The role of morning basal serum cortisol in assessment of hypothalamic pituitary-adrenal axis.

PURPOSE: The use of morning basal serum cortisol levels as an alternative to dynamic testing for assessment of hypothalamic-pituitary-adrenal (HPA) axis has previously been reported. The purpose of this study was to determine the lower and upper cutoff values that would obviate subsequent HPA axis testing. METHODS: A single-centre, retrospective study from a tertiary care endocrinology clinic was conducted, analyzing data from 106 adult individuals referred for HPA axis testing who had undergone a 0800-0900 morning basal serum cortisol test followed by a standard dose (250 µg) adrenocorticotropin (ACTH) stimulation test. The ability of morning basal serum cortisol values to predict post-ACTH 30 or 60 minute peak cortisol value of >500 or >550 nmol/L was investigated. RESULTS: A morning basal cutoff of <128 nmol/L is sufficient for predicting a post-ACTH value<550 nmol/L, and morning basal cutoff levels of >243 nmol/L and >266 nmol/L predict peak post-ACTH values of >500 and >550 nmol/L respectively, obviating the need for dynamic testing. Regression analysis further demonstrated the log-linear relationship between morning basal and peak levels, while also finding a significant decrease in peak post-ACTH levels for patients diagnosed with secondary hypothyroidism (76 nmol/L lower, p=0.003) or secondary hypogonadism (61 nmol/L lower, p=0.02). These data suggest that the risk of cortisol deficiency is significantly higher in individuals with additional pituitary insufficiencies. The odds ratios for cortisol deficiency in patients with history of isolated secondary hypothyroidism was 3.41 (p=0.015), with isolated secondary hypogonadism was 4.77 (p=0.002) and with both was 7.45 (p=0.0002). CONCLUSION: Morning basal serum cortisol levels show promise as an effective screening test for HPA insufficiency for most patients. Clinicians should consider the high probability of HPA insufficiency in patients with one or more pituitary insufficiencies.

KISS1 expression in human female adipose tissue.

OBJECTIVE: The current focus of kisspeptin research is an exploration of its key role in the hypothalamic control of human and animal fertility. Notwithstanding the importance of these studies, strong evidence exists that the gene encoding human kisspeptin, KISS1, is present in several peripheral sites, including the placenta. We also provided evidence that kiss1 is also expressed and regulated in rodent adipose tissue. This study describes a pilot investigation into the possibility that human female adipose tissue might also express the KISS1 gene. METHODS: Samples of fat were taken from women undergoing open abdominal surgery, for example, during caesarian section. Two small samples of fat were obtained, one from subcutaneous tissue (n = 35) and one from the omentum (n = 32). RNA was isolated from all fat samples and KISS1 mRNA was detected by realtime RT-PCR. RESULTS: KISS1 gene expression was detected at varying levels in all samples of fat tissue but levels were significantly higher in subcutaneous fat. There was no significant correlation between KISS1 gene expression and body mass index (BMI) in subcutaneous fat (P = 0.43), but there was a significant positive correlation (P = 0.01) between KISS1 mRNA levels and BMI in omental adipose tissue. CONCLUSION: We have shown for the first time that human female adipose tissue may be a source of kisspeptins. Further studies are required to establish whether kisspeptins of adipose tissue origin might be correlated with some aspects of infertility.

Management of prolactinomas during pregnancy -- a survey of four Canadian provinces.

