Colonial breeding impacts potentially fitness-relevant cognitive processes in barn swallows

Many animals breed colonially, often in dense clusters, representing a complex social environment with cognitive demands that could ultimately impact individual fitness. However, the effects of social breeding on the evolution of cognitive processes remain largely unknown. We tested the hypothesis that facultative colonial breeding influences attention and decision-making. Barn swallows (Hirundo rustica) breed in solitary pairs or in a range of colony sizes, up to dozens of pairs. We tested for selective attention to social information with playbacks of conspecific alarm calls and for decision-making with simulated predator intrusions, across a range of colony sizes from 1 to 33 pairs. We also evaluated the adaptive value of both processes by measuring seasonal reproductive success. Swallows breeding in larger colonies were more selective in their attention to social information. Birds breeding in larger colonies were also less risk averse, deciding to return more quickly to their nests after a predator approach paradigm. Finally, birds that showed higher selective attention hatched more eggs and birds that returned to their nests more quickly after a predator intrusion had more nestlings. Although we cannot fully attribute these fitness outcomes to the cognitive measures considered in this study, our results suggest that social breeding plays a role in adaptively shaping both the acquisition of social information and decision-making.

Females with Increased Costs Maintain Reproductive Output: A Field Experiment in a Common Songbird

Reproduction and self-maintenance are energetically costly activities involved in classic life history trade-offs. However, few studies have measured the responses of wild organisms to simultaneous changes in reproductive and self-maintenance costs, which may have interactive effects. In free-living female Barn Swallows (Hirundo rustica), we simultaneously manipulated reproductive costs (by adding or removing two nestlings) and self-maintenance costs (by attaching a ∼1 g weight in the form of a GPS tag to half of our study birds) and measured mass, immune status, blood glucose, feather growth, and reproductive output (likelihood of a second clutch, number of eggs, and time between clutches). GPS tags allowed us to analyze how movement range size affected response to brood size manipulation. Tagging altered females' immune function as evidenced by an elevated heterophil to lymphocyte (H:L) ratio, but all females were equally likely to lay more eggs. There was no evidence of interactive effects of the tagging and brood size treatment. Range size was highly variable, and birds with large ranges grew feathers more slowly, but analyzing the effect of brood size manipulation while accounting for variation in range size did not result in any physiological response. Our results support the theoretical prediction that short-lived vertebrates do face a trade-off between reproduction and self-maintenance and, when faced with increased costs, tend to preserve investment in reproduction at the expense of parental condition. This experiment also helps us to understand how movement patterns may be relevant to life history trade-offs in wild birds.

Sensitive periods during the development and expression of vertebrate sexual signals: A systematic review

Many sexually selected traits exhibit phenotypic plasticity. Despite a growing appreciation for the ecological context in which sexual selection occurs, and for the role of plasticity in shaping traits associated with local adaptation and divergence, there is an important gap in knowledge about the onset and duration of plasticity in sexual trait expression. Integrating this temporal dimension of plasticity into models of sexual selection informs our understanding of the information conveyed by sexual traits and our predictions related to trait evolution, and is critical in this time of unprecedented and rapid environmental change. We conducted a systematic review of 869 studies to ask how trait modalities (e.g., visual and chemical) relate to the onset and duration of plasticity in vertebrate sexual signals. We show that this literature is dominated by studies of coloration in birds and fish, and most studies take place during the breeding season. Where possible, we integrate results across studies to link physiology of specific trait modalities with the life stage (e.g., juvenile, breeding, or nonbreeding) during which plasticity occurs in well-studied traits. Limitations of our review included a lack of replication in our dataset, which precluded formal analysis. We argue that the timing of trait plasticity, in addition to environmental context, is critical for determining whether and how various communication signals are associated with ecological context, because plasticity may be ongoing or occur at only one point in an individual's lifetime, and determining a fixed trajectory of trait expression. We advocate for careful consideration of the onset and duration of plasticity when analyzing how environmental variation affects sexual trait expression and associated evolutionary outcomes.

Characterization of surfactant coatings in capillary electrophoresis by atomic force microscopy

This paper describes the adsorption mechanisms and aggregation properties of cetyltrimethylammonium bromide (CTAB) and didodecyldimethylammonium bromide (DDAB) surfactants that are used for dynamic coatings in capillary electrophoresis (CE). Atomic force microscopy is used to directly visualize surfactant adsorption on fused silica. It was found that the single-chained surfactant CTAB forms spherical aggregates on silica while the double-chained surfactant DDAB forms a bilayer. Aggregation at the surface occurs at approximately the same surfactant concentration in which EOF reversal is observed in CE. The nearest-neighbor distance between CTAB aggregates varies inversely with buffer pH and becomes constant at the point when the silanol groups are fully ionized. DDAB forms a flat, uniform coating independent of pH. Increasing the buffer ionic strength changes the morphology of the CTAB aggregates from spherical to cylindrical. The change in morphology can alter the surface coverage, which is related to the "normalized" EOF measured in identical buffers. The morphology of a surfactant coating is also shown to affect its ability to inhibit protein adsorption to the capillary wall. Specifically, the full surface coverage provided by DDAB proved superior in a head-to-head comparison with CTAB.

Management practices among primary care physicians and thyroid specialists in the care of hypothyroid patients

Prospective studies are not available to address various issues commonly encountered in the management of hypothyroid patients. We have conducted a case-based mail survey of American Thyroid Association (ATA) members and primary care providers (PCP) regarding hypothyroidism management issues. A majority of ATA members and a minority of PCPs used antithyroid antibody testing in the evaluation of hypothyroidism. Approximately 2/3 of all respondents indicated that they would treat patients with mild thyroid failure when antithyroid antibodies are negative; 77% of PCPs and 95% of ATA members recommended treatment when antibodies are positive. For a young patient with mild thyroid failure, 71% of ATA members would initiate a full levothyroxine (LT4) replacement dose of 1.6 microg/kg per day or slightly lower; PCPs were more likely to start with a low dose and titrate upwards. For a young patient with overt hypothyroidism, 42% of PCPs and 51% of ATA respondents recommended an initial full LT4 replacement dose. The majority of all respondents would start with a low LT4 dose and adjust the dose gradually in an elderly patient, regardless of the severity of thyroid hormone deficiency. More than 40% of ATA respondents chose a target thyrotropin (TSH) range of 0.5-2.0 microU/mL for a young patient while 39% favored a goal of 1.0-4.0 microU/mL for an elderly patient. PCPs more often chose a broader TSH goal of 0.5-5.0 microU/mL. In conclusion, the current practice patterns of PCPs and ATA members that were elicited in this survey differ significantly in regard to the evaluation and management of hypothyroidism.

