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Shalet S. 60 years on, growth hormone inches its way to safety. Lancet Diabetes Endocrinol 2020; 8:651-652. [PMID: 32707104 DOI: 10.1016/s2213-8587(20)30233-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022]
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Hokken-Koelega A, van der Lely AJ, Hauffa B, Häusler G, Johannsson G, Maghnie M, Argente J, DeSchepper J, Gleeson H, Gregory JW, Höybye C, Keleştimur F, Luger A, Müller HL, Neggers S, Popovic-Brkic V, Porcu E, Sävendahl L, Shalet S, Spiliotis B, Tauber M. Bridging the gap: metabolic and endocrine care of patients during transition. Endocr Connect 2016; 5:R44-R54. [PMID: 27803155 PMCID: PMC5118971 DOI: 10.1530/ec-16-0028] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 11/01/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Seamless transition of endocrine patients from the paediatric to adult setting is still suboptimal, especially in patients with complex disorders, i.e., small for gestational age, Turner or Prader-Willi syndromes; Childhood Cancer Survivors, and those with childhood-onset growth hormone deficiency. METHODS An expert panel meeting comprised of European paediatric and adult endocrinologists was convened to explore the current gaps in managing the healthcare of patients with endocrine diseases during transition from paediatric to adult care settings. RESULTS While a consensus was reached that a team approach is best, discussions revealed that a 'one size fits all' model for transition is largely unsuccessful in these patients. They need more tailored care during adolescence to prevent complications like failure to achieve target adult height, reduced bone mineral density, morbid obesity, metabolic perturbations (obesity and body composition), inappropriate/inadequate puberty, compromised fertility, diminished quality of life and failure to adapt to the demands of adult life. Sometimes it is difficult for young people to detach emotionally from their paediatric endocrinologist and/or the abrupt change from an environment of parental responsibility to one of autonomy. Discussions about impending transition and healthcare autonomy should begin in early adolescence and continue throughout young adulthood to ensure seamless continuum of care and optimal treatment outcomes. CONCLUSIONS Even amongst a group of healthcare professionals with a great interest in improving transition services for patients with endocrine diseases, there is still much work to be done to improve the quality of healthcare for transition patients.
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Affiliation(s)
| | | | | | - Gabriele Häusler
- Medical University and General Hospital of ViennaVienna, Austria
| | | | - Mohamad Maghnie
- Istituto Giannina GasliniUniversity of Genova, Genova, Italy
| | - Jesús Argente
- Hospital Infantil Universitario Niño JesúsMadrid, Spain
| | | | | | | | - Charlotte Höybye
- Department of Molecular Medicine and SurgeryKarolinska Institute and Department of Endocrinology, Metabolism and Diabetology, Karolinska University Hospital, Stockholm, Sweden
| | - Fahrettin Keleştimur
- Department of EndocrinologySchool of Medicine, Erciyes University, Kayseri, Turkey
| | - Anton Luger
- Sahlgrenska University HospitalGöteborg, Sweden
| | - Hermann L Müller
- Department of PediatricsKlinikum Oldenburg, Medical Campus University Oldenburg, Oldenburg, Germany
| | | | | | | | - Lars Sävendahl
- Department of Women's and Children's HealthKarolinska Institutet, and Pediatric Endocrinology Unit, Karolinska University Hospital, Stockholm, Sweden
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Lewis AL, Jordan F, Patel T, Jeffery K, King G, Savage M, Shalet S, Illum L. Intranasal Human Growth Hormone (hGH) Induces IGF-1 Levels Comparable With Subcutaneous Injection With Lower Systemic Exposure to hGH in Healthy Volunteers. J Clin Endocrinol Metab 2015; 100:4364-71. [PMID: 26425883 PMCID: PMC4702464 DOI: 10.1210/jc.2014-4146] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
CONTEXT The development of an improved, efficacious human GH (hGH) product administered by a noninjectable route of delivery such as the nasal route is highly desirable. We have developed a novel nasal hGH product (CP024) that showed excellent nasal absorption in animal models; however, the translation of these results into the clinical setting is essential because past attempts to develop such formulations by other groups have been unable to induce IGF-1 in man. OBJECTIVE The objective of the study was to assess the pharmacokinetics, pharmacodynamics, and tolerability of CP024 compared with a sc hGH injection. DESIGN This was a single-center, nonrandomized placebo-controlled, open-label, five-way crossover study in eight healthy volunteers. SETTING The study was carried out at a contract research organization, Quotient Bioresearch. VOLUNTEERS Eight healthy male volunteers, given an iv infusion of octreotide to suppress the endogenous GH secretion during the study period, participated in the study. No volunteers were withdrawn due to side effects. MAIN OUTCOME MEASURES Measurement of hGH and IGF-1 levels and tolerability of the drug product was performed. RESULTS No serious adverse events were reported and no subjects withdrawn from study due to the treatment. After the nasal administration of CP024, 3-fold higher hGH blood levels were obtained as compared with hGH nasal control. The relative bioavailability was about 3%. CP024 (given twice daily) induced a significant increase in IGF-1 levels up to 19 hours after administration, with no significant difference to those obtained after the sc injection of hGH. CONCLUSIONS The study indicates that CP024 is a promising candidate for an efficacious nasal product for the treatment of GH deficiency due to induction of IGF-1 similar to that after a sc injection, despite the lower plasma hGH concentration obtained. A dose-response study is needed to evaluate the optimal nasal dose.