PURPOSE: The guidelines for management of prolactinomas during pregnancy are mostly based on retrospective evidence or expert opinion. We conducted a survey to assess the current trends in management of prolactinomas during pregnancy. METHODS: A case-based electronic questionnaire was sent in January 2011 to all practicing endocrinologists, in four Canadian provinces: Nova Scotia, New Brunswick, Prince Edward Island and British Columbia with three cases of varying severity; ranging from a microprolactinomas to a large macroprolactinomas compressing the optic chiasm. RESULT: There was a considerable diversity among endocrinologists with regards to monitoring and managing prolactinomas during pregnancy. In case of microprolactinomas, 94% of specialists would discontinue dopamine agonist (DA) therapy upon confirmation of pregnancy, 79% would discontinue serum prolactin measurement during pregnancy, and 94% would not perform routine pituitary imaging in the absence of new symptoms whereas 32% would perform regular formal visual field (VF) testing throughout pregnancy. In the case of macroprolactinomas, 65% chose to discontinue DA therapy upon confirmation of pregnancy, 30% would either perform regular MRI during pregnancy or, if serum prolactin was thought to be elevated out of proportion, with clinical judgment and 40% would not perform regular formal VF monitoring during pregnancy. In management of large macroprolactinomas, 82% elected to continue DA therapy whereas 18% chose surgical excision as the treatment of choice. Forty nine percent would perform regular MRI during pregnancy and 94% would perform regular formal VF monitoring during pregnancy. CONCLUSION: Among endocrinologists there is considerable diversity in management of prolactinomas during pregnancy, indicating a need for better consensus and clearer guidelines.

Prevalence of atrial fibrillation in patients taking TSH suppression therapy for management of thyroid cancer.

BACKGROUND: Suppression of thyroid stimulating hormone (TSH) below the normal range with administration of L-thyroxine has been shown to improve survival in patients treated for thyroid cancer (TC). Although most TC patients require long-term TSH suppression therapy, the effect of this treatment on cardiac rhythm remains unknown. A cross-sectional study was conducted to determine the prevalence of atrial fibrillation (AF) in TC patients on TSH suppressive therapy. METHODS: All TC patients seen between June 2009 and March 2010 through a multidisciplinary thyroid oncology clinic, Halifax, Nova Scotia, Canada, for whom TSH suppressive therapy had previously been recommended, were recruited into the study. Each patient underwent an electrocardiogram and filled out a questionnaire relevant to causes, signs/symptoms of AF and/or its complications. The prevalence of AF in this population then was compared against the published prevalence of AF in general populations. RESULTS: A total of 351 patients were seen in the thyroid clinic of which 136 patients met the inclusion criteria for the study. The mean age was 52 years, 85% were female, and mean follow-up duration prior to recruitment was 11 years. The mean TSH was 0.17 mIU/L (Normal: 0.35 - 5.5 mIU/L). There were 14 patients found to have AF (two patients had long-standing persistent AF and 12 patients had paroxysmal AF). The mean ages of patients with and without AF were 61.6 years and 51.4 years, respectively (P = 0.01). Prevalence of AF in the study group was 10.3%; the rate of AF in the TC patients aged 60 years and over (17.5%) was higher than the rate of AF in published data in people 60 years and over (P < 0.001). AF was diagnosed after the initiation of the TSH suppression therapy in all except one patient. CONCLUSION: TSH suppression in thyroid cancer is associated with a high prevalence of AF, particularly in older individuals.

Valproic acid and CEBPalpha-mediated regulation of adipokine gene expression in hypothalamic neurons and 3T3-L1 adipocytes.

BACKGROUND/AIMS: Valproic acid (VPA) is the drug of choice for treating epilepsy, but has the unwanted effects of inducing weight gain and increasing the risk of developing insulin resistance. The mechanism through which these side effects occur is unknown. VPA inhibits histone deacetylase (HDAC), but also decreases the transcriptional activity of CCAAT enhancer binding protein alpha (CEBPalpha). Given the possible association between VPA, CEBPalpha and adipokine gene regulation, we hypothesized that they would alter the expression of resistin (rstn), fasting-induced adipose factor (fiaf) and suppressor of cytokine signaling-3 (socs-3), genes implicated in the development of leptin and insulin resistance. METHODS: We investigated the effects of VPA (1 mM; 24 or 48 h) on gene expression using real-time RT-PCR in 3 distinct models: N-1 hypothalamic neurons, 3T3-L1 adipocytes and male CD-1 mice. Subsequently, cells were treated with 5 nM of the more specific HDAC inhibitor trichostatin A (TSA). CEBPalpha expression was also modified in N-1 neurons using either RNA interference (RNAi) or an overexpression vector to evaluate its effects on target gene expression. RESULTS: In N-1 neurons, VPA induced significant increases in CEBPalpha and socs-3, but inhibited rstn and fiaf gene expression. In contrast, TSA induced rstn and socs-3, but inhibited fiaf. VPA also induced the expression of CEBPalphain 3T3-L1 adipocytes, but had no effect on other target genes, and TSA suppressed fiaf and socs-3.Subsequently, CEBPalpha was overexpressed (24 h) or silenced using RNAi (24 and 48 h) in N-1 neurons. The silencing of CEBPalpha led to significant decreases in rstn mRNA, but increased fiaf and socs-3 expression, whereas its overexpression had the opposite effect. When male CD-1 mice were treated with either a single (100 mg/kg; 24 h), or multiple (200 mg/kg; 72 h) daily injections of VPA, no changes in body weight or gene expression were detected in either hypothalamic or adipose tissues. CONCLUSIONS: In summary, these experiments reveal a potentially important role for CEBPalpha in the regulation of hypothalamic gene expression in N-1 neurons and suggest that it might modulate central energy metabolism. Although VPA also modified hypothalamic gene expression in vitro, it remains to be determined whether it has similar effects in vivo.

