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Chae HH, Ahmed A, Bone JN, Abdulhussein FS, Amed S, Patel T, Blydt-Hansen TD. Adrenal insufficiency in pediatric kidney transplantation recipients. Pediatr Transplant 2024; 28:e14768. [PMID: 38770694 DOI: 10.1111/petr.14768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 04/05/2024] [Accepted: 04/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Immunosuppression of pediatric kidney transplant (PKT) recipients often includes corticosteroids. Prolonged corticosteroid exposure has been associated with secondary adrenal insufficiency (AI); however, little is known about its impact on PKT recipients. METHODS This was a retrospective cohort review of PKT recipients to evaluate AI prevalence, risk factors, and adverse effects. AI risk was assessed using morning cortisol (MC) and diagnosis confirmed by an ACTH stimulation test. Potential risk factors and adverse effects were tested for associations with MC levels and AI diagnosis. RESULTS Fifty-one patients (60.8% male, age 7.4 (IQR 3.8, 13.1) years; 1 patient counted twice for repeat transplant) were included. Patients at risk for AI (MC < 240 nmol/L) underwent definitive ACTH stimulation testing, confirming AI in 13/51 (25.5%) patients. Identified risk factors for AI included current prednisone dosage (p = .001), 6-month prednisone exposure (p = .02), daily prednisone administration (p = .002), and rejection episodes since transplant (p = .001). MC level (2.5 years (IQR 1.1, 5.1) post-transplant) was associated with current prednisone dosage (p < .001), 6-month prednisone exposure (p = .001), daily prednisone administration (p = .006), rejection episodes since transplant (p = .003), greater number of medications (β = -16.3, p < .001), 6-month hospitalization days (β = -3.3, p = .013), creatinine variability (β = -2.4, p = .025), and occurrence of acute kidney injury (β = -70.6, p = .01). CONCLUSION Greater corticosteroid exposure was associated with a lower MC level and confirmatory diagnosis of AI noted with an ACTH stimulation test. Adverse clinical findings with AI included greater medical complexity and kidney function lability. These data support systematic clinical surveillance for AI in PKT recipients treated with corticosteroids.
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Affiliation(s)
- Hyunwoong Harry Chae
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Azim Ahmed
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey N Bone
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Fatema S Abdulhussein
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shazhan Amed
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Trisha Patel
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Endocrinology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tom D Blydt-Hansen
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of Nephrology, Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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2
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Bathla JS, Chitale A, Shahzad S, Elbathani M, Sarvadevabatla N. Too Dry for Primary Adrenal Insufficiency (PAI): PAI Masked by Volume Depletion. Cureus 2024; 16:e61018. [PMID: 38915992 PMCID: PMC11194124 DOI: 10.7759/cureus.61018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/24/2024] [Indexed: 06/26/2024] Open
Abstract
Adrenal insufficiency (AI) is a rare but potentially life-threatening endocrine disorder characterized by inadequate production or impaired response to adrenal hormones. Symptoms may range from acute emergent crisis presenting as hemodynamic shock or may be more chronic in presentation with a gradual onset of nonspecific symptoms. These vague symptoms are often accompanied by typical laboratory findings, such as hyponatremia, hypotension, and hyperkalemia, and point toward a diagnosis of chronic AI. In this case presentation, we demonstrate chronic AI presenting with severe hyponatremia, which was revealed after return to an euvolemic baseline. Because of an insidious presentation, AI can be both an incidental finding and easily missed. This case highlights the importance of evaluating suspected cases of AI at a baseline metabolic and hemodynamic state, including volume status. High clinical suspicion is warranted in these patients to avoid potential emergent adrenal crisis and to provide appropriate replacement therapy once etiology is established.
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Affiliation(s)
- Jasdeep S Bathla
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Anirudh Chitale
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Shahzana Shahzad
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
| | - Mohamed Elbathani
- Internal Medicine, Wayne State University/Detroit Medical Center, Detroit, USA
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3
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Peel A, Rushworth RL, Torpy DJ. Novel agents to treat adrenal insufficiency: findings of preclinical and early clinical trials. Expert Opin Investig Drugs 2024; 33:115-126. [PMID: 38284211 DOI: 10.1080/13543784.2024.2311207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/24/2024] [Indexed: 01/30/2024]
Abstract
INTRODUCTION Adrenal insufficiency currently affects over 300/million population, with higher morbidity and mortality compared to the general population. Current glucocorticoid replacement therapy is limited by a lack of reliable biomarkers to guide dosing, inter-patient variation in metabolism and narrow therapeutic window. Increased morbidity and mortality may relate to unappreciated under- or over-exposure to glucocorticoids and impaired cortisol circadian rhythm. New agents are required to emulate physiological cortisol secretion and individualize glucocorticoid dosing. AREAS COVERED History of glucocorticoid therapy, current limitations, and novel chronotherapeutic glucocorticoid delivery mechanisms. Literature search incorporated searches of PubMed and Embase utilizing terms such as adrenal insufficiency, Chronocort, Plenadren, continuous subcutaneous hydrocortisone infusion (CHSI), and glucocorticoid receptor modulator. EXPERT OPINION Glucocorticoid chronotherapy is necessary to optimize glucocorticoid exposure and minimize complications. Current oral chronotherapeutics provide improved dosing functionality, but are modifiable only in specific increments and cannot accommodate ultradian cortisol variation. Current data show improvement in quality of life but not morbidity or mortality outcomes. CHSI has significant potential for individualized glucocorticoid dosing, but would require a suitable biomarker of glucocorticoid adequacy to be implementable. Avenues for future research include determining a glucocorticoid sufficiency biomarker, development of interstitial or systemic cortisol monitoring, or development of glucocorticoid receptor modulators.
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Affiliation(s)
- Andrew Peel
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - R Louise Rushworth
- School of Medicine, Sydney, The University of Notre Dame, Australia, Sydney, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
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Russell G, Kalafatakis K, Durant C, Marchant N, Thakrar J, Thirard R, King J, Bowles J, Upton T, Thai NJ, Brooks JCW, Wilson A, Phillips K, Ferguson S, Grabski M, Rogers CA, Lampros T, Wilson S, Harmer C, Munafo M, Lightman SL. Ultradian hydrocortisone replacement alters neuronal processing, emotional ambiguity, affect and fatigue in adrenal insufficiency: The PULSES trial. J Intern Med 2024; 295:51-67. [PMID: 37857352 PMCID: PMC10952319 DOI: 10.1111/joim.13721] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Primary adrenal insufficiency (PAI) mortality and morbidity remain unacceptably high, possibly arising as glucocorticoid replacement does not replicate natural physiology. A pulsatile subcutaneous pump can closely replicate cortisol's circadian and ultradian rhythm. OBJECTIVES To assess the effect of pump therapy on quality of life, mood, functional neuroimaging, behavioural/cognitive responses, sleep and metabolism. METHODS A 6-week randomised, crossover, double-blinded and placebo-controlled feasibility study of usual dose hydrocortisone in PAI administered as either pulsed subcutaneous or standard care in Bristol, United Kingdom (ISRCTN67193733). Participants were stratified by adrenal insufficiency type. All participants who received study drugs are included in the analysis. The primary outcome, the facial expression recognition task (FERT), occurred at week 6. RESULTS Between December 2014 and 2017, 22 participants were recruited - 20 completed both arms, and 21 were analysed. The pump was well-tolerated. No change was seen in the FERT primary outcome; however, there were subjective improvements in fatigue and mood. Additionally, functional magnetic resonance imaging revealed differential neural processing to emotional cues and visual stimulation. Region of interest analysis identified the left amygdala and insula, key glucocorticoid-sensitive regions involved in emotional ambiguity. FERT post hoc analysis confirmed this response. There were four serious adverse events (AE): three intercurrent illnesses requiring hospitalisation (1/3, 33.3% pump) and a planned procedure (1/1, 100% pump). There was a small number of expected AEs: infusion site bruising/itching (3/5, 60% pump), intercurrent illness requiring extra (3/7, 42% pump) and no extra (4/6, 66% pump) steroid. CONCLUSIONS These findings support the administration of hormone therapy that mimics physiology.
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Affiliation(s)
- Georgina Russell
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Konstantinos Kalafatakis
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Faculty of Medicine and Dentistry (Malta Campus)Queen Mary University of LondonVictoriaMalta
| | - Claire Durant
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Nicola Marchant
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Jamini Thakrar
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Russell Thirard
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Jade King
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
- North Bristol NHS TrustBristolUK
| | - Jane Bowles
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Thomas Upton
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
| | - Ngoc Jade Thai
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
- Neurosciences and Mental HealthLiverpool Health PartnersLiverpoolUK
| | | | - Aileen Wilson
- Clinical Research and Imaging CentreUniversity of BristolBristolUK
| | - Kirsty Phillips
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
| | - Stuart Ferguson
- School of MedicineUniversity of TasmaniaHobartTasmaniaAustralia
| | | | - Chris A. Rogers
- Bristol Trials CentreBristol Medical SchoolUniversity of BristolBristolUK
| | - Theodoros Lampros
- Department of Informatics and Telecommunications, Human‐Computer Interaction LaboratoryUniversity of IoanninaArtaGreece
| | - Sue Wilson
- Department of Brain SciencesFaculty of MedicineImperial College LondonLondonUK
| | - Catherine Harmer
- Department of PsychiatryOxford University and Oxford Health NHS Foundation TrustOxfordUK
| | - Marcus Munafo
- MRC Integrative Epidemiology UnitSchool of Psychological ScienceUniversity of BristolBristolUK
| | - Stafford L. Lightman
- Laboratories of Integrative Neuroscience and EndocrinologyBristol Medical SchoolUniversity of BristolBristolUK
- University Hospital Bristol and Weston NHS Foundation TrustBristolUK
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5
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Brabham C, Cohen S, Covés-Datson E, Carbo AR. A First Presentation of Autoimmune Primary Adrenal Insufficiency. Am J Med 2023; 136:e237-e238. [PMID: 37699498 DOI: 10.1016/j.amjmed.2023.08.018] [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: 08/18/2023] [Accepted: 08/18/2023] [Indexed: 09/14/2023]
Affiliation(s)
| | | | - Evelyn Covés-Datson
- Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Boston, Mass
| | - Alexander R Carbo
- Harvard Medical School, Boston, Mass; Brigham and Women's Hospital, Boston, Mass
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6
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Nowotny HF, Marchant Seiter T, Ju J, Gottschlich A, Schneider H, Zopp S, Vogel F, Tschaidse L, Auer MK, Lottspeich C, Kobold S, Rothenfusser S, Beuschlein F, Reincke M, Braun L, Reisch N. Major immunophenotypic abnormalities in patients with primary adrenal insufficiency of different etiology. Front Immunol 2023; 14:1275828. [PMID: 38045693 PMCID: PMC10690587 DOI: 10.3389/fimmu.2023.1275828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 10/27/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Patients with primary adrenal insufficiency (PAI) suffer from increased risk of infection, adrenal crises and have a higher mortality rate. Such dismal outcomes have been inferred to immune cell dysregulation because of unphysiological cortisol replacement. As the immune landscape of patients with different types of PAI has not been systematically explored, we set out to immunophenotype PAI patients with different causes of glucocorticoid (GC) deficiency. Methods This cross-sectional single center study includes 28 patients with congenital adrenal hyperplasia (CAH), 27 after bilateral adrenalectomy due to Cushing's syndrome (BADx), 21 with Addison's disease (AD) and 52 healthy controls. All patients with PAI were on a stable GC replacement regimen with a median dose of 25 mg hydrocortisone per day. Peripheral blood mononuclear cells were isolated from heparinized blood samples. Immune cell subsets were analyzed using multicolor flow cytometry after four-hour stimulation with phorbol myristate acetate and ionomycin. Natural killer (NK-) cell cytotoxicity and clock gene expression were investigated. Results The percentage of T helper cell subsets was downregulated in AD patients (Th1 p = 0.0024, Th2 p = 0.0157, Th17 p < 0.0001) compared to controls. Cytotoxic T cell subsets were reduced in AD (Tc1 p = 0.0075, Tc2 p = 0.0154) and CAH patients (Tc1 p = 0.0055, Tc2 p = 0.0012) compared to controls. NKCC was reduced in all subsets of PAI patients, with smallest changes in CAH. Degranulation marker CD107a expression was upregulated in BADx and AD, not in CAH patients compared to controls (BADx p < 0.0001; AD p = 0.0002). In contrast to NK cell activating receptors, NK cell inhibiting receptor CD94 was upregulated in BADx and AD, but not in CAH patients (p < 0.0001). Although modulation in clock gene expression could be confirmed in our patient subgroups, major interindividual-intergroup dissimilarities were not detected. Discussion In patients with different etiologies of PAI, distinct differences in T and NK cell-phenotypes became apparent despite the use of same GC preparation and dose. Our results highlight unsuspected differences in immune cell composition and function in PAI patients of different causes and suggest disease-specific alterations that might necessitate disease-specific treatment.