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Affiliation(s)
- Andrew L Lewis
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Faron Jordan
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Tina Patel
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Kirk Jeffery
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Gareth King
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Martin Savage
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Stephen Shalet
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
| | - Lisbeth Illum
- Critical Pharmaceuticals Ltd (A.L.L., F.J., T.P., K.J., G.K., L.I.), BioCity Nottingham, Nottingham NG1 1GF, United Kingdom; Department of Endocrinology (M.S.), William Harvey Research Institute, Barts and the Royal London School of Medicine and Dentistry, London E1 1BB, United Kingdom; and Department of Endocrinology (S.S.), Christie Hospital, Manchester M20 4BX, United Kingdom
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Abstract
Hypopituitarism is not currently considered as a potential cause of immune disruption in humans. Accumulating data from in vitro and animal models support a role for the pituitary gland in immune regulation. Furthermore, the increased mortality risk noted in patients with adult hypopituitarism remains poorly explained and immune dysfunction could conceivably contribute to this observation. In a recent issue of Clinical & Experimental Immunology, we presented new data relating to immune status in adults with treated, severe hypopituitarism. We observed humoral immune deficiency in a significant proportion, despite stable pituitary replacement, including growth hormone (GH). This was especially evident in those with low pretreatment IGF-I levels and appeared independent of anticonvulsant use or corticosteroid replacement. These observations require substantiation with future studies. In this short review, we summarize existing data relating to the effects of pituitary hormones on immune function and discuss potential clinical implications surrounding the hypothesis of immune dysregulation in severe hypopituitarism.
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Dixit K, Kreitschmann-Andermahr I, Basu A, Dick JPR, Manoharan P, Shalet S, Brabant G. Human growth hormone-related iatrogenic Creutzfeldt-Jakob disease--being aware of diagnostic features 25 years later. J Clin Endocrinol Metab 2009; 94:2684-5. [PMID: 19657045 DOI: 10.1210/jc.2009-0167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Affiliation(s)
- Kashinath Dixit
- Department of Endocrinology, The Christie, Manchester, United Kingdom.
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Russell W, Harrison RF, Smith N, Darzy K, Shalet S, Weetman AP, Ross RJ. Free triiodothyronine has a distinct circadian rhythm that is delayed but parallels thyrotropin levels. J Clin Endocrinol Metab 2008; 93:2300-6. [PMID: 18364382 DOI: 10.1210/jc.2007-2674] [Citation(s) in RCA: 134] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT TSH is known to have a circadian rhythm, but the relationship between this and any rhythm in T(4) and T(3) has not been clearly demonstrated. OBJECTIVE With a view to optimizing thyroid hormone replacement therapy, we have used modern assays for free T(4) (FT4) and free T(3) (FT3) to investigate circadian rhythmicity. SETTING The study was performed at a university hospital. DESIGN AND SUBJECTS This was a cross-sectional study in 33 healthy individuals with 24-h blood sampling (TSH in 33 and FT4 and FT3 in 29 individuals) and cosinor analysis. RESULTS Of the individuals, 100% showed a sinusoidal signal in TSH, for FT4 76%, and for FT3 86% (P < 0.05). For FT4 and FT3, the amplitude was low. For TSH the acrophase occurred at a clock time of 0240 h, and for FT3 approximately 90 minutes later at 0404 h. The group cosinor model predicts that TSH hormone levels remain above the mesor between 2020 and 0820 h, and for FT3 from 2200-1000 h. Cross correlation of FT3 with TSH showed that the peak correlation occurred with a delay of 0.5-2.5 h. When time-adjusted profiles of TSH and FT3 were compared, there was a strong correlation between FT3 and TSH levels (rho = 0.80; P < 0.0001). In contrast, cross correlation revealed no temporal relationship between FT4 and TSH. CONCLUSIONS FT3 shows a circadian rhythm with a periodicity that lags behind TSH, suggesting that the periodic rhythm of FT3 is due to the proportion of T(3) derived from the thyroid. Optimizing thyroid hormone replacement may need to take these rhythms into account.
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Affiliation(s)
- W Russell
- University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, United Kingdom
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Abstract
PURPOSE OF REVIEW To consider the current status and types of drug therapy aimed at restoring eucortisolaemia in patients with Cushing's syndrome. RECENT FINDINGS Advances such as laparoscopic adrenalectomy modify the exact placing of drug therapy among the wide variety of therapies available to treat patients with Cushing's syndrome because of different causes; nonetheless, it is now clear that hypercortisolism, per se, if present for any length of time, modifies the future prognosis of the patient, even after cure of the Cushing's syndrome. Thus, early diagnosis and restoration of eucortisolsm are critical. There are three main types of drug therapy: steroidogenesis inhibitors, glucocorticoid antagonists and neuromodulatory compounds. Currently, steroidogenesis inhibitors such as metyrapone and ketaconazole are most commonly the first choice if drug therapy is to be used, but at least for the most common form of Cushing's syndrome, Cushing's disease, the neuromodulatory compounds such as cabergoline show potential. SUMMARY Pharmacological therapy for Cushing's syndrome remains critically important for normalizing cortisol levels while awaiting the impact of more definitive treatment.
