Introduction: Morning serum cortisol (SerF) is used to screen for adrenal insufficiency (AI), but requires venepuncture, clinic attendance, and could be affected by conditions alternating corticosteroid-binding globulin (CBG) levels. Salivary cortisone (SalE) has emerged as a non-invasive alternative. We aimed to assess the diagnostic accuracy of morning SalE and define clinically relevant thresholds for AI screening. Methods: This retrospective study was conducted at a UK tertiary oncology and endocrinology centre. We analysed consecutive short Synacthen test (SST; reference standard) with paired morning SerF, salivary cortisol (SalF), and SalE measurements in adults. Receiver operating characteristic analysis was used to derive thresholds, and decision curve analysis assessed net benefit across threshold probabilities of 0·10-0·30. Results: 517 SSTs in 449 participants were included; 104 SSTs (20·1%) showed AI. Baseline SalE was a strong predictor of AI (area under the receiver operating characteristic curve [AUC] 0·93, 95% CI 0·91–0·95]), comparable to SerF (0·93, 0·90–0·95; p = 0·67) and superior to SalF (0·87, 0·82–0·91; p = 0·00063). A baseline SalE rule-out threshold ≥ 19·5 nmol/L (sensitivity 0·97 [95% CI 0·92–0·99]; specificity 0·59 [0·54–0·63]) and a rule-in threshold < 5·0 nmol/L (sensitivity 0·58 [0·48–0·67]; specificity 0·97 [0·95–0·98]) provided the highest net benefit. An intermediate threshold < 10·8 nmol/L (sensitivity 0·83 [0·74–0·89]; specificity 0·87 [0·83–0·90]) identified patients for whom glucocorticoid cover should be considered while awaiting confirmatory SST. Conclusion: In conclusion, baseline morning SalE perform at least as well as conventional SerF approach for AI screening and could reduce unnecessary SSTs.

Introduction A proportion of adrenal adenomata exhibit autonomous cortisol secretion, now termed mild autonomous cortisol secretion (MACS), as defined by post-1mg overnight dexamethasone suppression test (ONDST) cortisol 51-137 nmol/l. Here, we characterized the cardiometabolic profile of MACS. Methods Clinical records of 98 individuals with adrenal adenomata were examined. Subcategorization into MACS1 (ONDST cortisol of 50-137 nmol/l) and MACS2 (ONDST cortisol of >137 nmol/l was created to take account of individuals with ONDST cortisol of more than 137 nmol/l and no diagnosis of Cushing's syndrome. Results Diagnosis of MACS1 associated with a higher diagnosis rate of cardiovascular disease (CVD) (17.7% MACS1) vs. non-MACS = nonfunctioning adenoma (NFA) (3.7%) (P = 0.009) and higher rates of prescription of lipid-lowering agents (51.6%) vs. (29.6%) (P = 0.01). ONDST cortisol levels in MACS1 patients correlated with a more adverse lipid profile (for higher low-density lipoprotein cholesterol, r(2) = 0.404, P = 0.007; high-density lipoprotein cholesterol r(2) = -0.346, P = 0.023; for higher serum triglycerides r(2) = 0.282, P = 0.02) in spite of higher rates of statin prescribing. There was a gradient of increasing numbers of antihypertensives prescribed, going from non-MACS NFA to MACS1 to MACS2. Dunn's post hoc analysis indicated an overall more adverse lipid profile in MACS1. Conclusion The positive direction of associations between serum cortisol and lipid measures highlights that MACS carries a metabolically adverse lipid profile. Diagnosis of MACS was associated with a higher diagnosis rate of CVD and appropriately higher rates of prescription of lipid-lowering agents and a greater number of antihypertensive agents prescribed. The question remains about whether a specific directed treatment of MACS should be offered beyond risk-factor-mitigating management.

