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Depression and Anxiety Scores Are Associated with Amygdala Volume in Cushing's Syndrome: Preliminary Study. BIOMED RESEARCH INTERNATIONAL 2017; 2017:2061935. [PMID: 28607927 PMCID: PMC5451775 DOI: 10.1155/2017/2061935] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/31/2017] [Accepted: 04/26/2017] [Indexed: 01/13/2023]
Abstract
Introduction Cushing's syndrome (CS) has repeatedly been associated with hippocampal volume reductions, while little information is available on the amygdala, another structure rich in glucocorticoid receptors. The aim of the study was to analyze amygdala volume in patients with CS and its relationship with anxiety, depression, and hormone levels. Material and Methods 39 CS patients (16 active and 23 patients in remission) and 39 healthy controls matched for age, sex, and education level completed anxiety (STAI) and depression tests (BDI-II) and underwent a 3 Tesla brain MRI and endocrine testing. Amygdala volumes were analysed with FreeSurfer software. Results Active CS patients had smaller right (but not left) amygdala volumes when compared to controls (P = 0.045). Left amygdala volumes negatively correlated with depression scores (r = −0.692, P = 0.003) and current anxiety state scores (r = −0.617, P = 0.011) in active CS patients and with anxiety trait scores (r = −0.440, P = 0.036) in patients in remission. No correlations were found between current ACTH, urinary free cortisol or blood cortisol levels, and amygdala volumes in either patient group. Conclusion Patients with active CS have a smaller right amygdala volume in comparison to controls, while left amygdala volumes are associated with mood state in both patient groups.
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Glad CAM, Andersson-Assarsson JC, Berglund P, Bergthorsdottir R, Ragnarsson O, Johannsson G. Reduced DNA methylation and psychopathology following endogenous hypercortisolism - a genome-wide study. Sci Rep 2017; 7:44445. [PMID: 28300138 PMCID: PMC5353706 DOI: 10.1038/srep44445] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/08/2017] [Indexed: 01/21/2023] Open
Abstract
Patients with Cushing’s Syndrome (CS) in remission were used as a model to test the hypothesis that long-standing excessive cortisol exposure induces changes in DNA methylation that are associated with persisting neuropsychological consequences. Genome-wide DNA methylation was assessed in 48 women with CS in long-term remission (cases) and 16 controls matched for age, gender and education. The Fatigue impact scale and the comprehensive psychopathological rating scale were used to evaluate fatigue, depression and anxiety. Cases had lower average global DNA methylation than controls (81.2% vs 82.7%; p = 0.002). Four hundred and sixty-one differentially methylated regions, containing 3,246 probes mapping to 337 genes were identified. After adjustment for age and smoking, 731 probes in 236 genes were associated with psychopathology (fatigue, depression and/or anxiety). Twenty-four gene ontology terms were associated with psychopathology; terms related to retinoic acid receptor signalling were the most common (adjusted p = 0.0007). One gene in particular, COL11A2, was associated with fatigue following a false discovery rate correction. Our findings indicate that hypomethylation of FKBP5 and retinoic acid receptor related genes serve a potential mechanistic explanation for long-lasting GC-induced psychopathology.
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Affiliation(s)
- Camilla A M Glad
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna C Andersson-Assarsson
- Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Berglund
- Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Jiang H, He NY, Sun YH, Jian FF, Bian LG, Shen JK, Yan FH, Pan SJ, Sun QF. Altered spontaneous brain activity in Cushing's disease: a resting-state functional MRI study. Clin Endocrinol (Oxf) 2017; 86:367-376. [PMID: 27859451 DOI: 10.1111/cen.13277] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 10/21/2016] [Accepted: 11/04/2016] [Indexed: 01/23/2023]
Abstract
CONTEXT AND OBJECTIVE Cushing's disease (CD) provides a unique and naturalist model for studying the influence of hypercortisolism on the human brain and the reversibility of these effects after resolution of the condition. This cross-sectional study used resting-state fMRI (rs-fMRI) to investigate the altered spontaneous brain activity in CD patients and the trends for potential reversibility after the resolution of the hypercortisolism. We also aim to determine the relationship of these changes with clinical characteristics and cortisol levels. SUBJECTS AND METHODS Active CD patients (n = 18), remitted CD patients (n = 14) and healthy control subjects (n = 22) were included in this study. Amplitude of low-frequency fluctuation (ALFF) and regional homogeneity (ReHo) values were calculated to represent spontaneous brain activity. RESULTS Our study resulted in three major findings: (i) active CD patients showed significantly altered spontaneous brain activity in the posterior cingulate cortex (PCC)/precuneus (PCu), occipital lobe (OC)/cerebellum, thalamus, right postcentral gyrus (PoCG) and left prefrontal cortex (PFC); (ii) trends for partial restoration of altered spontaneous brain activity after the resolution hypercortisolism were found in several brain regions; and (iii) active CD patients showed a significant correlation between cortisol levels and ALFF/ReHo values in the PCC/PCu, a small cluster in the OC and the right IPL. CONCLUSIONS This study provides a new approach to investigating brain function abnormalities in patients with CD and enhances our understanding of the effect of hypercortisolism on the human brain. Furthermore, our explorative potential reversibility study of patients with CD may facilitate the development of future longitudinal studies.
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Affiliation(s)
- Hong Jiang
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Na-Ying He
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu-Hao Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang-Fang Jian
- Department of Endocrinology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liu-Guan Bian
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Kang Shen
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fu-Hua Yan
- Department of Radiology, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Si-Jian Pan
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qing-Fang Sun
- Department of Neurosurgery, Rui-Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Neurosurgery, Rui-Jin Lu-Wan Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Salvat-Pujol N, Labad J, Urretavizcaya M, de Arriba-Arnau A, Segalàs C, Real E, Ferrer A, Crespo JM, Jiménez-Murcia S, Soriano-Mas C, Menchón JM, Soria V. Hypothalamic-pituitary-adrenal axis activity and cognition in major depression: The role of remission status. Psychoneuroendocrinology 2017; 76:38-48. [PMID: 27883963 DOI: 10.1016/j.psyneuen.2016.11.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 11/04/2016] [Accepted: 11/05/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Neuropsychological deficits and hypothalamic-pituitary-adrenal (HPA) axis dysfunction have been described in major depressive disorder (MDD). We conducted an exploratory study to investigate the role of remission status in the relationship between HPA axis and cognition in MDD. METHODS Ninety-seven MDD patients (44 remitted, 53 non-remitted) and 97 healthy controls (HC) were evaluated. We measured verbal and visual memory, working memory, processing speed, attention, and executive function. Three HPA axis measures were assessed: cortisol awakening response (CAR), diurnal cortisol slope, and cortisol suppression ratio with 0.25mg of dexamethasone (DSTR). Multiple linear regression analyses were performed to study the relationship between cortisol measures and cognition while controlling for potential confounders. We conducted an overall analysis in all participants to compare both MDD-remitted and MDD non-remitted groups with respect to HC. Another analysis including MDD patients only was used to explore a moderating effect by remission status. RESULTS MDD patients showed poorer cognitive performance compared with HC, without significant differences between remitters and non-remitters. Cortisol measures did not differ between remitters and non-remitters. Although most HPA axis measures were not associated with cognitive dysfunction, we found significant associations between cognitive performance in MDD-remitters and cortisol measures for visual memory, processing speed and executive function. A significant moderating effect for remission status was found between cortisol diurnal slope (but neither CAR nor DSTR) and performance in processing speed or executive function. CONCLUSIONS Remission status in MDD appears to moderate the association between some cognitive domains (processing speed and executive function) and HPA axis activity.
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Affiliation(s)
- Neus Salvat-Pujol
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain
| | - Javier Labad
- Corporació Sanitària Parc Taulí, Department of Mental Health, I3PT, Universitat Autònoma de Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain
| | - Mikel Urretavizcaya
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Aida de Arriba-Arnau
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain
| | - Cinto Segalàs
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain
| | - Eva Real
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain
| | - Alex Ferrer
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain
| | - José M Crespo
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Susana Jiménez-Murcia
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Fisiopatología Obesidad y Nutrición (CIBEROBN), Carlos III Health Institute, Spain
| | - Carles Soriano-Mas
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain; Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, Spain
| | - José M Menchón
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain
| | - Virginia Soria
- Bellvitge University Hospital, Psychiatry Department, Bellvitge Biomedical Research Institute (IDIBELL), Neurosciences Group - Psychiatry and Mental Health, Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Carlos III Health Institute, Spain; Department of Clinical Sciences, School of Medicine, Universitat de Barcelona, Barcelona, Spain.
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Resmini E, Santos A, Aulinas A, Webb SM, Vives-Gilabert Y, Cox O, Wand G, Lee RS. Reduced DNA methylation of FKBP5 in Cushing's syndrome. Endocrine 2016; 54:768-777. [PMID: 27664120 PMCID: PMC6391874 DOI: 10.1007/s12020-016-1083-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/09/2016] [Indexed: 12/21/2022]
Abstract
FKBP5 encodes a co-chaperone of HSP90 protein that regulates intracellular glucocorticoid receptor sensitivity. When it is bound to the glucocorticoid receptor complex, cortisol binds with lower affinity to glucocorticoid receptor. Cushing's syndrome is associated with memory deficits, smaller hippocampal volumes, and wide range of cognitive impairments. We aimed at evaluating blood DNA methylation of FKBP5 and its relationship with memory and hippocampal volumes in Cushing's syndrome patients. Polymorphism rs1360780 in FKBP5 has also been assessed to determine whether genetic variations can also govern CpG methylation. Thirty-two Cushing's syndrome patients and 32 matched controls underwent memory tests, 3-Tesla MRI of the brain, and DNA extraction from total leukocytes. DNA samples were bisulfite treated, PCR amplified, and pyrosequenced to assess a total of 41CpG-dinucleotides in the introns 1, 2, 5, and 7 of FKBP5. Significantly lower intronic FKBP5 DNA methylation in CS patients compared to controls was observed in ten CpG-dinucleotides. DNA methylation at these CpGs correlated with left and right HV (Intron-2-Region-2-CpG-3: LHV, r = 0.73, p = 0.02; RHV, r = 0.58, p = 0.03). Cured and active CS patients showed both lower methylation of intron 2 (92.37, 91.8, and 93.34 %, respectively, p = 0.03 for both) and of intron 7 (77.08, 73.74, and 79.71 %, respectively, p = 0.02 and p < 0.01) than controls. Twenty-two subjects had the CC genotype, 34 had the TC genotype, and eight had the TT genotype. Lower average DNA methylation in intron 7 was observed in the TT subjects compared to CC (72.5vs. 79.5 %, p = 0.02) and to TC (72.5 vs. 79.0 %, p = 0.03). Our data demonstrate, for the first time, a reduction of intronic DNA methylation of FKBP5 in CS patients.
