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Circulating levels of growth hormone in postural orthostatic tachycardia syndrome. Sci Rep 2021; 11:8575. [PMID: 33883597 PMCID: PMC8060383 DOI: 10.1038/s41598-021-87983-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 04/06/2021] [Indexed: 12/22/2022] Open
Abstract
Postural orthostatic tachycardia syndrome (POTS) is a cardiovascular autonomic disorder with poorly understood etiology and underlying pathophysiology. Since cardiovascular morbidity has been linked to growth hormone (GH), we studied GH levels in patients with POTS. We conducted an age-sex-matched case-control study in patients with POTS (age 31 ± 9 years; n = 42) and healthy controls (32 ± 9 years; n = 46). Plasma GH levels were measured using high-sensitivity chemiluminescence sandwich immunoassay. The burden of orthostatic intolerance symptoms was assessed by the Orthostatic Hypotension Questionnaire (OHQ), consisting of a symptom assessment scale (OHSA) and a daily activity scale (OHDAS). POTS patients had significantly higher composite OHQ score than controls, more symptoms and less activity. Supine heart rate and diastolic blood pressure (BP), but not systolic BP, were significantly higher in POTS. Median plasma GH levels were significantly lower in POTS (0.53 ng/mL) than controls (2.33 ng/mL, p = 0.04). GH levels were inversely related to OHDAS in POTS and supine systolic BP in POTS and controls, but not heart rate neither group. POTS is associated with lower GH levels. Impairment of daily life activities is inversely related with GH in POTS. A higher supine diastolic BP is inversely associated with GH levels in POTS and healthy individuals.
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Garcia JM, Biller BMK, Korbonits M, Popovic V, Luger A, Strasburger CJ, Chanson P, Swerdloff R, Wang C, Fleming RR, Cohen F, Ammer N, Mueller G, Kelepouris N, Strobl F, Ostrow V, Yuen KCJ. Sensitivity and specificity of the macimorelin test for diagnosis of AGHD. Endocr Connect 2021; 10:76-83. [PMID: 33320108 PMCID: PMC7923131 DOI: 10.1530/ec-20-0491] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 12/14/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The macimorelin test is approved for the diagnosis of adult growth hormone deficiency (AGHD) based on its efficacy vs the insulin tolerance test (ITT). Macimorelin has a significant advantage over ITT in avoiding hypoglycemia. Analyses were conducted to determine whether macimorelin performance is affected by age, BMI, or sex, and evaluate its performance vs ITT over a range of GH cutpoints. DESIGN Post hoc analyses of data from a previous randomized phase 3 study included participants aged 18-66 years with BMI <37 kg/m2 and high (Group A), intermediate (Group B), or low (Group C) likelihood for AGHD based on pituitary history, and matched controls (Group D). METHODS Probability of AGHD was estimated using unadjusted, age-adjusted, BMI-adjusted, and sex-adjusted logistic models. Area under the curve (AUC) of the estimated receiver operating characteristic (ROC) curve (range, 0-1; 1 = perfect) was compared for adjusted vs unadjusted models. Separate analyses evaluated agreement, sensitivity, and specificity for macimorelin and ITT using cutpoints of 2.8, 4.0, 5.1, and 6.5 ng/mL. RESULTS For participants in Group A (n = 41) and Group D (n = 29), unadjusted, age-adjusted, BMI-adjusted, and sex-adjusted models had ROC AUCs (95% CIs) of 0.9924 (0.9807-1), 0.9924 (0.9807-1), 0.9916 (0.9786-1), and 0.9950 (0.9861-1), respectively. CONCLUSIONS Macimorelin performance was not meaningfully affected by age, BMI, or sex, indicating robustness for AGHD diagnosis. Of the 4 GH cutpoints evaluated, the cutpoint of 5.1 ng/mL provided maximal specificity (96%) and high sensitivity (92%) and was in good overall agreement with the ITT at the same cutpoint (87%).