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Affiliation(s)
- Stephen Shalet
- Department of Endocrinology, Christie Hospital, Manchester, UK.
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Newell-Price J, Whiteman M, Rostami-Hodjegan A, Darzy K, Shalet S, Tucker GT, Ross RJM. Modified-release hydrocortisone for circadian therapy: a proof-of-principle study in dexamethasone-suppressed normal volunteers. Clin Endocrinol (Oxf) 2008; 68:130-5. [PMID: 17803699 DOI: 10.1111/j.1365-2265.2007.03011.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND All existing long-term glucocorticoid replacement therapy is suboptimal as the normal nocturnal rise and waking morning peak of serum cortisol is not reproduced. AIM To test whether it is possible to reproduce the normal overnight rise and morning peak in serum cortisol using an oral delayed and sustained release preparation of hydrocortisone (Cortisol(ds)). SUBJECTS AND METHODS Six healthy normal male volunteers attended on two occasions, in a single-dose, open-label, nonrandomized study. Endogenous cortisol secretion was suppressed by administration of dexamethasone. Cortisol(ds) (formulation A or B) was administered at 2200 h on day 1. Blood samples for measurement of cortisol were taken from 2200 h every 30 min until 0700 h, then hourly until 2200 h on day 2. Fifteen body mass index (BMI)-matched control subjects had serum cortisol levels measured at 20-min intervals for 24 h. Serum cortisol profiles and pharmacokinetics after Cortisol(ds) were compared with those in controls. RESULTS Formulations A and B were associated with delayed drug release (by 2 h and 4 h, respectively), with median peak cortisol concentrations at 4.5 h (0245 h) and 10 h (0800 h), respectively, thereby reproducing the normal early morning rise in serum cortisol. Total cortisol exposure was not different from controls. CONCLUSIONS For the first time we have shown that it is possible to mimic the normal circadian rhythm of circulating cortisol with an oral modified-release formulation of hydrocortisone, providing the basis for development of physiological circadian replacement therapy in patients with adrenal insufficiency.
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Affiliation(s)
- J Newell-Price
- Academic Unit of Diabetes, Endocrinology and Metabolism, The University of Sheffield, Sheffield, UK.
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9
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Pokrajac A, Berg C, Paisley A, Bidlingmaier M, Strasburger C, Shalet S, Trainer P. Can Adults with severe Growth Hormone Deficiency (AsGHD) and a low IGF-I be distinguished from those with a normal IGF-I? Exp Clin Endocrinol Diabetes 2006. [DOI: 10.1055/s-2006-932937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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10
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Abstract
The development of osteoporosis, with its attendant risk of fragility fracture, is in part related to the peak bone mass (PBM) achieved in early adulthood. Adolescence is a critical time for the acquisition of bone mass, with around 40% of skeletal mass being accrued during pubertal maturation. Growth hormone (GH) plays an integral role in the achievement of PBM after completion of linear growth, and several recent studies have suggested that GH replacement should continue in individuals with childhood-onset GHD until PBM has been attained - irrespective of the height achieved. In those with severe GHD after growth and pubertal development are complete, a seamless transition of GH therapy into adult life may be preferable to allowing a gap in GH treatment. The 'window of opportunity' concept for achieving PBM will, nevertheless, continue to be challenged by GHD teenagers who may resent the seamless continuation of GH replacement beyond adolescence. Preparation for this possibility should therefore begin during childhood, with all GHD teenagers being encouraged to remain on GH therapy until at least their mid-20s.
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Turton JPG, Reynaud R, Mehta A, Torpiano J, Saveanu A, Woods KS, Tiulpakov A, Zdravkovic V, Hamilton J, Attard-Montalto S, Parascandalo R, Vella C, Clayton PE, Shalet S, Barton J, Brue T, Dattani MT. Novel mutations within the POU1F1 gene associated with variable combined pituitary hormone deficiency. J Clin Endocrinol Metab 2005; 90:4762-70. [PMID: 15928241 DOI: 10.1210/jc.2005-0570] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Mutations within the gene encoding the pituitary-specific transcription factor POU1F1 are associated with combined pituitary hormone deficiency (CPHD). Most of the affected individuals manifest GH, prolactin, and TSH deficiency. OBJECTIVE We have now screened 129 individuals with CPHD and isolated GH deficiency for mutations within POU1F1. RESULTS Causative mutations were identified in 10 of 129 individuals (7.8%). Of these, five patients harbored the dominant negative R271W mutation, which is a well-recognized mutational hot spot. We have also identified a second frequently occurring mutation, E230K, which appears to be common in Maltese patients. Additionally, we describe two novel mutations within POU1F1, an insertion of a single base pair (ins778A) and a missense mutation (R172Q). Functional studies have revealed that POU1F1 (E230K) is associated with a reduction in transactivation, although DNA-binding affinity is similar to the wild-type protein. On the other hand, POU1F1 (R172Q) is associated with a reduction in DNA binding and transactivation, whereas POU1F1 (ins778A) is associated with loss of DNA binding and a reduction in transactivation. CONCLUSIONS Our data suggest that the phenotype associated with POU1F1 mutations may be more variable, with the occasional preservation of TSH secretion. Additionally, our data revealed POU1F1 mutations in three patients who were diagnosed as having ACTH deficiency but who, on further evaluation, were found to have normal cortisol secretion. Hence, elucidation of the genotype led to further evaluation of the phenotype, with the cessation of cortisol replacement that had been commenced unnecessarily. These data reflect the importance of mutational analysis in patients with CPHD.