The effects of region-specific resistance and aerobic exercises on bone mineral density in premenopausal women

Epidemiological, cross-sectional, and prospective studies strongly suggest that exercise has beneficial effects on bone mass in premenopausal women. We prospectively compared the effects of resistance or aerobic exercises on regional bone mass in premenopausal active duty military women ranging in age from 19 to 40 years. Subjects were assigned, by preference, to a resistance exercise group or an aerobic exercise group and instructed to exercise at least 30 minutes per day, three times per week, for a period of 1 year. Bone mineral density (BMD) was measured by dual photon absorptiometry at the lumbar spine and femoral neck and by single photon absorptiometry at the mid radius at baseline, 6 months, and 12 months. BMD increments during the study were statistically significant at all sites in both exercise groups. Comparisons between the groups showed that after 12 months, BMD increased similarly in the lumbar spine (2.2% resistance vs. 1.8% aerobics, p = not significant) but more in the resistance group in the femoral neck (5.0% vs. 2.7%, p < 0.001) and the mid radius (7.8% vs. 6.7%, p < 0.05). Both resistance and aerobic exercises increase regional bone mass, particularly cortical bone mass, in premenopausal women. Resistance work appears to have a slightly greater effect on cortical bone than aerobics alone. A combination of aerobics and resistance exercises, therefore, may be a useful strategy for increasing peak bone mass in premenopausal women.

Mapping interfacial chemistry induced variations in protein adsorption with scanning force microscopy

In this work, we demonstrate the sensitivity of scanning force microscopy (SFM), operated in friction force mode, to adsorbed protein conformation or orientation. We employ patterned films of methyl- and carboxylate-terminated alkanethiolate monolayers on gold as substrates for protein adsorption to observe the effect of each functional group in the same image. Infrared spectroscopic and SFM studies of bovine fibrinogen (BFG) adsorption to single-component monolayers indicate that complete films of BFG that are stable to imaging are formed at each functional group. After adsorption of BFG to a patterned monolayer, we observe a contrast in friction images due to differences in adsorbed BFG conformation or orientation induced by each functional group. We also observe frictional contrast in films of other proteins adsorbed on patterned monolayers. These observations lead to the conclusion that SFM-measured friction is sensitive to adsorbed protein state.

Genetic localization to chromosome 1p32 of the third locus for familial hypercholesterolemia in a Utah kindred

Clinical familial hypercholesterolemia has been shown to result from mutations in 2 genes, the low density lipoprotein (LDL) receptor on chromosome 19 and apolipoprotein B on chromosome 2. However, we have recently described a Utah pedigree in which linkage to both genes was clearly excluded. A multipoint linkage analysis of 583 markers genotyped on 31 (18 affected) members of this pedigree was undertaken to localize a genetic region that may harbor a third gene that could result in clinical familial hypercholesterolemia. A multipoint log of the odds score of 6.8 was obtained for markers on 1p32. Haplotype carriers and affected status are completely concordant (18/18 persons). The phenotype is also expressed in young children (ages 4 and 9). Specific recombinant individuals in the pedigree restrict the region of linkage to an approximately 17 cM interval between polymorphic markers D1S2130 and D1S1596. This region appears to overlap the region found linked to severe hypercholesterolemia in French and Spanish families. The identification of the gene in this region may provide important pathophysiological insights into new mechanisms that may lead to highly elevated LDL cholesterol and other associated dyslipidemic phenotypes.

Reverse transcription polymerase chain reaction analysis of pituitary hormone, Pit-1 and steroidogenic factor-1 messenger RNA expression in pituitary tumors

Pit-1 is a transcription factor that appears early in embryonic pituitary gland formation and is necessary for the development of somatotropes, lactotropes and thyrotropes. Steroidogenic factor-1 (SF-1) is another early appearing transcription factor that is involved in the development of gonadotropes. In this study we have compared RT-PCR analysis of hormone mRNA with traditional IHC for classification of 27 pituitary tumors and have evaluated the correlation of Pit-1 and SF-1 mRNA with hormone mRNA. RT-PCR detected concordant hormone mRNA in 100% of GH IHC positive, 100% of PRL IHC positive, 33% of TSH IHC positive, and 93% of gonadotropin IHC positive tumors. IHC, however, was concordant in only 71% of GH mRNA positive, 78% of PRL mRNA positive, 17% of TSH beta mRNA positive, and 76% of FSH beta mRNA positive tumors. Pit-1 mRNA was positive in 87% of tumors in which mRNA for GH, PRL or TSH beta was detected and in only 17% of GH, PRL and TSH beta mRNA negative tumors. SF-1 mRNA was positive in 94% of tumors in which mRNA for FSH beta was present and in no FSH beta mRNA negative tumors. We conclude that RT-PCR analysis of hormone mRNA may be more sensitive than traditional hormone IHC for classification of pituitary tumors. Furthermore, tumor Pit-1 mRNA positively correlates with GH, PRL and TSH beta mRNA while tumor SF-1 mRNA correlates well with FSH beta mRNA. Combined analysis of hormone and transcription factor mRNA in pituitary tumor tissue may therefore be a more meaningful approach to pituitary tumor characterization.

Functional interactions of an upstream enhancer of the mouse glycoprotein hormone alpha-subunit gene with proximal promoter sequences

Transcription of the glycoprotein hormone alpha-subunit gene in the pituitary is governed by different promoter elements in thyrotropes and gonadotropes. We recently identified an upstream enhancer that directs a high level of cell type specific expression in transgenic mice and stimulates proximal promoter activity in cultured alphaTSH and alphaT3 cells. To assess the contribution of promoter sequences that functionally interact with the enhancer, we mutated two proximal elements shown to be important in both thyrotrope and gonadotrope cells. Disruption of the pituitary glycoprotein hormone basal element (PGBE), which binds a LIM homeodomain protein, resulted in a decrease in basal promoter activity in both alphaTSH and alphaT3 cells. Enhancer function was completely abolished by the PGBE site mutation in alphaT3 gonadotropes, whereas some stimulatory activity remained in alphaTSH thyrotropes. Mutation of the gonadotrope specific element (GSE), which binds SF1 and is important for basal activity in gonadotropes and TRH response in thyrotropes, resulted in declines in basal and enhanced promoter activity only in alphaT3 cells and not in alphaTSH cells. Despite this decrease in enhanced activity, the GSE mutated promoter still retained some enhancer stimulated activity, suggesting that the PGBE site still functionally interacts in the absence of an intact GSE. This mutation had no effect in alphaTSH cells. These data suggest that although the enhancer works in both cell types it exhibits cell type specific functional characteristics.

