, progesterone, testosterone, free testosterone, DHT, SHBG,
inhibins: A and B, LH, FSH and Prl were measured. PvuII and XbaI
polymorphisms were analyzed by polymerase chain reaction restriction fragment
lengths polymorphism (PCR-RFLP).
Results
The percentages of genotype distribution for XbaI were 45.8-AA, 42.2-AG,
13-GG and PvuII: 32.5-TT, 41.0-TC, 26.5-TT respectively. XbaI polymorphism
was associated with prolactin (
2
10.81; P0.004) and DHEA (
2
6.57;
P0.038); the levels of estradiol (P0.015), progesterone (P0.013), SHBG
(P0.034) and inhibin A (P0.038) were higher in GG genotype. PvuII
polymorphism was associated with prolactin (
2
14.99; P0.001), DHEA
(
2
8.80; P0.012) and FEI (bioavailable estradiol) (
2
6.40; P0.041).
Estradiol levels were higher (P0.010) in CC genotype; estrone (P0.023),
DHT (0.013) was lower and SHBG was higher (P0.24) in heterozygote.
Conclusion
The fndings of this study support the view that ESR1 polymorphisms may affect
reproductive function through differences in hormonal secretion in women.
Supported by PNII no. 41-014/2007, Ministry of Education and Research.
P490
Spontaneous pregnancy in Sheehan syndrome
Mchirgui Nadia, Hadj Ali Insaf, Khiari Karima, Lakhoua Youssef &
Ben Abdallah Nejib
Department of Internal Medicine and Endocrinology Charles Nicolle
Spontaneous pregnancy in the course of Sheehan syndrome is extremely rare
because of gonadotrophic insuffciency, which is almost present.
The aim of our study is to analyse cases of pregnancies occurring spontaneously
in patients with Sheehan syndrome.
It is a retrospective study of 46 women who had a Sheehan syndrome diagnosed in
the Internal Medicine and endocrinology department of Charles Nicolle Hospital
during the period between 1977 and 2008.
Results
The gonadotrophines (FSH, LH) are dosed in 38 patients (87%). Gonadotrophic
insuffciency is diagnosed at 86, 8% of cases (33 patients). GnRh test was
achieved only in 6 cases (16%). Three patients have a low rate of FSH and LH.
Three patients have spontaneous pregnancies. Two of them have a secondary
amenorrhea whereas the third has irregular cycles. None patients had a
gonadotrophine insuffciency but they had thyrotropin and corticotropin
insuffciency. The GnRh stimulation shows a normal response of FSH and LH.
None of the three patients has received an ovulation inducing treatment and
pregnancy has occurred spontaneously. One patient had three spontaneous
abortion and the two others had full term delivery without incident.
Although pregnancy is exceptional in Sheehan Syndrome, the recovery of the
hypophyseal function is possible and ovulatory cycles may occur in the evolution
of the disease.
P491
Sheehan syndrome: metabolic and hormonal abnormalities (46 cases)
Hadj Ali Insaf, Haouat Emna, Mchirgui Nadia, Khiari Karima,
Lakhoua Youssef & Ben Abdallah Nejib
Department of Internal Medicine A and Endocrinology Charles Nicolle
Hospital, TUINS, Tunisia.
Sheehan syndrome is a global or partial pituitary defect occurring after an
obstetrical haemorrhage.
The aim of this study is to describe metabolic complications in 46 consecutive
patients with Sheehan syndrome and to determine correlations between these
complications and the clinical, hormonal and therapeutic aspects of this
syndrome.
All patients have had a physical examination: weight measurement, body mass
index (BMI) determination and blood pressure measurement. Fasting plasma
glucose and lipid profle are realised in all cases as well as hormonal investigation
of the pituitary gland.
Mean age at diagnosis is 39.3 years. Mean delay between the obstetrical event and
diagnosis is 7.6 years. None patient had arterial hypertension anterior to the
diagnosis of Sheehan syndrome.
At the diagnosis, mean BMI is 23 kg/m
2
. An overweight is found in 15.2% of
patients (n7) and obesity in 8.8% of them (n4). Hypertension is found in
4.4% of patients (n2). Glucose intolerance or diabetes is found in respectively
13.2 and 4.3% of them. Hypercholesterolemia and hyper triglyceridemia are
present in 43.3 and 32.6% of patients.
The number of pituitary axis affected is 3 in 20 patients, four in 12 patients, two in
10 patients, one in 3 patients and a panhypopituitarism is found in one patient.
Most affected axis are: gonadotrope (89.1%), corticotrope (80.4%), and
thyreotrope axis (74%). Hypertension appeared in 31.5% of patients (n12),
diabetes in 23.6% of them, hypercholesterolemia in 30% and hyper triglycer-
idemia in 25% of them.
Our results confrm the high prevalence of metabolic troubles in Sheehan
syndrome. Hyperlipidemia seems to be directly in relation to somatotrope and
thyreotrope defects.
P492
Progesterone receptor signaling: new tricks from an old dog
Ana Gracanin
1
, Carol Sartorius
2
, Willem Schoonen
3
& Jan Mol
1
1
Utrecht University, Utrecht, The Netherlands;
2
University of Colorado
Denver, Colorado, USA;
3
Schering-Plough, Oss, The Netherlands.
Two progesterone receptor (PR) isoforms, the full-length PR-B and the
N-terminally truncated PR-A, have distinct reproductive functions, with PR-B
being required for a proper mammary gland development. The functional
distinction between PR-B and PR-A has partially been attributed to the additional
activation function (AF3) domain, localized within the PR-B-unique sequence
(PR-BUS). Three highly conserved sequence motifs within AF3 domain are
required for the strong transactivation potential of human PR-B on most target
gene promoters. In dogs, however, these motifs have multiple amino acid
replacements, implicating a non-functional AF3 domain. Hence, we hypothesized
that canine PR-B (cPR-B) has a weakened transactivation potential.
In order to test this, human and canine PR isoforms, and a chimera cPR-B with
human PR-BUS (hBUS-cPR-B) were transiently transfected in human mammary
(T47D-Y), chinese hamster ovary (CHO-K1) and canine mammary (CNMp) cell
lines. Transactivation of PR target gene promoters (MMTV- and PRE2-luciferase
reporter plasmids) was subsequently measured after 20 nM progesterone
treatment. In addition, to determine the evolutionary origin of changes within
cPR-B, PR-BUS regions of additional dog-related species (cat, ferret, seal and
wolf) were sequenced.
Our results indicate that cPR-B is a poor transactivator on PRE-containing
promoters when compared to hPR-B and even PR-A. Moreover, the attenuated
transcriptional activity of cPR-B is dependent on cPR-BUS. Preliminary data
suggests that the observed amino acid replacements within the AF3 domain have
occurred in a common ancestor of dogs and wolfs. Interestingly, dogs are not
distinct from other mammals regarding progesterone-dependent mammary
development, but they show a very high incidence of spontaneous mammary
tumors and endometrial lesions. The lack of functional AF3 domain in cPR-B
may, therefore, suggest that the function of AF3 domain is not required for the
normal mammary gland development but rather has a tumor-protective role.
P493
Inammatory markers, adiponectin and metabolic characteristics in
different phenotypes of polycystic ovary syndrome
Irina Kowalska
1
, Monika Karczewska-Kupczewska
1
, Agnieszka Adamska
1
,
Agnieszka Nikolajuk
1
, Agnieszka Lebkowska
1
, Slawomir Wolczynski
2
,
Maria Gorska
1
& Marek Straczkowski
1
1
Department of Endocrinology, Diabetology and Internal Medicine,
Medical University of Bialystok, Bialystok, Poland;
2
Department of
Reproduction and Gynecological Endocrinology, Medical Univeristy of
Bialystok, Bialystok, Poland.
Polycystic ovary syndrome (PCOS) is heterogeneous disorder leading to
infertility. The introduction of Rotterdam criteria creates different PCOS
phenotypes, i.e. hyperandrogenic anovulatory with (A) and without (B) polycystic
ovaries (PCO) morphology in ultrasonography (usg), hyperandrogenic ovulatory
with PCO morphology in usg (C), non-hyperandrogenic anovulatory with PCO
morphology in usg (D). In PCOS insulin resistance might be involved in the
development of endocrine and metabolic abnormalities. It is suggested that low-
grade chronic infammation is related to the pathogenesis of insulin resistance.
The aim of the present study was to asses infammatory markers, adiponectin and
insulin sensitivity in hyperandrogenic anovulatory PCOS (A) in comparison to
non-hyperandrogenic anovulatory PCOS (D) and control group. We studied 129
PCOS women (phenotype A, n69, phenotype D, n60) and 62 healthy
controls. Antropomethric parameters, euglycemic-hyperinsulinemic clamp and
estimation of adiponectin, interleukin 18 (IL-18), hsCRP, sex hormone binding
globuline (SHBG) and sex hormones were performed. BMI, waist, % of body fat
and insulin sensitivity was not different between A and D phenotypes, however
hyperandrogenic anovulatory PCOS women had signifcantly higher systolic
blood pressure (P0.03). Comparison of both PCOS phenotypes with controls
revealed signifcantly lower insulin sensitivity (P0.036 versus phenotype A,
P0.003 versus phenotype D), lower SHBG serum concentration (P0.004
versus phenotype A, P,0.0001 versus phenotype D), higher LH (P,0.0001 for
both phenotypes) and higher free androgen index (FAI) (P,0.0001 versus
phenotype A and P0.0018 versus phenotype D). Serum adiponectin, hsCRP,
IL-18 did not differ between A and D phenotypes. We concluded that non-
hyperandrogenic anovulatory PCOS women have similar metabolic and
infammatory profle like hyperandrogenic anovulatory PCOS.
P494
Vitamin D levels in pregnant women in the city of Burgos (Spain)
Javier Pi
1
, Iria Flavia Vallina
2
, Felisa Alonso
2
, Javier Lozano
3
,
Estefania Santos
1
, Celia Guerrero
4
, Beatriz Caton
2
& Eva Tutor
2
1
Endocrinology and Nutrition, Burgos, Spain;
2
Clinical Laboratory, Burgos,
Spain;
3
Preventive Medicine, Burgos, Spain;
4
Research Unit Complejo
Asistencial De Burgos, Burgos, Spain.
Introduction
Vitamin D defciency is very common in the population, including pregnant
women. There are few studies in Spain to explain their causes, so we started one in
the city of Burgos, Spain (latitude 42.2? N) in April 2009 to study vitamin D
status, factors that can infuence and their relationship with gestational diabetes.
We present preliminary data from the study on vitamin D levels.
Aims
Study in pregnancy: i) vitamin levels, and ii) its variation throughout the
pregnancy and its possible relationship with several variables: anthropometric,
racial, nutritional, lifestyle and seasonal.
Subjecs/methods
i) Measurement of serum vitamin D levels (25-hydroxyvitamin D (25OHD)
(Modular Analytics E170, Roche) setting the following categories (ng/ml):
normal (N): 30; insuffciency (I): 20-29.9; defciency (D): 10-19.9; severe
defciency (SD): ,10 (grouped into N, I, D (D & SD) for analysis) in pregnant
women in the frst and third trimester of pregnancy during gynecological control.
ii) Questionnaire to collect the above mentioned variables in the frst trimester.
Results
i) Sample: 612 women tested with a mean age of 32.14.4 years, BMI (kg/m
2
)
23.63.5, 57.3% multiparous, 84.9% non-smokers, 90.8% caucasian, 4%
tanning bed users, 78% sunscreen users, 2.6% veil users, 78% urban residents,
39% 3 h of exercise/week, 17% 3 servings of dairy products/day, 11% 3
servings of fsh/week. ii) Mean serum 25OHD concentration by the time of
pregnancy: frst trimester (n340): 23.57.0 ng/ml; third trimester (n244):
26.68.3 ng/ml. iii) serum 25OHD according to season and trimester: frst
trimester: spring: 20.55.1 ng/ml, summer: 26.77.1 ng/ml; autumn: 28.5
7.5 ng/ml; third trimester: summer: 28.89.5 ng/ml; autumn: 25.8
7.7 ng/ml. iv) vitamin D categories by trimester and season: frst trimester:
N: 14.4%, I: 54.1%, D: 31.5% (spring: N: 2.8%, I: 51.7%, D: 45.5%, summer: N:
25.2%, I: 60.3%, D: 14.5%, autumn: N: 36.7%, I: 43.3%, D: 20.0%. third
trimester: N: 29,1%, I: 49.2% D 21.7% (summer: N: 43.5% I: 43.5% D: 13.0%,
autumn: N: 25.9% I: 50.7%, D: 23.4%. v) Relationship between serum 25OHD
and variables considered: We only found signifcant differences in serum 25OHD
levels between frst and third trimester of gestation (P,0.001).
Conclusions
Based on this preliminary data we can conclude: i) vitamin D levels in this group
of pregnant women are very low and neither group studied reached normal values.
ii) There is a signifcant differences in 25OHD levels between the frst and third
trimester. iii) There is no relationship between vitamin D levels and other
variables analyzed iv) These results may reconsider whether the degree of
normality proposed are adequate or if the protocols of nutritional supplementation
to pregnant women are inadequate, given the high proportion of insuffcient and
defcient values founded in a group of women otherwise completely healthy.
P495
The role of hyperprolactinemia in periductal and intraductal
inammation in mammary gland
Danijela Radojkovic
1
, Milica Pesic
1
, Slobodan Antic
1
, Milan Radojkovic
2
,
Sonja Kostic
1
& Sasa Radenkovic
1
1
Clinic of Endocrinology, Diabetes and Metabolic Disorders, Nis, Serbia;
2
Surgical Clinic, Nis, Serbia.
Background/aim
This study was conducted to determine hyperprolactinemia signifcance in
starting and maintaining sterile infammation in breast tissue.
Methods
We observed 50 patients with nipple discharge syndrome. Patients were divided
into clinical group (27 patients with hyperprolactinemia and nipple discharge) and
frst control group (23 patients with normal serum prolactin and nipple discharge).
The second control group included patients from clinical group after treatment of
hyperprolactinemia and achieving normalized serum prolactin levels. Cytologic
evaluation of samples, taken from all patients with mammary secretion, was done
using standard staining techniques haemathoxilin-eozine and May-Grunwald/
Giemsa.
Results
Our results showed signifcantly higher presence of lipid and protein material in
clinical group in comparison to frst control group (P,0.01). Our data also
demonstrated signifcantly higher number of ductal epithelial cells (P,0.05) and
ductal histiocities (P,0.001) in clinical group patients compared to frst control
group. Infammatory cells frequency was similar in clinical (22.22%) and frst
control group (26.09%), but completely withdrawn in second control group.
Macrophagies frequency was proportionally higher in clinical group (44.44%)
compared to frst control group (17.39%). Erythrocites were signifcantly lower in
the clinical group patients (P,0.001) than in the frst control group. Signifcantly
decreased mammary secretion (P,0.01), lower lipid (P,0.01) and protein
synthesis (P,0.01) and less presence of all cellular categories (P,0.01) were
obtained after normalization of serum prolactin levels. Bacteriological analysis of
mammary secretion revealed pathogens bacteria only in two clinical group
patients.
Conclusion
The most expressive role hyperprolactinemia demonstrated in domain of
mammary ductal secretory activity, making mammary secretion reach in lipid
and protein material and simultaneously increasing number of ductal epithelial
cells, ductal histiocytes, infammatory cells and 'foam cells`-macrophages. This
cytological fndings indicate that hyperprolactinemia promote periductal and
intraductal sterile infammation which is withdrawing after serum prolactin
normalization.
P49
The impact of the disease on life quality and health concept in young
women with Turner`s syndrome
Beata Wikiera, Elzbieta Szpich, Ewa Barg & Anna Noczynska
Medical University, Wroclaw, Poland.
The individual development of patients with Turner`s syndrome (TS) is
determined by the illness from the moment of diagnosis. The aim of the study
was to determine life quality (QL) of TS patients and their concept of health.
Twenty-six TS patients aged 18-25 who experienced many years of treatment. R
L Schaloc, K D Keith Life Quality Questionnaire was used to determine their QL.
Their views on health were analyzed on the basis of Health Criteria List by Z
Juczynski. The research questions concerned the subjective assessment of QL
level of TS patients, the comparison of their lives in chosen categories, and the
aspects of the feeling of health, relevant for the group. The study was based on the
opinion that the feeling of health is crucial for life activity.
Results
The preferred criteria concentrated on mental aspects of health. Life joy as an
element of health was signifcantly more important for the patients than the
perspective of a long life. Health features and the results of health manifestation
came second. The result in the category satisfaction refected the satisfaction felt
in connection with the current life and family situation, with a particular impact
on the position in the family. In the skills-productivity category the patients
interviewed rated the treatment in the work place as the most important. In the
category action opportunities-independence was rated as the most important. The
category in which the patients interviewed rated life quality as the lowest was
social integration.
Conclusions
The focus on the positive aspects of life creates good conditions for using personal
assets and coping with the physical aspects of the illness. In their long history of
illness, TS patients coped with the stress of being ill to such an extent, which did
not signifcantly affect their subjective life quality assessment.
P49I
The value of ovarian reserve markers in assisted reproductive
technology
Adela Voican, Gabriela Niculescu, Magdalena Manolea, Dominic Iliescu,
Carmen Gheta & Liliana Novac
University of Medicine and Pharmacy, Craiova, Dolj, Romania.
Background and aims
Ovarian reserve screening is considered to play a key role in the prediction of
quantitative and qualitative aspects in assisted reproductive technologies (ART).
The ovarian reserve markers currently used include the serum levels of FSH,
oestadiol, inhibin B, anti-Mullerian hormone (AMH) as well as ultrasound antral
follicular counts (AFC). Despite controversial results, most of the existing studies
suggest that, compared to other markers of the ovarian reserve, baseline AMH
levels have a better capacity in predicting the ovarian response to controlled
ovarian stimulation (COS).
The aim of our study was that of evaluating the predictive value of the different
biochemical and ultrasound markers of the ovarian reserve in correlation with the
age of the patients undergoing COS for IVF.
Patients and method
In this prospective study we have included 21 women, aged 29-40 years,
undergoing the frst cycle of COS for IVF. Clinical and paraclinical evaluation of
the patients (including the ovarian reserve assessment) was performed prior to
COS. The ovarian reserve assessment included: FSH, oestradiol, inhibin B, AMH
and AFC. The patients were divided into two groups according to their age: group
A (patients younger than 35 years) and group B (patients age 35 or older). Ethical
approval for this study was obtained.
Results
Six patients were included in group A and 15 patients in group B. We obtained a
strong correlation between AMH serum levels and AFC, as well as between AMH
and the response to COS (P,0.05). AMH and AFC showed a superior correlation
with the number of retrieved oocytes compared to FSH and inhibin B. Ovarian
reserve biomarkers showed a signifcant difference between group A and B
(P,0.01). After IVF, pregnancy was achieved in 4 patients, 2 in group A and 2 in
group B.
Conclusions
Ovarian reserve markers are considerably infuenced by the age of the patients
undergoing IVF. Among ovarian reserve markers, AMH and AFC are the best
correlated with COS results. These are the frst preliminary results of the study
and we need further investigations for a better correlation between ovarian reserve
markers and pregnancy outcome.
P498
CAG repeat alleles of the androgen receptor are associated with
polycystic ovary syndrome (PCOS) in the Romanian population
Serban Radian
1,2
, Nicoleta Baculescu
1,2
, Daniela Aforei
1
, Ilinca Gussi
3
,
Suzana Vladoiu
2
, Olga Ianas
2
, Florin Grigorescu
4
& Mihai Coculescu
1,2
1
Department of Endocrinology, C. Davila University of Medicine,
Bucharest, Romania;
2
C. I. Parhon National Institute of Endocrinology,
Bucharest, Romania;
3
Department of Obstetrics and Gynecology, C. Davila
University of Medicine, Bucharest, Romania;
4
Molecular Endocrinology
Laboratory, Institut Universitaire de Recherche Clinique, Montpellier 1
University, Montpellier, France.
Background
Androgen receptor (AR) activity is modulated by the length of CAG-repeat
polymorphism in exon 1. Published data suggest association between CAG-repeat
alleles and PCOS, but not all studies confrmed this fnding.
Aim
To test association of AR alleles with PCOS and clinical and biochemical signs of
hyperandrogenism.
Study design
Case-control association study, approved by the institutional ethical committee,
of 137 PCOS patients (Rotterdam criteria) and 130 control subjects of Romanian
origin. Androgen receptor genotyping, X-chromosome methylation analysis, and
phenotyping for PCOS were performed.
Results
Median CAG repeat numbers were 22 (range 11-30) in PCOS and 23 (range
13-30) in controls. Biallelic means of CAG repeats were signifcantly shorter
between PCOS and control groups (22.58 vs 23.16, P0.01, t-test).
X-inactivation analysis was done in 221 heterozygous subjects (109 PCOS and
112 controls). X-inactivation status did not differ signifcantly between PCOS and
control groups (non-random inactivation: 55.9 vs 48.2%, skewed inactivation:
11.9 vs 13.3%).
When stratifed by X-inactivation status, only the non-random subgroup of PCOS
patients (versus controls) had lower biallelic means (22.27 vs 23.39, P0.0014)
and X-weighted biallelic means (22.23 vs 23.39, P0.0054). There was no
evidence of preferential allele inactivation in favor of shorter alleles in PCOS.
In the control group, but not in PCOS, plasma testosterone values were
signifcantly correlated to AR X-weighted biallelic means (r
2
0.14, P0.014).
Ferriman-Gallwey hirsutism scores were not infuenced by AR alleles.
Conclusion
Our results demonstrate that the CAG polymorphism of the androgen receptor is
signifcantly associated with PCOS in Romanian women (Eastern Europe) and
may play an important role in PCOS pathogenesis.
P499
The unfavourable effect of oral contraceptive pills on the metabolic
parameters in women with polycystic ovary syndrome
Olgierd Gluszak
1
, Urszula Stopinska-Gluszak
1
& Romuald Debski
2
1
Endocrinology CMKP, Warsaw, Poland;
2
Gynecology and Obstetrics
CMKP, Warsaw, Poland.
The polycystic ovary syndrome (PCOS) is a common endocrinopathy (6-8%)
of the female population in the reproductive age. It is characterised by
oligomenorrhoea, hyperandrogenism and the presence of polycystic ovary.
PCOS is also associated with the disturbance of carbohydrate and lipid
metabolism. The basic treatment consists of the application of diet, physical
activities and the use of hormonal therapy. The aim of our study was to investigate
the effect of three months treatment with oral contraceptive pills (OCP) consisting
of desogestrel and ethinyloestradiol on the selected metabolic parameters in 100
women with PCOS. Results: After 3 months treatment we observed a signifcant
(P,0.05) reduction of total testosterone, androstenedione, 17-hydroxyprogester-
one (17OH-Prg), estradiol, LH, FSH, prothrombin time (PT), international
normalized ratio (INR) and an average ovarian volume; contrary to a signifcant
(P,0.05) increase of sex hormone binding globulin (SHBG), high-sensitivity
C-reactive protein (hsCRP), erythrocyte sedimentation rate (OB), total
cholesterol, LDL-cholesterol, triglycerides, fbrinogen, prothrombin index
(QUICK index) and a insulin level during the glucose tolerance test.
Conclusions
The use of OCP consisting of desogestrel and ethynyloestradiol can play an
effective role in the treatment of PCOS but simultaneously brings the
unfavourable effects on coagulatory and metabolic parameters such us
carbohydrate and lipid metabolism and can provoke faster arteriosclerosis.
P500
The effects of metformin therapy on hirsutism, androgen and metabolic
parameters in PCOS women
Zelija Velija-Asimi
Clinic of Endocrinology, University of Sarajevo Clinics Centre, Sarajevo,
Bosnia and Herzegovina.
Background
PCOS is the most common endocrinopathy in women of reproductive age,
characterized by hyperandrogenism and ovulatory dysfunction. The aim of this
study was to evaluate the effects of metformin therapy on hirsutism, androgen and
metabolic parameters in PCOS women.
Methods
Fifty PCOS women with hirsutism aged 20-40 years were included in the study.
PCOS diagnosis was made after excluding other causes of hirsutism and in
accordance with Rotterdam criteria. Patients to be included in the study required
not to receive any medication for PCOS, or for other conditions associated with
insulin resistance, within the last 6 months. Fasting serum glucose, basal insulin,
insulin during OGTT, HOMA-IR index, FSH, LH, PRL, TSH, total testosterone,
DHEA-S, androstendione and lipid profle were determined. All patients were
treated with metformin (1500 mg/day) for 12 months and all parameters were
re-evaluated.
Results
Metformin treatment after 12 months signifcantly reduced: BMI (27.263.58 vs
22.751.37 kg/m
2
); P0.009), waist circumference (87.326.93 vs 77.93
2.62 cm; P0.007), hirsutism FG score (10.44 vs 8.8), BI (127.6328.04 vs
70.1511.39 pmol/l; P,0.05), HOMA-IR index (2.610.52 vs 1.550.78;
P,0.01), total testosterone (2.930.67 vs 2.020.39 nmol/l; P0.02), DHEA-
S (45080 vs 344.970.23 g/dl; P,0.01), androstendione (3.670.88 vs
2.450.6 ng/ml; P,0.01), PRL (469.0971.79 vs 31785.79 IU/ml;
P,0.05), TSH (3.390.8 vs 2.320.46 mIU/l: P,0.01), total cholesterol
(5.810.38 vs 5.310.3 mmol/l; P,0.05), tryglicerides (1.810.25 vs 1.26
0.24 mmol/l; P,0.05) LDL (4.080.32 vs 3.60.25 mmol/l; P,0.01) and
not signifcantly changed fasting serum glucose levels, HDL cholesterol, FSH and
LH. Signifcantly correlations were between: HOMA-IR index and hirsutism
score (r0.68), HOMA-IR index and basal insulin (r0.96), testosterone and
basal insulin (r0.75), hirsutism score and waist circumference (r0.75),
hirsutism score and basal insulin (r0.74), basal insulin and androstendione
(r0.74), basal insulin and DHEA-S (r0.72).
Conclusion
The results of study shown that 12 months of metformin therapy had benefcial
effects on hirsutism score, androgen levels and insulin resistance in PCOS women
with hirsutism.
P501
Some subordinate steroid metabolites may better predict gestational
age than the main pregnancy steroids
Radmila Kanceva
1
, Martin Hill
1
, Antonin Parizek
2
, Jan
Evangelista Jirasek
2
, Michaela Duskova
1
& Luboslav Starka
1
1
2
First Medical School,
Charles University, Prague, Czech Republic.
The majority of pregnancy steroids originate in the fetal zone of the fetal adrenal
(FZ). The data in the literature indicates that placental CRH directly stimulates the
FZ. Despite the substantial alterations in the placental CRH production in late
pregnancy, the predictivity of CRH for an estimation of term is poor. To sidetrack
the expensive determination of unstable CRH, it may be expediential to use the
FZ steroids. However, even these substances may not be optimal for prediction
due to their rapid catabolism. Accordingly, we attempted to fnd the steroid
catabolites, which are rapidly synthesized from the key FZ steroids and, having
slower metabolic turnover, may be even better predictors for gestational age.
Therefore, we have measure 69 steroids and steroid polar conjugates in maternal
circulation at labor coming on from 28th to 41st week of gestation using GC-MS.
In contrast to the group of healthy women after the 38th week of gestation, all
preterm births were induced by sudden unexpected complications in which the
association with gradual changes in steroid metabolome was not the reason for
the preterm birth. Beside the expected rise in conjugated -5 steroids, estrogens
and their 16--hydroxy-metabolites, we have identifed a number of further
subordinate steroids like 4-ene-16-hydroxy-metabolites, conjugated 3-5/-
androstane catabolites, and conjugated 7/-metabolites of -5 steroids showing
excellent correlation with gestational age. Moreover, some of them and their
ratios to the parent steroids showed exponential rise near term and appeared to be
excellent predictors of ingoing labor.
The study was approved by the ethics committee of the Institute of Endocrinology
in Prague, Czech Republic.
Supported by grant projects IGA NS/9834 and NS/9790.
Growth factors
P502
Ghrelin (hunger hormone) and its effects on GH mean plasma
concentration with different energy levels in camel
Mansoure Mohammadi & Homayun Khazali
Shahid Beheshti University, Tehran, Islamic Republic of Iran.
Ghrelin is a novel acylated peptide predominantly purifed from stomach and
identifed as an endogenous ligand for GH secretagogue receptor (GHS-R).
Ghrelin is potent releaser of GH and in addition, actively participate in controlling
energy balance, regulation of food intake and appetite. The GH response to
ghrelin was higher than that after GHRH.
The aim of the present study was to investigate the infuence of ghrelin on the
mean plasma concentration of GH in animals with two different energy levels.
Also this experiment had not been performed on camels so far.
With this purpose, we selected twelve camels randomly and divided them into two
equal groups that each groups fed with different energy level (100 and 50%
standard camel diet). Animals in each groups received daily either infusion of
8 g/kg BW ghrelin for 4 days via jugular vein. Blood samples were collected for
6 days (1 day before frst ghrelin infusion until 1 day after last infusion). Samples
were assayed for plasma GH concentration by RIA.
The result of this experiment indicate that administration of ghrelin, signifcantly
increase GH mean plasma concentration among all animals through the infusion
period but this enhancement is more sensible in those animals who had 100%
energy level. Analysis of data done with repeated measures ANOVA procedure
and results were signifcant at PB0.05.
P503
Acromegaly: a prospective analysis of the oral and maxillofacial
pathologies and its impact of disease duration
Burkhard Herrmann
1,3
, Florentine Mortsch
1
, Christian Berg
1
,
Thomas Weischer
2
, Christopher Mohr
2
& Klaus Mann
1
1
Department of Endocrinology and Division of Laboratory Research,
University Duisburg-Essen, Essen, Germany;
2
Department of Oral and
Maxillofacial Surgery, University Duisburg-Essen, Essen, Germany;
3
Division of Endocrinology and Diabetology, Technology Center Bochum,
Bochum, Germany.
Context
It is well established that clinical features of acromegaly concern the teeth and the
jaw, but less is known about the degree of oral and maxillofacial pathologies and
its impact of the disease duration.
Patients
Twenty-eight acromegalics (13 females, 15 males) with a mean age 4911
(meanS.D.) years (range 31-70) were included in the study. Thirty-two percent
had active disease, 39% were well-controlled under the somatostatin analogue
octreotide, the dopamine agonist cabergoline, and the GH receptor antagonist
pegvisomant, and 29% were cured.
Methods
All subjects undergone intensive and complex examinations of a plaster model
and facial arch with articulator, an intra-oral bracket-pen registration, analysis of
a digital picture, panoramic and lateral radiographs with cephalometry in
comparison with a reference group (n201).
Results
Panoramic radiographs revealed that 82% had an irregularity of the tooth position.
At an average, 108 teeth of the denture were missing. Lacks between teeth were
detected in 65% of the maxilla and in 73% of the mandible. Forty-two percent had
a diastema mediale (0.91.1 mm). Overbite and overjet (vertical overbite)
correlated with the disease duration (r
2
0.2237; P0.011 respectively r
2
0.3364; P0.015). Thirty-nine percent had paradontitis. Ninety-six percent had

an asymmetric movement of the mandible. Fifty-seven percent had a
prognathism. The protrusion of the mandible correlated signifcantly with the
disease duration (r
2
0.1784; P0.028). The degree of the mandibular
prognathism (SNB-angle) was higher in the acromegalic group (847? vs
813?, P,0.05). The ANB-angle indicates the relation between maxilla and
mandible and was negative in the acromegalic group and positive in the controls
(0.35.0? vs 1.62.1?, PB0.05) and correlated negative with the disease
duration (r
2
0.2553; P0.0061). The mandibular angle was signifcantly
greater in the acromegalic group (1269? acromegalic group versus 1217?
control group, P0.003). The length of the mandible correlated with the disease
duration (r
2
0.2801; P0.0038). Eighty-six percent had an asymmetric face.
The high of the midface was in the acromegalic group higher (6.10.7 vs 5.5
0.4 cm, P0.0009) as well as the lower bony high of the face (9.51.0
acromegalics versus 6.90.5 cm controls, P0.0009). The high of the lower
bony face correlated as well with the disease duration (r
2
0.3224; P0.0016).
Conclusions
Patients with acromegaly suffer not only from cardiovascular, metabolic and
neoplastic complications, but also from dental and jaw disorders. The high
incidence of these manifestations and its relation to the disease duration requires a
carefully work-up of oral and maxillofacial examinations in close collaboration
with endocrinologists, dentists and dental surgeons.
P504
Designing a long acting human GH by fusing the carboxyl-terminal
peptide of human chorionic gonadotropin subunit to the coding
sequence of human GH
Fuad Fares
1,2
, Rachel Guy
2
, Ahuva Bar-Ilan
2
, Yana Felikman
2
& Eyal Fima
2
1
University of Haifa, Haifa, Israel;
2
ModigeneTech, Nes-Ziona, Israel.
Human GH is a member of a family of closely related hormones that include
prolactin and placental lactogen. GH regulates a wide variety of physiological
processes, including growth and differentiation of muscle, bone and cartilage
cells. The use of GH for the treatment of children with impaired linear growth has
been accepted as an important therapeutic modality for many years. In addition,
benefcial effects of GH replacement therapy in hypopituitary adults are well
established. One major issue regarding the clinical use of GH is its relatively short
half-life due to its rapid clearance by glomerular fltration. Thus the therapeutic
protocol used in the treatment of patient required frequent injections of GH. To
address this issue, we constructed fve chimeric genes by fusing hGH cDNA to
one, two or three cassettes of the carboxyl-terminal peptide (CTP) of human
chorionic gonadotropin (hCG) subunit. Chimeric genes, were inserted into the
pCI - DHFR plasmid, a eukaryotic expression vector, transfected into DG44 cells
and stable clones which secreted hGH variants were selected. For pharma-
cological evaluation of hGH variants, hypophysectomized Sprague-Dawley male
rats were used. The results indicated that s.c. injection of GH-CTPs once a week
for 2 weeks resulted in a dramatic increase in weight gain comparing to GH wild-
type. Similar effect was achieved by daily injection of GH wild-type.
Pharmacokinetic studies indicated that a higher level of the chimera is still
detectable in serum after 50 h where the level of biotropin (a commercial GH)
after 24 h was undetectable. The half-life of GH-CTPs is increased 4-5 folds
comparing to biotropin. These data suggest that the mechanism of GH metabolic
clearance is affected by the presence of CTP. This may establish a rationale for
using this chimera as a long-acting GH analog.
P505
Serum IGF1 levels in adult patients with type 1 Gaucher disease
Milan Petakov
1,2
, Nada Suvajdzic
2,3
, Marijana Petakov
1
, Djuro Macut
1,2
,
Sanja Ognjanovic
1
, Valentina Elezovic
1
, Marina Djurovic
1
&
Svetozar Damjanovic
1,2
1
Clinic for Endocrinology, Clinical Center of Serbia, Belgrade,
Serbia;
2
Belgrade University Medical School, Belgrade, Serbia;
3
Clinic for Hematology, Belgrade, Serbia.
Background/aims
Gaucher disease (GD) is autosomal recessive lysosomal storage disorder caused by
the defciency of enzyme glucocerebrosidase (GCD) with consequent massive
acumulation of lipid-laden macrophages in various tissues including liver. It has
been shown that chronic diseases with liver involvement might cause IGF1
defciency. The aimof the study was toassess the IGF1 systemin adult patients with
type 1 Gaucher disease with and without enzyme replacement therapy (ERT).
Methods
We studied serum concentration of total IGF1 in a cohort of 15 patients with type
1 GD (9 females and 6 males, mean age 44.23.4 years), and 15 healthy age- and
gender-matched control subjects. Also CT liver volumetry was done in patients
with GD. All the patients attained normal adult height during puberty. Most of
them (No 10) were on specifc enzyme replacement therapy (ERT) with
recombinant GCD for at least 2 years.
Results
We found signifcantly decreased serum IGF1 levels in Gaucher patients in
comparison with healthy controls (82.612.6 vs 195.715.8 g/l, respectively).
There was no signifcant difference in IGF1 levels between treated and untreated
patients with GD (94.316.7 vs 59.314.8 g/l). Total IGF1 serum
concentration was decreased in 11 patients with Gaucher disease (fve patients
without treatment and six patients on regular ERT). In seven patients total IGF1
was unmeasurable (three untreated, and four treated patients). There was no
correlation between liver volume and serum IGF1 level.
Conclusion
Our results indicate that type 1 Gaucher disease in adult patients with normal
height is associated with low, sometimes unmeasurable levels of IGF1 which is
probably the consequence of liver involvement and is irrespective of ERT. The
clinical impact of this fnding on the quality of life and life expectancy in these
patients has yet to be determined.
P50
Testicular TGF-1 system expression and its participation in
hypertrophy and hyperplasia of Leydig cells
Candela Rocio Gonzalez
1
, Betina Gonzalez
1
, Susana Rulli
1
, Luiz
Renato Franca
2
, Guillermi Mattos Jardim Costa
2
, Ilpo Huhtaniemi
3
,
Ricardo Saul Calandra
1
& Silvia Ines Gonzalez-Calvar
1,3
1
Instituto de Biologia y Medicina Experimental, CONICET, Buenos Aires,
Argentina;
2
Laboratory of Cellular Biology, Department of Morphology,
Federal University of Minas Gerais, Minas Gerais, Brazil;
3
Imperial College
London, London, UK;
4
Facultad de Medicina, UBA, Buenos Aires,
Argentina.
Transforming growth factor 1 has a critical role in the regulation of testicular
function. Transgenic male mice over expressing and subunits of hCG (hCG)
are infertile and testicular steroidogenesis is enhanced showing high levels of
testosterone and progesterone (P
4
). The chronic hCG hyperstimulation leads to
Leydig cell (LC) hypertrophy/hyperplasia in prepubertal mice.
Aims
To analyze: i) the expression of the TGF-1 system in LC from WT and hCG
mice of 21-days old by immunohistochemistry and by RT-PCR; ii) the in vitro
effect of hCG, P4 and T on the TGF-1 system in purifed LC from WT mice by
RT-PCR; iii) the in vitro effect of TGF-1 on proliferation markers in purifed LC
from WT animals and iv) the in vivo effect of TGF-1 on testicular morphometry
in WT mice. TGF-1, ALK-5 and ALK-1 were immunolocalized in WT and
hCG LC. The expression of TGF-1 and endoglin (EDG) was signifcantly
higher in hCGLC respect to control (P,0.05). hCG (10 IU/ml) stimulated the
expression of TGF-1 while P4 (10
6
M) increased the expression of EDG, and
this effect was blocked by RU486 (antiprogestin) (P,0.05). T (10
6
M) failed to
modify TGF-1 system expression. The action of TGF-1 (1 ng/ml) in the
presence of P4 caused: i) the phosporylation of Smad1/5 detected by western blot,
ii) an increase in PCNA expression levels detected by immunocytochemestry and
iii) a decrease in the Bax/Bcl2 ratio analyzed by RT-PCR (P,0.05).
Morphometric studies revealed that the intratesticular injection of TGF-1 and
P4 (s.c.) augmented the LC volume (V) due to an increase in the cytoplasmic V
(control 341.4943.86 vs TGF-1P4 511.1630.83, P,0.05) and a decrease
of the nuclear V(control 144.2817.74 vs TGF-1P4 125.024.89, P,0.05).
These results prompt us to speculate that the TGF-1-EDG-ALK-1-Smad1/5
signalling pathway could be involved in the LC hypertrophy/hyperplasia.
P50I
GH modulates migration of developing T cells
Mireille Dardenne
1
, Salete Smaniotto
3
, Daniela Mendes Da Cruz
2
&
Wilson Savino
2
1
CNRS UMR 8147-Universite Paris Descartes, Paris, France;
2
Laboratory
of Thymus Research, Oswaldo Cruz Institute, Rio de Janeiro, Brazil;
3
Laboratory of Immunohistology, Federal University of Alagoas, Maceio,
Brazil.
In the context of the cross-talk between the neuroendocrine and immune systems,
it is well known that GH exerts physiological effects in central as well as
peripheral compartments of the immune system. GH modulates a variety of
thymic functions. For example, GH upregulates proliferation of thymocytes and
thymic epithelial cells. Accordingly, GH-transgenic mice, as well as animals and
humans treated with exogenous GH, exhibit an enhanced cellularity in the organ.
GH also stimulates the secretion of thymic hormones, cytokines and chemokines
by the thymic microenvironment, as well as the production of extracellular matrix
proteins. These effects lead to an increase in thymocyte migratory responses and
intrathymic traffc of developing T cells, including the export of thymocytes from
the organ, as ascertained by experimental studies with intrathymic injection of
GH in normal mice and with GH-transgenic animals. In addition, GH alters
lymphocyte migration in the periphery of the immune system, as assessed by the
enhancement of migratory responses of lymphocytes from mesenteric lymph
nodes of GH transgenic mice, triggered by the chemokine CXCL12 in
conjunction with fbronectin or laminin,compared to lymphocytes from control
mice. Since, GH is used as an adjuvant therapeutic agent in immunodefciencies,
including AIDS, the concepts defned herein provide relevant background
knowledge for future GH-related immune interventions.
P508
Insulin resistance induced by GH is transient and reversible: glucose
clamp studies during different ambient GHlevels in GH-dehcient adults
Thomas Krusenstjerna-Hafstrm, Niels Mller, Jens Sandahl Christiansen,
Niels Jessen & Jens Otto Lunde Jrgensen
Medical Research Laboratory and Medical Department M (Endocrinology
and Diabetes), University Hospital of Aarhus, Aarhus, Denmark.
Background
The impact of GH on insulin sensitivity is ambiguous since both long standing
GH-defciency as well as acute GH exposure and prolonged GH-excess are
associated with insulin resistance.
Aim
To test the hypotheses that the insulin antagonistic effect of GH i) is dynamic and
depend on ambient GH levels and ii) subsides gradually with time after GH
exposure.
Methods
Eight GHDAparticipated in a randomised crossover study. Each subject was studied
thrice on three different occasions. On 2 study occasions a 7 h intravenous GH
infusion (5-10 ng/kg per min) was given from2000 to 0300 h (A) and 0200-0900 h
(B), respectively. On the third occasion no GH was infused (C). The following
morning a 6 h hyperinsulinemic-euglycemic clamp (0.5 mU/kg per min) was
performed in combination with tritiated glucose, indirect calorimetry and muscle
biopsies. Eight healthy control subjects were studied once without GH exposure.
Results
The total glucose infusionrate(Mvalue), whichrefects peripheral insulinsensitivity,
differed signifcantly between GH0200-0900 h (B) and no GH(C) (P0.023), and
between GH 2000-0300 h (A) and GH 0200-0900 h (B) (P0.025), but not
between (A) and (C) (P0.176). The time course changes in the glucose infusion
rate were different in study (B) versus study (C) (P0.007), and between study (A)
versus study (B) (P0.004), but not between study (A) and (C) (P0.172).
Conclusion
i) Acute GH exposure induces insulin resistance, which subsides within few hours
after GH discontinuation, ii) the data suggest that insulin sensitivity during regular
daily GH therapy may change as a function of time after each injection, iii) this
should be considered when evaluating the clinical impact of GH therapy on glucose
homeostasis.
P509
Two years of GH therapy improves body composition in adults with
Prader~Willi Syndrome
Rasmus Sode-Carlsen
1
, Stense Farholt
1
, Kai Fr. Rabben
2
, Jens Bollerslev
3
,
Thomas Schreiner
3
, Jens Sandahl Christiansen
4
& Charlotte Hoybye
5
1
Department of Paediatrics, Aarhus University Hospital Skejby, Aarhus,
Denmark;
2
Frambu, Siggerud, Norway;
3
Rikshospitalet, Oslo, Norway;
4
Department of Endocrinology M, Aarhus
University Hospital, Aarhus, Denmark;
5
Metabolism and Diabetology, Karolinska University Hospital, Stockholm,
Sweden.
Introduction
Prader-Willi syndrome (PWS) presents clinically with a multitude of fndings,
including abnormal body composition and partial GH defciency. Until now three
studies have reported benefcial effects upon body composition of GH treatment
in adults with PWS. However, only one of these studies had the optimal
randomised controlled design.
Aim
The aim of this study was to confrm and substantiate the results from previous
studies.
Forty-six patients, 25 women, 21 men, age 29 years (16-41) (median and range)
with genetically verifed PWS participated in a multinational Scandinavian study.
The patients were randomised to treatment with GH (0.6-0.8 mg daily)
(Norditropin SimpleXx) or placebo for 12 months, the following 12 months all
patients were treated with GH according to their IGF1 value. Body composition
was measured yearly by dual X-ray absorptiometry. The study was approved by
the local ethical committees.
Results
Body fat changed 2.05 vs 2.60 kg (P,0.001) and lean body mass 2.39 vs
0.00 kg (P0.006) the frst year. During the second year non signifcant
changes was found in body fat 0.70 kg (P0.37) and lean body mass 1.10 kg
(P0.15) in the group primarily randomised to GH, whereas the change in body
fat was 4.51 kg (P,0.001) and lean body mass 2.15 kg (P,0.001) in the
group primarily randomised to placebo.
Conclusion
In this frst large scale, long-termplacebo-controlled study the improvement in body
composition by GH treatment in adults with PWS was confrmed. No side effects
were observed. Based on our 2 years results, fndings persist during long-term
therapy.
P510
Growth failure in a girl harbouring digenic heterozygote mutations in
the Ferrapart/n1-gene and the HFE-gene
Marco Janner
1
, Christa Fluck
1
, Sabina Galllati
2
& Primus Mullis
1
1
Paediatric Endocrinology, Diabetology and Metabolism, University
Children`s Hospital, 3010 Bern, Switzerland;
2
Human Genetics, University
Children`s Hospital, 3010 Bern, Switzerland.
Background
GH defciency due to iron overload is well known in thalassaemic children, yet
this association has not been described in children with haemochromatosis.
Case report and methods
We report on a girl who was frst seen at the age of 9.6 years (height 117.5 cm,
3.3 SDS, weight 21 kg, 2.5 SDS). She had a normal physical examination
and was prepubertal. Target height-SDS was 0.9. Her bone age was delayed by
10 months. IGF1 was 78.7 ng/ml (2.17 SDS), IGFBP3 2.4 mg/l (1.7 SDS).
Thyroid hormones, tissue-transglutminase-IgA as well as liver function tests were
normal. Her caryotype was 46,XX. Ferritin concentration was 1136 g/l (50-400),
transferrin 2.1 g/l (1.8-3.3), transferrin-saturation 23% (15-50). For genetic
analysis of haemochromatosis genomic DNA was isolated.
Results and follow-up
Analysis of the ferroportin-1-gene and the HFE-gene revealed a heterozygote
point mutation Arg88Gly in the ferroportin-1-gene and a heterozygote point
mutation His63Asp in the HFE-gene. A frst GH stimulation test (insulin induced
hypoglycaemia) showed a maximal GH of 14.5 ng/ml (expected normal
peak10 ng/ml).
Two years later, at the age of 12 years (height 130.1 cm, 2.6 SDS; weight
26.8 kg, 2.4 SDS) her pubertal development corresponded to a Tanner stage 3
and bone age was delayed by 18 months. IGF1 was 116 ng/ml (1.86 SDS) and
IGFBP3 3.3 mg/l (2.86 SDS). Because of persistent growth failure a second GH
stimulation test (insulin induced hypoglycaemia) was performed which showed a
maximal GH of 7.8 ng/ml suggesting partial GH defciency. A MR of the pituitary
gland could not be performed because of the presence of an orthodontic device.
Conclusion
This is the frst case of patient with digenic heterozygote mutations in the
ferroportin-1 and HFE-genes and isolated partial GH defciency. We hypothesize
that iron overload in the pituitary developed over time and interferes with GH
secretion causing growth failure in our patient.
P511
IGF1 and IGFBP3 levels in relapsing-remitting and secondary
progressive multiple sclerosis (MP)
Carolina Di Somma
1
, Roberta Lanzillo
2
, Maria Cristina Savanelli
1
,
Elisabetta Scarano
1
, Paola Contaldi
1
, Gaetano Lombardi
1
, Vincenzo
Brescia Morra
2
& Annamaria Colao
1
1
Federico II University, Napoli, Italy;
2
Department of Neurological Sciences,
Federico II University, Napoli, Italy.
Background
There is a growing body of evidence of an alteration in GH/IGF1 axis in
neurological diseases. IGF1 and IGFBP3 serum levels are reported to be similar in
controls, relapsing remitting (RR) MS and primary progressive (PP) MS patients,
but in RR patients on IFN therapy they were found to be higher then in controls.
IGFBP3 was found to correlate to progression index in PPMS.
Objective
To compare IGF1 and IGFBP3 serum levels in RR MS and secondary progressive
(SP-MS) courses of multiple sclerosis, and to evaluate correlations between their
levels and disease activity and progression on IFN therapy.
Design/methods
Forty RRMS and 22 SPMS patients and 57 age-matched healthy controls were
enrolled. Patients were put on IFN- therapy and followed up for 2 years with
clinical, MRI and laboratory investigations. IGF1 and IGFBP3 were measured by
RIA kits on blood samples obtained at baseline and after 24 months of IFN-
therapy. A secondary progression index was calculated for SP patients at baseline.
Results
Serum levels of IGF1 and IGFBP3 were not different in the two MS patients
groups at all time-points. IGFBP3 levels were higher in MS patients then in
controls (P,0.001), with a corresponding reduction of IGF1/BP3 ratio
(P,0.001). No signifcant correlations were found between serum levels and
pre-treatment clinical and MRI (enhancement and fractional volumes) data.
Secondary progression index did not relate to IGFBP3. Thirty-one RR patients
were followed-up for 2 years. IGF1 and IGFBP3 serum levels did not change
signifcantly on IFN therapy.
Conclusions
IGFBP3 serum levels were higher in MS patients then in controls, with a decrease
of IGF1/BP3 ratio in the frst group. Serum levels of IGF1 and IGFBP3 were not
different in RR and SP patients and were not related to pre-treatment clinical and
neuroradiological markers of disease activity. Secondary progression index is not
related to IGFBP3, in contrast to what has been described for PP MS patients. No
changes of serum levels of IGF1 and IGFBP3 were found in patients on IFN
therapy.
P512
Decreased expression of apoptotic genes in skeletal muscles, but not in
hearts, of GH receptor knockout (GHRKO) mice
AdamGesing
1,2
, Michal Masternak
1
, Feiya Wang
1
, Andrzej Lewinski
3
,
Malgorzata Karbownik-Lewinska
2
& Andrzej Bartke
1
1
Department of Internal Medicine, Geriatrics Research, Southern Illinois
University School of Medicine, Springfeld, Illinois, USA;
2
Department of
Oncological Endocrinology, Chair of Endocrinology and Metabolic
Diseases, Medical University of Lodz, Lodz, Poland;
3
Department and
Chair of Endocrinology and Metabolic Diseases, Medical University of
Lodz, Lodz, Poland.
GH receptor knockout (GHRKO) mice were produced by a targeted disruption of
the GH receptor (Ghr) gene. These long-lived mice, which are GH resistant, are
characterized by a greatly reduced plasma levels of IGF1 and insulin and have
enhanced insulin sensitivity (these effects resemble the characteristics of animals
subjected to caloric restriction (CR), which is well known experimental model to
delay aging and increase lifespan).
Apoptosis, or programmed cell death, is a normal component of the development
and health of multicellular organisms and is a process in which cells play an active
role in their own death (which is why apoptosis is often referred to as cell suicide).
The aim of the study was to examine the expression of genes related to apoptosis
(using real-time PCR) in the homogenates of skeletal muscles and hearts collected
from female GHRKO mice subjected to CR (40%; 6 months), starting at 2 months
of age.
Results
Expression of the examined apoptotic genes (caspase 3, caspase 9, bax,
Smac/DIABLO) is decreased in skeletal muscles of GHRKO mice as compared
to normal controls (P,0.03, P,0.007, P,0.04, P,0.04, respectively); no
statistical differences were observed for the genes in question in hearts of
GHRKO mice (in comparison to normals). CR increased caspase 3 expression in
homogenates of hearts in normal and GHRKO mice.
Conclusion
Whereas expression of apoptosis-related genes is decreased in skeletal muscles,
but not in hearts, of GHRKO mice, it is not clearly affected by caloric restriction
in either tissue (supported by NIA).
P513
Overexpression of mRNA IGF1R during apoptosis in mice hepatic and
cardiac cells
Jacek Fedorczak, Ewa Oclon, Joanna Zubel & Krystyna Pierzchala-Koziec
University of Agriculture, Krakow, Poland.
The IGFs are cellular modulators that play essential roles in the regulation of
growth and development processes. Obviously, the action of IGF1 is depended on
the activation of the specifc receptor (IGF1R), which plays pivotal role in the
growth as well as in the protection of cells against different apoptotic damages.
The aim of the study was to examined the effect of IGF1, acted by its receptor, on
apoptosis process in mice hepatic and cardiac cells treated by anticancer agent-
iscador Q.
Apoptotic cell death was determined by the TUNEL reaction, using the In Situ
Cell Death Detection Kit, POD (Roche). The mRNA expression of IGF1 receptor
(IGF1R) was determined using quantitative PCR.
The Iscador Q signifcantly (P,0.01) increased the number of apoptotic damages
in cardiac and hepatic cells compare to control group, however its effect was
much stronger in the liver. IGF1 signifcantly reduced the number of DNA
fragmentation detected by TUNEL in both tissues, but its infuence was
attenuated in cardiac cells.
Quantitative PCR analysis revealed that the expressions of IGF1R mRNA in heart
as well as in liver were signifcantly (P,0.01) increased in the Iscador Q-treated
mice. Additionally, the same effects on IGF1R expression were observed after
IGF1 injection.
In summary, the results indicate that IGF1 was able to restrict the number of
apoptotic cells through overexpressed specifc receptor, which seems to be an
important mechanism involved in cells protection against apoptotic destruction.
P514
Statin modulation of growth factors in piglets with metabolic syndrome
Ewa Oclon, Joanna Zubel, Jacek Fedorczak & Krystyna Pierzchala-Koziec
University of Agriculture, Krakow, Poland.
Metabolic syndrome (MS) is characterized by low-grade infammation and
determined as an increased risk for cardiovascular disease. Recently, reports have
demonstrated the antiinfammatory effects of statins. Often, the inhibitor of
HMG-CoA reductase called atorvastatin was used in these experiments.
Therefore, the aim of the present study was to test the effect of atorvastatin
(10 mg/day) on growth factors (ghrelin, IGF1) levels in piglets with MS. The
changes of biomarkers of infammation such as IL-6, TNF in statin-treated
animals were examined as well.
In order to develop diabetic piglets model, animals received streptozotocin (STZ).
Atorvastatin was administrated alone (i.p.) or in combination with STZ. The
plasma cytokines (IL-6 and TNF) levels were measured by commercial ELISA
kits. The ghrelin and IGF1 plasma levels were estimated by radioimmunological
method. Plasma levels of cytokines were signifcantly increased in STZ treated
piglets what confrmed chronic infammation status. Atorvastatin alone did not
changed the control levels of infammatory factors but statin given with STZ
completely reversed the stimulatory effect of STZ on IL-6 and TNF. Interestingly,
the plasma ghrelin level was increased in STZ and atorvastatin alone treated
animals by 34 and 47%, respectively. Moreover, similar changes of IGF1 plasma
concentration were observed. In contrast, the co-administration of STZ and statin
decreased the IGF1 as well as ghrelin to the level observed in control group.
Thus, the obtained results clearly showed the anti-infammatory effect of
atorvastatin. Additionally, statin might be suggested as a factor promoting
protective effects of ghrelin and IGF1 during metabolic syndrome.
P515
Formation of neutralizing anti-human GH (hGH) antibodies does not
explain the lack of IGF1 increase after recombinant hGH treatment
in mice
Maximilian Bielohuby, Moritz Kummann & Martin Bidlingmaier
Medizinische Klinik - Innenstadt, LMU, Munich, Germany.
We previously have reported that short-term treatment of mice with recombinant
hGH leads to signifcant increases in bodyweight (BW), lean body mass (LBM)
and liver weight, but - unlike in humans - does not robustly increase circulating
levels of IGF1. We now tested the hypothesis that formation of neutralizing
antibodies in mice treated with rhGH could explain the lack of IGF1 response.
Therefore, we intentionally induced antibody formation against hGH in female
FVB mice by repeated immunization (6,) using rhGH and adjuvans (Titermax
Gold, Sigma). Subsequently, the 8 months old mice were treated with daily doses
of rhGH (Nordifex, Novo Nordisk, 0.5 mg/d i.p.) for 2 weeks. Age matched
control mice were sham immunized using adjuvans only prior to daily rhGH
treatment. Before start of rhGH treatment, BW was not signifcantly different
between groups, but rhGH immunized mice showed signifcantly higher anti-hGH
antibody titers (P,0.01). After 2 weeks of treatment, control mice had
signifcantly higher BW (control: 30.22.5 g, immunized: 262.4 g P,0.05),
LBM (control: 11.30.8 g, immunized: 9.50.9 g; P,0.05) and liver weights
(control: 1.770.15 g, immunized: 1.410.23 g; P,0.05) when compared to
hGH immunized mice. In contrast, serum IGF1 levels were not signifcantly
different between controls and immunized animals (controls: 44481 ng/ml,
immunized: 35653 ng/ml, P0.1). The IGF1 concentrations were in the range
we had seen in previous experiments in young mice treated daily with either the
same dose of rhGH or equal volumes of 0.9%NaCl for 2 weeks (rhGH-group:
48188 ng/ml NaCl-group: 45094 ng/ml). In conclusion, 2 weeks of daily
rhGH treatment in mice do not lead to signifcant formation of neutralizing
antibodies against rhGH. Intentionally induced anti-rhGH antibodies are capable
to block hGH effects on BW, LBM and liver weight, but have no effect on IGF1
levels obtained after rhGH treatment. These data suggest that formation of
neutralizing antibodies does not explain the lack of IGF1 response after rhGH
treatment in mice.
P51
The role of hbroblast grow factor 23 in vascular calcihcation
Bohumil Majtan
1,2
, Tatsuo Shimosawa
2
, Rika Saito
2
, Hong Wang
2
,
Shengyu Mu
2
, Fumiko Mori
2
, Yuzaburo Uetake
2
, Robert Holaj
1
&
Toshiro Fujita
2
1
3rd Medical Department, 1st Faculty of Medicine at Charles University and
General Teaching Hospital in Prague, Prague, Czech Republic;
2
Department
of Nephrology and Endocrinology, University of Tokyo, Tokyo, Japan.
Background
Patients in end stage chronic kidney disease suffer from vascular calcifcation
have high plasma level of phosphate SPO
2
4
7 and fbroblast grow factor 23
(FGF23). FGF23 is a newly identifed hormone that inhibits PO
2
4
reabsorption
and downregulates expression of vitamin D in kidney.
The aim of our work was to investigate the role of FGF23 in vascular calcifcation.
Methods
Aortic tissue and primary culture of vascular smooth muscle cells (VSMC) both
obtained from Sprague-Dawley rat were used during the experiment. Klotho
plasmid was frst transfected into VSMC and cultures were subsequently
cultivated in high (2.6 mmol) and low (1.4 mmol) phosphate buffer solutions.
Same medium was used for cultivation of aortic tissue. FGF23 was then added to
cultivation medium and expression of core osteoblast-like phenotype change
markers Pit-1 and Cbfa1 and involved transcription factors were examined.
Results
The expression of Pit-1 and Cbfa1 was upregulated by high PO
2
4
and reversed
after FGF23 application. This mechanism is MAPK dependent, both in vivo
(aortic tissue) and in vitro (Klotho transfected VSMC). Detailed results will be
presented.
Conclusion
We successfully downregulated the key osteoblast-like phenotype change
markers Pit-1 and Cbfa1, which are induced by high phosphate buffer, by
FGF23. This might demonstrate the possible protective effect of FGF23 in
vascular calcifcation.
Male reproduction
P51I
Gonadotrophins level in azoospermic patients in Plateau State
Abimibola Nanna, J A M Otubu & Patrick Dakum
Centre for Reproductive Health Research, Jos, Plateau State, Nigeria.
Background and objective
Azoospermia is the total absence of sperm cells from a patient semen sample. It
could be obstructive or non-obstructive and this is associated with chromosomal
defects, infections, gonadotrophins imbalance, etc. in the patient.
The objective of this study is to determine the prevalence of secondary testicular
failure in azoospermic patients in Plateau State as it is associated with
gonadotrophins.
Method
Eighty-six azoospermic infertile male patients attending the centre for
reproductive health research between 1995 and 2009 were selected for this
study and their personal history were also taken. Semen samples were collected
twice by masturbation within 6 weeks and analysed, using WHO laboratory
manual for the examination of human semen and sperm-cervical mucus
interaction. Subsequently their blood samples were collected for FSH, LH and
using enzyme immunoassay method, with automated serozyme, hormonal assays
results were obtained.
Results
Eighty-six azoospermic patients samples for semen and blood for FSH, LH were
studied. Thirty (35%) had high FSH and LH, 44 (51%) had high FSH and normal
LH, 5 (6%) had high FSH and below normal LH, 7 (8%) had normal FSH and LH.
Isolated increase in FSH and LH is 3524.7, 2410. Azoospermia patients with
normal FSH and LH, 51.3, 83.3. Below LH normal 0.51.0.
Conclusion
Ninety-two percent of the azoospermic patients studied had gonadotrophins
imbalance and this account for secondary testicular failure in these patients and
while 8% had normal gonadotrophins level (FSH and LH). Endocrinopathies are
common cause of azoospermia and account for higher percentage of secondary
testicular failure in azoospermia patients in Plateau State. The main reason for
endocrinopathies is not known but environmental factors, endocrine disruptors,
and genetic polymorphism have been suggested to be contributory.
P518
The case for comprehensive medical testing of gamete donors
Wendy Kramer
Donor Sibling Registry, Nederland, Colorado, USA.
The Donor Sibling Registry ('DSR`) is a non-proft worldwide organization
dedicated to educating, connecting and supporting those affected by gamete
donation, including donors, recipients and offspring. At 25 000 members, the
DSR has connected 7000 genetic frst degree relatives; hundreds of donors enjoy
contact with offspring and thousands of half-siblings interact together.
The DSR doesn`t just generate genetically related joy, it also shines light on
serious genetic concerns about gamete donation. Frequently the DSR counsels
recipients whose children have inherited undisclosed genetic disorders, or who`ve
discovered their donor was dishonest regarding health, or that the sperm bank
didn`t notify them about reported illness or amended the medical profle.
The number and severity of these health matters is discomfting. Since donors can
father many offspring (one DSR donor has more than 120 known offspring)
donors can transmit disease to scores of children.
Currently, many sperm banks either refuse to update donor/offspring medical
information, or even if they accept updates refuse to share the information, or
make the process of reporting so complex or expensive that donors and recipients
simply cannot comply or afford it.
Most sperm banks don`t carry out basic genetic screening techniques such as
karyotyping.
Recipients clearly need to be warned about hereditary disorders to prevent
unnecessarily sick children being born. To protect donors, recipients and offspring
the DSR is calling for the implementation of strict regulation, mandatory genetic
testing and the establishment of a central gamete donor registry run by an
independent authority.
P519
Exogenous gangliosides modulate cellular free radical production
Mirjana Gavella
1
, Vaskresenija Lipovac
1
, Mariastefania Antica
2
&
Verica Garaj-Vrhovac
3
1
Vuk Vrhovac University Clinic, Zagreb, Croatia;
2
Rudjer Boskovic
Institute, Zagreb, Croatia;
3
Institute for Medical Research and Occupational
Health, Zagreb, Croatia.
Recent studies have reported that gangliosides, the sialic acid containing
glycosphingolipids, are able to modulate many cellular functions. As reactive
oxygen species (ROS) in human semen originate from both spermatozoa and
infltrating leukocytes, we aimed to investigate i) the ability of gangliosides to
protect human spermatozoa from hydrogen peroxide (H
2
O
2
)-induced DNA and
membrane damage and ii) the effect of gangliosides on the production of ROS by
PMA-stimulated human polymorphonuclear neutrophils (PMN). Single-cell gel
electrophoresis (Comet assay) was used in the assessment of sperm DNA
integrity, Annexin V/PI staining was used to evaluate apoptosis after exposure to
H
2
O
2
, while fow cytometry using dichlorodihydrofuorescein diacetate dye
(DCFH-DA) was employed to measure intracellular ROS. Extracellular super-
oxide SO
(
2
7 production was investigated by SOD-inhibitable cytochrome c
reduction and EPR spectroscopy using DEPMPO spin trap. In vitro supplemented
GT1b (100 M) to the sperm suspension signifcantly reduced DNA damage
induced by 200 M H
2
O
2
(P,0.05), increased the percentage of live cells with
intact membrane (P,0.01) and decreased phosphatidylserine translocation after
exposure to H
2
O
2
. Flow cytometry analysis revealed that GT1b completely
inhibited the passage of H
2
O
2
through the sperm membrane. Experiments with
PMA-activated PMN showed that exogenously added mono- and trisialoganglio-
side GM1 and GT1b in a concentration of 100 M, which was above their
respective critical micellar concentrations, induced a signifcant delay (P,0.05)
in extracellular superoxide anion production. In addition, intracellular ROS
production was shown to be inhibited in the neutrophils pretreated with both
gangliosides. The results gave evidence that the attachment of gangliosides at the
surface of the cell protects human spermatozoa from DNA fragmentation and
increased apoptosis induced by exposure to H
2
O
2
. Furthermore, ganglioside
micelles added to neutrophils slowed down the uptake of PMA and consequently
activation of cells for O
(
2
generation. The observed phenomena can be attributed
to the ability of gangliosides to increase membrane diffusion barrier for toxic
oxidative agents and for stimulants responsible for triggering membrane events
leading to ROS production.
P520
Regulation of sperm EGFR by ouabain leads to initiation of the
acrosome reaction
Haim Breitbart, Limor Daniel-Dafna, Shirel Weiss, Debby Itzkovitz &
Nir Etkovitz
Bar-Ilan University, Ramat-Gan 52900, Israel.
It is well accepted that sperm acrosome reaction occurs after the binding of the
capacitated sperm to the egg zona-pellucida. This study describes a novel idea
regarding the regulation of the sperm epidermal growth factor receptor (EGFR)
under physiological conditions and the relevance to the acrosome reaction.
Ouabain, a known Na/K ATPase blocker is present in our blood and in the female
reproductive tract. We showed here for the frst time that physiological
concentrations (nano-molar) of ouabain enhance phosphorylation of EGFR on
tyr-845, stimulate Ca
2
infux and induce the occurrence of the acrosome
reaction in sperm. These effects could be only seen if very low concentrations of
EGF (0.1 ng/ml or 0.016 nM), were added together with ouabain. The three
processes are inhibited by EGFR blocker suggesting that trans-activation of the
EGFR is involved. Moreover, our data revealed that protein kinase A and the
tyrosine kinase Src, two known kinases involved in EGFR activation in sperm,
mediate the acrosome reaction induced by ouabain. Ouabain alone (without
adding EGF) at relatively high concentration (10 M) could enhance EGFR
phosphorylation, Ca
2
infux and acrosome reaction, and the three processes
were inhibited by EGFR blockers, further indicating that ouabain induce the
acrosome reaction by a mechanism mediated by the trans-activation of EGFR. In
conclusion, this study represents an interesting regulation of EGFR by
physiological concentration of ouabain and EGF found in the female reproductive
tract. None of these compounds can activate the EGFR when present at very low
doses, however when both are present, the interaction of ouabain with the Na/K
ATPase leads to the priming of the EGFR which undergoes its full activation
by EGF.
P521
Effect of melatonin in the phosphorylation of ERK42/44, P38 and
JNK46/54, and the expression of c-jun and c-fos in hamster Leydig cells
Soledad Rossi
1
, Maria Matzkin
1,2
, Ricardo Calandra
1
& Monica Frungieri
1,2
1
Institute of Biology and Experimental Medicine, CONICET, CABA,
Buenos Aires, Argentina;
2
School of Medicine, UBA, CABA, Buenos Aires,
Argentina.
Previously, we have described an inhibitory role of melatonin (Mel) in the
expression of StAR and key steroidogenic enzymes, as well as in the regulation of
testosterone production in testes of Syrian hamsters. The goal of the present work
was to further investigate the signaling pathway involves in the testicular action of
Mel. Thus, Leydig cells were purifed from reproductively active hamsters killed
by asphyxia with carbon dioxide, and incubated in the presence of Mel and
MAPK blockers. Subsequently, the expression of c-jun, c-fos, phospho-c-jun,
phospho-P42/44, phospho-P38 and phospho-JNK46/54 was evaluated by
quantitative PCR and/or immunobloting, and the levels of testosterone released
to the incubation media were determined by RIA.
Ten micromolar Mel signifcantly inhibited c-jun and c-fos expression after
30 min and 3 h incubation. Furthermore, we found a marked reduction in the
phosphorylation of c-jun, P42/44, P38, and JNK46/54 in the presence of Mel. In
addition, the incubation of hamster Leydig cells in the presence of blockers for
P42/44 (U0126, 10 M), JNK46/54 (SP600125, 20 M) and P38 (SB203580,
10 M) decreased the expression of c-jun and c-fos, and the production of
testosterone.
In conclusion, our studies described an inhibitory role of Mel in the
phosphorylation of c-jun, P42/44, P38, JNK46 and JNK54, and the expression
of c-jun and c-fos. These factors might act as mediators in the Mel-dependent
regulation of testosterone production in hamster Leydig cells.
P522
Effect of prolactin (PRL) and melatonin (Mel) in the regulation of
cyclooxygenase 2 (COX2) expression in Syrian hamster Leydig cells
Maria Matzkin
1,2
, Soledad Rossi
1
, Ricardo Calandra
1
& Monica Frungieri
1,2
1
Institute of Biology and Experimental Medicine, CONICET, CABA,
Buenos Aires, Argentina;
2
School of Medicine, CABA, Buenos Aires,
Argentina.
The Syrian hamster is a seasonal breeder that undergoes a testicular regression
when exposed to a short day photoperiod (SD, 6 h light per day) for 16 weeks, and
a subsequent gonadal reactivation after longer times of permanence in SD. In this
study, we investigated the role of melatonin (Mel) and prolactin (PRL), key
players in the recrudescence phase, on testicular cyclooxygenase 2 (COX2)
expression and prostaglandins (PGs) production during the photoperiodic
regression-reactivation transition. The number of COX2-immunoreactive Leydig
cells/mm
2
(COX2 LC) and the plasma levels of PRL were determined by
immunohistochemistry and RIA, respectively, in hamsters maintained in a long
day photoperiod (LD, 14 h light per day) or exposed to SD for 9, 12, 16, 22 and
28 weeks.
Furthermore, PRL signifcantly induced COX2 protein expression and PGF2
production in purifed Leydig cells from LD and 16SD hamsters, while Mel
inhibited COX2 mRNA expression. In conclusion, our results refect the
participation of PRL and Mel as modulators of COX2 expression and PGs
production during the photoperiodic-induced testicular active-inactive transition
in hamsters.
P523
The Moscow Study: a randomized, placebo-controlled, double-blind
trial of parenteral testosterone undecanoate on the prostate status and
blood count
George Mskhalaya
1
, Svetlana Kalinchenko
1
, Yuliya Tishova
1
,
Farid Saad
2,3
, Louis J G Gooren
4
& Erik J Giltay
5
1
Chair of Endocrinology, People`s Friendship University of Russia,
Moscow, Russian Federation;
2
Bayer Schering Pharma, Scientifc Affairs
Men`s Healthcare, Berlin, Germany;
3
Gulf Medical University School of
Medicine, Ajman, UAE;
4
Department of Endocrinology, VU University
5
Department of Psychiatry,
Background
For many years testosterone therapy in men was considered to be a risk factor for
increasing the PSA level and prostate volume as well as blood count parameters.
Objective was to investigate the infuence of testosterone therapy on prostate and
blood count in men with metabolic syndrome and hypogonadism.
Methods
In a randomized, placebo-controlled, double-blind, phase III trial (Clinical-
Trials.gov identifer: NCT00696748), 184 men suffering from both the metabolic
syndrome and hypogonadism (total testosterone level ,12 nmol/l) were
included. They were treated for 30 weeks with either parenteral testosterone
undecanoate (TU; 1000 mg testosterone undecanoate at baseline, and after 6 and
18 weeks; Nebido) or placebo. 105 (92.9%) men receiving TU and 65 (91.5%)
receiving placebo completed the trial. PSA total, red blood cells, hemoglobin and
hematocrit were measured, and prostate ultrasound was done before and after
30 weeks of treatment.
Results
The 184 men were aged between 35 and 70 years old, with a mean age of 51.6
(95% confdence interval (CI): 49.8-53.4) in the TU group and 52.8 (95% CI:
50.5-55.0) in the placebo group. In the Nebido group, levels of hemoglobin rose
signifcantly as did the red blood cell counts and the hematocrit, but values did not
exceed the upper limit of the reference range. In both the placebo group and the
testosterone treatment group values of PSA did not rise signifcantly. Prostate
volume did not increase over the treatment period. Levels of PSA and prostate
volume were not signifcantly different after 30 weeks in the men with
testosterone treatment compared to the placebo group.
Conclusion
Testosterone treatment in men didn`t lead to any change in prostate safety
parameters. Blood count monitoring should be performed in men receiving
testosterone treatment - dose adjustment may be required.
P524
Effects of testosterone supplementation on depressive symptoms and
sexual dysfunction in hypogonadal men with the metabolic syndrome:
the Moscow Study
Erik J Giltay
1
, Yuliya Tishova
2
, George Mskhalaya
2
, Louis J G Gooren
3
,
Farid Saad
4,5
& Svetlana Kalinchenko
2
1
Department of Psychiatry, Leiden University Medical Center, Leiden, The
Netherlands;
2
Chair of Endocrinology, People`s Friendship University of
Russia, Moscow, Russian Federation;
3
Department of Endocrinology, VU
University Medical Center, Amsterdam, The Netherlands;
4
Bayer Schering
Pharma, Scientifc Affairs Men`s Healthcare, Berlin, Germany;
5
Gulf
Medical University School of Medicine, Ajman, UAE.
Context
Low testosterone level in men is associated with the metabolic syndrome (MetS)
as well as with depressive symptoms, low vitality and sexual dysfunction.
Objective
To assess the effects of testosterone administration on these subjective symptoms,
which have not extensively been studied in hypogonadal men with the MetS.
Design: randomized, placebo-controlled trial. Setting: academic, ambulatory,
referral centre. Patients: 184 men suffering from both the MetS and
hypogonadism Intervention: 30 weeks with either parenteral testosterone
undecanoate (TU; 1000 mg i.m. testosterone undecanoate; NebidoR) or placebo
at baseline, and after 6 and 18 weeks. One hundred and fve (92.9%) men
receiving TU and 65 (91.5%) receiving placebo completed the 30 week trial.
The Beck depression inventory (BDI), Aging Males` symptoms (AMS) scale, and
international index of erectile function 5-item (IIEF-5) scale at baseline, 18 and
30 weeks were analyzed using multilevel analysis.
Results
The 184 men were aged mean 52.1 years old (S.D. 9.6; range 35-69), with a mean
body mass index of 35.5 kg/m
2
(S.D. 6.7; range 25.1-54.8), and a mean total
testosterone level of 8.0 nmol/l (S.D. 4.0). There were signifcant improvements in
BDI (mean difference versus placebo after 30 weeks: 2.5 points; 95%
confdence interval (CI): 0.9; 4.1; P0.003), AMS (7.4 points; 95% CI:
4.3; 10.5; P,0.001), and IIEF-5 (3.1 points; 95% CI: 1.8; 4.4;
P,0.001). The effects on the BDI, AMS, and IIEF-5 were strongest in men with
baseline total testosterone levels ,7.7 mmol/l (i.e. median value).
Conclusions
TU administration may improve depressive symptoms, aging male symptoms and
sexual dysfunction in hypogonadal men with the MetS. The benefcial effects of
testosterone were most prominent in men with the lowest baseline total
testosterone levels.
LD 9SD 12SD 16SD 22SD 28SD
COX2 LC 176.811.1 143.828.9 95.010.7 14.77.4 103.512.8 107.722.2
PRL (ng/ml) 17.22.7 4.61.8 0.70.1 0.40.03 2.40.9 6.81.1
P525
Total but not calculated free testosterone concentration is lowered in
young healthy South Asian men
Moushmi Biswas
1
, David Hampton
2
, Atilla Turkes
3
, Robert Newcombe
4
& Aled Rees
5
1
Department of Medicine, Royal Gwent Hospital, Newport, South Wales,
UK;
2
Department of Biochemistry, Royal Gwent Hospital, Newport, South
Wales, UK;
3
Department of Medical Biochemsitry and Immunology,
University Hospital of Wales, Cardiff, South Wales, UK;
4
Department of
Primary Care and Public Health Clinical Epidemiology Research Group,
Cardiff, South Wales, UK;
5
Centre for Endocrinology and Diabetes School
of Medicine Cardiff University, Cardiff, South Wales, UK.
Background and aim
Ethnic differences in testosterone concentrations may account for variation in the
prevalence of androgen-mediated disorders amongst different racial groups.
Previous reports in middle-aged subjects have either found no differences, or a
lowered TT and calculated free testosterone (CFT) in South Asian (SA) compared
with Caucasian men. In light of this uncertainty and to exclude any confounding
infuence of age we sought to determine the effect of ethnicity on TT and CFT in a
young population of healthy volunteers.
Methods
Following ethical approval, healthy males (age 20-40) of SA(n67) or Caucasian
(n67) origin were recruited. Subjects were excluded if they had a fasting plasma
glucose (FPG) 5.9 mmol/l, central obesity (waist circumference (wc)94 cm
(Caucasian) or 90 cm (SA)) or signifcant other disease. FPG, albumin, SHBG,
insulin and TT (mass spectrometry) were measured and CFT calculated by
Vermeulen`s formula. Insulin resistance was assessed by HOMA-IR.
Results
Subjects were well matched for age. TT was signifcantly lower in SA compared
with Caucasian males (16.3 nmol/l, 95%CI 9.3-28.6 (SA); 18.4 nmol/l, 95%CI
10.6-31.9 (Caucasian); P0.01) despite a lower BMI (23.2, 95%CI 18.4-29.2
(SA), 24.4, 95%CI 19.4-30.7 (Caucasian); P0.01) and wc (82.4 cm, 95%CI
73.2-92.8 (SA), 84.2 cm, 95%CI 74.8-94.7 (Caucasian); P0.04). HOMA-IR
was higher in SA men (1.92 (SA), 1.45 (Caucasian); P0.006) but CFT was not
different between groups (0.43 nmol/l, (SA), 0.437 (Caucasian); P0.73).
Adjusting for HOMA-IR, but not BMI or wc, partly attenuated the differences in
TT between groups.
Conclusions
TT levels are lower in young SA males than their Caucasian counterparts but this
is only partly explained by differences in insulin resistance. CFT may be a better
assessment method of androgen status in clinical practice.
P52
Effects of atorvastatin on male fertility
Hanae Pons-Rejraji
1,2
, Benoit Sion
1
, Florence Brugnon
1,2
,
Christine Artonne
1
, Gerald Gouby
3
, Genevie`ve Grizard
1,2
, Laurent Janny
1,2
& Igor Tauveron
4
1
EA975, Laboratoire Biologie de la Reproduction, UFR Medecine,
Universite Clermont 1, Clermont-Ferrand, France;
2
CHU Clermont Ferrand,
Ho`tel Dieu, Biologie de la Reproduction, CECOS, Clermont-Ferrand,
France;
3
Clermont-Ferrand, Delegation a` la Recherche Clinique & a`
lÌnnovation, Clermont-Ferrand, France;
4
CHU Clermont-Ferrand, Ho`pital
Gabriel Montpied, Service dèndocrinologie, Clermont-Ferrand, France.
Introduction
Dyslipidemia and impaired fertility are highly related. In animals, statin intake
reduces sperm parameters deterioration associated with hypercholesterolemia.
However, statin effects on human fertility are controversial. Their intake by
hypercholesterolemic patients could reduce circulating testosterone concentration
and sperm quality. While recommendations for cardiovascular prevention
advocate lowering total cholesterol and LDL-C, atorvastatin, the most prescribed
statin in France, is the subject of questions over its impact on male fertility.
Objective
This study aims to analyze the consequences on sperm parameters of atorvastatine
intake by normocholesterolemic subjects achieving lipids concentrations
recommended in secondary cardiovascular prevention.
Atorvastatin (10 mg/day) has been administrated per se to 17 men (24.40.9
years) with normal blood lipid and spermatozoa parameters during 5 months.
Blood lipids and hormones concentrations, conventional semen parameters
(WHO, 1999), functional markers of the genital tract, sterols levels in
spermatozoa and seminal fuid, sperm capacitation ability and acrosome
membrane integrity have been assayed before taking the treatment, after 5
months of treatment, and 3 months after its withdrawal.
Results
Atorvastatin signifcantly decreased circulating LDL-C and cholesterol concen-
trations (respectively 40 and 23%, P,0.0001), without affecting HDL-C
and triglycerides, reaching the targets for secondary prevention. The concen-
trations of gonadotropins and testosterone were not affected. Overall sperm
quality (concentration, mobility, sterols levels in spermatozoa and seminal fuid,
capacitation ability) was not affected. However, live spermatozoa percentage was
reduced by atorvastatin (8%, P,0.05). The seminal fuid concentrations of
-glucosidase was signifcantly decreased 3 months after ending the treatment
(P,0.01), as well as the proportion of spermatozoa having spontaneously lost
their acrosome (P,0.05).
Conclusion
The intake of atorvastatine, in secondary prevention conditions, signifcantly
affects epididymal functional marker and live spermatozoa proportion. However,
the low signifcance of differences measured is consistent with an absence of
clinically signifcant deleterious effects.
P52I
Tadalahl attenuates proliferation and transdifferentiation of prostatic
stromal cells indicating therapeutic potential for benignprostatic hyperplasia
Christoph Zenzmaier
1
, Gerold Untergasser
2
, Dominik Pernkopf
3
&
Peter Berger
1
1
Institute for Biomedical Aging Research, Austrian Academy of Sciences,
Innsbruck, Austria;
2
Department of Internal Medicine V, Innsbruck Medical
University, Innsbruck, Austria;
3
Department of Urology, Ludwig-Boltz-
mann Institute for Urology and Andrology, Hospital Hietzing, Vienna,
Austria.
Benign prostatic hyperplasia (BPH) is characterized by tissue overgrowth and
stromal reorganization primarily due to cellular proliferation and fbroblast-
to-myofbroblast transdifferentiation. Given the recently reported benefcial
effects of PDE5 inhibitors on lower urinary tract symptoms secondary to BPH this
study aimed to investigate the infuence of PDE5 inhibition on the prostate at a
cellular level. We investigated the expression of PDE5 in the human prostate and
demonstrated that PDE5 was mainly present in the stromal compartment of the
gland but absent from epithelium.
The effect of PDE5 inhibition on the prostate was thought to be mainly caused by
relaxation of smooth muscle lowering urethral pressure and thus affecting the
dynamic component of the disease. However, the infuence of PDE5 inhibition on
proliferation and stromal reorganization (i.e. myofbroblast/fbroblast ratio) has
not been investigated in detail.
To evaluate the potential of PDE5 inhibitors like Tadalafl for prevention and
treatment of BPH we analyzed the role of the NO/cGMP/PDE5 pathway for
cellular proliferation and transforming growth factor 1 (TGF1)-induced
fbroblast-to-myofbroblast transdifferentiation in primary prostate stromal cells
(PrSC). Inhibition of PDE5 by Tadalafl reduced proliferation of PrSCs and to a
lesser extent of primary prostate basal epithelial cells. Attenuated proliferation
due to elevated intracellular cGMP levels was verifed by application of the
membrane-permeable cGMP analog 8-Br-cGMP and inhibition of the cGMP
dependent protein kinase G by its inhibitor KT2358. Moreover, Tadalafl strongly
attenuated TGF1-induced fbroblast-to-myofbroblast transdifferentiation. The
inhibitory effect on transdifferentiation was also observed after siRNA-mediated
PDE5 knockdown. As confrmed by the MEK1 inhibitor PD98059 this effect was
mediated via MEK/ERK signaling.
We conclude that BPH patients might beneft from PDE5 inhibitors that inhibit
stromal cell proliferation as well as TGF1-induced transdifferentiation processes.
P528
Single nucleotide polymorphism (SNP) of endothelial nitric oxide
synthase (eNOS) gene (GLU298ASP VARIANT) in infertile men with
asthenozoospermia
Eddi Buldreghini
1
, Reda Z Mahfouz
2
, Arianna Vignini
3
, Ashok Agarwal
2
& Giancarlo Balercia
1
1
Department of Internal Medicine and Applied Biotechnologies, Umberto I
Hospital, School of Medicine, Polytechnic University of Marche, Ancona,
Marche, Italy;
2
Center for Reproductive Medicine, Glickman Urological
and Kidney Institute, & Ob-Gyn and Women`s Health Institute, Cleveland
Clinic, Ohio, USA;
3
Institute of Biochemistry, School of Medicine,
Polytechnic University of Marche, Ancona, Marche, Italy.
Objective(s)
Single nucleotide polymorphism (SNP) in endothelial nitric oxide synthase
(eNOS) G894T may affect the oxidative stress-response. Our objective was to
examine G894T SNP eNOS genotype frequencies and its potential role with
sperm motility in infertile men. Through this prospective controlled study in the
Andrology Unit, we have enrolled infertile (n70) and healthy (n60) men.
Sperm motion kinetics assessed by computer assisted semen analysis (CASA),
and allele-specifc polymerase chain reaction (PCR-RFLP) to investigate the
frequency of guanine (G) thymine (T) at position 894 within exon 7 of the
eNOS gene.
Finding(s)
An increased frequency of the G894T eNOS (T) allele observed in
asthenozoospermic patients (P0.02). In asthenozoospermic men, homozygotes
eNOS (TT) genotyping showed low percentages of rapid motile sperm (ab)
compared to wild-type eNOS (GG) (P0.02) or heterozygotes eNOS (GT)
genotyping (P0.01). In Fertile men, wild-type eNOS showed high percentages
of rapid motile sperm (ab) compared to eNOS (TT) (P0.03) or eNOS (GT)
genotyping (P0.04).
Conclusion(s)
Our fndings suggest that the T allele, encoding for aspartic acid, of the eNOS
(Glu298Asp) gene may play a role with low sperm motility.
P529
Infertility and low gonadotropin levels as the hrst sign of testicular
seminoma: a case report
Vladislav Volek
1
, Martin Hrivnak
2
& Dalibor Ondrus`
3
1
University Hospital of F. D. Roosevelt, Banska Bystrica, Slovakia;
2
Hospital Kosìce-S
`
aca, Kosìce-S
`
aca, Slovakia;
3
Medical Faculty, Komenius
University, Bratislava, Slovakia.
The case report demonstrates a case of a 31 years old patient referred to our
outpatient endocrinology clinic for suspicion for central hypogonadism.
He had undergone a frst line examination at a urology outpatient clinic for
infertility. His semen analysis showed azoospermia, palpation of the testicles did
nor reveal any abnormalities. Sex hormone levels were obtained where low
gonadotropin (LH and FSH) levels with total testosterone level within normal
range were noted.
Central hypogonadism as the possible reason for azoospermia and infertility was
suspected.
On clinical examination the patient appeared well virilised, gynecomastia was not
noticeable. Repeated blood samples confrmed low LH and FSH levels with total
testosterone level close to the upper limit of the normal range. Free testosterone
level was within normal range and so were the other pituitary hormones. Our
conclusion was that the patient did not have central hypogonadism and that the
low gonadotropins were a normal variant.
The patient was referred back to the urology outpatient clinic to search for the
testicular reason for azoospermia. Ultrasound examination revealed a small tumor
mass (1 cm in diameter) and high HCG plasma levels were obtained. The patient
underwent surgical removal of the right testicle. Histology revealed a seminoma
of the testis.
LH and FSH levels increased slightly above the upper normal limit shortly after
the surgery as the levels of HCG dropped. That is why we assume that
paraneoplastic HCG acted as the dominant gonadotropin hormone in the patient
and decreased the pituitary gonadotropin levels, while the testosterone level
remained unchanged.
Conclusion
It is very important to consider testicular tumors in young patients with low LH
and FSH levels, infertility and missing clinical sings of hypotestoteronemia.
P530
Congenital hypogonadotropic hypogonadism in men as a cause of
estradiol dehciency
Severine Trabado
1
, Luigi Maione
2
, Sylvie Salenave
1
, Stephanie Baron
1
,
Francoise Galland
1
, Antonio-Agostino Sinisi
2
, Sylvie Brailly-Tabard
1
&
Jacques Young
1
1
Univ Paris Sud 11-CHU Bice`tre-INSERM, Le Kremlin Bice`tre, France;
2
Endocrinology and Medical Andrology, Seconda Universita`di Napoli,
Napoli, Italy.
Context
Congenital hypogonadotropic hypogonadism (CHH), is a rare disorder associated
with severe testosterone defciency and with impaired bone mineral mass (BMM)
acquisition and osteoporosis. Estradiol (E
2
) play a major role in bone
development and maintain in BMM in humans.
Objective
To evaluate in detail the degree of E
2
defciency in adult men with CHH.
Design and patients
Using a sensitive E
2
assay, we measured serum total E
2
(TE
2
) and bioavailable E
2
(BE
2
) in 83 untreated CHH men (31.111.6 years (meanS.D.)) comparatively
to 63 similarly aged (34.011.4 years) normal men and to 33 subjects with
Klinefelter syndrome (34.511.8). In these three groups we also measured
SHBG and free E
2
(FE
2
).
Results
In CHH men, total E
2
(7.44.2 vs 17.66.6 pg/ml in controls; meanS.D.;
P,0.0001) and bioavailable serum E
2
(5.13.5 vs 13.75.7 pg/ml; P,0.0001)
as well as FE
2
(0.210.13 vs 0.590.23 pg/ml; P,0.0001) were very
signifcantly lower than in normal men and than in subjects with Klinefelter
syndrome (TE
2
: 16.07.2 pg/ml, BE
2
: 12.45.7 pg/ml and FE
2
: 0.53
0.22 pg/ml in the later respectively; P,0.01). Mean (S.D.) serum SHBG
concentrations were 28.210.3, 40.024.8 and 27.415.1 (nmol/l) in controls,
CHH and Klinefelter respectively. In CHH patients serum total E
2
was positively
correlated with serum total testosterone (r0.35, P,0.03). Finally, in CHH and
normal men taken on the whole, serum TE2 levels were very positively correlated
(R0.57; P,0.0001) with serum LH levels indicating a relationship between the
low E2 levels and the severity of LH-drived testosterone defciency in CHH.
Conclusion
Our data demonstrate that hypogonadism in CHH men is a condition clearly
associated with a deep E
2
defciency. The therapeutic relevance of these results
will be discussed.
P531
Prevalence and characterization of hypogonadism among men with
human immunodehciency virus infection: preliminary results
Vincenzo Rochira
1
, Giulia Brigante
1
, Daniele Santi
1
, Lucia Zirilli
1
,
Chiara Diazzi
1
, Gabriella Orlando
2
, Cesare Carani
1
& Giovanni Guaraldi
2
1
Department of Medicine, Endocrinology and Metabolism and Geriatrics,
University of Modena and Reggio Emilia, Modena, Italy;
2
Metabolic Clinic,
Infectious and Tropical Disease Unit, Department of Medicine, University
of Modena and Reggio Emilia, Modena, Italy.
Introduction
Among various comorbidities of human immunodefciency virus-1 (HIV-1)
infection, male hypogonadism is very frequent with a prevalence of 19% in
patients treated with highly active anti-retroviral therapy. However, literature data
are still lacking and achieved by studies with ,300 subjects each.
Aim of the study
Prevalence and clinical characterization of hypogonadism among a large number
of men with HIV-1.
Methods
Measurement of serum total testosterone, LH and FSH in 950 outpatients aged
20-69 years (mean age 45.5 years) attending the metabolic clinic of infectious
and tropical disease between 2005 and 2009.
Results
Mean serum total testosterone was 470.9205.5 ng/dl. Considering Endocrine
Society thresholds for hypogonadism, 15.7% of patients was hypogonadic
(T,300 ng/dl); (8% hypogonadotropic, 77.2% normogonadotropic and 14.8%
hypergonadotropic). According to thresholds proposed by the International
Society for the Study of the Aging Male (ISSAM) 23.7% of subjects resulted
hypogonadic (T,346 ng/dl) of which 5.8% was hypogonadotropic, 80%
normogonadotropic and 14.2% hypergonadotropic.
Conclusions
The prevalence of hypogonadism in HIV patients is comparable to that of older
healthy subjects (19.3% of hypogonadism in patients with mean age 58.7 years;
Schneider, Clin Endocrinol 2009) and is higher than in the general population.
Normogonadotropism predominance in subjects with hypotestosteronemia
suggests also a possible involvement of a pituitary dysfunction and/or
dysregulation as the underlying cause responsible for the development of
hypogonadism.
Endocrine Society
( ,300 ng/dI)
ISSAM
(,346 ng/dI)
Percentage of hypogonadism
(d hypogonadic/d total)
15.7% (149/950) 23.7% (225/950)
LH,1.4 mU/ml 8% (12/149) 5.8% (13/225)
1.4,LH,8.9 mU/ml 77.2% (115/149) 80% (180/225)
LH8.9 mU/ml 14.8% (22/149) 14.2% (32/225)
P532
Validation of salivary testosterone as a diagnostic test in the
hypothalamic~pituitary~gonadal axis diseases
Oscar Moreno-Perez
1
, Vi ctor Luis Gonzalez-Sanchez
1
, Luis Garci a de
Guadiana Romualdo
2
, Ruth Sanchez-Ortiga
1
, Roci o Alfayate Guerra
3
,
Monserrat Mauri Dot
3
& Antonio Miguel Pico Alfonso
1
1
Endocrinology and Nutrition Department, Hospital General Universitario,
Alicante, Spain;
2
Clinical analysis Department, Hospital Naval, Cartagena,
Spain;
3
Hormone Laboratory, Hospital General Universitario, Alicante,
Spain.
Introduction
Salivary testosterone (Sal-T) refects the plasma free testosterone fraction that can
fow passively through the salivary glands and appears to be a strong correlation
with the Calculated free testosterone (CFT) in both eugonadal and hypogonadal
men. Since the collection of saliva is simple, noninvasive and inexpensive, the
Sal-T is a promising tool for the screening of hypogonadism. Despite the initial
interest that Sal-T has aroused, new clinical studies are needed for validation.
Objective
i) To establish the reliability of the determination of Sal-T in the diagnosis of male
hypogonadism. ii) To determine the sensitivity and specifcity of Sal-T for the
diagnosis of hypogonadism in men using CFT as gold standard.
Methods
Cross-sectional study. Sequential sampling. Inclusion criteria: eugonadal men or
with clinical suspicion of hypogonadism. Sample size: 137 individuals. Statistical
analysis (SPSS 15.0.) Spearman correlation between CFT and Sal-T in the
different groups evaluated. Calculating sensitivity and specifcity of Sal-Tusing
CFT as gold standard.
Results
We studied 137 men: 123 eugonadal (age 18-44 years, BMI 243) 14
hypogonadal (age 18-77 years, BMI 243). The correlation between CFT and
Sal-T in eugonadal population was 0.53, while in hypogonadal population fell to
0.31. The Sal-T had a 36% of sensitivity and 98% of specifcity; positive
predictive value and negative predictive value were 63 and 93%, respectively.
Conclusions
i) Sal-T had a strong correlation with CFT in eugonadal population, being weak in
hypogonadal population. ii) Sal-T presented a high specifcity and low sensitivity
in the diagnosis of hypogonadism.
P533
Determination of the reference values of total testosterone, calculated
free testosterone, calculated bioavailable testosterone and salivary
testosterone in young, healthy population of the Mediterranean area
Vi ctor Luis Gonzalez-Sanchez
1
, Oscar Moreno-Perez
1
, Luis Garci a de
Guadiana Romualdo
2
, Pedro Sanchez Pellicer
3
, Monserrat Mauri Dot
2
,
Jose Sanchez Paya
4
& Antonio Miguel Pico Alfonso
1
1
Endocrinology and Nutrition department, Hospital General Universitario,
Alicante, Spain;
2
Clinical Analysis, Hospital Naval, Cartagena, Spain;
3
Hormone Laboratory, Hospital General Universitario, Alicante, Spain;
4
Preventive Medicine department, Hospital General Universitario, Alicante,
Spain.
Introduction
Free testosterone (FT) and bioavailable testosterone (BT), are better surrogate
markers of the androgenic status of the individual than total testosterone (TT).
Calculated FT (CFT) and calculated BT (CBT) which take into consideration the
kinetics of the bond between FT and albumin and SHBG, provide results
practically identical to those of the reference techniques. Salivary testosterone
(Sal-T) is a promising tool in the study of gonadal pathology. The interassay
variability justifes the need for each laboratory establish reference intervals for
these determinations.
Objective
To obtain reference values for TT, CFT, CBT, and Sal-T in healthy young
population in the Mediterranean area for the proper study of gonadal function in
our center.
Methods
Cross-sectional study. Sequential sampling. Inclusion criteria: healthy men,
18-30 years, BMI,30. Sample size: 127 individuals. Methodology: TT (ng/ml;
chemiluminescence immunoassay), CFT and CBT (ng/dl; Vermulen et al.), Sal-T
(pg/ml; RIA for TT in saliva specimen). Descriptive statistics (SPSS 15.0).
Results
We studied 127 eugonadal men, 243 years, SBP 11612 mmHg, DBP 69
8 mmHg, BMI 243. Hormonal reference values: TT 5.41.6 ng/ml
(P2.5 2.8-P97.5 9.6), CFT 11.1 ng/dl (P2.5 6.3-P97.5 22.2), CBT 281 ng/dl
(P2.5 143-P97.5 550) and Sal-T 94.2 pg/ml (P2.5 53.2-P97.5 195.8).
Conclusions
i) The reference values for healthy young population in the Mediterranean area for
TT are between 2.8 and 9.6 ng/ml, calculated Free-T 6.3-22.2 ng/dl, calculated
Bio-T 143-551 ng/dl and Sal-T 53.2-195.8 pg/ml. ii) It is necessary that each
laboratory validate the method and determine its own reference intervals in order
to establish reliable cut-off values in the diagnosis of hypogonadism.
P534
Blood pressure control and endothelial funtion in type 2 diabetes:
importance of nutritional educational program
Maria Chiara Masoni, Lorenzo Ghiadoni, Claudio Scarpellini,
Cristina Consani, Stefano Taddei, Elena Matteucci & Ottavio Giampietro
Internal Medicine Department, University of Pisa, Pisa, Tuscany, Italy.
Background
Achievement of blood pressure (BP) control is an important target in type 2
diabetic patients (T2DM) to prevent microvascular and macrovascular
complication. T2DM patients are characterized by endothelial dysfunction,
which represents a key mechanism for the development of atherosclerotic disease.
Aim
The aim of this study is to evaluate the effect of a nutritional and dietary
counseling on BP control and endothelial dysfunction in T2DM.
Methods
Nineteen T2DM patients (age 615 years, four females) were provided of a by a
2-day 24 h dietary recall at 1, 3, 6, 9 and 12 months. Blood pressure, endothelium-
dependent (fow-mediated dilation, FMD, after 5 min of forearm ischemia) and
independent (sublingual glycerol trinitrate, GTN, 25 g) vasodilation by high
resolution ultrasounds and computerized analysis of brachial artery diameter
(maximal % increase) were assessed at baseline and after 12 months. Twenty age
and gender matched healthy subjects were recruited as controls.
Results
At baseline T2DM had signifcantly (P,0.01) lower FMD (4.31.9%) and
FMD/GTN ratio (0.610.15) as compared to controls (6.92.1% and 0.91
0.22, respectively). Response to GTN was similar in T2DM (7.82.4%) and
controls (7.63.0%). After 12 months, there was a signifcant (P,0.01)
reduction in systolic BP (from 14517 to 1338 mmHg) and a not signifcant
reduction in diastolic BP (from 8512 to 789 mmHg, P0.06), HbA1c
(from 7.717 to 7.10.8%, P0.18) and plasma folate (from 6.18.4 to
11.48.5 mg/ml, P,0.001).
Number or dosage of antihypertensive drugs was increase in 25% of the study`s
patients.
FMD (5.92.9%) and FMD/GTN ratio (0.840.61), but not response to GTN
(7.41.7%) were also signifcantly (P,0.05) improved. However, the
improvement in FMD and FMD/GTN ratio was not related to changes in BP,
metabolic control, plasma folate concentration or pharmacological treatment, but
to sodium excretion reduction exclusively (r0.51, P,0.005).
Conclusions
A long term nutritional and dietary counseling have positive effect on dietary
behavior of T2DM patients resulting in a signifcant better BP control and an
improvement of endothelial dysfunction.
P535
Testosterone partially ameliorates metabolic prohle and erectile
responsiveness to PDE5 inhibitors in an animal model of male metabolic
syndrome
Linda Vignozzi
1
, Sandra Filippi
2
, Annamaria Morelli
1
, Aravinda
K Chavalmane
1
, Erica Sarchielli
3
, Gabriella B Vannelli
3
,
Edoardo Mannucci
4
& Mario Maggi
1
1
Sexual Medicine and Andrology Unit, University of Florence, Florence,
Italy;
2
Interdepartmental Laboratory of Functional and Cellular
Pharmacology of Reproduction, University
of Florence, Florence, Italy;
3
Department of Anatomy, Histology and
Forensic Medicine, University of Florence, Florence, Italy;
4
Diabetes
Section Geriatric Unit, Department of Critical Care, Florence, Italy.
Metabolic syndrome (MetS) is a clustering of cardio-metabolic risk factors
(hyperglycemia, hypertension, dyslipidemia, visceral fat accumulation) that is
also associated with hypogonadism and erectile dysfunction (ED). The study was
aimed at clarifying the relationships among MetS, hypogonadism, and ED, we
developed an animal model of MetS.
Methods
Male rabbits fed a high-fat diet (HFD), with or without testosterone (T)
supplementation, were compared with control rabbits (fed a standard chow) and
with rabbits made hypogonadal by a single injection of a long-acting GnRH-
analog, triptorelin.
Evaluation of metabolic disturbances (plasma glucose, cholesterol, triglycerides,
testosterone, LH, FSH level, glucose tolerance, mean arterial pressure, visceral fat
accumulation), and corpora cavernosa (CC) relaxant capacity (in vitro
contractility study) in HFD animals as compared with control, GnRH analog-
treated rabbits, and T-supplemented HFD rabbits.
Results
HFD rabbits showed all the features of MetS. HFD induced hypogonadotropic
hypogonadism is characterized by a reduction of plasma T, FSH, LH levels, testis
and seminal vesicles weight, and testicular steroidogenic enzymes. Such a
phenotype is similar to that induced by triptorelin administration. A reduced
GnRH immunopositivity in hypothalamus suggests a central origin of HFD-
related hypogonadism. HFD also induced penile alterations, as demonstrated by a
reduction of acetylcholine-and electrical feld stimulation-induced CC relaxation,
hyper-responsiveness to the NO donor, SNP, and unresponsiveness to PDE5
inhibitors. Similar penile alterations were observed in triptorelin treated rabbit. In
HFD, as well as in triptorelin treated rabbits, PDE5 and eNOS mRNA expression
quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) were
signifcantly decreased. T administration prevented almost all penile alterations
observed in HFD rabbits. T treatment dramatically reduced HFD-induced visceral
obesity, partially ameliorating also the metabolic profle.
Conclusion
We have developed an animal model of MetS associated with hypogonadotropic
hypogonadism and penile alterations including unresponsiveness to PDE5
inhibitors. T supplementation was able to partially revert HFD-induced
phenotype.
P53
Sexual dysfunctions in subjects with Klinefelter`s syndrome
Giovanni Corona
1,2
, Luisa Petrone
1
, Francesca Paggi
3
, Francesco Lotti
1
,
Valentina Boddi
1
, Alessandra Fisher
1
, Linda Vignozzi
1
,
Giancarlo Balercia
3
, Alessandra Sforza
2
, Gianni Forti
1
, Edoardo Mannucci
4
& Mario Maggi
1
1
2
Endocrinology
Unit, Maggiore-Bellaria Hospital, Bologna, Italy;
3
Endocrinology Unit,
Polytechnic University of Marche, Ancona, Italy;
4
Diabetes Section
Geriatric Unit, Department of Critical Care, University of Florence,
Florence, Italy.
Introduction
While the association of Klinefelter`s syndrome (KS) with infertility is well
known, very few investigations have evaluated the prevalence of sexual
dysfunction in KS. The aim of the present study is to systematically analyse
the prevalence of KS in a consecutive series of adult male patients consulting for
sexual problems and to investigate its specifc correlates.
Methods
Among a consecutive series of 1386 patients (mean age 48.912.7 years old), 23
(1.7%) subjects with KS were found.
Results
Patients with KS were younger and more often hypogonadal when compared to
the rest of the sample. Among patients with KS, 5 (22.7%) subjects reported
severe erectile dysfunction, 14 (60.9%) hypoactive sexual desire (HSD), 2 (9.5%)
premature and 2 (9.5%) delayed ejaculation. Only the association between KS and
HSD was confrmed after adjustment for age (HR3.2 (1.37-7.5)), however,
when patients with KS were compared with age, smoking habit, and testosterone
matched controls, even the association between KS with HSD disappeared. In
comparison to matched hypogonadal controls, subjects with KS had lower levels
of education, a higher frequency of cryptorchidism and poorer pubertal
progression.
Conclusions
Our results indicate that sexual symptoms eventually present in KS are not
specifcally associated with the syndrome but are due to the underlying
hypogonadal state. Further studies are needed to evaluate the effcacy of
testosterone substitution in ameliorating the hypoactive sexual desire often
reported in subjects with KS.
P53I
A case of partial androgen insensitivity syndrome with absence of breast
development
Andromachi Vryonidou
1
, Nikos Klonaris
1
, Alexandros Badila
1
,
Georgia Vasiliou
1
, Sofa Tagara
1
& Heraklis Poulias
2
1
Department of Endocrinology, Diabetes and Metabolism, Red Cross
2
Department of Urology, Red Cross Hospital,
Athens, Greece.
Introduction
Partial androgen insensitivity syndrome (PAIS) is a heterogeneous group of
intersex disorders arising from tissue resistance to androgen action due to
mutations of the androgen receptor. The phenotypic expression of the syndrome
varies considerably and external genitalia`s masculinization depends on residual
activity of the androgen receptor while gynecomastia is observed in most of
the cases.
Case report
We present the case of a 16 years old phenotypic female patient, who presented
with primary amenorrhea. Clinical examination revealed moderate hirsutism of
face and lower abdomen, normal axillary and pubic hair growth, complete
absence of breast development and clitoromegaly. Gynecological examination
revealed a blind vagina pouch. Hormonal evaluation revealed elevated serum
FSH and LH levels with normal serum estradiol while testosterone and DHT
levels were within the normal range for male adolescents. Ultrasound
examination of internal genitalia revealed the bilateral presence of testes at the
external opening of the inguinal canal. The karyotype from peripheral blood
lymphocytes was that of a normal male (46XY). The patient underwent bilateral
gonadectomy and then she was put on replacement therapy with conjugated
estrogens. A year later, she had a satisfactory breast development (Tanner 3) and
she underwent a vaginal widening in order to have a normal sexual life.
Conclusion
The possibility of partial androgen insensitivity syndrome (PAIS) should be
considered in any case of primary amenorrhea. Early diagnosis is important
because the risk of malignancy in intra-abdominal testes is high.
P538
Sexual and gonadal function in men after cardiac transplantation
Emmanuele Serra
1
, Stefano Serra
2
, Alessandro Oppo
1
, Francesca Atzeni
1
,
Antonello Cappai
1
, Maurizio Porcu
3
& Stefano Mariotti
1
1
Cagliari, Cagliari, Italy;
2
Andrology Unit, SantÈlena Hospital, Cagliari,
Italy;
3
Cardio-Thorax-Vascular Department, Azienda Ospedaliera Brotzu,
Cagliari, Italy.
Introduction
Gonadal and erectile function in patients submitted to heart transplantation has
not been previously investigated.
Aim of the study
To evaluate gonadal and sexual function in patients successfully submitted to
cardiac transplantation.
Fifty-two patients, aged 20-78 years (meanS.D.: 5415 years; range 20-78
years) transplanted 8865 (range 4-220) months before the present study. All
patients were in good haemodynamic compensation (86.5% in NYHA I and
13.5% in NYHA II class). Most patients (88.5%) were on antihypertensive drugs
and all patients were on immunosuppressive therapy. In all cases hormonal
parameters (LH, FSH, T total), lipid profle, sexual function (questionnaire IIEF)
and psychological status (MHQ questionnaire) were assessed. Statistical
evaluation was performed by
2
and by linear regression analysis.
Results
Overall erectile dysfunction (ED) prevalence was 71.1%, with a peak (90%) in
patients aged 60 years, while that of hypogonadism (Hypo: T total ,3 ng/ml)
was 34.6% with a peak (70%) in patients aged 50-59 years. ED prevalence
was signifcantly correlated only to depression (as assessed by MHQ) and
antihypertensive therapy. Hypo was signifcantly correlated to prednisone therapy
and triglyceride levels. The highest prevalence of Hypo was observed in the frst
4 years after transplantation, independently from the patients` age, possibly as a
consequence of higher doses of prednisone in immunosuppressive therapy. No
signifcant correlation was found between ED and T levels.
Conclusions
The prevalence of Hypo and ED in patients submitted to heart transplantation is
very high, in spite of good haemodynamic results. Main factors involved appear
to be anti-hypertensive therapy and psychological factors for ED, and prednisone
therapy and dyslipidemia for Hypo. The lack of correlation between ED and Hypo
indicates that low T does not play a major role in sexual dysfunction of these
peculiar patients.
P539
Partial androgen insensitivity may be the reason for impaired fertility
in men with Noonan Syndrome
Jovanna Dahlgren, Carina Ankarberg-Lindgren & Otto Westphal
Institution of Clinical Sciences, Goteborg, Sweden.
Background
Some previous reports point out undescended testes (UT) to be the main course of
impaired fertility in males with Noonan syndrome (NS). Whether abnormities in
gonadal function are present during prepuberal years or appear during pubertal
development has not been investigated previously.
Objective
To study the gonadal development during prepubertal and pubertal years in NS
males.
Patients
Twelve short NS males were followed from prepubertal years (median age 11,
range 10-12) throughout puberty until adulthood (median age 21 years, range
18-29). Bilateral UT was found in four and unilateral UT in one male. All of these
except one were surgical treated before start of puberty. The NS group was
compared with an age-matched male reference population.
Methods
Gonadotrophins, testosterone, estradiol and inhibin B concentrations were
determined by immunoassays and testicular volume by orchidometer.
Results
Only one of four adult NS males who underwent bilateral surgical treatment of UT
had normal testicular volumes. All males with bilateral UT had at adult age
elevated LH and FSH levels compared with the spontaneous descended group
(median 10.9 and 25.8 U/l vs 4.4 and 5.1 U/l, P,0.01) and compared with the
reference population (4.0 and 2.5 U/l, P,0.05). Inhibin B reached a peak level
during early to mid-puberty in all NS males, but to a lower level in the bilateral
UT-group compared to descended group (116 vs 227 pg/ml, P,0.01), and
declined to subnormal concentrations at adulthood (23 vs 139 pg/ml, P,0.001).
Conclusion
As previously reported, bilateral UT was found to be the main factor contributing
to impaired gonadal function in a substantial minority (30%) of NS males.
Interestingly, this was unrelated to whether surgery was performed at a young age
and to the achievement of normal testicular volume.
P540
Can high radioactive contamination possibly inuence frequency of
androgen receptor mutation?
Anastasiya Hlazkova, Viachaslau Vashchula, Serhey Nikanovich &
Denis Orlov
Belarussian Medical Academy of Post-Graduate Education, Minsk, Belarus.
In presence of androgen gene mutation, leading to androgen insensitivity because
of an impaired regulatory mechanism of the gonadotropin-androgen axis, both
LH and T in serum may be elevated, leading to a distinctively high value of the
LH,T multiplication product, which has been termed as the androgen sensitivity
index (ASI). The aim of our present study was to investigate a cohort of young
males for impaired ASI. One hundred and seventy-seven nearly healthy post-
pubertal boys at the age of 16 up to 26 years old, permanently living on the
territory of the Republic of Belarus (53- in Stolin region and 124 in Minsk), were
examined to evaluate their physical, sexual and hormonal state (TSH, FSH, T,
free T, PRL, SHBH, E
2
). ASI has been calculated according to the standard
formula, the normal range reported by Hiort et al., ranging from 1.930-
39.970 ng IU/l
2
(mean, 15.590 ng IU/l
2
), was used for comparison. Stolin region
has been contaminated after the Chernobyl catastrophe in 1984, till now high
radioactivity levels are registered there. Elevated ASI index (39.970 ng IU/l
2
)
has been determined in 25.4% (45/177) of all examined, in Minsk region it has
been elevated only in 12.1% (15/124) and in Stolin region in 56.6% (30/53).
Conclusion
Further studying, including molecular genetics analyses should be done in order
to prove presence of androgen receptor gene mutation and it`s spontaneous,
radiation induced genesis. But signifcant difference in frequency of impaired ASI
in two compared regions allows us to suspect possible radioactive infuence.
P541
The effect of undecanoat testosterone depot on the prostate volume
Dan Peretianu
1
, Mara Carsote
2
, Alexandrina Clodeanu
1
, Dana
Cristina Staicu
1
, Corina Chirita
3
, Cristina Ene
3
, Valentin Radoi
2
&
Catalina Poiana
2,3
1
SCM Povernei, Bucharest, Romania;
2
Carol Davila University of Medicine
and Pharmacy, Bucharest, Romania;
3
CI Parhon National Institute of
Endocrinology, Bucharest, Romania.
Introduction
Testosterone therapy in elderly is controversial, because of the effect on prostate.
The old age itself is not a contraindication in the therapy of hypogonadism.
Aim
We analyze the effect of 24 months of therapy with testosterone undecanoat depot
(1000 mg/4 ml) (TUD) on the volume of the prostate (VP).
Patients and method
The patients were 79 symptomatic hypogonadic men, with normal value of PSA
(,4 g/l). The urologic consult detected no prostate cancer. No contraindication of
testosterone therapy was diagnosed. VP was appreciated by per-abdominal
ultrasound, with a probe of 3.5 MHz, expressed by elliptical volume (cm
3
). The
statistics analyze was performed by Student`s t-test.
Results
The patients were divided into seven groups according to their age (18-29, 30-39,
40-49, 50-59, 60-69, 70-79, and 80-89 years). The VP was measured at baseline
and after14 days, 3, 6, 12, and respective 24 months of therapy. The initial VP
increased with age, with statistically signifcant changes between the seven
groups (P,0.5).
The differences between the variations of VP during TUD were analyzed for each
group and then compared between them. For the frst fve younger groups there
were no statistically signifcant differences, suggesting that correctly selected
patients may continue the therapy for a long time. Statistically signifcant
differences were found between the group 6 and all the others groups only at
14 days and 3 months of therapy, suggesting that for the patients aged between 70
and 79 years, after an initial increase, the VP had no major changes for 24 months.
The only different phenotype was found in the oldest group, where statistically
signifcant differences were found at every evaluation.
Conclusions
The effect of TUD on the prostate is important to be analyzed, providing data that
assure safety during a long time treatment.
P542
Initial characterization of the human seminal plasma proteome in a
fertile normogonadic man by top-down strategy
Domenico Milardi
1
, Federica Vincenzoni
3
, Giuseppe Grande
2
,
Giampietro Antonella
1
, Alfredo Pontecorvi
2
, Massimo Castagnola
3
,
Laura De Marinis
2
& Riccardo Marana
1
1
Department of Gynecology and Obstetrics, International Scientifc Institute
Paolo VI, Catholic University, Rome, Italy;
2
Catholic University, Rome, Italy;
3
Institute of Biochemistry and Clinical
Biochemistry, Catholic University, Rome, Italy.
Human seminal plasma contains a large array of proteins required for the normal
physiology of spermatozoa and fertilization. To provide informations about the
physiological mechanisms of male fertility we performed proteomic studies on
human seminal plasma by a top-down approach. A semen sample was collected in
a fertile normospermic man (sperm concentration 60,10
6
per ml; progressive
motility 58%; normal morphology 45%). Hormonal blood assay was performed:
testosterone 4.5 ng/ml (n.r. 3.5-8.0), estradiol 25 pg/ml (n.r. 20-40), LH 4.1 UI/l
(n.r. 2.5-10.0), FSH 3.2 UI/l (n.r. 2.5-8). An aliquot of seminal plasma was mixed
(1:40) with aqueous trifuoroacetic acid (TFA/H
2
O 0.2% v/v), and centrifuged.
The upper acidic supernatant was analyzed by an Ultimate 3000 Nano/
Micro-HPLC apparatus (Dionex, Sunnyvale, CA, USA) equipped with an
FLM-3000-Flow manager module coupled to an LTQ Orbitrap XL apparatus
(Thermo Fisher). The column was a Dionex C18 with 3 m particle diameter. The
chromatography eluents were A TFA/H2O 0.056% (v/v) and B CH3CN0.050%
TFA. The applied gradient was linear from 0 to 50% of solvent B in 60 min, at
fow rate of 4.5 l/min. The LTQ-Orbitrap mass spectrometer was operated in
data dependent mode in which each full MS scan (60 000 resolving power) was
followed by three MS/MS scans. The most abundant molecular ions were
dynamically selected and fragmented by collision-induced dissociation (CID)
using a normalized collision energy of 35%. Tandem mass spectra were searched
against the Swiss-Human.fasta database using SEQUEST (Proteome Discoverer
software, ThermoFisher). The results were fltered using the following criteria:
XCorr versus charge 1.8, 2.5, for 2, 3ions; mass accuracy 3 ppm; high value
peptide confdence. A total of 63 proteins were identifed in seminal plasma.
Based on the molecular function and biological process of the proteins, 18 were
classifed as sperm structural, 16 as secreted (14 of vescicular-prostatic and 2 of
epidydimal origin), 15 as testicular or sperm regulatory, 5 as sperm movement
proteins. Five proteins didn`t present known molecular function. This report is the
frst identifcation, based on new approach and stringent criteria, of seminal
plasma proteome in a man. Proteomics may give new insight about the molecular
mechanisms of reproduction and may permit the identifcation of molecular
markers in infertile patients.
P543
Serum INSL3 dynamics in young men with congenital hypogonado-
tropic hypogonadism treated with gonadotropins
Giuseppe Bellastella, Dario Esposito, Luigi Maione, Daniela Visconti,
Vincenzo Palumbo, Annamaria De Bellis, Antonio Bellastella
& Antonio Agostino Sinisi
University of Napoli, Napoli, Italy.
Insulin-like factor 3 (INSL3) is produced by Leydig cells. In boys, the levels of
INSL3 rise at pubertal stage P2 and further increase throughout puberty in close
correlation with T and LH concentrations. In men with hypogonadotropic
hypogonadism (HH) INSL3 levels have been found very low and increased after
short-term hCG treatment. Whether FSH plays a role in regulating INSL3
secretion is questioned. Aim of this study was to evaluate serum INSL3 levels
during long-term hCG and rFHhCG replacement therapy in men with HH.
Methods
Eighteen men (18-24 years old) with never treated prepubertal-onset HH received
2000 IU i.m. hCG to induce puberty. After 6-12 months, they were treated with
hCG plus rFSH (75 IU) twice a week. Serum INSL3 levels were assessed at
diagnosis and every 3 months throughout gonadotropin replacement therapy.
Results
INSL3 levels, low at diagnosis (33.35.4 pg/ml), signifcantly rose to 45353.1
(P,0.001) after 6-12 months of hCG alone, when near all patients reached
pubertal stage P3. A further signifcant increase was observed after 3 and 6
months of rFSHhCG administration (532.556.3 and 601.258.1, respect-
ively, P,0.04-0.07).
Conclusions
INSL3 concentration increases progressively under hCG therapy paralleling the
pubertal changes induced in men with HH. A further rise of INSL3 levels during
the combined rFSH and hCG administration suggest a positive effect of FSH on
Leydig cell secretion.
P544
Testosterone replacement therapy isn`t always contraindicated after
prostate cancer treatment: case report
Rachel Smith, N Karavitaki & John Wass
Department of Endocrinology, OCDEM, Churchill Hospital, Oxford, UK.
We present the case of a 62 year old gentleman who was diagnosed with
Acromegaly in 1998.
He commenced testosterone replacement therapy in the form of Sustanon every
three weeks in October 2000 following a testosterone level of 6.6 nmol/l.
PSA levels during treatment with Sustanon were: 01/03/01-5.1g/l.
06/04/01-4.9 g/l at which point he was referred for a urological opinion.
On the 13/02/02 he underwent prostate biopsies which were benign.
Sustanon was stopped August 2002.
PSA on the 14/11/02 was 5.3 g/l. More biopsies were taken which showed
Gleason 336 carcinoma stage T1c.
He commenced radical radiotherapy which was completed on the 30/05/03 - total
dose of 55Gy in 20 daily fractions.
PSA on the 19/09/03 was 1.0 g/l with a morning testosterone of 5.2 nmol/l.
Therefore he commenced Testogel 25 mg daily in November 2003 with 3
monthly PSA levels.
PSA levels have ranged from 0.6 to 1.0 g/l up to the present day with no cancer
recurrence.
In February 2009 he changed to Tostran 30 mg daily and continues to have
ongoing follow-up with the urologist and oncologist.
A literature review was undertaken exploring testosterone replacement therapy
following treatment for prostate cancer, and concluded that testosterone therapy
can be considered after radical treatment of prostate cancer by prostatectomy.
Conclusion
Testosterone replacement therapy isn`t always contraindicated forever, in patients
who have had prostate cancer.
Neuroendocrinology and Pituitary (Generaas/y sapparted by
Narart/s)
P545
Prothrombin time, activated thromboplastin time, hbrinogen, and
D-dimer levels, and von Willebrand activity of patients with Sheehan`s
syndrome and the effect of hormone replacement therapy
Semir Pasa
1
, Abdullah Altintas
2
, Cemil Tumer
3
& Mstafa Demircin
4
1
Ozel Dunya Tip Merkezi, Ergani, Diyarbakir, Turkey;
2
Van Devlet
Hastanesi, Van, Turkey;
3
Mustafa Kemal Universitesi, Hatay, Turkey;
4
Ergani Devlet Hatanesi, Ergani, Diyarbakir, Turkey.
Increased mortality due to atherosclerotic cardiovascular disease has been
described in adult patients with hypopituitarism, although the precise underlying
mechanisms remain undetermined. Various abnormalities of coagulation and
fbrinolysis occur in patients with thyroid diseases. Conversely, there are
conficting reports concerning the effects of growth hormone replacement on
coagulation and fbrinolytic pathways in adults with hypopituitarism, and there
are limited data on the effects of hypocortisolism on the thrombotic and
fbrinolytic systems. Similarly, controversial data were also reported in studies
evaluating the effects of estrogen replacement therapy on cardiovascular events
and on coagulation factors in post-menopausal women. The aim of this presented
study was to investigate the effects of Sheehan`s syndrome (SS), which is a
common cause of hypopituitarism on hemostatic factors and to assess the effects
of hormone replacement therapy (HRT), including L-thyroxine, prednisolone, and
conjugated estrogen/medroxyprogesterone acetate, on these coagulant factors.
Prothrombin time (PT), activated partial thromboplastin time (aPTT), fbrinogen,
and D-dimer levels, and von-Willebrand factor (vWF) activity were studied in 32
patients with SS and 35 age-matched healthy female control subjects (CS).
Decreased PT and aPTT, increased fbrinogen and D-dimer levels, and similar
vWF activity were determined in patients with SS as compared with CSs. In
addition, it was found that HRT did not signifcantly affect these coagulation
factors, apart from the fbrinogen level.
P54
Plasma agouti-related peptide (AgRP) levels in male patients with
hypogonadotropic hypogonadism
Hakan Demirci
1
, Arif Yonem
2
, Gunay Gozum
3
& Metin Ozata
2
1
Division of Internal Medicine, Gulhane School of Medicine, Istanbul,
Turkey;
2
Division of Endocrinology and Metabolism, Gulhane School of
Medicine, Istanbul, Turkey;
3
Hipokrat Biochemistry Laboratory, Istanbul,
Turkey.
Objective
Agouti related peptide (AgRP), the endogenous antagonist of the melanocortin 3
and 4 receptors, is expressed at high levels in the arcuate nucleus of the
hypothalamus. Some studies have demonstrated that intracerebroventricular
AgRP administration increases plasma LH, FSH, testosterone levels. It also
increases hypothalamic LHRH release in vitro, an effect that can be prevented by
addition of melanocyte stimulating hormone. These fndings suggest that AgRP
may play a role in the control of the hypothalamo-pituitary gonadal axis. Our aim
in this study was to investigate plasma AgRP levels in male hypogonadal patients.
Thirty males with hypogonadotropic hypogonadism were included in this study.
Twenty healthy male subjects were served as controls. A thorough physical exam
was performed in all participants. After an overnight fasting, blood samples were
drawn, centrifuged and studied collectively. Serum total and free testosterone,
FSH, LH, cortisol, free thyroxine, thyroid stimulating hormone, prolactin, and sex
hormone binding globuline were measured using by radioimmunoassay method.
Plasma AgRP levels were measured with a commercial ELISA kit.
Results
Serum testosterone and gonadotropin levels differed signifcantly between
patients and controls (P,0.001). Plasma AgRP levels of the patients (3.28
0.32 ng/ml) were found to be lower than those of controls (4.640.28 ng/ml)
(P,0.01).
Conclusion
This is the frst study that investigates plasma AgRP levels of male patients with
hypogonadotropic hypogonadism. Our limitations were small sample size and no
dynamic investigation. However, this study showed that there might be a relation
between AgRP and androgenic hormone defciency. It should be done more
comprehensive and prospective studies to draw a clearer conclusion on this
subject.
P54I
Ghrelin and leptin levels in acromegalic patients treated with
pegvisomant
Josefne Roemmler
1
, Baerbel Otto
1
, Arafat Ayman
2
, Bidlingmaier Martin
1
& Schopohl Jochen
1
1
Medizinische Klinik - Innenstadt, University, Munich, Germany;
2
Charite-
University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany.
Introduction
GH rises dose dependently during treatment with the GH receptor antagonist
pegvisomant. Ghrelin stimulates GH secretion. In de novo acromegalic patients
with high GH levels, ghrelin levels are lowered and fat mass is reduced. Leptin
levels are positively correlated to fat mass. We performed this cross-sectional
study to evaluate whether elevated endogenous GH in acromegalic patients on
pegvisomant treatment (peg) reduces ghrelin and leptin levels.
Methods
Ghrelin, leptin, endogenous GH, glucose, insulin and IGF1 were measured in 10
peg (3f/7m, median age 47 years (28-57)). Ten gender-, age- and BMI-matched
healthy volunteers (controls), 10 acromegalic patients with active (act) and 10
with inactive disease (inact) without medication for acromegaly referred to as
control groups. Endogenous GH was measured by special in-house assay without
interference with pegvisomant, total ghrelin by a commercial radioimmunoassay,
leptin by an immunfuorometric in-house assay and IGF1 by an automated
chemiluminescent immunoassay.
Results
Age, BMI, glucose and insulin did not differ between groups. IGF1 was
signifcantly higher in act (983 g/l (306-1560)) than in the other groups (peg:
178 g/l (95-680), controls 111 g/l (90-234), inact 160 g/l (66-383),
P,0.005). Endogenous GH was signifcantly higher in peg (6.3 g/l (1.5-41))
and act (9.3 g/l (1.7-70)) compared to controls (0.1 g/l (0.1-3.1)) and inact
(0.35 g/l (0.1-2.0), P,0.001). Ghrelin was signifcantly higher in peg (232 ng/l
(96-351)) compared to act (102 ng/l (33-232), P,0.01), whereas ghrelin was not
signifcantly different between the other groups. Leptin was the highest in controls
(19 g/l (4-57)) and the lowest in act (6 g/l (2-21)), but this difference did not
reach signifcance.
Conclusion
High endogenous GH in pegvisomant treated patients does not reduce ghrelin
levels, whereas ghrelin is lowered in act. GH receptor seems to play a crucial role
in the physiological regulation of ghrelin and GH.
P548
Evaluation of adrenal morphological and functional alterations in
acromegalic patients
Theodora Pappa
1
, Labrini Papanastasiou
1
, Vaios Tsiavos
1
,
Ermioni Tseniklidi
1
, Ioannis Androulakis
1
, Panagiotis Tsounas
1
,
Peggy Roussaki
2
, Gregory Kaltsas
2
& George Piaditis
1
1
Department of Endocrinology and Diabetes, General Hospital of Athens
'G. Gennimatas`, Athens, Attika, Greece;
2
Division of Endocrinology,
Department of Pathophysiology, Laiko University Hospital, Athens, Attika,
Greece.
Introduction
Acromegaly is well known to induce hypertrophy and hyperplasia in many
organs, i.e. thyroid gland, colon, prostate. This action is presumably exerted by
the elevated GH and IGF1 levels. In our study, we investigated the alterations of
the adrenal glands seen in acromegaly.
Aim
To assess the changes in adrenal morphology and functional status in a series of
patients with acromegaly.
Fifty-four acromegalic patients, 24 men and 30 women, mean aged 52 years old,
hospitalised in our Endocrinology Department in the time period 2004-2009,
were evaluated. The mean time from diagnosis of acromegaly was 4.9 years.
Computed tomography (CT) of the adrenals was performed in all studied subjects
to investigate adrenal morphology. In addition, patients underwent hormonal
evaluation of the anterior pituitary and adrenal glands as well as dynamic testing
procedures (oral glucose tolerance test, low dose dexamethasone suppression test
(LDDST)) to assess disease activity and adrenal function. Normal cut-off levels
for cortisol after LDDST and baseline aldosterone/renin ratio were developed
using the 97th percentile values of a control group with 72 non-acromegalic
subjects with normal adrenal CT, i.e. 35 nmol/l and 78 pg/ml/mIU/l respectively.
Results
Twenty-three of 54 patients (42.6%) showed morphological alterations in the
adrenal CT, i.e. hyperplasia or adenoma. Fourteen patients (25.9%) were found to
have autonomous cortisol secretion using the LDDST, whereas 13 subjects
(24.1%) had autonomous aldosterone secretion using the baseline aldosterone/
renin ratio. No correlation was found between IGF1 levels, refecting disease
activity, and altered adrenal morphology and function.
Conclusion
In this study, we report an increased prevalence of morphological and functional
changes in the adrenal glands of acromegalic patients. Further controlled studies
are needed to validate these observations.
P549
IGF(CA)19 and IGFBP-3-202A/C gene polymorphism in patients with
acromegaly
Fulya Akin
1
, Sebahat Turgut
2
, Bayram Cirak
3
& Raziye Kursunluoglu
2
1
Department of Endocrinology, Pamukkale University, Denizli, Turkey;
2
Department of Physiology, Pamukkale University, Denizli, Turkey;
3
Department of Neurosurgery, Pamukkale University, Denizli, Turkey.
Aims
We aimed to investigate IGF1 and IGFBP3 gene polymorphisms in patients with
acromegaly.
Methods
We included 34 patients with acromegaly and 37 healthy subjects to study.
At baseline examinations, antropometric measurements were done. Genomic
DNA from the patients and controls were prepared. Serum, glucose, insulin, total
cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, GH, IGF1 and
IGFBP3 levels of subjects were analyzed.
Results
The frequency of genotype IGF1(CA)19 and IGFBP3-202 A/C gene was
signifcantly different between control and patients. In acromegalic patients, a
signifcant difference in the serum IGF1 levels and LDL cholesterol levels among
the three IGF(CA)19 genotype. LDL levels were positively correlated with IGF1.
Subjects having 194 bp genotype had higher IGF1 and LDL cholesterol
levels.We observed that the patients with 194 bp genotype have more invasive
and bigger tumors and they require adjunctive therapies. Clinical characteristics
among the three IGFBP3-202 A/C genotype, AA, AC and CC, did not display any
signifcant difference.
Conclusion
In our study, 194 bp allele (20 CA repeats) of the IGF1 promoter have higher
circulating IGF1 levels than others. We have found that the patients with 194 bp
genotype are the resistant patients with active disease and they required high dose
medication. We think this study will help to defne the patients, who are resistant
to drug therapy, and possible cardiovascular disease.
P550
Angiotensin converting enzyme I/D and M235T angiotensinogen gene
polymorphism in patients with acromegaly
Sebahat Turgut
1
, Fulya Akin
2
, Raziye Kursunluoglu
1
& Gunfer Turgut
1
1
Department of Physiology, Pamukkale University, Denizli, Turkey;
2
Department of Endocrinology, Pamukkale University, Denizli, Turkey.
Background
Acromegaly is associated with increased morbidity and mortality from
cardiovascular disease. Hypertension is a number of common cardiovascular
risk factors in acromegalic patients. The aim of this study was to investigate
association between the frequencies of angiotensin converting enzyme (ACE) I/D
and angiotensinogen (AGT) M235T polymorphisms, the genes belongs to the
renin-angiotensin-aldosterone system, and clinical parameters of acromegaly
patients.
Methods
Total of 33 acromegalic patients and 63 controls were enrolled ttto study. We
determined the ACE I/D and AGT M235T gene polymorphism. Serum insulin,
glucose, triglyceride, HDL-cholesterol, LDL-cholesterol, GH and IGF1 levels of
subjects were analyzed.
Results
Distribution of I/D polymorphism of the ACE in acromegaly patients and controls
were as follows: 57.6% DD, 33.3% ID, 9.1% II genotype, whereas in control
group, 50.8% DD, 42.9% ID, 6.3% II genotype. AGT M235T genotypes
distributed in patients and controls were as follows: 12.1% MM, 63.6% MT,
24.2% TT patients and 19%MM, 60.3% MT, 20.6% TT healthy subjects.
The frequency of genotype ACE and M235T AGT gene was not signifcantly
different between control and patients. In acromegaly patients, clinical
characteristics among the three ACE genotype, DD, ID and II, did not display any
signifcant difference. A signifcant difference in the serum systolic blood pressure
and IGF-I levels among the three AGT genotype, MM, MT and TT genotypes was
found in patient group. In MT genotypes individuals systolic blood pressure and
IGF-I levels was found signifcantly higher than MM and TT genotypes with
subjects, P,0.05. In addition, triglyceride and HDL levels between MM and MT
genotypes differed signifcantly, P,0.05.
Conclusions
It can be say that angiotensinojen gene genotypes carriers may have more risk
than other genotypes individuals for development hypertension in acromegaly.
P551
Combined endoscopic and pharmacologic treatment of a suprasellar
arachnoid cyst associated with macroprolactinoma
Jean-Yves Fournier, Stefan Bilz, Kathrin Schimke, Ina Krull, Jan Tasman,
Michael Braendle & Gerhard Hildebrandt
Kantonsspital St Gallen, St Gallen, Switzerland.
A 58-year-old male patient presented with a 2 months history of bilateral
frontotemporal headache, fatigue and impaired vision. Further exploration
revealed short term memory losses, confusion, gait disturbances, decreased
libido and erectile dysfunction. Radiological investigation showed a 4 cm
pituitary mass with destruction of the upper clivus and left petrous apex
associated with a 5 cm large suprasellar cyst bulging upward into the 3d ventricle
with obstruction hydrocephalus. The greatly elevated prolactin level of
11 660 g/l (Norm,25 g/l) led to the diagnosis of a macroprolactinoma
associated with a suprasellar arachnoid cyst. Incomplete homonymous
quadrantanopia was disclosed by the ophthalmologic examination. The further
endocrine work-up showed hypogonadotropic hypogonadism with intact
remaining pituitary axes.
In a frst stage the acutely symptomatic obstructive hydrocephalus was treated
with an endoscopic fenestration of the arachnoid cyst through a frontal burrhole
leading to immediate relief of the headache and gait disturbances. Treatment with
cabergoline (2 mg weekly) led to a decrease of the serum prolactin to 330 g/l
within 6 weeks. Because of the persistence of the visual felds defects and the
impeding CSF fstula an endoscopic transsphenoidal resection of the adenoma
with a closure of the cranial base using the Hadad-Bassagasteguy pedicled
nasoseptal fap was performed.
Postoperative MR imaging showed a nearly complete resection with a
decompression of the optic chiasm and resolution of the obstructive
hydrocephalus without the need for a shunt device implantation. Upon continued
treatment with cabergoline for 6 months the serum prolactin decreased to normal
range with an increase of the testosterone to the normal range (8 nmol/l) and the
other pituitary axes remaining intact. The visual feld defects remained
unchanged. The patient had an excellent recovery and returned to normal work.
This case illustrates a combined endoscopic neurosurgical and pharmacological
treatment approach to an invasive macroprolactinoma associated with a large
suprasellar arachnoid cyst with symptomatic obstructive hydrocephalus with an
excellent result.
P552
Incidentally found nonfunctioning pituitary macroadenomas: should
we suspect them earlier?
Leonor Gomes
1
, Isabel Paiva
1
, Cristina Ribeiro
1
, Jacinta Santos
1
,
Alexandra Vieira
1
, Mariana Martinho
2
, Marcia Alves
1
, Sofa Gouveia
1
,
Manuel Rito
3
, Francisco Belo
3
, Olinda Rebelo
4
1
1
Servico de Endocrinologia, Diabetes e Metabolismo dos Hospitais da
Universidade de Coimbra-EPE, Coimbra, Portugal;
2
Servico de
Endocrinologia do Instituto Portugue`s de Oncologia Francisco Gentil de
Coimbra-EPE, Coimbra, Portugal;
3
Servico de Neurocirurgia dos Hospitais
da Universidade de Coimbra-EPE, Coimbra, Portugal;
4
Laboratorio de
Neuropatologia do Servico de Neurologia dos Hospitais da Universidade
de Coimbra-EPE, Coimbra, Portugal.
Background
Nonfunctioning pituitary adenomas are commonly diagnosed as large tumors.
Most are detected incidentally during imaging studies. The aim of this study was
to evaluate clinical presentation, characteristics and outcome of nonfunctioning
pituitary macroadenomas incidentally (NFPMI) discovered.
Methods
Twenty-seven patients (mean age 58.9 years, 45-82; 18 males:9 females) with
NFPMI were studied. They represent 13.1% of NFPM followed in our
department. The reasons for neuroradiological studies were head trauma in 4
(14.8%); cerebral attacks in 12 (44.4%); sinusitis in 4 (14.8%); lipothymia/
syncope in 3 (11.1%); hypoacusia 2 (7.4%) and cancer staging in 2 (7.4%).
Results
Of 62.9% had symptoms related with macroadenomas: vision alterations in 4
(14.8%); headache, dizziness, confusion, memory loss in 13 (48.1%); sexual
dysfunction in 4 (14.8%) and amenorrhea in 2 (7.4%). Endocrinological
evaluation showed global anterior hypopituitarism in one (14.2%) and partial
hypopituitarism in 72.7%. Visual defcits were present in 15 (71.4%) patients.
At MRI there was suprasselar extension in all cases, parasellar in 8 (29.6%) and
infrasellar in 9 (33.3%). Mean diameter was 25.3 mm (15-49.7 mm). Surgery was
performed in all but four patients and two underwent also radiotherapy.
Immunohistochemistry showed eighteen nonsecreting adenomas, two FSH, one
ACTH, one TSH and two inconclusive. Surgery was highly effective in improving
vision alterations (62.5%) but was enable to restore normal pituitary function in
most cases. Five patients were lost for followed-up. At last MRI (mean follow-up
4.5 years, 6 months-17 years) 6 (27.2%) patients were free of disease, 15 (68.1%)
had remnants and one is waiting surgery.
Conclusions
NFPMI were very frequent among NFPM. Symptoms related to the
macroadenomas were often overlooked. Hypopituitarism (86.9%) and vision
alterations (71.4%) were high and only the last one recovered with surgery. It is
important to be aware of the neurological and endocrinological symptoms in order
to perform earlier diagnosis. This can avoid exposing patients to the risks
of unrecognized hypopituitarism, permanent visual defcits and jeopardizing
post-surgical outcome.
P553
Efhcacy of acromegaly treatment in six Czech and Slovak tertiary
centers: hrst analysis of patient registry RESET (Registry of Sellar
Tumors)
Vaclav Hana
1
, L Bandurova
1
, P Brabec
8
, J Cap
2
, V Durovcova
1
,
V Hana Jr.
1
, Z Jarkovska
1
, P Kentos
5
, R Klapka
8
, K Klimasova
8
, D Klimes
8
,
M Krsek
1
, I Lazurova
6
, V Olsovska
3
, J Podoba
4
, M Pura
5
, H Siprova
3
,
J Steno
7
, M Sticha
8
, L Trejbalova
4
, P Vanuga
5
, H Wagnerova
6
, V Weiss
1
,
D Zeman
3
, L Dusek
8
& J Marek
1
1
Third Department of Internal Medicine, Faculty of Medicine 1, Charles
University, Prague, Czech Republic;
2
Second Department of Internal
Medicine Faculty of Medicine, Charles Unviersity, Hradec Kralove, Czech
Republic;
3
Second Department of Internal Medicine, Masaryk University,
Brno, Czech Republic;
4
First Department of Internal Medicine, Faculty
Hospital, Bratislava, Slovakia;
5
National Institute of Endocrinology and
Diabetes, Lùbochna, Slovakia;
6
First Department of Internal Medicine,
Faculty Hospital, Kosice, Slovakia;
7
Neurosurgery Department of Faculty
Hospital, Bratislava, Slovakia;
8
Institute of Biostatistics and Analysis,
Masaryk University, Brno, Czech Republic.
Acromegaly is frequently diagnosed late and pituitary macroadenoma is revealed
in the majority of patients. Treatment usually needs combination of several
treatment modalities to suppress the disease activity. Effcacy of our treatment of
acromegaly was not analysed till now.
Aim
First analysis of the diagnostics of acromegaly, effcacy of treatment, its
complications and status of acromegaly patients in six tertiary referral centers in
the Czech Republic and Slovakia.
Methods
Registry of patients with sellar tumors (RESET) was developed. Data of patients
registered in six centers since January 1, 2000 were entered.
Results
Data of 137 patients (8651, CRSR, 71 women, age 20-78 years, mean 47
years) were analysed. Diagnosis was established in mean age 47 years. Main signs
and symptoms were acral enlargement (in 87%, realised by patient in 45% or by
physician in 31%), sweating (54%), headache (35%), joint pain (31%), fatigue
(26%) and paresthesias (22%). Complications like arterial hypertension (33%)
and diabetes melitus (17%) were present in 49% of patients in time of diagnosis.
71% of patients had pituitary macroadenoma. Treatment before referral to tertiary
centers did not signifcantly suppress activity. A combined treatment with
surgery, radiotherapy and pharmacotherapy was most frequently needed to
suppress the disease activity. Operated were 75% of patients (reoperated 7%) and
majority of them transnasaly (91%). Irradiated were 43% of patients - majority of
them by Leksell gamma knife (LGK, 88%). Pharmacotherapy was represented
most frequently by somatostatin analogues (51%), dopamin agonists were used in
36% and pegvisomant in 9%. Operation suppressed basal GH below 2.5 g in
49%, below 1 g/l in 35% and normalised IGF-1 in 29%. Combined treatment of
LGK plus pharmacotherapy suppressed GH below 2.5 g/l in 92%, below 1 g/l
in 65% and normalised IGF-1 in 61%. SMSA treatment suppressed GH below
2.5 g/l in 62%, below 1 g /l in 35% and normalised IGF-1 in 41%.
Conclusions
An individually tailored combined treatment with modern modalities is used in
Czech and Slovak Republics and effectively suppresses the acromegaly activity in
the majority of patients. An early referral to tertiary centers is substantiated.
Better treatment results could be expected with earlier disease identifcation.
The project is supported by a grant of Novartis.
P554
Increased prevalence of psychopathology and maladaptive personality
traits in patients after long-term cure of Cushing`s disease
Jitske Tiemensma, Nienke Biermasz, Huub Middelkoop, Roos van der Mast,
Johannes Romijn & Alberto Pereira
LUMC, Leiden, The Netherlands.
Objective
Psychopathology and maladaptive personality traits are often observed during the
active phase of Cushing`s disease (CD). We hypothesized that patients with long-
term cure of CD show persistent psychopathology and maladaptive personality
traits.
Aim
To evaluate psychopathology and personality traits in patients with long-term
cure of CD.
We included 67 patients cured of CD (15% males, mean age 53 years) and 67
matched controls. In addition, we included 55 patients treated for nonfunctioning
pituitary macroadenomas (NFMA), and 55 matched controls (55% males, mean
age 62 years). All patients and controls completed questionnaires on frequently
occurring psychopathology in somatic illness including the apathy scale,
irritability scale, hospital anxiety and depression scale (HADS), and mood and
anxiety symptoms questionnaire short-form (MAQ8-30). Personality was
assessed using the dimensional assessment of personality pathology short-form
(DAPP). The protocol was approved by the Medical Ethics Committee.
Results
Mean remission duration of CD was 13 years (range 50 years). Compared to
matched controls, patients treated for CD scored signifcantly worse on virtually
all questionnaires. Compared to NFMA patients, patients treated for CD scored
worse on apathy (P0.010), irritability (P0.004), negative affect and lack of
positive affect (P0.006 and P0.003, respectively), somatic arousal
(P0.023), and 11 out of 18 subscales of the DAPP (P,0.05).
Conclusion
Patients with long-term cured CD show an increased prevalence of psychopatho-
logy and maladaptive personality traits, compared to matched controls as well as
patients treated for NFMA. This suggests an irreversible effect of previous
glucocorticoid excess on the central nervous system rather than an effect of a
pituitary tumor and/or its treatment in general. These observations may also be of
relevance for patients treated with high doses of exogenous glucocorticoids.
P555
Negative magnetic resonance imaging in Cushing`s disease
Milina Tancic-Gajic, Miomira Ivovic, Milos Stojanovic, Ljiljana Marina,
Ana Nenezic, Zorana Arizanovic, Marija Barac & Svetlana Vujovic
Institute of endocrinology, Belgrade, Serbia.
Introduction
Cushing`s syndrome (CS) results from inappropriate exposure to excessive
glucocorticoids. Untreated, it has signifcant morbidity and mortality.
Case report
A 38-year-old woman with a typical appearance of CS was admitted for further
evaluation of hypercortisolism. The serum cortisol level was elevated without
diurnal rhythm, with no adequate supression of cortisol after 1 mg dexamethasone
suppresion test. Twenty-four-hour urinary free cortisol level was elevated.
Differential diagnostic testing was showed ACTH-dependent lesion (ACTH
17.4/95.6 ng/l), of the pituitary origin: suppression of cortisol level to 83% of
baseline in 2 days 8 mg dexamethasone suppression test and a rise in the cortisol
value of 23%above basal level along with a rise in ACTHvalue of 85%above basal
level in CRH stimulation test. Pituitary abnormalities were not observed during
repeated MRI scanning. Inferior petrosal sinus (PS) sampling was performed:
i) baseline ratio ACTH PS/peripferal was ,2; ii) CRH stimulated ratio ACTH
PS/peripheral was ,3; iii) baseline intersinus ratio of ACTH, was ,1.4; iv) increase
in central and peripheral ACTH of more than 50% above basal level after CRH;
v) Baseline ratio ACTH v. jugularis inf./peripheral 1.7. Transsphenoidal
exploration and removal of the tumor was performed with hypopithyitarism as the
complication. Postoperativly morning serum cortisol levels are ,50 nmol/l on
adequatereplacement therapywithhydrocortisone, thyroxine andestro-progesterone.
Conclusions
The Cushing`s disease remains a challenge for diagnose and clinical management.
No single test provides an absolute distinction, but the combined results of several
tests generally provide a correct diagnose.
P55
Development of a new questionnaire for evaluating QOL in adult
hypopituitarism: adult hypopituitarism questionnaire (AHQ)
Akira Shimatsu
1
, Hitoshi Ishii
2
& Kazuo Chihara
3
1
Clinical Research Institute, NHO Kyoto Medical Center, Kyoto, Japan;
2
Department of Endocrinology, Tenri Hospital, Tenri, Nara, Japan;
3
Hyogo
Prefectural Kakogawa Medical Center, Kakogawa, Hyogo, Japan.
Objective
To develop and validate the adult hypopituitarism questionnaire (AHQ) as a
disease-specifc, self-administered questionnaire for evaluation of QOL in adult
patients with hypopituitarism.
Methods
The development and validation of a new questionnaire were performed in a
standardized manner: item development, pilot-testing and psychometric
validation.
Result
Content validity of the initial questionnaire was evaluated via two pilot-tests.
After these tests, we made minor revisions and fnalized the initial version of the
questionnaire. The questionnaire was constructed with two domains: psycho-
social and condition-related domain. For psychometric assessment, analyses were
performed on the responses of 196 adult patients with various degrees of
hypopituitarism. The intraclass correlations of the respective domains were 0.91
and 0.95, and Cronbach`s coeffcients were 0.96 and 0.94, indicating adequate
test-retest reliability and internal consistency for each domain. For known-group
validity, domain scores were closely associated with the investigator`s assessment
of symptom severity; the more severe the symptoms, the lower the QOL. For
construct validity, the domain structure was found to be almost the same as that
initially hypothesized. Exploratory factor analysis (n228) demonstrated that
each domain consisted of fve and seven sub-domains, respectively.
Conclusion
The AHQ showed good reliability and validity for evaluating QOL in adult
Japanese patients with hypopituitarism. Further assessments, such as factor
validity, responsiveness and translatability into other languages are required to
make the questionnaire more robust to meet international standards.
P55I
Plasma ghrelin concentrations in narcoleptic patients
Milan Lakocevic
1
, Milan Petakov
1
, Nenad Rajsic
2
, Djuro Macut
1
,
Jadranka Antic
1
, Vera Popovic
1
1
1
Institute of Endocrinology, Belgrade, Serbia;
2
Clinic of Neurology,
Military Medical Academy, Belgrade, Serbia.
Background
Narcolepsy is hypersomnia of central origin whose clinical features are excessive
daytime sleepiness, hypnagogic hallutinations, sleep paralysis and cataplexy
which comprises sudden transient loss of muscle tone often triggered by
emotions. Narcolepsy with cataplexy is assiociated with hypocretin 1/orexin-A
(HCRT 1/ORX-A) defciency in central nervous system. Because of the link
between ghrelin and HCRT 1/ORX-A wake-promoting effects there might be
ghrelin defciency also in narcoleptic patients with cataplexy.
Plasma ghrelin concentrations have been measured in 25 narcoleptic patients (20
with and 5 without cataplexy, mean age 40.82.8 years) and 20 healthy age and
BMI matched control subjects (mean age 41.33.2). Plasma ghrelin
concentrations were measured by RIA (kit LINCO Research).
Results
Mean ghrelin concentrations (meanS.E.M.) in narcoleptic patients with and
without cataplexy, and healthy controls were 1123.277.4, 992.2194.0 pg/ml
and 1125.473.3 pg/ml, respectively. There was no signifcant difference in
ghrelin levels between narcoleptic patients with and without cataplexy. Also, no
difference between patients with narcolepsy and healthy controls was found. No
correlation was observed between ghrelin plasma levels and clinical charac-
teristics of narcoleptic patients (cataplexy, gender, age, BMI, duration or age of
narcolepsy onset).
Conclusion
Our data show that there is no difference in plasma ghrelin concentrations in
narcoleptic patients with and without cataplexy in comparison with healthy
controls.
P558
Clinically silent pituitary macroadenomas: a clinicopathologic analysis
Sandra Pekic Djurdjevic
1
, Milica Skender Gazibara
2
, Angelina Obradovic
3
,
E Manojlovic Gacic
3
, Mirjana Doknic
1
, Dragana Miljic
1
, Marina Djurovic
1
,
Marko Stojanovic
1
& Vera Popovic
1
1
Neuroendocrine Unit, Institute of Endocrinology, University Clinical
Center, Belgrade, Serbia;
2
Institute of Pathology, School of Medicine,
University of Belgrade, Belgrade, Serbia;
3
General Hospital Subotica,
Subotica, Serbia.
Background
The so-called silent pituitary adenomas are a subtype of pituitary tumors showing
positive immunoreactivity for one or more pituitary hormones, but without any
clinical manifestations for oversecretion of these hormones. They are clinically
labeled as non-functional pituitary adenomas (NFPA), some of them with
particularly aggressive behavior. Rare patients might present with big
plurihormonal pituitary tumors which 'whisper` hormones (GH or ACTH) and
produce biochemical acromegaly or Cushing`s disease.
Objective
We undertook a systematic retrospective, single institution clinicopathologic
study of the patients with NFPA seen over a period of 6 years. Clinical,
biochemical and immunohistochemical data were analyzed.
We examined the data of 50 patients with NFPA, 23 men (46%) and 27 women
(54%). Mean age of patients at the time of the diagnosis and frst operation was
52.91.9 years (range, 19-79 years), females being signifcantly younger
compared with males (49.53.0 vs 56.82.1 years; P,0.05).
Results
All tumors were macroadenomas. Most tumors were plurihormonal, featuring
immunoreactivity for FSH (41 of 50 patients, 82%), LH (37 of 49 patients, 76%),
PRL (36 of 48 patients, 75%), GH (9 of 27 patients, 33%), TSH (14 of 32 patients,
44%) or ACTH (19 of 36 patients, 53%); only two being immunonegative for
hormones. There was a positive correlation between the intensity of ACTH
immunostaining and proliferative index Ki67 (r0.429, P,0.05). Male patients
had signifcantly greater intensity of LH immunostaining compared with females
(P,0.05). Although a radical resection was achieved in 42 cases (84%),
reoperation for recurrence was required in 8 cases (16%), predominantly in
females (n7). In our study group, we identifed four cases of 'whispering`
pituitary macroadenomas with GH (n3) and ACTH (n1) staining with
biochemical evidence of hormone oversecretion but with no clinical signs or
symptoms for acromegaly or Cushing`s disease.
Conclusion
Most pituitary macroadenomas labeled as NFPA are plurihormonal macro-
adenomas. Rare NFPA may be true GH- or ACTH-secreting tumors despite no
obvious clinical stigmata for acromegaly or Cushing`s syndrome.
P559
Hormonal and non-hormonal factors contributing to chronic fatigue in
traumatic brain injury patients
Jessica Schnieders
1,2,3
, Ron Meijer
1,2,3
, Darryl Telting
1,2,3
& Hans deBoer
1,2,3
1
Department of Rehabilitation Medicine Groot Klimmendaal, Arnhem,
The Netherlands;
2
Internal Medicine, and Clinical Chemistry, Rijnstate
Hospital, Arnhem, The Netherlands;
3
Epidemiology and Research,
University Medical Centre St Radboud, Nijmegen, The Netherlands.
Introduction
Every year 30 000 patients will suffer a traumatic brain injury (TBI) in The
Netherlands. About two-thirds will develop post-TBI chronic fatigue (CF).
Hormone defciencies related to pituitary damage might contribute.
Aim
To examine the clinical importance of hormonal and non-hormonal factors as
issues contributing to chronic fatigue in post-TBI subjects.
The checklist individual strain (CIS), a well-validated questionnaire to assess
fatigue severity, was sent to 332 TBI patients, age 18-65 years. The questionnaire
was returned by 166 patients. A random sample of 100 fatigued and non-fatigued
subjects was asked to participate: 26 females and 64 males agreed. All subjects
underwent an extensive endocrine evaluation and non-hormonal causes for
fatigue were studied by means of questionnaires evaluating, sleep, attention,
emotional well being, quality of life, coping style, and daily activity/dependency.
Physical performance was evaluated by the A
strand bicycle test.