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Affiliation(s)
- Eugenia Resmini
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
| | - Alicia Santos
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Anna Aulinas
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Susan M Webb
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | | | - Olivia Cox
- Departments of Psychiatry and Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gary Wand
- Departments of Psychiatry and Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard S Lee
- Departments of Psychiatry and Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Crespo I, Santos A, Gómez-Ansón B, López-Mourelo O, Pires P, Vives-Gilabert Y, Webb SM, Resmini E. Brain metabolite abnormalities in ventromedial prefrontal cortex are related to duration of hypercortisolism and anxiety in patients with Cushing's syndrome. Endocrine 2016; 53:848-56. [PMID: 27103571 DOI: 10.1007/s12020-016-0963-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/15/2016] [Indexed: 10/21/2022]
Abstract
Chronic exposure to excessive glucocorticoid (GC) concentration in Cushing's syndrome (CS) can affect the brain structurally and functionally; ventromedial prefrontal cortex (vmPFC) is rich in GC receptors and therefore particularly vulnerable to excessive GC concentration. Proton magnetic resonance spectroscopy ((1)H-MRS) is a sensitive, non-invasive imaging technique that provides information on brain metabolites in vivo. Our aim was to investigate metabolite concentrations in vmPFC of CS patients and their relationship with clinical outcome. Twenty-two right-handed CS patients (7 active/15 in remission, 19 females, 41.6 ± 12.3 years) and 22 right-handed healthy controls (14 females, 41.7 ± 11 years) underwent brain MRI and (1)H-MRS exams at 3 Tesla. Concentrations of glutamate (Glu), glutamate + glutamine (Glx), creatine (Cr), N-Acetyl-aspartate (NAA), N-Acetyl-aspartate + N-acetylaspartylglutamate (total NAA), choline-containing compounds (Cho) and myoinositol (MI) were determined. Moreover, anxiety and depressive symptoms were evaluated with the State-Trait Anxiety Inventory (STAI) and the Beck Depression Inventory-II (BDI-II) test, respectively. CS patients had lower concentrations of glutamate and total NAA in the vmPFC than healthy controls (8.6 ± 1.2 vs. 9.3 ± 0.7 mmol/L, and 6.4 ± 0.8 vs. 6.8 ± 0.4 mmol/L, respectively; p < 0.05). Duration of hypercortisolism was negatively correlated with total NAA (r = -0.488, p < 0.05). Moreover, the concentration of total NAA was negatively correlated with anxiety state (r = -0.359, p < 0.05). Brain metabolites are abnormal in the vmPFC of patients with CS. Decreased total NAA and glutamate concentrations indicate neuronal dysfunction that appear to be related with duration of hypercortisolism and anxiety.
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Affiliation(s)
- Iris Crespo
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret n.167, 08025, Barcelona, Spain
| | - Alicia Santos
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret n.167, 08025, Barcelona, Spain
| | - Beatriz Gómez-Ansón
- Neuroradiology Unit, Hospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, Spain
| | | | - Patricia Pires
- INNDACYT, Avda. Europa, 20, Planta Baja Puerta, D 08907, Hospitalet de Llobregat, Spain
| | | | - Susan M Webb
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret n.167, 08025, Barcelona, Spain
| | - Eugenia Resmini
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), C/Sant Antoni Maria Claret n.167, 08025, Barcelona, Spain.
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Forget H, Lacroix A, Bourdeau I, Cohen H. Long-term cognitive effects of glucocorticoid excess in Cushing's syndrome. Psychoneuroendocrinology 2016; 65:26-33. [PMID: 26708069 DOI: 10.1016/j.psyneuen.2015.11.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 11/19/2015] [Accepted: 11/20/2015] [Indexed: 11/28/2022]
Abstract
CONTEXT AND OBJECTIVE We previously found that patients with Cushing's syndrome (CS) scored lower than controls in several domains of cognitive function and that correction of hypercortisolism is not necessarily correlated with short-term improvement in intellectual performance. Here, we examined the long-term outcome in patients treated for CS by assessing the extent to which the detrimental effects of glucocorticoid (GC) excess on cognition can be reversed three years after corrective surgery. DESIGN A battery of neuropsychological tests, including tests of attention, visuospatial processing, learning and memory, and executive functioning were administered pre-treatment and 12, 24 and 36 months post-treatment. PATIENTS AND CONTROL SUBJECTS We included 18 patients with endogenous CS recruited before surgical treatment and 18 controls matched for age, sex and education. RESULTS CS patients performed worse than controls on tests of attention, executive functioning and nonverbal aspects of memory. Moreover, at 36 months following eucortisolism, executive function performance and, to a lesser extent, attention tasks showed limited change compared to pre-treatment testing. CONCLUSION Chronic hypercortisolism is accompanied by a deleterious impact on aspects of cognitive function. This negative effect on attention, executive performance and nonverbal memory seen in patients with CS suggests a differential effect of excess GCs upon different brain areas and networks. This influence persists years after the return to normal cortisol secretion levels.
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Affiliation(s)
- Hélène Forget
- Département de psychoéducation et de psychologie, Université du Québec en Outaouais, Gatineau, Québec J8X 3X7, Canada.
| | - André Lacroix
- Endocrinology Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, Québec H2W 1T8, Canada
| | - Isabelle Bourdeau
- Endocrinology Division, Department of Medicine, Centre hospitalier de l'Université de Montréal, Montréal, Québec H2W 1T8, Canada
| | - Henri Cohen
- Département de psychologie & Institut des Sciences Cognitives, Université du Québec à Montréal, Montréal, Québec H3C 3P8, Canada
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Moeller SJ, Couto L, Cohen V, Lalazar Y, Makotkine I, Williams N, Yehuda R, Goldstein RZ, Geer EB. Glucocorticoid Regulation of Food-Choice Behavior in Humans: Evidence from Cushing's Syndrome. Front Neurosci 2016; 10:21. [PMID: 26903790 PMCID: PMC4742561 DOI: 10.3389/fnins.2016.00021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/18/2016] [Indexed: 12/20/2022] Open
Abstract
The mechanisms by which glucocorticoids regulate food intake and resulting body mass in humans are not well-understood. One potential mechanism could involve modulation of reward processing, but human stress models examining effects of glucocorticoids on behavior contain important confounds. Here, we studied individuals with Cushing's syndrome, a rare endocrine disorder characterized by chronic excess endogenous glucocorticoids. Twenty-three patients with Cushing's syndrome (13 with active disease; 10 with disease in remission) and 15 controls with a comparably high body mass index (BMI) completed two simulated food-choice tasks (one with “explicit” task contingencies and one with “probabilistic” task contingencies), during which they indicated their objective preference for viewing high calorie food images vs. standardized pleasant, unpleasant, and neutral images. All participants also completed measures of food craving, and approximately half of the participants provided 24-h urine samples for assessment of cortisol and cortisone concentrations. Results showed that on the explicit task (but not the probabilistic task), participants with active Cushing's syndrome made fewer food-related choices than participants with Cushing's syndrome in remission, who in turn made fewer food-related choices than overweight controls. Corroborating this group effect, higher urine cortisone was negatively correlated with food-related choice in the subsample of all participants for whom these data were available. On the probabilistic task, despite a lack of group differences, higher food-related choice correlated with higher state and trait food craving in active Cushing's patients. Taken together, relative to overweight controls, Cushing's patients, particularly those with active disease, displayed a reduced vigor of responding for food rewards that was presumably attributable to glucocorticoid abnormalities. Beyond Cushing's, these results may have relevance for elucidating glucocorticoid contributions to food-seeking behavior, enhancing mechanistic understanding of weight fluctuations associated with oral glucocorticoid therapy and/or chronic stress, and informing the neurobiology of neuropsychiatric conditions marked by abnormal cortisol dynamics (e.g., major depression, Alzheimer's disease).
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Affiliation(s)
- Scott J Moeller
- Department of Psychiatry, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neuroscience, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Lizette Couto
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Vanessa Cohen
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Yelena Lalazar
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Iouri Makotkine
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai New York, NY, USA
| | - Nia Williams
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai New York, NY, USA
| | - Rachel Yehuda
- Department of Psychiatry, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neuroscience, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Rita Z Goldstein
- Department of Psychiatry, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neuroscience, Icahn School of Medicine at Mount SinaiNew York, NY, USA
| | - Eliza B Geer
- Department of Medicine, Icahn School of Medicine at Mount SinaiNew York, NY, USA; Department of Neurosurgery, Icahn School of Medicine at Mount SinaiNew York, NY, USA
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Santos A, Resmini E, Gómez-Ansón B, Crespo I, Granell E, Valassi E, Pires P, Vives-Gilabert Y, Martínez-Momblán MA, de Juan M, Mataró M, Webb SM. Cardiovascular risk and white matter lesions after endocrine control of Cushing's syndrome. Eur J Endocrinol 2015; 173:765-75. [PMID: 26497546 DOI: 10.1530/eje-15-0600] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Cushing's syndrome (CS) is associated with high cardiovascular risk. White matter lesions (WML) are common on brain magnetic resonance imaging (MRI) in patients with increased cardiovascular risk. AIM To investigate the relationship between cardiovascular risk, WML, neuropsychological performance and brain volume in CS. DESIGN/METHODS Thirty-eight patients with CS (23 in remission, 15 active) and 38 controls sex-, age- and education-level matched underwent a neuropsychological and clinical evaluation, blood and urine tests and 3Tesla brain MRI. WML were analysed with the Scheltens scale. Ten-year cardiovascular risk (10CVR) and vascular age (VA) were calculated according to an algorithm based on the Framingham heart study. RESULTS Patients in remission had a higher degree of WML than controls and active patients (P<0.001 and P=0.008 respectively), which did not correlate with cognitive performance in any group. WML severity positively correlated with diastolic blood pressure (r=0.659, P=0.001) and duration of hypertension (r=0.478, P=0.021) in patients in remission. Both patient groups (active and in remission) had higher 10CVR (P=0.030, P=0.041) and VA than controls (P=0.013, P=0.039). Neither the 10CVR nor the VA correlated with WML, although both negatively correlated with cognitive function and brain volume in patients in remission (P<0.05). Total brain volume and grey matter volume in both CS patient groups were reduced compared to controls (total volume: active P=0.006, in remission P=0.012; grey matter: active P=0.001, in remission P=0.003), with no differences in white matter volume between groups. CONCLUSIONS Patients in remission of Cushing's syndrome (but not active patients) have more severe white matter lesions than controls, positively correlated with diastolic pressure and duration of hypertension. Ten-year cardiovascular risk and vascular age appear to be negatively correlated with the cognitive function and brain volume in patients in remission of Cushing's syndrome.
