The Journal of Clinical Endocrinology & Metabolism

Background Glucagon-like peptide-1 receptor agonists (GLP1 RAs) are first-line pharmacotherapy for obesity and metabolic dysfunction-associated steatotic liver disease (MASLD); however, 20% to 35% of patients fail to achieve clinically meaningful weight loss despite guideline-directed therapy. Whether this GLP1 refractory obesity (GRO) phenotype is associated with distinct hepatic molecular abnormalities or influences bariatric surgical outcomes remains unknown. Objectives To characterize the hepatic histological, ultrastructural, and molecular phenotype of GRO at bariatric surgery, determine its recovery following surgery, and identify preoperative hepatic biomarkers associated with postoperative weight loss. Setting Academic tertiary referral bariatric surgery center. Methods Intraoperative liver biopsies were obtained from lean controls (n=3), GLP1 naive obese patients (GNO; n=10), and GLP1-refractory obese patients (GRO; n=10) undergoing Roux-en-Y gastric bypass. GRO was defined as <5% total weight loss after 12 months of guideline-directed GLP1 RA therapy. Paired liver biopsies were obtained six months postoperatively from subsets of GNO (n=5) and GRO (n=5). Histological, ultrastructural, and molecular analyses were performed, and preoperative hepatic protein expression was correlated with postoperative total weight loss. Results Compared with GNO, GRO patients exhibited more advanced hepatic steatosis, fibrosis, lipid accumulation, and mitochondrial ultrastructural disruption at surgery (all P<0.05). Despite equivalent Body mass index, GNO patients maintained lean-equivalent hepatic pCREB, pAMPK, pACC, and oxidative phosphorylation (OXPHOS) protein expression, whereas GRO patients demonstrated marked suppression of GLP1R downstream signaling (75 to 85%) and OXPHOS complex subunits (38 to 55%; all P<0.001). Six months after surgery, histological and molecular recovery remained significantly attenuated in GRO. GRO patients achieved less postoperative weight loss than GNO patients (25.2% vs. 29.51% total weight loss; P<0.001). Across the pooled cohort, several hepatic molecular markers correlated with postoperative weight loss; however, no individual biomarker independently predicted postoperative weight loss within the GRO subgroup. Conclusions GLP1 refractory obesity is associated with a distinct hepatic phenotype characterized by impaired GLP1R signaling, mitochondrial dysfunction, and attenuated hepatic recovery following bariatric surgery. The coordinated suppression of hepatic energy-sensing, mitochondrial biogenesis, and oxidative phosphorylation pathways supports the concept that GLP1 refractory obesity represents a biologically distinct metabolic phenotype. Larger prospective studies are required to determine the prognostic utility of hepatic molecular profiling for postoperative outcomes. Keywords: GLP1 receptor agonist refractoriness; bariatric surgery; hepatic steatosis; MASLD; AMPK; pCREB; mitochondrial dysfunction; OXPHOS; weight loss outcomes; biomarker

Context Polyendocrine metabolic ovarian syndrome (PMOS), formerly known as polycystic ovary syndrome (PCOS), is a biologically heterogeneous disorder, yet previous clustering studies have reported inconsistent phenotype structures. Whether these discrepancies reflect methodological variability or genuine multidimensional disease biology remains unknown. Objective To determine whether independently derived endocrine, metabolic, inflammatory, and thyroid phenotypes represent the same underlying biological structure or capture distinct dimensions of PMOS heterogeneity. Design Cross-sectional observational study using a cross-space phenotyping framework. Setting Tertiary referral outpatient endocrinology and gynecology clinic. Participants A total of 1,286 women were diagnosed with PCOS according to the Rotterdam criteria. Methods Four predefined biological spaces (endocrine, metabolic, inflammatory, and thyroid) were analyzed independently. Within each space, standardized preprocessing, dimensionality reduction, and unsupervised clustering were performed. Cluster robustness was evaluated using bootstrap resampling, while agreement between independently derived phenotypes was quantified using the adjusted Rand index (ARI). Biological relevance was assessed using independent non-circular validation with variables excluded from phenotype derivation. Sensitivity analyses compared complete-case and imputed datasets. Results All four biological spaces produced highly stable clustering solutions (bootstrap ARI: endocrine 0.915, metabolic 0.964, inflammatory 0.930, thyroid 0.990). Despite this robustness, agreement between independently derived phenotypes remained consistently low. The highest concordance was observed between metabolic and inflammatory phenotypes (ARI = 0.208), followed by endocrine and metabolic phenotypes (ARI = 0.159), whereas agreement involving thyroid phenotypes was close to zero. Independent non-circular validation confirmed that all identified phenotypes represented biologically coherent patient subgroups beyond the variables used for clustering. Sensitivity analyses demonstrated high agreement between complete-case and imputed solutions, supporting the robustness of the findings. Conclusions Stable biological phenotypes exist within individual physiological domains of PMOS but do not converge into a single overarching biological phenotype. These findings support a multidimensional model of PMOS heterogeneity in which endocrine, metabolic, inflammatory, and thyroid systems describe complementary rather than interchangeable aspects of disease biology. Cross-space phenotyping provides a general framework for investigating biological heterogeneity in complex disorders and may facilitate future precision medicine approaches.

