To explore the potential effect of dose schedule on the adrenal suppressive action of hydrocortisone in congenital adrenal hyperplasia, eight patients (six with 21-hydroxylase deficiency and two with 11-hydroxylase deficiency) were given five different dose schedules. Two of the schedules used single daily doses (morning or evening), two twice daily doses (two-thirds dose in the morning or evening), one and three equal doses at morning, noon, and night. Each dose schedule used the same total daily hydrocortisone dose (12.5 mg/m2/day), which is within the normal range of hydrocortisone production rate. Each schedule was given for 4 to 6 weeks. The different dose schedules caused the predicted alterations in the temporal pattern of adrenal steroid levels, with the greatest apparent suppression during the 2 to 4 hours after each dose. None of the schedules, however, caused significant differences in the mean 24-hour plasma concentration of <em>17</em>-hydroxyprogesterone (21-hydroxylase deficiency) or 11-deoxycortisol (11-hydroxylase deficiency) or in the 24-hour urine pregnanetriol or <em>17</em>-<em>ketosteroid</em> concentrations, either in the six patients undertreated at the dose of 12.5 mg/m2/day or in the two patients adequately treated. Nocturnal administration of all or a part of the daily dose did not improve adrenal suppression. These observations suggest that treatment of congenital adrenal hyperplasia with a once-a-day hydrocortisone dose schedule may be as effective as conventional multiple-dose schedules. Until this hypothesis has been tested by more extended clinical studies, however, we do not recommend a once-a-day schedule. Regardless of the dose schedule, the total daily hydrocortisone dose must be adjusted to achieve a normal rate of growth and bone age advancement.

Biological cycles with relatively long and some unusual periods in the range of the half-week, the half-year, years, or decades are being discovered. Their prior neglect constituted a confounder in aging and much other research, which then"flew blind" concerning the uncertainties associated with these cycles when they are not assessed. The resolution of more about 10-year and other cycles, some reported herein, replaces the admission of complete unpredictability, implied by using the label "secularity." Heretofore unaccounted-for variability becomes predictable insofar as it proves to be rhythmic and is mapped systematically to serve as a battery of useful reference values. About 10-year cycles in urinary <em>17</em>-<em>ketosteroid</em> excretion and in heart rate and its variability, among others, are aligned with cycles of similar length in mortality from myocardial infarction. Associations accumulate between cycles of natural physical time structures, chronomes such as the 10.5-year (circadecennian) Schwabe and the 21-year (circavigintunennian) Hale cycles of solar activity, and chronomes in biota. There are about 50-year (circasemicentennian) cycles in mortality from stroke in Minnesota and in the Czech Republic and also in human morphology at birth, the latter result reducing the likelihood that these cycles are purely human made. Associations among large populations warrant long-term systematic coordinated sampling of natural physical and biological variables of interest for the design of countermeasures against already documented elevated risks of stroke, myocardial infarction, and other catastrophic diseases, notably in elderly adults. New findings will be introduced against the background of the documented value of mapping rhythms in medicine and gerontology. In both these fields, rhythms promise the seeming paradox of better care for less.

Anticoagulant-related adrenal hemorrhage, as a cause of adrenal insufficiency, is rarely suspected and diagnosed during life. We report three patients in whom prompt diagnosis allowed successful treatment with replacement doses of corticosteroids. In all three patients, a hypotensive episode preceded the signs and symptoms of acute adrenal insufficiency. The symptoms and signs of adrenal hemorrhage were nonspecific and variable, making clinical diagnosis difficult. In none of our patients was the prothrombin time, partial thromboplastin time, or Lee White clotting time prolonged beyond the therapeutic range, and in none were excessive doses of anticoagulant therapy employed. Characteristic serum chemistry abnormalities, serum ACTH stimulation tests, and daily urinary collections for free cortisol, <em>17</em>-OH <em>ketosteroids</em>, and <em>17</em>-<em>ketosteroids</em> confirmed the clinical suspicion of primary adrenal insufficiency in all cases. Diagnosis was aided in one patient by abdominal computerized axial tomographic scan. In all patients, response to replacement doses of corticosteroids was prompt and gratifying, underlining the importance of suspecting this complication of anticoagulant therapy and instituting prompt lifesaving therapy. Adrenal hemorrhage is a complication of anticoagulant therapy that has been diagnosed during life in only 11 reported cases. We describe three patients in whom early diagnosis allowed prompt medical therapy and favorable outcome. The clinical presentation, diagnostic laboratory features, and therapeutic modalities are reviewed. Prolongation of prothrombin time, high levels of stress, and hypotension predispose to this complication in a patient maintained on anticoagulant therapy.