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Affiliation(s)
- James P G Turton
- Biochemistry, Endocrinology, and Metabolism Unit and London Centre for Paediatric Endocrinology, Institute of Child Health, London, United Kingdom
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Moore C, Shalet S, Manickam K, Willard T, Maheshwari H, Baumann G. Voice abnormality in adults with congenital and adult-acquired growth hormone deficiency. J Clin Endocrinol Metab 2005; 90:4128-32. [PMID: 15870127 DOI: 10.1210/jc.2004-2558] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Adult males with congenital, untreated, severe GH deficiency (GHD) due to genetic GHRH receptor deficiency exhibit distinctive, high-pitched, and raspy voice characteristics. OBJECTIVE/DESIGN To determine the physical underpinning of this phenomenon, we performed voice recordings, translarynx impedance measurements, spectral analysis, and estimates of spectral complexity [approximate entropy (ApEn)] in four affected men. Results were compared with those obtained in four men with untreated adult-onset GHD and a normal male population. RESULTS Congenital GHD subjects had a high-pitched voice with a fundamental frequency typical of normal females (174-266 Hz). Their frequency spectra were characterized by abnormal harmonics, with reversal/interruption of the normal amplitude decay among higher-order harmonics, findings consistent with a creaky quality of the voice. Patients with adult-onset GHD, acquired at ages 31, 38, and 40 yr, had a normal male pitch (fundamental frequency, 117-154 Hz) but pathologically low ApEn values, corresponding to a breathy quality of the voice and suggesting abnormal vocal fold function. A fourth patient who acquired GHD at age 22 yr had a pitch intermediate between male and female, high ApEn, and a spectral pattern similar to the congenital GHD patients. CONCLUSIONS This study demonstrates an effect of GH on laryngeal size and vocal fold compliance that results in a high pitch and disordered spectral quality. The time of onset of GHD determines which type of abnormality predominates.
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Affiliation(s)
- Christopher Moore
- North Western Medical Physics, Christie Hospital, Manchester, United Kingdom.
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13
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Abstract
The period of growth from late puberty to full adult maturation, termed the transition period, is important for tissue maturation. Peak bone mass, muscle mass and strength are usually attained in this period. However, it is common clinical practice in children with growth hormone deficiency (GHD) to discontinue growth hormone (GH) treatment in adolescence after attainment of final height. Therefore, patients with childhood-onset GHD that continues into adulthood and who do not receive treatment as adults may experience more severe consequences than patients who acquire GHD as an adult. Recent studies indicate that bone and muscle maturation are attenuated if GH treatment is discontinued at final height. Furthermore, these patients will also develop cardiovascular risk factors that are normally associated with GHD in adults. Much debate surrounds when retesting for GHD should be carried out and when GH treatment should be restarted in adolescents; many of these patients will not have severe GHD according to the criteria set for adults. The transition period is an appropriate time to modify GH doses. Finally, registries exist that have recorded clinical treatment experiences for children and adults. Tools that collect and analyse data provide an important opportunity to investigate issues related to transition.
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Affiliation(s)
- S Shalet
- Christie Hospital NHS Trust, Manchester, UK.
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14
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Abstract
In the human male, testosterone is the major circulating androgen. More than 95% of circulating testosterone is secreted by the testis with a production rate of 6-7 mg/day. The clinical effects of androgens are numerous, and testosterone deficiency is associated with a number of clinical abnormalities. Overt hypogonadism results in reductions in bone mineral density, alterations in body composition and effects on mood, aggressive behaviour, cognitive function, sexual function and several factors important for cardiovascular risk. Androgen replacement in this context is clearly beneficial, and numerous studies have demonstrated improvements in bone and muscle mass, reductions in body fat, and positive effects on quality of life following treatment. The benefits of therapy in men with milder degrees of hypogonadism, and elderly men with "physiological" testosterone deficiency, are less clear-cut, and the appropriate biochemical cut-off below which replacement should be offered has not been clearly defined. Several options are available for androgen replacement in adult men. Oral testosterone, intramuscular injections, subcutaneous implants and transdermal therapy have all been used. Each mode of delivery has advantages and drawbacks and the choice between them will often depend on patient reference. Recent advances include the development of longer-acting intramuscular preparations, which offer more stable androgen levels with fairly infrequent injections, and testosterone gel which appears to provide transdermal replacement without a high incidence of skin reactions. This article will examine the evidence concerning the impact of male hypogonadism and the response to androgen therapy. The question of who to treat will be addressed with particular reference to mild hypogonadism and hypogonadism in the elderly. Finally, an overview of the different modes of replacement therapy will be presented.