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Affiliation(s)
- Jose M Garcia
- GRECC VA Puget Sound HCS/University of Washington, Seattle, Washington, USA
| | - Beverly M K Biller
- Massachusetts General Hospital, Neuroendocrine Unit, Boston, Massachusetts, USA
| | - Márta Korbonits
- Barts and the London School of Medicine, Queen Mary University of London, Endocrinology, London, UK
| | - Vera Popovic
- University of Belgrade, Medical Faculty, Belgrade, Serbia
| | - Anton Luger
- Division of Endocrinology and Metabolism, Medical University, General Hospital, Vienna, Austria
| | | | - Philippe Chanson
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares de l’Hypophyse, and Université Paris-Saclay, Univ. Paris-Sud, Inserm, Signalisation Hormonale, Physiopathologie Endocrinienne et Métabolique, Le Kremlin-Bicêtre, France
| | - Ronald Swerdloff
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Christina Wang
- The Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | | | | | - Nicola Ammer
- Aeterna Zentaris GmbH, Frankfurt, Hessen, Germany
| | | | - Nicky Kelepouris
- Novo Nordisk Inc., Plainsboro, New Jersey, USA
- Correspondence should be addressed to N Kelepouris:
| | | | | | - Kevin C J Yuen
- University of Arizona College of Medicine and Creighton School of Medicine, Barrow Pituitary Center, Barrow Neurological Institute, Phoenix, Arizona, USA
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Tollerfield S, Criseno S, Fallon M, Jennings C, Jones J, Marland A, Martin L, Ward S, Whitehead A. Facilitating the adherence journey of children, adolescents, and adults on long-term growth hormone therapy. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2020; 29:1118-1123. [PMID: 33104418 DOI: 10.12968/bjon.2020.29.19.1118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Growth hormone deficiency in children and adolescents is treated with recombinant growth hormone injections, with the aim of helping patients reach a final height that falls within their genetically predicted adult height. While this treatment is very successful, overcoming issues of patient adherence is a challenge at each stage of the treatment journey, from early childhood to adulthood. An advisory board of senior endocrine nurses convened to discuss what strategies and tools work well in achieving adherence, and the best practices they identified-including the key strategies of choice, information, teamwork, and support-were presented at the 2016 meeting of The Endocrine Society. The advisers agreed that key steps to improve adherence include: patient/carer-centric endocrine nursing services, good-quality education and support, patient autonomy (where possible), broader treatment choice (in terms of device and self-injection), optimal follow-up from childhood to adulthood, and sharing of best practices.
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Affiliation(s)
- Sally Tollerfield
- Clinical Nurse Specialist, Endocrinology, Great Ormond Street Hospital for Children NHS Foundation Trust, London
| | - Sherwin Criseno
- Advanced Nurse Practitioner/Lead Nurse, Endocrinology, University Hospitals Birmingham NHS Foundation Trust
| | - Miriam Fallon
- Advanced Nurse Practitioner in Paediatric Endocrinology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | | | - Julie Jones
- Paediatric Endocrine Specialist Practitioner, Royal Manchester Children's Hospital
| | - Anne Marland
- Advanced Nurse Practitioner in Endocrinology, Oxford University NHS Foundation Trust
| | - Lee Martin
- Clinical Nurse Specialist, The Royal London Hospital
| | | | - Amanda Whitehead
- Children's Endocrine Specialist Nurse, The Leeds Children's Hospital
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Martínez-Moreno CG, Arámburo C. Growth hormone (GH) and synaptogenesis. VITAMINS AND HORMONES 2020; 114:91-123. [PMID: 32723552 DOI: 10.1016/bs.vh.2020.04.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Growth hormone (GH) is known to exert several roles during development and function of the nervous system. Initially, GH was exclusively considered a pituitary hormone that regulates body growth and metabolism, but now its alternative extrapituitary production and pleiotropic functions are widely accepted. Through excess and deficit models, the critical role of GH in nervous system development and adult brain function has been extensively demonstrated. Moreover, neurotrophic actions of GH in neural tissues include pro-survival effects, neuroprotection, axonal growth, synaptogenesis, neurogenesis and neuroregeneration. The positive effects of GH upon memory, behavior, mood, sensorimotor function and quality of life, clearly implicate a beneficial action in synaptic physiology. Experimental and clinical evidence about GH actions in synaptic function modulation, protection and restoration are revised in this chapter.
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Affiliation(s)
- Carlos G Martínez-Moreno
- Departamento de Neurobiología Celular y Molecular, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México
| | - Carlos Arámburo
- Departamento de Neurobiología Celular y Molecular, Instituto de Neurobiología, Universidad Nacional Autónoma de México, Querétaro, México.
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Colon G, Saccon T, Schneider A, Cavalcante MB, Huffman DM, Berryman D, List E, Ikeno Y, Musi N, Bartke A, Kopchick J, Kirkland JL, Tchkonia T, Masternak MM. The enigmatic role of growth hormone in age-related diseases, cognition, and longevity. GeroScience 2019; 41:759-774. [PMID: 31485887 PMCID: PMC6925094 DOI: 10.1007/s11357-019-00096-w] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 08/22/2019] [Indexed: 12/12/2022] Open
Abstract
Growth hormone (GH) is secreted by the anterior pituitary gland and regulates various metabolic processes throughout the body. GH and IGF-1 levels are markedly reduced in older humans, leading some to hypothesize GH supplementation could be a viable "anti-aging" therapy. However, there is still much debate over the benefits and risks of GH administration. While an early study of GH administration reported reduced adiposity and lipid levels and increased bone mineral density, subsequent studies failed to show significant benefits. Conversely, other studies found positive effects of GH deficiency including extended life span, improved cognitive function, resistance to diseases such as cancer and diabetes, and improved insulin sensitivity despite a higher fat percentage. Thus, the roles of GH in aging and cognition remain unclear, and there is currently not enough evidence to support use of GH as an anti-aging or cognitive impairment therapy. Additional robust and longer-duration studies of efficacy and safety of GH administration are needed to determine if modulating GH levels could be a successful strategy for treating aging and age-related diseases.