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Affiliation(s)
- Hanna F. Nowotny
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Jing Ju
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Adrian Gottschlich
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Department of Medicine III, LMU University Hospital, LMU Munich, Munich, Germany
| | - Holger Schneider
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Stephanie Zopp
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Frederick Vogel
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lea Tschaidse
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Matthias K. Auer
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | | | - Sebastian Kobold
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Simon Rothenfusser
- Division of Clinical Pharmacology, University Hospital, LMU Munich, Munich, Germany
- Einheit für Klinische Pharmakologie (EKLiP), Helmholtz Munich, Research Center for Environmental Health (HMGU), Neuherberg, Germany
| | - Felix Beuschlein
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, Universitätsspital Zürich (USZ) und Universität Zürich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Leah Braun
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
| | - Nicole Reisch
- Department of Medicine IV, LMU University Hospital, LMU Munich, Munich, Germany
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7
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Ciancia S, van den Berg SAA, van den Akker ELT. The Reliability of Salivary Cortisol Compared to Serum Cortisol for Diagnosing Adrenal Insufficiency with the Gold Standard ACTH Stimulation Test in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1569. [PMID: 37761530 PMCID: PMC10527706 DOI: 10.3390/children10091569] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/03/2023] [Accepted: 09/18/2023] [Indexed: 09/29/2023]
Abstract
The ACTH (adrenocorticotropic hormone) stimulation test is the gold standard for the diagnosis of adrenal insufficiency (AI), performed with ACTH high dose (HDT) or low dose (LDT). As salivary cortisol has been proposed as an alternative to serum cortisol, our aim was to evaluate the reliability of salivary cortisol compared to serum cortisol for diagnosing AI in children. Data were collected retrospectively. Salivary and serum cortisol values derived by 80 ACTH stimulation tests were obtained (39 F, 36 M; median age 11.5 years, IQR 6.9). Sampling was performed at baseline and after 30 and 60 min from ACTH administration during the HDT, and at baseline and 10, 20, 30, 40 and 60 min after the stimulation for the LDT. A serum cortisol level > 420 nmol/L ruled out AI. The correlation coefficients between serum and salivary cortisol for the HDT (n = 24) were 0.80 at t0, 0.48 at t30 and 0.75 at t60. All patients were adrenal sufficient. In 41% of the LDT, peak serum cortisol indicated insufficient adrenal function. The correlation coefficients between serum and salivary cortisol were 0.59 at t0 and 0.33 at the peak. For a cut-off of salivary cortisol < 15 nmol/L, sensitivity was 73.9% and specificity 69.6%. Our data do not support salivary cortisol as a valid alternative to serum cortisol during LDT. Regarding the HDT, results are more encouraging, however, further studies are needed.
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Affiliation(s)
- Silvia Ciancia
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Center, 3015 Rotterdam, The Netherlands
| | - Sjoerd A. A. van den Berg
- Department of Clinical Chemistry, Erasmus University Medical Center, 3015 Rotterdam, The Netherlands
| | - Erica L. T. van den Akker
- Division of Endocrinology, Department of Pediatrics, Erasmus MC-Sophia Children’s Hospital, University Medical Center, 3015 Rotterdam, The Netherlands
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8
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Malyukov M, Gelfgat E, Ruiz-Babot G, Schmid J, Lehmann S, Spinas G, Beuschlein F, Hantel C, Reisch N, Nawroth PP, Bornstein SR, Steenblock C, Ludwig B. Transplantation of porcine adrenal spheroids for the treatment of adrenal insufficiency. Xenotransplantation 2023; 30:e12819. [PMID: 37548062 DOI: 10.1111/xen.12819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/05/2023] [Accepted: 07/26/2023] [Indexed: 08/08/2023]
Abstract
Primary adrenal insufficiency is a life-threatening disorder, which requires lifelong hormone replacement therapy. Transplantation of xenogeneic adrenal cells is a potential alternative approach for the treatment of adrenal insufficiency. For a successful outcome of this replacement therapy, transplanted cells should provide adequate hormone secretion and respond to adrenal physiological stimuli. Here, we describe the generation and characterization of primary porcine adrenal spheroids capable of replacing the function of adrenal glands in vivo. Cells within the spheroids morphologically resembled adult adrenocortical cells and synthesized and secreted adrenal steroid hormones in a regulated manner. Moreover, the embedding of the spheroids in alginate led to the formation of cellular elongations of steroidogenic cells migrating centripetally towards the inner part of the slab, similar to zona Fasciculata cells in the intact organ. Finally, transplantation of adrenal spheroids in adrenalectomized SCID mice reversed the adrenal insufficiency phenotype, which significantly improved animals' survival. Overall, such adrenal models could be employed for disease modeling and drug testing, and represent the first step toward potential clinical trials in the future.
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Affiliation(s)
- Maria Malyukov
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Evgeny Gelfgat
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Gerard Ruiz-Babot
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Janine Schmid
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Susann Lehmann
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Giatgen Spinas
- Medical Faculty, University Hospital Zürich, Zürich, Switzerland
| | - Felix Beuschlein
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | - Constanze Hantel
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - Peter P Nawroth
- Medical Faculty Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan R Bornstein
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Faculty of Life Sciences & Medicine, School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, UK
| | - Charlotte Steenblock
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
| | - Barbara Ludwig
- Department of Internal Medicine III, University Hospital Carl Gustav Carus, Technical, University Dresden, Dresden, Germany
- Department of Endocrinology, Diabetology and Clinical Nutrition, University Hospital Zürich, Zürich, Switzerland
- Paul Langerhans Institute Dresden of Helmholtz Centre Munich at University Hospital Carl Gustav Carus of TU Dresden Faculty of Medicine, Dresden, Germany
- DFG-Center for Regenerative Therapies Dresden, Technical University Dresden, Dresden, Germany
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9
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Bouter J, Reznik Y, Thariat J. Effects on the Hypothalamo-Pituitary Axis in Patients with CNS or Head and Neck Tumors following Radiotherapy. Cancers (Basel) 2023; 15:3820. [PMID: 37568636 PMCID: PMC10417001 DOI: 10.3390/cancers15153820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/23/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Knowledge about the precise effects of radiotherapy on hypothalamo-pituitary functions is limited. Reduction of side effects is a major goal of advanced radiotherapy modalities. We assessed strategies for monitoring and replacement of hormone deficiencies in irradiated patients. METHODS A search strategy was systematically conducted on PubMed®. Additional articles were retrieved to describe endocrine mechanisms. RESULTS 45 studies were evaluated from 2000 to 2022. They were predominantly retrospective and highly heterogeneous concerning patient numbers, tumor types, radiotherapy technique and follow-up. Endocrine deficiencies occurred in about 40% of patients within a median follow-up of 5.6 years without a clear difference between radiotherapy modalities. Somatotropic and thyrotropic axes were, respectively, the most and least radiosensitive. CONCLUSIONS Current pituitary gland dose constraints may underestimate radiation-induced endocrine deficiencies, thus impairing quality of life. Little difference might be expected between radiation techniques for PG tumors. For non-PG tumors, dose constraints should be applied more systematically.
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Affiliation(s)
- Jordan Bouter
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
| | - Yves Reznik
- Department of Endocrinology, University Hospital of Caen, Avenue de la Côte de Nacre, 14033 Caen, France;
| | - Juliette Thariat
- Radiotherapy Department, Centre François Baclesse, Avenue du Général Harris, 14000 Caen, France;
- Corpuscular Physics Laboratory, ENSICAEN, Boulevard Maréchal Juin, 14050 Caen, France
- Unicaen—Normandie Université, 14050 Caen, France
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10
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Ozair S, Maldonado-Rivera H, Medina-Morales K, Marti E, Angueira-Serrano E, Michel G. When Stress Is Not the Only Culprit: A Case of Secondary Adrenal Insufficiency in a Young Patient With Graves' Disease. Cureus 2023; 15:e41528. [PMID: 37551210 PMCID: PMC10404451 DOI: 10.7759/cureus.41528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
This case report underscores the significance of maintaining a broad list of differential diagnoses, including adrenal insufficiency, when evaluating patients who present with recurring episodes of hypotension and generalized fatigue. It further underscores that T3 thyrotoxicosis can manifest as the initial and sole presenting feature of Graves' disease. Finally, it emphasizes the critical importance of employing a multidisciplinary approach to discharge high-risk patients from the hospital to minimize the risk of acute decompensation.
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Affiliation(s)
- Saleha Ozair
- Internal Medicine, Larkin Community Hospital, South Miami, USA
| | | | | | - Echols Marti
- Research, Larkin Community Hospital, South Miami, USA
| | | | - George Michel
- Internal Medicine, Larkin Community Hospital, South Miami, USA
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11
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Complete heart block revealing adrenal tuberculosis. Radiol Case Rep 2023; 18:1856-1861. [PMID: 36926541 PMCID: PMC10011682 DOI: 10.1016/j.radcr.2023.01.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 01/23/2023] [Accepted: 01/27/2023] [Indexed: 03/09/2023] Open
Abstract
Complete heart block is a commonly encountered entity in clinical cardiology practice, which may be secondary to a variety of diseases including metabolic disorders. Here, we report the case of a 60-year-old female patient who presented with persistent symptomatic complete heart block despite the correction of electrolyte disorder and required admission for permanent pacemaker implantation. The etiologic investigation revealed underlying adrenal insufficiency due to tuberculosis. The clinical and biological presentation of adrenal insufficiency is variable with a difficult etiologic assessment. Although cardiac manifestations are rare, significant electrocardiographic abnormalities can be observed in untreated adrenal insufficiency, such as conduction abnormalities. Hence, in our case, we highlight one of the rare etiologies of conductive disorders and the complexity of the extrapulmonary manifestations of tuberculosis that clinicians should be aware of it.
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12
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Zilberman S, Winner L, Giunta J, Rafii DC. A Delayed Presentation of Bilateral Adrenal Hemorrhage Secondary to COVID-19. AACE Clin Case Rep 2023; 9:71-73. [PMID: 37206647 PMCID: PMC9957334 DOI: 10.1016/j.aace.2023.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 05/21/2023] Open
Abstract
Background/Objective Bilateral adrenal hemorrhage is a rare cause of adrenal insufficiency. Cases have been reported of acute adrenal crisis with bilateral adrenal hemorrhage during acute coronavirus disease of 2019 (COVID-19). Our objective was to report a delayed presentation of acute adrenal crisis with bilateral adrenal hemorrhage 2 months after COVID-19. Case Report An 89-year-old man who was hospitalized for COVID-19 pneumonia 2 months prior presented with lethargy. He was disorientated and hypotensive to 70/50 mm Hg without improvement with intravenous fluids. According to his family, since his previous hospitalization for COVID-19, his mental status had continued to deteriorate, and he was no longer able to perform activities of daily living. A computed tomography scan of the abdomen revealed bilateral heterogeneous enlargement of the adrenal glands. Laboratory values were significant for an am cortisol level of 8.42 mcg/dL, a sodium level of 134 mEq/L, and a bicarbonate level of 17 mEq/L. He was treated intravenously with hydrocortisone 100 mg and showed rapid improvement. Discussion It has been shown that COVID-19 disease may cause an increased risk of bleeding or thromboembolism. The exact frequency of bilateral adrenal hemorrhage secondary to COVID-19 is unknown. Although there are a handful of cases reported, there are none to our knowledge with a delayed presentation, as exhibited in our patient. Conclusion The patient's presentation was consistent with acute adrenal crisis due to bilateral adrenal hemorrhage from prior COVID-19 disease. We aimed to highlight the importance of clinicians being aware of adrenal hemorrhage and adrenal insufficiency as a possible delayed consequence in patients with a history of COVID-19.