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Affiliation(s)
- S Howell
- Department of Endocrinology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20 4BX, UK.
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Kim SS, Radford J, Harris M, Varley J, Rutherford AJ, Lieberman B, Shalet S, Gosden R. Ovarian tissue harvested from lymphoma patients to preserve fertility may be safe for autotransplantation. Hum Reprod 2001; 16:2056-60. [PMID: 11574491 DOI: 10.1093/humrep/16.10.2056] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ovarian failure is a common sequel to chemo/radiotherapy in patients successfully treated for cancer. Harvesting, cryopreserving and subsequently re-implanting ovarian cortical grafts can be used to re-establish reproductive potential in women with cancer. The safety issue, however, is of great concern because residual disease in autografted ovarian tissues might cause recrudescence of disease. METHODS A total of 30 non-obese diabetic severe combined immunodeficient (NOD/LtSz-SCID) mice were individually xenografted s.c. with frozen-thawed ovarian tissue from 18 patients with lymphoma [13 Hodgkin's lymphoma (HL) and 5 non-Hodgkin's lymphoma (NHL)]. The animals were autopsied at 16 weeks, or earlier if cachectic. The xenograft, liver, spleen, sternum, para-aortic lymph nodes and thymus were prepared for histology, immunohistochemistry and human DNA microsatellite analysis. RESULTS None of the animals grafted with ovarian tissue from lymphoma patients developed disease. However, all 3 animals grafted with lymph node tissue from an NHL patient developed B-cell lymphomas that were confirmed as human in origin by DNA microsatellite analysis. CONCLUSION Ovarian tissue harvested before high-dose chemotherapy for HL or NHL may not carry a risk of disease transmission by autotransplantation, although the possibility is difficult to exclude completely.
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Affiliation(s)
- S S Kim
- Centre for Reproduction, Growth and Development, University of Leeds, Leeds, UK.
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16
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Radford J, Shalet S, Lieberman B. Fertility after treatment for cancer. Questions remain over ways of preserving ovarian and testicular tissue. BMJ 1999; 319:935-6. [PMID: 10514140 PMCID: PMC1116787 DOI: 10.1136/bmj.319.7215.935] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Quinton ND, Smith RF, Clayton PE, Gill MS, Shalet S, Justice SK, Simon SA, Walters S, Postel-Vinay MC, Blakemore AI, Ross RJ. Leptin binding activity changes with age: the link between leptin and puberty. J Clin Endocrinol Metab 1999. [PMID: 10404799 DOI: 10.1210/jc.84.7.2336] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The timing of the physical transition from child to adult is determined by a biological clock that switches off the pituitary gonadal axis during infancy until puberty. Body composition (and in particular, fat mass), through leptin, are critical signals to this clock. However, no direct relationship between leptin and puberty has been demonstrated. Leptin is bound in the circulation by a high-affinity binding protein, which has been identified as a soluble leptin receptor. We found circulating levels of leptin binding activity (LBA) to be low at birth, to be high in the prepubertal years, to fall through puberty, and then to remain stable during adult life. LBA correlated with pubertal status in both boys and girls. We postulate that the fall in LBA, associated with increasing age and puberty, reflects a reduction in expression of truncated leptin receptors, and leptin is then available to the full-length receptor, which transmits the biological signal for leptin. The high levels of LBA occur during the years when the pituitary gonadal axis is quiescent. Thus, the change in LBA could explain how leptin regulates puberty.
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Affiliation(s)
- N D Quinton
- The Division of Clinical Sciences, Sheffield University, Biomedical Research Centre, Sheffield Hallam University, United Kingdom
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Quinton ND, Smith RF, Clayton PE, Gill MS, Shalet S, Justice SK, Simon SA, Walters S, Postel-Vinay MC, Blakemore AI, Ross RJ. Leptin binding activity changes with age: the link between leptin and puberty. J Clin Endocrinol Metab 1999; 84:2336-41. [PMID: 10404799 DOI: 10.1210/jcem.84.7.5834] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The timing of the physical transition from child to adult is determined by a biological clock that switches off the pituitary gonadal axis during infancy until puberty. Body composition (and in particular, fat mass), through leptin, are critical signals to this clock. However, no direct relationship between leptin and puberty has been demonstrated. Leptin is bound in the circulation by a high-affinity binding protein, which has been identified as a soluble leptin receptor. We found circulating levels of leptin binding activity (LBA) to be low at birth, to be high in the prepubertal years, to fall through puberty, and then to remain stable during adult life. LBA correlated with pubertal status in both boys and girls. We postulate that the fall in LBA, associated with increasing age and puberty, reflects a reduction in expression of truncated leptin receptors, and leptin is then available to the full-length receptor, which transmits the biological signal for leptin. The high levels of LBA occur during the years when the pituitary gonadal axis is quiescent. Thus, the change in LBA could explain how leptin regulates puberty.