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Affiliation(s)
- Alicia Santos
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Eugenia Resmini
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Beatriz Gómez-Ansón
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Iris Crespo
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Esther Granell
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Elena Valassi
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Patricia Pires
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Yolanda Vives-Gilabert
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - M Antonia Martínez-Momblán
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Manuel de Juan
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Maria Mataró
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Susan M Webb
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Sant Antoni Maria Claret n. 167, 08025 Barcelona, SpainNeuroradiology UnitHospital de Sant Pau, and IIB-Sant Pau, UAB, Barcelona, SpainINNDACYTAvda. Europa, 20, planta baja puerta D 08907, Hospitalet de Llobregat, SpainEscola Universitària d'InfermeriaHospital de Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
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Abstract
We report the case of a woman with long-standing refractory depression and psychotic features who was eventually diagnosed with Cushing disease. After surgical treatment of a pituitary adenoma, she experienced gradual psychiatric recovery and was eventually able to discontinue all psychotropic medication. We review the psychiatric components of Cushing disease, implications of psychiatric illnesses for the treatment and prognosis of Cushing disease, and potential pathophysiological mechanisms linking glucocorticoid excess to psychiatric illness.
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Bas-Hoogendam JM, Andela CD, van der Werff SJA, Pannekoek JN, van Steenbergen H, Meijer OC, van Buchem MA, Rombouts SARB, van der Mast RC, Biermasz NR, van der Wee NJA, Pereira AM. Altered neural processing of emotional faces in remitted Cushing's disease. Psychoneuroendocrinology 2015; 59:134-46. [PMID: 26092780 DOI: 10.1016/j.psyneuen.2015.05.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/29/2015] [Accepted: 05/05/2015] [Indexed: 01/28/2023]
Abstract
Patients with long-term remission of Cushing's disease (CD) demonstrate residual psychological complaints. At present, it is not known how previous exposure to hypercortisolism affects psychological functioning in the long-term. Earlier magnetic resonance imaging (MRI) studies demonstrated abnormalities of brain structure and resting-state connectivity in patients with long-term remission of CD, but no data are available on functional alterations in the brain during the performance of emotional or cognitive tasks in these patients. We performed a cross-sectional functional MRI study, investigating brain activation during emotion processing in patients with long-term remission of CD. Processing of emotional faces versus a non-emotional control condition was examined in 21 patients and 21 matched healthy controls. Analyses focused on activation and connectivity of two a priori determined regions of interest: the amygdala and the medial prefrontal-orbitofrontal cortex (mPFC-OFC). We also assessed psychological functioning, cognitive failure, and clinical disease severity. Patients showed less mPFC activation during processing of emotional faces compared to controls, whereas no differences were found in amygdala activation. An exploratory psychophysiological interaction analysis demonstrated decreased functional coupling between the ventromedial PFC and posterior cingulate cortex (a region structurally connected to the PFC) in CD-patients. The present study is the first to show alterations in brain function and task-related functional coupling in patients with long-term remission of CD relative to matched healthy controls. These alterations may, together with abnormalities in brain structure, be related to the persisting psychological morbidity in patients with CD after long-term remission.
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Affiliation(s)
- Janna Marie Bas-Hoogendam
- Institute of Psychology, Leiden University, Leiden, The Netherlands; Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Cornelie D Andela
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands.
| | - Steven J A van der Werff
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - J Nienke Pannekoek
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Division of Brain Sciences, Centre for Neuropsychopharmacology, Imperial College London, United Kingdom
| | - Henk van Steenbergen
- Institute of Psychology, Leiden University, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Onno C Meijer
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark A van Buchem
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Serge A R B Rombouts
- Institute of Psychology, Leiden University, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Roos C van der Mast
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Nic J A van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands; Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Alberto M Pereira
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands; Department of Medicine, Division of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
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62
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Nieman LK, Biller BMK, Findling JW, Murad MH, Newell-Price J, Savage MO, Tabarin A. Treatment of Cushing's Syndrome: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2015; 100:2807-31. [PMID: 26222757 PMCID: PMC4525003 DOI: 10.1210/jc.2015-1818] [Citation(s) in RCA: 677] [Impact Index Per Article: 75.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 06/19/2015] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The objective is to formulate clinical practice guidelines for treating Cushing's syndrome. PARTICIPANTS Participants include an Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer. The European Society for Endocrinology co-sponsored the guideline. EVIDENCE The Task Force used the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned three systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS The Task Force achieved consensus through one group meeting, several conference calls, and numerous e-mail communications. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. CONCLUSIONS Treatment of Cushing's syndrome is essential to reduce mortality and associated comorbidities. Effective treatment includes the normalization of cortisol levels or action. It also includes the normalization of comorbidities via directly treating the cause of Cushing's syndrome and by adjunctive treatments (eg, antihypertensives). Surgical resection of the causal lesion(s) is generally the first-line approach. The choice of second-line treatments, including medication, bilateral adrenalectomy, and radiation therapy (for corticotrope tumors), must be individualized to each patient.
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Affiliation(s)
- Lynnette K Nieman
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Beverly M K Biller
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - James W Findling
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - M Hassan Murad
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - John Newell-Price
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Martin O Savage
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
| | - Antoine Tabarin
- Program in Reproductive and Adult Endocrinology (L.K.N.), The Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892; Neuroendocrine Unit (B.M.K.B.), Massachusetts General Hospital, Boston, Massachusetts 02114; Medical College of Wisconsin (J.W.F.), Milwaukee, Wisconsin 53226; Mayo Clinic (M.H.M.), Division of Preventive Medicine, Rochester, Minnesota 55905; Department of Human Metabolism (J.N.-P.), School of Medicine and Biomedical Science, University of Sheffield, Sheffield S10 2RX, United Kingdom; William Harvey Research Institute (M.O.S.), Barts and the London School of Medicine and Dentistry, London EC1M 6BQ, United Kingdom; and Department of Endocrinology (A.T.), Centre Hospitalier Universitaire de Bordeaux and Inserm 862, University of Bordeaux, 33077 Bordeaux, France
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Andela CD, van Haalen FM, Ragnarsson O, Papakokkinou E, Johannsson G, Santos A, Webb SM, Biermasz NR, van der Wee NJA, Pereira AM. MECHANISMS IN ENDOCRINOLOGY: Cushing's syndrome causes irreversible effects on the human brain: a systematic review of structural and functional magnetic resonance imaging studies. Eur J Endocrinol 2015; 173:R1-14. [PMID: 25650405 DOI: 10.1530/eje-14-1101] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 02/03/2015] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cushing's syndrome (CS) is characterized by excessive exposure to cortisol, and is associated with both metabolic and behavioral abnormalities. Symptoms improve substantially after biochemical cure, but may persist during long-term remission. The causes for persistent morbidity are probably multi-factorial, including a profound effect of cortisol excess on the brain, a major target area for glucocorticoids. OBJECTIVE To review publications evaluating brain characteristics in patients with CS using magnetic resonance imaging (MRI). METHODS Systematic review of literature published in PubMed, Embase, Web of Knowledge, and Cochrane databases. RESULTS Nineteen studies using MRI in patients with CS were selected, including studies in patients with active disease, patients in long-term remission, and longitudinal studies, covering a total of 339 unique patients. Patients with active disease showed smaller hippocampal volumes, enlarged ventricles, and cerebral atrophy as well as alterations in neurochemical concentrations and functional activity. After abrogation of cortisol excess, the reversibility of structural and neurochemical alterations was incomplete after long-term remission. MRI findings were related to clinical characteristics (i.e., cortisol levels, duration of exposure to hypercortisolism, current age, age at diagnosis, and triglyceride levels) and behavioral outcome (i.e., cognitive and emotional functioning, mood, and quality of life). CONCLUSION Patients with active CS demonstrate brain abnormalities, which only partly recover after biochemical cure, because these still occur even after long-term remission. CS might be considered as a human model of nature that provides a keyhole perspective of the neurotoxic effects of exogenous glucocorticoids on the brain.
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Affiliation(s)
- Cornelie D Andela
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Femke M van Haalen
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Oskar Ragnarsson
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Eleni Papakokkinou
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Gudmundur Johannsson
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Alicia Santos
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Susan M Webb
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Nic J A van der Wee
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands Department of MedicineDivision of Endocrinology and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The NetherlandsLeiden Institute for Brain and CognitionLeiden, The NetherlandsDepartment of Endocrinology Diabetes and MetabolismSahlgrenska University Hospital and Sahlgrenska Academy, University of Gothenburg, Gothenburg, SwedenEndocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainDepartment of PsychiatryLeiden University Medical Center, Leiden, The Netherlands
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van der Werff SJA, Pannekoek JN, Andela CD, Meijer OC, van Buchem MA, Rombouts SARB, van der Mast RC, Biermasz NR, Pereira AM, van der Wee NJA. Resting-State Functional Connectivity in Patients with Long-Term Remission of Cushing's Disease. Neuropsychopharmacology 2015; 40:1888-98. [PMID: 25652248 PMCID: PMC4839512 DOI: 10.1038/npp.2015.38] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 01/08/2015] [Accepted: 01/09/2015] [Indexed: 01/21/2023]
Abstract
Glucocorticoid disturbance can be a cause of psychiatric symptoms. Cushing's disease represents a unique model for examining the effects of prolonged exposure to high levels of endogenous cortisol on the human brain as well as for examining the relation between these effects and psychiatric symptomatology. This study aimed to investigate resting-state functional connectivity (RSFC) of the limbic network, the default mode network (DMN), and the executive control network in patients with long-term remission of Cushing's disease. RSFC of these three networks of interest was compared between patients in remission of Cushing's disease (n=24; 4 male, mean age=44.96 years) and matched healthy controls (n=24; 4 male, mean age=46.5 years), using probabilistic independent component analysis to extract the networks and a dual regression method to compare both groups. Psychological and cognitive functioning was assessed with validated questionnaires and interviews. In comparison with controls, patients with remission of Cushing's disease showed an increased RSFC between the limbic network and the subgenual subregion of the anterior cingulate cortex (ACC) as well as an increased RSFC of the DMN in the left lateral occipital cortex. However, these findings were not associated with psychiatric symptoms in the patient group. Our data indicate that previous exposure to hypercortisolism is related to persisting changes in brain function.