Hydroxylated naphthoquinones as substrates for Escherichia coli anaerobic reductases

We have used two hydroxylated naphthoquinol menaquinol analogues, reduced plumbagin (PBH2, 5-hydroxy-2-methyl-1,4-naphthoquinol) and reduced lapachol [LPCH2, 2-hydroxy-3-(3-methyl-2-butenyl)-1, 4-naphthoquinol], as substrates for Escherichia coli anaerobic reductases. These compounds have optical, solubility and redox properties that make them suitable for use in studies of the enzymology of menaquinol oxidation. Oxidized plumbagin and oxidized lapachol have well resolved absorbances at 419 nm (epsilon=3.95 mM-1. cm-1) and 481 nm (epsilon=2.66 mM-1.cm-1) respectively (in Mops/KOH buffer, pH 7.0). PBH2 is a good substrate for nitrate reductase A (Km=282+/-28 microM, kcat=120+/-6 s-1) and fumarate reductase (Km=155+/-24 microM, kcat=30+/-2 s-1), but not for DMSO reductase. LPCH2 is a good substrate for nitrate reductase A (Km=57+/-35 microM, kcat=68+/-13 s-1), fumarate reductase (Km=85+/-27 microM, kcat=74+/-6 s-1) and DMSO reductase (Km=238+/-30 microM, kcat=191+/-21 s-1). The sensitivity of enzymic LPCH2 and PBH2 oxidation to 2-n-heptyl-4-hydroxyquinoline N-oxide inhibition is consistent with their oxidation occurring at sites of physiological quinol binding.

Central hyperthyroidism

Central hyperthyroidism is a rare condition in which thyrotoxicosis results from primary overproduction of TSH by the pituitary gland with subsequent thyroid enlargement and hyperfunction. The two known causes of central hyperthyroidism are TSH-producing pituitary tumors (TSHomas) and the syndrome of PRTH. Both of these entities are characterized by clinical thyrotoxicosis, diffuse goiters, elevated circulating levels of free T4 and T3, and a nonsuppressed serum TSH. It is critical to distinguish central hyperthyroidism from the much more common types of primary hyperthyroidism, all of which have undetectable TSH values. TSHomas and PRTH can usually be differentiated from one another by measuring the serum alpha-subunit and the TSH response to intravenous TRH or exogenous thyroid hormone, and by pituitary imaging studies. TSHomas are usually benign adenomas arising from the monoclonal expansion of neoplastic thyrotropes. Causative oncogenes have not yet been convincingly identified. PRTH is a nonneoplastic disorder caused by inherited mutations in the gene for the thyroid hormone receptor beta; it is a poorly understood variant of GRTH. For unclear reasons, in PRTH, the pituitary gland is resistant to the feedback inhibitory effects of circulating thyroid hormones while peripheral tissues respond normally, causing patients to experience the toxic peripheral effects of thyroid hormone excess. TSHomas are best treated by transphenoidal surgical removal. Radiotherapy is indicated for inoperable or incompletely resected tumors. Octreotide administration is a useful adjunct for preoperatively reducing tumor size and for the medical management of surgical treatment failures. PRTH is ideally treated by chronically suppressing TSH secretion with medications such as D-thyroxine, TRIAC, octreotide, or bromocriptine. If such therapy is ineffective or unavailable, thyroid ablation with radioiodine or surgery may be employed with subsequent close monitoring of both thyroid hormone status and pituitary gland size.

Pit-1 and GATA-2 interact and functionally cooperate to activate the thyrotropin beta-subunit promoter

The molecular determinants governing cell-specific expression of the thyrotropin (TSH) beta-subunit gene in pituitary thyrotropes are not well understood. The P1 region of the mouse TSHbeta promoter (-133 to -88) region interacts with Pit-1 and an additional 50-kDa factor at an adjacent site that resembles a consensus GATA binding site. Northern and Western blot assays demonstrated the presence of GATA-2 transcripts and protein in TtT-97 thyrotropic tumors. In electrophoretic mobility shift assays, a comigrating complex was observed with both TtT-97 nuclear extracts and GATA-2 expressed in COS cells. The complex demonstrated binding specificity to the P1 region DNA probe and could be disrupted by a GATA-2 antibody. When both Pit-1 and GATA-2 were combined, a slower migrating complex, indicative of a ternary protein-DNA interaction was observed. Cotransfection of both Pit-1 and GATA-2 into CV-1 cells synergistically stimulated mouse TSHbeta promoter activity 8.5-fold, while each factor alone had a minimal effect. Mutations that abrogated this functional stimulatory effect mapped to the P1 region. Finally, we show that GATA-2 directly interacts with Pit-1 in solution. In summary, these data demonstrate functional synergy and physical interaction between homeobox and zinc finger factors and provide insights into the transcriptional mechanisms of thyrotrope-specific gene expression.

Bridging the gap between monkey neurophysiology and human perception: an ambiguity resolution theory of visual selective attention

When the visual system must process multiple objects simultaneously, as in the visual search paradigm, the neural coding of individual objects can become ambiguous due to the visual system's extensive use of coarse coding and distributed representations. Here we propose that the primary role of visual selective attention within the ventral object recognition pathway is to resolve these ambiguities. We begin by reviewing previous studies of the effects of attention on neural responses in monkeys, which provide the basis for this hypothesis, and then describe a new set of experiments showing that similar attentional mechanisms operate in the human brain. In these new experiments, event-related potentials (ERPs) were recorded from normal human observers while they performed tasks analogous to those used previously in monkeys. The central finding was that an attention-related ERP wave called the "N2pc component" was present under the same conditions that led to attentional modulations of neural responses in monkey visual cortex. These human electrophysiological results provide a bridge between cognitive-level theories of visual attention and the behavior of individual neurons in visual cortex.

Adrenal crisis in active duty service members

Primary adrenal insufficiency is a chronic, debilitating condition that usually produces a variety of characteristic but non-specific clinical features. Up to 25% of patients present instead with acute life-threatening adrenal crisis, marked by severe hypotension and shock. Recognition of the disease in the chronic indolent phase is critical because adrenal steroid replacement effectively relieves symptoms and prevents the development of most acute crises. To illustrate these points, we describe four case histories in which the manifestations of chronic adrenal insufficiency went unrecognized in active duty service members until they presented with near-fatal adrenal crises. The salient clinical features, diagnosis, and treatment of the disease are also reviewed.