A 76-year-old woman with virilization had menopausal levels of circulating LH and FSH, and a markedly elevated concentration of plasma testosterone (9130 pg/ml) into the range for adult men. Plasma cortisol and androstenedione levels andurinary <em>17</em>-<em>ketosteroid</em> secretion were normal. Ethinyl estradiol suppressed plasma testosterone, LH, and FSH levels into the normal range for premenopausal women, but the testosterone concentration was unaffected by the administration of dexamethasone or ACTH. Retrograde venous sampling and angiography localized a right adrenal adenoma preoperatively. Following adrenalectomy, there was a prompt fall in testosterone, but there was no change in the LH concentration. Thus, this patient had an adrenal adenoma which secreted only testosterone and appeared to be gonadotropin-responsive. Testosterone levels in the adult male range failed to suppress gonadotropins. The significance of these findings is discussed.

To determine whether serum 3 alpha-androstanediol glucuronide (3AG) reflects the overall effect of integrated adrenal androgen secretion in the virilizing form of congenital adrenal hyperplasia (CVAH), circadian levels (0800, 1200, 1600, and 2000 h) of serum 3AG and <em>17</em>-hydroxyprogesterone (<em>17</em>OHP) or 11-deoxycortisol (S), androstenedione (A), testosterone (T), and 24-h urinary <em>17</em>-<em>ketosteroids</em> (<em>17</em>KS) were examined in seven patients (pts) with classical 21-hydroxylase deficiency (21OHD) and one pt with classical 11 beta-hydroxylase deficiency (11 beta OHD). Hormonal studies were conducted during the second day of dexamethasone (Dex) administration (2 mg/day). In five poorly controlled CVAH pts, including the 11 beta OHD pt, highly elevated baseline morning (AM) serum <em>17</em>OHP or S as well as A levels, and elevated AM T levels in three pts decreased markedly in the evening (PM), while elevated serum 3AG showed no significant circadian changes; <em>17</em>KS levels were markedly elevated for age. During Dex, moderately or slightly elevated AM <em>17</em>OHP, A, or T in two to four pts with 21OHD decreased to the normal range in the PM. In the pt with 11 beta OHD, S, A, and T levels were suppressed. 3AG levels were modestly elevated or normal, without circadian changes, in these pts; <em>17</em>KS levels were elevated or normal. In two other 21OHD pts, modestly elevated AM baseline <em>17</em>OHP and A levels decreased in the PM; elevated AM T decreased in one pt in the PM; modestly elevated 3AG levels showed no circadian changes; <em>17</em>KS levels were modestly elevated. During Dex, normal or slightly elevated serum steroids and <em>17</em>KS levels were associated with normal or high normal 3AG levels without circadian changes. In one postpubertal female with 21OHD, modestly elevated AM baseline <em>17</em>OHP levels decreased at 2000 h; normal A and T levels throughout the day and low normal <em>17</em>KS were associated with slightly low 3AG levels, without circadian variation. During Dex treatment, normal <em>17</em>OHP, A, T, and low <em>17</em>KS levels were associated with low 3AG levels without circadian variation. In all pts as a group, an excellent correlation (r = 0.9) was found between either 0800 h or mean, or 2000 h serum 3AG levels and <em>17</em>KS. In addition, AM and PM serum 3AG levels in five normal women were similar. We conclude that the high correlation between serum 3AG and urinary <em>17</em>KS and the absence of a significant circadian variation in 3AG indicate that serum 3AG, regardless of sample time, is a useful metabolic index of integrated adrenal androgen secretion in CVAH.

