- Email: [email protected]
Androgenic disorders
roidism is the first case in this book where some potentially important information is not included. For example, there is no mention of the calcium-sensing receptor or potential for therapy with agonists for this receptor, the role of lithium in the pathogenesis of parathyroid cell growth, or the role of thiazide diuretics in possibly unmasking hypercalcemia and primary hyperparathyroidism, and a description of sestamibi scanning in the localization of parathyroid adenomas is noticeably absent. On the other hand, this chapter provides a very clear and concise discussion of the latest information concerning the potential molecular mechanisms, such as the PIUD- 1 oncogene and tumor suppressor gene, that have been implicated in the pathogenesis of primary hyperparathyroidism. Having read entire books devoted to Paget’s disease of bone, a classic disorder of bone remodeling, I was initially surprised that Dr. Mundy could cram all of the relevant information into just 10 pages. To his credit, he has succeeded in accomplishing this very well. True, others have had much more to say and write about Paget’s disease of bone, which is truly a fascinating disorder for those interested in metabolic bone diseases, but all but the true aficionado can glean the relevant information from this well-written chapter. Much the same could be said about the even shorter chapter on osteopetrosis. One of the pleasing features OFthis book on disorders of bone remodeling is that it includes osteoporosis as but one of several clinical consequences of those disorders. Nonetheless, osteoporosis is the entry point for an increasing number of clinicians into the whole field of metabolic bone disease, and may be the sole reason why potential readers pick up this book in the first place. Before reading this chapter,
it would be worthwhile to scan again the information in the introductory four
brief discussion of biochemical markers of bone resorption or bone formation. It
chapters, as they clearly set the scene ex-
does correctly identify that there are still many unanswered questions in this area
tremely well for understanding osteoporopathophysiology, sis, its pathogenesis, clinical manifestations, and therapy. This chapter should not be read on its own without a clear understanding of what has come before in this book. As for the chap ter itself, I found it a little disappointing. Bone remodeling occurs on bone surfaces and, with 80 percent of the skeletal surfaces being in cancellous bone, it should come as no surprise that it is cancellous bone that bears the brunt of a disorder of bone remodeling, such as osteoporosis. Although not ignored in this chapter, it is not given the importance I would have assigned to it given the title of this book. Five times as much space is devoted to secondary osteoporosis than to primary osteoporosis, although primary osteoporosis is probably five times more common. Dr. Mundy and I have a genuine difference of opinion as to whether skeletal pain is a clinical feature of osteoporosis in the absence of acute fracture. I believe it is not. He devotes a paragraph indicating that it is, although this paragraph is not referenced. This is a very trivial concern. Of more importance is the subheading “Differential Diagnosis of Osteopenia,” when osteopenia is nowhere clearly defined in this text, and the appropriate use of the terms osteopenia and osteoporosis are also nowhere clearly defined. The section entitled “Laboratory Evaluation of the Osteopenic Patient” is also, in my opinion, s&optimal. The f&t subsection in this part of the chapter is entitled “Abnormalities of Serum Calcium and Phosphorus,” which correctly begins with the sentence, “There are no known abnormalities in calcium or phosphorus homeostasis in patients with primary osteoporosis.” This section, however, provides an all too
of clinical investigation, but there is clearly much more information currently available than is provided in this text. This brief section contains just four references, only one of which is later than 1984. This clearly ignores substantial advances in this area over the last decade. Even more surprising is that an equal amount of space is dedicated to a discussion of bone biopsy, which has decreasing relevance in the evaluation of patients with osteoporosis. One measure of the inadequacy of this chapter is that only 2.5 of the 152 references are dated 1991 and beyond. It is very easy to find individual points to criticize in any publication of this nature. It is impossible to write a perfect monograph. Rather, this review seeks to provide a summation that clearly indicates that the many strengths of this monograph, taken as a whole, far outweigh any minor deficiencies in content, fact, or style. Anyone who takes the time to read this book in its entirety will come away well versed in bone remodeling and its disorders. Anyone who picks up this book simply to seek more information on a specific topic of interest in this field likewise will not be disappointed with what he or she reads. To reiterate, anybody preparing lectures on this topic must use this book for important reference material. Finally, in a note to the author and the publishers, I would love to have a copy of the illustrations in slide form. Preferably in color, please!
