Thèse d'exercice : Médecine. Pédiatrie : Université de Nantes : 2004. / Bibliogr. f. 46-52 [94 réf.].

Th.--Méd.--Reims, 1981. N°: 33.

Thesis advisor: Charles S. Hoffman / The biological roles of the most recently discovered mammalian cyclic nucleotide phosphodiesterase (PDE) family, PDE11, are poorly understood, in part due to the lack of selective inhibitors. To address this need for such compounds I completed a ~200,000 compound high throughput screen (HTS) for PDE11 inhibitors using a yeast-based growth assay. Further characterization of lead candidates using both growth-based assays in the fission yeast Schizosaccharomyces pombe and in vitro enzyme assays identified four potent and selective PDE11 inhibitors. I examined the effect of these compounds on human adrenocortical cells, where PDE11 is believed to regulate cortisol levels. One compound, along with two structural analogs, elevates cAMP levels and cortisol production through PDE11 inhibition, thus phenocopying the behavior of adrenocortical tumors associated with Cushing syndrome. These compounds can be used as research tools to study the biological function of PDE11, and can also serve as leads to develop therapeutic compounds for the treatment of adrenal insufficiencies. This study further validates the yeast-based HTS platform as a powerful tool for the discovery of potent, selective and biologically-active PDE inhibitors. / Thesis (PhD) — Boston College, 2012. / Submitted to: Boston College. Graduate School of Arts and Sciences. / Discipline: Biology.

A ocorrência de síndrome de Cushing (SC) durante a gestação é rara, e está associada com significativa morbidade e mortalidade materna. O diagnóstico da SC durante a gestação é, por vezes, problemático pela superposição de achados clínicos e laboratoriais com a gestação normal. Em relação aos aspectos laboratoriais, a ativação do eixo hipotálamo-hipófise-adrenal (HHA) materno na gestação altera parâmetros e testes utilizados para o rastreamento da SC. Desta forma, a confirmação do hipercortisolismo é mais difícil na gestação, particularmente no segundo e terceiro trimestres. Dentre os exames de rastreamento, o cortisol salivar noturno (CSN), por indicar alteração no ritmo circadiano de secreção de cortisol, que é característico da SC, tem sido considerado método importante para diferenciar grávidas com SC daquelas com gravidez normal, que apresentam ritmo circadiano preservado. No entanto, os valores de referência do CSN na gravidez não estão estabelecidos. Desta forma, o presente estudo tem como objetivo determinar os valores de referência de CSN em gestantes no primeiro, segundo e terceiro trimestres tendo como grupo controle mulheres não grávidas e pacientes portadoras de doença de Cushing (DC), com a finalidade de contribuir para o diagnóstico diferencial entre o hipercortisolismo fisiológico e o patológico durante a gestação. Para tanto, o CSN foi mensurado por meio do ensaio imunoenzimático (ELISA) em três grupos de indivíduos: 85 gestantes (grupo gestante), 33 mulheres não grávidas (grupo controle) e 25 mulheres não grávidas com DC (grupo DC). Observou-se menor concentração do CSN no grupo controle (mediana de 0,07 ug/dL) e as maiores no grupo DC (mediana de 0,51 ug/dL). Notou-se tendência de aumento das medianas do CSN no decorrer dos trimestres da gestação (primeiro trimestre: 0,08 ug/dL; segundo trimestre: 0,10 ug/dL; terceiro trimestre: 0,15 ug/dL). Em relação ao grupo controle, o CSN mostrou aumento de 1,1 vezes no primeiro trimestre, 1,4 vezes no segundo trimestre e de 2,1 vezes no terceiro trimestre da gestação. No grupo DC, o CSN foi significantemente superior ao do grupo controle e ao terceiro trimestre gestacional. Observou-se, ainda, que os valores de CSN foram significantemente superiores no terceiro trimestre da gestação em relação ao grupo controle. No presente estudo, determinamos valores de referência para o CSN na gestação, sendo o limite superior para o CSN nos respectivos trimestres gestacionais: 1º trimestre (0,25 ug/dL), 2º trimestre (0,26 ug/dL) e 3º trimestre (0,33 ug/dL). Os valores de corte do