OBJECTIVES:Patients with congenital adrenal hyperplasia (CAH) have increased prevalence of metabolic problems. We studied adiponectin, leptin and resistin in children with CAH, in relation to BMI, treatment, hormonal and metabolic biomarkers. DESIGN AND METHODS:We analysed 101 patients with 21-hydroxylase deficiency (54 females, 13.0 ± 2.92 years) from 13 centres in the United Kingdom, and 83 sex- and age-matched controls. Blood parameters (leptin, adiponectin, resistin, metabolic and hormonal markers) were measured in fasted state, between 09:00 and 11:00, after the first glucocorticoid (GC) dose. RESULTS:A difference in adipokines between patients and controls was only found for leptin in males (patients > control, P = .033). In patients and controls, leptin had a positive relationship with BMI-SDS (P < .001). However, adiponectin decreased with the BMI only in patients (P  <  .001). Contrary to published evidence on the effect of synthetic steroids on leptin, in our cohort, leptin decreased with the increasing first daily hydrocortisone (HC) dose (Log10Leptin  =  4.1- 0.08xfirstGCdose (mg/m2), P  =  .009) but not with the total daily dose. When correcting for BMI, a positive relationship between leptin and insulin was only found in controls (P  <  .001). Adiponectin decreased with steroid precursor and androgen concentrations (17-hydroxyprogesterone, androstenedione, testosterone, 11-hydroxyandrostenedione, 11-ketotestosterone) in patients. CONCLUSION:Our findings indicate a decrease in leptin with the HC dose, consistent with a detrimental effect of glucocorticoid on satiety and hunger pathways in CAH. Adiponectin was decreased in patients with increased androgens concentrations, suggesting it may be used as an indicator of metabolic risk associated with poor hormonal CAH control.

BackgroundSerum free testosterone is commonly used as a parameter to evaluate testosterone exposure and is mostly calculated using mathematical approximations. As the principal testosterone-binding protein, SHBG concentration is always included in such calculations. However, variability in SHBG measurements may affect reported SHBG levels and consequently free testosterone calculations. In this study, we re-evaluate the effects of SHBG assay choice and interlaboratory variability on calculated free testosterone (cFT).MethodsSerum samples from 113 men and 106 women were collected. SHBG levels were measured using three different SHBG immunoassays (Roche, Abbott and Siemens). Testosterone levels were measured using LC-MS/MS. Afterwards, cFT was calculated using the Vermeulen formula and measured directly. SHBG concentrations, and derived cFT concentrations, from different assays were compared. To simulate interlaboratory SHBG variability, measured levels were modified by 15% after which cFT was recalculated using the Vermeulen, Ly, Sartorius and Södergard formulae. The proportions of diagnoses of hypogonadism or hyperandrogenism were compared.ResultsAssessed SHBG assays showed very good conformity. The largest difference was 7%, between the Abbott and Siemens assay. The difference in cFT levels was at most 3% between the Abbott and Siemens assay. Interlaboratory variability affected the proportion of diagnoses depending on the used formula.ConclusionsOur results do not show large differences between SHBG assays and only minor effects on cFT levels. Therefore, SHBG assay choice is not expected to greatly influence clinical decision making. In contrast, interlaboratory variation in SHBG measurements and choice of formula might considerably affect cFT results and their interpretation.

BACKGROUND:Endocrine science remains underrepresented in European Union research programmes despite the fundamental role of hormone health in human wellbeing. Analysis of the CORDIS database reveals a persistent gap between the societal impact of endocrine disorders and their research prioritization. At national funding level, endocrine societies report limited or little attention of national research funding towards endocrinology. The EndoCompass project-a joint initiative between the European Society of Endocrinology and the European Society of Paediatric Endocrinology, aimed to identify and promote strategic research priorities in endocrine science to address critical hormone-related health challenges. METHODS:Research priorities were established through comprehensive analysis of the EU CORDIS database covering the Horizon 2020 framework period (2014-2020). Expert analysis examined current challenges and opportunities in hormone measurements, focusing on analytical quality, method validation, and emerging technologies to ensure reliable research and clinical care. RESULTS:Research priorities encompass optimization of pre-analytical processes, standardization and harmonization of endocrine tests, development of personalised reference intervals and clinical decision limits considering diversity, biological variation and environmental factors, innovation in biomarker discovery and point-of-care testing, and implementation of sustainable laboratory practices. Special emphasis is placed on leveraging artificial intelligence and health economics while maintaining analytical quality. CONCLUSIONS:This component of the EndoCompass project provides an evidence-based roadmap for advancing endocrine laboratory medicine. The findings support strategic investment in quality assurance and innovative technologies to enhance both research reliability and clinical outcomes, ultimately improving patient care in endocrine-related diseases.