Michael Kleerekoper Department of Internal Medicine Wayne State University Detroit, MI 48201-2153, USA PI1 SlO43-2760(96)00057-4
Androgenic Strengths and Weaknesses Androgenic Disorders Edited by Geoffrey P. Redmond. NW York, Raven, 1995, $99.00 (xv t 343 pages), ISBN O-781 7-0274-7. This book is a most comprehensive review of androgenic syndromes in women, with
TEM Vol. 7, No. 5, 1996
small sections on hyperandrogenism and hypoandrogenism in children and adolescents and on congenital adrenal hyperplasias. There is a great deal of extremely usem information in this volume, and most of it is quite accessible. It should be of considerable value to readers of Trends in hdocvitzology and Metabolism. Most of
01996,
Elsevier Science Inc., 1043-2760/96/$15.00
the chapters are suitable for primary care physicians and practicing gynecological and internist endocrinologists, and the chapter on polycystic ovarian (PCO) syndrome offers sophisticated information about complex physiologic mechanisms that are of interest mainly to researchers. The volume contains 343 pages, including
191
a useful index, and consists of 15 selfcontained chapters. Chapters deal with androgen physiology, cellular action, and syndromes associated with androgen excess, including polycystic ovarian disease, congenital adrenal hyperplasia, Cushing’s syndrome, and androgenic alopecia. Chapters are also devoted to evaluation and treatment of women with androgenie disorders. I wish that there had been a higher degree of editing because duplication of information pervades the volume. Redmond’s introductory chapter on the clinical evaluation of andmgenic disorders is a solid contribution of use to clinicians. He reviews all of the manifestations of ovarian androgenic syndromes, contributing insightful personal observations from his extensive experience. Unfortunately, he does not report on what hap pens to these women as they age. Do they progress inexorably? Do they all undergo hysterectomies for dysfunctional bleeding? What proportion of them actually have successful pregnancies? What is the incidence of endometrial carcinoma: of breast or ovarian carcinoma; of myocardial infarction or angina? What happens after the menopause? Do they lose weight as their ovaries cease to function? Do they have protection against osteoporosis? Redmond’s chapter on the treatment of androgenic disorders also is strongly written and deals well with his perception of the practical clinical effectiveness and complications of various treatments for hirsutism and anovulation. It does not review, however, the conclusions of important clinical hirsutism trials that provide the evidentiary basis for therapy or the long-term effects of therapy on the metabolic concomitants of androgen excess in women; for example, insulin resistance, hyperlipemia, obesity, and hypertension. A good example of somewhat inconsistent duplication is the chapter by Demers on laboratory measurement of androgens in women. His algorithm for the differential diagnosis of androgen excess is inconsistent with that of Redmond in that it seems to pay no attention to the clinical history. Most of the time the proposed extensive assessment is not necessary. Testing of 17a-hydroxyprogesterone and ACTH to implicate adrenal versus ovarian sources of the androgen
192
excess, an important consideration in therapy, is not considered. Sawoya’s chapter on androgen action at the cellular level is both detailed and deficient. It describes the interaction of androgens with the DHT receptor in some detail, but fails to indicate the relative potencies of different androgens. It fails to discuss the critical developmental aspects of androgen receptor activity that assure that the penis does not continue to grow throughout life. Nor does it provide important, clinically relevant information about the biological actions of androgens; for example, on the central nervous, hematopoietic, clotting, lipid, and musculoskeletal systems. The chapter by Lee and Siegel on androgens in the pediatric age group is very informative. After reiterating the steroidogenic pathways, they proceed to describe the production and levels of androgens in relation to fetal, neonatal, and pubertal development. I wish they had defined early adrenarche and puberty and delayed maturation in males and made it clear when andmgen excess in female and male adolescents requires therapy. I disagree with their recommendation (p. 71) that reassurance is the only method of handling delayed maturation in males. It has been the practice in many institutions to treat that condition with hCG, even early, to prevent adverse social and psychological consequences. In many respects, the heart of the book is the chapter on polycystic ovarian disease by Walter Futterweit, which cites 501 publications. It must be intended to educate experts in the field. Dr. Futterweit vigorously addresses the question of the pathogenesis of the PC0 syndrome, exploring sequentially the roles of the central nervous system, the ovaries and adrenals. He elaborates on the roles of dysregulation of gonadotropin secretion, abnormalities of prolactin secretion related to dopamine deficiency, and the role of inhibin and other neuroregulators in disrupting the cyclic the hypothalamicregulation of pituitary-ovarian system. He then proceeds to an analysis of ovarian defects with focus on estrogen, androgen, and progestin production and their impacts on the hypothalamus. He discusses the estrone hypothesis, adrenal contributions to the dysregulation of cytochrome p45Ocl ~CX.He reviews aberrant folliculo-
