Deficits in volumetric bone mineral density, bone microarchitecture, and estimated bone strength in women with atypical anorexia nervosa compared to healthy controls

OBJECTIVE

Anorexia nervosa is associated with low bone mineral density (BMD) and deficits in bone microarchitecture and strength. Low BMD is common in atypical anorexia nervosa, in which criteria for anorexia nervosa are met except for low weight. We investigated whether women with atypical anorexia nervosa have deficits in bone microarchitecture and estimated strength at the peripheral skeleton.

METHOD

Measures of BMD and microarchitecture were obtained in 28 women with atypical anorexia nervosa and 27 controls, aged 21-46 years.

RESULTS

Mean tibial volumetric BMD, cortical thickness, and failure load were lower, and radial trabecular number and separation impaired, in atypical anorexia nervosa versus controls (p < .05). Adjusting for weight, deficits in tibial cortical bone variables persisted (p < .05). Women with atypical anorexia nervosa and amenorrhea had lower volumetric BMD and deficits in microarchitecture and failure load versus those with eumenorrhea and controls. Those with a history of overweight/obesity or fracture had deficits in bone microarchitecture versus controls. Tibial deficits were particularly marked. Less lean mass and longer disease duration were associated with deficits in high-resolution peripheral quantitative computed tomography (HR-pQCT) variables in atypical anorexia nervosa.

DISCUSSION

Women with atypical anorexia nervosa have lower volumetric BMD and deficits in bone microarchitecture and strength at the peripheral skeleton versus controls, independent of weight, and particularly at the tibia. Women with atypical anorexia nervosa and amenorrhea, less lean mass, longer disease duration, history of overweight/obesity, or fracture history may be at higher risk. This is salient as deficits in HR-pQCT variables are associated with increased fracture risk.

PUBLIC SIGNIFICANCE

Atypical anorexia nervosa is a psychiatric disorder in which psychological criteria for anorexia nervosa are met despite weight being in the normal range. We demonstrate that despite weight in the normal range, women with atypical anorexia nervosa have impaired bone density, structure, and strength compared to healthy controls. Whether this translates to an increased risk of incident fracture in this population requires further investigation.

Growth Hormone Administration Improves Nonalcoholic Fatty Liver Disease in Overweight/Obesity: A Randomized Trial

CONTEXT

Overweight and obesity are associated with relative growth hormone (GH) deficiency, which has been implicated in the development of nonalcoholic fatty liver disease (NAFLD). NAFLD is a progressive disease without effective treatments.

OBJECTIVE

We hypothesized that GH administration would reduce hepatic steatosis in individuals with overweight/obesity and NAFLD.

METHODS

In this 6-month randomized, double-blind, placebo-controlled trial of low-dose GH administration, 53 adults aged 18 to 65 years with BMI ≥25 kg/m2 and NAFLD without diabetes were randomized to daily subcutaneous GH or placebo, targeting insulin-like growth factor 1 (IGF-1) to the upper normal quartile. The primary endpoint was intrahepatic lipid content (IHL) by proton magnetic resonance spectroscopy (1H-MRS) assessed before treatment and at 6 months.

RESULTS

Subjects were randomly assigned to a treatment group (27 GH; 26 placebo), with 41 completers (20 GH and 21 placebo) at 6 months. Reduction in absolute % IHL by 1H-MRS was significantly greater in the GH vs placebo group (mean ± SD: -5.2 ± 10.5% vs 3.8 ± 6.9%; P = .009), resulting in a net mean treatment effect of -8.9% (95% CI, -14.5 to -3.3%). All side effects were similar between groups, except for non-clinically significant lower extremity edema, which was more frequent in the GH vs placebo group (21% vs 0%, P = .02). There were no study discontinuations due to worsening of glycemic status, and there were no significant differences in change in glycemic measures or insulin resistance between the GH and placebo groups.

CONCLUSION

GH administration reduces hepatic steatosis in adults with overweight/obesity and NAFLD without worsening glycemic measures. The GH/IGF-1 axis may lead to future therapeutic targets for NAFLD.

The verification of wildland-urban interface fire evacuation models

This paper introduces a protocol for the verification of multi-physics wildfire evacuation models, including a set of tests used to ensure that the conceptual modelling representation of each modelling layer is accurately implemented, as well as the interactions between different modelling layers and sub-models (wildfire spread, pedestrian movement, traffic evacuation, and trigger buffers). This work presents a total of 24 verification tests, including (1) 4 tests related to pedestrians, (2) 15 tests for traffic evacuation, (3) 5 tests concerning the interaction between different modelling layers, along with 5 tests for wildfire spread and trigger buffers. The evacuation tests are organized in accordance with different core components related to evacuation modelling, namely Population, Pre-evacuation, Movement, Route/destination selection, Flow constraints, Events, Wildfire spread and Trigger buffers. A reporting template has also been developed to facilitate the application of the verification testing protocol. An example application of the testing protocol has been performed using an open wildfire evacuation modelling platform called WUI-NITY and its associated trigger buffer model k-PERIL. The verification testing protocol is deemed to improve the credibility of wildfire evacuation model results and stimulate future modelling efforts in this domain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11069-023-05913-2.

RF30 | PSAT172 Effects of 12 Months of Alendronate Therapy Subsequent to 12 Months of Denosumab Administration in Women With Anorexia Nervosa

Low bone mineral density (BMD) and increased fracture risk are common complications of anorexia nervosa. We assessed whether 12 months of alendronate subsequent to 12 months of denosumab would 1) maintain the increases in BMD observed with denosumab and 2) result in higher BMD than alendronate for 12 months alone in 30 ambulatory women with anorexia nervosa and areal BMD (aBMD) Z- or T-score &lt;-1.0. Participants were randomized in a 2: 1 ratio to 12 months of denosumab (60mg subcutaneously q6 months) followed by 12 months of open-label alendronate (70mg orally qweek)("denosumab-to-alendronate" n=20) or 12 months of subcutaneous placebo followed by 12 months of open-label alendronate (70mg orally qweek)("placebo-to-alendronate" n=10). The prespecified primary outcome was PA lumbar spine aBMD by DXA. Secondary outcome measures included tibial and radial volumetric BMD (vBMD) and microarchitecture by high-resolution peripheral quantitative CT (HR-pQCT), and markers of bone turnover. Twelve-month results were reported in abstract form; 24-month results have not been published.

At baseline, mean age [29±8 y (mean±SD)], BMI (18.6±1.9 kg/m2), and aBMD (PA lumbar spine Z-score -1.6±1.1) were similar between groups. From 12 to 24 months in the denosumab-to-alendronate group, favorable changes in spine aBMD, radial vBMD, and radial and tibial microarchitecture from 12 months of denosumab were maintained after 12 months of alendronate. However, there was a rebound increase in markers of bone turnover (p&lt;0.003), and PA and lateral lumbar spine aBMD decreased in 6 and 9 participants, respectively. Both a greater suppression of bone turnover markers and a greater increase in aBMD from baseline to 12 months were predictors of partial reversal of BMD gains from 12 to 24 months in the denosumab-to-alendronate group. Over 24 months, PA lumbar spine aBMD (3.9±4.3%), femoral neck aBMD (3.1±5.5%), tibial vBMD and failure load increased within the denosumab-to-alendronate group, and PA lumbar spine aBMD (5.8±5.3%) increased within the placebo-to-alendronate group (p&lt;0.05). In a 24-month between-group comparison, there was no difference in change in aBMD at any site; however, the denosumab-to-alendronate group demonstrated favorable changes in tibial vBMD and trabecular microarchitecture compared to the placebo-to-alendronate group (p&lt;0.05).

In conclusion, this pilot study suggests that 12 months of alendronate maintains BMD gains achieved with 12 months of denosumab administration in some, but not all, women with anorexia nervosa. A more robust response to denosumab may be a risk factor for partial reversal of denosumab-related BMD gains despite alendronate. Therefore, a more effective antiresorptive agent may be necessary to maintain gains in BMD achieved with denosumab therapy in some women with anorexia nervosa. Moreover, sequential therapy of denosumab followed by alendronate over 24 months results in greater improvements in tibial vBMD and microarchitecture than 12 months of alendronate, although increases in aBMD were similar between groups.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Monday, June 13, 2022 12:30 p.m. - 12:35 p.m.

RF06 | PSAT171 Impact of GH Administration on Skeletal Endpoints in Adults with Overweight/Obesity

Background

Obesity is associated with relative growth hormone (GH) deficiency and increased fracture risk. We hypothesized that GH administration would improve bone endpoints in individuals with overweight/obesity.

Methods

77 adults ages 18-65 years, BMI ≥25 kg/m², and BMD T- or Z-score ≤ -1.0 were randomized in a double-blind protocol to daily subcutaneous GH or placebo for 18 months, targeting IGF-1 in the upper quartile of the age-appropriate normal range. There was a post-treatment observation period from 18-24 months. DXA and high-resolution peripheral quantitative CT were performed at baseline, 18 months and 24 months. Volumetric quantitative CT was performed at baseline and 18 months. Results are reported as mean ±SD or mean (95% confidence interval).