Context: Polycystic ovary syndrome (PCOS) is a heterogeneous endocrine disorder involving complex interactions among endocrine, metabolic, inflammatory, and thyroid pathways. However, the systems-level organization of these interactions remains poorly understood. Objective: To reconstruct the endocrine-metabolic biomarker network in women with PCOS and identify bridge biomarkers integrating distinct physiological domains. Design: Retrospective cross-sectional study. Setting: Single tertiary referral center. Participants: A total of 1,286 women diagnosed with PCOS according to the revised Rotterdam criteria. Methods: Twenty-nine routinely measured laboratory biomarkers representing endocrine, metabolic, hematological/inflammatory, and thyroid domains were analyzed. Sparse Gaussian graphical models were estimated using Graphical LASSO with Extended Bayesian Information Criterion model selection. Network topology, node centrality, bridge centrality, bootstrap resampling, and predefined sensitivity analyses were performed. Results: The reconstructed network comprised 29 biomarkers connected by 73 conditional dependency edges (network density, 0.18), demonstrating a modular but highly integrated endocrine-metabolic architecture. Conventional centrality analysis primarily identified biomarkers organizing local physiological modules, whereas bridge-centrality analysis revealed biomarkers coordinating communication between biological domains. Sex hormone-binding globulin exhibited the highest bridge strength, followed by fasting insulin, triglycerides, and high-density lipoprotein cholesterol. Additional reproducible bridge biomarkers included free thyroxine, white blood cell count, 2-hour plasma glucose, absolute neutrophil count, androstenedione, and anti-thyroglobulin antibodies. The leading bridge biomarkers remained stable across bootstrap resampling, complete-case reconstruction, and alternative network specifications. Conclusions: PCOS is characterized by an integrated endocrine-metabolic network organized around a limited number of reproducible bridge biomarkers linking multiple physiological systems. Network analysis provides complementary systems-level information beyond conventional biomarker evaluation and may facilitate future biological phenotyping and precision medicine approaches in PCOS.

Autoimmune diseases have shown biased proportion in female population, existing clinical investigations of sex hormones in autoimmune populations have been relatively limited in terms of patient size and types of hormones investigated. In this study, we examined the relationship of sexual hormones and autoimmune antibodies in a large cohort of US women. This retrospective study sample included a total of 15319 female subjects medical information that were collected between December 2015 to May 2019 and tested in the Vibrant America Clinical Laboratory. The present serum sample was limited to female participants who had ever menstruated at the time of blood collection and completed the testing of the autoimmune antibodies and sex hormones. We focused on a total of 13 clinically significant autoantibodies including antinuclear antibody (ANA), 11 anti-extractable nuclear antigens (anti-ENAs), anti-cyclic citrullinated peptide 3 (anti-CCP3), and 11 female sex hormones. First, the prevalence of serological autoantibodies in a large set of adult female subjects divided by the menopause age was investigated. Next, the levels of sex hormones were compared in the seropositive autoimmune subjects and seronegative controls across the pre- and post-menopausal female groups. The presented study involving a large cohort of females showed no statistically different levels of sex hormones in seropositive autoimmune subjects and matched controls except for DHEA-s.

