Idiopathic central diabetes insipidus in a large cohort of patients: the hypopituitarism ENEA rare observational (HEROS) study.

Central Diabetes Insipidus (CDI) is mainly associated with structural pathologies of the hypothalamic-pituitary area. Etiologies underlying CDI are identified in most patients, however idiopathic CDI is reported in 13-17% of cases after excluding other etiologies. The Hypopituitarism ENEA Rare Observational Study (HEROS study) retrospectively collected data of patients with idiopathic CDI from 14 pituitary centers in 9 countries. The cohort included 92 patients (59 females 64%), mean age at diagnosis was 35.4 ± 20.7 years, and a mean follow up of 19.1 ± 13.5 years following CDI diagnosis. In 6 women, diagnosis was related to pregnancy. Of 83 patients with available data on pituitary imaging, 40(48%) had normal sellar imaging, and 43(52%) had pathology of the posterior pituitary or the stalk, including loss of the bright spot, posterior pituitary atrophy or stalk enlargement. Anterior pituitary hormone deficiencies at presentation included hypogonadism in 6 (6.5%) patients (5 females), and hypocortisolism in one; during follow-up new anterior pituitary deficiencies developed in 6 patients. Replacement treatment with desmopressin was given to all patients except one, usually with an oral preparation. During follow up, no underlying disease causing CDI was identified in any patient. Patients with idiopathic CDI following investigation at baseline are stable with no specific etiology depicted during long-term follow-up.

PREVALENCE AND CHARACTERISTICS OF THE POLYCYSTIC OVARIAN SYNDROME IN OVERWEIGHT AND OBESE PREMENOPAUSAL WOMEN.

Context: Polycystic ovarian syndrome (PCOS) is commonly associated with obesity, but the prevalence of the syndrome in obese patients is not well established. Objective: The present study aims to investigate the prevalence of PCOS among overweight and obese premenopausal women and to evaluate the possible associations between the syndrome and metabolic disturbances in obese patients. Methods: Medical records of all women referred to a single endocrine center because of obesity and/or metabolic disturbances during a three-year period were analyzed. A total of 262 overweight and obese patients of reproductive age were included in the retrospective study. Results: The overall prevalence of PCOS using the Rotterdam criteria in the group of overweight and obese women was 26%. The degree of obesity did not influence the PCOS prevalence. Women with PCOS had higher blood glucose and insulin levels after glucose load in comparison to other obese patients despite the younger age. Conclusions: PCOS is a common finding among obese women seeking endocrine help. The oral glucose tolerance test is an important tool for the early detection of carbohydrate disorders in women with the syndrome. Furthermore, screening for PCOS components might be justified in young obese women with pronounced insulin resistance or dysglycemia.

ARE THERE RELIABLE PREDICTORS FOR THE IMPAIRED QUALITY OF LIFE IN PATIENTS WITH CUSHING'S SYNDROME?

CONTEXT: Patients with Cushing's syndrome (CS) of any etiology experience a number of physical and psychological symptoms which impact negatively on health-related quality of life (HRQoL). SUBJECTS AND METHODS: HRQoL was measured using CushingQoL questionnaire. RESULTS: The first part of our study was a cross-sectional analysis of 141 patients with CS over a 10-year period. CushingQoL score was lower in pituitary CS compared to adrenal CS. Remission and older age were associated with better outcome on item 7 (physical appearance anxiety). In a multivariate regression analysis after adjustment for etiology, remission status, age, UFC, duration of hypercortisolism and presence of hypercortisolism-associated comorbidities the female gender was the only negative predictor associated with poorer outcome on each of the three scores. The presence of hypercortisolism-associated comorbidities independently predicted poorer outcome on the psychological and the global subscales.The second part of our research was a prospective study of 27 patients with adrenal adenoma. Achievement of remission independently predicted improvement of the total score of any patient. CONCLUSION: Studying in details and understanding the mechanisms of the impaired HRQoL in patients with CS is the only way to become aware of the problem and create methods that could help these patients.