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Affiliation(s)
- Gabriela Colon
- College of Medicine, Florida State University, Tallahassee, FL, 32304, USA
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd., Orlando, FL, 32827, USA
| | - Tatiana Saccon
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd., Orlando, FL, 32827, USA
- Faculdade de Nutrição, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - Augusto Schneider
- Faculdade de Nutrição, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - Marcelo B Cavalcante
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd., Orlando, FL, 32827, USA
- Faculdade de Medicina, Universidade de Fortaleza, Fortaleza, CE, Brazil
| | - Derek M Huffman
- Departments of Molecular Pharmacology, Medicine, and the Institute for Aging Research, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Darlene Berryman
- Edison Biotechnology Institute, Ohio University, Athens, OH, 45701, USA
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, 45701, USA
| | - Ed List
- Edison Biotechnology Institute, Ohio University, Athens, OH, 45701, USA
| | - Yuji Ikeno
- Barshop Institute for Longevity and Aging Studies, The University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- Department of Pathology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, 78229, USA
- Geriatric Research Education and Clinical Center (GRECC), Audie L. Murphy VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, 78229, USA
| | - Nicolas Musi
- Barshop Institute for Longevity and Aging Studies, San Antonio Geriatric, Research, Education and Clinical Center, San Antonio, TX, 78229, USA
| | - Andrzej Bartke
- Departments of Internal Medicine and Physiology, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - John Kopchick
- Edison Biotechnology Institute, Ohio University, Athens, OH, 45701, USA
- Department of Biomedical Sciences, Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, 45701, USA
| | - James L Kirkland
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, 55905, USA
| | - Tamara Tchkonia
- Robert and Arlene Kogod Center on Aging, Mayo Clinic, Rochester, MN, 55905, USA
| | - Michal M Masternak
- Burnett School of Biomedical Sciences, College of Medicine, University of Central Florida, 6900 Lake Nona Blvd., Orlando, FL, 32827, USA.
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Towards a Göttingen minipig model of adult onset growth hormone deficiency: evaluation of stereotactic electrocoagulation method. Heliyon 2019; 5:e02892. [PMID: 31844758 PMCID: PMC6895662 DOI: 10.1016/j.heliyon.2019.e02892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/24/2019] [Accepted: 11/18/2019] [Indexed: 01/09/2023] Open
Abstract
Background Adult onset growth hormone (GH) deficiency (AGDH) is a potentially underdiagnosed condition, caused by damage to the pituitary gland. AGHD is treated with growth hormone replacement therapy. A large variety of clinical symptoms and changes in the metabolic homeostasis can be observed and quantified. New large animal models are needed for future drug development. New method In this study, we evaluate methods for a new large non-primate animal model of GH deficiency in post pubertal Göttingen Minipigs (minipig). Lesions in the pituitary gland were made by stereotaxic monopolar thermo-coagulation guided by magnetic resonance imaging (MRI), and pituitary function was evaluated using insulin tolerance test (ITT) with measurements of growth hormone secretion induced by hypoglycemia. Results Lesions were successfully applied to the pituitary gland without any damage to surrounding tissue including the hypothalamus, which was confirmed by post-operative MRI and post mortem histology. Plasma levels of GH during ITT showed no decrease in secreted levels one week after surgery compared to levels obtained before surgery. Comparison with existing methods Compared to other GH insufficiency models, eloquent brain tissue is spared. Furthermore, alternatively to rodent models, a large animal model would allow the use of human intended equipment to evaluate disease. Using the minipig avoids social, economical and ethical issues, compared with primates. Conclusion The lesions did not remove all GH production, but proof of concept is demonstrated. In addition, the ITT is presented as a safe and efficient method to diagnose GH deficiency in minipigs.
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Yuen KCJ, Llahana S, Miller BS. Adult growth hormone deficiency: clinical advances and approaches to improve adherence. Expert Rev Endocrinol Metab 2019; 14:419-436. [PMID: 31721610 DOI: 10.1080/17446651.2019.1689119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 11/01/2019] [Indexed: 12/17/2022]
Abstract
Introduction: There have been significant clinical advances in the understanding of the diagnosis and benefits of long-term recombinant human growth hormone (rhGH) replacement in adults with GH deficiency (GHD) since its approval in 1996 by the United States Food and Drug Administration.Areas covered: We searched PubMed, Medline, CINAHL, EMBASE and PsychInfo databases between January 2000 and June 2019 for published studies evaluating adults with GHD. We reviewed the data of the oral macimorelin test compared to the GHRH plus arginine and the insulin tolerance tests that led to its approval by the United States FDA and European Medicines Agency for adult diagnostic testing. We summarize the clinical advances of long-term benefits of rhGH therapy and the potential effects of GH receptor polymorphisms on individual treatment responsiveness. We identify that non-adherence and discontinuation rates are high and recommend strategies to support patients to improve adherence. We also provide an overview of several long-acting GH (LAGH) preparations currently under development and their potential role in improving treatment adherence.Expert opinion: This article summarizes recent clinical advances in rhGH replacement therapy, the biological and molecular aspects that may influence rhGH action, and offers practical strategies to enhance adherence in adults with GHD.