Thyroid hormone receptor beta2 promoter activity in pituitary cells is regulated by Pit-1

There are three known thyroid hormone receptor (TR) isoforms that arise from two distinct alpha and beta gene loci. TRalpha1 and TRbeta1 mRNAs are found in many tissues, whereas mRNA for the N-terminal TRbeta2 variant derived from the beta locus is readily detectable only in the pituitary gland and derived cell sources such as GH3 somatotropes and TtT-97 thyrotropes. We previously isolated the genomic region governing expression of the TRbeta2 isoform in thyrotropes and showed that transcription arose from multiple origins within a 400-base pair (bp) region. We now report that the region extending 500 bp upstream of the putative AUG codon (A is +1) contains six areas of interaction with the pituitary-specific transcription factor Pit-1. In addition there are separate areas that bind other factors present in thyrotrope cells. Promoter deletions revealed that removal of regions containing the Pit-1 sites at -456 to -432, -149 to -127, and -124 to -102 progressively decreased TRbeta2 promoter activity in thyrotropes. A more proximal footprinted area from -65 to -19, which accounted for the remaining promoter activity, contained sites that interacted with recombinant Pit-1; however, extracts of TtT-97 thyrotropes, which express Pit-1, footprinted this proximal region with a pattern of protection that differed from that produced by Pit-1. A comparative deletional analysis demonstrated that a shorter region extending only 204 bp from the AUG was sufficient to support TRbeta2 promoter activity in GH3 somatotropes. The more proximal Pit-1 sites, including the area from -53 to -19, whose pattern differed from Pit-1 in thyrotrope extracts, showed protection patterns with GH3 extracts that were indistinguishable from recombinant Pit-1. Site-directed mutagenesis that abrogated binding of both recombinant Pit-1 and Pit-1-containing nuclear extracts revealed that the two Pit-1 sites between -149 and -102 were important for TRbeta2 promoter activity with the more proximal being most critical. Finally, we showed that TRbeta2 promoter activity in alpha-TSH cells, which do not transcribe the endogenous TRbeta2 locus or produce Pit-1 protein, could be reconstituted to a level approaching that seen in expressing TtT-97 thyrotropes by cotransfecting a Pit-1 expression vector. Activation by Pit-1 was dependent on the same Pit-1 sites shown to be important for basal TRbeta2 promoter activity in thyrotropes as constructs lacking them by deletion or mutation were not stimulated by Pit-1.

Correlation of liver density by magnetic resonance imaging and hepatic iron levels. A noninvasive means to exclude homozygous hemochromatosis

The diagnosis of hemochromatosis requires liver biopsy and the quantification of hepatic iron. Magnetic resonance imaging (MRI) of the liver shows a characteristic decrease in tissue signal intensity in iron overload states, but its role in the diagnosis of hemochromatosis has not been fully delineated. Forty-three patients (31 men and 12 women) were referred for the evaluation of hemochromatosis based upon a fasting transferrin saturation > 55% and/or a serum ferritin > 400 ng/ml in males or > 300 ng/ml in females. Each patient prospectively underwent MRI of the liver prior to percutaneous liver biopsy and quantitative hepatic iron determination. Homozygous hemochromatosis was diagnosed in 10 patients based upon an hepatic iron/age index > or = 2. MRI was performed with a 1.5 Tesla system using standard spin-echo sequences (T1; TR = 300-500 ms, TE = 13-17 ms, PD; TR = 2,000-2,600 ms, TE = 30 ms). Signal intensity values were blindly determined for regions of interest in liver and skeletal muscle at T1 and proton density. Ratios of liver to muscle (LM) for T1 and proton density (PD) calculated from these values showed a significant correlation with quantitative iron by multiple regression analysis. The LMPD ratio provided the best correlation with hepatic iron (r = -0.6946; p < 0.001). Linear regression analysis also provides an equation that can be used to predict hepatic iron based upon the LMPD ratio; micrograms/g of hepatic iron = (-5,174 x LMPD) + 9,932. All patients with LMPD ratios of > 0.5 had hepatic iron/age indices of < 2.0, thereby excluding homozygous hemochromatosis. These results suggest that LMPD ratios derived from MRI of the liver can accurately predict hepatic iron content. These ratios can be clinically useful in the evaluation of hemochromatosis among patients who either refuse or have contraindications to liver biopsy.

The effect of methotrexate on mouse bone cells in culture

OBJECTIVE

We have recently shown that administration of long-term, low-dose methotrexate (MTX) causes severe osteopenia in female rats. This osteopenia is characterized both by decreased osteoblast function without a decrease in osteoblast numbers, and by increased bone resorption that is believed to represent a physiologic remodeling response by osteoclasts. The present study investigates the effects of varying doses of MTX on mouse bone cells in culture.

METHODS

Cells were obtained by sequential digestion of neonatal mouse calvariae, and cultured with fetal calf serum (10% for osteoblast-like cells and 2% for osteoclast-like cells). After 1 week, MTX was added to each culture in concentrations of 0.6 microM, 0.4 microM, 0.2 microM, 0.1 microM, 1 nM, and 0.5 nM. All experiments were done on 24 wells for each MTX concentration and for the controls. The effect on osteoblastic cells was assessed, at 7 days, by cell counts and by measurement of lysate alkaline phosphatase and supernatant osteocalcin levels, and, at 21 days, by analysis of the calcified matrix production, which was cultured with ascorbic acid and beta-glycerophosphate. For osteoclastic cells, cell count and lysate acid phosphatase levels were determined.

RESULTS

Levels of osteoblastic cells and lysate alkaline phosphatase were not changed by any of the concentrations of MTX. Matrix calcification and supernatant osteocalcin levels were diminished by MTX in a dose-responsive manner. Osteoclast-like cell numbers and acid phosphatase levels were not significantly affected by MTX.

CONCLUSION

These results suggest that diminished mouse osteoblastic cell function occurs with very low mean concentrations of MTX, in a dose-responsive manner. The mechanism seems to be inability of the cell to synthesize and calcify matrix, possibly through defective osteocalcin production. Thus, low-dose MTX may have an important impact on bone density by slowing osteoblastic matrix production.

Determinants of thyrotrope-specific thyrotropin beta promoter activation. Cooperation of Pit-1 with another factor

Thyrotropin (TSH) beta is a subunit of TSH, the expression of which is limited to the thyrotrope cells of the anterior pituitary gland. We have utilized the thyrotrope-derived TtT-97 thyrotropic tumors to investigate tissue-specific expression of the TSH beta promoter. TSH beta promoter activity in thyrotropes is conferred by sequences between -270 and -80 of the 5'-flanking region. We have recently reported that the proximal region from -133 to -100 (P1) is required for promoter expression in thyrotropes. This region interacts with the pituitary-specific transcription factor Pit-1. While Pit-1 appears necessary for TSH beta promoter activity in thyrotropes, this transcription factor is not alone sufficient for promoter activity in pituitary-derived cells. In this report, we have generated a series of promoter mutations in the P1 region to identify additional protein-DNA interactions and determine their functional significance. We have found that Pit-1 interacts with the distal portion of the P1 region, and a second protein interacts with the proximal segment of this region. Each protein is able to independently interact with the TSH beta promoter, but neither alone can maintain promoter activity. Both proteins appear to be necessary for full promoter activity in thyrotropes. Southwestern analysis with the proximal segment of the P1 region (-117 to -88) reveals interaction with a 50-kDa protein. Interestingly, this protein is not found in the pituitary-derived GH3 cells and may represent a thyrotrope-specific transcription factor. Further characterization of this newly identified DNA-binding protein will further our understanding of the tissue-specific expression of the TSH beta gene.

