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Agrawal N, Urwyler SA, Mehta S, Karavitaki N, Feelders RA. How to manage Cushing's disease after failed primary pituitary surgery. Eur J Endocrinol 2024; 191:R37-R54. [PMID: 39276376 DOI: 10.1093/ejendo/lvae110] [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: 05/03/2024] [Revised: 07/10/2024] [Accepted: 09/12/2024] [Indexed: 09/17/2024]
Abstract
The first-line treatment for Cushing's disease is transsphenoidal adenomectomy, which can be curative in a significant number of patients. The second-line options in cases of failed primary pituitary surgery include repeat surgery, medical therapy, and radiation. The role for medical therapy has expanded in the last decade, and options include pituitary-targeting drugs, steroid synthesis inhibitors, and glucocorticoid receptor antagonists. Bilateral adrenalectomy is a more aggressive approach, which may be necessary in cases of persistent hypercortisolism despite surgery, medical treatment, or radiation or when rapid normalization of cortisol is needed. We review the available treatment options for Cushing's disease, focusing on the second-line treatment options to consider after failed primary pituitary surgery.
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Affiliation(s)
- Nidhi Agrawal
- Division of Endocrinology, Diabetes and Metabolism, New York University Langone Medical Center, New York, NY 10016, United States
| | - Sandrine A Urwyler
- Clinic of Endocrinology, Diabetes and Metabolism, Department of Clinical Research, University Hospital Basel, 4031 Basel, Switzerland
| | - Sonal Mehta
- Division of Endocrinology, Diabetes and Metabolism, New York University Langone Medical Center, New York, NY 10016, United States
| | - Niki Karavitaki
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, United Kingdom
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, B15 1PJ, United Kingdom
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2GW, United Kingdom
| | - Richard A Feelders
- Department of Internal Medicine, Division of Endocrinology, Erasmus MC, 3015 GD Rotterdam, Netherlands
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Germann S, Wimmer R, Laager R, Mueller B, Schuetz P, Kaegi-Braun N, Kutz A. Long-term outcomes in patients with Cushing's disease vs nonfunctioning pituitary adenoma after pituitary surgery: an active-comparator cohort study. Eur J Endocrinol 2024; 191:97-105. [PMID: 38946089 DOI: 10.1093/ejendo/lvae069] [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: 02/03/2024] [Revised: 03/27/2024] [Accepted: 06/19/2024] [Indexed: 07/02/2024]
Abstract
OBJECTIVE There is increasing evidence that multisystem morbidity in patients with Cushing's disease (CD) is only partially reversible following treatment. We investigated complications from multiple organs in hospitalized patients with CD compared to patients with nonfunctioning pituitary adenoma (NFPA) after pituitary surgery. DESIGN Population-based retrospective cohort study using data from the Swiss Federal Statistical Office between January 2012 and December 2021. METHODS Through 1:5 propensity score matching, we compared hospitalized patients undergoing pituitary surgery for CD or NFPA, addressing demographic differences. The primary composite endpoint included all-cause mortality, major adverse cardiac events (ie, myocardial infarction, unstable angina, heart failure, cardiac arrest, and ischemic stroke), hospitalization for psychiatric disorders, sepsis, severe thromboembolic events, and fractures in need of hospitalization. Secondary endpoints comprised individual components of the primary endpoint and surgical reintervention due to disease persistence or recurrence. RESULTS After matching, 116 patients with CD (mean age 45.4 years [SD, 14.4], 75.0% female) and 396 with NFPA (47.3 years [14.3], 69.7% female) were included and followed for a median time of 50.0 months (IQR 23.5, 82.0) after pituitary surgery. Cushing's disease presence was associated with a higher incidence rate of the primary endpoint (40.6 vs 15.7 events per 1000 person-years, hazard ratio [HR] 2.75; 95% CI, 1.54-4.90). Cushing's disease patients also showed increased hospitalization rates for psychiatric disorders (HR 3.27; 95% CI, 1.59-6.71) and a trend for sepsis (HR 3.15; 95% CI, .95-10.40). CONCLUSIONS Even after pituitary surgery, CD patients faced a higher hazard of complications, especially psychiatric hospitalizations and sepsis.
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Affiliation(s)
- Sara Germann
- University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Roxana Wimmer
- University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Rahel Laager
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Beat Mueller
- University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Philipp Schuetz
- University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Nina Kaegi-Braun
- University Department of Medicine, Clinic for Endocrinology, Diabetology, and Metabolism, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Alexander Kutz
- Medical University Department, Division of General Internal and Emergency Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, 02120 Boston, MA, United States
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Sabahi M, Yousefi O, Kehoe L, Sasannia S, Gerndt C, Adada B, Borghei-Razavi H, Shahlaie K, Palmisciano P. Correlation Between Pituitary Adenoma Surgery and Anxiety Disorder: Systematic Review and Meta-Analysis. World Neurosurg 2024; 187:184-193.e6. [PMID: 38697260 DOI: 10.1016/j.wneu.2024.04.154] [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: 03/29/2024] [Accepted: 04/24/2024] [Indexed: 05/04/2024]
Abstract
OBJECTIVE This study aims to evaluate the impact of surgical intervention on anxiety levels in patients with various types of pituitary adenoma (PA). METHOD A systematic review was conducted following PRISMA guidelines until October 2022, searching Embase, PubMed, Web of Sciences, and Scopus. RESULTS A total of 32 studies were included, encompassing 2,681 patients with the mean age of 53.33 ± 6.48 years (43.4% male). Among all subtypes, 664 diagnosed with Cushing's disease (25.8%), 612 with acromegaly (23.8%), 282 with prolactinoma (10.9%), and 969 with nonfunctional pituitary adenomas (37.6%). Pituitary insufficiency was the most common complication. Considering therapeutic modalities, 515 patients (29.8%) underwent endoscopic trans-sphenoidal surgery, while 222 (12.9%) underwent microscopic trans-sphenoidal surgery. The type of trans-sphenoidal surgery was not specified in 977 (56.6%) patients. A total of 17 studies including 1510 patients which mostly assessed anxiety using the Hospital Anxiety and Depression Scale (HADS) and Zung Self-Rating Anxiety Scale (SAS) were included in the meta-analysis. Preoperative evaluation using Hospital Anxiety and Depression Scale (HADS) questionnaire showed a pooled score of 8.27 (95%CI 4.54-12.01), while postoperative evaluation yielded a pooled score of 6.49 (95%CI 5.35-7.63), indicating no significant difference. Preoperative SAS assessment resulted in a pooled score of 50.43 (95%CI 37.40-63.45), with postoperative pooled score of 55.91 (95%CI 49.40-62.41), showing no significant difference. CONCLUSIONS Our analysis revealed no significant difference in anxiety scores pre- and postoperatively. While our findings suggest stability in anxiety levels following surgical intervention, it is imperative to recognize the limitations of the current evidence base. The observed lack of consensus may be influenced by factors such as the heterogeneous nature of the patient population, variations in the characteristics of pituitary adenomas, diverse therapeutic approaches, and potential confounding variables such as pre-existing mental health conditions and coping mechanisms. Further research is warranted to elucidate the nuanced relationship between surgical intervention for PA and anxiety outcomes, considering these complex interactions and employing rigorous methodologies to address potential sources of bias.
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Affiliation(s)
- Mohammadmahdi Sabahi
- Department of Neurologic Surgery, Pauline Braathen Neurologic Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Laura Kehoe
- School of Medicine, Trinity College Dublin, the University of Dublin, College Green, Dublin, Ireland
| | - Sarvin Sasannia
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Research Institute, Baltimore, Maryland, USA; Departments of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Clayton Gerndt
- Department of Neurologic Surgery, University of California, Davis, Sacramento, California, USA
| | - Badih Adada
- Department of Neurologic Surgery, Pauline Braathen Neurologic Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Hamid Borghei-Razavi
- Department of Neurologic Surgery, Pauline Braathen Neurologic Center, Cleveland Clinic Florida, Weston, Florida, USA
| | - Kiarash Shahlaie
- Department of Neurologic Surgery, University of California, Davis, Sacramento, California, USA
| | - Paolo Palmisciano
- Department of Neurologic Surgery, University of California, Davis, Sacramento, California, USA.
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Korbonits M, Blair JC, Boguslawska A, Ayuk J, Davies JH, Druce MR, Evanson J, Flanagan D, Glynn N, Higham CE, Jacques TS, Sinha S, Simmons I, Thorp N, Swords FM, Storr HL, Spoudeas HA. Consensus guideline for the diagnosis and management of pituitary adenomas in childhood and adolescence: Part 2, specific diseases. Nat Rev Endocrinol 2024; 20:290-309. [PMID: 38336898 DOI: 10.1038/s41574-023-00949-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2023] [Indexed: 02/12/2024]
Abstract
Pituitary adenomas are rare in children and young people under the age of 19 (hereafter referred to as CYP) but they pose some different diagnostic and management challenges in this age group than in adults. These rare neoplasms can disrupt maturational, visual, intellectual and developmental processes and, in CYP, they tend to have more occult presentation, aggressive behaviour and are more likely to have a genetic basis than in adults. Through standardized AGREE II methodology, literature review and Delphi consensus, a multidisciplinary expert group developed 74 pragmatic management recommendations aimed at optimizing care for CYP in the first-ever comprehensive consensus guideline to cover the care of CYP with pituitary adenoma. Part 2 of this consensus guideline details 57 recommendations for paediatric patients with prolactinomas, Cushing disease, growth hormone excess causing gigantism and acromegaly, clinically non-functioning adenomas, and the rare TSHomas. Compared with adult patients with pituitary adenomas, we highlight that, in the CYP group, there is a greater proportion of functioning tumours, including macroprolactinomas, greater likelihood of underlying genetic disease, more corticotrophinomas in boys aged under 10 years than in girls and difficulty of peri-pubertal diagnosis of growth hormone excess. Collaboration with pituitary specialists caring for adult patients, as part of commissioned and centralized multidisciplinary teams, is key for optimizing management, transition and lifelong care and facilitates the collection of health-related quality of survival outcomes of novel medical, surgical and radiotherapeutic treatments, which are currently largely missing.
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Affiliation(s)
- Márta Korbonits
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
| | | | - Anna Boguslawska
- Department of Endocrinology, Jagiellonian University Medical College, Krakow, Poland
| | - John Ayuk
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Justin H Davies
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maralyn R Druce
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Jane Evanson
- Neuroradiology, Barts Health NHS Trust, London, UK
| | | | - Nigel Glynn
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Thomas S Jacques
- Great Ormond Street Institute of Child Health, University College London, London, UK
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Saurabh Sinha
- Sheffield Children's and Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Simmons
- The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Nicky Thorp
- The Christie NHS Foundation Trust, Manchester, UK
| | | | - Helen L Storr
- Centre for Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Helen A Spoudeas
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
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Puglisi S, Perini AME, Botto C, Oliva F, Terzolo M. Long-Term Consequences of Cushing Syndrome: A Systematic Literature Review. J Clin Endocrinol Metab 2024; 109:e901-e919. [PMID: 37536275 DOI: 10.1210/clinem/dgad453] [Citation(s) in RCA: 1] [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: 05/08/2023] [Revised: 07/21/2023] [Accepted: 07/31/2023] [Indexed: 08/05/2023]
Abstract
It is held that the condition of endogenous chronic hypersecretion of cortisol (Cushing syndrome, CS), causes several comorbidities, including cardiovascular and metabolic disorders, musculoskeletal alterations, as well as cognitive and mood impairment. Therefore, CS has an adverse impact on the quality of life and life expectancy of affected patients. What remains unclear is whether disease remission may induce a normalization of the associated comorbid conditions. In order to retrieve updated information on this issue, we conducted a systematic search using the Pubmed and Embase databases to identify scientific papers published from January 1, 2000, to December 31, 2022. The initial search identified 1907 potentially eligible records. Papers were screened for eligibility and a total of 79 were included and classified by the main topic (cardiometabolic risk, thromboembolic disease, bone impairment, muscle damage, mood disturbances and quality of life, cognitive impairment, and mortality). Although the limited patient numbers in many studies preclude definitive conclusions, most recent evidence supports the persistence of increased morbidity and mortality even after long-term remission. It is conceivable that the degree of normalization of the associated comorbid conditions depends on individual factors and characteristics of the conditions. These findings highlight the need for early recognition and effective management of patients with CS, which should include active treatment of the related comorbid conditions. In addition, it is important to maintain a surveillance strategy in all patients with CS, even many years after disease remission, and to actively pursue specific treatment of comorbid conditions beyond cortisol normalization.