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Affiliation(s)
- Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
| | - Sofia Llahana
- Division of Nursing, School of Health Sciences, City University of London, London, UK
| | - Bradley S Miller
- Division of Pediatric Endocrinology, Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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Gohil A, Eugster E. Growth Hormone Deficiency and Excessive Sleepiness: A Case Report and Review of the Literature. PEDIATRIC ENDOCRINOLOGY REVIEWS : PER 2019; 17:41-46. [PMID: 31599135 DOI: 10.17458/per.vol17.2019.ge.ghdeficiencyandsleepiness] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The somatotropic axis is intricately involved in normal sleep, as evidenced by the fact that hypothalamic growth hormone-releasing hormone (GHRH) has sleep promoting effects and pituitary growth hormone (GH) release is strongly associated with slow-wave sleep (SWS). Abnormalities in the somatotropic axis, such as GH deficiency of hypothalamic or pituitary origin, result in an alteration of normal sleep patterns which may explain the fatigue reported in these individuals. Sleep disorders such as narcolepsy, in which individuals abnormally enter rapid eye movement (REM) sleep at sleep onset are also associated with an altered GHRH circadian rhythm and abnormal GH secretion. While few studies are available, this review explores what is known about sleep abnormalities in GH deficiency, the effect of treatment on sleep in patients with GH deficiency, and GH secretion in narcolepsy. Emerging evidence suggests a hypothalamic link between narcolepsy and GH secretion. We also describe the unique constellation of isolated idiopathic GH deficiency and severe excessive sleepiness in adopted Nicaraguan siblings, one of which has narcolepsy and the other idiopathic hypersomnia.
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Affiliation(s)
- Anisha Gohil
- Indiana University School of Medicine, Riley Hospital for Children, Fellow, Endocrinology and Diabetes, 705 Riley Hospital Drive, Room 5960, Indianapolis, IN 46202, USA, E-mail:
| | - Erica Eugster
- Indiana University School of Medicine, Riley Hospital for Children, Endocrinology and Diabetes, 705 Riley Hospital Drive, Room 5960, Indianapolis, IN 46202, USA
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Shimon I, Badiu C, Bossowski A, Doknic M, Dzivite-Krisane I, Hána V, Kollerova J, Natchev E, Pfeifer M, Szũcs N, Hey-Hadavi J, Gomez R. Adult growth hormone deficiency in CEE region: Heterogeneity of the patient pathway. Growth Horm IGF Res 2019; 46-47:44-49. [PMID: 31234055 DOI: 10.1016/j.ghir.2019.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 05/28/2019] [Accepted: 06/05/2019] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Adult growth hormone deficiency (AGHD) is a rare disease characterised by abnormal body composition, reduced strength and exercise capacity and impaired psychological wellbeing. An advisory board of leading Central and Eastern European (CEE) endocrinologists was assembled to gain insights into the status of AGHD care in the CEE region. Topics of discussion included the position of adult hypopituitarism/AGHD in health system priorities, availability and affordability of treatments, awareness of AGHD, practice guidelines used in CEE countries and provisions for long-term care of patients. DESIGN Prior to the meeting, the advisors were asked to summarise, using an itemised survey questionnaire, the usual standards of care for patients with AGHD in their country. At the meeting, the panel of experts discussed the findings and thereby elucidated similarities and differences among CEE countries; these were compared with international guideline-recommended practices for AGHD. RESULTS All CEE countries involved reported having some type of infrastructure in place for care of patients with GHD transitioning from adolescence to adulthood. Most countries reported having at least one specialist centre for patients with AGHD. The main variations across the region included initial entry into healthcare systems, tests required to confirm AGHD diagnosis and medication reimbursement by health authorities. Most CEE countries relied on international society-led guidelines, while some countries have developed national guidelines. CONCLUSION The CEE Adult Endocrinology Advisory Board meeting recognised considerable diversity in the care and patient pathways for AGHD across CEE countries. Additional work is needed to optimise care of patients with AGHD in the CEE region.