CSN que separaram da melhor forma possível o grupo DC do grupo gestante nos três trimestres foram, respectivamente, 0,255 ug/dL; 0,260 ug/dL e 0,285 ug/dL. A comparação dos valores de corte de CSN de gestantes sem DC com os de pacientes portadoras de DC mostrou alto grau de sensibilidade e especificidade, decrescendo no avançar da gestação. Mesmo no terceiro trimestre, foram de 80% e 93%, respectivamente. Em conclusão, foi observado um aumento progressivo do CSN no decorrer da gestação normal, sendo que concentrações máximas foram encontradas no terceiro trimestre. Um aumento estatisticamente significante do CSN foi encontrado entre o terceiro trimestre de gestação e o grupo controle. Foram estabelecidos valores de referência para o método CSN nos três trimestres gestacionais e foi encontrada uma boa acurácia diagnóstica do CSN na diferenciação entre gestantes normais e pacientes portadores de DC, mesmo no terceiro trimestre gestacional / Cushing\'s syndrome (CS) occurs rarely during pregnancy and is associated with significant maternal morbidity and mortality. Diagnosing CS during pregnancy is sometimes challenging, due to overlapping of clinical and laboratorial findings of the disease with characteristics of normal pregnancy. In addition, activation of the maternal hypothalamic-pituitary-adrenal (HPA) axis during pregnancy interferes with parameters and tests for screening of CS. Therefore, confirmation of hypercortisolism is more difficult during pregnancy, particularly in the second and third trimesters. Among the screening tests, nighttime salivary cortisol (NSC), which can detect changes in the circadian rhythm of cortisol secretion characteristic of CS, has been considered an important method to distinguish pregnant women with CS from normal pregnant women, in whom the cortisol circadian rhythm is preserved. However, NSC reference values in pregnancy have not yet been established. Thus, this study aims to determine the reference values for NSC in pregnant women in the first, second and third trimesters, using non-pregnant women and patients with Cushing\'s disease (CD) as controls, in order to establish values to distinguish between physiological and pathological hypercortisolism during pregnancy. To achieve that, we measured NSC by enzyme-linked immunosorbent assay (ELISA) in three groups of individuals: 85 pregnant women (pregnancy group), 33 non-pregnant women (control group) and 25 non-pregnant women with CD (CD group). Concentration of NSC was lowest in the control group (median 0.07 ?g/dL) and highest in the CD group (median 0.51 ?g/dL). Median NSC showed a trending increase at each consecutive gestation trimester (first trimester: 0.08 ug/dL; second trimester: 0.10 ug/dL; third trimester: 0.15 ug/dL). Compared with the control group, NSC showed increases of 1.1 times in the first trimester, 1.4 times in the second trimester and 2.1 times in the third trimester of pregnancy. Levels of NSC were significantly higher in the CD group compared with the control group and with the third gestational trimester. Values of NSC were also significantly higher in the third gestational trimester compared with the control group. The upper limit values for NSC during pregnancy determined in this study were 0.25 ug/dL in the first trimester, 0.26 ug/dL in the second trimester and 0.33 ug/dL in the third trimester. The cutoff NSC values that best separated the CD group from the pregnancy group in all three trimesters were, respectively, 0.255 ug/dL, 0.260 ug/dL and 0.285 ug/dL. The comparison between cutoff values of NSC in pregnant women without CD with those in patients with CD showed a high degree of sensitivity and specificity, which declined with the advancement of pregnancy. In the third trimester, sensitivity and specificity were still high at 80% and 93%, respectively. In conclusion, a progressive increase in NSC levels was observed during normal pregnancy, with maximum concentrations found in the third trimester. A statistically significant increase in NSC was found in the third gestational trimester when compared with the control group. Reference values were established for the NSC method in the three gestational trimesters with a good diagnostic accuracy of NSC in distinguishing between normal pregnant women, including those in the third gestational trimester, from patients with CD