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Affiliation(s)
- Steven J A van der Werff
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands,Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Psychiatry, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands, Tel: +31 71 526 2281, Fax: +31 71 524 8156, E-mail:
| | - J Nienke Pannekoek
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands,Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - Cornelie D Andela
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Onno C Meijer
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark A van Buchem
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Serge A R B Rombouts
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands,Institute of Psychology, Leiden University, Leiden, The Netherlands
| | - Roos C van der Mast
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke R Biermasz
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands,Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - Nic J A van der Wee
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands,Leiden Institute for Brain and Cognition, Leiden, The Netherlands
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Abstract
Patients with Cushing's syndrome (CS) in remission often suffer from impaired quality of life and cognitive dysfunction. The primary aim was to investigate the occurrence of mental fatigue, characterized by mental exhaustion and long recovery time following mentally strenuous tasks, in patients with CS in remission. The secondary aim was to examine whether the newly developed parts C and D of the trail making test (TMT) are more sensitive, compared to the conventional parts A and B, to evaluate attention and executive function. This was a cross-sectional study including 51 patients with CS in remission and 51 controls. All subjects completed the self-administrated mental fatigue scale (MFS) and performed all four parts of the TMT. The patients had worse outcome on all components of the MFS except for sensitivity to noise. After adjustment for mental fatigue, depression, and anxiety, the patients performed worse only on part D of the TMT (P < 0.05). Mental fatigue is common in patients with CS in remission and can be captured by using the MFS. The most demanding part of the TMT, part D, is more useful to capture cognitive deficits in patients with CS in remission compared to the conventional parts A and B.
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66
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Pires P, Santos A, Vives-Gilabert Y, Webb SM, Sainz-Ruiz A, Resmini E, Crespo I, de Juan-Delago M, Gómez-Anson B. White matter alterations in the brains of patients with active, remitted, and cured cushing syndrome: a DTI study. AJNR Am J Neuroradiol 2015; 36:1043-8. [PMID: 25929879 DOI: 10.3174/ajnr.a4322] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 12/14/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Cushing syndrome appears after chronic exposure to elevated glucocorticoid levels. Cortisol excess may alter white matter microstructure. Our purpose was to study WM changes in patients with Cushing syndrome compared with controls by using DTI and the influence of hypercortisolism. MATERIALS AND METHODS Thirty-five patients with Cushing syndrome and 35 healthy controls, matched for age, education, and sex, were analyzed through DTI (tract-based spatial statistics) for fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity (general linear model, family-wise error, and threshold-free cluster enhancement corrections, P < .05). Furthermore, the influence of hypercortisolism on WM DTI changes was studied by comparing 4 subgroups: 8 patients with Cushing syndrome with active hypercortisolism, 7 with Cushing syndrome with medication-remitted cortisol, 20 surgically cured, and 35 controls. Cardiovascular risk factors were used as covariates. In addition, correlations were analyzed among DTI values, concomitant 24-hour urinary free cortisol levels, and disease duration. RESULTS There were widespread alterations (reduced fractional anisotropy, and increased mean diffusivity, axial diffusivity, and radial diffusivity values; P < .05) in patients with Cushing syndrome compared with controls, independent of the cardiovascular risk factors present. Both active and cured Cushing syndrome subgroups showed similar changes compared with controls. Patients with medically remitted Cushing syndrome also had reduced fractional anisotropy and increased mean diffusivity and radial diffusivity values, compared with controls. No correlations were found between DTI maps and 24-hour urinary free cortisol levels or with disease duration. CONCLUSIONS Diffuse WM alterations in patients with Cushing syndrome suggest underlying loss of WM integrity and demyelination. Once present, they seem to be independent of concomitant hypercortisolism, persisting after remission/cure.
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Affiliation(s)
- P Pires
- From the Asociación para la Innovación en Análisis, Gestión y Procesamiento de Datos Científicos y Tecnológicos (P.P., Y.V.-G.), Barcelona, Spain Departments of Endocrinology/Medicine (P.P., A.S., S.M.W., E.R., I.C.), Hospital Sant Pau, IIB-Sant Pau, Instituto de Salud Carlos III, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Santos
- Departments of Endocrinology/Medicine (P.P., A.S., S.M.W., E.R., I.C.), Hospital Sant Pau, IIB-Sant Pau, Instituto de Salud Carlos III, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Y Vives-Gilabert
- From the Asociación para la Innovación en Análisis, Gestión y Procesamiento de Datos Científicos y Tecnológicos (P.P., Y.V.-G.), Barcelona, Spain Port d'Informació Científica (Y.V.-G., A.S.-R.), Bellaterra, Barcelona, Spain
| | - S M Webb
- Departments of Endocrinology/Medicine (P.P., A.S., S.M.W., E.R., I.C.), Hospital Sant Pau, IIB-Sant Pau, Instituto de Salud Carlos III, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - A Sainz-Ruiz
- Port d'Informació Científica (Y.V.-G., A.S.-R.), Bellaterra, Barcelona, Spain Institut de Fisica d'Altes Energies (A.S.-R.), Barcelona, Spain
| | - E Resmini
- Departments of Endocrinology/Medicine (P.P., A.S., S.M.W., E.R., I.C.), Hospital Sant Pau, IIB-Sant Pau, Instituto de Salud Carlos III, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - I Crespo
- Departments of Endocrinology/Medicine (P.P., A.S., S.M.W., E.R., I.C.), Hospital Sant Pau, IIB-Sant Pau, Instituto de Salud Carlos III, and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M de Juan-Delago
- Neuroradiology Unit (M.d.J.-D., B.G.-A.), Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - B Gómez-Anson
- Neuroradiology Unit (M.d.J.-D., B.G.-A.), Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Pivonello R, Simeoli C, De Martino MC, Cozzolino A, De Leo M, Iacuaniello D, Pivonello C, Negri M, Pellecchia MT, Iasevoli F, Colao A. Neuropsychiatric disorders in Cushing's syndrome. Front Neurosci 2015; 9:129. [PMID: 25941467 PMCID: PMC4403344 DOI: 10.3389/fnins.2015.00129] [Citation(s) in RCA: 103] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Accepted: 03/28/2015] [Indexed: 01/19/2023] Open
Abstract
Endogenous Cushing's syndrome (CS), a rare endocrine disorder characterized by cortisol hypersecretion, is associated with psychiatric and neurocognitive disorders. Major depression, mania, anxiety, and neurocognitive impairment are the most important clinical abnormalities. Moreover, patients most often complain of impairment in quality of life, interference with family life, social, and work performance. Surprisingly, after hypercortisolism resolution, despite the improvement of the overall prevalence of psychiatric and neurocognitive disorders, the brain volume loss at least partially persists and it should be noted that some patients may still display depression, anxiety, panic disorders, and neurocognitive impairment. This brief review aimed at describing the prevalence of psychiatric and neurocognitive disorders and their characterization both during the active and remission phases of CS. The last section of this review is dedicated to quality of life, impaired during active CS and only partially resolved after resolution of hypercortisolism.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Alessia Cozzolino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Monica De Leo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Davide Iacuaniello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Claudia Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Mariarosaria Negri
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
| | - Maria Teresa Pellecchia
- Department of Medicine and Surgery, Center for Neurodegenerative Diseases, University of SalernoSalerno, Italy
| | - Felice Iasevoli
- Laboratory of Molecular and Translational Psychiatry, Department of Neuroscience, Università “Federico II”Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università “Federico II”Naples, Italy
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Abstract
INTRODUCTION Cushing's syndrome is associated with a number of clinical manifestations and co-morbidities which may not resolve even after long-term remission leading to excessive mortality. MATERIALS AND METHODS This review summarizes the main manifestations of Cushing's syndrome (active or in remission) with particular focus on data from recently published literature. CONCLUSION Obesity and metabolic alterations, hypertension and cardio/cerebrovascular complications, hypercoagulability/thromboembolism, neuropsychiatric, muscle/skeletal and immune consequences remain the most challenging. Cardiovascular consequences and immunosuppression determine the main causes of death in Cushing's syndrome necessitating early intervention when possible.
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Affiliation(s)
- Georgia Ntali
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Old Rd, Headington, Oxford, OX3 7LJ, UK
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Crespo I, Esther GM, Santos A, Valassi E, Yolanda VG, De Juan-Delago M, Webb SM, Gómez-Ansón B, Resmini E. Impaired decision-making and selective cortical frontal thinning in Cushing's syndrome. Clin Endocrinol (Oxf) 2014; 81:826-33. [PMID: 25052342 DOI: 10.1111/cen.12564] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 05/16/2014] [Accepted: 07/17/2014] [Indexed: 12/28/2022]
Abstract
CONTEXT AND OBJECTIVE Cushing's syndrome (CS) is caused by a glucocorticoid excess. This hypercortisolism can damage the prefrontal cortex, known to be important in decision-making. Our aim was to evaluate decision-making in CS and to explore cortical thickness. SUBJECTS AND METHODS Thirty-five patients with CS (27 cured, eight medically treated) and thirty-five matched controls were evaluated using Iowa gambling task (IGT) and 3 Tesla magnetic resonance imaging (MRI) to assess cortical thickness. The IGT evaluates decision-making, including strategy and learning during the test. Cortical thickness was determined on MRI using freesurfer software tools, including a whole-brain analysis. RESULTS There were no differences between medically treated and cured CS patients. They presented an altered decision-making strategy compared to controls, choosing a lower number of the safer cards (P < 0·05). They showed more difficulties than controls to learn the correct profiles of wins and losses for each card group (P < 0·05). In whole-brain analysis, patients with CS showed decreased cortical thickness in the left superior frontal cortex, left precentral cortex, left insular cortex, left and right rostral anterior cingulate cortex, and right caudal middle frontal cortex compared to controls (P < 0·001). CONCLUSIONS Patients with CS failed to learn advantageous strategies and their behaviour was driven by short-term reward and long-term punishment, indicating learning problems because they did not use previous experience as a feedback factor to regulate their choices. These alterations in decision-making and the decreased cortical thickness in frontal areas suggest that chronic hypercortisolism promotes brain changes which are not completely reversible after endocrine remission.