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Affiliation(s)
| | - Corin Badiu
- "C. Davila" University of Medicine and Pharmacy, National Institute of Endocrinology, Bucharest, Romania
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, Diabetology with a Cardiology Unit, Medical University of Bialystok, Bialystok, Poland
| | - Mirjana Doknic
- Neuroendocrine Department, Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Medical Faculty University of Belgrade, Serbia
| | | | - Václav Hána
- 3(rd) Department of Internal Medicine, 1st Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jana Kollerova
- 5(th) Department of Internal Medicine, University Hospital of Comenius University Bratislava, Slovakia
| | - Emil Natchev
- Clinical Center of Endocrinology and Gerontology, Medical University, Sofia, Bulgaria
| | | | | | | | - Roy Gomez
- Pfizer Innovative Health, Brussels, Belgium
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Lobatto DJ, Steffens ANV, Zamanipoor Najafabadi AH, Andela CD, Pereira AM, van den Hout WB, Peul WC, Vliet Vlieland TPM, Biermasz NR, van Furth WR. Work disability and its determinants in patients with pituitary tumor-related disease. Pituitary 2018; 21:593-604. [PMID: 30288666 PMCID: PMC6244796 DOI: 10.1007/s11102-018-0913-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Pituitary tumors may have a considerable impact on patients' functional status, including paid employment, yet research in this area is sparse. OBJECTIVE To describe work disability and its determinants in patients treated for a pituitary tumor. METHODS Cross-sectional study including patients treated for a pituitary tumor in the working age (18-65 years), who completed five validated questionnaires assessing work disability [Short Form-Health and Labour Questionnaire, Work Role Functioning Questionnaire 2.0 (WRFQ)], health-related quality of life (HRQoL) and utility (Short Form-36, EuroQoL) and disease burden (Leiden Bother and Needs Questionnaire-Pituitary). Additional data were extracted from the medical records (age, gender, tumor type, treatment, date of diagnosis) and self-reports (marital status, education, endocrine status). Associations of disease-specific and sociodemographic characteristics, HRQoL, and disease burden with (not) having a paid job were examined through multivariate logistic regression. RESULTS We included 241 patients (61% female, median age 53 years, median time since diagnosis 11 years), of whom 68 (28%) were without a paid job. Patients who had acromegaly, Cushing's disease, (pan)hypopituitarism, radiotherapy, were single, less educated, lower HRQoL, and increased disease burden were more often without a paid job (p < 0.05). Among those with paid jobs, 41% reported health-related absenteeism in the previous year. The three work incapacitating problems reported by the largest proportion of patients were within the mental and social domain (WRFQ). CONCLUSION Work disability among patients treated for a pituitary tumor is substantial. As impact on social functioning is high, it is strongly advised to incorporate work disability during clinical guidance of patients.
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Affiliation(s)
- Daniel J Lobatto
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Anath N V Steffens
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | | | - Cornelie D Andela
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Alberto M Pereira
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilco C Peul
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | | | - Nienke R Biermasz
- Division of Endocrinology and Center for Endocrine Tumors, Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Wouter R van Furth
- Department of Neurosurgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Lithgow K, Debert CT, Kline GA. Limited Adherence to Growth Hormone Replacement in Patients with Traumatic Brain Injury. JOURNAL OF REHABILITATION MEDICINE - CLINICAL COMMUNICATIONS 2018; 3:1000008. [PMID: 33884124 PMCID: PMC8011678 DOI: 10.2340/20030711-1000008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 11/16/2022]
Abstract
Background Growth hormone deficiency is a recognized consequence of traumatic brain injury. The aim of this study was to determine adherence to human growth hormone therapy among patients with traumatic brain injury compared with patients with hypothalamic or pituitary disease. Methods A retrospective chart review of patients with traumatic brain injury referred for growth hormone stimulation testing since December 2013. Within the same electronic medical record, patients who were started on human growth hormone for aetiologies other than traumatic brain injury were reviewed. Adherence to therapy at 1-year followup was compared. Results Of the patients with traumatic brain injury, 12/23 (52%) returned for follow-up at 1 year to continue human growth hormone treatment, whereas 11/23 (48%) did not return at 1 year. Amongst the patients with non-traumatic brain injury: 25/29 (86%) continued human growth hormone treatment, vs 4/29 (14%) who did not return. A higher proportion of patients with non-traumatic brain injury continued human growth hormone treatment; x2 (1, n = 52)p = 7.238, p = 0.007. Conclusion There may be differences in the patient-perceived benefits of human growth hormone between these patient populations. However, it is important to consider the potential influences of cognitive and psychosocial dysfunction that can occur in patients with brain injuries.
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Affiliation(s)
- Kirstie Lithgow
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Chantel T Debert
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Gregory A Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Johannsson G, Feldt-Rasmussen U, Håkonsson IH, Biering H, Rodien P, Tahara S, Toogood A, Rasmussen MH. Safety and convenience of once-weekly somapacitan in adult GH deficiency: a 26-week randomized, controlled trial. Eur J Endocrinol 2018; 178:491-499. [PMID: 29500310 PMCID: PMC5920019 DOI: 10.1530/eje-17-1073] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/02/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Somapacitan is a reversible albumin-binding growth hormone (GH) derivative, developed for once-weekly administration. This study aimed to evaluate the safety of once-weekly somapacitan vs once-daily Norditropin®. Local tolerability and treatment satisfaction were also assessed. DESIGN 26-week randomized, controlled phase 3 safety and tolerability trial in six countries (Nbib2382939). METHODS Male or female patients aged 18-79 years with adult GH deficiency (AGHD), treated with once-daily GH for ≥6 months, were randomized to once-weekly somapacitan (n = 61) or once-daily Norditropin (n = 31) administered subcutaneously by pen. Both treatments were dose titrated for 8 weeks to achieve insulin-like growth factor I (IGF-I) standard deviation score (SDS) levels within the normal range, and then administered at a fixed dose. Outcome measures were adverse events (AEs), including injection site reactions; occurrence of anti-somapacitan/anti-GH antibodies and change in treatment satisfaction, assessed using the Treatment Satisfaction Questionnaire for Medication-9 (TSQM-9). RESULTS Mean IGF-I SDS remained between 0 and 2 SDS throughout the trial in both groups. AEs were mostly mild or moderate and transient in nature. The most common AEs were nasopharyngitis, headache and fatigue in both groups. More than 1500 somapacitan injections were administered and no clinically significant injection site reactions were reported. No anti-somapacitan or anti-GH antibodies were detected. The TSQM-9 score for convenience increased significantly more with somapacitan vs Norditropin (P = 0.0171). CONCLUSIONS In this 26-week trial in patients with AGHD, somapacitan was well tolerated and no safety issues were identified. Once-weekly somapacitan was reported to be more convenient than once-daily Norditropin.