Results

There were no pretreatment differences between the GH (n=39) and placebo groups (n=38), including mean age (48±12y), BMI (33.1±5.7kg/m²) and BMD at any site. Forty-nine subjects (47% female) completed 18 months. P1NP, osteocalcin and CTX increased (p<0.005) and visceral adipose tissue decreased (p=0.04) at 18 months in the GH vs placebo group. Hip and radius aBMD, spine and tibial vBMD, tibial cortical thickness, and radial and tibial failure load decreased at 18 months in the GH vs placebo group (p<0.05). During the post-treatment observation period (18 to 24 months), total radius aBMD and tibia cortical thickness increased in the GH vs placebo group (p<0.05); there was also a trend toward an increase in total hip aBMD in the GH vs placebo group (p=0.06). At 24 months, none of the differences between the GH and placebo groups remained significant. There was a higher incidence of numbness and tingling (33% vs 8%, p=0.01) and joint pain or stiffness (33% vs 5%, p=0.003) in the GH vs placebo group. There were no other differences in adverse events between groups.

Conclusions

We demonstrated that GH administration for 18 months to individuals with overweight/obesity and low BMD decreased some measures of BMD, bone microarchitecture, and bone strength compared with placebo. None of these differences remained significant after 6 months off therapy. A longer duration of treatment, or a longer duration of observation post-treatment, may be necessary to see the expected biphasic decline and then increase in BMD reflecting an expanding remodeling space followed by mineralization that has previously been seen with GH administration in other populations, including individuals with and without GH deficiency. Although future investigation of the effects of GH on bone is required to assess the true long-term impact on skeletal integrity as well as fracture reduction, our study suggests that GH administration for 18 months to adults with overweight/obesity does not improve BMD, bone microarchitecture, or bone strength.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:12 p.m. - 1:17 p.m.

Denosumab increases spine bone density in women with anorexia nervosa: a randomized clinical trial

Objective

Anorexia nervosa is complicated by high bone resorption, low bone mineral density (BMD), and increased fracture risk. We investigated whether off-label antiresorptive therapy with denosumab increases BMD in women with anorexia nervosa.

Design

Twelve-month, randomized, double-blind, placebo-controlled study.

Methods

Thirty ambulatory women with anorexia nervosa and areal BMD (aBMD) T-score <-1.0 at ≥1 sites were randomized to 12 months of denosumab (60 mg subcutaneously q6 months)(n = 20) or placebo (n = 10). Primary end point was postero-anterior (PA) lumbar spine aBMD by dual-energy x-ray absorptiometry. Secondary end points included femoral neck aBMD, tibia and radius volumetric BMD and bone microarchitecture by high-resolution peripheral quantitative CT, tibia and radius failure load by finite element analysis (FEA), and markers of bone turnover.

Results

Baseline mean (±s.d.) age (29 ± 8 (denosumab) vs 29 ± 7 years (placebo)), BMI (19.0 ± 1.7 vs 18.0 ± 2.0 kg/m2), and aBMD (PA spine Z-score -1.6±1.1 vs -1.7±1.4) were similar between groups. PA lumbar spine aBMD increased in the denosumab vs placebo group over 12 months (P = 0.009). The mean (95% CI) increase in PA lumbar spine aBMD was 5.5 (3.8-7.2)% in the denosumab group and 2.2 (-0.3-4.7)% in the placebo group. The change in femoral neck aBMD was similar between groups. Radial trabecular number increased, radial trabecular separation decreased, and tibial cortical porosity decreased in the denosumab vs placebo group (P ≤ 0.006). Serum C-terminal telopeptide of type I collagen and procollagen type I N-terminal propeptide decreased in the denosumab vs placebo group (P < 0.0001). Denosumab was well tolerated.

Conclusions

Twelve months of antiresorptive therapy with denosumab reduced bone turnover and increased spine aBMD, the skeletal site most severely affected in women with anorexia nervosa.

RF06 | PSAT147 Impairments in volumetric bone mineral density, bone microarchitecture, and estimated strength in women with atypical anorexia nervosa

 

While anorexia nervosa is associated with impaired skeletal integrity, less is known about the skeletal effects of atypical anorexia nervosa, in which psychological criteria for anorexia nervosa are met, but affected individuals are not low weight. Mean bone mineral density (BMD) is higher in atypical anorexia nervosa than in low-weight anorexia nervosa but lower than in healthy controls. However, it is unknown whether bone microarchitecture and strength are affected. We hypothesized that bone microarchitecture and estimated strength would be impaired in women with atypical anorexia nervosa.

This was a cross-sectional study of women ages 21-46 years (n=55): n=28 with atypical anorexia nervosa (body mass index (BMI) >18.5 kg/m²), n=27 healthy, normal weight, eumenorrheic controls. Exclusion criteria included use of oral contraceptives. Areal BMD (aBMD) was assessed by DXA. Volumetric BMD (vBMD), microarchitecture, and failure load (a bone strength estimate) at the distal tibia and radius were assessed by high-resolution peripheral quantitative CT.

Median(IQR) BMI was lower [19.4(18.6,20.2) vs 22.2(21.5,23.0), p<0.0001] and median serum 25OH vitamin D level was higher [31(24,39) vs 22(17,25), p=0.0001] in atypical anorexia nervosa than healthy controls. In the atypical anorexia nervosa group, 89% had a history of low weight, 21% had a history of overweight/obesity, 31% had current amenorrhea, and 88% had a history of amenorrhea; median duration of anorexia nervosa was 11(5,14) years.

Median lateral spine, total hip, femoral neck, and total radius aBMD Z-scores were lower in atypical anorexia nervosa than healthy controls [lateral spine: -1.1(-2.0,-0.1) vs -0.4(-0.7,0.4), total hip: -0.8(-1.3,0.2) vs 0.2(-0.4,0.7), femoral neck: -0.9(-1.4,0.1) vs -0.1(-0.9,0.6), radius: -0.2(-0.9,0.3) vs 0.1(-0.4,0.6); p≤0.04 for all]. At the tibia, median total, cortical, and trabecular vBMD; cortical thickness; trabecular bone volume fraction; and failure load were lower in atypical anorexia nervosa than healthy controls (p<0.05). At the radius, median trabecular number was lower and trabecular separation was higher in atypical anorexia nervosa than healthy controls (p≤0.04), but there was no difference in failure load between the groups. After controlling for baseline BMI, differences at the radius but not tibia remained significant. At the tibia and radius, median total vBMD, cortical vBMD, and cortical thickness were lower in atypical anorexia nervosa subjects with amenorrhea compared to healthy controls and to atypical anorexia nervosa subjects with eumenorrhea (p≤0.04).

Conclusions

We demonstrate that, despite normal weight, women with atypical anorexia nervosa have impaired vBMD, microarchitecture, and estimated strength compared to healthy controls, with differences more pronounced at the weight-bearing tibia vs non-weight-bearing radius. Individuals with amenorrhea had additional impairments in the non-weight-bearing radius, suggesting an effect of systemic estrogen deficiency. Our data suggest that current normal weight is not protective against impaired bone structure and strength in atypical anorexia nervosa.

Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m., Saturday, June 11, 2022 1:30 p.m. - 1:35 p.m.

The GH/IGF-1 Axis Is Associated With Intrahepatic Lipid Content and Hepatocellular Damage in Overweight/Obesity

CONTEXT

Obesity is a state of relative growth hormone (GH) deficiency, and GH has been identified as a candidate disease-modifying target in nonalcoholic fatty liver disease (NAFLD) because of its lipolytic and anti-inflammatory properties. However, the GH/IGF-1 axis has not been well characterized in NAFLD.

OBJECTIVE

We aimed to investigate serum GH and IGF-1 levels in relation to intrahepatic lipid content (IHL) and markers of hepatocellular damage and fibrosis in NAFLD.

METHODS

This cross-sectional study included 102 adults (43% women; age 19-67; BMI ≥ 25 kg/m2) without type 2 diabetes. IHL was measured by magnetic resonance spectroscopy; NAFLD was defined by ≥ 5% IHL. Peak-stimulated GH in response to GH releasing hormone and arginine was assessed as was serum IGF-1 (LC/MS).

RESULTS

There was no difference in mean age, BMI, or sex distribution in NAFLD vs controls. Mean (± SD) IHL was higher in NAFLD vs controls (21.8 ± 13.3% vs 2.9 ± 1.1%, P < 0.0001). Mean peak-stimulated GH was lower in NAFLD vs controls (9.0 ± 6.3 vs 15.4 ± 11.2 ng/mL, P = 0.003), including after controlling for age, sex, visceral adipose tissue, and fasting glucose. In a stepwise model, peak-stimulated GH predicted 14.6% of the variability in IHL (P = 0.004). Higher peak-stimulated GH was also associated with lower ALT. Higher serum IGF-1 levels were associated with lower risk of liver fibrosis by Fibrosis-4 scores.

CONCLUSION

Individuals with NAFLD have lower peak-stimulated GH levels but similar IGF-1 levels as compared to controls. Higher peak-stimulated GH levels are associated with lower IHL and less hepatocellular damage. Higher IGF-1 levels are associated with more favorable fibrosis risk scores. These data implicate GH and IGF-1 as potential disease modifiers in the development and progression of NAFLD.

Dehydroepiandrosterone sulfate levels predict weight gain in women with anorexia nervosa

OBJECTIVE

Anorexia nervosa (AN) is a serious condition characterized by undernutrition, complicated by endocrine dysregulation, and with few predictors of recovery. Urinary free cortisol (UFC) is a predictor of weight gain, but 24-h urine samples are challenging to collect. We hypothesized that serum dehydroepiandrosterone sulfate (DHEAS), which like cortisol is regulated by adrenocorticotropic hormone (ACTH), would predict weight gain and increases in fat mass in women with AN.