The coexistence of obesity and insulin resistance is associated with elevated plasma amino acid concentrations. However, it remains unclear whether adiposity or insulin resistance is the stronger determinant of plasma amino acid dysregulation in this setting. Twenty-two adults (10 women, 12 men) spanning a broad range of body mass index (BMI) and insulin resistance underwent a 75-g oral glucose tolerance test (OGTT) after an overnight fast. Plasma glucose, insulin, and amino acid concentrations were measured serially, and insulin resistance/sensitivity was estimated from OGTT-derived glucose and insulin responses, using the homeostasis model assessment of insulin resistance (HOMA-IR) and the Matsuda insulin sensitivity index (Matsuda-ISI). Principal component analysis (PCA) of fasting plasma amino acid concentrations showed no clear separation by obesity or insulin resistance classifications. In contrast, PCA of OGTT-stimulated plasma amino acid concentrations revealed clearer clustering by BMI, fat mass, and waist circumference, whereas separation by HOMA-IR and Matsuda-ISI was less distinct. Importantly, regression analyses showed that BMI, fat mass, and waist circumference were significant predictors of OGTT-stimulated, but not fasting, amino acid responses, with waist circumference accounting for the greatest proportion of the variance in branched-chain amino acid responses during the OGTT (R2 = 0.54). In conclusion, measures of adiposity, particularly total fat mass and waist circumference, accounted for a greater proportion of the variance in plasma amino acid responses under physiologically stimulated conditions than indices of insulin resistance. These findings support the view that plasma amino acid concentrations reflect adiposity-related metabolic alterations more strongly than insulin resistance.

Targeted mass spectrometry (multiple-reaction monitoring, MRM) enables reproducible, multiplexed quantification of plasma proteins, but whether a fixed targeted panel can resolve endocrine disorders with overlapping systemic features is unknown. We analyzed a 256-protein targeted panel (1,894 peptides; 3,790 transitions) quantified in 57 participants spanning autoimmune thyroid disease (Hashimotos thyroiditis, n=7; Graves disease, n=5) and growth-hormone deficiency (GHD; partial, n=26; complete, n=19). Protein abundances were obtained by transition summation, log2 transformation, and per-sample median normalization. We applied unsupervised analysis (PCA, PERMANOVA), differential expression (limma), an ordered severity-trend test, and leave-one-out cross-validated classification with feature selection performed strictly inside each fold. All 256 proteins were quantified in every sample (median inter-sample r=0.875). PC1 (36% variance) separated autoimmune thyroid disease from GHD (p=0.016), whereas the global four-group structure was not significant (PERMANOVA p=0.17). No protein reached FDR<0.05, but the autoimmune-versus-GHD contrast was strongly enriched for low p-values (26 proteins at p<0.05; binomial p=5.4x10-4). The signal was biologically coherent: immunoglobulin/B-cell-receptor proteins, including CD79A, were lower, whereas proteasome subunits (PSMC5, PSMC3) and the NF-{kappa}B subunit RELA were higher in autoimmune disease. A cross-validated classifier separated the two classes (AUC 0.72; permutation p=0.05; eight proteins selected in all folds), whereas GHD severity was not predictable (AUC 0.31). A fixed 256-protein targeted panel reproducibly captures an immunoglobulin/B-cell-receptor and proteasome/NF-{kappa}B axis that distinguishes autoimmune thyroid disease from GHD but cannot resolve within-class severity.

Objective: To characterize pregnancy outcomes and menstrual irregularities in Mexican women with systemic lupus erythematosus (SLE) and identify clinical factors associated with adverse pregnancy outcomes and early-onset menopause. Methods: We conducted a cross-sectional study of women with SLE enrolled in the Mexican Lupus Registry (LupusRGMX) between May 2021 and September 2024. Clinical and reproductive data were collected using standardized questionnaires. Menopause was defined as the absence of menstruation for [&ge;]12 consecutive months, and early menopause as onset before age 40. Univariable and multivariable logistic regression analyses were used to identify factors associated with pregnancy complications and early menopause. Results: A total of 210 women were included. Median age was 38 years (IQR 29-46) and median disease duration was 4 years (IQR 1-10). Among women with a history of pregnancy (47%), full-term delivery predominated (61%), while pregnancy loss occurred in 26% and preterm delivery in 13%. Pregnancy complications were reported in 9.6%, most commonly preeclampsia (6.7%). Younger maternal age was independently associated with pregnancy complications (OR 0.89, 95% CI 0.83-0.95) and adverse outcomes (OR 0.95, 95% CI 0.92-0.98). Higher disease activity was associated with complications in univariable analysis. Most pregnancies (68.3%) occurred before diagnosis. Early menopause was observed in 6.2% and independently associated with longer disease duration and older age. Conclusion: Younger maternal age was independently associated with adverse pregnancy outcomes, whereas disease activity showed an association in univariable analysis. Most pregnancies occurred prior to SLE diagnosis. Early menopause was associated with longer disease duration, suggesting impact of cumulative disease burden on ovarian function.