Results
The prevalence of severe fatigue was 51%. Fatigued subjects had more anxiety
and a lower quality of life (QoL). Pituitary hormone defciencies (PHD), defned
as a subnormal serum level of one or more pituitary hormones, was present in
29% of the subjects, GH defciency (GHD) was present in 24%, and gonadal
hormone defciencies (GnD) in 10%. PHD occurred about twice as frequently in
the fatigued group (P0.12). Vitamin D defciency, defned as a serum
25-hydroxyvitamin D level (25-OHD) ,50 nmol/l) was present in 65%. Sleep
disorders and serum 25-OHD levels were related with fatigue (P,0.05), whereas
PHD, gender, attention, BMI and coma duration were not.
Conclusions
Vitamin D defciency and sleep disturbances were identifed as the most important
factors contributing to post-TBI fatigue. Correction of vitamin D defciency and
improvement of sleep quality might reduce fatigue in these patients.
P50
Management of patients with childhood onset GH dehciency (COGHD)
in the transition phase
Mari a A
ngeles Bazarra Castro

1
, Caroline Sievers
1
, Susanne
Bechtold-Dalla Pozza
2
, Hans Peter Schwarz
2
& Gunter Karl Stalla
1
1
Clinical Neuroendocrinology Group, Max Planck Institute of Psychiatry,
Munich, Germany;
2
Division of Endocrinology and Diabetology,
University Children`s Hospital, Dr von Haunersches Kinderspital der
Ludwig-Maximilians Universitat, Munich, Germany.
Introduction
Discontinuation of GH therapy in patients with COGHD after attainment of fnal
height has been associated with impaired somatic development, altered peak bone
mass and cardiovascular risk factors. A well-managed transition of care between
paediatric and adult health services can improve the clinical and social outcomes
in adolescents with GHD.
Objective
To assess the quality of the transfer between children and adult medical services
in our clinic and to confrm the previous diagnosis.
Patients
One hundred and twenty-two transition patients (68 males and 54 females; age at
frst visit: ,25 years) with pituitary defciency (ICD-10: E.23) referred to us and
treated at our clinic between 2000 and 2009.
Results
Among the 122 transition patients, 75 presented with GHD(45 males, 30 females),
of which 20 suffered from an idiopathic GHD (iGHD) and 55 from an organic
GHD (oGHD). Most transferred males with iGHD discontinued endocrinologic
control and GH substitution completely (fve patients) or after the frst contact
(three patients). Most females with GHD presented regularly after transferral
for medical check-ups independent of diagnosis (22 patients). In case that the
previous test was borderline or performed more than 1 year ago and in order to
confrm the diagnosis, we retested 34 out of the 75 patients with GHD (45.3%).
The preferred test was GHRH-arginine (20 patients, 58.9%). Other test used
was IHT alone (nine patients) or together with GHRH-arginine (four patients). Out
of 20 patients with iGHD 11 (55%) were retested, of which seven were still
GH defcient (63.6%). All 23 oGHD retested patients (out of 55) were defcient.
Conclusion
Efforts should be made to improve the transferral of male adolescents with GHD,
particularly with iGHD, since they seem to escape medical care. An
individualised healthcare transition programme, created with paediatric in
collaboration with adult endocrinologists may help to contribute towards
successful transition.
P51
The diagnosis of GH dehciency in obese patients: what help from
pharmacological blockade of lipolysis?
Federica Orsini, Agnese Cattaneo, Alice Grasso, Barbara Filippini,
Maria Letizia Fatti, Mirella Moro, Massimo Scacchi & Francesco Cavagnini
Cattedra di Endocrinologia, Universita` di Milano, IRCCS Ospedale S Luca,
Milan, Italy.
The diagnostic approach to GH defciency (GHD) in obese patients is complicated
by the reduced spontaneous and stimulated GH secretion associated with
overweight. A GH response to GHRHarginine lower than 4.2 g/l is currently
considered indicative of GHD in obesity (Corneli et al., Eur J Endocrinol 2005).
Aim of the study was to verify the diagnostic validity of this cut-off value by
investigating the effect of acute pharmacological blockade of lipolysis on the GH
response to GHRH arginine in obese patients.
Two groups of patients were studied: 12 obese patients with proven GHD and
14 patients with essential obesity. On separate occasions two tests were carried
out in each patient: GHRHarginine, and GHRHarginine preceded by
acipimox 250 mg, given orally at 270 and 60 min. IGF1 and FFA values
were measured on serum samples collected at baseline; FFA were also assayed
after acipimox administration.
Results
The mean GH peak in response to GHRHarginine was signifcantly lower in
obese hypopituitary patients than in subjects with essential obesity (1.631.37 vs
5.994.38 g/l, P,0.01). Acipimox pretreatment signifcanly increased the GH
response to the combined test in patients with essential obesity (mean GH peak
from 5.994.38 to 9.313.86 g/l, P,0.05), but not in hypopituitary subjects
(mean GH peak from 1.631.37 to 2.201.70 g/l, NS). Seven out of
14 patients with essential obesity GH peaks lower than 4.2 g/l after GHRH
arginine. The GH response clearly increased after acipimox premedication in
fve of them. Baseline circulating FFA were superimposable in patients with
essential obesity and in hypopituitary subjects with a comparable decrease in
both groups after acipimox administration. All IGF SDS values were normal in
both groups of subjects.
Conclusions
Our study has demonstrated that the acipimox-induced acute reduction of
circulating FFA levels increases mean somatotropin response to
GHRHarginine in patients with essential obesity, whereas it has no effect in
hypopituitary subjects. Additional large studies revising GH cut-off values
following GHRHarginine according to different BMI groups within the
population of obese patients are needed, in order to avoid the possibility that
subjects affected by severe obesity are erroneously classifed as really
GH-defcient.
P52
Assessment of biochemical control of acromegaly during treatment with
somatostatin analogues: is there still a role for glucose oral load?
Chiara Carzaniga, Massimo Scacchi, Giovanni Vitale, Maria Letizia Fatti,
Francesca Pecori Giraldi, Massimiliano Andrioli & Francesco Cavagnini
Cattedra di Endocrinologia, Universita` di Milano, Ospedale San Luca
IRCCS, Istituto Auxologico Italiano, Milano, Italy.
Biochemical control of acromegaly is currently defned by the achievement of GH
suppression after oral glucose tolerance test (OGTT) and of normal age- and
gender-matched IGF1 levels. OGTT is believed to inhibit somatotropin secretion
by enhancing central somatostatinergic tone; thus, the use of this test in evaluating
biochemical control in acromegalic patients on somatostatin analogues (SSA) is
questionable. To gain further insights into this topic, we analyzed basal and nadir
GH levels during OGTT in acromegalic patients on SSA.
Basal IGF1 and GH values, as well as GH levels along the test, were analyzed in
115 standard OGTTs performed in 33 acromegalic patients (16 males and 17
females, aged 55.6114.48 years), followed between 1993 and 2009. All patients
were on SSA at the time of the study: in particular, 36 OGTTs were performed
during lanreotide, 52 during octreotide, 27 during combined therapy with SSA
and dopamine agonists. Seventy OGTTs were performed after unsuccessful
surgery in 22 patients. No patient had undergone radiotherapy. GH suppression
was considered normal when the hormonal value fell to ,1 g/l during OGTT.
Diagnostic accuracy was analyzed by receiver-operator characteristic (ROC).
Results
ROC analysis showed that the GH basal value yielding the best specifcity (100%)
was 3.9 g/l. All patients with basal GH3.9 g/l displayed lack of GH
suppression after OGTT and 80% also displayed high IGF1. Conversely, patients
with basal GH,3.9 g/l presented a variable biochemical pattern with half
failing to suppress GH after OGTT and over 35% displaying high IGF1 levels.
Conclusion
Our results show that baseline GH levels 3.9 g/l are predictive of absent
OGTT-dependent GH suppression; however, 20% of these patients display partial
biochemical control (normal IGF levels). On the other hand, basal GH values
,3.9 g/l, such as those suggested by Jayasena et al. (Clin Endocrinol 2007),
are not predictive of the GH suppressibility by glucose and are often discordant
with IGF1 levels.
P53
Inuence of psychological variables on partially and fully recovering in
patients with anorexia nervosa
Marina Djurovic, A Arsic, Sandra Pekic, Dragana Miljic, Mirjana Doknic,
Milan Petakov, Marko Stojanovic & Vera Popovic
Neuroendocrine Unit, Institute of Endocrinology, University Clinical
Center, Belgrade, Serbia.
Introduction
Anorexia nervosa (AN) is a chronic disorder characterized of profound reduction
in body weight and amenorrhoea. A product of complex interactions between
psychological and clinical variables are important for the presence of the disease.
Aim
The aim of the study was to investigate the variables which might predict full
reproductive recovery of patients with anorexia nervosa.
We studied closely matched cohorts of patients with partailly (n10) and fully
recovered (n13) AN patients (DSM-IV criteria). They were matched for age
(23.10.34 vs 25.11.2 years, P0.05), for body weight (49.21.1 vs 52.8
1.5, P0.05) and body mass index (BMI 18.30.4 vs 19.50.4 kg/m
2
,
P0.05). Samples for pooled serum leptin levels (RIA, Linco) and for LH and
FSH (Irma, INEP) were measured. Depression was assessed by Beck Depression
Inventory Second Edition (BEK-BD-II) and anxiety by Hamilton Anxiety Scale
(HAMA).
Results
There was a signifcant negative correlation between body weight and the score of
BEK (P0.04), body weight and HAMA scale score of anxiety (P0.03).
Patients with higher anxiety scores had lower body weight at baseline. The degree
of depression correlated signifcantly with presence of amenorrhoea (P0.04).
Conslusion
In a subset of AN patients, although regained weight, amenorrhoea was found. It
is reasonable to believe that pshychological factors are important for the presence
of disease.
P54
Use of cabergolin in Nelson`s syndrome: preliminary results in four
patients
Clara Giovannetti
1
, Luca Manetti
1
, Valentina Raffaelli
1
, Mirco Cosottini
2
,
Maura Genovesi
1
& Enio Martino
1
1
Department of Endocrinology, University of Pisa, Pisa, Tuscany, Italy;
2
Department of Oncology and Neuroscience, Univeristy of Pisa, Pisa,
Tuscany, Italy.
The Nelson`s syndrome (NS) is characterized by hyperpigmentation, sellar
growing mass, and increased plasma ACTH concentrations The management of
NS remains diffcult: neurosurgery represent the frst choice therapy. Many drugs
have been used with variable results: cyproeptadine, GABA-agonists, somato-
statin analogues, chemiotherapy, PPAR--agonists, and dopamin-agonists.
Aim of this study was to evaluate the effcacy of cabergoline administration to
reduce ACTH concentrations, hyperpigmentation and tumor`s size in NS.
Four women (28-59 years, mean age 4717 years) with NS, without aggressive
or invasive course, were enrolled between May 2007 and July 2008. All patients
were on replacement therapy with cortone acetate at the daily dose of 37.5 mg. All
patients before the enrolment showed intrasellar persistent residual tissue (main
diameter ,1 cm) at MRI; two of them (patient no. 1, patient no. 2) underwent to
radiosterotactic surgery 5 and 7 years before the enrollment respectively. In all
patients the starting dose was 1 mg/week in two administrations and the dosage
was increased every 3 months. All patients underwent every 3 months to clinical
and hormonal assessment. Every 6 months pituitary MRI was performed. To
exclude valvular abnormalities all patients were submitted to cardiac eco-
colordoppler basally and every 12 months. Preliminary data showed a decrease
of ACTH levels before and 2 h after corticosteroid therapy in two patients (patient
no. 1 and 2; percentage of reduction was 68.6 and 81.4%, respectively), while in
the other two patients (patient no. 3 and 4) we observed an increase (percentage of
increase was 41 and 35.7%, respectively). We observed an improvement of
hyperpigmentation in 2/4 patients (patient no. 1 and 2). During follow-up MRI
didn`t show any change with respect to time of enrollment in all patients.
These data suggest that cabergolin therapy could be useful to reduce ACTH
concentrations and to prevent regrowth or increase of ACTH secreting adenomas
in patients with NS previously treated with radiosterotactic surgery.
P55
Daily temozolomide therapy in Nelson`s syndrome
Ruth Sanchez Ortiga
1
, Victor L Gonzalez Sanchez
1
, Oscar Moreno Perez
1
,
Andres Meana
2
& Antonio A Pico Alfonso
1
1
Department of Endocrinology, Hospital General Universitario Alicante,
Alicante, Spain;
2
Departmen of Oncology, Hospital General Universtario
Alicante, Alicante, Spain.
Temozolomide, an alkylating agent used in malignant gliomas, has been recently
used too in the treatment of aggressive pituitary tumors. To date, two cases of
Nelson`s syndrome has successfully treated with 5 days of 28-day cycle, but the
follow-up has been shorter than 12 months. We reported the third patient with
Nelson`s syndrome treated with temozolomide, who after an initial goal response
to three 300 mg 5 days of 28-day cycles shown a clinical and biochemical
(ACTH) escape which was controlled changing the temozolomide regimen to
120-140 mg on alternate days.
Patient
A 55-year-old man presented in 2002 with Cushing`s syndrome. Magnetic
resonance imaging (MRI) scan revealed an intrasellar mass that infltrates right
cavernous sinus. Fourteen months after an initial disease control with
transsphenoidal pituitary surgery and postoperative stereotactic radiotherapy,
the patient had a recurrence and bilateral adrenalectomy was performed. Six
months afterwards he had headaches and right third cranial nerve palsy. The MRI
scan revealed a 2.5 cm pituitary tumor with large right cavernous sinus invasion
refecting a Nelson`s syndrome. The lesion was treated with tomotherapy with an
initial good disease control, lost 17 months after. 2 mg/week Cabergoline was
initiated with partial response so temozolomide 300 mg 5 days of 28-day cycles
was added initially and after 3 months changed to 120-140 mg on alternate days.
The evolution of plasma ACTH levels is resumed in the table. MRI control
showed no increase of the tumor during 8 months of follow-up. Astenia has been
the main adverse event.
Conclusions
The daily temozolomide therapy can be an alternative effective to 5 days of
28-day cycle regimen when ACTH escape occurs.
P5
Euthyroidism and tumor stability achieved in a TSH-secreting pituitary
macroadenoma treated with octreotide-LAR and cabergoline: case
report and literature review
Helder Simoes, Carolina Lalanda, Manuela Oliveira, Lui s Raposo,
Sequeira Duarte & Machado Saraiva
Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.
Introduction
TSH-secreting adenomas represent ,2% of pituitary tumors. Surgery and/or
radiotherapy are primary treatment options. Somatostatin analogues and also
dopamine agonists, represent valuable alternatives or adjuvant therapies.
Objective
To report a case of euthyroidism and tumor stability achieved in a TSH-secreting
pituitary macroadenoma, treated with octreotide-LAR, as frst line therapy,
and then added cabergoline. To review the effcacy of these therapeutic agents,
in controlling hormone secretion and tumor shrinkage, in TSH-omas.
Clinical case
Sixty-nine year-old men; absent personal or family thyroid disease history.
Physical exam: clinical hyperthyroidism and small diffuse goiter. Laboratory:
rising thyroid hormones and TSH (maximum: TSH14.1 mU/l, fT
4
59.2 pmol/l, T
3
4.9 nmol/l); negative thyroid antibodies; other pituitary
hormones were normal. Central hyperthyroidism was investigated. -Subunit
15.5 g/l; -subunit/TSH molar ratio8.1; pituitary MRI: Hardy grade II,
macroadenoma, measuring 22,18,17 mm (3.53 cm
3
). Campimetry was
normal. Methimazole used during 6.5 months to control fT
4
and thyrotoxic
symptoms, corresponding with signifcant increase in TSH (maximum
98.1 mU/l). Patient refused surgery or radiotherapy. Octreotide-LAR
20 mga30 mg, monthly injection, was initiated. Eleven months over the frst
MRI and after 8 months of therapy, follow-up MRI showed tumor stability
(3.52 cm
3
). TSH reduction was considerable (98.1a17.5 mU/l) and fT
4
normalized (22.6 pmol/l). Aiming further hormone control and tumor reduction,
we initiated cabergoline 0.5 mg twice a week and persistent euthyroidism was
achieved, with no need for methimazole.
Discussion
Somatostatin analogues can control TSH, thyroid hormones and induce tumor
shrinkage in ^90, 70 and 40% of TSH-omas, respectively. Dopamine agonists
are less effective. Few articles report the effciency of long acting somatostatin
agonists (lanreotide and octreotide-LAR) in TSH-omas. Published data show
tumor stability and equivalent effcacy of these formulations in controlling
TSH and thyroid hormones. Tumor shrinkage is yet to be demonstrated with
long acting analogues, but hormone control, tumor stability and treatment
simplicity represent important achievements.
P5I
Effects of GH replacement therapy on hematopoiesis and immune
function: a placebo controlled study
Ilkay Cakir
1
, Fatih Tanriverdi
1
, Zuleyha Karaca
1
, Leylagul Kaynar
2
,
Gulsah Elbuken
1
, Bulent Eser
2
1
1
1
Department of Endocrinology, Erciyes University Medical School,
Kayseri, Turkey;
2
Department of Hematology, Erciyes University Medical
School, Kayseri, Turkey.
Objectives
It has been recently recognized that GH may have a role in hematopoiesis and
immune system. However, there are conficting data regarding the effects of GH
defciency (GHD) and/or GH replacement therapy in GH defcient patients on
hematopoiesis and immune system. The aim of the present study was to
investigate the peripheral blood cell counts, T- and B-lymphocyte subsets and
immunoglobulin levels before and after GH replacement therapy in patients with
adult onset GHD.
Methods
Twenty patients (7 males and 13 females) with GHD were enrolled into the study.
All patients received appropriate hormonal replacement therapies for other
defcient pituitary hormones except GH. Patients were treated with either
recombinant human GH (rh GH) (13 patients) or placebo (7 patients) for 6
months. Hemoglobin, hematocrit, mean corpuscular volume, platelet, red blood
cells, white blood cells, percent (%) neutrophil and lymphocyte were evaluated.
Measurement of lymphocyte subsets CD3, CD4, CD8, CD16,
CD19and CD45was performed by fow cytometry. Serum immunoglobulin
concentrations (IgG, IgA, IgM) were also measured. All measurements were
evaluated at baseline and after 6 months of therapy.
Results
All investigated indices were within normal reference ranges before treatment.
Levels of IGF1 were signifcantly increased and reached to normal values after
6 months of therapy in rhGH treated group (P,0.05). Only red blood cell count
were signifcantly increased after 6 months with rh GH replacement therapy
(P,0.05), but not in placebo group. There were no signifcant changes in other
evaluated parameters after rhGH replacement.
Conclusions
Present data shows that short term GH replacement therapy has no any clinically
important effect on hematopoiesis and immune system. However, signifcant
increase in red blood cell count after treatment suggests that long term GH
replacement treatment may have a potential effect on hematopoietic parameters.
Date Treatment ACTH (pg/ml)
February 09 Cabergoline 2 mg/week 4610
April 09 Temozolomide 5 day/28 days 1368
July 09 Temozolomide 5 day/28 days 2945
December 09 Temozolomide daily 1064
P58
Comparison of 1 g ACTH, 250 g ACTH and glucagon tests for
assessment of the hypothalamo-pituitary~adrenal axis in healthy
subjects
Fatih Tanriverdi
1
, Ayhan Lale
2
, Zuleyha Karaca
1
, Mustafa Kula
3
,
Kursad Unluhizarci
1
1
1
Kayseri, Turkey;
2
Department of Internal Medicine, Erciyes University
Medical School, Kayseri, Turkey;
3
Erciyes University Medical School, Kayseri, Turkey.
Objectives
Evaluation of the HPA axis is still a big challenge. This study was performed
to compare 1 g ACTH, 250 g ACTH and glucagon tests for evaluation of HPA
axis in healthy male and female subjects with different ages.
This study was carried out on 57 healthy individuals (29 men, 28 women)
between 20 and 70 years of age (the number and gender of the subjects are
approximately equal for each decade). Low dose short synacthen test (1 g
ACTH), conventional dose short synacthen test (250 g ACTH) and glucagon
tests were performed consecutively, and there was at least 48 h time between
each test.
Results
Mean peak cortisol value in 250 g ACTH test was signifcantly higher than 1 g
ACTH and glucagon tests. Mean peak cortisol value in 1 g ACTH was similar to
glucagon test. Sex and age did not effect mean peak cortisol values in each test.
There were signifcant correlations between the peak cortisol value in 250 g
ACTH and 1 g ACTH tests, 250 g ACTH and glucagon tests. But there was not
a correlation between 1 g ACTH and glucagon tests. While cut-off level of peak
cortisol accepted as 18 g/dl the sensitivities of 1 g ACTH, 250 g ACTH and
glucagon tests were calculated as 86, 98.2 and 54.4%, respectively.
Conclusion
Conventional dose short synacthen test has the highest sensitivity in the
evaluation of HPA axis in healthy subjects. These fndings clearly suggest that to
obtain more accurate results in 1 g ACTH and glucagon tests appropriate cut off
values are required. In all the three tests, age and gender do not seem to have an
impact on the results of the HPA axis evaluation.
P59
Unsatished treatment outcomes of acromegaly patients: a single center
experience in Turkey
Feyza Yener Ozturk, Esra Cil, Aysenur Ozderya, Ozcan Karaman,
Sayid Shaf Zuhur & Yuksel Altuntas
Endocrinology and Metabolism Department, Sisli Etfal Training and
Research Hospital, Istanbul, Turkey.
Background
Acromegaly is a multi-systemic dysfguring disease caused by pituitary GH
secreting tumour. Pituitary surgery, medical treatment with somatostatin
analogues and radiotherapy have been cornerstone in the management of
acromegaly. However, all these treatment modalities do not provide suffcient
disease control especially in patients with macroadenomas.
Objective
To evaluate the follow-up outcomes and remission rates of acromegaly patients.
Method
Fifty acromegalic patients diagnosed between 2005 and 2009 at Sisli Etfal
Training and Research Hospital were retrospectively analysed. Normal IGF1
serum concentrations for age and sex, nadir GH ,1 ng/ml during OGTT and
random GH ,2.5 ng/ml were defned as biochemical control.
Results
The mean age of patients was 46.5612.95 years (age range: 25-76 years).
Preoperative mean concentrations of GH were 33.7268.45 ng/ml (range: 2.01-
106 ng/ml), IGF1 were 1154.88710.83 ng/ml (range: 308-3574 ng/ml) and
nadir GH during OGTT was 17.2223.76 ng/ml (range: 1.9-84 ng/ml). Forty-six
patients had macroadenomas (92%). Forty-fve patients (90%) underwent surgery
at different centers after the diagnosis. Five patients (10%) were followed with
primary somatostatin analogue treatment. Postoperative cure was defned in 8 of
50 patients (16%). Postoperatively active 9 patients (18%) were treated with
radiotherapy and 35 patients (70%) were started on treatment with octreotide
LAR as 10, 20 and 30 mg. According to the follow-up data, biochemically disease
control was defned in 20 of 50 patients (40%). Twenty-two patients (44%) had
active acromegaly. A discordance was found between serum IGF1 concentrations
and nadir GH during OGTT in 8 of 50 patients (16%). However, remission was
defned in all of these 8 patients if only serum IGF1 concentrations were assessed
for disease control.
Discussion
Maximum doses of somatostatin analogues and combined treatment modalities do
not provide effective control in the majority of patients. Newly developing
treatment options (GH receptor antagonist, pasireotideJ) should be used in the
management of active disease.
P5I0
The presentation of sellar and parasellar tumours in Uzbekistan
Said Ismailov, Ashley Grossman, Michael Powell,
Abdukhakim Khadjibaev, Yulduz Urmanova & Mukhlisa Shakirova
The Center for the Clinical and Scientifc Study of Endocrinology, 56,
Mirzo Ulugbek Street, Tashkent 100125, Republic of Uzbekistan.
Aim
To analyse the epidemiology and presentation of pituitary tumours in Uzbekistan.
Over a period of 1.5 years, we studied 53 consecutive patients with tumours in the
sellar and suprasellar region (mean age 41.5 years) in terms of neurological and
ophthalmological status, MRI imaging and detailed neuroendocrine functional
assessment. A detailed examination of the sellar area by means of computer and
magnetic resonance tomography was performed in all patients.
Results
Microadenomas (,10 mm) were found in 9 patients, mesoadenomas
(11-15 mm) in 19 and moderate macroadenomas (15-20 mm) in 7. Eighteen
(33% of the cohort) presented with large macroadenomas (2 cm). Thirty-nine
patients (73.5%) had non-functioning pituitary adenomas, fve had prolactinomas,
three had corticotroph tumours, two had craniopharyngioma, while there was one
each of a germinoma, a menngioma, and astrocytoma. Neurological complaints
included headache in 32 patients (60%), a decrease of memory in 28 (52.5%),
diplopia in one and unilateral ptosis in one. Abnormalities of the visual feld or of
visual acuity were seen in all 53 patients (100%). Panhypopituitarism was noted
in two persons (3.7%), GH defciency in 39 (73.5%), GHD and LH, FSH
defciency - in 12 patients (22.6%), primary infertility in 5 (10%), impotence in
one (1.8%), and secondary amenorrhoea in 13 (25%). Hypopituitarsin, that is,
reduction in the levels of pituitary tropic hormones, such as, STH, LH and FSH
was found in 26.4% (14 patients), large pituitary tumors with supra-, para- and
infrasellar growth being registered in the patients.
Conclusions
The distribution of sellar and parasellar lesions in Uzbekistan and their pathology
is similar to that reported in other parts of the world, but tumours tend to be larger
and visual problems predominate.
P5I1
Long-term morbidities in patients with Cushing`s disease
Georgia Ntali, Thomas Siamatras, John Komninos, Niki Karavitaki
& John Wass
Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology
and Metabolism, Churchill Hospital, Oxford, UK.
Introduction
Cushing`s disease (CD) is a rare condition, associated with signifcant morbidities
and potentially fatal, if untreated.
Objective
To assess the long-term morbidities in a large series of patients with CD during
a prolonged follow-up period.
All subjects with CD who presented/followed-up in our Department between
01/1967 and 06/2009 were studied. All information was collected as documented
in the records of the patients.
Results
One hundred and eighty-two patients were identifed (139 females/43 males).
The median age at diagnosis was 40 years (range 10-76) (females: 39 (13-72)
- males: 41 (10-76)). The mean duration of symptoms prior to diagnosis was 24
months (range 3-240) and the mean follow-up period was 145 months (121).
The treatment modalities were: TSA 118 patients (cured 75%), TSAexternal
radiotherapy 20 (cured 30%), TSAbilateral adrenalectomy 19 (cured 100%),
TSAbilateral adrenalectomyexternal radiotherapy 7 (cured 100%), bilateral
adrenalectomy 11 (cured 100%), external radiotherapy 2 (cured 0%). Two
patients are waiting for surgery, two had been treated medically due to high
surgical risk, and one died before any treatment. At last assessment, 73% of the
subjects were considered cured (132/182). The documented rates of morbidities
were: hypertension 36% (82% cured), dyslipidaemia 27% (70% cured), DM2
12% (68% cured), depression 15% (82% cured), osteopaenia/osteoporosis
37% (82% cured), cardiovascular disease 9% (69% cured), cerebrovascular
disease 4% (71% cured), tumours (meningioma, kidney carcinoma, gastric
carcinoma, breast cancer, melanoma, rectal carcinoma) 6% (100% cured), kidney
disease 3% (83% cured), gallstones 0.5% (100% cured). Partial or complete
hypopituitarism was reported in 64% of the subjects.
Conclusions
Remarkably high proportions of various morbidities in Cushing`s rectify
themselves after the successful treatment of this unpleasant disease but signifcant
morbidities also remain particularly with regard to hypertension, dyslipidaemia,
osteopaenia and osteoporosis. These will be likely to have an impact on long-term
mortality.
P5I2
Comparison of different therapy approaches in acromegaly
Zamira Khalimova, Adliya Kholikova, Yulduz Urmanova, Dinara Alieva,
Khurshida Nasirova, Gulrukh Alimukhamedova, Liliya Murtazaeva
& Shokhsanam Safarova
Mirzo Ulugbek Street, Tashkent, Uzbekistan.
Aim of the research
To study relationship between GH levels and acromegaly complications
development in different therapy approaches.
We evaluated 50 patients with GH secreting adenomas referred to CCSSE from
1999 to 2004. Age of patients was from 19 to 63 years-old (mean age 4019
years-old). Duration of the disease was from 1 to 23 years.
Methods
Clinical and biochemical tests of neurological status; RIA assay evaluation of
pituitary and peripheral hormones levels; US study of internal organs and thyroid;
vision evaluation: acuity, fundus, felds. Patients were divided into three groups:
1st group with medical therapy, 2nd group with radiotherapy, 3rd group with
surgical treatment.
Results
We revealed that complicated forms of AM were observed in patients with
medical therapy, whereas patients received radiotherapy and those operated
developed signifcantly lower complications.
Summarizing our data we can conclude that the key point for disease and its
complications progression is the activity of the disease which is confrmed by
high rate of complications in patients with medical therapy and on early
radiotherapy stages (several months to 3 years) and in cases of recurrent disease
after surgery. The research revealed that in all cases patients had high GH levels,
which determines the character of the disease. According to this, it is
recommended to use surgery and complex therapy approaches depending on
lesion size and patients age.
Conclusions
i) The most less complications development we observed in groups with surgical
treatment, whereas in radiotherapy and medical treatment groups complications
rate was mild and signifcantly high respectively. To confrm the causes of these
noticeable variables we analyzed the effect of GH levels, duration of the disease in
relation with complications depending on therapy approaches. ii) As the studies
and observations of acromegalic patients show, the medical therapy with
dopamine agonists is not effective in compensating the disease, to regress the
adenomas growth and it is impossible to prevent complications development
which is confrmed by ineffective monotherapy medical treatment.
P5I3
Clinical and epidemiologic features of acromegaly in the Republic of
Uzbekistan
Zamira Khalimova, Adliya Kholikova, Yulduz Urmanova, Dinara Alieva,
Gulchekhra Narimova, Shokhsanam Safarova, Khurshida Nasirova
& Gulrukh Alimukhamedova
Aim of the research
To study clinical and epidemiologic features of acromegaly in the Republic of
Uzbekistan.
We observed acromegalic patients registered from 2007 to 2009 who are
dispensarized in the regions of the country. Of the 369 patients 143 were males
(38.7%) and 226 females (61.3%). Mean age of the patients was 42.6 years-old.
Duration of the disease varied from 1 to 31 years.
Results
According to the register data by the end of 2009 there 369 patients with
acromegaly were registered of which 143 men (38.7%) and 226 women (61.3%).
Morbidity in acromegaly constitutes 1.36 cases per 100 000. Because of uneven
prevalence of acromegaly we divided regions according to low, mild and high
prevalence. Regions with high prevalence of 2.0 and higher per 100 000:
Tashkent (2.6) and Tashkent region (2.0) and Djizak region (2.3); 2) regions with
mild prevalence of 1.0 to 2.0: Republic of Karakalpakstan (1.06), Bukhara region
(1.08), Syrdaria region (1.4), Navoi region (1.9), Khorezm region (1.7),
Namangan region (1.6), Fergana region (1.8). Regions with low prevalence of
1.0 and lower: Samarkand region (0.8), Andijan (0.8), Kashkadarya (0.5) and
Surhadarya (0.9).
Mean age of patients was 42.6 years. Duration of the disease varied from 1 to 31
years. Age and sex distribution of patients with acromegaly showed the morbidity
prevalence in women and cases growth beginning from 30 to 44 years-old
(28.9%) with the peak in 45-59 years of age (39.7%) and by the age of 60 years it
constitutes similar numbers as in 16-29 years-old (12.9%). More than a half of
patients did not associate the beginning of the adenoma growth with any causes
and factors. Meanwhile in 15.7% of patients disease begun after psycho trauma
and stress. History analysis also revealed that viral infection and infammatory
brain disorders in 52 patients (14%) contributed to acromegaly development.
Forty-six female patients (12.5%) noticed disease development with pregnancy
whereas brain trauma and family history associated with adenoma growth in 32
patients (8.7%) and 19 patients (5.1%) respectively. Thus, acromegaly has subtle
beginning associated with neuroviral infections, psycho trauma and pregnancy.
The most common symptoms were changes in appearance such as nose, fngers,
feet enlargement in 94.8% of patients and headaches (81.8%), perspirations
(80%), face and hands edema (85.9%), weakness and work ability decrease
(81.8%). Additionally, 70.7% of women had dysmenorrhea or amenorrhea.
Conclusions
Acromegaly morbidity in the Republic of Uzbekistan constitutes 1.3 cases
per 100 000 and has uneven distribution in the regions of the country. High
prevalence revealed in Tashkent (2.6), Djzak rgion (2.3) and Tashkent region
(2.0). Peak age of acromegalic patients was 45-59 years (39.7%). Analysis of
contribution factors showed that the manifestation of the disease was associated
with psycho trauma and stress (15.7%), neuroviral infections (14%), pregnancy
(12.5%) and brain trauma (8.7%). Moreover the frst symptom of acromegaly can
be arterial hypertension (57.9%), headaches (81.8%), dysmenorrhea (70.7%),
lactorrhea (39.6%), hypothyroidism (62.3%) and IGT and diabetes (52.3%).
P5I4
Frequency of neuroendocrinal disturbances in patients with different
pituitary adenomas
Mukhlisa Shakirova & Yulduz Urmanova
Study objective
To study the frequency of neuroendocrinal disturbances in patients with different
pituitary adenomas.
Under our observation there were 53 patients with various pituitary adenomas, of
them female - 31, male - 22, middle age of 41.5 years. According to the aetiology
of the underlying disease patients were sorted out as follows: 39 patients had an
inactive pituitary adenoma, 2 - craniofaringeoma, 3 - Cushing`s disease, 25
prolactinoma, 1 - astrocytoma, 1 - meningioma, 1 - germinoma.
All patients underwent a complex of examinations including basic clinical,
biochemical, radio immune hormonal (GH, IGF1, prolactinum, LH, FSH, TSH,
ACTH, hydrocortisone, etc.), ophthalmologic (eyeground, vision felds) and
X-ray examination (CT, MRI of sella turcica), and also a questionnaire survey of
GH defciency (GHD) in adults (QoL). The control group consisted of 20 healthy
subjects of corresponding age.
Results
According to our data, in the 53 patients the following neuroendocrinal
disturbances were observed: secondary amenorrhea - in 13 (25%) patients,
primary infertility - in 5 (10%), galactorrhea - in 1 (2.5%), secondary
hypogonadism - in 6 (12.5%), secondary hypocorticoidism - in 6 (12.5%),
functional hyperprolactinemia - in 6 (12.5%), diabetes insipidus - in 1 (2.5%),
GH defciency - in 39 (73.5%), hypopituitarism - in 12 (22.6%), panhypo-
pituitarism - in 2 (3.7%), secondary hypothyrosis - in 6 (12.5%) patients.
The prevailing majority of patients had visual disturbances: bitemporal
hemianopsia - 41 (79.1%) patients, amaurosis unilateral - 4 (8.3%), 8 quadrant
unilateral hemianopsia - (16.6%), concentric narrowing of visual felds - 22
(41.6%), partial atrophy of optic nerves - 15 (29.1%), paracentral absolute
scotoma - 4 (8.3%) patients.
GHD in adults questionnaire (QoL) data analysis has shown that in our patients a
reliable signifcant depression of a psycho-emotional status took place in 39 cases
with GHD (73.5%).
Conclusions
i) The most frequent disturbance in patients with pituitary adenomas was the
bitemporal hemianopsia - 41 (79.1%) and GHD - in 39 patients (73.5%). ii) A
feature of clinical manifestations of GHD in adults is a signifcant depression of a
psycho-emotional status of patients against the background of neuroendocrinal
disturbances that is supported by the data of the special questionnaire (QoL) for
adults with GHD in all 39 patients (73.5%).
P5I5
Frequency of a postoperational hypopituitarism in patients with
pituitary tumors after transnasal hypophysectomies
Yulduz Urmanova & Mukhlisa Shakirova
Study objective
To estimate frequency of a postoperational hypopituitarism after transnasal
hypophysectomies (TNHE) in patients with pituitary adenomas.
Under our observation there were 24 patients with various pituitary adenomas, of
them: 14 females, 10 males; the middle age being 36.4 years. According to the
aetiology of the basic disease the patients were sorted out as follows: 17 patients
had an inactive pituitary adenoma, 1 - craniofaringeoma, 2 - Cushing`s disease,
2 - prolactinoma, 1 - astrocytoma, 1 - meningioma.
The 24 patients during the period from 2007 to 2009 underwent 33 surgical
operations under the guidance of Dr M P Powell (Great Britain) in neurosurgery
department of the Republican Scientifc Centre of Emergency Medical Aid
(the head - Prof. K E Mahkamov), of them TNHE was done on 32 patients,
bifrontal craniotomy - on 1 patient. Herewith 3 patients underwent TNHE
2 times, 3 - 3 times. Four patients underwent radial therapy as well.
All patients underwent a complex of examinations including radio immune
hormonal (STH, IGF1, prolactinum, LH, FSH, TSH, ACTH, hydrocortisone,
etc.), ophthalmologic (an eyeground, visual felds) and X-ray examination
(C?, MRI of cella turcica).
Results
According to our data, postoperational panhypopituitarism (defciency of GH,
LH, FSH, ACTHdiabetes insipidus) developed in 6 patients (25%), post-
operational partial hypopituitarism (defciency of GH, LH, FSH) - in 11 (45.8%)
and GH defciency - in 7 (29.1%) patients. Thus, the most obvious
neuroendocrinal disturbances after TNHE were revealed in 6 (25%) patients.
Conclusions
i) In the patients with pituitary adenomas who underwent TNHE, the monitoring
of all stimulating and peripheral pituitary hormones levels is recommended both
in the early and later postoperative periods. ii) Patients with pituitary adenomas
after TNHE require substitutive hormonal therapy by corresponding preparations
depending on the level of hormones (desmopressin, sexual and thyroid hormones,
corticosteroid preparations, GH).
P5I
Manifestation factors of the disease and complications rate in patients
with acromegaly from Aral Sea regions of the Republic of Uzbekistan
Yulduz Urmanova, Nazira Salakhova, Liliya Murtazaeva,
Khudoyar Askarov, Jenis Pirniyazov, Lola Romanova, Shukhrat Khodgaev
& Maryam Rakhmetova
Aim of the research
To study manifestation factors of the disease in patients with acromegaly in
patients from Aral sea regions of the Republic of Uzbekistan.
Of the 43 patients with acromegaly assessed in Khorezm Region and Republic of
Karakalpakstan (RKK) in 2009 22 were men (51.1%) and 21 women (48.8%).
Of the 17 acromegalic patients registered in RKK 4 male patients and 13 female
patients. Mean age of men 40.7 years-old and women 41.3 years-old. Of the
13 female patients 2 women (15.3%) received a radiotherapy while other
15 patients (88.2%) receive medical treatment with Bromergon. Duration of the
disease was from 1 to 25 years.
Of the 26 patients with acromegaly registered in Khorezm region 9 men and
17 women. Mean age of male patients 42.6 years-old and 42.1 years-old of
female patients. Of the 26 female patients with acromegaly 2 women (7.7%)
underwent transphenoidal surgery, whereas other 24 patients (92.3) receive
medical treatment with Bromergon.
Results
Seventeen patients with acromegaly registered and followed-up in RKK. These
patients developed complications such as secondary diabetes mellitus (DM)
in 2 patients (11.8%), impaired glucose tolerance (IGT) in 1 case (5.9%),
dyscirculation encephalopathy (DE) in 10 patients (58.8%), arterial hypertension
(AH) in 9 patients (52.9%), acromegalic cardiac myopathy in 4 patients (23.5%),
ischemic heart disease (IHD) in 2 patients (11.8%). Triggering factors were
traumas in 2 patients (11.8%), stress in 2 patients (11.8%) while 13 patients
(76.5%) had no any triggering issues.
Of the 26 patients with acromegaly registered in Khorezm region 9 men (34.6%)
and 17 women (65.4%). These patients developed complications such as
secondary diabetes mellitus (DM) in 11 patients (42.3%), IGT in 2 cases (7.7), DE
in 16 patients (61.5%), AH in 12 patients (46.2%), IHD in 2 patients (7.7%),
transitory brain blood fow failure in 16 patients (61.5%). Triggering factors were
traumas in 2 patients (3.8%), stress in 1 patient (3.8%) while 24 patients (92.3%)
had no any triggering issues.
Conclusions
i) Analysis of 43 patients with acromegaly in Aral Sea region showed the
prevalence of manifestation factors such as traumas in 3 patients (6.9%) and stress
in 3 cases (6.9%); ii) of the metabolic and vascular complications DE in 26
patients (60.4) prevailed, as well as AH in 12 patients (27.9%), transitory brain
blood fow failure in 16 patients (37.2%) and secondary DM in 13 cases (30.2%).
P5II
Pneumocystis pneumonia during conservative treatment of Cushing`s
syndrome: description of two cases
Filip Gabalec
1
, Jan Cap
1
, Eduard Havel
2
, Alzbeta Zavrelova
1
,
Jakub Radocha
1
& Jaroslav Cerman Jr
2
1
Second Department of Internal Medicine, Charles University Hospital,
Hradec Kralove, Czech Republic;
2
Department of Surgery, Charles
University Hospital, Hradec Kralove, Czech Republic.
The immunosuppressive effect of corticosteroids is well known. In some
circumstances prophylactic antibiotic therapy is routinely used to lower the risk of
opportunistic infections in immunocompromised patients with exogenous
hypercortisolemia. The incidence of opportunistic infection in endogenous
hypercortisolemia in Cushing`s syndrome is 11-17%, correlating with degree
of hypercotisolemia. Only several case reports have been published about
pneumocystis pneumonia in Cushing`s syndrome. Idea that pnemocystis
pneumonia appears after decreasing hypercortisolemia with medical treatment
is speculated. Two cases of severe pneumocystis pneumonia infection in severe
Cushing`s syndrome are described. The frst, 60 years old woman with
hypertension and hypokalemic alkalosis, who presented with plasma cortisol
3150 nmol/l (normal ,650), ACTH 250 pg/ml (normal ,50) and free urinary
cortisol 13 630 nmol/l/24 h (normal ,270). Dexamethasone suppression test
(0.5 mg, 6 hourly for 48 h) was not completed for bowel perforation (initially no
symptoms) incidentally founded during CT of abdomen. But no plasma cortisol
suppression was present even at frst day of test. Pituitary MR was negative and
inferior petrosal sinus sampling excluded pituitary dependent Cushing syndrome.
Treatment with etomidate and ketoconazole was started with rapid drop of plasma
cortisol (1222 nmol/l), but it was complicated with severe pneumocystis
pneumonia and sepsis. Antibiotics were used with good response. As no source
of ACTH production has been found the patient was subjected to bilateral
epinephrectomy.
The second case was a 20 years old man with severe osteoporosis and respiratory
failure with artifcial ventilation in recent history. There was no suppression in
plasma cortisol after dexamethasone test, central hypogonadism and pituitary
adenoma on MRI. Treatment with ketoconazole and etomidate was also started
before operation and depression in plasma cortisol was followed by severe
pneumocystis pneumonia requiring artifcial ventilation at ICU.
Both severe infections appeared soon after treatment inauguration. Trimetho-
prim/sulfamethoxazole prophylaxis seems to be reasonable during lowering
plasma cortisol with steroidogenesis blocking drugs.
P5I8
Use of the desmopressin test in the differential diagnosis of
Pseudo-Cushing state from Cushing`s disease
Giacomo Tirabassi, Emanuela Faloia, Roberta Papa, Giorgio Furlani,
Marco Boscaro & Giorgio Arnaldi
Division of Endocrinology, Polytechnic University of Marche, Ancona,
Marche, Italy.
Context
The desmopressin (DDAVP) test has been proposed to discriminate Cushing`s
disease (CD) from Pseudo-Cushing states (PC); however, current information on
its value is scarce and contradictory.
Objective
To assess the ability of the DDAVP test in distinguishing between these
conditions, with emphasis on subjects with mild hypercortisolism.
Design
Retrospective/prospective study.
Setting
Division of Endocrinology, Polytechnic University of Marche, Ancona, Italy.
Patients
Fifty-two subjects with CD, 28 with PC and 31 control subjects (CT).
Intervention(s)
DDAVP test and standard diagnostic procedures for the diagnosis of Cushing`s
syndrome.
Main outcome measure(s)
Diagnosis/exclusion of CD.
Results
Interpretation of the DDAVP test based on percent and absolute increment of
cortisol and ACTH did not afford acceptable values of both sensitivity (SE) and
specifcity (SP). CD diagnosis based on simultaneous positivity for basal serum
cortisol 331 nmol/l and absolute ACTH increment 4 pmol/l, and its
exclusion in subjects negative for one or both measures, yielded an SE of
90.3% and an SP of 91.5%.
The approach was also highly effective in distinguishing PC from: i) CD with
moderate values of urinary free cortisol (SE: 86.9%; SP: 92.8%); ii) CD with
moderate values of serum cortisol after dexamethasone suppression (SE: 86.6%;
SP: 92.8%); and iii) CD with moderate values of midnight serum cortisol (SE:
100%; SP: 92.8%).
Conclusions
Interpretation of the DDAVP test through a combination of parameters allowed
effective discrimination of CD from PC even in subjects with mild
hypercortisolism.
P5I9
The prognostic criteria for the efhciency of the long-termed
administration of somatostatin analogues
Vyacheslav Pronin
1
, Eugeny Gitel
1
, Irina Vasilyeva
1
, Mikhail Antsiferov
2
,
Tatiana Alexeeva
2
, Elena Goldman
2
& Olga Dorofeeva
2
1
Moscow Medical Academy, Moscow, Russian Federation;
2
Moscow
Endocrinology Health Center, Moscow, Russian Federation.
The effciency of the prolonged medical therapy of acromegaly with the
somatostatin analogues (SA) strictly correlates with the initial sensitivity to the
drug. Before the onset of SA therapy 114 patients with acromegaly (35 men and
79 women) aged 54 (48/61) years old (Me (25/75%) underwent the test with
Octreotide (Sandostatin): 300 g sc within 3 days. The decrease of IGF1 level
positively correlated with the age of the acromegaly onset (r0.38) and
negatively - with the growth hormone (r0.23) and IGF1 (r0.39) values,
as well as with the volume of the tumor (r0.39); P,0.001. The patients were
distributed into three groups due to the stage of decrease of IGF1 from the initial
level (,30, 31-60 and 60%). The treatment with Sandostatin LAR as a
primary or a secondary therapy proceeded within three years in dose of 20-40 mg
per 28 days. The biochemical remission was defned in 17% of 1st group (7/42),
in 44% of the 2nd group (16/36) and in 89% of the 3rd group (32/36) of patients
(P
1-2
0.012, P
1-3,2-3
,0.001). The term of remission onset in the 1st and the
3rd groups accounted for 12 (6/24) and 5.5 (3/6) months, respectively; the
suffcient dosage in these groups was 40 (30/40) and 20 (20/20) mg, respectively
(P
1-3
,0.001). The positive correlation (r0.7; P,0.001) was revealed between
the value of IGF1 decrease after the test with Octreotide and during the long-
termed treatment with SA. The tumor shrinkage in the 1st group was observed in
37%, the stabilization - in 22% and the subsequent growth - in 41% of the cases.
Defnitely, the lack of improvement was revealed in patients with the earlier onset
of the disease (31 (23/38) vs 42.5 (32/46) years old) and bigger volume of the
tumor (4.1 (2.8/6.3) vs 2.4 (1.3/2.8) ml). In the 3rd group the tumor shrinkage was
detected in 83%, the stabilization of the growth - in 17%, and the worsening - in
0% of the cases (P,0.001).
Conclusion
i) The maximum effciency of the prolonged medical treatment with the SA was
observed in patients with later acromegaly onset, lesser volume of the tumor and
in patients, sensitive to Octreotide. ii) The compulsory indications for the
operative treatment are the younger age of the patients, the big size of the tumor
and the resistance to Octreotide. iii) The test with the Octreotide enables to ensure
the prognostic criteria of effciency for the prolonged therapy, as well as to
develop the suffcient strategy of the treatment and to determine the starting
dosage of the SA.
P580
Incidence and dynamics of visual disturbances in hypothalamus and
pituitary mass lesions after transphenoidal surgery in the Republic
of Uzbekistan
Said Ismailov, Ashley Grossman, Michael Powell, Zamira Khalimova,
Yulduz Urmanova, Kozim Makhkamov, Gulchekhra Narimova
& Alisher Akbutaev
The Center for the Scientifc and Clinical Study of Endocrinology, Tashkent,
56, Mirzo Ulugbek Street, Uzbekistan.
Aim of the research
To study the visual complications rate in patients with different pituitary
adenomas.
We observed 24 patients with different pituitary adenomas, among them 14
women and 10 men. Mean age of patients was 36.4 years-old. According to the
ethiology pattern patients were divided as follow; 17 patients with non-
functioning pituitary adenomas, 1 patient with craniopharingioma, 2 patients
with Cushing disease, 2 patients with prolactinoma, 1 patient with astrocytoma
and 1 patient with meningioma. All 24 patients underwent transphenoidal surgery
(TSS). During the period from 2007 to 2009 there were 33 surgeries done one of
which was bifrontal craniotomy and 32 TSS. Three patients underwent 2 TSS, 3
patients underwent 3 TSS and 4 patients received radiotherapy after TSS.
Evaluations including hormonal (RIA GH. IGF1, prolactin, LH, FSH, TSH,
ACTH, cortisol), eye examinations (fundus, visual felds) and imaging (CT, MRI)
were performed in all patients before and after TSS.
Results
In pre-operative period 19 patients (79.1%) were presented with bitemporal
hemianopsia, 4 patients (16.6%) with unilateral quadrant hemianopsia, 10
patients (41.6%) with concentric visual narrowing, 2 patients (8.3%) with
unilateral amaurosis, and 7 (29.1%) and 1 (8.3%) patients with partial optic nerves
atrophy and paracentral absolute scotoma respectively.
Postoperativel vision signifcantly improved in operated patients. Complete
recovery was observed in 22 patients (91.6%), whereas visual acuity
improvement observed in 91.6% of patients.
Conclusions
i) The most common visual disturbance in patients with pituitary adenomas in
preoperative period was bitemporal hemianopsia (19 cases (79.1%)). ii) after TSS
visual recovery was observed in 22 of 24 patients (91.6%).
P581
The rate of vascular complications in acromegaly in the Republic of
Uzbekistan
Zamira Khalimova, Adliya Kholikova, Nazira Salakhova,
Yulduz Urmanova, Dinara Alieva, Khurshida Nasirova,
Gulchekhra Narimova & Shokhsanam Safarova
Aim of the research
To study the rate of vascular complications in acromegaly in the Republic of
Uzbekistan.
We observed acromegalic patients registered from 2007 to 2009 who are
dispensarized in the regions of the country. Of the 369 patients 143 were males
(38.7%) and 226 females (61.3%). Mean age of the patients was 42.6 years-old.
Duration of the disease varied from 1 to 31 years.
Results
We assessed the rate of ischemic heart disease (IHD), arterial hypertension (AH),
brain blood fow failure (BBF), dyscirculation encephalopathy (DE). As the
results show, patients with acromegaly have high rate of macrovascular, AH
revealed in 65.3% of patients, DE seen in 61.5% of cases whereas IHD and BBF
in 23.8 and 45.5% of patients respectively. To reveal the causes of high rate of
these complications we divided patients into groups according to the treatment
they were receiving. Analysis showed that of the 369 patients 60.4% had a
medical therapy with dopamine agonists, 113 patients (30.7%) had a radiotherapy
and 33 patients (8.9%) were operated. To assess the relation between the
treatment and complications we studied the rate of vascular complications in the
groups. Results in the medical treatment group showed 25.5% of IHD, 65.9% of
AH, 46.6% of BBF and 62.8% of DE, while in radiotherapy group these numbers
were 29.2, 68.1, 49.5 and 65.5% respectively. Operated patients developed IHD in
24.2% of cases, AH in 57.5%, BBF in 39.4% and DE in 60.5%. As the results
show, the complications rate in all groups is high, however, in operated patients
these numbers are relatively low than in other two groups. The highest vascular
complications rate seen in patients after radiotherapy.
Conclusions
Patients with acromegaly has a high rate of macrovascular complications, of
which the most common are AH (65.3%) and DE (61.5%). High rate of vascular
complications such as IHD (29.2%), AH (68.1%), BBF (49.5%) and DE (65.5%)
observed in patients after radiotherapy.
P582
Long and short-term therapy effectiveness with dopamine agonists in
acromegaly in the Republic of Uzbekistan
Said Ismailov, Zamira Khalimova, Adliya Kholikova, Yulduz Urmanova,
Liliya Murtazaeva, Dinara Alieva, Khurshida Nasirova
& Gulrukh Alimukhamedova
Aim of the research
To study long and short-term therapy effectiveness with dopamine agonists in
acromegaly.
Three hundred and sixty-nine patients with acromegaly registered by December, 1
2009 in the Republic of Uzbekistan. Of these patients we observed 20 cases with
GH-secreting pituitary adenoma. Age of the patients was from 19 to 63 years-old
(mean age 4019 years-old), duration of the disease was from 1 to 23 years.
Patients underwent clinical and biochemical assessment such as pituitary and
peripheral endocrine glands RIA tests, CT and MRI imaging of the pituitary, US
of internal organs and thyroid as well as visual felds, fundus, visual acuity and
neurological evaluation.
According to the duration of the disease we divided patients into two groups:
1st group with the duration of the disease of 1-5 years (10 patients with mean
duration of 2.61.2 years), 2nd group with the duration of the disease 6 and more
years (10 patients with mean duration of 8.22.2 years). All patients received
sole Parlodel (Bromergon, Bromocriptine) 5-7.5 mg per day, however in some
patients compliance was poor.
Results
Five year follow-up of patients with medical treatment allowed us to reveal
increase in cardiovascular complications in both groups despite regular dopamine
agonists treatment. In frst group these numbers increased by 90% while in second
group elevated by 100%. Central and peripheral nervous system complications
also increased in 8 patients from 1st group and in 10 patients from 2nd group.
Besides, all 20 patients had endocrine complications such as amenorrhea in all
women, lactorrhea in 12 patients, thyroid nodules in 9 patients and diabetes
mellitus anf impaired glucose tolerance in 2 and 6 patients respectively. Nervous
and gastrointestinal system disorders were similar in both groups and showed
90% of complications. Respiratory system complications were rare and did not
increase during 5 years (20% in frst group and 40% in second group). Growth of
oncology rate also did not revealed.
Conclusions
i) Treatment with dopamine agonists in patients with acromegaly is not effective to
suppress the activityof the disease andstopthe adenoma growth; ii) inorder toreduce
complications and to improve the quality of life of the patients complex therapy
recommended such as surgical and medical with more effective agents, e.g.
somatostatine, or radiotherapy with medical treatment depending on lesion size and
patient`s age; iii) analysis of complications development depending on the duration
of the disease showed less effectiveness of medical therapy alone. In this case on
early stages of the disease to decrease complications rate and to improve the quality
of life of the patients complex therapy recommended medical and radiotherapy or
medical and surgical depending on tumor size and age of the patient.
P583
Plasma asymmetric dimethylarginine, symmetric dimethylarginine,
homoarginine and arginine levels in patients with active acromegaly
Sibel Guldiken
1
, Bengur Taskiran
1
, C Hakan Karadag
2
, Ozgur Gunduz
2
,
Betul Ekiz Bilir
1
, Betul Ugur Altun
1
& Armagan Tugrul
1
1
Department of Endocrinology, Faculty of Medicine, Trakya University,
Edirne, Turkey;
2
Department of Pharmacology, Faculty of Medicine,
Trakya University, Edirne, Turkey.
Aim
Acromegaly is associated with accelerated atherosclerosis and cardiovascular
disease. Nitric oxide (NO) is enzimatically formed from L-arginine by endothelial
nitric oxide synthase (eNOS). Several studies have shown that reduction in NO
synthesis causes endothelial dysfunction and impaired endothelium-dependent
vasodilation. Asymmetric dimethylarginine (ADMA), the endogenous inhibitor
of NOS, accumulation plays a prominent role in the pathogenesis and in
progression of atherosclerosis. The aim of present study was to evaluate the
plasma ADMA, symmetric dimethylarginine (SDMA), homoarginine and
arginine levels as biochemical markers of endothelial functions in patients with
active acromegaly.
Twenty-one patients with active acromegaly and twenty controls were enrolled
in the study. Plasma ADMA, SDMA, homoarginine and arginine levels were
determined by HPLC. The patients and controls were matched for age, gender,
lipid levels, diabetes mellitus and hypertension.
Results
Plasma homoarginine and arginine levels were reduced in active acromegalic
patients compared to controls (P,0.001, P,0.05, respectively). There was no
signifcant difference in plasma ADMA and SDMA levels between groups
(P0.05).
Conclusion
In conclusion, our study demonstrated that reduced arginine levels rather than
ADMA levels play an important role for the development of endothelial
dysfunction in active acromegaly.
P584
Heparanase is highly expressed in GH-adenomas and regulates
proliferation of pituitary tumor cells
Hadara Rubinfeld
1
, Neta Ilan
2
, Dvora Nass
3
, Victoria Cohen-Kaplan
2
,
Orit Pappo
4
, Moshe Hadani
5
, Israel Vlodavsky
2
& Ilan Shimon
1
1
Institute of Endocrinology and Felsenstein Medical Research Center, Rabin
Medical Center, Petach Tikva, Israel;
2
Cancer and Vascular Biology
Research Center, Bruce Rappaport Faculty of Medicine, Technion, Haifa,
Israel;
3
Department of Pathology, Sheba Medical Center, Ramat-Gan,
Israel;
4
Department of Pathology, Hebrew University-Hadassah Medical
Center, Jerusalem, Israel;
5
Department of Neurosurgery, Sheba Medical
Center, Ramat-Gan, Israel.
Background
Pituitary adenomas are monoclonal neoplasms that may be either functional
(hormone-secreting) or non-functional. The processes associated with pituitary
tumor development and progression are mostly unknown. Remodeling of the
extracellular matrix (ECM) and cell adhesion were suggested to be involved in
pituitary tumorigenesis. Heparanase, an endoglycosidase capable of degrading
heparan sulfate, the main polysaccharide constituent of the ECM, is implicated in
diverse processes associated with ECM remodeling, such as development and
morphogenesis, angiogenesis, and tumor invasion. Here, we examined the role of
heparanase in pituitary tumorigenesis.
Methods
Human normal pituitaries and pituitary tumors were examined for heparanase
mRNA and protein expression using real-time PCR and immunohistochemistry,
respectively. Cell viability, assessed by XTT, and cell proliferation, assessed by
colony formation assays, were tested following incubation of GH3 and MtT/S
cells with recombinant heparanase. Cell viability and cell cycle progression, were
evaluated following heparanase gene silencing.
Results
Higher heparanase mRNA expression was noted in GH-tumors as compared with
normal pituitary. Non-functioning tumors usually presented low levels of
heparanase. Normal pituitaries and GH-tumors showed heparanase protein
expression, whereas it was absent in most non-functional tumors. Increased cell
viability of GH3 and MtT/S cells was observed following addition of recombinant
heparanase. Heparanase over-expression in these cells resulted in increased
colonies number by 2-3 fold, compared with control cells. Cell viability
decreased by 50%, following heparanase gene silencing, due to elevation of cells
at S and subG1 phases. Notably, addition of heparanase to MtT/S cells enhanced
Akt phosphorylation.
Conclusions
Our results suggest that heparanase enhances pituitary cell proliferation and may
thus contribute to pituitary tumor development and progression. This effect is
mediated, in part, by facilitating Akt phosphorylation, a well known survival
factor.
P585
The metabolic syndrome (MetS) in 2610 GH dehcient (GHD) subjects
before GH replacement: a KIMS (Phzer International Metabolic
Database) analysis
Johan Verhelst
1
, Anders F Mattsson
2
, Anton Luger
3
, Maria Thunander
4,7
,
Miklos Goth
5
, Maria Koltowska-Haggstrom
2
& Roger Abs
6
1
Department of Endocrinology, General Middelheim Hospital, Antwerp,
Belgium;
2
KIMS Medical Outcomes, Pfzer Endocrine Care, Sollentuna,
Sweden;
3
Universitatsklinik fur Innere Medizin III, Klinik Abt. fur
Endokrinologie und Stoffwechsel, Vienna, Austria;
4
Central Hospital,
Vaxjo, Sweden;
5
Department of Medicine, National Medical Centre,
Budapest, Hungary;
6
Department of Endocrinology, University of Antwerp,
Antwerp, Belgium;
7
Endocrinology, Lund University, Lund, Sweden.
Objective
To identify MetS and non-MetS in subjects with adult-onset GHD before start of
GH replacement and to compare prevalence of cardiovascular risk factors.
MetS was defned (IDF criteria) by the obligatory presence of increased waist
circumference (WC) and presence of at least two of following components:
hypertension, decreased HDL-cholesterol, increased triglycerides, diabetes
mellitus. The complementary group was defned as non-MetS.
The KIMS study population of 2610 subjects comprised 1243 (47.6%) MetS
(51% males, mean age 49.612.5 years, BMI 31.35.2 kg/m
2
) and 1367
(52.4%) non-MetS (51% males, mean age 45.513.6 years, BMI 27.0
5.0 kg/m
2
) subjects. Regression analyses with adjustment for age, gender and
BMI were done of relevant variables before start of GH treatment.
Results
The MetS group versus non-MetS group was characterized by: WC 101.6 vs
98.7 cm, HDL-cholesterol 1.07 vs 1.40 mmol/l, triglycerides 2.94 vs 1.66 mmol/l,
blood pressure 134/83 vs 128/78 mmHg (P,0.0001 for all). MetS group had
longer estimated GHD duration (P,0.05). With increasing number of MetS
components, an adverse trend for GHD duration (P,0.01), waist-hip ratio
(P,0.0001), WC (P,0.001), HDL-cholesterol (P,0.0001), triglycerides
(P,0.0001), and blood pressure (P,0.0001) was observed. No signifcant
differences were found for IGF1 SDS, lean or fat mass, total or LDL-cholesterol.
Presence of MetS was not infuenced by country of origin, aetiology of GHD,
previous radiotherapy, existence of isolated GHD, or number of additional
pituitary defciencies. History of cardiovascular (,2) and cerebrovascular
(,1.5) disorders and diabetes mellitus (,4.5) were more frequently encountered
in the MetS group.
Conclusion
In this KIMS population of adult-onset GHD, the metabolic syndrome was more
frequently encountered than in the general population, and subjects with Mets
were characterized by more adverse cardiovascular risk factor profle, an
increased frequency of vascular complications and diabetes mellitus before start
of GH replacement.
P58
Effect of octreotide LAR on the volume of pituitary adenoma in
acromegalic patients
Anna Krzentowska, Agata Baldys-Waligorska & Filip Golkowski
Department of Endocrinology, Collegikum Medicum, Jagiellonian
University, Krakow, Poland.
We evaluated the volume of pituitary adenoma in patients treated with ocreotide
LAR (SSLAR) prior to surgery.
Twenty-six patients (22 females and 4 males, mean age 57.515.0 years) were
treated with SSLAR: 5 patients with microadenoma - during 6 months, and 21
patients with macroadenoma - during 12 months before surgery, as recommended
by the Polish Society of Endocrinology. Concentration of hGH and IGF1 was
evaluated at 0, 3, 6 and 12 months, while MRI images were taken at 6 and
12 months prior to surgery. Volumes of pituitary adenomas, estimated as those of
an ellipsoid, were based on MRI image projections. Basic statistics, Shapiro-Wilk
and Wilcoxon tests were applied.
Results
Median values of hGH and IGF1 concentrations prior to treatment were 20 ng/ml
(min 3.1; max 143.0) and 743.1 ng/ml (min 196.6; max 4744.4), respectively.
After 6 and 12 months the median value of hGH concentration decreased to
10.3 ng/ml (min 2.1; max 68.3) and 3.0 ng/ml (min 1.2; max 17.7), respectively,
while the median values of IGF1 became 570.0 ng/ml (min 137.6; max 1372.7)
and 342.0 (min 154.8; max 1099.7), respectively. All differences were statistically
signifcant (P,0.05). Prior to treatment the median values of the projected
dimensions of pituitary adenomas along three orthogonal directions were:
15.5 mm (min 3.0; max 53.0), 12.0 mm (min 1.0; max 35.0) and 11.0 (min 1.0;
max 32.0), while after 12 months of SSLAR administration, the respective
median values were observed to decrease to: 9.0 mm (min 6.0; max 20.0), 8.5 mm
(min 5.0; max 17.0), and 8.0 mm (min 5.0; max 14.0). The median volumes of
adenomas were thus estimated at 1.1 ml (min 0.01; max 31.1) prior to treatment,
0.9 ml (min 0.1; max 11.7) after 6 months, and 0.37 ml (min 0.08; max 2.5) after
12 months of SSLAR administration.
Conclusions
Treatment of acromegalic patients with somatostatin analogues not only
decreases hGH and IGF1 concentrations, but also appears to diminish the size
of the tumour, in about 50% of patients treated, leading to general improvement of
surgery conditions.
P58I
Evaluation of efhcacy of somatostatin analogue octreotide LAR in
acromegalic patients following non-radical surgery of pituitary
adenoma
Agata Baldys-Waligorska, Anna Krzentowska & Filip Golkowski
Department of Endocrinology, Collegium Medicum, Jagiellonian
University, Krakow, Poland.
Treatment of acromegalic patients with somatostatin analogues decreases hGH
and IGF1 concentrations, improves general and metabolic conditions and
decreases morbidity and mortality in these patients. We assessed the effcacy of
octreotide LAR (SSLAR) in treating acromegalic patients following non-radical
surgery of pituitary adenoma at a single centre.
At our Centre we follow 85 acromegalic patients who underwent surgery,
including 47 patients (29 female and 18 male, of mean age 41.114.9 years) who
required further treatment with SSLAR due to non-radical surgery. Within this
group 44 patients presented with macroadenoma and 3 with microadenoma.
Following surgery, concentrations of hGH in OGTT and IGF1 were measured to
evaluate the result of surgery, and repeated 3, 6, 12, 18 and 24 months later. Basic
statistics, Shapiro-Wilk and Wilcoxon tests, and ANOVA Friedman test, using
the Statistica software, were applied.
Results
Following surgery, respective median values of hGH and IGF1 concentrations
were 5.65 ng/ml (min 1.7; max 43.5) and 520.0 ng/ml (min 154.0; max 1135.0).
After 6, 12, and 24 months of SSLAR treatment median values of hGH
signifcantly decreased (P,0.05) to 3.3 ng/ml (min 0.9; max 95.9), 3.15 ng/ml
(min 0.65; max 49.0) and 2.35 ng/ml (min 0.8; max 50.0), respectively. The
differences between median hGH concentrations at 12 and 24 months were
statistically signifcant (P,0.05). After 6, 12, and 24 months of SSLAR treatment
respective median IGF1 concentrations also decreased to 384.5 ng/ml (min 146.0;
max 1645.0), 316.0 ng/ml (min 114.8; max 840.0) and 404.6 ng/ml (min 174.4;
max 1235.0) which were statistically signifcant (P,0.05) against the value prior
to SSLAR treatment. After 6 months of SSLAR treatment, hGH,2.5 ng/ml and
IGF1 normalization were achieved in 36.4 and 44.4% of patients, respectively.
After 24 months of SSLAR treatment, hGH,2.5 ng/ml and IGF1 normalization
were achieved in 54.8 and 53.3% of patients, respectively.
Conclusions
(i) Long-term SSLAR treatment of non-radically operated acromegalic patients
is advisable as its effcacy improves with time; (ii) We believe that the
predomination of pituitary macroadenoma in our patient group (93%) has
negatively biased our results.
P588
Prospective evaluation of traumatic brain injury mediated
hypopituitarism 1 year after the event
Jacinta Santos
1
, Miguel Carvalho
2
, Isabel Paiva
1
, Carla Baptista
1
,
Carlos Ferro
2
, Alexandra Vieira
1
, Marcia Alves
1
, Sofa Gouveia
1
1
1
EPE - Endocrinology Department, Coimbra`s University Hospital,
Coimbra, Portugal;
2
EPE - Neurosurgery Department, Coimbra`s
University Hospital, Coimbra, Portugal.
Introduction
Traumatic brain injury (TBI) is considered a rare cause of pituitary dysfunction.
Recently, some retrospective studies demonstrated that TBI-mediated hypopi-
tuitarism is more frequent than previously known. However, its prevalence and
natural history are still unclear.
Objectives
To evaluate the prevalence of hypopituitarism 1 year after TBI and the association
between the seriousness of the traumatism and the pituitary defcits.
Twenty-two patients (64% male, 45.925.8 years; 36% female; 68.418.9
years) with TBI, but without previous pituitary dysfunction were included.
Clinical and hormonal evaluations were performed 1 year after the traumatic
event.
Results
Types of traumatism: subdural haematoma (twelve), brain contusion (eight), brain
haematoma (three) and bone fracture (three). The causes of traumatism were: falls
(59.1%), traffc accidents (22.7%), sportive accidents (9.1%) and working accidents
(9.1%). In what concerns to the seriousness, evaluated through the Glasgow Scale,
72.7%were mild traumatisms, 18.2%moderate and 9.1%severe. Atotal of 31.8%of
the patients were submitted to surgery. One year after the event, on clinical
evaluation: asymptomatic (45.5%), headaches (9.1%), amnesia (18.2%), VI pair
paralysis (4.5%) and disartria (4.5%). No patient presented diabetes insipidus.
Endocrine evaluation: TSH 1.680.97 (0.4-4.0 UI/ml), fT4 1.30.19
(0.8-1.9 ng/dl), PRL 6.323.56 ng/ml (,20), ACTH 24.4415.55 pg/ml (9-52),
cortisol 11.594.07 g/dl (5-25) and GH 1.511.51 ng/ml (,4). Through the
quantifcation of IGF-I, according to the age group, 31.8% presented defciency.
Conclusions
GH defciency, the most frequent endocrine consequence of TBI, according to the
literature, was the only pituitary insuffciency diagnosed. There wasn`t a relation
between the seriousness of the traumatismand the endocrine consequences, since six
of these patients suffered a mild TBI and one had a severe TBI. Considering the short
period of time between the traumatism and the evaluation, it`s essential to follow
these patients, in order to diagnose and treat precociously any pituitary insuffciency.
P589
The inuence of the successful treatment of acromegaly on tissue
distribution and overall BMD
Yuriy Poteshkin, Vyacheslav Pronin, Irina Sokolina & Evgeniy Gitel
I.M. Sechenov Moscow Medical Academy (MMA), The State Educational
Institution of Higher Professional Training under The Federal Agency of
Health Care and Social Development, Moscow, Russian Federation.
Acromegaly (A) is associated with the bone overgrowth and soft tissue
abnormalities due to anabolic, lipolytic and sodium retaining actions of GH.
Aim
To investigate the effects of medical treatment on bone mineral density (BMD) of
proximal femur, lumbar spine and tissue distribution. We observed 56 patients (14
M and 42 F) with A. BMD was measured using dual-energy X-ray absorptiometry
with 'total body` program. The patients were treated with SandostatinLARin
dose 20-40 mg/28 days. Patients were distributed into two groups: Group I - 24
patients with active A (53.512.6 years old (MeanS.D.), BMI - 32.6
7.1 kg/m
2
; IGF1 - 614.3286.7 ng/ml), Group II - 32 cured patients (58.89.8
years old, BMI - 31.814.9 kg/m
2
, IGF1 - 186.950.0 ng/ml). The control
group (Group III) included 18 healthy volunteers (6 M and 12 F) aged 55.48.0
years old and BMI 30.03.6 kg/m
2
. Osteopenia (T or Z criteria (depending on
the age) ,1.0 and 2.5) was diagnosed in 21% patients of Group I, in 31%
patients of the Group II and in 44% in controls. A moderate correlation was
revealed between IGF1 value and mineral bone mass (r0.43; P,0.05),
proximal femur T or Z criteria (r0.43; P,0.05). Correlation between the age
and femur T or Z criteria was stronger in Group III in comparison with the Group I
(r0.72 and r0.47, respectively; P,0.05). An age-specifc osteopenia
had lesser prevalence in Group I comparing with controls in contrast to Group II.
This data shows the protective role of IGF1 on BMD. Spondyls diameter in
patients of Group I was signifcantly bigger than in control group. Lean mass
in Group I was signifcantly higher than in Groups II and III. Peculiarities in tissue
distribution correlates with IGF1 level. The positive correlation (r0.52;
P,0.05) was found between the lean mass and the value of IGF1. The overall
lean mass growth in the Group I is mainly distributed in the abdomen area in
contrast to other groups.
Conclusion
i) Development and treatment of A. are accompanied by different functional and
morphological alterations which require the additional therapeutic intervention.
ii) After the normalization IGF1 value its protective action on BMD decreases and
such patients don`t differ from the subjects of the same age by tissue distribution
and overall BMD. iii) The investigation of the spine in patients with A is less
informative for the diagnostic of BMD due to the bone overgrowth this area
(osteophyte growth, intervertebral disk ossifcation and diameter extension).
P590
Sleeping apnea syndrome (SAS) in acromegaly and obesity
Daniela Amzar
1
, Stefan Mihaicuta
2
, Ioana Golu
1
, Melania Balas
1
& Ioana Zosin
1
1
Department of Endocrinology, University of Medicine and Pharmacy V.
Babes, Timisoara, Romania;
2
Clinic of Pneumology, University of Medicine
and Pharmacy V. Babes, Timisoara, Romania.
Acromegaly is associated with respiratory and cardiovascular morbidities and
high mortality rate. The present study evaluates clinical aspects in acromegalic
and obese patients with sleep apnea syndrome (SAS).
Material and method
The patients were diagnosed and followed-up in the Clinic of Endocrinology,
Timisoara, in the period 2006-2009. All the cases were confrmed and
investigated as present guidelines recommend. The polysomnographic investi-
gated study group comprised 19 acromegalic patients and 13 obese subjects
(BMI42.6 kg/m
2
).
Results
The prevalence SAS in acromegaly group was 47.3% (9 out of 19 patients). The
median of minimum GH level during OGTT was 8.9 ng/ml in apnea group and
5.3 ng/ml in nonapneic group (P0.05). The mean age was 5011.8 years
(95%CI 40.95-59.05), the neck circumference was 40.333.84 cm (95%CI
37.38-43.29), the BMI was 34.665.77 kg/m
2
and the waist circumference was
105.1110.6 cm (95% CI 96.94-113.3). A percent of 77.7% presented intense
snoring, Epworth score 7.554.16 (2-15) (95%CI 4.36-10.75). 47.3% presented
SAS (12.5%- mild, 37.5%-moderate, 50%-severe form). The mean saturation was
94.771.20% (93-97%) (95% CI 93.85-95.70), the desaturation index was
8.226.78 per hour (95% CI 3.01-3.43) and the lowest desaturation was 85.22
5.29% (76-93%) (95%CI 81.16-89.29). CPAP was performed in only one
patient, with normalization of the hypopnea-apnea index. Five cases presented
stage II and III essential hypertension, pulse rate 78.414.1 beats/min (62-110)
(CI 95% 68.29-88.51) and one case was diagnosed with coronary artery disease.
SAS in obesity group was present in 3 out of 13 patients (23.7%).
Conclusion
The study confrms the high prevalence of SAS in acromegaly; half of the
acromegaly cases showed severe forms of sleep apnea, with high cardiovascular
impact, with daily somnolence, despite the fact that they are snoring and have
quite normal neck circumference. GH serum level is not an indicator for the
presence and severity of sleep apnea.
P591
The effect of gonadal replacement on insulin resistance in hypogonadal
adult men with GH dehciency
Marko Stojanovic, Sandra Pekic, Mirjana Doknic, Dragana Miljic,
Marina Nikolic-Djurovic & Vera Popovic
Neuroendocrine Unit, Institute of Endocrinology, Diabetes and Metabolic
Diseases, University Clinical Center, Belgrade, Serbia.
Introduction
Both GH defciency (GHD) and male hypogonadism are thought to be associated
with an increased cardiovascular morbidity and mortality which is at least partly
attributed to higher Insulin resistance. Potential reversibility of increased risk
factors after gonadal replacement was assessed in this study, by comparing
replaced and unreplaced hypogonadal men with GHD.
Seventy-seven hypogonadal adult male patients with GHD have been divided in
two groups according to their gonadal replacement status: hypogonadal GHD
patients on standard monthly testosterone replacement (n42), and unreplaced
hypogonadal GHD men (n35). Body mass index (BMI) and waist to hip ratio
(WHR) were calculated from standard anthropometric measures. Glycaemia and
insulinaemia were followed in OGTT with area under the curve (AUC) and
HOMA index calculated.
Results
Unreplaced hypogonadal GHD men had a signifcantly higher WHR compared to
replaced hypogondal GHD men (0.980.11 vs 0.950.13; P,0.05). OGTT
revealed that unreplaced hypogonadal GHD men had a signifcantly higher basal
insulin (16.361.57 vs 12.251.02 mU/l; P,0.05), signifcantly higher insulin
peak (127.3917.14 vs 75.527.36 mU/l; P,0.05) and signifcantly higher
insulin AUC (8365.51093.8 vs 5050.0468.4 mU/l per 120 min; P,0.05) in
OGTT, and signifcantly higher HOMA index (3.240.32 vs 2.410.23;
P,0.05) as compared to replaced hypogondal GHD men.
Conclusion
Gonadal replacement in hypogonadal adult men with GHD appears to positively
infuence parameters of Insulin resistance such as WHR, peak insulin and insulin
AUC in OGTT and HOMA index.
P592
The anorexigenic neuropeptide, NUCB2/nesfatin-1, is indispensable for
normal puberty onset in the female rat
David Garcia-Galiano
1,2
, Victor M Navarro
1
, Juan Roa
1
, Francisco
Ruiz-Pino
1
, Juan M Castellano
1,2
, Carlos Dieguez
2,3
, Leonor Pinilla
1,2
& Manuel Tena-Sempere
1,2
1
University of Cordoba, Cordoba, Spain;
2
CIBER Fisiopatologia de la
Obesidad y Nutricion, Cordoba, Spain;
3
University of Santiago de
Compostela, Cordoba, Spain.
The hypothalamic peptide, nesfatin-1, derived from the precursor NEFA/nucleo-
bindin2 (NUCB2), was recently identifed as central anorexigenic molecule,
acting in a leptin-independent manner. Yet, its potential involvement in the
regulation of other biological functions gated by body energy status remains
unexplored. We show herein that NUCB2/nesfatin-1 is involved in the control of
female puberty. NUCB2/nesfatin mRNA and protein were detected at the
hypothalamus of pubertal female rats, with prominent signals at lateral
hypothalamus (LHA), paraventricular (PVN) and supraoptic (SON) nuclei.
Hypothalamic NUCB2 expression raised along pubertal transition, with
detectable elevations of its mRNA levels at LHA, PVN and SON, and three-
fold increase of its total protein content between late-infantile and peri-pubertal
periods. Conditions of negative energy balance, such as 48-h fasting or sustained
sub-nutrition, decreased hypothalamic NUCB2 mRNA and/or protein levels in
pubertal females. At this age, central administration of nesfatin-1 induced modest
but signifcant elevations of circulating gonadotropins, whose magnitude was
notably augmented in conditions of food-deprivation. Continuous i.c.v. infusion
of antisense morpholino oligonucleotides (as-MON) against NUCB2 along
pubertal maturation, which markedly reduced hypothalamic NUCB2 protein
content, delayed vaginal opening and decreased ovarian weights and serum LH
levels. Yet, in adult cyclic female rats, a similar as-MON strategy failed to alter
pre-ovulatory gonadotropin surges, despite analogous suppression of hypo-
thalamic NUCB2. In sum, our data are the frst to disclose the indispensable role
of the neuropeptide, NUCB2/nesfatin-1, in the central networks driving pubertal
activation of gonadotropic axis; a function that may contribute to the integral
control of energy homeostasis and puberty onset.
P593
Investigation of skin characteristics in patients with acromegaly
Murat Borlu
2
, Zuleyha Karaca
1
, Hatice Yildiz
2
, Fatih Tanriverdi
1
,
Gulsah Elbuken
1
1
1
1
Kayseri, Turkey;
2
Department of Dermatology, Erciyes University Medical
School, Kayseri, Turkey.
Introduction
Presence of GH receptor in human skin and its appendages suggests a direct effect
of GH on skin characteristics. Wet and oily skin due to hyperhidrosis and
increased sebum production were described in acromegaly patients.
Objective
The aim of the study was to examine the hydration via capacitance, sebum
content, transepidermal water loss, pH and temperature of the skin in patients with
acromegaly. The data were compared with that of control subjects.
A total of 42 patients with acromegaly (mean age: 43) and 22 control subjects
were included in this study. The patients had newly or previously diagnosed
acromegaly with active disease, which was confrmed with elevated IGF1 levels
according to age and sex and GH response to OGTT, at the time of investigation.
The patients were assessed after appropriate replacement therapy for defcient
hormone(s) if present. Skin properties were measured on forehead and forearm by
Sebumeter SM810, Corneometer CM825, Tewameter TM210 and Phmeter
PH900 as noninvasive and well-established measuring methods.
Results
The sebum content was increased on forehead and forearm in patients with
acromegaly when compared with control subjects (239.24 and 161.32 g/cm on
forehead, 36.66 and 12.77 g/cm on forearm in patients with acromegaly and
control group respectively). The skin pH measure, temperature and average
TEWL of the patients were not statistically different from the controls.
Discussion
These data suggest that GH and/or IGF1 have a modulator role on several skin
characteristics. Skin changes in patients with acromegaly could be explained by
increased sebum secretion, further functional and histomorphological studies are
warranted to clarify the effects of GH on skin physiology.
P594
Efhcacy and safety of combined treatment with somatostatin analogues
(SA) AND pegvisomant (PEG) in acromegalic patients resistant to SA
Renata S Auriemma, Ludovica F S Grasso, Mariano Galdiero, Maria C De
Martino, Alessia Cozzolino, Pasquale Vitale, Annamaria Colao
& Rosario Pivonello
University 'Federico II`, Naples, Italy.
The GH-receptor antagonist PEG, used as monotherapy or in combination to SA,
has been demonstrated to normalize IGF1 levels in up to 90% of acromegalic
patients after unsuccessful surgery and/or radiotherapy and resistant to
conventional SA treatment. The aim of this study is to evaluate the effcacy
and safety of combined treatment with SA plus PEG in a cohort of acromegalic
patients resistant to conventional SA therapy. Thirty-two acromegalic patients
(17 M, 15 F, age 39.612.6 years) were recruited; GH and IGF1 levels,
maximum tumoral diameter, systolic (SBP) and diastolic (DBP) blood pressure,
glucose and lipid profle and liver function enzymes were evaluated at diagnosis,
after long-term high-dose SA therapy and after 12-24 months of combined
therapy with SA plus PEG. Compared to baseline, SA induced a signifcant
reduction, but not normalization, in GH and IGF1 levels (P,0.001), as well as in
maximum tumoral diameter (P0.003) and insulin levels (INS, P,0.01). The
addiction of PEG to SA induced a further decrease, until normalization, of GH
and IGF1 levels (P,0.001), glycated haemoglobin (HbA1c, P,0.001) and INS
(P,0.001), as well as the signifcant increase of gamma glutamyltransferase
(GT, P0.03), although they were still normal. Eleven out of 32 patients were
treated also with PEG as monotherapy, inducing the signifcant reduction in IGF1
levels (P,0.001), SBP (P0.02), INS (P,0.001) and triglycerides levels
(TRIG, P,0.05) when compare to SA treatment. In those patients, combined
therapy with SA plus PEG induced a further decrease in GH and IGF1 levels
(P,0.001), without any further change in metabolic parameters and blood
pressure. None of the patients experienced a signifcant increase in liver function
enzymes or in tumor diameter during PEG monotherapy or SA plus PEG
combined treatment. At diagnosis, six patients were afficted with type 2 diabetes
mellitus and were treated with insulin-sensitizers; after SA plus PEG therapy,
only fve patients needed treatment with insulin-sensitizers, but at lower dose, and
one patient discontinued therapy. In conclusion, the results of the present study
demonstrated that combined treatment with SA plus PEG is safe and effective in
controlling GH and IGF1 levels excess as well as metabolic and cardiovascular
complications of acromegaly.
P595
Pituitary functions in patients with chronic subdural hematoma
Mikulas Kosak
1
, Vaclav Masopust
2
, David Netuka
2
, Zdenka Lacinova
1
,
Michal Krsek
1
, Josef Marek
1
& Vaclav Hana
1
1
Third Department of Internal Medicine, Faculty of Medicine 1, General
Faculty Hospital, Charles University, Prague, Czech Republic;
2
Neurosurgery Department, Faculty of Medicine 1, Charles University,
Military Hospital, Prague, Czech Republic.
Certain degree of hypopituitarism has been revealed in a signifcant number of
patients who suffered traumatic brain injuries or subarachnoid hemorrhage.
Microhemorrhages, necrosis, tissue infarcts and vasoconstriction are reported as
mechanism of hypothalamo-pituitary dysfunction. Assessment of hypothalamo-
pituitary endocrine functions in patients with chronic subdural hematomas has not
been published yet, although dysfunction of hypothalamo-pituitary unit can be
expected (head trauma, compression and oedema of the brain with shifting of the
midline structures.
Aims
Evaluation of the pituitary functions in patients with chronic subdural hematoma
immediately after surgical treatment and during 1 year follow-up.
We have examined 22 patients (17 men, 5 women, 51-86 years old, mean 70.6
S.D. 9.8 years) so far. Twelve patients (9 men/3 women) have been examined
prospectively (prospective group) and 10 patients (8 men/2 women) were tested
only 12 months after the operation (retrospective group). In the prospective group
the patients in the frst days after evacuation of the hematoma and then 3 and
12 months after the operation are being tested. Basal levels of pituitary hormones
and hormones of dependent peripheral glands, plasma cortisol during 250 g
tetrasoactrin (Synacthen) test, GH after GHRHarginin stimulation and TSH
after TRH stimulation are assesed.
Results
In the acute phase, central hypogonadism was diagnosed in four male patients
among the prospectively followed patients. In three of them gonadotrophic axis
normalised within 3 months after the operation (one patient hasn`t been retested
yet). In one patient partial hypocorticalism and central hypogonadism have
developed after 3 months. In the retrospective group central hypogonadism was
diagnosed in one patient.
Conclusions
Preliminary data from our group of patients show that chronic subdural hematoma
may be accompanied with a partial pituitary dysfunction and that it can develop
even with a time delay. Further evaluation of a larger group is necessary.
The project is supported by a grant of Czech Ministry of Health NS 9794 - 4.
P59
Comparison of the efhcacy of GH therapy in short children with
decreased nocturnal GH secretion and either normal or subnormal
results of GH stimulating tests
Maciej Hilczer
1,2
, Joanna Smyczynska
1,2
, Renata Stawerska
1,2
& Andrzej Lewinski
2,3
1
Department of Pediatric Endocrinology, Medical University of Lodz, Lodz,
Poland;
2
Department of Endocrinology and Metabolic Diseaeses, Polish
Mother`s Memorial Hospital - Research Institute, Lodz, Poland;
3
Department of Endocrinology and Metabolic Diseaeses, Medical
University of Lodz, Lodz, Poland.
Indications to GH therapy in children with short stature are still a matter of
discussion.
We compared frst-year response to GH therapy in 80 children (62 boys, 18 girls),
age 12.72.4 years (meanS.D.) with different disorders of GH secretion. In all
the patients nocturnal GH secretion assessed during 3 h after falling asleep was
decreased (,10 ng/ml). In 40 children GH defciency (GHD) was diagnosed on
the ground of decreased GH secretion (,10 ng/ml) in 2 standard stimulating tests
(with clonidine and glucagon). In other 40 age-matched children the results of GH
stimulating tests were normal but IGF1 secretion was decreased and
neurosecretory dysfunction of GH secretion (NSD) was diagnosed. All the
children were treated with GH in a dose of 0.210.02 mg/kg per week. Patients`
height velocity (HV), IGF1 secretion and its bioavailability (IGF1/IGFBP-3
molar ratio) were assessed before and after 1 year of GH therapy.
Before treatment height SDS was 2.970.72 in GHD and 2.990.64 in
NSD, HV was 3.50.8 cm/year and 3.60.9 cm/year, IGF1 SDS for age and sex
was 1.981.07 and 2.301.02, IGF1/IGFBP-3 molar ratio was 0.200.09
and 0.180.06, respectively. After 1 year of GH therapy, HV increased to 9.9
2.1 cm/year in GHD and 9.61.8 cm/year in NSD group, IGF1 SDS for age
and sex was 0.650.86 and 0.470.93, IGF1/IGFBP-3 molar ratio was 0.43
0.13 and 0.410.15, respectively. There were no signifcant differences in any
of the analysed auxological parameters and in IGF1 secretion between the children
with GHDand NSD, both before and after 1 year of GHadministration. An increase
of all the analysed indices in both groups was similar and signifcant (P,0.001).
The response to GHtherapy in children with decreased nocturnal GHsecretion and
either subnormal or normal results of GHstimulating tests was similar. It seems that
in children with decreased nocturnal GH secretion and decreased IGF1
concentration the indications to GH therapy should not depend on the results of
GH stimulating tests only, however, further observation up to fnal height is
necessary to confrm this preliminary conclusion.
P59I
Contribution of the molecular biology to the study of the behaviour of
pituitary adenomas
Laura Sanchez-Tejada
1
2
, Maria Niveiro
3
,
Gloria Peiro
3
, Oscar Moreno
2
, Ignacio Aranda
3
& Antonio A Pico Alfonso
3
1
Molecular Biology, Unidad Investigacion, Hospital General Universitario
de Alicante, Alicante, Spain;
2
Deparment of Endocrinoloy, Hospital General
Universitario de Alicante, Alicante, Spain;
3
Department of Pathological
Anatomy, Hospital General Universitario de Alicante, Alicante, Spain.
Background
There is an increasing interest to fnd specifc prognostic markers of the
aggressive behaviour of some pituitary adenomas (PA). The most studied markers
have been the immunohistochemical staining for Ki-67 and p53. The aim of this
study was to evaluate the relevance as possible prognostic markers of growth
factors (IGF1R), angiogenic factors (VEGF and his receptor) and new genes
(PTTG) versus the immunohistochemical expression of Ki-67 and p53 in PA.
Design
In this retrospective descriptive study, we analyzed 56 human PA samples: 32
gonadotrophic (GT), 6 corticotrophic (CT), 6 somatotrophic (ST), 4 lactotrophic
(LT), 1 thyrotrophic (TT), 1 null-cell and 6 GH-PRL-secreting adenomas (GLT),
based on OMS 2004 classifcation. We evaluated the VEGF, VEGFR, PTTG and
IGF1R mRNA expression by quantitative real-time PCR using Taqman
technology and TaqMan Gene Expression Assays (Applied Biosystems).
Immunohistochemical (IHC) staining was performed in whole sections for ER
(cut-off 10%), Ki-67 and p53 (cut-off 20%). In addition we revised the extension
in magnetic resonance imaging of 17 patients. The Student t-test was used for
statistical analysis.
Results
We observed than the histology subtype GT had the highest expression of VEGF
(P0.007), VEGFR (P0.011) and IGF1R (P0.003) while CT had the lowest
expression of these genes (P0.021, P0.004 and P0.026 respectively). The
expression of PTTG was decreased in the TT adenoma respect the above of the
other subtypes (P0.045). Overexpression of p53 was positively correlated with
the level of VEGF and VEGFR expression (P0.001 and P0.02). The tumors
with diffuse extension shown association with more IGF1R expression
(P0.003) but there was no correlation with Ki-67, p53 or ER status.
Conclusions
Our preliminary fndings suggest that these genes behave differently depending on
the histological subtype and that some of them could report more information
about the behaviour of PA than the expression for Ki-67 or p53.
P598
The occurrence of hypothyroidism during the initial phase of GH
replacement therapy in children with GH dehciency: clinical
implications
Joanna Smyczynska
1,2
, Renata Stawerska
1,2
, Andrzej Lewinski
2,3
& Maciej Hilczer
1,2
1
Department of Pediatric Endocrinology, Medical University of Lodz, Lodz,
Poland;
2
Department of Endocrinology and Metabolic Diseaeses, Polish
Mother`s Memorial Hospital - Research Institute, Lodz, Poland;
3
Department of Endocrinology and Metabolic Diseaeses, Medical
University of Lodz, Lodz, Poland.
Normal thyroid hormone secretion (or appropriate L-thyroxin substitution) is
necessary for the optimal effect GH administration on growing rate. The decrease
of free thyroxin (FT
4
) levels at GH therapy onset was reported in several studies.
The aim of our study was to assess the incidence of hypothyroidism (HT) during
the initial phase of GH administration in previously euthyroid children with GH
defciency (GHD) and to compare the frst-year response to the therapy in the
patients with and without HT.
The analysis comprised 67 children (53 boys, 14 girls), age 12.32.2 years
(meanS.D.), with GHD (GH secretion ,10.0 ng/ml, decreased IGF1 levels),
who were treated with GH in a dose of 0.200.02 mg/kg per week for - at
least - 1 year. In all the patients TSH and FT
4
concentration was assessed after
3-6 months of GH administration and HT was diagnosed in 17 of them (25.4%)
on the ground of either decreased FT
4
level (eight cases) or increased TSH (eight
cases), or both (one case). The appropriate L-thyroxin substitution was
administered very soon. Height velocity (HV), IGF1 secretion (expressed as
IGF1 SDS for age and sex) and its bioavailability (IGF1/IGFBP3 molar ratio)
before and after 1 year of GH therapy was compared in both groups.
There were no signifcant differences in any of the analysed parameters among the
groups before GH therapy. The increase of IGF1 SDS presented signifcant
(P,0.001) and similar in both groups (from 2.010.97 to 0.610.67 in
euthyroid children and from 1.991.00 to 0.830.83 in those who developed
HT). The increase of IGF1/IGFBP3 molar ratio was also signifcant (P,0.001)
and similar in both groups (from 0.190.07 to 0.410.09 and from 0.180.05
to 0.450.12, respectively). However, the increase of HV presented signifcantly
(P,0.01) lower in children with HT (from 3.80.9 to 9.32.0 cm/year) than in
those who remained euthyroid all the time (from 3.51.0 to 10.02.1 cm/year).
The incidence of HT during the initial phase of GH treatment in children with
GHD and the negative effect of even transient thyroid hormone defciency on
growing rate should be taken into account. Further studies on the possibility of
predicting the occurrence of HT in particular patients seem advisable.
P599
The prothrombotic state in patients with Cushing`s disease
Julia Khodakova
1
, Svetlana Arapova
1
, Galina Suhanova
2
, Lidia Chirkova
1
& Ludmila Rozhinskaya
1
1
Research center for Endocrinology, Moscow, Russian Federation;
2
Research center for Hematology, Moscow, Russian Federation.
Introduction
Cushing`s disease (CD) is associated with persistent risk of cardiovascular
complications, which were found to be four times higher than in age- and sex-
matched population. The main cause is cardiovascular disease with thrombotic
complications due to the activation of changes in haemostatic and fbrinolytic
system with high level of cortisol secretion.
Objective
To study hemostatic and fbrinolytic state in patients with CD.
We studied 78 patients with active CD (Group 1), 41 patients during 1 year CD
remission after successful surgical treatment (Group 2) and 20 patients were the
control (Group 3). Prothrombin index (PTI), thrombin time (TT), activated partial
thromboplastine time (APTT), fbrinogen, tissue plasminogen activator (tPA) and
inhibitor (PAI-1), endotelin, thrombomodulin were investigated. Statistical
analysis was performed using Kruskal-Wallis criteria. Results are presented as
median and 25;75 percentiles.
Results
Results are given for the Groups 1, 2 and 3 respectively. Fibrinogen level, mg/dl:
366 (329;421), 339 (283;376), 283 (239;339) (P0.01, P1,20.015,
P1,30.002, P2,30.019); PTI, %: 92 (86;100), 88 (80;92), 87.5 (78;95)
(P0.004, P1,20.003, P1,30.032, P2,30.93); TT, sec: 17.3 (16.4;18.8),
16.6 (15.7;17.9), 17.8 (16.9;18.5) (P0.05); APTT, sec: 29.1 (27.2;32), 33.1
(32.2;34.2), 33.85 (32.9;35.7) (P0.0001, P1,20.001, P1,30,0009,
P2,30,276); tPA, ng/dl: 1.90 (1.29;3.7), 1.82 (1.51;2.29), 1.45 (1.01;1.62)
(P0.02, P1,20.04, P1,30.001, P2,30.001); PAI-1, ng/ml: 67.5
(46.07;89.2), 63.99 (21.12;90.09), 39.76 (27.39;42.79) (P0.0012, P1,2
0.036, P1,30.0007, P2,30.039); endotelin, fmol/l: 1.34 (0.97;1.83), 1.75
(1.13;2.67), 1.51 (0.87;1.94) (P0.31); thrombomodulin, ng/ml: 1.13 (0.78;1.61)
, 1.59 (1.26;2.08), 1.10 (0.76;1.51) (P0.04, P1,20.02, P1,30.76, P2,3
0.04). Patients of Group 1 had signifcantly higher fbrinogen level and PTI and
lower APTT than patients of Groups 2 and 3. tPA, PAI-1 levels were signifcantly
increased before and during 1 year after surgical treatment than in patients of
control group.
Conclusion
Our results suggest, hypercoagulation found in patients with CD is predominantly
associated with alterations of fbrinolytic system and persisted after treatment.
P00
Usefulness of cabergoline determination by mass spectrometry during
prolactinoma treatment
Corin Badiu
1,2
, Andra Caragheorgheopol
2
, Simona Verzea Jercalau
2
& Luigi Silvestro
3
1
C Davila University of Medicine and Pharmacy, Bucharest, Romania;
2
Institute of Endocrinology, Bucharest, Romania;
3
3 S Pharmaceutical,
Bucharest, Romania.
Prolactinoma (PRM) treatment is based upon dopamine agonists, cabergoline
(CAB) being one of the most used in the last decade. Sensitivity to CAB varies in
terms of tumour volume and PRL secretion, up to 8-15% of PRM being defned as
resistant. Since it is known that increasing the dosage improves the response rate,
we aimed to measure plasma CAB levels in PRM patients under this treatment in
a prospective interventional study.
A total of 27 cases, 12F/ 15M, aged 40.217.1 years were included: 2 micro- and
23 macro PRM, as well as two acromegaly with PRL co-secretion. Surgery was
used in 11 cases. All were submitted to CAB treatment at 0.5-3 mg/week (2.06
0.82), for at least 3 months (15.211.52), with decrease of tumor volume
and PRL levels under 20 ng/ml in 20 cases. Seven were defned CAB resistant,
due to lack of tumor or PRL control. PRL levels were measured in serum samples
using an automated immunoassay. Plasma levels of cabergoline were assessed by
a mass-spectrometry based method on an HPLC tandem mass-spectrometer in the
multiple-reaction monitoring method.
Results
Under CAB treatment, average PRL levels decreased after 3 months at 11.64
9.1 ng/ml, at 6 months at 5.445.4 ng/ml and at 1 year 5.15.3 ng/ml in
sensitive cases; PRL levels decreased after 3 months at 137192.1 ng/ml, at 6
months at 123.83211.26 ng/ml and at 1 year at 23.4126.68 ng/ml in resistant
cases. At the time of evaluation, PRL levels were 6.367.6 ng/ml in sensitive
cases and 96.4156 ng/ml in resistant cases. In sensitive PRM, CAB levels were
17.1515.8 pg/ml, while in resistant, 12.69.66 pg/ml. However, from the
7 resistant cases, 3 were with CAB levels above 20 pg/ml, 4 being with values
between 2-11 pg/ml. This suggests a lack of absorption, explaining a pseudo-
resistance and suggesting the increase of CAB doses.
Conclusion
CAB measurement by HPLC-MS could be used to monitor the treatment of PRM
in apparently resistant PRM, suggesting in increase of dosage in those with low
levels or alternate treatment methods, in normal CAB levels.
P01
Basal and stimulated GH secretion in Cushing`s syndrome: effects of
ghrelin and GHRHarginine
Andreea Picu
1
, Elisa Marinazzo
1
, Flavia Prodam
2
, Fabio Broglio
1
,
Sara Belcastro
2
, Gianluca Aimaretti
2
, Roberta Giordano
3
, Ezio Ghigo
1
& Emanuela Arvat
1
1
University of Turin, Turin, Italy;
2
Department of Clinical and Experimental
Medicine, University of Piemonte Orientale, Novara, Italy;
3
Department of
Clinical and Biological Sciences, University of Turin, Turin, Italy.
GH secretion is usually impaired in active Cushing`s syndrome (CS), due to
concomitant mechanisms, including diminished GHRH and/or increased
somatostatin release and impaired pituitary somatotrope responsiveness.
Differently, IGF1 levels not parallel GH insuffciency in CS, being reported
reduced, normal or increased. Both ghrelin and GHRHarginine (ARG) are
powerful GH secretagogues, infuenced by age and/or BMI. In 27 CS (42.7
2.9 years, 28.80.9 kg/m
2
) we evaluated the GH response to both ghrelin
(n27) and GHRHARG (n15), comparing them with those in 27 healthy
controls (NS) (43.54.1 years, 26.01.3 kg/m
2
). Basal IGF1 levels were
assayed in all the subjects. Both ghrelin and GHRHARG induced a lower
(P,0.05) GH response in CS (28.24.0 and 13.52.6 g/l, respectively) than
in NS (64.46.1 and 39.45.2 g/l, respectively). Similarly to NS, in CS GH
levels after ghrelin were higher (P,0.05) than after GHRHARG. Differently
to NS, in CS both ghrelin- and GHRHARG-induced GH levels were
independent of age and BMI. A severe GHD was shown in six patients, based
on standard and BMI-correlated GH cut-off levels for GHRHARG test. No
association between GH peaks after both tests and HPA parameters (UFC,
basal cortisol levels or peaks cortisol to ghrelin) were found, while IGF1 levels
were positively correlated (P,0.01) with basal cortisol in CS. This study
shows that: chronic hypercortisolism induces a dissociation between
somatotrope and IGF1 secretion, probably due to an inhibitory effect at
hypothalamic/pituitaric level associated with a stimulatory hepatic action; the
GH-releasing effect of ghrelin in CS is higher than GHRHARG; chronic
hypercortisolism is likely to override the infuence of age and BMI on both
basal and stimulated GH/IGF1 activity; testing with ghrelin, given appropriate
hormonal cut-off levels, associated with basal IGF1, may be suggested for the
assessment of somatotrope function in active phase and possibly during the
follow up of treated CS patients.
P02
Application of the human chorionic gonadotropin immunoassay in
cerebrospinal uid for the diagnostic work-up of neurohypophyseal
germinomas
Vi ctor Luis Gonzalez-Sanchez
1
, Oscar Moreno-Perez
1
,
Pedro Sanchez Pellicer
2
1
, Monserrat Mauri Dot
2
,
Elena Gastaldo Simeon
3
, Ignacio Aranda Lopez
4
& Antonio Miguel
Pico Alfonso
1
1
Endocrinology and Nutrition Department, Hospital General Universitario,
Alicante, Spain;
2
Hormone Laboratory, Hospital General Universitario,
Alicante, Spain;
3
Pediatric Endocrinology Department, Hospital de la
Ribera, Alcira, Spain;
4
Pathology Department, Hospital General
Universitario, Alicante, Spain.
Context
The determination of human chorionic gonadotropin (hCG) in cerebrospinal fuid
(CSF) is useful for the differential diagnosis of suprasellar lesions. However, the
concentrations that prove diagnostic for neurohypophyseal germinoma have not
been well defned. In addition, the immunoassays used for such determination are
the same as those applied in serum, and few studies have been performed
regarding the validation of such techniques in CSF.
Objective
The present study aims to apply the hCG immunoassay from Roche
Diagnostics for determining hCG in CSF, in the diagnosis of neurohypophyseal
germinomas in children and young adults.
Design and patients
Validation of the immunoassay has been established calculating the functional
sensitivity and reference values for hCG in CSF in 35 subjects in the absence of
pregnancy, trophoblastic disease or tumor pathology. For the clinical application
study, three patients diagnosed with neurohypophyseal germinoma have been
reviewed.
Results
The functional sensitivity obtained was 0.4 mIU/ml. The reference values for
hCG in CSF ranged from undetectable values to 0.7 mIU/ml. The hCG
concentrations in CSF in the three studied patients with confrmed diagnosis of
germinoma by pathological sample or complete response to treatment, were 21.1,
32.6 and 23 mIU/ml, respectively.
Conclusions
The hCG immunoassay from Roche Diagnostics is useful in the diagnosis of
neurohypophyseal germinomas. Acording to our results, CSF-hCG levels that
exceed the established reference interval (undetectable values to 0.7 mIU/ml), in
children and young adults with suprasellar lesions and hypophyseal stalk
thickening, is highly suspicious of germinoma.
P03
Adrenalectomy (ADX) increases the activation of hypothalamic and
nucleus of the solitary tract (NTS) neurons related with food intake
control during endotoxemia
Rodrigo Rorato, Ernane Uchoa, Jose Antunes-Rodrigues & Lucila Elias
School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao
Preto, Sao Paulo, Brazil.
Endotoxemia induces behavioral changes, including a decrease of food intake.
Several studies have demonstrated that ADX modifes central nervous system
responsiveness to different paradigms. Control of energy homeostasis is regulated
by interplay of peripheral signaling conveyed to the hypothalamus and brainstem
that control appetite and meal size. We investigated the activity of oxytocin (OT)
neurons in the paraventricular nucleus of the hypothalamus (PVN) and tyrosine
hydroxylase (TH) neurons in the NTS, both related with control of food intake,
after lipopolysaccharide (LPS, 100 g/kg, i.p.) or saline injection in ADX and
sham rats. Food intake was determined 4 h after injections. Another set of rats was
transcardially perfused 4 h after injections for brain collection and subsequent
immunohistochemistry of hypothalamic slices. ADX rats showed lower food
intake, compared with sham, both after saline and LPS treatment. We observed
that LPS treatment increased Fos and Fos/OT neurons in the medial parvocellular
subdivision of the PVN in sham rats (Fos: 19.24.1 and Fos/OT: 2.61.3) and
this response was enhanced in ADX rats (Fos: 6117 and Fos/OT: 8.53.7).
In the posterior parvocellular subdivision of the PVN, an increased Fos and
Fos/OT double labeled neurons after LPS was observed only in ADX rats (Fos:
7.73.4 and Fos/OT: 2.00.9). LPS treatment increased Fos and Fos/TH double
labeled neurons in the NTS only in the ADX rats (Fos: 34.713 and Fos/TH:
6.10.6). In conclusion, adrenalectomy enhances hypophagia during endotox-
emia and this effect is associated with an increased activation of hypothalamic
and NTS pathways, mediated by oxytocinergic and catecholaminergic neurons.
P04
CB1 modulation of hormone secretion, neuronal activation and mRNA
expression following blood volume expansion (BVE)
Silvia Ruginsk, Ernane Uchoa, Lucila Elias & Jose Antunes-Rodrigues
School of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao
Preto, Sao Paulo, Brazil.
The endocannabinoid system is involved in several homeostatic and neuroendo-
crine functions. In the present study, we evaluated the effects of type 1 cannabinoid
(CB1) receptor antagonist, rimonabant (10 mg/kg, p.o.), on hormone secretion,
neuronal activation and mRNAexpression in the hypothalamus following isotonic
(I) or hypertonic (H) blood volume expansion (BVE). Our results showed that
the secretion of both oxytocin (OT) and vasopressin (AVP) were increased in
response to H-BVE. Both I- and H-BVE stimulated oxytocinergic neuronal
activation in the PVN and SON, although vasopressinergic cells were only
activated in response to H-BVE. Accordingly, increased expression of both AVP
and OT mRNAs were found in these nuclei following H-BVE. Pretreatment with
rimonabant signifcantly potentiated hormone secretion and also vasopressinergic
and oxytocinergic neuronal activation induced by BVE, although a decreased AVP
and OT mRNA expression was found in the hypothalami of rimonabant pretreated
groups. Taken together, these results suggest that the CB1 receptor may modulate
several events that contribute to the development of appropriate responses to
increased fuid volume and osmolality.
P05
The regulation of the hypothalamic-pituitary axis is altered in
transgenic male mice overexpressing human chorionic gonadotrophin
(hCG)
Betina Gonzalez
1
, Noelia Di Giorgio
1
, Laura Ratner
1
, Matti Poutanen
2
,
Ilpo Huhtaniemi
3
, Ricardo Calandra
1
, Victoria Lux-Lantos
1
& Susana Rulli
1
1
Instituto de Biologi a y Medicina Experimental -CONICET, Buenos Aires,
Argentina;
2
Department of Physiology, Turku University, Turku, Finland;
3
Imperial College London, London, UK.
Male transgenic (TG) mice overexpressing both the hCG- and hCG- subunits
present elevated levels of circulating hCG, Leydig cell hyperplasia/hypertrophy,
elevated androgen levels and infertility (Rulli et al. 2003). In addition, serum FSH
is signifcantly reduced in prepuberal and adult TG males compared with wild-
types (WT), and does not change after treatment with the antiandrogen futamide.
The aim of this study was to evaluate the regulation of the hypothalamic-pituitary
axis in 4-week-old TG and WT males, by analyzing the effect of castration (Cx)
for 2 weeks. We evaluated: i) serum FSH levels by RIA; ii) pituitary mRNA
expression of FSH (Fshb), GnRH receptor (Gnrhr), estrogen receptor (Esr1)
and the common -subunit (Cga) by qRT-PCR; iii) hypothalamic GnRH
concentration and GnRH pulsatility ex-vivo, by RIA. FSH serum levels were:
WT: 48.51.4, WT-Cx: 77.52.0*, TG: 5.40.4*, TG-Cx: 7.40.4* ng/ml
(*P,0.001 versus WT). Fshb expression was lower in TG compared with WT
(P,0.001), and Cx increased the expression in WT (P,0.001), without changes
in TG. The expression of Gnrhr and Esr1 were reduced in TG compared with WT,
and Cx showed no effects. The GnRH hypothalamic concentration (g/mg
protein) was higher in TG compared with WT (P,0.05), and no changes were
observed post-Cx. GnRH pulsatility showed a higher pulse frequency in TG
compared with WT, and Cx increased the pulse frequency in WT and decreased it
in TG (P,0.05). These results indicate that the chronic hypersecretion of hCG in
male mice produced a persistent inhibition of FSH synthesis and secretion,
through alterations at both the pituitary and hypothalamic level, and was not
modifed after Cx. Because hCG overexpression occurs from the fetal stage in this
model, this effect could be related to a higher exposure of the neuroendocrine
system to steroids during the early stages of sexual differentiation.
P0
Impact of rosiglitazone on serum IGF1 concentrations in uncontrolled
acromegalic patients under conventional medical therapy: results from
a pilot phase 2 study
Martina Lombardi
1
, Giuseppe Rossi
2
, Francesco Raggi
1
, Claudio Urbani
1
,
Chiara Sardella
1
, Chiara Cosci
1
, Enio Martino
1
& Fausto Bogazzi
1
1
Department of Endocrinology and Metabolism, University of Pisa, Pisa,
Italy;
2
Epidemiology and Biostatistics Unit, Institute of Clinical Physiology,
National Research Council, Pisa, Italy.
Current therapies for acromegaly are unsatisfactory for some patients. High dose
thiazoledinedines have been reported to shrink tumor size and reduce serum GH
levels in animal models of acromegaly. To study the effects of increasing doses of
rosiglitazone on serum GH and IGF1 concentrations in acromegalic patients, we
designed a phase two clinical trial. We enrolled fve consecutive patients with
active acromegaly uncontrolled under conventional therapies. They received
increasing doses of rosiglitazone (4 mg each month starting from 8 mg up to
20 mg/day), added to previous therapies for acromegaly. Mean serum IGF1
concentrations reduced from 54791 to 265126 g /l (P0.043) during the
4 months-course with rosiglitazone; main reduction occurred with the higher dose
of rosiglitazone; on the opposite, lower doses of rosiglitazone left serum IGF1
levels unaffected in 4/5 patients. IGF1 normalized in all patients. Serum GH
concentrations did not signifcantly changed as well as all other pituitary
hormones. No main side-effects were observed. Studies in Hep G2 cells
showed that rosiglitazone reduced hepatic GH-dependent generation of IGF1.
Conclusion: Rosiglitazone reduces serum IGF1 concentrations in patients with
active acromegaly, likely acting on the GH-dependent hepatic synthesis of IGF1.
Large studies are necessary to confrm whether rosiglitazone may have a role as a
new adjuvant therapy for acromegalic patients.
P0I
Quality of life after multimodality treatment of acromegaly
Cecilia Farrugia
1
, Mark Gruppetta
1,2
, Neville Calleja
3
& Josanne Vassallo
1,2
1
Department of Medicine, University of Malta Medical School, Msida,
Malta;
2
Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta;
3
Department of Health Information and Research, Gwardamangia, Malta.
Aim
To assess the impact of acromegaly on quality of life (QoL) as evaluated by the
acromegaly QoL (AcroQoL) questionnaire in Maltese patients with cured,
controlled and uncontrolled acromegaly.
Design
Cross-sectional survey study.
Methods
The AcroQol questionnaire was completed by all patients during their routine
outpatient visit. Clinical and hormonal data including GH and IGF1 levels were
also taken at the time of survey.
Results
Forty-seven patients were included in the study, (22 males, 25 females). The
median GH was 0.78 g/l (IQR 0.4-1.6), the median insulin-like growth factor 1
(IGF1) was 192 g/l (IQR 139-306) while the mean IGF1 z-score was 1.05 (SD
1.15) The mean AcroQol total score for the whole group was 67.3 (SD 16.89).
The score for the physical dimension was 66.5 (SD 23.41), and the score for the
psychological dimension was 67.8 (SD 16.14). The subscale appearance was
the worse affected, scoring 57.3 (SD 21.60), while for personal relations the score
was 78.3 (SD 16.03). Females had signifcantly lower total scores, (P,0.02) and
physical scores (P,0.001). No correlation was found between AcroQol scores
and age at diagnosis, size of tumour, previous treatment with radiotherapy and
surgery, hypopituitarism, presence of co-morbidities and GH and IGF1 levels.
Conclusions
This study shows that patients with acromegaly exhibit marked impairment of
QoL especially from the appearance point of view. Overall females when
compared to males have a worse QoL particularly in relation to the physical
aspect. No correlation was found between AcroQol and serum GH and IGF1
levels at time of administration of the questionnaire.
P08
Epidemiology and outcomes after multimodality therapy of acromegaly
over three decades in the Maltese population
Cecilia Farrugia
1
, Mark Gruppetta
1,2
& Josanne Vassallo
1,2
1
Malta;
2
Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta.
Aim
To ascertain epidemiology and outcomes in Maltese patients with acromegaly.
Method
Retrospective case record study of acromegalic patients diagnosed between 1979
and 2008.
Results
Forty-seven patients were recruited (25 females and 22 males). The prevalence of
acromegaly in the Maltese population was 11.4 per 100 000 population. Of 77%
had a macroadenoma (53% extrasellar, 24% intrasellar). Of 15% had a
microadenoma. Two tumours were unclassifable, while in two patients no
pituitary tumour was identifed.
Thirty-six patients underwent transsphenoidal surgery (TSS), 28 operations were
carried out prior to 1999 in two UK centres while after 2000, TSS was carried
locally by a single surgeon. Pre-operative median GH was 40 g/l (range
1.2-85.4) and 4.5 g/l (23.9-0.32) post-operatively. Mean IGF1 z scores were
7.22 (SD 1.8) pre-operatively and 2.6 (SD 1.92) post-operatively. Prior to year
2000 surgical success rate was 23% for extrasellar macroadenomas, 16% for
intrasellar macroadenomas and 33% for microadenomas success. After 2000
success rate for extrasellar macroadenomas was unchanged while for intrasellar
macroadenomas and microadenomas the success rate was 100%.
Twenty-nine patients were treated with radiotherapy (in three it was he sole
intervention). Two patients had radiotherapy prior to TSS while the remaining 24
patients had radiotherapy post-TSS.
GHlevel normalisation was obtained in 38%at 5 years and in 48%at 15 years. With
somatostatin analogues (n15) biochemical control was achieved in 54%.The
time interval fromdiagnosis till achievement of biochemical control was 6.35 years
prior to year 2000 and 7 months post year 2000 (P0.004).
Of 65% were found to have hypopituitarism, 62% had hypogonadotrophic
insuffciency, 45% had thyroptropic insuffciency and 57% had corticotrophic
insuffciency.
Conclusion
Surgical outcomes have improved for intrasellar and microadenomas but not for
extrasellar macradenomas. Success rates after medical treatment with somato-
statin analogues compare favourably to other published studies. Radiotherapy
effects are delayed and medical treatment is more popular.
P09
An adult patient with ectopic neurohypophysitis and
panhypopituitarism due to absent pituitary stalk
Fatih Kilicli, Fettah Acibucu & Sebila Dokmetas
Department of Endocrinology and Metabolism, Cumhuriyet University,
Sivas, Turkey.
We report a case of 28-year-old girl with panhypopituitarism and ectopic
neurohypophysitis due to absent pituitary stalk. She was admitted to
endocrinology policlinic with short stature, growth retardation and primary
amenorrhea. Basal hormones indicated tahat she has secondary hypothyroidism,
adrenal insuffciency, hypogonadism and GH insuffciency. Peak cortisol
response to the short ACTH test was normal but inadequate to insulin tolerance
test. The other dynamic pituitary function tests showed totally anterior pituitary
hormone defciency. Magnetic resonance imaging of brain revealed an ectopic
posterior pituitary tissue and absent pituitary stalk. We started to hormone
replacement therapy. Because this disorder is usually shown in the pediatric age
group, we report an adult patient with ectopic posterior pituitary tissue and absent
pituitary stalk and totally anterior pituitary hormone defciency.
Keywords: Ectopic posterior pituitary, hypopituitarism, absent pituitary stalk.
P10
Presentation, treatment and outcomes in patients with non-functioning
pituitary adenomas (NFPA) in Malta
Mark Gruppetta
1,2
, Cecilia Farrugia
1
& Josanne Vassallo
1,2
1
Malta;
2
Neuroendocrine Clinic, Mater Dei Hospital, Msida, Malta.
Aim
To evaluate epidemiology, clinical presentation, treatment and subsequent
outcomes in Maltese patients with NFPA.
Methods
Retrospective case record study of all patients with NFPA.
Results
Forty-eight patients with a NFPA were identifed with an estimated prevalence of
1.16 per 10 000 population. 58% of these were male and the mean age at
presentation was 50.6 years (S.D. 13.4 years) (men - 52.5 years; women - 48
years). The main presenting symptoms were visual feld defects (66.7%),
headache (54.2%) and hypogonadism (28.9%). 12.5% of patients presented with
pituitary apoplexy. All tumours were macroadenomas at presentation.
Surgery was the treatment of choice in 85.4% of the patients. Total extirpation of
the tumour was achieved in 43.9% of patients. Adjuvant radiotherapy was
performed after surgery in 58.5% of patients and in one patient without previous
surgery. At follow up (mean 9.0 years; S.D. 5.8 years), 56.1% of patients had
incomplete resection of tumour, with 30.4% of these having re-growth of the
tumour remnant. No recurrences were noted in those with total resection of tumour.
At diagnosis, 72.9% of patients were GH defcient, 64.6% were hypogonadal,
52.1% were thyroxine defcient and 45.8% cortisol defcient and adequately
replaced. At mean 9.0 years followup, 68.8%of patients were cortisol defcient and
79.2% were thyroxine defcient and adequately replaced. 22.9% of all the cohort
had DM at mean 9 years follow-up; 25.8% of those who had their adrenal axis
defcient and replaced, and 24.3% of those who had their GH axis suppressed
had DM.
Conclusions
NFPA need an extensive work up at diagnosis. Long-term follow up is essential
due to the risk of regrowth of the tumour and development of complications as a
result of the NFPA of hypopituitarism and onset of other diseases such as DM.
P11
Plasma levels of adiponectine and nutritional status in patients affected
by anorexia Nervosa
Maria Chiara Masoni, Claudio Scarpellini, Cristina Consani,
Elena Matteucci & Ottavio Giampietro
Internal Medicine Department, University of Pisa, Pisa, Tuscany, Italy.
Background
Anorexia nervosa (AN) is prevalent in modern societies, this pathogenesis is not
yet well understood.
Aim
The aim of this study is to evaluate circulating levels of adiponectine (Apn) and
the relationship between these levels and anthropometric and metabolic
parameters.
Methods
The study included 40 women, 20 with AN (BMI 15.72.1 kg/m
2
, age 30.2
10.5 years), 12 restricter (BMI 14.91.6 kg/m
2
) and 8 binge-purge subtype
(BMI 18.30.8 kg/m
2
), and 20 healthy controls (BMI 22.060.93 kg/m
2
, age
32.44.4 years). Food intake was evaluated by a 5-day 24 h dietary recall.
Results
Apn was higher (P,0.001) in AN (36.8413.12 ng/ml) than controls (15.1
3.0 ng/ml) and (P0.004) in restricter (41.811.0 ng/ml) than in binge-
purge AN subtype (22.14.5 ng/ml). Apn levels were negatively related with
BMI in total population (ANC), without signifcancy.
Total and low density lipoprotein (LDL) cholesterol levels were higher (P,0.05;
P0.001) in AN (193.0939.86 mg/dl; 107.9527.75 mg/dl) than C (166.09
13.70 mg/dl; 83.615 mg/dl), while Albumin was lower (P,0.05) in AN
than C (4.400.41 vs 4.650.57 g/dl); no difference between restricter and
binge-purge subtype. Prealbumin and C Somatomedine were similar in AN and C
because of these parameters rapidly change with changing of nutritional habits,
and the study`s patients were already included into nutritional educational
program: although their daily caloric intake was lower than the recommended
assumption levels of nutrients (LARN, National Institute of Nutrition), the caloric
division between macronutrients was correct.
Conclusions
Increase of Apn in AN might be related to fat mass reduction, in fact Apn
progressively increase in losing weight obese, or fat mass might exert negative
feedback on Apn production, the severe emaciation in AN could inhibit this
feedback.
P12
The predictors of the response to somatostatin analogue therapy in
patients with acromegaly
Dong-Sun Kim
1
, Joo-Hyung Kim
2
, Sin-Gon Kim Kim
2
, Sei-Hyun Baik
2
,
Soon-Jib Yoo
3
& Yeon-Ah Sung
4
1
Hanyang University, Seoul, Republic of Korea;
2
Korea University, Seoul,
Republic of Korea;
3
Catholic University, Seoul, Republic of Korea;
4
Ewha
Womans University, Seoul, Republic of Korea.
Somatostatin analogues (SSA) are widely used for the treatment of patients with
acromegaly, and the responses are variable. We investigated the possible
predictive factors of the response to SSA therapy in Korean acromegalic patients.
Twenty-eight patients were retrospectively analysed, who were treated by surgery
and adjunctively SSA. Somatostatin suppression tests (SST, hourly GH
measurements for 3 h following 100 g somatostatin injection) were done before
SSAs were given. The good response to SSA treatment was defned as a normal
IGF1 for age and a GH ,2.5 ng/ml. After SSA therapy, decrease of GH below
2.5 ng/ml and normalization of IGF1 were achieved in 40 and 46.4% of the
patients, respectively. It was 26.7% who showed both of normal IGF1 and GH
,2.5 ng/ml. There were no signifcant differences in gender, age, tumor size,
postoperative residual tumor, baseline GH/IGF1 and decrement of postoperative
GH levels between the good and poor responders. However, nadir GH (0.94 vs
3.11, P,0.05), mean GH (1.37 vs 4.36, P,0.05), and GH fall (90.6 vs 83.5%,
P,0.01) in SST were signifcantly different between two groups. In addition,
there were signifcant correlations between nadir and mean levels of GH during
SST and post-treatment levels of IGF1. In ROC curve analysis, the highest cut-off
value in predicting achievement of normal IGF1 was 2.94 ng/ml of mean GH and
2.30 ng/ml of nadir GH during SST. Both Criterion had sensitivity 72.2%,
specifcity 80%, positive predictive value 86.67% and negative predictive value
61.54%. This study suggests SST has some values for prediction of the response
to SSA treatment in patients with acromegaly. However, SST does not reach a
value of independent predictive factor for SSA therapy, and a poor response to
SST does not exclude the good response to SSA therapy.
P13
Tumor inhltrating lymphocytes but not serum pituitary antibodies are
associated with poor clinical outcome after surgery in patients with
pituitary adenoma
Isabella Lupi
1
, Luca Manetti
1
, Patrizio Caturegli
2
, Michele Menicagli
3
,
Genersoso Bevilacqua
3
, Fausto Bogazzi
1
& Enio Martino
1
1
Department of Endocrinology, University of Pisa, Pisa, Italy;
2
Department
of Pathology, The Johns Hopkins University, Baltimore, Maryland, USA;
3
Department of Oncology, University of Pisa, Pisa, Italy.
Serum pituitary antibodies (Pit Abs) and tumor infltrating lymphocytes (TILs)
have been described in a small percentage of pituitary adenomas but their clinical
signifcance remains unknown.
Aim of the study was to assess Pit Abs and TILs prevalence in patients with
pituitary adenomas and to determine their infuence on the clinical outcome.
In this prevalence case-control study were enrolled 291 pituitary adenoma cases,
(110 non-secreting, 30 ACTH-, 69 GH-, 71 PRL-, and 13 TSH-secreting
adenoma; 177 operated and 114 untreated), 409 healthy controls, and 14
autoimmune hypophysitis. Pit Abs were measured using immunofuorescence in
all cases and controls (n714). The presence of TILs was evaluated using CD45
staining in a subset of adenomas surgically treated (n72).
The main outcome measure of the study was the clinical response of pituitary
adenoma following surgery during a mean follow up time of 34 months.
Pit Abs prevalence was higher in adenomas (5.1%) than in healthy subjects (0.7%
P0.002) and lower than in autoimmune hypophysitis patients (57%,
P,0.0001). Similarly, TILs prevalence was higher in adenomas than in normal
pituitary (P0.01), and lower than in autoimmune hypophysitis (P,0.0001). No
correlation between Pit Abs and TILs was found (P0.78).
A poor clinical outcome was more common in adenoma patients with TILs (11 of
18, 61%) than in those without (17 of 54, 31%, P0.026). Multivariate
regression analysis identifed the presence of TILs as independent prognostic
factor for persistence/recurrence of pituitary adenoma.
In conclusion, cell-mediated and humoral pituitary autoimmunity are present in a
signifcant number of patients with pituitary adenoma. Only cell-mediated
immunity, however, appears to be predictive of a less favorable clinical outcome
in these patients.
P14
Risk factors for development of atherosclerosis in young women with
hyperprolatinemia
Milica Medic-Stojanoska
1,2
, Ivana Pletikosic
3
, Branka Kovacev-Zavisic
1,2
,
Ljiljana Todorovic-Djilas
1,3
, Bojan Vukovic
1
, Tijana Icin
1,2
, Ivana Bajkin
1
& Jovanka Novakovic-Paro
1,2
1
Clinical centre of Vojvodina, Novi Sad, Serbia;
2
University of Novi Sad,
Novi Sad, Serbia;
3
Medical centre Subotica, Subotica, Serbia.
Metabolic and immunological disturbances may be associated with hyper-
prolactinemia.
Aim
The aim of this study was examination the presence of some metabolic and
immunological disturbances, like as the changes in and body composition, as
risk factors for development of atherosclerosis, in young women with
hyperprolactinemia.
The investigation was performed as prospective study in a group of 20
premenopausal women with prolactinomas. The serum levels of prolactin, lipids
and fbrinogen were measured, like as body mass index and body composition by
bioelectric impedance. The examination was performed before and after therapy
by dopamine agonists that examination group was control itself.
Results
The mean values of serum prolactin were signifcantly higher before therapy
(171.89131.59 versus 14.0110.35 ng/ml; P ,0.000). Achievement of
normoprolactinemia was followed by non signifcant reduction of body mass
index and body fat. The signifcant decreases of total cholesterol (5.220.99
versus 4.570.88 mmol/l; P, 0.03), LDL cholesterol (3.340.90 versus 2.81
0.57 mmol/l; P,0.012) and non HDL cholesterol (3.821.03 versus 3.25
0.71 mmol/l; P,0.006) were present after treatment of hyperprolactinemia.
The reduction of triglyceride levels in normoproalcinemic state was non
signifcant. The fbrinogen was only slightly increased before treatment.
Conclusion
These results suggest of the possible infuence of hyperprolactinemia for
development accelerated atherosclerosis. Treatment of hyperprolactinemia could
be useful in prevention of atherosclerosis in young women.
P15
Lanreotide-ATG effectiveness on tumoral mass shrinkage of two
thyrotropin-secreting pituitary macroadenomas
Amalia Paniagua
1
, Ignacio Bernabeu
2
& Monica Marazuela
1
1
Hospital Universitario La Princesa, Madrid, Spain;
2
Complejo Hospitalario
Universitario Santiago de Compostela, La Coruna, Spain.
Context
There is scant evidence of tumoral mass reduction in Thyrotropin-secreting
pituitary adenomas (TSPA) treated with long-acting somatostatin analogs. There
are no reports that evaluate TSPA shrinkage after deep subcutaneous (sc)
Lanreotide-ATG (L-ATG) therapy.
Objective
The primary objective was to observe if L-ATG could reduce TSPA tumor mass.
Methods
A literature review on the subject was made. The biochemical and radiological
evolution of two TSPA macroadenomas treated with L-ATG for more than
12 months are presented.
Results
Case 1: A 47-year-old man underwent trans-sphenoidal removal of a 60 mm
pituitary adenoma, with no hormonal immunochemistry reactivity. One month
after surgery he showed elevated ?subunit, TSH and FT4. MRI demonstrated
persistence of a 30 , 55 mm sellar mass. He received monthly deep sc 120 mg
L-ATG treatment for 13 months. Campimetric amelioration and hormonal tests
normalization were achieved after the frst L-ATG dose. After 3 months of
treatment MRI revealed a tumor mass of 30 ,30 mm (a shrinkage 45%). After
13 months the tumor size was 25 , 30 mm.
Case 2: A 37-year-old man underwent trans-sphenoidal surgery for a 19 mm
pituitary adenoma seven years before consultation for clinical hyperthyroidism.
He showed elevated FT4 with inappropriately normal TSH and a positive
pituitary pentetreotide uptake coinciding with a 35 , 17 mm pituitary mass in
MRI. Treatment with monthly deep sc 120 mg L-ATG was administered for
17 months with normalization of FT4 levels. On the 10th month of treatment MRI
showed no residual tumor and at the end of follow-up there were no clinical signs
of hyperthyroidism.
Conclusion
These two case-reports show a positive role of L-ATG in TSPA tumor mass
shrinkage.
P1
Pain characteristics in patients with Cushing`s disease compared to
patients with non-functioning pituitary adenomas
Christina Dimopoulou
1
, Franziska Oehrlein
1
, Hildegard Pfster
1
,
Jochen Schopohl
2
, Guenter Karl Stalla
1
& Caroline Sievers
1
1
Max Planck Institute of Psychiatry, Munich, Germany;
2
Hospital of the
Objectives
It is known that patients with pituitary adenomas, especially acromegaly,
frequently suffer from pain syndromes such as headache and arthralgia. Whether
pain exists and to what extent in Cushing`s disease (CD), refecting chronic
cortisol excess, is not clear. We hypothesized that pain patterns should be also
altered and investigated pain laterisation, clinical characteristics, phenotypes as
well as underlying predictors.
Methods
In a cross-sectional study, we assessed 50 patients with CD and compared them to
60 patients with non-functioning pituitary adenomas (NFPA). Specifc pain
patterns were measured using three standardized pain questionnaires, MIDAS
(Migraine Disability Assessment), the painDETECT and the DGSS (German
Society for the Study of Pain) questionnaire.
Results
According to the DGSS questionnaire, patients with CD complained signifcantly
more often of any sort of pain (76.0 versus 51.7%; P0.010) compared to
patients with NFPA. In the MIDAS headache questionnaire, CD patients
presented with signifcantly reduced productivity at work or school because of
headache in the last 3 months (9.783.15 versus 2.251.12 days; P0.028) as
well as elevated headache intensity (pain intensity scale: 0no pain, 10highest
intensity) (4.110.5 versus 1.540.38; P0.000) compared to controls. The
screening for neuropathic vs. nociceptive pain via painDETECT showed
signifcant differences between CD and NFPA patients as far as the highest
(6.050.46 versus 3.980.44; P0.002) and average pain intensity during the
past 4 weeks (3.730.34 versus 2.630.33; P0.022) were concerned.
Conclusions
All three questionnaires revealed a high burden of diverse pain syndromes in
patients with pituitary adenomas. Moreover, patients with CD demonstrated a
distinct pattern regarding frequency, duration and intensity of pain, possibly
linked to cortisol excess. Specifc treatment should be offered for those patients
with CD associated pain syndromes.
P1I
Epidemiology of craniopharyngioma in Denmark 1985~2004: a 2%
increase in incidence rate per year
Eigil Husted Nielsen
1
, Ulla Feldt-Rasmussen
2
, Lars Poulsgaard
3
, Lars stergaard
Kristensen
4
, Jens Astrup
5
, Jens Otto Jrgensen
6
, Per Bjerre
7
, Marianne Andersen
8
,
Claus Andersen
9
, Jesper Jrgensen
10
, Jorgen Lindholm
1
& Peter Laurberg
1
1
Department of Endocrinology, Aalborg Hospital, Aarhus University
Hospital, Aalborg, Denmark;
2
Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark;
3
Department of Neurosurgery, Rigshospitalet, Copenhagen University
Hospital, Copenhagen, Denmark;
4
Department of Endocrinology, Herlev
Hospital, University of Copenhagen, Copenhagen, Denmark;
5
Department
of Neurosurgery, Glostrup Hospital, University of Copenhagen,
Copenhagen, Denmark;
6
Medical Department M (Endocrinology and
Diabetes), Aarhus University Hospital, Aarhus Sygehus, Aarhus,
Denmark;
7
Department of Neurosurgery, Aarhus University Hospital,
Aarhus Sygehus, Aarhus, Denmark;
8
Department of Endocrinology, Odense
University Hospital, Odense, Denmark;
9
Department of Neurosurgery,
Odense University Hospital, Odense, Denmark;
10
Department of
Neurosurgery, Aarhus University Hospital, Aalborg, Aalborg, Denmark.
Background
Craniopharyngioma may be associated with severe morbidity. Few data exist on
incidence rate (IR) and possible changes with time. The epidemiology of
craniopharyngioma in Denmark has never been evaluated in detail.
Objectives
To review the literature on craniopharyngioma incidence and to study the
epidemiology of craniopharyngioma in Denmark during a recent 20-year period.
Publications including data on craniopharyngioma incidence were identifed via
searches of PubMed (http://www.ncbi.nlm.nih.gov/pubmed/) and derived
reference lists.
Patients with craniopharyngioma diagnosed during the period 1985-2004 were
identifed from the Danish National Patient Registry, the Danish Cancer Registry
and various local registries. Medical records were manually reviewed. Age,
gender and calendar year specifc population data were obtained from Statistics
Denmark, while EU and WHO World population data were obtained from EU
(http://www.euphix.org) and WHO (http://www.who.int/healthinfo/paper31.pdf)
homepages. IRs are given as new cases/million/year.
Results
Fourteen previous studies reported craniopharyngioma IRs between 0.88 and
5.71. A geographical pattern was not obvious. All studies included children; 7
also included adults. Male/female IR ratios were 0.95-1.18. One study suggested
increasing IRs during the study period.
Our Danish survey revealed 189 new cases (among 697 candidates from
registries) of histologically verifed (162) or probable (27) craniopharyngioma.
The IR was 1.55 (95% CI: 1.32-1.81) for verifed cases (World-standardised 1.61
[1.37-1.87]) and 1.81 (1.56-2.08) for all cases (World-standardised 1.86
[1.60-2.14]). There was no difference in IR between women (1.72 [1.32-2.11])
and men (1.90 [1.54-2.32]). Peak IRs were seen in four 5-years age groups:
5-9/15-19/40-44/ 65-69 years (IRs 3.48/2.15/2.86/2.62). Regression analysis
showed increasing IR over time (P0.041), averaging 2.2% per year.
Conclusions
Reported IRs of craniopharyngioma vary considerably. In Denmark, the World-
standardised IR was 1.61 to 1.86 cases/million/year. The craniopharyngioma IR
in Denmark is increasing.
P18
Long term safety of recombinant human growth hormone (rhGH) in
patients treated during childhood
Giuseppe Reimondo
1
, Enrico Palmas
1
, Silvia Vannelli
2
, Jaele Bellone
3
,
Simonetta Bellone
5
, Patrizia Matarazzo
3
, Valentina Gasco
4
,
Alberto Borraccino
6
, Giuseppe Migliaretti
6
, Franco Cavallo
6
,
Aldo Ravaglia
1
, Alberto Angeli
1
, Gianluca Aimaretti
4
& Massimo Terzolo
1
1
Medicina Interna I ad indirizzo endocrinologico - AOU San Luigi,
Orbassano, Italy;
2
Auxologia - OIRM, Torino, Italy;
3
Endocrinologia -
OIRM, Torino, Italy;
4
Endocrinologia - AOU Maggiore della Carita`,
Novara, Italy;
5
Pediatria Medica - AOU Maggiore della Carita`, Novara,
Italy;
6
Dip. Sanita` Pubblica E Di Microbiologia, Torino, Italy;
7
Pediatrician
- Piedmont Region, Torino, Italy.
The potential side effects of the rhGH therapy have been evaluated only during
treatment and the accessible databases have been developed as a post-marketing
surveillance only by the Companies distributing rhGH. Aimof the present study was
to evaluate health consequences (metabolic diseases and/or malignancies) in adults
previously treated with rhGH during childhood. We recruited 284 patients (median
age at diagnosis 12years, range 3-17) whounderwent rhGHtreatment between 1986
and 2000 at four tertiary referral centers in Piedmont and were treated for a median
period of 36 months (range 12-132). Follow-up for this study was closed in
December 2006. When patients started with rhGH therapy, none of them had
diabetes mellitus or malignant neoplasia. We submitted by regular mail a
questionnaire including the following requests: a) present weight and height,
b) presence of diabetes, hypertension or dyslipidemia, c) other diseases (including
neoplasia). The responders to the questionnaire, by mail or phone interview, were
193 (68%). To obtain follow-up information of the 91 non-responders the individual
records were linked to the registry offce of Piedmont Region and the registry of the
National Institute of Statistics. During follow-up: 1 patient developed type 1 diabetes
mellitus, 1 had a diagnosis of melanoma and1 a synovial sarcoma, 8patients reported
dyslipidemia. None of the patients developed hypertension and cardiovascular
events or died during follow-up. In a multiple regression analysis, BMI of the male
patients at the time of administration of the questionnaire was inversely correlated to
the rhGH dose (P,0.0001), whereas in female patients the association was not
demonstrated. In conclusion, we did not observed an increased risk for metabolic
diseases or malignancies in patients who were treated with rhGH until reaching the
fnal height. In men, rhGH doses seems to infuence BMI during adulthood.
P19
Lymphocytic hypophysitis: clinical characteristics and endocrine
features of 64 GH dehcient patients in KIMS: Phzer International
Metabolic Database
Sophie Bensing
1
, Peter Jonsson
2
, Anna-Lena Hulting
1
, David Cook
3
,
Murray Gordon
4
, Michael Faust
5
, Maria Koltowska-Haggstrom
2
& Felipe Casanueva
6
1
2
Pfzer, Sollentuna, Sweden;
3
Oregon Health and Science University, Portland, Oregon, USA;
4
Allegheny General Hospital, Pittsburgh, Pennsylvania, USA;
5
University
of Koln, Koln, Germany;
6
University of Santiago di Compostela, Santiago
di Compostela, Spain.
Objective
To characterize patients with GH defciency associated with lymphocytic
hypophysitis (LyH).
Method
Patients with a diagnosis of LyH were identifed in the KIMS database. The
responsible clinicians were asked to confrm the diagnosis and to provide more
detailed information on the patient by flling in a questionnaire.
Results
One hundred and ffty patients with a diagnosis of LyH were identifed in the
database and 100 clinicians responded to our questionnaire. The LyH diagnosis
was confrmed in 64 patients (13 histopathological proven and 51 suspected). The
majority of the 64 LyH patients were female (n49, 76%) and the mean age at
diagnosis was 41.4 years. One patient was diagnosed with LyH during pregnancy
and nine patients during the postpartum period. At diagnosis 58 patients had
symptoms of pituitary hormonal defciency, 25 patients suffered from headaches
and 11 had visual disturbances. Low GH and IGF1 levels were detected in the
majority of patients already at diagnosis of LyH, often in combination with other
pituitary hormonal defciencies. Radiological examination revealed an enlarged
pituitary in 27 patients in some causing chiasmal compression or involvement of
cavernous sinus. Regarding treatment of LyH, 13 patients underwent
neurosurgical intervention and six received supraphysiological doses of
glucocorticoids. One patient with histopathological proven LyH also received
azathioprine and radiotherapy due to relapse of the disease. The most common
associated autoimmune conditions were Hashimoto`s thyroiditis (16/64), type 1
diabetes mellitus (6/64) and primary ovarian/testicular failure (5/64).
Conclusion
Defcits of ACTH, TSH and gonadotrophins are commonly reported in LyH.
However, to a great extent GH function has not been evaluated. Our survey shows
that GH defciency may be present at the time of diagnosis of LyH, stressing the
need for proper assessment of all pituitary hormones in these patients. LyH is
frequently associated with other autoimmune conditions.
P20
Epidemiology of acromegaly in Italy
Elena Malchiodi
1,2
, Maura Arosio
1,2
, Alberto Borraccino
5
,
Giuseppe Reimondo
3,4
, Barbara Zaggia
3,4
, Laura Montefusco
1,2
,
Anna Maria Colao
6
& Massimo Terzolo
3,4
1
Department of Medical Sciences, University of Milan, Milan, Italy;
2
Endocrinology Unit, S. Giuseppe-Multimedica Hospital, Milan, Italy;
3
Department of Clinical Science and Biology, University of Turin, Turin,
Italy;
4
Department of Internal Medicine, ASO San Luigi, Orbassano-Turin,
Turin, Italy;
5
Department of Public Health and Microbiology, University of
Turin, Turin, Italy;
6
Department of Endocrinology, University 'Federico II`
of Naples, Naples, Italy.
Aim of this study is to present preliminary epidemiological data on a population
of 1512 acromegalic patients attending 22 tertiary centers in Italy from 1980 to
2002. At our knowledge this is the frst large-scale epidemiological Italian study
on acromegaly. Gender was 624 (41.2%) men and 888 (58.8%) women. Mean age
at diagnosis was 4513 years, 4313 for men and 4713 for women. Median
estimated duration of acromegaly before diagnosis was 74 months (range:
36-144). 28% of cases were micro-adenomas and 68.6% macro-adenomas, the
lattest being intrasellar in 41.2% of patients. At baseline GH were over 50 g/liter
in 15.7% of patients, between 50 and 2.5 g/liter in 73.7% and under 2.5 g/liter
in 1%. Data were not available in 9.6% of patients. Two patients had GH nadir
during OGTT below 1 g/liter but elevated IGFI. Pre-treatment IGFI was
available in 67.3% patients. Hyperprolactinemia was observed in 251(19%)
patients (2/3 of whom women) and TSH hypersecretion in 9 (0.7%). 392 patients
(25.9%) had one or more pituitary defciencies: 4.1% hypoadrenalism, 8.1%
hypothyroidism, 16.4% hypogonadism and 0.6% diabetes insipidus. 32.2% of
patients presented hypertension, 16.2% diabetes mellitus, both diagnosed at a
younger age than in general population and more frequent in women. Surgery
represented frst treatment in 53% of patients, pharmacological therapy in 45.9%
and radiotherapy/radiosurgery in 0.8%. Only 34.3% of subjects underwent just
one treatment, other patients had multiple therapies in particular: two treatments
in 47.9%, three in 16.4% and four in 1.2%. At the end of the study 932 (62.6%)
patients resulted in remission, of whom 399 (43.7%) currently on pharma-
cological treatment. 61 patients died: the main causes were vascular disease and
malignancies. For vascular disease women had a major mortality for cerebral
disease (20 versus 4%) while men for cardiac disease (38 versus 28%).
P21
Decreased cortical thickness on MRI in patients with Cushing`s
syndrome: preliminary experience
Alicia Santos
1
, Esther Granell
3
, Eugenia Resmini
1
, Juan Ybarra
1
,
Maria J Portella
2
, Victor Perez
2
, Maria J Barahona
1
, Olga Lopez Mourelo
3
,
Yolanda Vives
4
, Manuel De Juan
4
, Patricia Pires
3
, Beatriz Gomez Anson
4
& Susan Webb
1
1
IIB-Sant Pau and Dep. Endocrinology/Medicine, Hospital Sant Pau, UAB
and Centro de Investigacion Biomedica en Red de Enfermedades Raras
(CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain;
2
Departments
Psychiatry (CIBERSAM)Hospital de Sant Pau, UAB, Barcelona, Spain;
3
PIC (Port dÌnformacio Cienti fca). UAB, Barcelona, Spain;
4
Radiology, Hospital S Pau, UAB, Barcelona, Spain.
Introduction
Patients with Cushing`s syndrome might present a variety of brain alterations.
There is however little evidence from MRI studies demonstrating atrophy of
either frontal or medial temporal brain regions.
Aims
To study cortical alterations (decreased cortical thickness) on MRI in patients
with Cushing`s syndrome (CS), as compared to controls (C), and long-standing
major depressive disorder (MDD).
Thirteen patients with CS (3 with active disease), 14 controls and 19 MDDpatients
were evaluated. MRI was obtained using a 3T Philips Achieva facility (software
version 2.1.3.2), the SENSE 8-channel head-coil, and a specifcally designed
acquisition protocol (3D-MPRAGE whole brain sequence, Turbo Field Echo,
TR6.7, TE3.1, Voxel size1,1,1.2). Cortical thickness was quantifed
using a MRI automatic software package (FreeSurfer), running on a GRID facility
in a parallel environment. The results of the cortical thickness were verifed by
experts, and in some cases manual modifcations were applied to obtain more
accurate results. The Freesurfer statistical package (QDEC tool) was used to
perform the comparisons between groups. Signifcance was defned at P,0.05.
Results
ANOVA results showed differences among the three groups in several brain
regions. CS patients displayed decreased cortical thickness in the posterior
cingulate, prefrontal and lateral temporal regions, of both cerebral hemispheres
compared to controls (df23; P,0.05). CS patients also showed decreased
cortical thickness in the posterior cingulate and lateral temporal regions (even
more pronounced) compared to MDD (df28; P0.01). These differences were
maintained when age, gender and years of education were included as covariates.
Conclusions
Cushing`s syndrome patients show a distinct pattern of cortical alterations, as
observed on MRI analyses, from controls and major depressive disorder. These
fndings could infuence the cognitive performance of Cushing`s syndrome patients.
Supported by FIS080302 and ERCUSYN PHP800200.
P22
Patients with prolactinomas exhibit distinct personality patterns:
comparison of 84 prolactinoma patients with 58 patients with
non-functioning pituitary adenomas and 168 age- and
gender-matched controls
Anastasia Athanasoulia, Marcus Ising, Hildegard Pfster, Guenter Stalla &
Caroline Sievers
Max-Planck-Institute of Psychiatry, Munich, Germany.
Objective
To examine whether prolactinoma patients have an altered personality profle.
Methods
In this cross-sectional study 84 prolactinoma patients were enrolled. As reference
groups, we compared 58 patients with non-functioning pituitary adenomas and
secondly 168 age and gender matched healthy control subjects. Personality traits
were measured with the standardized Eysenck (EPQ) and Cloninger personality
(TPQ) questionnaires.
Results
Compared with healthy controls, patients with prolactinomas described
themselves as distinctly more neurotic (EPQ-N; P,0.05) reporting also increased
fatigability and asthenia (TPQ-HA4; P,0.001). These personality patterns,
however, were not specifc for prolactinomas but could be similarly observed in
patients with non-functioning pituitary adenomas compared with controls.
In one personality trait, prolactinoma patients were different from both control
groups: they were less extraverted than healthy controls and NFPA patients
(EPQ-E; P,0.05, adjusted for age, sex, BMI).
Conclusion/discussion
To our knowledge, this is the frst study examining personality traits in patients
with prolactinomas systematically. So far it can only be speculated why the trait
extraversion in prolactinoma patients in comparison to NFPA patients is reduced.
An altered dopaminergic tone associated with reward activity might play a role
which should be further investigated in prospective studies.
P23
Circadian rhythmicity changes of gonadal and growth axis in adolescent
idiopathic scoliosis
Dana Manda
1
, Mariana Chiru Anton
2
, Suzana Vladoiu
1
, Oana Popa
1
& Olga Ianas
1
1
2
Emergency Hospital, Calarasi, Romania.
Adolescent idiopathic scoliosis (IS) represents an evolutive disease that occurs in
puberty and progresses till the skeletal maturation. The neuroendocrine
hypothesis involving a melatonin defciency as the source for IS is one of the
proposed causes of this plurifactorial disease.
Objective
To investigate the hormonal changes of both the gonadal and growth axis and
circadian rhythmicity in subjects with adolescent idiopathic scoliosis compared to
age matched healthy subjects.
The study group consisted in 15 patients aged 9-18 years. with (IS) and 8 healthy
subjects, age matched, as controls. The study had the Ethical Committee
approval. Blood was collected every 4 h during day and 2 h during night of 24 h
period (1200, 1600, 2000, 2400, 0200, 0400, 0800 h) for circadian profle. Serum
melatonin, cortisole, LH, FSH, E2, T, DHEA, androstendione, GH, GHBP, IGF1,
IGFBP3 levels were measured and statistically analyzed. The individual profles
of circadian markers (melatonin and cortisol) and studied hormones were
quantifed by a ft cosine curve yielding mesor, amplitude and acrophase.
Results
The levels of hormones were measured in blood samples collected at 0800 h
showed statistically signifcant differences in IS group compared to controls:
melatonin (24.566.39 versus 9.563.21 ng/ml, P0.02), LH (7.262.37
versus 2.480.63 U/l, P0.03), E
2
(107.729.61 versus 27.610.54 pg/ml),
IGF1 (2653.63 versus 24544.87 ng/ml P0.009). Circadian profles
analysis showed a signifcant increase in 24 h production of IGF1 and a decrease
secretion and phase shift in cortisol circadian rhythm. There were no signifcant
differences in melatonin circadian rhythm.
Conclusions
The results showed changes in growth axis. IGF1 signifcant increase and shifted
cortisol rhythm may be components of the plurifactorial etiology of adoloscent
idiopathic scoliosis.
P24
Ultrasound-assisted microsurgery for pituitary macroadenomas
Ulrich Knappe
1
, Juergen Rolfes
1
, Christian Jaspers
2
, Reinhard Santen
3
& Joachim Feldkamp
4
1
Neurosurgery, Johannes Wesling Klinikum, Minden, Germany;
2
Endocrinology, Johannes Wesling Klinikum, Minden, Germany;
3
German
Clinic of Endocrinology, Frankfurt/Main, Germany;
4
Endocrinology,
Klinikum Mitte, Bielefeld, Germany.
Subject
Use of intraoperative ultrasound (iUS) during transshenoidal surgery addresses
(a) resection control of macroadenomas and (b) identifcation of microadenomas,
thus avoiding extensive pituitary exploration.
Method
(a) For resection control of 33 pituitary macroadenomas and 2 meningeomas a
13 MHz US probe with a perpendicular 10 mm linear feld was introduced into the
sella after intrasellar resection to investigate the suprasellar and parasellar
compartments. (b) In 20 patients with Cushing's disease (CD) a 13 MHz probe
with straight ahead 5 mm linear feld was used for identifcation of
microadenomas before opening of the pituitary capsule.
Results
(a) In macroadenomas, total resection was accomplished in 22 out of 33 cases
(67%), in 10 Knosp
0
IV adenomas a tailored partial resection was performed.
Remission of hypersecretory syndrome was obtained in 9/14 cases (64%). Two
infltrative meningeomas were partially resected. In 18 out of 35 cases further
resection after iUS was undertaken (51%). Compared to postoperative MRI,
concerning suprasellar tumor remnants iUS was positive in 2/34 cases, false
negative in 2, and not applicable in 4 (due to air, one of those false negative).
Concerning parasellar tumor remnants iUS was positive in 11/35 cases
(2 meningeomas, 9 Knosp
0
IV adenomas), false positive in 1/34 (Knosp
0
III
adenoma), and false negative in one case (Knosp
0
II, acromegaly). (b) In CD, 15
out of 19 microadenomas were identifed by iUS (79%), including 3/4 cases
with negative preoperative MRI. Remission rate of hypercortisolism was 20/20
(100%), other pituitary function were unaltered compared to preoperative state in
19/20 cases (95%). No complications related to iUS occurred.
Conclusion
iUS with high-frequency probes during transsphenoidal surgery improves (a) the
extent of resection in infltrative macroadenomas, (b) the fnding rate of
microadenomas in CD, and the endocrinological outcome.
P25
Efhcacy and safety of co-administration of lanreotide Autogel 120 mg
monthly with pegvisomant weekly in patients with acromegaly partially
controlled by somatostatin analogues
Aart-Jan van der Lely
1
, Ignacio Bernabeu
2
, Jan Cap
7
, Philippe Caron
3
,
Annamaria Colao
4
, Catherine Lesage
5
, Josef Marek
5
, Sebastian Neggers
1
& Pascal Birman
5
1
Erasmus, Rotterdam, The Netherlands;
2
Universitario de Santiago,
La Coruna, Spain;
3
CHU Rangueil, Toulouse, France;
4
Federico II
University of Naples, Napoli, Italy;
5
Ipsen Innovation, Les Ulis, France;
6
1st School of Medicine Charles University, Prague, Czech Republic;
7
2nd Medical Clinic University Hospital Charles University, Hradec
Kralove, Czech Republic.
Recent studies have shown that the co-administration of lanreotide (lan) with
pegvisomant (peg) was able to normalise IGF1 secretion in patients with
acromegaly who were partial responders to somatostatin analogues (SSAs).
Fifty seven subjects with acromegaly (mean age 51.612.7 years) not previously
controlled by SSAs (either treated by SSAs for at least 6 months with IGF1
ULN, or on peg for at least 3 months) with IGF1 1.2 ULN (n54) or with
IGF1 ULN and GH nadir 1 g/l (n3) after a 4 month run-in period on lan
120 mg monthly entered into a co-administration period to evaluate the effcacy
and safety of combining monthly injections of lan 120 mg with peg for 28 weeks.
Peg starting dose of 60 mg once weekly could be progressively adapted every
8 weeks based on IGF1 levels from 40 to 80 mg once weekly up to 60 mg twice a
week. Serum IGF1 was normalized at the end of the co-administration period in
33 (58%) subjects. The median weekly dose of peg taken by subjects who
normalized IGF1 level was 60 mg. The percentage of subjects normalized
was signifcantly higher in non diabetics (24/3863% than in diabetic patients
9/1947%). Older subjects were more likely to achieve normalisation than
younger ones (odd ratio: 3.395 (P0.03)). Serum IGF1 was normalised in 45
(79%) subjects at least once at any time during the co-administration period
(P , 0.0001). Small mean improvements were seen in the quality of life
scores, however these changes were associated with large data variability.
Co-administration of lan and peg was well tolerated. Five subjects reported
treatment emergent adverse events (AEs) leading to peg withdrawal: thrombo-
cytopenia and urticaria were serious AEs considered drug-related while abdominal
pain and vomiting was a serious AE considered non drug-related; the 2 other (non
serious) TEAS were transaminases increase 5,ULNwhich returned to normal
after peg withdrawal. Altogether 6 (10.5%) subjects experienced transient
increases of transaminases 2,ULN, not related to their diabetic status.
Co-administration of lan Autogel 120 mg monthly with peg weekly appears to be
safe and to improve hormonal control in a majority of patients with acromegaly
partially controlled by somatostatin analogues alone. When compared to the
available data on peg monotherapy, co administration needs substantially less peg
per week to achieve the same effcacy.
P2
Longitudinal combined evaluation of antipituitary antibody titer and
immunouorescence pattern is a suitable tool in predicting autoimmune
hypophysitis in patients with autoimmune polyendocrine syndromes
Elena Pane
1
, Mario Rotondi
2
, Caterina Colella
1
, Assunta Dello Iacovo
1
,
Liliana Dalla Mora
3
, Giuseppe Bellastella
1
, Antonio Agostino Sinisi
1
,
Antonio Bizzarro
1
, Luca Chiovato
2
, Antonio Bellastella
1
& Annamaria De Bellis
1
1
Department of Clinical and Experimental Medicine and Surgery, Chair of
Endocrinology and Chair of Immunology and Allergology, 'F. Magrassi,
A. Lanzara`, Second University of Naples, Naples, Italy;
2
Unit of Internal
Medicine and Endocrinology, Fondazione S. Maugeri, Pavia, Italy;
3
Department of General Pathology, Second University of Naples, Naples,
Italy.
Antipituitary antibodies (APA) are frequently present in patients with
autoimmune polyendocrine syndrome (APS) but their role in predicting
autoimmune hypophysitis (LYH) is still discussed.
To evaluate the predictive value of APA investigated by immunofuorescence for
the occurrence of pituitary autoimmune dysfunction when considering together
some methodological characteristics as immunostaining pattern and antibody
titers, we studied 149 APA positive and 50 APA negative patients with APS but
without pituitary dysfunction, following them up for a time-span of 5 years.
APA by indirect immunofuorescence and anterior pituitary function were
assessed every 6 months in all patients.
Results
Among the 149 initially APA positive patients, 98 were positive at low/middle
titer (65.7%) and 51 at high titer (34.3%). As regards the immunostaining pattern,
99 patients (66.4%) showed an immunostaining only involving few or several
isolated pituitary cells (type 1 pattern) and 50 (33.6%) showed an immunostaining
involving all pituitary cells (type 2 pattern). During the follow-up all 50 APA
negative patients maintained a normal pituitary function. Instead, among the 149
APA positive patients, 28 (6 at low/middle and 22 at high titer at start) developed
hypopituitarism, while 121 (92 at low/middle and 29 at high titer) did not.
Interestingly, all patients developing pituitary dysfunction had shown a type 1
immunostaining at start and an increase of APA titer during the follow-up, while
all patients showing at start type 2 immunostaining pattern maintained a normal
pituitary function at the end with decrease of APA titer until disappearance in
most of them. Statistical analysis of our data showed that either higher titer and
type 1 pattern, considered separately, are unsuitable predictive markers of
pituitary dysfunction, instead, a signifcant predictive value is obtained
considering together these 2 parameters.
Conclusions
The predictive value of APA by immunofuorescence is still discussed due to
some methodological problems. Our results indicate that APA could be
considered good predictive markers of autoimmune pituitary dysfunction when
considering together their titers and some particular characteristics of
immunofuorescence pattern. The value of estimated risk of these fndings may
be useful to decide an appropriate follow-up of patients with APS without
pituitary dysfunction and possible future immune-therapy strategies.
P2I
Pituitary surgery for Cushing`s disease: the use of per-operative ACTH
sampling
Paul Menheere
1
, Erwin Cornips
2
& Jean-Pierre Sels
3
1
Department of Clinical Chemistry, Maastricht University Medical Center,
Maastricht, The Netherlands;
2
Department of Neurosurgery, Maastricht
University Medical Center, Maastricht, The Netherlands;
3
Department of
Internal Medicine, Maastricht University Medical Center, Maastricht,
The Netherlands.
Background
Treatment of choice of ACTH producing pituitary adenoma is transsphenoidal
resection. Owing to diffcult visual demarcation of the adenoma, peroperative
feedback about the completeness of the resection would be desirable. We inves-
tigated if rapid per-operative ACTH measurements is useful in surgical strategy.
Methods
Thirteen patients with pituitary adenomas were operated. An modifed ACTH-
assay delivered results within 30 min. Catheters were inserted in the internal
jugular veins at the site of the adenoma (four patients) or in both internal jugular
veins (eight patients). A third catheter permitted sampling in femoral vein. Once
the surgeon thought the adenoma was completely removed, surgery was
suspended and ACTH was repeatedly sampled in all catheters for 20 min. Next,
results were judged if they showed complete removal of adenoma or whether
re-inspection was indicated. Surgery was terminated only after visually
satisfactory removal of the adenoma together with biochemical confrmation.
Results
In three patients it was impossible to fnish the procedure, sampling being impossible
due to clotting. Four patients showed complete removal of the adenoma. Owing to
initial insuffcient decline of ACTH, re-exploring was decided in fve out of nine
patients; in three patients additional visual remnants were removed. In remaining
patients, there was doubt if any additional adenoma was removed.
Conclusions
Per-operative ACTH measurements seem useful to decide for more aggressive
approach to gain complete but selective resection of adenoma. Furthermore, the
ACTH concentrations proved to be predictive for the long-term follow-up. Results
are promising in increasing rate of cure in Cushing`s disease.
P28
Evaluation of the relationship between macroprolactin levels and
clinical and radiological hndings in patients with hyperprolactinemia
Serhat Isik, Dilek Berker, Yasemin Tutuncu, Ufuk Ozuguz, Ferhat Gokay,
Ferit Kerim Kucukler, Yusuf Aydin & Serdar Guler
Ministry of Health, Ankara Numune Research and Training Hospital,
Ankara, Turkey.
Objective
Hyperprolactinemia is the most common abnormality of the hypothalamic-
pituitary axis. In the majority of patients with hyperprolactinemia monomeric
prolactin (monoPRL) namely PRL with a molecular weight of 23 kDa
predominates. But, in some patients with hyperprolactinemia high molecular
weight forms of PRL namely macroprolactin (macroPRL) is detected. We aimed
to investigate the clinic and radiologic features associated with the macroPRL.
Methods
We evaluated 337 patients with elevated serum PRL concentrations who applied
to our Endocrinology outpatient clinics. Patients with hypothyroidism and renal
failure were excluded. The diagnosis of macroPRL is made if PRL value in the
supernatant is ,40% of total PRL after precipitation with polyethylene glycol.
Results
Mean age was 33.810.8 (16-66) years and male/female was 29/308. Eighty-
eight of the patients (26.1%) had an elevated macroPRL level (Group 1) and 249
of the patients (73.9%) had an elevated monoPRL level (Group 2). Two groups
were sex-matched (P0.091); however, mean age of Group 2 was higher than
