Society for Endocrinology BES 2011 11 –14 April 2011, Birmingham, UK Endocrine Abstracts Endocrine Abstracts April 2011 Volume 25 ISSN 1470-3947 (print) ISSN 1479-6848 (online) ISSN 2046-0368 (CD-ROM) Volume 25 April 2011Volume 25

Society for Endocrinology BES 2011 11 –14 April 2011, Birmingham, UK

Online version available at 1470-3947(201104)25;1-Z www.endocrine-abstracts.org

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Volume 25 Endocrine Abstracts April 2011

Society for Endocrinology BES 2011 11–14 April 2011, Birmingham, UK Abstract Book EDITORS

The abstracts submitted were marked by the Abstract Marking panel selected by the Programme Committee

Programme Committee M Korbonits Programme Secretary K Chapman Programme Co-ordinator S Orme Programme Co-ordinator

Members A Allahabadia M Druce K Meeran W Arlt C Duncan A Munir P Clayton J Johnston A Toogood E Davies V Kieffer J Wass W Dhillo C McArdle

Abstract Marking Panel

J Ahlquist Southend W Dhillo London A Lam Toronto, Canada R Quinton Newcastle upon Tyne F Ahmed Glasgow K Docherty Abderdeen G Lavery Birmingham S Razvi Gateshead B Allolio Wuerzburg, Germany W Drake London G Leese Dundee A Rees Cardiff R Amin London M Druce London A Levy Bristol E Scott Leeds R Andrew Edinburgh R Eastell Sheffield M Levy Leicester P Selby Manchester S Atkin Hull MEggoBirmingham N Martin London D Shapiro Glasgow S Aylwin London W Farrell Stoke C McArdle Bristol L Shepherd Birmingham L Bailey Liverpool D Flint Glasgow C McCabe Birmingham P Squires Warwick A Bates Birmingham R Fowkes London S McKenzie Glasgow C Stewart Cheshire K Boelaert Birmingham J Franklyn Birmingham A McNeilly Edinburgh N Taylor London P Bouloux London S Franks London J Miell London M Thomas London N Bridges London W Fraser Liverepool D Morganstein London J Tomlinson Birmingham J Burrin London M Grossman London D Morris Ipswich B Vaidya Plymouth K Chapman Edinburgh M Gurnell Cambridge J Morris Oxford M Vanderpump London T Cheetham Newcastle upon Tyne J Ham Cardiff N Morton Edinburgh B Walker Edinburgh P Clark Birmingham L Heisler Cambridge J Munday Portsmouth E Ward Leeds P Clayton Manchester M Holmes Edinburgh K Murphy London J Wass Oxford J Compston Cambridge T Howlett Leicester R Murray Leeds M Westwood Manchester M Cooper Birmingham S Hunter Belfast J Newell-Price Sheffield A Wheatman Sheffield SCoxTorquay A James Newcastle S Orme Leeds G Williams London M Dattani London R Jenkins Yorkshire S Peacey Bradford E Davies Glasgow K Jonas London S Pearce Newcastle J Davis Manchester N Karavitaki Oxford P Pickett Shrewsbury Society for Endocrinology BES 2011, Birmingham, UK

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Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

CONTENTS

Society forEndocrinology BES 2011

PLENARYLECTURERS’ BIOGRAPHICAL NOTES

PLENARYLECTURES Society for Endocrinology Dale Medal Lecture ...... PL1 Society for Endocrinology Hoffenberg International Medal Lecture ...... PL2 Society for Endocrinology Transatlantic Medal Lecture ...... PL3 Society for Endocrinology European Medal Lecture 2010 ...... PL4 Society for Endocrinology European Medal Lecture 2011 ...... PL5 Society for Endocrinology Medal Lecture ...... PL6 The British Thyroid Association Pitt Rivers Lecture ...... PL7 Clinical EndocrinologyTrust Visiting Professor Lecture ...... PL8 Clinical EndocrinologyTrust Lecture ...... PL9

SYMPOSIA All youneed to know about the genetics of diabetes (types 1and 2and MODY) ...... S1.1–S1.4 Novelpathwaysand treatments in neuroendocrine tumours ...... S2.1–S2.4 Fatendocrinology: disordersofadipose tissue and lipids important to the endocrinologist ...... S3.1–S3.4 Endocrine regulation of ageing ...... S4.1–S4.4 The novelrole of primarycilia in endocrine disease and obesity ...... S5.1–S5.4 Novelapplication of thyroid hormone analogues: thyroid hormones, thinking outside the capsule ...... S6.1–S6.4 Eat, bond, reproduce –what the hypothalamus dictates ...... S7.1–S7.4 Hormones and bone metabolism ...... S8.1–S8.4 Doping: performance enhancing substances in sportand their detection ...... S9.1–S9.4

CLINICAL MANAGEMENT WORKSHOPS The management of difficult Graves’ disease ...... CM1.1–CM1.4 Endocrine problems in pregnancy ...... CM2.1–CM2.4 Pituitaryradiotherapy: what are the options? ...... CM3.1–CM3.4 Management of disordersofsex development (DSD) across the lifespan ...... CM4.1–CM4.4

APPLIED PHYSIOLOGY WORKSHOP Seeing is believing –cutting edge in vivo cell imaging ...... AP1.1–AP1.3

CLINICAL GUIDELINES ...... CG1.1

SPECIAL INTEREST GROUPS Bone and mineral special interest group ...... SIG1.1–SIG1.4 Obesity special interest group ...... SIG2.1–SIG2.4 Laboratoryaspects of clinical endocrinologyspecial interest group ...... SIG3.1–SIG3.4

MEET THE EXPERTSESSIONS ...... MTE1–MTE9

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

NURSE SESSION Turner/Klinefelter’s/Noonan syndrome: case presentations ...... N1.1–N1.4 Hyperthyroidism: case presentations ...... N2.1–N2.4

YOUNG ENDOCRINOLOGISTS SESSION Young endocrinologists’ prizelectures ...... YEP1.1–YEP1.2 Asuccessful research career ...... YE1.1–YE1.4

SENIOR ENDOCRINOLOGISTS SESSION ...... SE1.1–SE1.6

ORAL COMMUNICATIONS Young Endocrinologists prizesession ...... OC1.1–OC1.8 Steroids ...... OC2.1–OC2.8 Pituitaryand thyroid ...... OC3.1–OC3.8 Bone and diabetes ...... OC4.1–OC4.8 Reproduction and fetal programming ...... OC5.1–OC5.8

POSTER PRESENTATIONS Bone ...... P1–P26 Clinical biochemistry...... P27–P108 Cytokines, growth factors, neuroendocrinology and behaviour ...... P109–P119 Diabetes, metabolism and cardiovascular ...... P120–P167 Endocrine tumoursand neoplasia ...... P168–P203 Growth and development ...... P204–P208 Nursing practise ...... P209–P221 Pituitary...... P222–P262 Reproduction ...... P263–P282 Steroids ...... P283–P311 Thyroid ...... P312–P354

INDEX OF AUTHORS

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Plenary Lecturers’ Biographical Notes

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology Dale Medal Lecture

ERSimpson, PrinceHenry’s Institute, Clayton,Victoria, Autralia Dr Evan Simpson is anative of Edinburgh, Scotland. He has had along interest in the basic biology of estrogen biosynthesis, especially its relationship to breast cancer. His group was the first to clone and characterize the aromatase gene and to show the unique use of tissue-specific promoters to regulate tissue-specific expression of the gene. This led in turn to the concept of breast-specific inhibitors of aromatase expression as anovel therapeutic modality for breast cancer in post-menopausal women. His group’sdevelopment of the aromatase knockout mouse, as amodel of estrogen deficiency, providedinsights into the role or estrogens in the physiology and pathophysiologyofboth male and females. More recently his group is working to understand the molecular mechanisms underlying the relationship betweenobesity, aging and breast cancer.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology Hoffenberg International Medal Lecture

Peter JFuller, Prince Henry’s Institute, Clayton,Victoria, Australia Professor Fuller is an NHMRC Senior PrincipalResearch Fellow at Prince Henry’s Institute of Medical Research in Melbourne where is the Associate Director and Head of the Steroid Receptor Biology Group.Heisalso Director of the Endocrinology Unit at the Monash Medical Centre/Southern Health and an AdjunctProfessor in Medicine and Biochemistry &Molecular Biology at Monash University. He trained in Melbourne in both clinical endocrinology and molecular endocrinologybefore postdoctoral training at the Massachusetts General Hospital in Boston. He was awarded aWellcome Trust Australian Senior Research Fellowship in 1987 and has received the Eric Susman Prize from the Royal Australasian College of Physicians. He has served on the Council and as President of the Endocrine Society of Australia; in 2008 he was made aLife Memberofthe Society. He has served as aReceiving Editor for Clinical Endocrinology and is currently an Editor of Endocrinology. He has published over 170 original articles, reviews and book chapters. His research interests lie primarily in understanding the molecular mechanisms of adrenal steroid hormone action. His laboratory also has collaborative programmes to study themolecular pathogenesis of granulosa cell tumours of the ovary.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology Transatlantic Medal Lecture

JJKopchick, Ohio University, Athens, Ohio, USA Dr John JKopchick is an internationally recognized leader in the growth hormone (GH) field. Since 1987, he has held the Milton and Lawrence HGoll Eminent Scholar Professorship in Molecular and Cellular Biology and directs the Growth/Obesity/Diabetes Section of the Edison Biotechnology Institute at Ohio University in Athens, Ohio. He also is Professor in the BiomedicalSciences Department in the College of Osteopathic Medicine at Ohio University. In 1989, Dr. Kopchick and his group were the first to discoverand characterize the molecular aspects of GH receptor antagonists, an accomplishment for which he and Ohio University were awarded several U.S. and Europeanpatents. He was instrumental in founding acompany, Sensus,which applied his laboratory discovery to development of adrug that has been evaluated in clinical trials for acromegaly. Dr Kopchick has been involved in the start up of two additional biotechnology companies. The latest, DiAthegen, focuses on the discovery of diagnostics, therapeutics,and therapeutic targets in the obesity and diabetes field. Born in Punxsutawney, Pennsylvania,DrKopchick spent most of his early years in Indiana, Pennsylvania. He received both his bachelor’s degree in biology and master’s degree in biology and chemistry from Indiana University of Pennsylvania.In1975, he enrolled in the Graduate School of Biomedical Sciences, University of Texas System Cancer Center in Houston, Texas and began research under the supervision of Dr Arlinghaus. While agraduate student at M.D. Anderson, he was awarded a RosalieBHite scholarshipthat supported his studies. His dissertation describedthe biosynthesis of Rauscher murine leukemia virus reverse transcriptase. He was awarded his Ph.D. in 1980. After completing his PhD, Dr Kopchick continuedresearch training as apostdoctoral fellow at the Roche Institute of Molecular Biology in Nutley, New Jersey where he received aNational Cancer Institute Postdoctoral Fellowship award to support his work.Hethen spent almost five years at Merck Sharp &Dohme Research Laboratories. At Merck, he progressed to the level of Director and developed asystem built around cloning and expression of GH genes, which he continues to study as director of the Edison Biotechnology Institute. Dr. Kopchick has published more than 290 scientific articles and 310 published abstracts in the area of growth, obesity and diabetes. His publication impact factor (h rating) is 44. Twelve patents have been granted based on his work with several more pending. He has also advisedseveral undergraduate, post graduate and doctoral students. He has served on the Editorial Boards of several journals including The JournalofBiological Chemistry, Endocrinology, Molecular Endocrinology,and currently serves on the editorial boardof GH &IGF-1 Research, and The Journal of Biological Chemistry, and The Polish JournalofEndocrinology.Heisalso President Elect of the Growth Hormone Research Society. Dr. Kopchick has received many awards including The Outstanding Alumnus award from Indiana University of Pennsylvania, Indiana, PA (2002);The Outstanding Alumnus Award from M.D. Anderson Hospital and Tumor Institute, Houston, TX (2002); The Outstanding Alumnus Award from the Graduate School of Biomedical Sciences, University of Texas, Houston (2006), The New York College of Osteopathic Medicine’s Riland Award (2007);anHonorary Dr of Sciences Degree from Indiana University of Pennsylvania, Indiana, PA (2008),and the Phillips Medal of Honor Award from the Ohio University of Osteopathic Medicine (2010).

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology European Medal Lecture 2010

Bruno Allolio, University of Wu¨ rzberg, Germany Bruno Allolio is Professor of Medicine at the University of Wu¨ rzburg and Head of the Departmentof Endocrinology at the University Hospital Wu¨ rzburg. He trained in Cologneinboth clinical and experimental endocrinology.For postdoctoral studies he worked at Bartholomew’s Hospital, London, and at the National Institutes of Health, Bethesda. After Habilitation in 1988 he moved to Wu¨ rzburg in 1992. In 1988 he received the Scho¨ ller-Junkmann Award of the German Society of Endocrinology. He has served as Editor for the European Journal of Endocrinology and the Journal of Clinical Endocrinology and Metabolism.Hewas the first media spokesman for the German Society of Endocrinology and he served in the first executive committee of the European Society of Endocrinology. He has published over 300 original articles, reviews and book chapters. His research interests focus on adrenal disorders, mineral metabolism, and recently also on hyponatraemia. He is afounding member of the European Network for the Study of Adrenal Tumours (ENSAT) and serves on theExpert Commission of the Deutsche Forschungsgemeinschaft.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology European Medal Lecture 2011

Xavier Bertagna, Cochin Hospital, Paris, France Xavier Bertagna is Professor of Endocrinology, Chief of the Department of Endocrinology of Cochin hospital, Faculte´ de Me´ decine Rene´ Descartes, Universite´ Paris, Paris, France. He trained at the Clinical Research Center(Dr.M.Chre´ tien), Montreal, Canada and at the Endocrine Division, Vanderbilt Medical School (Dr. D. Orth), Nashville, TN, USA. His research interest is in endocrine tumors, adrenal cancer, Cushing’ssyndrome,disorders of the pituitary-adrenal axis, polypeptide hormone precursors, and takes place in the Endocrinology Department of Institut Cochin (INSERM U-567), France. He was at the origin of two important Clinical and Scientific Networks devoted to the study of adrenal tumors, namely, the COMETE network in France and the ENS@T Network in Europe. Xavier Bertagna is involved in many National and Internationalprofessional bodies. He has been a memberofthe Executive Committee of the InternationalSociety of Endocrinology for two consecutive terms.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology Medal Lecture

GRWilliams, Imperial College London, London, UK GrahamRWilliams obtained aBSc in Anatomy and MBBS from St Thomas’sHospital, London and undertook PhD studies in Molecular Endocrinology at Birmingham University. He trained as aHoward Hughesand MRC Fellow at Harvard Medical School, USA and was an MRC Clinician Scientist Fellow in Birmingham. He was appointedSenior Lecturer at the Royal Postgraduate Medical School and received an MRC Career Establishment Award. He is currently Professor of Endocrinology at Imperial College London and Honorary Consultant Physician at HammersmithHospital. Professor Williams is Treasurer and aCouncil Memberofthe Society for Endocrinology, acurrent memberofthe European Thyroid Association Executive and former Member of the British Thyroid Association Committee. He is currently on the Editorial Boards of Endocrinology, Thyroid and Journal of Neuroendocrinology and sits on the EORTC Endocrine Task Force for Thyroid Cancer, the World Thyroid Foundation Advisory Committeeand the Wellcome Trust Physiological Sciences Funding Committee. His research is focused on the molecular mechanisms of thyroid hormone action in bone and cartilage. Amajor aim is to train and support young endocrinologists for the future, and fellows and post-docs in the Molecular Endocrinology Laboratory have received 24 prizes for their research.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

British Thyroid Association Pitt-Rivers Lecture

Samuel Refetoff, University of Chicago, IL, USA Samuel Refetoff is known for his discovery (1967) of resistance to thyroid hormone (Refetoff Syndrome) and elucidation of its genetic and molecular basis (1989/92). Devoted to the study of inherited thyroid disorders, his laboratory was first to identify mutations in: serumTHtransport proteins [TBG (1989) and albumin (1994)]; the TSH receptor producing resistance to TSH (1995); and two syndromic thyroid defects combining neuropsychological and thyroid abnormalities caused by mutations in the TTF1(2002) and the MCT8 (2004) genes. In 2005 his laboratory identifiedadefect of TH metabolism caused by mutations in the SBP2 gene, which is involved in the synthesis of selenoproteins. Agraduate of McGill University, Dr. Refetoff is professor of medicine, pediatrics and genetics at the University of Chicago. He is author of over 470 publications and recipient of numerousnationaland international prizes, two NIH MERIT awards (1989/2006) and two honorary doctorate degrees.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Clinical Endocrinology Trust Visiting Professor Lecture

James AFagin, Memorial Sloan-Kettering Cancer Center, New York, USA JamesA.Fagin is Chief of the Endocrine Service and aMember of the Human Oncologyand Pathogenesis Program at Memorial Sloan-Kettering Cancer Center in New York, and aProfessor of Medicine at Weill Medical College of Cornell University. He was formerly the James Heady Professor of Medicine and Director of the Division of Endocrinology and Metabolism at the University of Cincinnati. He has had along standing interest in the pathogenesis of thyroid neoplasms, and his laboratory focuses on thyroid cancer genetics, on the development of mouse models to understand the biology of these tumors, and on the identification of specific therapiesdirected at key oncoproteins that drive the disease. He was amember and then the chair of the NIH Endocrinology Study Section (1998–2002). In addition to serving on anumber of Editorial Boards, he is aformer Associate Editor of Endocrinology, former Editor (Americas) for ClinicalEndocrinology(Oxford),and recently retired as Editor-in-Chief of Endocrine-Related Cancer.Dr. Fagin is amember of the American Society of Clinical Investigation and the Association of American Physicians. His honors include the Merck Prize of the European Thyroid Association, and the Sidney H. Ingbar Distinguished Lectureship Award of the American Thyroid Association. He is also the President-elect of the American Thyroid Association.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Clinical Endocrinology Trust Lecture

John SBevan, Department of Endocrinology, Aberdeen RoyalInfirmary, Foresterhill, Aberdeen AB25 2ZN, UK John SBevan is senior Consultant Endocrinologist at Aberdeen Royal Infirmary and Honorary Professor of Endocrinology at Aberdeen University. He qualified MB ChB, with Honours, from Edinburgh University in 1978 and his clinical training in Medicine &Endocrinology took placein Edinburgh, Oxford and Cardiff, 1979–91. Whilst in Oxford he was awarded an MRCTraining Fellowship and wrote his MD thesis on dopamine agonist treatment of large pituitary tumours. As Head of Endocrinology at Aberdeen Royal Infirmary, Dr Bevan has responsibility for coordinating endocrine care across the North of Scotland, including the Orkney and Shetland Islands. He has been aCouncil Member of the Royal College of Physicians of Edinburgh since 2006 and Chair of the Scottish Paediatric Endocrinology Managed Clinical Network since 2009. Professor Bevan has been amember of the Clinical Committeeofthe Society for Endocrinology since it was first convened in 1997. During 2002–09 he was National Coordinator for Peer Review of UK Clinical Endocrinology. He has twice been amember of the UK AcromegalyDatabase Steering Group. He was Secretary/Treasurer to the Clinical Endocrinology Trust, 2006–10. He has been aSenior Editor of Clinical Endocrinology since 2008, having previously been Associate Editor, 1994–2004. Professor Bevan has alongstanding interest in clinical neuroendocrinology,particularly theuse of medical therapies for pituitary tumours; he has written and lectured extensively on prolactinoma, non-functioning pituitary tumour and acromegaly.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Plenary Lecturers

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Society for Endocrinology Dale Medal Lecture ligand, with the N-terminal domainand with putative co-regulatory molecules. Both agonist and antagonist binding has been characterised using chimera PL1 between the human (h)MR LBD and both the glucocorticoid receptor and the Fat, sex hormones and breast cancer zebra fish (z)MR together with molecular modelling. An interaction between the Evan Simpson &Kristy Brown N-terminusand C-terminus/LBD (N/C-interaction) observed in the MR is Department of Biochemistry and Physiology, Prince Henry’s Institute, aldosterone-dependent but is unexpectedly antagonisedbycortisol and DOC in Monash University, Clayton, Victoria 3168, Australia. the hMR but not the zMR. Nuclear receptor mediated transactivation is critically dependent on, and modulated by, co-regulatory molecules. Yeast-2-hybrid screens with the MR LBD have identified proteins which interact in the presence of either After the menopausal transition, the ovariescease to make oestrogens, yet the aldosterone or cortisol but not both. These have been confirmed as coactivators of incidence of breast cancer increases with aging and the majority of these tumours the full-length hMR in atransactivation assay. The successfulidentificationof are ER positive.So, where is the oestrogen driving this tumour development ligand-specific interactions of the MR may providethe basis for the development coming from? Several extra-gonadal sites synthesize oestrogens from circulating of novel MR ligands with tissue specificity. C19 steroids, such as bone, brain, and adipose. The largest of these depots is the adipose tissue, and increased BMI is associated with increased breast cancerrisk, so,given the global ‘pandemic’ of obesity, we are faced with the daunting prospect that tens of millions more women may be at risk of breast cancerintheir later years than was previously thought. Yet the mechanisms linking obesityto cancer risk are not completely understood. Factors increased in obesitysuch as Society for Endocrinology Transatlantic Medal Lecture leptin and insulin appear to increase breast cancer risk, probablyvia activation of the Akt/mTOR/HIF1a /SREBP pathways, whereas adiponectin has been PL3 shown to decrease the risk in anumber of studies. This appears to be due, in part, GH, GH receptor antagonists, GH receptor ‘knock-outs’: astory of fat to activation of the LKB1/AMPK pathway. The anti-diabetic drug metformin old mice has also been shown to decrease the risk of breast cancer, and it also acts to John Kopchick stimulate AMPK. Ohio University, Ahens, Ohio, USA. Given the capacity of adipose tissue to express aromatase, the enzyme responsible for oestrogen biosynthesis, we looked for alink betweenobesity and increased aromatase expression in breast adipose. In the presence of atumour, aromatase In this talk Iwill describe several genes that have been implicated in the action of expression locally in the breast is stimulated by inflammatorymediators produced GH as it relates to aging. Much of the data is derived from two dwarf and one giant by the tumour such as PGE and TNFa .Weobserved that AMPK is apotent strain of mice produced in our laboratory that possess very differentlife spans. One 2 of the dwarf lines contains adisruption of the GH receptor and binding protein inhibitor of aromatase expression stimulated by PGE2 in breast adipose stromal cells.The mechanism involves sequestration in the cytoplasm by phosphorylation gene (GHR/BP) (PNAS,94:13215–13220, 1997). Homozygous GHR/BP of aCREB coactivator, CRTC2. The LKB1/AMPK pathway is inhibited in breast ‘knockout’ mice (GHR/BPK / K )show severe postnatal growth retardation, absence of the GHR and GHBP mRNA and protein,low levelsofserum IGF1 and stromal cells by leptin and by PGE2 ,and is stimulated by adiponectin. Since leptin is increased, and adiponectin is decreased,inobesity, this provides anew IGFBP3 and elevated levels of GH. These parameters are characteristic of the GH mechanism whereby obesity increases breast cancer risk. Moreover, we observed insensitivity phenotype typical of humans with Laron syndrome. Surprisingly, the that metformin also inhibits aromatase expression in breast stromal cells, life span of the GHR/BPK / K mice is significantly longer than C / K or C / C associated with an increase in LKB1/AMPKactivity. Anumberoftrials are littermates. These micealso possess near normal levelsofserum glucose with very currently underway to establish if metformin could find utility as abreast cancer low levels of insulin and are extremely sensitive to insulin’s action. Furthermore, therapeutic agent,and we have commenced astudy to establish if metformin the mice are resistant to diabetes-induced glomerulosclerosis.Wealso have treatment in the neoadjuvant and adjuvantsettings results in an increase in the discovered aGHreceptorantagonist(A). Abrief history of this discovery along activity of the LKB1/AMPK pathway and adecrease in the expression of with clinical implicationswill be presented. Expression of the GHA transgene aromatase in the female breast. results in another dwarf strain of mice. These mice have low levels of IGF1 but do An advantage of metformin as an inhibitor of aromataseexpression is that such not possess an increased life expectancy. Additionally, we have produced giant inhibition is breast-specific in the post-menopausal woman. This is due to the GH transgenic mice that die prematurely of liver, heart and kidney pathology. A uniqueuse of tissue-specific promoters by the aromatasegene to regulate its comparison of the endocrine parameters of these three mouse lines will be shown. tissue-specific expression.Currently phase III aromataseinhibitors are used as Also, these three strains of mice were found to have very different adipose depot hormonal therapy for breast cancer, but their use has significant side-effects disposition profiles. The interaction of adipose tissue in the aging process will be including bone loss hot flushes and arthralgia, due to global inhibition of discussed. Finally, using both genomic and proteomicapproaches,wehave aromatase catalytic activity. Use of AMPK activators such as metformin should identified several genes/proteins whose levels change as afunctionof1)mouse inhibit aromatase expression uniquely in the breast, but leave protected other sites age, 2) diet induced type 2diabetes and 3) GH treatment of GH deficientpatients. of expression such as bone and brain, where oestrogens have important functions. This work was supported by the State of Ohio’s Eminent Scholar Program which includes agrant from Milton and Lawrence Goll; WADA;and NIH grants, R15DK075436, RO1 AG19899-05, and P01 AG031736-01A1.

Society for Endocrinology Hoffenberg International Medal Lecture Society for Endocrinology European Medal Lecture 2010 PL2 PL4 Aldosteroneaction and the mineralocorticoid receptor Adrenocortical carcinoma: advance through international cooperation Peter Fuller1,2,3 Bruno Allolio 1 Prince Henry’s Institute of Medical Research, Clayton, Victoria, Australia; Department of Endocrinology, University of Wuerzburg, 97080 Wuerzburg, 2 Department of Endocrinology, Southern Health, Clayton, Victoria, Germany. Australia; 3 Monash University, Clayton, Victoria, Australia. Adrenocortical carcinoma (ACC) is aheterogeneous neoplasm with an The mineralocorticoid receptor (MR)differs from the other steroid receptorsin incompletely understood pathogenesis and an unsatisfactory prognosis. However, that it responds to two physiological ligands, aldosterone and cortisol. In epithelial international initiatives like the European Network for the Study of Adrenal tissues, aldosteroneselectivity is determined by the activity of 11b -hydroxysteroid Tumours (ENSAT) and international trial consortia recentlyled to improved dehydrogenase type II. The aldosterone-induced genes that mediatesodium flux in diagnosis and treatment. Activated signalling pathways primarily involved in epithelial tissues are now well characterised. In other tissues, including the heart adrenal development like IGF2, SF1, and b -cateninpathways play also akey role in and regions of the CNS, cortisol is the primary ligand for the MR; in some tissues theACC developmentand provideimportant diagnostic andprognostic cortisol may act as an antagonist. Clinical trials have demonstrated the potential of information. Astandardized comprehensive diagnostic work up is now MR antagonists in the treatment of cardiovascular disease however their use has recommendedbyENSAT (www.ensat.org/ACC.htm). Amajor diagnostic been limited by concurrent hyperkalaemia. The mechanisms of these therapeutic advance is 18F-FDG-PET, as virtually all ACC patients demonstrate high uptake effects are currently being addressed by the use of animal modelsincludingtissue- leading to high diagnostic sensitivity. In addition, 11C-metomidate or 123I-iodo- specific deletions of the MR. In order to better target the MR an understanding of metomidate tracers bind selectively to CYB11B enzymes thereby conferring high the structuraldeterminants of tissue and ligand-specific MR activation is being specificity to ACC imaging. Survival in ACC is highlystage dependentwith the sought. We have focused on interactions of the ligand-binding domain (LBD) with new ENSAT staging system providing superior prognostic information compared

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK to the WHO/UICCsystem. Surgery aiming at R0 resection remains the treatment of cells. We showed that D2 activity in bone is restricted to osteoblasts and found that choiceand requiresanexperienced surgeon. Smaller ACCs (diameter ! 9cm) may D2 knockoutmicehavenormal skeletal developmentbut increased bone be removed safely by minimal invasive surgery. To establish an adequate basis for mineralization and brittle bones in adulthood. The phenotyperesulted from a treatment decisions pathology reports should include the Weiss score, resection discrete defectofosteoblastfunction, demonstrating an essentialrole for D2 to status (R0, R1, and R2) and the Ki67 proliferation index. After complete resection optimize bone mineralization and strength. Recently, we over-expressed D3 in most patients benefit from adjuvantmitotane. Depending on the individual risk chondrocytesbycre-lox mediated gene targeting to generatemice with cartilage- adjuvantradiation therapyofthe tumor bed may be added.Cytotoxicdrugs specific thyroid hormone deficiency. These studieshave identified amajor new role (including platinum compounds) will be added to mitotaneinadvanced disease. for thyroid hormones in chondrocytes that is requiredtoestablish the normal Results of the international FIRM-ACT trial, the largest ever trial in patients with structure of jointsand adult bone. advanced ACC, will become available in early 2011 and will establish abenchmark therapy. New targeted therapies (e.g. IGF1 receptor antagonists, 131I-iodometo- midate) are under investigation and may soon lead to improved treatment options. Furthermore, the recently funded (FP7 program) ENSAT-CANCER consortium holds great promise to keep the recently gainedmomentum in ACC research. The British Thyroid Association Pitt-Rivers Lecture PL7 An expanded view on resistance to thyroid hormone Samuel Refetoff Society for Endocrinology European Medal Lecture 2011 The University of Chicago, Chicago, Illinois, USA. PL5 Genes and adrenal Cushing’s syndrome: advance through European At least six major steps are requiredfor secreted thyroid hormone to exert its and world networks action on target tissues: thyroid hormone transport into cells, intracellular Xavier Bertagna1,2 activation of the prohormone thyroxine, transfer of the hormone from the 1 Service des Maladies Endocriniennes et Me´ taboliques, Hoˆ pital Cochin, cytoplasm to the nucleus, intact thyroid hormone receptors and intactnuclear and Paris, France; 2 Equipe Signalisation et Tumeurs Endocrines, INSERM cytosolic machinery required for the mediation of thyroid hormone action. U-567, Endocrinology Department,Faculte´ de Me´ decine Paris Descartes, Mutations interfering with three of these steps have been so far identified and are Institut Cochin, Universite´ Paris 5, Paris, France. the subject of this presentation. The first recognized defect, causing resistanceto thyroid hormone (RTH), involves the thyroid hormone receptor b ( TRb )gene and Adrenal tumors –like many endocrine tumors –bear two classical threats: carries the acronym, RTH. Occurring in w 1of40000 newborn, affected subjects hormone hypersecretion and/or oncogenic potential. Also,because they are rare, belonging to more than 400 families surpass 1500. The gene defect remains their recognition may be delayed; and syndromic- or malignant tumors may be unknown in 15% of subjects with RTH. Two novel syndromes causing reduced misdiagnosed. adding further threats. sensitivity to thyroid hormone were identified in the last 5years. One, producing This talk will concentrate on recent progress brought by genetic studies with the severe psychomotor defects in more than 150 males from 57 families, is caused by aim of improving our understanding of the pathophysiology of these tumors, our mutations in the monocarboxylate transporter 8(MCT8 or SLC16A2), athyroid diagnostic ability, therefore minimizing the risk of misdiagnosis. hormone cell-membrane transporter of particular importance in early brain We will present and discuss progress in two directions. development. The second defect, affecting the intracellular metabolism of thyroid Primary pigmented nodular adrenocortical dysplasia (PPNAD), with or without the hormone is caused by mutations in the selenocysteine insertion sequence binding CarneyComplex, is arecently identified cause of adrenal Cushing most often protein 2(SECISBP2 or SBP2)gene required for the synthesis of selenoproteins, associated with PRKAR1A germinal mutations. Apart from discussing its peculiar including the three iodothyronine deiodinases. Eight such individuals, belonging clinical presentations,wewill show the role of the various actors along the cAMP to unrelated families, have been identified. They manifest, in addition to thyroid pathway,some recently identified, includinginother clinical situations. test abnormalities, defects of variable magnitude in the reproductive, muscular In front of alocalized adrenal cortical tumor (ACT) it may be extremely difficult to and immune systems. Most challenging is the approach to therapy, when simple distinguish between abenign and amalignant tumor; yet it is the time when hormonal substitution is ineffective. ‘complete’ surgical removal of an adrenal cortical carcinoma (ACC), stages 1or2 of the ENS@T classification, is possible and the probability of cure is maximized. We will stress the role of the endocrinologist to recognize the potential malignant nature of these tumors, and the recent progress on the molecular classification of these tumors. Emphasis will be put on the inescapable role of National and International networks to improve our knowledge and management of these rare disorders, as exemplified, among others, by the interaction between Wurzburg,Paris, . and Birmingham. Partly supported by the Clinical Endocrinology Trust.

Society for Endocrinology Medal Lecture Clinical Endocrinology Trust Visiting Professor Lecture PL6 PL8 The bare bones of thyroid hormones Graham RWilliams Genetics of thyroid cancer: clinical and therapeutic implications Imperial College London, London, UK. James Fagin Memorial Sloan Kettering Cancer Center, New York, USA. Hypothyroidism delaysbone formation, whilst thyrotoxicosisaccelerates skeletal development but is arisk factor for osteoporosis. We characterized micewith Our understanding of the genetic abnormalities associated with thyroid cancers mutation or deletionofT3 receptors, TRa and TRb ,inseveral genetic backgrounds. has grown significantly over the past decade. Thus, papillary thyroid cancers Delayed ossification and growth retardation were observed in TRa mutants, (PTC) have non-overlapping activating mutations genes encoding the growth whereas TRb mutants had advanced bone age. Adult TRa mutants had high bone factor receptors RET or NTRK, the three isoforms of RAS, or of BRAF, which mass, whereas TRb mutants were osteoporotic. Target gene expression was altogether are found in w 70% of cases. In addition, mutations of effectors in the reduced in growth plate chondrocytes and osteoblasts in TRa mutants indicating phosphoinositol-3-kinase (PI3K) pathway are present at various stagesofthe tissue hypothyroidism, whereas increased expression in TRb mutants demon- disease, but in particular in advanced thyroid cancers. There is also astrong stratedtissue hyperthyroidism. TRa was expressed at much higher levels than TRb genotype/phenotype relationship in thyroidcancers, with specific mutations in bone at all ages, whereas TRb controlsfeedback regulation of the hypothalamic– associated with particular histological variants, and more importantly, with the pituitary–thyroid axis. Consequently,TR a mutant mice were euthyroid but TRb biological behaviour and prognosis of the cancers. The BRAF mutation, in mutants had elevated thyroid hormone concentrations and pituitary resistance to particular, is associatedwith invasive PTC, which more often become radioactive thyroidhormone. Thus, TRa mediates T 3 action in bone whereas the consequences iodine refractory. The relevance of many of the genotype–phenotype correlations of TRb disruption are due to effects on systemic thyroid status. Conversion of T 4 to first identified through association studies in human specimens is now supported activeT3 is mediated by the type 2deiodinase (D2) whilst the type 3enzyme (D3) by mouse models, in which oncogene activation through transgenic or gene inactivates T 4 and T 3 .The relative expression of D2 and D3 thus determines intra- targeting approaches recapitulates the main features of various forms of the cellular availabilityofT3 and regulates thyroid hormone responsiveness in target disease. It is now legitimate to ask whether this information can be leveraged to

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK makeclinical decisions, and improve the care of patients with the disease. For Clinical Endocrinology Trust Lecture example, FNA of thyroidnodules discriminates between benign and malignant thyroidcancers in most instances. Several groups have shown that immuno- PL9 histochemical or genetic assays can refine the accuracy of cytopathological Pituitary tumours: the goal is shrinking! diagnoses. Most oncogenic mutations in thyroid cancer result in constitutively John SBevan activekinases, which provide tractable targets for pharmacological inhibition. Aberdeen Royal Infirmary, Aberdeen, UK. This is based on the assumptionthat cancers will remain dependent on the activity of the initiating oncoprotein for viability, despite accumulating further genetic In 2011 is the 40th anniversary of prolactin (PRL) characterisation as adistinct damage during the course of their evolution. As aproof-of-principle, the multi- hormone. Only 30 years ago most patients with large pituitary tumours received kinase inhibitor AZD6474, which inhibits RET, EGFR and KDR, showed primarysurgery (often transcranial) followed by routine radiotherapy – promising evidence of activity in aphase 3clinical trial of patients with medullary treatments associated with significant morbidity and hypopituitarism. Much thyroidcancer. However, it is not clear that the beneficial effects of this agent are therapeutic progress has been made; effective medical treatments now exist for due to its inhibition of RET kinase, or to effects on other kinases.Several clinical many pituitary tumour subtypes, particularly the useoflong-acting dopamine trialsincorporating patients with papillary, follicular and Hurthle cell carcinoma agonists (DA) and somatostatin analogues (SA), with potential for growth control with multi kinase inhibitors have also been reported. Two studies with sorafenib, and tumour shrinkage (TS). Typical DA responses of amacroprolactinoma an inhibitor of KDR,RET and possibly RAF, showed ahigh percentage of include rapid PRL reduction, TS (within days/weeks), visual improvement (often patients with disease stabilization and some partial responses, particularly in PTC. within hours/days) and recovery of normal pituitary function. Up to 90% Although sorafenib was developed as aRAF inhibitor, it is not clear if it is of patients show these responses and most tumours shrink by at least 50%. sufficiently potent to block the activity of mutantBRAF in vivo.Indeed, it has Lactotroph cells shrink by over 50% with notable reductions in the cytoplasmic been proposed that the activity of sorafenib, as well as that of other multikinase and RER components.Inacromegaly, SAs control tumour growth in the majority inhibitors such as axitinib and motesanib, may be due to their antiangiogenic and induce significant TS in w 75% of de novo patients, with an average tumour activity, since they are all inhibitors of KDR, the receptor for vascular endothelial volume reduction of w 50%, but there is awide range of TS in unselected growth factor. Despite the promising results of these early trials, many important GH-tumours.Somatotroph cell size reduction is modest,but diminished questions remain. It is not clear if the favorable responses will prove to be durable. proliferation and angiogenesis have been demonstrated. SA are also effective in Moreover, no study so far has been designed to examine impact on mortality. de novo patients with TSH-secreting adenomaswith significant TS in the In view of these uncertainties, these drugs should be considered only for patients majority. Many non-functioning pituitary tumours expressD2dopamine with rapidly progressing metastatic disease, ideally as part of aclinical trial. receptors (albeitfewer than in prolactinomas) and DA therapy restrains tumour Although these compounds are quite well tolerated, they do have significant side growth in up to 70%, although only aminorityshow marked shrinkage. effects, and many participants in the trialsrequired dose reductions, drug Increasingly,dopamine and somatostatin receptor subtype analysis will guide holidays, and in some cases were unable to continue on the study. In other tumor specific medical therapies for individual tumours, not only with the agents types, the type of genetic mutation harboured by the cancer predicts response to currently available, but also with multiligand SA (such as pasireotide) and therapywith specific kinase inhibitors. Despite this, most trialsofthyroid cancers chimericmolecules (suchasdopastatin).Despitetheir frequent clinical derived from follicular cells were not designed to examine whether specific effectiveness, issues of drug safety, value for money and long-term cure rates oncogenic mutations might determine treatment outcome, ashortcoming that will associated with medical treatments for pituitary tumours continue to be evaluated hopefully be corrected as this promising research field continues to develop. and debated.

Generously supported by the Clinical Endocrinology Trust. Generously supported by the Clinical Endocrinology Trust.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Symposia

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

All you need to know about the genetics of diabetes (types 1 One approach to finding biomarkers is to use the fact that the transcription factor and 2 and MODY) mutations that cause the commonest forms of MODY have extra-pancreatic manifestations not shared by type 1 or type 2 diabetes. Looking at hepatic genes S1.1 regulated by HNF1A has lead to the identification that highly-sensitive C-reactive Immune mechanisms involved in type 1 diabetes: insights from genetics protein (hsCRP) is lower in HNF1A-MODY than in all other kinds of diabetes and V Plagnol non-diabetic individuals. Using hsCRP to differentiate HNF1A-MODY from type University College London Genetics Institute, London, UK. 2 diabetes diagnosed before 45 years has a sensitivity and specificity both around 80% and an area under the receiver operated characteristic curve of O0.8, indicating a good discriminative test. A model including simple clinical Recent advances in genotyping technologies combined with large scale characteristics can improve this further. recruitment of case–control cohorts have enabled the development of the Simple pathophysiological features can also form the basis for selection for genome-wide association (GWA) study design. As a consequence of this ongoing genetic testing – e.g. presence of C-peptide indicating endogenous insulin work, 64 single nucleotide polymorphisms (SNPs) located in 53 chromosome secretion can be a marker to differentiate MODY cases from those assumed to regions have now been associated with type 1 diabetes (T1D) risk (see www. have type 1 diabetes. t1dbase.org). These findings provide an unbiased assessment of the genetic The results of a novel discovery experiment using metabonomics to identify architecture of T1D and I will give an overview of these data. In addition, the putative MODY biomarkers will also be presented. comparison of these results with similar findings obtained from additional GWA scans designed for other auto-immune disease, as well as for autoantibody data in T1D patients, provides further insights into the shared aetiology of autoimmune pathways. Arguably one of the most striking conclusions is the indication that viral infections are involved in the pathogenesis of T1D as well as other autoimmune disorders.

S1.4 Genome-wide association studies for type 2 diabetes M Weedon S1.2 Exeter, UK. The diverse phenotypes of KATP channel mutations Sian Ellard Peninsula Medical School, University of Exeter, Exeter, UK. Abstract unavailable.

In recent years, there has been significant progress in defining the genetic aetiology of neonatal diabetes (NDM). It is likely that all cases result from single gene disorders since markers of autoimmunity associated with polygenic type 1 diabetes are rare in patients diagnosed before 6 months. Activating mutations in the KCNJ11 and ABCC8 genes encoding the Kir6.2 and Novel pathways and treatments in neuroendocrine tumours SUR1 subunits of the b-cell ATP sensitive potassium (KATP) channel are the most S2.1 common cause of neonatal diabetes, accounting for around 40% of case. The Signaling pathways in neuroendocrine tumors majority (w90%) of patients can achieve improved glycaemic control on high Mark Kidd & I Modlin dose sulphonylureas. Department of Surgery, Yale University School of Medicine, New Haven, The mutation severity defines the phenotype which ranges from isolated transient Connecticut, USA. neonatal diabetes to DEND syndrome (severe developmental delay, epilepsy and permanent neonatal diabetes). Around 20% of patients with activating KATP channel mutations have mild to moderate developmental delay and case reports Neuroendocrine tumor cells express a diverse array of activating and inhibitory have described improved neurological function in some of these patients receptors. Each receptor transduces a signal via individual pathways which often following transfer to sulphonylureas. interact or overlap. Common stimulatory receptor families include those for Some patients with transient neonatal diabetes caused by a KATP channel EGF/TGFa, FGF, IGF, PDGF, VEGF, and TGFb. EGF receptor (Her 1) mutation have inherited the mutation from a parent who did not present with activation results in several signal transduction cascades including Ras/Raf, diabetes in the neonatal period, but developed permanent diabetes in later life. MAPK, AKT and JNK leading to DNA synthesis and cell proliferation. Activated Analysis of a cohort of patients referred for HNF1A/4A MODY testing identified MAPK signaling is a common feature of GEP-NETs (‘carcinoids’), but the activating ABCC8 mutations in 6/86 cases (7%). The identification of specific absence of activating mutations in the EGF receptor suggests this is not due to subtypes of monogenic diabetes not only provides accurate information regarding EGF/TGFa. The four FGF receptors combine to create 48 isoforms; the inheritance and prognosis, but can inform treatment decisions and improve predominant isoforms FGFR1–4 are expressed in all GEP-NETs; signaling clinical outcome. activation is associated with mitogenesis and differentiation as well as cross-talk within the tumor microenvironment (endothelial cell activation). IGF1R is present in the majority (O70%) of GEP-NETs and is coupled to Ras/Raf, MAPK and the PI3K–AKT–mTOR pathway. IGF1R activation is associated with survival and proliferation in mitosis-competent cells (e.g. serotonin-mediated hepatocyte-production of IGFs by hepatic metastases) and hypertrophy in differentiated cells. PGFRs are occasionally expressed in GEP-NETs and are S1.3 associated with MAPK/AKT activation. The majority of expression, however, How to find all the cases of MODY in your diabetes clinic. occurs in tumor stroma, and is associated with angiogenesis. The VEGFR has also Katharine Owen been identified in GEP-NETs, and the production of VEGF by NETs is coupled to University of Oxford, Oxford, UK. endothelial cell mitogenesis/migration and angiogenesis. TGFbRs are present in the majority (w90%) of GEP-NETs. In pancreatic NETs, they are coupled to the classical SMAD2/3 pathway and inhibition of proliferation. In contrast, in small Maturity-onset diabetes of the young (MODY) is a group of monogenic disorders intestinal NETs, TGFbR are coupled to SMAD4/7 which results in tumor of b-cell function which causes diabetes in young adults. Diagnosing MODY is proliferation via cross-activation of MAPK and AKT. Common inhibitory important as the different subtypes have distinct first line treatments, e.g. low dose receptor families include those for TGFb, interferon, somatostatin, dopamine and sulphonylureas in HNF1A mutations while no treatment is required in GCK serotonin. Somatostatin receptors are coupled to PKA/cAMP and calcium mutations. This can lead to treatment changes including discontinuing insulin channels and activation inhibits cell secretion. There is some evidence that therapy. First degree family members can also be offered diabetes screening and proliferation may be diminished but the mechanisms have not been clearly genetic testing. However, there are considerable challenges in differentiating delineated. Dopamine D2/D4 receptors activation may inhibit NET function, MODY from type 1 and type 2 diabetes and this means that an estimated 80–90% largely via cAMP inhibition, although there is considerable heterogeneity in of cases in the UK are undiagnosed and on average there is a delay of around 15 dopamine receptor expression in tumors (D2 as well as stimulatory D1,3,5 – years after diagnosis of diabetes before a genetic diagnosis is established. which activate PKA/cAMP). Interferons activate IFNGR1/2 and signal through Finding economic, widely-available non-genetic biomarkers that can be used for JAK/STAT pathways leading to apoptosis. Certain subtypes of small intestinal screening to find those at high risk of MODY would be greatly advantageous. This NETs express serotonin receptors, usually 5-HT2A/B. Activation of these lecture describes the recent progress that has been made in this area. receptors inhibit serotonin secretion and cell proliferation via inhibition of

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

MAPK signaling. Many NETs also exhibit loss of the G1 checkpoint inhibitor These agents appear to be effective even when other treatments have failed and P21WAF1/CIP1. Other potential signaling pathways include hedgehog (SHH – over- herald a new era in the management of patients with pancreatic NETs. Emerging expressed in metastases) and NOTCH (potentially involved with secretion). In evidence suggests that tyrosine kinase inhibitors may also be active in non- conclusion, the expression of a variety of receptors activating diverse transduction pancreatic NETs although mature data is awaited. events that enable stimulation or inhibition of tumor growth provide a number of Achieving an understanding of the how these agents fit into the treatment opportunities for therapeutic intervention that might target growth, secretion or algorithm in relation to each other and alongside other treatment modalities as angiogenesis. well in early-stage disease will necessitate numerous clinical studies and require significant collaboration amongst investigators. 1. Raymond et al., NEJM 2011 364(6) 501–513. 2. Yao et al., NEJM 2011 364(6) 514–523.

S2.2 Integrated genome-wide DNA methylation and mRNA expression analysis of pancreatic NETs Christina Thirlwell1,2, Laura Schulz2, Marianne Eymard2, Tim Meyer1,2, S2.4 Brian Davidson1, Andrew Teschendorff2, Yan Jiao2, Tu-Vinh Luong1, New horizons in therapy Martyn Caplin1 & Stephan Beck2 D Hochhauser 1Royal Free Hospital Academic Unit for Neuroendocrine Tumours, Pond London, UK. Street, London NW3 2QG, UK; 2UCL Cancer Institute, 72 Huntley Street, London WC1E 6BT, UK. Abstract unavailable.

Integration of genetics and epigenetics has emerged as a powerful approach to study cellular differentiation and tumourigenesis. The study of DNA methylation is of particular importance in cancer as causal involvement has been demonstrated and it is the most stable of all epigenetic modifications, making it a desirable marker for both early detection and treatment of tumours. Hypermethylation of CpG sites in gene promoter regions leads to decreased gene expression, if such a Fat endocrinology: disorders of adipose tissue and lipids gene is a tumour suppressor this leads to carcinogenesis. important to the endocrinologist Ten fresh frozen sporadic pancreatic NET liver tumours (3 low grade, 3 S3.1 intermediate grade and 4 high grade) were analysed using the Illumina Can we make more brown adipose tissue to treat obesity? HumMeth27 beadarray (interrogating 27 500 CpG sites relating to 14 000 W Van Marken Lichtenbelt genes) and the Affymetrix HumanGene 1.0 ST mRNA expression array (which Maastricht University Medical Center, Maastricht, The Netherlands. has 26 probes covering the full coding region of 28 869 genes). Integrated DNA methylation and mRNA expression analysis comparing tumour grade in sporadic pancreatic NETs identified the HIF/p53 hypoxia pathway to be The incidence of the metabolic syndrome has reached epidemic levels in the differentially activated between low and intermediate grade tumours (PZ4! western world. With respect to the energy balance most attention has been given K 10 4). JUN, EP300, HIF1-a and ARNT which are integral member s of HIF to reducing energy (food) intake. Increasing energy expenditure is an important K pathway were identified. The IGF1 pathway was also identified (PZ3!10 3). alternative strategy. Adaptive thermogenesis, which is the increase in energy This study has highlighted the significance of the HIF/p53 hypoxia pathway in the expenditure in response to cold or diet, may be an effective way to affect the development and progression of pancreatic NETs. This confirms previous work, energy balance. which has utilised immunohistochemistry to study protein expression of HIF Several studies have confirmed that humans show significant (mild) cold induced pathway members. Once validated this pathway would provide ideal novel thermogenesis, i.e. without shivering. The individual variation in CIT is large. therapeutic targets for pancreatic NETs. There are indications that CIT is reduced in obese subjects. Tissues shown to be involved in adults are skeletal muscle and brown adipose tissue (BAT). The most likely cellular mechanism in both tissues is mitochondrial uncoupling. At the functional level, adipocytes can be subdivided into white and brown. The most important function of white adipocytes is energy storage, while the main function of brown adipocytes is heat production. Brown adipocytes are located in distinct BAT depots, in white adipose tissue (BRITE adipocytes), or in skeletal S2.3 muscle tissue (BRUSCLE adipocytes). Tyrosine kinase inhibitors for neuroendocrine tumours Intriguingly, functional and active BAT is inversely correlated with age and body Juan W Valle mass index (BMI) in humans. Indeed, thermogenic BAT is a major site for lipid Department of Medical Oncology, The Christie NHS Foundation Trust, breakdown and glucose uptake, and thus the thermogenic capacity of even small Wilmslow Road, Manchester, UK. amounts of brown adipocytes has emerged as an attractive target for anti-diabesity therapies. Animal and human studies indicate that recruitment and activation of brown and Neuroendocrine tumours (NETs) are a heterogeneous, uncommon tumours for brite adipocytes can potentially be accomplished by pharmacological, nutritional whom there have been few practice-changing clinical studies. Sub-groups of or environmental intervention. Crucial in the activation of adaptive thermogenesis patients may be defined by site of origin, histological sub-type, mitotic activity and brown adipocytes are the sympathetic nervous system and the thyroid and evidence of disease progression. hormone axis. In stimulating thermogenesis and BAT activity, thyroid hormone Chemotherapy is active in patients with advanced pancreatic NETs; however, works synergistically with the sympathetic nervous system at different levels. benefits are modest and associated with significant (albeit manageable) toxicity. Additional treatment options are sparse. Two recently published studies have challenged our treatment paradigm in such patients. Pancreatic NETs are known to be vascular tumours with over-expression of vascular endothelial growth factor (VEGF, a key regulator in angiogenesis) and VEGF receptor (VEGFR)-2, VEGFR-3, platelet derived growth factor receptors- a and -b and c-kit. Continuous dosing of sunitinib, an oral multi-targeted tyrosine S3.2 kinase inhibitor of this pathway, has been shown in a phase III, placebo-controlled Familial partial lipodystrophy: an introduction and the importance of study to significantly improve the progression-free survival (PFS, the primary diagnosing FPLD end-point), objective response rate and overall survival in patients with well- 1 S Suliman differentiated, progressive pancreatic NETs with acceptable toxicity. Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK. Another pathway over-stimulated in pancreatic NETs is the mammalian target of rapamycin (mTOR); stimulation of this serine-threonine kinase results in angiogenesis, cell growth and proliferation. Everolimus, an inhibitor of mTOR, Lipodystrophy including familial, acquired and secondary forms displays the full has recently been shown to significantly prolong PFS in a placebo-controlled, spectrum of the metabolic syndrome including severe insulin resistance, phase III study in patients with progressive low- or intermediate-grade advanced hyperinsulinaemia; hypertension, hypertriglyceridaemia, low HDL cholesterol, pancreatic NET, once again with manageable toxicity2. and hyperglycaemia1. This group have an absolute or partial reduction in fat mass,

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK yet often show more extreme metabolic features than obese individuals. Endocrine regulation of ageing Partial lipodystrophy may be genetic or acquired. Genetic causes of familial partial lipodystrophy (FPLD), often an autosomal dominant condition; include S4.1 mutations in LMNA, PPARG, AKT2, ZMPSTE24, CIDEC2 however the majority The aging process; somatotropic axis and calorie restriction of subjects have no identified genetic aetiology. Andrzej Bartke & Michal Masternak Diagnosing FPLD has depended mainly on clinical observations of fatless limbs SIU School of Medicine, Springfield, Illinois, USA. and phlebectasia (prominent leg veins). Using the Oxford Biobank (database of O1000 healthy individuals in Oxfordshire) and PLD subjects from the Oxford Mice with targeted deletion of GH receptor (GHRKO mice) are GH resistant, Lipodystrophy Clinic, we have been able to define a normal ratio of central to small, hypoinsulinemic, very sensitive to insulin and remarkably long-lived. We peripheral skin-fold measurements in healthy individuals. This ratio is markedly have previously reported that these animals failed to respond to calorie restriction increased (O95%CI) in LMNA mutation positive FPLD subjects and subjects (CR) by additional increase in insulin sensitivity or extension of longevity. Because with clinical lipodystrophy but no known genetic aetiology. GHRKO mice are characterized by increased adiposity and adiposity is normally Subjects with FPLD require individualised treatment in view of their adverse associated with insulin resistance rather than sensitivity, we hypothesized that the metabolic profile and increased cardiovascular risk. Specific treatments include impact of adipose tissue on metabolism must be profoundly altered in these leptin therapy, in leptin deficient subjects, which improves insulin resistance, animals. To test this hypothesis, we compared the effects of surgical removal of hyperglycaemia and dyslipidaemia3. Isolated reports suggest that thiazolidine- visceral (epididymal and perinephric) fat in GHRKO and normal males. diones have been successful although prospective studies have been less Visceral fat removal (VFR) enhanced insulin sensitivity (assessed by insulin rewarding. Bariatric surgery has been rewarding in patients with FPLD4. levels and insulin and glucose tolerance tests) and reduced intramuscular fat Familial partial lipodystrophy is less rare than previously reported with a content, body temperature and respiratory quotient in normal animals but prevalence of w0.3% in secondary care diabetes clinics, these subjects have a had disparate, generally opposite effects on the same parameters in GHRKO high cardiovascular risk and require identification and individualised manage- mice. Moreover, VFR in GHRKO but not normal mice reduced circulating levels ment. of adiponectin, which is known to promote insulin sensitivity and exert anti- References inflammatory effects. Functional differences between VF from normal and 1. Garg A. Acquired and inherited lipodystrophies. N Engl J Med 2004 350 GHRKO mice implied by these findings were confirmed by measurements of 1220–1234. lipolysis, adiponectin and iterleukin-6 levels and expression of genes related to 2. Huang-Doran I, Sleigh A, Rochford J, O’Rahilly S & Savage DB. fat metabolism. Lipodystrophy: metabolic insights from a rare disorder. J Endocrinol 2010 207 We conclude that in the absence of GH signals, VF acts to promote insulin 245–255. sensitivity rather than resistance. Lack of beneficial effects of VFR on insulin 3. Oral EA, Simha V, Ruiz E, Andewelt A, Premkumar A, Snell P, Wagner AJ, signaling and longevity-associated traits in GHRKO mice may explain why CR, DePaoli AM, Reitman ML, Taylor SI, Gorden P & Garg A. Leptin-replacement which drastically reduces adiposity, failed to improve insulin sensitivity or extend therapy for lipodystrophy. N Engl J Med 2002 346 570–578. longevity in these animals. 4. Utzschneider KM & Trence DL. Effectiveness of gastric bypass surgery in a Supported by grants from the National Institute on Aging. patient with familial partial lipodystrophy. Diabetes Care 2006 29 1380–1382.

S3.3 The link between insulin resistance, dyslipidaemia and fatty liver Robert Semple S4.2 University of Cambridge, Cambridge, UK. The ageing process: insulin signalling and mTOR signalling Colin Selman Insulin resistance (IR) is an important biochemical phenomenon because it is University of Aberdeen, Aberdeen, UK. closely linked to major and highly prevalent diseases including diabetes mellitus, atherogenic dyslipidaemia, the fatty liver disease dysfunction, and ovulatory Alterations in insulin/insulin-like growth factor 1 signalling (IIS) play a key role dysfunction. Yet major barriers to understanding the mechanisms linking IR to in lifespan extension in model organisms. For example, mice globally null for these clinical diseases have included 1. The difficulty in discerning cause and effect insulin receptor substrate protein 1 (IRS1), a major intracellular IIS effector, are relationships in associated phenomena in a complex multisystem disorder and 2. both long-lived and have improved health during this long life. However, unlike The limitation of conventional definitions of IR, which rely solely on impaired long-lived GH dwarf mice and dietary restricted (DR) mice, Irs1 null mice insulin action on glucose metabolism. Key analytical approaches to circumventing combine an increased lifespan with lifelong insulin resistance. These findings these problems include the creation of targeted genetic alterations in mice, and the suggest that enhanced insulin sensitivity is not a prerequisite for long-life. An study of naturally occurring single gene disorders of insulin action in humans. additional signalling pathway that appears to plays a key and highly conserved These complementary approaches over recent years have led to growing interest in role in longevity control is the target of rapamycin (TOR) pathway. Global the idea that fatty liver and metabolic dyslipidaemia only appear when IR is partial, deletion of ribosomal S6 protein kinase 1 (S6K1), a key effector of mTOR and IIS affecting the hypoinsulinaemic actions of insulin without impeding insulin’s signalling, extends healthspan in female (but not male) mice. In addition, these stimulatory effects on hepatic de novo lipogenesis. This means that compensatory mice are resistance to a range of age-related pathologies, including bone, immune hyperinsulinaemia can act through unaffected signalling pathways to drive liver fat and motor dysfunction. Unlike Irs1 nulls, S6K1 null mice were insulin sensitivity accumulation and hypersecretion of hepatic VLDL. I shall critically review the in old age. S6K1 deletion also induced hepatic gene expression profiles similar to evidence for this concept, focusing on metabolic studies in humans with rare single DR and Irs1 null mice, and muscle expression profiles of S6K1 null mice closely gene defects associated with severe IR. mimicked those of mice following AICAR treatment. Therefore, manipulation of mTOR (and AMPK) may mimic DR and may provide viable drug targets offering protection against diseases of aging.

S3.4 What you need to know about the genetics of hyperlipidaemia Carol Shoulders, Claire Hutchison, Emma Duncan & Rasheeta Sivapackianathan Queen Mary University of London, London, UK. S4.3 Cortisol, DHEAS and immunesenescence This presentation will consider the ways that modern genetics and lipidomics are Janet Lord, Anna Phillips & Wiebke Arlt beginning to increase our understanding of specific lipid disorders that bear on Birmingham University, Birmingham, UK. human disease, ranging from life-threatening conditions of infancy through severe coronary heart disease of young adulthood, to indolent disorders of middle- and old-age. The case will be made for replacing the traditional, but now Normal ageing is accompanied by increased organismal frailty, reflecting organ 45-year-old, Fredrickson and Lees essentially phenotypic classification of specific functional decline, with an associated increase in the likelihood of disease. hyperlipidaemia with one rising from genetic foundations. The immune system undergoes significant decline with age, termed immunesenes- cence, which results in increased susceptibility to infection and reduced vaccination

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK responses. Significant changes in the hormonal milieu also occur with age and it is movement of the organism or particle flow across the epithelial surface in fixed clear that age-related changes in adrenal hormone secretion can impose a significant structures. In vertebrates, such motile cilia are evident in the respiratory epithelia, environmental effect on tissues in the ageing body, including the immune system. In ependyma and oviducts. For over a century, non-motile cilia have been observed on humans the adrenopause results in a decline in the production of DHEA and DHEAS the surface of most vertebrate cells but until recently their function has eluded us. with age, while the production of cortisol is unaffected. Ageing is therefore Gathering evidence now points to critical roles for the mono-cilium in sensing the accompanied by an increase in the cortisol:DHEAS ratio. extracellular environment and perturbation gives rise to predictable panoply of The immune suppressive effect of cortisol is well established, but evidence is now clinical problems. I will review the evidence for cilia function during development increasing for an immune enhancing role for dehydroepiandrosterone (DHEA) and and examine the consequences of cilia dysfunction in disease (ciliopathies). dehydroepiandrosterone sulphate (DHEAS). We have reported recently that DHEAS is able to enhance the response of neutrophils to bacterial fMLP, significantly increasing superoxide generation. Moreover we showed that neutrophils were unique amongst leukocytes in expressing a transporter for sulphate steroids such as DHEAS and that the effect on neutrophil superoxide generation was mediated via direct activation of protein kinase C. As neutrophils are the dominant leukocyte in the circulation and are the first defence against rapidly dividing bacteria, DHEAS may represent a significant neutrophil priming agent able to overcome the suppressive effects of cortisol. Our previous data has also shown that at times of stress (both emotional and physical) S5.2 in the older adult the cortisol:DHEAS ratio is further increased and is associated with Sonic hedgehog signalling and primary cilia in the adrenal suppression of neutrophil function and increased risk of infection. We therefore Katy Cogger1, Leo Guasti1, Zahida Banu1, Phil Beales3, Alex Paul2, propose that the age-related changes in the HPA axis contribute to immunesenes- Ed Laufer2 & Peter King1 cence and that this effect is enhanced at times of stress in old age. 1WHRI, Queen Mary University of London, London, UK; 2Columbia University, New York, New York, USA; 3Institute of Child Health, London, UK.

The adrenogonadal primordium develops from a thickening of the coelomic epithelium covering the urogenital ridge. After segregation of the primordium S4.4 into the bipotential gonad and the adrenocortical primordium, the cortex is Ageing, hormones and cognition in humans encapsulated by mesenchymal cells and infiltrated by migrating sympathoadrenal A MacLullich cells, which form the medulla. We have shown that the cell fate regulator sonic Centre for Cardiovascular Diseases, QMRI, Edinburgh, UK. hedgehog (Shh) is not required for the formation of the adrenocortical primordium but is required for its subsequent growth and development. Its expression is restricted to relatively undifferentiated cortical subcapsular cells and Cognitive decline with ageing is highly variable, with some individuals showing it signals to cells within the capsule. Lineage tracing studies in mice demonstrate minimal change, and others developing dementias. Clinically significant that these signal receiving cells enter the cortex and adopt a steroidogenic cognitive impairment is among the most important unmet medical needs phenotype, becoming zona glomerulosa and zona fasciculata cells, at least in part, worldwide: currently there are virtually no generally accepted effective via a Shh-expressing intermediate cell population. prevention strategies or treatments. The primary cilium is required for hedgehog (Hh) signalling, with disruption of Ageing is associated with multiple changes in hormone levels and target tissue genes required for cilia formation phenocopying Hh pathway mutations. sensitivity. There is a rapidly growing evidence base exploring the associations Although there has been no report of ciliopathies associated with adrenal among these parameters and variations in the trajectories of cognitive decline insufficiency to date, our studies have documented adrenal phenotypes in BBS 4 with ageing. For example, elevated circulating glucocorticoids with ageing, likely and 6 null mice consistent with impaired Shh signalling, and knockdown of IFT88 occurring as a result of impaired feedback regulation of the hypothalamic– in the human adrenocortical carcinoma cell line H295R affects steroidogenesis. pituitary–adrenal axis, have been linked with cognitive decline in many studies. These data support a role for the primary cilium in adrenal development, Higher activity of the intracellular glucocorticoid-amplifying enzyme 11b- differentiation and function. hydroxysteroid dehydrogenase type 1 (11b-HSD1), which increases local action of glucocorticoids, has also recently been implicated in cognitive decline in animal and human studies. There are few interventional studies in animals or humans which have examined glucocorticoid antagonism (e.g. receptor antagonists, 11b-HSD1 inhibitors), but these have provided some promising results. Type II diabetes mellitus is a major risk factor for cognitive decline; improved prevention and treatment of will likely have positive impacts on cognition as well as other outcomes. Including adequate cognitive outcomes measures in trials of anti-diabetes drugs in older patients would help to clarify which treatments are most effective. Many hormones show mean reductions in S5.3 levels with ageing, e.g. DHEA, gonadal steroids, melatonin and GH. Some studies The importance of primary cilium in adipogenic differentiation have linked these declines with cognitive impairment; however, inteventional Vincent Marion studies in animals have not yet yielded clear conclusions and there is a paucity of INSERM, Strasbourg, France. clinical trials. In summary, many relationships among variations in hormones and cognitive Long considered as a vestige of evolution, the primary cilium has recently decline have been demonstrated. These provide multiple potential therapeutic targets. Definitive interventional trials are currently lacking but hold high promise emerged as a crucial orgnalle in the regulation of cell function. Ciliated cells are ubiquitously present in the organism and until recently only two cellular types for the development of new treatments. were considered as unciliated cells, namely the adipocyte and the hepatocyte. An in vitro approach evidenced that the preadipocyte was transiently ciliated during its terminal differentiation phase and that the primary cilium was acting as a detection siege for anti-adipogenic signals as it carried both the Wnt receptor as well as the Sonic Hedgehog receptor, Smoothened. Inactivation of the chaperone- like BBS protein resulted in unciliated preadiocytes which were more prone to The novel role of primary cilia in endocrine disease and undergo terminal differentiation as well as massive triglyceride accumulation combined with higher leptin secretion; a situation found back when using dermal obesity fibroblasts derived from BBS patients. BBS-associated obesity has been described S5.1 to be of central origin, namely due to a leptin resistance as the hypothalamic Making sense: primary cilia in disease and development arcuate nuclei were unable to sense plasma leptin. Our data indicate that the BBS- Philip Beales associated obesity could be of two origins, namely from a central hypothalamic UCL Institute of Child Health, London, UK. dysfuntion and from a more peripheric adipocyte-related one. Further in vivo studies on the adipocytes of our newly generated Bbs12 knock out mice and of the leptin resistant mouse, the Ob/Ob mouse, tend to confirm our previous in vitro Ubiquitous in nature, cilia and flagella comprise near identical structures with findings that BBS-related obesity is not solely linked to a leptin resistant status. similar functions. The most obvious example of the latter is motility; driving

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S5.4 T2 binds and activates the mitochondrial cytochrome-c-oxidase Va, whereas T3 The molecular pathophysiology of the human obesity disorder, Bardet binds two truncated TRa isoform (p28 and p43) in mitochondria. P28 co-localizes Biedl syndrome (BBS) with the adenine nuclear translocase and uncoupling proteins while liganded-p43 Val Sheffield binds mitochondrial-DNA response elements and regulates mitochondrial protein Department of Pediatrics and Howard Hughes Medical Institute, University synthesis. Thus, thyroid hormones exert important physiological actions by both of Iowa, Iowa, USA. genomic and non-genomic effects.

Bardet-Biedl syndrome (BBS) is a heterogeneous autosomal recessive disorder characterized by obesity, retinopathy, cognitive abnormalities, and polydactyly and other congenital anomalies. Patients also have an increased incidence of S6.2 hypertension and diabetes. Mutations in at least 14 genes have been reported to independently cause BBS. In order to better understand the pathophysiology of 3-Iodothyronamine: a novel, biologically active thyroid hormone BBS, we have generated BBS mouse models and have investigated the interaction metabolite of the protein products of the BBS genes. Seven BBS proteins form a stable Thomas Scanlan protein complex known as the BBSome, which promotes ciliary membrane Oregon Health and Science University, Portland, Oregon, USA. elongation through Rab8. In addition, we have shown that a component of the BBSome (BBS1) interacts directly with the leptin receptor. Three additional BBS We have recently discovered a novel, endogenous iodine containing aryl- proteins have chaperonin homology and play a role in BBSome formation. BBS3, ethylamine derivative that we believe is a metabolite of thyroxine, the major form an ADP-ribosylation factor (ARF)-like small GTPase also known as ARL6, is not of thyroid hormone produced in the thyroid gland of vertebrates. This compound part of the BBSome complex and does not have chaperonin homology. We used K/K is 3-iodothyronamine (T1AM), and it does not bind to or activate nuclear thyroid Bbs3 mice to determine whether Bbs3 is required for BBSome formation. hormone receptors – the established target receptors of thyroid hormones – but Loss of Bbs3 does not affect BBSome protein levels or BBSome formation. instead functions as a potent agonist of trace amine associated receptor 1 However, both the BBSome and Bbs3 localize to cilia, and loss of Bbs3 disrupts (TAAR1), an orphan G protein-coupled receptor (GPCR), to rapidly modulate localization of BBSome proteins to cilia. Conversely, the BBSome is required cAMP levels in cells expressing the GPCR. In addition, T1AM is an agonist of for ciliary localization of BBS3. alpha-2a-adrenergic receptors and inhibits certain plasma membrane and Many signaling proteins including G protein-coupled receptors localize to vesicular monoamine transporters; however, it is not clear that any of these primary cilia, regulating cellular processes including differentiation, proliferation, receptors or transporters are physiological targets of T1AM. The in vivo organogenesis, and tumorigenesis. Bardet-Biedl syndrome (BBS) proteins are pharmacology of T1AM in many ways induces physiological changes that occur involved in maintaining ciliary function by mediating protein trafficking to naturally in hibernating animals. Rodents treated with single pharmacological the cilia. doses of T1AM display profound changes in thermal regulation, cardiac The mechanisms governing ciliary trafficking by BBS proteins are not well performance, and blood glucose homeostasis. Similar to the in vitro cell-based understood. We show that a novel protein, Leucine-zipper transcription factor- experiments, these in vivo effects occur with rapid kinetics suggesting that they like 1 (LZTFL1), interacts with the BBSome, and regulates ciliary trafficking of are mediated by non-transcriptional mechanisms. In addition to displaying all this complex. We also show that all BBSome subunits are required for BBSome of the above effects, hibernating rodents treated with single-dose T1AM ciliary entry and that reduction of LZTFL1 restores BBSome ciliary trafficking demonstrate a fuel utilization preference away from carbohydrates and in BBS3 and BBS5 depleted cells. Our findings indicate that LZTFL1 is an toward lipids. This presentation will focus on the pharmacological and important regulator of BBSome ciliary trafficking, and as such is a target physiological properties of T1AM and explore the potential therapeutic utility for treatment. of this biogenic amine.

S6.3 Novel application of thyroid hormone analogues: thyroid The action of thyroid hormone in vascular tissues 1,2 1 1 2 hormones, thinking outside the capsule Paul Davis , Faith Davis , Hung-Yun Lin & Shaker Mousa 1Ordway Research Institute, Albany, New York, USA; 2Albany College of S6.1 Pharmacy, Albany, New York, USA. Thyroid hormone action: genomic and non-genomic effects J H Duncan Bassett Molecular Endocrinology Group, Department of Medicine and Medical Iodothyronines stimulate neovascularization in tumor beds, brain, ischemic Research Council Clinical Sciences Centre, Imperial College London, myocardium and striated muscle. The molecular basis of the action can be studied Hammersmith Campus, London, UK. in models such as the chick chorioallantoic membrane (CAM) and human microvascular endothelial cell (HDMEC) microtubule formation. Nongenomic and genomic actions of the hormone may contribute to angiogenesis. The initial 0 The classical genomic actions of triiodothyronine (T3) are mediated by high- description of the cell surface receptor for thyroid hormone (T4 and 3,5,3 -triiodo- affinity nuclear receptors that directly regulate gene expression. By contrast, the L-thyronine T3) on integrin avb3 nongenomically linked thyroid hormone to non-genomic effects of thyroid hormones occur rapidly and are unaffected by angiogenesis via mitogen-activated protein kinase (MAPK; ERK1/2) and inhibitors of transcription and protein synthesis. The genomic actions of thyroid involved downstream transcription of basic fibroblast growth factor (bFGF, hormone have an established role in the development, differentiation and FGF2) and vascular endothelial growth factor (VEGF) genes. Further, crosstalk homeostatic maintenance of target tissues. The THRA and THRB genes encode between the hormone receptor on the integrin and VEGF and bFGF receptors three thyroid hormone receptors (TRa1, TRb1 and TRb2) that bind T3 and clustered with the integrin has also been demonstrated. Other pro-angiogenic recognise specific thyroid hormone response elements (TREs) in the promoters of hormone analogues are diiodothyropropionic acid (DITPA) and GC-1. target genes. Unliganded-TRs bind TREs and co-repressors and maintain a local, Tetraiodothyroacetic acid (tetrac) is an inhibitor of the actions of T4 and T3 at transcriptionally non-permissive chromatin structure. T3 binding results in a the integrin and blocks thyroid hormone-induced angiogenesis. In the absence of conformational change, dissociation of co-repressor, recruitment of co-activators T4 and T3, however, tetrac will also inhibit the actions of VEGF, platelet-derived and through chromatin remodelling generation of a transcriptionally permissive growth factor (PDGF) and bFGF in CAM and HDMEC microtubule assays. chromatin structure. The non-genomic actions of thyroid hormones involve Iodothyronines may also stimulate angiogenesis about areas of infarction in the multiple physiological processes in many different cell types and are thought to be myocardium in the intact experimental animal by a mechanism that may involve 2C mediated by induction of [Ca ]I, cyclic-AMP or the protein kinase signalling TRb. Hypoxia-inducible factor-1a (HIF-1a) is a transcription factor important to cascades. Sites of non-genomic action are localized to the plasma membrane, ischemia-induced coronary artery collateralization; acting in cytoplasm, T3 cytoplasm, cytoskeleton and sub-cellular organelles. Recent advances in the field induces expression of the HIF1a gene. Thus, thyroid hormone is pro-angiogenic have identified Integrin avb5 as a high affinity membrane receptor for T4 which by mechanisms that may begin at the plasma membrane, in cytoplasm or within activates MAPK (ERK1/2) signalling and results in nuclear receptor phosphoryl- the nucleus. Pro-angiogenic actions of the hormone initiated at the integrin may ation, induction of angiogenesis and promotion of cell growth. Cytoplasmic involve crosstalk at the cell surface with vascular growth factor receptors or, T3/TRb1 has also been shown to activate phosphatidylinositol-3-kinase (PI3K) downstream, culminate in vascular growth factor gene expression. Acting at the and post-transcriptionally regulate expression of hypoxia-inducable-factor-1a. integrin, tetrac is anti-angiogenic by inhibiting actions of T4 and T3 and by Thyroid hormones are also major regulators of mitochondrial function and blocking effects of VEGF, bFGF and PDGF. diiodothyronine (T2) and T3 are thought to mediate rapid thermogenic responses.

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S6.4 The axons and terminals of GnRH neurons are closely apposed to and ensheathed Liver: selective TR agonists for the treatment of dyslipidemia by the tanycyte processes. Ultrastructural studies revealed that under conditions of Bo Angelin & Mats Rudling low gonadotropin output such as in diestrus, GnRH-secreting nerve terminals are Department of Medicine, Karolinska Institutet at Karolinska University completely surrounded or engulfed by tanycytes, which prevent direct access to the Hospital Huddinge, Stockholm, Sweden. portal vessels and thus create a diffusion barrier impeding GnRH entry into the pituitary portal circulation. During the preovulatory surge on the day of proestrus, a structural remodeling of tanycytes occurs, resulting in the release of the engulfed Thyroid hormones exert their effects by stimulation of thyroid hormone receptors axons and the establishment of a direct neurohaemal relationship between GnRH that have different tissue distribution and metabolic targets. TRb is predominant neuroendocrine neurons and the pituitary portal blood. These morphological in liver and mainly responsible for effects on cholesterol and lipoprotein changes presumably favor the release of GnRH into the portal vasculature; the lack metabolism, whereas TRa is most important in fat, muscle and heart. Thyroid of glia between the neuroendocrine terminals and the perivascular spaces results in hormone analogs (thyromimetics, tiromes) have been developed that activate the removal of a diffusion barrier, so that released neurohormones can reach the TRb are selectively taken up and/or activated by the liver. Such compounds fenestrated capillaries of the median eminence more efficiently. Underlying stimulate hepatic LDL receptors, cholesterol elimination as bile acids and signaling pathways responsible for these structural changes are comprised of cholesterol and presumably promote reverse cholesterol transport. In animals, highly diffusible gaseous molecules such as endothelial nitric oxide (NO) and they retard atherosclerosis progression. In humans, eprotirome exerts favourable paracrine communication processes involving receptors of the erbB tyrosine lipid-modulating effects while lacking thyroid hormone-related side-effects and kinase family, transforming growth factor b 1 (TGFb1) and eicosanoids such as maintaining normal hypothalamic–pituitary–thyroid feedback. When added prostagladin-E2 (PGE2). to statins, it reduces LDL and non-HDL cholesterol, apolipoprotein B, and triglycerides as well as lipoprotein (a). Conclusion Liver-specific and b-selective thyroid hormone analogs activate a spectrum of favourable thyroid hormone actions that optimize lipid metabolism and promote S7.3 cholesterol elimination. Further studies should establish long-term safety and potential clinical usefulness of thyromimetics. Food or sex: neuropeptides decide Iain Clarke Department of Physiology, Monash University, Clayton, Australia.

As a general rule, hypothalamic neuropeptides that stimulate food intake act to Eat, bond, reproduce – what the hypothalamus dictates inhibit the reproductive axis. We have studied the functions of two peptide systems in detail. Melanocortins, such as melanocyte stimulating hormone-a, b S7.1 and g, are products of the pro-opiomelanocortin (POMC) gene, produced in cells Vasopressin and the olfactory system of the arcuate nucleus and act to inhibit feeding. Melanocortins also stimulate the Mike Ludwig reproductive axis. In lean hypogonadotropic ovariectomised ewes, POMC gene University of Edinburgh, Edinburgh, UK. expression is reduced, but i.c.v. infusion of leptin increases expression of this gene and peptide levels as well as restoring pulsatile LH secretion. I.c.v. infusion of a melanocortin receptor agonist also increases LH secretion in lean animals, The neuropeptide vasopressin is now known to be released in the brain where it suggesting that the melanocortin system may be the means by which the rep- plays important roles in social behaviours. We have shown that the rat olfactory roductive axis is regulated by changing metabolic state. Furthermore, the agonist 1 2 bulb (OB) and the anterior olfactory nucleus (AON) contain large populations can stimulate pulsatile LH secretion in the luteal phase of the estrous cycle. of interneurones which express and release vasopressin. In the OB, single cell Melanocortin cells have reciprocal communication with kisspeptin cells of the recordings from mitral cells in vivo showed that vasopressin modulates the arcuate nucleus, so effects of these two systems on the GnRH cells may be integrated. processing of information by olfactory bulb neurones. Blocking the actions of Gonadotropin inhibitory hormone (GnIH) is produced by cells of the dorsomedial vasopressin in the OB (using antagonists or small interference RNA against the hypothalamic nucleus/paraventricular nucleus. These cells project to GnRH cells vasopressin V1a receptor, or local selective destruction of vasopressin cells with and appetite regulating cells as well as to the neurosecretory zone of the median diphtheria toxin in transgenic rats) impairs the social recognition abilities of rats. eminence. In sheep at least, GnIH acts to inhibit both GnRH cells and pituitary The treatments impaired habituation/dishabituation to juvenile cues, but not to gonadotropes. The peptide also has a potent effect to stimulate food intake. GnIH volatile odours or object recognition, and did not affect locomotor activity or gene expression is reduced in the periovulatory period, consistent with data from anxiety-related behaviours. Adult rats exposed to a conspecific juvenile showed other species showing a reduction in appetite at the time of ovulation. Thus, GnIH increased Egr-1 expression in vasopressin neurones in multiple subdivisions of signals to inhibit reproduction and stimulate food intake. AON as compared to animals exposed to no odour or a non-social odour. These The melanocortins and GnIH both act to regulate reproduction and food intake. data suggest that vasopressin neurones in the AON may also play an important Reduced melanocortin levels in lean condition may be the cause of lowered activity role in the coding of social odour information. The findings indicate that the of the reproductive axis. vasopressin process olfactory signals relevant to social discrimination and dendritic vasopressin release may be involved in filtering out familiar signals. Because this filtering is important for social recognition, it seems that the vasopressin release must depend on previous olfactory experience. In the hypothalamus, activity-dependent dendrictic vasopressin release can be con- ditionally regulated (primed) by recent experience; we are currently investigating whether such a mechanism in the olfactory bulb mediates conditional changes in the olfactory recognition. S7.4 A role for kisspeptin/neurokinin B/dynorphin neurons in initiating and maintaining reproduction Victor Navarro1,2 1University of Washington, Seattle, Washington, USA; 2University of S7.2 Cordoba, Cordoba, Spain. The role of tanycytes in the regulation of the reproductive axis Vincent Prevot1,2 1Inserm, Lille, France; 2University of Lille, Lille, France. Puberty is a tightly regulated process through which an individual attains reproductive capability. An intricate network of central and peripheral factors play a role in this process; however, the cellular and molecular events that initiate The neuroendocrine fraction of GnRH neurons sends axon to the median eminence and sustain adult reproductive function remain largely unknown. Recently, of the hypothalamus where they release their neurohormone into the pituitary kisspeptin (encoded by Kiss1) and neurokinin B (NKB, encoded by TAC3 in portal vasculature to regulate the reproductive axis. Specialized unciliated humans and Tac2 in rodents) have been shown to be gate-keepers of puberty ependymal cells named tanycytes, which line the floor of the third ventricle, onset. Studies in humans and rodents have shown loss-of-function mutations in confer to the median eminence its peculiar cytoarchitecture. Tanycyte cell bodies either Kiss1/NKB or their receptors, Kiss1r/NK3R, produce congenital hypo- are located in the ventral border of the third ventricle but they also send processes to gonadotropic hypogonadism and infertility, but beyond these observations and the pericapillary space, where they make contact with the pial surface of the brain correlations that link sexual development to changes in Kiss1 and NKB and fenestrated portal blood capillaries through ‘end feet’ specialized structures. expression, we have little understanding of precisely how NKB and kisspeptin

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK guide pubertal maturation. We and others have shown that kisspeptin, NKB and S8.4 dynorphin A (Dyn) are co-expressed in neurons of the arcuate nucleus; moreover, Protecting bone density during aromatase inhibitor therapy these neurons also co-express NK3R. NKB has been shown to stimulate LH Robert Coleman release, presumably by acting autosynaptically on these Kiss1/NKB/Dyn neurons Weston Park Hospital, Sheffield, UK. to induce kisspeptin-mediated GnRH secretion. We have proposed a model in which NKB works in concert with the counter-regulatory action of dyn (acting through interneurons) to shape the coordinated ultradian release of kisspeptin and There are increasing numbers of long-term survivors from breast cancer who will GnRH and thereby drive the pulsatile release of LH secretion that is essential for have received combination endocrine treatments alone or in addition to cytotoxic the onset of puberty and for the maintenance of reproductive function in the adult. chemotherapy. As a result, many of these individuals are at increased risk of osteoporosis, largely because of the endocrine changes induced by treatment characterised by a reduction in the level of bioavailable oestradiol. The associated increase in bone turnover that accompanies cancer treatment induced bone loss (CTIBL) can lead to a 40–50% increase in the rate of fragility fractures. The use of bisphosphonates in early cancer has become increasingly important to prevent adverse effects of cancer treatments on bone health. These include Hormones and bone metabolism chemotherapy induced ovarian failure and the use of aromatase inhibitors. Bisphosphonate strategies, similar to those used to treat post-menopausal S8.1 osteoporosis, are the intervention of choice for patients with low bone mineral Fracture risk in patients with diabetes density (BMD) or rapid bone loss, along with adequate calcium and vitamin D intake L Hofbauer and a healthy lifestyle. The results of several intervention studies with zoledronic Dresden, Germany. acid in early breast cancer indicate that BMD is maintained and increased bone turnover normalised. There are also preliminary data from smaller studies using oral bisphosphonates at standard osteoporosis doses, as well as the new bone targeted Abstract unavailable. agent denosumab, an antibody to RANKL. In addition to the beneficial effects of bisphosphonates on bone health, some data from trials in early breast cancer suggest that they may also reduce cancer recurrence rates in the adjuvant setting. Guidelines on the management of CTIBL have recently been formulated and utilise a risk adapted strategy similar to that used in the management of postmenopausal osteoporosis, with the exception that the recommended BMD threshold for S8.2 intervention with pharmacological treatments is somewhat higher due to the accelerated rate of bone loss. Muscle weakness, falls and vitamin D deficiency

Abstract unavailable. Doping: performance enhancing substances in sport and their detection S9.1 Anabolic steroids in the gym A Kicman S8.3 Department of Forensic Science and Drug Monitoring, King’s College, Drug Control Centre, London, UK. Effects of male hypogonadism on bone metabolism Jean-Marc Kaufman Ghent University Hospital, Gent, Belgium. Bodybuilders and athletes have recognised for several decades that the use of anabolic steroids can promote muscle growth and strength but it is only relatively recently that these agents are being revisited for clinical purposes. The Pubertal exposure to rising blood concentrations of sex steroids, partly in concert pharmacology of anabolic steroids is not well understood, although intracellular with transiently increased activity of the somatotropic axis, is instrumental in a steroid metabolism and also the topology of the bound androgen receptor pubertal acceleration of bone growth and acquisition of bone mass, followed by interacting with co-activators are considered to be important factors. Behavioural growth inhibition and closure of the epiphyseal cartilages in late puberty. As is changes by genomic and non-genomic pathways probably help motivate training. illustrated by experiments of nature, i.e. subjects with aromatase deficiency Doping with anabolic steroids can result in damage to health but it is important for or lack of functional oestrogen receptor a, and with androgen insensitivity endocrinologists not to exaggerate the risks but to emphasise to users that an syndrome, oestrogens are essential for skeletal maturation, acquisition of bone attitude of personal invulnerability to their adverse effects is certainly misguided. mass and epiphyseal closure, but androgen receptor-mediated action is required Despite the large number of xenobiotic anabolic steroids available, testosterone for achievement of optimal peak bone mass and size. In prepubertal causes of continues to be the most common adverse finding in drug control tests hypogonadism failure of timely and full pubertal development, and thus undertaken by World Anti-doping Agency accredited laboratories. The detection suboptimal sex steroid exposure, osteoporosis results from deficient accretion of testosterone administration, nonetheless, remains challenging and a number of of bone mass and size. Potential for reversibility by testosterone administration analytical approaches are now advocated, including using the individual as his depends on the advancement of skeletal maturation. own reference, a so-called athlete’s biological passport, and determination of Acquired profound hypogonadism in adulthood, e.g. following androgen steroid carbon-isotope ratio signatures. deprivation therapy for prostate cancer, induces a state of high bone turnover with accelerated bone loss and increased fracture risk, which results from combined deficiency of testosterone and oestradiol, its main aromatisation product. Ageing is accompanied by a limited progressive decrease of serum total testosterone levels, a marked increase of serum SHBG, which results in a more marked decline of the non SHBG-bound serum testosterone fractions readily S9.2 available for biological action. Whereas serum oestradiol is well maintained, Compounds enhancing oxygen delivery there is a decline of the non SHBG-bound serum fractions. There is considerable Peter Hemmersbach1,2 between subject variability of these age-related changes. As to their implication 1Norwegian Doping Control Laboratory, Oslo University Hospital, Oslo, for bone homeostasis, literature data concur to indicate that it is primarily Norway; 2School of Pharmacy, University of Oslo, Oslo, Norway. oestrogen deficiency that contributes to the determination of senile bone loss. In general, beneficial effects of testosterone treatment on bone mineral density have been limited to men with initially frank hypogonadism. On the other hand, For more than 25 years substances and methods enhancing oxygen delivery in the osteoporotic hypogonadal men have been shown to be equally responsive to body have been of great concern in the fight against doping. The clear influence of specific osteoporosis medication, e.g. bisphosphonates, denosumab or teripara- an increased amount of red blood cells on physical performance, most obvious for tide, than eugonadal osteoporotic men. endurance sports, has alerted the anti-doping authorities to put a high priority on efforts to disclose the administration of such doping practices.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

The annually updated WADA-prohibited list mentions several erythropoiesis and was introduced at the Athens Olympic Games in 2004. The first analytical stimulating agents (ESA) as well as methods for the enhancement of oxygen adverse finding using this test was made in February 2010 following an out- transfer. The indicated substances include all different glycoprotein forms of of-competition blood sample. The second approach is based on the measurement erythropoietin preparations, synthetic peptidic compounds (Hematide/Peginesatide) of IGF1 and N-terminal pro-peptide of type III collagen, both of which are as well as small molecular hypoxia-inducible factor (HIF) stabilizers. Prohibited markers of GH action. Both markers rise in a dose dependent manner and are methods like autologous and non-autologous blood transfusions are as well largely unaffected by other regulators of GH secretion. When combined with prohibited as haemoglobin-based oxygen carriers (HBOCs). gender specific discriminant function analysis, they achieve a greater sensitivity The analytical approaches to disclose these kinds of doping range from direct and longer window of detection than the isoform test. The development of this test detection of the actual prohibited substance or its markers (metabolites) to is nearing completion. indirect detection methods monitoring the effects of those doping practices through the establishment of the Athlete’s Biological Passport. A broad selection of analytical techniques has been developed including among others chromatographic separation with mass spectrometric detection (LC–MS), isoelectric focusing (IEF) and flow cytometry. For several of the discussed substances a possible performance enhancing effect lasts considerably longer than its presence in the body. Therefore, doping control measures have been extended by an indirect approach, monitoring an individual haematological profile over S9.4 time documented as the Athlete’s blood passport. Comprehensive harmonized Beyond reasonable doubt: catching the GH cheats guidelines have been established through the world anti-doping agency (WADA) Richard Holt in order to describe pre-analytical, analytical and interpretational criteria for its Faculty of Medicine, University of Southampton, Southampton, UK. application in doping control. There is widespread anecdotal evidence that GH has been misused by athletes for its anabolic and lipolytic properties since the early 1980s, at least a decade before GH was used therapeutically by adult endocrinologists. Since then a number of high profile athletes have admitted using GH. Despite its widespread abuse, there S9.3 is debate about whether GH is ergogenic. Until recently most scientific studies Beyond reasonable doubt: catching the GH cheats have not shown a performance enhancing effect but most have employed an R Holt inappropriate design to show a benefit. University of Southampton, Southampton, UK. Although GH is on the world anti-doping agency (WADA) list of banned substances, the detection of abuse with GH is challenging. Two approaches have been developed; the first is based on the measurement of pituitary GH isoforms There is widespread anecdotal evidence that GH has been misused by athletes for and was introduced at the Athens Olympic Games in 2004. The first analytical its anabolic and lipolytic properties since the early 1980s, at least a decade before adverse finding using this test was made in February 2010 following an GH was used therapeutically by adult endocrinologists. Since then a number of out-of-competition blood sample. The second approach is based on the high profile athletes have admitted using GH. Despite its widespread abuse, there measurement of IGF1 and N-terminal pro-peptide of type III collagen, both of is debate about whether GH is ergogenic. Until recently most scientific studies which are markers of GH action. Both markers rise in a dose dependent manner have not shown a performance enhancing effect but most have employed an and are largely unaffected by other regulators of GH secretion. When combined inappropriate design to show a benefit. with gender specific discriminant function analysis, they achieve a greater Although GH is on the World Anti-doping Agency (WADA) list of banned sensitivity and longer window of detection than the isoform test. The substances, the detection of abuse with GH is challenging. Two approaches have development of this test is nearing completion. been developed; the first is based on the measurement of pituitary GH isoforms

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Clinical Management Workshops Generously supported by Clinical Endocrinology

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

The management of difficult Graves’ disease operation is required, orbital decompression, squint surgery and eyelid surgery should be performed in this sequence. CM1.1 Dermopathy usually occurs in patients who also have severe GO. In mild- Autoimmune hyperthyroidism: a spectrum of causes to-moderate forms topical steroid ointment with sealing cover (steroid occlusive 1,2 S Pearce dressing technique) for at least 4–6 weeks is the treatment of choice, but the long- 1 Institute of Human Genetics, International Centre for Life, Newcastle term benefit of this treatment remains to be clearly determined. Systemic 2 University, Newcastle upon Tyne NE1 3BZ, UK; Endocrine Unit, Royal glucocorticoids are rarely employed, unless they are used for the concomitant GO. Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK. High-dose i.v. immunoglobulins, octreotide and plasmapheresis have occasion- ally been used for severe cases of dermopathy with some success, but evidence on the real effectiveness of these treatments is scant. Surgical excision has been Autoimmune hyperthyroidism has a complex aetiology including both reported in elephantiasic forms of dermopathy, but it is usually not recommended environmental and inherited components. Amongst the environmental factors because of the high recurrence rates. that are well documented to be important are smoking and stressful life events. The prevalence of all forms of autoimmune hyperthyroidism is known to be higher in women, but the effects of oestrogen are complex: the combined oral contraceptive pill protecting against Graves’ disease, whereas pregnancy predisposes. Autoimmune hyperthyroidism also occurs in rare individuals during recovery from an immunosuppressed state due to HIV infection or following alemtuzumab treatment. Genomic factors that are well documented include CM1.4 predisposing alleles at the MHC, CTLA4 and PTPN22 loci. Other candidate New therapies for Graves’ disease genes that have a role include TSHR. Recent genome-wide linkage studies have Colin Dayan also shown several other loci with weak effects that appear to contribute, Cardiff University, Cardiff, UK. including PTPN2 and CD226.

While the aetiology of Graves’ disease is now well-established, treatment for Graves’ disease has largely remained unchanged for 50 years. However, relapse rates following antithyroid drug treatment remain high, destructive therapy to the thyroid is not without its short and longer-term risks and there have been limited studies of the benefits of different treatments in terms of long-term outcomes such CM1.2 as cardiovascular disease. There therefore remains much room for optimisation Thyroid storm, aranulocytosis, vasculitis, hepatitis: what to do next? of our therapeutic approach. The advent of second generation assays for TSH A Allahabadia receptor antibodies offers the possibility of targeted timing of the duration of Sheffied, UK. antithyroid drug therapy and recent studies have improved predictive scores and identified additional factors such as serum selenium levels and common genetic variation that may modify the response to treatment. Prior thionamide therapy and Abstract unavailable. the use steroids also modulate the response to radioioidine therapy. The duration of exposure to high thyroid hormone levels may impact on long-term cardiovascular and osteoporotic outcomes and new data is gradually becoming available that may influence the selection of therapy for Graves’ disease. B-cell therapy has recently been trialled for Graves’ disease and Graves orbitopathy and may improve remissions rates after anti thyroid drug therapy. New developments CM1.3 in blocking anti-TSH receptor monoclonal antibodies and the design of small The management of Graves’ ophthalmopathy and dermopathy molecule inhibitors of the TSH receptor may allow for more rapid induction of Luigi Bartalena remission and improved outcomes especially in refractory disease. University of Insubria, Varese, Italy.

Extrathyroidal manifestations of Graves’ disease include eye disease (Graves’ ophthalmopathy, GO), dermopathy (also known as pretibial myxedema) and nail changes (acropachy). While about 50% of Graves’ patients are affected with mild to moderately severe GO, dermopathy is present only in 1–4% of cases, and acropachy in 0.1–0.4%. Endocrine problems in pregnancy Management of GO represents a complex and unresolved problem, and the CM2.1 treatment outcome is frequently unsatisfactory both to the patient and the Hypothyroidism and euthyroid antibody-positivity in pregnancy physician. Medical treatment is often followed by rehabilitative surgery, S Chan including orbital decompression, squint surgery, eyelid surgery. An aggressive Department of Fetal Medicine, Birmingham Women’s Hospital, medical treatment is indicated only when GO is active, i.e. in the inflammatory Birmingham, UK. phase of the disease. Mild active GO usually does not require a specific treatment but only local measures such as artificial tears, ointments, dark lenses, prisms (for mild diplopia), and general measures, such as refrain from smoking. If however Overt hypothyroidism, diagnosed and treated with L-thyroxine pre-pregnancy, the quality of life is severely affected, the patient can be admitted to active affects 1% of pregnancies. Untreated maternal hypothyroidism is associated with treatment as for moderate-to-severe cases. First-line treatment for moderate- adverse obstetric and neonatal outcomes, and even when partially treated the risks to-severe and active GO is represented by glucocorticoids. The latter can of miscarriage and prematurity remain elevated compared to euthyroidism. With administered via the oral route or the i.v. route. Randomized clinical trials have increased understanding of the normal physiological changes to thyroid function shown that the i.v. route is more effective and, in general, better tolerated. Severe during pregnancy, there should be a predictive approach to thyroxine dose side effects may however occur. Accordingly, this treatment should preferably be adjustments in order to prevent the development of abnormalities in thyroid performed in specialized centres under strict surveillance. There is no evidence as function, which could impact upon fetoplacental development. The vast majority to the optimal regimen. A commonly used schedule consists of 12 weekly slow of women will require a 30–50% dose increase by 5–8 weeks of gestation. infusion, with a cumulative dose of 4.5–5 g methylprednisolone. Some evidence Gestation specific reference ranges should be used, and these vary between assay suggests that a cumulative dose !8 g per cycle is associated with a low risk platforms and patient populations. Since subclinical hyperthyroidism is not of hepatotoxicity. Unfortunately, treatment outcome is not always favourable. associated with any adverse obstetric outcomes, and given that even within the If response is not satisfactory and GO is still active, treatment options include normal reference range there are correlations between serum TSH and free T4 a second course of i.v. glucocorticoids associated with orbital radiotherapy, or concentrations with perinatal loss and fetal malposition, the aim of treatment oral glucocorticoids combined with cyclosporine. A promising drug for GO (and should be to maintain TSH within the lower part and free T4 within the upper part Graves’ hyperthyroidism) is rituximab, but randomized clinical trials on the use of the respective normal reference ranges. of this drug are lacking. In cases of sight-threatening GO (mostly due to The roles of universal screening for and treatment of previously undiagnosed dysthyroid optic neuropathy), i.v. methylprednisolone at very high doses (1 g for subclinical hypothyroidism (defined as elevated serum TSH accompanied by three consecutive days, to be repeated on the next week) is the first-line treatment. normal free T4; 2.5% of pregnancies) and isolated hypothyroxinaemia (normal If the response is absent or poor within 2 weeks, the patient should be promptly serum TSH accompanied by low free T4; 2% of pregnancies) in pregnancy remain submitted to orbital decompression. Rehabilitative surgery, if needed, should be controversial. Although these biochemical abnormalities have been associated performed after GO has been inactive for at least 6 months. If more than one with increased obstetric risks and impaired offspring neurodevelopment in some

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK studies, recently completed intervention trials of L-thyroxine treatment have not The lecture will include brief remarks on the management of the pregnant patient yielded conclusive results. The Wales controlled antenatal thyroid screening with congenital adrenal hyperplasia. Cushing syndrome can present during (CATS) study which assessed the impact of antenatal screening and L-thyroxine pregnancy and the lecture will highlight the diagnostic and therapeutic problems treatment on offspring neurodevelopment found no significant differences in associated with this, including the choice and timing of medical and surgical mean IQ scores at aged 3 years between experimental and control groups. Another interventions. Finally, major issues associated with the management of adrenal study conducted in Italy comparing universal screening with targetted case masses during pregnancy will be discussed. finding in early pregnancy found no differences in obstetric outcome between groups. However, in both these studies, sub-analyses suggest that L-thyroxine may still be beneficial in some cases. It is possible that screening and treatment has been commenced too late to make a full impact on the pregnancy. A further 10–15% of pregnant women have thyroid autoimmunity (anti-thyroid CM2.4 peroxidase (TPO) positivity). Despite the majority being biochemically euthyroid, they are also at increased risk of miscarriage and preterm delivery. Pituitary disease in pregnancy (including NFPA, prolactinomas, DI) Two small clinical trials have suggested that L-thyroxine treatment could halve J Lenders these risks. Our group in Birmingham has just received EME-funding to Nijmegen, The Netherlands. commence a multi-centred (21 UK centres) randomised controlled trial (TABLET) to confirm this effect in a substantially larger group of women. Abstract unavailable. Two key issues which remain to be answered are i) whether screening for subclinical thyroid dysfunction and thyroid autoimmunity, and the commence- ment of L-thyroxine treatment PRECONCEPTION could normalize obstetric outcomes and offspring neurodevelopment, and ii) whether there are specific subgroups of women who would definitely benefit from L-thyroxine treatment. Pituitary radiotherapy: what are the options? CM3.1 Focused radiotherapy as primary treatment for pituitary disease M Brada CM2.2 The Institute of Cancer Research, London, UK. Treatment of hyperthyroidism in pregnancy: risk for the unborn Maurizio Clementi, Matteo Cassina & Elena Di Gianantonio Fractionated radiotherapy (RT) is effective in achieving disease control and Clinical Genetics - University, Padua, Italy. normalisation of hormone levels. While overall safe, it is not devoid of side effects and should only be employed when the risks from the disease are considered to outweigh the risks from treatment. Currently RT tends to be Clinical hyperthyroidism is not uncommon in pregnancy, with a reported withheld until progression unless there is a threat to function, particularly vision, prevalence of 0.1–0.4%, and is caused most frequently by Graves disease. Careful from progressive tumour. RT is recommended for patients with secreting monitoring of thyroid function is critical in preventing the many potential adenoma not achieving biochemical cure following surgery and medical complications that can occur in pregnancies of mothers with hyperthyroidism. treatment. Normalisation takes months to years and the delay is related to pre- Maternal complications include hypertension, thyroid storm, heart failure preterm treatment hormone levels. labour, and placental abruption. Foetal and neonatal complications include Modern developments in radiotherapy aim to treat less normal tissue to significant stillbirth, intrauterine growth restriction, low birth weight, heart failure, radiation doses minimising the risk of late normal tissue injury. Treatment can be hyperthyroidism, and hypothyroidism with or without goitre. Currently, the given as fractionated (fractionated stereotactic radiotherapy – fSRT/SCRT) or drugs used to control maternal hyperthyroidism are propylthiouracil (PTU) and single fraction treatment (stereotactic radiosurgery – SRS) and relies on increased methimazole (MMI)/carbimazole (CZ). Both medications cross the human accuracy of tumour delineation with MRI. While there is perception that it is the placenta with relatively similar transfer and placental clearance rates. PTU and use of modern technology which determines the outcome, the success is more MMI/CZ are equivalent in terms of their efficacy in the treatment of clinical likely related to operator skill and expertise and the accuracy in identifying the hyperthyroidism. Some reports suggested an association between specific tumour. congenital malformations (MMI embryopathy) and prenatal exposure to MMI. Conventional fractionated RT achieves tumour control in 90–95% of patients at Using prospective data from the European Teratogen Information Services, 10 and 85–90% at 20 years. Published results of fSRT show similar early results Di Gianantonio concluded that there might be a higher than expected incidence but have not reached the maturity of long term results of conventional RT. SRS, of choanal and oesophageal atresia in foetuses exposed to MMI between the third while apparently more convenient, is less effective in achieving tumour control and seventh weeks of gestation. Further reports of congenital anomalies, without faster decline in hormone levels in secreting tumours. SRS of larger specifically of choanal atresia, have definitely suggested that MMI may be a adenomas close to critical structures carries a significant risk of radiation damage. new teratogen. For PTU the association with possible teratogenic risk is unclear, Fractionated irradiation either as modern conformal or fractionated stereotactic but this difference could be an artifact due to the lack of studies on PTU. RT remains the standard of care with SRS considered as an experimental and in However, recent studies failed to detect a significant association between PTU some instances less effective treatment. exposure during the first trimester of pregnancy and congenital malformations. In view of these reports, it is generally recommended that, when available, PTU be preferred as the initial therapy for maternal hyperthyroidism during the first trimester of pregnancy. However, the prescription of PTU later in pregnancy and during lactation should take into account the reported risk of hepatotoxicity in both the mother and the child. CM3.2 Focussed radiotherapy as primary treatment for pituitary disease J Rowe Shrewsbury, UK.

CM2.3 Abstract unavailable. Management of adrenal disorders in pregnancy Wiebke Arlt Centre for Endocrinology, Diabetes and Metabolism, University of Birmingham, Birmingham, UK. CM3.3 The manifestation of adrenal disorders during pregnancy is a rare but regularly Focused radiotherapy as a salvage treatment for pituitary disease occurring event and can pose significant problems for the involved medical F Swords professionals. This lecture will give an overview of the major management issues Norfolk and Norwich University Hospital, Norwich, UK. surrounding disorders of the adrenal cortex during pregnancy. This includes the requirements for the adjustment of corticosteroid replacement therapy in adrenal insufficiency, due to the physiological changes in corticosteroid secretion during There have been enormous advances in the medical and surgical management of pregnancy and subsequent to the anti-mineralocorticoid action of progesterone. pituitary tumours in recent years. Stereotactic radiotherapy has also allowed the

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK use of more focused fractionated radiotherapy in the hope of minimising birth – the inability to sex assign instantaneously. The typical newborn phenotype bystander damage and the long term sequelae of radiotherapy to the surrounding is represented by the ambiguity of a small penis/enlarged clitoris, labioscrotal normal brain tissue. folds, a single perineal orifice and gonads which may, or may not, be palpable. With these advances, the number of patients requiring salvage treatment of any The paradigm of ‘true’ ambiguous genitalia of the newborn is congenital adrenal kind is reducing, and concerns persist about the long term safety of all forms of hyperplasia. This disorder needs to be confirmed or not, early, in view of its life- radiotherapy. However, there remains a small cohort of patients with refractory or threatening risk. The diagnosis should be straightforward. A similar phenotype, recurrent disease despite all conventional treatments. but associated with an XY karyotype, requires a more complex investigation This presentation will include the latest data on the use of focused radiotherapy or strategy which may not result in a definitive diagnosis. The boundaries of radiosurgery to such difficult cases, following surgery and fractionated radio- the spectrum can include conditions as common as isolated hypospadias, therapy. undescended testes, and isolated labial fusion or as rare as complete androgen The largest group of patients treated with focused radiotherapy as a salvage insensitivity syndrome. Whatever the underlying cause, investigators must treatment is acromegaly. This presentation will therefore concentrate on the approach the problem from a thorough understanding of the genetic and hormonal efficacy of the treatment in this patient group, as well as reviewing both published control of normal fetal sex development. and unpublished data from other tumours. Such heavily pre-treated cases also have a high incidence of pituitary failure: 63% in one series. We will present data to suggest that further loss of pituitary function is common after the application of focused radiotherapy – occurring in 66% of the remaining cases by 2 years, although in our series, no other adverse events have been recorded to date. The presentation will therefore discuss the safety data from both published and unpublished series in detail, and attempt to establish the best CM4.2 subset of patients in whom to consider this treatment modality. Management of disorders of sex development (DSD) across the lifespan: presentation in adolescence Olaf Hiort University of Lu¨beck, Lu¨beck, Germany.

Despite recent enormous advances in the understanding of the molecular mechanisms of sex development, the medical decisions made in patients with CM3.4 disorders of sex development (DSD) are mostly lacking evidence-based principles and are carried on case by case evaluations. Very critical discussions have focused Radiotherapy, cognition and cerebrovascular disease: what is the on approaches on gender assignment and treatment of DSD. Any decision should evidence? be based on a correct diagnosis and possible prediction of development during John Ayuk puberty and adulthood of the affected individual. Puberty plays a pivotal role not University Hospital Birmingham, Birmingham, UK. only because of the physical changes induced by endogenous or supplementary steroids, but also as a time for sexual orientation and promotion of gender identity. Contemporary management of pituitary tumours is based on a multidisciplinary Therefore, many aspects from psychosexual guidance to medical treatment approach involving surgery, radiotherapy (RT) and medical therapy. External including hormone supplementation and surgical procedures have to be beam RT significantly reduces the likelihood of tumour re-growth following considered. The patient should be fully aware of the underlying condition and surgery for non-functioning pituitary adenomas and suppresses hypersecretion in should be able to reflect any therapeutically valid options. This can only be hormonally-active tumours. However, over the years, a number of potentially managed by a multidisciplinary team involving many subspecialties. Most of all, significant complications of pituitary RT have been described. experienced professionalism is needed to deal with these patients. Radiation may cause a variety of vascular injuries and haemodynamic changes to the cerebral vasculature, and several authors have reported cerebrovascular complications and an increase in cerebrovascular mortality in patients receiving RT for pituitary and other central nervous system tumours. It is also possible that pituitary RT increases the risk of cerebrovascular disease by causing hypopituitarism, which is itself associated with an increase in vascular mortality. Turner/Klinefelter’s/Noonan syndrome: case presentations However, questions remain with regards to causation. Patients with pituitary tumours frequently report problems with memory and CM4.3 sustained attention that impact upon normal daily activities. During conventional Transitional care of the young person with DSD pituitary RT, the limbic system, the hippocampus, the mammillary bodies and the Gerard Conway pre-frontal cortex all receive a significant amount of radiation. It has been UCLH Foundation Trust, London, UK. suggested that pituitary RT may be associated with cognitive impairment, but at present it is unclear whether any causal link exists between pituitary RT and Women with a 46XY karyotype comprise a heterogeneous group who differ not abnormalities of memory and higher mental function. only in their diagnostic category and anatomy but also in their journey from Stereotactic radiosurgery delivers multiple low-energy beams toward a target paediatric to adult services. Transition care should be an individualised process with improved stereotactic accuracy. The principal advantage is that it reduces the covering past experiences, current medical and surgical needs and future dose of radiation received by transirradiated tissue close to the target. It is a prospects is required for optimal wellbeing. A multidisciplinary team is helpful relatively new technique, only recently introduced in the management of pituitary in providing this care and liaison with supports groups (for instance the AISSG) disease. Some authors have suggested the ability to accurately direct high doses of is essential in order to keep informed of current issues in this area. radiation to the pituitary area with relative sparing of the surrounding tissues In a prospective audit of the clinical indications for referral and on-going clinical results in a more beneficial adverse profile. However, further data are required to needs for girls aged 12–20 years seen in a specialist DSD clinic over a 6-month fully assess the long-term adverse profile of stereotactic radiosurgery. period we used a simple ‘traffic light’ classification: green for low, amber for moderate, and red for high. Fifty girls were seen during the study period and all were referred from paediatric services. Patients may have had one or more indication(s) for referral to the adult clinic and these were: urology/gynaecology (70%), endocrinology (42%) and psychology (14%). The most common indication for on-going clinical input was psychology, with 46% of patients Management of disorders of sex development (DSD) across requiring monitoring and intervention. Of the 14 patients (28%) classified red suggesting they had an urgent clinical need, psychology was a major factor in the lifespan all but one patient. CM4.1 Despite progress in the understanding the genetic basis of human sexual The clinical spectrum of DSD development a specific molecular diagnosis is identified in only in a small Ieuan Hughes percentage of cases of DSD presenting to an adults DSD clinic. Many previous University of Cambridge, Cambridge, UK. diagnoses made on clinical grounds are found to be inaccurate. This is especially true in older patients who have had their diagnosis many years previously. It is well recognised that a delayed recognition of the condition can lead to greater The variability in the manifestation of DSD covers a spectrum ranging from difficulties in accepting the diagnosis. Access to specialist laboratory services is normal external female and male phenotypes to ambiguous genitalia. The latter required to make an accurate diagnosis after gonadectomy. scenario represents the sino qua non of DSD and poses a fundamental problem at

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

CM4.4 linkage or mapping studies are relatively rare. Traditionally, a candidate gene New approaches to molecular diagnosis approach has been used to identify many cases of DSD, which can be time John Achermann consuming and costly. However, the development of new nano-technologies UCL Institute of Child Health, University College London, London, UK. means that we could potentially identify the genetic causes of DSD on a high- throughput scale, and can start to address some newer genetic mechanisms that might be important in influencing disease phenotype (e.g. digenic or oligogenic It is now around 20 years since the identification of SRY as a primary testis- inheritance, gene dosage, epigenetic regulation). Here, I will provide an overview determining gene and the molecular characterisation of many of the key enzymes of new approaches to: i) karyotyping and the assessment of copy number variation and receptors involved in androgen synthesis and action. Although significant (e.g. array CGH, SNP-based technologies); ii) high-throughput sequencing (such progress has been made since then in identifying other components involved in as ‘resequencing’ microarrays and next generation sequencing technologies); sex development, we are still unable to find an underlying genetic cause in many iii) determining protein or methylation ‘signatures’. The challenges will be cost, individuals with these conditions. Efforts to identify specific genetic causes of scale, organisation/collaboration, bioinformatics, bioethics, predicting in vivo DSD are impeded by several factors such as phenotypic variability, the lack of functional effects, and integrating this wealth of information into an appropriate specific biochemical markers and the high frequency of ‘unusual’ genetic systems model relevant to DSD and of positive benefit to individuals with mechanisms such as sex-limited dominant inheritance or de-novo events. Indeed, these conditions. as DSD is usually associated with infertility, classic large pedigrees amenable to

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Applied Physiology Workshop

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Seeing is believing – cutting edge in vivo cell imaging median lag-phase of 90 min until apoptosis of the target cell, and were followed by CTL detachment and sequential killing of multiple target cells (up to 11/24 h). AP1.1 Using this model, local factors present in the tumor microenvironment were Cellular imaging in the pituitary: in vivo confocal microscopy identified that interfere with or enhance the anti-tumor CTL response and serial P Mollard killing. CXCL12, a chemokine with pro-migratory effects on CTL and known to Department of Endocrinology, Institute of Functional Genomics, Centre be upregulated in most tumors, enhanced CTL migration, shortened interaction National de la Recherche Scientifique (CNRS), University of Montpellier, times with target cells and reduced the killing efficiency on a per-contact-basis Montpellier, France. which lead to near-complete abrogation of target cell killing at low CTL to target cell ratio. This effect was reversed by a CXCR4 antagonist, suggesting that enhancing serial killing by targeting the CXCR4/CXCL12 axis may improve anti- Understanding the dynamic control of hormonal and metabolic homeostasis tumor immunotherapy. requires a description of the input, secretory and output mechanisms that underlie Pro-migratory signals mediated by the tumor microenvironment further the life cycle of hormone pulses. Whilst input stimuli and hormone output have contribute to cancer invasion and metastasis. We investigated in vivo tumor been measured, in vivo measurements of the blood microcirculation during a cell invasion principles, potential guidance structures, the molecular mechanisms secretory pulse, and signalling at the cell and population level in the intact organ invasion, and the response of different tumor niches to anti-cancer therapy. have not. To achieve this long-standing question, we recently developed a Intravital fluorescence and multiphoton microscopy was used to study HT-1080 strategy to image in real-time the life cycle of hormone pulses in the pituitary fibrosarcoma xenografts implanted into the dorsal skin-fold chamber on nude gland by using a new imaging approach utilising long range objectives (Lafont mice. After initial growth, tumors developed zones of invasive growth consisting et al. PNAS 2010 107 4465–4470. It enabled us to measure local blood flow, of multicellular collective invasion strands that retained cell–cell contact and the oxygen partial pressure and cell activity at single-cell resolution in mouse ability to proliferate while invading at velocities of up to 200 mm/day. This pituitary glands in situ. When secretagogue (GHRH) distribution was modelled invasion occurred in a directed manner along blood/lymph vessels and muscle with fluorescent markers injected into either the bloodstream or the nearby strands of the deep dermis. Therapeutic irradiation induced complete regression intercapillary space, a restricted distribution gradient evolved within the pituitary of the tumor main mass yet failed to eradicate perivascular invasion strands. parenchyma. Injection of GHRH led to stimulation of both GH cell network Using knockdown and/or antibody-based treatment against b1/b3 integrins but activities and GH secretion, which was temporally associated with increases in not interference with EGFR prompted significant radiosensitization of both, blood flow rates and oxygen supply by capillaries, as well as oxygen tumor main mass as well as invasion strands implicating integrin-mediated consumption. Moreover, we observed a time-limiting step for hormone output adhesion and/or anti-apoptotic signaling (anoikis) in radioresistance. In at the perivascular level; macromolecules injected into the extracellular conclusion, collective invasion not only supports fast angiotropic invasion but parenchyma moved rapidly to the perivascular space, but were then cleared maintains an integrin-dependent survival niche. more slowly in a size-dependent manner into capillary blood. Hence, GH pulse Thus, visualizing cell kinetics in 3D in vitro and in vivo models provides novel generation is not simply a GH cell network response, but is shaped by a tissue cellular and molecular mechanisms of CTL-mediated immune defense and cancer microenvironment context, involving a functional association between the GH invasion, and the role of the local tumor microenvironment therein. cell network activity and fluid microcirculation. These new cellular in vivo imaging approaches will allow the future investigation of how the pituitary microenvironment influences different cell systems, not only during periods of normal physiological demand, but also when the endocrine tissue and microvasculature are altered (e.g. tumours).

AP1.3 Quantitative imaging for assessing physical phenotypes in stem cells AP1.2 Kevin Chalut, Andrew Ekpenyong & Jochen Guck Dynamic imaging of the tumor microenvironment: impact on invasion University of Cambridge, Cambridge, UK. and CTL effector function Peter Friedl1,2, Stephanie Alexander2 & Bettina Weigelin1 1Department of Cell Biology, Nijmegen Center for Molecular Life Science, It is becoming increasingly clear that stem cell function and differentiation state Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands; are affected by the physical environment of the stem cell, and the stem cell’s 2Rudolf-Virchow Center for Experimental Biomedicine and Department of physical properties – or physical phenotypes. Physical phenotypes include how Dermatology, Venerology, and Allergology, University of Wu¨rzburg, the cell responds to forces in its environment and its subcellular structure. This Wu¨rzburg, Germany. presentation will be primarily focused on subcellular structure, or structural phenotype. I will present two different techniques to quantitatively assess structural phenotype. The first is digital holographic microscopy (DHM), which is Improvements in real-time intravital imaging techniques and two-photon a marker-free method for assessing protein density within cells. The second is microscopy make it now possible to visualize the complex tumor microenviron- confocal microscopy, in which I used an anti-HP1a label for heterochromatin to ment in vivo, over time and deeply within intact tissues. Using dynamic imaging, deduce the distribution of chromatin and how it changes during cell we addressed central aspects of tumor progression, including dynamic differentiation. With both of these techniques, I observed significant changes in interactions of invading tumor cells with the tumor microenvironment and the the structural phenotype of HL60 cells as they differentiated into three different local regulation of tumor infiltrating immune cells in eradicating tumor cells. lineages. I extended these techniques to pluripotent stem cells (PSCs), and Immunological control of tumor progression requires the activation and assessed how the subcellular structure changed as PSCs make their first fate expansion of tumor-specific cytotoxic T lymphocytes (CTL) followed by an decisions. I will discuss the changes observed in the distribution of chromatin, efficient effector phase in the tumor lesion. To mimic in vivo dynamics of CTL novel ways to quantify it, and how it can be used as a biomarker for stem cell effector function we established a 3D collagen matrix based assay to observe CTL function and differentiation state. Furthermore, I will discuss how physics-based effector function in real time, including active migration, sequential interactions concepts and techniques can lead to a minimally invasive, quantitative toolbox for with and serial killing of target cells. Individual CTL-target cell contacts were assessing stem cells, both in the laboratory and in the clinic. variable in duration (min to hours) and kinetics (stable to dynamic), comprised a

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Clinical Guidelines

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

CG1.1 consciousness caused by haemorrhage and/or infarction of the pituitary gland. It Pituitary apoplexy new society guidelines for treatment is associated with the sudden onset of headache accompanied or not by John Wass, Senthil Kumar, Narendra Reddy, Mark Vanderpump neurological symptoms involving the second, third, fourth and sixth cranial & Stephanie Baldeweg nerves. If diagnosed patients should be referred to a multidisciplinary team Churchill Hospital, ORH, Oxford, UK. comprising, amongst others, of a neurosurgeon and an endocrinologist. Apart from patients with worsening neurological symptoms in whom surgery is indicated it is unclear currently for the majority of patients whether conservative The guidelines for the treatment of pituitary apoplexy have now been published in or surgical management carries the best outcome. Clinical Endocrinology (Clin Endocrinol 2011 Jan;74(1):9–20). These resulted Post apoplexy from a group set up during the London pituitary multidisciplinary meeting. There needs to be careful monitoring for recurrence of tumour growth. It is Classical pituitary apoplexy is a medical emergency and rapid replacement with suggested that further trials be carried out into the management of pituitary hydrocortisone maybe life saving. It is a clinical syndrome characterised by apoplexy in order to optimise treatment. the sudden onset of headache, vomiting, visual impairment and decreased

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Special Interest Groups

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Bone and mineral special interest group progressive deafness and scoliosis. The condition is divided into various subtypes with types I and IV being the commonest, type 2 is lethal in utero and type 3 is SIG1.1 associated with most disability and deformity. Patients with OI typically have a Osteopetrosis and other causes of high bone mass large number of fractures in childhood, a reduced number in early adulthood but Celia Gregson there appears to be an exaggerated risk of fracture with increasing age. In the past, University of Bristol, Bristol, UK. there was no treatment but children with the condition are now frequently treated with courses of i.v. bisphosphonates that increase the density of bone and improve mobility. It is far less clear how adult patients with OI should be managed. This is Knowledge of rare genetic skeletal disorders has helped guide innovative largely due to a lack of long-term data regarding the natural history of untreated treatment developments for osteoporosis, for example from our understanding of OI. Additionally, there is some evidence in support of the use of bisphosphonates pycnodysostosis balicatib has emerged, as have anti-SOST antibodies from our in adults with OI but it is unclear who these drugs should be targeted to (and experience of sclerosteosis and Van Buchem’s disease. Yet much high bone mass when) and whether there are any long-term adverse effects associated with these remains unexplained, better appreciation of which may translate into improved drugs in such patients. Long-term use of bisphosphonates has been linked to understanding of bone regulation and new therapeutic targets for future atypical fractures, suppressed bone turnover and osteonecrosis of the jaw in osteoporosis therapies. patients with osteoporosis. Whether similar risks exist in patients with OI is This presentation will review disorders of osteoclast function known to cause unclear. To address these issues we recently developed a combined bone/clinical osteopetrosis in adults, in addition to disorders of enhanced bone formation genetics clinic within the West Midlands. We have identified over 200 individuals leading to increased bone mass, for example those caused by mutations affecting with OI, the majority of which have not previously had specialist assessment as LRP5 and SOST, which up regulate wnt signalling. I will then describe the adults. This cohort will provide the basis for longitudinal observational studies epidemiology of the high bone mass phenotype in the UK, which to date has not relating to the natural history of treated and untreated OI. been explained by known mutations in LRP5 or SOST. I will also summarize some established diagnoses, aside from high bone mass, which can cause raised bone density on routine DXA scanning. Finally, I will present details of the clinical features of unexplained high bone mass, which include increased skeletal and mandibular size and impaired SIG1.4 buoyancy, suggestive of a mild skeletal dysplasia, although the underlying genetic basis remains to be determined. Interestingly, these high bone mass cases Osteoporosis also have evidence of a metabolic phenotype as evidenced by an increase in fat Andre Uitterlinden mass, providing support for recent laboratory studies suggesting that important The Netherlands. links exist between bone and fat metabolism. Abstract unavailable.

SIG1.2 Patients teaching doctors: hypophosphatemic rickets and the revelation Obesity special interest group of a novel phosphate homeostatic system SIG2.1 Thomas Carpenter Gut hormone based polypharmacy: same benefits without the surgery? Yale University, New Haven, Connecticut, USA. D Perez-Tilve Division of Endocrinology, Departments of Medicine and Psychiatry, Familial hypophosphatemic rickets was recognized in the 1950s, when Metabolic Diseases Institute, University of Cincinnati College of Medicine, hypophosphatemia due to renal phosphate wasting was identified in individuals Cincinatti, Ohio, USA. with rickets unresponsive to vitamin D therapy. X-linked dominant inheritance was evident in many cases, and the most common form of the disease is known as Obesity is reaching epidemic levels especially in western countries and has become X-linked hypophosphatemia (XLH). A description of vitamin D-refractory rickets a major public health issue because is frequently associated with other likely represents the first report of XLH (Albright F et al., Am J Dis Children 1937). comorbidities such as hypertension, dyslipidemia and diabetes. Therefore, there After trials of phosphate therapy, and then with vitamin D, combination therapy is increasing interest in the development of therapies against obesity that can offer using calcitriol together with phosphate salts eventually emerged as the standard additional improvements in those associated comorbidities. Unfortunately the of care for XLH in the 1980s. This therapy usually improves, but does not current pharmacological treatments have demonstrated limited efficacy, leaving completely heal, rachitic deformities and short stature. Later complications bariatric surgery as the only treatment that promotes a substantial reduction of body include eventual development of osteophytes, paradoxical calcification of tendons weight and in glycemic control. With the aim of establishing new pharmacological and ligaments, and osteoarthritis, all of which are poorly understood. The mutated alternatives to the use of bariatric surgery, we have developed new single gene in XLH, PHEX, is a product of the osteocyte, but its role in the pathogenesis molecules able to activate several hormone receptors involved in the control of of phosphate wasting is poorly understood. energy balance. We have previously proved the efficacy of a peptide with coagonist Study of XLH and its related disorders has led to the identification of a novel activity for both glucagon-like peptide-1 (GLP-1) and glucagon receptor, on body fibroblast growth factor family member, FGF23, a unique FGF with endocrine weight loss and glycemic control in rats and mice. Now we have designed a novel properties. Renal action of FGF23 leads to reduced expression of the type II single peptide coagonist that activates both GLP-1 and glucose-dependent sodium-phosphate co-transporters NaPi-IIa and NaPi-IIc which are instrumental in insulinotropic peptide (GIP) receptor. This coagonist is protected from degradation renal tubular phosphate reclamation, as well as to reduced expression of CYP27B1, in plasma by dipeptidyl peptidase IV (DPP-IV) and shows a long-lasting activity in which encodes the vitamin D 1a-hydroxylase enzyme. Selectivity of the renal rodent models, inducing a greater reduction in body weight and improving tubular action of FGF23 is mediated by a transmembrane protein, klotho, an glycemic control than other peptides with single agonist activity for the GLP-1 essential co-receptor for FGF23, converting generic FGF receptors to specific receptor, currently available therapies for the treatment of type 2 diabetes. Our data FGF23 receptors. The osteocyte is the primary source of FGF23; thus this novel suggest that the rational design of peptides that can simultaneously modulate the phosphate regulatory system serves as a mechanism by which the mineralizing activity of several receptors involved in the control of energy metabolism offers skeleton can communicate mineral abundance or demand to the kidney and thereby new pharmacological alternatives for the treatment of obesity and diabetes. signal the excretion or conservation of this important component of the skeleton.