Structured AbstractO_ST_ABSImportanceC_ST_ABSThymic involution in humans has traditionally been conceptualized as a linear, age-associated process. Animal studies suggest transient hormone-dependent fluctuations in thymus size during reproductive transitions, including across the estrous cycle, but translational evidence in humans remains limited. ObjectiveTo determine whether thymus size changes across the menstrual cycle in healthy women and whether these changes are associated with fluctuations in estradiol and progesterone levels. DesignObservational repeated-measures study using quantitative computed tomography (qCT). Data were collected as part of an imaging study examining menstrual cycle-related physiological variation. Participants underwent assessments during menses and the early luteal phase within the same menstrual cycle. Mixed-effects models with robust variance estimation evaluated associations between cycle phase, hormonal contraception, reproductive hormone levels, and thymus size. Thymus segmentation was independently conducted by 2 blinded raters. SettingSingle-center university-based imaging study conducted at the University of Iowa. ParticipantsThirty-one non-smoking women with regular menstrual cycles were included, of whom n = 16 used oral hormonal birth control and n = 15 did not use hormonal contraception. Exclusion criteria included pregnancy, breastfeeding, postmenopausal status, diabetes, body mass index greater than 30 kg/m2, hysterectomy, or use of long-term noncyclic hormonal contraception. Participants tracked menstrual cycles using temperature monitoring and ovulation kits before completing visits during menses and the early luteal phase. All participants provided informed consent before study participation. Main Outcomes and MeasuresPrimary outcome was thymus size measured in mm3 using ultra-low-dose qCT imaging. Secondary outcomes included serum estradiol and progesterone levels. ResultsEstradiol levels increased from menses to the early luteal phase independent of hormonal contraceptive status. Progesterone levels were significantly lower among women using hormonal birth control. Thymus size differed significantly by hormonal contraceptive group, with larger thymus volumes observed among women not using hormonal birth control. Among women not using hormonal contraception, 66.7% demonstrated thymic involution from menses to the early luteal phase, compared with 37.5% of women using hormonal contraception. Estradiol and progesterone significantly interacted in predicting thymus size. Conclusions and RelevanceThese findings provide first-in-human evidence suggesting that thymus involution demonstrates short-term dynamics across the menstrual cycle and may be influenced by reproductive hormones and hormonal contraception. Key PointsO_ST_ABSQuestionC_ST_ABSDoes thymus size change dynamically across the human menstrual cycle in association with fluctuations in reproductive hormones and hormonal contraception use? FindingsIn this repeated-measures quantitative computed tomography study of n = 31 healthy women, thymus size demonstrated within-person variation across the menstrual cycle. Greater thymic involution was associated with larger increases in estradiol, whereas increases in thymus size were associated with larger increases in progesterone; thymus size also differed significantly by hormonal contraceptive status. MeaningThese findings suggest that thymic involution in humans may demonstrate short-term hormone-dependent dynamics beyond age-related atrophy, with potential implications for sex differences in immune regulation and inflammatory disease.

Background: Insulin resistance is a core pathophysiologic feature of metabolic disease, but its reference-standard assessment by steady-state plasma glucose (SSPG) testing is procedurally demanding and labor-intensive, limiting use in routine clinical care and large-scale research. Because OGTT glucose profiles are widely available, we aimed to develop a glucose-only metric to characterize dynamic glucose responses and estimate SSPG-measured insulin resistance. Methods: We developed the Width-Delay Index (WDI), a glucose-only OGTT metric integrating relative exposure width, delayed exposure timing, and glycemic floor. In a dataset of 32 subjects with 16-point venous OGTT profiles and paired SSPG measurements, WDI performance was assessed using leave-one-out cross-validation (LOOCV) for SSPG prediction, together with insulin-resistance discrimination and sparse-sampling robustness analyses. Results: The 15-120 min OGTT window yielded the strongest WDI performance. WDI15-120 predicted SSPG with LOOCV R2 = 0.57 (95% CI, 0.27-0.77), Pearson r = 0.77, and Spearman rho = 0.74. WDI15-120 showed higher predictive performance than standard OGTT glucose measures and insulin-derived indices, including HOMA-IR, Matsuda index, and disposition index. WDI15-120 also discriminated insulin-resistant from insulin-sensitive subjects with AUROC = 0.969. When recalculated from conventional 5-point OGTT sampling, WDI15-120 retained substantial performance, with LOOCV R2 = 0.41 and AUROC = 0.945. Conclusions: WDI provides a simple, glucose-only, physiologically interpretable approach for estimating SSPG-measured insulin resistance from OGTT glucose dynamics.

