ACTA ENDOCRINOLOGICA (BUC)

The mechanism underlying anovulation in the polycystic ovary syndrome (PCOS) remains unclear, although an excessive number of small antral follicles at ultrasound scans and discrepancies with selected follicles sustain the hypothesis of altered follicular development. Anti-M?llerian (AMH) hormone is a member of TGF-b super family of growth factors produced by granulosa cells of pre- and small-antral follicle. The 2 to 3 fold increase in the number of growing follicles in the ovary from PCOS women is reflected by an increase in serum concentration of AMH and thus, this hormone may be a good marker of PCOS.\r\nAim. This study was intended to implement ultra-sensitive ELISA measurement of serum AMH from PCOS women and search for a potential correlation with clinical and laboratory parameters.\r\nSubjects and methods. Sera from patients with PCOS (n = 42) and control women (n = 22) were used for ELISA measurement of AMH (AMH-EIA, Beckman Coulter) with sensitivity of 0.7 pmol/L.\r\nResults. We found a serum concentration of AMH almost 3 folds higher in patients with PCOS compared to controls (73.7 ? 7.5 vs. 25.7 ? 3.9 pmol/L, P < 0.0001). Differences were even higher in lean subjects. A positive correlation was found between total testosterone and LH levels, but not with serum FSH or insulin. Moreover, AMH concentration was correlated to more hyperandrogenic PCOS and with amenorrhea, and thus to the severity of the syndrome.\r\nConclusion. Measurement of serum AMH may be used as a valuable marker for PCOS to confirm diagnosis and evaluate the extent of follicular dysfunction in relation with hyperandrogenism and menstrual disturbances.

Introduction. The blood brain barrier (BBB) restricts the transport of hydrophilic molecules such as peptidic pituitary hormones into the brain tissue. The blood-cerebrospinal fluid (CSF) is a part of the BBB.\r\nAim To compare the pituitary hormone levels on the two sides of the BBB in a group of subjects without endocrine diseases.\r\nPatients and methods. We investigated, with the approval of the local ethics committee, 78 subjects without endocrine diseases. Growth hormone (GH), prolactin (PRL), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and thyroid stimulating hormone (TSH) were measured by rapid fluoroimmunoassay with Europium in the blood and cerebrospinal fluid (CSF)sampled simultaneously before rachianestesia for minor surgery.\r\nResults. CSF concentrations are significantly lower than the corresponding serum ones for all hormones studied: 0.04 ? 0.009 mU/mL vs 2.29 ? 0.57 mU/mL for GH, 1.49 ? 0.078 ng/mL vs 10.07 ? 1.42 ng/mL for PRL, 0.57 ? 0.078 U/L vs 22.71 ? 3.65 U/L for FSH, 0.39 ? 0.038 U/L vs 11.11 ? 1.55 U/L for LH and 0.01 ? 0.003 &#956;U/mL vs 1.36 ? 0.17&#956;U/mL for TSH (mean ? SEM; p<0.001). The CSF/serum ratio was below 1 in the vast majority of cases (from all subjects studied we only found 3 cases with supraunitary CSF/serum ratio). The serum and CSF levels were not significantly correlated for\r\nany of the pituitary hormones. Comparing preand postmenopausal women the CSF gonadotropin levels were slightly but nonsignificantly increased after menopause,\r\ndespite marked differences in the serum concentrations: CSF FSH 1.21 ?0.17U/L after vs 0.84? 0.4U/L before menopause, CSF LH 0.60? 0.047U/L after vs 0.43? 0.14U/L before\r\nmenopause. The CSF/ serum ratio for FSH markedly decreased after menopause (0.02?0.003 vs 0.22?0.11) although the effect did not reach statistical significance. The same\r\nwas true for CSF/serum LH ratio (0.026?0.005 vs 0.09?0.002). For none of the hormones studied the CSF levels correlated with age.\r\nConclusion. Pituitary hormones are normally found in the CSF at much lower levels than in the serum. The CSF hormonal\r\nconcentrations do not significantly correlate with the serum ones.