A 40-YEAR FOLLOW-UP OF A PATIENT WITH MULTIPLE PARAGANGLIOMAS AND A SDHD MUTATION.

CONTEXT: Germline mutations in Succinate Dehydrogenase Complex Subunit D gene (SDHD) predispose to predominantly benign head and neck and/or thoracic-abdominal pelvic paragangliomas (PGLs). OBJECTIVE: We present the case of a patient carrying a germline SDHD mutation responsible for multiple PGLs, who was followed for 40 years. He was initially diagnosed with a left cervical PGL at the age of 23 years, treated by surgery. Then, he recurred and developed a multifocal disease. The second-line therapeutic option was a three-dimensional conformal radiotherapy performed in 2008. In 2013 the patient had clinical, hormonal, PET- and SPECT-CT data revealing a disease progression. The treatment with the long-acting somatostatin analogue Octreotide Lar was carried out till the patient's death caused by pulmonary embolism in December 2014. RESULTS: Complex treatment led to a long clinical and biochemical remission and control of tumor growth. CONCLUSIONS: Despite their usually benign behavior, multicentric SDHD-related PGLs can require a multimodal approach involving surgery, radiotherapy and medical treatment for providing a long-term control of the disease and maintaining a good quality of life.

ECHOCARDIOGRAPHIC MYOCARDIAL CHANGES IN ACROMEGALY: A CROSS-SECTIONAL ANALYSIS IN A TERTIARY CENTER IN BULGARIA.

CONTEXT: Cardiomyopathy is the most frequent cardiovascular complication in acromegaly. OBJECTIVE: We aimed to compare some echocardiographic markers in acromegaly patients with controls and find a correlation with disease duration, disease activity, levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1). DESIGN: We conducted a cross-sectional case-control study for the period of 2008-2012. SUBJECTS AND METHODS: Acromegaly patients altogether 146 (56 men and 90 women), were divided into four groups according to disease activity and the presence of arterial hypertension (AH). The control group included 83 subjects, matching the patient groups by age, gender and presence of AH. GH was measured by an immunofluorometric method, while IGF-1 by IRMA method. All patients and controls were subjected to one- and two-dimensional transthoracic echocardiography, color and pulse Doppler. RESULTS: We found a thickening of the left ventricular walls and an increase in the left ventricular mass. However, these changes were not statistically significant in all groups and no correlation with disease duration could be demonstrated. As markers of diastolic dysfunction, increased deceleration time and isovolumetric relaxation were registered, which were dependent mainly on age in a binary logistic regression analysis, but not GH or IGF-1. Using absolute values, ejection and shortening fractions were increased in some groups. Using cut-off values, a higher percentage of systolic dysfunction was demonstrated in patients compared to their corresponding controls. Engagement of the right heart ventricle was also found - increased deceleration time and decreased e/a tric ratio. CONCLUSIONS: In conclusion, functional impairments of both ventricles were present, with a predominance of left ventricular diastolic dysfunction.

Adipocytokines during pregnancy and postpartum in women with gestational diabetes and healthy controls.

BACKGROUND: This study aims to explore the changes in maternal serum adipocytokines during pregnancy and post partum in normal and complicated with gestational diabetes (GDM) pregnancies and to investigate the relationship between serum adipocytokines and some of major metabolic parameters. MATERIALS AND METHODS: 236 pregnant women (127 with GDM and 109 control group) and 50 postpartum women (30 with GDM during pregnancy and 20 controls). Using ELISA and EIA kits, serum levels of adipocytokines were tested during pregnancy and post partum. Maternal adipocytokines levels were correlated with some metabolic parameters. RESULTS: Women with GDM had lower values of adiponectin and higher values of leptin during pregnancy (p<0.001; 0.0001) and post partum (p<0.002; 0.0001). Serum apelin was significantly lower in GDM group (p<0.009). However, we did not find significance for resistin (p<0.317) and apelin (p<0.218). Positive correlation for leptin and negative for adiponectin was found for pre-pregnancy and pregnancy body mass index, glycated hemoglobin and homeostasis model assessment of insulin resistance index. Using cut point of 8.2 µg/ml for adiponectin and 28.7 ng/ml for leptin could exclude GDM with a sensitivity of 83.6%/81.2% and specificity of 56.6%/64.2% (area under the curve 0.702 and 0.827). CONCLUSION: There are constant differences in adiponectin and leptin levels between GDM and control group during pregnancy and post partum. Apelin was decreased in our GDM group and no differences were found for resistin and visfatin. Further studies are required to verify the mechanism of this alteration and whether the adipocytokines can be predictors for GDM at an early stage of pregnancy.