81996, Ekevier Science Inc., 1043-2760/96/$15.00
genesis caused by mistimed gonadotropin production or by the effects of IGF and their binding proteins on various cells of the ovaries. Also reviewed are potential pathogenic mechanisms for obesity and insulin resistance that so often accompany the androgenic syndrome(s). This is pretty complicated material and it is important to discard the rejected as well as include the pertinent. Eugene Garfield once indicated, when writing on the importance of reviews in science, that a good review does more than list the results of others; it integrates many thoughts, if possible, into an internally consistent conceptual framework that sheds new light on the phenomenon under review. In the case of the present volume, vast quantities of research have been digested and schemata for the main hypotheses are given in informative cartoons, but there is no personal viewpoint expressed or overall integrative framework created. Adult onset adrenal hyperplasia is not integrated into the conceptualizations of the PC0 syndrome, and, most disappointing, there has been no real attempt to consider the syndrome as a progressive condition with vicious cycles leading to anovulation, hirsutism, and weight gain of increasing severity. For example, the development of polycystic ovaries and anovulation characterizes maturation of females with 2 1-hydroxylase deficiency. What is the sequence of events leading to this state that mimics PCO? Does it produce the insulin resistance associated with classic PCO? What can it tell us about the progression of the PC0 phenotype over time regardless of the initiating lesion? The article by Loche and New on adrenal hyperplasia deals with the childhood forms in an illuminating manner, but it ignores the adult forms that they have studied so fully and whose clinical characteristics and prevalence remain an issue. That’s too bad. Sheeler’s article on Cushing’s syndrome, although intended to focus on androgen excess, turned out to be a classic review on the whole syndrome, with a page on virilizing adrenal tumors. The differences in degree of androgenization versus glucocorticoid excess could have virilization Serious been stressed. strongly suggests carcinoma because these tumors are inefficient cortisol producers. By contrast, adrenal adenomas, TEM Vol. 7, No. 5, 1996
and adrenal hyperplasia resulting from either eutopic or ectopic ACTH excess, provide very efficient cortisol production and, therefore, relatively little virilization. The diagnostic dilemma-is this woman androgenized or does she have Cushing’s syndrome-is almost always not from Cushing’s syndrome. Clinical clues include the lack of weakness, lack of fat redistribution, lack of striae, and onset early in menstrual life even if the presentation is much later. An occasional increased urinary free cortisol or dexamethasone suppression test may occur in androgenized women. The great danger is surgery for Cushing’s disease in someone who doesn’t have the condition, and that decision is for an expert. The articles on acne, alopecia, and local treatment of body and facial hair will
be quite
valuable
their patients. Derman’s article
to practitioners on androgens
and
the
and
those who succeed. Thus, we have flawed, contribution
oral contraceptives is a strong contribution. By reviewing the androgenic function of oral progestins, both as to binding to the androgen receptor and to sex hormone-binding globulin, as well as their effects on high-density lipoprotein and low-density lipoprotein (HDL) (LDL) cholesterol, he shows the scientific basis for the advantages of the newer progestins in selecting treatment for women with androgenic syndromes. Finally, Wild’s chapter on the relation of androgenic disorders to cardiovascular disease is both useful and disappointing. Although it gives the general rationale for treatment with exercise, weight loss, and cholesterol-lowering drugs, it fails to consider the important issue of
extent
to which
treatment
helps
an important, but both to the science
and to the practice of medicine as they pertain to androgenic syndromes. Some of the weaknesses surely result from a lack of reliable information, and I hope that new studies will shed much light on these disturbing conditions. The book was quite useful to me and I think it will be useful to physicians patients.
