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Alvarez R, Hogan E, Asuzu DT, Wu T, Oshegbo G, McGlotten R, Cortes M, Hayes C, Stratakis CA, Tatsi C, Nieman LK, Chittiboina P. Diurnal Range and Intra-patient Variability of ACTH Is Restored With Remission in Cushing's Disease. J Clin Endocrinol Metab 2023; 108:2812-2820. [PMID: 37261392 PMCID: PMC10584004 DOI: 10.1210/clinem/dgad309] [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: 01/18/2023] [Revised: 05/16/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
CONTEXT Single ACTH measurements have limited ability to distinguish patients with Cushing's disease (CD) from those in remission or with other conditions. OBJECTIVE To investigate the changes in ACTH levels before and after transsphenoidal surgery (TSS) to identify trends that could confirm remission from CD and help establish ACTH cutoffs for targeted clinical trials in CD. DESIGN Retrospective analysis of CD patients who underwent TSS from 2005 to -2019. SETTING Referral center. PATIENTS CD patients (n = 253) with ACTH measurements before and after TSS. INTERVENTIONS TSS for CD. MAIN OUTCOME MEASURES Remission after TSS. RESULTS Remission was observed in 223 patients after TSS. Those in remission had higher ACTH variability at AM (P = .02) and PM (P < .001) time points compared to nonremission. The nonremission group had a significantly narrower diurnal range compared to the remission group (P = <.0001). A decrease in plasma ACTH of ≥50% from mean preoperative levels predicted CD remission after TSS, especially when using PM values. The absolute plasma ACTH concentration and ratio of preoperative to postoperative values were significantly associated with nonremission after multivariable logistic regression (adj P < .001 and .001, respectively). CONCLUSIONS Our findings suggest that ACTH variability is suppressed in CD, and remission from CD is associated with the restoration of this variability. Furthermore, a decrease in plasma ACTH by 50% or more may serve as a predictor of remission post-TSS. These insights could guide clinicians in developing rational outcome measures for interventions targeting CD adenomas.
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Affiliation(s)
- Reinier Alvarez
- Neurosurgery Unit for Pituitary and Inheritable Diseases, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Elizabeth Hogan
- Neurosurgery Unit for Pituitary and Inheritable Diseases, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus School of Medicine, Aurora, CO, USA
| | - David T Asuzu
- Neurosurgery Unit for Pituitary and Inheritable Diseases, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Tianxia Wu
- Clinical Trials Unit, National Institute of Neurological Diseases and Stroke, Bethesda, MD, USA
| | - Gloria Oshegbo
- Biomedical Translational Research Information System, Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Raven McGlotten
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Michaela Cortes
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Christina Hayes
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Christina Tatsi
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA
| | - Lynnette K Nieman
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Prashant Chittiboina
- Neurosurgery Unit for Pituitary and Inheritable Diseases, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Le Tissier P, Fiordelisio Coll T, Mollard P. The Processes of Anterior Pituitary Hormone Pulse Generation. Endocrinology 2018; 159:3524-3535. [PMID: 30020429 DOI: 10.1210/en.2018-00508] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 07/11/2018] [Indexed: 12/16/2022]
Abstract
More than 60 years ago, Geoffrey Harris described his "neurohumoral theory," in which the regulation of pituitary hormone secretion was a "simple" hierarchal relationship, with the hypothalamus as the controller. In models based on this theory, the electrical activity of hypothalamic neurons determines the release of hypophysiotropic hormones into the portal circulation, and the pituitary simply responds with secretion of a pulse of hormone into the bloodstream. The development of methodologies allowing the monitoring of the activities of members of the hypothalamic-vascular-pituitary unit is increasingly allowing dissection of the mechanisms generating hypothalamic and pituitary pulses. These have revealed that whereas hypothalamic input is required, its role as a driver of pulsatile pituitary hormone secretion varies between pituitary axes. The organization of pituitary cells has a key role in the modification of their response to hypophysiotropic factors that can lead to a memory of previous demand and enhanced function. Feedback can lead to oscillatory hormone output that is independent of pulses of hypophysiotropic factors and instead, results from the temporal relationship between pituitary output and target organ response. Thus, the mechanisms underlying the generation of pulses cannot be generalized, and the circularity of feedforward and feedback interactions must be considered to understand both normal physiological function and pathology. We describe some examples of the clinical implications of recognizing the importance of the pituitary and target organs in pulse generation and suggest avenues for future research in both the short and long term.