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Affiliation(s)
- Soraya Puglisi
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Anna Maria Elena Perini
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Cristina Botto
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
| | - Francesco Oliva
- Clinical Psychology Unit, Department of Clinical and Biological Sciences, University Hospital "Città della Salute e della Scienza di Torino", University of Turin, 10126 Turin, Italy
| | - Massimo Terzolo
- Internal Medicine, San Luigi Hospital, Department of Clinical and Biological Sciences, University of Turin, 10043 Orbassano, Italy
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6
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Hong CS, Smith TR. Aerobic exercise interventions to address impaired quality of life in patients with pituitary tumors. PLoS One 2023; 18:e0295907. [PMID: 38100429 PMCID: PMC10723697 DOI: 10.1371/journal.pone.0295907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
Patients with pituitary tumors may experience persistent fatigue and reduced physical activity, based on subjective measures after treatment. These symptoms may persist despite gross total resection of their tumors and biochemical normalization of pituitary function. While reduced quality of life has been commonly acknowledged in pituitary tumor patients, there is a lack of studies on what interventions may be best implemented to ameliorate these issues, particularly when hormonal levels have otherwise normalized. Aerobic exercise programs have been previously described to ameliorate symptoms of chronic fatigue and reduced physical capacity across a variety of pathologies in the literature. As such, a prescribed aerobic exercise program may be an underrecognized but potentially impactful intervention to address quality of life in pituitary tumor patients. This review seeks to summarize the existing literature on aerobic exercise interventions in patients with pituitary tumors. In addition, future areas of study are discussed, including tailoring exercise programs to the hormonal status of the patient and incorporating more objective measures in monitoring response to interventions.
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Affiliation(s)
- Christopher S. Hong
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Computational Neuroscience Outcomes Center (CNOC), Boston, Masachusettts, United States of America
| | - Timothy R. Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- Computational Neuroscience Outcomes Center (CNOC), Boston, Masachusettts, United States of America
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7
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De Alcubierre D, Ferrari D, Mauro G, Isidori AM, Tomlinson JW, Pofi R. Glucocorticoids and cognitive function: a walkthrough in endogenous and exogenous alterations. J Endocrinol Invest 2023; 46:1961-1982. [PMID: 37058223 PMCID: PMC10514174 DOI: 10.1007/s40618-023-02091-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/05/2023] [Indexed: 04/15/2023]
Abstract
PURPOSE The hypothalamic-pituitary-adrenal (HPA) axis exerts many actions on the central nervous system (CNS) aside from stress regulation. Glucocorticoids (GCs) play an important role in affecting several cognitive functions through the effects on both glucocorticoid (GR) and mineralocorticoid receptors (MR). In this review, we aim to unravel the spectrum of cognitive dysfunction secondary to derangement of circulating levels of endogenous and exogenous glucocorticoids. METHODS All relevant human prospective and retrospective studies published up to 2022 in PubMed reporting information on HPA disorders, GCs, and cognition were included. RESULTS Cognitive impairment is commonly found in GC-related disorders. The main brain areas affected are the hippocampus and pre-frontal cortex, with memory being the most affected domain. Disease duration, circadian rhythm disruption, circulating GCs levels, and unbalanced MR/GR activation are all risk factors for cognitive decline in these patients, albeit with conflicting data among different conditions. Lack of normalization of cognitive dysfunction after treatment is potentially attributable to GC-dependent structural brain alterations, which can persist even after long-term remission. CONCLUSION The recognition of cognitive deficits in patients with GC-related disorders is challenging, often delayed, or mistaken. Prompt recognition and treatment of underlying disease may be important to avoid a long-lasting impact on GC-sensitive areas of the brain. However, the resolution of hormonal imbalance is not always followed by complete recovery, suggesting irreversible adverse effects on the CNS, for which there are no specific treatments. Further studies are needed to find the mechanisms involved, which may eventually be targeted for treatment strategies.
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Affiliation(s)
- D De Alcubierre
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - D Ferrari
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - G Mauro
- Department of Physiology and Pharmacology, Sapienza University of Rome, Rome, Italy
| | - A M Isidori
- Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy
| | - J W Tomlinson
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK
| | - R Pofi
- Oxford Centre for Diabetes, Endocrinology and Metabolism, NIHR Oxford Biomedical Research Centre, University of Oxford, Churchill Hospital, Oxford, UK.
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Papakokkinou E, Ragnarsson O. Functional brain alterations in Cushing's syndrome. Front Endocrinol (Lausanne) 2023; 14:1163482. [PMID: 37152946 PMCID: PMC10160675 DOI: 10.3389/fendo.2023.1163482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 03/28/2023] [Indexed: 05/09/2023] Open
Abstract
Cognitive impairment and affective disorders are common in patients with Cushing's syndrome (CS). In fact, as an effect of prolonged cortisol excess on the brain, patients with CS often have memory problems, concentration difficulties, impaired attention and executive function, that are not always reversible following successful treatment. Neuroimaging is essential for understanding the deleterious effects of hypercortisolism on the brain. In CS, structural alterations have been observed, including reduction of hippocampal volume, amygdala and the prefrontal cortex. The aim of this article is to summarize results from studies that have used functional magnetic resonance imaging (fMRI) to study functional brain alterations in patients with CS. In these studies, alterations in brain areas and networks essential for cognitive function, emotional processing, and executive function have been observed, both in patients with active CS as well as following treatment. Nevertheless, longitudinal studies with a comprehensive evaluation of functional brain alterations and neurocognitive evaluation are still needed to determine whether the apparent deleterious effects of hypercortisolism on the brain are reversible or not.
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Affiliation(s)
- Eleni Papakokkinou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- *Correspondence: Eleni Papakokkinou,
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
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9
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Liu YF, Pan L, Feng M. Structural and functional brain alterations in Cushing's disease: A narrative review. Front Neuroendocrinol 2022; 67:101033. [PMID: 36126747 DOI: 10.1016/j.yfrne.2022.101033] [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: 05/17/2022] [Revised: 08/21/2022] [Accepted: 08/26/2022] [Indexed: 11/26/2022]
Abstract
Neurocognitive and psychiatric symptoms are non-negligible in Cushing's disease and are accompanied by structural and functional alterations of the brain. In this review, we have summarized multimodal neuroimaging and neurophysiological studies to highlight the current and historical understandings of the structural and functional brain alterations in Cushing's disease. Specifically, structural studies showed atrophy of the gray matter, loss of white matter integrity, and demyelination in widespread brain regions. Functional imaging studies have identified three major functional brain connectome networks influenced by hypercortisolemia: the limbic network, the default mode network, and the executive control network. After endocrinological remission, atrophy of gray matter regions and the compromised functional network activities were partially reversible, and the widespread white matter integrity alterations cannot recover in years. In conclusion, Cushing's disease patients display structural and functional brain connectomic alterations, which provides insights into the neurocognitive and psychiatric symptoms observed in this disease.
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Affiliation(s)
- Yi-Fan Liu
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan, China
| | - Lei Pan
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China; School of Medicine, Tsinghua University, Beijing 100083, China
| | - Ming Feng
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
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10
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Dekkers AJ, Amaya JM, van der Meulen M, Biermasz NR, Meijer OC, Pereira AM. Long-term effects of glucocorticoid excess on the brain. J Neuroendocrinol 2022; 34:e13142. [PMID: 35980208 PMCID: PMC9541651 DOI: 10.1111/jne.13142] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/27/2022]
Abstract
The metabolic and cardiovascular clinical manifestations in patients with Cushing's syndrome (CS) are generally well known. However, recent studies have broadened the perspective of the effects of hypercortisolism, showing that both endogenous and exogenous glucocorticoid excess alter brain functioning on several time scales. Consequently, cognitive deficits and neuropsychological symptoms are highly prevalent during both active CS and CS in remission, as well as during glucocorticoid treatment. In this review, we discuss the effects of endogenous hypercortisolism and exogenously induced glucocorticoid excess on the brain, as well as the prevalence of cognitive and neuropsychological deficits and their course after biochemical remission. Furthermore, we propose possible mechanisms that may underly neuronal changes, based on experimental models and in vitro studies. Finally, we offer recommendations for future studies.
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Affiliation(s)
- Alies J. Dekkers
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Jorge Miguel Amaya
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
| | - Merel van der Meulen
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Nienke R. Biermasz
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine, Center for Endocrine Tumours LeidenLeiden University Medical CenterLeidenThe Netherlands
| | - Onno C. Meijer
- Department of Medicine, Division of Endocrinology, Pituitary Center and Center for Endocrine TumorsLeiden University Medical CenterLeidenThe Netherlands
| | - Alberto M. Pereira
- Department of Endocrinology & MetabolismAmsterdam UMC (AMC)AmsterdamThe Netherlands
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11
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Lee J, Li C, Liu CSJ, Shiroishi M, Carmichael JD, Zada G, Patel V. Ultra-high field 7 T MRI localizes regional brain volume recovery following corticotroph adenoma resection and hormonal remission in Cushing's disease: A case series. Surg Neurol Int 2022; 13:239. [PMID: 35855134 PMCID: PMC9282752 DOI: 10.25259/sni_787_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 04/29/2022] [Indexed: 01/28/2023] Open
Abstract
Background Cushing's disease (CD) is defined by glucocorticoid excess secondary to the increased section of corticotropin by a pituitary adenoma. Magnetic resonance imaging (MRI) studies performed at 1.5 or 3 Tesla (T) have demonstrated correlations between regional changes in brain structure and the progression of CD. In this report, we examine the changes in brain volume following corticotroph pituitary adenoma resection using ultra-high field 7 T MRI to increase the accuracy of our volumetric analyses. Methods Thirteen patients were referred to the endocrinology clinic at our institution from 2017 to 2020 with symptoms of cortisol excess and were diagnosed with ACTH-dependent endogenous Cushing syndrome. Five patients had follow-up 7 T imaging at varying time points after a transsphenoidal resection. Results Symmetrized percent change in regional volumes demonstrated a postoperative increase in cortical volume that was relatively larger than that of cerebral white matter or subcortical gray matter (percent changes = 0.0172%, 0.0052%, and 0.0120%, respectively). In the left cerebral hemisphere, the medial orbitofrontal, lateral orbitofrontal, and pars opercularis cortical regions experienced the most robust postoperative percent increases (percent changes = 0.0166%, 0.0122%, and 0.0068%, respectively). In the right cerebral hemisphere, the largest percent increases were observed in the pars triangularis, rostral portion of the middle frontal gyrus, and superior frontal gyrus (percent changes = 0.0156%, 0.0120%, and 0.0158%). Conclusion Cerebral volume recovery following pituitary adenoma resection is driven by changes in cortical thickness predominantly in the frontal lobe, while subcortical white and gray matter volumes increase more modestly.
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Affiliation(s)
- Jonathan Lee
- Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California
| | - Charles Li
- Departments of Radiology, University of Southern California, Los Angeles, California, United States
| | - Chia-Shang J. Liu
- Departments of Radiology, University of Southern California, Los Angeles, California, United States
| | - Mark Shiroishi
- Departments of Radiology, University of Southern California, Los Angeles, California, United States
| | - John D. Carmichael
- Medicine, Division of Endocrinology, University of Southern California, Los Angeles, California, United States
| | - Gabriel Zada
- Neurological Surgery, University of Southern California, Los Angeles, California, United States
| | - Vishal Patel
- Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California,,Departments of Radiology, University of Southern California, Los Angeles, California, United States,,Corresponding author: Vishal Patel, Mark and Mary Stevens Neuroimaging and Informatics Institute, University of Southern California, Los Angeles, California, United States.
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Vogel F, Reincke M. Endocrine risk factors for COVID-19: Endogenous and exogenous glucocorticoid excess. Rev Endocr Metab Disord 2022; 23:233-250. [PMID: 34241765 PMCID: PMC8267234 DOI: 10.1007/s11154-021-09670-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 01/08/2023]
Abstract
Patients with endogenous or exogenous glucocorticoid (GC) excess exhibit a range of side effects, including an increased risk of infections. Via both mechanism, immune impairments and cardiometabolic concomitant diseases, patients with GC excess could be at increased risk for COVID-19. The impact on incidence and outcome of a SARS-CoV-2 infection in this population are not yet completely clear. This review aims to compile the data available to date and to discuss the existing literature on this topic. Further we highlight potential effects of SARS-CoV-2 on the hypothalamic-pituitary-adrenal axis as well as the influence of endogenous or exogenous GC excess on SARS-CoV-2 mRNA vaccination. There is growing evidence suggesting an increased risk of infection and severe outcome in patients with high-dose GC therapy after contracting SARS-CoV-2. The few data and case reports on patients with endogenous GC excess and SARS-CoV-2 infection point in a similar direction: chronic GC excess seems to be associated with an unfavorable course of COVID-19. Whether this is mainly a primary immune-mediated effect, or also triggered by the many GC-associated comorbidities in this population, is not yet fully understood. Patients with endogenous or exogenous GC excess should be considered as a vulnerable group during the SARS-CoV-2 pandemic. Regardless of the cause, vaccination and consistent surveillance and control of associated comorbidities are recommended.