managing
these
Stanley G. Korenman Department of Medicine Division of Endocrinology University of California at Los Angeles School of Medicine Los Angeles, CA 90095,
USA
PII SlO43-276O(Y6)00058-6
Stress-Free Presentation Stress Proteins in Medicine Edited by Willem van Eden and Douglas B. Young. New York, Marcel Dekker, 1996, $195.00 (x + 569 pages), ISBN O-824 7-9623-3. This book is the first compilation of observations made on the topic of stress proteins in disease. It is an excellent resource for those people who want to stay informed in a variety of areas concerning stress proteins. The book is intended to reach readers who are experienced professionals in their fields; medical doctors, pathologists, cell biologists, immunologists, and microbiologists. The chapters are written by international experts in the field and are well referenced with up-to-date citations. The book begins with an overview of stress proteins as chaperones, as heatshock proteins, and of their clinical implications and immune system interactions. This introduction is followed by 15 chapters that focus on immunological responses to stress proteins in a range of immune-mediated disease, such as arthritis, lupus, and others of clinical significance. Three of these
TEM Vol.7,No. 5,1996
chapters focus on infertility, tumor immunology, and organ transplantation, respectively. The next section includes 12 chapters that consider local expression of stress proteins in diseased tissues, and include discussions of sarcoidosis, diabetes, and atherogenesis and diabetes. The final section has four chapters that describe the roles of stress proteins and their interactions with proteins or cells in immunity. Topics include the role of heat-shock proteins in cancer vaccination, and response of Tcells to heat-shock proteins. The general theme of the book is the involvement of stress proteins in immune response and in clinical disease. The chapter entitled “Clinical Implications of the Stress Response,” written by Minowada and Welch, is an excellent review of the heat-shock response and how it has clinical implications. The chapter
is easy to read and the refer-
ences are good and as up-to-date as can be expected from any book (the latest reference cited is from 1993 and this is true of all the chapters). The chapter “T-cell Responses Shock Proteins in Rheumatoid
01996,
to Heat Arthri-
Elsevier Science Inc., 1043-2760/96/$15.00
tis,” by Wiker, Harboe, and Natvig, is equally good. The experienced research immunologist and physician should have no trouble reading the material and there are abundant references from which to enter the primary literature. In addition, many authors use figures of primary data in their chapters to illustrate pertinent points. These figures allow the reader to examine the detail first hand, rather than simply reading the review and finding the viewpoints and bias of the authors. On the whole, the book is a very good review of the stress proteins in medicine. The approach is well rounded, giving examples in a variety of clinical situations, and it will serve clinicians well as a reference book. The reader should be familiar with the terms and concepts prior to reading the book, and thus it is not for the lay person or beginning medical student.
Indiana
Elliott J. Blumenthal Department of Biology University-Purdue University Fort Wayne, IN 46805,
USA
PII SlO43-2760(96)00059-B
193
it would be worthwhile to scan again the information in the introductory four
brief discussion of biochemical markers of bone resorption or bone formation. It
chapters, as they clearly set the scene ex-
does correctly identify that there are still many unanswered questions in this area
tremely well for understanding osteoporopathophysiology, sis, its pathogenesis, clinical manifestations, and therapy. This chapter should not be read on its own without a clear understanding of what has come before in this book. As for the chap ter itself, I found it a little disappointing. Bone remodeling occurs on bone surfaces and, with 80 percent of the skeletal surfaces being in cancellous bone, it should come as no surprise that it is cancellous bone that bears the brunt of a disorder of bone remodeling, such as osteoporosis. Although not ignored in this chapter, it is not given the importance I would have assigned to it given the title of this book. Five times as much space is devoted to secondary osteoporosis than to primary osteoporosis, although primary osteoporosis is probably five times more common. Dr. Mundy and I have a genuine difference of opinion as to whether skeletal pain is a clinical feature of osteoporosis in the absence of acute fracture. I believe it is not. He devotes a paragraph indicating that it is, although this paragraph is not referenced. This is a very trivial concern. Of more importance is the subheading “Differential Diagnosis of Osteopenia,” when osteopenia is nowhere clearly defined in this text, and the appropriate use of the terms osteopenia and osteoporosis are also nowhere clearly defined. The section entitled “Laboratory Evaluation of the Osteopenic Patient” is also, in my opinion, s&optimal. The f&t subsection in this part of the chapter is entitled “Abnormalities of Serum Calcium and Phosphorus,” which correctly begins with the sentence, “There are no known abnormalities in calcium or phosphorus homeostasis in patients with primary osteoporosis.” This section, however, provides an all too
