Psychosocial dwarfism: psychopathological aspects and putative neuroendocrine markers

What makes people grow? Love and hope

BACKGROUND

Hope and love are popular themes of literature and art in many human societies. The human physiology of love and hope is less well understood. This review presents evidence that the lack of love and/or hope delays growth disturbs development and maturation and even kills.

MAIN BODY

Love and hope intersect in promoting healthy human development. Love provides a sense of security and attachment, which are necessary for healthy physical, cognitive, and emotional development. Hope provides a sense of optimism and resilience in the face of adversity. Loving relationships can foster a sense of hope in individuals and in society by providing support systems during difficult times. Similarly, having a sense of hope can make it easier to form loving relationships by providing individuals with the confidence to connect with others. Hope and love are the fundamental basis of human biocultural reproduction, which is the human style of cooperation in the production, feeding, and care of offspring. Examples are given of the association between human growth in height with love and hope, including (1) the global "Long Depression" of 1873-1896, (2) "hospitalism" and the abuse/neglect of infants and children, (3) adoption, (4) international migration, (5) colonial conquest, and (6) social, economic, and political change in Japan between 1970 and 1990.

CONCLUSION

Overall, this review suggests that love and hope are both critical factors in promoting healthy human development and that they intersect in complex ways to support emotional well-being.

Effect of 4-Week Heartfulness Meditation on Stress Scores, Sleep Quality, and Oxidative and Inflammatory Biochemical Parameters in COVID-19 Patients after Completion of Standard Treatment - A Randomized Controlled Trial

Context

COVID-19-affected patients showed increased stress, impaired sleep quality, altered complete blood count, and increased inflammatory and oxidative parameters. Yoga is an add-on nonpharmacological treatment that is established to normalize the abovementioned parameters. Heartfulness meditation is a form of Raja yoga.

Aims

The present study aimed to study the effects of 4 weeks of heartfulness meditation on the abovementioned parameters in COVID-19 patients following treatment completion.

Settings and Design

The present study was a randomized controlled trial carried out in the Department of Physiology, AIIMS, Mangalagiri, Andhra Pradesh.

Subjects and Methods

Out of 50 COVID-19 treatment-completed patients recruited for the study, 25 were randomly assigned to the study group who received 4-week app-based heartfulness meditation. Other 25 patients were assigned to the control group who received app-based relaxation for 4 weeks. Perceived stress score, Pittsburgh Sleep Quality Index questionnaire, baseline cardiovascular parameters, complete blood count, serum cortisol, inflammatory parameters, oxidative stress parameters, and antioxidant parameters were assessed before and after 4 weeks of intervention in both the groups. The outcome assessor was blinded in the present study.

Statistical Analysis Used

The mean difference between the two groups was tested using the Student's t-test or Mann-Whitney U-test based on data distribution. Effect of intervention was analyzed using paired Student's t-test for dependent samples test or Wilcoxon signed-rank test based on data distribution.

Results

The groups were comparable before intervention for all the variables. After 4 weeks of intervention, we observed a significant decrease in stress, circulating cortisol, inflammatory markers, and oxidative stress biomarker in both the groups. Further, we observed improved sleep quality and antioxidant biomarkers in both the groups. These beneficial alterations following intervention were high in the study group compared to the control group.

Conclusions

Our results suggest that app-based heartfulness meditation/relaxation can be used as a nonpharmacological adjuvant to hasten the recovery process in patients who have completed the COVID-19 treatment protocol. Beneficial effects in subjects practicing heartfulness meditation were more than that observed in subjects practicing relaxation.

Change of pace: How developmental tempo varies to accommodate failed provision of early needs

The interplay of genes and environments (GxE) is a fundamental source of variation in behavioral and developmental outcomes. Although the role of developmental time (T) in the unfolding of such interactions has yet to be fully considered, GxE operates within a temporal frame of reference across multiple timescales and degrees of biological complexity. Here, we consider GxExT interactions to understand adversity-induced developmental acceleration or deceleration whereby environmental conditions hasten or hinder children's development. To date, developmental pace changes have been largely explained through a focus on the individual: for example, how adversity "wears down" aging biological systems or how adversity accelerates or decelerates maturation to optimize reproductive fitness. We broaden such theories by positing shifts in developmental pace in response to the parent-child dyad's capacity or incapacity for meeting children's early, physiological and safety needs. We describe empirical evidence and potential neurobiological mechanisms supporting this new conceptualization of developmental acceleration and deceleration. We conclude with suggestions for future research on the developmental consequences of early adverse exposures.