Group 1 (35.010.1 vs 30.79.8, P0.016). Mean PRL levels (ng/ml) of the
Group 1 and Group 2 were similar (168.0347.0 vs 238.8584.9, P0.239).
Frequency of amenorrhea, infertility, irregular menses, gynecomastia and erectile
dysfunction were similar in both groups (23.6 vs 11.9%; 7.1 vs 4.7%; 44.6 vs
34.5%, 12.0 vs 25.0; 72.0 vs 50.0, respectively, P0.05). Rate of asymptomatic
patients was higher in Group 1 (30.2 vs 12.0%, P0.006). Patients with
galactorrhea (57.1 vs 39.2%, P0.04) and abnormal magnetic resonance imaging
(MRI) fndings (81.1 vs 65.3%) (P0.02) were more prevalent in Group 2 (57.1
vs 39.2%, P0.04). In MRI, 54.5% of Group 1 had microadenoma, 6.8% had
macroadenoma and 4.5% had empty sella; 64.7% of Group 2 had microadenoma,
14.0% had macroadenoma, 1.2% had empty sella and 1.2% had hypophysitis.
MacroPRL levels were not signifcantly different between idiopathic hyperPRL
(34.218.5), drug-induced hyperPRL (18.921.0), and prolactinomas (24.2
20.5) (P0.136). MacroPRL percentages of patients with normal MRI
fndings were higher than patients with microadenoma and macroadenoma
(50.228.7 vs 35.728.1 and 31.831.7, respectively, P0.021).
Conclusion
Existence of high macroPRL level should be considered as a biochemical
variation of hyperprolactinemia that may lead to any symptom and that may be
accompanied by any radiological fndings.
P29
Flexion contractures syndrome as the initial manifestation of
hypopiptuitarism
Hadj Ali Insaf, Khiari Karima, Mchirgui Nadia, Lakhoua Youssef
& Ben Abdallah Nejib
Department of Internal Medicine and Endocrinology, Charles Nicolle
We present a 58 years old woman admitted in our department for bradycardia,
diarrhea, epigastralgia, anorexia and weight loss. Physical examination showed
low blood pressure and inability to walk or stand due to severe fexion
contractures of the lower extremities without neurological abnormalities. The
biological fndings showed severe hyponatremia, hyerkaliemia tendency, low
levels of plasma cortisol and ACTH suggesting pituitary adrenal axis defciency.
Hormonal investigations conclude at the association of thyroid and gonadal
defciency. Medical history suggest Sheehan syndrome as etiology of
hypopituitarism. The patient was submitted to glucocorticoid replacement
therapy and we observed a remarkable relief from all the above symptoms.
Hence, in patients with 'fexion contractures` syndrome, the pituitary axis and
specially pituitary adrenal axis should be evaluated.
P30
Outcome of patients with diabetes insipidus associated with adipsia
Regina Palmeiro Carballeira, Concepcion Paramo Fernandez, Paula
Sanchez Sobrino, Beatriz Mantinan Gil, Ines Seoane Cruz, Reyes
Luna Cano & Ricardo V Garcia-Mayor
Background
Patients with diabetes insipidus (DI) that suffer of adipsia usually are diffcult to
treat, and requiring close monitorization.
Aim
To know long-term outcome of patients with DI associated to adipsia.
Subjects
From January 1989 to December 2006 were attended fve patients (two males)
with DI plus adipsia, aged 3214.64 years, range 10-51. Being the aetiology X
histiocytosis, craneapharyngioma, suprasellar meningeoma, astrocytoma and
cranial trauma for each patient. All but one received cranial surgery, one out of
fve was treated with radiotherapy as adjuvant therapy. Three out of four patient
operated have residual tumour. Patients` follow-up was 13.88.9 years.
Main results
Mean of hospitalizations for hidroelectrolyte imbalance were 7.42.65 times.
Mean of hospitalization duration 24.412.68 days. Two of fve patients
developed morbid obesity, two anomalies in consciousness, two thromboembolic
disease, one dead for heart failure.
Conclusions
Patients with DI associated with adipsia are diffcult to treat requiring numerous
hospitalizations and have a high rate of morbilities. Training to patients relatives
is crucial in their outcome. A good surrogate to serum sodium measurements is
determination of variations in body weight.
P31
Correlation between GH and FSH in the cerebrospinal uid and sleep
respiratory events
Cristina Capatina
1,2
, Dan Niculescu
1,2
, Andra Caragheorgheopol
2
& Mihail Coculescu
1,2
1
2
Introduction
There are high levels of anterior pituitary hormones in the cerebrospinal fuid
(CSF), i.e. beyond the blood-brain barrier, in many patients with pituitary tumors.
Aim
To assess the infuence of CSF pituitary hormones on brain functions refected by
sleep architecture and sleep apnea.
Method
Twenty-nine patients (17 women, 12 men) with pituitary adenomas (20
acromegaly, 5 nonfunctioning pituitary adenomas, 4 prolactinomas) were
subjected to overnight polysomnography and serum and CSF sample collections.
Correlations between CSF concentrations of GH, PRL, FSH, LH and sleep
variables were analyzed, adjusting the results for the effect of serum
concentrations. In a control group of 41 cases without endocrine diseases the
CSF levels of hormones were also measured. The study was approved by the local
ethical committee.
Results
GH level in the CSF was signifcantly and positively correlated with the mean
duration of central apnea episodes (Spearman test P0.02). The mean duration of
central apnea was signifcantly higher in patients with high CSF GH than in those
with normal CSF GH (Mann-Whitney U test P0.014). CSF FSH showed
signifcant correlation with the obstructive apnea index (Spearman, P0.03).
Serum GH was signifcantly correlated with the index of REM-related apnea
(Spearman, P0.008). The other pituitary hormones investigated did not show an
effect upon sleep apnea. None of the pituitary hormones analyzed in serum and
CSF signifcantly infuenced the sleep stages or sleep latencies.
Conclusion
Among the pituitary hormones, GH and FSH infuence the brain functions, as
refected by the sleep events, after crossing the blood-brain barrier.
P32
Modihcation of epicardial fat thickness in adult GHD patients after
short-term replacement therapy with rhGH
Emanuele Ferrante
1
, Claudia Giavoli
1
, Alexis Malavazos
2
,
Federica Ermetici
2
, Silvia Bergamaschi
1
, Cristina Ronchi
1
, Calin Coman
3
,
Elena Passeri
2
, Sabrina Corbetta
2
, Andrea Lania
1
, Bruno Ambrosi
2
,
Anna Spada
1
& Paolo Beck-Peccoz
1
1
University of Milan, Fondazione IRCCS Ca` Granda - Ospedale Maggiore
2
Endocrinology Unit, Department of Medical and
Surgical Sciences, University of Milan, IRCCS Policlinico San Donato, San
Donato Milanese, Italy;
3
Echocardiographic Unit, IRCCS Policlinico San
Donato, San Donato Milanese, Italy.
Adult GH defciency syndrome is characterized by visceral obesity, dyslipidemia,
insulin resistance and is associated with an increased cardiovascular risk.
Epicardial adipose tissue, giving its relationship with abdominal visceral
adiposity, coronary artery disease, cardiac morphology and function and
metabolic syndrome, has been proposed as cardio-metabolic risk indicator.
In this study, we evaluated the echocardiographic epicardial fat thickness in 14
patients (8 M and 6 F, age 4811.8 years, BMI 26.43.0 kg/m
2
) with adult
onset GHD, before and after 12 months of rhGH therapy. Echocardiographic left
ventricular diameter (LVD), interventricular septum thickness (IVS), left
ventricular (LV) posterior wall thickness, LV mass (LVM) and left ventricular
mass indexed (LVMi), E/A ratio, isovolumetric relaxation velocity (IRV) and
deceleration time (DT) were measured. Anthropometric and metabolic
parameters (BMI, BF% by DEXA, waist circumference, fasting glucose and
insulin, HbA1c, lipid profle), indices of insulin sensitivity and QoL (through
QLS-H Z-scores) were also evaluated. At baseline, IGF1 levels were low in all
patients and epicardial fat thickness measured 7.62.0 mm. After 12 months of
rhGH therapy (mean dose: 0.340.1 mg), IGF1 levels signifcantly rose (51.4
19.3 vs 129.554.3, P,0.05). Epicardial fat thickness signifcantly decreased
(3.92.3 vs 7.62.0, P,0.05), as well as BF% (31.86.1 vs 35.26.3,
P,0.05) and IRV (94.517.0 vs 112.823.3, P,0.05), suggesting an
improvement in diastolic function. No other signifcant modifcations in
echocardiographic parameters were observed. QLS-H Z-scores increased from
1.750.9 at baseline to 1.01.3 after 1 year of GH treatment (P,0.05).
BMI, waist circumference, fasting glucose and insulin, HbA1c, lipid profle,
HOMA-IR and QUICKI values did not differ from baseline. In conclusion,
epicardial fat thickness, a marker of cardio-metabolic risk, signifcantly decreases
after 1 year of rhGH therapy. These data suggest that this measurement is a useful
tool to assess the positive therapeutic effects of rhGH therapy in adult GHD
patients.
P33
Relationship between metabolic parameters and central dopaminergic
activity in healthy men
Ludmila Brunerova
1
, Jiri Horacek
2
, Jana Potockova
1
& Michal Andel
1
1
Second Department of Medicine, Faculty Hospital Kralovske Vinohrady
and Third Faculty of Medicine, Prague, Czech Republic;
2
Third Faculty of
Medicine, Psychiatric Centre Prague, Prague, Czech Republic.
Background
Dopaminergic agonists have been proved to improve control of diabetes and
lipids. Central dopaminergic activity can be measured by apomorphin test
(apomorphin increases GH and decreases prolactin levels, which is a marker of
dopaminergic activity).
The aim of our study was to evaluate the relationship between central
dopaminergic activity and metabolic parameters in healthy men.
Methods
We examined 42 healthy men (average age 43.57.4 years, BMI 27.4
5.7 kg/m
2
), anthropometric (waist-hip ratio, blood pressure and body fat by
bioimpedance) and metabolic (glycaemia, lipids, HbA1c) parameters were
measured and HOMA index of insulin resistance was calculated at the beginning
of the study. Sublingual apomorphine (0.033 mg/kg with 4 mg as the highest
dose) was administered and basal prolactin and GH were measured in 30, 15,
0, 15, 30, 45, 60, 75, 90, 120, 50, 180 min. Area under the curve for prolactine
(AUCPRL) and GH (AUCGH) was calculated using trapezoideal rule.
Euglycemic-hyperinsulinemic clamp (insulin 1 mg/kg per min) was performed
and glucose disposal (M) calculated. Linear regression was used for statistical
analysis.
Results
Negative correlation was observed between AUCPRL resp. AUCGH and total
cholesterol (r0.52, P0.001; resp. r0.34, P0.04), triglycerides
(r0.42, P0.009; resp. 0.36, P0.03), HOMA index (r0.33,
P0.043; resp. r0.5, P0.001), percentage of body fat (r0.44,
P0.009; resp. r0.45, P0.007), BMI (r0.36, P0.013; resp.
r0.56, P0.0001). Negative correlation was also found between AUCGH
and HbA1c (r0.55, P0.0001), AUCGH and diastolic blood pressure
(r0.35; P0.039), waist hip ratio (r0.46; P0.006) and age
(r0.53; P0.001), whereas positive correlation between AUCGH and M
(r0.36. P0.039).
Conclusion
Higher central dopaminergic activity is connected with lower total cholesterol,
triglycerides, HbA1c and lower insulin resistance in healthy men.
P34
Results of French collaborative evaluation (DEPHY-TC) in patients
with suspected pituitary abnormalities after traumatic brain injury
(TBI)
S Courtois
1
, M L Nunes
2
, M F Malezet
3
, N Morlet-Barla
4
, F Borson-
Chazot
1
, P Peruzzi
3
, A Tabarin
2
, M Delarque
4
, S Ciancia
1
, F Boyer
3
,
E Cuny
2
, A Delarque
4
, B Delemer
3
, E Richer
2
, H Curallucci
5
, L Di Nicola
6
& G Raverot
1
1
Federation dèndocrinologie du pole Est, Hospices Civils de Lyon, Lyon,
France;
2
CHU de Bordeaux, Bordeaux, France;
3
CHU Robert Debre-Reims,
Reims, France;
4
Endocrinologie, medecine physique et readaptation,
assistance publique hopitaux de Marseille, Marseille, France;
5
Etablissement de Reeducation et readaptation fonctionnelle neurologique,
clinique Saint Martin, Marseille, France;
6
IPSEN Pharma SAS, Boulogne
Billancourt, France.
Study aim
Pituitary function evaluation in patients with traumatic brain injury (TBI).
Subjects
One hundred and forty-six patients (49 female, 97 men, age: 31.916.2 years)
recovered from moderate to severe TBI. Prospective follow up has been
performed 3/6 and 12 months from TBI for 79 subjects. Retrospective evaluation
(from 0.3 to 30 years) included 67 subjects selected in front of overt clinical
features (obesity, fatigue, sexual disorders).
Methods
Clinical (neurological, endocrine, and general) and hormonal evaluations were
performed using a standardized protocol including determination of FT
4
, TSH,
PRL, IGF1, testosterone/E
2
, FSH and LH. Corticotrope and somatotrope axes
were evaluated using glucagon-, insulin tolerance- or GHRH-arginine tests.
Results
Prospective group. 3-6 months after TBI (n79): 44.3% presented endocrine
dysfunction: GH defciency (GHD) (22%) gonadotrope defciency (19%),
corticotrope defciency (13%), thyrotrope defciency (5%). Twelve months after
TBI (n46) 34.8% presented endocrine dysfunction: GH defciency (GHD)
(15%) gonadotrope defciency (24%), corticotrope defciency (2%), thyrotrope
defciency (2%).
Combined defciency was observed in 12.6 and 6.5% of cases initially and after
12 months respectively.
Six of nine patients with GHD at frst evaluation recovered normal somatotrope
function after 12 months but three new patients with GHD were diagnosed at this
time.
Retrospective group (n67) 45.3% subjects presented endocrine dysfunction:
GHD (32.8%), gonadotrope defciency (17.1%), corticotrope defciency (9.3%),
thyrotrope defciency (4.7%). Combined defciency was observed in 17.1% of
cases.
Among patients with a follow-up after TBI 1 year (n99), GHD patients
(n25) presented signifcant increase of body mass index (P,0.05) compare to
GH suffcient patients (n74).
Conclusion
Our data in the prospective cohort confrm that pituitary dysfunction after TBI
may evolve over time and requires multiple evaluations. Prospective interven-
tions studies are needed to evaluate the benefts of hormonal supplementation in
these patients.
P35
A case of lymphocytic panhypophysitis
Zehra Candan
1
, Gonul Koc
1
, Dilek Dellal
1
, Serap U
cler
2
, Suheyla Gorar
1
,
Handan Bekdemir
1
, Cavit Culha
1
& Yalcin Aral
1
1
Endocrinology Department, Ankara Training and Research Hospital,
Ankara, Turkey;
2
Neurology Department, Ankara Training and Research
Hospital, Ankara, Turkey.
A 44-year-old man with 6 months history of headache, fatique, depressive mood,
anorexia, impotence, decreased libido, poliuria and polidypsia. The results of the
physical examination were normal, except the patient had noduler guatr. Baseline
hormonal investigations and dinamic tests showed panhypopituitarism and partial
central diabetes insipidus. Magnetic resonance imaging (MRI) of the pituitary
gland showed enlarged pituitary gland and a marked thickening (4.5 mm) of the
infundibulum, loss of the hyperintense signal over the neurohypophysis, also
8 mm adenoma in the center of adenohyphophisis which was lower contrast
enhancement than parancyma were positive. Visual feld and MRI of brain were
normal. During lumbar puncture, intracranial pressure, CSF examination were
normal. Neurosarcoidosis of hypophysis was excluded by the normal ACE levels
in serum and CSF samples, lack of systemic symptoms and signs of sarcoidosis.
Systemic autoantibodies and tumour markers were negative. Oral corticosteroid
replacement therapy with 7.5 mg prednisolone, desmopressin nasal sprey 10 g
was started, after 1 week 25 g L-tyroxine was added to glucocorticoid treatment
1 month after replacement therapy, he was well with normal thyroid hormone
levels and without any sign or symptom of secondary adrenal failure. During his
third month visit, MRI of the pituitary gland demonstrated that partial decrease of
infundibulum thickness (3 mm) and pituitary and adenoma volumes, marked
improvement of previous clinical symptoms. All fndings and follow up datas in
our male case showed that panhypopituitarism and diabetes insipidus related
with lymphocytic panhypophysitis and pseudotumour appearance. Our patient
improved clinically and radiologically after only replacement dose of steroid.
Lymphocytic hypophysitis is a rare disorder.and has a female predominance
with female to male ratio of ^8.1. It can rarely a psueudotumour which
mimicks pituitary adenom as or accompany by pituitary adenoma. A few cases
of lymphocytic hypophysitis have been reported in men on literature. We
present this case to state rarity of lymphocytic panhypophysitis and pseudutumour
in a man.
P3
Evaluation of quality of life in patients with acromegaly using the
acromegaly quality of life questionnaire (AcroQoL)
Silvia Vandeva
1
, Emil Nachev
1
, Mario Nikolov
1
, Joanna Matrozova
1
,
Krasimir Kalinov
2
& Sabina Zacharieva
1
1
Ushate 'Akad. Iv. Penchev` Medical University - Sofa, Sofa, Bulgaria;
2
New Bulgarian University, Sofa, Bulgaria.
Introduction
Acromegaly is a chronic disease with a serious impact on patients` morbidity,
mortality and health-related quality of life (HRQOL). Recently a disease-specifc
questionnaire assessing HRQOL in acromegaly was developed (AcroQoL). Using
this tool we have compared QoL in patients with controlled versus uncontrolled
acromegaly.
It was a prospective, cross-sectional study. For the period 2007-December 2008
163 patients with acromegaly completed the Bulgarian version of the AcroQol in
the endocrinology department of our clinics. They were divided into two groups:
patients with active acromegaly (n87, mean age 48.3312.72) and patients in
remission according to the consensus criteria (n76, mean age 51.5111.75).
Statistical analysis was performed by XPSS version 9, using
2
for categorical
data and Student`s t-test for continuous data.
Results
A marked impairment of the patients` QoL was observed in all scales. However,
no statistically signifcant difference was found between controlled versus the
uncontrolled group. Mean total score was 44.5922.91 vs 50.4525.94
(P0.131), mean physical scale score was 38.1623.03 vs 43.8926.18
(P0.143), mean appearance subscale score was 43.8523.91 vs 4927.69 and
mean personal relations score was 52.8026.93 vs 59.2127.95 (P0.14) in
patients in remission and active disease respectively.
Conslusion
Remission status, defned by biochemical criteria, does not ameliorate QoL in
patients with acromegaly. There could be several factors infuencing impaired
QoL and giving directions for further improvement: delayed diagnosis and
achievement of remission, relapses of the disease, inadequate approach to the
concomitant diseases and complications.
P3I
Rapid bone loss 23 years after diagnosis for childhood acute
lymfoblastic leukaemia (ALL) in spite of GH therapy
Cecilia Follin, Katarina Link, Thomas Wiebe, Christian Moell, Jonas Bjork
& Eva Marie Erfurth
Institution of Clinical Sciences, University of Lund, Lund, Sweden.
Context
Acute lymphoblastic leukaemia (ALL) is the most common pediatric malignancy
and its treatment includes many known risk factors for low bone mineral density
(BMD), e.g. glucocorticosteroids, methotrexat and cranial radiotherapy (CRT).
Objective
To evaluate bone mineral density (BMD) and markers of bone turn over in a
group of adults with childhood onset ALL, treated with CRT and to evaluate the
effect of 5 years with, and 8 years without GH therapy on BMD.
In 44 ALL patients (21 women), aged 25 years (19-31 years) we evaluated BMD
with DXA. Patients were GHD (91%) or insuffcient. Comparisons were made
with population controls, matched for age, gender, smoking and residence. Two
subgroups of patients and matched controls were investigated with DXA at
baseline and after 5 years with GH therapy (n15; GH dose 0.5 mg/day)) and
after 8 years without (n13).
Results
At baseline no signifcant differences in BMD or Z-scores at femoral neck or
L
2
-L
4
or in levels of osteocalcin and crosslaps (all P0.3) were recorded,
between 44 ALL patients and controls. After GH therapy in 15 ALL patients there
was a non-signifcant decline in BMD and Z-scores but without difference in these
levels compared to controls after 5 years. Among the 13 untreated GHD ALL
patients BMD at femoral neck and Z-scores (0.0 vs 0.5 SDS; P,0.05) together
with osteocalcin and crosslaps decreased signifcantly after 8 years compared to
baseline levels, and became signifcantly lower than matched controls after 8
years (0.5 vs 0.4 SDS; P0.05).
Conclusions
At the age of 25 years and 17 years after treatment for ALL, normal BMD and
Z-scores at femoral neck and L
2
-L
4
was recorded. After another 5-8 years, there
was a rather rapid decrease in Z-scores, irrespective of a moderate dose of GH
therapy.
P38
Effects on glucose metabolism of high-dose octreotide LAR in patients
with acromegaly inadequately controlled by conventional somatostatin
analog therapy
Gherardo Mazziotti
1
, Stefania Bonadonna
1
, Giovanna Bugari
2
,
Annamaria Colao
3
, Renato Cozzi
4
, Salvatore Cannavo`
5
,
Laura De Marinis
6
, Ettore degli Uberti
7
, Fausto Bogazzi
8
,
Francesco Minuto
9
, Marcella Montini
10
, Ezio Ghigo
11
& Andrea Giustina
1
1
Department of Medical and Surgical Sciences, University of Brescia,
Montichiari, Brescia, Italy;
2
Biomedical Sciences and Biotechnology,
University of Brescia, Brescia, Italy;
3
Endocrinology, University Federico
II, Naples, Italy;
4
Endocrinology, Niguarda Hospital, Milan, Italy;
5
Endocrinology, University of Messina, Messina, Italy;
6
Pituitary Unit,
Department of Endocrinology, Catholic University of the Sacred Heart,
Rome, Italy;
7
Endocrinology, University of Ferrara, Ferrara, Italy;
8
Endocrinology, University of Pisa, Pisa, Italy;
9
Endocrinology, University
of Genoa, Genoa, Italy;
10
Endocrinology, Bergamo Hospital, Bergamo,
Italy;
11
Endocrinology, University of Turin, Turin, Italy.
The effects of conventional somatostatin analog (SSA) regimens on glucose
homeostasis seem to have minor clinical impact in acromegaly. Recently, we
performed a trial showing that high dose octreotide LAR signifcantly reduces
IGF1 in acromegalic patients uncontrolled with conventional SSA doses. In this
post-hoc analysis, we evaluated the effects of high doses versus high frequency
octreotide LAR on glucose homeostasis (HbA1c, FPG, HOMA-R) in patients
with acromegaly enrolled in this trial. After approval by ethical committee and
informed consent, 26 patients (14 F, 12 M, median age 51 years, range: 27-78)
with uncontrolled acromegaly were randomly treated with high-dose (11 patients:
60 mg/28 days) or high-frequency (15 patients: 30 mg/21 days) octreotide LAR
for 6 months. At study entry, seven patients had diabetes mellitus and eight
impaired fasting glucose (IFG). After 6-month treatment, glucose metabolism
was impaired in six patients (23.1%), improved in two patients (7.7%) and
unchanged in the remaining 18 patients (69.2%). Rate of impairment in glucose
homeostasis was similar in high doses versus high frequency octreotide LAR
(27.3 vs 20.0%; P0.44). In all six patients with impaired glucose homeostasis,
serum IGF1 and/or GH values remained high during treatment, whereas
signifcant decrease (20%) in serum IGF-I or GH values was observed in
75% of patients in whom glucose homeostasis did not impair (P0.03).
Impairment of glucose homeostasis occurred in 26.7% of patients with pre-
existing diabetes mellitus or IFG and in 18.2% of patients with pre-existing
normal glucose metabolism (P0.35). In conclusion, the increase in octreotide
LAR doses or frequency did not produce negative effects on glucose metabolism
in the majority of patients. In the minority of patients who experienced
impairment of glucose homeostasis, this event occurred more frequently in those
with persistently uncontrolled acromegaly and it seems to be not dependent on the
pre-existing abnormalities of glucose metabolism.
P39
Sub-acute tumour debulking with somatostatin analogues in newly
diagnosed acromegaly due to macroadenomas
Cristina Olarescu
1,4
, ystein Husby
1
, Ansgar Heck
1
, Geir Ringstad
2
,
Jon Terje Ramm-Pettersen
3
, Anders Palmstrm Jrgensen
1
&
Jens Bollerslev
1
1
Section of Endocrinology, Rikshospitalet-Oslo University Hospital, Oslo,
Norway;
2
Department of Radiology, Rikshospitalet-Oslo University
Hospital, Oslo, Norway;
3
Department of Neurosurgery, Rikshospitalet-Oslo
University Hospital, Oslo, Norway;
4
University of Medicine and Pharmacy,
'Iuliu Hatieganu`, Cluj-Napoca, Romania.
Background
Surgery is accepted as frst line treatment of somatotroph macroadenomas with
involvement of the optic chiasm. However, during recent years somatostatin
analogues (SA) have increasingly been used as primary treatment improving
ultimate cure rate, as SA`s have anti-proliferative effects in most tumours. We
demonstrate here positive effect of subacute/acute SAtreatment ontumour shrinkage
and chiasm decompression in two recently diagnosed acromegalic patients.
Patients and results
Two female patients (P1 and P2) with newly diagnosed acromegaly due to GH
secreting macroadenomas are presented. Both tumours were invasive, unable to be
cured by direct surgery, and were compressing the optic chiasm. Ophthalmologic
examinationrevealedslight temporal and nasal visual felddefects but without vision
affection. Both responded extensively on octreotide test (50 g): GHdecreased from
64.7 to 1.8 mUI/l (96%), (P1) and from120 to 37 mUI/l, (P2). Both patients were
treated primarily with subcutaneous SA, under very close follow up.
P1 was treated with 3,50 g octreotide/day (for 15 days) and P2 received frst
3,50 g octreotide/day (for 4 days) then 3,100 g octreotide/day (for 8 days).
The table shows patients` pre-treatment and post-treatment characteristics.
Discussion and conclusion
We present selected cases of newly diagnosed acromegaly with slight visual feld
defects, impractical to be cured by direct surgery. Both were successfully treated
primarily with SA`s under close and careful follow-up, followed by signifcant
tumor volume reduction and consequently relieve of the optic chiasm. We suggest
that SA treatment is a possibility in selected cases for sub-acute debulking.
P40
Long-term treatment of Cushing`s disease with pasireotide (SOM230):
results from a Phase II extension study
Marco Boscaro
1
, Yilong Zhang
2
, Kapildeb Sen
2
, Mario Maldonado
3
,
Ulrike Schoenherr
3
& James Findling
4
1
Division of Endocrinology, Polytechnic University of Marche, Ancona,
Italy;
2
Clinical Pharmacology, Oncology Business Unit, Novartis
Pharmaceutical Corporation, Florham Park, New Jersey, USA;
3
Clinical
Development, Oncology Business Unit, Novartis Pharma AG, Basel,
Switzerland;
4
Division of Endocrinology, Metabolism, and Clinical
Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
Introduction
Pasireotide reduced UFC levels in 22 of 29 patients with Cushing`s disease after
15 days` treatment (Boscaro et al. JCEM 2009). Of these 22 patients, 5 achieved
normalized UFC (UFC-responders) and 17 had reduced but not normalized UFC
(UFC-reducers). Results of an extension phase to this study are presented.
Methods
Patients with de novo or persistent/recurrent Cushing`s disease received
pasireotide 600 g s.c. bid for 15 days in the core study. Patients with signifcant
clinical beneft after 15 days could enroll in an open-ended extension study.
Patients with normalized UFC at end-of-core were to receive pasireotide 600 g
bid, with dose titration to 900 g bid if required. All other patients were to receive
pasireotide 900 g bid. Primary endpoint: UFC response at month 6.
Results
Nineteen patients entered the extension phase, three of whom were UFC-
responders at end-of-core. Mean treatment duration was 16 months (2mo-4.8y).
Of 18 evaluable patients at 6 months, 10 (56%) had a reduction in UFC, of whom
4 (22%) were UFC-responders, and 6 (33%) were UFC-reducers. Of the 4 UFC-
responders at 6 months, 1 was a UFC-responder and 2 were UFC-reducers at the
end of the core study. In all patients, there was a trend toward a reduction in mean
serum cortisol and plasma ACTH. Mean change in systolic blood pressure and
bodyweight was 8.87 mmHg and 7.4 kg at 6 months. The most frequently
reported AEs were diarrhea (13 patients), nausea (12 patients), hyperglycemia
(11 patients), abdominal pain (9 patients). Most AEs were grade 1 or 2; 6 patients
reported grade 3 hyperglycemia and 1 patient reported grade 4 diabetes.
Conclusion
Long-term pasireotide treatment resulted in 50% of patients achieving
normalization or a reduction in UFC, and was generally well tolerated. These
results suggest pasireotide may be an effective long-term pituitary targeted
treatment for Cushing`s disease.
P41
Heterogeneous origin of idiopathic isolated central hypothyroidism
Marco Bonomi
1
, Domenico Vladimiro Libri
1
, Tiziana De Filippis
1
,
Mario Maggi
2
, Alba Pilotta
3
, Annamaria De Bellis
4
, Alessandro Salvatoni
5
,
Fabio Buzi
3
, Paolo Beck-Peccoz
1
, Luigi Nespoli
5
& Luca Persani
1
1
Department of Medical Sciences, Istituto Auxologico Italiano IRCCS and
Fondazione Ca` Granda Ospedale Maggiore, University of Milan, Milan,
Italy;
2
Department of Physiopathology, University of Florence, Florence,
Italy;
3
Growth and Development Unit, Children`s Hospital, Brescia, Italy;
4
Department of Clinical and Experimental Medicine and Surgery F.
Magrassi, A. Lanzara, Second University of Naples, Naples, Italy;
5
Department of Pediatrics, Insubria University, Varese, Italy.
Isolated central hypothyroidism (ICH) is a rare disease whose pathogenesis is so
far linked to germinal mutations of TSH (several cases) or TRH receptor
(TRHR) genes (only two cases). Here, we report the studies performed to
elucidate the pathogenesis of idiopathic ICH in fve cases (two men, three women)
with low/normal TSH levels and low freeT
4
levels (3-8 pmol/l). One male,
negative at neonatal TSH screening, showed signs of severe hypothyroidism at
44 days, while the other patients were diagnosed during childhood or adulthood
(age range: 3-42 years). All, but one with a partial empty sella, had a normal
pituitary MRI, and negative history of traumatic or ischemic brain injuries.
Thyroid ultrasound showed hypoplasia in two and normal glands in the others.
Thyroid autoantibodies were negative in all cases. Absent/impaired TSH
responses to TRH stimulation accompanied by normal PRL increases were
registered in the three female patients and in the neonate. In this latter case, a
homozygous intronic mutation (IVS25 GA) known to alter the splicing of
TSH gene was detected. No genetic alterations were detected in the 3 female
patients with acquired ICH. The remaining patient presented at 3 years of age with
severe obesity (48% excess of the ideal weight) and type 2 diabetes. He had a
conserved TSH response to TRH, but TSH, Leptin receptor and TRH genes were
normal. In all four negative cases, the possible autoimmune origin of ICH was
then tested by evaluating anti-pituitary antibodies (APA). Interestingly, APA
were positive in the three ICH women (two highly and one weakly positive) but
not in controls. In conclusion, idiopathic isolated CH can have a heterogeneous
pathogenesis involving genetic defects but, surprisingly, also autoimmunity.
Autoimmune origin should be suspected when ICH appears to be acquired beyond
infancy and the genetic origin has been excluded.
P42
Echocardiographic assessment of cardiac valves morphology and
function in patients with prolactinomas under long-termtreatment with
cabergoline or bromocriptine
Atanaska Elenkova, Sabina Zacharieva & Rabhat Shabani
Background
Long-term treatment with dopamine agonists (DAs) is considered to be the frst-
choice therapy for prolactinomas. According to current guidelines DAs can be
P1 pre-T P1 post-T P2 pre-T P2 post-T
GH mean (day
curve) (mU/l)
97.6 2.44 120 78
GF1 (nmol/l) 135 16 208 149
Tumour volume
(mm
3
)/(% of
decreasing)
2858 2231/(21.4) 6481 5043/(21.9)
Chiasma
compression/
visual fled defect
/ / / /?
safely withdrawn in patients with negative pituitary MRI and stable normalization
of prolactin levels for at least 3 years. On the other hand, recent studies have
shown an increased risk for valvular heart disease in patients with Parkinson`s
disease treated with high doses of cabergoline. The aim of this study was to assess
the prevalence of valvular lesions among prolactinoma patients treated with
2 different DAs (Bromocriptine or Cabergoline).
Methods
We performed an echocardiographic study in 167 subjects divided into 5 groups:
38 patients treated with Cabergoline for up to 3 years (treatment duration 6-36
months); 31 pts under long-term Cabergoline treatment (treatment duration 40-84
months); 37 pts on Bromocriptine; 31 newly diagnosed with prolactinoma and 30
age-matched healthy subjects. Subjects with chronic heart disease were excluded
from the trial. Severity of valve regurgitation was categorized as none (grade 0);
trace (1); mild (2); moderate (3) and severe (grade 4).
Results
We did not fnd any signifcant differences in prevalence of mitral regurgitation
grade 1 to 2 (13.5 vs 12.9 vs 10.8 vs 16.1 vs 10.2%) and mild tricuspid
regurgitation (39.5 vs 58.1 vs 35.1 vs 54.8 vs 35.6%; P0.158) in our
investigated groups. None of investigated subjects presented with pulmonary
valve lesions. A non-signifcant increase in the prevalence of mild aortic
regurgitation was observed in patients under long-term treatment with cabergo-
line (9.7 vs 0%; P0.064). Clinically important valve regurgitation (moderate or
severe, grade 3 and 4) was not found.
Conclusions
In contrast to chronic treatment with high dose cabergoline in patients with
Parkinson`s disease the low-dose long-term therapy in prolactinoma patients
appears not to be associated with an increased risk of valvular heart disease.
Keywords: valvular heart disease; prolactinoma; cabergoline; bromocriptine.
P43
The effect of GH on rat neurogenesis in the dentate gyrus of
hypocampus
Pablo Devesa
1,2,3
1
Centre for Neuroscience and Cell Biology, Coimbra, Portugal;
2
University
of Santiago de Compostela, Santiago de Compostela, Spain;
3
Association
for the Project FOLTRA, Teo, Spain.
We previously showed that GH administration to rats with induced brain injury
produces a clear proliferation of neural precursors within DG and a signifcant
reduction of apoptosis. In this study, we tried to delineate, in vitro, the signaling
pathways by which GH produces these effects on neurogenesis.
Methods
Neural stem cells were obtained from the Subgranular Zone of 9 days old mice
and then plated on petri dishes under proliferation conditions (DMEMEGF
FGF
2
) or in multiwells with differentiation medium (DMEMEGFFGF
2
). We
frst analysed whether in these cells there is GH and GH-R expression. The effects
of the hormone in the presence or absence of selective inhibitors of GH signaling
pathways was studied by using: SP600125 (20 M) to inhibit P-JNK, rapamycin
(20 nM) to inhibit mTor, and U0126 (20 M) to inhibit Erk. Apoptosis was
evaluated by TUNEL, while proliferation was evaluated by BrdU incorporation
(10 M). After fxing the cells in PFA results were evaluated by immuno-
histochemistry.
Results
GH and GH-R were showed to be present in neurospheres on proliferation
medium, and in different cell populations migrating from neurospheres when they
had been cultured in differentiation medium. Adding GH (500 ng/ml) to a
differentiation medium did not increase BrdU (10 M) incorporation, as it did
when the hormone was added under proliferation conditions. GH administration
signifcantly decreased apoptosis in basal differentiation conditions. Adding
GH-signaling inhibitors signifcantly increased basal Apoptosis; this effect was
reverted when GH was added to U0126- and rapamycin-tretaed cells, but not
when added to SP600125-treated cells.
Conclusions
For the frst time we demonstrate here the presence of GH and its receptor in stem
cells from SGZ of DG. This may explicate the effects of the hormone on
neurogenesis: increasing proliferation and decreasing apoptosis. Interestingly, the
anti-apoptotic pathway at this level seems to be regulated by Erk and mTor. Or
results open a new way for investigating the effects of GH in CNS regenerative
therapies, corroborating our pioneer results in human patients.
P44
Utility and limitations of the traditional diagnostic approach to
hyponatremia: a diagnostic study
Wiebke Fenske, Sebastian Maier, Anne Blechschmidt, Stefan Stork
& Bruno Allolio
University of Wuerzburg, Wuerzburg, Germany.
Background
The differential diagnosis of hyponatremia is often challenging because of its
association with multiple underlying pathophysiological mechanisms, diseases
and treatment options. Several algorithms are available in order to guide the
diagnostic approach to hyponatremia, but their diagnostic and clinical utility has
never been evaluated. We aimed to assess in detail the diagnostic utility as well
the limitations of the existing approaches to hyponatremia.
Methods
Each of the 121 consecutive subjects presenting with hyponatremia (serum
sodium ,130 mmol/l) underwent three different and independent diagnostic and
therapeutic approaches: i) unexperienced doctor applying an established
Algorithm, ii) intensive care senior physicians acting as Senior Physician, and
iii) senior endocrinologist serving as Reference Standard.
Results
The overall diagnostic agreement between Algorithm and Reference Standard
was 71% (respective Cohen`s and values were 0.64 and 0.70), the overall
diagnostic agreement between Senior Physician and Reference Standard was 32%
(0.20 and 0.19). Regarding the therapeutic consequences, the diagnostic accuracy
of the Algorithm and the Senior Physician was 86% (0.70 and 0.72) and 48%
(0.01 and 0.04), respectively. In retrospect, by disregarding patient`s extracellular
fuid volume and assessing the effective arterial blood volume by determination
of the fractional urate excretion, the Algorithm improved its diagnostic accuracy
to 95%.
Conclusion
Although the Algorithm performed reasonably well, several shortcomings
became apparent, rendering it diffcult to apply the Algorithm without reservation.
Whether some modifcations may enhance its diagnostic accuracy and simplify
the management of hyponatremia needs to be determined.
P45
Long-term treatment of acromegaly with pasireotide (SOM230): results
from a Phase II extension study
Andrew Farrall
1
, Matthieu Ruffn
2
, Karina Wetli-Hermosillo
2
& Stephan Petersenn
3
1
University of Edinburgh, Edinburgh, UK;
2
Novartis Pharma AG, Basel,
Switzerland;
3
University of Essen, Essen, Germany.
Introduction
Pasireotide (SOM230) is a multi-receptor targeted somatostatin analogue with
high binding affnity for sst
1,2,3
and sst
5
. In a Phase II study of pasireotide in
patients with active acromegaly, 27% achieved biochemical control after 1 month
of octreotide s.c. followed by 3 months of pasireotide, and pituitary tumor volume
decreased by 20% in 39% of patients. Results from the study`s extension phase
are presented.
Methods
The extension phase enrolled patients who achieved biochemical control (GH
2.5 g/l and normalized IGF1) or clinically relevant improvement during the
core study. Patients received pasireotide at the dose at which clinical beneft was
achieved (200, 400 or 6005 g s.c. bid), with dose adjustments up to 9005 g s.c.
bid if required. Effcacy and safety were assessed every 3 months. Patients
underwent pituitary MRI at the core and extension baselines and every 6 months.
Results
Thirty patients entered the extension phase. Biochemical control was achieved in
6/26 patients (23%) at 9 months and 3/9 (33%) at 27 months. 12/26 (46%) and
13/26 (50%) patients achieved GH control and IGF1 normalization at 9 months,
respectively; 5/9 (56%) and 5/9 (56%) achieved these goals at 27 months,
respectively. 16/29 patients (55%) who had a core baseline MRI achieved
signifcant tumor volume reduction by the time they exited the extension phase.
Mean percent (S.E.M.) tumor volume reduction was 133.9% at extension
baseline (n25), 265.9% by 9 months (n16), and 3811% by 27 months
(n5). All patients experienced an adverse event (AE), with diarrhea and nausea
the most common (n15 each). Two serious AEs with a suspected-drug
relationship were worsening of diabetes mellitus and gallbladder polyp. Four
patients discontinued the study because of an AE.
Conclusions
Extended pasireotide treatment maintained biochemical control and tumor
volume reduction in patients with acromegaly. AEs were mostly mild or
moderate.
P4
Growth modelling of non-functioning pituitary adenomas
Juergen Honegger
1
, Sanna Zimmermann
1
, Tsambika Psaras
1
,
Martin Reincke
2
& Klaus Dietz
3
1
Department of Neurosurgery, University of Tuebingen, Tuebingen,
Germany;
2
Department of Internal Medicine, University of Munich
(Campus Innenstadt), Munich, Germany;
3
Department of Medical
Biometry, University of Tuebingen, Tuebingen, Germany.
Objective
It is still unknown how pituitary adenomas grow over years and whether growth
kinetics follow a distinct growth model. Defnition of adenoma growth kinetics
would substantially enhance knowledge of biological behaviour. The objective of
this study was to defne a growth model for non-functioning pituitary adenomas.
Methods
Fifteen patients who had fve or more serial high-quality examinations with
magnetic resonance images or computerized tomography scans were detected
among 216 surgical cases with non-functioning pituitary adenomas. Tumour
volumes were assessed using a stereological method based on the Cavalieri
principle. Tumour growth during the observation period was analyzed and
different growth models were ftted to the data.
Results
Fifteen pituitary adenomas (3 newly diagnosed tumours and 12 recurrent
tumours) had been longitudinally observed during a median observation period of
7.4 years (range 2.3-11.9 years). Growth kinetics could be described either by an
exponential growth model (nine patients) or by a logistic model (fve patients).
One tumour remained nearly unchanged in size during the observation period.
None of the adenomas showed accelerated growth during the observation period.
The mean tumour volume doubling time for the 14 growing adenomas was
3.1 years (range: 0.8-27.2 years).
Conclusions
Growth of pituitary adenomas can be described by distinct growth models.
Understanding of biological behaviour is important to optimize patient
management, develop treatment algorithms and establish follow-up protocols.
P4I
A case of empty sella turcica and Cushing`s disease
Ana Goncalves, Fernando Batista & Isabel do Carmo
Santa Maria University Hospital, CHLN-EPE, Endocrinology, Diabetes and
Metabolism Service, Lisbon, Portugal.
Introduction
Cushing`s syndrome results from increased or aberrant expression of ACTH,
CHR, or neuroendocrine receptors that leads to uncontrolled hypersecretion of
cortisol. The most common cause is ACTH-secreting pituitary adenomas.
Alternatively, the glucocorticoid excess may be due to adrenal neoplasia or to
ectopic ACTH - secreting tumors. There are rare reports of patients with a
meningioma secreting CRH presenting paraneoplasic Cushing`s syndrome.
We report a case of Cushing`s disease in a patient with empty sella turcica and
recurrent meningioma, emphasizing its diagnostic challenges.
Case report
A 42 years old woman was admitted to our institution by secondary
hypothyroidism and primary empty sella turcica, with remaining pituitary
function normal. Four years later, endocrine evaluation showed parameters
indicative of Cushing`s syndrome. The patient presents obesity without typical fat
distribution, hypertension, hyperglycemia without any other clinical features
suggesting Cushing`s syndrome.
Recently, she was submitted to surgical excision of a cervical meningioma,
without biochemical remission of hypercorticolism or normalization of ACTH.
She was admitted to evaluate the etiology of hypercorticolism and biochemical
tests suggest an ACTH-dependent Cushing`s syndrome (ACTH and cortisol
suppression at 8 mg dexametasona test). Pituitary MRI confrms empty sella
turcica, failed to yield evidence for a pituitary tumor, and reveled two small dural
neoplasic lesions.
Inferior petrosal sinus sampling results are consistent with a pituitary ACTH-
secreting tumor and show lateralization to the right.
Discussion
We report a 46-year-old female with empty sella and partial loss of pituitary
function, to whom Cushing`s disease was diagnosed. The coexistence of a
cervical meningioma rises the hypothesis of an ectopic ACTH syndrome.
However endocrine evaluation strongly suggests a pituitary origin.
Transsphenoidal examination of the contents of the sella turcica will be
performed to clarify the diagnosis.
P48
Reproductive changes in females with 'empty sella` syndrome
Dilfuza Artikova & Barno Shagazatova
Tashkent Medical Academy, Tashkent, Uzbekistan.
Purpose of the study was to assess the condition of reproductive system in females
with 'empty sella` syndrome (ESS).
Of 159 females with ESS, mean age 37.60.93 years, of them 65 with primary
ESS, 42 with secondary ESS, 47 with forming ESS were studied. The diagnosis of
ESS was established by MRI fndings. Obstetrical and gynecological anamnesis,
hormonal background were investigated.
Results
Disorders of menstrual cycle were observed in 40 females (26%), of them in 19
(47.5%) as secondary amenorrhea, in 21 (52.5%) as oligomenorrhea. In 25% of
females lactorrhea was noted, of them in 43.5% with menstrual cycle disorders, in
56.5% without them. Fifty-two females, 56.5%, had no complaints about menstrual
dysfunction. In 23 (15%) hypergonatropic amenorrhea. Thirteen females applied for
primary infertility with concurrent ESS. Secondary amenorrhea in all forms of ESS
was due to a decrease of FSH and estradiol, increase of LHand progesterone levels.
Increase of a TTHlevel was also characteristic. Oligomenorrhea in primary ESS was
associated with higher values of LH and progesterone, while in secondary and
forming ESS with decreased levels of FSH and estradiol.
Conclusions
The most frequent menstrual disorder in females with ESS was amenorrhea with
decreased levels of FSH and estradiol. Increase of TTH level was noted in all three
forms of ESS.
P49
Aftercare in patients with Cushing`s disease and acromegaly: is there
room for improvement?
Juergen Honegger, Monika Milian & Tsambika Psaras
Germany.
Objective
Evaluation of aftercare, medical therapy and remission rate in Cushing`s disease
(CD) and acromegaly (AC).
Methods
Of 58 CD and 83 AC patients operated over 10 years were carefully evaluated.
The patients received a disease-related questionnaire and were invited for a
follow-up at the outpatient clinic of the Department of Neurosurgery. 33 CD and
52 AC patients returned the questionnaire, 25 CD and 37 AC patients participated
personally. CD patients underwent a dexamethasone-suppression-test, and IGF1
levels were assessed in AC patients. Data on postoperative therapy were assessed.
Results
CD of 84.8% and AC of 75.0% patients had been followed by endocrinologists. CD
of 9.1% and AC of 1.9% patients had been under no aftercare. CD of 96% patients
were in remission. A recurrence occurred in four patients, two were newly detected
by our study. IGF1 was postoperatively normalized in 25 of 37 ACpatients (67.6%).
Twenty patients remained in remission, fve relapsed. One patient received medical
therapy upon recurrence and presented normal IGF1, four patients with relapse were
not yet treated. Ten of 12 patients with elevated early postoperative IGF1 received
medical therapy that was commenced within 6 months in nine cases. The mean
duration of medical therapy was 36 months (range 2-92). IGF1 was still elevated at
the last follow-up in eight of these 10 patients, all of them receiving monotherapy.
In four patients, the dose had been increased once.
Conclusions
The postoperative transfer back to the endocrinologist after operative treatment is
achieved well in both groups. In uncured AC, medical therapy is initiated early, but
options of therapy offer room for improvement. Therapy of recurrence is delayed in
both pathologies.
P50
Persistent hypocortisolism in Cushing`s disease and persistent
comorbidities in acromegaly determine neurocognitive function and
quality of life after surgical treatment
Tsambika Psaras, Juergen Honegger & Monika Milian
Germany.
Objective
Cushing`s disease (CD) and acromegaly (AC) are associated with psychological
and psychiatric problems. Both pathologies cause a severe impairment in quality
of life (QoL) that can persist even if biochemical remission and cure are achieved.
The aim of the study was to investigate the infuence of the current disease status
(remission vs. no remission) on neurocognitive function and QoL in treated CD
and AC patients. The second objective was to determine predictive factors that
determine postoperative neuropsychological function and QoL.
Methods
CD and 37 AC patients underwent neuropsychological testing. The SF-36,
SCL-90-R and AcroQoL questionnaires were applied to assess QoL. CD patients
underwent a dexamethasone-suppression-test, IGF-1 levels were assessed in AC
patients to determine the current disease status. The results were compared with
28 sex-, education- and age-matched healthy controls (HC).
Results
Limitations in QoL evaluated for both pathologies compared to the HC were more
pronounced than neurocognitive decrease. This fnding was independent of the
current status of disease (remission vs. no remission). Regression analyses
revealed young age at operation and comorbidities to predict adverse post-
operative outcome in AC. Persistent hypocortisolism was best associated with
impaired neurocognition and QoL in CD.
Conclusions
In both pathologies, the current status of disease does not play the major role in
postoperative outcome. A possible explanation might be the considerably
improved endocrinopathy after treatment, even if no actual cure is achieved.
P51
Demographic factors and the presence of comorbidities do not promote
early detection of Cushing`s disease and acromegaly
Tsambika Psaras, Monika Milian & Juergen Honegger
Germany.
Objective
The aim of the study was to analyze the time-to-diagnosis interval in patients with
Cushing`s disease (CD) and acromegaly (AC), to assess factors that promote early
disease detection and to investigate the medical felds diagnosing the pathologies.
Design
Case-record retrospective study.
Patients
CD and 52 AC patients operated between June 1998 and December 2007.
Measurements
All patients received a self-designed disease-related questionnaire. Data about
symptoms and their duration prior to diagnosis, education level, age, gender and
place of residence (i.e. rural vs. urban, size of the city) were collected.
Results
The mean time-to-diagnosis interval was 6.0 years in CD and 5.8 years in AC
patients. The vast majority of 67% of all investigated patients was diagnosed after
they changed their primary health care provider or during a hospital stay owing to
comorbidities caused by their underlying disease. Only 33% of all cases were
diagnosed by their primary physician. In both groups neither gender, age, place of
residence, education level, typical comorbidities (e.g. hypertension or diabetes)
nor distinctive symptoms and bodily changes of the underlying disease (e.g.
prognathism, acral enlargement, weight gain, buffalo hump) were signifcant
factors promoting early detection.
Conclusions
Apparently, patient-related factors do not affect the time-to-diagnosis interval, but
rather the change of the primary health care provider. Knowledge of the disease
among physicians is prerequisite to early detection. Due to the deleterious
sequelae of delayed diagnosis, information programmes in the medical
community are of paramount importance. Institution of screening programmes
should be evaluated.
P52
A case of giant prolactinoma in a 14-year old boy
Ekaterina Giniyatullina, Larisa Dzeranova, Andrey Grigoriev,
Alexander Voronzov, Ekaterina Pigarova & Lyudmila Rozhinskaya
National Research Center for Endocrinology, Moscow, Russian Federation.
Prolactinomas are very rare, but usually more aggressive among children, than in
adults. Although treatment strategies for prolactinomas in adults are well
established and at present time the preference is given to dopamine agonists, the
use of these drugs in pediatric patients is limited due to lack of information on
safety and effciency in this group of patients.
A 14-year old boy presented with absent puberty, obesity (weight 4&) general
weakness, tiredness, headaches and fainting episodes. Examination revealed left
eyelid ptosis and left pupil dilation, bitemporal hemianopsia, PRL - 7341 mU/l,
LH - 0.2 U/l, FSH - 1.5 U/l, testosterone - 1.5 nmol/l, normal TSH and free T
4
,
elevation of total cholesterol and low density lipoproteins. MRI showed giant
pituitary adenoma (47,52,46 mm) with supra- and parasellar extension,
compromising brain stem, frontal, temporal lobes and third ventricle.
After obtaining an informed consent from parents of the patient we started therapy
with cabergoline 2 mg a week which was well tolerated and at 12 months resulted
in shrinkage of prolactinoma (22,26,35 mm), widening of the visual
felds. PRL level fell to 1943 mU/l, testosterone was 0.5 nmol/l, LH - 2.6 U/l,
FSH - 2.5 U/l. The patient`s physical appearance changed to normal (weight
2&), Tanner stage progressed in all regions from 0 to 1 point, and lipid profle
parameters were inside reference ranges.
This clinical case that we report here demonstrates high effciency and tolerability
of cabergoline in a 14-year boy with giant prolactinoma, complicated by visual,
neurological and metabolic disturbances, which allowed us to refrain from
surgical treatment and to reduce the degree of complications.
P53
Leptin receptor gene expression and its promoter methylation do not
change with age in peripheral blood mononuclear cells
Malgorzata Roszkowska-Gancarz
1
, Magdalena Owczarz
2
, Jacek Polosak
1
,
Alina Kurylowicz
3
& Monika Puzianowska-Kuznicka
1,3
1
The Medical Centre of Postgraduate Education, Warsaw, Poland;
2
The
International Institute of Molecular and Cell Biology, Warsaw, Poland;
3
Medical Research Centre Polish Academy of Sciences, Warsaw, Poland.
Introduction
Leptin is a protein hormone secreted mainly by adipose tissue. It exerts its
function via ubiquitously expressed receptors (LEPR). A number of LEPR
isoforms are known. Metabolism of lipids and carbohydrates, that, in part,
depends on leptin, might deteriorate with age. Aging is associated with a decrease
of the global methylation and with hypermethylation of some promoter-located
CpG islands. Such hypermethylation results in transcription inhibition.
Aim
To assess the expression of long, cell membrane-located isoform of LEPR and to
analyze LEPR promoter methylation pattern in different age groups.
Methylation and gene expression were assessed in young (Y, 22-37 years old),
middle-aged (M, 60-70 years old) and long-lived (N, 90-102 years old) age
groups. Total RNA and the genomic DNA were isolated from peripheral blood
mononuclear cells. Gene expression was measured by real-time PCR using
-actin as a reference gene. DNA methylation was analyzed by bisulfate
sequencing. Results were analyzed using Kruskal-Wallis ANOVA and U Mann-
Whitney tests.
Results
The expression of long LEPR isoform is similar in all age groups. It did not
depend on gender, however, a trend towards signifcance between young males
and females (P0.09, mean 1.371.85 vs 2.132.27 expressed in arbitrary
units, respectively). 29 potential sites of methylation in the analyzed LEPR
promoter fragment were analyzed. Methylation of this fragment is low and does
not change with age (2.8, 3.1 and 2.1%, in Y, M and in N groups, respectively).
Conclusions
Expression of long LEPR is stable in peripheral blood mononuclear cells and
methylation of the LEPR promoter do not change with age. The LEPR promoter
does not undergo age-related hypermethylation in blood mononuclear cells of
humans.
P54
Presence of kiss1/kiss1r system at the pituitary, testis and adipose tissue
in rodents: functional actions and regulation by physiological cues
Ester Gutierrez-Pascual, Jose Cordoba-Chacon, Leonor Pinilla,
Francisco Gracia-Navarro, Raul M Luque, Mari a M Malagon,
Manuel Tena-Sempere, Antonio J Marti nez-Fuentes & Justo P Castano
Department of Cell Biology, Physiology and Immunology, University of
Cordoba, IMIBIC, and CIBERobn 06/03, Cordoba, Spain.
It is now widely accepted that the kisspeptins (kps) and their receptor kiss1r play
an essential role in the neuroendocrine regulation of the reproductive axis by
stimulating hypothalamic GnRH secretion. However, kiss1 and kiss1r expression
in tissues distinct from, but related to, the hypothalamus, prompted us to propose
that these molecules may exert regulatory functions in additional places of the
neuroendocrine system, such as the pituitary and two of its physiological targets:
testis and adipose tissue. We have previously demonstrate that the kiss1/kiss1r
system is functionally expressed in pituitary cells from peripubertal rats, where
kp-10 directly acts on a subset of both gonadotropes and somatotropes by
increasing [Ca
2
]
i
and, consequently, stimulating LH and GH release,
respectively. Moreover, we have observed that estradiol differentially facilitates
kp-10 action at the pituitary level, by sensitizing, especially in somatotropes, the
response to this peptide. To clarify the function of kiss1/kiss1r system at these
different levels, we have analyzed the regulation of its expression by
physiologically relevant factors and conditions. This revealed that the kiss1/kiss1r
system is under a fne, age- and gender-dependent regulation in pituitary, where
their expression levels undergo dramatic changes throughout postnatal
development, as well as after in vitro treatment with GnRH, GHRH and/or kp-
10, and under different metabolic conditions. Additionally, we observed that the
kiss1/kiss1r system is expressed in peripheral tissues, such as testis and adipose
tissue, and that this expression is differentially regulated during postnatal
development, as well as by metabolic factors and energy status. Taken as a whole,
our results suggests that the kiss1/kiss1r system exerts additional neuroendocrine
functions, distinct from the hypothalamic control of reproductive axis, and
support the hypothesis that this system may operate as an integrator between
metabolic, somatotropic and reproductive axes, by acting at multiple levels, from
the hypothalamus to the pituitary and their peripheral target tissues.
BIO-0139, CTS-01705, BFU2007-60180/BFI, BFU2008-01136/BFI
P55
Kisspeptin selectively increases LH and GH, but not FSH, ACTH, PRL
or TSH, release in primary pituitary cell cultures from a non-human
primate (Papio anubis) via distinct signaling pathways and under
inuence of sex steroids
Jose Cordoba-Chacon
1
, Raul M Luque
1
, Manuel D Gahete
1
, Rhonda
D Kineman
2
, Manuel Tena-Sempere
1
& Justo P Castano
1
Department of Cell Biology, Physiology and Immunology, University of
2
Research and
Development Division, Section of Endocrinology, Diabetes and Metab-
olism, Department of Medicine, Jesse Brown Veterans Affairs Medical
Center, University of Illinois at Chicago, Chicago, Illinois, USA.
Kisspeptins (Kp), a peptide family encoded by Kiss1 gene, and their receptor
Kiss1r were frst identifed by their anti-metastatic actions but have emerged as
key regulators of the reproductive axis, where they integrate sexual, metabolic
and seasonal cues to control hypothalamic GnRH release. Recent data indicates
that some actions of Kps may be effected directly at the pituitary (PIT), since
Kissr1 is expressed in the PIT and Kp stimulate luteinizing hormone (LH)
secretion directly at the pituitary level in various species (mouse, rat, pig, cow).
Additionally, Kp have unexpectedly been found to moderately, albeit
signifcantly, stimulate growth hormone (GH) release directly from rat and cow
somatotropes. However, the potential role of Kiss1/Kiss1r in PIT cells from
normal adult primates, a model very close to humans at the physiologic and
genomic levels, has not yet been addressed. Here, primary PIT cell cultures from
female baboons (Papio anubis) were treated for 4 h with kp-10 and release for all
PIT hormones was assessed. In this model, kp-10 (10 nM) increased LH and GH
release in a dose-dependent fashion; however, it did not affect the release of other
hormones (FSH, ACTH, PRL, TSH). Use of specifc inhibitors of distinct
intracellular signaling pathways showed that Kp-10 signals through PLC, PKC,
MAPK and intracellular Ca
2
infux, but not AC, PKA, extracellular Ca
2
infux
or NOS to stimulate LH and GH release. Interestingly, blockade of mTOR and
PI3K activity fully abolished the stimulatory effect of kisspeptin on LH, but not
GH, release. Further, since sex steroids are key modulators for gonadotrope and
somatotrope function, we tested the infuence of estradiol (E
2
) on the
responsiveness of these cell types to kp-10. Although, preincubation with 2
(10 nM, 36 h pre-exposure) increased or decreased baseline LH or GH
respectively, it served to enhance the relative LH- and GH-releasing effect of
kp-10 alone and in combination with classical hypothalamic stimulatory peptides
of LH and GH release (GnRH and GHRH), as compared to E
2
-free control
cultures. Taken together, our results provide the frst evidence that kisspeptins
may play a relevant role in stimulating LH and GH from primate somatotropes
through a direct effect mediated by distinct signaling pathways, and that sex
steroids may sensitize gonadotrope/somatotrope responsiveness to the direct
action of kisspeptins. Support: BIO139&CTS1705; BFU2007-60180.
P5
Diabetes Mellitus inuence on GH and IGF-1 levels in acromegalic
patients
Dreval Alexander & Trigolosova Irina
Moscow Regional Scientifc Research Clinical Institute, Moscow, Russian
Federation.
Background
Diabetes mellitus is one of the serious acromegaly complication.
As well known, glycemia infuences growth hormone (GH) secretion. From this
point of view, it is interesting to investigate feature peculiarity of GH and Insulin
like Growth Factor 1 (IFG-1) secretion when acromegaly is coupled with diabetes
mellitus.
Aim
Of this study was to investigate diabetes mellitus infuence on GH and IGF-1
levels in acromegalic patients.
patients with no treated acromegaly were studied. 13 of them had diabetes
mellitus. Median of acromegalic patients age with DM was 58.0 (57.0-62.5) years
and without DM was 48.0 (35.0-55.0) years (P,0.05). GH and IGF-1 serum
levels were measured in fasting state.
Results
Relationships between fasting glucose and GH levels were negative and enough
strong (r0.5, P,0.05). GH serum level in acromegalic patients without DM
was more than twice higher than in DM patients: 39.7 (21.7-49.9) mME/l vs 16.2
(6.3-32.6) mME/l, (P,0.05). Accordingly, the percent of increase IGF-1 level in
acromegaly patients without DM was signifcantly higher than in patients with
diabetes (60.1 (5.17-67.8)% and 46.5 (28.9-52.4)%, (P,0.05)).
Conclusion
Fasting hyperglycemia suppresses GH and, correspondently, IGF-1 secretion.
P5I
Cabergoline treatment in Cushing`s disease: effect of cabergoline
withdrawal in patients with normalized cortisol secretion after
long-term treatment
Rosario Pivonello, Monica De Leo, Alessia Cozzolino, Pasquale Vitale,
Maria Cristina De Martino, Chiara Simeoli, Gaetano Lombardi &
Annamaria Colao
Federico II University, Naples, Italy.
The dopamine agonist cabergoline has been found to be effective in inducing
normalization of cortisol secretion in 25-50% of patients with Cushing`s disease
after long-term treatment. Moreover, tumor shrinkage have been documented in
selected patients with pituitary corticotroph tumors. The aim of the present study
was to evaluate the effect of cabergoline withdrawal in patients with a stable
normalization of cortisol secretion and stable or absent visualization of pituitary
tumor after long-term treatment. Ten patients unsuccessfully treated by surgery
and then successfully treated with cabergoline at the dose ranging from 1 to
7 mg/week for 3 years entered the study. All patients had normal urinary cortisol
levels; fve patients had a stable microadenoma for at least 1 year and the
remaining fve had no visible pituitary tumor at magnetic resonance imaging
(MRI) before the drug withdrawal. The patients were followed-up every month
through a clinical examination, biochemical evaluation together with the
measurement of plasma ACTH and serum and urinary cortisol levels, whereas
a pituitary MRI was performed every six months during the following year.
A progressive increase of serum and urinary cortisol as well as plasma ACTH
levels, together with a reappearance of clinical syndrome, was observed in four
patients, starting from 3-6 months from cabergoline withdrawal. No signifcant
change in tumor volume or features were observed after 1 year. A new treatment
was re-started in these patients. Two patients had an increase of plasma ACTH
levels associated with a persistently normal serum and urinary cortisol levels and
no signifcant change in clinical symptoms and signs after 1 year from the drug
withdrawal. In the remaining four patients, a completely normal ACTH and
cortisol secretion and persistently negative pituitary MRI was observed during
the year following the treatment withdrawal. No change in clinical syndrome was
observed in these latter patients. In conclusion, the results of the present study
suggested that a group of patients with Cushing`s disease, persistently controlled
by cabergoline treatment for 3 years, maintain cortisol secretion in normal
range during the year following treatment withdrawal. Further studies on a
larger population of patients are mandatory to understand the mechanism
underlying this phenomenon and the eventual persistence of this apparent
remission of the disease.
P58
Carbohydrate disorders in patients with acromegaly
Maria Kurowska
1
, Joanna Malicka
1
, Jerzy S Tarach
1
,
Ewa Kiszczak-Bochynska
1
& Jolanta Kijek
2
1
Endocrinology Department, Medical University, Lublin, Poland;
2
Nuclear
Medicine Department, Medical University, Lublin, Poland.
Introduction
Carbohydrate disorders in the form of glucose intolerance or overt diabetes are
prevalent and well-documented in acromegalic patients.
Aim
To assess the prevalence of carbohydrate disorders and the correlations between
BMI, the duration of the disease, GH and IGF-1 concentrations depending on the
stage of progression of glucose intolerance in our acromegalic patients.
Methods
Acromegaly was diagnosed using standards established by the Polish Society of
Endocrinology and hyperglycemia was diagnosed according to the recommen-
dations of the Polish Diabetes Association.
Material
A group of 28 patients (21 F; 7 M) aged 37-76, mean 58.68.6 years, treated
between 2000 and 2008. The duration of acromegaly ranged from 3 to 24 years,
the mean duration being 10.86.8 years. The mean BMI of the whole group
was 32.25.0 kg/m
2
.
Results
Carbohydrate disorders were found in 20 patients (13 F; 7 M), i.e. in 71.4% of
cases. IFG was diagnosed in 25% cases (seven patients: 4 F, 3M), IGT in 20%
(4 patients: 2 F, 2 M) and overt diabetes in 31% of them (nine patients: 7 F, 2 M).
The highest mean values of the estimated parameters were found in acromegalic
patients with co-occurring diabetes and the lowest ones in patients without
carbohydrate disorders (P,0.01). The parameters were, respectively: BMI
- 35.04.8 and 31.04.9 kg/m
2
; the duration of the disease - 12.77.2 and
94.2 years; the GH level - 36.432.8 and 12.729.9 ng/ml and the IGF-1
level - 830.7444.6 and 447.8254.8 ng/ml. Subgroups of patients with
acromegaly and subclinical glucose intolerance disorders did not differ
signifcantly from the group with normal carbohydrate metabolism in terms of
the parameters which were examined.
Conclusion
Glucose intolerance in different stages of progression was found in a high
percentage of patients with acromegaly. Apart from hormone disorders which are
diabetes-specifc, diabetes risk factors in acromegaly also include features of
metabolic syndrome, such as excessive body mass.
P59
Study of pituitary function in acromegaloidism
Wilfredo Guanipa Sierra
1,4
, Pablo Fernandez Catalina
1
, Concepcion
Paramo Fernandez
2
, Eli as A
lvarez Garci a
2
, Amalia Andrade Olivie
2
,
Eduardo Pena
3
& Federico Mallo Ferrer
4
1
Hospital Montecelo, Pontevedra, Pontevedra, Spain;
2
Hospital Xeral, Vigo,
Pontevedra, Spain;
3
Hospital Meixoeiro, Vigo, Pontevedra, Spain;
4
Vigo
University, Vigo, Pontevera, Spain.
Acromegaloidism includes clinical features of acromegaly with GH and IGF1
normal levels at baseline and dynamic, without fndings of extrapituitary or
pituitary tumour. It has been associated with various conditions without a defnite
pattern. The aim was to evaluate whether there are differences in some hormonal
pituitary axis from acromegaloid subjects with respect to acromegalic and healthy
subjects. We designed a comparative, multicenter, case-control study in three
hospitals. It was approved by the local ethics committee. Demographic-
anthropometric, clinical and analytical data were obtained in ffteen acromega-
loid, fourteen acromegalic (without previous radiotherapy) and twelve control
subjects, matched by age and sex. There were no signifcant differences in age,
height, weight or BMI. Was determined by chemiluminescent immunoassay: GH,
IGF1, IGFBP3, ACTH, cortisol, TSH, FT
4
, FT
3
, PRL, PTH, Vit D25, FSH, LH,
TST, SHBG, FAI, Insulin and C-peptide. Were used ANOVA and Student t-test
to evaluate parametric variables and Kruskal-Wallis for nonparametric variables.
The results show signifcant differences (P0.001) in mean TSH:
2.911.2 U/ml in acromegaloids (CI95: 2.24-3.57), 1.181.0 uU/ml in
acromegalics (CI95: 0.60-1.76) and 2.221.25 U/ml in controls (CI95:
1.42-3.01). When comparing acromegaloid versus acromegalic subjects
differences are more evident (P0.00027). FT
4
levels showed no differences
between groups. The FT
3
level was higher (P: 0.029) in acromegaloidism (mean:
3.050.78 pg/ml) than in acromegaly (2.410.67 pg/ml) and also higher
(P0.031) in acromegaloidism than in controls (mean: 2.530.34 pg/ml).
No differences were found in other axes. These fndings suggest that in
acromegaloidism there are higher levels from TSH and FT
3
, meaning an increase
in thyroid axis activity.
P0
Trends in acromegaly treatment in Spain
Gemma Sesmilo
1
, Sonia Gaztambide
2
, Antonio Pico
3
, Alfonso Soto
4
,
Elena Torres
5
, Carmen Fajardo
6
, Concepcion Blanco
7
& Susan Webb
8
Onbehalf of REA investigators
1
1
Institut Dexeus, Barcelona, Spain;
2
Hospital de Cruces, Bilbao, Spain;
3
Hospital General de Alicante, Alicante, Spain;
4
Hospital Universitario
Virgen del Roci o, Sevilla, Spain;
5
Hospital Universitario San Cecilio,
Granada, Spain;
6
Hospital de la Ribera, Alzira, Valencia, Spain;
7
Hospital
Pri ncipe de Asturias, Madrid, Spain;
8
IIBSant Pau and Department of
Endocrinology/Medicine, Hospital Sant Pau, UAB and Centro de
Investigacion Biomedica en Red de Enfermedades Raras (CIBER-ER,
Unidad 747), ISCIII, Barcelona, Spain.
The Spanish acromegaly registry (REA) is an online epidemiological database
created in 1997 to collect clinical and biochemical data of patients with
acromegaly followed in Spain.
Aim
To study trends in acromegaly treatment over time in Spain.
Methods
REA is an online database in which registered endocrinologists collect data from
all acromegalic patients seen at their practices in Spain. In the last year the
neuroendocrine group of the Spanish Society of Endocrinology and Nutrition
(SEEN) urged investigators for new data entry, and updating of previous patients.
Variables collected included: demographics, estimated date of symptoms, date of
diagnosis, pituitary imaging (tumor size and tumor extension), tumor persistence
after surgery, visual felds, baseline GH, GH after an oral glucose tolerance test
(OGTT) and IGF1 concentrations. GH and IGF1 measurements were performed
in each center, and IGF1- reported as normal or abnormally high or low,
according to local reference values, was also recorded. Date of diagnosis and
co-morbidities were included as well as medical, surgical and radiation treatments
and dates when received. All clinical variables were collected at diagnosis and at
yearly - biyearly intervals. For all treatments date of start and end was collected.
Descriptive statistics were used to analyse data only in updated patients.
Results
As of 31 of December 2009, 1570 patients with acromegaly were included in the
database of whom 620 have complete data follow-up and were suitable for
analysis. There was 62.5 women and 37.5% men. Sixty-seven percent of patients
had a macroadenoma and 33% had microadenomas. Ninety-two percent
of patients had surgery whereas 35% had radiation therapy. Eighty nine % of
patients received medical treatment for acromegaly. When analyzing type
of treatments performed by decades, we observed a trend towards less use of
radiation therapy (19, 85, 87, 21 treatments for decades 70-79, 80-89, 90-2000
and 2000-2010 respectively for a total of 67, 299, 411 and 329 treatments each
decade), surgical rates have been maintained over time (21, 117, 177, 159 for the
same number of total treatments by decade), and use of medical therapy has
increased (27, 97, 147, 149).
Conclusion
Treatment of acromegaly in Spain has changed over time. Surgery is still the
mainstay of treatment and use of medical therapy has increased whereas radiation
treatment rates have decreased.
P1
SSTR5 ligand binding domain immunohistological detection in
pituitary adenomas using Y-SSTR5 a new mouse monoclonal antibody
Valentina Rossi
1
, Stefania Staibano
2
, Laura Del Basso De Caro
2
,
Giuseppe Bellastella
1
, Gennaro Ilardi
2
, Luigi Cavallo
4
, Annamaria Colao
3
& Antonio Agostino Sinisi
1
1
University of Napoli, Napoli, Italy;
2
Department of Biomorphological
Science, Federico II University, Napoli, Italy;
3
Department of Molecular
and Clinical Endocrinology and Oncology, Federico II University, Napoli,
Italy;
4
Department of Neurological Science, Federico II University, Napoli,
Italy.
Polyclonal antibodies against somatostatin receptors (SSTRs) available up to now
recognizing intracellular sites of receptors and their recycling products do not
detect bioactive ligand binding domains (LBDs) and are of limited performance
in paraffn-embedded tissues. Aim of this study was to evaluate by
immunohistochemistry the expression of SSTR5 on an archival series of pituitary
tumors using a new MoAbs against the SST-binding domain (Y-SSTR5).
Methods
We used paraffned tissue sections from 20 non-secreting pituitary tumors (NS)
and 14 PRL-secreting (PRL) adenomas and, as control, sections from normal
tissue surrounding the same tumor. A standard streptavidin-biotin-labeled
peroxidase immunostaining was performed. Negative controls were performed
with non immune serum. The degree of immunopositivity was evaluated semi-
quantitatively according to an arbitrary scale.
Results
Immunostaining for SSTR5 was found in 90% of NS (low-medium 55%, high
35%) and in 100% of PRLS adenomas (low-medium 14%, high 86%).
Conclusion
SSTR5 was found in the majority of pituitary tumors examined. PRLS adenomas
showed a tendency to higher expression of receptor protein. Y SSTR5 MoAb can
be used to detect SSTR5 on the membrane of pituitary cells in classical paraffn
embedded histological sections. The specifc detection of LBD SSTR5 by MoAb
can support a potential choice of panligand or SST analogues targeting SSTR5 in
resistant/recurrent pituitary tumors.
P2
Acromegaloidism: description of hfteen cases
Wilfredo Guanipa Sierra
1,4
, Concepcion Paramo Fernandez
2
, Pablo
Fernandez Catalina
1
, Eli as A
lvarez Garci a
2
, Amalia Andrade Olivie
2
,
Eduardo Pena
3
& Federico Mallo Ferrer
4
1
Hospital Montecelo, Pontevedra, Pontevedra, Spain;
2
Hospital Xeral, Vigo,
Pontevedra, Spain;
3
Hospital Meixoeiro, Vigo, Pontevedra, Spain;
4
Universidad de Vigo, Vigo, Pontevedra, Spain.
Acromegaloidism is a very rare entity (have been 54 cases reported worldwide)
that presents with clinical acromegaly and normal somatotropic axis, without
fndings of pituitary or extrapituitary tumour. Its origin has not been clearly
established, although it is associated with several pathophysiological conditions.
The local ethics committee approved to perform an observational and multicenter
study in three hospitals from a region with approximately 800 000 people over
18 years, in order to determine the clinic, demographic, analytic and karyotypic
features from patients in whom acromegaly was discarded. Was determined
somatotropic hormonal profle by chemiluminescent immunoassay in all subjects,
as well as routine biochemical parameters. Also calculated the HOMA index,
according Turner-Matthews considering insulin-resistance values above the 75th
percentile. Was performed ffteen metaphases karyotype from peripheral blood in
twelve subjects. At twenty months had been evaluated 15 patients, of whom 5
(33%) were male and 10 were women (67%) with mean age 4917.85 years
(CI95: 39.11 58.88). Was estimated prevalence of period in 18.75 cases per
million. The most prominent symptoms were arthralgia (93.3%), acral growth
(86.7%), paresthesia, headache and fatigue (66.7% each). The most common
signs were acromegaloid facial appearance (93.3%), prognathism (73.3%) and
frontal wrinkles with broad forehead (53.3%). CI95 BMI was 28.63-33.82 kg/m
2
with mean of 31.224.68 kg/m
2
. CI95 GH levels was 0.13-3.65 ng/ml with
mean of 1.893.18 ng/ml and CI95 IGF1 was 146.75-231.11 ng/ml with mean
of 188.9376.17 ng/ml. The most frequent associated conditions were
hyperlipidemia (60%), obesity (53.3%), insulin resistance (40%), impaired
fasting glycemia (26.6%), hypertension (20%), and DM2 (13.4%). Was detected
one Trisomy X (8.3%). These results support the statement that acromegaloidism
is more common than thought, more frequently in women and mostly associated
with metabolic disorders than karyotypic abnormalities.
P3
Sellar lesions in Ollier disease: case report and a review of the literature
Marie-Lise Jaffrain-Rea
1,2
, Felice Giangaspero
1
, Vincenzo Esposito
1
&
Giampaolo Cantore
1
1
Neuromed Institute, Pozzilli, IS, Italy;
2
Department of Experimental
Medicine, University of LÀquila, LÀquila, AQ, Italy.
Ollier disease (OD) is a rare disease, with multiple enchondromas localized in the
metaphysis of long bones, hands and feet, developing in the frst decade of life,
with potential malignant transformation into chondrosarcomas. OD is usually
sporadic and probably caused by post-zygotic genetic alterations leading to
mosaicism. A PTH/PTHrP receptor type 1 (PTHR1) gene mutation is present in
some cases.
Case report
A 21-years old male patient was referred to the Neuromed Institute because of a
sellar/parasellar mass revealed by left subclinical hypoacusia. OD was diagnosed
at 10 years-old because of a wrist fracture, with multiple lesions in both hands,
followed by a large tibial osteolytic lesion. In April 2009, cerebral MRI showed a
voluminous, heterogenous lesion involving the sphenoid bone and the sella
turcica, with a left petroclival and suprasellar extension. The anterior pituitary
was poorly visualized, the neurohypophysis could not be identifed. The patient
was poorly symptomatic, partial diplopia but no visual feld defects were
observed. He had normal somatic growth (184 cm, 91 kg) and pubertal
development, no polyurodipsia. Basal pituitary functions were within normal
limits, as were serum electrolytes, calcemia and PTH. Transphenoidal biopsy was
performed, concluding for an enchondroma. Surgery was followed by transient
diabetes insipidus and close follow-up was proposed. No evolution was observed
over a 6-months period.
Comments
Patients with OD are followed-up for the evolution of peripheral bone
lesions. However, there is accumulating evidence that intracranial neoplasms
(chondrosarcomas and non-sarcomatous neoplasms) may develop in adults with
OD or its variant, associated with soft tissue hemangiomas, the Maffucci
syndrome (MS). Enchondromas of the sellar region can be observed in both OD
and MS, pituitary adenomas being also reported in MS. Systematic screening
for central lesions in enchondromatosis patients should be sought in order to
favour precocious diagnosis and resolutive treatment.
P4
Comparison of efhcacy of cabergoline and bromocriptine
retrospectively in patients with hyperprolactinemia
Serhat Isik
1
, Dilek Berker
1
, Yasemin Tutuncu
1
, Ufuk Ozuguz
1
,
Ayse Arduc
1
, Gulhan Akbaba
1
, Yusuf Aydin
2
& Serdar Guler
1
1
Ministry of Health, Ankara Numune Training and Research Hospital,
Ankara, Turkey;
2
Faculty of Medicine, Duzce University, Duzce, Turkey.
Objective
Patients with hyperprolactinemia who require medical therapy are typically
treated with dopamine agonists (DA). In most cases, medical therapy with DA
normalizes the level of prolactin (PRL), restores gonadal function and fertility,
and substantially reduces the size of the tumor. Here, we aimed to compare the
effcacy of cabergoline (CAB) and bromocriptine (BRC) in hyperprolactinemic
patients retrospectively.
Methods
Retrospective analysis of clinic records of 231 patients (mean age 34.010.6
(16-66) years, 210 women and 21 men) who had received either CAB (n190) or
BRC (n41) for a mean duration of 24.220.0 (6-120) months.
Results
The mean age, sex distribution and treatment duration were similar in CAB and
BRC groups (35.210.6 vs 32.57.2, P0.113; 20/170 versus 1/20, P0.102;
21.716.7 versus 28.024.6, P0.078). Mean dosage was 1.61.5 mg/per
week for CAB and 3.73.0 mg/day for BRC. Mean PRL levels (ng/ml) and
tumor volume (cm
3
) at baseline and were higher in CAB group (220.3524.5
vs 112.650.7, P0.02; 0.582.05 vs 0.110.20, P0.04, respectively).
Percentage of patients with nontumoral hyperprolactinemia was higher in BRC
group (31.7 vs 7.9%, respectively, P,0.001). Macroadenomas were more
frequent in CAB group compared to BRC group among patients with tumoral
hyperprolactinemia (20.7 vs 7.1%, P,0.001). Fifteen of patients with
macroadenoma had surgery either before or after medical treatment. Before
treatment frequency of galactorrhea, amenorrhea and irregular menses were
similar between groups whereas BRC was preferred for patients with infertility.
Eleven of 12 patients with visual feld defects and 19 of 22 patients using
antipsychotic were treated with CAB. After treatment relief of symptoms and
mean PRL levels were similar between CAB and BRC groups (23.353.0 vs
BRC 31.427.0, respectively, P0.390). Altough baseline PRL levels and
tumor volume were higher in CAB group, statistically signifcant tumor
volume shrinkage (%) and decrease in PRL levels were obtained in BRC group
(58.754.9, 34.842.8, P0.041 and 48.442.2, 23.252.0, P0.003,
respectively).
Conclusions
Our data suggest that both of DA were effective in controlling symptoms
associated with horman excess but CAB has been shown to be more effective in
normalizing serum PRL levels and tumor shrinkage compared to BRC.
P5
Transition from Cushing`s disease to a hormonally inactive adenoma or
vice versa: four unusual cases of corticotroph adenoma
Marco Faustini-Fustini
1
, Matteo Zoli
1
, Diego Mazzatenta
1
,
Ernesto Pasquini
1
, Maria Pia Foschini
2
, Antonio Granata
3
& Giorgio Frank
1
1
Centre of Surgery for Pituitary Tumours, Bellaria Hospital, Bologna, Italy;
2
Section of Pathology, Department of Oncology, University of Bologna,
Bologna, Italy;
3
Endocrine Unit, University of Modena, Modena, Italy.
Over the last decade 824 pituitary tumours have been removed in our centre. Of
these, 114 (13.8%) were corticotroph adenomas. We present four unusual cases of
corticotroph adenoma showing transition from Cushing`s disease to a hormonally
inactive adenoma (case 1 and 2) or vice versa (case 3 and 4).
Case 1
A 51-year-old man was admitted with a 2-year history of weight gain, arterial
hypertension and chiasmatic syndrome. Cushing`s disease (CD) due to an
aggressive pituitary macroadenoma (stage 2C) was diagnosed. The tumour was
partially removed by transphenoidal (TSF) approach. Six months later a second
operation was carried out to remove the residual tumour and the patient developed
panhypopituitarism requiring hormonal replacement therapy, which included
cortisone acetate. Three years later a recurrence of the tumour in the subfrontal
region was depicted by MRI without clinical or biochemical evidence of CD.
A third operation was performed, but craniotomy was\necessary. Immuno-
histochemistry (IHC) studies of the specimens from the frst, second, and third
surgery were similar and showed diffuse immunoreactivity for ACTH.
Case 2
A 40-year-old woman was admitted because of a recurrence of a large pituitary
adenoma (stage 2D). Five years before admission she had been operated by
TSF approach because of CD. On admission, there were no signs or symptoms
of hypercortisolism and biochemical analysis excluded CD. She underwent
surgery by TSF approach; 3 years later, she was operated by craniotomy. IHC
studies showed diffuse immunoreactivity for ACTH in all the specimens
obtained from frst, second, and third surgery. According to WHO classifcation,
a diagnosis of atypical adenoma was made in the specimen obtained from the
last operation.
Case 3
A 49-year-old man with a 2-year-history of nonfunctioning pituitary adenoma
(NFA) was admitted because of clinical suspicion of CD, which was confrmed by
biochemical tests. Of note, 1 year before admission a low-dose desametazone
suppression test had been excluded CD. IHC studies of the specimens from
surgery confrmed immunoreactivity for ACTH.
Case 4
A 47-year-old woman was operated because of aNFA (14 mm). IHC studies
revealed diffuse immunoreactivity for ACTH. Throughout the follow up, the
developed CD (3 years later).
P
comparison of octreotide LAR and lanreotide autogel treatments in
post-operative medical treatment of acromegaly
Yasemin Tutuncu, Dilek Berker, Serhat Isik, Ufuk Ozuguz, Gulhan Akbaba,
Ferit Kerim Kucukler & Serdar Guler
Ankara, Turkey.
Objective
Long acting somatostatin analogs commonly used as adjuvant treatment of
acromegalic patients after noncurative surgery. We aimed to compare the effcacy
of octreotide LAR (OCT) and lanreotide Autogel (LAN) in acromegalic patients.
Methods
Sixty-eight patients that cure could not be achieved by transsfenoidal endoscopic
or microscopic pituitary surgery between 2003 and 2009 were retrospectively
analyzed (25 men and 43 women; mean age 41.110.9 years (range 18-65)). The
patients, who found to be had a noncurative surgery at controls performed in the
postoperative 3rd month were assigned randomly to OCT (30 mg, n36) and
LAN (120 mg, n32) groups. The patients were evaluated with IGF1 (ng/ml),
and OGTT-GH suppression test in the 3rd, 6, 12 and 18th months; pituitary MRI
was performed before the treatment and in the 3rd and 12th months. IGF1 levels
in the normal boundaries according to age and gender and GH level suppressed
below 1 ng/ml as a response to OGTT-GH suppression test were considered to be
'biochemical cure`.
Results
The OCT and LAN groups were age and sex matched (39.312.0 vs 42.79.6
years; female/male 25/11 vs 18/14). Average IGF1 and GH values and tumor
volumes (cm
3
) of the patients in LAN and OCT groups were similar in the post-
operative period before the medical treatment. A statistically signifcant decrease
was obtained for both OCT and LAN groups in GH and IGF1 levels at each
follow-up visit performed in 3rd, 6, 12 and 18th months compared to previous
value ((OCT: 8.59.2, 6.67.6, 4.56.5, 3.04.0 and 2.33.4; 782.3392.3,
674.9386.8, 471.7291.8, 403.7296.6, and 326.6228.2), (LAN: 7.97.0,
5.45.5, 3.23.9, 1.71.7, and 1.41.4; 729.0237.1, 630.4253.2,
451.7219.5, 356.8211.8 and 259.0112.7), baseline, 3rd, 6, 12 and 18th
months respectively). Tumor shrinkage that evaluated in the 12th month of the
treatment was statistically signifcant in both groups but the percentages of tumor
shrinkages (28.5 vs 34.9%, P0.166) and the rate of patients achieved
biochemical cure (69.4 and 78.1%, P0.154) were similar between OCT and
LAN groups.
Conclusion
In acromegalic patients who had noncurative surgery, OCT and LAN treatment
options have equal effcacy for ensuring biochemical cure and tumor shrinkage.
PI
FSH-staining pituitary adenomas: a review of 37 cases
Kemal Agbaht
1
, Aylin Heper Okcu
2
, Ozan Yazici
3
, Mehmet Ali Tokgoz
4
,
Hulya Cebe
4
& Sevim Gullu
1
1
Department of Endocrinology and Metabolic Diseases, Ankara University
Faculty of Medicine, Ankara, Turkey;
2
Department of Pathology, Ankara
University Faculty of Medicine, Ankara, Turkey;
3
Department of Internal
Medicine, Ankara University Faculty of Medicine, Ankara, Turkey;
4
Ankara University Faculty of Medicine, Ankara, Turkey.
Objective
To document clinical and laboratory presentations of FSH-staining pituitary
adenomas, and to compare pure FSH-staining adenomas with mixed FSH and
other anterior pituitary hormones staining ones.
Methods
We analysed our inpatient records for patients who underwent pituitary surgery,
and analysed histopathological reports for FSH-staining pituitary adenomas.
Immunostaining positivity was defned as immunostaining of 5% of the
adenoma cells. Medical records including demographic features, symptoms at
presentation and physical examination, as well as hormone profles and dynamic
tests for over or underproduction of anterior pituitary.
Results
Thirty-seven patients underwent pituitary adenomectomy with FSH-immunos-
taining (19 were pure FSH-staining, 18 were mixed adenomas) during January
2006-November 2009. Mixed adenomas were also immunostaining positive for
LH in 12 (66.7%), ACTH in 13 (72.2%), GH 10 (55.6%), TSH in 12 (66.7), and
for prolactin in 13 (72.2%) cases. Pure FSH-secreting adenomas cases were older
(54.69.2 vs 44.511.3 years, P0.006), mostly affected male gender (73.7%),
and were larger in diameter (34.18.1 vs 24.010.3 mm), whereas mixed-
tumors mostly affected younger women (72.2%). Clinical presentation and
symptomatology were similar in both groups, whereas hypothyroidism tend to be
more frequent in pure FSH-staining adenomas, although it didn`t reach to
statistical signifcance (P0.073)
Conclusion
FSH-staining pituitary adenomas are mostly pure in males, whereas they are
mixed in women. In more than half of the cases they present with pituitary
insuffciency, mostly with hypogonadism and growth hormone insuffciency.
Critical insuffencies, namely hypocortisolism and hypothyroidism that need a
special attention, present in about half of the cases in pure adenomas, and in about
one fourth of the mixed ones.
P8
IGF1 levels as predictor factor of metabolic derangement in adult
patients with severe GH dehciency
Valentina Gasco
1
, Guglielmo Beccuti
1
, Silvia Rovere
1
, Filippa Marotta
1
,
Gianluca Aimaretti
2
, Mauro Maccario
1
, Silvia Grottoli
1
& Ezio Ghigo
1
1
Division of Endocrinology and Metabolism, Department of Internal
Medicine, University of Turin, Turin, Italy;
2
Endocrinology, Department of
Clinical and Experimental Medicine, University of Eastern Piedmont,
Novara, Italy.
GH defciency (GHD) in adults leads to impairment in body composition and
function, as well as to deranged lipoprotein and carbohydrate metabolismimplying
increased cardiovascular morbidity. The morphologic and metabolic alterations in
GHDsyndrome are more marked in patients with the most severe GHD, even when
evaluated by maximal provocative test such as GHRHarginine. IGF1 synthesis
and secretion are function of the GHstatus but also of major metabolic factors such
as insulin. In fact, even in a big population of normal subjects, IGF1 levels in lower
quartile are associated with increased risk for metabolic and cardiovascular
disease. Nevertheless, in GHD adults the severity of GHDis not strictly associated
to IGF1 levels. In fact, IGF1 levels in severe GHD adults are often within the
normal range. We retrospectively evaluated the relationship between total IGF1
levels and metabolic parameters in a large populations of adults with severe GHD
(139 M, 107 F; age (meanS.D.): 48.316.6 years). We evaluated the correlation
of IGF1 SDS with BMI, glucose, HbA1c, total cholesterol, triglyceride, HDL,
LDL, non-HDL cholesterol levels, bone T score and Z-score.
BMI adjusted for age was higher in the lower quartiles (P, 0.0001). Similarly,
after adjusting for age and BMI, the lowest IGF1 SDS quartiles associated with
highest levels of glucose (P,0.0001), HbA1c (P,0.0004), total cholesterol (P,
0.0001), HDL (P,0.0001), LDL (P,0.007), non-HDL cholesterol (P,0.003).
IGF1 SDS levels did not associate to triglyceride levels. On the other hand, the
highest IGF1 SDS quartiles associated with the highest levels of either bone T (P,
0.04) or Z-score (P,0.0004) adjusted for BMI.
In conclusion, this study shows that more severe impairment of the IGF1 status is
associated to more marked derangement in glucose and lipid metabolism.
P9
Hypertension as the hrst and for long time period the only sign of ACTH
producing pituitary adenoma: A case report
Zdravko Perkovic
IHC Sunce, Zagreb, Croatia.
A 37-years old woman was admitted to the Department of Endocrinology 3 years
ago because of hypertension with headaches. The highest value of blood pressure
was 210/130 mmHg. Colour doppler of renal arteries, electrolytes, cortisol, renin,
aldosteron, metanefrins and normetanefrins were normal. With perindopril 4 mg
and lacidipin 4 mg/day blood pressure was well controlled. After 3 years
gastroscopy was performed because of stomach discomfort and it revealed soor
oesophagitis, gastritis and positive H. pylori. At that time blood test showed
sideropenic anaemia. Potassium level was normal. She started to complain for
headaches and precordial oppressions, swelling of hands and legs. Hypertension
became uncontrolled in spite of the medications used. Laboratory results revealed
low potassium levels which lead to the suspicion of primary hyperaldosteronism.
Her face become oval and pletoric, with mild hirsutism. Urinary free cortisol
levels were very high, and basal and dynamic functional tests suggested ACTH-
dependent Cushing syndrome. Magnetic resonance imaging revealed a pituitary
mass 6,9 mm with signs of necrosis. After transphenoidal resection blood
pressure and potassium become normal. This case suggests that hypertension can
be the frst and for long time the only sign of ACTH secreting pituitary adenoma,
and thus suggests a need for periodic control of urinary free cortisol.
Obesity
PI0
Impact of sarcopenia on metabolic prohle in sarcopenic-obese post
menopausal women?
Annie Fex
1
, Myle`ne Aubertin Leheudre
1
, Antony Karelis
1
,
Marie E
`
ve Filion
1
& Isabelle J Dionne
2
1
Universite du Quebec a` Montreal, Quebec, Canada;
2
Universite de
Sherbrooke, Quebec, Canada.
Background
Menopause is associated to body composition transformations, such as an
increase in total fat mass (obesity), central fat mass and a decrease in lean body
mass (sarcopenia). Body fat distribution also changes with age, with an increase
in visceral abdominal fat and a decrease in subcutaneous abdominal fat.
Moreover, an increase in visceral fat may lead to increase the secretion of pro-
infammatory adipokines that further promote insulin resistance as well as
potentially having a direct catabolic effect on muscle. Thus, a vicious circle
between muscle loss and fat gain may lead to more sarcopenia and then to further
fat gain and infammation (c-reactive protein (CRP)). Sarcopenic-obesity, which
occurs in around 10% of postmenopausal women, has been reported to be a much
pejorative condition of the development of physical disabilities, morbidity and
mortality than either sarcopenia or obesity alone. In fact, being obese non-
metabolically healthy with an inadequate muscle mass may represent the worse
aspects of each condition. However, our group showed that obese women have
higher cardiovascular risks than metabolically healthy sarcopenic-obese post-
menopausal women.
Objective
The aim of this study is to examine if the degree of sarcopenia could infuence the
metabolic profle of sarcopenic-obese post-menopausal women.
Methods
Fifty-six postmenopausal sarcopenic-obese women were divided in 2 groups: class
II sarcopenic (n28), class I sarcopenic (n27). Obesity was defned as total fat
mass 35%. Appendicular muscle mass index (AMMI(legsarms FFM(kg))/
height (m
2
)) was used to determined sarcopenia. Class I sarcopenia is considered as
an AMMI ,7.12 kg/m
2
and class II as , 6.29 kg/m
2
. Lipid, glucose and
infammatory profles were measured as energy metabolism and dietary intake.
ANOVA was used to compare the groups (SPSS 17.00; P,0.05).
Results
No difference between groups for age, BMI, waist circumference, lipid profle
or glucose profle was found. We observed signifcant differences between
groups for fat-free mass (total and appendicular; P0.001), viscera fat mass
(P0.045), resting energy expenditure (P0.002), CRP (P0.034) and total
protein intake (g/d; P0.011) animal protein intake (g/d/BW); P0.037).
Type II sarcopenia presented a lower amount of visceral fat for the
same amount of abdominal fat, a lower resting energy expenditure, and a
lower CRP. But surprisingly they consumed a higher amount a total and animal
protein intake.
Discussion
Interestingly, this study showed that the metabolic profle is different regarding to
the type of sarcopenia. In fact, type II sarcopenia seems to be more protective
against cardiovascular risks than type I sarcopenia. Further studies are needed to
confrm our results and explore if the index and the cut-point used to determine
sarcopenia could explained the discrepancies in the literature. In fact, compared
to osteoporosis or obesity diagnosis, no international consensus (defnition and
cut-point) are available for the sarcopenia.
PI1
Metabolic surgery (gastric bypass) has no 'magical effect` in severely
obese patients with type 1 diabetes
Gideon Mlawa
1,2
, Sandeep Deshmukh
1
, Cecil Eboh
2
, Asrai Nasruddin
1
& Patrick Sharp
1
1
2
Colchester University
Hospital, Colchester, UK.
Background
Metabolic surgery has been hailed as a potential new treatment ('magic bullet`)
for obese patients with type2 diabetes. Several studies have shown that metabolic
surgery for morbid obese patients with type2 diabetes can lead to considerable
weight loss and also has positive impact on the incidence of type2 diabetes, in
some cases leading to elimination of the disease in up to 80% of patients. But
metabolic surgery do not seem to induce similar 'magic effect` and control of
glycaemia in patients with type1 diabetes.
Methods
We present a case report of 44 years old man type1 diabetes with severe obesity
for many years and poor glycaemia control (HbA1c 11.2%) He was
normotensive, and his cholesterol level was 6.8, and he was on simvastatin, he
had no diabetic retinopathy. He was on basal bolus regime and his daily insulin
requirement was 160 units, his weight was 163.83 kg, BMI 48 kg/m
2
underwent
Roux-en-Y gastric bypass in July 2008.
Results
he postoperative period was uneventful, 1 year after surgery his body weight was
108.6 kg, (25% reduction), cholesterol 4.7 his daily insulin dose reduced to
77 units. However his glycaemic control remained erratic and poor (HbA1c
10.2%). He was found to have proliferative diabetic retinopathy on the right eye,
and macula involvement in the left, and needed laser treatment to the right eye. He
is still being followed up, in diabetic clinic every 3 months.
Conclusion
Metabolic surgery leads to signifcant and maintained weight loss, and good
control in lipid profle in type1 diabetes patients with severe obesity, but has
less impact on glycaemic control itself as demonstrate in this case report. Severely
obese patients with type1 diabetes have to be informed that metabolic surgery will
not lead to the cure of diabetes but will improve other co-morbidities such as
hyperlipidaemia, hypertension and obstructive sleep apnoea syndrome.
PI2
Testosterone gel signihcantly increase lean body mass in ageing males
with relatively low bio-available testosterone and waist circumference
above 94 cm: a double blinded, randomized, placebo controlled
6 months study
Louise Frederiksen
1
, David M Hougaard
2
, Kim Brixen
1
& Marianne Andersen
1
1
Odense University Hospital, Odense, Denmark;
2
Statens Serum Institut,
Copenhagen, Denmark.
Background
Testosterone replacement therapy in severe hypogonadism is indicated, however,
the treatment of late onset hypogonadism (LOH) is debated, especially what the
diagnostic criteria should be. In LOH bio-available testosterone probably gives a
more accurate index of gonadal status as a diagnostic criterion as it takes SHBG
into consideration. SHBG is known to increase with ageing, however, SHBG is
also negatively infuenced by insulin and visceral adiposity.
Aim
To investigate the anabolic effects of testosterone in ageing men with bio-
available testosterone below the cut-off limit for young males (Nielsen et al.
JCEM 2006) and waist circumference above 94 cm.
A double-blinded, randomized, placebo-controlled 6 months study in men aged
68 (60-78) (mean and range) with bio available testosterone 4.9 (2.3-7.2) nmol/l
and waist circumference 108 (95-128) cm.
Thirty-eight participants were randomized to placebo (n18) or testosterone gel
50 mg/day (n20).
Testosterone levels were measured by liquid chromatography tandem mass
spectrometry after ether extraction and SHBG was measured by autoDELFIA
assay. Bio-available testosterone was calculated according to Vermeulen et al.
(JCEM 1999). Dual X-ray absorptiometry (DXA) was used to determine total lean
body mass and total fat mass.
Statistics were performed on delta values (0-6 months). The Students t-test was
used to compare mean delta values after 24 weeks of treatment.
Results
The randomization was successful. During the 6 months study total lean body
mass increased signifcantly (P0.004), in the testosterone treated group
compared to placebo 1.73 (1.1-6.2) kg versus 0.07 (3.4-1.7) kg,
respectively.
Total fat mass decreased signifcantly (P0.037) in the testosterone treated
group compared to placebo 1.2 (3.6-3.8) kg versus 0.6 (4.0-1.9) kg,
respectively.
Conclusion
Testosterone therapy signifcantly increased total lean body mass and
signifcantly decreased total fat mass in ageing men with relatively low bio-
available testosterone and waist circumference above 94 cm.
PI3
Ghrelin basal levels in people with abdominal obesity
Olga Charnysh
1
& Tatiana Mokhort
2
1
2
Belarus.
Study objective
To study the differences of ghrelin basal levels (BG) among people with
abdominal obesity.
One hundred and twenty-two patients aged 35-55 with obesity and 28 practically
healthy persons (control group) were examined. The groups were identical in the
sex and age, obesity. The BG levels in serum were measured by the immune-
enzyme method with DRG International reagents.
Results
Average basal ghrelin levels (BG) were found to be authentically lower in
the group of patients with obesity than in the control group (51.324.56 vs
88.766.46 ng/ml), P,0.001. Within the increase of obesity rate, the ghrelin
levels in serum decreased from 57.344.79 ng/ml - in patients with the 1st
obesity class, 49.467.1 ng/ml - in patients with the 2nd obesity class and up to
44.526.78 ng/ml - in patients with the 3rd obesity class; and its differed between
the indicators in patients with 1st and 2nd classes versus the patients with 3rd class,
P,0.05. The correlation analysis demonstrated the negative proved association of
ghrelin levels with the indicators refecting abdominal distribution of adipose
tissue - waist circumference and waist circumference/hips circumference
index (r0.46; P,0.001 and r0.35; P,0.001 correspondingly).
Conclusion
The ghrelin levels were found to be lower in patients with obesity than in patient
with normal weight (51.324.56 vs 88.766.46 ng/ml, P,0.01). Within the
increase of obesity rate the ghrelin levels decrease (from 57.344.79 up to
44.526.78 ng/ml, P,0.05), that was confrmed by its correlations with the
indicators OT (r0.46; P,0.001) and OT/OB (r0.35; P,0.001), and
that allow consider hypogrelinemia to be a component that take part in abdominal
obesity forming.
PI4
Osteocalcin and the metabolic syndrome
Sabina Oros
3,2
, Olga Ianas
1
, Roxana Rosca
1,2
, Suzana Vladoiu
1
,
Dana Manda
1
1,2
1
2
3
Euroclinic Hospital and Medical Centers, Bucharest, Romania.
Studies evaluated bone involvement in the metabolic control of fat cells. It has
been reported that osteocalcin acts as a hormone in the body, causing beta cells in
the pancreas to release more insulin, and at the same time directing fat cells to
release adiponectin, which increases sensitivity to insulin.
The aim
Of the study was to evaluate osteocalcin levels in subjects with metabolic
syndrome compared with age and sex matched control groups.
After signing a written consent form approved by the ethic committee, a number
of 245 subjects, aged between 20 and 81 years were enrolled in two groups, with
metabolic syndrome and controls. Both groups were subdivided in males with
metabolic syndrome (27 subjects), control males (17 subjects), menopausal
females with metabolic syndrome (33 subjects), menopausal control females
(27 subjects), nine fertile females with metabolic syndrome and 12 controls.
Fasting blood samples were taken in order to determine the hematological,
biochemical and hormonal status.
SPSS version 15 was used for statistical analysis.
Results
Results regarding the hematological, biochemical, hormonal profle, insulin
resistance index and osteocalcin levels have been analyzed and successively
compared, as means and as correlation coeffcients, on study groups.
Signifcant differences regarding mean values were found for insulinemia in the
metabolic syndrome group (P0.01), females with metabolic syndrome
(P0.036). High HOMA mean values proved insulin resistance (P0.002;
P0.011) in these groups.
Osteocalcin mean values, although in the normal range, were lower in men with
metabolic syndrome (P0.009), correlated negatively with waist circumference
in males with metabolic syndrome (P0.038), with triglycerides (P0.017) in
menopausal females with metabolic syndrome (P0.04) and positively with
HDL-cholesterol in these groups (P0.039; P0.046).
Conclusions
Osteocalcin is not only a bone marker but is also involved in insulin sensibility. Its
values are infuenced by sex, age and insulin resistance.
PI5
Relationship between obesity and classic cardiovascular risk factors
Jose Javier Gomez-Barrado
1,2
, Jose Polo
2
, Juan Ramon Gomez-Martino
1,2
,
Alfonso Barquilla
2
, Jorge Vega
1,2
, Soledad Turegano
2
, Roci o Gallego
1,2
& Francisco Javier Garciperez de Vargas
1,2
1
Hospital San Pedro de Alcantara, Caceres, Extremadura, Spain;
2
GERIVA
(Grupo de Estudio de Riesgo Vascular de Extremadura), Caceres,
Extremadura, Spain.
Obesity is a disease very prevalent and often associated with morbidities and
cardiovascular risk factors. We explore the relationship between the presence of
obesity with cardiovascular risk factors more frequent and the presence of
cardiovascular disease (CVD) after (ischemic heart disease, cerebrovascular
disease, peripheral artery).
A sample of 1491 individuals of both sexes, over 14 years, elected by random
sampling three of the general population in the province of Caceres (Spain) they
were determined the weight and height (BMI) and they were interrogated about
the presence of CVD prior, smoking, hypertension and diabetes, and the taking of
medication hipolipemiante.
The statistical analysis was conducted using the statistical package SPSS of health
sciences. We used the test of chi square for quantitative variables and the
t-Student for qualitative variable.
Results
Presented obesity (BMI30) the 18.3 percent of the population.
Conclusions
The double of the obese in the province of Caceres have a history of CVD.
Dislipidemia have more than double and presented three times more HTA and
diabetes mellitus; however the obese are fewer smokers.
PI
Pathological types of the family education as the risk factor of the
childhood obesity
Mariya Vishnevsksaya & Anjelika Solnceva
Belarusian State Medical University, Minsk, Belarus.
There are limited numbers of studies concerning family education as a risk factor
for obesity in children. We aimed to examine the relationship between a
children`s weight and family/psychosocial factors, to establish gender differences
in eating behavior in obese children.
This cross-sectional study involved 65 obese children (m/f33/32, mean age
13.50.5 years) and 65 mothers. Obesity was defned as BMI scores at or above
the 97th percentile for age and gender. Psychological examination was conducted
by Eidemiller test of family education and IEG-Kind test. All the analyses were
performed with the Statistics 6.0 software, P-value ,0.05 was accepting as
statistically signifcant. ANOVA test was used for unpaired data.
Results
Signifcant gender differences (P,0.05) were observed on the criteria: food remedy
against the emotional stress, food as a problem; food restriction, fear of weight gain.
In the girl
`
s group at the earlypuberty stage were revealed a negative correlationwith
BMI criteria: power and dependency needs for food (r0.36); importance and
infuence of foods (r0.41); forcing parents (r0.45). In older age girls a
correlation BMI and points of IEG-Kind were observed: food as a remedy against
stress (r0.41); strength and the need for food (r0.38); dissatisfaction with
their Default (r0.45) noted increased correlation BMI and coercion by parents
(r0.78). Two tests correlation analysis found differences depending on the stage
of pubertat stage: in early puberty marked by a strong relationship between parents
and the child`s body weight (r0.53), increased fear of its increasing (r0.56).
Before pubertat group increased importance of food as a remedy against stress,
excessive demands by the parents, satisfaction of requirements. Correlation between
body`s dissatisfaction and lack of child care parents were observed (r0.71).
Conclusion
Findings indicated on the sex and age differences regarding its own body, restriction
of food in children with obesity.
PII
TSH levels in overweight and obese euthyroid subjects with metabolic
syndrome
Milena Velojic Golubovic, Dragan Dimic, Danijela Stojic, Sasa Radenkovic
& Slobodan Antic
Clinic of Endocrinology, Clinical Center Nis, Nis, Serbia.
Objectives
There are reports which suggests that TSH levels are independetly associated with
components of metabolic syndrome. The aim of this study was to investigate the
relatinship between thyroid stimulating hormone (TSH) and metabolic syndrome
(MetS) in owerweight and obese euthyroid subjects.
Methods
In 80 euthyroid owerweight and obese subjects, 44 women and 36 man, fasting
blood semples were analyzed for glucose, triglycerides and HDL and estimated
BMI, waist circumference and blood pressure, which are parameters for
metabolic syndrome according to NCEP ATP III. Subjects were divided in two
groups, Group A, subjects with no or one parametar for MetS, and Group B,
subjects with two or more parametars for MetS.
Results
Average TSH level in Group B are signifcantly higher than average TSH level in
Group A, 2.871.23 vs 1.410.34, P,0.005. Levels of total triiodothyronine
(T
3
) was higher in group B, but there was no statistical signifcance between the
groups. There was no difference between levels of total thyroxin, free thyroxin
and free triiodothyronine.
Conclusion
Our results show association between TSH levels in euthyroid range and
parameters of metabolic syndrome. It seems that levels of TSH below 2.5 U/l is
associated with favourable metabolic profle. Total T
3
and TSH correlated mere
with variables of metabolic syndrome than T
4
, FT
3
and FT
4
.
PI8
Complementary and alternative treatment approaches in obese
patients: a cross-sectional study
Unal Kilic, Ozlem Geyik, Ayten Oguz, Fevzi Balkan, Reyhan Ersoy
& Bekir Cakir
Introduction
Effective conventional medical treatments for obesity are limited and patients
with obesity seeking alternative forms of health care for weight loss. While
several previous studies have examined patterns of complementary and
alternative treatment (CAT) use in different populations, limited data are
available on the relationship between obesity and use of CAT. In this cross-
sectional study, we aimed to overview the alternative therapy methods in obese
patients.
Total 105, 22(21%) male and 83(79%) female patients were included this study.
The body mass index (BMI) of female patients was 37.47.0 kg/m
2
and BMI of
male patient`s 35.53.8 kg/m
2
were. Sixty-six (% 62.9) of the patients used or
still using alternative therapy methods. While evaluating the study group there
were no signifcant difference found according to their economic status, sex and
educational level (P0.05). The BMI of the patients who use alternative therapy
methods were 38.027.2 kg/m
2
, and BMI of the patients who does not lean to
those alternative supplements is 35.44.5 kg/m
2
(P0.02). Comparing the -
duration of illness, it is most likely to use complimentary and alternative therapy
methods who suffer from obesity for over 15 years (P0.03). Most frequently
used products were natural herbs (83.4%). Following this comes; acupuncture and
massage. Of 30.1% of the cases claims that they temporary benefted from these
products and methods, 30.5% said that they didn`t beneft and 39.4% don`t have a
clear idea about whether they have benefted or not.
Conclusion
It is known that not only in our country but also all over the world the alternative
therapy methods are widely used. We think that in our country, because of lacking
education for obesity, patients are most likely to search alternative therapy
methods.
PI9
Differential expression of proteins in omental and subcutaneous adipose
tissue
Mari a Insenser
1,2
, Rafael Montes
1,2
, Rafael Simo
1,3
, Joan Vendrell
1,4
& Hector F Escobar-Morreale
1,2
1
Hospital Universitario Ramon y Cajal, Madrid, Spain;
2
CIBERdem,
Barcelona, Spain;
3
Hospital Universitari Vall d`Hebron, Barcelona, Spain;
4
Hospital Universitari Joan XXIII, Tarragona, Spain.
Background
Adipose tissue is considered a highly active metabolic and endocrine organ with
important physiological functions. The evaluation of protein expression has the
, (%) (%)
CVD prior 11.7 22.1 0.000
Hypertension 17.8 49.5 0.000
Smoking 31.4 19.4 0.000
Diabetes 6 21.6 0.000
Drugs lipid-lowering 12.4 27.1 0.000
potential advantage of providing a global vision of the cellular pathways
associated with adipose tissue dysfunction and obesity, permitting the
identifcation of novel candidate molecules that would have not been considered
of interest otherwise.
Objectives
To identify proteins differentially expressed in subcutaneous and in omental
adipose tissue from obese and non-obese patients by applying two-dimensional
differential in gel electrophoresis (2D-DIGE).
Methods
Subcutaneous and omental adipose tissue was obtained from 12 patients (six male
and six female), including six morbidly obese patients (age 36.616.3 years;
BMI 51.858.4 kg/m
2
) and six non-obese patients (age 4421.3 years; BMI
24.42.2 kg/m
2
).
Proteins from adipose tissue were extracted by using a homogenizer. 2D clean up
kit was used to remove interfering components. The protein extracts (n24) were
analyzed 2D-DIGE. Protein spots showing signifcant differences between
patients and controls were identifed, excised, trypsin-digested and analyzed by
matrix-assisted laser-desorption ionization time-of-fight time-of-fight (MALDI-
TOF-TOF).
Results
This technology allowed the analysis of ^1700 protein spots in the comparative
study of proteins. We considered changes within 95% confdence interval
(P,0.05) and standardized average spots volume ratio exceeding 1.4 in at least 9
of the 12 gels analyzed. A total of 48 spots showing statistically signifcant
differential expression between both tissues were identifed. The validation of
these spots by western blot and gene expression with real time PCR is ongoing at
present.
Conclusions
There are differences in the proteomic profles of subcutaneous and omental
adipose tissue that are also modulated by the presence or absence of obesity. The
precise identifcation of these proteins will provide some insight into the
molecular events in visceral and omental adipose tissue associated with obesity.
Grants: FIS PI 080944, CIBERDEM CB07/08/.
P80
Relationship between the breast cancer and abdominal obesity
Nermin Tuncbilek
1
, Sibel Guldiken
2
, Tulay Kilic Okman
3
, Atakan Sezer
4
,
Semsi Altaner
5
, Asli Mentes
1
& Huseyin Ozdemir
1
1
Department of Radiology, Faculty of Medicine, Trakya University, Edirne,
Turkey;
2
Department of Endocrinology, Faculty of Medicine, Trakya
University, Edirne, Turkey;
3
Department of Obstetrics and Gynecology,
Faculty of Medicine, Trakya University, Edirne, Turkey;
4
Department of
General Surgery, Faculty of Medicine, Trakya University, Edirne, Turkey;
5
Department of Pathology, Faculty of Medicine, Trakya University, Edirne,
Turkey.
Purpose
Numerous epidemiological studies have shown that obesity is a risk factor for
postmenopausal breast cancer and relapse. We aim to investigate the relation
between the upper abdominal obesity and breast cancer, by using ultrasonography
(USG).
The study population consisted of 44 women in control group and 17 breast
cancer patient in study group. In the whole study population fat tissue was
measured with high resolution B-mode USG. The anthropometric measurements
((body mass index (BMI), waist/hip ratio (WHR) and waist circumference (WC))
were assessed in all study groups. The statistical analysis between with breast
cancer and control group was assessed by Independent sample t-test.
Results
The mean BMI, total fat mass, and WC values were detected higher in breast
cancer group with respect to control group (29.9; 28.9 kg; 94 cm; and 28; 24 kg;
88 cm respectively). The mean USG examination value of visceral fat tissue was
measured 49.2 mm in breast cancer group, and 35.4 mm in control group. There
was statistically signifcant difference between the group breast cancer and
control group in visceral fat tissue, fat mass, and WC (P,0.05).
Discussion
This is the frst clinical ultrasonography examination study investigating detection
of the association between breast cancer and upper abdominal obesity. The
results of our study correspond with the previous literature data concerning
the relation of increased risk of breast cancer and general obesity. The data of the
current study presents that general obesity and increase visceral fat tissue is a
signifcant predictor of breast cancer, while subcutaneous and preperitoneal fat
tissue are not related to increased risk.
P81
The Moscow study: a randomized, placebo-controlled, double-blind
trial of parenteral testosterone undecanoate on the metabolic syndrome
components and body composition
Yuliya Tishova
1
, Svetlana Kalinchenko
1
, George Mskhalaya
1
,
Farid Saad
2,3
, Louis J G Gooren
4
& Erik J Giltay
1
1
Chair of Endocrinology, People`s Friendship University of Russia,
2
3
Gulf Medical University School of
Medicine, Ajman, UAE;
4
5
Background
Metabolic syndrome has a high prevalence in male population, leading to the high
rate of cardiovascular disease and mortality. Numerous studies show that low
androgen levels in men are associated with the metabolic syndrome. This study
tested whether normalization of testosterone levels improves metabolic
dysregulations and body composition.
Methods
receiving placebo completed the trial.
Results
50.5-55.0) in the placebo group. In the Nebido group, there were signifcant
improvements in weight, body mass index, waist circumference and waist-to-hip
ratio (P,0.001). Levels of leptin (P0.001) and insulin (P0.04) decreased.
There were no changes in glucose and lipids, although there was a statistical trend
for a reduction in LDL cholesterol (P0.07).
Conclusions
Thirty weeks of TU administration strongly improved anthropometric parameters
as compared to placebo.
P82
Effects of parenteral testosterone undecanoate administration on
inammatory markers: the Moscow study
Svetlana Kalinchenko
1
, Yuliya Tishova
1
, George Mskhalaya
1
,
Farid Saad
2,3
, Louis J G Gooren
4
& Erik J Giltay
5
1
Chair of Endocrinology, People`s Friendship, University of Russia,
2
3
School of Medicine, Gulf Medical
University, Ajman, UAE;
4
5
Background
Numerous studies (among which, studies of androgen deprivation in men with
prostate cancer) show that low androgen levels in men are associated with the
metabolic syndrome. Obesity and particularly visceral fat excess is associated
with pro-thrombotic and pro-infammatory states as well. This study tested
whether normalization of testosterone levels improves markers of infammation.
Methods
receiving placebo completed the trial. At baseline and after 30 weeks we assessed
the erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), interleukin 1
(IL-1-), interleukin-6 (IL-6), IL-10, and tumour necrosis factor- (TNF-).
Results
50.5-55.0) in the placebo group. The body mass index ranged from 25.1 to 54.8
kg/m
2
. Infammation markers IL-1- (P0.008), TNF- (0.03), and CRP
(P,0.001) decreased while ESR (P0.78) and IL-10 (0.15) did not change
signifcantly and a statistical trend was found for IL-6 (P0.07).
Conclusions
Our fndings suggest that 30 weeks of TU administration improves a number of
infammation markers, in hypogonadal men with the metabolic syndrome. These
effects might help to reduce the risk of cardiovascular disease.
P83
Visceral fat accumulation as a risk factor for the carotid plaque
occurrence in ischemic stroke patients
Baburhan Guldiken
1
, Nermin Tuncbilek
2
, Sibel Guldiken
3
, Yavuz Durmus
2
,
Remziye Hunkar
1
, Huseyin Ozdemir
2
, Mevlut Ture
4
, Nilda Turgut
1
& Kemal Demir
2
1
Department of Neurology, Faculty of Medicine, Edirne, Turkey;
2
Department of Radiology, Faculty of Medicine, Trakya University, Edirne,
Turkey;
3
Department of Endocrinology, Faculty of Medicine, Trakya
University, Edirne, Turkey;
4
Department of Biostatistics, Faculty of
Medicine, Adnan Menderes University, Aydin, Turkey.
Aim
The present study aimed to investigate the relationship of visceral fat
accumulation with the existence of the carotid plaque in ischemic stroke patients.
Seventy patients (37 male, 33 female) with acute ischemic stroke were enrolled in
the study. The carotid IMT and the existence of carotid plaque of the patients were
evaluated by high resolution ultrasonography with a 7.5 MHz linear superfcial
array probe in B-mode. The abdominal fat areas (visceral and subcutaneous fat
area) were measured by computed tomography scanning obtained at the umbilical
level.
Results
A carotid plaque was detected in 31 of the patients, whereas 39 patients had no
plaque. The mean visceral fat area was higher (P,0.05), and contrarily, the mean
subcutaneous fat area was smaller (P,0.01) in carotid plaque positive patients
than the negatives. The stroke subtypes showed no difference among two groups.
Diabetes mellitus was more frequent in plaque positive patients (P,0.05).
Conclusion
Visceral fat accumulation contributes to the development of the carotid plaque in
ischemic stroke patients.
P84
Relation of PPAR genetic polymorphism and testosterone levels in
males with metabolic syndrome
Joanna Stankiewicz-Olczyk & Marek Bolanowski
1
Copper Medical Center, Lubin, Poland;
2
Medical University, Wroclaw,
Poland.
Obesity and overweight are nowadays very important health problems. Metabolic
syndrome increases the risk of diabetes mellitus and coronary heart disease.
Patients suffering from metabolic syndrome, especially males, are at greater risk
of acute cardiovascular episodes, like heart infarct or brain stroke, than patients
without this, widely accepted atheromatosis` risk farctor. The aim of the study
was assessment of possible relations of PPAR genetic polymorphism and
selected hormones levels in males with metabolic syndrome. The study was
carried out in a group of 402 professionally active males aged 30-60 years. They
were studied PPAR gene polymorphism, TSH, testosterone and adiponectin
concentrations, and anthropometric measurements. We have shown no relation
between occurrence of metabolic syndrome and PPAR polymorphism. Subjects
with Pro12Pro genotype had higher testosterone levels than those with Pro12Ala
one. No such differences were observed when TSH and adiponectin
concentrations were studied. Conclusions: Pro12Ala PPAR genetic poly-
morphism does not determine the occurrence of metabolic syndrome in a studied
group of profesionally active males. In males with metabolic syndrome, higher
testosterone concentration coincides more often with Pro12Pro genotype than
with Pro12Ala one.
P85
The effects of orlistat on weight, serum lipids, blood pressure and fasting
plasma glucose in obese patients with prediabetes
Snjezana Pejicic
1
, Anja Pejicic
2
& Severin Dunovic
3
1
Clinical Center of Banja Luka, Clinic for Endocrinology, Diabetes and
Metabolic Diseases, Banja Luka, Bosnia and Herzegovina;
2
Faculty of
Stomatology, Medical University of Vienna, Vienna, Austria;
3
Medical
Care 'Sveti Vracevi`, Celinac, Bosnia and Herzegovina.
Orlistat selectively inhibits gastrointestinal lipase, thereby preventing fat
dissolution and reducing fat absorption. Many studies have shown good effect
of Orlistat on parameters of metabolic syndrome and diabetes mellitus type 2.
The aim of this study was to examine the effect of Orlistat on:body mass
reduction, serum lipid level, blood pressure level, fasting plasma glucose level
(FPG) by obese patients with prediabetes.
Study includes 60 obese subjects aged 20-58 years with hyperlipidemia;
hypertension (RR130/80 mmHg);body mass index (BMI) 30 kg/m
2
; LDL
serum cholesterol 4.2 mml/l; fasting plasma glucose level (FPG6.1 and
,7.00 mmol/l) The subjects have never had any medical treatment. The subjects
were divided into 2 groups: group 1:30 subjects (Orlistat caps., 120 mg,3/day);
group 2: 30 subjects (Placebo 3,1 caps.). Duration of survey: 12 weeks (total 6
check-ups - visits). All subjects were on a hypocaloric diet and have had a physical
activity.
The results of study show: body mass was decreased in group 1 by 8.8 kg (8.29%),
and in group 2 by 3.4 kg (3.82%); FPG was decreased in group 1 by 14.8%, group 2
has shown no change; LDL cholesterol in group 1 was decreased by 34.5%, and in
group 2 by 5.0%; HDLcholesterol was increased in group 1 by 2.7%, and in group 2
decreased by 2.5%; Total triglycerides were decreased in group 1 by 15.3%, and
in group 2 by 5.4%; blood pressure decrease in group 1 compared to group 2 has
shown statistical signifcance (P,0.05).
Orlistat signifcantly improve all metabolic parameters in patients with prediabetes
andreduceriskfactors for atherosclerosis andcardiovascular diseases. Goodeffect of
orlistat comparedtonon-medical therapy(diet andphysical activity) is accomplished
signifcantly by decreasing body mass.
P8
Increased oxidative damage to lipids and DNA in overweight and obese
patients
Janusz Szosland
1
, Agnieszka Kokoszko
1,3
, Krzysztof Zasada
1,3
,
Jan Stepniak
1
, Andrzej Lewinski
2,3
& Malgorzata Karbownik-Lewinska
1,3
1
Department of Oncological Endocrinology, Medical University of Lodz,
Lodz, Poland;
2
Department of Endocrinology and Metabolic Diseases,
Medical University of Lodz, Lodz, Poland;
3
Polish Mother`s Memorial
Hospital, Research Institute, Lodz, Poland.
Introduction
Obesity does constitute one of the most common modifable risk factors for
cancer. The process of cancerogenesis is associated with the enhanced oxidative
stress. Lipid peroxidation (LPO), resulting from oxidative damage to membrane
lipids, as well as oxidative damage to DNA, are the most frequently examined
processes to evaluate oxidative damage to macromolecules.
Aim
The aim of the study was to evaluate the level of oxidative damage to membrane
lipids and nuclear DNA in overweight and obese adult patients.
Serumconcentrations of malondialdehyde4-hydroxyalkenals (MDA4-HDA),
as an index of membrane LPO, and 8-oxo-7,8-dihydro-2
-deoxyguanosine
(8-oxodGuo) in peripheral blood leukocytes, as an index of oxidative damage to
nuclear DNA, were measured in ffty eight (58) overweight and obese adult patients
(BMI 25 kg/m
2
), and in twenty (20) healthy volunteers (BMI ,25 kg/m
2
),
matched for sex and age. Clinical and laboratory parameters, which are frequently
affected by obesity, were also measured in the study.
Results
Both LPO and 8-oxodGuo levels increased in overweight and obese patients and
further increase of both of them was observed with the increasing body mass and
BMI. Expectedly, positive correlation between oxidative damage to membrane lipids
and nuclear DNA was also found. Additionally, LPO level correlated positively with
waist/hip ratio, C-reactive protein, ferritin and glucose concentrations, whereas
8-oxodGuo correlated positively with triglyceride concentration and negatively with
iron concentration. BMI did constitute the only independent predictor of increased
oxidative damage to membrane lipids in overweight and obese patients.
Conclusions
Overweight and obesity in adults are associated with increased oxidative damage to
membrane lipids and nuclear DNA. BMI constitutes the independent risk factor for
oxidative damage to macromolecules. Enhanced oxidative stress in obesity may
contribute to increased risk of cancer.
P8I
Glucagon stimulates cholecystokinin secretion in humans
Ayman Arafat
1
, Barbel Otto
2
, Aikaterini Adamidou
1
, Joachim Spranger
1
,
Martin Weickert
1,3
, Matthias Mohlig
1
& Andreas Pfeiffer
1
1
Department of Endocrinology, Diabetes and Nutrition, Charite-University
Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany;
2
Medical
Department-Innenstadt, University Hospital Munich, Munich, Germany;
3
Warwickshire Institute for the Study of Diabetes, Endocrinology and
Metabolism, University Hospitals Coventry and Warwickshire,
Coventry, UK.
Objectives
Gastrointestinal hormones are known to modulate satiety. The mechanisms
underlying the impact of glucagon on satiety are so far unknown. However, it can
be postulated that the glucagon-induced reduction in hunger feeling is mediated
through changes in Cholecystokinin (CCK), which is known to play a role in meal
termination. It was the aim of the present study to evaluate the impact of glucagon
on CCK and the modulation of these effects in obesity.
Methods
In a cross-over design we studied the endocrine and metabolic responses to
intramuscular glucagon or placebo administration in 12 obese subjects (6 males;
BMI 33.91.6 kg/m
2
) and in 14 lean controls (6 males; 21.60.5 kg/m
2
). CCK
was measured using highly-sensitive radioimmunoassay.
Results
Age, fasting glucose and glucagon levels were comparable in both groups. Obese
subjects showed higher insulin and CCK levels as compared to lean controls
(P,0.05). After glucagon administration, insulin and glucagon levels increased
in both study groups (P,0.001), and these changes were comparable between
obese and lean subjects. Glucagon signifcantly increased CCK in both obese
(CCK-AUC240: 421.387.7 (glucagon) versus 201.522.7 (placebo),
P,0.05) and in lean controls (553.273.1 versus 190.417.4, P,0.001).
Conclusions
We show that glucagon signifcantly increased CCK in both obese and lean
subjects. However, further studies are needed to evaluate the mechanisms
underlying this effect and to address the pathophysiological role of glucagon-
induced changes in CCK with respect to satiety.
P88
Early genetic rescue of extremely obese POMC-dehcient mice is critical
for successful recovery of normal feeding behavior and body weight
Viviana Bumaschny
1,2
, Flavio de Souza
1
, Vanina Rodri guez
1
,
Malcolm Low
3
& Marcelo Rubinstein
1,2
1
INGEBI-CONICET, Buenos Aires, Argentina;
2
University of Buenos
Aires, Buenos Aires, Argentina;
3
University of Michigan, Ann Arbor,
Michigan, USA.
A major diffculty of obesity treatments is that patients stop losing weight after a
period of responsiveness and often experience a rebound. This could be caused by
an impairment in energy balance circuits that becomes irreversible as obesity
progresses. To test this hypothesis, we generated a reversible knockout-mouse
model of early onset obesity. These mice are unable to express the
proopiomelanocortin gene (Pomc) in hypothalamic neurons (CNS-Pomc
/
)
but maintain normal pituitary Pomc expression. They are hyperphagic and
extremely obese due to central anorexigenic melanocortin defciency. To restore
central Pomc expression, CNS-Pomc
/
mice were crossed with transgenic mice
expressing a tamoxifen-inducible Cre recombinase. Compound CNS-Pomc
/
:
Cre-ERT mice recover the production of central melanocortins upon tamoxifen
treatment. To test Pomc restoration at different ages, we injected tamoxifen to
CNS-Pomc
/
: Cre-ERT at postnatal days 25 or 60 (P25 or P60). No CNS-
Pomc
/
: Cre-ERT mice of either sex treated with tamoxifen at P25 developed
obesity, indicating that early recovery of central Pomc completely prevents
energy homeostasis imbalance. In contrast, despite losing some weight, obese
mice treated at P60 remained heavier than control animals. At the beginning of
treatment (P60), CNS-Pomc
/
: Cre-ERT female and male mice were 67% and
66% heavier than their WT littermates, whereas four months later this difference
dropped to 10% and 41%, respectively. Although CNS-Pomc
/
: Cre-ERT mice
treated at P60 dramatically reduced their food intake, they remained hyperphagic.
In females, tamoxifen treatment reduced food intake from 5.10.28 g/day to
3.70.28, somewhat more than WT females that ate 3.20.28 g/day
(P,0.0001). Males reduced their food intake from 5.40.34 to 4.1
0.29 g/day but did not reach normal WT male values of 3.10.18 g/day
(P,0.0001). The differences between sexes and treatment ages were observed
despite similar recovery in the number of neurons that express PomcP25 treated
males, 69%; P25 treated females, 63%; P60 treated males, 73%; and P60 treated
females, 77%. Our results indicate that the plasticity of satiety circuits necessary
to restore normal homeostatic values is progressively lost between weaning and
adulthood in mice with monogenic obesity.
P89
Inuence of age of onset of metabolic syndrome
Jose Javier Gomez-Barrado, Juan Ramon Gomez-Martino, Jose Polo,
Alfonso Barquilla, Soledad Turegano, Jorge Vega, Francisco Javier
Garciperez de Vargas & Javier Mendoza
GERIVA (Grupo de Estudio del Riesgo Vascular de Extremadura), Caceres,
Extremadura, Spain
The metabolic syndrome (MS) is a pathological entity that carries a high
cardiovascular risk, and whose risk factors may occur at an early age. No data are
available in our area on the infuence of age on the prevalence of MS.
Objectives
To determine the prevalence of MS in our area, by age group and compare the
frequency of occurrence of MS in young adults (,40 years) (J) and mature adults
(40 years) (M).
Methods
Observational and transversal. We included 1498 individuals of both sexes,
selected randomly in the 4 health areas of the province of Caceres (Spain).
Results
Of 44.73% of the subjects were men. The mean age was 19.94 years48.86. The
38.05% of individuals was J, with similar percentage of men and women (37.61 vs
38.41%).
A 3.51% of individuals J presents SM, compared with 24.27% of the M.
Conclusions
The MS is more frequent with increasing age of the population.
The MS is signifcantly more prevalent in mature than in young subjects.
P90
Serum hbroblast growth factor 21 in human obesity: regulation by
hyperinsulinemia and relationship with glucose and lipid oxidation
Marek Straczkowski, Monika Karczewska-Kupczewska,
Agnieszka Adamska, Agnieszka Nikolajuk, Agnieszka Lebkowska,
Elzbieta Otziomek, Maria Gorska & Irina Kowalska
Department of Endocrinology, Diabetology and Internal Medicine, Medical
University of Bialystok, Bialystok, Poland.
Fibroblast growth factor 21 (FGF21) might increase glucose uptake in adipocytes
and reduce plasma glucose and triglycerides in animal models of diabetes. The
aim of the present study was to assess serum FGF21 concentration in lean and
obese subjects, its regulation by hyperinsulinemia and relationship with insulin
sensitivity and glucose and lipid oxidation. We examined 76 subjects with normal
glucose tolerance, 36 lean (BMI ,25 kg/m
2
) and 39 overweight or obese (BMI
between 25 and 40 kg/m
2
). Euglycemic hyperinsulinemic clamp and indirect
calorimetry in the baseline state and during last 30 min of the clamp were
performed. An increase in respiratory quotient (RQ) in response to insulin was
used as a measure of metabolic fexibility. Serum FGF21 was measured in the
baseline state and after the clamp. Fasting serum FGF21 did not differ between the
lean and obese groups. Hyperinsulinemia resulted in an increase in serum FGF21
in the obese (P0.0002), but not in the lean group (P0.33). In consequence,
post-clamp serum FGF21 was higher in the obese subjects (P0.0002). Fasting
FGF21 was related to waist circumference (r0.26, P0.023), fasting insulin
(r0.31, P0.01) and triglycerides (r0.39, P0.001). Post-clamp FGF21
was associated with BMI (r0.42), waist circumference (r0.46, both
P,0.001), fasting insulin (r0.28, P0.031), lipid oxidation during the
clamp (r0.25, P0.039), the change in glucose oxidation in response to
insulin (r0.25, P0.043) and RQ (r0.26, P0.029). In the obese
group, correlations between fasting FGF21 and a change in glucose oxidation
By age, suffering from MS by ATP- criteria:
1420 Years 1.04% 50-59 Years 20.62%
20-29 years 2.75% 60-69 years 26.45%
30-39 years 5.08% 70-79 years 36.36%
40-49 years 9.49% 80 years 43.40%
(r0.35, P0.034) and lipid oxidation (r0.32, P0.049) in response to
insulin were observed. Our data show that serum FGF21 is associated with insulin
resistance-related abnormalities of human obesity.
P91
Predictive factors for a good response to antidepressant
pharmacotherapy in patients with metabolic syndrome
Lavinia Vija
1,2
, Sabina Oros
1
, Adina Dragomir
1,2
, Laura Iconaru
1
,
Emilia Gudovan
1,2
, Catalina Boanta
1,2
1,2
1
'C.I. Parhon` National Institute of Endocrinology, Bucharest, Romania;
2
University of Medicine 'Carol Davila`, Bucharest, Romania.
Objectives
Metabolic syndrome, especially obesity and diabetes are associated and
responsible for a depressive psychological status. Meanwhile, antidepressors
are responsible for metabolic disturbances, such as insulin resistance. The study
aims to determine predictive factors of response to antidepressant pharmacother-
apy in patients with metabolic syndrome.
A retrospective study conducted in Institute Parhon`s Department for metabolic
disease, gathering 50 patients with metabolic syndrome and depression on use of
antidepressant medicines (12 patiennts on benzodiazepines, seven patients on
selective serotonin reuptake inhibitors, 6 on monoamine oxidase inhibitors) for
the period 2007-2009. The therapeutiresponse has been assessed by the
psychiatrist using Hamilton`s scale.
Descriptive analysis and linear regression models have been used as statistical
interpretation using SPSS 12.0.
Conclusions
Smokers (P,0.001), male sex (P,0.031) type 2 diabetes, as well as
hyperglycaemia (OR 1.96) and hypertriglyceridaemia (OR 6.89) correlate
with SSRI response.
Depression and stress activation determine an unfavorable balance of glucose-
lipid metabolism. Diabetic smokers have a lower response to antidepressant
treatment.
P92
Assessment of correlations between IL-18, CRP and selected adrenal
androgens serum levels according to the anthropometrical and
biochemical indices of metabolic syndrome (MS) in ageing men
Waldemar Herman
1
, Katarzyna Le_cka
2
, Elzbieta Kaufman
3
,
Marlena Wojcicka
3
, Lucyna Kramer
4
& Jacek Losy
3
1
Unit of Endocrine Diseases 'Hermed` Wschowa, Poland;
2
Department of
Endocrinology, Metabolism and Internal Medicine, University of Medical
Sciences, Poznan, Poland;
3
Department of Clinical Neuroimmunology,
Chair of Neurology, University of Medical Sciences, Poznan, Poland;
4
Department of Computer Science and Statistics, University of Medical
Sciences, Poznan, Poland.
Aims
The aim of our study was to assess the relationships between systemic markers of
general infammation: interleukin 18 (IL-18) and C-reactive protein (CRP) and
dehydroepiandrosterone (DHEA) as well as dehydroepiandrosterone sulphate
(DHEA-S) serum levels, in addition to the anthropometrical and biochemical
indices of metabolic syndrome (MS) in men over the age of 40.
In 271 randomly chosen men aged 40 to 80 years living in Lubuskie province
(Poland) the features of metabolic syndrome were estimated. Additionally, the
hormonal and immunological parameters described above and lipoid parameters
were valuated. For the recognition of MS, the National Cholesterol Education
Program (NCEP) Adult Treatment Panel III (ATP III) criteria were used. Men
with acute infections and hormonal disturbances of hypophysis - gonadal and
pituitary-adrenal axis were excluded.
Results
The criteria of metabolic syndrome in our group were found in 80 men (29.52%).
Higher levels of IL-18 were observed in younger groups of men (namely
404.66103.26 pg/ml in their 40 s and 537.48162.86 pg/ml in their 50 s) and
in men suffering from MS (536.34182.02 pg/ml vs 451.49143.86 pg/ml;
P,0.005). BMI and waist circumference were positively correlated with IL-18
(r0.252; P,0.001 and r0.249; P,0.001 respectively) in all groups.
Although both adrenal androgens yielded a strong negative correlation with age
(r0.495; P,0.001 for DHEA and r0.551; P,0.001 for DHEA-S), we
observed no correlations between them and IL-18. CRP revealed a negative
correlation with DHEA (r0.248; P,0.05), although not with DHEA-S.
IL-18 serum levels were positive correlated with CRP (r0.339; P,0.0001),
especially for men aged over 70 years. CRP serum levels are correlated with an
occurrence of MS (P,0.001).
Conclusions
IL-18 and CRP (contrary to DHEA and DHEAS serum levels) identifed men over
the age of 40 suffering from MS.
P93
The obese phenotype is associated with more severe autoimmune
thyroiditis evolving towards primary hypothyroidism
Anna Ciampolillo
1
, Giovanni De Pergola
1
, Lucia Tarantino
1
,
Paolo Trerotoli
2
& Francesco Giorgino
1
1
Section of Internal Medicine, Endocrinology, Andrology and Metabolic
Disease, University of Bari, Bari, Italy;
2
Statistic Unit, University of Bari,
Bari, Italy.
Autoimmune thyroiditis is a common disease with different clinical aspects. It has
not been established whether a rapid cellular destruction, with evolution towards
hypothyroidism, may be associated with specifc clinical phenotypes. To clarify
this point, we studied 386 consecutive patients affected by autoimmune thyroiditis
diagnosed within the previous 3 years: 193 patients (170 female and 23 males, age
range 57.512.8, Group 1) were treated with L-thyroxine since they had clinical
or subclinical (TSH4 U/ml) hypothyroidism; and 193 patients (167 females
and 26 males, age range 4915.9, Group 2) were not submitted to drug therapy
(TSH range 0.7-3.0 U/ml). All patients underwent an accurate medical history
to assess the presence of metabolic and thyroid diseases in the family and
associated diseases (hypertension, hypercholesterolemia, type 2 diabetes, and
obesity), and were submitted to thyroid ultrasound and serum determination of
TSH, free T
3
, free T
4
, Tg-Ab, and TPO-Ab. Comparison between Group 1 and
Group 2 showed that type 2 diabetes, hypercholesterolemia, and hypertension
were signifcantly more frequent in Group 1 than in Group 2 (P,0.01). Moreover,
the proportion of obese patients was 45.6% (88/193) in Group 1 and 22.3%
(43/193) in Group 2 (
2
23.3992; P,0.0001). In addition, comparison of BMI
in the two groups showed mean BMI values of 31.100.62 in Group 1 and of
28.620.65 in Group 2 (P,0.001). To evaluate the relationship between obesity
and the need of L-thyroxine therapy (started when TSH4 U/ml), a multiple
regression logistic model, with stepwise selection, was applied. The need of
L-thyroxine therapy was signifcantly associated with obesity (P,0.001), as well
as with the family history of obesity (P,0.0001) and of type 2 diabetes
(P0.0016). Our study indicates that obesity and related metabolic abnormalities
are associated with evolution of thyroid autoimmunity towards hypothyroidism
and need of L-thyroxine therapy. This link may be potentially due to i) reduced
thyroid hormones favouring fat mass accumulation, and/or ii) Th1 cytokines (e.g.
TNF, IL-1, IFN), that are increased in obesity, promoting thyroid cell
destruction and metabolic abnormalities.
P94
Reference interval values of four plasmatic endocannabinoids measured
by isotopic dilution-liquid chromatography-tandem mass spectrometry
(ID-LC-MS/MS)
Flaminia Fanelli, Gaia Cuomo, Valentina Diana Di Lallo, Ilaria Belluomo,
Margherita Baccini, Alessandra Gambineri, Valentina Vicennati,
Renato Pasquali & Uberto Pagotto
S. Orsola Policlinic, Bologna, Italy.
The endocannabinoid system is involved in modulating many metabolic
and behavioural processes. Due to the instable nature of endocannabinoids
in biological fuids and to the poor sensitivity of traditional analytical
technologies, little is known about physiological circulating levels of these
lipid mediators. We developed and validated an ID-LC-MS/MS method for
the simultaneous measurement of four endocannabinoids: anandamide (AEA),
2-arachidonoylglycerol (2-AG), palmitoyl-ethanolamide (PEA) and oleoyl-
ethanolamide (OEA). Endocannabinoids were extracted by protein precipitation
and SPE purifcation from 1 ml of plasma added to phenylmethanesulfonyl-
fuoride 10 M immediately after blood withdrawal. Eluate was injected into an
HPLC system, and separated on a C18 column. Along 32 min isocratic run,
complete resolution of 2-AG and its inactive isomer 1-AG was achieved. Analytes
underwent atmospheric pressure chemical ionization before spectrometric
revelation in multiple reaction monitoring mode by a 4000Q-Trap triple
quadrupole (Applied Biosystems). Quantitative and qualitative transitions were
selected for each analyte in order to ensure specifcity of measurement. The
calibration curve showed linearity across four orders of magnitude. Limit of
quantifcation was 0.224, 0.153, 0.260 and 0.157 pmol/ml for AEA, 2AG, PEA
and OEA, respectively. Imprecision was below 8.5 and 14.1% in intra-assay and
inter-assay, respectively. Acceptable accuracy between 85 and 115% was
obtained. After given informed consent, 116 male and 61 female healthy subjects
were recruited. The study was approved by the local ethics committee. Central
95th percentile reference intervals estimated in 18-69 y.o. male and female
groups were: AEA: 1.228-3.725 and 0.998-2.949 pmol/ml; 2-AG: 0.550-2.994
and 0.466-2.389 pmol/ml; PEA: 10.65-27.08 and 8.55-23.18 pmol/ml and
OEA: 3.09-9.81 and 2.44-9.33 pmol/ml. We have therefore generated for the
frst time the reference intervals of the haematic circulating levels of four
endocannabinoids in a large number of subjects in view of further approaches to
various diseases in which endocannabinoids are known to play a role in their
pathogenesis.
P95
The metabolic syndrome and the non-alcoholic fatty liver disease:
metabolic and pathology aspects
Mihaela Popescu
1
, Alin Popescu
1
, Daniela Neagoe
1
, Violeta Comanescu
2
,
Mihaela Dinca
1
& Marian Bistriceanu
1
1
University of Medicine and Pharmacy, Craiova, Romania;
2
District
Clinical Emergency Hospital, Craiova, Romania.
Obesity and the metabolic syndrome show increased morbidity and mortality, by
inducing morphological and functional alterations of several organs, the liver
included (non-alcoholic fatty liver disease - NAFLD). They start with minimal
alterations ranging to terminal liver disease (non-alcoholic steatohepatitis -
NASH - and cirrhosis).
We intended to identify the histological aspects in NAFLD and to examine the
correlations between the histological aspect, the biochemical features and the
characteristics of the metabolic syndrome.
Material and method
The study group consisted of 35 patients diagnosed with hepato-steatosis who had
no history of alcohol consumption or hepatitis B or C. We analyzed the
parameters: sex, age, body weight, BMI, Waist circumference, blood pressure,
blood glucose (Diabetes Mellitus/Metabolic Syndrome), Insuline, IR-HOMA,
blood lipids, ALT, AST, CRP, liver ultrasound, liver biopsy. The identifcation of
the metabolic syndrome was made considering the ATP III diagnostic criteria. We
performed liver biopsy in 20 patients.
Results
Aminotransferases were elevated in the studied patients, while the CRP was
moderately elevated in the obese patients. The patients with mild steatosis showed
a lower level of the triglycerides compared to those with fbrosis (steatohepatitis)
9943 vs 16985 mg/dl. HOMA-IR was lower in the patients with simple
steatosis compared to those with severe steatosis and fbrosis (2.540.9 vs 4.5
2.5 P0.002). TG180 mg/dl or HOMA-IR4.5 were associated with
NASH. The main characteristic of NASH was the presence of the fatty cells in the
liver parenchyma, together with infammatory cells and degenerative lesions.
Conclusions
The NAFLD requires careful histological and clinical evaluation. Insulin
resistance is present in the majority of the patients with non-alcoholic steatosis.
The HOMA-IR Index 4.5 and the TG level 180 mg/dl can be predictive (risk
factors) for the presence of steatohepatitis and fbrosis. Insulin resistance could
play a role in the pathogenesis of the fbrosis` progression in the NAFLD patients
(non-alcoholic steatosis).
P9
Obesogenic environmental risk factors in Belarusian preschool children
Liudmila Viazova
1
, Anshalika Solntsava
2
, Alexander Sukalo
2
& Michail Maitak
2
1
Second City Children`s Hospital, Minsk, Belarus;
2
Belarusian State
Medical University, Minsk, Belarus.
Background
Manifestation of early age adiposity raises complicated forms of obesity and risks
for concomitant diseases development.
Objective
To detect obesogenic risk factors in preschool children screening study.
Of 1008 children from 8 Minsk kindergartens were screened. Anthropometrical
parameters, systolic and diastolic blood pressure (SBP and DBP) were measured.
Body mass index (BMI) standardized for age and sex, relative to Belarusian 2009
reference data, was used to defne the undernutrition group 0 (BMI ,3d
percentile), normal weight group 1 (3-90th), overweight group 2 (90-97th) and
obesity group 3 (97th). Due to a small sample size (n15), the undernutrition
group 0 was excluded from the analysis. There were also age and sex distribution.
Medical information as well as child`s sports activity, dietary and television-
viewing habits were obtained from 410 respondents. Statistical analysis was
performed in SPSS 16.0 (P0.05).
Results
There were age differences between group 1 (n883) 4.7 (1.5), 2 (n61)
5.3 (1.4) and group 3 (n49) 5.4 (1.1) years (P,0.05). BMI and waist
circumfex (WC) distinctions were noted: 15.2 (1.2) kg/m
2
and 51.1 (3.5) cm
in normal weight children; 18.0 (0.6) and 56.7 (3.4) in overweight; 21.3
(4.4) and 62.2 (6.0) in obese (P,0.05), respectively. SBP and DBP levels in
group 1 were decreased compared to those in groups 2 and 3: 98.7 (10.3) and
61.4 (9.8); 107.1 (10.0) and 66.5 (8.1); 108.9 (11.4) and 66.5 (8.7)
mmHg (P,0.05), respectively. Female: male ratio (f: m) was identical (1: 1.1) in
all clinical series. There were sexual WC diversities: f 50.6 (3.4) and 60.1
(5.4) cm; m 51.5 (3.6) and 64.3 (5.9) (P,0.05) in normal and obese
children accordingly. Gender mass differences were noticed in group 2: f 23.5
(4.4) kg and m 25.9(4.0) (P,0.05).
Overweight and obese rate rises in 4-5, 5-6 and 6-7 year-old children: 13.3 and
30.6; 36.1 and 34.7; 14.8 and 18.9% respectively (P,0.05). Questionnaire survey
did not show any sexual distinctions of daily leisure time (LT) during the week in
groups 1, 2 and 3 (p 0.05). Boys daily sport activity per week was more
intensive than that of girls (P,0.05).
Conclusions
Given that screening study data, daily sport activity rate and duration and 4-6
years old age should be considered to be obesogenic risk factors in preschool
children.
P9I
Waist circumference does not reect body fat distribution and insulin
resistance in young male patients with idiopathic hypogonadotrophic
hypogonadism
Aydogan Aydogdu
1
, O
zge Kucukerdonmez
1
, Gokhan U
ckaya
1
,
Abdullah Taslipinar
1
, S Erol Bolu
1
, Y Alper Sonmez
1
, U
mit Aydogan
2
& Mustafa Kutlu
1
1
Department of Endocrinology, Gulhane School of Medicine, Ankara,
Turkey;
2
Department of Family Medicine, Gulhane School of Medicine,
Ankara, Turkey.
Hypogonadism is associated with increased body fat content and insulin
resistance. Many associations including ADA, IDF and EASD declare that
waist circumference is a reliable measure of visceral adiposity and may account
for insulin resistance. Our observations in young male patients with idiopathic
hypogonadotrophic hypogonadism (IHH) are opposite. Thus, we aimed to
compare body fat content and anthropometric measurements between patients and
age-matched eugonadal healthy controls. Forty-nine new diagnosed patients with
IHH (meanS.D., age; 21.72.5 years, BMI; 23.23.3 kg/m
2
) and 44 healthy
age-matched control (age; 21.41.1 years, BMI; 22.82.5 kg/m
2
) were
examined with skin-fold caliper in triceps (TSFT), biceps (BSFT), suprailiac
(SSFT) regions. Body fat percents (BFP) and truncal fat percents (TFP) were
measured by 8-electrode bioimpedance device (BC-418, Tanita). Results were
compared with waist circumference (WC) by Mann-Whitney U test. HOMA-IR
was calculated with simultaneous fasting plasma glucose and insulin concen-
trations. Groups were statistically similar in age (P0.303), BMI (P0.887) and
WC (80.87.6 vs 78.36.7 cm, P0.141). HOMA-IR (2.691.6 vs 1.550.6,
P0.001) BFP (21.86.4 vs 10.34.7%, P0.001), TFP (25.27 vs 15.6
6%, P0.001), TSFT (15.74.1 vs 9.13.3 mm, P0.001), BSFT (8.4
2.7 vs 5.11.7 mm, P0.001), SSFT (17.46.6 vs 12.24.9 mm, P0.001)
were signifcantly increased in patients with IHH than controls. Waist
circumference is not increased in hypogonadal young males with IHH than
healthy age-matched control subjects, even though they are more insulin resistant
according to HOMA-IR levels and having signifcantly higher truncal fat
content. Diagnostic criteria for metabolic syndrome involve waist circumference.
Our results show that signifcant increase in total and truncal fat content does not
result in increased waist circumference but insulin resistance and subcutaneous
fat in patients with IHH. Visceral adiposity unfavourably affect glucose
metabolism but may not be the unique feature involved in insulin resistance.
Waist circumference might be re-examined in some certain conditions that are
associated with insulin resistance.
P98
Abdominal fat, insulin sensitivity, inammatory atheromatosis risk
factors and polymorphisms of 174-G/C IL-6 promoter and Pro12Ala
PPAR in non-obese subjects
Grazyna Bednarek-Tupikowska, Eliza Kubicka, Urszula Tworowska-
Bardzinska, Lukasz Laczmanski, Marek Bolanowski & Andrzej Milewicz
Wroclaw, Poland.
Some individuals with normal weight but probably visceral fat excess, called
Metabolically Obese Normal-Weight (MONW), have disturbances typical for
metabolic syndrome. We analyzed relationships between body fat distribution
(estimated by DXA) and insulin resistance, serum infammatory markers levels
(CRP, IL-6, IL-18) and polymorphisms of IL-6 promoter and PPAR in healthy,
non-obese Polish subjects: 232 women (age 31.45.5; BMI 21.52.5) and 199
men (age 30.36.0; BMI 24.62.8).
Results
In non-obese subjects abdominal fat volume (AFV) was signifcantly correlated
with serum level of fasting glucose, insulin and HOMA-IR, FIRI and QUICKI
indices. AFV was also signifcantly associated with CRP in women, but not with
IL-6 or IL-18. Similar correlation between AFV and CRP was noticed in men.
In this group IL-18 was correlated with abdominal to gynoidal fat ratio as well.
On the contrary, there were no signifcant correlations between AFV and serum
levels of IL-6. There were no correlations between PPAR polymorphism and
AFV as well as body fat distribution. Fasting insulin levels, HOMA and FIRI were
higher, while QUICKI was lower in men with Pro12Ala polymorphism. There
were no differences between infammation indices (CRP, IL-6, IL-18) in
homozygotes GG, CC and heterozygotes GC of IL-6 gene polymorphism in
non-obese subjects, but CC men had signifcantly lower fasting insulin compared
with GC. Men CC had signifcantly higher BMI, total fat mass and gynoidal fat
volume (GFV) then GG subjects and also higher GFV then GC. Women with
genotype GC had signifcantly lower waist circumference then GG.
Conclusions
Excessive abdominal fat volume in non-obese subjects predisposes to higher
levels of some atherogenic infammatory markers and insulin resistance. The
signifcance of genetic factors in the body fat distribution and the metabolic
disorders occurrence in MONW subjects appears to be important but requires
further study.
P99
FTO gene haplotypes are associated with GH levels in lean women
Petra Lukasova, Josef Vcelak, Marketa Vankova, Olga Bradnova,
Hana Kvasnickova & Bela Bendlova
Background and aims
The fat mass and obesity associated gene (FTO) was identifed as a gene with
strong obesity related traits nevertheless the exact mechanism is still unknown.
Our aim was to study the possible effects of FTO risk haplotype on
anthropometric data and metabolic and hormonal parameters in lean women (to
eliminate the infuence of BMI) and to evaluate the effect of hormone
contraception (HC).
The SNPs rs1421085(T/C), rs1121980(G/A), rs17817449(T/G) and
rs9939609(T/A) in the FTO gene were assessed by ABI TaqMan SNP Genotyping
Assays; haplotypes were generated using programme PHASE. Study cohort
contains 172 healthy lean women (age 26.87.26 years; BMI 21.51.99 kg/m
2
);
95 without HC and 77 with HC. All women were detailed anthropometrically and
biochemically characterized including 3 h OGTT. The protocol was approved by
the Ethic Committee. NCSS 2004 software was used for statistical analyses.
Results
The frequency of two major haplotypes was: 53.3% TGTT and 46.7% CAGA. We
compared the carriers of the risk haplotype CAGA (homo- and heterozygotes)
versus non-carriers (TGTT homozygotes). In lean women no infuence of CAGA
risk haplotype on body composition was found.
Except of increased glucagon levels we found no association of FTO variants with
glucose metabolism parameters in CAGA carriers who were not using HC. Lean
CAGA carriers who were using HC had higher levels of insulin and C-peptide in
late phase of OGTT. The signifcantly raised levels of GH were detected in CAGA
carriers irrespective of HC. As the HC usage alone stimulated GH levels, the HC
users with the risk haplotype had 1.5 fold higher GH than HC non-users.
Conclusion
In lean control women the CAGA carrier ship as well as the usage of HC increased
levels of GH.
Supported by the grant IGA MHCR NS-10209-3/2009 and NR/9839-4.
PI00
Obesity and malnutrition are associated with different inammation
patterns in rats
Darko Stevanovic
1
, Dragan Micic
2
, Mirjana Sumarac-Dumanovic
2
,
Dejan Nesic
1
, Vera Popovic
2
, Vesna Starcevic
1
& Vladimir Trajkovic
3
1
School of Medicine, Institute of Physiology, Belgrade, Serbi;
2
School of
Medicine, Institute of Endocrinology, Belgrade, Serbia;
3
School of
Medicine, Institute of Microbiology and Immunology, Belgrade, Serbia.
The infammatory response in rat models of obesity and malnutrition was
examined. Rats received standard chow (control), chow enriched with 30% lard
(obese) or 70, 50, 40 and 40% of expected food intake weekly for 4 weeks
(starved). The serum levels of cytokines were determined by ELISA, while the
expression of cytokine mRNA in heart and liver was analyzed by real-time
RT-PCR. The blood concentrations of pro-infammatory cytokines (TNF, IL-1)
and Th1 cytokine IFN-gamma were signifcantly higher in starved compared to
control rats, while no change was observed in the levels of anti-infammatory
TGF-beta. In contrast, TGF-beta, but not TNF, IL-1 or IFN-gamma, was
signifcantly higher in blood of obese versus control rats. In the heart, the mRNA
encoding TNF and IL-1 was increased to similar extent in starved and obese rats.
The expression of Th1 cytokine IFN-gamma and Th17 cytokines IL-17 and
IL-23p19 was increased in both starved and obese rats. However, while the
concentration of IFN-gamma mRNA was higher in starved vs. obese rats, the
expression of IL-17 and IL-23p19 mRNA was signifcantly elevated in obese vs
starved rats. Accordingly, the mRNA levels of Th17-inducing TGF-beta were
signifcantly increased in the hearts of obese, but not starved animals. No change
in cytokine mRNA expression was observed in the livers of either starved or
obese rats. In conclusion, malnutrition is associated with an increase in 'classic`
pro-infammatory mediators (TNF, IL-1) and IFN-gamma-controlled Th1
response, while production of Th17 cytokines IL-17, IL-23 and TGF-beta is
preferentially stimulated in obesity.
PI01
The circulating pattern of adiponectin and resistin in critically ill
patients with sepsis
Dimitra Vassiliadi
1
, Marinella Tzanela
1
, Ioanna Dimopoulou
2
,
Stylianos Orfanos
2
, Anastasia Kotanidou
2
, Apostolos Armaganidis
2
& Stylianos Tsagarakis
3
1
Department of Endocrinology, Diabetes and Metabolism, Evangelismos
2
Second Department of Critical Care Medicine,
Attikon University Hospital, Athens, Greece;
3
Department of
Endocrinology Athens` Polyclinic Hospital, Athens, Greece.
Several alterations of the metabolic processes develop during sepsis. Adiponectin
and resistin are amongst the main adipokines that may contribute to the metabolic
adaptations observed in the context of critical illness. However, there is scarce
data on the circulating pattern of these adipokines in human sepsis. Therefore we
aimed to describe the variation in circulating levels of resistin and adiponectin
during the course of sepsis and examine whether they are related to the severity of
sepsis or the outcome.
Forty-four patients diagnosed with sepsis within the last 24-h. None of the
patients received corticosteroids. Clinical severity was assessed using the
ApacheII and SOFA scores. Adiponectin, resistin, IL-1, IL-6, IL-8, IL-10,
IL-12 were measured in the morning on days 1, 4, 7, 10, and every 3 days
thereafter until death or recovery.
Results
Severity of sepsis was a signifcant predictor of mortality (simple sepsis (S)
compared to severe sepsis (SevS) and septic shock (SS): odds ratio for death:
0.088, P0.027). 30 patients survived. Adiponectin levels increased over time
(P0.008); no signifcant difference between survivors and non-survivors was
observed. Resistin levels did not change signifcantly over time. Although
baseline resistin levels were not different between survivors and non-survivors,
survivors had signifcantly lower resistin on recovery (17.22.2 vs 30.2
5.8 ng/ml, P,0.05). Baseline resistin correlated with ApacheII (r0.45,
P0.006) and SOFA (r0.53, r0.0008) and was signifcantly lower in S
compared to SevS and SS (14.810.8 vs 37.723.3 ng/ml, P,0.01). Resistin
correlated with IL-6 and IL-10. No correlations between adiponectin and SOFA,
ApacheII or cytokine levels were noted.
Conclusions
Although adiponectin levels rise during the course of sepsis no relationship with
the severity of sepsis or the outcome was detected. Resistin levels were related to
the severity of sepsis and the degree of infammatory response. A prolonged
elevation of resistin was associated with an unfavourable outcome.
PI02
Acylated, unacylated ghrelin and obestatin regulation during oral
glucose tolerance test in obese prepubertal and pubertal children
Flavia Prodam, Simonetta Bellone, Antonella Petri, Letizia Trovato,
Giulia Genoni, Elena Dondi, Irene Demarchi & Gianni Bona
Division of Pediatrics, University of Eastern Piedmont 'A. Avogadro`,
Novara, Italy.
Physiological role of acylated ghrelin (AG), unacylated ghrelin (UAG) and
obestatin is poorly understood especially in childhood. To understand their
biological implications in obesity and metabolic syndrome (MS), we measured
AG, UAG, obestatin, at fasting and every 60
during oral glucose tolerance test