METHODS

We prospectively studied 34 women with AN and atypical AN, mean age 27.4 ± 7.7 years (mean ± SD), who received placebo in a 6-month randomized trial. Baseline DHEAS and 24-h UFC were measured by liquid chromatography with tandem mass spectrometry. Body composition was assessed at baseline and 6 months by DXA and cross-sectional abdominal CT at L4.

RESULTS

Mean baseline DHEAS level was 173 ± 70 μg/dl (0.7 ± 0.3 times the mean normal range for age) and mean baseline UFC (n = 15) was 20 ± 18 μg/24 h (normal: 0-50 μg/24 h). Higher DHEAS levels predicted weight gain over 6 months (r = 0.61, p < .001). DHEAS levels also predicted increases in fat mass (r = 0.40, p = .03), appendicular lean mass (r = 0.38, p = .04), and abdominal adipose tissue (r = 0.60, p < .001). All associations remained significant after controlling for age, baseline BMI, OCP use, duration of AN, and SSRI/SNRI use. DHEAS levels correlated with UFC (r = 0.61, p = .02).

DISCUSSION

In women with AN, higher serum DHEAS predicts weight gain and increases in fat and muscle mass. Additional studies are needed to confirm these findings and further elucidate the association between DHEAS and weight gain.

PUBLIC SIGNIFICANCE

Anorexia nervosa is a severe psychiatric condition, and predictors of weight recovery are needed to improve prognostication and guide therapeutic decision making. While urinary cortisol is a predictor of weight gain, 24-h urine collections are challenging to obtain. Like cortisol, dehydroepiandrosterone sulfate (DHEAS) is a hormone produced by the adrenal glands. As a readily available blood test, DHEAS holds promise as more practical biomarker of weight gain in anorexia nervosa.

Quality of life after long-term biochemical control of acromegaly

PURPOSE

To assess long-term quality of life (QoL) in patients with sustained biochemical control of acromegaly, comparing those receiving vs not receiving pharmacotherapy (primary analysis); to assess change in QoL over time (secondary analysis).

METHODS

Cross-sectional study, with a secondary longitudinal component, of 58 patients with biochemically controlled acromegaly. All had participated in studies assessing QoL years previously, after having undergone surgery ± radiotherapy. One cohort received medical therapy [MED (n = 33)]; the other did not [NO-MED (n = 25)]. QoL was assessed by the 36-Item-Short-Form Health Survey (SF-36), Acromegaly Quality of Life Questionnaire (AcroQoL), Gastrointestinal Quality of Life Index (GIQLI), Symptom Questionnaire, and QoL-Assessment of Growth Hormone Deficiency in Adults (QoL-AGHDA).

RESULTS

Mean (± SD) duration of biochemical control was 15.0 ± 6.4 years for MED and 20.4 ± 8.2 years for NO-MED (p = 0.007). 58% of subjects scored < 25% of normal on ≥ 1 SF-36 domain and 32% scored < 25% of normal on ≥ 4 of 8 domains. Comparing MED vs NO-MED and controlling for duration of biochemical control, there were no significant differences in QoL by SF-36, AcroQOL, GIQLI, Symptom Questionnaire, or QoL-AGHDA. Growth hormone deficiency (GHD) but not radiotherapy predicted poorer QoL. In MED, QoL improved over time in three AcroQoL domains and two GIQLI domains. In NO-MED, QoL worsened in two SF-36 domains and two Symptom Questionnaire domains; QoL-AGHDA scores also worsened in subjects with GHD.

CONCLUSION

A history of acromegaly and development of GHD, but not pharmacologic or radiotherapy, are detrimental to QoL, which remains poor over the long-term despite biochemical control.

Impact of GH administration on skeletal endpoints in adults with overweight/obesity

OBJECTIVE

Overweight/obesity is associated with relative growth hormone (GH) deficiency and increased fracture risk. We hypothesized that GH administration would improve bone endpoints in individuals with overweight/obesity.

DESIGN

An 18-month, randomized, double-blind, placebo-controlled study of GH, followed by 6-month observation.

METHODS

In this study, 77 adults (53% men), aged 18-65 years, BMI ≥ 25 kg/m2, and BMD T- or Z-score ≤ -1.0 were randomized to daily subcutaneous GH or placebo, targeting IGF1 in the upper quartile of the age-appropriate normal range. Forty-nine completed 18 months. DXA, volumetric quantitative CT, and high-resolution peripheral quantitative CT were performed.

RESULTS

Pre-treatment mean age (48 ± 12 years), BMI (33.1 ± 5.7 kg/m2), and BMD were similar between groups. P1NP, osteocalcin, and CTX increased (P < 0.005) and visceral adipose tissue decreased (P = 0.04) at 18 months in the GH vs placebo group. Hip and radius aBMD, spine and tibial vBMD, tibial cortical thickness, and radial and tibial failure load decreased in the GH vs placebo group (P < 0.05). Between 18 and 24 months (post-treatment observation period), radius aBMD and tibia cortical thickness increased in the GH vs placebo group. At 24 months, there were no differences between the GH and placebo groups in bone density, structure, or strength compared to baseline.

CONCLUSIONS

GH administration for 18 months increased bone turnover in adults with overweight/obesity. It also decreased some measures of BMD, bone microarchitecture, and bone strength, which all returned to pre-treatment levels 6 months post-therapy. Whether GH administration increases BMD with longer treatment duration, or after mineralization of an expanded remodeling space post-treatment, requires further investigation.

Improving Rates of Vitamin D Supplementation in Somali Immigrant Infants: A Prospective Interventional Pilot Trial

PURPOSE

Rates of vitamin D deficiency and nutritional rickets have been rising over the past several decades, particularly in high-risk infants. This pilot study assessed the impact of providing free vitamin D supplements, a culturally-appropriate educational brochure, and a brief counseling session about the importance of both vitamin D supplementation and breastfeeding to the parents of Somali infants at routine office visits from newborn through 6 months of age at three Federally Qualified Health Centers in Colorado. We also assessed the impact this intervention had on rates of breastfeeding.

METHODS

Twenty-five Somali infants aged 24 weeks or less were identified by searching electronic health records and enrolled into a historic control group. The parents were then surveyed by phone regarding breastfeeding and vitamin D supplementation. Subsequently, 37 families with newborn Somali infants were identified and enrolled into the intervention arm of the trial.

RESULTS

The intervention group had a higher rate of vitamin D supplementation compared to the historical control group (67 vs. 48 percent, p=0.011) without significantly impacting breastfeeding rates.

CONCLUSION

These results suggest a practical way to increase vitamin D status in this high-risk population. Trial not registered as it was a pilot study, not a phase II to IV prospective clinical trial.

Virtual education programming for patients with acromegaly: a pilot study

OBJECTIVES

To assess the impact of virtual education programming for patients with acromegaly.

DESIGN

We conducted a mixed methods study to evaluate patient attitudes, examine if patient-centered educational forums change these attitudes, and determine the role of virtual education as a means to learn about patients' unmet needs, self-reported outcomes, and educational priorities.

METHODS

The study included 653 total virtual program registrants. Of these, 78 patients with acromegaly were included in the analysis. The programs consisted of patient-centered livestream education by a multidisciplinary team of pituitary experts and patient presenters. Multiple-choice questions were used to assess attitudes before and after the event, and short answer surveys were used to collect care goals and unmet needs related to treatment.

RESULTS

Attendance included participants from 37 countries. The number of patients who responded that they had no hope for improvement, had no choice in their treatment, and felt alone living with acromegaly each decreased significantly pre- to post-event (P < 0.05). The number of patients who felt anxious about their acromegaly diagnosis remained unchanged. 'Quality of life/mental health' was the most common personal care goals concern followed by 'medical therapies/tumor control.' Perceived acromegaly unmet needs were evenly distributed, with five of six categories reported by over 20% of patients.

CONCLUSION

Our findings indicate that virtual education may have a significant positive effect on acromegaly patients' perceptions of their disease. The lessons learned from these virtual programs may be used to inform future virtual education programming for acromegaly and other rare diseases.

Sequential Therapy With Recombinant Human IGF-1 Followed by Risedronate Increases Spine Bone Mineral Density in Women With Anorexia Nervosa: A Randomized, Placebo-Controlled Trial

Anorexia nervosa is complicated by low bone mineral density (BMD) and increased fracture risk associated with low bone formation and high bone resorption. The lumbar spine is most severely affected. Low bone formation is associated with relative insulin-like growth factor 1 (IGF-1) deficiency. Our objective was to determine whether bone anabolic therapy with recombinant human (rh) IGF-1 used off-label followed by antiresorptive therapy with risedronate would increase BMD more than risedronate or placebo in women with anorexia nervosa. We conducted a 12-month, randomized, placebo-controlled study of 90 ambulatory women with anorexia nervosa and low areal BMD (aBMD). Participants were randomized to three groups: 6 months of rhIGF-1 followed by 6 months of risedronate ("rhIGF-1/Risedronate") (n = 33), 12 months of risedronate ("Risedronate") (n = 33), or double placebo ("Placebo") (n = 16). Outcome measures were lumbar spine (1° endpoint: postero-anterior [PA] spine), hip, and radius aBMD by dual-energy X-ray absorptiometry (DXA), and vertebral, tibial, and radial volumetric BMD (vBMD) and estimated strength by high-resolution peripheral quantitative computed tomography (HR-pCT) (for extremity measurements) and multi-detector computed tomography (for vertebral measurements). At baseline, mean age, body mass index (BMI), aBMD, and vBMD were similar among groups. At 12 months, mean PA lumbar spine aBMD was higher in the rhIGF-1/Risedronate (p = 0.03) group and trended toward being higher in the Risedronate group than Placebo. Mean lateral lumbar spine aBMD was higher, in the rhIGF-1/Risedronate than the Risedronate or Placebo groups (p < 0.05). Vertebral vBMD was higher, and estimated strength trended toward being higher, in the rhIGF-1/Risedronate than Placebo group (p < 0.05). Neither hip or radial aBMD or vBMD, nor radial or tibial estimated strength, differed among groups. rhIGF-1 was well tolerated. Therefore, sequential therapy with rhIGF-1 followed by risedronate increased lateral lumbar spine aBMD more than risedronate or placebo. Strategies that are anabolic and antiresorptive to bone may be effective at increasing BMD in women with anorexia nervosa. © 2021 American Society for Bone and Mineral Research (ASBMR).

