1
|
Detomas M, Deutschbein T, Tamburello M, Chifu I, Kimpel O, Sbiera S, Kroiss M, Fassnacht M, Altieri B. Erythropoiesis in Cushing syndrome: sex-related and subtype-specific differences. Results from a monocentric study. J Endocrinol Invest 2024; 47:101-113. [PMID: 37314685 PMCID: PMC10776705 DOI: 10.1007/s40618-023-02128-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
CONTEXT Cushing syndrome (CS) is associated with different hematological abnormalities. Nevertheless, conflicting data about erythropoiesis in CS have been reported. Furthermore, it is unclear whether CS sex and subtype-specific alterations in red blood cells (RBC) parameters are present. OBJECTIVE To investigate sex and subtype-specific changes in RBC in patients with CS at initial diagnosis and after remission. DESIGN Retrospective, monocentric study including 210 patients with CS (women, n = 162) matched 1:1 for sex and age to patients with pituitary microadenomas or adrenal incidentalomas (both hormonally inactive). RBC parameters were evaluated at initial diagnosis and after remission. RESULTS Women with CS had higher hematocrit (median 42.2 vs 39.7%), hemoglobin (14.1 vs 13.4 g/dl) and mean corpuscular volume (MCV) (91.2 vs 87.9 fl) compared to the controls (all p < 0.0001). Women with Cushing disease (CD) showed higher hematocrit, RBC and hemoglobin levels than those with ectopic Cushing (ECS) (all p < 0.005). Men with CS had lower hematocrit (42.9 vs 44.7%), RBC count (4.8 vs 5.1n*106/µl) and hemoglobin (14.2 vs 15.4 g/dl), but higher MCV (90.8 vs 87.5 fl) than controls (all p < 0.05). In men with CS, no subtype-specific differences were identified. Three months after remission hemoglobin decreased in both sexes. CONCLUSION CS is characterized by sexual and subtype-specific differences in RBC parameters. Compared to controls, women with CS showed higher hematocrit/hemoglobin levels, whereas men had lower hematocrit/hemoglobin, which further decreased directly after remission. Therefore, anemia should be considered as complication of CS in men. In women, differences in RBC parameters may help to differentiate CD from ECS.
Collapse
Affiliation(s)
- M Detomas
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| | - T Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Medicover Oldenburg MVZ, Oldenburg, Germany
| | - M Tamburello
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Section of Pharmacology, Department of Molecular and Translational Medicine, University of Brescia, 25124, Brescia, Italy
| | - I Chifu
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - O Kimpel
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - S Sbiera
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - M Kroiss
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Department of Internal Medicine IV, University Hospital Munich, Ludwig-Maximilians-Universität München, Munich, Germany
| | - M Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Central Laboratory, University Hospital Würzburg, Würzburg, Germany
| | - B Altieri
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| |
Collapse
|
2
|
Costello HM, Krilis G, Grenier C, Severs D, Czopek A, Ivy JR, Nixon M, Holmes MC, Livingstone DEW, Hoorn EJ, Dhaun N, Bailey MA. High salt intake activates the hypothalamic-pituitary-adrenal axis, amplifies the stress response, and alters tissue glucocorticoid exposure in mice. Cardiovasc Res 2023; 119:1740-1750. [PMID: 36368681 PMCID: PMC10325699 DOI: 10.1093/cvr/cvac160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 09/09/2022] [Accepted: 09/24/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS High salt intake is common and contributes to poor cardiovascular health. Urinary sodium excretion correlates directly with glucocorticoid excretion in humans and experimental animals. We hypothesized that high salt intake activates the hypothalamic-pituitary-adrenal axis activation and leads to sustained glucocorticoid excess. METHODS AND RESULTS In male C57BL/6 mice, high salt intake for 2-8 weeks caused an increase in diurnal peak levels of plasma corticosterone. After 2 weeks, high salt increased Crh and Pomc mRNA abundance in the hypothalamus and anterior pituitary, consistent with basal hypothalamic-pituitary-adrenal axis activation. Additionally, high salt intake amplified glucocorticoid response to restraint stress, indicative of enhanced axis sensitivity. The binding capacity of Corticosteroid-Binding Globulin was reduced and its encoding mRNA downregulated in the liver. In the hippocampus and anterior pituitary, Fkbp5 mRNA levels were increased, indicating increased glucocorticoid exposure. The mRNA expression of the glucocorticoid-regenerating enzyme, 11β-hydroxysteroid dehydrogenase Type 1, was increased in these brain areas and in the liver. Sustained high salt intake activated a water conservation response by the kidney, increasing plasma levels of the vasopressin surrogate, copeptin. Increased mRNA abundance of Tonebp and Avpr1b in the anterior pituitary suggested that vasopressin signalling contributes to hypothalamic-pituitary-adrenal axis activation by high salt diet. CONCLUSION Chronic high salt intake amplifies basal and stress-induced glucocorticoid levels and resets glucocorticoid biology centrally, peripherally and within cells.
