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Oi-Yo Y, Yamamoto M, Urai S, Bando H, Ohmachi Y, Motomura Y, Kobatake M, Tsujimoto Y, Sasaki Y, Suzuki M, Yamamoto N, Takahashi M, Iguchi G, Ogawa W, Takahashi Y, Fukuoka H. Long-term metabolic effectiveness and safety of growth hormone replacement therapy in patients with adult growth hormone deficiency: a single-institution study in Japan. Pituitary 2024:10.1007/s11102-024-01459-z. [PMID: 39298061 DOI: 10.1007/s11102-024-01459-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/05/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE To elucidate the long-term efficacy and safety of growth hormone replacement therapy (GHRT) in Japanese patients with adult growth hormone deficiency (AGHD). METHODS We conducted a retrospective study. A total of 110 patients with AGHD receiving GHRT were enrolled. Clinical and laboratory data were collected annually from the beginning of the study. Statistical analysis was performed using a linear mixed-effects model. RESULTS Of all patients, 46.4% were males, 70.9% had adult-onset GHD, and follow-up was up to 196 months, with a median of 68 months. The insulin-like growth factor-1 standard deviation score increased after the start of GHRT and remained constant for more than 11 years. Seventeen patients were followed up for more than 11 years. The body mass index increased. Waist circumference decreased in the short term but increased in the long term. The diastolic blood pressure decreased 1-5 years after the start of GHRT, and the systolic blood pressure increased 11 years after GHRT. Moreover, a long-term decrease in low-density lipoprotein cholesterol, an increase in high-density lipoprotein cholesterol, and a decrease in aspartate aminotransferase and alanine aminotransferase levels were observed. The glycosylated hemoglobin level increased after 3 years. The bone mineral density in the lumbar spine and total hip increased significantly 3 years after the start of GHRT. Finally, the number of adverse events was eight. CONCLUSION We demonstrated the metabolic effectiveness and safety of GHRT in Japanese patients with AGHD over a long follow-up period of 16 years.
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Affiliation(s)
- Yuka Oi-Yo
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaaki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan.
| | - Shin Urai
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Hironori Bando
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Yuka Ohmachi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yuma Motomura
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaki Kobatake
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yasutaka Tsujimoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yuriko Sasaki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Masaki Suzuki
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Naoki Yamamoto
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Michiko Takahashi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
- Department of Nutrition, Kobe University Hospital, Kobe, Japan
| | - Genzo Iguchi
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
- Faculty of Clinical Nutrition and Dietetics, Department of Clinical Nutrition and Dietetics, Konan Women's University, Kobe, Japan
| | - Wataru Ogawa
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki, Chuo, Kobe, 650-0017, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Hidenori Fukuoka
- Division of Diabetes and Endocrinology, Department of Internal Medicine, Kobe University Hospital, Kobe, Japan
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Iglesias P. Clinical Management of Postoperative Growth Hormone Deficiency in Hypothalamic-Pituitary Tumors. J Clin Med 2024; 13:4307. [PMID: 39124574 PMCID: PMC11313223 DOI: 10.3390/jcm13154307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Revised: 07/15/2024] [Accepted: 07/20/2024] [Indexed: 08/12/2024] Open
Abstract
The present review focuses on growth hormone (GH) deficiency in pediatric and adult patients following surgery for hypothalamic-pituitary tumors, with a special emphasis on hormone replacement therapy with recombinant human growth hormone (rhGH). The symptoms and metabolic changes associated with GH deficiency are reviewed, and the potential risks and therapeutic outcomes of rhGH treatment in these patients are discussed. This review emphasizes the importance of rhGH in the normalization of growth in children and the improvement of quality of life (QoL) and metabolic health in adults. Aspects related to efficacy, safety, dosage, duration of treatment, and QoL in this population are analyzed. The need for regular follow-up and dose adjustment to maintain the optimal IGF-I levels in these patients is emphasized, as is the importance of individualized assessment and collaboration with a specialized multidisciplinary medical team to make the appropriate therapeutic decisions. Furthermore, continuous follow-up are necessary to optimize the clinical outcomes in this patient population.