Sequential Therapy With Recombinant Human IGF-1 Followed by Risedronate Increases Spine Bone Mineral Density in Women With Anorexia Nervosa

Anorexia nervosa is complicated by low bone mineral density (BMD) and increased fracture risk associated with low bone formation and high bone resorption. The spine, particularly its trabecular component as measured by lateral spine dual-energy x-ray absorptiometry (DXA), is most severely affected. Low BMD and bone formation are associated with relative insulin-like growth hormone-1 (IGF-1) deficiency. Our objective was to determine whether bone anabolic therapy with off-label recombinant human (rh)IGF-1 followed by antiresorptive therapy with risedronate would increase BMD more than risedronate alone or placebo in women with anorexia nervosa. We conducted a 12-month, randomized, placebo-controlled study of 90 ambulatory women with anorexia nervosa and low areal BMD (aBMD) (Z- or T-score <-1.0). Participants were randomized to 1 of 3 groups: 6 months of rhIGF-1 (starting dose 30 mcg/kg SQ BID) followed by 6 months of risedronate (35mg PO weekly) (“rhIGF-1/Risedronate”) (n=33), 12 months of risedronate (35mg PO weekly) (“Risedronate”) (n=33), or double placebo (“Placebo”) (n=16). Participants received calcium 1200 mg and vitamin D 800 IU daily. rhIGF-1 was titrated to maintain IGF-1 levels within the age-adjusted normal range. Main outcome measures were aBMD at the spine [1° endpoint: postero-anterior (PA) spine BMD], hip, and radius by DXA, and vertebral, tibial, and radial volumetric BMD (vBMD) and estimated strength by multi-detector computed tomography (MDCT) or high-resolution peripheral quantitative CT (HR-pQCT). At baseline, mean age [28 ± 7 y (mean ± SD)], BMI (18.5 ± 1.9 kg/m²), and BMD were similar among groups. At 12 months, mean PA spine aBMD was higher in the rhIGF-1/Risedronate (p=0.03), and trended towards being higher in the Risedronate (p=0.08), group than the Placebo group. Mean lateral spine aBMD was higher in the rhIGF-1/Risedronate than either the Risedronate (p=0.002) or Placebo (p=0.04) groups. From baseline to 12 months, mean PA and lateral spine aBMD increased by 1.9 ± 0.6% and 4.2 ± 1.0% in the rhIGF-1/Risedronate (p<0.05), 1.7 ± 0.8% and 1.7 ± 1.0% in the Risedronate (p=NS), and decreased by 0.3 ± 0.8% and 1.1 ± 1.3% in the Placebo (p=NS), groups, respectively. Areal BMD Z-scores did not normalize in any group. At 12 months, vertebral vBMD by MDCT was higher (p<0.05), and vertebral strength trended towards being higher, in the rhIGF-1/Risedronate than Placebo group. Neither hip or radial BMD, nor radial or tibial estimated strength, by HR-pQCT differed among groups. rhIGF-1 was well tolerated. In conclusion, sequential therapy of 6 months of rhIGF-1 followed by 6 months of risedronate increased lateral spine aBMD, the site most severely affected in women with anorexia nervosa, more than risedronate or placebo. These data suggest that strategies that are anabolic and antiresorptive to bone may be most effective in increasing BMD in women with anorexia nervosa.

Changes in Quality of Life After Long-Term Biochemical Control of Acromegaly

Acromegaly results in impaired quality of life (QoL), which improves but does not normalize after biochemical control of growth hormone (GH) excess. There are few data regarding long-term QoL in patients with sustained biochemical control of acromegaly. We hypothesized that QoL would continue to improve over time but remain poor. We studied 2 cohorts with biochemically controlled (normal IGF-1 level) acromegaly. MED (n=42) underwent surgery but required somatostatin analog (n=30) or GH receptor antagonist monotherapy (n=12); n=16 had undergone radiation. SURG (n=24) were in remission after surgery ± radiation (n=10). GH stimulation testing was performed in all SURG; n=11 had GH deficiency (GHD). QoL was assessed at 2 timepoints by the 36-Item-Short-Form Health Survey (SF-36) (MED, SURG), Acromegaly Quality of Life Questionnaire (AcroQoL) (MED), Gastrointestinal Quality of Life Index (GIQLI) (MED), Symptom Questionnaire (SQ) (SURG), and QoL-Assessment of GHD in Adults (AGHDA) (SURG). Time between timepoints 1 and 2 was 5.4 ± 1.0 vs 13.6 ± 1.2 years (MED vs SURG, p<0.001), and mean duration of biochemical control for MED vs SURG at timepoint 2 was 14.8 ± 6.6 vs 20.8 ± 8.2 years (p<0.001). At timepoint 2, mean (± SD) age (61 ± 12 years), mean BMI (30 ± 7 kg/m²), sex (68% female), and hypopituitarism (64% with ≥1 pituitary hormone deficiency) were similar between MED and SURG; mean IGF-1 index (IGF-1 level/mean normal range) was 1.00 ± 0.37 for MED vs 0.78 ± 0.40 for SURG (p=0.08); 79% of MED remained on medication. In MED, there was no change in SF-36 scores between timepoints, but all AcroQoL subscales and 2 GIQLI domains (Physical State, Emotions) improved, even after controlling for age, BMI, radiation treatment, and hypopituitarism. Results were similar in the 79% who remained on medication at timepoint 2. In SURG, QoL scores worsened on the SF-36 Pain domain and Physical Health Summary Score and SQ Depression and Somatic subscales (p≤0.01) but did not remain significant after controlling for age, BMI, radiation treatment, GHD, and adrenal insufficiency. After controlling for those variables, QoL by AGHDA worsened (p=0.02). At timepoint 2, % scoring in the lowest quartile (<25%) of normal for age on the SF-36 was similar between MED and SURG: 57% scored <25% of normal on ≥1 SF-36 domain and 29% scored <25% of normal on ≥4 of 8 domains. GHD in SURG was associated with poorer SF-36 scores at timepoint 2 (6 domains and Mental Health Summary Score; p<0.05). Radiation treatment did not predict poorer SF-36 scores. In conclusion, an average of 15 to 20 years after biochemical control of acromegaly by surgery ± radiation ± pharmacologic treatment, QoL remained low in many patients. QoL was poorer in patients with GHD than without but overall did not differ between those on and off pharmacologic therapy. Our data suggest that a history of acromegaly and development of GHD, but not medical treatment, are detrimental to QoL.

Effects of growth hormone receptor antagonism and somatostatin analog administration on quality of life in acromegaly

OBJECTIVE

Acromegaly is associated with impaired quality of life (QoL). We investigated the effects of biochemical control of acromegaly by growth hormone receptor antagonism vs somatostatin analog therapy on QoL.

DESIGN

Cross-sectional.

PATIENTS

116 subjects: n = 55 receiving a somatostatin analog (SSA group); n = 29 receiving pegvisomant (PEG group); n = 32 active acromegaly on no medical therapy (ACTIVE group).

MEASUREMENTS

Acromegaly QoL Questionnaire (AcroQoL), Rand 36-Item Short Form Survey (SF-36) and Gastrointestinal QoL Index (GIQLI); fasting glucose, insulin and IGF-1 levels (LC/MS, Quest Diagnostics).

RESULTS

There were no group differences in mean age, BMI or sex [(whole cohort mean ± SD) age 52 ± 14 years, BMI 30 ± 6 kg/m² , and male sex 38%]. Mean IGF-1 Z-scores were higher in ACTIVE (3.9 ± 1.0) vs SSA and PEG, which did not differ from one another (0.5 ± 0.7 and 0.5 ± 0.7, P < .0001 vs ACTIVE). Eighty-three per cent of PEG previously received somatostatin analogs, which had been discontinued due to lack of efficacy (52%) or side effects (41%). There were no differences in the four QoL primary end-points (AcroQoL Global Score, SF-36 Physical Component Summary Score, SF-36 Mental Health Summary Score and GIQLI Global Score) between SSA and PEG. Higher HbA1c, BMI and IGF-1 Z-scores were associated with poorer QoL in several domains.

CONCLUSION

Our data support a comparable QoL in patients receiving pegvisomant vs somatostatin analogs, despite the fact that the vast majority receiving pegvisomant did not respond to or were not able to tolerate somatostatin analogs.

Low-Dose Testosterone Augmentation for Antidepressant-Resistant Major Depressive Disorder in Women: An 8-Week Randomized Placebo-Controlled Study

OBJECTIVE

Low-dose testosterone has been shown to improve depression symptom severity, fatigue, and sexual function in small studies in women not formally diagnosed with major depressive disorder. The authors sought to determine whether adjunctive low-dose transdermal testosterone improves depression symptom severity, fatigue, and sexual function in women with antidepressant-resistant major depression. A functional MRI (fMRI) substudy examined effects on activity in the anterior cingulate cortex (ACC), a brain region important in mood regulation.