SIG2.2 SIG1.3 Gut, hormones, weight loss and metabolic improvement after bariatric Osteogenesis imperfecta surgery Mark Cooper Torsten Olbers College of Medical and Dental Science, University of Birmingham, Imperial College, London, UK. Birmingham, UK. Background Osteogenesis imperfecta (OI) is a rare but serious genetic disorder of bone leading Bariatric surgery is currently the only evidence based treatment for morbid to increased fragility and greatly increased susceptibility to fracture. Some obesity. However, we have limited knowledge regarding the mechanism of action patients experience additional problems such as abnormally formed teeth, in many of procedures used.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Method agonists and DPP-IV inhibitors, exploit mechanisms of action different to those of This is a review of the results from studies on weight loss, metabolic older drugs. Bariatric surgery is increasingly performed and Roux-en-Y Gastric normalisation and mechanism of action in patients undergoing bariatric surgery. Bypass (RYGB) is the surgical procedure for which the evidence base is greatest, Results with reported diabetes ‘remission’ rates of O80%. Most evidence derives from In the Swedish Obese Subject (SOS) study 2000 patients who underwent bariatric people who also had morbid obesity but recently, patients with lower BMIs have surgery was compared to a conservatively treated matched control group been studied. Irrespective of initial body weight, RYGB is followed by a fall in (nZ2000). Surgical mortality was 0.25%. The outcome revealed a significant and insulin resistance, detectable within days of surgery and thus unlikely to be caused sustained weight loss of in mean 16% over 10–15 years in the whole group (25% simply by weight loss. There is also an improvement in insulin secretion including after gastric bypass). Furthermore the QoL was improved in operated group as restoration of the first phase loss of which had previously been considered were most cardiovascular risk factors. We also found an adjusted reduction in irreversible. Multiple questions remain, however, before advocating RYGB mortality of 30% in the surgical group and a 40% reduction in cancer incidence in generally in diabetes management (in the absence of morbid obesity). Principal women. Gut hormone release after gastric bypass demonstrates a ‘supraphysio- amongst these is the lack of randomised controlled trials comparing surgery with logical’ release of GLP-1, PYY and other gut hormones promoting satiety after modern intensive medical management. RYGB is essentially irreversible and test meal, but no increase in fasting state. These effects along with changes in GIP, long term data are scanty. We do not know the subgroups of patients who will glucagon, etc. might contribute to weight independent improvements in type 2 benefit most and management strategies for care following operation have not diabetes after gastric bypass surgery. been defined. Comparisons of life quality and economic data are also scanty. Conclusion While promising, much remains to be learned. Bariatric surgery, and especially gastric bypass, is associated with substantial and sustained long-term weight loss. This leads to a normalisation of many metabolic risk factors and importantly also reduction in overall mortality and incidence of cancer. The mechanism of action in gastric bypass surgery appears to be complex and includes altered gut hormonal response to a meal. Laboratory aspects of clinical endocrinology special interest group SIG3.1 Vitamin D deficiency Jennifer Walsh NIHR Bone Biomedical Research Unit, Sheffield, UK. SIG2.3 Pre- and post-operative management of patients undergoing bariatric surgery There are many current uncertainties surrounding the definition and treatment R Andrews of vitamin D deficiency. Department of Exercise, Nutrition and Health Science, University of Bristol, This presentation will review the synthesis and metabolism of vitamin D and its Bristol, UK. multisystem effects. How should we define significant vitamin D deficiency? Should threshold be 30, 50 or 75 nmol/l? Current evidence suggests that bariatric surgery offers the best hope for How should vitamin D deficiency be treated? What is a safe upper limit of serum substantial and sustainable weight loss in patients with morbid obesity. These vitamin D, and are there adverse effects of high dose treatment? facts, coupled with the improved minimally invasive procedures, have driven a This presentation will review recent evidence and guidelines on definition and four-fold increase in the number of bariatric operations performed over recent treatment, and try to draw conclusions for clinical practice in the UK. years in the UK. Bariatric surgery though is not suitable for everyone. A BMIO59, AgeO50, smoking, sleep apnoea and CVD disease all increase the risk of death and complications. Weight loss is often suboptimal in patients who have significant psychiatric disease, those who are less well informed, or not motivated. Pre-operative evaluation and education of patients ensures that expected benefits SIG3.2 of the operation outweigh the risks. This involves determining a patient’s Definition of male hypogonadism indication for surgery, identifying issues which may interfere with the success of Christina Wang & Ronald Swerdloff surgery, and assessing and treating co-morbid diseases. Typically assessment Harbor-UCLA Medical Center and Los Angeles Biomedical Research includes psychological testing, nutrition evaluation and medical assessment. Institute, Torrance, California 90509, USA. Successful weight loss and prevention of complications post operatively require close follow-up by a multidisciplinary team. Frequent blood tests and nutritional input is needed to prevent micronutrient deficiencies and maintain good eating The Endocrine Society guidelines define male hypogonadism as a ‘clinical behaviour. For gastric bands regular fills are needed to reduce satiety but not syndrome’ where the diagnosis is based on symptoms or signs and unequivocally cause undue restriction. Medical input is also needed to prevent weight regain and low serum testosterone (T) levels. Generally accepted by most clinicians, manage the co-morbid diseases. diagnosis of male hypogonadism is clinically relevant because T replacement can This talk will provide clear guidance on how to assess, prepare and manage restore libido and correct sexual dysfunction, increase lean and decrease fat mass, patients undergoing bariatric surgery. increase in bone mineral density and vitality. Low serum T is associated with increased all cause mortality. Low serum T levels are commonly associated with aging, obesity, metabolic syndrome, type 2 diabetes and other chronic illness. Because symptoms of T deficiency are non-specific and variable, the diagnosis of male hypogonadism requires serum T concentration measurements. Serum T shows diurnal variation, and samples for T measurements should be drawn in the morning because comparison is made with reference ranges derived from SIG2.4 morning samples of adult men. Methods to determine serum T including Bariatric surgery: a cure for diabetes? immunoassays based assays and platforms and liquid chromatography tandem D Johnston mass spectrometry. The latter is regarded as the gold standard for serum T Barking, Havering and Redbridge University Hospitals NHS Trust, measurement. For the diagnosis of male hypogonadism all these methods are London, UK. generally adequate. There are wide between laboratory and method differences. The Endocrine Society is spear-heading a consensus among professional societies, references laboratories and manufacturers of platform instruments Type 2 diabetes is increasing in prevalence and is associated with, amongst and kits to achieve highly accurate clinical T testing. Clinicians should be familiar others, premature CVD, retinopathy and kidney failure. The aim of care is to with the adult male references ranges from the laboratory and how these are minimise the complications through euglycaemia but in the long term, this is derived. Free or bioavailable T estimations are usually not necessary unless there rarely possible. Treatment of hypertension and dyslipidaemia also has benefit and is a suspicion that the patient may have altered SHBG binding. Either a direct patients are often consigned to a lifetime of polypharmacy. Quality of life is measurement or a calculated free or bioavailable which may be estimated by total affected, especially in those with complications and in those who need treatment serum T and SHBG levels. Recent studies show that different thresholds of serum with insulin. Therapy with some second line drugs (sulphonylureas, thiazolidi- T predict symptoms of hypogonadism, e.g. sexual function requires lower serum nediones and insulin) often results in weight gain. Novel treatment modalities are T thresholds than vigorous activity. being sought and newer agents, such as thiazolidinediones, GLP-1 receptor

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

SIG3.3 SIG3.4 The definition of hypothyroidism Definition of hyperandrogenism Geoff Beckett Julian Barth Clinical Biochemistry, The Royal Infirmary of Edinburgh, Edinburgh, UK. Leeds General Infirmary, Leeds, UK.

Hypothyroidism has been defined as those conditions which result in suboptimal Polycystic ovary syndrome (PCOS) is a common disorder which has considerable circulating levels of thyroid hormones. The problem is how to define such phenotypic variability and this has led to controversy over its exact definition and suboptimal levels? In the 1970s, the advent of routine assays for TSH together with diagnosis. Over the past years a number of definitions have been developed by the concept that the most sensitive ‘peripheral tissue’ to diminished circulating professional associations. These consensus statements have used a combination of thyroid hormone concentrations is the pituitary led to the acceptance that elevated clinical, laboratory and imaging studies as the defining criteria. However, serum TSH was required to define primary hypothyroidism. There are problems, the statements imply that these measures are dichotomous variables without however, in defining what is an elevated serum TSH and what serum concentrations considering factors such as normal physiology, observer subjectivity or of TSH should trigger thyroxine replacement therapy. Routine TSH assays show measurement variability on the outcome. Published data would suggest that considerable between method biases, which do not appear to correlate with the there is considerable uncertainty of all the measurements and that there is a TSH reference ranges suggested by the manufacturers. These assay bias differences complete lack of clarity of the definition of the term ‘hyperandrogenaemia’- and are often ignored in research communications that present data supporting clinical all the factors can lead to misdiagnosis. This paper proposes that the current action limits for the implementation of T4 therapy. Furthermore it has been diagnostic strategies for PCOS are defined too vaguely to be certain that suggested that the log normal distribution of TSH observed in the ‘healthy’ individuals fit the definition of the syndrome. A pragmatic approach may be taken population may arise through the inclusion of subjects with occult hypothyroidism. in the management of an individual depending upon her particular symptoms If this were the case then the upper reference limit for TSH should be significantly and needs. However, research into the epidemiology, pathophysiology and lower than that currently used by most laboratories. In this lecture these problems treatment of PCOS will require the production of robust definitions of the and current evidence will be discussed. diagnostic criteria.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Meet the Expert Sessions Generously supported by Clinical Endocrinology

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

MTE1 MTE4 Abnormal growth and puberty presenting in late adolescence Managing Turner Syndrome through childhood and adolescence Peter Clayton Malcolm Donaldson Manchester Academic Health Sciences Centre, Manchester, UK. Glasgow University, Glasgow, UK.

Young people in their late teenage years may present to either paediatric or Turner syndrome (TS), defined as loss or abnormality of the second X adult endocrine clinics with abnormal growth (usually as short stature and/or chromosome in a phenotypic female, affects 1 in every 2500 live female births. recognition of slowing growth) and delayed or absent puberty. Anxieties about Around 155 females will be born with TS in the UK each year, with w2800 girls growth potential may be very significant, and the lack of puberty may blight social %18 years and w6500 women aged 18–60 years living with the condition. interactions and markedly reduce self-esteem. Short stature is a constant feature with gonadal dysgenesis present in w90%, Although constitutional delay in growth and puberty is the most common Associated features include dysmorphic features which are often mild, diagnosis for this type of presentation, there are a number of other significant lymphoedema, otitis media with effusion, sometimes followed by suppurative aetiologies which must be considered. These include – chromosome disorders, otitis mediaGcholesteatoma; bicuspid aortic valve, coarctation and dilatation of e.g. 47XXY, hitherto undiagnosed genetic disorders, e.g. hypogonadotrophic aortic root; hypertension; and an autoimmune diathesis. IQ is usually normal but hypogonadism including Kallmann’s syndrome, and acquired lesions in the there may be specific learning difficulties (commonly with mathematics) and a hypothalamic–pituitary axis, such as craniopharyngioma. degree of social vulnerability. It is therefore essential that there is close attention paid to family history of related Optimal management of TS begins with timely diagnosis followed by thorough disorders, social and educational history, co-morbidities (e.g. sense of smell), counselling and education of the family. Growth hormone (GH), of proven value symptoms and signs of endocrinopathy (including diabetes insipidus) and in improving final height, is usually started aged 5 years (earlier if the girl is CNS signs. especially short) in the dose of 10 mg/m2 per week given as daily s.c. injections. Investigations may be minimal (e.g. TFTs, bone age) if there is a clear family In the UK pubertal induction is currently with a 3-year low dose ethinyl oestradiol history of delayed puberty and clinical examination reveals that puberty has protocol, usually started at 12–13 years. Four-monthly outpatient review is commenced. However investigations may need to be extensive including required to monitor growth and development and for the surveillance of blood assessment of pituitary function (both basal and dynamic testing) and brain pressure, middle ear disease (present in over 60%), educational difficulties (often imaging. compounded by conductive hearing loss), and any psychosocial or family Treatment should be directed at the underlying disorder. There are many regimens problems (which affect compliance with GH). Bone age, thyroid function and for pubertal induction, but starting doses of sex steroids should be tailored to IGF1 are checked annually; gonadotrophins, pelvic/renal and cardiac ultrasound the degree of pubertal development already achieved and the need to promote at diagnosis, 11–12 years (prior to pubertal induction) and at adult transfer. growth – low doses for those with absent or minimal pubertal signs (e.g. testosterone At 16–18 years joint review by the paediatric endocrine team with an adult injections 50 mg monthly or ethinyloestradiol orally 5 mg daily), and higher doses colleague – gynaecologist, endocrine or reproductive physician – ensures smooth for those already established into puberty or with pubertal arrest. transition. Adult care involves lifelong surveillance of cardiovascular, reproduc- This clinical scenario is an excellent example of where both paediatric and adult tive, otological, endocrine and metabolic bone health. endocrinologists need the expertise to manage these young people, and seeing them within a joint clinic is a good strategy.

MTE5 Late effects of cancer therapy MTE2 Richard Ross Pitfalls in diagnosis and treatment of Cushing’s syndrome University of Sheffield, S Yorks, UK. Xavier Bertagna Cochin Hospital, Paris, France. One in eight hundred young adults is now a survivor of childhood cancer as a result of tremendous advances in cancer therapy. However, this success now Many difficulties can be encountered in the management of patients with brings with it the challenge that both the cancer and its therapy may have late Cushing’s syndrome or suspected Cushing’s syndrome. effects. In a recent review of 10 397 young adult survivors, 62.3% had at least one In the first step of the diagnosis strategy, establishing the state of chronic chronic condition; 27.5% had a severe or life-threatening condition (grade 3 or 4). hypercortisolism may be hampered by a number of pitfalls: drug interaction The adjusted relative risk of a chronic condition in a survivor, as compared with (inducers of high CBG levels, liver enzyme inducers, glucocorticoids, siblings, was 3.3 (95% CI, 3.0 to 3.5); for a severe or life-threatening condition, antiglucocorticoid RU 486, Glycyrrhetinic acid); intercurrent pathologic states the risk was 8.2 (95% CI, 6.9 to 9.7). Among survivors, the cumulative incidence (obesity, thyroid dysfunction, renal failure). Various pathologic or physiologic of a chronic health condition reached 73.4% (95% CI, 69.0 to 77.9) 30 years after conditions may be associated with biochemical, and sometimes clinical, the cancer diagnosis, with a cumulative incidence of 42.4% (95% CI, 33.7 to 51.2) evidences of endogenous glucocorticoid excess creating the ‘pseudo-Cushing’ for severe, disabling, or life-threatening conditions or death. Owing to a chronic syndrome (depression, anorexia nervosa, alcoholism, strenuous exercise, condition. Thus, late effects are common and many of these late effects are pregnancy). Familial resistance to glucocorticoids, a rare inherited condition, is endocrine in nature including; hypogonadism, infertility and hypopituitarism. associated with excess glucocorticoid, androgen, and mineralocorticoid pro- This expert session will address the management of endocrine late effects duction with no clinical manifestations of Cushing’s syndrome. Normal following cancer therapy. suppression with the classic low-dose dexamethasone test can be observed in authentic Cushing’s disease. Once the positive diagnosis of Cushing’s syndrome has been convincingly established, one may deal with numerous etiologic pitfalls. Cushing’s disease mimicking an autonomous adrenocortical tumor, severe Cushing’s disease mimicking the classic ectopic ACTH syndrome, mild ectopic ACTH MTE6 syndrome mimicking the classic Cushing’s disease. Assessing fracture risk and response to therapy in osteoporosis These various situations, and the ways to avoid pitfalls, will be presented and Eugene McCloskey discussed using illustrating clinical cases. University of Sheffield, Sheffield, UK.

Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. An individual with a hip or vertebral fracture has an excess risk of death that is highest during the first year. Moreover, MTE3 all osteoporosis related fractures can lead to significant long-term disability and The difficult Cushing’s or Nelson’s patient decreased quality of life. The ability to accurately gauge fracture risk is critical in P Selby identifying cost-effective thresholds for intervention. In 2008, the WHO Collaborating Centre for Metabolic Bone Diseases at Sheffield Manchester, UK. released the fracture risk assessment tool (FRAX) for estimation of individualized 10-year probability of hip and osteoporotic fracture (composite of hip, clinical Abstract unavailable. spine, distal forearm, and proximal humerus) with or without BMD. The FRAX tool integrates seven clinical risk factors (prior fragility fracture, a parental history

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK of hip fracture, smoking, use of systemic glucocorticoids, excess alcohol intake, The current platform at the WTCHG, Illumina HiSeq2000, is capable of body mass index (BMI), rheumatoid arthritis and other secondary causes of supporting a wide variety of applications that are changing research. Applications osteoporosis which, in addition to age and sex, contribute to a 10-year fracture range from whole genome to all exon re-sequencing for studies of complex risk estimate independently of BMD. disease traits, allowing variants to be detected. The world of expression analysis The importance of this tool in clinical practice is highlighted by the fact that many is now becoming cost effective through sequencing. Not only is RNA-Seq more recently published clinical guidelines recommend pharmacological treatment on sensitive than microarray for relative gene expression, its dynamic range is larger, the basis of 10-year fracture risk. A key question that arises is the reversible nature allowing identification of allele specific expression, splice variants, SNPS and of the risk that is identified. Several studies now demonstrate that patients at high regulatory RNA’s. Coupled with this, applications have been developed to probability of fracture have underlying low bone mass and respond to anti- support genome-wide epigenetic analysis. osteoporotic therapies. With researchers rapidly developing new protocols to allow them to make use of High Throughput Sequencing for their own research, this is just the beginning .

MTE7 MTE9 Managing infertility S Lavery microRNAs – key contributors to endocrinology London, UK. Lorraine O’Driscoll School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Dublin, Ireland. Abstract unavailable. MicroRNAs (miRNAs) are a family of endogenous small noncoding RNA molecules, of 19–28 nucleotides in length. In humans, up to 3% of all genes are estimated to encode these evolutionarily conserved sequences. miRNAs are thought to control expression of thousands of target mRNAs. Mammalian miRNAs generally negatively regulate gene expression by repressing translation, possibly through MTE8 effects on mRNA stability and compartmentalisation, and/or the translation process Applications of next generation sequencing: what can a key academic itself. An extensive range of in silico and experimental techniques have been applied service provider offer? to our understanding of the occurrence and functional relevance of such sequences, David Buck and antisense technologies have been successfully used to control miRNA Oxford University, Oxford, UK. expression in vitro and in vivo. Interestingly, miRNAs have been identified in both normal and pathological conditions, including differentiation and development, metabolism, proliferation, cell death, viral infection and cancer. Of specific Providing access to cutting edge technology and expertise in data analysis, the relevance and excitement to the area of endocrinology, miRNA regulation has Genomic Services group at the WTCHG are empowering users to drive the pace been implicated in insulin secretion from pancreatic beta-cells, diabetic heart of research into the underlying mechanisms of disease. conditions and nephropathy. For example, in our research, using global analysis The decade since the publication of the first full human genome has seen the approaches, we identified a panel of miRNAs down-regulated in glucose non- development of sequencing technologies, fuelled by competitive pressure and the responsive cells compared to glucose responsive cells. Subsequent functional challenge of the $1000 genome. The latest High Throughput Sequencing investigations suggested that members of this panel may decrease the capability of platforms from LifeTechnologies; SOLiD 4 and Illumina; HiSeq2000 are now cells to secrete insulin in response to stimulatory levels of glucose; with over- capable of generating w300 Gb of high quality data, equivalent to 10 full human expression enhancing levels of glucose stimulated insulin secretion. Furthermore, genomes at 10! coverage from a single w10 day run. A third wave of single our data suggests that extracellular miRNAs may have potential as biomarkers. molecule sequencing platforms is now available from Helicos Biosciences and Here we will consider miRNAs – what they are; their biogenesis; how they can be Pacific Biosciences and other companies are working on revolutionary measured; how they can be manipulated; and their clinical relevance as minimally- technologies that could herald the dawn of a new age of routine genome invasive biomarkers and as potential therapeutic targeted. sequencing and personalized medicine.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Nurse Session

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Turner/Klinefelter’s/Noonan syndrome: case presentations Reasons for setting up a Thyroid NLC in Oxford: Patients were waiting up to 3 months before seen by a consultant. Funding was available for a part-time N1.1 endocrine nurse. Turners/Klinefelters/Noonans syndrome Aims of the Thyroid NLC: To set up and provide a safe, efficient, cost-effective G Conway service for patients with uncomplicated hyperthyroidism (Graves’ disease, London, UK. nodular goitre and thyroiditis). To reduce patient waiting time and to audit the service provided. Components for setting up the NLC: Approval was obtained from the ORH NHS Abstract unavailable. Trust. Appropriate knowledge and skills on the subject were acquired by the nurse. A clinic consultation room for the NLC and an endocrine consultant was made available to work along side. A clinic code was given for the purpose of documenting and monitoring patients attendances. Proformas were prepared for history taking, physical examination, monitoring/evaluating results and N1.2 patient/GP correspondence. Slots were allocated to see 2 new and 4 follow-up Klinefelter’s case presentation patients per week and a direct access support-line was provided for patients. P Pickett Outcomes: Clinic has been running since 2005. Nurse prescribing course has Shrewsbury, UK. enabled medications to be prescribed and drug dose adjustments to be made by the nurse. Between 9/09-9/10, there were 81 new and 185 follow-up attendances. Abstract unavailable. The income generated during this time was £34,316. Non-face to face communications also generated income of around £3,000 per month. Two audits concluded the benefits of the NLC. Challenges & future developments: To maintain professional competence and expertise of the nurse to run an efficient and high quality clinic through regular auditing. N1.3 To expand the service by setting up a Nurse-led post-radioactive iodine clinic. Living with TS: an adult viewpoint H Cleaver Turner Syndrome Support Society, UK. N2.3 Abstract unavailable. Hyperthyroidism – Case presentation Dianne Wright Specialist Nurse in Endocrinology, Bradford NHS Teaching Hospitals Foundation Trust, Bradford, UK. N1.4 This 32 year old lady was referred in 2008 with Graves Disease. She presented Klinefelter’s Syndrome Association with typical symptoms which included tiredness, shaking, palpitations, itching, S Cook eye redness, opthalmopathy, and exopthalmos. She had lost 3 stones over 3 Klinefelter’s Syndrome Association, UK. months at Weight watchers. The GP had commenced carbimazole but she did not know the dose. In September 2008 results showed FT4 73.6, TT3 O12.5, TSH ! C O Abstract unavailable. 0.05 and TPO antibodies – 1300. This lady declined a referral to the ophthalmologists as her eyes were not much of a concern for her. She failed to attend her next 2 appointments so was discharged back to her GP. In October 2009 this lady was re-referred to the endocrine department. She failed to attend this appointment due to family problems and bereavements. She had Hyperthyroidism: case presentations stopped taking carbimazole due to mouth ulcers and boils. Clinically she was extremely hyperthyroid, with a moderate to large sized goitre and worsening of N2.1 her eye condition. She had bilateral exopthalmos, reduced vision in the left eye, Hyperthyroidism – overview of causes and treatment options pain, grittiness, lid lag and lid retraction but she thought this was normal for her. Jayne Franklyn Carbimazole and beta-blockers were re-commenced and she was referred to the University of Birmingham, Birmingham, UK. ophthalmology department. She did not attend her next endocrine appointment and postponed her following 2 appointments. In March 2010 a letter was sent to the patient requesting blood tests and her Hyperthyroidism is common, affecting up to 3% of the population. The major medication dose. In June 2010 she attended clinic saying she had taken carbimazole causes in the UK are autoimmune (Graves’ hyperthyroidism) and toxic nodular 20 mg BD forthe last 2 weeks.Shehad walked out of the ophthalmology waiting area goitre. Despite the prevalence of hyperthyroidism, there is relatively little due to clinic delay. She had severe proptosis, double vision, aching eyes, inability to agreement regarding the relative roles of the three principle treatment options – close her eyes at night but she did like the weight that she had lost. She also had a antithyroid drugs, radioiodine and surgery. The presentation will address these choking sensation with her goitre. At this point her medication was increased, thyroid roles and specifically will address areas of controversy regarding treatment function requested along with a thyroid ultrasound. She was re-referred to the through the use of clinical scenarios. These will include the young female patient ophthalmology department and the thyroid surgeon potentially for a thyroidectomy. with Graves’ hyperthyroidism – pros and cons of thionamide therapy. The next In clinic in September 2010 she said she felt ‘horrible all the time’ but had missed her scenario is the elderly male with known cardiovascular disease and AF – how best ultrasound, ophthalmology and thyroid surgeon appointments due to being away for to use radioiodine. The 3rd scenario will address the role of radioiodine in the a couple of months and was still non-compliant with her medication saying she was patient with ophthalmopathy, the 4th a patient with hyperthyroidism in early ‘scared of the side effects’ of treatment. She understands the problems associated pregnancy, and finally the teenage patient with Graves’ hyperthyroidism. These withsevere hyperthyroidism and eyedisease are potentially much worsethan the side scenarios will be used to assimilate evidence regarding best practice in these effects of the drugs. In November 2010 she postponed her appointment with us and relatively common clinical situations. had not attended any of her other appointments nor did she have her thyroid function checked as requested. It is difficult to know what to do with this lady as she is fully aware of the dangers of her condition.

N2.2 Nurse-led clinic and hyperthyroidism Violet Fazal-Sanderson N2.4 Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology Hyperthyroidism – case presentation and Metabolism, Oxford, UK. D Papadopoulou London, UK. Background of NLC’s: The emergence of Nurse-led clinics (NLC) has given nurses a pathway for innovation and excellence towards providing safe, efficient, Abstract unavailable. cost-effective and quality healthcare service.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Young Endocrinologists Session

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Young endocrinologists’ prize lectures increased ZAC1 mRNA expression in GH3 cells, while knock-out of AIP using siRNA resulted in a reduction of ZAC1 levels. These data suggest that i) ZAC1 is YEP1.1 part of the AIP pathway and ii) AIP may play a role in the mechanism of action of New insights into glucocorticoid receptor function somatostatin analogues, which would explain the lack of effect in AIP mutation- Laura Matthews positive FIPA families. University of Manchester, Manchester, UK. Our in vitro data support the previous suggestion that AIP is a tumour suppressor gene. Over-expression of wild-type AIP reduced cell proliferation compared with the empty vector control, while mutant AIP had no or reduced ability to block cell The current model of glucocorticoid receptor (GR) action is well established, proliferation. On the other hand, siRNA knockdown of endogenous AIP increased whereby GR remains inactive in the cytoplasm until bound by ligand, then rapidly cell proliferation compared to a non-coding siRNA control. In addition, using translocates to the nucleus to regulate target genes. However, our recent DAPI staining and caspase-assays, we showed that AIP over-expression increased observations challenge the simplicity of this model and suggest a greater range of apoptosis which can be inhibited by a caspase inhibitor. GR action. In addition to truncation mutations, which are likely to be disease-causing We have identified a novel pathway in which the GR is recruited to the plasma abnormalities, numerous variants have been described with missense or silent membrane through binding to the lipid raft marker caveolin-1, and then couples to changes leading to no alteration in the amino-acid sequence. The functional kinase cascades to mediate Gc effects. Using transcriptome profiling we found characterisation of these AIP variants is important to clarify their pathogenic role that many Gc-regulated genes require co-expression of caveolin-1 for their and allow appropriate counselling of families. We have studied 13 AIP variants regulation, indicating that recruitment of GR to the plasma membrane is including missense as well as promoter (using a luciferase assay) and splice-site necessary to regulate a subset of Gc targets. variants (using patient cDNA and a minigene approach). We have found that We have also identified a cytoplasmic role for the constitutive splice variant GRg. missense changes disrupting the conserved amino-acids of the molecule The mechanism for ligand-independent gene regulation by GRg appears indirect, tetratricopeptide domain reduced the protein–protein interaction between AIP through the activation of cytoplasmic kinases including JNK and subsequent and its phosphodiesterase partner PDE4A5. Exonic splice mutations led to a recruitment of SP1 and AP1 transcription factors. GR therefore mediates some truncated transcript or reduced AIP expression. Our promoter mutation caused cellular effects in the unliganded state. decreased basal and stimulated promoter activity. In addition we have, for the first In further support of unliganded GR effects, we have identified cell-cycle driven time, characterised the regulation of the AIP promoter and found that it is phosphorylation which targets GR to the mitotic spindle, suggesting a role for GR stimulated by the cAMP–PKA signalling pathway. in mitosis. Indeed, GR knockdown cells accumulate in metaphase, and show We have identified an AIP mutation in several families clustering to the same evidence of multiple spindle defects. It appears therefore, that during mitosis geographical area. To establish if these families have a common ancestor we when cells are transcriptionally silenced, GR adopts a new ligand-independent studied 14 microsatellites around the AIP gene and found a 2.68Mb common area. role in directing accurate chromosome segregation. Using the coalescent theory, which is a retrospective model of gene genealogy, We have therefore characterised a range of cellular effects that do not require we identified the time when the common ancestor was alive. nuclear translocation, and are influenced by GR isoform expression and ligand We have identified AIP protein in the secretory vesicles of GH-secreting normal availability. We also reveal a novel role for GR as a regulator of mitotic and tumour cells with electron-microscopy and showed that human adenoma progression. Identification of these novel pathways for GR function offer samples studied ex vivo release AIP protein. In collaboration, we have prepared explanations for physiological phenomena including rapid steroid responses, and synthetic AIP protein and set up a time-resolved fluorescence sandwich will inform novel approaches for selective therapeutic drug development in immunoassay to measure AIP levels in human serum. AIP is present in the inflammatory disease. circulation at 1.3–22 nmol/l range in normal volunteers. Finally, seventy percent of patients with FIPA do not have an AIP mutation, suggesting another gene or genes is/are involved in the pathogenesis of this condition. We have recently carried out a genome-wide analysis which has identified a novel locus for another candidate gene involved in this condition; YEP1.2 finer scale mapping is underway. Clinical, genetic and molecular characterisation of patients with In conclusion, detailed characterisation of FIPA patients, their mutations and the familial isolated pituitary adenomas (FIPA) pathway involved in AIP-related tumorigenesis together with the increasing H Chahal recognition of a genetic background of familial and early-onset pituitary adenoma Barts and The London School of Medicine and Dentistry, William Harvey cases indicate that these findings are likely to have considerable significance to practising clinical endocrinologists. Research Institute, London, UK.

There is increasing recognition that pituitary adenomas may occur in a familial setting, and a number of families have been identified to have familial isolated pituitary adenoma (FIPA), without features of the MEN1 syndrome, Carney complex, or other known familial disorders. Heterozygote germline mutations A successful research career were identified in a gene encoding AIP (aryl-hydrocarbon receptor interacting YE1.1 protein) in some FIPA families. We have characterised our unique large Research in clinical academia collection of 140 families in terms of clinical presentation, age of onset, Miguel Debono penetrance, genetic mutations, existence of other co-morbidities, responsiveness University of Sheffield, Sheffield, UK. to somatostatin analogue therapy and histological characteristics. FIPA is an autosomal dominant disease with a heterogeneous genetic background. A third of our families had a missense, nonsense, frameshift, splice-site, large Why would you want to be a clinical academic? Why is research so enticing for deletion, and the first described promoter AIP-mutation. We found striking some? Does intellectual stimulation overcome potentially lower salaries and differences in the clinical phenotype of AIP mutation positive and AIP mutation longer hours of harder work? Yes, for some, the possibility of making a difference negative FIPA families. Patients with AIP mutations were characterised by early to medical knowledge is provoking and stimulating. Clinical academia gives onset, often aggressive disease, and showed a predominance of somatotroph and researchers the possibility to express their own unique characteristics and traits lactotroph adenomas, but occasionally other types of pituitary tumours. The including creativity and communication skills, professionalism and humanism, penetrance of the disease in the AIP mutant families was 30–35%, while in AIP excitement, perseverance and mental strength. mutation-negative families it was lower. In addition, we studied over thirty There are a variety of ways to get into research. It may start off as early as medical patients with childhood-onset pituitary adenomas and AIP mutations can be school, where one through an intercalated bachelor of science (BSc), a medical identified in this cohort as well. Typically patients with AIP mutations respond science degree (BMedSci) or MB/PhD programme integrates a period of research less well to somatostatin analogue treatment and we further explored the with clinical education. This gives medical students the opportunity to mechanism of this lack of response. demonstrate interest and experience in a science at a very early stage in their We studied AIP immunohistochemical staining in sporadic somatotroph career and helps them discover whether they have the necessary aptitude for adenomas from patients pretreated with a somatostatin analogue before surgery research. The next possible routes into academia are either through academic and compared them to matched patients with no pre-treatment. We found foundation programmes or through academic specialist training where one increased AIP expression in the group pretreated with a somatostatin analogue. obtains a combination of clinical experience and exposure to an academic and Similar upregulation of AIP expression both at mRNA and protein levels were research environment. This then provides academic clinical fellows the observed in a rat pituitary cell line cell (GH3 cells) in vitro. AIP has been shown possibility of securing funding for a PhD or MD, provided by Universities or to bind the tumour suppressor gene ZAC1 and somatostatin analogues are known Biomedical Research Units/Centres, or even the option of applying for a to upregulate ZAC1 expression. Therefore, we speculated that AIP and ZAC1 competitive training fellowship, such as those provided by the National Institute might be involved in the somatostatin pathway. Over-expression of wild-type AIP of Health Research, the Medical Research Council or Wellcome trust. After

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK this stage, if committed to an academic pathway, one may apply for a clinical YE1.3 lectureship followed by a clinician scientist award or senior clinical lectureship. Postdoctoral research – the things I wish I knew In addition, if not on an academic pathway, doctors may still decide to spend Aylin Hanyaloglu some time out of their speciality training and getting research experience; this Imperial College London, London, UK. potentially leading to a higher degree. When applying for speciality training my intention was to pursue an academic career in Endocrinology, so when the opportunity arose in 2006 I jumped at the Many PhD graduates will pursue a postdoctoral training position, most commonly chance of obtaining a three year NIHR Academic Clinical Fellowship. I succeeded in an academic laboratory. What can you expect from this period in your career? in attaining this post at the University of Sheffield. My job over the three years Do you need to go abroad to do a postdoc? What could/should you do to benefit included a nine month research phase in the Department of Human Metabolism the most of this time? And how can you use your time as a postdoc to help you where I was exposed to research programmes focusing on diagnostic and with your career path once you leave? management strategies of patients with Cushing’s and on the development I recall being very excited about beginning my postdoc and leaving the ‘PhD of novel formulations of glucocorticoid replacement therapy. With an aim to nest’. I trained and stayed an unanticipated five years at UCSF, San Francisco, concentrate my efforts on the effects of glucocorticoids and sex steroids on bone, before coming back to the UK as an independent researcher. In this session I will I extended my fellowship to include a year working as an NIHR Academic share my experiences during those five years, and that of fellow postdocs, from Clinical Fellow in Bone Metabolism, in the Sheffield Bone Biomedical Research the time of pursuing these positions to the transition of postdoc to lectureship. Unit and this has lead to me obtaining funding to perform a PhD. I will discuss the highs, lows and unexpected realities of this period of training Full-time clinical research has proved to be challenging and exciting. Achieving that myself and others experienced. targets is extremely satisfying and an academic career is highly recommended. As a postdoc, you are in a unique position between not having to worry about completing a PhD, yet also without the role juggling and responsibilities of an independent academic. So to current PhD students thinking of postdoctoral research, or current postdocs, this period in your career will represent an exciting time with a tremendous amount of freedom to devote to your research and to YE1.2 explore possible career paths. With postdoctoral training periods getting longer and the unpredictable nature of research and the job market, there is an increased Managing your research career awareness of the need for long-term planning and to use this time to develop the A McNeilly necessary training in your postdoc. This should enable a successful move on to the MRC Human Reproductive Sciences Unit, Edinburgh, UK. next step of whatever chosen career path that is sought.

In these times of restricted funding, it becomes crucially important that you position yourself to be the only possible candidate for future employment in a postdoctoral position or any other career path that you chose. The time to do this is during your PhD and MD studies and during your first postdoc. There are no hard and fast rules about how you do this, but some pointers may help. First, you must have a passion for research if this is what you want to do. If this is a job from 0900 to 1700 h monday to friday, then I suggest that you immediately start looking for YE1.4 alternative employment. Research is not like that and many breakthroughs have Commercialisation and IP – translating scientific research come from lateral thinking and for this you need to keep an open mind and be aware Scott Webster of opportunities. Thus you should go to all the seminars etc. that you can since you University of Edinburgh, Edinburgh, UK. will either find it most boring or the most amazing talk that you have ever heard. However, often some gem of an idea will emerge, a link to the research you are doing, or a technique that you had not considered. In addition, in the face of the Commercialisation and the development of new technologies may be thought of enormous deluge of publications in every field of research it is often difficult to as the natural conclusion of academic research. Typically this has been the keep up with advances merely by reading, and certainly by only reading abstracts. preserve of industry, however, more recently translation has become a key aspect Thus by expanding your horizons you will become aware of other areas of research of any scientific research programme. The processes involved in the translation of or techniques by osmosis. Then when faced with an interview for your next position basic and clinical research will be discussed in the context of an in-house drug you can say that you either have first hand knowledge of the methods, have worked discovery programme, highlighting the differences between hypothesis and goal- beside someone who has used them, or that you are fully aware of the possibilities driven research. Funding streams, intellectual property and exit strategies will of such methods or techniques. Finally, a good mentor is very important. also be discussed.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Senior Endocrinologists Session

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

SE1.1 through a second prism. Newton favoured the corpuscular theory of light, The metamorphosis of testosterone from a sex steroid to a universal opposing the wave theory of Huygens, which was taken up about 1800 by health factor Thomas Young to explain experiments on diffraction and later formulated the Eberhard Nieschlag trichromatic theory of human colour perception, independently rediscovered by Centre for Reproductive Medicine and Andrology, University Hospitals Helmholtz and supported by Maxwell’s work on electromagnetic radiation. Mu¨nster, Mu¨nster, Germany. Modern physics encapsulates both elements, post Einstein and Planck. Landmarks in understanding colour vision include description of retinal topography and physiology, especially elucidation of rod and cone function. When in the 1930s testosterone was isolated, synthesized and introduced to the Humans have three types of cones with peak light absorption at 450 nm (blue clinic, it was considered predominantly a sex steroid to be used for the treatment receptor), 530 nm (green), 560 nm (yellow). These properties depend on small of erectile dysfunction and hypogonadism. In the 1950s the anabolic effect was variations in cone pigments, which single chains of about 350 amino acids ‘discovered’ and triggered the misuse of high doses of testosterone in sports, still containing seven transmembrane helices – the super family including many prevailing today. Consequently, pharmacologic research concentrated its efforts hormone receptors. Embedded in the pigment proteins of rods and cones is on anabolic steroids, i.e. testosterone analogues hopefully without sexual effects, the same chromophore 11 cis-retinal, which on light absorption straightens the thus neglecting the search for badly needed improved forms of testosterone side chain, altering the protein shape, which in turn catalyses the downstream application. Improved modes of application only became the focus of the biochemical and electrical events signalling on to the bipolar cells and then the pharmaceutical industry when in the 1990s, the increasing life expectancy of ganglion cells of the retina. These early stages encode topographically defined males and the anticipated parallel increase in late-onset hypogonadism (LOH) information about colour, contrast and provide substrates for phenomena such as precipitated the invention of transdermal testosterone preparations, finally after-image and shadow colours. The ganglion cells axons pass along the optic producing the desired physiological testosterone levels. Intensified research on nerves, via the optic chiasm (cave pituitary adenomas!) to the lateral geniculate the aging male revealed the role of testosterone in the pathognesis of obesity, bodies, whence further connections lead to the occipital cortex. Centrally there diabetes type II and the metabolic syndrome as well as in osteoporosis, are less well understood phenomena: colour constancy and relativism discussed sarcopenia, atherosclerosis and coronary heart disease. Indeed, testosterone levels by Monge, and yellow–blue, red–green antagonistic systems postulated during in blood are now considered a general predictor of morbidity and mortality. Thus, the mid-19th-century by Hering. while the role of testosterone in erection and sexual function (supplemented by phosphodiesterase-5-inhibitors if needed) remained, its spectrum of action broadened to become a universal health factor.

SE1.4 Two seminal case reports David Anderson SE1.2 The University of Manchester, Manchester, UK. Will we ever discover the mechanism of hormone action? Jamshed Tata I live in Umbria and have recently become concerned for the young couple, MRC National Institute for Medical Research, London, UK. Amanda Knox and Raffaele Sollecito, convicted of the horrific murder in Perugia on November 1st 2007 of English student Meredith Kercher, They were Even before the identities and structures of many hormones were established, supposedly acting with an Ivorian, Rudy Guede, who was tried and convicted endocrinologists and physiologists had speculated about the mechanism of their separately. action. A hundred years later, we are still struggling to establish in molecular and I am still haunted by a wrongful conviction half a lifetime ago, which involved the cellular terms the mode of physiological action of a given hormone. Two major murder of 11-year old Lesley Susan Molseed. Just before Christmas 1975, two reasons account for this situation: i) the failure to recognise that hormones as police inspectors visited me and said they believed the killer was Stefan Ivan signalling molecules have been highly conserved during evolution but that their Kiszko, a 25-year old Klinefelter’s patient I was treating. They asked casually if physiological actions vary enormously in different organisms or from one tissue such a man could produce sperm. Seven months later I was called to Kiszko’s to another in the same species; ii) that most investigations aiming to reveal the trial in Leeds, but was never cross-examined. The Defence lawyers wanted him to mechanism of action have been technology-driven and not hypothesis-based, as plead diminished responsibility from testosterone-induced aggression. will be illustrated with a few time-lines. The vital evidence suppressed by the police was that semen stains on Lesley Despite these shortcomings, a major advance was made with the introduction of Molseed’s clothes contained sperm heads. Kiszko always denied the crime, and the concept of hormone receptors, which, thanks to the advent of gene cloning fourteen years later the reviewing authorities presented me with the suppressed technologies, are now molecularly and structurally well defined as key elements evidence. As a result Kiszko, now schizophrenic, was eventually released; six of hormone action. They are cellular homologues of the oncogenes c-erbBor months later, aged 41, he died of a heart attack. Meanwhile his defence barrister c-erbA, located in the cell membrane or as transcription factors in the nucleus, had become Home Secretary; and the prosecuting barrister Lord Chief Justice. respectively. Current thinking on understanding of how hormones act at the The case was described by one MP as “the worst miscarriage of justice of all cellular and molecular levels is now focused on convergence of signalling time”. The real culprit, taxi driver Ronald Castree (strange coincidence that), was pathways from different cellular locations, attempts to understand the immediate convicted on DNA evidence in November 2007. consequence of hormone-receptor interaction and the wider involvement of I shall present parallels between the two cases. Kiszko was an outsider, deprived genomic and non-genomic networks. of legal representation and sleep, and was coerced into confessing to the crime In view of what may sound as a rather negative account, one may well ask: Is it after two days of intensive questioning. His conviction was supported by false worth continuing to look for mechanisms of hormone action? The answer is most witnesses, exculpatory evidence was ignored, and the tabloid press had a field emphatically yes. So many concepts of cellular signalling mechanisms have day. And the cases share willful legal seminal omissions. emerged from work on hormone action. Just consider the discovery of cyclic AMP and the functions of several transcription factors.

SE1.3 SE1.5 An exploration of colour theory The art of medicine Paul Belchetz T Toft Leeds Nuffield Hospital, Leeds, UK. Royal Infirmary Edinburgh, Edinburgh, UK.

Colour perception depends on light, photoreception and central processing in the For the last 15 years, I have suffered from the respectable addiction of collecting nervous system. Newton, in 1666, showed the coloured spectrum formed from modern Scottish art. During that same period I have become alarmed by the many white light passed through a prism underwent no further splitting on passing influences which have conspired, not always by chance, to reduce the

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK professionalism of doctors. The intention is to illustrate my many prejudices in sexual behaviour, but it is a fact that though many reproductive strategies exist respect of issues, ranging from the European Working Time Directive to national throughout the animal kingdom – and monogamy is perhaps surprisingly well guidelines, from loss of paternalism to the difficulties in conducting observational represented in all groups – relatively few species have the capacity for clinical research, by reference to parts of my collection. ‘facultative’ monogamy seen in humans. It seems important to understand the reasons for it, in biological, and also in specifically endocrinological terms. Among the hormones thought to be involved in pair bonding behaviours, prolactin, vasopressin, and above all testosterone have received attention. Testosterone levels are relatively high in promiscuous males, and several studies SE1.6 have shown that they are reduced in monogamous relationships, triggered The endocrinology of extramarital affairs apparently by proximity to young children. The task is now to identify the causes Gavin Vinson of this. School of Biological and Chemical Sciences, London, UK. One possibility is that the effect is pheromonal, and although previous attempts to identify human pheromones have not uniformly stood the test of time, a recent study claims that a pheromone in teardrops has a testosterone reducing effect. There are three types of academic research studies into the origins and There are undoubted rewards to be gained from elucidation of these mechanisms. maintenance of monogamous as opposed to promiscuous relationships in There is apparently a huge market for Viagra. Is there similarly a demand for an humans – economic, sociological, and biological – with seemingly little agent with the reverse activity? continuity between them. It may be obvious that all three influences can modify

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Oral Communications

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Young Endocrinologists prize session failure were reduced after successful surgery (P!0.01 in both instances) but not on cardiovascular disease, osteoporotic fractures or cancer. This observational OC1.1 study provides long-term results of treated and untreated PHPT and suggests that Thyroid hormones in the euthyroid range predict subsequent body mass w15% patients with mild untreated PHPT showed evidence of progression. PTH composition in women: the OPUS study concentration was an important predictor of calcium progression. Preethi Rao1, Graham Williams2, Elaine Murphy2, David Reid3, Christian Roux6, Dieter Felsenberg5, Claus Gluer4, Richard Eastell7 & Salman Razvi1 1Queen Elizabeth Hospital, Gateshead, UK; 2Molecular Endocrinology Group, Department of Medicine, and Medical Research Council, Imperial College London, Clinical Sciences Centre, London, UK; 3Division of OC1.3 Applied Medicine, School of Medicine and Dentistry, University of Prolonged exposure to GH impairs insulin signaling in the heart Aberdeen, Aberdeen, UK; 4Universita¨tsklinikum Schleswig-Holstein, Kiel, 1 1 1 5 6 Johanna G Miquet , Carolina S Martinez , Jorge F Giani , Germany; Free University of Berlin, Berlin, Germany; Paris Descartes ´ 1 1 1 2 7 Lorena Gonzalez , Ana I Sotelo , Fernando P Dominici , Andrzej Bartke University, Paris, France; University of Sheffield, Sheffield, UK. & Daniel Turyn1 1Department of Biological Chemistry, School of Pharmacy and Biochem- istry, University of Buenos Aires, IQUIFIB, CONICET, CABA, Buenos Background 2 Thyroid disease is associated with BMI with hyperthyroidism causing weight loss Aires, Argentina; Southern Illinois University School of Medicine, and hypothyroidism leading to weight gain. However, the relation of body weight Springfield, Illinois, USA. distribution to thyroid function in euthyroid individuals is unclear. This study assessed body composition in euthyroid women. GH and IGF1 play an important role in cardiac development and function. Methods Conditions leading to abnormal GH levels are associated with cardiovascular Euthyroid women (nZ1072) from the Osteoporosis and Ultrasound Study disease. Although acromegaly is associated with hypertension, insulin resistance, (OPUS), a population based cohort study recruited participants from 5 European diabetes type 2 and dislipemia, several studies ascribe the heart alterations cities, had their thyroid function measured in 2001/02. Individuals with history of displayed by these patients to the direct action of chronically elevated GH and thyroid illness, those on any drugs influencing thyroid metabolism and FT3 IGF1 levels. concentrations !2.1 pmol/l, as a marker of non-thyroidal illness were excluded. Given that insulin acts as a growth factor to the heart and is important to cardiac Whole body adiposity and lean mass was measured in 2007/08 by dual energy function and considering that GH excess induces hyperinsulinemia, insulin X-ray absorptiometry (DXA) scan. The association between body composition resistance and cardiac alterations, it is of interest to analyze insulin sensitivity in and thyroid function was analysed using correlation analyses (Pearson’s r for FT4 this tissue under conditions of chronic GH excess. Thus, in this study we used and FT3 and Spearman’s rho for TSH) and linear regression analyses after transgenic mice over-expressing GH (Tg) that develop concentric cardiac correction for other baseline confounding variables such as age, BMI, smoking hypertrophy associated with alterations in heart functionality, hyperinsulinemia and diabetes. and insulin resistance. Results Mice were anaesthetized, received a bolus insulin injection via cava vein and the The mean age (S.D.) was 61 (13) years. Median (range) TSH levels were 0.86 heart was removed after 2 min. Tg animals presented cardiomegaly and mild (0.25–3.48) mIU/l, mean FT4 and FT3 levels were 12.8 (1.8) pmol/l and 3.7 (0.84) perivascular fibrosis in the heart. The activation and abundance of insulin pmol/l respectively. Whole body and truncal lean mass were negatively correlated signaling mediators were assessed by immunoblotting. Insulin-induced tyrosine ZK K ZK K with FT4 (r 0.16 and 0.19), FT3 (r 0.18 and 0.21) and positively phosphorylation of the insulin receptor (IR) was conserved in Tg mice compared correlated with TSH (rZ0.09 and 0.11). Whole body and truncal fat mass were with their normal littermates. However, the phosphorylation of IR substrate-1 Z 0 positively correlated with FT3 (r 0.09 and 0.12) but not with FT4 and TSH (IRS1), its association with the regulatory subunit of the phosphatidil inositol 3 levels. In multiple linear regression analysis, FT3 and TSH independently kinase and the phosphorylation of Akt was 25, 50 and 40% decreased, predicted whole body and truncal lean mass whereas whole body and truncal fat respectively, in Tg mice (P!0.05, nZ5). Contrary to what was detected in mass were predicted by FT3 alone. FT3 to FT4 ratio was also significantly normal animals, insulin failed to stimulate the phosphorylation of mitogen correlated with truncal fat levels (rZ0.09, PZ0.002). activated protein kinases Erk1/2 in Tg mice. Protein content of the signaling Conclusions mediators in study was not affected by either hormone stimulation or genotype. Thyroid hormones levels, even in the euthyroid range, independently predict We conclude that GH over-expressing Tg mice exhibit decreased sensitivity to whole body lean and fat mass as well as central adiposity. This suggests that insulin at several signaling steps downstream the IR in the heart. These may be thyroid hormones play an important role in the pathogenesis of obesity. associated with the cardiac pathology observed in these animals.

OC1.2 OC1.4 Does ‘mild’ primary hyperparathyroidism progress if left untreated? Developing an in vitro model of tissue expansion in Graves A natural history study ophthalmopathy: exploring the role of IGF1 receptor targeting as a Ning Yu, Peter Donnan, David Smith & Graham Leese novel treatment University of Dundee, Dundee, UK. Daniel Ezra, Geoffrey Rose & Maryse Bailly Moorfields Eye Hospital and UCL Institute of Ophthalmology Biomedical Research Centre for Ophthalmology, London, UK. The prevalence of primary hyperparathyroidism (PHPT) is increasing and the majority (over 85%) are now asymptomatic and remain untreated. In order to know whether or not they can be left safely without surgery, issues on disease Introduction progression need to be addressed. We aimed to update the natural history of One of the most promising potential targets for new treatments in Graves PHPT, with a focus of serum calcium progression in mild untreated patients, ophthalmopathy (GO) is the insulin-like growth factor 1 receptor (IGF1R). selected from a large pre-defined cohort of PHPT in Tayside, Scotland. Possible However, a significant impediment to the translational pathway in developing predictors of progression and the cure rate and outcomes of parathyroidectomy new treatments for GO is the lack of any animal or in vitro model. (PTX) were also addressed, corresponding to the Proceedings of the Third Aims International Workshop on asymptomatic PHPT (2008). Using complete medical To characterise dysregulation of IGF1 pathway related gene expression in GO. To data at individual level, we identified 904 mild untreated patients (baseline develop a new in vitro model for tissue expansion in GO using 3D collagen calcium; 2.62 mmol/l) and 200 surgically treated patients (2.80 mmol/l). Their constructs. biochemical indices were followed up until September 2009, giving a median Methods follow-up time of 4.7 and 5.8 years respectively. In patients with untreated PHPT, RNA extraction and expression analysis was performed using the gold-standard there was a decreased trend in calcium but an increasing trend in PTH for up to 12 Affymetrix GeneChip Human Genome U133 Plus 2.0 genome level microarray years. Serum creatinine, alkaline phosphatase and cholesterol fluctuated around platform according to manufacturer’s protocols using 5 GO and 5 Control the normal ranges with no apparent trend. Disease progression, defined as an samples of orbital fat. Microarray findings were validated with qPCR. Cell lines increase in calcium concentration, was observed in 121 patients (13.4%). Baseline of orbital fibroblasts were derived from 3 GO and 3 control patients. Cells were age and PTH concentration were the only significant risk factors for disease seeded in compressed 3D collagen cultures under several conditions including progression. In comparison, in the PTX group, serum calcium was normalised recombinant IGF1, GO patient serum and IGF1R blocking antibody. Gel after surgery in 196 patients (98%). Hospital admissions for renal stones and renal thickness (expansion) was measured over 7 days using confocal microscopy.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Parallel experiments were conducted using 2D cell monolayers. Hyaluronic acid POR provides electrons to CYP17A1 thereby facilitating synthesis of the major (HA) synthesis was measures using ELISA. androgen precursor dehydroepiandrosterone (DHEA). ORD disrupts this Results enzymatic step, resulting in deficient synthesis of 5a-dihydrotestosterone Dysregulation of numerous IGF1 signalling genes, including: IGF1, IGFBP6, (DHT) via DHEA, readily explaining undervirilisation (46,XY DSD) in male SOCS3, IRS2, SGK and c-JUN were identified and validated with qPCR. HA ORD neonates. Female virilisation (46,XX DSD) in ORD despite disruption of synthesis was increased in the presence of both rIGF1 and GO patient serum. HA DHEA synthesis has been proposed to be explained by an alternative pathway to synthesis was significantly attenuated in the presence of IGF1R antibody. DHT synthesis present in human fetal life only. This pathway also involves Corresponding changes in gel thickness were found to correlate with HA CYP17A1 generating androsterone (An) from 17-hydroxyallopregnanolone concentrations measured with ELISA. (5a17HP), the preferred CYP17A1 substrate. The homozygous ORD mutants Conclusions A287P and H628P are associated with 46,XX DSD and 46,XY DSD, respectively, Our microarray data is the first data to demonstrate abnormal IGF1 signalling in and we hypothesized that this is explained by distinct effects on alternative human GO tissue and our in vitro model for tissue expansion may be of use as a androgen pathway activity. In vitro yeast microsomal co-expression of CYP17A1 functional assay for testing potential new treatments and accelerate the move to with both mutants revealed 65% residual conversion of 5a17HP to An in the clinical trials. presence of A287P whereas co-expression of H628P maintained only 16% of wild-type activity. Longitudinal urinary steroid profiling in ORD due to A287P (nZ3) in comparison to controls (nZ8) documented significantly increased 5a17HP and An excretion during the first three weeks of life. To determine whether there is also evidence for the alternative pathway in normal physiology we performed ex vivo fetal organ culture employing tissues from gestational weeks 7 to 9, the key period of human sexual differentiation, with steroid OC1.5 identification and quantification by tandem mass spectrometry. Results K/K Atheroprotection by 11b-HSD1 deficiency in ApoE mice: role of unanimously showed that the human fetal adrenal is capable of all conversions both glucocorticoid and 7-oxysterol factors within the proposed alternative pathway, except for the final step, the generation Tijana Mitic, Patrick W F Hadoke, Surawee Chuaiphichai, Taq Y Man, of DHT from androstanediol, which occurred in fetal genital skin. Our results Eileen Miller, Ruth Andrew, Brian R Walker, Karen E Chapman & provide conclusive evidence for the existence of an alternative androgen Jonathan R Seckl biosynthetic pathway in early human life, with major implications for human Queen’s Medical Research Institute, University/BHF Centre for physiology and disease. Cardiovascular Science, University of Edinburgh, Edinburgh, Scotland, UK.

11b-Hydroxysteroid dehydrogenase type 1 (11b-HSD1) regenerates active glucocorticoids thus amplifying their intracellular actions. 11b-HSD1 deficiency or inhibition, which improve metabolic syndrome and attenuate atherosclerosis in vulnerable rodent strains, is a target for drug development. However, 11b-HSD1 also converts 7-ketocholesterol (7KC) (which accumulates in fatty tissues), to the potentially more atherogenic, 7b-hydroxycholesterol. Whether atheroprotection with 11b-HSD1 deficiency is dependent on metabolism of glucocorticoids or of oxysterols is unknown. Male atherosclerosis-prone ApoEK/K and ApoEK/K.11b-HSD1K/K double OC1.7 knockout (DKO) mice (11 weeks) underwent adrenalectomy (Adx) or sham Mutant cytochrome b5 causing 46,XY disorder of sex development surgery (nZ8/group) under general anaesthesia (Isoflurane) after pre-operative (DSD) due to apparent CYP17A1 17,20 lyase deficiency analgesia (Vetergesic, 0.05 ml/30 g). Mice then received high (0.2%) cholesterol Jan Idkowiak1, Tabitha Randell2, Vivek Dhir1, Pushpa Patel1, ‘Western’ diet and saline (0.9%) for 12 weeks. The aorta and branches were Cedric H L Shackleton1, Nils Krone1 & Wiebke Arlt1 perfusion-fixed. Lesion volume and extracellular lipids were determined by 3D 1School of Clinical and Experimental Medicine, CEDAM Centre for optical projection tomography (OPT) and plasma and lesion lipid profiles by Endocrinology, Diabetes and Metabolism, University of Birmingham, colorimetric assays and gas chromatography mass spectrometry. Birmingham, UK; 2Department of Paediatric Endocrinology, Nottingham Body/organ weights were unaltered by adrenalectomy in either genotype. Children’s Hospital, Nottingham University Hospitals NHS Trust, K K Adrenalectomy in ApoE / mice did not alter lesion volume (232G24 vs Nottingham, UK. 235G34 mm3 sham control). DKO mice had reduced lesion volumes (139 G17 mm3) compared with ApoEK/K mice (P!0.05). Adrenalectomy reversed this effect (263G52 mm3). DKO mice (both sham and Adx) had increased plasma In humans, androgen synthesis crucially depends on the enzyme CYP17A1 levels of 7KC (66G8 ng/ml; 83G23 DKO Adx) compared with ApoEK/K (48 expressed in adrenals and gonads. The 17,20 lyase activity of CYP17A1 catalyses G8 ng/ml; 36G9ApoEK/K Adx). Whilst aortic cholesterol levels were the key step in human androgen biosynthesis, the conversion of 17-hydro- unchanged by adrenalectomy, aortic 7KC levels, expressed as a ratio to total xypregnenolone to the universal sex steroid precursor dehydroepiandrosterone plaque cholesterol, were increased in adrenalectomised DKO mice (51.2G13.8 (DHEA). For its catalytic activity, CYP17A1 requires electron transfer from P450 Adx versus 14.9G3.3 sham) but remained unaltered in ApoEK/K mice (18.9 oxidoreductase (POR). Mutations in CYP17A1 and POR are known to disrupt G3.7 vs 16.9G3.8). human androgen synthesis and causing 46,XY DSD. Cytochrome B5 (CYB5) is Circulating adrenal products, plausibly glucocorticoids, are therefore necessary thought to enhance allosteric interaction of CYP17A1 and POR proteins required for 11b-HSD1 deficiency to attenuate atherosclerosis. However, 11b-HSD1 for normal 17,20 lyase function. deficiency increases the lipid content of plaques in the absence of glucocorticoids, We have identified a disease-causing missense CYB5 mutation in a large perhaps due to accumulation of 7-ketocholesterol. Thus metabolism of both consanguineous family including three children with 46,XY DSD. The index glucocorticoids and 7-oxysterols by 11b-HSD1 appear involved in atherogenesis. case, a 46,XY female presented with lack of pubertal development at 13 years of age. She was fully pre-pubertal and her genitalia appeared predominantly female except for mild clitoromegaly; the gonads were not palpable. Serum DHEAS was undetectable; urinary steroid profiling revealed low or undetectable androgen metabolites with elevated excretion of 17-hydroxypregnenolone, indicative of isolated 17,20 lyase deficiency. No mutations were found in CYP17A1 nor POR. However, we detected a homozygous CYB5 missense mutation (g.2510AOT) OC1.6 replacing highly conserved histidine with leucine at amino acid position 44 Evidence for the existence and significance of an alternative pathway (p.H44L). Segregation analysis revealed parental heterozygosity for p.H44L and towards androgen synthesis during early human life homozygosity for p.H44L in two younger brothers who presented perineal Nicole Reisch1, Vivek Dhir1, Andrew Berry2, Angela Taylor1, Nils Krone1, hypospadias and bifid scrotum. We performed functional in vitro characterisation Edson Nogueira1, Cedric Shackleton1,3, Neil Hanley2 & Wiebke Arlt1 by co-expressing wild-type and mutant CYB5 with CYP17A1 in HEK293 cells. 1School of Experimental and Clinical Medicine, Centre for Endocrinology, Kinetic analysis revealed that p.H44L CYB5 decreases 17,20 lyase activity of Diabetes and Metabolism, University of Birmingham, Birmingham, UK; CYP17A1 to 38% of wild-type catalytic activity. 2Endocrinology and Diabetes University of Manchester, Manchester, UK; We have identified the first human CYB5 missense mutation, a novel co-factor 3Children’s Hospital Oakland Research Institute, Oakland, California, USA. mutation causing androgen deficiency. The considerable phenotypic variability in the degree of male undermasculinisation indicates variable penetrance, e.g. due to genetic differences in other determinants of 17,20 lyase activity such as Congenital adrenal hyperplasia due to P450 oxidoreductase (POR) deficiency CYP17A1 and POR. (ORD) results in disordered sex development (DSD) in individuals of both sexes.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

OC1.8 We have now examined the mechanisms underlying the regulation of 11b-HSD1 TSH levels and thyroid hormone prescribing in primary care in the UK activity in stromal cells. Regulation of activity was not due to any previously described 1 1 1,2 3 mechanism. The increase in activity induced by TNFa/IL-1b was independent of new Ahmed Iqbal , Peter Taylor , Vijay Panicker , Adrian Sayers , 0 Rosemary Greenwood5, Rasha Mukhtar4, Jonathan Evans6 & protein synthesis. 5 RACE analysis and luciferase gene reporter studies demonstrated Colin Dayan1,7 that this effect was mediated via the classical proximal HSD11B1 promoter. Chemical 1Henry Wellcome Laboratories for Integrative Neurosciences and Endo- inhibitor studies demonstrated that this increase in activity, along with basal enzyme crinology, University of Bristol, Bristol, UK; 2Department of Endocrinology activity, was mediated via the NF-kB pathway. Unexpectedly, the induction of 11b- and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, HSD1 by TNFa/IL-1b treatment (but not basal 11b-HSD1 activity) was increased in Australia; 3Academic Rheumatology, Avon Orthopaedic Centre, South- the presence of inhibitors of the p38MAPK pathway. This suggested that TNFa/IL-1b mead Hospital, Bristol, UK; 4Royal United Hospital, Bath, UK; 5University induced activation of the p38MAPK pathway resulted in an inhibition of 11b-HSD1 Hospitals Bristol NHS Foundation Trust, Bristol, UK; 6Academic Unit of expression. Glucocorticoids had a minor inhibitory effect on NF-kBnuclear Psychiatry, University of Bristol, Bristol, UK; 7Department of Medicine, translocation and induction of 11b-HSD1 but appeared to have their stimulatory Centre for Endocrine and Diabetes Sciences, Cardiff University School of effect on 11b-HSD1 expression through inhibition of TNFa/IL-1b induced p38MAPK Medicine, Cardiff, UK. activity. The mechanism by which expression of 11b-HSD1 is regulated in stromal cells appears distinct from that reported in non-stromal cells such as hepatocytes. The Objective finding that stromal cell expression of 11b-HSD1 activity is regulated by NF-kB opens Hypothyroidism is common and predominantly managed in primary care. up new opportunities to inhibit 11b-HSD1 activity in a tissue restricted manner. Symptoms are non-specific, with thyroid function tests (TFT) required for diagnosis. We sought to investigate current practice in levothyroxine prescribing in primary care. Methods We studied the initiation of levothyroxine using the General Practice Research Database (GPRD), the world’s largest database of anonymised medical records. OC2.2 Individuals with i) thyroid cancer ii) secondary hypothyroidism iii) other thyroid Anti-inflammatory mechanisms of 5a-reduced glucocorticoids: altering medication were excluded. This was combined with a study of 444 potential dissociated steroids patients (‘DEPTH’) referred for thyroid function testing from 5 general practices Mark Nixon, Chenjing Yang, Adriano Rossi, Brian Walker & Ruth Andrew and a detailed records-based analysis of the reasons for commencing University of Edinburgh, Edinburgh, UK. levothyroxine in 104 subjects from one general practice. Results Fourteen thousand and nine eligible patients prescribed levothyroxine between We recently showed that 5a-reduced metabolites of corticosterone (B), namely 2000 and 2009 were identified from GPRD. The median TSH at which 5a-dihydrocorticosterone (5aDHB) and 5a-tetrahydrocorticosterone (5aTHB), levothyroxine was initiated was 6.0 mU/l. 78.3% of individuals had levothyroxine possess similar anti-inflammatory properties to B, but have lesser metabolic initiated at a TSH level !10 mU/l and 36.2% at !5 mU/l. The odds ratio effects. Here, we explored the anti-inflammatory mechanisms of these 5a-reduced (OR) for psychological caseness amongst patients in DEPTH was 1.70 (95% CI metabolites in vitro. Data are mean % suppression/induction, compared by one 1.34–2.16, P!0.001) compared to routine general practice attenders. However, way ANOVA, *P!0.05 versus vehicle. when their thyroid function was analysed there was no increased case finding for In RAW264.7 murine macrophages stimulated with lipopolysaccharide (LPS, hypothyroidism ORZ0.87 (95% CI 0.53–1.42). Detailed records analysis of 104 30 ng/ml, 24 h), TNFa and IL6 release was suppressed by B (1 mM; 61.7%*, subjects in one general practice revealed 43.3% had levothyroxine prescribed 92.2%*, respectively), 5aDHB (1 mM; 20.4%*, 68.8%*) and 5aTHB (1 mM; despite being asymptomatic (median TSH 8.1 mU/l). 26.9% had levothyroxine 40.3%*, 47.5%* respectively), effects that were inhibited by co-incubation with prescribed due to ‘classical’ (cold intolerance, weight gain, thin hair) symptoms the glucocorticoid receptor (GR) antagonist RU486 (1 mM). Relevance to normal (median TSH 13.1 mU/l). 29.8% were prescribed levothyroxine for other ‘non- cells was confirmed in LPS-stimulated (100 ng/ml, 24 h) bone-marrow-derived classical reasons’ (median TSH 10.1 mU/l). murine macrophages, in which TNFa and IL6 release was suppressed by B Conclusion (1 mM; 74.2%*, 69.4%*, respectively), 5aDHB (1 mM, 47.1%*, 28.7%*) and It appears current guidelines for prescribing levothyroxine are not being adhered 5aTHB (1 mM, 21.9%*, 16.4%*). to, with large numbers of individuals with low mood undergoing thyroid function To examine underlying mechanisms, RAW264.7 macrophages were incubated testing, with subsequent inappropriate initiation of levothyroxine. Individuals with steroids (1 mM, 1 h) prior to LPS stimulation (100 ng/ml, 30 min). with depression appear to have a low probability of abnormal TFT and Phosphorylation of inflammatory kinases p38 and JNK were suppressed by B widespread use of TFT in individuals with depression may be unwarranted. A (42.5%*, 47.5%*), 5aDHB (35.7%*, 36.6%*) and 5aTHB (34.9%*, 38.4%*, greater awareness of current guidelines and appropriate use of TFT is required. respectively). Protein expression of MKP-1 and IkBa was stimulated by B (160%*, 458%*) and 5aDHB (116%*, 389%*, respectively), whilst 5aTHB induced MKP-1 (104%*) but not IkBa expression. To examine transcriptional effects, HEK293 cells transfected with NF-kB or AP-1 reporter plasmids, with or without a plasmid encoding GR, were treated with steroids (1 mM) and stimulated with phorbol ester (TPA, 5 ng/ml, 24 h). B and 5aDHB suppressed NF-kB-mediated transcription (42.2%*, 39.5%*) and AP-1- mediated transcription (67.6%*, 82.9%* respectively) in a GR-dependent manner. In contrast, 5aTHB increased NF-kB-mediated transcription (25.0%*) Steroids and AP-1-mediated transcription (22.1%*) independently of GR. OC2.1 In conclusion, 5a-reduced glucocorticoid metabolites exhibit anti-inflammatory properties in macrophages. The mechanisms of actions of the metabolites differ, Regulation of 11b-hydroxysteroid dehydrogenase type 1 by NF-kBin but both suppress inflammatory kinase pathways. Thus 5a-reduced glucocorticoid stromal cells: towards tissue specific enzyme inhibition metabolites have potential as ‘dissociated’ anti-inflammatory steroid therapy. Mohammad Ahasan1, Chris Jones1, Rowan Hardy1, Zaki Hassan-Smith1, Gareth Lavery1, Elizabeth Rabbitt1, Cristopher Buckley2, Karim Raza2, Paul Stewart1 & Mark Cooper1 1School of Clinical and Experimental Medicine, The University of Birmingham, Birmingham, West Midlands, UK; 2School of Immunity and Infection, The University of Birmingham, Birmingham, West Midlands, OC2.3 UK. APEX1, a novel, negative regulator of aldosterone synthase activity, differentially binds to a single nucleotide polymorphism in the aldosterone synthase gene and represses transcriptional activity both The 11b-hydroxysteroid dehydrogenase type 1 (11b-HSD1) enzyme is a tissue specific in vitro and in vivo regulator of glucocorticoid action that is linked to the development of osteoporosis, Frances McManus1, William Sands1, Robert Fraser1, Eleanor Davies1 inflammatory arthritis and myopathy. Systemic inhibition of 11b-HSD1 enzyme & John Connell2 activity has been proposed as a therapeutic option in these conditions. However, 1University of Glasgow, Glasgow, UK; 2University of Dundee, Dundee, 11b-HSD1 activity has also been reported to be important in regulation of the UK. immune response and the HPA axis. We have previously demonstrated that proinflammatory cytokines, glucocorticoids and their combination dramatically increase 11b-HSD1 expression and activity in osteoblasts, synovial fibroblasts and Aldosterone synthesis is heritable; a single nucleotide polymorphism (SNP) in the myoblasts. The mechanisms underlying this increase in activity are unknown. promoter of the aldosterone synthase gene (position K344, rs1799998) has been

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK associated with an increased plasma aldosterone levels and hypertension. OC2.5 However, deletion of this site has no effect on gene transcription in vitro and A novel entity of isolated adrenal insufficiency caused by partial therefore the mechanism that links genotype with phenotype is unclear. K inactivation of P450 side-chain cleavage (CYP11A1) enzyme We identified a polymorphism at position 1651 T/C (rs13268025) and show it Silvia Parajes1, Clemens Kamrath2, Ian Rose1, Angela Taylor1, to be in linkage disequilibrium with the K344 SNP. Reporter gene constructs 1 1 3 1 K Christiaan Mooij , Vivek Dhir , Joachim Grotzinger , Wiebke Arlt containing contrasting alleles at position 1651 were transfected into H295R & Nils Krone1 cells. The C allele had (75%) greater promoter activity than the T allele. An 1University of Birmingham, Birmingham, UK; 2University Children’s electromobility shift assay with oligonucleotides spanning the polymorphism of Hospital Giessen, Giessen, Germany; 3University of Kiel, Kiel, Germany. interest demonstrated a difference in protein/DNA complexes between the T and C allele. Biotinylated pull down assays of the protein: DNA complex were proteolised and peptides identified by tandem mass spectroscopy. Fragments Cytochrome P450 side-chain cleavage enzyme (CYP11A1) catalyses the first and derived from the transcription factor APEX1, were identified bound to the T allele rate-limiting step of steroidogenesis, facilitating conversion of cholesterol to and not the C allele. Chromatin immunoprecipitation confirmed the association of pregnenolone. Cholesterol, transported by steroidogenic acute regulatory APEX1 to the CYP11B2 promoter. Inhibition of APEX1 activity with a small protein (StAR) into the inner mitochondrial membrane, is converted by molecule inhibitor of APEX1 (E3330, Sigma–Aldrich), and siRNA for APEX1, CYP11A1 into 22R-hydroxycholesterol. Subsequently, CYP11A1 converts both increased transcriptional activity. The in vivo genotype/phenotype 22R-hydroxycholesterol by 20alpha-hydroxylation and cleavage of the relationship was explored in 60 normal volunteers, studied under standard salt C20–C22 bond into pregnenolone. All patients with CYP11A1 deficiency intake. Carriers of the C allele were confirmed to have higher 24 h urinary described so far presented with combined adrenal insufficiency (AI) and 46,XY aldosterone excretion (meanZ59.55 mg/24 h 95% CI 46.73–72.37 mg/24 h) than disorder of sex development (DSD). the subjects carrying the T allele at position K1651 (meanZ36.10 mg/24 h 95% Herein, we describe two siblings (46,XY) presenting with late-onset isolated AI CI 24.0–48.21 mg/24 h) PZ0.008. with normal male genital development. The older sibling had first symptoms APEX1 has been identified as a novel negative regulator of CYP11B2; a SNP at suggestive of AI at the age of 2 years with the diagnosis finally established at the K1651 demonstrates allele dependant binding, leading to increased transcrip- age of 4.1 years. His younger brother was diagnosed with adrenal insufficiency at tional activity in vitro and increased THAldo excretion in vivo. This offers a the age of 2.5 years. A maternal uncle died at the age of 9 years during an episode plausible mechanism behind the genotype/phenotype association of increased of febrile seizures. aldosterone secretion and hypertension. Mutation analysis of the DAX1 and StAR genes was performed but did not reveal disease-causing mutations. Finally, we detected a novel homozygous CYP11A1 mutation (c.1351COT; p.Arg451Trp) in both siblings. Segregation analysis confirmed that both parents were heterozygous carriers. Functional in vitro analysis was performed in COS7 cells co-transfected with wild-type or mutant CYP11A1, with or without wild-type StAR and adrenodoxin. Transfected cells were incubated with either cholesterol or 22R-hydroxycholes- terol and pregnenolone production was measured by liquid chromatography/ tandem mass spectrometry (LC–MS/MS). This demonstrated partial inactivation of CYP11A1 activity by the p.Ar451Trp mutation consistent with results of in silico analysis. For the first time, mutant CYP11A1 enzyme activity has been assessed in vitro employing the natural substrate cholesterol and the intermediate product 22R-hydroxycholesterol using LC–MS/MS. Importantly, we present a novel OC2.4 entity of isolated AI caused by a partially inactivating CYP11A1 mutation, which should be considered as differential diagnosis in patients with unexplained Altered miR-125 and miR-134 expression in aldosterone-producing isolated adrenal insufficiency. adenoma and post-transcriptional regulation of the CYP11B2 gene Stacy Wood1, Ayesha Ejaz1, Craig Livie1, Scott MacKenzie1, John Connell2 & Eleanor Davies1 1University of Glasgow, Glasgow, UK; 2University of Dundee, Dundee, UK.

Essential hypertension is known to have a large genetic component. Variation in the CYP11B2 gene, which encodes the aldosterone synthase enzyme, is associated with excess aldosterone production and hypertension but the causative mechanism remains elusive. miRNAs are a class of post-transcriptional regulatory molecules, implicated in cardiovascular disease, development and tumourogenesis. They act by targeting the 30 untranslated region (UTR) of OC2.6 mRNAs, inhibiting translation through mRNA cleavage or destabilisation Novel non-steroidal glucocorticoids that dissociate rapid signalling We propose a role for miRNAs in the regulation of CYP11B2 expression and in effects from gene transcription the development of essential hypertension. To study this, we characterised the Peter Trebble1, Karen Simpson2, Laura Matthews1, Stuart Farrow2 miRNA profile of four normal adrenal glands and four aldosterone-producing & David Ray1 adenomas (APA), which excrete excess aldosterone and cause hypertension. We 1Endocrinology and Diabetes, Developmental Biomedicine Research then investigated the effect of four miRNAs (miR-125a-5p, miR-125b, miR-134 Group, University of Manchester, Manchester, UK; 2Inflammation and and miR-495a) which are expressed in these tissues and using bioinformatics Resolution DPU, Respiratory CEDD, GlaxoSmithKline, Stevenage, UK. were predicted to bind the 30UTR of CYP11B2 mRNA. Comparison of miRNA expression levels showed that miR-125a-5p and miR-134 are significantly down-regulated in APAs. The interaction of all four miRNAs Glucocorticoids (GCs) are used extensively in the treatment of inflammatory with the CYP11B2 30UTR was tested using a pEZX-reporter plasmid containing disease. Unfortunately, as GC act on virtually every organ system they also carry the full-length CYP11B2 30UTR sequence. This was co-transfected into HeLa a broad range of serious side-effects which limits their clinical use. cells alongside a synthetic miRNA (pre-miR) or miRNA inhibitor (anti-miR). The structure of the bound GC strongly impacts the final conformation of the Both miR-125a-5p and miR-125b pre-miRs significantly decreased luciferase glucocorticoid receptor (GR) and thereby dictates downstream events. Designing activity when over-expressed. Conversely, their anti-miRs significantly increased drugs with different GR binding properties therefore offers a plausible route to luciferase activity. This is consistent with canonical miRNA binding and achieve dissociative effects on GR action. repression, confirming our bioinformatic predictions. miR-495a and miR-134 pre- This work describes two novel, high-affinity, high specificity, non-steroidal GCs miRs and anti-miRs did not alter luciferase activity significantly. (NSGs). Both NSGs were more potent than the synthetic GC dexamethasone for In summary, we have identified two miRNAs, miR-125a-5p and miR-134, with gene transactivation and transrepression and were equipotent for inhibition of cell aberrant expression in APA samples and putative binding sites in the CYP11B2 proliferation. gene. We also confirmed that miR-125a-5p and miR-125b, but not miR-134, can Compared with dexamethasone, short treatment with the NSGs induced repress CYP11B2 by directly targeting the 30UTR. The regulation of CYP11B2 significantly less phosphorylation of PKB, which was accompanied by delayed, mRNA by miRNAs and altered expression in adrenal adenomas may give rise to submaximal phosphorylation of GR at Ser211. Ser211GR is required for novel therapeutic targets for the treatment of essential hypertension and adrenal engagement of GR at some (eg IGFBP1) but not all gene targets, suggesting that tumours. the NSGs may mediate only a proportion of GR effects. Indeed, compared with dexamethasone, the NSGs showed impaired transactivation of IGFBP1.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Perhaps most surprisingly, the NSGs failed to promote downregulation of steady Five obese men (age 48G5 years, BMI 39.8G3.6 kg/m2) participated in a state GR expression, a well characterised response to dexamethasone. Previous randomised, double-blinded, crossover study comparing metformin (1 g BD reports have demonstrated that GSK3b, a downstream target of PKB, is important orally for 28 days) with placebo. At the end of each phase, subjects collected a for targeting the GR for degradation by the proteasome. As the NSGs also fail to 24 h urine sample and attended twice after overnight fast. On a first visit, 2 induce rapid activation of PKB, this provides a link between initiation of rapid 9,11,12,12-[ H]4-cortisol (d4-cortisol) was infused for 4 h, with repeated blood kinase signalling events and GR turnover. sampling to measure steady state d3-cortisol appearance (whole body 11b-HSD1 These novel NSGs therefore do not activate the full spectrum of rapid GC effects, activity). On a second visit, subjects took 0.25 mg oral dexamethasone at 2300 h impacting kinase signalling, GR activity and turnover. As a consequence the and 25 mg oral cortisone at 0900 h, with repeated blood sampling to measure NSGs show an unexpected specificity of action. In particular, this highlights the conversion to cortisol by hepatic 11b-HSD1. Steroids were quantified by RIA requirement of rapid signalling events to mediate the full range of GC effects, (cortisone test) or mass spectrometry (tracer and urinary steroids). Local ethical representing an important and tractable model for drug design. approval was obtained. Data are meanGS.E.M. Fasting glucose (5.3G0.3 vs 6.0G0.9 mmol/l) and insulin (11.4G3.5 vs 21.0 G7.8 mU/l) were non-significantly decreased by metformin. Metformin increased whole body rate of appearance of d3-cortisol (48G6vs39G5 nmol/min, PZ0.01), but did not alter the rate of conversion of oral cortisone to cortisol (area under curve 29 951G11 207 vs 34 128G3741, PZ0.7) or urinary cortisol metabolites (15.9G4.0 vs 18.3G4.2 mg/day). Metformin increases whole body 11b-HSD1 activity in euglycaemic obese men. However, whether this is mediated in the liver by reversal of hyperinsulinaemia remains unproven. There has been concern that 11b-HSD1 inhibitors will be less OC2.7 effective in the presence of metformin, given their shared mechanism of suppressing hepatic gluconeogenesis. These data suggest, however, that metformin Depot specific differences in the sensitivity to glucocorticoid and insulin may increase the local regeneration of cortisol by 11b-HSD1 and provide a bigger action in human adipose tissue target for 11b-HSD1 inhibitors. Laura Gathercole, David Hauton, Stuart Morgan, Iwona Bujalska, Paul Stewart & Jeremy Tomlinson University of Birmingham, Birmingham, UK.

Intra-abdominal adiposity is associated with insulin resistance and increased cardiovascular morbidity and mortality. Differences in gene expression between omental (om) and subcutaneous (sc) adipose have been described, but molecular mechanisms underpinning differences in adipose biology are not known. Patients with glucocorticoid excess, Cushing’s syndrome, develop a phenotype characterized by central obesity. We have characterized the regulation of lipogenesis by glucocorticoids and insulin in paired om and sc differentiated pre- adipocytes measuring lipogenic gene expression by real-time PCR and 1-[14C]- Pituitary and thyroid acetate incorporation into lipid. OC3.1 Differentiated sc pre-adipocytes had more lipid droplets, increased mRNA Development of a novel mass spectroscopy-based method for expression of lipogenic genes (ACC1 3.2 fold, FAS 10.9 fold, ACC2 17.8 fold, determining serum IGF1: assessment in a cohort of newly diagnosed LPL 44.7 fold) and higher 1-[14C]-acetate incorporation than om cells (8.9 fold). subjects with acromegaly However, lipogenesis in om cells was more responsive to insulin stimulation David Halsall1, Richard Kay2, Kevin Taylor1, Anand Annamalai1, (control (100%): sc 149G22.14%, om 209G1.86%, P!0.05). In the absence of Narayanan Kandasamy1, Gwen Wark3, Steve Pleasance2 & Mark Gurnell1 insulin, Dexamethasone (Dex) had no effect on lipogenic gene expression in sc or 1Addenbrookes Hospital, Cambridge, UK; 2Quotient Bioresearch Ltd, om cells. However, in the presence of insulin, in both sc and om cells, Dex Fordham, Cambridgeshire, UK; 3Royal Surrey County Hospital, increased FAS expression, (sc 2.4 fold; om 3 fold) and in om cells only, increased Guildford, UK. ACC1 expression (1.6 fold). Dex decreased lipogenesis in sc (100% (control), 81.9G3.9% (5 nM), 67.3G4.8% (500 nM)) and om (72.0G5.4% (5 nM), 46.9 G5.7% (500 nM)) cells in a dose dependent manner. In sc cells, in the presence Background of insulin (5 nM), Dex no longer inhibited lipogenesis and did not impair insulin- The recently published ‘Consensus on Criteria for Cure of Acromegaly’ (Giustina stimulated lipogenesis (100% (control), 149.0G22.1% (No Dex), 145.5G29.4% et al. JCEM, 2010) highlighted concerns regarding the quality of currently (5 nM), 128.2G39.3% (500 nM)). In contrast, Dex deceased lipogenesis in om available insulin-like growth factor 1 (IGF1) immunoassays which may cells in the presence of insulin, reflecting either a persistence of the direct action contribute, at least in part, to the discordance between GH and IGF1 that is of Dex, or its ability to induce insulin resistance and limit insulin-stimulated observed in up to 30% of patients with acromegaly after treatment. The lipogenesis (100% (control), 208.9G1.86 (No Dex), 181.45G11.8% (5 nM), development of mass spectroscopy (MS)-based technology has been proposed as 125.1G12.0% (500 nM)). a potential solution to these limitations. Om adipose tissue sensitivity to both glucocorticoids and insulin may drive lipid Methods flux, contributing to the Cushing’s phenotype and may also help to explain the Here, we report the development of a stable isotope dilution ultra-performance detrimental impact of om fat accumulation. liquid chromatography tandem MS (UPLC–MS/MS)-based method for the quantitation of serum IGF1. The method employs selected reaction monitoring (SRM) of two tryptic peptides derived from IGF1, and relies on solid phase extraction for enrichment of the peptide fraction containing IGF1 rather than immunocapture, so is less susceptible to antibody interference. The UPLC separation of the peptides was performed using a C18 column prior to MS/MS analysis on a 5500 QTrap MS. The method is not affected by concentrations of IGFBP3 up to 420 nmol/l. Results The method showed good correlation with an IGF1 immunoassay (Siemens OC2.8 Immulite 2000) over a wide range of serum IGF1 concentrations (5.4–261 nmol/l Metformin increases in vivo 11b-hydroxysteroid dehydrogenase type 1 by immunoassay) in a cohort of 45 patients that included 25 subjects with activity in euglycaemic obese men acromegaly, assessed both before and after primary medical therapy. The Passing Roland Stimson, Ruth Andrew, Gregory Jones, Dawn Livingstone, and Bablock regression was: LC–MS/MS (nmol/l)Z1.4!Immunoassay Kenneth Smith & Brian Walker (nmol/l)C4.4. Analysis of UKNEQAS material with an immunoassay method University of Edinburgh, Edinburgh, UK. mean of 22.2 and 45 nmol/l returned values of 22.3 and 47.6 nmol/l respectively. Conclusions This method relies on entirely different physicochemical principles to the Inhibiting cortisol regeneration by 11b-HSD1 is a promising therapy for type two ubiquitous ‘sandwich immunoassay’ for IGF1, and thus provides an independent diabetes. In obesity, 11b-HSD1 activity is increased in adipose tissue but validation of suspicious immunoassay-derived results. A further advantage of the decreased in the liver, the latter putatively mediated by hyperinsulinaemia. We method is that, with the addition of appropriate internal standards, there is tested whether insulin sensitisation with metformin regulates 11b-HSD1 activity potential for extensive multiplexing of serum peptide assays. in whole body and in liver in obesity.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

OC3.2 qRT-PCR analyses. Pre-miR-107 and anti-miR-107 were used to examine the Determination of method-specific normal cortisol responses to the short effects of miR-107 expression on cell proliferation and colony formation in human SH-SY5Y and rat GH3 cells. A luciferase reporter assay was used to Synacthen test 0 Nadia El-Farhan1,2, Alan Pickett1, David Ducroq3, Catherine Bailey4, examine the in silico predicted target sites in the 3 UTR of the aryl hydrocarbon Kelly Parham5, Nicola Morgan6, Anne Armston7, Carol Evans1 & receptor interacting protein (AIP) gene. Dafydd Aled Rees2 Results 1University Hospital of Wales, Cardiff, UK; 2Cardiff University, Cardiff, miR-107 expression was found significantly upregulated in pituitary adenoma UK; 3Welsh External Quality Assurance Scheme Laboratory, Cardiff, UK; tissues compared to normal pituitaries. Overexpression of miR-107 inhibited cell 4Royal Gwent Hospital, Newport, UK; 5Prince Charles Hospital, Merthyr proliferation of both the rat and the human cell lines tested. Anti-miR-107 6 7 increased colony formation by 2.5 fold in human cells. We provide direct Tydfil, UK; Bristol Royal Infirmary, Bristol, UK; Southampton General K 0 Hospital, Southampton, UK. evidence that AIP 3 UTR is a functional target of miR-107 as miR-107 inhibits human AIP expression to 53.9G2% of the scrambled miRNA control in a luciferase expression model and it reduces endogenous AIP expression to Introduction and aims 53G22% of the scrambled miRNA control in SH-SY5Y cells. The short Synacthen test (SST) is used to diagnose underactivity of the HPA axis, Conclusions with a cortisol response !550 nmol/l at 30 min widely accepted as diagnostic of These results suggest that miR-107 functions as a tumor suppressor gene in adrenal insufficiency. Earlier studies of the SST have shown variation in cortisol neuroblastoma and pituitary adenoma cells and that it may play a role in pituitary concentrations measured by different immunoassays, suggesting the need for adenoma pathogenesis. method-specific cut-offs. We sought to define the cortisol response to Synacthen in healthy volunteers (HV) and establish method-specific lower reference limits (LRL) for this response. Methods RCD, MHRA and ethical approval were obtained. A SST was undertaken in 165 HV (age 20–66 years, 105 female, 24 taking an oral contraceptive pill (OCP)). OC3.4 Serum cortisol was measured using GC–MS, Siemens (Centaur and Immulite), PTTG promotes mitogenic mechanisms in thyroid cells through Abbott, Roche and Beckmann automated immunoassays. The estimated LRL for autocrine pathways of interaction with growth factors the 30 min cortisol response to Synacthen was derived from the 2.5th percentile of Gregory Lewy, Gavin Ryan, Sarah Stewart, Martin Read, Vicki Smith, log-transformed concentrations. Jim Fong, Adrian Warfield, Margaret Eggo, Robert Seed, Neil Sharma, Results Perkin Kwan, Jayne Franklyn, Christopher McCabe & Kristien Boelaert The GC–MS-measured cortisol response was normally distributed in males but University of Birmingham, Birmingham, UK. not females, with no significant gender difference in concentration. Immunoassay cortisol was normally distributed in all subjects, with significant gender differences in the Abbott, Roche and Beckmann assays. Immunoassays were The human pituitary tumor transforming gene (hPTTG) is overexpressed in positively biased relative to GC–MS, except in samples from women on the OCP. thyroid cancers; it induces genetic instability and propagates growth through the The estimated LRL for cortisol is method-specific, and, for the Roche assay, also induction of growth factors. We investigated the pathways of interaction between gender-specific. A separate LRL is necessary for women on the OCP. hPTTG and epidermal growth factor (EGF), transforming growth factor-a (TGF-a), insulin-like growth factor 1 (IGF1) and basic fibroblast growth factor Table 1 Estimated LRL for cortisol (nmol/l). (FGF2) in vitro and in vivo. Synchronised K1 and TPC-1 papillary thyroid carcinoma cells were treated with TGF-a (5 nM), EGF (5 nM), IGF1 (10 ng/ml), or GC–MS Centaur Abbott Roche Immulite Beckmann FGF-2 (5 nM) and hPTTG protein expression was determined by western blotting at 24 h. EGF treatment in both K1 and TPC-1 cells induced a 2-fold upregulation Adults 420.4 498.7 430.4 M 573.5 F 524.4 474.4 458.6 OCP 649.4 682.3 577.0 791.2 687.7 603.8 of hPTTG, an effect abrogated by treatment with the specific MAPK inhibitor Females PD98059 (30 mM), but not with the specific PKC inhibitor BIS-I (50 nM). TGF-a treatment upregulated hPTTG in K1 (3.6-fold) and TPC-1 cells (4-fold), with similar abrogation by treatment with PD98059 but not with BIS-I. IGF1 treatment Conclusions induced hPTTG in K1 (2.3-fold) and TPC-1 cells (2.6-fold), where treatment with This is the largest study to examine cortisol responses to Synacthen in healthy either of the specific PI3-kinase inhibitors Wortmannin (20 mM) and LY294002 volunteers and provides clinical laboratories with method-specific estimated (50 mM) abrogated this effect. FGF2 had no effect in K1 cells but significantly lower cortisol limits for the SST. We recommend the use of separate cut-offs in upregulated hPTTG in TPC-1 cells (7-fold). To investigate if hPTTG in turn women on the OCP, and warn users that cortisol measurements in this subgroup induces expression of these growth factors, we determined TGF-a, EGF and are subject to assay interference. IGF1 mRNA expression through TaqMan RT-PCR following transient transfec- tion of primary human thyrocytes with hPTTG. EGF (1.7-fold, nZ4, PZ0.004), IGF1 (1.6-fold, nZ5, PZ0.002) and TGF-a mRNA (1.6-fold, nZ3, PZ0.024) were significantly upregulated by hPTTG. To investigate these findings in vivo, we evaluated mRNA expression of these mitogenic factors in our transgenic mouse model with thyroid-targeted hPTTG overexpression. Upregulation of mEGF OC3.3 (2.7-fold, nZ3, PZ0.012) and mIGF1 (2.0-fold, nZ3, PZ0.02) was confirmed miR-107 inhibits the expression of aryl hydrocarbon receptor when comparing 6-week-old hPTTGC/C mice to age-matched WT mice. interacting protein (AIP) and is potentially involved in pituitary Conclusion tumorigenesis PTTG is involved in autocrine signalling mechanisms with growth factors 1 1 1 1 Giampaolo Trivellin , Susana Igreja , Edwin Garcia , Harvinder Chahal , including TGF-a, EGF, IGF1 and FGF2 in the thyroid. Aberrant control of these 2 3 1 1 Henriett Butz , Attila Pato´cs , Ashley Grossman &Ma´rta Korbonits pathways may enhance tumour development and further elucidation of these 1 Department of Endocrinology, Barts and the London School of Medicine, pathways may provide novel therapeutic targets for the prevention of thyroid 2 Queen Mary University of London, London, UK; Second Department of tumour progression. Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary; 3Molecular Medicine Research Group, Hungarian Academy of Sciences and Second Department of Medicine, Faculty of Medicine, Semmelweis University, Budapest, Hungary. OC3.5 Background Metastatic characteristics and radiosensitivity of thyroid carcinoma Abnormal microRNAs (miRNAs) expression profiles have been recently cells depends on HIF-1 and PI3K signalling in vitro and in vivo associated with sporadic pituitary adenomas, suggesting that miRNAs can Natalie Burrows1, Muhammad Babur1, Julia Resch2, Sophie Ridsdale1, contribute to tumor formation. miRNAs are small noncoding RNAs which inhibit Joseph Williams1, Georg Brabant2 & Kaye Williams1 post-transcriptional expression of target mRNAs by binding to complementary 1 0 0 School of Pharmacy, University of Manchester, Manchester, Lancashire, sequences usually located in the 3 untranslated region (3 UTR). However, the UK; 2Department of Endocrinology, Christie Hospital, Manchester, substantial lack of knowledge about miRNAs’ targets hinder full understanding of Lancashire, UK. the mechanisms by which they influence tumorigenesis. Methods The expression level of miR-107 were evaluated in 17 sporadic pituitary adenoma The transcription factor HIF-1a regulates hypoxia-mediated gene expression tissues and nine normal pituitary samples using a microRNA screen TLDA and which promotes tumour growth, metastasis and desensitisation to chemo-and

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK radiotherapy. HIF-1 is functional in a range of thyroid-carcinoma cells and is OC3.7 regulated by hypoxia and the PI3K and MAPK-signalling pathways. Thyroid dysfunction and clot structure: a mechanism for increased We aimed to determine if HIF-1 and PI3K were important in the development of a thrombotic risk in hyperthyroid individuals? metastatic phenotype and play a role in desensitisation to radiotherapy in thyroid Jonathan Hooper1, Steve Orme2, Bregje van Zaane3, Katharina Hess1, carcinomas. Saad Alzahrani1, Kristina Standeven1, Simon Pearce4, Peter Grant1 Thyroid cell migration and adhesion were monitored as metastatic characteristics & Ramzi Ajjan1,2 in vitro. Migration increased with decreasing oxygen tension and was inhibited 1Division of Cardiovascular and Diabetes Research, Leeds Institute of by i) the PI3K-inhibitors PI-103 and GDC-0941; ii) reintroduction of PTEN into Genetics, Health and Therapeutics, University of Leeds, Leeds, West PTEN-null FTC133 cells and iii) inhibiting HIF-1 function using a dominant Yorkshire, UK; 2Department of Endocrinology, Leeds Teaching Hospital negative protein (dnHIF) that reduced expression of HIF-1-target genes CA-9, NHS Trust, Leeds General Infirmary, Leeds, West Yorkshire, UK; LDH-A, GLUT-1, VEGF. PTEN-expressing FTC133s, dnHIF-FTC133s and 3Department of Internal Medicine, Slotervaart Hospital, Amsterdam, The cells treated with GDC-0941 also had reduced ability to adhere/spread on Netherlands; 4Institute of Human Genetics, International Centre for Life, fibronectin. PI-103 and GDC-0941 inhibited expression of PI3K target proteins Newcastle-upon-Tyne, UK. (pAKT, pGSK-3b) and HIF-1 target genes. Radiation induced HIF-1 expression. GDC-0941 combined with radiation blocked HIF-1 induction, prolonged DNA double-strand breaks and reduced clonogenic survival suggesting a radio- Hyperthyroidism is associated with increased thrombotic risk through sensitising effect. mechanisms that are not fully understood. In contrast, a tendency to bleeding In vivo, PI-103 and GDC-0941 reduced PI3K and HIF-1a activity and has been reported in hypothyroidism. Fibrin network structure has been shown to downstream target genes in follicular and anaplastic tumours. Mice bearing determine susceptibility to atherothrombosis and venous thrombotic events and dnHIF-FTC133 tumours and those treated with GDC-0941 had decreased therefore, this study investigates the effects of thyroid-dysfunction on clot metastatic colonies in the lungs. FTC133, dnHIF-FTC133 and 8505c cells were structure and fibrinolysis using longitudinal interventional studies. manufactured to express eGFP. Spontaneous metastatic colonization to the lungs Seventeen hyperthyroid patients were recruited (mean age 39.41G2.6) and was confirmed by viewing eGFP-positive colonies grown from digested lung treated with antithyroid medication until euthyroid. Twenty hypothyroid subjects tissue and by immuno-blotting for eGFP. were also recruited (mean age 49.6G14.8) and treated with L-T4. In both groups, These data link PI3K, HIF-1-activation and aggressive disease in thyroid- blood samples were taken at baseline and after normalisation of thyroid function. carcinoma. With the known desensitising effects of HIF-1 and PI3K activity on Coagulation-fibrinolysis characteristics were investigated ex vivo using a radiation treatment, a combined approach involving both radiation and a PI3K validated turbidimetric assay and the following parameters studied: i) lag phase inhibitor may improve both the therapeutic response within the tumour and reduce (LP): indicating thrombotic tendency, ii) maximum absorbance (MA) measuring metastatic potential in thyroid carcinomas. This is a focus of ongoing studies. clot density, iii) time to 50% lysis (L50%), assessing fibrinolytic potential, iv) Lysis area (LA), measuring the balance between clot formation and lysis. Plasma levels of fibrinogen, plasminogen activator inhibitor-1 (PAI-1), C-reactive protein (CRP) and complement C3 were also measured. LP was 612G21.1 in hyperthyroid subjects, increasing to 709G23 s after normalising thyroid function (PZ0.001), whereas MA fell from 0.43G0.03 to 0.36G0.02 a.u. (PZ0.009). LA was larger at baseline than post treatment (246G26.4 and to 164G22, respectively; PZ0.02). Fibrinogen, PAI-1 and C3 levels were all higher in the hyperthyroid phase. In contrast, hypothyroid subjects had longer LP at baseline compared with post-normalisation of thyroid function (354G13 and 321G7 s, respectively; PZ0.005), whereas MA increased from 0.32G0.02 to 0.36G0.02 (PZ0.008). Hyperthyroid patients have a procoagulant tendency, with short lag phase, compact clot structure and impaired-lysis, whilst the opposite is true in OC3.6 hypothyroidism. We suggest that altered clot structure in hyperthyroid subjects is responsible, at least in part, for increased thrombotic risk in this population. Morbidity in patients with endogenous subclinical hyperthyroidism Thenmalar Vadiveloo, Peter Donnan, Lynda Cochrane & Graham Leese University of Dundee, Dundee, UK.

Objective OC3.8 To investigate the long term outcomes for patients with endogenous subclinical Assessment of the UK iodine status: a National Survey hyperthyroidism (SH). Mark Vanderpump1, John Lazarus2, Peter Smyth3, Robert Burns3, Design Margaret Eggo4, Thang Han1, Graham Williams5, Barbara Torlinska4, Population record-linkage technology was used retrospectively to identify Karen Mullan6, Simon Pearce7, Salman Razvi8, Mike Lean9, Emile patients with SH and hospital admissions from January 1, 1993 to December Combet Aspray9, Denise Bannon10, Prakash Abraham11, Bijay Vadia12, 31, 2009. Graham Leese13, Peter Laurberg14, Kristien Boelaert4 & Jayne Franklyn4 Patients 1Royal Free Hampstead NHS Trust, London, UK; 2University Hospital All residents over 18 years old with at least two serum TSH measurements below Wales, Cardiff, UK; 3University College, Dublin, Ireland; 4University of 5 6 the reference range for at least 4 months apart and normal free T4/total T4 and Birmingham, Birmingham, UK; Imperial College, London, UK; Royal 7 normal total T3 concentrations at baseline were included as potential cases. Using Infirmary, Belfast, UK; University of Newcastle, Newcastle-upon-Tyne, a unique patient identifier, data-linkage enabled a cohort of SH cases to be UK; 8Gateshead Health NHS Foundation Trust, Gateshead, UK; 9University identified from various medical records matched to five comparators from the of Glasgow, Glasgow, UK; 10Institute of Medical Genetics, Glasgow, UK; general population. 11Aberdeen Royal infirmary, Aberdeen, UK; 12Royal Devon and Exeter Outcome measures Hospital, Exeter, UK; 13University of Dundee, Dundee, UK; 14Aalborg Cardiovascular disease, fracture, dysrhythmia, dementia and cancer based on ICD Hospital, Aalborg, Denmark. 10 codes. Results Compared to the reference population, SH was associated with an increased risk Inadequate dietary iodine intake is the most common cause of preventable mental of non-fatal cardiovascular morbidity, osteoporotic fracture, dysrhythmia and impairment worldwide and is defined by the WHO as a population median urinary dementia: adjusted hazard ratios (HR) 1.39 (1.22–1.58), 1.25 (1.04–1.50), 1.65 iodine (UI) excretion !100 mg/l. No contemporary data are available for the UK (1.26–2.17) and 1.64 (1.20–2.25) respectively. When SH patients who developed according to the ICCIDD. The UK has no programme of food/salt iodination. overt hyperthyroidism during follow-up were excluded, SH patients were We have performed a systematic assessment of the current UK iodine status in associated with an increased risk of cardiovascular morbidity (HR 1.36 (1.19– 14–15 years old schoolgirls. Seven hundred and eighty-five participants from nine 1.57)), dysrhythmia (HR 1.39 (1.02–1.90)) and dementia (HR 1.79 (1.28–2.51)), UK centres provided 737 urine samples. UI concentrations were measured as mg but not fracture and cancer. iodine/l by a multiplate persulphate digestion method followed by Sandel– Conclusion Kolthoff colorimetry in specimens collected in Summer 2009 and Winter Patients with endogenous SH might have an increased risk of cardiovascular 2009/2010. Ethnicity, postcode and a diet questionnaire assessing sources of disease and dysrhythmia. There is an association with fracture and dementia iodine were recorded. Iodine concentrations were also measured in water samples that is not related to TSH concentration. No association was found between SH from each area. and cancer. The median UI value for this sample was 80 mg/l with 69% of samples !100 mg/l and 18% !50 mg/l. A multivariate regression analysis confirmed as independent

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK factors a difference in summer versus winter iodine status (R2 0.2, P!0.001) with proliferative chondrocytes, P!0.05). ATDC5 cells showed an initial decrease the median nadir of 76 mg/l in summer and a positive association with milk intake in Mepe expression at day-10 of culture, after which expression increased at day- (R2 0.2, P!0.001). There was no correlation with other foods, ethnicity or city 15. Treatment of ATDC5 cells with pASARM peptide caused an inhibition of of origin. mineralisation, as assessed by Alizarin Red staining (compared to control, These findings suggest that the UK is now iodine-deficient, consistent with a P!0.01). Treatment with npASARM promoted mineralization (compared to fall in iodine status recently reported in Australia and USA. Young women of control, P!0.01). In embryonic metatarsals, the percentage change in total length child-bearing age are the most susceptible to the adverse effects of iodine was not affected by treatment with 20 mM pASARM or npASARM peptides. deficiency. Even mild perturbations of fetal and maternal thyroid function have an However, the growth of the central diaphyseal mineralisation zone was inhibited impact upon neurodevelopment so these findings are consequently of huge public in bones treated with 20 mM pASARM (compared to control, P!0.001). health importance. These findings indicate an urgent need for a comprehensive Our findings indicate that Mepe is expressed by growth plate chondrocytes and investigation of UK iodine status and evidence based recommendations on the that it is likely to have a developmental role in the control of cartilage matrix need to implement a policy of iodine prophylaxis. mineralisation during endochondral ossification. Generously funded by the Clinical Endocrinology Trust.

Bone and diabetes OC4.3 Rapid bone turnover responses to increased hypothalamic–pituitary– OC4.1 thyroid-axis activity are mediated by thyroid hormones A mouse with an ENU-induced mutation (Tyr209Asn) in the natriuretic Apostolos Gogakos, Elaine Murphy, Duncan Bassett & Graham Williams peptide receptor 3 (Npr3) develops autosomal recessive kyphosis Molecular Endocrinology Group, Department of Medicine and MRC Christopher Esapa1,2, Rosie Head1,2, Gethin Thomas3, Matthew Brown3, Clinical Sciences Centre, Imperial College London, Hammersmith Hospital, Peter Croucher4, Roger Cox2, Steve Brown2 & Rajesh Thakker1 London, UK. 1University of Oxford, Oxford, Oxfordshire, UK; 2MRC Harwell, Harwell, Oxfordshire, UK; 3University of Queensland, Brisbane, Queensland, Australia; 4University of Sheffield, Sheffield, UK. Increased hypothalamic–pituitary–thyroid (HPT) axis activity results in high bone turnover. T3 stimulates osteoblast and osteoclast activities, whereas TSH is proposed to inhibit bone turnover directly. Resolving the relative importance of Kyphosis is a common spinal disorder affecting up to 8.3% of the population, and T3 and TSH is complicated by their physiological inverse relationship. We associated with significant morbidity. Familial and twin studies have implicated a studied 10 controls and 4 patients with resistance to thyroid hormone (RTH), in genetic involvement. However, the causative genes have not been identified. which mutation of thyroid hormone receptor beta (THRB) disrupts HPT-axis Studies investigating the underlying molecular mechanisms are hampered by negative feedback. RTH is characterized by increased T4,T3 and TSH genetic heterogeneity, small families and variable modes of inheritance displayed concentrations and a TSH response to TRH-stimulation that is not suppressed by different kindreds. To overcome these limitations, we investigated 12 week old by T3. We hypothesized that skeletal effects of T3 and TSH could be discriminated progeny of mice treated with the chemical mutagen N-ethyl-N-nitrosourea (ENU) by comparing bone formation (osteocalcin) and resorption (C-telopeptide of using phenotypic assessments that included dysmorphology, radiography, dual- type I collagen (CTX)) responses to graded T3-suppression-TRH-stimulation energy X-ray absorptiometry (DEXA). These studies identified a mouse with testing in control and RTH subjects. Fasting samples were collected prior to kyphosis, designated Kylb. Inheritance testing revealed the phenotype to be TRH administration and for 6 h. Testing was repeated three times following transmitted as an autosomal recessive trait. Kylb mice, when compared to increasing doses of T3 (50, 100, 200 mg/day for 3 days), and TSH, osteocalcin and unaffected littermates, had: a 12% lower body weight (P!0.05); a 7% greater CTX were determined in all samples. Baseline TSH increased 5.81G0.29 fold length (P!0.001); a 44% decrease in fat mass (P!0.05); a 14% increase in bone (P!0.0001) in controls and 4.0–6.8 fold (P!0.0001) in RTH patients following ! ! area (P 0.01); and a 6% reduction in areal bone mineral density (P 0.05). The TRH-stimulation. TSH responses to TRH were suppressed by T3 in control characteristic hunch back deformity was present in mice by 10 days of age. subjects but not RTH patients. Baseline osteocalcin (P!0.0001) and CTX Radiology and whole-skeletal staining using alcian blue and alizarin red revealed (P!0.0001) were higher in controls and T3-treatment increased osteocalcin Kylb mice to have lumbo-thoracic kyphosis, longer vertebrae and long bones. 1.55G0.08 fold (P!0.0001) and CTX 1.37G0.21 fold (P!0.05). In RTH Genetic mapping localised the Kylb locus to a 5.5 Mb region on chromosome 15 patients, osteocalcin and CTX responses to T3 were impaired and variable, which contains 51 genes, including the natriuretic peptide receptor 3 (Npr3) gene. reflecting heterogeneity of the condition and the different THRB mutations DNA sequence analysis of Npr3 identified a T to A transversion at codon 209, identified. By contrast, osteocalcin and CTX levels in all subjects remained which altered a highly conserved tyrosine (Tyr) residue to an asparagine (Asn) unchanged following TRH administration. These data demonstrate that T3 residue. Thus, our studies which have established a mouse model for kyphosis due stimulates bone turnover, whereas the rise in TSH following TRH-stimulation to excessive vertebral growth will help to identify the role of Npr3 in regulating does not inhibit osteocalcin or CTX. Thus, rapid bone turnover responses to the cellular and molecular mechanisms of vertebral bone growth. increased HPT-axis activity result from stimulatory actions of thyroid hormones and not the loss of any inhibitory effects of TSH.

OC4.2 Is Mepe a novel regulator of growth plate mineralisation? Katherine Staines, Vicky MacRae & Colin Farquharson OC4.4 Roslin Institute and R(D)SVS, The University of Edinburgh, Roslin, UK. CB1 receptor mediates the effects of glucocorticoids on AMPK activity in the hypothalamus but not in adipose tissues Miski Scerif1, Blerina Kola1, Csaba Fekete2, Ashley B Grossman1 Advances in the understanding of hypophosphatemic disorders have identified a &Ma´rta Korbonits1 novel group of molecules (FGF23, PHEX, MEPE, DMP1) that have been 1Department of Endocrinology, Barts and the London Medical School, implicated in osteoblast mineralisation directly.The specific binding of PHEX to William Harvey Research Institute, Queen Mary University of London, MEPE regulates the release of ASARM peptides which have an inhibitory role. London, UK; 2Department of Endocrine Neurobiology, Institute of Current concepts are speculative and the functional role of MEPE in chondrocyte Experimental Medicine, Hungarian Academy of Sciences, Budapest, mineralisation remains largely undefined. Hungary. Proximal tibiae from 3-week old wild-type mice were analysed by i) in situ hybridisation and ii) growth plate microdissection for Mepe quantification by RT-qPCR. Gene expression by the ATDC5 chondrogenic cell-line was examined Introduction by RT-qPCR over a 20 day culture period under calcifying conditions (ascorbic Adenosine monophosphate-activated protein kinase (AMPK) is a regulator of acid and 10 mM b-glycerophosphate). Twenty mM phosphorylated (pASARM) cellular and systemic energy homeostasis. Many of the changes seen in and non-phosphorylated ASARM (npASARM) peptides were added to ATDC5 glucocorticoid excess correspond to the metabolic steps regulated by AMPK. cultures, and to 17-day-old embryonic metatarsal explants. In the hypothalamus and adipose tissues, glucocorticoids and cannabiniods share Mepe expression was abundant throughout the growth plate as shown by in situ the same tissue specific effects on AMPK activity. Cannabinoids have central hybridisation. The accuracy of growth plate microdissection was validated by orexigenic and peripheral metabolic effects via the cannabinoid receptor type 1 assessment of collagen X expression and data confirmed an increased expression (CB1). The cannabiniod-CB1 system interacts with a number of hormonal of Mepe in the hypertrophic chondrocytes (9-fold increase compared to systems and perhaps mediates their effects.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Aims human health depends on the composition and the nature of fatty acids. To investigate if the CB1 receptor is required for the tissue-specific effects Arachidonic acid (AA) is a major omega-6 polyunsaturated fatty acid (PUFA) of glucocorticoids on hypothalamic and adipose tissue AMPK activity. with a controversial role in adipocyte differentiation. We investigated the effect Methods on pre-adipocyte differentiation after a brief exposure to AA. Wild-type (WT) and CB1-KO mice were treated for 2 weeks with a surgically We show that a short treatment of 3T3-L1 cells with AA at the start of implanted pellet containing either cholesterol (control) or corticosterone (5 mg). differentiation induces events with a long lasting inhibitory effect on Hypothalamic and adipose tissue AMPK activity was determined in a adipogenesis. Treatment of pre-adipocytes with AA for only 24 h prevented functional kinase assay by the entity of 32P incorporation into the synthetic differentiation since the expression of adipocyte markers (PPARg, c/EBPa etc.) AMPK substrate SAMS. and lipid accumulation were significantly reduced after 10 days of differentiation. Results In addition, after 24 h of differentiation in the presence of AA treatment the fatty- Corticosterone significantly increased hypothalamic AMPK activity in WT mice acid binding protein 4 (FABP4 or aP2) expression was induced 100-fold. We (PZ0.0007), but not in CB1-KO mice (PZ0.636). WT mice treated with show that this effect is PPARg-dependent since AA treatment was unable to corticosterone, as compared to cholesterol treated controls, showed significantly induce aP2 upregulation in PPARg knockdown cells. This appears to be a gene- decreased visceral (mesenteric) and subcutaneous (inguinal) fat AMPK activity specific event as other PPARg targets were not affected by AA. Treatment with (P!0.0001 for both). Corticosterone treated CB1-KO mice also showed indomethacin, a general cycloxygenase inhibitor, blocked AA action on aP2 significantly decreased visceral and subcutaneous fat AMPK activity as compared expression indicating that this effect is prostaglandin-mediated. to cholesterol-treated controls (PZ0.0017 and PZ0.0013, respectively). We suggest that a short treatment with AA during the early stages of adipocyte However, CB1-KO mice showed higher baseline visceral (PZ0.0125) and differentiation regulates PPARg expression and/or activity with two very subcutaneous (PZ0.0242) adipose tissue AMPK activity as compared to different outcomes. On the one hand, PPARg in the presence of AA causes the WT mice. rapid early upregulation of its primary target aP2. On the other hand, at the later Conclusion stages of differentiation in the absence of AA, PPARg expression fails to be The stimulatory effects of glucocorticiods on hypothalamic AMPK activity are induced and initiate the differentiation program. CB1-dependent. The CB1 receptor does not mediate the inhibitory effect of glucocorticoids on adipose tissue AMPK activity but has an independent inhibitory effect on adipose tissue AMPK activity.

OC4.5 Alterations to hypothalamic 5-HT and DA turnover in offspring OC4.7 induced by maternal exposure to a high caloric diet throughout Co-administration of the gut hormones PYY and GLP-1 to human lactation volunteers reduces food intake and brain activation in appetite centres Thomas Wright1, Peter Voigt1 & Simon Langley-Evans2 Akila De Silva1, Victoria Salem1, Christopher J Long2, Aidan Makwana2, 1School of Veterinary Medicine and Science, University of Nottingham, Rexford D Newbould2, Eugenii A Rabiner2, Aniket N Tavare1, Mohammed Loughborough, Lecestershire, UK; 2School of Biosciences, University of A Ghatei1, Stephen R Bloom1, Paul M Matthews2, John D Beaver2 Nottingham, Loughborough, Lecestershire, UK. & Waljit S Dhillo1 1Imperial College, London, UK; 2GlaxoSmithKline Clinical Imaging Exposure to maternal obesity or overfeeding during early development has lasting Centre, London, UK. effects upon the young adult rat. Maternal cafeteria (CD) feeding during lactation programmes behaviour in the adult offspring, reducing anxiety in males and The physiological post-prandial release of the gut hormones PYY and GLP-1 is altering the behavioural satiety sequence in females. The aim of the present study implicated in triggering CNS mechanisms underlying satiety. However, the was to examine the impact of early exposure to maternal over-nutrition upon combined effects of PYY and GLP-1 on brain circuits underlying satiety in bioactive amines in the brain. Lactating Wistar rats were fed either a control chow humans remain unknown. (nZ5) or CD (nZ5). CD consisted of a range of highly palatable human food Objective items, high in fat and sugar (including cheese, pate, pork-pie, peanut, chocolate, To determine changes in CNS neuronal activity following single and combined crisps and shortbread). At weaning all offspring were transferred to the control infusions of PYY and GLP-1, using blood oxygen level dependent functional diet. At 20 weeks of age offspring were culled and the hypothalamus, magnetic resonance imaging (BOLD fMRI) in human volunteers. hippocampus and frontal cortex were dissected. 5-HT, 5-HIAA, DA, DOPAC Methods and HVA concentrations were measured using HPLC. Exposure to CD during the Ten normal weight adult volunteers underwent 5 treatment visits in a randomized, suckling period had little effect upon body weight and adiposity of the offspring, cross-over design. On each visit each subject received a 90 min intravenous although CD females had 39% more perirenal fat than controls (P!0.001). infusion of one of the following: Hypothalamic concentrations of 5-HT were increased by 33% in both male and i) Saline following an 730 kcal breakfast female CD offspring (P!0.01). In these animals, 5-HT turnover was significantly ii) Saline following an overnight fast reduced (37%) in the hypothalamus (P!0.0001). In CD females, DA iii) GLP-1 0.8 pmol/kg per minute following an overnight fast concentrations were increased (37%, P!0.05) and DOPAC concentrations iv) PYY 0.3 pmol/kg per minute following an overnight fast were reduced (38%, P!0.05) in the hypothalamus. Hypothalamic DA turnover v) Combined GLP-1 and PYY following an overnight fast was significantly decreased in both male (31%, P!0.01) and female (22%, Twenty minutes following the start of each infusion, fMRI data were acquired P!0.01) CD offspring. There was no effect of maternal diet upon 5-HT or DA while participants viewed images of appetising and bland foods. An ad libitum turnover in the hippocampus or frontal cortex. The present findings suggest early buffet lunch was served to estimate caloric intake following the completion of life programming of hypothalamic 5-HT and DA turnover in response to maternal each infusion. over-feeding. The data is suggestive of a role for these neurotransmitters in Results determining the altered behaviour of such animals. Gut hormone infusion reduced caloric intake in the fasted state compared to saline infusion (15, 7 and 21% reductions for GLP-1, PYY and GLP-1CPYY respectively). On the fasted saline visit, appetising food images evoked greater BOLD signal relative to bland foods, in the putamen and insula. Single administration of GLP-1 or PYY alone attenuated the difference in BOLD OC4.6 response between appetising and bland foods in the fasted state. This was Dual effect of arachidonic acid on peroxisome proliferator-activated comparable with that observed in fed subjects receiving saline. Greater receptor g (PPARg)-dependent action in 3T3-L1 adipocytes attenuation was observed in fasted subjects receiving co-administration of Evanthia Nikolopoulou, Malcolm Parker & Mark Christian GLP-1 and PYY (P!0.05 cf saline). Imperial College London, London, UK. Conclusions These data show for the first time in humans, that changes in CNS neuronal activity following co-administration of GLP-1 and PYY are similar to those Dietary fat has been correlated with obesity since it induces the proliferation and observed physiologically after a meal. differentiation of pre-adipocytes. Now it has become clear that the effect of fat on

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

OC4.8 leads to reduced function in the overweight adult offspring. The VEGFA pathway Hyperghrelinaemia, hyperphagia, food hoarding and reduced adiposity likely plays a key role in this process. in an imprinting centre deletion mouse model of Prader–Willi syndrome Timothy Wells1, Dinko Relkovic2, Hannah Furby2, Irina Guschina1, Sachiko Nishimura3, James Resnick4 & Anthony Isles2 1School of Biosciences, Cardiff University, Cardiff, UK; 2Schools of Medicine and Psychology, Cardiff University, Cardiff, UK; 3School of OC5.2 Optometry, Cardiff University, Cardiff, UK; 4Center for Mammalian Maternal low protein diet and fetal growth restriction: new insights into Genetics, University of Florida, Gainesville, Florida, USA. the role of placental 11b-hydroxysteroid dehydrogenase-2 Elizabeth Cottrell, Megan Holmes & Jonathan Seckl University of Edinburgh, Edinburgh, UK. Prader–Willi syndrome (PWS) is a neurodevelopmental disorder caused by a lack of paternal gene expression from 15q11–q13 and is characterised by failure to thrive in infancy, followed by hyperphagia due to abnormal satiety responses and Placental 11b-hydroxysteroid dehydrogenase-2 (11b-HSD2) rapidly converts increased motivation by food. We investigated growth and metabolism a mouse glucocorticoids to inactive metabolites, thus protecting the developing fetus from model in which the imprinting centre (IC) of the homologous PWS interval has high maternal glucocorticoids. Genetic deficiency or inhibition of 11b-HSD2 been deleted (PWS-IC mice). Growth retardation only emerged post-natally, with associates with fetal growth restriction, low birth weight, and cardiometabolic adult PWS-IC mice weighing 40% less than controls, and tibial length reduced by disease in adulthood. Similar ‘programming’ effects are seen with maternal 7%. In contrast, liver and brain weights were normal. Analysis of daily food malnutrition or stress; these challenges associate with reduced placental intake over a 3-week period indicated that male PWS-IC mice showed 11b-HSD2 at term. We therefore explored the importance of 11b-HSD2 in proportionate hyperphagia, which became more pronounced after overnight dietary programming. fasting. In addition, PWS-IC mice displayed ‘food hoarding’ behaviour Feeding C57Bl/6J mice an isocaloric low protein (LP) diet throughout gestation reminiscent of that seen in PWS individuals. This hyperphagia may result from (8% protein versus 18% control diet) significantly decreased placental weight the 3-fold elevation in circulating ghrelin levels. Despite hyperphagia and (P!0.001) and fetal weight at embryonic day (E) 17.5 (0.89G0.05 g in control hyperghrelinaemia, PWS-IC mice were remarkably lean, with proportionate versus 0.74G0.03 g in low protein; P!0.001). This reduction in fetal weight was retroperitoneal, epididymal and inguinal white adipose tissue weights reduced by preceded by a downregulation of 11b-HSD2 enzyme activity from E16.5 82, 84 and 67% respectively; and proportionate interscapular brown adipose (decreased in LP by 28 and 20% at E16.5 and 17.5, respectively; P!0.05). tissue weight reduced by 48%, with additional reductions in marrow adiposity and However, at earlier gestational ages (E13.5–15.5), LP diet increased placental hepatic lipid content. This lack of body fat may explain the 1.3 8C reduction in 11b-HSD2 activity (increased in LP by 21, 23 and 41% at E13.5, 14.5 and 15.5, surface body temperature in PWS-IC mice, consistent with reduced heat respectively; P!0.05), perhaps to maximise midgestation fetal growth. Using a retention. In addition, despite proportionate over-eating, and in contrast to heterozygous 11b-HSD2C/K mating strategy to generate 11b-HSD2C/C, wild-type controls, PWS-IC mice did not gain fat mass, even when fed on a high- C/K and K/K offspring within the same litters, maternal LP diet reduced fetal fat diet. Our data show that the neuroendocrine regulation of metabolism is body weight to a similar extent in all genotypes compared with control offspring, severely compromised in PWS-IC mice and that loss of paternal gene expression although the magnitude was blunted in 11b-HSD2K/K offspring. Thus, LP diet from the PWS-cluster gives rise to hyperphagia, and hyperghrelinaemia, as seen has effects over-and-above 11b-HSD2 inhibition to reduce fetal weight gain. in the human condition. However, unlike individuals with PWS, the PWS-IC mice do not become obese. Whether this difference is due to the elevated energy demands of increased heat loss remains unclear.