(OGTT) in 60 prepubertal (PP-OB; 32) and pubertal (P-OB; 28) children.
Paediatric IDF 2007 criteria was used to identifying MS. In PP-OB group, 20
(62.5%) children had MS and four of them had glucose intolerance (impaired
fasting glucose or impaired glucose tolerance). In P-OB group, 28 (100%)
children had MS and fve had glucose intolerance. UAG (P,0.004), obestatin
(P,0.05) were lower in OB-P when compared to OB-PP. AG levels were higher
in both prepubertal and pubertal males when compared to females (P,0.04).
During OGTT: i) AG levels decreased at 60 min (P,0.04) and returned to basal
levels at 120 min in both PP-OB and P-OB; ii) UAG levels decreased for all the
testing session (P,0.0001) in both groups and more signifcantly in PP-OB when
compared to P-OB (P,0.02); iii) obestatin levels decreased at 120 min (P,0.04)
in both groups. Fasting UAG (P,0.01) and during OGTT obestatin levels
(P,0.01) were higher in children with MS when compared to those without MS.
Fasting UAG (P,0.05) and obestatin (P,0.02) were lower in PP-OB children
with glucose intolerance when compared to euglycemic PP-OB. The levels of
three peptides were positively correlated each others (P,0.004). The AG
decrease was correlated with glucose nadir during OGTT (r: 0.357; P,0.02). The
UAG decrease was associated with fasting insulin, HOMA index and insulin nadir
(r: 0.372; P,0.02) during OGTT. The obestatin decrease was associated with
fasting HDL-cholesterol (r: 0.497; P,0.002). In conclusion AG, UAG and
obestatin were differently inhibited during OGTT in OB children. MS infuences
the glucose-induced regulation of ghrelin system in childhood.
PI03
Melanocortin-4 receptor gene polymorphism (rs12970134) inuences
glucose metabolism, leptin and GH levels in women
Olga Bradnova, Marketa Vankova, Petra Lukasova, Josef Vcelak,
Hana Kvasnickova & Bela Bendlova
Melanocortin-4 receptor (MC4R) gene is expressed in the brain and has been
implicated in mediating most of the effects of melanocortin on food intake and
energy expenditure. Common variants of MC4R gene are associated with fat
mass, weight, risk of obesity and insulin resistance in several populations.
We investigated if rs12970134 A/G is associated with obesity and studied its
possible metabolic effects.
Polymorphism was assesed by ABI TaqMan SNP Genotyping Assay in 842
non-diabetic women: 120 lean (BMI,20 kg/m
2
), 405 normal weight (BMI
20-24.9 kg/m
2
), 172 overweight (BMI 25-29.9 kg/m
2
) and 145 obese women
(BMI30 kg/m
2
). All women were detailed anthropometrically and biochemi-
cally characterized. The protocol was approved by the Ethical Committee.
For statistical analyses the Mann-Whitney test and -square test were used
(NCSS 2004).
The allelic frequencies did not differ among groups (minor A allele: lean 23.3%;
normal 28%; overweight 21.8%; obese 23.8%) which correspond to the other
European populations. Genotypes were in Hardy-Weinberg equilibrium.
Polymorphism was not associated with obesity in our study cohort. Carriers of
the minor A allele (AAAG) versus non-carriers (GG) had signifcantly lower
levels of the fasting glucose (P,0.01), C-peptide (P,0.01), insulin (P,0.01)
and better insulin sensitivity (QUICKI; P,0.001). Carriers of A allele had also
higher leptin (P,0.05) and GH levels (P,0.01).
In conclusion, we did not confrm the association of rs12970134 of MC4R gene
with obesity. However, A allele carrier ship was associated with better glucose
metabolism and higher leptin and GH levels. Further study of hypothalamic
relations among MC4R - leptin - GH is needed.
Supported by the grant IGA MHCR NS/10209-3/2009.
PI04
Vitamin D levels in obese patients with and without metabolic syndrome
Savas Karatas, Zeliha Hekimsoy, Gonul Dinc, Ece Onur & Bilgin O
zmen
Medical Faculty, Celal Bayar University, Manisa, Turkey.
Vitamin D role is not only associated with mineral metabolism and bone health
but also in globally important diseases such as obesity and metabolic syndrome.
The aims of this study were to investigate: i) 25(OH) vitamin D levels in obese
patients with and without metabolic syndrome and compare these with levels in
healthy subjects, ii) the relationship between serum 25(OH) vitamin D levels and
metabolic syndrome components such as body mass index, waist circumference,
blood pressure, fasting blood glucose, lipid parameters and insulin resistance
(HOMA-IR). HOMA-IR was calculated as serum glucose (mg/dL),insulin level
(U/ml)/405. Two hundred eighty-seven (n287) subjects participated in the
study: 94 obese patients with metabolic syndrome, 120 obese patients without
metabolic syndrome and 73 non-obese patients without metabolic syndrome.
Serum 25(OH) vitamin D defciency, defned as a level ,20 ng/ml, was more
common in obese patients with (72.3%) and without (69.2%) metabolic syndrome
versus control group (49.2%) (P0.006). Serum 25(OH) vitamin D levels were
signifcantly lower in obese metabolic syndrome patients (16.87.3 ng/ml) than
in obese non-metabolic syndrome patients (18.38.6 ng/ml) and healthy subjects
(21.28.9 ng/ml, P0.001). A negative relationship was found between serum
25(OH) vitamin D levels and body mass index (r0.159, P0.007) and serum
triglyceride levels (r0.141, P0.018). Serum 25(OH) vitamin D levels
correlated inversely (not statistically signifcant) to waist circumference, fasting
blood glucose, HOMA-IR, and blood pressure, but positively (not statistically
signifcant) to HDL cholesterol levels. In conclusion, vitamin D defciency is very
common in obese patients, more so in patients with than in those without
metabolic syndrome.
PI05
Relation of waist line radius and subcutaneous adipose tissue thickness
positively correlates with markers of impaired glycemic control
Petar Ristic, Zoran Andjelkovic, Milica Cizmic, Tamara Dragovic,
Snezana Kuzmic, Zorana Djuran, Jelena Karajovic, Sasa Kikovic
& Ivan Tavcar
Military Medical Academy, Belgrade, Serbia.
Introduction
Tendency to store lipids centrally is well connected to development of diabetes
mellitus type 2 (T2DM) and cardiovascular morbidity. Providing insight in this
process is important.
Method
Relationship between radius of waist line and thickness of subcutaneous adipose
tissue (SAT) was compared among forty obese patients (BMI30 kg/m
2
) in the
light of their glycemic control parameters (fasting glucose, HOMA IR, HOMA
beta).Patients were divided as euglycemic, IFG or T2DM.
Waist line was considered as a circle and radius was determent from well known
equation. Thickness of subcutaneous adipose tissue under waist line was
measured with ultrasound.
Relation of waistline radius and thickness of subcutaneous adipose tissue we
called obesity index (Oi) and it was determent from equation Oiwaist (cm)/
6.28,SAT (cm). Higher Oi means higher central lipid deposition.
Results and conclusion
Oi was highest in T2DM group and correlates with glycemic control parameters.
This method allows insight in potentially damaging centralisation of lipid depots
among obese patients.
PI0
The inuence of weight-loss induced by bariatric surgery on serum
concentrations of novel metabolic regulators FGF-21 and FGF-19 in
morbidly obese subjects
Denisa Haluzikova
1
, Marketa Bartlova
1
, Milos Mraz
1
, Zdena Lacinova
1
,
Jarmila Krizova
1
, Petra Kavalkova
1
, Pavel Trachta
1
, David Michalsky
1
,
Mojmir Kasalicky
2
& Martin Haluzik
1
1
University Hospital of Charles University, Prague, Czech Republic;
2
Central Military Hospital, Prague, Czech Republic.
Objective
Fibroblast growth factor 19 (FGF-19) and FGF-21 are novel metabolic regulators
that improve insulin resistence and obesity in rodents. The objective of this study
was to explore whether changes in serum concentrations of FGF-19 and FGF-21
contribute to positive metabolic effects of weight loss induced by surgical
treatment of obesity - sleeve gastrectomy (SG).
Methods
Serum concentrations of FGF-19 and 21, adiponectin, resistin, fatty acid binding
protein-4 (FABP-4) and insulin were measured by commercial ELISA
(BioVendor, CZ) and RIA kits (Cis Bio International, France) in 15 morbidly
obese subjects before and 12 months after SG. The study was approved by the
Ethical Committee of General University Hospital in Prague.
Results
SG markedly decreased body weight (1227 vs 917 kg; P,0.01), body mass
index, serum triglyceride, serum C-reactive protein and serum FABP-4
concentrations (54.55.9 vs 35.85.1 ng/ml; P,0.01) and signifcantly
increased serum adiponectin and HDL concentrations. Serum insulin levels
tended to decrease but the difference did not reach statistical signifcance. Serum
resistin levels, blood glucose and glycated hemoglobin concentrations were not
signifcantly affected by SG. Serum FGF-21 levels markedly decreased (21442
vs 7826 pg/ml; P,0.01) while serum FGF-19 levels signifcantly increased
(11921 vs 17440 pg/ml; P,0.01) 12 months after SG. At baseline, serum
FGF-19 positively correlated with serum resistin levels and was inversely related
to serum insulin, leptin and free fatty acid levels. Serum FGF-21 positively
correlated with serum FABP-4 and CRP concentrations and was inversely related
to serum adiponectin levels. Neither baseline FGF-19 nor FGF-21 concentrations
predicted the extent of weight loss induced by SG.
Conclusion
We conclude that weight loss induced by SG decreased serum FGF-21 and
increased serum FGF-19 levels. The increase of FGF-19 after SG could contribute
to some of positive metabolic effects accompanying weight loss.
Acknowledgement
Supported by MSM0021620814 and IGA NS10024-4.
PI0I
Complementary and alternative medicine use in patients with obesity:
an anthropological approach
Duygu Yazgan Aksoy, Nese Cinar, Fuat Levendoglu, Yasemin Canikli,
Bulent Okan Yildiz, Miyase Bayraktar, Aydan Usman & Zafer Ilbars
Introduction
Complementary and alternative medicine (CAM) is a group of diverse medical
and health care systems, practices, and products that are not presently considered
to be part of conventional medicine. For most of CAM, there are key questions
that are yet to be answered through well-designed scientifc studies. Obesity is one
of the chronic health disorders which is diffcult to deal and most of the obese
patients are unable to lose or keep weight with diet, exercise or drugs.
Aim
The aim of this study was to determine the prevalence and types of CAM
modalities that obese patients use.
Methods
Fifty-fve consecutive patients with the diagnosis of obesity were included. Age,
sex, weight, body mass index (BMI), waist, fasting plasma glucose (FPG), fasting
insulin (FI), lipid, thyroid stimulating hormone (TSH), free thyroxine (fT
4
), and
HOMA were measured. A survey including 30 questions related to occupation,
educational level, marital status, accompanying diseases, treatment modalities
and any type of CAM use were recorded.
Results
All were women with mean age 35.693.73 and BMI 36.986.06. Of these
patients 69.1% reported to use at least one CAM modality. None of the laboratory
parameters predicted CAM use. 64.8% were married and 63% had an education
level of high school or less. Most of the patients (44.4%) wanted to be size
40. 58% wanted to lose weight for a better look and 63% reported to believe that
thin people are socially more acceptable. All of them tried diet and exercise
previously and 33.3% used medicine for weight loss. Of CAM modalities herbal
therapy has highest prevalence. 94.7 of CAM users had tried at least one herbal
therapy. Cabbage (Brassica oleracea), cinnamon (Cinnamomum verum), linseed
(Linum usitassinum) were the most common herbs that patients consumed.
Acupuncture was also frequent among patients with obesity (36.4%). 88.6% of
CAM users did not inform their physician about CAM use.
Conclusion
The prevalence of CAM use is higher than expected among patients with obesity.
Obese people do have realistic targets and their most common concerns about
their disease are social rather than medical. Unsuccesful efforts in loosing weight
prompted a need for alternative methods. Physicians should be aware of this fact
and interrogate patients about CAM use beside methods accepted within
conventional medicine.
PI08
Prevalence of no insulin-resistance in morbidly obese patients
Diego Fernandez-Garcia, Jose Manuel Garcia Almeida,
Arantzazu Sebastian-Ochoa & Francisco Tinahones Madueno
Endocrinologi a y Nutricion Hospital, Universitario Virgen de la Victoria,
Malaga, Spain.
Progression of metabolic syndrome to diabetes is not easily predicted in patients
with morbid obesity. We hypothesized that no insulin-resistance is more usual as
we thought.
Objective
Evaluate prevalence of no insulin-resistance status in patients with morbid
obesity.
Patients and method
The study was undertaken in 130 patients with a BMI of 53.936.67 kg/m
2
. The
morbidly obese patients were divided into four groups: patients without insulin-
resistance (MO-nonIR); morbidly obese patients with insulin resistance and
without IGT or T2DM (MO-IR); patients with IGT (MO-IGT) and fnally
morbidly obese patients with T2DM (MO-DM). We determined anthropometrics
parameters, serum glucose, cholesterol, HDL-cholesterol, triglycerides, CRP
insulin, leptin, adiponectin and HOMA IR.
Results
Twenty-four patients had no criteria for insulin-resistance (18%). The MO-IR
patients had signifcantly higher waist perimeter (P, 0.01) and systolic blood
pressure (P,0.04) than MO-nonIR. The MO-IR patients also had signifcantly
higher levels of CRP (P,0.05), triglycerides (P,0.002), VLDL-cholesterol
(P,0.01) and circulating GGT (P,0.001) in comparison with the MO-nonIR.
Additionally, the MO-IR had signifcantly higher serum glucose (P,0.002) and
insulin levels (P,0.001) in comparison with the MO-nonIR. Finally, the MO-IR
patients had signifcantly lower circulating adiponectin levels (P0.05). In
MO-IR group, HOMA IR correlated positively with weight (r:0.19; P:0.1), waist
circunference (r:0.22; P:0.01), glucose serum levels (r:0.19; P:0.01), triglycerides
(r:0.12; P:0.02), GOT (r:0.15; P:0.03), GPT (r:0.21; P:0.01), GGT (r:0.17;
P: 0.04) and CRP (r:0.2; P:0.04). In addition, HOMA IR correlated negatively
with HDL (r:0.26; P:0.001). Using stratifed HOMA status, a signifcant
relation was found with age, FFA, glucose, TG, LDL, VLDL and GGT.
Conclusion
This transversal study shows the prevalence of insulin-resistance in patients with
severe morbid obesity and clinical and biochemical factors related with this
condition.
PI09
Inuence of metformin therapy on peripheral blood androgenes
concentrations in young women with metabolic syndrome
Justyna Kuliczkowska-Plaksej, Grazyna Bednarek-Tupikowska,
Barbara Stachowska, Alicja Filus, Anna Trzmiel-Bira & Andrzej Milewicz
Wroclaw, Poland.
Introduction
Insulin resistance (IR) and visceral obesity, elements of metabolic syndrome (MS),
contribute to hyperandogenaemia and may lead to hirsutism and other signs of
hyperandrogenism. Little is known about the infuence of metformin therapy (MET)
on hormonal profle in women with MS and IR without menstrual irregularity.
Aim
To asses the infuence of MET on sex steroids concentrations in young women
with MS.
Methods
The study population consisted of 30 women aged 25-45 years, being evaluated
before (IR
1
) and after (IR
2
) MET therapy (1700 mg/day for 4 months).
Control group (K) consisted of 15 non-obese women. Anthropometric parameters
as well as concentrations of glucose (fasting), insulin (fasting), total testosterone
(TT), sex hormone binding globulin (SHBG) and dehydroepiandrosterone sulfate
(DHEA-S) in peripheral blood were estimated. Homeostasis model assessment
(HOMA), fasting insulin resistance index (FIRI), quantitative insulin-sensitivity
check index (QUICKI) and free androgen index (FAI) were estimated. All
parameters were evaluated before and after MET.
Results
DHEA-S concentrations did not differ among the groups and did not change after
therapy. TT concentration was signifcantly higher in IR
1
(P,0.005) and dicreased
after MET (P,0.01). SHBGconcentration was the lowest in IR
1
(P,0.05) and did
not change after therapy. FAI was the highest in IR
1
(P,0.001), after MET
signifcantly dicreased (P,0.01) and remained signifcantly higher than in K
(P,0.05). Fasting glucose and insulin concentrations, HOMA and FIRI were the
highest and QUICKI was the lowest in IR
1
(P,0.05) and did not change after
MET. Body mass, body mass index, waist and hip circumferences decreased after
therapy (P,0.05).
Conclusion
i) Visceral obesity and IR are connected with diminished SHBG concentration and
increased FAI values. ii) Metformin therapy has positive infuence on decrease of
free adrogenes levels. iii) Longer therapy and/or higher doses of metformin might
possibly contribute to further limitation of hyperandrogenism.
PI10
Sideways in treatment of obese child: a personal experience
Slavica Dautovic
Institute for Child and Youth Health Care of Vojvodina, Novi Sad, Serbia.
The prevalence of overweight children and adolescents is one of the most
important public health challenges today. The impact of this early obesity extends
into adulthood: increased mortality and morbidity from a variety of conditions
and adverse socio-economic consequences. No single approach to the treatment
of childhood overweight has been demonstrated to be more effective than another.
Challenges faced in managing obese child is selecting the approach that will be
adhered to on a long-term basis, involving whole family in the health lifestyle
regarding the child`s age, sex, cultural and entire environmental background.
Aim
Finding the best therapeutic approach for obese child.
Methods
A 2 years follow up effects of lifestyle modifcation (dietary, physical activity,
psychotherapy) and/or drug (sibutramine) for treating obesity in 40 children (mean
age 13 years) with the support of family members. Children with eating disorders,
diabetes mellitus, secondary or syndromic obesity were excluded. Lifestyle
interventions focused on physical activity and changing eating habits, with
behaviorally orientated treatment were implemented in all. Sibutramine used in
children with BMI 95th percentile (20 children). Reduction in overweight at 6, 12,
18 and 24 months follow up was observed in all children; addition of sibutramine
showed more signifcant weight lost in longer time period (15 vs 8% after 2 years)
with less psychological disturbances and better self-oriented outcomes.
Conclusions
Combined behavioral lifestyle interventions have a signifcant and meaningful
reduction in overweight in children and adolescents. Pharmacotherapy is an
effective adjunct to lifestyle interventions in morbid obese child.
PI11
Limited weight loss with gastric banding in patients with
craniopharyngeoma
Dirk Weismann
1
, Theresia Pelka
1
, Gwendolyn Bender
1
, Herrmann Muller
3
,
Ursel Gebhardt
3
, Andreas Thalheimer
2
, Christian Jurowich
2
,
Martin Fassnacht
1
& Bruno Allolio
1
1
Department of Internal Medicine I, University of Wurzburg, Wurzburg,
Germany;
2
Department of Visceral Surgery, University Wurzburg,
Wurzburg, Germany;
3
Department of Pediatrics, Klinikum Oldenburg,
Oldenburg, Germany.
While bariatric surgery is the most effective treatment strategy to maintain long-
term weight-loss and to improve survival, it has not been shown, that bariatric
surgery is as effective in craniopharyngeoma patients with hypothalamic obesity.
We retrospectively analyzed weight loss and metabolic parameters in 7
craniopharyngeoma patients and 14 controls who underwent gastric banding
surgery in fve centers in Germany and Austria. The last before and the frst
patient after the craniopharyngeoma patient were included as controls.
Craniopharyngeoma patients were signifcantly younger (17.4 (13.6-24.0) vs
37.8 (26.2-56.7) years, P,0.001) when bariatric surgery was performed.
However, body weight was not signifcantly different at the time of bariatric
surgery (46.52.6 vs 49.72 kg/m
2
, P0.4). Although data are incomplete, one
of 6 patients in the craniopharyngeoma group was taking antidiabetic drugs
preoperatively and the need for treatment persisted postoperatively. None of 6
patients was taking antihypertensive or cholesterin lowering drugs. Maximum
(13 (43- 2) vs 28 (4035) kg, P,0.001) and mean weight loss (8
(369.4) vs 20.5 (3932.5), P,0.001) was moderate in craniophar-
yngeoma patients and signifcantly less compared to controls during a follow up
period of 24 months. Total cholesterol increased from 1588 to 20212 mg/dl,
P,0.05. In three patients repeated surgical interventions were performed because
of insuffcient weight loss. Two patients received three bariatric surgical
interventions. In one patient a gastric sleeve was performed and one patient later
received a gastric bypass. After gastric bypass, this patient signifcantly lost weight.
We conclude, that gastric banding is less effective in patients with cranio-
pharyngeoma compared to obese patients without hypothalamic disease. The value
of other bariatric surgical procedures for patients with craniopharyngeoma related
obesity warrants further study.
PI12
Desacyl~ghrelin as a protective factor for obesity
Luisa Veiga
1
, Jose Silva-Nunes
2
, Alice Melao
1
, Ana Oliveira
1
,
Leone Duarte
2
& Miguel Brito
1
1
High School for Health Technology of Lisbony, Lisbon, Portugal;
2
Endocrinology Department, Curry Cabral Hospital, Lisbon, Portugal.
Background
Although acyl-ghrelin has been considered essential for ghrelin`s GH-releasing
activity, several recent in vitro studies have shown that desacyl-ghrelin exhibits
biological activities on metabolism and proliferation of adipocytes, myocytes,
cardiomyocytes, and myelocytes. The full desacyl-ghrelin biological activity still
remains a matter of debate.
Aims
To assess desacyl-ghrelin circulating levels and its R51Q polymorphism as a risk
factor for obesity in women.
Seventy three healthy women (35.98.1 years) and ninety one obese women
(34.78.0 years) were included in the study. Obese women were characterized
by a BMI43.18.1 kg/m
2
, waist1171.50 cm, hip1331.35 cm and
absence of kidney, hepatic, infammatory or neoplasic disease. The ghrelin
polymorphism was assessed by real time PCR with Taqman probes. Desacyl-
ghrelin plasma levels were obtained by ELISA (Cayman). All statistical analyses
were performed using the software SPSS, version 15.0.
Results
Desacyl-ghrelin levels were signifcantly lower in the obese group (P,0.001)
and signifcantly inverse associations were found between this form of ghrelin
and BMI, waist and hip circumferences and percentage of total body fat
(P,0.001 for all). Despite the absence of signifcance in allele or genotype
frequency between groups, R allele was signifcantly associated with higher
desacyl-ghrelin in non-obese women (P,0.001).
Conclusion
These results support recent in vitro fndings that desacyl-ghrelin may induce a
negative energy balance in contrast to the acylated form and that could be
genetically determined. Better understanding of the role of desacyl-ghrelin may
provide a new therapeutic approach for the treatment of obesity.
PI13
Gastric inhibitory polypeptide (GIP) suppresses circulating ghrelin in
humans: plasma metabolome based correlation network analysis for
support of hormone-to- hormone interactions
Natalia Rudovich
1,2
, Victoria J Nikiforova
3
, Baerbel Otto
4
,
Olga Pivovarova
1,2
, O
zlem Gogebakan
1,2
, Martin O Weickert
1,2
,
Michael A Nauck
5
& Andreas F H Pfeiffer
1,2
1
Institute of Human Nutrition Potsdam-Rehbrucke, Nuthetal, Germany;
2
Campus Benjamin Franklin, Charite University Medicine, Berlin,
Germany;
3
Max Planck Institute of Molecular Plant Physiology, Potsdam-
Golm, Germany;
4
Innenstadt University Hospital, Munich, Germany;
5
Diabetes Centre, Bad Lauterberg, Germany.
Aims
We investigate the infuence of GIP on ghrelin secretion in normal glucose
tolerant individuals with the use of the frstly applied correlation network analysis
on human plasma metabolome data.
Methods
To address this issue, we employed a GIP-infusion test and euglycemic- and
hyperglycemic glucose clamp experiments combined with infusion of GIP or
placebo in a cross-over manner in non diabetic obese male subjects (n14).
Moreover, we frstly applied correlation network analysis on GC-TOF/MS plasma
metabolite profles of the accomplished experiments for testing of the supposed
GIP to ghrelin interactions.
Results
Our major fnding is that GIP signifcantly suppressed ghrelin secretion under
hyperglycemic hyperinsulinemic conditions (34.3% versus baseline, P,0.05),
supported by the strongest involvement of ghrelin into the network of molecular
information exchange particularly at this condition. Only a moderate effect of GIP
on ghrelin secretion was observed during euglycemic, hyperinsulinemic clamps
(12.6%, P,0.05), with very weak ghrelin integration into the molecular
information exchange.
Conclusions
The suppression of ghrelin secretion requires hyperglycaemic conditions, similar
to the insulinotropic action of GIP. These fndings indicate an indirect effect of GIP
via ghrelin on the suppression of hunger sensation and appetite. Moreover we
considered necessary to apply systems analysis to the search of informational signals
for ghrelin regulation and involvement of different metabolites in this process.
PI14
Effects of breastfeeding on maternal appetite-regulating hormones
Greisa Vila, Judith Hopfgartner, Gabriele Grimm, Michaela Riedl,
Sabina Baumgartner-Parzer, Alexandra Kautzky-Willer, Martin Clodi
& Anton Luger
Medical University of Vienna, Vienna, Austria.
Gestational weight gain has been linked to obesity in women of childbearing age.
Mothers who breastfeed present less postpartum weight retention. The underlying
pathophysiological mechanisms are unknown. This study aimed at investigating
the impact of breastfeeding on maternal appetite-regulating hormones.
The clinical trial recruited 29 women divided in three age- and BMI-matched
groups. The frst group included 10 fully breastfeeding mothers of 3 to 6 month
old babies (lactating group), the second included 9 non-breastfeeding mothers of
3 to 6 month old babies (nonlactating group) and the third included 10 healthy
women (control group). Participants were studied at 5 time-points during 1.5 h.
The mothers of the lactating group breastfed their babies during the study period,
while participants of the nonlactating group either bottlefed their babies or did
not. Primary outcome parameters were ghrelin and PYY. Secondary outcome
parameters were leptin, adiponectin, prolactin, PTH, osteocalcin and lipid values.
We found that lactating mothers had signifcantly increased circulating
concentrations of the anorectic hormone PYY as compared to the two other
groups (P0.008 when compared to non-lactating mothers and P0.02 when
compared to the control group). We found no signifcant differences in ghrelin,
leptin and adiponectin values. Prolactin levels at baseline were over 4-fold higher
in lactating mothers (P,0.001) and further augmented during breastfeeding
(P,0.001). In addition, lactating women presented a lower waist circumference,
reduced triglyceride levels, lower total cholesterol/HDL ratio as well as
signifcantly increased osteocalcin levels when compared to the two other groups.
In summary, breastfeeding mothers present signifcantly elevated circulating
PYY concentrations, increased bone turnover and a better lipid profle.
Differences in appetite regulation and the increase in the anorectic PYY might
count among the factors underlying the higher rate of postpartum weight
reduction in women who breastfeed.
PI15
Relation of weight, height and BMI of child to parental characteristics
in families with obese or overweight parents before weight
management: diogenes project
Marie Kunesova
1
, Petr Hlavaty
1
, Pavla Kalouskova
1
, Magda Bajzova
1
,
Karolina Hlavata
1
, Martin Hill
1
, Wim Saris
2
& Arne Astrup
3
1
Obesity Centre, Institute of Endocrinology, Prague, Czech Republic;
2
Department of Human Biology, Nutrition and Toxicology Research
Institute Maastricht, Maastricht University, Maastricht, The Netherlands;
3
Department of Human Nutrition, Faculty of Life Sciences, University of
Copenhagen, Copenhagen, Denmark.
Background
Familial resemblance was shown for body composition and risk factors in several
studies. In twin studies which are powerful tool to assess genetically mediated
traits signifcant resemblance was found in twins reared apart. In pairs of
monozygotic twins was found signifcant resemblance in response to positive and
negative energy balance. Aim of the study was to evaluate relationship of
anthropometric parameters of parents and socioeconomic characteristics of family
to weight, height and BMI of their children.
Methods
In families participating in the multicentric paneuropean project DIOGenes (Diet,
Obesity and GENES) families with both parents being obese or overweight were
examined. Resemblance of anthropometric variables between parents and their
child participating in the study was assessed before start of weight management
programme. Families with at least one obese or overweight parent and at least one
child aged 6-18 years from 8 European countries were participating in the
Diogenes project. For assessment of familial resemblances 99 families in which
both parents entered the study were selected. Anthropometric characteristics of
subjects (weight, height, waist and hip circumferences) were measured, BMI and
waist to hip ratio was calculated. Body composition was examined by DEXA or
by bioelectrical impedance method. Anthropometric parameters of parents and
socioeconomic characteristics of families were included into statistical analysis as
independent variables. Multivariate regression with reduction of dimensionality
(method of bidirectional orthogonal projections to latent structures) was used.
Results
Signifcant relationship between weight, height and BMI of child (dependent
variables) and age of child, number of persons in family, height of father (positive
correlation) and age of father at birth of child and age of mother at birth of child
(negative correlation) was found. Variability shared between dependent and
independent variables was 52.8% (49.1% after cross validation).
Conclusion
Weight, height and BMI of child is positively correlated with height of father and
number of persons in family and negatively with age of parents at birth of child.
Supported by the European Community (Contract no. FP6-513946), http://www.
diogenes-eu.org and by the grant of the IGA of Ministry of Health CR No. IGA
NS/9830-4.
PI1
Childhood obesity surveillance initiative in the Czech Republic: the
association between BMI and school environment
Radka Braunerova, Marie Kunesòva, Bohumil Prochazka, Jana Vignerova,
Jana Parizkova, Anna S
`
tefova, Trudy Wijnhoven, Jana Riedlova
& Hana Zamrazilova
1
2
Pediatric Clinic,
Koli n, Czech Republic;
3
National Institute of Public Health, Prague, Czech
Republic;
4
WHO Prague, Prague, Czech Republic;
5
WHO Regional Offce
for Europe, Prague, Czech Republic.
Objective
Prevalence of childhood obesity has been increasing steadily. Unfortunately, only
a small number of European countries have functional system to monitor this
problem. Since it is very important to have comparable data on the international
level, Childhood obesity surveillance initiative has been established by WHO
Europe in 2006. The objective of the initiative is to monitor prevalence of obesity
and factors related to obesity among children (nutrition habits, physical activity,
socio-economic factors and school environment) using standardized method-
ology. In this paper, we will present data from the Czech branch of the initiative
concerning association between BMI and school environment.
Methods
Total number of 1704 7-years old children was examined by 46 paediatricians
during preventive check-ups. The clinical examination consisted of basic
anthropometry measurement (weight, height, waist and hip circumference).
Special questionnaires were flled in by parents, paediatricians and school
representatives (usually school director). Questions on school environment
included food availability at school (e.g. soft drinks with/without sugar, water, hot
drinks with/without sugar, milk, yoghurts, fruit, vegetables - in canteen, vending
machines or school shop), physical activity (physical training, possibility of sports
during breaks, sport clubs), organization of projects aimed on healthy life-style
propagation, etc.
Results
Among recorded factors regarding school environment, only the availability of
cold drinks without sugar and salty snacks were positively associated with Z-score
of BMI. Surprisingly, cold drinks without sugar were associated positively and
salty snacks negatively.
Conclusion
The availability of cold drinks without sugar at school was positively associated
with Z-score of BMI, whereas the availability of salty snacks was associated
negatively. Possible explanation for these unexpected results could be that they
are rather consequence than cause of obesity among children.
PI1I
Characterisation of serum and glucocorticoid-induced kinase 1 in
adipose tissue
Greisa Vila, Florian Kiefer, Marie Helene Reiter, Maximilian Zeyda,
Thomas M Stulnig & Anton Luger
Division of Endocrinology and Metabolism, Department of Medicine III,
Medical University of Vienna, Vienna, Austria.
Serum and glucocorticoid-induced kinase 1 (Sgk1) is an early transcriptional
target of glucocorticoids with antiapoptotic effects. Sgk1 becomes active after
phosphorylation by growth factors such as insulin and IGF1 through the PI3
kinase/PDK1 pathway. Activated Sgk1 increases the cellular uptake of glucose by
increasing the membrane abundance of glucose transporters GLUT1 and GLUT4.
Here we present data on the expression and regulation of Sgk1 in adipose tissue
using three different models: human obesity, diet-induced murine obesity and
adipogenesis in 3T3-L1 cells.
Sgk1 gene expression was increased in both omental and subcutaneous adipose
tissue of 20 morbidly obese patients when compared to 20 age- and sex-matched
control subjects. Adipose tissue fractionation revealed a predominant expression
of Sgk1 in adipose tissue macrophages and a very low expression in adipocytes.
Similarly, high-fat diet-induced obesity in mice was associated with a signifcant
upregulation of Sgk1 in adipose tissue, and predominantly in the stromal-vascular
tissue. Sgk1 transcription in 3T3-L1 preadipocytes was strongly induced by
dexamethasone and its phosphorylation was enhanced by insulin. Nevertheless,
induction of adipogenesis in 3T3-L1 cells led to a progressive reduction in Sgk1
mRNA and protein levels. During adipogenesis, Sgk1 mRNA levels were in a
strong negative correlation to the intracellular fat content and to the increase in
PPARgamma mRNA. Overexpression of Sgk1 in 3T3-L1 adipocytes did not
infuence PPARgamma levels, while the addition of rosiglitazone decreased Sgk1
transcription.
In summary we conclude that Sgk1 expression is increased in adipose tissue
macrophages in both human and murine obesity, but downregulated in adipocytes
during adipogenesis and after PPARgamma activation. The reduced Sgk1 levels
in adipocytes may be linked to increased insulin resistance, as Sgk1 increases
glucose uptake via upregulating the membrane abundance of glucose transporters.
In parallel, the increased Sgk1 expression in macrophages points towards a
potential role in adipose tissue infammation.
PI18
Carbohydrate metabolism in obese women: association with the
circulating levels of adiponectin and retinol binding protein-4
Jose Silva-Nunes
1,2
, Alice Melao
2
, Ana Oliveira
2
, Leone Duarte
1
,
Miguel Brito
2
& Lui sa Veiga
2
1
Endocrinology Department, Curry Cabral Hospital, Lisbon, Portugal;
2
High School for the Health Technology of Lisbon, Lisbon, Portugal.
Background
Adiponectin is an adipokine with anti-diabetic properties. Recently, retinol
binding protein-4 (RBP4) was identifed as an adipokine associated with insulin
resistance (IR) and a potential marker for type 2 diabetes (T2D) development.
Aims
To compare adiponectin and RBP4 circulating levels according to presence/
absence of diabetes/prediabetes, in obese women. To study the degree of
association of those adipokines with indexes of IR and insulin secretion (IS).
Methods
This study was conducted after approval by Hospital`s Ethical Committee. We
studied 84 obese women anthropometrically characterized. They were submitted
to fasting blood sample collection for adiponectin and RBP4 assessments,
followed by an oral glucose tolerance test. We used two IS indexes (homeostatic
model (HOMA%beta) and insulinogenic index (INS-i)), three insulin sensitivity
indexes (Matsuda formula (MATSUDA), McAuley index (McAULEY) and
QUICKI) and one IR index (HOMA-IR).
Results
Patients were characterized by mean age34.18.2 years, BMI43.6
8 kg/m
2
, waist circumference117.715.3 cm, waist:hip ratio (WHR)
0.880.08, adiponectin6.723.33 g/ml, RBP430.5713.92g/ml,
HOMA%beta261.8175.8, INS-i2420.1, MATSUDA3.932.92,
McAULEY6.591.62, QUICKI0.140.01 and HOMA-IR4.423.67.
Normoglycemia was present in 57 patients. Adiponectin and RBP4 were
inversely correlated (P0.01; r0.347). Normoglycemic women exhibited
higher adiponectin levels (P0.035), QUICKI (P,0.001), McAULEY
(P0.007), MATSUDA (P0.006) and INS-i (P0.013) and lower HOMA-
IR (P,0.001); they also presented non-signifcantly (P0.078) lower RBP4.
Adiponectin, but not RBP4, was inversely associated with WHR (P0.002;
r0.332). Adiponectin was negatively correlated with HOMA-IR (P0.006;
r0.298) and HOMA%beta (P0.035; r0.232) and directly with
QUICKI (P,0.001; r0.455), MATSUDA (P,0.001; r0.472) and McAU-
LEY (P,0.001; r0.465). RBP4 was directly associated with HOMA-IR
(P0.028; r0.265) and inversely with QUICKI (P0.035; r0.254),
MATSUDA (P0.023; r0.273) and McAULEY (P0.037; r0.251).
Conclusions
The IR in diabetic/prediabetic women accompanies a decrease in adiponectin and
increase in RBP4 levels. Adiponectin presents a parallel inverse association with
IR and anthropometry. Contrarily, RBP4 associates with IR in a non-
anthropometrically dependent way. This suggests a RBP4 specifc pathway in
compromising insulin sensitivity.
PI19
Lindaxa effectiveness in obesity treatment associated with IGT and
arterial hypertension
S I Ismailov, Z Yu Kahlimova, G D Narimova & Sh M Safarova
The Center for the Clinical and Scientifc Study of Endocrinology, Tashkent,
Uzbekistan.
This research was designed to estimate effectiveness and safety of Lindaxa in
treatment of obesity associated with IGT and arterial hypertension. Thus, 20
women (mean age 37.9 years-old) were treated with complex therapy including
traditional therapy (diet, physical exercises, dhydration, metabolic and
symptomatic treatment) including Lindaxa with dosage of 10-15 mg/day once
daily during 6 months. Physical exercises were determined individually according
to BMI and metabolic disorders.
Clinical evaluation included brain MRI, Echocardiography, US imaging of
abdominal cavity, lipids and carbohydrates metabolism (cholesterol, LDL, HDL,
triglycerides, -lipoproteids, fasting glucose concentration). Besides, BMI, waist
circumference, OGTT were evaluated in women with obesity. Control tests were
conducted before treatment and after 3, 6 months intervals with evaluation of
BMI, waist circumference, lipids profle, glucose levels and OGTT.
Women with arterial hypertension (eight women with mean blood pressure of
145/90 mmHg) treated with Lindaxa (sibutramine) we recommended hyperten-
sion and heart rate monitoring every 2 weeks during frst 3 months of therapy and
monthly during following 3 months of treatment. Results showed systolic blood
pressure (SBP) increase by 2.0 mmHg whereas diastolic blood pressure (DBP)
elevated by 1.6 mmHg and heart rate increased by 2-5 beats per minute during the
frst month of therapy, however, with body mass decrease with the Lindaxa
therapy blood pressure reliably decreased during the frst month of therapy. Thus,
after 6 months of treatment SBP decreased by 3.4 mmHg, while DBP reduced by
2.4 mmHg.
Comparative evaluation of metabolic data in obese patients treated with Lindaxa
after 6 months showed OGTT change from 5.2-11.1-5.6- to 4.8-5.8-4.7 mmol/l,
decrease in cholesterol levels from 5.2 to 4.6, while -lipoproteids and LDL
decreased from 0.62 and 3.1 to 0.54 and 2.4 respectively; triglycerides reduced
from 2.03 to 1.35 while HDL increased from 1.69 to 2.2. The more patient lost
weight the more evident improvement in above mentioned tests.
After 6 months of Lindaxa therapy weight loss achieved signifcant reliable
reduction with mean 11.0 kg, where mean body weight reduced from 84.5 to
73.5 kg and BMI decreased to 27.8 kg/m
2
. Two patients who showed no change in
body weight developed resistance to the treatment, however, IGT had positive
dynamics.
Treatment with Lindaxa improves lipids profle, reduces body mass, decreases
elevated blood pressure both systolic and diastolic, and glucose tolerance.
Moreover, Lindaxa shows positive effect on lipids metabolism, which is
important factor in treatment and reducing cardiovascular risk in patients with
obesity.
Signal transduction
PI20
Role of hlamin-A in the regulation of dopamine D2 receptor localization
and signaling in a lactotroph cell model
Giovanna Mantovani
1
, Erika Peverelli
1
, Stefano Ferrero
2
, Eleonora Vitali
1
,
Paolo Beck-Peccoz
1
, Anna Spada
1
& Andrea Lania
1
1
University of Milan, Fondazione Ospedale Maggiore IRCCS, Milan, Italy;
2
Pathology Unit, Department of Medicine, Surgery and Dentistry, Azienda
Ospedaliera San Paolo and Fondazione Ospedale Maggiore IRCCS, Milan,
Italy.
Dopamine agonists (DA) inhibit prolactin (PRL) secretion and expression on the
pituitary lactotrophs by binding dopamine D2 receptor. Prolactinomas are the
most common secreting pituitary adenomas, and DA are the frst choice for their
treatment because they reduce PRL levels and tumor size. However, a subset of
patients is resistant to DA. The mechanisms involved in DA resistance are not
fully understood, although decreased expression of D2 receptor or altered signal
transduction have been suggested. Recent studies identifed specifc protein-
protein interactions as determinant in the regulation of receptor anchoring and
signaling. D2 receptor was found to associate with flamin-A (FLNA), a widely
expressed cytoskeleton protein that, through its scaffolding properties, affects the
intracellular signaling and traffcking of a number of receptors.
The aimof our study was to investigate the role of FLNAin signaling and targeting
of D2 receptor in prolactinomas. We frst evaluated the expression of this protein in
normal and tumoral human pituitaries by immunohistochemistry: prolactinomas
showed a strong reduction of FLNA expression when compared to the normal
pituitary, this effect being generally more pronounced in DA resistant adenomas.
To study the effects of the reduced FLNA expression on D2 receptor signaling and
localization we silenced the expression of FLNA by siRNA technique in MMQ
cells, a rat lactotroph cell line, and we evaluated the effects on D2 membrane
expression as well as on the most relevant intracellular D2-mediated responses. We
found that FLNA silencing reduced D2 localization at the plasma membrane;
moreover, a prolonged absence of FLNA induced the down-regulation of receptor
expression. Finally, in silenced cells a reduced inhibition of intracellular cAMP
(46% inhibition versus 64% of control at 10 nM) and a reduced anti-proliferative
effect (7% inhibition versus 23% of control at 100 nM) were observed, suggesting
that FLNA is crucial for D2 receptor targeting and signaling in a lactotroph cell
model. We suggest that the strong reduction of FLNA expression observed in
prolactinomas may be associated with an impaired response to inhibitory effects of
D2 on PRL secretion and cell proliferation.
PI21
Lysyl oxidase interacts with AGEs signaling to modulate collagen
synthesis in polycystic ovarian tissue
Katerina Papachroni
1
, Christina Piperi
1
, Georgia Levidou
2
,
Penelope Korkolopoulou
2
, Leszek Pawelczyk
3
, Evanthia Diamanti-
Kandarakis & Athanasios Papavassiliou
1
1
Department of Biological Chemistry, Medical School, University of
Athens, Athens, Greece;
2
Department of Pathology, Medical School,
3
Division of Infertility and
Reproductive Endocrinology, Department of Gynecology and Obstetrics,
Karol Marcinkowski University of Medical Sciences, Poznan, Poland;
4
Endocrine Section, First Department of Internal Medicine, Medical School,
University of Athens, Athens, Greece.
The connective tissue components, collagen types I, III and IV, which surround
the ovarian follicles, undergo drastic changes during ovulation. Abnormal
collagen synthesis and increased volume and density of ovarian stroma
characterise the polycystic ovary syndrome (PCOS). Physiologically, collagen
synthesis in ovarian follicles is partly regulated by lysyl oxidase (LOX), which
catalyzes the collagen and elastin cross-linking and plays indispensable role in the
organization of ovarian extracellular matrix (ECM) during follicular develop-
ment. We have recently shown accumulation of advanced glycation end products
(AGEs), nutritional metabolic products that stimulate ECM production and
abnormal collagen cross-linking, in ovarian tissue of patients with PCOS.
However, the possible link between LOX and AGEs-induced signaling in
collagen assembly and stroma formation remain elusive. The present
investigation explores the hypothesis that AGE-mediated signaling affects LOX
gene transcription in ovarian tissue from patients with PCOS, in a study approved
by the local Ethical Committee. We used immunohistochemistry, Western
blotting, RT-PCR and EMSA to demonstrate that there is indeed an increased
distribution and co-localization of collagen type IV, LOX and AGE molecules in
the PCO tissue compared to control, as well as augmented expression of the AGE
signaling mediators/effectors, phospho(p)-ERK, phospho(p)-c-Jun and nuclear
factor B (NF-B). Moreover, we demonstrate binding of the AGE-induced
transcription factors, NF-B and activator protein-1 (AP-1) on LOX promoter,
which directly engages AGEs in LOX gene regulation and possibly accounts for
the revealed increase in LOX mRNA and protein levels compared to normal. Our
fndings imply that metabolic products can modulate gene transcription and thus
participate in complex cellular processes, such as the cystogenesis in PCO tissue.
PI22
Peroxisome-proliferator-activated receptor gamma is required for
modulating endothelial inammatory response through a novel
nongenomic mechanism
Giulia Cantini, Adriana Lombardi, Elisa Borgogni, Michela Francalanci,
Elisabetta Ceni, Stefania Gelmini, Giada Poli, Andrea Galli, Mario Serio,
Gianni Forti & Michaela Luconi
Department of Cinical Physiopathology, University of Florence, Florence,
Italy.
Besides their well-known anti-diabetic effects, the peroxisome proliferator-activated
receptor (PPAR) thiazolidinedione ligands (TZD) have been suggested to also
display anti-infammatory properties. The receptor role in mediating such effects is far
from being elucidated. Here, we demonstrate that PPAR is necessary for TZD to
interfere with TNF and IFN infammatory activity in human endothelial cells.
Different PPAR ligands similarly inhibit cytokinic stimulation of IFN-inducible-
protein-of-10-kDa (IP-10) secretion in a dose-dependent manner and prevent the
induced phosphorylation/activation of extracellular-signaling-regulated-kinases
(ERK1/2). To further confrm the role of PPAR in mediating both rapid and long
term anti-infammatory effects of its ligands, we evaluated RGZ inhibitory action in
PPAR-silenced and - overexpressing cells. PPAR-silencing results ina reversion of
RGZ inhibitory activity on cyto/chemokines secretion and rapid ERK phosphoryl-
ation. Conversely, receptor-overexpression signifcantly increases RGZ inhibitory
activity. Finally, PPAR-overexpression results in reduction of ERK1/2 phosphoryl-
ation and infammatory secretions in response to TNF and IFN even in the absence
of RGZ, suggesting a restraining effect controlled by endogenous ligands.
In conclusion, our data provide the frst evidence that PPAR is involved in the TZD
anti-infammatory action in endothelial cells, not only by modulating cyto/chemokine
secretions but also by restraining ERK activation through a novel rapid nongenomic
mechanism.
PI23
The subunits of heterotrimeric G-protein in thyroid plasma
membranes
Grazyna Adler, Urszula Piotrowska & Ireneusz Kozicki
Medical Center of Postgraduate Education, Warsaw, Poland.
TSH regulates thyroid function trough the receptor coupled to heterotrimeric
G-protein composed of , and gamma subunits. The activation of s /adenylyl
cyclase mediated pathway accounts for most of TSH biological effects. TSH can
also induce the other G- protein mediated activities. Five different isoforms of
subunit have been described and it can be assumed that specifc - combination
are essential for functional differentiation of G proteins.
The present work was done to characterize isoforms of the subunits of thyroid
G-protein.
Triton X100 solubilized membrane fraction from cultured thyroid cells and
postoperative thyroids from Graves` disease and struma nodosa patients were
studied. Soluble membrane proteins were characterized by immunoblotting with
specifc anti- subunits antibodies. Additionally the mRNA from cells and thyroid
homogenates were separated, translated into DNA, amplifed with -5 starters and
electrophoreticaly characterized.
In plasma membrane fractions from cultured thyroid cells and thyroid tissues the
-1, -2, -3 and -4 subunits, 35 kDa, were detected. Anti -5 antibodies
recognized 70 kDa protein with probably corresponded to -5 dimmer or its
complex with other protein. Both in cells and tissue homogenates the -5 mRNA
was found, which also supports the presence of -5 isoform in thyroid. In
membranes of cells and different thyroids the amount of particular isoform
differs. To estimate the relative amount of isoforms the concurrence in specifc
antibodies binding between pooled thyroids and individual thyroids were studied.
It was found that the main isoform of G-protein in thyroid membranes is -2.
We assume that in thyroid the -2 is the isoform cooperating with the subunit of
Gs-protein.
PI24
Spatial and temporal regulations of MAPKinases ERK1/2 in the
somatolactotroph cell line GH4C1
Caroline Zeiller
1
, Marie-Pierre Blanchard
2
, Morgane Pertuit
1
,
Sylvie Thirion
1
, Alain Enjalbert
1
, Anne Barlier
1
& Corinne Gerard
1
1
CRN2M CNRS UMR 6231, Marseille, France;
2
IFR Jean Roche, Marseille,
France.
Somatotroph adenomas are characterized by growth hormone hypersecretion and
cell proliferation. We have previously identifed crosstalk between the cAMP
pathway and the MAPKinases ERK1/2 cascade and shown the central place of the
MAPKinases in the control of the pituitary function in GH4C1 somatolactotroph
cell line.
The spatio-temporal organization of the signalling partners governs signalling
fdelity and encodes the specifcity of biological responses. Our aims consisted in
dynamic imaging of living GH4C1 cells to explore spatiotemporal dynamic
partners involved in the cross-talk between cAMP pathway and the ERK1/2
cascade in GH4C1. Time course, intensity and subcellular localisation of ERK1/2
activation are assessed by FRET imaging of genetically encoded biochemical
sensors (EKAR located in nucleus or in cytoplasm, Harvey et al. 2008).
Our frst results show that the activation of ERK1/2 biochemical sensors is
responsive in cytoplasm and in nucleus to cAMP-coupled neuropeptides. We are
investigating the kinetics of this activation in both compartments and their
potential alterations induced by overexpression of dominant negative mutants of
Ras and Rap1. Indeed, although Ras and Rap1 GTPases are recruited for the
activation of ERK1/2, they are involved in opposite effect on hormonal secretion
by cAMP coupled neuropeptide. These results showed that physiological
response of somatotroph cells is maintained by precise spatio-temporal
organization of ERK1/2.
PI25
Molecular origin of idiopathic central hypogonadism: variable
impairment of two signal-transduction pathways due to PROKR2
mutations
Domenico Vladimiro Libri
1
, Marco Bonomi
1,2
, Marta Busnelli
3
,
Gunnar Kleinau
4
, Csilla Krausz
5
, Paolo Beck-Peccoz
1
, Antonio Agostino
Sinisi
6
, Luca Persani
1,2
& ICH study group of the Italian Societies for
Endocrinology and Paediatric Endocrinology
1,2
1
Dip di Scienze Mediche, Universita` di Milano, Ist Auxologico Italiano
IRCCS e Fondazione 'Ca` Granda` Policlinico, Milan, Italy;
2
Centro
Interuniversitario per la Ricerca della Basi Molecolari delle Malattie della
Riproduzione CIRMAR, Milan, Italy;
3
Cellular and Molecular
Pharmacology Section, CNR Institute of Neuroscience, Milan, Italy;
4
Leibniz-Institut for Molecular Pharmacology, Berlin, Germany;
5
Dip. di Fisiopatologia Clinica, Universita` di Firenze, Florence, Italy;
6
Endocrinology and Medical Andrology Section, Department of Clinical
and Experimental Medicine and Surgery, Seconda Universita` di Napoli,
Naples, Italy.
ICH is a heterogeneous disease mainly due to functional defects of GnRH
neurons. Recent studies have described the importance of prokineticin pathway in
the pathogenesis of these defects. In a series of 166 ICH patients we found
germline mutations affecting this pathway in about 10% of the cases. PROKR2
gene analysis revealed 3 novel (V158I, T260M, V334M) and 4 already known
(L173R, R268C, V274D, V331M) mutations affecting different transmembrane
and intracellular regions of this G protein coupled receptor (GPCR). For the frst
time, we evaluate the functional effects of these mutations on the two different
PROKR2-dependent signalling pathways: IP3-Ca
2
(via G
q
coupling) and cAMP
(via Gs coupling) by HTRF-BRET and RIA techniques. At FACS analysis, the
expression levels in CHO-K1 cells were similar to the WT in the case of V158I,
V331M, V334M and reduced by 50% in the case of the other mutants.
Interestingly, functional studies showed highly variable degrees of impairment in
both signalling pathways for most of the mutations. For example, T260M, R268C
and V331M mutants showed no changes in cAMP EC
50
while the IP3 signalling
appeared strongly affected with an increase of tenfolds in the EC
50
versus WT. In
contrast, R173C and V274D presented no virtual response in terms of cAMP
accumulation, whereas R173C had an IP3 response similar to the WT and V274D
presented a tenfold increase of IP3 EC
50
. Differently, V334M showed a similar
fvefold increase of EC
50
for both cAMP and IP3. In conclusion, our study shows
the importance to evaluate both PROKR2-dependent signalling pathways since
single missense mutations can variably affect the two cascades, thus suggesting that
the integrity of both cAMP- and IP3-dependent signals should be required for a
physiological function of GnRHneuron. These studies open novel perspectives for
the understanding of the structure-function relationships of this class of GPCRs.
Steroid metabolism and action
PI2
Rapid non-genomic effects of cortisol on glucose-induced insulin
secretion in humans
Jana Kerlik
1
, Adela Penesova
1
, Miroslav Vlcek
1
, Richard Imrich
1,2
& Zofa Radikova
1
1
Laboratory of Human Endocrinology, Institute of Experimental
Endocrinology, Slovak Academy of Sciences, Bratislava, Slovakia;
2
Center
for Molecular Medicine, Slovak Academy of Sciences, Bratislava, Slovakia.
For a long time it has been suggested that glucocorticoids (GC) mediate their
effects solely on the genomic level. A number of studies reported an existence of
rapid GC effects independent on gene expression. These effects may play an
important role in stress response or during acute GC therapy. As far as we know,
rapid inhibitory GC effects on glucose-induced secretion of insulin have been
reported only in animals (1). The aim of our study was to evaluate effects of GC
on early phase of insulin secretion in subjects with normal fasting glycemia.
Methods
Seven healthy lean women (BMI 20.70.3 kg/m
2
, age 28.61.2 years) and
seven overweight women (BMI 28.91.1 kg/m
2
, age 29.41.5 years)
participated on the study. The dose of 20 mg of hydrocortisone (HC) or isotonic
saline solution was intravenously administrated during 5 min. Immediately
afterwards, 40% glucose solution (0.1g/kg) was injected during 1 min. Blood
samples for determination of insulin, C-peptide and glucose were drawn in
frequent intervals during 30 min after glucose administration. Concentration of
cortisol was determined before HC administration, then 16 and 30 min after
glucose administration.
Results
The maximal cortisol concentration was 117971.9 nmol/l in the 16 min of
investigation. In both groups, HC administration was followed by a signifcant
glucose-induced increase of insulin and C-peptide with the peak 5 min after
glucose infusion. HC administration did not infuence glucose-induced responses
of insulin and C-peptide in our group of normal and increased body weight
females.
Conclusion
We did not confrm rapid non-genomic effect of acute hypercortisolemia on early
phase of insulin secretion in normal and overweight females. Our results do not
support rapid effects of GC on metabolic changes during acute short-term stress
response in humans.
Literature: 1. Sutter-Dub MT: Steroids. 67:77-93, 2002.
The project was supported by grants VEGA 2/7178/27 a CENDO SAV.
PI2I
The response of creatine kinase specihc activity in rat pituitary to
estrogenic compounds and vitamin D less- calcemic analogs
Dalia Somjen
1
, Nitza Mirsky
2
, Snait Tamir
3
, Jacob Vaya
3
, Gary H Posner
4
& Alvin M Kaye
1
1
Institute of Endocrinology, Metabolism and Hypertension, Sourasky
Medical Center, Tel-Aviv; The Sackler Faculty of Medicine, Tel-Aviv
University, Tel-Aviv 64239, Israel;
2
Faculty of Science, University of Haifa,
Har- Hacarmel, Haifa, 31905, Israel;
3
Laboratory of Natural Compounds for
Medical Use, Migal-Galilee Technological Center, Kiryat-Shmona 10200,
Israel;
4
Department of Chemistry, The Johns Hopkins University,
Baltimore, Marry Land. France.
We examined the response of rat female pituitary at different metabolic stages to
treatments with estrogenic compounds and vitamin D analogs. Immature or
ovariectomized (Ovx) female rats, responded by increased creatine kinase
specifc activity (CK) to estradiol-17 (E
2
), genistein (G), daidzein (D),
biochainin A (BA), quecertin (Qu), carboxy- G (cG), carboxy- BA (cBA) and
raloxifene (Ral). The response was inhibited when Ral was injected together with
the estrogens. CK was increased when hormones were injected daily into Ovx rats
for 4 different time periods. Pre-treatment with the less-calcemic vitamin D
analogs JK 1624 F
2
2 (JKF) or QW 1624 F
2
-2 (QW) followed by estrogenic
injection, resulted in increased response and sensitivity to E
2
and loss of inhibition
of E
2
by Ral. CK was also increased by feeding with E
2
or licorice or its
components dose- and time- dependent in immature or Ovxrats. Diabetic female
rats did not respond to increased doses of E
2
. In conclusion, rat female pituitary is
estrogens-responsive organ, suggesting considering its response for HRT in post-
menopausal women for both benefcial and hazardous aspects.
PI28
Association of vitamin D status with serum androgen levels in men
Elisabeth Wehr
1
, Stefan Pilz
1
, Bernhard O Boehm
2
, Winfried Marz
3,4
& Barbara Obermayer-Pietsch
1
1
Medical University of Graz, Graz, Austria;
2
Ulm University, Ulm,
Germany;
3
University of Heidelberg, Mannheim, Germany;
4
Synlab Center
of Laboratory Diagnostics, Heidelberg, Germany.
Objective
Studies in rodents indicate a role of vitamin D in male reproduction but the
relationship between vitamin D and androgen levels in men is largely unexplored.
We aimed to investigate the association of 25-hydroxyvitamin D [25(OH)D]
levels with testosterone, FAI (free androgen index), and SHBG. Moreover, we
examined whether androgen levels show a similar seasonal variation to 25(OH)D.
Design
In this cross-sectional study, 25(OH)D, testosterone, and SHBG levels were
assessed by immunoassay in 2299 men who were routinely referred for coronary
angiography (1997-2000).
Measurements
Main outcome measures were associations of 25(OH)D levels with testosterone,
SHBG, and FAI. FAI was calculated as testosterone (nmol/l)/SHBG
(nmol/l),100.
Results
Men with suffcient 25(OH)D levels (30 g/l) had signifcantly higher levels of
testosterone and FAI and signifcantly lower levels of SHBG when compared to
25(OH)D insuffcient (20-29.9 g/l) and 25(OH)D defcient (,20 g/l) men
(P,0.05 for all). In linear regression analyses adjusted for possible confounders,
we found signifcant associations of 25(OH)D levels with testosterone, FAI, and
SHBG levels (P,0.05 for all). 25(OH)D, testosterone, and FAI levels followed a
similar seasonal pattern with a nadir in March (12.2 g/l, 15.9 nmol/l, and 40.8,
respectively) and peak levels in August (23.4 g/l, 18.7 nmol/l, and 49.7,
respectively) (P,0.05 for all).
Conclusion
Androgen levels and 25(OH)D levels are associated in men and reveal a
concordant seasonal variation. Randomized controlled trials are warranted to
evaluate the effect of vitamin D supplementation on androgen levels.
PI29
Testosterone levels in acute exacerbation of chronic obstructive
pulmonary disease: relationship with severity indices
Antonio Mancini
1
, Riccardo Inchingolo
2
, Alessandro Di Marco Berardino
2
,
Vincenzo Di Donna
1
, Erika Leone
1
, Giuseppe Maria Corbo
2
,
Salvatore Valente
2
& Alfredo Pontecorvi
1
1
Department of Internal Medicine, Catholic University of the Sacred Heart,
Rome, Italy;
2
Department of Respiratory Physiology, Catholic University of
the Sacred Heart, Rome, Italy.
Chronic obstructive pulmonary disease (COPD) patients could have altered
endocrine function as different endocrine organs (gonads, pituitary, thyroid and
pancreas) can be affected depending on the phenotype of the disease and the
degree of systemic infammation. Anabolic hormones can be involved as COPD
patients can show weight loss and muscle wasting and both these conditions can
modify natural history of the disease. Moreover COPD patients can frequently
have acute exacerbations (AECOPD) which are considered risk factors for a
worse quality life and mortality. The aim of our study is to investigate the
association between anabolic hormones, like insulin-like growth factor 1 (IGF1),
testosterone and its metabolites with prognostic indices of AECOPD.
Twenty inpatients, aged 7514 years, 15 males, hospitalised for acute
exacerbation, were enrolled. The severity of clinical status was evaluated by
acute physiology and chronic health evaluation (APACHE) II score. Hormones
(IGF1, testosterone, diidrotestosterone, estradiol) were assayed by RIA. Steroid
hormone binding globulin was also assayed to determinate free-testosterone
(f-testosterone).
Mean IGF1 levels were normal (8233 pg/ml), whereas both mean testosterone
levels (1.61.7 ng/ml) and mean f-testosterone levels (0.020.01 ng/ml) were
lower than normal values.
Patients with normal IGF1 values showed higher APACHE II then patients with
low values (P0.02). Patients with low testosterone values showed higher
APACHE II then patients with normal values (P0.03) and a linear inverse
relationship was found between APACHE II and f-testosterone. Moreover in the
multiple regression analysis adjusting for age and sex both testosterone and
f-testosterone were directly associated to the ratio PaO
2
/FiO
2
(P0.02).
In conclusion, our data demonstrated that COPD patients with low levels of
testosterone tended to have worse acute exacerbations with low values of PaO
2
.
PI30
Prospective association of low total testosterone levels with adverse lipid
prohle and incident dyslipidemia: results from the study of health in
Pomerania
Robin Haring, Sebastian Baumeister, Henry Volzke, Marcus Dorr,
Stephan Felix, Heyo Kroemer, Matthias Nauck & Henri Wallaschofski
University of Greifswald, Greifswald, Germany.
Context
Previous studies suggest that total testosterone levels infuences lipid metabolism.
It has not been investigated whether these levels are prospectively associated with
an unfavourable lipid profle including increased risk of incident dyslipidemia.
Design and setting
We used data of 1468 men aged 20-79 years, repeatedly examined in the
population-based Study of Health in Pomerania. Serum total testosterone levels,
measured by chemiluminescent enzyme immunoassays, were categorized into
age-specifc quartiles. We used generalized estimating Default (GEE) models to
assess the prospective association of total testosterone with lipid profle including
total cholesterol (TC), low-density lipoprotein cholesterol (LDL), high-density
lipoprotein cholesterol (HDL), and triglyceride (TG) levels, as well as incident
dyslipidemia at fve years follow-up.
Results
Multivariable models revealed that total testosterone levels in the lowest quartile
were associated with higher TC and TG levels in both, cross-sectional (TC:
0.23 mmol/l (95% CI, 0.02-0.42); TG: 0.73 mmol/l (95% CI, 0.53-0.94))
and longitudinal analyses (TC: 0.20 mmol/l (95% CI, 0.03-0.27); TG:
0.62 mmol/l (95% CI, 0.43-0.80)), but not with HDL or LDL levels.
Dyslipidemia was a frequent condition (baseline prevalence: 57.1%) with a
crude incidence rate of 46.6 per 1000 person-years. Total testosterone levels in the
lowest quartile predicted dyslipidemia (age-adjusted odds ratios (OR) as
compared with quartile 4 (highest) were 1.81 (95% CI, 1.13-2.89), 1.24 (95%
CI, 0.82-1.89), 1.12 (95% CI, 0.72-1.72), and 1.00, respectively), particularly
among men aged 20-39 years (OR, 2.82; 95% CI, 1.28-6.20).
Conclusions
Low total testosterone levels are prospectively associated with an unfavorable
lipid profle and increased risk of incident dyslipidemia. This fnding is of
particular interest as it could contribute to an explanation for the higher CVD risk
in men with lower total testosterone levels.
PI31
The relationship between aortic stiffness and left ventricular function
in patients with Cushing`s disease
Nihal Akar Bayram
1
, Reyhan Ersoy
2
, Didem Ozdemir Sen
2
,
Serap Soytac Inancli
2
, Tahir Durmaz
1
, Telat Keles
1
, Engin Bozkurt
1
& Bekir Cakir
2
1
Department of Cardiology, Ankara Ataturk Education and Research
Hospital, Bilkent, Ankara, Turkey;
2
Department of Endocrinology and
Metabolism, Ankara Ataturk Education and Research Hospital, Bilkent,
Ankara, Turkey.
Introduction
Aortic elastic properties and aortic stiffness are important determinants of
increased cardiovascular morbidity and mortality in different diseases. We aimed
to investigate the aortic function and to evaluate the relationship between aortic
stiffness and systolic and diastolic functions of the left ventricle in patients with
Cushing`s disease (CD).
Material and method
Fourteen women and one man with newly diagnosed CD, and 17 control cases
were enrolled in this study. All subjects underwent echocardiography and systolic
and diastolic aortic measurements were noted from M-mode aortic root. Aortic
elastic parameters, aortic strain, and distensibility were calculated. Left ventricle
functions were measured using echocardiography including, two dimensional,
M-mode, conventional Doppler, and tissue Doppler imaging.
Results
Aortic strain (7.41.9 vs 12.32.4%; P,0.001), and aortic distensibility (3.2
1.1 10
6
cm
2
/dyn versus 5.61.4 10
6
cm
2
/dyn; P,0.001) were signi-
fcantly decreased in patient group compared with control group. Mitral E
velocity and the ratio of E/A were signifcantly lower and deceleration time of E
was signifcantly prolonged in patients with CD. We also observed that patients
with CD had markedly lower early diastolic myocardial peak velocity (Em) and
Em/Am ratio and higher Tei index than in control group. Aortic elastic parameters
are deranged in patients with CD and there is a signifcant correlation between left
ventricular parameters determined by tissue Doppler echocardiography and aortic
elastic parameters in these patients.
Conclusion
Patients with CD should be screened with routine physical examination
(including anthropometric measures and blood pressure measurement) and
laboratory tests (including blood chemistry and electrocardiogram) as well as oral
glucose tolerance test, 24 h ambulatory blood pressure monitoring, echocardio-
graphy and carotid artery ultrasonography. In addition to these investigations, we
suggest evaluation of aortic stiffness which is an early marker for atherosclerosis
in patients with CS.
PI32
Inuence of steroid hormones on anthropometric parameters in men
Hana Pospisilova, Michaela Dus`kova, Martin Hill & Luboslav Starka
Introduction
Obese men and women still show their sex-specifc fat accumulation. Not only
does fat distribution differ between the sexes after puberty, but the dynamics of fat
cell size and fat metabolism differ as well. While there is reliable evidence that
pubertal sex steroids induce a sex-specifc fat distribution with preferential
abdominal/visceral fat accumulation in males and preferential gluteofemoral fat
accumulation in females, later in life a number of paradoxes occur in the
relationship between sex steroids and fat distribution. The difference between
aromatizable and non-aromatizable androgens could explain this paradox.
Methods
In our study we will search for the relation between steroid hormones and
antropometric parametres in group of 20 healthy men (mean age 33.5 years, mean
BMI 23.6). In all individuals, we analyzed all steroids in delta 4 and delta 5
metabolic pathways and their polar conjugates, progesterone-reduced metabolites
and their polar conjugates, 5/ reduced C
19
metabolites including polar
conjugates, 7/ hydroxymetabolites of delta 5 steroids, 20 metabolites of C
21
steroids, LH, FSH and SHBG. We measured BMI, waist, hip and waist-hip ratio.
Multivariate regression with reduction of dimensionality, bidirectional ortho-
gonal projection to latent structures, O2PLS was used for statistic comparison.
The local Ethics Committee approved the study, and all patients signed an
informed consent form before taking part in the study.
Results
The hormonal levels and antropomeric data were compared. We found the most
potent correlation between waist and DHEAS, androstanediol sulphate,
isopregnalone sulphate, 5-pregnan-3--20-diol sulphate, androsterone sul-
phate, epiandrosterone sulphate and 5-androstane-3, 17--diol sulphate
(P,0.05), The most confdential correlation we found between these steroids
and hip circumference (P,0.01).
Conclusions
The fnal metabolites of sterods originated from adrenocortical zone could
infuence male type of fat distribution.
The study was supported by grant No. NS 9831-4 and 10215-3 of the IGA MZCR
and GAUK.
PI33
Aldosterone-induced epithelial sodium channel (ENaC) expression and
trafhcking is regulated by protein kinase D1 in M1 renal cortical
collecting duct cells
Ruth Dooley, Brian Harvey & Warren Thomas
Aldosterone stimulates the rapid phosphorylation and activation of PKD1 in a
murine renal cortical collecting duct cell line (M1-CCD), through the
transactivation of the epidermal growth factor receptor (EGFR). PKD1 belongs
to a family of serine/threonine kinases known to be important modulators of
subcellular traffcking. The epithelial sodium channel ENaC is a major effector
of aldosterone action in the kidney and plays a crucial role in the maintenance of
whole body sodium homeostasis. In the distal nephron, the subunit of ENaC is
under transcriptional control of the ligand-bound mineralocorticoid receptor
(MR), while and are constitutively expressed. Using siRNA-mediated
stable knockdown of PKD1 in M1-CCD cells, we examined the role of PKD1 in
the regulation of ENaC activity. Aldosterone treatment (10 nM) resulted
in an increase in the amiloride-sensitive transepithelial current (I
TE
) from
10.21 A/cm
2
to 70.86 A/cm
2
(n8, P, 0.005) in wild-type (WT) cells
within 24 h, an effect which was inhibited in the PKD1-suppressed cells.
Furthermore, using immunocytochemistry and confocal microscopy, we observed
an increase in ENaC expression in WT cells treated with aldosterone for 24 h,
and this response was absent in PKD1 knockdown cells. Aldosterone stimulated
the apical membrane insertion of constitutively expressed ENaC in WT cells,
whereas no effect was observed in PKD1-suppressed cells. In conclusion, PKD1
plays a central role in the aldosterone-mediated regulation of ENaC activity,
through both transcriptional control and subcellular traffcking.
PI34
Muscle hber conduction slowing and decreased levels of circulating
muscle proteins after short-term dexamethasone administration in
healthy subjects
Fabio Lanfranco
1
, Marco Alessandro Minetto
1,2
, Alberto Botter
2
,
Matteo Domenico Baldi
1
, Giovanna Motta
1
, Ezio Ghigo
1
&Emanuela Arvat
1
1
Division of Endocrinology, Diabetology and Metabolism, Department of
Internal Medicine, University of Turin, Turin, Italy;
2
Laboratory for
Engineering of the Neuromuscular System, Department of Electronics,
Politecnico di Torino, Turin, Italy.
Context
Glucocorticoids are known to decrease protein synthesis and impair membrane
excitability of muscle fbres. However, their short-term effects on muscle
structure and function of healthy subjects remain poorly understood.
Objective
To investigate whether steroid administration could decrease the circulating
levels of muscle proteins and modify myoelectric indexes of sarcolemmal
excitability and fatigability.
Design
Single-blind, placebo controlled study in twenty men randomized to receive
dexamethasone (8 mg once daily per os) or placebo for 1 week. Blood sampling,
force measurements for knee extensors and elbow fexors, and electrophysio-
logical tests for biceps brachii, vastus lateralis and medialis, tibialis anterior
muscles were performed before and after the intervention.
Results
Dexamethasone administration improved force by 6.06.0%(P0.01) for elbow
fexors and by 8.55.5% (P,0.01) for knee extensors, decreased levels of
creatine kinase by 50.530.0% (P,0.01) and myoglobin by 41.817.5%
(P,0.01), and impaired sarcolemmal excitability, as shown by the decline of
muscle fber conduction velocity for the four muscles (range from6 to 10.5%,
P,0.05). Moreover, signifcant reductions of the myoelectric manifestations of
fatigue were observed for the four muscles: the decrease in the rate of change of the
mean frequency of the EMG power spectrum ranged from 22.6 to 43.9%
(P,0.05). In contrast, no signifcant changes were observed in muscle excitability
and fatigability in subjects who received the placebo.
Conclusions
The demonstration that glucocorticoid-induced muscle impairments can be
unravelled by means of blood sampling and non-invasive electrophysiological
tests has clinical implications for the early identifcation of subclinical or
preclinical forms of myopathy in treated patients.
PI35
Effect of body mass index on differences of sex hormone levels in
postmenopausal women receiving low-dose hormone therapy
Irene Lambrinoudaki
1
, Eleni Armeni
1
, Demetrios Rizos
2
,
Panagiotis Kofnakos
1
, George Kaparos
2
3
,
Maria Creatsa
1
, Emanuel Logothetis
2
, Dimitra Papadimitriou
1
,
Efstratios Tsakonas
1
2
1
Second Department of Obstetrics and Gynecology, Aretaieio Hospital,
2
Hormonal and Biochemical
Laboratory, Aretaieio Hospital, University of Athens, Athens, Greece;
3
First Department of Surgery, Laiko Hospital, University of Athens,
Athens, Greece.
Objective
To investigate the effect of BMI on the absolute change from baseline levels in
circulating sex hormone in postmenopausal women treated with oral continuous
combined low dose HT for 6 months.
Design
The study recruited 36 postmenopausal women who received daily E2
1 mg/NETA 0.5 mg for 6 months. Hormonal assessment included measures of
serum concentrations of FSH, LH, 17-estradiol and free estrogen index (FEI),
total and free testosterone (FAI), 4-Androstendione, SHBG and DHEA-S before
treatment and after 6 months of treatment. We compared percental changes of
hormone levels from baseline and mean absolute hormone concentrations
between lean and overweight women.
Results
Lean subjects had statistically signifcant higher increments of FEI compared
to overweight (lean women: 0.10.09 at baseline, and 0.30.1 at fnal levels,
181%; overweight women: 0.20.1 at baseline, and 0.40.3 at fnal levels,
87%, P0.034). Mean 17-estradiol increased in both groups at statistical
signifcant levels (lean women: 22.412.0 pg/ml at baseline, and 45.9
20.7 pg/ml at fnal levels, 105%, P0.006; overweight women: 22.4
8.7 pg/ml at baseline 58.423.4 pg/ml at fnal levels, 161%, P0.0001;
P(%) between groups0.619). Mean levels of FSH decreased signifcantly
in both groups (lean women: 45%, P0.0001; overweight women:
-39%, P0.003; P(%) between groups0.661).
Conclusions
Concentrations of free estrogens increase more sharply in lean women being
under treatment with oral low-dose HT. BMI did not infuence the changes of total
17-estradiol levels from baseline. This fnding might in part explain the
vulnerability of lean women under HT to develop breast cancer.
PI3
Measurement of testosterone in muscle tissue using microdialysis:
preliminary data
Vincent Wester
1
, Hong Bui
2
, Annemieke Heijboer
2
, Rien Blankenstein
2
& Willem de Ronde
1
1
Department of Endocrinology, VU University Medical Center, Amsterdam,
North Holland, The Netherlands;
2
Department of Clinical Chemistry, VU
University Medical Center, Amsterdam, North Holland, The Netherlands.
Introduction
For diagnostic purposes, total-testosterone levels are generally assessed in
plasma. However, as the primary site of action of testosterone is in tissue,
evaluation of the distribution of testosterone in tissue fuids could give enhanced
insight into the (patho)physiological state. Clinical microdialysis allows for
sampling at tissue level based on diffusion.
Objective
To compare the increase in testosterone levels in tissue and plasma after
cutaneous administration of testosterone.
Methods
A CMA20 microdialysis probe was continuously perfused with Ringer`s lactate
containing 0.6 nmol/l D5-testosterone as internal reference. A sample interval of
15 min was used, with a perfusion rate of 10 ml/min. Microdialysis was
performed on the vastus lateralis muscle in two healthy male volunteers for 4 h,
preceded by a 1h run in period. Additionally, blood specimens were drawn in each
interval. After one hour, 100 mg testosterone gel was applied to the skin of the
back in an attempt to vary plasma and tissue testosterone levels. Testosterone was
analyzed using a highly sensitive assay involving derivatization and
ID-LC-MS/MS.
Results
Testosterone profles in the collected microdialysis and plasma samples from both
volunteers were comparable. Testosterone levels increased after cutaneous
administration, in both microdialys fuid (70%) and plasma (60%).
Conclusion
The initial results of clinical microdialysis are promising. Low testosterone levels
as well as increased concentrations after supplementation could be reliably
detected. Further research is necessary to thoroughly evaluate the microdialysis
procedure. Hopefully, in vivo experiments in the near future will enrich our
knowledge about testosterone at the tissue level.
PI3I
Expression and biological function of sex steroid receptors in male
human bladder
Linda Vignozzi
1
, Aravinda K Chavalmane
1
, Paolo Comeglio
1
,
Annamaria Morelli
1
, Sandra Filippi
1
, Benedetta Fibbi
1
,
Gabriella B Vannelli
3
& Mario Maggi
1
1
Sexual Medicine and Andrology Unit, Department of Clincal
Physiopathology, University of Florence, Florence, Italy;
2
Interdept Lab of
Functional and Cellular Pharmacology of Reproduction, Departments of
Pharmacology and Clinical Physiopathology, University of Florence,
Florence, Italy;
3
Department of Anatomy, Histology and Forensic Medicine,
University of Florence, Florence, Italy.
In male, lower urinary tract symptoms (LUTS) have been associated, beside benign
prostatic hyperplasia, to some unexpected co-morbidities, such as hypogonadism,
obesity and metabolic syndrome, which are essentially characterized by an
unbalance between circulating androgens and estrogens. Within the bladder, LUTS
have been linked to overactivity of the RhoA/ROCKpathway. Here we investigate
the effects of changing sex steroids on bladder smooth muscle. The effects of
androgens and classical (ER, ER) and non-classical (GPR30/GPER1) estrogen
receptor ligands (17-estradiol and G1, respectively) on RhoA/ROCK- mediated
cell functions were studied in human bladder smooth muscle (hB) cells.
Contractility studies were also performed in bladder strips from castrated male
rats supplemented with testosterone or estradiol. Aromatase and sex steroid
receptors, including GPR30, were expressed in human bladder tissue and hB cells
and mediates several biological functions. In particular, both 17-estradiol and G1
activated calcium transients and induced RhoA/ROCK signaling (cell migration,
cytoskeleton remodeling and smooth muscle gene expression). RhoA/ROCK
inhibitors blunted these effects. In isolated bladder strips, estrogen-, but not
androgen-, supplementation to castrated male rats increased sensitivity to the
specifc ROCK inhibitor, Y27632. In hB cells, testosterone elicited effects similar
to estrogen, which were abrogated by blocking its aromatisation through letrozole.
In conclusion, our data indicate for the frst time that estrogen- more than androgen-
receptors up-regulate RhoA/ROCK signaling. Since an altered estrogen/androgen
ratio characterizes conditions, such as aging, obesity and metabolic syndrome,
often associated to LUTS, we speculate that a relative hyperestrogenism may
induce bladder overactivity through the up regulation of RhoA/ROCK pathway.
PI38
Androgenicity is enhanced in the presence of ala222val polymorphism
in healthy postmenopausal women
Dimitra Papadimitriou
1
, George Kaparos
2
, Dimitrios Rizos
2
, Eleni Armeni
1
,
Maria Kreatsa
1
3
1
& Irene Lambrinoudaki
1
1
Second Department of Obstetrics and Gynecology, Aretaieio Hospital,
2
Hormonal and Biochemical
Laboratory, Aretaieio Hospital, University of Athens, Athens, Greece,
3
First Department of Surgery, Medical School, Laiko Hospital, University of
Athens, Athens, Greece.
Objective
To assess the interrelation of the MTHFR ala222val polymorphism, correlated
with increased rates of cardiovascular disease, with indices of androgenicity in
healthy postmenopausal women.
Methods
The population of this cross-sectional study consisted of 84 healthy women who
had been menopausal for at least one year. The examined polymorphism was
Methylenetetrahydrofolate reductase ala222val, while the hormonal assays
included Testosterone, Sex Hormone Binding Globulin (SHBG), Dehydroepian-
drosterone sulphate (DHEAS), -4-androstendione (4A), free androgen index
(FAI) and the aminoacid homocysteine (Hcy). Written informed consent was
obtained by all participants. The local Institutional Review Board has approved
the present study.
Results
MTHFR ala222val polymorphism was positively associated with serum
testosterone, DHEAS, 4A and FAI (P0.001, P0.053, P0.054,
P0.0004 respectively) and negatively with SHBG (P0.047). No signifcant
association was found between MTHFR ala222val polymorphism and homo-
cysteine levels.
Conclusions
The presence of MTHFR ala222val polymorphism was associated with indices of
androgenicity in healthy postmenopausal women, but it was not associated with
hyperhomocysteinemia at a statistically signifcant level. Insulin resistance,
which has been correlated with increased androgenicity, may act as a mediator.
MTHFR ala222val polymorphism and the following impaired homocysteine
catabolism induce, at a cellular level, endothelial dysfunction along with insulin
resistance. This metabolic manifestation associates with increased androgenicity.
PI39
Synthesis of 1,25-dihydroxyvitamin D in human bladder epithelial cells
and vitamin D mediated cathelicidin induction
Jeanette Bennett
1
, Daniel Zehnder
1,2
, Kieran Jefferson
2
& Rosemary Bland
1
1
The University of Warwick, Coventry, UK;
2
University Hospital Coventry
and Warwickshire, Coventry, UK.
It is now recognized that vitamin D infuences the innate immune system and
recent studies have highlighted the importance of local synthesis of
1,25-dihydroxyvitamin D (1,25D) for these responses. Production of 1,25D from
25-hydroxvitamin D (25D) is catalyzed by 25-hydroxyvitamin D 1-
hydroxylase (CYP27B1; 1-OHase). Vitamin D is metabolized by 24-hydroxyl-
ase (CYP24A1; 24-OHase). A key part of the innate immune response is
pathogen recognition by the toll-like receptors (TLR) and an important immune
target gene is cathelicidin (LL37), a vitamin D responsive antimicrobial peptide.
This study examined the expression of vitamin D and TLR signaling
components, the synthesis of 1,25D and the induction of cathelicidin by vitamin
D in bladder epithelial cells. Studies used human bladder epithelial (urothelium)
cell lines (T24/83 and RT4) derived from transitional cell carcinomas. Both cell
lines expressed the VDR and 1-OHase mRNA (RT-PCR) and protein (Western
blot analysis). In addition, the cells expressed RXR, and and megalin
mRNA. 24-OHase mRNA, which was almost undetectable in unstimulated cells,
was signifcantly increased by 1,25D (10 nM; 3-24 h; P,0.05). 24-OHase
activity was confrmed. 24-OHase mRNA was also signifcantly increased by
25D (100 nM; 6-24 h; P,0.05) indicating epithelial 1-OHase activity.
Synthesis of 1,25D was confrmed by ELISA. Bladder cells produced 1,25D
at levels similar to HKC-8 cells (a human kidney cell line) and synthesis was
attenuated following pre-treatment with ketoconazole (2 h, 10 M). Both cell
types expressed TLR 1, 2 & 4 mRNA and the TLR partners MyD88 and CD14.
Cathelicindin mRNA was undetectable in both cell lines, but was induced by
1,25D in RT4 cells (10 nM; 6-24 h; P,0.05). It was also increased by 25D
(100 nM; 6 h; P,0.05). These data demonstrate that bladder epithelial cells
express functional vitamin D signaling and are able to synthesize suffcient
1,25D to stimulate a local immune response.
PI40
Simultaneous steroid measurement by isotopic dilution-liquid
chromatography-tandem mass spectrometry (ID-LC-MS/MS):
comparison with routine analysis methods and reference intervals in
normal subjects
Flaminia Fanelli, Ilaria Belluomo, Valentina Diana Di Lallo, Gaia Cuomo,
Margherita Baccini, Valentina Vicennati, Alessandra Gambineri,
Renato Pasquali & Uberto Pagotto
S. Orsola Policlinic, Bologna, Italy.
The development of a reliable and rapid method to simultaneously measure serum
steroids represents a compelling challenge for modern endocrinology. Immu-
noassays are very sensitive methods, being widely employed in automated routine
laboratories, lacking, however, in specifcity due to cross-reactivity and matrix
interference. Gas chromatography-mass spectrometry (GC-MS) constitutes the
reference method for quantitative analysis of steroids, but time-consuming
sample pre-treatment prevents its wide application. We developed and validated
an ID-LC-MS/MS method for simultaneous measurement of 8 serum steroids and
compared it to currently employed immunoassays. After protein precipitation of
0.9 ml serum, SPE eluate was injected into a 2D-chromatographic system,
purifed in perfusion column and separated on a C8 column during 21 minutes
gradient run. Each analyte undergoes atmospheric pressure chemical ionization
before spectrometric revelation of two transitions, quantitative and qualitative, in
multiple reaction monitoring mode by 4000Q-Trap triple quadrupole (Applied-
Biosystems), ensuring high specifcity. Accuracy was validated against GC-MS
certifed European sera. A comparison study, conducted on 200 samples, showed
substantial agreement between ID-LC-MS/MS and Elecsys-E170 for measure-
ment of cortisol, progesterone above 1 ng/ml and testosterone in males.
Overestimation by a factor 2 for androstenedione and 3 for DHEA was shown
by Immulite2000 and DSL9000, respectively, while disagreement was obtained
between ID-LC-MS/MS and 17OHP-Bridge for 17OH-progesterone, and
Elecsys-E170 for testosterone in females and progesterone below 1 ng/ml.
Preliminary reference intervals were obtained for cortisol, corticosterone,
11desoxycortisol, androstenedione, testosterone, 17OH-progesterone, DHEA
and progesterone in 134 male and 79 female healthy subjects. Participants had
given informed consent and the study was approved by local ethics committee.
Central 95th percentile was estimated for 18-69 y.o. male group, for 18-55 y.o.
fertile females and for 41-70 y.o. females in menopause. In conclusion, our data
highlighted the power of ID-LC-MS/MS in providing a simultaneous and reliable
steroid profle and in documenting the limits shown by the routine methods
runtime of 21 min/session.
PI41
Sex specihc association between estrogen receptor alpha PvuII and
XbaI gene polymorphisms and hormones
Susana Vladoiu
1
, Olga Ianas
1
, Dana Manda
1
, Lorand Savu
2
, Oana Popa
1
& Roxana Rosca
1
1
2
Genetic Lab SRL, Bucharest, Romania;
3
Carol Davila University of
Medicine and Farmacy, Bucharest, Romania.
Objective
To explore if the polymorphisms of the estrogen receptor alpha gene, XbaI (IVS1-
351 A/G) and PvuII (IVS1-397 T/C) are associated with age-dependent changes
in hormone levels for a better understanding of the biological actions of estrogens.
Subjects, both genders aged between 20 and 80 years were classifed into two
groups: reproductive age (1) and over 55 years (2). The study received the Ethical
Committee approval. Morning levels of serum prolactin, estradiol, estrone,
17-OHP, DHEA, DHEAS, androstendion, progesterone, testosterone, free
testosterone, DHT, SHBG, inhibin A and inhibin B, LH, FSH, TSH, GH, IGF1,
insulin, cortisol, thyroid hormones, total and freePSA were measured. PvuII and
XbaI polymorphisms were analyzed by PCR-RFLP.
Results
The percentages of both AA and CC genotypes signifcantly decreased and AG
and TC genotypes increased with age. The analysis of the relationship between
gene polymorphisms and circulating hormones showed signifcant difference in
prolactin levels among genotypes only in women group. In women group of
reproductive age, the polymorphisms associated with Prl (
2
6.1/6.9), cortisol
(
2
6.6/8.78) and inhibin B (
2
6.2); the Prl and cortisol levels were higher
and inhibin B levels were lower in AG/TC genotypes; in men group, bioavailable
estradiol levels were lower in AG/TC genotypes. In group over 55 yrs, (women)
FSH and testosterone levels were higher and osteocalcin levels were lower in both
GG and TC genotypes; in man group, PSAt and PSAf levels were higher in GG
and TC genotypes.
Conclusion
In women group, variants in the ESR1 gene (AG/TC) were associated with high
prolactin levels. Further researches are necessary to explain the sex specifc
association between these polymorphisms and the hormone levels that are related
to estrogen actions.
Supported by PNII no.41-014/2007, Ministry of Education and Research.
PI42
Tissue expression of the CYP19A1 gene and aromatase protein in male
cynomolgus monkeys (Macaca fasc/ca/ar/s)
Elisa Pignatti
1
, Asmaa Lachhab
1
, Livio Casarini
1
, Joachim Wistuba
2
,
Stefan Schlatt
2
, Cesare Carani
1
& Manuela Simoni
1
1
Integrated Department of Medicine, Endocrinology, Metabolism and
Geriatry, University of Modena and Reggio Emilia, Modena, Italy;
2
Institute
of Reproductive and Regenerative Biology of the Centre of Reproductive
Medicine and Andrology, University of Munster, Munster, German.
Objective
Aromatase, the key enzyme involved in estrogen synthesis, is expressed in a
variety of cells, including peripheral blood leukocytes (PBLs), and tissues. The
systematic study of aromatase expression and activity in different tissues in the
human and other primates, however, is diffcult and still missing. Although is not
really known, aromatase expression in PBLs could be used as parameter of
aromatase expression/activity making PBLs a potential alternative for other
tissues. The aim of this study was to characterize the expression of the CYP19A1
gene in several tissues of male cynomolgus monkeys and to compare the
expression levels with those in PBLs.
Design
CYP19A1 RNA and protein were measured in PBLs, skin fbroblasts, mammary
gland, testis, muscle, liver, epididymis and hypothalamus obtained from six
hemicastrated male animals aged between 24 and 26 years.
Methods and results
Aromatase RNA measured by real-time PCR was very variable within the
individual tissues and was the highest in mammary gland and hypothalamus,
(signifcant vs. PBLs, not vs. other tissues). Conversely, aromatase protein
expression by Western Blotting was relatively uniform between animals, with the
highest levels in testis and epididymis (signifcant vs. PBLs). However, no
signifcant correlation between the levels of transcripts and the relative quantity of
protein was seen.
Conclusions
Macaca fascicularis CYP19A1 RNA and protein are expressed in all cells and
tissues analysed. Lowest aromatase expression levels were seen in PBLs with no
correlation with other tissues. We conclude that aromatase expression in PBLs
cannot be used as parameter of aromatase expression/activity for other tissues. It
is postulated that in these blood cells aromatase produces estrogens with paracrine
activity on development and maintenance of the immune system.
PI43
Levels of 7-hydroxy DHEA derivates during menstrual cycle
Hana Hruskovicova, Michaela Duskova, Katerina Simunkova, Martin Hill,
Karel Vondra & Luboslav Starka
Introduction
7-hydroxyl DHEA derivatives are labelled as natural anti-glucocorticoid and
neuroprotective substances. Their impact on the production of cytokines, their
activation of apoptosis, infuence on the migration of macrophages to peripheral
tissue, their possible effect on angiogenesis, effect on infammatory mediators
(arachidonic acid metabolites) and their role in the mechanism of oxidative stress
have been described.
Methods
In our study we will search changing in these steroid hormones during menstrual
cycle in group of 20 healthy women, (age 20-40 years, non-smokers, without
hormonal contraception or other medication). In all individuals, we analyzed
DHEA, DHEAS, 7-hydroxyl DHEA derivates and their polar conjugates, LH,
FSH and SHBG in follicular and luteal phase. Repeated measures ANOVA
followed by least signifcant difference, multiple comparison was used for statistic
comparison. The local Ethics Committee approved the study, and all patients
signed an informed consent form before taking part in the study.
Results
We found a decrease of 7-hydroxyl DHEA derivatives in healthy women in the
luteal phase compared to the follicular phase.
Conclusion
This physiological decrease of natural anti-glucocorticoid could play the role
during ovulation and embryogenesis. But also they might be one of the cause of
different reaction on some pathologies in women during the menstrual cycle.
The study was supported by grant No.NS 9831-4 and 10215-3 of the IGA MZCR
and GAUK.
PI44
Sex steroid status in relation to birth weight and body composition in
young healthy men
Greet Roef, Griet Vanbillemont, Bruno Lapauw, Youri Taes & Jean
Marc Kaufman
Department Endocrinology, Ghent University Hospital, Ghent, Belgium.
Sex steroid concentrations have a strong genetic determination, but environ-
mental factors and body composition play an important role. Intrauterine growth
restriction, evidenced by low birth weight has been associated with altered
gonadotropin metabolism. If this relationship is also present across the wide range
of birth weight is unkown. Serum sex steroid concentrations were investigated in
healthy young brothers in relation to birth weight, body composition and parental
steroid concentrations. A total of 677 men (25-45 years) were included in this
study with 296 independent pairs of brothers and 122 fathers.
Birth weight was associated with serum testosterone (: 0.0450.012;
P0.0004) and sex hormone binding globulin (SHBG, :0.00010.00003;
P0.0001), independent from weight, age or fat mass., whereas no association
with (free) estradiol, LH or FSH was found. Paternal testosterone (P0.02),
estradiol (P0.04) and SHBG (P0.0004) were associated with the respective
sex steroid concentrations in the brothers. Weight increase (population rank)
during life, was associated with lower testosterone (15%; P,0.001),
independent from current weight and with higher free estradiol concentrations
(8%; P0.002), whereas weight decrease was associated with higher
testosterone (13%; P,0.001).
Birth weight and parental steroid concentrations are associated with testosterone
concentrations, independent from current weight, fat mass or changes in weight,
extending the concept of in utero programming across the range of birth weight.
Thyroid
PI45
Effectiveness of consevator treatment (antithyroidiennes and thyroxine)
on the autonomous nodule, toxic adenoma, and Plummer`s disease
(multinodular hyperthyroideous Goiter)
Jose Suarez-Lledo
Hospital de Leon, (Ambulatorio Condesa) Sacyl, Leon, Spain.
Objective
The goal of this paper is to investigate the effectiveness of antithyroidiennes,
associated or not, with the thyroid hormone.
Patients and their clinical histories were examined when each ambulatory patient
was personally visited, for one year, by the author. 156 cases were examined
(16 males and 140 females). The diagnoses were based on anamnesis, clinical
exploration, TSH thyroid hormone and bioquim determinations and
gammagraphie. Evolution was controlled by palpation, thorax radiographies
and, occasionally, ultrasonography.
Evolution was considered good when compensation was achieved without goiter
or antithyroidien dosis increase, very good when the thyroid volume decreased,
excellent if the dosis and volume decreased, and bad when the volume and/or
dosis increased progressively.
Results
Autonomous Nodule, Toxic Adenoma. (61 patients, nine males, 52 females, mean
treatment time 9.12 years S.D. 5.28, mean of age at diagnosis 60, SD 12.374) 6
were treated initially by I
131
, 2 by surgery and the rest by the procedures, and with
the results told below:
Among treated euthyroidiennes patients three had good evolution, four very good,
and eight excellent, none bad, among non-treated euthiroidiennes four had good
evolution, four very good, none bad and none excellent, among hyoerthyr-
oidiennes four patients had good evolution, very good nine and excellent 17, none
bad evolution.
Total effectiveness, 100% in both cases. The treated group had the best results
among euthyroidien patients, due to 'excellent degree` (P,0.05).
Plummer`s disease: (95 patients seven males and 88 females, mean treatment time
8.18 years S.D. 8.64. mean of age at diagnosis 58.26, S.D 22.58) 2 were treated
initially by I
131
and 3 by surgery, the rest by the procedures, and with the results
told below:
Among euthyroidiennes treated patients 3 had good evolution, very good 4, and
excellent 6, among non-treated euthyroidiennes 2 had bad evolution, and 2 very
good, among hyperthyroidiennes 5 had bad evolution, 17 good evolution, 4 very
good and 46 excellent.
Total effectiveness in the treated euthyroidienne group was 100%, in the non-
treated, 50% and in hyperthyroidiennes, 92.4%. The treated group had the best
results (P,0.05) among the euthyroidien patients.
Conclusion
The better effectiveness in the treated groups with respect to the non-treated
groups must be put down to drug effect. The high degree of conservator treatment
effectiveness makes this type of treatment absolutely reliable, constituting a very
good option without the problems of surgical or I
131
procedures.
PI4
Pheochromocytoma, papillary thyroid carcinoma: new entity
Tariq Nasser & Faiza Qari
Al Jawhera Center, Jeddah, Saudi Arabia.
A 53 year-old woman presented with labile and diffcult to control hypertension
on three deferent anti hypertensive medications. Abdominal computed
tomography (CT) and Ultrasonography of the thyroid gland showed 1.8 cm
thyroid nodule. Fine needle aspiration biopsy of the thyroid nodule revealed
papillary thyroid carcinoma. Serum TSH & FT
4
, calcitonin, CEA, intact PTH and
calcium levels were within normal limits. A 24-h urine metanephrines showed
signifcant elevation in urine metanephrine of approximately three times the upper
limit of normal and the result of 131I-metaiodobenzyleguanjdjne (131I-MIBG)
scintgraphy confrmed that the adrenal mass was pheochromocytoma. Right
adrenalectomy and total thyroidectomy were performed. The fnal pathology was
pheochromocytoma and papillary thyroid carcinoma. An analysis of RET porto-
oncogene mutation yielded negative result. Should this unusual association of
tumors represent a new entity.
PI4I
Outcome of pregnancy complicated by thyroid dysfunction in Iran
Morteza Taghavi, Nafseh Saghaf & Shirin Saber
Mashhad University, Mashhad, Islamic Republic of Iran.
Objective
Maternal thyroid hormone excess or defciency has been associated with adverse
health outcomes for both the mother and child. This study performed to study the
prevalence of thyroid disorders and its effect on pregnancy outcome in pregnant
women.
Methods
Five hundred pregnant women in frst trimester of pregnancy were enrolled in the
study. Serum Thyrotropin (TSH), Free T
4
(FT
4
), and Free T
3
(FT
3
) were measured
by high-sensitive radioimmunoassay. Overt hyperthyroidism was diagnosed
when both TSH was suppressed and FT
4
or FT
3
was elevated. Subclinical
hyperthyroidism was diagnosed when TSH was suppressed with normal FT
4
and
FT
3
. The diagnostic criteria for overt hypothyroidism was TSH 4 mU/l
accompanied by decreased FT
4
, and for subclinical hypothyroidism was TSH
4 mU/l with normal FT
4
level.
Those with thyroid disorders referred to an Endocrinologist for medical treatment
and all subjects were followed until delivery.
Results
Hypothyroidism found in 49 (9.8%) women (subclinical hypothyroidism: 7.4%,
overt hypothyroidism: 2.4%). Overt hyperthyroidism found in 3 (0.6%) women.
Subclinical hyperthyroidism occurred in 21 (4.2%) women and considered as
physiologic changes of pregnany. Nighteen women (3.8%) had preterm labor.
Out of 25 (5%) women developed pre-eclampsia. There was no signifcant
difference in the incidence of preterm labor and pre-eclampsia in pregnant women
with and without thyroid dysfunction.498 women delivered normal neonates and
2 (0.4%) mother delivered fetus with anomaly, but these mothers were euthyroid.
Conclusions
Thyroid dysfunction is common in pregnant women. The prevalence
complications were not greater in patients with thyroid dysfunction.
PI48
Detection of BRAF gene mutation in preoperative diagnostic of thyroid
gland cancer
Semyonov Dmitriy, Zarayskiy Mikhail, Boriskova Marina, Saburova Irina
& Farafonova Ulyana
Pavlov State Medical University, St Petersburg, Russian Federation.
Purpose
To assess the utility of BRAFV600E mutation detection in preoperative thyroid
cancer diagnostic.
We studied 46 aspirates taken by FNAfrompatients with thyroid gland nodes. Thyroid
tissue aspirates DNA was extracted by sorbent method. BRAF gene mutation was
analyzed with primers specifc for wild and mutant gen type by RT-PCR.
Results
All patients were divided into three groups by cytological conclusions: colloid nodules
(9), PTC(19), and suspicious for malignancy (18). In the group of patients with PTCall
diagnoses were confrmed by histology, and BRAF gene mutation was detected in 15
(79%) FNAB specimens. In the group with suspicious cytological diagnosis only one
patient had follicular cancer by histology and positive BRAF mutation. There were
detected no BRAF mutation in 16 patients with histologically proven follicular
adenoma, in nine patients with colloid nodular goiter and in one patient with follicular
cancer. Thereby, we received the following criteria valuers of method`s reliability:
sensitivity - 76%, specifcity - 100%, diagnostic accuracy - 89%.
Conclusions
Detection of the BRAFV600E mutation may be a useful adjunct marker for
preoperative diagnostic of thyroid gland cancer.
PI49
Evaluation of diagnostic utility of Galectin-3 protein detection in
preoperative diagnostic of high-differentiated thyroid gland cancer by
ow cytometry method
Semyonov Dmitriy, Koloskova Ludmila, Boriskova Marina,
Feshenko Natalia & Farafonov Ulyana
Pavlove State Medical University, St Petersburg, Russian Federation.
There were evaluated galectin-3 expression in 66 fne-needle aspiration biopsy
(FNAB) specimens from patients with thyroid gland nodules by fow cytometry
method. We include in our study 29 patients with papillary thyroid cancer (PTC),
31 - with follicular neoplasia, 6 - with nodular colloid goiter by cytological
examination. For specimens analysis, taken by FNAB of thyroid gland nodules,
were used indirect immunofuorence method /Coons/.
Results
Among 29 patients with preoperative PTC diagnosis, Gal-3 expression were
observed in 27 specimens and in 25 (92.6%) patients high differentiated thyroid
gland cancer were confrmed by histological study; in two cases (7.4%) were
diagnosed benign thyroid gland diseases. In two cases (6.9%), when gal-3
expression was not observed, on histological study was confrmed PTC. In group
of patients with follicular neoplasia cytological diagnose gal-3 expression was
observed in two cases of high differentiated thyroid gland cancer (PTC and
follicular thyroid cancer) and in two cases of follicular and oncocytic adenoma.
There was detected no Gal-3 expression in the rest of 27 patients with benign
thyroid gland diseases. In the six patients with nodular colloid goiter gal-3
expression was not detected (100%). Thereby, in our study sensitivity of
immunocytochemical method of Galectin-3 detection in thyroid gland nodules
aspirates was 93.1%, specifcity was 89.2%, and diagnostic accuracy 90.9%.
Conclusion
Immunocytochemical detection of Galectin-3 protein expression by fow
cytometry method could be useful adjunctive marker in preoperative diagnostic
of thyroid gland cancer.
PI50
Promoter methylation of gelsolin gene in thyroid cancer
Sangjin Kim, Mio Rho, Changhee Chung, Yeojoo Kim, Chulhee Kim,
Dongwon Byun, Kyoil Seo & Myunghee Yoo
College of Medicine, Soonchunhyang University, Cheonan, Republic of
Korea.
Gelsolin is an actin-binding protein involved in dynamic changes of the actin
cytoskeleton. This protein regulates the length of actin flaments by binding,
severing, and capping the fast-growing flament ends and promotes actin
nucleation. Gelsolin is widely expressed in normal tissues. Decreased gelsolin
expression occurs in many transformed cell types and in carcinomas of the colon,
bladder, breast, lung, stomach and prostate. Transcriptional silencing of tumor
suppressor genes by aberrant methylation of CpG islands plays a crucial role in
the development of various cancers. Noske et al. showed inactivation of gelsolin
might be mediated by epigenetic modifcation. But there is no information about
the relationship between the gelsolin gene and thyroid cancer.
We investigated DNA methylation in thyroid cancer cell lines and tissues from
papillary thyroid cancer.
We performed RT-polymerases chain reaction (RT-PCR) with methylation
inhibitor 5-aza-2
-deoxycytidine (DAC) treatment and histone deacetylase