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Affiliation(s)
- Iris Crespo
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Santos A, Resmini E, Crespo I, Pires P, Vives-Gilabert Y, Granell E, Valassi E, Gómez-Anson B, Martínez-Momblán MA, Mataró M, Webb SM. Small cerebellar cortex volume in patients with active Cushing's syndrome. Eur J Endocrinol 2014; 171:461-9. [PMID: 25005936 DOI: 10.1530/eje-14-0371] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Cushing's syndrome (CS) is associated with neuropsychological deficits. As the cerebellum plays a key role in neuropsychological functions it may be affected in CS. The aim of this study was to investigate whether patients with CS have a smaller cerebellar volume than healthy controls, and to analyse whether cerebellar volume is associated with neuropsychological performance and clinical parameters. DESIGN A cross-sectional study was performed. METHODS Thirty-six CS patients (15 with active CS and 21 with CS in remission) and 36 controls matched for age, sex, and education underwent neuropsychological testing, quality of life assessment, clinical evaluation, and magnetic resonance imaging brain scan. Cerebellar volumes (white matter and cortex, bilateral) were calculated using FreeSurfer Software. RESULTS Patients with active CS showed smaller bilateral cerebellar cortex volumes than controls (left, P=0.035 and right, P=0.034), as well as a trend toward smaller right cerebellar cortex volumes than patients in remission CS (P=0.051). No differences were observed in the volume of cerebellar white matter between the three groups. Both right and left cerebellar cortex volumes correlated negatively with triglyceride levels (right: r=-0.358, P=0.002 and left: r=-0.317, P=0.005) and age at diagnosis (right: r=-0.433, P=0.008 and left: r=-0.457, P=0.005). Left cerebellar cortex volume also correlated positively with visual memory performance (r=0.245, P=0.038). Right cerebellar cortex volume positively correlated with quality-of-life scores (r=0.468, P=0.004). CONCLUSIONS The cerebellar cortex volume is smaller in active CS patients than in controls. This finding is associated with poor visual memory and quality of life and is mostly pronounced in patients with higher triglyceride levels and older age at diagnosis.
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Affiliation(s)
- Alicia Santos
- Department of Endocrinology, Hospital de la Santa Creu i Sant Pau, C/Sant Antoni Maria Claret 167, 08025 Barcelona, Spain.
| | - Eugenia Resmini
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Iris Crespo
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Patricia Pires
- INNDACYT, Avenida Europa 20, Hospitalet de Llobregat, Barcelona, Spain
| | | | - Esther Granell
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Elena Valassi
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Beatriz Gómez-Anson
- Neuroradiology Unit, Hospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - M Antonia Martínez-Momblán
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Maria Mataró
- Department of Psychiatry and Clinical Psychobiology, Psychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
| | - Susan M Webb
- Endocrinology/Medicine DepartmentsHospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), 08193 Bellaterra (Cerdanyola del Vallès), SpainINNDACYTAvenida Europa 20, Hospitalet de Llobregat, Barcelona, SpainNeuroradiology UnitHospital Sant Pau, and IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, SpainEscola Universitària d'InfermeriaHospital Sant Pau. Universitat Autònoma de Barcelona (UAB), Barcelona, Spain andDepartment of Psychiatry and Clinical PsychobiologyPsychology Faculty, Institute for Brain, Cognition and Behaviour (IR3C), Universitat de Barcelona (UB), Barcelona, Spain
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Salpietro V, Polizzi A, Di Rosa G, Romeo AC, Dipasquale V, Morabito P, Chirico V, Arrigo T, Ruggieri M. Adrenal disorders and the paediatric brain: pathophysiological considerations and clinical implications. Int J Endocrinol 2014; 2014:282489. [PMID: 25276129 PMCID: PMC4167812 DOI: 10.1155/2014/282489] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/12/2014] [Indexed: 01/27/2023] Open
Abstract
Various neurological and psychiatric manifestations have been recorded in children with adrenal disorders. Based on literature review and on personal case-studies and case-series we focused on the pathophysiological and clinical implications of glucocorticoid-related, mineralcorticoid-related, and catecholamine-related paediatric nervous system involvement. Childhood Cushing syndrome can be associated with long-lasting cognitive deficits and abnormal behaviour, even after resolution of the hypercortisolism. Exposure to excessive replacement of exogenous glucocorticoids in the paediatric age group (e.g., during treatments for adrenal insufficiency) has been reported with neurological and magnetic resonance imaging (MRI) abnormalities (e.g., delayed myelination and brain atrophy) due to potential corticosteroid-related myelin damage in the developing brain and the possible impairment of limbic system ontogenesis. Idiopathic intracranial hypertension (IIH), a disorder of unclear pathophysiology characterised by increased cerebrospinal fluid (CSF) pressure, has been described in children with hypercortisolism, adrenal insufficiency, and hyperaldosteronism, reflecting the potential underlying involvement of the adrenal-brain axis in the regulation of CSF pressure homeostasis. Arterial hypertension caused by paediatric adenomas or tumours of the adrenal cortex or medulla has been associated with various hypertension-related neurological manifestations. The development and maturation of the central nervous system (CNS) through childhood is tightly regulated by intrinsic, paracrine, endocrine, and external modulators, and perturbations in any of these factors, including those related to adrenal hormone imbalance, could result in consequences that affect the structure and function of the paediatric brain. Animal experiments and clinical studies demonstrated that the developing (i.e., paediatric) CNS seems to be particularly vulnerable to alterations induced by adrenal disorders and/or supraphysiological doses of corticosteroids. Physicians should be aware of potential neurological manifestations in children with adrenal dysfunction to achieve better prevention and timely diagnosis and treatment of these disorders. Further studies are needed to explore the potential neurological, cognitive, and psychiatric long-term consequences of high doses of prolonged corticosteroid administration in childhood.
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Affiliation(s)
- Vincenzo Salpietro
- Department of Pediatric Neurology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK
- Unit of Genetics and Paediatric Immunology, Department of Pediatrics, University of Messina, Italy
| | - Agata Polizzi
- National Center for Rare Diseases, Istituto Superiore di Sanità, Rome, Italy
- Institute of Neurological Sciences, National Research Council, Catania, Italy
| | - Gabriella Di Rosa
- Infantile Neuropsychiatry Unit, Department of Pediatrics, University of Messina, Italy
| | - Anna Claudia Romeo
- Unit of Genetics and Paediatric Immunology, Department of Pediatrics, University of Messina, Italy
| | - Valeria Dipasquale
- Unit of Genetics and Paediatric Immunology, Department of Pediatrics, University of Messina, Italy
| | - Paolo Morabito
- Department of Clinical and Experimental Medicine and Pharmacology, University of Messina, Italy
| | - Valeria Chirico
- Unit of Genetics and Paediatric Immunology, Department of Pediatrics, University of Messina, Italy
| | - Teresa Arrigo
- Unit of Genetics and Paediatric Immunology, Department of Pediatrics, University of Messina, Italy
| | - Martino Ruggieri
- Chair of Pediatrics, Department of Educational Sciences, University of Catania, Italy
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Ragnarsson O, Glad CAM, Berglund P, Bergthorsdottir R, Eder DN, Johannsson G. Common genetic variants in the glucocorticoid receptor and the 11β-hydroxysteroid dehydrogenase type 1 genes influence long-term cognitive impairments in patients with Cushing's syndrome in remission. J Clin Endocrinol Metab 2014; 99:E1803-7. [PMID: 24915124 DOI: 10.1210/jc.2014-1906] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
CONTEXT Cognitive function is impaired in patients with Cushing's syndrome (CS) in remission. OBJECTIVE The objective of the investigation was to study the effects of polymorphisms in genes associated with glucocorticoid (GC) sensitivity on cognitive function in patients with CS in long-term remission. DESIGN This was a cross-sectional, case-controlled, single-center study. PATIENTS Fifty-three patients with CS in remission and 53 controls matched for age, gender, and educational level participated in the study. MAIN OUTCOME MEASURES Cognitive function, studied using standardized neuropsychological testing, and polymorphisms in the GC receptor (NR3C1; Bcl1 and A3669G), mineralocorticoid receptor (NR3C2; I180V), 11β-hydroxysteroid dehydrogenase type 1 (11βHSD1; rs11119328), and ATP binding cassette B1 (ABCB1; rs1045642) genes were measured. The association between cognitive function and polymorphisms were analyzed using linear regression with adjustments for age and educational level. RESULTS The mean age in patients and controls was 53 ± 14 years. The median (interquartile range) duration of remission was 13 (5-18) years. In patients, the single-nucleotide polymorphism rs11119328 was associated with impairments in processing speed, auditory attention, auditory working memory, and reading speed. This association was not seen in matched controls. The Bcl1 polymorphism was associated with fatigue and worse visual attention and working memory. The remaining single-nucleotide polymorphisms were not associated with cognitive performance. CONCLUSION In this study, polymorphisms in the 11βHSD1 and NR3C1 genes were associated with impaired cognitive function, indicating that GC sensitivity and prereceptor regulation of GC action may play a role in the long-term consequences of CS. The study provides a novel insight into the etiology of cognitive dysfunction in patients with CS in remission.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine (O.R., C.A.M.G., R.B., G.J.), Institute of Neuroscience and Physiology (P.B.), and Vigilance and Neurocognition Laboratory (D.N.E.), Sahlgrenska Academy, University of Gothenburg, SE-413 45 Göteborg Sweden
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Manetti L, Cavagnini F, Martino E, Ambrogio A. Effects of cocaine on the hypothalamic-pituitary-adrenal axis. J Endocrinol Invest 2014; 37:701-708. [PMID: 24852417 DOI: 10.1007/s40618-014-0091-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 04/30/2014] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Cocaine hydrochloride is a psychoactive substance extracted from the leaves of plants called Erythroxylum coca. Cocaine is the second most commonly used drug in the world after cannabis; 20 % of cocaine users will become long-term cocaine-dependent patients. Different routes of administration may be recognized: smokable modality, intranasal and intravenous. Cocaine is a potent stimulant of the sympathetic nervous system and causes structural changes on the brain, heart, lung, liver and kidney. It has long been known that use of cocaine may produce alterations to the endocrine system. Research on behavioral and neuroendocrine effects of cocaine dates back several years ago and has increasingly focused on alterations of the hypothalamic-pituitary-adrenal (HPA) axis, which appears to be the chief target of cocaine effects. STUDIES Animal (mainly rats and monkeys) and human studies have clearly shown a close relation between cocaine consumption and overdrive of the HPA axis. Such activation is likely involved, though via a still undefined mechanism, in the behavioral and cardiovascular changes of drug abusers as well as in the reinforcement/relapse phenomena. Further studies of the pathophysiology of cocaine addicts will help to devise new therapeutic strategies for these patients.