Traumatic brain injury induces adipokine gene expression in rat brain.

UNLABELLED: Traumatic brain injury (TBI) induces cachexia and neuroinflammation which profoundly impact patient recovery. Adipokine genes such as leptin (ob), resistin (rstn) and fasting-induced adipose factor (fiaf) are implicated in energy metabolism and body weight control and are also associated with chronic low grade inflammation. Since central rstn and fiaf expression was increased following hypoxic/ischemic brain injury, we hypothesized that these genes would also be induced in the rat brain following TBI. Realtime RT-PCR detected a 2-2.5-fold increase in ob mRNA in the ipsilateral cortex and thalamus 12h following lateral fluid percussion (FP)-induced brain injury. Fiaf mRNA was elevated 5-7.5-fold in cortex, hippocampus and thalamus, and modest increases were also detectable in the contralateral brain. Remarkably, rstn mRNA was elevated in ipsilateral (150-fold) and in contralateral (50-fold) hippocampus. To test whether these changes were part of an inflammatory response to TBI we also examined the effects of an intracerebral injection of lipopolysaccharide (LPS). We determined that central injection of LPS produced some, but not all, of the changes seen after TBI. For example, in contrast to the stimulatory influence of TBI, LPS had no effect on ob expression in any brain region, though fiaf and rstn mRNA levels were significantly elevated in both ipsi- and contralateral cortex. IN CONCLUSION: (a) brain-derived adipokines could be involved in the acute pathology of traumatic brain injury partly through modulation of central inflammatory responses, but also via leptin-mediated neuroprotective effects and (b) TBI-induced brain adipokines may induce the metabolic changes observed following neurotrauma.

Adipokine gene expression in brain and pituitary gland.

The brain has been recognized as a prominent site of peptide biosynthesis for more than 30 years, and many neuropeptides are now known to be common to gut and brain. With these precedents in mind it is remarkable that adipose-derived peptides like leptin have attracted minimal attention as brain-derived putative neuromodulators of energy balance. This review outlines the evidence that several adipose-specific genes are also expressed in the central nervous system and pituitary gland. We, and others, confirmed that the genes for leptin, resistin, adiponectin, FIAF (fasting-induced adipose factor) and adiponutrin are expressed and regulated in these tissues. For example, leptin mRNA was readily detectable in human, rat, sheep and pig brain, but not in the mouse. Leptin expression in rat brain and pituitary was regulated through development, by food restriction, and following traumatic brain injury. In contrast, hypothalamic resistin mRNA was unaffected by age or by fasting, but was significantly depleted by food restriction in mouse pituitary gland. Similar results were seen in the ob/ob mouse, and we noted a marked reduction in resistin-positive hypothalamic nerve fibres. Resistin and fiaf mRNA were also upregulated in hypoxic/ischaemic mouse brain. Our studies on the regulation of neuronal adipokines were greatly aided by the availability of clonal hypothalamic neuronal cell lines. One of these, N-1, expresses both rstn and fiaf together with several other neuropeptides and receptors involved in energy homeostasis. Selective silencing of rstn revealed an autocrine/paracrine regulatory system, mediated through socs-3 expression that may influence the feedback effects of insulin and leptin in vivo. A similar convergence of signals in the pituitary gland could also influence anterior pituitary hormone secretion. In conclusion, the evidence is suggestive that brain and pituitary-derived adipokines represent a local regulatory circuit that may fine tune the feedback effects of adipose hormones in the control of energy balance.

