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Harmsen WJ, Ribbers GM, Heijenbrok-Kal MH, Khajeh L, Sneekes EM, van Kooten F, Neggers SJCMM, van den Berg-Emons RJ. Fatigue After Aneurysmal Subarachnoid Hemorrhage Is Highly Prevalent in the First-Year Postonset and Related to Low Physical Fitness: A Longitudinal Study. Am J Phys Med Rehabil 2019; 98:7-13. [PMID: 29863585 DOI: 10.1097/phm.0000000000000976] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of the study was to investigate whether low physical fitness and inactive and sedentary lifestyles play a role in the severity of fatigue in patients with aneurysmal subarachnoid hemorrhage (a-SAH). DESIGN This is a prospective 1-yr follow-up study, including a total of 52 patients with a-SAH. Outcome measures included the Fatigue Severity Scale score, peak oxygen uptake (VO2peak), isokinetic knee muscle strength (peak torque), physical activity (% 24-hr period), and sedentary behavior (% waking hours) and were evaluated at 6 and 12 mos after onset. RESULTS Fatigue was highly prevalent in the first year and reported by 48% of the patients at 6 mos and by 52% at 12 mos after a-SAH. Fatigue was associated with the knee extension (P < 0.001) and flexion strength (P < 0.001). A nonsignificant trend for a relationship was found between fatigue and the aerobic capacity (P = 0.079). No relationships were found between fatigue and physical activity or sedentary behavior. Fatigue could not be predicted by disease-related characteristics. CONCLUSIONS Half of the patients were fatigued in the first year after a-SAH. Interventions are necessary to reduce fatigue and should consider exercise training as a potential contributor to a multimodal treatment, preventing debilitating conditions after a-SAH. TO CLAIM CME CREDITS Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Recognize the association between fatigue and physical fitness in patients after aneurysmal subarachnoid hemorrhage; (2) Determine the severity of fatigue complaints in patient after aneurysmal subarachnoid hemorrhage; and (3) Discuss the role of physical deconditioning in the management of fatigue in patients after aneurysmal subarachnoid hemorrhage. LEVEL Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
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Affiliation(s)
- Wouter J Harmsen
- From the Rijndam Rehabilitation Institute, Rotterdam, the Netherlands (WJH, GMR, MHH-K, EMS, RJvdB-E); and Departments of Rehabilitation Medicine (WJH, GMR, MHH-K, EMS, RJvdB-E), Neurology (LK, FvK), and Endocrinology (SJCMMN), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Fanchamps MHJ, de Kam D, Sneekes EM, Stam HJ, Weerdesteyn V, Bussmann JBJ. Effect of different operationalizations of sedentary behavior in people with chronic stroke. Disabil Rehabil 2018; 42:999-1005. [PMID: 30475079 DOI: 10.1080/09638288.2018.1512164] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Purpose: Sedentary behavior is common in people with stroke and has devastating impact on their health. Quantifying it is important to provide people with stroke with adequate physical behavior recommendations. Sedentary behavior can be quantified in terms of posture (sitting) or intensity (low energy expenditure). We compared the effect of different operationalizations of sedentary behavior on sedentary behavior outcomes (total time; way of accumulation) in people with stroke.Methods: Sedentary behavior was analyzed in 44 people with chronic stroke with an activity monitor that measured both body postures and movement intensity. It was operationalized as: (1) combining postural and intensity data; (2) using only postural data; (3) using only intensity data. For each operationalization, we quantified a set of outcomes. Repeated measures ANOVA and Bland-Altman plots were used to compare the operationalizations.Results: All sedentary behavior outcomes differed significantly between all operationalizations (p < 0.01). Bland-Altman plots showed large limits of agreement for all outcomes, showing large individual differences between operationalizations.Conclusions: Although it was neither possible nor our aim to investigate the validity of the two-component definition of sedentary behavior, our study shows that the type of operationalization of sedentary behavior significantly influences sedentary behavior outcomes in people with stroke.Implications for RehabilitationReliable assessment of sedentary behavior after stroke is important in order to provide adequate physical behavior recommendations for people with stroke.Sedentary behavior can be operationalized in terms of body posture (sitting time) or in terms of movement intensity (time <1.5 MET) or as a combination of both criteria; this study reveals that the type of operationalization affects the different outcome measures used to quantify sedentary behavior.Comparing sedentary behavior outcomes requires caution and should only be done when sedentary behavior is operationalized in the same way.