of clinical investigation, but there is clearly much more information currently available than is provided in this text. This brief section contains just four references, only one of which is later than 1984. This clearly ignores substantial advances in this area over the last decade. Even more surprising is that an equal amount of space is dedicated to a discussion of bone biopsy, which has decreasing relevance in the evaluation of patients with osteoporosis. One measure of the inadequacy of this chapter is that only 2.5 of the 152 references are dated 1991 and beyond. It is very easy to find individual points to criticize in any publication of this nature. It is impossible to write a perfect monograph. Rather, this review seeks to provide a summation that clearly indicates that the many strengths of this monograph, taken as a whole, far outweigh any minor deficiencies in content, fact, or style. Anyone who takes the time to read this book in its entirety will come away well versed in bone remodeling and its disorders. Anyone who picks up this book simply to seek more information on a specific topic of interest in this field likewise will not be disappointed with what he or she reads. To reiterate, anybody preparing lectures on this topic must use this book for important reference material. Finally, in a note to the author and the publishers, I would love to have a copy of the illustrations in slide form. Preferably in color, please!
Michael Kleerekoper Department of Internal Medicine Wayne State University Detroit, MI 48201-2153, USA PI1 SlO43-2760(96)00057-4
Androgenic Strengths and Weaknesses Androgenic Disorders Edited by Geoffrey P. Redmond. NW York, Raven, 1995, $99.00 (xv t 343 pages), ISBN O-781 7-0274-7. This book is a most comprehensive review of androgenic syndromes in women, with
TEM Vol. 7, No. 5, 1996
small sections on hyperandrogenism and hypoandrogenism in children and adolescents and on congenital adrenal hyperplasias. There is a great deal of extremely usem information in this volume, and most of it is quite accessible. It should be of considerable value to readers of Trends in hdocvitzology and Metabolism. Most of
01996,
Elsevier Science Inc., 1043-2760/96/$15.00
the chapters are suitable for primary care physicians and practicing gynecological and internist endocrinologists, and the chapter on polycystic ovarian (PCO) syndrome offers sophisticated information about complex physiologic mechanisms that are of interest mainly to researchers. The volume contains 343 pages, including
191
a useful index, and consists of 15 selfcontained chapters. Chapters deal with androgen physiology, cellular action, and syndromes associated with androgen excess, including polycystic ovarian disease, congenital adrenal hyperplasia, Cushing’s syndrome, and androgenic alopecia. Chapters are also devoted to evaluation and treatment of women with androgenie disorders. I wish that there had been a higher degree of editing because duplication of information pervades the volume. Redmond’s introductory chapter on the clinical evaluation of andmgenic disorders is a solid contribution of use to clinicians. He reviews all of the manifestations of ovarian androgenic syndromes, contributing insightful personal observations from his extensive experience. Unfortunately, he does not report on what hap pens to these women as they age. Do they progress inexorably? Do they all undergo hysterectomies for dysfunctional bleeding? What proportion of them actually have successful pregnancies? What is the incidence of endometrial carcinoma: of breast or ovarian carcinoma; of myocardial infarction or angina? What happens after the menopause? Do they lose weight as their ovaries cease to function? Do they have protection against osteoporosis? Redmond’s chapter on the treatment of androgenic disorders also is strongly written and deals well with his perception of the practical clinical effectiveness and complications of various treatments for hirsutism and anovulation. It does not review, however, the conclusions of important clinical hirsutism trials that provide the evidentiary basis for therapy or the long-term effects of therapy on the metabolic concomitants of androgen excess in women; for example, insulin resistance, hyperlipemia, obesity, and hypertension. A good example of somewhat inconsistent duplication is the chapter by Demers on laboratory measurement of androgens in women. His algorithm for the differential diagnosis of androgen excess is inconsistent with that of Redmond in that it seems to pay no attention to the clinical history. Most of the time the proposed extensive assessment is not necessary. Testing of 17a-hydroxyprogesterone and ACTH to implicate adrenal versus ovarian sources of the androgen