Background: Prolonged unsupplemented spiritual fasting (USF), complete caloric abstinence motivated by spiritual practice, is undertaken by many communities worldwide, yet its physiological consequences remain poorly characterized. No prior study has documented continuous real-time monitoring during free-living fasting beyond 10 days. Methods: We conducted a self-controlled observational study of 23 experienced Jain practitioners undergoing USF. Seventeen completed at least 8 days of fasting (11 completed eight days, six continued to 30 days); six discontinued early. Continuous glucose monitoring (CGM) and blood biomarkers at baseline (Day-0), post-fasting (Day-9), and 60-day follow-up (Day-69) were obtained. Mood was assessed daily using PANAS. Within-participant comparisons used both parametric and non-parametric t-tests. Results: CGM revealed near-complete suppression of glycaemic variability within 24-48 hours of fasting onset, sustained throughout with no clinical hypoglycaemia in either cohort. Blood biomarkers showed transient perturbation during fasting -- including rises in hepatic enzymes, bilirubin, uric acid, creatinine, and lipid fractions -- broadly reversible by follow-up (Day-69). hsCRP rose during fasting then fell below baseline at follow-up (5.52{+/-}13.67 to 3.68{+/-}13.18 mg/L, p=0.034). HDL significantly rose above baseline (45.71{+/-}112.32 to 48.97{+/-}111.19, p=0.045) and LDL similarly declined below baseline (122.33{+/-}132.10 to 106.96{+/-}131.62 mg/dL, p=0.035); and then both significantly improved by follow-up. Thyroid axis suppression fully normalized by follow-up. Psychological wellbeing was maintained throughout. Conclusions: Extended USF produces a safely reversible pattern of acute physiological adaptation with net cardiometabolic benefit. Absence of clinical hypoglycaemia during 30-day water-only USF, documented here for the first time with CGM, provides empirical grounding for future controlled trials.

Psychosocial distress is associated with adverse perinatal outcomes, yet its biological correlates remain incompletely understood. We evaluated associations of prenatal psychosocial distress with allopregnanolone (ALLO) and related steroids, and assessed race/ethnicity as a potential effect modifier, using data from 237 participants from the Healthy Start Study. We selected participants based on high distress (Edinburgh Perinatal Depression Scale [EPDS] >=13 or EPDS-3A >=7; n = 57) or low distress (EPDS <4 and EPDS-3A <2; n = 180). We quantified ALLO, progesterone, pregnanolone, cortisol, and cortisone in maternal serum using HPLC-MS/MS at two timepoints in pregnancy for each participant, (median ~17 and ~27 weeks gestation; range: 10-34 weeks). We modeled the relationship between high vs. low prenatal distress with repeated measures of the steroid hormones using linear mixed-effects models. We found that ALLO was 20.6% lower (95% CI: -30.9%, -8.7%) in high-distress individuals after adjusting for maternal age, fetal sex, smoking and gestational age at blood draw, with no evidence of effect modification by race/ethnicity. However, this association attenuated after additional adjustment for sociodemographic characteristics. Several ALLO-related ratios were lower with high distress, but only ALLO-to-progesterone remained significant across models. These findings suggest that associations between psychosocial distress and circulating ALLO concentrations during pregnancy are influenced by social and structural factors, with the exception of the ALLO-to-progesterone ratio, which may capture aspects of neurosteroid metabolism more closely linked to prenatal psychosocial distress.

Objectives: Menopausal symptoms are heterogeneous and commonly assessed by questionnaires. We explored serum two-dimensional gel electrophoresis (2-DE) protein spots associated with menopausal symptom burden. Methods: This exploratory cross-sectional study included 27 women aged 45-55 years. A total of 550 matched serum 2-DE spots were quantified. A frequency-adjusted symptom burden score was calculated as the sum of severity x frequency products across 10 symptoms. Spots were screened using Spearman rank correlation with Benjamini-Hochberg false discovery rate (FDR) adjustment, followed by qualitative image review. Spots #285 and #636 were prioritized for vasomotor and psychological domain analyses. Results: The median age was 51.0 years; 13 participants were menstruating and 14 were amenorrheic. The median overall symptom burden score was 45.0 (interquartile range, 6.5-58.5) and was inversely correlated with spots #285 and #636. Spot #285 was inversely correlated with vasomotor symptom score, including inverse correlations in both menstrual-status groups. Spot #636 was inversely correlated with psychological symptom score overall, with a stronger descriptive correlation among menstruating participants. Neither candidate remained significant after FDR adjustment. Conclusions: Spots #285 and #636 are hypothesis-generating candidates requiring molecular identification, analytical validation, multiplicity-aware confirmation, and independent replication.