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Affiliation(s)
- Pedro Iglesias
- Department of Endocrinology and Nutrition, Hospital Universitario Puerta de Hierro, 28222 Majadahonda, Madrid, Spain;
- Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana, 28222 Majadahonda, Madrid, Spain
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3
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Affiliation(s)
- Shlomo Melmed
- Correspondence: Shlomo Melmed, MB, ChB, Cedars-Sinai Medical Center, 8700 Beverly Blvd, NT 2015, Los Angeles, CA 90048, USA.
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Chen YJ, Hsieh HP, Hung KC, Shih YJ, Lim SW, Kuo YT, Chen JH, Ko CC. Deep Learning for Prediction of Progression and Recurrence in Nonfunctioning Pituitary Macroadenomas: Combination of Clinical and MRI Features. Front Oncol 2022; 12:813806. [PMID: 35515108 PMCID: PMC9065347 DOI: 10.3389/fonc.2022.813806] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives A subset of non-functioning pituitary macroadenomas (NFMAs) may exhibit early progression/recurrence (P/R) after tumor resection. The purpose of this study was to apply deep learning (DL) algorithms for prediction of P/R in NFMAs. Methods From June 2009 to December 2019, 78 patients diagnosed with pathologically confirmed NFMAs, and who had undergone complete preoperative MRI and postoperative MRI follow-up for more than one year, were included. DL classifiers including multi-layer perceptron (MLP) and convolutional neural network (CNN) were used to build predictive models. Categorical and continuous clinical data were fed into the MLP model, and images of preoperative MRI (T2WI and contrast enhanced T1WI) were analyzed by the CNN model. MLP, CNN and multimodal CNN-MLP architectures were performed to predict P/R in NFMAs. Results Forty-two (42/78, 53.8%) patients exhibited P/R after surgery. The median follow-up time was 42 months, and the median time to P/R was 25 months. As compared with CNN using MRI (accuracy 83%, precision 87%, and AUC 0.84) or MLP using clinical data (accuracy 73%, precision 73%, and AUC 0.73) alone, the multimodal CNN-MLP model using both clinical and MRI features showed the best performance for prediction of P/R in NFMAs, with accuracy 83%, precision 90%, and AUC 0.85. Conclusions DL architecture incorporating clinical and MRI features performs well to predict P/R in NFMAs. Pending more studies to support the findings, the results of this study may provide valuable information for NFMAs treatment planning.
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Affiliation(s)
- Yan-Jen Chen
- Department of Electrical Engineering, National Cheng Kung University, Tainan, Taiwan.,Graduate Institute of Electronics Engineering, National Taiwan University, Taipei, Taiwan
| | - Hsun-Ping Hsieh
- Department of Electrical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan.,Department of Hospital and Health Care Administration, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Yun-Ju Shih
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan
| | - Sher-Wei Lim
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan.,Department of Nursing, Min-Hwei College of Health Care Management, Tainan, Taiwan
| | - Yu-Ting Kuo
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Jeon-Hor Chen
- Department of Radiological Sciences, University of California, Irvine, Irvine, CA, United States.,Department of Radiology, E-DA Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Ching-Chung Ko
- Department of Medical Imaging, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-Sen University, Kaohsiung, Taiwan
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5
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Boguszewski MCS, Cardoso-Demartini AA, Boguszewski CL, Chemaitilly W, Higham CE, Johannsson G, Yuen KCJ. Safety of growth hormone (GH) treatment in GH deficient children and adults treated for cancer and non-malignant intracranial tumors-a review of research and clinical practice. Pituitary 2021; 24:810-827. [PMID: 34304361 PMCID: PMC8416866 DOI: 10.1007/s11102-021-01173-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 11/24/2022]
Abstract
Individuals surviving cancer and brain tumors may experience growth hormone (GH) deficiency as a result of tumor growth, surgical resection and/or radiotherapy involving the hypothalamic-pituitary region. Given the pro-mitogenic and anti-apoptotic properties of GH and insulin-like growth factor-I, the safety of GH replacement in this population has raised hypothetical safety concerns that have been debated for decades. Data from multicenter studies with extended follow-up have generally not found significant associations between GH replacement and cancer recurrence or mortality from cancer among childhood cancer survivors. Potential associations with secondary neoplasms, especially solid tumors, have been reported, although this risk appears to decline with longer follow-up. Data from survivors of pediatric or adult cancers who are treated with GH during adulthood are scarce, and the risk versus benefit profile of GH replacement of this population remains unclear. Studies pertaining to the safety of GH replacement in individuals treated for nonmalignant brain tumors, including craniopharyngioma and non-functioning pituitary adenoma, have generally been reassuring with regards to the risk of tumor recurrence. The present review offers a summary of the most current medical literature regarding GH treatment of patients who have survived cancer and brain tumors, with the emphasis on areas where active research is required and where consensus on clinical practice is lacking.