Increased expression of the adipokine genes resistin and fasting-induced adipose factor in hypoxic/ischaemic mouse brain.

Adipose tissue is the primary source of the adipokines resistin and fasting-induced adipose factor (FIAF). We reported that the brain is also a site of adipokine expression, although their function there is unknown. Peripheral resistin and fasting-induced adipose factor are reported to be inflammatory markers, and we hypothesized that they would be induced in the brain by hypoxia/ischaemia. We show that neonatal hypoxia/ischaemia rapidly increased fiaf mRNA in the injured cortex and hippocampus at 2 and 7 days after hypoxia/ischaemia. In contrast, resistin (retn) mRNA was increased in the cortex only at 21 days after hypoxia/ischaemia. As a lipopolysaccharide-induced inflammatory response did not increase brain fiaf and retn mRNA levels, we conclude that brain injury may be responsible for the novel hypoxia/ischaemia-induced changes in adipokine gene expression. In summary, our results indicate that brain injury, or an inflammatory stimulus, regulates the central expression of two genes normally considered to be adipose tissue-specific. These observations add to our previous evidence that the brain is an important site of adipokine gene expression.

Hypothalamic kiss1 mRNA and kisspeptin immunoreactivity are reduced in a rat model of polycystic ovary syndrome (PCOS).

An intact hypothalamic kiss1/kisspeptin/kiss1r complex is a prerequisite for reproductive competence, and kisspeptin treatment could be a practical therapeutic approach to some problems of infertility. One such disorder is polycystic ovarian syndrome (PCOS), a common cause of infertility affecting more than 100 million women. A rodent model of PCOS is the prepubertal female rat treated for a prolonged period with dihydrotestosterone (DHT), which induces many of the metabolic characteristics of the syndrome. We hypothesized that hypothalamic kiss1 mRNA levels, and kisspeptin immunoreactivity (ir), would be abnormal in these rats. Prepubertal female rats were exposed to DHT for 60 days. Rats were killed in two groups: at 26 and 60 days of DHT exposure. Kiss1 mRNA was quantified in hypothalamus, pituitary, ovary and visceral adipose tissue. Separate groups of rats provided brain tissue for immunohistochemical analysis of kisspeptin-ir. At 26 days of DHT exposure, hypothalamic kiss1 mRNA was severely depleted. In contrast DHT had no effect on pituitary kiss1 expression but it significantly increased levels of kiss1 mRNA in fat (+9-fold; p<0.01) and in ovary (+3-fold; p<0.05). At 60days, kiss1 expression had reverted to normal in hypothalamus and ovary but remained elevated in fat (+4-fold; p<0.05). Immunohistochemical analysis revealed that after 26 days of exposure to DHT, kisspeptin-ir was almost completely absent in the arcuate nucleus and a large depletion in kisspeptin +ve fibers was also seen in the paraventricular nucleus, supraoptic nucleus and in the anteroventral periventricular area. At 60 days, despite restored normal levels of kiss1 mRNA, hypothalamic kisspeptin-ir remained depleted in the treated rats. In summary Kiss1 gene expression is differentially affected in various tissues by chronic exposure to dihydrotestosterone in a rat model of polycystic ovary syndrome. In hypothalamus, specifically, kiss1 mRNA, and levels of kisspeptin immunoreactivity, are significantly reduced. Since these rats exhibit many of the characteristics of polycystic ovary syndrome, we suggest that atypical kiss1 expression may contribute to the multiple tissue abnormalities observed in women with this disorder. However, and of some importance, our data do not appear to be consistent with the elevated levels of LH seen in women with PCOS; i.e. reduced levels of hypothalamic kiss1 mRNA and kisspeptin immunoreactivity observed in DHT-treated rats are unlikely to produce elevated LH secretion.

