High prevalence of normal tests assessing hypercortisolism in subjects with mild and episodic Cushing's syndrome suggests that the paradigm for diagnosis and exclusion of Cushing's syndrome requires multiple testing.

Many Endocrinologists believe that a single determination of eucortisolism or a single demonstration of appropriate suppression to dexamethasone excluded Cushing's syndrome, except in what was previously thought to be the rare patient with episodic or periodic Cushing's syndrome. We hypothesize that episodic Cushing's syndrome is relatively common and a single test assessing hypercortisolism may not be sufficient to accurately rule out or diagnose Cushing's syndrome and retrospectively examined the number of normal and abnormal tests assessing hypercortisolism performed on multiple occasions in 66 patients found to have mild and/or episodic Cushing's syndrome compared to a similar group of 54 patients evaluated for, but determined not to have Cushing's syndrome. We found that 65 of the 66 patients with Cushing's syndrome had at least one normal test of cortisol status and most patients had several normal tests. The probability of having Cushing's syndrome when one test was negative was 92% for 23:00 h salivary cortisol, 88% for 24-h UFC, 86% for 24-h 17OHS, and 54% for nighttime plasma cortisol. These results demonstrated that episodic hypercortisolism is highly prevalent in subjects with mild Cushing's syndrome and no single test was effective in conclusively diagnosing or excluding the condition. Rather, the paradigm for the diagnosis should be a careful history and physical examination and in those patients in whom mild Cushing's syndrome/disease is strongly suspected, multiple tests assessing hypercortisolism should be performed on subsequent occasions, especially when the patient is experiencing signs and symptoms of short-term hypercortisolism.

Gene expression profiling following short-term and long-term morphine exposure in mice uncovers genes involved in food intake.

Addictive drugs including opioids activate signal transduction pathways that regulate gene expression in the brain. However, changes in CNS gene expression following morphine exposure are poorly understood. We determined changes in gene expression following short- and long-term morphine treatment in the hypothalamus and pituitary using genome-wide DNA microarray analysis and confirmed those alterations in gene expression by real-time reverse transcriptase polymerase chain reaction (RT-PCR) analysis. In the hypothalamus, short-term morphine administration up-regulated (at least twofold) 39 genes and down-regulated six genes. Long-term morphine treatment up-regulated 35 genes and down-regulated 51 genes. In the pituitary, short-term morphine administration up-regulated 110 genes and down-regulated 29 genes. Long-term morphine treatment up-regulated 85 genes and down-regulated 37 pituitary genes. Microarray analysis uncovered several genes involved in food intake (neuropeptide Y, agouti-related protein, and cocaine and amphetamine-regulated transcript) whose expression was strongly altered by morphine exposure in either the hypothalamus or pituitary. Subsequent RT-PCR analysis confirmed similar regulation in expression of these genes in the hypothalamus and pituitary. Finally, we found functional correlation between morphine-induced alterations in food intake and regulation of genes involved in this process. Changes in genes related to food intake may uncover new pathways related to some of the physiological effects of opioids.

Testosterone and bioavailable testosterone help to distinguish between mild Cushing's syndrome and polycystic ovarian syndrome.

Women with Cushing's syndrome (CS) and polycystic ovarian syndrome (PCOS) may present with similar symptoms. Subjects with mild CS lack clinical stigmata of classical CS and often have normal laboratory tests measuring hypercortisolism. Thus, distinguishing mild CS from PCOS may be difficult. We hypothesized that either total testosterone (TT) or bioavailable testosterone (BT) levels or the calculation of the free androgen index (FAI) would be low in patients with mild CS and elevated in patients with PCOS, and could help differentiate the two conditions. TT, BT, and FAI were measured in a group of 20 patients of reproductive age with mild CS and 20 PCOS patients matched for age and BMI. We used receiver operator characteristic (ROC) curves to assess the sensitivity and specificity of these measurements for the diagnosis of CS. TT (p<0.0001), BT (p=0.02), and FAI (p=0.003) were significantly elevated in PCOS patients compared to mild CS patients. Sex hormone-binding globulin was similar in both groups. The optimal cut-point for TT was 1.39 nmol/L, yielding a sensitivity of 95% and a specificity of 70%. The cut-point for BT was 0.24 nmol/L, resulting in a sensitivity of 75% and a specificity of 80%. The cut-point for FAI was 5.7, with a sensitivity of 88% and a specificity of 60%. We conclude that TT levels may be useful to discriminate between mild CS and PCOS. In patients with signs and symptoms consistent with CS and PCOS, a TT level of <1.39 nmol/L warrants a workup for CS.