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Affiliation(s)
- Frederick Vogel
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität, Ludwig-Maximilians-Universität München, Munich, Germany.
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Cao C, Song J, Lin P, Yan D, Yao S, Yue J, Liu B, Lu Y, Xu G. A Longitudinal, Prospective Study to Evaluate the Effects of Treatment on the Inhibitory Control Function After Transsphenoidal Surgery for Pituitary Adenomas. Clin EEG Neurosci 2021; 52:444-454. [PMID: 32412816 DOI: 10.1177/1550059420922744] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Injured cognitive abilities have been reported in patients with pituitary adenoma. However, to date, few researchers have directly investigated the electrophysiological study of inhibitory control function of pituitary patients both pre- and postsurgery. Thus, this study aimed to identify the factors affecting the inhibitory control function of pituitary patients. METHODS Thirty presurgery pituitary patients were recruited and 26 patients of them completed the postsurgery follow-up. Thirty healthy people were recruited for control group. Visual Go/Nogo tasks were carried out by the patients and controls to assess the inhibitory control function before surgery and 6 months after the surgery, respectively. The function of inhibitory control was analyzed with the components of N2 and P3. RESULTS Across 3 groups, Nogo stimuli evoked larger frontal-central N2nogo and P3nogo than Go stimuli did. Furthermore, N2d of presurgery patients (-1.14 μV) and postsurgery patients(-0.61 μV) were significantly decreased compared with that of control group (-3.09 μV), F(2, 83) = 13.92, P < .01, whereas no difference was detected between pre- and postsurgery groups. There was no remarkable difference in the amplitude of P3d among the 3 groups, F(2, 83) = 0.19, P > .05. With regard to the amplitude of P3 for Go condition, The P3 amplitude of healthy group (4.38 μV) was larger than both pre- and postsurgery (1.00 μV and 3.01 μV). With regard to the amplitude of P3 for Nogo condition, The P3 amplitude of healthy group (5.25 μV) was larger than both pre- and postsurgery groups (2.35 μV and 4.18 μV). CONCLUSIONS These results indicated that presurgery patients showed the dysfunction of inhibition, due to the nerve tissue damage or brain structure alteration caused by the presurgery physical pressure from tumor and abnormal hormone levels. Postsurgery patients showed a tendency toward recovery, but there was no obvious improvement in the inhibitory control function after successful treatments.
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Affiliation(s)
- Chenglong Cao
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Neurosurgery, General Hospital of Central Theater of the Chinese People's Liberation Army, Wuhan, China
| | - Jian Song
- Department of Neurosurgery, General Hospital of Central Theater of the Chinese People's Liberation Army, Wuhan, China
| | - Pan Lin
- Department of Psychology, Hunan Normal University, Changsha, China
| | - Deqi Yan
- Department of Neurosurgery, The 990th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Zhumadian, China
| | - Shun Yao
- Department of Neurosurgery, General Hospital of Central Theater of the Chinese People's Liberation Army, Wuhan, China
| | - Jianren Yue
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Binbin Liu
- Wuhan University of Science and Technology, Wuhan, China
| | - Yuzhao Lu
- Wuhan University of Science and Technology, Wuhan, China
| | - Guozheng Xu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, China.,Department of Neurosurgery, General Hospital of Central Theater of the Chinese People's Liberation Army, Wuhan, China
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Cao C, Huang Y, Chen A, Xu G, Song J. Improvement in Attention Processing After Surgical Treatment in Functional Pituitary Adenomas: Evidence From ERP Study. Front Neurol 2021; 12:656255. [PMID: 34659078 PMCID: PMC8517483 DOI: 10.3389/fneur.2021.656255] [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] [Received: 04/27/2021] [Accepted: 06/28/2021] [Indexed: 01/20/2023] Open
Abstract
Cognitive abilities are impaired in patients with pituitary adenoma. However, studies on attention processing impairment in preoperative patients and attention processing recovery after transsphenoidal adenomectomy are lacking. The study aims to identify the electrophysiological change that relates to attention processing in pituitary patients before and after treatment. Twenty five preoperative pituitary patients and 25 follow-up postoperative patients were recruited. 27 healthy controls (HCs) were matched to the patients with age, gender, and education. Event-related potentials were used to investigate the attention processing in the preoperative patients, postoperative patients, and HCs. Across three groups, all emotional stimuli evoked P200 components. Compared with the HCs or postoperative patients, the amplitudes of P200 in the preoperative patients were higher. Moreover, The amplitudes of P200 decreased in the postoperative patients, which were similar to that in the HCs. The attention processing was improved after surgery, but no significant differences were detected between the postoperative patients and HCs. Abnormal hormone levels may be relevant to the factor that impair attention processing. Compared with that of the HCs and postoperative patients, the P200 component elicited by negative stimuli is higher in preoperative patients, which may illustrate compensatory activity after attention impairments. Furthermore, these data indicate that improvements in attention processing may be attributed to the amelioration of endocrine disorders. This study shows that the P200 component may be used to diagnose attention processing in preoperative pituitary patients and prove the improvement of attention processing in postoperative patients.
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Affiliation(s)
- Chenglong Cao
- Department of Cognitive Neuroscience, Faculty of Psychology & Neuroscience, Maastricht University, Maastricht, Netherlands
- The First School of Clinical Medical University, Southern Medical University, Guangzhou, China
| | - Yujing Huang
- Key Laboratory of Structural Biology of Zhejiang Province, Westlake University, Hangzhou, China
| | - Aobo Chen
- The First School of Clinical Medical University, Southern Medical University, Guangzhou, China
| | - Guozheng Xu
- The First School of Clinical Medical University, Southern Medical University, Guangzhou, China
| | - Jian Song
- Department of Neurosurgery, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
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Potential associations between immune signaling genes, deactivated microglia, and oligodendrocytes and cortical gray matter loss in patients with long-term remitted Cushing's disease. Psychoneuroendocrinology 2021; 132:105334. [PMID: 34225183 DOI: 10.1016/j.psyneuen.2021.105334] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/30/2021] [Accepted: 06/15/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cushing's disease (CD) is a rare and severe endocrine disease characterized by hypercortisolemia. Previous studies have found structural brain alterations in remitted CD patients compared to healthy controls, specifically in the anterior cingulate cortex (ACC). However, potential mechanisms through which these persistent alterations may have occurred are currently unknown. METHODS Structural 3T MRI's from 25 remitted CD patients were linked with gene expression data from neurotypical donors, derived from the Allen Human Brain Atlas. Differences in gene expression between the ACC and an unaffected control cortical region were examined, followed by a Gene Ontology (GO) enrichment analysis. A cell type enrichment analysis was conducted on the differentially expressed genes, and a disease association enrichment analysis was conducted to determine possible associations between differentially expressed genes and specific diseases. Subsequently, cortisol sensitivity of these genes in existing datasets was examined. RESULTS The gene expression analysis identified 300 differentially expressed genes in the ACC compared to the cortical control region. GO analyses found underexpressed genes to represent immune function. The cell type specificity analysis indicated that underexpressed genes were enriched for deactivated microglia and oligodendrocytes. Neither significant associations with diseases, nor evidence of cortisol sensitivity with the differentially expressed genes were found. DISCUSSION Underexpressed genes in the ACC, the area vulnerable to permanent changes in remitted CD patients, were often associated with immune functioning. The specific lack of deactivated microglia and oligodendrocytes implicates protective effects of these cell types against the long-term effects of cortisol overexposure.
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Abstract
PURPOSE OF REVIEW The aim of this article is to review and discuss recent evidence of psychological complications in Cushing's syndrome. RECENT FINDINGS Recent research has described the presence of depression, anxiety, posttraumatic stress disorder, mania, bipolar disorder and psychotic symptoms in patients with Cushing's syndrome. Furthermore, the perspective of patients' partners has also been emphasized. SUMMARY Recent literature highlights the importance of screening for psychological alterations in Cushing's syndrome, as these alterations can be present in many patients, having a high impact in daily life. Depression is a very common symptom, although in rare cases, patients can also present mania or psychosis. Some studies highlight the importance of screening for organic disease (including Cushing's syndrome) in patients with unexpected or first onset psychiatric symptoms. Finally, the perspective of the patients' partners makes it clear that the partners can also suffer due to the disease of the patient. Intervention programmes involving patient's partners could be helpful to improve both patient and partner wellbeing.
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Affiliation(s)
- Alicia Santos
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
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Bengtsson D, Ragnarsson O, Berinder K, Dahlqvist P, Edén Engström B, Ekman B, Höybye C, Burman P, Wahlberg J. Psychotropic Drugs in Patients with Cushing's Disease Before Diagnosis and at Long-Term Follow-Up: A Nationwide Study. J Clin Endocrinol Metab 2021; 106:1750-1760. [PMID: 33567076 PMCID: PMC8118365 DOI: 10.1210/clinem/dgab079] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Indexed: 11/24/2022]
Abstract
CONTEXT Psychiatric symptoms are common in Cushing's disease (CD) and seem only partly reversible following treatment. OBJECTIVE To investigate drug dispenses associated to psychiatric morbidity in CD patients before treatment and during long-term follow-up. DESIGN Nationwide longitudinal register-based study. SETTING University Hospitals in Sweden. SUBJECTS CD patients diagnosed between 1990 and 2018 (N = 372) were identified in the Swedish Pituitary Register. Longitudinal data was collected from 5 years before, at diagnosis, and during follow-up. Four matched controls per patient were included. Cross-sectional subgroup analysis of 76 patients in sustained remission was also performed. MAIN OUTCOME MEASURES Data from the Swedish Prescribed Drug Register and the Patient Register. RESULTS In the 5-year period before and at diagnosis, use of antidepressants (odds ratio [OR] 2.2 [95% confidence interval (CI) 1.3-3.7]) and 2.3 [1.6-3.5]), anxiolytics [2.9 (1.6-5.3) and 3.9 (2.3-6.6)], and sleeping pills [2.1 (1.2-3.7) and 3.8 (2.4-5.9)] was more common in CD than controls. ORs remained elevated at 5-year follow-up for antidepressants [2.4 (1.5-3.9)] and sleeping pills [3.1 (1.9-5.3)]. Proportions of CD patients using antidepressants (26%) and sleeping pills (22%) were unchanged at diagnosis and 5-year follow-up, whereas drugs for hypertension and diabetes decreased. Patients in sustained remission for median 9.3 years (interquartile range 8.1-10.4) had higher use of antidepressants [OR 2.0 (1.1-3.8)] and sleeping pills [2.4 (1.3-4.7)], but not of drugs for hypertension. CONCLUSIONS Increased use of psychotropic drugs in CD was observed before diagnosis and remained elevated regardless of remission status, suggesting persisting negative effects on mental health. The study highlights the importance of early diagnosis of CD, and the need for long-term monitoring of mental health.
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Affiliation(s)
- Daniel Bengtsson
- Department of Internal Medicine, Kalmar, Region of Kalmar County, Kalmar, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Correspondence: Daniel Bengtsson, MD, Department of Internal Medicine, Hälsogränd 2, 391 85 Kalmar, Sweden.
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Katarina Berinder
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Britt Edén Engström
- Department of Medical Sciences, Endocrinology and Mineral Metabolism, Uppsala University, Uppsala, Sweden
- Department of Endocrinology and Diabetes, Uppsala University Hospital, Uppsala, Sweden
| | - Bertil Ekman
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Charlotte Höybye
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Pia Burman
- Department of Endocrinology, Skåne University Hospital, University of Lund, Malmö, Sweden
| | - Jeanette Wahlberg
- Department of Endocrinology in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Faculty of Medical Sciences, Örebro University, Örebro, Sweden
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Zhang SQ, Cao LL, Liang YY, Wang P. The Molecular Mechanism of Chronic High-Dose Corticosterone-Induced Aggravation of Cognitive Impairment in APP/PS1 Transgenic Mice. Front Mol Neurosci 2021; 13:613421. [PMID: 33519376 PMCID: PMC7844096 DOI: 10.3389/fnmol.2020.613421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/17/2020] [Indexed: 01/23/2023] Open
Abstract
Clinical studies have found that some Alzheimer’s disease (AD) patients suffer from Cushing’s syndrome (CS). CS is caused by the long-term release of excess glucocorticoids (GCs) from the adrenal gland, which in turn, impair brain function and induce dementia. Thus, we investigated the mechanism of the effect of corticosterone (CORT) on the development and progression of AD in a preclinical model. Specifically, the plasma CORT levels of 9-month-old APP/PS1 Tg mice were abnormally increased, suggesting an association between GCs and AD. Long-term administration of CORT accelerated cognitive dysfunction by increasing the production and deposition of β-amyloid (Aβ). The mechanism of action of CORT treatment involved stimulation of the expression of BACE-1 and presenilin (PS) 1 in in vitro and in vivo. This observation was confirmed in mice with adrenalectomy (ADX), which had lower levels of GCs. Moreover, the glucocorticoid receptor (GR) mediated the effects of CORT on the stimulation of the expression of BACE-1 and PS1 via the PKA and CREB pathways in neuroblastoma N2a cells. In addition to these mechanisms, CORT can induce a cognitive decline in APP/PS1 Tg mice by inducing apoptosis and decreasing the differentiation of neurons.