OC5.3 Mutations in the gene encoding the fibroblast growth factor 8 (FGF8) Reproduction and fetal programming are associated with complex midline defects including recessive holoprosencephaly and hypothalamo-pituitary dysfunction OC5.1 Mark McCabe1, Carles Gaston-Massuet2, Vaitsa Tziaferi1, Louise Gregory1, The effect of a maternal low protein diet on renal development and Kyriaki Alatzoglou1, Massimo Signore2, Sadaf Farooqi3, Jamal Raza4, function in the offspring Joanna Walker5, Scott Kavanaugh6, Pei-San Tsai6, Nelly Pitteloud7, Louise Lloyd1, Philip Rhodes1, Stuart Rhind2 & David Gardner1 Juan-Pedro Martinez-Barbera2 & Mehul Dattani1 1University of Nottingham, Nottingham, UK; 2Macauley Land Use 1Clinical and Molecular Genetics Unit, Institute of Child Health, London, Research Institute, Aberdeen, UK. UK; 2Neural Development Unit, Institute of Child Health, London, UK; 3Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK; 4National Institute of Child Health, Karachi, Pakistan; 5Department of Background Paediatrics, St Mary’s Hospital, Portsmouth, UK; 6Department of Previous studies have linked a low protein maternal diet with hypertension in Integrative Physiology, University of Colorado, Boulder, Colorado, USA; adult offspring, and have suggested that impaired kidney development may be an 7Harvard Reproductive Endocrine Sciences Center and Reproductive important predisposing factor. This study aims to identify the molecular and Endocrine Unit of the Department of Medicine, Boston, Massachusetts, structural changes that explain the decline in function. USA. Methods Pregnant ewes were fed either a control diet providing adequate dietary protein (control protein (CP); nZ15), or a low protein diet during early gestation (low Loss-of-function mutations in FGF8 in humans have been associated with protein early (LPE); nZ17) or late gestation (low protein late (LPL); nZ6). At Kallmann syndrome (KS), which is characterised by the combination of day 65 gestation 9 CP and 10 LPE sheep were euthanised and fetal kidneys hypogonadotrophic hypogonadism with anosmia, suggesting that FGF8 is critical collected. The remainder continued to term and at 2 years of age in vivo for GnRH neuronal development. Interestingly, hypomorphic Fgf8 mutant mice renography was carried out on the overweight offspring before they were demonstrate poor telencephalic development with deletions of midbrain tissue, euthanised. Kidney sections were stained using standard DAB immunohisto- absence of olfactory bulbs and optic chiasm, and holoprosencephaly (HPE) with chemical methods or TUNEL staining, and the results analysed using Image Pro. an abnormal corpus callosum; thus it appears that FGF8 is important for forebrain Nephron number was estimated stereologically, mRNA by QPCR. development, but its role in hypothalamo-pituitary (HP) development remains to Results be determined. We aimed to investigate the role of FGF8 in the formation of Renography indicated reduced renal function in LPE versus CP and LPL groups midline forebrain, HP and craniofacial development in mouse and human. associated with microalbuminuria, assessed by urinalysis. There were no Patients with congenital hypopituitarism and midline forebrain/craniofacial significant morphological differences, nor was mean glomerular area different defects (nZ421) were screened for FGF8 mutations. Two novel missense between groups. Nephron number was reduced by w15% in the adult LPE group. mutations were identified: i) homozygous p.R189H and ii) heterozygous In the fetal kidneys, renal apoptosis was greater in LPE group and VEGFA mRNA p.Q216E. The p.R189H mutation was identified in a female patient with semi- and protein were reduced. In contrast, in adult LPE kidneys, expression of lobar HPE, diabetes insipidus and ACTH insufficiency born to consanguineous VEGFA and its receptors VEGFR1 and VEGFR2 was increased along with parents. The p.Q216E mutation was identified in a female patient with an absent increased VEGFA protein. For all results P!0.05. corpus callosum, hypoplastic optic nerves and Moebius syndrome. In situ Conclusions hybridization revealed FGF8 expression in human embryonic ventral dience- This study suggests that protein restriction during early, but not late, pregnancy phalon and anterior forebrain but not in Rathke’s pouch, which parallels known (i.e. during rapid nephrogenesis) affects normal fetal kidney development and patterning in mice. Additionally, hypomorphic mice showed a reduction in

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK vasopressin and oxytocin, with small/hyperplastic anterior pituitary glands and landmarks assessed and adult behaviour characterised. Brain-specific reduction in absent posterior pituitary glands in the most severely affected mice. 11b-HSD2 activity was confirmed at E12.5 in the fetal heads of Nestin- To conclude, we demonstrate the first recessive case of HPE associated with a Cre.HSD2flx/flx mice in comparison to HSD2flx/flx (2.01G0.24 and 10.13G1.69 mutation in FGF8, a condition previously associated with heterozygous nmol A/mg per hour respectively, P!0.01). Birth weight and negative geotaxis and mutations in SIX3, TGIF and the Sonic Hedgehog signalling pathway. We have eye opening, markers of neurodevelopment, were unaltered. Anxiety was assessed shown that Fgf8/FGF8 appears to be important for forebrain and HP development by elevated plus maze and open field in the adult offspring and was unchanged in mouse and human, with overlapping phenotypes between KS and complex between the two genotypes. However depressive-like behaviour, as assessed by the midline defects with hypopituitarism. Furthermore, this is the first report to tail suspension test, was increased in mice with brain-specific deletion of 11b-HSD2 implicate FGF8 mutations in Moebius syndrome. with NestinCre.HSD2flx/flx spending a greater percentage of time hanging in comparison to the HSD2flx/flx mice (68 and 53% respectively, P!0.05). Our data suggest that neural 11b-HSD2 does indeed have a role in protecting the developing brain and thus determining adult psychiatry. However this may prove to be a minor role compared to that of 11b-HSD2 in the placenta as the current observed OC5.4 phenotype appears more subtle than the global 11b-HSD2 knockout. Impaired cardiac function in GRK/K fetal mice Eva Rog-Zielinska1, Adrian Thomson1,CarmelMoran1, David Brownstein1, Christopher Kenyon1, Zoi Michailidou1, Dorota Szumska2, Shoumo Bhattacharya2, Jennifer Richardson1, Elizabeth Owen1, Alistair Watt1, Lesley Forrester1,MeganHolmes1 & Karen Chapman1 OC5.6 1Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, Consequence of embryonic exposure to 17b-estradiol on brain UK; 2Wellcome Trust Centre for Human Genetics, University of Oxford, asymmetry development and neuroendocrine gene expression in Oxford, UK. Danio rerio Madeleine Pope, Julien Lambertucci-Bonnett, Imelda McGonnell, Robert Fowkes & Claire Russell Glucocorticoid levels rise dramatically in late gestation in mammals and are Royal Veterinary College, London, UK. essential for organ maturation in preparation for birth. They are widely used clinically to mature the lungs of premature infants and hypomorphic GR mice die neonatally due to severe lung atelectasis. Here, we describe fetal lethality in GR Exposure to a range of environmental endocrine disrupting chemicals is K K null (GR / ) mice with 51% loss at E17.5 (P!0.05) that could be due to associated with birth defects in several species. High levels of oestrogen, or K K impaired cardiac development. Histology showed reduced heart size in GR / compounds acting as oestrogen mimics (such as alkyl phenols and pesticides) can fetuses from E16.5, co-incident with a peak in heart corticosterone content, which alter gene expression and cause sex reversal in fish. In the current study, we use was undetectable at E14.5. Magnetic resonance imaging confirmed a 21.9G4.7% the versatile Zebrafish (Danio rerio) to examine the effect of embryonic exposure ! reduction in ventricular volume at E17.5 (P 0.05) yet no structural to 17b-estradiol (E2) on the development of brain asymmetry and neuroendocrine abnormalities were observed. In vivo high frequency ultrasound analysis revealed gene expression. Brain asymmetry was monitored using an assay of parapineal K K impaired left ventricular function in E17.5 GR / fetuses, with increased migration, that employs transgenic zebrafish (Tg(foxd3:GFP)) in which the pineal G G ! TEI-Doppler index (WT, 0.36 0.02 versus KO, 0.54 0.03, P 0.001), with complex is labeled with GFP. The effect of E2 on the hypothalamus and pituitary heterozygous mice showing an intermediate phenotype (0.45G0.02; P!0.01 was assayed using wholemount in situ hybridization (ISH) of previously validated G versus WT), and decreased E/A wave ratio (WT, 0.41 0.028 versus KO, pomc and prl mRNA probes. Embryos were exposed to E2 in aquaria water 0.28G0.038). Impaired cardiac performance was accompanied by oedema in (0, 100 nM, 1 mM, 10 mM) from for 3 days at 28 8C. At 72 hpf, the embryos were K K GR / fetuses (wet weight WT, 0.85G0.03 versus KO, 0.86G0.01, dry viewed under an microscope equipped to visualise GFP and scored according to weight WT, 0.12G0.004 versus KO, 0.1G0.002, P!0.01; fetal Na/K ratio the appearance of the parapineal organ (left-handed, right-handed or no WT, 0.9G0.02 versus KO, 1.03G0.01, P!0.001), indicative of heart failure. migration). Embryos were fixed in 4% paraformaldehyde prior to ISH. Initial The observed phenotype could not be attributed to deficiency in cardiac results of the parapineal migration assay suggest a decreased incidence of adrenaline content, which was normal at E17.5, nor were there any compensatory rightward migration of the parapineal organ in embryos exposed to E2 for 72 hpf. alterations in cardiac mineralocorticoid receptor mRNA levels. Cardiomyocytes There was also an increased incidence of parapineal organ migration failure, K/K of E17.5 GR hearts displayed cellular defects, including underdeveloped suggesting inappropriate exposure to E2 during development could cause myofibrils and dense nuclei. RNA analysis showed normal cardiac gene migrational defects associated with neurological disorders (e.g. autism, K K expression in GR / fetuses at E14.5 (prior to the glucocorticoid increase), schizophrenia). Neuroendocrine gene expression studies revealed enhanced prl but a lack of the normal maturational changes at E17.5 (e.g. increased a-myosin expression in the pituitary of E2-treated embryos, although it was unclear as to heavy chain, increased PGC1a, decreased UCP2). These data suggest that whether this represented increased gene expression or lactotroph hyperplasia. glucocorticoid action in late gestation heart is essential for its biochemical and Furthermore, the spatial profile of hypothalamic and pituitary pomc expression functional maturation and lack of the normal maturational effects of was also altered by E2 exposure. Collectively, these data suggest that neurological glucocorticoids leads to congestive heart failure. and neuroendocrine changes occur following a short exposure to E2, which may This work was supported by a British Heart Foundation studentship (to E R-Z) result in abnormal development. FS/08/065.

OC5.7 OC5.5 Plasma biomarkers for early prediction of preeclampsia Absence of 11b-HSD2 specifically within the fetal brain alters adult David Carty, Lesley Anderson, Jim Mcculloch, Anna Dominiczak ‘depressive’ behaviour & Christian Delles Caitlin Wyrwoll, Jonathan Seckl & Megan Holmes Institute of Cardiovascular and Medical Sciences, University of Glasgow, The University of Edinburgh, Edinburgh, UK. Glasgow, UK.

Prenatal glucocorticoid overexposure is a key risk factor for susceptibility to Introduction neuropsychiatric disorders in adult life. Fetal exposure to glucocorticoids is Several biomarkers are elevated in late pregnancy in women with preeclampsia regulated by 11b-hydroxysteroid dehydrogenase type 2 (11b-HSD2) an enzyme (PET), but none have been sensitive or specific enough to be used routinely in which inactivates glucocorticoids and is highly expressed in the placenta and early pregnancy to predict the condition. We measured plasma levels of the anti- fetus. Previous work has established that 11b-HSD2K/K offspring generated by angiogenic peptides FMS-like tyrosine kinase 1 (sFLT-1), soluble endoglin heterozygous matings exhibit altered placental development and function, (sENG), placental growth-factor (PGF), and an array of cytokines and adhesion decreased birth weight, delayed neurodevelopment and increased anxiety and molecules in early and mid pregnancy to assess their ability to predict PET. depression as adults. This raises the question as to whether it is placental or fetal Methods 11b-HSD2 that are key to subsequent programmed outcomes. The current study Two thousand women were recruited at gestational week 12–16 (booking); 36 investigated the significance of neural 11b-HSD2 on adult behaviour. A knockout (1.9%) developed PET, and were matched for age and BMI to 74 women who had of 11b-HSD2 specifically within the brain during development was created by normotensive pregnancies. 50 women with R2 risk factors were sampled again at crossing NestinCre mice with floxed 11b-HSD2 mice (HSD2flx/flx). 11b-HSD2 gestational week 28, of whom 11 developed pre-eclampsia. sFLT-1, sENG and activity in fetal tissue and placenta was measured at E12.5, neurodevelopmental PGF levels were measured using ELISA kits (R&D Systems); levels of cytokines

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK and adhesion-molecules were determined by immunoassay using biochip The plasma membrane thyroid hormone (TH) transporter, MCT8, is present in the technology (Randox Laboratories). human placenta from early gestation and is postulated to participate in Results transplacental transfer of TH. In vitro, MCT8 overexpression decreases the Systolic blood pressure was not different, but diastolic blood pressure higher survival of human cytotrophoblast in a TH-independent manner. (74G10 vs 69G9 mmHg; PZ0.022) at booking in women who developed PET. Objective sENG was higher (6.96G3 vs 5.72G2.1 ng/ml, PZ0.025), and PGF lower To examine the role of Mct8 in fetoplacental growth using the Mct8 knockout (25.8G27 vs 37.4G30 pg/ml, P!0.001) at booking in affected women. sFLT-1 (ko) mouse model. was not different between the 2 groups at booking (PZ0.52), but higher in Methods affected women at week 28 (1979G1118 vs 1230G624 pg/ml, PZ0.009.) Of the Heterozygous females were mated with male ko mice. Male wild-type (wt) and ko cytokines and growth factors, E-Selectin was higher in women who developed fetoplacental tissues were obtained from two litters before (E14.5) and after PET, both at booking (15.1G4.9 vs 12.9G4.5 ng/ml, PZ0.022) and week 28 (E18.5) the onset of fetal TH production. Mct8 protein was localized in the mouse (14.4G5.6 vs 10.73G3.5 ng/ml, PZ0.01). There was no difference between the 2 placenta by immunohistochemistry. The volume fractions of the labyrinthine (Lz) groups at either timepoint in levels of VCAM-1, ICAM-1, P-Selectin, L-Selectin, and junctional (Jz) zones of the placenta were estimated using stereology. Cyclin Interleukins 1-a,1-b, 2, 4, 6, 8 or 10, VEGF, TNF-a, interferon-g, MCP-1 D1 (proliferation) and Caspase 3 (apoptosis) protein expression was assessed by and EGF. western immunoblotting. Conclusion Results When measured in early pregnancy, along with maternal risk factors, sENG, PGF At both E14.5 and E18.5, Mct8 protein was expressed in decidua, in and E-Selectin may provide additional prognostic information about future risk of spongiotrophoblast and glycogen cells in the Jz, in cytotrophoblast and pre-eclampsia. syncytiotrophoblast cells in the Lz, in the wall of chorionic blood vessels and in the chorionic membrane. At E18.5, male ko fetuses were lighter (1273G24.5 mg) than male wt (1397G28.6 mg; P!0.05), whilst their placentae were heavier (ko: 90.3G6.5 mg; wt: 77.3G2.8 mg; P!0.05). This was accompanied by increased Cyclin D1 and decreased Caspase 3 protein expression OC5.8 in ko compared with wt placentae. Fetoplacental weight ratios were decreased (30%; P!0.01) in ko compared with wt fetuses. The volume fraction of the Lz Altered fetoplacental growth in monocarboxylate transporter 8 (Mct8) was reduced by 10% (P!0.05) in ko compared with wt placentae with no knockout mice difference in the absolute volume of Lz. Elisavet Vasilopoulou1, Heike Heuer2, Marija Trajkovic2, 1 1 1 1 Conclusions Laurence Loubie`re , Christopher McCabe , Jayne Franklyn , Mark Kilby The ubiquitous localization of Mct8 in mouse placenta is similar to that observed & Shiao Chan1 1 2 in humans. Its localisation in trophoblasts within the Lz, suggests a role for Mct8 University of Birmingham, Birmingham, UK; Leibniz Institute for Age in transplacental transport. Furthermore, lack of Mct8 results in reduced placental Research-Fritz Lipmann Institute, Jena, Germany. efficiency with a compensatory increase in placental size.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Poster Presentations

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Bone P3 P1 Evaluation of the association between serotonin and bone mineral Does preoperative localisation for total parthyroidectomy in patients density in patients with neuroendocrine tumours with renal failure improve outcome? Piya Sen Gupta, William M Drake, Scott A Akker, Shern L Chew, Thomas Hanna, Jo Edwards, Helen Grimsmo & Jacob Akoh Ashley B Grossman & Maralyn R Druce Derriford Hospital, Plymouth, UK. Barts and the London School of Medicine, QMUL, London, UK.

Background Introduction Bone mineral density (BMD) and fracture tendency are influenced by diet, Secondary hyperparathyroidism is a common complication of established renal failure (ERF) and is associated with significant morbidity and mortality. The aims activity, drugs, and hormones. Recent studies highlight an inverse relationship between serotonin and BMD, of uncertain mechanism. of this study were to determine patient and operative characteristics, which might predict persistent or recurrent hyperparathyroidism after surgery. To assess the Purpose We investigated the relationship between serotonin metabolites and BMD in influence of pre-operative imaging on the ability to locate and remove parathyroid patients with sporadic neuroendocrine tumours (NETs), with and without the glands during both the initial and repeat surgery and to assess the long-term effect of failed surgery. carcinoid syndrome. Materials and methods Methods A retrospective study of all chronic kidney disease patients who required a total One-year prospective audit [ref 09/104]. All patients underwent DEXA-scanning as standard care for chronic malignancy. Data collection included clinical details, parathyroidectomy because of failed medical management from 1st January 1999 to 31st December 2008. Patient characteristics, preoperative imaging, medical confounders influencing BMD and relevant investigation results. treatment, operative findings, histology and patient outcome were all studied. Results Of 41 eligible patients, 15 did not participate (too unwell, defaulted follow-up, Differences between groups (dialysis dependent and non dialysis dependent) were tested by the !2 statistic and a P value of !0.05 was regarded as significant. declined participation) and 3 were excluded due to confounding factors. Twenty- three subjects were reviewed (15 females, 59.9G19 years, BMI 26.8G5.6, 8 Results G G Seventy-five patients underwent total parathyroidectomy during this period and males, 69.0 3.0 years BMI 30.6 5.6). The mean interval since diagnosis was 5.7 years (range 0–20 years); 16 had carcinoid syndrome, 7 did not. Thirteen had were followed up for an average of 44.5 months. Sixty-one (81%) had removal of previous surgery, 4 chemotherapy, 11 radiolabelled-MIBG and 14 used all parathyroid glands with associated fall in parathyroid hormone level. Pre operative imaging was used in 15 patients (20%) and found to be unhelpful in somatostatin analogues. Low BMD was not prominent: only 4 subjects had Z score O1 S.D.belowthemean, directing surgery in 12 of 15 (80%) cases. Four patients underwent repeat T %K parathyroid surgery for recurrent/persistent RHPT with pre operative imaging with no unifying features in this group. 10 subjects had score 1.0 (osteopaenia or osteoporosis), all were females (P!0.01), and 7 had the carcinoid syndrome used in two cases. (PO0.05). Mean BMI was 25.4 cf 30.2 for those with normal T-score (P!0.05). The Conclusion T T A high success rate can be achieved without the use of pre-operative imaging and low -score group did not differ from the group with a normal -score in age, smoking,alcohol, medications, calcium or TSH but mean vitaminD was higher (77.8 is therefore not indicated prior to the first parathyroidectomy operation. The long- PZ term effects of pharmaceutical developments in this area are, at present unknown vs 48.6 nmol/l; 0.05). There was no difference in chromogranin-A (217.9 vs 281.9 pmol/l, PZ0.6) or urine 5HIAA (360.8 vs 147.5 mmol/24 h, PZ0.3). Z-scores but are likely to change indications for initial surgery and reoperation. An agreed PZ protocol is therefore essential for the management of CKD patients with did not differ between subjects with elevated or normal 5HIAA ( 0.28) or between PZ secondary hyperparathyroidism. subjects with and without the carcinoid syndrome ( 0.38). Conclusion NET patients do not show lower BMD related to serotonin metabolites or disease markers, although a larger cohort is required for confirmation of these preliminary data.

P2 Influence of age and gender on expression of primary hyperparathyroidism P4 Viral Shah, Sanjay Bhadada, Anil Bhansali, Pinaki Dutta & A Behara Management of hypovitaminosis D in patients with primary Postgraduate Institute of Medical Education and Research, Chandigarh, hyperparathyroidism India. Manjusha Rathi, Susana Gonzalez & Steve Peacey Bradford Teaching Hospitals NHS Trust, Bradford, UK. Background The geographical difference in presentation of primary hyperparathyroidism Epidemiological studies suggest that hypovitaminosis D is common in patients (PHPT) is well known however, there is spare literature on influence of age and with primary hyperparathyroidism (PHPT). They have higher levels of serum gender on presentation of PHPT. parathyroid hormone (PTH) and markers of bone turnover, and more frequent Objective fractures than vitamin D replete patients. There are concerns that vitamin D To study the effect of age and gender on clinical and biochemical presentation repletion in these patients might exacerbate pre-existent hypercalcaemia, of PHPT. although recent literature suggests this is uncommon. Method We aimed to determine the effects of vitamin D replacement on biochemical This is a retrospective analysis of 184 histopathologically proven PHPT patients indices of calcium metabolism in patients with combined PHPT and between March 1990 and March 2010 from a single centre of North India. PHPT hypovitaminosis D in a predominantly Asian cohort. patients were divided in five different age groups, i.e. children !12 years, Twenty-three patients with PHPT and hypovitaminosis D were studied: adolescent 12–18 years, young adult 19–25 years, adult 26–59 years and older Asian:Caucasian 19:4; M:F 2:21; age (range) 59 (31–85) years; basal calcium R60 years. Clinical presentations, biochemical parameters and parathyroid gland (meanGS.D.) 2.62G0.12 mmol/l, 25-OH vitamin D 14.8G7nmol/l. Each weight were compared among different age groups and between genders. received oral 20 000 IU cholecalciferol per week for 12 weeks. Results Mean baseline serum calcium, phosphate, alkaline phosphatase and PTH were Female:male ratio was 70:30%. 77.2% were between 25 and 59 years while 5.97% measured at week 4, 8 and 12 weeks. Mean 25-OH vitamin D levels before and were !12 years. There was no change in clinical presentations and biochemical after 12 weeks were compared and the relationship between 25-OH vitamin D and parameters among the different age groups except rickets in children and adolescent PTH was analysed. (2.2%), and renal stones in 25–59 years adults (41.3%) and markedly elevated A significant increase in 25-OH vitamin D was observed at 12 weeks: 14.8G7vs alkaline phosphatase in children and adolescent (P!0.01). Bone pain and muscle 75.8G21 nmol/l, PZ0.0001. A reduction in PTH was found at week 8; 21.9G11 aches (P!0.01), fracture (PZ0.04), renal stone (PZ0.05), cholelithiasis (PZ0.03) vs 15.3G6, PZ0.05, and at week 12; 21.9G11 vs 14.7G5, PZ0.02. There was and pancreatitis (PZ0.02) were more common among women. Serum calcium and no significant change in calcium (PZ0.85), phosphate (PZ0.37) or alkaline phosphate levels were similar in either sex but parathyroid hormone (PTH) level was phosphatase (PZ0.94). PTH and 25-OH vitamin D levels were inversely higher among women (PZ0.02). Parathyroid adenoma weight was higher in older correlated (rZK0.46; PZ0.002). compare to young but did not reach to level of statistical significance. Conclusion Conclusion We conclude that weekly vitamin D supplementation with 20 000 IU for a three There was no much difference in the clinical and biochemical presentation of PHPT month period corrects hypovitaminosis D in patients with mild PHPT without among different age groups but differences among genders were noticeable. causing significant increases in calcium.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P5 significantly higher in males compared to females whilst in the elderly Group C Z Z Risk factors for femoral neck fracture in Indian postmenopausal values were similar: serum bCTX (P 0.2) PINP (P 0.2). Using multiple linear women (BMD, Vitamin D study and Propensity for a fall) regression age, sex and oestradiol were significant predictors for serum bCTX (P!0.001), (PZ0.006) (P!0.001) and PINP (P!0.001), (PZ0.03) and Thomas Paul, Sivan Arulselvan, Nihal Thomas, Mandalam Seshadri Z & Arun Jose (P 0.02), respectively. PTH had no effect whilst oestradiol was a negative Christian Medical College, Vellore, India. predictor for bone marker levels. Conclusions/interpretation Younger men were found to have higher bone turnover markers then women but Introduction levels were similar in the elderly. This study highlights the importance of having Hip fractures are the most serious osteoporotic fractures and difficult to prevent different bone turnover marker reference intervals for young men and women. them without a precise knowledge of the causative factors. The risk factors, which precipitate hip fracture in elderly may vary according to the local customs and practices. Indian data on risk factors for hip fractures are scant. The present study was undertaken to assess the various risk factors leading to femoral neck fracture in postmenopausal women and also to define the threshold for BMD at femoral neck below which the risk for fracture is increased. Methods P7 This study included 31 postmenopausal subjects with femoral neck fracture and Vitamin D insufficiency in hyperparathyroidism 31 age and BMI matched controls. Drug history, history of other systemic Myint M Aye1,MoAye2, T Sathyapalan1, E S Kilpatrick2 & illnesses and visual and hearing impairment were assessed. Serum alkaline Stephen L Atkin1 phosphatase, albumin, creatinine and 25 (OH) vitamin D and intact PTH were 1University of Hull, Hull, UK; 2Hull and East Yorksire Hospitals NHS also assessed. Bone mineral density was assessed by using the DXA scanner at the Trust, Hull, UK. lumbar spine and the femoral neck. Results Background Significantly more patients with femoral neck fracture were using sedatives and Vitamin D insufficiency is very common in general population and in patients had hearing and visual impairment compared to controls (P%0.05). Mean serum with primary hyperparathyroidism (PHPT). Measurement of serum 25OHD albumin, serum 25(OH) vitamin D and femoral neck BMD were significantly (25hydroxy-vitamin D) is currently the best available test to assess vitamin D lower in femoral neck fracture group. Seventy four percent in the fracture group adequacy. However, it has a significant seasonal variation, and is difficult to had vitamin D deficiency (%20 ng/ml) when compared to 45% in the control define a serum 25OHD level that is sufficient for bone health, although a serum group (PZ0.05). 25OHD above 50 nmol/l has been suggested. Conclusion Previous studies confirm a significant negative correlation between 25OHD, and Significant proportion of femoral neck fracture patients had visual and hearing parathyroid hormone (PTH), alkaline phosphatase that is reversible. In the impairment and was using sedatives. They also had vitamin D deficiency. These NHANES study the higher serum 25OHD then the higher the BMD throughout factors are correctable and need special attention in the Indian context. the reference range. The greatest impact of vitamin D on PTH is found when 25OHD is !50 nmol/l. PTH levels have been shown to decline until 25OHD above 75 nmol/l. Aim To determine if a single recorded vitamin D level above 50 nmol/l in routine P6 clinic practice can safely exclude vitamin D deficient secondary hyperparathy- Effect of age and gender on bone turnover markers: relationships with roidism. oestradiol and parathyroid hormone Study method Miguel Debono, Fatima Gossiel, Jennifer Walsh & Richard Eastell A retrospective study of 480 postmenopausal women who had high PTH levels Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK. during screening at an osteoporosis clinic was conducted. Results Fifty-two of 480 patients (10.8%) had PHPT, 19 (4%) had renal related secondary Aims/hypothesis hyperparathyroidism, and 222 (46.25%) had 25OHD level !50 nmol/l. The Bone turnover markers mainly reflect three processes: bone remodelling, linear remaining 170 who had normal renal function, normal adjusted calcium but growth, and bone modelling. These occur at different rates depending on age. 25OHD O50 nmol/l and a high PTH appeared to have normocalcaemic Oestradiol levels, a mediator of all processes of bone turnover, vary according to hyperparathyroidism. Six month later, with continued replacement of vitamin D sex and age whereas, parathyroid hormone levels, an important regulator of bone and calcium, PTH was normalized in 65 patients, remained high with normal remodelling, vary with age. We hypothesised that gender and age differences in calcium in 55 patients and not checked in 47 patients. Three progressed to the bone formation marker, serum amino terminal propeptide of type 1 collagen hypercalcaemic PHPT. 38 of 55 patients who remained normocalcaemic (PINP) and the bone resorption marker, serum b carboxy (C) terminal telopeptide hyperparathyroidism showed 25OHD !50 nmol/l on repeat testing. (bCTX), could be related to differences in these hormones. Conclusion Methods The 25OH-D level is variable and a single measurement may not exclude vitamin We performed an observational, cross-sectional study in 180 participants, 90 men D insufficiency. The observation also suggested that many cases of and 90 women, divided into three groups (30/group) by age: Group A 16–18 normocalcaemic hyperparathyroidism might simply have or coexist with vitamin years, Group B 30–32 years and Groups C over 70 years. In all individuals we D insufficiency. measured fasting serum oestradiol, parathyroid hormone, serum bCTX and PINP at 9am. Results

Mean (S.D.) values for hormones and bone turnover markers. P8 Group A Group B Group C Thyrostimulin expression and signalling in the skeleton 1 1 1 Mean (S.D.) M F M F M F J H Duncan Bassett , Rebecca Hernandez , Charlotte Combs , Anne van der Spek1, Ming Yu1, Allan Williams1, Elaine Murphy1, Alan Boyde2, Oestradiol 21.0 (9) 68.3 (58) 22.9 (6) 88.8 (87) 24.3 (12) 8.4 (4) 3 3 1 (pg/ml) Clementine J J van Zeijl , Anita Boelen & Graham R Williams 1 PTH 34.5 (12) 35.2 (15) 35.3 (12) 36.2 (10.1) 46.7 (20) 46.3 (28) Molecular Endocrinology Group, Department of Medicine and Medical (pg/ml) Research Council Clinical Sciences Centre, Imperial College London, Serum 1.3 (0.4) 0.7 (0.2) 0.5 (0.2) 0.3 (0.1) 0.4 (0.2) 0.5 (0.2) 2 bCTX Hammersmith Hospital, London W12 0NN, UK; Oral Growth and (ng/ml) Development, Institute of Dentistry, Bart’s and London School of Medicine, PINP 201.4 (101) 106.4 (41) 53.6 (23) 38.7 (17) 54.2 (80) 50.7 (20) Queen Mary, University of London, London E1 1BB, UK; 3Department of (ng/ml) Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.

In Group A (16–18 years) serum bCTX (P!0.001); PINP (P!0.001) and in Hypothyroidism and thyrotoxicosis have detrimental effects on skeletal Group B (30–32 years) serum bCTX (P!0.001); PINP (PZ0.003) were development and adult bone strength. These effects result from thyroid hormone

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK actions in bone, although a direct role for TSH in osteoblasts and osteoclasts was P10 postulated following analysis of TSH receptor (TSHR) null mice. This hypothesis Serum 25-OH-vitamin D levels in thalassaemia major remains controversial as other studies failed to demonstrate osteoblast or Ploutarchos Tzoulis, Ai Leen Ang, Farrukh Shah & Maria Barnard osteoclast responses to TSH in vitro. Thyrostimulin is a heterodimeric The Whittington Hospital NHS Trust, London, UK. glycoprotein hormone composed of a2 (GPA2) and b5 (GPB5) subunits that has a 10-fold higher binding-affinity for TSHR than TSH and is thought to exert paracrine effects in peripheral tissues. We hypothesized that thyrostimulin Aims activates TSHR in bone and demonstrated expression of GPA2, GPB5 and TSHR Low vitamin D levels may contribute to the pathogenesis of bone disease in mRNAs in primary cultured osteoblasts and osteoclasts. To investigate thalassaemia major patients. Our haematology department serves one of the UK’s thyrostimulin actions in vitro,weexpressedtheproteininCos7cells. largest populations of thalassaemia patients. We evaluated our thalassaemia Co-expressed GPA2 and GPB5 subunits formed heterodimers and were major patients’ vitamin D levels and other serum bone markers. glycosylated and secreted appropriately. Conditioned medium from Cos7 cells Methods expressing thyrostimulin induced a robust cAMP response in CHO cells Blood specimens were collected from all thalassaemia major patients under active expressing the TSHR, but no response was evident in osteoblasts or osteoclasts. follow-up in March and April 2010 and serum 25-OH-vitamin D, calcium, To investigate thyrostimulin actions in vivo, we characterized GPB5 knockout phosphate, alkaline phosphatase, parathyroid hormone levels were measured. The (GPB5KO) mice. In juveniles circulating T3 was normal, but T4 was reduced by correlation of 25-OH vitamin D with these serum markers, patient demographics 25% and TSH increased twofold. Adult GPB5KO mice were euthyroid, and markers of iron overload was assessed. Vitamin D deficiency was defined as suggesting thyrostimulin may influence development of the hypothalamic– serum 25-OH-vitamin D !25 nmol/l, sufficiency as 25–75 nmol/l and normal as pituitary–thyroid axis. Consistent with the normal T3 level, endochondral 75–250 nmol/l. ossification, linear growth and bone maturation were unaffected in GPB5KO Results mice. Bone micro-architecture, cortical thickness, mineral content, mineralization Blood specimens were collected from 74 thalassaemia major adults (38 females, density and biomechanical properties were also normal in adult GPB5KO mice. 36 males) with median age of 35.5 years (range 17–58 years). In summary, although GPA2, GPB5 and TSHR are expressed in bone, Prevalence of vitamin D deficiency was 21.6%, vitamin D insufficiency 66.2% thyrostimulin does not induce a cAMP response in primary osteoblasts or and normal vitamin D levels 12.2%. Median serum 25-OH-vitamin D levels was osteoclasts. Furthermore, thyrostimulin-deficient mice display a normal skeletal 39 nmol/l (range 13–113 nmol/l). phenotype indicating that thyrostimulin does not have a physiological role Serum calcium levels, alkaline phosphatase and parathyroid hormone were not in bone. independently associated with vitamin D levels. The only serum marker which (GPB5KO mice were generated by Lexicon Genetics) was significantly associated with vitamin D levels was phosphate (PZ0.04), but the correlation was poor (Spearman correlation coefficient K0.243). No independent association between age or ethnic origin and vitamin D status was observed. No marker of iron overload was significantly associated to vitamin D status. Conclusions Most thalassaemia major patients have low serum vitamin D levels. This potentially has a significant impact on their bone health, which is already a major problem in patients with thalassaemia major. We would recommend regular measurement of vitamin D levels in all thalassaemia major patients and P9 subsequent appropriate replacement therapy. Bone mineral density in patients with primary adrenal insufficiency compared to patients with congenital adrenal hyperplasia Kathrin Koetz1, Manfred Ventz1, Sven Diederich2 & Marcus Quinkler1 1Charite´ Campus Mitte, Berlin, Germany; 2Endokrinologikum, Berlin, Germany.

Introduction Patients with primary adrenal insufficiency (Addison’s disease) and patients with congenital adrenal hyperplasia (CAH) still tend to receive more glucococorticoids than the normal endogenous production in healthy subjects. CAH patients start P11 glucocorticoid treatment usually with diagnosis in their early childhood, whereas Bone turnover markers in patients on aminobisphosphonate therapy for Addison’s patients have a later onset of their disease and start of their treatment. osteoporosis Objective R K Crowley1, J J Brady2, M Kilbane2 & M J McKenna1 To compare patients with Addison’s disease and CAH in regard to their bone 1Department of Endocrinology, St Vincent’s Hospital, Dublin, Ireland; mineral density (BMD), the duration of glucocorticoid therapy and the impact of 2Metabolism Laboratory, St Vincent’s Hospital, Dublin, Ireland. glucocorticoid pharmacogenetics. Design, setting and participants In a cross-sectional study patients from one university endocrine outpatient clinic Aminobisphosphonates impair osteoclast cell function and reduce bone were included (84 patients with Addison’s disease, 42 patients with CAH). Bone remodelling rate. It has been speculated that atypical femoral fractures in patients mineral density (BMD) was measured using DXA scan. Blood samples were on bisphosphonates are the result of impaired bone remodelling. analysed for bone markers and 24 h urinary samples were analyzed for bone The primary aim of this prospective study was to assess levels of bone resorption markers. remodelling in patients with osteoporosis on aminobisphosphonate therapy by Results measurement of bone turnover markers. The secondary aim was to assess the Patients with Addison’s disease were significantly older (55.1G15.2 vs 39.9 adequacy of concomitant vitamin D supplementation. G13.8y, P!0.001) and taller (168G10 vs 160G11 cm, P!0.001) than CAH We identified 77 subjects (6 males) consecutively from our endocrine practice; patients, but showed no difference in BMI. Time since diagnosis was shorter in details of aminobisphosphonate, vitamin D and calcium therapy were recorded. Addison’s patients (14.9G10.4 vs 30.5G13.5y, P!0.001). The calculated Serum parathyroid hormone (PTH), 25-hydroxyvitamin-D (25OHD), bone- hydrocortisone equivalent glucocorticoid dose per body surface was higher in specific alkaline phosphatase (bone ALP) and tartrate-resistant acid phosphatase CAH than Addison’s patients (15.6G7.2 vs 11.9G2.4 mg/m2, P!0.001). No (TRAP5b) were measured. differences were seen in serum Ca, aP, ostase, PTH, 25-vitamin D3, 1,25-vitamin The mean age of subjects was 71.3G9.3 years. Mean duration of bisphosphonate D3, osteocalcin or urinary cross-links. Femoral neck BMD Z-scores were therapy was 5.8G4 years. Only 2 subjects suppressed bone ALP to less than the significantly lower in patients with CAH compared to patients with Addison’s lower limit of the normal reference range, and none suppressed TRAP5b on disease (K0.59G1.17 vs 0.0G0.99, P!0.01); also Z-scores for femoral Ward’s aminobisphosphonate therapy. Mean 25OHD was 78G26 nmol/l; 41 subjects had region were lower in CAH patients (K0.96G1.04 vs K0.28G1.03, P!0.005). levels O75 nmol/l and only 10 had levels !50 nmol/l of whom 7 were taking No difference was found in lumbar spine Z-scores. 400 IU/day or less. Conclusions Mean PTH was 43.9G19 ng/ml, and correlated with age (rZ0.32), 25OHD level BMD at femoral neck and femoral Ward’s region were lower in CAH than (rZK0.44) and duration of therapy (rZ0.23, P!0.01). Addison’s disease patients, indicating undesirable effects of higher glucocorticoid In conclusion, aminobisphosphonate therapy is not associated with over- dose, usage of longer acting glucocorticoids, and longer duration of replacement suppression of bone turnover. Continuous low dose vitamin D supplementation therapy. achieved more than adequate vitamin D status if taking 800 IU daily.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P12 Conclusion Lithium-induced hypercalcaemia: ‘past, present, and future’ Baseline PTH, rather than calcium, predicts long-term outcomes in untreated Gideon Mlawa & Sandeep Deshmukh PHPT and will have a significant impact on the justification optimal management Southampton General Hospital, Southampton, UK. of the condition.

Background Lithium remains a first-line treatment for bipolar affective disorder and acute maniac states. Lithium therapy is associated with a variety of side effects including thyroid dysfunction and hypercalcaemia. Hypercalcaemia and more rarely biochemical picture resembling primary hyperparathyroidism or familial hypocalciuric P14 hypercalcaemia may develop. Recognition of this side effect is of vital A gene causing autosomal dominant kyphoscoliosis in an N-ethyl-N- importance as an increasing number of patients with bipolar disorder are on nitrosourea (ENU) mutagenised mouse model is located on a 5 Mb long-term lithium therapy. We present a case report of a 65 years old lady with interval on mouse chromosome 4 band A3 history of recurrent admissions with hypercalcaemia. On her last admission to Christopher Esapa1,2, Rosie Head1,2, Holly Evans3, Gethin Thomas4, the medical admission unit she was confused with increasing tiredness and Matthew Brown4, Peter Croucher3, Roger Cox2, Steve Brown2 slurring of speech. She had a background of bipolar disorder and was on long- & Rajesh Thakker1 term lithium therapy 300 mg bd, and depakote. Patient’s calcium level was 1University of Oxford, Oxford, Oxfordshire, UK; 2MRC Harwell, Harwell, normal prior to starting lithium treatment. The patient calcium level was Oxfordshire, UK; 3University of Sheffield, Sheffield, UK; 4University of 3.15 mmol, lithium level was high 2.03 mmol, ECG was unremarkable, chest Queensland, Queensland, Australia. X-ray and CT brain were normal. She was treated with intravenous fluids and i.v. pamidronate with improvement of her presenting symptoms. She had elevated parathyroid level (PTH) of 20 pmol/l her serum vitamin D level as well Kyphosis and scoliosis are common spinal disorders that lead to significant as ACE was normal. Ultrasound parathyroid and sestamibi scan were negative morbidity in childhood, adolescence and adulthood. Familial and twin studies and 24 h urine collection was 0.54, her urine calcium creatinine ratio was have implicated a genetic involvement, although the causative genes remain to be !0.01. Lithium was withdrawn after consultation with psychiatrist in charge of identified. To facilitate these studies, we investigated 12-week-old progeny of the patient by tapering the dose to 200 mg bd, then 100 mg bd and then it was mice treated with the chemical mutagen N-ethyl-N-nitrosourea (ENU) using stopped. The dose of depakote was increased. Calcium level remains normal phenotypic assessments that included dysmorphology, radiography and dual- 6 months after stopping lithium. energy X-ray absorptiometry (DEXA). These studies identified a mouse with Conclusion fused lumbar vertebrae in association with kyphoscoliosis, designated Hvf. Lithium-induced hypercalcaemia is common but underreported complication. Inheritance testing revealed the phenotype to be transmitted as an autosomal Most patients have mild asymptomatic hypercalcaemia. This case and previously dominant trait. Hvf mice, when compared to wild-type (WT) littermates, had: a reported cases support the diagnosis of lithium induced hypercalcaemia as 27% lower body weight (P!0.001); a 42% decrease in fat mass (P!0.001); a hypercalcaemia (hyperparathyroid state) is reversible on stopping lithium. 22% reduction in lean mass (P!0.001); and a 33% increase in weight-adjusted Measurement of serum calcium and PTH levels as well as thyroid function test whole body areal bone mineral density (BMD) (P!0.001). Histological analysis periodically after starting lithium treatment is advisable. using haematoxylin and eosin stained sections revealed the Hvf mutant mice to have irregularly shaped vertebral bodies and displacement of intervertebral discs and ossification centres. Micro-computed tomography analysis of lumbar vertebrae from female Hvf mutant mice, when compared to WT littermates, revealed significant increases in trabecular thickness (Hvf versus WTZ 0.036 mm!10K2 vs 0.028 mm!10K2, P!0.01), trabecular bone volume as a proportion of tissue volume (15 vs 11%, P!0.05), and bone density (Hvf versus WTZ1.27 vs 1.11 g/cm3, P!0.01). Genetic mapping localised the Hvf locus to a 5 Mb region on chromosome 4, which contains 50 genes. Thus, our studies which P13 have established a mouse model for a monogenic form of kyphoscoliosis associated with fusion of lumbar vertebrae will help to identify a gene that has a What predicts adverse outcomes in untreated primary role in the cellular and molecular mechanisms of kyphoscoliosis. hyperparathyroidism? Ning Yu, Peter Donnan & Graham Leese University of Dundee, Dundee, UK.

Context Rising evidence of the increased risk in mild PHPT suggests that serum calcium, which has been a main surgical criterion, maybe not an accurate indicator of disease severity or at least, not a reliable predictive factor of its long-term consequences. This study aims to identify the best biochemical predictor of P15 adverse outcomes in untreated PHPT. Parathyroid hormone concentrations in proton pump inhibitor induced Outcome measures and methods hypomagnesaemia Primary outcomes considered were all-cause mortality, fatal and non-fatal Amy Kennedy, Neil Gittoes & John Ayuk cardiovascular (CVD). Secondary outcomes were nine hospital-admitted Department of Endocrinology, Queen Elizabeth Hospital Birmingham, co-morbidities, including cerebrovascular disease, hypertension, renal failure, University Hospitals Birmingham, Birmingham, UK. renal stones, psychiatric condition, fractures, osteoporotic fractures, cancer, and diabetes. Data was examined using survival analysis. Potential biochemical predictors tested were baseline serum calcium, PTH, creatinine and alkaline Severe hypomagnesaemia associated with the use of proton pump inhibitors phosphatase (ALP) and other covariates considered were gender, age at diagnosis, (PPIs) is now increasingly recognised. The exact underlying mechanism is socio-economic status, previous usage of bisphosphonates, and previous unclear but is likely to involve altered intestinal absorption of magnesium ions. co-morbidities. Hypomagnesaemia from any cause results in functional hypoparathyroidism. Results PTH levels vary widely in reported cases of hypomagnesaemia associated with From 1997 to 2006, we identified 2097 untreated PHPT patients (mean age, 68.4 the use of PPIs. We examined PTH levels in patients admitted to hospital with years; 60.9% female) with a total follow-up of 7338 person-years, in Tayside, severe (Mg!0.4 mmol/l) hypomagnesaemia and concurrent PPI use in an Scotland. The baseline calcium was 2.65 mmol/l and PTH was 10.3 pmol/l. In attempt to clarify the biochemical profile of this increasingly recognised clinical total, 648 (30.9%) patients had died during the follow up, 249 (38.4%) of fatal problem. CVD. PTH was the only significant (indicated as P!0.05) risk factor in ALL Using the database of an in-house electronic prescribing system (PICS), all primary and secondary outcomes observed adjusting for other covariates. Serum inpatients prescribed an oral PPI between 2005 and 2009 and with severe creatinine and ALP predicted mortality outcomes in the short term (%3 years) but hypomagnesaemia were identified. Eleven patients fulfilling these criteria had not long term. In addition, high baseline serum creatinine and ALP were also concurrent PTH, serum calcium and albumin recorded. Comorbidities and other associated with increased risk of hypertension, renal failure, fractures and cancer. medications were also noted. Calcium was only associated with increased risk of all cause mortality in the short Plasma PTH range was 7.6 to 509 ng/l (median 57.2 ng/l, RR 12–65 ng/l). All 11 term but had no significant impact on other outcomes. had hypocalcaemia (sCa 1.26–2.00 mmol/l (RR 2.1–2.6)). Two patients with the

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK highest plasma PTH had coexisting chronic renal failure (PTH 215.3 and CH8 (cartilage cells) demonstrated that the ENU mutant (K225G) increases Gdf5 509 ng/l). In the remaining 9, PTH correlated positively with serum magnesium expression (1.5- and 2-fold respectively, P!0.005) in contrast to the human (rZ0.85). Only one patient had the PPI stopped (although subsequently restarted OA-associated polymorphism (K272T) which decreases expression (0.75- and within months). Six patients represented to the same hospital with a recurrent 0.7-fold respectively, P!0.05). For in vivo studies, ENU mutant and wild-type episode of hypomagnesaemia. mice were kept in accordance with national welfare guidelines and project license PTH concentrations in PPI-induced hypomagnesaemia vary widely and may be restrictions, aged for 14 weeks and investigated for the urinary excretion of the influenced by coexisting medical problems. The attenuated PTH response seen in cartilage degradation product, CTX-II, which may be elevated in OA patients. most patients with PPI-induced hypomagnesaemia does however appear to be This revealed that female homozygous mutant mice, when compared to wild-type related to the degree of hypomagnesaemia. Our results overtly demonstrate that littermates, had significantly reduced 24-h urinary CTX-II excretion (mutant PPIs have in the past rarely been considered as a cause of hypocalcaemia/ 2.90G0.01 ng/ml; wild-type 4.87G0.036 ng/ml, P!0.05) thereby suggesting hypomagnesaemia and legitimise our attempt to promote awareness of this that the mutant confers a protective effect against OA. Thus, we have established serious side effect and to clarify its biochemical pattern at presentation. a mouse model with a functional alteration in Gdf5 expression that will facilitate investigation of the molecular mechanisms of OA.

P16 Radius bone loss with ageing assessed by high-resolution peripheral computed tomography differs in men and women P18 Jennifer Walsh, Margaret Paggiosi & Richard Eastell Sheffield NIHR Bone Biomedical Research Unit, Sheffield, UK. The long-term safety and efficacy of zoledronic acid in the treatment of osteoporosis: a 3-year, randomized extension to the HORIZON-pivotal fracture trial (PFT) High-resolution peripheral computed tomography (HR-pQCT) (XtremeCT, Richard Eastell1, Ian Reid2, Jane Cauley3, Steven Boonen4, Scanco) obtains three-dimensional images of the distal radius with a resolution Felicia Cosman5, Ping Chung Leung6,Pe´ter Lakatos7, Zulema Man8, of 82 microns, which enables detailed study of the microarchitecture of cortical Steven Cummings9, Trisha Hue10, MaryEllen Ruzycky11, Ruvie Martinez11, and trabecular bone. Better description of the microarchitectural changes in bone Guoqin Su11, Christina Bucci-Rechtweg11 & Dennis Black10 with ageing will improve understanding of which preventative and therapeutic 1University of Sheffield, Sheffield, UK; 2University of Auckland, Auckland, interventions are most likely to be effective. New Zealand; 3University of Pittsburgh, Pittsburgh, Pennsylvania, USA; The aim of this study was to identify differences in cortical and trabecular bone in 4Katholieke Universiteit Leuven, Leuven, Belgium; 5Helen Hayes Hospital, men and women at peak bone mass and older age. West Haverstraw, New York, USA; 6Chinese University of Hong Kong, We studied 110 male and female healthy volunteers ages 30–32 and over 70. The Hong Kong, China; 7Semmelweis University Medical School, Budapest, study was approved by the local research ethics committee. We analysed Hungary; 8Centro Tratamiento Integral Endocrinologı´a, Buenos Aires, HR-pQCT images with standard software and a cortical microarchitecture Argentina; 9San Francisco Coordinating Center, San Francisco, California, programme supplied by Scanco. USA; 10University of California, San Francisco, California, USA; Radius cortical density was lower after age 70 than at ages 30–32 in men and 11Novartis Pharmaceuticals, East Hanover, New Jersy, USA. women (888 vs 952, 914 vs 1006 mg/cm3, P!0.001) due to higher porosity, greater pore size and lower tissue mineral density. Age differences in trabecular architecture differed between men and women. In men, trabecular thickness, but Treatment with a single annual infusion of zoledronic acid 5 mg (ZOL) for 3 years not trabecular number was lower in the older age group. In women, trabecular has been shown to be effective in increasing bone mineral density (BMD) and number, but not trabecular thickness was lower in the older age group. Older decreasing fractures. In order to investigate the long-term effects of ZOL, we women had greater trabecular separation and trabecular inhomogeneity (the S.D. performed a 3-year extension of the HORIZON-PFT to 6 years. A total of 1233 of trabecular separation) than younger women (0.25 vs 0.17 mm, P!0.01), but women who received ZOL for 3 years in the core study were randomly allocated Z Z trabecular separation and inhomogeneity did not differ between older and younger to 3 additional years of ZOL (Z6, n 616) or blinded placebo (Z3P3, n 617). men (0.18 vs 0.15 mm). Primary endpoint was percentage change in femoral neck (FN) BMD at year 6 In conclusion, patterns of cortical bone loss with ageing are similar in men and relative to year 3. Secondary endpoints included other BMD sites, bone turnover women, but patterns of trabecular bone loss differ, with greater disruption of markers, fractures and safety. FN BMD results are shown in the figure below. In trabecular microarchitecture in women. It is possible that cortical bone loss is due the Z6 group, FN BMD remained constant in years 3–6 while it decreased slightly Z to factors such as PTH and IGF1, which change similarly with age in men and in the Z3P3 group (between treatment difference at year 6 1.04%, 95% CI: Z women, and that trabecular disruption results from decreasing oestrogen levels. 0.43–1.65%, P 0.0009), and similar results were seen for total hip, trochanter and lumbar spine BMD. New vertebral morphometric fractures were lower in the Z6 group compared with the Z3P3 group (relative risk reduction of 52%, 95% CI: 10–74%, PZ0.03), while there were no differences between groups in clinical, non-vertebral, hip, and clinical vertebral fractures. Biochemical markers remained constant in the Z6 group but rose slightly in the Z3P3 group, remaining below pretreatment levels in both groups. The overall incidence of adverse events P17 was similar in both groups. A numerical increase in atrial fibrillation SAEs (2.0% in Z6 vs 1.1% in Z3P3) was not statistically significant (PZ0.26). No new safety A50-untranslated region mutation of the growth and differentiation concerns were identified. The BMD results, together with the fracture results, factor 5 (Gdf5) gene increases expression and is associated with suggest that patients at high risk of fracture, particularly vertebral fracture, should decreased urinary excretion of the cartilage degradation product, continue on annual ZOL therapy. CTX-II: relevance to osteoarthritis M Andrew Nesbit1, Chris Esapa1, Rosie Head1, Katie Gaynor1, Roger Cox2, Steve Brown2 & Rajesh Thakker1 1University of Oxford, Oxford, UK; 2MRC Harwell, Oxfordshire, UK.

Osteoarthritis (OA) may be associated with endocrine disorders such as hypothyroidism, obesity, primary hyperparathyroidism or acromegaly, although P19 often its cause remains undefined. To facilitate investigations of the underlying Cervical cord compression in a patient with Paget’s disease and molecular mechanisms of OA we have investigated N-ethyl-N-nitrosourea (ENU) primary hyperparathyroidism: a diagnostic challenge mutant mice using a genotype-driven approach in which candidate genes are Jan Hoong Ho1, Kashinath Dixit1, Aprajay Golash2 & Simon Howell1 examined for mutations. One such investigated gene is growth and differentiation 1 0 Department of Endocrinology, Royal Preston Hospital, Preston, Lanca- factor 5 (GDF5), as in man a single nucleotide polymorphism (SNP) in its 5 shire, UK; 2Department of Neurosurgery, Royal Preston Hospital, Preston, untranslated region, which reduces GDF5 expression in joints, has been reported Lancashire, UK. to be associated with susceptibility to knee and hip OA. Our analysis of 10 000 DNA samples from ENU mutagenised mice identified an A/G SNP in a conserved nucleotide 47 bp downstream of the human OA susceptibility SNP and 225 bp Case upstream of the translation start site of the Gdf5 gene. The in vitro and in vivo A 77-year-old man was admitted with a pathological fracture of the right femur, effects of this polymorphism on GDF5 expression were investigated. Luciferase which required intramedullary nailing. He had previously been diagnosed with reporter assays of Gdf5 promoter polymorphisms in MG63 (osteoblast cells) and Paget’s disease affecting the right femur and also hyperparathyroidism with a

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK large parathyroid adenoma on Sestamibi scan which had been managed at another P21 hospital. On this admission, his corrected calcium was 2.79 (2.15–2.55) mmol/l, Co-existing sarcoidosis, primary hyperparathyroidism and vitamin D PTH 643 (15–65) pg/ml and alkaline phosphatase 258 (30–130) U/l. During his deficiency in a patient with hypercalcaemia hospital stay, he developed right arm and bilateral leg weakness. MRI scan of the Michelle Kavanagh, Subhash Chander Rana, Nicholas Andrew Scriven, spine revealed a tumour causing destruction of C2 vertebral body and anterior Vijay Bangar & Abdulsalam Mousa subluxation resulting in spinal cord compression. He was transferred to the Calderdale Royal Hospital, Halifax, West Yorkshire, UK. neurosurgical unit at Royal Preston Hospital where he had posterior cervical decompression and biopsy. Initial histology suggested osteitis fibrosa cystica due to hyperparathyroidism, although Paget’s disease and fibrous dysplasia were Introduction considered as differential diagnoses, and the endocrinology team were therefore We describe a 31-year-old man with sarcoidosis found having concomitant asked to review him. Review of a previous bone scan demonstrated increased primary hyperparathyroidism and vitamin D deficiency. Although hypercalcae- uptake in C2 vertebral body consistent with active Paget’s and a review of the pre- mia is common in sarcoidosis, when accompanied by hypophosphatemia and operative CT and MRI imaging also confirmed Paget’s as the likely diagnosis. He resistance to steroids, should suggest coexisting primary hyperparathyroidism... was therefore treated with intravenous zoledronic acid and physiotherapy and his Associated vitamin D deficiency presented management difficulties. condition improved significantly. Subsequent histology review by a specialist Case report bone histopathologist confirmed the diagnosis of Paget’s. A 31-year-old bodybuilder presented with dyspnoea. Sarcoidosis was suspected Discussion on the basis of bi-hilar lyphadenapathy on chest X-ray. The diagnosis was Cervical cord compression is a relatively rare complication of Paget’s disease. In confirmed by biopsy from a large axillary lymph node. Further investigations this case the correct diagnosis was delayed by the initial imaging, which confirmed systemic respiratory and liver involvement. He had hypercalcemia suggested a bone tumour and then the histology which suggested osteitis fibrosa with serum calcium 3.06 mmol/l and phosphate of 0.84. He was treated with oral cystica associated with co-existing hyperparathyroidism. Careful review of the prednislone with good symptomatic relief. However, his calcium remained high previous imaging confirmed previous Pagetic involvement of the cervical spine despite steroid treatment. His PTH ranged between 8.6 and 11.8 in the presence of and features on plain imaging consistent with Paget’s which allowed the correct high Ca confirming coexisting hyperparathyroidism. His vitamin D was !10. He diagnosis to be made, and appropriate treatment to be instituted. was treated with vitamin D with close monitoring of Calcium, though his vitamin D is still only 43 mmol/l. He is arranged to have parathyroid adenoma localization scan in order to proceed for parathyroidictomy. Discussion Hypercalcaemia accompanying sarcoidosis is due to rise in circulating active vitamin D – 1,25-dihydroxycholecalciferol. Serum PTH concentration is generally low or normal. PTH remains high when there is co-existent primary hyperparathyroidism. Corticosteroid administration produces a simultaneous decline in serum calcium and 1,25-DHCC concentrations in sarcoidosis and can be used to distinguish between sarcoidosis-related hypercalcaemia and primary hyperparathyroidism. Our patient had low vitamin D which presented manage- ment difficulties as treatment with vitamin D may aggravate hypercalcaemia. The clinician, when confronts a patient with hypercalcaemia because of sarcoidosis should consider the possibility of coexistent hyperparathyroidism in the presence P20 of high PTH and inadequate response to steroids. Localisation studies in primary hyperparathyroidism: our experience Venkata Katreddy, A N B Abduk Aziz Al-akbar, Ashraf Bdiri, Andrew Ball & Khaled Ashawesh Russells Hall Hospital, Dudley, UK. P22 Immobility: a rare cause of hypercalcaemia 1 2 2 1 Introduction Rebecca Lim , Emma Lewis , Shirley Bowles , Niru Goenka , Frank Joseph1 & David Ewins1 Primary hyperparathyroidism is not an uncommon disease with incidence of 1 w Diabetes and Endocrinology Unit, Countess of Chester Hospital NHS 25–30 cases per 100 000 people, whether caused by adenoma or hyperplasia, 2 can be cured surgically with a high rate of success. Over past decade minimally Foundation Trust, Chester, UK; Department of Blood Sciences, Countess invasive surgery has become mainstay of treatment compared to traditional of Chester Hospital NHS Foundation Trust, Chester, UK. bilateral exploration approach. Accurate preoperative localisation of parathyroid disease is absolutely imperative for effective minimally invasive surgery. A 57-year-old man with a history of alcohol excess was admitted following a road Aim traffic accident. He suffered multiple trauma with fractures to his left femur, tibia To assess the effectiveness of ultrasound and Sestamibi scan in localising and fibula, his right pubic ramus and several ribs. In addition severe abdominal parathyroid adenoma in our hospital and compare with universal results. trauma necessitated nephrectomy and splenectomy. Routine biochemistry and Methodology and results bone profile on admission was within normal limits. Retrospective study of 50 patients who underwent parathyroidectomy. Radiology He had a prolonged stay in the Intensive Therapy Unit (ITU) with acute kidney results were compared with histological and operative notes. We audited 50 injury and type 2 respiratory failure complicating hospital acquired pneumonia. patients, out of which 28 were females and 22 males. Average age was 59 years Two months (64 days) into admission he was noted to have an elevated adjusted and females slightly older than males. calcium of 3.35 mmol/l (2.1–2.7 mmol/l), a low serum phosphate of 0.03 mmol/l Out of 50 patients 39 patients had primary hyperparathyroidism. (0.8–1.4 mmol/l), alkaline phosphatase of 91 IU/l (40–129 IU/l), albumin 35 g/l Out of 39 patients with primary hyperparathyroidism, 38/39 (97%) had (30–49 g/l), and mild renal impairment. ultrasound, 36/39 (92%) had Sestamibi scan. The adjusted calcium levels had progressively increased since admission and 26/38 (68%) had evidence of adenoma on ultrasound, 19/36 (53%) patients had PTH was suppressed at 0.5 pmol/l (1.5–6.9) excluding hyperparathyroidism. His adenoma on the Sestamibi scan. Concordance between ultrasound and Sestamibi thyroid function tests, serum electrophoresis, urine Bence-Jones protein and was 33% (12/36) preoperatively. PTHrP were all normal. Of 39 patients with primary hyperparathyroidism, histological findings showed, A diagnosis of immobility hypercalcaemia was made and excessive bone adenoma in 29/39 (75%), hyperplasia in 8/39 (20%), 1/39 (2.5%) had normal resorption confirmed by the presence of increased urinary excretion of pyridinium parathyroid tissue and 1 (2.5%) had no parathyroid tissue identified. crosslinks – urine pyridinoline/creatinine ratio 386 nmol/mmol (NR 5–21.8). Out of 39 patients with primary hyperparathyroidism, postoperatively ultrasound Following treatment with intravenous fluids and intravenous pamidronate localised the site of adenoma in 24/38 (63%) patients, Sestamibi localised in (90 mg) the hypercalcaemia returned to normal within one week and 20/38 (53%) patients. US and Sestamibi concordance was 29/38 (76%) normocalcaemia (and normophosphataemia) was maintained when mobilisation postoperatively. commenced over the next few weeks. Conclusion On reviewing the timeline and exclusion of other causes, it would appear the Ultrasound was slightly more accurate in localising parathyroid adenoma than elevated level of hypercalcaemia was related to severe trauma and prolonged Sestamibi scan in patients with primary hyperparathyroidism in our hospital. immobility. Immobilisation hypercalcaemia was first described by Albright et al. Concordance with both modalities was only 73 percent compared to 90–95% in 1941 and is thought to be due to increased bone resorption. It is an under- percent in various studies. Both US and sestamibi scans should be used whenever recognised cause of hypercalcaemia especially in hospitalised patients with available to localise adenomas preoperatively for patients to undergo minimally prolonged inactivity. Patients with pre-existent renal dysfunction are at increased invasive surgery and prevent complications with traditional bilateral exploration. risk and it has been associated, as in our patient, with the presence of sepsis.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P23 P25 Ablation of AMP-activated protein kinase (AMPK) a1 catalytic subunit Comparison of two high dose- bolus vitamin D regimens in women with in mice leads to decreased bone loss after ovariectomy and impaired low vitamin D levels bone response to intermittent PTH treatment Ioannis Charopoulos & Steve Orme Mittal Shah1, Benoit Viollet2, Marta Korbonits3 & Chantal Chenu1 Leeds General Infirmary, Leeds, UK. 1Veterinary Basic Sciences, Royal Veterinary College, London, UK; 2INSERM U567, Paris, France; 3Endocrinology, Queen Mary University of London, London, UK. Aim To compare the efficacy, tolerability and safety of high doses of i.m. vitamin D2 (ergocalciferol) with oral vitamin D3 (colecalciferol) supplementation in women AMPK is a key regulator of cellular and body energy homeostasis. We previously with low vitamin-D levels. demonstrated that AMPK activation in osteoblasts increases bone formation Design and settings in vitro while deletion of the AMPKa1 subunit leads to decreased bone mass Of 107 patients (s25(OH)D%50 nmol/l), aged 21–89 years were recruited in a in vivo. To determine whether bone turnover can be stimulated in the absence of retrospective audit. Participants were separated in two groups according to serum AMPKa1 subunit, we subjected WT and AMPKa1K/K mice to catabolic vitamin D levels. The Group 1 included individuals with serum vitamin D levels (ovariectomy: OVX) and anabolic (intermittent PTH administration: iPTH) 30–50 nmol/l and the Group 2 with more severe depletion (!30 nmol/l). All hormonal challenges. In vivo iPTH administration is a potent inducer of bone Group 1 patients (nZ65) were treated with three-doses regimen of oral monthly formation and can reverse OVX-induced bone loss. colecalciferol 40.000 IU (nZ33) or ergocalciferol 300.000 IU bolus injection A 3-month-old female AMPKa1K/K (nZ16) and WT (nZ16) mice were regimen (nZ32). The Group 2 (nZ42) received 300.000 IU oral colecalciferol ovariectomised. Four weeks after OVX, mice were randomly divided into two (nZ21) or 300.000 IU i.m. ergocalciferol (nZ21). The primary end points were groups, one receiving saline and the other PTH (1–34) treatment (80 mg/kg per the serum levels in 25(OH)Vit D at 3 and 6 months for the Group 1 and at 6 weeks, day) for 4 weeks. Tibiae were harvested from these mice and bone micro- 3 months and 6 months for Group 2. architecture determined by micro-computed tomography. Results AMPKa1K/K mice displayed a decreased bone loss after OVX in the trabecular Oral colecalciferol regimen showed significantly greater levels of 25(OH)vit D compartment. This was demonstrated by higher trabecular bone volume (C38%; from i.m. ergocalciferol treatment at 6 weeks, 3 and 6 months in both groups P!0.01), trabecular number (C40%; P!0.001) and decreased trabecular (Group 1 P!0.008, P!0.05; Group 2 P!0.0001, P!0.001 and P!0.05). The separation (K37%; P!0.001) in AMPKa1K/K mice versus WT mice. The mean difference of 25(OH)vit D concentrations from baseline was significantly cortical indexes showed nonsignificant increases in bone area (C1%) and cortical greater for oral colecalciferol treatment at 6 weeks and 3 months in both groups. thickness (C6%) in AMPKa1K/K mice versus WT mice after OVX. As Less than 5% of patients on i.m. ergocalciferol treatment achieved levels expected, iPTH increased cortical and trabecular bone indexes. However, O50 nmol/l at 6 weeks, 3 and 6 months, whereas in oral treatment, 100 and 75% AMPKa1K/K mice showed lower trabecular bone volume (K17%; P!0.01), of individuals obtained O50 nmol/l at 6 weeks and 3 months, respectively. trabecular number (K10.4%; P!0.05), trabecular thickness (K10%; P!0.05) All patients in the oral colecalciferol regimen with secondary hyperparathyroid- and increased trabecular separation (C13%; P!0.05) compared to WT mice in ism at baseline (45%, nZ23) normalized their PTH levels at 3 months, whereas response to iPTH treatment. The cortical indexes, bone area (K15%; P!0.01) only 49% (41%, nZ22) was corrected at 3 months, in the injection ergocalciferol and cortical thickness (K9.8%), were similarly lower in AMPKa1K/K mice regimen. compared to WT mice. Neither AMPKa1K/K nor WT mice bone length or body No case of hypercalcemia, vitamin D toxicity, hypercalciuria or nephrolithiasis weight were altered. Overall these results demonstrate that AMPKa1K/K mice were observed. are less affected by catabolic and anabolic changes in bone turnover induced by Conclusion OVX and PTH respectively, suggesting that AMPK activation plays a role in the The high dose-bolus oral colecalciferol treatment seems more potent than i.m. hormonal regulation of bone remodelling. injection ergocalciferol regimen at least in the treatment of low vitamin D due to nutritional or environmental factors. The bolus 300.000 IU and the monthly 40.000 IU of oral colecalciferol produced higher and sustained increase in serum 25(OH)vit D.

P24 Management of primary hyperparathyroidism Anna Irina Palalau & Diana Raskauskiene Walsall Manor Hospital, Walsall, West Midlands, UK.

Primary hyperparathyroidism (PHPT) is a common reason for referral to the P26 endocrinology team. We aimed to estimate the prevalence of associated vitamin D Audit of local management of hyperparathyroidism and evaluation of deficiency and osteoporosis, to evaluate the usefulness of imaging studies in vitamin D deficiency in PHPT identifying a parathyroid adenoma prior to surgery and to assess response to Tannaz Vakilgilani surgical treatment in the setting of a District General Hospital. Queen Elizabeth Hospital, Welwyn Garden City, UK. We searched our outpatient clinic letters and identified 64 patients diagnosed with PHPT between July 1996 and May 2009. Thirty-four (53.1%) patients were of white British ethnic origin and 3 (4.7%) were of Asian Pakistani origi. Mean age Introduction (GS.D.) was 61.0 (G13.7) with 50 patients under the age of 50. The mean (GS.D.) Primary hyperparathyroidism (PHPT) is a relatively frequent problem presenting highest recorded calcium was 2.95 (G0.19) mmol/l. Eleven patients had a with hypercalaemia detected on a routine blood test. All PHPT patients should calcium level above 3 at diagnosis and during follow-up the level rose above 3 in have a urine calcium concentration, DEXA scan and vitamin D level checked at 20 patients. Vitamin D levels were measured in 44 patients: 11 (25%) had levels the time of diagnosis. Vitamin D supplementation aims to achieve a vitamin D between 10 and 15 mg/l and 9 (20%) levels below 10 mg/l. Bone densitometry level over 50 nmol/l which may be associated with positive outcomes such as a scans were done in 22 patients: 7 (31.8%) had osteopaenia and 12 (54.5%) had lower serum parathormone (PTH), calcium and alkaline phosphatase concen- osteoporosis. The age range of patients with osteoporosis was 38–86 (mean 63). tration and decreased bone turnover. Twenty-three patients received surgical treatment (4 in our hospital, 17 in a Aim tertiary referral centre and 2 elsewhere). Following surgery 21 (91.3%) patients We conducted a retrospective observational study into the diagnosis and had normal calcium levels. In 5 patients in whom we could correlate the report of management of primary hyperparathyroidism and the evaluation and replacement a Tc sestamibi scan with surgical findings an adenoma was correctly identified in of vitamin D deficiency in this group to determine compliance with national 2 (40%) patients by the isotope scan. Neck ultrasound correctly identified an guidelines. adenoma in 3 (60%) of patients. Method In our cohort of patients with primary hyperparathyroidism there was a significant PHPT patients were identified from the pathology database as those with incidence of vitamin D deficiency and osteoporosis. Based on our data we think hypercalcemia and a normal or inappropriately high PTH with no concomitant screening for these conditions is advisable in patients being assessed for PHPT. renal impairment. 67 patients were identified. Further data was collected from patient records, biochemistry results and radiology reports.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Results vitamin D (25-OHD) due to improved performance and potential cost benefits. As LC–MS/MS is appropriate for the analysis of other clinically relevant hormones

Radiological tandem mass spectrometers are becoming commonplace in UK clinical Vitamin D level imaging (ultra- laboratories. However, like immunoassay, LC–MS/MS methods are not foolproof Urinary checked at diagnosis/ sound scan/ calcium vitamin D level checked Sestamibi scan) and inappropriate use of LC–MS/MS methods can have an adverse impact on creatinine at any time DEXA scan prior patient care. Triple quadrupole mass spectrometers allow the monitoring of at diagnosis to surgery Performed? nZ41 (71%) nZ4//54 (60%/ 82%) nZ50 (86%) nZ16 (100%) several fragment ions derived from a single molecular ion. This allows quantitation using one fragment (the quantifier) and analysis of other fragments Results 71% deficient Significant 66% hip 68% spine (33% improvement osteopenia osteopenia or (qualifiers) to confirm the identity of the molecular ion. Examples are provided as achieved in PTH and or osteoporosis repletion no serum osteoporosis (mean spine T to the use of qualifier ions to detect both endogenous and exogenous interferences of which (calcium) (mean hip T score K1.55) that would otherwise bias LC–MS/MS 25-OHD methods. During optimisation of 58% change with score K1.37) maintained vit D treatment an LC–MS/MS 25-OHD method, the use of qualifier ions detected an endemic vitamin D compared to interference which was significant in 1023 of the 3060 patient samples studied levels) no vit D treatment using a commonly used quantifier ion of m/z 211. We identified three cases that were classified as severely 25-OHD deficient (!12.5 nmol/l) using a 383–257 transition who would be classified as vitamin D replete (O50 nmol/l) using the Conclusion 383–211 transition. The interference was still present despite use of a variety of The diagnostic work-up for PHPT needs to be improved to achieve full sample preparation methods (liquid/liquid extraction, off-line and on-line solid compliance with national guidelines. This could be achieved with the use of phase extraction). Accurate mass MS studies show the interference to have a an out-patient proforma and requesting a panel of bloods (e.g. ‘PHPT Panel’) mono-isotopic m/z of 383.2964 compared to m/z 383.3308 for 25-OHD. Further rather than individual tests. Vitamin D supplementation is beneficial for the studies suggest that this is an exogenous compound, probably exuded from the treatment of PHPT. sample collection tubes. The isobaric C-3 epimer of 25-OHD [3-epi-25(OH)D3] has also been shown to be a potential interference in LC–MS/MS based serum 25-OHD assays. The use of appropriate qualifier ions to rule out the presence of 3-epi-25(OH)D3 is demonstrated.

Clinical biochemistry P27 A semi-automated method for measuring salivary cortisol and cortisone by tandem mass spectrometry with sample extraction Laura Owen, Rachel Jones & Brian Keevil P29 University Hospital of South Manchester, Manchester, UK. Turbulent flow liquid chromatography–tandem mass spectrometry for the analysis of bio-available testosterone in serum Michael Wright1, Lewis Couchman2 & David Halsall1 Introduction 1Department of Clinical Biochemistry, Addenbrooke’s Hospital, There has been much interest recently in measuring both salivary cortisol and Cambridge, UK; 2King’s College Hospital, London, UK. cortisone due to the presence of 11b-hydroxysteroid dehydrogenase type 2 enzyme in the salivary glands. This enzyme facilitates the conversion of cortisol to cortisone; hence the concentration of cortisone in saliva may also be of interest. Testosterone in serum may be unbound (free), or bound to either sex hormone Studies have shown recently that salivary cortisone and cortisol are good markers binding globulin (SHBG) or albumin. Consequently, ‘total’ serum testosterone of serum free cortisol status. analysis may be misleading in situations where binding protein concentrations are Methods abnormal. Current methods for estimating the biologically active (bio-available) Calibrator, quality control or sample (50 ml), 10 ml internal standard (D4 cortisol) serum testosterone concentration involve physical separation of testosterone and 150 ml water were added to wells of 96 deep-well plate. Online solid phase fractions and are not amenable to high-throughput analysis. The use of automated extraction (SPE) of 150 ml of this was performed using the Spark Holland immunoassays for total serum testosterone has also been questioned. Liquid Symbiosis in XLC mode (eXtraction Liquid Chromatography) with HySphere chromatography–tandem mass spectrometric (LC–MS/MS) methods for C18 HD 7 mm cartridges. Chromatography was performed using a Phenomenex measuring testosterone have gained favour due to their superior selectivity. The Onyx Monolithic C18 column (25!4.6 mm). separation of testosterone fractions by turbulent flow chromatography (TFC – Results TurboFlow technology, ThermoFisher Scientific) prior to MS/MS analysis.was Retention times using the chromatography conditions was 2.22 min for cortisol investigated. TFC is based on the direct injection of biological samples onto a and 1.98 min for cortisone with resolution of the two compounds. The limits column packed with relatively large particles at high flow-rates. In the resulting of detection were 0.75 nmol/l for cortisol and 0.5 nmol/l minutes for cortisone. turbulent flow, smaller analytes can enter the column interstices but larger No ion suppression was observed 10 patient samples tested using Sarstedt proteinaceous material is excluded. Serum from a male volunteer was analysed Salivettes for cortisol (blue top), however green top Salivettes were found to be (i) following protein precipitation with equal volumes of methanol (total unsuitable due to a large background signal. Extraction cartridges were reliable testosterone) and (ii) by direct injection onto the TFC column (retained fraction). for up to 15 uses. By comparison of peak areas, it was found that 25% of the total serum Discussion testosterone was retained after direct injection. This agrees well with an We have developed a novel assay for measuring salivary cortisol and cortisone ammonium sulfate precipitation method for bio-available testosterone (22%) used in saliva utilising semi-automated solid phase extraction. This allows a sample on the same sample. Based on the known binding affinities of SHBG and albumin clean-up step, which improves upon a previously published assay without adding for testosterone, it is likely that the more weakly bound albumin fraction was, to to the length of time required to prepare an assay. We have found that the blue some degree, dissociated during the TFC process. Testosterone and SHBG were top Salivettes for cortisol are the preferred device for collecting samples for added separately to serum pools and analysed as previously described. The peak this assay. area ratio was independent of total testosterone concentration, but decreased at higher SHBG concentrations. Whilst further validation is required to prove the utility of TFC, it has considerable potential for the analysis of bio-available steroid hormones in serum.

P28 25OH vitamin D analysis by liquid chromatography tandem mass spectrometry: interpret results with caution Michael Wright1, Kevin Taylor1, Deborah Mawson2, Phillip Grace2 P30 & David Halsall1 Recurrent phaeochromocytoma? 1Addenbrooke’s Hospital, Cambridge, UK; 2HFL Sport Science Ltd, Helen Partridge & Tristan Richardson Cambridgeshire, UK. Royal Bournemouth Hospital, Bournemouth, UK.

Liquid chromatography tandem mass spectrometry (LC–MS/MS) methods are A 74-year-old man was referred urgently for investigation of recurrent considered superior to immunoassay for the analysis of serum 25-hydroxy phaeochromocytoma.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

In 2006, he was referred to another hospital with nocturnal sweating and tremors. was also observed between and within this population. Clinicians should consider He was found to have a left sided phaeochromocytoma which was removed determination of vitamin D level in these women especially menopausal and laparoscopically with uneventful follow up. Unfortunately no initial results or advice proper supplementations. histology were available on referral to our department. Follow up in primary care had involved annual 24 h urinary catecholamines but no imaging. The patient had remained well with no recurrence of his symptoms and stable blood pressure. Routine annual collection in 2010 revealed a striking abnormality in biochemistry. On examination the patient was well and reported P32 no symptommatology with blood pressure 125/73 mmHg. Significance of insulin-C-peptide ratio in the diagnostic algorithm for endogenous hyperinsulinaemia Suma Sugunendran1, Deepa Narayanan1, Waqas Shafiq1, Mohamed Malik2 & Thozhukat Sathyapalan3 1 2 24 h urine collection 2008 2010 Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; Scunthorpe District General Hospital, Scunthorpe, UK; 3Hull York Medical School, Urinary adrenaline 53 nmol/d (normal 798 nmol/d Hull, UK. !100 nmol/d) Urinary noradrenaline 170 nmol/d (normal 315 nmol/d !500 nmol/d) Background Urinary dopamine 750 nmol/d (normal 89 128 nmol/d Insulin, derived from a single chain precursor pro-insulin, is cleaved by !3000 nmol/d) convertases to form insulin (t1/2 – 4 min) and C-peptide (t1/2 – 30 min). The Urinary volume 1655 ml 2099 ml ratio of insulin to C-peptide levels, which is usually less than one, is reversed in presence of exogenous insulin and insulin autoimmune syndrome. We present the significance of insulin-C-peptide ratio (ICR) in the diagnostic algorithm for the investigation of endogenous hyperinsulinaemia. He was urgently referred for management of his recurrent phaeochromocytoma. Methods Plasma metanephrines were reassuringly normal with normetadrenaline All requests for measurement of insulin and C-peptide levels were retrospectively 0.48 nmol/l and metadrenaline 0.16 nmol/l (!1.3 and !0.7 nmol/l respectively reviewed over a 4 years period from 2006 to 2009 from two hospitals. Information indicate low probability of phaeochromocytoma). regarding the indications for the requisitions, the clinical history and the final On direct questioning of the patient he had been diagnosed earlier in the year diagnosis was retrieved after review of the clinical notes. with Parkinson’s disease and started on co-Beneldopa with the dose gradually Results titrated up. Of 52 samples from 21 patients were analysed. 11/21 patients were being Drug interactions in the case of investigation of phaeochromocytoma with 24 h investigated for hypoglycaemia (Table 1) and 10 patients were investigated for urinary catecholamines are well documented. In this case the cause for a sudden determining the type of diabetes mellitus. and dramatic rise in the urinary catecholamines was revealed by detailed history taking and spared the gentleman unnecessary further investigation. Questioning of changes in medication and dosing should be routine in every clinical assessment. Table 1 Causes of hypoglycaemia. We will be following up this gentleman with annual plasma metanephrines. Diagnosis Number Insulinoma 1 Endogenous insulina 1 Exogenous insulin use 1 Insulin autoimmune syndrome (IAS) 1 P31 Miscellaneous causesb 2 Seasonal variation of vitamin D level among menopausal and Hypoglycaemia not achieved 5 postmenopausal saudi women a Waleed Tamimi, Raad Kanan, Myson Adham & Salih Aljasser Incomplete investigation- patient died due to gastric adenocarcinoma. b College of Applied Medical Sciences and College of Medicine, King Saud Ca oesophagusC poor nutrition, renal failure C diabetes. Bin Abdulaziz for Health Science, King Abdulaziz Medical City, Riyadh, Saudi Arabia. ICR was !1 (Mean-0.05) in all cases except in two cases (exogenous insulin administration and insulin autoimmune syndrome (IAS)). In the former, insulin Objective ! Vitamin D deficiency is common among women despite abundant sunshine in was elevated (445 pmol/l) with undetectable C-peptide levels ( 94 pmol/l). In the patient with IAS, insulin levels was disproportionately high (17 750 pmol/l) along Saudi Arabia. No local study has evaluated the seasonal vitamin D level among O hospitalized menopausal and postmenopausal Saudi women. The aim of this with corresponding high levels of C-peptide levels (8520 pmol/l) i.e. ICR 1. study was to estimate the prevalence of vitamin D deficiency among menopausal Conclusion When exogenous insulin administration is excluded, the reversal of ICR and postmenopausal in Saudi Arabia during summer and winter. ! Methods (normally 1) can be considered as a surrogate marker for causes associated Data were retrospectively collected for 1556 female patients (O19 years) during with elevated insulin antibody levels. This may negate the necessity of measuring their hospital visits between January 2009 and December 2009 in Riyadh, Saudi insulin antibody levels in all cases of endogenous hyperinsulinaemia. Arabia. The patients were divided into two groups 659 (42%) and 897 (58%) patients during summer and winter respectively. The summer group was subdivided into menopausal 425 (27%) (19–49 years) and postmenopausal 234 (15%) (R50 years); and in winter, 543 (35%) and 354 (23%) respectively. Serum levels of 25-hydoxy vitamin D (25OH VIT D) were measured by HPLC method. Results The prevalence of hypovitaminosis (!37 nmol/l) in menopausal and post- menopausal women was 18 and 7.6% during summer; 26 and 14% during winter P33 respectively. There was a significant difference between the mean of vitamin D Cross reactivity of Spironolactone with androstenedione immunoassay level of menopausal (33.3G33) and postmenopausal (44.4G35) women ! G G Venkata Katreddy, Ashraf Bdiri & Khaled Ashawesh during summer (P 0.0001) and (28.5 27) and (36.3 28) during winter Russells Hall Hospital, Dudley, Westmidlands, UK. (P!0.0001) respectively. The between and within seasonal vitamin D variations were observed among menopausal and postmenopausal women (P!0.05). The between seasonal variations represented a 14% increase in vitamin D level Introduction for menopausal and 18.5% for postmenopausal women and that for within Hirsutism, the presence of terminal (coarse) hairs that appear in a male-like seasonal variation were 25 and 21% increase respectively. pattern, affects 5–10% of women and may cause concern for an underlying Conclusion endocrine disorder or malignancy. Spironolactone compete for the androgen A higher prevalence of vitamin D deficiency among the hospitalized menopausal receptor in the hair follicle, therefore, it is frequently used in treatment of and postmenopausal Saudi women was observed in winter. Seasonal variation hirsutism. We report a case, in which treatment of hirsutism with Spironolactone

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK interfered with androstenedione immunoassay and raised unnecessary concern Hypothesis about androgen secreting tumour. A protocol involving one assessment of plasma cortisol levels post Synacthen Case administration is as effective at confirming hypoadrenalism as the standard two A 24-year-old lady was referred to our endocrine clinic with history of excessive sample protocol. hair growth since age of 16, with significant psychological impact. She had no We studied 101 patients who had undergone a SST at Hammersmith Hospital significant past medical history, apart from coil insertion for contraception. Her between January 2009 and Nov 2010. We accepted a post Synacthen cortisol level initial investigations revealed normal testosterone, FSH, LH, prolactin, thyroid of R550 nmol/l (R440 nmol/L on new Abbott immunoassay as cortisol levels on function. US pelvis revealed polycystic ovaries. Diagnosis of polycystic ovary this assay are reported to be 20% lower) as evidence of an intact HPA axis. syndrome was made and was subsequently treated with Spironolactone 50 mg Overall 88% showed an adequate response (ie passed) on SST. Of this group BD, which further increased to 100 mg BD in 6 weeks time, and referred for 100% passed the SST based on the 60 min cortisol value alone. 95% passed if the funding for laser treatment. A repeat hormonal profile, 3 months later, showed 30 min cortisol value alone was assessed, giving a false negative (i.e. failed test) elevated androstenedione at 59.5 nmol/l (1–11.5 nmol/l), with normal DHEAS, rate of 5%. Reduction of the upper range of normal for the 30 min time point to testosterone, LH, FSH, estradiol and SHBG. On repeat testing in a month, R444 nmol/l (R355 nmol/l on Abbott immunoassay) provided a sensitivity of androstenedione was high at 80.5 nmol/l, while other androgens remained within 100% with respect to the full protocol results, and did not provide any false normal range. Because of a very high androstenedione level, MRI adrenals and negatives or false positives. ovaries were arranged to rule out androgen producing tumour; this was We conclude that a modified SST protocol could be based on either a sole 60 min unremarkable except for polycystic ovaries. At this stage, Spironolactone post Synacthen cortisol level assessment, or a sole 30 min post Synacthen interference in the immunoassay of androstenedione was suspected and cortisol assessment with an adjusted lower cut off at this time point. A Spironolactone was subsequently stopped. Few months later, on a repeat testing, retrospective audit of 100 further SSTs is planned to check the performance of androstenedione level returned to normal. both these strategies. Discussion Cross reactivity of Spironolactone or its metabolites with the immunoassay of androstenedione has previously been reported. It is important, therefore, for the clinicians treating patients with Spironolactone for Hirsutism to be aware of this and communicate with biochemist to prevent any unwarranted investigations and P36 distress for patients. Comparison of serum cortisol measurement by immunoassay and liquid chromatography–tandem mass spectrometry in patients receiving the 11b-hydroxylase inhibitor metyrapone Phillip Monaghan1, Laura Owen2, Peter Trainer1, Georg Brabant1, Brian Keevil2 & Denise Darby1 P34 1The Christie NHS Foundation Trust, Manchester, UK; 2University Hospital An unusual case of leg weakness in a patient with diabetes and of South Manchester, Manchester, UK. Addison’s disease (Is there a common link?) Julia Platts, Maitrayee Choudhury, Alexis Manning & Nicholas Withenshaw The accurate measurement of cortisol by immunoassay is compromised by the University Hospital Llandough, Cardiff, UK. potential for cross-reactivity of reagent antibodies with structurally-related steroid compounds present in patient serum. This susceptibility is potentiated when normal steroid metabolism is altered pharmacologically by anti- Both diabetes and Addisons’ are conditions which can be associated with muscle steroidogenic drugs. This class of drug is utilised in the management of weakness and altered potassium levels. This is a case of recurrent muscle Cushing’s syndrome to moderate cortisol production. To investigate the effect of paralysis in a patient with both conditions with the underlying abnormality being the 11b-hydroxylase inhibitor metyrapone on serum cortisol assay, a comparison the neurological condition of hypokalaemic periodic paralysis. of measurement by immunoassay versus liquid chromatography–tandem mass A 23-year-old Caucasian gentleman was admitted to medical admissions with spectrometry (LC–MS/MS) as gold standard was conducted. sudden onset weakness of his lower legs. On examination he had reduced power Cortisol was measured in serum from three patient groups; i) patients receiving of his hips and knees, with intact sensation. The main finding from his blood tests metyrapone therapy (nZ112), ii) control group of patients diagnosed with was a serum potassium level of 3.2 mmol/l. He had a past medical history of Cushing’s syndrome currently receiving no treatment (nZ32) and iii) control poorly controlled type 1 diabetes and Addisons’ disease. His weakness improved group of normal patients with no known adrenal pathology and not receiving following a short course of oral potassium replacement. He was discharged home medication known to interfere in the immunoassay of cortisol (nZ79). but readmitted 2 days later with similar symptoms and potassium of 2.9 with. Bland-Altman plots showed good agreement between methods for the normal Autoimmune markers, thyroid function tests and plasma renin levels were control group (biasZC2.5% (4.4 nmol/l)) and Cushing’s control group normal. He underwent an EMG study, which revealed abnormalities showing (biasZC1.3% (3.5 nmol/l)). This was in contrast to the metyrapone therapy reduced myotonic discharges, which supported a diagnosis of hypokalaemic group (biasZK23% (K59 nmol/l)). Passing-Bablok linear regression revealed periodic paralysis. bias observations were constant in nature with minimal contribution from This is an autosomal dominant condition characterised by intermittent episodes of proportional error. Pearson correlation coefficients for the three patients groups flaccid paralysis with associated hypokalaemia, which are reversible. The genetic were rZ0.39*, 0.17 and 0.36* for the normal control, Cushing’s control and defect leads to an alteration in voltage gated sodium and calcium channels in the metyrapone therapy groups, respectively (*indicates Pearson correlation skeletal muscle. Rare associations have been made with diabetes and coefficient significant at P!0.05). LC–MS/MS results were positively correlated hypokalaemic periodic paralysis, which has been triggered by insulin with the difference. Further interrogation of metyrapone group data showed the administration. Hypokalaemia may also be precipitated by excessive corticoster- degree of difference between LC–MS/MS versus immunoassay positively oid or excessive mineralocorticoid replacement. This case raises some interesting correlated with dose. This trend was also noted for serum 11-deoxycortisol and challenging questions regarding the complex management of the condition in concentration with dose. view of the electrolyte abnormalities in the background of his medical conditions In conclusion, these data show that the liability of immunoassay measurement of and whether there may a genetic link underlying all three diseases. serum cortisol to interference in patients receiving metyrapone may lead to erroneous clinical decisions concerning dose titration.

P35 The short Synacthen test (SST): should we be testing at both 30 and P37 60 min? Polycythaemia in men treated with transdermal and intramuscular Richard Carroll, Jalini Joharatnam & Jeannie Todd testosterone Imperial College Healthcare NHS Trust, London, UK. Tomas Agustsson, Barbara McGowan, Jake Powrie, Stephen Thomas & Paul Carroll Department of Diabetes and Endocrinology, Guy’s and St Thomas’ The short Synacthen test (SST) is used to evaluate adrenal glucocorticoid Foundation NHS Trust, London, UK. secretion in response to synthetic ACTH (also known as tetracosactide or Synacthen). Traditionally, after a baseline cortisol and ACTH, two plasma cortisol samples have been taken after i.v. or i.m. administration of Synacthen Background 250 mg, one at 30 min and one at 60 min. However practice varies and some Testosterone replacement therapy has been shown to produce a wide range of physicians only take one cortisol measurement at 30 min. benefits for men with hypogonadism with studies showing improvement in libido,

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK bone density, muscle mass, body composition, mood, cognition, and erythopoi- P39 esis. The risks associated with testosterone replacement therapy are less well Severe hyponatraemia in pregnancy associated with pre-eclampsia characterised and there is a lack of larger randomised trials. One recognised risk is Ammar Tarik & Emma Ward polycythaemia. The aim of this study is to assess the frequency of polycythaemia Department of Diabetes and Endocrinology, St James University Hospital, in men treated with testosterone and to compare it’s frequency with different Leeds, Leeds, West Yorkshire, UK. treatment modalities. Methods This is a retrospective observational study. We analysed biochemical and A 29-year-old woman was admitted at 33 weeks gestation with pre-eclampsia haematological parameters of all men on testosterone therapy who attended our (BP 145/107 mmHg, 3C proteinuria and significant oedema). On admission endocrinology unit from the 1st of January 2009 until the 30th of June 2010. Of a her Na was 133 mmol/l and urinary Na 49 mmol/day (ref range 130–260). total of 173 men, 86 (50%) were treated with testosterone undecnoate (Nebido), Twenty-four hours urine protein was 4.43 g/day. Foetal assessment revealed intra 57 (33%) with transdermal testosterone gel, and 30 with intramuscular uterine growth retardation. She was started on labetolol and the dose titrated testosterone in the form of Sustanon. Data were collected on haemoglobin upwards to control her blood pressure. concentrations and packed cell volumes. Polycythaemia was defined as Her serum sodium level gradually fell reaching 120 mmol/l on the seventh day of haemoglobin concentration O17 g/dl or packed cell volume O0.505. admission. At this stage the Obstetricians instituted fluid restriction of 1 l/day. Results Her sodium continued to fall and reached a nadir of 112 mmol/l on the ninth day. Out of the 173 men 25 (14.5%) developed polycythaemia on at least one blood At this point, her urine sodium was 3 mmol/l, urine osmolality 318 mOsm/kg. She sample during the above period. 12 of the 86 men treated with Nebido (14%), 8 still showed signs of fluid overload with marked oedema. The Endocrine team out of the 57 men treated with transdermal gel (14%), and 5 of the 30 men treated were then involved. Her adrenal and thyroid function was normal. with Sustanon (17%) developed polycythaemia. There was therefore no The decision was made to deliver the baby by emergency caesarean section in significant difference between the different treatment groups. view of the rapidly falling sodium levels based on the theory that the Conclusion hyponatraemia would resolve as the stimulus for pre-eclampsia was removed. In our experience polycthaemia is a common risk with any testosterone After delivery the patient developed a diuresis, her sodium level gradually replacement therapy. Although previous studies have indicated that this is less improved and had returned to near normal 3 days post delivery. Her baby was also likely with transdermal preparations we found the risk to be equally high in all initially hyponatraemic with a serum sodium of 114 mmol/l – this was actively treatment groups. This demonstrates the importance of careful monitoring of corrected by the paediatricians. haematological variables during any testosterone treatment so that appropriate We believe that the likely explanation for our patient’s hyponatremia was measures can be taken if erythrocytosis occurs. dilutional; we postulate that our patient may have experienced a reduction in her diluting capacity along with a reduced rate of free water clearance as a consequence of her pre-eclampsia. Severe hyponatraemia in pregnancy is rare with only a few cases reported. However, in view of the great risks posed to both mother and baby we recommend regular monitoring of serum sodium levels in all patients with pre-eclampsia.

P38 Hypocalcaemia presenting via an acute medical admissions unit is only rarely adequately investigated Rebecca Griffiths2, Stewart Pattman2 & Richard Quinton1 1Endocrine Research Group, Institute of Human Genetics, Newcastle upon Tyne, UK; 2Newcastle upon Tyne NHS Hospitals Trust, Newcastle upon Tyne, UK. P40 Audit of Causes and Consequences of Hyponatraemia in an Inpatient Aim Cohort at a Tertiary Health Centre: Abstract To determine whether cases of hypocalcaemia presenting via an emergency Christopher Hadjittofi, Ryan Haines & Dilan Pathmajothy medical admissions unit (EAU) are appropriately investigated. University College London, London, UK. Background Hypocalcaemia is a potentially life threatening abnormality, with a prevalence of 18% among hospital inpatients.1,2 Risk factors include vitamin D deficiency, Introduction renal disease, hypoparathyroidism (typically post-neck surgery) and hypomagne- Hyponatraemia is the commonest inpatient electrolyte disturbance, and its saemia. A reasonable investigational dataset comprises UCEs and serum levels severity has been shown to correlate with in-patient mortality, length of stay, and of 25OHVitD, PTH, Mg, phosphate (P) and alkaline phosphatase (ALP). use of hospital resources. Unfortunately, hyponatraemia goes frequently Methods unrecognised. The purpose of this audit was to see how a tertiary health centre The biochemistry database was interrogated for the year beginning 1st December manages hyponatraemia and how patient journey is affected. 2008 to identify EAU patients with aCa !2.12 mmol/l. A secondary search was Goals undertaken to identify any appropriate investigations. To identify hyponatraemic patients in a tertiary centre in a 2-week timeframe and Results through case note and electronic record scrutiny, record the aetiology and Of the 6384 individual patients with aCa checked on EAU, 184 were compare management to current best practice. hypocalcaemic: Methods † 4% had all appropriate investigations done within 1 week. Two hundred and eighty-six hyponatraemic patients were identified within a † 25OHVitD and PTH levels were measured in 8.1% within a week of admission 2-week window from a biochemistry database. The cohort was divided into two (21.7% across all time periods). groups. The audit focussed on group 1, which comprised patients with serum † Results were better for renal function (100%), ALP (100%), Mg (98.3%) and sodium below 131 mmol/l (nZ58). Group 2 included the remaining patients P (62%) (nZ228). † Abnormal investigations: 25OHVitD!30 nmol/l)Z50%; PTHO60 ng/lZ Results 66%; Mg!0.7 mmol/lZ28%; ALPO120 U/lZ35%; high/low P Z60%; Twenty percentage of the cohort had moderate/severe hyponatraemia renal impairmentZ59%. (!131 mmol/l). Only 17% of group one patients were assigned an aetiology, † Severe hypocalcaemia (aCa!2.01 mmol/lZbottom quartile of abnormals), the commonest being SIADH (7%). Urinary sodium, plasma osmolality, and was better investigated (25OHVitD and PTH measured in 40 and 58%, urinary osmolality were measured in 8, 7, and 4 patients respectively. Group 1 respectively). patients remained in hospital for 29 days on average, with 37% being discharged Conclusions hyponatraemic and 34% readmitted within 5 months. Hypocalcaemia is less prevalent among patients presenting via EAU than in Conclusions hospital inpatients, so the resource implications of investigating it properly are not In a tertiary centre, only a minority of patients with hyponatraemia were huge. Yet this is not happening reliably, despite the high percentage of abnormal appropriately investigated and where SIADH was diagnosed, there was poor results when tests are done. Owing to delayed/incomplete investigation, enforcement of fluid restriction, the only treatment option recorded. This audit has therapeutic interventions will necessarily be delayed/omitted and hospital identified hyponatraemia as a poorly managed clinical entity, which is associated admissions likely to be correspondingly prolonged. Guidelines are in with increased hospital stay. Increased awareness amongst clinical staff development to improve understanding of this issue. accompanied by practical guidelines highlighting investigation and treatment are needed to enable correct management of this condition, especially at a time

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK where newer treatment options are becoming available and greater importance is guidelines on endocrine transition care is of major importance for the continuing attached to length of hospital stay. wellbeing of the patients and their willingness to take responsibility of their own health and to comply with health support and treatment.

P41 P43 Tanned and pregnant-primary adrenal insufficiency during pregnancy Tolvaptan in a patient with hyponatraemia and a normal chest X-ray Naik Haya & Ramzi Ajjan Hema Venkataraman & Zayd Merza Leeds Teaching Hospitals, Leeds, UK. Barnsley Hospital NHS Foundation Trust, Barnsley, UK.

Primary adrenal failure is a rare condition with an incidence during pregnancy of A 61-year-old man was referred to the Endocrinology clinic with a 5-month around 1 case in 12 000 gestations. history of hyponatraemia. It was first detected as part of a routine test, which A 31 years old primi gravida presented 10 days after giving birth to a healthy child revealed a serum sodium of 124 mmol/l. His serum osmolality was at full term with postural dizziness and severe fatigue. There was no history of 253 mOsmol/kg, urine sodium was 32 mmol/l and urine osmolality excessive blood loss during delivery and her past medical history was 317 mOsmol/kg. His results suggested SIADH. He already had a chest X-ray unremarkable, but low blood pressure (BP) was reported throughout pregnancy. and brain MRI scan done which were reported as normal. His thyroid function test She mentioned increased body pigmentation over the past year and had a severely and short synacthen test were normal. He had been commenced on fluid pigmented scar on her leg with normal buccal mucosa. BP was 80/50 mmHg with restriction and demeclocycline, however his sodium remained low with a mean of a significant postural drop. 122G3.4 mmol/l and when seen in clinic it was 118 mmol/l. Accordingly a CT She had low sodium (127 mmol/l) and raised potassium (5.7 mmol/l), associated scan of his chest was arranged. The patient was admitted to hospital and with dehydration (urea 11.6 mmol/l) and marginally low bicarbonate commenced on Tolvaptan (a selective vasopressin V2- receptor antagonist). After (21 mmol/l). A synacthen test failed to show a cortisol response (0 and 30 min only two doses of 15 mg/day his sodium came up to 132 mmol/l within 48 h and cortisol !50 nmol/l) and adrenal antibodies were positive with elevated ACTH at the Tolvaptan was stopped. Over the next 6 days his sodium remained stable 1075 ng/l consistent with primary adrenal failure. Her endocrine investigations between 128 and 133 mmol/l and he was discharged on fluid restriction. His CT showed low IGF1, normal prolactin (548 IU/l) with undetectable oestradiol, FSH scan revealed a 2.2 cm lesion in his left lung and a biopsy confirmed small cell and LH. FT was 9.4 pmol/l and TSH 1.0 mIU/l. Given her normal prolactin with 4 carcinoma. Nine days after discharge a repeat test showed his sodium was down low IGF1 and FT , the possibility of associated hypophysitis was considered, 4 again to 116 mmol/l. although abnormal TFTs may have been indicating sick euthyroid syndrome. This case illustrates the importance of excluding an underlying malignancy in a She was immediately treated with hydrocortisone and fludrocortisone was added patient with significant hyponatraemia even if the chest X-ray is reported as 2 weeks later resulting in complete resolution of her symptoms. Endocrine testing normal. It also demonstrates the efficacy of Tolvaptan in rectifying hypona- 2 weeks after initial presentation showed FSH 3.4 IU/l, LH 2.7 IU/l, oestradiol traemia in SIADH. 146 pmol/l, FT4 15 pmol/l, TSH 1.2 mIU/l IGF1 30.2 nmol/l with normal U&Es. In summary, we present a case of primary adrenal failure with classical symptoms during pregnancy but with the diagnosis made in the postpartum period. The patient had undergone a largely uneventful pregnancy and delivered a healthy child at full term. Her low IGF1 and deranged TFTs at presentation normalised following hydrocortisone replacement therapy.

P44 A case of thyrotropinoma co-secreting FSH and LH U Y Raja, M A Karamat, Sadaf Ul Nasah, Lisa Shephard & Asad Rahim Birmingham Heartlands Hospital, Birmingham, West Midlands, UK. P42 A review of the Endocrine Transition Service over the last 10 years Nilanjana Ray1, Tania Davison1, Fiona Ryan1, John Wass2 Introduction & Niki Karavitaki2 Thyrotropinomas are rare pituitary tumour accounting for 0.5–1.0% of all 1Department of Paediatric Endocrinology, John Radcliffe Hospital, Oxford, pituitary tumours. There are only seven reported cases of mixed TSH/LH/FSH UK; 2Department of Endocrinology, Churchill Hospital, Oxford, UK. producing adenoma. We report a patient with secondary hyperthyroidism due to TSH producing adenoma co-secreting FSH and LH. Case report Poor transitional care leads to increased loss to follow up, non-adherence to A 75-year-old Caucasian male was seen with 2-year history of tiredness, anxiety treatment, high morbidity and mortality. The paediatric and adult endocrinology and palpitations along with 7-month history of weight loss. He also complained of teams in our Trust have been running a joint transition service since 10/2000. A impotence for 2 years along with lack of sex drive. His thyroid function tests review of this service was undertaken, in order to examine its effectiveness and to showed fT4 level of 55.1 pmol/l along with TSH level of 8.3 mU/l and anti TPO aid its improvement. antibodies of 7 IU/ml. His other anterior pituitary tests were: FSH 3.7 IU/l, LH The details of all 81 patients, who had been through transitional care between 3.0 IU/l, IGF1 !3.2 nmol/l and prolactin level of 389 mU/l. His alpha Sub Unit 10/00-09/09 were acquired. Their records were reviewed for relevant information. came back high at 1.95 IU/l and pituitary MRI showed a 1.8 by 2.5 cm lesion in A questionnaire and covering letter were sent to survey patient satisfaction and the pituitary gland compressing the right optic nerve and invading the right their views on their transition process. cavernous sinus. He was started on octeotride LAR 60 mg along with carbimazole The mean age of transition was 18.6 years. Currently, 34 out of 77 (44%) patients 30 mg once daily and following discussion in pituitary MDT meeting was referred have replied to the questionnaire (4 had died). 79% felt that the timing of for trans-sphenoidal pituitary surgery. Following pituitary surgery his TFT came transition was appropriate, 100% that it was helpful to meet the adult back as fT4 of 26.2 pmol/l with TSH of 3.3 mU/l. Biopsy of the lesion confirmed endocrinologist prior to transfer and 12% that they would prefer two transition mixed TSH/LH/FSH producing adenoma. clinic appointments. 76% reported that they were given enough information about Discussion their condition and the transition process and 53% that they felt confident to be Thyrotropinomas are rare with a prevalence of about one case/million. Most cases seen without their parents present in 1st or 2nd appointment in the adult clinic. are found in the fifth-sixth decade of life. Around 30% of TSH producing The mortality rate was 5%, 4% of the patients had been admitted acutely within adenoma also co-secrete other pituitary hormones most commonly GH and 2 years of transition and 11% had issues with adherance to treatment. The DNA prolactin. Majority of thyrotropinomas are macroadenomas (90%) and clinical rate at the second adult follow-up appointment was 16% (for general adult features of hyperthyroidism are usually present. Definite treatment consists of endocrine clinics 6–10%). pituitary surgery though octeotride therapy lead to normalization of thyroid Overall, the patient satisfaction with the service is high. Providing written hormones in about 70% of cases with partial shrinkage of tumour in 40% of information about the transition process and the conditions affecting the patients thyrotropinomas. and addressing compliance issues will further improve it. Generation of national

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P45 P47 Audit on the management of adrenal incidentaloma Severe hirsutism of rapid onset in an 81-year-old female Sumudu Bujawansa & David Bowen-Jones Rajesh Rajendran & Tristan Richardson Wirral University Teaching Hospital NHS Foundation Trust, Wirral, UK. Royal Bournemouth Hospital, Bournemouth, UK.

Introduction An 81-year-old lady was referred with a 2-month history of frontal balding and Adrenal incidentaloma is defined as a clinically inapparent adrenal mass that is hirsutism over the face and chest that required daily shaving. Her symptoms were incidentally detected after imaging studies conducted for reasons other than the progressing weekly. She did not have any history of hot flushes, voice changes or evaluation of the adrenal glands. Existing guidance suggests that excess weight loss. Clinical examination revealed marked hirsutism over the face, neck, catecholamine and cortisol secretion should be ruled out all cases and excess upper back, thorax and abdomen with a fullness in the right iliac fossa. She had a aldosterone secretion should be ruled out hypertensive patients. Certain features past medical history of hypertension and hypercholesterolemia. on CT scanning such as a Hounsfield value of over 10 are useful in differentiating Investigations showed a testosterone of 21.8 nmol/l (0.1–1.5 nmol/l), androste- between incidentaloma and other lesions. In addition repeat evaluation after a nedione 7.1 nmol/l (0–3.5 nmol/l), dehydroepiandrosterone 1.9 mmol/l period of time is suggested. (0–4.6 mmol/l), free androgen index 43.8, estradiol 148 pmol/l (0–200 pmol/l) We audited how adrenal incidentaloma are investigated in a large district general and haemoglobin 160 g/l. Urgent CT scan of abdomen and pelvis confirmed a hospital in the North West of England. right ovarian cystic mass measuring 51!35!31 mm. Method She was referred to the gynaecologists who performed a total abdominal We reviewed abdominal CT scan reports from 2694 patients who had their scans hysterectomy with bilateral salpingo-oophorectomy. Histology revealed a 10 mm between August 2007 and February 2010. Patients with adrenal incidentaloma steroid cell tumour in the right ovary with a benign serous cyst. There was no were identified and their clinical records were reviewed. evidence of metastases. Results Repeat testosterone level and haemoglobin one month post-surgery was Adrenal incidentaloma were reported in 93 patients giving rise to an approximate 1.1 nmol/l and 130 g/l respectively. She had made an uncomplicated post- prevalence of 3.45%. Thirty-four of the scans were requested by physicians. operative recovery and had noticed a reduction in the ‘greasiness’ of her hair. Forty-five percent of the lesions were left sided and 26% had bilateral lesions. The Steroid cell tumours of the ovary are rare tumours accounting for !0.1% of all size of the lesion was reported in 68 scans with the largest being 6 cm. The ovarian tumours. They are associated with androgenic changes with frequency average size was 1.68 cm. The Hounsfield value was reported in 13 scans and it ranging from 12 to 50%, which are slowly progressive. Our case presented was more than 10 in 6 scans. with rapid onset of severe hirsutism over a 2-month period that was successfully Only five patients had excess catecholamine secretion ruled out and only three treated with surgery, which remains the mainstay of management of had excess cortisol secretion ruled out. Only two patients had excess aldoseterone such tumours. secretion ruled out. Only twelve patients had repeat imaging done and only three had their biochemistry repeated. Discussion Adrenal incidentaloma are inadequately managed by non specialists. The quality of radiology reports with regard to Adrenal incidentaloma is inadequate. This deficiency may be improved by increasing the awareness of the importance of investigating these lesions amongst non-endocrinologists.

P48 Hypercortisolaemia in congenital adrenal hyperplasia: a diagnostic dilemma Rajesh Rajendran1, John Morton2, Joe Begley2, Abubakr Fadl1 & P46 Tristan Richardson1 A case of Di George’s syndrome presenting in late adulthood 1Royal Bournemouth Hospital, Bournemouth, UK; 2Poole General Hospital, Sarah Brewster1, Rajesh Rajendran1, David Coppini2 & Tristan Richardson1 Poole, UK. 1Royal Bournemouth Hospital, Bournemouth, UK; 2Poole General Hospital, Poole, UK. Case report A 67-year-old female with untreated congenital adrenal hyperplasia Introduction (21-hydoxylase deficiency) was diagnosed with bilateral vulval carcinomata. Di George’s syndrome is a rare congenital disease that is usually diagnosed in She was referred to another unit with serum sodium of 121 mmol/l, potassium childhood due to its presentation with velo-cardio-facial abnormalities. 4.6 mmol/l and 17-hydroxyprogesterone of 714 nmol/l (0–14 nmol/l). A short Case report synacthen test performed in the evening demonstrated a baseline cortisol of A 42-year-old man was incidentally found to be hypocalcaemic (corrected 558 nmol/l, rising to 643 nmol/l at 80 min. The baseline cortisol was deemed calcium 1.71 mmol/l) during a ‘well-man check’. A subsequent parathyroid adequate but in view of the stunted rise following synacthen, steroid cover for hormone (PTH) was inappropriately low at 0.8 pmol/l (reference range 0.5– surgical procedures was advised. 4.4 pmol/l). Despite surgical resection, radiotherapy and chemotherapy, the vulval carcino- He was referred to our calcium clinic after having been started on 1-alfacalcidol in mata recurred. She was then admitted to our hospital unwell with BP the general endocrinology clinic (at another unit). Past medical history included 79/50 mmHg. Blood tests showed sodium 119 mmol/l, potassium 5.8 mmol/l mild congenital palatal abnormalities, and a single kidney on a recent ultrasound and 9am cortisol of 1357 nmol/l. Further 9am investigations showed a repeat scan. He had had no previous neck surgery. cortisol of 1350 nmol/l, testosterone 13.6 nmol/l (0.1–1.5 nmol/l), FSH 2.9 IU/l, Renal function, magnesium and phosphate levels were normal. Examination LH!0.2 IU/l, 17-hydroxyprogesterone 470 nmol/l (0–14 nmol/l), ACTH revealed an oval shaped face and tapering fingers. Chvostek and Trousseau’s 371 ng/l (0–40 ng/l), and dehydroepiandrosterone 2.1 mmol/l (0–4.6 mmol/l). signs were negative. DEXA scan diagnosed osteoporosis at the spine (T-score 24 h urine collections for free cortisol were raised at 378 nmol/day and K2.7) and osteopaenia at the hip (T-score K1.8). 483 nmol/day (0–260 nmol/day). Di George’s syndrome was suspected and subsequently confirmed on Clinically there was evidence of hypoadrenalism but there was biochemical chromosomal analysis that showed the characteristic heterozygous deletion of evidence of hypercortisolaemia. MRI pituitary to rule out Nelson’s syndrome was 22q11. Genetic counselling has been offered. normal. The possibility of cortisol assay interference was considered accounting Discussion for the elevated serum and urine cortisol. Her 24-h urine sample was then Di George’s syndrome is usually diagnosed in childhood, but our case was analysed at two national reference laboratories who confirmed steroid precursor identified in late adulthood following the incidental finding of hypocalcaemia. A assay interference accounting for the markedly elevated ‘cortisol’ measurements. thorough review of the patient history is important in order to pick up rarer She unfortunately succumbed to her carcinoma (on steroid replacement therapy). presentations of hypocalcaemia. It is important to identify Di George’s syndrome Discussion early, because children can develop immune paresis, and special precautions are This case demonstrates how tests can be misleading. The clinical picture indicated required for blood transfusion and immunisation with live vaccines. Genetic a hyopadrenal state (hyponatraemia/hyperkalaemia/hypotension) but the counselling should be offered, as there is a one in two chance of passing the measured cortisol was falsely reassuring. This serves us to remember that a deletion on to their offspring. good clinical assessment is crucial.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P49 Summary and conclusion Hyponatraemia: the view from primary care Pus and tissue cultures were predominantly poly-microbial. Most common Anh Tran1,2, Steve Hyer1, Padmini Manghat3, Marta Lapsley3 bacterial specimen was E. coli. Proper culture and antibiotic susceptibility helps & Andrew Rodin1 in formulating empirical treatment protocol. 1Endocrine Department, St Helier Hospital, Carshalton, Surrey, UK; 2Shadbolt Park House Surgery, Worcester Park, Surrey, UK; 3Chemical Pathology Department, Epsom General Hospital, Epsom, Surrey, UK.

Introduction Hyponatraemia is not uncommon in primary care and its management can be P51 complex. It is vital that initial assessment is carried out properly as A calcium sensing receptor mutation associated with hypercalcaemia mismanagement can have serious consequences. and recurrent pancreatitis Aim Lesley Hall1, Dairena Gaffney2, Joanne Ramsay2, Andrew Gallagher1 To investigate general practitioners’ views and perceptions on the management of & John Hinnie1 hyponatraemia encountered in primary care. 1Diabetes Centre, New Victoria Hospital, Glasgow, UK; 2Department of Method Biochemistry, Glasgow Royal Infiirmary, Glasgow, UK. Local general practitioners were surveyed with a questionnaire via email and at local postgraduate meetings. Questions were themed around the following areas i) the management of hyponatraemia ii), confidence in managing hyponatraemia, A 29-year-old man of South Asian descent presented with pancreatitis. Adjusted m iii) experience managing hyponatraemia including long-term complications and calcium was 3.10 mmol/l and PTH 9.8 mol/l. Of note was that his parents were iv) training needs. first cousins, and a cousin had undergone parathyroidectomy for hypercalcaemia. Results Pituitary, adrenal and thyroid function, calcitonin, prolactin, phosphate, A total of 65 general practitioners returned completed questionnaires. magnesium, alkaline phosphatase and urinary catecholamines were all normal. The median (range) suggested serum sodium concentration (mmol/l) for 25-Hydroxyvitamin D was 20 nmol/l (15–100) The patient was therefore arranging further investigations was 130 (118–135), for routine referral to commenced on ergocalciferol, 0.25 mg daily. Urinary calcium excretion was low at 0.5 mmol/24 h (2.50–7.50). Parathyroid imaging was normal. secondary care was 125 (105–130), and urgent referral 120 (100–128). O When asked about the importance of a serum sodium of 125–130, 63% of Calcium sensing receptor (CASR) sequencing showed a C T mutation 10 bps respondents replied ‘moderately’ important, 25% very important and 12% little before the CASR start codon. This created an ATG sequence which could be a importance. When asked what further tests would be considered at this level of premature out-of-frame start codon. The patient was homozygous for this hyponatraemia, the majority (65%) would repeat serum electrolytes. Only 9% mutation while both parents and all 5 siblings were heterozygous and had normal mentioned urinary sodium and paired plasma/urine osmolarity. serum calcium concentrations. The patient went on to have several further The commonest cause of hyponatraemia that respondents had encountered was episodes of pancreatitis associated with hypercalcaemia, following which he was drug-related (78%). commenced on cinacalcet. Serum calcium gradually decreased and he remained Most respondents felt they had not received sufficient training (85%) and lacked well for 18 months. Unfortunately thereafter he had further episodes of confidence in the initial assessment of hyponatraemia (64%). Those qualified pancreatitis and hypercalcaemia, suggesting non-compliance with cinacalcet or O20 years felt less confident and were less likely to suggest further tests as loss of drug effect. recommended by specialists. Three years after initial presentation he underwent total parathyroidectomy. 77% of respondents would like a management protocol or algorithm and 60% Parathyroid histology was normal. Postoperatively, he was commenced calcium were keen to attend a local educational event on hyponatraemia. carbonate and alfacalcidol. He went on to have a further episode of pancreatitis m Conclusion with hypercalcaemia, but with a PTH of only 0.8 mol/l. Following this In our area, many general practitioners lack confidence in the management of alfacalcidol dose was reduced and calcium carbonate discontinued. Since then he hyponatraemia and practice varies widely. There is a large unmet educational has not experienced further hypercalcaemia. However, he continues to have need in this area and future studies will look at how best this can be addressed. intermittent pancreatitis which is felt to be due to pancreatic duct stenosis. We discuss the possibility that the mutation detected leads to a lack of functioning receptor and thus hypercalcaemia.

P50 A clinico-microbiological study of infected diabetic foot ulcers Pinaki Dutta, M N Parvez, P Ray, L Kaman, Anil Bhansali, K Mahesh & N Khandelwal P52 Postgraduate Institute of Medical Education and Research, Chandigarh, An unusual goitre India. Olubiyi Adesina & O Oguntoyinbo Federal Medical Centre, Abeokuta, Ogun State, Nigeria. Background According to western literature aerobic Gram-positive cocci are the predominant Objective microorganisms that are isolated from diabetic foot ulcers. In contrast, whatever To present an unusual case of a goitre co-existing with bilateral thryoglossal limited data is available from India Gram-negative aerobic bacteria were most fistula. frequently isolated. Introduction Aims and objectives AF, a 32-year-old male presented with 4 years history of an anterior neck swelling To know the clinical and microbiological profile of patients with infected diabetic associated with palpitations, heat intolerance, protrusion of the eyeballs, weight foot ulcers. loss, tremors of the hands and generalized weakness. Patients and methods Prior to onset of the neck swelling, he had noticed since childhood that whenever A descriptive cross-sectional study conducted between January 2009 to May he drinks any fluid, some of the fluid drips out from two points on either side of 2010. Patients with diabetic foot-ulcers with clinical signs and symptoms of the lower part of his neck. No associated history of neck pain, no family history of infection admitted in our inpatient words. Soft tissue cultures (nZ62) from deep thyroid disease. No associated ear or nasal symptoms. portion of ulcer and bone specimens (nZ35) in patients with suspected Examination osteomyelitis were taken for both aerobic and anaerobic cultures. Antibiotic Young man with thyroid stare, bilateral proptosis, diaphoretic, with tremors of the susceptibility was done according to standard protocol. outstretched hands and warm and moist palms. Neck: anterior neck mass about Results 80 g in size, with scarification marks, soft, non-nodular, non-tender, with Total 157 organisms were isolated from 117 specimens (1.34 organisms/speci- discharge of clear fluid from the inferior region bilaterally. CVS: pulse rate 104 men). In majority aerobic (78.3%) and gram-negative organisms (66.2%) beats per minute, Blood pressure 120/70 mmHg. Precordium was hyperactive. dominated. Bone culture was positive in (80%) and was predominantly mono- Cardiac apex was not displaced. First and second heart sounds were heard. microbial, soft tissue culture and pus cultures were positive in 76.2 and 75.9% Assessment respectively. Specimens showing maximum number of organisms in descending Toxic Goitre co-existing with bilateral thyroglossal fistula. order are soft tissue, pus and bone. Duration of ulcer was most important predictor Results of osteomyelitis (PZ0.002, odds ratio 1.19). Twelve (20%) required amputation Ultrasound: diffuse goiter. No nodule or cyst demonstrated. at various sites. Thyroid function test:

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Methods Test Result Range An electronic search of all radiology reports for CT scans incorporating the T 7.5 0.8–2.0 ng/ml abdomen and undertaken at our Health Board between 2005 and 2010 was 3 performed using the search terms ‘adrenal incidentaloma’, ‘adrenal mass’, T4 415 45–115 ng/ml TSH 0.1 0.5–3.7 mIU/l ‘adrenal myelolipoma’, ‘adrenal adenoma’ and ‘adrenal hyperplasia’. Patients were subsequently assigned to one of 5 categories based on case note/report review: no adrenal mass, adrenal metastasis, primary adrenal malignancy, AI, radiological investigation for known endocrine disorder. He was commenced on anti-thyroid medications and is scheduled for Results Fistulography. 1153/28 809 scans were positive for the search criteria; 504 were excluded as they had no adrenal mass, 98 were excluded for malignancy (94 metastasis, 4 primary) and 27 as they were being investigated for a known endocrine disorder. This left 475 with a diagnosis of AI (prevalence 1.65%) but only 17% were referred for endocrine review, of whom 95% had appropriate repeat radiology (no malignancy and only 4 reported a change in lesion size). 77% (ARR), 88% (CATS) and 92% (ONDST) were evaluated biochemically; subclinical Cushing’s syndrome was the P53 commonest hormonal abnormality (16%). Conclusions Echocardiogram in prolactinoma patients taking ergot derived The reported prevalence of AI is lower at our centre compared with the referenced dopamine agonists 1 2 literature and only a small proportion of patients are referred appropriately for Auditi Naziat & Mohgah Elsheikh endocrine review. 1Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK; 2Centre for Endocrinology and Diabetes, Royal Berkshire Hospital, Reading, UK.

Background The use of high dose Ergot derived dopamine agonists in patients with Parkinson’s disease has been associated with an increased risk of cardiac P55 valvular fibrosis. The UK Medicines and Health products Regulatory Agency Hypoadrenalism then adrenal haemorrhage as manifestation of (MHRA) currently advises baseline Echocardiogram within 3–6 months and lymphoma relapse after 3.5 years follow up Echocardiogram at 6–12 monthly intervals in all patients taking ergot Mansour Seidahmad, Panagiota Anna Chousou, Firas Haddadin, derived dopamine agonists. However, the risk of cardiac valvulopathy with lower Emad George & Adrian Jennings doses used to treat prolactinomas remains unclear. Diabetes and Endocrinology Centre, Queen Elizabeth Hospital, King’s The aims of this study were to audit our adherence to the MHRA guidance in Lynn, Norfolk, UK. patients treated with ergot derived dopamine agonists for prolactinoma and to determine the prevalence of valvular heart disease in this cohort of patients. Methods Hypoadrenalism and bilateral adrenal haemorrhage are rare manifestations of Retrospective casenote review (nZ48) of patients with prolactinoma on lymphoma. We present a case of diffuse large B cell non-Hodgkins lymphoma Cabergoline (nZ42) or Bromocriptine (nZ6) attending Endocrine clinic. (NHL) in whom the main manifestations of relapse included hypoadrenalism and Thirty-six were already on treatment prior to the publication of MHRA drug then bilateral adrenal haemorrhage. safety advice. Seventeen patients were on treatment for O5 years, 26 under A 75-year-old male presented with a 2-week history of severe left sided 5 years, four !6 months and one of unknown duration. abdominal pain. He was known to have NHL predominantly involving the right The median Cabergoline does was 500 mg/week and Bromocriptine 1.88 mg/day. maxillary sinus, which had been treated with chemotherapy and had been in Results remission for 3.5 years. He also had a history of type 2 diabetes mellitus, Thirty-five patients (72.9%) had a baseline echocardiogram of whom 22 (62.8%) adenocarcinoma of the prostate and pulmonary embolism treated with warfarin. had a normal result and 13 had (37.50%) mild/trivial TR, AR or MR. Thirteen He had been admitted 3 months previously under another team with transient leg patients had not had an echocardiogram. weakness and had been noted to be hyponatraemic. A short synacthen test had None had follow up echocardiograms; 26 were not due (!12 months of baseline shown a suboptimal response (peak cortisol 434 nmol/l) so he received ECHO), one discontinued cabergoline and no reason documented in 7. hydrocortisone replacement. Conclusion Examination showed he was afebrile, heart rate 82/min and blood pressure 83.33% patients diagnosed after the MHRA advice had baseline echocardiograms 135/62 mmHg. There was left sided abdominal tenderness. within 6 months of treatment. Sixty-six percent patients on treatment predating His initial blood results showed haemoglobin 7.2 g/dl and a prolonged INR of 9. MHRA advice had an echocardiogram as soon as the advice was published. In An urgent CT scan showed massive bilateral adrenal haemorrhage with mild contrast to treatment with high dose cabergoline in patients with Parkinson’s splenomegaly and some enlarged retroperitoneal lymph nodes. disease no significant cardiac valvular dysfunction was found on echocardiogram His anticoagulation was reversed, he was transfused and treated with i.v. in patients with prolactinoma treated with low-dose dopamine agonists. hydrocortisone. He responded well but then developed recurrent febrile episodes. These responded to antibiotics initially, but despite aggressive treatment, the patient’s condition deteriorated and he died 52 days after admission. Post mortem examination revealed lymphoma and haemorrhage in both adrenal glands. There was also recurrent lymphoma in an intra-abdominal lymph node. No other factors contributing to his death were identified. P54 Adrenal imaging is warranted when hypoadrenalism presents in a patient with lymphoma in remission as it may indicate relapse. When adrenal haemorrhage Management of adrenal incidentaloma: are we getting it right? occurs in patients with lymphoma adrenal lymphoma should be considered. Lauren Price, Srini Munigoti & Aled Rees Cardiff University, Cardiff, UK.

Background Adrenal incidentalomas (AI) are a common radiological finding (estimated prevalence 4%). Guidelines from the American Association of Clinical P56 Endocrinologists (AACE) and the American Association of Endocrine Surgeons Hormone profile of patients referred for Bariatric surgery (AAES) recommend radiological evaluation at 3–6 months then annually for 1–2 Lakshminarayanan Varadhan, C V N Cheruvu, George Varughese years, and hormonal evaluation by measurement of plasma aldosterone/renin & Richard Clayton (ARR) activity, 24 h catecholamines/metanephrines (CATS), and 1 mg overnight University Hospitals of North Staffordshire NHS Trust, Stoke on Trent, UK. dexamethasone suppression test (ONDST). Aims To compare the prevalence of AI reported on abdominal CT scans at our Aim institution with the literature and to identify how many patients were referred for An increasing proportion of patients are referred to endocrine clinics for endocrine review. To compare our management of AI with the AACE/AAES assessment of an endocrine reason for obesity. The aim of our study was to assess guidelines. the hormone profiles of patients referred for bariatric surgery.