A longitudinal assessment of bone loss in women with levothyroxine-suppressed benign thyroid disease and thyroid cancer

To determine if differing degrees of levothyroxine (LT4) suppression therapy for benign and malignant thyroid disease are associated with proportionately increased rates of bone loss, this longitudinal assessment of bone densitometry changes (single-photon and dual-photon absorptiometry) was conducted in three groups of subjects: 24 thyroid cancer patients who were treated with near-total thyroidectomy, radioiodine ablation, and aggressive LT4-suppression; 44 patients who were treated with more conservative LT4-suppression for benign thyroid disorders; and 24 normal controls. Bone densitometry values were adjusted for age, weight, height, and menopausal status. The rates of bone loss in benign LT4-suppressed patients were greater than those in controls at the midradius, distal radius, lumbar spine, and femoral neck. The rates of loss in the thyroid cancer patients were also greater than those in the controls at all four sites and greater than in the benign LT4-suppressed patients at the midradius, distal radius, and femoral neck but not in the lumbar spine. Rates of bone loss were not significantly correlated with LT4 dose or with the serum level of T4 or TSH. LT4-suppression therapy for benign thyroid disease is associated with accelerated bone loss. More aggressive LT4-suppression for thyroid cancer is associated with even greater bone loss, particularly in cortical bone regions. These risks must be weighed against the benefits of LT4 therapy in individual patients.

Thyroid adaptation to chronic tetraglycine hydroperiodide water purification tablet use

Tetraglycine hydroperiodide tablets purify water by liberating 8 mg free iodine/tablet. The effects of ingesting four tablets daily for 3 months on thyroid size, function, and radioactive iodine uptake were studied prospectively in eight healthy volunteers. Serum inorganic iodide increased from 2.7 to approximately 100 micrograms/dL. Urinary iodide excretion rose 150-fold from a pretreatment mean of 0.276 to 40 mg/day. Radioactive iodine uptake was less than 2% after 7 days and remained below 2% in all subjects at 90 days. Mean serum T4 and T3 declined after 7 days. T4 remained below baseline, whereas T3 had recovered by the end of the treatment period. Serum TSH and the TSH response to TRH rose significantly after 7 days and remained elevated at 3 months. The average thyroid volume, determined by ultrasound, increased by 37%. Neither hyperthyroidism nor hypothyroidism was observed. The mean thyroid volume in seven subjects available for repeat determinations an average of 7.1 months after the study was not different from the baseline value. In normal subjects, a reversible TSH-dependent thyroid enlargement occurs in response to the iodine load from daily use of tetraglycine hydroperiodide water purification tablets.

Effects of mild asymptomatic primary hyperparathyroidism on bone mass in women with and without estrogen replacement therapy

Primary hyperparathyroidism (HPT) presents most commonly as a mild elevation of the serum calcium concentration in an asymptomatic individual. There are conflicting data regarding the effects of mild primary HPT on bone mass. This cross-sectional study was conducted to examine this question further and to determine whether estrogen replacement therapy (ERT) in postmenopausal women with primary HPT might be beneficial. We measured bone mass in 59 women with mild asymptomatic primary HPT, of whom 43 (HPT) had never taken and 16 (estrogen-replaced HPT) were currently taking ERT. We also studied 84 healthy normocalcemic women who were not on ERT (controls) and 45 who were on ERT (estrogen-replaced controls). After adjustment for age, height, and weight, mean bone mass values in the HPT group were significantly reduced in the midradius (20%), distal radius (20%), lumbar spine (17%), and femoral neck (11%) compared with the controls. The estrogen-replaced HPT group had mean bone mass values greater than those in the HPT group, similar to those in the controls, and lower than those in the estrogen-replaced controls. Mild asymptomatic primary HPT results in bone loss from both the appendicular and axial skeleton, and ERT in postmenopausal women with primary HPT may ameliorate this loss.

The effect of low-dose methotrexate on bone metabolism and histomorphometry in rats

OBJECTIVE

To ascertain the effects of low-dose methotrexate (MTX) on bone metabolism and histomorphometry in rats.

METHODS

Female Sprague-Dawley rats (6 months old, n = 42) were divided into the following 4 groups: intraperitoneal (IP) injections of MTX, with and without ovariectomy, and IP saline (controls), with and without ovariectomy. Injections were given for 16 weeks. The MTX dose was equivalent to a standard dose for rheumatoid arthritis in humans that would yield similar serum MTX levels (0.6 +/- 0.1 mumoles).

RESULTS

Bone formation (assessed by serum alkaline phosphatase and osteocalcin levels and histomorphometry) was significantly lower in the MTX groups, and bone resorption (assessed by urinary hydroxyproline levels and histomorphometry) was increased in the MTX groups. Bone mass was significantly diminished in the MTX groups.

CONCLUSION

Prolonged administration of low-dose MTX in rats causes significant osteopenia via suppression of osteoblast activity and stimulation of osteoclast recruitment, which results in increased bone resorption.

An iodine load from water-purification tablets alters thyroid function in humans

Tablets containing tetraglycine hydroperiodide are used to purify small quantities of water for drinking. Because short-term administration of stable iodide can alter thyroid function in normal adults, we evaluated the effects of these tablets on thyroid function during a military field training exercise. Fourteen normal volunteers participated in the study. After an adjustment period of 2 weeks to the field environment, half of the subjects received four dissolved water-purification tablets (32 mg free iodine) daily for 7 consecutive days while the other half served as controls. At the end of the study the treatment group showed reductions in the mean serum levels of thyroxine (14%) and total triiodothyronine (15%) and significant increments in basal thyrotropin (TSH) (122%) and the TSH response to thyrotropin-releasing hormone (49%) compared to baseline values. The basal TSH level rose above the normal range in two subjects. No significant changes in any parameter of thyroid function were observed in the control subjects. One week of daily exposure to the iodine load from four tetraglycine hydroperiodide water-purification tablets causes mild impairment of thyroid function in humans.