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Affiliation(s)
- Malou H J Fanchamps
- Department of Rehabilitation Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands.,Rijndam Rehabilitation, Rotterdam, The Netherlands
| | - Digna de Kam
- Department of Rehabilitation, Radboud University Medical Center Donders Center for Neuroscience, Nijmegen, The Netherlands
| | - Emiel M Sneekes
- Department of Rehabilitation Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Henk J Stam
- Department of Rehabilitation Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Vivian Weerdesteyn
- Department of Rehabilitation, Radboud University Medical Center Donders Center for Neuroscience, Nijmegen, The Netherlands.,Sint Maartenskliniek Research, Nijmegen, The Netherlands
| | - Johannes B J Bussmann
- Department of Rehabilitation Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Schasfoort F, Pangalila R, Sneekes EM, Catsman C, Becher J, Horemans H, Stam HJ, Dallmeijer AJ, Bussmann JBJ. Intramuscular botulinum toxin prior to comprehensive rehabilitation has no added value for improving motor impairments, gait kinematics and goal attainment in walking children with spastic cerebral palsy. J Rehabil Med 2018; 50:732-742. [PMID: 30080235 DOI: 10.2340/16501977-2369] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Botulinum toxin (BoNT-A) is widely used in combined treatment for spastic cerebral palsy, but its added value preceding comprehensive rehabilitation for motor impairments, gait, and goal attainment has not been studied. DESIGN A comparative multi-centre trial, in which two groups underwent comprehensive rehabilitation (i.e. high-intensive functional physiotherapy, and indicated casting/orthoses). One group received intramuscular BoNT-A prior to rehabilitation, and the other group did not receive BoNT-A. SUBJECTS/PATIENTS Children with spastic cerebral palsy, Gross Motor Function Classification System (GMFCS) levels I-III, age range 4-12 years, indicated for BoNT-A treatment regarding mobility problems. METHODS Sixty-five children participated (37 boys), mean age 7.3 years (standard deviation (SD) 2.3, range 4-12 years), equally distributed across GMFCS levels. Forty-one children received BoNT-A+ comprehensive rehabilitation and 24 received comprehensive rehabilitation only. Functional leg muscle strength, passive range of motion, angle of catch, cerebral palsy-related pain, walking speed, kinematic gait parameters, goal attainment, and proxy-reported general functioning were assessed at baseline, primary end-point (12 weeks) and 24-week follow-up. Statistical analyses were performed with linear mixed models. RESULTS At the primary end-point there were no statistically significant differences in treatment effects between the groups, except for the angle-of-catch of the rectus femoris, which was in favour of comprehensive rehabilitation without BoNT-A (12° difference, 95% confidence interval (95% CI) 2:23, p = 0.025). Results at follow-up were similar. CONCLUSION At the group level, treating with BoNT-A prior to comprehensive rehabilitation did not add to the clinical effectiveness of rehabilitation. Thus, BoNT-A prescription and use should be critically reconsidered in this cerebral palsy age- and GMFCS-subgroup.
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Harmsen WJ, Ribbers GM, Heijenbrok-Kal MH, Bussmann JBJ, Sneekes EM, Khajeh L, van Kooten F, Neggers SJCMM, van den Berg-Emons RJ. Inactive lifestyles and sedentary behavior in persons with chronic aneurysmal subarachnoid hemorrhage: evidence from accelerometer-based activity monitoring. J Neuroeng Rehabil 2017; 14:120. [PMID: 29169368 PMCID: PMC5701368 DOI: 10.1186/s12984-017-0331-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 10/31/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (a-SAH) is a potential life-threatening stroke. Because survivors may be at increased risk for inactive and sedentary lifestyles, this study evaluates physical activity (PA) and sedentary behavior (SB) in the chronic phase after a-SAH. METHODS PA and SB were objectively measured at six months post a-SAH with an accelerometer-based activity monitor, with the aim to cover three consecutive weekdays. Total time spent in PA (comprising walking, cycling, running and non-cyclic movement) and SB (comprising sitting and lying) was determined. Also, in-depth analyses were performed to determine the accumulation and distribution of PA and SB throughout the day. Binary time series were created to determine the mean bout length and the fragmentation index. Measures of PA and SB in persons with a-SAH were compared to those in sex- and age-matched healthy controls. RESULTS The 51 participants comprised 33 persons with a-SAH and 18 controls. None of the participants had signs of paresis or spasticity. Persons with a-SAH spent 105 min/24 h being physically active, which was 35 min/24 h less than healthy controls (p = 0.005). For PA, compared with healthy controls, the mean bout length was shorter in those with a-SAH (12.0 vs. 13.5 s, p = 0.006) and the fragmentation index was higher (0.053 vs. 0.041, p < 0.001). Total sedentary time during waking hours showed no significant difference between groups (514 min vs. 474 min, p = 0.291). For SB, the mean bout length was longer in persons with a-SAH (122.3 vs. 80.5 s, p = 0.024), whereas there was no difference in fragmentation index between groups (0.0032 vs 0.0036, p = 0.396). CONCLUSIONS Persons with a-SAH are less physically active, they break PA time into shorter periods, and SB periods last longer compared to healthy controls. Since inactive lifestyles and prolonged uninterrupted periods of SB are independent risk factors for poor cardiovascular health, interventions seem necessary and should target both PA and SB. STUDY REGISTRATION Dutch registry number: NTR 2085.