METHODS

The authors conducted an 8-week randomized double-blind placebo-controlled trial of adjunctive testosterone cream in 101 women, ages 21-70, with antidepressant-resistant major depression. The primary outcome measure was depression symptom severity as assessed by the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary endpoints included fatigue, sexual function, and safety measures. The primary outcome of the fMRI substudy (N=20) was change in ACC activity.

RESULTS

The participants' mean age was 47 years (SD=14) and their mean baseline MADRS score was 26.6 (SD=5.9). Eighty-seven (86%) participants completed 8 weeks of treatment. MADRS scores decreased in both study arms from baseline to week 8 (testosterone arm: from 26.8 [SD=6.3] to 15.3 [SD=9.6]; placebo arm: from 26.3 [SD=5.4] to 14.4 [SD=9.3]), with no significant difference between groups. Improvement in fatigue and sexual function did not differ between groups, nor did side effects. fMRI results showed a relationship between ACC activation and androgen levels before treatment but no difference in ACC activation with testosterone compared with placebo.

CONCLUSIONS

Adjunctive transdermal testosterone, although well tolerated, was not more effective than placebo in improving symptoms of depression, fatigue, or sexual dysfunction. Imaging in a subset of participants demonstrated that testosterone did not result in greater activation of the ACC.

SAT-737 Low-Dose Testosterone Augmentation for Treatment-Resistant Depression in Women: An 8-Week, Two-Site, Randomized, Placebo-Controlled Study

Objective: Nonresponse to selective serotonin reuptake inhibitor and serotonin norepinephrine reuptake inhibitor treatment is common in patients with major depressive disorder (MDD), particularly in women, occurring in about 70% of patients despite adequate dosing. Well-tolerated augmentation strategies are needed, particularly ones that do not cause or exacerbate symptoms such as fatigue and sexual dysfunction. Low-dose testosterone has been shown to improve depression symptom severity, fatigue and sexual function in small studies of women not formally diagnosed with MDD. We sought to determine whether adjunctive low-dose transdermal testosterone improves depression symptom severity, fatigue, and sexual function in women with treatment-resistant MDD. A functional MRI (fMRI) substudy examined effects of testosterone on activity in the anterior cingulate cortex (ACC), a brain region important in mood regulation.

Methods: Randomized, double-blind, placebo-controlled, 8-week trial of adjunctive testosterone cream (AndroFeme^® 1, Lawley Pharmaceuticals, Australia) in 101 women, ages 21–70, with treatment-resistant MDD. Testosterone was titrated to achieve blood levels near the upper normal reference limit. Primary outcome measure was depression severity by Montgomery-Asberg Depression Rating Scale (MADRS). Secondary endpoints included fatigue, sexual function, and safety measures. fMRI substudy (n=20) primary outcome was change in ACC activity.

Results: Mean age was 47±14 (SD) years and mean baseline MADRS score was 26.6±5.9. Eighty-seven (86%) participants completed 8 weeks of treatment. MADRS depression scores decreased in both arms [testosterone: 26.8±6.3 to 15.3±9.6; placebo: 26.3±5.4 to 14.4±9.3 (baseline to 8 weeks, respectively)], with no difference between groups (p=0.91). Fatigue and sexual function improved without differences between groups. There were no group differences in side effects. fMRI results demonstrated a relationship between ACC activation and androgen levels pretreatment but no difference in ACC activation with treatment.

Conclusions: This rigorously designed, double-blinded clinical trial did not find significant group differences between adjunctive low dose transdermal testosterone and placebo for antidepressant augmentation in women with treatment-resistant MDD and had a high placebo response rate. Low-dose testosterone was well tolerated but failed to differentially impact overall depressive symptom severity, fatigue, or sexual dysfunction. Testosterone did not result in greater activity in a brain region (ACC) implicated in MDD etiopathology compared to placebo. Thus, the addition of low-dose testosterone to ineffective antidepressant treatment should not be recommended for women with MDD. Further studies using strategies designed to reduce placebo effects may be warranted.

SAT-167 Dehydroepiandrosterone Sulfate (DHEAS) Levels Predict Weight Gain in Women with Anorexia Nervosa

Introduction: Anorexia nervosa (AN) and atypical AN (defined as weight loss and all the psychological features of AN but BMI>18.5 kg/m²) are serious disorders characterized by undernutrition and complicated by endocrine dysregulation. Predictors of recovery, including serum biomarkers, are lacking. Prior studies have suggested that higher urinary free cortisol (UFC) may predict weight gain in women with AN, but 24-hour urine collections are not feasible in a real-world setting. Like cortisol, the adrenal androgen dehydroepiandrosterone (DHEA) and its sulfated form DHEAS, which has a longer half-life, are stimulated by ACTH. We hypothesized that DHEAS levels would correlate with UFC and be a predictor of weight gain in women with AN.

Methods: We prospectively studied 34 women with AN and atypical AN, mean age 27.4 ± 7.7 years (mean ± SD), who received placebo in a randomized trial. AN and atypical AN were diagnosed by SCID. Baseline DHEAS and 24-hour UFC were measured by LC-MS/MS (Endocrine Sciences, Calabasas Hills, CA). Weight and body composition were assessed at baseline and 6 months later by DXA and cross-sectional abdominal CT at L4.

Results: At baseline, mean weight was 51.3 ± 4.9 kg. Of the 18 subjects who gained weight (range 0.1–10.3 kg), 28% were eumenorrheic, 39% amenorrheic, and 33% on oral contraceptives at baseline; baseline reproductive status was similar for subjects who did not subsequently gain weight. In the group as a whole, mean baseline DHEAS level was 173 ± 70 µg/dL (0.7 ± 0.3 times the mean normal range for age) and mean baseline UFC for subjects who completed testing (n=15) was 20 ± 18 µg/24h (normal range 0–50 µg/24h). Higher DHEAS levels at baseline predicted weight gain over 6 months (r=0.61, p<0.001), which remained significant after controlling for age, baseline BMI, OCP use, and SSRI/SNRI use (p<0.001); none of these covariates were predictors of weight gain. Baseline DHEAS levels predicted an increase in fat mass (r=0.40, p=0.03) and appendicular lean mass (r=0.38, p=0.04) by DXA, and abdominal fat by CT (r=0.60, p<0.001); the associations remained significant after controlling for the above factors. UFC did not predict change in weight (r=0.37, p=0.17) or body composition. DHEAS levels were positively associated with UFC (r=0.61, p=0.02).

Conclusion: In women with AN, higher DHEAS levels are a predictor of weight gain and increases in fat mass, skeletal muscle mass, and abdominal fat. Serum DHEAS correlates with UFC, a predictor of weight gain in prior studies. DHEAS may be a more practical biomarker of recovery, as 24-hour urine collections are challenging. Further studies are needed to determine whether higher DHEAS levels are a marker of global adrenal stress response and a reflection of higher cortisol levels, which may stimulate weight gain, or an independent predictor of weight gain in AN and atypical AN, perhaps through neuromodulation.

OR26-03 Lower Serum Myostatin Levels Are Associated with Higher Insulin Sensitivity in Adults with Overweight/Obesity

In preclinical models, inhibition of the myokine myostatin prevents or improves insulin resistance (IR). However, studies investigating the association between serum myostatin levels and IR in humans are discrepant, perhaps in part because myostatin immunoassays lack specificity and sensitivity. New sensitive and specific myostatin LC-MS/MS assays make it possible to determine if higher serum myostatin levels are independently associated with greater IR in adults with overweight/obesity. If true, therapeutic manipulation of myostatin pathways may be a potential therapeutic target to prevent or treat type 2 diabetes (T2DM) in this high-risk population, in which current strategies, e.g. weight loss, are difficult to implement and maintain.

We studied 75 adults (53% women), 20–65 yo, BMI ≥25 kg/m² and generally healthy without T2DM. Serum myostatin levels (1° independent variable) were measured by LC-MS/MS (Brigham Research Assay Core, Boston, MA), with no cross-reactivity with growth differentiation factor 11 (GDF11), activins or transforming growth factor beta (TGF-β), sensitivity of 0.5 ng/mL and intra- and inter-assay coefficient of variation of 10 and 12%. Insulin sensitivity (IS) (1° dependent variable) was estimated by QUICKI, appendicular lean mass (ALM) by DXA, visceral adipose tissue (VAT) by CT and intrahepatic (IHL) and intramyocellular lipids (IMCL) by MR spectroscopy. Models were run sex- combined and stratified given sex differences in muscle mass.

Mean age was 47.9±12.2 years and BMI was 33.2±5.7 kg/m² (mean±SD). Compared to men, women had lower mean ALM (20.9±3.3 vs 29.2±3.3 kg, p<0.0001) and serum myostatin levels (7.28±1.87 vs 8.28±1.89 ng/mL, p=0.02) and similar mean IS (0.16±0.02 vs 0.15±0.02, p=0.13). Lower serum myostatin levels were associated with higher IS in the whole group (R=-0.32, p=0.008) and in women (R=-0.41, p=0.02)—both remained significant after controlling for ALM—but not in men (R=-0.16, p=0.36). In a multivariate model including VAT, IHL, IMCL and ALM, lower serum myostatin levels were associated with higher IS in the whole group (B₁= -0.37, p=0.003), in women (B₁= -0.43, p=0.02) and in men (B₁= -0.37, p=0.05). In a stepwise regression model including VAT, IHL, IMCL and ALM, VAT explained 18%, IHL explained 10% and myostatin explained 8% of the variability in IS in the whole group; in women, myostatin explained 18% and IHL explained 12% of the variability; in men, VAT explained 26% of the variability and myostatin was not a significant determinant.