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Methods P58 Patients referred to bariatric surgery clinic were investigated for hypothyroidism Long-term single centre outcome of phaeochromocytoma/ (TSH, T4), Cushing’s disease (2 mg-overnight dexamethasone suppression test), paraganglioma acromegaly (IGF1) and Vitamin D deficiency (PTH, Ca and Vitamin D) based on Huda Al-Kutubi1, Joanne Greenwood2, Maneesh Udiawar2, Atul Kalhan2, clinical suspicion. A retrospective observational analysis was conducted to David Scott-Coombes2 & Aled Rees1 analyse the prevalence of endocrine disorders and distribution of comorbidities. 1Cardiff University, Cardiff, UK; 2Cardiff and Vale University Health Results Board, Cardiff, UK. Demographics: nZ159 patients; mean age: 42.6 years (17–67); females: 80%; mean BMI 49.5 kg/m2 (35–73). Distribution of comorbidities: Clinical Diabetes mellitus: 30.2%, Hypertension: Background 37.7%, Dyslipidemia: 34%, Severe arthritis: 39%, Obstructive sleep apnoea: Phaeochromocytomas (PHAEOs) and paragangliomas (PGLs) are rare catechol- 6.3%. amine producing tumours which are potentially lethal if left untreated and may be Cushing’s syndrome: nZ85; None of the patients had documented cushingoid associated with a wide variety of complications. Optimum management demands morphology. Apart from one patient who had unsuppressed cortisol (Z68 nmol/l; multidisciplinary input from endocrinologists, biochemists, geneticists and urinary free cortisol normal – not investigated further), all the others were endocrine surgeons. negative. Objective Thyroid status: nZ159; 13% were known hypothyroidism on replacement; 33% A retrospective audit into the management of PHAEOs/PGLs at our institution of them were inadequately replaced. 1.4% had sub-clinical hypothyroidism not against the 2005 recommendations made at the 1st International Symposium. being treated so far. Methods Acromegaly: nZ52; All had normal age-related IGF1 levels. Data were collected on all patients who had presented to the endocrine department Bone: PTH: nZ105; 61% had high PTH (O6.4 pmol/l). Serum calcium was with a diagnosis of PHAEO or PGL over a 12 year period (1997–2009). This was within normal range in all patients. PTH values correlated positively to BMI cross-checked with a biochemistry database capturing all patients with raised (rZ0.1). Vitamin D: nZ81; 16.1% deficient (!10 mg/l); 60.5% were insufficient urinary catecholamines and/or metadrenalines. (11–30 mg/l); 23.4% were Vitamin D replete (O30 mg/l). Vitamin D correlated Results negatively to BMI (rZK0.2). Fifty-nine patients with a confirmed diagnosis of PHAEO (48 unilateral, Conclusion 6 bilateral) or PGL (5) were identified. Biochemistry (post-2003: 24 h urine for A vast majority of patients with morbid obesity, who are referred for bariatric fractionated metadrenalines (metadrenaline and normetadrenaline) plus catechol- surgery, do not have an endocrine aetiology. Vitamin D deficiency or amines (adrenaline, noradrenaline and dopamine) if R top 25% of the reference insufficiency is present in a high proportion of this cohort (77%) and hence range; pre-2003: various methods) demonstrated elevation of at least one should be treated prior to surgery and reassessed post-operatively. Thyroxine fractionated metabolite in all subjects bar 1 at presentation. Localisation studies treatment should be optimized in patients with prior hypothyroidism. Screening included a combination of CT (60%), MRI (42%) and 123I-MIBG (64%). 30% of for Cushing’s syndrome or acromegaly need not be performed unless clinically patients were found to harbour a mutation in a susceptibility gene (8% VHL, 8% indicated. MEN2A, 7% NF1, 7% SDHB/D); of the remaining 41 subjects, genetic testing was indicated in 37% but only undertaken in half of these. All patients were treated surgically (84% laparoscopic since 2004) with low morbidity and mortality (!2%); preoperative adrenergic blockade was undertaken in all. Conclusions Biochemical screening using fractionated urinary metadrenalines provides a high diagnostic sensitivity for PHAEO and PGL. Functional imaging is used selectively in our institution but surgical outcome is good. Genetic testing P57 reveals a relatively high rate of inherited endocrine tumour syndromes but is under-requested in a small minority of cases. Effective use of Cinacalcet in tertiary hyperparathyroidism in a patient with hypophosphataemic rickets Madeleine Bastawrous1, Helen Moore1, Niru Goenka1, David Ewins1, Anindya Banerjee2 & Frank Joseph1 1Department of Diabetes and Endocrinology, Countess of Chester Hospital, Chester, UK; 2Department of Nephrology, Countess of Chester Hospital, Chester, UK. P59 A 22-year-old woman with hypophosphataemic rickets was diagnosed at age four An analysis of false positive urinary catecholamine and metabolite when she presented with short stature and valgus deformity of the lower limbs. results in a tertiary endocrine centre Biochemical testing, genetic screening and radiological investigation of her Huda Al-Kutubi1, Joanne Greenwood2, Atul Kalhan2, Maneesh Udiawar2 family showed no abnormality and it was concluded that she had a de novo & Aled Rees1 mutation. 1Cardiff University, Cardiff, UK; 2Cardiff and Vale University Health She was treated with 1a-calcidol and phosphate Sandoz with regularly monitored Board, Cardiff, UK. biochemistry. She had poor adherence to her medication and her phosphate levels fluctuated. Her valgus deformity showed little improvement and she required stapling of her left distal medial epiphyseal plate at age 15 years. Background At age 14 she had been diagnosed with secondary hyperparathyroidism with The screening investigation of choice for phaeochromocytomas (PHAEO) and calcium 2.38 mmol/l, phosphate 0.91 mmol/l and parathyroid hormone (PTH) paragangliomas (PGL) in the UK is usually a 24 h urine collection for fractionated 24.71 pmol/l. Her renal function was normal. The need to adhere to 1a-calcidol metadrenalines C/K free catecholamines. These assays have high diagnostic was reiterated, but her PTH remained elevated. At age 18 she developed sensitivity (approaching 98%) but lower specificity. hypercalcaemia with calcium 3.19 mmol/l, phosphate 1.61 mmol/l and PTH Aim 10.3 pmol/l and her 1a-calcidol was gradually reduced to 500 mg once a week. To review causes of false positive (FP) catecholamine and metabolite results in Despite this her calcium remained elevated at 2.85 mmol/l with a progressively our centre over a 12-year period. increasing PTH (65.4 pmol/l) confirming a diagnosis of tertiary hyperparathy- Methods roidism. She had a sestamibi scan which identified bilateral lower pole Data were collected on all patients who presented to our endocrine department parathyroid adenomas, for which she declined surgery and was therefore treated with a histologically confirmed diagnosis of PHAEO or PGL between 1997 and with cinacalcet, starting at 30 mg daily and increased to 90 mg daily in divided 2009. This was compared with a biochemistry database capturing all patients with doses. The calcium and PTH decreased to 2.58 mmol/l and 23.4 pmol/l raised urinary catecholamines and/or metadrenalines. A test was deemed to be FP respectively over a period of 8 months. b-CTX a marker of bone resorption when repeat biochemistry and/or radiology (CT/MRI/MIBG) was consistently was normal at 0.3 mg/l (NR 0.1–0.5). negative. Clonidine-suppression tests were not performed. Although cinacalcet is unlicensed for treatment of tertiary hyperparathyroidism, Results this case demonstrates the effective use of cinacalcet in lowering PTH and Fifty-nine patients with PHAEO or PGL were identified and compared with 57 FP calcium in tertiary hyperparathyroidism in hypophosphataemic rickets. The results in 47 patients (elevated metadrenaline nZ11, normetadrenaline nZ11, normal b-CTX concentration would also suggest that there is benefit at the target adrenaline nZ7, noradrenaline nZ17, dopamine nZ11). Compared with organ, bone, by maintaining normal bone resorption which would otherwise be PHAEO/PGL, FP typically showed only moderately elevated catecholamines/me- high in hyperparathyroidism. tadrenalines: results were no higher than 1.75 (adrenaline), 1.8 (noradrenaline), 1.8 (dopamine), 2.9 (metadrenaline) or 3.1 (normetadrenaline)!upper limit of normal

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

(ULN) (100% specificity). Potential drugs causing FP results included methyldopa she required inotropes and CPAP non-invasive ventilation for persistent acute (nZ4), amitryptiline (nZ2), beta blockers (nZ5), calcium channel blockers respiratory failure. Echocardiogram confirmed normal cardiac function. She (nZ5) and alpha blockers (nZ3). Three patients with FP results were pregnant, a made a rapid recovery and was discharged home well 2 days later. She further 5 had high urinary volumes, 2 had evidence of adrenal infarction (repeat subsequently recalled that she had felt slightly unwell after her first MRI scan scans normal) and one patient was noted to have obstructive sleep apnoea (OSA). 3 years earlier. Conclusions Acute lung injury has not previously been reported after gadolinium False positive urinary catecholamines and metadrenalines tend to cluster around administration. Gadolinium-induced serious adverse reactions are extremely the ULN. Factors such as medications, pregnancy, urine volume, adrenal rare (1–3 per million administered doses). Gadovist is a modern contrast agent infarction and OSA should be considered as causes of FP findings where regarded as having a very low potential for anaphylactoid reactions; it includes a biochemical results are only modestly elevated. macrocyclic chelate which is thought to give less risk of gadolinium toxicity than older agents with a linear chelate such as Omniscan. However, macrocyclic gadolinium agents may be associated with a higher frequency of allergic reactions. Pituitary disease is rarely fatal. Endocrinologists should be aware that pituitary MRI carries a small risk of iatrogenic adverse reaction which may be life- threatening. P60 Juxta-adrenal Schwannoma presenting as ‘Giant’ adrenal adenoma Smitha Amirchetty, Peter Donaldson, Charlotte Etheridge, Ian Driver & Craig Parkinson Ipswich Hospital NHS Trust, Ipswich, UK. P62 Audit on colonoscopy screening in acromegaly patients in a tertiary endocrine unit A 65-year-old female, with a 4 month history of left upper quadrant discomfort, Daniel Kannappan, Sami Kenz & Tara Kearney was identified as having a multi-loculated para-renal ‘cyst’ on ultrasound Salford Royal Hospital, Manchester, UK. scanning. CT identified a 13!11!10 cm heterogeneous mass arising from the left adrenal. An enlarged ill-defined left retro-crural ‘lymph node’ was also noted. There was no history of weight loss. Past medical history was unremarkable. She Aim was no medication. Examination was unremarkable apart from a BP of To find out all Acromegalic patients above the age of 40 years had their 181/102 mmHg. colonoscopic screening or not. Pre-operative endocrine assessment: normal electrolytes, 24 h UFC, urinary Reason for colonoscopy screening metanephrines (!2), testosterone, androstenedione, and DHEAs. Post 48 h low There is 13 to 14 fold increased risk of colorectal cancer in Acromegaly patients dose dexamethasone suppression test (LDDST) serum cortisolZ55 nmol/l. and 2.5 fold increase in mortality from Colonic cancer. Based on size criteria, lymph node involvement and apparent low grade Standards Cushing’s syndrome, the patient was informed that the mass most likely represented an adrenal adenocarcinoma and she was listed for surgery. i) Patientts with acromegaly should be offered regular colonoscopy from the Under corticosteroid cover, left radical adrenalectomy, nephrectomy, and age of 40 years. excision of the retro-crural lesion was undertaken. She was discharged on ii) The Frequency of repeat colonoscopy depends on the findings at the original replacement hydrocortisone. After a normal short synacthen test hydrocortisone screening and the activity of the underlying acromegaly. was withdrawn. A repeat LDDST was normal. iii) Patients with adenoma or increased IGF1 needs screening at 3 yearly The solid cystic encapsulated mass weighed 670 g, measured 130!120! intervals. 110 mm and was histologically separate from the left adrenal. Composed of iv) Negative or hyperplastic polyp in the first colonoscopy needs screening at 5 spindle cells (positive for S-100 protein and Vimentin but negative for Actin) with yearly intervals. Verocay bodies (Antoni A areas) and less cellular Antoni B areas, there was no v) Total colonoscopy is required rather than sigmoidoscopy as 25% of evidence of cellular pleomorphism or mitotic figures. The retro-crural mass was adenomas and 50% of carcinomas occur in ascending and transverse colon. composed of similar spindle cells. Data analysis Pathological diagnosis was a benign ‘giant’ juxta-adrenal schwannoma and retro- crural schwannoma. i) Total number of Acromegaly patients who had treatment in our centre Retroperitoneal and juxta-adrenal schwannomas are extremely rare and may was 89. appear pre-operatively as adrenal tumours. Given their size (O4 cm) they may be ii) Out of this 53 patients were under follow up in our hospital and 36 patients confused with adrenocortical carcinomas and phaeochromocytomas, particularly were referred back to their original hospital. given that some case reports highlight uptake of MIBG by these lesions. The iii) 25 patients (47%) had colonoscopy or virtual colonoscopy and for 5 patients failure of cortisol suppression following dexamethasone administration was, in no information was available. retrospect, spurious. iv) 18 patients had normal screening, 4 patients had hyperplasic polyp and the remaining 3 patients had adenoma, ulcer and Crohns colitis respectively. v) 23 patients did not have colonoscopy. Out of which 8 patients were less than 40 years and screening is not indicated. vi) Remaining 15 patients (30%) did not have colonoscopy screening. Conclusion The above audit showed nearly one third of our Acromegaly patients did not have P61 colonoscopy screening. This audit has changed our clinical practice and going to be re audited in 12 months. Life-threatening adverse reaction following pituitary MRI Katerina Achilleos, Tehmina Irani & James Ahlquist Southend Hospital, Westcliff on Sea, Essex, UK.

Pituitary MRI is widely used in endocrine practice, and is regarded as entirely safe. We report here a life-threatening outcome from a routine pituitary MRI scan. P63 A 23-year-old female with a 3-year history of microprolactinoma confirmed by Adrenal haemorrhage associated with therapeutic Clexane and MRI underwent a routine repeat MRI scan with gadolinium. During injection of subtherapeutic warfarin Gadovist she experienced minimal chest tightness which rapidly resolved. Four Panagiota Anna Chousou, Mansour Seidahmad, Firas Haddadin hours after the injection she rapidly became very breathless. On admission to & Adrian Jennings hospital she was shocked, profoundly breathless, with cyanosis, hypotension and Diabetes and Endocrinology Centre, Queen Elizabeth Hospital, King’s marked hypoxia (HR 162 bpm, BP 72/50 mmHg, PaO2 7 kPa despite FiO2 60%); Lynn, Norfolk, UK. there were diffuse crepitations throughout both lung fields and no signs of cardiac disease or angioedema. CXR showed bilateral perihilar alveolar shadowing, indicating pulmonary oedema/ARDS. Adrenal haemorrhage is rarely associated with anticoagulation according to a She was treated with high-flow oxygen, adrenaline, hydrocortisone, chlorphenir- large American series. We present 2 cases in whom there was no evidence of over amine and furosemide. She remained critically ill and was admitted to ITU, where anticoagulation, both of whom developed a degree of hypoadrenalism.

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Case 1 beyond their core indications. However dose-dependent adverse reactions A 72-year-old-male presented with severe non-pleuritic left flank pain. He had increasingly reported include diarrhoea, resistant hypomagnesaemia/hypocalcae- been seen the previous day with possible deep venous thrombosis (DVT) and had mia and interstitial nephritis. Moreover, they are associated with increased rates received a single dose of enoxaparin (1.5 mg/kg). He was tender in the left flank. of vertebral and wrist fractures, and increased C. difficile carriage rate. Investigations confirmed pulmonary embolism and DVT, so he continued Aims therapeutic enoxaparin. He became progressively hypotensive, hyponatraemic To ascertain the extent and appropriateness of PPR prescribing in patients and hyperkalaemic 3 days after admission. A short Synacthen test confirmed admitted to the Diabetes and Endocrine medical base ward in the Royal Victoria hypoadrenalism (peak serum cortisol 85 nmol/l). Adrenal CT showed bilateral Infirmary (RVI). adrenal enlargement, compatible with haemorrhage. Extensive investigations for Standards malignancy were negative and repeat CT 3 months later showed normal adrenals. All PPIs prescribed should have a clear indication, duration for treatment and/or Case 2 date of review. A 64-year-old-male presented with sudden vertigo, right loin pain and vomiting. Methods He was taking warfarin for apical thrombus following a myocardial infarction. He Over an 8 week period, 105 consecutive admissions to Ward 31, RVI were was tender in the right renal angle, but haemodynamically stable. His INR was 1.8 evaluated for i) dose of PPI prescribed (‘low-dose’, ‘standard dose’ or ‘high and recent results did not show over-anticoagulation. CT scan showed bilateral dose’); ii) identifiable indication from patient history, admissions proforma, adrenal enlargement and features consistent with adrenal haemorrhage, especially pharmacist history, GP referral letters and/or electronic records. on the right. Investigations for underlying neoplasia were negative. Short Results Synacthen testing showed a suboptimal response (peak serum cortisol 524 nmol/l). 50/105 patients were taking on a PPI, 20 of whom (40%) had no current clear Eleven months after discharge a repeat CT scan was normal apart from minor indication (9 patients low-dose, 10 standard dose, 1 high-dose). thickening in the left adrenal gland. Conclusion Adrenal haemorrhage was associated with anticoagulation in only 2% of 141 cases Nineteen percent of new patients admitted to a general medical ward were taking in a large American series collected over 25 years (1972–97). More recently there a PPI for no clear indication. When a drug is perceived to be safe, effective and has been increasing use of anticoagulation so the incidence may have increased. inexpensive, documentation tends to be sparse. Although PPIs cause The presentation can be non-specific so it is important to consider this diagnosis in hypomagnesaemia/hypocalcaemia in only a tiny proportion of patients, they are patients with abdominal or flank pain and those with any features of so widely prescribed that they possibly constitute the most common cause of hypoadrenalism. hypomagnesaemia/hypocalcaemia among hospital inpatients. Suggestions PPIs should only be used for their core indications. When a PPI is started, expected duration of therapy and date of review should ideally be established at the outset. Clear record keeping by GPs and hospital doctors is essential. If no indication is found in secondary care, the PPI dose should be reduced at least and P64 the primary care physician informed. A case of SIADH and hyponatremia treated successfully with Tolvaptan Kamal Abouglila, Nicola Robinson & Emily Curran UHND, Durham, UK.

Hyponatremia complicates 1% of hospital admissions and can be associated with serious CNS effects. We report a case of an 84-year-old woman with longstanding hyponatremia resulting in several hospital admissions because of acute confusion due to severe hypoatremia. This case emphasizes the need to consider selective vasopressin V2-receptor antagonist (Tolvaptan) as a potential therapy for hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone (SIADH). Case report P66 An 84-year-old female presented with acute confusion, agitation, and generally Pituitary thyroid hormone resistance (PTHR) unwell. Past medical history of significance included hypothyroidism and Ahmed El-Laboudi & Steve Orme diabetes mellitus and she was not taken any medication to contribute to here Leeds Teaching Hospitals NHS Trust, Leeds, UK. confusion. Physical examination, Chest X-ray and CT of the head were unremarkable. Serum sodium was 118 mmol/l, serum osmolality 267 mOsm/kg, urine osmolality 362 mOsm/kg, and urine sodium 70 mmol/l, Thyroid function A 32-year-old lady was referred to our centre with thyrotoxicosis and elevated test and serum cortisol results were both normal. Looking back to her notes us FT4 and TSH levels. She was already on carbimazole. Interestingly, her notes that the serum sodium results were low most of the time for the last few symptoms started at childhood. She was nicknamed ‘shaky’ by her school friends 18 months. Cognitive testing revealed time disorientation and poor concentration. because of her tremors. There was no family history of thyroid disease. All the investigation confirms SAIDH as a cause of hyponatremia and the cause of She was clinically and biochemically thyrotoxic with FT4 of 12.4–38.8 pmol/l SIADH was idiopathic. She treated initially with restrict fluid restriction for and TSH of 7.24–38.8 mIU/l. 12 days but here sodium remain low 122 mmol/l. The decision was then made to After excluding assay interference as a possibility, Investigations revealed a start her on Tolvaptan and the fluid restriction was stopped. She remained on normal a-subunit/TSH molar ratio, an appropriate rise in TSH during TRH test Tolvaptan for 8 days until her was 132 mmol/l. She was discharged two days later and no evidence of a pituitary adenoma on MRI. This suggested a diagnosis of with sodium of 134 mmol/l. pituitary thyroid hormone resistance (PTHR). However, sequencing thyroid Conclusion hormone receptor-b (THR-b) gene did not identify any abnormality. This case highlights the importance of the use of Tolvaptan to correct sodium Following a TSH day curve to assess response to cabergoline and octreotide, gradually and its potential for reducing the length of stay in hospital. carbimazole was switched to cabergoline which only resulted in partial clinical and biochemical improvement. She underwent further assessment at Adden- broke’s Hospital. Negative genetic testing raised doubts about initial diagnosis. Re-sequencing THR-b gene and repeat MRI scan again did not identify any abnormality. Also, measurement of BMR, sleeping heart rate, SHBG and BMD to assess peripheral thyroid hormone actions confirmed the initial diagnosis. P65 Her thyrotoxicosis improved after adding triiodo-thyroacetic acid (TRAIC) to her Proton pump inhibitor (PPI) therapy in patients admitted to a diabetes treatment regimen. However, following MHRA guidance, a routine echocardio- and endocrine medical ward: are there clear indications? gram revealed severe MR. Therefore, cabergoline was switched to quinagolide Luke Teo, Michelle Mok, Andrew Macnair, Prakashmini Nunkoo, following a repeat TSH day curve. Albert Lim, Siobhan Muttiah, Margaret Warlow, Christian Dipper She underwent successful cardiac surgery. Currently, she is clinically and & Richard Quinton biochemically euthyroid and in addition to nadolol is taking TRAIC 700 mgBD Royal Victoria Infirmary, Newcastle Upon Tyne, UK. and quinagolide 150 mg daily. This case that revealed symptoms of thyrotoxicosis since childhood (nickname ‘shaky’) highlights important learning points including: diagnostic approach to a Introduction patient with TSH-induced thyrotoxicosis, value of TSH day curve, use of TRIAC Proton pump inhibitors (PPIs) were until very recently perceived to be safe, and the relationship between cabergoline and fibrotic valvular heart disease. effective and inexpensive. As a result they are widely prescribed empirically,

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P67 P69 Status epilepticus in addisonian crisis Hyponatraemia in a patient presenting with diabetic ketoacidosis: a Bashir El-Mahmoudi, Gabreil Yaacoub & Mureed Hussain case of polyglandular autoimmune syndrome type 2 Tameside General Hospital, Ashton-U-Lyne, Manchester, UK. Shivani Misra, Claire Feeney, Debbie Peters, Nick Oliver, Anne Dornhorst & Emma Hatfield Imperial Healthcare NHS Trust, London, UK. A 76-year-old man with history of oesophageal carcinoma was successfully treated by surgery and radiotherapy 4 years previously. He presented with anorexia and 4 stones weight loss associated with abdominal discomfort. He was A 31-year-old male presented to A&E with confusion, lethargy, polyuria and not on any medication. On examination blood pressure 100/60, no peripheral blurred vision. The previous month he had been diagnosed with diabetes and oedema, systemic examination otherwise was unremarkable. Soon after started on metformin by his GP. On examination he was cachectic (BMI admission, he developed a generalised tonic clonic seizure requiring a Lorazepam 17 kg/m2), dehydrated and hypotensive (88/56). Baseline investigations revealed and Phenytoin infusion to control it in critical care setting. He became a metabolic acidosis (pH 7.30), with capillary glucose 20 mmol/l and moderate hypotensive with blood pressure of 93/49. Subsequent investigations revealed ketonuria. Treatment for diabetic ketoacidosis was commenced. Further results significant hyponatraemia of 118 mmol/l, severe hypoglycaemia, blood glucose revealed he was hyponatraemic (sodium 111 mmol/l). 1.8 mmol/l, potassium 4.4 mmol/l and serum bicarbonate 21 mmol/l. The rest of Over the next 48 h, his condition improved significantly with insulin sliding scale blood testes including; full blood count, liver functions, corrected calcium, urea (converted to basal bolus regime after 24 h) and i.v. fluids, however his sodium and creatinine were all normal. did not fully correct and reached a plateau of 127 mmol/l by day 4 post admission. As an urgent CT head revealed no metastasis and his clinical and biochemical Further investigations revealed a 0900 h cortisol of 521 nmol/l, however his indices pointed towards Addisonian crisis therefore the patient was commenced ACTH was markedly elevated at 329 ng/l. The diagnosis of Addisons was on hydrocortisone, normal saline and the hypoglycaemia was treated with confirmed on a short synacthen test (time 0 min cortisol 386 nmol/l, 30 min glucagon and dextrose. On the following day there was no further seizure activity, 397 nmol/l and 60 min 378 nmol/l). He was started on hydrocortisone and biochemical profile normalised and patient started mobilising independently. fludrocortisone after which his sodium corrected to normal. Short synecthen test showed a flat cortisol response consistent with adrenal Co-presentation of type 1 diabetes and adrenal insufficiency is uncommon but failure. Furthermore, abdominal CT scan revealed bilateral adrenal enlargement suggests an underlying diagnosis of type 2 polyglandular autoimmune syndrome. with heterogeneous appearance suggestive of metastatic deposits. He was seen by Further tests revealed he was positive for islet cell and anti-GAD antibodies, but the oncologist and allowed home on hydrocortisone and fludrocortisone. not adrenal cortex antibodies. Thyroid and gonadal function was normal, as were We report a case of status epilepticus due to a combination of severe his vitamin B12 levels. The hyponatraemia was likely contributed to by hyponatraemia and hypoglycaemia as a presentation of an undiagnosed Addison’s hyperglycaemia, an appropriate ADH response to hypotension and hypocortiso- disease in a patient with underlying neoplasm. Hyponatraemia and hypoglycae- laemia. mia, both of which could be features of malignancy as in SIADH and Conclusions hypoglycaemia with malignancy. This case highlights the importance of high Though the prevalence of type 2 diabetes is on the increase, practitioners should index of suspicion in relevant settings to make a diagnosis of Addison’s disease. be alert to the possibility of late-onset autoimmune type 1 diabetes, particularly in those of a lean phenotype. Hyponatraemia can be multifactorial in origin, and an incompletely corrected level should prompt further investigation. A normal cortisol in the context of acute illness may be misleading and an ACTH is of value in this setting.

P68 Improving communication in clinical care: a re-audit of an Endocrinology and Diabetes GP e-mail advisory service following commissioning P70 Barbara Alberts, Neil Walker, Niki Karavitaki, Jonathan Levy & John Wass Sweating is only half the story Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK. Smitha Amirchetty & Craig Parkinson Ipswich Hospital NHS Trust, Ipswich, UK. Introduction and aim An e-mail based GP advisory service was launched by the authors’ centre in 2005. A 30-year-old female reported a 2-year history of excessive sweating / flushing The PCT commissioned the service in July 2009. Enquiries are handled by affecting the right hand side of the face and scalp along with the right arm. These specialist registrars with consultant supervision. The charge is £23/enquiry. symptoms were generally related to exercise and demonstrated a sharp midline Pre-commissioning, annual audits demonstrated an efficient and popular service, demarcation, being present only on the right hand side. enhancing communication links between primary and secondary/tertiary care. Past medical history included hypothyroidism secondary to Hashimoto’s We re-audited the service post-commissioning to ensure a high quality service Thyroiditis. She was euthyroid on levothyroxine. She also reported unequal was maintained and still widely utilised. We also added a user satisfaction survey. pupils since age 12. Results On examination, she was normotensive with no postural change in blood pressure. The number of enquiries between July 2009–July 2010 reduced to 543 compared A tachycardia of 132 bpm was confirmed on ECG. She had tonic pupils, the right to 701 in 2008, 501 in 2007, 400 in 2006 and 180 in 2005. larger than left, with absent knee and ankle reflexes. No goitre or thyroid nodules Post-commissioning the proportion of more complex and detailed enquiries were palpable. increased – possibly reflecting a more cost conscious use of the service. 75.1% of Urine collections were negative for metanephrines and 5-HIAA. MRI cervical e-mails dealt with endocrine problems. 13.3% with lipids and 11.6% with spine showed normal cervical spine with no surrounding mass lesions or thyroid diabetes. Of the endocrine queries, 40.4% dealt with thyroid abnormalities, 15.4% abnormality. pituitary and 14% bone. Other endocrine categories added !10% each. A diagnosis of Ross’ syndrome, with left sided anhidrosis and compensatory Referral was suggested in 25.9% of cases, an increase from 15% in 2008, again hyperhidrosis on the right, was established. reflecting the complexity of enquiries. Ross’ syndrome is the triad of tonic pupils, hyporeflexia and segmental anhidrosis The survey response rate was 41% (41/100). 97.5% of respondents were satisfied with compensatory hyperhidrosis. This encompasses Holmes Adie syndrome – with the clinical answers. 92.7% felt they received a timely response. 55.3% tonic pupils and hyporeflexia. The cause is unknown but is thought to result from reported that the advice prevented a clinic referral. generalised injury to peripheral autonomic and dorsal root ganglia. Prognosis is Conclusions unclear and although generally benign, progression of cardiovascular autonomic The service continues to be valued and well utilised. It delivers structured, dysfunction and widespread autonomic involvement is described in 28–40% of medico-legally recorded advice, at a convenient time, and has proven benefits in patients. Females are more commonly affected with average age on onset of 32. preventing unnecessary clinic referrals. Presentation may be with orthostatic hypotension, due to afferent baroreceptor Future developments failure. The centre aims to answer 90% of queries within 2 working days. GP feedback The diagnosis can be confirmed by autonomic testing and pupillography. No and the nature of queries will be used to develop targeted teaching modules for specific treatment is possible for the hyperhidrosis, but this may respond to GPs and trainees. cervical or thoracic sympathectomy. Building on the success of the E-mail advice line, the centre hopes to make use of Ross’ syndrome is distinct from Harlequin’s syndrome where a Horner’s complex more E-Health Technologies in the future. is usually present and abnormalities of the inferior thyroid artery are often found.

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P71 P73 Does the glucagon challenge test add to the utility of a 72 h fast for Introduction of day-case thyroid and parathyroid surgery has allowed spontaneous hypoglycemia? achievement of the shortest length-of-stay in the United Kingdom Anupam Brahma, Steven Romans, Sondra Gorick, K Swe Myint & Rajeev Parameswaran, Gregory Sadler & Radu Mihai F M Swords John Radcliffe Hospital, Oxford, UK. Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK. Background Length-of-stay (LOS) after various surgical procedures varies greatly between Supervised 72 h fast is historically the gold standard screen for spontaneous centres and countries. In the US there is increasing tendency towards day-case hypoglycaemia. Consensus guidelines published in 2009 suggested that thyroid and parathyroid surgery but their model of care cannot be easily b-hydroxy-butyrate levels be measured every 6 h, and the glucose response to extrapolated. In the UK the average LOS for such operations is 3–4 days. an i.v. injection of glucagon be assessed at the time of documented Methods hypoglycaemia, or at the end of the 72 h fast. We incorporated these Retrospective review of data retrieved from hospital-based software regarding the recommendations into our protocol, and here examine the results of the first 10 surgical activity during a decade in a large University hospital. Data was analysed cases. on 3-years intervals (2000–2002, 2003–2005, 2006–2008, 2009–2010). A rise in plasma b-hydroxy-butyrate levels R2.7 mmol/l may be interpreted as a Results surrogate for hypoinsulinaemia. During the 72 h fast period, all 10 patients in During January 2000–June 2010 a total of 1934 patients underwent thyroid whom hypoglycaemia was ultimately excluded exhibited a rise in plasma (nZ1264) and parathyroid (nZ670) surgery. Gender ratio (1339 F:595 M) and b-hydroxy-butyrate levels. By the end of the fast, 50% had plasma b-hydroxy- age of patients (54G17 years, range 12–89 years) did not vary significantly butyrate levels R2.7 mmol/l indicating that their fasts could have been during the study period. Indication for surgery was hyperthyroidism (nZ192), terminated earlier. Twenty percent had levels of 2.6 mmol/l and 30% were malignancy (nZ239), multinodular goitre (nZ833), primary hyperparathyroid- !2 mmol/l. We interpret the rise to confirm adherence to the fast, but patients in ism (nZ670). Main operating surgeon was a Consultant (nZ2) or an advanced whom levels remain !2.7 mmol/l require the fast to continue. surgical trainee (nZ3). This entire cohort also underwent glucagon stimulation at the end of the negative During each time period, LOS decreased from 2.8G2.5 to 1.9G2.5 days. The fast. No serious adverse reactions were reported, though nausea and flushing were percentage of patients discharged on the day of their operation increased common, and the challenge also prolonged the total test period. In the presence of progressively from 20 to 45% for thyroid surgery and from 30 to 75% for hypoglycaemia, a rise in glucose by more than 1.4 mmol/l (25 mg/dl) in response parathyroid surgery. Readmission rate was 0.8%. There was no peri-operative to glucagon is consistent with insulin or IGF mediated hypoglycaemia. A smaller mortality. Introduction of routine short-term hypocalcaemia prophylaxis (2000), rise is found in normal subjects, and hypoglycaemia of other mechanisms. scan-directed parathyroidectomy (2003), Harmonic scalpel (2005) and local- Hundred percent patients demonstrated a rise !1.4 mmol/l in this study. anaesthetic parathyroid surgery (2009) had impacted on LOS during the study We suggest that serial monitoring of plasma b-hydroxy-butyrate levels during a period. At the present time patients expect to be discharged on the day of surgery fast may allow premature termination of the fast if levels O2.7 mmol/l, and for parathyroid surgery and on postoperative day 1 after total thyroidectomy for confirms adherence to the fast when spontaneous hypoglycaemia is not benign disease. According to official DOH figures the current LOS for our unit is confirmed. However, glucagon challenge at the end of a negative fast adds little the shortest in the UK. to the interpretation, and is unnecessary. Conclusion Reducing LOS for thyroid and parathyroid surgery has been facilitated by pioneering acceptance of new technologies and by a ‘critical mass’ effect that allows a confident multidisciplinary approach with safe outcomes that can complement likely financial benefits (though not formally assessed in this study).

P72 Thyroid swelling and tracheal compression: a cautionary tale Matthew Fenech, James MacKay, Simon Pain & Francesca Swords P74 Norfolk and Norwich University Hospital, Norwich, UK. Ectopic prolactinoma in a patient with a clivoid mass Patrice Queenan & Tristan Richardson Royal Bournemouth Hospital, Bournemouth, UK. A 28-year old Lithuanian woman presented with a 6-week history of firm anterior neck swelling. There were no symptoms of local obstruction, invasion, or thyroid dysfunction, and no past medical history, medication use or relevant family We present a case of a 71-year-old gentleman who presented with a clivoid mass history. On initial assessment, she was euthyroid, with a 6 cm hard mass replacing to the opthalmologists. the right lobe of the thyroid, a 2 cm lymph node lateral to it, but no other The patient presented with left retro-orbital pain. He was generally fit and well, lymphadenopathy. No cellular material could be obtained on initial clinical and but his past medical history included cancer of the prostate and gout. An MRI ultrasound-guided fine-needle aspirates. An ultrasound-guided core biopsy of the brain was performed, which demonstrated a lesion between the left internal thyroid mass revealed a diffuse inflammatory cell infiltrate comprising carotid artery and the clivus. CT chest/abdomen/pelvis confirmed no evidence of lymphocytes and eosinophils, no thyroid follicles, and extrathyroidal fibrosis. metastatic prostate cancer. These appearances were thought to be in keeping with Reidel’s thyroiditis. Interval scanning was performed at four months and demonstrated an increasing The patient then deteriorated, developing stridor, dysphagia and snoring. Her lesional size involving the clivus. The pituitary was of normal in size, shape and tracheal diameter fell from 8 to 4 mm over a 6-week period. She was admitted position. The patient was referred to the Neurosurgeons. The differential immediately and started on 1 mg/kg oral prednisolone. Within hours of the first diagnosis of a chordoma or clival tumour were considered. An excision biopsy dose, her symptoms improved. Her FEV1 rose from 2.54 to 2.8 l over 48 h, was performed via image-guided endoscopy. There were no postoperative accompanied by a clinically appreciable 20% reduction in the size of the mass. complications. Though the histology was compelling for Reidel’s thyroiditis, this was not in Histology was consistent with a prolactinoma. Prolactin levels were then keeping with the clinical finding of lymphadenopathy. She was also perceived to measured and found to be elevated at 9500 m/l (reference range !650 m/l). The be at increased risk of papillary thyroid cancer, due to childhood exposure to pituitary gland was not felt to have been disturbed during surgery. fallout from the Chernobyl disaster. Lymph node biopsy was therefore performed The patient was referred to Endocrinology for follow up and dynamic testing. He prior to starting prednisolone therapy. This revealed a mixed lymphoid population was commenced on Cabergoline with a reduction in the serum prolactin to and Reed Sternberg cells staining for CD30 and CD15. Subsequent immunohis- 1677 m/l. tochemical staining of the thyroid biopsy revealed the same appearances, and the Tumours arising at the clivus are uncommon. However, the differential diagnoses patient is now responding to ABVD chemotherapy. to be considered are chordomas, meningiomas, metastases, and pituitary Intrathyroidal Hodgkin’s lymphoma is a rare form of a rare disease – in 6 series macroadenomas. Investigation of these patients should always include comprising 248 cases of thyroidal lymphoma, only 3 patients had Hodgkin’s measurement of serum prolactin in order to prevent unnecessary and potentially lymphoma – and was an unexpected underlying diagnosis in this case. harmful surgical intervention.

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P75 Discussion Prevalence and prediction of endocrinopathies in thalassaemia major Although pregnancy is a ‘pseudocushingoid’ state, symptomatic hyperandorgen- Ploutarchos Tzoulis, Ai Leen Ang, Farrukh Shah & Maria Barnard ism occurs only rarely. In hyperandrogenic states, the foetus is protected from The Whittington Hospital NHS Trust, London, UK. virilization by several mechanisms. The cause for hirsutism in our patient was clearly reversible in the postpartum period and suggested a benign pregnancy specific source. Although a luteoma of pregnancy or hyperreactio luteinalis (both Aims of which regress after delivery) were possibile diagnoses, she was a Caucasian Endocrine deficiencies are common complications of thalassaemia major. Our and these usually large tumours were not visible at MRI scanning. The haematology department serves one of the UK’s largest populations of appearances of the ovaries postpartum on ultrasound scanning indicates PCOS thalassaemia patients. We assessed our thalassaemia major patients’ endocrine (unlikely) or the hyperandorgenism during pregnancy. status and factors associated with endocrinopathies. Methods Retrospective analysis of our thalassaemia major patients on active follow-up in April 2010. Parameters such as age, gender, hepatitis C infection, compliance with chelation therapy, mean ferritin over 10 years, highest Ferriscan liver iron concentration from 2007 to 2010, lowest cardiac magnetic resonance T2* value P77 between 1999 and 2010 were tested for independent association with each endocrinopathy, using multivariate analysis. A case of cerebral salt wasting syndrome Results Simmi Krishnan, Kalpana Kaushal & Simon Howell Data was reviewed from 102 thalassaemia major adults (52 females, 50 males) Royal Preston Hospital, Lancashire, UK. with median age 35.5 years (range 17–58 years). Clinical hypothyroidism was recorded in 11.8% of patients (9.8% primary, 2.0% A 55-year-old lady was admitted with sudden onset headache, diplopia, secondary), subclinical hypothyroidism in 2.9%, normal thyroid status in 85.3%. photophobia and confusion. CT brain showed SAH with hydrocephalus. Coiling Prevalence of hypoparathyroidism was 13.7%. Hypothyroidism and hypopara- of the aneurysm with EVD insertion was done on the same day. On day 5 post- thyroidism were not independently related with any of the parameters tested. operatively she developed hyponatremia and dropped her GCS to 10/15. Hypogonadotrophic hypogonadism was recorded in 64.7% and primary On examination she was volume depleted with dry mucous membranes and loss hypogonadism in 2.9%. Hypogonadism was associated with myocardial iron of skin turgor. Urine output over the previous 4 days had been 2.5–4 l/day, urinary loading. For every 1 ms decrease in the lowest cardiac magnetic resonance T2* sodium was elevated at 195 mmol/l with low serum sodium of 123 mmol/l. In value between 1999 and 2010, there was a 4.4% (95% CI 0.8–7.8%, P value view of the high urine output and clinical signs of hypovolaemia, cerebral salt 0.016) increase in odds of having hypogonadism. wasting syndrome (CSWS) was felt to be the most likely diagnosis. No cases of GH deficiency or glucocorticoid deficiency were documented. She was treated with i.v. 0.9% saline (200 ml/h), and CVP monitoring was Conclusions instituted. After 2 h, her serum Na had dropped to 117 mmol/l, and therefore 0.9% A significant proportion of thalassaemia major patients have endocrine saline was changed to hypertonic saline (1.8%). deficiencies. Ferritin concentrations are not a reliable predictor of endocrine By the following day GCS (14/15) and serum Na (129 mmol/l) had improved. deficiency. Patients with evidence of cardiac iron loading over the previous 11 However, on switching to 0.9% saline the serum Na dropped to 123 mmol/l and years were more likely to have hypogonadism. This suggests that tissue iron therefore hypertonic saline was recommenced. By day 9 serum Na had stabilised loading is an important factor leading to hypogonadism. Controlling total body at 127 mmol/l and she was switched to normal saline. iron in thalassaemia major is critical in preventing damage to multiple major The next day her serum Na dropped again to 119 mmol/l with persistently organs. elevated urinary sodium (225 mmol/l) and high urine output. She was therefore changed back to hypertonic saline and this was continued until her urinary sodium level was !150 mmol/l. By day 15, her serum Na was stable at 134 mmol/l, urinary sodium was 100 mmol/l, and GCS had improved to 15. Normal saline was recommenced with P76 no drop in serum Na, and she was gradually weaned off i.v. fluids. Significant hirsutism complicating pregnancy with postpartum Treatment of CSWS requires replacement of excreted sodium, which can usually resolution be achieved with i.v. normal saline. If sodium losses are very large then Mohammed Adlan & Lakdasa Premawardhana hypertonic saline may be required. Caerphilly Miners’ Hospital, Caerphilly, UK.

Introduction A 28-year-old primigravida developed increasing hairgrowth in androgen sensitive areas in the first trimester of her first pregnancy. She was previously P78 well with menarche at 14 years, normal periods thereafter and no difficulty in Milk–alkali syndrome: not to be forgotten conceiving. She took no medication. Clinically, at 34 weeks gestation she had Ramona Verdaguer & James Lawrence significant hirsutism of her face, arms, legs and a prominent male escutcheon. She Salisbury Foundation NHS Trust, Salisbury, Wiltshire, UK. was obese but not Cushingoid. Investigations and results A 50-year-old woman with learning difficulties and schizophrenia presented to accident and emergency with 5 days of epigastic pain and vomiting. Table 1 Initially, she was peripherally shut down, with a pulse of 120 and blood pressure of 115/80. Chest examination was normal. Abdominal examination showed 34/52 36/52 4 days 11 days epigastric tenderness with guarding. gestation gestation postpartum postpartum Blood tests confirmed a diagnosis of acute pancreatitis (Amylase 1972 IU/l), with Testosterone 12 nmol/l 19 4.4 2 hypercalcaemia (corrected calcium 3.46 mmol/l) and acute renal failure Androstenedione 41 nmol/l 61 (creatinine 692 mmol/l, urea 31.8 mmol/l). DHEAS 3.4 3.3 4.8 4.8 Initial management included i.v. fluids, i.v. antibiotics and transfer to high SHBG 30 34 dependency unit. The following day her bloods were as follows: Corrected UFC 35 nmol/24 h 342 Calcium 2.64 mmol/l, PTH 17.6 pmol/l.

Days Day 1 Day 2 Day 3 Day 4 Day 7 Day 44 Day 119 Urinary androstenedione metabolites, androsterone (4000) and aetiocholanolone (3000) were significantly elevated compared to pregnant women of a similar Corrected 3.46 2.64 1.82 1.64 2.45 2.49 2.36 gestational age (!1000 mg/g creatinine), and investigations for CAH were calcium normal. MRI scans of the abdomen and pelvis revealed a normal female foetus, (mmol/l) normal adrenal glands but her ovaries were not visible. A postpartum transvaginal PTH 17.6 3.6 (pmol/l) ultrasound scan revealed polycystic ovaries but no tumour. Creatinine 692 627 594 506 185 61 69 She delivered a healthy, normal female child and her hyperandrogenism (Table 1) (mmol/l) and hirsutism resolved completely postpartum.

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Over the coming days she became more unwell and was intubated on intensive 81.2% of patients with differentiated carcinoma had radio-iodine ablation post- care unit. Her calcium plummeted and was managed with calcium infusion. She operatively. Three patients had external beam radiation. TSH suppression was not then slowly recovered and calcium normalised. achieved in 66% of patients; 37% of these were not managed by endocrinology. On further discussion it was apparent that she had been consuming excessive Only 69% of patients had had a basal thyroglobulin measured and 36.7% a indigestion remedies (rennes and gaviscon) for years before admission. She has stimulated thyroglobulin; in patients with undetectable basal levels, only two had now been started on a proton pump inhibitor and calcium and PTH have both detectable thyroglobulin when TSH was O50. normalised and remained normal. This audit highlights the need to plan the extent of surgical resection prior to This is a case of milk–alkali syndrome complicated by severe pancreatitis and completion thyroidectomy and for management of TSH suppression by an renal failure. The raised PTH on day two is due to the huge drop in calcium over endocrinologist. the first 24 h. It is important to still consider milk–alkali syndrome in the differential for severe hypercalcaemia. Measurement of PTH after initial treatment of hypercalcaemia can give a misleading result as in this case and teams should be encouraged to measure PTH at initial assessment in all patients with hypercalcaemia. P81 Use of Tolvaptan in hyponatraemia: how long is treatment required? Kalpita Majumdar & B S Aditya Aintree University Hospitals NHS Foundation Trust, Liverpool, UK. P79 A case of lymphocytic hypophysitis 1 1 2 2 Introduction Simmi Krishnan , Julian Davis , Piyali Pal , Kanna Gnanalingham & Hyponatraemia is common biochemical abnormality in hospitalised patients and Fredrick Wu1 1 2 is difficult to manage in some cases. Tolvaptan is presently licensed in the UK for Manchester Royal Infirmary, Manchester, UK; Salford Royal Hospital, the treatment of hyponatraemia secondary to SIADH. We present our experience Manchester, UK. of using Tolvaptan. Cases A 22-year-old pregnant lady presented to the Emergency Department (ED) at 36 Patient 1 was admitted with sagittal sinus thrombosis. Over 9 days serum sodium weeks of gestation with sudden onset of severe headache and blurring of vision. dropped from normal to 121 mmol/l with biochemical evidence of SIADH. The On examination, she was alert, conscious (GCS: 15/15) and had bitemporal patient was treated with Tolvaptan for 4 days, after management with fluid hemianopia, confirmed on formal visual field assessment. MRI brain scan (limited restriction and Demeclocycline had failed. Sodium increased to 133 mmol/l and views due to pregnancy) showed a pituitary mass extending into the suprasellar remained stable. Patient 2, an 83-year-old woman with background problems region and reaching the optic chiasm. Serum prolactin (PRL) was elevated at including atrial fibrillation, was admitted electively for pacemaker insertion. 3876 m/l (102–496) and she was commenced on Bromocriptine 2.5 mg OD by the Serum sodium on admission was 129 mmol/l. Following pacemaker insertion, she attending team and discharged home. developed heart failure and needed diuretics, which were difficult to continue as She was later admitted for delivery when the endocrine team was involved in she developed significant hyponatraemia. Her nadir sodium level was further management. She was given i.v. hydrocortisone until delivery and was 114 mmol/l, leading to neurological sequelae. She was prescribed Tolvaptan started on PO hydrocortisone following delivery. A short synacthen test (SST) for 8 days, which improved her sodium. Over the next few months her sodium 10 days post delivery was suggestive of cortisol deficiency (baseline cortisol of levels have remained stable. Patient 3 was admitted with fractured neck of femur 183 nmol/l and 30 min cortisol of 399 nmol/l) and her PRL level had improved to and operated. Sodium on admission was normal, but dropped to 110 mmol/l by 290 m/l. the 15th day. She became confused and biochemically had SIADH. She was Three weeks post delivery, she presented to the ED with worsening of her visual initially managed with strict fluid restriction but this failed to improve matters. symptoms. Repeat MRI brain scan showed increase in the size of the pituitary She was given Tolvaptan for 10 days. Hyponatraemia resolved rapidly and tumour with lateral extension towards the cavernous sinus and optic chiasm sodium levels remained normal since. compression. She underwent trans-sphenoidal resection of the pituitary tumour. Discussion Microscopic features and histology was suggestive of lymphocytic hypophysitis. Hospitalised patients can develop hyponatraemia due to a variety of causes and Her thyroid functions, IGF1 and gonadotropins were normal. Insulin tolerance some can be very symptomatic. Tolvaptan use has been studied in multiple test confirmed ACTH deficiency (peak cortisol of 336 nmol/l). experimental and clinical trials which have used Tolvaptan for over 30 days. In Lymphocytic hypophysitis is a rare inflammatory lesion of the pituitary gland and clinical practice Tolvaptan appears to restore salt and water homeostasis rapidly has a female preponderance. It usually presents in late pregnancy or postpartum following short-term use. Once the cause of hyponatraemia is treated normal period. Presentation of lymphocytic hypophysitis often mimics pituitary sodium levels are maintained long-term. adenoma. It has preference for destruction of ACTH and TSH secreting cells with normal gonadotropins and GH.

P82 The thyroid and the skin Niranjala Hewapathirana & Peter Mansell P80 Nottingham University Hospitals, Nottingham, UK. Targets for improvement of care for thyroid carcinoma patients in the multidisciplinary setting Aoife Lowney, Rachel Crowley, Domhnall O’Halloran & Antoinette Tuthill Case Cork University Hospital, Wilton, Cork, Ireland. A 41-year-man presented to his GP with a pruritic skin rash affecting the whole body but sparing the face. He was treated with antihistamines with no improvement. On investigation thyroid function tests showed free T4 48 pmol/l, The British Thyroid Association recommends that a specialist multidisciplinary free T3 11.6 pmol/l with suppressed TSH!0.1 mU/l. He was started on team (MDT) is responsible for thyroid cancer management. In accordance with carbimazole and referred to endocrinology. At the clinic it was noted that he this recommendation, a team was formed to manage thyroid carcinoma in a has lost weight, felt hot all the time. There was no past history of rash. He was not tertiary referral centre. The team included endocrinology, general surgery, ENT, on any medication prior to the rash. He had a wide spread urticarial skin rash, lid cytology, radiology and radiation oncology consultants. lag and a small diffuse goitre. The TPO antibodies titre was raised at 285.7 IU/ml This audit was performed to assess management of thyroid carcinoma before the (0–60), normal ESR and normal vasculitic screen. establishment of the MDT and to identify areas for improvement. A skin rash as a presentation of thyrotoxicosis is a very rare finding. We sought a Eighty-five patients (60 female) were included and most had undergone surgery dermatology opinion but no alternative diagnosis was found. Our patient’s since 2000 (4 patients 1990–1999). In total 6 surgeons had performed thyroid hyperthyroidism came under control with 30 mg of carbimazole once daily. surgery; one general surgeon was responsible for 87% of cases. Where data was Thyroid function tests improved and the rash lessened but was still troublesome. available with regard to the extent of surgery, 68% had had thyroidectomy He was therefore referred for therapeutic radio-iodine as definitive treatment. The without neck dissection. The histological diagnosis was papillary 64%, follicular thyroid over-activity came under control requiring a small dose of carbimazole at 29%, medullary 4% and anaplastic 3%. The surgical practice of limited resection present. The rash is much improved. Interestingly he had a flare up when he was reflected in histology reporting; the extent of nodal disease could not be stopped carbimazole for two weeks around the time of radioiodine treatment, reported in 58.4% of cases (Nx). when there will have been a transient minor deterioration of thyroid over-activity.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Discussion P85 This case illustrates a rare presentation of thyrotoxicosis. The skin rash is thought A case of carcinoid syndrome due to medullary thyroid carcinoma to be the result of thyroxine modulating the cAMP levels within the mast cells. Daniel Flanagan1,2, Thomas Fox1,2 & Jamie Fulton1,2 The condition is fairly resistant to symptomatic management with antihistamines 1Derriford Hospital, Plymouth, UK; 2Peninsula College of Medicine and but generally regress only once the hyperthyroidism is under control. Dentistry, Devon, UK.

A 73-year-old man was referred to the general medical clinic with a 3-year history of shortness of breath and wheeze. During assessment he commented that over the P83 same period he had also had intermittent sweats, flushing and redness of the face especially after eating and taking red wine. Echocardiogram and urinary 24-h An unusual case of medullary thyroid cancer presented with T3 toxicosis and type 2 diabetes 5-hydroxyindoleacetic acid (5-HIAA) were arranged. Surprisingly two of three Pesh Amin urinary 24-h urinary 5-HIAA were positive (43 and 47.5 mmol/24 h and Royal Derby Hospital, Derby, UK. 30 mmol/24 h, NR 6–36 mmol/24 h). Given the clinical suspicion of carcinoid syndrome an octreotide scan was performed in anticipation of finding an intestinal lesion. Unusually this A 76-year-old man with recent history of diet control diabetes and hypertension demonstrated avid tracer uptake in the neck corresponding to a 3!4 cm mass presented to his GP with change in his voice and biochemical T3 toxicosis. He had in the thyroid gland on computerised tomography. He was referred to the no further assessment and received no treatment. Few months later he presented endocrine services for further evaluation. with right side goitre and found to have right vocal cord palsy and medullary MIBG SPECT confirmed avid uptake in the right lobe of the thyroid gland. thyroid cancer and hyperthyroidism. He had evidence of local nodal and distant Neither imaging modalities showed associated lymphadenopathy. The diagnosis metastases. Soon after biochemical euthyroidism he underwent total thyroid- of a neuroendocirne thyroid tumour was made and ultrasound guided fine-needle ectomy and local lymph node resection. aspiration cytology of the thyroid mass was performed. Initial cytology indicated Thyroid cancer is occasionally associated with hyperthyroidism. Medullary a follicular lesion grade Thy3. Repeat FNAC was more suggestive of a medullary thyroid carcinoma (MTC) has been rarely described in association with Graves’ neoplasm. Core thyroid biopsy confirmed a medullary carcinoma of the thyroid disease or other forms of hyperthyroidism. Careful evaluation of hyperthyroid which was calcitonin positive. MRI of the adrenals and serum calcium were patients is always necessary to exclude the presence of associated malignancy and normal making MEN2 unlikely. to determine the most appropriate therapeutic plan. The patient was commenced on lanreotide 60 mg monthly and underwent total A recent study presented at the International Thyroid Congress suggests that thyroidectomy and neck dissection. Histology showed a well-circumscribed endogenous subclinical types of hyperthyroidism may have a larger metabolic medullary thyroid carcinoma. He made an excellent post-operative recovery with effect on insulin resistance than the exogenous type of the condition. While it is total resolution of his symptoms of flushing. Post-operative urine collections for obvious that hyperthyroidism does not protect against thyroid cancer but in actual 5-HIAA were normal, as were calcitonin and chromogranin A levels. A follow-up fact can have impact on insulin resistance and probably increasing chance of octreotide scan 4 months after surgery showed no avid uptake in the neck. mutation and thyroid cancer. Although carcinoid most commonly is derived from an intestinal tumour source it The MTC is not common and such presentation like our case is quite rare. is important to note that medullary thyroid carcinoma is also a rare source. However, this case highlights the importance of clinical vigilance and proper assessment of thyroid dysfunction. Furthermore studies are required to explore cause and relationship between thyroid dysfunction, insulin resistance and increase risk of thyroid mutation.

P84 P86 Tramadol-induced adrenal insufficiency. A case report. Calcitonin negative medullary thyroid cancer Sharon Chan, Miguel Debono & T Hugh Jones David Woods1,2, Anjali Santhakumar1, Sara Johnson2,3 & Seb Aspinall1,2 Department of Endocrinology, Barnsley Hospital NHS Foundation Trust, 1Newcastle and Northumbria NHS Trusts, Newcastle, UK; 2University of Barnsley, UK. Newcastle, Newcastle, UK; 3Royal Victoria Infirmary, Newcastle, UK.

Background Medullary thyroid cancers (MTC) account for about 5% of thyroid cancers. The The effect of long term opioids on the hypothalamo-pituitary–adrenal (HPA) axis biochemical hallmark of MTC is the secretion of calcitonin (CT). CT levels are is conflicting. We present a case of a 21-year-old female who presented with both a key feature of pre-operative diagnosis and post-operative follow up. CT adrenal insufficiency (AI) secondary to chronic tramadol use. screening in a cohort of over 10 000 patients with thyroid nodular disease has Case summary demonstrated that a positive CT test has a higher diagnostic sensitivity and Our patient presented with a three year history of non-specific abdominal pain, specificity for MTC than fine needle aspiration (FNA). They may also secrete lethargy and dizziness. No cause was found for these symptoms despite thorough carcinoembryonic antigen (CEA). We report a patient with histologically proven investigations. One month before referral to Endocrinology outpatients, she was MTC with negative CT and CEA pre-operatively who originally presented with hospitalised with a three day history of dizziness, vomiting and pressure-like evidence of primary hyperparathyroidism. headaches. An MRI scan showed an incidental pituitary microadenoma whilst the Case presentation pituitary profile revealed a mildly abnormal Synacthen test with a baseline 0900 h A 63-year-old retired plasterer attended the endocrinology clinic with cortisol of 54 nmol/l and a 30-min cortisol of 537 nmol/l. Her medications included biochemical evidence of primary hyperparathyroidism: calcium of 2.76 mmol/l Tramadol 50 mg TDS besides Sumatriptan, Metoclopramide, Omeprazole and (2.12–2.60), parathyroid hormone (PTH) level of 76 ng/l (10–60), 24 h urinary Ibuprofen. Her Synacthen test normalized when advised to stop tramadol. calcium of 11.2 mmol/24 h (2.5–7.5), vitamin D replete. Pre-operative Two months later, she was readmitted with similar symptoms. Tramadol 100 mg investigation revealed a 2.5!1.7!1.4 cm dominant left thyroid nodule which QDS had been inadvertently restarted by her GP for persistent abdominal pain. was hypoechoic and associated with specks of calcification. FNA was reported as Cortisol levels from the Synacthen test were 45 and 307 nmol/l at 0 and 30 min THY3, consistent with a follicular neoplasm. Owing to the association of MTC respectively. ACTH was relatively low at 9.7 ng/l. The rest of the pituitary profile with primary hyperparathyroidism in MEN2 he had a pre-operative assessment of was normal. A diagnosis of tramadol-induced AI was made. Repeat Synacthen tests CT and CEA. CT was reported on 2 separate occasions as !11 ng/l (!11) and and ACTH normalized when stopping tramadol. Her quality of life improved 12 ng/l (!11). CEA was 4.1 mg/l (!5). Overnight urinary metanephrine and significantly. normetanephrine levels as well as plasma metanephrines and normetanephrines Conclusion assessed pre-operatively were normal. The sequence of events and development of AI on re-challenge with tramadol The patient underwent bilateral neck exploration with left hemi-thyroidectomy. support this drug as the cause for this event. To our knowledge this is the first The overall histological features were consistent with medullary thyroid clinical case of tramadol-induced AI although this effect on the HPA axis has carcinoma pT1b pNX pMX (TNM 7th edition). Immunohistochemistry showed been previously reported with other opioids. There are currently no guidelines diffuse cytoplasmic positivity for CT and heterogeneous labelling with CEA. His recommending routine screening of adrenal status in patients on opioids but RET proto oncogene status is awaited. These patients may constitute a subset of clinicians should be aware of the possibility of AI in opioid users. Systematic patients with ‘atypical’ MTC where the tumour can produce CT (hence positive studies on the effects of opioids on the HPA axis are necessary. staining) but is unable to secrete the protein.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P87 P89 A case of complete androgen insensitivity syndrome (CAIS), late Congenital adrenal hyperplasia: spontaneous resolution or cure? presentation and difficult management Aysha Javed, Sherine Thomas, David Ewins, Niru Goenka & Frank Joseph Shiva Mongolu, Jana Bujanova & Darryl Meeking Countess of Chester Hospital, Liverpool Road, CH1 1UL Chester, UK. Queen Alexandra Hospital, Portsmouth, UK. We present the case of a woman who first presented at age 18 with hirsutism. Introduction Menarche had been normal and she had regular menses. She gave no past medical Complete androgen insensitivity syndrome (CAIS) is an X-linked genetic history except that at age 6 she had been admitted to hospital with tonsillitis that disorder characterised by normal female appearance, including external genitalia was complicated by diarrhoea and vomiting, drowsiness and hypotension. At that and the presence of 46XY karyotype. We report a case of CAIS, diagnosed in time, NaC was 130 mmol/l and KC5.8 mmol/l. She was treated with antibiotics adulthood, and discuss ethical issues surrounding the disclosure of diagnosis and and fluids and improved; electrolytes returned to normal. associated difficulties in further management. On examination her blood pressure was 140/105 mmHg. She had acne but no Case history features of virilisation; her BMI was 20.8 kg/m2. A 33-year-old Nigerian lady was referred to our endocrine service with Primary Routine biochemistry was normal. Two random measurements of 17 hydroxy- amenorrhoea. She stated that she was partially investigated in another centre and progesterone (17-OHP) were raised at 47 and 55 nmol/l (1.4–12). Synacthen was found to have a shrunken uterus on ultrasound scanning and Laparoscopy, stimulation resulted in an increase of 17-OHP from 72 to 79 nmol/l and then and normal ovaries. She had normal external genitalia with paucity of axillary and 88 nmol/l at 30 and 60 min respectively. Peak cortisol response was suboptimal at pubic hair. Although her testosterone level was markedly elevated at 21 nmol/l, 412 mmol/l. DHEAS was high at O26 mmol/l (1.8–10.2) with a high testosterone she was not hirsuite with no masculine features. Her DHEAS was normal 5.1 nmol/l (1.4–3.8). A 24 h urine collection showed normal cortisol excretion at (3.2 mmol/l) and 17OH Progesterone was midly raised (5 nmol/l). 498 nmol/24 h and cortisol suppressed after overnight dexamethasone of 1 mg. Chromosomal analysis demonstrated 46XY karyotype consistent with androgen A diagnosis of non-classical heterozygous congenital adrenal hyperplasia insensitivity syndrome. Each time the issue of chromosomal abnormality was was made and she was started on prednisolone 2.5 mg in the morning and 5 mg mentioned, she declined further information and refused to see a clinical at night. geneticist. Diagnosis was disclosed to the patient and her family but, she refused Her hirsutism improved and due to over-suppression of 17-OHP, prednisolone to accept stating her previous ‘normal’ investigations. was tapered and eventually stopped 9 years later at age 27. A repeat short After constant persuasion, she underwent an MRI scan of her pelvis which synacthen test (SST) showed a 17-OHP peak of 20.0 nmol/l and a cortisol peak of confirmed absence of uterine tissue and presence of reproductive tissue within 500 nmol/l, again suboptimal. She also tested negative for known 21-hydroxylase pelvis (probably testicular in origin). She refused referral to Gynaecologist for mutations and repeat androgen levels had normalised. surgical removal of the tissue, despite being warned of malignancy risk and did Repeated SSTs have resulted in suboptimal cortisol response but normal 17OHP not attend her further follow-up appointments. responses but with no clinical features of androgenisation or hypoadrenalism. We Discussion have no explanation for the resolved abnormalities but she remains well having This case highlights the psychological trauma which can be associated when declined long term steroid therapy and has steroids at times of illness. faced with a diagnosis of CAIS and how they frequently avoid medical care. Sensitivity, awareness and a multi-disciplinary approach are needed in the management of these patients.

P88 ‘Old Red-Eyes Is Back’: a case of calcium–alkali syndrome P90 Sarah Ali, Ali Abara, Tricia Tan, Owais Chaudhri, Emma Hatfield, Multiple endocrine dysfunction in the context of psychiatric medication Karim Meeran & Katie Wynne Richard Carroll, Karim Meeran & Jeannie Todd Endocrine Unit, Imperial College Healthcare NHS Trust, London, UK. Imperial College Healthcare NHS Trust, London, UK.

A 31-year gentleman presented with a four day history of anxiety and confusion. MM, a 51-year-old female was reviewed in the Endocrinology clinic for the Over several months, he had noticed red eyes and a ‘stomach-ache’. A collateral assessment of hypercalcaemia, hyperprolactinaemia, and an adrenal mass. history revealed a previous episode of confusion and concern about excessive Bipolar depression had been diagnosed 24 years previously with continuous alcohol intake. He denied any current medication. On examination, he had use of Lithium Carbonate since. An acute deterioration in mental state 3 years bilateral conjunctivitis. Investigations demonstrated severe hypercalcaemia of previously prompted Risperidone treatment which was ongoing. Hypercalcaemia 3.54 mmol/l (NR 2.15–2.6 mmol/l). He was treated with intravenous fluids and (calciumZ2.78 mmol/l, PTHZ13.8 pmol/l, vitamin DZ33 nmol/l) was furosemide, and discharged when calcium levels normalised. recorded. Polyuria and nocturia was noted. A renal ultrasound and bone mineral He was re-admitted soon afterwards with confusion following a seizure. density DEXA scan were normal. The 24 h urinary calcium/creatinine clearance Investigations revealed severe hypercalcaemia (3.80 mmol/l), metabolic alkalosis ratio was calculated at 0.027. An ultrasound of the neck and sestamibi nuclear and acute renal failure (creatinine 468 mmol/l; NR 60–125 mmol/l). Free scan are awaited. thyroxine, cortisol, vitamin D and renal ultrasound were normal. Parathyroid An adrenal mass was detected incidentally during the assessment of non-specific hormone was low-normal (1.7–2.1 pmol/l; NR 1.1–6.8 pmol/l). Treatment was abdominal pain. CT imaging revealed a 23 mm right adrenal mass with with intravenous fluids and furosemide. Hounsfield units of 17. A functional screen revealed the following; During this admission, calcium carbonate antacid tablets were discovered on his reninZ2.0 pmol/ml per hour, aldosteroneZ460 pmol/l, (RatioZ230 NR bedside table. Specific questioning revealed he regularly ingested three packets a !800); AndrostenedioneZ2.8 nmol/l (NRZ4.0–10.2), DHEASZ2.7 mmol/l day (24 g calcium) for chronic alcohol-induced indigestion. Calcium–alkali (NRZ0.8–6.9) and extracted testosteroneZ0.8 nmol/l (NR!3.0); Following a syndrome (CAS) leading to hypercalcaemic conjunctivitis, psychosis, seizure and 48 h LDDST-T 48 cortisolZ43 nmol/l (normal!50); Urinary catecholamines renal failure was diagnosed. As the hypercalcaemia resolved, his cognitive state were elevated on two occasions (Urinary adrenalineZ0.13 mmol (NR!0.1), returned to normal and his eye signs resolved. At follow-up, calcium levels NoradrenalineZ1.63 mmol/l (NR!0.5), DopamineZ11.18 mmol/l (NR!2.7) in remained normal. the context of normal urinary metanephrines. There were no clinical features Conclusions suggestive of phaeochromocytoma apart from hypertension (168/95 mmHg). Originally described as Milk-Alkali syndrome as associated with excessive milk Hyperprolactinaemia (2223 mU/l, NRZ125–625) had been noted on multiple and bicarbonate consumption for treatment of peptic ulcer disease; change in occasions and coincided with the commencement of risperidone therapy. The nomenclature to CAS is suggested since milk is no longer the prevalent aetiologic patient did not report galactorrhoea but did note amenorrhoea with suppressed source. Use of H2 antagonists and proton pump inhibitors made CAS uncommon, gonadotrophins. An MRI scan of the pituitary was normal. however increasing use of calcium carbonate preparations for osteoporosis and It is likely that the primary hyperparathyroidism and hyperprolactinaemia are renal disease has resulted in resurgence. In this case, an over-the-counter agent for attributable to lithium induced parathyroid hyperplasia and risperidone induced dyspepsia was the culprit. hyperprolactinaemia respectively. In addition, the elevated catacholamines are Clinical suspicion of CAS should be raised if hypercalcaemia, suppressed PTH, also likely to be due to risperidone and /or anxiety confusing the investigation of alkalosis and renal failure are present. If a careful medication history is not an adrenal incidentaloma. The case illustrates the effect psychiatric medications obtained the consumption of calcium and alkali may be unrecognised, resulting in can have on endocrine systems, and the difficulties the clinician experiences when unnecessary investigations and inappropriate treatment. trying to differentiate medication induced abnormalities from other aetiologies.

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P91 This highlights the need to increase awareness among physicians so that Primary care records in hospital clinics: implementing two-way abnormalities can be detected at an early stage. communication in Cheshire, UK Ram Prakash Narayanan1, Dhanya Kalathil2, Farheen Raza2, Elizabeth Jarman3, David Lowes3, M Zubair Qureshi2 & Adrian H Heald2 1Vascular Research Group, The University of Manchester, Manchester, UK; 2Leighton Hospital, Crewe, UK; 3Medical School, The University of Manchester, Manchester, UK. P93 Psychiatric illness: a cause and hurdle to management of nephrogenic diabetes insipidus In Central and Eastern Cheshire, Secondary Care endocrinology/diabetes Lisa Turner, Giridhar Tarigopula, Olympia Koulouri & Marie-France Kong clinicians can now access a summary of the patient’s primary care electronic Department of Diabetes and Endocrinology, University Hospitals of patient record (EPR), using a secure Web browser for GP data held by the GP Leicester NHS Trust, Leicester, UK. provider EMIS. This improves decision making at the point of care. The clinicians, including consultants, SpRs, dieticians and specialist nurses can access details of medication, allergies, and previous diagnoses, available for 95% A 54-year-old lady with a 27-year history of schizoaffective disorder presented of attendees. The GP summary record appears on the screen as a ‘Read-only’ with shaking episodes, polyuria and polydipsia. She was found to have a serum document. Consent is given by the patient and audited. sodium of 157 mmol/l. Of note, she had been on lithium for several years but this Importantly, none of the patients participating in the project has refused access. had been stopped three months previously as her serum sodium was raised at Feedback has been extremely positive. They view sharing information as a way to 156 mmol/l. improve their own healthcare and also health outcomes for the wider community. On admission her lithium level was undetectable, confirming no recent use. One patient said: ‘this is a big step forward for patient safety’. Another patient Serum osmolality was 343 mOsm/kg and urine osmolality 82 mOsm/kg, observed ‘why aren’t all services sharing my information like this’. suggesting diabetes insipidus. Thyroid function tests and other pituitary function Hospital clinicians can record certain details from the consultation into a template tests were normal. Initially desmopressin was given as a diagnostic trial but this and write short notes to the GP, that are added to the patient’s record in real-time. had no impact and her serum sodium rose to 167 mmol/l. Her urine osmolality did The patient’s GP is then able to view this back at the practice and include the not rise above 159 mOsm/kg. A paired serum osmolality was 360 mOsm/kg. comments in their own record if they wish. This has the potential to feed directly During admission her serum sodium peaked at 175 mmol/l. As a result of her into individualised care pathways. mental health issues, she was not drinking adequately to compensate for the fluid In a separate development, the anonymised search facility means that we can take loss and required i.v. supplementation of up to 7 l/day. Indomethacin 50 mg BD a longitudinal view of trends, such as results of testing for thyroid hormone and subsequently Chlortalidone 100 mg BD were started while encouraging her to imbalance or testosterone deficiency in patients with diabetes across one or increase her fluid intake. I.v. fluids were gradually weaned off. At discharge several Primary Care Trusts. This affords an audit tool that can assess real her serum sodium was 140 mmol/l, serum osmolality 302 mOsm/kg and urine outcomes. osmolality 226 mOsm/kg. Conclusion Unfortunately she was readmitted one month later with dehydration and Access to primary care information affords a radically different perspective, hypokalaemia and she remains an inpatient 4 weeks later. Her diabetes insipidus enhancing the clinic consultation and facilitating cross-boundary working with persists despite not having taken lithium for almost 6 months and it is patient satisfaction. It offers a potential frameshift in the management of compounded by her inability to maintain her fluid intake. long-term metabolic and endocrine conditions. Diabetes insipidus may persist for several months or years after discontinuing lithium. Management of our patient remains a challenge. Drugs have had little impact on her condition which is exacerbated by her underlying mental health problems.

P92 Thyroid function monitoring in amiodarone treated patients: the need to increase awareness among prescribing physicians Graham Dunthorne & Zayd Merza P94 Barnsley Hospital NHS Foundation Trust, Barnsley, UK. Pseudo-Cushing’s syndrome and central pontine myelinolysis Marie-France Kong1, Kaustubh Nisal1, Michael Knopp2, Siew Lee Wong2, Yusuf Rajabally2 & Trevor Howlett1 Introduction 1Department of Diabetes and Endocrinology, University Hospitals of Amiodarone is a commonly prescribed antiarrythmic drug. It can cause potentially Leicester NHS Trust, Leicester, UK; 2Department of Neurology, University serious adverse effects involving the thyroid gland, lungs, liver and eyes. It is Hospitals of Leicester NHS Trust, Leicester, UK. recommended that patients on amiodarone have regular monitoring tests. Methods We conducted an audit of patients who were prescribed amiodarone by various A 52-year-old man was referred in June 2009 with weakness, unsteadiness, physicians in our hospital between January 2007 and March 2008. The data was diarrhoea and weight loss of 14 kg in the last 4 months. His past medical history obtained from the patients case notes. We looked at tests done at baseline and included hypertension, ischaemic heart disease and chronic obstructive regular intervals thereafter up to two years, including thyroid, liver, renal and pulmonary disease. He was a heavy smoker and admitted to drinking heavily pulmonary function tests and chest X-rays. for the past 9 months. His serum sodium was 126 mmol/l, serum potassium Results 2.0 mmol/l, serum bicarbonate 31 mmol/l. His chest X-ray was normal. He had The case notes of 79 patients (52 males and 27 females) were reviewed. The mean had persistent hypokalaemia for 4 months which had been attributed to his age was 70G11 years. The commonest indication for amiodarone was atrial diarrhoea. His serum potassium was normal in December 2008. A 24 h urinary fibrillation (77%). 55, 39, 32, 27 and 26 patients continued therapy at 3, 6, 12, 18 free cortisol was very high at 1491 (normal range 28–221 nmol/24 h). However, and 24 months respectively. Thyroid function tests were performed in 78% of he had no stigmata of Cushing’s disease. In view of his weight loss, smoking patients at baseline, 31% at 3 months, 64% at 6 months, 53% at 12 months, 55% at history and hypokalaemia ectopic ACTH syndrome was considered. He did not 18 months and 35% at 24 months. Liver function tests were performed in 82% of suppress fully after a 48 h high dose dexamethasone suppression test. ACTH was patients at baseline, 59% at 6 months, 50% at 12 months, 48% at 18 months and 6 ng/l. A CT thorax/abdomen/pelvis showed no evidence of a neoplasm and no 31% at 24 months. Urea and electrolytes were checked in 95% of patients at adrenal mass. MRI of the pituitary gland was unhelpful as he was unable to keep baseline. Chest radiography was performed in 48% of patients at baseline, 9% at still. A 24 h urine collection for 5-HIAA to exclude carcinoid syndrome was 12 months and 4% at 24 months. Pulmonary function tests were performed in 9% normal. Corticotrophin-releasing hormone stimulation test did not support a of patients at baseline. pituitary source of ACTH. He was readmitted a month later with recurrent Conclusion hypokalaemia and muscle weakness. Serum sodium was 114 mmol/l, serum This audit shows that a significant number of patients on amiodarone do not get potassium 2.2 mmol/l. Over the next few days he became confused and agitated. the recommended regular monitoring for potential adverse effects of amiodarone. A CT head scan excluded a subdural haematoma. CSF culture was negative.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

An EEG showed mild diffuse slowing. MRI of the brain showed features detection. AAS use is associated with side effects of Cardiovascular, hepatic, compatible with central pontine myelinolysis. We concluded that our patient’s gynaecological, behavioural, skin and endocrinological disorders. cortisol abnormalities was due to pseudo-Cushing’s syndrome caused by his Hepatic excessive alcohol consumption which also accounted for his hyponatraemia and With AAS abuse there is an elevated risk for liver tumours, cholestasis, toxic hypokalaemia. Some patients have no physical evidence of glucocorticoid excess hepatitis and peliosis hepatitis. This is likely due to the liver being the primary like in our patient. site of steroid clearance. The alkylated AAS are highly hepatotoxic. Cardiovascular AAS can induce hypertension, MI, abnormal lipoproteins and possibly LVH. AAS can affect lipid profile adversely leading to reduction in HDL cholesterol raised LDL leading to early atherosclerosis. Conclusion As there is rise in unregulated abuse of AAS, so we need to be aware and consider anabolic steroid as cause of unexplained liver failure, deranged lipid profile and P95 endocrinological abnormalities. Cyclical Cushing’s or poorly controlled diabetes in an insulin resistant Main treatment is stopping the drugs and monitoring regularly. patient? Marie-France Kong, Giridhar Tarigopula, Olympia Koulouri, Lisa Turner & Robert Gregory Department of Diabetes and Endocrinology, University Hospitals of Leicester NHS Trust, Leicester, UK.

A 30-year-old Caucasian lady was diagnosed with type 2 diabetes in July 2005 on an oral glucose tolerance test and was treated with metformin. Sixteen months later she presented with urinary symptoms and was noted to have 2C ketonuria. P97 2 Her blood glucose was 13.4 mmol/l. Her BMI was 26 kg/m and she was noted Hypercalcaemia following parathyroidectomy in a pregnant lady with to have Cushingoid habitus and acanthosis nigricans. Her blood pressure was MEN-1 normal. Her serum sodium was 130 mmol/l, potassium 3.7 mmol/l and Rhodri King, Emma Ward, Andy Scarsbrook & Steve Orme bicarbonate 8 mmol/l. She was noted to have severe hypertriglyceridaemia Leeds Teaching Hospitals NHS Trust, Leeds, UK. of 58.4 mmol/l. Serum cholesterol was 16.1 mmol/l. She was treated with intravenous insulin and discharged home on twice daily pre-mix insulin. Investigations for Cushing’s syndrome were negative. 24 h urinary free cortisol We present a 20-year-old lady who was known to have MEN-1 and had was normal. 0900 h serum cortisol after overnight dexamethasone suppression previously been treated for hyperparathyroidism at a different hospital in 2003 test was 36 nmol/l. ACTH was 6 ng/l. Cyclical Cushing’s was considered but six with excision of right upper and lower and left lower parathyroid glands and left 24 h urinary free cortisol collections were negative. Despite taking w300 units of thyroid lobectomy, resulting in normalisation of adjusted calcium (adjCa) levels. insulin her HbA1c remained above 11% on a basal bolus regimen. Anti GADA She presented to our department with persistently elevated adjusted calcium was negative. Genetic analysis confirmed severe hyperinsulinaemia with levels (adjCa 2.69 mmol/l) along with raised parathyroid hormone (PTH dyslipidaemia with very low adiponectin and high leptin levels, in keeping 16 pmol/l) and low total vitamin D levels (14.2 nmol/l). She was also roughly with patients with Cushingoid body habitus. On the basis that she could have a 8 weeks pregnant at this stage. Correction of her vitamin D deficiency did not PPARg gene mutation she was commenced on pioglitazone with marked improve her biochemistry and in July 2010 she was now 15 weeks pregnant improvement of her diabetes control and sharp reduction in insulin requirement. with adjCa 2.86 mmol/l, PTH 10.6 pmol/l and total vitamin D 139 nmol/l. An HbA1c improved from 11.8 to 7.5% in 3 months. Subsequently the sequence of ultrasound of her neck demonstrated a normal right thyroid lobe and no masses her PPARg gene has been reported to be normal. Her diabetes control has and a foetal anatomy scan was normal other than a possibility of a hyper echoic subsequently deteriorated with her most recent HbA1c being around 12%. Should bowel. we still investigate further for cyclical Cushing’s syndrome? After discussion with the radiology department she had an MRI of her neck and thorax which demonstrated a solitary parathyroid adenoma in the lower pole of the right lobe of the thyroid, likely to be an ectopic PTH adenoma. A focussed neck ultrasound confirmed a uniformly echo poor lesion measuring 16 mm!7 mm with blood flow within it. Fluid aspirated from the nodule under ultrasound guidance had elevated PTH levels (280 pmol/l) consistent with an ectopic PTH adenoma. The lesion was excised during her second trimester and post-operatively her biochemistry normalised (adjCa 2.39 mmol/l, PTH!0.3 pmol/l). P96 This case illustrates the need for long term monitoring and follow up of MEN patients. It was complicated further by pregnancy, and careful choice of imaging Recreational jaundice enabled prompt diagnosis and treatment to minimise foetal complications of Rajesh Gupta, Damodharan Suresh & Vrijraj Rathod hypercalcaemia. Mid Essex Hospital NHS Trust, Chelmsford, Essex, UK.

A young fit male readmitted with three weeks history of malaise, pale stool, dark urine, pruritus with recent travel to Greece. He denied alcohol, illicit drug abuse. Examination revealed jaundice. Investigation showed cholestatic liver impairment with Bilirubin: 448 mmol/l (7-35), ALT: 134 IU/l (17–63), ALP: 190 IU/l (32–91), HDL 0.34 mmol/l (O0.9). Viral Screen, autoantibody, porphyria and tumour markers were negative. CT Abdomen showed tiny gall stone with normal bile duct and pancreas. MRI MRCP was normal. Testosterone: 11.7 nmol/l (6–27), 17 B Oestradiol: 556 pmol/l (up to 73), LH: 4 U/l (0.7–11), FSH: 1 U/l (0.8–7.7), TFT: Normal, SHBG: 30.3 nmol/l (13–71), P98 PRL: 165 mU/l (0–280). Disappearing adrenal insufficiency Cause of Cholestasis remains unidentified at this point. Earn H Gan1, Andy James2 & Simon H S Pearce1,2 Pt admits taking Creatin/Protein powder but denied taking any steroid. When 1Institute of Human Genetics, Newcastle University, Newcastle upon Tyne, asked repeatedly informed taking ALPHA SD (2a 17a dimethyl eticholan 3-one UK; 2Endocrine Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK. 17b-01) 10 mg BD for one month. Patient improved without treatment after stopping AAS. Impression After adrenal insufficiency is confirmed by synacthen testing, lifelong steroid Anabolic steroid induced cholestasis and deranged lipid profile. replacement is expected. We report a case of apparent reversal of adrenal Discussion insufficiency. Case details: a 66-year-old man was referred for oral pigmentation, Anabolic-androgenic steroids (AAS) are the synthetic derivatives of testosterone and a random cortisol level of 184 nmol/l. He reported a 2-year history of and altered to reduce metabolism, achieve desirable anabolic effects and difficult tiredness, nocturia, dry mouth and reduced libido. There was no dizziness,

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK salt-craving, or weight loss. He denied taking any form of steroid or over-the- patients with midgut carcinoid treated with octreotide. Nevertheless, a number of counter drugs. Examination showed punctate oral pigmentation and a pigmented new therapeutic indications and the clinical effectiveness of SA for other clinical patch on his finger, without generalised pigmentation. His blood pressure was conditions are appearing. A 69-year-old man was investigated for anaemia 118/72 mmHg with a postural drop of 10 mmHg. He had a raised HbA1c (7.6%) (haemoglobin: 8.0 g/dl). He required blood transfusion every 2–3 weeks. He had a and mild hyponatraemia (134 mmol/l). A 250 mg synacthen test showed a basal medical history of peripheral vascular disease, coronary artery disease and cortisol of 288 nmol/l; 30 min at 182 nmol/l and 60 min at 143 nmol/l. by-pass graft, decreased left ventricular function, and pulmonary hypertension. Hydrocortisone (20C10 mg daily) was instigated with the diagnosis of probable Following a set of investigations, chronic digestive bleeding likely secondary to Addison’s disease. However, his ACTH level came back at 25 ng/l (5–55 ng/l); angiodysplasia was diagnosed but surgical approach was not feasible. The plasma renin and aldosterone levels were normal. Basal measurements of other radiological investigations incidentally discovered abdominal and inguinal lymph anterior pituitary hormones and paired plasma/urine osmolality were normal. node metastases and subsequent lymph node biopsy revealed metastatic NET. Adrenal autoantibody test was negative. Unfortunately, the primary tumour remained unidentified. Treatment with long- He was well taking hydrocortisone for 6 months but his HbA1c worsened to 10%. acting octreotide was established. The need for blood transfusions dramatically The original diagnosis of adrenal failure was re-considered. Serum DHEAS levels decreased starting from the first month of treatment with long-acting octreotide. were normal, and there were detectable cortisol and aldosterone precursors in the His haemoglobin levels improved and remained stable around 10.0 g/dl over the urine. The hydrocortisone dose was weaned and repeat short synacthen testing following 12 months. Since commencement of octreotide, he required one blood demonstrated a basal cortisol of 258 nmol/l; peak 672 nmol/l. The diagnosis of transfusion every 4–5 months only. No adverse events occurred and the patient adrenal insufficiency was revoked. This case illustrates the need to make a clear remained stable from a NET-related point of view. To the best of our knowledge, aetiological diagnosis of adrenal insufficiency. The abnormal initial synacthen this is the first report of a serendipitous effect on anaemia due to chronic lower test result could have been due to either unwitting exogenous steroid digestive bleeding achieved by long-acting octreotide treatment prescribed for administration, transient isolated ACTH deficiency or failure to administer the metastatic NET. This report is consistent with the literature reporting a potential ACTH1–34 during the synacthen test. The normal serum DHEAS and the urine indication of SA for the treatment of lower digestive bleeding from a known or steroid profile were helpful clues to the safety of a staged withdrawal of unknown source. In our opinion, this report shows that treatment with SA in hydrocortisone. patients with lower digestive bleeding can be beneficial if the surgical approach is not feasible and only palliative therapies are available.

P99 Metastatic insulinoma in a patient with type 2 diabetes mellitus: case report Noormuhammad Abbasakoor1, Marie-Louise Healy1, Donal O’Shea2, P101 Donal Maguire2, Cian Muldoon1, Kieran Sheahan2 & Dermot O’Toole1 Thyroid storm in a teacup: an unusual presentation of thyrotoxicosis 1St James’ Hospital, Dublin, Ireland; 2St Vincent’s University Hospital, Category: clinical practice/governance and case reports Dublin, Ireland. Alexander Blackmore, Iain Anderson, Annice Mukherjee & Helen Doran Salford Royal NHS Foundation Trust, Salford, UK. Introduction Insulinoma is a tumour, derived from the beta cells of the pancreas. The incidence A 43-year-old woman presented acutely with Graves disease and hyperthyroid- in the general population is 4 cases per million a year. 80 to 90% of insulinomas ism. She had thyroid eye disease and a large diffuse goitre with pressure are benign and !10% are malignant. symptoms. She reported hearing a bruit herself without a stethoscope. She was Case presentation tachycardic, with capillary nail fold pulsation and a positive Pemberton’s sign. A 67-year-old lady was admitted via the emergency department after being found Initial T4 was 78.6, TSH not detected. unresponsive at home. She was found to be hypoglycaemic and responded to i.v. Betablockers to control the patients tachycardia were contraindicated due to a dextrose. She was diagnosed with type 2 diabetes mellitus a year ago and had been history of asthma, and despite a previous splenectomy, the patient did not take suffering from episodes of confusion and has had significant weight loss over 1 prophylactic penicillin due to a previous allergic reaction, although she had year. A 72 h fast test was stopped after two hours as she suffered another episode received the appropriate vaccinations. After receiving carbimazole for 8 days she of hypoglycemia. Laboratory investigations revealed low blood glucose and developed a severe, exanthematous reaction with pyrexia, and a 5 cm ulcerating elevated C Peptide levels and elevated insulin levels. She underwent CT facial lesion that was suspected to be infective although a focal fixed drug reaction Abdomen and Endoscopic Ultrasound which revealed a 6 cm pancreatic was considered. Carbimazole was discontinued and she received intravenous hypoechoic lesion and large volume right sided liver metastases. Ultrasound steroids, antibiotics and topical antiseptics. After discontinuing steroids she guided biopsy confirmed a pancreatic neuroendocrine tumour. The patient developed hyperpyrexia and steroids were recommenced. Propylthiouracil was underwent successful one-step RO surgical resection – distal pancreatectomy, contraindicated due to potential cross-reactivity with carbimazole, so she was splenectomy and right hepatectomy and was recurrence free 12 months post commenced on Lugol’s iodine solution at a high dose of 500 mg of iodine per day operatively. Her only residual problem is diabetes mellitus. to control her thyroid status prior to urgent surgery. Conclusion This case raises a number of concerns as to the timing of surgery. Thyroidectomy This case highlights a rare cause of hypoglycemia in a diabetic patient. Medical in the presence of facial sepsis, particularly in the context of asplenia and treatment with diazoxide and somatostatin analogues can be used until treatment with steroids, carries a risk of severe infective complications. However, oncological resection. Surgical resection of insulinomas remain the main curative following administration of iodine, delaying surgery risks a relapse of treatment where possible. thyrotoxicosis, and given the severity of this patient’s thyrotoxicosis this was undesirable. Seven days after commencing Lugol’s iodine, which was tolerated well, the patient’s skin lesion and clinical thyroid status had improved, and she was biochemically euthyroid. She opted to proceed with urgent surgery. Total thyroidectomy was uneventful, and the patient had an uncomplicated post- operative course.

P100 The beneficial effects of long-acting octreotide in a patient with concomitant metastatic neuroendocrine tumour and anaemia due to lower digestive bleeding P102 Saket Gupta, Lisa McGowan, Donal O’Shea & Gianluca Tamagno Hyponatraemia and SIADH as a presenting feature of acquired Department of Endocrinology and Diabetes Mellitus, St Vincent University immunodeficiency syndrome Hospital, Dublin, Co. Dublin, Ireland. Zoe Cousland, Chris Payne & Bashir El-Mahmoudi Tameside General Hospital, Ashton-U-Lyne-Manchester, UK. Somatostatin analogues (SA) represent the most effective medical treatment for the control of neuroendocrine tumour (NET) symptoms, like carcinoid syndrome. A 59-year-old Caucasian heterosexual man presented with malaise and dizziness. Recently there has been evidence of lengthened time to tumour progression in General examination revealed no peripheral oedema, no clubbing or

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK lymphadenopathy and systemic examination was otherwise normal. His initial P104 investigations showed hyponatremia with serum sodium 121 mmol/l, potassium Unwanted recovery from secondary hypogonadism: paradoxical effect 3.4 mmol/, serum osmolality 255 mOsml/kg, and urine osmolality of Zoladex 672 mOsml/kg. The rest of blood tests including; thyroid function, short Suresha Muniyappa, Ruth MacInerney & Rob Robinson Synacthen test, full blood count, liver functions, urea and creatinine were all Chesterfield Royal Hospital, Chesterfield, UK. normal chest X-ray showed consolidation at the left base. He was treated for pneumonia with secondary SIADH. He returned 1 month later with anorexia, weight loss, night sweats and We present the case of an 80-year-old man found to have a non-functioning unsteadiness, with a sodium of 122 mmol/l. He underwent CT thorax and pituitary macroadenoma causing secondary adrenal insufficiency and hypogonad- abdomen which revealed 5 mm pulmonary nodule. His case was discussed in the ism in 2006. Thyroid function and prolactin levels were normal. With chest multidisciplinary team meeting with a decision to monitor this nodule with hydrocortisone replacement he was doing well. There was no visual field defect interval CT scanning to exclude an underlying neoplasm or TB. Tumour markers and he continued with conservative management. On enquiring about testosterone were normal and sodium improved with demeclocycline. treatment, it had been started in Oct 2008, but discontinued within a month as Several months later – repeat CT showed the pulmonary nodule had increased to there was no change in his wellbeing. A DEXA scan was normal. His testosterone 6 mm with hilar and abdominal lymphadenopathy. He was referred to the tertiary levels remained low, between 4.3 and 5.6 nmol/l. PSA was 4.3 mg/l and rectal centre where the nodule was excised and found to be benign. examination was normal. He was admitted later with fever, night sweats and weight loss. He had oral Testosterone therapy was discussed and re-started in May 2009. His PSA, candidiasis. An HIV test was carried out and reported positive. Subsequently he however, rose to 12.2 mg/l in July 2009. Testosterone replacement was stopped was found to have pneumocystic jiroveci, syphilis, cytomegalovirus (serologi- immediately, with the PSA level falling to 4.3 nmol/l. A biopsy of his prostate cally), B-cell lymphoma, HIV encephalopathy and he was transferred to the confirmed adenocarcinoma of prostate and he was referred to the oncologists. infectious diseases unit for treatment. LHRH agonist therapy (Zoladex) was started with cyproterone acetate cover, Hyponatraemia can be associated with HIV for multiple reasons including aiming for chemical castration, in December 2009. After one dose, testosterone SIADH (secondary to pulmonary and CNS infections or malignancy), adrenal levels in February 2010 had surprisingly risen to 15.8, with PSA of 12.2 mg/l. insufficiency (usually infective involvement of the adrenal glands), HIV With this paradoxical result and after endocrine consultation, he had bilateral enteropathy, HIV-associated nephropathy or direct infection of the posterior orchidectomy to achieve a testosterone level consistent with castration. Post pituitary (CMV). operatively, testosterone fell down to 0.4 nmol/l with PSA of 0.4 mg/l. He also had Learning points radiotherapy to the prostate. Tumour reduced in size from T3 to T2. He remains 1. Hyponatraemia can be associated with HIV and AIDS. under regular follow up. 2. HIV should be part of the differential diagnosis in unexplained hyponatraemia, This case highlights a prolonged ‘flare’ effect after LHRH agonist therapy in a even in ‘low risk’ patients. man with a non-secretary pituitary adenoma. Normally after such therapy there is a surge in LH lasting about 1 week, before levels fall. In this case testosterone levels were elevated more than two months after such therapy, suggesting a paradoxical response of his pituitary gonadotrophs to LHRH agonist therapy.

P103 Testosterone undecanoate has a beneficial effect on lipid profile in men with hypogonadism in routine clinical practice Vakkat Muraleedharan1,2, Christen Rolfe1, Nishant Ranjan3 & Hugh Jones1,2 P105 1Barnsley Hospital NHS Foundation Trust, Barnsley, UK; 2University of Review of 125 individuals with adrenal incidentalomas: a single centre Sheffield, Sheffield, UK; 3Doncaster Royal Infirmary, Doncaster, UK. cohort Aikaterini Theodoraki, Bernard Khoo, Sithara Perera, Anna Schwappach, Arif Hamda, Mark Vanderpump & Pierre-Marc Bouloux Background Royal Free Hampstead NHS Trust, London, UK. There is a close association between low testosterone and metabolic syndrome. Testosterone replacement therapy (TRT) has beneficial effects on cardiovascular (CV) risk factors in men with hypogonadism. Background Aim Adrenal masses discovered incidentally during imaging studies (adrenal This is a retrospective audit of CV parameters in hypogonadal men treated with incidentalomas – AIs) are common and prompt investigations to exclude testosterone undecanoate (Nebido) in standard clinical practice. secretory lesions and malignancy. Uncertainty exists over the best management Methods strategy of AI. Patients with hypogonadism on testosterone undecanoate injections from 2005 to Objective 2009 were identified from hospital data base. Weight, blood pressure, non-fasting To monitor the current practice against the local protocol and existing guidelines; lipid profile and HbA1c (diabetic men nZ42) were collected at 3, 6, and 12 to identify the biochemical and imaging outcomes in a single centre cohort. months. Methods Results Retrospective review of medical records, biochemistry and imaging of all 125 Of the 120 patients 99 (82%) had previous TRT with other preparations. Mean patients referred to our centre between 2005 and 2009 with an AI. age was 48G16 years. After excluding patients with changes in lipid lowering Results medications over the treatment period, the total cholesterol (TC) and calculated Eighty-two percent of the AIs were unilateral, average diameter on imaging was LDL cholesterol (cLDL) demonstrated significant improvement. 20.4 mm. Eighty-seven percent of the patients had at least one repeat scan done, TC at 3 months was 3.8G1.4 (compared with 4.6 mmol/lG1.4 at baseline with a 17 months mean interval between the first and the last scan. 5.5% of AIs PZ0.006, nZ47), at 6 months 4.2G1.3 (PZ0.03, nZ36) and at 1 year 4.1G1.1 increased R5 mm in size on follow up, 7.8% decreased R5 mm, while 86.7% (PZ0.005, nZ41). remained unchanged. cLDL at 3 months was 1.9 mmol/lG1 (vs 2.3G1.1 at baseline; PZ0.006, nZ43) Following our local protocol and including only patients who completed all the at 6 months 2.1G1(PZ0.13, nZ38) and at 12 months 2.1G1(PZ0.046, nZ33). investigations (82%), 67% patients were diagnosed with non secretory benign HDL-cholesterol (HDL) did not show any significant change at 6 months 1.05 adenomas, 2% primary hyperaldosteronism, 2% phaeochromocytoma, 1% G0.3 (vs 1.08G0.3 at baseline PZ0.33, nZ44) or at 12 months 1.04G0.28 adrenal metastasis and 5% with other diagnosis. 24 patients (23%) failed to (PZ0.08, nZ35). suppress on a low dose or overnight dexamethasone suppression test using a cut- At 12 months no significant changes in weight (98 vs 99 kg; PZ0.09, nZ67) or off of 50 nmol/l; of those 4 were diagnosed with adrenal Cushing’s, 5 had false blood pressure (SBP 135 vs 137 PZ0.3 DBP 78 vs 80 PZ0.2, nZ69) were noted. positive results. None of the remaining 15 patients had clinical features of HbA1c fell by 0.4% (PZ0.07) at 6 months in diabetic patients. Cushing’s syndrome and all but one had normal 24 h urinary free cortisol Discussion excretion. Finally, seven patients with at least two abnormal tests of the HPA axis Testosterone undecanoate therapy in routine clinical practice had beneficial were diagnosed with mild cortisol secretion. The use of a higher cut-off for post effects on total cholesterol and cLDL, but no significant effect on HDL. No effects dexamethasone cortisol (83 nmol/l) would exclude four of these patients, while were found on weight and blood pressure. the recommended by the NIH consensus cut-off (138 nmol/l) would exclude all these patients but one.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Conclusion to the control group (11.3G2.7575 ng/ml, P!0.01) while the diabetic patients Eleven percent of the AIs in our cohort were functional. Altering the post without AMI showed insignificant difference (12.2G3.15 ng/ml) with the control dexamethasone cortisol cut-off in accordance to published guidelines radically group (PZ1). Group1 showed minimal decline in serum prolactin level 2 weeks changed the performance of the suppression test in our cohort. after the onset of AMI (22.36G4.26 ng/ml) but still was significantly higher than the control group (P!0.01) while group3 showed marked decline (9.15 G2.89 ng/ml) and showed insignificant difference with the control group (PZ0.67). Serum prolactin showed significant positive correlation with hs-CRP among patients with AMI whether diabetic (rZ0.679, PZ0.001) or non diabetic (rZ0.593, PZ0.006). Conclusion P106 Hyperprolactinemia may be associated with increased risk of myocardial Glucagon like peptide-1 in congestive heart failure cases and type 2 infarction but the levels of prolactin are variable among diabetics. In addition, diabetes mellitus cases the increase in both prolactin and hs-CRP increases the atherosclerotic process Nermin Sheriba, Khaled Makboul, Mona Abdelsalam, Hesham Mohamed & and hence the macrovascular complications revealing a new mechanism for Ahmed Hamam atherosclerosis in diabetics. Ain Shams University, Cairo, Egypt. Key words: Prolactin, acute myocardial infarction, atherosclerosis, diabetes. Abbreviations: AMI: acute myocardial infarction. GLP-1 stimulates b-cell proliferation, it also enhances the differentiation of new beta cells from progenitor cells in the pancreatic duct epithelium and it is capable of inhibiting apoptosis of b cells. GLP-1 also exhibits other effects of importance for glucose homeostasis, such as, inhibiting glucagon secretion, delaying gastric emptying, and stimulating insulin biosynthesis. These effects come along with a P108 potential increase in peripheral insulin action. Type 2 diabetic patients have an impaired secretion of GLP-1. On the other hand, patients with type 2 diabetes Identifying patients with familial hypercholesterolaemia and evaluating mellitus are considered to be at high risk for cardiovascular disease. A mutual management locally relationship exists between insulin resistance and heart failure. High affinity Raj Tanday & Peter Winocour receptors for GLP-1 are present in the heart and vascular tissue, so it is QE2 Hospital, Welwyn Garden City, Hertfordshire, UK. conceivable that the incretins may improve cardiovascular function. Aim Introduction The aim of this study was To assess the plasma level of GLP-1 in patients with Familial hypercholesterolaemia (FH) is a severe form of hyperlipidaemia congestive heart failure, both those with type 2 diabetes mellitus and those who resulting in early coronary heart disease (CHD). It has autosomal dominant are non diabetic and to assess the possible role of GLP-1 in the development of inheritance with a prevalence of 1 in 500. congestive heart failure. Aim Method Given this prevalence we would expect 1000 cases in our local catchment area of Our study included 54 subjects, divided into 4 groups; ‘group 1’ included 15 East and North Hertfordshire. Far fewer cases are know about. We tried to find out non diabetic patients with congestive heart failure, ‘group 2’ included 15 type where potential cases were and assess the management of all cases. 2 diabetic patients with congestive heart failure, ‘group 3’ included 12 type 2 Method diabetic patients with normal cardiac function and ‘group 4’ included 12 normal Forty-two known cases under secondary care were reviewed. Taking a laboratory control subjects. All subjects were submitted to full clinical and biochemical spreadsheet of the highest cholesterol levels from blood tests between Jan 2009 assessment, Fasting plasma glucagon-like peptide 1 measured by ELISA and and Dec 2009, the top 200 levels were taken. Excluded were those with mixed echocardiogram. dyslipidaemias. These patients were all found to be in primary care and 52 Results practices identified. Permission for visiting and case note reviewing only granted In the presenting study fasting serum GLP-1 was found to be significantly lower in from 17 practices. Evaluation of management of all patients was based upon a cases suffering of either heart failure or type 2 DM in comparison to those healthy modified version of the RCP audit proforma for FH. control cases. Furthermore, diabetic cases with heart failure showed significant Results lower level of serum GLP-1 in comparison to non-diabetic heart failure cases. From primary care 65 patients found with fitting lipid profile but 49% of cases Therefore, our results may suggest a role for GLP-1 deficiency in development of identified had insufficient data to make a diagnosis. Modal age group 51–70 congestive heart failure either in type 2 diabetic or non-diabetic cases. yearrs. Mostly female (71%), mostly white (15%) but ethnicity poorly recorded, mostly non smoking (62%), lifestyle advice given in most (75%), mostly treated with statin alone (58%) but other combinations were used, good evidence of treatment efficacy in secondary care (52% reduction in total cholesterol from baseline), majority not had cardiology testing for CHD (60%) and cascade testing done in a majority (60%). P107 Conclusions It appears that patients who we suspect to have FH on biochemistry are not being Study of serum prolactin and cardiovascular risk in patients with type 2 assessed thoroughly to make a diagnosis of the condition – family history of diabetes mellitus premature cardiovascular disease/hypercholesterolemia and assessment for Hesham Elgayar, Manal Abu-Shady, Iman Zaki, Mona Abdelsalam & stigmata not done. Management appears to be good otherwise with evidence of Alyaa Elsherbeny efficacy with treatment and progress with screening relatives. Ain Shams University, Cairo, Egypt.

Background Prolactin is an identified marker associated with atherosclerosis. Atherosclerotic process and hence the macrovascular complications are causes for high mortality and morbidity rates among people with diabetes. Cytokines, growth factors, neuroendocrinology and Aim To assess the relationship between serum prolactin and cardiovascular risk in behaviour patients with acute myocardial infarction (AMI) and patients with type 2 diabetes P109 mellitus. Altered corticosterone homeostatsis in hippocampus leads to memory Subjects and methods impairment in hypobaric hypoxia A case–control study was done in Ain Shams University Hospitals, Cairo, Egypt; Iswar Baitharu1, Satya Narayan Deep1, Vishal Jain1, Kalpana Barhwal2, serum prolactin was determined in 20 non-diabetic (group 1) and 20 diabetic Sunil Kumar Hota2, Dipti Prasad1 & Govindasamy Ilavazhagan1 (group 3) male patients within 24 h of the onset of AMI and after 2 weeks. Twenty 1Defence Institute of Physiology and Allied Sciences, DRDO, Delhi, Delhi, type 2 diabetic male patients without AMI and 15 healthy age and sex-matched India; 2Defence Institute of High Altitude research, DRDO, Leh, Jammu controls represented (group 2 and group 4, respectively). The inflammatory Kashmir, India. marker hs-CRP was also measured in the studied population. Results Serum prolactin was significantly higher among non-diabetic (27.52 Hypobaric hypoxia, an environmental condition arising due to the reduced partial G6.75 ng/ml) and diabetic patients with AMI (21.05G6.93 ng/ml) compared pressure of oxygen on ascent to high altitude, is known to cause memory

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK impairment. The mechanism underlying the cognitive dysfunction has been P112 2C attributed to oxidative stress, glutamate excitotoxicity and Ca mediated death Characterisation of the stress–response in BACE1 heterozygous mice cascade. Though the role of corticosterone in higher order brain function Paul Meakin, Johnathan Winter, Mike Ashford & Alison McNeilly including cognition has been well documented in restrained stress, social stress University of Dundee, Dundee, UK. and other moderate stress, its impact in hypobaric hypoxia induced cognitive dysfunction still remains to be investigated. To determine the effect, five groups of rat were exposed in a simulated decompression chamber at an altitude of Alzheimer’s disease (AD) is one of the most common causes of dementia world 25 000 ft for 0, 3, 7, 14 and 21 days. Corticosterone synthesis was blocked using wide. Accumulation of b-amyloid (Ab) has been implicated as a causal factor of metyrapone (75 mg/kg BW) on the day showing maximum corticosterone level AD. Beta secretase (BACE1) catalyses the rate limiting step in the production Ab and neuronal damage. Our study revealed a duration dependent elevation in and has been postulated as a potential therapeutic target for AD treatment. corticosterone level in plasma and hippocampus. There was increased ROS Environmental factors, including psychological stress, accelerate the develop- generation, decreased antioxidant defence system and compromised neuronal ment of dementia and AD. This study examined hypothalamic–pituitary–adrenal energy status. Exposure to hypobaric hypoxia upregulated the expression of (HPA) axis activation in BACE1C/K transgenic mice following three different glucocorticoid and mineralocorticoid receptor in a duration dependent manner. forms of behavioural stress. Neuronal glucose transporter Glut3 and blood–brain barrier glucose transporter Male BACE1C/K and wildtype (WT) mice (nZ8/group) were exposed to an Glut1 was found to be upregulated during initial period of exposure to hypobaric acute inescapable stress (elevated platform), acute escapable stress (elevated plus hypoxia. There was decreased citrate synthase activity and increased glutamate maze) or repeated inescapable stress (elevated plus maze for 10 days). Behaviour dehydrogenase activity along with altered expression of proteins (MDR1apG and was assessed in the elevated plus-maze as the number of entries and time spent in HSD1) regulating the corticosterone bioavailability in hippocampus. These the open and closed arms of the maze. Plasma corticosterone was measured by findings suggest that chronic elevation in corticosterone level may lead to ELISA. Statistical analysis was performed using SPSS and significance set at induction of glutamate excitotoxicity, perturbance in neuronal energy status and P!0.05. enhanced oxidative stress leading to neuronal damage and ultimately to memory BACE1C/K mice made significantly fewer entries into the open arm of the plus impairment following exposure to hypobaric hypoxia as shown by behaviour maze and made fewer total entries (closed and open arms) compared to WT studies. Maintenance of optimal corticosterone level by metyrapone adminis- animals. However, there was no significant difference in the total time spent in tration however reduced oxidative damage, improved energy status, reduced each arm. Plasma corticosterone was comparable at baseline. All animals showed caspase 3 expression in CA3 region of the hippocampus indicating reduced a significant increase in corticosterone following exposure to acute or repeated neurodegeneration and improved memory functions. stress. However, BACE1C/K mice showed a heightened response to the acute Key words: Glut1, hypobaric hypoxia, metyrapone, hippocampus, corticosterone, inescapable stressor (elevated platform). There was no effect of genotype on citrate synthase. thymus or adrenal weight. These findings demonstrate that BACE1C/K mice are more anxious and have an elevated stress response to an acute psychological stressor. These results show that reduction of BACE1 levels produce a maladaptive response in the HPA axis as reported for AD patients. This suggests that BACE1 may play a role in regulation of the HPA axis independent of Ab production.

P110 Selected adipocytokines serum levels in patients with ischemic stroke Bogdan Marek, Radoslaw Bienek, Dariusz Kajdaniuk, Mariusz Nowak, Lucyna Sieminska, Joanna Glogowska-Szelag & Beata Kos-Kudla Department Pathophysiology and Endocrinology, Silesian Medical University, Zabrze, Poland. P113 Adiponectin (ADPN), resistin (RSN) and leptin are proteins that affect insulin Salivary cortisol monitoring in sheep and cows: evidence for acute resistance and atherosclerosis significantly. Although low levels of adiponectin activation of the hypothalamo–pituitary–adrenal (HPA) axis using two and high levels of resistin and leptin are associated with coronary heart models of stress disease and cardiovascular disease risk factors, it is unclear whether adiponectin, Sarah Gibbs1, Emma Green1, Alun Stedman1, Robert Abayasekara1, resistin and leptin levels are related to the risk of developing ischemic stroke. The Derek Renshaw2 & Robert Fowkes1 aim of the study was to evaluate the adiponectin, resistin and leptin serum levels 1Royal Veterinary College, London, UK; 2University of Westminster, in patients with acute ischemic stroke and theirs role in the pathogenesis of London, UK. cerebrovascular diseases. We examined 70 patients with acute ischemic stroke and 30 stroke-free subjects of similar age and sex distribution. In all subjects we examined lipid pattern (cholesterol, HDL-cholesterol, LDL-cholesterol, triglicer- Inappropriate control of the hypothalamo–pituitary–adrenal (HPA) axis in ydes), blood glucose level, blood pressure, BMI and HOMA-IR. production animals has serious consequences for animal welfare, and economic Results consequences in relation to food production. Fertility rates have declined as a In comparison with referents, patients with stroke had significantly higher leptin consequence of farming practice and selective breeding, which may result in an (14.98 vs 10.47 ng/ml) and resistin (28.92 vs 12.25 ng/ml) levels, but adiponectin increased susceptibility to disease and infection. Whilst precise monitoring of (15.49 vs 14.32 mg/ml) did not differ between groups. HPA status can be achieved through measurement of plasma cortisol levels, Conclusions obtaining these samples from production animals can be time-consuming and Despite moderate associations between adiponectin and cardiovascular disease invasive. Our current study was performed to determine the usefulness of salivary risk factors, we found no evidence of an association between serum adiponectin cortisol samples from sheep and cows, in assessing HPA activity. Two studies to levels and incident ischemic stroke. Leptin and resistin may are an important links model stress were employed; in the first, the stress response to shearing was to the development of cerebrovascular disease. determined in Suffolk x mule ewe lambs (nZ10); in the second, the anxiety response following maternal separation in Holstein-Fresian or Angus-Fresian calves (nZ8) was determined. In both studies, saliva samples were collected using either a swab or with a modified stomach tube and syringe. All samples were stored in salivettes and kept at K20 8C, prior to centrifugation and assay for salivary cortisol (by ELISA). In the sheep studies, salivary cortisol dramatically increased within 1 h of shearing, compared with time-matched controls, and remained elevated for up to 6 h post-shearing. In the cow studies, salivary cortisol was also dramatically elevated in calves within 1 h of maternal separation; P111 however, despite having a similar basal cortisol value, the stress response in calves allowed a longer period with their mothers prior to separation was only half that of those separated within 24 h of birth. In summary, we have shown that salivary cortisol measurements in sheep and cows are effective at quantifying HPA activity in these models of restraint and psychosocial stress. Such an approach could be used to improve monitoring of husbandry practice in Abstract withdrawn. production animals.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P114 Results The effects of recombinant human IGF1/IGF binding protein-3 on body No significant changes in serum lipids were observed in the placebo group. In both women and men treated with rhIGF1/rhIGFBP3, there were significant composition and physical fitness in recreational athletes G Z Nishan Guha1, Ioulietta Erotokritou-Mulligan1, Simon Nevitt1, reductions in fasting triglycerides (mean decrease 0.13 0.06 mmol/l, P 0.025 1 1 2 1 in women; 0.24G0.08 mmol/l, PZ0.01 in men). In women, but not in men, there Michael Francis , John Woodland , Eryl Bassett , Peter Sonksen & G Richard Holt1 were significant increases in total cholesterol (mean increase 0.47 0.12 mmol/l, 1 PZ0.001), HDL (mean increase 0.16G0.03 mmol/l, P!0.001) and LDL (mean University of Southampton School of Medicine, Southampton, UK; G Z 2School of Mathematics, Statistics and Actuarial Science, University of increase 0.37 0.1 mmol/l, P 0.001). No changes in cholesterol:HDL ratio or Kent, Kent, UK. fasting NEFA were observed. Fasting insulin and HOMA-IR decreased in both women and men treated with rhIGF1/rhIGFBP3; there was also a significant decrease in HbA1c in women (mean reduction 0.3G0.1%, P!0.001) but not Introduction in men. GH is widely abused by athletes for its anabolic and lipolytic properties. As the Conclusions tests for detecting GH abuse develop further, it is possible that athletes will Fasting triglycerides decrease in recreational athletes after the administration of exploit IGF1 as an alternative or additional doping agent. There is currently no rhIGF1/rhIGFBP3 for 28 days; these changes are associated with increased evidence to suggest that IGF1 administration improves athletic performance. insulin sensitivity. RhIGF1/rhIGFBP3 appears to have a more pronounced effect Objectives on lipid and glucose homeostasis in women than in men. To determine the effects of rhIGF1/rhIGFBP3 administration on body composition and physical fitness in recreational athletes. This study was part of a randomised, double-blind, placebo-controlled trial studying detection methods for IGF1 abuse. Methods P116 The study received approval from the local ethics committee. Fifty-six Hypothalamic tanycytes express nuclear receptor regulating enzymes in recreational athletes (age 18–30 years, 30 males, 26 females) were randomly the absence of mRNA transcript assigned to receive placebo, low dose rhIGF1/rhIGFBP3 complex (30 mg/day) or Kirsty Shearer, Patrick Stoney, Jemma Ransom, Gisela Helfer, Sandy Ross, high dose rhIGF1/rhIGFBP3 complex (60 mg/day). Treatment was self- Peter Morgan & Peter McCaffery administered by s.c. injection for 28 consecutive days. Body composition University of Aberdeen, Aberdeen, UK. (assessed by dual energy X-ray absorptiometry) and cardiorespiratory fitness, measured in terms of maximal oxygen uptake (VO2 max), were assessed before and immediately after treatment. Data from subjects in low and high dose Tanycytes line the wall of the third ventricle sitting at the boundary between the treatment groups were combined and intra-individual changes were analysed cerebral spinal fluid (CSF) and the hypothalamus. Tanycytes actively take up using paired t-tests. substances from the CSF using their villi-like apical projections that extend into Results the third ventricle. Retinol is one such compound and can be oxidized by these There were no significant changes in body fat percentage or lean body mass in cells to retinoic acid, which can be released to regulate transcription in the women or men after administration of rhIGF1/rhIGFBP3 complex. In both hypothalamus via specific nuclear receptors. Two retinal dehydrogenases women and men, there were significant increases in VO2 max after treatment (RALDHs) required to catalyze this reaction, RALDH1 and RALDH2, are (PZ0.013 women, PZ0.046 men, PZ0.001 men and women combined). In present in tanycyte processes that infiltrate the hypothalamus. However, when women, the mean increase in VO2 max was 4.2G1.5 ml/min per kg, relative mRNA from rat hypothalamic tissue is quantified for these enzymes only increase 10.5G3.8%. In men, the mean increase in VO2 max was 3.0 RALDH1 is present in tissue but both proteins are clearly present. G1.5 ml/min per kg, relative increase 7.9G3.6%. No significant changes in The possible absence of RALDH2 mRNA transcript in tanycytes suggests that the VO2 max were observed in the placebo group. enzyme may be derived from an alternative source. Western blotting of CSF Conclusions identified that RALDH2 is present in CSF and may, hypothetically, be taken up by The administration of rhIGF1/rhIGFBP3 for 28 days improves aerobic tanycytes. Thus CSF may potentially provide both retinol and the enzyme performance in recreational athletes although it has no significant effect on required to convert retinol to retinoic acid. One possible source of RALDH2 for body composition. the CSF is the choroid plexus, which produces the CSF including the proteins transthyretin and retinol binding protein that transport retinol. RALDH2 protein and transcript were detected in the choroid plexus by immunohistochemistry and in-situ hybridization respectively. Interestingly, a second source of RALDH2 for the CSF is the meninges which, in the lateral ventricles, borders the hippocampus and is in direct contact with the CSF. RALDH2 transcript was detected in the meninges by in-situ hybridization while protein was detected immunohisto- chemically in cytoplasmic vesicles. Other hypotheses for the source of RALDH2 P115 are presently being tested. The effects of recombinant human IGF1/IGF binding protein-3 on lipid The unique origins and tanycyte subtype expression patterns of RALDH1 and and glucose metabolism in recreational athletes RALDH2 in the hypothalamus suggest that retinoic acid generated by these two Nishan Guha1, Ioulietta Erotokritou-Mulligan1, Simon Nevitt1, enzymes is required to regulate differing events. Michael Francis1, Eryl Bassett2, Peter Sonksen1 & Richard Holt1 1University of Southampton School of Medicine, Southampton, UK; 2School of Mathematics, Statistics and Actuarial Science, University of Kent, Kent, UK. P117 Differential regulation of the neurotrophins, NGF and BDNF, and their Introduction receptors in the myometrium of women affected by adenomyosis Recombinant human IGF1 (rhIGF1) improves insulin sensitivity and glycaemic Anthony Taylor, Michael Hawes, Vijay Kalathy, Muna Abbas, control when administered to people with diabetes. The effects of rhIGF1 on lipid Mohamed Mehasseb & Marwan Habiba metabolism in vivo are unclear. University of Leicester, Leicester, Leicestershire, UK. Objectives To determine the effects of rhIGF1/rhIGFBP3 administration on fasting lipids, non-esterified fatty acids (NEFA) and glucose homeostasis in recreational Adenomyosis is an oestrogen-dependent uterine disease where ectopic, non- athletes. This study was part of a randomised, double-blind, placebo-controlled neoplastic endometrium is histologically observed within the myometrium. Its trial studying detection methods for IGF1 abuse. incidence ranges between 5 and 70% and although presenting symptoms; Methods menorrhagia (40–50%), dysmenorrhoea (10–30%) and metrorrhagia (10–12%) The study received approval from the local ethics committee. 56 recreational are well known, its aetiopathology remains unclear. The neurotrophin, nerve athletes (age 18–30 years, 30 males, 26 females) were randomly assigned to growth factor (NGF), has been implicated in the aetiopathology of adenomyosis, receive placebo, low dose rhIGF1/rhIGFBP3 complex (30 mg/day) or high dose especially in the tamoxifen-dosed neonatal CD-1 mouse, which develops severe rhIGF1/rhIGFBP3 complex (60 mg/day) by subcutaneous injection for 28 adenomyosis through increased NGF expression. Preliminary data indicates that consecutive days. Variables measured before and immediately after the treatment the neurotrophin system (ligands and receptors) are present in the human uterus, period were: fasting lipids, NEFA, glucose, insulin and HbA1c. The homeostatic but have not been examined in adenomyosis. model assessment (HOMA-IR) was used to estimate insulin sensitivity. Intra- In this study, immunohistochemistry and quantitative RT-PCR were used to individual changes were assessed using paired t-tests. examine NGF, BDNF, p75, trkA, trkB and trkC expression in human

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK adenomyotic myometrium. The effect of oestradiol and tamoxifen on NGF cytokines. To this end, we recruited 42 healthy non diabetics and subjected them mRNA levels measured in control and adenomyotic myometrial cell cultures. to 75 g OGTT after an overnight fast. We profiled the cytokines that are present in Histomorphometric analyses of the immunohistochemical staining indicated an the serum of non diabetics (nZ33, BMI 27.3G3.6, HbA1c 5.5G0.2%) and increase in NGF protein in the inner and outer myometrium of adenomyosis compare to pre-diabetic patients (nZ9, BMI 33.2G8.5, HbA1c 6.0G0.3%) by throughout the menstrual cycle, whilst trkC expression was unchanged. In the multiplex cytokine profiling. proliferative phase, trkB was significantly decreased throughout the myometrium Our data clearly show for the first time that levels of serum interferon-b (IFN-b) and significantly increased in the secretory phase, whilst trkA showed a are significantly increased in pre-diabetic patients. In contrast, comparable significant decrease only in the outer myometrium during the secretory phase; levels of IL6, TNFa and IL1b are evident in the serum of pre-diabetic patients. p75 was undetectable. NGF transcript levels were significantly increased in Together, these data demonstrate that pre-diabetic patients exhibit perturbations adenomyotic inner myometrium, (1.5-fold; P!0.05; Student’s t-test) and in cytokine levels compared to normal individuals and support a role for these significantly decreased in the outer myometrium, whilst BDNF, p75, trkB and molecules in the disease progression to a diabetic pathology. Supported by HRB trkC transcript levels were significantly decreased by 60, 90, 50 and 35%, and SFI Ireland. respectively. Furthermore, NGF transcript levels were significantly (P!0.001; one-way ANOVA; nZ12) reduced in both normal (4.5-fold) and adenomyotic Table 1 Cytokine profiling of pre-diabetic patients. (1.25-fold) cultures in response to oestradiol and to a lesser extent in both normal (2.6-fold) and adenomyotic (1.36-fold) cultures by tamoxifen. Cytokine Normal Pre-diabetic These differences suggest a possible role for the neurotrophins and their receptors (pg/ml) (meanGS.D.) (meanGS.D.) in the adenomyotic myometrium and in the aetiopathology of this common disease. IL6 1.14G0.59 1.59G0.59 TNFa 14.28G1.24 16.80G1.86 IL1b 0.84G0.41 0.91G0.69 IFNb 1.29G1.2 5.54G2.09 P118 Impact of synovial fibroblasts on adipose tissue Ahkeb Hussain1, Rowan Hardy1, Pushpa Patel1, Mohammad Ahassan1, Andrew Filer2, Paul Stewart1 & Mark Cooper1 1The University of Birmingham, School of Clinical and Experimental Medicine, Birmingham, West Midlands, UK; 2The University of Birming- Diabetes, metabolism and cardiovascular ham, School of Immunity and Infection, Birmingham, West Midlands, UK. P120 Inflammatory markers are not strongly associated with the metabolic Rheumatoid arthritis (RA) is associated with a loss of lean mass and a syndrome in type 2 DM corresponding increase in fat mass. How fat accumulation in RA is linked to Anthonia Ogbera1,2 & Alfred Azenabor1,2 synovial inflammation is unknown. Wnts comprise a family of secreted 1Lagos State University Teaching Hospital, Lagos, Nigeria; 2Lagos glycoproteins that are crucial in regulating adipocyte proliferation, apoptosis and University Teaching Hospital, Idi-araba, Lagos, Nigeria. differentiation. Recently we demonstrated that endogenously generated gluco- corticoids (GCs) alter the pattern of wnt secretion by synovial fibroblasts (SFs), favouring production of wnt inhibitors. Inhibition of wnt signalling in adipocytes Background promotes their differentiation through inhibition of PPARg. In this study we have We sought to document the pattern of distribution of cytokines in patients with investigated whether wnt production by SFs could influence adipocyte type 2 DM and compare cytokine levels between DM subjects with and without differentiation and thus contribute to the increased fat accumulation seen in RA. the Mets. Media conditioned for 24 h (CM) was collected from primary human SFs following Methods 24 h pre-treatment with vehicle, TNFa or dexamethasone. 200 mlofCMwas Out of 200 patients with type 2 DM and 100 healthy sex and aged matched co-cultured with Chub-S7 human pre-adipocytes for 10 days C/K differentiation controls were studied. Anthropometric indices, lipid parameters and cytokines media. Differentiation was assessed by Nile red staining followed by FACS levels which included interleukin 10 (IL10), tumor necrosis factor a (TNF), g analysis and expression of adipocyte differentiation genes G6PDH, 11b-HSD1, interferon (IFN) and C reactive protein (CRP) were determined. Continuous lipoprotein lipase (LPL) and leptin by real time RT-PCR in three separate variables were compared between subjects with type 2 DM and the controls and experiments. also between DM patients with and without the Mets. The test statistics used c2 Co-culture with un-stimulated CM did not induce adipocyte differentiation, as included t-test, , correlation coefficient and multiple regression analyses. measured by lipid accumulation or gene expression. Significant increases in all Results markers of adipocyte differentiation were observed in response to TNFa treated The mean levels of all studied cytokines were significantly higher in the subjects CM (11b-HSD1, 3.6-fold; G6PDH, 18-fold; LPL, 30-fold; leptin, 15-fold; with type 2 DM than in the control subjects. The mean cytokine levels were P!0.05). Similarly treatment with CM from SFs exposed to Dex significantly comparable in the DM subjects with and without the Mets and also comparable in increased expression of adipocyte differentiation genes (G6PDH, 156-fold; LPL, obese DM and non-obese DM patients. Of the Mets defining criteria, waist 37-fold; Leptin, 5.4-fold; P!0.05). CM from cells previously exposed to TNFa or circumference and TG were found to be significantly associated with only two Dex resulted in increased lipid accumulation (3%G0.13; 2.8%G0.11 respect- of the studied cytokines, The correlation coefficient and P values of these ! findings are as follows: WC versus TNF-a (rZ0.16, PZ0.001) and TG versus ively; P 0.05) determined by FACS. Z Z These data suggest that when exposed to pro-inflammatory cytokines or GCs, CRP (r 0.15, P 0.03). SFs produce secreted factors, likely of the wnt family, that enhance adipocyte Conclusions differentiation. These data provide a direct link between joint inflammation and Cytokine levels are higher in DM patients than in non DM subjects. However the abnormal fat accumulation. cytokine levels are not strongly associated with the Mets. Limited correlations were found between each of the cytokines and the parameters of the Mets.

P119 Cytokine profiling of pre-diabetic patients P121 Saket Gupta1,2, Ashwini Maratha1,2, Thusitha Gajanayake1,2, Renal ischemia/reperfusion injury in type II DM: possible role of Jakub Siednienko1,2, Anandan Natarajan1,2, Shu Hoashi1,2 & proinflammatory cytokines, apoptosis, and nitric oxide Sinead Miggin1,2 Mahmoud Gabr1, Abdel-aziz Hussein1, Iman Sherif2, Sousou Ali2 & 1Immune Signalling Laboratory, Institute of Immunology, National Hoda Mohamed2 University of Ireland, Maynooth, Co. Kildare, Ireland; 2Midlands Regional 1Faculty of Medicine, Mansoura, Egypt; 2Faculty of Pharmacy, Zagazig Hospital, Mullingar and Royal College of Surgeons in Ireland, Mullingar, University, Zagazig, Egypt. Co. Westmeath, Ireland. Background Inflammation is a component of obesity-associated insulin resistance. Significant Diabetes mellitus (DM) especially type II is a major health problem and diabetic increases in inflammatory mediators such as IL6, TNFa and IL1b have been nephropathy is the main cause of end stage renal disease (ESRD). Renal detected in the serum of diabetic patients. Herein, we investigated whether ischemia/reperfusion (I/R) injury is common in diabetic patients. Recent studies pre-diabetic patients also exhibited perturbations in circulating pro-inflammatory reported increased vulnerability of kidney to I/R injury in diabetic rats.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Mechanisms behind this increased vulnerability not fully understood. The present glycogenic enzymes resulting in depletion of liver and muscle glycogen. study investigated the effect of acute ischemia for 45 min on proinflammatory Accordingly, this study assessed the influence of OA on two key glycogenic cytokines, apoptotic markers, and nitric oxide (NO) in a rat model of type II enzymes of skeletal muscle and liver tissues in STZ-induced diabetic rats. We diabetes. have, however, reported that the anti-hyperglycaemic effects of Syzygium Material and methods aromaticum derived oleanolic acid (OA) in streptozotocin (STZ)-induced Sixty male Sprague–Dawley rats were divided into 4 groups (nZ15, each); Group I: diabetic rats are mediated in part via increased hepatic glycogen synthesis. normal rats, Group II: normal rats underwent left renal ischemia for 45 min, Group Hepatic and gastrocnemius muscle glycogen concentrations and activities of III: diabetic rats without renal ischemia, Group IV: diabetic rats underwent left renal glucokinase (GK) and hexokinase (HK) of STZ-induced diabetic rats were ischemia for 45 min. Blood and kidney samples were taken 24 h after ischemia. measured after 5 weeks of twice daily treatment with OA (80 mg/kg, p.o.). Rats Serum glucose, fructosamine, creatinine, TNFa, as well as the expression of TGFb, treated with deionised water (3 ml/kg, p.o.), or standard hypoglycaemic drugs NFkB, iNOS, survivin, and Bcl2 in kidney tissue were measured. (insulin, 200 mg/kg, s.c.; metformin, 500 mg/kg, p.o.) acted as untreated and Results treated positive controls, respectively. HK and GK activities were measured Type II DM caused significant increase in serum glucose, fructosamine, creatinine, spectrophotometrically in reactions where the oxidation of glucose-6-phosphate C and TNFa and expression of TGFb,NFkB and iNOS in renal tissue (P!0.001). formed was coupled to NADP reduction catalyzed by glucose-6-phosphate Also, DM caused significant increase in apoptotic cell death with increase in Bcl-2 dehydrogenase. After 5 weeks STZ-induced diabetic rats exhibited depleted expression and decreased survivin in kidney. 45 min ischemia in diabetic rats glycogen levels and low activities of glycogenic enzymes in muscle and hepatic caused more significant increase in serum TNF-a and expression of TGF-b,NF-kB tissues. OA administration increased the activity of glycogenic enzymes with and iNOS (P!0.001). Also; there was a positive correlation between blood glucose concomitant restoration of muscle and hepatic glycogen concentrations to near and TNFa,TGFb,NFkB and iNOS with negative correlation with survivin normalcy. Interestingly, the combination of OA and insulin did not significantly (P!0.01). alter the activities of HK and GK of STZ-induced diabetic rats suggesting that that Conclusion glycogen synthesis can also occur from precursors such as amino acids or fructose Type II DM render the kidney more susceptible to ischemic injury. Proinflammatory and lactate. Our data suggest that OA administration restores the activity of key cytokines TNFa,TGFb,andNFkB and iNOS as well as Bcl2 and survivin may glycogenic enzymes in the liver and skeletal muscle of STZ-induced diabetic rats contribute to the enhanced renalischemic injuryin type II DM. Also,hyperglycaemia to enhance glycogen synthesis to improve the glycaemic status. The restoration of may be involved in hypersensitivity of kidney to ischemic injury in DM. this principal glucose utilization pathway by OA will constitute a novel therapeutic strategy for diabetes treatment.