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Affiliation(s)
- L Manetti
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy.
| | - F Cavagnini
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, 20149, Milan, Italy
| | - E Martino
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - A Ambrogio
- Neuroendocrinology Research Laboratory, Istituto Auxologico Italiano IRCCS, 20149, Milan, Italy
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Abstract
It was assumed that resolution of hypercortisolism in Cushing syndrome (CS) was followed by normalization of morbidity; however, in the last decade evidence is accumulating that patients with cured CS still have increased morbidity and mortality after the biochemical control of hypercortisolism. Patients with CS have an increased cardiovascular and metabolic risk and persistent accumulation of central fat, with an unfavorable adipokine profile, not only during the active phase of the disease but also long after biochemical remission. Clinical management should be particularly careful in identifying global cardiovascular risk, as a primary goal during the followup of these patients, aimed at improving global vascular morbidity. Moreover bone mass is reduced not only due to the endogenous hypercortisolism but also due to duration and dose of exogenous glucocorticoid (GC) replacement therapy after surgery. Thus, therapy in operated patients with inhibition of the hypothalamic-pituitary-adrenal axis should be reduced to the lowest dose and duration possible. Specific treatments should be considered in patients with decreased bone mass, aimed at reducing the increased fracture incidence. Finally, cognitive and health related quality of life impairments, described in active disease, are still abnormal after endocrine cure. Thus, residual morbidity persists in cured CS, suggesting irreversibility of GC-induced phenomena, typical of chronic hypercortisolism.
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Widespread reductions of white matter integrity in patients with long-term remission of Cushing's disease. NEUROIMAGE-CLINICAL 2014; 4:659-67. [PMID: 24936417 PMCID: PMC4053612 DOI: 10.1016/j.nicl.2014.01.017] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/09/2014] [Accepted: 01/31/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Hypercortisolism leads to various physical, psychological and cognitive symptoms, which may partly persist after the treatment of Cushing's disease. The aim of the present study was to investigate abnormalities in white matter integrity in patients with long-term remission of Cushing's disease, and their relation with psychological symptoms, cognitive impairment and clinical characteristics. METHODS In patients with long-term remission of Cushing's disease (n = 22) and matched healthy controls (n = 22) we examined fractional anisotropy (FA) values of white matter in a region-of-interest (ROI; bilateral cingulate cingulum, bilateral hippocampal cingulum, bilateral uncinate fasciculus and corpus callosum) and the whole brain, using 3 T diffusion tensor imaging (DTI) and a tract-based spatial statistics (TBSS) approach. Psychological and cognitive functioning were assessed with validated questionnaires and clinical severity was assessed using the Cushing's syndrome Severity Index. RESULTS The ROI analysis showed FA reductions in all of the hypothesized regions, with the exception of the bilateral hippocampal cingulum, in patients when compared to controls. The exploratory whole brain analysis showed multiple regions with lower FA values throughout the brain. Patients reported more apathy (p = .003) and more depressive symptoms (p < .001), whereas depression symptom severity in the patient group was negatively associated with FA in the left uncinate fasciculus (p < 0.05). Post-hoc analyses showed increased radial and mean diffusivity in the patient group. CONCLUSION Patients with a history of endogenous hypercortisolism in present remission show widespread changes of white matter integrity in the brain, with abnormalities in the integrity of the uncinate fasciculus being related to the severity of depressive symptoms, suggesting persistent structural effects of hypercortisolism.
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Tatomir A, Micu C, Crivii C. The impact of stress and glucocorticoids on memory. CLUJUL MEDICAL 2014; 87:3-6. [PMID: 26527987 PMCID: PMC4462413 DOI: 10.15386/cjm.2014.8872.871.at1cm2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 02/10/2014] [Indexed: 11/23/2022]
Abstract
Responses to stress are mediated by a complex network of the nervous and endocrine systems. Glucocorticoids, which are among the most important “players” in stress resilience, may have important implications in the cognitive functions, particularly in the modulation of memory. Declarative memory, the memory for facts, events and word meaning is the most studied type of memory on which glucocorticoids exert an influence, both positively through consolidation and negatively through impairment. These effects depend on the receptor type, dose, time of exposure, memory component and the salience of stimuli, retrieval being generally affected and storage being facilitated, especially for emotionally relevant events. Glucocorticoids also induce hippocampal atrophy, which is a hallmark seen in various diseases accompanied by a chronic high level of cortisol, such as the Cushing syndrome, major depression, post-traumatic stress disorder. Also, chronic stress might be a risk factor for the development of Alzheimer’s disease, especially when a genetic background and other environmental influences are present.
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Affiliation(s)
- Alexandru Tatomir
- "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen Micu
- Department of Anatomy and Embryology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Carmen Crivii
- Department of Anatomy and Embryology, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
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Aulinas A, Valassi E, Webb SM. Pronóstico del paciente tratado de síndrome de Cushing. ACTA ACUST UNITED AC 2014; 61:52-61. [DOI: 10.1016/j.endonu.2013.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 03/07/2013] [Accepted: 03/11/2013] [Indexed: 10/26/2022]
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Ohara N, Suzuki H, Suzuki A, Kaneko M, Ishizawa M, Furukawa K, Abe T, Matsubayashi Y, Yamada T, Hanyu O, Shimohata T, Sone H. Reversible brain atrophy and cognitive impairment in an adolescent Japanese patient with primary adrenal Cushing's syndrome. Neuropsychiatr Dis Treat 2014; 10:1763-7. [PMID: 25246796 PMCID: PMC4168879 DOI: 10.2147/ndt.s70611] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Endogenous Cushing's syndrome is an endocrine disease resulting from chronic exposure to excessive glucocorticoids produced in the adrenal cortex. Although the ultimate outcome remains uncertain, functional and morphological brain changes are not uncommon in patients with this syndrome, and generally persist even after resolution of hypercortisolemia. We present an adolescent patient with Cushing's syndrome who exhibited cognitive impairment with brain atrophy. A 19-year-old Japanese male visited a local hospital following 5 days of behavioral abnormalities, such as money wasting or nighttime wandering. He had hypertension and a 1-year history of a rounded face. Magnetic resonance imaging (MRI) revealed apparently diffuse brain atrophy. Because of high random plasma cortisol levels (28.7 μg/dL) at 10 AM, he was referred to our hospital in August 2011. Endocrinological testing showed adrenocorticotropic hormone-independent hypercortisolemia, and abdominal computed tomography demonstrated a 2.7 cm tumor in the left adrenal gland. The patient underwent left adrenalectomy in September 2011, and the diagnosis of cortisol-secreting adenoma was confirmed histologically. His hypertension and Cushingoid features regressed. Behavioral abnormalities were no longer observed, and he was classified as cured of his cognitive disturbance caused by Cushing's syndrome in February 2012. MRI performed 8 months after surgery revealed reversal of brain atrophy, and his subsequent course has been uneventful. In summary, the young age at onset and the short duration of Cushing's syndrome probably contributed to the rapid recovery of both cognitive dysfunction and brain atrophy in our patient. Cushing's syndrome should be considered as a possible etiological factor in patients with cognitive impairment and brain atrophy that is atypical for their age.
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Affiliation(s)
- Nobumasa Ohara
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Hiroshi Suzuki
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Akiko Suzuki
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Masanori Kaneko
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Masahiro Ishizawa
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Kazuo Furukawa
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Takahiro Abe
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Yasuhiro Matsubayashi
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Takaho Yamada
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Osamu Hanyu
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
| | - Takayoshi Shimohata
- Department of Neurology, Brain Research Institute, Niigata University, Niigata, Japan
| | - Hirohito Sone
- Department of Hematology, Endocrinology and Metabolism, Faculty of Medicine, Niigata University, Niigata, Japan
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Andela CD, van der Werff SJA, Pannekoek JN, van den Berg SM, Meijer OC, van Buchem MA, Rombouts SARB, van der Mast RC, Romijn JA, Tiemensma J, Biermasz NR, van der Wee NJA, Pereira AM. Smaller grey matter volumes in the anterior cingulate cortex and greater cerebellar volumes in patients with long-term remission of Cushing's disease: a case-control study. Eur J Endocrinol 2013; 169:811-9. [PMID: 24031092 DOI: 10.1530/eje-13-0471] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Patients with long-term remission of Cushing's disease (CD) have persistent psychological and cognitive impairments. It is unknown whether, and to what extent, these impairments are accompanied by structural abnormalities in the brain. We aim to investigate structural changes in the brain in patients with predominantly long-term remission of CD and to examine whether these changes are associated with psychological and cognitive dysfunction and clinical severity. DESIGN A cross-sectional, case-control study. METHODS In 25 patients with predominantly long-term remission of CD and 25 matched healthy controls, grey matter volumes in the regions of interest (hippocampus, amygdala, and anterior cingulate cortex (ACC)) and in the whole brain were examined, using 3T magnetic resonance imaging and a voxel-based morphometry approach. Psychological and cognitive functioning were assessed using validated questionnaires and clinical severity was assessed using the Cushing's syndrome severity index. RESULTS Compared with controls, patients had smaller grey matter volumes of areas in the ACC (on average 14%, P<0.05) and greater volume of the left posterior lobe of the cerebellum (on average 34%, P<0.05). As expected, patients with remitted CD reported more depressive symptoms (P=0.005), more anxiety (P=0.003), more social phobia (P=0.034), more apathy (P=0.002), and more cognitive failure (P=0.023) compared with controls, but the differences in grey matter volumes were not associated with psychological or cognitive measures, nor with clinical severity. CONCLUSION Patients with predominantly long-term remission of CD showed specific structural brain abnormalities, in the presence of psychological dysfunction. Our data form a basis for future work aimed at elucidating the relation of the structural brain abnormalities and the sustained psychological deficits after long-term exposure to high cortisol levels.
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Affiliation(s)
- Cornelie D Andela
- Department of Endocrinology and Metabolic Diseases, C7-Q, Center for Endocrine Tumors, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, The Netherlands
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Aulinas A, Ramírez MJ, Barahona MJ, Mato E, Bell O, Surrallés J, Webb SM. Telomeres and endocrine dysfunction of the adrenal and GH/IGF-1 axes. Clin Endocrinol (Oxf) 2013; 79:751-9. [PMID: 23937625 DOI: 10.1111/cen.12310] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 05/11/2013] [Accepted: 08/02/2013] [Indexed: 12/22/2022]
Abstract
Telomeres, located at the end of linear chromosomes, are essential to maintain genomic stability. Telomere biology has recently emerged as an important player in the fields of ageing and disease. To maintain telomere length (TL) and reduce its degradation after mitosis, the telomerase enzyme complex is produced. Genetic, epigenetic, hormonal and environmental factors can regulate telomerase function. These include stress hormones such as cortisol and growth factors. The hypothalamic-pituitary-adrenal (HPA) axis has been evaluated in psychiatric diseases where hypercortisolism and oxidative stress are often present. Some researches have linked TL shortening to increases in stress-related cortisol, but others have not. The effects of cortisol on the telomere system are complex and may depend on the intensity and duration of exposure. On the other hand, low levels of IGF-1 are associated with inflammation and ageing-related diseases (ischaemic heart disease, congestive heart failure). Both IGF-1 and TL diminish with age and are positively and strongly correlated with each other. It is not clear whether this positive correlation reflects a single association or a cause-effect relationship. Further research will ideally investigate longitudinal changes in telomeres and both these hormonal axes. To our knowledge, TL dysfunction has not been described in either endogenous hypercortisolism (Cushing's syndrome) or acromegaly where excessive amounts of GH and consequently IGF-1 are produced. This review focuses on the possible relationships between telomere dysfunction and the hypothalamic-pituitary-adrenal (HPA) axis and GH-IGF-1 system.