In conclusion, lower serum myostatin levels were associated with greater IS in adults with overweight/obesity, independent of muscle and adipose depots known to be associated with T2DM risk. Future studies should investigate potential sex differences in the association between myostatin and IS. Therapeutic manipulation of myostatin pathways may be a potential therapeutic target to prevent or treat T2DM.

MON-286 Peak Stimulated Growth Hormone Is Lower in Subjects with Nonalcoholic Fatty Liver Disease Than Controls of Similar Sex, Age and BMI

Background: Nonalcoholic fatty liver disease (NAFLD), fatty infiltration of the liver in the absence of alcohol use, is a prevalent and serious complication of obesity. Obesity is a state of relative growth hormone (GH) deficiency, and GH has been identified as a candidate disease-modifying target in NAFLD because of its lipolytic and anti-inflammatory properties. However, it is not known whether individuals with NAFLD phenotyped by proton magnetic resonance spectroscopy (1H-MRS), the gold standard imaging modality for assessment of intrahepatic lipid (IHL) content, have lower peak stimulated GH levels as compared to those of similar age, sex and BMI without NAFLD.

Methods: We studied 99 generally healthy adults without diabetes or significant alcohol use, ages 19-67 y and BMI >25 kg/m². All subjects underwent 1H-MRS for assessment of IHL content. Using a cutoff of >5.5%, 65 subjects had NAFLD and 34 did not (controls). GHRH-arginine stimulation testing was performed. GH was measured by immunoassay and IGF-1 by LC/MS/MS (Quest Diagnostics, CA, USA). Visceral and subcutaneous adipose tissue (VAT/SAT) were assessed by cross-sectional CT at L4. Results are reported as mean ±SD.

Results: There was no difference between NAFLD vs controls in mean age (48±12 vs 45±14 y, p=0.30), BMI (33±4 vs 33±7 kg/m², p=0.96), sex (43% vs 44% female, p=0.90) or premenopausal status (50% vs 60%, p=0.50). Mean IHL was 21.8±13.3% (range 5.5-57.8%) and 2.9±1.1% (range 1.0-4.9%) in the NAFLD and control groups, respectively (p<0.0001). NAFLD subjects had higher ALT, total cholesterol, triglycerides, VLDL, LDL and lower HDL than controls. Fasting glucose was statistically but not clinically significantly higher in NAFLD vs controls (90±9 vs 86±7 mg/dL, p=0.03), and mean HbA1c did not differ significantly. There was a trend towards a higher mean VAT in the NAFLD vs controls (157±70 vs 131±67 g, p=0.07) but no difference in SAT. Mean peak stimulated GH was significantly lower in NAFLD vs controls (9.0±6.3 vs 15.4±11.2 ng/mL, p=0.003) which remained significant after controlled for age, BMI, sex and VAT. In a stepwise model including peak stimulated GH, VAT, age, BMI and sex, peak stimulated GH predicted 8% of the variability in IHL (p=0.004); no other variables were significant predictors of IHL. Mean IGF-1 (149±53 vs 151±49 ng/mL, p=0.80) and IGF-1 Z-score (-0.03±0.61 vs -0.03±0.68, p=0.90) were not significantly different between the groups.

Conclusion: Subjects with NAFLD have lower peak stimulated GH but similar IGF-1 levels compared to non-NAFLD controls of similar age, BMI and sex. Additionally, lower peak stimulated GH was predictive of higher IHL, independent of age, BMI, sex and VAT. This suggests that the relative GH deficiency of obesity may be an independent contributor to the development of NAFLD and that the GH axis and downstream signaling pathways may be a therapeutic target for this disease where few currently exist.

SUN-303 Effects of Open-Label, Adjunctive Ganaxalone Treatment on Resistant Depression in Postmenopausal Women: A Pilot Study

Resistance to selective serotonin reuptake inhibitor and serotonin norepinephrine reuptake inhibitor treatment occurs in about 50% to 70% of patients with major depressive disorder (MDD), a condition associated with significant morbidity that affects women at higher rates than men. Few well-tolerated, effective augmentation therapies are available for such patients, and new therapeutic strategies for resistant depression are needed. The neuroactive steroid metabolite of progesterone, allopregnanolone, is a positive allosteric modulator of GABA_A receptors and a putative treatment for mood disorders. We performed a pilot study to determine whether an oral allopregnanolone analog (ganaxolone) may be effective adjunctive therapy for resistant depression in postmenopausal women. Ten postmenopausal women (age 62.8±6.3 years, range 53–69) with resistant depression [current DSM-IV major depressive episode per the Structured Clinical Interview for DSM-IV, Montgomery-Asberg Depression Rating Scale (MADRS) ≥16 despite treatment with an adequately dosed antidepressant for ≥6 weeks] were studied. Open-label ganaxolone (225 mg BID, increased to 450 mg BID if tolerated) was administered for 8 weeks, followed by a 2-week taper. Mean total MADRS depression score (primary endpoint) decreased by 8 weeks [24.4±1.6 (SEM) to 12.8±2.9, p=0.015] and persisted over the two-week taper (p=0.019); 44% of subjects experienced response (score decrease ≥50%) and remission (final score <10), which persisted in 100% and 50% of subjects at 10 weeks, respectively. Secondary endpoints showed significant improvement, including the Inventory of Depressive Symptomatology-Self-Report (IDS-SR; p=0.003), MADRS Reduced Sleep subscale (p<0.001), Symptoms of Depression Questionnaire (SDQ) total score (p=0.012), and SDQ subscales for disruptions in sleep quality (p=0.003) and changes in appetite and weight (p=0.009) over 8 weeks. No significant effects were observed on quality of life or sexual function. All subjects experienced sleepiness and fatigue; 60% experienced dizziness. In conclusion, adjunctive ganaxolone in this open label pilot study appeared to exert antidepressant effects in postmenopausal women with resistant depression but produces sedation with twice-daily dosing. The observed positive effects on sleep and the potential for sustained treatment effects merit further study, as ganaxolone may be particularly beneficial to patients with depression and insomnia. Randomized, placebo-controlled studies are necessary to rule out placebo effects. Given the sedation experienced by most participants, nighttime dosing only should be considered for future studies. Finally, should rigorous studies confirm an antidepressant effect, it will be important to identify subsets of women who respond (e.g. women with neuroactive steroid dysregulation) and mechanisms of action.

Differences in Trabecular Plate and Rod Structure in Premenopausal Women Across the Weight Spectrum

CONTEXT

Premenopausal women with anorexia nervosa (AN) and obesity (OB) have elevated fracture risk. More plate-like and axially aligned trabecular bone, assessed by individual trabeculae segmentation (ITS), is associated with higher estimated bone strength. Trabecular plate and rod structure has not been reported across the weight spectrum.

OBJECTIVE

To investigate trabecular plate and rod structure in premenopausal women.

DESIGN

Cross-sectional study.

SETTING

Clinical research center.

PARTICIPANTS

A total of 105 women age 21 to 46 years: (i) women with AN (n = 46), (ii) eumenorrheic lean healthy controls (HCs) (n = 29), and (iii) eumenorrheic women with OB (n = 30).

MEASURES

Trabecular microarchitecture by ITS.

RESULTS

Mean age (±SD) was similar (28.9 ± 6.3 years) and body mass index differed (16.7 ± 1.8 vs 22.6 ± 1.4 vs 35.1 ± 3.3 kg/m2; P < 0.0001) across groups. Bone was less plate-like and axially aligned in AN (P ≤ 0.01) and did not differ between OB and HC. After controlling for weight, plate and axial bone volume fraction and plate number density were lower in OB vs HC; some were lower in OB than AN (P < 0.05). The relationship between weight and plate variables was quadratic (R = 0.39 to 0.70; P ≤ 0.0006) (i.e., positive associations were attenuated at high weight). Appendicular lean mass and IGF-1 levels were positively associated with plate variables (R = 0.27 to 0.67; P < 0.05). Amenorrhea was associated with lower radial plate variables than eumenorrhea in AN (P < 0.05).

CONCLUSIONS

In women with AN, trabecular bone is less plate-like. In women with OB, trabecular plates do not adapt to high weight. This is relevant because trabecular plates are associated with greater estimated bone strength. Higher muscle mass and IGF-1 levels may mitigate some of the adverse effects of low weight or excess adiposity on bone.

A Randomized Placebo-Controlled Trial of Low-Dose Testosterone Therapy in Women With Anorexia Nervosa

CONTEXT

Anorexia nervosa (AN) is a psychiatric illness with considerable morbidity and no approved medical therapies. We have shown that relative androgen deficiency in AN is associated with greater depression and anxiety symptom severity.

OBJECTIVE

To determine whether low-dose testosterone therapy is an effective endocrine-targeted therapy for AN.

DESIGN

Double-blind, randomized, placebo-controlled trial.

SETTING

Clinical research center.

PARTICIPANTS

Ninety women, 18 to 45 years, with AN and free testosterone levels below the median for healthy women.

INTERVENTION

Transdermal testosterone, 300 μg daily, or placebo patch for 24 weeks.