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Affiliation(s)
- Wouter J Harmsen
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands. .,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - Gerard M Ribbers
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Majanka H Heijenbrok-Kal
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Johannes B J Bussmann
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Emiel M Sneekes
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - Ladbon Khajeh
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Fop van Kooten
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sebastian J C M M Neggers
- Department of Endocrinology, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rita J van den Berg-Emons
- Rijndam Rehabilitation Institute, Rotterdam, the Netherlands.,Department of Rehabilitation Medicine, Erasmus MC University Medical Center Rotterdam, P.O. Box 2040, 3000, CA, Rotterdam, The Netherlands
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Khajeh L, Ribbers GM, Heijenbrok-Kal MH, Blijdorp K, Dippel DWJ, Sneekes EM, van den Berg-Emons HJG, van der Lely AJ, Neggers SJCMM, van Kooten F. The effect of hypopituitarism on fatigue after subarachnoid hemorrhage. Eur J Neurol 2016; 23:1269-74. [PMID: 27128968 DOI: 10.1111/ene.13014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 03/02/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Aneurysmal subarachnoid hemorrhage (SAH) survivors often complain of fatigue, which is disabling. Fatigue is also a common symptom of pituitary dysfunction (PD), in particular in patients with growth hormone deficiency (GHD). A possible association between fatigue after SAH and long-term pituitary deficiency in SAH survivors has not yet been established. METHODS A single center observational study was conducted amongst 84 aneurysmal SAH survivors to study the relationship between PD and fatigue over time after SAH, using mixed model analysis. Fatigue was measured with the Fatigue Severity Scale and its relationships with other clinical variables were studied. RESULTS Three-quarters of respondents (76%) have pathological fatigue directly after SAH and almost two-thirds (60%) of patients still have pathological levels of fatigue after 14 months. The severity of SAH measured with a World Federation of Neurosurgical Societies (WFNS) score higher than 1 (P = 0.008) was associated with long-term fatigue. There is no statistically significant effect of PD (P = 0.8) or GHD (P = 0.23) on fatigue in SAH survivors over time. CONCLUSIONS Fatigue is a common symptom amongst SAH survivors. WFNS is a usable clinical determinant of fatigue in SAH survivors. Neither PD nor GHD has a significant effect on long-term fatigue after SAH.
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Affiliation(s)
- L Khajeh
- Department of Neurology, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - G M Ribbers
- Department of Rehabilitation, Erasmus University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - M H Heijenbrok-Kal
- Department of Rehabilitation, Erasmus University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - K Blijdorp
- Department of Medicine, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D W J Dippel
- Department of Neurology, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - E M Sneekes
- Department of Rehabilitation, Erasmus University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - H J G van den Berg-Emons
- Department of Rehabilitation, Erasmus University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - A J van der Lely
- Department of Medicine, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S J C M M Neggers
- Department of Medicine, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - F van Kooten
- Department of Neurology, Section Endocrinology, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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Khajeh L, Blijdorp K, Heijenbrok-Kal MH, Sneekes EM, van den Berg-Emons HJG, van der Lely AJ, Dippel DWJ, Neggers SJCMM, Ribbers GM, van Kooten F. Pituitary dysfunction after aneurysmal subarachnoid haemorrhage: course and clinical predictors—the HIPS study. J Neurol Neurosurg Psychiatry 2015; 86:905-10. [PMID: 25378238 PMCID: PMC4516005 DOI: 10.1136/jnnp-2014-307897] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 08/28/2014] [Indexed: 01/20/2023]
Abstract
OBJECTIVE We describe the occurrence and course of anterior pituitary dysfunction (PD) after aneurysmal subarachnoid haemorrhage (SAH), and identify clinical determinants for PD in patients with recent SAH. METHODS We prospectively collected demographic and clinical parameters of consecutive survivors of SAH and measured fasting state endocrine function at baseline, 6 and 14 months. We included dynamic tests for growth-hormone function. We used logistic regression analysis to compare demographic and clinical characteristics of patients with SAH with and without PD. RESULTS 84 patients with a mean age of 55.8 (±11.9) were included. Thirty-three patients (39%) had PD in one or more axes at baseline, 22 (26%) after 6 months and 6 (7%) after 14 months. Gonadotropin deficiency in 29 (34%) patients and growth hormone deficiency (GHD) in 26 (31%) patients were the most common deficiencies. PD persisted until 14 months in 6 (8%) patients: GHD in 5 (6%) patients and gonadotropin deficiency in 4 (5%). Occurrence of a SAH-related complication was associated with PD at baseline (OR 2.6, CI 2.2 to 3.0). Hydrocephalus was an independent predictor of PD 6 months after SAH (OR 3.3 CI 2.7 to 3.8). PD was associated with a lower score on health-related quality of life at baseline (p=0.06), but not at 6 and 14 months. CONCLUSIONS Almost 40% of SAH survivors have PD. In a small but substantial proportion of patients GHD or gonadotropin deficiency persists over time. Hydrocephalus is independently associated with PD 6 months after SAH. TRIAL REGISTRATION NUMBER NTR 2085.