inhibitor trichostatin (TSA) in 3 thyroid cancer cell lines, and combined bisulfte
restriction analysis (COBRA) in 10 thyroid cancer cell lines and thyroid tissues
from 12 papillary thyroid cancers.
Almost all thyroid cancer cell lines showed promoter hypermethylation of
gelsolin. Gelsolin was not methylated in all of 12 papillary thyroid cancer tissue
specimens. DAC and TSA treatment did not increase the expression of gelsolin
mRNA in thyroid cancer cell lines. These results suggest that DNA methylation of
gelsolin do not contribute to thyroid tumor development, especially in papillary
thyroid carcinoma.
PI51
Role of hypothyroidism in predicting a worse prognosis of heart failure
outpatients treated with amiodarone
Vincenzo Triggiani
1
, Massimo Iacoviello
2
, Edoardo Guastamacchia
1
,
Pietro Guida
2
, Cinzia Forleo
2
, Agata Puzzovivo
2
, Emilio Tafaro
1
& Stefano Favale
2
1
Institute of Endocrinology, University of Bari, Bari, Italy;
2
Institute of
Cardiology, University of Bari, Bari, Italy.
Amiodarone, an iodine-containing antiarrhythmic drug frequently used in chronic
heart failure (CHF) patients, is often the cause of primary hypothyroidism. It has
not been well investigated, however, whether its use could lead to a poor
prognosis in these patients by inducing and/or worsening thyroid function. The
aim of this study was to evaluate the prognostic signifcance of hypothyroidism
detection in CHF outpatients treated with amiodarone. Out of 355 patients
affected by CHF, 107 (6510 years, 89 male, NYHA 2.50.5, left ventricular
ejection fraction, LVEF298%) in stable clinical condition, treated with
amiodarone and conventional therapy (93% ACE-inhibitors and/or ARBs, 90%
betablockers, 93% diuretics) were enrolled. Mean arterial pressure (MAP),
NYHA class, LVEF, calculated glomerular fltration rate (GFR), Na
,
Haemoglobin, NT-proBNP, fT
3
, fT
4
and TSH were evaluated. Patients with
hyperthyroidism were excluded.
Results
During follow-up (2410 months) 39 patients showed heart failure progression
(26 were hospitalized, 4 underwent cardiac transplantation and 9 died after
worsening of heart failure). Hypothyroidism (TSH 5.5 U/ml) was observed in
20 (19%) patients, only in one with a concomitant reduction of fT
3
. The presence
of hypothyroidism was associated to events at univariate (HR: 2.6, P: 0.006) as
well as at multivariate Cox regression analysis (HR: 2.3, P: 0.035) after correcting
for age, MAP, NYHA class, LVEF, GFR, Na
, Haemoglobin and NT-proBNP.