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Affiliation(s)
- Shen-Qing Zhang
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Long-Long Cao
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Yun-Yue Liang
- College of Life and Health Sciences, Northeastern University, Shenyang, China
| | - Pu Wang
- College of Life and Health Sciences, Northeastern University, Shenyang, China
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Molecular Mechanisms of Glucocorticoid-Induced Insulin Resistance. Int J Mol Sci 2021; 22:ijms22020623. [PMID: 33435513 PMCID: PMC7827500 DOI: 10.3390/ijms22020623] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 12/29/2020] [Accepted: 01/02/2021] [Indexed: 12/12/2022] Open
Abstract
Glucocorticoids (GCs) are steroids secreted by the adrenal cortex under the hypothalamic-pituitary-adrenal axis control, one of the major neuro-endocrine systems of the organism. These hormones are involved in tissue repair, immune stability, and metabolic processes, such as the regulation of carbohydrate, lipid, and protein metabolism. Globally, GCs are presented as ‘flight and fight’ hormones and, in that purpose, they are catabolic hormones required to mobilize storage to provide energy for the organism. If acute GC secretion allows fast metabolic adaptations to respond to danger, stress, or metabolic imbalance, long-term GC exposure arising from treatment or Cushing’s syndrome, progressively leads to insulin resistance and, in fine, cardiometabolic disorders. In this review, we briefly summarize the pharmacological actions of GC and metabolic dysregulations observed in patients exposed to an excess of GCs. Next, we describe in detail the molecular mechanisms underlying GC-induced insulin resistance in adipose tissue, liver, muscle, and to a lesser extent in gut, bone, and brain, mainly identified by numerous studies performed in animal models. Finally, we present the paradoxical effects of GCs on beta cell mass and insulin secretion by the pancreas with a specific focus on the direct and indirect (through insulin-sensitive organs) effects of GCs. Overall, a better knowledge of the specific action of GCs on several organs and their molecular targets may help foster the understanding of GCs’ side effects and design new drugs that possess therapeutic benefits without metabolic adverse effects.
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Vogel F, Braun L, Rubinstein G, Zopp S, Oßwald A, Schilbach K, Schmidmaier R, Bidlingmaier M, Reincke M. Metformin and Bone Metabolism in Endogenous Glucocorticoid Excess: An Exploratory Study. Front Endocrinol (Lausanne) 2021; 12:765067. [PMID: 34777259 PMCID: PMC8578886 DOI: 10.3389/fendo.2021.765067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/11/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Glucocorticoid excess exhibits multiple detrimental effects by its catabolic properties. Metformin was recently suggested to protect from adverse metabolic side-effects of glucocorticoid treatment. Whether metformin is beneficial in patients with endogenous glucocorticoid excess has not been clarified. OBJECTIVE To evaluate the phenotype in patients with endogenous Cushing's syndrome (CS) treated with metformin at the time of diagnosis. PATIENTS AND METHODS As part of the German Cushing's Registry we selected from our prospective cohort of 96 patients all 10 patients who had been on pre-existing metformin treatment at time of diagnosis (CS-MET). These 10 patients were matched for age, sex and BMI with 16 patients without metformin treatment (CS-NOMET). All patients had florid CS at time of diagnosis. We analyzed body composition, metabolic parameters, bone mineral density and bone remodeling markers, muscle function and quality of life. RESULTS As expected, diabetes was more prevalent in the CS-MET group, and HbA1c was higher. In terms of comorbidities and the degree of hypercortisolism, the two groups were comparable. We did not observe differences in terms of muscle function or body composition. In contrast, bone mineral density in metformin-treated patients was superior to the CS-NOMET group at time of diagnosis (median T-Score -0.8 versus -1.4, p = 0.030). CS-MET patients showed decreased β-CTX levels at baseline (p = 0.041), suggesting reduced bone resorption under metformin treatment during glucocorticoid excess. CONCLUSION This retrospective cohort study supports potential protective effects of metformin in patients with endogenous glucocorticoid excess, in particular on bone metabolism.
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Vogel F, Braun LT, Rubinstein G, Zopp S, Künzel H, Strasding F, Albani A, Riester A, Schmidmaier R, Bidlingmaier M, Quinkler M, Deutschbein T, Beuschlein F, Reincke M. Persisting Muscle Dysfunction in Cushing's Syndrome Despite Biochemical Remission. J Clin Endocrinol Metab 2020; 105:dgaa625. [PMID: 32882010 PMCID: PMC7538105 DOI: 10.1210/clinem/dgaa625] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 08/31/2020] [Indexed: 01/09/2023]
Abstract
CONTEXT Glucocorticoid-induced myopathy is a characteristic symptom of endogenous Cushing's syndrome (CS). Its long-term outcome is largely unknown. OBJECTIVE To evaluate long-term muscle function following the remission of endogenous CS. STUDY DESIGN Observational longitudinal cohort study. SETTING Tertiary care hospitals and a specialized outpatient clinic. PATIENTS As part of the prospective multicenter German Cushing's Registry, we assessed muscle strength in patients with overt endogenous CS. We studied the patients at the time of diagnosis (n = 88), after 6 months (n = 69), and thereafter annually, following surgical remission over a period of up to 4 years (1 year: n = 55; 2 years: n = 34; 3 years: n = 29; 4 years: n = 22). Muscle function was evaluated by hand grip strength and by chair rising test. RESULTS Grip strength was decreased to 83% of normal controls (100%) at the time of diagnosis. It further decreased to 71% after 6 months in remission (P ≤ 0.001) and showed no improvement during further follow-up compared with baseline. Chair rising test performance improved initially (8 seconds at baseline vs 7 seconds after 6 months, P = 0.004) but remained at this reduced level thereafter (7 seconds after 3 years vs 5 seconds in controls, P = 0.038). In multivariate analysis, we identified, as predictors for long-term muscle dysfunction, age, waist-to-hip ratio, and hemoglobin A1c at baseline. Furthermore, muscle strength during follow-up was strongly correlated with quality of life. CONCLUSION This study shows that CS-associated myopathy does not spontaneously resolve during remission. This calls for action to identify effective interventions to improve muscle dysfunction in this setting.
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Affiliation(s)
- Frederick Vogel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Leah T Braun
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - German Rubinstein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Stephanie Zopp
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Heike Künzel
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Finn Strasding
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Adriana Albani
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Anna Riester
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Ralf Schmidmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | - Martin Bidlingmaier
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
| | | | - Timo Deutschbein
- Department of Internal Medicine I, Division of Endocrinology and Diabetes, University Hospital, University of Würzburg, Würzburg, Germany
| | - Felix Beuschlein
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich, Zürich, Switzerland
| | - Martin Reincke
- Department of Endocrinology, Medizinische Klinik und Poliklinik IV, LMU Klinikum, Ludwig Maximilians University Munich, München, Germany
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Siegel S, Kirstein CF, Grzywotz A, Hütter BO, Wrede KH, Kuhna V, Kreitschmann-Andermahr I. Neuropsychological Functioning in Patients with Cushing's Disease and Cushing's Syndrome. Exp Clin Endocrinol Diabetes 2020; 129:194-202. [PMID: 32992348 DOI: 10.1055/a-1247-4651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To present a systematic review of the presence and severity of neuropsychological impairment in the six main neuropsychological domains (attention, executive function, language, visuospatial processing, intelligence, and memory) in patients with Cushing's disease (CD) and/or Cushing's Syndrome (CS) at various stages of the illness. The work aims to identify neuropsychological leverage points for focused diagnosis and rehabilitation in CS/CD patients. METHODS A pubmed literature search was performed and augmented by searching the reference lists of review articles identified by this search strategy. After excluding irrelevant hits, we systematically extracted data from 27 studies for each main neuropsychological domain, differentiating between active disease, short- and long-term remission. RESULTS The literature gives evidence for neuropsychological impairment in all domains in Cushing patients with active disease. The most consistent impairments concerned memory and visuo-spatial processing, whereas the data are discordant for all other domains. Significant improvement of neuropsychological function - although not returning to normal in all domains - is shown in short-term and long-term remission of the disease. However, the published literature is thin, suffering from repetitive subsample analyses publishing, methodological concerns as lack of control for confounders such as depression. CONCLUSIONS Memory is the most extensively investigated domain in CS/CD patients and impairment is most prominent in active disease. Patients should be counseled that neuropsychological function will improve with normalization of hypercortisolism and over time. More studies with more stringent methodological criteria, larger patient samples and controlling for confounders are required to enhance our understanding of neuropsychological function in patients with CS/CD.
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Affiliation(s)
- Sonja Siegel
- Department of Neurosurgery, University of Duisburg-Essen, Essen
| | | | | | | | | | - Victoria Kuhna
- Department of Neurosurgery, University Hospital Oldenburg
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23
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Kumar N, Jarial KDS, Bhansali A, Nehra R, Vyas S, Walia R. Neurocognitive Functions and Brain Volume in Patients with Endogenous Cushing's Syndrome Before and After Curative Surgery. Indian J Endocrinol Metab 2020; 24:396-401. [PMID: 33489843 PMCID: PMC7810051 DOI: 10.4103/ijem.ijem_162_20] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 05/04/2020] [Accepted: 08/28/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Cushing's syndrome (CS) leads to various neuropsychiatric manifestations due to structural and functional changes of the brain and contributes significantly in the impairment of health-related quality of life. AIM AND OBJECTIVE This study is conducted with aims to evaluate neurocognitive functions and brain volume in patients with endogenous Cushing's syndrome before and after curative surgery. METHODS The diagnosis of CS was made by clinical features, abnormal cortisol dynamics, ACTH levels, and imaging studies. Neuropsychiatric tests (Beck depression Index, Spatial span test, PGI memory scale, Color trail test, Verbal fluency test), and Brain volume (Bi-caudate and third ventricular diameter) were done before and after curative surgery. RESULTS Fifteen patients of CS were included for the study; all patients underwent curative surgery, neuropsychiatric assessment, and brain volume measurements. Nine patients were followed successfully till remission and repeat evaluation of these patients was done. Depression was the most common neuropsychiatric illness. Severity of depression positively correlated with 0800 h plasma cortisol and ACTH. Patients with higher severity of depression had maximum improvement after curative surgery. Significant decrease in the third ventricular, as well as bicaudate diameter, was observed after curative surgery (P < 0.01). CONCLUSION Neuropsychiatric functions and structural brain changes reverse after curative surgery in patients with endogenous CS, however, long term follow-up is required to know whether these changes reverse completely or not.
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Affiliation(s)
- Nachimuthu Kumar
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kush D. S. Jarial
- Department of Endocrinology, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - Anil Bhansali
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritu Nehra
- Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rama Walia
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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24
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Bauduin SEEC, van der Pal Z, Pereira AM, Meijer OC, Giltay EJ, van der Wee NJA, van der Werff SJA. Cortical thickness abnormalities in long-term remitted Cushing's disease. Transl Psychiatry 2020; 10:293. [PMID: 32826851 PMCID: PMC7443132 DOI: 10.1038/s41398-020-00980-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 05/31/2020] [Accepted: 06/02/2020] [Indexed: 01/06/2023] Open
Abstract
Long-term remitted Cushing's disease (LTRCD) patients commonly continue to present persistent psychological and cognitive deficits, and alterations in brain function and structure. Although previous studies have conducted gray matter volume analyses, assessing cortical thickness and surface area of LTRCD patients may offer further insight into the neuroanatomical substrates of Cushing's disease. Structural 3T magnetic resonance images were obtained from 25 LTRCD patients, and 25 age-, gender-, and education-matched healthy controls (HCs). T1-weighted images were segmented using FreeSurfer software to extract mean cortical thickness and surface area values of 68 cortical gray matter regions and two whole hemispheres. Paired sample t tests explored differences between the anterior cingulate cortex (ACC; region of interest), and the whole brain. Validated scales assessed psychiatric symptomatology, self-reported cognitive functioning, and disease severity. After correction for multiple comparisons, ROI analyses indicated that LTRCD-patients showed reduced cortical thickness of the left caudal ACC and the right rostral ACC compared to HCs. Whole-brain analyses indicated thinner cortices of the left caudal ACC, left cuneus, left posterior cingulate cortex, right rostral ACC, and bilateral precuneus compared to HCs. No cortical surface area differences were identified. Cortical thickness of the left caudal ACC and left cuneus were inversely associated with anxiety symptoms, depressive symptoms, and disease duration, although certain associations did not persist after correction for multiple testing. In six of 68 regions examined, LTRCD patients had reduced cortical thickness in comparison to HCs. Cortical thickness of the left caudal ACC was inversely associated with disease duration. This suggests that prolonged and excessive exposure to glucocorticoids may be related to cortical thinning of brain structures involved in emotional and cognitive processing.