The adrenal gland requires a continuous supply of cholesterol for the biosynthesis of adrenal corticosteroids, which can be supplied by low density lipoprotein receptor-mediated uptake or local synthesis. The present study examined whether hypolipidemic therapy with a potent HMG CoA reductase inhibitor, simvastatin, compromises the adrenal response to ACTH stimulation in adult patients with heterozygous familial hypercholesterolemia. The adrenal response to a 36-h continuous ACTH infusion was determined at baseline and after 2 months of simvastatin treatment (40 mg, twice daily) in eight patients. Simvastatin reduced total and low density lipoprotein cholesterol levels by 36% and 45%, respectively. The time course of the increase in serum cortisol concentrations with continuous ACTH infusion was the same before and during simvastatin therapy, as were the rates of urinary excretion of free cortisol, <em>17</em>-hydroxycorticosteroids, and <em>17</em>-<em>ketosteroids</em>. Urinary excretion of mevalonate, which correlates with rates of whole body cholesterol synthesis, decreased from 3.8 +/- 0.42 (+/- SEM) mu,ol/24 h at baseline to 2.75 +/- 0.56 on simvastatin; no significant changes were seen in the urinary mevalonate levels before and after simvastatin therapy during ACTH stimulation. We conclude that the hypolipidemic effects of simvastatin in patients with heterozygous familial hypercholesterolemia are paralleled by a decrease in urinary mevalonate, but that the drug does not adversely affect ACTH-stimulated adrenal corticosteroid production.

We have tested the hypothesis that idiopathic hirsutism (IH) may be due to abnormality of androgen-responsive hair follicles. Because androgen metabolism within target cells is an important determinant of androgen action, we have analyzed the rates of formation and disposition of the major mediators of androgen action, testosterone (T) and dihydrotestosterone (DHT). In normal women, the pattern of androgen metabolism by growing hairs favors T predominance over DHT and inactivation of both these <em>17</em> beta-hydroxysteroids to <em>17</em>-<em>ketosteroids</em>. This pattern results greatly from predominance of <em>17</em> beta-hydroxysteroid dehydrogenation. For example, in normal women's scalp hair, DHT disposition to 5 alpha-androstanedione proceeded at the rate of 8.6 +/- 2.0 (SEM) %/micrograms DNA/min, whereas DHT was formed from T at a rate of 0.14 +/- 0.02, and T was formed from androstenedione at a rate of 0.60 +/- 0.12, all significantly different from one another. Both the formation of <em>17</em>-<em>ketosteroids</em> and the apparent 5 alpha-reductase activity were exaggerated in the pubic hair of men; whether these differences are site-, sex-, or androgen-related, remains to be determined. Pubic hairs tended to metabolize androgens at a greater rate than did scalp hair. This was related to the significantly greater DNA content of plucked pubic hairs, a difference unrelated to sex or androgen levels. Women with IH had heterogeneous pubic hair abnormalities. Only 1 of the 4 IH patients studied had abnormal pubic hair follicle androgen metabolism, with the greatest abnormality being an exaggerated rate of <em>17</em> beta-hydroxysteroid inactivation to <em>17</em>-<em>ketosteroids</em>. Two of the other 3 IH cases had increased DNA content of plucked pubic hairs, a different kind of exaggeration of normal, which suggests an abnormality of hair follicle growth unrelated to androgen sensitivity. We favor the concept that IH is related to various distinct types of sexual hair abnormalities which reflect fundamental defects in the regulation of hair growth.

A 46,XY phenotypically male patient with <em>17</em>-<em>ketosteroid</em> reductase deficiency is described. The patient was a 6-month-old infant who presented with micropenis and bilateral cryptorchidism. Baseline plasma levels of testosterone (T), delta 4-androstenedione (delta 4A), and 5 alpha-dihydrotestosterone (5 alpha-DHT) were within the normal range [patient: 0.<em>17</em> (T), 0.12 (delta 4A), and 0.032 (5 alpha-DHT) ng/ml; normal infants: 0.03-0.55 (T), 0.14-0.45 (delta 4A), and 0.01-0.23 (5 alpha-DHT) ng/ml]. hCG administration induced a significant rise in plasma delta 4A levels (up to 8.39 ng/ml) and a slight increase in T and 5 alpha-DHT levels. The delta 4A/T ratios before and during the hCG challenge were 0.86 and 55.61, respectively (controls: 0.83 and 0.13). Incubation of genital skin-derived fibroblasts from the patient with either [3H]T or [3H] delta 4A revealed normal formation of delta 4A from T and diminished conversion of delta 4A to T. The development of a male phenotype despite both a testicular and peripheral <em>17</em>-<em>ketosteroid</em> reductase deficiency is difficult to explain. It is possible that the fetal testes were the source of sufficient amounts of T during the early periods of embryonic life, and that late onset of the enzyme deficiency prevented the development of completely normal male genitalia. The in vitro finding of normal T to delta 4A conversion by the mutant fibroblasts suggests that in this particular tissue <em>17</em> beta-reduction and dehydrogenation of androgens are mediated by two isoenzymes with distinct substrate and/or cofactor specificities.