Figure shows Kaplan-Meier curves for events in patients with and without
hypothyroidism. In conclusion, our results suggest that in CHF patients with
amiodarone therapy the detection of hypothyroidism, even the suclinical form,
should be considered a marker of risk of heart failure progression. Further studies
should also clarify the optimal therapeutical strategy in these patients: substitutive
hormonal therapy and/or amiodarone withdrawal.
PI52
Results from an observational study on general practitioners` and
endocrinologists` medical practice for the management of simple goiter
in France
Caron Philippe
1,2
& Landron Frederic
1,2
1
Service dÈndocrinologie, Maladies Metaboliques et Nutrition, CHU
Larrey, 31059 Toulouse, France;
2
Merck Serono, 69495 Lyon, France.
The primary objective of this observational study was to determine the medical
practice for the management of simple goiter in France from a representative
sample of general practitioners (GPs) and endocrinologists (ENDOs). As
secondary objective, this study reported the incidence rate of simple goiter,
toxic and non-toxic nodular goiters in France.
Four hundred and sixty-nine general practitioners and 195 endocrinologists
participated in the study. Eighty percent of GPs were men and 70% of ENDOs
were women. For both groups of physicians (GPs versus ENDOs), the
circumstances of diagnosis of simple goiter in adults were: clinical examination
(39.4 vs 20.6%), physical signs (20.6 vs 12.1%) and functional signs (13.8 vs
7.3%).
The clinical history almost systematically showed a family or autoimmune
disease history (86.1 vs 100%), a smoking habit (69.2 vs 78.5%) and a treatment
with amiodarone (70.9 vs 76.4%). However, the iodine intake or eating habits
were less often asked (24.2 vs 15.4%). A treatment with lithium (31.6 vs 63.1%)
and the notion of previous injection of iodine-containing contrast media (39.1 vs
62.6%) was more often asked by ENDOs than by GPs.
The clinical examination systematically included the palpation of the lower
cervical region which determined the goiter consistence and the presence of
nodules in more than 90% cases. However, the neck size and goiter size were
more seldom measured.
Among the additional investigations (TSH, free T
4
, Ac anti TPO, ultrasono-
graphy, scintigraphy), TSH levels were systematically assayed, an ultrasono-
graphy was requested by more than 97% of physicians, and 77.4% of GPs
performed a scintigraphy versus 46.9% of endocrinologists.
Regarding their clinical practice, 28.6% of GPs systematically refer their patients
with simple goiter to endocrinologists, and the latter see 53% of the patients
referred to by GPs, occupational physicians or PMI (Mother and Child Protection
centers) and gynecologists. 74.1% of GPs and 96.9% of ENDOs initiated a
treatment. When a medical treatment was prescribed, it was levothyroxine (89 vs
92%). The objective of TSH levels was of 2 mIU/l for GPs and 1 mIU/l for
ENDOs. Finally, 67.2% of GPs and 56.7% of endocrinologists may ask their
patients to undergo surgery.
The incidence rate of simple goiter was 0.45% for GPs and 3.10% for ENDOs. It
especially concerned women, 80.5% for GPs including 6% of pregnant or
lactating women and 75.3% for endocrinologists including 16.8% of pregnant or
lactating women. Non-toxic nodular goiter reached an incidence rate of 9% for
endocrinologists.
In conclusion, the study confrms the role of endocrinologists as referent
physicians for the management of simple goiter in France, and especially for
pregnant women and teenagers.
PI53
The effect of urine iodine excretion in patients with euthyroid noduler
disease: a randomised, controlled study
Evrim C akir
1
, Yusuf Aydin
2
, Erdal Eskioglu
3
, Selma Karaahmetoglu
O
zkan
3
& Serdar Guler
2
1
Diskapi Yildirim Beyazit Trainig and Research Hospital Endocrinology
and Metabolism Department, Ankara, Turkey;
2
Numune Training and
Research Hospital Endocrinology and Metabolism Department, Ankara,
Turkey;
3
Numune Training and Research Hospital Internal Medicine,
Ankara, Turkey.
Introduction
Different nutritional and environmental factors are responsible for pathogenesis
of goiter but iodine defciency is the most important factor. However, little is
known about the natural course of benign thyroid nodules in euthyroid patients
over time. Few studies have used ultrasonographic evaluation to address this
issue, especially in iodine-defcient areas. In this study, we present the long-term
follow-up of benign thyroid nodules in a moderately iodine-defcient area.
This study included 62 randomly selected patients with benign euthyroid nodular
goiter and thyroid volume and nodularity were measured with ultrasonography.
Iodine intake was estimated by patient diet history and by measuring iodine
excretion in spot urine samples. Patients were followed 1 year.
Results
Patients were divided into 3 groups according to level of urine iodine excretion:
i) Lower than 50 g/l (severe iodine defciency group), ii) 50-100 g/l, iii) Higher
100 g/l. Additional disease existency and percentage of smoking were statistical
signifcantly high in frst group compared to second and third group. Between
groups no signifcant difference observed in both right and left thyroid lobe
volume. Clinically signifcant increase in nodule volume was observed in the frst
group, on the other hand there is statistically signifcant decrease in the second
and third group.
Conclusion
This study has shown the signifcance of iodine defciency and detection of this
situation by measuring urine iodine excretion and also it has shown that
signifcance of iodine defciency and smoking, additional disease existency and
diet have found to be related with iodine status of the body. We thought that
increased level of smoking and additional disease existency may have caused
iodine intake difference in same area. So that patients with thyroid nodule related
with iodine defciency can be evaluated and if this needed iodine supplementation
can be recomended by iodine rich diet.
PI54
Carotid intima media thickness increased similarly in subclinical
hypothyroidism and clinical hypothyroidism
Elif Onder
1
, Yusuf Aydin
1
, Emel Acar
2
, Hakan Cinemre
2
, Seher Kir
1
,
Adem Gungor
2
, Esra Yildizhan
2
& Gokhan Celbek
1
1
Endocrinology Department, Faculty of Medicine, Duzce University,
Duzce, Turkey;
2
Internal Medicine Department, Faculty of Medicine, Duzce
University, Duzce, Turkey.
Introduction
Recent conducted studies show that clinical hypothyroidism (CH) has similar
cardiovascular risk with subclinical hypothyroidism (SCH). Carotid intima
1.0
0.8
0.6
E
v
e
n
t
-
f
r
e
e
s
u
r
v
i
v
a
l
0.4
0.2
0 6 12 18
Months
TSH e 5.5 yU/l
TSH r 5.5 yU/l
24 30 36
media thickness (CIMT) that is an important marker of early atherosclerotic
changes is an indicator of cardiovascular events. In our study, we evaluated
CIMT in female patients, who have both CH and SCH, with similar age and
demographic features.
We recruited 38 healthy female and 81 female patients who admitted to
endocrinology outpatient clinic of Duzce University School of Medicine,
diagnosed as either CH (30) or SCH (51) and have not previously received
treatment. Patients` BMI (body mass index), systolic and diastolic blood pressure,
triglyceride, total cholesterol, LDL cholesterol, HDL cholesterol, vitamin B12,
folate, homocysteine, high-sensitivity C-reactive protein (Hs CRP) and CIMT
were measured.
Results
There was no statistically signifcant difference between groups in terms of age,
BMI and lipid profles (P0.05). There was a statistically signifcant difference
between groups in Hs CRP (P: 0.011) and homocysteine (P,0.001) and also
there was a signifcant difference in mean CIMT between healthy control group
and CH/SCH groups (P,0.001). In multiple linear regression analysis of patients
with CH and SCH, the age was identifed as the most important indicator of an
increase in CIMT.
Discussion
Lack of difference between CH and SCH patients in terms of Hs CRP,
homocysteine and CIMT shows that infammation starts and CIMT increases in
SCH period. Therefore, we think as, in order to primary prevention of the
cardiovascular diseases in patients with SCH regardless of the TSH levels,
treatment of patients is clinically important.
PI55
Realtime elastography for the differentiation of benign and malignant
thyroid nodules: a meta-analysis
Joerg Bojunga, Eva Herrmann, Stefan Zeuzem & Mireen Friedrich-Rust
J.W. Goethe-University Hospital, Frankfurt am Mein, Germany.
Background
Work-up of thyroid nodules remains challenging. Fine needle aspiration (FNA)
has been shown to be the most cost-effective way to select patients for surgery
with sensitivities of 54-69% and specifcities of 60-96% for the detection of
malignant lesions. Ultrasound-based Realtime Elastography (RTE) enables
the determination of tissue elasticity and has shown promising results for the
differentiation of thyroid nodules. A meta-analysis was performed to assess
the overall performance of RTE for the differentiation of thyroid nodules.
Methods
Literature databases were searched. Inclusion criteria were: evaluation of RTE,
cytology (FNA) or histology (surgery) as reference method, assessment of
sensitivity and specifcity of RTE. The meta-analysis was performed using the
DerSimonian and Laird Random Effect estimator was used to combine results
between the selected studies.
Results
Eight studies with overall 639 thyroid nodules were included in the analysis.
Mean sensitivity and specifcity for the diagnosis of malignant thyroid
nodules were 92% (CI (88; 96), and 96% (CI (94; 97)), respectively (s. Figure).
A signifcant heterogeneity was found for specifcity of the different studies.
Discussion
RTE can be used with high sensitivity and specifcity in the work-up of thyroid
nodules and might be a useful method in addition to or even instead of FNA to
select patients for surgery.
PI5
Have the hypothyroid patients really had 'euthyroid` quality of life after
the euthyroid state is established with levothyroxine-substitution?
Zoran Gluvic
1
, Jelena Tica
1
, Vesna Popovic-Radinovic
1
, Marina Vujovic
1
,
Zorica Rasic-Milutinovic
1
, Milena Lackovic
1
, Esma Isenovic
2
&
Nevena Paunovic
3
1
Department of Endocrinology and Diabetes, Zemun Clinical Hospital,
Zemun, Serbia;
2
Laboratory of Radiobiology and Molecular Genetics,
Institute Vinca, Belgrade, Serbia;
3
National Health Centre for the Railway
Employees, Belgrade, Serbia.
Introduction
Subclinical and clinical primary hypothyroidism potentially makes a negative
infuence on the patient`s quality of life. Present study examined the level of
hypothyroid symptoms and signs expression as well patient`s quality of life
before levothyroxine and after substitutionally-induced laboratory euthyroidism.
Prospective case-control study consisted of 75 female patients divided into three
groups based on blood levels of TSH and thyroid hormones before levothyroxine
substitution began. Examinees autonomously fulflled two structured interviews,
TSQ and GHQ-12. Obtained answers were numerically transformed into ranks
and presented through two scores, standard and modifed. Data were analyzed by
usage of SPSS for Windows 12.0.
A mean follow-up period of study enrolled patients until levothyroxine-induced
laboratory euthyroidism was 6 months, with no signifcant difference among
groups (Z1.708, P0.05). The mean standard and modifed TSQ and GHQ-
12 scores were 13 and 10 respectively and statistically signifcant difference was
not registered between groups (
2
TSQstandard
2923;
2
TSQmodified
3125;
2
GHQstandard
0334;
2
GHQmodified
0388; df2; P0.05). Obtained scores
correlated with the individual patient`s satisfaction of levothyroxine therapy
(%
TSQstandard
0.309; %
TSQmodifed
0.323; %
GHQstandard
0.405; %
GHQmodifed
0.399; P,0.01).
Conclusion
Given scores classifed the study patients in the group 'with no mental distress`.
That pointed out levothyroxine substitution as adequate and satisfed quality of
life of treated patients.
PI5I
Histological results in the cases of thyroid cytology indeterminate or
suspicious for malignancy
Antonio Lopez-Guzman
1
, Angel Luis Fraile
1
, Fernando Gomez Peralta
1
,
Marcelo Francos
1
& Cristina A
lvarez Escola
2
1
Departments of Endocrinology and Surgery, Complejo Asistencial de
A
vila, A
vila, Spain;
2
Department of Endocrinology, Hospital La Paz,
Madrid, Spain.
Introduction
Nodular thyroid disease is a common problem in clinical practice. Fine-needle
aspiration (FNA) has become the principal test in the diagnosis of nodular thyroid
disease. However, sometimes the information provided by this procedure is not
defnitive as it happens in those cases where the cytologic specimens are
suspicious or indeterminate and a clear cytologic diagnosis can not be made.
Based on that, we therefore undertook a study to investigate the histological
results in our series of patients with thyroid cytology indeterminate or suspicious
for malignancy.
Two hundred and thirty three suspicious lesion specimens on FNA corresponding
to 208 patients were studied (174 females and 34 males, mean age: 47.614.6
years, range: 17-82). All cases were operated on and a pathological result was
obtained in each case.
Results
Of the 233 specimens with the cytologic diagnosis of suspicious or indeterminate,
in seventy nine of them (33.9%) the pathological result was malignant (19
follicular carcinoma, 26 papillary carcinoma, 14 Hurthle cell carcinoma, 13
follicular variant of papillary carcinoma and 7 medullary carcinoma); while in the
remaining one hundred and ffty four (66.1%), the result was benign lesions (83
nodular hyperplasia, 41 follicular adenoma, 18 Hashimoto thyroiditis, 11 Hurthle
cell adenoma and 1 case of Graves disease).
Conclusions
From our current results, it can be interred that cytologic fndings indeterminate or
suspicious for malignancy could appear in different thyroid conditions. The high
percentage of thyroid carcinoma found in our series (33.9%) suggests that in the
0.4 0.5 0.6 0.7
Sensitivity
Combined
Tranquart i >.
Friedrich-Rust i >.
Hong i >.
Rago i >.
Rubatelli i >.
Asteria i >.
Lyshchik i >.
Dighe i >.
0.8 0.9 1.0 0.6 0.7
Specificity
0.8 0.9 1.0
patients with thyroid lesions with a cytologic result of suspicious for malignancy
or indeterminate, the lesion must be excised surgically to determine whether it is
benign or malignant.
PI58
Increased frequency of the glucocorticoid receptor gene polymorphisms
in patients with autoimmune thyroid diseases
Jadranka Antic
1
, Milan Petakov
1,2
, Sanja Ognjanovic
1
, Neda Dragicevic
1
,
Milan Lakocevic
1
1,2
1
Institute of Endocrinology, Diabetes and Metabolic Diseases, Clinical
Centre of Serbia, Belgrade, Serbia;
2
Medical Faculty, University of
Belgrade, Belgrade, Serbia.
Background
Glucocorticoids (GCs) have an important modulatory infuence on immune
system. GCs accomplish their effects on target tissue through binding to the
glucocorticoid receptor (GR). Alterations in glucocorticoid signaling due to
polymorphisms of the GR gene may have an impact on the pathophysiology of
autoimmune disorders.
Aims/methods
We examined the presence of BclI, N363S, A3669G and ER22/23EK GR gene
variants in patients with autoimmune thyroid disorders i.e. primary hypothyroid-
ism due to Hashimoto thyroiditis and Graves hyperthyroidism and healthy control
subjects (30 patients, mean age 45.92.2 years; 36 patients mean age 36.12.1
years; and 221 healthy controls mean age 42.30.7 respectively).
Results
We found signifcantly increased frequency of heterozygous and homozygous
polymorphic BclI and A3669G allele in patients with autoimmune thyroid
disorders in comparison with healthy control subjects, while there was no
difference in other GR gene polymorphisms. There was no difference in BclI and
A3669G frequency between patients with Hashimoto thyroiditis and Graves
hyperthyroidism.
Conclusion
Increased frequency of the GR gene BclI and A3669G polymophisms suggests
possible role of this polymorphic alleles in pathogenesis of autoimmune thyroid
disease. Concerning the fact that presence of BclI polymorphism is associated
with glucocorticoid hypersensitivity, and presence of A3669G results in relative
GC insensitivity seen in a variety of immunerelated diseases, their precise role in
AITD has to be defned in the future.
PI59
Expressions of vascular endothelial growth factor (VEGF), VEGF
receptor 1 (VEGF1), insulin like growth factor 1 (IGF1) and IGF1
receptor in differentiated thyroid carcinoma
Zuleyha Karaca
1
, Fatih Tanriverdi
1
, Figen Ozturk
2
, Gulsah Elbuken
1
,
Ilkay Cakir
1
1
, Fahri Bayram
1
1
1
Department of Endocrinology, Erciyes University Kayseri, Kayseri,
Turkey;
2
Department of Pathology, Erciyes University Kayseri, Kayseri,
Turkey.
Objective
Vascular endothelial growth factor (VEGF) and vascular endothelial growth
factor receptor 1 (VEGFR1) are known to be related to thyroid tumorigenesis, but
data are limited about their relationship with insulin like growth factor 1 (IGF1)
and IGF1 receptor. The aim of this study was to clarify the role of VEGF,
VEGFR-1, IGF1 and IGF1 receptor in thyroid tumorigenesis.
Methods
We examined 40 patients with differentiated thyroid carcinoma (DTC) and
compared them with 25 patients who had pathological diagnosis of nodular goiter
(NG) after thyroidectomy. Immunohistochemical analysis for VEGF, VEGFR-1,
IGF1 and IGF1 receptor were carried out in the paraffn-blocks of thyroidectomy
materials of the patients.
Results
The scores of the immunostainings of VEGF, VEGFR-1, IGF1 and IGF1 receptor
were higher in the patients with DTC than in the patients with NG. Only the
expression of VEGFR-1 was found to be related to the lymph node metastasis at
the time of surgery.
Conclusion
VEGFR-1 expression may be an important index for the presence of lymph node
metastasis at the time of thyroidectomy, but expressions of VEGF, IGF1 and IGF1
receptor do not seem to be related to the tumour capsule invasion, multicentrity or
lymph node metastasis.
PI0
Follicular tumour in hne needle aspiration byopsy of thyroid: predictive
factors of mallignancy
Alexandra Vieira
1
, Francisco Carrilho
1
, Cristina Ribeiro
1
, Sandra Paiva
1
,
Maria Joao Martins
2
, Graca Fernandes
2
, Jacinta Santos
1
,
Mariana Martinho
3
, Marcia Alves
1
, Sofa Gouveia
1
,
Fernanda Xavier da Cunha
2
1
1
Endocrinology, Diabetes and Metabolism Department, University Hospital
of Coimbra, EPE, Coimbra, Portugal;
2
Anatomopathology Department,
University Hospital of Coimbra, EPE, Coimbra, Portugal;
3
Endocrinology
Department, Portuguese Institute of Oncology, EPE, Coimbra, Portugal.
Introduction
About 20% of fne needle aspiration biopsy of thyroid (FNA) with result of
follicular tumour (FT) is malignant. Several factors have been suggested as
indicators of malignancy.
Objectives
To determine predictive factors of malignancy in FNA with result of FT.
Methods
We evaluated retrospectively 140 clinical fles of patients with cytology
(ultrasound-guided or palpation) of FT. Presence of relationship between
malignancy (in histology) and age, sex, family history, cervical symptoms
(choking, dysphagia, dysphonia, tightness, discomfort, volume increase), multi-
nodular goiter (MG), palpable nodules/adenopathys, scintigraphic/sonographic
features, previous benign cytology, richness of Hurthle cells was investigated.
Results
In 40 clinical cases it wasn`t possible histological classifcation (2 with 'uncertain
malignant potential`, 38 non-operated). Of the 100 remaining, 27 were malignant:
papillary microcarcinoma (9), minimally invasive follicular carcinoma (4),
follicular variant of papillary carcinoma (4), oxyphilic variant of papillary
carcinoma (2), multifocal papillary carcinoma (2), multifocal papillary
microcarcinoma (2), medullary microcarcinoma (1), papillary carcinoma (1),
columnar cell variant of papillary carcinoma (1), poorly differentiated thyroid
carcinoma (1). There was no statistically signifcant relationship between
malignancy (excluding microcarcinoma or not) and age, sex, family history,
autoimmune thyroiditis, MG, palpable nodules, size/number of nodules,
calcifcations, nodule solid/heterogeneous, nodule growth (3 mm), adeno-
pathys in ultrasonography, scintigraphic result, richness of Hurthle cell, previous
cytology benign.
The 2 patients with palpable adenopathys had papillary carcinoma.
There was statistically signifcant relationship between cervical symptoms and
malignancy (P0.039, OR2.55; P0.196 excluding microcarcinoma) as well
as between malignancy and ill-defned nodule on ultrasonography (P0.020,
OR5.93; P0.05, OR5.33 excluding microcarcinoma). Many sonographic
data are insuffcient not allowing for statistical analysis.
Conclusions
Predictive factors of malignancy were: presence of cervical symptoms and ill-
defned nodule on ultrasonography. Malignancy prevalence (18% if we exclude
the papillary microcarcinoma) was similar to that described in literature. These
data reinforce the need for surgery for defnitive diagnosis.
PI1
Crescent incidence of pap `llary thyroid microcarcinoma: 2000~09
Juan A Hernandez Bayo
1
, Monica Belinchon Sz.-Somoza
2
,
Jose M Hernandez Bayo
3
, Luis Acosta Criado
4
& Manuel Garci a Viera
5
1
Endocrinology, General Hospital of La Palma, Brena Alta (Canary
Islands), Spain;
2
Family Care, Primare Care of La Palma (Canary Islands),
Spain;
3
Radiology, Hospital Virgen del Puerto, Plasencia (Caceres), Spain;
4
Otorrhinolaringology, General Hospital of La Palma, Brena Alta (Canary
Islands), Spain;
5
Pathology, General Hospital of La Palma, Brena Alta
(Canary Islands), Spain.
Objective
Papillary thyroid microcarcinoma (PTM) is a malignant thyroid tumour with
potential multifocality and diameter B1 cm. Usually is found like incidentaloma,
and the epidemiology is not clearly established. We have analysed their
epidemiologic in La Palma Island at last 10 years.
We collected all cases of PTM diagnosed in 345 consecutive thyroid surgeries
performed for whichever benign thyroid disease (thyrogloss duct cyst - TDC -
included), at the last 10 years (from 2000 to 2009). Prevalence and incidence were
expressed as % and % per year, respectively; and the mean values like meanS.D.
To compare variables, Student`s t and
2
-tests were used.
Results
Thyroidectomy was performed in 297 females and 48 males with mean age
49.615.3 years (4-85). We found 53 cases of PTM (8 M, 45 F) with mean age
50.911.9 years (25-78). Just one was diagnosed before thyroidectomy (PTM in
a TDC). The PTM prevalence was higher in euthyroid multinodular goitre - MNG
- (20.1%) followed by thyroid solitary nodule (18.2%), toxic adenoma and
hypofunctioning MNG (14.3%), Graves` disease (10%), toxic MNG (9%) and
TDC (3.8%). The mean tumour size was 3.42.9 mm. Multifocality was
observed in 13.2%. TNM and staging classifcation according 2006 European
Thyroid Cancer Consensus was T
1a
N
0
M
0
and stage I, respectively, in all subjects.
Total prevalence was 15.4% without differences respect to sex (16.7% in M,
15.2% in F). The annual incidence oscilated between 3.3 and 20.8%, showing a
striking and progressive increase at the last years (9.8% in 2000-2004 vs 18% in
2005-2009, P0.048).
Conclusions
PTM is more frequent in nodular thyroid disease. The prognosis is excellent in
relation to the TNM and staging classifcation. The prevalence is high, as well as
its multifocality, increasing at the last years. It depends on the extended
indications for total thyroidectomy for benign diseases, on progress in the feld of
diagnostic procedures, and on the pathology examination.
PI2
An increase in serum CA 19-9 leading to the discovery of thyroid cancer
in patient with the history of rectosigmoid cancer
Jana Vrbikova
1
, Miroslav Trubac
2
, Svatopluk Adamek
2
, Vladimir Zeman
2
& Jaroslava Duskova
2
1
2
Charles University,
CA19-9 (sialyl Lewis[a] antigen) was originally described as a gastrointestinal
system and pancreas specifc tumour marker. Immunohistochemical studies have
demonstrated that CA19-9 is expressed in both differentiated and anaplastic
thyroid carcinomas. Increased serum levels of CA 19-9 were reported in few
patients with anaplastic thyroid cancer; however, to the best of our knowledge,
there is no previous report about serum levels of CA 19-9 in differentiated thyroid
cancer. Sixty-eight years old man underwent low anterior resection for the
adenocarcinoma of rectum and after the subsequent chemotherapy he was in the
remission of the disease. An increase in serum CA 19-9 from 11 to 53 kIU/l
(normal values ,39; ECLIA Roche) was detected during regular check-up
6 years after initial treatment. The only remarkable pathological fnding was the
focus of hypermetabolism in the upper mediastinum on PET scan. Ultrasono-
graphy of the thyroid and CT confrmed 95 ml nodule in right thyroid lobe. FNAB
was performed with the cytological fnding of oncocytic tumour. Total
thyroidectomy followed. Histological examination confrmed oncocytic variant
of minimally invasive follicular cancer together with lymphocytic thyroiditis.
Immunohistochemistry revealed the dispersed positivity of CA 19-9. Two months
after operation, patient underwent the diagnostic iodine scan with the fnding of
2 foci of isotope accumulation in mediastinum suspected for lymph node
metastasis. Therapeutic dose 5.5 GBq of 131 I was immediately applied. CA 19-9
levels normalised during 1 month. The patient is now, 14 months after
thyroidectomy, in the complete remission of both thyroid cancer (undetectable
serum thyroglobulin, negative ultrasound of the neck and negative diagnostic
radioiodine scan) and of rectosigmoid cancer.
Conclusion
Serum levels of CA-19-9 could be increased also in differentiated thyroid cancer
and could lead to a false suspicion of GIT tumour.
PI3
Effect of hyperthyroidism on parameters of oxidative stress and
antioxidant status in Wistar rats
Mirela Sanda Petrulea, Ileana Duncea & Adriana Muresan
Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca,
Romania.
Introduction
Thyroid hormones are the most important factors involved in the regulation of the
basal metabolic state, as well as in the oxidative metabolism. Oxidative stress
accompanying hyperthyroidism is caused by increased synthesis of reactive
oxygen species (ROS) and changes in the antioxidant defence system.
Aim of the study
To evaluate the pro-oxidant/antioxidant status and the effect of vitamin E
supplementation in damage caused by the excessive administration of thyroid
hormones.
Methods
White, male Wistar rats were used in the study. Thirty male Wistar rats were
divided into three groups (1-control group, 2-animals treated with L-thyroxin
10 g/animal per day for 30 days, 3-L-thyroxin treated rats protected with vitamin
E 10 mg/animal per day). Malondialdehyde (MDA), the marker of lipid
peroxidation, carbonyl proteins, SH groups, glutathion (GSH) and superoxide
dismutase (SOD) were determined from the serum, while MDA, carbonyl
proteins, SH groups and GSH were determined from the thyroid tissue
homogenates.
Results
The results showed increased levels of carbonyl proteins in serum in thyrotoxic
group as compared with the control group. MDA levels did not differ signifcantly
from the euthyroid group. SH groups, GSH and SOD decreased signifcantly by
thyroxin treatment. Vitamin E supplementation signifcantly increased serum
MDA levels in the thyroxin treated group as compared with the control group and
with animals treated only with thyroxin. Carbonyl protein levels increased
signifcantly in serum of the hyperthyroid supplemented rats as compared to the
controls. Antioxidant capacity markers in serum of group 3 were decreased
compared with group 1. MDA signifcantly decreased in thyroid homogenates of
the group 2 as compared with group 1. Signifcantly high levels of the SH groups
and low levels of GSH were found in thyroid homogenates of the hyperthyroid
rats.
These results suggest that experimental hyperthyroidism is accompanied with
increased oxidative stress and impairment of the antioxidant system.
Vitamin E supplementation in hyperthyroidism could exert benefcial effects in
favour of the diminution of thyroid hormone levels.
PI4
Evaluation of PKC isoforms expression in thyroid cells lines and effects
of a PKC beta II selective inhibitor
Daniela Mole`, Mariella Minoia, Federico Tagliati, Maria Chiara Zatelli
& Ettore C degli Uberti
Section of Endocrinology, University of Ferrara, Ferrara, Italy.
Protein kinase C (PKC) is a key enzyme which regulates proliferation, apoptosis
and differentiation, representing a pharmacological target for tumor therapy. PKC
is a serin/threonin kinase involved in the control of neoplastic transformation,
carcinogenesis, neoplastic invasion, chemoresistance. The role of PKC depends
on the tissue and on the specifc isoform, among the 11 identifed so far.
In particular, PKC beta II inhibits cell functions, while PKC delta has a protective
role. The aim of our study was to verify PKC isoform expression levels in thyroid
follicular and parafollicular cell lines, evaluating the effects of a selective PKC
beta II inhibitor. We therefore evaluated PKC beta II and PKC delta expression by
immunofuorescence in two thyroid follicular cell lines, N-thy-ori (normal
follicular cells) and FTC-133 (follicular cancer cells) and in one parafollicular
cell line, TT. Both PKC isoforms are expressed in the investigated cell lines with
different patterns. In particular, PKC beta II and PKC delta are localized in the
cytoplasm in N-thy-ori cells. Treatment with a selective PKC beta II inhibitor in
the presence of serum stimulates and in the absence of serum inhibits cell
proliferation. In FTC-133 PKC beta II localizes in the cytoplasm and in the
nucleus, while PCK delta is exclusively cytoplasmic. Treatment with a selective
PKC beta II inhibitor in the presence of serum stimulates and in the absence of
serum inhibits cell proliferation. In TT cells, PKC beta II localizes in the nucleus.
Treatment with a selective PKC beta II inhibitor in the presence of serum does not
infuence cell proliferation, while in the absence of serum has an antiproliferative
effect. These preliminary data confrm that PKC isoforms are expressed in
different cellular compartments depending on the tissue. Moreover, a selective
PKC beta II inhibitor has tissue-dependent effects. The stimulatory effect on
proliferation in follicular cells in the presence of serum suggests that serum
contains growth factors (likely TSH) which profoundly modify the effects of PKC
inhibition. Further studies are needed to clarify the role of PKC in thyroid
neoplasia.
PI5
Amiodarone-induced thyrotoxicosis in patients with multinodular
goiter: type 1 or type 2 AIT?
Luca Tomisti, Enrica DellÙnto, Sandra Brogioni, Chiara Cosci,
Enio Martino & Fausto Bogazzi
Department of Endocrinology, University of Pisa, Pisa, Italy.
Introduction
Type 2 amiodarone-induced thyrotoxicosis (AIT) is a form of destructive
thyroiditis, commonly responsive to glucocorticoids. On the contrary, type 1 AIT
is an iodine-induced hyperthyroidism, occurring in patients with underlying
thyroid disease often responding to thionamides.
Aim of the study
To compare the effectiveness of methimazole (MMI) or prednisone (GLU) in the
treatment of AIT patients with multinodular goiter with biochemical features of
destructive thyroditis.
We enrolled 22 untreated AIT patients with multinodular goiter in a historical
prospective study. The patients showed similar biochemical fndings; particularly
all patients showed low thyroidal radioactive iodine uptake (24th h RAIU ,5%)
and an estimated thyroid volume with conventional ultrasonography 25 ml.
Eleven patients were treated with metimazole (initial dose 40 mg/day) (MMI
GROUP) and 11 patients were treated with prednisone (initial dose, 0.5 mg/kg per
day) (GLU GROUP) for 4 months (120 days).
Results
After 120 days euthyroidism was restored in 9/11 patients treated with
glucocorticoids (81.8%) and in 4/11 patients treated with MMI (36.3%)
(P 0.03). Furthermore, patients in GLU GROUP reached euthyroidism more
rapidly than those in MMI Group (median cure time GLU GROUP 33 days versus
median cure time MMI GROUP 120 days, P0.01).
Conclusion
This data suggest that AIT patients with multinodulare goiter but biochemical
features of destructive thyroiditis could respond more favorable to glucocorti-
coids therapy than to thionamides therapy.
PI
Deiodinase impairment in the autoimmune thyroid disease: case report
Gianmarco Mezzacapo, Luciano Persico & Giuseppe Lavra
San Giovanni Hospital, Rome, Italy.
A 63-year-old woman came to our observation. She has been affected by a
nodular goiter for 20 years. She was treated with 6 months short L-thyroxine
therapy cycle (75 g/day); the therapy was interrupted on her own initiative 3
months before we saw her. Symptoms: constriction, tachycardia. US: diffusely
enlarged and hypoechogenic thyroid, a 5 cm well defned solid nodule on the right
lobe. FNAB: poor colloid, numerous follicular cells, some of them showing
oxyphil cells aspects, numerous lymphocytes. RMN: normal hypothalamic-
pituitary axis. The clinical results linked to the anamnestic and actual laboratory
data leaded us to the following diagnosis: nodular goiter with aspects of
autoimmune thyroiditis in deiodinase impairment from TT
4
to TT
3
; a therapy with
triiodothyronine (20 ,3 time a day) was started. A 18 months follow-up
evidenced the normalization of the metabolic picture and a gradual reduction of
the nodular pathology as well as the resolution of the compressive
symptomatology.
PII
Panobinostat restores iodine uptake in primary cultures of
undifferentiated thyroid tumours
Maria Graziella Catalano
1
, Mariateresa Pugliese
1
, Antonina Germano
1
,
Roberta Poli
1
, Nicola Palestini
2
, Franco Mainini
3
, Nicoletta Fortunati
4
& Giuseppe Boccuzzi
1,4
1
Department of Clinical Pathophysiology, University of Torino, Torino,
Italy;
2
Department of Surgery, University of Torino, Torino, Italy;
3
Novartis
Farma S.p.A., Origgio, Italy;
4
Oncological Endocrinology, AOU San
Giovanni Battista, Torino, Italy.
A functional sodium iodide symporter (NIS) is essential for radioiodine treatment
of thyroid cancer. Unfortunately, most of de-differentiated tumours as well as
anaplastic thyroid cancers loss the ability to concentrate iodine. Loss of NIS
expression usually depends on epigenetic modifcations, suggesting the use of
epigenetic drugs as promising tools for re-differentiation. Panobinostat (LBH589)
is a novel deacetylase inhibitor, acting at nanomolar concentrations, currently in
phase I-II clinical evaluation for its anti-tumour activity in advanced refractory
solid tumours and hematologic malignancies. The aim of the present work was to
defne the pro-differentiating activity of LBH589 with particular regards to NIS
expression and function in both immortalized cell lines as well as in primary
cultures. To this aim, two different immortalized anaplastic thyroid cancer cell
lines (BHT-101 and CAL-62) and four primary cultures derived from patients
who underwent thyroidectomy for undifferentiated thyroid cancers (1 sternal
metastasis from a recurrent PDTC, and 3 ATC), were treated with LBH589
(5-100 nM). LBH589 induced NIS mRNA expression in BHT-101 and CAL-62
cells in a dose dependent manner and in all the four primary cultures, as revealed
by RT-Real-Time PCR. Immunofuorescence microscopy clearly demonstrated
the presence of NIS protein in all the cell cultures. Finally,
125
I uptake was
performed and demonstrated that LBH589 resulted in a signifcant up-take of
iodide in thyroid cancer cells.
In conclusion, data from our study on both immortalized and primary cultures
strongly suggest that LBH589 is a very good candidate for carefully designed
clinical trials aimed at restoring iodide uptake in patients with undifferentiated
thyroid cancer. Moreover, the novelty of testing the drug on primary cultures
could allow an increase in the effectiveness of the treatment in single patients.
PI8
Nodular goiter and its natural selection in modern terms
Vadim Khaziev, Svetlana Shtandel, Yurii Karachentsev
& Helena Svetlova-Kovalenko
Aim
The aim of the study was to analyze the nodular goiter (NG) natural selection
features in modern terms.
The average fertility indices per person, 211 patients with NG from the female
cohort of Kharkov (eastern Ukraine) inhabitants, years of birth - 1925-1950,
mean age - 58.60.5 years with the physiological cessation of fertility and 2105
normal healthy ones were analyzed. The dead (P
d
) and survive (P
s
) till
reproductive period (25 years) parts of comparison groups offspring, relative
adaptability (w) and natural selection (s) were estimated. NG family aggregation
at 1st and 2nd degree relatives for 69 patients with multinodular goiters patients
and 79 patients with mononodular goiters were studied.
Results
NG women had more offspring by comparison to the healthy ones: number of
labors (births) (1.600.06 vs 1.410.02, correspondingly, P,0.001). The
values of P
d
and P
s
in NG women were different in comparison with the healthy
ones (0.002 vs 0.028), (0.980 vs 0.972), accordingly. Natural selection (s) against
NG and healthy ones has made 0.000 and 0.126, respectively (P,0.001). NG
prevalence in Kharkov population was increased from 0.02% in 1989 to 0.238%
in 2007, P,0.001. NG clinical variant of mononodular goiters is characterized by
higher familiar accumulation by comparison to multinodular goiter clinical
variant (4.360.85 vs 1.750.58%, respectively; P,0.05). It has been shown,
that mononodular goiters prevailed among the total nodal goiters cases and were
increased last 24 years (1985-2009) from 34.1 to 46.2% (
2
7.817; P0.005).
Conclusions
In modern terms the positive tendency of NG natural selection is a factor, which
increases NG prevalence in population and promotes the increasing of all clinical
NG cases with the greater family accumulation.
Date
FT3*
(g/ml)
FT4
(g/ml)
TSH
(U/ml) TPO
Size
(cm) Therapy
02/2007 2.6 (2.2-4.7) 37 (8-20) 37 (0.2-4) 1:2230 5 -
05-10/2007 3.0 36.3 21.7 5 5 LT4 75
01/2008 2.7 34 52 1:3058 5 -
06/2008 3.6 15.4 0.65 3 TiTre 20,3
06/2009 2.8 9.9 1.1 Pseudonodular Titre 20,3
PI9
Thyroid metastases due to lung adenocarcinoma
Idriz Gerqari
1,2
, Neshet Rizvanolli
2
, Antigona Gerqari
1
, Rame Miftari
1
,
Lule Abdullahu
1
& Blond Gerqari
3
1
University Clinical Center of Kosovo, Prishtina, Kosovo;
2
Diagnostika
plus, Prishtina, Kosovo;
3
American University in Kosovo, Prishtina,
Kosovo.
Introduction
Thyroid nodules are common and are often found incidentally by palpation. Most
of thyroid nodules are benign but 0-10% are malignant. A small proportion are
due to metastatic lesions from other primary tumors. FNA is a standard diagnostic
procedure to differentiate between benign and malignant nodules. But the use of
additional immunochemistry markers will be important for diagnosis.
Lung adenocarcinoma is one of the tumors which may metastasize to the thyroid
gland. We will present the case of a man who presented with neck enlargement
and was subsequently diagnosed with metastases due to lung adenocarcinoma.
Case report
An 63-year-old man was referred to us for the neck enlargement.He had thyroid
enlargement of the right lobe. Ultrasound revealed the solid hypoechoechoic mass
and the afunctional nodule in the scintigraphy of thyroid.
After the fne needle aspiration cytology a primary thyroid carcinoma was
suspected.
The whole body scintigraphy with Tc MDP shows the small photopenic zone in
the body of 12th thoracic vertebra. The CT of thorax reveled a small pulmonary
nodule.
The patient was suspected on a carcinoma of thyroid gland and was referred for
total thyroidectomia.
The histopathology after total thyroidectomia based on the immunohistochem-
istry results, in one of the slides a small focus of a moderately to poorly
differentiated adenocarcinoma was found. Tumor focus shows a negative reaction
for TTF1, chromogranine and P53. But the tumor was positive for CEA and
reveals a doubtful reaction for thyreoglobulin.
The thyroid tumor was diagnosed as metastases to the thyroid from lung
adenocarcinoma.
Conclusion
This case shows the need of considering even rare possibilities in the differential
diagnosis of thyroid nodule. Also the importance of immunohistochemistry
markers.
PII0
The evaluation of some severity and activity parameters in Graves`
ophthalmopathy
Ioana Zosin
1
, Melania Balas
1
, Ioana Golu
1
, Oana Vonica
2
, Mihaela Vlad
1
& Luiza Badescu
3
1
Clinic of Endocrinology, University of Medicine and Pharmacy 'V. Babes`,
Timisoara, Romania;
2
Royal Eye Unit, Kingston Hospital, New Castle upon
Thames, UK;
3
Ophtalmological Unit, County Hospital, Timisoara,
Romania.
Aim of the study
The paper presents some clinical and laboratory parameters refecting activity
and severity of Graves ophtalmopathy (GO) and discusses the correlation
between them.
The study included 25 GO cases, with mean age 47.711.2 years and a
female/male ratio of 21/4. The patients were evaluated clinically, by assessment
of thyroid status (TSH, FT
3
, FT
4
, thyrotropin receptor autoantibodies (TRAb))
and by orbital imagistic means (CT or MRI scan). The mean duration of GO
was 19.7 months (3-96 months). The patients were under treatment with
antithyroid drugs.
Results
Based on EUGOGO activity and severity criteria, the cases were divided in two
subgroups: 16 cases with active ophtalmopathy (4 mild and 12 moderate/severe
forms) and 9 cases with inactive disease (5 mild and 4 moderate/severe forms).
The severity of GO was quantifed, using EUGOGO recommendations, allotting
points for each parameter. Active GO cases showed higher severity scores (right
eye: 7.22.83; left eye: 5.862.74), as compared to inactive cases (right eye:
2.662.5, P0.002; left eye: 2.661.86, P0.01, t-test).
The severity score correlated signifcantly with clinical activity score (CAS):
Pearson correlation index r0.599, r
2
0.313, P0.008, for right eye, and
respectively r0.547, r
2
0.299, P0.01 for left eye.
Serum TRAb values correlated signifcantly with CAS in both subgroups of cases,
but did not correlate with severity score. None of the cases with inactive GO was
present smoker, although among active GO, 7 patiens were active smokers
(P0.02, Fisher`s exact test). There was no signifcant correlation between the
degree of thyrotoxicosis and CAS or severity scores.
Conclusion
CAS as much as severity parameters are required for a correct evaluation of GO,
its prognosis and therapy.
PII1
High fT
3
(free triiodothyronine), new syndrome or innocent bystandar
Saranac Ljiljana, Zivanovic Snezana & Novak Martin
Pediatric Clinic, University Clinical Centre, Nis, Serbia.
Aim
To evaluate clinical presentation and thyroid dysfunction types in children with
thyromegaly.
Thirty-nine children were referred to endocrinologist examination because of
thyromegaly. Assessment of clinical history, physical examination, auxological
data pubertal staging and complete evaluation of basal thyroid function were
carried out in all children. Thyroid autoantibodies, urinary iodine excretion (UIE)
and ultrasound examination of thyroid gland volume and structure were also
performed. Twelve healthy children were control.
Results
Majority of children were euthyroid (64.10%), Subclinical hypothyroidism was
present in 7 children (17.95%), subclinical hyperthyroidism in one child (2.56%)
and 6 children (15.38) showed high fT
3
levels. Mean UIE in the study group was
suboptimal (94.88 g/l) versus 135.00 in control group, but without signifcance.
UIE was under lower limit of normal value in 48.72%, normal in 46.15 and high
in 5.13%. The mean thyroid volume/body mass ratio was signifcantly higher in
the study group (P,0.001). Diagnosis of CAT (chronic autoimmune thyroiditis)
was made in 6 patients among children with goiter. The characteristics of children
with high fT
3
values were an increased linear growth and signs of mild
hyperthyroidism (heat intolerance, tachycardia, nervousness, fne tremor).
Goitrious children started puberty earlier and presented excellent growth (the
mean percentile was 71.24 (0.99 S.D).
Conclusion
Among children with thyromegaly small group presented high fT
3
values, tall
stature and clinical signs that could be attributed to hyperthyroidism. It might be
homeostasis modulation due to hyper caloric intake. Further studies are
necessary.
PII2
Vitamin D dehciency contributes to post-thyroidectomy hypocalcemia
Aurelie Jacques
1
, Cyril Page
2
, Etienne Justinien
1
, Vladimir Strunski
2
& Rachel Desailloud
1
1
Endocrinology Unit, Universitary Hospital, Amiens, France;
2
Oto-Rhino-
Laryngology Unit, Universitary Hospital, Amiens, France.
Hypocalcemia is a classic complication after total thyroidectomy, mostly due to
post-operative hypoparathyroidism. However others factors, like vitamin D
defciency, may contribute to this hypocalcemia.
Objective
To determine if vitamin D preoperative status infuence early postoperative serum
calcium levels after total thyroidectomy.
Seventy-nine patients (65 women/14 men), mean age 52.8 (12.7), were
included. Patients were distributed in 3 groups according to their early
postoperative serum calcium levels: - severe hypocalcemia B1.8 mmol/l (1.72
(1.48-1.8)), - mild hypocalcemia 1.8 to 2.1 mmol/l (1.95 (1.83-2.08)), -
normocalcemia 2.1 mmol/l (2.13 (2.1-2.21)).
Results
Severe vitamin D defciency (B10 ng/ml) is present only in the mild
hypocalcemia group (0 vs 20.9 vs 0%, P0.01).There is a trend for lower levels
in the mild hypocalcemia group (21.9 (11.1-87) vs 16.5 (0-71) vs 24 (12.9-47.5),
P0.057). FT
4
is signifcantly lower in patients with hypocalcemia (severe and
mild) (1.15 ng/dl (0.52 and 1.67) vs 1.26 ng/dl (1.05 and 1.96), P0.02). In
univariate logistic regression analysis, 25OHD and FT
4
levels are predictive
factors of early postoperative hypocalcemia (1.006 (1.003-1.009), P,0.0001 and
1.01 (1.005-1.015), P,0.0001 respectively). In multivariate analysis, only
25OHD remain with a statistical trend (P0.06).
Conclusion
Severe hypocalcemia is due to hypoparathyroidism but vitamin D defciency
participate to mild hypocalcemia. Screening and treatment of vitamin D
defciency as well as obtaining FT
4
normal levels before surgery could avoid
some hypocalcemia after total thyroidectomy.
PII3
Antenatal thyroid function and pgp!b mood disturbances
Irene Lambrinoudaki
1
, Demetrios Rizos
3
, Eleni Armeni
1
,
Paraskevi Pliatsika
1
, Angeliki Leonardou
2
, Angeliki Sygelou
1
,
John Argeitis
1
, Georgia Spentzou
1
, Dimitrios Hasiakos
1
, Ioannis Zervas
2
& Constantinos Papadias
1
1
Second Department of Obstetrics and Gynecology, Aretaieion Hospital,
2
Women`s Mental Health Clinic,
Department of Psychiatry, Eginition Hospital, University of Athens, Athens,
Greece;
3
Hormonal Laboratory, Aretaieion Hospital, University of Athens,
Athens, Greece.
Background
Postpartum mood disturbances occur very often in otherwise healthy women,
whereas thyroid function is affected during a normal pregnancy. We examined
whether thyroid hormone levels in women free from thyroid dysfunction associate
with the prevalence of postpartum mood disturbances.
Methods
This cross-sectional study included 57 Greek women. Concentrations of thyroid
hormones (free T
3
, free T
4
, TSH) and antibodies (anti-thyroglobulin and anti-
peroxidase) were assessed before delivery and daily during the frst four
postpartum days. Mood disturbances were evaluated using the Edinburgh
Postnatal Depression Scale and the Maternity Blues Questionnaire on the frst
and sixth week postpartum. The association between mood scores of both scales
and thyroid hormone and antibody levels was evaluated.
Results
Blues scores in the frst week postpartum correlated negatively with prepartum
serum levels of FT
3
and FT
4
(blues on day 4: with FT
3
, %0.44, PB0.01; with
FT
4
, %0.36, PB0.01). Women with lower FT
3
and FT
4
levels had higher
mood scores in both scales (high scoring group: FT
3
1.22 pg/ml, FT
4
0.66 ng/dl; low scoring group: FT

3
1.64 pg/ml, FT
4
0.73 ng/dl). In addition,
postpartum blues scores correlated negatively with serum levels of FT
3
in the frst
postpartum days.
Conclusion
The results of this study indicate an association between prepartum thyroid
function and the prevalence of postpartum mood disturbances. Within the normal
range, lower levels of serum FT
3
and FT
4
prepartum are associated with increased
incidence of mood swings in the frst postpartum week.
PII4
The evidence of TSH variation according to the temperature and
geographic region in patients with thyroid pathology
Diana Loreta Paun, Rodica Petris, Carmen Andrei, Nicoleta Ene,
Florin Alexiu & Constantin Dumitrache
National Institute of Endocrinology C.I. Parhon, Bucharest, Romania.
Because of the increased prevalence of thyroid disorders in Romania we realized
a retrospective study in which we followed the variance of TSH, function of
temperature, in different seasons. In this context, based on TSH value we
appreciated the need of thyroid hormones and antithyroid drugs to maintain an
euthyroid state.
The group of study consist of 634 patients, men and women over 18-years-old
with thyroid disorders: hypo, hyper, euthyroidism per novo or under treatment
which presented in summer and winter months in C. I. Parhon Institute. The
patients were followed in the summer months versus winter months being
distributed on geographical regions.
Results
In the case of hypothyroid patients, the mean TSH value in summer month was
9.375.53 UI/ml and in winter month was 18.682.31 UI/ml. Based on the
TSH value we appreciated that the need of thyroid hormones is lesser in summer
months than in winter months with a P0.12 and actually lesser in the
geographical regions with high temperature.
In the case of hyperthyroid patients we remarked that the need of antithyroid
drugs, appreciated by the TSH value, is bigger in summer months (mean TSH
value: 0.1480.76 UI/ml) than in winter months (mean TSH value: 0.23
0.021 UI/ml) with a P0.46 and even bigger in the geographical regions with
high temperature.
For the patients with multinodular goiter but with euthyroidism we remarked
mean TSH values lesser in summer months (mean TSH value: 1.57
0.496 UI/ml) than in winter months (mean TSH value: 2.390.78 UI/ml)
with a P0.08.
Conclusions
TSH value has circanual variations being lesser in spring-summer and bigger in
winter. Based on TSH value we appreciate that the need of thyroid hormones is
bigger in winter than in summer and the need of antithyroid drugs in bigger in
summer than in winter.
PII5
Insulin resistance, lipid prohle, C-reactive protein and homocysteine in
patients with autoimmune thyroiditis and subclinical hypothyroidism
Celestino Neves
1,2
, Marta Alves
1,2
, Ema Carvalho
1
, Isolina Pimentel
1
,
Miguel Pereira
1
, Renata Ramalho
1,2
, Carmo Palmares
1,2
,
Cristina Guimaraes
1,2
, Joao Ramos
1,2
, Davide Carvalho
1,2
, Lui s Delgado
1,2
& Jose Lui s Medina
1,2
1
Hospital S. Joao, Porto, Portugal;
2
Faculty of Medicine, Porto, Portugal.
Background
Thyroid function, insulin resistance, serum lipid, C-reactive protein (CRP) and
homocysteine are associated with an increased cardiovascular risk in patients with
autoimmune thyroiditis (AIT).
Objective
To evaluate the interrelations between thyroid function, insulin resistance, serum
lipid concentrations, CRP and homocysteine in patients with AIT and subclinical
hypothyroidism.
We recorded thyroid function tests, BMI and the levels of total cholesterol (TC),
HDL, LDL-cholesterol, triglycerides (TG), apolipoprotein B (ApoB), ApoA1,
lipoprotein (a) (Lp[a]), homocysteine, CRP, folic acid, vitamin B12, and insulin
resistance markers comprising the HOMA-IR, HISI (Hepatic Insulin Sensitivity
Index), WBISI (Whole-Body Insulin Sensitivity Index), IGI (Insulinogenic
Index) in 500 patients with AIT, with a mean age of 47.214.8 years. A 75-g
OGTT was performed in the morning, and blood samples were obtained every
30 min for 120 min for measurements of plasma glucose, insulin, and C-peptide.
Statistical analysis was performed with ANOVA and Pearson`s Correlations test.
A two-tailed P value , 0.05 was considered signifcant.
Results
TSH levels were 3.68011.877 UI/ml and BMI was 27.55.6 kg/m
2
. There
were signifcant positive correlations between TSH and serum TC (r0.167;
P,0.001), LDL (r0.131; P0.004), TG (r0.168; P,0.001), and ApoB
(0.141; P0.008). We found signifcant positive correlations between IGI and
anti-TPO (r0.179; P0.005), CRP (r0.162; P0.02), and TSH (r0.126;
P0.048). We also found signifcant positive correlations between HISI and TSH
(r0.173; P0.006), and signifcant negative correlations between WBISI and
CRP (r0.181; P0.008).
Conclusions
In patients with AIT, there are positive associations between the levels of TSH,
the lipid profle, and insulin resistance markers, such as IGI, and HISI.
PII
Thyrotoxic normokalemic periodic paralysis: a case report
Ayten Oguz
1
, Fevzi Balkan
1
, Husniye Baser
1
, Fikri Ak
2
, Reyhan Ersoy
1
& Bekir Cakir
1
1
2
Department of
Neurology, Ankara Numune Training and Research Hospital, Ankara,
Turkey.
Introduction
Hypokalemic periodic paralysis associated with hyperthyroidism is a well-known
acute electrolyte and acute muscle disorder. Lesser known is normokalemic
periodic paralysis associated with hyperthyroidism (TNPP). Because plasma
potassium is normal, and it can be misdiagnosed as some other disorder if thyroid
function is not evaluated. We report a case of TNPP due to non-autoimmune
thyroiditis.
Case report
A 23-year-old woman was admitted to emergency department with muscular
weakness of the lower extremities. She also presented to weight loss, increased
appetite, and heat intolerance for the last 2 months. She denied any previous disease
history or medication. In physical examination, her thyroid gland was minimal
enlarged diffusely and non tender. In neurologic examination, there was symmetric
faccid paralysis with arefexia and impaired sensation in the lower extremities.
Fasciculations, myoclonus and muscular atrophy were not observed. Cranial
nerves were intact. ENMG and cranial MR were normal. Lumbar puncture was
applied. Cerebrospinal fuids pressure and other related studies were normal.
Laboratory studies revealed normal renal and hepatic function. Serum potassium
4.6 mmol/l (3.6-5 mmol/l) was. The thyroid function tests revealed a decreased
level of TSH, an elevated level of fT
4
, and fT
3
. The thyroglobuline antibody and
microsomal antibody test were negative. Thyroid ultrasonography revealed
chronic thyroiditis. I-131 uptake was 2% in 4 h (normal: 15-25%), and 1% in
24 h (normal: 25-35%). The diagnosis was non-autoimmune thyroiditis
accompanied by TNPP. Propranolol at a dose 20 mg four times per day was
given to control of symptoms of hyperthyroidism. The paralysis completely
improved without potassium supplementation.
Conclusion
Periodic paralysis can present with initial symptoms of thyrotoxicosis associated
with normokalemia. Thyroid function should be evaluated in patients presenting
with muscle weakness, normal potassium concentrations and thyrotoxic
symptoms to avoid inappropriate management and missing a curable form of
paralysis.
PIII
Simple clinical and paraclinical factors may predict outcome of
treatment for Graves` hyperthyroidism
Sorina Martin
1,2
, Gheorghe Adrian Tatucu
2
, Elena Roxana Smadeanu
2
,
Suzana Florea
1
& Simona Fica
1,2
1
Elias Emergency Hospital, Bucharest, Romania;
2
Carol Davila University
of Medicine and Pharmacology, Bucharest, Romania.
Objective
The aim of this study was to assess the value of some clinical and paraclinical
factors in an attempt to predict outcome following antithyroid drug therapy.
Methodology
We performed a retrospective audit of 101 new patients, aged 16-85, separated
into two groups: 59 patients with Graves` disease (GD) and control group of 42
patients with other ethyologic forms of hyperthyroidism, admitted to our clinic
between 2003 and 2008. Data were collected at diagnosis, before initiation of
treatment, and then patients were followed up at least until TSH became
unsuppressed (0.45 mUI/l).
Results
In the GD group, mean age at diagnosis (47.09 years) was negatively correlated
with the time needed until TSH become unsuppressed (P0.002) and with TT
3
levels (P0.010). The heart rate was positively correlated with time needed until
TSH become unsuppressed (P0.034). Total cholesterol and triglycerides were
negatively correlated with the time needed until TSH become unsuppressed
(P0.04). The GDpatients with large goiters (P0.034), family history of thyroid
disease (P0.008) or personal history of autoimmune disease needed more time
until TSH become unsuppressed. Graves ophthalmopathy developed more
frequently in older patients, mean age 49.17 years (P0.01). In the GD patients
who could be followed after the cessation of treatment the total dose of antithyroid
drugs was positively correlated with remission period after stopping the treatment
(P0.023). These correlations were not found in the control group.
Conclusion
Our study suggests that, in GD patients age at diagnosis, heart rate, lipid profle,
goiter size, personal/family history and dose of antithyroid drugs may predict
outcome of treatment for Graves` hyperthyroidism.
PII8
Clinical and histological different features in the form of presentation
between papillary microcarcinomas and papillary carcinomas of
larger size
Carles Zafon, Jose Manuel Fort, Juan Antonio Baena, Josep Castellvi ,
Gabriel Obiols, Gabriela Monroy & Jordi Mesa
Hospital Universitari Vall d`Hebron, Barcelona, Spain.
Background and aim
Papillary thyroid carcinomas (PTCs) with a diameter ,1 cm are referred to as
papillary microcarcinomas (PTMCs). They are being diagnosed with increasing
frequency. Within this type of tumour some clinical and histological
characteristics with prognostic and therapeutic impact have been proposed. In
the present study we describe the clinical and pathological presentation of PTMCs
and compare them with papillary thyroid carcinomas of larger size.
Methods
Clinical and histopathological variables, such as gender, age, multifocality,
lymph node metastases, and mode of diagnosis were studied in 152 PTCs,
including 74 PTMCs and 78 PTCs of larger size.
Results
PTMCs were associated with less multifocality (P0.046) and bilaterality
(P0.003), fewer lymphadenectomies (P,0.001), and a decreased rate of
nonincidental tumours (P,0.001). Patients with a low aggressive profle were
signifcantly older that the remaining patients (5413.7 vs 45.813.1 years;
P0.001). This lowaggressive proflewas observedin28(36.8%) of 76patients older
than 45 years and only in 12 (17.9%) of 67 patients younger than 45 years (P0.006).
Conclusions
PTMCs show signifcant differences in the form of presentation, though, a subset of
PTMCs exhibits aggressive features that may be associated with signs of poor
prognosis. Furthermore, it is possible that classical risk factors well validated in
PTCs, such as age, must be cautiously interpreted in the current increasing subgroup
of PTMCs.
PII9
Selenium serum levels in patients with mild Graves` orbitopathy:
results of a controlled study
Gerasimos Krassas, Spiros Karras, Kostas Boboridis & Evagelos Spanos
Panagia General Hospital, Thessaloniki, Greece.
It has been reported recently that selenium (SE) administration over a 6-month
period signifcantly improved the eye involvement in patients with mild GO.
Aim
To investigate SE levels in such patients and fnd out if they differ from controls,
fnding which might explain the benefcial effect of SE in such patients.
Patients
One hundred and four patients (82F) mean age 47.88827 (S.D.) (range 32-65)
with mild form of GO, with a disease duration of ,18 months were studied. All
the patients had been euthyroid for at least 2 months after antithyroid drugs or
surgery or 6 months after I
131
radioactive iodine. No patients received previous
treatment for GO, except for local measures. Thirty normal individuals (18 F),
mean age 50.139.54 (range 32-65) were used as controls. In all patients and
controls SE serum levels were measured by atomic absorption method. Normal
range for SE in our population is 46-143 g/l. Also, FT4, TSH, TPO Ab, TG Ab
and TRAb were measured in all patients by chemiluminescence.
Results
Mean SE levels in the GO group was 66.812.9 while in the controls was 65.6
15.8. These results were not signifcant (P0.672). No correlation was found
between SE levels and FT4, TSH, TPO Ab, TG Ab and TRAb.
Conclusions
No difference in SE levels was found between patients with mild GO and controls.
Also, no correlation was found between SE and all the other thyroid parameters
studied. These fndings indicate that the benefcial effect of SE is not associated
with its blood concentrations and other mechanism should be investigated to
explain this action.
PI80
The serum C-reactive proteine in dysthyreosis
Annamaria Laszlo, Ionela Pascanu, Melinda Kolcsar, Camelia Gliga
& Alexandru Schiopu
University of Medicine and Pharmacy, Ta`rgu Mures, Romania.
Introduction
The thyroid is a multifaced endocrine gland. By its hormones it has an effect on
almost all organs of the body, metabolism and defence system too. The
relationship between the thyroid hormones and the nonspecifc defence system
has been less studied.
Aim
To study and prove whether the endogenous thyroxin (FT
4
) is involved in the
nonspecifc defence system of the organism. We followed the correlation between
the FT
4
and the C-reactive protein (CRP) in dysthyreosis, because the CRP is a
highly sensible acute phase protein (APP), which has an opsonization effect, thus
being part of the phagocytosis as well as activates the complement through the C
1q
.
We performed a study on 93 patients between the ages of 7-78 out of which 50
cases were of hyperthyreosis and 43 of hypothyreosis, 79 women and 14 men. We
used the method of ECLIA to measure the FT
4
and the method of nephelometry to
measure the CRP.
Results
We found that in case of hyperthyreosis (FT
4
21.6492.93 pg/ml) free of age
and gender, 42 (84%) were negative for mean values 4.121.87 mg/l, 6 (12%)
positive, 2 (4%) slightly positive values; in hypothyreosis (FT
4
3.745
2.0 pg/ml) 36 (83.73%) were negative for mean values 6.802.30 mg/l,
2 (4.65%) positive, 5 (11.62%) slightly positive values.The dominant negative
values in the two groups are almost the same, but in hypothyroidism proved to be
signifcantly higher than in hyperthyroidism (P,0.001).
Conclusion
The FT
4
neither in the hyperthyreosis nor in the hypothyreosis has an effect on the
CRP synthesis. It does not modify this phase of the nonspecifc defence system.
PI81
Coagulation disorders in hypothyroidism: effects of thyroid hormones
dehciency and/or of TSH?
John Yango, Orsalia Alexopoulou, Stephane Eeckoudt, Cedric Hermans
& Chantal Daumerie
Universite Catholique de Louvain, Brussels, Belgium.
Various haemostatic abnormalities have been associated with thyroid dysfunc-
tion, especially with hypothyroidism. The underlying mechanisms are not well
established.
The aim of the study was to evaluate the primary and secondary haemostasis in
patients with severe hypothyroidism, to assess the role of thyroid hormone
defciency and to determine whether increased serum TSH level despite normal
free thyroid hormone concentrations could infuence the coagulation system.
Platelet count, fbrinogen, prothrombin time, activated partial thromboplastin time
(APTT), INR, thrombin time, factor VIII activity, factor von Willebrand were
measured in 52 patients (age 4514 years, 40 women and 12 men) with previous
total thyroidectomy for differentiated thyroid cancer. Factor von Willebrand and
factor VIII activity were signifcantly decreased while APTT was signifcantly
increased in hypothyroidism(after withdrawing of thyroid hormones) compared to
euthyroidism in 22 patients: TSH (U/ml): 94.336.0 vs 1.011.44, P,0.001;
FT
4
(ng/dl): 0.190.07 vs 1.30.2, P,0.001; factor VIII activity (%): 109.3
39.4 vs 144.533.3, P,0.001; factor von Willebrand activity(%): 102.640.8
vs 140.545.6, P,0.001; factor von Willebrand antigen (%): 97.435.9 vs
120.733.5, P,0.001; APTT (seconds): 27.82.3 vs 25.21.6, P,0.001). No
changes in all clotting parameters were observed in 30 patients evaluated before
administration of recombinant human thyrotropin and at day 3 of the peak of TSH.
This prospective study shows that a short termsevere hypothyroidismis associated
with signifcant changes of factor VIII activity and factor von Willebrand.
Increased TSH has no effect on coagulation parameters. This suggests that low
thyroid hormone concentration is the main possible cause of alteration of
coagulation parameters.
Surgery may be thus performed in subclinical hypothyroidism without risk of
bleeding
PI82
Mild hypothyroidism in young patients with congenital heart defects:
association with 22q11.2 microdeletion
Passeri Elena
1
, Frigerio Marcello
2
, De Filippis Tiziana
3
, Valaperta Rea
2
,
Costa Elena
2
, Fugazzola Laura
4
, Porazzi Patrizia
3
, Calebiro Davide
3
,
Arcidiacono Carmelo
5
, Carminati Mario
5
, Ambrosi Bruno
1
, Persani Luca
3
& Corbetta Sabrina
1
1
Endocrinology and Diabetology Unit, Department of Medical-Surgical
Sciences, University of Milan, IRCCS Policlinico San Donato, San Donato
Milanese (MI), Italy;
2
Molecular Biology Laboratory, IRCCS Policlinico
San Donato, San Donato Milanese (MI), Italy;
3
Experimental Endocrine
Lab, Department of Medical Sciences, University of Milan, IRCCS Istituto
Auxologico Italiano, Cusano Milanino (MI), Italy;
4
Endocrine Unit,
Department of Medical Sciences, University of Milan, IRCCS Fondazione
Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Milan, Italy;
5
Pediatric Cardiosurgery, IRCCS Policlinico San Donato, San Donato
Milanese (MI), Italy.
Congenital hypothyroidism (CH) is frequently associated with congenital heart
defects (CHD). Thyroid defects may have a higher prevalence in children with
CHD as embryonic thyroid gland share nuclear transcription factors with heart
and great vessels during organogenesis. We investigated thyroid function in
325 children (165 M/160 F, aged 0.2-15.4 years), affected by CHD. Patients
with Down syndrome, recent administration of iodinated contrast agents, low
T
3
syndrome or receiving amiodarone were excluded. Two patients were
diagnosed with CH at the neonatal screening. Mild or subclinical
hypothyroidism (serum TSH4.0 U/ml) was diagnosed in 37 children
(11.4%), fully normal at neonatal screening (TSH 5.41.5 U/ml; free T
4
1.30.2 ng/dl (nv 0.8-1.9)). Increased TSH levels were confrmed six months
later. No relationship between hypothyroidism and type of CHD as well as age
was detected. TSH levels inversely correlated with free T
4
levels (r0.115,
P0.044). We investigated the pathogenesis of the mild hypothyroidism.
Thyroid autoimmunity with inhomogeneous ecogenicity was present in 3
hypothyroid children (8.1%). Thyroid ultrasound examination was normal in all
except one patient with hemiagenesis (2.7%). Patients with CHD and non-
autoimmune hypothyroidism (n36) were screened for genomic variations in
candidate genes. NKX2.5 coding sequence was normal in all samples. A qPCR
Real-Time analysis detected a 3 Mb microdeletion in 22q11.2 in 3 patients
(8.1%). Thus, in the present series mild hypothyroidism affected 50% of the
patients with 22q11.2 microdeletion (n6). Interestingly, one 22q11.2-deleted
patient with mild hypothyroidism had a monozygotic twin with TSH
3.44 U/ml and normal free T
4
. Mutational screening of the TBX1 gene
identifed known polymorphisms but did not detect any mutation. In
conclusion, a mild hypothyroidism occurs in about 12% of children with
CHD and is rarely related to thyroid autoimmunity or dysgenesia. Finally,
22q11.2 deletion is frequently found in CHD patients with nonautoimmune
mild hypothyroidism.
PI83
Changing trends in the incidence of thyroid carcinoma in a single
clinical centre
Ryszard Anielski
1
, Stanislaw Cichon
1
, Malgorzata Trofmiuk
2
,
Pawel Orlicki
1
& Alicja Hubalewska-Dydejczyk
2
1
Department of Endocrine Surgery, 3rd Chair of General Surgery,
Jagiellonian University Medical College, Krakow, Poland;
2
Chair and
Department of Endocrinology, Jagiellonian University Medical College,
Krakow, Poland.
Introduction
The incidence of the thyroid carcinoma (TC) is relatively low, although its
increase has been observed in the last 20 years.
Aim
A comparative clinical and epidemiological analysis of two cohorts of patients
surgically treated for the thyroid diseases in the Endocrine Surgery Department in
Cracow during two fve-year periods: 1982-1986 and 2000-2005.
Two subsets of patients, who underwent thyroid surgery, were included: group I
consisting of 988 subjects operated in 1982-1986 and group II of 4760 patients
operated in 2000-2005. Data from both groups were analyzed for age, sex and TC
frequency and from TC subgroups - for histotypes and pTNM stage.
Results
Both groups did not differ demographically. The carcinoma percentage was 3.7%
(n37) in group I, and 11.3% (n537) in group II (P,0.001). Papillary TC
prevailed in both subgroups (40.6 and 67.9% in subgroup I and II, respectively;
P,0.001). Both subgroups differed signifcantly in anaplastic TC (16.2 and
2.8%, respectively) and epithelial carcinoma frequency (5.5 and 0.4%,
respectively) (P,0.05). The percentage of the follicular TC was similar in
both subgroups (24.3 and 20.1%, respectively). The TC in subgroup I was more
clinically advanced in subgroup I at the time of surgery. The pT1a stage was
found in 8.1% of cases of subgroup I, and in 34.3% of subgroup II, whereas the
pT4 stage in 40.5%, and 17.5%, respectively (P,0.001). The percentage of
patients with N was similar, whereas M was higher in subgroup I (8.1 vs
0.6%, respectively) (P,0.01).
Conclusions
i) The increase in TC percentage, mostly papillary subtype, among patients
surgically treated for thyroid diseases was observed.
ii) Nowadays patients are operated on at signifcantly earlier stage of TC.
iii) This trends most probably refects the changing diagnostic approach to the
nodular goiter and the infuence of the iodine prophylaxis.
PI84
Beverage iodine levels in Germany
Rainer Hampel
1
, Julia Kairies
1
& Harald Below
2
1
Universitatsklinik fur Innere Medizin, Abteilung fur Endokrinologie und
Stoffwechselkrankheiten, Rostock, Germany;
2
Institut fur Hygiene und
Umweltmedizin, Universitat, Greifswald, Germany.
Background
Sales of iodized table salt (household use, bulk containers) have been fat in
Germany since 1996/97. Nevertheless, the amount of iodide excreted with the
urine has been steadily on the rise in the German population since 1993.
Aim of the study
We investigated the beverage iodine levels as possible source of the increased
input of iodine into the food chain. No systematic studies on this topic have yet
been carried out in Germany.
Methods
A total of 510 samples were drawn from large grocery discounters who supply all
German states with their products (35% fruit and vegetable juices, 35% beers,
10% pooled milk and yoghurt drinks, 10% mineral water, 10% soda).
Determination of iodine: Sample preparation by solid phase extraction in the
water-based beverages. Sample preparation of milk and milk products by
trichloroacetic acid precipitation and centrifugation. Determination of the iodide
concentration by HPLC and electrochemical detection.
Results
Since the iodine concentrations in the beverage samples showed a left-skewed
distribution, all expressed values are median values. Low iodine concentrations
were observed in the water-based beverages: fruit and vegetable juices 2.92 g
I
/l, beers 2.91 g I
/l, mineral waters 0.5 g I
/l, sodas 0.5 g I
/l. The
median value measured in pooled milk and its derived products was 117 g I
/l
and 126 g/l, retrospectively. As expected, summer milk was lower in iodine than
winter milk (x
~
108 g I
/l and x
~
134.2 g I
/l, retrospectively). Although

not statistically signifcant, beers from Northern Germany had higher
concentrations of iodine than did beers from Southern Germany (x
~
3.6 vs
0.5 g I
/l).
Conclusions
Based on our results, milk and milk products (117 g I
/l and 126 g/l,

retrospectively) contribute signifcantly to the increased nutritional iodine supply
of the German population.
PI85
Urinary iodide excretion in adults in Germany 2005 meets WHO target
Rainer Hampel
1
, Gundolf Bennohr
1
, Ansgar Gordalla
1
& Harald Below
2
1
Universitatsklinik fur Innere Medizin, Abteilung fur Endokrinologie und
Stoffwechselkrankheiten, Rostock, Germany;
2
Institut fur Hygiene und
Umweltmedizin, Universitat, Greifswald, Germany.
Background
Recent regional and German wide investigations have shown that the abolition of
the requirement to declare iodine in foodstuffs and the greater emphasis on
information about goitre prevention led to an increase in urinary iodine excretion
in German schoolchildren. There was also a decrease in thyroid size and goitre
prevalence in children. No up to date results in adults for the whole of Germany
are available.
Methods
In 2005, we examined the urinary iodine excretion in the spontaneous morning
urine of 1538 healthy adults in 357 places from all over Germany. The iodine was
measured by the Cer-arsenit method.
Results
The median iodine excretion amounted to 132 g/l. There were no signifcant
differences between age groups, sexes or regions. 64% had no iodine defciency
(100 g/l). In 23% the defciency was slight (50-99 g/l), in 10% moderate
(20-49 g/l) and in 3% there was severe iodine defciency (,20 g/l). 29%
excreted 200 g iodide per litre urine.
Conclusion
According to the WHO guidelines, there is no longer an iodine defciency in
German adults.
PI8
Effect of pentoxifylline and glucocorticoids on peripheral blood
mononuclear cells proliferation and apoptosis in Graves`
ophthalmopathy
Anastasiya Hlazkova
1
, Irina Melnik
1
, Larissa Danilova
1
,
Svetlana Kosmacheva
2
, Nataliya Goncharova
2
, Denis Antipovich
1
& Janna Kirilenko
1
1
Belarussian Medical Academy of Post-Graduate Education, Minsk,
Belarus;
2
Research and Practical Centre of Hematology and Transfusion,
Minsk, Belarus.
The phosphodiesterase inhibitor pentoxifylline (PTX) is known to have
immunomodulatory effects in some autoimmune diseases. The aim of our study
was to assess the infuence of glucocorticoids monotherapy and additive treatment
with PTX on peripheral blood mononuclear cells (PBMC) proliferation and
apoptosis in patients with Graves` ophthalmopathy (GO).
Eighteen patients with GO and 28 healthy controls were investigated. GO patients
were divided into two groups: A - 10 patients treated with glucocorticoids, B - 8
patients treated with glucocorticoids and PTX for 6 weeks. We assessed the
proliferation of PBMC stimulated with phytohemagglutinin (PHA) 0.5 g/ml,
10.0 g/ml. Both spontaneous and PHA-induced three-day apoptosis was
evaluated by fow cytometric analysis. Results of proliferation assay being
expressed as stimulation index (SI). Mean SI for patients with GO prior to therapy
was signifcantly higher then controls (PHA 0.5 g/ml, PHA 10.0 g/ml,
P,0.05). After treatment SI reduced in both groups, but signifcant differences
observed in group B (PHA 0.5 g/ml 19.9110.68 vs 9.384.68, P,0.05; PHA
10.0 g/ml 98.3916.72 vs 53.538.62, P,0.05).There was a signifcant
difference of stimulated apoptosis between GO patients and controls before
treatment (P,0.001). Following 6 weeks of therapy apoptosis level increased in
both groups of patients. However, the apoptosis value signifcantly increased after
the combination therapy with PTX only (4.01.36 vs 21.07.42%, P,0.05) in
comparison with glucocorticoids monotherapy (3.41.45 vs 12.34.72%,
P0.05). Thus, our investigation indicates that PTX potentiate the effect of
glucocorticoids on PBMC proliferation and apoptosis in GO patients.
PI8I
Serum levels of antibodies to thyroid peroxidase in women after
miscarriages in comparison with the 1st trimester of pregnancy and
healthy non-pregnant women
Jan Jiskra
1
, Tomas Fait
2
, Zdenka Limanova
1
, Marie Antosova
1
,
Zdenek Telicka
1
, Drahomira Springer
3
& Eliska Potlukova
1
1
3rd Department of Medicine, Department of Endocrinology and
Metabolism, First Faculty of Medicine, Charles University in Prague and
General University Hospital, Prague, Czech Republic;
2
Department of
Obstetrics and Gynaecology, First Faculty of Medicine, Charles University
in Prague and General University Hospital, Prague, Czech Republic;
3
First
Faculty of Medicine, Institute of Clinical Biochemistry and Laboratory
Diagnostics, Charles University in Prague and General University Hospital,
Background
Etiology of infertility and miscarriages is multifactorial. Negative impact of overt
thyroid dysfunction on fertility, pregnancy and development of offspring is
known. Moreover, even presence of euthyroid autoimmune thyroid diseases may
increase risk of miscarriages. The prevalence of positive antibodies to thyroid
peroxidase (TPOAb) ranges 9-39% in women with recurrent miscarriages and
0-37% in controls. The aim of the study was to compare serum concentrations of
thyroid stimulating hormone (TSH), free thyroxine (FT
4
) and TPOAb between
women after early miscarriages (until 16th week), women in the 1st trimester of
pregnancy and controls.
One hundred and ffty randomly chosen women after at least one early
miscarriage (until 16th week), 150 age-matched non-selected women in 9-11th
week of pregnancy and 49 healthy non-pregnant women as controls were included
in the study. All women were examined clinically and family and personal history
with respect to thyroid and autoimmune diseases will be taken. Complete
laboratory and ultrasound examination of thyroid gland were performed. Serum
concentrations of TSH, FT
4
and TPOAb were determined by chemiluminiscence
method (analyser Centaur, Bayer, Germany).
Results
Although there was not a difference between prevalence of positive TPOAb
(143 kIU/l) after miscarriages, in the 1st trimester of pregnancy and controls
(9.2 vs 12.0 vs 12.2%), slightly increased serum levels of TPOAb in women after
miscarriages in comparison with the 1st trimester were found (medians: 37.00 vs
26.00, P,0.001). Similarly, serum TSH was slightly higher in women after
miscarriages in comparison to the 1st trimester (medians of TSH: 1.67 mIU/l vs
1.41, P0.04). On the contrary, serum FT
4
was lower in the 1st trimester as
compared with women after miscarriages (means of FT
4
: 14.792.11 vs 13.99
1.53 pmol/l).
Conclusion
Prevalence of positive serum TPOAb did not signifcantly differ between women
after miscarriages, in the 1st trimester of pregnancy and controls. Nevertheless,
serum levels of TPOAb were slightly higher in women after miscarriages as
compared to non-selected pregnant women in the 1st trimester.
PI88
Role of calcitonin (Ct) in wash-out uid from hne-needle aspiration
(FNAB) in the diagnosis of medullary thyroid cancer (MTC):
comparison with basal calcitonin, cytology and pentagastrin stimulation
test (Pg-Test)
Vincenzo Rochira, Chiara Diazzi, Lucia Zirilli, Stefania Romano,
Cesare Carani & Bruno Madeo
Department of Medicine, Endocrinology and Metabolism, and Geriatrics,
University of Modena and Reggio Emilia, Modena, Italy.
Introduction
Serum Ct is considered the most sensitive tool for MTC screening, but with poor
specifcity. Pg-test sensitivity and specifcity are high, but doubtful for
30-100 pg/ml of Ct peak. FNAB is not routinely used due to its very low
sensitivity and specifcity. Only few studies from a small number of patients are
available on the role of Ct measurement in the wash-out fuid (Ct-FNAB) for
MTC diagnosis, providing conficting results.
Aim of the study
To assess clinical usefulness of Ct-FNAB in the identifcation of primary MTC in
thyroid nodules.
Thirty-three patients (10M, 23F, meanS.D. age: 55.511 years), with thyroid
nodules and concomitant increased basal serum Ct. All subjects underwent a
Pg-stimulated Ct evaluation and a total of 54 thyroid nodules underwent
US-guided FNAB for both cytology and Ct-FNAB.
Results
Ct-FNAB levels in nodules with MTC or C-Cells Hyperplasia (CCH) was
signifcantly (P,0.0001) higher than in hyperplastic nodules and than serum Ct
(P0.02). The sensitivity and the specifcity for basal Ct were 100 and 18.2%
respectively. The sensitivity for Pg-test resulted 100%, and the specifcity 95.4%.
Cytology sensitivity was very low (10%) with a specifcity of 95.4%. The ROC
curves showed that both Ct-FNAB and Pg-test to correctly distinguish MTC or
CCH nodules from hyperplastic nodules better than basal Ct. Regarding
Ct-FNAB alone the best pair of values for highest sensitivity (90%) and
specifcity (100%) was found using a cut-off of 100 pg/ml or of 36 pg/ml, with the
best values at 100 pg/ml.
Discussion
The results of this study suggest that using both the cut-offs of 36 and 100 pg/ml,
Ct-FNAB may be an highly reliable marker with a high sensitivity and specifcity
for MTC early detection in skilled hands. In clinical practice, only Ct-FNAB
allows to know the exact localization and size of MTC already before
thyroidectomy.
PI89
BRAFV600E analysis on hne needle aspiration biopsy increases
diagnostic accuracy for papillary thyroid cancer in clinically
unsuspected nodules
Martina Rossi
1
, Giorgio Trasforini
1
, Stefania Leoni
1
, Federico Tagliati
1
,
Roberta Rossi
1
, Elio Roti
2
, Ettore C degli Uberti
1
& Maria Chiara Zatelli
1
1
2
General
Medicine Ospedale di Suzzara SpA, Suzzara, Italy.
Papillary thyroid cancer (PTC) represents the majority of differentiated thyroid
cancers, presenting in 29-83% of cases the activating BRAF V600E mutation.
The aim of our study was to analyse the infuence of BRAF V600E mutation
analysis on diagnostic accuracy of fne needle aspiration biopsies (FNAB) in
clinically unsuspected thyroid nodules. We therefore enrolled 496 patients (383
females, 113 males; mean age 52 years), for a total of 671 samples. FNAB were
evaluated by the cytologist and the syringe wash out was employed for BRAF
mutation analysis, performed after DNA isolation by direct sequencing and allelic
discrimination. Among the 671 samples, BRAF V600E mutation was found 34,
including 24 diagnosed as PTC also citology-wise (also confrmed by histology).
Total thyroidectomy was also performed in 10 patients with BRAF V600E
mutation but negative cytology, all confrmed as PTC at histology. Among the
637 samples with negative BRAF V600E mutation, 629 had benign citology,
while 8 were consistent with PTC then confrmed by histology. Statistical analysis
showed an incidence of 74% for the BRAF V600E mutation in PTC cases;
sensitivity was 73.9% and specifcity was 100%. Positive and negative predictive
values were 100 and 98.1%, respectively. Diagnostic accuracy of cytology was
97.9%, and increate to 99.4% when combined with BRAF mutation analysis.
These data indicate that BRAF V600E mutation analysis can signifcantly
improve diagnostic accuracy in clinically unsuspected cases. On the other hand
biomolecular analysis is complimentary to citology, since it is not suffcient to
diagnose every malignant case.
PI90
Diagnosing a cribriform papillary thyroid cancer in a patient with
familial adenomatous polyposis
Do Cao Christine, El Ouahabi Hanan, Berdelou Amandine,
Leuteurtre Emmanuelle, Carnaille Bruno, Beron Amandine
& Wemeau Jean Louis
University Hospital Claude Huriez, Lille, France.
Papillary thyroid carcinoma (PTC) is the most common malignancy originating
from the thyroid gland. Although occurring predominantly as a sporadic disease,
it may be associated with rare inherited circumstances such as familial
adenomatous polyposis (FAP) FAP is an autosomal dominantly inherited cancer
predisposition syndrome characterized by the progressive development of
colorectal carcinoma. Most of available data report accompanying thyroid
carcinoma in no more than 1-2% of FAP patients. Ninety-fve percent of these
cases are papillary thyroid carcinoma, most of them corresponding to an unusual
subtype, called cribriform histotype.
We describe the case of a 30-year-female presenting with a thyroid mass. She
reported a familial history of adenomatous polyposis, had undergone a total
colectomy at the age of 14. Physical examination revealed an asymetric goiter
containing several palpable nodules in the right lobe. Ultrasound demonstrated six
nodules in the right lobe and three smaller nodules in the left lobe, Enlarged
lymph nodes were also seen within both submandibular triangles. Aspiration
cytology under sonographic guidance performed in the right dominant nodule
strongly suggested diagnosis of PTC. Computed tomography scan confrmed the
presence of multiple thyroid nodules. TSH level, serum calcitonin and
carcinoembryonic antigen measurements were within normal limits. Total
thyroidectomy with a central compartment neck node dissection was performed
and the patient was later referred for radio metabolic treatment as malignancy was
confrmed.
The pathology report actually gave the diagnosis of multifocal cribriform morular
variant of PTC with immunohistochemical staining for the presence of estrogen
and progesteron receptors. On genetic analysis, germline mutation was identifed
at codon 637 of the APC gene.
Special attention has to be devoted to cervical examination in patients with FAP
as cribriform papillary thyroid cancer can develop early in young adults. It can be
notably suspected in presence of multiple thyroid nodules sharing the same
ultrasound features.
PI91
Is there a relationship between colonic polyps and thyroid nodules?
Huseyin Savas Gokturk
1
, Cevdet Duran
2
, Mustafa Kulaksizoglu
2
, Gulhan
Kanat Unler
1
, Mustafa Erbayrak
1
, Guven Ozkaya
3
, Baris Onder Pamuk
2
& Mustafa Sait Gonen
4
1
Department of Gastroenterology, Konya Research Hospital, Baskent
University, Konya, Turkey;
2
Division of Endocrinology, Konya Education
and Research Hospital, Konya, Turkey;
3
Department of Biostatistic,
Medical Faculty, Uludag University, Bursa, Turkey;
4
Division of
Endocrinology, Medical Faculty, Selcuk University, Konya, Turkey.
Aim
Colonic polyps and thyroid nodules are common diseases and frequency increases
with age. In the literature, there is no study investigating the relationship between
colonic polyps and thyroid nodules. Therefore, this study was designed to
investigate thyroid nodule frequency in patients who have colonic polyps.
Sixty-six patients with colonic polyps and 146 patients without colonic polyps
enrolled in the study. Age and sex matched control group was composed from
patients without colonic polyps. Colonoscopic examinations, thyroid ultrasono-
graphies were performed in all patients and TSH, fT
4
levels were measured.
Results
Male/female ratio in polyp and control groups were 40/26 vs 68/78 respectively
(P0.058). Mean patient ages were similar in both groups (53.311.4 vs 51.8
11.4, P0.373). Thyroid nodule was detected in 44 (66.7%) patients in
polyp group and 61 (41.8%) in controls (P0.001). Forty-six patients had single
polyp, 9 had 2 polyps, 7 had 3 and 4 had 4 or more polyps. Most of them localized
in rectosigmoidal region. Histopathological examination revealed adenomateous
polyp in 36 patients, hyperplastic polyp in 20 patients, and mixed type in 10
patients. Mean TSH levels were lower in the polyp group than controls (1.17
0.95 vs 1.541.3, P0.002, respectively). In 95 patients, number of nodules
were lower than 5 and in 10 patient 5 or more. Thyroid nodules were 10 mm in
34 patients.
Conclusion
Thyroid nodules were detected more common in patients with colonic polyps.
Further studies are needed to clarify this coexistence.
PI92
Improving the accuracy of clinical diagnosis in hyperthyroid disorders
using ultrasound assessment
Jessica Triay & Parag Singhal
Weston Area Health Trust, Weson-Super-Mare, UK.
Background
Thyroid ultrasound (US) is not routinely used in the evaluation of hyperthyroid-
ism, although studies show that clinical exam may miss lesions up to 2 cm in
diameter. We reviewed our department`s practice of thyroid US to consider
(1) accuracy of our clinical diagnosis and (2) whether this could improve
management. Our hospital has no facility for isotope scanning.
Methods
Seventy-three cases (13 male, 60 female) identifed from thyroid US requests.
Clinical notes, thyroid autoantibodies and fne needle aspiration (FNA) reviewed,
excluding those with thyroid imaging prior to consultation and Amiodarone
related disease.
Results
Clinical diagnoses - 24 Graves disease, 21 Multinodular disease (MND),
2 postpartum thyroiditis, 2 transient thyroiditis, 20 no clear diagnosis.
i) Graves. Of 24 clinical cases only 7 had consistent US and antibody fndings.
ii) MND. Of 21 clinical cases 18 had ultimate diagnosis of MND
iii) Overlap. 9 had US features of MND and positive antibodies
iv) Dissociation. 6 had US features of Graves but negative antibodies
v) Missed solitary/dominant nodule in 3 cases of clinical Graves (all antibody
negative). 1 solitary nodule missed in 'no clear diagnosis` group.
Conclusions
Palpation can miss important thyroid abnormalities. Accurately diagnosing
Graves` disease is challenging, but, as up to 80% of this patient group may be
treated with antithyroid drugs alone, this is current frst line practice in Europe.
Multinodular and autoimmune thyroid changes can coexist, making it unclear
which disease process predominates and what the natural course may be.
Knowledge of multinodular changes may prompt earlier recommendation of
defnitive therapy to avoid relapse (radioactive iodine or surgery). Ultrasound is
simple, widely available and inexpensive. Knowledge of the underlying problem
can be used to facilitate treatment discussions with patients for improved
informed decision making, which may reduce follow up time.
PI93
Differences in Graves` orbitopathy between hyperthyroid and
hypothyroid/euthyroid patients
Biljana Beleslin, Jasmina Ciric, Milos Zarkovic, Mirjana Stojkovic,
Slavica Ciric, Miroslav Knezevic & Bozo Trbojevic
Clinic for Endocrinology, Diabetes and Metabolic Disorders, Belgrade,
Serbia.
Aim
The aim of this study was to compare clinical symptoms and TSH receptor
antibodies (TRAb) in Graves orbitopathy (GO) in hyperthyroid patients to those
patients with primarily hypothyroid and euthyroid status.
Methods
Study group consisted of 54 primarily hyperthyroid (39 female, 14 male, 479
years) and 8 primarily hypothyroid and euthyroid patients (5 female, 3 male, 46
14 years). Clinical symptoms and TRAb were assessed. Assessment of the
activity and severity of GO was carried out according to the proposed criteria of
the European group on GO.
Results
CAS score was lower in hypothyroid/euthyroid patients than in hyperthyroid but
not signifcantly (4.3 vs 3.6, Pns). There was no differences in rate of diplopia,
visual acuity and intraocular pressure between groups. On the other hand, there
was a trend towards more asymmetrical presentation of GO in patients who were
hypo/euthyroid (proptosis OD vs OS: 20.4 vs 22.3, P0.08) than in hyperthyroid
patients (proptosis OD vs OS: 21.7 vs. 21.8, Pns). TRAb levels were
signifcantly lower in hypothyroid/euthyroid patients than in hyperthyroid (2.5 vs
16.3 IU/l, P0.002).
Conclusion
Those fndings of lower levels of TRAb and more asymmetrical presentation of
GO in hypothyroid/euthyroid patients could be helpful in clinical practice,
especially differential diagnosis of GO.
PI94
Prevalence of undiagnosed thyroid disease in pregnancy
Anargyros Kourtis
1
, Kali Makedou
1
, Athina Giomisi
1
, Maria Mouzaki
1
,
Aristides Slavakis
2
, Ioannis Kalogiannidis
1
, Nikolaos Prapas
1
&
Theodoros Agorastos
1
1
Aristotle University of Thessaloniki, Thessaloniki, Greece;
2
Hormone
Laboratory, Hippokratio General Hospital, Thessaloniki, Greece.
Background-aim
Normal thyroid function during pregnancy is critical for fetal development.
Defcient maternal thyroid hormone levels are associated with impaired
neuropsychological development in childhood, premature birth, preeclampsia
and fetal mortality. Conversely, excessive maternal thyroid levels have been
linked to fetal loss, disturbed fetal growth, preeclampsia and preterm delivery.
Recent consensus guidelines do not advocate universal thyroid function screening
during pregnancy. The aim of the present study was to investigate the prevalence
of undiagnosed thyroid disease in pregnancy.
During 2009, we studied 178 consecutive pregnant women (mean ageS.D.
28.265.56 years), during their antenatal visit between 26 and 28th week of
pregnancy. Serum levels of TSH, free T
3
and free T
4
were measured.
Results
Median (range) values of TSH, FT
4
and FT
3
were 1.61 (0.11-6.4), 0.96
(0.71-1.53) and 3.77 (2.17-5.93), respectively. Of the 178 pregnant women, none
presented hyperthyroidism or hypothyroidism. Nevertheless, 9 women (5.1%)
reached the second trimester of pregnancy with subclinical hyperthyroidism
(normal free T
4
values and TSH values below normal) and 27 (15.2%) were found
to have subclinical hypothyroidism (normal free T
4
values and TSH values above
normal).
Conclusions
There is still a high percentage of pregnant women that reach second trimester of
pregnancy with undiagnosed thyroid disease. Although it remains controversial
whether to screen for thyroid disease or not, it seems reasonable to screen women
with a serum TSH, if they are pregnant or contemplating pregnancy.
PI95
Parvovirus B19 infection: a possible role in autoimmune thyroid
diseases
Etienne Justinien
1
, Christine Pannier
2
, Cyril Page
3
, Christine Segard
2
,
Vladimir Strunski
3
, Henri Sevestre
4
, Gilles Duverlie
2
& Rachel Desailloud
1
1
Endocrinology Unit, University Hospital, Amiens, France;
2
Virology Unit,
University Hospital, Amiens, France;
3
Oto-Rhinolaryngology Unit,
University Hospital, Amiens, France;
4
Pathology Unit, University Hospital,
Amiens, France.
Introduction
Autoimmune thyroid disease (AITD) is a common disease. It arise due to
interactions between genetic background and environmental factors. However
this interactions remain unclear. As it induces other autoimmune diseases,
parvovirus is an attractive candidate.
Objective
To investigate the presence of parvoviral DNA in postoperative thyroid tissues.
We collect prospectively postoperative thyroid specimens and serum samples
from 90 patients. We investigate presence of IgG antibodies on serum samples
(IgG Parvovirus B19 - Biotrin). Presence of parvoviral genome sequences in
thyroid was investigated by real-time PCR (Artus` ParvoB19 TM PCR Kit -
Qiagen) in serum samples and in thyroid specimens of patients, who were IgG
positive (which prove a contact with parvovirus).
Results
Thirty-three patients were IgG positive. Parvoviral DNA detection was positive in
6 out of the 33 thyroid specimens. Only 1 serum sample was DNA positive out of
these 6 patients. Final diagnosis was Grave`s disease in 3 out of 6 'DNA
parvoviral positive`patients (50%) and in 3 out of 27 'DNA parvoviral negative`
patients (11.1%) (P0.08). Lymphocytic infltration was observed in 5 out of the
6 'DNA parvoviral positive` patients (83.3%) and in 9 out of the 27 'DNA
parvoviral negative`patients (33.3%) (P0.08). Two serum samples were DNA
positive out of these 27 patients.
Conclusion
DNA parvoviral presence in thyroid tissue is observed and is not due to viremia.
This study suggests a possible relation between Grave`s disease, thyroid
lymphocytic infltration and parvovirus infection. Further study are needed to
confrm these results.
PI9
Echocardiographyc features in resistance to thyroid hormone
Serafno Lio, Alfredo Danese & Ignazio Roiter
Ospedale Civile Tomitano, Oderzo, TV, Italy.
Resistance to thyroid hormone (RTH) is a rare dominantly inherited condition of
impaired tissue responsiveness to thyroid hormones. Different tissue may exhibit
variable degree of resistance and clinical presentation probably depending on the
heterogeneity of factors that modulate the isoform of thyroid hormone receptor
(THR). The heart shows different isoforms of THR and few data is reported on the
cardiac functionally effects of the phenotypic heterogeneity; echocardiography is
considered an accurate non-invasive technique for the evaluation of cardiac
function. We report the data of three patients with RTH. Two of these is father
(pt no. 1) and the only child (pt no. 2) of 59- and 20-year-old, respectively; the
third patient (pt no. 3) is a male of 69-year-old. The pt no. 1 and no. 2 revealed a
mutation of exon 8-codon 268 of THR-1-gene whereas the pt no. 3 is wild-type.
None are positive for thyroid autoantibodies. The other principal data were
reported in Table.
In conclusion, in RTH the cardiac abnornmality it doesn`t seem only related with
mutation but probably also with duration of the condition. In fact is evident an
intrafamilial and phenotipic heterogeneity of cardiac manifestation Pulmonary
hypertension, shows only in pt no. 1 and previous reported in hyperthyroidism, is
probably related to the duration of the disease.
PI9I
Reversible thyrotoxic cardiomyopathy
Tariq Nasser, Abdulhalim Kjnsarah & Abdullah Karawgh
King Abdulaziz National Guard Medical City, Jeddah/Western Region,
Saudi Arabia.
A 47-year-old, previously healthy, ex-smoker male presented with a two-week
history of dyspnea grade 4 with progressive course, palpitations, orthopnea, and
paroxysmal nocturnal dyspnea. There was no history of chest pain or fever, but he
had noticed recent an unintentional 10 to 15 kg weight loss over the previous
3 months. There was no previous history of cardiorespiratory problems,
hypertension, and diabetes. On examination he was dyspenic, anxious and
tremulous. His temperature 37 ?C, the respiratory rate was 30/min and the blood
pressure was 140/60 mmHg with an irregular pulse of 170 bpm. He had staring
look, but no lid lag and no exopthalmos, and the thyroid gland was not palpable.
The cardiovascular examination was remarkable for a jugular venous pressure of
10 cm above the sternal angle, a displaced point of maximal impulse, an S3 and
bilateral pitting edema. There were bilateral crackles on chest examination. Chest
radiograph showed cardiomegaly, right sided pleural effusion and pulmonary
congestion. Electrocardiogram showed rapid atrial fbrilation with non-specifc
ST-T wave changes. Transthoracic echocardiograms demonstrated dilated left
ventricular and left atrium with ejection fraction 26% and diffuse global
hypokinesia, global and moderate bi-atrial enlargement. TEE echo-cardiogram
demonstrated left atrium thrombus. Laboratory investigations were signifcant for
normal electrolytes, renal function, and cardiac enzymes. Free T
4
was 40 ng/dl
(9-19), free T
3
24 ng/dl (2-5.7), TSH was ,0.01 U/l (0.5-4.9) and thyroid-
stimulating immunoglobulin was elevated at 20.7 U/l (negative ,1.0).Thyroid
ultrasound and CT-neck demonstrated Diffuse enlargement of the thyroid gland
that is moderate in degree with no focal lesion or obvious nodule consistent with
diffuse toxic goiter. The diagnosis of dilated Cardiomyopathy likely secondary to
thyrotoxicosis was made, and the patient was started on diuretics, heparin,
digoxin, and metoprolol. After the thyroid result was obtained, he was started on
Antithyroid drug initially high dose propyl-thiouracil and then methimazole and
continued on warfarin. The patient`s condition subsequently improved, One
month later he was clinically and chemically euthyroid, and out of heart failure,
and a repeat systolic ejection fraction was 55%. Neomarcazole was stopped for
seven days and thyroid technetium scan demonstrated diffuse increase thyroid
uptake, subsequently radioactive iodine was given, after which he became
hypothyroid and he was started on levothyroxine replacement. Three months later
his rhythm was still in atrial fbrillation, so the patient was successfully converted
mechanical to sinus rhythm. Currently, he is on thyroxine and all other
medications were stopped. Repeated echocardiogram after 6 months revealed
resolution of left ventricular hypertrophy, with an ejection fraction of 60%.
Thyrotoxicosis seemed to be directly responsible for the development of
sustained tachycardia - induced cardiomyopathy causing severe heart failure.
Although thyrotoxic cardiomyopathy relatively uncommon, this aetiology should
not be overlooked in patients with thyrotoxicosis and heart failure. This case
shows that hyperthyroidism by itself can cause a reversible cardiomyopathy.
PI98
Usefulness of sorafenib in the management of advanced thyroid
carcinoma
Gabriel Obiols, Jaume Capdevila, Carles Zafon & Jordi Mesa
Hospital Vall d`Hebron, Barcelona, Spain.
One of the most important activating genetic aberrations in differentiated thyroid
cancer (DTC) development pathways involves the RET/PTC-RAS-RAF-MAPK
axis. Mutations in the RET gene are essential in medullary thyroid carcinoma
(MTC). Sorafenib is the frst compound to reach clinical practice that is capable of
inhibiting all the RAF kinases. Moreover, it targets a panel of tyrosine kinase
receptors, such as VEGF receptors which gives to sorafenib not only
proapoptotic, but also antiangiogenic properties.
Aim
To investigate the usefulness of sorafenib in the treatment of thyroid cancer.
Eleven patients (6 MTC, 4 DTC, 1 anaplastic carcinoma) with advanced disease
(distant metastases) have been treated with sorafenib (age at diagnosis 22-80
years; follow-up from diagnosis 1-18 years; duration of treatment 2-37 months).
To evaluate the response, we have used RECIST criteria and thyroglobulin (TG)
(in DTC and anaplastic) or calcitonin (CT) and carcinoembryonic antigen (CEA)
(in MTC) measurements.
dgu j dgu dgu
BM 26.4 19.3 28.2
Thyroid function Hyper Eu Hyper
Pulse rate Atrial fbrillation Sinusal rhythm Atrial fbrillation
LV ejection
fraction %
56 62 66
LV shortening
fraction %
31 38 37
Valvular
abnormality
Fibrosis annulus M Thickening LAM Normal
nsuffciency M A nsuffciency M
nsuffciency T Thickening A
Other Pulmonary - Hypertrophy LV
hypertension
LV, left ventricle; M, mitral; A, aorta; LAM, anterior mitralic lemb; T, tricuspid.
Results
Four MTC cases have shown partial response (PR) with tumour volume
reductions from 30 to 55%. Median CT levels decreased from 35 269 to
13 420 pg/ml and CEA from 260 to 115 ng/ml. Two cases have stable disease
(SD); CT decreased from 9805 to 5579 and from 65 495 to 36 397 pg/ml and CEA
from 52 to 32 and from 2104 to 894 ng/ml.
Three patients with DTC showed SD; median TG decreased from 1280 to
622 ng/ml. Two patients, including a follicular variant papillary TC and the
anaplastic carcinoma, experienced a progressive disease with tumours increasing
53 and 29% respectively, but with a reduction in Tg levels (from 137 to 107, and
from 65 to 32 ng/ml).
The most frequent side effects were hand-foot syndrome (8), oral mucositis (10)
and diarrhoea (8).
Conclusion
Sorafenib could be useful in advanced thyroid carcinoma. MTC appears to have a
better response than DTC.
PI99
Therapeutic effect of sesame oil on monosodium urate monohydrate
crystal-induced acute inammation in rat air pouches
Te-Jung Hsu, Pey-Yi Chu & Ming-Yie Liu
National Cheng Kung University Medical College, Tainan, Taiwan, ROC.
Hyperuricemia, results from the disorder of purine metabolism or endocrine
system, leads to an infammatory arthritis and gout. Sesame oil has been reported
to have a potent anti-infammatory effect in various animal models. The aim of the
present study is to examine the therapeutic effect of sesame oil on monosodium
urate monohydrate (MSU) crystal-induced acute infammation in air pouch in
unanaesthetised Sprague-Dawley rats. Air pouch, a commonly used model for
gouty arthritis, was established in rats by injecting 10 and 3 ml of sterilized air
into subcutaneous tissue of the back at day -6 and day -3, respectively. At day 0,
infammation in air pouch was induced by injecting MSU crystal (5 mg/rat,
suspended in sterilized phosphate buffered saline, pH 7.4), while sesame oil
(0, 1, 2, or 4 ml/kg, orally) was given 6 h after MSU injection. Total cell counts,
nitrite, and infammatory cytokines levels in lavage and tissue from pouch were
determined 6 h after sesame oil administration. MSU crystal increased the total
cell counts, nitrite, interleukin (IL)-1, and IL-6 levels in lavage compared with
normal group. Sesame oil signifcantly decreased all the parameters in a dose-
dependent manner compared with MSU alone group. In addition, sesame oil
signifcantly decreased tumour necrosis factor-, IL-1, IL-6 levels in pouch
tissue compared with MSU alone group. In conclusion, sesame oil showed a
potent therapeutic effect against MSU-induced infammation in rats. Further,
sesame oil may have the potential in treating patients with gouty arthritis in
the future.
P800
CTLA-4 1661A/G and 658C/T gene polymorphisms in autoimmune
thyroid diseases
Ileana Duncea
1
, Laura Crisan
1
, Radu Popp
2
, Carmen Georgescu
1
,
Ioana Ilie
1
, Adrian Paul
1
, T Crisan
2
& Cristian Brad
1
Department of Endocrinology, University of Medicine and Pharmacy
Cluj-Napoca, Cluj-Napoca, Romania;
2
Department of Genetics, University
of Medicine and Pharmacy Cluj-Napoca, Cluj-Napoca, Romania.
Genetic predisposition to autoimmunity is probably predominant. Major
histocompatibility complex (MHC) alleles and non-MHC loci such as
polymorphism of the cytotoxic T lymphocyte antigen-4 (CTLA4) gene have
been identifed as susceptibility markers. The autoimmune thyroid diseases are
the most common organ-specifc autoimmune diseases. They are characterized by
the infltration of the parenchyma by immune cells including T and B cells as well
as macrophages. Ones a T cell is activated, it expresses proteins that transmit
co-stimulatory signals to sustain or modify clonal expansion and differentiation.
CTLA4 is a protein that inhibits co-stimulation. CTLA4 belongs to the
immunological super family Ig and is also known as the molecule CD 152; it is
expressed on T Helper surface and the CTLA4 gene was found on the
chromosome 2q33. There are few studies regarding association between
autoimmune thyroid diseases and polymorphisms of CTLA4 gene (49A/G,
CT 60). We aimed to investigate in a case-control study whether CTLA4
1661A/G and/or 658C/T are involved in genetic predisposition to
autoimmune thyroid diseases. Between January and April 2009 we observed
42 patients - 21 diagnosed with Hashimoto`s thyroiditis or Graves`s disease by
specifcs antibodies, 21 with no signs of autoimmunity. Written consent was
obtained from patients. After the isolation of genomic DNA from peripheral
blood mononuclear cells CTLA4 1661A/G and -658C/T gene polymorphisms
were genotyped by restriction fragment length polymorphism and the data were
statistical analyzed using SPSS program.
Results
Our results demonstrate a lack of association between CTLA-4 1661A\G and
658C\T polymorphisms and autoimmune thyroid disorders. It was not
statistically different between control group and patients group for both
polymorphisms: 1661A\G (P0.094), 658C\T (P0.889).
Conclusion
Our study illustrates the necessity to include a large number of patients in genetic
case-control studies and to investigate the association between these polymorph-
isms and other markers such as level of thyroid auto-antibodies.
P801
Cytokine prohle in Graves` ophthalmopathy patients
Reti Zsuzsanna
1,2
, Kun Imre Zoltan
1,2
, Gliga Camelia
1,2
,
Pop Radu Corina
1,2
, Nasalean Anisie
2
& Balazs Jozsef
2
1
University of Medicine and Pharmacy, Targu Mures, Mures, Romania;
2
Endocrinology Clinic, Targu Mures, Mures, Romania.
Objective
The latest studies on Graves` ophthalmopathy (GO) emphasize the importance of
the orbital adipose tissue and fbroblasts in the pathogenesis of the disease by
secreting proinfammatory cytokines. In vitro, these cytokines were proved to
have a major role in the maintenance and progress of infammation in the orbit.
The aim of this study was to investigate serum cytokine levels in patients
with GO.
Serum interleukins IL-1a, IL-2, IL-6, IL-8, and monocyte chemotactic protein-1
(MCP1) were determined with biochip-cytokine array (Randox) in ten patients
with Graves` ophthalmopathy. Thyroid function was investigated by measuring
TSH, FT
4
/TT
3
levels. TSH-receptor and antiTPO antibodies were also
measured. Smoking status was recorded. Activity and staging of the disease were
recorded following EUGOGO recommendations.
Results
There was no difference in interleukin levels between smokers and non-smokers,
euthyroid vs. hyperthyroid patients or in patient with active (CAS4) versus
inactive (CAS,4) GO. Patients with stages NOSPECS 0-III.c presented higher
MCP 1 levels compared with patients stages IV.a-IV.c (P0.045). In relation
with disease duration, there was only a difference in IL-2 levels, which were lower
in patients with evolution over 3 years (P0.052, r0.6301). Previous
corticotherapy or antithyroid therapy did not infuence measured serum
interleukin levels.
Conclusions
There is a high variability between individuals with GO in both clinical and
paraclinical parameters. In patients with early stages there seems to be a Th1
profle cytokine dominancy (IL-2, TNFa, IFNg). MCP 1 is likely to play a
protective or reparative role in less severe stages of GO. This study must be
extended to a larger number of patients.
P802
Predictors of cardiovascular risk in patients with hyperthyroidism
before and after radioiodine therapy
Anna Brona, Andrzej Milewicz, Anna Bohdanowicz-Pawlak,
Diana Jedrzejuk & Anna Arkowska
Medical University, Wroclaw, Poland.
It is suggested that radioiodine therapy in hyperthyroidism can increase mortality
because of cardiovascular diseases. To determine that fact we have evaluated how
the levels of predictors of the cardiovascular risk in serum such as: glucose,
insulin, total cholesterol and high-density cholesterol, low-density cholesterol and
triglycerides as well as CRP, fbrinogen and D-dimers changed in hyperthyroid-
ism cases before and 12 up to 16 and 24 up to 28 weeks after radioiodine therapy.
We studied 20 patients (nonsmoking women, age 51-69 years) with
hyperthyroidism, before and after treatment. The following parameters were
measured and estimated in serum using the commercial methods: TSH, fT
4
and
fT
3
, insulin, glucose, HOMA-IR, lipid profle, CRP, fbrinogen and
D-dimers.Thyroid function was in the normal range in 19 patients 12 up to 16
weeks after therapy. Statistical analysis showed no signifcant changes in serum
glucose (94.2514.07 vs 93.911.73 mg/dl), total cholesterol (203.4550.56
vs 213.7543.98 mg/dl) and HDL cholesterol (64.716.99 vs 65.5
13.85 mg/dl) before and 24 up to 28 months after therapy. In contrast LDL
cholesterol (110.1539.82 vs 12440.96 mg/dl), triglycerides (111.3554.9 vs
120.2541.42 mg/dl) and CRP (3.252.9 vs 3.981.97 mg/l) levels in serum
increased signifcantly (P ,0.05) 24 up to 28 months after radioiodine therapy.
The insulin level increased 24 up to 28 months after treatment (6.442.5
vs 7.453.65 IU/ml) accompanied by slight increase in HOMA-IR (1.520.67
vs 1.660.81 mM mU/l). Serum levels of D-dimers (632.85606.62 vs 500.5
281.36 ng/ml) as well as fbrinogen (39389.68 vs 355.886.17 mg/l)
decreased signifcantly 24 up to 28 months after therapy.
Our results suggest that radioiodine treatment have role in changing carbohydrate
metabolism as well as lipid profle. The results support the observation about
negative infuence of radioiodine on cardiovascular risk in patients with
hyperthyroidismwhen insulin, LDLcholesterol, triglycerides and CRP serumlevels
are considered. However it reduced hypercoagulable state. Due to small number of
patients and short time of observation the answer for the question about the infuence
of radioiodine therapy on cardiovascular risk factors require further studies.
P803
Thyroid lymphoma: a rare pathology: study on 9 cases
Voichita Mogos
1
, Carmen Vulpoi
1
, Cristina Burlacu
1
, Elena Cotea
2
,
Dan Niculescu
2
, Niculina Florea
3
, Delia Ciobanu
3
& Dan Ferariu
3
1
Department of Endocrinology, UMF Gr.T. Popa, Iasi, Romania;
2
Department of Surgery, UMF Gr.T.Popa, Iasi, Romania;
3
Department of
Morphology, UMF Gr.T.Popa, Iasi, Romania.
Thyroid lymphoma accounts for less than 5% of thyroid malignancies. The aim of
this study was to analyze the particularities of 9 patients (7 females and 2 males,
aged 42 to 76 years) diagnosed with thyroid lymphoma, representing 2.45% of
340 cases of thyroid malignancies. Patients were assessed by ultrasound
examination (7 cases), fne needle biopsy (FNB) (8 cases), lymph node biopsy
(2 cases), and histological examination after surgery (7 cases). Clinically, 6 cases
presented rapid growing multinodular goiter, and lymph node enlargement, and
3 cases had apparently uninodular goiter. In 6 cases ultasound showed multiple
hypoechoic nodules with enlarged hypoechoic lymph nodes. One case presented
with painful thyroid and a hypoechoic, large non-vascular nodule, which frst
responded well to glucocorticoids, but continued to grow after few time. FNB was
suspicious for malignancy in 4 cases and showed lymphocytes in 4. Antithyroid
antibodies were positive in 3 cases. Total thyroidectomy was performed in
7 cases, only lymph node biopsy in 1 case, and biopsy of an amigdala metastasis
in 1 case. Pathology showed MALT type lymphoma in 8 cases, among which one
with important plasmocytic differentiation, and one of large B cell lymphoma. In
one case thyroid lymphoma was limited to one lobe and in the controlateral lobe
an occult papillary microcarcinoma was found. In 4 cases the surrounding thyroid
tissue had lesions of Hashimoto`s thyroiditis. After surgery external irradiation
and chemotherapy was performed in 3 cases and chemotherapy in 6 cases.
Conclusion
Our cases presented typical features for thyroid lymphoma: middle- to old-age
persons, predominant females, with rapidly growing mass in the thyroid,
associated in 1/3 cases with Hashimoto thyroiditis. Although useful, FNB was
diagnostic in only 50% cases. Thyroidectomy was followed only by
chemotherapy in most cases and radiochemotherapy in a few cases which
accepted external irradiation.
P804
Ultrasound hne needle aspiration (US ~ FNA) in an Endocrinology
Department: our reality and results quality
Cristina Ribeiro, Sandra Paiva, Sofa Gouveia, Graca Fernandes, Miguel
Melo, Jacinta Santos, Alexandra Vieira, Marcia Alves, Francisco Carrilho &
Manuela Carvalheiro
University Hospital of Coimbra, Coimbra, Portugal.
Introduction
High-resolution US and US FNA are techniques of great relevance in the
evaluation of thyroid nodules. They are being used much more often by
endocrinologists all over the world. In our Endocrinology Department, we started
them in 2006; since then they have been progressively amplifed. We present our
results of US FNA performed from January 2007 until December 2009.
Two thousand eight hundred and seventy-seven FNA were performed in this
period. Data were collected according to the gender and age of the patients,
thyroid nodules size and location, and cytological diagnosis. Statistically, SPSS
16 was used.
Results
In these biopsies, 85.6% of the cytological diagnosis were colloid nodules
(n2462); 5.8%, insuffcient for diagnosis (n166); 3.6%, follicular
tumours (n105); 1.8%, lymphocytic thyroiditis (n51); 1.5%, papillary
carcinoma (n44); 0.7%, reactive lymphadenitis (n19); 0.2%, lymphoma
(n6); 0.2%, parathyroid adenoma (n6); 0.1%, medullar carcinoma (n4);
0.1%, lesions of uncertain benignity (n4). The mean age was 5715
(13-92) years, with statistically signifcant difference among some groups,
particularly the lymphomas (statistically older) and the thyroiditis, (statistically
younger). 87.8% of the patients were female (n2525) and 12.2% were male
(n350). The nodule size ranged from 0.7 to 7.0 cm (mean1.930.85).
On what concerns to the nodule location 44.2% were in the right lobe
(n1270), 42.8% in the left lobe (n1231) and 5.5% in the isthmus (n157).
Discussion
The huge number of FNA performed as well as the good results, with a small
number of nondiagnostic cytology, confrms the advantages of this exam
executed by endocrinologists. The best understanding of thyroid nodular
disease and the accuracy of the practitioner are important in the evaluation of
these patients.
P805
Cytologic comparison between growing and non-growing
benign thyroid nodules evaluated using two different
growth criteria
Mehmet Muhittin Yalcin
1
, Serkan Yener
1
, Sena Yesil
1
, Baris Akinci
1
,
Firat Bayraktar
1
, Abdurrahman Comlekci
1
, Sinan Unal
1
, Aytac Gullu
2
,
Sevinc Biberoglu
1
& Tulay Canda
3
1
Department of Endocrinology and Metabolism, Dokuz Eylul University,
Izmir, Turkey;
2
Department of Radiology, Dokuz Eylul University,
Izmir, Turkey;
3
Department of Pathology, Dokuz Eylul University, Izmir,
Turkey.
Aim
Thyroid nodules are frequent in the adult population. Thyroid fne needle
aspiration biopsy is the frst choice for diagnosing cancer in the nodule. It is
suggested that biopsy-proven benign thyroid nodules should be followed up
clinically and if they grow, re-biopsy should be performed. However, certain
growth criteria have not been defned yet.
Method
We retrospectively reviewed thyroid fne needle aspiration records of all patients
seen in our clinic between January 2006 and June 2009. Growth follow-up of the
nodules which had second thyroid fne needle aspiration biopsy were evaluated
using two different growth criteria (at least 50% increase in nodule maximal
diameter and at least 20% increase in nodule diameter with a minimum increase in
two or more dimensions of at least two mm). Cytology results were compared
using two different criteria.
Results
From a total of 4217 thyroid nodules, we evaluated the cytology results of the
benign thyroid nodules which had follow up biopsies. There is no signifcant
difference in cytological results between the growing group (n: 43) which have at
least 50% increase in maximal nodule diameter and the non growing group
(n: 136) (P: 1.00). Likewise, using the growth criteria of at least 20% increase in
nodule diameter with a minimum increase in two or more dimensions of at least
two mm, there was no signifcant difference in cytological results between
growing (n: 47) and non growing (n: 70) benign thyroid nodules (P: 0.7).
Conclusion
According to two different growth criteria used in our study, growth of a benign
nodule is not an additional risk factor for cancer.
P80
Scintigraphy 131I-mIBG in patient with positive ret germline mutation
for medullary thyroid carcinoma
Petr Vlcek, Jaroslav Zimak & Pavla Sykorova
2nd Faculty of Medicine, Charles University, Prague, Czech Republic.
Purpose
Familial medullary thyroid carcinoma (FMTC) is an autosomal dominant
inherited disease, characterized by germ-line mutations in the RET proto-
oncogene, mainly in exons 10 and 11, but also in exons 13, 14 and 15. Activating
germ-line mutations in the RET proto-oncogene cause the development of
familial medullary thyroid carcinoma (FMTC) or medullary thyroid carcinoma
(MTC) as a part of multiple endocrine neoplasia type 2 syndrome (MEN2).
Methods
The 1st patient, women 52 years old and mother of son, 32 years old, frstly visited
endocrinologist for a goitre in right lobe in 2007. In October, 2008 she underwent
total thyroidectomy with regional lymph node dissection for a palpable enlarged
lymph node on the right side of neck. Histologically, the neoplasm exhibited
invasive growth in the capsule and surrounding thyroid tissue. The diagnosis of
MTC was confrmed with the subsequently investigated high basal and stimulated
calcitonin levels (intravenous injection of calcium 2.5-3 mg/kg of body weight
together with subcutaneous injection of pentagastrin 5-7 g per kilogram of body
weight). In January, 2009 123I-mIBG (metaiodobenzylguanidine) scintigraphy
showed normal accumulation.
The son of this patient, 32-year-old man, was examined, too. He had slightly
normal basal but increased of stimulated plasma calcitonin levels. Neck
ultrasound was performed with normal results. We tested for RET germ-line
mutations both of patients in exons 10, 11, 13, 14, 15 and 16. Direct fuorescent
sequencing of genomic DNA revealed heterozygous mutation in the RET proto-
oncogene in the exon 13 in both tested persons.
In March, 2009 he underwent total thyroidectomy. C-cell hyperplasia features
were present in the operated thyroid tissue. The postoperative basal calcitonin
level was normal, but stimulated calcitonin level were slightly increased
(500 pg/ml).
The diagnostic scintigraphy with 123-mIBG were performed and the liver
metastases were found. In June, 2009 the therapy with 3.7 GBq 131I-mIBG was
performed. After therapy the calcitonin level goes down (100 pg/ml). Next
treatment is properted after 4 months.
Conclusion
The therapy 3.7 GBq 131I-mIBG was performed in patient, where germ-line
mutation was detected due to the systematic genetic screening of the RET proto-
oncogene, which is useful for genetic counselling of potential risk of MTC in
other family members.
P80I
Cytologic results of thyroid hne needle aspiration biopsy from geriatric
patients; A single centre experience
Mehmet Muhittin Yalcin
1
, Serkan Yener
1
, Baris Akinci
1
, Sena Yesil
1
,
Firat Bayraktar
1
, Abdurrahman Comlekci
1
, Mustafa Secil
2
& Tulay Canda
3
1
Department of Endocrinology and Metabolism, Dokuz Eylul University,
Izmir, Turkey;
2
Department of Radiology, Dokuz Eylul University, Izmir,
Turkey;
3
Department of Pathology, Dokuz Eylul University, Izmir, Turkey.
Fine needle aspiration biopsy is the cornerstone for cytologic evaluation of
thyroid nodules. Thyroid nodule prevelance increases with age, however there is
no cytologic study exclusively from geriatric patients.
We examined the thyroid fne needle biopsy records taken from patients age 65
years or older between January 2006 and June 2009 at Dokuz Eylul University
Hospital; and reviewed the cytological results of this group.
We analyzed 861 thyroid fne needle aspiration biopsy results from 642 patients
65 years or older. Mean age of patients were 71 (65-106) years. Sixty-nine
percent of patients were female. Cytologic results were benign in 713 (82.8%),
indeterminate in 25 (2.9%), malign in 7 (0.8%) and insuffcient for diagnosis in
116 (13.5%) nodules. From the 26 nodules which had initially benign cytology,
the fnal surgical pathology was benign in 23, malign in 3 nodules. From the 12
nodules which initially had indeterminate cytology, the fnal surgical pathology
was benign in 8, malign in 4 nodules. Final surgical pathologies were malign in all
of the nodules which had initially malign cytology (n: 5).
The female dominance in geriatric patients with thyroid nodules is similar with
the general population. The occurrence of malign cytologies in geriatric patients
is lower than that of the general population.
P808
Thyroid hormones regulate the production of complement mannan-
binding lectin regardless of the genotype: a cohort study
of 95 patients with autoimmune thyroid disorders.
Eliska Potlukova
1
, Jan Jiskra
1
, Tomas Freiberger
2
, Zdenka Limanova
1
,
Dana Zivorova
3
, Karin Malickova
3
, Drahomira Springer
3
, Lucie Grodecka
2
,
Marie Antosova
1
, Zdenek Telicka
1
, Sattu Sinikka Pesickova
4
&
Marten Trendelenburg
5
1
Third Department of Medicine, General University Hospital and First
Faculty of Medicine, Charles University, Prague, Czech Republic;
2
Molecular Genetics Laboratory, Centre for Cardiovascular Surgery and
Transplantation, Brno, Czech Republic;
3
Laboratory of Clinical Allergology
and Immunology, Institute of Clinical Biochemistry and Laboratory
Diagnostics, General Teaching Hospital and 1st Faculty of Medicine,
Charles University, Prague, Czech Republic;
4
Clinic of Nephrology,
General Teaching Hospital and 1st Faculty of Medicine, Charles University,
Prague, Czech Republic;
5
Laboratory of Clinical Immunology, Department
of Biomedicine, University Hospital Basel, Basel, Switzerland.
Introduction
Complement mannan-binding lectin (MBL) defciency is associated with
increased susceptibility to infections and autoimmune diseases. Previous studies
suggested that the production of MBL is stimulated by thyroid hormones. The aim
of our study was to investigate this association in patients with autoimmune
thyroid diseases (AITD).
Methods
Serum levels of MBL and parameters of the thyroid function were determined in
62 patients with Hashimoto`s thyroiditis, 33 with Graves` disease and 47 blood
donors. Follow-up measurements were performed after 6 to 24 months. MBL2
genotypes were determined using multiplex PCR and compared to 359 healthy
Czech individuals.
Results
Serum levels of MBL tightly correlated with thyroid hormones, leading to
strongly increased MBL levels in hyperthyroidism and decreased levels in
hypothyroidism. With normalisation of the thyroid function during follow-up,
MBL levels decreased or increased respectively. The observed correlations
weren`t due to MBL polymorphisms since the frequency of MBL2 polymorph-
isms in AITD patients was not different from the general population.
Conclusion
AITD are not associated with MBL polymorphisms. However, the MBL
production is strongly dependent upon the thyroid function, regardless of the
genotype.
P809
Pitfalls in calcitonin measurement: case report
Ioana Vasiliu
1
, Delia Ciobanu
2
, Didona Ungureanu
3
, Roxana Balcan
1
,
Safae ElMekkaoui
1
, Jeanina Idriceanu
1
, Voichita Mogos
1
& Carmen Vulpoi
1
1
2
Department of Morphology, UMF Gr.T.Popa, Iasi, Romania;
3
Department
of Immunology, UMF Gr.T.Popa, Iasi, Romania.
Calcitonin (CT) is a sensitive marker for medullary thyroid carcinoma, but its
routine measurement in patients with thyroid nodules is a controversial issue.
Generally, an elevated serum calcitonin strongly suggests the presence of
medullary thyroid carcinoma (MTC); however high CT levels may be found in
other thyroid or non-thyroidal conditions. We report the case of a 49-year-old
woman who consulted at the ambulatory of endocrinology for recent thyroid
soreness. Biological fndings revealed inhibited TSH (0.1 mUI/l) and elevated CT
(128.4 pg/ml, n,11 pg/ml), and she was refered to the Endocrinological
Departament. Clinical examination found asymmetrical enlargement of the
thyroid gland, subfebrility (37.3 ?C), tachycardia (100/min), tremor. Thyroid
ultrasound revealed inhomogeneous, hypo echoic pattern with the presence of two
adjacent nodules in the right lob: of 0.9 and 2.4 cm with intense internal Doppler
signal. She had minor sensitivity at thyroid palpation, but when FNAB was
performed she complained of intensive pain. Low TSH with high fT
4
values
(3.8 ng/ml, n 0.8-2) confrmed thyrotoxicosis. Positive antithyroid antibodies
(ATPO102 UI/ml n,40, ATg15.3UI/ml n,4) suggested an autoimmune
disorder, but high ESR (77 mm/h), clinical and ultrasound data and cytology
(multinuclear giant cells) diagnosed a subacute thyroiditis (SAT), whitch had a
spectacular improvement after corticotherapy (ESR8 mm/h, CT4.1 pg/ml).
Measurement of calcitonin is a highly sensitive method for the detection of MTC,
but has a low specifcity. Several physiological and pathological thyroid
conditions other than medullary thyroid carcinoma have been associated with
increased calcitonin levels (follicular and papillary carcinoma, chronic
autoimmune thyroiditis). Patients with chronic lymphocytic thyroiditis present
C-cell hyperplasia that may lead to increased calcitonin levels. We believe that
during the infammatory process (existed in SAT) not only follicular, but also
parafollicular (C) cells may be destroyed, leading to high CT levels. Normal-
ization of CT after remission of SAT sustains this supposition.
P810
Atorvastatin inhibited proliferation in papillary thyroid cancer cell line
Nese Ersoz Gulcelik
1
, Dilara Zeybek
2
, Figen Kaymaz
2
, Can Sarisozen
3
,
Esin Asan
2
, Imran Vural
3
& Aydan Usman
1
1
Department of Endocrinology and Metabolism, Hacettepe University
Medical School, Ankara, Turkey;
2
Department of Histology and
Embryology, Hacettepe University Medical School, Ankara, Turkey;
3
Hacettepe University Faculty of Pharmacy, Ankara, Turkey.
Aim
The role of statins on thyroid cell proliferation is of clinical interest. In this study,
we investigated the effect of atorvastatin on papillary thyroid cell line (B-CPAP)
and normal thyroid (Nthy-ori3-1) cell lines.
In this in vitro study, B-CPAP and Nthy-ori3-1 cell lines were treated with
atorvastatin at 12.5, 25, 50, 100, 200 M concentrations. At 48 and 72 h MTT,
electron microscopy and immunohistochemistry were performed.
Results
Atorvastatin treatment at different concentrations of 12.5 M to 200 M resulted
in increased cell death of B-CPAP cells after 48 and 72 h (72.1 to 98.7% and 97.0
to 98.8%, respectively). Atorvastatin treatment at the same concentrations
resulted in death of Nthy-ori3-1 cells after 48 and 72 h (39.6 to 94.2% and 57.7 to
98.0%, respectively). We observed euchromatic nucleus, prominent nucleolus
and normal RER, ribosomes, mitochondria, glycogen in the cytoplasm of control
groups of both cell lines. In atorvastatin treated cell lines the ratio of the cells with
cytoplasmic vaculozations and chromatin condensations was increased. We also
observed an increase in the number of apoptotic cells with chromatin
condensation and cytoplasmic blebbing in higher treatment doses in both cell
lines. Beside apoptotic cells, we also observed mitotic cells in normal thyroid cell
line. This data was confrmed with positive immunoreactivity of Ki-67 on normal
thyroid cells. However, mitotic cells weren`t detected in B-CPAP cells treated
with different doses and intervals of atorvastatin.
Conclusion
Atorvastatin yielded cell death in both normal thyroid cells and papillary thyroid
cancer cells. Atorvastatin inhibited proliferation of papillary thyroid cancer cells.
This inhibition wasn`t seen in normal thyroid cells. Atorvastatin treatment may be
of clinical use in patients with papillary thyroid cancer, particularly in metastatic
patients. Clinical implications of these fndings need to be tested by in vivo
studies.
P811
Reference interval of TSH in the hrst trimester of pregnancy and its
relationship to further thyroid examinations
Drahomira Springer
1,2
1
First Medical Faculty of Charles University, Prague, Czech Republic;
2
General Teaching Hospital, Prague, Czech Republic.
Introduction
Determining TSH in the serum is a basic test for the diagnosis of thyroid function
in the general population. Its regulation is based on feedback, however during
pregnancy there are other mechanisms - mainly suppression of TSH due to a high
hCG and the iodine saturation.
Aim
Results of TSH, anti TPOAb and FT
4
by ADVIA Centaur (Siemens) in our group
of 7530 women living in iodine suffcient area in 9-11 week of pregnancy were
determined. For evaluation of the reference intervals for pregnant women was
calculated from selected group in accordance with the recommendations of the
NACB. A reference interval for TSH in the frst trimester of pregnancy was
determined as 0.06-3.67 mU/l. Determination of anti-TPOAb in pregnancy is
diagnostically and prognostic important. The limit for anti-TPOAb positive was
determined to be 143 kU/l. Higher TSH is also very often associated with
positivity of anti-TPO antibodies. In the group with TSH3.67 mU/l there were
44.1% of women with antibody positivity. The relationship to ultrasound results
will be presented.
The average level of hCG in the group of pregnant women with suppressed TSH
was almost double (Mean95.6 mg/ml) in comparison with the group with TSH
in reference interval (Mean68.9 mg/ml).
Conclusion
The pivotal importance of each laboratory test (TSH, TPOAb, FT
4
and thyroid
ultrasound) and the necessity of reference interval for each method in the study
region for early diagnosis of thyroid disease in pregnancy is emphasized.
P812
Analytical performances and reference ranges of new ultrasensitive
TSH and free thyroxine assays on the ADVIA Centaur
Immunoassay
Systems
Catherine Massart
1
, Francoise Gasser
2
& Arnaud Agin
2,3
1
UF Hormonologie, INSERM 0203, CHU, Rennes, France;
2
Explorations
Fonctionnelles, CHU, Strasbourg, France;
3
CNRS FRE 3289, Faculte de
Medecine, Strasbourg, France.
Introduction
Highly sensitive TSH assay is required for thyroid exploration and free thyroxine
(T
4
) concentrations should be measured in some cases of thyroid dysfunction.
Objective
To study the analytical performances and reference ranges of new ultrasensitive
TSH(TSH3-UL) and newfree T
4
(FT
4
) assays performed on the ADVIACentaur
Immunoassay Systems (Siemens Healthcare Diagnostics).