Central precocius puberty (CPP) is characterized by abnormalities in the setting up of the gonadotropin ?pubertal? release, which occurs earlier. The gonadotropin releasing hormone (GnRH) was used initially to test the pituitary regarding FSH and LH release in both precocious and delayed puberty. Various GnRH superagonists were used for the same purpose, including triptorelin. A triptorelin test was applied to 14 girls with premature thelarche by using the subcutaneous administration of 0.1 mg/sqm and blood sampling at 2, 3 and 4 hours for serum LH and FSH and at 24 hours for serum estradiol. Serum mean levels of LH were >7.8 mIU/ml at all intervals, suggesting a ?pubertal? type of LH release. As concerns the individual levels of LH, only 5 out of 14 girls showed a value greater than 8 mIU/ml, which is the cutoff limit for the diagnosis of precocious puberty. These girls also met the other clinical and radiological criteria necessary for the diagnosis of precocious puberty. It was concluded that soluble triptorelin may be useful in detecting ?pubertal? type of LH release in girls exhibiting premature thelarche. Regarding the FSH and estradiol levels, they were considered irrelevant for the diagnosis.

INTRODUCTION: The aim of our study was to evaluate the cure rate of macroprolactinomas treated for a long term (> 4 years) or a short term (<4 years) with dopamine agonists (DA) alone or combined with radiotherapy (RT). Sometimes pituitary\r\nsurgery was performed.\r\nMATERIAL AND METHODS: We performed a retrospective study in 111 patients with macroprolactinomas, hospitalized in the Institute of Endocrinology, Bucharest, between 1978-2005. There were two groups, according to the length of DA therapy: group\r\nA =41 patients, treated more than 4 years and group B =70 patients, treated less than 4 years. Overall, 25 patients underwent additional radiotherapy, 13 in group A and 12 in group B. 28 patients were submitted to pituitary surgery, 9 in group A and 19 in group B.\r\nRESULTS: The cure rate (i.e. normalization of prolactin=PRL level and absence or minimal residual tumor mass, stable minimum 2 years after DA withdrawal) was 5/41 (12.1%) in group A and none in group B. 48 out of 111 patients achieved significant improvement (serum prolactin level less than 20 ng/ml and tumor shrinkage more than 50%) during DA therapy, but not after DA withdrawal: 17/41patients (41.5%) in group A and in 31/70 patients (44.3%) in group B, p=NS. Radiotherapy produced an additional improvement: in serum PRL levels only in group A, in 4/13 patients- 2/8 patients responsive to DA therapy and 2/5 patients resistant to DA therapy. In group B, the 3 patients resistant to DA submitted to radiotherapy were evaluated before the interval necessary for maximal effect of radiotherapy, but in 4/9 patients responsive to DA, we noticed further reduction in tumor volume, 2/4 progressing from mild to significant tumor shrinkage and ? progressing from no shrinkage to mild shrinkage. After radiotherapy, the medium prolactin level was 5.1 ng/ml in 10 patients from both groups on low bromocriptine (BRC) dose (7.5 mg/day), significantly less than in patients without radiotherapy, i.e. than in 19 patients from group A (serum PRL 49.5 ng/ml, p=0.02) and in 29 patients from group B (serum PRL 30.3 ng/ml, p=0.01). So, the daily BRC dose could safely decrease from 30 mg/day to 7.5 mg/day in those patients previously submitted to radiotherapy. Among 23 patients resistant to initial DA treatment, only 8 patients were submitted to radiotherapy, 2 became responsive to DA thereafter and 2 others obtained a significant decrease of prolactin levels.\r\nCONCLUSIONS: The overall cure rate is quite low in prolactinomas and it was noticed only after long-term treatment with dopamine agonists; it was improved up to 12.1% by the additional high voltage radiotherapy, useful even in DA resistant cases. The addition of radiotherapy is indicated for the cure of most prolactinomas.