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Affiliation(s)
- Stephanie Zilberman
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Laura Winner
- Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Judith Giunta
- Division of Endocrinology, Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
| | - Daniel C. Rafii
- Division of Endocrinology, Department of Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York
- Department of Medicine, Weill Cornell Medicine, New York, New York
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Nowotny HF, Bryce J, Ali SR, Giordano R, Baronio F, Chifu I, Tschaidse L, Cools M, van den Akker ELT, Falhammar H, Appelman-Dijkstra NM, Persani L, Beccuti G, Ross IL, Grozinsky-Glasberg S, Pereira AM, Husebye ES, Hahner S, Faisal Ahmed S, Reisch N. Outcome of COVID-19 infections in patients with adrenal insufficiency and excess. Endocr Connect 2023; 12:EC-22-0416. [PMID: 36715679 PMCID: PMC10083676 DOI: 10.1530/ec-22-0416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/26/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Information on clinical outcomes of coronavirus disease 19 (COVID-19) infection in patients with adrenal disorders is scarce. METHODS A collaboration between the European Society of Endocrinology (ESE) Rare Disease Committee and European Reference Network on Rare Endocrine Conditions via the European Registries for Rare Endocrine Conditions allowed the collection of data on 64 cases (57 adrenal insufficiency (AI), 7 Cushing's syndrome) that had been reported by 12 centres in 8 European countries between January 2020 and December 2021. RESULTS Of all 64 patients, 23 were males and 41 females (13 of those children) with a median age of 37 and 51 years. In 45/57 (95%) AI cases, COVID-19 infection was confirmed by testing. Primary insufficiency was present in 45/57 patients; 19 were affected by Addison's disease, 19 by congenital adrenal hyperplasia and 7 by primary AI (PAI) due to other causes. The most relevant comorbidities were hypertension (12%), obesity (n = 14%) and diabetes mellitus (9%). An increase by a median of 2.0 (IQR 1.4) times the daily replacement dose was reported in 42 (74%) patients. Two patients were administered i.m. injection of 100 mg hydrocortisone, and 11/64 were admitted to the hospital. Two patients had to be transferred to the intensive care unit, one with a fatal outcome. Four patients reported persistent SARS-CoV-2 infection, all others complete remission. CONCLUSION This European multicentre questionnaire is the first to collect data on the outcome of COVID-19 infection in patients with adrenal gland disorders. It suggests good clinical outcomes in case of duly dose adjustments and emphasizes the importance of patient education on sick day rules.
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Affiliation(s)
- Hanna F Nowotny
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Munich, Germany
| | - Jillian Bryce
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
| | - Salma R Ali
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
| | - Roberta Giordano
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Federico Baronio
- Pediatric Unit, Department Hospital of Woman and Child, Endo-ERN Centre IT11, IRCSS AOU S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Irina Chifu
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital of Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - Lea Tschaidse
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Munich, Germany
| | - Martine Cools
- Department of Paediatric Endocrinology, Ghent University Hospital, University of Ghent, Ghent, Belgium
| | - Erica LT van den Akker
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus MC - Sophia Children’s Hospital, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Natasha M Appelman-Dijkstra
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, Istituto Auxologico Italiano IRCCS, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan Italy
| | - Guglielmo Beccuti
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Ian L Ross
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Simona Grozinsky-Glasberg
- Neuroendocrine Tumor Unit, ENETS Center of Excellence, Department of Endocrinology and Metabolism, Hadassah Medical Organisation and Faculty of Medicine, the Hebrew University, Jerusalem, Israel
| | - Alberto M Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
| | - Eystein S Husebye
- Department of Clinical Science and KG Jebsen Center for Autoimmune Disorders, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Stefanie Hahner
- Division of Endocrinology and Diabetology, Department of Internal Medicine I, University Hospital of Wuerzburg, University of Wuerzburg, Wuerzburg, Germany
| | - S Faisal Ahmed
- Office for Rare Conditions, University of Glasgow, Glasgow, UK
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, The Netherlands
- Developmental Endocrinology Research Group, University of Glasgow, Glasgow, United Kingdom
| | - Nicole Reisch
- Medizinische Klinik IV, Department of Endocrinology, Klinikum der Universität München, Munich, Germany
- Correspondence should be addressed to N Reisch:
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Zeding Z, Liu L, Wang C, Tian Q, Zhang J, Zen Y, Zhang N, Shen J, Na A M, BaSang P, Lv X, Yang S, Meng S, Yang L. A retrospective analysis of 25 cases of Addison's disease caused by adrenal tuberculosis in Tibet and review of related literature. J Clin Tuberc Other Mycobact Dis 2023; 31:100358. [PMID: 37102162 PMCID: PMC10123242 DOI: 10.1016/j.jctube.2023.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
Background To investigate the clinical characteristics of Addison's disease caused by adrenal tuberculosis in Tibet. After the anti-tuberculosis treatment, the clinical features between continuous glucocorticoid therapy and glucocorticoid withdrawal were analyzed. Methods Clinical data of patients with Addison's disease caused by adrenal tuberculosis diagnosed in The People's Hospital of Tibet Autonomous Region from January 2015 to October 2021 were collected and analyzed. All patients were taking anti-tuberculosis and glucocorticoids replacement therapy, and the root cause of the disease was analyzed following prognosis observations. Results There were 25 patients (24 Tibetan and 1 Han patient) with Addison's disease caused by adrenal tuberculosis, including 18 males and 7 females. A total of 21 cases were followed up successfully, of which 13 cases discontinued anti-tuberculosis drugs successfully, 6 cases discontinued glucocorticoid therapy among the rest, 6 cases continued anti-tuberculosis + glucocorticoid replacement therapy, and 2 cases died. Conclusion Early diagnosis and proper anti-tuberculosis treatment can improve the prognosis of patients with adrenal tuberculosis. Moreover, screening and educating Tibetan people regarding the potential risk and adversities of adrenal tuberculosis is crucial for eradicating the disease.
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15
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Silva C, Patel TJ, Lam C. Diagnosis of adrenal insufficiency in children: a survey among pediatric endocrinologists in North America. J Pediatr Endocrinol Metab 2023; 36:195-198. [PMID: 36524854 DOI: 10.1515/jpem-2022-0444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Adrenal insufficiency (AI) is a life-threatening condition where an accurate diagnosis is critical. While the ACTH stimulation test is the diagnostic test of choice, there remains uncertainty around its protocols and interpretation of results. In this context, the objective of this study was to understand practices of North American pediatric endocrinology providers on the diagnosis of AI in children. METHODS An anonymous electronic survey was sent to members of the Pediatric Endocrine Society. RESULTS A total of 221 participants were included. The majority practiced in academic centers (78%). All respondents ordered ACTH stimulation tests. While 85% used high-dose ACTH stimulation tests (HDST) to diagnose primary AI, there was less consistency in the choice of tests (HDST vs. low-dose ACTH stimulation test; LDST) when diagnosing secondary AI. When interpreting results, 95% used peak cortisol levels, 70% considered the clinical picture, and 49% used relative increase in cortisol levels. Median (IQR) cortisol cutoff level after ACTH stimulation test that was considered sufficient was 18 (15.5-18) μg/L [496 (428-496) nmol/L]; 17% used different cutoffs for LDST, and 18% used different cutoffs for newborns. Finally, 47% were unaware of the assay that was used in their institution for cortisol measurements. CONCLUSIONS Pediatric endocrinology providers use ACTH stimulation tests variably, including in the choice between HDST vs. LDST, test protocols, and interpretation of results.
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Affiliation(s)
- Carolina Silva
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Trisha J Patel
- Endocrinology Division, BC Children's Hospital, Vancouver, BC, Canada
| | - Carol Lam
- 4480 Oak st., Vancouver, BC, Canada, V6H 3V4
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16
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Bilginer MC, Tam AA, Faki S, Bestepe N, Dellal FD, Ozdemir D, Topaloglu O, Ersoy R, Cakir B. Evaluation of Adrenal Reserve in Patients with Differentiated Thyroid Cancer Receiving Thyroid Hormone Suppression Therapy- case-control Comparative Study. Endocr Res 2023; 48:9-15. [PMID: 36524715 DOI: 10.1080/07435800.2022.2158338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Patients with differentiated thyroid cancer (DTC) are exposed to subclinical exogenous hyperthyroidism for the suppression of thyroid-stimulating hormone (TSH). In this study, we aimed to evaluate the adrenal reserve in DTC patients receiving suppression therapy. MATERIALS AND METHODS The study included 55 DTC patients on suppression therapy and 32 healthy volunteers. Basal serum cortisol of all participants and adrenocorticotropic hormone (ACTH) of the patient group were measured. A standard-dose ACTH test (0.25 mg) was performed in patients with a basal cortisol <14.5 mcg/dL. RESULTS In the patient group, TSH was lower, free thyroxine (fT4) was higher, and free triiodothyronine (fT3) was similar to those of the control group (p < .01, p < .01, p = .140, respectively). The serum cortisol of the patient group was significantly lower than the control group (12.14 ± 5.12 mcg/dL vs 18.00 ± 5.56 mcg/dL, p < .001). A total of 34 (61.8%) patients with DTC had a basal cortisol <14.5 mcg/dL. Prolonged TSH suppression (≥5 years vs <5 years) was associated with lower basal cortisol (7.46 ± 2.63 mcg/dL vs 9.48 ± 2.65 mcg/dL, p = .022). The ACTH stimulation test showed that 2 (5.8%) patients had a cortisol response <18 mcg/dL. The rate of adrenal insufficiency was 3.6% in DTC patients. A moderate negative correlation was found between ACTH and fT3 of patients with low basal cortisol (r = -0.358, p = .038). CONCLUSION Patients with DTC receiving TSH suppression therapy are at risk for adrenal insufficiency. The duration and severity of suppression might increase this possibility. Dynamic testing with synthetic ACTH can be used to reveal insufficient cortisol response in case of clinical suspicion.
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Affiliation(s)
- Muhammet Cuneyt Bilginer
- Faculty of Medicine, Department of Endocrinology and Metabolism, Karadeniz Technical University, Trabzon, Turkey
| | - Abbas Ali Tam
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Sevgul Faki
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Nagihan Bestepe
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Fatma Dilek Dellal
- Department of Endocrinology and Metabolism, University of Health Sciences Turkey, Ankara City Hospital, Ankara, Turkey
| | - Didem Ozdemir
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Oya Topaloglu
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Reyhan Ersoy
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Bekir Cakir
- Faculty of Medicine, Department of Endocrinology and Metabolism, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Is Preoperative Adrenal Insufficiency Screening Necessary for Cardiovascular Thoracic Surgery Patients? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59010152. [PMID: 36676776 PMCID: PMC9864834 DOI: 10.3390/medicina59010152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/07/2023] [Accepted: 01/11/2023] [Indexed: 01/15/2023]
Abstract
Background: The association between adrenal insufficiency (AI) and the treatment outcomes of cardiothoracic surgery patients has been little reported. The aims of this study were to investigate the incidence of AI and to compare the post-surgical outcomes of patients with perioperatively treated AI and patients with a normal adrenal response. Methods: A 1.5-year prospective study was conducted in 98 patients scheduled for cardiothoracic surgery. Patients were categorized as either AI or normal-adrenal-response patients. Those with AI were treated with stress doses of glucocorticoid perioperatively. The post-surgical outcomes of patients with AI and of those with a normal adrenaline response were analyzed using multivariable analysis. Results: The overall incidence of AI was 34.7%. There were no statistically significant differences in post-surgical outcomes, including prolonged hospital stay, postoperative infection, prolonged inotropic drug use and relative AI, between the two groups. Only the rate of hyperglycemia requiring insulin infusion was significantly higher in the AI group than in the non-AI group (OR = 14.15, 95% CI = 1.44-138.60, p = 0.02). Conclusions: The proper diagnosis and management of AI can result in surgical outcomes in AI patients comparable to those of normal-adrenal-response patients. Non-life-threatening hyperglycemia requiring insulin infusion was found only in the AI group.