Premature ovarian insufficiency (POI) significantly impacts quality of life, yet the immediate cognitive landscape and lived experience of younger women remain under-researched. In 125 young women (aged 19-48; 66 with idiopathic POI, 59 age-matched controls), we examined self-reported cognitive distress and symptom burden within the POI cohort and compared objective global and domain-specific cognitive performance between groups. Objective accuracy scores were derived from six online tasks (Cognitron) and combined into a robust global measure. Within the POI cohort, there were significant differences in symptom burden domains ({chi}(3) = 61.90, p<0.001), with psychological and sexual symptoms reported at a significantly higher intensity than physical and vasomotor symptoms (all p<0.001). Furthermore, the standardised magnitude of perceived cognitive distress (56.20%) was significantly greater than that of overall symptom burden (42.00%, p<0.001). Case-control comparisons revealed no significant differences in global cognitive performance (p=0.615), yet the POI cohort performed significantly less accurate than controls in verbal analogical reasoning (-0.86 SD, 95% CI: -1.52, -0.20, p = 0.011). The findings highlight an urgent need for comprehensive emotional and psychosexual support in POI care. Additionally, the presence of high cognitive distress alongside localised objective deficits demonstrates that cognitive health monitoring must be proactive in early adulthood, especially given their established long-term risks for later-life cognitive decline and dementia.

Importance: Higher coffee intake has been associated with lower risk of type 2 diabetes (T2D), but the underlying biological pathways remain incompletely understood. Objective: To examine associations of coffee intake with insulin sensitivity, adiposity, and T2D risk, and assess whether coffee intake modifies associations between pathway-specific genetic susceptibility and incident T2D. Design, Setting, and Participants: Cross-sectional analyses among 806 participants without T2D in the VITamin D and OmegA-3 TriaL (VITAL) clinical sub-cohort, who underwent repeated dietary assessment, clinical phenotyping, and dual-energy X-ray absorptiometry imaging at baseline and year-2. Prospective analyses among 333,053 UK Biobank participants without T2D at baseline who had dietary and genetic data and were followed for a median of 13.3 years. Exposures: Coffee intake assessed by food frequency questionnaires. In UK Biobank, 12 pathway-specific polygenic scores (pPS) representing distinct T2D pathophysiological mechanisms were evaluated. Main Outcomes and Measures: The primary outcomes, in VITAL, were HbA1c, oral glucose tolerance test-derived measures of glucose response and insulin sensitivity, beta-cell function, and overall, truncal, and visceral adiposity; in UK Biobank, was incident T2D. Results: In VITAL, higher coffee intake was associated with higher insulin sensitivity (standardized beta; per cup/day, 0.046; P = .004) and lower visceral adipose tissue mass (beta -0.047; P = .006), after adjusting for demographic, lifestyle, and clinical factors, including body mass index. In UK Biobank, higher coffee intake was associated with lower T2D incidence (hazard ratio per cup/day, 0.96; 95% CI, 0.95-0.97), lower triglyceride-to-HDL cholesterol ratio (beta: -0.01; P = 2.51 x 10-19), and lower visceral adipose tissue mass (beta: -0.01; P = 4.28 x 10-9). Associations of 3 pPS related to insulin resistance and fat distribution with incident T2D were attenuated among participants consuming higher amount of coffee than among non-consumers (P for interaction < .0043). Conclusions and Relevance: Higher coffee intake was associated with greater insulin sensitivity, lower visceral adiposity, and lower risk of T2D. Together with the attenuation of associations between pathway-specific genetic susceptibility and T2D risk among higher coffee consumers, these findings suggest that insulin resistance and visceral adiposity-related pathways may contribute to the association between coffee intake and T2D risk.