Introduction: Diagnosed adrenal incidentalomas (AI) are increasing and dexamethasonesuppression test (DST) is gold standard for detection of excess cortisol production. Patients canbe categorized into three groups based on the DST level; non-functional adrenal adenomas(NFAA), possible autonomous cortisol secretion (PACS) and autonomous cortisol secretion(ACS), the latter two associated with increased risk of cardiovascular morbidity and mortality. Aim: The aim of this study was to compare cardiovascular morbidity and mortality in patientswith adrenal incidentalomas with and without hypercortisolemia defined by the EuropeanSociety of Endocrinology (2016) guidelines. Method: Retrospectively 160 consecutive patient charts between 2008 and 2015 were reviewedand 59 included. They were further categorized in NFAA (n = 37) or PACS (n = 22). Patientswith signs and symptoms of hormonal overproduction or AI found during malignancyinvestigations were excluded. Due to strict adherence to inclusion and exclusion criteria, onlyone case of ACS was found and excluded due to ethical reason. Results: Increased prevalence of type 2 diabetes in PACS group at baseline. No difference incardiovascular disease or mortality between the groups could be seen after mean follow up of7 years. Three (8%) patients in the NFAA group deceased, all of malignancy. In the PACSgroup, five (23%) deceased. Cause of death was cerebral infarction (n = 2), malignancy (n =1)and other causes (n =2). Conclusion: No significant difference of cardiovascular morbidity and mortality could be seenbetween NFAA and PACS during follow up. A prospective multicentre study is needed toidentify the long-term outcomes.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

A ocorrência de síndrome de Cushing (SC) durante a gestação é rara, e está associada com significativa morbidade e mortalidade materna. O diagnóstico da SC durante a gestação é, por vezes, problemático pela superposição de achados clínicos e laboratoriais com a gestação normal. Em relação aos aspectos laboratoriais, a ativação do eixo hipotálamo-hipófise-adrenal (HHA) materno na gestação altera parâmetros e testes utilizados para o rastreamento da SC. Desta forma, a confirmação do hipercortisolismo é mais difícil na gestação, particularmente no segundo e terceiro trimestres. Dentre os exames de rastreamento, o cortisol salivar noturno (CSN), por indicar alteração no ritmo circadiano de secreção de cortisol, que é característico da SC, tem sido considerado método importante para diferenciar grávidas com SC daquelas com gravidez normal, que apresentam ritmo circadiano preservado. No entanto, os valores de referência do CSN na gravidez não estão estabelecidos. Desta forma, o presente estudo tem como objetivo determinar os valores de referência de CSN em gestantes no primeiro, segundo e terceiro trimestres tendo como grupo controle mulheres não grávidas e pacientes portadoras de doença de Cushing (DC), com a finalidade de contribuir para o diagnóstico diferencial entre o hipercortisolismo fisiológico e o patológico durante a gestação. Para tanto, o CSN foi mensurado por meio do ensaio imunoenzimático (ELISA) em três grupos de indivíduos: 85 gestantes (grupo gestante), 33 mulheres não grávidas (grupo controle) e 25 mulheres não grávidas com DC (grupo DC). Observou-se menor concentração do CSN no grupo controle (mediana de 0,07 ug/dL) e as maiores no grupo DC (mediana de 0,51 ug/dL). Notou-se tendência de aumento das medianas do CSN no decorrer dos trimestres da gestação (primeiro trimestre: 0,08 ug/dL; segundo trimestre: 0,10 ug/dL; terceiro trimestre: 0,15 ug/dL). Em relação ao grupo controle, o CSN mostrou aumento de 1,1 vezes no primeiro trimestre, 1,4 vezes no segundo trimestre e de 2,1 vezes no terceiro trimestre da gestação. No grupo DC, o CSN foi significantemente superior ao do grupo