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18
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Giri S, Angadi S, Morupoju G, Bhrugumalla S. Intractable vomiting as a presentation of adrenal insufficiency - a case report. Trop Doct 2023; 53:179-180. [PMID: 36062734 DOI: 10.1177/00494755221122621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
An array of pathophysiological processes can lead to chronic nausea and vomiting, including gastrointestinal and non-gastrointestinal disorders. Initial symptoms of adrenal insufficiency are usually non-specific, but intractable nausea and vomiting are infrequently associated, posing a diagnostic dilemma for clinicians. Here we present such a patient, who responded to glucocorticoid replacement with complete improvement.
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Affiliation(s)
- Suprabhat Giri
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sumaswi Angadi
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Gautham Morupoju
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Sukanya Bhrugumalla
- Department of Gastroenterology, 28605Nizam's Institute of Medical Sciences, Hyderabad, India
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19
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Muacevic A, Adler JR, Gujarathi R, Candula N. Acute Spontaneous Bilateral Adrenal Hemorrhage Presenting as Hyponatremia. Cureus 2022; 14:e33060. [PMID: 36721537 PMCID: PMC9882998 DOI: 10.7759/cureus.33060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2022] [Indexed: 12/29/2022] Open
Abstract
Bilateral adrenal hemorrhage is a very unusual cause of severe adrenal insufficiency and hyponatremia. It can result from trauma, infections, or antiphospholipid antibody syndrome and can be fatal if not diagnosed and treated early. Here, we present a 58-year-old Caucasian man with fatigue, altered sensorium, bradycardia, and hypotension. He denied any abdominal pain, recent trauma, or anti-platelet or anti-coagulation agents. His laboratory workup showed hyponatremia with low serum cortisol levels. He was further worked up and underwent computerized tomography (CT) of the abdomen, which showed bilateral adrenal hemorrhage. He was treated with intravenous (IV) steroids followed by oral hydrocortisone and fludrocortisone. His symptoms resolved, and he was safely discharged home. Asymptomatic bilateral adrenal hemorrhage is a sporadic disease, and it should be in the differential diagnosis for disproportionately sick people with other adrenal insufficiency features.
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20
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Angulo MA, Butler MG, Hossain WA, Castro-Magana M, Corletto J. Central adrenal insufficiency screening with morning plasma cortisol and ACTH levels in Prader-Willi syndrome. J Pediatr Endocrinol Metab 2022; 35:733-740. [PMID: 35437976 DOI: 10.1515/jpem-2022-0074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/21/2022] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Prader-Willi syndrome (PWS) is a complex genetic disorder with severe hypotonia, failure to thrive, childhood obesity, hypogonadism/hypogenitalism and learning/behavioral problems with endocrine-related growth and other hormone deficiencies. The prevalence of central adrenal insufficiency (CAI) using dynamic testing ranges from rare to 60%. We compared routine morning plasma cortisol (MPC) and ACTH levels in large cohorts of PWS and control children to address CAI. METHODS Retrospective analysis of MPC and ACTH levels was undertaken in 128 PWS growth hormone (GH)-treated children under medical care before considering dynamic testing for CAI and 128 non-syndromic control children with short stature evaluated for GH deficiency. RESULTS The average MPC level in PWS was 9.7 ± 3.7 μg/dL with no difference in age, gender or PWS genetic subtype and 13.4 ± 5.7 μg/dL in the control group. MPC levels were significantly lower (p < 0.05) in PWS but in the normal range. The morning plasma ACTH level in the PWS group was 22.1 ± 8.0 pg/mL with one individual having an initial low plasma ACTH level (8 pg/mL), but normal upon repeat. CONCLUSIONS MPC levels in PWS are normal and comparable with control children, without evidence or increased risk of CAI. Lower but normal MPC levels were seen in PWS and suggestive of reduced local regeneration of cortisol from cortisone in adipose tissue by the GH-IGF-I system. Hence, MPC measures alone or in combination with ACTH should be considered for initial screening for CAI in PWS but prior to dynamic testing.
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Affiliation(s)
- Moris A Angulo
- Department of Pediatrics, NYU Langone Hospital-Long Island, Mineola, NY, USA
| | - Merlin G Butler
- Departments of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS, USA
| | - Waheeda A Hossain
- Departments of Psychiatry & Behavioral Sciences, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jorge Corletto
- Department of Pediatrics, NYU Langone Hospital-Long Island, Mineola, NY, USA
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21
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Mosca SMFS, Santos TS, Mendes ACB, Ribeiro LFM, Freitas JMC, Oliveira MJR, Rocha CA, Borges TMS. Pediatric adrenal insufficiency: thirty years experience at a Portuguese hospital. J Pediatr Endocrinol Metab 2022; 35:631-638. [PMID: 35357097 DOI: 10.1515/jpem-2021-0725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/07/2022] [Indexed: 11/15/2022]
Abstract
BACKGROUND Adrenal insufficiency (AI) is a life-threatening condition caused by an impaired secretion of the adrenal glucocorticoid and mineralocorticoid hormones. It comprises a heterogeneous group of primary, secondary and acquired disorders. Presentation differs according to the child's age, but it usually presents with nonspecific and insidious symptoms and signs. The main purpose of this study was to describe and compare patients with primary or secondary AI. METHODS Retrospective analysis of all patients with adrenal insufficiency followed at the Pediatric Endocrinology Unit in a tertiary care Portuguese hospital over the last 30 years. Data on family history, age at the first manifestation and at etiological diagnosis, and clinical presentation (symptoms, signs and laboratory evaluation) was gathered for all patients. RESULTS Twenty-eight patients with AI were included; 67.9% were male, with a median (25th-75th percentile, P25-P75) age of 1 (0.5-36) month at the first presentation. The principal diagnostic categories were panhypopituitarism (42.9%) and congenital adrenal hyperplasia (25%). The most frequent manifestations (75%) were vomiting and weight loss. They were followed for a median (P25-P75) period of 3.5 (0.6-15.5) years. In respect to neurodevelopmental delay and learning difficulties, they were more common in the secondary AI group. CONCLUSIONS Despite medical advances, the diagnosis and management of AI remains a challenge, particularly in the pediatric population, and clinicians must have a high index of suspicion. An early identification of AI can prevent a potential lethal outcome, which may result from severe cardiovascular and hemodynamic instability.
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Affiliation(s)
- Sara M F S Mosca
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Tiago S Santos
- Department of Endocrinology, Diabetes and Metabolism, CHUPorto, Porto, Portugal
| | - Ana C B Mendes
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Luís F M Ribeiro
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Joana M C Freitas
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Maria J R Oliveira
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Carla A Rocha
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
| | - Teresa M S Borges
- Department of Pediatrics, Pediatric Endocrinology Unit, Centro Materno-Infantil do Norte, Centro Hospitalar Universitário do Porto (CMIN-CHUPorto), Porto, Portugal
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22
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Gruber LM, Bancos I. Secondary Adrenal Insufficiency: Recent Updates and New Directions for Diagnosis and Management. Endocr Pract 2022; 28:110-117. [PMID: 34610473 DOI: 10.1016/j.eprac.2021.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/18/2021] [Accepted: 09/20/2021] [Indexed: 12/20/2022]
Abstract
Secondary adrenal insufficiency is the most common subtype of adrenal insufficiency; it is caused by certain medications and pituitary destruction (pituitary masses, inflammation, or infiltration) and is rarely associated with certain germline variants. In this review, we discuss the etiology, epidemiology, and clinical presentation of secondary adrenal insufficiency and focus on the diagnostic and management challenges. We also review the management of selected special populations of patients and discuss patient-important outcomes associated with secondary adrenal insufficiency.
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Affiliation(s)
- Lucinda M Gruber
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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23
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Vulto A, van Faassen M, Kerstens MN, van Beek AP. Susceptibility to Adrenal Crisis Is Associated With Differences in Cortisol Excretion in Patients With Secondary Adrenal Insufficiency. Front Endocrinol (Lausanne) 2022; 13:849188. [PMID: 35518935 PMCID: PMC9065259 DOI: 10.3389/fendo.2022.849188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare cortisol pharmacokinetics and pharmacodynamics mapped through several glucocorticoid sensitive pathways in patients on hydrocortisone substitution with or without an adrenal crisis. DESIGN A post-hoc analysis of a previously conducted randomized controlled trial in patients with secondary adrenal insufficiency examining the effects of 2 weight-adjusted hydrocortisone doses. METHODS Comparisons were primarily made on a hydrocortisone dose of 0.2-0.3 mg/kg/day for plasma cortisol and cortisone, 24-hour urinary steroid profile, the glucocorticoid sensitive tryptophan-kynurenine pathway, the renin-angiotensin-aldosterone system and aspects of quality of life. Variables of interest were also analyzed on the hydrocortisone dose of 0.4-0.6 mg/kg/day. RESULTS Out of 52 patients, 9 (17%) experienced at least one adrenal crisis (AC+ group) and 43 did not develop an adrenal crisis (AC- group) during an observation period of 10 years. 24-hour urinary excretion of cortisol and cortisone were lower in the AC+ group (0.05 [IQR 0.03; 0.05] vs. 0.09 [0.05; 0.12] µmol/24h, P=0.01and 0.13 [0.10; 0.23] vs. 0.24 [0.19; 0.38] µmol/24h, P=0.04, respectively). No differences in pharmacokinetics of cortisol were observed. Kynurenine concentrations were higher in the AC+ group (2.64 [2.43; 3.28] vs. 2.23 [1.82; 2.38] µmol/L, P=0.03) as was general fatigue (Z-scores 1.02 [-0.11; 1.42] vs. -0.16 [- 0.80; 0.28], P=0.04). On the higher hydrocortisone dose urinary excretion of cortisol and cortisone was still significantly lower between the AC- and AC + group. The differences in glucocorticoid sensitive variables disappeared. CONCLUSION Patients susceptible to an adrenal crisis demonstrated differences in cortisol and cortisone excretion as well as in pharmacodynamics when compared to patients who did not experience an adrenal crisis, suggesting a biological predisposition in certain patients for the development of an adrenal crisis.
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Affiliation(s)
- Annet Vulto
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: Annet Vulto,
| | - Martijn van Faassen
- Department of Laboratory Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Michiel N. Kerstens
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - André P. van Beek
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
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Guarnotta V, Ferrigno R, Martino M, Barbot M, Isidori AM, Scaroni C, Ferrante A, Arnaldi G, Pivonello R, Giordano C. Glucocorticoid excess and COVID-19 disease. Rev Endocr Metab Disord 2021; 22:703-714. [PMID: 33025384 PMCID: PMC7538187 DOI: 10.1007/s11154-020-09598-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/15/2022]
Abstract
The pandemic of coronavirus disease (COVID-19), a disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is causing high and rapid morbidity and mortality. Immune system response plays a crucial role in controlling and resolving the viral infection. Exogenous or endogenous glucocorticoid excess is characterized by increased susceptibility to infections, due to impairment of the innate and adaptive immune system. In addition, diabetes, hypertension, obesity and thromboembolism are conditions overrepresented in patients with hypercortisolism. Thus patients with chronic glucocorticoid (GC) excess may be at high risk of developing COVID-19 infection with a severe clinical course. Care and control of all comorbidities should be one of the primary goals in patients with hypercortisolism requiring immediate and aggressive treatment. The European Society of Endocrinology (ESE), has recently commissioned an urgent clinical guidance document on management of Cushing's syndrome in a COVID-19 period. In this review, we aim to discuss and expand some clinical points related to GC excess that may have an impact on COVID-19 infection, in terms of both contagion risk and clinical outcome. This document is addressed to all specialists who approach patients with endogenous or exogenous GC excess and COVID-19 infection.
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Affiliation(s)
- Valentina Guarnotta
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UOC di Malattie endocrine, del Ricambio e della Nutrizione, Università degli studi di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy
| | - Rosario Ferrigno
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Marianna Martino
- Clinica di Endocrinologia e Malattie del Metabolismo, Dipartimento di Scienze Cliniche e Molecolari (DISCLIMO), Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy
| | - Mattia Barbot
- Endocrinology Unit, Department of Medicine, DIME University-Hospital of Padova, Padua, Italy
| | - Andrea M Isidori
- Department of Experimental Medicine, Policlinico Umberto I, COVID Hospital, Sapienza University of Rome, 00161, Rome, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine, DIME University-Hospital of Padova, Padua, Italy
| | - Angelo Ferrante
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UO di Reumatologia, Università degli studi di Palermo, Palermo, Italy
| | - Giorgio Arnaldi
- Clinica di Endocrinologia e Malattie del Metabolismo, Dipartimento di Scienze Cliniche e Molecolari (DISCLIMO), Università Politecnica delle Marche, Ospedali Riuniti di Ancona, Via Conca 71, 60126, Ancona, Italy.
| | - Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via Sergio Pansini 5, 80131, Naples, Italy.
| | - Carla Giordano
- Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", UOC di Malattie endocrine, del Ricambio e della Nutrizione, Università degli studi di Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
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25
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Lousada LM, Mendonca BB, Bachega TASS. Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:488-494. [PMID: 34283908 PMCID: PMC10522175 DOI: 10.20945/2359-3997000000392] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/18/2021] [Indexed: 11/23/2022]
Abstract
Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.