Resistant prolactinomas.

Prolactinomas are the most common hormonally active pituitary tumors and are usually successfully treated with dopamine agonists. A small proportion, however, appears not to respond to such treatment and such cases are termed resistant prolactinomas. Resistance is generally defined as failure to achieve normoprolactinemia and inability to induce tumor shrinkage. Reduced dopamine receptor density on lactotroph cells is currently considered the major underlying mechanism of resistance. Treatment options in resistant cases usually include substitution with another dopamine agonist, increasing the dose of the drug, as well as surgery, radiotherapy, and experimental medical therapies.

[Screening for gestational diabetes in Bulgaria--preliminary results].

Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance with onset or first recognition during pregnancy. There is no data regarding the prevalence of GDM in Bulgaria. The aim of this study is to present the preliminary results from a pilot study for GDM in Bulgaria, including the prevalence and the epidemiological differences between women with or without this disorder. A 2 h oral glucose tolerance test (OGTT) with 75g glucose was performed on 330 pregnant women between 24 and 28 weeks of gestation, using ADA criteria to define pregnancies complicated by GDM. Blood glucose levels, insulin levels, HbA1c, hsCRP and lipid parameters were evaluated. GDM was found in 11.3% of the patients. Women with GDM were older than the ones without the disorder (p < 0.006), had higher fasting glucose levels (p < 0.0001), higher fasting insulin levels (p < 0.0001), higher HOMA index (p < 0.0001) and higher HbA1c (p < 0.001). There was a significant difference in body mass index (BMI) before pregnancy (p < 0.003) and at the time of screening (p < 0.001) between GDM and control groups (p < 0.001). GDM women more frequently had thyroid disease, developed early preeclampsia, had family history of type 2 diabetes mellitus and history of PCOS. In conclusion the prevalence of GDM in high risk Bulgarian population is relatively high--11.3%. This confirms the necessity of establishing of a national screening program. If financial recourses are limited selective screening in high risk patients should be considered.

Increased plasma endothelin level as an endothelial marker of cardiovascular risk in patients with active acromegaly: a comparison with plasma homocysteine.

The aim of the present study was to evaluate the plasma endothelin-1 (ET-1) and total homocysteine (tHcy) levels as biochemical markers of endothelial dysfunction and atherosclerosis in patients with active and cured acromegaly in order to assess the relationship between the secretory status of growth hormone (GH)/insulin-like growth factor I (IGF-I) and ET-1/tHcy levels. The patients were divided in two subgroups: 1) patients with active disease (n = 30); and 2) patients with nonactive cured acromegaly (n = 21). Plasma ET-1 levels were directly determined by a highly sensitive enzyme immunoassay and plasma tHcy concentrations were measured by a fluorescence polarization immunoassay. In active acromegaly subjects, plasma ET-1 levels were 1.24 +/- 0.2 pmol/L, significantly higher than in both nonactive acromegalics (0.39 +/- 0.1 pmol/L) and age-matched healthy controls (0.49 +/- 0.2 pmol/L) (P < 0.001). Plasma tHcy concentrations, however, did not differ significantly in all studied groups: nonactive acromegalics: 9.54 +/- 4.42 micromol/L; active acromegalics: 9.0 +/- 3.14 micromol/L; and control subjects: 9.96 +/- 2.95 micromol/L (P > 0.05). In conclusion, our study demonstrated that elevated ET-1 levels probably contributed to premature atherosclerosis and cardiovascular disease and represent a new risk factor for endothelial dysfunction and early vascular complications in acromegaly. We propose that GH and IGF-I secretory status are important determinants of plasma ET-1 but not tHcy levels.