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Affiliation(s)
- Margaret C S Boguszewski
- Departamento de Pediatria, Universidade Federal do Paraná, Avenida Agostinho Leão Junior, 285 - Alto da Glória, Curitiba, PR, 80030-110, Brazil.
| | | | - Cesar Luiz Boguszewski
- SEMPR, Serviço de Endocrinologia e Metabologia, Departamento de Clínica Médica, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Brazil
| | - Wassim Chemaitilly
- Departments of Pediatric Medicine-Endocrinology and Epidemiology-Cancer Control, St. Jude Children's Research Hospital, Memphis, USA
| | - Claire E Higham
- Department of Endocrinology, Christie Hospital NHS Foundation Trust and University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gudmundur Johannsson
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kevin C J Yuen
- Barrow Pituitary Center, Barrow Neurological Institute, Departments of Neuroendocrinology and Neurosurgery, University of Arizona College of Medicine and Creighton School of Medicine, Phoenix, AZ, USA
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MRI radiomics for the prediction of recurrence in patients with clinically non-functioning pituitary macroadenomas. Comput Biol Med 2020; 124:103966. [DOI: 10.1016/j.compbiomed.2020.103966] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 07/31/2020] [Accepted: 08/08/2020] [Indexed: 11/21/2022]
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7
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Losa M, Castellino L, Pagnano A, Rossini A, Mortini P, Lanzi R. Growth Hormone Therapy Does Not Increase the Risk of Craniopharyngioma and Nonfunctioning Pituitary Adenoma Recurrence. J Clin Endocrinol Metab 2020; 105:5766671. [PMID: 32112101 DOI: 10.1210/clinem/dgaa089] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 02/25/2020] [Indexed: 02/07/2023]
Abstract
CONTEXT Recombinant human growth hormone (rhGH) replacement therapy is often prescribed in patients with nonfunctioning pituitary adenoma (NFPA) or craniopharyngioma. OBJECTIVE To study whether rhGH therapy in patients with adult growth hormone deficiency (AGHD) increases the risk of pituitary tumor recurrence. DESIGN Retrospective, observational study. SETTING Tertiary care center. PATIENTS We studied 283 consecutive patients with AGHD due to NFPA or craniopharyngioma between 1995 and 2018. INTERVENTION rhGH treatment at standard doses was initiated in 123 patients (43.5%). The remaining 160 patients served as controls. MAIN OUTCOME MEASURE Risk of tumor recurrence in rhGH-treated and control patients. RESULTS In univariate analysis, recurrence of the pituitary tumor was less frequent in rhGH-treated patients (19.5%) than in controls (29.7%; hazard ratio [HR] 0.53, 95% confidence interval [CI] 0.32-0.86; P = .01). Multivariate Cox analysis demonstrated that the risk of tumor recurrence was associated with detection of residual disease at the baseline magnetic resonance imaging (HR 9.17; 95% CI, 4.88-17.22; P < .001) and not having performed radiotherapy (HR 16.97; 95% CI, 7.55-38.16; P < .001), while rhGH treatment was no longer associated with a lower risk of recurrence (HR 0.82; 95% CI, 0.47-1.44; P = .50). CONCLUSIONS We found no association between rhGH replacement and the risk of tumor recurrence in patients with AGHD caused by NFPA or craniopharyngioma. These data add to the mounting evidence that rhGH therapy has a neutral effect on the recurrence of pituitary tumors. PRÉCIS Replacement therapy with rhGH is prescribed to patients with adult growth hormone deficiency. Our study found no increased risk of pituitary tumor recurrence.