We studied an 18-year-old woman with progressive hirsutism, secondary amenorrhea, and polycystic ovarian disease. Excess androstenedione was secreted by the ovaries, most likely because of a genetic deficiency of ovarian <em>17</em>-<em>ketosteroid</em> reductase, the enzyme that converts androstenedione to testosterone. Markedly elevated basal plasma levels of androstenedione, estrone, and testosterone were regulated by gonadotropin but not by ACTH. The rate of androstenedione production in the patient's blood at base line and after administration of dexamethasone was very high (10.0 to 11.6 mg per day; value in control women with hirsutism, less than 4.1 mg per day), whereas her blood production of testosterone was 0.64 to 0.7 mg per day, similar to or higher than that in control women with hirsutism. The fractional blood conversion ratio of androstenedione to testosterone was normal (5.6 percent). Thus, 88 to 93 percent of the testosterone in the blood was derived from the peripheral conversion of androstenedione, and very little testosterone was secreted by the ovaries. These in vivo biochemical data suggest that the patient had a deficiency of ovarian <em>17</em>-<em>ketosteroid</em> reductase activity but normal pubertal activity. The patient's two younger sisters with peripubertal symptoms of androgen excess also had elevated serum levels of androstenedione. We propose that the increased secretion of androstenedione in the three siblings in this family was probably due to a genetic deficiency of ovarian <em>17</em>-<em>ketosteroid</em> reductase.

Seventy-eight patients with clinical findings pointing to possible polycystic ovarian disease (POD) were studied by ultrasound examination. The endocrine status of each patient was evaluated by assay of blood progesterone levels and gonadotropin luteinizing hormone and follicle-stimulating hormone (LH-FSH), both under basal conditions and after luteinizing hormone releasing factor (LH-RH) and androgen hormone stimulation (testosterone and <em>17</em>-<em>ketosteroids</em> under basal conditions and after a suppression test with dexamethasone). POD was diagnosed in nine cases and confirmed in four at operation. Ultrasound examination as an aid to POD diagnosis is discussed and its value underlined as a precise method in determining ovarian size, shape, and structure, and as a follow-up for patients after surgery.

An inhibitor of adrenal steroid biosynthesis, aminoglutethimide, was administered to seven patients with low renin essential hypertension, and the antihypertensive action of the drug was compared with its effects on adrenal steroid production. In all patients aldosterone concentrations in plasma and urine were within normal limits before the study. Mean arterial pressure was reduced from a pretreatment value of 1<em>17</em>+/-2 (mean+/-SE) mm Hg to 108+/-3 mm Hg after 4 days of aminoglutethimide therapy and further to 99+/-3 mm Hg when drug administration was stopped (usually 21 days). Body weight was also reduced from 81.6+/-7.2 kg in the control period to 80.6+/-7.0 kg after 4 days of drug treatment and to 80.1+/-6.7 kg at the termination of therapy. Plasma renin activity was not significantly increased after 4 days of treatment but had risen to the normal range by the termination of aminoglutethimide therapy. Mean plasma concentrations of deoxycorticosterone and cortisol were unchanged during aminoglutethimide treatment whereas those of 18-hydroxydeoxycorticosterone, progesterone, <em>17</em>alpha-hydroxyprogesterone, and 11-deoxycortisol were increased as compared to pretreatment values. In contrast, aminoglutethimide treatment reduced mean plasma aldosterone concentrations to about 30% of control values. Excretion rates of 16beta-hydroxydehydroepiandrosterone, 16-oxo-androstenediol, <em>17</em>-hydroxycorticosteroids and <em>17</em>-<em>ketosteroids</em>, and the secretion rate of 16beta-hydroxydehydroepiandrosterone were not significantly altered by aminoglutethimide treatment whereas the excretion rate of aldosterone was reduced from 3.62+/-0.5 (mean+/-SE) in the control period to 0.9+/-0.2 mug/24 h after 4 days and to 1.1+/-0.3 mug/24 h at the termination of aminoglutethimide treatment. The gradual lowering of blood pressure and body weight during aminoglutethimide therapy is consistent with the view that the antihypertensive effect of the drug is mediated through a reduction in the patients' extracellular fluid volume, probably secondary to the persistent decrease in aldosterone production. The observation that chronic administration of aminoglutethimide lowered blood pressure in these patients and elevated their plasma renin activity to the normal range without decreasing production of the adrenal steroids, deoxycorticosterone, 18-hydroxydeoxycorticosterone, and 16beta-hydroxydehydroepiandrosterone, makes it unlikely that these steroids are responsible either for the decreased renin or the elevated blood pressure in patients with low renin essential hypertension.