192
excess, an important consideration in therapy, is not considered. Sawoya’s chapter on androgen action at the cellular level is both detailed and deficient. It describes the interaction of androgens with the DHT receptor in some detail, but fails to indicate the relative potencies of different androgens. It fails to discuss the critical developmental aspects of androgen receptor activity that assure that the penis does not continue to grow throughout life. Nor does it provide important, clinically relevant information about the biological actions of androgens; for example, on the central nervous, hematopoietic, clotting, lipid, and musculoskeletal systems. The chapter by Lee and Siegel on androgens in the pediatric age group is very informative. After reiterating the steroidogenic pathways, they proceed to describe the production and levels of androgens in relation to fetal, neonatal, and pubertal development. I wish they had defined early adrenarche and puberty and delayed maturation in males and made it clear when andmgen excess in female and male adolescents requires therapy. I disagree with their recommendation (p. 71) that reassurance is the only method of handling delayed maturation in males. It has been the practice in many institutions to treat that condition with hCG, even early, to prevent adverse social and psychological consequences. In many respects, the heart of the book is the chapter on polycystic ovarian disease by Walter Futterweit, which cites 501 publications. It must be intended to educate experts in the field. Dr. Futterweit vigorously addresses the question of the pathogenesis of the PC0 syndrome, exploring sequentially the roles of the central nervous system, the ovaries and adrenals. He elaborates on the roles of dysregulation of gonadotropin secretion, abnormalities of prolactin secretion related to dopamine deficiency, and the role of inhibin and other neuroregulators in disrupting the cyclic the hypothalamicregulation of pituitary-ovarian system. He then proceeds to an analysis of ovarian defects with focus on estrogen, androgen, and progestin production and their impacts on the hypothalamus. He discusses the estrone hypothesis, adrenal contributions to the dysregulation of cytochrome p45Ocl ~CX.He reviews aberrant folliculo-
81996, Ekevier Science Inc., 1043-2760/96/$15.00
genesis caused by mistimed gonadotropin production or by the effects of IGF and their binding proteins on various cells of the ovaries. Also reviewed are potential pathogenic mechanisms for obesity and insulin resistance that so often accompany the androgenic syndrome(s). This is pretty complicated material and it is important to discard the rejected as well as include the pertinent. Eugene Garfield once indicated, when writing on the importance of reviews in science, that a good review does more than list the results of others; it integrates many thoughts, if possible, into an internally consistent conceptual framework that sheds new light on the phenomenon under review. In the case of the present volume, vast quantities of research have been digested and schemata for the main hypotheses are given in informative cartoons, but there is no personal viewpoint expressed or overall integrative framework created. Adult onset adrenal hyperplasia is not integrated into the conceptualizations of the PC0 syndrome, and, most disappointing, there has been no real attempt to consider the syndrome as a progressive condition with vicious cycles leading to anovulation, hirsutism, and weight gain of increasing severity. For example, the development of polycystic ovaries and anovulation characterizes maturation of females with 2 1-hydroxylase deficiency. What is the sequence of events leading to this state that mimics PCO? Does it produce the insulin resistance associated with classic PCO? What can it tell us about the progression of the PC0 phenotype over time regardless of the initiating lesion? The article by Loche and New on adrenal hyperplasia deals with the childhood forms in an illuminating manner, but it ignores the adult forms that they have studied so fully and whose clinical characteristics and prevalence remain an issue. That’s too bad. Sheeler’s article on Cushing’s syndrome, although intended to focus on androgen excess, turned out to be a classic review on the whole syndrome, with a page on virilizing adrenal tumors. The differences in degree of androgenization versus glucocorticoid excess could have virilization Serious been stressed. strongly suggests carcinoma because these tumors are inefficient cortisol producers. By contrast, adrenal adenomas, TEM Vol. 7, No. 5, 1996