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Affiliation(s)
- Marco Losa
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University Milan, Milan, Italy
| | - Laura Castellino
- Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Pagnano
- Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Rossini
- Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University Milan, Milan, Italy
| | - Roberto Lanzi
- Endocrinology Unit, Department of Internal Medicine, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Irwig MS, Fleseriu M, Jonklaas J, Tritos NA, Yuen KCJ, Correa R, Elhomsy G, Garla V, Jasim S, Soe K, Baldeweg SE, Boguszewski CL, Bancos I. OFF-LABEL USE AND MISUSE OF TESTOSTERONE, GROWTH HORMONE, THYROID HORMONE, AND ADRENAL SUPPLEMENTS: RISKS AND COSTS OF A GROWING PROBLEM. Endocr Pract 2020; 26:340-353. [PMID: 32163313 DOI: 10.4158/ps-2019-0540] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Over the past few decades, there has been an unprecedented rise in off-label use and misuse of testosterone, growth hormone, thyroid hormone, and adrenal supplements. Testosterone therapy is often promoted to men for the treatment of low energy, lower libido, erectile dysfunction, and other symptoms. Growth hormone is used in attempts to improve athletic performance in athletes and to attenuate aging in older adults. Thyroid hormone and/or thyroid supplements or boosters are taken to treat fatigue, obesity, depression, cognitive impairment, impaired physical performance, and infertility. Adrenal supplements are used to treat common nonspecific symptoms due to "adrenal fatigue," an entity that has not been recognized as a legitimate medical diagnosis. Several factors have contributed to the surge in off-label use and misuse of these hormones and supplements: direct-to-consumer advertising, websites claiming to provide legitimate medical information, and for-profit facilities promoting therapies for men's health and anti-aging. The off-label use and misuse of hormones and supplements in individuals without an established endocrine diagnosis carries known and unknown risks. For example, the risks of growth hormone abuse in athletes and older adults are unknown due to a paucity of studies and because those who abuse this hormone often take supraphysiologic doses in sporadic intervals. In addition to the health risks, off-label use of these hormones and supplements generates billions of dollars of unnecessary costs to patients and to the overall health-care system. It is important that patients honestly disclose to their providers off-label hormone use, as it may affect their health and treatment plan. General medical practitioners and adult endocrinologists should be able to begin a discussion with their patients regarding the unfavorable balance between the risks and benefits associated with off-label use of testosterone, growth hormone, thyroid hormone, and adrenal supplements. Abbreviations: DHEA = dehydroepiandrosterone; FDA = U.S. Food and Drug Administration; GH = growth hormone; IGF-1 = insulin-like growth factor 1; LT3 = L-triiodothyronine; LT4 = levothyroxine; T3 = total triiodothyronine; T4 = thyroxine; TSH = thyroid-stimulating hormone.
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Alexandraki KI, Grossman AB. Management of Hypopituitarism. J Clin Med 2019; 8:jcm8122153. [PMID: 31817511 PMCID: PMC6947162 DOI: 10.3390/jcm8122153] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/01/2019] [Accepted: 12/02/2019] [Indexed: 12/14/2022] Open
Abstract
Hypopituitarism includes all clinical conditions that result in partial or complete failure of the anterior and posterior lobe of the pituitary gland’s ability to secrete hormones. The aim of management is usually to replace the target-hormone of hypothalamo-pituitary-endocrine gland axis with the exceptions of secondary hypogonadism when fertility is required, and growth hormone deficiency (GHD), and to safely minimise both symptoms and clinical signs. Adrenocorticotropic hormone deficiency replacement is best performed with the immediate-release oral glucocorticoid hydrocortisone (HC) in 2–3 divided doses. However, novel once-daily modified-release HC targets a more physiological exposure of glucocorticoids. GHD is treated currently with daily subcutaneous GH, but current research is focusing on the development of once-weekly administration of recombinant GH. Hypogonadism is targeted with testosterone replacement in men and on estrogen replacement therapy in women; when fertility is wanted, replacement targets secondary or tertiary levels of hormonal settings. Thyroid-stimulating hormone replacement therapy follows the rules of primary thyroid gland failure with L-thyroxine replacement. Central diabetes insipidus is nowadays replaced by desmopressin. Certain clinical scenarios may have to be promptly managed to avoid short-term or long-term sequelae such as pregnancy in patients with hypopituitarism, pituitary apoplexy, adrenal crisis, and pituitary metastases.