Cigarette smoking has been reported to produce acute increases in plasma ACTH and cortisol, but the effect of chronic smoking on integrated adrenal steroid production has not been studied. The effects of chronic smoking on 24-hour urinary-free cortisol, 11-deoxycortisol, DHEAS, and <em>17</em>-keto-steroids were studied in 10 premenopausal smokers, and their results were compared with 15 premenopausal nonsmokers. The 24-hour excretion of urinary-free cortisol (85.0 +/- 40.8 nmol/d in smokers versus 81.7 +/- 49.7 nmol/d in nonsmokers), 11-deoxycortisol (259 +/- <em>17</em>0 nmol/d in smokers versus 222 +/- 147 nmol/d in nonsmokers), DHEAS (3,140 +/- 2,909 nmol/d in smokers versus 2,890 +/- 1,960 nmol/d in nonsmokers), and <em>17</em>-<em>ketosteroids</em> (<em>17</em>.4 +/- 8.3 mumol/d in smokers versus 23.4 +/- 19.9 mumol/d in nonsmokers) were similar in smokers and nonsmokers (all P values not significant). We conclude that chronic smoking does not result in abnormal levels of 24-hour urinary-free cortisol.

Using as a criterion the inhibition of serum beta-glucuronidase activity, dietary calcium D-glucarate is shown to serve as an efficient slow-release source in vivo of D-glucaro-1,4-lactone, the potent endogenous inhibitor of this enzyme. Using the 7,12-dimethylbenz[a]anthracene model of mammary tumor induction in rats it is shown for the first time that feeding the rats calcium D-glucarate-supplemented diet after treatment with the carcinogen, inhibits tumor development by over 70%. Supportive evidence is presented for the theory that calcium D-glucarate inhibits or delays the promotion phase of mammary carcinogenesis by lowering endogenous levels of estradiol and precursors of <em>17</em>-<em>ketosteroids</em>. Therefore, dietary glucarate can be used to lower blood and tissue levels of beta-glucuronidase, and in turn of those carcinogens and promoting agents which are excreted, at least in part, as glucuronide conjugates.