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Affiliation(s)
- Anna Aulinas
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Endocrinology/Medicine Departments, Hospital de Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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Ragnarsson O, Johannsson G. Cushing's syndrome: a structured short- and long-term management plan for patients in remission. Eur J Endocrinol 2013; 169:R139-52. [PMID: 23985132 DOI: 10.1530/eje-13-0534] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
One hundred years have passed since Harvey Williams Cushing presented the first patient with the syndrome that bears his name. In patients with Cushing's syndrome (CS), body composition and lipid, carbohydrate and protein metabolism are dramatically affected and psychopathology and cognitive dysfunction are frequently observed. Untreated patients with CS have a grave prognosis with an estimated 5-year survival of only 50%. Remission can be achieved by surgery, radiotherapy and sometimes with medical therapy. Recent data indicate that the adverse metabolic consequences of CS are present for years after successful treatment.In addition, recent studies have demonstrated that health-related quality of life and cognitive function are impaired in patients with CS in long-term remission. The focus of specialised care should therefore be not only on the diagnostic work-up and the early postoperative management but also on the long-term follow-up. In this paper, we review the long-term consequences in patients with CS in remission with focus on the neuropsychological effects and discuss the importance of these findings for long-term management. We also discuss three different phases in the postoperative management of surgically-treated patients with CS, each phase distinguished by specific challenges: the immediate postoperative phase, the glucocorticoid dose tapering phase and the long-term management. The focus of the long-term specialised care should be to identify cognitive impairments and psychiatric disorders, evaluate cardiovascular risk, follow pituitary function and detect possible recurrence of CS.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gröna Stråket 8, SE-413 45 Gothenburg, Sweden
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Boguszewski CL. Are patients in remission from Cushing's syndrome mentally healthy? Clin Endocrinol (Oxf) 2013; 79:615-6. [PMID: 23808843 DOI: 10.1111/cen.12278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 06/22/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Cesar L Boguszewski
- Endocrine Division (SEMPR), Department of Internal Medicine, Federal University Hospital of Parana, Curitiba, Brazil
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Resmini E, Santos A, Gómez-Anson B, López-Mourelo O, Pires P, Vives-Gilabert Y, Crespo I, Portella MJ, de Juan-Delago M, Webb SM. Hippocampal dysfunction in cured Cushing's syndrome patients, detected by (1) H-MR-spectroscopy. Clin Endocrinol (Oxf) 2013; 79:700-7. [PMID: 23594250 DOI: 10.1111/cen.12224] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 02/13/2013] [Accepted: 04/14/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Proton magnetic resonance spectroscopy ((1) H-MRS) is a sensitive, noninvasive imaging technique capable of measuring brain metabolites in vivo. Chronic exposure to endogenous hypercortisolism in Cushing's syndrome (CS) is associated with negative effects on memory and hippocampal volumes, even after biochemical cure. OBJECTIVE To investigate metabolites in the hippocampi of CS patients and controls, using (1) H-MRS. PATIENTS AND METHODS Eighteen right-handed cured CS patients (age 44·8 ± 12·5 years, 12·6 ± 3·8 years of education) and 18 right-handed healthy controls, matched for age (40·0 ± 11·9) and years of education (14·4 ± 3·8), underwent 3-Tesla magnetic resonance imaging (3T MRI) and (1) H-MRS including the head of each hippocampus. Concentrations of Glu (Glutamate), Glx (Glutamate + Glutamine), NAA (N-Acetyl-aspartate), total NAA (N-Acetyl-aspartate + N-Acetyl-aspartyl-Glutamate), Cho (Glycerophosphocholine and Phosphocholine compounds), Cr (Creatine) and MI (mionositol) were measured (mmol/l). Hippocampal volumes (mm(3) ) were additionally calculated using an automated procedure (FreeSurfer). RESULTS CS patients had lower NAA than controls in the left and right hippocampus (5·2 ± 1·0 vs 6·1 ± 0·7, P < 0·05; 4·9 ± 0·8 vs 6·1 ± 0·6, P < 0·001, respectively), and lower total NAA on the right side (5·7 ± 0·9 vs 6·3 ± 0·9, P < 0·05), suggesting neuronal dysfunction/loss. CS patients had higher Glx than controls in both hippocampi (10·4 ± 1·9 vs 8·6 ± 1·4, P < 0·01; 9·9 ± 1·6 vs 8·9 ± 1·3, P < 0·05, respectively), suggesting glial proliferation, as a repair mechanism after neuronal dysfunction. No differences were found in the other brain metabolites, and there were no differences in left (3815·78 ± 502·96) and right (3980·75 ± 369·44) total hippocampal volumes between CS patients and controls (3945·08 ± 408·90 and 4108·39 ± 365·11, respectively). CONCLUSION Persistently abnormal metabolites are evidenced in the hippocampi of CS patients despite endocrine cure. These functional alterations could be early markers of glucocorticoid neurotoxicity, preceding hippocampal volume reduction.
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Affiliation(s)
- Eugenia Resmini
- Endocrinology/Medicine Department, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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84
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Starkman MN. Neuropsychiatric findings in Cushing syndrome and exogenous glucocorticoid administration. Endocrinol Metab Clin North Am 2013; 42:477-88. [PMID: 24011881 DOI: 10.1016/j.ecl.2013.05.010] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This article reviews the neuropsychiatric presentations elicited by spontaneous hypercortisolism and exogenous supraphysiologic glucocorticoids. Patients with Cushing disease and syndrome develop a depressive syndrome: irritable and depressed mood, decreased libido, disrupted sleep and cognitive decrements. Exogenous short-term glucocorticoid administration may elicit a hypomanic syndrome with mood, sleep and cognitive disruptions. Treatment options are discussed. Brain imaging and neuropsychological studies indicate elevated cortisol and other glucocorticoids are especially deleterious to hippocampus and frontal lobe. The research findings also shed light on neuropsychiatric abnormalities in conditions that have substantial subgroups exhibiting elevated and dysregulated cortisol: aging, major depressive disorder and Alzheimer's disease.
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Affiliation(s)
- Monica N Starkman
- Department of Psychiatry, University of Michigan Medical Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109, USA.
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85
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Ragnarsson O, Berglund P, Eder DN, Zetterberg H, Hietala MA, Blennow K, Johannsson G. Neurodegenerative and inflammatory biomarkers in cerebrospinal fluid in patients with Cushing's syndrome in remission. Eur J Endocrinol 2013; 169:211-5. [PMID: 23733371 DOI: 10.1530/eje-13-0205] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Patients with Cushing's syndrome (CS) in long-term remission have impaired cognitive function. Cerebrospinal fluid (CSF) biomarkers are important diagnostic tools in the work-up of patients with cognitive impairment. The aim of this study was to analyze neurodegenerative and inflammatory biomarkers in the CSF of patients with CS in remission. DESIGN A cross-sectional, single-center study. PATIENTS Twelve women previously treated for CS and six healthy subjects. MEASUREMENTS Neurodegenerative CSF markers: total tau, hyperphosphorylated tau, amyloid beta peptides, soluble amyloid precursor protein alpha and beta, neurofilament light proteins, glial fibrillary acidic protein, and monocyte chemoattractant protein 1; and inflammatory CSF markers: interferon gamma, interleukin (IL) 1B, IL2, IL4, IL5, IL8, IL10, IL12p70, IL13, and tumor necrosis factor alpha. RESULTS The mean age (mean±S.D.) was similar in patients with CS in remission (44.9±14 years) and healthy subjects (42.3±15.7 years; P=0.726). No differences were observed in the concentrations of any neurodegenerative biomarkers between the patients and healthy subjects. Nor were the concentrations of inflammatory biomarkers different between the groups. CONCLUSIONS The pattern of neurodegenerative and inflammatory biomarkers in the CSF of patients with CS in remission does not differ from that of the healthy subjects. The underlying mechanisms of the cognitive deficits in patients with CS in remission are different from those observed in patients with neurodegenerative disorders and remain to be explained.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden.
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86
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Keil MF. Quality of life and other outcomes in children treated for Cushing syndrome. J Clin Endocrinol Metab 2013; 98:2667-78. [PMID: 23640970 PMCID: PMC3701267 DOI: 10.1210/jc.2013-1123] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Accepted: 04/22/2013] [Indexed: 11/19/2022]
Abstract
CONTEXT Cushing syndrome (CS) in children is associated with residual impairment in measures of health-related quality of life, even after successful resolution of hypercortisolemia, highlighting the need for early identification of morbidities and improvements in long-term management of these patients. EVIDENCE ACQUISITION AND SYNTHESIS A PubMed, Scopus, and Web of Science search of articles from 1900 onward identified available studies related to quality of life and complications of pediatric CS as well as important historical articles. This review summarizes studies through November 2012 and highlights recent developments. CONCLUSIONS A review of the literature identifies significant morbidities associated with CS of pediatric onset, which must not be treated in isolation. CS affects children and adolescents in many ways that are different than adults. Post-treatment challenges for the child or adolescent treated for CS include: optimize growth and pubertal development, normalize body composition, and promote psychological health and cognitive maturation. All these factors impact health-related quality of life, which is an important outcome measure to assess the burden of disease as well as the effect of treatment. Future research efforts are needed to improve management of the physical, psychological, and emotional aspects of this disease in order to diminish the residual impairments experienced by the pediatric CS patient population.
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Affiliation(s)
- Margaret F Keil
- Section on Endocrinology Genetics, Program on Developmental Endocrinology Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892, USA.