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Affiliation(s)
- Krystallenia I. Alexandraki
- Endocrine Unit, 1st Department of Propaedeutic Medicine, School of Medicine, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Ashley B. Grossman
- Department of Endocrinology, Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Oxford OX3 7LE, UK
- Centre for Endocrinology, Barts and the London School of Medicine, London EC1M 6BQ, UK
- Correspondence:
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10
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Affiliation(s)
- Shlomo Melmed
- From the Pituitary Center, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles
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11
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Derrick KM, Gomes WA, Gensure RC. Incidence and Outcomes of Pituitary Microadenomas in Children with Short Stature/Growth Hormone Deficiency. Horm Res Paediatr 2019; 90:151-160. [PMID: 30261514 DOI: 10.1159/000489456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 04/17/2018] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS Patients with short stature (SS)/growth hormone deficiency (GHD) and precocious puberty (PP) undergo brain MRI to evaluate for structural brain abnormalities or pituitary lesions, and pituitary microadenomas are a common finding. Theoretically, a mass effect from these lesions could cause GHD and growth hormone treatment could cause them to enlarge, but they should not cause PP, at least in females. METHODS We investigated if pituitary microadenomas cause GHD by comparing their incidence in patients with SS/GHD to that in females with PP. We performed a retrospective chart review of patients with these disorders who had a brain MRI between 2000 and 2013. RESULTS The incidence of microadenoma was high in both groups, 18.5% for SS (n = 346) and 21.1% for PP females (n = 194), but did not differ between groups (p = 0.46). In patients with microadenomas, repeat imaging showed resolution in 58% (SS, n = 33) and 67% (PP females, n = 21). Importantly, none of the lesions grew, even in patients treated with growth hormone. CONCLUSIONS Pituitary microadenomas are common in children with GHD/SS and PP, but it does not appear that they are a cause of GHD. They appear to be of limited clinical significance and should not be considered a contraindication to growth hormone therapy.
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Affiliation(s)
- Kristina M Derrick
- Division of Pediatric Endocrinology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York,
| | - William A Gomes
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York, USA
| | - Robert C Gensure
- Division of Pediatric Endocrinology, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, New York, USA
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12
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Gasco V, Caputo M, Cambria V, Beccuti G, Caprino MP, Ghigo E, Maccario M, Grottoli S. Progression of pituitary tumours: impact of GH secretory status and long-term GH replacement therapy. Endocrine 2019; 63:341-347. [PMID: 30341707 DOI: 10.1007/s12020-018-1787-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/08/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Most patients treated for hypothalamic-pituitary tumours develop GH deficiency. Long-term GH replacement treatment in adults with a previous history of hypothalamic-pituitary tumour could represent a concern about increasing the risk of tumour enlargement or recurrence. PURPOSE To assess the progression risk of hypothalamic-pituitary tumours according to the GH secretory status (normal GH secretion, non-treated and treated GH deficiency). and determine the predictors of neoplasm recurrence. METHODS We retrospectively reviewed 309 patients with tumours of the hypothalamic-pituitary region (294 subjects underwent neurosurgery while 81 radiotherapy) who were followed for 9.9 ± 8.3 years. RESULTS Out of 309 patients, 200 were affected by severe GH deficiency; 90 of these underwent GH therapy. The tumour progression rate did not differ among GH-sufficient, not-treated and treated GH-deficient patients (16.5%, 16.4%. and 10.0%, respectively). In a multivariate analysis, previous radiotherapy (HR 0.12, CI 0.03-0.52, p < 0.005) and residual tumour (HR 8.20, CI 2.38-28.29, p < 0.001) were independent predictors of recurrence. After controlling for multiple covariates, the tumour recurrence risk in GH-sufficient and GH-treated patients was similar to that observed in not-treated GH-deficient patients. CONCLUSIONS With limitations of retrospective analysis, GH therapy is not associated with an increased progression rate of tumours of the hypotalamic-pituitary region during long follow-up, thus supporting the long-term safety of GH treatment. The only predictors of tumour recurrence appear to be the presence of residual disease and the lack of radiotherapy.