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Affiliation(s)
- Lia Mesquita Lousada
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Berenice B Mendonca
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
| | - Tania A S S Bachega
- Unidade de Endocrinologia do Desenvolvimento, Laboratório de Hormônios e Genética Molecular (LIM42), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brasil
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26
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Younes N, Bourdeau I, Lacroix A. Latent Adrenal Insufficiency: From Concept to Diagnosis. Front Endocrinol (Lausanne) 2021; 12:720769. [PMID: 34512551 PMCID: PMC8429826 DOI: 10.3389/fendo.2021.720769] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/09/2021] [Indexed: 11/22/2022] Open
Abstract
Primary adrenal insufficiency (PAI) is a rare disease and potentially fatal if unrecognized. It is characterized by destruction of the adrenal cortex, most frequently of autoimmune origin, resulting in glucocorticoid, mineralocorticoid, and adrenal androgen deficiencies. Initial signs and symptoms can be nonspecific, contributing to late diagnosis. Loss of zona glomerulosa function may precede zona fasciculata and reticularis deficiencies. Patients present with hallmark manifestations including fatigue, weight loss, abdominal pain, melanoderma, hypotension, salt craving, hyponatremia, hyperkalemia, or acute adrenal crisis. Diagnosis is established by unequivocally low morning serum cortisol/aldosterone and elevated ACTH and renin concentrations. A standard dose (250 µg) Cosyntropin stimulation test may be needed to confirm adrenal insufficiency (AI) in partial deficiencies. Glucocorticoid and mineralocorticoid substitution is the hallmark of treatment, alongside patient education regarding dose adjustments in periods of stress and prevention of acute adrenal crisis. Recent studies identified partial residual adrenocortical function in patients with AI and rare cases have recuperated normal hormonal function. Modulating therapies using rituximab or ACTH injections are in early stages of investigation hoping it could maintain glucocorticoid residual function and delay complete destruction of adrenal cortex.
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Affiliation(s)
| | | | - Andre Lacroix
- Division of Endocrinology, Department of Medicine and Research Center, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
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27
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Čechová A, Honzík T, Edmondson AC, Ficicioglu C, Serrano M, Barone R, De Lonlay P, Schiff M, Witters P, Lam C, Patterson M, Janssen MCH, Correia J, Quelhas D, Sykut-Cegielska J, Plotkin H, Morava E, Sarafoglou K. Should patients with Phosphomannomutase 2-CDG (PMM2-CDG) be screened for adrenal insufficiency? Mol Genet Metab 2021; 133:397-399. [PMID: 34140212 PMCID: PMC8754259 DOI: 10.1016/j.ymgme.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/21/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
PMM2-CDG is the most common congenital disorder of glycosylation (CDG) accounting for almost 65% of known CDG cases affecting N-glycosylation. Abnormalities in N-glycosylation could have a negative impact on many endocrine axes. There is very little known on the effect of impaired N-glycosylation on the hypothalamic-pituitary-adrenal axis function and whether CDG patients are at risk of secondary adrenal insufficiency and decreased adrenal cortisol production. Cortisol and ACTH concentrations were simultaneously measured between 7:44 am to 1 pm in forty-three subjects (20 female, median age 12.8 years, range 0.1 to 48.6 years) participating in an ongoing international, multi-center Natural History study for PMM2-CDG (ClinicalTrials.gov Identifier: NCT03173300). Of the 43 subjects, 11 (25.6%) had cortisol below 5 μg/dl and low to normal ACTH levels, suggestive of secondary adrenal insufficiency. Two of the 11 subjects have confirmed central adrenal insufficiency and are on hydrocortisone replacement and/or stress dosing during illness; 3 had normal and 1 had subnormal cortisol response to ACTH low-dose stimulation test but has not yet been started on therapy; the remaining 5 have upcoming stimulation testing planned. Our findings suggest that patients with PMM2-CDG may be at risk for adrenal insufficiency. Monitoring of morning cortisol and ACTH levels should be part of the standard care in patients with PMM2-CDG.
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Affiliation(s)
- Anna Čechová
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Tomáš Honzík
- Department of Pediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Andrew C Edmondson
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Can Ficicioglu
- Division of Human Genetics, Department of Pediatrics, Children's Hospital of Philadelphia, USA
| | - Mercedes Serrano
- Pediatric Neurology Department, Hospital Sant Joan de Déu, Institut de Recerca Sant Joan de Déu, Barcelona, Spain; U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Spain
| | - Rita Barone
- Child Neuropsychiatry Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Pascale De Lonlay
- Necker Hospital, APHP, Reference Center for Inborn Errors of Metabolism, University of Paris, Paris, France; Inserm UMR_S1163, Institut Imagine, Paris, France
| | - Manuel Schiff
- Necker Hospital, APHP, Reference Center for Inborn Errors of Metabolism, University of Paris, Paris, France
| | - Peter Witters
- Metabolic Center, Department of Pediatrics, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Christina Lam
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, WA 98101, USA; Division of Genetic Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA
| | - Marc Patterson
- Department of Clinical Genomics-Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA
| | - Mirian C H Janssen
- Radboud University Medical Centre, Department of Internal Medicine, Nijmegen, the Netherlands
| | - Joana Correia
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Dulce Quelhas
- Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jolanta Sykut-Cegielska
- Department of Inborn Errors of Metabolism and Paediatrics, the Institute of Mother and Child, Warsaw, Poland
| | - Horacio Plotkin
- Glycomine, Inc, San Francisco, CA, USA; Department of Pediatrics, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Eva Morava
- Department of Clinical Genomics-Department of Laboratory Medicine and Pathology, Mayo Clinic, MN, USA.
| | - Kyriakie Sarafoglou
- Dept. of Pediatrics - Divisions of Endocrinology and Genetics & Metabolism, Dept. of Experimental & Clinical Pharmacology, University of Minnesota, USA
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28
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Gurnell M, Heaney LG, Price D, Menzies‐Gow A. Long-term corticosteroid use, adrenal insufficiency and the need for steroid-sparing treatment in adult severe asthma. J Intern Med 2021; 290:240-256. [PMID: 33598993 PMCID: PMC8360169 DOI: 10.1111/joim.13273] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/04/2021] [Accepted: 01/20/2021] [Indexed: 12/24/2022]
Abstract
Secondary adrenal insufficiency (AI) occurs as the result of any process that disrupts normal hypothalamic and/or anterior pituitary function and causes a decrease in the secretion of steroid hormones from the adrenal cortex. The most common cause of secondary AI is exogenous corticosteroid therapy administered at supraphysiologic dosages for ≥ 1 month. AI caused by oral corticosteroids (OCS) is not well-recognized or commonly diagnosed but is often associated with reduced well-being and can be life-threatening in the event of an adrenal crisis. Corticosteroid use is common in respiratory diseases, and asthma is a representative condition that illustrates the potential challenges and opportunities related to corticosteroid-sparing therapies. For individuals with severe asthma (approximately 5%-10% of all cases), reduction or elimination of maintenance OCS without loss of control can now be accomplished with biologic therapies targeting inflammatory mediators. However, the optimal strategy to ensure early identification and treatment of AI and safe OCS withdrawal in routine clinical practice remains to be defined. Many studies with biologics have involved short evaluation periods and small sample sizes; in addition, cautious approaches to OCS tapering in studies with a placebo arm, coupled with inconsistent monitoring for AI, have contributed to the lack of clarity. If the goal is to greatly reduce and, where possible, eliminate long-term OCS use in severe asthma through the increasing adoption of biologic treatments, there is an urgent need for clinical trials that address both the speed of OCS withdrawal and how to monitor for AI.
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Affiliation(s)
- M. Gurnell
- From theMetabolic Research LaboratoriesWellcome–MRC Institute of Metabolic ScienceUniversity of CambridgeNIHR Cambridge Biomedical Research CentreAddenbrooke’s HospitalCambridgeUK
| | - L. G. Heaney
- Centre for Experimental MedicineQueens University BelfastBelfastUK
| | - D. Price
- Observational and Pragmatic Research Institute Pte LtdSingaporeSingapore
- Division of Applied Health SciencesCentre of Academic Primary CareUniversity of AberdeenAberdeenUK
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29
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Crafa A, Calogero AE, Cannarella R, Mongioi’ LM, Condorelli RA, Greco EA, Aversa A, La Vignera S. The Burden of Hormonal Disorders: A Worldwide Overview With a Particular Look in Italy. Front Endocrinol (Lausanne) 2021; 12:694325. [PMID: 34220719 PMCID: PMC8242938 DOI: 10.3389/fendo.2021.694325] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/02/2021] [Indexed: 01/15/2023] Open
Abstract
Endocrine diseases have a considerable impact on public health from an epidemiological point of view and because they may cause long-term disability, alteration of the quality-of-life of the affected patients, and are the fifth leading cause of death. In this extensive review of the literature, we have evaluated the prevalence of the different disorders of endocrine interest in the world and Italy, highlighting their epidemiological, clinical, and economic impact.
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Affiliation(s)
- Andrea Crafa
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Aldo E. Calogero
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Rossella Cannarella
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Laura M. Mongioi’
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Rosita A. Condorelli
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Emanuela A. Greco
- Department of Health Sciences, University Magna Græcia of Catanzaro, Catanzaro, Italy
| | - Antonio Aversa
- Department of Experimental and Clinical Medicine, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Sandro La Vignera
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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30
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Quénéhervé L, Drui D, Blin J, Péré M, Coron E, Barbara G, Barbaro MR, Cariou B, Neunlist M, Masson D, Bach-Ngohou K. Digestive symptoms in daily life of chronic adrenal insufficiency patients are similar to irritable bowel syndrome symptoms. Sci Rep 2021; 11:8077. [PMID: 33850177 PMCID: PMC8044180 DOI: 10.1038/s41598-021-87158-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 03/19/2021] [Indexed: 12/13/2022] Open
Abstract
Gastrointestinal symptoms are frequent in acute adrenal insufficiency. Although digestive symptoms can significantly reduce quality of life, they are rarely described in patients with treated chronic adrenal insufficiency (CAI). We aimed to characterize digestive symptoms in CAI patients. We used the section pertaining functional bowel disorders of the Rome IV questionnaire. A questionnaire was published on the website of the non-profit patient association "Adrenals" (NPPA of CAI patients) for five months. Information on demographics, characteristics of adrenal insufficiency, digestive symptoms and quality of life was collected. The relatives of CAI patients served as a control group. We analyzed responses of 33 control subjects and 119 patients (68 primary adrenal insufficiency (PAI), 30 secondary adrenal insufficiency (SAI) and 21 congenital adrenal hyperplasia (CAH)). Abdominal pain at least once a week over the past 3 months was reported by 40%, 47% and 33% of patients with PAI, SAI and CAH respectively versus 15% for the controls (p = 0.01). Symptoms were consistent with the Rome IV criteria for irritable bowel syndrome in 27%, 33% and 33% of patients respectively versus 6% for the controls (p < 0.0001). Quality of life was described as poor or very poor in 35%, 57% and 24% of patients respectively versus 5% for the controls (p < 0.0001). In conclusion, digestive symptoms are frequent and incapacitating in CAI patients and similar to symptoms of irritable bowel syndrome in 30% of CAI patients. Assessment and management of digestive symptoms should be considered a priority for physicians treating patients with CAI.