Methylphenidate ameliorates the homeostatic balance between levels of kynurenines in ADHD children

The kynurenine pathway of tryptophan metabolism has been involved in ADHD We quantified basal levels and daily fluctuations of tryptophan and several kynurenine metabolites, as well as their changes after treatment with methylphenidate (MPH). A total of 179 children were recruited, grouped into ADHD (n = 130) and healthy controls (CG,n = 49). Blood samples were drawn at 20:00 and 09:00 h and only in the ADHD group after 4.63±2.3 months of treatment. Nocturnal urine was collected between both draws. Factorial analysis (Stata12.0) was performed with Groups, Time, Hour of Day and Depressive Symptoms (DS) as factors. MPH significantly increased plasma Kynurenic acid (2.4 ± 1.03/2.78±1.3 ng/mL; baseline/post-treatment, morning; z = 1.96,p<0.05) and Xanthurenic acid (2.39±0.95/2.88±1.19 ng/mL; baseline/post, morning; z = 2.7,p<0.007) levels, both with higher values in the evening. In DS+ patients, MPH caused a pronounced decrease in evening Anthranilic acid [3.08±5.02/ 1.82±1.46 ng/mL, z = 2.68,p = 0.0074] until matching values to other subgroups. In urine, MPH decreased the excretion of both Nicotinamide and Quinolinic acids, but only in the DS- subgroup. The kynurenine pathway may participate in the highly clinical favorable response to MPH. The observed changes could be considered as protective (i.e. increased plasma kynurenic acid vs. decreased quinolinic acid excretion) based on the knowledge of its physiological homeostatic functions.

Indole Tryptophan Metabolism and Cytokine S100B in Children with Attention-Deficit/Hyperactivity Disorder: Daily Fluctuations, Responses to Methylphenidate, and Interrelationship with Depressive Symptomatology

Background: Indole tryptophan metabolites (ITMs), mainly produced at the gastrointestinal level, participate in bidirectional gut-brain communication and have been implicated in neuropsychiatric pathologies, including attention-deficit/hyperactivity disorder (ADHD). Method: A total of 179 children, 5-14 years of age, including a healthy control group (CG, n = 49), and 107 patients with ADHD participated in the study. The ADHD group was further subdivided into predominantly attention deficit (PAD) and predominantly hyperactive impulsive (PHI) subgroups. Blood samples were drawn at 20:00 and 09:00 hours, and urine was collected between blood draws, at baseline and after 4.63 ± 2.3 months of methylphenidate treatment in the ADHD group. Levels and daily fluctuations of ITM were measured by tandem mass spectrometer, and S100B (as a glial inflammatory marker) by enzyme-linked immunosorbent assay. Factorial analysis of variance (Stata 12.0) was performed with groups/subgroups, time (baseline/after treatment), hour of day (morning/evening), and presence of depressive symptoms (DS; no/yes) as factors. Results: Tryptamine and indoleacetic acid (IAA) showed no differences between the CG and ADHD groups. Tryptamine exhibited higher evening values (p < 0.0001) in both groups. No changes were associated with methylphenidate or DS. At baseline, in comparison with the rest of study sample, PHI with DS+ group showed among them much greater morning than evening IAA (p < 0.0001), with treatment causing a 50% decrease (p = 0.002). Concerning indolepropionic acid (IPA) MPH was associated with a morning IPA decrease and restored the daily profile observed in the CG. S100B protein showed greater morning than evening concentrations (p = 0.001) in both groups. Conclusion: Variations in ITM may reflect changes associated with the presence of DS, including improvement, among ADHD patients.