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Affiliation(s)
- Valentina Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy.
| | - Marina Caputo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Valeria Cambria
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Guglielmo Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Mirko Parasiliti Caprino
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Mauro Maccario
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
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Pallister-Hall syndrome with orofacial narrowing and tethered cord: a case report. J Med Case Rep 2018; 12:354. [PMID: 30486853 PMCID: PMC6262955 DOI: 10.1186/s13256-018-1868-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/03/2018] [Indexed: 11/14/2022] Open
Abstract
Background Pallister–Hall syndrome is a rare, autosomal dominant, genetic disorder characterized by different congenital abnormalities: hypothalamic hamartoblastoma, bifid or shortened epiglottis, polydactyly, renal anomalies, and imperforate anus. Case presentation In this case report, we describe the case of a 13-year-old Lebanese-Armenian boy born with Pallister–Hall syndrome showing newly associated manifestations (orofacial narrowing and tethered cord), and currently showing a spontaneous puberty with normal growth pattern following management with growth hormones. Conclusions This case report shows a practical approach to this very rare syndrome, mainly with testosterone and growth hormones, and its follow-up in the long term. Being familiar with such cases may allow improvement of our knowledge for better management in the future.
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14
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Abstract
PURPOSE Silent corticotroph adenomas (SCAs) present clinically as non-functioning adenomas (NFAs) but are immunopositive for adrenocorticotrophic hormone (ACTH) without biochemical and clinical manifestation of hypercortisolism. Pathologic examination of resected NFAs that demonstrate positive ACTH and/or TPIT expression confirms its corticotroph lineage. SCAs comprise up to 20% of NFAs and exhibit a higher rate of recurrence. Studies of molecular mechanisms have generated multiple hypotheses on SCA tumorigenesis, pathophysiology, and growth that as yet remain to be proven. An improved understanding of their pathologic and clinical characteristics is needed. METHODS A literature review was performed using PubMed to identify research reports and clinical case series on SCAs. RESULTS Up to date findings regarding epidemiology, mechanisms of pathogenesis, differentiation, progression, and growth, as well as clinical presentation, postoperative course, and treatment options for patients with SCAs are presented. Pooled results demonstrate that 25-40% of cases show cavernous sinus invasion, preoperative hypopituitarism, new-onset hypopituitarism, and recurrence. CONCLUSION This article reviews the incidence, molecular pathology, and clinical behavior of these unique non-functioning pituitary corticotroph adenomas, and highlights the need for rigorous monitoring for recurrences and hypopituitarism in patients with SCAs.
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Affiliation(s)
- Anat Ben-Shlomo
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A6600, Los Angeles, CA, 90048, USA
| | - Odelia Cooper
- Pituitary Center, Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, 127 S. San Vicente Blvd, A6600, Los Angeles, CA, 90048, USA.
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15
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Jasim S, Alahdab F, Ahmed AT, Tamhane SU, Sharma A, Donegan D, Nippoldt TB, Murad MH. The effect of growth hormone replacement in patients with hypopituitarism on pituitary tumor recurrence, secondary cancer, and stroke. Endocrine 2017; 56:267-278. [PMID: 27815769 DOI: 10.1007/s12020-016-1156-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/18/2016] [Indexed: 12/29/2022]
Abstract
Growth hormone replacement therapy has benefits for patients with hypopituitarism. The safety profile in regard to tumor recurrence or progression, development of secondary malignancies, or cerebrovascular stroke is still an area of debate. A comprehensive search of multiple databases-MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was conducted through August 2015. Eligible studies that evaluated long-term adverse events in adult patients with hypopituitarism treated with growth hormone replacement therapy and reported development of pituitary tumor recurrence or progression, secondary malignancies, or cerebrovascular stroke were selected following a predefined protocol. Reviewers, independently and in duplicate, extracted data and assessed the risk of bias. Random-effects meta-analysis was used to pool relative risks and 95 % confidence intervals. We included 15 studies (published 1995-2015) that reported on 46,148 patients. Compared to non-replacement, growth hormone replacement therapy in adults with hypopituitarism was not associated with statistically significant change in pituitary tumor progression or recurrence (relative risk, 0.77; 95 % confidence interval, 0.53-1.13) or development of secondary malignancy (relative risk, 0.99; 95 % confidence interval, 0.70-1.39). In two retrospective studies, there was higher risk of stroke in patients who did not receive replacement (relative risk, 2.07; 95 % confidence interval, 1.51-2.83). The quality of evidence is low due to study limitations and imprecision. This systematic review and meta-analysis supports the overall safety of growth hormone therapeutic use in adults with hypopituitarism with no clear evidence of increased risk of pituitary tumor recurrence, malignancy, or stroke.