Introduction: The dexamethasone suppression tests (DST) in the diagnosis of Cushing's syndrome (CS) give frequently equivocal results. Our study evaluated the precision of DST in the diagnosis of CS. Patients and methods: 223 patients (15 - 77 years, 130 F / 93 M) were studied for putative CS by morning and midnight serum cortisol, urinary free cortisol (UFC) and 17 hydroxycorticosteroids (17OHCS) levels at baseline and after DST as follows: 1 mg overnight (oDST), 0.5mg q.d., 2 days (LDDST) and 2 mg q.d. 2 days (HDDST). Since not all cases were evaluated by all tests, statistical analysis used available results. Results: 79 patients had CS (47 pituitary, 3 ectopic, 21 adrenal adenoma and 8 adrenal carcinoma), 45 had adrenal tumor without all the criteria for CS (NCT) and 99 were controls. All patients with CS had abnormal cortisol biorhythm, but also 31.8% patients with NCT and 50% evaluated controls. The best basal screening test for CS is UFC, with a cut-off value of 100 g/24 h. For DST with a serum cortisol cutoff level (CCL) of 5 ?g/dl, oDST correctly diagnosed all CS, while lowering the CCL at 1.8 ?g/dl increased the false positive rate to 6.8%. At LDDST, the serum CCL of 5 ?g/dl correctly identified all patients with CS, but was 2.5 % false positive in controls. A significant correlation of serum cortisol values after oDST or LDDST with basal 17OHCS and UFC was found (r=0.6, p<0.001), suggesting that patients with mild CS are more prone to test as false negatives. The classical criterion of 50% suppression for UFC after LDDST correctly identified 12/14 CS patients and all 8 controls. Better sensitivity (Sn) had an UFC cutoff level of 10?g/24h, p<0.001. A 50% suppression of 17OHCS identified 45/61 CS patients and excluded the disease in 30/37 patients. In HDDST, serum cortisol suppression by > 50% diagnosed Cushing's disease (CD) with 85 % Sn and 57% specificity (Sp). The best HDDST accuracy had UFC (83%), with 27% false negative results (3/11 patients) for a cut-off value of\r\n50% from baseline. 17OHCS were suppressed by 50% in 19/35 patients with CD (54%) and in 3/33 (9%) patients with other causes of CS. NCT patients had higher basal values of UFC and 17OHCS than controls (p<0.01) and up to 50% had an abnormal biorhythm, suggesting a degree of hypercortisolism, with an inadequate oDST or LDDST . Therefore, only 6/45 NCT fulfilled the criteria for subclinical CS.\r\nConclusion: The best screening test was oDST (100% Sn and Sp), followed by UFC (100% Sn and 92% Sp). LDDST with serum CCL at 5 ?g/dl had 100% Sn and 97% Sp. HDDST identified CD by UFC with 73% Sn and 92% Sp and by serum cortisol with 85% Sn and 57% Sp. For NCT, the standard tests identified SCS in 13%. However, a thorough evaluation including multiple tests should be undertaken for the positive and differential diagnosis of Cushing's syndrome.

Objective. The extremely negative effects of diabetic neuropathy over the entire human organism make the detection of modifications in early stages very important. Introduction. The purpose of this study is to establish a correlation between early modifications appeared at the level of corneal nerves fibers and the glycemic values of patients with type 2 diabetes. The affection of corneal nerves fibers has been emphasized with the help of corneal confocal microscopy (CCM). Method. A total number of 70 subjects have been evaluated of which 55 suffered from type 2 diabetes (group A) and 15 have been subject to control (group B). The ophthalmologic control also contained a confocal microscopy that has highlighted the decrease of the number of nerves filets of the sub-basal plexus, modifications associated with type 2 diabetes. Results. The density of nerves fibers (12.11± 1.064 n/mm2 compared to 28.33 ± 2.101 n/mm2, P= 0.001); the density of nerves branches (29.94 ± 3.980 n/mm2 compared to 43.75 ± 4.605 n/mm2, P<0.001); the length of nerves fibers (11.77 ± 0.638 mm/mm2 compared to 17.82 ± 0.479 mm/mm2, P=0.002), the total density of nerves fibers (23.25 ± 3.213 n/ mm2 compared to 63.75 ± 8.278 n/mm2, P=0.042) and the area of corneal nerves fibers (0.0044 ± 0.000247 mm2 /mm2 compared to 0.007893 ± 0.00054 mm2 /mm2, P=0.014) have been significantly smaller in patients with diabetes compared to healthy subjects. Conclusions. Being a non invasive technique, corneal confocal microscopy represents a technique that can be easily used in the detection of early modifications of fibers of subbasal corneal nerves stratum, in the case of patients suffering from type 2 diabetes.