MAIN OUTCOME MEASURES

Primary end point: body mass index (BMI). Secondary end points: depression symptom severity [Hamilton Depression Rating Scale (HAM-D)], anxiety symptom severity [Hamilton Anxiety Rating Scale (HAM-A)], and eating disorder psychopathology and behaviors.

RESULTS

Mean BMI increased by 0.0 ± 1.0 kg/m2 in the testosterone group and 0.5 ± 1.1 kg/m2 in the placebo group (P = 0.03) over 24 weeks. At 4 weeks, there was a trend toward a greater decrease in HAM-D score (P = 0.09) in the testosterone vs placebo group. At 24 weeks, mean HAM-D and HAM-A scores decreased similarly in both groups [HAM-D: -2.9 ± 4.9 (testosterone) vs -3.0 ± 5.0 (placebo), P = 0.72; HAM-A: -4.5 ± 5.3 (testosterone) vs -4.3 ± 4.4 (placebo), P = 0.25]. There were no significant differences in eating disorder scores between groups. Testosterone therapy was safe and well tolerated with no increase in androgenic side effects compared with placebo.

CONCLUSION

Low-dose testosterone therapy for 24 weeks was associated with less weight gain-and did not lead to sustained improvements in depression, anxiety, or disordered eating symptoms-compared with placebo in women with AN.

OR03-6 Tibial and Radial Bone Structure as Assessed by HRpQCT May Explain Differences in Peripheral Skeletal Integrity and Fracture Risk Across the Weight Spectrum That Cannot Be Explained by Areal BMD Alone

No study has investigated tibial or radial bone structure or estimated strength by high-resolution peripheral quantitative CT (HRpQCT) in women across the weight spectrum. We studied 139 women, 17-46yo: 1) anorexia nervosa (AN n=74), 2) lean controls (HC n=33) and 3) overweight/obese (OB n=32). All HC and OB were eumenorrheic. Areal BMD (aBMD) and appendicular lean mass (ALM) were measured by DXA; cortical and trabecular volumetric BMD (vBMD), cortical thickness, cortical porosity, failure load (finite element analysis) and trabecular plate parameters (individual trabecular segmentation) at the tibia and radius by HRpQCT. Mean age was similar among groups. Mean BMI was 17.7 ± 2.1 vs 22.6 ± 1.4 vs 35.2 ± 3.2 kg/m² (p<0.0001). Mean aBMD Z-scores were lowest in AN, intermediate in HC and highest in OB (PA spine -1.6 ± 1.3 vs -0.5 ± 0.8 vs 0.5 ± 0.8; total hip -1.0 ± 1.1 vs 0.2 ± 0.9 vs 1.0 ± 0.9; radius -0.6 ± 1.0 vs 0.1 ± 0.9 vs 0.7 ± 0.9; p<0.0001). At the tibia and radius, mean trabecular vBMD and failure load were lowest in AN, intermediate in HC and highest in OB, while mean trabecular plate bone volume fraction, plate number density and plate-plate junction density were lower in AN (p<0.05) and similar in HC and OB. Mean cortical vBMD and cortical porosity were similar among groups, but cortical thickness was lower in AN vs OB (p<0.01). There was a quadratic relationship between BMI and trabecular vBMD, failure load and all plate parameters (R=0.40-0.67, p<0.0001), such that the higher the BMI, the smaller the increase in these parameters. In contrast, ALM had a consistent positive linear relationship with these parameters (R=0.37-0.78, p<0.0001). IGF-1 levels were positively associated with tibial and radial estimated strength and trabecular structure (R=0.21-0.37, p<0.05). Duration of amenorrhea in AN was negatively associated with radial estimated strength and trabecular structure (R= -0.25- -0.37, p<0.01). Despite similar mean aBMD at all sites, those with a history of fracture (n=57) had lower mean tibial and radial trabecular vBMD and plate-plate junction density; lower mean tibial cortical vBMD, plate bone volume fraction and plate number; and higher mean tibial cortical porosity compared to those without (n=72) (p<0.05). Conclusions: Trabecular bone structure and estimated strength were generally higher with greater weight, but the incremental increase was smaller as BMI increased into the obese range. Cortical bone parameters generally did not increase with greater weight. This suggests that the skeleton in women with obesity may not be able to fully adapt to an increased weight load. Muscle mass and IGF-1 levels were positive, and duration of amenorrhea a negative, determinant of bone structure and estimated strength. Across the weight spectrum, tibial and radial bone structure by HRpQCT may explain differences in peripheral skeletal integrity and fracture risk that cannot be explained by aBMD alone.

MON-449 Serum Neuroactive Steroid Levels in Postmenopausal Women with Treatment-Resistant Major Depressive Disorder

Background: Neuroactive steroids such as 3α-5α-tetrahydroprogesterone (allopregnanolone) and 5α-androstane-3α,17β-diol (3α-androstanediol) are modulators of traditional neurotransmitter receptors and have been implicated in the etiopathology of psychiatric disorders, including depression, but levels have not been assessed in women with treatment-resistant major depressive disorder (MDD). We hypothesized that allopregnanolone, 3α-androstanediol, and the ratio of these steroid levels to their precursors (progesterone and testosterone, respectively) would be lower in postmenopausal women with treatment-resistant MDD than non-depressed controls. Methods: Fasting serum neuroactive steroid levels measured by gas chromatography/mass spectrometry were compared in women with treatment-resistant MDD (MDD, n=12) [Montgomery-Asberg Depression Rating Scale (MADRS) >12 despite an adequately dosed antidepressant] and in healthy controls without depression (HC, n=28). All subjects were postmenopausal nonsmokers; none were receiving systemic estrogen. Results: Mean age and BMI did not differ between groups. In MDD, mean number of antidepressants per subject was 1.5±0.5 (SD), with 58% receiving selective serotonin reuptake inhibitors and 50% bupropion. Mean MADRS was 24.4±5.8 (moderate depression severity). In MDD vs HC, the mean allopregnanolone/progesterone ratio was lower (0.20±0.19 vs 0.47±0.46, p=0.03) and progesterone levels were higher (153±177 vs 57±50 pg/mL, p=0.04). There was no difference in mean allopregnanolone levels between groups. Compared with HC, MDD subjects had lower serum free testosterone (0.21±0.16 vs 0.38±0.18 ng/dL, p=0.006) and a trend toward lower total testosterone (13.3±5.9 vs 18.6±9.9 ng/dL, p=0.06). There was no difference in 3α-androstanediol levels or 3α-androstanediol/total testosterone ratio between groups. There was a trend toward a positive association between progesterone levels and depression severity (r=0.34, p=0.06) and an inverse association between the allopregnanolone/progesterone ratio and depression severity (r=-0.36, p=0.07). Lower free testosterone levels were associated with greater depression severity (r=-0.45, p=0.03). Conclusion: In postmenopausal women with treatment-resistant MDD, the allopregnanolone/progesterone ratio was lower and progesterone levels higher than in non-depressed controls. Allopregnanolone levels did not differ between groups. This may be due to reduced metabolism of progesterone to allopregnanolone and could have treatment implications. Additionally, testosterone levels were lower in depressed women, but there was no difference in 3α-androstanediol levels or the 3α-androstanediol/total testosterone ratio between depressed and non-depressed women, suggesting that testosterone may play a greater role in depression symptomatology than its metabolite.

Apremilast, an oral phosphodiesterase 4 inhibitor, improves patient-reported outcomes in the treatment of moderate to severe psoriasis: results of two phase III randomized, controlled trials

Background

Apremilast, an oral phosphodiesterase 4 inhibitor, has an acceptable safety profile and is effective for treatment of plaque psoriasis and psoriatic arthritis.

Objectives

To evaluate the impact of apremilast on health‐related quality of life (HRQOL), general functioning and mental health using patient‐reported outcome (PRO) assessments among patients with moderate to severe plaque psoriasis in the ESTEEM 1 and 2 trials.

Methods

A total of 1255 patients were randomized (2 : 1) to apremilast 30 mg BID or placebo for 16 weeks; all received apremilast through Week 32. PRO assessments included the Dermatology Life Quality Index (DLQI), 36‐Item Short‐Form Health Survey version 2 mental/physical component summary scores (SF‐36v2 MCS/PCS), Patient Health Questionnaire‐8 (PHQ‐8), EuroQol‐5D (EQ‐5D) and Work Limitations Questionnaire‐25 (WLQ‐25). Post hoc analyses examined relationships between Psoriasis Area and Severity Index (PASI) scores and PHQ‐8 in the apremilast‐treated population at Week 16.

Results

Treatment with apremilast improved all HRQOL PROs at Week 16 (vs. placebo), except the SF‐36v2 PCS, and improvements were sustained through Week 32. Mean DLQI and SF‐36v2 MCS improvements exceeded minimal clinically important differences. Changes at Week 16 in PHQ‐8 and PASI were weakly correlated, and only 35.8% of patients who achieved a ≥75% reduction from baseline in PASI score (PASI‐75) with apremilast treatment also achieved PHQ‐8 scores of 0–4.

Conclusions

Apremilast led to improvements in HRQOL PROs vs. placebo in patients with moderate to severe plaque psoriasis.

Invasive serotype a Haemophilus influenzae infections with a virulence genotype resembling Haemophilus influenzae type b: emerging pathogen in the vaccine era?

OBJECTIVE

Haemophilus influenzae type b causes severe disease in nonimmune infants and young children; other serotypes are uncommon pathogens and thought to have low virulence. Some have hypothesized that with the virtual elimination of H influenzae type b, other serotypes might acquire virulence traits and emerge as important pathogens of children. We describe the clinical, epidemiologic, and molecular biologic features of 5 cases of severe disease attributable to Haemophilus influenzae type a.