Homocysteine, renin and aldosterone in patients with Cushing's syndrome.

In the present study, we assessed the levels of fasting homocysteine in patients with active Cushing's syndrome using two different assay methods. To determine a possible link between homocysteine and renin-angiotensin-aldosterone system (RAAS), nine patients with Cushing's syndrome and nine patients with metabolic syndrome were given a 1-month treatment with angiotensin II (AII) receptor blocker valsartan. Plasma homocysteine, active renin and aldosterone did not differ significantly among patients with Cushing's syndrome, patients with metabolic syndrome and controls. As expected, active renin increased significantly during valsartan treatment in patients with Cushing's syndrome as well as in patients with metabolic syndrome. Plasma homocysteine did not change after valsartan treatment, suggesting a lack of direct relationship between homocysteine and RAAS. Our data suggest that homocysteine might not serve as a reliable marker of endogenous hypercortisolism or of cardiovascular risk associated with Cushing's syndrome and metabolic syndrome.

Individual risk factors of the metabolic syndrome in adult patients with growth hormone deficiency--a cross-sectional case-control study.

OBJECTIVE: Growth hormone deficiency in adults (GHDA) is considered to be associated with increased cardiovascular risk, most commonly reflected by the prevalence of the metabolic syndrome (MS). However, there are still a limited number of studies comparing directly the MS prevalence in GHD patients to that in general population. The aim of this study was to investigate the individual risk factors of the MS in a cohort of GHD patients and to compare its prevalence with an age- and sex-matched control group. DESIGN: A cross-sectional case-control study. METHODS: In total, 54 adult patients with GHD (childhood onset GHD (COGHD): n=19, adult onset GHD (AOGHD): n=35) and 2 153 control subjects were studied. GHD was diagnosed according to the Endocrine Society Clinical Practice Guideline recommendations from 2011 and MS was scored by the NCEP-ATP III definition. RESULTS: The main metabolic abnormalities in GHD group were increased waist circumference (50.0%), low HDL-cholesterol (42.6%) and hypertriglyceridemia (40.7%) and their prevalence was significantly higher (p=0.013, p=0.019 and p=0.010, respectively) than in control group, where increased blood pressure prevailed (64.2%, p<0.0001). However, the difference in the MS prevalence between the 2 groups (29.6% vs. 24.9% in controls) failed to reach statistical significance (p=0.429). Patients with MS from both groups did not differ significantly in their metabolic profile (except for increased blood pressure), mean age and gender distribution. CONCLUSIONS: Although GHDA was associated with the development of visceral obesity and dyslipidemia, these adverse cardiovascular risk factors did not determine a higher prevalence of the MS in Bulgarian GHD patients compared to control subjects. Furthermore, the individual risk factors of the MS did not significantly differ between patients with MS from both groups.

Treatment outcome results from the Bulgarian Acromegaly Database: adjuvant dopamine agonist therapy is efficient in less than one fifth of non-irradiated patients.