Thyroid hormone resistance syndromes

The thyroid hormone resistance syndromes are disorders in which the body's tissues are resistant to the effects of thyroid hormone. Generalized resistance to thyroid hormone (GRTH) is characterized by resistance in the pituitary gland and in most or all of the peripheral tissues. Affected individuals have elevated serum thyroid hormone levels and inappropriately normal or elevated thyroid-stimulating hormone (TSH) but are usually clinically euthyroid and require no treatment. Selective pituitary resistance to thyroid hormone (PRTH) is characterized by resistance in the pituitary gland but not in peripheral tissues. Patients have elevated serum thyroid hormone levels and normal or elevated TSH levels and are clinically thyrotoxic. Therapy is usually necessary, but current choices are not completely satisfactory. Selective peripheral resistance to thyroid hormone (PerRTH) is characterized by resistance in peripheral tissues but not in the pituitary. The only patient thus far described had normal serum thyroid hormone and TSH levels but was clinically hypothyroid and improved with thyroid hormone administration. All of these disorders are probably more common than is generally recognized and are often misdiagnosed and inappropriately treated. GRTH, in most cases studied, results from a mutation in the thyroid hormone receptor beta gene causing an amino acid substitution in or a partial or complete deletion of the thyroid hormone-binding domain of the receptor. The causes of PRTH and PerRTH remain to be determined.

Endocrine profiles for outcome prediction from the intensive care unit

OBJECTIVE

To evaluate the discriminating ability of various specific endocrine studies on patient outcome from the intensive care unit (ICU).

DESIGN

Prospective cohort study of patients requiring intensive care.

SETTING

Adult medical and coronary care units in a military referral hospital.

PATIENTS

A total of 61 consecutive patients requiring intensive care over a 5-month period and 20 control subjects.

INTERVENTIONS

Patients were evaluated within 24 hrs of ICU admission (day 1) with determination of the following variables: serum triiodothyronine, thyroxine, triiodothyronine resin uptake, thyrotropin, luteinizing hormone, follicle-stimulating hormone, testosterone, basal cortisol, adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and Acute Physiology and Chronic Health Evaluation (APACHE II) score. A total of 24 hrs later (day 2), the same battery of tests was repeated with the exception of the adrenocorticotropic hormone-stimulated cortisol, cortisol increment, and APACHE II score. Individual variables were compared between survivors and nonsurvivors.

MEASUREMENTS AND MAIN RESULTS

The best discriminators of patient outcome in descending order were the basal serum cortisol and triiodothyronine concentrations obtained on day 2 and the APACHE II score with predictive abilities of 81%, 74%, and 70%, respectively. No combination of variables was superior to the day 2 basal cortisol concentration for discrimination of outcome.

CONCLUSIONS

The basal cortisol and triiodothyronine concentrations obtained from blood samples collected within 48 hrs of ICU admission appear to be better discriminators of patient outcome than the APACHE II score.

Familial hyperinsulinism presenting in adults

Two adult siblings presented with recurrent syncope due to severe hyperinsulinemic hypoglycemia. Exploratory laparotomy in the elder sibling showed a grossly normal pancreas, but histologic examination revealed islet cell hyperplasia. Neither sibling has any evidence of the multiple endocrine neoplasia type 1 syndrome, nor is there any other family history to suggest this diagnosis. To our knowledge, this is the first report of adult-onset familial hyperinsulinism without other manifestations of multiple endocrine neoplasia type 1 syndrome. A simple provocative test for hyperinsulinism was also suggested by these cases. Because the initial patient related his symptoms to exercise, we used treadmill exercise in both patients to diagnose hyperinsulinism and observe its response to therapy.

Reduced bone-mineral content is a risk factor for hip fractures

To evaluate skeletal osteopenia as a risk factor for hip fractures, we measured bone-mineral content in 18 postmenopausal women (aged 50 to 85 years) within 5 days of sustaining a nontraumatic hip fracture. We compared these findings to those in 50 women without a hip fracture who were matched for age, postmenopausal years, height, and weight to the study participants. With the use of dual-photon absorptiometry, the hip fracture patients were found to have a significantly reduced mean bone-mineral content (P less than .005) at three sites in the unaffected hip and a marginally lower mean value (P less than .057) in the lumbar spine as compared to the controls. Other findings in the fracture group included a history of little physical activity, diminished visual acuity, and a somewhat high prevalence of psychiatric/organic brain disorders. Reduced bone mass is an important risk factor for hip fractures. However, other conditions such as physical inactivity, reduced visual acuity, and cognitive impairment may also affect the tendency to fall and/or the ability to cushion the impact of a fall and thus further increase the risk of fracture occurrence.

Crossover comparison of maximum dose glyburide and glipizide

Patients with non-insulin-dependent diabetes mellitus (NIDDM) failing to respond to therapy with a maximum dose of glyburide (GB) or glipizide (GZ) are often given a trial of the alternate second-generation sulfonylurea (SGS) before insulin therapy is considered. The efficacy of this therapeutic maneuver has not been thoroughly tested. We studied 26 subjects with fasting serum glucose (FSG) levels greater than 8.3 mmol/L (150 mg/dL) despite maximum doses of either GB (20 mg/day) or GZ (40 mg/day). Group 1 consisted of 16 subjects taking GB (mean FSG = 12.7 mmol/L [228 mg/dL]) and group 2 included 10 subjects taking GZ (mean FSG = 13.0 mmol/L [234 mg/dL]). Subjects continued taking their original SGS for 8 weeks then switched to a maximum dose of the alternate agent for an additional 8 weeks. Values for FSG, hemoglobin A1c, and lipids were recorded before the study and after 8 weeks on each SGS trial. No significant changes were noted for any variable in either group. When maximum dose GB therapy was compared to maximum dose GZ therapy in the combined study group (n = 26), no advantage was noted for either agent. We conclude that metabolic control in NIDDM patients failing to respond to therapy with maximum dose GB or GZ is not improved by switching to the alternate SGS.

Tamoxifen therapy for painful idiopathic gynecomastia

We have evaluated the efficacy of the antiestrogen tamoxifen in six men with painful idiopathic gynecomastia. Subjects were given either tamoxifen or placebo for 2 to 4 months and then were given the other agent for an identical period. Breast size was considered to have been reduced only if it had decreased by one or more Marshall-Tanner stages during the treatment period. Pain reduction with tamoxifen therapy was statistically significant for the group, occurring in five of six subjects during tamoxifen treatment and in only one of six during the placebo period. Size reduction with tamoxifen was only marginally significant for the entire group, but occurred in all three subjects who were initially in Marshall-Tanner stage III and in none of the three subjects who were initially in stage V. During tamoxifen treatment, there was a significant increase in the serum levels of luteinizing hormone and total estradiol and a marginally significant increment in the total testosterone level.