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Affiliation(s)
- S E E C Bauduin
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands.
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands.
| | - Z van der Pal
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - A M Pereira
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - O C Meijer
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
- Department of Endocrinology and Metabolic Diseases and Center for Endocrine Tumors, Leiden University Medical Center, Leiden, The Netherlands
| | - E J Giltay
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - N J A van der Wee
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
| | - S J A van der Werff
- Department of Psychiatry, Leiden University Medical Center (LUMC), Leiden, The Netherlands
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands
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25
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Piasecka M, Papakokkinou E, Valassi E, Santos A, Webb SM, de Vries F, Pereira AM, Ragnarsson O. Psychiatric and neurocognitive consequences of endogenous hypercortisolism. J Intern Med 2020; 288:168-182. [PMID: 32181937 DOI: 10.1111/joim.13056] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/03/2020] [Accepted: 03/12/2020] [Indexed: 12/18/2022]
Abstract
Psychiatric and neurocognitive symptoms due to hypercortisolism were already described by Harvey Cushing in his original paper on patients with Cushing's syndrome (CS). Nowadays, it is well known that psychiatric and cognitive complaints are two of the most common, and most distressing, symptoms in patients with CS. Psychiatric symptoms are indeed a major clinical manifestation of CS. The most commonly observed psychiatric conditions are depression and anxiety, whilst mania and psychosis are less common. Several domains of cognitive function are impaired at diagnosis, including episodic and working memory, executive function and attention. Following treatment, one-fourth of the patients still experience depressed mood, and the cognitive impairments are only partially restored. Consequently, quality of life in patients with CS is severely and persistently affected. Neuroimaging studies have also illustrated the deleterious effects of hypercortisolism on the brain by demonstrating reduced grey matter volumes and cortical thickness, altered resting-state functional responses and during cognitive tasks, as well as widespread reduced white matter integrity, especially in structures important for cognitive function and emotional processing, both before and after successful abrogation of hypercortisolism. In this paper, we summarize the current knowledge on the psychiatric and neurocognitive consequences of hypercortisolism in patients with CS, both before, and after successful treatment. In addition, we review the structural and functional brain abnormalities associated with hypercortisolism and discuss the influence of these factors on quality of life.
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Affiliation(s)
- M Piasecka
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Papakokkinou
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - E Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - A Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - S M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, Univ Autonoma de Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - F de Vries
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - A M Pereira
- Department of Medicine, Division of Endocrinology, Center for Endocrine Tumours Leiden, Leiden University Medical Center, Leiden, The Netherlands
| | - O Ragnarsson
- From the, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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26
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Inoue S, Hayashi T, Teishima J, Matsubara A. Impact of Adrenalectomy on Cortisol-Producing Adenoma: Longitudinal Evaluation of Health-Related Quality of Life following Laparoscopic Adrenalectomy. Urol Int 2020; 104:789-796. [PMID: 32645700 DOI: 10.1159/000508765] [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: 03/09/2020] [Accepted: 05/16/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION There is increasing interest in evaluating the quality of life of patients with cortisol-producing adrenocortical adenoma (CPA). Our objective was to assess patient-reported health-related quality of life (HRQOL) in patients with CPA compared to non-CPA. METHODS Between January 2012 and September 2015, a total of 24 and 62 patients who had laparoscopic adrenalectomy with CPA and non-CPA, respectively, were included in the study. General HRQOL was evaluated on Short Form 8 (SF-8) questionnaire. The SF-8 questionnaire was administered at preoperative baseline and at 3, 6, 9, 12, 18, and 24 months after adrenalectomy. The impact of changing 2 measures of the summary score on the physical component summary (PCS) and mental component summary (MCS) score of SF-8 was evaluated in prospective and longitudinal studies. RESULTS The baseline PCS score was significantly lower in the CPA than in the non-CPA group (43.6 vs. 49.0; p = 0.0075). Thereafter, the PCS score was significantly lower in the CPA group at 3, 6, 9, and 12 months postoperatively. The PCS score increased in the CPA group with no significant difference between both groups at 18 months (48.1 vs. 50.2; p = 0.1202) and 24 months (48.0 vs. 50.8; p = 0.3625) postoperatively. However, the baseline MCS score was not significantly different between the CPA and non-CPA group. The MCS score in both groups gradually increased with no significant differences between the groups at any time points after surgery. The PCS score was not significantly improved at all postoperative points than the baseline score in the CPA and non-CPA group. The MCS score was significantly improved than the baseline score from 6 months postoperatively only in the CPA group. CONCLUSION Our research suggests that laparoscopic adrenalectomy may contribute to improving the physical and mental function in HRQOL.
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Affiliation(s)
- Shogo Inoue
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan,
| | - Tetsutaro Hayashi
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Jun Teishima
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Akio Matsubara
- Department of Urology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
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Tirosh A, RaviPrakash H, Papadakis GZ, Tatsi C, Belyavskaya E, Charalampos L, Lodish MB, Bagci U, Stratakis CA. Computerized Analysis of Brain MRI Parameter Dynamics in Young Patients With Cushing Syndrome-A Case-Control Study. J Clin Endocrinol Metab 2020; 105:dgz303. [PMID: 31875913 PMCID: PMC7089850 DOI: 10.1210/clinem/dgz303] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 12/22/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Young patients with Cushing Syndrome (CS) may develop cognitive and behavioral alterations during disease course. METHODS To investigate the effects of CS on the brain, we analyzed consecutive MRI scans of patients with (n = 29) versus without CS (n = 8). Multiple brain compartments were processed for total and gray/white matter (GM/WM) volumes and intensities, and cortical volume, thickness, and surface area. Dynamics (last/baseline scans ratio per parameter) were analyzed versus cortisol levels and CS status (persistent, resolved, and non-CS). RESULTS Twenty-four-hour urinary free cortisol (24hUFC) measurements had inverse correlation with the intensity of subcortical GM structures and of the corpus callosum, and with the cerebral WM intensity. 24hUFC dynamics had negative correlation with volume dynamics of multiple cerebral and cerebellar structures. Patients with persistent CS had less of an increase in cortical thickness and WM intensity, and less of a decrease in WM volume compared with patients with resolution of CS. Patients with resolution of their CS had less of an increase in subcortical GM and cerebral WM volumes, but a greater increase in cortical thickness of frontal lobe versus controls. CONCLUSION Changes in WM/GM consistency, intensity, and homogeneity in patients with CS may correlate with CS clinical consequences better than volume dynamics alone.
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Affiliation(s)
- Amit Tirosh
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
- NET Service and Endocrine Oncology Bioinformatics Lab, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Harish RaviPrakash
- Center for Research in Computer Vision (CRCV), University of Central Florida, Orlando, Florida
| | - Georgios Z Papadakis
- Computational Biomedicine Laboratory (CBML), Institute of Computer Science (ICS), Foundation for Research and Technology (FORTH), Heraklion, Crete, Greece
- Skeletal Clinical Studies Unit, National Institute of Dental and Craniofacial Research (NIDCR), National Institutes of Health (NIH), Bethesda, Maryland
- Department of Medical Imaging, Heraklion University Hospital, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Christina Tatsi
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Elena Belyavskaya
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Lyssikatos Charalampos
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Maya B Lodish
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
| | - Ulas Bagci
- Center for Research in Computer Vision (CRCV), University of Central Florida, Orlando, Florida
| | - Constantine A Stratakis
- Section on Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland
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28
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Yao S, Lin P, Vera M, Akter F, Zhang RY, Zeng A, Golby AJ, Xu G, Tie Y, Song J. Hormone levels are related to functional compensation in prolactinomas: A resting-state fMRI study. J Neurol Sci 2020; 411:116720. [PMID: 32044686 DOI: 10.1016/j.jns.2020.116720] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 01/16/2020] [Accepted: 01/31/2020] [Indexed: 12/27/2022]
Abstract
Prolactinomas are tumors of the pituitary gland, which overproduces prolactin leading to dramatic fluctuations of endogenous hormone levels throughout the body. While it is not fully understood how endogenous hormone disorders affect a patient's brain, it is well known that fluctuating hormone levels can have negative neuropsychological effects. Using resting-state functional magnetic resonance imaging (rs-fMRI), we investigated whole-brain functional connectivity (FC) and its relationship with hormone levels in prolactinomas. By performing seed-based FC analyses, we compared FC metrics between 33 prolactinoma patients and 31 healthy controls matched for age, sex, and hand dominance. We then carried out a partial correlation analysis to examine the relationship between FC metrics and hormone levels. Compared to healthy controls, prolactinoma patients showed significantly increased thalamocortical and cerebellar-cerebral FC. Endogenous hormone levels were also positively correlated with increased FC metrics, and these hormone-FC relationships exhibited sex differences in prolactinoma patients. Our study is the first to reveal altered FC patterns in prolactinomas and to quantify the hormone-FC relationships. These results indicate the importance of endogenous hormones on functional compensation of the brain in patients with prolactinomas.
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Affiliation(s)
- Shun Yao
- Center for Pituitary Tumor Surgery, Department of Neurosurgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Department of Neurosurgery, The General Hospital of Chinese PLA Central Theater Command, Southern Medical University, Wuhan, China; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Pan Lin
- Department of Psychology, Cognition and Human Behavior Key Laboratory of Hunan Province, Hunan Normal University, Changsha, China
| | - Matthew Vera
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Farhana Akter
- Faculty of Arts and Sciences, Harvard University, Cambridge, MA, USA; Massachussets General Hospital Cancer Center, Harvard Medical School, Boston, MA, USA
| | - Ru-Yuan Zhang
- Center for Magnetic Resonance Research, Department of Neuroscience, University of Minnesota at Twin Cities, MN, USA
| | - Ailiang Zeng
- Department of Neurosurgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Alexandra J Golby
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, MA, USA; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, MA, USA
| | - Guozheng Xu
- Department of Neurosurgery, The General Hospital of Chinese PLA Central Theater Command, Southern Medical University, Wuhan, China
| | - Yanmei Tie
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, MA, USA.
| | - Jian Song
- Department of Neurosurgery, The General Hospital of Chinese PLA Central Theater Command, Southern Medical University, Wuhan, China.
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Gao L, Liu L, Shi L, Luo Y, Wang Z, Guo X, Xing B. Dynamic changes of views on the brain changes of Cushing's syndrome using different computer-assisted tool. Rev Endocr Metab Disord 2020; 21:185-200. [PMID: 31974674 DOI: 10.1007/s11154-020-09540-1] [Citation(s) in RCA: 4] [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] [Indexed: 12/13/2022]
Abstract
Cushing's syndrome (CS) provides a unique model for assessing the neurotoxic effect of chronic hypercortisolism on human brains. With the ongoing development of different computer-assisted tools, four research stages emerged, each with its own pearls and pitfalls. This review summarizes current knowledge and describes the dynamic changes of views on the brain changes of CS, especially in the current era of the rapid development of artificial intelligence and big data. The adverse effects of GC on brain are proven to be on structural, functional and cellular levels at the same time.
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Affiliation(s)
- Lu Gao
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China.
| | - Lu Liu
- Department of Senior Officials Health Care, China-Japan Friendship Hospital, Beijing, China
| | - Lin Shi
- Department of Imaging and Interventional Radiology, The Chinese University of Hong Kong, Hong Kong, China
- BrainNow Research Institute, Shenzhen, China
| | - Yishan Luo
- BrainNow Research Institute, Shenzhen, China
| | - Zihao Wang
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
| | - Xiaopeng Guo
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China
| | - Bing Xing
- Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
- Peking Union Medical College Hospital, No. 1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, 100730, China.
- China Pituitary Disease Registry Center, Chinese Pituitary Adenoma Cooperative Group, Beijing, China.