OBJECTIVE: We described biochemical outcome in regards to different treatment modalities in patients with acromegaly in Bulgaria. PATIENTS AND METHODS: It was a retrospective analysis using data from the Bulgarian Acromegaly Database. Patients with eligible data on at least one treatment modality were included in the study. Disease control was assessed by both GH and IGF-1 values or by GH/IGF-1 alone in cases with one marker. Last follow-up was median 7.0 (range 0.5-51) years after diagnosis. RESULTS: We identified 534 patients with interpretable data, 65.4% of whom were females. Overall surgical cure rate was 28.8%. Adjuvant bromocriptine and cabergoline treatment was analyzed in 133 and 70 patients with disease control achieved in 18.8% and 31.4% respectively. Patients without prior radiotherapy had 16.3% and 18.2% control rates respectively. Predictors of response to dopamine agonist (DA) therapy were disease activity, radiotherapy and medication dose. Adjuvant somatostatin analog (SSA) treatment led to biochemical control in 38.6% of 70 patients. Combination of SSA and cabergoline led to remission in 25% of 20 patients. Growth hormone receptor antagonist (GHRA) alone or in combination resulted in remission in 61.5% of 13 patients. Approximately one third of the patients were cured median 10 years after irradiation. Overall disease control was observed in 51.4% of our patients increasing to 70.3% in the last 5 years of the study period. CONCLUSION: DAs are efficient in less than 20% of non-irradiated patients. They are a good cost-effective alternative for carefully selected patients.

Linker histone binding to superhelical DNA: electrophoretic and filter binding studies.

It has been known for years that linker histones bind preferentially to supercoiled DNA. This preference has been demonstrated by a number of different techniques including deoxyribonucleoprotein electrophoresis, sedimentation, and filter binding under non-competitive conditions. In an attempt to further study this issue, we used one- and two-dimensional electrophoretic gels and filter binding under competitive conditions, with all DNA forms of interest being simultaneously present in the incubation mixture. Comparison between results obtained by the two methods showed that whereas the preference for superhelical molecules was clearly seen in the electrophoretic gels, the filter binding assay failed to reveal this preference. These results reveal limitations to the filter binding technique, which must be borne in mind in studies involving superhelical DNA molecules.

Isolation and characterization of [3H]fucose-labeled glycoproteins from the serum of normal rats and rats bearing Zajdela hepatoma.

Specific [3H]fucose-labeled glycoproteins were found in the serum of rats bearing Zajdela hepatoma, which possess different isoelectric points in comparison with serum glycoproteins from normal rats. The electrophoretic profile of the serum glycoproteins is significantly altered. There is approximately a 2.5 times increase of [3H]fucose incorporation into serum glycoproteins from rats with an ascitic form of hepatoma, compared with normal rats and to animals bearing a solid form of the tumor (which have a considerably greater survival). Serum fucoproteins identical for the two forms of hepatoma were isolated, as well as glycoproteins strongly specific for each of the forms.

Lack of a specific effect of corticotropin-releasing hormone (CRH) on plasma levels of 13,14-dihydro-15-keto-prostaglandin E2 in normal subjects.

The responses of plasma adrenocorticotrophic hormone (corticotrophin, ACTH), cortisol and 13,14-dihydro-15-keto-prostaglandin E2 (PGE2-M), a stable metabolite of prostaglandin E2 (PGE2) to i.v. injection of corticotrophin-releasing hormone (CRH) were studied in eight healthy subjects before and after a dexamethasone suppression test. We demonstrated a slight increase in PGE2-M after CRH injection in a dose that markedly augmented ACTH and cortisol levels. CRH did not produce any significant changes in ACTH, cortisol or PGE2-M after dexamethasone treatment. The results did not confirm a specific effect of CRH on PGE2 production.

Effects of a single dose and short-term captopril treatment on some pressor and depressor humoral factors in healthy subjects.

14 healthy subjects (8 males and 6 females), aged 25-40 years, were studied before and after oral administration of a single dose of 50 mg captopril as well as after 3 d treatment with 100 mg captopril daily per os. We found that in addition to the well-known effects on the renin-angiotensin-aldosterone system, captopril, after 3 d treatment, significantly increases plasma and urinary kallikrein activity, plasma vasopressin and urinary prostaglandin (PG) E2. Atrial natriuretic peptide did not change significantly after either the single dose or the short-term treatment. We conclude that the blood pressure lowering effect of captopril could be mediated by increasing activity of the kallikrein-kinin system and of PGE2 without any participation of atrial natriuretic peptide.

