ACTA ENDOCRINOLOGICA (BUC)

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Objective. To assess in a bicentric study the current iodine status of schoolchildren, ten years after implementation of the universal salt iodization (USI) in Romania. Subjects and methods. 102 children from 2 towns, aged between 6 and 11 years, were included in the study group: 66 children from Sibiu, a previously endemic area for iodine deficiency disorders and 36 children from Bucharest, a previously borderline iodine intake area. Body mass index (BMI), total body surface area (BSA), median urinary iodine concentration (UIC) and prevalence of goiter were evaluated. Thyroid volume was measured by ultrasonography. The study was approved by the Local Ethics Committee. An informed consent from the parents was obtained. Results. From the 102 schoolchildren in the study group, 59 were girls and 43 were boys. Median UIC in the total number of samples was 175.2 mcg/L, reflecting a sufficient iodine intake, with statistically significant differences between the two urban regions. The median UIC was 187.35 mcg/L in the Sibiu subgroup and 160.2 mcg/L in the Bucharest subgroup (p < 0.001). The total percentage of goiter in the studied subjects was 5.88%. Percentage of goiter, determined by adjusting ultrasound thyroid volume to sex and BSA, was 1.51% in Sibiu and 13.88% in Bucharest, a statistically significant difference (p = 0.011). None of the subjects showed ultrasonographic pattern suggestive of Hashimoto thyroiditis or macronodules. There was no statistically significant difference between the percentages of overweight or obesity in the two subgroups. Conclusions. Ten years after implementation of USI in Romania, a bicentric study suggests that our country is iodine sufficient in urban areas. In order to prevent recurrence of mild iodine deficiency in schoolchildren, a persistent surveillance, use of sustainable measures and public awareness are required. Recurrence of mild iodine deficiency should be avoided, because even mild iodine deficiency impairs cognition in children.

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.

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.

The thyroid gland is one of the most vascularized organs in the body. However, metastatic disease to the thyroid gland is rare. When it does occur kidney is the most common primary tumor site, followed by melanoma, lung, breast, esophagus, uterus and colon carcinoma. We describe the case of an isolated thyroid metastasis from clear cell renal carcinoma occurring 16 years after nephrectomy. An 82 years-old woman presented for the recent growth of a right thyroid nodule, diagnosed 3 years before, when a fine needle aspiration biopsy found a benign cytology suggesting a well-differentiated follicular thyroid adenoma. Her medical history included type 2 diabetes mellitus, atrial fibrillation and a right nephrectomy for a clear cell renal carcinoma done 16 years before. The patient has lost weight but she was otherwise asymptomatic. The right lobe goiter was painless, firm, and mobile with deglutition, without signs of local compression or latero-cervical lymphadenopathy. Thyroid ultrasonography revealed an enlarged (9.9 cm) macronodular right lobe, with multiple cystic areas, with normal left lobe and a thrombus in the right internal jugular vein. Thyroid function tests were normal. The patient was suspected of thyroid carcinoma and underwent a near total thyroidectomy. Histopathological examination revealed a metastasis of clear cell renal carcinoma in the right thyroid gland lobe (8.5/5/5 cm). Further imaging showed no primary tumor or other metastases. Metastatic renal carcinoma to the thyroid should be considered in any patient presenting with a thyroid mass and a medical history of operated renal cell carcinoma, since it can occur up to 25 years after nephrectomy.

Objective. To monitor the iodine status in Romanian schoolchildren and neonates after 20 years of mandatory salt iodization. Subjects and methods. In a national representative sample of 1352 children (7-12 years) we measured median urinary iodine concentration (mUIC) and creatinine (UCC) in spot urine samples and investigated household use of iodized salt. From 18349 neonates registered in the MEDILOG program for TSH screening we calculated the percentage of neonatal TSH >5 mIU/L (<3% indicating adequate iodine intake). Results. mUIC in schoolchildren was 141 μg/L (bootstrapped 95% CI 134, 146), showing adequate iodine intake in all but 1 county; mUIC was similar in historical endemic and non-endemic counties (140 μg/L and 143 ug/L, respectively) and in urban and rural areas (140 μg/L and 142 μg/L, respectively); mUIC/UCC = 118 ug/g. Iodized salt was used in 62% of households. In children using iodized salt (61.7%), mUIC was higher than in those using coarse (non-iodized) salt (24.6%): 150 vs. 121 μg/L (p<0.001). The percentage of nTSH >5 mIU/L was 14.7% (3.2%-27.3%), higher in non-endemic counties and urban areas. Conclusion. The current salt iodization program for households and bakery industry ensures an adequate iodine intake in schoolchildren. Discordantly, nTSH levels indicate a mild-moderate ID in neonates, suggesting ID in pregnant women. The percentage of households using iodized salt is below the recommended >90% needed for an efficient ID prevention program. More efforts should be directed to increase the public awareness on the health risks of ID and the benefits of ID prevention, notably for the neurointellectual development in children.

Recent updates on the epidemiology, diagnosis, complications and therapy in acromegaly have been published in the 1st 2017 issue of Pituitary journal. A review of 12 epidemiological studies published since 2004 shows that the prevalence of acromegaly ranges 2.8 - 13.7 cases per 100,000 people and the annual incidence rates range 0.2 - 1.1 cases/100,000 people. The median age at diagnosis ranges between 40.5 and 47 years. At the time of diagnosis, over 2/3 of the patients have macroadenomas. Acromegalic osteopathy is characterized by increase in bone turnover, alterations in bone microarchitecture and high risk of vertebral fractures, which occur in about 1/3 of acromegaly patients. Fractures may occur even in the presence of normal bone mineral density (BMD), in close relationship with male gender, hypogonadism, and active acromegaly. Following treatment for acromegaly in 48 patients, the mean trabecular bone score decreased by 3.0 (±7.0) %, whereas BMD at the lumbar spine increased by 3.2 (±4.9) % (both P<0.01). Alterations in trabecular bone architecture may explain the persistent fracture risk despite the increase in BMD after disease control. Stereotactic radiotherapy in acromegaly after surgery and/or during medical therapy provide tumor control in 93–100% of patients at 5–10 years and endocrinological remission in 40–60% of patients at 5 years, with a hypopituitarism rate of 10-50% at 5 years. Hypofractionated radiosurgery is an optimal option for tumors located near the optic structures, due to its lower toxicity for the optic nerves compared to single-dose radiosurgery. A dose-response model for visual pathway tolerance to SRS has been recently published.

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