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Affiliation(s)
| | | | | | | | - Patrice Rodien
- Reference Centre for Rare Diseases of Thyroid and Hormone ReceptorsMember of EndoERN Network, CHU Angers Centre Hospitalier Universitaire, Angers, France
| | | | | | - Michael Højby Rasmussen
- Global DevelopmentNovo Nordisk A/S, Søborg, Denmark
- Correspondence should be addressed to M H Rasmussen;
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13
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Gabreanu GR. An update on the diagnosis of growth hormone deficiency. Discoveries (Craiova) 2018; 6:e82. [PMID: 32309600 PMCID: PMC6941588 DOI: 10.15190/d.2018.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 11/23/2022] Open
Abstract
Growth hormone deficiency (GHD) is an endocrine disorder, which may be either isolated or associated with other pituitary hormone deficiencies. In children, short stature is a useful clinical marker for GHD. In contrast, symptomatology is not always so obvious in adults, and the existing methods of testing might be inaccurate and imprecise, especially in the lack of a suggestive clinical profile. Since the quality of life of patients diagnosed with GHD could also be significantly affected, in both children and adults, a correct and accurate diagnosis is therefore tremendously important to select those patients that can benefit from the GH treatment. In general, the endocrine diseases are challenging in terms of diagnosis, the simple measurement of the basal level of hormones is not sufficient for distinguishing between the physiological and pathological conditions. Traditionally, several stimulation tests have been considered by professional clinical guidelines, such as insulin tolerance test (ITT), GHRH-arginine stimulation test and the glucagon stimulation test, and all of them have both advantages and limitations. More recently (December 2017), FDA approved a growth hormone secretagogue receptor agonist, macimorelin, for the diagnosis of adults with GHD. The obvious advantage for macimorelin is the simple oral administration and the high level of agreement with the insulin tolerance test for those patients with organic disease and low levels of insulin-like growth factor (IGF-I). However, the safety profile and the diagnostic value was not yet established for the pediatric population and for those adults with extreme or morbid obesity. In addition, administration of macimorelin with drugs that prolong QT interval and CYP3A4 inducers should be avoided. Genetic screening could obviously bring a great insight in the GHD pathology. However, it remains an open question if it would be also cost effective to include it in the routine evaluation of the patients with GHD. Although major progresses have been made in this area, genetic testing continues to be difficult to access, mostly because of its high costs, especially in the low-income and middle-income countries.
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Lithgow K, Chin A, Debert CT, Kline GA. Utility of serum IGF-1 for diagnosis of growth hormone deficiency following traumatic brain injury and sport-related concussion. BMC Endocr Disord 2018; 18:20. [PMID: 29609574 PMCID: PMC5879553 DOI: 10.1186/s12902-018-0247-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 03/20/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Growth hormone deficiency (GHD) is a potential consequence of traumatic brain injury (TBI), including sport-related concussion (SRC). GH stimulation testing is required for definitive diagnosis; however, this is resource intensive and can be associated with adverse symptoms or risks. Measurement of serum IGF-1 is more practical and accessible, and pituitary tumour patients with hypopituitarism and low serum IGF-1 have been shown to have a high probability of GHD. We aimed to evaluate IGF-1 measurement for diagnosing GHD in our local TBI population. METHODS We conducted a retrospective chart review of patients evaluated for GHD at the TBI clinic and referred for GH stimulation testing with insulin tolerance test (ITT) or glucagon stimulation test (GST) since December 2013. We obtained demographics, TBI severity, IGF-1, data pertaining to pituitary function, and GH stimulation results. IGF-1 values were used to calculate z-scores per age and gender specific reference ranges. Receiver operator curve analysis was performed to evaluate diagnostic threshold of IGF-1 z-score for determining GHD by GST or ITT. RESULTS Sixty four patient charts were reviewed. 48 patients had mild, six had moderate, eight had severe TBI, and two had non-traumatic brain injuries. 47 patients underwent ITT or GST. 27 were confirmed to have GHD (peak hGH < 5 μg/L). IGF-1 level was within the age and gender specific reference range for all patients with confirmed GHD following GH stimulation testing. Only one patient had a baseline IGF-1 level below the age and gender specific reference range; this patient had a normal response to GH stimulation testing. ROC analysis showed IGF-1 z-score AUC f, confirming lack of diagnostic utility. CONCLUSION Baseline IGF-1 is not a useful predictor of GHD in our local TBI population, and therefore has no value as a screening tool. TBI patients undergoing pituitary evaluation will require a dynamic test of GH reserve.