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Affiliation(s)
- N D Quinton
- The Division of Clinical Sciences, Sheffield University, Biomedical Research Centre, Sheffield Hallam University, United Kingdom
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Abstract
Treatment with cytotoxic chemotherapy and radiotherapy is associated with significant gonadal damage in men and women. Alkylating agents such as cyclophosphamide and procarbazine are the most common agents implicated. The vast majority of men receiving procarbazine-containing regimens for the treatment of lymphomas become permanently infertile. Cisplatin-based chemotherapy for testicular cancer results in temporary azoospermia in most men, with a recovery of spermatogenesis in about 50% after 2 years and in 80% after 5 years. There is also evidence of Leydig cell impairment in a proportion of these men, although the clinical significance of this is not clear. The germinal epithelium is very sensitive to radiation-induced damage, with changes to spermatogonia occurring following as little as 0.1 Gy and permanent infertility after fractionated doses of 2 Gy and above. Cytotoxic-induced premature ovarian failure is age- and drug-dependent and ensues in approximately half of women treated with procarbazine-containing chemotherapy for lymphomas. High-dose chemotherapy, total body irradiation, and irradiation at an ovarian dose above 6 Gy usually result in permanent ovarian failure. The course of ovarian function after chemotherapy is variable, and late recovery occurs in some patients. Several methods of preserving gonadal function during potentially sterilizing treatment have been considered. Currently, sperm banking remains the only proven method in men, although hormonal manipulation to enhance the recovery of spermatogenesis and cryopreservation of testicular germ cells are possibilities for the future. Transposition of the ovaries to allow better shielding during radiotherapy is of use in some women, and the prospect of cryopreservation and reimplantation of ovarian tissue is promising.
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Affiliation(s)
- S Howell
- Department of Endocrinology, Christie Hospital NHS Trust, Manchester, United Kingdom
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Robson H, Anderson E, Eden O, Isaksson O, Shalet S. Glucocorticoid pretreatment reduces the cytotoxic effects of a variety of DNA-damaging agents on rat tibial growth-plate chondrocytes in vitro. Cancer Chemother Pharmacol 1998; 42:171-6. [PMID: 9654119 DOI: 10.1007/s002800050802] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
It is apparent that cytotoxic chemotherapy used to treat childhood malignancies has a major impact on subsequent growth. Our initial studies have demonstrated a direct adverse effect of individual glucocorticoids and cytotoxic agents on the proliferative capacity of rat tibial growth-plate chondrocytes in vitro. In the present study we investigated the interaction between these classes of agents using in vitro cultures of chondrocytes and examined the potential of these cells to recover from the adverse effects of the drugs as applied either alone or in combination. The glucocorticoids prednisolone and dexamethasone significantly reduced the growth rate of chondrocytes when present in cultures for 3 days. The growth rate increased following the removal of prednisolone and dexamethasone from cultures and reached 83.9+/-0.8% and 62.4+/-4.0%, respectively, of the control values after 11 days of culture. In contrast, cell numbers were significantly reduced when the DNA-damaging agents cisplatin, carboplatin, etoposide or actinomycin-D were present in cultures for 3 days. Very little recovery of cell growth was observed after removal of the drugs from cultures, with cell loss occurring in the cisplatin- and actinomycin-D-treated cultures. However, pretreatment of chondrocytes with either of the glucocorticoids completely ameliorated the cytotoxic effects of etoposide and carboplatin and significantly reduced those of cisplatin and actinomycin-D. Recovery of the cells treated with a combination of glucocorticoid and DNA-damaging agent was demonstrated by a significant increase in their ability to form colonies in suspension culture. Colony numbers were increased by a factor of between 5 and 80 as compared with the cells receiving medium alone followed by DNA-damaging agent. The glucocorticoids offer a protective effect in terms of the reduced cytotoxicity of DNA-damaging agents and improve the subsequent clonogenicity and recovery of growth-plate chondrocytes. This has important implications for treatment schedules involving both cytotoxic agents and glucocorticoids in childhood malignancies.
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Affiliation(s)
- H Robson
- Clinical Research Department, Christie Hospital NHS Trust, Manchester, UK
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Robson H, Anderson E, Eden OB, Isaksson O, Shalet S. Chemotherapeutic agents used in the treatment of childhood malignancies have direct effects on growth plate chondrocyte proliferation. J Endocrinol 1998; 157:225-35. [PMID: 9659285 DOI: 10.1677/joe.0.1570225] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Short stature is one of the most well recorded long term sequelae for adult survivors of childhood malignancies. It has become increasingly apparent that cytotoxic chemotherapy, as well as craniospinal irradiation, has a major impact on growth, but there are virtually no studies which explore the mechanisms by which these cytotoxic drugs affect growth. We have used an in vitro system to investigate the direct effects of a range of chemotherapeutic agents on the proliferative responses of rat tibial growth plate chondrocytes, both in suspension and monolayer culture. The glucocorticoids and purine anti-metabolites reduced chondrocyte proliferation both in monolayer and suspension cultures and this resulted from an increase in cell doubling times with a concomittant reduction in the numbers of S phase cells. DNA damaging agents (e.g. actinomycin-D) were also able to reduce chondrocyte proliferation, both in monolayer and suspension culture. This, however, was the result of a cell cycle arrest and subsequent cell death. In our studies, methotrexate had no significant effect on the proliferative responses of the chondrocytes either in monolayer or suspension culture. These results indicate direct effects of a range of chemotherapeutic agents on the proliferative responses of growth plate chondrocytes. Both cytostatic and cytotoxic effects were observed although the impact of either the potential loss of cells from the proliferative pool during chondrocyte differentiation, or the reduction in the rate of chondrocyte turnover on long bone growth remains to be elucidated.