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Affiliation(s)
- Paul Le Tissier
- Centre for Discovery Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Tatiana Fiordelisio Coll
- Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, University of Montpellier, Montpellier, France
- Laboratorio de Neuroendocrinología Comparada, Departamento de Ecología y Recursos Naturales, Biología, Facultad de Ciencias, Universidad Nacional Autónoma de México, Ciudad Universitaria, México City, Distrito Federal, México
| | - Patrice Mollard
- Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, University of Montpellier, Montpellier, France
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Dorin RI, Qiao ZG, Bouchonville M, Qualls CR, Schrader RM, Urban FK. Characterization of Cortisol Secretion Rate in Secondary Adrenal Insufficiency. J Endocr Soc 2017; 1:945-956. [PMID: 29264545 PMCID: PMC5686692 DOI: 10.1210/js.2017-00198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 05/26/2017] [Indexed: 01/28/2023] Open
Abstract
Context: In secondary adrenal insufficiency (SAI), chronic deficiency of adrenocorticotropin (ACTH) is believed to result in secondary changes in adrenocortical function, causing an altered dose-response relationship between ACTH concentration and cortisol secretion rate (CSR). Objective: We sought to characterize maximal cortisol secretion rate (CSRmax) and free cortisol half-life in patients with SAI, compare results with those of age-matched healthy controls, and examine the influence of predictor variables on ACTH-stimulated cortisol concentrations. Design: CSRmax was estimated from ACTH1-24 (250 μg)–stimulated cortisol time-concentration data. Estimates for CSRmax and free cortisol half-life were obtained for both dexamethasone (DEX) and placebo pretreatment conditions for all subjects. Setting: Single academic medical center. Patients: Patients with SAI (n = 10) compared with age-matched healthy controls (n = 21). Interventions: The order of DEX vs placebo pretreatment was randomized and double-blind. Cortisol concentrations were obtained at baseline and at intervals for 120 minutes after ACTH1-24. Main Outcome Measures: CSRmax and free cortisol half-life were obtained by numerical modeling analysis. Predictors of stimulated cortisol concentrations were evaluated using a multivariate model. Results: CSRmax was significantly (P < 0.001) reduced in patients with SAI compared with controls for both placebo (0.17 ± 0.09 vs 0.46 ± 0.14 nM/s) and DEX (0.18 ± 0.13 vs 0.43 ± 0.13 nM/s) conditions. Significant predictors of ACTH1-24–stimulated total cortisol concentrations included CSRmax, free cortisol half-life, and baseline total cortisol, corticosteroid-binding globulin, and albumin concentrations (all P < 0.05). Conclusions: Our finding of significantly decreased CSRmax confirms that SAI is associated with alterations in the CSR-ACTH dose-response curve. Decreased CSRmax contributes importantly to the laboratory diagnosis of SAI.
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Affiliation(s)
- Richard I Dorin
- Medical Service, New Mexico VA Healthcare System, University of New Mexico School of Medicine, Albuquerque, New Mexico 87108.,Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Zhi George Qiao
- Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Matthew Bouchonville
- Departments of Medicine and Biochemistry, University of New Mexico School of Medicine, Albuquerque, New Mexico 87106
| | - Clifford R Qualls
- Clinical and Translational Science Center, University of New Mexico, Albuquerque, New Mexico 87106
| | | | - Frank K Urban
- Department of Electrical and Computer Engineering, Florida International University, Miami, Florida 33174
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Keenan DM, Veldhuis JD. Pulsatility of Hypothalamo-Pituitary Hormones: A Challenge in Quantification. Physiology (Bethesda) 2017; 31:34-50. [PMID: 26674550 DOI: 10.1152/physiol.00027.2015] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Neuroendocrine systems control many of the most fundamental physiological processes, e.g., reproduction, growth, adaptations to stress, and metabolism. Each such system involves the hypothalamus, the pituitary, and a specific target gland or organ. In the quantification of the interactions among these components, biostatistical modeling has played an important role. In the present article, five key challenges to an understanding of the interactions of these systems are illustrated and discussed critically.
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Affiliation(s)
- Daniel M Keenan
- Department of Statistics, University of Virginia, Charlottesville, Virginia; and
| | - Johannes D Veldhuis
- Department of Medicine, Endocrine Research Unit, Mayo School of Graduate Medical Education, Clinical Translational Science Center, Mayo Clinic, Rochester, Minnesota
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Rutkowski MJ, Breshears JD, Kunwar S, Aghi MK, Blevins LS. Approach to the postoperative patient with Cushing's disease. Pituitary 2015; 18:232-7. [PMID: 25702104 DOI: 10.1007/s11102-015-0644-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cushing's disease is a neuroendocrine disorder marked by hypercortisolemia secondary to overproduction of ACTH by a corticotropic pituitary adenoma. Due to the diverse and deleterious effects of hypercortisolemia including diabetes mellitus, hypertension, and cardiovascular disease, prompt and accurate diagnosis followed by surgical resection of the responsible corticotropic adenoma is critical. METHODS In the following review, we present a focused synopsis of recently published data and management strategies for the post-operative Cushing's disease patient with a particular focus on studies examining perioperative complications, establishment of biochemical remission, factors associated with disease remission, and predictors of recurrence. CONCLUSIONS Although no standard definition of remission exists, we suggest measurement of serum cortisol level on the morning of postoperative day 1 given the preponderance of evidence in the published literature suggesting its association with long-term remission and relatively low rates of recurrence. Nevertheless, all patients should be counseled that recurrence can occur in a delayed fashion and that annual endocrine testing should be utilized to track and confirm disease status.