Introduction. This study evaluates the clinical efficacy of androgen replacement therapy with the new long-acting intramuscular (i.m.) testosterone undecanoate (T.U.) in comparison to oral T.U. in adult men with hypogonadotropic hypogonadism.\r\nPatients and methods. In 41 patients with central hypogonadism (30 with pituitary tumors or craniopharyngiomas, 11 with non-tumor hypogonadism), aged 20-62 years, we evaluated, before and after androgen replacement therapy, morning serum total testosterone\r\n(T), hemoglobin, hematocrit, cholesterol, triglycerides (measured with commercial kits in venous blood sampled at 8.00-9.30 a.m) and the sexual dysfunction (SD) by questions on libido, frequency and quality of erections.\r\nResults. In group A, including 28 patients treated with oral T.U. median dose 120 mg/day (range 80-160) in 3 divided doses, for 4-60 (median 14) months, T rose from 0.37 ? 0.40 ng/mL (mean ? standard deviation) to 1.43 ? 1.36 ng/mL (p<0.01), reaching normal levels only in 4 patients (14%). In group B, including 20 patients treated with 1000 mg i.m. T.U. at 12 weeks intervals, for 1-12 (median 6) months, T rose from 0.88 ? 0.83 ng/mL to 5.88 ? 3.50 ng/ml (p<0.01). T was low in 1 patient (5%) and above normal in 6 patients (30%). A subgroup (C) of 7 patients was switched from oral to i.m.T.U. T was higher after i.m. than after oral T.U in group B vs. A and within subgroup C (p < 0.01). SD improved in 7/16 patients (43.7 %) on oral T.U. and in 11/12 patients (91.6%) on i.m. T.U (p < 0.05). Hematocrit increased significantly from baseline in both groups, while serum cholesterol and triglycerides did not change significantly on either T.U. treatment.\r\nConclusions. Clinical efficacy, judged by normal morning T and sexual dysfunction improvement, was reached in over 90% of patients with central hypogonadism after i.m.T.U. and in less than half after oral T.U.

IGF-I (Insulin like growth factor-I) plays a definitive role in the central nervous system (CNS) by modulating neuronal regeneration and survival. The local production of IGF-I in CNS has been demonstrated, but the contribution of circulating IGF-I transported through blood-brain barrier (BBB) has been just suggested in animals. There is currently no data available concerning IGF-I transport in CNS in humans. In order to investigate the passage of IGF-I over BBB in humans we have simultaneously measured the IGF-I and GH levels in serum and CSF in 25 patients with active acromegaly. IGF-I and GH levels in CSF were lower than in serum (2.2 ? 0.24 ng/mL vs 686.6 ? 46.83 ng/mL for IGF-I and 2.13 ? 0.627 mU/l vs 58.8 ? 15.86 mU/L for GH). However, both IGF-I and GH serum levels correlated with their CSF levels (r= 0.4, p<0.05 for IGF-I and r= 0.651, p= 0.006 for GH), suggesting that BBB is permeable for both hormones. In conclusion, we demonstrate the correlation of the IGF-I levels in serum and CSF, providing indirect evidence for IGF-I passage through BBB.