Collapse
Affiliation(s)
- Hannah M Costello
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Georgios Krilis
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Celine Grenier
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - David Severs
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Alicja Czopek
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Jessica R Ivy
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Mark Nixon
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Megan C Holmes
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Dawn E W Livingstone
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Ewout J Hoorn
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Neeraj Dhaun
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| | - Matthew A Bailey
- Edinburgh Kidney, British Heart Foundation Centre for Cardiovascular Science, The Universtiy of Edinburgh, Edinburgh, EH16 4TJ, United Kingdom
| |
Collapse
|
3
|
Martín FM, Alzamendi A, Harnichar AE, Castrogiovanni D, Zubiría MG, Spinedi E, Giovambattista A. Role of glucocorticoid receptor (GR) in white adipose tissue beiging. Life Sci 2023; 322:121681. [PMID: 37040814 DOI: 10.1016/j.lfs.2023.121681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 01/27/2023] [Accepted: 04/04/2023] [Indexed: 04/13/2023]
Abstract
AIM Glucocorticoids (GCs) play a crucial role in energy homeostasis including white adipose tissue function; however, chronic GC excess is detrimental to mammals' health. White hypertrophic adiposity is a main factor for neuroendocrine-metabolic dysfunctions in monosodium L-glutamate (MSG)-damaged hypercorticosteronemic rat. Nevertheless, little is known about the receptor path in endogenous GC impact on white adipose tissue-resident precursor cells to bring them into beige lineage. Thus, our aim was to explore whether transient/chronic endogenous hypercorticosteronemia affects browning capacity in white adipose tissue pads from MSG rats during development. MAIN METHODS Control and MSG male rats aged 30 and 90 days were 7-day exposed to cold conditions in order to stimulate wet white epidydimal adipose tissue (wEAT) beiging capacity. This procedure was also replicated in adrenalectomized rats. KEY FINDINGS Data indicated that whereas epidydimal white adipose tissue pads from prepubertal hypercorticosteronemic rats retained full expression of GR/MR genes resulting in a drastic reduction in wEAT beiging capacity, conversely, chronic hypercorticosteronemic adult MSG rats developed down-regulation of corticoid genes (and reduced GR cytosolic mediators) in wEAT pads and consequently partially restored local beiging capacity. Finally, wEAT pads from adrenalectomized rats revealed up-regulation of GR gene accompanied by full local beiging capacity. SIGNIFICANCE This study strongly supports a GR-dependent inhibitory effect of GC excess on white adipose tissue browning, an issue strongly supporting a key role of GR in the non-shivering thermogenic process. As a consequence, normalizing the GC milieu could be a relevant factor to handle dysmetabolism in white hyperadipose phenotypes.