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Affiliation(s)
- Martin J Rutkowski
- Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, M-779, San Francisco, CA, 94143, USA,
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Roelfsema F, Pereira AM, Biermasz NR, Veldhuis JD. Hormone secretion by pituitary adenomas is characterized by increased disorderliness and spikiness but more regular pulsing. J Clin Endocrinol Metab 2014; 99:3836-44. [PMID: 25014002 PMCID: PMC4184075 DOI: 10.1210/jc.2014-2363] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
CONTEXT Hormone secretion by functioning pituitary tumors is characterized by increased basal (nonpulsatile) secretion, enhanced pulse frequency, amplified pulse mass, and increased disorderliness. OBJECTIVE The objective of the study was to quantify (subtle) abnormalities of hormone secretion by pituitary adenomas and the influence of selective pituitary surgery and suppressive medications on these parameters. METHODS Approximate entropy (ApEn) was quantified with a refined algorithm, spikiness by a new method to evaluate sudden short-lived increases in hormone levels, and pulsing regularity, determined with a fully automated deconvolution program. These 3 distinct measures of secretory disruption were compared in untreated and treated patients with acromegaly, prolactinoma, and Cushing's disease together with matching profiles in healthy controls. RESULTS ApEn and spikiness were markedly increased in all untreated patient groups and normalized after pituitary surgery in acromegaly and hypercortisolism. In contrast, hormone-suppressive medical treatment in acromegaly and prolactinoma did not normalize ApEn. Spikiness normalized in acromegalic patients but not in prolactinoma. GH and cortisol pulsing regularity was elevated in acromegaly and Cushing's disease, respectively, and normalized after surgery. Medical treatment caused normalization of pulsing regularity in acromegaly but not in prolactinoma patients. CONCLUSION This study extends the understanding of disorganized hormone secretion by hyperfunctioning pituitary adenomas. The new findings are increased spikiness in all 3 tumor groups and increased pulsing regularity in GH- and ACTH-secreting adenomas. The mechanisms behind the marked pattern irregularity and the selective normalization by surgical and medical therapies are not established yet but may include diminished feedback signaling in addition to the anatomical and functional disorganization of intrapituitary cell networks.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases (F.R., A.M.P., N.R.B.), Leiden University Medical Center, 2333ZA Leiden, The Netherlands; and Endocrine Research Unit (J.D.V.), Mayo Medical and Graduate Schools, Clinical Translational Research Center, Mayo Clinic, Rochester, Minnesota 55901
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Hameed N, Yedinak CG, Brzana J, Gultekin SH, Coppa ND, Dogan A, Delashaw JB, Fleseriu M. Remission rate after transsphenoidal surgery in patients with pathologically confirmed Cushing's disease, the role of cortisol, ACTH assessment and immediate reoperation: a large single center experience. Pituitary 2013; 16:452-8. [PMID: 23242860 DOI: 10.1007/s11102-012-0455-z] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Postoperative serum cortisol is used as an indicator of Cushing's disease (CD) remission following transsphenoidal surgery (TSS) and guides (controversially) the need for immediate adjuvant treatment for CD. We investigated postoperative cortisol and adrenocorticotropic hormone (ACTH) levels as predictors of remission/recurrence in CD in a large retrospective cohort of patients with pathologically confirmed CD, over 6 years at a single institution. Midnight and morning cortisol, and ACTH at 24-48 h postoperatively (>24 h after last hydrocortisone dose) were measured. Remission was defined as normal 24-h urine free cortisol, normal midnight salivary cortisol, a normal dexamethasone-corticotropin releasing hormone (CRH) test or continued need for hydrocortisone, assessed periodically. Statistical analysis was performed using PASW 18. Follow up data was available for 52 patients (38 females and 14 males), median follow up was 16.5 month (range 2-143 months), median age was 45 years (range 21-72 years), 28 tumors were microadenomas and 16 were macroadenomas, and in eight cases no tumor was observed on magnetic resonance imaging. No patient with postoperative cortisol levels >10 mcg/dl were found to be in remission. Ten of the 52 patients with cortisol >10 mcg/dl by postoperative day 1-2 underwent a second TSS within 7 days. Forty-three patients (82.7%) achieved CD remission (36 after one TSS and 7 after a second early TSS) and six patients suffered disease recurrence (mean 39.2 ± 52.4 months). An immediate second TSS induced additional hormonal deficiencies (diabetes insipidus) in three patients with no surgical