P122 P124 Adult patients with congenital adrenal hyperplasia have elevated blood Serum 25-hydroxy-vitamin D is associated with adiponectin and insulin pressure but otherwise a normal cardiovascular risk profile resistance in diabetic Saudi adults Christiaan Mooij, Jeanne Margot Kroese, Fred Sweep, Ad Hermus & Nasser Al-Daghri1, Omar Al-Attas1, Majed Alokail1, Khalid Alkharfy1, Cees Tack Hossam Draz1 & Mario Clerici1,2 Radboud University Nijmegen Medical Centre, Nijmege, The Netherlands. 1King Saud University, Riyadh, Saudi Arabia; 2University of Milan, Milan, Italy. Objective Treatment with glucocorticoids and mineralocorticoids has changed congenital Hypovitaminosis D is associated with an increased prevalence of diabetes adrenal hyperplasia (CAH) from a fatal to a chronic lifelong disease. As a result of mellitus type 2 (DMT2) and the metabolic syndrome. The purpose of this study long-term treatment, including chronic (over-)treatment with glucocorticoids, was to examine the association between 25-hydroxy-vitamin D (25-OH-VitD) patients with CAH may develop an adverse cardiovascular risk profile. The levels and adipocytokines and other indices of insulin resistance in a Saudi objective of this study was to evaluate the cardiovascular risk profile of adult population with DMT2. One-hundred and fifty-five male and female Saudi adults CAH patients. aged 26–80 were randomly selected from the existing Biomarkers Screening in Patients and measurements Riyadh Program (RIYADH Cohort). Subjects were clinically assessed, In this case–control study the cardiovascular risk profile of 27 adult CAH patients anthropometry was obtained and serum 25-OH-VitD, leptin, adiponectin, resistin, and 27 controls, matched for age, gender and body mass index was evaluated by insulin, CRP, TNF-a, glucose, triglycerides, total cholesterol, LDL, and HDL measuring ambulatory 24-h blood pressure, insulin sensitivity (HOMA-IR), lipid concentrations were measured. Results showed a negative correlation between profiles, albuminuria and circulating cardiovascular risk markers (PAI-1, tPA, 25-OH-VitD and BMI, LDL and glucose and a positive correlation between uPA, tPA/PAI-1 complex, hsCRP, adiponectin, IL6, IL18, and leptin). 25-OH-VitD and adiponectin, which remained significant after controlling for Results BMI. Thus, 25-OH-VitD serum levels are negatively correlated with adiposity, Twenty-four-hour systolic (126.3 mmHgG15.5 vs 124.8 mmHgG15.1 in insulin resistance, and LDL levels in Saudi patients with DMT2. These results, controls, PZ0.019) and diastolic (76.4 mmHgG12.7 vs 73.5 mmHgG12.4 in together with the observed positive association between adiponectin and controls, P!0.001) blood pressure was significantly elevated in CAH patients 25-OH-VitD suggest a role for this hormone as a link between 25-OH-VitD compared to the control population. CAH patients had higher HDL cholesterol and insulin resistance and a possible beneficial effect of 25-OH-VitD on levels (P!0.01), lower hsCRP levels (PZ0.03) and there was a trend toward cardiovascular pathology. elevated adiponectin levels compared to controls. Other cardiovascular risk factors were similar in both groups. Average BMI was high in CAH patients (27.2G4.6 kg/m2). It was not possible to evaluate BMI as an individual cardiovascular risk marker because controls were matched for BMI. Conclusion Adult CAH patients have higher ambulatory blood pressure compared to age, P125 gender and body mass matched controls, which may be related to glucocorticoid Endoplasmic reticulum oxidoreductases and insulin folding and mineralocorticoid treatment. Average body mass was high. Other Gautam Rajpal, Ming Liu & Peter Arvan cardiovascular risk markers did not differ, while HDL-cholesterol, hsCRP and University of Michigan, Ann Arbor, Michigan, USA. adiponectin levels tended to be more favourable. Proinsulin makes three evolutionarily-conserved disulfide bonds, two of which connect the insulin B and A chains, and one intrachain bond within the A chain. In Type II diabetes mellitus, increasing evidence suggests that insulin-secreting pancreatic b cells show signs of endoplasmic reticulum (ER) stress and an P123 increase in the presence of proinsulin with mispaired disulfide bonds. In addition, The effects of Syzygium aromaticum derived oleanolic acid on glycogenic heterozygous expression of misfolded mutant proinsulin is known to cause enzymes in streptozotocin induced-diabetic rats autosomal dominant diabetes, resulting in a loss of b cell mass. ER Phikelelani Ngubane, Bubuya Masola & Cephas Musabayane oxidoreductases are involved in protein chaperone activity as well as redox University of KwaZulu-Natal, Durban, KwaZulu-Natal, South Africa. reactions leading to formation of disulfide bonds of secretory proteins. The ER is a more oxidizing environment than that of the cytosol, at least in part due to the actions of Ero1a and Ero1b which become reduced by ER oxidoreductases. In Diabetes mellitus is characterized by partial or total deficiency of insulin resulting turn, cargo proteins in the ER lumen transfer reducing equivalents to ER in derangement of carbohydrate metabolism and a decrease in the activity of oxidoreductases, which results in formation of disulfide bonds within the

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK secretory cargo. In endocrine pancreatic b cells, the major secretory cargo protein Methods is proinsulin, the precursor in insulin biosynthesis. Thus, proinsulin is a major Cross-sectional randomized population survey involving 2368 adults, aged R20 source for donating reducing equivalents to ER oxidoreductases, yet very little is years. HbA1c was measured on a Bio-Rad 10 system in 1972 subjects. known about the oxidoreductases that facilitate its proper disulfide bond Results formation within the ER. To begin to characterize the relationship between ER Among 1972 studied subjects, 329 were detected to have prediabetes based on oxidoreductases and proinsulin within the ER of b cells, I have employed isolated IFG in 125 (6.3%), isolated IGT in 141 (7.1%) and both in 63 (3.2%) of selective RNAi-mediated knock-down of ER oxidoreductases. Using anti-insulin subjects. The optimal HbA1c cut-off for diagnosis of prediabetes based on IFG immunoprecipitates from metabolically-labeled cells, I have used Tris-tricine- criteria (6.1 to !7 mmol/l) was 5.5% which had a sensitivity of 67%, specificity urea-SDS-PAGE to closely examine disulfide bond formation in endogenous of 52% with accuracy of 45%, and for 2 h PG (7.8 to !11.1 mmol/l), it was 5.7% proinsulin. By pinpointing the key ER oxidoreductases involved in forming with sensitivity, specificity and accuracy of 67, 67 and 59%, respectively. proinsulin’s three native disulfide bonds, we can potentially manipulate these ER Subjects who had both IFG and IGT had optimal HbA1c cut-off of 5.7% with oxidoreductases to enhance proper proinsulin disulfide bond formation. In turn, sensitivity, specificity and accuracy of 69, 60 and 57%, respectively. One hundred this may alleviate ER stress, preventing b cell failure and the development of and thirty-four subjects (6.8%) were newly detected to have diabetes and HbA1c Type II diabetes mellitus. cut-off of 6.1% had an optimal sensitivity and specificity of 81% each with accuracy of 77% for diagnosis of diabetes. Conclusions HbA1c between 5.5 and 6% corresponds to the presence of prediabetes in Asian Indians. P126 Does the effect of non-alcoholic fatty liver disease confer increased cardiovascular risk in patients with polycystic ovary syndrome? Alison Dawson1, Thozhukat Sathyapalan2, Eric Kilpatrick3 & 2 Stephen Atkin P128 1University of Hull, Hull, UK; 2Hull York Medical School, Hull, UK; 3Hull and East Yorkshire NHS Trust, Hull, UK. Safety profile of Vildagliptin in clinical practice: 2-year data from 2 Tertiary hospitals Mohammad Siddiqui1, Mukul Gupta1, Subhash Wangnoo1 & Jamal Ahmad2 Background 1Apollo centre for Obesity, Diabetes and Endocrinology, Indraprastha Polycystic ovary syndrome (PCOS) and non-alcoholic fatty liver disease Apollo Hospital, New Delhi, India; 2Centre for Diabetes and Metabolism, (NAFLD) are both associated with the metabolic syndrome and are each Aligarh Muslim University, Aligarh, Uttar Pradesh, India. associated with increased cardiovascular risk. Endothelial function, an early feature in the development of atherosclerosis, has been shown to be abnormal in both PCOS and NAFLD. Background and aims The aim of this study was to determine if NAFLD conferred additional Proper assessment of long-term safety of newer antidiabetic agents (ADAs) is of cardiovascular risk compared to PCOS alone. prime importance as diabetes is a chronic disease requiring life-long manage- Method ment. The purpose of this analysis was to assess the safety of vildagliptin as Twelve patients with PCOS alone and 10 patients who were matched for age, free monotherapy or as an add-on therapy to already existing ADAs (vildagliptin androgen index and menstrual cycle irregularity were recruited. group) compared to non-vildagliptin group. Patients were diagnosed with PCOS as per Rotterdam criteria. The PCOS alone Materials and methods group had a normal liver ultrasound scan and normal liver function tests. The Nine hundred and eighty-three patients in vildagliptin group and 1013 patients in PCOS-NAFLD group had a histological diagnosis of steatosis or steatohepatitis. non-vildagliptin group were included in the study drawn from the diabetes clinics. Other known aetiological factors of chronic liver disease (including alcohol The dose of vildagliptin was either 50 or 100 mg/day, either as monotherapy or as intake more than 20 g/day) were excluded. an add-on therapy. Safety data included evaluation of clinical and laboratory The patients attended after an overnight fast and endothelial function (RH-PAT) adverse experiences (AEs). as determined using peripheral arterial tonometry (endoPAT 2000). Anthropo- Results metric and blood samples were subsequently taken. The incidence of drug-related AEs overall and discontinuations were higher in Results non-vildagliptin group, primarily due to hypoglycemia in SUs and basal insulin- There was no difference between the PCOS-NAFLD and PCOS groups with treated, and due to GI side effects, especially due to AGIs. For specific AEs respected to systolic (125.20G13.73 vs 116.67G9.55 PZ0.15) or diastolic reported more frequently in the vildagliptin group (with 95% CI), 4 AEs were (72.80G12.93 vs 71.00G5.90 PZ0.21) blood pressure. Cholesterol (4.67G0.68 higher in the vildagliptin group (generalized itching, non-specific bullous rash, vs 4.51G0.78 PZ0.68), HDL (1.13G0.52 vs 1.09G0.26 PZ0.60), LDL 2.96 small joint pain and dysguesia) and 6 were higher in ADAs group (nausea, G0.70 vs 2.89G0.70 PZ0.93) and triglycerides (1.58G0.68 vs 1.19G0.43 diarrhea, fatigue, headache, dizziness, and weight gain). There was no increased PZ0.46) were no different between the two groups. The PCOS-NAFLD group incidence of any infections, including urinary tract infections in vildagliptin had a higher body mass index (BMI) (43.72G9.78 vs 37.47G3.87 PZ0.03) with group compared to other ADAs, slight but non-specific elevation of hepatic increased waist (128.60G15.14 vs 113.54G9.11 PZ0.01) and hip (135.85 transaminases with vildagliptin monotherapy/add-on therapy, which resolved G12.86 vs 123.35G9.14 PZ0.01) circumference. There was no difference in spontaneously. RH-PAT between the PCOS-NAFLD and PCOS groups (1.91G0.39 vs 1.80 Conclusion G0.45 PZ0.38). Patients with type 2 diabetes tolerated vildagliptin as a monotherapy or as an Conclusion add-on therapy for nearly 2 years without any increased incidence of significant This study suggests that additional fatty liver disease in PCOS does not confer side effects. additional cardiovascular risk compared to PCOS alone, and despite the PCOS- NAFLD group having a higher BMI.

P129 Sound mind, but sweet blood: olanzapine induced hyperglycaemia P127 Gideon Mlawa, Rakhi Seth, Sandeep Deshmukh & Patrick Sharp Utility of glycated haemoglobin in diagnosing prediabetes in Asian Southampton General Hospital, Southampton, UK. Indians- A Community Survey: Chandigarh Urban Diabetes Study (CUDS) group Ravikumar Padala, Anil Bhansali, Rama Walia, M Ravikiran, G Sunder, Background Shobhit Bhansali, Sanjay Bhadada & Pinaki Dutta Atypical antipsychotic agents are useful in treating patients with schizophrenia Postgraduate Institute of Medical Education and Research, Chandigarh, and other psychoses, but may cause hyperglycaemia. Hyperglycaemia is not dose India. dependent and is reversible on stopping the treatment. Occurrence of diabetes after atypical antipsychotic drug administration is of major concern as patients may not recognise their symptoms, and health workers Aim may fail to reach an early diagnosis, with major implications for morbidity and To determine the HbA1c cut-offs for diagnosis of prediabetes based on isolated mortality. The effect and ability of various atypical antipsychotic drugs to cause IFG, isolated IGT and both IFG and IGT. diabetes is debatable. The current available evidence seems to indicate that

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK olanzapine and clonazapine have the highest propensity to induce diabetes P131 compared to other atypical antipsychotics. Interactions between glucagon and GLP-1 in neuronal pathways We present a case of a 37-year-old lady with advanced Huntington’s chorea who affecting food intake was admitted after general deterioration at home over 3 days, with loss of Jennifer Parker, Katherine Simpson, James Minnion, Ben Field, appetite, high temperature, worsening of chorei form movements, urinary Mohammad Ghatei & Steve Bloom frequency and reduced level of consciousness. On admission she was found to be Imperial College, London, UK. in significant metabolic acidosis (pH 7.22), hyperglycaemic (glucose 73.3 mmol/l), renal failure and hypernatraemic (NaC170). Inflammatory markers were raised (WCC 23.6, CRP 42) and her urine dipstick was positive for blood, Glucagon is released from a-cells in the pancreatic islets and is best known for its protein, glucose, and ketones. She was treated for urinary sepsis with IV role in glucose homeostasis. Glucagon/GLP-1 receptor co-agonists have recently antibiotics, IV fluids and insulin sliding scale. There was no family history of been shown to improve glucose homeostasis and reduce body weight in diet- diabetes. She was on olanzapine 20 mg once/day started 2 years prior to induced obese mice. Glucagon receptor agonism increases energy expenditure admission as well as sulpiride 200 mg mornings, and 600 mg evenings. She was while the GLP-1 receptor agonism prevents glucagon-induced hyperglycemia. discharged home on insulin (Mixtard 30) 34 units morning, and 16 units evening. Peripherally administered glucagon is also capable of reducing food intake, and Olanzapine and sulpiride were not stopped as these formed an important part in glucagon neutralising antibodies increase food intake. The neuronal pathways symptom control for her Huntington’s chorea. involved in this effect have not been identified. Conclusion We have used c-fos immunohistochemistry to examine the effect of peripherally Patients on atypical antipsychotics should be monitored for any signs and administered glucagon on neuronal activity in the brain. Anorectic doses of symptoms of hyperglycaemia and the complications associated with diabetes. glucagon increased c-fos levels in the nucleus tractus solitarius (NTS), area Physicians must be made aware of the growing association between atypical postrema (AP) and central nucleus of the amygdala (CeA). These effects appeared antipyschotic agents and hyperglycaemia. to be dose dependent and restricted to doses capable of inhibiting food intake. The same nuclei were also activated in a dose responsive manner by the related hormone GLP-1. In addition, we have studied the effect of combined administration of glucagon and GLP-1 on food intake in fasted mice. Doses of each hormone that were individually too small to significantly affect food intake were shown, when administered together, to reduce food intake significantly. In parallel studies, c-fos expression in the AP, NTS, and CeA also appeared greater when the two hormones were administered in combination. P130 Our studies show that glucagon and GLP-1 have an effect on food intake that is, at Cabergoline prevents weight gain in patients evaluated for minimum, additive. This effect appears to involve the same neuronal pathways hyperprolactinaemia activated by either hormone individually. This suggests it may be possible to Martin Whyte1, Riaz Aziz1, Sesha Pramodh2 & Simon Aylwin1 achieve the same maximal effect produced by a high dose of a GLP-1 by 1King’s College Hospital, London, UK; 2Yeovil Hospital, London, UK. combining a low dose of GLP-1 with glucagon. This approach may be valuable in developing novel treatments for diabetes and obesity.

Introduction Food reward stimuli elevate dopamine levels in brain reward circuits. Decreased dopaminergic signalling may be involved in pathophysiological processes leading to obesity and D2 receptor antagonists (antipsychotics) are associated with a higher risk of obesity. One study has demonstrated an association between the use of a dopamine D2 agonist (bromocriptine) and weight-loss in patients with prolactinoma. We have investigated the effect of cabergoline on body weight in a population presenting with hyperprolactinaemia. Methods One hundred medical records were studied. All patients had been evaluated for P132 prolactin excess with a cannulated prolactin study. Macroprolactinaemia was The effect of environmental enrichment on food intake, body weight and excluded in all samples. Patients with panhypopitutiarism or previously treated the HPA axis in laboratory rats with another dopamine agonist were excluded. Data was also unavailable in Kylie Beale, Eleanor Harrison, Kirsty Smith, Angela Kerton, 3 patients, leaving 89 patients. Weight and cabergoline dose was recorded at each Mohammad Ghatei, Steve Bloom & Kevin Murphy visit. Imperial College London, London, UK. Results (meanGS.E.M.). At Visit 1, prolactin was 1614.4G447.8 mU/l in cabergoline group (CG) and 534.1G75.8 mU/l in controls (P!0.001). Body weight and BMI Laboratory rats are commonly used to study energy homeostasis. To accurately 2 at the first visit was 72.5G13.7 kg and 27.0G6.5 kg/m in CG and 70.6G9.0 kg record food intake or energy expenditure it is necessary to house rats individually, and 26.9G1.1 kg/m2 in controls (PZNS). Cabergoline dose was 493.2 which can be stressful for social animals. Environmental enrichment may reduce G15.4 mg/week. stress and improve welfare in laboratory rodents. However, the effect of environmental enrichment on food intake and thus experimental outcome in rats is unknown. We aimed to determine the effect of environmental enrichment on food intake, body weight, behaviour and faecal and plasma stress hormones in Visit 1 male Wistar rats. (pre-treatment) Visit 2 Visit 3 Visit 4 Singly housed rats were given either no environmental enrichment, chew sticks, a plastic tube, or both chew sticks and a tube (nZ6–8 per group). These forms of CG Control CG Control CG Control CG Control enrichment are commonly used in rodent husbandry and have been shown to Number 27 62 27 61 22 23 14 10 promote species-specific behaviour. Days NA NA 166.4 168.05 329.3 345.2 511.4 540.2 No differences in body weight or food intake were seen over a seven-day period. since G33.3 G21.2 G67.2 G75.3 G161.7 G170.8 Importantly, the re-feeding response following a 24-h fast was unaffected by first visit Change NA NA K0.50 C0.8 K0.3 C1.8 K0.4 C2.7 environmental enrichment. Rearing, a behaviour associated with stress, was in weight G0.10* G0.09 G0.06* G0.4 G0.1* G0.9 significantly reduced in all enriched groups compared to controls. No differences from first in faecal corticosterone were noted between groups throughout the study. visit (kg) However, there was a significant increase in faecal Immunoglobulin A and a trend towards a reduction in plasma corticosterone in animals housed with both forms *P!0.05 compared to control. of enrichment compared to controls at the termination of the study, suggesting enrichment may reduce hypothalamo–pituitary–adrenal axis activity in singly housed rats. Conclusion In summary, environmental enrichment does not influence body weight and food Cabergoline is unlikely to be considered as a useful weight loss agent, but in this intake in singly housed male Wistar rats and may therefore be used to refine the study it was associated with weight stability compared to the weight gain that living conditions of animals used in the study of energy homeostasis without occurred amongst individuals who did not start dopamine agonist treatment. compromising experimental outcome.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P133 became significant already after the first hour. The pattern of IGFBP1 Plasma Annexin A1 (AnxA1) is inversely correlated with waist to hip phosphorylation and oligomerisation has been investigated using immunoaffinity ratio in healthy males chromatography with immobilised anti-a2M antibodies, SDS-PAGE and SELDI Anna Kosicka-Knox1, Adam Cunliffe2, Richard Mackenzie1, Rod Flower3 techniques. The relative ratio of IGFBP1 isoforms seemed the same in all three & Derek Renshaw1 study groups, but the groups differed in respect to oligomer formation (90– 1University of Westminster, London, UK; 2London South Bank University, 100 kDa). There were three oligomeric forms detected in the circulation of DM2 London, UK; 3Bart’s and The London, London, UK. patients, compared to one in HG patients and two in healthy persons. Oligomers had characteristic masses in samples from three study groups. These results suggest a possible greater involvement of IGF system in glucose/insulin The escalating public health problem represented by obesity has spurred multi- metabolism in patients with diabetes mellitus type 2, than in healthy persons and disciplinary research into adipose tissue and importantly, the molecular biology of the patients with hypoglycemia. adipocyte. Recent studies suggest that obesity related metabolic disorders are characterised by chronic mild inflammation as a result of adipocytokine production from fat tissue leading to dysregulation in the pro/anti-inflammatory systemic balance. Adipokines and pro-inflammatory markers are implicated in insulin insensitivity, blood glucose dysregulation, inflammation and atherosclerosis. As a result, circulating levels of adipokines and pro-inflammatory markers may be valuable biomarkers in identifying future risk of disease states associated with obesity. Whilst there is a considerable P136 amount of research into the characterisation of adipokines and pro-inflammatory The Megalin-Cubilin receptor-mediated endocytic pathway is impaired cytokines, the anti-inflammatory adipocytokines warrant further exploration. in Dent’s disease renal proximal tubule cell-lines 1 2 1 1 AnxA1, is an endogenous glucocorticoid regulated protein, which mediates systemic Caroline Gorvin , Martijn Wilmer , Nellie Loh , Sian Piret , 1 2 2 anti-inflammatory processess. The expression of AnxA1 with increased adiposity has Brian Harding , Lambertus van den Heuvel , Elena Levtchenko 1 not been investigated to date. However, given the balance that exists between pro and & Rajesh Thakker 1 anti-inflammatory substances, it seems plausable that AnxA1 may be altered in Academic Endocrine Unit, OCDEM, University of Oxford, Oxford, UK; 2 individuals with increasing adiposity. Laboratory of Pediatrics and Neurology (656), Radboud University We recruited 94 healthy males for an in vivo study measuring both metabolic and Nijmegen Medical Center, PO Box 9101, 6500 HB, Nijmegen, anthropometric parameters. Plasma AnxA1 levels were correlated with levels of The Netherlands. adiposity and distribution of fat, body mass index (BMI), waist to hip ratio, adipocytokines, blood cholesterol, glucose and blood pressure. AnxA1 was measured Receptor-mediated endocytosis (RME), involving megalin and cubilin, mediates using an in-house sandwich ELISA. Ethical approval was granted by the University of renal proximal-tubular reabsorption of glucose, proteins and hormones including Westminster (08/09/22). insulin, parathyroid-hormone and vitamin D. RME disruption occurs in Dent’s Our results show that plasma AnxA1 protein is significantly inversely correlated with Z disease patients with mutations of the chloride/proton antiporter, CLC-5, who waist to hip ratio (P 0.03) in healthy male subjects suggesting that as central fat mass suffer from low-molecular-weight proteinuria, hypercalciuria, nephrolithiasis and increases the concentration of plasma AnxA1 decreases. renal failure. To further investigate the RME role of CLC-5 we established AnxA1 could potentially represent a (fat) depot specific biomarker whose decline with conditionally immortalized proximal-tubular epithelial cell-lines (ciPTECs) from increasing central adiposity may relate to the phenomena of increasing systemic three patients with CLC-5 mutations (30insHis, Arg637Stop and del132-241). inflammation and associated disease risk. Clonal populations of urinary cells were established by selection of aminopepti- dase-N-positive cells using fluorescence-activated cell sorting, and characterised by flow cytometry, RT-PCR, western blot and confocal microscopy to establish expression of ATP-binding cassette sub-family C member 4 (ABCC4), Aquaporin-1, dipeptidyl peptidase-4 (DPPIV/CD26) and P-glycoprotein to demonstrate their proximal-tubular origin. Endocytosis was investigated by fluorescent-labelled albumin and transferrin uptake assays with and without 10-fold excess of unlabelled albumin or transferrin, and compared to two control P134 ciPTECs. Confocal microscopy using the tight junction marker ZO-1, and EB1 which is specific for the plus-end of microtubules, were used to demonstrate that the ciPTECs polarised. Fluorescent-albumin-uptake in the three Dent’s disease ciPTECs was significantly decreased to 20–65% of control values (P!0.02). In ciPTECs with the 30insHis and Arg637Stop, albumin-uptake was demonstrated Abstract withdrawn. to be further reduced by competition with unlabelled albumin and transferrin (13.23G3.01% and 16.44G7.43%, respectively for 30insHis (P!0.02); and 36.16G6.62% and 43.72G3.54%, respectively for Arg637Stop (P!0.05) when compared to uptake without competition), thereby confirming the specificity of the albumin uptake by the megalin-cubilin RME pathway in these ciPTECs. Furthermore, transferrin-uptake was similarly reduced in the ciPTECs with CLC- 5 mutations, consistent with impairment of CLC-5-megalin-cubilin RME in these Dent’s disease ciPTECs. Thus, these Dent’s disease ciPTECs which have P135 defective RME, will help in elucidating the mechanisms involved in renal Characterisation of IGFBP1 molecular forms in healthy persons and proximal-tubular reabsorption of solutes. patients with diabetes mellitus type 2 or hypoglycemia Dragana Lagundzin & Olgica Nedic Institute for the Application of Nuclear Energy-INEP, 11080 Belgrade, Serbia.

Insulin-like growth factors (IGFs) and their binding proteins (IGFBPs) are involved in the regulation of glucose metabolism and metabolic disorders. P137 IGFBP1 is the only IGF-binding protein that shows diurnal variation and is Influence of metabolic decompensation in children with diabetes inversely correlated to the insulin level. IGFBP1 exists as non-phosphorylated mellitus type 1 on changes of QT interval protein and several phosphoforms. Phosphorylation affects the affinity of Galina Meraai & Angelika Solntseva IGFBP1 for IGFs and, therefore, the ability to regulate IGF action. In the First Department of Childhood Diseases, Belarussian State Medical circulation IGFBP1 is associated with a2-macroglobulin (a2M) in a complex University, Minsk, Belarus. that may have an important role in controlling IGF action by regulating the amount of free IGFBP1. IGFBP1 was found to form multimers as well, which have low affinity for IGFs. The aim of this work was to investigate the kinetics The basic manifestations of dystrophic changes in heart of children suffering form of the alteration of IGFBP1 concentration during OGTT, together with the diabetes mellitus type 1 (DM1) are disturbances of repolarization and molecular distribution of IGFBP1, in healthy persons, patients with diabetes depolarization processes, including QT and QTc intervals prolongation. Research mellitus type 2 (DM2) or hypoglycemia (HG). It was found that IGFBP1 objective: to evaluate indices of QT and QTc in children with DM1, to reveal concentration significantly decreased 2 h after glucose intake in healthy and interrelation of the observed changes with the duration of disease, age, sex, levels hypoglycemic persons, whereas in patients with diabetes a reduction in IGFBP1 of cholesterol (CH) and glycemie, BMI, blood pressure, pulse rate.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Materials and methods Exercise and metabolic processes are known to produce ROS. Pomegranates are QT and QTc were evaluated on ECG in 164 children with DM1 (middle age rich in polyphenolic antioxidants. The aim of this study is to investigate the effects 13.4G0.92 years, duration of disease 5.85G0.89 years) and in 60 sex- and age- of pomegranate pure juice consumption on blood pressure, lipid peroxidation matched healthy children. Level of HbA1c in children with DM1 made up 9.65 and urinary glucocorticoid levels before and after a moderate exercise bout. G0.51% (N to 7.5%; P!0.0005). Methods Results A randomized placebo controlled 2-arm study was conducted. Participants QT and QT are increased in children with DM1 in comparison with control group (2 groups of 10 each) attended two 30 min treadmill exercise sessions (50% Wmax); (363.51G8.5 ms and 421.13G12.5 ms, 352.97G15.1 ms and 392.73G13.0 ms pre and one week post pomegranate juice (500 ml/day containing 1685 mg respectively, P!0.0001). Values of QTc in girls with DM1 are higher than that total phenolics/l) or water consumption. 24 h urine samples were collected and values in boys (425.36G14.8 ms versus 416.24G14.8 ms, P!0.002). 21.59% of blood pressure monitored before and after each session. Urinary lipid peroxidation girls and 15.79% of boys with DM1 have QTcO440 ms. At the same time values levels (TBARS), free cortisol and cortisone levels were determined in all urine of fructozamine level are higher in boys than in girls (412.88G11.35 and samples using in house ELISA methods. 377.66G8.76 mkmol/l respectively, P!0.001). The difference in pulse rate Results between girls and boys is insignificant for the group studied. Connection of QTc Pomegranate juice consumption was found to significantly decrease systolic with age (rZ0.334, P!0.0003) and level of HbA1c (rZ0.37, P!0.0001) was blood pressure (pre-exercise: 141G20.7 to 136.1G17.3, PZ0.03 and post- established. Feedback connection of QT with pulse rate was revealed (rZK0.48, exercise:156.4G17.5 to 149.5G10.2 mmHg, PZ0.04), diastolic blood pressure P!0.0001). Reliable correlation between QTc and values of BMI, level of CH, (90.9G11.6 to 87.1G8.7, PZ0.04 and 102.6G23.9 to 94.6G20.4 mmHg, duration of the disease and values of systolic and diastolic blood pressure was not PZ0.05) and TBARS levels (0.312G0.106 to 0.264G0.098 MDA mM/l, established. PZ0.035). There was no significant change in lipid peroxidation or blood Conclusions pressure for subjects consuming water. Urinary free cortisol was reduced The increase of QT and QTc is noticed in children with DM1. Age, level of from 39.1G26.6 to 26.4G16.5 nmol/24 h (PZ0.064), however there was glycemie, pulse rate and sex are the factors defining values of QTc. a statistically significant increase in urinary free cortisone (28.1G20.4 to 51.9 G45.1 nmol/24 h, PZ0.045), and decrease in free cortisol/cortisone ratio (1.81G1.24 to 0.82G0.56, PZ0.009) following one week of pomegranate juice intake. Conclusions Our results suggest that pomegranate juice seems to exert beneficial effects in P138 reducing blood pressure pre/post exercise and lipid peroxidation levels due to Hypogonadism with subsequent multi-organ involvement: a mystery exercise-induced oxidative stress. The reduction in blood pressure could solved presumably be due to the inhibition of 11b-HSD1 activity as evidenced by the Cynthia Mohandas1, Dennis Barnes2, Derek Harrington2 & Masud Haq2 reduction in cortisol/cortisone ratio or other mechanisms yet to be investigated. 1University Hospital Lewisham, Lewisham, UK; 2Kent and Sussex Hospital, Royal Tunbridge Wells, UK.

A 53-year-old gentleman was seen following a recent diagnosis of type 2 diabetes in May 2009. He had suffered a subarachnoid haemorrhage in 1993 and remained under the local tertiary centre after developing secondary hypogonadism treated with testosterone replacement. The cause had never been established. The patient had previously been diagnosed with seronegative HLA B27 arthropathy and in December 2008 was admitted with acute cardiac failure and atrial fibrillation. An echocardiogram demonstrated a moderately dilated right and left heart, global left ventricular hypokinesia, an ejection fraction of 20% consistent with dilated cardiomyopathy. He responded well to medical therapy. P140 He had mildly abnormal liver function tests in the past but his AST level was Insulin sensitivity and cytokine response to different exercise modalities in hypoxia in type 2 diabetics twice the upper limit of normal in May 2009. Subsequent iron studies revealed a 1 2 1 2 transferrin saturation of 90% and ferritin of 8989 mg/l. Testosterone replacement Richard Mackenzie , Neil Maxwell , Bradley Elliott , Gary Brickley & Peter Watt2 was therefore discontinued. 1 2 Hepatitis screen and liver autoantibodies proved negative. AFP level was !2. University of Westminster, London, UK; University of Brighton, Abdominal ultrasound confirmed 23 cm hepatomegaly but no splenomegaly. The Brighton, UK. patient was confirmed to have hereditary haemochromatosis (codon 63-HH, codon 282-YY). Continuous aerobic exercise improves glucose tolerance in type 2 diabetics Baseline tests revealed: FT4 12.5 pmol/l, TSH of 0.6 mU/l; 9am cortisol (T2D), with greater improvements during exercise in hypoxia. Continuous 454 nmol/l; prolactin 101 mIU/l; testosterone 0.2 nmol/l, LH !0.1 IU/l, FSH ! exercise has been linked with poor adherence. Positive effects with intermittent 0.2 IU/l; IGF1 7.1 nmol/l and GH 1.26 mg/l. exercise (IE) with reduced time commitments would have clear benefits. Exercise A TRH test was normal but a glucagon test confirmed GH deficiency with normal and hypoxia both increase pro-inflammatory cytokines, potentially reducing cortisol response. benefits of hypoxia. This study aimed to establish the effects of IE under hypoxic An MRI did not demonstrate pituitary enhancement but cardiac MRI has shown a conditions in T2D on i) glucose homeostasis and ii) TNFa and adiopnectin. grossly dilated LV with globally impaired function and severe myocardial iron Seven overnight fasted individuals with T2D completed 3 trials separated by loading. Ferritin levels have fallen to 3203 mg/l with regular venesection and he w7 days; i) 60 min continuous exercise at 90% lactate threshold (LT) in remains under annual surveillance by the gastroenterologists. normobaric hypoxia (O2 w14.9%) (HyEx60); 5 min exercise at 120% LT, Hereditary haemochromatosis is an autosomal recessive disorder characterised by separated by 5 min passive recovery repeated for 60 min in ii) normoxia (Nor5:5) excess iron deposition especially in the liver, heart, pancreas, and pituitary. This or iii) hypoxia (Hy5:5). Rates of glucose appearance (Ra) and disappearance (Rd) case is an excellent example of why this diagnosis should be excluded in patients were determined during, immediately post, 24 and 48 h post hypoxia. with unexplained cardiac failure or hypogonadism. Homeostasis model of insulin resistance (HOMAIR) and Fast Insulin Resistance Index (FIRI) were estimated. Serum samples were analysed by ELISA for TNFa and adiponectin. Values are presented as means (GS.E.M.). All trials acutely lowered blood glucose concentrations. Rd increased 24 h following HyEx60 (baseline:1.85 (0.11), 24 h:2.01 (0.12) mg/kg per min). No P139 difference was seen in Rd in Nor5:5 or Hy5:5. HOMAIR and FIRI decreased by 29 Pomegranate juice consumption influences urinary glucocorticoids, and 27% 48 h post HyEx60. Difference in Ra and Rd was depressed in HyEx60 attenuates blood pressure and exercise-induced oxidative stress in only. TNFa decreased below baseline in HyEx60 both 24 and 48 h post exercise. healthy volunteers Hy5:5 decreased TNFa at 24 but not 48 h. No change in TNFa was seen in Catherine Tsang, Gillian Wood & Emad Al-Dujaili Nor5:5. Non-significant trends towards decreased adiponectin levels were seen Queen Margaret University, Edinburgh, Scotland, UK. post Hy5:5 and Nor5:5. Continuous exercise demonstrated the greatest improvements in glucose tolerance, while decreasing systemic circulation of TNFa. Findings are in Background and aim agreement with previous work and suggest that hypoxic exercise may have Antioxidants have been postulated to exert beneficial effects on cardiovascular clinical applications in the treatment of T2D. and neurodegenerative diseases by neutralizing reactive oxygen species (ROS).

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P141 work is needed to identify the patient and systematic barriers that prevented Audit of short synacthen tests in patients with type 2 diabetes mellitus screening in these women. Logan Manikam1, Nadia Othonos1, Harit Buch1 & Rousseau Gama1,2 1New Cross Hospital, Wolverhampton, UK; 2Wolverhampton University, Wolverhampton, UK. P143 Background and objective Addison’s disease occurs more frequently in patients with type 1 diabetes mellitus Insulin-mediated pseudoacromegaly (T1DM) as part of the autoimmune polyendocrine syndromes. There is, however, Amir Sam, Tricia Tan & Karim Meeran no such association between adrenal failure and type 2 diabetes mellitus (T2DM). Imperial College London, London, UK. We, therefore, retrospectively audited referrals for short synacthen tests (SST) on patients with T2DM. Patients with acromegaly have characteristic clinical features of soft tissue Methodology overgrowth. Both somatic and metabolic features of acromegaly are secondary to Seven years retrospective study of indications for and results of SST on patients excess GH secretion and high circulating levels of insulin-like growth factor 1 with T2DM referred for exclusion of adrenal failure. A normal SST was defined (IGF1). However, an acromegaloid phenotype associated with severe insulin O as a serum cortisol increase of 200 nmol/l over baseline and peak serum cortisol resistance is occasionally seen in the absence of biochemical hallmarks of O response 550 nmol/l. acromegaly (insulin-mediated pseudoacromegaly). Here we present a case of Results ‘insulin-mediated pseudoacromegaly’ with an acromegaloid phenotype, insulin There were 89 referrals SSTs in patients with T2DM. Recurrent hypoglycaemia resistance, history of adenomatous colonic polyp, and suppressed IGF1 levels. was the sole indication for a SST in 55 (61.8%) patients and in 4 (4.3%) patients in Patients with this rare condition are likely to have a selective post-receptor defect Z Z combination with weight loss (n 1), hyponatraemia (n 1), hypogonadotrophic of insulin signalling. The insulin resistance in this condition may be secondary to Z Z hypogonadism (n 1) and dizziness without hypotension (n 1). Seventeen impaired insulin-stimulated phosphatidylinositol (PI) 3-kinase activity. The (19.0%) SSTs were performed on patients with known or suspected hyperinsulinaemia occurring in compensation for the impaired metabolic hypothalamic–pituitary–adrenal axis disorder including three on long-term signalling may activate intact mitogenic signalling pathways and stimulate steroids. The remaining 12 (13.5%) SSTs were requested because of weight pathological tissue growth. Endocrinologists should be aware of this diagnosis Z Z Z loss (n 3), hyperkalaemia (n 3), hyponatraemia (n 1), postural hypotension when assessing patients with clinical features of acromegaly and insulin Z Z Z (n 3), tiredness (n 1), reduction in insulin requirements (n 1) and to resistance, in the absence of elevated levels of GH and IGF1. assess adrenal reserve prior to starting thyroxine (nZ1). Three (3.2%) patients had suboptimal cortisol responses to synacthen, all of who were on long-term steroid therapy. Discussion Addison’s disease occurs more frequently only in T1DM and not T2DM. It is recommended that patients with T1DM with unexplained recurrent hypoglycae- P144 mia be screened for Addison’s disease. This, perhaps, has been inadvertently Brain natriuretic peptide rises with exercise at high altitude and is extrapolated to T2DM since the commonest indication for SST in patients with associated with acute mountain sickness scores T2DM was recurrent hypoglycaemia but all had normal SSTs. David Woods1,2, Tim Hooper3, Pete Hodkinson3,4, Steve Ball2, Conclusion Rob Wakeford3, Bob Peaston5, Claire Bairsto3, Nic Green3,4 Recurrent hypoglycaemia, in the absence of other features of adrenal failure, is & Adrian Mellor3 not an indication for a short synacthen test in patients with T2DM. 1Newcastle and Northumbria NHS Trusts, Newcastle, UK; 2University of Newcastle, Newcastle, UK; 3Defence Medical Services, MDHU North- allerton, UK; 4Centre for Aviation Medicine, Henlow, UK; 5Freeman Hospital, Newcastle, UK.

Acute mountain sickness (AMS) is common at high altitude (HA) and is P142 associated with a relative failure of the natriuresis and diuresis that occurs at HA. The role of brain natriuretic peptide (BNP) in this context has not been thoroughly Retinal screening in pregnant women with diabetes: ‘are we doing investigated. We aimed to clarify if BNP rises in response to exercise at HA and if enough’ so whether this is related to markers of acclimatization. Thirty-two healthy Gideon Mlawa, Richard Holt, Mathew Coleman, Christina Rennie subjects had assessments of BNP, aldosterone and markers of HA acclimatization & Roger Smith (as assessed by the AMS-C score of the environmental symptom questionnaire Southampton General Hospital, Southampton l, UK. (EQ12) and lake louise questionnaire) made following exertion at sea-level (SL), 3400, 4300 and 5150 m. Data were analysed in the 23 subjects who did not Introduction consume drugs known to affect acclimatization. BNP (pg/ml, meanGS.E.M.) was NICE recommends that pregnant women with pre-existing diabetes should be significantly higher at 5150 m versus the lower altitudes (P!0.001 for all): 7.1 offered retinal assessment in the 1st and 3rd trimester by digital retinal imaging. G1; 6.1G0.3; 6.8G0.9 and 17.7G5.1 at sea-level; 3400; 4300 and 5150 m Where retinopathy is already present, an additional assessment should be made in respectively. In those that showed no BNP response at 5150 m (nZ4) versus the 2nd trimester. those that did demonstrate a BNP response (nZ19) there was a significant Objectives difference in lake louise (LL) acute mountain sickness scores at 5150 m on day 10 To assess the feasibility of retinal screening in pregnancy by a community based of the expedition (mean LL score 0.75 vs 3.3, PZ0.034) and day 11 (mean LL mobile retinal screening programme (MRSP). score 0 vs 3.3, PZ0.003). Acute mountain sickness is defined by a LL score O3. Methods This is the first report to demonstrate a significant rise in BNP at HA. A BNP A retrospective audit of 58 pregnant women with pre-existing diabetes who response at 5150 m is associated with a greater likelihood of suffering AMS. attended the diabetes antenatal clinic between 2008 and 2009 was performed. The hospital notes and MRSP database were examined to assess whether the women were registered with MRSP, were offered a screening appointment and whether Lake Louise acute mountain sickness score on they attended at the appropriate time. day 10 at 5150 m (those with BNP rise versus those without) Results 5 Forty-six patients were sent appointments offering retinal screening. 41 patients were screened in the 1st trimester or at first contact and again during the 3rd 4 trimester. In addition all 8 patients with pre-existing retinopathy were screened in 3 the 2nd trimesters. Five patients did not attend the appointment despite reminders. Their GPs were informed and direct fundoscopy was undertaken in clinic. One 2 woman was already receiving care from the eye unit. Seven women lived outside 1

our catchment area and may have received screening elsewhere. Four women Louise score Lake were not registered with the programme. 0 Conclusion Rise in BNP No rise in BNP At least 72% of women received eye care as recommended by NICE. 9% did not attend despite reminders and 7% were not registered with the programme. Further

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P145 Conclusion Diet-induced obesity with metabolic dysfunction does not alter vascular Postprandial hypertriglyceridaemia is higher in patients with PCOS compared function or remodelling in young C57Bl/6 mice to normal women and could potentially contribute to their higher Rachel Dakin, Amanda Drake, Brian Walker, Jonathan Seckl cardiovascular risk. & Patrick Hadoke University of Edinburgh, Edinburgh, UK.

Obesity is associated with metabolic and vascular dysfunction. Many models have shown insulin resistance reduces endothelium-dependent vasodilation but P147 this is also seen in obese subjects with normal glucose tolerance. There is also evidence of increased response to vascular injury in obese animals, although the mechanisms underpinning this are not fully understood. This study used a mouse model of diet-induced obesity (DIO) to address the hypothesis that obesity causes metabolic dysfunction, inhibition of endothelium-dependent relaxation and increased neointimal proliferation following wire-induced injury. Abstract withdrawn. Male C57Bl/6 mice (5 weeks old) were fed obesogenic or control diets (8 weeks) and then underwent metabolic testing, including blood pressure measurement by tail cuff plethysmography. They were then either killed and femoral arteries collected for function analysis (nZ7/group), or subjected to femoral artery luminal wire injury surgery (NZ5 CON 7 DIO/group) and killed 4 weeks post injury. Injured vessels were excised and lesion volume assessed using 3-dimensional optical projection tomography (OPT) and histology. P148 ! DIO mice were heavier than controls (P 0.01), had higher circulating Continuous feeding in rats: a novel paradigm for inducing hypocaloric cholesterol and triglyceride levels and were hyperglycaemic and hyperinsuli- obesity? naemic (DIO 1.39G0.16 versus CON 0.52G0.08 ng/ml P!0.001) on fasting and ! Bradley Arms-Williams & Timothy Wells following a glucose load (repeated measures ANOVA; glucose P 0.001, insulin School of Biosciences, Cardiff University, Cardiff, UK. P!0.05). Development of obesity did not alter blood pressure (DIO 119G4 versus CON 121G3 mmHg), agonist-mediated contraction or endothelium- dependent or -independent relaxation of isolated femoral arteries. Similarly, DIO Patterns of food consumption have a profound influence on hormone rhythmicity had no effect on the size of neointimal lesions following femoral artery injury and fat storage, but until now only crude manipulations of food availability have whether analysed using OPT (Lesion volume; DIO 29.9G9.0 versus CON 38.2 been possible in rodents. We have used a CLAMS-based system in conjunction G7.1%), or histology (maximum cross sectional area; CON 58.3G7.9 vesus with automated serial blood sampling to investigate the effect of continuous DIO 53.8G11.5%). feeding on ghrelin secretion and adiposity. Six-week old male Sprague–Dawley Thus, in young mice, obesity-induced alterations in glucose/insulin and lipid rats (nZ6) were housed in metabolic cages and ad-libitum fed with standard chow metabolism occur in the absence of vascular dysfunction. More prolonged for 3 weeks (12 h light:12 h darkness; lights on at 0600 h). A cohort of age- and exposure to diet-induced obesity or metabolic abnormalities may induce vascular weight-matched rats (nZ4) were housed in CLAMS cages in the same room and changes, though this remains to be explored. subjected to paired, continuous nocturnal feeding (1/24th of the total daily food intake of ad-libitum-fed rats being available every 30 min of the 12 h dark phase) for 3 weeks. During week 3 jugular vein catheters were introduced under isofluorane anaesthesia and automated hourly blood sampling initiated after 48 h recovery. Continuously fed rats consumed only 86% of their total daily allowance P146 (P!0.01), but body weight (BW) was not significantly reduced. The feeding- associated suppression of circulating octanoylated ghrelin in the early dark phase Postprandial hypertriglyceridaemia in patients with polycystic ovary was significantly delayed in continuously fed rats: plasma concentrations at 1800, syndrome 1900 and 2400 h being 4.1-, 2.7- and 3.3-fold that in ad-libitum-fed rats. Although Myint M Aye1, Paul R Afolabi2, T Sathyapalan1, Ammar Wakil3, nose-anus length and pituitary weight were unaffected by continuous feeding, S A Wootton2, Derek D Sandeman4, Eric S Kilpatrick3 & Stephen L Atkin1 femoral length was reduced by 2% (P!0.05) and proportionate liver weight 1University of Hull, Hull, UK; 2Southampton NIHR Biomedical Research increased by 6% (P!0.05). Proportionate abdominal fat pad weights were not Unit in Nutrition, Diet and Lifestyle, Southampton University Hospital NHS significantly affected by continuous feeding, but when corrected for cumulative Trust, Southampton, UK; 3Hull and East Yorkshire Hospitals NHS trust, food intake, the retroperitoneal depot (which is most sensitive to ghrelin Hull, UK; 4Department of Diabetes, Endocrinology and Metabolism, exposure) showed elevated lipid storage efficiency (increased by 24%; P!0.05). Southampton University Hospital NHS trust, Southampton, UK. Thus, continuous feeding fails to induce the post-prandial suppression of ghrelin secretion and predisposes rats to increased fat accumulation, suggesting that Background longer-term grazing may be obesogenic without increasing caloric intake. Postprandial hypertriglyceridaemia is an independent risk factor for cardiovas- cular diseases. An acute rise of insulin in the fed state suppresses hormone- sensitive lipase to inhibit free fatty acids (FFAs) mobilisation from adipose tissue, and up-regulates lipoprotein lipase to increase FFAs influx to adipose tissue from chylomicrons, that is blunted in insulin resistant states. Polycystic ovary syndrome (PCOS) is associated with insulin resistance and cardiovascular risk P149 markers and therefore may have an exaggerated postprandial hypertriglycer- Improvement of cardiovascular risk factors 12 months after Roux-en-Y idaemia akin to diabetes mellitus. surgery Methods Alison Dawson1, Thozhukat Sathyapalan3, Peter Sedman2, Eric Kilpatrick2 Nine patients with PCOS fulfilling all the three criteria of Rotterdam consensus & Stephen Atkin3 statement and 7 controls were recruited after informed consent. All patients 1University of Hull, Hull, UK; 2Hull and East Yorkshire NHS Trust, Hull, underwent a high fat meal test after an overnight fast. A 900 kcal meal was given UK; 3Hull York Medical School, Hull, UK. and bloods were taken at baseline, half hourly for 3 h and hourly for a further 3 h. Results The age (PCOS versus controls) (meanGS.D.) (31.4G3.5 vs 31.5G6.5 year, Background PZ0.27) and body mass index (31.4G3.5 vs 33.7G5.5 kg/m2, PZ0.33) were Obesity is associated with increased insulin resistance, type 2 diabetes and comparable between the two groups. The free androgen index (13.8G2.4 vs 6.3 increased cardiovascular risk leading to atherosclerosis. Bariatric surgery has been G1.7, PZ0.02), androstenandione (10.8G2.8 vs 7.8G2.7 nmol/l PZ0.04), shown to improve some of these factors in obese patients with glucose intolerance. dihydroepiandostenedione sulphate (6.7G0.5 vs 4.8G0.8 mmol/l PZ0.05) were A form of bariatric surgery is the Roux-en-Y procedure which can result in greater higher in PCOS women. Fasting glucose and lipid profile including triglyceride, weight loss and restriction with less malabsorption than other procedures (such as total cholesterol, HDL-C and LDL-C were comparable between the two groups. the bilious-pancreatic diversion); but the effect of some metabolic parameters on The median and interquartile range of triglyceride area under the curve (AUC) patients with normal glucose tolerance is not fully known. were significantly higher in the PCOS group (11.9, 9.0, 13.6 vs 6.4, 4.8, Aim 7.6 mmol/l/6 h, PZ0.04) but of FFAs AUC were not significantly different (1373, To examine the effect of Roux-en-Y surgery on endothelial function and 1118, 1643 vs 1190, 1131, 1411 mmol/l/6 h PZNS). metabolic parameters in patients without type 2 diabetes.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Method warranted. Erythropoietin (EPO) was found to be a cytoprotective molecule that Ten patients with a body mass index (BMI) O40 kg/m2 were recruited and might represent a novel strategy to limit the infarct size. followed up for 12 months after surgery. Fasting blood samples were taken before Aim of the work surgery and at 3 monthly intervals after surgery. Endothelial function (RH-PAT) To investigate serum erythropoietin level and its relation to infarct size in was also determined at these time points using peripheral arterial tonometry Egyptian patients with AMI. (endoPAT2000) technique. A 75 g oral glucose tolerance test was performed at Methods the start of the study to exclude diabetes. We studied 20 patients with AMI who underwent PCI within 12 h. Serum EPO Results levels were measured within 6 h and 7 days after the onset of AMI. Ten healthy BMI reduced from 49.47G7.54 kg/m2 pre surgery to 33.32G5.21 (P%0.001) 12 subjects were controls. months after surgery. Fasting glucose levels reduced from 5.26G0.78 mmol/l to Results 4.56G0.33 (PZ0.02), C-reactive protein (CRP) from 7.22G7.81 mmol/l to Serum EPO was higher among patients compared to controls. This increase was 2.41G4.41 (PZ0.039). Systolic blood pressure reduced from 129.64 not related to haemoglobin and had a negative significant correlation with CK and G16.18 mmHg to 114.22G10.71 (PZ0.05) and diastolic blood pressure reduced wall motion score index while a positive significant correlation with ejection from 76.55G14.24 mmHg to 72.56G7.50 (PZ0.95). RH-PAT improved from fraction. Patients with above median EPO level had lower CK and higher ejection 1.80G0.39 to 2.01G0.54 (PZ0.035). fraction compared to those with below median EPO. Serum EPO significantly Conclusion increased 7 days after the onset of MI and showed significant positive correlation Roux-en-Y surgery in patients with normal glucose tolerance improved with EPO within 6 h of the onset of MI. cardiovascular risk factors. Thus is shown by a reduction in the inflammatory Conclusion markers CRP, a reduction in systolic and diastolic blood pressure and also High endogenous EPO level can predict a smaller infarct size in Egyptian patients improved endothelial function 12 months after surgery. with acute MI. Key words: Erythropoietin, acute myocardial infarction, Egyptian Abbreviations: AMI: Acute myocardial infarction, EPO: Erythropoietin, PCI: Percutaneous coronary intervention, CK: creatine phosphokinase

P150 The prevalence of non alcoholic fatty liver disease in GH deficiency and the effect of GH replacement Chris Gardner1, Andrew Irwin1, Francis Joseph2, Chris Wong1, Val Adams3, Christina Daousi1,3, Graham Kemp3 & Daniel Cuthbertson1,3 1Aintree University Hospital NHS Foundation Trust, Liverpool, UK; 2Countess of Cheister NHS Foundation Trust, Chester, UK; 3University of Liverpool, Liverpool, UK.

Background P152 Non-alcoholic fatty liver disease (NAFLD) is reported to be more prevalent in Low testosterone and severity of erectile dysfunction (ED) are patients with GH deficiency (GHD) than in the general population. Case control independently associated with poor health related quality of life studies have not however been undertaken. Recognition of NAFLD is important (HRQoL) in men with type 2 diabetes due to its association with cardiovascular disease and chronic liver disease. Jonathan Brooke1,2, Debbie Walter1,2, Vakkat Muraleedharan1,2, Aims Hazel Marsh1, Dheeraj Kapoor1,2 & T Hugh Jones1,2 To determine i) the prevalence of NAFLD in patients with severe GHD compared 1Centre for Diabetes and Endocrinology, Barnsley NHS Foundation Trust to age and BMI-matched controls, and, ii) the effect of 6 months GH replacement Hospital, Barnsley, UK; 2Department of Human Metabolism, University of (GHR) onliver fat. Sheffield, Sheffield, UK. Patients and methods Twelve patients (7 males) with GHD for O12 months (Peak GH !3 mg/l on glucagon stimulation test) and 12 controls matched for age, gender and BMI were Introduction studied. GHD patients were studied before and 6 months after initiation of GHR. Both low testosterone levels and erectile dysfunction (ED) are highly prevalent in Anthropometric measures as well as AST, ALT gGT, IGF1 and lipid profiles were men with type 2 diabetes. Lower testosterone levels are known to be associated measured at each visit. Intrahepatocellular lipid (IHCL) was measured by with worsening severity of ED as assessed using the International Index of magnetic resonance spectroscopy, with NAFLD defined as liver fat O5.5%. Erectile Function score (IIEF). Testosterone deficiency and erectile dysfunction Ethics committee approval was obtained. are both independently correlated with increased risk of cardiovascular disease. Results Aim Values are quoted as median (range). Age of patients was 44.5 (35, 63) years To investigate the effect of low testosterone and erectile dysfunction on Health- versus controls 48.5 (33, 66) years (PZ0.68). Patient BMI was 30.8 kg/m2 (22.4, Related Quality of Life (HRQoL) in a cohort of 356 men with type 2 diabetes. 45.3) versus controls 31.7 kg/m2 (24.3, 43). IGF1 was significantly lower in the Method patient group, (11.5 vs 16 nmol/l PZ0.03). There was no significant difference in Total testosterone (TT), bioavailable testosterone (BT) and SHBG levels were ALT, AST, gGT, Cholesterol, HDL, LDL or percentage IHCL (3.6% (0.2, 44.8) analysed from morning blood samples. Free testosterone (cFT) levels were patients versus 6.6% (0.5, 32.1) controls, PZ0.68). 5 patients and 6 controls had calculated using Vermeulen’s equation. SF-36 scores were obtained from 356 IHCLO5.5%. Of the patients with elevated IHCL, 4 commenced GH. Liver fat patients, of whom 126 completed IIEF questionnaires. Data were analysed using reduced from 28.1% (20.4, 44.8) pre treatment to 16.3% (5.5, 20.6) post treatment PASW software. Local Ethical Committee approval was obtained. (PZ0.06). Results Conclusions Mean baseline characteristics were: age 58.5 (G8.1), TT 12.17 nmol/l (G5.86), Patients with GHD do not have an increased prevalence of NAFLD compared BT 3.84 nmol/l (G1.64), cFT 260 pmol/l (G0.14). Mean SF-36 score was 67.7 to matched healthy controls. GH replacement may reduce liver fat in patients (G17.3) and mean IIEF score was 12.16 (G4.29). with GHD. This is significant as patients with GHD have elevated cardio- Regression analyses were carried out correcting for age, BMI, HbA1c, smoking, metabolic risk. alcohol consumption and cardiovascular disease. Total testosterone levels significantly correlated with HRQoL scores (rZ0.353, PZ0.044, nZ356) when corrected for SHBG. In the 126 patients who completed IIEF questionnaires, IIEF scores significantly correlated with total SF-36 scores (rZ0.491, PZ0.003). IIEF scores also correlated Z Z P151 with SF-36 domains: Physical (r 0.500, P 0.003), Physical role limitations (rZ0.350, PZ0.031), Social (rZ0.445, PZ0.022), Vitality (rZ0.383, PZ0.025), Serum erythropoietin levels in patients with acute myocardial infarction Pain (rZ0.428, PZ0.012), and General health (rZ0.408, PZ0.001). Elham Islam, Iman Zaki, Mona Abdelsalam, Ahmed Abdelsalam, IIEF scores significantly correlated with levels of TT (rZ0.546, P!0.001), BT Samya Eltohamy & Ahmed Morsi (rZ0.506, PZ0.004) and cFT (rZ0.532, P!0.001). TT was corrected for SHBG Ain Shams University, Cairo, Egypt. in addition to the above factors. Conclusion Background This is the first study to report that lower testosterone and severity of erectile dysfunc- Mortality and morbidity after acute myocardial infarction (AMI) remain high tion are both independently associated with reduced quality of life in diabetic men. even when myocardial reperfusion is successful. Thus, additional approaches are

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P153 P155 Glucagon like peptide-1 in congestive heart failure cases and type 2 The effect of glucose on hypothalamic neuropeptide Y release diabetes mellitus cases investigated using static incubation of hypothalamic explants Nrmin Sheriba, Makboul Khaled, Mona Abdelsalam, Hisham Mohamed Syed Sufyan Hussain, Errol Richardson, Niki Buckley, Gavin Bewick, & Ahmed Hamam Stephen Bloom & James Gardiner Ain Shams University, Cairo, Egypt. Imperial College London, London, UK.

GLP-1 stimulates b-cell proliferation, it also enhances the differentiation of new Attenuated glucoprivic feeding responses are a feature of hypoglycaemic beta cells from progenitor cells in the pancreatic duct epithelium and it is capable unawareness in insulin-treated diabetes. Glucose alters the activity of of inhibiting apoptosis of beta cells. GLP-1 also exhibits other effects of hypothalamic neurones involved in regulating appetite. Arcuate nucleus (ARC) importance for glucose homeostasis, such as, inhibiting glucagon secretion, Neuropeptide Y (NPY) releasing neurones stimulate feeding. The identification of delaying gastric emptying, and stimulating insulin biosynthesis. These effects glucose-sensitive NPY releasing hypothalamic neurones suggests a strong role for come along with a potential increase in peripheral insulin action. Type 2 diabetic these neurones in mediating changes in appetite induced by alterations of glucose. patients have an impaired secretion of GLP-1. On the other hand, patients with To gain a better understanding of the mechanism involved in glucoprivic feeding, type 2 diabetes mellitus are considered to be at high risk for cardiovascular we investigated the changes in NPY release by the hypothalamus at different disease. A mutual relationship exists between insulin resistance and heart failure. concentrations of glucose, using static incubation of hypothalamic explants. G High affinity receptors for GLP-1 are present in the heart and vascular tissue, so it Hypothalami from 20 male Wistar rats (mean weight 280.4 2.3 g) were incubated is conceivable that the incretins may improve cardiovascular function. in artificial CSF (aCSF) for a 2-h equilibration period. The hypothalamic explants Aim were then incubated for three 45 min periods in 600 ml aCSF containing 3, 8 The aim of this study was To assess the plasma level of GLP-1 in patients with (baseline) and 15 mM glucose in randomised order. Finally, the viability of the tissue congestive heart failure, both those with type 2 diabetes mellitus and those who was verified by 45-min incubation in aCSF containing 56 mM KCl. At the end of are non diabetic and to assess the possible role of GLP-1 in the development of each incubation period, supernatants were removed and assayed for NPY release by congestive heart failure. radioimmunoassay. Only explants that showed a greater secretion of NPY with Method 56 mM KCl as compared to baseline were considered viable. G Our study included 54 subjects, divided into 4 groups; ‘group 1’ included 15 NPY release in aCSF containing 3 mM, 15 mM and KCl was 285.2 92.8, 130.7 G G non diabetic patients with congestive heart failure, ‘group 2’ included 15 type 2 25.8 and 818.8 210.7 percent of basal NPY release, respectively. There was a diabetic patients with congestive heart failure, ‘group 3’ included 12 type 2 significant increase in NPY release with aCSF containing 3 mM glucose versus diabetic patients with normal cardiac function and ‘group 4’ included 12 normal baseline glucose. This supports the presence of glucose-sensitive NPY releasing control subjects. All subjects were submitted to full clinical and biochemical hypothalamic neurones. These findings are consistent with previous findings that assessment, Fasting plasma glucagon-like peptide 1 measured by enzyme linked suggest an important role for NPY releasing hypothalamic neurones in stimulating immunosorbant assay (ELISA) and Echocardiogram. glucoprivic feeding. Defects in the responses of these neurones to glucose may Results contribute to the development of hypoglycaemia unawareness in insulin-treated In the presenting study fasting serum GLP-1 was found to be significantly lower in diabetes. Our work also supports the useof static incubation of hypothalamic explants cases suffering of either heart failure or type 2 DM in comparison to those healthy to study the effects of glucose on neuropeptides involved in regulating appetite. control cases. Furthermore, diabetic cases with heart failure showed significant lower level of serum GLP-1 in comparison to non diabetic heart failure cases. Therefore, our results may suggest a role for GLP-1 deficiency in development of congestive heart failure either in type 2 diabetic or non diabetic cases. P156 Attenuated atherosclerosis in 11b-hydroxysteroid dehydrogenase type 1 deficient ApoEK/K mice is associated with reduced aortic VCAM-1 expression and reduced MCP-1 in the visceral fat Tiina Kipari, Tak-Yung Man, Patrick Hadoke, John Savill, Karen Chapman & Jonathan Seckl University of Edinburgh, Edinburgh, UK.

11b-Hydroxysteroid dehydrogenase type 1 (11b-HSD1) regenerates glucocorti- coids in intact cells, converting inert cortisone into active cortisol. We have previously shown attenuated atherosclerosis development, reduced plasma P154 monocyte chemoattractant protein-1 (MCP-1) and reduced macrophage/T cell K/K! K/K Over-expression of iodothyronine deiodinase III in the hypothalamic infiltration within atherosclerotic lesions in 11b-HSD1 ApoE double VMN as a potential model of local hypothyroidism knock-out (DKO) mice fed western diet (WD). Hannah Greenwood1, John Counsell1, Errol Richardson1, Waljit Dhillo1, To determine the mechanism responsible for reduced inflammatory cell Anita Boelen2, Graham Williams1, Duncan Bassett1, Steve Bloom1 infiltration, we analysed gene expression by real-time PCR in the ascending & James Gardiner1 aorta for MCP-1 and adhesion molecules. Aortic MCP-1 mRNA levels were 1 2 increased by WD, but there was no difference by genotype (DKO 1.34G0.19; Imperial College London, London, UK; University of Amsterdam, K/K G Z Amsterdam, The Netherlands. ApoE 1.31 0.29, P 0.95), suggesting that differences in aortic MCP-1 expression did not underline the reduced macrophage recruitment in WD fed DKO mice. Aortic vascular cell adhesion molecule-1 (VCAM-1) mRNA The hypothalamo-pituitary–thyroid (HPT) axis maintains controlled systemic levels expression was significantly lower in DKO mice fed WD (DKO 0.69G0.10; of thyroid hormone (TH). This is achieved through negative feedback via the ApoEK/K 1.08G0.09, P!0.05), suggesting reduced inflammatory cell adhesion. hypothalamic arcuate and paraventricular nuclei. The effects of thyroid hormone in This was specific to VCAM-1, since aortic inter-cellular adhesion molecule-1 other hypothalamic nuclei are yet to be elucidated. Administration of triiodothyronine (ICAM-1) mRNA levels were unaffected by 11b-HSD1-deficiency (DKO 1.09 K/K (T3, thyroid hormone) into the hypothalamic ventromedial nucleus (VMN) increases G0.08; ApoE 1.19G0.05, PZ0.33). food intake in rats. Thyroid hormone activation and inactivation is mediated by To investigate inflammation beyond the arterial wall, we measured the levels of the iodothyronine deiodinases (D1, D2 and D3). D2 deiodinates tetraiodothyronine adipocytokines and cytokines in the mesenteric adipose tissue (MesAT, i.e. (T4) to produce the active T3 hormone, whilst D3 is the principal inactivating hormone. visceral fat). Chow fed DKO mice exhibited increased leptin mRNA expression in Recombinant adeno-associated virus (rAAV) constitutively expressing D3 (rAAV- MesAT (DKO 0.85G0.20; ApoEK/K 0.25G0.07, P!0.01), but following WD D3) was used to overexpress D3. Male Wistar rats received either rAAV-D3 (nZ10) or there was no difference by genotype (DKO WD 1.27G0.38; ApoEK/K WD rAAV-green fluorescent protein (rAVV-GFP) as a control (nZ11) bilaterally in the 1.24G0.23, PZ0.95). MesAT expression of 11b-HSD1 was down-regulated in VMN. On day 17 post-surgery, animals were transferred from a normal chow diet WD fed ApoE KO mice (ApoEK/K WD 0.97G0.19; ApoEK/K chow 2.31G0.47, (NFD) onto a 60% fat diet (HFD), and the study continued until 72 days post-surgery. P!0.01). Lastly MCP-1 mRNA expression and interleukin 6 (IL6) in the MesAT Hypothalamic D3 mRNA was 10-fold higher following treatment with rAAV-D3 was lower in WD fed DKO mice (MCP1:DKO 0.56G0.08; ApoEK/K 1.43 K/K compared to the rAAV-GFP treated group (P!0.001). Plasma free T3 and free T4, G0.36, P!0.05, IL6/: DKO 0.44G0.03; ApoE 0.68G0.13, P!0.05. however, were unchanged, indicating that systemic thyroid hormone status was unaffected. In conclusion atheroprotection in 11b-HSD1 deficiency is plausibly via reduced These data confirm an increase in hypothalamic D3 following rAAV-D3 administration adhesion of monocytes and lymphocytes to the endothelium, whereas reduced into the rat VMN. This model is currently undergoing extensive metabolic phenotyping in inflammation in visceral fat is via reduced local chemoattraction. This highlights order to determine the effects of T3 inactivation in the VMN on energy homeostasis. tissue-specific changes in inflammation with 11b-HSD1 deficiency.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P157 P159 Study of serum prolactin and cardiovascular risk in patients with type 2 Investigating the effects of testosterone on inflammatory markers of diabetes mellitus early aortic atherosclerosis in the testicular feminised mouse (Tfm) Hisham Elgayar, Manal Abu-Shady, Iman Zaki, Mona Abdelsalam & model Alyaa Elsherbeny Daniel Kelly1, Donna Sellers1, Nicola Woodroofe1, Hugh Jones2 & Ain Shams University, Cairo, Egypt. Kevin Channer3 1Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK; 2Centre for Diiabetes and Endocrinology, Barnsley Hospital NHS Background Foundation Trust, Barnsley, UK; 3Cardiovascular Department, Sheffield Prolactin is an identified marker associated with atherosclerosis. Atherosclerotic teaching Hospitals NHS Foundation Trust, Sheffield, UK. process and hence the macrovascular complications are causes for high mortality and morbidity rates among people with diabetes. Aim Objectives To assess the relationship between serum prolactin and cardiovascular risk in The over-recruitment and activation of leukocytes characteristic of early patients with AMI and patients with type 2 diabetes mellitus. atherosclerosis is considered the driving force behind atheroma development Subjects and methods and is regulated by the concerted activities of several cytokines, chemokines and A case–control study was done in Ain Shams University Hospitals, Cairo, Egypt; adhesion molecules surrounding a lipid core. Low serum testosterone levels are serum prolactin was determined in 20 non-diabetic (group 1) and 20 diabetic associated with cardiovascular disease in men and clinical trials demonstrate that (group 3) male patients within 24 h of the onset of AMI and after 2 weeks. Twenty testosterone replacement therapy (TRT) improves symptoms and reduces the type 2 diabetic male patients without AMI and 15 healthy age and sex-matched inflammatory burden of atherosclerosis. This study investigates whether the controls represented (group 2 and group 4, respectively). The inflammatory known atheroprotective effect of testosterone in the testicular feminised (Tfm) marker hs-CRP was also measured in the studied population. mouse model1 is associated with an effect on inflammatory factors. Results Methods Serum prolactin was significantly higher among non-diabetic (27.52 Tfm mice express a non-functional androgen receptor (AR) and low levels of G6.75 ng/ml) and diabetic patients with AMI (21.05G6.93 ng/ml) compared circulating testosterone. Tfm mice were fed a high-cholesterol diet (42% to the control group (11.3G2.7575 ng/ml, P!0.01) while the diabetic patients butterfat, 1.25% cholesterol and 0.5% cholate) ad libitum for 28 weeks and without AMI showed insignificant difference (12.2G3.15 ng/ml) with the control received either physiological testosterone replacement (intramuscular mixed group (PZ1). Group 1 showed minimal decline in serum prolactin level 2 weeks testosterone esters, Sustanon 100w, 25 mg/kg) or placebo (saline) and were after the onset of AMI (22.36G4.26 ng/ml) but still was significantly higher than compared to wild type littermate controls. Aortic root serial sections were the control group (P!0.01) while group 3 showed marked decline (9.15 analysed by oil red O staining and percentage lipid deposition calculated. G2.89 ng/ml) and showed insignificant difference with the control group Presence of inflammatory cells was investigated by immunohistochemistry in (PZ0.67). Serum prolactin showed significant positive correlation with hs-CRP addition to expression of the novel inflammatory chemokine, CX3CL1. Blood was among patients with AMI whether diabetic (rZ0.679, PZ0.001) or non diabetic analysed for testosterone, 17b-estradiol, lipids and cytokines (TNFa, IL6, IL1b, (rZ0.593, PZ0.006). IL10 and MCP-1). Investigators were blinded to treatment group throughout Conclusion sample analysis (ANOVA). Hyperprolactinemia may be associated with increased risk of myocardial Results infarction but the levels of prolactin are variable among diabetics. In addition, TRT reduced lipid deposition in Tfm mice receiving a high cholesterol diet the increase in both prolactin and hs-CRP increases the atherosclerotic process compared to placebo (2.15G0.17 vs 4.70G1.04%, respectively; PZ0.05), but and hence the macrovascular complications revealing a new mechanism for demonstrated no effect on serum lipids and cytokines. Immunohistochemistry atherosclerosis in diabetics. detected monocyte infiltration locally adjacent to lipid streaks. CX3CL1 and its Key words: Prolactin, acute myocardial infarction, atherosclerosis, diabetes. receptor were detected in plaque regions but were not influenced by testosterone Abbreviations: AMI: acute myocardial infarction. or AR function (nZ6). Discussion Physiological concentrations of testosterone can inhibit fatty streak formation, via AR-independent mechanisms in Tfm mice, although not through systemic anti- inflammatory actions or local effects on chemokine expression. P158 Effect of diet/lifestyle advice on weight change in an unselected polycystic ovary syndrome (PCOS) population Khushboo Sinha1, Abdullah Albeyatti1, Davinia White2, Stephen Franks1 & Lisa Webber2 1Imperial College London, London, UK; 2Imperial College Healthcare NHS P160 Trust, London, UK. Study of the adipocytokine visfatin in obesity and type 2 diabetes mellitus Objectives Salah Shelbaya, Nehad Shoeib, Salwa Seddik, Khalid Makboul, Rania Abd To examine the effect on weight change of diet/lifestyle advice to maintain/ El Baki, Eman Fahmy & Eman El-ghohary achieve a healthy weight in an unselected PCOS population. Ain Shams University, Cairo, Egypt. Methods All overweight patients attending the Reproductive Endocrine clinic with PCOS are routinely given lifestyle advice for weight loss by their consultant, offered Background referral to see a dietician and, when clinically appropriate, prescribed orlistat. Visceral fat-derived protein named visfatin was discovered in 2005. Visfatin may Clinical notes were reviewed for 50 consecutive patients with PCOS attending the improve glucose tolerance, and its plasma levels correlate strongly with the clinic. Their height, weight and BMI on their first two or three attendances were amount of visceral adipose tissue in humans. Visfatin has insulin-like metabolic recorded. Mean weight change between visits was calculated and analysed with effects on glucose metabolism but has a distinct binding site on insulin receptors. reference to starting BMI. Time between the first 2 appointments varied from 1 to These findings triggered great interest for many researchers to explore the 24 months, and 3 to 50 months between the first and third appointments. mechanism(s) of regulation of visfatin expression, and the possible relationships Results between visfatin and obesity, insulin resistance, and T2DM. However, the Mean weight change for the total group of 50 women between their 1st and 2nd available information on visfatin is still too little and controversial. appointments was a gain of 0.1 kg (range K8.6 to C13.7 kg). Twenty-five Aim women gained a mean of 2.3 kg, 20 lost a mean of 2.6 kg and 5 remained The aim is to study the levels of visfatin and its relationship to each of obesity, unchanged. Thirty-seven women were seen 3 times and their mean weight change insulin resistance and T2DM. between visits 1 and 3 was the same as for the total group (a gain of 0.1 kg; range Subjects and methods K18.5 to C13.2 kg). Nineteen of these women gained a mean of 4.4 kg and 18 The study was conducted on 80 subjects divided into Group I a: 20 obese T2DM women lost 4.4 kg. This pattern of weight change was the same for those with a patients, Group I b: 20 lean T2DM patients, Group II a: 20 obese nondiabetic, BMI of between 19 and 29.9 kg/m2 and for those 30 kg/m2 and over. Group II b: 20 lean nondiabetic subjects. They were subjected to, full clinical Conclusions history, thorough clinical examination, fasting plasma glucose (FPG), glycated The overall weight gain of this group over 2–3 visits was very little and less than hemoglobin (HbA1c), fasting plasma insulin (FI), homeostasis model assessment expected. This suggests that giving lifestyle advice to women with PCOS is at (HOMA-IR), cholesterol, TG, LDL-c, HDL-c, serum visfatin and CT abdomen to least partially effective. assess the visceral (VAT) and subcutaneous (SAT) adipose tissue of the patients chosen randomly.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Results subjects with T2DM with CVD. Group II: 20 subjects with T2DM without CVD. Serum visfatin was found to be higher in T2DM patients than control group as Group III: 20 non diabetic subjects with CVD. Group IV: 10 healthy subjects. well as in T2DM obese patients than obese control group and in T2DM lean FPG and 2h PPPG, HbA1c, kidney function test, lipid profile, Urinary albumin patients than lean control group. Also serum visfatin was higher in obese T2DM excretion, hs-CRP, 25OH vitamin D by ELISA, ECG and echocardiography were patients than T2DM lean patients. There was a highly significant positive done for all subjects. correlation (P%0.001) between serum visfatin and BMI, FPG, HbA1c, TG, Results cholesterol, HOMA IR and FI and a significant positive correlation (P%0.05) Serum 25 OH vitamin D was lower in T2DM patients with CVD than those between visfatin and waist circumference and VAT. without CVD than non diabetic patients with CVD than control subjects Conclusion (P!0.01). hs-CRP level was significantly higher in T2DM patients with CVD These results may postulate the presence of a link between visfatin and diabetes and non diabetic patients with CVD than in T2DM patients without CVD mellitus independent of obesity. (P!0.01). Microalbuminurea was higher in T2DM patients with CVD than those without CVD and non diabetic patients with CVD (P!0.01). There was significant negative correlation between serum 25 OH vitamin D and age, BMI, waist circumference, systolic blood pressure, diastolic blood pressure, FPG, 2hPPG, HbA1c, TC, TG, LDL-c, hs-CRP and microalbuminurea (P!0.01). Conclusion T2DM patients and patients with CVD had a significant reduction in serum 25 OH P161 vitamin D concentrations, so ongoing evaluation of the protective role of vitamin Study of lipoprotein phospholipase A2 as a biomarker for D3 supplementation in the development of atherosclerosis is needed. cardiovascular events in type 2 diabetes mellitus Mohamed El-Gayar, Inas Sabry, Rania Abd El Baki, Magdy Abass & Abd-El-Azeem Attia Ain Shams University, Cairo, Egypt. P163 Background Type 2 diabetes (T2DM) represents an independent risk factor for cardiovascular Low testosterone predicts increased mortality and testosterone diseases (CVD), being characterized by a continuous low-grade inflammation and replacement therapy improves survival in men with type 2 diabetes Vakkat Muraleedharan1,2, Hazel Marsh1 & Hugh Jones1,2 endothelial activation state. Lipoprotein-associated phospholipase A2 (Lp-PLA2) 1 2 may have a pro-inflammatory role as growing evidence suggests that it acts in Barnsley Hospital NHS Foundation Trust, Barnley, UK; University of several pathways that contribute to atherogenesis. Sheffield, Sheffield, UK. Objective The objective is to study Lp-PLA2 as a possible biomarker for cardiovascular Background disease in T2DM. Low testosterone in men is associated with increase in all-cause and cardiovascular Subjects and methods mortality. There is a high prevalence of hypogonadism in men with type 2 diabetes A case control study included 45 diabetic subjects who were divided into 3 and testosterone replacement therapy (TRT) improves cardiovascular risk. groups. Group (1): 15 T2DM patients with recent ischemic stroke (!24 h). Group However there is no published data regarding mortality in these patients in (2): 20 T2DM patients with acute myocardial infarction. Group (3): 10 recently relation to testosterone levels, and the long term effect of TRT on mortality. diagnosed uncomplicated T2DM individuals matching age and sex. All Aim individuals were subjected to full history, thorough clinical examination, serum We report a 6 year follow-up study examining the effect of baseline testosterone Lp-PLA2 by enzyme-linked immunosorbent assay (ELISA); serum highly and TRT in hypogonadal men with type 2 diabetes on all-cause mortality. sensitive C-reactive protein (hsCRP) by Nephlometry; lipid profile, fasting Methods (FPG) and postprandial plasma glucose (PPBG), glycated hemoglobin (HbA1c), Five hundred eighty-seven patients with type 2 diabetes had total testosterone Electocardiography (ECG), Echocardiography and computerized tomography (TT) performed between 2002 and 2005 and were followed up for 5.8G1.3 years. (CT) of brain. Cardiac enzymes were done for patients with acute myocardial Deaths during the first 6 months were excluded. Patients were then analysed in infarction. three groups. i) normal TT (O10.4 nmol/l) ii) low TT (%10.4 nmol/l) without Results TRT. iii) low TT receiving TRT for 2 years or more. The study showed that there was significant difference between patients with Results either cerebrovascular stroke and acute myocardial infarction in comparison with Of 580 patients analysed, 338 had normal TT (58%) and 240 low TT (42%). In the uncomplicated T2DM subjects respectively as regards Lp-PLA2, and hsCRP, low TT group 58 patients received TRT. Mean age 61G11 S.D. and similarly ! being higher in patients with cardiovascular complications (P 0.05). Lp-PLA2 matched in all three groups. Total deaths 72 (12.4%). Mortality rates – low TT was significantly positively correlated with hsCRP only in patients with without treatment (36/182-20%), normal TT (31/338-9%) and low TT with TRT cerebrovascular stroke (r: 0.532) (P!0.05) but not in patients with acute (5/58-8.6%). Survival was significantly decreased in patients with low TT without myocardial infarction (r: K0.22) (PO0.05). TRT (PZ0.001 log rank) compared to normal. The treated group had improved Conclusion survival (PZ0.049 log rank). In the Cox Regression model multi-variate (age, Levels of Lp-PLA2 and hsCRP may be complementary beyond traditional risk weight, HbA1c, pre existing cardiovascular disease, smoking, statin and factor in identifying middle aged individuals at increased risk for cardiovascular ACEi/ARB use) adjusted hazard ratio for all-cause mortality was 2.2 (95% CI events in type 2 diabetes mellitus. 1.3–3.7 PZ0.001) for low TT. Conclusions This study shows that men with type 2 diabetes and low testosterone have a significant increased mortality. TRT improved survival compared to those untreated, recording a similar mortality rate to the normal TT group. P162

Serum 25-hydroxyvitamin D3 concentrations and cardiovascular risk among type 2 diabetic patients Salah Shelbaya, Salwa Sedeek, Rania Abd El Baki & Nesma Ibrahim Ain Shams University, Cairo, Egypt. P164 Chronic GH excess is associated with adenosine monophosphate- activated protein kinase (AMPK) threonine-172 phosphorylation Background changes that do not lead to changes in AMPK activity There is accumulating evidence suggesting that altered vitamin D may play a role Julia Thomas1, Edward List2, John Kopchick2, Ashley Grossman1 & in the development of T2DM. A growing body of evidence suggests that low Marta Korbonits1 levels of vitamin D may adversely affect the cardiovascular system. 1Barts and the London School of Medicine and Dentistry, QMUL, London, Objective UK; 2Ohio University, Athens, Ohio, USA. This is to assess the relation of serum 25 OH vitamin D concentrations and risk of CVD in T2DM patients. Subjects and methods GH influences multiple metabolic pathways. Excess GH (acromegaly) causes a Seventy subjects aged from 40 to 60 years were chosen excluding those with any distinct form of cardiomyopathy, which may progress to fulminant heart failure. other chronic illness and those receiving any medication that affects vitamin D AMPK is an energy conservation enzyme that modulates multiple areas of the cell metabolism or taking vitamin D supplement. They were divided into: Group I: 20 stress response, inhibiting anabolism and promoting catabolism. AMPK is

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK activated by phosphorylation at Thr172 and measurement of Thr172 phosphoryl- P166 ation is thought to correlate with enzyme activity. We investigated the influence Lack of beneficial metabolic profile in liver-specific 11b-hydroxysteroid of GH on cardiac AMPK in transgenic mouse models of chronic GH excess. dehydrogenase type 1 (11b-HSD1) knockout mice Methods Gareth Lavery, Elizabeth Rabbitt, Agnieszka Zielinszka, Beverley Huges, Bovine-GH-overexpressing (bGH) transgenic mice were produced by the Nina Semjonous, Khalid Saqib, Stuart Morgan, Laura Gathercole, microinjection of bGH cDNA into the pronucleus of C57BL/6J embryos. Elizabeth Walker & Paul Stewart Animals were sacrificed at 2 and 8 months of age. Cardiac tissue was University of Birmingham, Birmingham, UK. homogenised and AMPK immunoprecipitated using AMPK-a1and-a2 antibodies. Functional AMPK assay was performed using the synthetic target peptide SAMS and 32P-ATP. Western blotting was performed for total AMPK In humans glucocorticoid (GC) excess can promote hepatic glucose and (tAMPK) and Thr172 phospho-AMPK (pAMPK) using monoclonal antibodies. triglyceride production contributing to obesity, fatty liver and diabetes. 11b- Bands were corrected for the house-keeping protein GAPDH. HSD1 activates GCs (11-DHC to corticosterone in mice), thereby increasing Results tissue concentrations. The liver has the highest 11b-HSD1 activity, and its There were no significant differences in cardiac AMPK activity, measured by inhibition has emerged as a therapeutic option. To investigate this we generated functional assay, between transgenic mice and their appropriate littermates at 11b-HSD1 liver-specific knockouts (HSD1LKO) and examined GC metabolism either timepoint. However, 2 month-old bGH mice demonstrated an increase in and responses to high-fat diet (HFD). pAMPK/tAMPK ratio compared to controls and 8 month-old bGH mice We generated HSD1LKOs using an albumin-Cre transgenic mouse and showed demonstrated a reduction in pAMPK/tAMPK ratio compared to controls. abolished 11b-HSD1 activity only in the liver; 11b-HSD1 knockout (HSD1KO) Conclusion mice were used as additional controls. Chronic GH excess is associated with alterations in cardiac AMPK Thr172 An oral cortisone challenge resulted in serum cortisol concentrations of 1830 phophorylation which do not appear to influence its activity. A discrepancy G184 nM (control), 691G70 nM (HSD1LKO) and 67G24 nM (HSD1KO) between AMPK Thr172 phosphorylation levels and the functional assay is (control vs. HSD1LKO P!0.002, nZ7–9), indicating significant extra-hepatic unusual and may represent other factors influencing AMPK function, such as GC production in HSD1LKOs. Corticosterone/11-DHC urinary metabolite ratios phosphorylation at inhibitory sites. The low levels of pAMPK/tAMPK in older were the same in HSD1LKO and controls (0.08) and elevated (0.5) in HSD1KOs, bGH transgenics may be a contributing factor to the heart failure of acromegalic indicating that despite diminished hepatic GC production there is no impact on cardiomyopathy. hepatic metabolism set-point in HSD1LKOs. HSD1LKO and controls had similar basal serum corticosterone concentrations and adrenals were only significantly larger in HSD1KOs. HSD1LKO and controls were alike for body, liver, epididymal fat pad and muscle weight. No differences were observed for fed and fasting glucose and insulin levels on regular and HFD. HFD induced glucose intolerance to similar levels in both HSD1LKO and controls subjected to glucose tolerance tests. Both HSD1LKO and controls developed fatty liver on HFD assessed by Oil Red O staining and hepatic triglyceride (TAG) assays, and no differences were observed between serum TAG, NEFA and cholesterol profiles. P165 Despite the loss of hepatic GC regeneration, HSD1LKOs had no protection from the metabolic consequences of a HFD as seen in HSD1KOs. This model produces Differential effects of olanzapine and risperidone on plasma adiponectin a novel insight into the target for 11b-HSD1 inhibition in terms of improving levels over time: results from a 3-month prospective open-label study 1 2 3,4 2 metabolic homeostasis and suggests a primary role for extra-hepatic enzyme Adrian Heald , Linda Hanssens , Ruud van Winkel , Julien Collette , expression. Joseph Peuskens4, Jean Yves Reginster2, Andre Scheen2, Martien Wampers4 & Marc de Hert4 1Leighton Hospital, Crewe, UK; 2University of Liege, Liege, Belgium; 3Maastricht University Medical Centre, Maastricht, The Netherlands; 4University Psychiatric Centre Catholic University, Leuven, Kortenberg, Belgium.

Aims P167 Second-generation antipsychotics (SGA), especially clozapine and olanzapine, Defining multipotent progenitors in the human fetal pancreas by are associated with increased metabolic risk. Plasma adiponectin levels, vary in expression and ChIP-seq schizophrenia patients as in the general population according to gender, adiposity Rachel Jennings1,4, Andrew Berry1, Santiago Rodriguez2,3, and metabolic syndrome (MetS). Lorenzo Pasquali2,3, Ignasi Moran2,3, Neil Roberts1, Karen Piper Hanley1, Here, we investigated whether different SGAs differentially influence plasma Jorge Ferrer2,3 & Neil Hanley1,4 adiponectin levels independent of body mass index (BMI) and MetS status. 1University of Manchester, Manchester, UK; 2Centro de Investigacio´n Methods Biome´dica en Red (CIBER) de Diabetes y Enfermedades Metabo´licas One hundred and thirteen schizophrenia patients (65.5% males) who were free of Asociadas (CIBERDEM), Barcelona, Spain; 3Genomic Programming of antipsychotic medication were enrolled in this open-label prospective single- Beta Cells, Institut d’Investigacions Biomediques August Pi i Sunyer, centre study and received either risperidone (nZ54) or olanzapine (nZ59). They Barcelona, Spain; 4Biomedical Research Centre, Central Manchester and were followed-up for 12 weeks. Average daily dose was 4.35 mg/day for Manchester Children’s University Hospitals, Manchester, UK. risperidone and 17.36 mg/day for olanzapine. Plasma adiponectin levels as well as fasting metabolic parameters were measured at baseline, 6 and 12 weeks. Results Understanding how fate choices are made by multipotent progenitors during Baseline BMI (23.7 vs 23.2 kg/m2), mean fasting plasma glucose (FPG) (mean pancreas development is valuable information in the quest for regenerative fasting plasma insulin (11.3 vs 12.0 mIU/ml) and mean plasma adiponectin levels medicine and cell therapy to treat diabetes mellitus. Pancreatic differentiation is (10 154 vs 11 280 ng/ml) were similar in the risperidone group and in the well defined and understood in rodents however, human data are comparably olanzapine group. A significant increase in body weight occurred over time in scarce. Specifically, when human pancreatic progenitors are multipotent is the olanzapine group as opposed to a numerical increase in the risperidone group unknown as are the epigenetic changes that these cells undergo during their (C7.0 kg vs C3.1 kg, P!0.05). Changes in MetS prevalence, in glucose and differentiation to beta-cells. We have addressed this in human embryos by insulin levels and in HOMA-IR were not significant. studying expression of critical transcription factors and applied chromatin We observed a significant (PZ0.0002) treatment by time interaction showing an immunoprecipitation/next generation sequencing (ChIP-seq) to examine adiponectin increase in the risperidone-treated patients (from 10 154 to genome-wide chromatin modifications linked to expression (using anti- 11 124 ng/ml) but an adiponectin decrease in olanzapine-treated patients (from H3K4me3 and anti-H3K4me1). 11 280 to 8988 ng/ml). This effect was independent of BMI and the Pancreas was first observed at Carnegie Stage (CS12; 26 days post-conception presence/absence of MetS. (dpc)) at which stage the pancreatic epithelial cells expressed nuclear PDX1 and Conclusion GATA4 in the presumptive dorsal and ventral buds. SOX9 expression appeared in The differential effect of antipsychotic treatment (risperidone versus olanzapine) pancreatic progenitor cells slightly later in development. GATA4 detection on plasma adiponectin levels over time suggests a specific effect on adipose declined in intensity later in the embryonic period and by 8 weeks of development tissues, similar in humans to animal models. The observed specific olanzapine- it had become restricted to the peripheral ‘tip’ cells of pancreatic epithelial nests associated reduction in plasma adiponectin levels may contribute to the increased demarcating the earliest report of exocrine cells. metabolic risk with olanzapine compared to risperidone. Based on these data, pancreas at w50–54 dpc was isolated and processed for ChIP-seq. Analyses for potential growth factor signals that might regulate early

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK human development identified multiple loci of interest. For instance, compared to Twenty-four hour urinary metanephrine and normetanephrine levels plus serum our data from adult islets (Gaulton et al. Nature Genetics 42 255–259, 2010) dihydroepiandrosterone sulphate (DHEAS) were within normal limits. Biopsy of INSULIN was largely silenced in progenitor cells whereas the adjacent IGF2 the left ovary revealed a steroid cell tumour strongly positive for calretinin. She locus was active in progenitors but silenced in adult islets. underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy. Taken together, these data define for the first time when multipotent human Post operatively testosterone levels normalised and the features of virilisation pancreatic epithelial cells are present facilitating opportunities to determine what regressed. regulates their differentiation into different pancreatic cell lineages. Discovering Discussion these data will underpin either beta-cell regenerative approaches or the Von Hippel–Lindau disease is an autosomal dominant condition with an assessment of insulin-secreting cells generated from human ES cells. incidence of 1 in 36 000 live births. It is characterised by CNS haemangio- blastomas and visceral tumours. The VHL gene is a tumour suppressor gene found on chromosome 3. Gonadal involvement is in the form of epididymal cystadenomas in men and broad ligament cystadenomas in women. Steroid cell tumours are rare, accounting for !0.1% of ovarian tumours. They are unilateral in 96% of cases, and 30% are malignant. They commonly secrete androgens and present with virilisation, often in the 3rd or 4th decade. The Endocrine tumours and neoplasia management is surgical. P168 Conclusion Ectopic ACTH syndrome: experience of a tertiary referral centre: from We report an unusual case of an ovarian steroid cell tumour in association with diagnosis to outcome VHLD. This highlights the need to remain vigilant for unusual pathologies and a Andreia Veloza, Georgia Ntali, John Wass & Niki Karavitaki possible link between the two diseases. Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK.

Introduction Ectopic Cushing’s syndrome (ECS) accounts for approximately 10% cases of P170 Cushing’s syndrome. Its recognition may be delayed and its diagnosis and Simplified minimally invasive parathyroidectomy: a series of 100 cases treatment remain challenging. and a review of the literature Aim William Wong, Fung Jun Foo, Michael Lau, Ashima Sarin & To analyze the clinical, biochemical, radiological features, as well as the outcome Pasupathy Kiruparan of patients with ECS presenting in a tertiary referral centre. Blackpool Victoria Hospital, Blackpool, Lancashire, UK. Material and methods The records of patients with ECS followed presenting in our Department between 1/1996–1/2010 were reviewed. Background Results Minimally invasive parathyroidectomy (MIP) is usually performed with the concurrent use of intraoperative adjuncts for good outcome. Thirteen patients were identified (7 men). The mean (GS.D.) age of onset of symptoms was 42.7G13.8 years (range 13–67). The period between onset of Objective symptoms and diagnosis of hypercortisolism was 10.5G8 months (1–24). The We wanted to show that a good success rate can be achieved in MIP without most frequent reported manifestations were muscle weakness (85%), weight gain routine use of any intraoperative adjuncts. (85%), easy bruising (69%), hypertension (62%), hypokalemia (62%). 100% (8/8) Methods of the patients did not respond to CRH test and 89% (8/9) did not suppress on the A prospective case series of the first 100 patients who underwent MIP for primary high dose Dexamethazone suppression test. No subject (nZ5) showed gradient on hyperparathyroidism by a single surgeon at a single institution were included in the bilateral inferior petrosal sinus sampling. The localization of the source of this study. Preoperatively, patients undergo ultrasonography and/or 99 mTc- the ECS was achieved between 1 and 90 months; in 9 it was of lung origin labelled sestamibi scan for localization. Methylene blue contrast is used (8 pulmonary carcinoid, 1 small cell lung cancer), 1 had gastric adenocarcinoma, preoperatively. Parathyroidectomy is performed via a focussed lateral approach 1 prostate adenocarcinoma, 1 intestinal carcinoid tumour and 1 occult tumour. on the side indicated by preoperative imaging. An algorithm of intraoperative The median duration of follow-up was 27 months (1–148). 39% (5/13) of the decisions is followed. No intraoperative adjuncts such as gamma probe, subjects died within a median period of 6 months (1 pulmonary carcinoid, 1 small intraoperative PTH or frozen sections are used routinely. Patients are followed cell lung cancer, 1 gastric adenocarcinoma, 1 prostate adenocarcinoma, 1 occult up in the outpatient clinic, where serum calcium and/or parathyroid hormone tumour). Amongst the 8 patients with pulmonary carcinoid, tumour resection was levels are checked to determine success. Postoperative normocalcaemia is performed in 7 (with lymph node removal/biopsy in 5 and proven metastatic considered success independent of serum PTH levels. disease in 2); no evidence of recurrence was documented in 71% (5/7). Results Conclusions Patients had a median age of 63 years (range 26–85 years). Eighty-three were ECS is a heterogeneous disease mainly attributed to lung origin. Tumour female and 17 were male. Ninety-three patients underwent MIP, with 7 patients having a conversion from MIP to bilateral exploration. The mean operative time localization may be delayed necessitating regular imaging. Mortality primarily G G attributed to the original tumour is significant. for unilateral and bilateral exploration was 42.38 12.31 and 76.43 16.51 min respectively. When used separately MIBI and USS were able to accurately lateralise side of the lesion in 82.8 and 79.5% respectively but when USS and MIBI agreed, the predictive accuracy of the side of the lesion was 87.5%. Ninety- six percent of patients had a successful return to normocalcaemia. No intraoperative or postoperative complications were encountered. Conclusion P169 Excellent results are achievable with MIP even without intraoperative adjuncts. Ovarian steroid cell tumour in association with Von Hippel–Lindau Preoperative localisation is helpful in determining side of incision. Our technique disease demonstrates a key principle of surgery: to keep things simple. Jenny Prouten, Sana Mota & Malcolm Littley East Lancashire Hospital Trust, Blackburn, UK.

Case A 46-year-old woman presented to the gynaecology department with secondary P171 amenorrhoea, hirsutism and acne. At the age of 25, she was diagnosed with Von ‘Uterine neuroendocrine tumour: an unusual cause of hyponatraemia’ Hippel–Lindau disease (VHLD) on the basis of multiple right retinal and the role of tolvaptan, a vasopressin V2 receptor antagonist haemangioblastomas. Investigation revealed an elevated testosterone Gideon Mlawa, Laura Fraser, Sophie Price, Robert Green, Ben Turner & 13.4 nmol/l (0.3–2.6 nmol/l), 17 hydroxyprogesterone 18 nmol/l and free Rowland Guy androgen index 53.6 (0.0–7.5). A solid lesion in the left ovary was demonstrated Basingstoke and Norh Hampshire Foundation Trust, Basingstoke, UK. on ultrasound scan of the pelvis. This was confirmed by computerised tomography (CT), where a right adrenal mass measuring 21!22 mm in dimension and a cortical cyst in the lower pole of the left kidney were Background incidentally noted. An endocrinology opinion was sought prior to exploratory Hyponatraemia is the commonest electrolyte abnormality in clinical practice, and surgery. may be a biochemical manifestation of different diseases including malignancy.

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Uterine neuroendocrine tumours causing hyponatraemia are rare and can cause a vascularity reflects increased tumour related angiogenesis. Adenosine, a major diagnostic challenge. regulator of angiogenesis, is released by enhanced degradation of ATP, during We present a case of 68 years widow who presented with 3 weeks history of nausea, cellular stress, damage and hypoxia. occasional vomiting, confusion, increased urinary frequency, urinary incon- Material and methods tinence, chronic constipation, and weight loss. Her past medical history included The expression of adenosine receptors (AR) was investigated in two human left knee arthroscopy, cochlea implant and sterilisation in 1976. On admission she neuroendocrine tumors cell lines BON-1 (pancreatic) and KRJ-1 (intestinal) and was haemodynamically stable with normal observations. Blood test revealed in archival material from neuroendocrine tumors patients. profound hyponatraemia (NaC118 mmol/l), and serum osmolality of Results K7 247 mOsm/kg, urine osmolality of 701 mOsm/kg, urinary sodium of Adenosine (ED50 5–10!10 M) stimulated a 3–15 fold increase in cAMP 110 mmol/l, random cortisol of 542 nmol/l, in keeping with SIADH. Tumour levels (P!0.01) indicating a predominance of the A2a and A2b subtypes. The markers were negative. Staging CT revealed heterogeneous enhancing uterine stable AR agonist NECA and the A2aR selective agonist CGS21680 stimulated mass. Flexible sigmoidoscopy was normal. Her medications included Paracetamol, cell proliferation by 20–30% at 10K5 M agonist (P!0.001) which was attenuated Codeine Phosphate and laxatives. She was started on fluid restriction of by A2bR (PSB603 and MRS1706) and by the A2aR (SCH442416) but not the K6 750 ml/24 h. She remained hyponatraemic (116–117 mmol/l) despite this. Oral A1R (PSB36) antagonists. In BON-1 cells, adenosine (ED50 5!10 M) and K7 Demeclocycline 300 mg TDS was added, but she was unable to tolerate it and was NECA (ED50 10 M) stimulated a 2-fold (P!0.05) secretion in Chromogranin started on tolvaptan (30 mg od). Discharged on tolvaptan (30 mg) and was A but had little effect on serotonin secretion. Eighteen archival human reviewed by gynaecology team in outpatient clinic. Cervical biopsy histology neuroendocrine tumors histopathological tissue samples were immunostained showed a high grade neuroendocrine malignant tumour confirmed by positive for AR. Strong labelling for the A2bR was seen in 4/4 appendiceal tumours, 4/4 immuno labelling for chromogranin, AE1/3 and CAM5.2. She is currently pancreatic tumours and 4/9 intestinal tumours and all tumours were strongly undergoing chemotherapy and still on tolvaptan. Her sodium remains low but at positive for the A2aR. There was very weak or no staining for the A1R or A3R in safer levels of 127–130 mmol/l. any of the tumours. Discussion Conclusions Hyponatraemia secondary to uterine neuroendocrine tumours is rare and Our data suggest that neuroendocrine tumors express predominantly the A2aR generally associated with chemotherapy treatment rather than being related to and A2bR and their activation leads to increased proliferation and secretion of the uterine neuroendocrine tumour. Conventional treatment for hyponatraemia Chromogranin A. Targeting adenosine signal pathways may thus be useful in the due to SIADH was ineffective or not tolerated. Tolvaptan treatment was more therapeutic management of neuroendocrine tumours. successful even though it is mainly used in patient with mild to moderate euvolaemic hyponatraemia. This case report demonstrates the possibility of using tolvalptan in severe hyponatraemia.

P172 Toll receptor-mediated inflammatory system is present in tumour cells P174 from endocrine-related tissues Christopher Newton, Denys Bilko, Gu¨nter Stalla & Ulrich Renner Low rate of recurrence after excision of non-familial phaeochromocytomas Neuroendocrinology Group, Max Planck Institute of Psychiatry, D-80804 1 2 1 2 1 Munich, Germany. Sophie Russell , Radu Mihai , Lisa Walker , Gregory Sadler & John Wass 1Churchill Hospital, OCDEM, Oxford, UK; 2John Radcliffe Hospital, Oxford, UK. Blood-borne bacteria, fungi and viral agents can activate cells of the innate immune system by interacting with pattern-recognition or Toll receptors on the Background surface of immune cells. We demonstrate here that mRNA for Toll receptors is Phaeochromocytomas (PHAEO) and paragangliomas (PGGL) are rare neuro- ubiquitously expressed in a range of transformed and normal cell types. These endocrine tumours. The traditional ‘10%’ teaching mnemonic has recently been findings raise the possibility that infection could induce an inflammatory response challenged. in somatic tissues and this might i), provide a milieu for changes in normal cells Methods that lead to neoplastic growth and/or ii), that it might provide conditions suitable Clinical and biochemical/pathological data were collected prospectively. A 24-h for enhancing the growth of an existing neoplastic lesion. As a preliminary step to urine sample for metanephrine assay was used for postoperative biochemical investigate this, we have studied the response of breast tumour MCF-7 cells to a follow-up. sonicate of a mixed bacteria cell population. Using quantitative PCR (QPCR) and Results primers for Toll receptors 1 to 10, we have shown that 24 h exposure to the Between ‘Jan 89 and June 10’ 110 patients were operated for PHAEO or PGGL. bacterial cell sonicate up-regulates the expression of mRNA for Toll-2 and Toll-4 Thirty-four patients were lost to follow-up and further analysis was made on 76 by between 5 and 8 fold. The expression of other Toll receptors was not patients (35 M:41 F, age 5–87 years, median 48 years) with PGGL (nZ2) and significantly altered. Given that the cytokine IL6 is induced in immune cells by unilateral (nZ67) or bilateral (nZ7) PHAEOs (nZ74). One malignant metastatic ligands of Toll receptor 4, we have further demonstrated by QPCR, that mRNA PHAEO was diagnosed on presentation. Five PHAEOs presented in childhood for this inflammatory cytokine is markedly induced in MCF-7 cells by exposure to (ages 5–17 years), of which two recurred 16 years later. the sonicated bacteria and that this effect is blocked by prior exposure of the Syndromic disease was present in 18 patients with MEN-2A (nZ5), VHL (nZ7) MCF-7 cells to dexamethasone. These finding strongly suggest that the full Toll- or neurofibromatosis 1 (nZ6). A further 11 patients (29–74 years) demonstrated mediated inflammatory system is present in breast tumour cells and they provide a no mutation (nZ9) or mutations of unknown clinical significance (nZ2). Forty- rationale for tumour therapy, targeted to the Toll receptors. seven patients (21–87 years) either declined genetic testing or presented over 50 years. Patients underwent laparoscopic (nZ49), open (nZ13) or open-on-bypass (nZ2) adrenalectomy (operation details were missing in 12 patients). During the follow- up period (range 1–210 months, median 48 months) eight patients died of P173 unrelated malignant conditions (nZ6) or unknown cause (nZ2). Adenosine receptors modulate chromogranin A secretion and growth Recurrent disease (nZ8) of local abdominal PHAEO (nZ7, with two occurring of neuroendocrine tumours: potential targets for therapy contralaterally) and PGGL (nZ1) was diagnosed at 24–210 months (median 108 Atul Kalhan1, Borzo Garibi1, Bharat Jasani1, Mark Kidd2, Irvin Modlin2, months) after initial laparoscopic (nZ3), open (nZ4) or open bilateral (nZ1) Roswitha Pfragner3, Aled Rees1 & Jack Ham1 adrenalectomy. These patients (4 M:4 F, age 5–72 years, median 57 years) 1University Hospital of Wales, Cardiff, UK; 2Yale University School of presented with familial VHL (nZ2) or sporadic malignant tumours (nZ6). Medicine, New Haven, Connecticut, USA; 3Institute of Pathophysiology, Conclusion Graz, Austria. This study demonstrates the importance of life-long follow-up of PHAEOs, particularly for those who presented in childhood. It questions the original 10% mnemonic, showing that, in this surgical series, 24% of PHAEOs are familial, 7% Introduction occur in childhood, 11% recur, 3% are extra adrenal, 9% are bilateral and 1% are Neuroendocrine tumors of GI tract are a heterogeneous group of rare neoplasms metastatic malignant on initial presentation. that secrete peptides and amines. These tumors are highly vascular and their

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P175 P177 Phaeochromocytoma presenting as polycythaemia Clinical and biochemical features of sporadic and hereditary Ian Seetho & Koshy Jacob phaeochromocytomas and paragangliomas: an analysis of 47 cases Department of Diabetes and Endocrinology, United Lincolnshire Hospitals investigated in a single centre NHS Trust, Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire, UK. Shahina Begum, Paul Carroll & Barbara McGowan King’s College London, London, UK. Case A 35-year-old man was referred by the haematologists. He had been previously Introduction diagnosed with dilated cardiomyopathy and later underwent a cardiac transplant. Advances in the understanding of the natural history and genetics of Following this, he suffered an anterior wall myocardial infarction with subsequent phaechromocytomas and paragangliomas have altered the demographics of congestive cardiac failure. A coronary angiogram did not reveal any evidence of these conditions resulting in much higher rates of malignancy and association allograft coronary artery disease. His medications included diuretics, immuno- with known genetic abnormalities. suppressants and warfarin. There was no significant family history. Clinical Objective examination revealed a pansystolic murmur but was otherwise unremarkable. To analyse the clinical and biochemical features of hereditary (H) and sporadic He was found to have polycythaemia and he was investigated for this by the (S) phaeochromocytomas and paragangliomas. haematologists. His CT scan abdomen revealed a left suprarenal mass and the Design biopsy histology was consistent with an adrenal phaeochromocytoma. Retrospective case-series at Guys and St Thomas’ NHS Foundation Trust The 24 h urinary catecholamines excretion was consistent with the diagnosis. identified using our in-house electronic database (Diabeta-3). (Normetadrenaline excretion 21 446 nmol/d (0–4900); Noradrenaline excretion Results 5578 nmol/d (0–430); Metadrenaline 529 nmol/d (0–2000); Adrenaline excretion Forty-seven patients were reviewed over a period of 30 years, 36% (n-17) of these 29 nmol/d (0–70); Dopamine excretion 927 nmol/d (0–2700)). His Methyl-iodo patients had hereditary phaeochromocytomas or paragangliomas (SDHB 5, benyzyl guanidine (MIBG) scan showed focal increased uptake of the left SDHD 2, VHL 5, RET 3, NF1 2). adrenal. An MRI of the CNS did not yield features to suggest Von Hippel Lindau The hereditary group presented at a significantly younger mean age (S: 44.7 and genetic tests did not show pathogenic mutations of VHL, RET, SDHB, SDHC G15.3 years, H: 29.5G16.9 years, PZ0.006). The hereditary group had and SDHD genes. significantly more bilateral adrenal phaeochromocytomas (S: 4.5%, H: 45.5%, Discussion PZ0.03) and a positive trend for multiple paragangliomas, although not This man was diagnosed with phaeochromocytoma that was found during statistically significant. investigations for polycythaemia. Although an elevated haematocrit has been Sporadic tumours were bigger than hereditary but this was not significant observed in association with phaeochromocytomas, the occurrence of absolute (S: 6.39G1.07 cm, H: 3.43G0.85 cm, PZ0.25). All patients showed the classic polycythemia in such cases is not common. The pathogenesis may involve triad of headaches, palpitations and diaphoresis as the most commonly reported induced unregulated erythropoietin secretion from the tumour, resulting in symptoms, but hypertension was more prevalent in the sporadic group (S: 60%, secondary erythocytosis. Awareness of this association is important in order that H: 35.3%). either diagnosis is not delayed and definitive management can be established. Urine catecholamine concentration was highly variable and failed to show any Reversal of alpha-mediated vasoconstriction may lead to haemodilution and significant difference between both groups. Adrenal phaeochromocytomas curative surgical resection of the phaeochromocytoma can result in reduction in secreted more noradrenaline than paragangliomas regardless of their classi- erythropoietin levels with regression of the polycythaemia. fication. There was no significant difference between the malignant potential of tumours however only adrenal phaeochromocytomas showed malignant change. Conclusions The data suggest that patients with hereditary phaeochromocytomas and paragangliomas present at a younger age with more bilateral tumours compared to the sporadic group. There may be a higher susceptibility fro malignancy in adrenal tumours compared to extra-adrenal tumours. It is difficult to differentiate the 2 groups based on clinical presentation, size and features of catecholamine secretion. Genetic testing remains key to differentiating between sporadic and P176 hereditary disease. Development and validation of a LC–MS/MS method for the measurement of plasma renin activity using on-line solid phase extraction Stephanie Carter, Laura Owen & Brian Keevil University Hospital of South Manchester, Manchester, UK. P178 The measurement of plasma renin activity is required in a number of clinical Metastatic insulinoma treated by transhepatic arterial embolisation situations, in particular screening for primary aldosteronism (PA) and monitoring E Marie Freel1, Claire McDougall1, Karen Campbell1, Donna Grant1, mineralocorticoid replacement therapy. PA is a treatable cause of hypertension Ram Kasthuri2 & Nicholas Reed3 and has an estimated prevalence of up to 20% amongst resistant hypertensives. 1Department of Endocrinology, Western Infirmary, Glasgow, UK; Consequently, recent guidelines now recommend screening for PA in all patients 2Department of Radiology, Gartnavel General Hospital, Glasgow, UK; groups with a high prevalence of PA. At present, the most reliable method of 3Beaston West of Scotland Cancer Centre, Glasgow, UK. screening for PA is to calculate the plasma aldosterone to renin ratio (ARR), with a raised ARR being suggestive of PA. The plasma renin activity (PRA) assay measures the ability of plasma renin to A 64-year-old man (HM) was admitted to our local hospital with transient generate angiotensin I (Ang1) from endogenous angiotensinogen, with all dysarthria and right hemiparesis; formal blood glucose was 2.2 mmol/l on established assays using an immunoassay to quantitate AngI. We have now admission. During his in-patient stay, he had frequent episodes of hypoglycaemia. developed and validated a method for the measurement of PRA which involves Further questioning revealed a 4 week history of recurring dizzy spells which extraction and quantitation of Ang1 by online solid phase extraction-LC–MS/MS. improved on eating. This method requires a sample volume of 50 ml and has an intra-assay precision Cerebral imaging and adrenal function were normal and so the patient underwent !7% across the working range of the assay. A 6.5 h incubation step gave a LLOQ further investigations (summarised below) which confirmed insulinoma. of 0.3 nmol/l per hour and this can be reduced to 80 pmol/l per hour using a 24 h incubation, allowing the measurement of very low activity samples. In comparison to the established immunoassays, this method will potentially 12 3 improve assay specificity and will also reduce turnaround time, consumable costs, Insulin (!13 mU/l) 166 172 136 staff time, sample handling and sample volume requirement. Glucose (mmol/l) 2.3 2.1 1.8 There is uncertainty in the literature regarding the stability of renin at room C-peptide (0.4–1.1 nmol/l) 1.8 1.7 1.5 temperature and also the extent to which prorenin cryoactivation occurs. We have Insulin–glucose ratio (!5) 276 429 680 now studied the stability of PRA, with preliminary results suggesting that PRA is unaffected by storage of whole blood at room temperature for at least 24 h. This would enable us to analyse blood samples taken in primary care, potentially In addition, plasma chromogranin-A was elevated (590 pmol/l) consistent with a providing more effective screening of the hypertensive population. neuroendocrine tumour. Abdominal imaging demonstrated a thickened pancreatic tail and widespread liver metastases; these were octreotide avid on

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK octreoSPECT-CT scanning. Subsequent liver biopsy confirmed metastatic We assessed the functionality of adrenal incidentalomas referred to the insulinoma. endocrinology team at the Queen Elizabeth Hospital in Gateshead. Primary surgical cure was impossible and HM required a combination of Methods diazoxide, octreotide and dexamethasone to control hypoglycaemia. HM Patients with adrenal incidentalomas that were referred to the endocrine team subsequently underwent transhepatic arterial embolisation to treat his metastatic between January 2008 and August 2009 were identified. Patient notes, laboratory liver disease. This has resulted in normalisation of blood glucose on sandostatin results, images and radiological reports were reviewed. LAR and reducing dose dexamethasone. Results Insulinomas are rare tumours of the pancreatic islet cells with an incidence of w4 Sixty-two patients (27 females) were referred to the endocrinologists with a per million/year; around 5–10% of cases are malignant. When surgical cure is finding of an incidental adrenal nodule with sizes ranging between 6 and 42 mm. unattainable alternative palliative treatments include medical therapy, radio- Twenty-nine (47%) patients had left sided tumours, 23 (37%) were on the right frequency ablation or arterial embolisation to hepatic metastases. The response and 10 (16%) were bilateral. All patients underwent a series of hormonal rates associated with embolisation (decreased hormone secretion/symptomatic investigations: 94% had 24 h cortisol levels measured, 87% had an overnight benefit/ radiographic regression) are over 50%. However, the duration of response dexamethasone suppression test, 95% had urinary metadrenalines measured and can be brief, ranging from 4 to 24 months in uncontrolled series. aldosterone/ renin activity was measured in 90% of patients. Everolimus, a rapamycin analogue, is a new oral mTOR inhibitor. In a recent The largest group of patients (87%) were found to have benign non-functional study, everolimus associated with regression of neuroendocrine tumours and there adenomas. One patient had a phaeochromocytoma, 1 had a cortisol secreting have been some case reports of everolimus improving glycaemic control in adrenal mass, and 6 (10%) patients were found to have sub-clinical Cushing’s insulinoma. This would be a possible alternative therapy for HM when syndrome. No patients were found to have primary hyperaldosteronism. Four he relapses. (6%) patients (one with overt Cushing’s syndrome, one with a phaeochromocy- toma and two with subclinical Cushing’s) underwent definitive surgical management. Conclusions Nearly 13% of patients that are referred with adrenal incidentalomas are functional on subsequent endocrine evaluation. Potentially serious conditions such as phaeochromocytomas and overt Cushing’s syndrome can be identified and treated. However, the most common functional abnormality is subclinical Cushing’s syndrome for which there is current lack of sufficient evidence P179 regarding its long term management. Pro-opiomelanocortin is a marker of liver and brain metastases from small cell lung cancer xenografts Suzanne Meredith1, Muhammad Babur1, Ghazala Begum1, Brian Telfer1, Roben Gieling1, Emma Dean2, Caroline Dive2, Kaye Williams1 & Anne White1 1The University of Manchester, Manchester, UK; 2The Paterson Institute for Cancer Research, Manchester, UK.

Small cell lung cancer (SCLC) is highly aggressive with a particularly poor prognosis. This is due to tumours quickly metastasising and developing chemoresistance. SCLC tumours possess neuroendocrine properties in that they secrete prohormones such as pro-opiomelanocortin (POMC) and pro-gastrin P181 releasing peptide (pro-GRP). These can be detected in the circulation and Laparoscopic adrenalectomy for Conn’s syndrome benefits is beneficial therefore have potential as biomarkers for prognosis and relapse. The aims of this to patients and to health finances study are; i) develop a model of SCLC metastasis in vivo, ii) determine if POMC is a biomarker of tumour burden and iii) analyse the presence of POMC in liver Heather White, Samantha Jayaweera, Gregory Sadler & Radu Mihai John Radcliffe Hospital, Oxford, UK. and brain metastases. We have shown that POMC is secreted from 6 of 15 (40%) SCLC cell lines in vitro. The POMC-secreting SCLC cell line, DMS79, was seeded subcu- Background taneously as a xenograft in 9 nude mice. Tumours were identified after 3 days and Primary hyperaldosteronism is allegedly present in 10% of hypertensive patients. circulating POMC rapidly increased after day 17. POMC secretion correlated Conn’s syndrome is present in a third of such patients and adrenalectomy has with tumour burden and also with number of days post-inoculation. DMS79 cells the potential to cure/improve the control of hypertension. This study assesses the were injected i.v. in 4 nude mice, but they did not establish visible tumours up to benefits/costs of laparoscopic adrenalectomy (LA) in a cohort of consecutive 79 days and POMC did not increase in the circulation. The POMC non-secreting patients with Conn’s syndrome operated in a tertiary referral centre. cell line, H526, grew as a xenograft but POMC concentrations did not increase in Methods the circulation. Micro-metastases were identified by H&E staining in 7 of 8 livers Clinical, radiological, operative and pathological data were collected on patients of the DMS79 xenografted mice and POMC positive metastatic areas were undergoing adrenalectomy for Conn’s syndrome over a 6 years period. detected in 6 of 8 livers by immunohistochemistry. We also saw POMC positive Results metastases in all brains analysed. Between Jan 05 and Oct 10 a total of 24 patients (9M:15F, age 34–75 years, In summary, we have produced a model of SCLC metastasis in vivo and identified median 51 years) underwent LA for Conn’s syndrome. Localisation of the POMC in metastatic areas of the liver and brain. This suggests that circulating adenoma was based on results of CT scans (nZ19), MRI scans (nZ6) and POMC may be a biomarker of tumour metastasis, which could be used for better selective adrenal venous sampling (nZ17). Uneventful LA was performed in 21 prognosis and tailored treatment of SCLC. patients and three patients needed conversion to open operation. Mean operative time was 80 min (range 20–125 min) and mean postoperative stay was 2G1.4 days (range 1–7 days, mode 1 day). Hospital costs were calculated to be £9180 for radiological investigations, £7920 for outpatient assessment, £14 100 for in-hospital stay, £30 000 for operating theatre use and £12 000 for disposable surgical instruments. These costs averaged to £3050/patient, that is within the national tariff for adrenalectomy (HRGKA04zZ£3333). P180 Follow-up by postal questionnaire in September 2010 had a response rate of Prevalence of functionality in adrenal incidental masses 61% (14 of 23 patients) at a mean post-operative time of 37G4 months. 93% Jennifer Cochrane, Preethi Rao, Mike Newby, Graham Handley, (13 of 14) patients reported taking no/fewer anti-hypertensive medications, with Kilimangalam Narayanan, Jolanta Weaver & Salman Razvi each patient being prescribed two fewer medications on average. 86% (12 of 14) Queen Elizabeth Hospital, Gateshead, UK. patients reported improved quality of life post-operatively (10-point scale) and all patients stated that they would definitely have the operation again in preference to anti-hypertensive medications. Background Conclusion Adrenal incidental masses (incidentalomas) are present in up to 10% of patients. Laparoscopic adrenalectomy for Conn’s syndrome has a positive impact on blood The majority of these adrenal masses are clinically inapparent, but may be pressure control and quality of life of patients. This diagnostic and therapeutic functionally active in a significant proportion; thus assessment by endocrinolo- protocol is cost-effective. gists is essential.

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P182 had nodular disease (25 of whom had received neck radiotherapy), and 2 had had A rare case of calcitonin and carcinoembryonic antigen negative differentiated thyroid carcinoma. medullary thyroid cancer Conclusion Anjali Santhakumar, Sebastien Aspinall & David Woods Long-term follow up, identification of risk factors and careful documentation of Wansbeck General Hospital, Northumberland, UK. late effects together with appropriate screening may enable identification and treatment of morbidity in patients cured of childhood HL.

Background Routine measurements of serum calcitonin levels are considered an integral part of the diagnostic evaluation of medullary thyroid cancer (MTC). We report a rare case of calcitonin and carcinoembryonic antigen (CEA) negative MTC. Case presentation A 63-year-old retired plasterer attending a well mans clinic was referred to the P184 endocrinology service with elevated calcium (2.75 mmol/dl). Systemic exami- Parathyroid carcinoma: an important differential diagnosis in primary nation was unremarkable and there was no endocrine history of note in the family. hyperparathyroidism Repeat calcium at the clinic was 2.76 mmol/l (2.12–2.60) and PTH level was Srinivasa Kummaraganti1, Dilip Eapen1, Jennifer Thomas2 & 76 ng/l (10–60). Twenty-four hour urinary calcium was 11.2 mmol/24 h (2.5–7.5). 1 He was investigated with neck ultrasound and bone densitometry for suspected Karthik Prabhakar 1Department of Endocrinology, Pinderfields General Hospital, Mid primary hyperparathyroidism. The bone scan showed osteopenia and the 2 ultrasound showed a 2.5!1.7!1.4 cm dominant left thyroid hypoechoiec nodule Yorkshire Hospitals NHS Trust, Wakefield, UK; Department of Histo- with specks of calcification. pathology, Dewsbury and District Hospital, Mid Yorkshire Hospitals NHS Calcitonin level was !11 ng/l. CEA was normal at 4.1 mg/l (!5). Overnight Trust, Dewsbury, UK. urinary metanephrine and normetanephrine levels were normal 0.06 mmol/mmol creat(0–0.30) and 0.12 mmol/mmol creat (0–0.35) respectively.Plasma metane- Parathyroid carcinoma is an uncommon cause of PTH-mediated hypercalcaemia, phrines and normetanephrines were 180 pmol/l (120–1180) and 267 pmol/l accounting for 0.5–5% of patients with primary hyperparathyroidism. We (80–510) respectively. describe a case of parathyroid carcinoma where the usual pre-operative features of Fine needle aspiration of the thyroid nodule under ultrasound guidance was this condition were absent, and hence diagnosed on histopathology. reported as THY3 and he was referred to the endocrine surgeon. A 72-year-old woman was referred to endocrinology with incidentally noted He underwent bilateral neck exploration along with left hemithyroidectomy. Post hypercalcaemia. Past medical history included hypothyroidism and essential surgery his histology report was consistent with MTC and he went onto completion hypertension. Family history was unremarkable. Clinical examination including thyroidectomy. RET proto-oncogene mutation is awaited. neck was normal. Discussion Relevant investigations To this date reports of calcitonin and CEA negative MTCs are rare in the English Serum adjusted calcium 2.82 (2.10–2.60 mmol/l), Alkaline phosphatase 109 literature. This case illustrates that the diagnosis of MTC cannot be excluded by (25–140 m/l), PTH 17.6 (1.5–7.6 pmol/l), Vitamin D 19.8 (O60 nmol/l), Renal means of a negative serum calcitonin. When serum calcitonin is negative a Ultrasound and DEXA scans were normal. Other causes of hypercalcaemia were cytomorphologic analysis of fine needle aspiration and RET proto-oncogene excluded. She was started on Vitamin D capsules; subsequent calcium levels were mutations are two diagnostic tools which are available for detection and accurate 2.82–2.87mmol/l, with one off reading of 3.01. management of patients in whom MTC is suspected. Neck USS revealed 1.5 cm adenoma in the left superior parathyroid area and Sestamibi scan confirmed this. On patient’s choice, parathyroidectomy was performed with complete excision of the tumour – weighing 900 mg and measuring 17 mm in size. Histology revealed an enlarged parathyroid with a thick capsule, showing areas of incipient capsular invasion and intra-capsular vascular invasion, compatible with a parathyroid carcinoma. Post operatively she remained well and normocalcaemic. At the regional MDT meeting, no further treatment was advised as the tumour was completely removed. Repeat ultrasound of neck was normal at 6 months. P183 Pre-operative features more suggestive of a diagnosis of parathyroid carcinoma – Endocrine disorders in adults treated for Hodgkin lymphoma in young age, palpable neck mass, recurrent laryngeal nerve palsy, extremely high childhood calcium (above 3.5 mmol/l) and PTH levels (3–10 times above the upper limit), Golsa Ehteshamirad, Rachel Johnson, Judith Kingston & Maralyn Druce renal and skeletal disease, were all absent. Barts and the London School of Medicine, London, UK. This case highlights the importance of considering parathyroid carcinoma as a differential diagnosis in PTH-mediated hypercalcaemia, despite being rare, and the lack of typical features. Introduction Successful treatment for childhood-onset Hodgkin lymphoma (HL) has high- lighted long-term effects of therapy. We review endocrinopathy in HL survivors attending a hospital follow-up clinic and consider, together with published data, appropriate disease screening and monitoring. Method Retrospective review of notes and investigations from survivors of childhood HL R5 years from diagnosis. P185 Results A patient with adrenal carcinoma Forty-four subjects were included (30 male, 14 female). Mean age at diagnosis G G Thet Koko, Andrew Pettit & Cornelle Parker was 10.6 3.5 years; mean follow-up 23.6 8.3 years. Thirty-five (79.5%) had Airedale General Hospital, Keighley, UK. received chemotherapy with or without radiotherapy. Thirty-two (72.7%) had received radiotherapy, 29 including the neck (median dose 35 Gy). Mean height was 163.0 cm (females) and 175.5 cm (males). Median BMI was Background BMI 27.5 (females) and 24.5 (males) with 27 subjects (61%) of BMI R25. We describe a 64-year-old lady with past medical history of Thalassaemia Trait Routine diabetes mellitus screening was not performed but there were no and Hypertension, who was presented with Cushing’s syndrome. diagnosed cases. Mean total cholesterol (nZ27) was 4.8 mmol/l in females and Clinical presentation 5.5 mmol/l in males; 17 subjects had cholesterol R5 mmol/l. This patient was admitted with severe bi-basal pneumonia in February 2010 and Where documented, for females, mean age at menarche was 13.7 years. Three treated successfully. But unfortunately her symptoms persisted with increasing women (all over 40 years) had LH/FSH O20 U/l, with a further 4 on HRT or facial swelling in end of May 2010, therefore, a staging CT was arranged and contraceptive pill. In 10 females with reproductive data available; 7 had had found incidental 6!5 cm left adrenal mass which was initially thought to be 2 spontaneous pregnancies (9 offspring). separate left adrenal and renal masses with no evidence of metastasis or other In males, mean testosterone was 12.9 nmol/l (nZ26) and 2 patients had required primary site. She also had weight gain, facial plethora, thinning of the skin, easy testosterone replacement. Seven men with azoospermia and 3 with oligospermia bruising, moon face and increased subcutaneous fat deposition in the nape of were noted – all had had chemotherapy (one with additional groin radiotherapy). the neck. Her 24 h urinary free Cortisol levels were raised at 552 and 736 (normal Thyroid status was available for 43 subjects; 11 (25.6%) had no disease, 30 10–147). She had an over night 2 mg Dexamethasone suppression test which (69.8%) were taking thyroxine (mean dose 124 mg daily). Of these, 26 (60.5%) showed failure to suppress cortisol at 537 and ACTH was fully suppressed at

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!5.0. She also had a plasma rennin activity:aldosterone, plasma metanephrine, Objective 24 h urinary metanephrines (2 samples), DHEA, Andostenedione which were all To review the frequency and type of genetic testing undertaken in subjects normal. LH, FSH and oestradiol levels were post-menopausal range. She presenting to our unit over a 20-year period who have developed a underwent radical left adrenalectomy and left nephrectomy in June 2010 with phaeochromocytoma and/or paraganglioma. hydrcortisone cover peri-operatively. Histology showed left adenocorticol Results carcinoma with penetration into the capsule and adjacent fat. We have started A retrospective examination of pathology and genetic databases from our unit Mitotane 1 g BD along with Hydrocortisone 10/5/5 postoperatively and referred identified 160 subjects who developed a phaeochromocytoma and/or para- to Neuroendocrine Oncology team. She has been continuing to complain of ganglioma between 1989 and 2009 (in whom data was available). Of the 160 significant fatigue and lethargy despite of adequate hydrocortisone supplement. subjects, 61% of subjects developed a phaeochromocytoma, 42% developed a She is due for hydrocortisone day curve and staging CT in a few weeks time. paraganglioma. Seventy-eight percent of subjects where followed-up by an Conclusion endocrinologist while 22% where follow-up by other specialties. Eighty-four Our patient is experiencing fatigue and lethargy for a prolonged period of time percent of subjects have been under long term follow-up while the remaining 16% without a clear reason, after radical surgery, within the therapeutic range of were not followed-up. Mitotane (14–20) and adequate hydrocortisone replacement. Only 35% (56/160) of subjects have undergone genetic testing but 70% of subjects have been appropriately considered for genetic analysis if testing is not deemed mandatory for subjects over the age of 50 years. Of those subjects who had genetic analysis, approximately two-thirds of subjects were tested for both VHL and SDH mutations while 10% were tested for RET mutations. P186 Approximately a fifth of the whole cohort was found to have mutations in the Adrenal incidentaloma: how frequently do adrenal incidentalomas SDH genes (11%), the VHL gene (6%) and RET (3%). Thirty percent of subjects cause problems in terms of hormone hypersecretion or tumour growth? have not had appropriate genetic assessment. Patricia Richters1,2 & John Wass1 Conclusions 1Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK; A substantial minority of subjects have not had appropriate genetic assessment. 2Leiden University, Leiden, The Netherlands. Some were seen prior to the advent of routine genetic testing. Old databases need to be re-examined and genetic testing reconsidered. Future services for these subjects must be integrated between relevant sub-specialties so that genetic Background analysis may be appropriately considered. Adrenal incidentalomas are becoming increasingly common due to the improvements in imaging techniques, increasing numbers of radiological investigations and an aging population. The current follow-up protocols are designed to avoid missing clinically relevant lesions (e.g. malignancy or hormone hypersecretion) by recommending repeated radiological and biochemical investigations. Large amounts of money are spent on patients who as it seems mostly have benign and non-functioning lesions that warrant no further treatment. Objectives The aim of this study is to assess how frequently these tumours cause problems in P188 terms of tumour growth, malignancy and/or hypersecretion of hormones. Methods Clinical outcomes of adrenal incidentalomas over a 3 year period: a The design of the study is a retrospective study based on patient records. Eighty- retrospective analysis to evaluate a new referral pathway Ioannis Dimitropoulos1, Roanna George2, Emma Pickering1, one patients (42 females and 39 males) were investigated. General data (age, sex, 2 2 1 etc), imaging characteristics, hormone work-up and diagnoses were collected and Lynne Bower , Mike Waterson & Jamie Smith 1Department of Diabetes and Endocrinology, South Devon Healthcare NHS analysed. The number of operations has also been included. 2 Results Foundation Trust, Torquay, Devon, UK; Department of Clinical The median age at discovery of the adrenal incidentalomas was 63 years old Biochemistry, South Devon Healthcare NHS Foundation Trust, Torquay, (range 20–84). The prevalence of NFAs was highest in the age group from 60 to Devon, UK. 70 years old. The median size of the adrenal incidentalomas when discovered was 2.3 cm (range 0.7–22 cm). During the follow-up only one mass (1%) showed a Aims significant increase in size, all the other masses remained stable. None of the Prior to 2007, there was no agreed guideline at our hospital for the management of incidentalomas became functional (excessive hormone production) during the adrenal incidentalomas and referrals to our endocrine service were rare. follow-up period. Four (5%) patients were diagnosed with adrenal cortical Following evidence-based guidelines, we have developed a local protocol for carcinoma, 56 (69%) with NFA, two (3%) with Cushing’s, 5 (6%) with the assessment of adrenal incidentalomas. We now report clinical outcomes of Subclinical Cushing’s, 5 (6%) with pheochromocytoma, 1 (1%) with Conn’s and adrenal incidentaloma patients referred to our endocrine service since its 8 (10%) were diagnosed otherwise. There were no metastases. Seventeen patients implementation. underwent adrenalectomy. The difference in prevalence between males and Methods females was statistically not significant (P value: 0.345). The CT scan was the Using a retrospective analysis we collected data on 47 patients with adrenal most used diagnostic technique. incidentalomas presenting to our endocrine service over 3 years (2007–2010). Discussion The patient list was generated by biochemistry records and other clinical data The majority of the incidentalomas were benign and non-functioning. However, a were accessed from medical notes and radiology reports. Audit standards were considerate number of functional and malignant tumours was found. Only one based on international consensus guidelines (AACE/AAES Guidelines 2009, mass progressed during the follow-up period. A cost-effectiveness evaluation is Young WF. The incidentally discovered adrenal mass NEJM 2007) for the necessary to assess how the expenses that are currently spent on the follow-up of management of adrenal incidentalomas. benign tumours can be minimised. Results With respect to endocrine investigations, of the 47 cases of adrenal incidentalomas identified (age range, 19–86 years, 20 males, 27 females) 89% were referred to Endocrinology. 28% were diabetic and 45% hypertensive. 100% underwent urinary measurement of catecholamines, 60% testing of Cortisol axis P187 and 74% testing of Aldosterone secretion. Radiological reporting of size of lesion Phaeochromocytoma, paraganglioma and tumour genetics: clinical was present in 100% whereas density measurement in Hounsfield units in only practice lagging theory? 28%. Mean size of lesion was 3.4 cm (range 1.1–10 cm). Thirteen (28% of total) Umasuthan Srirangalingam1, Nirupa Sivathasan1, Romaan Akhtar1, of lesions where O4 cm. Adrenalectomy was undertaken in 17%. Hormonally Daniel Berney1, Eamonn Maher2 & Shern Chew1 active lesions were identified in 8.7% and included 3 Phaeochromocytomas and 2 1St Bartholomew’s Hospital, London, UK; 2University of Birmingham, sub-clinical Cushing’s. Birmingham, UK. Conclusions Adrenal incidentalomas represent an increasingly common clinical problem. The development of our guideline has led to a significant increase in the referral rate of Background adrenal incidentalomas and enabled a more systematic endocrine evaluation. Up to a third of subjects who develop a phaeochromocytoma or a paraganglioma Amongst referrals, hormonally-active lesions are relatively common and have will do so as the result of mutations in one of several familial genes. Identifying a been amenable to surgical cure. There are however, areas for improvement in causative mutation may have significant implications for family screening and order for our service to comply with international standards of best practice. future disease surveillance.

