Multifocal, Asymmetric Bilateral Primary Aldosteronism Cannot be Excluded by Strong Adrenal Vein Sampling Lateralization: An International Retrospective Cohort Study

BACKGROUND

Primary aldosteronism (PA) has been broadly dichotomized into unilateral and bilateral forms. Adrenal vein sampling (AVS) lateralization indices (LI) ≥2 to 4 are the standard-of-care to recommend unilateral adrenalectomy for presumed unilateral PA. We aimed to assess the rates and characteristics of residual PA after AVS-guided adrenalectomy.

METHODS

We conducted an international, retrospective, cohort study of patients with PA from 7 referral centers who underwent unilateral adrenalectomy based on LI≥4 on baseline and/or cosyntropin-stimulated AVS. Aldosterone synthase (CYP11B2) immunohistochemistry and next generation sequencing were performed on available formalin-fixed paraffin-embedded adrenal tissue.

RESULTS

The cohort included 283 patients who underwent AVS-guided adrenalectomy, followed for a median of 326 days postoperatively. Lack of PA cure was observed in 16% of consecutive patients, and in 22 patients with lateralized PA on both baseline and cosyntropin-stimulated AVS. Among patients with residual PA postoperatively, 73% had multiple CYP11B2 positive areas within the resected adrenal tissue (versus 23% in those cured), wherein CACNA1D mutations were most prevalent (63% versus 33% in those cured). In adjusted regression models, independent predictors of postoperative residual PA included Black versus White race (odds ratio, 5.10 [95% CI, 1.45-17.86]), AVS lateralization only at baseline (odds ratio, 8.93 [95% CI 3.00-26.32] versus both at baseline and after cosyntropin stimulation), and CT-AVS disagreement (odds ratio, 2.75 [95% CI, 1.20-6.31]).

CONCLUSIONS

Multifocal, asymmetrical bilateral PA is relatively common, and it cannot be excluded by robust AVS lateralization. Long-term postoperative monitoring should be routinely pursued, to identify residual PA and afford timely initiation of targeted medical therapy.

High prevalence of frailty in patients with adrenal adenomas and adrenocortical hormone excess: a cross-sectional multi-centre study with prospective enrolment

OBJECTIVE

Frailty, characterized by multi-system decline, increases vulnerability to adverse health outcomes and can be measured using Frailty Index (FI). We aimed to assess the prevalence of frailty in patients with adrenal disorders (based on hormonal sub-type) and examine association between FI and performance-based measures of physical function.

DESIGN

Multi-centre, cross-sectional study (March 2019-August 2022).

METHODS

Adult patients with adrenal disorders (non-functioning adrenal adenomas [NFA], mild autonomous cortisol secretion [MACS], Cushing syndrome [CS], primary aldosteronism [PA]) and referent subjects without adrenal disorders completed a questionnaire encompassing 47 health variables (comorbidities, symptoms, daily living activities). FI was calculated as the average score of all variables and frailty defined as FI ≥ 0.25. Physical function was assessed with hand grip, timed up-and-go test, chair rising test, 6-minute walk test, and gait speed.

RESULTS

Compared to referent subjects (n = 89), patients with adrenal disorders (n = 520) showed increased age, sex, and body mass index-adjusted prevalence of frailty (CS [odds ratio-OR 19.2, 95% confidence interval-CI 6.7-70], MACS [OR 12.5, 95% CI 4.8-42.9], PA [OR 8.4, 95% CI 2.9-30.4], NFA [OR 4.5, 95% CI 1.7-15.9]). Prevalence of frailty was similar to referent subjects when post-dexamethasone cortisol was <28 nmol/L and was higher when post-dexamethasone cortisol was 28-50 nmol/L (OR 4.6, 95% CI 1.7-16.5). FI correlated with all measures of physical function (P < .001).

CONCLUSIONS

Whilst frailty prevalence was highest in patients with adrenocortical hormone excess, even patients with NFA demonstrated an increased prevalence compared to the referent population. Future longitudinal studies are needed to evaluate the impact of various management strategies on frailty.