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Affiliation(s)
- Kirstie Lithgow
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Rd SW, Calgary, AB T2T 5C7 Canada
| | - Alex Chin
- Clinical Biochemistry, Calgary Laboratory Services and Department of Pathology and Laboratory Medicine, Cumming School of Medicine, University of Calgary, 9, 3535 Research Road NW, Calgary, AB T2L 2K8 Canada
| | - Chantel T. Debert
- Division of Physical Medicine and Rehabilitation, Department of Clinical Neurosciences Cumming School of Medicine, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4 Canada
| | - Gregory A. Kline
- Division of Endocrinology, Department of Medicine, Cumming School of Medicine, University of Calgary, 1820 Richmond Rd SW, Calgary, AB T2T 5C7 Canada
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Kann PH, Bergmann S, Bidlingmaier M, Dimopoulou C, Pedersen BT, Stalla GK, Weber MM, Meckes-Ferber S. Design of the Growth hormone deficiency and Efficacy of Treatment (GET) score and non-interventional proof of concept study. BMC Endocr Disord 2018; 18:10. [PMID: 29433573 PMCID: PMC5810096 DOI: 10.1186/s12902-018-0237-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 02/01/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND The adverse effects of growth hormone (GH) deficiency (GHD) in adults (AGHD) on metabolism and health-related quality of life (HRQoL) can be improved with GH substitution. This investigation aimed to design a score summarising the features of GHD and evaluate its ability to measure the effect of GH substitution in AGHD. METHODS The Growth hormone deficiency and Efficacy of Treatment (GET) score (0-100 points) assessed (weighting): HRQoL (40%), disease-related days off work (10%), bone mineral density (20%), waist circumference (10%), low-density lipoprotein cholesterol (10%) and body fat mass (10%). A prospective, non-interventional, multicentre proof-of-concept study investigated whether the score could distinguish between untreated and GH-treated patients with AGHD. A 10-point difference in GET score during a 2-year study period was expected based on pre-existing knowledge of the effect of GH substitution in AGHD. RESULTS Of 106 patients eligible for analysis, 22 were untreated GHD controls (9 females, mean ± SD age 52 ± 17 years; 13 males, 57 ± 13 years) and 84 were GH-treated (31 females, age 45 ± 13 years, GH dose 0.30 ± 0.16 mg/day; 53 males, age 49 ± 15 years, GH dose 0.25 ± 0.10 mg/day). Follow-up was 706 ± 258 days in females and 653 ± 242 days in males. The GET score differed between the untreated control and treated groups with a least squares mean difference of + 10.01 ± 4.01 (p = 0.0145). CONCLUSIONS The GET score appeared to be a suitable integrative instrument to summarise the clinical features of GHD and measure the effects of GH substitution in adults. Exercise capacity and muscle strength/body muscle mass could be included in the GET score. TRIAL REGISTRATION NCT number: NCT00934063 . Date of registration: 02 July 2009.
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Affiliation(s)
- Peter H. Kann
- Division of Endocrinology & Diabetology, Philipp’s University Marburg, D-35033 Marburg, Germany
| | - Simona Bergmann
- Division of Endocrinology & Diabetology, Philipp’s University Marburg, D-35033 Marburg, Germany
| | - Martin Bidlingmaier
- Endocrine Laboratory, Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians University, 80336 Munich, Germany
| | | | | | - Günter K. Stalla
- Neuroendocrinology, Max-Planck-Institute for Psychiatry, 80804 Munich, Germany
| | - Matthias M. Weber
- Endocrinology & Metabolism, Johannes Gutenberg University Hospital, 55131 Mainz, Germany
| | - Stefanie Meckes-Ferber
- Clinical, Medical & Regulatory Department, Novo Nordisk Pharma GmbH, 55127 Mainz, Germany
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Ishii H, Shimatsu A, Nishinaga H, Murai O, Chihara K. Assessment of quality of life on 4-year growth hormone therapy in Japanese patients with adult growth hormone deficiency: A post-marketing, multicenter, observational study. Growth Horm IGF Res 2017; 36:36-43. [PMID: 28923784 DOI: 10.1016/j.ghir.2017.08.005] [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: 01/24/2017] [Revised: 08/10/2017] [Accepted: 08/24/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Improvement of quality of life (QOL) by growth hormone (GH) therapy was not demonstrated in Japanese adult growth hormone deficiency (AGHD) patients by either the QOL Assessment of Growth Hormone Deficiency in Adults or the Questions on Life Satisfaction-Hypopituitarism, which are widely used to evaluate QOL in Western AGHD patients. We therefore evaluated QOL in Japanese AGHD patients receiving recombinant GH, Norditropin® (Novo Nordisk A/S, Denmark), using the newly developed Adult Hypopituitarism Questionnaire (AHQ). DESIGN This multicenter, non-interventional, observational study in Japanese patients with severe AGHD was conducted from 1 October 2009 to 30 September 2014. Patients with severe AGHD already receiving somatropin and somatropin-naïve patients were included. GH therapy (Norditropin®) was initiated as injections of 0.021mg/kg/week divided into 6-7 doses/week, and was adjusted according to clinical responses. Demographic/clinical data were obtained from medical records or by patient recall. QOL was assessed using the AHQ at baseline; 3, 6, and 12months; and annually up to 4years. RESULTS Of 387 registered patients, 161 were eligible for QOL analysis. AHQ scores significantly improved after 3months of treatment. Improvements in the psycho-social and physical domains were statistically significant throughout the 4-year study period. Although the GH dose was increased in females such that insulin-like growth factor-1 levels reached those of males, QOL improvements in females did not reach those of males. Despite the greater GH dose in child-onset patients, limited QOL improvements were observed in child-onset vs adult-onset cases. CONCLUSIONS Four-year GH treatment in Japanese AGHD patients elicits sustained improvement in QOL as assessed by AHQ scores.