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Affiliation(s)
- L Quénéhervé
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, Nantes, France
| | - D Drui
- Department of Endocrinology, l'Institut du Thorax, CHU Nantes, 44400, Nantes, France
| | - J Blin
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, 9 Quai Moncousu, 44000, Nantes, France
| | - M Péré
- Biostatistics Unit, Research Board, CHU Nantes, Nantes, France
| | - E Coron
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, Nantes, France
| | - G Barbara
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, IRCCS S. Orsola, Bologna, Italy
| | - M R Barbaro
- Department of Medical and Surgical Sciences, Centre for Applied Biomedical Research, University of Bologna, IRCCS S. Orsola, Bologna, Italy
| | - B Cariou
- Department of Endocrinology, CNRS, INSERM, l'Institut du Thorax, CHU Nantes, Université de Nantes, 44400, Nantes, France
| | - M Neunlist
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France
- Institut des Maladies de l'Appareil Digestif, IMAD, CHU Nantes, Hôpital Hôtel-Dieu, Nantes, France
| | - D Masson
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, 9 Quai Moncousu, 44000, Nantes, France
| | - K Bach-Ngohou
- INSERM, TENS, The Enteric Nervous System in Gut and Brain Diseases, IMAD, University of Nantes, Nantes, France.
- Department of Biology, Laboratory of Clinical Biochemistry, CHU Nantes, 9 Quai Moncousu, 44000, Nantes, France.
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31
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Li D, Genere N, Behnken E, Xhikola M, Abbondanza T, Vaidya A, Bancos I. Determinants of Self-reported Health Outcomes in Adrenal Insufficiency: A Multisite Survey Study. J Clin Endocrinol Metab 2021; 106:e1408-e1419. [PMID: 32995875 PMCID: PMC7947833 DOI: 10.1210/clinem/dgaa668] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/28/2020] [Indexed: 12/22/2022]
Abstract
CONTEXT Current evidence on determinants of adverse health outcomes in patients with adrenal insufficiency (AI) is scarce, especially in regards to AI subtypes. OBJECTIVE To determine predictors of adverse outcomes in different subtypes of AI. DESIGN AND SETTING Cross-sectional survey study at 2 tertiary centers. PARTICIPANTS A total of 696 patients with AI: primary AI (PAI, 42%), secondary AI (SAI, 32%), and glucocorticoid-induced AI (GIAI, 26%). INTERVENTION Patient-centered questionnaire. MAIN OUTCOME MEASURES Patients' knowledge, self-management of AI, self-perceived health, and adverse outcomes. RESULTS The incidence rate of adrenal crisis was 24/100 patient-years with 44% experiencing at least 1 adrenal crisis since diagnosis (59% in PAI vs 31% in SAI vs 37% in GIAI, P < .0001). All patients described high degrees of discomfort with self-management and receiving prompt treatment. Patients with PAI were most likely to develop adrenal crises (adjusted OR 2.8, 95% CI 1.9-4.0) despite reporting better self-perceived health (adjusted OR 3.3, 95% CI 2.1-5.3), understanding of their diagnosis (89% vs 74-81% in other subtypes, P = .002), higher comfort with self-management (62% vs 52-61% in other sub types, P = .005), and higher likelihood to receive prompt treatment for adrenal crises in the emergency department (42% vs 19-30% in other subtypes, P < .0001). CONCLUSIONS Patients with AI reported high degrees of discomfort with self-management and treatment delays when presenting with adrenal crises. Despite better self-perceived health and understanding of diagnosis, patients with PAI experienced the highest frequency of adrenal crises. A multidimensional educational effort is needed for patients and providers to improve the outcomes of all subtypes of AI.
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Affiliation(s)
- Dingfeng Li
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Natalia Genere
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Emma Behnken
- Knowledge and Evaluation Research (KER) Unit, Mayo Clinic, Rochester, Minnesota
| | - Majlinda Xhikola
- Division of Endocrinology, University of Florida and Malcom Randall VA Medical Center, Gainesville, Florida
| | - Tiffany Abbondanza
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Boston, Massachusetts
- Correspondence and Reprint requests: Irina Bancos M.D., Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. E-mail: ; or Anand Vaidya, MD MMSc, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB 287, Boston, MA 02115 USA. E-mail:
| | - Irina Bancos
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
- Correspondence and Reprint requests: Irina Bancos M.D., Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA. E-mail: ; or Anand Vaidya, MD MMSc, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB 287, Boston, MA 02115 USA. E-mail:
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Lee MS, Moon HS. Safety of epidural steroids: a review. Anesth Pain Med (Seoul) 2021; 16:16-27. [PMID: 33530678 PMCID: PMC7861892 DOI: 10.17085/apm.21002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/18/2021] [Indexed: 01/12/2023] Open
Abstract
Spine disease is one of the most common musculoskeletal diseases, especially in an aging society. An epidural steroid injection (ESI) is a highly effective treatment that can be used to bridge the gap between physical therapy and surgery. Recently, it has been increasingly used clinically. The purpose of this article is to review the complications of corticosteroids administered epidurally. Common complications include: hypothalamic-pituitary-adrenal (HPA) axis suppression, adrenal insufficiency, iatrogenic Cushing's syndrome, hyperglycemia, osteoporosis, and immunological or infectious diseases. Other less common complications include psychiatric problems and ocular ailments. However, the incidence of complications related to epidural steroids is not high, and most of them are not serious. The use of nonparticulate steroids is recommended to minimize the complications associated with epidural steroids. The appropriate interval and dosage of ESI are disputed. We recommend that the selection of appropriate ESI protocol should be based on the suppression of HPA axis, which reflects the systemic absorption of the corticosteroid.
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Affiliation(s)
- Min Soo Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Watanabe M, Yasuda J, Ashida K, Matsuo Y, Nagayama A, Goto Y, Iwata S, Watanabe M, Sasaki J, Hoshino T, Nomura M. Masked Diabetes Insipidus Hidden by Severe Hyponatremia: A Case of Pituitary Metastasis of Lung Adenocarcinoma. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e928113. [PMID: 33335085 PMCID: PMC7755591 DOI: 10.12659/ajcr.928113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Patient: Male, 70-year-old Final Diagnosis: Adrenal insufficiency • diabetes insipidus • lung adenocarcinoma Symptoms: Anorexia • fatigue Medication: — Clinical Procedure: — Specialty: Endocrinology and Metabolic • Neurosurgery • Oncology
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Affiliation(s)
- Miki Watanabe
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Junichi Yasuda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yuko Matsuo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Yuka Goto
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Shimpei Iwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Masayuki Watanabe
- Division of Respiratory, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Jun Sasaki
- Division of Respiratory, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Tomoaki Hoshino
- Division of Respiratory, Neurology, and Rheumatology, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Division of Respiratory, Neurology, and Rheumatology, Department of Internal Medicine, Kurume, Fukuoka, Japan
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Lundholm MD, Poku C, Emanuele N, Emanuele MA, Lopez N. SARS-CoV-2 (COVID-19) and the Endocrine System. J Endocr Soc 2020; 4:bvaa144. [PMID: 33145472 PMCID: PMC7543511 DOI: 10.1210/jendso/bvaa144] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/23/2020] [Indexed: 01/08/2023] Open
Abstract
As SARS-CoV-2 (COVID-19) overtakes the world, causing moderate to severe disease in about 15% of infected patients, COVID-19 is also found to have widespread effects throughout the body with a myriad of clinical manifestations including the endocrine system. This manuscript reviews what is known about the impact of COVID-19 on the pathophysiology and management of diabetes (both outpatient and inpatient) as well as pituitary, adrenal, thyroid, bone, and gonadal function. Findings in this area are evolving, and long-term effects of infection remain an active area of further research.
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Affiliation(s)
- Michelle D Lundholm
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Caroline Poku
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
| | - Nicholas Emanuele
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois.,Endocrinology Section, Medical Service, VA Hospital, Hines, Illinois
| | - Mary Ann Emanuele
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
| | - Norma Lopez
- Department of Medicine, Division of Endocrinology, Loyola University Health Care System, Maywood, Illinois
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Grouthier V, Lebrun‐Vignes B, Moey M, Johnson DB, Moslehi JJ, Salem J, Bachelot A. Immune Checkpoint Inhibitor-Associated Primary Adrenal Insufficiency: WHO VigiBase Report Analysis. Oncologist 2020; 25:696-701. [PMID: 32390168 PMCID: PMC7418341 DOI: 10.1634/theoncologist.2019-0555] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 04/03/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICIs) have transformed cancer therapy but may also trigger autoimmune adverse drug reactions (ADRs) referred to as immune-related adverse events (irAEs). Although endocrinopathies are among the most common form of irAEs, primary adrenal insufficiency (PAI) is infrequent and has only been published in case reports. The aim of this study was to identify and characterize the main features of PAI-irAE. MATERIALS AND METHODS Suspected PAI-irAE cases were identified using VigiBase, the World Health Organization's pharmacovigilance database of individual case safety reports. RESULTS From September 2, 2008, through October 5, 2018, a total of 50,108 ICI-associated ADRs were reported. Since 2008, there were 451 cases of PAI-irAE identified of which 45 were "definite PAI" and 406 "possible PAI." Patients were mainly male (58.1%) with a median age of 66 years (range, 30-95). Indications of ICI were predominantly for melanoma (41.2%) and lung cancer (28.6%). The majority of patients were treated with ICI monotherapy (nivolumab: 44.3%, pembrolizumab: 11.7%, ipilimumab: 23.6%), and 17.9% were treated with ICI combination therapy. These events occurred with a median time to onset of 120 days (range, 6-576). ICI-associated PAI was associated with significant morbidity (≥90% severe) and mortality (7.3%). Fatality rates were similar in the subgroups of combination therapy versus monotherapy. There were no relevant differences in clinical or demographical characteristics and outcomes between "definite" versus "possible" PAI group. CONCLUSION Our study represents the largest clinical description and characterization of PAI-irAE. Although ICI-associated PAI is a rare adverse event, early recognition is important to implement corticosteroid treatment. Further studies are required to elucidate risk factors and reversibility of this rare but severe irAE. Clinical trial identification number. NCT03492242 IMPLICATIONS FOR PRACTICE: Immune checkpoint inhibitor (ICI)-associated primary adrenal insufficiency (PAI) is a rare adverse event that is important to recognize because it may be severe and life-threatening, requiring emergent and often lifelong hormonal replacement therapy. Awareness regarding this ICI-related endocrinopathy is strongly encouraged among clinicians in addition to patient education about common PAI symptoms that should prompt urgent medical evaluation. In clinical practice, close monitoring and investigation for PAI is crucial to allow for early management and to further define the pathophysiology and prognosis of ICI-PAI. Corticotrophin (adrenocorticotrophic hormone) circulating level evaluation may be often lacking but should be considered as part of the diagnostic workup to differentiate PAI from secondary (central) adrenal insufficiency.
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Affiliation(s)
- Virginie Grouthier
- Department of Endocrinology, Diabetes and Nutrition, University of Bordeaux, USN Haut LevequeBordeauxFrance
| | - Bénédicte Lebrun‐Vignes
- Pharmacovigilance Unit, Department of Pharmacology, Unité de Cardio‐Oncologie Sorbonne Université–Groupe de Recherche Clinique en Cardio‐Oncologie (UNICO‐GRECO), INSERM Centre d'Investigation Clinique (CIC)‐1901, Pitié‐Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP‐HP)ParisFrance
- Equipe d'Accueil 7379 EpiDermE, Université Paris‐Est Créteil (UPEC)ParisFrance
| | - Melissa Moey
- Cardio‐Oncology Program, Departments of Medicine and Pharmacology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Douglas B. Johnson
- Cardio‐Oncology Program, Departments of Medicine and Pharmacology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Javid J. Moslehi
- Cardio‐Oncology Program, Departments of Medicine and Pharmacology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Joe‐Elie Salem
- Pharmacovigilance Unit, Department of Pharmacology, Unité de Cardio‐Oncologie Sorbonne Université–Groupe de Recherche Clinique en Cardio‐Oncologie (UNICO‐GRECO), INSERM Centre d'Investigation Clinique (CIC)‐1901, Pitié‐Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP‐HP)ParisFrance
- Cardio‐Oncology Program, Departments of Medicine and Pharmacology, Vanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anne Bachelot
- Department of Endocrinology and Reproductive Medicine, Centre de Référence des Maladies Endocriniennes Rares de la Croissance and Centre de Référence des Pathologies Gynécologiques Rares, Institute of Cardiometabolism and Nutrition (ICAN), Pitié‐Salpêtrière Hospital, Assistance Publique–Hôpitaux de Paris (AP‐HP)ParisFrance
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Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N. Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan. Clin Endocrinol (Oxf) 2020; 93:87-96. [PMID: 32419166 DOI: 10.1111/cen.14250] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 01/24/2023]
Abstract
There are limited recommendations for fasting in many chronic diseases such as adrenal insufficiency (AI). Research in such situations highlights potential for complications and need for education for patients with AI undertaking fasting during Ramadan. This article aimed to provide up-to-date guidance for healthcare professionals to educate, discuss and manage patients with AI who are considering fasting in Ramadan and is religiously compatible. Latest guidance on this topic and the evidence base for steroid dosing are reviewed and discussed. Risk stratification for patients with AI and optimal strategies for management, including steroid dosing, are detailed. Our review highlights that patients with AI wishing to fast should undergo a thorough risk assessment ideally several months before Ramadan. 'High risk' and 'Very high risk' patients should be encouraged to explore alternative options to fasting discussed below. Prior to the commencement of Ramadan, all patients must receive up-to-date education on sick day rules, instructions on when to terminate their fast or abstain from fasting, carry steroid warning information and must have a valid intramuscular (IM) hydrocortisone pack and know how to administer this. Switching patients with AI desiring to fast from multiple daily hydrocortisone replacement to prednisolone 5 mg once daily at dawn (during Suhoor or Sehri) is recommended and discussed. Patients on fludrocortisone for AI should be advised to take their total dose at dawn. We provide practically relevant case-based scenarios to help with the application of this guidance. Future efforts need to focus on healthcare professional awareness and further research in this setting.