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Affiliation(s)
- Sina Jasim
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Fares Alahdab
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Ahmed T Ahmed
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Shrikant U Tamhane
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Anu Sharma
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Diane Donegan
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Todd B Nippoldt
- Division of Endocrinology, Diabetes, Metabolism, & Nutrition, Mayo Clinic, Rochester, MN, USA
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA.
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16
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Gasco V, Caputo M, Lanfranco F, Ghigo E, Grottoli S. Management of GH treatment in adult GH deficiency. Best Pract Res Clin Endocrinol Metab 2017; 31:13-24. [PMID: 28477728 DOI: 10.1016/j.beem.2017.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Growth hormone (GH) replacement therapy in adults with GH deficiency is still a challenge for the clinical endocrinologist and its implementation has still numerous difficulties and uncertainties. The decision to treat GH deficient adults requires a thoughtful and individualized evaluation of risks and benefits. Benefits have been found in body composition, bone health, cardiovascular risk factors, and quality of life. However, evidences for a reduction in cardiovascular events and mortality are still lacking, and treatment costs remain high. It is advisable to start treatment with low doses of GH, the goals being an appropriate clinical response, an avoidance of side effects, and IGF-I levels in the age-adjusted reference range. Although treatment appears to be overall safe, certain areas continue to require long-term surveillance, such as risks of glucose intolerance, pituitary/hypothalamic tumor recurrence, and cancer.
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Affiliation(s)
- Valentina Gasco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy.
| | - Marina Caputo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Fabio Lanfranco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Ezio Ghigo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
| | - Silvia Grottoli
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Science, University of Turin, Turin, Italy
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17
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Abstract
Growth hormone (GH) replacement in GH deficient (GHD) children secures normal linear growth, while in GHD adults it improves metabolic status, body composition and quality of life. Safety of GH treatment is an important issue in particular concerning the controversy of potential cancer risk. Unlike in congenital IGF-1 deficiency, there is no complete protection against cancer in GHD patients. Important modifiable risk factors in GHD patients are obesity, insulin resistance, sedentary behavior, circadian rhythm disruption, chronic low grade inflammation and concomitant sex hormone replacement. Age, family history, hereditary cancer predisposition syndromes or cranial irradiation may present non-modifiable risk factors. Quantifying the risk of cancer in relation to GH therapy in adult GHD patients is complex. There is evidence that links GH to cancer occurrence or promotion, but the evidence is progressively weaker when moving from in vitro studies to in vivo animal studies to epidemiological studies and finally to studies on GH treated patients. GH-IGF inhibition in experimental animals leads to decreased cancer incidence and progression. Epidemiological studies suggest an association of high normal circulating IGF-1 or GH to cancer incidence in general population. Data regarding cancer incidence in acromegaly are inconsistent but thyroid and colorectal neoplasias are the main source of concern. Replacement therapy with rhGH for GHD is generally safe. Overall the rate of de novo cancers was not increased in studies of GH-treated GHD patients. Additional caution is mandated in patients with history of cancer, strong family history of cancer and with advancing age. Childhood cancer survivors may be at increased risk for secondary neoplasms compared with general population. In this subgroup GH therapy should be used cautiously and with respect to other risk factors (cranial irradiation etc). We believe that the benefits of GH therapy against the morbidity of untreated GH deficiency outweigh the theoretical cancer risk. Proper monitoring of GH treatment with diligent cancer surveillance remains essential.
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Affiliation(s)
- Sandra Pekic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Marko Stojanovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia; Clinic for Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Serbia, Dr Subotica 13, 11000 Belgrade, Serbia
| | - Vera Popovic
- University of Belgrade, School of Medicine, Dr Subotica 8, 11000 Belgrade, Serbia.