Introduction: The necessity to determine the levels of pituitary hormones in the cerebrospinal fluid is motivated both by difficulties in the diagnosis of different neuroendocrine disorders, as well as by research purposes such as understanding the transport mechanisms of hormones through the blood brain barrier.\r\nObjective: The aim of this study was to compare the results obtained with different immunometric methods for some pituitary hormones in the serum and CSF in patients with neuroendocrine tumors.\r\nMaterials and methods: The levels of LH, FSH, PRL and TSH were determined simultaneously in the serum and CSF with 3 different immunometric methods using commercial kits: IRMA, FIA and Chemiluminescence for 36 patients. The validation of IRMA method on CSF samples was performed using the dilution test.\r\nResults: The dilution test - as one of validation criteria of an immunoassay - proved that the results obtained in the CSF using the commercially available kits were correct. This enables the use of this sensitive method to accurately demonstrate abnormal levels of pituitary hormones beyond the blood-brain barrier. The correlation between IRMA and FIA: Hormonal concentrations values obtained by IRMA correlate well with those measured by FIA for serum with no significant differences of the mean concentration value for FSH (r=0.93, p: NS) and LH (r=0.99, p: NS), but with a significant difference for PRL (r=0.88, p=0.002). In CSF, mean concentrations values correlate well and we found no differences for TSH (r =0.97, p: NS) and LH (r = 0.94, p: NS), but significant differences for PRL (r= 0.98, p=0.001) and FSH (r=0.98, p=0.001). Statistically significant differences were also found for the CSF/serum ratio for PRL (p=0.08), FSH (p=0.001) and LH (p=0.001). The ratios CSF/serum are significantly higher with IRMA method than with FIA for all the hormones. Except for one patient for all the others we found the ratio CSF/serum less than 1 showing that the pathologic significance of this parameter is not modified due to the type of immunometric assay. A statistically significant difference (p<0.001) was found for mean FSH concentration in CSF with FIA and Chemiluminescent assays .\r\nConclusions: Any immunometric method currently used for the determination of hormones in the serum or plasma has to be validated accordingly in order to be used on CSF. For obtaining results that can be interpreted and compared it is preferred that the same immunometric method is used on both serum and CSF, inside one group of patients. The presence of a control group for the results determined with that method is strongly recommended.

Introduction: The impaired transport of leptin into the brain through a decreased permeability of the blood-brain barrier (BBB) for leptin in obesity represents one of the important mechanisms involved in leptin resistance which is characteristic in human obesity. Some pituitary tumors can increase the blood-cerebrospinal fluid barrier (BCB) permeability for peptides. BCB is a part of BBB.\r\nObjectives: The aim of our study was to search if the by-pass of BCB for pituitary hormones produced by adenomas does influence the transport of leptin into the central nervous system in obese patients.\r\nMaterials and methods: We investigated 20 males with pituitary adenomas: group A (11 patients) had cerebrospinal fluid (CSF) to serum ratio more than one for prolactin (PRL) and in some patients for growth hormone (GH) and follicle stimulating hormone (FSH), suggesting an increased permeability of BCB and a control group C (9 patients), which had CSF/serum ratio less than one for GH, PRL or FSH, suggesting an intact BCB. Both A and C groups contain subgroups of patients with obesity (body mass index, BMI>30 kg/m2) and normal body weight (BMI<25 kg/m2). In these patients we measured the CSF to serum leptin ratio in order to clinically evaluate the leptin transport into the brain. Rapid fluoroimmunoassay method with europium was used. Leptin was assayed by ELISA method.\r\nResults: The patients of group A with pituitary adenomas show a higher level of pituitary peptides, PRL and in some cases GH, FSH in CSF as compared to serum (ratio CSF/serum over 1), both in obese and non-obese. By contrast, in the same patients, there is\r\na low level of CSF leptin as compared to serum leptin (ratio CSF/serum less than 1). In the subgroup of obese patients from group A we found even less ratio of CSF to serum leptin, than in non-obese. There is a well known higher leptin concentration in the plasma of obese patients with pituitary adenomas as compared to non-obese ones (26.4?3.8ng/ml vs 12.4?3.4ng/ml, p<0.05). In the control group C, both pituitary peptides (PRL, or GH, FSH) and leptin showed a ratio CSF/serum less than 1, in all patients.\r\nConclusions: These data show a decrease in hemato-encephalic barrier permeability for leptin in obese patients through a specific mechanism, not influenced by other peptides passing through injuries of BBB produced by pituitary adenomas. It is tempting to suggest that there is a specific by-pass of BCB for pituitary peptides, in some pituitary adenomas.