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Pupier E, Santos A, Etchamendy N, Lavielle A, Ferriere A, Marighetto A, Resmini E, Cota D, Webb SM, Tabarin A. Impaired quality of life, but not cognition, is linked to a history of chronic hypercortisolism in patients with Cushing's disease in remission. Front Endocrinol (Lausanne) 2022; 13:934347. [PMID: 36004342 PMCID: PMC9393704 DOI: 10.3389/fendo.2022.934347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
CONTEXT Impaired cognition and altered quality of life (QoL) may persist despite long-term remission of Cushing's disease (CD). Persistent comorbidities and treatment modalities may account for cognitive impairments. Therefore, the role of hypercortisolism per se on cognitive sequelae remains debatable. OBJECTIVE To investigate whether memory and QoL are impaired after long-term remission of CD in patients with no confounding comorbidity. DESIGN AND SETTING Cross-sectional case-control study in two tertiary referral centers. PATIENTS 25 patients (44.5 ± 2.4 years) in remission from CD for 102.7 ± 19.3 Mo and 25 well-matched controls, without comorbidity or treatment liable to impair cognition. MAIN OUTCOME MEASURES Hippocampus- and prefrontal cortex-dependent memory, including memory flexibility and working memory, were investigated using multiple tests including sensitive locally-developed computerized tasks. Depression and anxiety were evaluated with the MADRS and HADS questionnaires. QoL was evaluated with the SF-36 and CushingQoL questionnaires. The intensity of CD was assessed using mean urinary free cortisol and a score for clinical symptoms. RESULTS CD patients displayed similar performance to controls in all cognitive tests. In contrast, despite the absence of depression and a minimal residual clinical Cushing score, patients had worse QoL. Most of the SF36 subscales and the CushingQoL score were negatively associated only with the duration of exposure to hypercortisolism (p≤ 0.01 to 0.001). CONCLUSIONS Persistent comorbidities can be a primary cause of long-lasting cognitive impairment and should be actively treated. Persistently altered QoL may reflect irreversible effects of hypercortisolism, highlighting the need to reduce its duration. CLINICAL TRIAL REGISTRATION NUMBER https://clinicaltrials.gov, identifier NCT02603653.
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Affiliation(s)
- Emilie Pupier
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, Pessac, France
| | - Alicia Santos
- Endocrinology Department, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747) Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department Medicine, Research Center for Pituitary Diseases, Hospital Sant Pau, Institut d'Investigació Biomèdica (IIB)-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Nicole Etchamendy
- Neurocentre Magendie, University of Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM), Bordeaux, France
| | - Aurélie Lavielle
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, Pessac, France
| | - Amandine Ferriere
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, Pessac, France
| | - Aline Marighetto
- Neurocentre Magendie, University of Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM), Bordeaux, France
| | - Eugenia Resmini
- Endocrinology Department, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747) Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department Medicine, Research Center for Pituitary Diseases, Hospital Sant Pau, Institut d'Investigació Biomèdica (IIB)-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Daniela Cota
- Neurocentre Magendie, University of Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM), Bordeaux, France
| | - Susan M. Webb
- Endocrinology Department, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER, Unidad 747) Instituto de Salud Carlos III (ISCIII), Barcelona, Spain
- Department Medicine, Research Center for Pituitary Diseases, Hospital Sant Pau, Institut d'Investigació Biomèdica (IIB)-Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Antoine Tabarin
- Department of Endocrinology, Diabetes and Nutrition, CHU of Bordeaux and University of Bordeaux, Pessac, France
- Neurocentre Magendie, University of Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM), Bordeaux, France
- *Correspondence: Antoine Tabarin,
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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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Geraedts VJ, Andela CD, Stalla GK, Pereira AM, van Furth WR, Sievers C, Biermasz NR. Predictors of Quality of Life in Acromegaly: No Consensus on Biochemical Parameters. Front Endocrinol (Lausanne) 2017; 8:40. [PMID: 28316591 PMCID: PMC5334635 DOI: 10.3389/fendo.2017.00040] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/16/2017] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Quality of life (QoL) in patients with acromegaly is reduced irrespective of disease state. The contributions of multifactorial determinants of QoL in several disease stages are presently not well known. OBJECTIVE To systematically review predictors of QoL in acromegalic patients. METHODS Main databases were systematically searched using predefined search terms for potentially relevant articles up to January 