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Roa SLR, Elias PCL, Castro M, Moreira AC. The cortisol awakening response is blunted in patients with active Cushing's disease. Eur J Endocrinol 2013; 168:657-64. [PMID: 23392212 DOI: 10.1530/eje-12-0982] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Cortisol awakening response (CAR) is a rapid increase of cortisol levels within 30-45 min after awakening. OBJECTIVE This study evaluates CAR compared with cortisol circadian rhythm in active and in remission Cushing's disease (CD). MATERIALS AND METHODS We evaluated healthy controls (HC, n=19), obese (OB, n=10), in remission (n=08), and active CD patients (n=10). Salivary free cortisol (SF) was determined at 0800, 1100, 1700, 2000, and 2300 h on the first day. CAR was obtained the next morning immediately upon awakening and at 15, 30, 45, and 60-min post-wake up. RESULTS We observed differences in SF levels throughout the day in HC, OB, and in remission CD (ANOVA P=0.0001) but not in active CD (P=0.2). We demonstrated SF increment after awakening in HC, OB, and in remission CD (ANOVA P=0.007), with no effect of time on SF in active CD. The relative increment of SF obtained at the peak after awakening (CARi%) in the active CD (67±57%) was lower than in HC (154±107%), OB (240±188%), and in remission CD (186±184%) patients (P=0.009). There was a negative correlation between the SF at awakening and the CARi% in HC (r=-0.8), OB (r=-0.78), and in remission CD (r=-0.74) but not in active CD (r=-0.35; P=0.31). CONCLUSION This study originally described a blunted CAR in active CD in contrast to its presence in HC, OB, and in remission CD. This subtle dysfunction of the hypothalamus-pituitary-adrenal axis may represent a distinct and additional physiopathological phenomenon superimposing the dysregulated cortisol circadian rhythm in this disease.
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Affiliation(s)
- Silvia Liliana Ruiz Roa
- Department of Medicine, School of Medicine of Ribeirao Preto, University of Sao Paulo, Monte Alegre, Ribeirao Preto, SP, Brazil
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88
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de Diego-Adeliño J, Portella MJ, Gómez-Ansón B, López-Moruelo O, Serra-Blasco M, Vives Y, Puigdemont D, Pérez-Egea R, Álvarez E, Pérez V. Hippocampal abnormalities of glutamate/glutamine, N-acetylaspartate and choline in patients with depression are related to past illness burden. J Psychiatry Neurosci 2013; 38:107-16. [PMID: 23425950 PMCID: PMC3581591 DOI: 10.1503/jpn.110185] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Smaller hippocampal volumes in major depressive disorder (MDD) have been linked with earlier onset, previous recurrences and treatment refractoriness. The aim of our study was to investigate metabolite abnormalities in the hippocampus associated with past depressive illness burden. METHODS Glutamate/glutamine (Glx), N-acetylaspartate (NAA) and choline (Cho), potential markers of glial/neuronal integrity and membrane turnover, respectively, were measured in adults with depression and healthy controls using a 3 T magnetic resonance spectroscopy scanner. Voxels were placed in the head of the right and left hippocampus. We controlled for systematic differences resulting from volume-of-interest (VOI) tissue composition and total hippocampal volume. RESULTS Our final sample comprised a total of 16 healthy controls and 52 adult patients with depression in different stages of the illness (20 treatment-resistant/chronic, 18 remitted-recurrent and 14 first-episode), comparable for age and sex distribution. Patients with treatment-resistant/chronic and remitted-recurrent depression had significantly lower levels of Glx and NAA than controls, especially in the right hippocampal region (p ≤ 0.025). Diminished levels of Glx were correlated with longer illness duration (left VOI r = -0.34, p = 0.01). By contrast, Cho levels were significantly higher in patients with treatment-resistant/chronic depression than those with first-episode depression or controls in the right and left hippocampus (up to 19% higher; all p ≤ 0.025) and were consistently related to longer illness duration (right VOI r = 0.30, p = 0.028; left VOI r = 0.38, p = 0.004) and more previous episodes (right VOI r = 0.46, p = 0.001; left VOI r = 0.44, p = 0.001). LIMITATIONS The cross-sectional design and the inclusion of treated patients are the main limitations of the study. CONCLUSION Our results support that metabolite alterations within the hippocampus are more pronounced in patients with a clinical evolution characterized by recurrences and/or chronicity and add further evidence to the potential deleterious effects of stress and depression on this region.
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Affiliation(s)
| | - Maria J. Portella
- Correspondence to: M.J. Portella, Department of Psychiatry, Hospital de la Santa Creu i Sant Pau (UAB, CIBERSAM), Institut d’Investigació Biomèdica Sant Pau (IIB Sant Pau), Sant Antoni Ma. Claret, 167, 08025 Barcelona, Spain;
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Aulinas A, Santos A, Valassi E, Mato E, Crespo I, Resmini E, Roig O, Bell O, Webb SM. [Telomeres, aging and Cushing's syndrome: are they related?]. ACTA ACUST UNITED AC 2012; 60:329-35. [PMID: 23218933 DOI: 10.1016/j.endonu.2012.10.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 09/29/2012] [Accepted: 10/01/2012] [Indexed: 10/27/2022]
Abstract
Cushing's syndrome is due to excess cortisol secretion and is associated to increased mortality and severe morbidity that are not fully reversible despite biochemical control. The syndrome consists of a set of systemic manifestations similar to those found in aging. Chronic stress, which also causes hyperstimulation of the hypothalamic-pituitary-adrenal axis, has been related to accelerated telomere shortening, oxidative damage, and cell aging. Although premature aging in patients with Cushing's syndrome could be related to environmental factors, the possibility that chronic exposure to hypercortisolism causes telomere shortening, and thus premature aging, cannot be ruled out. This review discusses the available evidence supporting a link between Cushing's syndrome and cell aging.
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Affiliation(s)
- Anna Aulinas
- Servicio de Endocrinología y Nutrición, Institut d'Investigació Biomèdica Sant Pau, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, España.
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90
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Wagenmakers MAEM, Netea-Maier RT, Prins JB, Dekkers T, den Heijer M, Hermus ARMM. Impaired quality of life in patients in long-term remission of Cushing's syndrome of both adrenal and pituitary origin: a remaining effect of long-standing hypercortisolism? Eur J Endocrinol 2012; 167:687-95. [PMID: 22936421 DOI: 10.1530/eje-12-0308] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The determinants that cause impaired quality of life (QOL) in patients in long-term remission of Cushing's syndrome (CS) are unknown. The aim of this study was to get more insight into the patient and disease characteristics related to impaired QOL in these patients. DESIGN Cross-sectional study. METHODS The QOL of 123 patients in remission of CS (age 52.2 ± 12.0 years, 106 women, duration of remission 13.3 ± 10.4 years, 80% pituitary CS), assessed with seven validated questionnaires, was compared with the QOL of an age- and sex-matched control group (n=105). To investigate the influence of the aetiology of CS on QOL, patients in remission of pituitary and adrenal CS were compared. Furthermore, the influence of hormonal deficiencies, treatment strategy, duration of remission, gender and age on QOL was investigated. RESULTS QOL in the total patient group and each patient subgroup was significantly worse on practically all dimensions of questionnaires compared with the control group (P<0.05), except for patients in remission of pituitary CS without hormonal deficiencies who had an impaired QOL on 50% of the QOL dimensions. Subgroup analysis revealed no difference in QOL between different patient groups, especially no difference between patients in remission of adrenal and pituitary CS. Female gender and a shorter duration of remission had a negative influence on QOL in the patient group. CONCLUSIONS QOL remains impaired in patients in long-term remission of CS regardless of aetiology, presence of hormonal deficiencies and treatment strategies. More research is needed to establish the causes.
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Affiliation(s)
- M A E M Wagenmakers
- Department of Endocrinology, Radboud University Nijmegen Medical Centre, The Netherlands.
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91
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Abstract
Recent evidence suggests that correction of hypercortisolism in Cushing's syndrome (CS) may not lead to complete remission of the clinical abnormalities associated with this condition. In particular, elevated cardiovascular risk may persist in "cured" CS patients long-term after eucortisolism has been reached. This is believed to be related with the maintenance of visceral obesity and altered adipokine secretory pattern which perpetuate features of metabolic syndrome, including impaired glucose tolerance, hypertension, dyslipidemia, atherosclerosis and hypercoagulability. Nephrolithiasis and incomplete recovery of bone mineral density have also been described in "cured" CS patients. Moreover, previous exposure to excess cortisol may have irreversible effects on the structures of the central nervous system controlling cognitive function and mood. Thus, sustained deterioration of the cardiovascular system, bone remodelling and cognitive function may be associated with high morbidity and poor quality of life in CS patients in remission for many years. Although mortality in "cured" CS patients may not differ from that in the general population, data beyond 20 years follow-up are very scarce, so further studies evaluating larger cohorts for longer follow-up periods are needed to draw definitive conclusions on longevity. Life-long monitoring is mandatory in CS patients in order to control long term complications of previous cortisol excess and, possibly, normalize life expectancy.
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Affiliation(s)
- Elena Valassi
- Department of Medicine/Endocrinology, Research Group on Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Pare Claret 167, 08025, Barcelona, Spain.
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92
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Ragnarsson O, Berglund P, Eder DN, Johannsson G. Long-term cognitive impairments and attentional deficits in patients with Cushing's disease and cortisol-producing adrenal adenoma in remission. J Clin Endocrinol Metab 2012; 97:E1640-8. [PMID: 22761462 DOI: 10.1210/jc.2012-1945] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Cognitive function is impaired in patients with active Cushing's syndrome (CS). OBJECTIVE The aim was to study cognitive function in patients with CS in long-term remission. DESIGN We conducted a cross-sectional, case-controlled, single center study. PATIENTS Fifty-five patients previously treated for Cushing's disease (n = 43) and cortisol-producing adrenal adenoma (n = 12) and 55 controls matched for age, gender, and educational level participated in the study. METHODS Working memory, attention, information-processing speed, verbal fluency, and reading speed were studied using standardized neuropsychological testing and alerting, orienting, and executive control using the Attentional Network Test. Fatigue impact scale and the comprehensive psychopathological rating scale were used to evaluate fatigue and affective disorder. RESULTS Median (interquartile range) duration of remission was 13 (5-19) yr and the mean ± SD age at follow-up was 54 ± 14 yr. Compared to controls, patients had a higher score on the fatigue impact scale, indicating greater burdens of fatigue, and a higher score on the comprehensive psychopathological rating scale subscales for depression and anxiety. In a multivariate analysis, attention, spatial orienting, alerting, working memory, verbal fluency, and reading speed were all diminished in comparison to controls, independent of scores for affective disorder and fatigue. No overall difference in outcome was seen between patients in long-term remission for Cushing's disease and cortisol-producing adrenal adenoma. CONCLUSION Patients with CS in remission have impaired cognitive function that cannot be explained by the coexistence of affective disorder or chronic fatigue. The pattern of cognitive and attentional deficits suggests a more global involvement of the brain function than has previously been suggested.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, SE-413 45 Göteborg, Sweden.
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