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30
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Pertichetti M, Serioli S, Belotti F, Mattavelli D, Schreiber A, Cappelli C, Padovani A, Gasparotti R, Nicolai P, Fontanella MM, Doglietto F. Pituitary adenomas and neuropsychological status: a systematic literature review. Neurosurg Rev 2019; 43:1065-1078. [DOI: 10.1007/s10143-019-01134-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 05/16/2019] [Accepted: 06/10/2019] [Indexed: 12/16/2022]
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31
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Stomby A, Salami A, Dahlqvist P, Evang JA, Ryberg M, Bollerslev J, Olsson T, Johannsson G, Ragnarsson O. Elevated resting-state connectivity in the medial temporal lobe and the prefrontal cortex among patients with Cushing's syndrome in remission. Eur J Endocrinol 2019; 180:329-338. [PMID: 30939453 DOI: 10.1530/eje-19-0028] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/02/2019] [Indexed: 12/29/2022]
Abstract
Objective Cushing's syndrome is associated with long-term cognitive deficits and affective symptoms such as depression and anxiety. The alterations in brain function underlying these deficits after Cushing's syndrome are unclear and therefore we aimed to explore alterations in resting-state functional connectivity in patients with Cushing's syndrome in remission. Design Cross-sectional case-control study. Methods Nineteen women with Cushing's syndrome in remission for a median time of 7 years (IQR: 6-10) and a mean age of 45 years were included at three university clinics. These patients and 38 age-matched female controls underwent brain imaging at a single center. The main outcome measure was functional connectivity at rest, measured with functional magnetic resonance imaging. Results The medial temporal lobe (MTL) and prefrontal cortex networks, exhibited elevated functional connectivity among patients compared to controls. The degree of elevated functional connectivity in the MTL was negatively associated with time in remission. Conclusions Resting-state functional connectivity within glucocorticoid receptor-rich regions, particularly the MTL and medial prefrontal cortex, was increased in patients. These differences in connectivity may provide a neural basis for the cognitive deficits and affective symptoms commonly experienced by patients with Cushing's syndrome in remission.
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Affiliation(s)
- Andreas Stomby
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
- Region Jönköping County, Jönköping, Sweden
| | - Alireza Salami
- Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan Arild Evang
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway
| | - Mats Ryberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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32
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Lamos EM, Munir KM. Cushing disease: highlighting the importance of early diagnosis for both de novo and recurrent disease in light of evolving treatment patterns. Endocr Pract 2019; 20:945-55. [PMID: 25100372 DOI: 10.4158/ep14068.ra] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To highlight and summarize current literature on Cushing disease (CD)-related morbidity and mortality, focusing on residual complications after "cure" and the changing role of pharmacologic therapy in CD. METHODS Current journal articles on the consequences of untreated or undertreated CD, CD recurrence, and recent trends in CD treatment were collected from PubMed searches and analyzed in combination in view of the authors' clinical experience. RESULTS Timely recognition and treatment of de novo and recurrent CD remains a singular clinical challenge. Chronic excess cortisol exposure leads to potentially irreversible sequelae and death, stressing the importance of early diagnosis and treatment. Disease relapse after primary pituitary adenomectomy is prevalent and recurrence may manifest decades after initial surgery. Increased risk for mortality and hypercortisolism-related complications in postsurgical CD patients may indicate persistent subclinical disease and further underscores the need for cautious, ongoing observation and testing. Potential long-term pharmacologic treatment options (e.g., pasireotide, mifepristone) have recently emerged that may provide biochemical and symptomatic remission for those with refractory CD, or those for whom surgery is contraindicated. CONCLUSION Delays in CD diagnosis, management, and follow-up are common and lead to increased adverse metabolic complications and mortality. Rapid recognition and treatment as well as vigilant monitoring are therefore essential. After surgical treatment, some patients may suffer from persistent subclinical CD that remains difficult to detect with routine testing. Although long-term pharmacologic treatment has historically been limited by adverse reactions or escape from response, new treatments may offer more options for patients with refractory disease.
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Affiliation(s)
- Elizabeth M Lamos
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kashif M Munir
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
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Chornenkyy Y, Wang W, Wei A, Nelson PT. Alzheimer's disease and type 2 diabetes mellitus are distinct diseases with potential overlapping metabolic dysfunction upstream of observed cognitive decline. Brain Pathol 2019; 29:3-17. [PMID: 30106209 PMCID: PMC6427919 DOI: 10.1111/bpa.12655] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/13/2022] Open
Abstract
Alzheimer's disease (AD) and type 2 diabetes mellitus (T2DM) are highly prevalent aging-related diseases associated with significant morbidity and mortality. Some findings in human and animal models have linked T2DM to AD-type dementia. Despite epidemiological associations between the T2DM and cognitive impairment, the interrelational mechanisms are unclear. The preponderance of evidence in longitudinal studies with autopsy confirmation have indicated that vascular mechanisms, rather than classic AD-type pathologies, underlie the cognitive decline often seen in self-reported T2DM. T2DM is associated with cardiovascular and cerebrovascular disease (CVD), and is associated with increased risk of infarcts and small vessel disease in the brain and other organs. Neuropathological examinations of post-mortem brains demonstrated evidence of cerebrovascular disease and little to no correlation between T2DM and β-amyloid deposits or neurofibrillary tangles. Nevertheless, the mechanisms upstream of early AD-specific pathology remain obscure. In this regard, there may indeed be overlap between the pathologic mechanisms of T2DM/"metabolic syndrome," and AD. More specifically, cerebral insulin processing, glucose metabolism, mitochondrial function, and/or lipid metabolism could be altered in patients in early AD and directly influence symptomatology and/or neuropathology.
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Affiliation(s)
| | - Wang‐Xia Wang
- University of Kentucky College of MedicineLexingtonKY
- Sanders‐Brown Center on Aging, Department of PathologyUniversity of KentuckyLexingtonKY
| | - Angela Wei
- Department of BiologyUniversity of KentuckyLexingtonKY
| | - Peter T. Nelson
- University of Kentucky College of MedicineLexingtonKY
- Sanders‐Brown Center on Aging, Department of PathologyUniversity of KentuckyLexingtonKY
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Santos A, Resmini E, Martínez Momblán MA, Valassi E, Martel L, Webb SM. Quality of Life in Patients With Cushing's Disease. Front Endocrinol (Lausanne) 2019; 10:862. [PMID: 31920973 PMCID: PMC6917662 DOI: 10.3389/fendo.2019.00862] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 11/25/2019] [Indexed: 01/05/2023] Open
Abstract
Cushing's disease (and by extension, Cushing's syndrome) is a rare disease due to a chronic cortisol excess, which usually has an important impact on quality of life (QoL). It can lead to numerous comorbidities that can interfere with daily life, as fatigability, myopathy, bone loss and fragility, increased cardiovascular risk, depression, and cognitive alterations. Of note, psychological alterations (including depression and anxiety) occur often, and are an important determinant of impaired quality QoL. QoL scores using different questionnaires are poorer in comparison to healthy controls, other pituitary adenomas and some chronic diseases. Even if some improvements can be observed after successful treatment, recovery does not seem to be complete, and comorbidities persist. This persistent QoL impairment has been found using both generic and disease-specific QoL questionnaires, and is also reported by the patients themselves, when asked directly. Multidisciplinary teams are essential to improve patients' well-being. Clinicians should take into account the whole scope of clinical problems and address the different comorbidites associated with the disease. Screening in the psychological sphere, with further intervention if necessary, can be helpful in the management of these patients. Interventions and programs have shown promising results, although there is a need for further development of new strategies for the benefit of these patients.
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Affiliation(s)
- Alicia Santos
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eugenia Resmini
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mª Antonia Martínez Momblán
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
- Fundamental and Medico-Surgical Nursing Department, School of Medicine and Health Sciences, University of Barcelona, L'Hospitalet de Llobregat, Spain
| | - Elena Valassi
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Luciana Martel
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susan M. Webb
- Endocrinology/Medicine Departments, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), IIB-Sant Pau, ISCIII and Universitat Autònoma de Barcelona, Barcelona, Spain
- *Correspondence: Susan M. Webb
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 564] [Impact Index Per Article: 94.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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Valassi E, Feelders R, Maiter D, Chanson P, Yaneva M, Reincke M, Krsek M, Tóth M, Webb SM, Santos A, Paiva I, Komerdus I, Droste M, Tabarin A, Strasburger CJ, Franz H, Trainer PJ, Newell-Price J, Wass JA, Papakokkinou E, Ragnarsson O. Worse Health-Related Quality of Life at long-term follow-up in patients with Cushing's disease than patients with cortisol producing adenoma. Data from the ERCUSYN. Clin Endocrinol (Oxf) 2018; 88:787-798. [PMID: 29574994 DOI: 10.1111/cen.13600] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/05/2018] [Accepted: 03/16/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Hypercortisolism in Cushing's syndrome (CS) is associated with impaired health-related quality of life (HRQoL), which may persist despite remission. We used the data entered into the European Registry on Cushing's syndrome (ERCUSYN) to evaluate if patients with CS of pituitary origin (PIT-CS) have worse HRQoL, both before and after treatment than patients with adrenal causes (ADR-CS). METHODS Data from 595 patients (492 women; 83%) who completed the CushingQoL and/or EQ-5D questionnaires at baseline and/or following treatment were analysed. RESULTS At baseline, HRQoL did not differ between PIT-CS (n = 293) and ADR-CS (n = 120) on both EuroQoL and CushingQoL. Total CushingQoL score in PIT-CS and ADR-CS was 41 ± 18 and 44 ± 20, respectively (P = .7). At long-time follow-up (>1 year after treatment) total CushingQoL score was however lower in PIT-CS than ADR-CS (56 ± 20 vs 62 ± 23; P = .045). In a regression analysis, after adjustment for baseline age, gender, remission status, duration of active CS, glucocorticoid dependency and follow-up time, no association was observed between aetiology and HRQoL. Remission was associated with better total CushingQoL score (P < .001), and older age at diagnosis with worse total score (P = .01). Depression at diagnosis was associated with worse total CushingQoL score at the last follow-up (P < .001). CONCLUSION PIT-CS patients had poorer HRQoL than ADR-CS at long-term follow-up, despite similar baseline scoring. After adjusting for remission status, no interaetiology differences in HRQoL scoring were found. Age and presence of depression at diagnosis of CS may be potential predictors of worse HRQoL regardless of CS aetiology.
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Affiliation(s)
- Elena Valassi
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | | | | | - Philippe Chanson
- Univ Paris-Sud, Université Paris-Saclay UMR-S1185, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service de Endocrinologie et des Maladies de la Reproduction, Paris, France
- Institut National de la Santé et de la Recherche Médicale U1185, Paris, France
| | | | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, München, Germany
| | - Michal Krsek
- 2nd Department of Medicine, 3rd Faculty of Medicine, Charle University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Miklós Tóth
- 2nd Department of Medicine, Semmelweis University, Budapest, Hungary
| | - Susan M Webb
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Alicia Santos
- IIB-Sant Pau and Department of Endocrinology/Medicine, Hospital Sant Pau, UAB, and Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), ISCIII, Barcelona, Spain
| | - Isabel Paiva
- Hospitais da Universidade de Coimbra, Coimbra, Portugal
| | - Irina Komerdus
- Moscow Regional Research Clinical Institute n.a. Vladimirsky, Moscow, Russia
| | | | - Antoine Tabarin
- Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Christian J Strasburger
- Division of Clinical Endocrinology, Department of Medicine CCM, Charité- Universitätsmedizin, Berlin, Germany
| | - Holger Franz
- Lohmann & Birkner Health Care Consulting GmbH, Berlin, Germany
| | - Peter J Trainer
- Department of Endocrinology, Christie Hospital, Manchester, UK
| | - John Newell-Price
- Academic Unit of Diabetes, Endocrinology and Reproduction, Department of Oncology and Metabolism, The Medical School, University of Sheffield, Sheffield, UK
| | - John Ah Wass
- Oxford Radcliffe Hospitals NHS Trust, Oxford, UK
| | - Eleni Papakokkinou
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and the Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and the Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
Cortisol excess in Cushing's syndrome is associated with metabolic, cardiovascular, and cognitive alterations, only partially reversible after resolution of hypercortisolism. Elevated cardiovascular risk may persist after eucortisolism has been achieved. Fractures and low bone mineral density are also described in Cushing's syndrome in remission. Hypercortisolism may induce irreversible structural and functional changes in the brain, leading to neuropsychiatric disorders in the active phase of the disease, which persist. Sustained deterioration of the cardiovascular system, bone remodeling, and cognitive function along with neuropsychological impairment are associated with high morbidity and poor quality of life before and after remission.
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Affiliation(s)
- Susan M Webb
- Department of Endocrinology, Hospital Sant Pau, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, c/Sant Antoni Maria Claret 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, c/Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Elena Valassi
- Department of Endocrinology, Hospital Sant Pau, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, c/Sant Antoni Maria Claret 167, Barcelona 08025, Spain; Department of Medicine, Hospital Sant Pau, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBER-ER, Unidad 747), IIB-Sant Pau, ISCIII, c/Sant Antoni Maria Claret 167, Barcelona 08025, Spain.