2017. Inclusion criteria included separate acromegaly cohort, non-hereditary acromegaly, QoL as study parameter with clearly described method of measurement and quantitative results, N ≥ 10 patients, article in English and adult patients only. Data extraction was performed by two independent reviewers; studies were included using the PRISMA flow diagram. RESULTS We identified 1,162 studies; 51 studies met the inclusion criteria: 31 cross-sectional observational studies [mean AcroQoL score 62.7 (range 46.6-87.0, n = 1,597)], 9 had a longitudinal component [mean baseline AcroQoL score 61.4 (range 54.3-69.0, n = 386)], and 15 were intervention studies [mean baseline AcroQoL score 58.6 (range 52.2-75.3, n = 521)]. Disease-activity reflected by biochemical control measures yielded mixed, and therefore inconclusive results with respect to their effect on QoL. Addition of pegvisomant to somatostatin analogs and start of lanreotide autogel resulted in improvement in QoL. Data from intervention studies on other treatment modalities were too limited to draw conclusions on the effects of these modalities on QoL. Interestingly, higher BMI and greater degree of depression showed consistently negative associations with QoL. Hypopituitarism was not significantly correlated with QoL in acromegaly. CONCLUSION At present, there is insufficient published data to support that biochemical control, or treatment of acromegaly in general, is associated with improved QoL. Studies with somatostatin receptor ligand treatment, i.e., particularly lanreotide autogel and pegvisomant have shown improved QoL, but consensus on the correlation with biochemical control is missing. Longitudinal studies investigating predictors in treatment-naive patients and their follow-up after therapeutic interventions are lacking but are urgently needed. Other factors, i.e., depression and obesity were identified from cross-sectional cohort studies as consistent factors associated with poor QoL. Perhaps treatment strategies of acromegaly patients should not only focus on normalizing biochemical markers but emphasize improvement of QoL by alternative interventions such as psychosocial or weight lowering interventions.
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Affiliation(s)
- Victor J. Geraedts
- Department of Clinical Neuroendocrinology, Max Planck Institut für Psychiatrie, Munich, Germany
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - Cornelie D. Andela
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - Günter K. Stalla
- Department of Clinical Neuroendocrinology, Max Planck Institut für Psychiatrie, Munich, Germany
| | - Alberto M. Pereira
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
| | - Wouter R. van Furth
- Department of Medicine, Division of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Caroline Sievers
- Department of Clinical Neuroendocrinology, Max Planck Institut für Psychiatrie, Munich, Germany
| | - Nienke R. Biermasz
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Nienke R. Biermasz,
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Abstract
Patients with Cushing's syndrome (CS) in remission often suffer from impaired quality of life and cognitive dysfunction. The primary aim was to investigate the occurrence of mental fatigue, characterized by mental exhaustion and long recovery time following mentally strenuous tasks, in patients with CS in remission. The secondary aim was to examine whether the newly developed parts C and D of the trail making test (TMT) are more sensitive, compared to the conventional parts A and B, to evaluate attention and executive function. This was a cross-sectional study including 51 patients with CS in remission and 51 controls. All subjects completed the self-administrated mental fatigue scale (MFS) and performed all four parts of the TMT. The patients had worse outcome on all components of the MFS except for sensitivity to noise. After adjustment for mental fatigue, depression, and anxiety, the patients performed worse only on part D of the TMT (P < 0.05). Mental fatigue is common in patients with CS in remission and can be captured by using the MFS. The most demanding part of the TMT, part D, is more useful to capture cognitive deficits in patients with CS in remission compared to the conventional parts A and B.
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Huguet I, Ntali G, Grossman A, Karavitaki N. Cushing's Disease - Quality of Life, Recurrence and Long-term Morbidity. EUROPEAN ENDOCRINOLOGY 2015; 11:34-38. [PMID: 29632565 PMCID: PMC5819060 DOI: 10.17925/ee.2015.11.01.34] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 03/16/2015] [Indexed: 11/24/2022]
Abstract
Cushing's disease (CD) is a rare disorder caused by an adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma. Chronic exposure to hypercortisolism leads to significant morbidities, which may be only partially reversible after remission of the disease, as well as to impairment of the health-related quality of life (HRQoL) and an increase in mortality. Transsphenoidal surgery (TSS) is the treatment of choice, and recurrence rates vary widely, confirming the need for lifelong follow-up. This review summarises the studies performed on HRQoL, recurrence rates and morbidities in patients who have CD.