controle e ao terceiro trimestre gestacional. Observou-se, ainda, que os valores de CSN foram significantemente superiores no terceiro trimestre da gestação em relação ao grupo controle. No presente estudo, determinamos valores de referência para o CSN na gestação, sendo o limite superior para o CSN nos respectivos trimestres gestacionais: 1º trimestre (0,25 ug/dL), 2º trimestre (0,26 ug/dL) e 3º trimestre (0,33 ug/dL). Os valores de corte do CSN que separaram da melhor forma possível o grupo DC do grupo gestante nos três trimestres foram, respectivamente, 0,255 ug/dL; 0,260 ug/dL e 0,285 ug/dL. A comparação dos valores de corte de CSN de gestantes sem DC com os de pacientes portadoras de DC mostrou alto grau de sensibilidade e especificidade, decrescendo no avançar da gestação. Mesmo no terceiro trimestre, foram de 80% e 93%, respectivamente. Em conclusão, foi observado um aumento progressivo do CSN no decorrer da gestação normal, sendo que concentrações máximas foram encontradas no terceiro trimestre. Um aumento estatisticamente significante do CSN foi encontrado entre o terceiro trimestre de gestação e o grupo controle. Foram estabelecidos valores de referência para o método CSN nos três trimestres gestacionais e foi encontrada uma boa acurácia diagnóstica do CSN na diferenciação entre gestantes normais e pacientes portadores de DC, mesmo no terceiro trimestre gestacional / Cushing\'s syndrome (CS) occurs rarely during pregnancy and is associated with significant maternal morbidity and mortality. Diagnosing CS during pregnancy is sometimes challenging, due to overlapping of clinical and laboratorial findings of the disease with characteristics of normal pregnancy. In addition, activation of the maternal hypothalamic-pituitary-adrenal (HPA) axis during pregnancy interferes with parameters and tests for screening of CS. Therefore, confirmation of hypercortisolism is more difficult during pregnancy, particularly in the second and third trimesters. Among the screening tests, nighttime salivary cortisol (NSC), which can detect changes in the circadian rhythm of cortisol secretion characteristic of CS, has been considered an important method to distinguish pregnant women with CS from normal pregnant women, in whom the cortisol circadian rhythm is preserved. However, NSC reference values in pregnancy have not yet been established. Thus, this study aims to determine the reference values for NSC in pregnant women in the first, second and third trimesters, using non-pregnant women and patients with Cushing\'s disease (CD) as controls, in order to establish values to distinguish between physiological and pathological hypercortisolism during pregnancy. To achieve that, we measured NSC by enzyme-linked immunosorbent assay (ELISA) in three groups of individuals: 85 pregnant women (pregnancy group), 33 non-pregnant women (control group) and 25 non-pregnant women with CD (CD group). Concentration of NSC was lowest in the control group (median 0.07 ?g/dL) and highest in the CD group (median 0.51 ?g/dL). Median NSC showed a trending increase at each consecutive gestation trimester (first trimester: 0.08 ug/dL; second trimester: 0.10 ug/dL; third trimester: 0.15 ug/dL). Compared with the control group, NSC showed increases of 1.1 times in the first trimester, 1.4 times in the second trimester and 2.1 times in the third trimester of pregnancy. Levels of NSC were significantly higher in the CD group compared with the control group and with the third gestational trimester. Values of NSC were also significantly higher in the third gestational trimester compared with the control group. The upper limit values for NSC during pregnancy determined in this study were 0.25 ug/dL in the first trimester, 0.26 ug/dL in the second trimester and 0.33 ug/dL in the third trimester. The cutoff NSC values that best separated the CD group from the pregnancy group in all three trimesters were, respectively, 0.255 ug/dL, 0.260 ug/dL and 0.285 ug/dL. The comparison between cutoff values of NSC in pregnant women without CD with those in patients with CD showed a high degree of