Context: Prader-Willi syndrome is a genetic neurodevelopmental disorder characterized by hyperphagia and early-onset obesity from hypothalamic dysfunction with endocrinopathies and learning disability. Management is challenging with strict control of the food environment needed. While newer glucagon-like peptide-1 receptor agonists, such as semaglutide, have efficacy in non-PWS obesity, there have been limited case reports in PWS. Objective/Design/Setting: Retrospective records review of 12 adults with PWS and overweight/obesity treated with semaglutide at a UK academic hospital centre specialist clinic. Patients: mean +/- SD age 28.3 +/- 10.1 years, 83% female, BMI 46.6 +/- 8.2kg/m2, 75% type 2 diabetes mellitus. Intervention: Median follow-up 17.2 months (range 8.7-36.1) with median semaglutide dose 2.4mg once weekly (1.0-2.4). Results: Although there was no significant weight loss on semaglutide, there was stabilisation of the weight gain prior to treatment over previous 12.4 months (7.6-23.0) (post -3.1 +/- 9.9% vs. pre +5.7 +/- 5.6%: d -0.72, P=0.037). There was a significant decrease in hyperphagia on semaglutide from hyperphagia questionnaire for clinical trials (n=11, -7.3 +/- 6.1 (max 36), d -1.19, P=0.003), having been stable before treatment. HbA1c improved in those with elevated baseline levels (n=6, -4.2 +/- 4.9%, d -0.74, P=0.13). Mild gastrointestinal side effects were seen in 25% but did not lead to discontinuation. Conclusions: In adults with PWS, semaglutide produced weight maintenance, reduced hyperphagia, and improved glycaemic control, with good tolerability. Larger placebo-controlled trials are needed to confirm these findings in adults and adolescents with PWS, especially in those without T2DM, where efficacy may be greater.

Background: Pathologic aldosteronism induces oxidative stress, tissue injury, and increases in hemoglobin. Conversely, aldosterone antagonist therapy decreases hemoglobin. Whether these effects are attributable to aldosterone-mediated changes in iron and oxygen metabolism is unknown. Methods: The plasma proteome of participants with overt primary aldosteronism (PA) (n=50) was compared with participants without overt PA (n=61). To isolate aldosterone-dependent effects, participants without overt PA underwent oral sodium suppression testing to quantify the magnitude of renin-independent aldosterone production, enabling monotonic dose-response analyses across the continuum of renin-independent aldosteronism (subclinical to overt PA). Differential abundance testing was performed using empirical Bayes linear modeling, followed by Reactome pathway enrichment analysis and covariate-adjusted sensitivity analyses. To validate clinical relevance, aldosterone dose-response trends with blood count parameters were examined in this cohort, and an independent population-based cohort of 5,713 people with hypertension. Results: 903 proteins in the peripheral circulation were differentially abundant in overt PA versus participants without PA. The most significantly increased protein in overt PA was CYBRD1, involved in iron reduction and absorption. Pathway enrichment identified 16 iron- and heme-related pathways, including erythropoietin signaling, heme biosynthesis and mitochondrial iron-sulfur cluster biogenesis, with increases in heme and erythroid proteins and decreases in mitochondrial iron-sulfur proteins. Linear aldosterone dose-dependent trend analyses across the PA continuum further supported this signature, identifying progressive increases in hemoglobin subunits (HBA1/HBB), heme-related proteins (HMBS, UROS, AMBP, HPX, GLO1) and erythrocyte oxygen handling enzymes (CA1/CA3), alongside progressive reductions in mitochondrial electron transport chain subunits (CYCS, ETFA). These proteomic changes corresponded with aldosterone dose-dependent increases in red blood cell count, hemoglobin, and hematocrit, in this cohort and another population-based cohort. Conclusion: The continuum of PA is characterized by a progressive shift away from mitochondrial oxidative phosphorylation and toward increased intestinal iron absorption, preferential iron transport over storage, and enhanced heme synthesis and recycling, possibly reflecting cellular pseudohypoxia and systemic adaptations to increase oxygen delivery. These findings provide a novel mechanistic basis for aldosterone-mediated tissue injury and the benefits of aldosterone-directed therapy.

Background Isotretinoin (ISO) is a systemic retinoid widely used for the treatment of acne vulgaris, yet its potential effects on male reproductive function remain unclear with previous studies reporting inconsistent findings. Methods and finding We conducted a multi-model study combining data from the Danish Young Men Study (DYMS) cohort with ex vivo cultured human testis tissue and an in vitro Retinoic Acid Receptor alpha (RAR) reporter gene assay. In the DYMS cohort semen parameters and reproductive hormone concentrations assessed on a specific examination day were compared between ISO-users (n=322) and non-users (n=4,065). Ex vivo human testis tissue was exposed to ISO and RA for 96 hours to assess changes in hormone secretion and germ cell dynamics, while the in vitro RAR assay evaluated ISO for effects on RA-induced RAR-signaling. In the DYMS cohort, ISO use was associated with reduced FSH concentrations, higher inhibin B/FSH ratio, and elevated estradiol concentrations, along non-significant tendencies of lower sperm counts. These associations persisted even after cessation of ISO use but were not evident in men first initiating ISO use 1 year after their examination date. In the ex vivo testis tissue, ISO exposure altered hormone secretion, including increased testosterone, but did not affect germ cell proliferation or apoptosis. ISO also inhibited RA-induced RAR-signaling in vitro in a competitive manner. Conclusions These findings suggests that ISO-use may influence male reproductive function, potentially with persistent effects. Further randomized clinical trials are needed to validate these effects.