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Webb SM, Santos A, Resmini E, Martínez-Momblán MA, Martel L, Valassi E. Quality of Life in Cushing's disease: A long term issue? ANNALES D'ENDOCRINOLOGIE 2018; 79:132-137. [PMID: 29625700 DOI: 10.1016/j.ando.2018.03.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/12/2018] [Indexed: 11/30/2022]
Abstract
The purpose of this review is to describe how quality of life (QoL) is impaired in patients with hypercortisolism due to Cushing's syndrome of any aetiology, including pituitary-dependent Cushing's disease. It is worse in active disease, but improvement after successful therapy is often incomplete, due to persistent physical and psychological co-morbidities, even years after endocrine "cure". Physical symptoms like extreme fatigability, central obesity with limb atrophy, hypertension, fractures, and different skin abnormalities severely impair the affected patients' everyday life. Psychological and cognitive problems like bad memory, difficulties to concentrate and emotional distress, often associated with anxiety and depression, make it difficult for many patients to overcome the aftermath of treated Cushing's syndrome. Recent studies have shown diffuse structural abnormalities in the central nervous system during active hypercortisolism, thought to be related to the wide distribution of glucocorticoid receptors throughout the brain. Even though they improve after treatment, normalization is often not complete. Shortening the exposure to active Cushing's syndrome by reducing the often long delay to diagnosis and promptly receiving effective treatment is highly desirable, together with preparing the patient for the difficult periods, especially after surgery. In this way they are prepared for the impairments they perceive in every day life, and live with the hope of later improvement, which can be therapeutic in many instances.
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Affiliation(s)
- Susan M Webb
- Endocrinology/Medicine Department, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Pare Claret 167, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Spain.
| | - Alicia Santos
- Endocrinology/Medicine Department, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Pare Claret 167, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Spain.
| | - Eugenia Resmini
- Endocrinology/Medicine Department, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Pare Claret 167, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Spain.
| | - Maria-Antonia Martínez-Momblán
- Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Spain; Fundamental and medico-surgical Nursing Department, School of Medicine and Health Sciences, University of Barcelona, L'Hospitalet de Llobregat, Bellvitge Campus, Feixa Llarga, s/n, Pavelló de Govern, 3ª planta, despatx 339, 08907 Llobregat, Spain.
| | - Luciana Martel
- Endocrinology/Medicine Department, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Pare Claret 167, 08025 Barcelona, Spain.
| | - Elena Valassi
- Endocrinology/Medicine Department, Research Center for Pituitary Diseases, Hospital Sant Pau, IIB-Sant Pau, Universitat Autònoma de Barcelona (UAB), Pare Claret 167, 08025 Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747), ISCIII, Spain.
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The dysfunction of processing task-irrelevant emotional faces in pituitary patients: an evidence from expression-related visual mismatch negativity. Neuroreport 2018; 29:328-333. [PMID: 29369901 DOI: 10.1097/wnr.0000000000000965] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Evidence showed impaired cognitive ability of patients with pituitary adenoma as an intracranial tumor. In the present study, we investigated the preattentive processing of emotional faces in pituitary adenoma patients by recording and analyzing the visual mismatch negativity elicited by deviant emotional faces. In the normal control group, deviant emotional faces elicited expression-related mismatch negativity (EMMN), with a more pronounced negative waveform for sad than happy face conditions. Compared with the normal group, EMMN related to sad faces was smaller in patients, whereas the EMMN related to happy faces remained the same. These data indicate the functional dysfunction of negative emotional processing at the preattentive stage of information processing in pituitary adenoma patients.
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The dysfunction of inhibition control in pituitary patients: evidence from the Go/Nogo event-related potential study. Neuroreport 2018; 28:272-278. [PMID: 28225481 DOI: 10.1097/wnr.0000000000000757] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Pituitary tumor is an intracranial tumor; because of the development of neuroimaging technology in recent years, morbidity is likely to increase. Evidence showed impaired cognitive ability of patients with pituitary adenoma. There is evidence that neurobehavioral disorders are common in pituitary adenoma patients. This disorder is because of the cognitive and emotional function of the important functional areas of the brain oppressed and hormone imbalance. Individuals' mental activity is controlled by the brain and the abnormal mental activity is caused by both the structural abnormalities of the brain and neurochemical dysfunction. Event-related potentials have been used widely in the early assessment of cognitive functions associated with disease, taking advantage of the high temporal resolution, and then analyzing the characteristics of emotional competence from the perspective of cognitive processing. A visual Go/Nogo task was used. A larger Nogo-N2 and Nogo-P3 was found in the control group compared with the pituitary group. This reflects the nonphysiological process of conflict monitoring and inhibitory control in pituitary patients. The results also showed that the difference waves between Go and Nogo conditions (N2d and P3d) over the frontal electrode sites were more robust and earlier in the control group compared with the pituitary group, which reflects frontal dysfunction in the pituitary group. These data suggest reduced earlier and later stages of inhibitory processes in pituitary individuals, implicating the dysfunction of conflict detection and inhibitory control.
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Ragnarsson O, Stomby A, Dahlqvist P, Evang JA, Ryberg M, Olsson T, Bollerslev J, Nyberg L, Johannsson G. Decreased prefrontal functional brain response during memory testing in women with Cushing's syndrome in remission. Psychoneuroendocrinology 2017; 82:117-125. [PMID: 28544904 DOI: 10.1016/j.psyneuen.2017.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 05/03/2017] [Accepted: 05/10/2017] [Indexed: 01/09/2023]
Abstract
Neurocognitive dysfunction is an important feature of Cushing's syndrome (CS). Our hypothesis was that patients with CS in remission have decreased functional brain responses in the prefrontal cortex and hippocampus during memory testing. In this cross-sectional study we included 19 women previously treated for CS and 19 controls matched for age, gender, and education. The median remission time was 7 (IQR 6-10) years. Brain activity was studied with functional magnetic resonance imaging during episodic- and working-memory tasks. The primary regions of interest were the prefrontal cortex and the hippocampus. A voxel-wise comparison of functional brain responses in patients and controls was performed. During episodic-memory encoding, patients displayed lower functional brain responses in the left and right prefrontal gyrus (p<0.001) and in the right inferior occipital gyrus (p<0.001) compared with controls. There was a trend towards lower functional brain responses in the left posterior hippocampus in patients (p=0.05). During episodic-memory retrieval, the patients displayed lower functional brain responses in several brain areas with the most predominant difference in the right prefrontal cortex (p<0.001). During the working memory task, patients had lower response in the prefrontal cortices bilaterally (p<0.005). Patients, but not controls, had lower functional brain response during a more complex working memory task compared with a simpler one. In conclusion, women with CS in long-term remission have reduced functional brain responses during episodic and working memory testing. This observation extends previous findings showing long-term adverse effects of severe hypercortisolaemia on brain function.
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Affiliation(s)
- Oskar Ragnarsson
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden.
| | - Andreas Stomby
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden; Ryhov County Hospital, Jönköping, Sweden
| | - Per Dahlqvist
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Johan A Evang
- Section of Specialised Endocrinology, Oslo University Hospital-Rikshospitalet, Norway
| | - Mats Ryberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jens Bollerslev
- Section of Specialised Endocrinology, Oslo University Hospital-Rikshospitalet, Norway; Faculty of Medicine, University in Oslo, Norway
| | - Lars Nyberg
- Diagnostic Radiology, Department of Radiation Sciences and Umeå Center for Functional Brain Imaging, Umeå University, Umeå, Sweden
| | - Gudmundur Johannsson
- Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Göteborg, Sweden
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Santos A, Resmini E, Pascual JC, Crespo I, Webb SM. Psychiatric Symptoms in Patients with Cushing's Syndrome: Prevalence, Diagnosis and Management. Drugs 2017; 77:829-842. [PMID: 28393326 DOI: 10.1007/s40265-017-0735-z] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Cushing's syndrome (CS) results from chronic exposure to cortisol excess, produced by the adrenal cortex. Hypercortisolism predisposes to psychiatric and neurocognitive disorders, mainly to depression and anxiety disorders. Screening tools to identify psychiatric symptoms are available for clinicians in their daily practice, although a specific diagnosis should be performed by specialists. Even if psychiatric symptoms improve after remission of hypercortisolism, complete recovery may not be achieved. Given the burden of these symptoms, psychiatric or psychological monitoring and treatment should be offered through all phases of CS, with a multidisciplinary approach. The aim of this article is to review data on the prevalence, diagnosis and management of psychiatric symptoms seen in patients with CS and to propose therapeutic approaches that may be followed in clinical practice. The prevalence of different psychiatric disorders has been described in both the active phase and after CS remission. Patients may not talk spontaneously about psychiatric symptoms they present, thus clinicians should ask directly about them. We recommend the use of screening tools in clinical practice to detect and treat these symptoms promptly. Even if reference endocrinologists cannot perform a definite psychiatric diagnosis, it will be important to ask patients directly about the presence of symptoms and refer if necessary to a psychiatrist. Additionally, patient information and educational programmes could be useful to manage psychiatric symptoms and to improve quality of life in patients with CS.
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Affiliation(s)
- Alicia Santos
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Eugenia Resmini
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain. .,Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Juan Carlos Pascual
- Department of Psychiatry, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Iris Crespo
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Susan M Webb
- Department of Endocrinology/Medicine, Hospital Sant Pau, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER 747), Institut d'Investigació Biomèdica-Sant Pau (IIB-SANT PAU), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
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Berr CM, Stieg MR, Deutschbein T, Quinkler M, Schmidmaier R, Osswald A, Reisch N, Ritzel K, Dimopoulou C, Fazel J, Hahner S, Stalla GK, Beuschlein F, Reincke M. Persistence of myopathy in Cushing's syndrome: evaluation of the German Cushing's Registry. Eur J Endocrinol 2017; 176:737-746. [PMID: 28325824 DOI: 10.1530/eje-16-0689] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2016] [Revised: 03/14/2017] [Accepted: 03/20/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cushing's syndrome (CS) is characterized by an excessive secretion of glucocorticoids that results in a characteristic clinical phenotype. One feature of clinical hypercortisolism is breakdown of protein metabolism translating into clinical consequences including glucocorticoid-induced myopathy. While surgery is effective in control of cortisol excess, the effect of biochemical remission on muscular function is yet unclear. METHODS In a cross-sectional study we analyzed 47 patients with CS during the florid phase (ActiveCS). 149 additional patients were studied 2-53 years (mean: 13 years) after surgery in biochemical long-term remission (RemissionCS). Also, 93 rule-out CS patients were used as controls (CON). All subjects were assessed for grip strength using a hand grip dynamometer and underwent the chair rising test (CRT). RESULTS Hand grip strength (85% vs 97% of norm, P = 0.002) and the CRT performance (9.5 s vs 7.1 s, P = 0.001) were significantly lower in ActiveCS compared to the CON group. Six months after treatment grip strength further decreased in CS (P = 0.002) and CRT performance remained impaired. The RemissionCS group (mean follow-up 13 years) had reduced hand grip strength (92% compared to normal reference values for dominant hand, P < 0.001). The chair rising test performance was at 9.0 s and not significantly different from the ActiveCS group (P = 0.45). CONCLUSION CS affects muscle strength in the acute phase, but functional impairment remains detectable also during long-term follow-up despite biochemical remission.
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Affiliation(s)
- Christina M Berr
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Mareike R Stieg
- RG NeuroendocrinologyMax Planck Institute of Psychiatry, Munich, Germany
| | - Timo Deutschbein
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | | | - Ralf Schmidmaier
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Andrea Osswald
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Nicole Reisch
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | | | - Julia Fazel
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Stefanie Hahner
- Department of Internal Medicine IDivision of Endocrinology and Diabetes, University Hospital, University of Wuerzburg, Wuerzburg, Germany
| | - Günter K Stalla
- RG NeuroendocrinologyMax Planck Institute of Psychiatry, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IVKlinikum der Ludwig-Maximilians-Universität München, Munich, Germany
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Pivonello R, De Martino MC, De Leo M, Simeoli C, Colao A. Cushing's disease: the burden of illness. Endocrine 2017; 56:10-18. [PMID: 27189147 DOI: 10.1007/s12020-016-0984-8] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 05/06/2016] [Indexed: 12/20/2022]
Abstract
Cushing's syndrome is caused by prolonged exposure to elevated cortisol levels. The most common form of endogenous Cushing's syndrome is Cushing's disease, which results from an adrenocorticotropic hormone-secreting pituitary tumour. Cushing's disease is associated with increased mortality, mostly attributable to cardiovascular complications, and a host of comorbidities such as metabolic and skeletal disorders, infections and neuropsychiatric disturbances. As a consequence, Cushing's disease substantially impairs health-related quality of life. It is crucial that the condition is diagnosed as early as possible, and that rapid and effective treatment is initiated in order to limit long-term morbidity and mortality. The initial treatment of choice for Cushing's disease is selective transsphenoidal pituitary surgery; however, the risk of recurrence after initial surgery is high and remains so for many decades after surgery. A particular concern is the growing body of evidence indicating that the negative physical and psychosocial sequelae of chronic hypercortisolism may persist in patients with Cushing's disease even after long-term surgical 'cure'. Current treatment options for post-surgical patients with persistent or recurrent Cushing's disease include second surgery, radiotherapy, bilateral adrenalectomy and medical therapy; however, each approach has its limitations and there is an unmet need for more efficacious treatments. The current review provides an overview of the burden of illness of Cushing's disease, underscoring the need for prompt diagnosis and effective treatment, as well as highlighting the need for better therapies.
