Excess Mortality Among Hospitalized Patients With Hypopituitarism-A Population-Based, Matched-Cohort Study

CONTEXT

Patients with hypopituitarism face excess mortality in the long-term outpatient setting. However, associations of pituitary dysfunction with outcomes in acutely hospitalized patients are lacking.

OBJECTIVE

The objective of this work is to assess clinical outcomes of hospitalized patients with hypopituitarism with or without diabetes insipidus (DI).

DESIGN, SETTING, AND PATIENTS

In this population-based, matched-cohort study from 2012 to 2017, hospitalized adult patients with a history of hypopituitarism were 1:1 propensity score-matched with a general medical inpatient cohort.

MAIN OUTCOME MEASURES

The primary outcome was in-hospital mortality. Secondary outcomes included all-cause readmission rates within 30 days and 1 year, intensive care unit (ICU) admission rates, and length of hospital stay.

RESULTS

After matching, 6764 cases were included in the study. In total, 3382 patients had hypopituitarism and of those 807 (24%) suffered from DI. All-cause in-hospital mortality occurred in 198 (5.9%) of patients with hypopituitarism and in 164 (4.9%) of matched controls (odds ratio [OR] 1.32, [95% CI, 1.06-1.65], P = .013). Increased mortality was primarily observed in patients with DI (OR 3.69 [95% CI, 2.44-5.58], P < .001). Patients with hypopituitarism had higher ICU admissions (OR 1.50 [95% CI, 1.30-1.74], P < .001), and faced a 2.4-day prolonged length of hospitalization (95% CI, 1.94-2.95, P < .001) compared to matched controls. Risk of 30-day (OR 1.31 [95% CI, 1.13-1.51], P < .001) and 1-year readmission (OR 1.29 [95% CI, 1.17-1.42], P < .001) was higher among patients with hypopituitarism as compared with medical controls.

CONCLUSIONS

Patients with hypopituitarism are highly vulnerable once hospitalized for acute medical conditions with increased risk of mortality and adverse clinical outcomes. This was most pronounced among those with DI.

Development of pediatric comorbidity prediction model

OBJECTIVE

To develop a comorbidity model for children that can be used with hospital discharge administrative databases.

DESIGN

Retrospective study using administrative data obtained from the Canadian Institute for Health Information Discharge Abstract Database and the Deaths File to develop a logistic regression model. Hosmer-Lemeshow chi2 test was used to examine model fit. The C statistic was used to assess model discrimination. Bootstrapping was used to determine the stability of regression coefficients.

SETTING

We used linked administrative databases to compile 339,077 hospital discharge abstracts from April 1, 1991, through March 31, 2002.

PARTICIPANTS

Children between ages 1 and 14 years in Ontario, Canada.

MAIN OUTCOME MEASURE

Death within 1 year of hospital discharge.

RESULTS

The 27-variable pediatric comorbidity model predicted 1-year mortality with a C statistic of 0.83 in the Ontario data set from which it was derived. The presence of brain cancer (odds ratio, 76.38 [95% confidence interval, 53.40-109.27]) at hospital admission was the strongest predictor, followed by diabetes insipidus (odds ratio, 39.23 [95% confidence interval, 20.75-74.17]).

CONCLUSION

Using clinical judgment and empirical modeling strategies, we were able to identify 27 diagnoses highly predictive of death for children between 1 and 14 years of age within 1 year of hospital discharge.

Vector analysis correlating bullet trajectory to outcome after civilian through-and-through gunshot wound to the head: using imaging cues to predict fatal outcome

OBJECTIVE

We identify radiographic imaging similarities found on head computed tomographic (CT) scans of patients with through-and-through gunshot wounds to the head with fatal outcomes.

METHODS

A retrospective analysis was conducted over an 18-month period from June 2001 through December 2002. Two hundred seventeen gunshot wound patients were evaluated. Exclusion criteria included any patient with cardiopulmonary injury and instability, airway compromise, or extracranial injuries affecting prognosis. Thirty-seven patients with isolated gunshot wounds to the head were included, 10 of which were fatal. Vital signs, examination results, Glasgow coma scale (GCS) score, intracranial pressure monitoring, surgical data, days in the intensive care unit, and CT scan appearance were collected. A Cartesian xyz coordinate system was created centered on the dorsum sella. Bullet pathways on CT scans were plotted and graphed onto a standardized magnetic resonance imaging scan.