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18
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Felicetti F, Fortunati N, Arvat E, Brignardello E. GH deficiency in adult survivors of childhood cancer. Best Pract Res Clin Endocrinol Metab 2016; 30:795-804. [PMID: 27974192 DOI: 10.1016/j.beem.2016.11.007] [Citation(s) in RCA: 8] [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: 11/28/2022]
Abstract
Childhood cancer survivors (CCS) are a fast growing population, but late adverse effects of cancer therapies are not rare. In CCS treated with cranial radiotherapy, growth hormone deficiency (GHD) is a well-known occurrence and the potential impact of GH replacement therapy on the global outcome of CCS is under continuous evaluation. In the present review, we discuss advantages and disadvantages of GH replacement therapy in survivors of pediatric malignancies, taking into consideration the different reasons for treating GHD during childhood or adult life. It is doubtless that GH treatment is advisable to obtain a normal growth in pediatric patients. As far as the beginning/continuation of the replacement therapy in adult age is concerned, contrasting results have been reported in literature. The suggestion is that the decision to treat adult CCS should be taken after careful evaluation of each patient's clinical history and of the potential side effects, in agreement with the patients.
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Affiliation(s)
- Francesco Felicetti
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
| | - Nicoletta Fortunati
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy; Oncological Endocrinology Unit, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
| | - Emanuela Arvat
- Oncological Endocrinology Unit, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy; Department of Medical Sciences, University of Torino, Via Genova 3, 10126, Turin, Italy.
| | - Enrico Brignardello
- Transition Unit for Childhood Cancer Survivors, Department of Oncology, Città della Salute e della Scienza Hospital, C.so Bramante 88, 10126, Turin, Italy.
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19
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Fleseriu M, Hashim IA, Karavitaki N, Melmed S, Murad MH, Salvatori R, Samuels MH. Hormonal Replacement in Hypopituitarism in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2016; 101:3888-3921. [PMID: 27736313 DOI: 10.1210/jc.2016-2118] [Citation(s) in RCA: 484] [Impact Index Per Article: 60.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To formulate clinical practice guidelines for hormonal replacement in hypopituitarism in adults. PARTICIPANTS The participants include an Endocrine Society-appointed Task Force of six experts, a methodologist, and a medical writer. The American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology co-sponsored this guideline. EVIDENCE The Task Force developed this evidence-based guideline using the Grading of Recommendations, Assessment, Development, and Evaluation system to describe the strength of recommendations and the quality of evidence. The Task Force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies. CONSENSUS PROCESS One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the American Association for Clinical Chemistry, the Pituitary Society, and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. CONCLUSIONS Using an evidence-based approach, this guideline addresses important clinical issues regarding the evaluation and management of hypopituitarism in adults, including appropriate biochemical assessments, specific therapeutic decisions to decrease the risk of co-morbidities due to hormonal over-replacement or under-replacement, and managing hypopituitarism during pregnancy, pituitary surgery, and other types of surgeries.
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Affiliation(s)
- Maria Fleseriu
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Ibrahim A Hashim
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Niki Karavitaki
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Shlomo Melmed
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - M Hassan Murad
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Roberto Salvatori
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
| | - Mary H Samuels
- Oregon Health & Science University, Northwest Pituitary Center (M.F.), and Departments of Neurological Surgery and Medicine (Division of Endocrinology, Diabetes, and Clinical Nutrition), Portland, Oregon 97239; Department of Pathology (I.A.H.), University of Texas Southwestern Medical Center, Dallas, Texas 75390; Institute of Metabolism and Systems Research (N.K.), College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom; Centre for Endocrinology, Diabetes, and Metabolism (N.K.), Birmingham Health Partners, Birmingham B15 2TH, United Kingdom, Pituitary Center (S.M.), Cedars-Sinai Medical Center, Los Angeles, California 90048; Mayo Clinic Evidence-Based Practice Center, (M.H.M), Rochester, Minnesota 55905; Department of Medicine, Division of Endocrinology and Metabolism (R.S.), Pituitary Center, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287; and Division of Endocrinology, Diabetes, and Clinical Nutrition (M.H.S.), Oregon Health & Science University, Portland, Oregon 97239
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