Antideoxyribonucleic acid antibodies in Graves' disease

Antidouble stranded DNA (dsDNA) antibodies have been detected by a sensitive RIA in the sera of 28-100% of patients with Graves' disease, but it remains unclear whether these assays have detected authentic dsDNA antibodies. We have obtained sera from 42 patients with active Graves' disease and no known connective tissue disorders. All sera were tested for dsDNA antibodies by 2 quantitative RIAs (Farr assay and Millipore filter assay; normal, less than 20% for both assays) and by an enzyme-linked immunosorbant assay for antibodies to dsDNA and to single stranded DNA (ssDNA). All sera were negative for dsDNA antibodies by the Farr assay and by enzyme-linked immunosorbant assay, 2 of 42 had mildly elevated levels (33% and 23%) by the Millipore filter assay, and 7 of 42 were positive for ssDNA antibodies. The 2 positive sera for dsDNA antibodies were also tested using the Crithidia luciliae indirect immunofluorescence assay, and both were negative. Patients with Graves' disease have been reported to have an increased prevalence of antinuclear antibodies, but the more recent findings of dsDNA antibodies in these patients is of interest because dsDNA antibodies are considered to be specific for systemic lupus erythematosus. Our data suggest that true immunoglobulin G dsDNA antibodies are not elevated during active Graves' disease, and positive assay results may be due to measurement of ssDNA antibodies, immunoglobulin M dsDNA antibodies, or nonantibody DNA binding.

Effects of a continuous thyrotropin-releasing hormone infusion on gonadotropin-releasing hormone-stimulated gonadotropin secretion

We examined the effects of elevated thyrotropin-releasing hormone (TRH) levels on the gonadotropin response to gonadotropin-releasing hormone (GnRH) in 16 healthy men. A TRH infusion, which was begun 15 minutes before and continued for 120 minutes after the bolus administration of GnRH, was compared with a saline infusion. During the TRH infusion the gonadotropin responses to acute GnRH stimulation were higher than in the saline control period but, although statistically significant, the differences were small in magnitude and were similar to the intraindividual coefficient of variation in gonadotropin responses determined under control conditions. They did not appear to be of clinical significance. TRH significantly lengthened the interval between GnRH administration and the appearance of peak gonadotropin levels. These results indicate that a brief TRH infusion, producing mild elevations of thyrotropin and prolactin, causes slight alterations predominantly in the timing of GnRH-stimulated gonadotropin secretion.

Effect of theophylline on calcium metabolism and circulating vitamin D metabolites

Theophylline has been shown to induce the hepatic microsomal enzyme system. These same enzymes increase the metabolism of vitamin D and 25-hydroxyvitamin D when induced by chronic barbiturate or phenytoin administration. To assess the long-term effects of theophylline on vitamin D and calcium metabolism, young rats were treated for 4 weeks with constant subcutaneous theophylline infusions. Theophylline-treated animals had a significantly increased urinary calcium excretion (p less than 0.0001), a significantly decreased total body calcium per gram body weight (p less than 0.05), and significantly decreased serum 25-hydroxy-vitamin D concentrations (p less than 0.002) when compared to control animals. These alterations in the concentration of 25-hydroxyvitamin D may impair the ability to increase 1,25-dihydroxyvitamin D-dependent intestinal calcium absorption to compensate for excessive urinary calcium losses. These data suggest that theophylline promotes skeletal calcium loss, and its use may be a risk factor for the development of osteopenia in humans.

The effects of theophylline and nifedipine on corticotropin-stimulated cortisol secretion

The adrenal cortisol response to corticotropin appears to involve both calcium and cyclic adenosine 3',5'-monophosphate (cAMP) as intracellular mediators. In 10 healthy male volunteers, the short-term administration of theophylline, which affects both intracellular calcium and cAMP, lowered basal cortisol levels but augmented the in vivo cortisol response to short-term corticotropin stimulation. Short-term administration of nifedipine, a calcium channel antagonist, had no effect on basal or peak cortisol levels but reduced the incremental cortisol response to corticotropin. The effects of both theophylline and nifedipine, although statistically significant, were modest and of questionable clinical significance but should be considered in the interpretation of the clinical corticotropin stimulation test. They may also provide some insight into the post-receptor actions of corticotropin.

Effect of hypophysectomy and growth hormone administration on hypothalamic growth hormone-releasing hormone and somatostatin content: relationship to age-related growth rate

The purpose of these studies was to evaluate the effect of age-related differences in growth rate on the hypothalamic content of growth hormone-releasing factor (GHRH) and somatostatin (SS) and on the short loop feedback regulation of GHRH and SS. Percent weight gain, GHRH content, and SS content in control adolescent (8 weeks) and adult rats (6 months) were compared in normal rats administered supraphysiologic amounts of rat growth hormone (rGH) or in hypophysectomized rats receiving thyroxine and corticosterone with or without physiologic rGH replacement. In control adolescent rats, the rate of weight gain was 5-fold higher than in adult rats. GHRH content was higher in adolescent rats, while SS content was lower. After the administration of supraphysiologic amounts of rGH, GHRH content increased in adolescent rats but did not change in adult rats. SS content was unchanged in either age group. Following hypophysectomy GHRH content declined similarly in both groups, whereas the decrease in SS content was greater in adolescent rats. With replacement rGH, weight gain was restored, GHRH content increased but not fully to control, and SS content did not change. The ratio of SS content to GHRH content (SS/GHRH) was higher in control adult rats than in adolescent rats. SS/GHRH increased following hypophysectomy and returned to control values by rGH replacement. We conclude that age-related differences in growth rate are accompanied by appropriate changes in SS/GHRH and that SS and GHRH are regulated by short loop feedback at both ages with increased responses in adolescent rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Evidence of endocrine involvement early in the course of human immunodeficiency virus infection

Adrenal, gonadal, and thyroid function were assessed in 40 asymptomatic subjects in whom infection with the human immunodeficiency virus (HIV) had recently been documented. None of the patients had historical or clinical evidence of endocrine dysfunction. Their mean serum hormone levels were also within the expected ranges, but several differences were noted compared to those of seronegative controls. Basal cortisol, basal aldosterone, and ACTH-stimulated cortisol were significantly lower in the HIV group. One subject (2.5%) had a subnormal cortisol response, and two (5%) had abnormal aldosterone responses to ACTH. PRA tended to be higher, and serum angiotensin-converting enzyme levels somewhat lower in the HIV group. Serum free testosterone was markedly elevated in the HIV patients and was associated with an exaggerated LH response to GnRH, but PRL, estradiol, and basal and peak GnRH-stimulated FSH did not differ between groups. Three subjects (8%) had subclinical hypothyroidism. Serum thyroid hormone levels were normal, but basal T3 was lower in the HIV group compared to control values. While of little immediate clinical importance, many subtle endocrine aberrations are evident very early in the course of HIV infection. These findings obtained in HIV-seropositive subjects without infections or tumors and who were not receiving medical therapy suggest an effect of HIV on each of the endocrine systems examined.