The reaction catalyzed by delta 5-3-<em>ketosteroid</em> isomerase has been shown to occur via the concerted enolization of the delta 5-3-<em>ketosteroid</em> substrate to form a dienolic intermediate, brought about by Tyr-14, which hydrogen bonds to and protonates the 3-keto group, and Asp-38, which removes and axial (beta) proton from C-4 of the substrate, in the same rate-limiting step [Xue, L., Talalay, P., & Mildvan, A.S. (1990) Biochemistry 29, 7491-7500; Kuliopulos, A., Mildvan, A.S., Shortle, D., & Talalay, P. (1989) Biochemistry 26, 3927-3937]. Since the axial C-4 proton is removed by Asp-38 from above the substrate, a determination of the complete stereochemistry of this rapid, concerted enolization requires information on the direction of approach of Tyr-14 to the enzyme-bound steroid. The double mutant enzyme, Y55F + Y88F, which retains Tyr-14 as the sole Tyr residue, was prepared and showed only a 4.5-fold decrease in kcat (12,000 s-1) and a 3.6-fold decrease in KM (94 microM) for delta 5-androstene-3, <em>17</em>,dione, in comparison with the wild-type enzyme. Deuteration of the aromatic rings of the 10 Phe residues further facilitated the assignment of the aromatic proton resonances of Tyr-14 in the 600-MHz TOCSY spectrum at 6.66 +/- 0.01 ppm (3,5H) and at 6.82 +/- 0.01 ppm (2,6H). Variation of the pH from 4.9 to 10.9 did not alter these shifts, indicating that the pKa of Tyr-14 exceeds 10.9. Resonances assigned to the three His residues titrated with pKa values very similar to those found with the wild-type enzyme. The binding of 19-nortestosterone, a product analogue and substrate of the reverse isomerase reaction, induced downfield shifts of -0.12 and -0.06 ppm of the 3,5-and 2,6-proton resonances of Tyr-14, respectively, possibly due to deshielding by the 3-keto group of the steroid, but also induced +0.29 to -0.41 ppm changes in the chemical shifts of 8 of the 10 Phe residues and smaller changes in 10 of the 12 ring-shifted methyl resonances, indicating a steroid-induced conformation change in the enzyme. NOESY spectra in H2O revealed strong negative Overhauser effects from the 3,5-proton resonance of Tyr-14 to the overlapping 2 alpha-, 2 beta-, or 6 beta-proton resonances of the bound steroid but no NOE's to the 4- or 6 alpha-protons of the steroid.(ABSTRACT TRUNCATED AT 400 WORDS)

During a 28-week study, vasectomy and vasoligation of immature male Wistar rats revealed that there was a significant decrease in urinary <em>17</em>-<em>ketosteroid</em> in the vasectomized group at week 15; at week 28 there were significant decreases in the weights of the testes of the test groups, as compared to those receiving sham operations, with maximum alterations in the vasectomized rats. Small, soft discolored testes with cysts in the cauda epididymis and vas deferens regions occurred frequently in the test groups. The output of <em>17</em>-<em>ketosteroid</em> in the urine and the findings in the testes indicate significant alterations in the morphology and function of the testes and suggest the need for caution and extensive investigations in man before recommending vasectomy as a simple, innocuous, "physiologic" means to ensure conception control.

An ovarian lipid cell tumor without Reinke's crystalloids in a woman with secondary amenorrhea, minimal hirsutism, and elevated <em>17</em>-<em>ketosteroid</em> excretion was studied by light and electron microscopy. Tumor cells were found in small clumps or scattered singly within a collagenous matrix. The cytoplasm of the tumor cells contained abundant smooth endoplasmic reticula, numerous mitochondria with tubular cristae, lipid droplets, lysosomal dense bodies, and concentric membranous whorls, characteristic of steroidogenic cells. In addition, "peripheral canalicular systems" were found at the outer margins of the nests of the tumor cells. These "peripheral canalicular systems" were bordered by the cell membranes and the surrounding collagenous stroma into which microvilli projected. Since the intercellular canalicular system present between the tumor cells was continuous with the "peripheral canalicular system," both systems probably have a common function related to steroid metabolism. The intercellular and "peripheral" canalicular systems and cytoplasmic microfilaments found in this tumor suggest that this ovarian lipid cell tumor was derived from the ovarian stroma.

One of the rarest situations regarding an adrenal incidentaloma is an adrenal cyst. We present the case of a 61-year-old male patient diagnosed with peritonitis. During surgery, a right adrenal tumor of 2 cm is discovered. The patient was referred to endocrinology. 6 months later the diameter of the tumor is 7 times bigger than the initial stage. It has no secretory phenotype, except for the small increase of serum aldosterone and the 24-h <em>17</em>-<em>ketosteroids</em>. Open right adrenalectomy is performed and a cyst of 15 cm is removed. The evolution after surgery is good. The pathological exam reveals an adrenal cyst with calcifications and osteoid metaplasia. The immunohistochemistry showed a positive reaction for CD34 and ACT in the vessels and VIM in the stroma. The adrenal cysts are not frequent and represent a challenge regarding the preoperative diagnostic and surgical procedure of resection. The pathological exam highlights the major aspects.