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Jacopo Burrello, Alessio Burrello, Jacopo Pieroni, Elisa Sconfienza, Vittorio Forestiero, Martina Amongero, Denis Rossato, Franco Veglio, Tracy A Williams, Silvia Monticone, and Paolo Mulatero

Objective – Adrenal venous sampling (AVS) is the gold standard to discriminate patients with unilateral primary aldosteronism (UPA) from bilateral disease (BPA). AVS is technically-demanding and in cases of unsuccessful cannulation of adrenal veins, the results may not be interpreted. The aim of our study was to develop diagnostic models to distinguish UPA from BPA, in cases of unilateral successful AVS and the presence of contralateral suppression of aldosterone secretion.

Design – Retrospective evaluation of 158 patients referred to a tertiary hypertension unit who underwent AVS. We randomly assigned 110 patients to a training cohort and 48 patients to a validation cohort to develop and test the diagnostic models.

Methods – Supervised machine learning algorithms and regression models were used to develop and validate two prediction models and a 19-point score system to stratify patients according to subtype diagnosis.

Results – Aldosterone levels at screening and after confirmatory testing, lowest potassium, ipsilateral and contralateral imaging findings at CT scanning, and contralateral ratio at AVS, were associated with a diagnosis of UPA and were included in the diagnostic models. Machine learning algorithms correctly classified the majority of patients both at training and validation (accuracy 82.9-95.7%). The score system displayed a sensitivity/specificity of 95.2/96.9%, with an AUC of 0.971. A flow-chart integrating our score correctly managed all patients except 3 (98.1% accuracy), avoiding the potential repetition of 77.2% of AVS.

Conclusions – Our score could be integrated in clinical practice and guide decision-making in patients with unilateral successful AVS and contralateral suppression.

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Anke Tönjes, Annett Hoffmann, Susan Kralisch, Abdul Rashid Qureshi, Nora Klöting, Markus Scholz, Dorit Schleinitz, Anette Bachmann, Jürgen Kratzsch, Marcin Nowicki, Sabine Paeschke, Kerstin Wirkner, Cornelia Enzenbach, Ronny Baber, Joachim Beige, Matthias Anders, Ingolf Bast, Matthias Blüher, Peter Kovacs, Markus Löffler, Ming-Zhi Zhang, Raymond C. Harris, Peter Stenvinkel, Michael Stumvoll, Mathias Fasshauer, and Thomas Ebert

Background:

Patients with chronic kidney disease (CKD) have a high risk of premature cardiovascular diseases (CVD) and show increased mortality. Pro-neurotensin (Pro-NT) was associated with metabolic diseases and predicted incident CVD and mortality. However, Pro-NT regulation in CKD and its potential role linking CKD and mortality have not been investigated, so far.

Methods:

In a central lab, circulating Pro-NT was quantified in three independent cohorts comprising 4715 participants (cohort 1: patients with CKD; cohort 2: general population study; and cohort 3: non-diabetic population study). Urinary Pro-NT was assessed in part of the patients from cohort 1. In a 4th independent cohort, serum Pro-NT was further related to mortality in patients with advanced CKD. Tissue-specific Nts expression was further investigated in two mouse models of diabetic CKD and compared to non-diabetic control mice.

Results:

Pro-NT significantly increased with deteriorating renal function (P < 0.001). In meta-analysis of cohorts 1–3, Pro-NT was significantly and independently associated with estimated glomerular filtration rate (P ≤ 0.002). Patients in the middle/high Pro-NT tertiles at baseline had a higher all-cause mortality compared to the low Pro-NT tertile (Hazard ratio: 2.11, P = 0.046). Mice with severe diabetic CKD did not show increased Nts mRNA expression in different tissues compared to control animals.

Conclusions:

Circulating Pro-NT is associated with impaired renal function in independent cohorts comprising 4715 subjects and is related to all-cause mortality in patients with end-stage kidney disease. Our human and rodent data are in accordance with the hypotheses that Pro-NT is eliminated by the kidneys and could potentially contribute to increased mortality observed in patients with CKD.

Open access

Claire L Wood, Michael Cole, Malcolm Donaldson, David P Dunger, Ruth Wood, Niamh Morrison, John Ns Matthews, Simon Hs Pearce, and Timothy D Cheetham

Objective

First line treatment of thyrotoxicosis in young people is thionamide antithyroid drug (ATD) in a blocking dose with levothyroxine replacement (block and replace, BR) or in a smaller dose tailored to render the patient euthyroid (dose titration, DT). Our objective was to determine which regimen provides more stable biochemical control.

Design

A multi-centre phase III, open-label randomised trial comparing BR with DT in patients aged 2-16 years with newly diagnosed thyrotoxicosis at 15 UK centres.

Methods

Patients were randomised shortly after diagnosis and treated for 3 years. The primary outcome was the percentage of serum thyroid stimulating hormone (TSH) levels in the reference range between 6 months and 3 years. Secondary outcomes included the proportion of Free thyroxine (FT4) levels in the reference range, adverse event frequency and 4y outcome (remission/relapse).

Results

Eighty-two patients were randomised, with details on clinical course in 81 (62 Female); 40 were allocated to BR (41 DT). Three withdrew with one ineligible. The mean percentage of serum TSH within reference range was 60·2% in BR and 63·8% in DT patients; adjusted difference 4·3%, 95% CI (-7·8 to 16·4);p=0.48. Proportions for FT4 were 79·2% in BR and 85·7% in DT patients; adjusted difference 6·8%, (-0·2 to 15·6);p=0·13. Three patients developed neutropenia – all on BR. 6 BR and 10 DT patients were in remission at 4y.