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Affiliation(s)
- Hitoshi Ishii
- Nara Medical University, 840 Shijo-cho, Kashihara, Nara 634-8521, Japan.
| | - Akira Shimatsu
- National Hospital Organization Kyoto Medical Center, 1-1 Fukakusamukaihata-cho, Fushimi-ku, Kyoto 612-8555, Japan
| | - Hiromi Nishinaga
- Novo Nordisk Pharma Ltd., 2-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-0005, Japan
| | - Osamu Murai
- Novo Nordisk Pharma Ltd., 2-1-1 Marunouchi, Chiyoda-ku, Tokyo 100-0005, Japan
| | - Kazuo Chihara
- Akashi Medical Center, 743-33, Yagi, Okubo-cho, Akashi, Hyogo 674-0063, Japan
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Abstract
Growth hormone (GH) replacement in GH deficient (GHD) children secures normal linear growth, while in GHD adults it improves metabolic status, body composition and quality of life. Safety of GH treatment is an important issue in particular concerning the controversy of potential cancer risk. Unlike in congenital IGF-1 deficiency, there is no complete protection against cancer in GHD patients. Important modifiable risk factors in GHD patients are obesity, insulin resistance, sedentary behavior, circadian rhythm disruption, chronic low grade inflammation and concomitant sex hormone replacement. Age, family history, hereditary cancer predisposition syndromes or cranial irradiation may present non-modifiable risk factors. Quantifying the risk of cancer in relation to GH therapy in adult GHD patients is complex. There is evidence that links GH to cancer occurrence or promotion, but the evidence is progressively weaker when moving from in vitro studies to in vivo animal studies to epidemiological studies and finally to studies on GH treated patients. GH-IGF inhibition in experimental animals leads to decreased cancer incidence and progression. Epidemiological studies suggest an association of high normal circulating IGF-1 or GH to cancer incidence in general population. Data regarding cancer incidence in acromegaly are inconsistent but thyroid and colorectal neoplasias are the main source of concern. Replacement therapy with rhGH for GHD is generally safe. Overall the rate of de novo cancers was not increased in studies of GH-treated GHD patients. Additional caution is mandated in patients with history of cancer, strong family history of cancer and with advancing age. Childhood cancer survivors may be at increased risk for secondary neoplasms compared with general population. In this subgroup GH therapy should be used cautiously and with respect to other risk factors (cranial irradiation etc). We believe that the benefits of GH therapy against the morbidity of untreated GH deficiency outweigh the theoretical cancer risk. Proper monitoring of GH treatment with diligent cancer surveillance remains essential.
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Affiliation(s)
- Sandra Pekic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Marko Stojanovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Vera Popovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia.
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Rose SR, Horne VE, Howell J, Lawson SA, Rutter MM, Trotman GE, Corathers SD. Late endocrine effects of childhood cancer. Nat Rev Endocrinol 2016; 12:319-36. [PMID: 27032982 DOI: 10.1038/nrendo.2016.45] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The cure rate for paediatric malignancies is increasing, and most patients who have cancer during childhood survive and enter adulthood. Surveillance for late endocrine effects after childhood cancer is required to ensure early diagnosis and treatment and to optimize physical, cognitive and psychosocial health. The degree of risk of endocrine deficiency is related to the child's sex and their age at the time the tumour is diagnosed, as well as to tumour location and characteristics and the therapies used (surgery, chemotherapy or radiation therapy). Potential endocrine problems can include growth hormone deficiency, hypothyroidism (primary or central), adrenocorticotropin deficiency, hyperprolactinaemia, precocious puberty, hypogonadism (primary or central), altered fertility and/or sexual function, low BMD, the metabolic syndrome and hypothalamic obesity. Optimal endocrine care for survivors of childhood cancer should be delivered in a multidisciplinary setting, providing continuity from acute cancer treatment to long-term follow-up of late endocrine effects throughout the lifespan. Endocrine therapies are important to improve long-term quality of life for survivors of childhood cancer.
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Affiliation(s)
- Susan R Rose
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Vincent E Horne
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Jonathan Howell
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Sarah A Lawson
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Meilan M Rutter
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Gylynthia E Trotman
- Division of Pediatric and Adolescent Gynecology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
| | - Sarah D Corathers
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, Cincinnati, Ohio 45229, USA
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