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P189 P191 Pituitary apoplexy: headache and beyond Endocrine neoplastic manifestations of neurofibromatosis type 1 (NF1): Mureed Hussain, Gabriel Yaacoub & Haris Rathur a case and discussion Tameside General Hospital, Ashton Under Lyne, UK. Richard Carroll & Jeannie Todd Imperial College Healthcare NHS Trust, London, UK. Case 1 A 43-year-old man presented with two day history of sudden onset of headache SB, a 54-year-old male, was diagnosed with NF1 aged 11 on the basis of multiple and vomiting associated with diplopia and declining vision in the left eye for a cafe´ au lait spots and neurofibromas. In 1991 he presented with diarrhoea and few months. On admission he had a high grade fever. Neurological examination weightloss and investigations revealed a duodenal mass and suspected hepatic was unremarkable except for left sided blindness and blurred vision in right eye. metastases. Somatostatin levels were elevated, and histology confirmed a Initial investigations revealed CRP of 181. CT head reported no haemorrhage or duodenal somatostatinma following Whipple’s procedure in 1991. The hepatic infarct. CSF analysis: WCC 24 (polymorphs 60% lymphocytes 40%), protein metastases were excised with good results. At follow up, SB remained symptom 0.92, glucose 3.3, no bacterial growth. free treated only with Creon supplements. An Indium-111 Octreotide scan in 2001 After further deterioration in the right eye vision and no response to antibiotics showed normal distribution with no evidence of recurrence. Unfortunately, he and antiviral therapy, an urgent brain MRI was arranged which confirmed a represented in 2010 with abdominal pain, jaundice, and diarrhoea. Somatostatin pituitary macroadenoma with suprasellar extension causing compression and levels increased to 684 nmol/l (NR!150 nmol/l), having been !495 nmol/l stretching of the optic chiasm. Subsequently, the patient underwent a successful during the years of radiological stability. CT imaging revealed recurrent hepatic transsphenoid debulking of the pituitary lesion. Postoperatively the patient disease obstructing the common bile duct along with significant paraaortic and regained partial right eye vision but the left eye remained blind. mesenteric lymphadenopathy. Gallium 68 DOTATATE PET CT scan revealed no Case 2 uptake in the lesions and therefore, following MDT discussion, SB has been A 75-year-old type 2 diabetic male presented with a three day history of mild referred for systemic chemotherapy. headache, diplopia and drowsiness. Initial investigations: Na 125, K 4.1, glucose Neurofibromatosis type 1 was first described by Von Ricklinghausen in 1882, and the 7.7, random cortisol 482, CT head findings consistent with cerebral atrophy. CSF various phenotypes were documented 1956. It is an autosomal dominant disorder analysis: WCC 1, glucose 4.9, protein 0.80. affecting 1 in 3500 people, characterised by the presence of multiple cafe´ au lait Within 48 h of admission, GCS dropped to 3/15 with flaccid tetraparesis and spots, skinfold freckling, and neurofibromas amongst other features. Endocrine arreflexia He subsequently developed poluyuria and diabetes insipidus. MRI head neoplasia is rare in association with NF1 but phaeochromocytoma, gastrointestinal confirmed pituitary fossa lesion with elevated optic chiasm. GCS improved to neuroendocrine tumours, medullary thyroid cancer, and hyperparathyroidism are 15/15 after initiation of steroids. He also developed a right 6th nerve palsy. He described. Of these, phaeochromocytoma has the highest frequency at 1–5%. was deemed unfit for neurosurgical intervention. Six months later, he remains Additionally, optic gliomas seen in 15% of children with NF1 are associated with stable with steroid and thyroxine replacement. precocious puberty. The diagnosis of NF1 will be discussed based on current Conclusion guidelines, along with a review of the literature documenting NF1 related endocrine The diagnosis of pituitary apoplexy is often delayed due to atypical presentation. neoplasia. The clinical management of NF 1 should include screening for endocrine Due to the serious complications of pituitary apoplexy, timely recognition and neoplasia and pheochromocytomas and NF1 should be considered in the differential appropriate management is critical. diagnosis for patients presenting with these neoplasms.

P192 Familial adrenocortical carcinoma associated with HNPCC Narayanan Kandasamy1, Serena Nik-Zainal2, Anand Kumar Annamalai1, P190 Lisa Walker4, Lisa C Happerfield3, Mark J Arends3, Joan Patterson2 & Adrenal incidentalomas: should we be doing PET scans? Mark Gurnell1 Nisha Kaimal, Simon Taggart, Harry Mamtora, Stephanie Soteriadou, 1Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, UK; Helen Doran & Annice Mukherjee 2Department of Medical Genetics, Addenbrooke’s Hospital, Camrbidge, Salford Royal Foundation Trust, Manchester, UK. UK; 3Department of Histopathology, Addenbrooke’s Hospital, Camrbidge, UK; 4Department of Clinical Genetics, Oxford Radcliffe Hospitals, Oxford, UK. A 60-year-old man underwent investigations for weight loss and abdominal pain. A CT thorax/abdomen revealed a 2 cm right adrenal nodule, 3 nodules in the left adrenal all !1.4 cm and a 5 mm lung nodule in the right middle lobe. The single We report the first case of familial adrenocortical carcinoma (ACC) in association phase CT was unable to characterize the adrenal lesions. MRI adrenal showed with hereditary non-polyposis colorectal cancer (HNPCC) in a family with a solid mixed signal pattern in the nodules with signal drop off in opposed phase MSH2 germline mutation. series consistent with adenomata. Twenty-four hour urine catecholamines, HNPCC, an autosomal dominant disorder caused by mutations in one of the DNA cortisol, DHEAS and renin aldosterone levels were normal. GI investigations mismatch repair (MMR) genes, is the commonest cause of hereditary colon demonstrated no cause for weight loss. Repeat CT after 6 months showed stable carcinoma, and is associated with an increased risk of certain non-colonic cancers appearances of lungs and adrenals. Adrenal CT at 14 months from initial scan (e.g. endometrial, ovarian, urinary tract, biliary tract). Currently, ACC is not a showed an increase in size of 0.5 cm in the right and 0.3 cm in the left adrenal recognised feature of the HNPCC syndrome, and there are only two previous nodules, considered marginal. Four months later the patient presented with chest reports of ACC arising in the context of HNPCC, both of which were non-familial pain. A chest X-ray demonstrated a new left lung lesion. Staging CT suggested a tumours. new left upper lobe lung carcinoma with mediastinal lymphadenopathy. The Amsterdam II/Revised Bethesda criteria are used to select patients, based on Endobronchial ultrasound guided FNA of an enlarged mediastinal lymph node family history of colorectal cancer or other HNPCC-associated tumours, for confirmed a squamous cell lung cancer. Both adrenal glands showed high avidity immunohistochemical (IHC) analysis to detect loss of MMR protein expression, to FDG on PET-CT imaging. The patient is currently undergoing palliative or for microsatellite instability (MSI) in the tumour DNA. Those with loss of chemotherapy. MMR expression or MSI are offered mutation analysis of the four MMR genes Discussion that are associated with HNPCC – MLH1, MSH2, MSH6 and PMS2. This patient developed a new lung cancer after follow-up of presumed benign The proband presented aged 54 years with generalised abdominal pain. Her past adrenal incidentalomata. The lung cancer was not visible on initial or early medical history included ovarian cancer (age 44 years) and a malignant colonic follow-up imaging. polyp (age 47 years). Investigation showed an extensive right adrenal mass, which The prevalence of malignancy in adrenal incidentalomas is !5%. In view of the was surgically resected. Histology confirmed an ACC with capsular, vascular and patient’s symptoms and multiple adrenal nodules an underlying malignancy was lymphatic invasion. Review of the family history revealed several individuals initially sought but not found, however PET was not performed at that stage. An with colorectal cancer and other HNPCC-associated tumours. In addition, her earlier PET scan may have expedited the diagnosis of malignancy in this case. mother had died of metastatic ACC. IHC analysis demonstrated loss of MSH2 The utility, indication and timing of PET scanning in the evaluation of adrenal protein expression in both the ACC from the proband and her mother. Mutation nodules are pertinent issues raised by this case. analysis confirmed a germline MSH2 mutation (deletion of exons 1–3) in the proband and several other family members.

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The familial occurrence of a rare tumour in this HNPCC family, strongly argues followed by surgical resection of the Phaeochromocytoma will bring about cure in for a causal link with the underlying MMR defect. the majority of cases.

P195 P193 PBF is induced by ionising radiation and functionally inactivates p53 in Prevalence and follow-up of adrenal incidentalomas after CT renal colic thyroid cancer Olympia Koulouri, Lisa Turner, Giridhar Tarigopula & Marie-France Kong Robert Seed, Martin Read, Jim Fong, Greg Lewy, Vicki Smith, University Hospitals of Leicester, Leicester, UK. Perkin Kwan, Gavin Ryan, Kristien Boelaert, Jayne Franklyn & Chris McCabe Introduction University of Birmingham, Birmingham, UK. CT renal tract is commonly requested by the urologists for suspected renal colic as it is recognized as the most accurate technique for the detection of ureteric PTTG is a multifunctional proto-oncogene overexpressed in thyroid cancers, stones. However, follow-up of adrenal incidentalomas identified on such scans which binds to p53 and modulates its function. PBF, a binding partner of PTTG, is could pose a challenge for the non-endocrinologist. We investigated the also overexpressed in thyroid cancer and can transform cells independently of prevalence and follow-up of incidentally discovered adrenal masses after CT PTTG. Moreover, subcutaneous expression of PBF elicits large tumours in nude renal colic. mice. Given the established role of ionising radiation in thyroid tumourigenesis, Methods we investigated the relationship between PBF and the tumour suppressor protein We looked through the reports of all CT renal tract during a 12-month period to p53. PBF repressed p53-mediated gene regulation through HDM2 promoter identify adrenal incidentalomas. We then sought evidence of further investi- assays in p53-null H1299 cells. Transfection of p53 elicited a 143G17-fold gations and follow-up. stimulation of promoter activity, whereas co-transfection of PBF significantly Results repressed p53 transcriptional activity (41G5-fold, P!0.001). Exposure of wild- Eight hundred and sixty-three scans were identified. Nine patients (1%) were type mouse thyrocytes to gamma-irradiation resulted in a significant increase in found to have adrenal incidentalomas. Median age was 60 years (range 40–75 PBF protein expression after 24 h (1.88G0.09-fold, P!0.017). Co-immunopre- years). Seventy-eight percent of the patients were male. In 2 cases malignancy cipitation assays revealed direct binding of PBF and p53 in TPC-1 human thyroid with adrenal metastases was diagnosed on further contrast enhanced imaging. In a papillary carcinoma cells, with a marked increase in binding after treatment with further case a contrast CT revealed no adrenal abnormality. One patient with a left gamma-irradiation. Furthermore, transient overexpression of PBF in TPC-1 cells sided 13 mm adrenal mass is awaiting further imaging and 1 with a 16 mm mass resulted in a significant decrease in p53 protein levels compared to controls (75G has had a negative screen for urinary catecholamines under the urologists but no 2.5% decrease after 90 min, P!0.028, nZ4). Finally in MTT proliferation other follow-up. The remaining 4 patients have not had any follow up arranged. assays, we observed a significant reduction of cell viability in mock-transfected Furthermore, the abnormal adrenal findings were not included in the discharge TPC-1 cells after treatment with gamma-irradiation compared to untreated summaries. None of the 9 patients have been referred to the endocrine clinic. controls (17.9G0.008% decrease, P!0.016, nZ4). Critically, overexpression of Conclusion PBF abrogated this observed decrease of cell viability (0.2G0.007%, PZNS, The prevalence of adrenal incidentalomas varies according to inclusion criteria nZ4). Taken together these data highlight a novel potential mechanism of thyroid and patient populations studied. In our audit, we studied patients presenting with tumourigenesis, whereby PBF stabilises in response to DNA damage, binds suspected renal colic and found a 1% prevalence of adrenal incidentalomas. This directly to p53 and inhibits its function. is relatively low, perhaps due to the young age of the subjects. None of the patients were referred for a specialist opinion and there was a lack of structured follow up, thus highlighting the need for a local protocol which will dictate appropriate further management of such cases. P196 MEN-1 mosaic: the founder of a family Seleena Farook, Daniel Kannappan, Sami Kenz, Fiona Lalloo, Peter Trainer & Georg Brabant P194 Christie Hospital, Manchester, UK. Bowel obstruction can be the presenting symptom of phaeochromocytoma Anna de Lloyd, J Stephen Davies & David Scott-Coombes Multiple endocrine neoplasia 1 (MEN-1) is an inherited autosomal dominant University Hospital of Wales, Cardiff, UK. tumour syndrome affecting mainly the parathyroid gland, pituitary and pancreas. Genetic defect appears to be deletion mutation of MEN1 gene coding for tumour suppression. We describe a case of MEN1 mosaic mutation never reported in the We describe the case of two patients who presented with non-mechanical bowel literature. obstruction as a consequence of an underlying, undiagnosed Phaeochromocy- The index case presented aged 52 in 1985 with headaches and dizziness when toma. The first patient was referred in to the surgical team by his GP with signs hypercalcemia of 3.2 mmol/l was noted. Past medical history included stable and symptoms of small bowel obstruction. He described abdominal pain, ulcerative colitis, duodenal ulcers, renal stones and arthritis. In 1990 she had distension and vomiting and had not opened his bowels for a week. The X-ray excision of an enlarged parathyroid gland and histology confirmed benign supported the clinical diagnosis and he went on to have an abdominal CT scan. adenoma. She required further neck exploration surgeries in 1992 and 2002 for The scan did not identify an obstructing mass however it did reveal a unilateral persistent hypercalcaemia and recurrence of adenoma. 10 cm adrenal tumour. Urine catecholamines were consistent with the diagnosis When her daughter developed hypercalcaemia due to a parathyroid adenoma, we of phaeochromocytoma. Alpha-blockers were introduced with prompt restoration investigated the family for familial hyperparathyroidism. Mutation testing of the of normal bowel movements. He went on to have a curative adrenal resection. index case identified low level mosaicism for 188delG mutation of MEN1. This is The second patient was referred for a surgical opinion on her 8th post-operative likely to have arisen due to a sporadic mutation in a single cell of a 4–8 cell day; abdominal pain, distension and vomiting had developed over the course of embryo, resulting in only a proportion of cells with the mutation. Genetic testing the day. On examination her abdomen was soft but tender and she appeared to be on her daughter confirmed heterozygous for 188delG mutation confirming distended. On account of a progressive deterioration in her clinical parameters; germline mosaicism in index case. labile hypertension, tachyarrhythmia’s, and progressive lactic acidosis (14.5 (0.5– Surveillance imaging of the index case in 2008 revealed a pituitary 1.6)) she was transferred urgently to the ITU. An abdominal scan was arranged microadenoma and two pancreatic lesions (2.5!2 cm, 1.1!0.7 cm) with normal which again did not establish an obstructing lesion but did confirm a locally serial fasting gut peptides and pituitary function. Serial followup imaging showed infiltrative adrenal tumour. Despite radical medical and surgical treatment for a stable appearances. Calcium levels remain normal. presumed phaeochromocytoma crisis, she died on the ITU. Histology and The family described is unique for MEN1 showing a founder effect in the index biochemistry confirmed the diagnosis of a malignant phaeochromocytoma. case due to mutation of single cells very early in development. Mosaicism is a Pseudo-obstruction can be caused by Phaeochromocytoma. Pseudo-obstruction recognised mechanism in a number of other inherited cancer syndromes but not was the presenting symptom of undiagnosed Phaeochromocytoma in both the reported in MEN-1 to date. We could argue that a lower dose of mutated protein patients described. We advocate greater awareness of this rare association could explain the relatively milder clinical presentation which nevertheless leads particularly as surgical procedures or certain therapeutic drugs can have fatal to a classical pattern of tumour formation. consequences in the unprepared patient. By contrast, appropriate medical therapy

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P197 Conclusion Rare association of simultaneous adrenal Cushing’s and primary PTTG and PBF potently repress NIS expression and function in vivo. Studies hyperparathyroidism in patient with previous Graves disease using PBF transgenic mice and human primary thyroid cultures emphasise PBF as a critical regulator of NIS function, and implicate PBF as a therapeutic target to Dilip Eapen, Ryan D’Costa & Dinesh Nagi 131 Pinderfields General Hospital, Wakefield, Yorkshire, UK. improve treatment with I in thyroid tumours.

A 33-year-old lady was referred to the endocrinology clinic with weight gain, hirsuitism and amenorrhea. She had been diagnosed with hypertension a year ago which was difficult to control despite being on three anti-hypertensive agents – Ramipril, Amlodipine and Bendroflumethazide. Past medical history included hypothyroidism secondary to radioactive-iodine therapy for Graves disease aged P199 22. Her GP organised an ultrasound scan querying polycystic ovaries but this A case of phaeochromocytoma of the urinary bladder revealed a large left adrenal mass. Jana Bujanova, Shiva Mongolu & Partha Kar In the endocrine clinic her history was suggestive of phaeochromocytoma with Queen Alexandra Hospital, Portsmouth, UK. paroxysms of chest pain, palpitations and a feeling of impending doom. On examination however, she appeared cushingoid with hirsuitism, central obesity, abdominal striae and proximal myopathy. She had no history of headaches and Introduction visual fields were full on confrontation. There was no family history of clinically Phaeochromocytoma of the urinary bladder is a rare neoplasm and accounts for overt endocrine disease. !1% of all phaeochromocytomas. It is more common in females and the majority Results of patients present in second and fourth decade. Its common presentation is Urinary free Cortisol 260 and 424 nmol/d (normal 10–147), failure to suppress on painless haematuria, headache, palpitation, hypertension and syncope during or both low and high dose dexamethasone tests, ACTH !5 ng/l (0–47), corrected immediately after urination. calcium 2.82 mmol/l (2.1–2.6), PTH 18.1 pmol/l (1.5–7.6), 24 h urine calcium Case history 18.4 mmol/d (2.5–7.5), two sets of 24-h urine catecholamines were normal. We present a case of 48-year-old man who presented to Endocrinology with a few MRI Adrenals showed an 8 cm left adrenal mass. Neck ultrasound showed a right months history of having increased bouts of headaches associated with inferior lobe parathyroid adenoma. palpitations and feeling generally unwell during micturition. He had a background She underwent laparoscopic adrenalectomy followed by parathyroidectomy a few history of type 2 diabetes and hypertension for which he was on Metformin and months later. Histology showed a benign adrenal cortex adenoma and a Candesartan. During these episodes his systolic blood pressure rose to 250 mmHg parathyroid adenoma respectively. Interestingly soon after the adrenalectomy (asked to self monitor) with reduction of his symptoms spontaneously within the hypercalcaemia got worse (levels rising above 3 mmol/l) and symptomatic minutes. that required intravenous fluids and bisphosphonate treatment. Twenty-four hour urine catecholamine collection was requested to exclude phaeo- Four months post surgery she had lost 10 kg in weight and stopped her anti- chromocytoma. This showed highly elevated noradrenaline levels – 16.9 hypertensive treatment. She remains on hydrocortisone replacement. mmol/24 h specimen (0.07–0.48) and normetadrenaline levels – 45.6 mmol/24 h This case highlights the rare concomitant presentation of adrenal Cushing’s and specimen (0–0.3). Urinary dopamine was also elevated at 4.21 mmol/24 h hyperparathyroidism as well as the unusual association of Graves disease in the specimen (0.49–2.85). same patient. CT scan showed a bladder mass with subsequent staging CT confirming a 5.4 cm It also reminds us the importance of screening for secondary causes in young vascular mass relating to the bladder wall. No other masses were demonstrated and hypertensive patients. his adrenal glands were normal. The clinical diagnosis of solitary phaeochromo- cytoma of the urinary bladder was made. He was started on Phenoxybenzamine and referred to surgeons and is currently awaiting partial cystectomy. Discussion Though this condition is rare, the history was key in raising the index of suspicion, thereby helping early diagnosis and treatment of the tumour. Because of its rarity, diagnosis may however be difficult and delayed despite the characteristic diagnostic clues associated with micturition. P198 PTTG and PBF: targets for enhancement of radioiodine uptake in thyroid tumours Gregory Lewy, Martin Read, Vicki Smith, Fong Jim, Gavin Ryan, Sarah Stewart, Robert Seed, Neil Sharma, Perkin Kwan, Margaret Eggo, Jayne Franklyn, Christopher McCabe & Kristien Boelaert University of Birmingham, Birmingham, UK. P200 An atypical presentation of primary hyperparathyroidism Claire Feeney, Dimitri Hadjiminas, Ranju Dhawan & Jeremy Cox Iodide uptake via the sodium iodide symporter (NIS) is reduced in many thyroid Imperial College, London, UK. cancers, resulting in poor prognosis following treatment with 131I. The pituitary tumor transforming gene (PTTG) and its binding factor (PBF) are proto- oncogenes implicated in thyroid tumourigenesis and we previously demonstrated A 62-year-old man was referred from secondary care with a long history of PTTG and PBF-induced repression of NIS in vitro. We have recently generated recurrent ureteric colic, borderline hypercalcaemia with parathyroid hormone murine transgenic models of targeted overexpression of PBF and PTTG in the level in the low-normal range and a normal serum phosphate. There was no family thyroid to investigate their function in vivo. Thyroid glands were harvested from history of kidney stones or osteoporosis and no history of childhood urinary 6-week old age- and gender-matched wild-type (WT), PBF and PTTG transgenic infections. mice for mRNA analysis, immunohistochemistry or primary murine thyroid Repeated biochemistry at presentation was as follows: PTH 2.1 pmol/l (1.1–6.8), culture. Analysis by TaqMan RT-PCR showed that NIS mRNA expression was corrected calcium 2.56 mmol/l (2.15–2.55), phosphate 1.10 mmol/l (0.8–1.40) significantly reduced in PBF (0.5G0.1, PZ0.0002, nZ7), PTTG heterozygote and 25 OH vitamin D 48 nmol/l (25–100). A 24 h urine collection of 6.9 l (0.64-foldG0.15, PZ0.01, nZ5) and PTTG homozygote (0.62-foldG0.25, contained an elevated total calcium of 12.01 mmol. A myeloma screen was PZ0.03, nZ3) mouse thyroids. In parallel, the reduction of NIS protein negative and serum ACE was within the normal range. Renal stone analysis on expression was confirmed in PBF and PTTG transgenic mice immunohisto- 3 occasions demonstrated 100% calcium phosphate stones. chemically. Subsequent functional studies demonstrated repressed uptake of 125I The differential diagnosis at this stage was i) Atypical hyperparathyroidism, in primary PBF (77.6G0.2% reduction, PZ0.0004, nZ6), PTTG heterozygote ii) Idiopathic hypercalciuria with stone formation, iii) Partial distal renal tubular (43.4G0.7% reduction, PZ0.042, nZ15) and PTTG homozygote (65.4G0.9% acidosis iv) Other causes e.g. elevated activated vitamin D or a circulating PTH reduction, PZ0.004, nZ14) mouse thyrocytes compared with WT controls. related peptide. An ammonium chloride load test excluded partial distal renal Following transfection with a PBF-specific siRNA, iodide uptake was restored in tubular acidosis. Urine excretion of urate, oxalate, Mg and citrate was within PBF thyroid cultures (2.4G0.64 fold increase, nZ20, PZ0.04) compared with normal limits. PTH rP was !0.7 pmol/l and 1,25-OH vitamin D was also normal scrambled siRNA controls, with uptake levels indistinguishable from those in WT at 0.49 pmol/l. A CT urogram revealed ongoing stone formation with evidence of thyroid cultures (PZ0.86). Further, human primary thyroid cells transfected with 4 separate calcific densities within the urinary tract. In order to reduce the PBF siRNA had elevated iodide uptake levels (2G0.07 fold, PZ0.0001, nZ11) hypercalciuria, a thiazide diuretic was prescribed and this produced a sustained compared to scrambled siRNA controls, and this correlated with increased NIS elevation in plasma calcium (2.69–2.82 mmol/l). Primary hyperparathyroidism mRNA expression (4.76G0.58 fold, PZ0.07, nZ5). was now strongly suspected and localisation studies were pursued.

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Ultrasound of the neck showed a possible left superior parathyroid adenoma and accompanied by diffuse nodularity throughout both lung fields on CT scanning. sestamibi was unsurprisingly negative. An MDT discussion based on the options Biopsy showed the mass to be a low grade spindle cell carcinoid tumour. of surgery or watchful waiting fell temporarily in favour of the latter. However Subsequent Video Assisted Thoracic Surgery confirmed the presence of several months later urinary calcium remained high despite thiazide therapy and neuroendocrine tumourlets and multiple foci of neuroendocrine cell hyperplasia cinacalcet was able to suppress the plasma calcium to the lower half of the normal in the contralateral lung. 68Ga-Octreotate-PET scanning failed to demonstrate any range (2.17 mmol/l) suggesting a relatively large parathyroid component to the uptake in either the tumour or pulmonary nodules, suggesting no significant hypercalcaemia. A DEXA scan also demonstrated lumbar osteopaenia. The somatostatin receptor expression. The patient underwent a right middle patient went onto have an uncomplicated 4 gland exploration of the parathyroids. lobectomy, and has remained symptomatically well since the procedure. The left superior parathyroid gland appeared abnormal to the naked eye and Interestingly, a single subcarinal lymph node showed minimal tracer activity reported histologically as a parathyroid adenoma confirming our original during PET scanning, whilst histologically metastatic spread to a single lymph diagnosis. node was reported. Although perhaps typical in its presentation, we feel that this case merits reporting, in the hope that it will promote further discussion about the management and surveillance of DIPNECH.

P201 Insulinoma presenting as post-prandial hypoglycaemia Asgar Madathil1 & Jolanta Weaver2 P203 1 2 Gateshead Health NHS Trust, Gateshead, UK; Faculty of Medical Five year experience of investigation and management of histologically Sciences, Institute of Cellular Medicine, Newcastle Univeristy, Newcastle proven chromaffin cell tumours upon Tyne, UK. Anjali Amin, Fausto Palazzo, Karim Meeran & Jeannie Todd Imperial College Healthcare NHS Trust, London, UK. Although insulinoma commonly presents as fasting hypoglycaemia it can rarely present as post prandial hypoglycaemia and even less rarely in association with Background Type 2 Diabetes Mellitus (T2DM). We describe a case of insulinoma presenting Chromaffin cell tumours are rare but potentially curable endocrine tumours. These as post-prandial hypoglycaemia and T2DM. tumours may be sporadic or familial in nature. Biochemical tests are normally A 60 year old man presented with a 6 year history of episodes of double vision and performed initially, followed by radiological investigation. loss of concentration occurring post-prandially. His symptoms were associated Aim with capillary blood glucose of less than 3 mmol/l and relieved with sugary To assess the correlation of biochemical and radiological investigations with drinks. A prolonged 5 h oral glucose tolerance test (OGTT) using capillary blood histologically proven chromaffin-cell tumours in patients with sporadic and glucose showed 2 h glucose of 11.3 mmol/l, but no drop in blood glucose during familial disease. the test. A diagnosis of T2DM was made subsequently using a standard OGTT Methods (2 h glucose 11.3 mmol/l) to which patient’s post prandial hypoglycaemia was We retrospectively reviewed data for 28 patients who underwent adrenalectomy attributed. He was given dietetic advice for post-prandial hypoglycaemia and was for presumed chromaffin cell tumours between October 2005 and October 2010. followed up routinely. Results After 2 years, hypoglycaemic symptoms worsened by exercise and delayed meals. 18 of 28 patients underwent laparascopic adrenalectomy. 5 patients had MEN2A, A number of supervised fasting glucose measurements failed to demonstrate 2hadNF1,1hadVHLand2wereSHDBCve. Histology confirmed biochemical hypoglycaemia. His insulin, c-peptide and pro-insulin levels were phaeochromocytoma in 19, 1 of which was malignant and 5 paragangliomas, 1 mildly elevated but plasma glucose levels were normal. A CT scan showed of which was malignant. Biochemical data were available for 21 patients. 20 mm hypervascular lesion in the distal pancreas which was confirmed as Pre-operative 24-hour urine catecholamines showed mean urine adrenaline insulinoma with pancreatic arterial calcium stimulation studies. Laparoscopic 1.51G1.38 mmol (NR 0.00–0.10), mean noradrenaline 3.05G1.44 mmol (NR resection confirmed benign insulinoma and hypoglycaemia resolved. A repeat 0.00–0.50), and mean dopamine 2.10G0.41 mmol (NR 0.00–2.70). All patients OGTT after 12 months showed T2DM and at 18 months impaired glucose with MEN2A, NF1 and VHL had negative urine catecholamines. Both patients tolerance. with SHDB mutations had positive urine catecholamines. Two of the patients with Persistence of hypoglycaemic symptoms should always be taken seriously. Our MEN2A had urine metanephrines performed, one of which was positive despite case illustrates the importance of considering insulinoma as a cause of post- negative urine catecholamines. Similarly, one of the NF1 patients had positive prandial hypoglycaemia. A high index of suspicion in patients with post-prandial urine metanephrines with negative urine catecholamines. MIBG scan was hypoglycaemia, who do not respond to conventional treatment or whose pattern positive in 18 of 20 patients; of the two patients with negative MIBG, one was of symptoms change will lead to further investigations. also negative on Gallium-68 DOTATATE scan. One of the patients with MEN2A had a negative MIBG scan. Conclusion Our results show that urine catecholamines are poor markers in the detection of phaeochromocytoma in patients with familial syndromes. We have shown that the sensitivity of urine metanephrines is superior to that of urine catecholamines in patients with MEN2A and NF1. In addition, there are limitations to MIBG scanning; care needs to be taken in interpreting these scans in patients with a P202 genetic predisposition to phaeochromocytoma. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a precursor to pulmonary carcinoid Mark Stephens & Aled Rees University Hospital of Wales, Cardiff, UK.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is a rare pulmonary pathology which encompasses a spectrum of findings ranging Growth and development from simple neuroendocrine cell proliferation to discrete nodules, and is strongly P204 associated with carcinoid tumours. Patients, typically female, are often Association between plasma steroid hormone level, growth and obesity asymptomatic, but may present with overt pulmonary symptoms, such a in adolescent girls dyspnoea, cough or pleuritic chest pain; however, even in their absence, a degree Barbora Matejovicova´1, Tomas Zatko1, Alexandra Beza´kova´1 & of obstructive or mixed obstructive/restrictive deficit on formal pulmonary Alexander V Sirotkin1,2 function testing is common. 1Constantine the Philosopher University, Nitra, Slovakia; 2Animal We describe the case of a 60 year old female non-smoker who initially presented Production Research Centre Nitra, Luzianky, Slovakia. with a chronic non-productive cough and right subcostal pain. Whilst obese and hypertensive, pituitary imaging and endocrine function were generally unremarkable, though both FSH and LH were inappropriately low for a post- The aim of the present study was to examine the role of steroid hormones in menopausal woman. A single discrete 2 cm mass in the right upper zone was control of growth and obesity. We have measured plasma level of progesterone

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

(P4), testosteron (T) and estradiol (E2) in 301 adolescent girls at different stages of euthanased. The biceps femoris was sampled for histological analysis and real- their ovarian cycle, and compared they with standard morphometric indexes of time gene expression of IGF1, 11b-hydroxysteroid dehydrogenase (HSD)-1 and their growth and obesity – body height, body mass, abdomen and hip 2, glucocorticoid receptor GR. circumstances and waist to hip ratio (WHR). The ovarian cycle-dependent Sodium and creatinine plasma concentrations increased in SL/H offspring changes in plasma P4 and E2, but not in T level was found. Girls with higher body compared to the controls. The total serum protein rose in both intra-uterine weight, higher body height, higher abdomen circumstance and higher WHR had compromised groups in relation to MH/L (SL/H 49.83G3.1*; CL/H31.00G4.8; significant higher plasma E2, but not of P4 or T than subjects with lower MH/L 43.04G4; g/l *(P!0.05)). The GR and 11b-HSD-1 genes were upregulated expression of these indexes in both follicular an luteal phases of the ovarian cycle. in H/L offspring in relation to the control group, whilst IGF1 expression (SL/H -(DDCT) These interrelationships between growth and obesity indexes and plasma E2 but 0.96G0.3; CL/H 1.0G0.1; MH/L 2.2G0.4*; 2 *(P!0.05)) and 11b-HSD-2 not of P4 or T level were confirmed by results of correllation analysis. No was highest in MH/L, compared to the other groups, with more internal nuclei association between hip circumstances and hormonal indexes were found. The fibres than the SL/H. present observations suggest, i) that luteal phase of the human ovarian cycle is Our study suggests that IGF1 and 11b-HSD-2 gene expression in MH/L offspring characterised by dramatical increase in both P4 and E2, but not in T release, and muscle increase in response to the reduced maternal calorie intake during the ii) that in human females both growth and obesity are up-regulated by E2, but not second half of gestation. Increased numbers of fibres with central nuclei may by P4 or T. indicate glucocorticoid activation. Further investigations will determine whether this promotes a degenerative or regenerative process. This study was supported by the BBSRC (BB/H002650/1) Reference 1. Schakman, O, et al. J Endocrinol 2001 197 (1) 1-10.

P205 Identification of turner syndrome specific mRNA expression profiles that correlate with clinical response to growth hormone Adam Stevens, Shahin Tajbakhsh, Andrew Whatmore, Melissa Westwood & Peter Clayton University of Manchester, Manchester, UK. P207 Genetic characterisation of primary GH Insensitivity (GHI) presenting Girls with Turner syndrome (TS) are treated with recombinant human growth as growth failure: 10 years experience at the Centre for Endocrinology, hormone (rhGH) to improve their adult height but the gain is variable (0–20 cm). William Harvey Research Institute, Barts and the London Current prediction models can account for only w46% of the variability in the Louise Metherell, Alessia David, Martin Savage, Adrian Clark & first year response to rhGH, thus genetic profiling has been suggested as a possible Helen Storr means of improving this prediction. The aim of this study was to explore mRNA William Harvey Research Institute, Barts and the London, London, UK. expression profiles in an ex-vivo fibroblast model to characterise response to rhGH and to associate mRNA expression profiles with biological pathways. Three fibroblast cell lines were used, a control line (C10)(4 replicates) and two TS GHI is a genetic condition in which patients present with growth failure due to lines (4 replicates each); T1, from a TS patient responding well to rhGH (Height primary IGF1 deficiency caused by a defect in the GH-IGF1 axis. In the last SDS at startZK4.9 with a change in height SDS at 4 years of C1.8) and T5, from 10 years in the Centre for Endocrinology of WHRI at Barts and the London, a poor responder to rhGH (Height SDS at startZK2.5 with a change in height 24 causative mutations in genes of the GH–IGF1 axis have been determined in SDS at 4 years of – 0.3). Gene expression was measured using Affymetrix 58 patients (Table 1). STAT5B mutations were responsible in 2 cases, IGFALS in HG-U133 plus 2.0 arrays, differential gene expression was analysed using 4 but the majority of defects identified were in GHR. Most mutations identified ANOVA and Igenuity Pathway Analysis software (IPA) was used to assess were autosomal recessive, missense or nonsense changes in extracellular domain biological function of genes. coding exons of GHR, but we also described pseudoexon activation as a cause and Comparison of control fibroblasts to the combined TS lines showed that reported the first polypyrimidine tract mutation. Other unusual cases included a variability in gene expression clustered by cell line and genes in pathways homozygous deletion of 22 bp in the intracellular domain and a dominant associated with ‘skeletal and muscular function’ showed the greatest differential negative mode of inheritance in a child with a mild short stature phenotype. expression (35 out of 301 genes, P!0.0001) with insulin-like growth factor binding protein 5 (IGFBP5) upregulated in TS (670-fold). When the T1 and T5 cell lines were compared, 8 out of 25 differentially expressed genes were associated with ‘cellular growth and development’ (P!0.0001) and a Wnt Table 1 pathway protein, Secreted frizzled-related protein 4 (SFRP4), was upregulated in T1 52 fold. Mutation Number of individuals Country of origin Identification of GH-dependent growth pathway genes is an important step GHR towards the identification of biomarkers that may determine treatment decisions. S40L 7 Turkey V125A 2 Iraq, UK R161C 1 Israel G223G 2 Bahamas, Spain L229P 1 UK R43X 7 Turkey C48X 2 Argentina Q65X 1 Turkey P206 E180X 1 Mexico Effects of the prenatal environment on haematological and skeletal Q216X 1 Turkey IVS2 dsC1 G to A 2 Turkey muscle parameters in one-week-old piglets: a role for glucocorticoids? IVS6 dsC1 G to A 1 Hong Kong Hernan Fainberg, Kayleigh Almond, Paul Bikker, Michael Symonds & Pseudoexon insertion 15 Pakistan Alison Mostyn IVS7 as-6 T to A 1 Bangladesh University of Nottingham, Sutton Bonington, UK. IVS8 ds-1 G to C or R274T 3 UK IVS8 as-6 G to A 1 UK IVS9 dsC2 T to C (hetero- 2 Spain Changes in maternal dietary intake during gestation can affect muscle zygous) development1 and may be linked to the catabolic actions of hormones, such as c.1323_1344del22 (450X) 2 Spain glucocorticoids, which inhibits the insulin like growth factor 1 (IGF1) pathway. STAT5B This study examines the potential effects of glucocorticoids and skeletal muscle c.1680delG 2 Saudi Arabia IGFALS adaptations in seven-day-old offspring exposed to suboptimal gestational P73L 1 UK environments. L134Q/546-548delGG- 1UK Pregnant sows were randomly assigned to a commercial diet (L/H nZ8), which CinsAG increased in energy content during gestation, or an inverse diet (H/L nZ8). L/H c.1490insT 1 Kurdish offspring were ranked according to birth weight as small (SL/H, nZ7) or median D440N 1 Turkey Z Z (CL/H, n 7). Only the H/L median offspring (MH/L, n 8) were selected for this Total 58 study. Blood samples were taken from week-old piglets before they were

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In conclusion, genotyping of candidate genes was informative in the investigation Summary of a significant proportion of patients with GHI. Most cases were caused by The LDDT is a simple, well tolerated test. It has allowed confident exclusion of defects in GHR but mutations in other genes of the GH-IGF1 axis such as STAT5B tumourous causes of hyperandrogenism, and dramatically reduced the need for and IGFALS are being increasingly recognised as causal. further complex investigation. In the light of 1/34 significant anomalous result, we propose that a normal result requires suppression of testosterone levels by both O40% AND into the normal range in future.

P208 P210 The use of a novel injection delivery system to address compliance in Care of cancer survivors: the role of endocrinologists patients receiving GH replacement therapy Diana Greenfield1,2 & Andrew Toogood1,2 Stephen McGlynn, Michael Edwards, Linda Smethurt & Georg Brabant 1Teaching Hospitals NHS Foundation Trust, Sheffield, UK; 2University The Christie, Manchester, UK. Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.

The majority of adult GH replaced patients reach target IGF1 levels using Background established injection devices. However, a small but significant cohort of these Increasing numbers of children and adults are surviving cancer and living with the patients fail to achieve these intended goals. This can be manifested as either a consequences of their disease or its treatment. The commonest long term failure to improve (biochemically or symptomatically) despite escalating GH consequences observed following childhood cancer are endocrine and there is a doses, or large variations in IGF1 measurements despite steady GH dosing. growing body of evidence indicating that adults treated for malignant disease are The Easypodw device has a memory chip which allows recording of time, number also at risk of endocrine dysfunction. and dose of GH injections given. Aim Ten patients from the cohort described above were invited to trial the Easypod To determine the involvement of Endocrinologists in the management of cancer device, and were standardly trained and followed up by a dedicated nurse. IGF1 survivors and resources that will improve the outcome of this growing patient levels were monitored as per usual clinical practice both before and after cohort. commencing the novel device. Methods The device was well tolerated, with 8/10 patients remaining on the device at the Clinical members of the Society for Endocrinology were invited to complete an time of submission. Mean duration for use of the device was 191 days (19–397d). online questionnaire. Two patients discontinued use of the device due to mechanical failure and Results difficulty preparing the injection respectively. One hundred and ten physicians (64% male) responded of whom 60.9% were Three patients were identified with compliance issues missing over 20% of doses, involved in the care of cancer survivors. Respondents cared for patients treated with a mean compliance of 89% (range 68–99%). during childhood (18%), adulthood (20%) or both (62%), but only 31% had a Adequate compliance as evidenced by the administration history in the other dedicated late effects clinic. 97% felt the Endocrinologist should be part of the patients formed the basis for further dose adaptation to reach target levels which late effects MDT and 92% agreed that standardised guidelines and specialist were achieved in 9/10 patients. nursing support would help them provide a clinically appropriate late effects Particularly with current uncertainties around IGF1 measurements the down- service. 86% of Endocrinologists felt they would benefit from specific training in loadable injection history enables clinicians to draw more accurate conclusions endocrinology. regarding the validity of the IGF1 result. This may have potential benefits in Discussion and recommendations reducing unnecessary dose escalations and allowing to identify non-compliance at This survey demonstrates that Endocrinologists are engaged in the care of cancer an early stage. survivors although provision is not universal. The survey has identified the following needs: development of guidelines for the management of late effects of treatment for cancer in adulthood and standards of care, links with cancer networks; attendance of Endocrinologists at late effects MDTs when established. There is a particular need to establish training for Endocrinologists who are keen to be involved in the care of these patients.

Nursing practise P209 Audit of low dose dexamethasone suppression test to exclude androgen secreting tumours in hyperandrogenic women Katherine Powell, Rosemary Temple & Francesca Swords Norfolk and Norwich University Hospital, Norwich, UK. P211 Nebido (testosterone undecanoate) in patients over 60 years of age: a time to reduce dose frequency? The low dose dexamethasone suppression test (LDDT) is used routinely to Diana Mantripp, Rachel Franklin, John Wass & Niki Karavitaki exclude Cushings. This test can also be used to exclude androgen secreting Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK. tumours in females with elevated testosterone levels through normalisation of, or O40% suppression of serum levels. We have audited the use of the LDDT to assess its value in investigating women Background with raised androgens, to ascertain whether it reduced the need for other Clinical experience has shown that men over 60 years of age frequently (40%) investigations and to identify any problems encountered in performing the test. require extended intervals of greater than 12 weeks between administrations of Method Nebido. No work has assessed whether this is specific to men over 60 years of age. We reviewed the notes and results of all female patients referred to the clinical Methods investigation unit for LDDT investigation of elevated androgen levels. We analysed men on Nebido over 60 years (nZ12, mean age 66 years) and Results compared them with a BMI matched group aged 40–60 years. We assessed 26/34 patients suppressed their testosterone levels by O40%. 6/34 suppressed testosterone levels, injection intervals, PSA and haematocrit over the first 4 by !40%, all of whom underwent further investigation. 50% were found to have injections. a tumourous cause for the hyperandrogenism. Results 1/26 patient suppressed by 43% but her testosterone levels remained elevated Baseline mean serum testosterone in the over 60 age group was 4.13 nmol/l (5.3 nmol/l). A repeat LDDT resulted in 33% suppression. Further investigation (range 1.5–12.1) and in the 40–60 age group was 5.85 nmol/l (range 0.4–16.1). is underway to rule out a tumourous cause in this case. Over 60 age group Two patients having the LDDT for the investigation of hyperandrogenism were 3 out of 12 patients had an elevated trough testosterone pre-2nd injection (21.3, found to have non-suppressible cortisol. Cushing’s syndrome has subsequently 22.2, 24.2 nmol/l) and had next injection interval extended to 15, 15, 24 weeks been confirmed in both cases. No adverse events were encountered in any patient. respectively.

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4 out of 12 patients had elevated trough testosterone levels pre-3rd injection (23.9, air showed pH 7.41, PCO2 3.5, PaO2 11.0. She was initially treated with 17.2, 17.5, 17.8). Two of these patients stopped Nebido due to elevated intravenous KCl and received a total of 280 mmol in the first 48 h. On day 2 the testosterone levels and polycythaemia. One patient stopped due to interval potassium improved only to 2.4 but she developed evidence of sepsis (temp 39 8 extending greater than 24 weeks. C) and metabolic acidosis (pH 7.08). She was treated in ITU with IV antibiotics. 1 out of 9 patients who continued with Nebido had an elevated trough testosterone Random cortisol came back at 2712 nmol/l with ACTH 50 pmol/l. Pituitary MRI level pre-4th injection (18.9 nmol/l) and had next injection interval extended to was normal while CT of chest, abdomen and pelvis showed a bulky left adrenal 20 weeks. gland and two focal liver lesions suggestive of metastasis but no primary tumour 3 out of 12 patients developed polycythaemia, 2 requiring venesection. detected. A liver biopsy was eventually performed which showed a poorly 1 out of 12 patients developed an elevated PSA above the normal range. differentiated large cell neuroendocrine carcinoma. The patient had a stormy 40–60 age group hospital stay complicated by severe sepsis, DVT, C. Difficile diarrhea and acute No patients required the injection interval extending. No patients developed renal failure needing haemofiltration. She died after 6 weeks stay in ITU. polycythaemia. No patients developed a raised PSA. Metastatic neuroendocrine tumours causing ectopic Cushing’s syndrome are rare Conclusions and as illustrated in this case these tumours can be very aggressive and have a This is the first study to compare injection frequency and side effects in men over very poor prognosis. 60 with men of 40–60 years. Of the men aged over 60 years, 33.3% had elevated testosterone levels pre 3rd injection and 25% developed polycythaemia compared to no men aged 40–60. We have shown that the necessity for 12 weekly injections for men over 60 years is significantly decreased. Particularly careful monitoring for polycythaemia in this group is necessary.

P214 An unusual complication in a patient with Graves’ disease Ullal Ananth Nayak, Yasmeen Khalid, Ananth Viswanath, Abdul Rasheed Mohamed Zahir, Baldev Malkiat Singh & Harit Narendra Buch New cross hospital, Wolverhampton, UK. P212 Diagnosis denial exacerbated by thyrotoxicosis Introduction Adrianna Omar & Jackie Gilbert Hyperthyroidism secondary to Graves’ disease is well-recognised to be associated King’s College Hospital, London, UK. with non-thyroidal immunological manifestations like ophthalmopathy and pretibial myxoedema. We report a patient with Graves’ disease who presented with an unusual complication. A 45 year old female civil servant presented to primary care for a routine Case evaluation of her lipid profile. When questioned, she described a history of A 68 year old Caucasian lady presented with typical features of hyperthyroidism lethargy and low mood. The patient’s GP noted features of agitation and sweating which was confirmed by free T4 72.0 pmol/l (12.0–22.0 pmol/l) and TSH and organised a range investigations including thyroid function tests. Past medical !0.01 mU/l (0.27–4.20 mU/l). Graves’ disease was confirmed by diffusely history included systemic lupus erythematosus, a diagnosis that the patient had increased uptake on radio-nuclide scan and TSH receptor antibodies level of experienced difficulty accepting, requiring an extended period of counselling. 13 U/l (normal !1.0 U/l). She was commenced on carbimazole and beta- Thyrotoxicosis was confirmed; fT4 32.1 pmol/l, TSH!0.01 mU/l likely blockers. Shortly thereafter she was admitted to hospital with shortness of breath secondary to Graves’ disease with elevated thyroid microsomal and TSHR and atrial fibrillation with a fast ventricular rate. She had a loud pericardial rub antibodies. The patient was adamant that she had neither discussed nor consented and raised jugular venous pressure. Chest X-ray showed cardiomegaly and mild to an assessment of thyroid function. As a result, she persistently expressed denial pleural effusion. An urgent echocardiogram confirmed moderately large global regarding the diagnosis, initially declining all intervention and subsequently pericardial effusion but there were no features of cardiac tamponade. WCC 20.5, demonstrating non-compliance with thionamide medication. CRP 187, ESR 75, autoantibodies were negative and complement levels were After six months, the patient agreed to be reviewed by a liaison psychiatrist to normal. Pleural biopsy showed benign inflammatory changes. Stable euthyroid- explore her anxieties accepting the diagnosis. In conjunction with frequent ism was maintained with block and replacement therapy and 6 weeks after specialist thyroid nurse contact, reassurance, reminders and encouragement she commencement of anti-thyroid therapy a repeat echocardiogram confirmed adhered to a six month course of carbimazole and thyroxine. On becoming resolution of pericardial effusion and inflammatory markers normalised. euthyroid, the patient was able to achieve a coherent perspective of the disease. She Unfortunately pleural effusion was complicated by secondary infection leading has remained in remission seven months after discontinuation of medical therapy. to empyema requiring intercostal drainage and antibiotic therapy. Six months Patients may experience prolonged difficulties accepting a diagnosis due to later, she remains euthyroid with no serous membrane involvement. psychosocial circumstances, religious beliefs, level of education, cognitive Discussion impairment and psychiatric disorders. This is observed more commonly with We believe that pericardial and pleural effusions were related to Graves’ disease diagnoses of malignancy and conditions requiring long term management such as with which they had a strong temporal relationship. Other causes for serous diabetes mellitus. membrane involvement were excluded. Although this is uncommon it has been As thyrotoxicosis may be associated with anxiety, depression, cognitive previously described and inflammatory changes related to an autoimmune process impairment and paranoid ideation, this may exacerbate pre-existing difficulties are considered to be involved. in rationalising illness. Such patients should be counselled carefully regarding Conclusion planned investigations with maintenance of thorough documentation. Pleural and pericardial effusions are rare but recognised and serious complications of Graves’ disease and should be considered in patients who present with dyspnoea or chest pain.

P213 Cushing’s syndrome due to ectopic ACTH secretion from a hepatic neuroendocrine tumour Yahya Mahgoub, Mohamed Suliman & Jeff Simmonds P215 Southport and Ormskirk NHS trust, Southport, UK. What is the appropriate time for radioactive iodine re-dosing to achieve cure of persistent hyperthyroidism? Yasmeen Khalid, Ullal Ananth Nayak & HaritNarendra Buch A 44-year-old lady with hypertension and type 2 diabetes of 10 years duration New Cross Hospital, Wolverhampton, UK. (BMI 47, HbA1c 9.1%) treated with metformin and exenatide presented with a few days history of feeling generally unwell, vomiting and confusion. Initial examination showed pulse 120 per min, BP 115/74 mmHg, normal temperature Background and multiple abdominal striae. Admission investigations showed Na 140, K 1.4, Radioactive iodine (RAI) therapy effectively cures hyperthyroidism although a urea 3.9, creatinine 74, glucose 26, CRP 23 Hb 16.2, WBC 11.6. ABGS on room varying proportion of patients need repeat RAI doses. There is no consensus on

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK the timing of redosing for RAI which varies in different centres between 6 weeks P217 and 12 months depending on the perceived time to respond to therapy. Use of plasma metanephrine estimation in the diagnostic work-up of Aim phaeochromocytoma: an audit of local practice We have undertaken a retrospective study to assess if after the initial RAI dose of Marco-Daniel Egawhary1, Yasmeen Khalid2, Varadarajan Baskar2, 400 MBq a second RAI dose can be administered earlier than at 6 months, which Rousseau Gama3 & Harit Narendra Buch2 is the redosing policy at our centre. 1Birmingham Medical School, Birmingham, UK; 2Department of Endo- Patients and methods crinology, New Cross Hospital, Wolverhampton, UK; 3Department of Retrospective assessment of 199 patients for whom 6 month follow-up data was Clinical Chemistry, New Cross Hospital, Wolverhampton, UK. available. Clinical and laboratory data was obtained from patient notes and electronic database. Cure of hyperthyroidism was defined as achieving euthyroidism or hypothyroidism on the basis on FT4 and FT3. Background Results Urinary catecholamine measurement has been the mainstay for diagnosis of a At 6 weeks post-RAI, 70 patients were hyperthyroid, of whom 58 (83%) patients phaeochromocytoma. Plasma metanephrine estimation has been introduced more achieved spontaneous cure and 12 (13%) patients remained hyperthyroid recently although its precise position remains unclear. We have undertaken a requiring a second RAI dose. At the 3 month-stage, 29 patients were hyperthyroid retrospective analysis of patients who have undergone this test to assess its of whom 17 (59%) patients achieved spontaneous cure and 12 (14%) patients usefulness in the diagnostic process. required a second RAI dose. For patients who were hyperthyroid at 3 months, a Patients and methods high initial FT4 at diagnosis predicted persistence of hyperthyroidism at 6 months We evaluated all patients who have had plasma metanephrine estimation over the and the need for redosing (74.47G24.65 pmol/l (meanGS.D.) for patients past 4 years. The pre-test clinical and biochemical information and patient not cured at 6 months vs 40.19G18.92 pmol/l (meanGS.D.) for those cured, outcomes at a minimum of 2-year follow up was correlated with the test result. PZ0.001). Persistence of hyperthyroidism was not correlated to any other We also evaluated clinical and biochemical profile of the last 10 consecutive clinical or biochemical predictors studied. patients who underwent surgery for suspected phaeochromocytoma. Conclusion Results Following the administration of 400 MBq RAI, a significant proportion of Twenty-three patients had plasma metanephrine estimation. Four patients had patients who were hyperthyroid at 6 weeks and 3 months, revert to euthyroidism typical clinical features with normal multiple urinary catecholamines and 19 by the end of 6 months. In view of this an earlier use of second dose cannot be patients had raised one or both catecholamines of !3 times upper limit of recommended as a routine measure although this may be considered in patients reference range (ULRR). 22/23 had normal plasma metanephrines. All patients with high FT4 at diagnosis. have been stable over a 2-year follow-up period excluding phaeochromocytoma. 1/23 had raised plasma metanephrines with unequivocally positive imaging studies but was unfit for surgery. During the same period, 10 patients had surgery for excision of a suspected phaeochromocytoma. None of these patients had plasma metanephrines estimation. 9/10 had a strong clinical suspicion and urinary adrenaline or noradrenaline O3 times ULRR in at least one urinary sample. Phaeochromocytoma was confirmed histologically in all patients. 10th patient had surgery without biochemical confirmation due to an increase in size of adrenal incidentaloma. Histological examination excluded phaeochromocytoma. Conclusion Our results confirm that plasma metanephrines estimation has a high negative predictive value in the diagnosis of a phaeochromocytoma. This test does not appear to have a significant role in patients with high clinical suspicion and unequivocally raised urinary catecholamines. This selective approach would avoid unnecessary use of this expensive and logistically difficult test. P216 A comparison between post-radioiodine outcomes following the use of two different fixed-dose regimes Yasmeen Khalid1, Ullal Ananth Nayak1, Baldev M Singh1, David M Barton2 & Harit Narendra Buch1 1New Cross Hospital, Wolverhampton, UK; 2Princess Royal Hospital, Telford, UK. P218 Bilateral testicular tumours, a case of mistaken identity? Background and aim Nihad Jaleel, Sindhu Padmabhaskaran & Ken Laji Fixed dose radioiodine therapy (RAI) is considered to be the standard regime for St Richards Hospital, Chichester, UK. management of hyperthyroidism although the actual RAI activity used varies between different centres. We have undertaken a retrospective comparison between various outcomes achieved following the use of fixed RAI doses of 400 Case and 550 MBq at two different centres. Twenty seven year old male presented to Urologist with heamospermia. He wa Patients and methods noted to have a lump in his scrotum. No evidence of infection. Ultrasound showed An electronic database has been prepared for all patients who receive RAI therapy bilateral testicular tumours. Previous medical history of congenital adrenal at both hospitals. 220 patients received a fixed dose of 400 MBq over the past hyperplasia and hypertension. Medication include Atenolol and Prednisolone 6 years (Group A) and 584 patients received 550 MBq over a 10-year period (poor compliance). Non smoker. Very strong family h/o cancer. O/E bilateral (Group B). At both centres antithyroid drugs were withdrawn for a week prior to upper pole testicular lumps 2 cm. firm, irregular. Tumour markers normal. All RAI therapy and patients were considered to be cured if they were euthyroid or blood tests normal: serum testosterone 17 mmol/l. CT chest abdomen and pelvis hypothyroid. Second dose was administered if the patient remained hyperthyroid showed grossly enlarged adrenal glands but nil else significant. Flexible at 6 months. cystoscopy: normal bladder. Results Patient was posted unilateral orchidectomy (and biopsy) and ‘sperm banking’ Both groups were comparable for age, gender distribution, aetiology of was arranged. hyperthyroidism and FT4 level at diagnosis. Group A had a significantly higher Patients case was discussed at MDTM and a referral to Endocrinologist made. rate of persistent hyperthyroidism at 3 months (19 vs 9%, P!0.01) and at It was concluded this was adrenal rest tissue and not primary testicular tumours. 6 months (13.6 vs 6.5%, P!0.01). The proportion of patients who were Orchidectomy was abandoned and patient’s glucocroticoid therapy intensified hypothyroid at the end of one year was lower in Group A although this was not after counselling. statistically significant (67.1 vs 69.9%, PZ0.2). Mean total RAI activity Further surveillance scans showed no increase in size of the tumours and patient administered to patients in Group A was significantly lower (463 vs 596 MBq) is currently doing well on Prednisolone. and post-RAI restrictions were 4–5 days shorter. Discussion Conclusions Adrenal rest tissue is a rare but very important differential in any young person Fixed dose RAI activity of 550 MBq achieves cure of hyperthyroidism early and presenting with testicular masses. The importance of being aware of the previous in a higher proportion of patients. These improved outcomes are achieved at the medical history of CAH cannot be over-emphasized here. It would have been expense of a higher mean RAI dose, an extended period of post-RAI restrictions disastrous if this young man had an orchidectomy due to a case of ‘mistaken and possibly higher early hypothyroidism rate. identity’, luckily this was avoided.

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P219 Low bone mass is an infrequent long-term sequelea of pituitary disease Julie Lynch & Robert Murray Not answered/ Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK. Satisfactory Unsatisfactory unsure Pre clinic information 96 2 2 Leaflet regarding the treatment 96 1 2 Introduction Treatment explained 100 0 0 Within the setting of putative or established pituitary disease the primary disease Post procedure precautions 95 1 4 process (i.e. Cushing’s disease), hormone deficits (i.e. sex steroids, GH), and explained inappropriate replacement therapy (i.e. glucocorticoids) are reputed to predispose Accessibility to hospital 94 5 1 to low bone mass. Overall satisfaction 98 0 2 Patients and Methods We examined bone mass at the lumbar spine (LS) and total hip (TH) using DXA in 259 patients with an insult to the hypothalamo–pituitary axis (51.6G15.7 Conclusion years; 133F; BMI 29.3G5.5 kg/m2). Mean duration of follow-up 11.4G9.5 years. Majority of patients surveyed were well informed about the radioiodine treatment In patients who were receiving treatment for osteoporosis the scan result and precautions related to radiation protection following their clinic appointment. immediately before therapeutic intervention was used in this analysis. We recommend a joint practitioner and operator assessment of patients Results undergoing radioiodine therapy to ensure a unified and detailed information In the cohort overall Z-scores at the LS and TH were C0.09G1.81 and C0.54 with regards to radiation protection and implication of radioiodine treatment. G1.21 respectively. A Z-score of less than K2.0 was observed at the LS in 10.4% and at the TH in 2.2% of individuals. No difference was observed in bone mass between subgroups at either the LS or TH following stratification for the primary pathology (Table). Further analysis of bone mass (Z-scores) by the number of additional anterior pituitary hormone deficits revealed no evidence of a trend towards lower bone mass with greater degree of hypopituitarism. P221 Assessment of bone density in patient with adrenal insufficiency Bhano Varupula, Angelos Kyriacou & Abu Ahmed Table 1 Blackpool Victoria Hospital, Blackpool, UK. Lumbar spine Total hip nZ (Z-score) (Z-score) In a retrospective study, we studied the medical notes of 35 patients with adrenal insufficiency; aged 61G15 (mean GS.D.) years. Their average age at diagnosis C G C G NFPA 72 0.136 1.676 0.663 1.054 was 45G18 years, and duration of the disease was 17G15 years. C G C G Acromegaly 35 0.553 1.632 0.813 1.109 Most patients were on hydrocortisone replacement (32 patients); taking 23G4mg C G C G Cushing’s Dis 21 0.305 1.879 0.900 0.923 daily in divided doses, and only 3 (9%) patients were on single dose of prednisone C G C G Hyperprolactinaemia 39 0.419 1.436 0.789 1.052 7.5G05 mg daily in a single dose. Average body weight at diagnosis was 66G15 K G C G Craniopharyngioma 21 0.261 2.152 0.418 1.610 years, and last body at time of this study was 75G15 years. K G K G XRT-Induced 10 0.410 1.847 0.267 1.533 Thirty patients (86%) have reduced bone density on Dual-energy absorptiometry K G C G Others 61 0.333 2.037 0.128 1.269 (BMD) scan, 14 patients have osteoporosis and 16 had osteopenia. The t-score spine and hip were reduced, but were both marginally higher at diagnosis compared to time of study, but the difference was not significant (K1.6G0.8 vs K1.3G0.7) and (K1.6G0.8 vs 1.15G0.7) respectively. The Z-score of hip and Conclusion spine were also reduced. There was no difference in the daily hydrocortisone dose The impact of hypopituitarism and hormone replacement therapy has negligible in patients with osteoporosis (13 patients), compared to the 19 patients on impact on bone mass in long-term survivors of patients with a putative or hydrocortisone with no osteoporosis (22.2 vs 24.2 mg daily). Conversely, when established insult to the hypothalamo–pituitary axis. we stratified the hydrocortisone dose cohort into those with total daily dose of 20 mg (17 patients), 25 (9 patients) and 30 mg (6 patients), the prevalence of reduced bone density was 52.9% (9), 33.3% (3) and 16.7% (1) (Pearson c2 PZ0.26). Among the three patients receiving prednisolone only one had osteoporosis (total daily doseZ8 mg). In conclusion, osteoporosis and osteopenia were very common (85.7%) in those with adrenal insufficiency. No correlation was identified between the dose of steroid replacement and the prevalence of reduced bone density. P220 Joint radioiodine clinic – patient satisfaction survey Srilatha Dampetla1, Waqas Shafiq1, Akrem Elmalti1, David Pears2 & Mohamed Malik2 1Scunthorpe General Hospital, Lincolnshire, UK; 2Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, Lincolnshire, UK. Pituitary P222 Back ground Has you appearance changed over the last few years? Oh I’m really Radio iodine treatment is widely used in the management of hyperthyroidism. ugly now! Recent guidelines have stressed the importance of advising patients of the Vinay Somashekar Eligar, Thomas Dacruz, Munveer Thind, Srinivas Rao, recommendations with regard to radiation protection, and the implications Meurig Williams & Samuel Rice of radioiodine treatment in relation to work, travel and contact with the family. Prince Philip hospital, Llanelli, Carmarthenshire, UK. We carried out a survey to assess our joint radioiodine clinic approach where all patients referred for treatment are assessed jointly by a consultant endocrinologist (Practitioner) and Medical Physicist Expert (Operator) to ensure adequacy of Forty two year Mrs SJ, community support worker with a background history of information received. hypothyroidism was referred by her GP with excessive tiredness and weight gain. Survey process She had been attending her surgery for few months with somatic symptoms and A questionnaire was devised and posted to patients who had been given her GP had noticed significant change in facial characteristics and large hands. radioiodine capsule from January 2007 – January 2009. The questionnaire were She complained of increase in her feet size from a size 6 to a 9. No disturbance of divided into four main domains; i) Written information received prior to the clinic vision was reported. appointment, ii) Information given at the clinic appointment, iii) Information She was noted to have hyperglycaemia and oral glucose tolerance test confirmed at the time of treatment administration, and iv) How happy patients with the abnormal growth hormone levels. IGF1 was 128 nmol/l and GH levels were information provided and the journey through the radioiodine treatment. O40 mg/l at 0 min and 37.3 mg/l at 120 min. Prolactin level was elevated at Results 1800 mIU/l. Her synacthen and thyroid function tests were normal. An MRI scan One hundred and fifty patients were sent a questionnaire to complete with 100 demonstrated a predominantly intrasellar pituitary macroadenoma with no optic (66.6%) returning a completed questionnaire. chiasm compression.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

A week following the biochemical diagnosis of acromegaly she presented with Hypothesis headache, vomiting and fatigue for 2 days. We suspected pituitary apoplexy, Fpr2-selective ligands inhibit secretagogue-induced ACTH release from pituitary however pituitary CT did not show any change in size of the pituitary adenoma tissue in vitro. nor did it demonstrate any sign of haemorrhage. A synacthen test was again Methods normal. Her symptoms resolved spontaneously after 1 day. She was started on Firstly, we cultured anterior pituitary cells from Sprague–Dawley rats (nZ12, cabergoline 0.5 mg twice weekly and discharged. Following 4 weeks of treatment male, 200–220 g) in CRH-stimulated (100 nmol/l) or basal conditions, along with her prolactin had normalised but her IGF1 remained elevated (134 nmol/l). peptide agonists for Fpr2 (WKYMVm (10K10,10K9,10K8,10K7,10K6 mol/l) She then presented with sudden onset polyuria and polydipsia and was admitted and F2L (50, 100, 200, 400, 800 nmol/l)) or Fpr1 (fMLF (10K9,10K8,10K7, for a water deprivation test that confirmed the diagnosis of cranial diabetes 10K6,10K5 mol/l)). ACTH was measured by RIA after 4 h and data (mean inspidus. Her osmotic symptoms resolved with DDAVP 10 mg twice daily. GS.E.M.) analysed by two-way ANOVA. Secondly, the pituitary Fpr2/3 A subsequent MRI again showed a pituitary tumour measuring 2!1.5 cm as distribution was determined by immuno-fluorescent detection of pituitary cell before but now with a concave superior border indicating shrinkage of tumour. subtypes and green fluorescent protein (GFP) in sections of Fpr2/3-null/GFP- The posterior pituitary bright spot had also disappeared. positive mice (nZ4, male). The diagnosis here is pituitary adenoma producing GH which has undergone Results structural change, most likely as a result of haemorrhage or infarction, leading to Concordant with previous data, low dose fMLF did not affect ACTH release, the development of diabetes insipidus. confirming Fpr1 is not instrumental in ACTH regulation. Surprisingly, in separate experiments, two-way ANOVA revealed a significant stimulatory effect of WKYMVm and F2L on ACTH release (F(7,176)Z71.38 and 49.17 respectively; P!0.0001). ACTH release from CRH-stimulated, WKYMVm-treated (10K9 mol/l) and CRH-stimulated, F2L-treated cells (800 nmol/l) versus CRH control was 20% (1680 pg/mlG111 vs 1320 pg/mlG75) and 60% (2953 pg/ml G188 vs 1817 pg/mlG227) higher, respectively (P!0.05). GFP as a proxy for Fpr2/3, was evident in corticotrophs, somatotrophs, and lactotrophs, but, P223 importantly, not in folliculo-stellates (anti-S100b). Mortality in cushing’s disease: stoke-on-trent data and meta-analysis Conclusion Richard Clayton1, Diana Raskauskiene2, Raoul Reulen3 & Peter Jones4 Our work shows rodent Fpr2-selective ligands stimulate ACTH release and 1University Hospital of North Staffordshire, Stoke-on-Trent, UK; 2Walsall suggests Fpr2 does not mediate feedback-like regulation of pituitary ACTH Manor Hospital, Walsall, UK; 3School of Health and population Sciences, release. Ongoing work will determine whether inhibition of ACTH is mediated University of Birmingham, Birmingham, UK; 4School of Computing and by Fpr3 ligands, namely, 15-epi lipoxin A4. Mathematics, Keele University, Stoke-on-Trent, UK.

There are very limited data on long-term mortality in pituitary ACTH dependent Cushing’s disease (CD). We report on our data from Stoke-on-Trent, UK, spanning 50 years and provide a meta-analysis of six other reports which addressed mortality of CD. Case records P225 of 60 CD patients from 1958-31 Dec 2009 from Stoke-on-Trent were reviewed. Pituitary dysfunction is uncommon in pituitary incidentalomas The standardised mortality ratio (SMR) overall and separately for patients in Ammar Tarik & Steven Peacey remission and having persistent disease was calculated. Remission was defined Department of Diabetes and Endocrinology, Bradford Teaching Hospitals as resolution of clinical features and normalisation of biochemical hypercorti- NHS Foundation Trust, Bradford, West Yorkshire, UK. solism according to the methods extant at the time within 3 years of diagnosis. Overall SMR for the whole cohort was 4.8 (2.8–8.3 95% confidence intervals) PZ!0.001. SMR for vascular diseaseZ13.8 (7.2–36.5) PZ!0.001. For The frequent use of brain and head MRI/CT has lead to an increase in the number persistent disease (nZ6pts)SMRZ16 (6.7–38-4) vs remission (nZ54) of incidental pituitary lesions reported, so called pituitary ‘incidentalomas’. Such SMRZ3.3 (1.7–6.7); after adjustment for age and sex relative risk of death for lesions require endocrine evaluation of pituitary function and radiological follow persistent disease was 10.7 (2.3–48.6) PZ0.002. Hypertension and diabetes up. We performed a retrospective study to examine the source of these referrals, mellitus were associated with significantly worse survival. Using a random effects size of the incidentalomas, frequency of pituitary dysfunction and changes during model meta-analysis of seven studies (including our own) revealed an overall follow-up. We performed a search of the departmental endocrine database and SMR of 2.2 (1.45–3.41) PZ!0.001 indicating decreased survival. Pooled SMR clinical letters for the term ‘incidentaloma’ from 2005 onwards. for patients in remission (4 studies which compared the remission versus Thirty six patients, age ranged 23–86 years, F 22:M14 were identified with persistent disease) was 1.2 (0.45–3.2) PZNS and 5.5 (2.7–11.3) PZ0.001 for pituitary incidentalomas. The majority of referrals were from the departments patients with persistent disease. Persistence of disease, older age at diagnosis, and of neurology and ophthalmology, to a lesser extent from general practitioners, presence of hypertension and diabetes appear as the main determinants of elderly care and psychiatry. Of these 36 pituitary incidentalomas, there were mortality. 18 macroadenomas, 14 microadenomas, 3 pituitary ‘hyperplasia’ and 1 intrasellar Conclusions meningioma. Overall mortality in CD is double that of the general population. Patients in Following endocrine evaluation, hypopituitarism was rare and found in only one remission fare much better than those with persistence of hypercortisolism. SMR macroadenoma and not in any microadenomas. Hypersecretion was also of 1.2 for patients in remission may not be statistically significant but could infrequent; 1/18 macroadenomas secreting prolactin. Three microadenomas become so with larger numbers followed for a much longer time (30–40 years). were secreting excess hormones; 2/14 prolactin, 1/14 growth hormone. The optic chiasm was radiologically involved in 7/18 macroadenomas; however visual fields were affected in only 2/18. Of those patients who did not undergo surgery (nZ22), radiological follow up in the remainder, confirmed an increase in tumour size in 2/10 macroadenomas and 1/12 microadenomas. We conclude that pituitary dysfunction is uncommon in pituitary incidentalomas, which may explain why these lesions are found ‘incidentally’ even though the P224 majority of these are macroadenomas. Negotiating with a pea-sized hormone factory: the mediatory role of pituitary formyl peptide receptor (FPR) ligands in times of stress Vance Naughton1, Bradley Spencer-Dene2, Chris John1 & Julia Buckingham1 1Imperial College London, London, UK; 2London Resarch Institute, London, UK. P226 A case of lymphocytic hypophysitis with spontaneous remission Pituitary folliculo-stellate cells express annexin-A1 (ANXA1), a mediator Amalia Iliopoulou, Julie Kyaw Tun & Emma Ward protein necessary for glucocorticoid(GC)-induced negative feedback of adreno- St James’ University Hospital, Leeds, UK. corticotrophic hormone (ACTH) release. ANXA1 acts via formyl peptide receptors (FPR in man, Fpr in rodents). Whilst pituitary tissue does not express Fpr1, functional data suggested Fpr2/Fpr3-selective ligands mediate feedback- A 19 year old girl presented at 39 weeks gestation with headache and blurring of like inhibition of ACTH. vision. MRI showed an enhancing pituitary mass measuring 1.2 cm maximum

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK height, extending suprasellarly and distorting the optic chiasm. Visual field Result testing showed bilateral constriction. 0900 h cortisol was 502 nmol/l, thought to The major indication for ITT was non-functioning pituitary macro adenomas. be relatively low for the stage of pregnancy and FT4 was 9.3 pmol/l suggesting 76% of the cohort was hypoglycaemic (!2.0 mmol/l) for 60 min or more. TSH deficiency. Prolactin was appropriately raised for the gestational age at The nadir plasma glucose (NBG) ranged from 0.1–4.6 mmol/l and correlated 4951 mU/l. significantly with basal plasma glucose (BPG) (rZ0.56; P!0.001), Insulin dose A diagnosis of probable lymphocytic hypophysitis was made. Given her advanced (rZ0.27; P!0.001) and weight (rZ0.21; P!0.01). 24 patients received an gestational age, pituitary surgery or biopsy was not thought to be appropriate. insulin dose exceeding 0.15 IU/kg body weight. These patients were charac- Regular hydrocortisone was started with high dose cover during labour. She was terized by higher weight (mean 93 vs 86 kg) and BPG (mean 5.7 vs 4.8 mmol/l) also given 1mg of cabergoline, based on the presumption that dopamine agonist compared with the rest of the population. treatment would stop the lactotroph hyperplasia and result in some tumour Using multiple regression analysis, the factors determining nadir blood glucose shrinkage. She delivered a healthy baby girl a week later and was asked not to were plasma glucose (bZ0.56; P!0.001 20% contribution) and weight (bZ0.14; attempt to lactate. P!0.05 2% contribution). A month later repeat MRI showed regression of the pituitary mass to 8 mm and Only one patient had an adverse effect during the test. He developed unstable visual fields showed a substantial improvement. Prolactin was 411 mIU/l and FT4 angina and needed coronary artery by-pass surgery following a finding of 3 vessel was 12.9 pmol/l, implying recovery of the pituitary–thyroid axis. The glucagon coronary artery disease. The mean NPG and insulin dose in this patient was stimulation test showed a suboptimal peak cortisol at 429 nmol/l. comparable with the rest of the population. Consecutive MRI scans have shown a progressive reduction in the tumour size Discussion over subsequent months. The limitations of the ITT include the perceived risks of prolonged hypo- Insulin stress test 7 months post delivery showed a peak cortisol of 498 nmol/l and glycaemia. Our data shows that it is a relatively safe test but that hypoglycaemia a peak GH of 1.8 mg/l. Gonadotrophins are normal and she is menstruating can be prolonged and unpredictable in a significant proportion of patients. regularly. She takes hydrocortisone for intercurrent illness and remains We have also shown that baseline plasma glucose and the patient’s weight predict asymptomatic from her GH deficiency. the nadir plasma glucose. Lymphocytic hypophysitis is a rare condition, thought to be autoimmune in We therefore propose that a better way to avoid unnecessarily prolonged origin, with a strong predilection for women in the peripartum period. It usually hypoglycaemia is the use of an insulin and glucose infusion with bed-side plasma presents with enlarging pituitary mass and variable degrees of hypopituitarism. glucose analysis. This case illustrates that conservative management of lymphocytic hypophysitis should be considered, as in some cases it may remit spontaneously.

P227 An unusual cause of a sellar mass presenting as a pituitary adenoma P229 Abdul Mohammed, Peshraw Amin & Carolyn Chee 20 year experience in the surgical management of cushing’s disease in a Derby Hospitals NHS Foundation Trust, Derby, UK. UK tertiary referral centre Zaki Hassan-Smith1, Alan Johnson2, Andrew Toogood1, Wiebke Arlt1, Mark Sherlock1 & Paul Stewart1 A 57-year-old man presented with a 6-month history of worsening headaches and 1 2 bitemporal hemianopia on visual field examination. MRI of the brain revealed a University of Birmingham, Birmingham, UK; University Hospitals 3 cm pituitary lesion impinging the optic chiasm and indenting the pons. Birmingham NHS Foundation Trust, Birmingham, UK. Appearances of the lesion on imaging and the patient’s normal anterior pituitary hormonal profile were highly suggestive of a non-functioning pituitary adenoma Objective and this was the presumed diagnosis. The patient underwent trans-sphenoidal The past 2 decades have seen advances in the surgical management of Cushing’s resection of the tumour. Histopathology and immunohistochemical staining disease (CD). Our aim was to meet the need for current data on clinical features, confirmed the unexpected diagnosis of a chordoma. Chordomas are rare long-term outcomes, and prognostic indicators. malignant tumours of the axial skeleton arising from primitive remnants of the Patients and methods notochord. It can mimic a pituitary adenoma or craniopharyngioma. Tumours are We conducted a retrospective study of 71 patients treated by trans-sphenoidal usually slow-growing but can be locally aggressive and have high recurrence surgery (TSS) for CD. All patients were operated on by the same surgeon in a rates. Few literature reports have described pseudoprolactinomas, chordomas single centre between 1988–2009. Diagnosis was confirmed using Low and high masquerading as prolactin-secreting tumours that may present a pre-operative dose-DSTs, and CRH tests, with selected patients undergoing IPSS. 58 patients diagnostic dilemma. Treatment options include extensive surgical resection, underwent microscopic-TSS at first surgery, whereas 13 had Endoscopic-TSS. radiotherapy or both. This case demonstrates that although extremely rare, Results chordomas can directly involve the sellar region and mimic features of a pituitary Median follow up was 50 months (IQR 22–115 months). Median age at diagnosis adenoma. Clinicians should consider this as a differential diagnosis of a pituitary was 39 years (IQR 30–50 years). Male:female ratio was 1:3.4. Follow up data sellar or suprasellar mass. were available on 67/71 patients. 82% (55/67) achieved initial clinical remission, of which 8 suffered disease recurrence. Mean time to recurrence was 3.9 years (IQR 3 months-14 years). 3 outcome groups were identified: ‘Long-term Cure’ 70% (47/67), ‘Persistent Disease’ 18% (12/67), and ‘Recurrent Disease’ 12% (8/67). Long-term cure rates were higher in patients with undetectable (!30 nmol/l) post-operative cortisol levels (87%). They were also increased in patients with histology positive for ACTH-containing adenomas (82%), compared to those with negative histology (57%). Further treatment for patients with recurrent/ P228 persistent disease included revision TSS (nZ11), Radiotherapy (nZ7), and Z An audit of 220 insulin tolerance tests Adrenalectomy (n 7). Common complications following TSS were transient DI Olubukola Ajala & Daniel Flanagan (60%), and CSF leak (16%). Hypopituitarism was present in 81% of patients at Plymouth Hospitals NHS trust, Plymouth, UK. final follow up. Mortality was increased in persistent/recurrent disease, compared to the long-term cured (PZ0.04). 4 deaths were documented (2 recurrent, 1 persistent disease, 1 cured 20 years previously). Objective Conclusion We reviewed the depth and length of hypoglycaemia in a cohort of patients Our favourable remission/cure rates, serve to underline the importance of an undergoing Insulin Tolerance Tests (ITTs). We evaluated the safety of the test, its experienced surgeon in the management of CD. Favourable prognostic factors reproducibility and explored factors that might predict the optimal dose of insulin. include undetectable post-operative cortisols and ACTH-positive histology. The Methodology reduced mortality in the long-term cured, demonstrates the importance of ITTs were performed at a teaching hospital in the south of England between 2005 aggressive treatment of CD. and 2010.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P230 P232 Suspected spontaneous resolution of pituitary cushing’s disease Rare case of disseminated adenocarcinoma prostate metastasising to the Wen Bun Leong & Darren Warner pituitary, with a normal PSA Princess Royal Hospital, Telford, UK. Huong Trinh1, Mohsen Javadpour2, Atik Baborie3, David Ewins1, Niru Goenka1 & Franklin Joseph1 1Department of Diabetes and Endocrinology, Countess of Chester Hospital A 49-year-old lady was referred by her GP with lethargy, oligomenorrhoea and NHS Foundation Trust, Cheshire, UK; 2Department of Neurosurgery, persistent hypertension despite three anti-hypertensives (lisinopril, amlodipine, Walton Centre for Neurology and Neurosurgery, The Walton Centre NHS and atenolol). She denied exogenous steroid usage and had no other medical Foundation Trust, Liverpool, UK; 3Department of Histopathology, Walton history. Centre for Neurology and Neurosurgery, The Walton Centre NHS On examination, she had features of Cushing’s syndrome including plethora, Foundation Trust, Liverpool, UK. moon face, central obesity and androgenisation of her facial skin. She weighed 98 kg. Overnight (1 mg) low dose dexamethasone suppression test disclosed no Mr DP was referred by palliative care to ophthalmology with anisocoria, diplopia suppression of cortisol. High dose dexamethasone suppression test suggested and nystagmus. He was known to have a poorly differentiated carcinoma of the pituitary-dependant Cushing’s. A confirmatory CRF test showed marked rise in prostate with skeletal metastasis (Gleason score 4C5Z9). He was on hormonal serum cortisol and ACTH. MRI brain showed a 9 mm low signal area in the left therapy and had received radiotherapy to the cervical spine. PSA was normal, side of pituitary post gadolinium in keeping with pituitary adenoma. Her pituitary at 5.31 mg/l. profile was otherwise unremarkable. An MRI scan revealed a 12 mm mass in the left side of the pituitary gland, She was referred for hypophysectomy. Four months later, on the day of surgery, displacing the stalk to the right and lying close to the inferior surface of the optic her pre-operative MRI brain showed spontaneous shrinkage of her pituitary chiasm. Prolactin was elevated at 897 mg/l in keeping with stalk compression, adenoma with no signs of haemorrhage to suggest apoplexy. Her surgery was IGF1 was normal at 24 mg/l and cortisol peaked at 626 nmol/l on a short cancelled. synacthen test. A repeat MRI 3 months later showed the tumour had grown to Two months later, she had lost 8 kg in weight with a normalising body habitus and 15.5 mm, and was extending into the cistern touching the chiasm from below. no proximal myopathy. Her repeat low dose dexamethasone suppression test was Although a non-functioning pituitary adenoma was more probable in this normal; CRF testing shows residual but much improved cortisol secretion 10 location, the rate of growth was suggestive of possible metastasis. months later. Her static pituitary screen is otherwise normal and her weight loss Image guided endoscopic trans-sphenoidal resection of the tumour was arranged, continues. Repeat MRI pituitary showed a normal pituitary gland in August 2010. and histological examination confirmed a moderately differentiated adenocarci- This is the first case report which showed a near spontaneous resolution of noma consistent with a metastatic deposit of the prostate. There were no pituitary Cushing’s disease without any medical or surgical intervention. Possible postoperative visual complications. Follow up imaging at 3 months showed causes include spontaneous infarction of the tumour. tumour residue reduced to 7 mm. Postoperative radiotherapy was not initiated as the patient became too unwell due to disseminated malignancy. Prostate cancer is usually associated with lymph node, hepatic, skeletal and pulmonary metastases. Intracranial metastases are uncommon, with involvement of the pituitary gland rarer still. Small cell carcinoma of the prostate has a greater predilection to distant metastasis but this case represents a typical adenocarci- noma. Although unusual this case highlights the need to consider prostate metastasis to the pituitary, even with a normal PSA, as a metastatic deposit would potentially be more aggressive than a concurrent pituitary adenoma and would warrant earlier intervention.

P231 Tri-phasic changes in sodium levels post pituitary surgery Hollie Ellis1, David Webb1, Iain Robertson2, Trevor Howlett1 P233 & Miles Levy1 An unusual case of extremely high prolactin due to stalk disconnection 1Department of Endocrinology, Leicester Royal Infirmary, Leicester, UK; hyperprolactinaemia 2Department of Neurosurgery, Queens Medical Centre, Nottingham, UK. Haliza Haniff1, Paul V Marks2, Azzam Ismail2 & Robert S Moisey1 1Huddersfield Royal Infirmary, Huddersfield, UK; 2Leeds Teaching Hospitals NHS Trust, Leeds, UK. Case A 73-year-old lady presented with hyponatraemia six days post-transphenoidal surgery for a non functioning pituitary macro-adenoma. Peri-operatively she A 75-year-old man was admitted acutely with a 1 week history of headaches, developed diabetes insipidus requiring short term desmopressin whilst on the reduced visual acuity, diplopia and ptosis of his left eye. Examination confirmed a neurosurgical ward. At post-operative presentation she complained of weakness, left III and VI nerve palsies with decreased visual acuity in the left eye. A CT and confusion and nausea; sodium 125 mmol/l, serum osmolality 268 mOsmol/kg, subsequent MRI revealed pituitary mass lesion measuring 2.4!2.1!1.5 cm with urine osmolality 474 mOsmol/kg. Over the next few days she became extension into the left cavernous sinus. The pituitary stalk appeared thickened and symptomatically worse and her hyponatraemia more severe; sodium was deviated to the right. The optic apparatus was uninvolved. 114 mmol/l, serum osmolality 252 mOsmol/kg, urine sodium 52 mmol/l. He had a background history of adenocarcinoma of the ascending colon with right A diagnosis of post-operative SIADH was made and she was admitted for hemicolectomy in March 2007 and in July 2009 he had undergone a left upper optimisation of fluid balance. Because she was clinically dehydrated, she was lobe metastectomy for a lung metastasis. A repeat CT of his chest and abdomen given slow intravenous normal saline. After 5 days her sodium gradually revealed a left upper lobe mass with enlarged mediastinal lymph nodes. increased to 140 mmol/l and she was symptomatically much improved. Nine days His pituitary hormone profile showed a markedly elevated prolactin and anterior later, her sodium increased to 145 mmol/l, serum osmolality 311 mOsmol/kg, pituitary failure: prolactin 8766 mU/l (50–700), LH 0.6 U/l (1.0–9.0), FSH urine osmolality 464 mOsmol/kg. Subsequently her sodium rose to a peak of 2.0 U/l (1.0–10.0), testosterone !0.4 nmol/l (8.0–27.0), IGF1 8.0 nmol/l 150 mmol/l; she developed polyuria and polydipsia and also reported numbness (7.0–22.0), cortisol 68 nmol/l (184–623), TSH 0.08 mU/l (0.2–4.0) and T4 in the face and both feet and general loss of balance. A diagnosis of diabetes 7.9 pmol/l (8.0–21.0). Macroprolactin was excluded. He was commenced on insipidus was made on the basis of the high urine osmolality and polyuria, and the cabergoline 500 mg once daily, hydrocortisone and levothyroxine. His prolactin patient was started on DDAVP. We have not yet explained her neurological corrected rapidly, falling to 83 mU/l after two weeks. However a repeat MRI symptoms and she awaits a post-operative MRI brain and pituitary fossa. showed no change in the size of the pituitary mass. Subsequently he underwent Discussion transsphenoidal surgery to debulk his pituitary mass and confirm the aetiology. This case is interesting as it displays the tri-phasic response pattern of sodium that Histology showed moderately differentiated adenocarcinoma compatible with a can be seen post pituitary surgery. The development of SIADH is thought to be metastasis from gut primary. Immunohistochemistry showed no evidence of due to degeneration of paraventricular neurones, which may predispose to prolactin secretion from within the tumour. He deteriorated quickly and died four permanent diabetes insipidus. This case highlights the need to closely observe months later. sodium levels in the short to mid-term post pituitary surgery. We discuss a This case demonstrates an unusually high prolactin level which is not due to a possible short term role for the vaptans in temporary post operative SIADH prolactinoma but instead is due to stalk disconnection hyperprolactinaemia from which might prevent hospital admission in this situation. a rare occurrence of a pituitary metastasis.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P234 P236 The risk of cardiac valvulopathy in cabergoline-treated endocrine Long term morbidities in a large series of patients with Cushing’s patients in a district general hospital disease Saravanan Balaguruswamy, Natalie Lewis, Sid McNulty & Niall Furlong Georgia Ntali1,2, Thomas Siamatras1, John Komninos1, Stelios Tsagarakis1,2, St Helens and Knowsley NHS Trust, Merseyside, UK. John Wass1 & Niki Karavitaki1 1Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK; 2Department of Endocrinology, Athens’ Aim Polyclinic Hospital, Athens, Greece. Over the last decade, cardiac valvular fibrosis has been associated with the use of high dose (ergot-derived) dopamine agonist therapy in Parkinson’s disease. Although the risk in endocrine patients appears significantly lower, routine Cushing’s disease (CD) is a rare condition, associated with significant echocardiographic monitoring is now recommended. This study evaluated the morbidities. incidence of significant cardiac valvulopathy in endocrine patients treated with The long-term morbidities in a series of patients with CD who presented in two cabergoline in a District General Hospital Population, and compliance with tertiary referral centres between 01/1967-06/2009 were assessed. All information MHRA 2008 recommendations for chronic endocrine use of ergot-derived was collected as documented in the records of the patients. dopamine agonists. 224 patients were identified (174 females) with median age at diagnosis 39 years Methods (range 10–76 (females 38 (12–72) – males 40.5 (10–76)) and median follow-up 113 We identified 18 patients treated with cabergoline in the Endocrine Clinic over a months (0–550) (mean 143 months (G121)). Treatment modalities were: TSA 6 year period (August 2004 – May 2010), 16 for hyperprolactinaemia (8 with 144patients(cured70%),TSACexternal radiotherapy 22 (cured 32%), microadenoma, 4 with macroadenoma and 4 with primary hyperprolactinaemia) TSACbilateral adrenalectomy 21 (cured 100%), TSACbilateral adrenalectomy and 2 for acromegaly. For hyperprolactinaemia mean (GS.D.) age was 40.75 Cradiotherapy 8 (cured 100%), bilateral adrenalectomy 19 (cured 100%), (G17.79) years, 88% were female (nZ16). The median (range) cumulative dose radiotherapy 3 (cured 33%). Two patients are waiting for surgery, 4 had been of cabergoline was 88 mg (9–781) and treatment duration 33 months (6–152). treated medically due to high surgical risk, and one died before any treatment. The Both acromegaly patients were female, age 81 and 73 years, cumulative median time between cure and last assessment was 102 months (0–549) (data cabergoline doses 1564 and 715 mg, and treatment duration 10 years and 6 years available for 192 patients (85.7%). At last assessment, 70.5% of the subjects and 9 months, respectively. were considered cured (157/224). Morbidity rates and median (range) age at Results last follow-up were: hypertension 35.3% (79.8% cured – 54 years (17–82)) Baseline echocardiography was documented in 86% patients. 81% of eligible dyslipidaemia 27.2% (75.4% cured – 52 years (25–82)), DM2 13.4% (66.6% patients received echocardiography monitoring as per MHRA guidelines. In the cured – 55 years (18–75)), depression 14.3% (81.3% cured – 60 years (22–78)), hyperprolactinaemia patients, no significant cardiac valvulopathy was identified osteopaenia/osteoporosis 39.7% (76.4% cured – 52 years (18–78)), cardiovascular (one case of mild aortic regurgitation (with no serial progression), all others disease 9.4% (66.6% cured – 52 years (26–71)), cerebrovascular disease 3.6% echocardiographically normal). Both acromegaly patients were found to have (62.5% cured – 59 years (26–71)), kidney stones and/or dysfunction 5.35% (83.3% significant aortic valve disease (moderate AR). cured – 48 years (30–69)), gallstones 0.4% (100% cured – 39 years (33–45)). Conclusions High proportions of various morbidities in CD rectify themselves after successful - In our cohort we found no evidence of new or worsening valvular lesions in treatment but significant morbidities also remain, particularly with regard to hyperprolactinaemic patients treated with cabergoline. In line with other similar hypertension, dyslipidaemia, osteopaenia/osteoporosis and are likely to have an studies, the risk of cardiac valvulopathy in hyperprolactinaemic patients treated impact on long-term mortality. Whether these morbidities are the result of previous with standard doses of cabergoline appears low. Although acromegaly is associated steroid exposure or of possible hypopituitarism remains to be clarified. with cardiac valvulopathy per se, it is noteworthy that these patients received higher doses and longer duration of treatment and both developed valvulopathy.

P237 Molecular and functional characterisation of an endocannabinoid P235 system in LbT2 gonadotrophs Cancer stem cells with a stabilising mutation in beta-catenin are Lorna Smith1, Elizabeth Davies1, Annalisa Gastaldello1, Iain Thompson1, implicated in the aetiology of human adamantinomatous Edward Perello1, Marta Korbonits2, Michelangelo Campanella1 craniopharyngioma & Robert Fowkes1 Cynthia Lilian Andoniadou1, Carles Gaston-Massuet1, Paul Le Tissier2, 1Royal Veterinary College, London, UK; 2Barts and the London School of Mehul Dattani1,3 & Juan Pedro Martinez-Barbera1 Medicine and Dentistry, London, UK. 1UCL Institute of Child Health, London, UK; 2MRC National Institute for Medical Research, London, UK; 3Great Ormond Street Hospital for Children, London, UK. Cannabinoids are known to exert effects throughout the endocrine system, including in the anterior pituitary. Whilst cannabinoid receptors (CB1 in particular) are expressed in numerous tissues, expression and function of an endocannabinoid Somatic stem cells of multiple tissues such as brain, blood, gut epithelium and system within specific anterior cell types has not been investigated. We have used epidermis, have specific roles in tissue homeostasis and plasticity of cell types. well-characterised gonadotroph (LbT2 and aT3-1) and somatolactotroph (GH3) There is evidence that, when mutated, such cells, termed cancer stem cells cell lines to establish the expression and functional role for cannabinoid signalling. (CSCs), also underlie tumorigenesis, but their presence in many tumours is Initial RT-PCR studies established that LbT2 cells expressed Cnr1, as well as the elusive. In the pituitary gland, somatic stem cells (PSCs) have been previously cannabinoid synthetic enzymes, Faah, Mgll and Napepld. aT3-1 and GH3 cells, identified and characterised in vitro and in vivo, but so far there is no evidence and primary mouse pituitary tissue only expressed some of these components. that PSCs may underlie the formation of pituitary tumours. We recently Having established that LbT2 cells expressed a complete endocannabinoid system, generated a genetic mouse model for adamantinomatous craniopharyngioma functional studies were undertaken. As the CB1 (Cnr1) receptor couples to Gai in (ACP) by conditionally expressing in the pituitary a stable form of beta-catenin many tissues, the potential inhibitory effect of CB1 signalling was determined in that cannot be degraded, leading to an activation of the Wnt pathway LbT2 cells. Following transient transfection with reporter genes expressing either (Hesx1Cre/C;Ctnnb1lox(ex3)/C). Unexpectedly, Wnt signalling activation occurs the human aGSU promoter, the murine Egr-1 promoter, or a Gal4CREB two- only in a subset of cells, despite all pituitary cells carrying the mutation. hybrid system, cells were stimulated with 0 or 10 mM Forskolin (FSK, adenylyl Phenotypic analyses reveal that these cells are quiescent in vivo,are cyclase activator), in the absence or presence of a range of concentrations of HU210 undifferentiated and express SOX2 but not SOX9, all of which are features of (a CB1 agonist). HU210 caused an inhibition of the aGSU and Gal4CREB the PSC population. Combining in vitro stem cell culture and time-lapse response to FSK, but failed to alter Egr-1 promoter activity. Similar studies in GH3 microscopy, we demonstrate that there is both an expansion of the PSC cells revealed dramatic inhibition in FSK-stimulated aGSU promoter activity in population and an increase in their proliferation rate in our mouse ACP model, the presence of HU210, suggesting that CB1 couples to Gai in both LbT2 and GH3 both of which may contribute to formation of the tumour. Moreover, through cells. As CB1 receptors can couple to numerous G-protein a-subunits, dynamic 2C flow-sorting isolate of the putative beta-catenin accumulating CSCs, we show confocal imaging of intracellular calcium concentrations ([Ca ]i) was performed, 2C that they have functional properties of PSCs and also reveal their unique genetic following Fluo4A/M loading. HU210 caused a rapid increase in [Ca ]i in LbT2 signature through microarray analysis. Finally, we show that human ACP also cells, suggesting potential coupling to Gaq/11. Collectively, these data reveal displays beta-catenin accumulating clusters in which the cells demonstrate gonadotrophs and somatolactotroph lineage cells to be putative targets of similar characteristics to PSCs, strongly suggesting that ACP shares a CSC (endo)cannabinoid signalling in the pituitary, which may reveal potential origin in both mouse and human. therapeutic benefits for fertility and growth disorders.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P238 She underwent successful transsphenoidal surgery with a day 4 cortisol of Assessment of the feasibility of early hospital discharge following trans- 67 nmol/l, and histology confirming a corticotroph adenoma. She was discharged sphenoidal pituitary surgery into a rehabilitation programme on hydrocortisone, and 6 months later her Sujata Biswas1, Thomas Barber1, Simon Cudlip2 & John Wass1 weakness was still present, although her weight and acne had improved. 1Department of Endocrinology, OCDEM, John Radcliffe Hospital, Oxford, This unusual case of cushing’s disease presenting concurrently with MND has not UK; 2Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK. previously been described in the literature. It highlights the importance of looking for other pathologies, and not making the assumption that all the clinical features are due to the cushing’s disease. Objectives Reducing length of inpatient stay following trans-sphenoidal pituitary adenectomy (TSA) could create significant financial saving for the NHS. We assessed early complication rates post-TSA to determine feasibility of early hospital discharge (3 days) post-TSA. P240 Methods We identified retrospectively 60 patients who underwent TSA at the John Cranial nerve palsy related to previous radiotherapy in a treated case Radcliffe Hospital. These consisted of patients with a pre-operative confirmed of acromegaly diagnosis of non-functioning adenoma (NFA, nZ20), Cushing’s disease (nZ20) Allison Martin & Gul Bano and acromegaly (nZ20). Data collected included age, gender, town of residence, St Georges Hospital, London, UK. length of stay, requirement for hydrocortisone and desmopressin at discharge, serum [Na] excursions and post-operative complications. Data are reported as A 56-year-old woman presented with an acute onset of left sided ptosis, diplopia mean (S.D.). For comparison between sub-groups, the ANOVA test was used. and failure of upward gaze almost 20 years after conventional pituitary irradiation Results for a growth hormone secreting tumour. Her visual fields were full. Visual acuities The NFA sub-group was older than other sub-groups (NFA, 60.9 years (14.3); were 6/9 in the right eye and 6/6 in the left eye. She had a complete left third nerve ! Cushing’s, 44.4 years (13.6); acromegaly, 43.7 years (13.4); P 0.0001). There palsy. She was growth hormone deficient and had primary hypothyroidism, were 30 male and 30 female patients, and 42 patients lived outside Oxfordshire. hypercholesterolemia and hypertension. These were well controlled on treatment. Average length of in-patient stay was significantly greater for the Cushing’s A MRI of the pituitary showed a haemorrhagic cyst. Her pituitary MRI had been sub-group compared to others (NFA, 6.0 days (5.6); Cushing’s, 12.4 days (11.9); stable for many years. acromegaly, 5.6 days (1.8); P 0.01). Discharge on hydrocortisone therapy was There are only two other reported cases of radiation induced acute third nerve Z Z Z Z required for NFA (n 15), Cushing’s (n 18) and acromegaly (n 8); P 0.002. palsy in the literature. This condition is rare but has lasting debilitating effects. Z Z Discharge on desmopressin was required for NFA (n 3), Cushing’s (n 6) and Conventional radiotherapy is a highly effective form of treatment for pituitary Z Z acromegaly (n 2); P NS. Serum [Na] excursions in the early post-operative tumours. It is recommended as second or third line treatment after subtotal period were equivalent between subgroups (NFA, 2.5 mmol/l (3.5); Cushing’s, resection of large aggressive tumours to prevent tumour regrowth; after near total Z 3.5 mmol/l (3.0); acromegaly, 3.5 mmol/l (3.9); P NS). Early post-operative resection of hormone secreting adenomas which demonstrate hormone activity complications (including CSF leak, epistaxis, chest infection and need for further postoperatively and also after a pituitary apoplectic event to reduce the risk of surgery) occurred significantly more frequently in the Cushing’s subgroup (NFA, recurrence. It is sometimes used as first line treatment in patients deemed unfit Z Z Z Z n 3; Cushing’s, n 11; acromegaly, n 3; P 0.01). for surgery. Conclusions Hypopituitarism is still the most common long term side effect of pituitary Our data clearly demonstrate that Cushing’s patients are significantly more likely irradiation with an incidence of 13–56%. If single doses of 2.0 Gy and total doses to develop early post-operative complications and require longer hospital stay of 50 Gy are not exceeded the risk of other complications is small: brain necrosis compared with acromegaly and NFA patients. Although our data do not support a 0.2%, deterioration in vision 1.7%, vascular changes 6%, neuropsychological policy of early discharge post-TSA in Cushing’s patients, they do support an disorders such as dementia 0.7% and secondary malignancies 0.8%. audited trial of early post-TSA discharge in patients with NFA and acromegaly.

P241 P239 Worsening of thyroid functions following surgical removal of a A debilitating case of cushing’s disease? combined GH/TSHoma Anjali Amin, Emma Hatfield & Karim Meeran Nisha Kaimal, Ahmed Elsadig, Donal Bradley, Kanna Gnanalingham Imperial College Healthcare NHS Trust, London, UK. & Tara Kearney Salford Royal hospital, Manchester, UK. A 48-year-old lady presented to neurology with a 2 year history of progressive leg weakness, rendering her wheelchair-bound. Neurological examination revealed A 51 year old lady presented with a 3 week history of persistent headache, a proximal myopathy. She had a 2 year history of diabetes, and an endocrine sweating, increase in shoe and ring size and prognathism. Imaging confirmed an opinion was sought to see if the clinical features could be related to diabetes. It 18!19 mm pituitary macroadenoma indenting the optic chiasma. Visual fields was then noted that she appeared Cushingoid, with a blood pressure of 158/92, were normal. central obesity, striae and facial acne. She had been amenorrhoeic for 2 years. Bloods: IGF1-181 nmol/l (11.3–30.9 nmol/l), prolactin 76 mU/l (102–496 mU/l), Endocrine investigations showed: midnight cortisol 345 nmol/l, LH 3.4 IU/l, FSH LH 22 U/l (2–13 U/l), FSH 46.6 U/l (4–13 U/l), TSH 0.63 mU/l (0.27–4.2 mU/l), ! 17.2 IU/l, oestradiol 70 pmol/l, prolactin 204 mU/l, IGF1 34.3 nmol/l, TSH FT4- 25.9 pmol/l (12–22 pmol/l). OGTT confirmed excess growth hormone 1.90 mU/l T4 18.3 pmol/l. She had 2 low-dose dexamethasone suppression tests, secretion. A diagnosis of acromegaly was made. She underwent transphenoidal which showed failure to suppress cortisol: resection and subsequent OGTT and growth hormone day curve showed satisfactory response. Histology showed a densely granulated somatotrophade- noma with FSH immunoreactivity and prolactin immunopositivity. Post- operative imaging showed a very small rim of residual pituitary tissue. Cortisol ACTH Cortisol ACTH However, IGF1 remained elevated. Post-operatively, her FT4 started to increase (nmol/l) (ng/l) (nmol/l) (ng/l) with a corresponding slower rise in TSH (normal alpha sub unit). She noticed TZ0 417 59.4 557 51.9 sweating and hair loss and carbimazole was commenced. TC48 h 108 101

TSH FT4 IGF1 MRI scan of the pituitary showed a bulky gland, asymmetry of the fossa and stalk deviation. She went on to have inferior petrosal sinus sampling, with a baseline 1.1 27 30.8 and stimulated ACTH to peripheral ratio consistent with a pituitary source 1.2 33.1 18.3 / Carbimazole commenced of ACTH. 2.9 20.4 43.8 A diagnosis of a proximal myopathy secondary to ACTH-dependent Cushing’s 4.5 21.1 30.9 disease was considered, however the severity of weakness led to further 6.4 16.1 28.9 investigation. Nerve conduction studies were performed, which supported a 18 15.3 33.7 diagnosis of possible motor neurone disease (MND).

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Carbimazole dose titration brought the FT4 levels to normal range but the TSH P244 continued to rise. This suggested the diagnosis of a combined GH/TSHoma. BAC recombineering to understand the role of the alternative promoter Repeat OGTT showed borderline failure of suppression of growth hormone but in the regulation of prolactin expression MRI was unchanged. Somatostatin analogues, SOM230, pituitary irradiation Raheela Awais1, Anne McNamara1,2, Claire Harper1, Anthony Adamson2, and thyroidectomy were discussed. A multi-disciplinary decision was made to Dave Spiller1, Sabrina Semprini3, John Mullins3, Julian Davis4 commence her on octreotide prior to definitive radiotherapy. & Michael R H White1,2 There are very few cases in literature of combined GH/TSHoma. This case 1Institute of Integrative Biology, University of Liverpool, Liverpool, UK; highlights the challenges in the diagnosis and management of this relatively rare 2Faculty of Life Sciences, University of Manchester, Michael Smith tumour. While growth hormone excess was the prominent clinical and Building, Manchester, UK; 3Queen’s Medical Research Institute, University biochemical feature pre-operatively, the thyroid axis abnormality was the of Edinburgh, Edinburgh, UK; 4Faculty of Medical and Human Sciences, predominant feature post-operatively, even before carbimazole was commenced. University of Manchester., Manchester, UK. This case also illustrates the significant increase in TSH in response to a small reduction in FT4 levels – a known characteristic of this tumour. Alternative promoters control many genes including prolactin (PRL), which in man is expressed at extra-pituitary sites controlled by an alternative promoter located 5.8 Kbp upstream of the pituitary transcription start site. Previous studies using short promoter fragments may be misleading, as the human hPRL genomic locus has many conserved far-upstream regions. To study the function of the alternative promoter, we engineered a bacterial artificial chromosome (BAC) P242 expressing Luciferase (Luc) under the control of a 163 Kb hPRL genomic Pitfalls in transphenoidal surgery: a 10 years experience fragment (1), deleting the entire 5 kbp pituitary promoter by BAC-recombineer- Kanchan Mukherjee, Virender Khosla, Suresh Mathuriya, Anil Bhansali, ing, leaving intact the upstream exon 1a and alternative promoter. The alternative Pinaki Dutta, Nilanjan Khandelwal, Paramjeet Singh, Rakesh Vasishta, splice acceptor site was reinserted after mutating three adjacent Pit-1 binding Bhisham Radotra, Ashis Pathak, Sunil Gupta, Manoj Tewari & sites. This alternative PRL promoter BAC- Luc reporter gene (AP-BAC-Luc) was Rajesh Chhabra used to generate stably-transfected rat pituitary GH3 and Jurkat lymphoblastoid Postgraduate Institute of Medical Education and Research, Chandigarh, cell lines, representing cellular models of pituitary and extra-pituitary sites of India. expression. Surprisingly, AP-BAC-Luc was active in both GH3 and Jurkat cell lines, with greater signal measured in pituitary cells. PRL-regulating stimuli, including Three hundred and thirty six cases of pituitary adenomas were operated by the FGF2, forskolin and PMA, induced an increase in AP-BAC-Luc expression in the transpenoidal route in the last 10 years by a single surgeon. Majority of these were GH3 recombinant stable clones (similar fold-activation to that seen from the giant non functioning adenomas. Prolactinomas were excluded unless a part of pituitary PRL promoter). Oestrogen and TNFa failed to induce AP-BAC-Luc dual adenoma. expression, in contrast to their strong induction of PRL pituitary promoter activity In nearly 80% of tumours, total or near total removal was achieved. Long term in GH3 cells. Real-time luminescence imaging of living cells showed dynamic outcome with follow up of more than 5 years revealed recurrence requiring patterns of expression, as seen with pituitary promoter constructs, indicating that resurgery in only 4 out of 102 patients. Endocrine recovery was seen in many with cyclical transcriptional function is shared by the alternative promoter. permanent added hormonal deficit in around 5% of cases. Added visual deficit These results provide new insights into how alternative promoters differentially or was seen in 1 patient. coordinately regulate PRL expression. Our data indicate that both promoters share Mortality was 14 patients and the avoidable reasons will be discussed.The activity within the same cell, and both display cyclical function. In this context, advantages and disadvantages of an aggressive approach in a developing country the AP-BAC-Luc generated in this study offers a powerful model approach to were the cost of hormonal supplementation is prohibitive will be highlighted. understand mechanisms responsible for differential activation of alternative promoters in alternative sites of gene expression.

P243 Pituitary apoplexy is a rare endocrine emergency, historically confused P245 with other acute medical conditions, which delayed the diagnosis, Evaluation of the interaction of phosphodiesterases 2A and 4A5 with however with advances in brain imaging, diagnosing this condition is the aryl hydrocarbon receptor interacting protein in pituitary cells much easier Carole Lennox, Giampaolo Trivellin & Marta Korbonits Acharya Jayashekara & Daniel Flanagan Barts and the London School of Medicine and Dentistry, London, UK. Derriford Hospital, Plymouth, UK. Background We describe seven patients with pituitary apoplexy diagnosed between July 2009 Aryl hydrocarbon receptor interacting protein (AIP) mutations have been and Oct 2010. identified in w15% of patients with familial isolated pituitary adenomas Presentation and Management (FIPA). In addition, dysregulation of the cyclic adenosine monophosphate Five patients presented with sudden onset headache, nausea and vomiting. One (cAMP) signalling pathway has been identified in both syndromic and sporadic developed headache while on carbegoline and other presented with fluctuating somatotropinomas. While crosstalk between these two systems is known to occur, level of consciousness. the exact mechanism of interaction remains elusive. The identification of direct All but two patients were inpatients at the hospital when diagnosed and all had binding between AIP and two cAMP-hydrolysing phosphodiesterases PDE2A MRI scan of pituitary to confirm the diagnosis and any mass effects. and PDE4A5 may provide a starting point to explore this relationship (1, 2). All but two patients had visual field assessment. These two patients had cognitive Aims and objectives impairment that made this test impossible. To investigate the presence of PDE2A and PDE4A4 in pituitary tumours. To Six patients had baseline pituitary function test. Four patients had insulin stress assess whether overexpression of AIP, PDE4A5 and PDE2A affects their binding test to assess dynamic pituitary function. partner’s expression. Two patients underwent trans-sphenoidal hypophysectomy due to the presence of Methods focal neurology (visual field defect and third cranial nerve palsy). Five patients Presence of PDE2A and PDE4A4 in pituitary tumour cDNA samples was were managed conservatively. evaluated by RT-PCR. Rodent pituitary somatomammotroph cell line (GH3) All seven patients were started on hydrocortisone after the diagnosis and two were were transiently transfected with wild type AIP, PDE2A, PDE4A5, mutant able to come off hydrocortisone after dynamic testing. PDE4A5 and empty vector. Expression of AIP, PDE2A and PDE4A5 was All seven patients are under the follow up of Endocrinologist. assessed by RT-PCR and western blot. Summary and Conclusion Results Our case series shows we are following the UK guidelines for the management of PDE2A and PDE4A4 was found to be present within pituitary adenomas. There Pituitary apoplexy. MRI scan is very sensitive in diagnosing pituitary apoplexy was no significant difference in PDE2A and PDE4A4 expression between tumour even when there is low clinical suspicion. subtypes and normal pituitary samples. There was no significant effect of AIP, PDE2A and PDE4A5 transfection on the cellular levels of their binding partners.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Discussion His GST showed flat cortisol response with peak of 293, confirming cortisol AIP binding partners are present in sporadic pituitary adenomas but there was no deficiency and GH peak was only ! 0.3 mU/l confirming GH deficiency. difference in PDE2A and PDE4A4 expression in pituitary adenomas types or His MRI pituitary showed Empty sella with no evidence of intra sellar mass normal pituitary. Increased levels of AIP, PDE2A and PDE4A5 did not alter the or Haemorrhage.visual fields were normal. expression of each other therefore different approaches are needed for the He was commenced on Hydrocortisone replacement follwed by Thyroxine and identification of possible tumorigenic mechanism involving these proteins. Testosterone replacement. His energy levels had improved and patient felt much better. Now he is under regular endocrine follow up. Hypopituitarism is a well recognised and rare complication of bacterial meningitis and only few cases have been reported in the literature. Endocrinologist should be aware of this potential complication of meningitis. P246 SIADH of cancer: rapid diagnostic evaluation using copeptin as a marker of AVP Kashinath Dixit1, Nils Morgenthaler2 & Georg Brabant1 P248 1 2 The Christie, Manchester, UK; BRAHMS, Henningsdorf, Germany. Thyroid function in patients with pituitary disease: difficulties of individualisation 1,2 1,2 1,2 1,2 With the advent of vaptans as a therapeutic option, rapid and precise diagnosis of Ahmed El-Laboudi , Julie Lynch , Paul Baxter , Julian Barth & Robert Murray1,2 SIADH is essential. SIADH due to paraneoplastic stimulation of AVP is an 1 2 expected but not the only cause of hyponatraemia in cancer patients. Therefore a Teaching Hospitals NHS Trust, Leeds, West yorkshire, UK; University of precise evaluation of the cause of hyponatraemia is necessary before any Leeds, Leeds, West Yorkshire, UK. therapeutic approach. Using Copeptin, a stable marker of AVP, which is stoichiometrically released with AVP, we evaluated 49 patients with hypona- Introduction tremia due to various forms of cancer. We followed classical diagnostic criteria Identification and treatment of central hypothyroidism in hypopituitarism is for the assement of hyponatraemia which included clinical evaluation of the fluid crucial particularly in patients with significant lethargy under consideration for status, measurement of serum cortisol, thyroid hormones, glucose, serum and GH replacement. Early Identification of TSH deficiency can be challenging urine osmolality and urinary sodium excretion. Only patients with hyponatremia particularly when both the TSH and fT4 lie within the normal range. ! of 130 mmol/l were selected for the study. Serum copeptin levels were Methods measured in addition to the above investigations with a specific immunoassay 26 362 TFTs derived from ambulatory community dwelling individuals (detection limit of 1.7 pmol/l). The maximal inter and intra-assay CV being 6.5% represented the control group. TFTs from 227 patients with a putative or for copeptin. established insult to the hypothalamo-pituitary axis were studied; 145 from Compared to a control group and to the physiological variation found in the patients with central hypothyroidism on levothyroxine replacement and 82 pattern of 24 h rhythm of copeptin obtained by sampling every 20 min in healthy samples from patients with hypopituitarism without a diagnosis of central subjects, 20 patients exceeded the maximal range of copeptin obtained in these hypothyroidism. healthy controls. The mean copeptin value of these patients (36 pmol/l) is more Results than twice the upper limit of normal of healthy subjects (14 pmol/l). Copeptin Median fT4 (5th and 95th percentiles) value for the control group was 14.3 levels in the remaining group of patients was not significantly different to the (10.9–19.5) pmol/l. Hypopituitary patients without a formal diagnosis of control group. secondary hypothyroidism showed median fT4 13.1 (9.5–16.5) pmol/l, Our data support the idea that measurement of serum copeptin levels may help to significantly lower than in the control group (P!0.001). Of these individuals rapidly categorize SIADH as the cause of hyponatremia in cancer patients as 11% showed fT4 levels below the 5th percentile of the control group. Graphically, compared to other causes of hyponatremia. These determinations may guide the a left shift of the fT4 distribution curve was observed in this subgroup. The degree decision for treatment with blockers of the AVP receptor. of hypopituitarism, defined by the number of pituitary hormone deficits, had no effect on the median fT4 level within this subgroup. In hypopituitary patients with a diagnosis of secondary hypothyroidism, and established on levothyroxine replacement, the median fT4 was 16.3 (11.1–23.7) pmol/l representing significantly higher values than observed in the control group (P!0.001). P247 Graphically, the distribution curve for these individuals showed a wider base and Hypopituitarism: is it due to bacterial meningitis? lower peak frequency. Daniel Kannappan, Sami Kenz, Selena Farook & Georg Brabant Conclusion Christie Hospital, Manchester, UK. These data suggest that a subtle decrease in fT4 is present in a relatively large proportion of patients who receive a putative insult to the hypothalamo–pituitary axis. In the majority of these individuals fT4 values remain well within the A 75-year-old man presented to Emergency department with fever and 3 episodes normative range. Furthermore, examination of fT4 values of patients on of tonic clonic seizures. He had recent ear infection. He was intubated and levothyroxine shows difficulties with placement of the fT4 and potential over- ventilated and taken to ICU. treatment in a number of individuals. He had CT head which was normal. Lumbar puncture results were consistent with Pneumococcal meningitis. He was treated with appropriate antibiotics. During recovery he had persistent hyponatremia. He was reviewed by Endocrine team and his TFT, cortisol and other pituitary hormones were normal. His repeat CT head was normal. Further investigations confirmed SIADH possibly P249 secondary to meningitis. Prospective assessment of pituitary function in patients with He presented to the GP 8 months later, with increasing tiredeness and lethargy. macroprolactinoma treated with cabergoline Investigations showed testostrone was 0.4 nmol/l, FSH 2 U/l and LH1 U/l. His Niki Karavitaki, Ruxandra Dobrescu & John Wass TSH was 1.92 mU/l with free T4 7.5 pmol/l. His cortisol was 120 nmol/l and Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology prolactin was 471 mU/l. and Metabolism, Churchill Hospital, Oxford, UK. He was reviewed in the Endocrine clinic and Basal pituitary function test and Glucagon stimulaton test were arranged. Background Patients with macroprolactinoma often present with pituitary hormone deficits associated with hyperprolactinaemia or mass effect. Restoration of normopro- lactinaemia and tumour shrinkage by dopamine agonist is expected to reverse, at TSH 1.66 mU/l (0.5–6 mU/l) least partially, the pituitary dysfunction. Studies assessing prospectively the FT4 6 pmol/l (9–25 pmol/l) pituitary function in subjects with macroprolactinoma treated with cabergoline Cortisol 230 nmol/l (280–700 nmol/l) are lacking. LH 1 U/l (3–8 U/l) Aim FSH 2 U/l (0.5–5 U/l) To check the time course of recovery of the anterior pituitary reserve in patients Testosterone 1.6 nmol/l (9–42 noml/l) with macroprolactinoma responding to cabergoline. Prolactin 392 mU/l (!450 mU/l) Patients/Methods IGF1 25 nmol/l (59–177 nmol/l) All patients presenting to our Department with macroprolactinoma between 10/2005-10/2007 were studied prospectively. The subjects underwent assessment

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK of their pituitary function at diagnosis and, if deficient, at yearly intervals. Serum compartments and it has recently been shown that two-pore channels (TPCs) prolactin was checked at regular intervals during the titration of the dose of comprise a family of NAADP receptors, with TPC1 expressed on endosomal cabergoline and 6 monthly after the achievement of normoprolactinaemia. membranes. Western blot analysis and RT-PCR have revealed TPC1 expression Pituitary imaging was performed 3 months after starting treatment and at yearly in anterior pituitary and double-labelling immunofluorescence labelling for intervals thereafter. prolactin PRL and TPC1 demonstrated colocalisation in lactotrophs. Here we test Results the hypothesis that PRL secretion in lactotrophs from TPC1 null mice would be Thirteen patients were identified, one of which was lost to follow-up (final group 11 impaired and excess storage of secretory granules would result. Anterior pituitary males and 1 female, median age at diagnosis 40.5 years (range 17–81), mean serum sections from male and female wild-type (WT) and TPC1 null mice (nZ4of prolactin at diagnosis 27.247 mU/l (range 17.168–305.847)). Amongst those each) were immunogold labelled for PRL and examined by quantitative electron with pituitary hormone deficits, mean follow-up was 2.9 yrs (range 2–3). Normal microscopy to determine lactotroph size, secretory granule characteristics and prolactin was achieved in 11 and tumour shrinkage in 11 subjects. Hormone deficits distribution. In male TPC1 null mice there was a significant (P!0.01 versus WT) at diagnosis and at last evaluation were GH (severe): 10/12 (83%) and 10/12 (83%), decrease in cell and cytoplasmic area, and a significant decrease (P!0.01) in FSH/LH: 10/10 (100%) and 6/10 (60%) (female on oral contraceptive pill and male granule density suggesting decreased synthesis and storage of PRL. Furthermore, on Leuprolelin Acetate excluded), ACTH: 2/12 (17%) and 2/12 (17%), TSH: 4/11 there was an increase in the percentage of secretory granules within a 300 nm (36%) (patient with primary hypothyroidism excluded) and 4/11 (36%). margin of the plasma membrane indicating that more granules were distributed Conclusions adjacent to sites of secretion (P!0.01). In female TPC1 null mice there was no In this first prospective study of pituitary function in treated macroprolactinoma significant difference measured in cell and cytoplasmic area, granule distribution subjects, apart from gonadotroph axis recovery (probably related to the treatment or size but a significant (P!0.05 versus WT) decrease in granule density. RIA of hyperprolactinaemia), we found no improvement of pituitary hormone deficits, demonstrated that pituitary PRL content was significantly decreased (P!0.05 even after tumour shrinkage. Therefore, relevant replacement therapy should be versus WT) in male and female TPC1 null mice. In conclusion, the data are commenced at the outset of dopamine agonist treatment. consistent with dysregulation of PRL control in the absence of TPC1 but leading to decreased PRL storage in lactotrophs.