METHODS

After observing 4 cases of invasive disease caused by H influenzae type a, we reviewed microbiology records at 3 reference laboratories that perform all serotyping in Utah and surveillance databases. Strains of H influenzae type a and control strains were examined by Southern blotting with the use of the cap probe pUO38 and by pulsed-field gel electrophoresis. The putative virulence mutation, the IS1016-bexA deletion, was detected by polymerase chain reaction amplification and sequencing.

RESULTS

During a 10-month period, we observed 5 children with severe invasive disease caused by H influenzae type a. No isolates of H influenzae type a had been submitted to the reference laboratories between 1992 and 1998. The median age of patients was 12 months (range: 6-48 months). Four of 5 had meningitis and bacteremia; 1 had purpura fulminans. Three isolates, representing 1 of 2 pulsed-field gel electrophoresis patterns, contained the IS1016-bexA deletion and were associated with particularly severe disease.

CONCLUSIONS

We describe an unusual cluster of severe disease caused by H influenzae type a that resembles the clinical and epidemiologic features of H influenzae type b disease. Our data support the hypothesis that the IS1016-bexA deletion may identify more virulent strains of H influenzae. Haemophilus influenzae, epidemiology, virulence, serotyping, pathogenicity.

The effect of regular exercise on women receiving danazol for treatment of endometriosis

OBJECTIVE

To determine the effects of regular exercise on women receiving danazol for the treatment of endometriosis.

METHODS

Thirty-nine patients were randomized to a danazol-only or a danazol/exercise regimen in a prospective clinical trial carried out at tertiary care institutions. Patients in the danazol/exercise group were instructed to exercise four times per week, for 40 min per session, at an intensity of 20 metabolic units. Side effect profiles, pelvic symptoms, aerobic fitness, strength and hormone levels were compared for all subjects. The number of side effects of danazol was analyzed by the method of generalized estimating equations.

RESULTS

The number of side effects reported during a 4-week period was 1.09-2.17 times greater for the danazol-only than for the danazol/exercise group. All patients had improvement of symptoms during treatment. The danazol/exercise group had significantly lower testosterone levels during treatment. The time to recurrence of endometriosis was not different between groups.

CONCLUSIONS

Exercise during danazol therapy reduces the number of androgenic side effects. Relief of pain and time to recurrence are unaffected.

Measurement of benzodiazepine receptor number and affinity in humans using tracer kinetic modeling, positron emission tomography, and [11C]flumazenil

Kinetic methods were used to obtain regional estimates of benzodiazepine receptor concentration (Bmax) and equilibrium dissociation constant (Kd) from high and low specific activity (SA) [11C]flumazenil ([11C] Ro 15-1788) positron emission tomography studies of five normal volunteers. The high and low SA data were simultaneously fit to linear and nonlinear three-compartment models, respectively. An additional inhibition study (pretreatment with 0.15 mg/kg of flumazenil) was performed on one of the volunteers, which resulted in an average gray matter K1/k2 estimate of 0.68 +/- 0.08 ml/ml (linear three-compartment model, nine brain regions). The free fraction of flumazenil in plasma (f1) was determined for each study (high SA f1: 0.50 +/- 0.03; low SA f1: 0.48 +/- 0.05). The free fraction in brain (f2) was calculated using the inhibition K1/k2 ratio and each volunteer's mean f1 value (f2 across volunteers = 0.72 +/- 0.03 ml/ml). Three methods (Methods I-III) were examined. Method I determined five kinetic parameters simultaneously [K1, k2, k3 (= konf2Bmax), k4, and konf2/SA] with no priori constraints. An average kon value of 0.030 +/- 0.003 nM-1 min-1 was estimated for receptor-rich regions using Method I. In Methods II and III, the konf2/SA parameter was specifically constrained using the Method I value of kon and the volunteer's values of f2 and low SA (Ci/mumol). Four parameters were determined simultaneously using Method II. In Method III, K1/k2 was fixed to the inhibition value and only three parameters were estimated. Method I provided the most variable results and convergence problems for regions with low receptor binding. Method II provided results that were less variable but very similar to the Method I results, without convergence problems. However, the K1/k2 ratios obtained by Method II ranged from 1.07 in the occipital cortex to 0.61 in the thalamus. Fixing the K1/k2 ratio in Method III provided a method that was physiologically consistent with the fixed value of f2 and resulted in parameters with considerably lower variability. The average Bmax values obtained using Method III were 100 +/- 25 nM in the occipital cortex, 64 +/- 18 nM in the cerebellum, and 38 +/- 5.5 nM in the thalamus; the average Kd was 8.9 +/- 1.0 nM (five brain regions).

Superovulation with or without intrauterine insemination for the treatment of infertility

Patients undergoing human menopausal gonadotropin (hMG) superovulation were reviewed retrospectively to determine whether fecundity was greater for intrauterine insemination (IUI) than timed intercourse. Forty patients with unexplained infertility, American Fertility Society I or II endometriosis, luteal phase defect and/or cervical factor were treated with hMG alone or hMG plus IUI. Twenty-eight underwent 52 cycles of hMG/IUI, and 19 underwent 31 cycles of hMG. The probability of pregnancy after four cycles was significantly better in the hMG/IUI group (.90) than the hMG group (.37, P = .049). There was a 54.5% multiple pregnancy rate, and one patient was admitted to the hospital for hyperstimulation. When traditional therapy fails, hMG/IUI significantly increases the pregnancy rates as compared to hMG with timed intercourse in a "good prognosis" group of patients.

The efficacy of presacral neurectomy for the relief of midline dysmenorrhea

The present study was undertaken to evaluate prospectively the efficacy of presacral neurectomy for the treatment of midline dysmenorrhea. All patients had moderate to severe dysmenorrhea and stage III-IV endometriosis. Of the patients undergoing presacral neurectomy (N = 17), only two had a recurrence of pain. The remainder of the patients undergoing presacral neurectomy remain pain-free at 42 months of follow-up. Of the patients undergoing resection of endometriosis but not presacral neurectomy (N = 9), none received relief of midline pain. Relief of lateral pain, back pain, and dyspareunia was variable in both groups. Our findings corroborate previous retrospective studies showing that presacral neurectomy is highly effective in the treatment of dysmenorrhea. We speculate that the most common reasons for failure of presacral neurectomy are inappropriate selection of patients and incomplete resection of the presacral nerve plexus.

Construction and analysis of parallel and antiparallel Holliday junctions

The Holliday junction is a four-stranded DNA intermediate that arises during recombination reactions. We have designed and constructed a set of Holliday junction analogs that model each of the ideal conformations available to a 2-fold symmetric four-arm junction. The strategy used is to connect two arms of a junction molecule with a short tether of thymidines. These DNA molecules share a common core sequence but have different arms that are connected so that each molecule is constrained in either an antiparallel or a parallel structure. For tethered antiparallel molecules the identity of the crossover strands is determined by which arms are connected. Different arm connections gave molecules representing each of the two antiparallel crossover isomers. Two parallel molecules that differ in the length and position of the tether exhibit opposite biases in their choice of crossover strands. Thus, a physical constraint applied at a distance from the branch point can determine the conformation of a junction.

Branch vein occlusion. Retinal neovascularization outside the involved segment

Three hundred sixty-six cases of branch vein occlusion entered within the multicenter Branch Vein Occlusion Randomized Clinical Trial have been reviewed. Four cases that developed retinal neovascularization outside of the retinal area involved with the occlusion have been documented by photography and fluorescein angiography.

Fetal acceleration determinations and perinatal outcome

The importance of a laboratory test, especially when used as a screening procedure, is its ability to accurately provide information which can be used in the clinical management of patients. The fetal acceleration determination (FAD) has been utilized by many clinical obstetric services to assess the fetus at risk and to avoid the cumbersome and expensive oxytocin challenge test (OCT). In an effort to determine the usefulness of this modality in assessing the high-risk obstetric patient, a retrospective study of FADs was performed on 264 patients. All the tests were performed within one week of delivery. Fetal outcome was measured by Apgar scores, fetal morbidity and mortality and length of nursery stay. Chi square row by column contingency analysis was performed, and Bayes theorem was applied to our data to predict FAD specificity. The probability of false-positive and false-negative tests was high, and no correlation with outcome was observed. Analysis of these data indicates that the FAD is of limited value in identifying the fetus at risk.

Composition of biliary lipids and kinetics of bile acids after cholecystectomy in man

Postcholecystectomy biliary lipid composition and bile acid kinetics were studied in 24 women and 4 men. Hepatic bile was collected periodically for as long as 4 months without interrupting the enterohepatic circulation and without infecting the biliary system. In 23 patients with cholesterol gallstones, fasting biliary cholesterol made up 10.2% of total lipids in the steady state; in 5 patients with bilirubinate stones, saturation of fasting hepatic bile with cholesterol was lower (8.7% of total lipids). The percentage of deoxycholic acid after cholecystectomy was not higher than that of seven healthy, noncholecystectomized controls. Postcholecystectomy studies of diurnal variation of biliary lipids (7 patients) showed that postprandial hepatic bile had a significantly lower cholesterol saturation than fasting bile. Pool sizes of cholic and chenodeoxycholic acids were low (average 0.4 g/70 kg, each); total synthesis for both bile acids was normal (average 460 mg/day/70 kg), but fractional turnover rates of the two primary bile acids increased after cholecystectomy, probably due to more frequent recycling of the small bile acid pool.