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Affiliation(s)
- Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospital NHS Trust, London, UK
- Department of Diabetes and Endocrinology, King's College London, London, UK
| | - Shazia Hussain
- Department of Diabetes and Endocrinology, Barts Health NHS Trust, London, UK
| | | | - Karim Meeran
- Division of Diabetes, Endocrinology and Metabolism, Department of Medicine, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College London NHS Trust, London, UK
| | - Nazim Ghouri
- Department of Diabetes and Endocrinology, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Queen Elizabeth University Hospital, Glasgow, UK
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Park J, Kwak J, Chung S, Hong HJ, Chon JY, Moon HS. Incidence of Adrenal Insufficiency and Cushing's Syndrome After Long-Term Epidural Steroid Injections Over Six Months or Longer: A Preliminary Study. J Pain Res 2020; 13:1505-1514. [PMID: 32606916 PMCID: PMC7321692 DOI: 10.2147/jpr.s252278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/27/2020] [Indexed: 12/22/2022] Open
Abstract
Purpose Endocrinological complications of an epidural steroid injection (ESI) are rare but dangerous. Nevertheless, despite the associated risks, repeated long-term ESIs are indispensable in some clinical situations. However, only a few reports to date have assessed the safety of this procedure. In this study, we evaluate the incidence of adrenal insufficiency (AI) and Cushing's syndrome after long-term ESIs. Methods This clinical observational study enrolled herniated nucleus pulposus or spinal stenosis patients who had received ESIs over a period of six months or longer. The adrenocorticotropic hormone (ACTH) stimulation test was performed to confirm AI and the late-night salivary cortisol (LNSC) test was performed to diagnose Cushing's syndrome. To evaluate the hypothalamus pituitary adrenal axis suppression, salivary cortisol (SC) levels were measured on days 0, 1, 7, 21, 28, 35, and 42. Results This study included 17 patients. Among these, two patients (11.8%) developed AI, but no cases of Cushing's syndrome were reported. There was no predictor for the development of AI. The SC levels tended to increase with time after an ESI (β = 0.003). The slope of the mixed effect model between the AI and non-AI groups showed a significant difference (p value = 0.015). However, the differences in mean SC levels at each time point between the two groups were not significant (adjusted p value = 0.053). Conclusion Long-term ESI use may be associated with AI development. An unexpected adrenal crisis due to AI could be life threatening. Therefore, regular monitoring of adrenal function in patients who have received long-term ESIs may be prudent.
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Affiliation(s)
- JungHyun Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jueun Kwak
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sukyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Ju Hong
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jin Young Chon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ho Sik Moon
- Department of Anesthesiology and Pain Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Gaba N, Gaba S, Singla M, Gupta M. Type 2 Autoimmune Polyglandular Syndrome Presenting with Hyperpigmentation and Amenorrhea. Cureus 2020; 12:e7772. [PMID: 32455083 PMCID: PMC7243617 DOI: 10.7759/cureus.7772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 36-year-old female presented with lethargy, anorexia, nausea, hyperpigmentation, weight loss and amenorrhea for six months. On examination, she had hyperpigmentation of face, hands and oral mucosa. Investigations revealed adrenal insufficiency and subclinical hyperthyroidism with elevated anti-thyroid peroxidase antibodies. Adrenal insufficiency in combination with Grave's disease and/or type 1 diabetes mellitus occurs in type 2 autoimmune polyglandular syndrome. It is a polygenic disorder occurring due to mutations in the human leukocyte antigen complex on chromosome 6. The patient was treated with oral hydrocortisone which led to improvement in all the symptoms.
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Affiliation(s)
- Nayana Gaba
- Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Saurabh Gaba
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Mandeep Singla
- Internal Medicine, Government Medical College and Hospital, Chandigarh, IND
| | - Monica Gupta
- General Medicine, Government Medical College and Hospital, Chandigarh, IND
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Araque DP, Zuniga G, Ayala AR. PRIMARY ADRENAL INSUFFICIENCY SECONDARY TO CHRONIC POSACONAZOLE USE. AACE Clin Case Rep 2020; 6:e62-e64. [PMID: 32524012 DOI: 10.4158/accr-2019-0176] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/20/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Posaconazole (PSO) is commonly used in the treatment of invasive fungal infections. PSO-induced primary adrenal insufficiency (PAI) is rare, and we present what we think to be the third case report of its incidence. We want to bring awareness to this rare but significant side effect that can impact management and monitoring of patients on this medication. Methods After clinical assessment, the patient was evaluated with diagnostic studies including measurements of cortisol, adrenocorticotropic hormone, renin activity, and aldosterone levels. Imaging studies such as abdominal computed tomography were also performed. Results A 65-year-old man with a history of hemophagocytic lymphohistiocytosis on a dexamethasone taper, complicated with mucormycosis on PSO presented to the emergency department with weakness, fatigue, decreased appetite, orthostatic hypotension, low morning cortisol (0.4 μg/dL), low adrenocorticotropic hormone (3.4 pg/mL), elevated plasma renin (16.7 ng/mL/hour), and low-normal aldosterone (1.7 ng/dL). Abdominal computed tomography imaging revealed bilaterally intact adrenal glands. A diagnosis of PSO-induced PAI was made. Fludrocortisone was initiated in addition to glucocorticoids with improvement of fatigue, appetite, blood pressure, and normalization of sodium and potassium. A month after discontinuing PSO, steroids and fludrocortisone were discontinued with measured morning cortisol of 13 μg/dL and an adrenocorticotropic hormone level of 53.9 pg/mL, both normal. Conclusion Available data suggest that the adverse effect profile of PSO is more favorable than other triazoles. However, our case is the third report suggesting that PAI may be an underrecognized side effect. Awareness of this complication is particularly important in patients with severe or resistant fungal infections.
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Adrenal insufficiency: Physiology, clinical presentation and diagnostic challenges. Clin Chim Acta 2020; 505:78-91. [PMID: 32035851 DOI: 10.1016/j.cca.2020.01.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
Adrenal insufficiency (AI) is a serious condition, which can arise from pathology affecting the adrenal gland itself (primary adrenal insufficiency, PAI), hypothalamic or pituitary pathology (secondary adrenal insufficiency, SAI), or as a result of suppression of the hypothalamic-pituitaryadrenal (HPA) axis by exogenous glucocorticoid therapy (tertiary adrenal insufficiency, TAI). AI is associated with an increase in morbidity and mortality and a reduction in quality of life. In addition, the most common cause of PAI, autoimmune adrenalitis, may be associated with a variety of other autoimmune disorders. Untreated AI can present with chronic fatigue, weight loss and vulnerability to infection. The inability to cope with acute illness or infection can precipitate life-threatening adrenal crisis. It is therefore a critical diagnosis to make in a timely fashion, in order to institute appropriate management, aimed at reversing chronic ill health, preventing acute crises, and restoring quality of life. In this review, we will describe the normal physiology of the HPA axis and explain how knowledge of the physiology of this axis helps us understand the clinical presentation of AI, and forms the basis for the biochemical investigations which lead to the diagnosis of AI.
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Manosroi W, Phimphilai M, Khorana J, Atthakomol P, Pipanmekaporn T. Predictive Factors of Adrenal Insufficiency in Outpatients with Indeterminate Serum Cortisol Levels: A Retrospective Study. ACTA ACUST UNITED AC 2020; 56:medicina56010023. [PMID: 31936335 PMCID: PMC7022503 DOI: 10.3390/medicina56010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/26/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: To diagnose adrenal insufficiency (AI), adrenocorticotropic hormone (ACTH) stimulation tests may need to be performed, but those tests may not be available in some institutions. In addition, they may not be necessary for some patients. The objective of this study was to identify clinical and biochemical factors that could facilitate AI diagnosis in outpatient departments and decrease the number of unnecessary dynamic tests. Materials and Methods: This seven-year retrospective study was performed in a tertiary care medical center. A total of 517 patients who had undergone ACTH stimulation tests in the outpatient department were identified. AI was described as a peak serum cortisol level of <18 µg/dL at 30 or 60 min after stimulation. The associations between clinical factors, biochemical factors, and AI were analyzed using the Poisson regression model and reported by the risk ratio (RR). Results: AI was identified in 128 patients (24.7%). Significant predictive factors for the diagnosis of AI were chronic kidney disease (RR = 2.52, p < 0.001), Cushingoid appearance (RR = 3.44, p < 0.001), nausea and/or vomiting (RR = 1.84, p = 0.003), fatigue (RR = 1.23, p < 0.001), serum basal cortisol <9 µg/dL (RR = 3.36, p < 0.001), serum cholesterol <150 mg/dL (RR = 1.26, p < 0.001), and serum sodium <135 mEq/L (RR = 1.09, p = 0.001). The predictive ability of the model was 83% based on the area under the curve. Conclusion: The easy-to-obtain clinical and biochemical factors identified may facilitate AI diagnosis and help identify patients with suspected AI. Using these factors in clinical practice may also reduce the number of nonessential dynamic tests for AI.
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Affiliation(s)
- Worapaka Manosroi
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Mattabhorn Phimphilai
- Division of Endocrinology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand; (W.M.); (M.P.)
| | - Jiraporn Khorana
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
| | - Pichitchai Atthakomol
- Department of Orthopedics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Tanyong Pipanmekaporn
- Clinical Epidemiology and Clinical Statistic Center, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Anesthesiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200 Thailand
- Correspondence: ; Tel.: +66-53-936453
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Vinolas H, Lombès M, Tabarin A. Insuffisance surrénalienne secondaire : actualités diagnostiques et thérapeutiques. ANNALES D'ENDOCRINOLOGIE 2019; 80 Suppl 1:S1-S9. [PMID: 31606056 DOI: 10.1016/s0003-4266(19)30111-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunotherapy and opioids treatment are new causes of secondary adrenal insufficiency (SAI). Prevalence of SAI with immunotherapy is more frequent with combined therapy (8% vs 4 to 10% with CTLA4 blocking antibody and 1% with PD1 blocking antibody). Although hypophysitis are more frequently observed with CTLA4 blocking antibody, some cases of Isolated SAI have been reported in patients treated by PD1 blocking antibody. SAI could be transient, requiring long-term monitoring. The use of opioid analgesics is increasing in many countries, thus becoming a public health problem. Prevalence of opioid-related SAI is unclear but recent prospective studies reveal a prevalence between 5 and 20%. The main risk factor to develop this pathology is morphine-equivalent daily dose. Diagnosis relies on 8.00 am plasma cortisol measurement and cortisol increase after Synacthen® administration. Recent cortisol immuno-assays, in agreement with mass spectrometry, give lower reference values, encouraging reevaluation of the current cut-off of 500 nmol/L. New modified-release hydrocortisone preparations have been recently developed to better mimic the physiological cortisol rhythm and to improve compliance in adrenocortical deficient patients. Nowadays, continuous subcutaneous hydrocortisone infusion seems to be a unique replacement therapy allowing adequate circadian biorhythm but should be restricted to specific patients due to the complexity of this substituting strategy. © 2019 Published by Elsevier Masson SAS. All rights reserved. Cet article fait partie du numéro supplément Les Must de l'Endocrinologie 2019 réalisé avec le soutien institutionnel de Ipsen-Pharma.