Effects of corticotropin-releasing hormone on ACTH, cortisol and 13, 14-dihydro-15-keto prostaglandin E2 in patients with diabetes insipidus before and after captopril treatment.

A corticotropin-releasing hormone (CRH) test was performed on 7 patients with central diabetes insipidus (DI) and on 7 healthy subjects. The test was repeated on the patients with DI after 3 days of oral treatment with captopril at a dose of 100 mg daily. No significant difference in the responses of plasma ACTH and cortisol to CRH between the patients and the controls was found. The short-term captopril treatment resulted in a significant decrease of both basal and CRH-stimulated ACTH and cortisol levels in the patients with DI. CRH did not induce any changes in the stable metabolite of prostaglandin E2 13, 14-dihydro-15-keto-prostaglandin E2 (PGE2-M) in the patients with DI before or after the captopril treatment. The results obtained suggest that vasopressin is not an obligatory factor for a normal ACTH response to CRH. Angiotensin II (A II) is involved in the regulation of ACTH. This study confirmed our previous data showing the lack of any specific effect of CRH on PGE2 production.

Fluorescent and electron-microscopy immunoassays employing polyclonal and monoclonal antibodies for detection of goose parvovirus infection.

Polyclonal antibodies (PAbs) raised in geese and eight mice hybridomas secreting monoclonal antibodies (MAbs) against the goose parvovirus (GPV) were prepared. They were used for development of immunofluorescence (IF) and immunoelectron-microscopic (IEM) techniques to demonstrate the GPV infection in infected organs and biological fluids. The GPV antigens were established by immunofluorescence within the nuclei and the cytoplasm of many infected cells of the chorioallantoic membrane of goose and Peckin duck embryos, liver and heart of mortally diseased goslings. By means of IEM it was possible to detect the GPV in native organ homogenate supernatants and allantoic fluids. All techniques used in the study could be successfully applied for rapid diagnosis of the GPV infection. The test systems on the basis of MAbs should, however, be preferred. By means of immunoblotting (IB) using PAbs and MAbs four viral proteins (VP) with MW 88, 77, 65 and 60 kDa were demonstrated. Contrary to the others the VP with MW 65 kDa was the most antigenically reactive though invisible in the SDS-PAGE and Coomassie-blue dye-stained preparations.

Ectopic ACTH-syndrome due to ovarian carcinoma.

The case of a 60-year-old female with severe and rapidly progressing Cushing's syndrome with fatal consequences is described. Both the clinical and the biochemical findings were consistent with ectopic ACTH production. A computed tomographic (CT) scan revealed intact pituitary and enlarged adrenal glands. Liver metastases were seen but the primary neoplasm was not found. Treatment with aminoglutethimide and other therapeutic measures were unsuccessful. A carcinoma of the right ovary was discovered on autopsy. The tumour cells showed immunoreactivity for neuron-specific enolase (NSE), ACTH and beta-endorphin with differing degree of intensity.

Monoclonal antibodies to a tumour-associated antigen isolated from circulating immune complexes of bovine leukemia virus-infected cattle.

From circulating immune complexes (ICs) of BLV-infected cattle, an antigen preparation was produced that contained some virus-specific proteins and a tumour-associated antigen. Eleven hybridoma clones were produced that secreted monoclonal antibodies (MoAbs) to this tumour-associated antigen, and two of them, MoAbs 1B4 and 1E9, were used in further studies. Most antibodies were of IgG1 subclass and showed no cytotoxic activity towards lymphocytes of BLV-positive cattle or to certain tumour cells. The MoAbs 1B4 and 1E9 recognized an antigen of about 75 kD on the cell surface of bovine lymphosarcoma cells and circulating lymphocytes from BLV-infected cattle with persistent lymphocytosis. The results presented indicate that the circulating immune complexes from BLV-positive cattle contain a tumour-associated antigen that is expressed on tumour cells and on lymphocytes from cattle with persistent lymphocytosis.