Superinduction of leptin mRNA in mouse hypothalamic neurons.

In marked contrast to several other species, including rats and humans, leptin gene expression is undetectable in mouse brain. This unexpected finding may reflect unique energy regulation pathways in the mouse. We investigated possible mechanisms by which leptin (ob) gene expression is suppressed in mouse brain: (a) the possibility that ob mRNA levels might be detectable in vitro through the superinduction of gene expression following protein synthesis inhibition and (b) whether chromatin modification of the ob gene was responsible for this repression. Experiments were conducted on mouse hypothalamic neurons in vitro. Cells were treated with (a) protein synthesis inhibitors: cycloheximide (CHX; 25 µg/ml); puromycin (50 µg/ml); anisomycin (5 µM); (b) trichostatin A (histone deacetylase inhibitor; 500 nM); and (c) 5-aza-2'-deoxycytidine (DNA methylation inhibitor; 5 µM). Following the incubations, cells were harvested for the preparation of RNA and ob mRNA was detected using real-time reverse transcription PCR. Protein synthesis inhibitors induced a rapid increase in ob mRNA levels in mouse hypothalamic neurons in vitro. For example CHX stimulation of ob mRNA was detectable at 60 min after treatment and reached a maximum between 4 and 6 h. A dose-response analysis, with concentrations of CHX of 1, 2, 10, 25, and 50 µg/ml, indicated that CHX was already effective at 1.0 µg/ml, with a maximal effect by 25 µg/ml. In contrast, incubation with trichostatin A and 5-aza-2'-deoxycytidine had no effect and ob mRNA remained undetectable. These data show that leptin gene expression is superinduced in ob-negative mouse hypothalamic neurons following inhibition of protein synthesis. They confirm that the previously reported absence of leptin mRNA in mouse brain is probably because of an active repressive mechanism, although this may not involve chromatin modification.

Lipopolysaccharide (LPS) stimulates adipokine and socs3 gene expression in mouse brain and pituitary gland in vivo, and in N-1 hypothalamic neurons in vitro.

Adipokines that modulate metabolic and inflammatory responses, such as resistin (rstn) and fasting-induced adipose factor (fiaf), are also expressed in mouse brain and pituitary gland. Since lipopolysaccharide (LPS)-induced endotoxinemia provokes an anorectic response via a hypothalamic-dependent mechanism we hypothesized that LPS would also modify hypothalamic adipokine expression. Challenging male CD-1 mice with LPS (5 mg/kg; s.c.) significantly reduced bodyweight (24 h) and realtime RT-PCR revealed time- and tissue-dependent increases in rstn, fiaf and suppressor of cytokine signaling-3 (socs-3) mRNA in hypothalamic, pituitary, cortical and adipose tissues. Gene expression was rapidly increased (3-6 h) in the hypothalamus and pituitary, but returned to normal within 24 h. In contrast, with the exception of rstn in fat, the expression of target genes remained elevated in cortex and visceral fat at 24 h post-injection. In order to more specifically examine the hypothalamic response to LPS we investigated its effects directly on N-1 hypothalamic neurons in vitro. LPS (25 microg/mL; 3 h) had no effect on rstn mRNA, but significantly stimulated fiaf and socs-3 expression. Although various toll-like receptor 4 (TLR4) antagonists (parthenolide, PD098059, and SB202190) did not prevent the LPS-induced increases in fiaf and socs-3, they did partially attenuate its stimulatory effects. We conclude that LPS treatment increases the expression of central, and possibly neuronal, adipokine genes which may influence local tissue repair and function, but could also have downstream consequences on the hypothalamic control of appetite and energy metabolism following an inflammatory insult.

Resistin differentially modulates neuropeptide gene expression and AMP-activated protein kinase activity in N-1 hypothalamic neurons.