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Affiliation(s)
- Hélène Vinolas
- Service d'endocrinologie et diabétologie, CHU Henri-Mondor, 94010 Créteil, France
| | - Marc Lombès
- Unité INSERM 1185, faculté de médecine Paris-Sud, 63 rue Gabriel-Péri, 94276 Le Kremlin-Bicêtre, France
| | - Antoine Tabarin
- Service d'endocrinologie, diabétologie et nutrition, CHU Bordeaux, hôpital Haut-Lévêque, 1, avenue Magellan, 33600 Pessac, France.
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Burgos N, Ghayee HK, Singh-Ospina N. Pitfalls in the interpretation of the cosyntropin stimulation test for the diagnosis of adrenal insufficiency. Curr Opin Endocrinol Diabetes Obes 2019; 26:139-145. [PMID: 30855285 DOI: 10.1097/med.0000000000000473] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Adrenal insufficiency is a rare disease characterized by cortisol deficiency. The evaluation of patients suspected of having adrenal insufficiency can be challenging because of the rarity of the disease and limitations in the biochemical assessment of the cortisol status by either basal or dynamic testing [adrenocorticotropic hormone (ACTH) stimulation test]. Prompt and adequate diagnosis is of paramount importance to avoid adverse outcomes. We aimed to summarize the recent developments in the conduction and interpretation of the ACTH stimulation test for the diagnosis of adrenal insufficiency. RECENT FINDINGS The ACTH stimulation test is commonly performed in patients suspected of having adrenal insufficiency when the basal serum cortisol levels are inconclusive. Recent literature has evaluated the impact of technical aspects such as time of the day the test is performed, type of assay and sample source used for cortisol measurement on the clinical value of this test, as well as the feasibility of reliable low dose ACTH testing. SUMMARY Clinicians evaluating patients with suspected adrenal insufficiency should take into consideration the clinical presentation (likelihood of adrenal insufficiency before testing) when interpreting the results of the ACTH stimulation test and be aware of clinical and technical factors that can affect cortisol values and diagnostic accuracy of this test.
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Affiliation(s)
- Nydia Burgos
- Internal Medicine Department, VA Caribbean Healthcare System, San Juan, Puerto Rico
| | - Hans K Ghayee
- Division Of Endocrinology, Department of Medicine, Malcom Randall VA Medical Center
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, University of Florida, Gainesville, Florida, USA
| | - Naykky Singh-Ospina
- Department of Medicine, Division of Endocrinology, Diabetes, & Metabolism, University of Florida, Gainesville, Florida, USA
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Halpin KL, Paprocki EL, McDonough RJ. Utilizing health information technology to improve the recognition and management of life-threatening adrenal crisis in the pediatric emergency department: medical alert identification in the 21st century. J Pediatr Endocrinol Metab 2019; 32:513-518. [PMID: 31042645 DOI: 10.1515/jpem-2018-0566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/07/2019] [Indexed: 11/15/2022]
Abstract
Background Many barriers exist to the appropriate recognition and management of life-threatening adrenal crisis in the emergency department (ED). Clinical decision support (CDS) is a health information technology (IT) component that provides useful information to providers as healthcare is being delivered. We hypothesized that CDS incorporated into the electronic health record (EHR) could improve the recognition and management of adrenal crisis within the pediatric ED. Methods We retrospectively analyzed the impact of electronic CDS on the management of patients with known adrenal insufficiency (AI) presenting to two pediatric ED locations over a 19-month period with symptoms suggestive of adrenal crisis. Outcome variables assessed included the frequency of hydrocortisone (HC) administration, appropriateness of HC dosing, and timing to HC order placement and administration. Results A total of 145 encounters were reviewed. When the electronic CDS was in place at the time of the ED visit, patients were nearly 3 times as likely to receive HC (p = 0.002). Among those patients who received HC, the presence of the CDS increased the likelihood of an appropriate 50-mg/m2 dose of HC being given from 20 to 53% (p = 0.02). However, the CDS did not significantly reduce the time from ED arrival to HC order placement (p = 0.36) or administration (p = 0.59). Conclusions The use of innovative health IT strategies, such as the electronic CDS, can improve the recognition and management of adrenal crisis among patients with AI presenting to the pediatric ED.
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Affiliation(s)
- Kelsee L Halpin
- Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine, 2401 Gillham Rd., Kansas City, MO 64108, USA.,Division of Pediatric Endocrinology and Diabetes, Children's Mercy - Kansas City, Kansas City, MO, USA
| | - Emily L Paprocki
- Division of Pediatric Endocrinology and Diabetes, Children's Mercy - Kansas City, Kansas City, MO, USA
| | - Ryan J McDonough
- Division of Pediatric Endocrinology and Diabetes, Children's Mercy - Kansas City, Kansas City, MO, USA
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Settas N, Persky R, Faucz FR, Sheanon N, Voutetakis A, Lodish M, Metherell LA, Stratakis CA. SGPL1 Deficiency: A Rare Cause of Primary Adrenal Insufficiency. J Clin Endocrinol Metab 2019; 104:1484-1490. [PMID: 30517686 PMCID: PMC6435096 DOI: 10.1210/jc.2018-02238] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 11/28/2018] [Indexed: 12/19/2022]
Abstract
CONTEXT Multiple autosomal recessive genes have been etiologically linked to primary adrenal insufficiency (PAI). Recently, sphingosine-1-phosphate lyase 1 (SGPL1) gene mutations were recognized as a cause of steroid-resistant nephrotic syndrome type 14 (NPHS14), a sphingolipidosis with multisystemic manifestations, including PAI. OBJECTIVE To check if SGPL1 mutations are involved in the pathogenesis of PAI in patients who do not exhibit nephrotic syndrome. METHODS Sequencing of the SGPL1 gene in 21 patients with familial glucocorticoid disease or triple A syndrome. RESULTS We identified two missense SGPL1 variants in four patients, two of whom were first cousins. We describe in detail the proband, a boy born to Saudi Arabian consanguineous parents with a homozygous c.665G>A, p.R222Q SGPL1 variant. The patient presented with hypoglycemia and seizures at age 2 years and was ultimately diagnosed with PAI (isolated glucocorticoid deficiency). Brain MRI showed abnormalities in the basal ganglia consistent with a degenerative process albeit the patient had no neurologic symptoms. CONCLUSIONS New genetic causes of PAI continue to be identified. We suggest that screening for SGPL1 mutations should not be reserved only for patients with nephrotic syndrome but may also include patients with PAI who lack other clinical manifestations of NPHS14 because, in certain cases, kidney disease and accompanying features might develop. Timely diagnosis of this specific sphingolipidosis while the kidneys still function normally can lead to prompt initiation of therapy and improve outcome.
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Affiliation(s)
- Nikolaos Settas
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Rebecca Persky
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Fabio R Faucz
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Nicole Sheanon
- Division of Pediatric Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Antonis Voutetakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Maya Lodish
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Louise A Metherell
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, United Kingdom
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics & Pediatric Endocrinology Inter-Institute Training Program, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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Iqbal K, Halsby K, Murray RD, Carroll PV, Petermann R. Glucocorticoid management of adrenal insufficiency in the United Kingdom: assessment using real-world data. Endocr Connect 2019; 8:20-31. [PMID: 30562160 PMCID: PMC6330716 DOI: 10.1530/ec-18-0418] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 12/18/2018] [Indexed: 12/20/2022]
Abstract
Background and objectives Glucocorticoids are used to manage adrenal insufficiency (AI). We describe treatments used in the United Kingdom and real-world clinical outcomes for each treatment. Methods We used 2010-2016 primary care data from The Health Improvement Network (THIN). Descriptive analyses were conducted, and differences in variables between patients prescribed immediate-release hydrocortisone (IR HC), prednisolone or modified-release hydrocortisone (MR HC) were assessed using Fisher's exact test. Results Overall, 2648 patients were included: 1912 on IR HC (72%), 691 on prednisolone (26%) and 45 (2%) on MR HC. A total of 1174 (44.3%) had primary and 1150 (43.4%) had secondary AI. Patients on prednisolone were older (P < 0.001) and had a greater history of smoking (292/691, P < 0.001) and CVD (275/691, P < 0.001). Patients on MR HC had more PCOS (3/45, P = 0.001) and diabetes (27/45, P = 0.004). The number of GP visits/patient/year was 6.50 in IR HC, 9.54 in prednisolone and 9.11 in MR HC cohorts. The mean number of A&E visits and inpatient and outpatient hospital admissions ranged from 0.42 to 0.93 visits/patient/year. The mean number of adrenal crises/patient/year was between 0.02 and 0.03 for all cohorts. Conclusion IR HC is most commonly used for the management of AI in the United Kingdom, followed by prednisolone. Few patients receive MR HC. The prednisolone and MR HC cohorts displayed a greater prevalence of vascular risk factors compared with IR HC. The occurrence of AC and primary and secondary resource use were similar between treatment cohorts, and they indicate significant resource utilisation. Improved treatment and management of patients with AI is needed.
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Affiliation(s)
| | - Kate Halsby
- pH Associates, Marlow, UK
- Correspondence should be addressed to K Halsby:
| | - Robert D Murray
- Leeds Centre for Diabetes & Endocrinology, St James’s University Hospital, Leeds, UK
| | - Paul V Carroll
- Department of Endocrinology, Guy’s & St. Thomas’ NHS Foundation Trust, London, UK
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Patti G, Guzzeti C, Di Iorgi N, Maria Allegri AE, Napoli F, Loche S, Maghnie M. Central adrenal insufficiency in children and adolescents. Best Pract Res Clin Endocrinol Metab 2018; 32:425-444. [PMID: 30086867 DOI: 10.1016/j.beem.2018.03.012] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Central adrenal insufficiency (CAI) is a life-threatening condition caused by either pituitary disease (secondary adrenal insufficiency) or impaired hypothalamic function with inadequate CRH production (tertiary adrenal insufficiency). ACTH deficiency may be isolated or, more frequently, occur in conjunction with other pituitary hormone deficiencies and midline defects. Genetic mutations of the TBX19 causing isolated CAI are rare but a number of genes encoding transcription factors involved in hypothalamic-pituitary gland development, as well as other genes including POMC and PC1, are associated with ACTH deficiency. CAI is frequently identified in congenital, malformative, genetic, and epigenetic syndromes as well as in several acquired conditions of different etiologies. The signs and symptoms vary considerably and depend on the age of onset and the number and severity of associated pituitary defects. They may include hypoglycemia, lethargy, apnea, poor feeding, prolonged cholestatic jaundice, jitteriness, seizures, and sepsis in the neonate, or nonspecific signs such as fatigue, hypotension, vomiting and hyponatremia without hyperkalemia in children. The diagnosis of CAI relies on the measurement of morning cortisol concentrations along with dynamic test for cortisol release with different stimulating agents. Early recognition of CAI and its correct management are mandatory in order to avoid both morbidity and mortality in affected neonates, children and adolescents.
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Affiliation(s)
- Giuseppa Patti
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Chiara Guzzeti
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Natascia Di Iorgi
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | | | - Flavia Napoli
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy
| | - Sandro Loche
- SSD Endocrinologia Pediatrica, Ospedale Pediatrico Microcitemico "A. Cao", AO Brotzu, Cagliari, Italy
| | - Mohamad Maghnie
- Departments of Pediatrics, Istituto Giannina Gaslini, University of Genova, Genova, Italy.
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Reznik Y, Barat P, Bertherat J, Bouvattier C, Castinetti F, Chabre O, Chanson P, Cortet C, Delemer B, Goichot B, Gruson D, Guignat L, Proust-Lemoine E, Sanson MLR, Reynaud R, Boustani DS, Simon D, Tabarin A, Zenaty D. SFE/SFEDP adrenal insufficiency French consensus: Introduction and handbook. ANNALES D'ENDOCRINOLOGIE 2018; 79:1-22. [DOI: 10.1016/j.ando.2017.12.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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