and adrenal hyperplasia resulting from either eutopic or ectopic ACTH excess, provide very efficient cortisol production and, therefore, relatively little virilization. The diagnostic dilemma-is this woman androgenized or does she have Cushing’s syndrome-is almost always not from Cushing’s syndrome. Clinical clues include the lack of weakness, lack of fat redistribution, lack of striae, and onset early in menstrual life even if the presentation is much later. An occasional increased urinary free cortisol or dexamethasone suppression test may occur in androgenized women. The great danger is surgery for Cushing’s disease in someone who doesn’t have the condition, and that decision is for an expert. The articles on acne, alopecia, and local treatment of body and facial hair will
be quite
valuable
their patients. Derman’s article
to practitioners on androgens
and
the
and
those who succeed. Thus, we have flawed, contribution
oral contraceptives is a strong contribution. By reviewing the androgenic function of oral progestins, both as to binding to the androgen receptor and to sex hormone-binding globulin, as well as their effects on high-density lipoprotein and low-density lipoprotein (HDL) (LDL) cholesterol, he shows the scientific basis for the advantages of the newer progestins in selecting treatment for women with androgenic syndromes. Finally, Wild’s chapter on the relation of androgenic disorders to cardiovascular disease is both useful and disappointing. Although it gives the general rationale for treatment with exercise, weight loss, and cholesterol-lowering drugs, it fails to consider the important issue of
extent
to which
treatment
helps
an important, but both to the science
and to the practice of medicine as they pertain to androgenic syndromes. Some of the weaknesses surely result from a lack of reliable information, and I hope that new studies will shed much light on these disturbing conditions. The book was quite useful to me and I think it will be useful to physicians patients.
managing
these
Stanley G. Korenman Department of Medicine Division of Endocrinology University of California at Los Angeles School of Medicine Los Angeles, CA 90095,
USA
PII SlO43-276O(Y6)00058-6
Stress-Free Presentation Stress Proteins in Medicine Edited by Willem van Eden and Douglas B. Young. New York, Marcel Dekker, 1996, $195.00 (x + 569 pages), ISBN O-824 7-9623-3. This book is the first compilation of observations made on the topic of stress proteins in disease. It is an excellent resource for those people who want to stay informed in a variety of areas concerning stress proteins. The book is intended to reach readers who are experienced professionals in their fields; medical doctors, pathologists, cell biologists, immunologists, and microbiologists. The chapters are written by international experts in the field and are well referenced with up-to-date citations. The book begins with an overview of stress proteins as chaperones, as heatshock proteins, and of their clinical implications and immune system interactions. This introduction is followed by 15 chapters that focus on immunological responses to stress proteins in a range of immune-mediated disease, such as arthritis, lupus, and others of clinical significance. Three of these
TEM Vol.7,No. 5,1996
chapters focus on infertility, tumor immunology, and organ transplantation, respectively. The next section includes 12 chapters that consider local expression of stress proteins in diseased tissues, and include discussions of sarcoidosis, diabetes, and atherogenesis and diabetes. The final section has four chapters that describe the roles of stress proteins and their interactions with proteins or cells in immunity. Topics include the role of heat-shock proteins in cancer vaccination, and response of Tcells to heat-shock proteins. The general theme of the book is the involvement of stress proteins in immune response and in clinical disease. The chapter entitled “Clinical Implications of the Stress Response,” written by Minowada and Welch, is an excellent review of the heat-shock response and how it has clinical implications. The chapter
is easy to read and the refer-
ences are good and as up-to-date as can be expected from any book (the latest reference cited is from 1993 and this is true of all the chapters). The chapter “T-cell Responses Shock Proteins in Rheumatoid
01996,
to Heat Arthri-
Elsevier Science Inc., 1043-2760/96/$15.00
tis,” by Wiker, Harboe, and Natvig, is equally good. The experienced research immunologist and physician should have no trouble reading the material and there are abundant references from which to enter the primary literature. In addition, many authors use figures of primary data in their chapters to illustrate pertinent points. These figures allow the reader to examine the detail first hand, rather than simply reading the review and finding the viewpoints and bias of the authors. On the whole, the book is a very good review of the stress proteins in medicine. The approach is well rounded, giving examples in a variety of clinical situations, and it will serve clinicians well as a reference book. The reader should be familiar with the terms and concepts prior to reading the book, and thus it is not for the lay person or beginning medical student.
Indiana
Elliott J. Blumenthal Department of Biology University-Purdue University Fort Wayne, IN 46805,
USA
PII SlO43-2760(96)00059-B
193