A Translational Model of Incomplete Catch-Up Growth: Early-Life Hypoxia and the Effect of Physical Activity

Advances in therapies have led to prolonged survival from many previously lethal health threats in children, notably among prematurely born babies and those with congenital heart disease. Evidence for catch‐up growth is common in these children, but in many cases the adult phenotype is never achieved. A translational animal model is required in which specific tissues can be studied over a reasonable time interval. We investigated the impact of postnatal hypoxia (HY) (12%O₂ (HY12) or 10% O₂ (HY10)) on growth in rats relative to animals raised in room air. Subgroups had access to running wheels following the HY period. Growth was fully compensated in adult HY12 rats but not HY10 rats. The results of this study indicate that neonatal hypoxia can be a useful model for the elucidation of mechanisms that mediate successful catch‐up growth following neonatal insults and identify the critical factors that prevent successful catch‐up growth.

Breastfeeding Challenges and the Preterm Mother-Infant Dyad: A Conceptual Model

Breastfeeding is an experience that only a mother and her infant(s) can share. Infants who can feed from the breast receive not only the best nutrition but also, due to the close physical contact between mother and child, it is the optimal nurturance they can receive from their mother. When breastfeeding is trouble free, maternal well-being is uniquely heightened. However, breastfeeding remains a challenge for many mother-infant dyads and more so for those whose infants are born prematurely. This article introduces a conceptual model of the breastfeeding challenges facing preterm mother-infant dyads. It distinguishes between a maternal caregiving and an infant growth/development components. Within the maternal component, two primary elements are considered, that is, maternal behavioral and nutritional care. The two primary elements within the infant component include infant non-nutritional and nutritional growth/development. It is proposed that an improved understanding of the factors associated with these four elements and how they interplay with each other within individual dyads will facilitate the identification of the breastfeeding challenges facing these mother-infant entities. Due to the intimate relationships existing between a mother and her infant(s), it is further advanced that breastfeeding studies would be optimized if mother-infant pairs are studied as one entity rather than mother and infant separately. It is proposed that this conceptual model will assist health professionals develop personalized breastfeeding management plans for individual preterm mother-infant dyads, while furthering the development of evidence-based interventions to optimize their breastfeeding experiences.

BDNF concentrations and daily fluctuations differ among ADHD children and respond differently to methylphenidate with no relationship with depressive symptomatology

RATIONALE

Brain-derived neurotrophic factor (BDNF) enhances the growth and maintenance of several monoamine neuronal systems, serves as a neurotransmitter modulator and participates in the mechanisms of neuronal plasticity. Therefore, BDNF is a good candidate for interventions in the pathogenesis and/or treatment response of attention deficit hyperactivity disorder (ADHD).

OBJECTIVE

We quantified the basal concentration and daily fluctuation of serum BDNF, as well as changes after methylphenidate treatment.

METHOD

A total of 148 children, 4-5 years old, were classified into groups as follows: ADHD group (n = 107, DSM-IV-TR criteria) and a control group (CG, n = 41). Blood samples were drawn at 2000 and 0900 hours from both groups, and after 4.63 ± 2.3 months of treatment, blood was drawn only from the ADHD group for BDNF measurements. Factorial analysis was performed (Stata software, version 12.0).

RESULTS

Morning BDNF (36.36 ± 11.62 ng/ml) in the CG was very similar to that in the predominantly inattentive children (PAD), although the evening concentration in the CG was higher (CG 31.78 ± 11.92 vs PAD 26.41 ± 11.55 ng/ml). The hyperactive-impulsive group, including patients with comorbid conduct disorder (PHI/CD), had lower concentrations. Methylphenidate (MPH) did not modify the concentration or the absence of daily BDNF fluctuations in the PHI/CD children; however, MPH induced a significant decrease in BDNF in PAD and basal day/night fluctuations disappeared in this ADHD subtype. This profile was not altered by the presence of depressive symptoms.

CONCLUSIONS

Our data support a reduction in BDNF in untreated ADHD due to the lower concentrations in PHI/CD children, which is similar to other psychopathologic and cognitive disorders. MPH decreased BDNF only in the PAD group, which might indicate that BDNF is not directly implicated in the methylphenidate-induced amelioration of the neuropsychological and organic immaturity of ADHD patients.