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Affiliation(s)
- Rosario Pivonello
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via S. Pansini, 5, 80131, Naples, Italy.
| | - Maria Cristina De Martino
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via S. Pansini, 5, 80131, Naples, Italy
| | - Monica De Leo
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via S. Pansini, 5, 80131, Naples, Italy
| | - Chiara Simeoli
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via S. Pansini, 5, 80131, Naples, Italy
| | - Annamaria Colao
- Dipartimento di Medicina Clinica e Chirurgia, Sezione di Endocrinologia, Università Federico II di Napoli, Via S. Pansini, 5, 80131, Naples, Italy
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45
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Glad CAM, Andersson-Assarsson JC, Berglund P, Bergthorsdottir R, Ragnarsson O, Johannsson G. Reduced DNA methylation and psychopathology following endogenous hypercortisolism - a genome-wide study. Sci Rep 2017; 7:44445. [PMID: 28300138 PMCID: PMC5353706 DOI: 10.1038/srep44445] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 02/08/2017] [Indexed: 01/21/2023] Open
Abstract
Patients with Cushing’s Syndrome (CS) in remission were used as a model to test the hypothesis that long-standing excessive cortisol exposure induces changes in DNA methylation that are associated with persisting neuropsychological consequences. Genome-wide DNA methylation was assessed in 48 women with CS in long-term remission (cases) and 16 controls matched for age, gender and education. The Fatigue impact scale and the comprehensive psychopathological rating scale were used to evaluate fatigue, depression and anxiety. Cases had lower average global DNA methylation than controls (81.2% vs 82.7%; p = 0.002). Four hundred and sixty-one differentially methylated regions, containing 3,246 probes mapping to 337 genes were identified. After adjustment for age and smoking, 731 probes in 236 genes were associated with psychopathology (fatigue, depression and/or anxiety). Twenty-four gene ontology terms were associated with psychopathology; terms related to retinoic acid receptor signalling were the most common (adjusted p = 0.0007). One gene in particular, COL11A2, was associated with fatigue following a false discovery rate correction. Our findings indicate that hypomethylation of FKBP5 and retinoic acid receptor related genes serve a potential mechanistic explanation for long-lasting GC-induced psychopathology.
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Affiliation(s)
- Camilla A M Glad
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Johanna C Andersson-Assarsson
- Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Peter Berglund
- Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ragnhildur Bergthorsdottir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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The Roles of Exercise and Yoga in Ameliorating Depression as a Risk Factor for Cognitive Decline. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 2016:4612953. [PMID: 28044084 PMCID: PMC5156813 DOI: 10.1155/2016/4612953] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/25/2016] [Indexed: 11/17/2022]
Abstract
Currently, there are no effective pharmaceutical treatments to reduce cognitive decline or prevent dementia. At the same time, the global population is aging, and rates of dementia and mild cognitive impairment (MCI) are on the rise. As such, there is an increasing interest in complementary and alternative interventions to treat or reduce the risk of cognitive decline. Depression is one potentially modifiable risk factor for cognitive decline and dementia. Notably, exercise and yoga are two interventions known to both reduce symptoms of depression and improve cognitive function. The current review discusses the efficacy of exercise and yoga to ameliorate depression and thereby reduce the risk of cognitive decline and potentially prevent dementia. Potential mechanisms of change, treatment implications, and future directions are discussed.
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47
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Stomby A, Boraxbekk CJ, Lundquist A, Nordin A, Nilsson LG, Adolfsson R, Nyberg L, Olsson T. Higher diurnal salivary cortisol levels are related to smaller prefrontal cortex surface area in elderly men and women. Eur J Endocrinol 2016; 175:117-26. [PMID: 27190207 DOI: 10.1530/eje-16-0352] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 05/17/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Elevated cortisol levels with aging have been associated with atrophy of the hippocampus and prefrontal cortex (PFC), as well as with impaired cognitive functions in men. However, coexisting diseases have confounded many studies examining these relationships. Studies in women are lacking. Our objective was to test whether salivary cortisol levels were related to morphology of the hippocampus and the PFC, and to cognitive performance. DESIGN A cross-sectional study including 200 elderly (55-80 years old) men and women. METHOD We used magnetic resonance imaging, tests of episodic-, semantic-, and working memory, visuospatial ability, and cortisol levels in four saliva samples collected during 1 day. RESULTS Area under the curve (AUC) for cortisol levels was negatively related to cortical surface area of the left anterior cingulate gyrus (caudal P<0.001; rostral P=0.006), right lateral orbitofrontal cortex (P=0.004), and right rostral middle frontal gyrus (P=0.003). In women, there was also a negative relationship with cortical surface area in the left rostral middle frontal gyrus (P=0.006). No relationship was found between cortisol levels and hippocampal volume. CONCLUSION This study suggests that the structure of the medial PFC is related to cortisol levels in both elderly women and men.
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Affiliation(s)
- Andreas Stomby
- Department of Public Health and Clinical MedicineMedicine, Umeå University, Umeå, Sweden Region Jönköping CountyJönköping, Sweden
| | - Carl-Johan Boraxbekk
- CEDAR, Center for Demographic and Aging ResearchUmeå University, Umeå, Sweden Umeå Center for Functional Brain Imaging (UFBI)Umeå University, Umeå, Sweden
| | - Anders Lundquist
- Umeå Center for Functional Brain Imaging (UFBI)Umeå University, Umeå, Sweden
| | - Annelie Nordin
- Department of Clinical Sciences, PsychiatryUmeå University, Umeå, Sweden
| | - Lars-Göran Nilsson
- Umeå Center for Functional Brain Imaging (UFBI)Umeå University, Umeå, Sweden Department of PsychologyStockholm University, Stockholm, Sweden
| | - Rolf Adolfsson
- Department of Clinical Sciences, PsychiatryUmeå University, Umeå, Sweden
| | - Lars Nyberg
- Umeå Center for Functional Brain Imaging (UFBI)Umeå University, Umeå, Sweden Integrative Medical Biology, PhysiologyUmeå University, Umeå, Sweden Radiation Sciences, Diagnostic RadiologyUmeå University, Umeå, Sweden
| | - Tommy Olsson
- Department of Public Health and Clinical MedicineMedicine, Umeå University, Umeå, Sweden
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Abstract
Cushing's disease (CD) is the result of excess secretion of adrenocorticotropic hormone (ACTH) by a benign monoclonal pituitary adenoma. The excessive secretion of ACTH stimulates secretion of cortisol by the adrenal glands, resulting in supraphysiological levels of circulating cortisol. The pathophysiological levels of cortisol are associated with hypertension, diabetes, obesity, and early death. Successful resection of the CD-associated ACTH-secreting pituitary adenoma is the treatment of choice and results in immediate biochemical remission with preservation of pituitary function. Accurate and early identification of CD is critical for effective surgical management and optimal prognosis. The authors review the current pathophysiological principles, diagnostic methods, and management of CD.
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Affiliation(s)
- Russell R Lonser
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Lynnette Nieman
- Program in Reproductive and Adult Endocrinology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland; and
| | - Edward H Oldfield
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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49
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Keil MF, Zametkin A, Ryder C, Lodish M, Stratakis CA. Cases of Psychiatric Morbidity in Pediatric Patients After Remission of Cushing Syndrome. Pediatrics 2016; 137:peds.2015-2234. [PMID: 27025959 PMCID: PMC4811308 DOI: 10.1542/peds.2015-2234] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2015] [Indexed: 11/24/2022] Open
Abstract
Endogenous Cushing syndrome (CS) may have different effects in children than what has been described in adults. Previous studies of children and adolescents with CS have identified cognitive decline despite reversal of brain atrophy after remission of CS. Although the observations of parents of children and adolescents with CS support personality changes, significant psychopathology has not been described in the literature. We report 9 children who underwent successful surgery (transsphenoidal surgery [TSS] or resection of bronchial carcinoid) for treatment of CS and subsequently developed significant affective pathology. Affective symptoms included anger-rage outbursts, suicidal ideation, irritability, anxiety, and depression. One child, who committed suicide 60 months after TSS, had recently discontinued antidepressant medication. She had a history of anxiety during active CS and was treated with an anxiolytic. The 7 patients with onset of symptoms within 7 months of TSS were on glucocorticoid replacement, and 1-year follow-up evaluation showed recovery of hypothalamic-pituitary-adrenal axis and biochemical evidence of remission. The 2 patients who presented with onset of symptoms at 48 months or later underwent endocrine evaluation that showed biochemical evidence of remission and normal anterior pituitary hormone levels. This is the first report of affective symptoms and behavioral dysregulation, including suicidal ideation, in a subgroup of children and adolescents after remission of CS. Health care providers caring for children with CS who have been cured should continue to screen for mental illness, monitor for changes in behavior, and refer as appropriate to mental health professionals.
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Affiliation(s)
- Margaret F. Keil
- Program on Developmental Endocrinology & Genetics and Pediatric Endocrinology Inter-institute Training Program, National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland
| | | | - Celia Ryder
- Clinical Center Nursing Department, National Institutes of Health, Bethesda, Maryland
| | - Maya Lodish
- Program on Developmental Endocrinology & Genetics and Pediatric Endocrinology Inter-institute Training Program, National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland
| | - Constantine A. Stratakis
- Program on Developmental Endocrinology & Genetics and Pediatric Endocrinology Inter-institute Training Program, National Institute of Child Health & Human Development, National Institutes of Health, Bethesda, Maryland
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Herbert J, Lucassen PJ. Depression as a risk factor for Alzheimer's disease: Genes, steroids, cytokines and neurogenesis - What do we need to know? Front Neuroendocrinol 2016; 41:153-71. [PMID: 26746105 DOI: 10.1016/j.yfrne.2015.12.001] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/23/2015] [Accepted: 12/27/2015] [Indexed: 01/18/2023]
Abstract
Depression (MDD) is prodromal to, and a component of, Alzheimer's disease (AD): it may also be a trigger for incipient AD. MDD is not a unitary disorder, so there may be particular subtypes of early life MDD that pose independent high risks for later AD, though the identification of these subtypes is problematical. There may either be a common pathological event underlying both MDD and AD, or MDD may sensitize the brain to a second event ('hit') that precipitates AD. MDD may also accelerate brain ageing, including altered DNA methylation, increased cortisol but decreasing DHEA and thus the risk for AD. So far, genes predicting AD (e.g. APOEε4) are not risk factors for MDD, and those implicated in MDD (e.g. SLC6A4) are not risks for AD, so a common genetic predisposition looks unlikely. There is as yet no strong indication that an epigenetic event occurs during some forms of MDD that predisposes to later AD, though the evidence is limited. Glucocorticoids (GCs) are disturbed in some cases of MDD and in AD. GCs have marked degenerative actions on the hippocampus, a site of early β-amyloid deposition, and rare genetic variants of GC-regulating enzymes (e.g. 11β-HSD) predispose to AD. GCs also inhibit hippocampal neurogenesis and plasticity, and thus episodic memory, a core symptom of AD. Disordered GCs in MDD may inhibit neurogenesis, but the contribution of diminished neurogenesis to the onset or progression of AD is still debated. GCs and cytokines also reduce BDNF, implicated in both MDD and AD and hippocampal neurogenesis, reinforcing the notion that those cases of MDD with disordered GCs may be a risk for AD. Cytokines, including IL1β, IL6 and TNFα, are increased in the blood in some cases of MDD. They also reduce hippocampal neurogenesis, and increased cytokines are a known risk for later AD. Inflammatory changes occur in both MDD and AD (e.g. raised CRP, TNFα). Both cytokines and GCs can have pro-inflammatory actions in the brain. Inflammation (e.g. microglial activation) may be a common link, but this has not been systematically investigated. We lack substantial, rigorous and comprehensive follow-up studies to better identify possible subtypes of MDD that may represent a major predictor for later AD. This would enable specific interventions during critical episodes of these subtypes of MDD that should reduce this substantial risk.
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Affiliation(s)
- Joe Herbert
- John van Geest Centre for Brain Repair, Department of Clinical Neurosciences, University of Cambridge, UK.
| | - Paul J Lucassen
- Swammerdam Institute for Life Sciences, Center for Neuroscience, University of Amsterdam, The Netherlands
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