We compared the values of TSH and free T
4
measured in 251 sera on the ADVIA
Centaur
Systems with the previous (TSH-3 and FT

4
) and the new (TSH3-UL
and FT
4
) assays. Reference intervals were obtained from 270 blood donors (128
women and 142 men, 20-61 years old) from the Western (n137) or the Eastern
(n133) regions of France. They were euthyroid, without any medical treatment
and negative for the research of anti-thyroperoxidase antibodies (DYNOTest anti-
TPO
n
RIA, Brahms or Access
TPOAb, Beckman Coulter). Regression linear test

and Bland-Altman method were used for comparison of results.
Results
Intra- and inter-assay variabilities were correct with CVs B5% or B7.2% for
TSH3-UL or FT
4
, respectively. The functional sensitivity of the TSH3-UL assay
performed on 49 series during a 8 months period was 0.012 mIU/l. Dilution tests
carried out on fve sera for TSH3-UL assay gave straight lines. Good agreement
and excellent correlations were found between the previous and the new assays
(r0.98 and 0.92 for the TSH and the free T
4
assays, respectively). The reference
range for TSH3-UL performed after logarithmic transformation of values
was 0.63-3.4 (median: 1.5) mIU/l. For FT
4
, the reference range was found at
10.3-17.6 (median:14.3) pmol/l.
Conclusion
The new TSH3-UL shows a functional sensitivity in agreement with NACB
guidelines. The reference ranges obtained in a large population of healthy subjects
can be used for interpretation of TSH and free T
4
results in exploration of thyroid.
P813
Association of Pro
12
Ala PPAR- gene polymorphism with Graves`
orbitopathy
Jacek Daroszewski
1
, Edyta Pawlak
2
, Marek Bolanowski
1
& Irena Frydecka
2,3
1
Department of Endocrinology, Diabetology, and Isotope Therapy, Medical
University, Wroclaw, Poland;
2
Department of Experimental Therapy,
Institute of Immunology and Experimental Therapy, Polish Academy of
Sciences, Wroclaw, Poland;
3
Department of Hematology, Blood Neoplastic
Diseases, and Bone Marrow Transplantation, Medical University, Wroclaw,
Poland.
Introduction
Peroxisome proliferation-activated receptors- (PPAR-) have been shown to be
involved in adipogenesis as well as in immunoregulation and infammation
control. Orbital fbroblast differentiation to adipocytes is a PPAR- dependent
process essential for pathogenic tissue remodeling in Graves orbitopathy (GO).
Purpose
We studied the occurrence and possible associations of the Pro
115
Gln and
Pro
12
Ala in the PPAR2 gene with clinical manifestation of GO.
The Pro
12
Ala and Pro
115
Gln polymorphisms were examined using PCR-RFLP
technique with restriction enzymes: HpaII and HincII, respectively, in 202
Graves` disease patients. There were 168 patients with GO and 34 subjects
without eye changes. Patients with GO were grouped according to the stage of the
disease severity.
Results
We found that Ala allele and (Pro
12
AlaAla
12
Ala) genotype decreased the risk
of OT by a factor of 3.33 and 3.45 (P0.0002, 95% CI: 0.16-0.59 and P0.001,
95% CI: 0.13-0.63, respectively). Moreover, the Ala
12
Ala genotype was not
observed in the group of patients with GO. The patients heterozygous at this
polymorphic site were signifcantly more frequent in a group of patients without
GO as compared to GO group (38.2 vs 18.5%, P0.01, 95% CI: 0.17-0.81).
However, this polymorphism was not associated with a stage of GO.
The Pro
115
Gln mutation was not found in any of subjects examined.
Conclusions
We found that the Ala variant in Pro
12
Ala polymorphism is associated with
decreased risk of GO and may be considered as a protective factor.
P814
Age and size of goitre in hyperthyroidism
Jolanta Kijek
1
, Jerzy S Tarach
2
, Maria Kurowska
2
, Helena Jankowska
1
,
Beata Chrapko
1
& Anna Dabrowska
2
1
Department of Nuclear Medicine, Medical University, Lublin, Poland;
2
Department of Endocrinology, Medical University, Lublin, Poland.
Aim
The aim of the study was to evaluate the patients` age and goitre size in relation to
the form of hyperthyroidism, as well as the relationship between patients` age and
goitre size and function.
The subject group included 484 patients (420 females and 64 males) with hyper-
thyroidism. Graves` disease (GD) was diagnosed in 171 subjects and toxic nodular
goitre (TNG) was found in 313 subjects. FT
3
, fT
4
, TSH (DELFIA technique) and
TSHAb (radioreceptor method) were measured in all patients. Thyroid technetium-
99m scan was performed and iodine uptake (RIU) was measured after 24 and 48 h.
Thyroid mass was calculated based on thyroid scintigraphy.
Results
The results of biochemical tests were the following: fT
3
- 17.2714.74 pmol/l
(1.1-95.4), fT
4
- 31.9919.67pmol/l (5.6-107), TSH - 0.030.025mIU/l
(0.02-0.23) and TSHAb - 20.450.78 U/l (1.1-405). RIU24 h ranged from 8.3
to 89.8% (54.5616.6) and RIU48h was from 6.2% to 86.5% (50.815.5). The
mean age of GD patients was 47.1213.14 years (18-84) and the one of TNG
patients was 52.5114.89 years (7-83). Thyroid mass in GD patients was 69.75
38.15g (5.4-204) and in TNG patients it was 36.0529.27g (3.6-184).
A comparison of mean values showed a statistically signifcant difference in age
(P0.0001) and thyroid mass (P,0.0001) between GD and TNG patients.
A statistical analysis showed that there was relationship between age and goitre
size in the whole group of patients (P0.03), while there was no such relationship
in GD and TNG patients. Moreover, no relationship between age and thyroid
function was found.
Conclusions
Patients with GD are statistically younger than those with TNG, whereas goitre
size in GD patients is statistically signifcantly bigger than in TNG patients.
Moreover, no statistically signifcant relationship between age and thyroid
function was found.
P815
Evaluation of theurapeutic modalities in Graves` hyperthyroidism
Yavuz Yalcin, Oya Topaloglu, Dilek Berker, Serhat Isik & Serdar Guler
Ankara, Turkey.
Objective
Currently there are three well-established treatment options for hyperthyroid
Graves` disease (GD): antithyroid drug therapy with thionamides, radioactive
iodine (RAI) treatment with (131)I, and surgery. The aim of this study was to
investigate retrospectively theurapeutic options of the patients with GD treated at
outpatient clinics of Endocrinology and Metabolism between January 2007 and
December 2009.
Methods
We evaluated 122 patients (37 male, 85 women, aged 17-73 years) with GD
retrospectively. Thirty-six patients (29.5%) were still on treatment so we
excluded these patients. After the 18 months primary medical treatment period,
recurrence rate in following one year was evaluated.
Results
Among 122 patients with GD, in 86 patients (70.5%) therapy was completed. For
the therapy completed patients mean medical treatment period was 19.54.9
months. Among the 86 patients whose therapy was completed, in 32 patients
(37.2%) relapse was not detected but in 54 patients (62.8%) disease was
recurrenced. Because of the recurrence 54 patients were evaluated for surgery or
RAI treatment. Thirty-nine patients (72.2%) were conducted to RAI treatment,
15 patients (27.8%) were went on surgery. Total thyroidectomy was performed.
Among 39 patients who were treated with RAI, hyperthyroidism was relapsed in
5 patients (12.8%). Three of these 5 patients were conducted to second RAI
treatment other 2 patients were treated by surgery. After the RAI treatment in
26 patients (66.7%) hypothyroidism has been developed. All of the 86 patients
were treated with medical options initially. No adverse effects with thionamides
were detected in 81 patients (94.2%). Neutropenia was seen in only 2 patients
(2.3%), hepatotoxicity was developed in 3 patients (3.5%). Graves ophthalmo-
pathy was present in only 5 patients (5.81%).
Conclusion
Medical treatment has fewer side effects and also reliable so it is the frst choice in
the Graves` hyperthyroidism but in our study the recurrence rate was high so RAI
treatment can be considered as initial option for these patients. Prospective
randomized studies comparing available and novel therapeutic options of GD are
needed.
P81
A single small dose of rituximab may be effective in Graves` orbitopathy
Danila Covelli
1
, Guia Vannucchi
1
, Nicola Curro`
2
, Davide Dazzi
1
,
Paolo Beck-Peccoz
1
& Mario Salvi
1
1
Endocrine Unit, Fondazione IRCCS Ca` Granda-Ospedale Maggiore
2
Ophthalmology, Fondazione IRCCS Ca`
Granda-Ospedale Maggiore Policlinico, Milan, Italy.
The anti-CD 20 antibody rituximab (RTX) has been employed in the treatment of
several autoimmune diseases and its effect may not involve autoantibody secretion.
Preliminary studies have shown that RTX induced improvement of active Graves`
orbitopathy (GO) but caused no change of serumanti-thyroid antibodies in relation
to peripheral CD 20cells depletion, usually observed at the second week after
therapy. A 50-year-old woman with GO predominantly active in the left eye
(clinical activity score, CAS6) was treated with RTX, administered intrave-
nously with an increasing rate of 25 mg in the frst 30 min, 50 mg in the following
30 min, then 100 mg/h. Sixty minutes after infusion she complained of pain and
progressive decrease of visual acuity only in the left orbit, that led to transient
blindness. Infusion was immediately stopped after 75 mg RTX had been
administered. In fact, orbital pain ceased in 30 min with no optic nerve
compression shown by CT scan. Three hours later, at ophthalmological
examination, vision was again 10/10. On follow-up, the patient showed unexpected
progressive clinical improvement of GO over a week and complete inactivation of
the infammatory signs in 3-4 months. Peripheral blood lymphocytes and the CAS
were measured at baseline and weekly after RTXinfusion. Peripheral CD20and
CD19cells were depleted at the time of reaction, after infusing only 75 mg of
RTX. In conclusion, 75 mg of RTX, instead of the standard dose of 2000 mg, may
be suffcient to cause total B cell depletion in the peripheral blood; moreover, this
small dose may induce inactivation of the infammatory phase of an organ-specifc
autoimmune disease like GO, without requirement of further therapy. In this patient
with unilateral GO, the transient loss of visual acuity was probably caused by acute
orbital edema due to RTX induced complement activation.
P81I
Nonthyroidal illness in pregnancy
Josip Z
`
mire, Kristijan Peros`, Kresìmir Martinac, Bozè Colak,
Kristina Kljajic & Lea Sokolic
Vuk Vrhovac University Clinic, Zagreb, Croatia.
We retrospectively collected data from 62 pregnant females who were followed
for hyperthyroidism (n17), hypothyroidism (n21), euthyroid Hashimoto`s
thyroiditis (n9), and simple goitre and other non-autoimmune thyroid diseases
(n15).Among them 33 showed at least once during pregnancy low FT
4
, or low
FT
3
and FT
4
in total on 74 occasions. Low FT
4
was found on 15, low FT
3
on 15
and low FT
3
and FT
4
on 44 occasions. Accompanying TSH was lowered on 23
and normal on 51 occasions. Changes spontaneously disappeared on 8 occasions,
normalized after levothyroxine treatment on 10 occasions, persisted despite
levothyroxine administration on 23 occasions and persisted without therapy on
18 occasions. On 15 occasions we were unable to follow the effect of therapy
because patients came next time after delivery. We see that levothyroxine
treatment normalized hormone levels on 10 occasions but failed to do so on 23
occasions. At the same time changes spontaneously disappeared on 8 occasions.
Aforementioned changes of thyroid hormones ft in non-thyroidal illness pattern.
Changes were observed during the whole pregnancy from 4th to 36th week of
gestation. All children from these pregnancies were healthy and had so far normal
development. Albeit maintenance of maternal euthyroidism during pregnancy,
especially normal thyroxinemia, is of paramount importance for development of
child, still there is a number of pregnant females in which this cannot be
accomplished due to non-thyroidal changes, fortunately without any adverse
effect on the foetus. It is important to stress that we live in iodine suffcient
environment and that in all cases hypothyroidism was excluded. Changes
appeared equally in patients receiving no therapy and in patients taking
levothyroxine. Previously hyperthyroid patients showed these changes while
being in remission.
P818
Long-term results of selective thyroid surgery for benign nodular goiter
(BNG)
Panagiotis Fikatas, Babette Koch, Christian Vorlander & Robert A Wahl
Buergerhospital, Frankfurt, Hessen, Germany.
Background
Total thyroidectomy is postulated by many centers as the standard procedure in
treatment of benign nodular goiter (BNG) to avoid recurrent goiter (reported 30%
and more). In our hospital a wide spectrum of methods regarding extent of
resection is performed, adapted to morphology and respecting function.
We advocate a variable strategy of operations for BNG (selective thyroid surgery,
KOCHER 1917) and report on long-term results.
Patients/methods
In 2009, we performed a reinvestigation of patients operated due to BNG in
1997(n261).
Focus of our interest were permanent complication rates and recurrence of goiter.
Besides clinical examination, we performed ultrasound (10 000 MHz) and
determined TSH, T
3
, T
4
. Additional diagnostics were performed when necessary.
A total of 111 patients were reevaluated.
Recurrence was defned by any stage of goiter, circumscript lesions of more than
10 mm of diameter, over-norm thyroid volume and any non-facticious
hyperthyroidism.
Results
RLN paralysis was permanent in 1 (0.9%), hypocalcemia in 1 (0.9%) patient.
One palpable node found in a non resected lobe.
Sonographically, besides this node, one lesion of 12 mm was detected in a
selectively resected lobe.
Three patients showed over-norm volumes in lobes after contralateral lobectomy
(compensatory enlargement, 2.7%).
No hyperthyroidism was present.
In another 10 patients small lesions (2-10 mm) were detected.
Thus, by defnition, recurrence occured in two patients (1.8%), one of them is a
pseudorecurrence.
Conclusions
Strategy of selective surgery bears a low risk of complications as well as a low
risk of recurrence.
We enforce this strategy which is both radical and preserving function.
There is no necessity to claim total thyroidectomy as the standard procedure.
Although substitution with thyroxine is seemingly unproblematic (depending also
on socioeconomic conditions), we are fully convinced that it is unjustifed to make
numbers of patients completely drug-dependant without any necessity.
P819
Haemorheopheresis in the treatment of Graves` ophtalmopathy:
A randomized study
Michal Skacha
1
, Vera Ceeova
2
, Jan Cap
2
, Petr Vlcek
1
, Milan Blaha
2
& Pavel Rezek
1
1
Department of Nuclear Medicine and Endocrinology, Second Faculty of
Medicine and University Hospital Motol, Charles University in Prague,
Prague, Czech Republic;
2
Second Department of Internal Medicine, Faculty
of Medicine in Hradec Kralove and University Hospital Hradec Kralove,
Charles University in Prague, Hradec Kralove, Czech Republic.
The aim of this study was to perform a randomized study to evaluate the role of
haemorheopheresis in the treatment of severe thyroid associated ophtalmopathy
(TAO). Twenty patients were enrolled. All patients were treated with
methylprednisolone i.v. pulses (Solumedrol 1 g i.v. three times a week for
3 weeks - 9 pulses altogether). Ten randomly chosen patients were also subjected
to haemorheopheresis (twice weekly for 2 weeks and than once in 3 weeks - 10
procedures altogether).
The procedure proved to be safe. All immunoglobulin classes as well as
autoantibodies directed against thyroglobulin, thyroidal peroxidase and TSH
receptor statistically signifcantly decreased. Markers of cell mediated immunity
- soluble antigen CD30, monocyte chemotactic protein 1 decreased, but serum
levels of CD40 ligand and soluble protein Fas/Apo-1 did not change signifcantly.
Adhesion molecules selectin and endoglin decreased only insignifcantly.
Clinical activity score (CAS) dropped more rapidly in patients treated with
haemorheopheresis (from 3.6 before treatment to 0.6 after one month) than in
patients treated with glucocorticoid pulses only (from 4 to 2 after one month). The
CAS difference between the two groups was statistically signifcant (P0.027).
After three months the CAS was already low in both groups.
Amplitude of visual evoked potentials (VEP) improved after three months in
haemorheopheresis group only. At the end of the study, there was no difference
between patients treated with haemorheophereses and control group. Eye muscle
width and proptosis measured by CT scan did not differ between the two groups.
We conclude that haemorheopheresis has only limited role in the treatment of
TAO. It can decrease disease activity more rapidly than standard high dose i.v.
glucocorticoid therapy. However, the fnal clinical outcome after longer time
period did not differ signifcantly.
P820
Rapid solid-phase-extraction for the quantitative analysis of serum
iodothyronine prohles
Carolin Hoefg, Franziska Wohlgemuth, Jeannette Klein,
Oliver Blankenstein, Ulrich Schweizer & Josef Kohrle
Charite-Universitatsmedizin, Berlin, Germany.
A novel solid-phase-extraction (SPE) method followed by liquid chromatography
tandem mass spectrometry (LC-MS/MS) was established for the simultaneous
detection and quantifcation of thyroid hormone profles in one sample of human
or mouse serum.
Recovery during preanalytical steps was monitored by addition of an internal
deuterated standard (d5-T
4
) to 200 l serum, which was deproteinized by adding a
precipitating agent consisting of 1% formic acid in acetonitrile (1:3, v/v). After
vortexing precipitated protein was removed by centrifugation and the resulting
supernatant was transferred to a HybridSPE cartridge. After applying vacuum, the
resulting eluent was concentrated in a speedvac prior to LC-MS/MS analysis. This
new SPE cartridge offers the advantage of removing proteins and phospholipids
thus reducing ion-suppression in LC-MS/MS measurements.
LC-MS/MS analyses were performed using a Shimadzu UFLC system and a
4000QTRAP triple-quadrupole tandem mass spectrometer equipped with
TurboIonSpray interface. The detection was performed using positive electro-
spray ionization (ESI) in the multiple reaction monitoring (MRM) mode.
Chromatographic separation of all iodothyronines was achieved using a Synergi
Polar-RP 80-A
column (150,2 mm) with Guard Cartridge using a gradient

elution program at a fow rate of 300 l/min. The optimized elution parameters
were generated by a gradient of mobile phase A (water-acetonitrile-acetic acid)
and mobile phase B (acetonitrile-water-acetic acid).
Using this rapid SPE method it is possible to quantitatively and simultaneously
detect T
4
, T
3
, rT
3
and 3,5-T
2
in biological concentrations within a single sample
of human as well as in mouse serum in good correlation to antibody based routine
procedures. T
4
, the most abundant iodothyronine with the highest avidity to serum
distributor proteins showed the lowest recovery (66%). Further standardization
and validation experiments are required for measurement of clinical cohorts and
samples of animal models.
Supported by Graduate College 1208, Deutsche Forschungsgemeinschaft (DFG).
P821
Long termresults of Isthmus preserving total bilobectomy (IPTB) as the
optimized treatment for C-cell hyperplasia
Carlo Dietl, Babette Koch, Christian Vorlander & Robert A Wahl
Buerger hospital Frankfurt, Frankfurt, Hessen, Germany.
Background
The thyroid isthmus contains no C-cells, thus we established IPTB for cases with
nodular goiter and moderate hypercalcitonemia (stimulated up to 350 pg/ml).
In these cases C-Cell-Hyperplasia is the primary pathologic correlate. Exclusion
criteria were pre- or intraoperative signs of malignancy.
We furthermore established IPTB as a prophylactic operation for patients with
hereditary medullary thyroid carcinoma, excluding high-risk mutations.
(WJS 30 (2006): 860). Now, we report on ongoing follow-up over 7 years.
From2001 to 2007, IPTB was the defnite procedure in 78 out of 107 patients with
intended IPTB. Seventy with sporadic hypercalcitoninemia in nodular goiter
(preop Calcitonin : 19.84 pg/ml basal, 129.72 pg/ml stimulated), 8 with
hereditary MTC. The remaining 29 patients were converted to Total
Thyroidectomy (TTX).
Patients were prospectively evaluated for long-term postoperative outcome,
regarding recurrence of nodular goiter and C-Cell disease.
Results
No permanent RLN-palsy, 1.9% permanent Hypocalcemia occurred.
Follow-up (6-84 months, median 42 months) showed Calcitonin always under the
measurable limit in 69 out of the 78 patients (88%) and intermittently measurable
basal in the lower normal range (,10 pg/ml) in 9 patients. Those 9 patients
showed no response to pentagastrin stimulation. Sonographic examinations of the
isthmic remnants showed early postoperative volumes of 2 ml (median; range 1
to 5) and 2 ml (median; range 0.5 to 6) in follow-up.
One hypoechoic lesion of 0.1 ml was found after 42 months.
Substitution with L-thyroxine was lower (12122 g) after IPTB than after TTX
(14721 g) (P,0.001), without a signifcant correlation between functional
data and morphologic development of isthmic volumes.
Conclusions
By IPTB C-Cells are removed completely and permanently. The risk of
recurrence of goiter (nodular, hyperplastic) or c-cell disease is low.
The basic production and regulatory function of tissue-remnants might well be
of importance for many patients.
P822
Thyroid function and autoimmunity in -Thalassemia (-Thal)
Maria Chiara Cocco
1
, Francesca Pigliaru
1
, Stefania Vacquer
2
,
Maria Paola Carta
2
, Maria Eliana Lai
2
& Stefano Mariotti
1
1
Endocrinology, Department of Medical Sciences M. Aresu, University
of Cagliari, Cagliari, Italy;
2
Thalassemic Unit, Department of Medical
Sciences M. Aresu, Microcitemico Hospital, University of Cagliari,
Cagliari, Italy.
Introduction
Primary endocrine failure in -Thal is caused by iron overload in epithelial cells
and in interstitial macrophages. Autoimmune phenomena are not believed to play
any signifcant role, although iron overload, through non-specifc infammatory
process, could trigger autoimmunity, as recently suggested for the pathogenesis of
diabetes mellitus in -Thal patients.
Purpose
We investigated thyroid function and anti-thyroid autoantibodies (ATA) in 132
-Thal patients (94 with -Thal major, 60 F and 34 M and 38 with -Thal
intermedia, 16 F and 22 M, age range 28-45 years) compared with a large age-
matched group (1002 subjects) from general population. All -Thal patients and
control subjects come from Sardinia, Italy, where a high the prevalence of both
-Thal and autoimmunity is well documented.
Results
The prevalence of primary overt and subclinical hypothyroidism in -Thal
patients was 28.7% (38/132), without signifcant difference between M and F;
ATA were detected in 3/38 (7.8%) hypothyroid -Thal patients, a prevalence
similar to that observed in euthyroid -Thal (7/947.4%). Although the
prevalence of ATA observed in the entire group of -Thal patients was not
different when compared to controls, it is worth noting that the prevalence of ATA
in -Thal women was 7/769.2%, a value signifcantly lower (P,0.01) than that
found in control women (81/40819.8%).
Conclusions
Our study confrms that thyroid autoimmunity has no role in the pathogenesis
of hypothyroidism in -Thal even in Sardinia, where the prevalence of
autoimmunity is elevated. Moreover, -Thal women show a lower ATA
prevalence than control women, suggesting a possible role of iron overload as
inhibiting rather triggering factor in the development of thyroid autoimmunity.
P823
DNA repair genes in the thyroid cell lines and human tumors
Justyna Janik, Karolina Hanusek & Barbara Czarnocka
Department of Biochemistry and Molecular Biology, Medical Center for
Postgraduate Education, Warsaw, Poland.
Free radicals and reactive oxygen species (ROS) participate in physiological and
pathological processes in the thyroid gland. Oxidative stress caused by ROS is
involved in many types of DNA damage that are associated with the initiation or
the progression of numerous human cancers including thyroid tumors. One of the
most mutagenic products of oxygen radical forming agents is 7,8-dihydro-8-
oxoguanine (8-oxoG). The aim of the current study was to investigate expression
of OGG1 and XRCC1 genes which belong to BER system and take part in the
elimination of 8-oxoG from DNA. We determined OGG1 and XRCC1 expression
on both transcript and protein levels in the thyroid cancer cell lines and a series of
human thyroid tumors and normal thyroid tissues. We analyzed expression of
these genes in the lines derived from papillary carcinomas: BCPAP, ONCO-
DG-1, TPC-1; follicular carcinomas:FTC-133, FTC-238, CGTH-W-1, ML-1 and
non-differentiated carcinoma - 8505C. The normal human thyroid follicular
epithelial cells Nthy-ori 3-1 served as a control. In all, but one cell line OGG1 and
XRCC1 mRNA expression was on the level similar to that found in the normal
thyroid cell line. Signifcantly decreased expression of both genes was detected in
the TPC-1 cell line. Then, thyroid tumours (42), mostly PTC, and normal thyroid
(15), were screened for the expression of above genes. Q-RT-PCR method
showed that mRNA expression range was similar in cancer and normal tissues.
Although we found that the expression of OGG1 and XRCC1 genes in the thyroid
cancer cell lines and human thyroid tumors do not differ from the expression in
the normal thyroid, further studies are needed to fully investigate DNA
modifcations and repair mechanisms in the thyroid tumors development.
P824
Evaluation of interrelationships between thyroid function, insulin
resistance, lipid prohle and inammation in autoimmune thyroiditis
Celestino Neves
1
, Marta Alves
1
, Miguel Pereira
1
, Isolina Pimentel
1
,
Ema Carvalho
1
, Renata Ramalho
2
, Carmo Palmares
2
, Cristina Guimaraes
2
,
Joao Pedro Ramos
2
, Davide Carvalho
1
, Lui s Delgado
2
& Jose Lui s Medina
1
1
Endocrinology Service, Faculty of Medicine, Sao Joao Hospital, University
of Porto, Porto, Portugal;
2
Immunology Service, Faculty of Medicine,
Sao Joao Hospital, University of Porto, Porto, Portugal.
Background
Autoimmune thyroiditis (AIT) is associated with increased risk of cardiovascular
disease.
Objective
To evaluate the interrelationships between insulin resistance (IR) and other
cardiovascular risk factors, such as high sensitivity CRP (C reactive protein) and
homocysteine in patients with AIT.
We analysed thyroid function, anti-thyroid antibodies, BMI, indices of IR, such
as HOMA-IR, HISI (Hepatic Insulin Sensitivity Index), WBISI (Whole-Body
Insulin Sensitivity Index), IGI (Insulinogenic Index), total cholesterol (TC),
HDL-cholesterol, LDL-cholesterol, triglycerides (TG), ApoB, ApoA1, Lp(a),
homocysteine, CRP, folic acid and B12 vitamin levels in 260 patients with AIT,
93.8% female, with a mean age of 47.214.8 years old and BMI 27.5
5.6 kg/m
2
. Each patient was submitted to an OGTT (75 g glucose) with
measurements of glucose, insulin and C-peptide each 30 min, during 2 h. Statistic
analysis was done with ANOVA and Pearson correlation tests. Results are
expressed as meanSD. A P,0.05 was considered signifcant.
Results
Analitical results are presented: TSH 3.68011.877 UI/ml; FT
3
2.94
0.99 pg/ml; FT
4
1.521.84 ng/dl; C-peptide 2.621.04 ng/ml; TC 203.58
41.12 mg/dl; TG 117.2783.87 mg/dl; HDL-cholesterol 57.0814.87 mg/dl;
ApoA1 145.2429.71 mg/dl; ApoB 97.0224.36 mg/dl; Lp(a) 28.21
32.22 mg/dl; CRP 0.470.83 mg/dl. We found positive signifcant corre-
lations between IGI and anti-TPO (r0.179; P0.005), C-peptide (r0.463;
P,0.001), TG (r0.227; P,0.001), CRP (r0.162; P0.02) and TSH
(r0.126, P0.048) levels. HISI results positively correlated with TSH
(r0.173; P0.006). We also detected signifcant negative correlations between
WBISI and TG (r0.191; P0.003), and CRP (r0.181; P0.008) levels.
Conclusion
The interrelationships between thyroid function, insulin resistance, lipid profle
and infammation may explain the increased cardiovascular risk associated
with AIT.
P825
Effects of hyperthyroidism, hypothyroidism and thyroid autoimmunity
on female sexual function
Elisa Franceschi, Alessandro Oppo, Francesca Atzeni, Alessandro Taberlet
& Stefano Mariotti
Cagliari, Cagliari, Italy.
Introduction
Thyroid hormones affect male and female sexual and reproductive function, but
few studies have been performed on sexual dysfunctions in hyper- and
hypothyroid women.
Aim of the study
To evaluate female sexual function in untreated and treated hyper- and
hypothyroidism and in euthyroid Hashimoto`s thyroiditis (HT).
Fifty consecutive women (38.58.2 years, range 18-53 years), 22 with
hyperthyroidism (20 Graves` disease, 2 nodular toxic goitre), 17 with hypothyroid
and 11 with euthyroid TH were compared to 30 age-matched healthy women
(37.57.7 years, range 19-50 years). A validated, multidimensional ques-
tionnaire on female sexual function domains (FSFI, addressing desire,
arousal/lubrication, orgasm, satisfaction and pain) was administered to all
participants. Thyroid function was evaluated by measuring TSH, FT3, FT4,
TPOAb and TgAb.
Results
With the exception of satisfaction, all sexual domains scores were signifcantly
reduced (P ranging ,0.0001-,0.02) in both hyper- and hypothyroid women.
After 3 months of therapy able to normalize serum TSH, a signifcant increase in
sexual desire (P,0.01), arousal/lubrication (P,0.005), satisfaction (P,0.05)
and pain (P, 0.05) was found in hyperthyroid women, whereas a signifcant
increase in sexual desire (P,0.05) and orgasm (P,0.05) was observed in
hypothyroidism; however, both in hyper- and hypothyroid treated patients most
sexual domains remained signifcantly impaired. The small group of euthyroid
HT women displayed a signifcant decrease in sexual desire (P,0.005).
Conclusions
Hyper- and hypothyroidism markedly impair women sexual function. Restoration
of euthyroidism rapidly (3 months) improves sexual function, but a longer period
may be needed for full normalization. Preliminary data on euthyroid HT women
suggest that thyroid autoimmunity may impair sexual desire independently from
thyroid function, but further studies are needed to confrm this fnding.
P82
Evaluation of interrelationships between thyroid function, lipid prohle,
homocysteine and high sensitivity C-reactive protein in patients with
autoimmune thyroiditis
Celestino Neves
1
, Marta Alves
1
, Miguel Pereira
1
, Ema Carvalho
1
,
Isolina Pimentel
1
, Renata Ramalho
2
, Carmo Palmares
2
,
Cristina Guimaraes
2
, Joao Pedro Ramos
2
, Davide Carvalho
1
, Lui s Delgado
2
& Jose Lui s Medina
1
1
Endocrinology Service, Faculty of Medicine, Sao Joao Hospital, University
of Porto, Porto, Portugal;
2
Immunology Service, Faculty of Medicine,
Sao Joao Hospital, University of Porto, Porto, Portugal.
Background
Thyroid dysfunction and lipid profle are associated with cardiovascular disease
in patients with autoimmune thyroiditis (AIT).
Objective
To evaluate the association between thyroid function, lipid concentrations,
C-reactive protein (CRP) and homocysteine in patients with AIT.
We assessed thyroid function tests, BMI, total cholesterol (TC), HDL-cholesterol,
LDL-cholesterol, triglycerides (TG), apolipoprotein B (ApoB), apolipoprotein A1
(ApoA1), lipoprotein (a) [Lp (a)], homocysteine, CRP, folic acid and B12 vitamin
in 500 patients with AIT, 93.6% female, with a mean age of 46.715.8 years old
and BMI 27.05.4 kg/m
2
. Statistic analysis was done with ANOVA and Pearson
correlation tests. Results are expressed as meanSD or percentage. A P,0.05
was considered signifcant.
Results
We found signifcant positive correlations between TSH and TC (r0.167;
P,0.001), LDL-cholesterol (r0.131; P0.004), TG (r0.168; P,0.001)
and ApoB (0.141; P0.008). BMI was positively correlated with free T
4
(FT
4
)
(r0.125; P0.005), ApoB (r0.152; P0.004), TG (r0.193; P,0.001)
and LDL-cholesterol (r0.141; P0.002), and was negatively correlated with
HDL-cholesterol (r0.238; P,0.001), ApoA1 (r0.129; P0.01) and
FT
3
(r0.103; P0.02). We also found negative correlations between CRP
and ApoA1 (r0.183; P0.01), B12 vitamin (r0.158; P0.005) and
FT
3
(r0.176; P,0.001), and signifcant positive correlations between CRP
and folic acid (r0.858; P,0.001), FT
4
(r0.168; P0.001) and anti-TPO
antibodies (r0.120; P0.01). We did not fnd signifcant correlations with
homocysteine.
Conclusion
In patients with AIT the interrelationships between thyroid function and TC,
LDL-cholesterol, TG, ApoB and CRP determine an increased cardiovascular risk.
Thus, diagnostic and therapeutic strategies should be implemented to minimize
the impact of AIT, which has a high prevalence in the general population.
P82I
Cito-histologycal correlations in nodular thyroid pathology
Joana Couto, Claudia Lobo, Ana Paula Barbosa, Raquel Martins,
Ana Paula Santos, Paula Monteiro, Teresina Amaro & Isabel Torres
Portuguese Oncology Institute, Oporto, Portugal.
Introduction
Fine needle biopsy (FNB) is a very important diagnostic tool in the assessment of
thyroid nodules and plays a prominent role in therapeutic approach. It has a
sensitivity around 83 to 85% and a specifcity around 80 to 92%.
Aims
To correlate cytological (FNB) and fnal histopathological data in patients with
nodular thyroid pathology.
Methods
A retrospective study of patients who underwent surgical procedure from January
2007 to November 2009, with FNB performed at our Institution. FNB and
histopathological data were compared.
Results
Fifty-nine patients, 48 women (81%) e 11 men (19%) with a mean age of 51 years
(minimum 14, maximum 82). FNB results: Papillary Carcinoma (PC): 32 (54%);
Follicular tumor (FT): 18 (31%); Medullary Carcinoma (MC): 3 (5%); Hurthle
cell tumor: 3 (5%); Follicular Carcinoma (FC): 2 (3%); Anaplastic carcinoma
(AC): 1 (2%). Histopathological results: PC: 35 (59%); Follicular Adenoma(FA):
8 (14%); Hurthle cell FA: 7 (12%); MC: 4 (7%); FC: 2 (3%); Multinodular
Follicular Hyperplasia: 2 (3%); AC: 1 (2%). The sensitivity and specifcity for
diagnosing malignant thyroid nodules were 100%. Of the 18 FT, 4 (22%) turned
out to be malignant lesions and 14 (78%), benign lesions.
Conclusions
The high rate of malignancy found is explained by the fact that our Institution is a
referral center for oncologic patients. FNB was highly sensitive and specifc
(100%) in diagnosing malignant nodular thyroid pathology. The percentage of
malignancy found in the nodules classifed as FT on FNB was similar to that
found in literature (around 20%). These data confrm that FNB plays a key role in
evaluating thyroid nodules.
P828
Prognostic value of recombinant TSH-stimulated thyroglobulin
determination in follow-up of differentiated thyroid cancer
Javier Santamaria, Maria Dolores Moure, Teresa Ruiz-Azua,
Maria Angeles Aniel-Quiroga & Maria Sonia Gaztambide
Cruces Hospital, Vizcaya, Spain.
Introduction
There is no known reliability about an undetectable recombinant human TSH
(rhTSH) stimulated serum thyroglobulin (Tg) concentrations, predicts no long-
term relapse, or the threshold of it. An rhTSH-stimulated serum Tg determination
was made to all patients with DTC that maintained undetectable baseline Tg and
negative imaging tests. We correlate their fndings with their long-term evolution.
Methods
We collected 91 patients with DTC, 73 women and 18 men, 75 papillar, 16
follicular. All had a total thyroidectomy and I-131ablation before performing the
test (mean 79.682.9, median 40 months). All cases had a successful treatment:
negative imaging tests, undetectable rhTSH-stimulated serum Tg, and negative
anti-Tg-Abs. We correlated these results with clinical outcome. Follow-up time
until the last query or to the detection of recurrence was 31.119.9, median:
30 months.
Results
At the end of follow-up period recurrence was detected in 4 cases. Another 8 cases
had Tg 2 ng/ml but without either imaging or pathologic testing of tumor
recurrence.
Conclusions
The measured of stimulated serum thyroglogulin is imperative, 9% of our cases
with undetectable basal Tg shows a positive stimulation. Although detection of
recurrence is more frequent with increasing the stimulated Tg level, there is no
value that ensures the absence of recurrence, so these patients should be
monitored indefnitely. The presence of lymphadenopathy at the time of diagnosis
is the major predictor of recurrence in this group of patient.
P829
Metastasis in differentiated carcinomas of the thyroid
Ana Paula Barbosa
1
, Claudia Lobo
1
, Joao Pedro Teixeira
1
, Carlos Soares
2
,
Joao Capela
2
, Joana Couto
1
, Raquel Martins
1
, Ana Paula Santos
1
,
Lima Bastos
1
, Maria Jose Bento
1
, Teresina Amaro
1
& Isabel Torres
1
1
Portuguese Institute of Oncology, Oporto, Portugal;
2
Sao Joao Hospital,
Oporto, Portugal.
Differentiated carcinoma of the thyroid (DCT) of follicular origin is the most
frequent endocrine neoplasia and it usually has a good prognosis even in the
disseminated disease, due to its slow growing pattern and low dissemination rate.
The prevalence of metastasis described in the literature varies between 5 and more
than 20%.
Aims
To analyze the clinical-pathological data and their relation with survival of
patients (pts) with metastatic DTC.
Retrospective study of clinical, imagiological, cintigraphic, surgical and
pathological data of pts with metastatic DTC treated in our institutions between
January 1975 and February 2009.
Differences between groups were analyzed with the
2
-test. Survival curve was
analyzed with Kaplan-Meyer method. Results were considered signifcant for
P,0.05.
Results
One hundred and sixteen pts, 88 (75.9%) women (median age 42 years), 28 (24.1%)
men (median age 53 years) underwent total 113 (97.4%) and subtotal 3 (2.6%)
thyroidectomies followed by radioactive iodine in 115 (99.1%) pts. Pathological
study: 54 (46.6%) papillary limited to the thyroid (T
1
and T
2
), 41 (35.3%) papillary
with minimal extra-thyroidal extension (T
3
), 14 (12.1%), follicular, 7 (6.0%)
microcarcinoma. Metastatic spread: 43 (37.1%) cervical lymph nodes (N), 25
(21.6%) lung (L), 19 (16.4%) NL, 5 (4.3%) mediastinal lymph nodes (M), 5
(4.3%) ML, 5 (4.3%) NML, 3 (2.6%) bone (B), 3 (2.6%) BL, 2 (1.7%)
NLB, 1 (0.9%) liver (LV)BL, 1 (0.9%) NB, 1 (0.9%) LVL, 1 (0.9%)
brainNL, 1 (0.9%) NMLV. Only 1 microcarcinoma had minimal
extra-thyroidal extension and NLmetastasis. Bone metastasis were signifcantly
more frequent in follicular than papillary T
1
and T
2
carcinomas (42.9 vs 7.4%,
P,0.001). In the median follow-up time (51 months, minimum9, maximum400),
3 patients died, 2 with folicullar and 1 with papillary T
3
carcinomas.
Conclusions
Metastatic spread was more frequently observed to the cervical lymph nodes and
to the lungs. Bone metastasis were more frequent in the follicular than in the
papillary T
1
and T
2
carcinomas. Despite such metastization, only 3 patients died.
P830
TSH receptor antibody levels (TSHAb) in hyperthyroid patients with
Graves` disease (GD): an evaluation of the outcome of
131
I therapy
Jolanta Kijek
1
, Jerzy S Tarach
2
, Maria Kurowska
2
, Bozena Szymanek
1
,
Beata Chrapko
1
& Anna Dabrowska
2
1
Department of Nuclear Medicine, Medical University, Lublin, Poland;
2
Department of Endocrinology, Medical University, Lublin, Poland.
Aim
The aim of the study was to evaluate the relationship between TSHAb levels and
thyroid function and size in patients with Graves` disease and then to estimate the
infuence of TSHAb on the outcome of
131
I therapy.
Two hundred and one patients (168 females and 33 males, mean age 47.76 years,
range 18-84) with Graves` disease were enrolled. Before therapy, plasma fT
3
,
fT
4
, TSH (DELFIA technique) and TSHAb (radioreceptor method) were
measured in all patients. A thyroid technetium-99m scan was performed and
iodine uptake (RIU) was measured after 24 and 48 h, then effective half-life
(EHL-RIU) was determined. The therapeutic activity of
131
I was calculated by
Marinelli`s formula. During the one-year follow-up thyroid function was
assessed.
Results
The levels of TSHAb ranged from 1.1 to 405 U/l (mean 56.9886.95) before
therapy. One year after
131
I therapy 69 patients were hypothyroid (HP), 56 were
euthyroid (E), and 76 were hyperthyroid (H). In the 126 effectively treated
patients (E and HP), TSHAb concentration was 23.4 U/l27.66, and in the 76
ineffectively treated patients it was 71.4 U/l97.46. A comparison of mean
values showed a statistically signifcant difference (P0.0001). A statistical
analysis also showed that there was a statistically signifcant relationship between
TSHAb and thyroid mass (P0.0001) as well as EHL-RIU (P0.002).
Conclusions
There is a relationship between TSHAb concentration and thyroid size as well as
effective half-life. In patients ineffectively treated with
131
I therapy TSHAb
concentration was higher than in those treated effectively.
P831
A difhcult case of the medullary thyroid cancer
Fatma Dilek Dellal, Suheyla Gorar, Zehra Candan, Anil Gonenc,
Cavit Culha, Gonul Koc, Yavuz Selim Demir & Yalcin Aral
Ankara Training and Research Hospital, Ankara, Turkey.
A 49-year-old man with history of nodular goitre operation was referred to our
clinic because of MTC in postoperative pathology. He had hypertension,
postoperative hypothyroidism, no family history of thyroid carcinoma and sudden
death. Laboratuary investigations showed high level of calcitonin (C) (763 pg/ml;
normal,150), Carcino embryogenic antigen (CEA) (175 ng/ml; normal,2.5),
normal thyroid function tests, parathormone, urinary catecholamines. Ser904
polymorphism in exon15 of RET protooncogen was found. When the post-
operative pathologic preperations were reevaluated, immunohistochemical
stainings resulted in positivity of C and chromogranin. The postoperative thyroid
ultrasonography (TUSG) demonstrated residual tissue with dimensions of 34,
27 mm on right, 23,18 mm on left side, multiple lymph nodes (LN) up to 2 cm
in diameter at neck regions. He underwent complementary thyroidectomy and
neck exploration. Thyroid residual tissue wasn`t seen, established LN were
excised during operation. Postoperative pathology revealed metastasis of MTC,
TUSG demonstrated residual tissue and C raised to 1146. After 2 months,
modifed neck disection and complementary thyroidectomy were performed.
Tissue at the left thyroid region and bilateral detectable LN were resected. The
pathologic examination of LN was positive for MTC. At postoperative frst
month, C was 1896. Residual tissue dimensions were measured as 4,3 cm on the
left, 2,1 cm on the right side, and 2,1 cm at the isthmus during TUSG.
Radiotherapy was performed to neck and thyroid region. After two months, C was
high, at 850. Meanwhile; heterogen, hypodense, nodular lesion which extended to
retrosternal region and had semisolid, cystic components was determined at
tomography Whole body imaging with I-131 MIBG and 18 FDG PET were
normal. Nadir value of C and CEA were determined as 253, 18.4 respectively at
postradiotherapy period, but C levels reincreased later. FNA was performed from
thyroid tissue with dimensions of 20,16 mm. Its pathology was consistent with
metastasis of MTC. He was operated for fourth time. Despite there was no
residual tissue at postoperative thyroid screening, C and CEA levels increased to
385 and 15.77, subsequently. We present this case to state diffculties in
management of MTC. He and his frst degree relatives have been followed up at
our clinic.
P832
Scarless neck by conducting robot-assisted thyroidectomy: our initial
experience
Dimitrios Linos, Andreas Kiriakopoulos & Efthimios Poulios
Hygeia Hospital, Athens, Greece.
Background
Robotic thyroid operation using the gasless transaxillary approach is an
applicable and safe method providing a scarless in the neck result in selected
Tg,0.5
(ng/ml)
Tg 0.5-2
(ng/ml)
Tg2
(ng/ml) TotaI
Stimulated
serum Tg (%)
71 (78%) 12 (13%) 8 (9%)
Metastatic
lymph nodes
yes/no
15/56 9/3 4/4 28/63
patients. The application of robotic technology offer a three-dimensional view
and tremor free movements which enable a potential advantage in recurrent
laryngeal nerve and parathyroid glands preservation.
Seven patients with history of bad scars from previous surgeries underwent robot-
assisted endoscopic thyroid operations using the gasless transaxillary approach.
All the operations were performed using the Da Vinci S surgical robotic system.
The preoperative evaluation of thyroid pathology consisted in ultrasound
examination and FNA biopsy. In all cases we performed laryngoscopy to
examine the vocal cords function preoperatively and postoperatively. Patients`
clinicopathologic data, operation times, postoperative hospital stays, compli-
cations, conversions, postoperative pain and cosmetic results were all analyzed.
Results
The mean patient age was 41.6 years (range 30-56).
Two patients had papillary carcinoma; one had toxic adenoma and four
multinodular disease. Three totals, one lobectomy and three near total
thyroidectomies were performed. Mean diameter of the largest nodule was
27.2 mm (range 18-20). No conversions occurred.
Four patients complained about hypoesthesia in the fap dissection area whereas
two presented mild seroma. Transient hypocalcaemia occurred in two patients and
one had a temporary recurrent laryngeal nerve paralysis, which improved
gradually.
The total operation time was177 min (range 120-250) and consisted of a mean
34 min (range 20-40) working space time, a mean 21 min (range 10-30) docking
time and a mean 122 min (range 70-210) console time.
Mean hospital stay was 1.6 days (range 1-3). Postoperative pain was minimal and
the cosmetic result excellent.
Conclusions
Our initial experience shows that the robot assisted gasless transaxillary approach
is feasible and provides safe excision of thyroid pathology, an easy identifcation
of the vital structures with the perfect aesthetic outcome of a scarless neck.
P833
Is there a need to constitute laboratory- and/or region-specihc reference
ranges for the screening of thyroid disorders?
Dora Horvath
1
, Erzsebet Toldy
2,3
, Zoltan Locsei
1
, Rita Nagy
1
,
Gabor L Kovacs
3,5
& Istvan Szabolcs
4
1
First Department of Internal Medicine, Markusovszky Teaching Hospital
of County Vas, Szombathely, Hungary;
2
Central Laboratory of
Markusovszky Teaching Hospital of County Vas, Szombathely, Hungary;
3
Institute of Diagnostics and Management, University of Pecs, Pecs,
Hungary;
4
Faculty of Health Sciences Semmelweis University, Budapest,
Hungary;
5
Laboratory Medicine University of Pecs, Pecs, Hungary.
Usually, the frst laboratory marker for thyroid disorders is TSH. FT
4
and FT
3
must not be measured unless TSH is out of the reference range. However, the
reference range for TSH (and for free thyroid hormones) given by the
manufacturers of immunoassays may be not completely valid for screening in
iodine-defcient areas and among hospitalized patients either.
Aim
Our aim was to constitute specifc TSH, FT
4
, FT
3
reference ranges for the
population of our moderately iodine defcient western-Hungarian area, to use
them for ambulatory and hospitalized patients by comparing to the
manufacturer`s reference ranges (TSH: 0.4-4.0 mU/l, FT
4
: 9-19, FT
3
:
2.7-5.9 pmol/l) to analyze the difference of the number of free hormone
estimations needed and also the difference in the expenses.
Methods
To calculate TSH, FT
4
, and FT
3
reference ranges in the disease-free population
living in our area, sera of 151 healthy blood donors (without positive personal and
familiar thyroid anamnesis) were used. 25 639 thyroid tests - on the Architect
i2000 analyzer (Abbott) - from 14 918 out-patients and 1874 hospitalized patients
seen in 2008 were analyzed retrospectively.
Results
In our disease-free population the reference range for TSH is 0.34-4.32 mU/l, for
FT
4
9.4-17.7 and FT
3
3.4-6.3 pmol/l. Among hospitalized patients the reference
ranges are wider (TSH: 0.27-5.9, FT
4
: 9.6-21.91, FT
3
: 1.5-8.3). By using these
reference ranges instead of that of the manufacturers, the need for free hormone
tests would have been less by 5082 measurements. (fT
4
: 1928. fT
3
: 3158).
That would have reduced the expense by 20%, (4400 saving per year)
without affecting the diagnostic accuracy of the method.
Conclusion
It is well known that the distribution of TSH in the normal population is
infuenced by the iodine intake. Our results show that is worth and cost-effective
to use area- and laboratory-specifc reference ranges for evaluation of in vitro
thyroid tests.
P834
The accuracy of hne needle aspiration cytology in the tryroid nodule
study, in a tertiary hospital
Beatriz Torres Torres
1
, Gonzalo Maldonado Castro
1
,
Luis Irigoyen Cucalon
1
, Blanca Caton Santaren
2
, Julia De Diego
2
& Rafael Ezquerra Larreina
1
1
Endocrinology Department, Santiago Apostol Hospital, Vitoria-Gasteiz,
A
lava, Spain;
2
Pathology Department, Santiago Apostol Hospital,
Vitoria-Gasteiz, A
lava, Spain.
Background
Fine Needle Aspiration (FNA) is currently the primary diagnostic procedure in
diagnosing thyroid malignancy. The aim of this study was to report our
experience with FNA, and its accuracy.
Retrospective analysis of 166 patients who were operated of thyroid nodule in our
hospital from 2003 to 2008, all of them had a previous FNA cytology results.
There were evaluated some clinical variables and the correlation with fnal
histopathologic diagnosis, we also studied the specifcity, sensitivity, positive
predictive value, negative predictive value of the FNA.
Results
A total of 212 thyroid FNA were obtained from 166 patients; 88.5% were women,
28.8% were solitary nodules, the average nodule size was 28.8 mm (10-72), of
which 48.2% on the right side. After the frst FNA 72 (42%) were negative for
malignacy, 55 (33%) were suspicious for malignancy, 12 (7.2%) malignant and
27 (16.2%) unsatisfactory. The FNA was repeated in 36 patients (27 for
unsatisfactory previous cytology and 9 for thyroid nodule change during the
follow-up) being the results: 18 (50%) were benign, 10 (27.7%) were suspicious
for malignancy, 1 (3.3%) malignant and 7 (19%) unsatisfactory. Ten patients did a
third FNA being 1 malignant, 7 negative for malignancy and 2 unsatisfactory.
Sixty-six (40%)patients were operated for other causes than FNA cytology
results, such the size of nodule or compressive goiter. The histologic results were:
33 (20%) follicular adenoma, 100 (60%) nodular goiter, coloide nodule or
lymphocytic thyroiditis and 33 (20%) carcinomas - 21 (63.6%) papillary
carcinoma, 11 (33.3%) follicular carcinoma, 1 (3%) medullar carcinoma. In the
carcinoma group after two FNA 2 patients had a benign cytology, both were
described as micropapillary carcinoma. The specifcity, sensitivity, positive
predictive value, negative predictive value of the FNA cytology were 91.5, 92.3,
90, 93% respectively. Sixty percent were palpation-guide FNA and 40% were
US-guide FNA. Comparing the accuracy between both (palpation guide vs
US-guide): the unsatisfactory FNA was 20 vs 12.5% and the specifcity,
sensitivity of the FNA cytology were respectively: 88 vs 94.7%; 75 vs 100%.
Conclusions
The accuracy of FNA improves with US-guide FNA although if the indication of
palpation-guide FNA is well-done the accuracy would be similar, however FNA
cytology is an excellent diagnostic test in the thyroid nodule study.
P835
Hypothyroidism related to tyrosine kinase inhibitors:
an underdiagnosed disorder?
Teresa Azevedo, Mariana Martinho, Teresa Martins, Florbela Dias,
Nuno Cunha, Frederico Valido, Helena Gervasio & Fernando Rodrigues
IPO Coimbra, Coimbra, Portugal.
Introduction
Tyrosine Kinase Inhibitors (TKIs) are approved for the treatment of several
cancers and can induce hypothyroidism by unclarifed mechanisms.
Objectives
To assess the prevalence of hypothyroidism in patients treated with TKIs.
Methods
Retrospective review of clinical records of patients treated with TKIs in our
institution between 2003 and 2009. We evaluated parameters such as sex,
oncologic pathology, TKI used, TSH and free T
4
, dose of levothyroxine.
Results
We evaluated 37 patients, 20 were men (54%) and 17 women (46%). Imatinib was
used in 24 patients, sunitinib in 11, lopatinib in 1 and sorafenib in another.
Twenty-one patients (56.8%) had gastrointestinal stromal tumour, 8 (21.6%)
chronic myeloid leukaemia, 6 (16.2%) renal cell carcinoma, 1 (2.7%) breast
cancer and 1 (2.7%) hepatocellular carcinoma. Thyroid function tests (TFT) were
assessed prior to treatment with TKI in 6 patients (all euthyroid) and during or
after treatment with TKI in 13 patients (35.1%). Of these 13 patients, 6 were
hypothyroid (46.2%) after a mean period of 12.25.2 months of TKI therapy.
Thyroid function was not evaluated in 24 of 37 patients (64.9%). Only 3 out of 24
patients treated with imatinib were screened for thyroid dysfunction and all were
euthyroid. TFT were assessed in 8 of the 11 patients treated with sunitinib, 5 of
which were hypothyroid (62.5%). The patient treated with sorafenib was
euthyroid and the one treated with lopatinib had hypothyroidism.
Conclusion
A high percentage of patients was not screened for thyroid dysfunction. The
prevalence of hypothyroidism in the patients who performed TFT was 46.2%.
Sunitinib seems to induce hypothyroidism more frequently. It is important to
consider this TKI adverse effect and include TFT in routine toxicity assessment of
these patients.
P83
Procalcitonin: a promising role in medullary thyroid carcinoma?
Teresa Azevedo, Mariana Martinho, Teresa Martins, Nuno Cunha,
Frederico Valido & Fernando Rodrigues
IPO Coimbra, Coimbra, Portugal.
Introduction
Procalcitonin (PCT) is currently used as a sepsis marker. Studies have shown that
this prohormone is elevated in patients with medullary thyroid carcinoma (MTC)
and, additionally, that its assay could have less limitation than calcitonin (CT).
Objective
To evaluate the concordance between the values of CT and PCT.
Methods
CT, PCT and carcinoembryonic antigen (CEA) were measured in a total of 57
subjects. CEA and CT were measured by an immunochemiluminometric assay
using an Immulite 2000 analyzer (Siemens Healthcare) and PCT was measured on
a Kryptor system (BRAHMS) TRACE technology (Time Resolved Amplifed
Cryptate Emission). We used the Pearson correlation test.
Results
We included 41 patients with MTC and 16 controls (9 with follicular cell-derived
carcinoma and 7 with benign thyroid disease). Sixty six percent of the patients
were female. In the control group all patients had normal CT, PCT and CEA
levels. Of the 41 patients with MTC, high CT was detected in 15 (range:
24-31 745 pg/ml), high procalcitonin in 12 (range: 0.9-134 ng/ml) and elevated
CEA in 12 (range: 7.52-536 ng/ml). All 3 patients with borderline high CT
(range: 24.1-36.6 pg/ml) had normal PCT levels (,0.5 ng/ml) and no evidence
of residual disease. A signifcant positive correlation between levels of CT and
PCT (r
2
0.9, P,0.001) was found.
Conclusion
A strong correlation was observed between CT and PCT levels in patients with
MTC. The PCT assay together with CT could represent, in future, a promising
complementary MTC tumor marker. Long-term prospective studies will be
fundamental to determine the value of each one on detection of residual disease.
P83I
Prevalence of associated thyroid pathologies in patients with thyroid
hemiagenesis and normally developed thyroid gland
Ewelina Szczepanek, Marek Ruchala, Agata Czarnywojtek
& Jerzy Sowinski
Department of Endocrinology, Metabolism and Internal Medicine,
University of Medical Sciences, Poznan, Poland.
Introduction
Thyroid hemiagenesis (TH) is a rare inborn anomaly occurring if one of the
thyroid lobes fails to develop. Due to limited literature data and lack of large-
cohort case-control studies, the clinical signifcance and management with
patients in whom TH was diagnosed, are still a matter of debate. The objective of
the study was a complex analysis of a large group of patients with TH in
comparison to a control group of subjects born with normal, bilobed thyroid gland
in regard to prevalence of associated morphological, functional and autoimmune
thyroid pathologies.
The studied group consisted of 50 patients newly diagnosed with TH. The control
group was composed of 100 subjects with bilobate thyroid, matched for age and
gender. In the studied patients, serum concentration of TSH, free thyroid
hormones (FT
4
and FT
3
), anti-thyroid autoantibodies, calcium, calcitonin and
parathormon were measured. Additionally, thyroid ultrasound and scintiscans
were performed.
Results
The hormonal production of a single thyroid lobe was, provided no concomitant
thyroid disease exists, suffcient to maintain clinical euthyroidism. In patients
with TH, in comparison to a control group, higher concentration of TSH and FT
3
were observed, while no differences in FT
4
, calcium, calcitonin and parathormon
levels were observed. In patients with TH, hypothyroidism, morphological
abnormalities and autoimmune thyroid diseases, in comparison to control group,
were more frequently diagnosed (P,0.05). In patients with TH, the incidence of
some associated thyroid pathologies was shown to increase with age (P,0.05);
along with age also increase in thyroid volume (P0.0003, r0.750) parallel to
decrease in TSH concentration (P0.0509, r 0.4666) was observed.
Conclusions
Obtained results indicate increased risk of associated thyroid pathologies in
patients with TH, therefore a need for systematic observation and introduction of
L-thyroxine treatment in case of elevated TSH level.
P838
Simultaneous thyroid and gastric autoimmune disease: clinical aspects
of 78 cases
Miguel Paja, Aitzol Lizarraga, Cristina Moreno, Esti baliz Ugarte,
Josu Perez-Yeboles & Amelia Oleaga
Hospital de Basurto, Basque Country, Bilbao, Spain.
Autoimmune polyendocrinopathy syndromes (APS) gather a wide range of
diseases. The association of autoimmune thyroid disease (ATD) with other organ
specifc diseases is frequent. Atrophic body gastritis (ABP) is characterized by the
loss of ClH and intrinsic factor (IF) production. Both ATD and ABP are known to
be associated since 1960 but there are scarce publications describing its clinical
features.
We review patients with this association selected from the clinical database of our
outpatient endocrine clinic (2000-2009). Mayor criteria were evidence of ATD
(regardless thyroid function) as well as B
12
vitamin defciency and/or ABP in
gastroscopy and/or hypergastrinemia (neither taking gastric acid antisecretory
drugs nor renal insuffciency). ATD patients with antiparietal cell antibodies
(PCAb) and unexplained iron defciency or other autoimmune disease patients
were also selected even if gastrine had not been measured nor gastroendoscopy
performed. The chief complaint of the patients, B
12
levels, analytic and
immunologic tests and gastroscopic features were colleted. We included 78 (9
men), aged 24 to 85 years (mean 53), 67 with mayor criteria. Goiter or thyroid
dysfunction were the most frequent presenting symptom (62) followed by
pernicious anaemia (8).In ATD patients ABG was discovered in 28 due to B12
defciency, and 22 due to iron defciency. Immunologic studies showed PCAb in
62/72 and IFAb in 7/30. Gastrine levels ranged from 30 to 3513 pg/ml.
Chromogranine A levels were over 1000 pg/ml in 18/21. There were other
autoimmune diseases in 23 (vitiligo in 11). At the time of diagnosis of ABP
45 patients had received thyroid treatment (9 hyperthyroidism). Results of
gastroendoscopy were obtained in 45 cases with evident gastric atrophy in 32 and
1 single case with neuroendocrine hyperplasia.
Diagnosis of the named thyrogastric syndrome is increasingly diagnosed in recent
years. Detection of this association and gastroscopy surveillance seems to be
mandatory since its increased risk of gastric cancer and carcinoids.
P839
FOXE1 polyalanine tract (FOXE1-polyA) length polymorphism in
patients with thyroid hemiagenesis and subjects with normal thyroid
Ewelina Szczepanek
1
, Marek Ruchala
1
, Lidia Kilinska
1
,
Malgorzata Jaroniec
2
, Witold Szafarski
2
, Maciej Zabel
2
& Jerzy Sowinski
1
1
Department of Endocrinology, Metabolism and Internal Medicine,
University of Medical Sciences, Poznan, Poland;
2
Department of Histology
and Embryology, University of Medical Sciences, Poznan, Poland.
Introduction
Thyroid hemiagenesis (TH) is a rare inborn anomaly presenting as developmental
failure of one thyroid lobe. Recent research on the molecular background
underlying thyroid dysgenesis have mainly focused on patients with congenital
hypothyroidism. In contrast, subjects presenting TH were only sporadically
involved. In addition, whether the same factors are responsible for development
of TH and other forms of thyroid dysgenesis is still to be elucidated. Recent
studies have pointed to the correlation between FOXE1-polyA length
polymorphism and genetic susceptibility to thyroid ectopy and agenesis.
However, the evaluation of its length in a large group of patients with TH has
never been performed. The objective to the study to assess FOXE1-polyA length
in patients with TH and normal thyroid gland.
The studied group consisted of 40 patients with TH, including 6 familial cases.
The condition was diagnosed during medically indicated or performed as
screening examination, thyroid ultrasound. Unilateral absence of functional
thyroid tissue was confrmed by thyroid scintiscan. The control group consisted of
89 subjects with fully developed bilobed thyroid gland. The fragment of FOXE1
coding sequence, comprising polyA tract was amplifed using standard PCR
conditions; one of the primers was marked with fuorescent dye. The length of
reaction products was subsequently assessed by the means of capillary
electrophoresis, performed in Genetic Analyzer 3130 (Applied Biosystems) in
the presence of marker LIZ 600.
Results
Short variant of FOXE1-polyA, containing 12 codones, was present in 5 control
subjects (5.6%), but never in TH. However, there difference in the FOXE1-polyA
length between patients with TH and control group did not reach statistical
signifcance.
Conclusions
Short variant of FOXE1-polyA length was detected only in control subjects.
However, the length of FOXE1-polyA does not seem to be the key factor
determining risk of TH development.
P840
Isolated maternal hypothyroxinemia in women with gestational
diabetes mellitus and its connection to necessity of insulinotherapy
Michal Krcma
2
, Eva Dvorakova
2
, Daniela Cechurova
1
, Lenka Vokurkova
2
& Zdenek Rusavy
1
1
First Department of Clinic Medicine, Diabetology Centre, University
Hospital, Plzen, Czech Republic;
2
First Department of Clinic Medicine,
Endocrinology, University Hospital, Plzen, Czech Republic.
Introduction
Isolated maternal hypothyroxinemia leads to higher prevalence of children
autism, attention-defcit/hyperactivity disorder and mild cognitive defciency.
Frequency of hypothyroxinemia among women with gestational diabetes mellitus
(GDM) is unclear and routine screening is not well established.
Objective
Find prevalence of maternal isolated hypothyroxinemia in women with GDM and
assess relations with necessity of insulinotherapy.
Methods
Retrospective observational open study. Four hundred and eighty-fve women
with GDM were enrolled. In all women were measured free thyroxin (fT
4
),
thyroid stimulation hormone (TSH) and thyroid peroxidase antibodies by RIA.
Women with pre-existent or newly discovered thyroidal illness or with elevated
thyroid-peroxidase antibodies or with other autoimmune disease were excluded.
All subjects had common iodine supplementation (multivitamins with iodine).
Statistical analysis was performed using Mann-Whitney test and Spearman
correlation test.
Results
Serum fT
4
levels were below 10th percentile according to normal values in 173
women, below 5th percentile in 65 women. In this three groups - below 5th
percentile, below 10th percentile and above 10th percentile - were observed no
differences in initial metabolic (TSH, serum total cholesterol, serum triglycerides,
fasting plasma glucose, glycosylated haemoglobin, manifestation of GDM) and
anthropometric (age, weight, BMI) parameters. Insulinotherapy was needed
signifcantly frequently in the group below 10th percentile (62 women - 35.8%)
than in the group above 10th percentile (59 women - 18.9%).
Conclusion
In our patients with gestational diabetes mellitus we observed higher frequency of
isolated maternal hypothyroxinemia in comparison with literary data (1-5%).
Women with lower fT
4
needed signifcantly more often insulinotherapy (approx.
twice).
P841
Effects of rhTSH administration on 24 h arterial pressure in subjects
undergoing evaluation for differentiated thyroid cancer
Gianna Rentziou
1
, Eustathios Manios
3
, Emily Mantzou
2
, Katerina Saltiki
1,2
,
Fotios Michas
3
, Nikos Zakopoulos
3
& Maria Alevizaki
1,2
1
Endocrine Unit, Department of Medical Therapeutics, Alexandra Hospital,
2
Endocrine Unit,
Evgenidion Hospital, Athens University School of Medicine, Athens,
Greece;
3
Hypertension Unit, Department of Medical Therapeutics,
Alexandra Hospital, Athens University School of Medicine, Athens, Greece.
Background
TSH levels within the normal range have been associated with increased blood
pressure (BP). TSH itself might be involved, especially as extrathyroidal actions
of TSH exist.
We investigated whether elevated TSH levels after acute rhTSH administration
may result in alterations in BP in euthyroid individuals.
Methods
Twenty-six euthyroid female subjects thyroidectomised and on T
4
suppressive
dose, were evaluated by the rhTSH (Thyrogen) test to assess cure of the disease.
A 24 h ambulatory blood pressure monitoring (24 h ABPM) was performed on
days 2-3 (D2-3) of the test, immediately after the second intramuscular rhTSH
injection (0.9 mg/day on D1&2), when TSH levels are highest. TSH levels were
measured on D1, D3, D5. Twelve subjects underwent one further 24 h BPM 1-3
weeks before the Thyrogen test (control). Patients took stable T
4
dose throughout
the study.
Results
All subjects were euthyroid. TSH levels were D1: 0.0590.039 mU/l, D3:
125.1333.40 mU/l, D5: 14.215.58 mU/l (P,0.001). There were no
signifcant associations between TSH levels on D3 and any BP measurements
either systolic (SBP), or diastolic(DBP) on day and night time measurements.
There was a signifcant positive correlation of TSH on D5 with SBP and DBP
(r values0.396, 0.461, P,0.05).
In the group with control measurements mean SBP was signifcantly higher at the
time when the rhTSH was administered compared to control (paired sample T
test), (SBP control111.112.0 mmHg, after rhTSH115.09.7 mmHg,
P0.024). Similar differences were found when day-time and night-time SBP
measurements were assessed. Both groups did not differ signifcantly regarding
DBP (control68.66.3 mmHg, after rhTSH69.86.5 mmHg, P0.135).
Conclusions
This study provides indirect evidence that TSH per se, when acutely elevated,
may increase diastolic and systolic arterial pressure. Although night measure-
ments were also elevated, one cannot exclude the possibility that the stress related
to 'medical test performance` may have contributed to this increase in BP.
P842
The association of autonomous thyroid functional nodules with
autoimmune thyroid disease
Cristina-Corina Pop-Radu
University of Medicine and Pharmacy, Tg-Mures/Mures, Romania.
Chronic autoimmune thyroiditis and Graves` disease (GD) are two forms of
autoimmune thyroid disease (AITD).
The association of GD or other thyrotoxic forms of autoimmune thyroiditis with
one or several toxic nodules is the Marine - Lenhart syndrome (SML). It is a rare
pathology with prevalence between 2.7 and 4.1%. Its physiopathology remains
complicated and misunderstood, incriminating antithyroidian auto-antibodies
such as TSH receptors antibodies and genetic alterations of the TSH receptors.
The present study was accomplished afterwards, on the basis of the clinical
records of the patients that were hospitalized in the Endocrinology Clinic in
Tg-Mures, between January 1999 and June 2004. In our study SML represented
1.42% (12 cases) of hyperthyroiditises, the majority of which were in females
(91.67%). The highest incidence was in the age group 40-60 years (average age
being 49.5 years). In 58.33% of the cases the two diseases (the autoimmune and
the autonomous one) were diagnosed simultaneously. The succesive form: GD
followed by TTA - thyroid toxic adenoma) - 25%, whereas TTA followed by GD
was present merely in 16.67% of the subjects under study. GD/Hashitoxicosis
emerged after two, eight, and 10 years respectively after TTA was diagnosed.
Exophtalmus was present in 25% (3) of patients. Compressive phenomena were
detected in fve patients (41.67%). After subtotal thyroidectomy for GD, in three
patients (25%), recurrence of struma was detected after 17, 20 and 22 years
respectively, and the struma eventually proved to be TTA. In one patient of male
sex a microinvasive papillary thyroid carcinoma was also diagnosed, which
recurred three years after subtotal thyroidectomy. Patients with autonomous
thyroid nodules should be carefully evaluated with a view to a possible
autoimmune predisposition, surgery being the most adequate therapy for SML, in
order to prevent recurrences.
P843
Effects of L-thyroxine treatment on resistin and high-sensitive CRP
levels in patients with subclinical hypothyroidism
Duygu Yazgan Aksoy, Ayla Harmanci, Nese Cinar, Bulent Okan Yildiz,
Aydan Usman & Miyase Bayraktar
Background
Subclinical hypothyroidism (SH) is an endocrine disorder defned by increased
thyrotropin (TSH) levels associated with normal free thyroxine (fT
4
) and free
triiodothyronine (fT
3
). Resistin is secreted from the adipose tissue and is reported
to be associated with insulin resistance and/or infammation. High-sensitive CRP
(hs-CRP) is a reliable marker of infammation. Data related to levels of resistin
and hS-CRP in SH is limited.
Aim
We aimed to determine the levels of resistin and hs-CRP in women with SH and
potential effects of L-thyroxine therapy on those levels.
Thirty-four women with SH were included. All patients received L-thyroxine for
6 months and reevaluated. Resistin and hs-CRP levels were from studied frozen
samples after the completion of the study.
Results
All patients reached euthyroid status after therapy. TSH decreased and fT
4
increased (P,0.001). Resistin and hs-CRP levels did not change signifcantly
after 6 months of L-thyroxine therapy.
Conclusions
Our results suggest that achievement of euthyroid status by replacement therapy
did not change resistin or hs-CRP levels in women with SH. SH is known to alter
metabolic functions. Previous studies reported different changes in adipokines
according to thyroid status. Further studies are needed to clarify the interaction
between thyroid function status, metabolic parameters, infammatory markers and
adipokines.
P844
The predictive value of ultrasonography in detection of autoimmune
thyroiditis
Fevzi Balkan, Ihsan Vuray, Rifki Ucler, Alper C Usluogullari,
Introduction
Diagnosis of autoimmune thyroiditis is made by determination of elevated
antibodies against thyroid peroxidase and thyroglobulin, and a hypoechoic pattern
in ultrasound. In the present study we have performed a grey-scale quantitative
analysis of thyroid echogenicity in the patients affected by autoimmune
thyroiditis, obtaining the degree of hypoechogenicity associated with the
appearance of thyroid dysfunction.
Six hundred and thirty-two patients who had autoimmune thyroiditis proven
clinically, by laboratory and ultrasonographically were included in our study.
Serum thyrotropin (TSH), thyroid hormones (fT3, fT4) and thyroid autoanti-
bodies (Anti TPO Ab, Anti Tg Ab) were evaluated. Thyroid ultrasonography was
performed in all subjects. An experienced endocrinologist who was uninformed
about the laboratory results performed thyroid ultrasonography.
Results
Five hundred and ffty-one (%87.2) of 632 patients were female and 81 (%12.8)
were male. Mean age of the female and male patients were 46.20.5 and
48.61.71 years respectively. The thyroid parenchyma was classifed as minimal
heterogeneous, heterogeneous, and severe heterogeneous. TSH, Anti TPO Ab,
and Anti Tg Ab levels were compared between these groups. TSH levels in the
minimal heterogeneous and heterogeneous groups were signifcantly lower than
the severe heterogeneous group (P,0.01 and P,0.001 respectively). When Anti
TPO levels were compared signifcant difference was detected between groups
(P,0.001). Anti TPO levels were lowest in the minimal heterogeneous, and
highest in the severe heterogeneous group. In addition, Anti Tg levels were lower
in the minimal heterogeneous and heterogeneous groups when compared with the
severe heterogeneous group (P,0.001 and P,0.001 respectively). As with Anti
TPO, Anti Tg levels were lowest in the minimal heterogeneous, and highest in the
severe heterogeneous group.
Conclusion
Our study has shown that the paranchymal destruction has strongly associated
with thyroid antibodies and TSH levels when it is classifed by grey-scale
ultrasonography.
P845
Fine needle aspiration biopsy of a thyroid nodule: a comparison of
diagnostic performance of experienced and inexperienced physicians
Alptekin Gursoy
1
, Cuneyd Anil
1
& Betul Erismis
2
1
Department of Endocrinology and Metabolism, Baskent University Faculty
of Medicine, Ankara, Turkey;
2
Department of Internal Medicine, Baskent
University Faculty of Medicine, Ankara, Turkey.
Objectives
Ultrasound-guided fne needle aspiration biopsy (US-FNAC) technique has the
advantage of obtaining tissue for cytological examination. The diagnostic yield
may depend on factors related to both technical aspects and the lesions sampled.
However, the variability between experienced and inexperienced physicians in
obtaining adequate cytological sample has not been specifcally studied
previously. The aim of the study was to determine whether there is a difference
in terms of adequacy of cytological material between experienced and
inexperienced physicians in a tertiary referral center-based service.
Methods
All patients with thyroid nodules of at least 10 mm in diameter were referred for
US-FNAC tissue sampling as a part of their diagnostic workup. From May 2006
to September 2009, 997 euthyroid patients with thyroid nodules were referred for
US-FNAC by the attending endocrinologist (experienced) or endocrinology
fellows (inexperienced) in the outpatient clinics of the Endocrinology department
of Baskent University Hospital in a prospective design.
Results
Of the 1320 nodules, 713 were biopsied by the experienced physician and 607
were biopsied by the inexperienced physicians. There were no differences in age,
gender, thyroid function, nodule location and distribution of nodule structure
between the two groups. Nodule size was signifcantly higher in the
endocrinologist group than the fellow group (17 vs 14 mm, respectively;
P,0.001). The inadequacy rate of the FNAC performed by the experienced
physician (22/713 thyroid nodules, 3.1%) was signifcantly lower than those
performed by inexperienced physicians (102/607 thyroid nodules, 16.8%)
(P,0.001).
Conclusion
We conclude that with increasing operator experience, the number of inadequate
cytological specimens generated by ultrasound-guided fne needle aspiration
biopsies of thyroid nodules greatly reduces. This limits both direct and indirect
costs, and also the risks of possibly unnecessary surgeries.
P84
Limited therapeutically options in a case of invasive papillary thyroid
carcinoma
Mara Carsote
1
, Raluca Trifanescu
1,2
, Corina Chirita
2
, Cristina Ene
2
,
Dumitru Ioachim
2
, Dana Terzea
1,3
, Catalina Poiana
1,2
&
Mihail Coculescu
1,2
1
2
C. I. Parhon National Institute of Endocrinology, Bucharest, Romania;
3
Babes Institute of Research and Development, Bucharest, Romania.
Introduction
Even the differentiated thyroid neoplasm have good prognostic, there are some
particular cases that become very aggressive in short time, with poor
management.
Aim
We report a female case diagnosed with invasive papillary thyroid carcinoma.
Case report
Seventy-three-year old female was diagnosed at age of 71 with a right lobe
thyroid nodule (of almost 6 cm). At that moment the computed tomography (CT)
of the cervical region revealed invasion into the scalen muscle and the hyoid bone,
and multiple cervical lymph nodes of maxim 1 cm. The fne needle aspiration
biopsy (FNAB) suggested very well differentiated papillary carcinoma. The
patient consulted the general practitioner who did not recommend surgery. On
admission, 2 years later, the thyroid function was normal but the patient had
obstructive symptoms. She presented local invasion into the larynx, up to the base
of the tongue of 11 cm, according to MRI and CT of the region. The common
carotid artery was invaded of 2.5 cm. The FNAB aspects still revealed low
aggressive profle with no anaplasic shift. Multidisciplinary consult was
performed but the case was considered inoperable due the carotid artery invasion
as revealed by angioMRI. Further tracheotomy will be necessary.
Conclusion
This is a rare case when the fne needle aspiration biopsy suggested a
differentiated thyroid cancer, apparently with a good prognosis. Despite the
cellular aspects, the histological profle would be a useful tool but the case was
considered inoperable due to the aggressive local invasion, especially into the
carotid artery. Eventually, palliative surgery will be necessary.
P84I
Prevalence of benign breast diseases in nodular goiter and autoimmune
thyroid diseases
Alptekin Gursoy
1
, Tekin Guney
2
& Cuneyd Anil
1
1
of Medicine, Ankara, Turkey;
2
Department of Internal Medicine, Baskent
University Faculty of Medicine, Ankara, Turkey.
Objective
The evidence regarding association between thyroid diseases and benign and
malign breast diseases is increasing. It has been shown that thyroid disorders are
more frequent in those with benign breast diseases and that different thyroid
diseases have associations with benign and malign breast diseases and their
outcomes. In this study, we aimed to reveal the frequency of benign breast
conditions in patients with nodular thyroid disease and Hashimoto`s disease.
Design
Seventy-one women with nodular thyroid disease, ninety-fve women with
Hashimoto`s disease and as a control group, 72 euthyroid cases were included in
the study. A detailed clinical assessment of the participants was carried out, serum
thyroid stimulating hormone, free triiodothyronine, free thyroxine and thyroid
peroxidase autoantibody levels were measured, and thyroid and breast
ultrasonography were performed by a single operator in order to determine
thyroid and breast pathology.
Results
Benign breast diseases were detected in 55.7% of patients with nodular thyroid
diseases, in 47.4% of those with Hashimoto`s disease and 29.2% of control group
in the study. The results showed that the frequency of benign breast diseases was
signifcantly higher in nodular thyroid disease and Hashimoto`s disease than the
control group (P,0.01 and P,0.01 respectively). Simple cyst was found to be
the most frequent pathology among benign breast diseases; fbrocystic changes,
mixed lesions, benign solid mass, ductal ectasia and complex cyst followed it. No
signifcant relation was found regarding thyroid function and autoimmunity in
patients diagnosed with benign breast disease (P0.05).
Conclusion
The results of our study supports the presence of an association between benign
breast conditions and thyroid diseases. An important implication of this fnding
may be a reasonable role of scanning for potential breast pathology in women
with nodular or autoimmune thyroid disease in clinical practice.
P848
Angiogenesis: the new orientation in medullary thyroid carcinoma
Laura Iconaru, Dana Terzea, Diana Paun, Suzana Vladoiu, Serban Radian,
Dumitru Ioachim & Constantin Dumitrache
National Institute of Endocrinology C. I. Parhon Bucharest, Bucharest,
Romania.
Background
Angiogenesis are correlated with the aggressiveness, evolution`s rapidity and
appearance of the locally advanced and metastatic medullary thyroid cancer
(CMT), but in the same time is a selection criteria for actual therapy tested in the
clinical studies.
Objective
Study of angiogenesis in patients diagnosticated with CMT.
Methods
Our study is conducted for 20 patients with sporadic and familial CMT, who are
diagnosticated and surgically treated in our institute; we examine the
angiogenesis by investigate the vascular growth factors - vascular endothelial
growth factor (VEGF), vascular endothelial growth factor receptor - VEGFR3,
epidermal growth factor receptor - EGFR and D2-40 - marker of lymphangio-
genesis - in tumour tissue by immunohistochemistry.
Results
Nineteen patients presented VEGF positive in tumor. For these patients VEGFR3
was studied and the result was positive for 15 subjects. In this lot 6 patients have
EGFR positive in tumor or vessels. Only 3 subjects have presented D2-40
positive in tumor, vessels or in tumor and vessels. We correlated these results with
clinical data.
Conclusions
The vascular growth factors are correlated with the aggressiveness, evolution`s
rapidity and appearance of the locally advanced and metastatic medullary thyroid
cancer.
The study shows that the angiogenesis plays an important part in tumour`s growth
and extension of the blood fow in the tumour, being considered an independent
prognostic indicator. Focusing the research on blood vessels could represent a
new perspective for medullary thyroid carcinoma. These are preliminary results
from a more comprehensive study.
P849
The thyroid volume reference values for Polish children
Zbigniew Szybinski
1
, Malgorzata Trofmiuk
1
, Monika Buziak-Bereza
1
,
Agnieszka Kieltyka
2
, Grzegorz Sokolowski
1
& Alicja Hubalewska-
Dydejczyk
1
1
Chair and Department of Endocrinology, Jagiellonian University Medical
College, Krakow, Poland;
2
Unit of Molecular Epidemiology, Chair of
Epidemiology and Preventive Medicine, Jagiellonian University Medical
College, Krakow, Poland.
Measuring of goiter by ultrasonography is one of the generally accepted methods
for iodine nutrition assessment. Discordance between previously used and lately
proposed thyroid volume (TV) reference values (TVRV) is the subject of
discussion and makes it diffcult to properly interpret the effects of iodine
prophylaxis.
Aim
To establish TVRV for Polish schoolchildren population.
2903 schoolchildren aged 6-12 years (1418 boys, 1485 girls) were studied in
years 2006 and 2008 (all subject living in the Polish coastal area previously
recognized as iodine suffcient). Seventy-two percent of subjects were born after
implementation of the obligatory iodine prophylaxis model. TV was assessed in
all children ultrasonographically according to standard procedures by two trained
physicians. Urinary iodine concentration (UIC) was assessed in casual morning
urine sample by Sandell-Kolthoff`s method.
Results
Median UIC was 96.02 g/l (mean 109.5170.06 g/l). UIC higher than
100 g/l was noted in 47.5% of children. Goiter frequency (GF) was 2.2%
when TVRV by Delange et al. were applied, and 54.2% when TVRV by
Zimmermann et al. were used. GF didn`t differ signifcantly between subgroups
with UIC below and over 100 g/l, regardless TVRV used. The 50th and 97th
percentile of TV (ml) were: (a) for boys: 6 years - 2.75 and 4.80, 7 years - 3.58
and 5.41, 8 years - 3.91 and 6.44, 9 years - 4.44 and 7.13, 10 years - 5.13 and
7.65, 11 years - 5.44 and 8.56, 12 years - 6.50 and 11.31, respectively; (b) for
girls: 6 years - 2,60 and 4.60, 7 years - 3.42 and 5.21, 8 years - 3.90 and 6.54,
9 years - 4.29 and 6.90, 10 years - 5.02 and 8.40, 11 years - 5.58 and 10.06,
12 years - 7.10 and 12.23, respectively.
Conclusions
i) Newly proposed TVRV don`t seem to be applicable for populations with
recently improved iodine nutrition, and should not be used for therapeutic
purposes; ii) establishing of regional TVRV for ethnically uniform populations
with adequate iodine intake is necessary.
P850
Lp(A) levels in thyroid disfunctions
Cristina-Corina Pop-Radu
1
& Ana Iazigian
2
1
Clinic of Endocrinology, University of Medicine and Pharmacy, Targu
Mures, Mures, Romania;
2
Department of Laboratory Medicine, County
Clinical Hospital, Targu Mures, Mures, Romania.
The aim of the study was to assess lipid status in subjects with hypothyroidism
(overt and subclinical) and hyperthyroidism. Therefore, we analyzed the
relationship between the levels of blood lipids (Lp(a), Apo AI, Apo B, Apo
AI/B, total cholesterol (TC), triglyceride (TG), LDL, HDL, LDL) and TSH, FT
4
,
T
3
, TPOAb concentration. The study groups included 38 subjects with overt
hypothyroidism (meanS.E.M., age 48.613.25 years), 30 with subclinical
hypothyroidism (47.613.23 years), 30 with hyperthyroidism (age 41.5312.29
years) and 55 with euthyroidism. Lp(a) was found to register increased average
serial levels in hypothyroidic subjects, (483.28281.55 mg/l, with limits
between 214 and 1550 mg/l), apparently normal ones in hyperthyroidic persons
(253.1394.29 mg/l, with limits between 140 and 530 mg/l), but signifcantly
lower than hypothyroidic patients and slightly increased ones in the control group
(305100.44 mg/l). In hypothyroidism Lp(a) levels were positively correlated,
signifcantly strong with TSH, Apo B, TC/HDL, CT, TG, VLDL and signifcantly
mild with LDL/HDL (P,0.01) and with LDL (P,0.05). Lp(a) levels were
negatively correlated signifcantly strong with Apo AI/B, FT
4
and T
3
(P,0.01).
In subclinical hypothyroidism subgroup Lp(a) was not correlated with FT
4
, but it
was signifcantly correlated with TSH. TC, HDL, LDL were neither correlated
with FT
4
, nor with the TSH concentration. Between TPOAb and Lp(a) levels no
correlation was found. In hyperthyroidism no correlation between Lp(a) levels
and the parameters under study was found. The association of hypothyroidism
with increased serial levels of Lp(a) which represents independently a relevant
factor of cardiovasculary risk, contributing to atherosclerosis even in case of
relatively normal cholesterol levels, seems to increase the higher cardiovasculary
risk in hypothyroidic subjects. In conclusion, increased levels of Lp(a), in
association with an increase in TSH level can be another argument in favour of the
active treatment of the subclinical hypothyroidism.
P851
Drug induced hyperthyroidism (a rare reaction of sorafenib): case
report
Dan Peretianu
1
, Mara Carsote
2
, Alexandrina Clodeanu
1
,
Dana Cristina Staicu
1
, Corina Chirita
3
, Dana Terzea
2,4
,
Valentin Radoi
2
& Catalina Poiana
2,3
1
SCM Povernei, Bucharest, Romania;
2
Carol Davila University of Medicine
and Pharmacy, Bucharest, Romania;
3
CI Parhon National Institute of
Endocrinology, Bucharest, Romania;
4
Babes National Institute of
Development and Research, Bucharest, Romania.
Introduction
Sorafenib, an orphan medication, is an oral protein kinase inhibitor, used in the
treatment of hepatic, advanced renal and breast cancer, or metastatic iodine-
refractary thyroid cancer. The drug also inhibits angiogenesis, and VEGF, having
a dual effect on the tumor cells as well as on the tumor vasculature.
Aim
We present a case with hyperthyroidism, as adverse effect of the therapy with
sorafenib, but with no markers of thyroid autoimmunity or prior hypothyroidism.
Case report
Sixty-six-year-old female patient, coming from non-endemic zone, has a history
of hepatic cancer since the last year. The hepatic resection of the ffth lobe was
performed. The pathological report revealed carcinoma with clare cells, as well as
the imunohistochemistry reaction (positive for OCH1E5, negative for VIM,
CROMO, CD10, Ck7 in the tumor cells and positive in the biliary ducts). Five
months after the initiation of the therapy with sorafenib (400 mg/day), the patient
experienced symptoms of hyperthyroidism. The thyroid parameters revealed:
FT
4
26.8 pmol/l (normal levels between 12 and 22), TSH-0.044 UI/ml, and
negative anti TSH-receptor, antithyreoglobulin and antithyreoperoxidase
antibodies. Therapy with carbimazol 20 mg/day was started while close follow-
up of the hepatic function and hematological profle. In case of non-response, a
short term stopping of the sorafenib would be advisable. In case of rapid response,
the
131
radioactive iodine therapies are recommended.
Conclusion
Hyperthyroidism is an extremely rare situation in patients treated with sorafenib.
This may be an effect over VEGF, because inhibition of VEGF may lead to
thyroiditis, with consequent hyperthyroidism followed by hypothyroidism, but
most of the mechanisms are not completely understood. The situation can become
more diffcult in case of modifed liver profle or if the patient already has ordinary
hematological reactions as leucopenia, (that is frequently induced by sorafenib)
because these interfere with the antithyroid drugs.
P852
Metabolic syndrome and its components are associated with increased
thyroid volume and nodule prevalence in a mild-to-moderate iodine
dehcient area
Semra Ayturk, Alptekin Gursoy, Altug Kut, Cuneyd Anil, Asli Nar
& Neslihan Bascil Tutuncu
of Medicine, Ankara, Turkey.
Objective
The metabolic syndrome (MetS) is a cluster of metabolic abnormalities with
insulin resistance (IR) as a major characteristic. It has been recently questioned
that MetS and its related components are associated with functional and
morphological alterations of thyroid gland. Aim of our study is to examine thyroid
volume and nodule prevalence in patients with MetS in a mild-to-moderate iodine
defcient area.
Design
Two hundred and seventy-eight patients with MetS were compared with 261
subjects without MetS. Serum thyroid-stimulating hormone (TSH), free T
3
and
T
4
, and the level of insulin resistance, estimated by the homeostasis model
assessment for IR (HOMA-IR), as well as other MetS parameters were evaluated.
Thyroid ultrasonography was performed in all participants. All thyroid nodules
1 cm underwent fne needle aspiration biopsy.
Results
TSH was signifcantly positively correlated with the presence of MetS diagnosis.
Mean thyroid volume was higher in patients with MetS than in controls (17.5
5.5 vs 12.24.2 ml, P,0.0001). Thyroid nodules were more frequent in
patients with MetS (50.4 vs 14.6%, P,0.0001). Subjects with IR had increased
thyroid volume and nodule formation. The odds ratio for the development of
thyroid nodule in the presence of IR was 3.2. TSH as well as all MetS components
were found to be independent predictors for thyroid volume increase. IR but not
TSH was found to be correlated with thyroid nodule formation. Thyroid cancer
was diagnosed in 3/38 patients with MetS (7.9%). No cancer cases were found
in control subjects.
Conclusions
The results suggest that patients with MetS have signifcantly increased thyroid
volume and nodule prevalence. The presence of IR contributed substantially to
this increased risk. Our data provide the frst evidence that IR is an independent
risk factor for nodule formation in an iodine defcient environment.
P853
Marked sensitivity of pituitary feedback to levothyroxine in
asymptomatic primary autoimmune hypothyroidism
Raluca-Alexandra Trifanescu
1,2
& Mihail Coculescu
1,2
1
2
'C.I.Parhon` Institute of Endocrinology, Bucharest, Romania.
Background
Few cases of hypersensitivity of thyroid-pituitary feedback in hypothyroid
children were reported.
Aim
To present a family with asymptomatic, severe biochemical primary autoimmune
hypothyroidism who showed a marked sensitivity of pituitary feedback to
levothyroxine treatment.
Methods
TSH was measured by 3rd generation immunoassay kit.
Case report
R.G, woman, aged 22, presented for asymptomatic goiter. Family history
consisted in autoimmune hypothyroidism in proband`s mother (TSH375 mIU/l,
FT
4
0.46 ng/dl, FT
3
1.17 pg/ml, TPO antibodies392 IU/ml) and euthyroid
autoimmune thyroid disease (TSH0.7 mIU/l, FT
4
1.35 ng/dl, TPO anti-
bodies30.4 IU/ml), vitiligo and recurrent urticaria in her sister. Physical exam
revealed a medium goiter, with no signs of hypothyroidism. Mental development
and stature were normal. Biochemical data showed severe primary autoimmune
hypothyroidism (TSH121 mIU/l, FT
4
0.4 ng/dl, antithyroglobulin antibodies
(Ab)771.9 IU/ml). TSH receptor Ab, TPO Ab were negative. Treatment with
levothyroxine 50 g/day for 6 weeks determined subclinical thyrotoxicosis
(TSH0.04 mIU/l, FT
4
1.5 ng/dl). Subsequent decrease in levothyroxine
dose to 25 g/day rapidly led in 2 weeks to TSH increase up to 18 mIU/l and
decrease in thyroid hormones (FT
4
0.86 ng/dl, FT
3
0.85 pg/ml). One month
after levothyroxine`s withdrawal, severe biochemical hypothyroidism occurred
once again, without any clinical signs (TSH173.8 mIU/l, FT
4
,0.4 ng/dl,
FT
3
0.74 pg/ml).
There is a hypersensitivity to levothyroxine`s effect both centrally (suppressed
TSH at low levothyroxine doses, administered for short time) and peripherally
(absence of myxedema signs despite of very low FT
4
levels for many months).
Conclusion
It is tempting to suggest that thyroid-pituitary feedback hypersensitivity could be
an additional cause of hypothyroidism along with thyroid autoimmunity in this
case. Genetics of thyroid hormones` receptors and of deiodinases could also be
involved in this family.
P854
Differentiated thyroid carcinoma in young adults
Anastasios Gkountouvas, Ifgenia Kostoglou-Athanassiou,
Anastasios Pappas, Eirini Veniou, Marios Nikas, Anastasia Aggelopoulou,
Dimitrios Thomas & Philippos Kaldrymides
Department of Endocrinology, Metaxa Hospital, Piraeus, Greece.
Differentiated thyroid carcinoma represents a small percentage of human
carcinomas. However, it is the commonest endocrine neoplasm and if diagnosed
and treated properly does not affect the long-term survival of the patients.
Aim
The aim was to study differentiated thyroid carcinoma affecting young adults.
All patients presenting with thyroid carcinoma to the department from 01.01.2002
to 31.12.2008 were reviewed. Amongst this group patients with differentiated
thyroid carcinoma were selected, in whom the diagnosis was made in the age of
17-30 years.
Results
During the aforementioned period 1606 were admitted with thyroid carcinoma,
1510 suffering from differentiated thyroid carcinoma. Within this group 167
(11%) were diagnosed with differentiated thyroid carcinoma in the age of 17-30
years. Most of them were women (139 patients, 83%), while only 17%
(28 patients) were men. Within this group 148 young adults (89%) had papillary
thyroid carcinoma, 14 (8%) had follicular thyroid carcinoma, while in 5 (3%) a
coexistence of papillary and follicular thyroid carcinoma was noted. In 51% of the
patients the diagnosis was made at the age of 26-30 years, in 33% at the age of
21-25 years, while in 16% at the age of 17-20 years.
Conclusion
Differentiated thyroid carcinoma has been studied extensively in the adulthood
and childhood. However, the study of this carcinoma in young adults has not been
performed till today. It is quite impressive that young women are preferentially
affected by thyroid cancer, a fnding which is in agreement with the detection of
oestrogen receptors in follicular thyroid cells, as young women have levels of
oestrogen that may stimulate follicular thyroid cells and cause their neoplastic
transformation.
P855
Molecular classihcation of benign and malignant thyroid nodules
Klemens Vierlinger & Christa Noehammer
AIT, Seibersdorf, Austria.
We aim to distinguish malignant from benign thyroid nodules by their molecular
profles. To this end we employ a range of different genomic and epigenetic
technologies such as classical whole genome microarray based transcriptomics,
integration and meta analysis of published microarray data, DNA methylation
testing and micro-RNA profling. Our transcriptomics and meta analysis
approaches include all major histological entities. The other approaches (DNA
methylation and microRNA) focus on the distinction of follicular adenoma (FTA)
and follicular carcinoma (FTC). We compare the performance of these profles
with respect to their classifcation task and present functional and genome-level
integration of the data.
Transcriptomics and meta analysis
We conducted microarray analysis of 49 thyroid tumour nodules including all
major histological classes. From this data we calculated inference statistics and
employed different feature selection algorithms for classifcation of (1) malignant
versus benign and (2) FTA versus FTC (using only a subset of 24 samples). This
yielded two set of genes comprising of 20 and 22 genes, respectively.
Classifcation accuracies in our data were 100 and 92%, respectively. Then,
these gene sets were tested on seven different publicly available datasets (totalling
197 samples), two of those included FTA and FTC nodules. The classifcation
accuracy of the FTA/FTC gene set was: 96 and 100%; the accuracy of the
benign/malignant gene set was: 92, 87, 90, 92, 100, 94 and 100%.
Micro RNA
The 24 follicular samples used for mRNA analyses were also used for measuring
their miRNA levels in a genome wide assay. We identifed a set of six miRNAs
which are potentially capable of distinguishing FTA from FTC.
DNA methylation
We used an in-house developed assay, based on methylation sensitive restriction
digestion of DNA followed by microarray readout to assess the methylation status
of 360 selected CpG islands. As little as two CpG islands were suffcient to
distinguish between follicular adenoma and carcinoma.
P85
The limitations of thyroid volume reference values in assessment of
iodine nutrition after recent introduction of iodine prophylaxis
Malgorzata Trofmiuk
1
, Monika Buziak-Bereza
1
, Zbigniew Szybinski
1
,
Andrzej Lewinski
2
, Arkadiusz Zygmunt
2
, Filip Golkowski
1
,
Jerzy Sowinski
3
, Bohdana Dorant
4
, Elzbieta Bandurska-Stankiewicz
5
,
Jerzy Naskalski
6
, Witold Rostworowski
6
& Alicja Hubalewska-Dydejczyk
1
1
Chair and Department of Endocrinology, Medical College, Jagiellonian
University, Krakow, Poland;
2
Department of Endocrinology and Metabolic
Diseases, Medical University, Lodz, Poland;
3
Chair and Department of
Endocrinology, Metabolism, and Internal Diseases, Medical University in
Poznan, Poznan, Poland;
4
Chair and Department of Pediatrics, Hematology,
Oncology and Endocrinology, Medical University in Gdansk, Gdansk,
Poland;
5
Endocrinology, Diabetology and Internal Diseases Ward,
General District Hospital, Olsztyn, Poland;
6
Department of Clinical
Biochemistry, Medical College, Jagiellonian University, Krakow, Poland.
Goiter frequency (GF) in schoolchildren and urinary iodine concentration (UIC)
in an appropriately large population sample are iodine nutrition (IN) best
indicators. GF in mildly iodine defcient areas should be assessed ultrasono-
graphically, as palpation sensitivity in such cases is low.
Aim
To assess thyroid volume reference values as IN marker in population with
recently introduced obligatory iodine prophylaxis (OIP).
Data from 7489 schoolchildren aged 6-12 years examined between 1999 and
2009 were analyzed. 36.33% of children were born after OIP implementation.
Thyroid volume was assessed ultrasonographically according to standard
procedures. Reference values by Delange et al. (DRV) and Zimmermann et al.
(ZRV) were used for GF calculation. UIC was assessed in casual morning sample
using Sandell-Kolthoff method.
Results
Median UIC value in study sample was 92.29 g/l (mean 106.3968.76 g/l),
54.05% of children excreted ,100 g/l. GF was 4.23 and 51.14% according to
DRV and ZRV, respectively. There was no statistically signifcant difference in
GF according to DRV between children with UIC less and more than 100 g/l
(4.42 vs 4.0%), whereas GF was signifcantly lower (P0.01) with UIC
100 g/l when ZRV were applied (52.42% vs. 49.85%). GF in children born
after 1996 was signifcantly lower according to DRV and higher according to
ZRV (1.95 vs 5.54% for born before 1997, P0.00 and 53.40 vs 49.85%,
P0.03; respectively). GF in children aged 10-12 years was higher than in
younger ones (DRV: 5.32 vs 3.31%, P0.00; ZRV: 52.48 vs 50.0%, P0.03;
respectively).
Conclusions
Although UIC indicates that Poland is area of borderline iodine suffciency, ZRV
overrate GF in schoolchildren. Previously recommended DRV don`t mirror all
trends in GF resulting from improved IN (children born after OIP implementation
were younger). Establishing of the separate reference values for mildly
insuffcient and recently iodine suffcient populations seems to be reasonable.
P85I
A study of thyroid disorders in pregnancy
Adela Voican
1
, Oana Pavel
1
, Ionut Vasile
1
, Areta Cerga
2
& Marian Bistriceanu
1
1
University of Medicine and Pharmacy, Craiova, Dolj, Romania;
2
Department of Endocrinology, County Emergency Hospital, Craiova, Dolj,
Romania.
Background and aims
Thyroid disorders (TDs) are frequent in women of reproductive age, with a major
infuence on both female reproductive function and fetal development. During
pregnancy, TDs associate a high risk of miscarriages, premature birth or neonatal
morbidity. Our study aimed to assess both TDs prevalence in pregnant women
and the need to adjust the necessary treatment during pregnancies complicated
with TDs.
Patients and method
This is a retrospective study of 146 pregnant women (with clinical signs or
symptoms suggesting thyroid dysfunctions) addressing the Endocrinology
ambulatory care unit of the County Emergency Hospital of Craiova from January
2008 till December 2009. Thyroid function assessment included the following
serum parameters: thyroid-stimulating hormone (TSH), thyroxine (T
4
), triio-
dothyronine (T
3
), free thyroxine (FT
4
), free triiodothyronine (FT
3
), anti-thyroid
peroxidase antibodies (anti-TPO Ab) and antithyroglobulin antibodies (ATG Ab).
After exclusion of the pregnant women with normal thyroid function, the patients
were divided into two groups according to the presence or absence of thyroid
antibodies: group A (positive thyroid antibodies) and group B (negative thyroid
antibodies). Assessment of changes in instituted treatment was also performed in
pregnancies associated with TDs.
Results
Thyroid dysfunctions were found in 91 patients (61.48%), 46 patients being
included in group A and 45 in group B. According to thyroid hormones values,
31 patients (67.4%) from group A had hypothyroidism, 4 of them (8.7%)
thyrotoxicosis and the remaining 11 (23.9%) being eufunctional. In group B, 42
patients (93.3%) were diagnosed with hypothyroidism and 3 patients (6.7%) with
hyperthyroidism. Changes in the therapeutic attitude of the 73 hypothyroid
patients showed an increased need of thyroid hormone substitution in 41 patients
and a decreased need in 1 patient. Concerning the 7 hyperthyroid patients,
antithyroid therapy was needed in 3 cases.
Conclusions
The high prevalence of thyroid abnormalities in pregnant women suggests the
need for thyroid screening in early pregnancy, while the treatment changes of
these patients show the importance of a close endocrine follow-up in order to
obtain good pregnancy outcome.
P858
The evaluation of radioiodine therapy out come after hve years in
patient with subclinical hyperthyroidism
Saeid Abdelrazek
1
, Franciszek Rogowski
1
, Adam Parfenczyk
1
,
Malgorzata Szelachowska
2
, Malgorzaea Franckiel
2
, Anna Zonenberg
2
,
Malgorzata Karolczuk-Zarachowicz
2
& Piotr Szumowski
1
1
Department of Nuclear Medicine, Medical University of Bialystok,
Bialystok, Poland;
2
Department of Endocrinology, Diabetology and Internal
Medicine, Medical University of Bialystok, Bialystok, Poland.
Aim
The aim of our study was to evaluate the short-term (5 years) effect of radioiodine
therapy (RAIT) on the achievement of euthyroidism, and prevention evolvement
to overt hyperthyroidism.
We treated 150 patients, aged 30-70 years; 54 patients with multinodular goitre
(MNG), and 96 patients with autonomous nodule (ATN). Malignant changes were
excluded in all nodules by fne needle aspiration biopsy. All the patients had
serum TSH levels ,0.1 mU/l and effective T-half measured by the use of T24
and T48 was more than 3 days at the time of treatment. The activity dose was
calculated by the use of Marinelli`s formula and ranged between 200 and
600 MBq. The absorbed dose (Gy) for MNG ranged between 150 and 260, and for
ATN: 200-300. Follow up control was done every 6 weeks in the frst year. Then
every 6 months for 4 years.
Results
In general the success of treatment after 1 year was: 99% of patient with ATN and
92% of patient with MNG achieved euthyroidism. 1% of patient with ATN and
7% of patient with MNG develop hypothyroidism. 1% of the patients had
persistent hyperthyroidism and received second dose of radioiodine therapy. After
3 years of RAIT 2% of patient with ATN and 8% of patient with MNG develop
hypothyroidism. After 5 years of RAIT 2% of patient with ATN and 9% of patient
with MNG develop hypothyroidism. In all the patients the symptoms and signs of
subclinical hyperthyroidism disappeared (palpitation, tachycardia, atrial fbril-
lation, exercise tolerance improved, the blood pressure normalised and the quality
of life improved).
Conclusions
The achievement of euthyroidism and the remission of the symptoms and signs of
subclinical hyperthyroidism, were due to good diagnosis, well preparation of the
patients; accurate measurement of administered activity, effective half-life, and
well-organised follow up.
P859
The inuence of radioiodine therapy on some parameters of
oxidant/antioxidant balance in patients with Graves` disease
Saeid Abdelrazek
1
1
, Anna Zonenberg
2
,
Malgorzata Szelachowska
2
, Maria Gorska
2
, Malgorzata Frackiel
2
,
Agnieszka Nikolajuk
2
& Piotr Szumowski
1
1
Bialystok, Poland;
2
Department of Endocrinology, Diabetology and Internal
Oxidative stress plays an important role in hyperthyroidism-induced tissue
damage. We aimed to determine whether radioiodine therapy has beneft effect on
the oxidant and antioxidant status in patients with Graves` Disease.
We studied 30 patients with Graves` disease, aged 18-48 years. 12 normal adult
volunteers were studied as control group. All the patients were treated
unsuccessfully by antithyroid drugs. The effective half-life measured by the use
of radioiodine uptake (RAIU) after 24 and 48 h was more than 3 days at the time
of treatment. Malondialdehyde (MDA) as a marker of oxidative stress,
glutathione (GSH) and glutathione peroxidase (GPx) activity as a parameters of
antioxidant system, were evaluated in the investigated groups before and
6 months after radioiodine therapy. The serum fT4, fT3, TSH, TSHRAb were
evaluated before and monthly up to 12 months after RIT. Thyroid ultrasound, and
thyroid scan with thyroid RAIU were done before and after12 months of
radioiodine therapy. The activity dose was calculated by Marinelli`s formula
and was ranged between 280 and 600 MBq. The absorbed dose ranged between
120 and 200 Gy, Follow up control was done every 4 weeks.
Results
Hyperthyroidism cause a signifcant increase in MDA level (P, 0.05), with
signifcant decrease in GPx activities (P, 0.05) and GSH level, compared with
controls subject. A signifcant decrease of MDA level with signifcant increase of
GSH level and GPx activities was observed after 6 months of radioiodine therapy
in patients who achieved euthyroidism. In 21 patients euthyroidism was achieved,
5 patients received L-thyroxin replacement therapy due to hypothyroidism, two
patients were in subclinical hyperthyroidism, and hyperthyroidim persist in 2
patients. Thyroid volume reduced to about 47% (average).
Conclusions
Our results confrm the imbalance of the antioxidant/oxidant status in patients
with Graves` disease. Radioiodine therapy was more effective to improve these
balances.
P80
Thyroid incidentaloma: palpable problems of an impalpable nodule
Carmen Vulpoi
1
, Voichita Mogos
1
, Delia Ciobanu
2
, Cristina Preda
1
,
Cristina Cristea
1
, Maria-Christina Ungureanu
1
, Letitia Leustean
1
& Eusebie Zbranca
1
1
2
Department of Morphology, UMF Gr.T.Popa, Iasi, Romania.
The widespread of sensitive imaging methods have substantially increased the
incidental fnding of subclinical thyroid nodules. The 'epidemic` of thyroid
incidentaloma has raised numerous discussions regarding their management: Is it
necessary to investigate all nodules or is surveillance suffcient? Which criteria
should be used in order to identify the nodules which must be investigated by fne-
needle aspiration (FNA) (size, echogenicity, vascularisation)? Should we always
rely on cytology? We performed an ultrasonographic screening in 535 subjects
(190 males, 345 females, aged between 25 and 63 years-old) from a region with
borderline iodine defciency. Thyroid ultrasonography was performed with the
same engine by 7 endocrinologists with similar training. Including criteria were
absence of any known thyroid pathology and residency for 10 years in the
investigatred area. Prior to the ultrasonography, thyroid was clinically examined.
The incidence of thyroid nodules was 17.4%, concordant with literature data.
After elimination of the palpable nodules, 9.7% were retained as 'true`
incidentaloma. Considering the diameters, 69% were micronodules, 18.4% had
the main diameter between 1 and 1.5 cm and the rest had 1.5 cm. 2.6% of all
subjects had positive antithyroid antibodies, and 1.4% patients had previously
unknown thyroid dysfunction. Ultrasound-guided FNA was performed in 25
subjects and one (already suspicious on ultrasonography) had malignant cytology,
postsurgical morphology confrming papillary thyroid carcinoma (7% of the
explored nodules 4 to 12% in the literature data). We believe that subjects with
nodules larger than 1 cm and those with suspicious ultrasound aspect should be
investigated by ultrasound-guided FNAB, and smaller nodules with no other risk
factors could be followed-up in 6-12 months. However this general attitude must
be adapted to every individual case. Larger randomized prospective studies are
necessary in order to propose a consensual diagnostic and management guide.
P81
Elastography based on tissue Doppler in the diagnosis of thyroid
nodules: a pilot study
Zbigniew Adamczewski
1
, Kinga Krawczyk-Rusiecka
1
, Marek Dedecjus
2
,
Jan Brzezinski
2
& Andrzej Lewinski
1
1
Department of Endocrinology and Metabolic Diseases, Research Institute,
Polish Mother`s Memorial Hospital, Medical University of Lodz, Lodz,
Poland;
2
Department of General, Oncological and Endocrine Surgery,
Research Institute, Polish Mother`s Memorial Hospital, Medical University
of Lodz, Lodz, Poland.
Objective
Aiming at the highest specifty in differentiating benign from malignant thyroid
nodules effects in new diagnostics developments. Recent technologies such as
elastography enable determination of tissue stiffness difference between focal
lesions and surrounding thyroid tissue - reference tissue. This method is based on
quantifying the stiffness of the lesion - the malignant changes show decreased
elasticity when compared to adjacent tissue. Tissue Doppler used in Toshiba
ultrasound system requires external tissue compression made by the researcher by
means of the transducer. Due to individual technique differences, some artifacts
interfering the diagnosis may occur during examination.
Design
The aim of the study was to assess a potential role of elastography based on tissue
Doppler in the diagnosis of focal thyroid lesions.
In this study, 100 thyroid nodules in 76 consecutive patients were examined
(68 women, 15 men), using Toshiba Aplio XG ultrasound with linear PLT 1204
BT transducer. Final diagnoses were obtained from cytological and, in 54 cases,
histological evaluation. There were 5 cases of papillary thyroid carcinoma, 1 case
of anaplastic carcinoma, and 70 benign nodules. After achieving fnal results all
the conducted examinations were reviewed.
Results
Retrospective evaluation study revealed presence of the artifacts causing different
outcomes. The results interpretation was more diffcult in nodules localized
between isthmus and thyroid lobes, in peripheral thyroid and in cases when the
lesion and lobe transverse parameters were equal.
Conclusions
Elastographic examination based on tissue Doppler imaging reveal stiffness
differences between thyroid lesions and reference tissue. The awareness of the
circumstances of artifacts appearing and correct examination technique are
crucial for proper results interpretation. Nevertheless, prospective studies are
needed to defne useful applications and the clinical signifcance of the method.
P82
Clinical and histopathologial characteristics of papillary thyroid
microcarcinoma (PTMC)
Elisabete Rodrigues
1,2
, Ana Sousa
1
, Luis Matos Lima
1
, Amadeu Pimenta
1,2
& Jose Luis Medina
1,2
1
Hospital S. Joao, EPE, Porto, Portugal;
2
Faculdade de Medicina do Porto,
Porto, Portugal.
Introduction
The recognition of thyroid microcarcinoma has been increasing in recent years
probably as a result of the widespread use of ultrasound-guided fne-needle
aspiration biopsies (FNAB) of small non palpable nodules and possibly of a more
extensive histological examination.
Objectives
To describe clinical and histological characteristics of papillary thyroid
microcarcinoma and compare them according to its size (, or 5 mm).
Methods
Retrospective analysis of clinical and pathological data of all patients operated on
for thyroid cancer at our hospital between 2006 and 2008. Statistical analysis was
done with SPSS 17.0 for Windows.
Results
During this period 533 patients (83 males, 450 females with a mean age of 54.5
14.0 and 51.814.7 years old, respectively) were diagnosed and treated
for thyroid cancer at our institution. Of the 588 pathology reports evaluated in
370 there was a diagnosis of PTMC. Of these 172 were 5 mm (group A) and
198 ,5 mm (group B). When comparing these groups according to gender, age at
diagnosis (,45 or 45 years), coexistence of Hashimoto`s thyroiditis,
mutifocality/multicentricity, capsular invasion, vascular invasion, extrathyroidal
extension and lymph node involvement we found differences between them in
terms of age at diagnosis (58 (55%) were ,45 years in group A vs 107(43%)
in group B; P0.04) and lymph node metastasis (6 in group A (3,5%) vs 1 (0.5%)
in group B; P,0.035). No distant metastasis was observed in this study.
Conclusions
PTMC is frequently found and the optimal treatment is still debatable. Some
patients with PTMC have clinical and histopathogical poor prognostic factors, but
in these series only tumors larger than 5 mm were signifcantly associated with
lymph node metastasis. An interesting fnding was the higher frequency of PTMC
,5 mm in older patients. We can hypothesize that they refect the indolent course
of some of these tumors, that belong to the papillary family neoplasm, but are not
necessarily malignant. Papillary microtumor was proposed in 2003 as a new term
for a subset of PTMC, by a group of pathologists (Rosai J et al.).
P83
The inuence of radioiodine therapy in patient with non-toxic goiter
with low RAIU in the enlarged nodule: a case report
Saeid Abdelrazek
1
1
, Adam Parfenczyk
1
,
Malgorzata Frackiel
2
, Malgorzata Szelachowska
2
& Katarzyna Siewko
2
1
Bialystok, Poland;
2
Department of Endocrinology, Diebatology and Internal
A young woman aged 23 years, with non-toxic goiter was treated in our
Department. Serum levels of FT
4
, FT
3
and TSH were within normal range, high
resolution ultrasonography show very large glands (60 ml), with large nodule in
left lobe and smaller one in the right lobe. Malignancy was ruled out by
ultrasound-guided fne-needle aspiration biopsy. Thyroid radioiodine scintigra-
phy showed homogenous and diffuse uptake in the right lobe, with very low
uptake in the left lobe, radioiodine uptake (RAIU) after 24 and 48 h was 29 and
27%. The effective half-life measured by the use of RAIU was about 7 days. The
patient refused surgical operations and agreed to be treated with radioiodine. The
activity dose was calculated by Marinelli`s formula and the patient received
280 MBq of I-131. The absorbed dose was about 240Gy. Follow up control was
done every 4 weeks. After 6 months of radioiodine therapy, thyroid scintigraphy
showed homogenous and diffuse uptake in the left lobe and very low uptake with
reduction of the size of right lobe. Thyroid USG also show a decrease in the
volume of right lobe. RAIU after 24 and 48 h was 36 and 35% respectively. The
patient received a second dose of radioiodine 600 MBq, the absorbed dose was
about 300 Gy. Thyroid USG and thyroid scan were done after 12 months to assess
thyroid volume. The patients received L-thyroxin replacement therapy for
hypothyroidism. Thyroid volume decreased about 53%. Radioiodine therapy is
non-invasive, safe and cost effective method of therapy for reduction of goitre
even in patient with low radioiodine uptake and should not be restricted to elderly,
or to patients with high operative risk, but should be used as frst choice in every
patient with non-toxic nodular goitre (40 ml) especially in patients with special
professions or patients wish a non-invasive treatment modality.
P84
HOMA index and waist circumference do not correlate with TSH levels
in a group of euthyroid adults
Alexander Shinkov, Anna-Maria Borissova, Iliana Atanassova,
Roussanka Kovatcheva, Jordan Vlahov & Nina Aslanova
University Hospital of Endocrinology, Sofa, Bulgaria.
The aimof the study was to investigate the relationship among the indices of insulin
resistance (IR), the lipid parameters and thyroid function in euthyroid adults.
Two hundred and sixteen euthyroid adults, mean age 57.0813.81 years
(112 female and 104 male) were included. Serum lipirds, Immunoreactive
insulin, glucose, TSH, waist circumference (WC), body height and weight were
measured. HOMAi and BMI were calculated.
Results
Mean HOMA was 3.696.02, BMI was 29.404.99. The major laboratory data
are presented in Table 1.
HOMA index, WC, Tgl were signifcantly higher in the males. In the females
HOMA correlated positively with the age (r0.238, P0.011), BMI (r0.288,
P0.002), WC (r0.280, P0.003) and Tgl (r0.375, P,0.001). In the males
HOMAi correlated positively with the age (r0.260, P0.008), WC (r0.225,
P0.023) and BMI (r0.201, P0.041). HOMA correlated negatively with
HDL-c in both genders (r286, P0.002 in females and r212, P0.031
in males). No correlation was found between the TSH and any of the other
parameters (all P0.05). HOMAi and Tgl were higher in the females with
increased WC (all P,0.005), but not in the males. TSH did not differ between the
groups with normal and increased WC.
Conclusion
In our study we found strong correlations among the indices of IR and the lipids
in the euthyroid subjects with some variances between the genders. We did not
fnd however data of an infuence of thyroid function on the studied parameters
in this group.
P85
The relation of the history of hypothyroidism with the risk for breast
cancer: A review.
Anna Angelousi
1
, Michael Stamatakos
2
& Kontzoglou Konstantinos
3
1
Department of Internal Medicine, Chuv University Hospital, Lausanne,
Switzerland;
2
Department of Surgery, Attiko Hospital, University Hospital,
Athens, Greece;
3
Department of Surgery, Laiko Hospital, University
Hospital, Athens, Greece.
Introduction
The relation of hypothyroidism with the breast cancer is described early in the
literature based in some common pathophysiological paths which associate
thyroid gland and breast tissue.
Methods
A literature research in PubMed and Cochrane library database was performed
for articles studying any possible association between the risk for
development of breast cancer with the presence of hypothyroidism history
in women.
Results
Seven out of the 11 included studies showed no signifcant relation of the history
of hypothyroidism to the risk for breast cancer. Four studies showed a relation
between the history of hypothyroidism and the risk for breast cancer. In one of
them the history of hypothyroidism was related signifcantly with an increased
risk for breast cancer. In another one only the non treated hypothyroidism was
related signifcantly to the risk for breast cancer.
Conclusions
The majority of the included studies showed that the history of hypothyroidism is
not related signifcantly to an increased risk for breast cancer. However there are
many contradictory fndings particularly as far as the association of the treatment
of replacement of thyroid hormones with the risk for breast cancer.
P8
Selenium and pentoxifylline in patients with mild Graves` orbitopathy:
Results of a randomized placebo-controlled double-blind clinical trial
Claudio Marcocci, Maria Antonietta Altea, George Kahaly, Susanne Pitz,
Gerasimos Krassas, Kostas Boboridia, Luigi Bartalena, Mario Sivelli,
Georg von Arx, Matthias Stahl, Marco Nardi, Maarten Mourits,
Leilo Baldeschi, Also Pinchera, Wilmar Wiersinga & EUGOGO Group
University of Pisa, Pisa, Italy.
We studied 152 patients with Graves` disease mild orbitopathy (GO), with a
disease duration of ,18 months, who had been euthyroid for at least 2 months
after antithyroid drug or surgery, or 6 months after 131-Iodine. No patient
received previous treatment for GO, except for local measures. Patients were
randomized to receive either selenium (SE), an antioxidant (as selenium selenite,
100 (g b.i.d), or pentoxifylline (PF), an anti-infammatory and antifbrotic
agent (600 mg b.i.d.), or placebo (PL, b.i.d) tablets. The intervention lasted for
6 months, followed by a follow-up of another 6 months. Primary outcomes were:
i) objective assessment of the eye changes by a blinded ophthalmologist;
ii) subjective GO-QoL, using a disease-specifc questionnaire. Secondary
outcome were: i) Clinical Activity Score (CAS); ii) diplopia Gorman`s score;
iii) tolerability and safety. At 6- and 12-month evaluations treatment with SE, but
not with PF, resulted in a statistically signifcant improvement, as compared to
PL, of eye involvement (P0.012 and P0.116, respectively) and QoL
(P,0.0001 and P0.570, respectively). SE was also more effective as compared
to PF on both outcomes (0.043 and 0.0006, respectively). The CAS decreased in
all groups, but the change was signifcantly greater in patients treated with SE.
No effects of treatment was observed on the Gorman`s score. GO worsened in 2
patients of the PL group and 1 of the PF group; no patients treated with SE showed
worsening of GO. SE was well tolerated, whereas PF caused gastrointestinal side
effects in a substantial number of patients. In conclusion, SE administration over a
6-month period, as compared to PL or PF, signifcantly improved the eye
involvement and the QoL in patients with mild GO. Thus, a 6-month course of SE
should be offered to patients with mild GO.
d Minimum Maximum Mean S.D.
Chol (mmol/l) 216 3.16 10.01 5.8331 1.18597
HDL-c (mmol/l) 216 0.68 2.27 1.3192 0.32394
Tgl (mmol/l) 216 0.28 22.44 1.9687 1.92882
TSH (mU/l) 216 0.408 3.890 1.43082 0.667430
Authur Index
l Aultoncn S.1
S Abdclruzck P5, P59
& P0!
Y AbdclWulub P29!
l Abdullulu P709
C Abcguilc 0C0.!
l Abcrg P141
A Abrislumilur P4!
R Abs P55
l Acur P274 & P754
R Acltcrbcrgl 0C2.4
l Acibucu P!2! & P009
M Ackcrmuns S2.1
l Acostu Criudo P701
Z Adumczcwski P2!7
& P01
S Adumck P702
A Adumidou P142 & P07
C Adums 0C5.4
A Adumsku P152, P!45,
P49! & P090
l Adcmoglu P5!
C Adlcr P72!
l Ahorci P247 & P49
A Agurwul P52
K Agbult P122 & P007
A Aggclopoulou P445
& P54
M Agluic P209
A Agin P12
T Agorustos P!!9, P!42
& P794
N Agruwul P177, P279
& P20
M Aguilur-liosdudo P!29
H Alungur P!49
B Allcmcycr H1.1
R Alluwuliu P454
T Aigncr P429
C Aimurctti P421, P001,
P01 & P00
l Ak P770
S Akulin P147
N Akulin P410
A Akulin P109
NAkur Buyrum P59, P1!!
& P7!1
l Akursu P24
T Akusli P259
C Akbubu P9, P004
& P000
H Akbulut P!20
A Akbutucv P50
A Akcun P204
H Akgun P204
l Akin P549 & P550
B Akinci P05 & P07
S Akturun P24
A Al Cluzlun P29, P410
& P41
C Al Klzouz P2
} AlAumu P!0
l Alugol P20!
M Albcrcu Vclu P75
} Alcgbclcyc P174 & P20
M Alcvizuki P127, P!15,
P47 & P41
l Alcxundcr P050
A Alcxundrou P150,
P401, P402, P7!5
& P7!
T Alcxccvu P579
l Alcxiu P774
0 Alcxopoulou P71
R Alluyutc Cucrru P5!2
l Algu n P272 & P27
l Alicvu P572, P57!,
P51 & P52
C Alimuklumcdovu P572,
P57! & P52
l Alissu P!4!
Y Aliyuzicioglu P!70
} Allcr P412 & P414
} Allcr Crundu P44
B Allolio 0C4.1, P2!, P57,
P424, P044 & P711
PAlmcidu P220
R Almcidu P220
l Alonso P494
N Alonso Blusi P1!2
& P1!
PAlonso-Mugdulcnu S25.2
M Alpun cs Bucsu P199
S Altuncr P00
M Altcu P00
R Altloll P55
A Altintus P545
Y Altuntus P509
PAlvurcz P221
C A
lvurcz lscolu P757

l A
lvurcz Curcr u P059

& P002
M Alvcs P90, P15, P217,
P22!, P244, P41!,
P552, P5, P700,
P775, P04, P24
& P20
B Amundinc P790
B Amunn-Vcsti P154
C Amurul P225
T Amuro P27 & P29
l Amuzit 0C4.!
B Ambosi P21
A Ambrogio P12
B Ambrosi 0C!.4, P7, P!9
& P0!2
M Ambrosio 0C5.1, P!4,
P!5, P!0 & P!7
A Ambrosio P7
l Amzur P197, P447
& P590
l Anuloroglu P155, P272
& P27
PAnugnostis P5
A Anustusilukis P77
l Anustusiou P!15
& P47
l Anustusiu P7
C Ancu-Roxunu P442
M Andcl P0!!
M Andcrscn P40!, P42,
P017 & P072
C Andcrscn S7.1 & P017
VAndr u P221 & P!2
M Andjclic }clic P129
Z Andjclkovic P705
A Andrudc 0livic P059
& P002
M Andruslulvy H1.2
N Andrccscu P197
C Andrci P774
M Andrioli P1! & P502
l Androulukis P54
A Angcli P01
A Angclousi P05
l Angclovu P!99
M Anicl-Quirogu P2
R Aniclski P7!
C Anil P45, P47 & P52
N Anisic P01
C Ankurbcrg-lindgrcn
P5!9
M Anluul P05
S Annu P20!
l Ansurudccn P04
C Antczuk P242
} Antic P557 & P75
S Antic P21, P495
& P077
} Antic P109
M Anticu P519
l Antipovicl P70
C Antoncllu P542
A Antoniou-Tsigos P25
M Antosovu P77 & P0
M Antsilcrov P579
} Antuncs-Rodrigucs P00!
& P004
l Apostu P212 & P21!
A Arulut P142 & P07
Y Arul P5!, P0!5 & P!1
S Arumputzi P0, P1,
P29 & P291
l Arundu P597
l Arundu lopcz P002
S Arupovu P599
l Arus P10
l Aruvuntinos P401
M Aruz P24
A Arduc P004
A Arcs Cumcrino P1!2
& P1!
} Argcitis P77!
M Argcntc P400
A Argyropoulos P25
N Arik P175
Z Arizunovic P555
T Arklypkinu P471
A Arkowsku P02
WArlt P2!
A Armugunidis P701
l Armcni P150, P7!5,
P7! & P77!
C Arnuldi P57
M Arosio 0C!.4, P7, P21
& P020
l Arpuci P195, P2!9
& P!02
A Arsic P50!
C Arsos P77
} Artlur P411
l Artikovu P04
C Artonnc P520
l Arvut P!, P001 & P7!4
l Asun P10
N Ascnjo Aruquc P1!0
& P474
K Asluwcsl P2!5, P2!0
& P450
K Askurov P570
N Aslunovu P04
R Assukcr P!!
C Assic P47
} Astrup P017
A Astrup P715
B A
svold S1!.2
l Atunussovu P04
VAtusoy P272
A Atlunusiudou P!15
A Atlunusouliu P022
PAtlunussiou P99, P114
& P!!
l Atzcni P5! & P25
M Aubcrtin-lclcudrc
P251 & P070
N Aubcrvul P!54 & P!5
A Aupcrin P41
l Auricclio S25.1
R Auricmmu P594
l Avugliuno 0C1.5
C Awustli P2
Y Aydin P274, P02,
P004, P75! & P754
C Aydin P!17 & P!02
L
Aydogun P!20 & P097