Deep data science to prevent and treat growth faltering in Maya children

The Maya people are descended from the indigenous inhabitants of southern Mexico, Guatemala and adjacent regions of Central America. In Guatemala, 50% of infants and children are stunted (very low height-for-age), and some rural Maya regions have >70% children stunted. A large, longitudinal, intergenerational database was created to (1) provide deep data to prevent and treat somatic growth faltering and impaired neurocognitive development, (2) detect key dependencies and predictive relations between highly complex, time-varying, and interacting biological and cultural variables and (3) identify targeted multifactorial intervention strategies for field testing and validation. Contributions to this database included data from the Universidad del Valle de Guatemala Longitudinal Study of Child and Adolescent Development, child growth and intergenerational studies among the Maya in Mexico and studies about Maya migrants in the United States.

New TRPM6 mutation and management of hypomagnesaemia with secondary hypocalcaemia

BACKGROUND

TRPM6 gene mutation has been reported to cause hypomagnesemia with secondary hypocalcemia (HSH). However, the genotype-phenotype correlation for TRPM6 gene mutations has not been clarified.

OBJECTIVE

To elucidate the factors underlying the severe neurological complications in HSH and evaluate the potential association between the location of TRPM6 gene mutations and clinical data of HSH.

METHODS

A Japanese patient diagnosed with HSH at 10 weeks of age exhibited neurological damage and failed to thrive. Magnesium supplements were therefore started at 12 weeks of age. Mutational analysis of the TRPM6 gene was performed using a direct sequencing method to determine the position and type of mutation. Using the data of 29 HSH patients reported in the literature, linear regression analysis was also performed to examine the association between TRPM6 gene mutation location and HSH onset age, initial serum magnesium and calcium concentrations, and dose of oral magnesium.

RESULTS

A novel stop-codon homozygous mutation [c.4190 G>A] W1397X was identified in exon 26 of the patient's TRPM6 gene. No statistical correlation was found between the location of mutations in the TRPM6 gene and the clinical data for 4 clinical indicators of HSH.

CONCLUSIONS

We identified the first Japanese HSH patient with a novel nonsense mutation in the TRPM6 gene. Regression analysis of mutation locations in the protein-coding region of TRPM6 and the reported clinical data for 4 clinical indicators of HSH in 30 HSH patients did not detect a genotype-phenotype correlation.

Early-life adversity programs emotional functions and the neuroendocrine stress system: the contribution of nutrition, metabolic hormones and epigenetic mechanisms

Clinical and pre-clinical studies have shown that early-life adversities, such as abuse or neglect, can increase the vulnerability to develop psychopathologies and cognitive decline later in life. Remarkably, the lasting consequences of stress during this sensitive period on the hypothalamic-pituitary-adrenal axis and emotional function closely resemble the long-term effects of early malnutrition and suggest a possible common pathway mediating these effects. During early-life, brain development is affected by both exogenous factors, like nutrition and maternal care as well as by endogenous modulators including stress hormones. These elements, while mostly considered for their independent actions, clearly do not act alone but rather in a synergistic manner. In order to better understand how the programming by early-life stress takes place, it is important to gain further insight into the exact interplay of these key elements, the possible common pathways as well as the underlying molecular mechanisms that mediate their effects. We here review evidence that exposure to both early-life stress and early-life under-/malnutrition similarly lead to life-long alterations on the neuroendocrine stress system and modify emotional functions. We further discuss how the different key elements of the early-life environment interact and affect one another and next suggest a possible role for the early-life adversity induced alterations in metabolic hormones and nutrient availability in shaping later stress responses and emotional function throughout life, possibly via epigenetic mechanisms. Such knowledge will help to develop intervention strategies, which gives the advantage of viewing the synergistic action of a more complete set of changes induced by early-life adversity.