sensitivity and specificity, which declined with the advancement of pregnancy. In the third trimester, sensitivity and specificity were still high at 80% and 93%, respectively. In conclusion, a progressive increase in NSC levels was observed during normal pregnancy, with maximum concentrations found in the third trimester. A statistically significant increase in NSC was found in the third gestational trimester when compared with the control group. Reference values were established for the NSC method in the three gestational trimesters with a good diagnostic accuracy of NSC in distinguishing between normal pregnant women, including those in the third gestational trimester, from patients with CD

Prostate cancer is among the most common malignancies in males in the United States and adenocarcinoma accounts for 95% of all malignancies of prostate. Rarely prostate cancer can also present as small cell carcinoma. Pure small cell carcinoma is rare at time of initial diagnosis (<2%) however neuroendocrine differentiation into small cell carcinoma may emerge in men who have had previous treatment with ADT for prostate adenocarcinoma. These tumors, sometimes called treatment-related neuroendocrine prostate cancers or aggressive-variant prostate cancers, are increasingly recognized in the castration-resistant phases of disease progression. They account for less than 1% of all prostate cancers. A 73-year-old otherwise male had routine health screening in May 2018. Prostate specific antigen (PSA) level was elevated at 9.53 ng/mL. He had not had a screening PSA for at least two prior years but this was a significant change from prior levels. Patient was asymptomatic however the abnormal laboratory evaluation prompted consultation with Urology. Biopsy of prostate gland confirmed prostatic adenocarcinoma with Gleason's score of 5+ 4 = 9 with bilateral gland involvement. Imaging studies including CT scan of abdomen and pelvis, a bone scan and a PET scan showed no clear evidence of metastatic disease. Patient's clinical stage was determined to be IIIC with T2c N0 M0 disease. Patient began treatment with androgen deprivation therapy and received definitive radiation treatment with external bean radiation therapy from July to September 2018. PSA was 0.08 ng/ml at the end of radiation treatment. Patient did well for about 15 months, after which he had multiple hospital admissions for dyspnea, fluid retention and lower extremity edema. He was also found to have refractory hypokalemia. Patient underwent MRI brain which revealed numerous small enhancing calvarial and skull base lesions consistent with bony metastasis in the skull. Patient also underwent PET/CT scan which showed numerous thoracic spine bony lesions, numerous to count bony metastasis throughout the lumbar spine and pelvis, as well as multiple hepatic lesions. Patient underwent biopsy of right hepatic lobe lesion and pathology was consistent with small cell carcinoma with positive neuroendocrine markers including CD56, synaptophysin and TTF-1. Interestingly patient’s PSA was only 0.09ng/dL. Given refractory hypokalemia, paraneoplastic syndrome was suspected and further work-up was initiated. Serum cortisol levels were elevated at 119.6 mcg/dL (3.7-19.4) and ACTH level was 333 pg/mL (7.2 - 63.3). Aldosterone level was <1 ng/dL (0 - 30.0). Patient was diagnosed with paraneoplastic Cushing syndrome. Given aggressive nature of this small cell transformation, patient was started on treatment with systemic chemotherapy with Carboplatin/Etoposide during the hospital stay, with stabilization of potassium levels. Prostate small cell carcinoma poses a challenge for diagnosis and treatment. In contrast to adenocarcinoma of the prostate, serum prostate-specific antigen (PSA) is not predictive of disease severity, nor is it a useful tumor marker for monitoring progression or surveillance. Patients with prostate small cell cancer presents with more diverse symptoms than any other prostate cancer since it tends to metastasize early. Also paraneoplastic syndromes are more common in prostate small cell cancers as well.