OR20-2 Bilateral Primary Aldosteronism Is Not Excluded by High Adrenal Vein Sampling Lateralization Indices

Background

Primary aldosteronism (PA) is broadly divided into unilateral and bilateral forms, and the most reliable subtyping tool available is adrenal vein sampling (AVS). Unilateral PA is generally diagnosed based on AVS lateralization indices (LI=[aldosterone/cortisol] ratio between the dominant and contralateral adrenal vein) ≥4, or even ≥2 when AVS is performed without cosyntopin stimulation. Long-term follow-up data from patients with PA treated with unilateral adrenalectomy have been minimal.

Objective

To assess the rates of residual and recurrent PA after AVS-guided unilateral adrenalectomy.

Methods

We enrolled patients with PA who underwent unilateral adrenalectomy between 09/2017 and 08/2021 in a single tertiary referral center and followed them longitudinally. Demographics, laboratory, imaging, and pathology data were collected. Aldosterone synthase (CYP11B2) immunohistochemistry and next generation sequencing were performed on available formalin-fixed paraffin-embedded adrenal tissue blocks.

Results

During the study period, 80 patients (52 men) with median age 53 (range, 19-76) years underwent unilateral adenectomy, and were followed for a median 80 days (range, 6-653 days). In total 14 (17.5%) patients had evidence of residual PA following surgery, including 3 who had complete biochemical failure, and 1 who had apparent cure of PA immediately post-operatively. All 14 patients had severe PA, with baseline plasma aldosterone concentrations between 23.4 and 496 ng/dL and suppressed renin. Baseline and post-cosyntropin stimulation LIs ranged from 2.7- 187.5 and 1.3-53.7. The LI was >4 only at baseline in 3 cases, and only after cosyntropin stimulation in 2 cases. Histology showed single adenomas, ranging from 0.7-5.3 cm in 7 (50%) patients, and multiple adenomas and/or nodular hyperplasia in 7 (50%) patients. Of the 7 cases analyzed for aldosterone-driver mutations so far, 4 harbored CACNA1D mutations, 2 ATP1A1 mutations, and 1 a KCNJ5 mutation.

Conclusions

Patients with severe PA and frank AVS aldosterone lateralization might have multifocal, bilateral disease. Long-term follow up and targeted medical therapy should be pursued after unilateral adrenalectomy for presumed unilateral PA.

Presentation: Monday, June 13, 2022 11:15 a.m. - 11:30 a.m.

Precision Measurement of the Lamb Shift in Muonium

We report a new measurement of the n=2 Lamb shift in Muonium. Our result of 1047.2(2.3)_{stat}(1.1)_{syst}  MHz comprises an order of magnitude improvement upon the previous best measurement. This value matches the theoretical calculation within 1 standard deviation allowing us to set limits on Lorentz and CPT violation in the muonic sector, as well as on new physics coupled to muons and electrons which could provide an explanation of the muon g-2 anomaly.

Unveiling unconventional magnetism at the surface of Sr2RuO4

Materials with strongly correlated electrons often exhibit interesting physical properties. An example of these materials is the layered oxide perovskite Sr₂RuO₄, which has been intensively investigated due to its unusual properties. Whilst the debate on the symmetry of the superconducting state in Sr₂RuO₄ is still ongoing, a deeper understanding of the Sr₂RuO₄ normal state appears crucial as this is the background in which electron pairing occurs. Here, by using low-energy muon spin spectroscopy we discover the existence of surface magnetism in Sr₂RuO₄ in its normal state. We detect static weak dipolar fields yet manifesting at an onset temperature higher than 50 K. We ascribe this unconventional magnetism to orbital loop currents forming at the reconstructed Sr₂RuO₄ surface. Our observations set a reference for the discovery of the same magnetic phase in other materials and unveil an electronic ordering mechanism that can influence electron pairing with broken time reversal symmetry.

Intense beam of metastable Muonium

Precision spectroscopy of the Muonium Lamb shift and fine structure requires a robust source of 2S Muonium. To date, the beam-foil technique is the only demonstrated method for creating such a beam in vacuum. Previous experiments using this technique were statistics limited, and new measurements would benefit tremendously from the efficient 2S production at a low energy muon ( < 20  keV) facility. Such a source of abundant low energyμ + has only become available in recent years, e.g. at the Low-Energy Muon beamline at the Paul Scherrer Institute. Using this source, we report on the successful creation of an intense, directed beam of metastable Muonium. We find that even though the theoretical Muonium fraction is maximal in the low energy range of 2-5 keV, scattering by the foil and transport characteristics of the beamline favor slightly higherμ + energies of 7-10 keV. We estimate that an event detection rate of a few events per second for a future Lamb shift measurement is feasible, enabling an increase in precision by two orders of magnitude over previous determinations.