Methylphenidate ameliorates depressive comorbidity in ADHD children without any modification on differences in serum melatonin concentration between ADHD subtypes

The vast majority of Attention-deficit/hyperactivity disorder (ADHD) patients have other associated pathologies, with depressive symptoms as one of the most prevalent. Among the mediators that may participate in ADHD, melatonin is thought to regulate circadian rhythms, neurological function and stress response. To determine (1) the serum baseline daily variations and nocturnal excretion of melatonin in ADHD subtypes and (2) the effect of chronic administration of methylphenidate, as well as the effects on symptomatology, 136 children with ADHD (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: DSM-IV-TR criteria) were divided into subgroups using the “Children’s Depression Inventory” (CDI). Blood samples were drawn at 20:00 and 09:00 h, and urine was collected between 21:00 and 09:00 h, at inclusion and after 4.61 ± 2.29 months of treatment. Melatonin and its urine metabolite were measured by radioimmunoassay RIA. Factorial analysis was performed using STATA 12.0. Melatonin was higher predominantly in hyperactive-impulsive/conduct disordered children (PHI/CD) of the ADHD subtype, without the influence of comorbid depressive symptoms. Methylphenidate ameliorated this comorbidity without induction of any changes in the serum melatonin profile, but treatment with it was associated with a decrease in 6-s-melatonin excretion in both ADHD subtypes. Conclusions: In untreated children, partial homeostatic restoration of disrupted neuroendocrine equilibrium most likely led to an increased serum melatonin in PHI/CD children. A differential cerebral melatonin metabolization after methylphenidate may underlie some of the clinical benefit.

Differential responses of two related neurosteroids to methylphenidate based on ADHD subtype and the presence of depressive symptomatology

RATIONALE

Attention deficit with hyperactivity disorder is a neurodevelopmental disorder associated with alterations in the prefrontal cortex via dopaminergic and noradrenergic neurotransmission. Neurosteroids (e.g. allopregnanolone and dehydroepiandrosterone) modulate the release of multiple neurotransmitters.

OBJECTIVE

This study aims to determine the baseline concentrations and daily variations in allopregnanolone and dehydroepiandrosterone in children with attention deficit hyperactivity disorder (ADHD) and to determine the effect of chronic administration of methylphenidate on clinical symptoms and on the concentrations of these two neurosteroids.

METHODS

We included 148 children aged 5 to 14 years, subdivided into two groups: ADHD group (n = 107, with a diagnosis of ADHD (DSM-IV-TR criteria), further classified in subtypes by an "attention deficit and hyperactivity scale" and subgroups by the "Children's Depression Inventory") and a control group (n = 41). The clinical workup included blood samples that were drawn at 20:00 and 09:00 hours, at inclusion in both groups, and after 4.61 ± 2.29 months of treatment only in the ADHD group, for measurements for allopregnanolone and dehydroepiandrosterone. Factorial analysis, adjusted for age and gender, was performed by using Stata 12.0.

RESULTS

Methylphenidate induced the doubling of allopregnanolone levels in the predominantly inattentive ADHD patients without depressive symptoms (27.26 ± 12.90 vs. 12.67 ± 6.22 ng/ml, morning values). Although without statistical differences, baseline dehydroepiandrosterone levels were higher and slightly increased after methylphenidate in the ADHD subtype with depressive symptoms (7.74 ± 11.46 vs. 6.18 ± 5.99 ng/ml, in the morning), opposite to the lower baseline levels, and further decrease after methylphenidate in the inattentive subtype with depressive symptoms.

CONCLUSIONS

Different neurosteroids may have different baseline concentrations and differential responses to methylphenidate treatment as a function of ADHD subtype and subgroup. These differential responses may be a clinical marker of ADHD subtype and/or co-morbidities.

Modeling determinants of growth: evidence for a community-based target in height?

BACKGROUND

Human growth is traditionally envisaged as a target-seeking process regulated by genes, nutrition, health, and the state of an individual's social and economic environment; it is believed that under optimal physical conditions, an individual will achieve his or her full genetic potential.

METHODS

Using a panel data set on individual height increments, we suggest a statistical modeling approach that characterizes growth as first-order trend stationary and allows for controlling individual growth tempo via observable measures of individual maturity. A Bayesian framework and corresponding Markov-chain Monte Carlo techniques allowing for a conceptually stringent treatment of missing values are adapted for parameter estimation.

RESULTS

The model provides evidence for the adjustment of the individual growth rate toward average height of the population.