Collapse
Affiliation(s)
- Florencia M Martín
- Centro de Endocrinología Experimental y Aplicada (CENEXA, UNLP-CONICET-CICPBA-CA), Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 1900 La Plata, Argentina; Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| | - Ana Alzamendi
- Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| | - Alejandro E Harnichar
- Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| | - Daniel Castrogiovanni
- Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| | - María Guillermina Zubiría
- Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| | - Eduardo Spinedi
- Centro de Endocrinología Experimental y Aplicada (CENEXA, UNLP-CONICET-CICPBA-CA), Facultad de Ciencias Médicas, Universidad Nacional de La Plata, 1900 La Plata, Argentina.
| | - Andrés Giovambattista
- Laboratorio de Neuroendocrinología, Instituto Multidisciplinario de Biología Celular (IMBICE, CICPBA-CONICET-UNLP), 1900 La Plata, Argentina
| |
Collapse
|
4
|
Ehrlich K, Morbach C, Reiter T, Heuschmann PU, Hannemann A, Fassnacht M, Störk S, Hahner S, Deutschbein T. Rationale and design of the cardiovascular status in patients with endogenous cortisol excess study (CV-CORT-EX): a prospective non-interventional follow-up study. BMC Endocr Disord 2021; 21:11. [PMID: 33419423 PMCID: PMC7791745 DOI: 10.1186/s12902-020-00665-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 12/11/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Endogenous Cushing's syndrome (CS) results in increased cardiovascular (CV) morbidity and mortality. So far, most studies focussed on distinct disease entities rather than the integrity of the CV system. We here describe the design of the Cardiovascular Status in Endogenous Cortisol Excess Study (CV-CORT-EX), a study aiming to comprehensively investigate the health status of patients with endogenous CS (with a particular focus on CV phenotypes, biochemical aspects, quality of life, and psychosocial status). METHOD A prospective non-interventional cohort study performed at a German tertiary referral centre. At the time of enrolment, patients will be categorised as: (1) newly diagnosed overt CS, (2) recurrent overt CS, (3) CS in remission, (4) presence of mild autonomous cortisol excess (MACE). The target cohorts will be n = 40 (groups 1 + 2), n = 80 (group 3), and n = 20 (group 4). Patients with overt CS at the time of enrolment will be followed for 12 months after remission (with re-evaluations after 6 and 12 months). At each visit, patients will undergo transthoracic echocardiography, cardiac magnetic resonance imaging, 24-h electrocardiogram, 24-h blood pressure measurement, and indirect evaluation of endothelial function. Furthermore, a standardised clinical investigation, an extensive biochemical workup, and a detailed assessment of quality of life and psychosocial status will be applied. Study results (e.g. cardiac morphology and function according to transthoracic echocardiography and cardiac magnetic resonance imaging; e.g. prevalence of CV risk factors) from patients with CS will be compared with matched controls without CS derived from two German population-based studies. DISCUSSION CV-CORT-EX is designed to provide a comprehensive overview of the health status of patients with endogenous CS, mainly focussing on CV aspects, and the holistic changes following remission. TRAIL REGISTRATION ClinicalTrials.gov ( https://clinicaltrials.gov/ ) NCT03880513, registration date: 19 March 2019 (retrospectively registered). Protocol Date: 28 March 2014, Version 2.
Collapse
Affiliation(s)
- Kristina Ehrlich
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Caroline Morbach
- Department of Internal Medicine I, Division of Cardiology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Academic Core Lab Ultrasound-based Cardiovascular Imaging, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Theresa Reiter
- Department of Internal Medicine I, Division of Cardiology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Peter Ulrich Heuschmann
- Clinical Trial Centre, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany
| | - Anke Hannemann
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany
- German Centre for Cardiovascular Research DZHK, Partner Site Greifswald, University Medicine Greifswald, Greifswald, Germany
| | - Martin Fassnacht
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Stefan Störk
- Department of Internal Medicine I, Division of Cardiology, University Hospital Würzburg, University of Würzburg, Würzburg, Germany
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, University of Würzburg, Würzburg, Germany
| | - Stefanie Hahner
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany
| | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital Würzburg, University of Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
- Medicover Oldenburg MVZ, Oldenburg, Germany.