A Aydogdu P14, P102,
P!20, P!27 & P097
A Aymun P547
M Ayrcs Bustos P4!!
S Ayturk P52
T Azcvcdo P!5 & P!0
l Azzum 0C!.5
S Azzolini P4!
M Buccini P094 & P740
A Buclclot 0C4.5 & 0C5.5
l Buciu P107, P200 &
P455
M Buckdull P2
N Buculcscu P49
K Budcnloop S19.!, P20
& P!1
l Budcscu P770
R Budilu P!!, P99, P214,
P2!4, P!!, P40,
P409 & P4!
A Budilu P5!7
C Budiu P140, P!70,
P!77, P40!, P420,
P4!7, P455 & P000
H Buc P191
} Bucnu P77
M Bucnu P!29
C Bulloni 0C0.2
S Bulijri P!4!
C Buls P157
S Buik P40 & P012
l Bujkin P, P219 &
P014
A Bujrukturcvic P252
M Bujzovu P715
l Bulumi P17! & P20
M Bulus P!, P590
& P770
M Bulbo P!
R Bulcun P107, P11,
P42 & P09
l Buldcscli P00
M Buldi P7!4
A Buldys-Wuligorsku P50
& P57
C Bulcrciu 0C1.4, P52
& P5!0
l Bulkun P07, P770
& P44
l Bulzi P149 & P105
A Bunuru P455
l Bundurovu P55!
l Bundursku-Stunkicwicz
P50
A Bunikurim P209
M Bunks P411
C Bunti 0C0.1
A Buntilu P!1
C Buptistu P5
M Buruc P0 & P555
M Burulonu P021
S Burbut P!79
A Burbosu P120, P27
& P29
C Burbu P207
C Burcin P14
l Burg P490
A Bur-llun P504
M Burisu P1
A Burlicr 0C!.0 & P724
C Burmpulios P77
S Buron P5!0
A Burquillu P075 & P09
0 Burrcuu P47
l Burros P90
l Burtulcnu P00
M Burtcls P429
A Burtkc P512
M Burtlovu P700
N Buscil Tutuncu P155
& P52
HBuscr P!02, P477&P770
A Buslumboo S11.1
C Buskol P!72 & P!74
} Bussctt S!.!
M Bustos P217
l Bustos P29
M Butissc P5
l Butistu P047
C Buttistu P21
l Buudin 0C4.4, P29,
P410, P41 & P424
S Buumcistcr P7!0
S Buumgurtncr-Purzcr
0C!.1 & P714
l Buumgurt-Vogt H1.1
P Buvcnlolm 0C1.0
l Buyruktur P05 & P07
M Buyruktur P707 & P4!
T Buyrukturoglu P20!
l Buyrum P!72, P!7!,
P!74 & P759
M Buzurru Custro P500
H Buzrulslun P209
H Buzrulslun P!49
C Bcccuti P00
A Bcccrru lcrnundcz P1!0
& P474
W Bcclstcin P!1
S Bccltold-lullu Pozzu
P500
A Bcckcrs S.!, 0C!.0
& 0C0.5
P Bcck-Pcccoz H1.5, H2.2,
0C1.5, 0C!.4, P7, P21,
P0!2, P041, P720,
P725 & P10
l Bcdnurck-Pupicrsku P12
C Bcdnurck-Tupikowsku
P145, P09 & P709
W Bcdnorz P145
l Bcgmu P!00
N Bclnumpur P209
S Bcicr P110
H Bckdcmir P0!5
S Bclcustro P001 & P421
V Bclcngcunu P197
A Bclcngcunu P197
B Bclcslin P4 & P79!
M Bclinclon Sz.-Somozu
P701
T Bcljic Zivkovic P129
C Bcllustcllu P451, P54!,
P020 & P001
A Bcllustcllu P451, P54!
& P020
V Bcllido Custuncdu P44
l Bcllocclio H2.1
} Bcllonc P01
S Bcllonc P01 & P702
l Bclluomo P094 & P740
l Bclo P217 & P552
M Bclovuri P97
M Bclovici P14! & P15
H Bclow P74 & P75
H Bcn Humidu P200
Z Bcnclcllul P!95
C Bcndcr P711
B Bcndlovu 0C1.!, P!20,
P!52, P427, P4!0,
P099 & P70!
P Bcnito-lopcz P4!5
M Bcnncscl S22.!
A Bcnnct P!2
} Bcnnctt P7!9
C Bcnnolr P75
S Bcnsing P12 & P019
M Bcnto P29
R Bcrurdclli P!
C Bcrg P50!
S Bcrgumuscli 0C!.4
& P0!2
N Bcrgcr P!97
C Bcrgcr P!97
P Bcrgcr P527
l Bcrkcr P9, P15!,
P02, P004, P000
& P15
l Bcrnubcu P015 & P025
R Bcrnul P11
K Bcrncis P154 & P!50
} Bcrnlcim P270
M Bcrnicr P!!
A Bcrruti P424
X Bcrtugnu H1.! & P47
A Bcrtuni 0C2.0
} Bcrtlcrut H1.!, P!7, P47
& P51
l Bctcu 0C0.5
M Bcurun P40!
l Bcuscllcin 0C4.1, 0C4.2
& P!91
M Bcvilucquu P94
C Bcvilucquu P01!
M Bcycr P2! & P57
A Biuncli P9! & P112
S Bibcroglu P05
M Biclo P120
M Bidct 0C5.5
M Bidlingmuicr S10.!,
0C4.1, 0C4.2, P!91
& P515
B Bidzinsku-Spciclcrt
P40 & P409
M Bicloluby P515
M Bicnkicwicz P45
N Bicrmusz H2.!, 0C!.!
& P554
W Bictigcr P!54
R Bilck P!20 & P!57
R Bilous P10
S Bilz P551
R Bingisscr P14
W Birclmcicr S15.1
P Birmun P025
l Bissuugc 0C5.5
P Bissclop 0C!.!
l Bistriccunu P72, P7!
& P74
M Bistriccunu P72, P7!,
P74, P095 & P57
M Biswus P525
N Bitgcn P!7!
M Bizid P200
A Bizzurro P020
P Bjcrrc P017
} Bjork P0!7
M Blulu P19
} Blulu P159
M Blunclurd P724
C Blunco P000
R Blund P7!9
M Blundino-Rosuno P!29
R Blunkcnstcin P7!0
0 Blunkcnstcin P204
& P20
A Blcclsclmidt P044
l Blcvc P4!
C Blomstrund P141
l Bloom P!2
S Bloom P404
C Blum P14
C Bountu P140 & P091
l Bobcscu P104
K Boboridis P779 & P00
M Bobu P10
C Boccuzzi P!90 & P707
C Bock P!44
A Bockiscl 0C2.1
V Boddi 0C1.4, P149,
P151, P440, P47
& P5!0
C Bodmcr P17!, P174
& P20
B Boclm 0C4.0 & P72
A Boclcn H2.5
C Bocscl P!00
T Boguvuc P472 & P47!
l Boguzzi P5, P000, P01!,
P0! & P705
} Bogusluwsku P4!1
A Boldunowicz-Puwluk
P02
l Boi P4!4
P Boilcuu P257
P Boix P412 & P414
P Boix Pullurcs P44
} Bojungu P1 & P755
l Bokun P120
M Bolunowski P04, P09
& P1!
A Bolut lcmirczcr P190
} Bollcrslcv P509 & P0!9
l Bolu P14 & P102
S Bolu P097
C Bonu P702
S Bonudonnu P0!
S Bonukdurun P125
T Bondurcnko P190
& P205
S Bonduri P72,P7! & P74
V Bonillu }imcncz P75
M Bonomi P041 & P725
A Bordu P407
l Borgct P29
l Borgogni P722
A Borini S7.!
A Borissovu P04
M Borlu P59!
l Bormunc P157
S Bornstcin P1!7
N Borojcvic P!0!
A Borruccino P01
& P020
C Borrcttu 0C0.2
l Borson-Cluzot P!!,
P!97, P!9, p0!4
M Boscuro P57 & P040
l Bosicu P401
A Boss P!00
T Bostucu P212
A Bottcr P7!4
S Bouuziz P200
P Bouclurd P40
S Boudcrbu P!01
} Bouligund H2.4 & 0C4.!
C Bournuud P!97
M Boyudzlicvu P!99
l Boycr P0!4
C Bozlok P190
l Bozic P1!5, P109, P24!,
P4!9, P472 & P47!
l Bozkurt P59, P1!!
& P7!1
T Bozoglu 0C4.2
C Brubunt 0C!.2
P Brubcc P55!
C Brud P00
0 Brudnovu P!52, P099
& P70!
A Brudwcll 0C0.5
M Brucndlc P551
l Brugu P4!!
A Brulmu P14
S Bruilly-Tuburd H2.4,
0C4.5 & P5!0
l Brunistcunu P210
l Bruulkc H2.1
R Bruuncrovu P710
A Brclur P441
H Brcitburt P520
A Brcsciu P1!
V Brcsciu Morru P511
C Briguntc P5!1
A Brionidou P!1
M Brito P712 & P71
K Brixcn P072
M Brocckcr-Prcuss P55
S Brogioni P705
l Broglio P001
A Bronu P02
} Brossuud P!0 & P419
P Broulik P!92
T Bruc P1! & P!!
l Brugnon P520
l Bruncrovu P0!!
A Bruno P72
C Bruno P790
} Brunovu P111
K Bru ssow P201
S Bryunt P17
} Brzczinski P2!7 & P01
l Bubunju P144
S Buccrzun P2
l Bucurus P7, P79
& P215
V Bud P!0
M Budcc P250
M Bugullo P41!
C Buguri P0!
H Bui P7!0
l Buldrcglini P52
C Bullumuntc 0C1.5
A Bulgur P441
V Bumusclny P0
M Bunck P!1!
M Burutto 0C2.!, P!4
& P!5
B Buric P129
l Burko P101
C Burlucu P0!
l Buscuil P!2
M Busnclli P725
A Busti P421
M Buyssclucrt P14!
& P15
l Buzi P041
M Buziuk-Bcrczu P49
& P50
M Bystriunsku P205
A Bystriunsky P205
l Byun P750
A Bzioucl P200
A C Lsluogulluri P44
C Cucciutorc S11.4
C Cuggiuno P475
l Cuggiuno P475
l Cuiuzzu P417
B Cuillou P410
A Cujdlcr-lubu P45
l Cukul P1!9, P407,
P270, P!70 & P470
l Cukir P204, P!72, P!7!,
P!74, P507 & P759
B Cukir P15, P59, P1!!,
P194, P195, P190,
P2!9, P!17, P!02,
P477, P07, P7!1,
P770 & P44
l C ukir P1!9, P270, P!70
& P75!
V Culubro` P!4
R Culundru P45, P500,
P521, P522 & P005
Culcium Study Croup
P92
H Culiskun P!2!
} Culisscndorll P2
N Cullcju P007
R Cumuru P400
C Cumcliu P01
M Cumcron-Smitl P105
} Cumolus P120
V Cumpos P400
C Cumussi P!00
T Cundu P05 & P07
Z Cundun P0!5 & P!1
S Cundcr P2!2 & P2!!
M Cuncpu P42!
Y Cunikli P707
S Cunnuvo' P0!
M Cuno Mcgr us P199
C Cuntini P722
C Cuntorc P00!
} Cup P20, P55!, P577,
P025 & P19
C Cuputinu P0!1
} Cupdcvilu P79
} Cupclu P29
M Cuppu H2.2
A Cuppui P5!
M Cuputo P421
A Curuglcorglcopol
P10!, P000
& P0!1
C Curundinu 0C5.1
C Curuni P5!1, P742
& P7
S Curdu P94
M Curini P440
A Curmclo P72
V Curmcn P442
B Curocciu P50
P Curon P!2, P!!
& P025
M Currusco dc lu lucntc
P199
N Currcrc P!2
l Currillo P101, P15,
P700 & P04
M Cursotc P50, P541,
P40 & P51
M Curtu P22
M Curvullciro P90, P101,
P15, P217, P41!,
P552, P5, P700
& P04
l Curvullo P775, P24
& P20
M Curvullo P120 & P5
l Curvullo P22, P4!!,
P775, P24 & P20
l Curvullo Brugu P22!
& P244
C Curzunigu P1! & P502
l Cusudio P40 & P420
A Cusudo-lr uz P110
l Cusunucvu P019
l Cusurini P742
l Cussurino P12
M Custugnolu P542
M Custuing P410
} Custun o P4!5, P44!,
P054 & P055
} Custcdo P227 & P22
} Custclluno P592
} Custcllvr P77
l Custinctti P1!
C Custoriu S25.1
P Custorinu H1.5
l Custro P4!!
A Custro Hcnriqucs P220
M Cutuluno P!90 & P707
l Cutlcrinc P4!2
B Cuton P494
B Cuton Sunturcn P!4
A Cuttunco P501
P Cuturcgli P01!
l Cuudct P10
l Cuvugnini P12, P1!,
P501 & P502
l Cuvulicr 0C0.5
l Cuvullo P01
l Cuvullo P001
P Cuvullo Pcrin P!00
l Cuvcdu P!21
S Cuvus Akin P!51
l Cuzubut 0C4.4
H Ccbc P007
l Ccclurovu P40
l Cccoli P42!
V Cccovu P19
C Cclbck P754
C Cclcbi P!27
} Ccmun Suric P252
A Ccngizcroglu 0C2.2
l Ccni P722
A Ccrgu P57
} Ccrmun }r. P577
l Ccrnudus P22
l Ccsurio 0C0.2
l Cctuni 0C0.1 & P10!
A Cctkovic P404
N Clubbcrt-Bullct P40
R Cludurcviun P424
} Cludcyrus P5
K Clulvutzi P0
Y Clung P!02
P Clunson 0C4.4, P29
& P410
} Clupcllc 0C0.5
0 Clurnysl P07!
A Cluvulmunc P5!5
& P7!7
C Clcliz P1!4
l Clcng P!5
C Clcrcvko P205
P Cliclh P401 & P451
K Cliluru P550
l Cliodini P7 & P21
l Clioukl P200
l Cliovuto P020
C Cliritu P50, P541, P40
& P51
l Clirkovu P599
M Cliru Anton P100 &
P02!
P Cllostu P245
Y Clou H1.4
B Clrupko P14 & P!0
S Clrcnovu P00
l Clrist P!00
M Clrist-Cruin P14
} Clristiunscn P229,
P204, P!75, P42
& P50
l Clristinc P790
C Clristodoulukos P150,
P401, P402 & P7!
A Clronuiou P!!, P99,
P114, P214, P2!4,
P!!, P40, P409
& P4!
P Clu P799
C Clung P750
A Ciumpolillo P09!
S Ciunciu P0!4
l Ciunlcrotti P10!
A Ciclocki P19
S Ciclon P7!
0 Cigcrli P!04 & P!07
l Cil P509
V Cimino P9!
N Cinur P707 & P4!
H Cincmrc P274 & P754
l Ciobunu P2!1, P0!,
P09 & P00
B Ciruk P549
l Circgiu 0C0.1
V Circllo H1.5
} Ciric P4 & 79!
S Ciric P79!
K Cirulc P157
C Cisuri P94
A Cismus P10
M Cistcrnino H2.2
M Cizmic P705
l Cluirc P4!2
l Cluuscr H1.! & P47
A Clodcunu P541 & P51
M Clodi P714
M Cocco P4!4 & P22
M Coculcscu S20.2, P50,
P10!, P104, P107,
P200, P4!7, P455,
P49, P0!1, P40
& P5!
V Colcn-Kuplun P54
N Coluk P1!9 & P!70
B Coluk P17
N C oluk Bozkurt P270
l Colungclo P112
A Coluo P49, P52, P405,
P400, P475, P470,
P511, P594, P020,
P025, P0!, P057
& P001
C Colcllu P020
l Colctti P7 & P21
l Colluku P24
W Collcdgc S17.1
C Comun P!9 & P0!2
V Comuncscu P095
P Comcglio P7!7
A Comlckci P05 & P07
C Consuni P5!4 & P011
P Contuldi P511
l Cook P019
M Coopcr P2!
M Copctti P7
S Corbcttu 0C1.5, 0C!.4,
P20! & P0!2
C Corbo P729
} Corcull P!0 & P419
} Cordobu-Clucon P44!,
P054 & P055
P Corinu P01
M Corniunu P11! & P447
l Cornips P027
C Coronu 0C1.4, P149,
P151, P105, P440,
P47 & P5!0
S Corscllo P422
M Corsi P!9
M Cortcs Pcn u P1!2
& P1!
C Cortct-Rudclli P!!
C Cosci P000 & P705
H Coskun P274
C Cosmu P4!
M Cosottini P504
} Costc H1.!
l Cotu H2.1
l Cotcu P0!
N Coudruy 0C0.!
S Courtois P0!4
C Coussicu 0C4.5
} Couto P27 & P29
A Covci P72, P7! & P74
l Covclli P10
R Cowcn P174
T Cox P24
R Cozzi 0C!.0 & P0!
A Cozzolino P49, P594
& P057
A Cruciun P215
M Crcutsu P150, P401,
P402 & P7!5
l Crisun P00
T Crisun P00
C Cristu P10
C Cristcu P2!1 & P00
l Cristinu P20!
RCristinu Ticko Mori P271
C Crocc 0C0.2
P Crock-ludcckc P12
M Crolt P17! & P20
l Crumpci P11
l
Csujbok P!1 & P250

N Culuci P195, P190
& P2!9
C Cullu P5!, P0!5 &
P!1
N Cunlu P!5 & P!0
l Cuny P0!4
C Cuomo P094 & P740
H Curullucci P0!4
N Curro` P10
A Cuttittu P7
C Cvijovic P!12, P!!7
& P!5!
B Czurnocku P12 & P2!
A Czurnywojtck P!7
R l'lsouzu P20
Y lu Vullc 0C0.1
A lubrowsku P14
& P!0
C lucscu P215
l lulluru 0C5.1 & P424
S lugdclcn 0C2.5
} lullgrcn P5!9
P lukum P517
P lulino Ciurumcllu P27
l lullu Moru P020
S lul-Ros P!54
A luly 0C!.0 & 0C0.5
S lumjunovic P1!5,
P109, P24!, P4!9,
P442, P472, P47!,
P505, P557 & P75
l lun P442
R lunciulcscu P247
A luncsc P790
X d'Anglcmont dc
Tussigny S17.1
B luniclu P151
l lunicl-lulnu P520
l lunilovu P101 & P70
M lunjoux P!2
V luruki P415
M lurdcnnc P507
} luroszcwski P1!
C luumcric P71
S luutovic P54 & P710
C luvidc P72
A luy P275
l luzzi P10
T dc Bucrc P410
A lc Bcllis P54!, P020
& P041
H dc Bocr P95
l dc Culun P!95
} lc licgo P!4
T lc lilippis P041
l lc lruipont P!!
C dc Corospc Pcrcz-
}uurcgui P!07
W dc Hcrdcr P22, P41
& P52
l dc }ong P22
M lc }uun P021
R dc Krijgcr P41
C lc lu Cucstu P!!!
M lc lco P49 & P057
l lc Murinis P9!, P112,
P542 & P0!
M lc Murtin P12
M lc Murtino P52, P594
& P057
C lc Pcrgolu P09!
A lc Rcynic`s P47
W dc Rondc P7!0
A lc Rosu P422
l dc Souzu P0
C lc Vitu 0C1.4, P149,
P105, P440 & P47
R dc Vrics 0C2.4
l lcundrcis P41
H dcBocr P559
R lcbski P499
M lcdccjus P2!7 & P01
l lcdov P!41 & P44
C lcguni P255
M lcgcrblud 0C1.0
l dcgli Lbcrti 0C2.!,
0C5.1, P!4, P!5,
P!0, P!7, P0!,
P704 & P79
C lckomicn P05
l lcl Busso lc Curo P001
l dcl Cun izo-Comcz P!07
M lcl 0lmo P400
P lclunuyc 0C0.5
M lclurquc P0!4
A lclurquc P0!4
B lclcmcr 0C4.! & P0!4
l lclgudo P775, P24
& P20
l lclgudo P412 & P414
l lclgudo A
lvurcz P44
T lclibusi P1!9, P270
& P!70
l lcllul P5! & P0!5
l lcllul P!1
A lcllo lucovo P020
l lcll'Lnto P705
A lcmu P11! & P447
l lcmurcli P702
K lcmir P0!
Y lcmir P!1
N lcmirug Cuvcncr P!04
& P!07
H lcmirci P540
M lcmircin P545
L lcmirkopurun P!72
A dcn Bocr 0C2.4
} dcn Hurtigl P424
} lcncs P1
M lcrcli P42!
R lcrzlko P145
R lcsuilloud P772 & P795
l lcsbicz P5
S lcslmukl P17!, P174,
P20 & P071
C lcsidcri P1
l lctuillc P!01
T lcutsclbcin P55 & P!90
P lcvcsu P04!
T lcxncit P57
0 lcyncli P410
R lczmun P150
K lluturiyu P14
V llir P2!
C li lulmuzi P40
& P420
V li lonnu P729
N li Ciorgio P005
V li lullo P094 & P740
A li Murco Bcrurdino
P729
l li Nicolu P0!4
C li Sommu P405 & P511
M liuconcscu P171
A liuconcscu P91
l liumunti-Kundurukis
P41 & P721
l lius P220
l lius P!5
P lr uz Cuurdiolu P75
C liuzzi P5!1 & P7
S licdcricl 0C4.1
C licgucz P592
M licgucz P412 & P414
M licguz lclcclosu P44
C lictl P21
K lictz P040
V limurukis P25
l limic P21 & P077
C limopoulou P010
l limopoulou P701
l linc P!04 & P!07
C linc P100 & P704
M lincu P095
l lionnc P070
A lirikoc P!17 & P!02
K lixit 0C!.2
l ljikic P250
l ljrolo P! & P!4
A ljukic P202 & P!!0
V ljukic P!!1
Z ljurun P705
A ljurdjcvic ljulcpu P252
S ljuricic P250
M ljurovic P404, P505,
P55 & P50!
B llubulovu 0C5.0
S lmitriy P74 & P749
l do Curmo P120 & P047
R lobrcscu P40! & P420
l lobrcvu P459 & P400
C lodc S17.!
C logliotti P!9
T logru P!27
A logruk Lnul P!04
& P!07
S lokmctus P!2! & P009
M loknic P404, P55,
P50! & P591
l lolomic P!0
l lominiquc P100
l lonudio 0C0.1
l londi P702
H lonmcz-Altuntus P!7!
R loolcy S25.! & P7!!
B lorunt P50
} lorcs P220
0 lorolccvu P579
M lorr P7!0
N lrugiccvic P75
A lrugomir P140 & P091
T lrugovic P705
} lrupulovu P159
l lruvccku P4
l lruvct P!95
C lrcclslcr 0C4.0
N lrndurcvic P250
C lromuin P410 & P41
l lrouurd P29
C lroumuguct 0C4.4
l lrugurin P!
S luurtc P500
l luurtc P712 & P71
H lulour P!!
K lugi P292
R lulluurt P402
} lulon 0C4.5 & 0C5.5
l lumu P!0
C lumitruclc P70, P140,
P17, P179, P!70,
P!77, P4!7, P441,
P074, P091, P774
& P4
A lumitruscu P200
& P247
l lunccu P70! & P00
S lunovic P20 & P05
C lupurc P51
C lurun P791
T lurmuz P7!1
Y lurmus P0!
V lurovcovu P55!
l lusck P55!
} luskovu P702
M luskovu P200, P501,
P7!2 & P74!
C luvcrlic P795
K lvorukovu P!52
S lvorukovu P427 & P4!0
l lvorukovu P40
l lvoryuslinu P12
l lzcrunovu P052
N lzcrovycl P4, P1!1
C lbol P174 & P071
S lbrulimzudcl P125
H lbrulimzudcl mosuvi
P4!
S lcckoudt P71
B llc P109
S llcndic 0C1.0
Z llstutliudou P5 & P77
M lllcrs 0C1.1
B lkiz Bilir P5!
l lksi Huydurdcdcoglu
P155
C llbukcn P204, P!7!,
P507, P59! & P759
P llcnu P72
C llcnu P72
A llcnkovu P042
V llczovic P1!5, P24!,
P4!9 & P505
l llius P00! & P004
l llius P410
C lllcr Vuiniclcr P7 & P21
M lllmcrcr P!44
S llMckkuoui P107&P09
M ll-Mir P!01
} llorzu P240
l llowc-Cruuu P!54
B lmudi P209
l lmmunucllc P790
H lmnu P491
L lnbcrg P2
l lndrclly P!09
S lndrcs 0C4.1
N lnc P774
C lnc P50, P541 & P40
C lngclkc 0C4.1
R lngcrs P05
Y lngin-Lstun P407 &
P470
A lnjulbcrt P724
S lruslun P90
l lruslun P122
A lruydin P90
M lrbuyruk P791
C lrdcm P!27
H lrcn P!2!
l lrlurtl P0!7
l lrickson P17
B lrismis P45
l lrmctici 0C1.5 & P0!2
0 lrsoy P190
P lrsoy P15
R lrsoy P15, P59, P1!!,
P194, P195, P190,
P2!9, P!17, P!02,
P477, P07, P7!1,
P770 & P44
M lrtorcr P155
l lrturk P2!2 & P2!!
H lscobur-Morrculc P400
& P079
B lscr P507
S A lskcs S20.2
l lskioglu P75!
l lsposito P401
l lsposito P54!
V lsposito P00!
N ltkovitz P520
P lugcniu P442
R lzqucrru lurrcinu P!4
L lubrcs Mucludo P271
l luggiun P4!
A luggiuno P405 & P400
T luit P77
C lujurdo P000
C lujurdo Montun unu
0C!.0
B lululutkur P40
A lulbo P470
H lullummur P2
l luloiu P57
A lulorni P!
A lulus H1.2
l lunclli P094 & P740
S lurcus P197
l lurcs P504
H lurgluli P!!5
S lurlolt P!75 & P509
A lurrull P045
C lurrugiu P4!0, P007,
P00 & P010
0 luruk Cicck P1!!
M lussluucr 0C4.1, P2!,
P57, P424, P429 &
P711
M lutti P501 & P502
l luur P447
M luust P019
M luustini-lustini P005
S luvulc P751
l luvuro P!00
M lcdclc P401
N lcdcrico P151
} lcdorczuk P51! & P514
R lccldcrs S1.0, P22, P41
& P52
C lckctc H2.1
} lcldkump P024
L lcldt-Rusmusscn P017
C lcliciu P442
Y lclikmun P504
M lclipc dos Suntos
lcrrciru Murqucs P271
S lclix P7!0
W lcnskc P044
l lcruriu P0!
C lcrnundcs P700 & P04
l lcrnundcz P294, P295,
P290 & P!!!
l lcrnundcz P221 & P!2
P lcrnundcz Cutulinu
P059 & P002
l lcrnundcz-Curciu P115
& P70
l lcrruntc H2.2, 0C!.4 &
P0!2
S lcrruri S10.2
} lcrrciru P120
S lcrrcro P720
C lcrro P5
A lcx P251 & P070
T liud P450
B libbi P7!7
S licu P207 & P777
l ligurcllu-Brungcr P!!
P likutus P1
C lilicri P!4, P!0
& P!7
M lilion P251 & P070
S lilippi P5!5 & P7!7
B lilippini P501
M lilopunti 0C!.4
A lilus P709
l limu P504
} lindling P040
H lisclcr 0C1.0
A lislcr P149 & P5!0
P llutt P29!
l llicrs S2.1 & H2.5
S llorcu P777
N llorcu P0!
A llorcscu P202, P212
& P21!
C llu ck P510
C lollin P0!7
C lorlco P751
l lormisuno 0C2.0
R lormosu P4!0
} lort P77
C lorti 0C1.4, P149,
P151, P105, P440,
P47, P5!0 & P722
N lortunuti P!90 & P707
M losclini P005
} lournicr P551
M lruckicl P59 & P0!
A lruilc P757
l lruncu P500
M lrunculunci P722
l lrunccscli P25
l lruncis P2!0
M lrunckicl P5
R lrunco P401
P lruncois P!!
l lruncoisc P4!2
M lruncos P757
B lruncou H2.4
l lrunck P!50
C lrunk P005
A lrunkcn 0C!.!
H lrunz S1.0
R lrunzcv P!91
A lrutticci H1.!
l lrcdcric P752
l lrcdcrikscn P072
T lrcibcrgcr P0
C lrcitus P220
M lricdricl-Rust P1
& P755
l lricscmu S12.1
R lritzcn P24
M lrungicri P521 & P522
l lrydccku P1!
Z lrysuk P00, P7 & P124
l lucntcs S25.2
l luguzzolu H1.5
T lujitu P510
C lurluni P57
A lusco P9!, P112, P401
l Cubulcc P577
M Cucci P440
B Cuctuno P20!
M Culctc P44! & P055
S Cuillurd P!!
S Cuillcz H2.4
M Culdicro P594
C Culcsunu P202, P212
& P21!
M Culcsunu P202
l Cullund P5!0
R Cullcgo P075
A Culli P722
C Culli P10!
S Cullluti P510
l Cullo P422
S Culoiu P107
V Culton S12.2
M Culvcz-Morcno P4!5
ACumbincri P094 & P740
V Curuj-Vrlovuc P519
C Curciu P294, P295,
P290 & P!!!
l Curciu P!01
R Curciu P221 & P!2
} Curciu Almcidu P70
l Curcr u dc Cuudiunu
Romuuldo P5!2 &
P5!!
} Curciu dc Quiros P290
& P!!!
C Curciu lomr ngucz P1!2
& P1!
R Curcr u Muyor P!10
& P!05
M Curcr u Vicru P701
l Curciu-Culiuno P592
R Curciu-Muyor P425
& P0!0
} Curciu-Quiros P294
& P295
l Curcipcrcz dc Vurgus
P075 & P09
} Curdi P!1
V Cusco P01 & P00
l Cusior-Pcrczuk P242
& P245
l Cusscr P12
B Cussncr S25.2
l Custuldo Simcon P002
B Cuttu P!0 & P419
V Cuvun P420
M Cuvcllu P519
B Cuylinn P254
M Cuztumbidc P2
S Cuztumbidc P000
L Ccblurdt P711
A Ccdik P90
S Cclmini P722
H Ccnc P!27
C Ccnoni P702
M Ccnovcsi P5 & P504
l Ccntilin 0C5.1
C Ccorgcscu P00
C Ccrurd P724
A Ccrmuno P707
l Ccrquri P709
A Ccrquri P709
B Ccrquri P709
M Ccrvuin P241
H Ccrvusio P!5
A Ccsing P512
0 Ccyik P07
C Clucdi P40
S Clurcl P27!
M Clutci P404
A Clcmigcun P140
A Clcmigiun P70, P17
& P179
M Clcmigiun P17
M Clcorgliu P50 & P455
C Clctu P497
l Cliudoni P5!4
l Cligo P!, P!00, P001,
P0!, P00 & P7!4
A Clolumrczunczlud
P!49
T Ciucomclli P10!
A Ciukoumi P!15
l Ciulluuriu P475
& P470
A Ciumpictro P9!
0 Ciumpictro P5!4 &
P011
l Ciunguspcro P00!
l Ciunotti 0C0.2
C Ciuvoli 0C!.4 & P0!2
A Cicsscn P95
A Cicstus P225 & P220
l Cildcluus 0C2.2
l Ciltuy P19, P52!,
P524, P01 & P02
C Cincstc P254
C Cinglinu P107
l Ciniyutullinu P052
l Ciouclino P!
A Ciomisi P!!9, P!41
& P794
R Ciorduno P! & P001
l Ciorgino P09!
P Ciovunnclli S25.1
C Ciovunnctti P5 & P504
T Ciruldi S25.1
M Ciri P!
l Citcl P579 & P59
R Ciuliu 0C1.4
C Ciurcu P247
l Ciusti 0C0.1
M Ciusti P42!
A Ciustinu P9! & P0!
M Cjutu P24
A Ckountouvus P445
& P54
T Cluscmunn P1
l Cluz P!2
C Cligu P70
l Clinski P4!
l Clintborg P40!
M Clod P171
0 Cluszuk P499
Z Cluvic P120 & P750
l Cogus Yuvuz P147
0
Cogcbukun P71!
l Cokuy P15! & P02
B Cokc 0C2.2
L Coksu P175
H Cokturk P791
l Coldmun P579
0 Colcu P79
l Colkowski P50, P57
& P50
l Colu P11!, P211, P447,
P590 & P770
l Comcs P552
B Comcz Anson P021
} Comcz Murtr n P199
l Comcz Pcrultu P757
} Comcz-Burrudo P075
& P09
} Comcz-Murtino P075
& P09
A Conculvcs P120 & P047
N Conclurov P44
N Conclurovu P70
M Concn P791
A Concnc P!1
C Conululun P1!9
C Conzulcz P500
B Conzulcz P45, P500
& P005
M Conzulcz Boillos P10
& P11
V Conzulcz Sunclcz P505
S Conzulcz-Culvur P500
T Conzulcz-losudu P!07
V Conzulcz-Sunclcz P5!2,
P5!! & P002
l Coorcn P19, P!1!,
P52!, P524, P01
& P02
R Copulu Ruo P411
l Copkulovu 0C0.4
S Corur P5!, P0!5 & P!1
A Cordullu P75
M Cordon P019
V Corclyslcvu P!41
Z Corombcy P1
M Corsku P152, P!45,
P49!, P090 & P59
M Cotl P1 & P55
Y Cotlill P255
S Cotiu P!
l Cotiu P!
Y Coto P259
V Cotovuc P20
C Couby P520
S Cougouru P100
A Coutzioulis P!42
S Couvciu P90, P15,
P217, P41!, P552,
P5, P700 & P04
S Cozdz P242 & P245
C Cozum P540
M Crubncr P201
A Crucunin P492
l Cruciu-Nuvurro P44!
& P054
L Cruclc-Mody P292
T Crummcr 0C4.0
R Crunutu S2.! & P!00
A Crunutu P005
C Crundc P542
l Cruncll P021
M Crunzotto P4!
A Crusso P501
l Crusso P594
C Cruvlolt 0C5.! & P42
} Crccn P270
Y Crccnmun 0C!.5
M Crcpl P00
A Cricco P475 & P470
l Crigorus P7
l Crigorcscu P49
P Crigorcscu Sido P2
l Crigoric P91 & P4!7
A Crigoricv P052
0 Crigoriou P402
M Crigorovici P171
A Crigorovici P2!1
C Crimm P714
C Crizurd P520
l Crodccku P0
} Cromoll 0C5.4
R Crootc Vcldmun 0C!.!
A Crossmun P570 & P50
l Crossrubutsclcr P27
S Crottoli P00
l Croup P00
l Croussin H1.! & P47
l Crozuvu P202, P212
& P21!
l Cru nwuld P!1
M Cruppcttu P007, P00
& P010
l Cruson P!40
M Crzywu P19
W Cuunipu Sicrru P059
& P002
C Cuuruldi P5!1
l Cuustumuccliu P751
l Cu clu P100 & P10
l Cudovun P091
R Cucnnoun S27.!
l Cucrru P405
l Cucrru P244 & P4!!
C Cucrrcro P494
C Cugliclmi P21
P Cuidu P751
M Cuilluud-Butuillc H1.!
C Cuimurucs P775, P24
& P20
P Cuimurucs P227
} Cuimurucs P227
R Cuimbuud P!2
A Cuioclon-Muntcl H2.4
& 0C4.!
N Culcclik P!51 & P10
S Culdikcn P5! & P00
B Culdikcn P0!
S Culdikcn P0!
M Culdstrund S2!.!
M Culcc P204
C Culcr P15, P9, P15!,
P02, P004, P000
& P75!
A Cullu P05
S Cullu P122 & P007
0 Culmcz P!04
P Cun P147
K Cundogun P!72
0 Cunduz P5!
R Cuncr P194
M Cuncs P90 & P410
T Cuncy P47
A Cungor P754
C Curbun P!
l Curicvu P!00
A Cursoy P45, P47
& P52
S Curzu P407
l Cussi P49
T Custulsson 0C1.0
} Custulsson S25.2
l Cuticrrcz-Puscuul P054
Y Cu vcnc P100
R Cuy P504
S Cuyctunt P!95
H Cylling P25
H Huuk P424
M Huusc P0! & P24
V Hubulovu P4
M Huduni P54
P Hucntjcns S1!.!
S Hulncr 0C4.1
A Huidcr P19
Z Hujdukovic P144
M Hulcnku P124
M Huluzik P159 & P700
l Huluzikovu P700
B Humbcrgcr P2
P Humct 0C1.!
R Humpcl P110, P74
& P75
R Humpl P!57
l Humpton P525
Z Humurcu P!7!
V Hunu P55! & P595
V Hunu }r. P55!
l Hunun P790
0 Hunduyuni P!0, P!09
& P!10
l Huns P2!0
M Hunsmunn P!1
C Huntcl P!91
K Hunusck P2!
A Hunyuloglu H1.4
} Hurdclin S17.!
R Huring P7!0
A Hurmunci P4!
K Hurslu P297
M Hurtmunn P2! & P55
l Hurtmunn P00
B Hurvcy S25.!, P417
& P7!!
S Hurvcy P254
l Husupopoulou P0
l Husiukos P77!
K Hussc-luzur P449
l Huvcl P577
l Huwkins P!01
M Huyusli P259
B Huydurdcdcoglu P155
C Huymunu P14
& P!27
A Hcck P0!9
A Hcijbocr P7!0
S Hcjuzi Noglubi P125
Z Hckimsoy P100, P10
& P704
C Hclu P104 & P105
A Hclicn P1!4
A Hcnkc 0C5.4
A Hcpcr 0kcu P007
M Hcrguctu P44!
W Hcrmun P092
C Hcrmuns P71
l Hcrmscn P424
A Hcrnundcz S12.2
} Hcrnundcz Buyo P701
B Hcrrmunn 0C2.1
& P50!
l Hcrrmunn P1 & P755
A Hculcldcr P!1!
M Hcwison S14.!
M Hilczcr P590 & P59
C Hildcbrundt P551
} Hilgcrtovu 0C1.2
M Hill 0c1.2, P200, P!57,
P501, P715, P7!2
& P74!
N Hinscl P!1
0 Hiort S1.4
N Hiruwu P11
B Hjcrrild P42
K Hluvutu P715
P Hluvuty P715
A Hluzkovu P101, P540
& P70
K Ho P!02
} Hodis P!!5
C Hochg P20
l Hohund P22, P41 & P52
R Holuj P510
K Holzcr P1 & P!1
} Honcggcr P040, P049,
P050 & P051
l Hoorn P209
} Hoplgurtncr P714
} Horucck 0C5.0 & P0!!
l Horovu P!40
l Hortopun P200
l Horvutl P01, P240 &
P!!
A Horvutl H1.!
P Hoskovcovu P200
l Houguurd P072
S Houtcrmun P424
C Hoybyc P229 & P509
C Hoybyc P!75
P Hoycm P!24
M Hrubc dc Angclis 0C4.2
K Hristozov P!99
M Hrivnuk P529
H Hruskovicovu P0!,
P200 & P74!
T Hsu P799
A Hubulcwsku-lydcjczyk
P7!, P49 & P50
l Hubinu P1
l Huglcs P2!
l Hultunicmi S4.1, H1.4,
P47, P45, P500
& P005
A Hulting P12 & P019
R Hunkur P0!
0 Husby P0!9
l Huscbyc S1.5
M lucovicllo P751
0 lunus P100, P49,
P49, P02!, P074
& P741
l lunni P422
A luzigiun P50
Y lbrulim Mokltur P!71
T lcin P, P219 & P014
l lconuru P4!7, P091 &
P4
} ldriccunu P107, P11,
P42 & P09
A ldrisov P!19
P lguz H1.2 & P!2
P lglcsius Bolun os P75
T lgor P4!2
l lkcoku P!44
N llun P54
C llurdi P001
Z llburs P707
l llclcnko P!22
K lldiko P210
l llic P00
l llicscu P42 & P497
A lljin P44
l llovuyskuyu P44
S lmumoglu P2!2 & P2!!
Y lmunisli 0C0.0
K lmrc Zoltun P01
R lmricl P720
M lnubu 0C0.0
S lnccrpi S25.4
R lnclingolo P729
l lnglcsc P421
T lnouc P259
H lnsul P104, P105,
P490, P491 & P029
M lnscnscr P079
M lnvcrnizzi P94
l louclim P17, P200,
P40 & P4
l lounnidis P42
l loncscu P107 & P11
l lonitu P207
C lorduclcscu P49
l lorio P7, P21 & P!9
M lovino P292
P lovitu P202
l lrigoycn Cuculon P!4
S lrinu P74
T lrinu P050
T lsuilovic P1!5, P109,
P24!, P4!9, P472
& P47!
l lscnovic P750
} lsguurd P141
H lslii P550
A lslii 0C0.0
S lsik P9, P02, P004,
P000 & P15
M lsing P022
S lsmuilov P570, P50,
P52 & P719
A lsusquizu P240
M ltl P!00
M ltol P259
l ltzkovitz P520
M lvun P91
K lvunov P!99
M lvovic P0, P555
P }uckuliuk P9
l }uckuliukovu P124
B }ucobs 0C1.1
A }ucqucs P772
M }ullruin-Rcu 0C!.0
& P00!
A }ugodzinsku P9, P17,
P19! & P201
K }ulnukuincn P0
l }unickovu-Zdursku P!57
} }unik P2!
H }unkowsku P14
M }unncr P510
l }unnini P47
l }unny P520
} }unos P210
A }uru P!2
P }urck P!9
Z }urkovsku P55!
M }urolr mkovu 0C1.2
M }uronicc P!9
B }urzub P449
C }uspcrs P024
Z }utic P252
K }uzdzcwski S22.2
W }cun-louis P100
& P790
N }cundidicr P!54
M }cunpicrrc H2.4
l }cdrzcjuk P02
K }cllcrson P7!9
S }cnni P290 & P!00
l }crcmic P!12, P!!7
& P!5!
C }crn P141
W }cskc P12 & P19
N }csscn P50
T }i H1.4
M }imcncz dcl Vullc P!!0
l }imcncz-Rcinu P4!5
} }irusck P501
} }iskru P77 & P0
S }oclcn P547
S }olunsscn P2!
B }ojic P129
H }okclu P25
H }oki P0
K }onus H1.4
P }onsson P019
K }ood P141
} }orgcnscn P229, P204,
P50 & P017
A }orgcnscn P0!9
l }ouunncuu P!! & P!9
A }ovclic P144
B }ozscl P01
} }ulcsz P!1 & P250
C }ulio P!2
} }ung P407
R }urcut P107
A }urku P157
C }urowicl P711
l }ustinicn P772, P795
R Kudi P175
S Kulcscilcr P100 & P10
P Kulritsu P!7
H Kulul P10 & P220
C Kululy P00
H Kullcs P20 & P!1
Z Kullimovu P719
l Kulrumun P15!
} Kuirics P74
P Kuldrymidcs P445
& P54
C Kulikukis P415
S Kulinclcnko P!00,
P52!, P524, P01
& P02
K Kulinov P0!0
C Kulisku P205
K Kullurus P140
} Kullio P0
l Kulogiunnidis P!!9
& P794
P Kulouskovu P715
S Kulru P177, P279, P20
& P29
B Kulru P177, P279, P20
& P29
A Kulsbcck S2.1
C Kultsus P54
S Kumukuri P!7
P Kumcnicky 0C4.4
C Kuminski 0C5.2
l Kuminski P24
0 Kumpc P12
L Kumpmunn P!24
C Kunut Lnlcr P791
R Kunccvu P501
l Kunitz P201
C Kupuros P150, P401,
P402, P7!5 & P7!
S Kuruulmctoglu 0
zkun
P75!
0 Kuruurslun P122
Z Kurucu P204, P!7!,
P507, P50, P59!
& P579
Y Kuruclcntscv P!05,
P471 & P70
M Kuruczun P14
C Kurudug P5!
N Kurudurmus P277
M Kuruhou P401 & P402
0 Kurugiunni P214
& P2!4
} Kurujovic P705
} Kurukuyu P!51
S Kurukurt P410
K Kuruliotus P409
0 Kurumun P509
l Kurumouzis P!, P0,
P1, P29 & P291
M Kurumouzis P140
P Kurupuvlidou P09
l Kurusck P124
S Kurutus P704
N Kuruvituki P544 & P571
A Kuruwgl P!0 & P797
B Kurbck P175 & P270
M Kurbownik-lcwinsku
P512 & P00
C Kurcsunc Kiss P10
M Kurczcwsku-Kupczcwsku
P152, P!45, P49!
& P090
l Kurczmurcwicz P117
A Kurclis P251 & P070
A Kurh P!!, P99, P114,
P214, P2!4, P!!,
P40, P409 & P4!
K Kurimu P104, P105,
P490, P491 & P029
M Kurolczuk-Zuruclowicz
P5
S Kurrus P779
0 Kurtuvtscvu P205
V Kusubri P29!
M Kusulicky P700
A Kuspcrlik-Zulusku P12
& P19
M Kusscm S!.1
l Kutulinic P54, P22
& P2!
M Kutrcddy P2!5 & P2!0
V Kutrcddy P450
l Kutsikis P41
K Kutsoulis P42
A Kuullmun S0.1
l Kuulmun P092
} Kuulmun P744
A Kuutzky-Willcr S1.1
& P714
P Kuvulkovu P700
A Kuyc P727
l Kuymuz P10
l Kuynur P507
N Kcbupci P109
B Kcijscr H2.!
l Kckcnuk P444
T Kclcs P7!1
l Kclcstimur P204, P507,
P50, P59! & P759
R Kclly P174
l Kcmu P402
M Kcmcn 0C2.1
l Kcmp P224
A Kcndcrcski P!5!
A Kcnncdy P2!
P Kcntos P00, P450
& P55!
} Kcrlik P720
} Kctclslcgcrs P14!
& P15
A Kludjibucv P570
Z Klulimovu P572, P57!,
P50, P51 & P52
H Kluzuli P502
V Kluzicv P70
} Klodukovu P599
S Klodgucv P570
A Klolikovu P572, P57!,
P51 & P52
K Klolmutovu P12
R Kickutl 0C4.1
l Kiclcr P717
A Kicltyku P49
S Kicncr P1
} Kijck P222, P05, P14
& P!0
S Kikovic P705
L Kilic P07
T Kilic 0kmun P00
l Kilicli P!2! & P009
M Kilinc P470
l Kilinsku P!9
Z Killingcr P9
S Kim P, P191, P299,
P012 & P750
Y Kim P750
C Kim P750
l Kim P299, P40 & P012
H Kim P & P1!0
} Kim P191 & P012
R Kincmun P44! & P055
S Kinovu P444
S Kir P274 & P754
A Kiriukopoulos P!2
} Kirilcnko P70
C Kirilov P459 & P400
l Kiss P!1
l Kiszczuk-Boclynsku
P05
M Kitu P5 & P77
A Kjnsurul P797
C Klungos P114 & P4!
R Klupku P55!
l Klcin P419
} Klcin P20
C Klcinuu P725
l Klicvcrik S2.1
K Klimusovu P55!
l Klimcs P55!
K Kljujic P17
N Klonuris P2!4, P!1,
P40 & P5!7
K Klutz 0C2.2
Z Kmccovu P9
L Knuppc P024
A Knuucrlusc P110
M Knczcvic P79!
l Knosp 0C!.1
K Kobuyusli 0C0.0
C Koc P5!, P0!5 & P!1
l Koccr P!74
B Kocl P1 & P21
C Kocl P224 & P429
l Kodctovu P427
P Kohnukos P7!5
} Kolrlc P20
A Kokoszko P00
N Koksloorn H2.! &
0C!.!
N Koluitis P!47
M Kolcsur P!09 & P70
M Koltowsku-Huggstrom
P55 & P019
} Komninos P571
l Konrud P290
K Konstuntinos P05
P Kopccky P159
M Korbonits P4!0
M Korcn P444
l Korkmuz P!2!
P Korkolopoulou P721
M Kosuk P595
S Kosmuclcvu P70
S Kostic P495
l Kostoglou-Atlunussiou
P!!, P99, P114, P214,
P2!4, P!!, P40,
P409, P4!, P445
& P54
A Kotunidou P701
S Kotunoglou P114
& P4!
l Kotrlikovu P159
M Kottlcr 0C0.!
T Kotuluk P159
C Koukoulis P100
S Koulouris P!50
A Kourtis P!!9, P!42
& P794
l Kouskouni P401, P402
& P7!5
B Kovuccv-Zuvisic P,
P219 & P014
l Kovucovu P444
C Kovucs P01, P1,
P240 & P!!
l Kovucs P1
P T Kovuncn S9.2
R Kovutclcvu P04
A Kowulik P245
l Kowulsku P152, P!45,
P49! & P090
A Kowulsku P242 & P245
l Kozunoglu P155
l Kozicki P72!
l Krulikovu P200
P Krumur P159
W Krumcr p51
l Krumcr P092
l Krusnulicv P!99
C Krussus P779 & P00
l Kruus P57
C Kruusz P725
A Kruwczyk P449
K Kruwczyk-Rusiccku
P01
M Krcmu P40
M Krcutsu P7!
R Krcis P!00
l Krcitsclmunn-
Andcrmulr P2!0
} Krcmcn P159
K Krcpulu P40
A Krczc }r. P450
P Kristcnscn P!14
l Kristcnscn P017
S Krisztiun P210
} Krizovu P700
H Krocmcr P7!0
M Kroiss P2!
M Krsck P55! & P595
l Krull P551
T Kruscnstjcrnu-Hulstrom
P50
A Krzcntowsku P50
& P57
l Kubu P00
l Kubicku P09
0
Ku cu kcrdonmcz P097
l Kucuklcr P02 & P000
0 Kudus P274
M Ku ln S25.2, P04
& P102
M Kulu P50
M Kuluksizoglu P791
M Kulicl P249
} Kuliczkowsku-Plukscj
P145 & P709
l Kumunov P459 & P400
S Kumur P20 & P29
M Kummunn P515
l Kun P!0 & P407
M Kuncsòvu 0C1.2, P715
& P710
M Kurujol 0C0.0
M Kurowsku P222, P05,
P14 & P!0
R Kursunluoglu P549
& P550
M Kurt P477
l Kurt P!27
W Kurtz P19
M Kuru P!17
A Kurylowicz P!50
& P05!
A Kut P52
R Kutunis P272 & P27
M Kutlu P14, P102,
P277, P!20, P!27
& P097
l Kuzinu P!00
S Kuzmic P705
H Kvusnickovu P099
& P70!
} Kwukkcl H2.5
N Kypruios P!4
A lucllub P742
} luclucr P!9
Z lucinovu P595 & P700
K lucku P092
M luckovic P120 & P750
l luczmunski P09
C ludcnvull P141
H lulncr P!90
M lui P4!4 & P22
T luitulu-lcinoncn P0
S lujic H1.4
M lukoccvic P557 & P75
C lulundu P500
A lulc P50
S lumbcrts S1.0, P41
& P52
l lumbrinouduki P150,
P401, P402, P7!5,
P7! & P77!
T lummincn P25
V lumounicr-Zcptcr P1!7
l lunlrunco P7!4
K lung 0C4.1
B lungdull P192
A luniu 0C!.4, P0!2
& P720
R lunzillo P511
B lupuuw P744
l lusuitc P200
l lusus P200
l lusicnc P200
A luszlo P70
l luszlo P10 & P241
P luszlo P210
l luuru P72
P luurbcrg P017
A luuru P20!
C luurc`nc P4!2
A luvillu P412 & P414
A luvillu Corcovudo P44
C luvru P700
l luzur P447
M luzurcvic P129
l luzuridou P291
C luzurcunu P11!
l luzu rovu P4 & P55!
A lcbkowsku P152, P49!
& P090
S lcboullcux P29, P410,
P41 & P424
A lcclugu-Sunclo P!29
P lccomtc P!95
H lcc P40
H lclcbvrc P51
l lcgucl P190
M N lclmun S0.2
A lcnurcik P40 & P409
M lcnurt-lipinsku P!0
A lcnzi P47
l lcnzini P50
A lconurdou P77!
l lconc P729
Slconi 0c2.!, P!7&P79
C lcsugc P025
N lcsuvrc P1!
l lct P!0
C lctiziu P1
A lctkovsku P9
l lcustcun P2!1
l lcustcun P00
0 lcvullc P1!4
T lcvclcnko P!05
l lcvcndoglu P707
C lcvidou P721
} lcvinc S0.!
C lcvy P255
K lcwundowski P45
A lcwinski P45
A lcwinski P117, P2!7,
P512, P590, P59,
P00, P50 & P01
l lczcuno P221 & P!2
l li P!5
P liukos P100
R libc H1.! & P51
l libri P041 & P725
C lics P45!
B lilu P45!
Z limunovu P77 & P0
R limor 0C!.5
T linckc P429
} lindlolm P017
A linglurt H2.2 & 0C0.!
K link P0!7
l linos P!2
S lio P790
V lipovuc P519
N lisnic P212 & P21!
l litsus P5 & P77
M liu P799
K liu S11.2
l liubimovu P471
S livudus P41
A lizurrugu P240 & P!
S ljiljunu P771
A ljubic P404
} llopis Agclun P1!0
& P474
C lobo P27 & P29
P locuntorc P422
Z locsci P01, P240 & P!!
C loddcnkcmpcr S15.1
l logotlctis P401, P402
& P7!5
C logroscino P112
V lol P2
V loi P!! & P409
P loli P27
l lomus-Romcro P!29
C lomburdi P49, P400,
P475, P470, P511
& P057
A lomburdi P722
M lomburdi P000
C lomburdo P4!4
M lombcs 0C4.! & P257
Z loncur P!!1
C look P1!7
P lopcz lburru P10
& P!!0
M lopcz S2.2
A lopcz-Cuzmun P757
0 lopcz-Mourclo P021
R lorcnc P117
l losudu P11
l losudu Crundc P10
} losy P092
l lotti P105, P440, P47
& P5!0
l louisct P51
M low P0
} lozuno P494
P lucu P72
A lucucclini 0C0.1
M lucluvovu P121
l lucilc P100
M lucio Pcrcz P1!0
& P474
M luconi P722
l lu dcckc P24
K ludmilu P749
A lugcr 0C!.1, P55,
P714 & P717
C luigi P20!
P lukusovu 0C1.!, P!52,
P099 & P70!
R lunu cuno P!10, P!05
& P0!0
l lundorl P42
l lupi P01!
A lupu P247
R luquc P44!, P054
& P055
M luquc-Rumr rcz P400
B lutz H2.1
V lux-luntos P005
} Muuttu P0
M Muccurio P1 & P00
R Mucludo P220
M Muckovu P440 & P44
l Mucut P1!5, P109,
P24!, P4!9, P472,
P47!, P505 & P557
B Mudco P7
} Mudcr P!44
K Mudlusudunu P2!5
& P2!0
C Mucrc P!
W Mucrz 0C4.0
P Mullci P4!
M Muggi 0C1.4, P151,
P105, P149, P440,
P47, P5!5, P5!0,
P041 & P7!7
M Muglnic H2.2
S Mugony P!1 & P250
R Mullouz P52
A Muiu Silvu P225 & P220
K Muicr 0C4.1
S Muicr P044
l Muinini P707
l Muionc P451, P5!0
& P54!
M Muituk P090
l Muitcr 0C!.0
V Mujitliu P224
B Mujtun P510
l Mukuiovu P444
} Mukurcwicz P!9
K Mukcdou P!!9, P!42
& P794
K Muklkumov P50
l Mukllinu P!11
M Mulugon P054
P Mulundrino P410
A Muluvuzos P!9 & P0!2
l Mulcliodi P020
M Muldonudo P040
C Muldonudo Custro P!4
l Mulck P45!
M Mulczct P0!4
} Mulicku P222 & P05
K Mulickovu P0
M Mulik P10 & P220
l Mulirovu 0C5.0
l Mullo lcrrcr P059 &
P002
} Muly 0C5.0 & P159
S Mulyutinu P170
l Mumuluki P415
A Muncini P729
C Muncini H2.1
l Mundu P100, P49,
P02!, P074 & P741
C Mundrilc P!
l Munctti P5, P504
& P01!
M Mungulugiu P455
l Munios P41
N Munjunutl P10
K Munn 0C2.1, P55, P!90
& P50!
l Munnucci 0C1.4, P149,
P151, P105, P440,
P47, P5!5 & P5!0
l Munojlovic Cucic P55
M Munolcu P497
A Munolis P!50
A Munsluripovu P!19
C Munsmunn P0!
P Munso P110
B Muntinun Cil P!10
& P!05
B Muntin un Cil P425
& P0!0
C Muntovuni H2.2, 0C1.5
& P720
A Muntziou P41
C Muntzoros S2!.1
l Muntzou P127, P47
& P41
S Muqdusy P5
R Murunu P542
M Muruzuclu P015
l Murccllo P72
C Murcocci 0C0.1, P10!
& P00
} Murck P55!, P595 &
P025
0 Murgincun P215
M Muriu Cluirc P100
A Muric P97
B Muric P4!2
V Muric-Clristinc P100
B Murinu P74 & P749
l Murinu P0 & P555
M Murinu P20!
l Murinuzzo P! & P001
l Murincscu P4!7
C Murio P72
S Muriotti P4!4, P5!,
P22, P25 & S1!.4
l Muris P215
A Murkou P!7
B Murkovic P!0!
l Murottu P00
C Mursicuno H2.1
} Murti P172
B Murtin P547
N Murtin P771
S Murtin P777
K Murtinuc P17
l Murtincric P257
C Murtincz P!01
A Murtincz-lucntcs P4!5
A Murtr ncz-lucntcs P054
M Murtinlo P15, P217,
P552, P700, P!5
& P!0
l Murtino P5, P504,
P000, P01! & P705
M Murtins P700
R Murtins P27 & P29
l Murtins P220
T Murtins P!5 & P!0
A Murtinsons P157
l Murtyntyuk P1!1
l Murtynyuk P1!1
W Murz P72
S Murzotti P!
P Musuryk P9
M Muscurcnlus P120
C Muscr-Clutl P05
M Musoni P5!4 & P011
V Musopust P595
S Musouru P!42
C Mussurt P12
B Musscrini P21
A Mustcr P4!1
M Mustcrnuk P512
P Muturuzzo P01
M Mutos P4!!
l Mutos limu P02
} Mutrozovu P0!0
l Muttcucci P5!4 & P011
C Muttos }urdim Costu
P500
A Muttsson P55
B Mutuszck P!0
M Mutzkin P521 & P522
S Muuclc`rc-lcnost P29
C Muurugc P!!
l Muurclli P4!4
M Muuri lot P5!2, P5!!
& P002
R Muzzu H2.1
l Muzzutcntu P005
C Muzziotti P9! & P0!
C McCrutl 0C5.0
C McKunc P454
A Mcunu P505
T Mcclundjicv P459
M Mcdic-Stojunosku P,
P219 & P014
} Mcdinu P22!, P227,
P22, P244, P4!!,
P775, P24, P20
& P02
V Mclrotru P2
R Mcijcr P559
C Mcjiu P9!
C Mcluni P149, P151
& P105
A Mcluo P712 & P71
l Mclccscu P224
C Mclniclcnko P44
l Mclnik P70
M Mclo P101 & P04
M Mcnuclo P1!0 & P474
l Mcndcs lu Cruz P507
} Mcndozu P09
l Mcncndcz P412 & P414
l Mcncndcz Torrc P44
A Mcngcl P!24
P Mcnlccrc P027
M Mcnicugli P01!
A Mcntcs P00
A Mcntcsc P!70
0 Mcru Cullurdo P1!2
& P1!
C Mcruui P!25
} Mcrino-Torrcs P400
M Mcrtcr P2!2
} Mcsu P77 & P79
} Mcsquitu P244 & P4!!
V Mctuxu-Muriutou P!7
C Mctgcs P201
A Mctin P195
M Mctin Sugutlugil P15
C Mcycr P20
C Mczzucupo P700
l Miccli P!00
l Micluilidou P0, P1
& P29
R Micluluk P9, P17,
P19! & P201
M Miclulckovu P450
S Miclulopoulou P42
l Miclulsku P121
l Miclulsky P700
l Miclus P41
A Miclou P!!, P99,
P114, P214, P2!4,
P!!, P409 & P4!
l Micic P27, P!12,
P!!1, P!!2, P!!7,
P!5! & P700
M Micic P250
} Micic P!!1 & P!!2
l Micic }r P!!1
l Miclc P11!
H Middclkoop H2.!
& P554
T Micttincn P25
R Milturi P709
A Migliuccio S25.1
C Migliurctti P01
S Miluicutu P590
Z Mikluil P74
T Miki 0C0.0
M Mikoluj P97
S Mikosinski P!9
l Milurdi P542
K Milcnkovic-Vulovic
P27
A Milcwicz P145, P09,
P709 & P02
M Miliun P049, P050
& P051
N Milic P129
M Miliccscu P247
l Miljic P404, P55, P50!
& P591
l Milonc P405 & P400
Z Miloscvic P!0!
l Milutin P!0
l Mincu P207
M Minctto P7!4
M Minoiu P!0, P!7
& P704
l Minuto P42! & P0!
R Mioni P4!
C Miron P107
N Mirsky P727
S Mirzurgur P4!
M Mitiko 0kumoto P271
0 Mitrovic P250
} Mittug S12.4
R Miyutu P259
V Mludcnovic P202
& P!!0
C Mluwu P17!, P174,
P20, P20 & P071
R Mlynski P57
C Mocll P0!7
S Mogos P210
V Mogos P107, P11,
P210, P0!, P09
& P00
B Molumcd Sulul P!71
M Molummudi P502
M Mollig P142 & P07
C Molr P50!
l Moisii P212 & P21!
T Moklort P71, P21,
P!0!, P!04, P!11
& P07!
N Mokryslcvu P452
} Mol P492
l Molc` P!0, P!7
& P704
N Mollcr P!24 & P50
A Molnur P241
M Monumi P149, P151
& P105
K Monustiri P200
C Monroy P77
l Montclusco 0C!.4
& P020
P Montciro P27
R Montcs P079
M Montini P0!
C Morulcs P294, P295,
P290 & P!!!
l Morulidis P77
l Moruno P1!7
A Moruvcikovu P450
Y Morcl 0C4.5
V Morclli P7 & P21
A Morclli P5!5 & P7!7
0 Morcno P597
C Morcno P240 & P!
C Morcno-Bucno P44!
0 Morcno-Pcrcz P5!2,
P5!!, P505
& P002
l Morcno-Rur z P!07
A Morgunti P1
N Morgcntlulcr 0C!.2
l Mori P510
N Morlct-Burlu P0!4
l Mormundi P1!4
M Mormundo P112
l Mornct P119
M Moro P501
H Morovvuti P25!
l Morturu P42!
K Mortcnscn P42
l Mortscl P50!
C Mottu P7!4
M Mourc P2
M Mourits P00
Z Mousuvi P27!
M Mouzuki P!!9, P!42
& P794
A Movulcdiniu P25!
A Moyu P400
M Mruz P159 & P700
C Mskluluyu P52!, P524,
P01 & P02
S Mu P510
C Mucllcr P14
B Mucllcr P14
M Mujic P252
C Mukliddinovu P!!4
S Mulkibuycvu P!19
M Mull P2!0
M Mullcr P!!
H Mu llcr P711
P Mullis P510
H Mumm P40!
} Mundjur Pulusck P97
A Munir P10
A Munoz S14.2
M Mun oz Torrcs P92 &
P115
A Murut P!95
A Murcsun P11!, P197
& P70!
l Murtuzucvu P572, P570
& P52
L Musubuk P277
M Musut P247
T Mussuck P!91
S Mustuhnu P170
M Muzzu H1.5
l Nuclcv P0!0
A Nudul S25.2
M Nudiu P104, P105,
P490, P491 & P029
S Nug P10
T Nugutu 0C0.0
A Nugclbcrg P1!4
R Nugy P01 & P!!
l Nujjur P200
A Nunnu P517
T Nupolituno P49
A Nur P52
M Nurdi P00
C Nurimovu P57!, P50,
P51 & P719
K Nusirovu P572, P57!,
P51 & P52
} Nuskulski P50
A Nusruddin P071
l Nuss P54
T Nusscr P!0, P740
& P797
l Nusto P112
l Nutuliu P749
M Nuuck P71! & P7!0
A Nuumun P4!1
V Nuvurro P592
M Nuvus P400
l Nuvcs 0C!.0
Y Nuvmcnovu P21
l Ncucsu P70 & P91
l Ncugoc P095
S Ncggcrs P025
B Ncjib P104, P105,
P490, P491 & P029
Z Ncjjuri P!97
l Ncluj P24
A Ncnczic P555
R Ncnkov P!99
B Ncruud P404
B Ncs P10
l Ncsic P700
l Ncspoli P041
l Nctuku P595
l Nctuku P159
C Ncvcs P22!, P244,
P775, P24 & P20
R Ncwcombc P525
A Ngli-Bcron P404
A Nicolosi P4!4
l Niculcscu P200, P212,
P0!1 & P0!
C Niculcscu P497
l Niclscn P017
l Nicmun P40
W Nicuwluut 0C!.!
S Nikunovicl P540
M Nikus P445 & P54
V Nikilorovu P71!
Y Nikitin P170
N Nikoluc P22 & P2!
A Nikolujuk P152, P!45,
P49!, P090 & P59
M Nikolic-ljurovic P591
M Nikolov P0!0
T Nikonovu P!41
M Nilsson P141
Y Nislizuwu 0C0.0
0 Nislkumuy P12!
l Nisoli H2.1
C Nivcditlu P297
M Nivciro P597
l Nobrc P120
A Noczynsku P490
C Noclummcr P55
R Novuc P210 & P2!1
l Novuc P497
} Novukovic-Puro P,
P219 & P014
l Novotny P124
A Nowukowski P!0
C Ntuli P45 & P571
C Ntutsis P214
M Nuncs P0!4
M Nurmio P0
T Nystrom S21.1
B 0bcrmuycr-Pictscl P405
& P72
M 0bcrt H1.1
C 0biols P77 & P79
A 0brudovic P55
l 0clon P51! & P514
l 0clrlcin P010
l 0ctjcn P04
S 0gnjunovic P1!5, P109,
P24!, P4!9, P472,
P47!, P505 & P75
M 0gris 0C2.2
A 0guz P15, P194, P07
& P770
} 0l P40
S 0kuzuki P259
R 0lu P25
C 0lurcscu P0!9
A 0lcugu P!
l 0lgiuti 0C!.4
M 0livciru P500
l 0livciru P220
A 0livciru P712 & P71
C 0livcr P1!
l 0livicr P100
0 0liynyk P70
N 0lscn P!14
V 0lsovsku P55!
K 0nbusi P109
l 0ndcr P274 & P754
l 0ndrus` P529
l 0nur P100 & P704
A 0ppo P5! & P25
B 0pru P240
S 0'Rulilly Pl
S 0rlunos P701
l 0rio P475 & P470
C 0rlundo P5!1
P 0rlicki P7!
l 0rlov P540
R 0rlowsku-llorck P19
T 0rlyk P4
V 0ron-Kurni P270
S 0ros P074 & P091
l 0rsini P501
l 0rskov P!24
} 0ry P!79
T 0singu P402
} 0stcrguurd P!75
P 0tul P!2
P 0tcro P1!4
W 0ttcn P201
B 0tto P547, P07 & P71!
M 0tto P19
} 0tubu P517
l 0tziomck P152, P!45
& P090
l 0uliuc P1!
M 0wczurz P05!
0 0z Cul P2!2 & P2!!
M 0zutu P540
M 0zbck P1!9
M 0
zbck P270 & P!70

H 0zdcmir P00 & P0!
l 0zdcmir 0C2.5
l 0zdcmir Scn P190,
P2!9, P!17 & P7!1
A 0zdcryu P509
A 0zimck P!91
M 0zkuyu P407
& P470
C 0zkuyu P791
B 0
zmcn P100, P10

& P704
M 0
zsun P24
l 0zsuri P277
l 0zturk P759
0 0zturk P!27
L 0zuguz P9, P02,
P004, P000
K Pucuk Pl7
C Puccllu 0C2.0
C Pucllcr P!44
A Puci P29
l Puguno P421
C Pugc P772 & P795
l Puggi P5!0
l Pugliurdini P12
L Pugotto H2.1, P40,
P420, P094 & P740
T Pui P!5
l Puivu P90, P217, P552
& P5
S Puivu P101, P15,
P41!, P700
& P04
M Puju P240 & P!
P Pukurincn P25
T Pulu P100
N Pulcstini P707
C Pulmurcs P775, P24
& P20
l Pulmus P01
R Pulmciro Curbullciru
P!10, P!05, P425
& P0!0
S Pulombu P475 & P470
C Pulumbo P1
V Pulumbo P54!
l Pulygu P242 & P245
B Pumuk P791
A Punugiotou P5 & P77
M Punugou P42
K Punuyiotopoulos P42
P Punczcl P250
l Pundcy S22.!
l Punc P020
A Puniuguu P015
l Punidis P41
C Punnicr P795
C Punoulis P402
C Punsini P!5
B Puolo P20!
R Pupu P57
K Pupuclroni P721
C Pupudius P77!
l Pupudimitriou P150,
P7!5 & P7!
C Pupudopoulos P!47
K Pupudopoulou P!4
C Pupugcorgiou P!15
C Pupumiclucl P127
l Pupunustusiou P!7
& P54
A Puputlcodorou P77
S Pupuvusiliou P415
A Pupuvussiliou P41
& P721
C Pupcwulis 0C1.1
T Puppu P!7, P47
& P54
A Puppus P54
0 Puppo P54
R Purugliolu P422
C Purumo lcrnundcz P0!0
C Purumo lcrnundcz
P!10, P!05, P425,
P059 & P002
A Purhcnczyk P5
& P0!
H Purildur P!04 & P!07
A Purizck P501
} Purizkovu P710
S Pusu P545
l Puscunu P70
R Pusclkc P429
S Pusclou P!47
A Puscu P104
M Pusmunik-Clor P270
R Pusquuli H2.1, P40,
P420, P094 & P740
l Pusquini P005
l Pussulidou P09
l Pusscri 0C!.4 & P0!2
S Pustromus P!50
A Putuluno P1
K Putbcrg P2
M Putcl P17! & P20
l Putclli P9!
A Putocs H1.2
A Putocs P!2
P Putriziu P72
M Puttcrson P404
l Puttou P404
A Puul P00
P Puulinc P4!2
l Puun P!70, P!77,
P4!7, P774 & P4
N Puunovic P750
l Puvui P249
l Puvcl P215
0 Puvcl P57
P Puvlovic P144
l Puvon dc Puz P75
l Puwclczyk P721
A Puwluczck P449
l Puwluk P1!
K Puwlowsku P479
} Puycr P9
l Pccori Ciruldi P12
& P502
B Pcdcrscn P229 & P204
L Pcdcrscn-Bjcrguurd
P!14
C Pciro P597
} Pcix P!97
A Pcjicic P20 & P05
S Pcjicic P20 & P05
l Pckurcvu P!41
S Pckic P404, P50!
& P591
S Pckic ljurdjcvic P55
M Pclizzo P50 & P!5
T Pclku P711
N Pcllcgutu P!
C Pcllcgrini P5
l Pcllcgrini P7
M Pcllcgrino 0C0.2
l Pcnu P059 & P002
S Pcnuvu P252
A Pcncsovu P720
M Pcnin Alvurcz P!05
M Pcnnu-Murtincz P20
& P!1
A Pcrciru H2.!, 0C!.!,
P554 & S10.2
M Pcrciru P775, P24
& P20
} Pcrciru P4!!
l Pcrctiunu P541 & P51
0 Pcrcts P205
P Pcrcz S10.1
V Pcrcz P021
C Pcrcz lopcz P1!0, P199
& P474
A Pcrcz Pcdrosu P425
C Pcrcz-Arunu P!29
} Pcrcz-Ycbolcs P240
& P!
A Pcri S27.1
Z Pcrkovic P457 & P009
l Pcrnkopl P527
K Pcros` P17
V Pcrruudin P51
l Pcrsuni P041, P725
& S11.4
l Pcrsico P700
} Pcrticrru P412 & P414
M Pcrtuit P724
C Pcrunicic-Pckovic P120
P Pcruzzi P0!4
M Pcsic P495
S Pcsickovu P0
A Pcssinu P1
M Pctukov P1!5, P109,
P24!, P4!9, P472,
P47!, P505, P557,
P50! & P75
S Pctcrscnn P55, P!90
& P045
} Pcticrru dc lu Lz P44
l Pctrusòvu P4
A Pctri P702
R Pctris P774
l Pctronc P5!0
l Pctrovu P70, P17
& P179
} Pctrovic P202 & P!!0
M Pctrulcu P70!
l Pcvcc P97
l Pcvcrclli 0C1.5 & P720
M Plcilcr P150
A Plcillcr P142, P07
& P71!
H Phstcr P010 & P022
C Plilippc P752
M Plilippc P100
} Pi P494
C Piuditis P!7,P54
l Picurd S22.!
C Piccioni P!90
A Pico P000
A Pico Allonso P597
A Pico Allonso P5!2,
P5!! & P002
A Pico-Allonso P505
A Picu P! & P001
T Picbcr P!44 & P405
A Pickiclko-Witkowsku
P4!1
P Picrrc P!95
K Picrzclulu-Kozicc P51!
& P514
M Pigu P4!4
l Pigurovu P052
l Pigliuru P22
l Pignutti P742
A Pilottu P041
S Pilz 0C4.0, P405 & P72
A Pimcntu P02
l Pimcntcl P775, P24
& P20
A Pinclcru P10! & P00
M Pingct P!54 & P!5
l Pinillu P592 & P054
L Piotrowsku P72!
C Pipcri P41 & P721
V Pirugs P157
P Pircs P021
} Pirniyuzov P570
S Pitz P00
C Pivoncllo P49
R Pivoncllo P49, P52,
P594 & P057
0 Pivovurovu P71!
R Plukscj P145
} Plunk P!44
V Plcsinuc Kurupundzic
P!0!
S Plcstinu P22 & P2!
l Plctikosic P014
P Pliutsiku P77!
P Pludowski P117
Z Podgujny 0C5.2
} Podobu P55!
l Pocutu P21!
l Pocnuru P7 & P79
C Poiunu P50, P10!,
P247, P455, P541,
P40 & P51
l Polu P112
R Poli P707
C Poli P722
} Polo P075 & P09
} Polosuk P!50 & P05!
S Polovinu P27, P!!1,
P!!2 & P!!7
A Poltu P1
S Polyzos P5 & P77
l Pomorski P!9
H Pons-Rcjruji P520
A Pontccorvi P422, P542
& P729
0 Popu P100, P49, P02!
& P741
R Popu P42
l Popcscu P70, P140,
P17, P179,
M Popcscu P095
A Popcscu P095
P Popluwski P4!1
V Popovic P120, P404,
P557, P55, P50!,
P591 & P700
B Popovic P109, P1!5,
P24!, P4!9, P472
& P47!
V Popovic-Rudinovic P750
R Popp P00
C Pop-Rudu P42 & P50
T Porcclli P9!
M Porcu P5!
A Port P292
M Portcllu P021
A Posu P10
C Posncr P727
H Pospisilovu P7!2
C Poston P411
Y Potcslkin P59
N Potlinu P10 & P220
l Potlukovu P77 & P0
} Potockovu P0!!
H Poulius P5!7
l Poulios P!2
l Poulsguurd P017
M Poutuncn P25, P45
& P005
V Povoroznyuk 0C0.4,
P70, P4, P12! &
P1!1
M Powcll P570 & P50
B Prudcrc P!2
M Pruct P!
l Prulong S0.4
N Prupus P!!9, P!42
& P794
K Prusunnu Kumur P297
S Pruzukovu P!52
M Pruzny P!40
M Prcdu P72, P7! & P74
C Prcdu P2!1 & P00
V Prcumont P!40
A Prcvoli P!7
B Procluzku P710
l Produm P001 & P702
l Prolku 0C!.4
S Prokohcv P!41
l Prokovus P25
V Pronin P579 & P59
V Prusty P20
T Psurus P040, P049,
P050 & P051
M Pugcut P!9
M Puglicsc P707
l Pundovu P4
P Punzo P451
M Puru P00, P450 & P55!
M Puricc P107
l Putinclu P72, P7! & P74
M Puziunowsku-Kuznicku
P!50 & P05!
A Puzzovivo P751
l Quri P07, P!0 & P740
C Qiun H1.1
C Quurtu H2.1
} Qucsudu P110
l Qucsudu S25.2
A Quintcro P4!5
M Quninklcr 0C4.1
A Rubul P412 & P414
A Rubul Artul P44
K Rubbcn P509
M Ruclid P!71
K Rucz H1.2, P01 & P240
K Rucz P!2
S Rudcnkovic P21, P495
& P077
R Rudcv P!99
S Rudiun P4!7, P49
& P4
Z Rudikovu P720
} Rudoclu P577
V Rudoi P541 & P51
M Rudoi P104
Z Rudojicic P!0!
l Rudojkovic P495
M Rudojkovic P495
V Rulluclli P5 & P504
M Rulhn Sunson H1.!
& H2.4
B Ruguzzon P!7
l Ruggi P000
R Rugluvun P275
N Rulmun H1.4
N Rujsic P557
M Ruklmctovu P570
V Rukov P229 & P204
S Rulston P192
R Rumullo P775, P24
& P20
l Rumuzunogulluri P27
M Rumczuni P!49
} Rumm-Pcttcrscn P0!9
} Rumos P775, P24
& P20
A Rumos P400
l Rumos-lopcz P20
& P!1
V Rumundo P405 & P400
M Runduzzo P27
P Runtukuri P25
P Ruo-Bulukrislnu P!00
l Ruposo P500
Z Rusic-Milutinovic P120
& P750
l Rusku P121
S Rustcgury P0
B Rutlkolb 0C4.2
l Rutncr P45 & P005
A Ruvugliu P01
V Ruvcrdy P404
C Ruvcrot P!!, P!9
& P0!4
P Ruvn P40!
V Rcu P72
A Rculdi P1
0 Rcbclo P552
C Rccurti P50
S Rcddy P297
l Rcddy P02
A Rccs P525
C Rcllcldt P201
H Rciclurdt P57
C Rcimondo 0C5.1, P01
& P020
M Rcinckc 0C4.1 & P040
M Rcitcr 0C!.1 & P717
R Rcnurd 0C4.5
S Rcnoul P51
C Rcntziou P41
A Rcpuci P40
l Rcpcdc P210
A Rcsmun P150
l Rcsmini P021
M Rcuss P2!
} Rcviricgo P!21
l Rcvollo P292
H Rcy P1!4
R Rcycs gurcr u P115
P Rczck P19
M Rlo P750
C Ribciro P101, P15,
P41!, P552, P700
& P04
M Ricciuto P422
N Riclurd 0C0.!
l Riclcr P0!4
M Ricdl P714
} Ricdlovu P710
M Ricstru lcrnundcz P44
l Rigunti 0C2.0
H Rilu P159
A Ring P292
C Ringstud P0!9
C Rini P!50
R Ripuni P420
C Ripoll S25.2
P Ristic P705
M Rito P552
R Ritunnuno P4!
l Ritz 0C4.0
A Rivcro-Mu llcr H1.4
M Rizk-Rubin P!7
l Rizos P150, P401,
P7!5, P7! & P77!
N Rizvunolli P709
M Rizzo P154 & P!50
} Rou P592
R Robcvu P459 & P400
S Roblcs P!59
l Robu P5
M Roclu P227
B Roclc P5
l Roclcr 0C4.5
V Rocliru P5!1 & P7
P Rodicn S20.1
W Rodl 0C2.2
P Rodrigucs P227 & P22
l Rodrigucs P244 & P02
l Rodrigucs P!5
& P!0
l Rodrigucz P!59
A Rodrr gucz P!21
V Rodrr gucz P0
P Rodrr gucz P221
} Rodrigucz Molinu P1!0
& P474
C Rocl P744
l Rocllscmu 0C!.!
} Rocmmlcr P547
l Rogowski P5, P59
& P0!
l Roitcr P790
H Rokni P27!
} Rollcs P024
S Romugnoli P!
l Romun P1
S Romuno P7
l Romunovu P570
M Romcro Mun oz P!!0
} Romijn H2.!, 0C!.!
& P554
C Roncli 0C!.4, 0C!.0
& P0!2
A Ropcro S25.2
R Roruto P00!
S Ros P!5
R Roscu P49, P074
& P741
l Roslonowsku P19
R Rossctti S11.4
S Rossi P521 & P522
R Rossi 0C2.! & P79
C Rossi P1, P50 & P000
M Rossi P79
V Rossi P451 & P001
l Rostomyun P452
W Rostworowski P50
M Roszkowsku-Cuncurz
P!50 & P05!
l Rotu P405
C Rotu P422
C Rotcllu P151
l Roti P79
M Rotondi P020
P Roussuki P54
S Rovcrc P00
l Rozlinskuyu P452,
P599 & P052
H Rubinlcld P54
M Rubinstcin P0
M Ruclulu P!7 & P!9
M Rudoni P421
N Rudovicl P142 & P71!
M Rulhn P045
S Ruginsk P004
T Ruiz-Azuu P2
l Ruiz-Pino P592
S Rulli P45, P500
& P005
l Rump 0C4.1
l Ruocco P5
M Rusulcnko P!0! & P!04
Z Rusuvy P40
T Russo P470
0 Rymur P170
A Rysku P427
l Suud P19, P!1!, P52!,
P524, P01 & P02
} Suuvcdru lulcro P75
S Subcr P747
C Subrinu P72
l Sudiku P24
W Sucgcr P24
S Sulurovu P572, P57!,
P51 & P719
L Sulcr P!27
C Sugun P!95
C Sugcrt P0!
N Sugluh P747
l Suglum P477
R Suluy P177
M Sulin P277
K Sulru P4
R Sulruciun P40
K Suinio P25
B Suinz Vcru P1!2 & P1!
R Suito P510
l Sukclluriou P!50
N Suluklovu P570 & P51
l Sulutu P45
A Suluti P40
A Sulcuni P7 & P21
S Sulcnuvc 0C4.4, 0C4.5,
P!! & P5!0
Z Sulmun Montc P10
K Sultiki P127, P47
& P41
A Sulvutoni P041
M Sulvi P10
M Sulwun P4!2
M Sumu` P421
M Sumbo P221 & P!2
0 Sumiu P4
R Sumoilu P50
B Sumucl P100
S Suncuk P410
R Sunclcz P!01
C Sunclcz P412 & P414
} Sunclcz Puyu P5!!
P Sunclcz Pclliccr P5!!
& P002
C Sunclcz Rugnursson
P44
P Sunclcz Sobrino P!10,
P!05 & P0!0
P Sunclcz Sobrino P425
C Sunclcz-Murtr n P!01
R Sunclcz-0rtigu P5!2,
P505, P597 & P002
l Sunclcz-Tcjudu P597
} Sundull Clristiunscn
P509
S Sungovu-Crigoriudi P!4
} Suntumuriu P2
R Suntcn P024
l Sunti P5!1
R Suntiugo-Moru P110
} Suntos P90, P15, P217,
P41!, P552, P5,
P700 & P04
A Suntos P021, P27,
P29 & S1.0
l Suntos P494
l Suntos Pinto P120
M Sunz P!01
S Surul P2!5, P2!0
& P450
M Suruivu P500
l Surcliclli P5!5
C Surdcllu P000
W Suris P715
C Surisozcn P10
C Surtorius P492
C Sussolus P!97
A Sutlununtlun P17
A Sutturi P4!
M Suvunclli P511
A Suvuri P25!
W Suvino P507
C Suvocu P21
A Suvov P459 & P400
l Suvu P49,P741
0 Suvu P107
S Sbicru P2! & P57
M Scuccli P501 & P502
M Scunurini P!0
T Scunlun Pl4
l Scuruno P511
C Scurpcllini P5!4 & P011
l Sclullcrt 0C2.2
C Sclulin-}untti P119
C Sclulkwijk P!14
WSclcrbuum 0C1.1, P0!,
P04, P05, P102 &
P24
C Sclcrntluncr S1.!
K Sclimkc P551
V Sclini-Kcrtl P!5
S Sclinncr 0C1.1, P0!,
P04, P102 & S15.2
A Scliopu P70
S Sclipor P!70 & P!77
S Scllutt P742
M Scllumbcrgcr P29,
P410 & P41
K Sclmid 0C2.1
S Sclmull P57
H Sclncidcr P!55
} Sclnicdcrs P559
L Sclocnlcrr P040
W Sclooncn P492
} Sclopoll P010
M Sclott 0C1.1, P0!, P04,
P05 & P24
T Sclrcincr P509
A Sclrcwc 0C4.2
P Scluctz P14
l Sclulzc P2 & P20!
M Sclumuclcr S27.!
C Sclwulcrtz P04
H Sclwurz P500
L Sclwcizcr P20
A Scillituni P7 & P21
l Scul P2
A Scbustiun-0clou P115
& P70
T Sccciu P1 & P50
A Scclmun P479
M Sccil P07
0 Scdu 0C1.!
C Scgurd P795
C Scgundo P!29
A Scguru-Culindo P!07
l Sclkinski P!1
} Scls P027
} Sclvcs P!2
K Scn P040
A Scndon P294, P295
& P!!!
A Scndon P290
P Scncs P422
K Sco P750
l Scounc Cruz P!10, P425
& P0!0
M Scrcg P!2
l Scrgicnko P205
M Scrio P722
l Scrru P5!
S Scrru P5!
l Scrruno P294, P295,
P290 & P!!!
C Scsmilo P000
} Sctli S15.!
l Scttunni P!00
R Scvcrino P400
H Scvcstrc P795
l Scylritz P!54
A Sczcr P00
S Slur P200
A Slorzu 0C1.4, P149,
P151, P105, P5!0
& P440
R Slubuni P042
B Sluguzutovu P!!4
& P04
M Slukirovu P570, P574
& P575
A Slurmu P20
P Slurp P071
H Slciklolcslumi P0
S Slciklolcslumi P0
M Sliuu P!02
A Slimutsu P550
l Slimon P54
T Slimosuwu P510
A Slinkov P04
A Slirulkun P!49
M C Slivumurtly P297
S Sltundcl P!05 & P70
M Slvcd P1!1
T Siumutrus P571
N Sicolo P4!
M Sidcrovu P!99
C Sicvcrs 0C!.0, P500,
P010 & P022
K Sicwko P0!
S Sigrist P!54 & P!5
} Silvu-Nuncs P712
& P71
M Silvciru-Rodrr gucz P!07
l Silvcstro P000
l Simcdrcu P215
C Simcoli P057
R Simo P079
H Simocs P500
V Simocs P120
N Simon P1!
M Simoni P742
W Simonidcs S12.!
C Simonovu P170
K Simunkovu P200, P!57
& P74!
} Singcr P429
R Singl P17
P Singlul P275 & P792
A Sinisi P451, P5!0,
P54!, P020, P001
& P725
B Sion P520
A Sioulis P1
S Sipctic P202
H Siprovu P55!
H S
`
iprovu P7
0 Sirikci P147
M Sivclli P00
M Skuclu P19
N Skukkcbuck Pl2
V Skurpu P25
M Skcndcr Cuziburu P55
l Skowronsku-}ozwiuk
P117
} Skrlu P!40
} S
`
krlu 0C1.2
A Sluvukis P794
l Sluvik P124
} Slowinsku-Srzcdnicku
P19
A Sluszniuk P242
} Sluszniuk P245
l Smudcunu P777
0 Smukul P00
S Smuniotto P507
l Smirnov P!22
S Smirnov P!00
} Smit 0C!.! & S5.!
R Smitl P2!5, P2!0
& P544
} Smyczynsku P590
& P59
Z Snczunu P771
C Sourcs P29
C Sobujo P!00
R Sodc-Curlscn P!75
& P509
K Socrcnscn P42
l Sokolic P17
l Sokolinu P59
C Sokolowski P49
A Solnccvu P070
A Solntscvu P!25 & P090
} Solski P!0
M Soltcr P22 & P2!
l Somjcn P727
S Song P
A Sonmcz P14 & P!27
Y Sonmcz P102
Y Sonmcz P!20 & P097
S Soriuno S25.2
A Soto P000
A Sousu P02
S Souto P244
} Sowinski P!7, P!9
& P50
S Soytuc lnuncli P59,
P477 & P7!1
A Spudu H2.2, 0C1.5,
0C!.4, P0!2 & P720
P Spullurossu P42!
l Spunos P779
M Sputl P05
C Spcntzou P77!
C Spinus P154
l Spisùkovu P4
S Spitulnikovu 0C5.0
C Spitzwcg 0C2.2 & S5.1
l Sporiscvic P252
S Sporny P!9
} Sprungcr P142 & P07
l Sprij-Mooij P52
A Spring P145
l Springcr P77, P0
& P11
A Spyroglou 0C4.2
P Srinivus P02
l St Ccrmuin S12.2
B Stubcnow P201
B Stuclowsku P709
B Stucls S21.2
M Stull P00
S Stuibuno P001
l Stuicu P541 & P51
C Stullu 0C!.1, P!55,
P500, P010 & P022
M Stumutukos P05
K Stumutclopoulos P127
l Stumcnkovic-Pcjkovic
P!12 & P!5!
K Stumou P415
} Stunkicwicz-0lczyk P04
V Sturccvic P700
V Sturcvu P!!4
l Sturku P200, P501,
P7!2 & P74!
R Stuwcrsku P590 & P59
A Stcluncscu P10!, P!70,
P!77 & P40!
C Stcluncscu P11 & P42
l Stclunopoulos P!!, P99,
P114, P2!4, P!!,
P40, P409 & P4!
l Stclunovic P!12
A S
`
tchovu P710
M Stcinling P404
} Stcno P55!
} Stcpniuk P00
V Stcrgiou-Micluilidou
P140
} Stcrn P!1
N Stcrn 0C!.5
C Stcttlcr P290 & P!00
l Stcvunovic P700
M Sticlu P55!
K Stocllolm 0C5.!
& P42
M Stoiun P197
l Stoicuncscu P197
M Stojunovic P0, P404,
P555, P55, P50!
& P591
} Stojunovic P129
l Stojic P21 & P077
M Stojkovic P4 & P79!
l Stolz P14
L Stopinsku-Cluszuk P499
S Stork P044
M Struczkowski P152,
P!45, P49! & P090
C Strusburgcr S1.0
C Strutukis H1.!, P51
& S.2
T Strutigou P!4
l Struuss P25
C Strcctz-vun-dcr-Wcrl
P2!0
V Strunski P772 & P795
P Stubbs 0C0.5
V Studcnt P00
T Stulnig P717
N Sturm P!!
} Suurcz-llcdo P207
& P745
A Suculiuc P91
B Suclmunn 0C2.4
C Sulunovu P599
A Sukulo P090
P Sulcntic P!9! & P!94
M Sumuruc-lumunovic
P!12, P!!7, P!5!
& P700
Y Sung P40 & P012
T Supryudkinu P12
0 Surovtscvu H2.5
l Suvugundlu P170
N Suvujdzic P505
S Svucinu P159
H Svctlovu-Kovulcnko
P70
l Svilius 0C5.0 & P20
A Sygclou P77!
V Sykorovu P427 & P4!0
P Sykorovu P440 & P44
P Sykorovu P00
P Szublics P10
P Szubo H1.2
l Szubolcs P01, P1
& P!!
W Szuhurski P!9
Z Szului P10
N Szulus 0C5.2
Z Szunto P!0 & P407
A
Szuppunos P!2
l Szczcpunck P!7
& P!9
M Szcluclowsku P5,
P59 & P0!
B Szcndc S24.!
} Szoslund P00
S Szpuk-Llczok P449
l Szpicl P490
N Szucs P!2
P Szumowski P5
& P59
Z Szybinski P49 & P50
B Szymunck P!0
S Tubun P11! & P447
A Tuburin S10.1, P!0 &
P0!4
A Tubcrlct P25
S Tuddci P5!4
Y Tucs P744
l Tuluro P751
S Tuguru P5!7
M Tugluvi P747
l Tugliuti 0C2.!, P!4,
P!5, P!0, P!7,
P704 & P79
A Tulruni P10
M Tukir P!04 & P!07
V Tumusi H1.2
H Tumcz P!59
S Tumir P727
M Tumm P14
M Tumpourlou P!4
M Tuncic-Cujic P0 & P555
H Tundru P!0, P!09
& P!10
l Tuncli P10
l Tunrivcrdi P204, P!74,
P507, P50, P59!
& P759
S Tupun P14, P102
& P!27
} Turucl P222, P05,
P14 & P!0
l Turuntino P09!
0 Turcin P147
l Tusci P!27
M Tusc P24
B Tuskirun P5!
A Tuslipinur P14, P102,
P!20, P!27 & P097
C Tuslitcli P420
} Tusmun P551
l Tussonc 0C0.2
C Tutucu P777
l Tuuvcron P5 & P520
l Tuvcur P705
S Tcixciru P225 & P220
M Tcixciru P220
} Tcixciru P29
Z Tclicku P77 & P0
l Tclting P95 & P559
S Tcmizkun P410
M Tcnu-Scmpcrc P592,
P054 & P055
C Tcnorio }imcncz P!!0
l Tcrpos P77
l Tcrzcu P200, P40,
P4 & P51
T Tcrzi P99 & P!!
M Tcrzolo 0C5.1, P424,
P01 & P020
A Tlullcimcr P711
P Tlclunoyiunnis P2
A Tlcmmcn S11.!
A Tlicl 0C1.1
S Tlirion P724
K Tlisiudou P0, P1,
P29 & P291
W Tlomus P7!!, P417
& S25.!
l Tlomus P445 & P54
M Tlorcn P2
B Tlorstcinsson P!14
M Tlunundcr P55
} Ticu P120 & P750
M Ticlomirowu 0C!.0
} Ticmcnsmu H2.!, 0C!.!
& P554
T Tiklonovu P!05
l Tinuloncs Muducn o
P70
C Tirubussi P57
Y Tislovu P52!, P524,
P01 & P02
l Tissicr P47
A Tiulpukov P452
l Tiziunu P72
V Todorovic P250
l Todorovic-ljilus P,
P219 & P014
M Tolungclilu P0
} Tokc P!2
M Tokgoz P007
l Toldy P01, P240 & P!!
C Tolkcmitt P110
A Tomusclitz 0C4.0
M Tomc P294, P295
& P!!!
M Tomc P290
Y Tomcr S20.!
l Tomisti P705
S Tomkovu P9
} Tomlinson S2!.2
K Tomos P29
A Tomovu P459 & P400
0 Topuloglu P15! & P15
S Topuloglu P15!
A Topuloglu S17.2
l Topic P22 & P2!
} Toppuri P0 & S1.2
M Torlontuno P7
l Torrcs P27 & P29
l Torrcs P000
B Torrcs Torrcs P!4
M Totl H1.2
M Totl P!2
P Touruinc 0C4.5 & 0C5.5
S Trubudo 0C4.!, 0C4.4
& P5!0
P Trucltu P700
A Truiunos P!!9
P Truincr S1.0
V Trujkovic P!12 & P700
C Truslorini 0C2.! & P79
H Truupc H1.1
} Truvugli P410
B Trbojcvic P4 & P79!
l Trcjbulovu P55!
} Trcmbluy 0C1.!
M Trcndclcnburg P0
P Trcrotoli P09!
P Trctjukovs P157
} Triunu P!59
} Triuy P275 & P792
R Triluncscu P50, P10!,
P40 & P5!
V Triggiuni P751
V Trisclittu P7
S Trninic P252
M Trohmiuk P7!, P49
& P50
} Trouillus P!! & P!9
l Trovuto P702
M Trubuc P702
M Trummlcr P14
A Trzmicl-Biru P709
S Tsugurukis P!4, P45,
P701 & S20.!
l Tsukonus P7!5
V Tsutlidis P!4
A Tsutsoulis P!47
l Tscniklidi P54
C Tscntidis P25
V Tsiuvos P54
C T'Sjocn P!
A Tsolukidou P1
K Tsolukidou P5
P Tsounus P54
M Tuclsclcrcr P201
K Tucic Ncmct P!!2
A Tugrul P5!
C Tumcr P545
N Tuncbilck P00 & P0!
l Turun P!70
M Turc P0!
S Turcguno P075 & P09
M Turgut P274
S Turgut P549 & P550
C Turgut P550
N Turgut P0!
A Turkcs P525
S Turliuc P210
l Turliuc P210
0 Turowsku P!50
l Tutor P494
Y Tutuncu P9, P02,
P004 & P000
l Tuzun P59 & P1!!
L Tworowsku-Burdzinsku
P40, P409 & P09
M Tzunclu P701
l Tzuvuru P42
C Tziorus P!1
K Tziorus P214, P40
Z Lc P5!
l Lclou P00! & P004
C Lckuyu P102 & P277
C L
ckuyu P!20 & P097

R Lclcr P195, P2!9
& P44
S L
clcr P0!5
Y Lctukc P510
l Lgurtc P!
B Lgur Altun P5!
P Littcrlindcn P22
l Llyunu P74 & P749
S Lmcmuru P11
S Lnul P05
0 Lnul P2!2 & P2!!
N Lngcr P!90
l Lngurcunu P09
M Lngurcunu P2!1
& P00
K Lnlulizurci P204,
P507, P50, P59!
& P759
A Lnnikrislnun P177
& P279
C Lntcrgusscr P527
l Lnuunc S1!.!
A Lrul P277
C Lrbuni P000
Y Lrmunovu P570, P572,
P57!, P574, P575,
P570, P50, P51
& P52
A Lsmun 0C2.5, P!51,
P707, P10 & P4!
Y Lstun P407 & P470
C Lwuilo P224
K Vuununcn P0
l Vucluvikovu P427
& P4!0
S Vucqucr P22
RVulcuvi 0C2.0
S Vulcntc P729
l Vulido P!5 & P!0
M Vulimuki P119
Z Vulkusz P!1 & P250
l Vullinu P494
M vun Bccrcn H2.5
} vun dcn Brundt P57
A vun dcr Horst-Sclrivcrs
P402
S vun dcr lcij 0C2.4
A vun dcr lcly P025
R vun dcr Must P554
R vun dcr Pus P22
l vun Croningcn P95
T vun Hucltcn 0C2.4
P vun Koctssvcld P41
P vun Koctsvcld P22
& P52
H vun lccuwcn S14.4
AVun Mccrlucglc S1!.!
K vun Ruttc P41
A vun Sorgc P95
C Vunbillcmont P744
B Vundclccnc P!40
l Vundcrsclucrcn S4.2
S Vundcvu P0!0
M Vunkovu 0C1.!, P!20,
P!52, P099 & P70!
C Vunnclli P5!5 & P7!7
S Vunnclli P01
C Vunnuccli P10
M Vuntyglcm P404
P Vunugu P00, P9, P249,
P450 & P55!
AVunzulli P27
AVurclu P244 & P4!!
l Vurgu P!2
C Vurgu P10
B Vuri P10
C Vurtlolomutos P!47
T Vusutko P20
V Vuslclulu P540
l Vusilc P57
V Vusilciou P!15
C Vusiliou P5!7
l Vusiliu P107, P11,
P42 & P09
0 Vusilkovu P71
l Vusilycvu P579
} Vussullo P4!0, P007,
P00 & P010
l Vussilutou P42
l Vussiliudi P45 & P701
C Vussiliou P!!
H Vuvcrkovu P124
} Vuyu P727
V Vuydu P1!1
l Vuz P225
} Vccluk 0C1.!, P!52,
P099 & P70!
} Vcgu P075 & P09
l Vcigu P712 & P71
} Vckic P!50
Z Vcliju-Asimi P500
B Vclkcnicrs S1!.!
AVcllu P17
M Vclojic Colubovic P21
& P077
} Vcndrcll P079
l Vcniou P445 & P54
} Vcrbulis P209
} Vcrbovcnko P157
} Vcrlclst P55
l Vcrruu 0C!.4
S Vcrzcu }crculuu P40!
& P000
RVcttor P4!
l Vczzosi H1.! & P!2
l Viuzovu P090
V Viccnnuti P40, P420,
P094 & P740
l Viccntini P7
l Viclu P45
C Victor-Vlud P442
AViciru P90, P101, P15,
P217, P41!, P552,
P5, P700 & P04
} Viciru P120
S Vicngclurcun 0C4.!
& P257
K Vicrlingcr P55
l Vignuli P10!
} Vigncrovu P710
AVignini P52
S Vignjcvic P250
l Vignozzi P5!5, P5!0
& P7!7
l Viju P091
V Vijuyukumur P224
C Vilu 0C!.1, P714
& P717
l Vinccnzoni P542
l Vinlu P4!!
S Vinjumuri P454
l Visconti P54!
M Vislncvsksuyu P070
l Visonti P451
C Vitulc P502
P Vitulc P49, P594 & P057
l Vituli P720
RViti P21
P Vitti S20.1
Y Vivcs P021
} Vizdu 0C5.0
M Vlud P11!, P211
& P770
AVluduiu P107
S Vludoiu P100, P49,
P49, P02!, P074,
P741 & P4
} Vlulov P04
} Vluski P54
H Vlussuru S9.!
M Vlcck P720
P Vlcck P427, P4!0,
P440, P44, P00
& P19
l Vloduvsky P54
AVoicun P497 & P57
RVoicu P10
P Voidonikolu P127
l Vokurkovu P40
V Volck P529
C Volpc P2
H Volzkc P7!0 & S1!.1
C von Arx P00
M von Wolll S7.2
K Vondru P!20, P!57
& P74!
0 Voncnd 0C4.1
0 Vonicu P770
} Voru P454
C Vorlundcr P!1, P1
& P21
C Voroncu P!2
AVoronzov P052
l Voros P241
X Vos H2.5
M Vrublik S21.!
} Vrbikovu 0C1.!, P!20,
P!52 & P702
M Vrkljun P97, P!9!
& P!94
AVryonidou P42,P5!7
M Vujovic P120 & P750
S Vujovic P0 & P555
B Vukovic P014
M Vuksunovic P129
C Vulpoi P107, P11,
P42, P0!, P09
& P00
l Vuolo P405
l Vurul P10
l Vuruy P44
M Wuuijcrs P22 & P41
l Wugncr 0C2.2
S Wugncr 0C4.2
l Wugncr 0C!.1
H Wugncr 0C1.0
H Wugncrovu P55!
H Wugncrovu P4
R Wull P!1, P1
& P21
H Wulrcnbcrg P2
} Wulkowski P245
H Wullusclolski P!55
& P7!0
B Wultcr P292
l Wung P512
H Wung P510
} Wuss P544, P571 & S1.0
M Wusscnuur H2.!
& 0C!.!
S Wcbb P021, P000
& S1.0
M Wcbcr P2, P229 & P204
l Wclr P405 & P72
M Wcickcrt P142, P07
& P71!
H Wcinlundl P!44
T Wcisclcr P50!
l Wcismunn P711
S Wciss P520
V Wciss P55!
} Wcmcuu P404
P Wcnd S15.1
V Wcstcr P7!0
0 Wcstplul P5!9
K Wctli-Hcrmosillo P045
T Wicbc P0!7
} Wicbolt 0C2.4
AWicrinckx P!9
W Wicrsing P00
W Wicrsingu S1.!
W M Wicrsingu S20.2
T Wijnlovcn P710
B Wikicru P490
l Wild P404
l Wildovu P205
H Willcnbcrg 0C1.1,P20,
P0!, P04, P05 & P24
M Willluuck 0C2.2
l Williums Pl1
} Wistubu P742
H Wittclcn P!55
H Wocrlc P292
l Wollgcmutl P20
AWojcicku P4!1
M Wojcicku P092
S Wolczynski P49!
C Wordu S1.2
l Wozny P19
l Wu S1.1
S Wudy P2!,P55
S Wuccst P290
N Wundcrlicl 0C2.2
l Xuntlukou P40
l Xuvicr du Cunlu P700
A Xucrcb-Anustusi P4!0
M Yulcin P05 & P07
Y Yulcin P15
AYulin P410
Y Yumumoto P11
M Yuncvu 0C!.0
} Yungo P71
N Yuroslcvicl P101
C Yusudu P11
K Yutsu P11
V Yuvuri P40
l Yuvuz P410
l Yuzgun Aksoy P!51,
P707 & P4!
0 Yuzici P007
} Yburru P021
S Ycncr P05 & P07
l Ycncr 0zturk P509
S Ycsil P05 & P07
C Yi S2.1
AYildirim P5!
H Yildiz P59!
B Yildiz P707 & P4!
l Yildizlun P754
M Yilmuz P90,P!27
AYoncm P540
M Yoo P750
S Yoo P299, P40 & P012
C Yorulmuz P109
} Young H2.4, 0C4.!,
0C4.4, 0C4.5, P29,
P410, P41 & P5!0
l Yousscl P104, P105,
P490, P491 & P029
AYuccc P!90
RYui P!19
M Zubcl P!9
S Zucluricvu 0C!.0, P0!0
& P042
l Zulciriudou P77
C Zulon P77 & P79
B Zuggiu P020
K Zulru P45!
N Zukopoulos P41
V Zumruzil P!57
H Zumruzilovu P710
M Zunonc P!00
l Zupunti P!15
T Zuruboukus P140
M Zurkovic P4 & P79!
K Zusudu P00
M Zutclli 0C2.!, 0C5.1,
P!4, P!5, P!0,
P!7, P704 & P79
A Zuvrclovu P577
l Zbruncu P2!1, P42
& P00
V Zdruvkovic P!!0
l Zclndcr P7!9
C Zcillcr P724
V Zcktscr P44
R Zcluscli P!9
l Zcmun P55!
V Zcmun P702
C Zcnzmuicr P527
l Zcrvus P77!
S Zcuzcm P1, P!1
& P755
l Zcybck P10
M Zcydu P717
W Zgliczynski P19
Y Zlung P040
l Zluruvlyovu P!22
} Ziuju P449
L Zicbold S15.1
W Ziclcnicwski P9, P17,
P19! & P201
V Zikun P121
} Zimuk P00
A Zimmcrmunn P2
T Zimmcrmunn P2
S Zimmcrmunn P040
C Zinglcr P110
M Zink P2!
N Zirus P445
l Zirilli P5!1 & P7
T Zitmun-Cul P270
l Zivorovu P0
V Zjucic-Rotkvic P22
& P2!
} Z
`
mirc P17
M Zoli P005
A Zoncnbcrg P5
& P59
S Zoric P!5!
l Zosin P!, P211, P447,
P590 & P770
V Zsuzsunnu P210
R Zsuzsunnu P01
} Zubcl P51! & P514
S Zulur P509
l Zuliuni P4!
P Zuritu Scpu lvcdu P199
C Zwimplcr P154
A Zygmunt P50
1470-3947(201004)22;1-4

Ece 2010 Abstracts

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Ece 2010 Abstracts

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April 2010 Volume 22

ISSN 1470-3947 (print) ISSN 1479-6848 (online)

-deiodinases indicate that: i) maintenance of a normal serum T

stemcells, and as fewas 500 of these cells induced

UTR of the ER mRNA to reduce its stability

channel (ENaC) and Na

-ATPase, and also

11.681.88 vs 13.203.32 pg/ml) and returned to baseline within 1 month. No

zsan, Ersin Akarsu, Sebnem Aktaran & Mustafa Araz

niversitesi Medical Faculty Endocrinology and Metabolism

lvarez, Antonio Lavilla Corcovado, Joaquin Petierra

) currents, the twik-related acid-sensitive K channel 1 (TASK-1)

channels of the TASK family in a series

chennels in the adrenal cortex

zmen & Feyzullah Guclu

seo, Hospital Universitario San Cecilio,

niversty, Ankara, Turkey.

zbek, Nujen C olak Bozkurt, Erman C akal,

assays was confrmed

insulin and C-peptide assays allow their use for

CAGGGCCTAAACAGTCTAGCAGT; amplifed products were

-UTR of exon 8 has

, P, and alkaline phosphatase (AP) were within

1.13 (1.08; 1.19) mmol/l and 1.05

concentrations 1.05 (1.03; 1.10) mmol/l

AMH (pM) 4318 4414

NS versus baseline values.

0.3364; P0.015). Thirty-nine percent had paradontitis. Ninety-six percent had

strand bicycle test.

ngeles Bazarra Castro

during oral glucose tolerance test

-deoxycytidine (DAC) treatment and histone deacetylase

, Haemoglobin and NT-proBNP.

0.66 ng/dl; low scoring group: FT

/l, beers 2.91 g I

/l, mineral waters 0.5 g I

/l, sodas 0.5 g I

/l, retrospectively). Although

/l and 126 g/l,

Immunoassay Systems (Siemens Healthcare Diagnostics).

Systems with the previous (TSH-3 and FT

TPOAb, Beckman Coulter). Regression linear test

column (150,2 mm) with Guard Cartridge using a gradient

lvurcz lscolu P757

lvurcz Curcr u P059

Aydogun P!20 & P097

Csujbok P!1 & P250

zbck P270 & P!70

zmcn P100, P10

ckuyu P!20 & P097

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