BACKGROUND:There is no consensus on how to monitor adrenal androgens in Congenital Adrenal Hyperplasia (CAH). METHODS:Modelling of serum and salivary steroid profiles in healthy participants and patients with CAH randomised to either standard treatment or modified-release hydrocortisone hard capsules (MRHC). FINDINGS:Changes in serum 17-hydroxyprogesterone (17OHP) and androstenedione (A4) paralleled each other in healthy participants (n = 19) and patients with CAH (n = 122). However, healthy participants had similar absolute levels of 17OHP and A4 whereas patients with CAH had proportionally higher levels of 17OHP. Cross-correlation showed no lag between serum 17OHP and A4. In CAH, Bayesian multiple change point analysis converged on a 17OHP of 4.5 nmol/l below which in proportion to 17OHP the A4 is lower. Patients on standard treatment had a morning peak in 17OHP and A4 whereas patients on MRHC had relatively flat profiles. Salivary androgens including 11-ketotestosterone correlated with serum 17OHP and A4 in female patients (r = 0.7 to 0.9). INTERPRETATION:In CAH, elevated 17OHP drives the production of A4. High A4 reflects poor control, but low A4 does not indicate overtreatment. Accepting 17OHP is higher than A4, both measurements give similar reflection of control, and a 17OHP <38 nmol/l (1250 ng/dl) was associated with an A4 in the normal range <5 nmol/l (143 ng/dl) in 95% of patients and in clinical trials was used to define good control. On MRHC, which controls androgen levels over 24 h, a single sample of 17OHP and/or A4 can be used to monitor control. Salivary measurements reflect similar results to serum. FUNDING:Diurnal; MRC; NIH; NIHR.

BACKGROUND:The diagnosis and management of childhood adrenal disorders is challenging. Clinical markers of hormone excess or deficiency may take months to manifest, and traditional biomarkers correlate only partially with clinical outcomes. Recent work has indicated that 11 oxygenated 19-carbon (11oxC19) steroids may be useful in the assessment of adrenal function. 11oxC19 steroids, testosterone (T) and androstenedione (A4), can be measured in saliva, but very little is known about these hormones in healthy children. METHODS:Participants collected saliva samples 30 min after waking and every 2 h until bedtime. Samples were analysed for T, A4, 11 ketotestosterone (11KT) and 11βhydroxyandrostenedione (11OHA4) by liquid chromatography tandem mass spectrometry. RESULTS:Fifty-two (30 male) healthy children aged 10.4 ± 3.9 (5.0-17.5) participated. Median height SDS was 0.4 (IQR -0.3 to 1.01) and median BMI SDS was 0.3 (IQR -0.2 to 1.3). All steroids showed a diurnal rhythm, with all hormones decreasing in measured concentration at time points that are 30 min after waking. Salivary T was higher in postpubertal children, particularly boys (p < 0.001). Salivary A4 was lower in boys compared to girls (p = 0.009) and did not differ with pubertal development. 11KT increased with age (p < 0.001) and concentrations were similar between boys and girls. 11OHA4 reduced in concentration with age (p = 0.03) and was below detectable limits after the early morning peak in both sexes. CONCLUSION:For the first time we describe the physiological profile of 11KT and 11OHA4 in children. Further data are required to establish reference ranges, which should consider age, sex, pubertal status and time of sampling.

The objective of this study was to demonstrate the safety and efficacy of a novel cryo renal denervation system (Cryo-RDN) in a porcine model. Procedural and mid-term safety of the Cryo-RDN was demonstrated. Efficacy of the cryoablation was evidenced by histological findings in the renal arteries and reduced renal tissue norepinephrine concentrations on the treated sides. Despite some morphological nerve repair observed between 7 and 28 days, the greater renal norepinephrine suppression in the 28-day animals suggests irreversibly ablated sympathetic nerves.