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Affiliation(s)
- H Robson
- Christie Hospital NHS Trust, Manchester, UK
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Andersson AM, Orskov H, Ranke MB, Shalet S, Skakkebaek NE. Interpretation of growth hormone provocative tests: comparison of cut-off values in four European laboratories. Eur J Endocrinol 1995; 132:340-3. [PMID: 7889184 DOI: 10.1530/eje.0.1320340] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
To compare interpretations of growth hormone (GH) provocative tests in laboratories using six different GH immunoassays (one enzymeimmunometric assay (EIMA, assay 1), one immunoradiometric assay (IRMA, assay 5), one time-resolved fluorimmunometric assay (TRFIA, assay 3) and three radioimmunoassays (RIAs, assays 2, 4 and 6)), aliquots of peak samples from GH provocative tests were distributed between the four participating laboratories, quantified in the respective immunoassays and interpreted according to the cut-off values for provocative tests defined for each assay method. There was a high degree of relative correlation between the different assays, but absolute GH estimates differed. Assays 2, 4, 5 and 6 yielded almost identical GH levels. Assays 1 and 3 yielded serum GH levels approximately 39% and 70%, respectively, of those of assays 2, 4, 5 and 6. Although the absolute GH level measured in the various assay methods varied, there was good agreement between the interpretation of a given sample among the participating laboratories. This indicates that the differences in estimates of serum GH concentration by different immunoassay systems can be compensated for when cut-off values are defined for each method.
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Affiliation(s)
- A M Andersson
- Dept. of Growth and Reproduction, University Hospital of Copenhagen, Denmark
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Toogood A, O'Neill P, Shalet S. Growth Hormone (GH) Deficiency in the Elderly with Pituitary Disease. Age Ageing 1995. [DOI: 10.1093/ageing/24.suppl_2.p9-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Unilateral renal agenesis is an uncommon association with Kallmann's syndrome (KS) (hypogonadotrophic hypogonadism and olfactory defect). We have investigated affected individuals from six pedigrees: five with X-linked KS, and one with X-linked KS and X-linked ichthyosis (XLI). Seventeen affected individuals have had renal imaging performed, and six scans demonstrated only one kidney. In addition, two pedigrees had males who died in the neonatal period with bilateral renal agenesis. Only two of the four affected individuals in the family with X-linked KS and X-linked ichthyosis (Pedigree 6) showed unilateral renal agenesis, despite all four patients demonstrating an interstitial deletion within the short arm of the X-chromosome. These data indicate that unilateral renal agenesis is much commoner than previously suspected in patients with X-linked Kallmann's syndrome, but that it may have incomplete penetrance within a family.
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Affiliation(s)
- J M Kirk
- Royal Free Hospital, London, U.K
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Abstract
A technically simple and rapid two-site immunoradiometric assay (IRMA) for human ACTH, based on monoclonal antibodies (MAbs), was compared with a clinically validated ACTH radioimmunoassay (RIA). Both methods measure ACTH 1-39 in unextracted plasma and cross-react less than 0.5% with ACTH fragments. ACTH levels were assessed in 103 patient samples: for concentrations in the range 5.3-1000 ng/L, results by the two methods were significantly correlated (r = 0.82, n = 86, P less than 0.001). The IRMA was more sensitive and had a wider working range than the RIA (detection limits 5.3 ng/L (IRMA) vs 11 ng/L (RIA); CV less than 10% between 19 and 1000 ng/L (IRMA) and CV less than 15% between 30 and 400 ng/L (RIA). In two patients for whom discrepant results were obtained, measurement of ACTH by bioassay and ACTH precursors by direct IRMA demonstrated the greater accuracy of the ACTH IRMA result. The improved performance of the IRMA combined with its many practical advantages compared to RIA, make it ideal for use in detailed clinical and physiological studies which have previously been hampered by the poor reliability of ACTH measurement.
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Affiliation(s)
- S Gibson
- Department of Clinical Biochemistry, Hope Hospital, Salford, UK
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Ponder BA, Finer N, Coffey R, Harmer CL, Maisey M, Ormerod MG, Pembrey ME, Ponder MA, Rosswick P, Shalet S. Family screening in medullary thyroid carcinoma presenting without a family history. Q J Med 1988; 67:299-308. [PMID: 2905066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Systematic screening of the families of a series of 39 patients with apparently sporadic medullary thyroid carcinoma detected seven new cases in four families. A negative family history in a patient presenting with medullary thyroid carcinoma is not reliable in excluding familial disease, and family screening should be considered for new patients with medullary thyroid carcinoma.