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Affiliation(s)
- Isabel Huguet
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Headington, UK
| | - Georgia Ntali
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Headington, UK
| | - Ashley Grossman
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Headington, UK
| | - Niki Karavitaki
- Centre for Endocrinology, Diabetes and Metabolism, School of Clinical and Experimental Medicine, University of Birmingham, UK
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Geraedts VJ, Dimopoulou C, Auer M, Schopohl J, Stalla GK, Sievers C. Health Outcomes in Acromegaly: Depression and Anxiety are Promising Targets for Improving Reduced Quality of Life. Front Endocrinol (Lausanne) 2014; 5:229. [PMID: 25610427 PMCID: PMC4285111 DOI: 10.3389/fendo.2014.00229] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 12/10/2014] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Remission criteria of acromegaly are based on biochemical variables, i.e., normalization of increased hormone levels. However, the established reduction in Quality of Life (QoL) is suggested to be independent of biochemical control. The aim of this study was to test which aspects predict QoL best in acromegaly. METHODS/DESIGN This is a prospective cohort study in 80 acromegalic patients, with a cross-sectional and longitudinal part. The main outcome measure was health-related QoL, measured by a generic and a disease-specific questionnaire (the SF-36 and AcroQoL). Main predictors were age, gender, biochemical control, disease characteristics, treatment modalities, and psychopathology. RESULTS Our cohort of 80 acromegalics had a mean age 54.7 ± 12.3 years with an average disease duration of 10.8 ± 10.0 years. Ratio macro-/microadenoma was 54/26. In adjusted mixed method models, we found that psychopathology significantly predicts QoL in acromegaly (in models including the variables age, gender, disease duration, tumor size, basal hormone levels, relevant treatment modalities, and relevant comorbidities), with a higher degree of psychopathology indicating a lower QoL (depression vs. AcroQoL: B = -1.175, p < 0.001, depression vs. SF-36: B = -1.648, p < 0.001, anxiety vs. AcroQoL: B = -0.399, p < 0.001, anxiety vs. SF-36: B = -0.661, p < 0.001). The explained variances demonstrate superiority of psychopathology over biochemical control and other variables in predicting QoL in our models. DISCUSSION Superiority of psychopathology over biochemical control calls for a more extensive approach regarding diagnosing depression and anxiety in pituitary adenomas to improve QoL. Depressive symptoms and anxiety are modifiable factors that might provide valuable targets for possible future treatment interventions.
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Affiliation(s)
- Victor Jacobus Geraedts
- Max Planck Institute of Psychiatry, Munich, Germany
- Leiden University Medical Center, Leiden, Netherlands
| | | | | | - Jochen Schopohl
- Medizinische Klinik Innenstadt, Ludwig-Maximilians University, Munich, Germany
| | | | - Caroline Sievers
- Max Planck Institute of Psychiatry, Munich, Germany
- *Correspondence: Caroline Sievers, Department of Endocrinology, Max Planck Institute of Psychiatry, Kraepelinstraße 2-10, Munich 80804, Germany e-mail:
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Milian M, Honegger J, Teufel P, Wolf A, Psaras T. Tuebingen CD-25 is a sensitive tool to investigate health-related quality of life in Cushing's disease patients in the course of the disease. Neuroendocrinology 2013; 98:188-99. [PMID: 24080783 DOI: 10.1159/000355622] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 09/10/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND The primary object was to investigate whether the Tuebingen CD-25 captures changes in health-related quality of life (HRQoL) sensitively in Cushing's disease (CD) and to identify factors that favour postoperative HRQoL. METHODS 17 CD patients were scheduled for transsphenoidal tumour removal and filled out the inventory before and after surgery. The mean time elapsed after surgery was 14.4 ± 11.3 months. All patients were in remission at the second timepoint of investigation. RESULTS HRQoL as assessed with the Tuebingen CD-25 improved significantly after successful surgical tumour removal. A large effect size (Cohen's d = 0.84) in the total score indicates good sensitivity to change. 13 patients (76.5%) showed impaired HRQoL preoperatively compared with a general population sample. Postoperatively, 35.3% of the patients still suffered from an impaired HRQoL. Stepwise linear regression analysis revealed that less comorbidities (≤2) and greater morning cortisol decrease were promotive factors for better postoperative HRQoL (p < 0.05). The postoperative improvement in HRQoL could be best predicted by the presence of preoperative HRQoL impairment and age of the patients, i.e. patients who were younger were more likely to improve. Moreover, patients without postoperative pituitary deficiencies improved significantly more in the cognition scale. A tendency towards more improvement in overall HRQoL was observed in non-hypocortisolaemic patients. CONCLUSIONS The Tuebingen CD-25 has proved to be a capable and sensitive instrument to investigate HRQoL in the course of disease. The number of postoperative comorbidities had the greatest impact on postoperative well-being.
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Affiliation(s)
- Monika Milian
- Department of Neurosurgery, University Hospital Tuebingen, Tuebingen, Germany
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