P250 Delivery of anti-POMC siRNA using a novel polymer P252 Helen Prescott1, Alia Munir1, Irene Canton2, Giuseppe Battaglia3 An uncommon cause of panhypopituitarism & John Newell-Price1 Upendram Srinivas-Shankar1, Sumudu Bujawansa1, Niamh Leonard2, 1University of Sheffield, Sheffield, UK; 2Tissue Engineering, University of Peter Clark3, Isabel Syndikus3, Leigh Forsyth1 & Sian Hickey1 Sheffield, Sheffield, UK; 3Department of Biomedical Science, University of 1St Helens and Knowsley Teaching Hospital NHS Trust, St Helens, UK; Sheffield, Sheffield, UK. 2Royal Liverpool University Hospital NHS Trust, Liverpool, UK; 3Clatterbride Centre for Oncology NHS Trust, Clatterbridge, UK. Background Previously, we have demonstrated highly potent knockdown of POMC mRNA Introduction and significant reduction in secreted ACTH using siRNA, both in vitro and Langerhans’ Cell Histiocytosis (LCH) is a rare disease, more common in children in vivo. Highly efficient delivery of siRNA to a target tissue is of critical than in adults, resulting from aberrant proliferation of Langerhans’ cells, importance for any therapeutic approach. Here we assess the suitability of a belonging to the monocyte–macrophage system. pH-sensitive polymer, PMPC-PDPA polymersomes encapsulating siRNA, as a Case history novel delivery system as these have potential for tissue-directed delivery by We present the case report of a 40-year-old man with a 16-year history of co-complexing with appropriate antibodies, with intracellular release dependent polyuria, polydipsia and tiredness. For 10 years he had perianal, groin, abdomen on pH change after uptake. and scalp scarring, hyperpigementation along with follicles and pustules. Skin Methods biopsy confirmed LCH. Twenty-four hour urine volume excretion was over 4 l The lowest effective dose of siRNA targeting POMC was assessed in vitro in and water deprivation test confirmed diabetes insipidus (DI). He also had AtT20 cells using a commercial lipid delivery agent. PMPC-PDPA polymer- secondary adrenocortical insufficiency (short synacthen test: baseline and 30-min somes were devised and optimized used to encapsulate the siRNA and the cortisol, 92 and 263 nmol/l respectively) and hypogonadotrophic hypogonadism physical characteristics determined. Immunofluorescence was used to investigate (FSH, LH were 1.0 and 0.4 IU/l respectively; Total testosterone 3.9 nmol/l). IGF1 the presence of corticotrophin releasing hormone receptor 1 (CRHR1) on the was low (8 nmol/l; NR 12–47). Thyroid function tests and serum prolactin level surface of AtT20 cells. were normal. Magnetic resonance imaging (MRI) scan of the pituitary confirmed Results loss of high signal of the posterior pituitary on T1 enhancement and marked Suppression of POMC mRNA was demonstrated in a dose dependent manner. enhancement of the hypothalamus. Although lung function tests revealed A 1 nM concentration of siRNA achieved a 50% reduction in ACTH compared to restrictive pattern, High Resolution CT scan of the chest excluded pulmonary a negative siRNA control (P!0.001). Electron microscopy revealed PMPC- involvement. DEXA scan revealed osteopenia (lumbar spine and left femoral PDPA polymersomes encapsulating siRNA had a diameter of 100 nm, whilst neck, T score K2.1 and K1.9 respectively). He was treated with desmopressin, having a neutral surface charge – consistent with these particles having oral hydrocortisone and testosterone, with significant improvement of symptoms. characteristics suitable for in vivo delivery. Real time quantitative PCR Radiotherapy was considered but was deferred as subsequent MRI scan showed demonstrated the expression of CRHR1 mRNA in AtT20 cells and immuno- improvement of the hypothalamic lesion. fluorescence demonstrated the presence of CRHR1 on the surface of AtT20 cells. Conclusion Conclusion Hypothalmo-pituitary axis involvement occurs in up to 50% of patients with Polymersome-encapsulated siRNA targeting POMC have potential as a LCH; unexplained skin and mucosal lesions of the scalp and intertriginous areas therapeutic for Cushing’s disease, with corticotroph targeting possible by with polyuria should prompt clinicians to consider this condition. Although DI is antibody-particle complexes. the earliest and commonest pituitary manifestation (25%) of LCH, up to 20% may have anterior pituitary involvement; long-term follow up is needed to detect endocrine deficiencies.

P251 Structure and function of lactotrophs in the anterior pituitary of TPC1 null mice P253 Ayo Ajanaku, John Parrington, John Morris & Helen Christian Associations of overall GH and IGF1 exposure with ischaemic heart University of Oxford, Oxford, UK. disease and cardiomyopathy in patients with treated acromegaly Holly Clarke, Channa Jayasena, Alexander Comninos, Mandy Donaldson, Karim Meeran & Waljit Dhillo Calcium mobilization from intracellular stores represents an important cell Imperial College London, London, UK. signalling process that is regulated, in mammalian cells, by inositol-1,4,5- triphosphate (IP3), cyclic ADP ribose (cADPR) and nicotinic acid adenine dinucleotide phosphate (NAADP). Intracellular calcium is important for Background mobilization of secretory granules to the plasma membrane in preparation for Patients with acromegaly require lifetime monitoring due to the excess mortality exocytosis. NAADP mobilizes calcium from lysosome-related acidic and morbidity associated with untreated disease, and the propensity for disease

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK relapse following treatment. There is controversy whether GH or insulin-like P255 growth factor 1 (IGF1), better predicts the onset of cardiovascular complications Morphological analysis of lactotrophs in pregnant and lactating mice such as cardiomyopathy and ischaemic heart disease (IHD) in acromegalic Joe Lockey, John Morris & Helen Christian patients. University of Oxford, Oxford, UK. Aim To examine associations of overall GH and IGF1 exposure with IHD and cardiomyopathy, in patients with treated acromegaly. Recent studies have demonstrated that rather than being a collection of Methods heterogeneously dispersed cells, the pituitary gland is wired by multiple and Records of 116 patients with treated acromegaly attending a single Endocrine specific endocrine cell networks to synchronise hormone release. Prolactin (PRL) centre were examined retrospectively. GH and IGF1 burdens were calculated by is primarily important for lactation. In response to changing physiological multiplying the overall mean basal GH and mean IGF1 index during patient demands during pregnancy and lactation the pituitary has the ability to expand follow-up, by the number of years since diagnosis of acromegaly. IGF1 index was and contract its cell number. We have investigated changes in lactotroph defined as serum IGF1 divided by the upper limit of reference range. Mean GH morphology and cell-to-cell contacts in virgin, pregnant and lactating mice. and IGF1 burdens were compared between patients with and without Anterior pituitary sections from virgin, 1 week pregnant (1P), 3 week pregnant cardiomyopathy and IHD. (3P) and lactating mice (nZ4 per group) were immunogold labelled for PRL and Results examined by quantitative electron microscopy to determine lactotroph size, IHD was present in 11.2% of treated acromegalic patients. GH burden was secretory granule characteristics and rough endoplasmic reticulum (rER) density. significantly higher in patients with IHD when compared with patients without The identity of cell types contacting lactotrophs were also quantified. Lactotroph IHD (mean GH burden in years.mg/l: 94.6G32.8, IHD; 56.7G7.4, no IHD; number was increased in lactation but cytoplasmic area was not significantly PZ0.009). Mean IGF1 burden was not significantly different between patients different between groups. Secretory granule density was significantly (P!0.01) with and without IHD. Evidence of cardiomyopathy was recorded in 20% of increased in 1P mice but decreased in 3P (P!0.01) and the density of rER treated acromegalic patients. Mean IGF1 burden was significantly higher in was significantly greater in lactating and 1P and 3P groups compared to virgin patients with cardiomyopathy when compared with patients without cardiomyo- consistent with greater secretory activity. In virgin mice, lactotrophs made pathy (mean IGF1 burden in years: 23.5G4.4, cardiomyopathy; 16.2G1.6, no junctional contacts with all the major classes of pituitary endocrine cell types but cardiomyopathy; PZ0.011). Mean GH burden was not significantly different mostly with GH, PRL and folliculo-stellate cells, and only a few ACTH, LH and between patients with and without cardiomyopathy. TSH cells which probably reflects the relative proportion of the cell types in the Conclusion pituitary. In lactation there was a significant increase (P!0.01) in the number of These results suggest that both GH burden and IGF1 burden are useful markers of contacts made with other lactotrophs and a significant decrease (P!0.01) in cardiovascular morbidity in treated acromegalic patients. This study highlights contacts made with folliculo-stellate cells. Folliculo-stellate cells release a the importance of monitoring both serum GH and IGF1 in treated acromegalic number of factors inhibitory to PRL release, such as annexin 1, and these data patients. suggest that increased lactotroph connectivity coupled with a retraction of the folliculo-stellate cell network contributes to increased PRL secretion in lactation.

P256 P254 Hypertrophic pachymeningitis and pituitary pathology: lymphocyctic Overall GH exposure is raised in acromegalic patients with type 2 hypophysitis or cabergoline related fibrosis? diabetes and impaired glucose tolerance, when compared with Rajeev Raghavan1, Elizabeth Mallam2, Neil Scolding2,3 & Karin Bradley1,3 euglycaemic acromegalic patients 1Department of Endocrinology, University Hospitals Bristol NHS Holly Clarke, Channa Jayasena, Alexander Comninos, Mandy Donaldson, Foundation Trust, Bristol Royal Infirmary, Bristol, UK; 2Department of Karim Meeran & Waljit Dhillo Neurology, North Bristol NHS Trust, Frenchay Hospital, Bristol, UK; Imperial College London, London, UK. 3University of Bristol, Bristol, UK.

Background Case history A cardinal feature of acromegaly is insulin resistance. Patients with acromegaly A 51-year-old lady with a background of classical migraine and amenorrhoea are therefore predisposed to developing impaired glucose tolerance (IGT) and conceived successfully via IVF, without prior endocrine assessment. Symptoms type 2 diabetes mellitus (T2DM). It is therefore imperative to develop better during the third trimester of pregnancy led to the diagnosis of a pituitary mass biomarkers predicting the onset of IGT and T2DM in treated acromegalic lesion (see Table). Possible differential diagnoses, on subsequent endocrine patients. There is controversy whether GH or insulin-like growth factor 1 (IGF1) review, included macroprolactinoma, microprolactinoma with expansion during better predict the onset of IGT or T2DM in treated acromegalic patients. However pregnancy, or lymphocytic hypophysitis. the associations of overall GH and IGF1 exposure in patients with treated After 6 years of dopamine agonist therapy, the patient was then admitted with acromegaly have not been investigated previously. progressive generalised headaches and vomiting (similar to her symptoms during Aim pregnancy and different from her usual migraine). Neurological assessment, To compare overall GH and IGF1 exposure in treated acromegalic patients including a comprehensive autoimmune workup and gallium scan, were all classified according to the presence or absence of IGT and T2DM. unremarkable. CSF analysis was normal except for a mildly elevated protein. Methods Records of 116 patients with treated acromegaly attending a single endocrine centre were examined retrospectively. T2DM and IGF were diagnosed using a 75g oral glucose tolerance test. GH and IGF1 burdens were calculated by Prolactin multiplying the overall mean basal GH and mean IGF1 index during patient Time-line History (!700 mIU/l) MR imaging follow-up, by the number of years since diagnosis of acromegaly. IGF1 index was 1998 Secondary amenorrhoea – – defined as serum IGF1 divided by the upper limit of reference range. GH and 2002 Fertility clinic/IVF therapy – – IGF1 burdens were compared between euglycaemic patients, and patients with 2002 Pregnancy 36 weeks–significant – Macroadenoma headaches, small left temporal IGT or T2DM. field defect Results 2002 Rapid resolution of field defect –– IGT and T2DM were present in 28 and 27% of treated acromegalic patients, postpartum without intervention 2003 Persistent amenorrhoea 6 months 3818 Macroadenoma unchanged respectively. The mean GH burden was significantly lower in euglycaemic postpartum, Cabergoline patients when compared with patients with IGT or T2DM (mean GH burden in started mcg/L: 46.1G5.2, euglycaemic; 80.7G20.1, IGT, P!0.01 versus euglycaemic; 2004 Cabergoline 500 mg/week 36 Excellent involution of pituitary lesion 65.0G13.0, T2DM, P!0.05 versus euglycaemic). Mean IGF1 burdens were not 02/2008 Cabergoline reduced to 33 Pituitary appearance unchanged significantly different between patient groups. 250 mg/week Conclusion 08/2008 Disabling headaches 60 Pituitary appearance unchanged 01/2009 Pachymeningitis diagnosed. 41 Diffuse dura mater thickening. These results suggest a strong association between overall GH exposure and Cabergoline weaned and Pituitary appearance abnormal glucose tolerance in patients with treated acromegaly. GH burden may stopped 07/2009 unchanged therefore provide a useful prognostic marker in predicting the onset of IGT or 2009–2010 Headaches resolved within weeks 599–1990 Complete resolution of meningeal of Cabergoline withdrawal thickening. Pituitary T2DM in treated acromegalic patients. appearance unchanged

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A repeat MRI demonstrated new diffuse meningeal thickening. Hypertrophic Vertical diplopia on left lateral gaze and left upper arm paraesthesia persisted, pachymeningitis (patchy widespread inflammatory thickening of the dura mater) however, and 4 months later, following repeat normal baseline bloods and normal was diagnosed. CSF examination, a repeat MRI head demonstrated a 12!12 mm pituitary Conclusion adenoma that was unchanged but had been overlooked on initial MRI. We report the rare association of pituitary pathology, treated with an ergot- Endocrine review derived dopamine agonist, and hypertrophic pachymeningitis. Withdrawal of He was phenotypically normal with full visual fields. The only additional history the cabergoline (implicated in cardiac valvular fibrosis) coincided with rapid was of anger and mood disturbance. Baseline pituitary function revealed a TSH of resolution of the clinical and radiological features associated with pachyme- 4.5 mU/l with a FT4 of 28.5 pmol/l (10–24) and FT3 of 7.6 pmol/l (2.8–7.1). ningitis. Whilst this could be purely coincidental, a causal link cannot be Random PRL was 198 mIU/l (! 700), testosterone 20.6 nmol/l (10–35) and GH definitively excluded. 0.1 mg/l. Management Almost one year after his initial presentation and following 4 weeks of pre-operative preparation with carbimazole (15 mg/day), a transsphenoidal microadenomectomy for thyrotrophinoma was carried out. Post-operative FT4 and FT3 were 20.8 and 5.8 pmol/l respectively, with a TSH of 2.4 mIU/l. P257 Immunohistochemistry showed predominantly GH immunostaining, with weak, Thyroid function in patients with pituitary disease: difficulties of scattered TSH positivity. individualisation Discussion Ahmed El-Laboudi1, Julie Lynch1, Paul Baxter2, Julian Barth3 & The involvement of the left trochlear nerve is difficult to explain unless some Robert Murray1 degree of vascular shunting is adduced. The thyrotrophinoma did not encroach 1Department of Endocrinology, Leeds Teaching Hospitals NHS Trust, into the cavernous sinuses, however, and such a mechanism could certainly not Leeds, UK; 2Department of Statistics, University of Leeds, Leeds, UK; explain the left arm symptoms. This case is a reminder that pituitary pathology 3Department of Clinical Biochesmistry, Leeds Teaching Hospitals NHS which is generally straightforward to exclude, should be considered in the Trust, Leeds, UK. differential diagnoses of atypical headache, and that pituitary adenomas may cause very unusual neurological symptoms. Introduction Identification and treatment of central hypothyroidism in hypopituitarism is crucial particularly in patients with significant lethargy under consideration for GH replacement. Early Identification of TSH deficiency can be challenging particularly when both the TSH and fT4 lie within the normal range. Methods 26 362 TFTs derived from ambulatory community dwelling individuals represented the control group. TFTs from 227 patients with a putative or established insult to the hypothalamo-pituitary axis were studied; 145 from P259 patients with central hypothyroidism on levothyroxine replacement and 82 Wide range of eye abnormalities in patients with hypopituitarism; samples from patients with hypopituitarism without a diagnosis of central implications for diagnosis and treatment hypothyroidism. Kyriaki S Alatzoglou1, Daniel Kelberman1, Emanuella Spadoni2, Results Carles Gaston-Massuet1, Kathrine Woods1, Mohamad Maghnie3, 2 1 Median fT4 (5th and 95th percentiles) value for the control group was 14.3 Maria Bitner-Glindzicz & Mehul T Dattani (10.9–19.5) pmol/l. Hypopituitary patients without a formal diagnosis of 1Developmental Endocrinology Research Group, UCL Institute of Child 2 secondary hypothyroidism showed median fT4 13.1 (9.5–16.5) pmol/l, Health, London, UK; Clinical and Molecular Genetics Unit, UCL Institute significantly lower than in the control group (P!0.001). Of these individuals of Child Health, London, UK; 3Department of Paediatrics, University of 11% showed fT4 levels below the 5th percentile of the control group. Graphically, Pavia, Pavia, Italy. a left shift of the fT4 distribution curve was observed in this subgroup. The degree of hypopituitarism, defined by the number of pituitary hormone deficits, had no effect on the median fT level within this subgroup. In hypopituitary patients with Background and aim 4 The development of the pituitary gland is closely linked to this of the eyes and a diagnosis of secondary hypothyroidism, and established on levothyroxine forebrain, as they all originate from the same embryonic origin, the anterior neural replacement, the median fT4 was 16.3 (11.1–23.7) pmol/l representing significantly higher values than observed in the control group (P!0.001). ridge. The constellation of symptoms leading to septo-optic dysplasia (SOD) is well established; other ophthalmic signs may be under-reported. The aim of the Graphically, the distribution curve for these individuals showed a wider base and lower peak frequency. study was to define if patients with hypopituitarism present with eye abnormalities, which are distinct from SOD, and if this association could help Conclusion the genetic diagnosis of the condition. These data suggest that a subtle decrease in fT4 is present in a relatively large proportion of patients who receive a putative insult to the hypothalamo-pituitary Methods We studied case records of patients referred over the last 10 years from national axis. In the majority of these individuals fT4 values remain well within the normative range. Furthermore, examination of fT values of patients on and international centres. 4 Results levothyroxine shows difficulties with placement of the fT4 and potential over- treatment in a number of individuals. We identified 96 patients with hypopituitarism (male:female 1.2:1), who had eye abnormalities that were distinct from SOD. Hypopituitarism was familial in 14.5% (nZ14) and in 5.2%, patients were of consanguineous pedigrees. The spectrum of eye abnormalities included: colobomas not associated with CHARGE syndrome (nZ11, 1.5%), pigmented disorders of the retina (nZ4, 4.2%), retinal dysplasia (nZ13, 13.5%), congenital cataracts, (nZ3, 3.5%), P258 amaurosis (nZ3, 3.5%), anophthalmia or microphthalmia (nZ32, 33.3%). Other An unusual presentation of thyrotroph adenoma eye abnormalities (nZ30, 31.2%), ranged from glaucoma to blepharophimosis, Rajeev Raghavan1, Puneet Plaha2, Richard Nelson2, Stafford Lightman1,3 staphylomas and atypical appearance of the optic discs. In four cases with retinal & Andrew Levy1,3 pigment defects or retinal dysplasia there was a single pituitary hormone 1Department of Endocrinology, Bristol Royal Infirmary, University deficiency, isolated GHD (nZ2) or ACTHD (nZ2). In all other cases, retinal Hospitals Bristol NHS Foundation Trust, Bristol, UK; 2Department of abnormalities were associated with multiple pituitary hormone deficiencies. Neurosurgery, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK; SOX2 mutations were identified in 40% (13/32) of patients with anophthalmia or 3Henry Wellcome Laboratory for Integrative Neuroscience and microphthalmia and they all had gonadotrophin deficiency; we identified a novel Endocrinology, University of Bristol, Bristol, UK. OTX2 mutation (p.E79X) in one a patient. We found no mutations in HESX1, GH1, SIX3, PAX6 or SOX3 in this cohort. Conclusions Background and case Patients with hypopituitarism may present with variable eye abnormalities. A 38-year-old man presented acutely with left-sided retro-orbital pain, a Monitoring for pituitary hormone deficiencies is recommended in children with heavy/numb sensation in his left arm and blurred vision and diplopia on left congenital eye abnormalities. The study of the association of eye and pituitary lateral gaze. Baseline biochemistry, liver function and haematology were normal. abnormalities may help to identify novel genes implicated in pituitary His TSH was 3.9 (0.3–4 mU/l) and CRP 92 mg/l (!10). Plain CT head was development. unremarkable as was the MRI as reported, and atypical migraine was suspected.

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P260 145/92, cushingoid plethoric rounded face and mild proximal muscular weakness. His initial investigations revealed high serum cortisol of 931 and low K 3.4. Further investigations revealed very high urinary free cortisol excretion 2454 and high urinary cortisol 944. Cortisol failed to suppress on both low dose and high dose dexamethasone tests 835 and 621 respectively. MRI pituitary with contrast (dynamic) shows a small area of non-enhancement at the base of pituitary stalk. Abstract withdrawn. The pituitary fossa itself was normal. IPSS failed to show a definite gradient and was equivocal (19 on the left, 22 on the right, 17 peripherally), and after CRH administrated there was no discernable rise. CT chest and abdomen revealed no ectopic source of ACTH. His Octreotide scan was also normal with no evidence of abnormal uptake. P261 He became more symptomatic especially with regards to his proximal myopathy. He was then started on metyrapone. However, he was not able to tolerate Lymphocytic hypophysitis–extrapancreatic manifestation of metyrapone and it was stopped. Pituitary surgery was not considered as his MRI autoimmune pancreatitis findings were not entirely convincing. Damodharan Suresh & Gerard Conway Discussion UCLH, London, UK. Difficulties encountering in the investigations of his Cushing’s syndrome. Would we consider alternative medical therapy? And if after exhaustive investigation, Background we failed to find a source of the ACTH, then bilateral adrenalectomy could be Auto-immune pancreatitis (AIP) is a rare chronic inflammatory disease, considered! characterised by raised serum levels of IgG4, which may mimic pancreaticobili- ary malignancy, and is noted to have an IgG4-positive plasma cell infiltrate on pancreatic histology. Extrahepatic manifestations in liver, kidneys, and retro- peritoneum, are increasingly recognised. We present a case of extrapancreatic manifestation of AIP in the pituitary gland Reproduction causing lymphocytic hypophysitis leading to panhypopituitarism. Case history P263 A 67-year-old man presented with obstructive jaundice. A diagnosis of AIP/IgG4- Endocrine disruptors and their association with male reproductive associated cholangitis was made based on imaging, serology and biopsy. Oral disorders and testicular dysgenesis syndrome: establishing a steroids and azathioprine led to resolution of jaundice and normalisation of liver xenografting model of human fetal testis development 1,3 1 2 function tests. Steroids were weaned and stopped over 6 months with maintenance Rod Mitchell , Philippa Saunders , Andrew Childs , Claire 3 3 2 azathioprine. He presented again with weakness and malaise. Examination Cassidy-Kojima , Richard Anderson , Hamish Wallace , 2 1 revealed heart rate 80 bpm, blood pressure 80/40 mmHg, but no other signs Chris Kelnar & Richard Sharpe 1 2 of note. MRC Human Reproductive Sciences Unit, Edinburgh, UK; Edinburgh Royal Hospital for Sick Children, Edinburgh, UK; 3Edinburgh University, Edinburgh, UK. Table 1 Results and clinical impression of adrenal insufficiency. Testicular dysgenesis syndrome (TDS) is a group of associated conditions Investigations Results Normal range Impression (testicular germ cell tumours (TGCT), cryptorchidism, hypospadias and low sperm counts) that are thought to have a common origin in fetal life. Exposure of fetal rats Random cortisol !20 mol/l !140 nmol/l Adrenal insufficiency (assumed secondary to prolonged steroid use) to environmental chemicals such as the endocrine disrupting chemical di(n-butyl) phthalate (DBP) results in a TDS-like syndrome. However, exposed rats do not develop TGCT and the rodent is a poor model in this context. The effects of Table 2 Further endocrine profile. phthalates on human fetal testis development and function are difficult to study in the short-term in vitro. Development of a model system in which to investigate Investigations Results Normal range Diagnosis normal human fetal testis development and the mechanisms underpinning the fetal origin of TDS/TGCT cells would represent a major advance. TSH 0.7 mIU/l 0.27–4.2 mIU/l Panhypopitutiarism We have, therefore, xenografted human fetal testis tissue from first and second T4 7.2 pmol/l 12–22 pmol/l LH !0.1 IU/l 1.7–8.6 IU/l trimester fetuses into nude mice hosts for 6 weeks and demonstrated normal FSH 0.8 IU/l 1.5–12.4 IU/l development of tissue (including normal seminiferous cord formation) in Testosterone !0.1 nmol/l 9.9–27.8 nmol/l comparison to age-matched controls. Xenografts continue to grow, and the Serum osmolality 300 mOsmol/kg 285–295 mOsmol/kg component cells proliferate and functionally differentiate normally. Xenografts are Urine osmolality 263 mOsmol/kg 300–900 mOsmol/kg able to produce basal levels of testosterone that can be increased by injection of host mice with hCG. Exposure of xenografts to DBP for 24–96 h by daily oral Gadolinium-enhanced MRI showed significant enlargement and infiltration of the gavage results in germ cell aggregation and formation of multinucleated pituitary stalk, consistent with inflammation. Hormone replacement led to gonocytes, whereas GC aggregation was not demonstrated in vehicle treated resolution of symptoms. Prednisolone 30 mg was re commenced with complete controls and MNG were found infrequently. resolution of the pituitary infiltrate on repeat gadolinium MRI 6 weeks later. He These results have validated an exciting and novel way in which to investigate the remained clinically well. mechanisms of human fetal testis development in health and disease. Importantly, Autoimmune pancreatitis is now recognised as a disease which can occur this model may also be applied to study the effects of other environmental factors globally.Extra-pancreatic disease is increasingly recognised as a common feature, on human testis development. Results of such studies will help to determine the and there have been two other case reports of lymphocytic hypophysitis in AIP. risk posed to human health by exposure to these chemicals during a critical time in Early recognition of this is important in rational management of these patients. gonadal development.

P262 P264 Elusive ectopic ACTH source Sami Kenz, S McGlynn, Daniel Kannappan & Tara Kearney Distinct expression pattern of Dicer1 correlates with ovarian-derived Salford Royal Foundation NHS Trust, Manchester, UK. steroid hormone receptors in human Fallopian tubes during the ovulatory process and in the mid-secretory phase. Ruijin Shao & Ha˚kan Billig Introduction Institute of Neuroscience and Physiology, The Sahlgrenska Academy at The ectopic ACTH syndrome accounts for 12% of patients with Cushing’s University of Gothenburg, Go¨teborg, Sweden. syndrome. Its diagnosis and treatment remains a challenge. This especially true in patients with ectopic ACTH production. Case Context We report the case of a 41-year-old man who presented with progressive muscle Tissue-specific dicer1 knockout female mice display severe and irreversible weakness in his arms and legs. He was found to be borderline hypertensive BP damage to the Fallopian tubes that eventually leads to disruption of tubal transport

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK of the gametes and the early embryo. The impact of Dicer1 on the function of metformin maintained the reduction of androstenedione and DHEAS levels with human Fallopian tubes remains to be clarified. atorvastatin compared to baseline. There were no changes in either DHEAS or Objective androstenedione concentrations in the initial placebo group after 12 weeks of To determine how the expression of tubal Dicer1 is regulated in women during the metformin. ovulatory process and in the mid-secretory phase. Furthermore, the association Conclusions between tubal Dicer1 expression and alterations in estrogen receptor (ER) Twelve weeks of atorvastatin significantly reduced both DHEAS and subtype and progesterone receptor (PR) isoform expression was investigated. androstenedione contributing to the total reduction of androgen levels and Research design and methods indicating that the reduction of the hyperandrogenaemia is due to the action of The three phases of the ovulatory process was defined as followed: (1) the early atorvastatin at both the ovary and the adrenal gland in PCOS. ovulatory phase (nZ4); (2) the late ovulatory phase (nZ4); and (3) the post- ovulatory phase (nZ5). The mid-secretory phase (nZ4) was determined by the last menstrual period and endometrial histology. Serum was obtained immediately before surgery to confirm the ovulatory and mid-secretory phase categories. Localization and regulation of Dicer1, ER subtypes, and PR isoforms were determined by immunofluorescence, confocal microscopy and quantitative RT-PCR. Correlations were evaluated by bivariate Pearson’s correlation coefficients. Results Dicer1 protein expression was most abundant in epithelial cells of the Fallopian P266 tubes. The expression levels of Dicer1 mRNA and protein were significantly higher in the late ovulatory phase than in other phases. Moreover, no significant relationship between stages in ER subtype and PR isoform mRNA levels was found during the ovulatory process; however, expression levels of ERb1 and b ER 2 mRNA and protein were significantly lower in all phases of the ovulatory Abstract withdrawn. process compared to the mid-secretory phase. The opposite pattern was seen in the expression levels of PRA/B and PRB mRNA and protein. Dicer1 mRNA expression was positively correlated with expression of ERa mRNA in the late ovulatory phase and negatively correlated with expression of ERb2 mRNA in the mid-secretory phase, as well as PRB mRNA in the early ovulatory phase. Conclusion This is the first study to identify the cell-specific upregulation of Dicer1 expression in human Fallopian tubes during the ovulatory process. While the regulation of steroid hormone receptors is well established, stage-dependent expression of Dicer1 and its correlation to ERa,ERb2 and PRB mRNA suggest P267 that tubal Dicer1 may participate in the regulation of tubal steroid hormone Placental iodothyronine deiodinase activity across the placental bed in receptor expression in a cycle-dependent manner and may be an important normotensive (NT) and pre-eclamptic (PE) pregnancies. contributor to the tubal transport process in humans. Lesia Kurlak1, Hiten Mistry2, Ellen Kaptein3, Theo Visser3 Key words: Dicer, microRNA, steroid hormone receptor, Fallopian tube, human & Fiona Broughton Pipkin1 1Department of Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK; 2Division of Women’s Health, King’s College London, London, UK; 3Department of Internal Medicine III, Erasmus University Medical School, Rotterdam, The Netherlands.

Background PE affects w2% of pregnancies and is associated with generalised endothelial cell P265 dysfunction. Antioxidant selenoproteins may limit such effects. Serum selenium is lower in mothers and babies affected by PE and associated with lower activity of the The effect of atorvastatin on adrenal and ovarian hyperandrogenemia selenoprotein glutathione peroxidases. Other selenoproteins, the iodothyronine in patients with polycystic ovary syndrome. 1 2 3 deiodinases (IDs; D2 and D3) regulate fetal thyroid hormone synthesis. The IDs Thozhukat Sathyapalan , Karen A Smith , Anne-Marie Coady , utilise selenium preferentially; we have reported similar triiodothyronine (T )and Eric S Kilpatrick2 & Stephen L Atkin1 3 1 thyroxine (T4) in both maternal and umbilical serum from NT and PE pregnancies. Department of Academic Endocrinology Diabetes and Metabolism, Hull We hypothesised that ID enzyme activities would be conserved in PE placentae. York Medical School, Hull, UK; 2Department of Clinical Biochemistry, 3 Design Hull Royal Infirmary, Hull, UK; Department of Obstetric Ultrasound, Hull Hospital based cross-sectional study with full ethics approval. Placental biopsies and East Yorkshire Women’s and Children’s Hospital, Hull, UK. were obtained at delivery from 3 sites; 1 cm from cord insertion (near), midway between insertion and edge (middle) and 1 cm from the edge (outer) from 27 NT Context and 21 PE European women. Homogenate D2 and D3 activities were determined Hyperandrogenemia in polycystic ovary syndrome (PCOS) represents a by HPLC analysis following formation of the radioactive T4 and T3 respectively. composite of raised serum concentrations of testosterone, androstenedione, Protein localisation was confirmed by immunohistochemistry. dehydroepiandrosterone (DHEA), and DHEA sulfate (DHEAS). In patients with Results PCOS, testosterone and androstenedione are primarily derived from the ovaries D3 enzyme activity was identified in all placentae; immunoreactivity was and DHEAS is a metabolite predominantly from the adrenals. It has been shown confirmed in the syncytiotrophoblasts. Friedman – Repeated Measures demon- Z that atorvastatin reduces testosterone levels in patients with PCOS. strated a significant (P 0.034) gradient in placental D3 activity (Table 1) in NT Objective but not PE; activity in individual sampling sites did not differ between NT and PE. This randomized double blind placebo controlled study was conducted to study Neither D2 protein expression nor activity were detected. the effects of atorvastatin on serum androstenedione and DHEAS concentrations in patients with PCOS. Intervention Forty medication naı¨ve patients with PCOS were randomized to either Table 1. atorvastatin 20 mg daily or placebo for 3 months. Subsequently, a 3 month extension study for all patients was undertaken with metformin 1500 mg daily. The main outcome measures were the changes in androstenedione and DHEAS D3 activity (fmol/min per mg protein) concentrations. median (interquartiles) Results Site Normotensive PE The mean (S.D.) baseline androstenedione (5.6 (0.9) vs 5.5(1.3) nmol/l; PZ0.58) and DHEAS (7.1 (1.0) vs 7.2 (1.2) mmol/l; PZ0.72) levels were comparable Near 7.6 (4.3, 12.5) 5.2 (3.0, 11.8) between two groups. There was a significant reduction of androstenedione (5.6 Middle 4.9 (3.3, 8.3) 4.3 (3.1, 8.8) (0.9) vs 4.7 (0.7) nmol/l; PZ0.03) and DHEAS (7.1 (1.0) vs 6.0 (0.9) mmol/l; Outer 4.8 (3.2, 7.5) 5.3 (2.9, 10.3) PZ0.02) with atorvastatin compared to placebo. Three months treatment with

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Conclusions P269 These data show no effect of PE at delivery on placental D3 activity which Kisspeptin-54 injection stimulates activity of the human GnRH pulse corroborates our earlier data showing comparable mRNA expression and similar generator in healthy women (T3)and(T4) in NT and PE samples. The difference in activity across the placental Channa N Jayasena1, Alexander N Comninos1, Shivani Misra1, Abbara Ali1, bed only in NT pregnancy suggests a possible blunting in enzyme regulation in PE Tavare Aniket1, Mandy Donaldson2, Mohammad A Ghatei1, which may relate to the lower tissue oxygenation at the periphery of the placenta. Stephen R Bloom1 & Waljit S Dhillo1 Acknowledgment 1Section of Investigative Medicine, Imperial College London, LOK was generously funded by an Early Career Grant and HDM by a Lab Visit Hammersmith Hospital, London, UK; 2Department of Clinical Grant from the Society for Endocrinology. Biochemistry, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, UK.

Background Kisspeptin is a novel hypothalamic hormone with powerful stimulatory effects on the hypothalamo-pituitary–gonadal (HPG) axis. Inactivating mutations in the kisspeptin receptor lead to pubertal failure. We have previously demonstrated that injection of kisspeptin-54 stimulates LH release in healthy men and women. Recent studies in animals suggest that endogenous kisspeptin may be involved in stimulating the GnRH pulse generator. Determining whether exogenous administration of kisspeptin can stimulate the human GnRH pulse generator, has important therapeutic implications. Aim To determine if kisspeptin-54 administration can stimulate the GnRH pulse generator in healthy female volunteers. P268 Methods Six healthy female volunteers underwent frequent blood sampling for serum LH In support of the ‘Rotterdam’ PCOS criteria: Identical LH responses to measurement every 10 min for 8 h (as a surrogate marker of the GnRH pulse GnRH stimulation in women with oligo-/amenorrhoea and polycystic generator) during the follicular phase of menstrual cycle. A s.c. injection of saline ovaries regardless of androgen status or kisspeptin-54 (0.3–0.6 nmol/kg) was administered 4 h after commencing the Krzysztof Lewandowski1,2, Agata Cajdler-Luba2, Malgorzata Bienkiewicz3 1,2 study. LH pulsatility within each subject was compared between the 4 h pre- & Andrzej Lewinski injection and 4 h post-injection. 1Department of Endocrinology and Metabolic Diseases, Medical University 2 Results of Lodz, Lodz, Poland; Department of Endocrinology and Metabolic No significant differences in number of LH pulses and LH pulse amplitude were Diseases, Polish Mother, Memorial Research Institute, Lodz, Poland; 3 observed before and after saline injection. A 6-fold increase in mean number of Department of Quality Control and Radiological Protection, Medical LH pulses was observed following kisspeptin-54 injection when compared University of Lodz, Lodz, Poland. the pre-injection period (mean number of LH pulses during 4 h: 0.50G0.48, pre-injection; 3.00G0.69, post-injection, P!0.05 versus pre-injection). The LH Objective pulse amplitude was nearly 2-fold higher after kisspeptin-54 injection when There is no universal consensus as to the criteria of PCOS (i.e. Rotterdam compared with the pre-injection period (mean pulse amplitude in IU/l during 4 h: ESHRE/ASRM versus Androgen Excess Society (AES) criteria). Furthermore, 1.31G0.09, pre-injection; 2.31G0.25, post-injection, P!0.05 versus androgen measurements within the female range are fraught with several pre-injection). methodological problems. As GnRH stimulation can reveal a relative LH excess, Conclusions caused by an increased frequency of hypothalamic GnRH pulses, then we have We have demonstrated for the first time that kisspeptin-54 stimulates activity of endeavoured to assess gonadotrophin response to GnRH in women with PCOS the GnRH pulse generator in humans. A single injection of kisspeptin-54 injection and healthy controls. increases LH pulse frequency and LH pulse amplitude in healthy women. This Design, patients and methods data has important therapeutic implications for the future development of The study involved 155 subjects: PCOS (‘Rotterdam’ criteria), nZ121, age kisspeptin to treat patients with disorders of reproduction. 2 (meanGS.D.) 24.8G5.4 years, BMI 24.5G6.0 kg/m , all with oligo-/amenor- rhoea and polycystic ovarian morphology, and 34 regularly menstruating controls, matched for age and BMI, with normal ovarian morphology. Total testosterone, androstendione, DHEAS, 17OH-progesterone and prolactin were measured in early follicular phase. LH and FSH were measured before and at 30 and 60 min after GnRH stimulation (100 mg i.v.). Insulin resistance was assessed by HOMA and Insulin Resistance Index derived from glucose and insulin during 75g OGTT. P270 Results Expression and functional activity of thyroid hormone transporters in As expected women with PCOS had higher androgens and were more insulin microvillous plasma membranes from human term placental resistant. Fifty-four (41.9%) women with PCOS had, however, all androgens syncytiotrophoblasts within the reference range, and thus would fulfil the ‘Rotterdam’, but not the AES Laurence Loubiere, Elisavet Vasilopoulou, Jayne Franklyn, Mark Kilby & criteria for diagnosis of PCOS. Baseline and GnRH-stimulated LH concentrations Shiao Chan were higher in PCOS (9.09G5.56 vs 4.83G1.71 IU/l, 35.48G31.4 vs 16.30 University of Birmingham, Birmingham, West Midland, UK. G6.68 IU/l, 33.86G31.8 vs 13.45G5.2 IU/l, at 0, 30 and 60 min. post GnRH, respectively, P!0.0001). An LH/FSH ratio in PCOS group increased further after GnRH stimulation (P!0.01). ROC analysis revealed that LH30min/FSH30minO Background 2.11 or LH60min/FSH60minO1.72 had 78.3 and 87.5% sensitivity and 81.7 and Thyroid hormones (TH) are vital for fetal and placental development. TH 81.3% specificity for the diagnosis of PCOS. In contrast, both baseline and transporters including monocarboxylate transporters 8 and 10 (MCT8, MCT10), GnRH-stimulated LH and FSH concentrations were no different in women with organic anion transporters (OATP1A2, OATP4A1) and system-L amino acid PCOS and raised androgens versus those with androgens within the reference transporters (LAT1, LAT2) are expressed in human placenta from 6 weeks of range (PZ0.71 and PZ0.20 for LH and FSH, respectively). Both these groups, gestation. All of these TH transporters have been localized to the human however, had higher LH levels and higher baseline and GnRH-stimulated syncytiotrophoblast layer of placental villi, which is in direct contact with LH/FSH ratio than controls (P!0.001). maternal blood. Thyroxine (T4) is postulated to be the major TH transported from Conclusions the maternal circulation to fetal circulation. This study aims to determine the Regardless of their androgen status, women with polycystic ovarian morphology contribution of each TH transporter to T4 uptake at the apical membrane of and oligo-/amenorrhoea have higher baseline and GnRH-stimulated LH syncytiotrophoblasts. concentrations and higher GnRH-stimulated LH/FSH ratio in comparison to Methods and results healthy controls. This suggests the existence of similar underlying mechanism ‘Maternal-facing’ syncytiotrophoblast microvillous plasma membranes (MVM) C accounting for menstrual irregularities. In our opinion these observations support were isolated from normal human term placentae by Mg2 precipitation and clinical validity of diagnostic criteria for PCOS based on the Rotterdam differential centrifugation. MCT10, MCT8, OATP1A2, OATP4A1 and LAT1 125 consensus. protein were detected in MVM using western-blot. [ I]T4 uptake by MVM vesicles was linear over the first 2 min and reached equilibrium after 20 min.

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C 125 T4 uptake was Na -independent. Excess T4 reduced [ I]T4 uptake by 22% (32% energy from fat) for 4 weeks and body weight monitored daily to determine 125 (nZ5, P!0.05). T3 did not affect [ I]T4 uptake whereas TRIAC significantly whether age of pubertal onset predicted susceptibility to diet-induced obesity. 125 reduced [ I]T4 uptake by 19% (nZ3, P!0.01). Competitive inhibitors of TH Following 28 days of post-pubertal high-fat feeding, females who had undergone transport by MCT10, LATs and OATPs, such as tryptophan, leucine, probenecid early vaginal opening remained significantly more sensitive to the anorexigenic 125 and bromosulphtalein, alone, did not affect [ I]T4 uptake significantly. effects of exogenous leptin than those which had undergone late vaginal opening. 125 However, combinations of these inhibitors could significantly affect [ I]T4 There was no significant difference detected in leptin sensitivity between rats uptake. The strongest inhibition of T4 uptake was achieved with desipramine, a which underwent early vaginal opening and those that underwent late vaginal non-competitive inhibitor of TH transport mediated by MCT8, MCT10 and LAT1 opening in either the pre-pubertal or peri-pubertal period. There was no (31%, nZ4, P!0.05). significant difference in overall body weight or food intake between the early Conclusion and late groups at the end of the study. In human term placenta, TH transporters are ubiquitously present in These data suggest that early vaginal opening may be associated with improved syncytiotrophoblast MVM, which can regulate placental TH entry and leptin sensitivity in later life, but that vaginal opening age does not predict acute transplacental TH transfer from the mother to the fetus. Our data suggest that leptin sensitivity in the pre-pubertal or post-pubertal period. maternal T4 uptake by syncytiotrophoblasts is not mediated by a single predominant TH transporter but rather by a combination of these proteins.

P273 P271 A case of severe refractory hypercalcaemia in pregnancy caused by Increased epididymal Rnase9 expression in Rnase10 (K/K) mice 1 1 2 3 hypersecretion of parathyroid hormone related peptide (PTHrP) by the Victoria Sharp , Anton Krutskikh , Jean-Louis Dacheux , Matti Poutanen placenta. & Ilpo Huhtaniemi1,3 1 2 Allison Martin & Mark Spring Imperial College London, London, UK; UMRINRA-CNRS6175, Kingston Hospital, Surrey, UK. Nouzilly, France; 3University of Turku, Turku, Finland.

A 39-year-old woman presented at 23 weeks gestation with extreme fatigue and Spermatozoa are dependent on the proximal epididymis environment to complete non-specific neurological symptoms. Other than mild hypertension her physical their maturation. However, no single specific factor crucial for this process has examination was normal. Serum calcium was 3.36 mmol/l (normal 2.12–2.62) been identified. Rnase9 and Rnase10 are expressed specifically in the murine and phosphate 0.8 mmol/l (Normal 0.8–1.5). She was severely hypercalcemic proximal epididymis. Located on chromosome 14C1 only 28 kb apart, they do not throughout pregnancy and her corrected calcium ranged between 2.82 and show high homology with each other. An orthologue of both genes exist in the rat 3.48 mmol/l. Other investigations included 25 hydroxy-Vitamin D3 98 (normal and human, and ‘Train A’ (porcine orthologue) is the most abundant (80–90%) 75–200), undetectable PTH !1.2 pmol/l (normal 1.6–6.9) confirmed by two secretory protein in the initial segment (IS). Testosterone replacement laboratories, 1,25 dihydoxy-Vitamin D 209 pmol/l (normal value for pregnancy) experiments revealed that Rnase9 expression is under direct/indirect regulation and an inappropriately normal PTH related peptide level of 1.3 pmol/l (normal by androgens and Rnase10 expression is regulated by testicular factors other than range 0.7–1.8 pmol/l). The serum angiotensin-converting enzyme and serum androgen. We recently observed that spermatozoa from Rnase10 KO mice lacked protein electrophoresis were normal. association with glutinous extra-cellular material in the distal epididymis, were A trial of steroids and intravenous fluids did not affect the hypercalcaemia. In released as single vigorously motile cells into bicarbonate-free medium, view of poorly controlled hypertension and proteinuria she had caesarean displayed no tendency for head-to-head agglutination and lacked affinity to the delivery at 36 weeks. Both she and her male neonate were hypercalcemic oviductal epithelium. Failure to gain the site of fertilization was associated with a at delivery but this fully resolved within 24 h, suggesting a placental aetiology gradual loss of ADAM3 protein from sperm surface during epididymal transit. of the hypercalcaemia. Regrettably the placenta was inadvertently discarded Spermatozoa from KO mice are also unable to establish tenacious associations after delivery. with the zona pellucida, yet they were capable of fertilization in vitro. The murine The literature suggests that the physiological changes in placental and mammary epididymal secretome of Rnase10 was assessed by incubating isolated IS PTH related peptide production observed in pregnancy and the peripartum period 35 fragments, with [ S]-methionine. Accumulated methionine-labeled proteins might play a significant role in calcium homeostasis in both the mother and foetus. were fractionated by 2D gel. In contrast to porcine Train A, murine Rnase10 This may be independent of other calcitrophic hormones including parathyroid secretion represents only 1.5–1.7% of the total IS secretion. Total RNA from IS of hormone and calcitriol. WT and Rnase10 KO mice was analysed using the Affymetrix GeneChipw Parathyroid hormone related peptide hypersecretion in pregnancy is a rare entity ! Mouse Exon 1.0 ST Array. Rnase9 expression was increased 4.10 fold (P 0.05) and this has only very rarely been described. We believe this severe form of as a result of the loss of Rnase10. Human Rnase9 is a sperm binding protein, hypercalcaemia in both the mother and neonate was precipitated by an whereas Train A does not interact directly with passing sperm. Therefore, overproduction of PTH related peptide by the placenta. This case demonstrates Rnase9 may be an intermediary, involved in the stabilisation of ADAM3 to the the diagnostic and therapeutic challenges posed by this very rare but potentially sperm surface. life-threatening pregnancy related condition.

P272 Is age of vaginal opening an indicator of leptin sensitivity in female P274 Sprague Dawley rats? Comparison of cardiovascular markers and variability of insulin Michelle Sleeth, Kylie Beale, Emily Thompson, Jordan Baxter, resistance in women with anovulatory and ovulatory polycystic ovary Stephen Bloom & Kevin Murphy syndrome Imperial College, London, UK. Li Wei Cho1,2, Eric Kilpatrick1, Brian Keavil3, Vijay Jayagopal4, Anne Marie Coady5 & Stephen Atkin1 1University of Hull, Hull, UK; 2Changi General Hospital, Singapore, Leptin is an adipocyte-derived cytokine critical to the integration of energy Singapore; 3Wythenshawe Hospital, Manchester, UK; 4York Hospital, homeostasis and reproduction which putatively acts as a metabolic gate for the York, UK; 5Hull Royal Infirmary, Hull, UK. onset of puberty. However, it is unknown whether the age of puberty reflects leptin levels or leptin sensitivity. If pubertal age reflects leptin sensitivity, it may also reflect susceptibility to diet-induced obesity. Objective We hypothesised that age of pubertal onset reflects leptin sensitivity. We assessed We aim to study whether a difference exists in cardiovascular risk and variability leptin sensitivity in female Sprague Dawley rats at three pubertal stages: pre- of IR within the hyperandrogenic group of women with PCOS who are ovulatory pubertal, peri-pubertal and one month post pubertal. Rats were administered an and anovulatory. intraperitoneal injection of vehicle or leptin (3 mg/kg) at the onset of the dark Method phase in a cross-over design. Leptin sensitivity was assessed by measuring food Fifty-three women with PCOS were recruited. All subjects were diagnosed to intake following leptin versus vehicle at 4 and 24 h post-injection. Rats were have PCOS by the ESHRE/ASRM Rotterdam criteria where all patients had retrospectively classified into early (days 33–36) or late (days 41–44) vaginal evidence of biochemical hyperandrogenism and hirsutism, chronic anovulation opening. Following vaginal opening, rats were switched to a high-fat diet and polycystic ovaries on transvaginal ultrasound. Non classical 21-hydroxylase

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK deficiency, hyperprolactinemia, and androgen secreting tumours were excluded to delineate insulin-signalling pathways in GL cells from women with anovPCO prior to diagnosis of PCOS. Diabetes was excluded by OGTT test. All subjects and to compare the response to insulin with that in GL cells from ovulatory gave their informed written consent prior to entering the study. Fasting venous women with (ovPCO) and without polycystic ovaries (controls). blood was collected at the same time each day (0800–0900) on 10 consecutive Methods occasions at 3–4 day intervals to include measurements over a period of 5 weeks Primary culture of GL cells obtained at time of egg collection from 3 groups of that included at least a complete menstrual cycle. Ovulation was defined by a patients undergoing routine IVF: women with normal ovaries and regular cycles progesterone level O20 nmol/l. Statistical calculations were done using SPSS (nZ12), women with polycystic ovaries and regular cycles (nZ8) and women version 16.0 and Mann Whitney test was used for non parametric comparisons. with polycystic ovaries and oligomenorrhoea (nZ11). Primary cultures of GL Results cells were incubated with insulin (1, 10, 100 ng/ml) and analysed for glucose Analysis of progesterone levels showed twenty two of fifty three women with uptake, lactate accumulation and progesterone production. Cell lysates were PCOS to have had an ovulatory cycle (42%). Women with anovulatory PCOS prepared for identification of insulin signalling pathways, specifically those have higher variability of IR compared to those having an ovulatory cycle (5.9 involving PI3-kinase (P13-K) and MAPK, using western immunoblotting. G4.8 vs 1.0G0.4). Mean IR was also higher in anovulatory PCOS but did not Results reach statistical significance (4.7G0.2 vs 3.9G0.1). There was no significant As previously shown by there was impairment of glucose metabolism in cells difference in BMI. Hs-CRP was higher in anovulatory PCOS but did not reach from anovPCO women with conservation of insulin stimulated progesterone statistical significance (7.19G0.56 vs 4.56G0.37). Triglyceride is significantly formation. Using phospho-specific antibodies to Akt Ser 473 and GSK 3b Ser 9, higher and HDL lower in anovulatory PCOS but surprisingly LDL is higher in the no significant impairment insulin stimulated PI3K signalling was observed. In the ovulatory group. MAPK pathways, p42 ERK phosphorylation was significantly greater in controls Conclusion compared to anovulatory and ovulatory PCOS patients in response to 100ng/ml Women with anovulatory PCOS have higher mean and biological variability of IR insulin. as well as increased markers for cardiovascular disease suggesting that they may Conclusions be at higher risk compared to those with ovulatory PCOS. We have confirmed selective resistance to insulin in glucose metabolism in granulosa lutein cells in women with anovulatory PCOS. The absence of any obvious impairment in the insulin-stimulated PI3K signalling pathway in response to insulin in women with anovulatory PCOS is unexpected. We did however see impairment in MARK signalling and the significance of this finding with respect to impaired glucose metabolism in granulosa cells remains to be P275 determined. Male germ cell activity during perinatal reproductive development in the mouse Sheba Jarvis1, Robert Winston1, Scott Fraser2 & Carol Readhead2 1Imperial College London, Hammersmith Hospital, DU Cane Road, UK; 2California Institute of Technology, E California Boulevard, Pasadena, California, USA. P277 Dynamic changes in gene expression patterns and cell behaviour are evident Increased intensity of P450c17 protein expression in theca cells from throughout embryonic and neonatal germ cell development in the mouse. polycystic ovaries In the testes, the postnatal period represents a time when the male germline stem Fabio Comim, Kate Hardy & Stephen Franks cells (GSCs) or, gonocytes migrate to the basement membrane of the Imperial College London, London, UK. seminiferous tubules preparing for a lifetime of spermatogenesis and is an important area of study. Here we use the transgenic mouse that expresses green Background/aims fluorescent protein under the Oct 4 promoter (Oct4::GFP transgenic mouse). Polycystic ovary syndrome (PCOS) is the most common endocrine disorder in A novel ex vivo model was developed to image cell migration, proliferation and women, being characterized by ovarian hyperandrogenism attributed to intrinsic apoptotic events during GSCs development in the seminiferous tubules of the overproduction by theca cells (TCs). Although previous reports pointed a higher late mouse embryo and neonate. In the male neonatal testes, the germ cells stability and transcription of CYP17mRNA (Wickenheisser JK et al. 2006)1, few demonstrated motile behaviour as they translocate from the centre to the have examined (and none has quantified) P450c17 protein expression in TCs from basement membrane of the seminiferous tubules. PCOS ovaries. Therefore, the aim of this study is to quantify and compare protein We identified live germ cell movements, proliferation and apoptotic events expression of the steroidogenic enzymes in normal and PCOS ovaries employing within the seminiferous tubules during the late fetal and early neonatal period in the use of optical density measurements. the mouse. Timelapse microscopy captured 2 peaks of apoptosis in the Materials and methods Oct4::GFP germ cells- during late embryonic stages and most notably at We used quantitative immunohistochemitry (IHC) to examine expression of postnatal day 4 (P4), which was correlated with high levels of cleaved caspase-3 P450c17 and 3bHSD in archived ovarian tissue from PCOS (nZ16) and normal expression. At postnatal P4 there was terminal deoxynucleotidyl transferase women (nZ10) obtained from the Histopathology Bank of St Mary’s Hospital, dUTP nick end labelling (TUNEL) staining. Correspondingly, the number London. Overall, 82 follicles were classified as healthy (nZ30) or atretic (nZ52) of Oct 4::GFP cells per seminiferous tubule (meanGS.D.) decreased from based on previously established criteria (Brailly et al. 1981)2. Optical density 9.1G3.67 cells/tubule at E17.5 to 2.7G2.72 cells at P0, and 2.2G1.89 cells by measurements in theca cells were made using the software NIS-Elements AR P5 thus correlating with apoptosis captured during live imaging. Concomitant 3.1(Nikon). Differences between groups were analysed using the Student t-test or germ cell proliferation was noted during apoptotic waves. Confocal Mann-Whitney test according with the distribution of data. videomicroscopy has allowed us to visualize living peri- and neonatal events Results during mouse testicular development. Male germ cells change their charac- Compared with normal ovaries, healthy follicles from PCOS had a higher teristics dramatically during perinatal development and the paracrine factors proportion of theca cells strongly expressing P450c17 protein, PCOS: 0.40 (0.27– involved in this process is an exciting area of future work. 0.68) vs controls: 0.17 (0.07–0.37), (median (interquartile range); PZ0.04, Mann Whitney test). Intensity of expression, (optical density arbitrary units) was also increased in PCOS: 0.82 (0.52–1.2) vs controls: 0.37 (0.28–0.57), PZ0.04, (Mann Whitney test). No differences were seen in theca cell labelling for 3bHSD protein in terms of its optical density; PCOS (meanGS.D.): 0.16G0.008 vs P276 controls 0.13G0.017, PZ0.19 (Student’s t-test). Defining insulin signalling pathways in granulosa-lutein (GL) cells in Conclusion women with polycystic ovary syndrome (PCOS) The increased proportion of P450c17 positive cells and the higher intensity of Jalini Joharatnam1, Giuseppina Lamanna2, Geoffrey Trew2, Stuart Lavery2, staining support the view that dysregulation of 17-hydroxlase/17-20 lyase activity Kate Hardy1 & Stephen Franks1,2 in theca is a key abnormality in the aetiology of hyperandrogenism in PCOS. 1Imperial College, London, UK; 2Division of Reproductive Medicine, References Imperial College Healthcare, NHS Trust, London, UK. 1. Wickenheisser JK et al. Trends in Endocrinology and Metabolism.200617(2): 63–69. 2. Brailly S et al. JCEM. 1981 53(1): 128–134. Aim Acknowledgements PCOS is associated with peripheral insulin resistance and we have previously MRC, Capes Foundation, Dr R Parker (Univ Alabama,USA) (P450c17 Ab), shown that glucose uptake and metabolism are impaired in granulosa lutein (GL) Dr J L Mason (University of Edinburgh, UK) (3bHSDII Ab). cells of anovulatory women with PCOS (anovPCO). The aim of this study was

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P278 Aim Neuromedin B stimulates the hypothalamo-pituitary–gonadal axis in To investigate whether serum RBP4 level is correlated with metabolic male rats parameters, indices of insulin resistance, and endocrine variables in PCOS Charlotte Boughton, Sejal Patel, Anjali Amin, Emily Thompson, women. Mohammad Ghatei, Stephen Bloom & Kevin Murphy Subjects and methods Imperial College, London, UK. Our study was conducted on 90 women their age ranged from 20 to 39 years. They were divided into:Group I: 30 lean patients with PCOS, Group II: 30 obese patients with PCOS, Group III: 15 lean control women and Group IV: 15 obese Neuromedin B (NMB) is a highly conserved bombesin-related peptide found in control women excluding those receiving oral contraceptives, glucocorticoids, mammals. The mammalian bombesin family of receptors consists of three closely oral hypoglycemic, anti-obesity or anti-androgenic drugs. Fasting and 2 h related G protein coupled receptors, BB1,BB2 and BB3.TheBB1 receptor postprandial plasma glucose (2 h PPPG), HbA1c, fasting insulin level, HOMA IR, subtype has the highest affinity for NMB. NMB mRNA is detected in the CNS and lipid profile, LH, free testosterone, serum RBP4, serum uric acid, pelvic is expressed at relatively high levels in the rat hypothalamus, in particular the ultrasonography were done for all subjects. medial preoptic area and the arcuate nucleus. Results NMB has well documented roles in the regulation of the thyroid axis and We found that serum RBP4, fasting insulin level and HOMA IR were higher in the stress axis in rats. However, there is little available data regarding the role PCOS group than control group. Furthermore, there was a high significant of NMB in the regulation of the hypothalamo-pituitary–gonadal (HPG) axis. positive correlation between RBP4 and weight, BMI, waist circumference, W/H It is known that the NMB receptor is expressed in immortalised GnRH-releasing ratio, fasting insulin, HOMA-IR, triglyceride and LDL-c with P value !0.01, GT1-7 cells, and that anterior pituitary NMB-immunoreactivity is altered by and a positive significant correlation between RBP4 and 2 h PPPG and HbA1c changes in the sex steroid environment. The objective of these studies was thus to with P value !0.05 but there was a high significant negative correlation between further investigate the effects of NMB on the HPG axis. RBP4 and HDL-c with P value !0.01. I.c.v. administration of NMB (10 nmol) to adult male rats significantly increased Conclusion plasma LH levels 30 min after injection (plasma LH ng/ml; saline 0.7G0.1, Serum RBP4 is higher in the PCOS group than non-PCOS group, so RBP4 may 10 nmol NMB 1.3G0.2, P!0.01). In vitro, NMB stimulated GnRH release from play a role in the pathophysiology of PCOS. Further studies are needed to clarify hypothalamic explants from male rats and from GT1-7 cells. NMB had no the role of RBP4 in these women. significant effect on LH release from anterior pituitary explants from male rats, or from LbT2 cells in vitro. These results suggest a previously unreported role for NMB in the stimulation of the HPG axis via hypothalamic GnRH. Further work is now required to determine the receptor mediating the effects of NMB on the reproductive axis and the physiological role of NMB in reproduction.

P281 HRPE773 (ZG16B) expression is elevated in human endometrium during the early secretory phase of the menstrual cycle and in uterine P279 decidua following miscarriage Bonnie Ng1, Sarah McDonald1, Xia Ren1, John Mullins2, Michael Rae3, Nesfatin stimulates the hypothalamic–pituitary–gonadal axis in male Hillary Critchley1, Andrew Horne1 & Steven Morley1 rats 1Centre for Reproductive Biology, University of Edinburgh, Edinburgh, Michael Patterson, Katie Wynne, Sejal Patel, Keisuke Suzuki, John Tadross, UK; 2Centre for Cardiovascular Science, University of Edinburgh, Mohammad Ghatei & Stephen Bloom Edinburgh, UK; 3School of Life, Sport and Social Sciences, Edinburgh Imperial College London, London, UK. Napier University, Edinburgh, UK.

Nesfatin is an 82 amino acid peptide identified as a novel hypothalamic regulator Introduction of feeding. In rodents, central administration of nesfatin acutely inhibits feeding Expression of murine CSP-1/Dcpp secretory proteins was first identified in and chronic administration reduces weight gain. Subsequent research has sublingual salivary glands and subsequently in secretory epithelia of several other demonstrated nesfatin is involved in the control of puberty in female rats. During tissues, including the mouse female reproductive tract where expression is puberty i.c.v. administration of nesfatin stimulates release of LH and FSH but has regulated by oestrogen. Preliminary studies indicated that HRPE773, the human no effect in adult female rats. CSP-1/Dcpp orthologue, displayed a similar pattern of expression to its murine We investigated the effects of i.c.v. injection of nesfatin on the release of pituitary counterparts. We therefore hypothesized that HRPE773 might be expressed in hormones in ad libitum fed unanaesthetised adult male rats. In contrast to the data human endometrium and uterine decidua under the influence of steroid hormones. from adult female rats, i.c.v. administration of nesfatin (1 nmol) significantly Methods increased plasma LH and FSH levels 30 min post injection. There were no Timed endometrial biopsies were collected with informed consent from patients significant changes in plasma ACTH, TSH and prolactin. In a second experiment, undergoing elective hysterectomy or investigation for benign gynaecological i.c.v. administration of nesfatin (1 nmol) significantly increased plasma conditions and during spontaneous miscarriage or termination of pregnancy. testosterone 60 min post injection. To further investigate the role of nesfatin in Quantitative Real-Time PCR and immunohistochemistry were used to determine the hypothalamic–pituitary–gonadal (HPG) axis we examined the effect of HRPE773 mRNA levels and protein localization. HRPE773 expression was also nesfatin on the release of GnRH from static hypothalamic explants. Treatment measured in telomerase-immortalized human endometrial epithelial cells with 100 and 1000 nM nesfatin significantly increased GnRH release from in vitro (hTERT-EECs) treated with oestradiol, medroxyprogesterone acetate (MPA), hypothalamic explants. Data from these studies suggests nesfatin is a novel or both oestradiol and MPA for 8 and 24 h at physiological doses. Statistical regulator of the HPG axis in adult male rats. analyses were performed using the Kruskal–Wallis test (CI 95%) with appropriate post hoc testing. Results HRPE773 was expressed in human endometrium in all phases of the menstrual cycle, but was significantly higher in the early-secretory phase compared to P280 proliferative, mid-secretory, late-secretory or menstrual phases, while decidual Study of role of retinol-binding protein 4 in women with polycystic expression was elevated in women with miscarriage, but not in extra-uterine ovary syndrome (tubal) or viable intrauterine termination of pregnancy. HRPE773 immunor- Abdel-Sattar Eldieb, Khalid Makboul & Rania Abd El Baki eactivity was located primarily in the cytoplasm of endometrial luminal and Ain Shams University, Cairo, Egypt. glandular epithelia, with some staining also in stromal cells. HRPE773 mRNA levels in hTERT-EECs treated with oestradiol alone and both oestradiol and MPA was significantly lower after 24 h compared to vehicle. Background Conclusion Obesity is a common feature of women with PCOS in different ethnic cohorts. It is HRPE773 expression is elevated in endometrial luminal and glandular epithelia suggested that retinol binding protein 4 (RBP4) is a central mediator of obesity- during the early secretory phase of the menstrual cycle and in uterine decidua induced insulin resistance in mice and humans. In addition, elevated serum RBP4 following miscarriage, while cell culture experiments suggest that HRPE773 levels have been associated with cardiovascular risk factors and metabolic expression is likely to be inhibited by oestrogen. syndromes.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P282 This small survey reinforces the importance of the endocrinologist’s role in Case–control study of 5-alpha reductase type 2 Val89Leu providing patient education for the prevention and management of adrenal crisis. polymorphism in Romanian PCOS patients Serban Radian1,2, Cristina Ramona Radulescu1, Daniela Aflorei2, Monica Gheorghiu1,2, Nicoleta Baculescu1, Alice Albu3, Simona Fica1,3, Florin Grigorescu4 & Mihail Coculescu1,2 1C. Davila University of Medicine, Bucharest, Romania; 2C.I. Parhon Institute of Endocrinology, Bucharest, Romania; 3Elias Emergency University Hospital, Bucharest, Romania; 4Molecular Endocrinology Laboratory, UMR-204 NUTRIPASS, Montpellier, France. P284 Dehydroepiandrosterone (DHEA) supplementation improves cognitive function in perimenopausal rhesus monkeys Background Henryk Urbanski, Laurie Renner, Alison Weiss, Jamie Garten, Hyperandrogenism (HA) is required for diagnosis of polycystic ovary syndrome Krystina Sorwell, Steven Kohama & Martha Neuringer (PCOS) and it is central to PCOS pathogenesis. Putative mechanisms of Oregon Health and Science University, Beaverton, Oregon, USA. hyperandrogenism include disregulation of steroidogenesis, plasma transport and peripheral tissue regulation. Therefore, 5-alpha reductase genes (SRD5A1, SRD5A2), that regulate peripheral tissue conversion of testosterone to more Age-related cognitive decline in postmenopausal women is thought to be partially potent dihydrotestosterone are good PCOS candidate genes. The single published related to the loss of sex steroids. Like women, old female rhesus monkeys study of SRD5A1 and SRD5A in PCOS showed association of several (Macaca mulatta) undergo menopause and show an associated decline in SNPs/haplotypes with PCOS, including rs523349 (Val89Leu in SRD5A2). circulating estradiol levels. Similarly, they show an age-related decline in the Aim release of dehydroepiandrosterone (DHEA) from their adrenal glands. Because To test association of rs523349 with PCOS and related traits in the Romanian DHEA acts as a substrate for estradiol synthesis in the brain, it is plausible that population. DHEA supplementation could enhance cognitive function in the elderly. To test Patients and methods this hypothesis, old ovary-intact female rhesus monkeys were given 5 mg of oral Two hundred and fifteen PCOS patients (Rotterdam criteria) and 107 DHEA each morning for 2 months; this administration paradigm was found to eumenorrheic, non-hirsute controls, 15–40 years. old, recruited at the C.I. Parhon recreate the physiological 24-h circulating DHEA levels of young adults. In a National Institute of Endocrinology and Elias Emergency University Hospital, delayed matching-to-sample test of recognition memory, with a 240-s retention Bucharest. rs523349 genotyping was performed by HRM-PCR (Corbett interval, the regularly-cycling old animals showed a significant improvement in Research), with Razor probes (Primer Design, UK) and validated by direct performance after 2 months of DHEA treatment, relative to age-matched sequencing. irregularly-cycling perimenopausal monkeys (P!0.01, nZ3 per group). Results Irregularly-cycling animals showed no improvement relative to their baseline rs523349 allelic frequency did not differ significantly between PCOS and control measurement. These findings demonstrate that 2 months of DHEA hormone (0.72 vs 0.71, PZNS) and was comparable to that observed by Goodarzi et al. supplementation is sufficient to cause a detectable improvement in cognitive rs523349 genotypes were not significantly associated with PCOS. rs523349 function in old females. However, they emphasize that there is a critical period of (genotypes or allelic frequency) was not associated with PCOS phenotypic/ sensitivity; for DHEA therapy to be effective, it needs to be initiated before the biochemical traits. The statistical power of our study was limited (0.39), but individuals show significant age-related attenuation of estradiol levels. Although comparable to the original study (0.5). the underlying mechanism is unclear, detection of 17b-HSD, 3b-HSD and Conclusions aromatase enzyme gene expression in the prefrontal cortex and hippocampus, by Our negative association result suggests that SRD5A2, through rs523349, is not a RT-PCR, suggests that it may involve intracrine conversion of DHEA to estradiol major gene in PCOS genetics in our population. However, exclusion of a true within the CNS. effect will require an adequately-powered study.

Steroids P285 Measurement of salivary testosterone in female samples using a highly P283 sensitive LC–MS/MS assay GPs say they rely on endocrinologists to manage adrenal crisis and Brian Keevil1, Philip McDonald1, Wendy McDowell2, Alan Wallace3 & patient education for Addison’s disease Fred Wu4 Katherine White & Alick Mackay 1University Hospital of South Manchester, Manchester, UK; 2London Addison’s Disease Self-Help Group, Guildford, UK. School of Hygiene and Tropical Medicine, London, UK; 3Glasgow Royal Infirmary, Glasgow, UK; 4Manchester Royal Infirmary, Manchester, UK. In early 2010, the Addison’s Disease Self-Help Group sent an information pack to 10 500 GP practices across the UK, outlining the GP’s role in diagnosis and care Introduction of the Addison’s patient. We asked the practice head to return a reply-paid We have developed a highly sensitive LC–MS assay in an attempt to improve the questionnaire, detailing the number of steroid-dependent patients in the practice, measurement of salivary testosterone in female samples. their repeat prescription length, if they had an in-date supply of injectable Methods hydrocortisone, and any comments on the challenges they faced in providing care A 200 ml saliva sample, calibrators or QC were mixed with 10 ml working internal for their steroid-dependent patients. standard (0.1 mg/l) and 1 ml of methyl tert-butyl ether (MTBE). Vortex mixed for Predictably, only a tiny proportion of GP practices sent a reply (nZ22), so that 4 min and frozen at K80 8C (1 h). Unfrozen organic layer was transferred to a their responses do not offer statistical validity. Nevertheless, this small sample glass tube and evaporated. The residue was reconstituted with 100 ml of 50:50 offers some qualitative insights. mobile, vortex mixed and transferred to a 96-well microtitre plate. The 22 GP practices that replied contained an average of 4.4 GPs, 6700 patients Liquid chromatography was performed using a Waters Acquity UPLC system. and 1.7 Addison’s patients. This is only a slightly higher proportion than Extract (30 ml) was injected directly from the microtitre plate onto a C18 Acquity epidemiological research would have suggested. 1.8 mm HSS T3 analytical column (2.1!50 mm). A solvent gradient was used to Thirty-three percent of practices with steroid-dependent patients (nZ18) reported elute testosterone and D5Testosterone from the column. TMS was performed on a that they were on 28-day repeat prescriptions. Only 3 of these practices were able Waters Quattro Xevo TQ-S in positive ionization mode. Multiple reaction to confirm that their patients had an in-date supply of injectable hydrocortisone. monitoring transitions for testosterone were m/z 289.2O108.8 (quantifier) Several GPs stated that prevention and management of adrenal crisis was their and m/z 289.2O96.8 (qualifier) and for D5-testosterone internal standard was biggest challenge, as neither practice staff nor their adrenal patients had a good m/z 294.1O99.8. understanding of what this entailed. Others said they had insufficient experience Results to offer guidance to the patient on what to do if they became unwell and relied on Lower limit of quantitation was 2 pmol/l, recovery was 98–109%. Interbatch patients to ‘self-care’. One respondent commented that he had yet to see an precision (CV) was 4.4, 6.0 and 2.8% at 17, 100 and 154 pmol/l respectively. adrenal patient after 30 years as a GP, and would rely on secondary care to The median female range (nZ96) was 10–15 pmol/l and the median male range provide the follow-up and patient education required. (nZ96) was 100–150 pmol/l. Although cross validation of calibrators was

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK performed to eliminate any calibration issues/bias we still found the LC–MS Results method gave 25% lower values than the RIA method in males and 400% lower in Re-calculating the results from serum samples using matched serum calibrators females improved the inter laboratory precision (CV) from 10% down to 5%, likewise re Conclusions calculating the results from aqueous samples using aqueous calibrators improved Using a highly sensitive mass spectrometer we have developed an assay for the inter laboratory precision from 7% down to 3%. Trying to re calculate the salivary testosterone with greatly improved detection limits and confirmed that serum results using aqueous calibrators actually made the inter laboratory RIA was unsuitable for measuring salivary testosterone especially in female variability worse. This suggests that the matrix in which the calibrator is made samples. We established reference ranges in saliva samples and found good will affect the result significantly. demarcation between the male and female reference ranges. Conclusion All laboratories gave clinically acceptable results but the accuracy of the results and hence the variability between laboratories was improved if common calibration material was used. If labs are to use a variety of different LC columns it is important that they thoroughly evaluate the effects of ion suppression, caused by sample matrix, which can vary profoundly with LC columns from different suppliers. The choice of column will also have a bearing on the type of calibrator matrix that is suitable for use in the assay.

P286 Steroid Replacement Education: Impact on Patients and their Carers Mujahid Saeed, Theingi Aung, Judy MacDonald, John Wass & Niki Karavitaki Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK.

Steroid replacement is life-saving in patients with steroid axis deficiency; P288 education surrounding steroid replacement is vital in their management. The effect of prednisolone on different cortisol methods We organised ‘Steroid Replacement Education Days’ for patients and their family Laura Owen & Brian Keevil members/carers to help enhance their knowledge on steroids and intercurrent University Hospital of South Manchester, Manchester, UK. illness. Lectures detailed manifestations, causes, management of steroid deficiency and the practical issues surrounding steroid replacement. This was followed by a practical demonstration of steroid emergency injections by our Introduction endocrine specialist nurse team. Questionnaires were offered to attendees to look Prednisolone is well known to interfere in routine immunoassays for cortisol with at the impact of the course. uncertainty surrounding the degree of this interference. Methods using tandem The patient questionnaire had 16 questions and there were 33 respondents. 51.5% mass spectrometry technologies offer more specificity, however there have been (nZ17) reported that they had received prior training on adjusting the dose of some reports of prednisolone interference in mass spectrometry assays. We aimed steroids during intercurrent illness, with 45.5% (nZ15) having underwent adrenal to characterise the extent of prednisolone interference in both an automated crisis due to untimely adjustment of their steroids. 27.2% (nZ9) were already immunoassay and a tandem mass spectrometry method (TMS). fully confident (score rating of 8–10 on a 0–10 scale) in adjusting their steroids; Methods this increased to 81.8% (nZ27) after the training day. From 6.1% (nZ2), 45.5% Sera were spiked with prednisolone to a final concentration of 200 mg/l (nZ15) felt fully confident in injecting steroids after the course. 94% (nZ31) (555 nmol/l), 500 mg/l (1388 nmol/l) or 1000 mg/l (2776 nmol/l) nZ20 at each found the practical demonstration by the nurses extremely useful and a similar concentration. These samples were then analysed using a Roche chemi- percentage rated the course excellent (score rating of 8–10 on a 0–10 scale). The luminescent immunoassay and a TMS assay. The calibration of the tandem questionnaire given to guests had 12 questions and 24 responded. 16.7% (nZ4) mass spectrometry assay had been checked using a reference material. A sample had been trained on steroids and intercurrent illness prior to the course. 12.5% containing 1390 mg/l (3856 nmol/l) prednisolone was prepared and analysed (nZ3) felt confident in injecting steroids before; this rose to 50% (nZ12) after using the TMS assay to quantify any interference. the practical demonstration, which 87.5% (nZ21) rated as excellent. 91.6% Results (nZ22) rated the event as excellent. Prednisolone was found to have a significant interference in the immunoassay at Surprisingly, the confidence of patients on steroid replacement in dealing with clinical concentrations. The degree of this interference increased disproportio- intercurrent illness remains suboptimal. Events educating them and their carers nately with the amount of prednisolone added. In the TMS assay, a sample are required on a regular basis aiming to enhance understanding of steroid containing 1390 mg/l (3856 nmol/l) prednisolone was not found to cause a peak treatment and to improve confidence in the emergency and life-saving above the lower limit of the assay. Comparing the spiked and unspiked samples at management. all concentrations of prednisolone showed no significant difference in the TMS assay. Discussion Despite previous reports of prednisolone interfering in mass spectrometry assays for cortisol, this was not found to be the case in our assay. This means that this mass spectrometry assay can give reliable cortisol results on people on prednisolone therapy.

P287 How reproducible are LC–MS testosterone results? A calibration exercise Brian Keevil, Philip McDonald & Laura Owen University Hospital of South Manchester, Manchester, UK. P289 Introduction Glucocorticoid receptor antagonism as a decision making tool in It has been recognised in EQA schemes in Europe and America that the patients with adrenal incidentaloma and low-grade excess cortisol reproducibility between labs using LC–MS for testosterone analysis is not optimal secretion: a pilot study for this technique. We decided to conduct a calibration exercise to investigate the Miguel Debono, Sam Houghton, Richard Eastell, Richard Ross & variability seen between labs. John Newell-Price Methods Academic Unit of Endocrinology, University of Sheffield, Sheffield, South Aqueous and matrix matched serum samples were sent to labs participating in the Yorkshire, UK. NEQAS testosterone scheme. The labs were asked to measure these samples blind using their routine assays and their own calibration material. We then re-calculated the results for these samples using assigned values from our routine Aims/hypothesis assay which has been shown to align closely to a reference method. Most labs Adrenal incidentaloma (AI) are very common, but optimal management of used liquid–liquid extraction to prepare samples but a variety of different LC patients with AI and low-grade excess cortisol secretion is not established. columns and calibration matrices were used. Uncontrolled studies reporting outcomes of adrenalectomy suggest improvements

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK in cardiovascular risk, but all are subject to selection bias, and it is unclear if P291 benefits are due to removal of excess cortisol. We reasoned that short-term use of Urinary tetrahydrodeoxycorticosterone excretion is a significant mifepristone, a rapidly-acting glucocorticoid receptor (GR) antagonist, could independent predictor of LV mass in patients with chronic kidney improve GR-mediated cardiovascular and metabolic risk, with the ultimate aim of disease devising a individualised means of selecting those most likely to benefit from Emily McQuarrie1, Patrick Mark1, Rajan Patel1, Robert Fraser1, surgical intervention. Eleanor Davies1, Tracey Steedman2, John Connell3 & E Marie Freel1 Methods 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, In a prospective open label pilot study, six patients with mild cortisol excess from Glasgow, UK; 2Cardiac MRI Unit, Western Infirmary, Glasgow, UK; adrenal incidentalomas (mean serum cortisol post 1 mg ONDST was 79.8 nmol/l) 3Ninewells Hospital and Medical School, University of Dundee, Dundee, were treated with mifepristone 200 mg twice/day for up to 8 weeks. Primary end- UK. points were 2-h glucose from OGTT and resting/24-h BP at 4 weeks. Secondary end-points included insulin sensitivity, fasting and AUC insulin and glucose at 4 weeks, resting/24-h BP at 8 weeks, serum 0900 h ACTH/cortisol and salivary Aim 0900/2300 h cortisol at 4 and 8 weeks, lipids and bone markers at 8 weeks. Increasing left ventricular mass index (LVMI) is associated with a poor prognosis Results in patients with chronic kidney disease (CKD). Blockade of the mineralocorticoid All subjects showed clear biochemical evidence of GR antagonism, with receptor (MR) in CKD leads to improvement in proteinuria and LV mass. significant elevations of serum and salivary cortisol, and plasma ACTH. As a However, the MR can be activated by aldosterone, cortisol and deoxycorticoster- group, at 4 weeks, there was a significant improvement in all indices of insulin one (DOC) and their relative contribution to adverse events in CKD is unclear. sensitivity/resistance including HOMA-IR (3.16 vs 2.3; PZ0.05), HOMA-%b We aimed to assess the correlation between mineralocorticoid excretion and (147.6 vs 91.67; PZ0.03) and Matsuda index (3.31 vs 4.98; PZ0.03). In one LVMI in patients with CKD. subject, however, there was no improvement. There were no significant changes Methods in resting/24 h BP, mean serum osteocalcin levels and urine NTX/Creat. Fifty-eight patients with CKD stages 3/4 and 29 patients with essential Conclusions/interpretation hypertension (EH) were recruited. Patients underwent 24 h urine collection for Short-term GR antagonism with mifepristone improves insulin sensitivity in urinary tetrahydroaldosterone (THAldo) and tetrahydrodeoxycorticosterone some, but not all, patients with mild cortisol excess. Larger studies are needed, but (THDOC) (measured using GCMS), urinary electrolytes and protein (QP). our data suggest that GR antagonism may form the basis of a clinical tool to LVMI was measured using gold standard cardiac MRI scanning. Factors which stratify patients for intervention in an individualised manner. correlated significantly with LVMI were entered into linear regression models. Results Mean age was 57.1 years, 75.9% were male, mean BMI 29.2 kg/m2, systolic blood pressure (SBP) 148 mmHg, DBP 86 mmHg and the mean number of anti- hypertensive agents was 2.4 (range 0–6). In CKD patients, mean eGFR was 38.5 ml/min per 1.73 m2 and median QP 0.8 g/24 h. LVMI was significantly higher in patients with EH compared with CKD (86.1 vs 81.2 g/m2 PZ0.009). There were no significant differences in drug therapies, THAldo or THDOC excretion between the two groups. In patients with CKD, significant predictors of LVMI were male gender, SBP, 24 h QP, THAldo and THDOC excretion. On multivariate linear regression P290 analysis, the significant independent predictors were SBP, male gender and THDOC excretion. THAldo was not an independent predictor. In patients with Urinary tetrahydroaldosterone excretion is determined by rising EH, plasma aldosterone concentration was the only significant independent urinary sodium excretion in patients with chronic kidney disease predictor of LVMI. No association was seen with THAldo or THDOC. Emily McQuarrie1, Patrick Mark1, Robert Fraser1, Eleanor Davies1, 2 1 Conclusions John Connell & E Marie Freel Using cardiac MRI to assess LVMI, we have demonstrated that the 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, 2 mineralocorticoid THDOC is a novel independent predictor of LVMI in patients Glasgow, UK; Ninewells Hospital and Medical School, University of with CKD and not subjects with essential hypertension. Dundee, Dundee, UK.

Aim In chronic kidney disease (CKD) elevated aldosterone (Aldo) levels are a poor prognostic indicator, particularly in the context of a high dietary sodium intake, through unclear mechanisms. Blockade of the mineralocorticoid receptor (MR) improves surrogate patient outcomes. We hypothesised that regulation of aldosterone biosynthesis is disordered in CKD and aimed to compare this in a P292 cohort of patients with CKD with subjects with essential hypertension (EH). Glycyrrhetinic acid disrupts the synthesis of adrenocorticosteroid Methods hormones at multiple sites Seventy patients with CKD stages 3/4 and 30 patients with EH were recruited. Emad Al-Dujaili1, Christopher Kenyon2, Moira Nicol2 & Ian Mason2 Patients underwent 24 h urine collection for urinary tetrahydroaldosterone 1Queen Margaret University, Edinburgh, Scotland, UK; 2QMRI, Edinburgh (THAldo) and tetrahydrodeoxycorticosterone (THDOC) (measured using University, Edinburgh, Scotland, UK. GCMS) and urinary electrolytes. Factors which correlated significantly with THAldo were entered into a linear regression model. Results Background and aims Mean age was 57.4 years, 78% of patients were male, mean SBP was 149 mmHg, Previously we showed that the bioactive liquorice constituent glycyrrhetinic acid mean DBP 86 mmHg, mean BMI was 29.3 kg/m2. Patients with EH and CKD (GA) inhibits not only 11b-hydroxysteroid dehydrogenase enzymes but also the demonstrated no significant differences in gender, age or weight. Drug therapies sulphation of corticosteroids by the enzyme sulphotransferase 2A1 (SULT2A1). were similar across the cohorts although EH patients were significantly more Since pregnenolone, 17a-hydroxy-pregnenolone, deoxycorticosterone (DOC) likely to be prescribed thiazide diuretics (56% vs. 6%). Urinary excretion of and dehydroepiandrosterone (DHEA) are all prime substrates for SULT2A1, GA THAldo (58.4 mg/24 h) and sodium (160.7 mmol/24 h) did not differ between could have important effects in directing pathways of glucocorticoid, patient groups. Mean eGFR in CKD patients was 40.3 ml/min per 1.73 m2. mineralocorticoid and androgen biosynthesis. This hypothesis has been In EH patients, the strongest correlate with THAldo excretion was THDOC. In investigated by comparing aldosterone, cortisol, cortisone, corticosterone, CKD, THAldo (0.917, P!0.001) correlated positively and significantly with DOC, DHEA and testosterone output by human adrenocortical H295 cells THDOC excretion, as did 24 h USodium (rZ0.614, P!0.001) and 24 h treated with GA in the presence of added steroids. UPotassium (0.538, P!0.001). These relationships were not seen in EH. On Methods multivariate linear regression analysis 24 h USodium was the strongest Cells were incubated for 24 h in DMEM/F12, with 0, 3, 10, 25 or 100 mMGAand independent predictor (PZ0.004) of THAldo excretion in CKD. either 0.2 mM DOC or 1 mM DHEA. Free and conjugated steroids in the Conclusions incubation medium were analysed by in-house ELISAs following extraction with In patients with CKD, 24 h urinary sodium is the strongest predictor of THAldo Sep-Pak C18 cartridges and hydrolysis with Helix pomatia juice. SULT2A1 excretion. This relationship is unexpected, novel, not seen in patients with EH and expression in cells was quantified by RTPCR. may help explain the association between high urinary sodium excretion, Results and discussion aldosterone and poor outcomes in patients with CKD. GA inhibited DHEA and DOC conjugation in a dose-dependent manner without affecting SULT2A1 transcription. However, total DOC (free C conjugated) was

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK negatively correlated with GA-inhibition of sulphation in cells incubated in the disease (NAFLD). NAFLD is a progressive spectrum of disease ranging from presence of either DOC or DHEA (rZK0.74, P!0.02). We suggest that hepatic steatosis to steatohepatitis, fibrosis and cirrhosis. Many processes inhibition of pregnenolone sulphation (an early endogenous intermediate) contribute to lipid accumulation within heaptocytes including de novo lipogenesis channels steroidogenesis towards mineralocorticoid/glucocorticoid hormones. which includes the rate-limiting carboxylation of acetyl CoA to malonyl-CoA by However, the total amounts of cortisol, cortisone and aldosterone were reduced acetyl CoA carboxylase (ACC) and conversion to palmitate by fatty acid synthase rather than increased by GA; corticosterone levels were increased but not in line (FAS). We have hypothesized that increased GC exposure drives insulin with DOC changes. Together, these results suggest that GA treatment affects the resistance and promotes the development of NAFLD. synthesis of 17a-hydroxylated steroid hormones (O75% reduction in cortisol:- C3A cells (human hepatoma derived), which express the GC receptor, were corticosterone ratios; P!0.01). DOC to aldosterone ratios were also reduced treated with cortisol (250 nM, 24 h) in the presence or absence of insulin (80 nM, (P!0.001). 24 h). Lipogenic gene expression was determined by real-time PCR and Conclusions lipogenesis measured by 1-[14C] acetate incorporation into triglyceride. GA effects on steroid hormone profiles could be more complex than hitherto Cortisol increased mRNA expression of ACC2 (0.005G0.003 (control) vs appreciated. It seems that GA can modulate adrenal steroidogenesis in vitro at 0.008G0.004 (cortisol), P!0.05) and FAS (0.071G0.007 (control) vs 0.110 multiple sites. The possibility of adrenocortical side-effects is, therefore, an G0.019 (cortisol), P!0.05) but not ACC1, diacyly glycerol acyl transferase important consideration in the development of 11b-HSD enzyme inhibitors to (DGAT) and glycerol phosphate acyl transferase (GPAT). However, cortisol modulate glucocorticoid activity. decreased functional lipogenesis (78.68G4.5% vs control (100%), P!0.05) probably reflecting rate-limiting, post-transcriptional regulation. Interestingly, in the absence of cortisol, insulin only had a modest effect to increase lipogenesis and this did not reach statistical significance (114.9G12.4% vs control (100%), PZns). In contrast, when C3A cells were pre-treated with cortisol for 24 h, the stimulatory effect of insulin upon lipogenesis was augmented (mean % increase in lipogenesis following insulin, 14.9G12.4% (control) vs 38.2G12.3% (cortisol), P!0.05). In C3A cells, in the absence of insulin, GCs decreased lipogenesis despite increasing FAS and ACC2 expression. Consequent increased hepatic free fatty acid exposure may contribute to hepatic insulin resistance. Our data also suggest P293 that GCs may potentially enhance the ability of insulin to promote lipid storage in Clinical outcomes of 250 mg short synacthen tests in a tertiary referral hepatocytes. centre Hiang Leng Tan, Srilatha Dampetla, Jen M Ng & Ammar Wakil Diabetes Center, Michael White Center, Hull Royal Infirmary, Hull, England, UK.

Introduction The short synacthen test (SST) is commonly used to assess the hypothalamic pituitary adrenal (HPA) axis in clinical practice. We evaluated the underlying clinical conditions pre-empting the request for a SST in a general medical ward and the adequacy of clinical follow up of patients with suboptimal responses to the test. Methods P295 All patients with suboptimal SST results (30 min cortisol level 450–540 nmol/l) Systems biology reveals a novel mechanism regulating glucocorticoid performed in the Acute Assessment Unit in our hospital between 01/10/2007 to action 30/09/2009 inclusive were analysed. All patients who were on steroid therapy for David Morgan1,4, Namshik Han3,4, Laura Matthews1, Michael Norman2, more than 1 month or were deceased were excluded from the analysis. Andy Brass3,4 & David Ray1 Results 1Endocrine Sciences Research Group, University of Manchester, Manche- One hundred and twenty-two patients were included in the study. The different ster, UK; 2Laboratory of Neuroendocrinology (LINE), Universtiy of Bristol, clinical indications for performing SST were as follows; recurrent falls/postural Bristol, UK; 3Faculty of Life Sciences, University of Manchester, hypotension, 47 patients(38.5%), weight loss, 17 patients (13.9%), hyponatremia, Manchester, UK; 4School of Computer Science, University of Manchester, 14 patients (11.5%), pre-post pituitary surgery, 13 patients (1.7%) and others, 31 Manchester, UK. patients (25.4%). Of the 122 patients with suboptimal SST, 98 patients received further clinical follow up; 44 of which were consequently treated with steroids. Crucially this meant that 24 patients (19.6%) did not receive any further follow up Glucocorticoids act through the glucocorticoid receptor (GR) to regulate cell as evidenced by the absence of any documentation in the clinical case notes. function. GR gamma (GRg) is a constitutive exon3/4 splice variant, contributing Conclusions 4–8% of the total GR transcripts and is highly conserved through mammalian The SST is a commonly used endocrinological test in clinical practice. The evolution, but its biological function remains unknown. Using microarray findings show that almost a fifth of patients tested with a SST may not be analysis we identified the transcriptome response for GRg in stable HEK-Flp adequately followed up in clinical practice. The findings of the present study cells. This revealed that although GRg effectively modulated gene expression in highlight a potential clinical risk as patients with disorders of the HPA axis are at response to the synthetic glucocorticoid dexamethasone, a significant proportion increased risk of mortality and morbidity. It is essential that the results of all of the GRg specific genes were regulated in the absence of ligand (when abnormal SSTs are brought into the attention of the referring physician and a compared to control transfected or GRa expressing cells). Immunofluorescent referral made to the endocrinology for any cases where there is uncertainty. microscopy suggested that GRg was predominantly cytoplasmic at rest, showing distinctly slower ligand-induced nuclear translocation kinetics, compared to the more heterogeneously distributed GRa. The apparent paradox of GRg regulation of transcription, from a cytoplasmic location suggested a novel mechanism of action, which may be through altered trafficking kinetics, or cytoplasmic signalling. A novel in-silico strategy, utilizing forward engineering (a conservative strategy) to construct the connection topology, and reverse engineering (a probabilistic inference model) to identify genomic regulatory responses with transcription factor networks, was used to investigate this further. Using this approach we identified a panel of transcription factors with inferred activity, specifically in the GRg expressing cells in the absence of ligand. These P294 included the SP1 and AP1 families of transcription factors, known GR partner Cortisol decreases lipogenesis in human hepatocytes proteins, and downstream targets of JNK and p38 pathways. Phosphoimmunoblot Maryam Nasiri, Laura Gathercole, David Hauton, Stuart Morgan, analysis revealed that GRg activates the JNK signalling pathway independent of Iwona Bujalska, Paul Stewart & Jeremy Tomlinson ligand, compared to GRa, providing a link between localisation of GRg in the The University of Birmingham, Birmingham, UK. cytoplasm and ligand-independent regulation of target genes. GRg therefore subserves a variety of biological effects that appear to be less reliant on ligand activation than GRa. The evolutionary conservation of GRg also supports the Glucocorticoid (GC) excess (Cushing’s syndrome) is characterized by central importance of this mechanism of action. obesity, insulin resistance and in up to 20% of cases, non-alcoholic fatty liver

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P296 These results are part of a work aiming to evidence hormonal concentration Spitting out the issues: Identifying optimal procedures for saliva modifications related to reproductive toxicology effects in in vitro models collection and storage compared to in vivo model. Taken together and discussed with regards to extra- Gillian Cooper & Gillian Bentley gonadal regulation, they contribute to provide information concerning the action Department of Anthropology, Durham University, Durham, UK. of endocrine disruptors, which need to be considered when assessing the effects on human health.

Background Human saliva is a valuable and flexible source of endocrine biomarkers, from which several significant steroids representing indices of development, well being, stress and reproduction can be quantified. Although for many disciplines blood represents the ‘gold standard’ for endocrine measurement, it also has its limitations, specifically requiring trained phlebotomists and appropriate facilities. The painful and invasive nature of blood draws can deter research participation and restricts frequent collection. Alternatively, saliva collection is straightforward P298 in settings beyond clinical and laboratory boundaries and advances our access to An unusual case of hypoadrenalism presenting with hypercalcaemia populations and behavioural contexts for which blood sampling is unfeasible. following severe Legionella sepsis Objectives Hayley Bentley, Ye Kyaw, Emma Bingham & Jennifer Tringham This validation project investigates optimal protocols to adopt when collecting Frimley Park Hospital NHS Trust, Frimley, Surrey, UK. and storing saliva to improve reliability and increase comparability across research sites and studies. Our primary objective was to investigate and validate methods to successfully preserve saliva in a manner compatible with Enzyme Hypercalcaemia is a rare, albeit well-described feature of hypoadrenalism, Immuno-Assay (EIA). Identification of a preservation method could enhance although the mechanism underlying this is remains controversial. Primary adrenal flexibility of both field site conditions and collection protocols. This work is failure is known to occur secondary to infective agents, and indeed tuberculous critical as previously established preservatives, such as sodium azide that were infiltration of adrenal tissue represents one of the leading aetiologies worldwide. compatible with RIA, interfere with Horseradish Peroxidase commonly found in Primary adrenal failure has also been shown to occur secondary to sepsis with most EIA preparations. Meningococcus or Pseudomonas species, but classically this presents with an Methods acute adrenal failure in the Waterhouse-Friderichsen syndrome. Ethical Approval was granted by the local recognised University Ethics We present the case of a 48-year-old woman who presented in July 2010 with a Committee. Raw human saliva samples were collected, spiked with different severe legionella pneumonia and septicaemia necessitating ventilatory and concentrations of the preservative Proclin300 and stored at room temperature. circulatory support in the Intensive Care Unit. Her illness was complicated by Following defined time periods (7d, 1, 3 and 6 months) samples were analysed for peripheral ischaemia, which led to her having bilateral below knee, multiple right reproductive steroids using commercially available EIA kits, estradiol and finger, and left hand amputations. She made a steady systemic recovery, but two progesterone. months following her admission was noted to have a persistently raised serum Results and conclusions corrected calcium level. Investigation of this excluded common aetiologies, and Early results suggest that Proclin300 has potential for preserving saliva samples. she went on to have a short Synacthen test, which showed a baseline cortisol of Further novel preservation data are presented. We also report the stability of 146 nmol/l, and a 30 min cortisol level of 357 nmol/l, consistent with a diagnosis saliva content in conjunction with collection vial material (e.g. polystyrene, of hypoadrenalism. The patient was started on hydrocortisone replacement, and polypropylene). Such validation data are essential to further develop opportu- within a few days her calcium level had returned to normal. nities to capture endocrine profiles that are beyond reach of clinical settings. Primary adrenal failure has been shown to occur acutely during septic episodes, however we have found no reports of this occurring following Legionella sepsis. This case is interesting both in terms of the rare presentation with hypercalcaemia, because of the duration between the septicaemia and the development of hypoadrenalism, and because of the association of this with an unusual organism.

P297 Effects of endocrine disruptors in adult rats: integrative evaluation from gonadal steroidogenic gene expression profiles to hormonal balance P299 Nadia Quignot1, Sophie Desmots1, Robert Barouki2 & A retrospective analysis of Short Synachthen Tests to assess the effect of Emmanuel Lemazurier1 a change in the normal reference range 1Ineris, Verneuil-en-Halatte, France; 2INSERM U747, Paris, France. Thomas Fox1,2, Vicky Clough1 & Daniel Flanagan1,2 1Derriford Hospital, Plymouth, UK; 2Peninsula College of Medicine and Dentistry, Devon, UK. Endocrine disruptors are chemicals that can alter functions of the endocrine system by several ways. Their risk assessment with regard to REACH legislation remains a challenge. In the present study, we propose an integrative evaluation for The short synacthen test (SST) is the first-line test of adrenal insufficiency. the effects of some endocrine disruptors on hormonal balance in male and female Different centres have varying protocols for cortisol response. At Derriford adult rats. We focused our work on the last step of steroidogenesis, where two Hospital cortisol is measured at 0, 30 and 60 min post-synacthen 250 mg enzymes are implicated: aromatase, which plays a central role by catalyzing the (i.m./i.v.). A normal response is judged with a measured cortisol O550 nmol/l. irreversible conversion of androgens to estrogens, and 17b-hydroxysteroid A recent national audit questioned the bias created by the discrepancy between dehydrogenase, which catalyses the conversion of inactive sexual hormones to true cortisol (measured by mass spectrometry) and many laboratory assays. We active ones. carried out a retrospective study of the last 12 months of SST to assess the effect We have evaluated the selected chemicals for their ability to i) modulate the of a change of reference range for normal cortisol response from 550 to expression and activity of steroidogenic enzymes in gonads, to ii) disrupt 465 nmol/l and to assess the utility of both a 30 and 60 min cortisol measurement. hormonal balance, and to iii) disrupt certain fertility parameters, during a Data was obtained for 157 SSTs carried out. 137 (87.3%) passed with a peak sub-acute exposure. Gene expression profile was assessed by RT-qPCR, ex vivo cortisol O550 nmol/l compared with 144 (91.7%) pass rate O465 nmol/l. aromatase activity was assessed by the method of tritiated water, blood and There were 7 (4.5%) tests in which a reduction of the target cortisol from O550 to gonadal steroid concentrations were evaluated with LC–MS/MS. O465 nmol/l would have resulted in a test being passed instead of failed. 2 results Our results showed that all treatments induced disturbance of hormonal balance, were from the same patient and 1 was discounted as only a 90 min sample was related or not with gene expression disorders. For example, rats treated with taken. Only 1 case lead to regular hydrocortisone therapy initiation. In two cases atrazine presented high levels of estradiol and low levels of testosterone. It may be the patient was retested and subsequently passed the SST. In one case advice was related to aromatase induction observed in testes and ovaries as well as in gonadal given but no treatment was commenced. In the final case repeat testing was primary cultures. A decrease of testosterone level is also observed in male rats planned the following year. treated with methoxychlor, which can be linked not only to aromatase induction, Only 5/157 (3.2%) of the 60 min cortisol samples were lower than the 30 min but also to HSD17B3 down-regulation. cortisols (the overall SST result was unchanged in these cases).

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It was concluded that the results of an SST always requires interpretation in view The index case presented aged 4 years with hypoglycaemia after prolonged of the clinical scenario. Alteration of the reference range for cortisol would lead to fasting during a respiratory tract infection. She had further hypoglycaemic attacks an increased pass rate but might not change management greatly. The test should and was diagnosed with hypocortisolemia at 6 years (14 nmol/l during be repeated if the re is any doubt. hypoglycaemia) and hypercorticotropinemia (ACTH O1250 pg/ml). Her parents were consanguineous and she had one unaffected sister. Her physical examination was normal except her height and weight were greater than the 97th centile for age. Interestingly, she had no hyperpigmentation despite very high ACTH levels. Nucleotide sequence analysis revealed homozygous mutations c.478COTin MC1R and c.455COAinMC2R leading to R160W and T152K changes in the proteins respectively. The R160W MC1R change has previously been implicated in a red hair/pale skin phenotype and the T152K change in MC2R is novel. Both parents were P300 heterozygous for the mutations and her unaffected sister was heterozygous for the Concurrent analysis of 10 serum steroids by mass spectrometry: MC1R mutation and had a wild-type MC2R. investigation of the viability of the Perkin-Elmer CHSe MSMS steroids We report an unusual case of FGD without hyperpigmentation due to co-existent kit on a waters xevo mass spectrometer with acquity UPLC system MC1R/MC2R mutations. This case is important as it clearly demonstrates for the Angela Taylor1, Cedric Shackleton1, Stuart Taylor2, Ulrich Glumer Jensen2, first time that the assumption that skin pigmentation is caused by the action of Marko Ojala2 & Wiebke Arlt1 ACTH on the MC1R is correct. 1University of Birmingham, Birmingham, UK; 2Perkin-Elmer LAS (UK) Ltd, Buckinghamshire, UK.

Steroids present in human serum can be used to identify a number of conditions such as congenital adrenal hyperplasia, Addison’s disease and Cushing’s disorder. Historically this has been completed using immunoassays; currently there is a move towards mass spectrometry which reduces analysis time, cross reactivity and P302 improves sensitivity. When mass spectrometers are coupled with liquid Cushing’s syndrome in a patient with two lung tumours chromatography systems (LC–MS) it is possible to monitor a number of steroids Haliza Haniff, Andrew F Scarsbrook & Stephen M Orme in a single assay. Problems with inter-laboratory variation of LC–MS results can Leeds Teaching Hospitals NHS Trust, Leeds, UK. lead to errors when analysing nationwide data sets. Implication of a kit with its own mass spectrometry parameters such as sample preparation methods, columns, solvent additives and mass transitions should reduce inter-laboratory variation. A 21-year-old man presented with 2 months history of weight gain, acne, Recent introduction of a 10 steroid serum kit (Perkin-Elmer) has been completed, hirsutism, lethargy, and muscle weakness. Examination revealed that he was due to the number of different mass spectrometers available these kits needs to be cushingoid in appearance, had pustular acne and proximal myopathy. Initial 24 h thoroughly tested on a number of systems to ensure comparability. The viability of urinary free cortisol was significantly raised at 5320 nmol/day (10–147), with the Perkin-Elmer 10 steroid CHS MSMS kit was examined on a Waters Xevo TQ raised ACTH of 120 ng/l (!47). He failed to suppress his cortisol on the low dose mass spectrometer with an Acquity UPLC system. We carried out concurrent dexamethasone suppression test (baseline 708 nmol/l and 48 h 706 nmol/l). analysis over a range of concentrations for each steroid: aldosterone (0.8– Urinary and plasma 5-HIAA were normal. MRI pituitary showed no abnormality. 18 nmol/l), androstenedione (0.3–74 nmol/l) corticosterone (1–204 nmol/l), He was started on metyrapone. cortisol (5–1008 nmol/l), DHEA (1–255 nmol/l), DHEAS (37–7557 nmol/l), Thoracic CT scan revealed a 2 cm spiculated soft tissue nodule in right upper lobe 11-deoxycortisol (0.2–54 nmol/l), 17-hydroxyprogesterone (0.5–77 nmol/l), pro- and 1 cm well defined, round nodule in the left lower lobe. Further imaging gesterone (0.5–91 nmol/l) and testosterone (0.1–26 nmol/l). The method was (octreotide scan & PET-FDG scan) revealed the nodules to be consistent with validated through investigation of spiked serum (Randox) and sera of healthy functioning neuroendocrine tumours, with the right upper lobe nodule being volunteers. Concurrent analysis of 10 steroids using LC–MS was completed with markedly more FDG-avid than the left. The adrenal glands were bulky consistent reliable quantitation in !15 min. For optimum results using a Xevo mass with ACTH-driven adrenal hyperplasia. spectrometer a number of parameters were adjusted, for example the ESI source The patient underwent a right upper lobectomy but histology revealed an was superior to the APCI and some mass transitions were altered. unexpected finding- cryptococcal infection instead of a neuroendocrine tumour. The concurrent analysis of multiple steroids in a single LC–MS run demonstrates a He had never travelled abroad and was HIV negative. Post-operatively, his major advance in the fast reliable diagnosis of steroid related disorders, which can Cushing’s was still active and he was recommenced on metyrapone. He also be employed in clinical laboratories. received fluconazole for 6 months. He then underwent inferior petrosal sinus sampling (IPSS) which did not indicate a pituitary source of ACTH. He subsequently had a left lower lobectomy. Histology and immunohistochemistry confirmed a carcinoid tumour. Post- operatively, his IMGST showed a peak cortisol of !50 nmol/l indicating cure. Although there are a handful of cases describing opportunistic cryptococcal infection in pituitary Cushing’s disease, we believe that this is the first described case of opportunistic cryptococcal infection in a patient with Cushing’s syndrome due to bronchial carcinoid. P301 An atypical case of familial glucocorticoid deficiency without pigmentation caused by coexistent homozygous mutations in MC2R (T152K) and MC1R (R160W) Claire Hughes1, Serap Turan2, Zeynep Atay2, Tulay Guran2, Abdullah Bereket2, Adrian Clark1 & Louise Metherell1 1Bart’s and the London School of Medicine, Centre for Endocrinology, P303 WHRI, London, UK; 2Department of Paediatric Endocrinology, Marmara Accidental long-term ingestion of androgenic steroid in a young female: University, Istanbul, Turkey. a case report Venkata Katreddy, Jane Dale & Haroon Siddique Russells Hall Hospital, Dudley, Westmidlands, UK. Familial glucocorticoid deficiency (FGD) is a rare autosomal recessive disorder characterised by unresponsiveness to ACTH and isolated cortisol deficiency. FGD is caused by mutations in genes encoding the ACTH receptor (melanocortin Aim 2 receptor (MC2R)), its accessory protein (MRAP) or the steroidogenic acute We present an unusual case of long-term accidental ingestion of androgenic regulatory protein (StAR). One significant feature is generalized skin steroid in a young female. hyperpigmentation which is thought to be due to elevated ACTH acting on the Case melanocortin 1 receptor (MC1R). MC1R plays a central role in the regulation of A 28-year-old lady presented with male pattern of hair growth, weight gain of skin pigmentation, is expressed in melanocytes and binds a-MSH and ACTH with three stones, change in voice, and secondary amenorrhea. On direct questioning similar affinity. MC1R activation increases the ratio of black, strongly she admitted she was taking ‘fat bursting pills’ for nearly 6 months, obtained from photoprotective eumelanins to reddish, poorly photoprotective pheomelanins. a gym, to lose weight. Examination revealed a blood pressure of 150/77 mmHg, Several MC1R variants are associated with red hair/fair skin. increased muscle bulk, hirsutism and significant clitoromegaly.

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Investigations morning cortisol concentration one should consider performing the SST. FSH 1.8 IU/l, LH 0.9 IU/l, oestradiol 169 pmol/l (8–2500), prolactin 268 mU/l Methods (0-445), SHBG 16 nmol/l (18–114), androstenedione 9.7 nmol/l (1.0–11.5), 17 Retrospective observational study of consecutively performed SST (250 mg) OH progesterone of 2.9 nmol/l (0.7–17.4) and testosterone of 29.2 nmol/l (0–2.8). between January 2009 and March 2010. Plasma cortisol was measured by enzyme Ultra sonogram showed normal ovaries, MRI revealed normal adrenal glands. immunoassay (Siemens Advia, Siemens plc, UK). A cut-off value of The pills were stopped immediately. Within 4 months she had substantial weight R550 nmol/l was used to differentiate adequate from inadequate response. loss, her periods returned, her physical appearance changed and blood pressure Results dropped to 116/80 mmHg. The testosterone levels dropped to 3.7 nmol/l and 76 consecutively reviewed endocrine out patients (females n (%), 53 (70)), SHBG improved to 31 nmol/l. median age (interquartile range) 46.5 (35.0–55.7) years underwent SST. Baseline Discussion and 30–min cortisol levels were 367 (266–502) and 745 (640–845) nmol/l Androgenic steroid hormones are increasingly used by male and some female respectively. Cortisol levels increased by 318 (219–436) nmol/l. There was no athletes to improve their performance. In one survey with 1667 participants correlation between age and rise in cortisol level from baseline. There was no w2.3% of women had taken androgenic steroid at some point. Our case is unique significant difference between baseline and 30 min cortisol and rise in cortisol as the ingestion was accidental and had resulted in physical changes. Change in between males and females. 50% (7/14) patients with baseline cortisol voice, increased facial hair growth, clitoromegaly, decreased body fat, menstrual !250 nmol/l had 30 min cortisol !550 nmol/l. No patient with a baseline irregularities and aggressiveness are some of the perceived side effects. Chronic cortisol O250nmol/l had 30min cortisol !550 nmol/l (sensitivity 57%, administration results in supraphysiological concentrations of testosterone and specificity 91%). 92% (70/76) underwent the test before 1100 h. 30 min (not decreased SHBG as seen in our case. Stopping the pills resulted in reversal of baseline) cortisol levels of the SST done after 1100 h versus before 1100 h were these values. The reversal of clinical and biochemical abnormalities, confirms the significantly lower, 751 (642–851) vs 642 (524–699); PZ0.04. diagnosis of exogenous androgenic steroid ingestion. Conclusion Conclusion Morning (before 1100 h) cortisol levels of O250 nmol/l seems to be associated Accidental ingestion of long term androgenic steroid is uncommon. A clear with adequate adrenocortical reserve. In such situations it may not be necessary to history and a high level of suspicion are helpful in such circumstances, for the do a SST, unless clinical suspicion is high. Further studies are needed to managing physician. determine the effect of timing of SST on its sensitivity and specificity.

P304 Exogenous Cushing’s syndrome due to topical corticosteroid P306 application Ahmed Elsadig, Nisha Kaimal & Tara Kearney Why does MRAP2 fail to save familial glucocorticoid deficiency type 2 Salford Royal Hospital, Manchester, UK. patients? Rebecca Gorrigan, Leonardo Guasti, Adrian Clark & Li Chan Barts and the London School of Medicine and Dentistry, London, UK. Introduction Prolonged use of topical corticosteroids causes systemic adverse effects including Cushing’s syndrome and hypothalamic–pituitary–adrenal (HPA) axis suppres- Background and aims sion, which is less common than that of the oral or parenteral route. The melanocortin-2-receptor accessory protein (MRAP) is essential for History melanocortin-2-receptor (MC2R) function through receptor trafficking and A 31-year-old female patient was referred from the dermatology clinic with signalling, enabling adrenal glucocorticoid synthesis in response to ACTH symptoms and signs consistent with Cushing’s syndrome. She has been treated for stimulation. Disabling mutations of MRAP result in life-threatening glucocorti- psoriasis with a prolonged course of topical corticosteroids. She has been using coid deficiency, known as familial glucocorticoid deficiency type 2. MRAP has a the cream more often than has been advised by the treating dermatologist. single paralogue in the human genome, MRAP2. In vitro MRAP2 has a similar Clinical examination action to MRAP, facilitating MC2R function. However patients with FGD type 2 Examination showed excess facial hair, moon-shaped face, centripetal obesity, fail to be rescued by a functioning MRAP2 protein – the aim of this study is to purple striae on abdominal wall, an obvious buffalo hump and some areas of investigate why. pigmentation in her skin. Systems examination revealed proximal myopathy. Methods Investigations and diagnosis cAMP production in response to ACTH stimulation of HEK293 cells transfected 9 am cortisol was !10 nmol/l. Short synacthen test showed cortisol level of with MC2R and MRAP/MRAP2/MRAP and MRAP2 was quantified using dual- !10 nmol/l at 0 min, 29 nmol/l at 30 min. She was diagnosed with exogenous reporter luciferase assays. In situ hybridisation (ISH) was used to localise adrenal Cushing’s syndrome due to topical corticosteroid application. MRAP, MRAP2 and MC2R mRNA expression. MRAP and MRAP2 adrenal expression was quantified using real-time qPCR. Results Higher concentrations of ACTH were required to induce cAMP production in HEK293 cells transfected with MC2R/MRAP2 compared with cells transfected with MC2R/MRAP (EC50 9.33e-007 vs 1.08e-009; P!0.0001). ISH demon- strated MRAP and MC2R expression in the adult rat zona fasciculata (ZF), (in cells capable of glucocorticoid synthesis), with highest concentrations in the undifferentiated zone (in cells incapable of glucocorticoid synthesis). MRAP2 was expressed at low levels throughout the adrenal cortex. Real-time qPCR of adrenal cDNA demonstrated a 20-fold greater expression of MRAP compared with MRAP2. P305 Conclusions Is there a threshold morning cortisol level at which to perform the short – MRAP2 enables MC2R function only when stimulated with supraphysiological synacthen test? ACTH concentrations. Sumudu Bujawansa, Shalini Kunasegaran, Steve McNulty, Kevin Hardy, – MRAP expression is 20-fold greater than MRAP2 expression in the human Mohammad Al-jabouri, Niall Furlong & Upendram Srinivas-Shankar adrenal gland. St Helens and Knowsley Teaching Hospitals NHS Trust, St Helens, UK. – MRAP2 is expressed throughout the rat adrenal cortex. Its role in the adrenal gland remains unclear. – Adrenal MRAP and MC2R expression is confined to the ZF and highest Introduction expression is seen in the undifferentiated zone of the adult rat adrenal, suggesting Short synacthen test (SST) is of value in assessing the adequacy of hypothalamic– ACTH may have a role in adrenal cell differentiation and migration. pituitary–adrenal axis (HPA). Although it is extensively used, it is unclear at what

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P307 Derivatisation using FMP and dansyl chloride may be used for quantitative Epidemiology of Addison’s disease in the area of banbury, oxfordshire analysis of estrogens in men and postmenopausal women. The sensitivities John Komninos, Sybil Kohler, Niki Karavitaki & John Wass achieved using these agents was comparable but enhanced selectivity was Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, achieved using FMP since the product ion relates to the steroid moiety. This Oxfordshire, UK. approach could be extended to include other phenolic steroids.

Introduction Addison’s disease (AD) is a rare condition (reported prevalence of 40–110 per million) that requires prompt recognition and optimal management to prevent the risks associated with cortisol deficiency. Aim P309 To assess the prevalence, presentation and clinical course of patients diagnosed Utility of basal DHEAS measurement in the detection of subclinical with AD in the geographical area of Banbury in Oxfordshire. autonomous glucocorticoid hypersecretion in adrenal incidentaloma Patients and methods Anand K Annamalai1,2, Narayanan Kandasamy1,2, Natalie Freeman1,2, Notes of subjects with AD currently registered in 15 of the Surgeries in the area of Kuhan Venugopal1,2, Jonathan Chia1,2, Ashley Shaw1,3, Helen L Simpson1,2, Banbury were reviewed. All cases of AD were found following an exhaustive David Halsall1,4 & Mark Gurnell1,2 computer database search of agreed terms by the staff of each Practice. 1Addenbrookes Hospital, Cambridge, UK; 2Wolfson Diabetes and Results Endocrine Clinic, Cambridge, UK; 3Department of Radiology, Cambridge, Amongst a population of 81 225 inhabitants, 15 patients (8 females/7 males) were UK; 4Department of Biochemistry, Cambridge, UK. diagnosed with AD, yielding a prevalence of 185 per million. Median age of diagnosis was 36 years (range 10–71). Median time to diagnosis since the first Background manifestations of the disease was 9 months (range 0.5–42) and the most frequent Adrenal incidentalomas (AI) are identified in 4–7% of patients O40 years ones were tiredness (64.3%) and weight loss (64.3%). At diagnosis, the most undergoing abdominal CT/MRI. Evidence of subclinical autonomous glucocorti- frequent manifestations were postural dizziness (85.7%), nausea or vomiting coid hypersecretion (SAGH) is found in 5–10% of cases depending on the (78.5%) and abdominal pain (57.1%). Adrenal antibodies were identified in 7 diagnostic criteria/thresholds adopted. (46.7%) patients. Other autoimmunities/endocrinopathies (most commonly Aim thyroid disease and gonadal failure), suggested autoimmune adrenal insufficiency To examine the utility of basal DHEAS measurement in the detection of SAGH in 10 patients (prevalence of 123 per million). In two cases cause was adrenal in a cohort of patients with AI. hemorrhage, one was diagnosed with haemochromatosis, while in two the cause Methods remained unclear. Median follow up period was 10 years (range 1.8–46.3). Mean Ninety-six consecutive subjects (49 females, 47 males: mean age 62 years, range daily hydrocortisone and fludrocortisone replacement dose at last assessment was 29–84 years) were referred to our clinic over a 3-year period. All patients were 22.3 mg and 96.2 mg, respectively. Most frequent complaints on follow up were assessed by two clinicians (AA and MG), and underwent repeat dedicated adrenal excessive weight gain (33.3%) and tiredness (33.3%). imaging and biochemical profiling, including overnight dexamethasone suppres- Conclusions sion testing (normal cortisol suppression: !50 nmol/l). Cases in whom there was Prevalence of AD in Banbury is higher than described in literature and in line with no clinical or biochemical evidence of endocrine hyperfunction, and with recent reports suggesting rising of its incidence. Alertness on early manifestations appropriate radiological features, were categorised as non-functioning adrenal can reduce diagnostic delay and risks associated with unrecognized cortisol adenomas (NFAA). SAGH was confirmed by the finding of low ACTH levels, deficiency. abnormal circadian rhythm, and failure of cortisol to suppress during a 48 h low dose dexamethasone suppression test (normal: !50 nmol/l). DHEAS levels were classified as undetectable, suppressed (but detectable) and normal. Results Amongst NFAA (nZ41), DHEAS levels were normal in 38, suppressed in one, and undetectable in two subjects. Amongst SAGH (nZ18) subjects, nine had undetectable DHEAS, three had suppressed, and six normal levels. Receiver operating characteristic analysis using DHEAS concentration to diagnose SAGH returned an area under the curve of 0.85 (0.75–0.96). At the optimum cut-off of P308 0.9 nmol/l, sensitivity and specificity were 78% (52–94%) and 74% (58–87%) Derivatisation of estrogens enhances sensitivity of analysis by liquid respectively. At a cut-point of 0.5 nmol/l the test is specific (95%) with a chromatography tandem mass spectrometry sensitivity for the detection of SAGH of 50%. Natalie Homer, Diego Cobice, Fraser Gibb, Gregorio Naredo, Conclusion Scott Denham, Brian Walker & Ruth Andrew The finding of a subnormal DHEAS level in a patient with an AI is an important University of Edinburgh, Edinburgh, UK. pointer to the potential presence of SAGH and merits further investigation.

Circulating estrogens decrease after the menopause from 60–400 to 5–30 pg/ml in postmenopausal women and in men are below 30 pg/ml. These low physiological concentrations present an analytical challenge. Analysis of steroids by tandem mass spectrometry is attractive due to its high specificity compared with immunoassays. However, estrogens do not ionise efficiently and therefore chemical modifications are necessary to achieve the sensitivity required. Two derivatising agents were evaluated; dansyl chloride and 2-fluoro-1- P310 methylpyridinium (FMP). These react with the phenolic moiety of estrogens Effects of topical betamethasone and calcipotriol therapy in improving and introduce an easily ionisable and charged group respectively. Reaction the tolerogenic potential of a ‘vaccine’ for type 1 diabetes conditions, short term stability, linearity of response and limit of quantitation Mohammad Alhadj Ali1,2, Sally Thrower1, Stephanie Harris2, Susan Wong2 (LOQ) were assessed. & Colin Dayan1 Analysis was performed on a TQ2 quantum discovery triple quadrupole mass 1Henry Wellcome Laboratories, University of Bristol, Bristol, UK; spectrometer in positive electrospray ionisation mode with a Surveyor LC, 2 ! Department of Cellular and Molecular Medicine, University of Bristol, equipped with a Waters Atlantis T3 3 mm; 2.1 100 mm column. Bristol, UK. Transitions for dansylated estrone (E1) and estradiol (E2) were m/z 504-O171 and m/z 506KO171 respectively, and in both cases the product ion related to the dansyl moiety. The FMP derivative of E1 gave m/z 362KO252 and that of E2 Introduction gave m/z 364KO128; the product ions represented the steroid fragment. Peptide immunotherapy has been shown to be a simple and effective method of Fragmentation patterns were corroborated using 13C- and 2H-labelled estrogens. restoring tolerance and reversing disease in animal models of type 1 diabetes. It is Rapid reactions were achieved with dansyl chloride (60 8C, 10 min) or FMP highly important to administer the peptide interadermally into an environment in (30 8C, 5 min), permitting high-throughput. Responses were linear between 2 and which antigen presenting cells such as dendritic cells are maintained in a 500 pg/ml (r 2O0.99). Short term stability was acceptable with no detectable tolerogenic state. degradation of derivatives over 30 h. The LOQ was 2 pg/ml for both estrogens Objective and both derivatives. E1 and E2 were analysed simultaneously with run times of Our aim was to determine whether topical pre-treatment of the skin has the 10 min/sample. potential to enhance tolerogenic immunity during peptide immunotherapy.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Methods Objective Healthy volunteers received one of three pre-treatment regimes twice daily for Are to find out the prevalence and complications of overt and subclinical 4 days to the skin of a small area of the arm: 0.05% betamethasone (S), 50 mg/mg hypothyroidism among pregnant Saudi women living at ALMadinah region. calcipotriol (D), 0.05% betamethasoneCcalcipotriol (SCD). 12 h later, all Materials and methods subjects had a 10–15 mm suction blister raised at the site of treatment. Blister A hospital-based prospective study performed at Madina Maternity and Children fluid was then withdrawn for the measurement of cytokine production. The blister hospital and Ohud hospital, were Nine hundred and thirty six pregnant women roof was removed and epidermal cells isolated for study using 9-colour flow between 12 and 30 weeks of gestation enrolled between July 2009 and June 2010. cytometry and for functional analysis in a mixed lymphocyte reaction (MLR) All women received the usual anti natal care. TSH level estimation was done and using allogeneic PBMC. if TSH level was deranged then free T4, free T3 levels were added. Patients were Results managed accordingly. Epidermal cells comprised around 2% of the CD1aC dendritic cells (EDC). In S Results subjects MLR proliferation was markedly suppressed with an associated (9.3%) pregnant women were found to have overt hypothyroidism, and (14.9%) reduction in interferon-g (IFN-g), interleukin 2 (IL2), and IL13 in the blister were diagnosed as subclinical hypothyroidism, reflecting high prevalence rate for fluid. However, IL10 remained constant. A reduction in expression of CD86 and both disorders. There was a high rate of caesarean section (35.6%)* for women HLA-DR was seen in CD1aCEDC from S subjects but ILT3 expression was with overt hypothyroidism and of (30.2%)* for women with subclinical maintained. In contrast, D had no effect on MLR proliferation, but tended to hypothyroidism. reduced CD40, CD80 and ILT3 expression on EDCs. SCD had little effect on Gestational DM developed in (23%)* of women with overt hypothyroidism and proliferative responses but reduced expression of CD86 by EDC. (34.5%)* with subclinical hypothyroidism. Intrauterine foetal deaths complicated Conclusion (3.4%)* of overt hypothyroid pregnant women, a low apgar score at delivery was Pretreatment of the skin for as little as 4 days appears to have marked effects on encountered in (16.1%)* of neonates of overt hypothyroid mothers and (10.1%) epidermal dendritic cell function. Further functional studies are required to of neonates of subclinical hypothyroid mothers. determine which combination will prove optimal for tolerance induction in Conclusion peptide immunotherapy. Pregnancy was associated with a high prevalence rate of subclinical and overt hypothyroidism among pregnant Saudi women. Significant adverse foetal and maternal outcomes may be prevented by screening all Saudi pregnant women as early as first antenatal visit by simple TSH testing. P311 Hepatic 11b-hydroxysteroid dehydrogenase type 1 expression is dynamically related across the liver lobule and is linked to metabolic status Adeeba Ahmed, Nina Semjonous, Elizabeth Rabbitt & Paul Stewart P313 University of Birminghan, Birmingham, UK. Hashimoto’s encephalopathy: an unusual cause for coma Aswathiah Srinath & Serife Mehmet Nearly all the functions of the liver display zonation in distribution within each Queen Marys Hospital, Sidcup, Kent, UK. the lobule. Hepatic cortisol availability is controlled by enzymes that regenerate cortisol from inactive cortisone (11b-hydroxysteroid dehydrogenase type 1, 11b- A 58-year old female with long standing type 1 diabetes and treated HSD1). Dysregulation of hepatic 11b-HSD1 activity has been implicated in hypothyroidism presented to casualty with a 1-day history of vomiting and insulin resistance. Key processes such as gluconeogenesis are located in the breathlessness. Clinically she was dehydrated with a depressed conscious level periportal hepatocytes, although current dogma describes hepatic 11b-HSD1 to (GCSZ12). Initial investigations confirmed diabetic ketoacidosis (pHZ6.8, show strong pericentral zonation. bicarbonateZ4.7 mmol/l, urinary ketonesZ4C, blood glucoseZ54.6 mmol/l) 11b-HSD1 immunohistochemistry and laser capture microdissection studies for and acute renal failure, likely to be secondary to pneumonia as there was mRNA expression on normal human liver samples showed strong pericentral consolidation on her CXR and a raised WCC. Despite correcting her acidosis and staining and variable degrees of periportal staining in different samples. It was electrolyte disturbances and treating her sepsis she remained drowsy and was speculated that this may be related to hepatic energy state. subsequently ventilated. Abnormal bodily movements were observed. Brain MRI Male C57BL/6 mice age 10 weeks (6 per group) had livers harvested after timed was normal and EEG showed generalised slow waves with diffuse cortical fast of 0, 2, 4, 8 and 12 h, and refed for 12 h following a 12 h fast. 11b-HSD1 dysfunction without any epiletiform features. Lumber puncture showed raised protein expression was increased throughout the liver parenchyma as well in CSF protein with negative viral PCR studies. Abnormal admission TFTs were pericentral areas, in addition to intense periportal staining of hepatic 11b-HSD1 noted: FT4Z8.0 pmol/l (NR: 9.0–19.0), TSHZ0.72 mIU/l (NR: 0.35–4.94). in the fasted mice. Periportal expression was minimal in livers from fed and Thyroid microsomal antibodies were raised: 113 IU/ml (NR!50). Four months refed mice. prior to admission TFTs were normal (FT4Z15.3 pmol/l, TSHZ0.48 mIU/l) on This zonation of 11b-HSD1 expression is entirely novel but may account for some 100 mg of thyroxine. TFTs may be in keeping with the sick euthyroid syndrome of the known actions of GC in the liver. This may account for some of the known but hashimoto’s encephalopathy was considered especially as other causes for actions of GC in the liver. Periportal cortisol generation during fasting would coma were excluded. Subsequently she was commenced on intravenous promote metabolic processes including gluconeogenesis. Conversely, in the fed Methylprednisolone and gradually ventilatory support was weaned off. A full state, pericentral cortisol generation would promote pericentral metabolic recovery was made. Hashimoto’s encephalopathy is a rare condition charac- functions including lipogenesis. This strongly implicates hepatic 11b-HSD1 in terized by non-specific neurological and/or psychiatric symptoms often the regulation of key hepatic metabolic functions in health, with of course the associated with high serum and/or CSF levels of anti-thyroid antibodies, possibility of dysregulation having impact upon metabolic disease states increased CSF protein concentration, non-specific diffuse EEG abnormalities, including insulin resistance and diabetes mellitus. At a molecular level, dynamic and responsiveness to treatment with steroids. Many cases go undiagnosed. hepatic 11b-HSD1 expression has key implications upon the regulation of hepatic Hashimoto’s encephalopathy should be considered in ‘investigation negative ER nutrient signalling. These concepts represent a significant paradigm shift in encephalopathies’ as it is responsive to steroid therapy and is readily reversible. the thus far understood role and expression of hepatic 11b-HSD1. Normal or slightly abnormal TFTs do not exclude the diagnosis. The association with type 1 diabetes is not well reported.