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Waxman JH, Ahmed R, Smith D, Wrigley PF, Gregory W, Shalet S, Crowther D, Rees LH, Besser GM, Malpas JS. Failure to preserve fertility in patients with Hodgkin's disease. Cancer Chemother Pharmacol 1987; 19:159-62. [PMID: 3105906 DOI: 10.1007/bf00254570] [Citation(s) in RCA: 192] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
The hypothesis that the "down-regulated" gonad is less vulnerable to the effects of cytotoxic chemotherapy for advanced Hodgkin's disease has been investigated. Thirty men and eighteen women were randomly allocated to receive an agonist analogue of gonadotrophin-releasing hormone prior to, and for the duration of, cytotoxic chemotherapy. Buserelin (d-Ser-[TBU]6 LHRH ethylamide) was prescribed in two different dosage schedules to twenty men, and in a single dosage schedule to eight women. A standard gonadotrophin-releasing hormone test (GnRH 100 micrograms) was performed 1 week prior to and on day 1 of each cycle of chemotherapy. In all patients peak luteinizing hormone responses to GnRH were suppressed throughout treatment. The higher of the two dosage schedules used in the men caused more effective suppression of luteinizing hormone, and both regimens led to an initial suppression of peak follicle-stimulating hormone responses to GnRH, which was not maintained. At follow-up assessment up to 3 years from the completion of treatment, all men treated with buserelin were profoundly oligospermic and four of the eight women were amenorrhoeic. All ten male controls were profoundly oligospermic, and six of nine female controls were amenorrhoeic. In the dosages and schedules investigated, buserelin was ineffective in conserving fertility.
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Surtees R, Adams J, Price D, Clayton P, Shalet S. Association of adverse perinatal events with an empty sella turcica in children with growth hormone deficiency. Horm Res 1987; 28:5-12. [PMID: 3447941 DOI: 10.1159/000180918] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
High-resolution computed tomography (HR-CT) of the hypothalamo-pituitary region was performed in 26 consecutive children presenting with growth hormone deficiency (GHD) at one clinic. 58% had an empty sella turcica (ES) and 42% a full sella turcica (FS). There was no difference between the ES and FS groups for mean (+/- 95% confidence limits) presentation age (ES 6.7 (+/- 1.8) years, FS 5.6 (+/- 2.2) years), height standard deviation score (SDS) (ES -3.9 (+/- 0.8), FS -3.3 (+/- 0.5] nor head circumference SDS (ES -1.9 (+/- 1.1), FS -0.7 (+/- 1.1]. There were significant associations between the ES group and a history of adverse perinatal events (p less than 0.001) and multiple pituitary deficiency (p = 0.014). Growth hormone response to an acute growth hormone releasing factor test showed no association with HR-CT diagnosis. Sella turcica volumes were calculated from the HR-CT scans. All sella volumes were small; mean SDS for height was -2.6 (+/- 0.2). There was no difference in sella volume SDS between the ES and FS groups (ES -2.9 (+/- 0.3), FS -2.5 (+/- 0.4]. Adverse perinatal events may cause an ES and GHD by compromising the blood supply to the pituitary gland or infundibulum.
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Affiliation(s)
- R Surtees
- Department of Child Health, University of Manchester School of Medicine, UK
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Shalet S. Endocrine Problems in Cancer; Molecular Basis and Clinical Management. Br J Cancer 1985. [DOI: 10.1038/bjc.1985.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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Abstract
A case of Cushing's syndrome due to micronodular adrenal disease in a 17-year-old girl is presented. The adrenals showed both black and yellow nodules. Histologically the cells contained lipofuschin and either had a clear cytoplasm or an eosinophilic cytoplasm with a prominent nucleus. Lymphocytes were a prominent feature. No cells of the zona reticularis were identified. The cell of origin of these nodules appeared to be from the inner layer of the zona fasciculata. We postulate that the disease is caused by an abnormality in the migration and ultimate destruction of cells from the zona fasciculata to the zona reticularis with a build up of cells at the interface zone.
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Cairns SA, Shalet S, Marshall AJ, Hartog M. A comparison of phenformin and metformin in the treatment of maturity onset diabetes. Diabete Metab 1977; 3:183-8. [PMID: 913750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A comparison of the effects of two dose levels of phenformin (50 mg once and twice daily) and metformin (850 mg twice daily and 1,700 mg twice daily) has been undertaken in 24 maturity onset diabetics whose diabetes had remained inadequately controlled with dietary measures alone. Both biguanides effectively reduced the fasting blood sugar and body weight of the patients, metformin apparently having a greater effect on blood sugar than phenformin. Serum triglycerides were lower on the larger dose of metformin than on either dose of phenformin. Both drugs in the larger doses reduced the serum cholesterol. Side effects were more common with metformin, particularly in the higher dosage and overall control of the diabetes was achieved in the same proportion of patients (33%).
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