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Affiliation(s)
- L Khajeh
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - K Blijdorp
- Department of Medicine, Section Endocrinology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - M H Heijenbrok-Kal
- Department of Rehabilitation, Erasmus MC University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - E M Sneekes
- Department of Rehabilitation, Erasmus MC University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - H J G van den Berg-Emons
- Department of Rehabilitation, Erasmus MC University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - A J van der Lely
- Department of Medicine, Section Endocrinology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - D W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - S J C M M Neggers
- Department of Medicine, Section Endocrinology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - G M Ribbers
- Department of Rehabilitation, Erasmus MC University Medical Center and Rijndam Rehabilitation Center Rotterdam, Rotterdam, The Netherlands
| | - F van Kooten
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Blijdorp K, Khajeh L, Ribbers GM, Sneekes EM, Heijenbrok-Kal MH, van den Berg-Emons HJG, van der Lely AJ, van Kooten F, Neggers SJCMM. Diagnostic value of a ghrelin test for the diagnosis of GH deficiency after subarachnoid hemorrhage. Eur J Endocrinol 2013; 169:497-502. [PMID: 24037787 PMCID: PMC3776685 DOI: 10.1530/eje-13-0436] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine the diagnostic value of a ghrelin test in the diagnosis of GH deficiency (GHD) shortly after aneurysmal subarachnoid hemorrhage (SAH). DESIGN Prospective single-center observational cohort study. METHODS A ghrelin test was assessed after the acute phase of SAH and a GH-releasing hormone (GHRH)-arginine test 6 months post SAH. Primary outcome was the diagnostic value of a ghrelin test compared with the GHRH-arginine test in the diagnosis of GHD. The secondary outcome was to assess the safety of the ghrelin test, including patients' comfort, adverse events, and idiosyncratic reactions. RESULTS Forty-three survivors of SAH were included (15 males, 35%, mean age 56. 6 ± 11.7). Six out of 43 (14%) SAH survivors were diagnosed with GHD by GHRH-arginine test. In GHD subjects, median GH peak during ghrelin test was significantly lower than that of non-GHD subjects (5.4 vs 16.6, P=0.002). Receiver operating characteristics analysis showed an area under the curve of 0.869. A cutoff limit of a GH peak of 15 μg/l corresponded with a sensitivity of 100% and a false-positive rate of 40%. No adverse events or idiosyncratic reactions were observed in subjects undergoing a ghrelin test, except for one subject who reported flushing shortly after ghrelin infusion. CONCLUSION Owing to its convenience, validity, and safety, the ghrelin test might be a valuable GH provocative test, especially in the early phase of SAH.
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Affiliation(s)
- K Blijdorp
- Department of Medicine – EndocrinologyErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
| | - L Khajeh
- Department of NeurologyErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
- (Correspondence should be addressed to L Khajeh; )
| | - G M Ribbers
- Department of Rehabilitation MedicineErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
- Rijndam Rehabilitation CenterRotterdamThe Netherlands
| | - E M Sneekes
- Department of Rehabilitation MedicineErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
| | - M H Heijenbrok-Kal
- Department of Rehabilitation MedicineErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
- Rijndam Rehabilitation CenterRotterdamThe Netherlands
| | - H J G van den Berg-Emons
- Department of Rehabilitation MedicineErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
| | - A J van der Lely
- Department of Medicine – EndocrinologyErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
| | - F van Kooten
- Department of NeurologyErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
| | - S J C M M Neggers
- Department of Medicine – EndocrinologyErasmus University Medical Center RotterdamPO Box 20403000 CA, RotterdamThe Netherlands
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