Muon implantation experiments in films: Obtaining depth-resolved information

Implanted positive muons with low energies (in the range 1-30 keV) are extremely useful local probes in the study of thin films and multi-layer structures. The average muon stopping depth, typically in the order of tens of nanometers, is a function of the muon implantation energy and of the density of the material, but the stopping range extends over a broad region, which is also in the order of tens of nanometers. Therefore, an adequate simulation procedure is required in order to extract the depth dependence of the experimental parameters. Here, we present a method to extract depth-resolved information from the implantation energy dependence of the experimental parameters in a low-energy muon spin spectroscopy experiment. The method and corresponding results are exemplified for a semiconductor film, Cu(In,Ga)Se₂, covered with a thin layer of Al₂O₃, but can be applied to any heterostructure studied with low-energy muons. It is shown that if an effect is present in the experimental data, this method is an important tool to identify its location and depth extent.

Intrinsic Ferromagnetism in the Diluted Magnetic Semiconductor Co:TiO_{2}

Here we present a study of magnetism in Co_{0.05}Ti_{0.95}O_{2-δ} anatase films grown by pulsed laser deposition under a variety of oxygen partial pressures and deposition rates. Energy-dispersive spectrometry and transmission electron microscopy analyses indicate that a high deposition rate leads to a homogeneous microstructure, while a very low rate or postannealing results in cobalt clustering. Depth resolved low-energy muon spin rotation experiments show that films grown at a low oxygen partial pressure (≈10^{-6}  torr) with a uniform structure are fully magnetic, indicating intrinsic ferromagnetism. First principles calculations identify the beneficial role of low oxygen partial pressure in the realization of uniform carrier-mediated ferromagnetism. This work demonstrates that Co:TiO_{2} is an intrinsic diluted magnetic semiconductor.

The phase diagram of electron-doped La(2-x)Ce(x)CuO(4-δ)

Superconductivity is a striking example of a quantum phenomenon in which electrons move coherently over macroscopic distances without scattering. The high-temperature superconducting oxides (cuprates) are the most studied class of superconductors, composed of two-dimensional CuO2 planes separated by other layers that control the electron concentration in the planes. A key unresolved issue in cuprates is the relationship between superconductivity and magnetism. Here we report a sharp phase boundary of static three-dimensional magnetic order in the electron-doped superconductor La(2-x)Ce(x)CuO(4-δ), where small changes in doping or depth from the surface switch the material from superconducting to magnetic. Using low-energy spin-polarized muons, we find that static magnetism disappears close to where superconductivity begins and well below the doping level at which dramatic changes in the transport properties are reported. These results indicate a higher degree of symmetry between the electron and hole-doped cuprates than previously thought.

Direct spectroscopic observation of a shallow hydrogenlike donor state in insulating SrTiO3

We present a direct spectroscopic observation of a shallow hydrogenlike muonium state in SrTiO(3) which confirms the theoretical prediction that interstitial hydrogen may act as a shallow donor in this material. The formation of this muonium state is temperature dependent and appears below ∼ 70K. From the temperature dependence we estimate an activation energy of ∼ 50 meV in the bulk and ∼ 23 meV near the free surface. The field and directional dependence of the muonium precession frequencies further supports the shallow impurity state with a rare example of a fully anisotropic hyperfine tensor. From these measurements we determine the strength of the hyperfine interaction and propose that the muon occupies an interstitial site near the face of the oxygen octahedron in SrTiO(3). The observed shallow donor state provides new insight for tailoring the electronic and optical properties of SrTiO(3)-based oxide interface systems.