Massive extracapsular hemorrhage from a parathyroid cyst

A 32-year-old man had a giant cervical mass, dysphagia, dyspnea, and severe hypercalcemia. A computed tomographic scan showed the mass to extend from the left mandible to the level of the aortic arch. Exploratory surgery of the neck revealed a ruptured parathyroid cyst complicated by massive hemorrhage into the cervical tissues and mediastinum. The postoperative course was uncomplicated with prompt resolution of the hypercalcemia. Although a rare occurrence, extracapsular parathyroid hemorrhage should be considered in the differential diagnosis of all rapidly evolving cervical and mediastinal masses, especially when hypercalcemia is present.

Bone mineral content in smokers

We did a cross-sectional evaluation of the effect of heavy cigarette smoking on bone mass using single photon absorptiometry (SPA) of the radius in 35 smokers (24 women, 11 men) and 35 nonsmokers (24 women, 11 men). Individuals from the two groups were carefully matched for sex, age, weight, height, calcium intake, and, for women, menopausal history and estrogen use. We found no differences between smokers and nonsmokers at the middle or distal portion of the radius. This suggests that smoking has no direct effect on appendicular bone mass; however, it may still influence bone loss indirectly through effects on other factors such as age at menopause, body weight, diet, and possibly physical activity.

The role of calcitonin in the development and treatment of osteoporosis

CT is a peptide hormone produced predominantly by thyroid C cells and probably to a lesser extent by extrathyroidal tissues. Although its physiological function has not yet been established, it is a pharmacological inhibitor of osteoclastic bone resorption. There is currently no convincing evidence that naturally occurring or iatrogenic CT deficiency is involved in the pathogenesis of osteoporosis; however, a selective examination of patients with various rates of bone turnover would help to resolve this issue. As a pharmacological inhibitor of bone resorption, CT has potential usefulness in the therapy of osteoporosis. CT has been shown to stabilize or modestly increase indices of cortical and trabecular bone mass and total body calcium when administered to patients with established osteoporosis for periods of 1-2 yr. The increments in bone mass seen in some studies appear to be transient and are likely due to reductions in bone resorption with bone formation remaining unaffected until remodeling spaces are filled. The duration and magnitude of these increases are probably limited by the eventual decline in bone formation as remodeling equilibrium is reestablished. Therefore, reduction in the rate of bone loss with maintenance of the existing skeletal mass, rather than significant sustained increases in bone mass, should be considered the most realistic therapeutic goal with this agent. Whether or not a reduction in the rate of bone loss persists for longer periods needs further evaluation as does the important issue of subsequent fracture rates. The identification of patients with increased bone resorption rates (high turnover osteoporosis) should help provide a basis for more selective treatment of those patients who would be most likely to respond to this form of therapy. Whether there is additional benefit to using intermittent CT concurrently or sequentially with bone formation stimulating agents (coherence therapy) also needs to be explored. CT may also be of benefit in the prevention of osteoporosis, particularly in postmenopausal women who are unable or unwilling to take estrogen replacement. These potential benefits must be weighed carefully against the current cost of CT and the inconvenience of it having to be given by injection, problems which should be solved by future research.

Influence of testosterone on breathing during sleep

Apneas and hypopneas during sleep occur more frequently in men than women. Disordered breathing is also reported to increase in hypogonadal men following testosterone administration. This suggests a hormonal influence on sleeping respiratory pattern. We therefore studied respiratory rhythm during sleep in 11 hypogonadal males both on and off testosterone-replacement therapy. In four subjects the anatomy (computerized tomography) and airflow resistance of the upper airway were also determined on both occasions. Sleep stage distribution and duration were unchanged following androgen administration. However, both apneas and hypopneas increased significantly during testosterone replacement so that the total number of disordered breathing events (apneas + hypopneas) per hour of sleep rose from 6.4 +/- 2.1 to 15.4 +/- 7.0 (P less than 0.05). This was a highly variable event with some subjects demonstrating large increases in apneas and hypopneas when androgen was replaced, whereas others had little change in respiration during sleep. Upper airway dimensions, on the other hand, were unaffected by testosterone. These results suggest that testosterone contributes to sleep-disordered breathing through mechanisms independent of anatomic changes in the upper airway.

Lithium-associated thyrotoxicosis

Primary hypothyroidism developed in a 57-year-old woman treated for eight years with lithium carbonate for manic-depressive illness, and nine months later she became thyrotoxic. Although autoimmune disease appeared to be responsible, lithium was suspected to play a contributory role in both phases of her illness. This is the first reported case of hyperthyroidism following hypothyroidism in a lithium-treated patient. The 24 reported cases of lithium-associated thyrotoxicosis and the possible mechanisms that may explain this poorly understood phenomenon are also reviewed.

Hyperthyroidism following hypothyroidism

Two patients are presented who developed autonomous thyrotoxicosis following a diagnosis of primary hypothyroidism. In one of these patients, antibodies to the TSH receptor were typical of Graves' disease when measured as thyrotropin binding inhibitor immunoglobulins (TBII) and as human thyroid adenylate cyclase stimulating (HTACS) activity, while a needle biopsy of the thyroid gland was consistent with lymphocytic thyroiditis. Twenty-one other reported cases of this unusual sequence found in the literature are reviewed. This occurrence is more common than is generally appreciated.

Glucose tolerance in granuloma annulare

Granuloma annulare (GA) may be associated with glucose intolerance. Twenty-one patients with GA were evaluated. Four patients were found to have frank diabetes mellitus and 2 were excluded from the data analysis because of obesity. The remaining patients and 14 age- and weight-matched controls had oral and intravenous glucose tolerance tests (GTT). During the oral GTT the fasting plasma glucose, the 2-h plasma glucose, the area of the glucose curve, the 1-h serum insulin, and the area of the insulin curve were all significantly greater in the GA patients than in the controls. During the intravenous GTT the immediately releasable insulin pool was intact, while the fasting plasma glucose and the area of the glucose curve were greater in the GA patients than in the controls. The data taken together suggest that glucose tolerance may be reduced in GA and that insulin resistance may exist.