P312 Prevalence of overt and subclinical hypothyroidism among Saudi pregnant women attending tow referral hospitals in Saudi Arabia and P314 associated maternal and fetal complications Carbimazole embryopathy: implications for the choice of antithyroid Inass Taha & Jihan Alhazmi drugs in pregnancy Taibah University, Almadinah, Saudi Arabia. Pamela Bowman, Nigel Osborne, Rachel Sturley & Bijay Vaidya Royal Devon and Exeter Hospital, Exeter, UK. Background Thyroid disorders are among the common endocrine problems in pregnant Background women. Overt and subclinical hypothyroidism has been shown to be associated Maternal thyrotoxicosis affects 0.2% of pregnancies. Pharmacological treatments with an adverse outcome for both the mother and offspring. include carbimazole, methimazole and propylthiouracil. The Endocrine Society

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK recommends the use of propylthiouracil as first line during pregnancy, because of P316 possible associations between carbimazole and congenital anomalies. However, The mystery of persistent thyrotoxicosis recent reports link propylthiouracil to liver injury in adults, children, pregnant Auditi Naziat1, Mohgah Elsheikh1,2 & Gearoid Kingston2 women and fetuses, raising questions over its safety. 1Oxford Centre for Diabetes, Endocrinology and Metabolism, Oxford, UK; Case 2Centre for Endocrinology, Royal Berkshire Hospital, Reading, UK. Our case is a 1-year-old girl who was exposed to carbimazole in utero due to treatment of maternal Graves’ disease. At conception her mother was taking 40 mg carbimazole with 100 mg thyroxine. On discovering she was pregnant, the We report an unusual case of struma ovarii diagnosed after thyroidectomy for thyroxine was stopped and the carbimazole gradually reduced to 10 mg for the Graves’ disease and papillary thyroid cancer. remainder of the pregnancy. The mother remained euthyroid. The baby was born A 46-year-old woman presented with a 3-month history of weight loss, at 38 weeks gestation by forceps delivery. Birth weight was within the normal palpitations and irregular periods. Physical examination revealed tachycardia, range at 2.78 kg. She was noted to have an atypical umbilical stump which was fine tremor and a diffuse goitre. TSH !0.1 (0.5–4.2 mU/l), FreeT4 26 (10.8– identified as a patent vitellointestinal duct. This was surgically repaired at the age 19.3 pmol/l) confirmed thyrotoxicosis. of 5 months. She also had a scalp defect consistent with aplasia cutis, Thyroid ultrasound scan showed a diffusely enlarged gland with an 8 mm solitary characteristic facial features (large forehead, broad flat nasal bridge and thin nodule in the left lobe and scintigraphy of the neck revealed diffusely increased upper lip) and persistent upper airway noise due to laryngomalacia. Further uptake. Fine needle aspiration cytology of the thyroid nodule was suspicious of a investigations excluded oesophageal atresia, tracheo-oesophageal fistula and follicular lesion (THY 3). She underwent a total thyroidectomy. Histology choanal atresia. revealed a papillary thyroid carcinoma, stage pT4 N1 Mx and the rest of the gland Evidence was consistent with Grave’s disease. Shortly after receiving Radio iodine ablation A review of English publications in Medline revealed 31 other cases of 2 or more for the thyroid cancer she became thyrotoxic (TSH!0.01, FT4 54, FT3 13). Post congenital anomalies reported in babies born to mothers treated with carbimazole ablation scan showed increased uptake in the lower abdomen. or methimazole in pregnancy. Anomalies in these cases include distinctive facial A CT scan of the pelvis revealed a 13 cm mass originating from the right ovary. features (68%), choanal atresia (65%), aplasia cutis (29%), nipple deformities She underwent a right salphingo- oophorectomy. The histology of the ovary (23%) developmental delay (16%), patent vitellointestinal duct (16%), tracheo- showed struma ovarii consistent of focally hyperplastic benign thyroid tissue oesophageal fistula (13%), oesophageal atresia (13%) and omphalocele (6%). which had completely replaced the normal ovarian tissue. Conclusion She remained euthyroid on levothyroxine replacement. Constellation of several congenital anomalies in our case and others supports the Reports of coexisting Graves’ disease and struma ovarii or papillary carcinoma concept of a carbimazole embryopathy and the Endocrine Society advice to avoid and struma ovarii are very rare and we believe this is the first case report carbimazole during the first trimester. confirming the clinical and pathological features of benign struma ovarii, Graves’ disease and papillary thyroid carcinoma in the same patient. Only 5–15% of women with struma ovarii develop hyperthyroidism. In our patient it is likely that the high iodine load given for radioablation triggered thyroid tissue hyperactivity in the struma ovarii and subsequent thyrotoxicosis. Ovarian metastasis from thyroid cancer is very rare and in our case there was no such histology evidence.

P315 P317 Outcomes of radioactive iodine treatment for hyperthyroidism: 1 year Anaplastic thyroid carcinoma presenting with stridor after ablative follow up survey in subjects attending a general hospital endocrine radioiodine therapy for Graves’ disease clinic Sajid Kalathil, Atif Munir & Sath Nag Rajesh Rajendran, Ramona Verdaguer & David Coppini James Cook University Hospital, Middlesbrough, UK. Poole General Hospital, Poole, UK. Anaplastic carcinoma accounts for !5% of thyroid cancer. The simultaneous Aim occurrence of anaplastic carcinoma (ATC) and Graves’s thyrotoxicosis is Retrospective survey on outcomes of 131I therapy in subjects with hyperthyroidism. extremely uncommon with only six cases described in the literature. Methods A 73-year-old female presented with weight loss and atrial fibrillation. We analysed the outcomes at 1 year, of 55 episodes of 131I therapy in 52 patients Investigations showed TSH-0.02 mU with T4-40 pmol/l and T3-16 pmol/l (36 males, 15 females) who were treated between January 2007 and January 2009. suggesting thyrotoxicosis.There was no thyromegaly or orbitopathy. TBII was Results elevated at 10.3 U/l suggesting Graves’s disease. Carbimazole was commenced At 1 year post 131I therapy, 31 (56.3%) subjects were hypothyroid (median age with good biochemical response followed by a 400 MBq dose of ablative I131. 54 years), 14 (25.5%) were euthyroid (median age 69 years) and 10 (18.2%) Post radioiodine hypothyroidism was managed with levothyroxine. remained hyperthyroid (median age 73 years). 31 subjects (56.3%) had Graves’ She presented four months later with severe respiratory distress. An anterior disease, 20 (36.4%) had mutlinodular goitre (MNG) and 4 (7.3%) were not indurated neck mass was noted. CT showed a diffusely enlarged, heterogeneous classified. thyroid gland with calcification causing laryngeal stenosis. Bronchoscopy In 39 female subjects treated with 131I, 22 (56.4%) became hypothyroid, revealed tracheal stenosis below the vocal cords due to external compression 10 (25.7%) remained euthyroid and 7 (17.9%) became hyperthyroid. Amongst the and tumour infiltration. FNAC was initially suspicious for papillary thyroid 16 male subjects, 9 (56.2%) became hypothyroid, 4 (25%) remained euthyroid, carcinoma but subsequent core biopsy immunohistochemistry was consistent with and 3 (18.8%) became hyperthyroid. anaplastic thyroid carcinoma. Surgical debulking of the tumour was planned and Out of 31 subjects who became hypothyroid, 21 (67.8%) had received 350 MBq, an elective tracheostomy performed. However her condition deteriorated acutely 9 (29%) had received 550 MBq and 1 (3.2%) had 650 MBq. Out of 14 subjects due to a respiratory tract infection and concurrent acute coronary syndrome. who were rendered euthyroid, 5 (35.7%) had 350 MBq, 8 (57.1%) had 550 MBq Palliative care was instituted and the patient died a week later. and 1 (7.1%) had 620 MBq. In the 10 subjects who remained hyperthyroid after Discussion 131I therapy, 5 (50%) had received 350 MBq and 5 (50%) had 550 MBq. Our case initially presented with Graves’ disease with no thyromegaly or palpable Thirteen subjects became profoundly hypothyroid (TSHO50) within one year. nodules and developed a massive tumour with compressive symptoms 8 months Of these, 10 (77%) had Graves’, 2 had MNG (15%) and 1 (8%) was not classified. later. 12 to 26% of patients with GD are reported to have palpable thyroid nodule 7 subjects (54%) had received 350 MBq whereas 6 (46%) had received 550 MBq and 33.6% when detected ultrasonographically. Malignancy rate of nodule of 131I therapy. detected in association with Grave’s disease is 10–17% and becomes higher if the Conclusions nodule is palpable or scintigraphically cold. Most carcinomas associated with Despite the relatively small sample size, age, sex, aetiology and dose of 131I did Graves appear to be papillary. There are case reports which show association with not seem to influence the outcome of 131I therapy. Although larger studies are Graves’s disease and ATC and it has been postulated that thyrotropin receptor needed to confirm our observations, our series suggests an increased risk of antibodies promote transformation in well differentiated thyroid cancer. Further profound hypothyroidism following 131I in subjects with Graves’ disease when studies are warranted to clarify whether Grave’s disease or thyroid stimulatory compared to subjects with MNG. receptor antibodies are independent risk factors for anaplastic transformation.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

P318 P320 Serum phosphate predicts temporary hypocalcaemia following Serum homocysteine concentrations in hypothroid, euthyroid and thyroidectomy hyperthyroid patients Amir H Sam, Waljit S Dhillo, Mandy Donaldson, Ahmad Moolla, Dariusz Kajdaniuk1, Bogdan Marek1, Danuta Niedziolka1, Karim Meeran, Neil S Tolley & Fausto Palazzo Elzbieta Swietochowska1,2, Gani Zeka1, Mariusz Nowak1, Imperial College London, London, UK. Lucyna Sieminska1, Joanna Glogowska-Szelag1, Beata Kos-Kudla1 & Zofia Ostrowska1,2 1Department of Pathophysiology and Endocrinology, Medical University of Background Silesia, Zabrze, Poland; 2Department of Clinical Biochemistry, Medical Temporary hypocalcaemia occurs in up to 40% of patients following a total University of Silesia, Zabrze, Poland. thyroidectomy. Serum calcium and parathyroid hormone (PTH) measurements are currently used to predict post-thyroidectomy hypocalcaemia. However, immediate access to PTH measurement is expensive and not widely available. Background Serum phosphate responds rapidly to changes in circulating PTH levels and its Thyroid hormone deficiency is associated with increased cardiovascular measurement is readily available in all hospitals. We evaluated the use of serum morbidity, which cannot be fully explained by the atherogenic changes in lipid phosphate to predict temporary hypocalcaemia post-thyroidectomy. profile observed in these patients. Hyperhomocysteinemia could help to explain Methods the increased risk for arteriosclerotic coronary artery disease in hypothyroidism We retrospectively assessed 111 consecutive patients who had total or completion because is an important and independent risk factor for cardiovascular disease. thyroidectomy. Patients had serum calcium and phosphate measured pre- Hypothyroidism decreases hepatic levels of enzymes involved in the remethyla- operatively, on the evening of surgery (day 0), on the morning of day 1 and tion pathway of homocysteine. over the following week as clinically indicated. Serum PTH was measured on the Aim morning of day 1. Vitamin D levels were measured pre-operatively. Hypothyroid (TSHO10 mIU/l, low fT4 and fT3) were compared with Results hyperthyroid patients and euthyroid control to examine the relationship among Seventy-six patients did not develop treatment-demanding hypocalcaemia. In homocysteine serum levels and thyroid hormonal status. these patients, the mean serum phosphate concentration was lower on the morning Material of day 1 compared to that on the evening of surgery. Seventeen patients with a Of 99 patients with hypothyroidism (27–59 years of age): 44 with autoimmune vitamin D O25 nmol/l developed hypocalcaemia requiring treatment from day 1 thyroiditis and 54 after thyroidectomy for thyroid multinodular goiter or onwards. All had an overnight rise in serum phosphate to O1.44 mmol/l (100% carcinoma. 63 patients with hypothyroidism (23–61 years of age): 28 with sensitivity and specificity for predicting hypocalcaemia). Twelve patients who toxic nodular goiter and 35 with Graves’ disease. Control group was consisted of had a vitamin D !25 nmol/l also developed hypocalcaemia but had an attenuated 30 healthy volunteers. rise in serum phosphate. Methods Conclusion Homocysteine serum concentration was measured by fluorimetric HPLC. Serum phosphate is a reliable biochemical predictor of post-thyroidectomy Results hypocalcaemia in patients without vitamin D deficiency. Use of serum phosphate Serum homocysteine levels were significantly higher in patients with may facilitate safe day 1 discharge of patients undergoing thyroidectomy. hypothyroidism in comparison with those of healthy controls (19.1G8.4 vs 10.2G2.7 mmol/l, P!0.05). Homocysteine levels were positively related to TSH blood concentrations and inversely related to folates. Thyroid hormone replacement significantly decreased homocysteine serum levels. There were no differences in homocysteine levels between patients with hyperthyroidism and healthy controls. P319 Conclusion We found an increase in serum homocysteine during hypothyroidism. The Audit on follow up of thyroid function tests done during osteoporosis increase in serum homocysteine concentration may confer increased cardio- screening vascular risk in hypothyroid patients. A Santhakumar, H Sugathan & D Woods Wansbeck General Hospital, Northumberland, UK.

Background National osteoporosis guideline group recommend routine measurement of thyroid function tests. However it is well recognised that abnormal thyroid P321 function tests done during acute hospital stays is not always suggestive of thyroid PTTG-binding factor (PBF) induces hyperplastic lesions in thyroids dysfunction and that they need to be repeated to determine the need for further of aged mice management. Martin Read1, Greg Lewy1, Neil Sharma1, Jim Fong1, Vicki Smith1, Aim Gavin Ryan1, Robert Seed1, Perkin Kwan1, Wendy Leadbeater1, To identify and assess the follow up of thyroid function tests (TFTs) done Adrian Warfield2, Jeffrey Knauf3, John Watkinson2, Jayne Franklyn1, between June 2009 and Feb 2010 in the orthopaedic ward of our hospital as part of Kristien Boelaert1 & Chris McCabe1 osteoporosis screening. 1University of Birmingham, Birmingham, West Midlands, UK; 2University Method Hospitals Birmingham NHS Foundation Trust, Birmingham, West TFTs requested from the orthopaedic ward at our hospital between June 2009 and Midlands, UK; 3Memorial Sloan-Kettering Cancer Center, New York, Feb 2010 were identified via the pathology lab database. Abnormal TFTs were New York, USA. followed up on the hospital database to determine if they had been repeated, investigated further or referred to the endocrine service. Results Previously we showed that thyroid-targeted overexpression of the PTTG binding Three hundred and three patients (65 males, 258 females) had TFTs requested factor (PBF) induced significant goitrogenesis in transgenic mice (PBF-Tg). In 10 from the orthopaedic ward during the specified period. week old PBF-Tg mice thyroid weight was increased by 1.8G0.3-fold compared 59/303 patients had initially abnormal TFTs. 29 patients had isolated suppressed to wild-type (WT) controls (nZ20, P!0.0001). We have now examined the TSH mean 0.28 (range 0.04–0.38) and 26 patients had isolated raised TSH mean long-term effects of PBF overexpression on thyroid gland weight and histology in 8.4 (range 5.2–37). 4 patients had suppressed TSH with elevated free thyroid aged PBF-Tg mice. Our study shows that the penetrance of increased thyroid hormones (free T4 range 13.9–32). weight was 100% with all PBF-Tg mice demonstrating markedly enlarged thyroid 20/59 patients had repeat TFTs while 39 patients had no recorded repeat tests on glands (nZ256). By 12 months of age PBF-Tg thyroid glands were 3.2-fold larger the hospital database. The median interval of repeat TFTs was 6 weeks (range than that of WT littermates (nZ22, P!0.0001), which persisted to 18 months of 3 days to 12 weeks). None of the patients with abnormal TFTs had thyroid age (2.7G0.5-fold, nZ27, P!0.0001). Histological examination showed that antibodies done and only one was referred to endocrine services. PBF-Tg mice were prone to macrofollicular lesions with O90% of mice Conclusion (nZ11/12) demonstrating follicles O250 microns in diameter by 18 months of There is a wide variability in the follow up of thyroid function tests done for age (PZ0.02 compared with WT). Focal and nodular hyperplasia was also osteoporosis screening with majority of patients not having follow up apparent, with 75% of PBF-Tg mice (nZ9/12) demonstrating evidence of investigations. hyperplastic lesions by 18 months of age (PZ0.009 compared with WT). Western There needs to be more awareness among the health professionals about the blot analysis showed a significant 3.4G1.2-fold (nZ7, PZ0.0007) activation of appropriate follow up of thyroid function tests done in acute hospital setting. phosphorylated Akt, a known regulator of thyroid cell proliferation, in transgenic thyroids. In contrast there was no significant increase in total Akt levels. Positive

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK immunostaining with the proliferation marker cyclin D1 in diffuse goitre regions The remaining two patients developed transient hyperthyroidism, later reverting was significantly higher in aged PBF-Tg mice (nZ4834/35958 positive cells) to permanent hypothyroidism requiring eltroxin. compared to WT mice (nZ1231/25987 positive cells; P!0.0001). Further, We detected clinically relevant thyroid dysfunction at a frequency similar to hyperplastic lesions of aged PBF-Tg mice demonstrated much greater cyclin D1 previous studies. Thyroid dysfunction was more common in female patients and staining, ranging from 19 to 68% of cells, with a mean value of 37.7G20.7% those of Eastern European origin. All patients continued IFNa treatment and (nZ5). These results demonstrate that targeted overexpression of PBF induces euthyroid status was achieved with medical intervention. These data suggest that goitre in vivo, and causes significant hyperplastic growth of the thyroid gland. frequency of TFT testing could possibly be reduced in male patients and may Further, our findings implicate the Akt pathway in mediating PBF-induced need to be increased in Eastern European patients. Those who develop thyroid thyroid cell proliferation in vivo. dysfunction can be managed without discontinuation of IFNa therapy.

P324 P322 Effect of weight loss through gastric bypass on thyroid function in Does the introduction of a pregnancy-specific TSH reference range euthyroid people with morbid obesity improve the increases in management of treated hypothyroidism during Antonia MacCuish1, Salman Razvi2,3 & Akheel Syed1,4 pregnancy? 1University of Manchester, Manchester, UK; 2Newcastle University, John Parr, Cecil Thomas & Shahid Wahid Newcastle upon Tyne, UK; 3Queen Elizabeth Hospital, Gateshead, UK; South Tyneside District Hospital, South Shields, UK. 4Salford Royal Hospital, Salford, UK.

Aims Background In 2005 we defined a specific reference range for TSH in our pregnant population. Thyroid function within the normal range has been shown to influence body We have assessed whether this has resulted in changed management of treated weight in a population. Even slightly elevated serum TSH levels are associated hypothyroidism in pregnant. with an increase in the occurrence of obesity. It is unclear whether significant Methods weight loss has the reverse effect on thyroid function, and studies to date have The management of 73 mothers (Group 1) between January 2000 and July 2005 yielded inconsistent results. was compared to that of 67 mothers (Group 2) between August 2005 and Aims December 2009. The upper limit of normal for TSH was 4.5 mU/l till July 2005; Our aim was to describe changes in TSH and fT4 in relation to durable and the specific TSH range defined for pregnancy was 0.1–1.82 mU/l at booking and significant weight loss in obese people with normal thyroid function before and 0.03–2.15 mU/l at 28 weeks. For pragmatic reasons an upper level of 2.5 mU/l after Roux-en-Y gastric bypass (RYGB) surgery. was used for this study. Methods Results We conducted a retrospective cohort study in 55 patients (13 men) who had The meanGS.D. of TSH measurements during pregnancy were Gp 1: 4.4G0.91; undergone RYGB. Data recorded included TSH, fT4 and excess weight loss at Gp2: 4.7G1.13. The number of increased TSH levels were Gp1: 1.3G1.57; Gp2: baseline and median 4.5, 15 and 24 months after RYGB. Means were compared 1.8G1.7. The number of increases in levothyroxine doses were Gp1: 0.9G1.06; by t-test. Gp2: 1.2G0.91. The incremental increase in levothyroxine was Gp1: 52.4 mg Results G37.77; Gp2: 43.4 mg G26.23. The mean TSH levels at booking were Gp1: Patients had a mean (S.E.M.) preoperative BMI of 48.1 (1.58) and achieved 6.96G12.99 (number O4.5Z13; O2.5Z24); Gp2: 5.2G7.17 (number O2.5Z26). significant weight loss over time. Mean (S.E.M.) baseline serum TSH levels was The mean TSH levels at 28 weeks were Gp1: 1.95G2.46 (number O4.5Z6; 2.00 (0.14) mU/l with no significant change over time (2.02 mU/l at 24 months). O2.5Z13); Gp2: 2.35G3.53 (number O2.5Z18). Mean (S.E.M.) baseline fT4 concentrations were 13.02 (0.42) pmol/l, and increased Conclusions significantly following bariatric surgery to 15.20 (0.57) pmol/l at 24 months TSH testing and levothyroxine increases were increased following the introduction (P!0.0001). of a specific TSH range in pregnancy, but a significant number were hypothyroid by Conclusion this lower reference range at both booking and 28 weeks. Thus biochemical Weight loss after RYGB is accompanied by significant increase in fT4 but no management remained suboptimal. change in TSH. Further work is required to address the mechanism of alteration in the pituitary–thyroid axis after weight loss.

P323 Spectrum of thyroid dysfunction in interferon-a treated hepatitis P325 C-positive patients Iodine induced thyrotoxicosis: the danger of over the counter slimming Carla Moran1, Maggie Nicholls1 & Paddy Mallon1,2 aids 1Mater Misericordiae Hospital, Dublin, Ireland; 2University College Dublin, Ravikumar Bachuwar & Mark Freeman Dublin, Ireland. Dewsbury District Hospital, Dewsbury, UK.

The reported incidence of thyroid dysfunction associated with interferon-a Over recent years, the numbers of commercially available slimming aids have (IFNa) treatment for hepatitis C infection varies widely between countries.1 To increased dramatically. Whilst the majority of these aids are harmless, their our knowledge the spectrum of thyroid dysfunction in IFNa-treated Irish patients interaction with normal physiology is either not understood or not brought to the has not been described outside of an anti-D-related, hepatitis C-infected cohort. attention of the customer. We report the case of a 45-year-old woman who We reviewed thyroid function tests (TFTs) from all Hepatitis C positive patients presented with clinical and biochemical thyrotoxicosis (fT4 31.5 pmol/l, fT3 undergoing IFNa treatment over a 2 year period. 64 patients were included (41 14.3 pmol/l, TSH !0.02 mIU/l). She had elevated TPO antibodies (51 IU/ml). males, 23 females). The majority of patients were Irish (48), the remainder were She denied taking any prescription or homeopathic medication or iodine Eastern European (12), Italian (2), Mongolian (2). containing compounds. There was no history of intravenous contrast use. Of 11 patients (17.2%) developed abnormal TFTs (9 female, 6 Irish). The mean Her thyroid function settled rapidly suggesting a thyroiditis rather than Graves age was 35 years (range 20–60). The incidence of thyroid dysfunction was 12.5% disease as the underlying cause for her condition. for Irish patients, 33% for Eastern Europeans. Mean treatment duration at time of At her follow up appointment, she asked if she could continue to take an over the diagnosis of thyroid dysfunction was 18 weeks. counter slimming aid (Tesco slimming aid 60S, one tablet taken three times per Transient subclinical hypothyroidism occurred in 3 patients; TSH levels ranged day), having started this therapy 4 months previously. She was advised against from 4.3 to 7.1 mIU/l (RR 0.3–4.0 mIU/l) and none required treatment. Two this. According to the product literature, this slimming aid contains bladderwrack patients developed hypothyroidism requiring eltroxin, one of whom was 32 mg. Bladderwrack (Fucus vesiculosus), a commonly used food supplement, is profoundly hypothyroid (TSH 83.6 mIU/l, FT4 7.9 pmol/l, TPO Ab positive). a significant source of iodine. This is known to increase the risk of thyrotoxicosis Two developed transient hypo- and hyperthyroidism respectively, which via the Jod-Basedow phenomenon. spontaneously resolved. Two patients developed thyrotoxicosis due to destructive The accompanying product literature advises against using these tablets in the thyroiditis (TSH !0.1 mIU/l, FT4 18–26 pmol/l, TPO Ab positive) with presence of thyroid disease. However, the majority of patients will be unaware of subsequent transient hypothyroidism, requiring temporary eltroxin treatment. their thyroid status. This case reinforces the need to take a full dietary history in

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK patients with thyrotoxicosis. Furthermore, patients wishing to take over the likelihood of all 131I being retained in the hepatic lesion, and as the patient counter medication should be advised to seek medical advice before doing so. required one-to-one nursing due to her psychiatric condition. The patient was unfit for hepatic surgery, so underwent percutaneous arterial embolisation, with the aim of tumour debulking and amelioration of symptoms. This has allowed palliative control of the thyrotoxic state with carbimazole and thyroxine, and concomitantly improved the patient’s psychiatric condition. Her psychiatric team, and family (predominantly living abroad), were included in all P326 stages of treatment. The effect of parathyroidectomy on neuropsychological symptoms in This case presents an unusual history of thyroid follicular malignancy, coupled patients with asymptomatic primary hyperparathyroidism with significant psychiatric disease. Management decisions highlight the benefit Hassan Kahal1,MoAye2, Alan Rigby3, Thozhukat Sathyapalan1, of discussion though Network Multidisciplinary teams, and access to/ James England4 & Stephen Atkin1 consideration of all available treatment options. Hepatic metastases are a 1Academic Endocrinology, Diabetes and Metabolism, Hull York Medical relatively unusual feature of follicular thyroid cancer, but like other School, Hull, UK; 2Department of Diabetes, Endocrinology, and neuroendocrine hepatic disease may be hyperfunctioning. Cases have previously Metabolism, Hull Royal Infirmary, Hull, UK; 3University of Hull, Hull, UK; reported radiofrequency ablation or hepatic surgery as alternative approaches to 4Department of Otolaryngology Head and Neck Surgery, Hull Royal their treatment. Infirmary, Hull, UK.

Introduction With increased biochemical screening primary hyperparathyroidism (pHPT) is discovered incidentally while patients are still asymptomatic. P328 Objective Thyrotoxic crisis: a stormy period on intensive care To assess the impact of surgery on neuropsychological symptoms in people with Dilip Eapen & Ryan D’Costa apparent asymptomatic pHPT. Pinderfields General Hospital, Wakefield, Yorkshire, UK. Methods Twenty-four patients with asymptomatic pHPT requiring parathyroidectomy, in accordance with NIH recommendations, were recruited prospectively between Thyroid storm or thyrotoxic crisis is a manifestation of an extreme state of May 2005 and August 2007. The control group of 23 subjects was recruited thyrotoxicosis. It is both rare and potentially fatal. Its presentation can be clouded simultaneously from consecutive patients undergoing diagnostic hemithyroidect- by the precipitating illness and the involvement of one or more organ systems omy (HT) for cold thyroid nodules. Operations were performed by a single underlining the importance of clinical suspicion, early recognition and prompt surgeon. intervention. Biochemical investigations and quality of life (QoL), using the hospital anxiety We present a case of a 37-year-old man presenting to hospital with a community (HAD-A) and depression (HAD-D) scales and the mood rating scale (MRS), were acquired chest infection that had not settled with oral antibiotics from his general measured preoperatively and 3 months post-operatively. Data are presented as practitioner. Twenty-four hours into the admission he suddenly deteriorated mean and S.D. and analysed using Student’s t-test. developing hypotension (BP 80/60 mmHg), fast atrial fibrillation and pulmonary Results oedema. At baseline, patients with pHPT compared to the HT group were older, average Past history included Graves’ disease but he had been non compliant with age (GS.D.) 60.0 (G13.56) vs 43.0 (G14.56) years, respectively (P!0.001), had treatment for the preceding 8 months. Although he was initially thought to have more females 93.1% (nZ27) vs 70.4% (nZ19), and higher scores only on the sepsis secondary to pneumonia with associated cardiogenic shock, his thyroid HAD – D (depression) scale, 14.1 (G4.14) vs 11.0 (G3.49), PZ0.0065. function tests indicated severe thyrotoxicosis: TSH!0.05 (normal 0.2–4 mU/l), Postoperatively, there was a significant improvement in Qol with a pre and post- free T3 29.9 (normal 2.5–5.7 pmol/l), free T4 46 (normal 9–24 pmol/l). This along op mean change of 2.45 (G2.57), P!0.001 on HAD – A, 2.79 (G3.85), with the clinical picture of thyrotoxic state was consistent with a diagnosis of PZ0.0017 on HAD – D, and 3.2 (G4.57), PZ0.0022 on MRS in patients with thyroid storm. pHPT. In the HT group; HAD – A mean change 1.0 (G3.8), PZ0.22; HAD – D Prompt anti thyroid medications and supportive management on intensive care K0.173 (G3.0), PZ0.786; and MRS K0.086 (G4.1), PZ0.919. was instituted. This included carbimazole (later changed to propylthiouracil), Postoperatively, calcium and PTH normalised in all patients in the pPTH group; Lugol’s iodine and high dose dexamethasone along with broad spectrum 2.44 (G0.09) mmol/l and 49 (G27.18) ng/l, respectively. Calcium levels antibiotics, inotropic and ventilatory support. Recovery was complicated by liver remained normal in the HT group. There were no changes in CRP, uric acid, and dysfunction and renal failure requiring haemo-filtration for a short period. malondialdehyde levels in either group. His thyroid function improved alongside his response to treatment. Following 2 Conclusions weeks on intensive care he made a remarkable recovery. After discharge his Apparent asymptomatic pHPT is associated with neuropsychological symptoms thyrotoxicosis was successively treated as an out-patient with two separate and a reduced quality of life that improve after parathyroidectomy. courses of radioiodine. This case serves to remind us of this rare form of severe thyrotoxicosis. In this case it had occurred complicating sepsis. It also demonstrates the multiple organ systems that can be involved and the importance of prompt and aggressive multifaceted therapeutic intervention. P327 Management of hyperfunctioning thyroid malignancy with psychiatric co-morbidity David Till, Jackie Gilbert, Dylan Lewis, James Crane, Simon Aylwin & Alan McGregor P329 Kings College Hospital, London, UK. Hypothyroidism and adrenaleukodystrophy, a rare association Venkata Katreddy, Ashraf Bdiri, Azizul Aziz Al-Akbar & Khaled Ashawesh Russells Hall Hospital, Dudley, Westmidlands, UK. A 70-year-old female with known schizophrenia presented in hyperthyroid crisis. Examination revealed muscle wasting, tremor, sweating, low-grade fever, and sinus tachycardia. Biochemistry confirmed the diagnosis (TSH !0.1 mlU/l, Introduction thyroxine 41 pmol/l (9–25), tri-iodothyronine 25 pmol/l (3.5–6.5)). The patient Adrenaleukodystrophy is an X linked disorder associated with functional defect was commenced on i.v. esmolol and carbimazole (40 mg) crushed into of very long fatty acid (VLFCA) oxidation leading to accumulation of VLFCA in warm milk. the white matter of brain and adrenal cortex. It usually presents with adrenal However, lacking mental capacity, and refusing to take all medication, she insufficiency and neurological problems and has association with other underwent emergency thyroidectomy. The thyroid was recognised to be autoimmune conditions reported so far including vitiligo, ulcerative colitis. We malignant intra-operatively, so total thyroidectomy and extensive lymph node report a case of adrenaleukodystrophy, vitiligo and hypothyroidism. dissection was undertaken. A histological diagnosis of follicular thyroid Case carcinoma was made (FTC pT4c N0 (0/8) Mx STAGE IV). A 60-year-old male was diagnosed with idiopathic epilepsy at the age 15 was Postoperative thyroid hormone levels proved difficult to control with high dose referred to neurology clinic with right foot drop at the age of 20. MRI scan thionamides. CT and NM imaging revealed a large (8!10!12 cm), highly showed marked high signal changes in white matter in occipito-parietal regions vascular, hepatic metastasis, as well as persistent neck disease. Radioiodine bilaterally extending temporal regions, internal capsule and cerebellar peduncles therapy was determined to be inappropriate, due to her overactive status, the consistent with degenerative disease. After long work up his VLFCA were found

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK to be abnormally elevated. Genetic screening showed Deletion 2252-15del14, unique patient identifier, data-linkage enabled a cohort of SH cases to be affecting the intron 8 splice receptor on X chromosome. Family screening was identified from prescription, admission and radioactive iodine treatment records. done. He was referred to our Endocrine clinic with symptoms of hypothyroidism Outcome measures and elevated TSH12.mIU/l and borderline T4 of 10.3 pmol/l which was confirmed The status of patients was investigated at 2, 5 and 7 years after diagnosis. on repeat. Examination revealed small palpable goitre and marked vitiligo. His Results microsomal antibodies were just positive. He was started on thyroxin and We identified 2024 cases with SH, a prevalence of 0.63% and an incidence of 29 continued on it. Later he was diagnosed with adrenal insufficiency and is currently per 100 000 in 2008. Most SH cases without thyroid treatment remained as SH at on hydrocortisone and fludrocortisone. 2 (81.8%), 5 (67.5%) and 7 (63.0%) after diagnosis. Few patients (0.5–0.7%) Conclusion developed hyperthyroidism at 2, 5 and 7 years. The percentage of SH cases Hypothyroidism in association with adrenaleukodystrophy and vitiligo is not reverting to normal increased with time: 17.2% (2 years), 31.5% (5 years) and reported so far. There is one case report in literature with adrenal 35.6% (7 years) and this was more common in SH patients with baseline TSH myeloneuropathy with hypothyroidism but not vitiligo. It is difficult to establish between 0.1 and 0.4 mU/l. the cause of hypothyroidism in this case whether it is due to adrenaleukodystro- Conclusion phy perse or due to autoimmune process as his microsomal antibodies were Very few SH patients develop frank hyperthyroidism whilst a much larger slightly positive. This case highlights the importance of looking for other proportion revert to normal, and many remain with SH. autoimmune diseases in adrenaleukodystrophy as they have been reported increasingly.

P332 A case of amiodarone induced thyrotoxicosis, type II followed by P330 subsequent hypothyroidism Should individuals with a Thy 3 result always undergo surgery? Fred McElwaine & Ahmed Helmy Jessica Green, Toby Hunt, Rasha Mukhtar, Alexandra Ward, Kate Allen, Erne Hospital, Enniskillen, UK. Anthony Robinson & Paul Maddox Royal United Hospital, Bath, UK. Introduction Amiodarone is a class III antiarrhythmic agent widely used in the treatment of Introduction atrial and ventricular arrhythmias. British Thyroid Association Guidelines state that the diagnosis of thyroid Amiodarone is known to cause thyroid dysfunction in three ways; amiodarone malignancy cannot be based on the results of an aspiration’s cytology alone and induced hypothyroidism, amiodarone induced thyrotoxicosis (AIT) type I and will usually require surgical removal for confirmation. There has been much type II. debate about the management of indeterminate fine needle aspirations (Thy 3). We present a case of a patient with AIT type II who subsequently developed Recent publications have reported that the prevalence of thyroid carcinoma hypothyroidism. following a Thy 3 result to be as high has 28%, emphasising the importance of Case presentation surgical management in such individuals. To assess the outcomes within our own A 43-year-old man was admitted in December 2009 with increasing sense of practice, we performed a retrospective review of all patients undergoing thyroid hotness. At the time of his presentation TFTs were measured revealing a FT4 of surgery between January 2006 and April 2010 identifying those with initial 121 pmol/l, FT3 of 21 pmol/l respectively with TSH completely suppressed. histology of Thy3. He had a history of pulmonary and cardiac sarcoidosis, as a result of which he had Results had episodes of wide complex tachycardia in 2007 for which he was commenced A total of 235 thyroid surgeries were performed, of which 44 (19%), were on Amiodarone with normal baseline and follow up thyroid function (TFTs). identified as Thy 3 on cytology. Patient’s average age was 49 years with the Examination revealed no tremors but he had a small, palpable diffuse goitre with majority being female 37 (84%). 15 (35%) patients underwent more than one no retrosternal extension and no thyroid eye disease. aspiration. The average size of the nodules was 34 mm. Management decisions Antithyroid antibodies were normal, as was a thyroid ultrasound scan. were made by a dedicated multidisciplinary team for those with cytological Subsequently he underwent a thyroid uptake scan which showed no significant features of a follicular neoplasm (Thy 3). accumulation of radioactive iodine within the thyroid. A total of 30 (68%) individuals had benign lesions of which 9 were colloid, 15 A diagnosis of Amiodarone induced thyrotoxicosis, type II was made. Amiodarone follicular lesions and 6 dominant nodules on a background of multi-nodular was replaced by bisoprolol and he was commenced on 40 mg prednisolone tapered goitre. gradually over 3 months. He became clinically and biochemically euthyroid until The remaining 14 (32%) were confirmed to have malignant histology. Unlike a June 2010 when his TFTs revealed overt hypothyroidism: FT4 7.9 pmol/l, TSH recent series only 2 were follicular (14%), while the other 12 were papillary 31.2 mU/l requiring thyroxine replacement therapy. (86%). 3 (25%) were micro-papillary, which if excluded as being incidental, Discussion reduces the prevalence of carcinoma to 11 (25%). While hypothyroidism and thyrotoxicosis in patients taking Amiodarone are seen Conclusions relatively frequently it is uncommon for a patient to develop hypothyroidism after The incidence of malignancy among our patients with Thy 3 cytology on fine having previously been treated for AIT. needle aspiration is similar to reports by other institutions. Differences resided in This case emphasises the importance of following up patients with AIT even the unexpected prevalence of papillary carcinoma within our series. The results when they have become euthyroid and are off treatment. add further weight to the recommendation that following a confirmed Thy3 cytology result surgical intervention should be advocated.

P333 Audit of thyroid function testing in patients on amiodarone P331 Vidya Srinivas, Ramalingam Srinivasan & Joanne Randall The natural history of endogenous subclinical hyperthyroidism Jammes Paget University Hospital, Gorleston, Lowestoft, UK. Thenmalar Vadiveloo, Peter Donnan, Lynda Cochrane & Graham Leese University of Dundee, Dundee, UK. Objective Amiodarone is an iodine rich, potent antiarrhythmic drug that is highly lipid Objective soluble and total body iodine stores remain increased for up to 9 months. To define the rates of progression to frank hyperthyroidism and to normal thyroid Abnormal thyroid functions, either thyrotoxicosis or hypothyroidism occur in function for subclinical hyperthyroid patients (SH). upto 14–18% of patients receiving long-term amiodarone therapy. Hence regular Design thyroid function tests are required in patients on long-term amiodarone treatment. Record-linkage technology was used retrospectively to identify patients with SH The BNF clearly states that thyroid function tests should be done at a minimum 6 in the general population from 1st January 1993 to 31st December 2009. monthly intervals. Patients Methods All residents over 18 years old with at least two measurements of TSH below the We did a retrospective notes review on 75 consecutive patients prescribed reference range for at least 4 months from baseline and normal free T4/total T4 amiodarone from April 2008, and followed up the thyroid function tests done on and total T3 concentrations at baseline were included as potential cases. Using a these patients, as well as the action taken on these findings.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Results Understanding the range of interactions PBF has within thyroid cells is therefore Of a total of 75 patients, 39 were men (52%). 39 patients were over 80 years. 12 vital; these were explored by tandem mass spectrometry (MS/MS), which relies patients had previous thyroid disease, (2 hyperthyroid treated, 1 amio related and on the predictable fragmentation pattern of an amino acid chain to identify the 9 hypothyroid). 52 were new prescription started as inpatients of whom 26 had exact proteins present in a sample. baseline TFTs, and 23 were follow ups of whom 11 had TFTs done within 6 K1 and TPC1 papillary thyroid cancer (PTC) cells transfected with HA-tagged months. PBF were lysed and immunoprecipitated with anti-HA and passed through Of 44 patients had no appropriate follow up testing, 31 patients had testing done MS/MS (nZ4). 2587 proteins were identified. Those appearing in vector-only appropriately and 2 patients moved out of the area. controls were eliminated, as were those identified by only 1 peptide in a single Interestingly, 2 patients had pulmonary complications and Amiodarone had to be run. Ten proteins were classed as being most likely to interact with PBF. Lyn, a withdrawn and 9 patients died within 6 months of whom, 2 had TFTs within 6 Src tyrosine kinase, was identified by 2 peptides in the TPC1 immunoprecipitant months. Of all TFT reports, 13 were abnormal, with 2 patients being hyperthyroid, but not the K1. This was supported by western blotting, where K1 cells were 2 patients significant hypothyroid and 9 had a raised TSH with normal T4.Of shown to have a low expression of Lyn compared to TPC1 cells. Cortactin, a these 13 patients, only 6 had appropriate TFTs. substrate of Src, was identified by 8 peptides, as were FAK2 (2 peptides, 2 runs) Conclusion and the serine/threonine kinases cMos (1 peptide, 3 runs) and SMG (9 peptides). Thyroid function testing at regular interval is only done in about 40% of Given that we have recently identified PBF as a phosphorylated protein, prescriptions issued. Almost 17% of those who have had regular testing did show interaction with Lyn, cMos and SMG may thus be critical to PBF abnormal values. Hence it is strongly advised that regular thyroid testing is phosphorylation. Binding to Familial adenomatous polyposis (FAP) protein (9 encouraged in the outpatient as well as inpatient settings. peptides) and ERC1 (2 peptides) was also apparent. There is a well documented link between FAP and thyroid cancer and an ERC1/ret mutation is able to induce PTC. Additionally identified proteins were CIT (3 peptides, 2 runs), ARAP (1 peptide, 2 runs), UACA (2 peptides) and ADAMTS18 (2 peptides). Future work will seek to validate these interactions using pull-down assays and co-immuno- precipitation, and to evaluate their function alongside PBF in thyroid cancer.

P334 Depot specific differences in regulation of hyaluronan production of relevance to Graves’ orbitopathy Lei Zhang1, Fiona Grennan-Jones1, Carol Lane2, D Aled Rees1, P336 Colin Dayan1 & Marian Ludgate1 Variation in levels of skewed X chromosome inactivation represents a 1School of Medicine, Centre for Endocrine and Diabetes Sciences, Cardiff shared pathogenic pathway for the common autoimmune thyroid University, Cardiff, UK; 2Department of Ophthalmology, Cardiff and Vale diseases University Health Board, Heath Park, Cardiff, UK. Matthew Simmonds1, Oliver Brand1, Paul Newby2, Laura Jackson2, Chantal Hargreaves2, Jackie Carr-Smith2, Jayne Franklyn2 & 1 Expansion of the orbital contents, by adipogenesis and hyaluronan (HA) Stephen Gough 1 2 overproduction, causes Graves orbitopathy (GO). Orbital HA is generated University of Oxford, Oxford, UK; University of Birmingham, predominantly by hyaluronan synthase 2 (HAS2) whose transcription is positively Birmingham, UK. regulated by pAkt in cell lines. GO is most frequently associated with Graves’ disease (GD) in which thyroid stimulating antibodies bind the TSH receptor Graves’ disease (GD) and Hashimotos’ thyroiditis (HT), two of the most common (TSHR) increasing cAMP. Previous studies highlight a role for TSAB and autoimmune thyroid diseases (AITD), are caused by both shared and disease ‘neutral’ TSHR antibodies in GO, suggesting the involvement of additional specific genetic determinants. In females one copy of the X chromosome is TSHR or other signalling cascades e.g. IGF1 via pAkt. Furthermore the effects of randomly inactivated, and although inactivation should occur with a parent of TSHR activation may vary with its expression level and orbital fat (neural crest origin ratio of 50:50, skewed X chromosome inactivation (XCI) can occur, derived) may exhibit depot specific differences relevant to GO. whereby O80% of a specific copy of the X chromosome is inactivated. Increased We have investigated using in vitro models to assess adipogenesis and HA skewed XCI in GD is believed to explain the strong female preponderance seen. production in preadipocyte/fibroblasts from orbital (nZ10) and subcutaneous Using data taken from all known GD XCI studies (5 studies totalling 454 GD and (nZ10) adipose tissue in response to TSHR (activating mutation) and IGF1R 610 controls), we performed meta-analysis which supported a role for skewed activation (IGF1 addition). K XCI in GD PZ1.61!10 8,ORZ2.56 (95% CIZ1.83–3.57). Some evidence for In orbital preadipocytes adipogenesis significantly increased (40–60%) HAS2 a role of skewed XCI in HT has previously been reported, but from relatively transcripts (but decreased HAS1 and HAS3) and secreted HA (P!0.002). In small datasets. We aimed to confirm these findings using microsatellite marker contrast, subcutaneous preadipocyte adipogenesis significantly decreased (50– genotyping within the androgen receptor to determine XCI levels in a large UK 75%) all three HAS isoforms and secreted HA (P!0.03). Combining TSHR and Caucasian HT cohort consisting of 490 informative female HT patients and 325 IGF1R activation did not induce spontaneous adipogenesis but produced a female controls. All subjects gave informed written consent and the project was synergistic effect on HAS2 transcription and HA generation in both depots. approved by the local ethics committee. Even using the largest HT dataset Surprisingly IGF1 treatment alone, either chronic or acute, had no effect on HAS2 investigated to date only a trend towards increased skewed XCI (PZ0.079) was transcription, despite significantly increasing the phospho:total Akt ratio; a pAkt found in our HT patients. Clinical correlations revealed that skewed XCI was inhibitor increased orbital HAS2 transcription. A stimulating effect of IGF1 on more frequent in thyroid autoantibody negative HT patients than autoantibody HAS2 transcription can be revealed by rapamycin in subcutaneous but a MEK positive patients (27.6 vs 13.6%), suggesting XCI skewing does not contribute to inhibitor in orbital preadipocytes. thyroid autoantibody production. However, meta-analysis of the current data and We conclude that a single physiological process (adipogenesis) in the orbit others (five studies totalling 671 HT cases and 592 controls) produced an overall produces both mechanisms causing GO. Depot specific variations in HAS2 K significant pooled PZ2.39!10 5 ORZ1.93 (95% CIZ1.41–2.64), confirming a transcriptional control (feedback inhibition by mTOR or MEK in subcutaneous role for XCI in HT. These and other ongoing studies determining how skewed and orbit respectively) provide an explanation for these differences and the XCI contributes to GD and HT will increase our understanding of this important pathogenesis of GO. shared AITD pathogenic pathway.

P335 P337 The use of tandem mass spectrometry to identify binding partners of Seasonal variation in thyroid autoimmunity as assessed by anti-thyroid PBF in thyroid cells peroxidase antibodies is related to temperature Neil Sharma, Robert Seed, Martin Read, Vicki Smith, Gregory Lewy, Gina Middleton2, John Barker2 & Salman Razvi1,2 Gavin Ryan, Jim Fong, Perkin Kwan, Kristien Boelaert, Jayne Franklyn, 1Newcastle University, Gateshead, Tyne and Wear, UK; 2Gateshead Health Ashley Martin & Christopher McCabe NHS Foundation Trust, Gateshead, Tyne and Wear, UK. University of Birmingham, Birmingham, UK. Background PBF is a proto-oncogene implicated in the aetiology of thyroid cancer. PBF binds Environmental factors play a role in the pathogenesis of autoimmune conditions. to several proteins, including PTTG and NIS, but its full function is unknown. The incidence of type 1 diabetes is higher in winter. It is unclear whether

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK autoimmune thyroid disease is similarly affected by seasonal variation. We aimed P339 to study the variation in anti thyroid peroxidase (TPO) antibodies in relation to Thyroid hormone receptor alpha is a permissive factor that regulates calendar month of sampling. osteoclastogenesis indirectly Methods Jonathan J Nicholls, Charlotte E Combs, Graham R Williams We obtained TPO-antibody results for the 12 months (October 2009 till & J H Duncan Bassett September 2010). Individuals with known thyroid disease were excluded. TPO- O Molecular Endocrinology Group, Department of Medicine and MRC antibody levels were measured quantitatively by ELISA and levels 50 IU/ml Clinical Sciences Centre, Imperial College London, Hammersmith Hospital, were classed as high. Geometric mean TPO-antibody concentrations were London, UK. compared against month of sampling after correcting for multiple comparisons. Mean maximum temperatures and sunshine hours for the north east of England for the same time period were obtained from the Met Office. Stepwise linear Thyrotoxicosis is characterised by increased osteoclast activity. Thyroid hormone regression analyses were performed to determine factors predicting TPO levels. receptor alpha (TRa) is the predominant TR-isoform in bone and mice lacking Results TRa have skeletal hypothyroidism with impaired osteoclastic bone resorption. The mean age (S.D.) of the cohort (nZ841) was 51.2 (21.7) years and majority By contrast, mice lacking TRb have skeletal hyperthyroidism and increased were female (73.1%). The age and gender distribution of the cohort was similar bone resorption. Thus, we hypothesized that T3 acts via TRa to stimulate in each month of sampling. Geometric mean (range) TPO-antibody levels were osteoclastogenesis. Osteoclasts were differentiated in vitro from wild-type (WT), lower in winter than in summer with the lowest level in December of 15.25 TRa-null and TRb-null bone marrow precursors using M-CSF and RANKL in the (3–540) IU/ml and highest in August of 32.6 (9–3000) IU/ml (P!0.001). The absence or presence of T3 and total RNA was isolated after 1 and 5 days of culture. proportion of individuals with high TPO levels was higher in August (32.9%) Numbers of multinucleated tartrate-resistant acid phosphatase (TRAP) positive than in December (18.6%), P!0.01. Age, gender and maximum temperature on osteoclasts were quantified and TRAP activity determined at day 5. Data were the day of sampling explained 6% of the variation in TPO levels with temperature analysed by ANOVA to determine the effect of genotype on osteoclast parameters. alone accounting for 3% of variation. The expression of genes involved in thyroid hormone signalling was investigated Conclusions by RT-PCR. Precursor cells and mature osteoclasts expressed monocarboxylate Thyroid autoimmunity as measured by TPO-antibody levels has a seasonal transporters 8 and 10 (Mct8, Mct10), the type 2 and type 3 deiodinases (Dio2, Dio3) variation with lower concentrations in winter and higher in summer which is and TRa1, TRa2 and TRb1. Despite expression of these key genes, T3-treatment partly explained by the effect of temperature. This apparent association of thyroid did not affect WT osteoclast numbers (osteoclasts/field 4.3G0.84 vs 3.0G0.78, autoimmunity with temperature may have implications for the future, especially control versus T3-treatment (nZ6)) or differentiation (TRAP activity (mU/ml) in the context of global warming. 2.8G0.7 vs 2.5G0.7, control versus T3-treatment (nZ9)). Similarly, osteoclast cultures from TRa-null and TRb-null mice were unaffected by T3-treatment. These data demonstrate that T3 does not regulate osteoclastogenesis directly. Never- theless, increased numbers of mature osteoclasts were generated from TRa-null bone marrow cultures (osteoclasts/field 4.6G0.9 vs 9.3G2.2 vs 2.5G0.7, WT versus TRa-null versus TRb-null, P!0.05 WT versus TRa-null (nZ4)) and TRAP activity was increased 2.5-fold (TRAP activity (mU/ml) 4.4G1.1 vs 11.7 G3.6 vs 4.5G2.0, WT versus TRa-null versus TRb-null, P!0.05 WT versus TRa-null (nZ4)). Together with the finding that TRa-null mice have fewer osteoclasts and reduced bone resorption, these data indicate that TRa plays a key permissive role to regulate osteoclastogenesis in vivo.

P338 A case of Graves’ disease associated with severe hypercalcaemia Sarah Ali, Katie Wynne & Karim Meeran P340 Endocrine Unit, Imperial College Healthcare NHS Trust, London, UK. Targeted hPTTG overexpression in vivo induces reduced cellular proliferation and p53 stabilisation resulting in decreased thyroid size Gavin Ryan, Gregory Lewy, Martin Read, Robert Seed, Neil Sharma, A 25-year lady was referred by her GP with a six-month history of symptoms Vicki Smith, Jim Fong, Perkin Kwan, Jayne Franklyn, Christopher McCabe suggestive of thyrotoxicosis; weight loss, palpitations, heat intolerance and & Kristien Boelaert lethargy. She also complained of thirst, polyuria and nocturia. Examination University of Birmingham, Birmingham, UK. findings included tachycardia, tremor and a moderately enlarged goitre. In clinic, blood tests performed confirmed thyrotoxicosis: TSH!0.05 mU/l (NR 0.3–4.2 mU/l), free T3 O46.1 pmol/l (NR 2.5–5.7 pmol/l) and free The human pituitary tumor transforming gene (hPTTG) plays important roles in T4 69.1 pmol/l (NR 9.0–26.0 pmol/l). Serum anti-TSH receptor antibody tumourigenesis through its function as a securin and by interaction with the tumour was positive (O30.0 u/ml; NR 0–0.4 u/ml). Interestingly, corrected calcium suppressor gene p53. We have previously indentified hPTTG expression as a was significantly raised at 3.35 mmol/l (NR 2.15–2.60 mmol/l), phosphate was prognostic indicator for differentiated thyroid cancer. We recently generated a 1.50 mmol/l (NR 0.8–1.4 mmol/l) and parathyroid hormone was non-suppressed transgenic mouse model overexpressing hPTTG targeted to the thyroid gland via a but low-normal: 2.1 pmol/l (NR 1.1–6.8 pmol/l). Alkaline phosphate was normal thyroglobulin promoter to delineate PTTG effects on thyroid tumourigenesis and other causes of hypercalcaemia were excluded. in vivo. Interestingly, following screening of 82 pups (nZ12 l), from heterozygote She was admitted for treatment of the hypercalcaemia with aggressive hPTTG mice matings, no homozygote mice were identified. Furthermore, hPTTG intravenous fluids. Carbimazole 20 mg tds and propranolol 40 mg tds were mouse litter sizes were significantly reduced compared with WT litters (nZ6.83 vs concurrently started. She was discharged home once the corrected calcium fell nZ9.35, PZ0.001), suggesting homozygous thyroidal PTTG overexpression may to 2.79 mmol/l and was closely followed up in the outpatient setting. be embryonically lethal. At 6 weeks transgenic mice exhibited significantly Following aggressive treatment of the Graves’ disease, biochemical results were reduced thyroid weights (0.86-fold, PZ0.005, nZ36) when compared with age significantly better two weeks later, including resolution of the hypercalcaemia and gender matched WT mice. To determine if this reduction in size was due to (TSH!0.05 mU/l, fT4 16.0 pmol/l, fT3 4.2 pmol/l, corrected Ca 2.14 mmol/l, lower cellular proliferation rates we assessed PCNA and cyclin D1 expression in phosphate 0.87 mmol/l, PTH 2.5 pmol/l). This severe hypercalcaemia was excised thyroids. Cyclin D1 levels, measured by immunohistochemisty, were therefore attributed to thyrotoxicosis as opposed to primary hyperparathyroidism. significantly reduced (0.59-fold, PZ0.015) while PCNA, measured by western Interestingly, this lady was seen in clinic two months later and due to five weeks blotting, showed a non-significant reduction in expression (0.61-fold, PZ0.07) in of noncompliance with Carbimazole, she was once again thyrotoxic and transgenic mice. Expression of p53, an important gene in DNA repair and cell cycle hypercalcaemic. regulation, was significantly increased at both mRNA (1.7-fold, PZ0.02) and Conclusions protein level (2.1-fold, PZ0.02) in hPTTG mice. Furthermore expression of p21 Thyrotoxicosis is commonly associated with abnormalities in bone metabolism, mRNA, an effector of p53 action and an inhibitor of cyclin-dependent kinases and however the resultant hypercalcaemia is usually mild and asymptomatic. PCNA expression was significantly increased in transgenic mouse thyroids (1.6- If hypercalcaemia is severe and symptomatic, there is often an alternative fold, PZ0.04, nZ7). In vitro experiments confirmed significantly increased p21 cause. In support of severe hypercalcaemia due to thyrotoxicosis is the reversal of mRNA expression (1.9-fold, PZ0.01) following hPTTG transfection in the K1 hypercalcaemia with treatment of the hyperthyroidism. This case is interesting as human papillary thyroid cancer cell line. thyrotoxicosis with such marked hypercalcaemia is uncommon and a corrected In conclusion, targeted thyroidal hPTTG overexpression results in reduced cellular calcium of 3.35 mmol/l appears to be one of the most significantly elevated proliferation and upregulation of p53 and p21, suggesting activation of DNA levels reported. damage repair pathways and apoptosis.

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P341 P343 What is the influence of rheumatologic conditions on response to Optimal use of thyroid antibody assays in the identification of medical therapy of Graves’ disease? auto-immune thyroid disease Kavita Gulati1,2, Miriam O’Sullivan1, Michael Molloy2, Mary Stapleton1, Dulmini Kariyawasam1, Lingling Chuah1, Swana Granville2, Sinead Harney1, John O’Halloran1, John Ryan1 & Antoinette Tuthill1 Yousuf Karim2 & Paul Carroll1 1Cork University Hospital, Cork, Ireland; 2University College Cork, 1Department of Endocrinology, Guy’s and St. Thomas’ NHS Foundation Cork, Ireland. Trust, London, UK; 2Department of Immunology, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK. Anecdotal reports suggest that management of Graves’ disease (GD) is more challenging in patients with concomitant autoimmune disease, however there are Background few studies evaluating this premise and thus no satisfactory evidence base to A variety of thyroid antibody assays are used in the diagnosis of auto-immune guide clinicians. We aimed to identify the impact of rheumatoid arthritis (RA) and thyroid disease (AITD). Commonly both thyroid peroxidase (TPOab) and systemic lupus erythematosus (SLE) on treatment outcomes of GD. thyroglobulin antibodies (TGab) are measured but the added value of testing We identified all GD patients (nZ265) who attended endocrinology clinics at a two markers has not been established. large tertiary referral hospital (1994–2001). Patients with GD and either RA or Method SLE (nZ16) were selected as cases and matched by age and gender to patients We retrospectively collected clinical and laboratory data on 500 consecutive with GD alone (nZ48) and those with RA or SLE alone (nZ48). patients who had thyroid autoantibodies requested from a specialist endocrine Patients were excluded as controls if they had another autoimmune disease or department of a tertiary hospital from December 2008 to October 2010. TPOab treatment with steroid therapy O3 months. Factors assessed included patient and TGab were simultaneously analysed using the FIDIS multiplex bead assay demographics, immunologic markers and treatment outcomes. (BMD, Marne La Vallee, France). Patients with GD were predominantly female (86%) with a mean age of 50 years Results (range 16–96 yrs). 14% of patients with GD had another autoimmune disease, the There were 399 (79.8%) females and 101 (20.2%) males in the cohort, aged commonest being RA. 44% of patients suffered from Graves’ ophthalmopathy 43.5G15.3 (meanGSD) years. 163 (32.6%) patients had Graves’ disease and 118 with significantly (PZ0.04) increased risk of ophthalmopathy in smokers. (23.6%) had Hashimoto’s thyroiditis. The other diagnoses included; thyroid We found that there were no differences in response to initial anti-thyroid drug nodules 101 (20.2%), other autoimmune diseases e.g. type 1 diabetes 58 (11.6%), therapy between patients with GD alone and those with GDCRA/SLE (PZ0.75). primary hypothyroidism 41 (8.2%) and transient thyroiditis 19 (3.8%). From the However, patients with GDCRA/SLE relapsed much more quickly after 1st 163 patients with Graves’ disease 107 (65.6%) had TPOab, 64 (39.3%) had TGab. treatment (mean 6.2G5.8 months) compared to the GD alone group (mean Of the 118 patients with Hashimoto’s thyroiditis, 103 (87.3%) were positive for 22.48G37.2 months) (PZ0.034). TPOab and 73 (61.9%) positive for TGab. A greater proportion of patients with GD alone underwent radioactive iodine therapy (45.8%) than in the GDCRA/SLE group (13%) PZ0.03. This was partially explained by difference in rates of Graves’ ophthalmopathy between groups. Both We found that concomitant RA or SLE did not alter initial response rates to anti- TPO only TPO and TG TG only negative thyroid medication, although this group had significantly higher relapse rates, suggesting that close monitoring for relapse is required even when the patient has Graves’ 53 (32.5%) 50 (30.6%) 14 (8.6%) 46 (28.2%) achieved euthyroid state. Hashimoto’s 44 (37.3%) 60 (50.8%) 14 (11.9%) 0

Conclusion TPOab testing was superior to TGab assay in identifying patients with both Graves’ disease and Hashimoto’s thyroiditis. Although there may be a rationale in P342 reserving TGab testing as a second-line test in patients testing negative for TPOab, this would miss 8.6% of Graves’ and 11.9% of Hashimoto’s thyroiditis Hashimoto’s thyroiditis with associated neurological deficits patients. The multiplex assay tests both antibodies concurrently and dual testing (Hashimoto’s encephalopathy) provides increased sensitivity for AITD. The higher cost of the multiplex assay Elin Owen, Stella Woodward, Avril Wayte, Sarah Wenham would be offset by the need to test TGab separately in the anti-TPO negative & Antony Wilton patients, which constitute 34.4% of Graves’ disease and 12.7% of Hashimoto’s University of Wales, Bangor, UK. patients.

A 48-year-old female received radioiodine ablation therapy for thyrotoxicosis secondary to a solitary toxic nodule. The subsequent unexpected requirement for replacement thyroxine was explained by Hashimoto’s thyroiditis with an anti- thyroid peroxidase antibody level of 692.3 IU/ml. Thirty months later she P344 presented with debilitating left facial pain and painful sensory symptoms of her Thyroid hormone changes and psychological response to high altitude left arm and leg. She was euthyroid taking thyroxine 75 mg daily with a fT4 of stress: effect of ethnicity 19.2 pmol/l, fT3 4.2 pmol/l and TSH 2.15 mU/l. Anti-thyroid peroxidase level Meenakshi Sachidhanandam1, Suresh Arumugam2 & UdaySankar Ray1 was 826.9 IU/ml. 1Defence Institute of Physiology and Allied Sciences, Delhi, India; Examination revealed an absent left corneal reflex and impaired sensation over 2Defence Institute of Psychological Research, Delhi, India. the second and third divisions of the fifth cranial nerve and the left arm and leg. An MRI of brain and lumbar puncture were normal. EEG was abnormal with temporal sharp and slow waves. A diagnosis of Hashimoto’s encephalopathy was Objective considered and treatment with prednisolone 30 mg daily commenced. At one Acclimatization to high-altitude is a dynamic process affecting the neuro- month she was symptom free and neurological examination was normal. EEG was endocrine and physiological systems. Psychological well-being is also influenced also normal. She remained symptom free for 3 months at which time there was a by hypobaric-hypoxia. Psychic stress is known to influence the hypothalamo– relapse of symptoms and signs with the left corneal reflex being present but pituitary–adrenal/thyroid axis. However, the involvement/contribution of impaired. She remained euthyroid with fT4 of 17.6 pmol/l, fT3 3.4 pmol/l and ‘psychological-performance’ on hormone changes at high-altitude is not TSH 0.79 mU/l taking thyroxine 100 mg daily. EEG again demonstrated right known. The objective of this study was to examine: i) the effect of ethnicity on temporal sharp and slow waves and anti-thyroid peroxidase antibody level was cortisol, thyroid hormones and psychological performance during high-altitude O500 IU/ml. Her prednisolone dose of 2.5 mg was not increased as symptoms exposure in lowlanders as compared to sea-level, and with high-altitude-natives were not troublesome and was stopped one month later. Over the ensuing (HAN) at high-altitude; ii) if there is any relation between psychological variables six months symptoms resolved completely and a repeat EEG was normal. and hormones at high-altitude in the Indian population. Anti-thyroid peroxidase antibodies however remained strongly positive at Methods O500 IU/ml. This case describes a rare complication of Hashimoto’s thyroiditis Male volunteers (20–50 years) belonging to Caucasoid/Indo-European (nZ25), with debilitating neurological deficits which responded to treatment with Mongoloid/Tibeto-Burman (nZ31) and Australoid/Dravidian (nZ28) ethnicities prednisolone. The condition is regarded as an uncommon associated auto- were studied at sea-level and after 3–4 weeks of stay at w4500 m. High-altitude- immune encephalopathy not caused by thyroid dysfunction (she was euthyroid natives (HAN, nZ21) were studied at w4500 m only. Plasma hormone throughout) or thyroid auto-antibody titres which remained elevated. (EIA/ELISA)/biochemical estimation, physiological and psychological evalu- ation was conducted on all subjects. Significance at P!0.05.

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Results (P!0.01). On the contrary it had negative significant correlation with fT3,fT4 In lowlanders, there was a significant change in loneliness, fear-of-death; thyroid and adiponectin (P!0.05). hormones at high-altitude. Interactive effect between high-altitude!ethnicity Conclusion was observed for psychological and hormone variables (except hopelessness, The circulating adiponectin and leptin are affected by thyroid hormone levels. freeT3). Significant variation in hormones and psychological variables was Adiposity could be the metabolic link between thyroid status and adipocytokines. observed between lowlanders and HAN at high-altitude (except memory, loneliness, TSH). Significant correlation was observed between fear-of-death/ loneliness for Caucasoids (rZ0.55) and Mongoloids (rZ0.49); loneliness/freeT4 (rZK0.37) and fear-of-death/freeT4 (rZK0.36) for Mongoloids.

P346 Changes in urinary fractional excretion (FE) of calcium and phosphate High-altitude effect in lowlanders following treatment of hyperthyroid cats Tim Williams, Jonathan Elliott & Harriet Syme Variables Caucasoid Mongoloid Australoid Royal Veterinary College, London, UK. Memory (digit-symbol-test)/ / depression (beck-depression- Hyperthyroid cats have elevated parathyroid hormone (PTH) concentrations and inventory/hopelessness (beck- suppressed fibroblast growth factor-23 (FGF-23) concentrations, both of which hopelessness-scale)/cortisol/ normalise following treatment of hyperthyroidism. PTH, FGF-23, and thyroid TSH/respiratory-rate hormone can influence the renal reabsorption of calcium and phosphate. The aim Loneliness (UCLA-loneliness-scale) Y[Y of the present study was to assess the influence of hyperthyroidism on renal Fear-of-death [YY tubular function in cats indirectly, by comparing the FE of electrolytes in [Y T3 hyperthyroid cats with and without chronic kidney disease (CKD), which could [Y[ T4 also alter the FE of electrolytes, before and after treatment of hyperthyroidism. Y[ FreeT4 Hyperthyroid cats were treated for hyperthyroidism and monitored for the [ FreeT3/protein/heart-rate/ development of azotaemia over a 240-day follow up period. Blood and urine mean-arterial-pressure samples were collected at baseline and following treatment and the FE of calcium Free-fatty-acid (mmol/l) [Yand phosphate calculated. The Wilcoxon signed rank test was used to compare FE Arterial-oxygen-saturation/ Y before and after treatment. Data are presented as median (25th, 75th percentile). body-weight Forty-two hyperthyroid cats (27 non-azotaemic and 15 azotaemic) were included in the study. In the non-azotaemic cats, there was an increase in the FE of calcium /-no change; [-increase; Y-decrease. (0.10 (0.07, 0.15) vs 0.14 (0.10, 0.29) %; PZ0.001) and phosphate following treatment (37.2 (19.8, 42.3) vs 51.9 (34.8, 63.0)%; PZ0.001). Following treatment of azotaemic cats, there was an increase in the FE of calcium (0.24 (0.11, 0.49) vs 0.77 (0.19, 1.31) %; PZ0.005), however the FE of phosphate did Conclusions Z Thyroid hormones and emotionality during high-altitude acclimatization are not increase significantly (48.1 (37.7, 58.9) vs 61.2 (47.6, 80.9) %; P 0.156). influenced by ethnicity, and social-isolation/fear-of-death influences freeT . FE of calcium and phosphate increased following treatment of hyperthyroidism, 4 however the non-significant increase in FE of phosphate following treatment of azotaemic cats might indicate that the maximum level of phosphate excretion was reached in some animals.

P345 Study of serum adiponectin and leptin in a cohort of Egyptian women with thyroid dysfunction Rania Abdel Baki1, Hanaa Gamil2, Ashraf Elsherbiny3, Tahany Yasme P347 Abdel MONEIM1, Samia Ismail1 & Yasmeen Taha1 Retrospective analysis of thyroid fine needle aspiration (FNA) in a 1Ain Shams University, Cairo, Egypt; 2Mataria Teaching Hospital, Cairo, tertiary hospital Egypt; 3National Research Centre, Cairo, Egypt. Alia Nasir, Subash Sivaraman, Hala Alsafadi, Steve Ferryman, Paul Mathews, Yen Ching Yeo, Tom Goodfellow, Nick Hedley, Kim Brett, Barbara Smith, Hisham Mehanna, Martin O Weickert & Sailesh Sankar Background Wisdem Centre, Coventry and Warwickshire, Coventry, UK. Adipocytokines are biologically active substances produced by adipocyte with different physiological functions. Adiponectin, an adipocyte derived protein has multiple effects on homeostatic mechanism that regulate body weight and Aim metabolism. Leptin, a signal of satiety to the brain, is considered as a In this study we have compared the adequacy rates of FNA samples between more proinflammatory adipocytokine. Thyroid hormones act on several aspects of experienced and less experienced operators in thyroid FNA. metabolic and energy homeostasis influencing body weight, thermogenesis, and Introduction lipolysis in adipose tissue. Attention has recently been focused on the relationship The prevalence of thyroid nodules is estimated to be about 4–7%, increasing up to between adipocytokines and thyroid dysfunction, however studies showed a 50% in the adult population. US guided FNA has become the preliminary controversial results. investigation of choice for thyroid nodules, as it is widely available and has been Objectives proven to increase diagnostic efficacy. To study the serum adiponectin and leptin in patients with thyroid dysfunction In 2004, NICE recommended the setup of ‘one-stop clinics’ for patients with both hypothyroidism and hyperthyroidism in a cohort of Egyptian females. neck lumps. Design and method Material and methods This study included 45 female subjects aged 25–55 years who were divided into: Data was collected retrospectively from 180 patients who underwent ultrasound Group I: 15 subjects newly diagnosed to have hyperthyroidism. Group II:15 scan (US) FNA of thyroid over a period of 21 months, from January 2008 to subjects newly diagnosed to have hypothyroidism. Group III: 15 healthy October 2009; either through One-stop clinic or routine referrals from clinics. individuals. All individuals were subjected to full clinical history, thorough Results were analysed using SPSS version 16. clinical examination, fT3,fT4, TSH, serum adiponectin and leptin. Results Results Of 312 FNA were performed in 180 (156 females) patients, 143 were reported Our study revealed that serum adiponectin was significantly higher in patients as inadequate sample/indeterminate. with hyperthyroidism (51.87G10.01 ng/ml) than hypothyroid (9.27 Logistic regression analysis using diagnostic (Thy 2–5) versus non-diagnostic G1.98 ng/ml) and euthyroid subjects (13.93G2.81 ng/ml) (P!0.05) while (Thy1) samples as the dependent variable and age, sex, TSH and operator as serum leptin was significantly higher in hypothyroid group (13.27G2.46 ng/ml) covariates showed a significantly higher rate of Thy1 samples when FNA was (P!0.05). We also found that serum adiponectin had positive highly significant performed by less experienced investigators (59 vs 39%, PZ0.031), although correlation with fT3 and fT4 (P!0.01) while it had negative highly significant only 5% of the variation was explained by the total model. correlation with BMI, weight, TSH and leptin (P!0.01). A highly positive FNAC had sensitivity of 72.2% and specificity of 55.9% when compared with significant correlation was found between serum leptin and weight, BMI and TSH histopathology in the 58 patients who underwent thyroidectomy. Positive

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK predictive value of possible/definite malignancy was 46.4%. Negative predictive Symptoms include visual distortion or discomfort (often ameliorated by value of non-neoplastic lesion was 79.1%. squinting), monocular diplopia or ‘ghosting’ and photosensitivity. The reduced Conclusion tear production and rubbing of eyes, common in Graves’ disease, is a known This study showed a relatively high proportion of inadequacy of FNA sampling. precipitant of keratoconus. There is an increased prevalence of keratoconus in Although there was a higher success rate in more experienced operators, the immune disorders, including hashimoto’s thyroiditis (OR 2 (CI 1.2–3.3)) (1). In contribution of the operator to total variation was small, this on its own account patients with keratoconus the normal thyroxine level in tears has been found to be will not account for the results. Other factors including case selection, size and two orders of magnitude lower than in the serum. Interestingly, independently of nature of nodule may explain our findings and this needs further evaluation. their serum thyroid function, patients with keratoconus have tear thyroxine levels 2–50 fold higher than subjects free of ocular pathology (2). Indeed tear thyroxine levels are higher during progression of keratoconus and decline once corneal curvature reaches a new steady value (2). References P348 1. Nemet AY, Vinker S, Bahar I & Kaiserman I 2010 The association of keratoconus with immune disorders. Cornea 29 1261–1264. Weight gain following treatment of hyperthyroidism depends on gender 2. I Kahan, M Varsanyi-Nagy, M Toth, A Nadraj 1990 The possible role of tear and disease severity but not on the treatment administered fluid thyroxine in keratoconus development. Exp Eye Res 50 339–343. Barbara Torlinska, Jayne Franklyn & Kristien Boelaert School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK.

Obesity is a global heath concern and the proportion of overweight and obese P350 people in the UK is rapidly increasing. Patients undergoing treatment for hyperthyroidism frequently express concerns regarding excessive weight gain Sialorrhoea: an uncommon symptom of Graves’ disease especially when offered treatment with 131I. We followed 1159 patients with overt Rebecca Mills, Ali Abbara, Elaine Hui, Karim Meeran & Katie Wynne hyperthyroidism to determine the extent of weight changes and to identify risk Imperial College London, London, UK. factors for weight gain following treatment. Overall, BMI remained unchanged in 135 (11.7%), reduced in 68 (5.9%) and increased in 956 (82.4%). Mean weight A 47-year-old afrocaribbean lady was referred to endocrinology clinic with G G gain was 8.42 0.2 kg and increase in BMI was 3.15 0.07, over a mean 26.55 a 1-month history of weight loss, heat intolerance, palpitations, fatigue and G R 0.61 months. At presentation, 29.9% of patients were overweight (BMI 25) hair loss. She reported symptoms consistent with proximal myopathy including ! and this ratio rose to 38.1% at the end of follow-up (P 0.001). The proportion of myalgia and difficulty rising from chairs. Interestingly she noted a 1-month R ! obese patients (BMI 30) increased from 17.2 to 34.9% (P 0.001). The history of hypersalivation, which had caused her significant distress in her social Z ! reporting of symptoms of prior weight loss (n 724, AOR: 1.88, P 0.001), male and work life. The hypersalivation had resulted in a change in her voice and had Z Z gender (n 276, AOR: 1.50, P 0.04), an underlying aetiology of Graves’ also intermittently resulted in drooling, which had caused her significant Z Z disease (n 446, AOR: 1.41, P 0.04), and higher fT4 concentration at embarrassment at work. She had no significant past medical or psychiatric history ! presentation (AOR: 1.01 per 1 pmol/l increase, P 0.001) were associated with and had no family history of any autoimmune conditions. She was a non-smoker. Z increased risk of weight gain, whereas the presence of obesity (n 164, AOR: On examination, her pulse was 72 beats/min, but had a mild postural tremor and Z 0.62, P 0.02) reduced this probability. The proportion of patients gaining weight palmar erythema. She did not have thyroid acropachy, proptosis, exopthalmos, was similar in 332 subjects treated with thionamides only when compared with complex external opthalmoplegia or pretibial myxoedema. She did not have any 131 Z 827 receiving I (weight gain in 79.1 vs 84.7%, P NS). Following radioiodine, obvious swelling or clinically detectable abnormality of the salivary glands or 645 developed permanent hypothyroidism and the proportion gaining weight was the throat. She had a mildly enlarged symmetrical diffuse goitre with no bruit. similar when compared with those not becoming hypothyroid (84.7 vs 79.1%, Her thyroid function tests showed a free T 18.2 pmol/l (9–26), free T 7.2 pmol/l Z Z 4 3 P 0.08). Multivariate analyses identified male gender (AOR: 1.48, P 0.05), (2.5–5.7) and TSH!0.05 mU/l (0.3–4.2). TSH receptor antibodies were positive Z symptoms of prior weight loss (AOR: 1.66, P 0.003) and higher presenting at 4 U/ml (0–0.4). Her inflammatory markers were normal. A technetium uptake Z fT4 (AOR: 1.01, P 0.008) as independent predictors of weight gain. scan was consistent with a diagnosis of Graves’ disease. She had been started on Conclusion anti-thyroid medication by her general practitioner 3weeks prior to consultation Treatment of hyperthyroidism is associated with marked weight gain and and her symptoms including hypersalivation were settling. increased risks of becoming overweight or obese. Males, subjects with more Discussion severe hyperthyroidism and those with prior weight loss are particularly at risk Hypersalivation is an extremely uncommon symptom of Graves’ disease. To our 131 of gaining weight. Neither the administration of I nor the development of knowledge this has only previously been described on once previously in a 3year hypothyroidism subsequently, are associated with increased probabilities of old boy with Graves’ disease (1). However the timing of onset, the resolution with gaining weight. therapy and the absence of signs consistent with other causes of hypersalivation such as parkinson’s disease, infection or the use of antipsychotic medications are suggestive that this symptom is related to her Graves’ disease. Reference 1. Andersen UM 1993 Basedow disease in a young boy. Ugeskr Laeger 155 3213–3215. P349 A novel prospective ocular manifestation of Graves’ disease Ali Abbara, Ramya Rajakulasingam, Elaine Hui, Katie Wynne & Karim Meeran Imperial College London, London, UK. P351 Thyroid dysfunction in patients receiving interferon treatment for A 31-year-old engineer presented with a 6-week history of tremor, weight loss, hepatitis C: an audit mild goitre and palpitations. At the onset of these symptoms, he also presented to Suma Sugunendran1, Jeanny Verghese1,MoAye1, Thozhukat Sathyapalan2, a specialist eye hospital for difficulty with focussing his vision. He had no past George Abouda1 & Kamrudeen Mohamed1 medical history and was taking no medications. He did not have any family 1Hull and East Yorkshire Hospitals NHS Trust, Hull, UK; 2Hull York history of ocular or autoimmune conditions and was a non-smoker. On Medical School, Hull, UK. examination his BMI was 20, he had very mild proptosis, no diplopia and a diffuse symmetrical goitre. His biochemistry confirmed a diagnosis of Graves’ thyrotoxicosis with fT4 20.6 pmol/l (9.0–26.0), fT3 10.2 pmol/l (2.5–5.7), TSH Aims and objective !0.05 mU/l (0.3–4.2) and positive TSH receptor antibodies 9.7 U/ml (0–0.4). He Pegylated interferon is widely used in the treatment of hepatitis C. Thyroid was commenced on anti-thyroid medications and further definitive management dysfunction (TD) is a well recognised side effect of interferon treatment. As the was discussed. Interestingly, it transpired that he was diagnosed with keratoconus use of interferon therapy in hepatitis C is on the rise, we conducted an audit to of the eye concomitant to the onset of his thyrotoxic symptomatology. determine its prevalence and to formulate local guidelines for the monitoring and Discussion management of thyroid dysfunction in these patients. Keratoconus is a degenerative disorder in which corneal morphology becomes Methods more conical as a result of stromal thinning. Its aetiology may relate to A case note based retrospective audit of all patients who received interferon modifications in corneal collagenases, resulting in breakdown of stromal collagen treatment between 2007 and 2009 was done. Data on the monitoring of thyroid and is associated with an increased expression of inflammatory mediators in tears. function in these patients was collected.

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Results an unexplained mechanism between fT3 and childhood adiposity rather than a Seventy-two patients completed interferon therapy during this period. Forty- direct effect between fT3 and fat mass. seven patients (65%) had baseline thyroid function tests (TFT) and regular monitoring (at least 3 monthly) during the treatment period. A further 17 patients (24%) had TFT after completion of interferon treatment. Of the 61 patients with TFT monitoring, 8 (13%) developed TD (5 had transient hyperthyroidism, one subclinical hyperthyroidism, one hyperthyroidism followed by hypothyroidism P353 and one hypothyroidism). There was female preponderance (62.5%) among patients who developed thyroid dysfunction. Hyperthyroidism developed at an Langerhans cell histiocytosis of the thyroid gland -does it needs average of 18 weeks after commencement of interferon. prophylactic thyroidectomy? Conclusion Damodharan Suresh, Gerard Conway & Clementina Larosa The findings in this audit is similar to other studies regarding the incidence UCLH, London, UK. and female preponderance of thyroid dysfunction. Baseline TFT, TPO and TFT i monitoring during and after IFN-based therapy is important. TD in most cases Langerhans cell histiocytosis (histiocytosis X) is a rare, proliferative monoclonal is transient and a wait and watch policy should be adopted before instituting histiocytic disease of unknown cause that can involve many systems. Intermediate definitive therapy. forms of the disease are characterized by a chronic course of a multi-organ involvement, including skin, bone lesions, interstitial lung disease, diabetes insipidus and rarely can involve primarily the thyroid gland. A 23-year-old gentleman presented with weight gain, lethargy and headaches. Investigations showed raised baseline plasma osmolality at 298 mOsm/kg with P352 hypotonic paired urine at 121 mOsm/kg. Water deprivation test confirmed the presence of cranial diabetes insipidus. Anterior pituitary hormone testing showed: Variation in free T3 (fT3) within the reference range is associated with bone development in children, and mediated via alteration in body mass indices Peter Taylor1, Adrian Sayers2, Ahmed Iqbal1, Andrew Taylor3, 2 1 Colin Dayan & Jonathan Tobias Value Normal levels 1Henry Wellcome Laboratories for Integrative Neurosciences and Endo- 2 crinology, University of Bristol, Bristol, UK; Academic Rheumatology, Prolactin 111 mU/l 0–500 mU/l 3 Avon Orthopaedic Centre, Southmead Hospital, Bristol, UK; Department Total testosterone 4.6 nmol/l 8.0–28.0 nmol/l of Medicine, Centre for Endocrine and Diabetes Sciences, Cardiff LH 1.4 U/l 1.0–8.0 U/l University School of Medicine, Cardiff, UK. FSH 1.6 U/l 1.0–10.0 U/l TSH 0.25 mU/l 0.40–5.00 mU/l Free T 8.3 pmol/l 10.0–26.0 pmol/l Objective 4 The hypothalamus–pituitary–thyroid axis profoundly influences skeletal develop- ment. Whilst the adverse effects of thyroid dysfunction on bone are well established; the effects of variation within the normal range is less clear. Design ITT confirmed low cortisol reserve. Panhypopituitarism was diagnosed and he In a subset of the Avon Longitudinal Study of Parents and Children we performed was started on hormone replacement. MRI pituitary showed large patchily- full thyroid function tests from stored samples taken at age 7. 668 children enhancing suprasellar mass close to optic chiasm superiorly and compressing the had thyroid hormone parameters within the reference range. They underwent a pituitary gland itself is normal. Appearance consistent with deposit of total body DXA scan aged 9 to analyse body mass indices, bone mineral density histiocytosis. His disease involved pituitary, hypothalamus and thyroid. On (BMD), bone area (BA), bone mineral content (BMC) and BMC adjusted follow-up, goitre developed: further imaging of thyroid and FNA showed for area-(aBMC). At age 15, 460 children underwent repeat total body DXA. papillary carcinoma thyroid with metastasis to cervical lymph nodes. He We adjusted analyses for age, fat mass, lean mass and height. underwent total thyroidectomy with bilateral neck dissections, a difficult Results procedure because of deep infiltration of the disease. He also received 3 doses of ablative dose of radioiodine. Interestingly, his brother is also affected with FT and body mass indices (age 9). langerhans histiocytosis involving pituitary gland. 3 We suggest that patients with histiocytosis X, with involvement of thyroid, should undergo thyroidectomy if there is goitre of sufficient size to cause obstructive b (95% CI) P% symptoms. We also consider whether patients with thyroid and systemic disease

T3 Fat mass 0.16 (0.09, 0.22) !0.0001 may be treated with combination therapy including thyroid surgery, glucocorti- Lean mass 0.131 (0.062, 0.199) 0.043 coid therapy, radiotherapy and chemotherapy, though there have been no clinical Height 0.183 (0.26, 1.21) 0.002 trials for this disorder, because of its rarity.

FT3 and bone outcomes (age 9).

Crude Adjusted P354 % % Generalised anxiety disorder following thyroidectomy b P b P Eleftheria Panteliou & Khash Nikookam King George’s Hospital, BHR University Hospitals, London, UK. T3 BMD 0.107 0.005 K0.007 0.8125 BA 0.17 !0.001 K0.009 0.5654 ! K BMC 0.159 0.001 0.009 0.6504 A 38-year-old woman presented with tremor and anxiety 3 weeks into her K aBMC 0.056 0.1496 0.002 0.9547 pregnancy and was diagnosed with thyrotoxicosis. One year postpartum, the thyroid appeared multinodular with a dominant nodule that showed deficient uptake on the technetium scan. Her thyroid function was normal and thyroid peroxidase antibodies were negative. She developed an enlarging goitre and FT3 was associated with fat mass at age 15 (P%0.0001). No associations were underwent total thyroidectomy following which she developed persistent seen with TSH and fT4 levels on body mass indices or bone outcomes. hypocalcaemia and hypomagnesaemia. Conclusion She represented with similar to her gestational symptoms, 3 months later. Her free Variation within the reference range in fT3, but not fT4 or TSH was strongly T4 was 25 pmol/l and her symptoms were attributed to metabolic causes. Despite associated with body mass indices, and BMC. The BMC association was via BA, normal thyroid profile and electrolytes her symptoms deteriorated. A psychiatric not BMD as no association was observed with aBMC. The associations between review concluded that her symptoms were associated to a generalised anxiety fT3 and bone were lost when adjusted for body mass indices highlighting that this disorder. association is mediated through them. Surprisingly there was a positive Thyroid has an important effect on cognition and mood. Hypothyroidism is association between fT3 and fat mass consistent at ages 9 and 15; likely due to associated with depression that can improve with treatment although full

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK resolution is uncertain. Neuropsychiatric symptoms can persist in thyrotoxicosis nausea, urinary frequency, body pains and anxiety. It results from a combination despite maintaining a euthyroid state. of genetic propensity and stressful environmental conditions that can alter Up to 7% of women can develop postpartum thyroid dysfunction. Antibodies the function in amygdala and cingulated gyrus and increase the cortisol levels against thyroid peroxidase can be a marker of postpartum depression. and sympathetic activity. Some studies support that the persistence of Post-operative cognitive dysfunction is common in advanced age and possibly neuropsychiatric symptoms, despite the withdrawal of the triggering event, can caused by cerebral microemboli. Although neuropsychiatric changes following be associated with permanent changes in the brain. major surgery are known, there is not a well established association between Cases like this should potentiate our vigilance in the early recognition and anxiety disorders and minor surgery. management of such symptoms. Generalised anxiety disorder is associated with headache, paraesthesia, insomnia, tremor, fatigue, difficulty in concentration, sweating, palpitations, dyspnoea,

Endocrine Abstracts (2011) Vol 25 Society for Endocrinology BES 2011, Birmingham, UK

Author Index

Abara, A P88 Ali, MA P310 Ayuk, J CM3.4 & P15 Bereket, A P301 Abass, M P161 Ali, S P88, P121 Azenabor, A P120 Berney, D P187 Abayasekara, R P113 & P338 Aziz, R P130 Berry, A OC1.6 & P167 Abbara, A P349 & P350 Aljasser, S P31 Bertagna, X PL5 & MTE2 Abbas, M P117 Alkharfy, K P124 Baborie, A P232 Bevan, JS PL9 Abbasakoor, N P99 Allahabadia, A CM1.2 Babur, M OC3.5 & P179 Bewick, G P155 Abd El Baki, R P160, Allen, K P330 Bachuwar, R P325 Beza´kova´, A P204 P161, P162 & P280 Allolio, B PL4 Baculescu, N P282 Bhadada, S P2 & P127 Abdelsalam, A P151 Almond, K P206 Bailey, C OC3.2 Bhansali, A P2, P50, P127 Abdelsalam, M P106, Alokail, M P124 Bailly, M OC1.4 &P242 P107, P151, P153 Alsafadi, H P347 Bairsto, C P144 Bhansali, S P127 & P157 Alzahrani, S OC3.7 Baitharu, I P109 Bhattacharya, S OC5.4 Abouda, G P351 Amin, A P203, P239 Baki, RA P345 Bienek, R P110 Abouglila, K P64 & P278 Balaguruswamy, S P234 Bienkiewicz, M P268 Abraham, P OC3.8 Amin, P P83 & P227 Baldeweg, S CG1.1 Bikker, P P206 Abu-Shady, M P107 Amirchetty, S P60 & P70 Ball, A P20 Bilko, D P172 & P157 Anderson, D SE1.4 Ball, S P144 Billig, H P264 Achermann, J CM4.4 Anderson, I P101 Banerjee, A P57 Bingham, E P298 Achilleos, K P61 Anderson, L OC5.7 Bangar, V P21 Biswas, S P238 Adams, V P150 Anderson, R P263 Bannon, D OC3.8 Bitner-Glindzicz, M P259 Adamson, A P244 Andoniadou, CL P235 Bano, G P240 Black, D P18 Adesina, O P52 Andrew, R OC1.5, OC2.2, Banu, Z S5.2 Blackmore, A P101 Adham, M P31 OC2.8 & P308 Barber, T P238 Bloom, S P131, P132, Aditya, BS P81 Andrews, R SIG2.3 Barhwal, K P109 P154, P155, P272, Adlan, M P76 Ang, AL P10 & P75 Barker, J P337 P278 & P279 Aflorei, D P282 Angelin, B S6.4 Barnard, M P10 & P75 Bloom, SR OC4.7 Afolabi, PR P146 Aniket, T P269 Barnes, D P138 & P269 Agustsson, T P37 Annamalai, A OC3.1 Barouki, R P297 Boelaert, K OC3.4, OC3.8, Ahasan, M OC2.1 Annamalai, AK P192 Bartalena, L CM1.3 P195, P198, P321, Ahassan, M P118 & P309 Barth, J SIG3.4, P248 P335, P340 Ahlquist, J P61 Arends, MJ P192 & P257 & P348 Ahmad, J P128 Arlt, W S4.3, CM2.3, Bartke, A S4.1 & OC1.3 Boelen, A P8 & P154 Ahmed, A P221 & P311 OC1.6, OC1.7, OC2.5, Barton, DM P216 Boonen, S P18 Ajala, O P228 P229 & P300 Baskar, V P217 Boughton, C P278 Ajanaku, A P251 Arms-Williams, B P148 Bassett, D OC4.3 & P154 Bouloux, P-M P105 Ajjan, R OC3.7 & P41 Armston, A OC3.2 Bassett, E P114 & P115 Bowen-Jones, D P45 Akhtar, R P187 Arulselvan, S P5 Bassett, JHD S6.1, P8 Bower, L P188 Akker, SA P3 Arumugam, S P344 & P339 Bowles, S P22 Akoh, J P1 Arvan, P P125 Bastawrous, M P57 Bowman, P P314 Al-Akbar, AA P329 Ashawesh, K P20, P33 Battaglia, G P250 Boyde, A P8 Al-akbar, ANBAA P20 & P329 Baxter, J P272 Brabant, G OC3.5, P36, Al-Attas, O P124 Ashford, M P112 Baxter, P P248 & P257 P196, P208, P246 Al-Daghri, N P124 Aspinall, S P86 & P182 Bdiri, A P20, P33 & P329 & P247 Al-Dujaili, E P139 Aspray, EC OC3.8 Beale, K P132 & P272 Brada, M CM3.1 & P292 Atay, Z P301 Beales, P S5.1 & S5.2 Bradley, D P241 Al-jabouri, M P305 Atkin, S P126, P149, Beaver, JD OC4.7 Bradley, K P256 Al-Kutubi, H P58 & P59 P274 & P326 Beck, S S2.2 Brady, JJ P11 Alatzoglou, K OC5.3 Atkin, SL P7, P146 Beckett, G SIG3.3 Brahma, A P71 Alatzoglou, KS P259 & P265 Begley, J P48 Brand, O P336 Alberts, B P68 Attia, A-E-A P161 Begum, G P179 Brass, A P295 Albeyatti, A P158 Aung, T P286 Begum, S P177 Brett, K P347 Albu, A P282 Awais, R P244 Behara, A P2 Brewster, S P46 Alexander, S AP1.2 Aye, M P7, P326 & P351 Belchetz, P SE1.3 Brickley, G P140 Alhazmi, J P312 Aye, MM P7 & P146 Bentley, G P296 Brooke, J P152 Ali, A P269 Aylwin, S P130 & P327 Bentley, H P298 Brown, K PL1 Society for Endocrinology BES 2011, Birmingham, UK

Brown, M OC4.1 & P14 Choudhury, M P34 D’Costa, R P197 & P328 Draz, H P124 Brown, S OC4.1, P14 Chousou, PA P55 & P63 Dacheux, J-L P271 Driver, I P60 & P17 Christian, H P251 Dacruz, T P222 Druce, M P183 Brownstein, D OC5.4 & P255 Dakin, R P145 Druce, MR P3 Bucci-Rechtweg, C P18 Christian, M OC4.6 Dale, J P303 Ducroq, D OC3.2 Buch, H P141 Chuah, L P343 Dampetla, S P220 & P293 Duncan, E S3.4 Buch, HN P214, P215, Chuaiphichai, S OC1.5 Daousi, C P150 Dunthorne, G P92 P216 & P217 Clark, A P207, P301 Darby, D P36 Dutta, P P2, P50, P127 Buck, D MTE8 & P306 Dattani, M OC5.3 & P235 & P242 Buckingham, J P224 Clark, P P252 Dattani, MT P259 Buckley, C OC2.1 Clarke, H P253 & P254 David, A P207 Eapen, D P184, P197 Buckley, N P155 Clarke, I S7.3 Davies, E OC2.3, OC2.4, & P328 Bujalska, I OC2.7 Clayton, P MTE1 & P205 P237, P290 & P291 Eastell, R OC1.1, P6, P16, & P294 Clayton, R P56 & P223 Davies, JS P194 P18 & P289 Bujanova, J P199 & P87 Clementi, M CM2.2 Davis, F S6.3 Edwards, J P1 Bujawansa, S P45, P252 Clerici, M P124 Davis, J P79 & P244 Edwards, M P208 & P305 Clough, V P299 Davis, P S6.3 Egawhary, M-D P217 Burns, R OC3.8 Coady, A-M P265 Davidson, B S2.2 Eggo, M OC3.4, OC3.8 Burrows, N OC3.5 Coady, AM P274 Davison, T P42 & P198 Butz, H OC3.3 Cobice, D P308 Dawson, A P126 & P149 Ehteshamirad, G P183 Cochrane, J P180 Dayan, C CM1.4, OC1.8, Ejaz, A OC2.4 Cajdler-Luba, A P268 Cochrane, L OC3.6 & P331 P310, P334 & P352 Ekpenyong, A AP1.3 Campanella, M P237 Coculescu, M P282 Dean, E P179 El-Farhan, N OC3.2 Campbell, K P178 Cogger, K S5.2 Debono, M YE1.1, P6, P84 El-Gayar, M P161 Canton, I P250 Coleman, M P142 & P289 El-ghohary, E P160 Caplin, M S2.2 Coleman, R S8.4 Deep, SN P109 El-Laboudi, A P66, P248 Carpenter, T SIG1.2 Collette, J P165 Delles, C OC5.7 & P257 Carr-Smith, J P336 Combs, C P8 Denham, S P308 El-Mahmoudi, B P67 Carroll, P P37, P177 Combs, CE P339 Deshmukh, S P12 & P102 & P343 Comim, F P277 & P129 Eldieb, A P280 Carroll, R P35, P90 Comninos, A P253 & P254 Desmots, S P297 Elgayar, H P107 & P157 & P191 Comninos, AN P269 Dhawan, R P200 Eligar, VS P222 Carter, S P176 Connell, J OC2.3, OC2.4, Dhillo, W P154, P253 Ellard, S S1.2 Carty, D OC5.7 P290 & P291 & P254 Elliott, B P140 Cassidy-Kojima, C P263 Conway, G CM4.3, P261 Dhillo, WS OC4.7, P269 Elliott, J P346 Cassina, M CM2.2 & P353 & P318 Ellis, H P231 Cauley, J P18 Cook, S N1.4 Dhir, V OC1.6, OC1.7 Elmalti, A P220 Chahal, H YEP1.2 Cooper, G P296 & OC2.5 Elsadig, A P241 & & OC3.3 Cooper, M SIG1.3, OC2.1 Di Gianantonio, E CM2.2 P304 Chalut, K AP1.3 & P118 Diederich, S P9 Elsheikh, M P316 Chan, L P306 Coppini, D P46 & P315 Dimitropoulos, I P188 & P53 Chan, S CM2.1, OC5.8, Cosman, F P18 Dipper, C P65 Elsherbeny, A P107 P84 & P270 Cottrell, E OC5.2 Dive, C P179 & P157 Channer, K P159 Couchman, L P29 Dixit, K P19 & P246 Elsherbiny, A P345 Chapman, K OC5.4 Counsell, J P154 Dobrescu, R P249 Eltohamy, S P151 & P156 Cousland, Z P102 Dominici, FP OC1.3 England, J P326 Chapman, KE OC1.5 Cox, J P200 Dominiczak, A OC5.7 Erotokritou-Mulligan, I Charopoulos, I P25 Cox, R OC4.1, P14 & P17 Donaldson, M MTE4, P114 & P115 Chaudhri, O P88 Crane, J P327 P253, P254, P269 Esapa, C OC4.1, P14 Chee, C P227 Critchley, H P281 & P318 & P17 Chenu, C P23 Croucher, P OC4.1 & P14 Donaldson, P P60 Etheridge, C P60 Cheruvu, CVN P56 Crowley, R P80 Donnan, P OC1.2, OC3.6, Evans, C OC3.2 Chew, S P187 Crowley, RK P11 P13 & P331 Evans, H P14 Chew, SL P3 Cudlip, S P238 Doran, H P101 Evans, J OC1.8 Chhabra, R P242 Cummings, S P18 & P190 Ewins, D P22, P57, Chia, J P309 Cunliffe, A P133 Dornhorst, A P69 P89 & P232 Childs, A P263 Curran, E P64 Drake, A P145 Eymard, M S2.2 Cho, LW P274 Cuthbertson, D P150 Drake, WM P3 Ezra, D OC1.4 Society for Endocrinology BES 2011, Birmingham, UK

Fadl, A P48 Gan, EH P98 Griffiths, R P38 Hatfield, E P69, P88 Fagin, J PL8 Garcia, E OC3.3 Grigorescu, F P282 & P239 Fahmy, E P160 Gardiner, J P154 & P155 Grimsmo, H P1 Hauton, D OC2.7 & P294 Fainberg, H P206 Gardner, C P150 Grossman, A OC3.3 Hawes, M P117 Farook, S P196 & P247 Gardner, D OC5.1 & P164 Haya, N P41 Farooqi, S OC5.3 Garibi, B P173 Grossman, AB OC4.4 & P3 Head, R OC4.1, P14 Farquharson, C OC4.2 Garten, J P284 Grotzinger, J OC2.5 & P17 Farrow, S OC2.6 Gastaldello, A P237 Guasti, L S5.2 & P306 Heald, A P165 Fazal-Sanderson, V N2.2 Gaston-Massuet, C OC5.3, Guck, J AP1.3 Heald, AH P91 Feeney, C P69 & P200 P235 & P259 Guha, N P114 & P115 Healy, M-L P99 Fekete, C OC4.4 Gathercole, L OC2.7, P166 Gulati, K P341 Hedley, N P347 Felsenberg, D OC1.1 & P294 Gupta, M P128 Helfer, G P116 Fenech, M P72 Gaynor, K P17 Gupta, PS P3 Helmy, A P332 Ferrer, J P167 George, E P55 Gupta, R P96 Hemmersbach, P S9.2 Ferryman, S P347 George, R P188 Gupta, S P100, P119 Hermus, A P122 Fica, S P282 Ghatei, M P131, P132, & P242 Hernandez, R P8 Field, B P131 P278 & P279 Guran, T P301 de Hert, M P165 Filer, A P118 Ghatei, MA OC4.7 & P269 Gurnell, M OC3.1, P192 Hess, K OC3.7 Flanagan, D P85, P228, Gheorghiu, M P282 & P309 Heuer, H OC5.8 P243 & P299 Giani, JF OC1.3 Guschina, I OC4.8 van den Heuvel, L P136 Flower, R P133 Gibb, F P308 Guy, R P171 Hewapathirana, N P82 Fong, J OC3.4, P195, Gibbs, S P113 Hickey, S P252 P321, P335 & P340 Gieling, R P179 Habiba, M P117 Hinnie, J P51 Foo, FJ P170 Gilbert, J P212 & P327 Haddadin, F P55 & P63 Hiort, O CM4.2 Forrester, L OC5.4 Gittoes, N P15 Hadjiminas, D P200 Ho, JH P19 Forsyth, L P252 Glogowska-Szelag, J P110 Hadjittofi, C P40 Hoashi, S P119 Fowkes, R OC5.6, P113 & P320 Hadoke, P P145 & P156 Hochhauser, D S2.4 & P237 Gluer, C OC1.1 Hadoke, PWF OC1.5 Hodkinson, P P144 Fox, T P85 & P299 Gnanalingham, K P79 Haines, R P40 Hofbauer, L S8.1 Francis, M P114 & P115 & P241 Hall, L P51 Holmes, M OC5.2, OC5.4 Franklin, R P211 Goenka, N P22, P57, Halsall, D OC3.1, P28, P29 & OC5.5 Franklyn, J N2.1, OC3.4, P89 & P232 & P309 Holt, R S9.3, S9.4, P114, OC3.8, OC5.8, P195, Gogakos, A OC4.3 Ham, J P173 P115 & P142 P198, P270, P321, Golash, A P19 Hamam, A P106 & P153 Homer, N P308 P335, P336, P340 Gonza´lez, L OC1.3 Hamda, A P105 Hooper, J OC3.7 & P348 Gonzalez, S P4 Han, N P295 Hooper, T P144 Franks, S P158, P276 & Goodfellow, T P347 Han, T OC3.8 Horne, A P281 P277 Gorick, S P71 Handley, G P180 Hota, SK P109 Fraser, L P171 Gorrigan, R P306 Haniff, H P233 & P302 Houghton, S P289 Fraser, R OC2.3, P290 Gorvin, C P136 Hanley, KP P167 Howell, S P19 & P77 & P291 Gossiel, F P6 Hanley, N OC1.6 & P167 Howlett, T P94 & P231 Fraser, S P275 Gough, S P336 Hanna, T P1 Hue, T P18 Freel, EM P178, P290 Grace, P P28 Hanssens, L P165 Huges, B P166 & P291 Grant, D P178 Hanyaloglu, A YE1.3 Hughes, C P301 Freeman, M P325 Grant, P OC3.7 Happerfield, LC P192 Hughes, I CM4.1 Freeman, N P309 Granville, S P343 Haq, M P138 Huhtaniemi, I P271 Friedl, P AP1.2 Green, E P113 Harding, B P136 Hui, E P349 & P350 Fuller, P PL2 Green, J P330 Hardy, K P276, P277 Hunt, T P330 Fulton, J P85 Green, N P144 & P305 Hussain, A P118 Furby, H OC4.8 Green, R P171 Hardy, R OC2.1 & P118 Hussain, M P67 & P189 Furlong, N P234 & P305 Greenfield, D P210 Hargreaves, C P336 Hussain, SS P155 Greenwood, H P154 Harney, S P341 Hussein, A-a P121 Gabr, M P121 Greenwood, J P58 & P59 Harper, C P244 Hutchison, C S3.4 Gaffney, D P51 Greenwood, R OC1.8 Harrington, D P138 Hyer, S P49 Gajanayake, T P119 Gregory, L OC5.3 Harris, S P310 Gallagher, A P51 Gregory, R P95 Harrison, E P132 Ibrahim, N P162 Gama, R P141 & P217 Gregson, C SIG1.1 Hassan-Smith, Z OC2.1 Idkowiak, J OC1.7 Gamil, H P345 Grennan-Jones, F P334 & P229 Igreja, S OC3.3 Society for Endocrinology BES 2011, Birmingham, UK

Ilavazhagan, G P109 Kalhan, A P58, Kingston, G P316 Leese, G OC1.2, OC3.6, Iliopoulou, A P226 P59 & P173 Kingston, J P183 OC3.8, P13 & P331 Iqbal, A OC1.8 & P352 Kaman, L P50 Kipari, T P156 Lemazurier, E P297 Irani, T P61 Kamrath, C OC2.5 Kiruparan, P P170 Lenders J CM2.4 Irwin, A P150 Kanan, R P31 Knauf, J P321 Lennox, C P245 Islam, E P151 Kandasamy, N OC3.1, Knopp, M P94 Leonard, N P252 Isles, A OC4.8 P192 & P309 Koetz, K P9 Leong, WB P230 Ismail, A P233 Kannappan, D P62, P196, Kohama, S P284 Leung, PC P18 Ismail, S P345 P247 & P262 Kohler, S P307 Levtchenko, E P136 Kapoor, D P152 Koko, T P185 Levy, A P258 Kaptein, E P267 Kola, B OC4.4 Levy, J P68 Jackson, L P336 Kar, P P199 Komninos, J P236 Levy, M P231 Jacob, K P175 Karamat, MA P44 & P307 Lewandowski, K P268 Jain, V P109 Karavitaki, N-F P42, P68, Kong, M P93, P94, P95 Lewinski, A P268 Jaleel, N P218 P168, P211, P236, & P193 Lewis, D P327 James, A P98 P249, P286 & P307 Kopchick, J PL3 & P164 Lewis, E P22 Jarman, E P91 Karim, Y P343 Korbonits, M OC3.3, Lewis, N P234 Jarvis, S P275 Kariyawasam, D P343 OC4.4, P23, P164, Lewy, G OC3.4, P195, Jasani, B P173 Kasthuri, R P178 P237 & P245 P198, P321, P335 Javadpour, M P232 Katreddy, V P20, P33, Kos-Kudla, B P110 & P320 & P340 Javed, A P89 P303 & P329 Kosicka-Knox, A P133 Lightman, S P258 Jayagopal, V P274 Kaufman, J S8.3 Koulouri, O P93, P95 Lim, A P65 Jayasena, C P253 Kaushal, K P77 & P193 Lim, R P22 & P254 Kavanagh, M P21 Krishnan, S P77 & P79 Lin, H-Y S6.3 Jayasena, CN P269 Kavanaugh, S OC5.3 Kroese, JM P122 List, E P164 Jayashekara, A P243 Kay, R OC3.1 Krone, N OC1.6, OC1.7 Littley, M P169 Jayaweera, S P181 Kearney, T P62, P241, & OC2.5 Liu, M P125 Jennings, A P55 & P63 P262 & P304 Krutskikh, A P271 Livie, C OC2.4 Jennings, R P167 Keavil, B P274 Kumar, S CG1.1 Livingstone, D OC2.8 Jensen, UG P300 Keevil, B P27, P36, P176, Kummaraganti, S P184 de Lloyd, A P194 Jiao, Y S2.2 P285, P287 & P288 Kunasegaran, S P305 Lloyd, L OC5.1 Jim, F P198 Kelberman, D P259 Kurlak, L P267 Lockey, J P255 Joharatnam, J P35 & Kelly, D P159 Kwan, P OC3.4, P195, Loh, N P136 P276 Kelnar, C P263 P198, P321, P335 Long, CJ OC4.7 John, C P224 Kemp, G P150 & P340 Lord, J S4.3 Johnson, A P229 Kennedy, A P15 Kyaw, Y P298 Loubie`re, L OC5.8 Johnson, R P183 Kenyon, C OC5.4 Kyriacou, A P221 Loubiere, L P270 Johnson, S P86 & P292 Lowes, D P91 Johnston, D SIG2.4 Kenz, S P62, P196, P247 Lagundzin, D P135 Lowney, A P80 Jones, C OC2.1 & P262 Laji, K P218 Ludgate, M P334 Jones, G OC2.8 Kerton, A P132 Lakatos, P P18 Ludwig, M S7.1 Jones, H P103, P159 & Khaled, M P153 Lalloo, F P196 Luong, T-V S2.2 P163 Khalid, Y P214, P215, Lamanna, G P276 Lynch, J P219, P248 Jones, P P223 P216 & P217 Lambertucci-Bonnett, J & P257 Jones, R P27 Khandelwal, N P50 OC5.6 Jones, TH P84 & P152 & P242 Lane, C P334 MacCuish, A P324 Jose, A P5 Khoo, B P105 Langley-Evans, S OC4.5 MacDonald, J P286 Joseph, F P22, P57, P89, Khosla, V P242 Lapsley, M P49 MacInerney, R P104 P150 & P232 Kicman, A S9.1 Larosa, C P353 Mackay, A P283 Kidd, M S2.1 & P173 Lau, M P170 MacKay, J P72 Kahal, H P326 Kilbane, M P11 Laufer, E S5.2 Mackenzie, R P133 Kaimal, N P190, P241 & Kilby, M OC5.8 & P270 Laurberg, P OC3.8 & P140 P304 Kilpatrick, E P126, P149 Lavery, G OC2.1 & P166 MacKenzie, S OC2.4 Kajdaniuk, D P110 & P274 Lavery, S MTE7 & P276 MacLullich, A S4.4 & P320 Kilpatrick, ES P7, P146 Lawrence, J P78 Macnair, A P65 Kalathil, D P91 & P265 Lazarus, J OC3.8 MacRae, V OC4.2 Kalathil, S P317 King, P S5.2 Leadbeater, W P321 Madathil, A P201 Kalathy, V P117 King, R P97 Lean, M OC3.8 Maddox, P P330 Society for Endocrinology BES 2011, Birmingham, UK

Maghnie, M P259 McElwaine, F P332 Mongolu, S P87 & P199 Nesbit, MA P17 Maguire, D P99 McGlynn, S P208 Mooij, C OC2.5 & P122 Neuringer, M P284 Maher, E P187 & P262 Moolla, A P318 Nevitt, S P114 & P115 Mahesh, K P50 McGonnell, I OC5.6 Moore, H P57 Newbould, RD OC4.7 Mahgoub, Y P213 McGowan, B P37 Moran, C OC5.4 & P323 Newby, M P180 Majumdar, K P81 & P177 Moran, I P167 Newby, P P336 Makboul, K P106, P160 McGowan, L P100 Morgan, D P295 Newell-Price, J P250 & P280 McGregor, A P327 Morgan, N OC3.2 & P289 Makwana, A OC4.7 McKenna, MJ P11 Morgan, P P116 Newton, C P172 Malik, M P32 & P220 McManus, F OC2.3 Morgan, S OC2.7, P166 & Ng, B P281 Mallam, E P256 McNamara, A P244 P294 Ng, JM P293 Mallon, P P323 McNeilly, A YE1.2 & P112 Morgenthaler, N P246 Ngubane, P P123 Mamtora, H P190 McNulty, S P234 & P305 Morley, S P281 Nicholls, JJ P339 Man, T-Y P156 McQuarrie, E P290 Morris, J P251 & P255 Nicholls, M P323 Man, TY OC1.5 & P291 Morsi, A P151 Nicol, M P292 Man, Z P18 Meakin, P P112 Morton, J P48 Niedziolka, D P320 Manghat, P P49 Meeking, D P87 Mostyn, A P206 Nieschlag, E SE1.1 Manikam, L P141 Meeran, K P88, P90, P143, Mota, S P169 Nik-Zainal, S P192 Manning, A P34 P203, P239, P253, Mousa, A P21 Nikolopoulou, E OC4.6 Mansell, P P82 P254, P318, P338, Mousa, S S6.3 Nikookam, K P354 Mantripp, D P211 P349 & P350 Mukherjee, A P101 Nisal, K P94 Maratha, A P119 Mehanna, H P347 & P190 Nishimura, S OC4.8 Marek, B P110 & P320 Mehasseb, M P117 Mukherjee, K P242 Nixon, M OC2.2 Marion, V S5.3 Mehmet, S P313 Mukhtar, R OC1.8 & P330 Nogueira, E OC1.6 Mark, P P290 & P291 Mellor, A P144 Muldoon, C P99 Norman, M P295 Van Marken Lichtenbelt, Meraai, G P137 Mullan, K OC3.8 Nowak, M P110 W S3.1 Meredith, S P179 Mullins, J P244 & P281 & P320 Marks, PV P233 Meyer, T S2.2 Munigoti, S P54 Ntali, G P168 & P236 Marsh, H P152 & P163 Merza, Z P43 & P92 Munir, A P250 & P317 Nunkoo, P P65 Martin, A P240, P273 Metherell, L P207 Muniyappa, S P104 & P335 & P301 Muraleedharan, V P103, O’Driscoll, L MTE9 Martinez, CS OC1.3 Michailidou, Z OC5.4 P152 & P163 O’Halloran, D P80 Martinez, R P18 Middleton, G P337 Murphy, E OC1.1, OC4.3 O’Halloran, J P341 Martinez-Barbera, J-P OC5.3 Miggin, S P119 &P8 O’Shea, D P99 & P100 Martinez-Barbera, JP P235 Mihai, R P73, P174 Murphy, K P132, P272 O’Sullivan, M P341 Masola, B P123 & P181 & P278 O’Toole, D P99 Mason, I P292 Miller, E OC1.5 Murray, R P219, P248 Ogbera, A P120 Masternak, M S4.1 Mills, R P350 & P257 Oguntoyinbo, O P52 Matejovicova´, B P204 Minnion, J P131 Musabayane, C P123 Ojala, M P300 Mathews, P P347 Miquet, JG OC1.3 Muttiah, S P65 Olbers, T SIG2.2 Mathuriya, S P242 Misra, S P69 & P269 Myint, KS P71 Oliver, N P69 Matthews, L YEP1.1, Mistry, H P267 Omar, A P212 OC2.6 & P295 Mitchell, R P263 Nag, S P317 Orme, S OC3.7, P25, P66 Matthews, PM OC4.7 Mitic, T OC1.5 Nagi, D P197 & P97 Mawson, D P28 Mlawa, G P12, P129, Narayanan, D P32 Orme, SM P302 Maxwell, N P140 P142 & P171 Narayanan, K P180 Osborne, N P314 McCabe, C OC3.4, OC5.8, Modlin, I S2.1 & P173 Narayanan, RP P91 Ostrowska, Z P320 P195, P198, P321, Mohamed, H P106, P121 Naredo, G P308 Othonos, N P141 P335 & P340 & P153 Nasir, A P347 Owen, E OC5.4 & P342 McCabe, M OC5.3 Mohamed, K P351 Nasiri, M P294 Owen, K S1.3 McCaffery, P P116 Mohammed, A P227 Natarajan, A P119 Owen, L P27, P36, P176, McCloskey, E MTE6 Mohandas, C P138 Naughton, V P224 P287 & P288 Mcculloch, J OC5.7 Moisey, RS P233 Navarro, V S7.4 McDonald, P P285 Mok, M P65 Nayak, UA P214, P215 & & P287 Mollard, P AP1.1 P216 Padala, R P127 McDonald, S P281 Molloy, M P341 Naziat, A P53 & P316 Padmabhaskaran, S P218 McDougall, C P178 Monaghan, P P36 Nedic, O P135 Paggiosi, M P16 McDowell, W P285 Moneim, TYA P345 Nelson, R P258 Pain, S P72 Society for Endocrinology BES 2011, Birmingham, UK

Pal, P P79 Powrie, J P37 Readhead, C P275 Sabry, I P161 Palalau, AI P24 Prabhakar, K P184 Reddy, N CG1.1 Sachidhanandam, M P344 Palazzo, F P203 Pramodh, S P130 Reed, N P178 Sadler, G P73, P174 & P318 Prasad, D P109 Rees, A P54, P58, P59, & P181 Panicker, V OC1.8 Premawardhana, L P76 P173 & P202, Saeed, M P286 Panteliou, E P354 Prescott, H P250 Rees, DA OC3.2 Salem, V OC4.7 Papadopoulou, D N2.4 Prevot, V S7.2 & P334 Sam, A P143 Parajes, S OC2.5 Price, L P54 Refetoff, S PL7 Sam, AH P318 Parameswaran, R P73 Price, S P171 Reginster, JY P165 Sandeman, DD P146 Parham, K OC3.2 Prouten, J P169 Reid, D OC1.1 Sands, W OC2.3 Parker, C P185 Reid, I P18 Sankar, S P347 Parker, J P131 Queenan, P P74 Reisch, N OC1.6 Santhakumar, A P86, Parker, M OC4.6 Quignot, N P297 Relkovic, D OC4.8 P182 & P319 Parkinson, C P60 Quinkler, M P9 Ren, X P281 Saqib, K P166 & P70 Quinton, R P38 & P65 Renner, L P284 Sarin, A P170 Parr, J P322 Qureshi, MZ P91 Renner, U P172 Sathyapalan, T P7, P32, Parrington, J P251 Rennie, C P142 P126, P146, P149, Partridge, H P30 Rabbitt, E OC2.1, P166 Renshaw, D P113 & P133 P265, P326 & P351 Parvez, MN P50 & P311 Resch, J OC3.5 Saunders, P P263 Pasquali, L P167 Rabiner, EA OC4.7 Resnick, J OC4.8 Savage, M P207 Pato´cs, A OC3.3 Radian, S P282 Reulen, R P223 Savill, J P156 Patel, P OC1.7 & P118 Radotra, B P242 Rhind, S OC5.1 Sayers, A OC1.8 & P352 Patel, R P291 Radulescu, CR P282 Rhodes, P OC5.1 Scanlan, T S6.2 Patel, S P278 & P279 Rae, M P281 Rice, S P222 Scarsbrook, A P97 Pathak, A P242 Raghavan, R P256 & P258 Richardson, E P154 Scarsbrook, AF P302 Pathmajothy, D P40 Rahim, A P44 & P155 Scerif, M OC4.4 Patterson, J P192 Raja, UY P44 Richardson, J OC5.4 Scheen, A P165 Patterson, M P279 Rajabally, Y P94 Richardson, T P30, P46, Schulz, L S2.2 Pattman, S P38 Rajakulasingam, R P349 P47, P48 & P74 Schwappach, A P105 Paul, A S5.2 Rajendran, R P46, P47, Richters, P P186 Scolding, N P256 Paul, T P5 P48 & P315 Ridsdale, S OC3.5 Scott-Coombes, D P58 Payne, C P102 Rajpal, G P125 Rigby, A P326 & P194 Peacey, S P4 & P225 Ramsay, J P51 Roberts, N P167 Scriven, NA P21 Pearce, S CM1.1, OC3.7 Rana, SC P21 Robertson, I P231 Seckl, J OC5.2, OC5.5, & OC3.8 Randall, J P333 Robinson, A P330 P145 & P156 Pearce, SHS P98 Randell, T OC1.7 Robinson, N P64 Seckl, JR OC1.5 Pears, D P220 Ranjan, N P103 Robinson, R P104 Seddik, S P160 Peaston, B P144 Ransom, J P116 Rodin, A P49 Sedeek, S P162 Perello, E P237 Rao, P OC1.1 & P180 Rodriguez, S P167 Sedman, P P149 Perera, S P105 Rao, S P222 Rog-Zielinska, E OC5.4 Seed, R OC3.4, P195, Perez-Tilve, D SIG2.1 Raskauskiene, D P24 Rolfe, C P103 P198, P321, P335 Peters, D P69 & P223 Romans, S P71 & P340 Pettit, A P185 Rathi, M P4 Rose, G OC1.4 Seetho, I P175 Peuskens, J P165 Rathod, V P96 Rose, I OC2.5 Seidahmad, M P55 & P63 Pfragner, R P173 Rathur, H P189 Ross, R MTE5 & P289 Selby, P MTE3 Phillips, A S4.3 Ravikiran, M P127 Ross, S P116 Sellers, D P159 Pickering, E P188 Ray, D OC2.6 & P295 Rossi, A OC2.2 Selman, C S4.2 Pickett, A OC3.2 Ray, N P42 Roux, C OC1.1 Semjonous, N P166 Pipkin, FB P267 Ray, P P50 Rowe J CM3.2 & P311 Piret, S P136 Ray, US P344 Rudling, M S6.4 Semple, R S3.3 Pitteloud, N OC5.3 Raza, F P91 Russell, C OC5.6 Semprini, S P244 Plaha, P P258 Raza, J OC5.3 Russell, S P174 Seshadri, M P5 Platts, J P34 Raza, K OC2.1 Ruzycky, M P18 Seth, R P129 Plagnol V S1.1 Razvi, S OC1.1, OC3.8, Ryan, F P42 Shackleton, C OC1.6 Pleasance, S OC3.1 P180, P324 & P337 Ryan, G OC3.4, P195, & P300 Pope, M OC5.6 Read, M OC3.4, P195, P198, P321, P335 Shackleton, CHL OC1.7 Poutanen, M P271 P198, P321, P335 & P340 Shafiq, W P32 Powell, K P209 & P340 Ryan, J P341 & P220 Society for Endocrinology BES 2011, Birmingham, UK

Shah, F P10 & P75 Sorwell, K P284 Tajbakhsh, S P205 Tsang, C P139 Shah, M P23 Sotelo, AI OC1.3 Tamagno, G P100 Tun, JK P226 Shah, V P2 Soteriadou, S P190 Tamimi, W P31 Turan, S P301 Shao, R P264 Spadoni, E P259 Tan, HL P293 Turner, B P171 Sharma, N OC3.4, P198, van der Spek A P8 Tan, T P88 & P143 Turner, L P93, P95 P321, P335 & P340 Spencer-Dene, B P224 Tanday, R P108 & P193 Sharp, P P129 Spiller, D P244 Tarigopula, G P93, P95 Turyn, D OC1.3 Sharp, V P271 Spring, M P273 & P193 Tuthill, A P80 & P341 Sharpe, R P263 Srinath, A P313 Tarik, A P39 & P225 Tziaferi, V OC5.3 Shaw, A P309 Srinivas, V P333 Tata, J SE1.2 Tzoulis, P P10 & P75 Sheahan, K P99 Srinivas-Shankar, U P252 Tavare, AN OC4.7 Shearer, K P116 & P305 Taylor, A OC1.6, OC2.5, Udiawar, M P58 & P59 Sheffield, V S5.4 Srinivasan, R P333 P117, P300 & P352 Uitterlinden, A SIG1.4 Shelbaya, S P160 & P162 Srirangalingam, U P187 Taylor, K OC3.1 & P28 Ul Nasah, S P44 Shephard, L P44 Staines, K OC4.2 Taylor, P OC1.8 & P352 Urbanski, H P284 Sheriba, N P106 & P153 Stalla, G P172 Taylor, S P300 Sherif, I P121 Standeven, K OC3.7 Telfer, B P179 Vadia, B OC3.8 Sherlock, M P229 Stapleton, M P341 Teschendorff, A S2.2 Vadiveloo, T OC3.6 Shoeib, N P160 Stedman, A P113 Temple, R P209 & P331 Shoulders, C S3.4 Steedman, T P291 Teo, L P65 Vaidya, B P314 Siamatras, T P236 Stephens, M P202 Tewari, M P242 Vakilgilani, T P26 Siddique, H P303 Stevens, A P205 Thakker, R OC4.1, P14, Valle, JW S2.3 Siddiqui, M P128 Stewart, P OC2.1, OC2.7, P17 & P136, Vanderpump, M CG1.1, Siednienko, J P119 P118, P166, P229, Theodoraki, A P105 OC3.8 & P105 Sieminska, L P110 P294 & P311 Thind, M P222 Varadhan, L P56 & P320 Stewart, S OC3.4 Thirlwell, C S2.2 Varughese, G P56 Signore, M OC5.3 & P198 Thomas, C P322 Varupula, B P221 De Silva, A OC4.7 Stimson, R OC2.8 Thomas, G OC4.1 & P14 Vasilopoulou, E OC5.8 Simmonds, J P213 Stoney, P P116 Thomas, J P164 & P184 & P270 Simmonds, M P336 Storr, H P207 Thomas, N P5 Vasishta, R P242 Simpson, E PL1 Sturley, R P314 Thomas, S P37 & P89 Veloza, A P168 Simpson, HL P309 Su, G P18 Thompson, E P272 Venkataraman, H P43 Simpson, K OC2.6 Sugathan, H P319 & P278 Ventz, M P9 & P131 Sugunendran, S P32 Thompson, I P237 Venugopal, K P309 Singh, BM P214 & P351 Thomson, A OC5.4 Verdaguer, R P78 & P216 Suliman, M P213 Thrower, S P310 & P315 Singh, P P242 Suliman, S S3.2 Till, D P327 Verghese, J P351 Sinha, K P158 Sunder, G P127 Tissier, PL P235 Vinson, G SE1.6 Sirotkin, AV P204 Suresh, D P96, P261 Tobias, J P352 Viollet, B P23 Sivapackianathan, R S3.4 & P353 Todd, J P35, P90, P191 Visser, T P267 Sivaraman, S P347 Suzuki, K P279 & P203, Viswanath, A P214 Sivathasan, N P187 Sweep, F P122 Toft, T SE1.5 Voigt, P OC4.5 Sleeth, M P272 Swerdloff, R SIG3.2 Tolley, NS P318 Smethurt, L P208 Swietochowska, E P320 Tomlinson, J OC2.7 Wahid, S P322 Smith, B P347 Swords, F CM3.3, P72 & P294 Wakeford, R P144 Smith, D OC1.2 & P209 Toogood, A P210 & P229 Wakil, A P146 & P293 Smith, J P188 Swords, FM P71 Torlinska, B OC3.8 Walia, R P127 Smith, K OC2.8 & P132 Syed, A P324 & P348 Walker, B OC2.2, OC2.8, Smith, KA P265 Syme, H P346 Trainer, P P36 & P196 P145 & P308 Smith, L P237 Symonds, M P206 Trajkovic, M OC5.8 Walker, BR OC1.5 Smith, R P142 Syndikus, I P252 Tran, A P49 Walker, E P166 Smith, V OC3.4, P195, Szumska, D OC5.4 Trebble, P OC2.6 Walker, J OC5.3 P198, P321, P335 Trew, G P276 Walker, L P174 & P192 & P340 Tack, C P122 Tringham, J P298 Walker, N P68 Smyth, P OC3.8 Tadross, J P279 Trinh, H P232 Wallace, A P285 Solntseva, A P137 Taggart, S P190 Trivellin, G OC3.3 & P245 Wallace, H P263 Sonksen, P P114 & Taha, I P312 Tsagarakis, S P236 Walsh, J SIG3.1, P6 P115 Taha, Y P345 Tsai, P-S OC5.3 & P16 Society for Endocrinology BES 2011, Birmingham, UK

Walter, D P152 Webster, S YE1.4 Williams, T P346 Wu, F P79 & P285 Wampers, M P165 Weedon, M S1.4 Wilmer, M P136 Wynne, K P88, P279, Wang, C SIG3.2 Weickert, MO P347 Wilton, A P342 P338, P349 Wangnoo, S P128 Weigelin, B AP1.2 van Winkel, R P165 & P350 Ward, A P330 Weiss, A P284 Winocour, P P108 Wyrwoll, C OC5.5 Ward, E P39, P97 Wells, T OC4.8 & P148 Winston, R P275 & P226 Wenham, S P342 Winter, J P112 Yaacoub, G P67 Warfield, A OC3.4 Westwood, M P205 Withenshaw, N P34 & P189 & P321 Whatmore, A P205 Wong, C P150 Yang, C OC2.2 Wark, G OC3.1 White, A P179 Wong, S P310 Yeo, YC P347 Warlow, M P65 White, D P158 Wong, SL P94 Yu, M P8 Warner, D P230 White, H P181 Wong, W P170 Yu, N OC1.2 Wass, J CG1.1, P42, P68, White, K P283 Wood, G P139 & P13 P168, P174, P186, White, MRH P244 Wood, S OC2.4 P211, P236, P238, Whyte, M P130 Woodland, J P114 P249, P286 & P307 Williams, A P8 Woodroofe, N P159 van Zaane, B OC3.7 Waterson, M P188 Williams, G OC1.1, OC3.8, Woods, D P86, P144, Zahir, ARM P214 Watkinson, J P321 OC4.3 & P154 P182 & P319 Zaki, I P107, P151 Watt, A OC5.4 Williams, GR PL6, P8 Woods, K P259 & P157 Watt, P P140 & P339, Woodward, S P342 Zatko, T P204 Wayte, A P342 Williams, J OC3.5 Wootton, SA P146 van Zeijl, CJJ P8 Weaver, J P180 & P201 Williams, K OC3.5 Wright, D N2.3 Zeka, G P320 Webb, D P231 & P179 Wright, M P28 & P29 Zhang, L P334 Webber, L P158 Williams, M P222 Wright, T OC4.5 Zielinszka, A P166

Society for Endocrinology BES 2011 11 –14 April 2011, Birmingham, UK Endocrine Abstracts Endocrine Abstracts April 2011 Volume 25 ISSN 1470-3947 (print) ISSN 1479-6848 (online) ISSN 2046-0368 (CD-ROM) Volume 25 April 2011Volume 25

Society for Endocrinology BES 2011 11 –14 April 2011, Birmingham, UK

Online version available at 1470-3947(201104)25;1-Z www.endocrine-abstracts.org

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