RESULTS

Ten patients progressed to brain death. GCS score and pupil irregularity were associated with fatal outcome (P < 0.0001). CT scans showed that brain shift was more common in survivors. Seventy percent of nonsurvivors had minimal brain shift. A tram-track sign on CT scans correlated with fatal outcome (P = 0.005). Vector analysis of nonsurvivors showed an area of the brain approximately 4 cm above the dorsum sella that, when penetrated through the midline, led to brain death (P = 0.0006). This zone was coined the zona fatalis.

CONCLUSION

We confirm that GCS score and diabetes insipidus correlated with fatal outcome. In the setting of low-velocity gunshot wounds, fatal outcome and low GCS score were associated with a tram-track sign on CT scans. Bullet passage through a particular supra-dorsum sellar transventricular zone was associated with fatal outcome.

Morbidity and mortality associated with vasopressin replacement therapy in children

OBJECTIVE

To assess the incidence and associated risk factors of adverse reactions of DDAVP treatment of children with diabetes insipidus, comparing different routes of administration.

DESIGN

We retrospectively studied 103 children (44 females, 59 males) with cranial diabetes insipidus (mean age 6.9 years at diagnosis) treated with intramuscular (59), intranasal (84) and/or oral (64) DDAVP, over a mean follow-up period of 5.2 years.

RESULTS

Eight patients died. For at least two children death was related to water intoxication. Major complications (symptomatic water overload with or without seizures) or asymptomatic hyponatraemia were observed in 33 patients. The incidence of total complications was significantly higher in cortisol deficient patients than in those with normal cortisol reserve (36% vs 6%). In patients on concomitant carbamazapine treatment major complications were more frequent in comparison to the remaining patients (33% vs 10%). Although not achieving significance, there were fewer complications using the oral route.

CONCLUSIONS

Caution is needed in managing patients with DI, especially if risk factors such as cortisol deficiency or concomitant carbamazepine treatment are present. The oral route of administration seems to be preferred for both convenience and safety. Major changes in dose and formulation should be undertaken in hospital.

Generation and phenotype of mice harboring a nonsense mutation in the V2 vasopressin receptor gene

The V2 vasopressin receptor (V2R) plays a key role in the maintenance of a normal body water balance. To generate an in vivo model that allows the physiological and molecular analysis of the role of V2Rs in kidney function, we have created mouse lines that lack functional V2Rs by using targeted mutagenesis in mouse embryonic stem cells. Specifically, we introduced a nonsense mutation known to cause X-linked nephrogenic diabetes insipidus (XNDI) in humans (Glu242stop) into the mouse genome. V2R-deficient hemizygous male pups showed a decrease in basal urine osmolalities and were unable to concentrate their urine. These pups also exhibited an enlargement of renal pelvic space, failed to thrive, and died within the first week after birth due to hypernatremic dehydration. Interestingly, female mice heterozygous for the V2R mutation showed normal growth but displayed an XNDI-like phenotype, characterized by reduced urine concentrating ability of the kidney, polyuria, and polydipsia. Western blot analysis and immunoelectron microscopic studies showed that the loss of functional V2Rs had no significant effect on the basal expression levels of aquaporin-2 and the bumetanide-sensitive Na-K-2Cl cotransporter (BSC-1). The V2R mutant mice described here should serve as highly useful tools for the development of novel therapeutic strategies for the treatment of XNDI.

Dioxin exposure and non-malignant health effects: a mortality study

OBJECTIVE

To investigate, in a population heavily exposed to 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), the possible unusual occurrence of diseases other than cancer.

METHODS

Five year extension of the follow up of the cohort involved in the Seveso accident. Soil measurements identified three exposure zones: (A) highest contamination, (B) substantial, and (R) low but higher than background contamination. Blood TCDD measurements, although limited in number, confirmed zone exposure ranking. The 15 year mortality in the exposed cohort was compared with that of a large population in the surrounding non-contaminated territory. Relative risks (RRs) and 95% confidence intervals (95% CIs) were estimated with Poisson regression techniques.