complications. Persistent disease was noted in nine patients despite three patients having an immediate second TSS. Positive predictive value for remission of cortisol <2 mcg/dl and ACTH <5 pg/ml was 100%. Cortisol and ACTH levels (at all postoperative time points and at 2 months) were correlated (r = 0.37, P < 0.001). Nadir serum cortisol of ≤2 mcg/dl and ACTH <5 pg/ml predicted remission (P < 0.005), but no level predicted lack of recurrence. Immediate postoperative ACTH/cortisol did not predict length of remission. No patients with postoperative cortisol >10 mcg/dl were observed to have delayed remission; all required additional treatment. There was no significant difference in age, body mass index, tumor size and length of follow-up between postoperative cortisol groups: cortisol ≤2 mcg/dl, cortisol >5 mcg/dl and cortisol >10 mcg/dl. Immediate postoperative cortisol levels should routinely be obtained in CD patients post TSS, until better tools to identify early remission are available. Immediate repeat TSS could be beneficial in patients with cortisol >10 mcg/dl and positive CD pathology: our combined (micro- and macroadenomas) remission rate with this approach was 82.7%. ACTH measurements correlate well with cortisol. However, because no single cortisol or ACTH cutoff value excludes all recurrences, patients require long-term clinical and biochemical follow-up. Further research is needed in this area.
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Affiliation(s)
- Nadia Hameed
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
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Abstract
Thyroid hormones are extremely important for metabolism, development, and growth during the lifetime. The hypothalamo-pituitary-thyroid axis is precisely regulated for these purposes. Much of our knowledge of this hormonal axis is derived from experiments in animals and mutations in man. This review examines the hypothalamo-pituitary-thyroid axis particularly in relation to the regulated 24-hour serum TSH concentration profiles in physiological and pathophysiological conditions, including obesity, primary hypothyroidism, pituitary diseases, psychiatric disorders, and selected neurological diseases. Diurnal TSH rhythms can be analyzed with novel and precise techniques, eg, operator-independent deconvolution and approximate entropy. These approaches provide indirect insight in the regulatory components in pathophysiological conditions.
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Affiliation(s)
- Ferdinand Roelfsema
- Leiden University Medical Center, Department of Endocrinology and Metabolic Diseases, PO Box 9600, 2300 RC Leiden, The Netherlands.
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Roelfsema F, Pijl H, Keenan DM, Veldhuis JD. Diminished adrenal sensitivity and ACTH efficacy in obese premenopausal women. Eur J Endocrinol 2012; 167:633-42. [PMID: 22909443 DOI: 10.1530/eje-12-0592] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The ACTH-cortisol axis in women is activated and associated with decreased ACTH potency, estimated by relating ACTH and cortisol pulse masses. Recently, a new accurate method for constructing the endogenous dose-response relationship was introduced, which is based on the relation between ACTH concentrations and associated cortisol secretion rates within cortisol bursts. HYPOTHESIS The endogenous dose-response relation between ACTH and cortisol in obesity is changed, leading to diminished responsiveness. SUBJECTS Twenty-five obese premenopausal women and 16 normal weight premenopausal women were studied by 10-min blood sampling for 24 h. OUTCOMES ACTH and cortisol secretion rates, analytical dose-response estimates of endogenous ACTH efficacy (maximal cortisol secretion), dynamic ACTH potency, and adrenal sensitivity (slope term) from 24-h ACTH-cortisol profiles were quantified. RESULTS The initial potency (negative logarithm) was -7.83 ± 0.75 (mean ± s.e.m.) in obese women and -10.14 ± 1.08 in lean women (P=0.10), and the corresponding values for the recovery phase were -26.62 ± 2.21 and -36.67 ± 1.66 (P=0.004). The sensitivity (curve slope) amounted to 0.468 ± 0.05 in obese women and 0.784 ± 0.09 in normal weight women (P=0.004). The efficacy (maximal value) was 17.6 ± 4.9 nmol/l per min in obese women and 26.3 ± 3.8 nmol/l per min in normal weight women (P=0.009). Basal secretion rate, inflection point, and EC(50) values were not different. Bromocriptine or acipimox did not change the dose-response curve. CONCLUSION The ACTH-cortisol relation in obesity in women is characterized by decreased sensitivity and efficacy, thus explaining non-elevated serum cortisol concentrations despite increased plasma ACTH levels.
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Affiliation(s)
- Ferdinand Roelfsema
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, The Netherlands.
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