Photo-induced persistent inversion of germanium in a 200-nm-deep surface region

The controlled manipulation of the charge carrier concentration in nanometer thin layers is the basis of current semiconductor technology and of fundamental importance for device applications. Here we show that it is possible to induce a persistent inversion from n- to p-type in a 200-nm-thick surface layer of a germanium wafer by illumination with white and blue light. We induce the inversion with a half-life of ~12 hours at a temperature of 220 K which disappears above 280 K. The photo-induced inversion is absent for a sample with a 20-nm-thick gold capping layer providing a Schottky barrier at the interface. This indicates that charge accumulation at the surface is essential to explain the observed inversion. The contactless change of carrier concentration is potentially interesting for device applications in opto-electronics where the gate electrode and gate oxide could be replaced by the semiconductor surface.

Nature of weak magnetism in SrTiO3/LaAlO3 multilayers

We report the observation of weak magnetism in superlattices of LaAlO(3)/SrTiO(3) using β-detected nuclear magnetic resonance. The spin lattice relaxation rate of ^{8}Li in superlattices with a spacer layers of 8 and 6 unit cells of LaAlO(3) exhibits a strong peak near ~35 K, whereas no such peak is observed in a superlattice with spacer layer thickness of 3 unit cells. We attribute the observed temperature dependence to slowing down of weakly coupled electronic moments at the LaAlO(3)/SrTiO(3) interface. These results show that the magnetism at the interface depends strongly on the thickness of the spacer layer, and that a minimal thickness of ~4-6 unit cells is required for the appearance of magnetism. A simple model is used to determine that the observed relaxation is due to small fluctuating moments (~0.002μ(B)) in the two samples with a larger LaAlO(3) spacer thickness.

Nanoscale layering of antiferromagnetic and superconducting phases in Rb(2)Fe(4)Se(5) single crystals

We studied phase separation in the single-crystalline antiferromagnetic superconductor Rb(2)Fe(4)Se(5) (RFS) using a combination of scattering-type scanning near-field optical microscopy and low-energy muon spin rotation (LE-μSR). We demonstrate that the antiferromagnetic and superconducting phases segregate into nanometer-thick layers perpendicular to the iron-selenide planes, while the characteristic in-plane size of the metallic domains reaches 10  μm. By means of LE-μSR we further show that in a 40-nm thick surface layer the ordered antiferromagnetic moment is drastically reduced, while the volume fraction of the paramagnetic phase is significantly enhanced over its bulk value. Self-organization into a quasiregular heterostructure indicates an intimate connection between the modulated superconducting and antiferromagnetic phases.

Muonium emission into vacuum from mesoporous thin films at cryogenic temperatures

We report on muonium (Mu) emission into vacuum following μ(+) implantation in mesoporous thin SiO(2) films. We obtain a yield of Mu into vacuum of (38±4)% at 250 K and (20±4)% at 100 K for 5 keV μ(+) implantation energy. From the implantation energy dependence of the Mu vacuum yield we determine the Mu diffusion constants in these films: D(Mu)(250 K)=(1.6±0.1)×10(-4)  cm(2)/s and D(Mu)(100 K)=(4.2±0.5)×10(-5) cm(2)/s. Describing the diffusion process as quantum mechanical tunneling from pore to pore, we reproduce the measured temperature dependence ∼T(3/2) of the diffusion constant. We extract a potential barrier of (-0.3±0.1) eV which is consistent with our computed Mu work function in SiO(2) of [-0.3,-0.9] eV. The high Mu vacuum yield, even at low temperatures, represents an important step toward next generation Mu spectroscopy experiments.

Design and commissioning of a high magnetic field muon spin relaxation spectrometer at the ISIS pulsed neutron and muon source

The high magnetic field (HiFi) muon instrument at the ISIS pulsed neutron and muon source is a state-of-the-art spectrometer designed to provide applied magnetic fields up to 5 T for muon studies of condensed matter and molecular systems. The spectrometer is optimised for time-differential muon spin relaxation studies at a pulsed muon source. We describe the challenges involved in its design and construction, detailing, in particular, the magnet and detector performance. Commissioning experiments have been conducted and the results are presented to demonstrate the scientific capabilities of the new instrument.