Objective: Maternal body mass index (BMI) is often used as a measure of metabolic status and increased or decreased maternal BMI is associated with a heightened risk of cardiometabolic diseases across generations. The placenta mediates these maternal metabolic cues; however, its genome wide transcriptional adaptations in response to maternal BMI remain incompletely defined. Methods: To delineate placental genes, pathways, and interaction clusters whose transcript abundance varies with maternal prepregnancy BMI through a genome wide meta analysis of human placental RNA sequencing datasets. Placental RNA seq reads from four publicly available cohorts (n=146) were mapped to the GRCh38 reference genome and differentially expressed genes were identified. An independent microarray cohort (n=19) was reanalysed separately to facilitate cross platform comparison. Functional enrichment employed GO, KEGG, and STRING protein interaction resources. Results: Meta-analysis of 146 RNA seq samples identified eight genes with genome-wide significance in placentae from underweight pregnancies including inflammatory signaling gene MAP4K1 and metabolic enzyme PSPH, while overweight and obese categories revealed nominally significant differential expression. KEGG analysis demonstrated significant downregulation of oxidative phosphorylation with increasing maternal BMI, and protein-protein interaction networks revealed inflammatory mediators as central nodes in overweight and obese groups. Independent microarray validation corroborated key findings, including consistent downregulation of oxidative phosphorylation in obesity. Conclusion: Maternal BMI is associated with placental transcriptomic signatures involving inflammatory, metabolic, and hormonal pathways, with consistent downregulation of oxidative phosphorylation across platforms. This genome-wide meta-analysis provides a reproducible catalogue of BMI-responsive placental transcripts that may contribute to developmental programming of offspring health.

Gastroschisis is a congenital abdominal wall defect in which fetal intestines herniate into the amniotic cavity. Despite 97% surgical repair success rate, 40% of affected infants require hospital readmission due to gastrointestinal complications, where underlying mechanisms remain poorly characterized. We hypopthesized that the cord blood metabolome of neonates with gastroschisis differs systematically from controls and may reveal pathway-level alterations relevant to neonatal physiology. Cord blood plasma collected at delivery (23 samples each group) was analyzed using ultra-performance liquid chromatography coupled with tandem mass spectrometry. Unsupervised principal component analysis and hierarchical clustering demonstrated significant separation between groups (PERMANOVA pseudo-F = 4.632, R{superscript 2} = 0.095, p = 0.001). 53 metabolites met criteria for differential abundance, 75% were lipids. Key alterations included reduced free fatty acids, increased fatty acid amides and ceramides, disrupted steroid and bile acid metabolism, and decreased biliverdin and bilirubin isomers. Our findings provide insight into gastroschisis pathophysiology and identify potential biomarkers for future investigation.

The insulin-like growth factor (IGF)/IGF-binding protein (IGFBP) axis has been implicated in diabetes mellitus and the associated burden of cardiovascular complications. Higher circulating levels of IGFBP-1 and IGFBP-2 have been established as markers of protection from incident type 2 diabetes, yet their associations with cardiovascular disease remain unclear. Utilising the UK Biobank (UKB) resource to integrate disease outcomes, plasma proteomics and MRI data, we examined associations of IGFBP-1 and IGFBP-2 with incident diabetes and cardiovascular disease. Approximately 50,000 UKB participants with plasma proteomic measurements for IGFBP-1 and IGFBP-2 were included. Multivariate Cox regression models revealed that participants in the highest quartiles of IGFBP-1 and IGFBP-2 had a substantially lower risk of incident diabetes (hazard ratio (HR) = 0.31 and 0.32 respectively), but, paradoxically, had increased risks of incident macrovascular disease, all-cause and cardiovascular-related mortality (HR = 1.81 and 2.39). Both proteins were negatively associated with HbA1c levels, triglyceride/HDL ratio and abdominal adiposity, yet positively associated with NT-proBNP, troponin I, cardiac chamber size and aortic dimensions. In summary, negative associations of IGFBP-1 and IGFBP-2 with incident diabetes mellitus did not translate to a reduced cardiovascular risk, suggesting potentially complex actions of IGFBP-1 and IGFBP-2 in the pathophysiology of cardiometabolic disease.