Conclusion

This randomised trial has shown no evidence to suggest that BR, when managing the young patient with thyrotoxicosis, is associated with improved biochemical stability when compared to DT.

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Colin Patrick Hawkes, Dorothy I Shulman, and Michael A Levine

Introduction: Gain-of-function mutations in the CASR gene cause Autosomal Dominant Hypocalcemia Type 1 (ADH1), the most common genetic cause of isolated hypoparathyroidism. Subjects have increased calcium sensitivity in the renal tubule, leading to increased urinary calcium excretion, nephrocalcinosis and nephrolithiasis when compared with other causes of hypoparathyroidism. The traditional approach to treatment includes activated vitamin D but this further increases urinary calcium excretion.

Methods: In this case series, we describe the use of recombinant human parathyroid hormone (rhPTH) 1-84 to treat subjects with ADH1, with improved control of serum and urinary calcium levels.

Results: We describe two children and one adult with ADH1 due to heterozygous CASR mutations who were treated with rhPTH(1-84). Case 1 was a 9.4 year-old female whose 24-hour urinary calcium decreased from 7.5 mg/kg to 3.9 mg/kg at one year. Calcitriol and calcium supplementation were discontinued after titration of rhPTH(1-84). Case 2 was a 9.5-year-old male whose 24-hour urinary calcium decreased from 11.7 mg/kg to 1.7 mg/kg at one year, and calcitriol was also discontinued. Case 3 was a 24-year-old female whose treatment was switched from multi-dose teriparatide to daily rhPTH(1-84). All three subjects achieved or maintained target serum levels of calcium and normal or improved urinary calcium levels with daily rhPTH(1-84) monotherapy.

Conclusions: We have described three subjects with ADH1 who were treated effectively with rhPTH(1-84). In all cases, hypercalciuria improved by comparison to treatment with conventional therapy consisting of calcium supplementation and calcitriol.

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Robin Michelet, Johanna Melin, Zinnia P Parra-Guillen, Uta Neumann, Martin J Whitaker, Viktoria Stachanow, Wilhelm Huisinga, John Porter, Oliver Blankenstein, Richard J Ross, and Charlotte Kloft

N/A

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Hanneke M van Santen

Dr Thomas Teinturier et al. describe the influence of growth hormone (GH) therapy on the development of second neoplasms in childhood cancer survivors (CCS)1. The manuscript is an important contribution to literature, as GH deficiency (GHD) is frequently observed in CCS, especially in the childhood brain tumor survivors after exposure to cranial irradiation or in children surviving a tumor in the hypothalamic-pituitary region. In their study, no increased risk was found for recurrence of the original tumor, nor for the development of a second tumor. A slight non significant increased risk is described for the development of meningioma, which may be confounded by previous radiotherapy. These results are reassuring for children who have been diagnosed with GHD after surviving a malignancy and who are treated with GH injections on a daily basis. There are however still some concerns and unanswered questions that need attention in future studies.

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Robin P. Peeters and Juan P. Brito

There is controversy on the treatment of subclinical hypothyroidism (SCH). While a number of guidelines from professional societies recommend treatment of SCH based on TSH levels, age, and presence of comorbidities, a recent guideline issued a recommendation against thyroid hormone treatment in adults with SCH. In this debate article, we explore this controversy by presenting two points of view about SCH and its treatment. Treatment of patients who are pregnant or trying to become pregnant will not be discussed.

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Ola Nilsson

Short stature is one of the most common causes for referrals to pediatric endocrinologists. However, in a majority of the children, no underlying cause can be identified and the child instead receives the unhelpful diagnosis of idiopathic short stature (ISS), often after extensive work-up and testing. Recent advances in genetic methodology have allowed for the identification of a number of different monogenic conditions within the large cohort of ISS children. Isolated short stature and advanced bone age, with or without early-onset osteoarthritis and/or osteochondritis dissecans (MIM#165800) due to heterozygous aggrecan gene mutations exemplifies how this progress is changing the way we assess, counsel and treat children with non-endocrine growth disorders.

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Mischa de Ridder, Els Nieveen van Dijkum, Anton Engelsman, Ellen Kapiteijn, Heinz-Josef Klümpen, and Coen R N Rasch

Objective

To perform a nationwide population based study in ATC on incidence, treatment and survival.

Design

Retrospective cohort study.

Methods

All patients with primary ATC between 1989 and 2016 were identified in the Netherlands Cancer Registry (NCR). Of all these patients excerpts from the pathology reports from PALGA: Dutch Pathology registry were linked to the data of the NCR. Standardized incidences were calculated, survival was estimated using Kaplan–Meier method and univariable statistically significant factors were included in a multivariable regression model.

Results

In total, 812 patients were included. Mean standardized incidence rates were 0.18/100 000 (range 0.11–0.27/100 000) with a significant trend over the years with an estimated annual percentage change of 1.3% per year (95% CI 0.4–2.1%). Median overall survival was 2.2 months, and estimated 1-year survival was 12%. Patients without distant metastases at diagnosis had an estimated 1-year survival of 21.6%. Prognostic factors for prolonged survival were double or triple therapy, age below 65 years, M0-status and absence of bilateral lymph node metastases.

Conclusions

ATC is rare, but often lethal, form of thyroid cancer, with a median survival of 2 months and 1-year survival of approximately 10%. The incidence is slightly rising in the Netherlands over the past 3 decades. There appears to be a subgroup of patients that survive longer, mainly those with relatively limited disease who underwent double or triple therapy. Further research is needed to define these patients more distinctively.