CONCLUSION

The increase in adult body height during the past 150 y has been explained by the steady improvement of living conditions that are now being considered to have reached an optimum in Western societies. The current investigation questions the notion that the traditional concept in the understanding of this target-seeking process is sufficient. We consider an additional regulator that possibly points at community-based target seeking in growth.

Methylphenidate effects on blood serotonin and melatonin levels may help to synchronise biological rhythms in children with ADHD

The neuroendocrine mediators that may contribute to ADHD (Attention deficit and hyperactivity disorder), serotonin and melatonin, are both thought to regulate circadian rhythms, neurological function and stress response. The objective of this study was to determine the effect of the chronic administration of prolonged release methylphenidate (PRMPH) on daily variations in blood serotonin and melatonin and on the excretion of 6-sulphatoxy-melatonin. A total of 179 children (136 males, 42 females) between the ages of 5 and 14 (9.70 ± 2.55) years were enrolled in a controlled quasi-experimental open clinical study. Of the sample, there were 136 Children with ADHD (based on DSM-IV-TR criteria), who were further grouped into subtypes, and the 42 siblings of the participants who did not ADHD patients. Blood samples were taken at 20:00 and 09:00; urine was collected between 21:00 and 09:00. In the ADHD group, the study protocol was repeated after 4.61 ± 2.3 months of treatment. Measurements included melatonin and serotonin by RIA and urine 6-S-aMT by ELISA. Factorial analyses were conducted by STATA 12.0.

RESULTS

ADHD patients showed reduced morning serotonin with a daily profile that was different than the control group due to the predominance of nocturnal concentrations. PRMPH did not result in any significant changes. Melatonin and its daily profile did not differ between controls and the ADHD group with a diurnal rhythm showing higher morning levels that disappear after PRMPH administration. Melatonin was higher in children with predominantly hyperactive-impulsive/conduct disorder subtype. PRMPH resulted in a decrease in 6-S-aMT excretion for both ADHD subtypes.

CONCLUSION

Chronic treatment with prolonged release methylphenidate induces subtle changes in the daily fluctuations and concentrations of both serotonin and melatonin. Improvement in Children's Depression Inventory (CDI) scores was not related to a morning increase in serotonin.

Endogenous opiates and behavior: 2011

This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).

Psychological maltreatment

Psychological or emotional maltreatment of children may be the most challenging and prevalent form of child abuse and neglect. Caregiver behaviors include acts of omission (ignoring need for social interactions) or commission (spurning, terrorizing); may be verbal or nonverbal, active or passive, and with or without intent to harm; and negatively affect the child's cognitive, social, emotional, and/or physical development. Psychological maltreatment has been linked with disorders of attachment, developmental and educational problems, socialization problems, disruptive behavior, and later psychopathology. Although no evidence-based interventions that can prevent psychological maltreatment have been identified to date, it is possible that interventions shown to be effective in reducing overall types of child maltreatment, such as the Nurse Family Partnership, may have a role to play. Furthermore, prevention before occurrence will require both the use of universal interventions aimed at promoting the type of parenting that is now recognized to be necessary for optimal child development, alongside the use of targeted interventions directed at improving parental sensitivity to a child's cues during infancy and later parent-child interactions. Intervention should, first and foremost, focus on a thorough assessment and ensuring the child's safety. Potentially effective treatments include cognitive behavioral parenting programs and other psychotherapeutic interventions. The high prevalence of psychological abuse in advanced Western societies, along with the serious consequences, point to the importance of effective management. Pediatricians should be alert to the occurrence of psychological maltreatment and identify ways to support families who have risk indicators for, or evidence of, this problem.

Stress and hormones

In the modern environment one is exposed to various stressful conditions. Stress can lead to changes in the serum level of many hormones including glucocorticoids, catecholamines, growth hormone and prolactin. Some of these changes are necessary for the fight or flight response to protect oneself. Some of these stressful responses can lead to endocrine disorders like Graves' disease, gonadal dysfunction, psychosexual dwarfism and obesity. Stress can also alter the clinical status of many preexisting endocrine disorders such as precipitation of adrenal crisis and thyroid storm.