Intraventricular resistin is known to reduce food intake, modify hypothalamic gene expression (e.g. NPY, POMC) and influence the activity of novel metabolic enzymes (e.g. 5'AMP-activated protein kinase; AMPK) in the rodent brain. Previously we demonstrated that the hypothalamus, and the N-1 hypothalamic neuronal cell line, also expressed several adipokines, including resistin and adiponectin (ADPN). These data suggested that they might also impact brain function and metabolism. We used the N-1 hypothalamic neuronal cell line to examine NPY, AgRP, POMC, and ADPN expression following acute resistin treatment (45 min; 100 ng/mL and 1000 ng/mL). The total and phosphorylated levels of AMPKalpha and acetyl-CoA carboxylase (ACC) were subsequently assessed using Western blot analysis. Parallel investigations were also conducted following a) resistin overexpression, or b) after the RNAi-mediated attenuation of resistin mRNA in N-1 neurons. Resistin overexpression lowered POMC (-35%, p<0.01), ADPN (-23%, p<0.05) and NPY (-36%, p<0.05) mRNA as evaluated using realtime RT-PCR, although AgRP remained unchanged, and significant increases in pAMPKalpha and pACC were detected (+47% and +34% respectively, p<0.001). In contrast recombinant resistin only significantly increased the level of pAMPKalpha (+31%; p<0.05), but failed to significantly modify gene expression, in N-1 neurons. Conversely the RNAi-mediated silencing of resistin expression increased AgRP (+37%, p<0.05), POMC (+66%, p<0.0001), ADPN (+87%, p<0.0001), whereas NPY was reduced (-22%, p<0.01) along with pAMPKalpha and pACC (-43% and -35% respectively, p<0.001). In summary, these in vitro data suggest that endogenous resistin might be capable of fine-tuning the expression and enzymatic activity of various hypothalamic targets previously implicated in the delicate homeostatic control of food intake. As such, resistin may be part of an autocrine/paracrine loop, which may in turn contribute to some of the reported effects of resistin on energy metabolism.

Adipokine gene expression in a novel hypothalamic neuronal cell line: resistin-dependent regulation of fasting-induced adipose factor and SOCS-3.

Adipokines such as leptin, resistin, and fasting-induced adipose factor (FIAF) are secreted by adipocytes, but their expression is also detectable in the brain and pituitary. The role of central adipokines remains elusive, but we speculate that they may modulate those hypothalamic signaling pathways that control energy homeostasis. Here we describe experiments to test this in which we exploited a novel hypothalamic neuronal cell line (N-1) that expresses a variety of neuropeptides and receptors that are known to be implicated in appetite regulation. Using real-time RT-PCR, we confirmed that N-1 neurons express resistin (rstn) and fiaf, as well as suppressor of cytokine signaling-3 (socs-3), a feedback inhibitor of leptin signaling. Treating N-1 cells with recombinant resistin (200 ng/ml, 30 min) reduced both fiaf (25%, p < 0.005) and socs-3 (29%, p < 0.005) mRNA levels, and similar reductions in fiaf (40%, p < 0.001) and socs-3 (25%, p < 0.001) resulted following the overexpression of resistin. Conversely, when RNA interference (RNAi) was used to reduce endogenous rstn levels (-60%, p < 0.005), fiaf and socs-3 expression was increased (46 and 65% respectively, p < 0.005). A similar reduction in rstn mRNA was achieved using RNAi in differentiated 3T3-L1 adipocytes, and this manipulation also reduced fiaf and socs-3 expression (-53, -21 and -20% respectively, p < 0.005). In contrast, although RNAi successfully reduced fiaf mRNA by 50% (p < 0.001) in N-1 cells and 40% (p < 0.001) in 3T3-L1 cells, there was no effect on rstn or socs-3 mRNA. These data suggest that resistin exerts a novel autocrine/paracrine control over fiaf and socs-3 expression in both 3T3-L1 adipocytes and N-1 neurons. Such a mechanism could be part of the central feedback system that modulates the effects of adipokines, and other adiposity signals, implicated in hypothalamic energy homeostasis. However, it remains to be determined whether these in vitro results can be translated to the control of adipokine expression in brain and adipose tissue.