RESULTS

The already noted increased occurrence of cardiovascular deaths was confirmed, in particular in zone A, among males for chronic ischaemic heart disease (five deaths, RR 3.0, 95% CI 1.2 to 7.3), and among females for hypertensive disease (three deaths, RR 3.6, 95% CI 1.2 to 11.4) and chronic rheumatic heart disease. Novel findings were the increase of chronic obstructive pulmonary disease, most notably among males in zone A (four deaths, RR 3.7, 95% CI 1.4 to 9.9) and females in zone B (seven deaths, RR 2.4, 95% CI 1.1 to 5.1); and from diabetes, which was significantly increased in females in zone B (13 deaths, RR 1.9, 95% CI 1.1 to 3.2). In zone R, chronic ischaemic heart disease (males and females), hypertension (females), and diabetes (females) showed less pronounced, although significant excesses.

CONCLUSIONS

As well as high TCDD exposure, the accident caused a severe burden of strain in the population. Both these factors might have contributed to the noted increased risks (in particular, circulatory and respiratory). The cardiovascular and immune toxicity of TCDD, as well as its complex interaction with the endocrine system, might be relevant to the explanations of these findings. These results, although not conclusive, concur with previous data in suggesting cardiopulmonary and endocrine effects in humans highly exposed to TCDD.

Central diabetes insipidus in dogs: 20 cases (1986-1995)

OBJECTIVE

To assess clinical signs, biochemical findings, results of modified water deprivation and other diagnostic tests, response to treatment, and survival time in dogs with central diabetes insipidus (CDI).

DESIGN

Retrospective study.

ANIMALS

20 dogs with CDI.

PROCEDURE

Signalment, history, physical examination, results of diagnostic tests, response to treatment, and survival time were extracted from the medical record of each dog and supplemented with information obtained from owners via telephone.

RESULTS

Isosthenuria or hyposthenuria was a consistent finding. Seven dogs with complete CDI and 13 dogs with partial CDI were identified on the basis of results of a modified water deprivation test. Dogs treated with desmopressin acetate responded well to treatment. Seven dogs were alive 18 to 72 months (median, 36 months) after diagnosis, and 10 dogs died or were euthanatized 1 week to 2 years (median, 2 months) after diagnosis. Seven of 10 dogs that died developed neurologic signs after diagnosis of CDI. Computed tomography revealed a mass in the region of the pituitary gland in 5 of 7 dogs. Necropsy of 6 dogs, including 2 dogs on which computed tomography had been performed, revealed neoplasia in the pituitary gland.

CLINICAL IMPLICATIONS

Onset of neurologic signs after diagnosis of CDI in middle- to old-aged dogs indicates that CDI may not be a benign disease that is treated easily. Brain imaging is recommended after diagnosis of CDI in middle- to old-aged dogs. Also, because many dogs are isosthenuric on initial examination, CDI cannot be ruled out as a cause of polyuria and polydipsia on the basis of lack of hyposthenuria.

Neurogenic diabetes insipidus in children with hypoxic encephalopathy: six new cases and a review of the literature

Hypoxic encephalopathy is rarely mentioned as a cause of neurogenic diabetes insipidus (DI) in children. We here report six cases of DI which occurred after severe hypoxic/ischaemic brain damage and include a review of the literature on 28 paediatric cases of neurogenic DI due solely to severe hypoxia/ischaemia. Airway obstruction, haemorrhagic shock and sudden infant death syndrome are the three major causes of hypoxia/ischaemia. The ages (25/28) ranged from 0.03 to 18 years (mean 7.27 years, median 5 years). The intervals between the hypoxic insult and the onset of DI (23/28) ranged from 0.08 days (2 h) to 13 days (mean 4.07 days, median 3.5 days). Linear regression analysis revealed no significant correlation between the age and the interval. Nineteen cases (82.6%) developed DI within 6 days after the hypoxic/ischaemic insult. Only two neonates survived with developmental delay. The remaining 26 cases died.