Der niedrig dosierte Dexamethason-Suppressionstest (LDDST) wird als Screeningverfahren in der Diagnostik des Cushing-Syndroms angewendet. Allerdings können Faktoren wie die variable Resorption, sowie ein gesteigerter Metabolismus von Dexamethason die Testergebnisse beeinflussen und zu falsch positiven Resultaten führen. Ein falsch positives Testresultat wird hierbei insbesondere bei adipösen Patienten häufiger beobachtet. In der vorliegenden Arbeit wurde daher der Einfluss des Körpergewichts auf das Ergebnis des Dexamethason-Suppressionstestes (DST) untersucht. Hierzu wurden hospitalisierte Patienten und ein aus gesunden Probanden bestehendes Kontrollkollektiv rekrutiert und diese einem regulären LDDST unterzogen. Es konnte gezeigt werden, dass übergewichtige Menschen im Rahmen des DST signifikant niedrigere Dexamethasonwerte erreichen als normalgewichtige Personen. Es ist daher davon auszugehen, dass Unterschiede im Body-Mass-Index (BMI) Einfluss auf die Resorptionsrate und den Metabolismus von Dexamethason nehmen und daraus resultierend die Serum-Dexamethasonspiegel wesentlich verringern können. Diese Prozesse scheinen allerdings keinen nachhaltigen Einfluss auf die Cortisolsuppression im DST zu haben, da die Cortisolwerte nach Dexamethasongabe zwischen adipösen und nicht adipösen Testpersonen nicht signifikant differierten. Diese Ergebnisse belegen, dass ein Zusammenhang zwischen BMI-Unterschieden und der Dexamethasonkinetik im LDDST besteht. Die erniedrigten Dexamethasonspiegel bei übergewichtigen Patienten scheinen hierbei insbesondere durch das wesentlich höhere Verteilungsvolumen und durch Unterschiede im hepatogenen Metabolismus bedingt zu sein. Trotz der erniedrigten Dexamethasonwerte bleibt die Feed-Back-Sensitivität der Hypothalamus-Hypophysen-Nebennieren-Achse (HHNA) auch bei Adipositas erhalten, weshalb der LDDST als zuverlässiges Screeningverfahren bei adipösen Patienten mit Verdacht auf Cushing-Syndrom einzustufen ist.

Der niedrig dosierte Dexamethason-Suppressionstest (LDDST) wird als Screeningverfahren in der Diagnostik des Cushing-Syndroms angewendet. Allerdings können Faktoren wie die variable Resorption, sowie ein gesteigerter Metabolismus von Dexamethason die Testergebnisse beeinflussen und zu falsch positiven Resultaten führen. Ein falsch positives Testresultat wird hierbei insbesondere bei adipösen Patienten häufiger beobachtet. In der vorliegenden Arbeit wurde daher der Einfluss des Körpergewichts auf das Ergebnis des Dexamethason-Suppressionstestes (DST) untersucht. Hierzu wurden hospitalisierte Patienten und ein aus gesunden Probanden bestehendes Kontrollkollektiv rekrutiert und diese einem regulären LDDST unterzogen. Es konnte gezeigt werden, dass übergewichtige Menschen im Rahmen des DST signifikant niedrigere Dexamethasonwerte erreichen als normalgewichtige Personen. Es ist daher davon auszugehen, dass Unterschiede im Body-Mass-Index (BMI) Einfluss auf die Resorptionsrate und den Metabolismus von Dexamethason nehmen und daraus resultierend die Serum-Dexamethasonspiegel wesentlich verringern können. Diese Prozesse scheinen allerdings keinen nachhaltigen Einfluss auf die Cortisolsuppression im DST zu haben, da die Cortisolwerte nach Dexamethasongabe zwischen adipösen und nicht adipösen Testpersonen nicht signifikant differierten. Diese Ergebnisse belegen, dass ein Zusammenhang zwischen BMI-Unterschieden und der Dexamethasonkinetik im LDDST besteht. Die erniedrigten Dexamethasonspiegel bei übergewichtigen Patienten scheinen hierbei insbesondere durch das wesentlich höhere Verteilungsvolumen und durch Unterschiede im hepatogenen Metabolismus bedingt zu sein. Trotz der erniedrigten Dexamethasonwerte bleibt die Feed-Back-Sensitivität der Hypothalamus-Hypophysen-Nebennieren-Achse (HHNA) auch bei Adipositas erhalten, weshalb der LDDST als zuverlässiges Screeningverfahren bei adipösen Patienten mit Verdacht auf Cushing-Syndrom einzustufen ist.