| |
Collapse
|
5
|
Abstract
The metabolic syndrome describes a clustering of risk factors—visceral obesity, dyslipidaemia, insulin resistance, and salt-sensitive hypertension—that increases mortality related to cardiovascular disease, type 2 diabetes, cancer, and non-alcoholic fatty liver disease. The prevalence of these concurrent comorbidities is ~ 25–30% worldwide, and metabolic syndrome therefore presents a significant global public health burden. Evidence from clinical and preclinical studies indicates that glucocorticoid excess is a key causal feature of metabolic syndrome. This is not increased systemic in circulating cortisol, rather increased bioavailability of active glucocorticoids within tissues. This review examines the role of covert glucocorticoid excess on the hypertension of the metabolic syndrome. Here, the role of the 11β-hydroxysteroid dehydrogenase enzymes, which exert intracrine and paracrine control over glucocorticoid signalling, is examined. 11βHSD1 amplifies glucocorticoid action in cells and contributes to hypertension through direct and indirect effects on the kidney and vasculature. The deactivation of glucocorticoid by 11βHSD2 controls ligand access to glucocorticoid and mineralocorticoid receptors: loss of function promotes salt retention and hypertension. As for hypertension in general, high blood pressure in the metabolic syndrome reflects a complex interaction between multiple systems. The clear association between high dietary salt, glucocorticoid production, and metabolic disorders has major relevance for human health and warrants systematic evaluation.
Collapse
Affiliation(s)
- Matthew A Bailey
- The British Heart Foundation Centre for Cardiovascular Science, The University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
| |
Collapse
|
6
|
Baroni MG, Giorgino F, Pezzino V, Scaroni C, Avogaro A. Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly. J Endocrinol Invest 2016; 39:235-55. [PMID: 26718207 DOI: 10.1007/s40618-015-0404-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 10/27/2015] [Indexed: 12/27/2022]
Abstract
Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce-and regularly update-conflicts of interest. The authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.
Collapse
Affiliation(s)
- M G Baroni
- Endocrinology and Diabetes, Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - F Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - V Pezzino
- Endocrinology, Department of Clinical and Molecular Bio-Medicine, Cannizzaro Hospital, University of Catania, Catania, Italy
| | - C Scaroni
- Section of Endocrinology, Department of Medicine, University of Padova, Padua, Italy
| | - A Avogaro
- Section of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani, 2, 3128, Padua, Italy.
| |
Collapse
|
7
|
Baroni MG, Giorgino F, Pezzino V, Scaroni C, Avogaro A. Italian Society for the Study of Diabetes (SID)/Italian Endocrinological Society (SIE) guidelines on the treatment of hyperglycemia in Cushing's syndrome and acromegaly. Nutr Metab Cardiovasc Dis 2016; 26:85-102. [PMID: 26905474 DOI: 10.1016/j.numecd.2016.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Hyperglycemia is a common feature associated with states of increased growth hormone secretion and glucocorticoid levels. AIMS The purpose of these guidelines is to assist clinicians and other health care providers to take evidence-based therapeutic decisions for the treatment of hyperglycemia in patients with growth hormone and corticosteroid excess. METHODOLOGY Both the SID and SIE appointed members to represent each society and to collaborate in Guidelines writing. Members were chosen for their specific knowledge in the field. Each member agreed to produce--and regularly update--conflicts of interest. The Authors of these guidelines prepared their contributions following the recommendations for the development of Guidelines, using the standard classes of recommendation shown below. All members of the writing committee provided editing and systematic review of each part of the manuscript, and discussed the grading of evidence. Consensus was guided by a systematic review of all available trials and by interactive discussions.
Collapse
Affiliation(s)
- M G Baroni
- Endocrinology and Diabetes, Department of Experimental Medicine, Sapienza University of Rome, Italy
| | - F Giorgino
- Section of Internal Medicine, Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Italy
| | - V Pezzino
- Endocrinology, Department of Clinical and Molecular Bio-Medicine, Cannizzaro Hospital, University of Catania, Italy
| | - C Scaroni
- Section of Endocrinology, Department of Medicine, University of Padova, Italy
| | - A Avogaro
- Section of Metabolic Diseases, Department of Medicine, University of Padova, Italy.
| |
Collapse
|