INTRODUCTION:Saliva hormone measurement is increasingly being applied in everyday clinical practice. In relation to salivary cortisone measurement, there is a particular advantage, with minimal chance of cross-reaction with prescribed glucocorticoids and greater convenience. We evaluated the utility of salivary cortisone measurement in patients undergoing an overnight dexamethasone suppression test (ONDST). METHODS:Individuals undergoing an ONDST had parallel measurement of serum cortisol and salivary cortisone at 0900 following midnight dexamethasone (1 mg). Salivary cortisone was measured by electrospray positive liquid chromatography tandem mass spectrometry. The threshold for adequate suppression of salivary cortisone was< 2.7nmol/L; serum cortisol was< 50nmol/L. RESULTS:Results for 34 individuals which included 21% men (mean age 49.4 years) and 79% women (mean age 56.7 years) were analysed. Serum cortisol did not suppress in 22/34 cases. Salivary cortisone did not suppress in two of the cases where cortisol did suppress. We found a strong correlation between 0900 salivary cortisone and serum cortisol after 1 mg ONDST (r2 = 0.65, p = 0.009). When performance of post-dexamethasone salivary cortisone (< 2.7nmol/L) alone in relation to suppression of serum cortisol (< 50nmol/L) was analysed all but 2 individuals were correctly classified. They had values for post dexamethasone salivary cortisone/serum cortisol of respectively 5.9/23 nmol/L (presented with unexplained fatigue, case 25) and 7/32 nmol/L (investigated for cyclical Cushing's Syndrome that was excluded, case 29). Agreement was 94.1%, kappa 0.87, p < 0.0001. The sensitivity of salivary cortisone for potential Cushing's syndrome as indicated by the post-dexamethasone 0900 serum cortisol was 100% (all cases of potential cortisol excess (0900 cortisol > 50nmol/L) were picked up) and specificity of 84.6% with a positive predictive value of 90.5% of salivary cortisone (using serum cortisol as the standard) and negative predictive value of 100% in relation to ruling out cortisol excess. CONCLUSION:We have provided further evidence that ONDST salivary cortisone has potential to be the first-line test for suspected Cushing's syndrome, not requiring venepuncture or attendance at hospital, with 100% sensitivity and reasonable specificity. Application of the salivary cortisone test has the potential for significant savings of money and time in this and other contexts.

Objectives: Current LC-MS/MS applications for circulating androgen measurements are technically diverse. Previously, variable results have been reported for testosterone. Data are scarce for androstenedione and absent for DHEAS. We assessed the agreement of androstenedione, DHEAS and testosterone LC-MS/MS measurements among nine European centers and explored benefits of calibration system unification.Methods: Androgens were measured twice by laboratory-specific procedures in 78 patient samples and in EQA materials. Results were obtained by in-house and external calibration. Intra- and inter-laboratory performances were valued.Results: Intra-laboratory CVs ranged between 4.2-13.2 % for androstenedione, 1.6-10.8 % for DHEAS, and 4.3-8.7 % and 2.6-7.1 % for female and male testosterone, respectively. Bias and trueness in EQA materials were within +/- 20 %. Median inter-laboratory CV with in-house vs. external calibration were 12.0 vs. 9.6 % for androstenedione (p<0.001), 7.2 vs. 4.9 % for DHEAS (p<0.001), 6.4 vs. 7.6 % for female testosterone (p<0.001) and 6.8 and 7.4 % for male testosterone (p=0.111). Median bias vs. all laboratory median with in-house and external calibration were -13.3 to 20.5 % and -4.9 to 18.7 % for androstenedione, -10.9 to 4.8 % and -3.4 to 3.5 % for DHEAS, -2.7 to 6.5 % and -11.3 to 6.6 % for testosterone in females, and -7.0 to 8.5 % and -7.5 to 11.8 % for testosterone in males, respectively.Conclusions: Methods showed high intra-laboratory precision but variable bias and trueness. Inter-laboratory agreement was remarkably good. Calibration system unification improved agreement in androstenedione and DHEAS, but not in testosterone measurements. Multiple components, such as commutability of calibrators and EQA materials and internal standard choices, likely contribute to inter-laboratory variability.

OBJECTIVES:7α-Hydroxy-4-cholesten-3-one (C4) is the common intermediary of both primary bile acids. C4 is recommended by the British Society of Gastroenterology for the investigation of bile acid diarrhoea (BAD) in patients with chronic diarrhoea. This project aimed to develop and validate an assay to quantitate C4 in serum and assess the stability of C4 in unseparated blood. METHODS:Accuracy was underpinned by calibrating to quantitative nuclear magnetic resonance analysis. C4 was analysed in a 96-well plate format with a deuterated C4 internal standard and liquid-liquid extraction. Validation followed the 2018 Food and Drug Administration guidelines. To assess C4 stability, healthy volunteers (n=12) donated 8 fasted samples each. Samples were incubated at 20 °C for up to 72 h and retrieved, centrifuged, aliquoted and frozen for storage at different time points prior to C4 analysis. RESULTS:The C4 method demonstrated excellent analytical performance and passed all validation criteria. The method was found to be accurate, precise, free from matrix effects and interference. After 72 h of delayed sample separation, C4 concentration gradually declined by up to 14 % from baseline. However, the change was not significant for up to 12 h. CONCLUSIONS:We present a robust method of analysing serum C4, offering a convenient alternative to 75SeHCAT for BAD investigation. C4 was found to decline in unseparated blood over time; however, after 12 h the mean change was <5 % from baseline. Our results suggest C4 is suitable for collection from both primary and secondary care prior to gastroenterology referral.