Dynamics and reactivity of positively charged muonium in heavily doped Si:B and comparisons with hydrogen

The detailed dynamics of the positively charged muonium (Mu+) in heavily doped p-type Si:B is reported. Below 200 K, Mu+ is static and isolated, and is located in a stretched Si-Si bond. Above approximately 200 K, Mu+ diffuses incoherently. At temperatures higher than 300 K, the Mu+-B- complex is formed while above 520 K, it starts to dissociate. There is significant enhancement of the diffusion of Mu+ in Si compared to H+ and D+-this is attributed to its smaller mass.

Proximal magnetometry in thin films using betaNMR

Low energy ion implantation of hyperpolarized radioactive magnetic resonance probes allows the NMR study of thin film heterostructures by enabling depth-resolved measurements on a nanometer lengthscale. By stopping the probe ions in a layer adjacent to a layer of interest, it is possible to study magnetic fields proximally. Here we show that, in the simplest case of a uniformly magnetized layer, this yields an unperturbed in situ frequency reference. We also discuss demagnetization contributions to measured shifts for this case. With a simple illustrative calculation, we show how a nonuniformly magnetized layer causes a strongly depth-dependent line broadening in an adjacent layer. We then give some experimental examples of resonance line broadening in heterostructures.

Local magnetic properties of a monolayer of Mn12 single molecule magnets

The magnetic properties of a monolayer of Mn12 single molecule magnets grafted onto a silicon (Si) substrate have been investigated using depth-controlled beta-detected nuclear magnetic resonance. A low-energy beam of spin-polarized radioactive 8Li was used to probe the local static magnetic field distribution near the Mn12 monolayer in the Si substrate. The resonance line width varies strongly as a function of implantation depth as a result of the magnetic dipolar fields generated by the Mn12 electronic magnetic moments. The temperature dependence of the line width indicates that the magnetic properties of the Mn12 moments in this low-dimensional configuration differ from bulk Mn12.

Magnetic-field effects on the size of vortices below the surface of NbSe2 detected using low energy beta-NMR

A low energy radioactive beam of polarized 8Li has been used to observe the vortex lattice near the surface of superconducting NbSe2. The inhomogeneous magnetic-field distribution associated with the vortex lattice was measured using depth-resolved beta-detected NMR. Below Tc, one observes the characteristic line shape for a triangular vortex lattice which depends on the magnetic penetration depth and vortex core radius. The size of the vortex core varies strongly with the magnetic field. In particular, in a low field of 10.8 mT, the core radius is much larger than the coherence length. The possible origin of these giant vortices is discussed.

beta-NMR of isolated lithium in nearly ferromagnetic palladium

The temperature dependence of the frequency shift and spin-lattice relaxation rate of isolated, nonmagnetic (8)Li impurities implanted in a nearly ferromagnetic host (Pd) are measured by means of beta-detected nuclear magnetic resonance (beta-NMR). The shift is negative, very large, and increases monotonically with decreasing T in proportion to the bulk susceptibility of Pd for T > T* approximately 100 K. Below T*, an additional shift occurs which we attribute to the response of Pd to the defect. The relaxation rate is much slower than expected for the large shift and is linear with T below T*, showing no sign of additional relaxation mechanisms associated with the defect.

Near-surface structural phase transition of SrTiO3 studied with zero-field beta-detected nuclear spin relaxation and resonance

We demonstrate that zero-field beta-detected nuclear quadrupole resonance and spin relaxation of low energy (8)Li can be used as a sensitive local probe of structural phase transitions near a surface. We find that the transition near the surface of a SrTiO(3) single crystal occurs at T(c) approximately 150K, i.e., approximately 45K higher than T(c)bulk, and that the tetragonal domains formed below T(c) are randomly oriented.

Depth-controlled beta-NMR of 8Li in a thin silver film

Depth-controlled beta-NMR can be used to probe the magnetic properties of thin films and interfaces on a nanometer length scale. A 30 keV beam of highly spin-polarized 8Li+ ions was slowed down and implanted into a 50 nm film of Ag deposited on a SrTiO3 substrate. A novel high field beta-NMR spectrometer was used to observe two well resolved resonances which are attributed to Li occupying substitutional and octahedral interstitial sites in the Ag lattice. The temperature dependence of the Knight shifts and spin relaxation rates are consistent with the Korringa law for a simple metal, implying that the NMR of implanted 8Li reflects the spin suspectibility of bulk metallic silver.