CONCLUSION

Neurogenic DI can be caused by hypoxia/ischaemia and is an ominous sign of severe brain damage in children with hypoxic encephalopathy. It is important to recognize this potential sequel by regularly monitoring intake and output, plasma sodium level, and urine specific gravity.

Radiation therapy for diabetes insipidus caused by Langerhans cell histiocytosis

Hypothalamic-pituitary radiation therapy has been the standard treatment for the diabetes insipidus of Langerhans cell histiocytosis. The goal of this study was to assess the role of radiation therapy in Langerhans cell histiocytosis-associated diabetes insipidus and to compare the results with nonirradiated controls. Forty-seven patients with pathologically confirmed Langerhans cell histiocytosis were diagnosed with diabetes insipidus between 1950 and 1989 and were treated at the Mayo Clinic. These patients were divided into two groups on the basis of treatment for the diabetes insipidus: The first group (radiation group) included 30 patients (28 of whom were evaluable for response) who received hypothalamic-pituitary radiation therapy, and the second group (control group) included 17 patients who did not. A partial response to treatment was defined as a reduction in vasopressin dosage or improvement in computed tomography (CT) or magnetic resonance imaging (MRI). A complete response was defined as no further need for vasopressin therapy or normalization of CT or MRI. End points analyzed included treatment response, patient characteristics, morbidity, dose-response relationship, and survival. Patient characteristics of the two groups were similar except for age and lung involvement, both of which were significantly less in the radiation group. Thirty-six percent of patients (10 of 28) in the radiation group responded to hypothalamic-pituitary radiation therapy (22% complete response and 14% partial response), whereas none in the control group responded. Five of the six complete responders were irradiated within 14 days of the diagnosis of diabetes insipidus. The mean dose used in the responding and nonresponding patients was 11.2 and 10 Gy, respectively. Three of five patients (60%) treated with more than 15 Gy responded compared to seven of 23 (30%) treated with less than 15 Gy. Eight of the 10 responders (80%), compared to 16 of 35 nonresponders (46%), were female. Only one in 20 patients with concomitant lung histiocytosis responded. Complications of therapy may include insufficiency in other hypothalamic-pituitary axes in the treated patients. Actuarial survivals at 5, 10, 20, and 40 years for the entire group were 80%, 78%, 75%, and 65%, respectively, with a median follow-up in living patients of 14.7 years.

Radiation therapy in soft-tissue lesions in histiocytosis X (Langerhans' cell histiocytosis)

Langerhans' cell histiocytosis (LCH) (previously histiocytosis X) is an infrequent disease with protean clinical manifestations and an unpredictable course. The role of radiotherapy in the soft tissue complications of LCH was evaluated in this retrospective study of 40 patients seen in two major Philadelphia institutions between 1970 and 1984. The patients were divided into two groups according to the extent of disease: unifocal versus multifocal. There was a higher rate of complete response in the unifocal form (4 of 12 patients), but this was associated with a high rate of spontaneous remissions (6 out of 12 patients). Multifocal LCH has a more aggressive course, and the major organs involved (lung, liver, and spleen) did not respond to radiotherapy. Eight patients had diabetes insipidus, and none of them responded to radiotherapy or chemotherapy. Autopsies were performed in two patients with diabetes insipidus who died of disease. There were no pathologic changes in the pituitary gland or stalk, hypothalamus, or supraoptic nuclei.

Perioperative morbidity associated with operative resection of craniopharyngioma: a review of ten years experience

A ten-year review of perioperative morbidity after operative resection of craniopharyngioma is presented. From 1974 to 1983, 23 patients underwent a total of 34 operations. Patients were subdivided into 95% or greater resection and partial resection groups. Features compared between the two groups included sodium, glucose, temperature, diabetes insipidus, major complications, neurological deficits and death. Patients undergoing 95% or greater resection had significant fluctuations in sodium, temperature and glucose (p less than .01). Diabetes insipidus and major postoperative complications were also significantly elevated in the 95% or greater resection group (p less than .05). Therefore, the extent of surgical resection correlated well with the degree of metabolic dysfunction and major postoperative complications. Careful assessment of surgical morbidity is warranted in the management of patients with craniopharyngioma.